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subfolder_0/A SURVEY ON THE NEED FOR DEVELOPING AN AYURVEDA BASED.txt

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+Jour. of Ayurveda & Holistic Medicine 
+Volume-II, Issue-VII 
+8 
+ 
+ 
+A SURVEY ON THE NEED FOR DEVELOPING AN AYURVEDA BASED 
+PERSONALITY (TRIDOSHAPRAKRTI) INVENTORY 
+ Ramakrishna B R 1 Kishore K R2  Vaidya V 3 Nagaratna R4 Nagendra H R5 
+ 
+INTRODUCTION: 
+Background 
+With increasing prevalence of life style related diseases/non 
+communicable diseases and failure of the conventional 
+medical system to tackle them holistically, a division of CAM 
+(complementary and alternative medicine) came into 
+existence to carry out research on the potential benefits of 
+many of these traditional systems of medical practice [1]. Of 
+these, TCM (Traditional Chinese Medicine) and Ayurveda 
+have been classified under whole medical systems [2]. 
+Ayurveda defined as the science of life [3], aims at maintaining 
+health of the healthy and cure of the sick through life style 
+management and therapeutic measures with natural 
+resources [4]. The assessment of personality type (prakrti) is 
+one of the basic steps in Ayurvedic diagnosis, prevention and 
+therapeutics. 
+Personality 
+Personality (Prakrti) is defined as the characteristic behaviour 
+of Physical, Physiological and Psychological features, that 
+emerges out of an intense interaction between the human 
+system and his environment. Prakrti is a Sanskrit word 
+meaning “nature” that refers to the natural constitution of an 
+individual.  Prakrti gets ingrained genetically in an organism 
+at the time of conception based on the predominant 
+dosha/doshas 
+and 
+gets 
+modified 
+by 
+environmental 
+influences.Prakrti constitute the basic substratum of a living 
+organism which is used to classify different types of 
+personalities. The nature of each doshaprakari has been well 
+defined among Ayurvedic classics. Predominance of one or 
+two of these doshas decides the physical, physiological and 
+psychological features of an individual that is determined at 
+the time of conception itself [5].  Accordingly, seven types of 
+Prakriti are manifested, three formed by the predominance 
+of a single dosha (Vatala, Pittala, Kaphala) , three by a 
+combination of two doshas (VataPittala, VataKaphala, 
+PittaKaphla)and one by a balance of all the threedoshas 
+(SamaPrakrti)[6]. This classification helps an Ayurveda 
+physician to determine the diagnosis and prognosis of a 
+disease, select suitable therapies, fix appropriate dose of the 
+pharmacological agents and advise right type of lifestyle 
+ABSTRACT: 
+Prakrti is a Sanskrit word that means “nature” or natural form of constitution of an individual. It is one of the bases of 
+classifying human population in general and in the diagnosis and prognosis of diseases,selection of drugs, dosage 
+fixation and therapeutic management according to Ayurveda. Prakrti gets ingrained in an organism at the time of 
+conception and gets modified according to one’s habitat, habit,age, environmental influences,  lifestyle and etc. 
+Ayurvedic physicians invariably use Prakrti concept to understand specific Prakrti of a patient in their practice out of 
+their experience. Till date Prakrti assessment has remained subjective. Although there are Prakrti assessment tools in 
+the form of Questionnaires, Checklists and Inventories they are either arbitrary or falling short of key standardization 
+parameters. In this study it was planned to establish whether there is a necessity to develop a standardized tool in the 
+evaluation of Prakrti. A standardized self-rating questionnaire was developed and administered to 34 qualified 
+Ayurvedic physicians (M: F=12:22) with mean age 30.29 ± 6.15 yrs (mean ± SD) and clinical experience [5.53 ± 4.57 
+(mean years ±SD)], belonging to different areas of Bangalore to assure proper representation of the cohort.  
+The study revealed that Ayurvedic physicians invariably use Prakrti in their clinical practice. They also agreed that their 
+assessment of Prakrti differed from another physician and accepted that they were not convinced about the reliability 
+of available tools and unanimously agreed on the need to develop a research based standardized tool for Prakrti 
+assessment. 
+Key Words: Prakrti, Ayurveda, Ayurveda Physician, Tridosha. 
+1PhD (Yoga) scholar, 5Chancellor, Swami Vivekananda Yoga 
+Anusandhana Samsthana (SVYASA) University, Bengaluru (India) 
+2Research officer, National Ayurveda Dietetics Research Institute, 
+Bengaluru (India) 
+3Deputy Medical Superintendent, Sushrutha Ayurveda Medical 
+College and Hospital, Bengaluru (India) 
+4Medical Director, Arogyadhama, SVYASA university, Bengaluru 
+(India) 
+Corresponding author email:  [email protected] 
+Access this article online: www.jahm.in 
+Published by Atreya Ayurveda Publications, Ilkal-587125 (India) 
+all rights reserved. 
+Received on: 29/07/14, Revised on: 12/08/14, Accepted on: 
+20/08/14 
+ 
+Jour. of Ayurveda & Holistic Medicine 
+Volume-II, Issue-VII 
+9 
+ 
+modifications. It is widely used for career counselling, 
+lifestyle counselling, marital counselling and etc. by 
+traditional Ayurvedic community which is being significantly 
+followed by the western Ayurvedic followers too. 
+Assessment of personlaity 
+Detailed descriptions of assessment of prakritibased on 
+subjective and objective methods of examination are 
+available in all major texts of Ayurveda. A major component 
+of the theoretical and practical training of an Ayurveda 
+physician is dedicated to recognize the prakriti and its 
+imbalances. With Ayurveda becoming one of the accepted 
+medical educational systems that trains many young 
+practitioners who may not have yet developed the capacity 
+to detect the prakriti that comes through long experience, 
+there seems to be an urgent need for an objective and 
+standardized paper pencil Inventory to help them fix the 
+basic personality and then go on to recognize the imbalances. 
+To date, there are a few such paper pencil audits and 
+software based tools available and none of them have gone 
+through the process of validation using the standard 
+statistical methods. Hence, we plan to develop a validated 
+prakriti assessment tool. As a preparatory step, the present 
+study was aimed at eliciting the need among practicing 
+Ayurveda physicians for developing a standardized tool to 
+assess Prakriti.  
+Methodology  
+Step 1: A focused group discussion (FGD) was carried out to 
+develop a check list to be administered to the physicians. The 
+group 
+consisted 
+of 
+five 
+Ayurveda 
+physicians 
+with 
+postgraduate qualification. Likert scale of check list was 
+developed comprising of 15 questions (table 1) intending to 
+cover the following objectives - Awareness, Utility, 
+Employability, Access, Acceptance and Need for research 
+based standardized tool to assess Prakrti.  
+Table 1 - Check-list of questions to elicit opinions from Ayurvedic physicians on the utility of prakriti assessment tool. 
+Please answer all questions. Mark your choice in the columns provided. 
+(MA : Mildly agree; A : Agree; SA : Strongly agree; NS : Not sure; MD : Mildly disagree; 
+D: Disagree; SD: Strongly disagree) 
+ No. 
+Questions 
+MA 
+A 
+SA 
+NS 
+MD 
+D 
+SD 
+1 
+Assessment of prakriti is an essential and integral part of 
+diagnosis 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+2 
+Prakriti forms an important basis of my disease management 
+plan 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+3 
+I carry out Prakriti assessment of all my patients 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+4 
+Prakriti assessment helps me to assess severity of the disease, 
+decide the dosage of the medicines, and predict response to 
+treatment and prognosis. 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+5 
+Prakriti evaluation is not a must in my clinical practice 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+6 
+I rarely carry out prakriti assessment of all my patients 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+7 
+I get expected treatment response irrespective of prakriti 
+assessment 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+8 
+Ayurveda approach is incomplete without prakriti assessment 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+9 
+My assessment of prakriti might differ significantly from 
+another Ayurveda physician 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+10 
+I use a standardized tool to assess prakriti of my patients 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+11 
+ I disagree with question number 10 because  there is no 
+standardized tool available to assess prakriti (if you have any 
+other reason please explain  in the space provided for ‘other 
+comments’ ) 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+12 
+I would not have reservations to use a standardized tool to 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+Jour. of Ayurveda & Holistic Medicine 
+Volume-II, Issue-VII 
+10 
+ 
+ 
+Step 2:  The researcher approached 125 Ayurveda 
+practitioners who satisfied the selection criteria for the 
+survey. The inclusion criteria were:  
+a) Ayurveda practitioners with > 5 years of practice,  
+b) Both genders,  
+c) Age between 30 to 70 years, and  
+d) Those who are working in Private clinics and Govt 
+hospitals.  
+A representative sample of 125 that included physicians 
+practicing Ayurveda in the East, West, North, and South parts 
+of Bengaluru who satisfied the selection criteria were 
+approached.  After seeking the consent by telephone calls to 
+participate in the survey, the researcher visited the 
+physicians at a mutually convenient time (with prior 
+appointment) to complete the check list that took about ten 
+minutes of their time.  
+Statistical Analysis  
+The answer sheets were collected and data entry was carried 
+out in excel sheets. The data was analysed using multiple 
+responses analysis and Non-parametric Chi-squared test. 
+RESULT 
+Table 2 shows the results of the validation scores by the FGD 
+comprising four subject experts and a Statistician. We 
+retained all the questions as all participants of the FGD 
+agreed that the questions were appropriate. We reworded 
+the questions 13 and 14 to make them more explicit as only 
+20% said ‘most appropriate’ and 80% said ‘appropriate’.  
+  
+Table 2:  Validation of the contents of the questionnaire by the FGD. 
+assess prakriti of my patients. 
+13 
+A standardized tool to assess prakriti will help Ayurveda 
+practitioners in their practice 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+14 
+Are you aware of paper pencil tools in English language to 
+assess prakriti (mention the reasons)? 
+Yes 
+No 
+Reasons 
+ 
+ 
+ 
+15 
+If your answer to qn. No. 14 is ‘yes’ , do you use them in your 
+clinical practice (mention with reasons) 
+ 
+ 
+ 
+ 
+If your answer  to qn. no 14 is ‘no’,   mention the reasons 
+ 
+Comments or suggestions: -------------------------------------------------------------------------------------------------------------------------------------------
+Name:....................................age:....................................gender: male/ female  
+Qualifications:.......................................... Affiliation : self-employed/ employee  
+Signature : .................................... date: ............................ 
+Key : 1 = Most appropriate, 2 = Appropriate, 3 = Less appropriate, 4 = Not appropriate 
+Question no. 
+Expert 1 
+Expert 2 
+Expert 3 
+Expert 4 
+Expert 5 
+% Agreement 
+Most-Appropriate 
+Appropriate 
+1 
+1 
+2 
+1 
+2 
+1 
+60 
+40 
+2 
+2 
+1 
+1 
+2 
+1 
+60 
+40 
+3 
+1 
+2 
+1 
+2 
+1 
+60 
+40 
+4 
+1 
+1 
+1 
+1 
+2 
+80 
+20 
+5 
+2 
+1 
+2 
+2 
+1 
+40 
+60 
+6 
+2 
+1 
+1 
+2 
+2 
+40 
+60 
+7 
+1 
+1 
+2 
+2 
+2 
+40 
+60 
+8 
+2 
+2 
+1 
+1 
+1 
+60 
+40 
+9 
+1 
+1 
+1 
+1 
+1 
+100 
+0 
+11 
+1 
+2 
+1 
+1 
+1 
+80 
+20 
+Jour. of Ayurveda & Holistic Medicine 
+Volume-II, Issue-VII 
+11 
+ 
+ 
+Table 3: Showing the details of the participants of the Survey. 
+ 
+Out of 125 physicians approached, 34 participated in the 
+study, 12 male and 22 female doctors. Of these, 14 were in 
+the age range of 30 to 40 years, 11in 40 to 50 range, 6  in 50 
+to 60 range and 3 in the range of 60 to 70 years .  
+Although the answer sheets had 7 options, after going 
+through an initial analysis, the FGD agreed to regroup the 
+answers under four categories to make it a meaningful 
+analysis . Questions 14 and 15 which had binary answers 
+were not included in this table 
+Table 4 :  Analysis of answers by 34 physician participants 
+Question No. 
+Total Agreement 
+Not sure 
+Total Disagreement 
+Not Answered 
+χ2 value 
+ 
+Sig p value 
+1 
+33 (97.06%) 
+1(2.94%) 
+0 
+0 
+30.118 
+<0.001 
+2 
+31 (91.18) 
+1(2.94%) 
+1(2.94%) 
+1(2.94%) 
+79.412 
+<0.001 
+3 
+30 (88.24) 
+4 (11.76) 
+0 
+0 
+19.882 
+<0.001 
+4 
+34 (100%) 
+0 
+0 
+0 
+No comparison 
+5 
+8 (23.53%) 
+0 
+24 (70.59%) 
+2 (5.88%) 
+22.824 
+<0.001 
+6 
+11 (32.35%) 
+1(2.94%) 
+21 (61.76%) 
+1(2.94%) 
+32.353 
+<0.001 
+7 
+14 (41.18%) 
+3 (8.82%) 
+16 (47.06%) 
+1(2.94%) 
+20.353 
+<0.001 
+8 
+31 (91.18) 
+0 
+2 (5.88%) 
+1(2.94%) 
+51.235 
+<0.001 
+9 
+23 (67.65%) 
+2 (5.88%) 
+7 (20.59%) 
+2 (5.88%) 
+34.941 
+<0.001 
+10 
+18 (52.94%) 
+2 (5.88%) 
+11 (32.35%) 
+3 (8.82%) 
+19.882 
+<0.001 
+11 
+7 (20.59%) 
+0 
+1(2.94%) 
+26 (76.47%) 
+20.059 
+<0.001 
+12 
+12 (35.29%) 
+2 (5.88%) 
+8 (23.53%) 
+12 (35.29%) 
+0.882 
+0.049 
+13 
+30 (88.24) 
+3 (8.82%) 
+1(2.94%) 
+3 (8.82%) 
+46.294 
+<0.001 
+ 
+Q no 1,2,3,4: 33 out of 34Doctors (97%) agreed that 
+Assessment of prakriti is an essential and integral part of 
+diagnosis(Q1)  and all of them (100%) agreed that Prakriti 
+assessment helps  in assessing the severity of the disease, 
+decide the dosage of the medicines, and predict response to 
+treatment and prognosis. 33 out of 34Doctors (97%) agreed 
+that  it forms an important basis of their disease 
+management plan(Q2) and 30 out of 34Doctors (88%)  carry 
+out  Prakriti assessment of all their patients(Q3)   and 8 out of 
+12 
+1 
+2 
+2 
+2 
+1 
+40 
+60 
+13 
+2 
+1 
+2 
+2 
+2 
+20 
+80 
+14 
+2 
+2 
+2 
+1 
+2 
+20 
+80 
+15 
+1 
+2 
+1 
+1 
+1 
+80 
+20 
+16 
+1 
+1 
+1 
+1 
+2 
+80 
+20 
+Variable 
+Number 
+Gender  
+Males  
+12 
+Females 
+22 
+Age 
+Mean± SD 
+30.29± 6.15 yrs 
+Duration of Clinical Experience 
+Mean± SD 
+5.53 ±  4.57 yrs 
+Location in Bengaluru city 
+North  
+09 
+South  
+13 
+East 
+07 
+West 
+05 
+Type of practice  
+Private clinics  
+19 
+Govt. Hospital faculty 
+15 
+Jour. of Ayurveda & Holistic Medicine 
+Volume-II, Issue-VII 
+12 
+ 
+34Doctors (23%)  did not agree that  Prakriti evaluation is  a 
+must in his/ her clinical practice.(Q5). 
+Q 6,7, 8:   31Doctors(91%) agreed that  Ayurveda approach is 
+incomplete without prakriti assessment (Q 8) , 11 
+Doctors(32%) rarely carried out prakriti assessment of all 
+their patients (Q 6), and 14 Doctors(41%) expressed that  
+they get expected treatment response irrespective of prakriti 
+assessment.  
+Q9: 23 Doctors (68%) agreed that their assessment of prakriti 
+might differ significantly from another Ayurveda physician’s 
+assessment and 7 Doctors (21%) disagreed which may point 
+to the confidence in these Doctors had about the clarity with 
+which the tradition would have laid down the objective ways 
+of assessing the prakriti.    
+Q 10,11,14:18 Doctors (53%)opined that they are actually 
+using one of the available tools (Qn. no.10); 18 Doctors(53%) 
+said that they are aware of existence of a tool (Qn. no. 14) ;  
+of the 11 Doctors(32%) who opined that they are not using 
+any tool , 7 Doctors(32%)said that they are not using because  
+there is no such standardized tool  available(Q.11)  . It 
+appears that many doctors did not know the difference 
+between a standardized tool from a non-standardized tool. 
+Q 12, 13: Although 30 Doctors (89%) agreed that   a 
+standardized questionnaire   would help Ayurveda 
+practitioners in their practice (Q.13).Only 12 Doctors (35%) 
+were willing to use them (Q.12)  while 8 Doctors (23%) of 
+them were not willing to use, 2 Doctors (6%) were not sure 
+and 12 Doctors (35%) did not respond. 
+DISCUSSION:  
+The study revealed that there is a need for a standardized 
+tool for assessment of Prakriti based on Ayurvedic concepts 
+for clinical usage among the Ayurvedic Doctors. Majority of 
+the Ayurvedic Doctors   confirmed that prakriti assessment is 
+a part and parcel of Ayurvedic methods of clinical diagnosis 
+and management 
+This was a pilot survey on Ayurveda clinicians in different 
+zones of Bengaluru to assess the need for developing a 
+standardized tool. A   questionnaire for the survey was 
+developed by the researcher and validated by a focussed 
+group (FGD) of 5 experts. After making minor corrections in 
+the questions for statistical analysis, the survey was carried 
+out amongst 34 physicians who satisfied the selection 
+criteria. 
+There was complete agreement that assessment of prakriti is 
+an integral part of Ayurveda practice and it helps in diagnosis, 
+prognosis and therapeutic management .Most of them did 
+carry out prakriti assessment. Looking at the questions that 
+asked about the awareness and need for developing a 
+standardized tool, 53% were aware of existence of a tool 
+prepared in English language.  It was interesting to note that 
+53% are already using the existing tools.  Although 35 % felt 
+that developing a standardized tool would be useful, 88.24%  
+agreed to use them in their practice and 24 % were silent . 
+ The question no 1to 4, Assessment of prakruti is an essential 
+and integral part of diagnosis ,Prakruti forms an important 
+basis of my disease management plan ,I carry out Prakruti 
+assessment of all my patients and Prakruti assessment helps 
+me to predict response to treatment/deciding dosage/ assess 
+severity of the disease/predicting prognosis/have drawn the 
+attention of all the participants(97%,91% ,88% and 100% 
+respectively) of the survey and have affirmed that prakrti 
+analysis is an integral part of Ayurvedic clinical practice. 
+The question no 5 to 7, Prakruti evaluation is not a must in 
+clinical practice, I rarely carry out prakruti assessment of all 
+my patients and I get expected treatment response 
+irrespective of prakruti have drawn attention of very less 
+participants (23.53%, 41.18% and 32.35%) and indirectly it 
+shows that Ayurvedic clinical Practice is incomplete without 
+prakriti assessment. 
+The question no 9, My assessment of prakruti might differ 
+significantly from another Ayurvedic physician has drawn the 
+attentionofmajorityof 
+practitioners(67.65%) 
+and 
+have 
+affirmed that in order to attain uniform results with varied 
+investigators ,a standardized tool of prakriti assessment is 
+required. 
+The question no 10, I use a standardized tool to assess 
+prakruti of my patients has drawn the attention of 52.94% of 
+participants. 
+It 
+affirms 
+that 
+majority 
+of 
+Ayurvedic 
+practitioners want to use a scientifically developed tool. 
+The question no 12,I would not have reservations to use a 
+standardized tool to assess prakruti of my patients has drawn 
+the attention of 35.29% with total agreement,5.88%not sure 
+,23.53%  not answered and 35.29% dis-agreement. It affirms 
+that if there is a scientific tool majority of the clinicians would 
+prefer to use it in their clinical practice. 
+The question no 13, A standardized tool to assess prakruti 
+will help Ayurvedic practitioners in their practice hasdrawn 
+the attention of 88.24% of participants. It further affirms that 
+majority of Ayurvedic practitioners want to use a scientifically 
+developed tool. 
+The question no 14 and 15, Are you aware of tools to assess 
+prakrutianddo you use them in your clinical practice have 
+drawn the attention of 41.18% and 52.94%with total 
+agreement respectively.It affirms that majority of Ayurvedic 
+practitioners prefer to use scientific tool it in their clinical 
+practice. 
+To address the above requirements of the Ayurvedic 
+physicians indeed it is necessary to develop a scientific tool of 
+assessment of prakriti. 
+In the direction of a survey study in relation to CAM a few 
+studies have been published. Characteristics of yoga users: 
+Results of a National survey byGurjeet S Birdee, et.al has 
+used the methodology of utilizing cross sectional survey on 
+31044 samples by using a questionnaire with leading 
+questions. The study concluded that Yoga Users are more 
+likely to be white female, young and college educated. Yoga 
+users report benefit for musculoskeletal conditions and 
+mental health. 
+Use of complementary and alternative medicine in 
+cancerpatients: a European survey by 
+A. Molassiotis1, et.al was carried out based on a descriptive 
+survey design spread over 14 countries on 956 samples. The 
+questionnaire used was based on one developed by 
+Swisha,et.al. There were 27 items including demographic 
+Jour. of Ayurveda & Holistic Medicine 
+Volume-II, Issue-VII 
+13 
+ 
+data and questions about CAM.Thestudy concluded that it is 
+imperative that health professionals explore the use of CAM 
+with their Cancer patients. 
+Use of complementary or alternative medicine in a general 
+population in Great Britain. 
+Results from the National Omnibus survey by Kate Thomas 
+and Pat Coleman,et. Al has followed multipurpose survey 
+methods which included interviews and advance letters 
+methods on 2761 samples with checklist comprising 8 
+questions module.The study concluded that there was a 
+strong correlation between the uses of CAMand gross 
+socioeconomicindicators. 
+Utilization of Complementary and Alternative Medicine by 
+UnitedStates Adults: Results From the 1999 National Health 
+Interview 
+Survey 
+by 
+Ni, 
+Hanyu,et.al 
+has 
+followed 
+NHIS(National Health Interview Survey) which covers the 
+non-Institutionalized 
+civilian 
+of 
+US 
+population 
+on 
+30801samples.The survey revealed that The sample size were 
+considerably lower than the reports of previous surveys. 
+Most CAM therapies are based by US adults in conjunction 
+with conventional medical services. 
+CONCLUSION: 
+Prakrtiassessment being one of the important aspects of 
+Ayurvedic clinical medicine is useful in medical and related 
+activities. It helps to classify human population in general to 
+advocate ideal lifestyle for prevention of diseases and 
+improve quality of life.it also helps in selection of therapeutic 
+measures, assessment of drug response & dosage fixation. 
+Ayurvedic physicians invariably use Prakrti in diagnosis and 
+therapeutic management. In order to explicit the need of a 
+scientifically 
+developed& 
+standardised 
+tool 
+for 
+the 
+assessment of prakrti a questionnaire based survey was 
+under taken. The survey reveals that a significant percentage 
+of physicians agreed that Prakrti forms an important basis of 
+disease management and majority of the physicians agreed 
+employment of Prakrti evaluation in their clinical practice. 
+Significant percentage of physicians agreed that their 
+assessment of Prakrtidiffered from another physician. Many 
+expressed thatthey were not sure of any such standardized 
+tool by research and shown their interest to use a 
+standardized prakrti assessment tool in their clinical practice. 
+This demonstrates the need for a standardized tool for 
+Prakrti assessment among Ayurvedic physicians.  
+REFERENCES: 
+1. 
+Complement Med. 2005 Apr; 11(2):221-5. 
+2. 
+Available from NCCAM Website 
+http://nccam.nih.gov/health/Ayurveda/introduction.htm 
+3. 
+Manyam BV, Kumar A. Ayurvedic constitution (prakrti) 
+identifies risk factor of developing Parkinson's disease. J Altern 
+Complement Med. 2013 Jul; 19(7):644-9. 
+4. 
+Website of Central Council for Research in Ayurvedic Sciences, 
+Departmenty of AYUSH, Ministry of Health and Family Welfare, 
+Government 
+of 
+India, 
+New 
+Delhi. 
+Available 
+from  
+http://www.ccras.nic.in/Ayurveda/Ayurveda_origin_01.htm 
+5. 
+Murthy AR, Singh RH.The concept of psychotherapy in 
+Ayurveda with special reference to satvavajaya. ASL. 1987 Apr; 
+6(4):255-61. 
+6. 
+Patwardhan Bhushan, Joshi Kalpana, PhD. And Chopra Arvind. 
+Classification of Human Population Based on HLA Gene 
+Polymorphism and the Concept of Prakriti in Ayurveda the 
+Journal of Alternative and Complementary Medicine. Volume 
+11, Number 2, 2005;349–353 
+7. 
+Sushruta. ShareeraSthana, Chapter 4, Verse 62-63. Dalhana 
+Commentary In: Yadavaji Trikamji (eds.) Sushruta Samhita. 1st 
+ed. Varanasi: ChaukhambhaOrientalia; 1997;360-1 
+8. 
+Joshi RR.A bio statistical approach to Ayurveda: quantifying the 
+tridosha. J Altern Complement Med. 2005 Apr; 11(2):221-5. 
+Cite this article as: Cite this article as: Ramakrishna B R, 
+Kishore K R, Vaidya V, Nagaratna R, Nagendra H R. A survey 
+on the need for developing an Ayurveda based personality 
+(Tridoshaprakrti) Inventory. J of Ayurveda and Hol Med 
+(JAHM); 2014;2(7):8-13. 
+Source of support: Nil, Conflict of interest: None Declared 
+ 
+ 

subfolder_0/A nonrandomized non-naïve, comparative study of the effects of kapalabhati and breath awareness on event- related potentials in trained yoga practitioners.txt

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+THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE
+Volume 15, Number 3, 2009, pp. 281–285
+© Mary Ann Liebert, Inc.
+DOI: 10.1089/acm.2008.0250
+A Nonrandomized Non-Naive Comparative Study 
+of the Effects of Kapalabhati and Breath Awareness 
+on Event-Related Potentials in Trained Yoga Practitioners
+Meesha Joshi, M.Sc., and Shirley Telles, Ph.D.
+Abstract
+Objectives: The study was conducted to compare the P300 event-related potentials recorded before and after
+(1) high-frequency yoga breathing (HFYB) and (2) breath awareness.
+Design: The P300 was recorded in participants of two groups before and after the intervention session (1 minute
+in duration).
+Settings and location: All participants were receiving yoga training in a residential yoga center, Swami
+Vivekanada Yoga Research Foundation in Bangalore, India.
+Subjects: Thirty (30) male participants formed two groups (n  15 each) with comparable ages (within an age
+range of 20–35 years) and comparable experience of the two techniques, the minimum experience being 3
+months.
+Interventions: The two groups were each given a separate intervention. One group practiced a HFYB at a fre-
+quency of approximately 2.0 Hz, called kapalabhati. The other group practiced breath awareness during which
+participants were aware of their breath while seated, relaxed.
+Outcome measures: The P300 event-related potential, which is generated when attending to and discriminat-
+ing between auditory stimuli, was recorded before and after both techniques.
+Results: The P300 peak latency decreased after HFYB and the P300 peak amplitude increased after breath aware-
+ness.
+Conclusions: Both practices (HFYB and Breath awareness), though very different, influenced the P300. HFYB
+reduced the peak latency, suggesting a decrease in time needed for this task, which requires selective atten-
+tion. Breath awareness increased the P300 peak amplitude, suggesting an increase in the neural resources avail-
+able for the task.
+281
+Introduction
+B
+reath regulation is an important part of Hatha yoga prac-
+tice, and there are several practices that involve chang-
+ing the rate, depth, and other aspects of breathing.1,2 One of
+the techniques involves high-frequency breathing (i.e., ap-
+proximately at 2.0 Hz) with forceful exhalation. This tech-
+nique is called kapalabhati in Sanskrit (kapala  forehead,
+bhati  shining), which suggests that the practice stimulates
+the brain.3 Kapalabhati is hence a high-frequency yoga breath-
+ing (HFYB) technique.
+In 11 advanced practitioners, the  and -1 activity in the
+electroencephalogram (EEG) increased during the first 5
+minutes of a 15-minute HFYB (kapalabhati) session.4 -1 ac-
+tivity remained high in the next 5 minutes, though  activ-
+ity increased in the later part in the practice. This trend of
+increased  activity continued after the 15-minute practice
+session, which was characterized by a relative increase of
+slower EEG frequencies and subjective relaxation.
+HFYB practice was associated with autonomic changes,
+based on the heart rate variability, suggestive of increased
+sympathetic and reduced vagal activity.5 Increased sympa-
+Swami Vivekananda Yoga Research Foundation, Bangalore, India.
+thetic tone is associated with better vigilance.6 Hence the
+shift in the autonomic balance toward sympathetic domi-
+nance following HFYB may have some bearing on the fact
+that HFYB practice improved performance in a task for at-
+tention and was reported as a Letter to the Editor.7
+The effect of HFYB on attention was studied in medical
+students, middle-aged adults, and people over the age of 60
+years.7 All of them were given a cancellation task before and
+after a 1-minute session of HFYB on one day and before and
+after a breath awareness session (as an alternate intervention)
+on another day. All three categories of volunteers showed im-
+proved performance in the cancellation task, which requires
+selective and sustained attention, as well as the ability to shift
+attention, after HFYB. The study did not attempt to under-
+stand the mechanisms underlying the improvement.
+The present study was designed to assess the effects of
+HFYB (i.e., kapalabhati) and breath awareness on an event-re-
+lated potential generated and associated with the ability to
+pay attention to a given stimulus and discriminate between
+stimuli. The P300 component of event-related potentials is
+considered a neuro-electric phenomenon, since it is gener-
+ated when participants attend to and discriminate between
+stimuli that differ on a single aspect.8 In auditory stimuli, the
+difference is in their frequency. The P300 reflects cognitive
+events requiring attentional and immediate memory pro-
+cesses. In the present study, the P300 was recorded before
+and after (1) high-frequency yoga breathing (i.e., HFYB or
+kapalabhati) and (2) breath awareness.
+Materials and Methods
+Participants
+The participants were 30 male volunteers with ages be-
+tween 20 and 35 years. The 30 participants actually com-
+prised two groups (n  15 each). One (1) was asked to prac-
+tice HFYB group average and the other group was asked to
+practice breath awareness. The mean age  standard devia-
+tion (SD) of the group who practiced kapalabhati was 26.0 
+4.6 years, and for the breath awareness group it was 27.6 
+3.7 years. The two groups’ ages did not differ significantly
+(p  0.05, t-test for unpaired data). The immediate effects of
+these practices were assessed as described below, under “De-
+sign of the Study.” They were all residing at a yoga center
+(i.e., Swami Vivekanada Yoga Research Foundation, in Ban-
+galore, India). These two groups were drawn from a larger
+sample, based on (1) their willingness to participate in the
+trial, (2) their having normal health and not being on med-
+ication, and (3) all of them having a minimum of 3 months
+experience of both HFYB (kapalabhati) and breath awareness.
+Males alone were studied as the P300 (evoked by visual stim-
+uli) varied with gender.9 The study was approved by the in-
+stitution’s Ethics Committee, and all participants gave their
+signed consent to participate.
+Design of the Study
+All 30 participants were assessed before and after 1-minute
+practice sessions. For half of the participants, the practice ses-
+sion was HFYB, and for the remaining 15 participants the
+practice was breath awareness. For both groups, the dura-
+tion of a practice session was 1 minute. While all participants
+were drawn from a comparable larger sample (i.e., persons
+receiving training in yoga at a residential training center),
+they were not randomly assigned to the two groups. On the
+other hand, participants did not self-select to which group
+they would be assigned. Hence, they can be considered as
+two comparable, though nonrandomized groups. The ab-
+sence of a standard method to assign persons to the two
+groups is a methodological limitation of the study.
+Also, the participants were all yoga practitioners, residing
+at a yoga center. While being given training, participants are
+taught that the practice of HFYB (kapalabhati) could increase
+alertness and the ability to be attentive. Participants are also
+taught that breath awareness is practiced to increase the abil-
+ity to be aware of internal sensations. Given this background,
+even though they were not especially told that the P300 task
+is a task to assess attention, participants can be considered
+non-naïve and may have been aware of the hypothesis of the
+study, which is another limitation of the study and arises
+from the participants’ knowledge about the yoga practices.
+Recording Conditions
+P300 auditory event-related potentials were recorded using
+a Nicolet Bravo System (Nicolet Biomedical, Madison, WI).
+The P300 component is generated by giving a simple task re-
+quiring discrimination between two stimuli that are presented
+in a random sequence known as the “oddball” paradigm (i.e.,
+with the infrequent stimulus being considered the oddball).8
+During assessments, subjects were seated in a sound-attenu-
+ated and dimly lit cabin and were monitored on a closed cir-
+cuit television, receiving instructions through an intercom.
+Electrode Positions
+Ag/AgCl disk electrodes were affixed with electrode gel
+(10–20 conductive paste, D.O. Weaver & Co., Aurora, CO) at
+Cz referred to linked earlobes with the ground electrode at
+FPz, based on the International 10–20 system for electrode
+placement.10 Eye movements were recorded with an electro-
+oculogram (EOG) as a bipolar derivation with electrodes
+placed 1 cm above and 1 cm below the outer canthus of the
+right eye. All electrode impedances were kept below 5 k.
+Amplifier Settings
+The EEG activity was amplified with a sensitivity of 100
+V. The prestimulus delay was set at 75 ms and the P300
+event-related potentials were computer averaged in 300 trial
+sweeps, with a range between 75 and 750 ms. The rejection
+level for artifacts was kept at 90%. The low-pass filter was
+set at 0.01 Hz and the high-pass filter was set at 30 Hz.
+Stimulus Characteristics
+Binaural tone stimuli of alternating polarity delivered at
+0.9 ms with a frequency of 1 KHz for standard stimuli and
+2 KHz for target stimuli were used to trigger online averag-
+ing of the EEG.8 The percentage of standard stimuli was set
+at 80 and for the target stimuli was set at 20. The stimulus
+intensity was kept at 70 db sound pressure level (SPL).
+Recording Procedure
+Assessments were recorded immediately before and after
+the intervention. Participants were asked to keep their eyes
+JOSHI AND TELLES
+282
+closed during a recording. They were asked to avoid sub-
+stances that would influence their cognitive functions (e.g.,
+tea and coffee for the caffeine content) on the day prior to
+and on the day of the assessments. The standard and target
+stimuli were delivered through close-fitting earphones
+(TDH-39, Amplivox, Oxford, UK). Participants were asked
+to distinguish between tones and mentally count target stim-
+uli.
+Interventions
+HFYB or kapalabhati practice involves rapid breathing with
+a frequency of approximately 2.0 Hz, during which only ex-
+halation is an active process. Participants were asked to start
+the practice and after approximately 10 seconds they would
+reach the final rate (in this case, approximately 2.0 Hz). This
+would be the actual beginning of the 1-minute session. The
+subjects were timed by the experimenter and after a minute
+they were asked to stop. Hence their actual breathing ses-
+sion was for 70 seconds, out of which they would have been
+breathing at the expected rate for approximately 60 seconds
+and taking 10 seconds to attain the final rate. The fact that
+approximately 10 seconds is required to reach the expected
+rate of approximately 2.0 Hz is based on previous unpub-
+lished observations. Throughout the practice the practition-
+ers sit upright, close their eyes, and breathe in and out
+through their nose. At the end of each session participants
+were asked whether they experienced dizziness, tingling, or
+numbness of the fingers or lightheadedness, as possible signs
+of hyperventilation. None of them reported any of these
+symptoms. However, attempting to assess hyperventilation
+based on these symptoms rather than measured carbon diox-
+ide levels is recognized as inadequate and is a limitation of
+the study.
+Breath awareness was the “alternate” intervention. Dur-
+ing this practice the participants were asked to sit quietly,
+being aware of their breath without manipulating their
+breathing. They were asked to be aware of the flow of air as
+it enters and passes through the nasal passage. Hence,
+throughout the practice the attention is directed toward the
+breath.
+Data Extraction
+The peak amplitude (in V) was defined as the voltage
+difference between a prestimulus baseline and the largest
+positive peak of the P300 within a 250–450-ms latency win-
+dow. 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 peak am-
+plitude were measured for potentials recorded at Cz referred
+to linked earlobes.
+Data Analysis
+The peak amplitudes and peak latencies obtained before
+and after HFYB practice and after breath awareness were
+compared using a repeated-measures analysis of variance,
+with one between-subjects factor (i.e., groups, with two lev-
+els, HFYB group and Breath awareness group), and one
+Within-subjects factor (i.e., States, with two levels, Pre and
+Post).
+Post-hoc analysis with multiple comparisons and Bonfer-
+roni adjustment was carried out to compare values recorded
+before and after HFYB, as well as before and after breath
+awareness.
+Results
+Repeated measures analysis of variance
+The peak latency of the P300 potential showed a signifi-
+cant difference between States [i.e., Pre and Post, with F 
+7.829, df  1,14, p  0.05]. For the P300 peak amplitude, there
+was a significant interaction between Groups (i.e., HFYB and
+Breath awareness groups) and States (i.e., Pre and Post) [F 
+4.746, df  1,14, p  0.05]. In both cases the Hyunh-Feldt ep-
+silon was equal to 1.
+Post-hoc comparisons
+Multiple post-hoc comparisons were carried out with Bon-
+ferroni adjustment. There was a significant reduction in the
+P300 peak latency following HFYB compared to before (p 
+0.05, one tailed). Following breath awareness, on the other
+hand, the P300 peak amplitude increased significantly com-
+pared to before (p  0.05, two-tailed).
+The group mean values  SD of the P300 peak latencies
+and peak amplitudes recorded from Cz are given in Table 1.
+Discussion
+One minute of HFYB at approximately 2.0 Hz decreased
+the P300 peak latency, while a 1-minute session of breath
+awareness increased the P300 peak amplitude.
+In earlier studies the P300 has been recorded before and
+after meditation techniques and after another yoga breath-
+ing practice. For example, definite changes were recorded in
+YOGA BREATHING AND ERPs
+283
+TABLE 1.
+PEAK LATENCIES AND PEAK AMPLITUDES OF P300 
+PRE- AND POST-KAPALABHATI SESSIONS
+HFYB
+Breath Awareness
+(n  15)
+(n  15)
+Latency (ms)
+Pre
+358.20  32.53
+362.80  25.32
+Post
+339.20*  29.99
+340.40  45.57
+Amplitude (V)
+Pre
+8.25  4.90
+5.23  4.04
+Post
+6.79  2.79
+6.55**  3.96
+Values are group means  standard deviation.
+*p  0.05 (one-tailed), **p  0.05 (two-tailed), post-hoc tests with Bonferroni adjustment, comparing
+“post” with respective “pre” values.
+the P300 following transcendental meditation (TM).11 The
+P300 was recorded using a passive auditory listening trial
+paradigm with variable interstimulus intervals between
+identical tone stimuli. There were three groups (viz., expe-
+rienced TM meditators, novices to TM and nonmeditator
+controls). The two groups of meditators had shorter laten-
+cies despite differences in ages (e.g., an average age of 41
+years in experienced mediators and an average age of 20
+years in novices). In another study, the P300 was assessed in
+experienced TM practitioners at pretest baseline, after 10
+minutes of rest, or after 10 minutes of TM practice with con-
+ditions counterbalanced across meditators.12 After TM, the
+P300 latency decreased relative to no change after the rest
+condition.
+The P300 was also studied before and after practicing an-
+other meditation technique, called cyclic mediation (CM).13
+CM consists of cycles of ‘stimulating’ and of ‘calming’ prac-
+tices. Comparisons were made with P300 recordings taken
+before and after an equal duration of supine rest. A greater
+magnitude of decrease in latency was noted after CM com-
+pared to supine rest.
+There is a single report of the effect of practicing a volun-
+tarily regulated breathing technique (or pranayama) on the
+P300.14 The participants were patients with depression and
+the comparison was with people with normal health. P300
+amplitudes were lower in depressives to begin with, but the
+amplitudes increased after practicing the yoga breathing tech-
+nique (Sudarshan Kriya Yoga), for three months, so that the am-
+plitudes were comparable with those of unaffected persons.
+The P300 latency reflects the speed of stimulus classifica-
+tion, is generally not related to the overt response, and is in-
+dependent of the behavioral reaction time.15 Hence, the P300
+latency is an index of stimulus processing rather than re-
+sponse generation and is used as a motor-free measure of cog-
+nitive function. The P300 peak latency is negatively correlated
+with mental functions in normal persons; shorter latencies are
+associated with superior cognitive performance in tasks for
+attention and immediate memory. The P300 amplitude is be-
+lieved to indicate the level of activity related to processing
+incoming information and is sensitive to the resources avail-
+able for attention engaged in completing the task.16
+The neuroelectric events that underlie the generation of
+the P300 arise from interaction between the frontal lobe, the
+hippocampus, and the temporoparietal lobe.17 The primary
+neural generators for the P300 are in the anterior cingulate
+when new stimuli are processed into working memory. Sub-
+sequent activation of the hippocampal formation occurs
+when interconnections between the frontal lobe and the tem-
+poral or parietal lobe are active.18
+The decreased P300 peak latency following HFYB suggests
+that the practice may have reduced the time required for this
+task, which requires selective attention. Based on the change
+in the P300 peak amplitude, breath awareness appeared to
+increase the neural resources available for the attentional task.
+The decrease in P300 latency after different yoga practices
+such as HFYB in the present study and following meditation
+techniques such as TM11,12 and cyclic meditation (CM)13 in
+earlier studies, could be related to two factors. These two fac-
+tors, which are mentioned below, may also apply to the in-
+creased P300 amplitude following breath awareness (in the
+present study) and following Sudarshan Kriya yoga, in an
+earlier study.14 However, the contribution of these factors to
+the changes in P300 is entirely speculative and is not backed
+by any additional recordings.
+The first factor is that all yoga practices, including yoga
+postures (yogasanas), voluntarily regulated breathing (prana-
+yama), and meditation, emphasize the importance of relax-
+ation and awareness of internal sensations.19
+In connection with this, an objective assessment was made
+of the ability of experienced meditators to detect their heart-
+beat, which is a standard, noninvasive measure of resting in-
+teroceptive awareness.20 While no objectively recorded dif-
+ference was found between meditators and nonmeditators,
+meditators consistently self-rated their interoceptive perfor-
+mance as superior and the difficulty of the task as easier.
+Hence, a feeling of being able to be aware of internal sensa-
+tions could facilitate overall awareness and the ability to be
+attentive. However, this again is speculation. This factor may
+be particularly relevant for the increased P300 peak ampli-
+tude following breath awareness.
+The second factor is that a substantial percentage of yoga
+practices are recognized to involve a certain amount of strain.
+In contrast, some of the changes associated with practicing
+yoga techniques, which includes postures (asanas), regulated
+breathing (pranayama), and meditation, reflect reduced strain.
+The most often quoted and early documented changes were
+a decrease in heart and breath rates and in oxygen consump-
+tion following TM.21 These changes suggested that medita-
+tion was a state of parasympathetic dominance. However,
+subsequent studies have shown that most yoga techniques
+do show increased activity in some subdivisions of the sym-
+pathetic nervous system (this may be cardiosympathetic, va-
+somotor, or sudomotor sympathetic nervous system activity)
+that often occur along with other changes suggestive of re-
+duced arousal, hence giving rise to the description of these
+practices as producing a state of “alertful rest.”
+This has been shown for meditation,22,24 HFYB or kapal-
+abhati,5,25 and even for yoga postures (asanas).26 Since in-
+creased sympathetic activity is associated with better vigi-
+lance,5 the fact that yoga practice may increase activity in
+some subdivisions of the sympathetic nervous system may
+also explain the improved performance in the P300 oddball
+task after HFYB. However, though autonomic changes have
+been studied during breath awareness, there were no signs
+of increased sympathetic nervous system activity during
+breath awareness.27 Hence, this explanation (i.e., of increased
+sympathetic activity and of better vigilance) may more
+clearly explain the improved P300 performance after HFYB,
+while the improved interoception may better explain the im-
+provement after breath awareness.
+Hence, both interventions (i.e., HFYB and breath aware-
+ness) influenced the performance in the P300 task. HFYB re-
+duced the time required for the task, whereas breath aware-
+ness appeared to increase the available neural resources
+required for the task. Further studies with simultaneous
+monitoring of autonomic variables would be helpful for un-
+derstanding whether autonomic changes did contribute to
+the changes in the P300 component following these practices.
+In the absence of such recordings, all the ideas presented
+here about the possible mechanisms involved are mere spec-
+ulations, which is a limitation of the study. Other limitations
+of the study include the fact that the subjects were non-naive
+to the intervention, and hence there was no way of knowing
+whether the brain effects were influenced by their expecta-
+JOSHI AND TELLES
+284
+tions. Finally, since both interventions were given for a very
+brief duration (i.e., 1 minute each), this limits interpreting
+the findings and future studies would use longer-duration
+interventions.
+Conclusions
+Both practices (i.e., HFYB and breath awareness), though
+very different, influenced the P300. HFYB (at approximately
+2.0 Hz) reduced the P300 peak latency, suggesting a decrease
+in the time needed for this task, which requires selective at-
+tention. Breath awareness increased the P300 peak ampli-
+tude, suggesting an increase in the neural resources avail-
+able for the task.
+Acknowledgments
+The study formed part of a project funded by the Central
+Council for Research in Yoga and Naturopathy, under the
+Ministry of Health and Family Welfare, Government of In-
+dia, and is gratefully acknowledged. Also, the authors would
+like to mention that the study was inspired by the ideas of
+the late T. Desiraju, who was a professor at the National In-
+stitute of Mental Health and Neurosciences, Bangalore, In-
+dia.
+Disclosure Statement
+The authors state that no competing financial interests ex-
+ist.
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+Address reprint requests to:
+Shirley Telles, Ph.D.
+Patanjali Yogpeeth
+Maharishi Dayanand Gram
+Bahadrabad, Haridwar, Uttarakhand 249408
+India
+E-mail: [email protected]
+YOGA BREATHING AND ERPs
+285

subfolder_0/A recipe for Policy research in AYUSH educational and research.txt

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+www.jimcr.com	
+INTEGRATIVE MEDICINE CASE REPORTS  VOLUME 2  NUMBER 1  JANUARY 2021
+IMCR
+EDITORIAL
+1
+A recipe for Policy research in AYUSH educational and research  
+programs
+Kalyan Maity1, Vijaya Majumdar1, Amit Singh1, Akshay Anand2*
+Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana (S-VYASA), Bengaluru, Karnataka, India1
+Neuroscience Research Lab, Department of Neurology, PGIMER, Chandigarh, India2
+*Corresponding Author:
+Akshay Anand, PhD
+Professor, Neuroscience Research Lab
+Department of Neurology, PGIMER, Chandigarh, India
+Contact no: +91-9914209090
+E-mail: [email protected]
+Yoga, Ayurveda, and Siddha represent the ancient science of 
+healthy living originated in India. Some of the oldest texts 
+from around 5000 years back, such as Vedas and Upanishads, 
+provide evidence of such lifestyle. Many seals and fossils from 
+Indus Valley Civilization authenticate the practice of Yoga in 
+ancient India. According to yogic tradition, Shiva, one of the 
+Hindu Gods, is the first yogi (Adi yogi) and the first teacher 
+(Adi Guru). The meticulous practice of Yoga is widely believed 
+to play a major role to overcome mental and physical suffer-
+ing and leads to self-regulation, and finally to self-realization 
+or liberation. Since the Pre-Vedic period around 2700 B.C., 
+people started practicing Yoga. Later on, Patanjali Maharshi 
+(between 3rd to 6th centuries BC) systematized and codified 
+knowledge of Yoga through his Yoga Sutras. Later, with the 
+help of many sages and masters, Yoga spread through differ-
+ent traditions, lineages and Guru-shishya parampara. Various 
+Yoga schools viz. Jnana, Bhakti, Karma, Raja, Dhyana, Patan-
+jali, Kundalini, Hatha, Laya, Jain, Buddha, Hatha etc. which 
+follow their own practice, principles and tradition. However, 
+they all lead to the same goal. The history of modern Yoga 
+started in 1893 when the Parliament of Religions was held. 
+After that many yogacharya, teachers and practitioners tried 
+to spread Yoga, not only in India but worldwide (1). One of 
+the milestones in the history of Yoga has been the adoption of 
+the International Day of Yoga. The Honorable Prime Minister 
+ 
+Sri Narendra Modi addressed the world community on 
+27th  September 2014 in 69 sessions of the United Nations 
+General Assembly (UNGA) (2). The proposal was approved on 
+11th December 2014 by 193 members of UNGA to establish 
+21 June as “International Day of Yoga”. Six months later after 
+passing the resolution and confirmation to establish IDY, the 
+first IDY held in 2015. Several Yogic events were organized and 
+publicized throughout India as well as abroad and got nation-
+al and international publicity that Yoga has originated from 
+Indian culture. The essential and pivotal role of Yoga in edu-
+cation, pedagogy, curriculum, as well as clinical research has 
+been realized well across the globe (3). To achieve the same, 
+AYUSH Ministry was established November 9, 2014 (http://
+ayush.gov.in) to facilitate research and educational activity in 
+Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoe-
+opathy. The existence and excellence of Yoga-based research-
+es in the premier Institutes of India is another milestone to-
+wards the implementation of yogic sciences in the academic 
+sphere. Several Yoga departments and centers in the premier 
+Institutes and central universities of India, their existence and 
+establishment, is the result of the consultative meeting on 
+Yoga Education in Universities held in Bangalore on 2nd Janu-
+ary 2016, chaired by the Hon’ble Minister for Human Resource 
+Development in the presence of Vice-Chancellors from Indian 
+universities. It was resolved to set up a Department of Yogic 
+Art and Science in the Universities and constitute a committee 
+on Yoga Education in universities to look into various aspects 
+pertaining to setting up of these Departments. Further, collab-
+orative efforts were made to support Psychology, Philosophy, 
+and Yogic Science at different collaborating organizations, 
+by utilizing their respective expertise, knowledge, resources 
+ 
+and infrastructure (https://www.nhp.gov.in/list-of-yoga- 
+institutes_mtl). The aim of such centers was to understand 
+KEY WORDS 
+Ayush
+Integrative health
+Yoga
+Research
+INTEGRATIVE MEDICINE CASE REPORTS  VOLUME 2  NUMBER 1  JANUARY 2021
+www.jimcr.com
+IMCR
+EDITORIAL
+2
+deeper knowledge of Yoga philosophy and Yoga therapy based 
+on classical Yogic texts. For the last several years, S-VYASA 
+University has been doing research on evidence-based Yoga 
+& its application, to prevent diseases and to promote posi-
+tive health (https://svyasa.edu.in/Research_Publications.
+html). Swami Vivekananda Yoga Anusandhana Samsathana 
+ 
+(S-VYASA), established in 1986, is a pioneer Institute in the 
+field of Yoga Research. It is the first and foremost Institute 
+with a broad vision of scientifically evaluating yoga, its appli-
+cations, and policies led by Dr. H R Nagendra (4).
+A tremendous increase in Yoga participation has been 
+reported in the US since 2005. About 30 million people per-
+form Yoga daily to get health benefits (5,6). The increased 
+global interest in Yoga in recent decades could be based on 
+the health-promoting benefits of Yoga. Yoga therapy is evolv-
+ing rapidly and advocated as a safe and effective intervention 
+by National Health Services (UK) and National Institutes of 
+Health (US) (7–13). A continuous rise in Yoga schools and 
+practitioners is also evident across the globe (5). The science 
+of Yoga and the underlying technology of this mind-body med-
+icine need a more thorough investigation through carefully 
+designed mechanistic and clinical studies. There are many 
+challenges and barriers that hinder the realization of the op-
+timal potential of Yoga in education and Research (14). For 
+example, the current understanding of Yoga is limited as a be-
+havioral therapy or lifestyle intervention (14). Barriers to the 
+practice of Yoga and the knowledge gap in its understanding 
+also serve as the key determinants of the success of Yoga for 
+its successful implementation as public health administration 
+as well as its practical acceptance in the academic sector. Mod-
+ern lifestyle, occupational pressure, family commitments are a 
+few suggested barriers for Yoga Practice (9).
+Many Western medical schools viz. Columbia University, 
+Harvard University, Johns Hopkins University, University of 
+California, Stanford University, and research centers in Europe 
+have rapidly developed centers of excellence in Mind-Body 
+medicine. However there is a lack of active participation of many 
+of the corresponding premier Indian Institutions and Universi-
+ties. There is an urgent need to evaluate the perceptions and 
+barriers as perceived by the Institutions of National Eminence 
+and their Ethical and Academic committees that belong to the 
+Indian scientific and academic community for successful eval-
+uation of Yoga-based research and educational programs. This 
+can provide a necessary policy framework for evidence-based 
+decisions for Yoga research, barrier and benefits of Yogic prac-
+tices and identify the knowledge gap in the research and health 
+care fraternity. There is a need to develop policies that promote 
+the participation of the Indian Institutions and Universities that 
+have not shown their active participation in Yoga research so 
+far. An evaluation of Institutions that have been ranked highest 
+in MHRD’s National Institutional Ranking Framework (NIRF) 
+(https://www.nirfindia.org/Home) provides a framework to 
+methodologically rank Institutions across the country driven 
+by the overall recommendations by a Core Committee set up by 
+MHRD. This process can aim to assess the performance of the 
+Institutions based on broad parameters that cover “Teaching, 
+Learning and Resources,” “Research and Professional Practic-
+es,” “Graduation Outcomes,” “Outreach and Inclusivity,” and 
+“Perception”. The active participation of Institutes with high 
+NIRF rankings and inclusion assessment of AYUSH programs 
+in such Institutions along with their Ethical committees would 
+trigger changes that may lead to the adoption of Integrative 
+medicine in such Institutes and utilize the public health poten-
+tial of AYUSH research conducted since the launch of Ministry 
+of AYUSH. Until new publication characterized by biomarker, 
+animal models and cell culture studies have dominated the life 
+science ranking (15–33).
+References
+1.	
+Certification of yoga professionals guide book, Ministry of AYUSH, Govern-
+ment of India, 2016.
+2.	
+Bhattacharyya A, Patil NJ, Muninarayana C. “Yoga for promotion of health”: 
+conference held on International day of yoga-2015 at Kolar. Journal of 
+Ayurveda and integrative medicine. 2015 Oct;6(4):305.
+3.	
+Marques CS, Ferreira J, Rodrigues RG, Ferreira M. The contribution of 
+yoga to the entrepreneurial potential of university students: a SEM 
+approach. International Entrepreneurship and Management Journal. 
+2011 Jun 1;7(2):255–78.
+4.	
+Nagendra HR, Anand A. Indian PM’s evidence based wellness approach 
+inspires politico-scientific activism. Annals of Neurosciences. 2019; 
+26(1):3.
+5.	
+McCall MC. In search of yoga: Research trends in a western medical data-
+base. Int J Yoga. 2014;7(1):4–8.
+6.	
+Birdee GS, Legedza AT, Saper RB, Bertisch SM, Eisenberg DM, Phillips RS. 
+Characteristics of yoga users: results of a national survey. Journal of 
+General Internal Medicine. 2008 Oct 1;23(10):1653–8.
+7.	
+Hoyez AC. The ‘world of yoga’: the production and reproduction of thera-
+peutic landscapes. Soc Sci Med. 2007 Jul;65(1):112–24.
+8.	
+Dayananda H, Ilavarasu JV, Rajesh S, Babu N. Barriers in the path of yoga 
+practice: An online survey. Int J Yoga. 2014;7(1):66–71. 
+9.	
+Chu P, Gotink RA, Yeh GY, Goldie SJ, Hunink MM. The effectiveness of yoga 
+in modifying risk factors for cardiovascular disease and metabolic 
+syndrome: A systematic review and meta-analysis of randomized 
+controlled trials. European journal of preventive cardiology. 2016 
+Feb;23(3):291–307.
+10.	 Aljasir B, Bryson M, Al-shehri B. Yoga practice for the management of type II 
+diabetes mellitus in adults: a systematic review. Evidence-Based 
+Complementary and Alternative Medicine. 2010;7(4):399–408.
+11.	 Posadzki P, Ernst E. Yoga for asthma? A systematic review of randomized 
+clinical trials. Journal of Asthma. 2011 Aug 1;48(6):632–9.
+12.	 Kirkwood G, Rampes H, Tuffrey V, Richardson J, Pilkington K. Yoga for anx-
+iety: a systematic review of the research evidence. British journal of 
+sports medicine. 2005 Dec 1;39(12):884–91.
+13.	 Tabish SA. Complementary and Alternative Healthcare: Is it Evidence- 
+based? Int J Health Sci (Qassim). 2008;2(1):5–9.
+14.	 Mutalik G, Tillu G, Patwardhan B. AyurYoga, the confluence of healing 
+sciences: A call for global action. J Ayurveda Integr Med. 2019;10(2): 
+79–80. 
+15.	 Sharma NK, Gupta A, Prabhakar S, Singh R, Bhatt AK, Anand A. CC chemo-
+kine receptor-3 as new target for age-related macular degeneration. 
+Gene. 2013 Jul 1;523(1):106–11.
+16.	 Anand A, Banik A, Thakur K, L Masters C. The animal models of dementia 
+and Alzheimer’s disease for pre-clinical testing and clinical transla-
+tion. Current Alzheimer Research. 2012 Nov 1;9(9):1010–29.
+17.	 Anand A, Gupta PK, Sharma NK, Prabhakar S. Soluble VEGFR1 (sVEG-
+FR1) as a novel marker of amyotrophic lateral sclerosis (ALS) in the 
+North Indian ALS patients. European Journal of Neurology. 2012 
+May;19(5):788–92.
+www.jimcr.com	
+INTEGRATIVE MEDICINE CASE REPORTS  VOLUME 2  NUMBER 1  JANUARY 2021
+IMCR
+EDITORIAL
+3
+18.	 Goyal K, Koul V, Singh Y, Anand A. Targeted drug delivery to central ner-
+vous system (CNS) for the treatment of neurodegenerative disorders: 
+trends and advances. Central Nervous System Agents in Medicinal 
+Chemistry (Formerly Current Medicinal Chemistry-Central Nervous 
+System Agents). 2014 Apr 1;14(1):43–59.
+19.	 Kamal Sharma N, Gupta A, Prabhakar S, Singh R, Sharma S, Anand A. Single 
+nucleotide polymorphism and serum levels of VEGFR2 are associ-
+ated with age related macular degeneration. Current neurovascular 
+ 
+research. 2012 Nov 1;9(4):256–65.
+20.	 Anand A, Saraf MK, Prabhakar S. Sustained inhibition of brotizolam in-
+duced anterograde amnesia by norharmane and retrograde amne-
+sia by l-glutamic acid in mice. Behavioural brain research. 2007 Aug 
+22;182(1):12–20.
+21.	 Anand A, Saraf MK, Prabhakar S. Antiamnesic effect of B. monniera on 
+L-NNA induced amnesia involves calmodulin. Neurochemical re-
+search. 2010 Aug 1;35(8):1172–81.
+22.	 Singh T, Prabhakar S, Gupta A, Anand A. Recruitment of stem cells into the 
+injured retina after laser injury. Stem cells and development. 2012 
+Feb 10;21(3):448–54.
+23.	 Gupta PK, Prabhakar S, Abburi C, Sharma NK, Anand A. Vascular endothe-
+lial growth factor-A and chemokine ligand (CCL2) genes are upregu-
+lated in peripheral blood mononuclear cells in Indian amyotrophic 
+lateral sclerosis patients. Journal of neuroinflammation. 2011 Dec 1; 
+8(1):114.
+24.	 Vinish M, Prabhakar S, Khullar M, Verma I, Anand A. Genetic screen-
+ing reveals high frequency of PARK2 mutations and reduced Par-
+kin expression conferring risk for Parkinsonism in North West 
+India. Journal of Neurology, Neurosurgery & Psychiatry. 2010 Feb 
+1;81(2):166–70.
+25.	 Anand A, Tyagi R, Mohanty M, Goyal M, De Silva KR, Wijekoon N. Dystro-
+phin induced cognitive impairment: mechanisms, models and thera-
+peutic strategies. Annals of neurosciences. 2015 Apr;22(2):108.
+26.	 Banik A, Brown RE, Bamburg J, Lahiri DK, Khurana D, Friedland RP, Chen 
+W, Ding Y, Mudher A, Padjen AL, Mukaetova-Ladinska E. Translation 
+of Pre-Clinical Studies into Successful Clinical Trials for Alzheimer’s 
+Disease: What are the Roadblocks and How Can They Be Overcome? 
+1. Journal of Alzheimer’s Disease. 2015 Jan 1;47(4):815–43.
+27.	 Anand A, Sharma NK, Gupta A, Prabhakar S, Sharma SK, Singh R, Gupta PK. 
+Single nucleotide polymorphisms in MCP-1 and its receptor are as-
+sociated with the risk of age related macular degeneration. PloS one. 
+2012 Nov 21;7(11):e49905.
+28.	 Sharma K, Sharma NK, Anand A. Why AMD is a disease of ageing and not 
+of development: mechanisms and insights. Frontiers in aging neuro-
+science. 2014 Jul 10;6:151.
+29.	 Sharma NK, Gupta A, Prabhakar S, Singh R, Sharma SK, Chen W, Anand A. As-
+sociation between CFH Y402H polymorphism and age related macular 
+degeneration in North Indian cohort. PloS one. 2013 Jul 29;8(7):e70193.
+30.	 Mathur D, Goyal K, Koul V, Anand A. The molecular links of re-emerging 
+therapy: a review of evidence of Brahmi (Bacopa monniera). Fron-
+tiers in pharmacology. 2016 Mar 4;7:44.
+31.	 Anand A, Thakur K, Gupta PK. ALS and oxidative stress: the neurovascular 
+scenario. Oxidative medicine and cellular longevity. 2013 Oct;2013.
+32.	 English D, Sharma NK, Sharma K, Anand A. Neural stem cells—trends and 
+advances. Journal of cellular biochemistry. 2013 Apr;114(4):764–72.
+33.	 Sharma NK, Prabhakar S, Gupta A, Singh R, Gupta PK, Gupta PK, Anand 
+A. New biomarker for neovascular age-related macular degeneration: 
+eotaxin-2. DNA and cell biology. 2012 Nov 1;31(11):1618–27.
+doi: 10.38205/imcr.020101

subfolder_0/A self-rating scale to measure states of tridosha in children..txt

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+© 2021  Indian Journal of Ayurveda and Integrative Medicine KLEU | Published by Wolters Kluwer - Medknow
+Suchitra S. Patil, R. Nagarathna 1, H. R. Nagendra
+ 
+Department of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana, 1Department of Yoga and Life Sciences, 
+Arogyadhama, SVYASA, Bengaluru, Karnataka, India
+Address for correspondence: Dr. Suchitra S. Patil, Swami Vivekananda Yoga Anusandhana Samsthana, Eknath Bhavan, No. 19, 
+Gavipuram Circle, Kempegowda Nagar, Bengaluru ‑ 560 019, Karnataka, India. E‑mail: [email protected]
+Submitted: 18-Feb-2021, Revised: 25-Feb-2021, Accepted: 02-Mar-2021, Published: 17-Apr-2021
+ABSTRACT
+Background: In Western psychology, inventories are available for state (temporary change) and trait (which is the basis of 
+personality‑character) aspects of personality. Ayurveda inventories for measuring tridosha (which is the basis of both trait 
+and state of personality) in children have been developed and standardized, which pertains to trait aspect of personality. 
+There is no scale to assess the state aspects of tridosha in children.
+Methods: The design of the study was descriptive type. Sampling design was purposive sampling. The 6‑item Tridosha 
+State Scale for Children (TSSC) was developed on the basis of translation of the Sanskrit verses describing the states of 
+vāta, pitta, and kapha prakriti, which represent the temporary change in tridosha and by taking the opinions of experts (ten 
+Āyurveda experts and three psychologists who helped in judging the items and assessed. The study was carried out in Bapuji 
+School, Davangere. The scale was administered on 108 children in the age group of 8–12 years (mean age: 9.75 ± 1.30). 
+Moreover, for 30 children, the scores are compared with Caraka Child Personality Inventory (CCPI) – a self‑rating scale to 
+measure the trait aspects of prakriti).
+Results: TSSC was associated with excellent internal consistency. The Cronbach’s alpha for Vataja, Pittaja, and Kaphaja 
+scales was 0.826, 0.885, and 0.911, respectively. Scores on Vātaja, Pittaja, and Kaphaja scales were inversely correlated, 
+suggesting that they are mutually exclusive. Correlation of scores on subscales with CCPI was 0.97, 0.92, and 0.94, 
+respectively, for Vata, Pitta, and Kapha.
+Conclusions: The state of tridosha in children can be measured reliably by this instrument. This can be utilized by clinicians 
+and researchers to check the immediate effect of the interventions.
+Key words: Health, state, tridosha
+Introduction
+According to Western psychologists, Allport, Cattell, and 
+Guilford personality is made up of traits which are the 
+dispositions or a fundamental construct that accounts for 
+behavior regularity or consistency.[1] Trait is a permanent 
+character in one’s personality, while state is a temporary 
+change in personality or reaction of an individual to a situation.
+Ayurveda classics proclaim tridosha (Vata, Pitta, and Kapha 
+metabolic principles maintaining the functions of the body) 
+forms trait (character) and state (temporary -mood) aspects 
+of the personality. Accordingly, scriptures quote the state of 
+tridosha changes in a day, afternoon, night, during, before, 
+and after digestion. Detailed description of character of 
+personality formed by tridosha is explained.[2‑9]
+A Self‑Rating Scale to Measure States of Tridosha in Children
+This is an open access journal, and articles are distributed under the 
+terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 
+4.0 License, which allows others to remix, tweak, and build upon the 
+work non‑commercially, as long as appropriate credit is given and 
+the new creations are licensed under the identical terms.
+For reprints contact: [email protected]
+How to cite this article: Patil SS, Nagarathna R, Nagendra HR. 
+A self‑rating scale to measure states of tridosha in children. Indian J 
+Ayurveda lntegr Med  2021;2:3-7.
+Original Article
+Access this article online
+Website:
+www.ijaim.in
+Quick Response Code
+DOI:
+10.4103/ijaim.ijaim_1_21
+[Downloaded free from http://www.ijaim.in on Monday, June 6, 2022, IP: 136.232.192.146]
+Patil, et al.: State scale for children
+4
+ Indian Journal of Ayurveda and Integrative Medicine KLEU / Volume 2 / Issue 1 / January-June 2021
+Statistical model of dosha prakriti based on analysis of a 
+questionnaire has been developed.[10] An analysis of tridosha 
+physiology, linking it to process of cellular physiology, has 
+been carried out.[11,12] Similarly, a genetic basis of tridosha 
+constitution has been postulated.[13‑15] Importance of doshas 
+in health and treatment methods has been discussed.[16] A 
+study comparing the Āyurveda personality concepts and 
+Western psychology concepts is available.[17] Ayurveda 
+tridosha theory and four elements of Buddhist medicine and 
+Chinese humorology have been compared.[18,19] Importance 
+of Prakriti in aging has been discussed.[20] Differences in 
+cardiovascular responses to postural changes, exercise, and 
+cold pressor test of different prakriti have been explained.[21] 
+Left and right hemisphere chemical dominance has been 
+observed with predominance of doshas.[22] A scale to measure 
+tridoshas in psychotic patients has been developed.[23] A 
+parent‑rating scale and self‑rating scales are developed 
+and standardized to measure the trait aspects of tridosha 
+in children.[23,24] Scales to assess the state and trait aspects 
+of personality and anxiety are developed and standardized 
+according to Western psychology concepts.[25‑27]
+However, a simple self‑rating scale to assess the state aspects 
+of tridosha in personality of children according to Āyurveda 
+comprehensive concepts is not available. This may point 
+to observe the immediate changes in tridoshas after the 
+intervention.
+The objective of the present study was to develop a self‑rating 
+scale “Tridosha State Scale for Children” (TSSC) to assess the 
+mood state of the children pertaining to respective doshas 
+and to correlate with the trait prakriti scale Caraka Child 
+Personality Inventory (CCPI).[24] The reliability of subscales 
+was supported by Cronbach’s alpha co‑efficient ranging from 
+0.54 to 0.64 and split‑half analysis ranging from 0.60 to 0.66.
+Methods
+“TSSC” was developed based on six important Sanskrit 
+characteristics from nine authoritative ancient Ayurveda texts 
+describing characteristics typical of state aspect of Vātaja, 
+Pittaja, and Kaphaja Prakṛti.  Twenty‑five items in Sanskrit and 
+translation in English were presented to ten Āyurveda experts 
+for content validity. They were asked to judge the correctness 
+of each statement and to check (1) if the items constructed 
+represented acceptable translation of the Sanskrit in the 
+original texts and (2) whether the items selected represent 
+the state aspects of Vātaja, Pittaja, and Kaphaja Prakṛti?
+All the experts agreed on all items. Finally, six questions of 
+TSSC were framed. The scale was again presented to five 
+Āyurveda experts and two psychologists who reviewed the 
+format of this scale and recommended a two‑point scoring 
+(0 and 1); this was adopted in the final CCPI. Suggestions in 
+the phrasing of questions were also incorporated.
+The final TSSC has six items – two items for Vāta state, 
+2 items for Pitta state, and 2 items for Kapha state subscales. 
+The scale was to be answered by the children [Appendix 1].
+Data collection and analysis
+Item difficulty level was analyzed by administering the scale 
+on 108 children in the age group of 8–12 years.
+For testing the reliability and validity, the final scale of 6 items 
+was administered on 30 children who were the students of 
+Bapuji School in Davangere, Karnataka, India, of both sexes 
+with an age range of 8–12 years.
+The Statistical Package for Social Sciences (SPSS‑16.0, SPSS 
+Inc., Chicago, Ill., USA) was used for data analysis. The data 
+were analyzed for reliability. Cronbach’s alpha test was 
+applied for reliability analysis. Discriminant validity was 
+analyzed by Pearson’s correlation analysis. This was done to 
+check the degree of association between Vātaja, Pittaja, and 
+Kaphaja scores.
+Table  1 gives the demographic data of the children. 
+Sixty‑eight boys were there and 40 girls were there 
+(age: 9.75 ± 1.30).
+Results
+Content validity
+Among seven experts, who served as judges, all six questions 
+were agreed by four to five experts.
+Internal consistency
+An analysis of the data collected from 30 children showed 
+that the Cronbach’s alpha is at an acceptable range.[28]
+Table 2 gives the reliability coefficients of Vata, Pitta, and 
+Kapha subscales ranging above 0.8.
+Table 3 gives the correlation between Vata, Pitta, and Kapha 
+subscales. Vata has correlated significantly negatively with 
+Pitta and Kapha. Pitta has correlated significantly negatively 
+with Kapha.Table 4 gives the correlations of subscales of TSSC 
+Table 1: Demographic data
+Sample
+n/mean
+Percentage/SD
+Gender
+68 boys/n=108
+62.9
+Age
+9.75
+1.30
+SD: Standard deviation
+[Downloaded free from http://www.ijaim.in on Monday, June 6, 2022, IP: 136.232.192.146]
+Patil, et al.: State scale for children
+5
+ Indian Journal of Ayurveda and Integrative Medicine KLEU / Volume 2 / Issue 1 / January-June 2021
+and CCPI. Vata scale of TSSC correlated highly significantly 
+with vata scale of CCPI. Similarly, Pitta and Kapha scales of 
+TSSC correlated highly significantly with Pitta and Kapha 
+subscales of CCPI.
+Discussion
+The present study has described the development and initial 
+standardization of a self‑rating scale TSSC to measure the 
+state of tridosha with six items.
+The reliability of subscales was supported by Cronbach’s alpha 
+co‑efficient ranging from 0.800 to 0.911. This supported the 
+consistency of the scale[29] [Table 2]. Correlation between 
+Vātaja, Pittaja, and Kaphaja scale scores was negative, 
+suggesting discriminant validity [Table 3]. Correlation values 
+range from 0.332 to 0.657, significance at 99% confidence 
+for all correlations. This suggests that the three subscales 
+measure different aspects of state of personality of the 
+children. Correlation with CCPI[24] supported criterion related 
+validity[30] [Table 4].
+The strength of the study was that it is the first attempt 
+to standardize a self‑rating scale to measure the state 
+aspects of Prakriti of the children, which is an important 
+step to analyze the immediate effect of an intervention.[1,9] 
+This scale was developed with an intention to check the 
+immediate effect of yoga and meditation on tridoshas 
+importantly. Although published scales are available to 
+assess the Prakriti of the children,[23,24] there are no scales to 
+assess the state of tridosha. Hence, TSSC can be potentially 
+used to measure the mood state because of predominant 
+doshas in children.
+Limitations of the study
+Although TSSC is a reliable valid instrument, it has not 
+addressed test–retest reliability. The study should be done on 
+more number of samples and norms should be established.
+Conclusions
+A TSSC is a reliable and valid instrument. Researchers can 
+employ this instrument to assess the immediate effect of 
+diet, yoga, and personality development program on the 
+prakriti of the children.
+Acknowledgment
+We thank Dr. Kishore, Dr. Aarti Jagannathan, Dr. Uma, and 
+Āyurveda experts in Hubli, Bengaluru Āyurveda College, for 
+their support and participation in the study.
+Financial support and sponsorship
+Nil.
+Conflicts of interest
+There are no conflicts of interest.
+References
+1.	
+Misched M. Introduction to Personality. New York: Holt. Rinehart and 
+Winston Inc.; 1971.
+2.	
+Tripati R. Ashtanga Sangraha: Hindi Commentary. 2nd ed. New Delhi: 
+Choukamba Publications; 2001.
+3.	
+Panday GS. Caraka Samhita: Hindi Commentary. 5th ed. New Delhi: 
+Choukamba Publications; 1997.
+4.	
+Shastry KA. Sushruta Samhita: Hindi Vyakhya. 15th ed. New Delhi: 
+Choukamba Publications; 2002.
+5.	
+Brahmashankaramishra. Bhavaprakash: Hindi Vyakhya. 10th ed. 
+Varanasi: Chaukamba Smaskrita Bhavan; 2002.
+6.	
+Pandit Parashram Shastri. Sharangadhara Samhita: Samskrita Vyakhya. 
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+13. 
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+based on HLA gene polymorphism and the concept of Prakriti in 
+ayurveda. J Altern Complement Med 2005;11:349‑53.
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+15.	
+Prasher B, Negi S, Aggarwal S, Mandal AK, Sethi TP, Deshmukh SR, 
+et al. Whole genome expression and biochemical correlates of extreme 
+constitutional types defined in Ayurveda. J Transl Med 2008;6:48.
+Table 2: Reliability coefficients of the tridosha subscales
+Subscales
+Cronbach’s alpha
+Vata
+0.826
+Pitta
+0.885
+Kapha
+0.911
+Table 4: Correlation with Caraka Child Personality Inventory 
+(trait scale)
+r
+Vs versus Vt
+0.97**
+Ps versus Pt
+0.92**
+Ks versus Kt
+0.94**
+Table 3: Correlation among subscales
+Tridosha
+r
+P
+Vataja versus Pittaja
+0.425**
+<0.01
+Vataja versus Kaphaja
+0.657**
+<0.01
+Pittaja versus Kaphaja
+0.332**
+<0.05
+[Downloaded free from http://www.ijaim.in on Monday, June 6, 2022, IP: 136.232.192.146]
+Patil, et al.: State scale for children
+6
+ Indian Journal of Ayurveda and Integrative Medicine KLEU / Volume 2 / Issue 1 / January-June 2021
+16.	
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+in Ayurveda. Altern Ther Health Med 2001;7:44‑50.
+17.	
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+Med 1983;11:25‑34.
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+Ayurveda and the theory of the four deranged elements in Buddhist 
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+19.	
+Mahdihassan  S. A  comparative study of Chinese cosmology 
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+20.	
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+2011;32:20‑4.
+21.	
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+to postural changes, exercise, and cold press or test: Do they vary in 
+accordance with the dual constitutional types of ayurveda? Evid Based 
+Complement Alternat Med 2011;2011:251850.
+22.	
+Kurup RK, Kurup PA. Hypothalamic digoxin, hemispheric chemical 
+dominance, and the tridosha theory. Int J Neurosci 2003;113:657‑81.
+23.	
+Suchitra SP, Devika HS, Gangadhar BN, Nagarathna R, Nagendra HR, 
+Kulkarni R. Measuring the tridosha symptoms of unmāda (psychosis): 
+A preliminary study. J Altern Complement Med 2010;16:457‑62.
+24.	
+Suchitra  SP, Aarati  J, Nagendra  HR. Development and initial 
+standardization of Ayurveda: J Ayurveda Integr Med 2014;5:205‑8.
+25.	
+Spielberger CD. State‑Trait Anxiety Inventory: Bibliography. 2nd ed. 
+Palo Alto, CA: Consulting Psychologists Press; 1989.
+26.	
+Spielberger CD, Gorsuch RL, Lushene R, Vagg PR, Jacobs GA. Manual 
+for the State‑Trait Anxiety Inventory. Palo Alto, CA: Consulting 
+Psychologists Press; 1983.
+27.	
+Marteau TM, Bekker H. The development of a six‑item short‑form of 
+the state scale of the Spielberger State‑Trait Anxiety Inventory (STAI). 
+Br J Clin Psychol 1992;31:301‑6.
+28.	
+Freeman FS. Theory and Practice of Psychological Testing. 3rd ed. 
+New Delhi: Surjeet Publications; 2006.
+29.	
+Anastasi A, Urbina S. Psychological Testing. 7th ed. New Delhi: Pearson 
+Education; 2005.
+30.	
+Nunnaly JC. Psychometric Theory. 2nd ed. New York: Mc‑Grow‑Hill; 
+1978.
+[Downloaded free from http://www.ijaim.in on Monday, June 6, 2022, IP: 136.232.192.146]
+Patil, et al.: State scale for children
+7
+ Indian Journal of Ayurveda and Integrative Medicine KLEU / Volume 2 / Issue 1 / January-June 2021
+Appendix 1
+Tridosha State Scale for Children
+Instructions: There are no correct or wrong answers. Fill how you are feeling right now?
+1.	 I am active Yes/No
+2.	 I am upset Yes/No
+3.	 I am sweating Yes/No
+4.	 I am tensed Yes/No
+5.	 I feel enthusiastic Yes/No
+6.	 I feel silence Yes/No
+[Downloaded free from http://www.ijaim.in on Monday, June 6, 2022, IP: 136.232.192.146]

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+74
+© 2018 International Journal of Yoga - Philosophy, Psychology and Parapsychology | Published by Wolters Kluwer - Medknow
+A Statistical Model for Quantification of Panchakośas of Large 
+Collective Entities
+Bhalachadra Laxmanrao Tembe, Promila Choudhary1, H R Nagendra1
+Access this article online
+Quick Response Code:
+Website: www.ijoyppp.org
+DOI: 10.4103/ijny.ijoyppp_16_17
+Address for correspondence: Dr. Bhalachadra Laxmanrao Tembe, 
+Indian Institute of Technology Bombay, Mumbai ‑ 400 076, 
+Maharashtra, India. 
+ 
+E‑mail: [email protected]
+and meanings for the kośas in these different entities. 
+Although there could be multiple sets of definitions of 
+these kośas, the effort would be all the same worthwhile, 
+particularly if such a definition could provide a means 
+for healing these sheaths in these units.
+The first step would be to define the five kośas for 
+families. Since human beings are strongly interacting 
+systems, the manomaya kośa of a family is unlikely to 
+be a linear combination of the manomaya kośas for the 
+individual members of the family. In addition, in children 
+Original Article
+Introduction
+T
+he panchakośa viveka that has been formalized in 
+the Taittiriya Upaniśad[1] provides a way to classify 
+a human being into five interrelated sheaths. Such a 
+classification helps in studying these sheaths individually 
+as well as jointly and has also provided a basis for 
+therapy[2‑5] for curing individuals, in whom these sheaths 
+are not functioning in an optimal manner. These five 
+sheaths are developed differently in different individuals. 
+It is natural to expect that an analogous classification will 
+be useful to study different units in societies, such as a 
+family and communities in villages and cities, and this 
+could be extended to countries as well as the whole world.
+Such an extension of the concept of kośa  (sheaths) to 
+different units will require reasonable to good definitions 
+Department of Chemistry, 
+Indian Institute of 
+Technology Bombay, 
+Mumbai, Maharashtra, 
+1Directorate of Distance 
+Education, SVYASA 
+University, Bengaluru, 
+Karnataka, India
+How to cite this article: Tembe BL, Choudhary P, Nagendra HR. 
+A statistical model for quantification of Panchakośas of large collective 
+entities. Int J Yoga - Philosop Psychol Parapsychol 2018;6:74-93.
+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]
+There are several ways of assessing the well‑being of individuals as well as 
+a collection of individuals. The panchakośa model is an evolved model for 
+analyzing the well‑being of individuals. For large collections of individuals 
+such as nations, several ways are available for estimating the gross national 
+happiness indices. In the present article, quantification of the five sheaths or the 
+panchakośa of large collections of individuals is outlined. Methodology: The 
+methodology uses large sets of data available from reliable sources such as World 
+Development Indicators reports as well as the United Nations Organization data. 
+Different characteristics of nations and its people are used as parameters for 
+quantifying the five kośas of collective entities and these are rescaled so that a 
+numerical estimate is made on a scale of 0–100 for each kośa. Results: The data 
+for the five kośas can be combined to get an effective quantitative measure of 
+happiness or well‑being of a nation. The happiness levels in different kośas for 
+24 countries from different continents are estimated by a simple weighted average 
+or a statistical method using 41 parameters. The results show a fair amount of 
+ruggedness after the number of parameters increases beyond about 5 or 6 for 
+each kośa. Conclusions: This Panchakośa Model of Happiness‑I appears to be a 
+fairly systematic way of analyzing the happiness levels in different kośas and can 
+be used as a basis for a healthy model of development and interactions of large 
+collective entities such as nations.
+Keywords: Collective panchakośas, happiness levels, normalized parameters, 
+quantification
+Abstract
+[Downloaded free from http://www.ijoyppp.org on Monday, January 25, 2021, IP: 136.232.192.146]
+Tembe, et al.: Panchakosha model of happiness of nations
+75
+International Journal of Yoga ‑ Philosophy, Psychology and Parapsychology  ¦  Volume 6  ¦  Issue 2  ¦  July‑December 2018
+aged 0–15  years, these kośas are generally not fully 
+developed. To develop and characterize the kośas of the 
+families, one needs to collect the data of several family 
+members and this is an arduous task. Similar argument 
+will apply to a cooperative society or a village or a city. 
+While modern family counseling services contribute 
+toward solving problems in families, the elders in joint 
+families in the past and the village elders in ancient 
+and even recent times continue to provide valuable 
+suggestions to maintain healthy manomaya kośas of 
+families and villages.
+If we turn our attention to a group of persons in very 
+large numbers such as the states of a country or countries 
+themselves, we can use the methods of statistics to come 
+up with a suitable definition of the five kośas of countries. 
+A recent mathematical definition of happiness[6,7] and the 
+metric developed for gross national happiness (GNH)[8,9] 
+can provide suitable guidelines to provide definitions 
+for different kośas of collective entities such as nations. 
+Possible steps toward this approach are outlined below. 
+Such a definition for families too will certainly be useful.
+• Annamaya kośa: An estimate for this kośa may be 
+derived using the following data: Available land and 
+water resources, agricultural area, gross domestic 
+product (GDP), gross national product (GNP), road, 
+rail, water, and air connectivity.[10‑19] The proposed 
+method will be normalized to the population.
+• Prānamaya kośa: Life expectancy, employment 
+levels, deaths caused by cancer and AIDS, the 
+number of doctors available, internet and mobile 
+connectivity, etc.[20‑36]
+• Manomaya kośa: Mental health status of the country, 
+crime and insurgency levels, corruption levels, strikes 
+and agitations, suicide levels, divorce levels, smoking 
+and drug related problems, number of professional 
+counseling centers, psychiatric centers, number of 
+jailed persons.[37‑43]
+• Vijyānamaya kośa: Literacy, educational institutions 
+at 
+various 
+levels, 
+index 
+of 
+entrepreneurship, 
+effectiveness of legal systems, research institutions, 
+research publications, conferences and workshops, 
+effectiveness in legislations.[44‑49]
+• Ānandamaya kośa: GNH, levels of charity, and social 
+work.[50‑52] This is a difficult kośa to measure as 
+Bhrigu relates this kośa to a state of bliss. The closest 
+measures are taken from different approaches of 
+happiness in societies including the social measures 
+and the Cantril ladder.[53‑66] These include the ideas 
+of happiness in education,[61] the Sach’s happiness 
+report,[62] quality‑of‑life research,[64] quality‑of‑life 
+scale reliability,[65] and sensitivity of subjective 
+well‑being measures.[66]
+After developing an index system, it will be applied to the 
+following nations: India, Pakistan, China, Japan, Bhutan, 
+Singapore  (Asia), United  Kingdom  (UK), Sweden, the 
+Netherlands, Romania, Greece, Russia  (Europe), the 
+United States of America  (USA), Brazil, Mexico, Chile, 
+Nicaragua  (America), Egypt, Nigeria, Ethiopia, Yemen, 
+Niger, Namibia  (Africa) and Australia. It would be 
+interesting to compare the countries which have similar 
+economies. It will also be interesting to explore the role if 
+any of the basic differences of religion, spirituality, and the 
+political economy of these countries has an impact on the 
+differences in the happiness parameters of these nations.
+Most planning models of growth of nations do not 
+include spiritual levels  (levels of happiness) in their 
+conceptualization or implementation. This leads to 
+societies or nations where happiness levels do not increase 
+in spite of exceptional technological levels. A study such 
+as the proposed one could help in a complementary or a 
+supportive manner toward the well‑being of a nation in a 
+manner similar to how an Integrated Approach to Yoga 
+Therapy  (IAYT)[2‑5] is having an impact on the health 
+of individuals. The methodology of the present work is 
+given in the next section. Data and results are given in the 
+results and discussion section, followed by conclusions.
+Methodology
+The subject of happiness is subtle, difficult, as well 
+as elusive. The concept of happiness has evolved 
+over time, right from the Vedic period as well as 
+from the time of Aristotle. The notion of happiness 
+as activity, virtue, satisfaction of desire, pleasure 
+(Eudaemonism vs. Hedonism), fortune, stoic nature, 
+duty, transcendence, utilitarianism, self‑realization, and 
+supreme good has evolved over time, and a perfect 
+definition has not been arrived at.[55] The conventional 
+economic approach took monetary and physical 
+income as the most important indicator for well‑being. 
+This has serious limitations. The capability approach 
+to well‑being has been developed by Amartya Sen 
+and Martha Nussbaum, and the happiness approach 
+to well‑being has been championed by Richard 
+Easterlin’s aim to overcome the conventional economic 
+approaches.[56] Even the methods of education as well 
+as therapy, whose primary aim is to increase the overall 
+happiness in a society, do get questioned from time to 
+time.[57] Even more challenging is the task to define 
+a quantitative scale for happiness. This too has been 
+discussed for a long time in literature. A  lot of effort 
+across all the continents has been invested in arriving 
+at a scale. We shall mention only representative efforts 
+in this area. These will also help us in setting up a 
+statistical model.
+[Downloaded free from http://www.ijoyppp.org on Monday, January 25, 2021, IP: 136.232.192.146]
+Tembe, et al.: Panchakosha model of happiness of nations
+76
+International Journal of Yoga ‑ Philosophy, Psychology and Parapsychology  ¦  Volume 6  ¦  Issue 2  ¦  July‑December 2018
+There are significant differences between the happiness 
+in ānandamaya kośa and the happiness that is 
+understood in common practice. The ānandamaya kośa 
+mentioned in the Taittiriya Upaniśad goes well beyond 
+the manomaya and vijyānamaya kośas; it is thought to 
+be a dominantly subjective experience, approaching 
+bliss, intuitive harmony, and peace[58] and is not easy to 
+measure. However, as a first approximation, we shall 
+adopt a measure obtained from the common measures of 
+happiness and extend it to our statistical model.
+Among several models that are available in literature, we 
+choose two statistical models. One is an experimental 
+definition of happiness which has been recently verified 
+by functional nuclear magnetic resonance measurements[6] 
+and which is based on the subjective response to rewards. 
+We refer this model as a Computational Model‑I (CM‑I). 
+The other is the GNH Index for happiness defined in the 
+studies in Bhutan.[8] We refer this second model as Survey 
+Model‑I (SM‑I). In the work presented here, we construct 
+a model based on the panchakośa analysis. We refer this 
+model as a panchakośa Model of Happiness‑I (PKMH‑I).
+CM‑I analyzes happiness as a subjective response to 
+rewards, such as money that might elicit affective and 
+motivational responses.[6] The behavioral findings were 
+based on two laboratory‑based behavioral experiments as 
+well as a large‑scale smartphone‑based experiment. The 
+relationship between reward‑related task events, neural 
+responses to those events, and subjective well‑being 
+was also probed by functional magnetic resonance 
+imaging  (fMRI). fMRI is used to trace task‑dependent 
+neural activity in the ventral striatum of the brain, a 
+major projection site for dopamine neurons, correlated 
+with subsequent reports of subjective well‑being.
+By repeatedly asking participants to report on their 
+subjective emotional state, their feelings can be related 
+to antecedent life events including rewards. The subjects 
+were asked to perform a probabilistic reward task, in 
+which they are asked to choose between certain and 
+risky monetary options. After every few trials, they were 
+asked the question, “How happy are you right now?” 
+Such an approach is expected to elicit rapid changes in 
+affective state. Similarly, experience sampling adapted 
+to laboratory and fMRI settings was also used for 
+corroboration of data obtained from questionnaires in 
+a survey using mobile response data. The experiential 
+sampling questions make no reference to past events and 
+concern the present overall subjective emotional states.
+From brain responses to rewards, it is known 
+that midbrain dopamine neurons represent reward 
+prediction error  (RPE) signals in animals and humans. 
+Neuroimaging studies report the correlations of RPEs 
+in the ventral striatum. This is an area of the brain 
+that is a target for dopamine projections, in tasks from 
+reinforcement learning to gambling. Many studies have 
+also related subjective feelings about discrete events 
+to neural activity. The behavioral data on a sample 
+of 21–26 persons were fitted using a CM inspired 
+by models of dopamine function. It was shown that 
+momentary subjective well‑being is explained not by 
+task earnings but by the cumulative influence of recent 
+reward expectations and prediction errors, resulting 
+from those expectations. Temporal difference errors that 
+dopamine neurons are thought to represent are closely 
+related to these quantities. In the first case, the happiness 
+at time t is fitted by the following model.[6]
+Happiness (t) = w0 + w1 Σj γt‑j CRj + w2 Σj γt‑j EVj + w3 
+Σj γt‑j RPEj
+where CRj refers to certain rewards, EVj refers to expected 
+values or outcomes and RPEj refers to reward prediction 
+error  (differences between experienced and predicted 
+rewards). The summation is for j going from 1 to t. All the 
+coefficients w0, w1, w2, and w3 turned out to be positive. 
+All the gammas  (γt‑j) are forgetting factors which are all 
+positive and these decay exponentially as one goes back 
+further to earlier events. The weights for EVs were smaller 
+than the weights for RPEs. One advantage of CM‑I is that 
+it is based on experimentally measurable data and also 
+data based on surveys (a smartphone‑based platform: The 
+Great Brain Experiment, www.thegreatbrainexperiment.
+com; for iOS  [Apple] and Android  [Google] systems). 
+The sample consisted of 18,420 anonymous unpaid 
+participants who made over  200,000 happiness ratings.  
+However, experiments which require highly sophisticated 
+equipment  (such as fMRI) and also huge surveys are 
+prohibitively expensive and cannot be readily extended 
+to other samples.
+In the GNH model used in Bhutan which is referred 
+here as SM‑I, a comprehensive study was undertaken 
+using 124 variables grouped into nine equally weighted 
+domains to define an index of happiness.[8]
+A quantitative GNH value has been proposed to be an 
+index function of the total average per capita of the 
+following nine measures:
+1. Economic wellness or living standard indicated via 
+direct survey and statistical measurement of economic 
+metrics such as consumer debt, average income to 
+consumer price index ratio, and income distribution
+2. Environmental wellness or ecological resilience 
+indicated 
+via 
+direct 
+survey 
+and 
+statistical 
+measurement of environmental metrics such as 
+pollution, noise, and traffic
+3. Physical wellness or health indicated via statistical 
+measurement of physical health metrics such as 
+severe illnesses
+[Downloaded free from http://www.ijoyppp.org on Monday, January 25, 2021, IP: 136.232.192.146]
+Tembe, et al.: Panchakosha model of happiness of nations
+77
+International Journal of Yoga ‑ Philosophy, Psychology and Parapsychology  ¦  Volume 6  ¦  Issue 2  ¦  July‑December 2018
+4. Mental 
+wellness 
+or 
+psychological 
+well‑being 
+indicated 
+via 
+direct 
+survey 
+and 
+statistical 
+measurement of mental health metrics such as 
+usage of antidepressants and rise or decline of 
+psychotherapy patients
+5. Workplace wellness  (time use) indicated via direct 
+survey and statistical measurement of labor metrics 
+such as jobless claims, job change, workplace 
+complaints, and lawsuits
+6. Social wellness or community vitality indicated via 
+direct survey and statistical measurement of social 
+metrics such as discrimination, safety, divorce rates, 
+complaints of domestic conflicts and family lawsuits, 
+public lawsuits, crime rates
+7. Political wellness or good governance indicated via 
+direct survey and statistical measurement of political 
+metrics such as the quality of local democracy, 
+individual freedom, and foreign conflicts
+8. Education 
+indicated 
+via 
+literacy, 
+schooling, 
+knowledge
+9. Cultural diversity indicated via customs in societies, 
+values, sports, drama, and films.
+The above nine domains were built from 124 variables 
+which constitute the basic building blocks of GNH. 
+These variables could be packed into 33 clusters, but 
+the important feature is that subjective variables had 
+smaller weights. A  threshold or sufficiency level was 
+attached to each variable. The population was finally 
+categorized into deeply happy  (77% level sufficiency), 
+extensively 
+happy 
+(66%–76% 
+level 
+sufficiency), 
+narrowly happy  (50%–65% level sufficiency), and 
+unhappy  (<50% level of sufficiency). Furthermore, it is 
+to be noted that one needs to score equally high points 
+in all the domains to be happy. Using a complementary 
+matrix of sufficiency indices and the normalized weights 
+for each of the factors, a GNH index has been defined. 
+The concept of multidimensional poverty of  Alkire and 
+Foster[60] has also been used in defining the GNH.
+The weights of 33 variables, i.e.  weights of different 
+variables in nine domains in the GNH model of Bhutan, 
+are depicted in Table 1 .
+The method of estimating the GNH placed the data 
+collected from people from different districts and age 
+groups into a matrix form. The main data matrix M is 
+an n  ×  d matrix with rows, i ranging from 1 to n. The 
+rows i refer to individuals and columns j ranging from 1 
+to d refer to different dimensions of achievements. Rows 
+represent individuals and columns represent achievements 
+in dimensions. To obtain a GNH, one needs a set of 
+criteria for the range of sufficiency (adequateness) of the 
+parameter to be placed into different levels of happiness. 
+If the element Mij is less than some critical value Zj for 
+a given column  (predefined), then a depravation matrix 
+G is defined, whose element Gij is 1 if Mij < Zj. Nonzero 
+values of depravation matrix indicate depravation. For 
+each of the d dimensions, weighting factors are applied 
+such that the sum of weights Wj  =  1. By summing the 
+weighted columns, the depravation for the dimension is 
+obtained. Let us call the depravation row vector as D. 
+If this is subtracted from the unit row vector U, U − D 
+gives the GNH row vector, which can be normalized and 
+summed to get the GNH index. Details of the indices 
+are given in the Bhutan report.[8]
+As we mentioned, ours is a modeling study wherein the 
+data are collected from different sources, particularly 
+the sites of the United  Nations Organization and the 
+World Development Indices/Indicators of the World 
+Bank. From these data, statistical methods are used for 
+Table 1: Weights of different variables in nine domains 
+in the gross national happiness model of Bhutan
+Domain
+Indicators
+Weight (%)
+Psychological 
+well‑being
+Life satisfaction
+33
+Positive emotions
+17
+Negative emotions
+17
+Spirituality
+33
+Health
+Self‑reported health
+10
+Healthy days
+30
+Disability
+30
+Mental health
+30
+Time use
+Work
+50
+Sleep
+50
+Education
+Literacy
+30
+Schooling
+30
+Knowledge
+20
+Value
+20
+Cultural 
+diversity and 
+resilience
+Zorig chusum skills (skills in arts and 
+crafts)
+30
+Cultural participation
+30
+Speak native language
+20
+Driglam Namzha (the way of harmony)
+20
+Good 
+governance
+Political participation
+40
+Services
+40
+Governance participation
+10
+Fundamental rights
+10
+Community 
+vitality
+Donation (time and money)
+30
+Safety
+30
+Community relationship
+20
+Family
+20
+Ecological 
+diversity and 
+resilience
+Wildlife damage
+40
+Urban issues
+40
+Responsibility toward environment
+10
+Ecological issues
+10
+Living 
+standard
+Per capita income
+34
+Assets
+33
+Housing
+33
+[Downloaded free from http://www.ijoyppp.org on Monday, January 25, 2021, IP: 136.232.192.146]
+Tembe, et al.: Panchakosha model of happiness of nations
+78
+International Journal of Yoga ‑ Philosophy, Psychology and Parapsychology  ¦  Volume 6  ¦  Issue 2  ¦  July‑December 2018
+converting them into suitable normalized parameters 
+in the range of 0–100 for each kośa. The subjects 
+used herein include all the members in the country for 
+analysis purposes. A  plan of computing the happiness 
+of the PKMH‑I is outlined below. Since the collected 
+data are based on statistical reports, the chances of 
+subjectivity are considerably reduced and equal weights 
+may be assigned to each of the parameters of the present 
+study. If we choose to define a scale of 0–100, the 
+PKMH‑I may be defined as:
+PKMH‑I for a kośa = Σ wi yi,
+where 
+wi 
+is 
+the 
+weight 
+of 
+the 
+parameter 
+(in fraction or percentage) and yi is the normalized 
+statistical measure of the parameter (in the range of 0–1 
+or from 0% to 100%). We will compute an overall score, 
+but individual kośa scores will be more informative.
+Since our model is a statistical method, the required data 
+are collected from a wide range of sites and from recent 
+reported literature. While there could be some uncertainties 
+and minor variations in the data from different sources, 
+these data will certainly help us to come up with a 
+quantitative model which can be improved by additional 
+checks on the self‑consistency of the data. The application 
+of the method across more than one calendar or financial 
+year and extending to other countries can be explored later.
+In our proposed model PKMH‑I, we are using N (presently 
+41) variables that are presumed to be independent. 
+Although there are a few residual dependences among 
+these variables, we test for the impact of these by 
+randomly removing, say 10% of the variables and noting 
+their impact on the final results. The robustness of a 
+statistical model is known to increase when the number 
+of variables contributing to the model increases. The N 
+variables are redistributed into different kośas by taking 
+n1 parameters or variables for the annamaya kośa, n2 
+for the prānamaya kośa, n3 variables for the manomaya 
+kośa, n4 for the vijyānamaya kośa, and n5 variables for the 
+ānandamaya kośa. Of course, N = n1 + n2 + n3 + n4 + n5.
+The rationale is based on extending the ideas relevant 
+to the kośa of a given individual to large collections 
+of individuals. Prānamaya kośa for an individual 
+refers to the human body, the intake of food, clothing, 
+and shelter.[54] For a large collection, this kośa will 
+consider the total food available for the nation; the total 
+Table 2: Annamaya kośa parameters
+Country
+A1
+A2
+A3
+A4
+A5
+A6
+A7
+A8
+A9
+A10
+A11
+A12
+China
+9,572,900.0
+54.8
+1.4
+49.0
+3603.0
+9.4
+4660.0
+112.0
+645.0
+2.6
+3.8
+1,368,999,940.0
+India
+3,166,414.0
+60.3
+9.6
+91.0
+1150.0
+48.0
+4865.0
+65.0
+1083.0
+78.0
+0.9
+1,267,000,060.0
+Pakistan
+881,912.0
+35.1
+2.9
+91.0
+833.0
+45.0
+262.0
+7.0
+494.0
+9.0
+0.6
+181,000,000.0
+Bhutan
+38,394.0
+13.6
+0.2
+53.0
+1847.0
+33.6
+10.0
+0.0
+2220.0
+0.0
+1.8
+575,000.00
+Singapore
+718.0
+7.2
+3.0
+1.0
+36,525.0
+4.4
+3.4
+0.2
+2300.0
+0.0
+2.7
+5,540,000.00
+Japan
+337,930.0
+12.5
+3.5
+0.5
+38,890.0
+8.3
+1215.0
+27.0
+1650.0
+0.0
+13.7
+128,000,000.0
+UK
+242,900.0
+71.0
+8.9
+0.1
+39,883.0
+3.9
+394.0
+17.0
+1220.0
+0.1
+3.0
+64,000,000.0
+Sweden
+450,295.0
+7.5
+8.9
+0.1
+47,097.0
+1.0
+580.0
+9.9
+624.0
+0.1
+2.7
+9,753,000.00
+Netherlands
+41,850.0
+55.6
+18.4
+0.1
+42,984.0
+1.8
+139.0
+3.0
+778.0
+0.0
+4.7
+16,909,000.0
+Romania
+238,391.0
+59.0
+3.6
+18.3
+5685.0
+12.8
+84.1
+13.6
+637.0
+0.0
+6.3
+19,942,000.0
+Greece
+131,990.0
+63.4
+1.0
+15.0
+18,358.0
+10.0
+116.0
+2.5
+652.0
+1.0
+4.9
+10,816,000.0
+Russia
+17,098,242.0
+13.1
+4.4
+12.7
+6599.0
+8.0
+1396.0
+86.0
+460.0
+5.0
+9.7
+143,000,000.0
+USA
+9,526,468.0
+44.7
+4.6
+0.1
+46,393.0
+2.1
+6587.0
+225.0
+715.0
+6.3
+3.0
+318,000,000.0
+Brazil
+8,515,767.0
+33.0
+9.5
+21.0
+5740.0
+7.1
+1751.0
+27.0
+1761.0
+10.0
+2.3
+201,000,000.0
+Mexico
+1,964,375.0
+54.9
+1.0
+21.3
+8199.0
+13.6
+379.0
+26.7
+758.0
+16.5
+1.7
+127,000,000.0
+Chile
+756,102.0
+21.2
+1.6
+9.9
+9540.0
+1.8
+77.7
+5.3
+1522.0
+0.3
+2.0
+17,819,000.0
+Nicaragua
+130,373.0
+41.8
+41.8
+52.2
+900.0
+23.0
+23.9
+0.0
+2280.0
+1.6
+1.1
+6,071,000.00
+Australia
+7,692,024.0
+52.8
+0.8
+0.1
+36,487.0
+1.8
+823.0
+38.0
+534.0
+0.1
+3.9
+22,700,000.0
+Egypt
+1,003,450.0
+3.7
+0.6
+71.6
+1428.0
+30.7
+137.0
+5.1
+51.0
+15.0
+1.7
+87,000,000.0
+Nigeria
+923,678.0
+79.1
+1.4
+96.0
+1019.0
+36.4
+193.0
+3.5
+1160.0
+24.2
+0.5
+177,000,000.0
+Ethiopia
+1,104,300.0
+35.7
+0.7
+95.4
+900.0
+40.4
+49.5
+0.5
+848.0
+23.0
+6.3
+100,000,000.0
+Yemen
+527,968.0
+44.7
+0.1
+82.0
+800.0
+46.6
+72.4
+0.0
+167.0
+6.0
+0.7
+26,000,000.0
+Niger
+1,127,000.0
+34.7
+0.0
+96.0
+849.0
+43.0
+19.0
+0.1
+151.0
+8.0
+0.3
+17,138,000.0
+Namibia
+825,615.0
+44.1
+0.1
+89.0
+4442.0
+23.1
+44.1
+2.4
+285.0
+0.3
+2.7
+2,283,000.00
+The vertical columns indicate the actual values of different parameters for different countries, such as total land + water area in km2 (A1), 
+percentage of agricultural area (A2), percentage of water (A3), percentage of people below poverty lines, measured as less than 4 US 
+dollars per day (A4), percentage of malnourished people (A5), GNP in million US dollars (A6), road lengths in 1000 km (A7), rail length in 
+1000 km (A8), average precipitation rate in mm per year (A9), the populations of homeless people (A10), the number of hospital beds per 
+1000 population (A11) and the total populations of these countries (A12). GNP: Gross national product
+[Downloaded free from http://www.ijoyppp.org on Monday, January 25, 2021, IP: 136.232.192.146]
+Tembe, et al.: Panchakosha model of happiness of nations
+79
+International Journal of Yoga ‑ Philosophy, Psychology and Parapsychology  ¦  Volume 6  ¦  Issue 2  ¦  July‑December 2018
+While most indices do serve the purpose of quantifying 
+the happiness levels of populations, there are several 
+ambiguities if the domains are not made sufficiently 
+distinct. For example, in Table  1  (GNH model), mental 
+health is not included in psychological well‑being. This 
+would correspond to the manomaya kośa. Similarly, 
+harmony and spirituality are counted in distinct domains, 
+while they should be classified under ānandamaya 
+kośa. The state of bliss cannot be obtained unless there 
+are peace, harmony, and contentment. The panchakośa 
+model (PKMH‑I) provides a less ambiguous and a more 
+unique way of classifying the parameters of the above 
+domains and this model is quantified in the present work.
+As we mentioned, this is a modeling study wherein the 
+data are collected from different sources, particularly the 
+sites of the United  Nations Organization and the World 
+Development Indices/Indicators of the World Bank. From 
+the data, statistical methods are used for converting 
+the data into suitable parameters in the range of 0–100 
+for each kośa. The subjects used herein include all the 
+members in the country for analysis purposes. Since the 
+collected data are based on statistical reports, the chances 
+of subjectivity are considerably reduced and equal 
+space, water resources, GDP, etc. are also considered. 
+For the prānamaya kośa of a nation, life expectancy, 
+employment, etc. are considered. There are negative 
+characteristics such as HIV and cancer deaths too. The 
+collective manomaya kośa deals with the mental and 
+emotional health of a nation. Crime and corruption affect 
+mental health negatively. Thus, the least corrupt country 
+will have a better mental health for this particular 
+parameter. One feature of these models is that we 
+cannot easily say that the specification of parameters 
+is complete for any kośa. However, the advantage is 
+that if more parameters are identified, they can be very 
+easily included in the model. Another feature is that 
+all parameters are not completely independent. Large 
+amount of corruption will lead to crime, and thus, these 
+two, namely, corruption and crime, are not independent. 
+However, they are both very good indicators of the 
+mental health of a nation. In fact, larger the set of 
+parameters one uses for specification of a kośa, the effect 
+of interdependencies of the parameters gets diminished. 
+For the vijyānamaya kośa, the intellectual growth of a 
+nation through its academic and research institutions can 
+provide a very good measure.
+Table 3: Annamaya kośa normalized parameters (relative scale factors)
+Country
+A1N
+A2N
+A3N
+A4N
+A5N
+A6N
+A7N
+A8N
+A9N
+A10N
+A11N
+China
+23.3
+54.8
+14.1
+51.0
+14.4
+90.6
+48.7
+11.7
+64.5
+99.8
+38.0
+India
+8.3
+60.3
+95.5
+9.0
+4.6
+52.0
+100.0
+20.5
+100.0
+93.8
+9.0
+Pakistan
+16.3
+35.1
+28.6
+9.0
+3.3
+55.0
+29.7
+7.9
+49.4
+95.0
+6.0
+Bhutan
+100.0
+13.6
+2.0
+47.0
+7.4
+66.4
+26.0
+0.0
+100.0
+97.4
+18.0
+Singapore
+0.4
+7.2
+30.0
+99.0
+100.0
+95.6
+100.0
+100.0
+100.0
+99.6
+27.0
+Japan
+8.8
+12.5
+35.5
+99.5
+100.0
+91.7
+100.0
+79.9
+100.0
+100.0
+100.0
+UK
+12.7
+71.0
+89.0
+99.9
+100.0
+96.1
+100.0
+70.0
+100.0
+99.8
+30.0
+Sweden
+100.0
+7.5
+88.7
+99.9
+100.0
+99.0
+100.0
+22.0
+62.4
+99.1
+27.0
+Netherlands
+8.3
+55.6
+100.0
+99.9
+100.0
+98.2
+100.0
+71.9
+77.8
+99.8
+47.0
+Romania
+39.9
+59.0
+35.7
+81.7
+22.7
+87.2
+35.3
+57.0
+63.7
+99.9
+63.0
+Greece
+40.7
+63.4
+10.0
+85.0
+73.4
+90.0
+87.9
+18.9
+65.2
+90.8
+49.0
+Russia
+100.0
+13.1
+44.1
+87.3
+26.4
+92.0
+8.2
+5.0
+46.0
+96.5
+97.0
+USA
+100.0
+44.7
+46.0
+99.9
+100.0
+97.9
+69.1
+23.6
+71.5
+98.0
+30.0
+Brazil
+100.0
+33.0
+95.0
+79.0
+23.0
+92.9
+20.6
+3.2
+100.0
+95.0
+23.0
+Mexico
+51.6
+54.9
+10.4
+78.7
+32.8
+86.4
+19.3
+13.6
+75.8
+87.0
+17.0
+Chile
+100.0
+21.2
+16.3
+90.1
+38.2
+98.2
+10.3
+7.0
+100.0
+98.0
+20.0
+Nicaragua
+71.7
+41.8
+100.0
+47.8
+3.6
+77.0
+18.3
+0.0
+100.0
+73.6
+11.0
+Australia
+100.0
+52.8
+7.6
+99.9
+100.0
+98.2
+10.7
+4.9
+53.4
+99.6
+39.0
+Egypt
+38.5
+3.7
+6.0
+28.4
+5.7
+69.3
+13.7
+5.1
+5.1
+82.8
+17.0
+Nigeria
+17.4
+79.1
+14.1
+4.0
+4.1
+63.6
+20.9
+3.8
+100.0
+86.3
+5.3
+Ethiopia
+36.9
+35.7
+7.0
+4.6
+3.6
+59.6
+4.5
+0.5
+84.8
+77.0
+63.0
+Yemen
+67.8
+44.7
+1.0
+18.0
+3.2
+53.4
+13.7
+0.0
+16.7
+76.9
+7.0
+Niger
+100.0
+34.7
+0.2
+4.0
+3.4
+57.0
+1.7
+0.1
+15.1
+53.3
+3.1
+Namibia
+100.0
+44.1
+1.2
+11.0
+17.8
+76.9
+5.3
+2.9
+28.5
+89.0
+27.0
+The vertical columns indicate normalized values of different variables (on a scale of 0‑100) for different countries, such as total land + 
+water area (A1N), percentage of agricultural area (A2N), percentage of water (A3N), percentage of people below poverty lines, measured 
+as <4 dollars per day (A4N), percentage of malnourished people (A5N), GNP in US dollars (A6N), road lengths in 1000 km (A7N), rail 
+length in 1000 km (A8N), average precipitation rate (A9N), the populations of homeless people (A10N) and the number of hospital beds 
+per 1000 members of population (A11N). GNP: Gross national product
+[Downloaded free from http://www.ijoyppp.org on Monday, January 25, 2021, IP: 136.232.192.146]
+Tembe, et al.: Panchakosha model of happiness of nations
+80
+International Journal of Yoga ‑ Philosophy, Psychology and Parapsychology  ¦  Volume 6  ¦  Issue 2  ¦  July‑December 2018
+weights may be assigned to each of the parameter of the 
+present study. Other models for unequal weights will also 
+be alluded to. The next section describes the quantitative 
+characterization of the kośas followed by conclusions 
+and perspectives.
+Results
+We present the results for each kośa first and then 
+combine them for a total score. The data extraction has 
+been primarily done using the internet and published 
+articles. The major sites used are the WHO sites and the 
+sites that use published literature from reputed journals. 
+Later, a comparison with mainly published literature data 
+could be made.
+We have collected the data for 24 countries from across 
+the continents. These countries are China, India, Pakistan, 
+Bhutan, Singapore, and Japan (from the Asian region); 
+UK, Sweden, the Netherlands, Romania, Greece, and 
+Russia (from the European region); USA, Brazil, Mexico, 
+Chile, Nicaragua, and Australia  (from the American and 
+Australian continents); and Egypt, Nigeria, Ethiopia, 
+Yemen, Niger, and Namibia (from the African continent). 
+This will enable us to compare countries across the 
+continents. We begin with the annamaya kośa parameters.
+Annamaya kośa parameters
+Annamaya kośa has to deal with all the physical 
+resources available to the nation and how well they get 
+distributed in the population. Land and water resources 
+have to be scaled to the population. As outlined in the 
+Methods section, the total score for each kośa has to 
+be scaled or normalized between 0 and 100. There are 
+11 parameters chosen for the annamaya kośa and each 
+of these parameters has been given 9.09 weightage for 
+estimating the total annamaya kosha happiness parameter. 
+To calculate the relative values of each parameter, the 
+parameter is individually scaled between 0 and 100, and 
+then, the values for all parameters are averaged. The 
+actual values of these parameters are given in Table 2. 
+The first parameter is the land and water area available 
+for each country  (A1). The parameters are labeled 
+from A1 to A11 for annamaya kosha, B1 to B9 for 
+prānamaya kosha, C1 to C9 for manomaya kosha, and 
+so on. The areas in km2 per person in Australia, Russia, 
+Bhutan, Brazil, and USA are 0.366, 0.122, 0.054, 0.043, 
+and 0.03 km2, respectively, and for all other countries, 
+the values are much smaller. We assign all values >0.03 
+km2 per person as 100% and scale the remaining areas 
+by the ratios of actual area per person divided by 0.03. 
+In this way, countries such as India and Japan get at 
+Table 4: Prānamaya kośa parameters
+Country
+B1
+B2
+B3
+B4
+B5
+B6
+B7
+B8
+B9
+China
+75.1
+4.0
+75.2
+145.0
+2.3
+1.5
+482.0
+46.0
+93.2
+India
+65.0
+6.8
+67.8
+75.0
+17.0
+0.6
+349.0
+24.0
+78.0
+Pakistan
+65.0
+7.4
+67.5
+95.0
+4.0
+0.8
+143.0
+11.0
+77.0
+Bhutan
+70.0
+2.5
+69.0
+95.0
+3.5
+0.1
+2.0
+30.0
+60.0
+Singapore
+68.0
+2.0
+83.0
+100.0
+0.5
+1.9
+5.0
+73.0
+148.0
+Japan
+71.7
+4.2
+84.0
+115.0
+3.3
+2.1
+175.0
+86.0
+95.0
+UK
+73.4
+5.5
+80.4
+137.0
+3.3
+2.8
+506.0
+90.0
+130.0
+Sweden
+74.4
+7.2
+82.0
+112.0
+0.3
+3.3
+249.0
+94.8
+122.9
+Netherlands
+74.3
+6.8
+81.1
+157.6
+1.8
+3.2
+27.0
+94.0
+121.0
+Romania
+58.5
+6.8
+74.7
+149.0
+1.2
+2.4
+54.0
+49.8
+123.4
+Greece
+49.3
+25.2
+80.3
+123.7
+10.0
+4.4
+81.0
+59.9
+111.0
+Russia
+68.8
+6.2
+70.2
+130.0
+29.0
+4.3
+1216.0
+61.4
+156.0
+USA
+67.4
+7.2
+79.6
+124.0
+3.3
+2.4
+15095.0
+84.0
+103.0
+Brazil
+66.7
+8.0
+73.3
+115.0
+7.5
+1.8
+4000.0
+51.0
+141.0
+Mexico
+61.0
+4.9
+75.4
+71.7
+13.6
+2.0
+1819.0
+43.0
+90.2
+Chile
+62.3
+6.5
+78.4
+119.7
+1.8
+1.0
+366.0
+66.5
+122.9
+Nicaragua
+60.0
+5.9
+72.7
+91.4
+3.0
+0.9
+143.0
+15.5
+115.0
+Australia
+72.0
+4.5
+82.0
+120.0
+4.4
+3.8
+464.0
+83.0
+133.0
+Egypt
+46.0
+8.1
+73.4
+116.8
+30.7
+2.8
+86.0
+49.6
+112.8
+Nigeria
+60.0
+4.9
+52.6
+70.0
+170.0
+0.4
+60.0
+38.0
+94.5
+Ethiopia
+45.0
+17.5
+60.7
+80.8
+40.4
+0.4
+61.0
+1.9
+21.8
+Yemen
+46.0
+35.0
+51.9
+67.9
+466.0
+0.2
+26.0
+20.0
+68.0
+Niger
+45.0
+11.7
+54.7
+53.1
+43.0
+0.0
+27.0
+1.7
+44.0
+Namibia
+45.0
+27.4
+51.8
+58.1
+23.1
+0.4
+129.0
+13.9
+114.0
+The columns represent the employment rates (B1), unemployment rates (B2), life expectancy (B3), the number of cancer deaths per 
+100,000 of population (B4), the number of HIV deaths per lakh of population (B5), the number of doctors per 1000 of population (B6), the 
+number of airports (B7), the percentage of internet users (B8), the number of mobile phones per 100 members of population (B9)
+[Downloaded free from http://www.ijoyppp.org on Monday, January 25, 2021, IP: 136.232.192.146]
+Tembe, et al.: Panchakosha model of happiness of nations
+81
+International Journal of Yoga ‑ Philosophy, Psychology and Parapsychology  ¦  Volume 6  ¦  Issue 2  ¦  July‑December 2018
+least 7% relative value. Dividing all areas by the 
+highest value of 0.366 give a value of  <10% to the 
+USA and hardly any value to countries such as India 
+and Japan. This discussion illustrates that there is some 
+degree of arbitrariness in these computations. However, 
+if the number of parameters is increased, the impact of 
+this arbitrariness is significantly minimized. The next 
+parameter is the agricultural area in each country (A2). 
+Nigeria has the highest value of 79%. For this parameter, 
+we simply use the percentage of agricultural area. Thus, 
+although India and Nigeria have very low scores for 
+the land area available per person, the large agricultural 
+area in these countries helps these countries to gain 
+quite a bit in their scores through the agricultural area 
+percentages. The percentage of water in the countries 
+ranges from 0.1 to 18.4 (A3). This is multiplied by 10 to 
+convert it into a percentage. For all countries where the 
+percentage exceeds 100, a value of 100 is assigned. The 
+purpose for rescaling the larger percentages (over 100) 
+to 100 is to get a good spread in the normalized values. 
+The distributions at the higher ends are often very far 
+from a normal distribution, and this rescaling helps in 
+keeping the overall parameters in a reasonable range 
+between 0 and 100 across all countries. Poverty lines 
+and malnutrition are an indication of severe deficiency 
+in the annamaya kośa  (A4). The indexed measure for 
+poverty line is 100  minus the percentage of persons 
+living at an income of < 4 US Dollars a day. Countries 
+such as Australia, UK, Japan, and Russia get high scores 
+here. However, India, Nigeria, Pakistan, and Bhutan all 
+get small scores. For malnutrition (A5), the scaling used 
+is 100 minus ten times the percentage of malnourished. 
+Countries such as USA, Russia, and China get high 
+scores, while India, Bhutan, Pakistan, and African 
+countries get small scores. The next parameter is GNP 
+measured in million US Dollars  (2005 value). For this 
+parameter, the value of 25,000 million US $ and above 
+is taken as 100 and other GNPs are divided by 25,000 
+million US $ and this fraction is multiplied by 100 to 
+get a percentage. For the malnutrition parameter  (A6), 
+we take 100  minus the percentage of malnourished 
+population. Road lengths  (A7) and rail lengths  (A8) 
+are considered next. These are first divided by the area 
+of the country. To get the normalized values between 
+0 and 100, the ratio is multiplied by 100,000 for road 
+length ratio and 1,000,000 for the rail length ratio. 
+For road lengths, India, Singapore, Japan, Sweden, 
+UK, and the Netherlands score a 100, while for rail 
+lengths, only Singapore and the Netherlands score high. 
+Precipitation rate  (A9) is scored as follows. Countries 
+Table 5: Normalized Prānamaya kośa parameters (relative scale factors)
+Country
+B1N
+B2N
+B3N
+B4N
+B5N
+B6N
+B7N
+B8N
+B9N
+China
+75.1
+96.0
+75.2
+59.7
+97.7
+36.5
+3.4
+46.0
+93.2
+India
+65.0
+93.2
+67.8
+79.2
+83.0
+16.2
+7.3
+24.0
+78.0
+Pakistan
+65.0
+92.6
+67.5
+73.6
+96.0
+20.2
+10.8
+11.0
+77.0
+Bhutan
+70.0
+97.5
+69.0
+73.6
+96.5
+2.5
+3.5
+30.0
+60.0
+Singapore
+68.0
+98.0
+83.0
+72.2
+99.5
+48.0
+100.0
+73.0
+100.0
+Japan
+71.7
+95.8
+84.0
+68.1
+96.7
+53.5
+34.5
+86.0
+95.0
+UK
+73.4
+94.5
+80.4
+61.9
+96.7
+69.2
+100.0
+90.0
+100.0
+Sweden
+74.4
+92.8
+82.0
+68.9
+99.7
+82.5
+36.9
+94.8
+100.0
+Netherlands
+74.3
+93.2
+81.1
+56.2
+98.2
+80.0
+43.0
+94.0
+100.0
+Romania
+58.5
+93.2
+74.7
+58.6
+98.8
+60.0
+15.1
+49.8
+100.0
+Greece
+49.3
+74.8
+80.3
+65.6
+90.0
+100.0
+40.9
+59.9
+100.0
+Russia
+68.8
+93.8
+70.2
+63.9
+71.0
+100.0
+4.7
+61.4
+100.0
+USA
+67.4
+92.8
+79.6
+65.6
+96.7
+60.5
+100.0
+84.0
+100.0
+Brazil
+66.7
+92.0
+73.3
+68.1
+92.5
+44.0
+31.3
+51.0
+100.0
+Mexico
+61.0
+95.1
+75.4
+80.1
+86.4
+50.0
+61.7
+43.0
+90.2
+Chile
+62.3
+93.5
+78.4
+66.8
+98.2
+25.0
+32.3
+66.5
+100.0
+Nicaragua
+60.0
+94.1
+72.7
+74.6
+97.0
+22.5
+73.1
+15.5
+100.0
+Australia
+72.0
+95.5
+82.0
+66.7
+95.6
+96.2
+4.0
+83.0
+100.0
+Egypt
+46.0
+91.9
+73.4
+67.6
+69.3
+70.0
+5.7
+49.6
+100.0
+Nigeria
+60.0
+95.1
+52.6
+80.6
+0.0
+10.0
+4.3
+38.0
+94.5
+Ethiopia
+45.0
+82.5
+60.7
+77.6
+59.6
+10.0
+3.7
+1.9
+21.8
+Yemen
+46.0
+65.0
+51.9
+81.1
+0.0
+5.0
+3.3
+20.0
+68.0
+Niger
+45.0
+88.3
+54.7
+85.2
+57.0
+0.5
+1.6
+1.7
+44.0
+Namibia
+45.0
+72.6
+51.8
+83.9
+76.9
+10.0
+10.4
+13.9
+100.0
+The columns represent rescaled values of employment rates (B1N), unemployment rates (B2N), life expectancy (B3N), the number of cancer 
+deaths per 100,000 of population (B4N), the number of HIV deaths per lakh of population (B5N), the number of doctors per 1000 of population 
+(B6N), the number of airports (B7N), the percentage of internet users (B8N), the number of mobile phones (B9N)
+[Downloaded free from http://www.ijoyppp.org on Monday, January 25, 2021, IP: 136.232.192.146]
+Tembe, et al.: Panchakosha model of happiness of nations
+82
+International Journal of Yoga ‑ Philosophy, Psychology and Parapsychology  ¦  Volume 6  ¦  Issue 2  ¦  July‑December 2018
+Table 6: Manomaya kośa parameters
+Country
+C1
+C2
+C3
+C4
+C5
+C6
+C7
+C8
+C9
+China
+7.8
+40.0
+119.0
+22.0
+−0.4
+42.8
+37.0
+0.5
+1.5
+India
+21.1
+36.0
+33.0
+3.0
+−0.1
+54.3
+16.0
+1.0
+4.8
+Pakistan
+9.3
+28.0
+41.0
+3.0
+−0.5
+23.6
+16.0
+1.0
+4.8
+Bhutan
+17.8
+63.0
+143.0
+5.0
+0.0
+67.8
+13.0
+0.5
+6.0
+Singapore
+20.0
+82.0
+900.0
+15.0
+2.5
+95.2
+30.0
+0.5
+0.5
+Japan
+18.5
+74.0
+149.0
+36.0
+0.0
+89.4
+26.0
+0.5
+0.4
+UK
+6.2
+76.0
+148.0
+47.0
+2.2
+94.2
+32.0
+2.1
+1.1
+Sweden
+12.3
+89.0
+60.0
+47.0
+5.5
+97.6
+24.0
+2.5
+1.0
+Netherlands
+8.2
+83.0
+75.0
+43.0
+2.0
+97.1
+39.0
+0.5
+1.0
+Romania
+10.5
+43.0
+144.0
+28.0
+−0.2
+63.5
+35.0
+0.8
+2.0
+Greece
+3.8
+40.0
+111.0
+25.0
+2.3
+67.3
+32.0
+2.0
+1.5
+Russia
+19.5
+28.0
+563.0
+51.0
+0.3
+26.4
+28.0
+2.0
+16.2
+USA
+12.1
+73.0
+698.0
+53.0
+4.3
+89.9
+38.0
+1.5
+6.5
+Brazil
+5.8
+42.0
+301.0
+21.0
+−0.1
+55.3
+19.0
+1.0
+28.5
+Mexico
+4.2
+34.0
+212.0
+15.0
+−1.6
+38.0
+11.0
+1.0
+27.0
+Chile
+12.2
+71.0
+242.0
+3.0
+0.3
+88.0
+17.0
+0.6
+4.0
+Nicaragua
+4.7
+28.0
+160.0
+18.0
+−3.1
+28.8
+10.0
+1.0
+13.5
+Australia
+10.6
+81.0
+151.0
+43.0
+6.2
+96.1
+24.0
+0.5
+1.3
+Egypt
+1.7
+32.0
+76.0
+17.0
+−0.2
+31.3
+7.0
+3.0
+3.0
+Nigeria
+6.5
+25.0
+32.0
+10.0
+−0.1
+11.5
+15.0
+2.0
+14.9
+Ethiopia
+11.5
+33.0
+111.0
+10.0
+−0.2
+40.9
+5.0
+3.0
+13.0
+Yemen
+3.7
+18.0
+53.0
+10.0
+2.6
+8.2
+5.0
+2.5
+3.0
+Niger
+3.5
+34.0
+40.0
+10.0
+−0.6
+27.4
+4.0
+2.0
+5.5
+Namibia
+2.7
+48.0
+144.0
+10.0
+0.1
+63.0
+4.0
+3.6
+20.0
+The columns give the values of suicide rate per year for 100,000 population (C1), the corruption index on a scale wherein 0 is the most corrupt 
+and 100 is the least corrupt (C2), prison population rate (C3), percentage of divorces to marriages (C4), the net migration rate (C5), the and 
+the rule of law index (C6), smoking and alcohol related deaths (C7), drugs related deaths (C8) and deaths due to violence (C9)
+with  >1000  mm rain per year get a score of 100, 
+while countries with  <1000  mm rain get a score of 
+0.1 times the rain in mm. The populations of homeless 
+people  (A10) are scored by subtracting the percentage 
+of homeless people from 100. The number of hospital 
+beds per 1000 of population (A11) is the last parameter 
+for the annamaya kośa. This number is multiplied by 10 
+to get a normalized score. The total populations of these 
+individual countries are given in the last column (A12).
+Table  3 presents the normalized data for all these 
+parameters on a scale of 0–100. The columns are labeled 
+as A1N to A11N and they correspond to columns A1 to 
+A11 which contain the actual/unscaled/nonnormalized 
+data given in Table  2. The scaling procedure has been 
+described above.
+Prānamaya kośa parameters
+Prāna is energy and the flow of prāna is the flow of 
+energy. For a population, Prana represents its vitality 
+and vibrancy. This is by and large determined by the 
+mobility of the population  and how the population 
+spends its energy and thus gainfully employed. For 
+computing the index for this kośa, we have identified the 
+following parameters. They are employment rates  (B1), 
+unemployment rates  (B2), life expectancy  (B3), the 
+number of cancer deaths per lakh of population  (B4), 
+number of HIV deaths per lakh of population  (B5), the 
+number of doctors per 1000 members of population (B6), 
+the number of airports  (B7), the percentage of internet 
+users  (B8), and the percentage of mobile phone 
+users  (B9). These parameters are depicted in Table  4. 
+Normalizing these is a bit easier than normalizing the 
+annamaya kośa parameters. Employment rate is counted 
+as it is since it is a percentage. The unemployment rate 
+is counted as 100  minus the unemployment percentage 
+rate. Life expectancy is the next parameter. Japan with a 
+life expectancy value of 84 gets 84%, while Nigeria with 
+a 52.6‑year life expectancy gets a score of 53. Cancer 
+death data are age normalized per 100,000 of population. 
+Maldives has the highest value of cancer deaths per 
+100,000 population. The data for all the countries are 
+normalized with 360 as the highest value. Countries with 
+values close to 360 get 0%, while countries with smaller 
+cancer deaths get a larger score. HIV deaths are in the range 
+of 1/100,000–6/100,000 of population. The normalized 
+score for this parameter is 100 times (1 − number of HIV 
+deaths/10). The number of airports is divided by the area 
+of the country and multiplied by 106/15. With this scaling, 
+UK, USA, and Singapore get a normalized score of 100. 
+Since the number of internet users and the number of 
+[Downloaded free from http://www.ijoyppp.org on Monday, January 25, 2021, IP: 136.232.192.146]
+Tembe, et al.: Panchakosha model of happiness of nations
+83
+International Journal of Yoga ‑ Philosophy, Psychology and Parapsychology  ¦  Volume 6  ¦  Issue 2  ¦  July‑December 2018
+mobile users are given in percentages, there is no need to 
+rescale them. Only when the values are >100%, the value 
+of 100 is assigned to the normalized parameter. Table  5 
+gives the normalized parameters  (relative scale factors) 
+for prānamaya kośa. The normalized scores are given 
+in columns B1N to B9N of Table 5 corresponding to the 
+columns B1 to B9 of Table 4.
+Manomaya kośa parameters
+Manomaya kośa of large collection of people deals with 
+the mental satisfaction of the countries or societies. Mobs 
+that are rioting have an extremely ill‑developed manomaya 
+kośa. They may do anything in frenzy and we witness 
+these phenomena on several occasions. A war is the “best 
+example” of a disturbed and highly tense population. The 
+after‑effects of the World Wars are still being felt and so 
+are the effects of riots. The indices for the manomaya kośa 
+comprise the following factors. They are suicide rate per 
+year for 100,000 population  (C1), corruption index on a 
+scale wherein 0 is the most corrupt and 100 is the least 
+corrupt  (C2), prison population rates  (C3), percentage of 
+divorces to marriages (C4), net migration rate (C5), rule of 
+law index (C6), smoking‑ and alcohol‑related deaths (C7), 
+drug‑related deaths (C8), and violence‑related deaths (C9). 
+These indices are not strongly correlated with the GNP 
+of a nation. Rich countries have suicide rates comparable 
+to the poor countries and they have higher divorce rates. 
+While the causes need to be analyzed carefully, these data 
+indicate that even countries with a very large GNP or 
+GDP need to improve their manomaya kosha. The scale 
+for suicide rates is computed as 100 minus 100 multiplied 
+by suicide rate/25. The last denominator is chosen to be 
+a slightly larger value than the largest suicide rate. Least 
+suicide rates get high scores in the happiness indices. In 
+the corruption index, 0 corresponds to the most corrupt. 
+As the values range between 0 and 100, the actual value 
+may be taken either as a percentage of corruption‑less‑ness 
+or as a percentage of being uncorrupted. For prison 
+population rates, we take the value of 0.1  times the rate. 
+Large prison populations or conviction rates are both good 
+and bad. Here, we take it to be good as it may increase 
+order in society at least due to the fear of being punished. 
+The negative or bad part is that so many crimes are 
+committed in the first place. The divorce rates are given 
+in column C4. Higher rates of divorce indicate smaller 
+capacities to accommodate alternative points of view. The 
+index is calculated as 100 minus the percentage of divorce 
+rate. Low divorce rates indicate greater stability, although a 
+flip side of this is that if there is greater inequality between 
+Table 7: Normalized manomaya kośa parameters (relative scale factors) corresponding to the columns C1 to C9 of 
+Table 6
+Country
+C1N
+C2N
+C3N
+C4N
+C5N
+C6N
+C7N
+C8N
+C9N
+China
+61.0
+40.0
+11.9
+78.0
+48.0
+42.8
+63.0
+90.0
+94.0
+India
+0.0
+36.0
+3.3
+97.0
+49.8
+54.3
+84.0
+80.0
+80.8
+Pakistan
+53.5
+28.0
+4.1
+97.0
+47.6
+23.6
+84.0
+80.0
+80.8
+Bhutan
+11.0
+63.0
+14.3
+95.0
+50.0
+67.8
+87.0
+90.0
+76.0
+Singapore
+0.0
+82.0
+90.0
+85.0
+62.5
+95.2
+70.0
+90.0
+98.0
+Japan
+7.5
+74.0
+14.9
+64.0
+50.0
+89.4
+74.0
+90.0
+98.4
+UK
+69.0
+76.0
+14.8
+53.0
+60.8
+94.2
+68.0
+58.0
+95.6
+Sweden
+38.5
+89.0
+6.0
+53.0
+77.3
+97.6
+76.0
+50.0
+96.0
+Netherlands
+59.0
+83.0
+7.5
+57.0
+59.8
+97.1
+61.0
+90.0
+96.0
+Romania
+47.5
+43.0
+14.4
+72.0
+48.8
+63.5
+65.0
+84.8
+92.0
+Greece
+81.0
+40.0
+11.1
+75.0
+61.6
+67.3
+68.0
+60.0
+94.0
+Russia
+2.5
+28.0
+56.3
+49.0
+51.4
+26.4
+72.0
+60.0
+35.2
+USA
+39.5
+73.0
+69.8
+47.0
+71.6
+89.9
+62.0
+71.0
+74.0
+Brazil
+71.0
+42.0
+30.1
+79.0
+49.5
+55.3
+81.0
+80.0
+0.0
+Mexico
+79.0
+34.0
+21.2
+85.0
+41.8
+38.0
+89.0
+80.0
+0.0
+Chile
+39.0
+71.0
+24.2
+97.0
+51.8
+88.0
+83.0
+88.0
+84.0
+Nicaragua
+76.5
+28.0
+16.0
+82.0
+34.3
+28.8
+90.0
+80.0
+46.0
+Australia
+47.0
+81.0
+15.1
+57.0
+81.2
+96.1
+76.0
+90.4
+94.8
+Egypt
+91.5
+32.0
+7.6
+83.0
+49.0
+31.3
+93.0
+40.0
+88.0
+Nigeria
+67.5
+25.0
+3.2
+90.0
+49.5
+11.5
+85.0
+60.0
+40.4
+Ethiopia
+42.5
+33.0
+11.1
+90.0
+48.8
+40.9
+95.0
+40.0
+48.0
+Yemen
+81.5
+18.0
+5.3
+90.0
+63.0
+8.2
+95.0
+50.0
+88.0
+Niger
+82.5
+34.0
+4.0
+90.0
+47.1
+27.4
+96.0
+60.0
+78.0
+Namibia
+86.5
+48.0
+14.4
+90.0
+50.2
+63.0
+96.0
+28.0
+20.0
+The columns give the normalized values of suicide rate (C1N), the corruption index (C2N), prison population rate (C3N), percentage of divorces 
+to marriages (C4N), the net migration rate (C5N), the rule of law index (C6N), smoking‑ and alcohol‑related deaths (C7N), drugs‑related 
+deaths (C8N) and deaths due to violence (C9N)
+[Downloaded free from http://www.ijoyppp.org on Monday, January 25, 2021, IP: 136.232.192.146]
+Tembe, et al.: Panchakosha model of happiness of nations
+84
+International Journal of Yoga ‑ Philosophy, Psychology and Parapsychology  ¦  Volume 6  ¦  Issue 2  ¦  July‑December 2018
+men and women, women may be far more accommodative 
+so as to avoid divorce even at a great personal cost. 
+Net migration percentages are given in column C5. An 
+influx into a country indicates that there is a considerable 
+well‑being. People migrate to better environments. This is 
+a major reason for the overcrowding of cities all over the 
+world. The normalized index for this parameter is taken as 
+50 + 5 times the migration rate. The migration rates are in 
+the range of 5–6 per 1000 of population. A country with 
+a high rate of migration will have a large value of this 
+parameter. The rule of law index given in column C6 is 
+given as a percentage. Higher values of this index indicate 
+conformity of the population to the prevailing laws. This is 
+taken as a percentage. Alcohol‑related and smoking‑related 
+deaths are in the range of 0–50 per lakh of population. This 
+parameter is normalized as 100 minus the parameter value, 
+C7. Drug‑related deaths are in the range of 0–5 (C8). For 
+this, normalization is done as 100  minus five times the 
+value of the parameter. Violence‑related deaths are in the 
+range of 0–25 (C9). This is normalized  as 100 minus four 
+times  the parameter value  (C9N). The manomaya kośa 
+parameters are given in Table 6.
+The normalized values of the manomaya kośa parameters 
+are summarized in Table 7.
+Vijyānamaya kośa parameters
+Vijyānamaya kośa parameters include the literacy rate 
+percentage  (D1), percentage of graduates  (D2), number 
+of research papers  (D3), the number of researchers per 
+million of population  (D4), number of colleges and 
+universities  (D5), the ratio of male literacy to female 
+literacy  (D6), and the role of voice of people and the 
+accountability of the governance (D7). For an individual 
+human being, this kośa corresponds to “viveka” or the 
+ability for discrimination. For a society, these parameters 
+should reflect its ability to increase intellectual and social 
+awareness. There has been a remarkable increase in these 
+factors along with economic development. Literacy, arts, 
+culture, science, and education contribute to this kośa. 
+For normalizing, for the first two columns (D1 and D2), 
+which represent percentages of literacy and graduates, the 
+values are taken as such. The next three parameters are 
+normalized as follows. The number of research papers in 
+million is multiplied by 250 to get the rescaled values in 
+the range of 0–100. Many countries such as China, India, 
+UK, and USA score high on this scale, while the African 
+countries score low values. The number of researchers 
+per million of population is multiplied by 0.02 to get 
+normalized scores in the range of 0–100. Singapore and 
+Table 8: Vijyānamaya kośa parameters
+Country
+D1
+D2
+D3
+D4
+D5
+D6
+D7
+China
+95.0
+14.0
+0.6
+990.0
+2555.0
+0.9
+5.4
+India
+63.0
+4.0
+0.5
+160.0
+1622.0
+0.6
+61.1
+Pakistan
+55.0
+3.0
+0.1
+150.0
+291.0
+0.7
+27.1
+Bhutan
+53.0
+3.0
+0.0
+10.0
+4.0
+0.6
+43.8
+Singapore
+96.0
+30.0
+0.0
+6400.0
+40.0
+1.0
+45.3
+Japan
+99.0
+53.7
+1.0
+4000.0
+989.0
+1.0
+79.3
+UK
+99.0
+47.0
+0.7
+4020.0
+292.0
+1.0
+92.1
+Sweden
+99.0
+42.0
+0.5
+5180.0
+53.0
+1.0
+99.5
+Netherlands
+99.0
+35.0
+0.7
+3500.0
+139.0
+1.0
+98.5
+Romania
+97.7
+20.0
+0.1
+800.0
+108.0
+1.0
+60.1
+Greece
+98.9
+32.0
+0.2
+2200.0
+79.0
+1.0
+67.5
+Russia
+99.7
+55.5
+0.3
+2500.0
+1531.0
+1.0
+20.2
+USA
+99.0
+43.0
+2.9
+3900.0
+3289.0
+1.0
+79.8
+Brazil
+90.4
+10.0
+0.5
+700.0
+1613.0
+1.0
+60.6
+Mexico
+95.1
+16.0
+0.2
+386.0
+942.0
+1.0
+55.0
+Chile
+98.6
+41.0
+0.1
+300.0
+79.0
+1.0
+80.3
+Nicaragua
+82.8
+3.0
+0.0
+10.0
+40.0
+1.0
+35.5
+Australia
+99.0
+45.0
+0.3
+3500.0
+211.0
+1.0
+93.6
+Egypt
+73.8
+5.0
+0.1
+500.0
+62.0
+0.8
+14.8
+Nigeria
+61.3
+2.0
+0.1
+70.0
+136.0
+0.8
+29.6
+Ethiopia
+49.1
+2.5
+0.0
+42.0
+35.0
+0.6
+12.8
+Yemen
+63.9
+0.0
+0.0
+10.0
+28.0
+0.6
+10.3
+Niger
+28.7
+0.5
+0.0
+10.0
+1.0
+0.3
+39.9
+Namibia
+88.8
+2.0
+0.0
+10.0
+4.0
+1.0
+66.5
+The columns include the literacy rate percentage (D1), percentage of graduates (D2), number of research papers in millions (D3), number of 
+researchers per million of population (D4), number of colleges and universities (D5), the ratio of female literacy to male literacy (D6) and 
+voice and accountability (D7)
+[Downloaded free from http://www.ijoyppp.org on Monday, January 25, 2021, IP: 136.232.192.146]
+Tembe, et al.: Panchakosha model of happiness of nations
+85
+International Journal of Yoga ‑ Philosophy, Psychology and Parapsychology  ¦  Volume 6  ¦  Issue 2  ¦  July‑December 2018
+Sweden score 100 in the normalization. The number of 
+universities and colleges is divided by the population of 
+the country and multiplied by 6 × 106 to get normalized 
+values in the range of 0–100. The next column  (D6) is 
+the ratio of female literacy to male literacy. This value 
+is converted to a percentage by multiplying by 100. 
+Treating all human beings  (as well as other creatures 
+as well) as equal is a great sign of viveka and it is 
+reassuring to note that this aspect of development is far 
+more encouraging in the present century than what it 
+used to be, a 100  years or even 50  years ago. Having 
+a good representation of female members in panchayats 
+or local bodies of governance and legislative assemblies 
+and reserving seats for them in these bodies is very 
+encouraging for the social and global Vijyānamaya kośa. 
+The last column is the role of the voice of the people and 
+the accountability of the government (D7). This is higher 
+for democratic countries where the people have a greater 
+say in the mode and functioning of the government. 
+Since this is given as a percentage, the value is already 
+normalized. The Vijyānamaya kośa parameter values are 
+given in Table 8.
+The normalized scores/indices for the Vijyānamaya kośa 
+parameters are given in Table 9.
+Anandamaya kośa parameters
+The parameters for ānandamaya kośa include the values 
+for the human development index  (E1), charity work in 
+terms of money  (E2) and time  (E3) given, world giving 
+rank index  (E4), and the Cantril ladder of life scale 
+gallup (E5). Among all the kośas, it is hardest to compute 
+the values for this kośa as ānanda or the state of bliss is 
+indescribable. When Bhrigu attains this state, he does 
+not return to his father Varuna for confirmation since 
+he is convinced that he is in the state of Brahman. For a 
+nation, instead of estimating the state of bliss, it is easier 
+to estimate the extent of spirituality through the acts of 
+giving or the extent of karma yoga in their citizens. To 
+add a bit of corresponding materialistic content as well 
+as to consider the opinions of populations  (happiness has 
+a strong subjective component too), we have considered 
+the human development index and the Cantril ladder. The 
+Cantril ladder is one of the scales to measure global life 
+satisfaction.[59‑66] It may be considered as a satisfaction 
+with life scale  (SWLS). Among various components of 
+subjective well‑being, the SWLS assesses global life 
+satisfaction. Many of these scales do not consider features 
+such as loneliness that are responsible for dissatisfaction. 
+The SWLS is shown to have favorable psychometric 
+Table 9: Normalized 1 Vijyānamaya kośa parameters (relative scale factors)
+Country
+D1N
+D2N
+D3N
+D4N
+D5N
+D6N
+D7N
+China
+95.0
+14.0
+100.0
+19.8
+11.2
+91.0
+5.4
+India
+63.0
+4.0
+100.0
+3.2
+7.7
+65.0
+61.1
+Pakistan
+55.0
+3.0
+25.0
+3.0
+9.6
+67.0
+27.1
+Bhutan
+53.0
+3.0
+2.5
+0.2
+31.0
+56.0
+43.8
+Singapore
+96.0
+30.0
+5.0
+100.0
+43.3
+99.0
+45.3
+Japan
+99.0
+53.7
+100.0
+80.0
+46.4
+100.0
+79.3
+UK
+99.0
+47.0
+100.0
+80.4
+27.4
+100.0
+92.1
+Sweden
+99.0
+42.0
+100.0
+100.0
+32.6
+100.0
+99.5
+Netherlands
+99.0
+35.0
+100.0
+70.0
+49.3
+100.0
+98.5
+Romania
+97.7
+20.0
+31.5
+16.0
+32.5
+98.5
+60.1
+Greece
+98.9
+32.0
+56.2
+44.0
+43.8
+100.0
+67.5
+Russia
+99.7
+55.5
+68.2
+50.0
+64.2
+99.5
+20.2
+USA
+99.0
+43.0
+100.0
+78.0
+62.1
+100.0
+79.8
+Brazil
+90.4
+10.0
+100.0
+14.0
+48.1
+100.0
+60.6
+Mexico
+95.1
+16.0
+52.5
+7.7
+44.5
+97.5
+55.0
+Chile
+98.6
+41.0
+22.5
+6.0
+26.6
+99.5
+80.3
+Nicaragua
+82.8
+3.0
+0.2
+0.2
+39.5
+100.0
+35.5
+Australia
+99.0
+45.0
+69.0
+70.0
+55.8
+100.0
+93.6
+Egypt
+73.8
+5.0
+30.0
+10.0
+4.3
+81.0
+14.8
+Nigeria
+61.3
+2.0
+25.0
+1.4
+4.6
+78.0
+29.6
+Ethiopia
+49.1
+2.5
+2.5
+0.8
+2.1
+61.0
+12.8
+Yemen
+63.9
+0.0
+2.5
+0.2
+6.5
+58.0
+10.3
+Niger
+28.7
+0.5
+0.2
+0.2
+0.4
+35.0
+39.9
+Namibia
+88.8
+2.0
+0.5
+0.2
+10.5
+99.0
+66.5
+The columns include the normalized values of literacy rate (percentage, D1N), percentage of graduates (D2N), number of research papers (D3N), 
+number of researchers per million of population (D4N), number of colleges and universities (D5N), the ratio of male literacy to female 
+literacy (D6N) and voice and accountability (D7N)
+[Downloaded free from http://www.ijoyppp.org on Monday, January 25, 2021, IP: 136.232.192.146]
+Tembe, et al.: Panchakosha model of happiness of nations
+86
+International Journal of Yoga ‑ Philosophy, Psychology and Parapsychology  ¦  Volume 6  ¦  Issue 2  ¦  July‑December 2018
+properties, including high internal consistency and high 
+temporal reliability. Scores on the SWLS correlate well with 
+other measures of subjective well‑being and also correlate 
+predictably with specific personality characteristics. SWLS 
+is suited for use with different age groups. Thus, we thought 
+that this ladder can be added as one of the parameters for 
+the anandamaya kośa. Cantril’s ladder elicits respondents 
+to rate their current life satisfaction on a ladder that ranges 
+from 0 to 10, where 0 reflects worst imaginable life 
+satisfaction and 10 reflects best imaginable life satisfaction. 
+Respondents are first asked to describe these two anchors 
+and then requested to rate their current life satisfaction 
+on this “ideographically anchored” continuum. These 
+parameters are given in Table 10.
+For normalization, the human development index (E1) and 
+the Cantril ladder (E5) are already in the 0–100 scale. Charity 
+work in terms of money and time is also in a percentage. 
+The world giving indices are ranked from 1 to 222. Since 
+all these countries chosen here have ranks between 0 and 
+100, the percentage is calculated as 100 minus the rank of 
+the country. If all the countries in the world are included, 
+then a formula such as  (222  −  rank) ×100/221 is more 
+appropriate for normalization. The normalized ānandamaya 
+kośa parameters are given in Table 11.
+Combined 
+happiness 
+indices 
+and 
+graphical 
+representations
+The data obtained in the last five sections of the previous 
+section are summarized in Table 12. Each column gives 
+the total happiness index for a given kosha, which is 
+averaged over all the parameters for that kosha with 
+equal weightage. The last column gives an overall 
+happiness index, the statistical index that was sought in 
+the present work. The next few figures present these data 
+in a pictorial way.
+The happiness indices for the five kośas and the total 
+happiness index (averaged over the five kośas) for the 24 
+countries are shown in Figures 1‑6.
+To see how sensitive the normalized parameters are to 
+the choice of the parameters, we recalculate the total 
+happiness indices by choosing  (n1, n2, n3, n4, n5) to 
+be  (10, 8, 8, 6, 4). We have done this by removing the 
+last parameter for each one of the kośas. This altered set 
+of total happiness indices is given in Figure  7. We see 
+that none of the happiness indices for the same countries 
+between the two figures  [Figures  6 and 7] differ by 
+Table 11: Normalized ānandamaya kośa 
+parameters (relative scale factors)
+Country
+E1N
+E2N
+E3N
+E4N
+E5N
+China
+71.9
+4.0
+11.0
+10.0
+46.5
+India
+58.6
+12.0
+14.0
+31.0
+50.0
+Pakistan
+53.7
+8.0
+20.0
+39.0
+52.0
+Bhutan
+58.4
+15.0
+15.0
+89.0
+58.0
+Singapore
+90.1
+15.0
+15.0
+36.0
+70.0
+Japan
+89.0
+23.0
+17.0
+10.0
+61.0
+UK
+89.2
+29.0
+73.0
+93.0
+69.0
+Sweden
+89.8
+52.0
+12.0
+60.0
+74.0
+Netherlands
+91.5
+77.0
+39.0
+88.0
+74.0
+Romania
+78.5
+14.0
+5.0
+0.0
+60.0
+Greece
+85.3
+8.0
+5.0
+0.0
+57.0
+Russia
+77.8
+20.0
+6.0
+0.0
+53.0
+USA
+91.4
+39.0
+60.0
+99.0
+72.0
+Brazil
+74.4
+15.0
+25.0
+10.0
+66.5
+Mexico
+75.6
+25.0
+20.0
+15.0
+67.0
+Chile
+82.2
+48.0
+16.0
+50.0
+66.0
+Nicaragua
+61.4
+30.0
+20.0
+33.0
+52.0
+Australia
+93.3
+38.0
+70.0
+94.0
+74.0
+Egypt
+68.2
+19.0
+6.0
+0.0
+47.0
+Nigeria
+50.4
+28.0
+29.0
+80.0
+58.0
+Ethiopia
+43.5
+24.0
+13.0
+28.0
+42.0
+Yemen
+50.0
+17.0
+7.0
+0.0
+44.0
+Niger
+33.7
+11.0
+11.0
+0.0
+42.0
+Namibia
+33.7
+17.0
+17.0
+0.0
+42.0
+The columns in this table correspond the respective columns of 
+Table 10. The columns are the normalized values for the human 
+development index (E1N), charity work in terms money given (E2N) 
+and time given (E3N), world giving rank index (E4N) and the Cantril 
+ladder of life scale gallup (E5N)
+Table 10: The parameters for ānandamaya kośa
+Country
+E1
+E2
+E3
+E4
+E5
+China
+71.9
+4.0
+11.0
+90.0
+46.5
+India
+58.6
+12.0
+14.0
+69.0
+50.0
+Pakistan
+53.7
+8.0
+20.0
+61.0
+52.0
+Bhutan
+58.4
+15.0
+15.0
+11.0
+58.0
+Singapore
+90.1
+15.0
+15.0
+64.0
+70.0
+Japan
+89.0
+23.0
+17.0
+90.0
+61.0
+UK
+89.2
+29.0
+73.0
+7.0
+69.0
+Sweden
+89.8
+52.0
+12.0
+40.0
+74.0
+Netherlands
+91.5
+77.0
+39.0
+12.0
+74.0
+Romania
+78.5
+14.0
+5.0
+108.0
+60.0
+Greece
+85.3
+8.0
+5.0
+120.0
+57.0
+Russia
+77.8
+20.0
+6.0
+100.0
+53.0
+USA
+91.4
+39.0
+60.0
+1.0
+72.0
+Brazil
+74.4
+15.0
+25.0
+90.0
+66.5
+Mexico
+75.6
+25.0
+20.0
+85.0
+67.0
+Chile
+82.2
+48.0
+16.0
+50.0
+66.0
+Nicaragua
+61.4
+30.0
+20.0
+67.0
+52.0
+Australia
+93.3
+38.0
+70.0
+6.0
+74.0
+Egypt
+68.2
+19.0
+6.0
+120.0
+47.0
+Nigeria
+50.4
+28.0
+29.0
+20.0
+58.0
+Ethiopia
+43.5
+24.0
+13.0
+72.0
+42.0
+Yemen
+50.0
+17.0
+7.0
+134.0
+44.0
+Niger
+33.7
+11.0
+11.0
+102.0
+42.0
+Namibia
+33.7
+17.0
+17.0
+100.0
+42.0
+The columns include the values for the human development index 
+(E1), charity work in terms money given (E2) and time given (E3), 
+world giving rank index (E4) and the Cantril ladder of life scale 
+gallup (E5)
+[Downloaded free from http://www.ijoyppp.org on Monday, January 25, 2021, IP: 136.232.192.146]
+Tembe, et al.: Panchakosha model of happiness of nations
+87
+International Journal of Yoga ‑ Philosophy, Psychology and Parapsychology  ¦  Volume 6  ¦  Issue 2  ¦  July‑December 2018
+Table 12: Computed happiness indices in the five kośas
+Country
+Anna (11)
+Prāna (9)
+Mano (9)
+Vijāna (7)
+Ānanda (5)
+Total Average
+China
+46.4
+64.7
+58.8
+48.1
+28.7
+49.3
+India
+50.3
+57.1
+53.9
+43.4
+33.1
+47.6
+Pakistan
+30.5
+57.1
+55.4
+27.1
+34.5
+40.9
+Bhutan
+43.4
+55.8
+61.6
+27.1
+47.1
+47.0
+Singapore
+69.0
+82.4
+74.7
+59.8
+45.2
+66.2
+Japan
+75.3
+76.1
+62.5
+79.8
+40.0
+66.7
+UK
+79.0
+85.1
+65.5
+78.0
+70.6
+75.6
+Sweden
+73.2
+81.3
+64.8
+81.9
+57.6
+71.8
+Netherlands
+78.0
+80.0
+67.8
+78.8
+73.9
+75.7
+Romania
+58.7
+67.6
+59.0
+50.9
+31.5
+53.5
+Greece
+61.3
+73.4
+62.0
+63.2
+31.1
+58.2
+Russia
+56.0
+70.4
+42.3
+65.3
+31.4
+53.1
+USA
+71.0
+82.9
+66.4
+80.3
+72.3
+74.6
+Brazil
+60.4
+68.8
+54.2
+60.4
+38.2
+56.4
+Mexico
+48.0
+71.4
+52.0
+52.6
+40.5
+52.9
+Chile
+54.5
+69.2
+69.6
+53.5
+52.4
+59.8
+Nicaragua
+49.5
+67.7
+53.5
+37.3
+39.3
+49.5
+Australia
+60.6
+77.2
+70.9
+76.1
+73.9
+71.7
+Egypt
+25.0
+63.7
+57.3
+31.3
+28.0
+41.1
+Nigeria
+36.2
+48.3
+48.0
+28.8
+49.1
+42.1
+Ethiopia
+34.3
+40.3
+49.9
+18.7
+30.1
+34.7
+Yemen
+27.5
+37.8
+55.5
+20.2
+23.6
+32.9
+Niger
+24.8
+42.0
+57.7
+15.0
+19.5
+31.8
+Namibia
+36.7
+51.6
+55.1
+38.2
+21.9
+40.7
+In each column, the averaging is done with equal weights to all the parameters (indicated in parenthesis) for that kośa. The last column is 
+the average over the five kośas for each country, which is the total country happiness index
+Figure 1: Total happiness indices in the annamaya kośas for 24 countries
+more than 5%–6%. However, the average values of the 
+individual koshas change by about 10%.
+This confirms our stand that as the number of parameters 
+increases beyond 7 or 8, there is a great degree if 
+invariance between the predictions from different 
+parameterizations. This supports one of the goals of the 
+model to capture the essence of the kośas.
+Another model to consider is to look at various linear 
+combinations of different kośas to see if this has a major 
+impact on the happiness indices. In principle, all the 
+kośas have a great degree of independence; otherwise, 
+a person such as Shri Ramakrishna who paid so little 
+attention to his annamaya kośa could have hardly 
+attained the highest states of Samadhis, so characteristic 
+[Downloaded free from http://www.ijoyppp.org on Monday, January 25, 2021, IP: 136.232.192.146]
+Tembe, et al.: Panchakosha model of happiness of nations
+88
+International Journal of Yoga ‑ Philosophy, Psychology and Parapsychology  ¦  Volume 6  ¦  Issue 2  ¦  July‑December 2018
+Figure 2: Total happiness indices in the pranamaya kośas for 24 countries
+Figure 3: Total happiness indices in the manomaya kośas for 24 countries
+Figure 4: Total happiness indices in the vijnyanamaya kośas for 24 countries
+[Downloaded free from http://www.ijoyppp.org on Monday, January 25, 2021, IP: 136.232.192.146]
+Tembe, et al.: Panchakosha model of happiness of nations
+89
+International Journal of Yoga ‑ Philosophy, Psychology and Parapsychology  ¦  Volume 6  ¦  Issue 2  ¦  July‑December 2018
+Figure 5: Total happiness indices in the anandamaya kośas for 24 countries
+Figure 6: Total happiness indices (averaged over all the kośas) for 24 countries
+Figure 7: Total happiness indices (averaged over all the kośas) for twenty four countries with different parameterization (the last parameter for each 
+kośa removed) than the one used in Figure 6
+[Downloaded free from http://www.ijoyppp.org on Monday, January 25, 2021, IP: 136.232.192.146]
+Tembe, et al.: Panchakosha model of happiness of nations
+90
+International Journal of Yoga ‑ Philosophy, Psychology and Parapsychology  ¦  Volume 6  ¦  Issue 2  ¦  July‑December 2018
+of the ānandamaya kośa. The result of a recalculation 
+with the weights of 1, 1.1, 1.3, 1.5, and 1.7 for the 
+annamaya, prānamaya, manomaya, vijyānamaya, and 
+ānandamaya kośas, respectively, for the 24 countries is 
+shown in Figure  8. The new results do not differ from 
+the old ones by more than 2%–4%. The deviations are 
+both positive and negative. An explanation could be that 
+the values of happiness parameters for different kośas of 
+different countries have very weak correlations between 
+themselves.
+Discussion
+We thus have a quantitative model for happiness indices 
+of different nations based on the panchakośas (PKMH‑I) 
+that are familiar to the individuals as outlined in the 
+Taittiriya Upaniśad. The available data could be classified 
+into the parameters for different kośas and simple 
+normalization procedures could be adopted to give a 
+spread of each of the parameters between 0 and 100. As 
+the weights for each of the parameter chosen for a given 
+kośa were the same, the final score for a kośa could be 
+simply computed as an equally weighted average. The 
+scores for different kośas for each country are quite 
+different, and thus, these can be used as good indicators 
+for a holistic planning for a nation, just as IAYT has 
+been used for improving the health of individual patients. 
+A remarkable observation is that the countries with very 
+high level of satisfaction or happiness  (many affluent 
+countries) are not having equally high values of the 
+manomaya kośa parameters  (except for Australia and 
+Singapore which are rather small populations), while 
+a small country such as Bhutan with a difficult terrain 
+and a low value of annamaya kośa parameter has a 
+happiness level at the manomaya kośa in the same range 
+as for countries such as UK, Japan, and USA. It is thus 
+not surprising that the GNH[8] Index study of Bhutan has 
+been praised so highly. There is so much to learn even 
+from such a small country.
+We note that some of the results are on the expected lines. 
+Countries with high levels of annamaya kośa tend to do 
+quite well on the vijyānamaya kośa. While our model 
+can certainly be improved, let us assess how this can be 
+used by these nations. The two dominant messages are 
+that even for the countries with large values of happiness 
+indices, improvements are certainly possible and those 
+areas can be identified by looking at individual kośas. In 
+countries with large natural resources, a lot of room exists 
+for improvements in manomaya and ānandamaya kośas. 
+The second message is that for countries with low scores, 
+all is not lost as there are areas in which they are doing 
+well. These countries just have to plan better and adopt 
+a more holistic model of development. This also brings 
+out the main feature that only economic development 
+is not a complete development and the countries may 
+now choose to interact so that they can increase mutual 
+happiness indices rather than try to dominate one another 
+through military or economic wars. The interaction 
+models between countries that led to tragedies such as 
+the Bhopal Gas Tragedy or even the models where 
+powerful countries simply go and occupy smaller and 
+weaker countries are so harmful to both the interacting 
+countries. Had the British or the North Americans 
+considered to interact favorably with the manomaya kośa 
+of all its occupied territories, they would have been a 
+much happier nation and society today and would have 
+increased goodwill toward themselves from a large part 
+of the world. Their nations would not have faced such 
+intense security threats so often. Thus, the interaction 
+model that uses the Upaniśadic kośa concepts has a lot to 
+offer for the models of interaction between the countries. 
+Figure 8: A total happiness model with weights of 1, 1.1, 1.3, 1.5, and 1.7 for the annamaya, Pranamaya, manomaya, Vijyanamana, and anandamaya 
+kośas, respectively
+[Downloaded free from http://www.ijoyppp.org on Monday, January 25, 2021, IP: 136.232.192.146]
+Tembe, et al.: Panchakosha model of happiness of nations
+91
+International Journal of Yoga ‑ Philosophy, Psychology and Parapsychology  ¦  Volume 6  ¦  Issue 2  ¦  July‑December 2018
+This is where quantification of the kośas is likely to be 
+of good use.
+An interesting feature in the normalized kośas is that the 
+so‑called developed countries do very well in all the other 
+four kośas relative to the manomaya kosha. The opposite 
+is true for Asian and African countries (except Russia) 
+which do much better in the manomaya kośa relative 
+to the other four kośas. A  possible explanation is that 
+in these developing countries, the population is aware 
+of the deficiencies in theirs annamaya, prānamaya, 
+and vijyānamaya koshas and adopt themselves better 
+to the limited resources. The opposite seems to be 
+true in developed countries, wherein there is a lot of 
+material prosperity and comfort. In their quest for 
+material happiness, their populations have lost quite a 
+bit in emotional tolerance as witnessed by larger divorce 
+rates and problems associated with drugs, smoking, 
+and alcohol. We thus note that our model provides an 
+alternative to the present available models of happiness.
+Conclusions and Perspectives
+Improvements in our model are certainly possible as there 
+are many factors such as the environment that need to be 
+considered in greater detail. The factors such as freedom 
+for individual pursuit and the aggressive policies of 
+nations in interfering with the affairs of remote countries 
+to increase their individual domination need to be taken 
+into account in a more elaborate manner. These data will 
+also help economically developed countries to inspect 
+their policies with other nations, by asking the question: 
+Do our policies with other nations help us to increase the 
+happiness levels of both countries? These will clearly 
+bring out the answer that either wars of sanctions or 
+vetos do not add to the happiness indices in any of the 
+kośas. Thus, there is a need for greater harmony and 
+peace rather than aggression. Just as the purpose of 
+yoga is to harmonize and elevate different kośas of the 
+individual bodies, these indices can be used to plan the 
+activities of nations to improve harmony and peace.
+Another feature of this study is that we did not get data 
+for all the parameters that we initially planned to get and 
+some new parameters were found along the way. Some 
+parameters had to be inferred from other available data. 
+A considerable portion of the data is from fairly reliable 
+web‑sites. However, these need to be cross checked 
+with published literature from the journals of the social 
+sciences. Some of the data need to be checked for internal 
+consistency as well. Another interesting observation is 
+that the aggregate happiness index computed for Bhutan 
+in its national study was well over 60 and the percentage 
+of very happy people was 43. The value that we compute 
+is near 46. A  conclusion from this observation is that 
+when we develop a comparative and nonsurvey‑based 
+scale, there is a greater objectivity. At the same time, 
+there is some satisfaction that the numbers represented 
+here can be classified into different kośas and that our 
+value and the national value for aggregate GNH for 
+Bhutan have a strikingly close similarity.
+The greatest strength of this study, like all statistical 
+models, is the opportunity it provides for quantitative 
+classification of the kośas of populations based on the 
+model proposed in the Taittiriya Upaniśad. At the time of 
+Bhrigu and Varuna, there were hardly any hospitals or even 
+machines to measure weights or blood pressures. While 
+Bhrigu’s analysis was entirely spiritual and theoretical, 
+it is remarkable that this model provides a basis for an 
+alternative therapy to improve the physical and mental 
+health of people. It would be certainly tempting to speculate 
+that a study such as this or a similar one which analyzes 
+the overall state of a nation into well‑defined and distinct 
+segments could be used to improve the development 
+models that nations use in their planning. Another strength 
+of this study is that the number of parameters used for 
+each kośa can be easily increased systematically so that all 
+the koshas can be comprehensively defined. We may then 
+get good limiting values for the well‑being of nations in 
+their different kośas.
+Financial support and sponsorship
+Nil.
+Conflicts of interest
+There are no conflicts of interest.
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subfolder_0/AUTONOMIC AND RESPIRATORY MEASURES IN CHILDREN WITH IMPAIRED VISION FOLLOWING YOGA AND PHYSICAL ACTIVITY PROGRAMS.txt

@@ -0,0 +1,290 @@
+International Journal of Rehabilitation and Health, Vol. 
+4, No. 2, 1998
+Autonomic and Respiratory Measures in Children
+with Impaired Vision Following Yoga and Physical
+Activity Programs
+Shirley Telles1,2 and Rajesh B. Srinivas1
+We conducted assessments of 28 children with impaired vision (VI group), with ages rang-
+ing from 12 to 17 years, and an equal number of age-matched, normal-sighted children
+(NS group). The VI group had significantly higher rates of breathing, heart rates, and
+diastolic blood pressure values compared to the NS group (Mann-Whitney U test). Twenty-
+fourofthe VI group formed pairs matched for age and degree of blindness, and we ran-
+domly assigned members of the pairs to two groups, viz., yoga and physical activity. Both
+groups spent an hour each day practicing yoga or working in the garden, depending on
+their group. After 3 weeks, the yoga group showed a significant decrease in breath rate
+(Wilcoxon paired signed ranks test). There was no change after the physical activity pro-
+gram. The results showed that children with visual impairment have higher physiological
+arousal than children with normal sight, with a marginal reduction in arousal following
+yoga.
+INTRODUCTION
+Young people with impaired vision have significantly higher levels of anxiety related to
+physical injury compared to an age-matched group of subjects with normal vision (Ollendick
+et al., 1985). In addition, one study reported that, in comparison to persons who have
+vision, persons who are blind have a significantly higher heart rate while walking along an
+unfamiliar route as well as for 5 minutes afterward (Wycherley and Wicklin, 1970). The
+authors ascribed this to psychological rather than physical stress.
+The purpose of the present study was to compare the autonomic and respiratory mea-
+sures of children with congenital visual impairment with those of a group of age- and
+sex-matched children with normal vision. This was the first part of the study. The second
+part of the present study aimed at comparing the effects of yoga practice with physical
+activity in children with visual impairment. The practice of yoga, as based on relaxation
+1 Vivekananda Kendra Yoga Research Foundation, No. 9, Appajappa Agrahara, 1st Main, Chamarajpet, Bangalore
+560 018, India.
+2To whom correspondence should be addressed. Fax: 91.80.6610666. e-mail: [email protected].
+KEY WORDS: visual impairment; normal sight; autonomic measures; yoga; gardening.
+117
+1068-9591/98/0400-0117$15.00/0 © 1998 Plenum Publishing Corporation
+(Nagendra, 1989), is able to bring about reduced sympathetic activity along with other
+physiological signs of reduced arousal (Joseph et al., 1981; Wallace et al., 1971).
+METHODS
+Subjects
+In the first part of the study, we selected 28 children (aged between 11 and 17 years;
+group average age ± SD, 14.2 ± 1.9 
+years) at random from a special school for persons with
+visual impairements (Raman Maharshi Academy for the Blind, Bangalore, India). All of
+them had congenital visual impairment with an uncorrectable visual acuity of 6/60 or less
+in the better eye from birth, which is the conventional description of blindness (Sheridan,
+1969). Blindness was due to peripheral 
+causes, e.g., microphthalmos, congenital cataract, 
+or
+optic atrophy. We selected 28 children with normal vision (6/6 without correction) so as to
+match exactly those with impaired vision with respect to age and sex. We obtained 
+informed
+consent of the subjects and their guardians 
+in accordance with the ethical guidelines of the
+Indian Council of Medical Research, New Delhi, India.
+The second part of the study involved 24 children of the 28 assessed in the first part of
+the study. We selected these 24 children because we could match them to form pairs on the
+basis of age, sex, and degree of visual impairment. 
+The method for grading appears below,
+under Measurements. We then randomly assigned subjects of a pair to either of two groups,
+viz., yoga or physical activity. The group average ages ± SD were 14.1 ±1.9 years (yoga
+group) and 14.1 ± 2.2 years (physical activity group).
+Design of the Study
+In the first part of the study, we randomly selected 40 children with ages between 11
+and 17 years from among a total of 340 children attending a special school for persons
+who are blind. Of the 40, we selected 28 children with congenital visual impairment for the
+first part of the study (VI group) because we could exactly match them with 28 children
+with normal sight (NS group). We based matching on age and sex and assessed both groups
+(visually impaired and normal sighted) under similar conditions, described in detail below.
+The second part of the study involved 24 children with impaired vision of the 28
+assessed in the first part of the study. We conducted the baseline assessment in the same
+way as in the first part of the study, 1 month later. After this, the yoga group received training
+in yoga and the physical activity group spent time in an outdoor activity (i.e., gardening)
+for the allotted hour for 5 days a week. The yoga instructor spent an equal amount of time
+with children of both groups. After 3 weeks, we assessed both groups once more, with the
+final assessments performed by the same persons under similar conditions as the baseline
+assessments.
+Measurements
+Recordings for the first part of the study (VI group versus NS group), as well as for the
+second part (yoga versus physical activity group of visually impaired children), took place
+in a moderately lit, sound-attenuated room. After an initial 15-min period of supine rest,
+US
+Telles and Srinivas
+we conducted assessments for 10 min, also in the supine position and with eyes closed. We
+recorded the blood pressure from the right arm using a standard sphygmomanometer while
+the subject was in a seated position. It was not possible to obtain blood pressure records for
+the second part of the study.
+We used a 10-channel polygraph (Polyrite, Recorders and Medicare, Chandigarh,
+India) to record the electrocardiogram (EKG), respiration, and skin resistance level (SRL).
+We recorded the EKG using the standard limb lead I configuration. We recorded skin
+resistance using Ag/AgCl disk electrodes with electrode gel (Medicon, Madras, India)
+placed in contact with the volar surfaces of the distal phalanges of the index and middle
+fingers of the left hand. We used a low-level DC preamplifier and passed a constant current
+of 10 nA. between the electrodes. We recorded respiration using a volumetric pressure
+transducer. Subjects stood erect and an experimenter placed the transducer around the
+trunk, approximately 5 cm below the lower costal margin. We recorded blood pressure with
+a sphygmomanometer.
+We graded degree of visual impairment for all the children with impaired vision as
+follows: grade 0, inability to differentiate between light and dark; grade 1, ability to differ-
+entiate between light and dark; grade 2, ability to perceive gross movements; and grade 3,
+ability to count fingers held at a distance of 30 cm.
+Data Extraction and Analysis
+Data extraction took place similarly for both parts of the study. We obtained heart rates
+(beats per minute) by counting the QRS complexes in successive 60-sec epochs, continu-
+ously, and we similarly calculated breath rate (in cycles per minute) by counting the breath
+cycles in 60-sec epochs, continuously. We sampled SRL at 20-sec intervals and, for data anal-
+ysis, used the average of the values obtained during the 10 minute session for each subject.
+We compared the data for the VI group and the NS group using the Mann-Whitney U
+test. We compared the data for the yoga and physical activity groups obtained at the end of
+3 weeks to the respective baseline data using the Wilcoxon paired signed ranks test.
+Yoga Training
+A trained instructor taught the yoga intervention. Individuals with normal vision learn
+yoga by observing a demonstration while listening to instructions. Persons with visual
+impairment received detailed verbal instructions to compensate. In addition, the instructor
+spent time with each subject correcting their practice (e.g., repositioning their limbs) with
+verbal instructions. Subjects received special emphasis on relaxing between practices and
+being aware of body sensations. Practices included simple yoga postures and yoga breathing
+exercises (50 min), followed by guided relaxation (10 min). Throughout the practices, the
+emphasis was on awareness (of physical and other sensations) and relaxation.
+Physical Activity
+The physical activity group did not learn yoga. During the allotted hour, they spent
+time in the garden doing a comparable amount of physical activity 
+as the yoga group, such as
+bending forward and stretching upward. The yoga instructor spent time with these children
+every day and was equally familiar with them as with the yoga group.
+Autonomic and Respiratory Measures in Children with Impaired Vision
+119
+RESULTS
+Part 1
+In comparison with subjects who had normal sight, subjects with impaired vision
+had significantly higher breath rates, diastolic blood pressure values, and heart rates. For
+breath rate, Za = 2.71 and Z.01(2)a = 2.57, hence p < .01; for diastolic blood pressure,
+Za = 3.79 and Z.001(2)a = 3.20, hence p<.001; and for heart rates, Za = 1.66 and
+Z.05(l)a = 1.64, hence p < .05. The group mean values ± SD appear in Table I.
+Part 2
+There was a significant decrease in the breath rate of the yoga group at the end of
+3 weeks as indicated by the Wilcoxon paired signed ranks test [t = 10, t .05(2)12 = 13, hence
+p < .05]. The group mean values ± SD appear in Table II.
+DISCUSSION
+The present study occurred in two parts. Part 1 showed that children with impaired
+vision had higher diastolic blood pressure values and heart and breath rates compared with
+children of the same age who had normal sight. Comparing children with impaired vision
+randomly assigned to yoga and physical activity (i.e., gardening groups), 3 weeks of yoga
+practice caused a reduction in the rate of breathing.
+Table I. Autonomic Measures in Children with Visual Impairment
+(VI) and Normal Sight (NS) (Group Means ± SD)
+Heart rate (beats/min)
+Breath rate (cycles/min)
+Skin resistance (kf)
+Systolic BP (mm Hg)
+Diastolic BP (mm Hg)
+VI(N = 28)
+88. 
+8 ± 14.5*
+22.8 ±5.4**
+176.7 ± 153.3
+113. 0± 11.5
+76.1 ±6.4***
+NS(N = 28)
+81.6± 11.3
+19.2 ±3.2
+136.9 ± 100.9
+110.7 ±9.5
+66.5 ± 8.9
+Note. Mann-Whitney U test. VI versus NS. N, number of subjects.
+*p<.05(1).
+**p<.0l 
+(2).
+***p<.001 (2).
+Table II. Heart Rate (HR), Rate of Respiration (RR), and Skin Resistance (SR) in Two
+Groups (Yoga, Physical Activity) of Children with Impaired Vision Before and After
+the 3-Week Programs (Group Mean ± SD)
+HR (beats/min)
+RR (cycles/min)
+SR (k£)
+Yoga training (N= 12)
+Before
+89.0 ± 19.4
+21. 
+4 ±6.3
+130.8 ± 124.8
+After
+82.8 ± 13.4
+17.5 ±6.9*
+67.6 ± 74.0
+Physical activity (N = 12)
+Before
+84.7 ±8.1
+22.9 ±5.1
+128.7 ± 103.0
+After
+84.9 ± 12.3
+21. 
+5 ±4.8
+136.3 ± 172.6
+Note. Wilcoxon paired signed ranks test, after versus before. N, number of subjects.
+*p<0.05(2).
+120
+Telles and Srinivas
+An increase in breath rate correlates experimentally with evoked fear and anxiety
+(Ax, 1953) as well as before situations such as parachute jumping (Fenz and Jones, 1972).
+The nature of waveforms recorded in a standard spirogram using a strain gauge transducer
+show that there are different patterns as the immediate response to six selected emotions,
+including fear and anxiety (Bloch et al., 1991). These two emotions are particularly likely to
+cause irregularity of breathing, with frequent periods of breath holding, whereas anger and
+sadness produce regularly recurring abnormal patterns. Visual assessment of the records of
+the children with impaired vision and those with normal sight showed that the former had
+irregular breath cycles with frequent periods of breath holding. This may be due to higher
+levels of fear and anxiety among children with visual impairments. This is in keeping
+with data that indicate higher levels of fear (particularly related to physical injury) among
+children with visual impairments (Ollendick et al., 1985). These subjects were possibly
+apprehensive because they were not familiar with the laboratory. In connection with this,
+it is important to note that the subjects with normal sight were also visiting the laboratory
+for the first time. Also, we made equal effort to reduce the apprehension of both groups by
+explaining the procedure in detail and answering their questions.
+A low resting heart rate is an indicator of routine physical activity (Williams and
+Sperryn, 1962). One study found that children with impaired vision have poor physiological
+adjustment to exercise compared to their normal-sighted counterparts (Hopkins et al., 1987).
+The authors of the study ascribed the findings to an overall lower level of physical activity
+in children with visual impairments. This hypothesis provides an explanation for the higher
+resting heart rates found in the children with impaired vision in the present study and could
+also apply to the higher (though not abnormally so) diastolic blood pressure values, relative
+to the children with normal vision.
+In Part 2, we assessed the effect of two programs (yoga and increased physical activity
+during gardening) using the same parameters as for the first part of the study. Previous
+reports have shown that yoga reduces psychophysiological signs of arousal (e.g., Wallace
+et al., 1971). The present results revealed that the yoga group showed a significant reduction
+in respiratory rate after 3 weeks of practice, but the group who spent time gardening showed
+no change. The reduction in respiratory rate is consistent with previous literature describing
+effects of yoga on the rate of respiration. The practice of yoga reduces the breath rate, both
+as an immediate effect (Wallace et al., 1971) and over a 3-month period (Joseph et al.,
+1981).
+The present study showed that practicing yoga for 3 weeks reduced the breath rate in
+children with impaired vision. Other known effects of yoga practice (e.g., a reduction in heart
+rate or an increase in skin resistance) were not present. In fact, there was a nonsignificant
+decrease in skin resistance following yoga, which was not fully explainable. It is possible that
+the duration of practice required to bring about a change in these parameters among persons
+with visual impairments is longer than that for other individuals because the former have
+higher baseline heart and breath rates and diastolic blood pressure values. The unfamiliar
+laboratory setting may have contributed to these higher values.
+The practice of yoga also modified the irregularity of breathing observed in the baseline
+assessment. These results are similar to the effects of yoga observed in community home
+children (Telles et al., 1997). As described earlier, an increase in breath rate occurs in
+response to fear, anxiety, and other psychological stressors (Ax, 1953).
+Hence, the present results suggest that children with visual impairments have higher
+levels of cardiac sympathetic activation and faster breathing than children with normal
+Autonomic and Respiratory Measures in Children with Impaired Vision
+121
+sight. A comparison of 3 weeks of yoga practice with a physical activity program showed
+that after the practice of yoga, the rate and irregularity of respiration declined among
+children with visual impairments. 
+There were no other significant changes for these subjects.
+Yoga techniques involve increased physical activity, with an emphasis on relaxation and
+awareness. This type of program appears to be useful for children with visual impairments
+to help them reduce irregularities in breathing associated with anxiety.
+ACKNOWLEDGMENTS
+The authors are grateful to the staff and the children of the Raman Maharshi Academy
+for the Blind, Bangalore, India, for their enthusiastic participation in the study.
+REFERENCES
+Ax, A. F. (1953). The physiologic differentiation between fear and anger in humans. 
+Psychosam. Med. 15:433-442.
+Bloch, S., Lemeignan, M., and Aquilera, T. N. (1991). Specific respiratory patterns distinguish among human
+basic emotions. Int. J. Psychoxom. 11: 141-154.
+Fenz, W. D., and Jones, G. B. (1972). Individual differences in physiologic arousal and performances in sports
+parachutists. Psychosom. Med. 34: 1-8.
+Hopkins, W. D., Gaeta, H., Thomas, A. C., and Hill, P. M. (1987). Physical fitness of blind and sighted 
+children.
+Eur. J. Appl. Phyxiol. 56(1): 69-73.
+Joseph, S., Sridharan, S. K. B., Patil, M. D., Kumaria, 
+A., Selvamurthy, 
+W., Joseph, N. T., and Nayar, H. S. (1981).
+Study of some physiological and biochemical parameters in subjects undergoing yogic training. Indian J.
+Med. Res. 74: 120-124.
+Nagendra, H. R. (1989). Yoga—Its Basis and Applications, Vol. I, Vivekananda Kendra Yoga Anusandhan Samas-
+than, Bangalore.
+Ollendick, T. H., Matson, J. L., and Helsel, W. J. (1985). Fears in visually impaired and normal sighted youths.
+Behav. Res. 23(3): 375-378.
+Sheridan, M. D. (1969). Vision screening procedures for very young children or handicapped children. In Gardiner,
+P. A., MacKeith, M. A. C., and Smith, V. (eds.), Aspects of Developmental and Pediatric Ophthalmology.
+Clinics in Developmental Medicine, Heinemann Medical, London, pp. 39-40.
+Telles, S., Narendran, S., Raghuraj, P., Nagarathna, R., and Nagendra, H. R. (1997). Comparison of changes in
+autonomic and respiratory parameters of girls after yoga and games at a community home. Percept. Motor
+Skills 84: 251-257.
+Wallace, R. K., Benson, H., and Wilson, A. F. (1971). A wakeful hypometabolic physiologic state. Am. J. Physiol.
+221:795-799.
+Williams, J. G. P., and Sperryn, P. N. (1962). Sports Medicine, Edward Arnold, London.
+Wycherley, R. J., and Wicklin, B. H. (1970). The heart rate of blind and sighted pedestrians on a town route.
+Ergonomics 13(2): 181-192.
+122
+Telles and Srinivas

subfolder_0/AYURVEDA FOR CHEMO-RADIOTHERAPY INDUCED SIDE EFFECTS IN CANCER PATIENTS_unlocked.txt

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+Journal of Stem Cells 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ISSN: 1556-8539 
+Volume 8, Number 2 
+ 
+ © Nova Science Publishers, Inc. 
+ 
+ 
+ 
+ 
+AYURVEDA FOR CHEMO-RADIOTHERAPY INDUCED SIDE 
+EFFECTS IN CANCER PATIENTS 
+ 
+ 
+ 
+Kashinath Metri1, Hemant Bhargav1, 
+Praerna Chowdhury1, and 
+Prasad S. Koka2, 3‡ 
+1Division of Yoga and Life Sciences, Swami 
+Vivekananda Yoga Anusandhana Samsthana 
+University, 19 Eknath Bhavan, Gavipuram Circle, 
+Kempegowda Nagar, Bangalore, India 
+2Department of Virology and Immunology, 
+Haffkine Institute, Acharya Donde Marg, Parel, 
+Mumbai, India 
+3Laboratory of Stem Cell Biology, Torrey Pines 
+Institute for Molecular Studies, 3550 General 
+Atomics Court, San Diego, California, USA 
+ 
+                                                        
+ Corresponding Authors: Kashinath G Metri, BAMS, MD. 
+Assistant Professor, S-VYASA University. Mob: +91 
+9035257626. Email: [email protected]. 
+ Email: [email protected] 
+‡ Email: [email protected] 
+ABSTRACT 
+ 
+Chemotherapy drugs and radiotherapy are highly toxic and 
+both damage adjacent healthy cells. Side effects may be 
+acute (occurring within few weeks after therapy), 
+intermediate or late (occurring months or years after the 
+therapy). Some important side effects of chemotherapy are: 
+nausea, 
+vomiting, 
+diarrhea, 
+mucositis, 
+alopecia, 
+constipation etc; whereas radiation therapy though 
+administered locally, can produce systemic side effects 
+such as fatigue, anorexia, nausea, vomiting, alteration in the 
+taste, sleep disturbance, headache, anemia, dry skin, 
+constipation  etc. Late complications of these therapies also 
+include pharyngitis, esophagitis, laryngitis, persistent 
+dysphagia, fatigue, hepatotoxicity, infertility and cognitive 
+deficits. These arrays of side effects have a devastating 
+effect on the quality of life of cancer survivors. 
+Due to the inadequacy of most of the radio-protectors and 
+chemo-protectors in controlling the side effects of 
+conventional cancer therapy the complementary and 
+alternative medicines have attracted the view of researchers 
+and medical practitioners more recently. This review aims 
+at providing a comprehensive management protocol of 
+above mentioned chemo-radiotherapy induced side effects 
+based on Ayurveda, which is an ancient system of 
+traditional medicine practiced in Indian peninsula since 
+5000 BC. When the major side effects of chemo-
+radiotherapy are looked through an  ayurvedic perspective, 
+it appears that they are the manifestations of aggravated 
+pitta dosha, especially under the group of disorders called 
+Raktapitta 
+(haemorrhage) 
+or 
+Raktadushti 
+(vascular 
+inflammation). Based on comprehensive review of ancient 
+vedic literature and modern scientific evidences, ayurveda 
+based interventions are put forth. This manuscript should 
+help clinicians and people suffering from cancer to combat 
+serious chemo-radiotherapy related side effects through 
+simple but effective home-based ayurveda remedies. The 
+remedies described are commonly available and safe. These 
+simple ayurveda based solutions may act as an important 
+adjuvant to chemo-radiotherapy and enhance the quality of 
+life of cancer patients. 
+ 
+Keywords: 
+Ayurveda, 
+Cancer, 
+Chemotherapy, 
+Radiotherapy, Side Effects 
+Kashinath Metri, Hemant Bhargav, Praerna Chowdhury et al. 
+116 
+INTRODUCTION 
+ 
+Cancer is a major illness and a leading cause of 
+death world over, causing suffering of large 
+population and global economic loss worldwide [1, 
+2]. There were 12.7 million cancer cases and 7.2 
+million deaths due to cancer worldwide in the year 
+2008 [2]. Thus, studies are being conducted globally 
+to prevent cancer or develop nontoxic therapeutic 
+agents which include those using ayurvedic herbal 
+medications [3]. In the last few decades though there 
+has been tremendous advancement in the diagnostic 
+modalities and treatment of cancer which has 
+increased cancer survival rates, the long term effects 
+of these treatment modalities on the quality of life of 
+the cancer survivors have attracted the attention [4]. 
+ 
+ 
+Conventional Management of Cancer and 
+Its Side Effects 
+ 
+Conventional 
+management 
+of 
+cancer 
+encompasses four major strategies – surgery, radiation 
+therapy 
+(including 
+photodynamic 
+therapy), 
+chemotherapy (including hormonal therapy and 
+molecular targeted therapy) and biologic therapy 
+(including immunotherapy and gene therapy). These 
+modalities are usually given in combination, and they 
+work through different mechanisms to a synergistic 
+effect [5]. Adverse effect of these therapies and drug 
+resistance are two important obstacles in better 
+outcome of treatment and quality of life of the patient 
+respectively. Chemotherapy drugs and radiotherapy 
+are highly toxic and both damage adjacent healthy 
+cells. Most of the patients suffer from adverse effects 
+of chemotherapy and radiation therapy. These side 
+effects may be acute (occurring within few weeks 
+after therapy), intermediate or late (occurring months 
+or years after the therapy) [6]. Some important side 
+effects of chemotherapy are: nausea, vomiting, 
+diarrhea, mucositis, alopecia, constipation etc [5,7]; 
+whereas radiation therapy though administered 
+locally, can produce systemic side effects like fatigue, 
+anorexia, nausea, vomiting, alteration in the taste, 
+sleep disturbance, headache, anemia, dry skin 
+constipation etc. Late complications of these therapies 
+also include pharyngitis, esophagitis, laryngitis, 
+persistent 
+dysphagia, 
+fatigue, 
+hepatotoxicity, 
+infertility and cognitive deficits [5-7]. There is also a 
+possibility of development of secondary cancer due to 
+chemo-radiotherapy [6]. These arrays of side effects 
+have a devastating effect on the quality of life of 
+cancer survivors. 
+To manage these, usually three kind of 
+therapeutic agents are used in conventional medicine; 
+first, which are given to prevent tissue damage before 
+the symptoms appear, they are called protectors, 
+second those that are given during or shortly after a 
+course of radiation therapy (mitigators) and third are 
+the treatments given when toxicity develops months 
+to years after therapy [6]. Due to failure of most of the 
+radio-protectors and chemo-protectors in controlling 
+the side effects of conventional cancer therapy 
+completely, the complementary and alternative 
+medicines have attracted the view of researchers and 
+medical practitioners more recently. This review aims 
+at providing a comprehensive management protocol 
+of above mentioned chemo-radiotherapy side effects 
+based on Ayurveda, which is the most ancient system 
+of traditional medicine of the world that has been 
+practiced in Indian peninsula since 5000 BC [8]. After 
+an extensive literature survey of both traditional 
+ayurvedic texts and modern scientific literature we 
+provide an ayurveda based approach and solution to 
+above mentioned problems. 
+ 
+ 
+Ayurveda Based Approaches towards 
+Mitigating Chemo-Radiotherapy Side 
+Effects 
+ 
+Ayurveda is a well-documented traditional system 
+of medicine [9]. Ayurveda considers human body as 
+an indivisible whole and is based on the principle that 
+health is a state of stability of network of interrelated 
+functions of body, mind and consciousness whereas 
+disease manifests itself as a byproduct of disturbance 
+in the stability of this network [10].  
+According to Ayurveda, vata, pitta and kapha are 
+three basic humors (doshas) responsible for all the 
+physiological processes in the body; vata causes 
+motion, pitta helps metabolism and kapha is 
+responsible for structure or stability. Health is 
+identified as balanced functioning of these three 
+doshas [11].  
+ 
+Ayurveda for Chemo-radiotherapy Induced Side Effects in Cancer Patients 
+117
+Qualities of the Three Doshas 
+ 
+An ancient samskrit ayurvedic text called 
+Ashtanga Samgraha (Ash. Sam.) [12] describes the 
+qualities of three doshas. Literal meaning of the word 
+vata is “air”. The qualities of vata as per ayurvedic 
+science include: dryness, cold, lightness, mobility, 
+penetration and roughness. These are responsible for 
+all kinds of movements in the body such as 
+circulation, nerve impulse, respiration etc [Ash. Sam. 
+19/3 ; ref no. 12].  
+Qualities of pitta mentioned in ayurvedic texts 
+include: heat, sourness and moisture together. Bodily 
+functions 
+such 
+as 
+appetite, 
+thirst, 
+digestion, 
+metabolism, body heat, eyesight, softness of the body, 
+lustre, mental calmness, and intelligence are governed 
+by the pitta dosha. Pitta manifests itself through the 
+processes 
+of 
+digestion, 
+metabolism, 
+oxidation, 
+conjugation, reduction, enzymatic and hormonal 
+activities etc.  
+The third dosa is kapha, which has the qualities 
+of moisture, steadiness, coolness, heaviness, softness 
+and stickiness. Kapha is responsible for body 
+moisture, stability of the joints, firmness of the body, 
+bulk, strength, weight and endurance [Ash. Sam. 19/3 
+; ref no. 12]. 
+ 
+ 
+Chemo-Radio Therapy Side Effects As 
+Manifestations of Aggravated Pitta Dosha 
+ 
+When the major side effects of chemo-
+radiotherapy are looked through an ayurvedic 
+perspective, it appears that they are the manifestations 
+of aggravated pitta dosha especially under the group 
+of disorders called Raktapitta (haemorrhage) or 
+Raktadushti (vascular inflammation). 
+The signs and symptoms of aggravated pitta as 
+per ancient ayurveda texts are: dav (burning 
+sensation), 
+mukhapaka 
+(stomatitis), 
+trushna 
+(excessive thirst), osha (feeling of hot sensation in the 
+body), galpaka (pharyngitis), payupaka (urethritis), 
+gudapaka (proctitis), davatu (acid regurgitation), dava 
+(burning sensation in the oral cavity), abhishandha 
+(conjunctivitis) [Ash. Sam. 20/14; ref no. 12]. 
+Ayurveda 
+texts 
+also 
+mention 
+“atapa 
+sevana” 
+(excessive exposure to sunlight or radiations) as one 
+of the cause for increase in the pitta dosha. This leads 
+to excess of pitta and imbalance in the nature 
+(prakruthi vikruthi). 
+ 
+ 
+Aggravated Pitta Dosha As Fundamental 
+Basis for Management of Chemo-
+Radiotherapy Side Effects 
+ 
+Ayurveda principles describe that to reduce pitta 
+dosha our lifestyle should be such that it promotes 
+other qualities (qualities of kapha and vata) and it 
+should oppose the qualities of pitta. According to the 
+sage Charaka, one of the famous authors of ancient 
+ayurvedic texts, “Virechana” (therapeutic purgation) 
+is the best treatment for aggravated pitta dosha. The 
+line of management is; first – snehana (oleation 
+therapy) with pure or medicated ghee (clarified 
+butter), then followed by virechana (therapeutic 
+purgation) using ayurveda herbal medications such as 
+draksha (vitex venifera or raisins), vidarikhanda 
+(pueraria tuberosa), ikhsuras (saccaurum officinarum 
+or sugar cane juice) and trivrutta (operculina 
+turpethum) and then finally administration of 
+medications (shamana) which are having sweet, 
+astringent, bitter taste and are cold in potency for e.g. 
+draksha, sugarcane, kharjura (phoenix dactylifera or 
+dates), 
+yashtimadhu 
+(glyccrhiza 
+glabra), 
+vasa 
+(adatoda vasika), Chandana (santalum album or 
+sandalwood), ushir (vtiveria zizanioides) preparation 
+containing rose and honey (gulkand), milk and ghee 
+(clarified butter) etc. 
+Along with this one should adopt a cool 
+atmosphere around [Ash. Sam. 21/4; ref no. 12]. 
+Vasadi ghrita (calrified butter medicated with 
+Adatoda Vasika ), shatavaryai ghrita (calrified butter 
+medicated with asparagus racemosa) and kiratatiktadi 
+churna (swetia chirata) are special multidrug 
+preparations recommended by Charaka for treatment 
+of diseases born out of aggravated pitta as mentioned 
+in an authentic ayurveda text called Charak Samhita 
+Chikitasasthana (Cha. Sam.) [Cha. Sam. 4/76, 4/88, 
+4/97; ref no. 13].  
+Figure 
+1 
+shows 
+schematic 
+summary 
+of 
+management of aggravated pitta dosha. 
+ 
+ 
+Kashinath Metri, Hemant Bhargav, Praerna Chowdhury et al. 
+118 
+ 
+Figure1. Schematic Representation of Management of Aggravated Pitta dosha. 
+ 
+AYURVEDA-BASED MANAGEMENT 
+OF COMMON CHEMO-RADIOTHERAPY 
+SIDE EFFECTS IN CANCER PATIENTS 
+ 
+Following paragraphs in this section of the 
+manuscript describe major side effects of chemo-
+radiotherapy one by one along with probable 
+ayurveda based remedies for the problem on the basis 
+of both ancient ayurvedic and modern scientific 
+literature survey: 
+ 
+ 
+Radio-Protective Effects of Ayurveda 
+Polyherbal Preparations 
+ 
+Chavanprash avaleha is a well-known ayurvedic 
+poly herbal preparation, which has Indian gooseberry 
+(embelica officinalis) as its principal component. In a 
+randomised control study, oral administration of 
+another poly herbal ayurvedic preparation called 
+Rasyana avaleha (embelica officinalis is the principle 
+ingredient) has shown significantly better effect in 
+controlling the adverse effects of chemotherapy and 
+radiotherapy than the control group [14]. Similarly in 
+an animal study it was observed that Chavanprash 
+avaleha has a potential radio-protective effect in the 
+animals which are exposed to gamma radiation [15]. 
+A 
+review 
+describes 
+a 
+polyherbal 
+ayurvedic 
+preparation called Triphala which contains three 
+ingredients 
+viz. 
+haritaki 
+(Terminala 
+chebula), 
+vibhitaki (Terminala belerica) and amalaki (Embilica 
+officinalis), as useful in cancer as an anti-cancer, 
+chemo-protective and radio-protective agent [16]. 
+Another ayurvedic herb – guduchi (Tinospora 
+cardifolia) has shown its potent radio protective effect 
+in animal experiments. In an animal study it was 
+found that radiation induced testicular injury was 
+significantly ameliorated in the experimental group 
+who consumed guduchi, leading to significant 
+increase in the body as well as the tissue weight in 
+Ayurveda for Chemo-radiotherapy Induced Side Effects in Cancer Patients 
+119
+comparison with the control group (which was 
+deprived of the herb) [17]. 
+ 
+ 
+Anorexia 
+ 
+Nearly 80% of the cancer patients develop 
+anorexia-cachexia syndrome in advanced stages 
+which is worsened further with the administration of 
+chemotherapy [18]. Anorexia is the commonest 
+chemotherapy side effect and is associated with 
+weight loss, fatigability and decreased appetite which 
+further leads to reduced chances of better outcome 
+and diminished survival [19]. 
+Ayurveda recognizes this condition as arochak in 
+which patient feels loss of interest, hunger, and taste 
+in the food. Ancient ayurvedic treatise called Charak 
+samhita [13] recommends mouth gargles by the liquid 
+formulations made from the herbs such as shunthi 
+(dried ginger) maricha (Black pepper), pippali 
+(Pepper longum) ), lodra (Symplocos racemosa), teja 
+patra 
+(Cinnamomum 
+zeylanicum) 
+and 
+yavaksharas(Hordeum vulgare) [Cha. Sam. 26/217; 
+ref no. 13]. As per Sharangdhar Samhita (Sha. Sam.) 
+Lavangadi churna is another polyherbal preparation 
+indicated for patients suffering from anorexia due to 
+chronic illnesses [Sha. Sam. 6/65-69; ref no. 20], it 
+also improves physical strength. This polyherbal 
+preparation indicated in the diseases of throat 
+tuberculosis, etc. Other important causes of anorexia 
+are oral ulcers and dryness of mouth induced by 
+chemo and radiotherapy. In such cases another multi-
+herb preparation called Khadiradi vati is advised for 
+chewing several times in a day [Cha. Sam. 26/213; ref 
+no. 13]. 
+ 
+ 
+Mucositis 
+ 
+Oral mucositis is one of the common and serious 
+complications 
+of 
+chemotherapy. 
+Chemotherapy-
+induced mucositis is highly painful condition without 
+any definite cure; this condition is an important cause 
+of poor quality of life in cancer patients receiving 
+chemotherapy [21]. 
+As per Charak Samhita, the symptoms of 
+mucositis resemble the sign and symptoms of pittaja 
+mukh roga, which is basically due to increased pitta 
+dosha in the body. Mouth gargles with kalaka churna 
+mixed with liquids such as water and honey is 
+indicated for such health problems, it is written in the 
+text that this treatment cures all types of mouth 
+disorders caused by excess of pitta dosha (i.e. 
+showing signs of inflammation such as heat, redness 
+and burning sensation)[Cha. Sam. 26/195-199; ref no. 
+13]. 
+Recent scientific study showed that local 
+application of Yastimadhu (Glycrrhiza Glabra or 
+licorice) powder (mixed with honey) in the oral 
+cavity, prior to radiotherapy, reduces radiotherapy 
+induced mucositis [22]. Oral application of honey is 
+considered as a simple remedy for skin and mucosal 
+surface damage as a result of radiotherapy [23]. 
+Another ayurvedic herb called arka (caltropus 
+procera) has shown its anti-inflammatory property 
+against chemotherapy induced mucositis [24]. 
+Rectal mucosal damage is also a common 
+complication of radiotherapy in ano-rectal carcinoma. 
+In one study, oral administration of triphala prior to 
+the radiotherapy, daily for consecutive five days, 
+significantly reduced the mucosal damage associated 
+with radiotherapy [25]. 
+ 
+ 
+Nausea and Vomiting 
+ 
+They are the most common occurrence during 
+chemo-radiotherapy. In spite of use of anti-emetic 
+drugs, 70% of patients show persistent symptoms 
+[26]. Ayurveda recognizes this condition as Chardi. 
+Nausea and vomiting induced by chemo-radiotherapy 
+can well correlate with pittaja chhardi (pitta dosha 
+dominant). The treatment mentioned for the same in 
+ayurveda is as follows: Powder of haritaki (terminal 
+chebula) mixed with honey or the Juice of resins or 
+cold water processed with tender leaves of mango 
+(mangifera indica) and jamun (Syzygium Cumini) are 
+all indicated for nausea and vomiting [27]. Multidrug 
+preparations like Kalyanaka Grita, Jivaneeya Ghrita 
+are also useful in the treatment of vomiting. 
+Khandkushmandavaleha a poly-herbal preparation is 
+indicated in various conditions like vomiting, 
+hoarseness of the voice, fatigue, debility, burning 
+sensation and cough [27]. Eladi churna is another 
+multi-drug preparation which has potential of curing 
+any kind of vomiting [Sha. Sam. 6/65-69; ref no. 20]. 
+Kashinath Metri, Hemant Bhargav, Praerna Chowdhury et al. 
+120 
+One scientific study has shown that ginger 
+(Zingiber officinalis) supplementation at daily dose of 
+0.5g-1.0g significantly aids in reduction of the 
+severity of acute chemotherapy-induced nausea in 
+adult cancer patients [26].  
+ 
+ 
+Anemia 
+ 
+Anemia is another common condition in cancer 
+patients receiving chemotherapy. It significantly 
+hampers the quality of life and is an important cause 
+for blood transfusion in cancer patients [28]. 
+Ayurveda mentions anemia under the heading of 
+pandu roga. The treatment of pandu roga includes 
+systemic 
+purificatory 
+therapy 
+(Panchakarma), 
+oleation therapy (internal and external application of 
+medicated oil or ghee) followed by purgation, dietary 
+modifications and oral medications. Charak samhita 
+advocates use of cow’s urine with other formulations 
+for anemia. Cow’s urine with haritaki or with triphala 
+decoction or cow’s milk is also indicated in case of 
+anemia [Cha. Sam. 16/64; ref no. 13]. Dhatriavaleha 
+is one of the best multidrug preparations for 
+panduroga mentioned in ayurveda texts [Cha. Sam. 
+16/16; ref no. 13]. 
+In a recent scientific study Dhatriavaleha was 
+found as a good adjuvant in the management of 
+thalassemia by reducing symptoms of fatigue, 
+abdomen pain, pallor and joint pain in thalassemia 
+patients [29].  
+ 
+ 
+Diarrhoea 
+ 
+Fifty to eighty percent of patients receiving 
+chemotherapy 
+suffer 
+from 
+diarrhea 
+which 
+is 
+contributor to poor quality of life and reduced 
+treatment output [30]. Ayurveda identifies this 
+condition as atisara. pittaja atisara is a type of 
+atisara which is characterized by symptoms of 
+excessive thirst, burning sensation and fainting. These 
+symptoms are commonly found in diarrhea associated 
+with 
+chemo-radiotherapy. 
+Treatment 
+remedy 
+mentioned in ayurveda is pepper powder with honey 
+or butter milk with powder of chitraka. It has 
+potential to cure all kind of diarrheas [Cha. Sam. 
+29/79; ref no. 13]. Pippalyadi yoga and dadimastaka 
+churna are also few of the multi-drug preparations 
+indicated in diarrhea [Cha. Sam. 29/113; ref no. 13, 
+Sha. Sam. 6/65-69; ref no. 20]. 
+Brahmi (Boswellia serrate) [31] and Jatiphala 
+(Myristica fragrans) [32] are other herbs with proven 
+anti-diarrheal properties. 
+ 
+ 
+Sleep Disturbances 
+ 
+Disturbed sleep is a major problem in patients 
+receiving radiotherapy [33]. Ayurveda considers sleep 
+as one of the important components of health. As per 
+ayurveda, disturbed sleep leads to anxiety, worry, 
+stress and vomiting [Cha. Sam. 21/55-56; ref no. 13]. 
+Ayurvedic management of disturbed sleep includes 
+whole body massage, bath, food items such as rice 
+with curd or milk or ghee etc., meat soup of aquatic or 
+forest animals, listening to soft and pleasant music, 
+taking 
+pleasant 
+smell, 
+sleeping 
+in 
+soft 
+and 
+comfortable bed [Cha. Sam. 21/52-54; ref no. 13]. 
+Kshirbala oil and mahamasha oil are considered good 
+for body massage. 
+The herbs Shweta Musli (borivilianum) and 
+Atmagupta (Velvet bean) have significantly increased 
+sleep quality in a scientific study [34]. Methionic 
+extract of another herb called Mundi (S. Indicus) has 
+shown its sedative property [35]. 
+ 
+ 
+Constipation 
+ 
+Constipation is another major problem in patients 
+receiving specific chemotherapeutic agents such as 
+cisplatin [36]. According to ayurveda, increased pitta 
+aggravates vata, which leads to drying up of the colon 
+and causes constipation [37]. 
+Erand tail (caser oil) with the decoction of 
+triphala or milk or with meat soup is indicated in 
+constipation caused by increased pitta and vata dosha 
+[Cha. Sam. 26/27-28; ref no. 13]. Triphala powder 2-
+6 gms with warm water and ghee is considered as 
+good remedy for constipation [Cha. Sam. 26/27-28; 
+ref no. 13]. 
+In a scientific study a polyherbal preparation, 
+which contains ayurvedic herbs such as Isabgol husk, 
+senna extract and triphala, has shown its efficacy and 
+Ayurveda for Chemo-radiotherapy Induced Side Effects in Cancer Patients 
+121
+safety in the management of functional constipation 
+[38]. 
+ 
+ 
+Fatigue 
+ 
+Deterioration of the general physical health with 
+reduced exercise tolerance and muscle strength and 
+fatigue are common manifestations of chemotherapy 
+related side effects [39]. Ayurveda recognizes fatigue 
+as krish or dourbalya and advocates use of drugs 
+which are having the property of promoting strength 
+(Balya). Ashwagandha (Withenia Somnifera) and 
+Shatavari (Asparagus Racemosa) are the famous 
+drugs which are mentioned in this category [Cha. 
+Sam. Sutra 4/7; ref no. 13]. 
+In a randomized control trial, consumption of 
+medicated ghee called Ashwagandha ghrita lead to 
+significant improvement in shoulder stretch and 
+weight bearing capacity. It indicates that this 
+formulation may help in the patient suffering from 
+fatigue [40].  
+Also in many studies anti-tumor activity of 
+Ashwagandha has been reported. In one of them 
+ashwagandha has shown anti-tumor property on 
+chinese hamster ovary (CHO) cells carcinoma, hence 
+it can synergize with conventional therapies of cancer 
+[41]. 
+ 
+ 
+Cognitive Deficits 
+ 
+Nearly 
+61% 
+of 
+the 
+patients 
+receiving 
+chemotherapy have cognitive declines in learning, 
+attention and processing speed and cognitive 
+difficulties in the domains of executive function, 
+memory, psychomotor speed, and attention [42].  
+Ayurveda uses terms like dhriti, medha, smriti 
+etc., which are different facets of cognition. There 
+several drugs mentioned under the heading of Medhya 
+rasayana which improve these facets of cognition 
+[Cha. Sam. chi 1/73; ref no. 13]. Multi-drug 
+formulations 
+like 
+shankhapushpa 
+(Convolvolus 
+pluricaulis), 
+Brahmi 
+(Bacopa 
+monniera), 
+Mandukaparni (Centella asiatica), Vacha etc. are 
+considered as medhya rasayana [Cha. Sam. chi 1/73; 
+ref no. 13]. Chavanprash is one of the rasayana 
+which has vast use as per ayurveda, in relation to 
+cognition, it improves memory and intellect. It also 
+helps in relieving excessive thirst and fatigue which is 
+commonly seen during cancer treatment [Cha. Sam. 
+chi 1/73; ref no. 13].  
+In recent study, Chavanprash has shown its 
+protective effect against memory impairment along 
+with decreased free radical generation and increased 
+scavenging of free radicals [43]. In another animal 
+experimental study ayurvedic herb Brahmi (Bacopa 
+monniera) which is considered as one of the best 
+medhya rasayanas ( which enhances the intellect and 
+memory) has shown its effect improving the special 
+learning performance and enhancing the memory 
+retention [44].  
+Another herb Ashwaganda (Withania Somnifera) 
+has a cognition promoting effect and was found useful 
+in children with memory deficit and in old age people 
+loss of memory [45]. Ashwaganda also been shown to 
+have anti-tumor property in an animal study where it 
+reduced cell proliferation and increased apoptosis 
+[46]. 
+In another animal experiment, a poly herbal 
+preparation 
+containing 
+Withania 
+somnifera 
+(Ashwagandha), Nardostachys jatamansi (Jatamansi), 
+Rauwolfia 
+serpentina 
+(Sarpagandha), 
+Evolvulus 
+alsinoides (Shankhpushpi), Asparagus racemosus 
+(Shatavari), Emblica officinalis (Amalki), Mucuna 
+pruriens (Kauch bij extract), Hyoscyamus niger 
+(Khurasani Ajmo), Mineral resin (Shilajit), Pearl 
+(Mukta Shukhti Pishti), and coral calcium (Praval 
+pishti) has shown significant improvement in learning 
+and memory retrieval [47]. 
+ 
+ 
+Pharyngitis 
+ 
+Phyaryngitis is another common problem in 
+patients receiving chemo-radiotherapy. A spray 
+prepared from five aromatic essential oils (Eucalyptus 
+citriodora, Eucalyptus globulus, Mentha piperita, 
+Origanum syriacum, and Rosmarinus officinalis) has 
+shown better immediate relief from the symptoms of 
+sore throat than placebo control group [48]. 
+ 
+ 
+ 
+ 
+ 
+Kashinath Metri, Hemant Bhargav, Praerna Chowdhury et al. 
+122 
+Skin Toxicity 
+ 
+Cutaneous adverse effects are among the more 
+common adverse effects of newer antitumor drugs, 
+they occur in up to 34% of patients receiving 
+multikinase inhibitors, up to 90% of those receiving 
+selective tyrosine kinase inhibitors (such as EGFR or 
+mutant BRAF inhibitors) and up to 68% of those 
+receiving immunotherapeutic agents (such as CTLA4 
+inhibitors) 
+[49]. 
+Commonly 
+found 
+cutaneous 
+conditions side effects are - sebostasis, epidermal 
+atrophy, xerosis cutis, itching, dry eczema and 
+vulnerability of the skin to fissures - especially on the 
+fingers, toes, and heels [49]. 
+The above mentioned symptoms of the skin 
+toxicity due to chemotherapy or radiotherapy are 
+similar to skin disease due to increased vata dosha as 
+mentioned in the Charaka samhita. While describing 
+the treatment of these conditions Charaka mentioned 
+Abhyanga (massage) and swedana karma (sudation 
+therapy) and basti (enema) for vata related disorders 
+[Cha. Sam. chi 28/30; ref no. 13]. Bala taila is 
+mentioned in the context of treatment of vata related 
+disorders. This oil can be used for massage, enema or 
+internal use also. So body massage with bala taila 
+may help to overcome skin related problems due to 
+chemotherapy or radiotherapy [Cha. Sam. Chi. 
+28/148-154; ref no. 13]. 
+ 
+ 
+Infertility 
+ 
+Cancer treatment affects fertility through both 
+psychological as well as physiological effects; 
+infertility could cause long-term distress [50].  
+Ayurveda has explained in detail about male 
+infertility under the heading klaibya and female 
+infertility under vandhya. Regarding the treatment in 
+both male and female infertility Sage Charaka 
+prescribed all the therapeutic cleansing procedures. 
+These procedures are vamana (emesis therapy), 
+virechana (therapeutic purgation), basti (enema with 
+medicated decoctions or oils) etc. Once cleansing is 
+over one should follow the prescribed dietary 
+regimens [Cha. Sam. chi 30/45, 30/196; ref no. 13]. 
+ 
+ 
+Male Infertility and Ayurveda 
+ 
+This condition is called klaibya in ayurveda. The 
+therapy which is given to maintain or regain the 
+fertility in order to have good progeny is called 
+vajikarana. Bhavprakash (Bha. Pra.) is another 
+ayurveda text which describes that one should avoid 
+everything which is the cause of the infertility [Bha. 
+Pra. 72/22; ref no. 51]; stress anxiety are given as the 
+common factors which contribute to infertility along 
+with chemotherapy. These factors can be removed by 
+the help yoga brahatashatavari grita, which is poly-
+herbal preparation indicated for problems related to 
+reproductive system both in male and female [Bha. 
+Pra. 26/30; ref no. 51]. Several single drugs and poly-
+herbal preparations are mentioned in ayurveda texts 
+for infertility. Wheat powder cooked with milk along 
+with cow ghee [Bha. Pra. 72/39; ref no. 51] or milk 
+preparation with powder of wheat mixed with powder 
+of kapikachhu (Mucuna pruriens) should be taken first 
+then one should drink the milk which is also good 
+aphrodisiac [Bha. Pra. 72/39; ref no. 51]. Several 
+multidrug preparations like gorakshadi modak, 
+amrapaka, vanari vati are also considered as few of 
+the best aphrodisiac agents [Bha. Pra. 25/27; ref no. 
+51]. 
+In a recent clinical study on the Ayurvedic herb 
+Mucuna pruriens (Kapikachhu), which is considered 
+as a best among the Aphrodisiac, has significantly 
+reduced psychological stress and seminal plasma lipid 
+peroxide levels along with significant improvement in 
+the sperm count and motility at the end of three 
+months [52]. In an animal experiment, herb Tribulus 
+terrestris also mentioned as Gokshura in the 
+Ayurvedic text, has shown its aphrodisiac property by 
+increasing mount frequency, intromission frequency, 
+and penile erection index, as well as a decrease in 
+mount latency and intromission latency along with 
+increase in the serum testosterone levels [53]. 
+ 
+ 
+Female Infertility 
+ 
+Infertility is common in women receiving 
+chemotherapy [54]. Vandhya is the term used to 
+denote this condition in females in Ayurveda. Like in 
+male infertility female also should undergo systemic 
+cleansing procedures and then oral medication. 
+Ayurveda for Chemo-radiotherapy Induced Side Effects in Cancer Patients 
+123
+Following are the few remedies told in the Ayurveda - 
+as the first and for most line of treatment, the women 
+should avoid all foods and lifestyles that aggravate 
+this problem. The herb of choice for female infertility 
+is ashoka (Saraca asoca Roxb De Wilde) – by its 
+astringent taste and cold potency, it strengthens the 
+uterus. It stops bleeding by contracting the uterine 
+blood vessels and promoting uterine muscular 
+contraction. 
+It 
+stimulates 
+uterine 
+function 
+by 
+stimulating the decidual and ovarian functions. 
+Kumari (Aloe vera) is another herb that improves 
+blood flow to the decidual membrane and it stimulates 
+uterine musculature to contract. It thus improves the 
+menstrual flow. It should not be given during 
+pregnancy as it may cause abortion [55]. It is useful in 
+inducing ovulation. Shatavari (Asperagus recemosus) 
+also nourishes the uterus and gives strength to the 
+muscles. It induces ovulation and it also prevents 
+abortion or miscarriage. Ashokarista (fermented 
+medicine which is prepared by using Saraca asoca and 
+other herbs) is most commonly used to regulate the 
+menstrual cycle, improve endometrium and to 
+stimulate ovulation. From the 4th day of the 
+menstruation, Ashokarista, in combination with 
+Kumaryasava (fermented medicine which is made by 
+using Aloe vera and other herbs) should be given. It is 
+usually combined with Aloes compound [a tablet 
+which is made by using Aloe vera, Manjista (Rubia 
+cardifolia), etc], Rajapravrtinivati (asafoetida, etc) to 
+induce ovulation [55].  
+ 
+ 
+Ayurvedic anti-oxidants 
+ 
+Psychological stress due to cancer diagnosis and 
+cancer treatment itself can be cause for deficiency of 
+anti-oxidants. Deficiency of anti-oxidants may have 
+impact on tolerance of normal tissue to antitumor 
+treatment and anti-oxidant supplements may lead to 
+dose reductions and compromised treatment outcome 
+[56].  
+Recently, studies have been conducted on the 
+Ayurvedic medicinal herbs and many of them are 
+found to be rich in antioxidants. Amalaki Rasayana 
+(AR) is one among them. AR is a polyherbal 
+preparation mentioned in the Charaka Samhita, it 
+revitalizes and rejuvenates the cells to work against 
+age-related deterioration. In one of the in-vitro studies 
+on methanoic extract of AR, its antioxidant property 
+and free radicals scavenging activity have been 
+demonstrated [57]. Selagenella bryipteris is another 
+ayurvedic herb with proven anti-cancer, anti-oxidant, 
+ani-inflammatory and chemo protective activity [58]. 
+Other drugs such as vyaghra nakhi (Capparis 
+zeylanica), amalaki (Amlica officinalis), bhunimba 
+(Andrographis 
+paniculata), 
+Mango 
+(Mongefera 
+indica), haritaki (Terminalia chebula), Brahmi (Bopa 
+monniera) etc. are other powerful anti-oxidants [59-
+61]. One of the most well-known preparations called 
+Triphala is a polyherbal ayurvedic compound which 
+contains three ingredients viz. Haritaki (Terminala 
+chebula), vibhitaki (Terminala belerica) and Amalaki 
+(Embilica officinalis). It is a potent anti-oxidant and 
+laxative. Experimental studies on triphala have 
+emphasized its importance as an anti-cancer, chemo-
+protective and radio-protective agent, especially 
+Haritaki 
+have 
+been 
+shown 
+to 
+reduce 
+lipid 
+peroxidation by increasing the glutathione levels [62-
+63]. 
+ 
+ 
+Hepatotoxicity 
+ 
+Many of the chemotherapeutic agents are 
+hepatotoxic and they commonly cause hepatic injury 
+in the patients [64]. 
+Ayurveda identifies abnormalities related to liver 
+by the term yakrittodar. It is associated with 
+symptoms of fatigue, anorexia, constipation, nausea, 
+vomiting, excessive thirst, emaciation, mild fever, 
+loss of taste, abdominal distension, indigestion, 
+prominent veins on the abdomen fainting, dyspnoea 
+and cough [Cha. Sam. Chi. 13/38, ref no. 13].  
+Ayurveda recommends systemic purificatory 
+therapy (panchakarma) depending on dominancy of 
+the dosha (considering the strength of the patient). 
+Massage, medicated enemas and intake of milk are 
+strongly 
+recommended. 
+Oral 
+administration 
+of 
+different poly-herbal preparations is also given for 
+long term [Cha. Sam. Chi. 13/67; ref no. 13]. 
+The multi-drug preparations such as rohitaka 
+ghrita, 
+panchakola 
+ghrita, 
+pippalyadi 
+churna 
+panchgavya ghrita etc. are recommended in such 
+conditions associated with liver and abdominal 
+diseases [Cha. Sam. chi 13/83-85, 13/149, 13/79; ref 
+no. 13]. 
+Kashinath Metri, Hemant Bhargav, Praerna Chowdhury et al. 
+124 
+In a recent animal study where albino rats were 
+exposed to gamma radiations, the rats treated with 
+Ashwagandha 
+(Withenia 
+somnifera) 
+showed 
+significant reduction in serum hepatic enzymes, DNA 
+damage, malondialdehyde (MDA levels), hepatic 
+nitrates and significant increase in heme-oxygenase, 
+super oxide dismutase and glutathione peroxidase 
+activity respectively, as compared to the controls. 
+This suggests its hepato-protective and anti-oxidant 
+enhancing effect against radiation induced hepato-
+toxiticity [65]. In another animal study, root extract of 
+ayurveda herb Himsra (Capparis sepiaria L) was 
+found to have significant hepato-protective property 
+against acetaminophen induced hepatotoxicity [66]. 
+Similarly, ayurvedic polyherbal formulation called 
+Punarnavastaka kwath has also been demonstrated to 
+have hepato-protective property against CCL-4 
+induced hepatotoxicity [67]. Liv 52 is another multi-
+herb preparation proven to have hepato-protective 
+effects against CCL-4 induced liver toxicity [68]. 
+Kumaryasava 
+is 
+another 
+important 
+polyherbal 
+compound shown to reduce liver weight that is 
+increased due to CCL-4 induced hepatotoxicity [68]. 
+Table 1 summarizes all major chem.-radiotherapy 
+related side effects and ayurveda based remedies for 
+them. 
+ 
+Table 1. Summary of Chemo-radiotherapy side effects and Ayurveda based remedies 
+ 
+S. No. 
+Side effects of 
+chemo-radiotherapy 
+Ayurvedic remedy 
+Classical 
+Research based 
+1 
+Mucositis 
+Khadiradi vati for chewing 
+Mouth gargles with kala churna [ Cha. Sam. 
+26/195-199; ref no. 13] 
+Oral application of Yestimadhu powder 
+with honey [22] 
+Triphala administration for five day prior 
+to chemo [23] 
+2 
+Nausea and Vomiting 
+powder of Haritaki with honey or 
+Khandkushmandavaleha [28] 
+Eladi churna [29] 
+Gut-Gard a extract from the ayurvedic 
+herb Yestimadhu (glycrrhiza glabra) 
+[Kadur Ramamurthy Raveendra et al] 
+2012 
+Ginger supplementation [26] 
+3 
+Anaemia 
+Oliation, purgation, oral intake cows urine 
+with milk or 
+Cow’s urine with decoction of triphala for 7 
+days [ Cha. Sam. 16/64; ref no. 13] 
+Dhatriavaleha [29] 
+4 
+Diarrhoea 
+Pippali powder with honey then butter milk 
+with powder of chitraka or Pippalyadi yoga 
+[ Cha. Sam. 29/79; ref no. 13] 
+Dadimashtaka churna 
+[ Cha. Sam. 29/113; ref no. 13, Sha. Sam. 
+6/65-69; ref no. 20] 
+Extract from herb Brahmi [31] and 
+Jatiphala 
+[32] 
+5 
+Constipation 
+Triphala with warm water and ghee(evidence 
+based) 
+[Cha. Sam. 26/27-28; ref no. 13] 
+Constipation caused by vata and pitta castor 
+oil (Erand taila) with decoction of triphala 
+or milk or meat soup. [56,47] 
+Isab husk, senna extract and Triphala. 
+TLPL/AY/01/2008 
+[Cha. Sam. 26/27-28; ref no. 13] 
+6 
+Pharyngitis 
+Khadiradi vati for chewing 
+Spray of five aromatic plant oils [48] 
+7 
+Sleep problem 
+Whole body massage, bath, rice with curd or 
+ghee or milk etc. music, comfortable bed, 
+cuddling before sleeping. 
+[Cha. Sam. 21/52-54; ref no. 13] 
+Methoinic extract of Mundi (Sphaeranthus 
+indicus) has sedative effect [35] 
+dietary supplement of Shweta musli and 
+atmagupta [43] 
+8 
+Hepatotoxicity 
+Panchakola ghrita 
+Rohitaka ghrita 
+[Cha. Sam. chi 13/83-85, 13/149, 13/79; ref 
+no. 13]. 
+Punarnavashtaka kwath [65] 
+Syr Liv 52 [68] 
+Syr Kumaryasav [68] 
+ 
+Ayurveda for Chemo-radiotherapy Induced Side Effects in Cancer Patients 
+125
+S. No. 
+Side effects of 
+chemo-radiotherapy 
+Ayurvedic remedy 
+Classical 
+Research based 
+9 
+Male Infertility 
+Gokshuradi modaka 
+[Bha. Pra. 25/27; ref no. 51]. 
+Mucuna pruriens [52] 
+10 
+Female infertility 
+Brahatashatavari Ghrita 
+Ashokarista [55] 
+11 
+Fatigue 
+Ashwagandha , Shatavari 
+[Cha. Sam. Sutra 4/7; ref no. 13] 
+Ashwagandha ghrita [41] 
+12 
+Skin changes 
+Massage with bala taila 
+[Cha. Sam. chi 28/30; ref no. 13] 
+ 
+13 
+Cognitive deficit 
+Kalyanaka GritaCharaka chikatsa 9 
+Chavanprash 
+[Cha. Sam. chi 1/73; ref no. 13]. 
+Chavanprash [43] 
+Ashwagandha [46] 
+ 
+ 
+ 
+Ayurvedic drugs having anti-cancer 
+property: Scientific Evidences 
+ 
+In series of animal experiments Wathaferin A, a 
+constituent of Ashwagandha (Withenia somnifera) has 
+been found effective in reducing mammary tumor 
+size, microscopic tumor area and incidences of 
+pulmonary metastasis [69-70]. It is being shown that 
+Aswagangadha selectively kills cancer cells by 
+inducing of ROS-signaling [71]. In another study, 
+Bhandirah (Clerodendrum viscosum) was shown to 
+have selective bioactivity against cervical cancer 
+cells, its pro-apoptotic, anti-proliferative, and anti-
+migratory activities were demonstrated in a dose-
+dependent fashion against cervical cancer cell lines 
+[72]. In one of the studies, Haridra (Curcuma longa) 
+with an active ingredient of curcumin was shown to 
+bind to cancer cell surface membrane and then 
+infiltrate into cytoplasm to initiate apoptotic process. 
+It was also reported that curcumin induced growth 
+inhibition and cell cycle arrest at G2/M phase in the 
+glioblastoma and medulloblastoma cells. This shows 
+that 
+curcumin 
+has 
+anti-cancer 
+property 
+[73]. 
+Manjistha (Rubia cardifolia) is another widely used 
+herb. Recent in-vitro study used its methanolic extract 
+to induce apoptosis in HEP-2 (Human laryngeal cell 
+line) as evidenced by cytotoxicity, morphological 
+changes and modification in the levels of pro-oxidants 
+[74]. Another study showed that aqueous extract of 
+Palash 
+(Butea 
+monosperma) 
+inhibited 
+cell 
+proliferation and accumulation of cells in G1 phase. 
+Also there was a marked reduction in the levels of 
+activated Erk1/2 and SAPK/JNK along with induction 
+of apoptotic cell death [75]. Triphala is another useful 
+ayurveda formulation for treatment and prevention of 
+cancer [76].  
+ 
+ 
+Ayurveda for Inhibition of Cancer Stem 
+Cells: Hypothesis 
+ 
+Many studies report association of inflammation 
+and cancer. The identification of transcription factors 
+such as NF-κB, AP-1 and STAT3 and their gene 
+products such as tumor necrosis factor, interleukin-1, 
+interleukin-6, chemokines, cyclooxygenase-2, 5-
+lipooxygenase, matrix metalloproteases, and vascular 
+endothelial growth factor have provided the molecular 
+basis for the role of inflammation in cancer [77]. 
+These inflammatory pathways may get activated by 
+tobacco, stress, dietary agents, obesity, alcohol, 
+infectious agents, irradiation, and environmental 
+stimuli. These pathways have been implicated in 
+transformation, cancer cell survival, proliferation, 
+invasion, chemo-resistance, and radio-resistance in 
+cancer. The survival and proliferation of most types of 
+cancer cells themselves appear to be dependent on the 
+activation of these inflammatory pathways through 
+their precursors, presumably cancer stem cells [77].  
+Ayurveda works on the fundamental principles of 
+tridosha and panchamahabhuta (five basic elements 
+of nature). According to ayurveda the inflammatory 
+process is manifestation of abnormally increased pitta 
+dosha. Most of the above mentioned herbs in the 
+management of chemo-radiotherapy side effects are 
+pitta dosha mitigating and thus, these herbs may 
+indirectly inhibit growth of cancer stem cells via 
+reducing inflammation. Further scientific studies are 
+needed in this area. Till now one study on methanolic 
+extract of the whole fruit of bitter melon also called 
+Kashinath Metri, Hemant Bhargav, Praerna Chowdhury et al. 
+126 
+karravella (Momordica charantia) has shown dose-
+dependent reduction in the number and size of 
+colonospheres. The extracts also inhibited cancer stem 
+cells by reducing the expression of DCLK1 and Lgr5, 
+which are markers of quiescent and activated stem 
+cells [78]. 
+Rasayana is one among the eight limbs of 
+ayurvedic treatment which acts through various ways. 
+The emerging data suggest that the possible 
+mechanisms 
+may 
+be 
+by 
+immune-stimulation, 
+quenching 
+free 
+radicals, 
+enhancing 
+cellular 
+detoxification mechanisms; repair damaged non-
+proliferating cells, inducing cell proliferation and self-
+renewal of damaged proliferating tissues, and 
+replenishing them by eliminating damaged or mutated 
+cells with fresh cells [79]. These rasayana may also 
+inhibit cancer stem cells; future studies should test the 
+effect of these groups of medications on cancer stem 
+cell survival and growth. 
+ 
+ 
+CONCLUSION 
+ 
+This manuscript highlights a very important area 
+of chemo-radiotherapy induced side effects in cancer 
+patients. All the major and common side effects are 
+covered and based on comprehensive review of 
+ancient vedic literature and modern scientific 
+evidences, ayurveda based management strategies are 
+put forth. This manuscript should help clinicians and 
+people suffering from cancer to combat serious 
+chemo-radiotherapy related side effects through 
+simple but effective home-based ayurveda remedies. 
+The remedies described are commonly available and 
+safe. These simple ayurveda based solutions may act 
+as an important adjuvant to chemo-radiotherapy and 
+enhance the quality of life of cancer patients. Future 
+studies 
+should 
+scientifically 
+test 
+these 
+recommendations for various side effects induced by 
+conventional management of cancer. 
+ 
+ 
+ACKNOWLEDGMENT 
+ 
+Dr. Prasad S Koka is funded by Ramalingaswami 
+Fellowship Re-entry Scheme of the Department of 
+Biotechnology, Government of India, New Delhi.  
+ 
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+ 
+ 

subfolder_0/An innovative approach in health sciences Yoga for obesity.txt

@@ -0,0 +1,278 @@
+162 
+Archives of Medicine and Health Sciences / Jan-Jun 2015 / Vol 3 | Issue 1
+Short Communication
+Corresponding Author: 
+Dr. Tikhe Sham Ganpat, Swami Vivekananda Yoga Anusandhana Samsthana University, (Prashanti Kutiram), 19, Eknath Bhavan, 
+Gavipuram Circle, Kempegowda Nagar, Bangalore - 560 019, Karnataka, India. E-mail: [email protected]
+Sharma Dushyant, Tekur Padmini, Tikhe Sham Ganpat, Nagendra Hongasandra Ramarao
+Department of Yoga and Management, Swami Vivekananda Yoga Anusandhana Samsthana University, Bangalore, Karnataka, India
+An innovative approach in health sciences: 
+Yoga for obesity
+ABSTRACT
+Obesity is a global health burden and its prevalence is increasing substantially due to changing lifestyle. A yoga-based lifestyle 
+intervention appears to be a promising option in obesity. The present study is designed to assess the effects of Integrated Approach 
+of Yoga Therapy (IAYT) in patients with obesity. Twenty-four obese patients (8 males and 16 females) between18 to 60 years were 
+assessed on the fi
+ rst and last day of a 7 days’ residential intensive IAYT program. The body mass index (BMI), waist circumference 
+(WC), hip circumferences (HC), and mid-arm circumference (MC) were recorded before and after the IAYT program. Paired Samples t 
+test (Statistical Package for the Social Sciences, SPSS-16) was used to compare the means before (pre) and after (post) the intervention. 
+The statistical analysis showed that there was a signifi
+ cant (P < 0.01, all comparisons) decrease (↓) in mean body weight from 
+86.52 ± 15.23 to 84.54 ± 14.95 (2.29% ↓), mean BMI from 32.04 ± 5.02 to 31.30 ± 4.88 (2.33% ↓), WC by 3.46% ↓, HC by 
+4.65% ↓, and MC by 4.74% ↓. The results suggest that IAYT program was benefi
+ cial for patients with obesity and may offer better 
+option to obesity-related problems. Randomized control trials are needed before a strong recommendation can be made.
+Key words: Body mass index, circumference, integrated approach of yoga therapy, obesity
+through self-regulatory behavioral change that improves 
+autonomic balance.[4] Yoga is known to be an effective tool 
+to reduce anxiety and depression symptoms as well as the 
+body mass index (BMI) in obese subjects.[5] The present study 
+was designed to assess the effect of Integrated Approach of 
+Yoga Therapy (IAYT) on anthropometric variables in patients 
+with obesity.
+Materials and Methods
+Subjects
+The data derived from the previous study with similar 
+design on yoga[6] has been used to calculate effect size using 
+G  Power. The power analysis (alpha = 0.05, power = 0.50, 
+effect size = 0.5196) yielded a number of 24 subjects for 
+the study.
+Inclusion criteria
+Both male and female patients with obesity. 
+Access this article online
+Quick Response Code:
+Website: 
+www.amhsjournal.org
+DOI: 
+10.4103/2321-4848.154974
+Introduction
+Most of the primary healthcare providers are convinced 
+of their critical role in obesity management but do not feel 
+sufficiently competent and look for acceptable and effective 
+interventions to tackle the problem of increasing prevalence 
+of obesity.[1] We know that there exists an etiological 
+relationship between obesity and stress.[2] It is also well-
+documented that yoga has been utilized as a therapeutic tool 
+to achieve positive health and treat stress-related diseases[3] 
+[Downloaded free from http://www.amhsjournal.org on Thursday, February 4, 2021, IP: 136.232.192.146]
+Sharma, et al.: Yoga for obesity
+Archives of Medicine and Health Sciences / Jan-Jun 2015 / Vol 3 | Issue 1 
+163
+Exclusion criteria
+Physically unable to participate and those participating in 
+other interventions.
+Ethical consideration
+An informed consent was obtained from all the participants 
+and the study was approved by the institutional review 
+board of Swami Vivekananda Yoga Anusandhana Samsthana 
+(S-VYASA) University, Bangalore.
+Design
+This is a single group pre-post study. Twenty-four obesity 
+patients (8 males and 16 females) between18 to 60 years of 
+age participated in IAYT program at the residential wellness 
+center of S-VYASA University, Bangalore, India.
+Intervention
+The IAYT program[7] was practiced by all the participants of 
+this study. It includes Kriya (yogic cleansing techniques), 
+Sukhma Vyayama (loosening and stretching practices), 
+Suryanamaskara (salutation to the sun), Asanas 
+(postures), Pranayama (breathing practices), relaxation 
+techniques, meditation, lectures on yoga philosophy, 
+group discussions, and devotional session along with 
+individualized low-fat-high-fiber vegetarian yogic diet 
+[Table 1].
+Assessments
+The BMI is a measure for human body shape based on an 
+individual’s mass and height. It is defined as the individual’s 
+body mass divided by the square of their height, with the 
+value universally being given in units of kg/m2. Height and 
+weight were recorded for each participant to determine their 
+BMI. Height was measured on a tape attached to a wall and 
+rounded down to nearest centimeter. Weight was measured 
+on a body fat monitor HBF 375 (Omron Co., Ltd, Singapore) 
+and rounded up to nearest kilogram. Cut-off points according 
+to World Health Organization (WHO)[8] were used to define 
+the prevalence of obesity. The hip circumference (HC), waist 
+circumference (WC), and mid-arm circumference (MC) were 
+measured by a tape in centimeter.
+Statistical analysis
+Statistical Package for the Social Sciences (SPSS) 16.0 
+showed that the data is normally distributed. Hence, Paired 
+Samples t test was used to compare the means before (pre) 
+and after (post) the intervention.
+Results
+Following the 7-days IAYT program, there was a significant 
+(P < 0.01, all comparisons) decrease (↓) in mean body 
+weight from 86.52 ± 15.23 to 84.54 ± 14.95 (2.29% ↓), 
+mean BMI from 32.04 ± 5.02 to 31.30 ± 4.88 (2.33% ↓), WC 
+by 3.46% ↓, HC by 4.65% ↓, and MC by 4.74% ↓ [Table 2].
+Discussion
+Medical authorities have identified obesity as a causal 
+factor in the development of diabetes, hypertension, and 
+cardiovascular disease and more broadly of metabolic 
+syndrome/insulin resistance syndrome. To provide solutions 
+that can modify this risk factor, researchers need to identify 
+methods of effective risk reduction and primary prevention of 
+obesity. Research on the effectiveness of yoga as a treatment 
+for obesity is limited, and studies vary in overall quality and 
+methodological rigor. The present study is an indication of 
+positive impact of IAYT in patients with obesity by reducing 
+BMI, WC, HC, and MC effectively. The underlying principle 
+of the benefits seen in this study may be attributed to the 
+following key features:[7]
+1. Supervised practice,
+2. Long duration of intervention,
+3. Yogic dietary component,
+4. A residential set up away from all responsibilities, and
+5. The comprehensive module of yoga that emphasized on 
+mind and stress management.
+It is well-known that psychobiological wellness and social 
+support can contribute to a better understanding and 
+management of obesity.[9] IAYT offers a holistic approach to 
+care and management with a strong conceptual basis for 
+self regulation and mastery over the modifications of mind 
+Table 1: Integrated approach of yoga therapy schedule
+Time
+Activity
+Time
+Activity
+05.00 AM
+Prayer (Prathasmaran)
+03.00 PM
+Lecture session 2
+05.30 AM
+Asanas/special yoga technique
+04.00 PM
+Special technique
+7.30 AM
+Breakfast
+05.00 PM
+Tuning to nature/walking
+08.15 AM
+Gita Sloka chanting and discourse 
+06.00 PM
+Devotional session (Bhajan)
+10.00 AM
+Parameter assessment
+06.45 PM
+Mind sound resonance 
+technique/Trataka
+11.00 AM
+Special technique
+07.30 PM
+Dinner 
+12.00
+Asana/Pranayama/Meditation
+08.30 PM
+Happy assembly (yoga game/
+cultural program 
+01.00 PM
+Lunch and rest
+09.15 PM
+Group discussion
+10.00 PM
+Lights off
+Table 2: Data analysis
+Variables
+Mean ± SD
+% decrease
+P value
+Pre (Before)
+Post (After)
+Weight
+86.52±15.23
+84.54±14.95
+2.29
+<0.001***
+BMI
+32.04±5.02
+31.30±4.88
+2.33
+<0.001***
+WC
+106.52±12.07
+102.83±12.22
+3.46
+<0.001***
+HC
+116.15±12.39
+110.75±10.68
+4.65
+=0.006**
+MC 
+32.06±3.57
+30.54±3.14
+4.74
+<0.001***
+**Signifi
+ cant at P < 0.01, ***Signifi
+ cant at P < 0.001 (Paired Samples t Test), SD: Standard 
+deviation, WC: Waist circumference, HC: Hip circumference, MC: Mid-arm circumference
+[Downloaded free from http://www.amhsjournal.org on Thursday, February 4, 2021, IP: 136.232.192.146]
+Sharma, et al.: Yoga for obesity
+164 
+Archives of Medicine and Health Sciences / Jan-Jun 2015 / Vol 3 | Issue 1
+as defined by sage Patanjali in chapter 1 aphorism 2 of 
+Patanjali Yoga Sutra. It is possible to promote better health 
+and well-being in those with obesity as yoga offers innovative 
+solutions at low cost, with easy stretches with emphasis on 
+relaxation that makes it acceptable and effective and hence 
+may be used as an add on or alternative in public health 
+programs for management of obesity.[10]
+Conclusion
+The present study suggests that IAYT may be adopted as a 
+way of life to deal with obesity. Randomized control trials 
+are needed before a strong recommendation can be made.
+Acknowledgement
+Authors acknowledge Chancellor of S-VYASA University for granting 
+permission to carry out this work.
+References
+1. 
+Mazur A, Matusik P
+, Revert K, Nyankovskyy S, Socha P
+, 
+Binkowska-Bury M, et al. Childhood obesity: Knowledge, 
+attitudes, and practices of European pediatric care providers. 
+Pediatrics 2013;132:e100-8.
+2. 
+Beals CA, Lampman RM, Banwell BF, Braunstein EM, 
+Albers JW, Castor CW. Measurement of exercise tolerance 
+in patients with rheumatoid arthritis and osteoarthritis. 
+J Rheumatol 1985;12:458-61.
+3. 
+Vaze N, Joshi S. Yoga and menopausal transition. J Midlife 
+Health 2010;1:56-8.
+4. 
+Sahay BK. Yoga in medicine. API textbook of medicine. 5th 
+ed. 1995. p. 1444-5.
+5. 
+Dhananjai S, Sadashiv, Tiwari S, Dutt K, Kumar R. Reducing 
+psychological distress and obesity through Yoga practice. Int 
+J Yoga 2013;6:66-70.
+6. 
+Sarvottam K, Magan D, Yadav RK, Mehta N, Mahapatra SC. 
+Adiponectin, interleukin-6, and cardiovascular disease risk 
+factors are modified by a short-term yoga-based lifestyle 
+intervention in overweight and obese men. J Altern 
+Complement Med 2013;19:397-402.
+7. 
+Villacres Mdel C, Jagannathan A, Nagarathna R, Ramakrsihna J. 
+Decoding the integrated approach to yoga therapy: Qualitative 
+evidence based conceptual framework. Int J Yoga 2014;7:22-31.
+8. 
+WHO Expert Consultation. Appropriate body mass index 
+for Asian population and its implications for policy and 
+intervention strategies. Lancet 2004;363:157-63.
+9. 
+Brown J, Wimpenny P
+. Developing a holistic approach to 
+obesity management. Int J Nurs Pract 2011;17:9-18.
+10. Unnikrishnan AG, Kalra S, Garg MK. Preventing obesity 
+in India: Weighing the options. Indian J Endocrinol Metab 
+2012;16:4-6.
+How to cite this article: Dushyant S, Padmini T, Ganpat TS, Ramarao NH. 
+An innovative approach in health sciences: Yoga for obesity. Arch Med Health 
+Sci 2015;3:162-4.
+Source of Support: Nil, Confl
+ ict of Interest: None declared.
+[Downloaded free from http://www.amhsjournal.org on Thursday, February 4, 2021, IP: 136.232.192.146]

subfolder_0/Assessment of risk of diabetes by using Indian Diabetic risk score (IDRS) in Indian population.txt

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+Assessment of risk of diabetes by using Indian
+Diabetic risk score (IDRS) in Indian population
+Raghuram Nagarathna b,*, Rahul T
+yagi a, Priya Battu a, Amit Singh b, Akshay Anand a,1,
+Hongasandra Ramarao Nagendra b
+a Neuroscience Research Lab, Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
+b Swami Vivekananda Yoga Research Foundation, Bengaluru, India
+A R T I C L E
+I N F O
+Article history:
+Received 7 December 2019
+Received in revised form
+30 January 2020
+Accepted 18 February 2020
+Available online 19 February 2020
+Keywords:
+T2DM
+Diabetic Yoga Protocol
+IDRS
+Diagnosis
+DYP
+A B S T R A C T
+Aims: To screen the Indian population for Type 2 Diabetes Mellitus (DM) based on Indian
+Diabetes Risk Score. Our main question was; Does Indian Diabetic risk score (IDRS) effec-
+tively screen diabetic subjects in Indian population?
+Methods: Multi-centric nationwide screening for DM and its risk in all populous states and
+Union territories of India in 2017. It is the first pan India DM screening study conducted on
+240,000 subjects in a short period of 3 months based on IDRS. This was a stratified transla-
+tional research study in randomly selected cluster populations from all zones of rural and
+urban India. Two non-modifiable (age, family history) and two modifiable (waist circumfer-
+ence & physical activity) were used to obtain the score. High, moderate and low risk groups
+were selected based on scores.
+Results: In this study 40.9% subjects were detected to be high risk, known or newly diag-
+nosed DM subjects in urban and rural regions. IDRS could detect 78.1% known diabetic sub-
+jects as high risk group. Age group 50–59 (17.4%); 60–69 (22%); 70–79 (22.8%); >80 (19.2%)
+revealed high percentage of subjects. ROC was found to be 0.763 at CI 95% of 0.761–0.765
+with statistical significance of p < 0.0001. At >50 cut off, youden index showed the sensitiv-
+ity of 78.05 and specificity of 62.68. Regression analysis revealed that IDRS and Diabetes are
+significantly positively associated.
+Conclusions: Data reveals that IDRS is a good indicator of high risk diabetic subjects.
+
 2020 Elsevier B.V. All rights reserved.
+1.
+Introduction:
+As per the International Diabetes Federation (IDF), the num-
+ber of people with Type 2 Diabetes (DM) is increasing in each
+country. Currently, 387 million people are living with Diabetes
+across the world, and it is expected to rise to a whopping fig-
+ure of 592 million in 2035 [1]. In the year 2000, India had high-
+est number of DM patients followed by china and US. This DM
+patient population is expected to increase to 79.4 million by
+2030 in India [36]. Co-morbidities associated with Diabetes
+and resulting mortality go unidentified because of late diag-
+nosis and delay in initiation of therapy. This is largely pre-
+ventable by early diagnosis of DM and increasing awareness
+about the disease both in public as well as among the
+https://doi.org/10.1016/j.diabres.2020.108088
+0168-8227/
 2020 Elsevier B.V. All rights reserved.
+* Corresponding author at: Swami Vivekananda Yoga Research Foundation (SVYASA), Bengaluru, India.
+E-mail addresses: [email protected] (R. Nagarathna), [email protected] (A. Anand).
+1 Co-Corresponding author at: Neuroscience Research Lab, Department of Neurology, PGIMER, Chandigarh, India.
+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 2 ( 2 0 2 0 ) 1 0 8 0 8 8
+Contents available at ScienceDirect
+Diabetes Research
+and Clinical Practice
+journal homepage: www.elsevier.com/locate/diabres
+health-care providers. The strategy for the prevention of DM
+is mainly based on the regulation of modifiable risk factors.
+Bassuk and Manson have reviewed studies where 30 min/
+day moderate physical activity was linked with reduced risk
+of development of DM and cardiovascular diseases. They con-
+cluded that physical exercise helps in weight reduction, regu-
+lation of blood pressure, inflammation, improvement in
+insulin sensitivity etc. showing that changes in modifiable
+risk factors helps in lower risk of DM development. The pop-
+ulation may, therefore, be divided into two target groups-high
+risk individuals and the remaining population.
+A strong argument exists in favor of screening for partici-
+pants who are at an increased risk for DM [2]. Attempts have
+been made to devise risk scores to screen population for DM
+[3–6]. The Indian Diabetes Risk Score (IDRS), has been
+emerged as a simple screening tool for prediction of undiag-
+nosed DM, which was developed by Mohan et al. at the
+Madras Diabetes Research Foundation (MDRF), Chennai. The
+score referred to as MDRF-IDRS was derived from the Chennai
+Urban Rural Epidemiology Population Study (CURES) and was
+internally validated using the data from the Chennai Urban
+Population Study [7]. Several other studies also have demon-
+strated the sensitivity, specificity and accuracy of MDRF-
+IDRS [8].
+The IDRS is a cost effective simple tool based on four sim-
+ple parameters derived from known risk factors for DM, two
+modifiable risk factors (waist circumference and physical
+inactivity) and two non-modifiable risk factors (age and fam-
+ily history of diabetes) which may be amenable to interven-
+tion [9]. Significant correlation between BMI and IDRS, with
+DM in rural area of Tamil Nadu has been reported. It was
+found that with increase in BMI likelihood of maximum dia-
+betic score was also high [10]. Additionally, Mohan et al. has
+also estimated the cost-effectiveness of MDRF-IDRS for popu-
+lation screening and found it to be of low cost and user
+friendly for screening Prediabetes and DM in population
+[11]. IDRS has been shown to be having a sensitivity of
+95.12% and specificity of 28.95% in DM subjects with >60
+score[12]. A north Indian study has shown its 100% sensitivity
+at a cut off value 
30 recommending it to screen medium to
+high risk DM cases [13]. Studies have also reported an excel-
+lent predictive capacity of IDRS to undiagnosed DM condi-
+tions
+[8,14].
+However,
+no
+nationwide
+study
+with
+large
+sample size has been carried out to estimate its utility for glo-
+bal application. The study data will benefit the government to
+frame as well as implement national diabetic control pro-
+grammes in different zones, aged populations, genders and
+social settings.
+Subject Recruitment and Screening: The objective of the
+first phase of this study was to conduct a multi-centric
+nationwide screening for DM and its risk in all states/union
+territories of India in 2017. Subjects were recruited based on
+defined inclusion and exclusion criteria under the guidelines
+of Institutional ethics Committee (Vide Res/IEC-IYA/001 dated
+16.12.16). This community based study was called Niyantrita
+Madhumeha Bharata Abhiyaan (NMB-2017)(Diabetes control
+mission in India) and was carried out by Indian Yoga associa-
+tion. It was funded by the Ministry of Health and Family Wel-
+fare and the Ministry of AYUSH, Govt. of India, New Delhi.
+Methodological details were used according to previous study
+[15]. Briefly, the steps included: a) Formation of international
+research advisory committee of 16 experts who designed
+the study protocol and monitor the quality control processes
+adopted at various levels of the rapid survey. b) Random selec-
+tion of districts (1/10) from all states/Union territories, fol-
+lowed
+by
+random
+selection
+of
+clusters
+of
+urban
+(cities/towns) and rural (villages) areas across India. c) Screen-
+ing of all men and women above 20 years of age in all house-
+holds in these selected areas covering a population of 4000/
+District (50% rural and 50% urban) by 1200 trained field volun-
+teers (20/ district), further monitored by 35 senior research
+fellows and 2 research associates. Door to door screening
+was carried out by requesting information in the screening
+form (hard copy and mobile app) that consisted of questions
+related to age, gender, education, occupation, marital status,
+socio-economic status (education of Head, occupation of
+head, family income), Diabetes information, IDRS risk factors,
+body vitals (height, weight, hip circumference) and diet
+information.
+1.1.
+Risk assessment tool
+Indian Diabetes Risk Score (IDRS), developed and validated by
+Madras Diabetes Research Foundation (MDRF), Chennai [7],
+was administered to detect high risk population. IDRS com-
+prises of two modifiable (waist circumference, physical activ-
+ity) and two non-modfiable risk factors (age, family history)
+for Diabetes.
+1.2.
+Procedure
+1.2.1.
+Subjects
+Subjects were recruited based on defined inclusion and exclu-
+sion criteria as per the guidelines of Institution Ethics Com-
+mittee. The screening of all men and women above 20 years
+of age covering a population of 4000/District (50% rural and
+50% urban) was carried out. Door to door screening was car-
+ried out by requesting information in the screening form
+(hard copy and mobile app) that consisted of questions
+related to age, gender, education, occupation, marital status,
+socio-economic status (education of Head, occupation of
+Head, family income), Diabetes information (history of dia-
+betes, time since diagnosis, whether undergoing any treat-
+ment or not etc), IDRS risk factors, body vitals (height,
+weight, hip circumference) and diet information.
+Information related to IDRS (age, physical activity at
+home/work, family history) was collected from all those
+above 20 years of age in all households in the selected area.
+The trained field research volunteers who visited each house-
+hold recorded the information about age, physical activity
+and family history during the interview, in a hard copy of
+the screening form.
+The waist circumference (in centimeters) was measured
+using a flexible (non metallic) 6 m long measuring tape that
+had centimeter/millimeter marking. The individuals were
+asked to remove their clothing around the abdomen, stand
+straight with both feet together, raise the upper limbs, and
+stay relaxed. The measuring tape was wrapped around the
+abdomen between iliac crest and the lower margin of the
+rib cage, and the umbilicus in front. Measurement was taken
+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 2 ( 2 0 2 0 ) 1 0 8 0 8 8
+by keeping the tape parallel to the ground. Special care was
+taken to ensure that there are no twists in the tape and it does
+not cause any compression in the skin.). Scoring for 4 differ-
+ent risk factors of IDRS was done as per Table 1. Only those
+individuals with high score of 
60 on IDRS were called for
+the second level of testing meant for blood tests and detailed
+data.
+Statistical analysis: The statistical analysis was carried out
+using SPSS software in order to analyze the mean, standard
+deviations, proportions and CI at 95%. P value <0.05 was con-
+sidered statistically significant. ROC curve was plotted to ana-
+lyze the sensitivity and specificity of IDRS among various risk
+groups. Chi square test was used to test the significance
+between proportions. Entire statistical analysis was con-
+ducted at SVYASA, Bangalore and raw data deposited there.
+2.
+Results
+Demographic Details: Pan-India, a total of 240,000 individuals
+were recruited for screening based on IDRS. Demographical
+details including age, sex, Body-mass Index, Waist circumfer-
+ence, socio-economic Status have been tabulated in Table 2.
+Zone wise prevalence: Zone wise prevalence was esti-
+mated 40.9% prevalence of high risk, whether known or newly
+diagnosed DM subjects, in urban (23.1%) and rural (17.8%)
+regions. Moreover, 29.7% populations were found to have
+moderate risk for DM. Regions including North, North West
+(J&K), North East (NE), Central, West, East and South, were
+segregated. Among these Zones, urban settings of J&K region
+showed 33% prevalence with (0.321–0.337) of 95% CI, however,
+rural areas of North Indian Zone showed 27.5% prevalence.
+South Indian urban Zone showed an increased number of
+moderate risk group (23.3%) whereas North Indian rural Zone
+showed 19.5% prevalence. Table 3 depicts the prevalence in
+various urban and rural zones.
+Table 3 shows the zone wise distribution of IDRS risk fac-
+tors. The highest percentage of high risk population (33. %)
+was in northwest zone (Jammu and Kashmir). Least percent-
+age of high risk population (15.7%) was in the East zone. Sub-
+jects in the urban areas were at higher risk than the rural
+area.
+2.1.
+Distribution of known DM subjects
+Majority of known DM subjects (78.1%) were found in the high
+risk group confirming the importance of IDRS. The north
+western region remains the highest prevalence zone followed
+by South India (in the urban region) whereas north Indian
+rural areas showed high risk diabetic subjects. Out of 766
+low risk candidates, only 0.3% were from J&K region whereas
+central Indian urban as well as rural regions were found to
+report more cases in this category. Statistical analysis has
+been shown in the Table 4.
+Table 4
+Age wise distribution of IDRS: Data indicates that 50–59
+age groups are crucial in the screening of DM subjects. A shift
+of 10% increase in the high risk category was observed in this
+age group. The increase in age, as anticipated, had an
+increased proportion of high risk individuals, 50–59 (17.4%);
+Table 1 – IDRS Scoring based on non-modifiable and modifiable risk factors.
+Parameters
+Scores
+Non-modifiable Risk Factor
+Age
+<35 years = 10
+35–49 years = 20
+
50 years = 30.
+Family history:
+Both non-diabetic parents = 0
+One parent having Diabetes = 10
+Both Diabetic parents = 20
+Modifiable Risk Factor
+Physical activity at home or work
+Vigorous exercise or strenuous
+work = 0
+Moderate exercise = 10
+Mild exercise = 20
+no exercise = 30
+Male: Waist circumference:
+less than < 90 cm = 0
+90–99 cm = 20
+
100 cm = 30
+Female: Waist circumference:
+<80 cm = 0
+80–89 cm = 20
+
90 cm = 30
+IDRS Risk Score
+<30 = Low Risk
+30–50 = Moderate risk
+
60 = High Risk
+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 2 ( 2 0 2 0 ) 1 0 8 0 8 8
+3
+Table 2 – Demographic details of the screened population in different zones of India.
+Zone
+area
+All India
+Central (n = 24854) East (n = 22430) J&K (n = 14495) North (n = 17602) North East (n = 16251) South (n = 39338) West (n = 27360)
+Age Mean (SD) Total
+40.5 (13.3)
+40.4 (13.7)
+41.8 (13.5)
+41.0 (13.5)
+41.2 (13.3)
+41 (13.9)
+43.4 (14.3)
+Rural
+41.1 (13.69)
+39.06 (12.94)
+41.01 (13.87)
+41.52 (13.44)
+40.42 (13.24)
+40.41 (12.98)
+42.73 (14.71)
+42.67 (14.4)
+Urban
+41.8 (13.8)
+42.15 (13.65)
+40 (13.59)
+42.06 (13.7)
+42.25 (13.89)
+42.18 (13.62)
+40.01 (13.34)
+44.16 (14.31)
+Sex
+Male
+76,801
+13,255 (53.3)
+11,169 (49.8)
+6891 (47.5)
+7602 (43.2)
+7439 (45.8)
+17,506 (44.5)
+140,663
+Urban
+39,407 (51.3%) 6122 (46.2%)
+5550 (49.6%)
+4159 (60.4%)
+2909 (38.3%)
+3600 (48.4%)
+10,566 (60.4%)
+6500 (50.2%)
+Rural
+37,394 (48.7%) 7133 (43.8%)
+5619 (50.4%)
+2732 (39.6%)
+4693 (61.7%)
+3839 (51.6%)
+6940 (39.6%)
+7132 (49.8%)
+Ratio
+1:0.94
+1:1.16
+1:1.01
+1:0.66
+1:1.6
+1:1.17
+1:0.66
+1:1.11
+Female 84,856
+11,573 (46.6)
+11,248 (50.1)
+7587 (52.3)
+9987 (56.7)
+8804 (54.2)
+21,264 (55.5)
+14,393 (52.6)
+Urban
+44,247 (52.1%) 5936 (51.3%)
+5929 (52.7%)
+4201 (50.2%)
+3364 (33.7%)
+4222 (48%)
+13,213 (62.1%)
+7382 (51.3%)
+Rural
+40,609 (47.9%) 5637 (48.7%)
+5319 (47.3%)
+3386 (49.8%)
+6623 (66.3%)
+4582 (52%)
+8051 (37.8%)
+7011 (48.7%)
+Ratio
+1:0.92
+1:0.95
+1:089
+1:0.81
+1:1.96
+1:1.1
+1:0.61
+1:0.95
+BMI*
+Overall 24.6 (4.7)
+19.09 (3.69)
+18.5 (3.23)
+19.7 (3.29)
+19.5 (3.96)
+19.0 (3.35)
+19.8 (3.27)
+19.7 (3.67)
+WC*
+Male
+88.8 (11.3)
+89.5 (12.4)
+85.6 (8.9)
+91.6 (8.7)
+89 (11.6)
+87.6 (9.8)
+88.4 (13.9)
+90.2 (11.0)
+Female 85.20 (14.3)
+83.8 (11.8)
+81.8 (9.7)
+89.4 (11.6)
+87.9 (13.1)
+85.4 (10.9)
+83.1 (20.3)
+87.1 (12.0)
+Overall 86.8 (13.3)
+86.9 (12.4)
+83.7 (9.5)
+90.4 (9.8)
+88.3 (12.5)
+86.4 (10.4)
+85.3 (18.2)
+88.5 (11.6)
+SES*
+Low
+51,664 (41.6)
+7583 (54.7)
+8909 (57.4)
+4424 (32.2)
+6595 (47.8)
+6681 (44.5)
+10,392 (38.3)
+7080 (37.3)
+Middle
+52,222 (42.1)
+4703 (33.9)
+5632 (36.3)
+8088 (58.9)
+5647 (40.9)
+7064 (47.1)
+11,900 (43.9)
+9188 (48.4)
+High
+17,007 (13.4)
+1554 (11.2)
+1962 (6.2)
+2209 (8.8)
+2540 (11.1)
+1236 (8.25)
+4800 (17.7)
+2706 (14.2)
+Table 3 – Distribution of IDRS scores in urban and rural areas in different zones.
+IDRS
+Area
+J&K (NW) n
+(%) 95%CI
+NE n
+(%) 95%CI
+North n
+(%) 95%CI
+Central n
+(%) 95%CI
+West n
+(%) 95%CI
+East n
+(%) 95%CI
+South n
+(%) 95%CI
+Total n
+(%) 95%CI
+High risk (>60)
+Urban
+4771 (33.0%)
+(0.321–0.337)
+3413 (21%)
+(0.203–0.216)
+3372 (19.2%)
+(0.186–0.197)
+4160(16.8%)
+(0.162–0.172)
+7544(27.7%)
+(0.271–0.281)
+3513(15.7%)
+(0.152–0.161)
+8311(29.0%)
+(0.284–0.295)
+35.084(23.1%)
+(0.229–0.233)
+Rural
+2886 (19.9%)
+(0.192–0.205)
+2746 (16.9%)
+(0.146–0.158)
+4823 (27.5%)
+(0.267–0.281)
+1749(7.0%)
+(0.067–0.073)
+6088(22.0%)
+(0.218–0.228)
+3234 (14.4%)
+(0.139–0.148)
+5567 (19.4%)
+(0.189–0.198)
+27,073(17.8%)
+(0.176–0.180)
+Moderate risk(30–50)
+Urban
+2033 (14.0%)
+(0.134–0.146)
+2349 (14.5%)
+(0.139–0.150)
+1677(9.5%)
+(0.091–0.099)
+3049 (12.3%
+(0.118–0.127)
+3493 (12.8%)
+(0.124–0.132)
+3896 (17.4%)
+(0.168–0.178)
+6670 (23.3%)
+(0.227–0.237)
+23,167(15.2%)
+(0.151–0.154)
+Rural
+1861 (12.9%)
+(0.123–0.134)
+2689(16.6%)
+(0.159–0.171)
+3433(19.5%)
+(0.189–0.201)
+3020(12.2%)
+(0.117–0.125)
+3770(13.8%)
+(0.134–0.142)
+4117 (18.4%)
+(0.178–0.188)
+3114 (10.9%)
+(0.104–0.112)
+22,004(14.5%)
+(0.143–0.146)
+Low risk (<30)
+Urban
+1556 (10.7%)
+(0.102–0.112)
+2057 (12.7%)
+(0.121–0.131)
+1207(6.9%)
+(0.065–0.072)
+4843(19.5%)
+(0.190–0.200)
+2804(10.3%)
+(0.099–0.106)
+4065(18.1%)
+(0.176–0.186)
+2667(9.3%)
+(0.089–0.096)
+19,199(12.6%)
+(0.125–0.128)
+Rural
+1371 (9.5%)
+(0.089–0.099)
+2985 (18.4%)
+(0.177–0.189)
+3055 (17.4%)
+(0.168–0.179)
+7996 (32.2%)
+(0.316–0.328)
+3657 (13.4%)
+(0.130–0.138)
+3583 (16.0%)
+(0.155–0.164)
+2358 (8.2%)
+(0.079–0.085)
+25,005(16.5%)
+(0.163–0.166)
+Total
+14,478
+16,238
+17,567
+24,817
+27,276
+22,408
+28,687
+1,51,532
+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 2 ( 2 0 2 0 ) 1 0 8 0 8 8
+Table 4 – Distribution of known Diabetes patients in different ranges of risk scores on IDRS in Rural and Urban sectors of different zones of India.
+IDRS
+Area
+J&K (NW) n (%)
+95%CI
+NE n (%) 95%CI
+North n (%)
+95%CI
+Central n (%)
+95%CI
+West n (%) 95%
+CI
+East n (%) 95%
+CI
+South n (%)
+95%CI
+=Total n (%)
+95%CI
+High risk
+(>60)
+Urban
+634 (62.9)
+(0.598–0.659)
+592 (45.7)
+(0.430–0.485)
+469 (32.5)
+(0.300–0.349)
+722 (49.7)
+(0.471–0.523)
+1490 (48.0)
+(0.462–0.497)
+669 (37.1)
+(0.365–0.411)
+2401 (55.0)
+(0.535–0.565)
+7007 (48.3)
+(0.47–0.49)
+Rural
+273 (27.1)
+(0.243–0.299)
+295 (22.8)
+(0.205–0.232)
+723 (50.1)
+(0.474–0.527)
+266 (18.3)
+(0.163–0.204)
+1094 (35.2)
+(0.335–0.369)
+553 (30.7)
+(0.285–0.329)
+1101 (25.2)
+(0.239–0.265)
+4305 (29.7%)
+(0.29–0.30)
+Total
+907 (8.01%)
+887 (7.8%)
+1192(10.53%)
+988 (8.73%)
+2584(22.84%)
+1,222 (10.80)
+3502 (30.95)
+11,312
+Moderate risk(30–50)
+Urban
+55 (5.4)
+(0.04–0.07)
+202 (15.6)
+(0.136–0.177)
+91 (6.3)
+(0.05–0.07)
+162 (11.1)
+(0.095–0.128)
+257 (8.2)
+(0.073–0.083)
+209 (11.6)
+(0.101–0.131)
+431 (9.9)
+(0.09–0.108)
+1407 (9.7%)
+(0.092–0.102)
+Rural
+29 (2.87)
+(0.019–0.041)
+121 (9.35)
+(0.078–0.110)
+103 (7.1)
+(0.058–0.085)
+99 (6.8)
+(0.055–0.082)
+170 (5.4)
+(0.047–0.063)
+228 (12.6)
+(0.111–0.142)
+253 (5.8)
+(0.051–0.065)
+1003 (6.9%)
+(0.065–0.073)
+Total
+84
+323
+194
+261
+427
+437
+684
+2410
+Low risk (<30)
+Urban
+4 (0.39)
+(0.001–0.01)
+42 (3.2)
+(0.023–0.043)
+16 (1.1)
+(0.006–0.017)
+81 (5.5)
+(0.044–0.068)
+54 (1.7)
+(0.013–0.022)
+83 (4.6)
+(0.036–0.056)
+104 (2.38)
+(0.019–0.028)
+384 (2.69%)
+(0.023–0.029)
+Rural
+12 (1.1)
+(0.006–0.02)
+41 (3.17)
+(0.022–0.042)
+41 (2.8)
+(0.02–0.038)
+122 (8.4)
+(0.070–0.099)
+39 (1.25)
+(0.008–0.017)
+58 (3.2)
+(0.024–0.041)
+69 (1.58)
+(0.012–0.019)
+382 (2.62%)
+(0.023–0.029)
+Total
+16
+83
+57
+203
+93
+141
+173
+766
+Zone wise Total
+1007
+1293
+1443
+1452
+3104
+1800
+4359
+14,458
+Note: >95% of self reported diabetics were in high and moderate scores on IDRS.
+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 2 ( 2 0 2 0 ) 1 0 8 0 8 8
+5
+Table 5 – Age wise distribution of IDRS in known diabetes patients in the Screened population.
+Age range
+IDRS
+High
+Moderate
+Low
+Total number
+Known DM
+Total number
+Known DM
+Total number
+Known DM
+<20
+196
+18 (0.5%)
+793
+12(0.3%)
+2940
+26 (0.7%)
+20–29
+1810
+112 (0.4%)
+8421
+108 (0.4%)
+16,811
+161 (0.6%)
+30–39
+9045
+643 (1.9%)
+12,806
+363 (1.1%)
+12,343
+199 (0.6%)
+40–49
+15,558
+2336 (7.6%)
+10,149
+778 (2.5%)
+4858
+185 (0.6%)
+50–59
+16,617
+3959 (17.4%)
+4824
+566 (2.5%)
+1296
+93 (0.4%)
+60–69
+11,191
+3355 (22%)
+3310
+438 (2.9%)
+731
+67 (0.4%)
+70–79
+2408
+737 (22.8%)
+672
+110 (3.4%)
+152
+11 (0.3%)
+>80
+262
+75 (19.8%)
+91
+14 (3.7%)
+25
+3 (0.8%)
+Total
+57,087
+11,215
+41,066
+2376
+39,156
+745
+Table 6 – Sensitivity and Specificity of IDRS.
+Criterion
+Sensitivity
+95% CI
+Specificity
+95% CI
++LR
+95% CI
+LR
+95% CI
+
0
+100.00
+100.0–100.0
+0.00
+0.0–0.003
+1.00
+1.0–1.0
+>0
+99.54
+99.4–99.6
+3.14
+3.0–3.2
+1.03
+1.0–1.0
+0.15
+0.1–0.2
+>10
+99.11
+98.9–99.3
+8.81
+8.7–9.0
+1.09
+1.1–1.1
+0.10
+0.09–0.1
+>20
+97.99
+97.7–98.2
+18.24
+18.0–18.5
+1.20
+1.2–1.2
+0.11
+0.10–0.1
+>30
+94.70
+94.3–95.1
+31.24
+31.0–31.5
+1.38
+1.4–1.4
+0.17
+0.2–0.2
+>40
+88.66
+88.1–89.2
+45.13
+44.9–45.4
+1.62
+1.6–1.6
+0.25
+0.2–0.3
+>50
+78.05
+77.4–78.7
+62.68
+62.4–62.9
+2.09
+2.1–2.1
+0.35
+0.3–0.4
+>60
+61.32
+60.5–62.1
+76.50
+76.3–76.7
+2.61
+2.6–2.7
+0.51
+0.5–0.5
+>70
+40.74
+39.9–41.5
+88.27
+88.1–88.5
+3.47
+3.4–3.6
+0.67
+0.7–0.7
+>80
+17.64
+17.0–18.3
+96.45
+96.3–96.6
+4.97
+4.7–5.2
+0.85
+0.8–0.9
+>90
+4.11
+3.8–4.4
+99.49
+99.5–99.5
+8.12
+7.3–9.1
+0.96
+1.0–1.0
+>100
+0.00
+0.0–0.03
+100.00
+100.0–100.0
+1.00
+1.0–1.0
+Table 7 – a & b: Regression analysis showing prediction of self reported diabetes by IDRS.
+a) Multinomial regression
+Parameter Estimates
+IDRS3riskfcatora
+B
+Std. Error
+Wald
+df
+Sig.
+Odds ratio
+95% CI for Exp (B)
+Lower Bound
+Upper Bound
+1.00
+Intercept
+2.597
+0.158
+269.822
+1
+<0.001
+[PreRdiabetes = 0.0]
+0.988
+0.165
+35.747
+1
+<0.001
+2.686
+1.943
+3.713
+[PreRdiabetes = 1.0]
+0b
+.
+.
+0
+.
+.
+.
+.
+2.00
+Intercept
+1.100
+0.083
+174.425
+1
+<0.001
+[PreRdiabetes = 0.0]
+0.410
+0.090
+20.787
+1
+<0.001
+1.507
+1.264
+1.798
+[PreRdiabetes = 1.0]
+0b
+.
+.
+0
+.
+.
+.
+.
+a. The reference category is: 3.00.
+b. This parameter is set to zero because it is redundant.
+b) Binary logistic regression
+Variables in the Equation
+B
+S.E.
+Wald
+df
+Sig.
+Odds ratio
+95% C.I.for EXP (B)
+Lower
+Upper
+Step 1a
+IDRS3riskfcator
+49.774
+2
+<0.001
+IDRS3riskfcator(1)
+0.578
+0.177
+10.708
+1
+0.001
+1.782
+1.261
+2.519
+IDRS3riskfcator(2)
+0.988
+0.165
+35.747
+1
+<0.001
+2.686
+1.943
+3.713
+Constant
+2.489
+0.159
+245.927
+1
+<0.001
+0.083
+a. Variable(s) entered on step 1: IDRS3riskfcator.
+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 2 ( 2 0 2 0 ) 1 0 8 0 8 8
+60–69 (22%); 70–79 (22.8%); >80 (19.2%). Age wise distribution
+has been shown in Table 5
+2.2.
+Sensitivity & specificity of IDRS
+ROC curve was plotted for 137,947 participants. Area under
+the ROC curve was found to be 0.763 at CI 95% of 0.761 to
+0.765 with statistical significance of p < 0.0001. Youden index
+at >50 criterion, the sensitivity of 78.05 and specificity of 62.68
+was observed. Sensitivity and specificity at different criterion
+have been provided in Table 6. Prediction of self reported dia-
+betes through IDRS was found to be positively significantly
+associated with odds ratios 1.782 (1.261–2.519) and 2.686
+(1.943–3.713) as provided in Table 7.
+3.
+Discussion
+IDRS is one of the cost-effective methods to detect the DM
+risk among the Indian population.[8,16] This is the first
+nationwide study on 240,000 population conducted within
+3 months in all zones of India. Based on IDRS data, we report
+that 40.9% & 29.7% of known DM subjects fall in high risk and
+moderate risk groups, respectively. This increased to 78.1%
+among the known subjects. However, North western J&K
+and south Indian zones were found to be affected. In a Luc-
+know based study, conducted on 272 subjects, 67.2% were
+found to be high risk. [17] Similar studies reported high risk
+populations of 43% [18] and 19% in the rural Tamil nadu
+[10]. Undoubtedly, IDRS has emerged as a sensitive tool to
+detect undiagnosed Diabetic subjects, though the sensitivity
+and specificity scores varied in various studies. Dudega et al
+reported a sensitivity of 95.12% and specificity of 28.95% at
+the cutoff score of >60. [12] Similarly, Adhikari et al reported
+best sensitivity (62.2%) and specificity of (73.7%) at the cut
+off IDRS score of 60[8]. However, a large study based on
+26,000 subjects identified IDRS detection sensitivity and
+specificity to be 72.5% and 60.1% respectively (for determining
+undiagnosed diabetes). [7]. Diabetes prediction scales have
+been developed in various other populations [19,20]. Different
+diabetes risk scores including FINDRISC [21], DANISH[22],
+DESIR[23], ARIC[24] and QDScore[25] have also been used for
+predicting diabetes in different populations.
+We observed that females are at a higher risk for develop-
+ment of DM with the highest number of cases in North Indian
+females [26] as compared to males. Previous studies, based on
+different zones, have reported mixed results where some
+researchers indicated gender differences [27,28] while others
+found it more prevalent in females [29] or males [30–32]. Geo-
+graphical distribution of DM showed a maximum number of
+Diabetic subjects in west and south zone and the zone with
+the lowest number of Diabetic incidence was Central followed
+by Eastern zone. A study done by Agarwal and Ebrahim seek-
+ing to screen the variations in Diabetes prevalence in different
+geographical regions in India, reported maximum incidence
+of Diabetic subjects in south Indian states like Kerala and
+Goa in comparison with the central zone state like Rajasthan
+[31].
+The MDRF–IDRS is considered a simple tool of assessment,
+since a non-physician may collect the data based on age,
+family history, physical activity and a single measurement
+of waist circumference. Moreover, its accuracy strengthens
+the utility for screening Diabetic subjects[33] especially in
+India where more than 41 million are suffering with Diabetes
+while majority among these are unaware of it. IDRS is thus a
+good screening tool before carrying out the blood sugar test in
+the population. Further, the risk assessment using IDRS score
+has revealed that more than half of Indian population (55.7%)
+falls under high risk of developing DM. Therefore, a big
+increase in the Diabetes subjects in India in near future is
+expected. This may be partly due to higher proportion of pop-
+ulation falling in the middle and old age group. Similar rising
+trends of DM in India have been reported by other studies [34].
+Other studies have similarly used IDRS for screening high risk
+population and found about 41% [7] and 31.5% [35] population
+to fall under this category. Females were reported to have
+higher risk of DM incidence than males. Besides, age was
+found to be a strong risk factor for its occurrence [28]. It
+was found that DM incidence is expected to increase in South,
+North and West Zones in near future. Ominously, DM is
+spreading very rapidly in Indian population which requires
+immediate preventive public health initiatives like multiple
+educational and awareness programs in the direction for pre-
+vention and amelioration of DM.
+Conclusion: IDRS score distribution showed higher preva-
+lence of DM patients falling into high risk group. >50 cut off
+youden index showed the sensitivity of 78.05 and specificity
+of 62.68 which approves the utility of IDRS as a cost effective
+tool. IDRS was found to be a strong predictor for cases with
+diabetes. IDRS tool based on this study findings have public
+health implications. Moreover method can be utilized by the
+practicing clinicians in early diagnosis of DM.
+Funding
+This research was funded by Central Council for Research in
+Yoga and Naturopathy (CCRYN), New Delhi (Ref F.No. 16-63/2
+016-17/CCRYN/RES/Y&D/MCT/Dated: 15.12.2016).
+Declaration of Competing Interest
+None exists.
+Acknowledgement
+We acknowledge Ministry of AYUSH, Govt of India, New Delhi,
+for funding this project. We also acknowledge support of
+CCRYN for manpower, MOHFW for supporting the cost of
+investigations and IYA for the overall project implementation.
+We thank the advisory research committee, senior research
+fellows, Mr Sabzar, Dr Sanjay, Ms Radhika, Dr Sunanda Rathi,
+Yoga volunteers and the President of Indian Yoga Association
+for their contribution in this project.
+Author contributions
+R.N. and H.R.N. Conceptualization, Data Curation and acquisi-
+tion, Funding Acquisition, Supervision R.N. and A.S. Formal
+Analysis, Investigation, Methodology, Validation and Writ-
+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 2 ( 2 0 2 0 ) 1 0 8 0 8 8
+7
+ing—review and editing. R.T. and P.B. Drafting of the Original
+draft, critical review and editing. A.A. Concept of manuscript.
+Appendix A.
+Supplementary material
+Supplementary data to this article can be found online at
+https://doi.org/10.1016/j.diabres.2020.108088.
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+9

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+Citation: Deepeshwar S, Telles S. Auditory Information Processing During Meditation Based on Evoked Potential Studies. J Neurol Psychol. 2013;1(2): 7.
+J Neurol Psychol
+December 2013 Vol.:1, Issue:2	
+© All rights are reserved by Telles et al.
+Auditory Information Processing 
+During Meditation Based on 
+Evoked Potential Studies
+Abstract
+Background: Auditory evoked potentials (AEPs) were recorded 
+to examine the neurophysiological correlates of four mental states 
+described in ancient yoga texts. These are (i) focused attention 
+(dharana), 
+(ii) 
+contemplation 
+(dhyana) 
+(iii) 
+random 
+thinking 
+(cancalata) and (iv) non meditative focused thinking (ekagrata). 
+The auditory evoked potentials allowed changes from the periphery 
+(cochlear nucleus) to the center (auditory association cortex) were 
+measured. 
+Method: There were sixty male participants with ages ranging 
+from 18 to 45 years (group mean age ± SD, 27.0 ± 8.3 years) who were 
+assessed in four sessions. These four sessions were i) random thinking 
+(cancalata), ii) non meditative focusing (ekagrata), (iii) meditative 
+focusing (dharana), and (iv) contemplation (dhyana). The order of the 
+sessions was randomly assigned. 
+The data were analysed with repeated measure ANOVA followed 
+by a post hoc analysis.
+Results: The BAEPs results showed that the wave V peak latency 
+significantly increased in random thinking (p<0.05), non-meditative 
+focused thinking (p<0.01) and meditative focused thinking (p<0.05) 
+sessions which suggest that during meditation there was no change 
+in processing time of information at the inferior colliculus. MLAEPs 
+results showed that there were significantly increased latencies of the 
+Na and Pa waves during meditation (p<0.05) which suggest reduced 
+auditory information transmission at the medial geniculate and primary 
+auditory cortices. The LLAEPs result showed that there was a significant 
+decrease in the amplitude of P1, P2 and N2 waves during random 
+thinking (p<0.01; p<0.001; p<0.01, respectively) and non-meditative 
+focused thinking (p<0.01; p<0.01; p<0.05, respectively) sessions and 
+a decrease in the latency of P2 wave during and after meditation 
+(p<0.001) session which suggest facilitated auditory transmission at 
+the auditory association cortex. The changes in P300 event related 
+potentials suggested that meditation improved the interaction 
+between the frontal lobe; hippocampus and temporal-parietal parts 
+of the brain during the P300 auditory oddball task. Hence, through 
+brainstem, midlatency, long latency and event related potentials 
+changes in the auditory sensory pathway were assessed in different 
+mental states.
+Conclusion: 
+Meditation 
+showed 
+no 
+changes 
+in 
+auditory 
+information transmission at the collicular level, but decreases it at the 
+geniculate, primary and association auditory cortices. 
+Background
+Meditation has been described as a mental training through which 
+practitioners try to develop and increase flexibility and awareness of 
+their mental processes, culminating in mental stability [1]. Practice 
+of meditation over a period of time produces definite changes in 
+perception, attention, and cognition [2]. Meditation is recognized as 
+a specific consciousness state in which deep relaxation and increased 
+internalized attention exist at the same time [3]. 
+The concepts of meditation described in ancient yoga texts are 
+associated with heightened attention or even of being aware of the 
+experience as it happens. In Patanjali’s Yoga Sutras (circa 900 B.C.) 
+two meditative states are described [4]. The first is focusing with 
+effort (or dharana) to confine the mind within a limited mental 
+area (Patanjali’s Yoga Sutras, Chapter 3, Verse 1). The next stage is 
+effortless expansion or dhyana (Patanjali’s Yoga Sutras, Chapter 3, 
+Verse 2), which is the uninterrupted flow of the mind towards the 
+object chosen for meditation. The practice of dharana is supposed to 
+precede the practice of dhyana. When the mind is not in meditation, 
+another ancient yoga text says that it may be in two other states, 
+cancalata which is a state of random thinking (Bhagavad Gita, circa 
+500 B.C. Chapter 6, Verse 34) and ekagrata (Bhagavad Gita, Chapter 
+6, Verse 12), or focused attention without meditation, during which 
+the attention is directed to a number of associated thoughts.
+These four mental states have been studied to evaluate auditory 
+information processing from the cochlear nerve at the periphery to 
+the association cortices located centrally. Auditory evoked potentials 
+were chosen to begin with, instead of other modalities of evoked 
+potentials to avoid compounding with any other sensory or motor 
+potentials. The auditory modality of stimuli was particularly chosen 
+as it was found to be least disturbing to the meditator during their 
+practice [5]. It is the premise that conscious processes actively involve 
+several cortical mechanisms and also that corticofugal control 
+processes may exert significant alterations in the processing of 
+information at brainstem, thalamic and cortical levels [6-9]. Evoked 
+potentials which form the basis of this report include brainstem (0-10 
+ms), mid latency (10-100 ms), long latency auditory evoked potentials 
+(100-250 ms) and the P300 event-related evoked potentials recorded 
+with the auditory oddball paradigm (280-450 ms). For each auditory 
+evoked potential component the peak latency and peak amplitude 
+has been assessed. The peak latency (msec) is defined as the time 
+from stimulus onset to the point of maximum positive or negative 
+amplitude within a specified latency window. The peak amplitude 
+(µV) is defined as the voltage difference between a pre-stimulus 
+baseline and the largest positive and negative going peak within a 
+latency window. A decrease in peak latency is considered as suggestive 
+of facilitated transmission due to increased speed of conduction in 
+the underlying neural generators [10]. Conversely, an increase in 
+peak latency can be assumed to suggest inhibited transmission due 
+to slower conduction in the underlying neural generators. With 
+respect to changes in peak amplitude, an increase in the amplitude 
+of an evoked potential component has been interpreted as being 
+indicative of effective activation of the underlying neural generator, 
+with recruitment of additional neurons [11].
+Singh Deepeshwar1 and Shirley Telles1,2*
+1Indian Council of Medical Research Center for Advanced 
+Research in Yoga and Neurophysiology, Swami Vivekananda Yoga 
+Anusandhana Samsthana, Bengaluru, India
+2Patanjali Research Foundation, Haridwar, Uttarakhand, India
+*Address for Correspondence
+Shirley Telles, Ph.D., Director, Patanjali Research Foundation, Patanjali 
+Yogpeeth, Haridwar, Uttarakhand 249405, India, Tel: +91.01334.244805; 
+Fax: +91.01334.244805; E-mail: [email protected]
+Submission: 01 October 2013
+Accepted: 16 December 2013
+Published: 20 December 2013
+Research Article
+Open Access
+Journal of
+Neurology and 
+Psychology
+Avens Publishing Group
+Inviting Innovations
+Avens Publishing Group
+Inviting Innovations
+Citation: Deepeshwar S, Telles S. Auditory Information Processing During Meditation Based on Evoked Potential Studies. J Neurol Psychol. 2013;1(2): 7.
+J Neurol Psychol 1(2): 7 (2013) 
+Page - 02
+ISSN: 2332-3469
+A series of experiments on auditory evoked potentials were 
+carried out between June 2007 and December 2012 to understand 
+the neurophysiological effects of two meditative states (dharana and 
+dhyana) and two non-meditative states (cancalata and ekagrata). 
+Method 
+Sixty healthy male volunteers whose ages ranged between 20 
+and 45 years (group mean age ± SD, 27.0 ± 8.3 years) were recruited 
+for recording of BAEPs, MLAEPs, LLAEPs and P300 ERPs. All of 
+them were residing at a yoga center in South India and were actively 
+engaged in practicing yoga. Their health status was based on a routine 
+case history and clinical examination. All the participants had a 
+minimum of 6 months experience of meditation (group average 
+experience ± SD, 22.5 ± 17.5 months) on the Sanskrit syllable, OM. 
+This meditation technique can be separately practiced as dharana 
+(focusing on thoughts of OM) and dhyana (effortless focusing 
+on OM). Participants were trained to practice the two techniques 
+(dharana and dhyana) separately and at will. To attempt to ensure 
+that all of them were doing it correctly, they were given a 3-month 
+orientation course, during which time they were supervised by an 
+experienced meditation teacher.
+All participants were assessed in four sessions on four separate 
+days, at the same time of the day. The four sessions were (i) meditation 
+with focusing (dharana), (ii) meditation without focusing (dhyana), 
+(iii) nonmeditative focused thinking (ekagrata), and (iv) random 
+thinking (cancalata). The evaluation of the participants’ ability to 
+attain these four mental states was based on their self-report on a scale 
+of 0 to 10, as well as on consultations with the meditation teacher. 
+Assessments
+The assessments included (i) brainstem auditory evoked 
+potentials, (ii) mid latency auditory evoked potentials (iii) long 
+latency auditory evoked potentials and (iv) P300 auditory event 
+related potentials with the auditory oddball paradigm. Each of these 
+assessments and the results obtained will be discussed below in detail.
+Statistical analysis
+Statistical analysis was done using SPSS (Version 16.0). Data 
+were tested for normality by Kolmogorov-Smirnov test. Since the 
+same individuals were assessed in repeated sessions on separate days 
+(i.e., random thinking, non-meditative focused thinking, meditative 
+focusing and meditation), repeated measures analysis of variance was 
+used (ANOVA). Repeated measures analyses of variance (ANOVA) 
+were performed with two ‘within subjects’ factors, i.e., Factor 1: 
+Sessions; Random thinking, Non-meditative focused thinking, 
+Meditative focusing and Meditation, and Factor 2: States; Before, 
+During (Dur1 to Dur4), and After. Repeated measures ANOVAs were 
+carried out for each component of BAEPs, MLAEPs, LLAEPs and 
+P300 ERPs separately, for both peak latencies and peak amplitudes. 
+This was followed by a post-hoc analysis with Bonferroni adjustment 
+for multiple comparisons between the mean values of different 
+states (“During” and “After”). All comparisons were made with the 
+respective “Before” state.
+Results
+The group mean values ± S.D. for the peak latencies (ms) and 
+peak amplitudes (µV) for each component of BAEPs, MLAEPs and 
+LLAEPs in four sessions (random thinking, non-meditative focused 
+thinking, meditative focusing and meditation) in Before, During and 
+After states are given in Table 4, Table 5 and Table 6, respectively.
+Discussions
+The results of the BAEPs, MLAEPs, LLAEPs and P300 ERPs are 
+discussed below.
+Brain stem auditory evoked potentials (BAEPs)
+Brainstem auditory evoked potentials (BAEPs) provide an 
+objective physiological index of auditory function at a subcortical 
+level [12]. They reflect neuronal activity in the cochlear nerve, 
+cochlear nucleus, superior olive and inferior colliculus of the 
+brainstem. BAEPs (0 – 10 ms) were recorded using standard methods 
+[13]. The peak latency and peak amplitude of BAEP components were 
+measured. The neural generators of these components are given in 
+Table 1. A typical trace is shown in Figure 1.
+The BAEP recordings showed that the peak latency of a specific 
+component, wave V (5.8 – 6.0 ms), increased significantly during 
+dharana, ekagrata, and cancalata sessions, but there was no change 
+during the practice of dhyana [13]. Since wave V is considered to 
+correspond to the inferior colliculus located in the tectum (midbrain) 
+[10,12], this suggested that neural transmission at the level of mid-
+brain may be improved by meditation without focusing. The results 
+also suggested that dhyana practice alone does not delay auditory 
+sensory transmission at the brainstem level, whereas dharana 
+practice is associated with a delay which was also seen in the practices 
+of ekagrata and cancalata. The traces of BAEPs before and after 
+meditation are given in Figure 1a and 1b respectively.
+Midlatency auditory evoked potentials (MLAEPs)
+Midlatency auditory evoked potentials (MLAEPs) have been 
+used to assess subcortical and cortical changes in meditation [14]. It 
+is believed that even if the main changes occur in the cortex, cortico-
+efferent connections would result in sub-cortical changes [11]. The 
+mid latency auditory evoked potentials reflect neural activity at the 
+mesencephalic or diencephalic level [15], the superior temporal 
+gyrus [16], and the dorso-posterior-medial part of the Heschl’s 
+gyrus, i.e., the primary auditory cortex [17]. The peak latency and 
+peak amplitude of MLAEPs were measured with three components 
+BAEP 
+components
+Latency
+(ms)
+Neural Generators
+Wave I
+1.9
+Auditory portion of the eighth cranial nerve
+Wave II
+3.6
+Near or at the cochlear nucleus. A portion - from 
+the eighth nerve fibers around the cochlear 
+nucleus
+Wave III
+4.2
+The lower pons through the superior olive and 
+trapezoid body
+Wave IV
+5.2
+The upper pons or lower midbrain, in the 
+lateral lemniscus and the inferior colliculus; A 
+contralateral brainstem generator for wave V is 
+suggested
+Wave V
+5.8
+Table 1: The latencies and the neural generators for the five components of 
+BAEP.
+MLAEP 
+components
+Latency (ms) Neural Generators
+Na wave
+14-19
+Medial geniculate body
+Pa wave
+25-32
+Superior temporal gyrus
+Nb wave
+35-65
+Dorso-posterior-medial part of the Heschl’s 
+gyrus i.e., the primary auditory cortex
+Table 2: The latencies and the neural generators for the three components of 
+MLAEPs.
+Citation: Deepeshwar S, Telles S. Auditory Information Processing During Meditation Based on Evoked Potential Studies. J Neurol Psychol. 2013;1(2): 7.
+J Neurol Psychol 1(2): 7 (2013) 
+Page - 03
+ISSN: 2332-3469
+which correspond to the different neural generators given in Table 
+2. A typical trace is shown in Figure 2. MLAEPs (10 – 100 ms) were 
+recorded using standard methods [18].
+The MLAEPs show the prolonged peak latencies of two 
+components (the Na wave and the Pa wave) during meditation. 
+The Pa wave amplitude decreased during all four states. Prolonged 
+latencies of the Na and Pa wave suggest delayed auditory information 
+transmission at mesencephalic – diencephalic levels and at the level of 
+the primary auditory cortex (i.e., the neural generators corresponding 
+to the Na and Pa waves) [18,19]. The traces of MLAEPs before and 
+after meditation are given in Figure 2a and 2b respectively.
+Long latency auditory evoked potentials (LLAEPs)
+Long latency auditory evoked potentials (LLAEP) assess auditory 
+information processing at the central level. LLAEPs measures 
+are thought to reflect the activation of primary auditory cortex 
+and association cortices [20,21]. In long latency auditory evoked 
+potentials, currently the neural generators is believed to be due to 
+activity at the secondary auditory cortex in the lateral Heschl’s gyrus 
+[17], bilateral parts of the auditory cortex (superior temporal gyrus) 
+[22], and auditory association complex [20] which responds to input 
+LLAEPs 
+components
+Latency 
+(ms)
+Neural Generators
+P1 wave
+40-60 ms
+Secondary auditory cortex in the lateral Heschl’s 
+gyrus
+N1 wave
+75-150 ms
+Bilateral Parts of the Auditory Superior Cortex
+P2 wave
+150-250 ms
+Planum Temporale (PT) and the Auditory 
+Association Complex (AAC)
+N2 wave
+250-280 ms
+Left superior temporal gyrus and bilateral medial 
+temporal lobe structure
+Table 3: The latencies and the neural generators for the four components of 
+LLAEPs.
+Brainstem auditory evoked potentials (BAEPs) in four sessions
+Components
+Session
+Latency
+Amplitude
+Pre
+During
+Post
+P=(During vs Pre);
+(Post vs  Pre)
+Pre
+During
+Post
+P=(During vs Pre);
+(Post vs  Pre)
+Wave V
+Random Thinking 
+(n= 60)
+5.8 ± 0.2
+5.8 ± 0.5
+5.8 ± 0.2
+During vs Pre= 0.042
+0.7 ± 0.2
+0.7 ± 0.4
+0.8 ± 0.3
+NS
+Non meditative 
+focused thinking (n= 
+60)
+5.8 ± 0.2
+5.8 ± 0.4
+5.8 ± 0.6
+During vs Pre= 0.009;
+Post vs Pre= 0.001
+0.8 ± 0.2
+0.7 ± 0.1
+0.7 ± 0.2
+NS
+Meditative Focused 
+thinking (n= 60)
+5.7 ± 0.2
+5.9 ± 0.2
+5.8 ± 0.2
+Post vs Pre= 0.018
+0.7 ± 0.2
+0.8 ± 0.2
+0.8 ± 0.4
+NS
+Meditation (n= 60)
+5.8 ± 0.2
+5.8 ± 0.2
+5.8 ± 0.8
+NS
+0.8 ± 0.2
+0.7 ± 0.2
+0.8 ± 0.2
+NS
+Table 4: BAEPs showing peak latency and peak amplitude for four Sessions in six States for wave V.
+NS: Non Significant
+Midlatency auditory evoked potentials (MLAEPs) in four sessions
+Components
+Session
+Latency
+Amplitude
+Pre
+During
+Post
+P=(During vs 
+Pre); (Post vs  
+Pre)
+Pre
+During
+Post
+P=(During vs Pre);
+(Post vs  Pre)
+Na Wave
+Random Thinking 
+(n= 60)
+16.0 ± 1.6
+16.5 ± 2.0
+16.1 ± 1.8
+NS
+0.6 ± 0.5
+0.5 ± 0.4
+0.5±0.4
+NS
+Non meditative focused 
+thinking (n= 60)
+16.2 ± 1.8
+16.3 ± 1.9
+16.3 ± 2.1
+NS
+0.6 ± 0.5
+0.5 ± 0.4
+0.4±0.4
+NS
+Meditative Focused 
+thinking (n= 60)
+16.0 ± 1.6
+16.4 ± 1.7
+16.0 ± 1.6
+NS
+0.5 ± 0.5
+0.5 ± 0.4
+0.6±0.6
+NS
+Meditation 
+(n= 60)
+16.0 ± 1.6
+16.5 ± 1.7
+16.1 ± 1.9
+During vs Pre= 
+0.032
+0.5 ± 0.4
+0.5 ± 0.4
+0.6±0.6
+NS
+Pa Wave
+Random Thinking 
+(n= 60)
+34.8 ± 2.8
+34.6 ± 2.8
+35.2 ± 2.7
+NS
+1.3±0.5
+0.9 ± 0.4
+1.3±0.6
+During vs Pre= 0.001
+Non meditative focused 
+thinking (n= 60)
+35.0 ± 2.5
+35.4 ± 1.7
+35.5 ± 2.4
+NS
+1.2±0.6
+0.9±0.4
+1.4±0.6
+During vs Pre= 0.001
+Meditative Focused  
+thinking (n= 60)
+34.9 ± 2.6
+35.7 ± 2.4
+35.2 ± 3.2
+NS
+1.3±0.5
+1.1±0.5
+1.3±0.5
+During vs Pre= 0.004
+Meditation (n= 60)
+16.0 ± 1.6
+16.5 ± 1.7
+16.1 ± 1.9
+During vs Pre= 
+0.011
+1.3±0.6
+1.1±0.6
+1.3±0.6
+During vs Pre= 0.041
+Nb Wave
+Random Thinking 
+(n= 60)
+52.7 ± 9.0
+53.0 ± 8.3
+54.8 ± 9.0
+0.4±0.3
+0.3±0.3
+0.5±0.4
+NS
+Non meditative focused 
+thinking (n= 60)
+53.8 ± 9.1
+55.9 ± 8.3
+56.9 ± 9.0
+Post vs  Pre = 
+0.018
+0.4±0.4
+0.4±0.3
+0.5±0.4
+NS
+Meditative Focused 
+thinking (n= 60)
+53.4 ± 9.0
+55.1 ± 8.3
+54.7 ± 8.8
+NS
+0.5±0.4
+0.4±0.4
+0.5±0.4
+NS
+Meditation (n= 60)
+53.3 ± 8.7
+55.4 ± 7.9
+54.9 ± 8.5
+NS
+0.4±0.4
+0.5±0.4
+0.5±0.4
+NS
+Table 5: MLAEPs showing peak latency and peak amplitude for four Sessions in six States for Na wave, Pa wave and Nb wave.
+NS: Non Significant
+Citation: Deepeshwar S, Telles S. Auditory Information Processing During Meditation Based on Evoked Potential Studies. J Neurol Psychol. 2013;1(2): 7.
+J Neurol Psychol 1(2): 7 (2013) 
+Page - 04
+ISSN: 2332-3469
+Table 6: LLAEPs showing peak latency and peak amplitude for four Sessions in six States for P1 wave,   N1 wave, P2 wave and N2 wave.
+Long latency auditory evoked potentials (LLAEPs) in four sessions
+Components
+Session
+Latency
+Amplitude
+Pre
+During
+Post
+P=(During vs 
+Pre); 
+(Post vs  Pre)
+Pre
+During
+Post
+P=(During vs Pre); 
+(Post vs  Pre)
+P1 Wave
+Random Thinking
+(n= 60)
+46.5 ± 7.9
+47.0 ± 0.8
+48.5 ± 8.3
+NS
+1.2 ± 1.0
+0.6 ± 0.5
+1.0 ± 0.7
+During vs Pre 
+0.002
+Non meditative focused 
+thinking (n= 60)
+47.3 ± 8.3
+46.6 ± 0.8
+48.4 ± 8.1
+NS
+1.0 ± 0.8
+0.8 ± 0.6
+1.0 ± 0.7
+During vs Pre 
+0.001
+Meditative Focused 
+thinking (n= 60)
+48.1 ± 9.7
+47.8 ± 0.1
+50.4 ± 9.0
+NS
+1.2 ± 1.0
+1.0 ± 0.9
+1.1 ± 0.8
+NS
+Meditation (n= 60)
+48.7 ± 9.5
+46.7 ± 0.4
+47.8 ± 7.9
+NS
+1.0 ± 0.7
+0.9 ± 0.6
+1.0 ± 0.6
+NS
+N1 Wave
+Random Thinking 
+(n= 60)
+98.7 ± 14.6
+97.6 ± 2.3
+100.5 ± 15.8
+NS
+0.6 ± 0.5
+0.4 ± 0.4
+0.5 ± 0.4
+NS
+Non meditative focused 
+thinking (n= 60)
+97.5 ± 15.2
+100.3 ± 2.0
+103.3 ± 15.1
+NS
+0.4 ± 0.3
+0.4 ± 0.3
+0.4 ± 0.4
+NS
+Meditative Focused 
+thinking (n= 60)
+98.2 ± 15.1
+99.1 ± 1.7
+101.1 ± 15.1
+NS
+0.4 ± 0.4
+0.4 ± 0.5
+0.5 ± 0.5
+NS
+Meditation (n= 60)
+98.8 ± 14.2
+99.3 ± 1.0
+100.8 ± 15.7
+NS
+0.3 ± 0.4
+0.7 ± 1.8
+0.4 ± 0.4
+NS
+P2 Wave
+Random Thinking 
+(n= 60)
+154.9 ± 13.5
+154.9 ± 2.4
+155.0 ± 12.4
+NS
+0.9 ± 0.8
+0.5 ± 0.5
+0.8 ± 0.6
+During vs Pre= 
+0.001
+Non meditative focused 
+thinking (n= 60)
+155.7 ± 10.4
+155.5 ± 1.1
+156.6 ± 11.5
+NS
+0.8 ± 0.5
+0.6 ± 0.6
+0.9 ± 0.5
+During vs Pre= 
+0.006
+Meditative Focused 
+thinking (n= 60)
+157.7 ± 14.2
+154.5 ± 2.8
+153.9 ± 11.5
+NS
+0.9 ± 0.6
+0.7 ± 0.5
+0.9 ± 0.6
+NS
+Meditation 
+(n= 60)
+158.2 ± 9.2
+153.3 ± 1.3
+151.8 ± 9.1
+Post vs pre= 
+0.005
+0.8 ± 0.6
+0.7 ± 0.6
+0.8 ± 0.5
+NS
+N2 Wave
+Random Thinking
+(n= 60)
+221.6 ± 3.1
+222.1 ± 0.3
+222.6 ± 3.7
+NS
+0.4 ± 0.4
+0.3 ± 0.3
+0.4 ± 0.4
+During vs Pre= 
+0.007
+Non meditative focused 
+thinking 
+(n= 60)
+222.3 ± 3.7
+222.4 ± 0.5
+222.3 ± 3.5
+NS
+0.4 ± 0.3
+0.3 ± 0.2
+0.3 ± 0.3
+During vs Pre= 
+0.049
+Meditative Focused 
+thinking (n= 60)
+223.21±6.0
+221.92 ± 0.7 222.0 ± 3.4
+NS
+0.4 ± 0.5
+0.3 ± 0.3
+0.4 ± 0.3
+NS
+Meditation (n= 60)
+223.1 ± 5.6
+223.1 ± 0.6
+223.0 ± 5.6
+NS
+0.4 ± 0.3
+0.4 ± 0.5
+0.3 ± 0.2
+NS
+NS: Non Significant
+from all sensory modalities [22] and left superior temporal gyrus and 
+bilateral medial temporal lobe structure [23]. The peak latency and 
+peak amplitude of LLAEP components (100 – 300 ms) were measured 
+[24,25]. The neural generators of these components are given in Table 
+3. A typical trace is shown in Figure 3.
+There were decreased peaks amplitudes of the P1 and P2 waves 
+after random thinking and non-meditative focusing and the N2 wave 
+after non-meditative focusing suggesting that the neural activity 
+was reduced at the level of secondary auditory cortex, auditory 
+association complex and anterior cingulate cortex, respectively [26]. 
+The reason for decrease in P1, P2 and N2 amplitudes may be due 
+to selective inhibition of certain areas within the primary, auditory 
+association complex and secondary auditory cortex suppressing 
+sensory responses to reduce distracting auditory stimuli, which could 
+prevent the participants directing their attention on instructions [27] 
+during random thinking and non-meditative focusing. The traces of 
+MLAEPs before and after meditation are given in Figure 3a and 3b 
+respectively.
+P300 auditory oddball paradigm 
+The P300 component of event-related potentials (ERPs) is 
+considered a cognitive neuro-electric phenomenon because it 
+is generated in psychological tasks when subjects attend to and 
+discriminate between stimuli that differ from one another in some 
+dimension [28]. It is also called the “oddball” paradigm since subjects 
+are required to distinguish between frequent and rare stimuli 
+presented as a random series; responding to the rare (target) stimulus 
+and ignoring the frequent stimuli. The generation of a P300 positive 
+deflection is believed occur from the interaction between the frontal 
+lobe and hippocampal and temporoparietal function [29]. The 
+primary neural generator for the P300 components are in the anterior 
+cingulate and hippocampal formation [30]. 
+There was a significant reduction of the P300 peak amplitude after 
+random thinking session (cancalata) whereas the peak amplitude 
+significantly increased after focused meditation (dharana) and 
+meditation without focusing (dhyana) [31]. These results show 
+that following meditation with focusing and meditation without 
+focusing, the ability to perform the P300 auditory oddball task was 
+better, while after a session of equal duration of random thinking 
+reduced. The neuro-electric events which underlie the P300 arise 
+from the interaction between the frontal lobe; hippocampus and 
+temporo-parietal function parts of the brain known to be involved in 
+meditation [28] (Figure 4).
+Summary
+Auditory evoked potentials, a noninvasive method of evaluating 
+auditory information transmission from the periphery to the center. 
+Brainstem, mid latency, long latency, and P300 auditory event 
+related potentials were recorded in meditation, meditative focusing, 
+random thinking and non-meditative focused thinking. The findings 
+Citation: Deepeshwar S, Telles S. Auditory Information Processing During Meditation Based on Evoked Potential Studies. J Neurol Psychol. 2013;1(2): 7.
+J Neurol Psychol 1(2): 7 (2013) 
+Page - 05
+ISSN: 2332-3469
+ 
+ 
+i) Traces of BAEPs before and after meditation 
+a. Before Meditation 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+b. After Meditation (with reduced wave V peak latency) 
+ 
+ 
+ 
+I 
+1.94ms 
+0.41 µV 
+II 
+2.96ms 
+0.35 µV 
+III 
+3.92ms 
+0.37 µV 
+IV 
+5.28ms 
+0.61 µV 
+V 
+5.66ms 
+0.85 µV 
+IV 
+7.20ms 
+0.35 µV 
+BAEPs – ICMR 
+After Meditation 
+ 
+I 
+(1.9ms) 
+II 
+(3.6ms) 
+III 
+(4.2ms) 
+V 
+(5.8ms) 
+IV 
+(5.2ms) 
+Brainstem Auditory Evoked 
+Potential components 
+ 
+µV 
+IV 
+8.68ms 
+0.04 µV 
+I 
+1.94ms 
+0.38 µV 
+II 
+3.00ms 
+0.31 µV 
+III 
+3.98ms 
+0.28µV 
+IV 
+5.20ms 
+0.50 µV 
+V 
+5.68ms 
+0.76µV 
+VI 
+7.16ms 
+0.24µV 
+BAEPs – ICMR 
+Before Meditation 
+VII 
+8.88ms 
+0.04µV 
+Figure 1: Typical Trace of BAEPs.
+MLAEPs – ICMR 
+Before Meditation 
+Pa 
+34.60ms 
+1.19µV 
+Na 
+17.00ms 
+0.22µV 
+ 
+Nb 
+48.00ms 
+0.05µV 
+ 
+i) Typical Trace of MLAEPs 
+ii)
+ 
+MLAEPs Traces before and after meditation 
+a. Before Meditation 
+b. After Meditation (with reduced Na, Pa peak latency) 
+ 
+Na 
+(14-19) 
+Pa 
+(25-32) 
+Nb 
+(35-65) 
+Mid Latency Auditory 
+Evoked Potential 
+components 
+Pa 
+34.00ms 
+1.31µV 
+Na 
+16.00ms 
+0.45 µV 
+Nb 
+54.20ms 
+0.14µV 
+MLAEPs – ICMR 
+ 
+ 
+After Meditation 
+Figure 2: 
+Citation: Deepeshwar S, Telles S. Auditory Information Processing During Meditation Based on Evoked Potential Studies. J Neurol Psychol. 2013;1(2): 7.
+J Neurol Psychol 1(2): 7 (2013) 
+Page - 06
+ISSN: 2332-3469
+i) 
+Typical Trace of LLAEPs 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ii) Traces of LLAEPs before and after meditation 
+a. Before Meditation 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+b. After Meditation (with reduced P2 wave peak latency) 
+ 
+ 
+P1 
+46 ms 
+0.84 µV 
+N1 
+116 ms 
+1.14 µV 
+P2 
+162 ms 
+0.15 µV 
+N2 
+225 ms 
+1.52 µV 
+LLAEPs - ICMR 
+ 
+ 
+Before Meditation 
+P1 
+41 ms 
+3.24 µV 
+N1 
+110 ms 
+0.28 µV 
+P2 
+151 ms 
+1.40 µV 
+N2 
+218 ms 
+1.07 µV 
+LLAEPs - ICMR 
+ 
+After Meditation 
+P1 (40-60ms) 
+P2 (80-150ms) 
+Long Latency Auditory 
+Evoked Potential 
+Components 
+N1 
+(75-120ms) 
+N2 
+(180-220ms) 
+µV 
+0 
+250 
+Figure 3: 
+i)
+ 
+Typical Trace of P300 ERPs 
+ 
+ii) Traces of P300 ERPs before and after meditation 
+a. Before Meditation 
+ 
+b. After Meditation (with increase P300 peak Amplitude) 
+P300 Event Related 
+Potentials 
+ 
+Standard 
+Target 
+P300 ERPs - ICMR 
+ 
+ 
+Before Meditation 
+ 
+Standard 
+Target 
+P3 
+354ms 
+20.54µV 
+ 
+P300 ERPs - ICMR 
+ 
+ 
+After Meditation 
+P3 
+387ms 
+14.07µV 
+ 
+Figure 4: 
+Citation: Deepeshwar S, Telles S. Auditory Information Processing During Meditation Based on Evoked Potential Studies. J Neurol Psychol. 2013;1(2): 7.
+J Neurol Psychol 1(2): 7 (2013) 
+Page - 07
+ISSN: 2332-3469
+demonstrated that meditation had distinctly different effects 
+compared to the other three states. 
+In summary during meditation there was:
+i)	 A decrease in the brainsteim auditory evoked potentials 
+at wave V peak latency suggesting reduces the speed of 
+transmission in the midbrain (inferior colliculous).
+ii)	 Peak latencies of midlatency of Na and Pa wave were 
+reduced suggesting reduction in speed of transmission ot 
+mesencephalic – diencephalic region and Heschle’s gyrus. 
+iii)	The peak amplitude of the P2 component of LLAEPs, evoke 
+potentials was increase suggesting involvement of large area 
+within the auditory association cortex along with recruitment 
+of more neurons.
+iv)	P300 amplitude of auditory event related potentials increased 
+while the latency reduced suggesting improved attention for 
+the auditory oddball. 
+Hence, meditation is distinct state in which attention to auditory 
+stimuli improve while the speed of auditory information up to the 
+primary appears to be slower. 
+References
+1.	 Wallace BA, Shapiro SL (2006) Mental balance and well-being: building 
+bridges between Buddhism and Western psychology. Am Psychol 61: 690-
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+Exp Hypn 25: 236-73.
+3.	 Murata T, Takahashi T, Hamada T, Omori M, Kosaka H, et al. (2004) 
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+7.	 Desiraju T (1984) Neurophysiology and Consciousness. An integrated non – 
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+8.	 Pribram KH, McGuinness D (1992) Attention and para-attentional processing. 
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+9.	 Brazier MAB (1979) Electrophysiology of Prefrontal and Dorsolateral Cortex 
+elucidating the basis and nature of Higher nervous associations. Brain Mech. 
+Mem. Learn. from single neuron to man, Raven Press, Limited, p. 400.
+10.	Malhotra A (1997) Auditory evoked responses in clinical practice. Springer-
+Verlag.
+11.	Woods DL, Clayworth CC (1985) Click spatial position influences middle 
+latency auditory evoked potentials (MAEPs) in humans. Electroencephalogr 
+Clin Neurophysiol 60: 122-129.
+12.	McEvoy TM, Frumkin LR, Harkins SW (1980) Effects of meditation on 
+brainstem auditory evoked potentials. Int J Neurosci 10: 165-170.
+13.	Kumar S, Nagendra H, Naveen K, Manjunath N, Telles S (2010) Brainstem 
+auditory-evoked potentials in two meditative mental states. Int J Yoga 3: 37-41.
+14.	Telles S, Nagarathna R, Nagendra HR, Desiraju T (1994) Alterations in 
+auditory middle latency evoked potentials during meditation on a meaningful 
+symbol--“Om”. Int J Neurosci 76: 87-93.
+15.	Deiber MP, Ibañez V, Fischer C, Perrin F, Mauguière F (1988) Sequential 
+mapping favours the hypothesis of distinct generators for Na and Pa middle 
+latency auditory evoked potentials. Electroencephalogr Clin Neurophysiol 71: 
+187-197.
+16.	Kileny P, Paccioretti D, Wilson AF (1987) Effects of cortical lesions on 
+middle-latency auditory evoked responses (MLR). Electroencephalogr Clin 
+Neurophysiol 66: 108-120.
+17.	Liégeois-Chauvel C, Musolino A, Badier JM, Marquis P, Chauvel P (1994) 
+Evoked potentials recorded from the auditory cortex in man: evaluation and 
+topography of the middle latency components. Electroencephalogr Clin 
+Neurophysiol 92: 204-214.
+18.	Telles S, Raghavendra BR, Naveen KV, Manjunath NK, Subramanya P 
+(2012) Mid-latency auditory evoked potentials in 2 meditative states. Clin 
+EEG Neurosci 43: 154-160.
+19.	Subramanya P, Telles S (2009) Changes in midlatency auditory evoked 
+potentials following two yoga-based relaxation techniques. Clin EEG 
+Neurosci 40: 190-195.
+20.	Crowley KE, Colrain IM (2004) A review of the evidence for P2 being an 
+independent component process: age, sleep and modality. Clin Neurophysiol 
+115: 732-144.
+21.	Wolpaw JR, Wood CC (1982) Scalp distribution of human auditory evoked 
+potentials. I. Evaluation of reference electrode sites. Electroencephalogr Clin 
+Neurophysiol 54: 15-24.
+22.	Näätänen R, Picton T (1987) The N1 wave of the human electric and 
+magnetic response to sound: a review and an analysis of the component 
+structure. Psychophysiology 24: 375-425.
+23.	Halgren E, Baudena P (1992) Endogenous potentials recorded in the human 
+superior temporal plane, including Heschl’s gyms. Present. 10th Int. Congr. 
+Evoked Potentials (EPIC X), Eger, Hungary, p. 55.
+24.	Vaughan HG Jr, Ritter W (1970) The sources of auditory evoked responses 
+recorded from the human scalp. Electroencephalogr Clin Neurophysiol 28: 
+360-367.
+25.	Picton TW, Hillyard SA (1974) Human auditory evoked potentials. II. Effects 
+of attention. Electroencephalogr Clin Neurophysiol 36: 191-199.
+26.	(2011) ICMR Report 2011. Neurophysiological correlates of phases of 
+wakefulness and sleep in meditators. Bangalore, India (Unpublished data).
+27.	Nuñez A, Malmierca E (2007) Corticofugal modulation of sensory information. 
+Adv Anat Embryol Cell Biol 187: 1-74.
+28.	Polich J, Kok A (1995) Cognitive and biological determinants of P300: an 
+integrative review. Biol Psychol 41: 103-146.
+29.	Halgren E, Marinkovic K, Chauvel P (1998) Generators of the late cognitive 
+potentials in auditory and visual oddball tasks. Electroencephalogr Clin 
+Neurophysiol 106: 156-164.
+30.	Polich 
+J 
+(1999) 
+Electroencephalography: 
+Basic 
+principles, 
+Clinical 
+applications and related fields p. 1073-1091.
+31.	(2012) ICMR Report 2012. Neurophysiological correlates of phases of 
+wakefulness and sleep in meditators. Bangalore, India (Unpublished data). 
+The authors gratefully acknowledge the funding from the Indian 
+Council of Medical Research (ICMR), Government of India, as 
+part of a grant (Project No. 2001-05010) towards the Center for 
+Advanced Research in Yoga and Neurophysiology (CAR-Y&N). 
+The authors would like to thank all ICMR-CAR scientists, Naveen 
+K.V., Manjunath N.K., Subramanya P., Sanjay K, Raghvendra B.R. 
+for their help at different stages of this work.
+Acknowledgements

subfolder_0/Ayurveda Perspective of Management of Cancer Chemotherapy.txt

@@ -0,0 +1,348 @@
+Online International Interdisciplinary Research Journal, {Bi-Monthly}, ISSN2249-9598, Volume-IV, Nov 2014 Special Issue 
+ 
+w w w . o i i r j . o r g                      I S S N  2 2 4 9 - 9 5 9 8  
+Page 22 
+Ayurveda Perspective of Management of Cancer Chemotherapy 
+Induced Nausea and Vomiting 
+ 
+Lalitha Nandini P K a, Raghavendra Rao M b, Amritanshu Ram R a, Nagarathna 
+Raghurama, Radheshyam Naikb, Shubha V Hegdec 
+a Swami Vivekananda Yoga Anusandhana Samsthana university, Bengaluru, India 
+b Health Care Global Enterprises Ltd., Bengaluru, India 
+c Sri Kalabhireshwara Ayurveda Medical College, Bengaluru, India 
+Corresponding Author: Raghavendra Rao M  
+ 
+ 
+This article offers a conceptual model from authentic Ayurveda literature that looks at 
+Cancer Chemotherapy induced Nausea and Vomiting (CCINV) in a new light. It 
+offers the basis to understand and manage the psychological and physiological 
+distress by addressing the subjective concerns of the patients giving them better 
+treatment satisfaction and quality of Life. This model extrapolates the Ayurveda 
+concept of disturbed Jatharagni (gastric fire), the subtle energy that controls all 
+digestive activities, to understand CCINV. The model also proposes that these 
+disturbances can be corrected by regulation of energy channels (Vayuniyantrana) by 
+therapies recommended in yoga and Ayurveda. 
+KEYWORDS; Cancer, Chemotherapy, Yoga, Ayurveda, Nausea. 
+Chemotherapy has enabled Cancer patients to live longer, but still has a high cost, in 
+terms of adverse events and quality of life [1].  In two studies, nausea ranks number 1 
+as the adverse event of chemotherapy of most concern to patients, with vomiting 
+ranking as the 3rd and the 5th most distressing symptom [2]. Advancements in 
+antiemetic therapies have been successful in controlling vomiting but have 
+exacerbated nausea [3]. Pathophysiology behind this chemotherapy induced nausea and 
+emesis is fully not known. The chemotherapy trigger zone (CTZ) is located in a 
+medullary center located in the area postrema, which is susceptible to emetic stimuli 
+delivered through the blood or cerebrospinal fluid (CSF) [4, 5]. The chemotherapy 
+trigger zone stimulates the vomiting center, an area of the medulla oblongata that acts 
+by stimulating the phrenic, spinal, and visceral nerves. These efferent signals induce 
+vomiting by their effects on the diaphragm, abdominal muscles, and stomach. The 
+vomiting center also receives signals of increased intracranial pressure from visceral 
+organs, the inner ear labyrinthine apparatus, and higher CNS structures. The 
+antiemetic’s act on CTZ or on the receptors on gastric mucosal lining and induce 
+gastro paresis. Though numerous studies highlight the role of psychological distress 
+and susceptible risk factors in modulating nausea and emesis in cancer patients, they 
+have not been able to address this issue holistically thereby having nausea as a 
+predictable Side effect of chemotherapy [6]. Ayurveda is an ancient Indian medical 
+Science that lays emphasis on holistic approach to treatment of diseases by restoring 
+the homeostatic mechanisms that confer health. Health according to Ayurveda is 
+defined as (a) equilibrium of doshas or vital Bio factors that are responsible for 
+metabolic processes in the body, (b) equilibrium in the thirteen Agni’s that are the Bio 
+energy/Power components responsible for functional activities of all tissue systems, 
+Abstract 
+Online International Interdisciplinary Research Journal, {Bi-Monthly}, ISSN2249-9598, Volume-IV, Nov 2014 Special Issue 
+ 
+w w w . o i i r j . o r g                      I S S N  2 2 4 9 - 9 5 9 8  
+Page 23 
+(c) health of the seven tissue systems or Dhatus, (d) proper excretion of waste 
+products of metabolism and (e) restraint over sensory organs, a happy mind and inner 
+peace [7].  Ayurveda emphasizes assessment and corrections of several factors that are 
+disturbed during illhealth, dosha being the most important among them.  Doshas -
+“doshas are the three bodily humors that make up one's constitution.   Vāta   is the 
+impulse principle necessary to mobilize the function of the nervous system. It has five 
+components:Prana Vata located in the brain, head, throat, heart and respiratory organs 
+that governs inhalation, perception through the senses and  the mind ; Udana Vata 
+located in the naval, lungs and throat that governs speech, self expression, effort, 
+enthusiasm, strength and vitality; Samana Vata located in the stomach and small 
+intestines that governs peristaltic movement of the digestive system; Apaana Vata 
+located between the naval and the anus that governs all downward impulses 
+(urination, elimination, menstruation, sexual discharges etc.); Vyana Vata centered  in 
+the heart and permeates through the whole body that governs circulation, heart 
+rhythm, locomotion. Pitta is the energy principle which uses bile to direct digestion 
+and hence metabolism with heat as its chief quality. The five aspects of pitta are: 
+Pachaka Pitta that Governs digestion of food which is broken down into nutrients and 
+waste. Located in the lower stomach and small intestine;Ranjaka Pitta - Governs 
+formation of red blood cells, Gives colour to blood and stools,Located in the liver, 
+gallbladder and spleen;Alochaka Pitta - Governs visual perception. Located in the 
+eyes;Sadhaka Pitta - Governs emotions such as contentment, memory, intelligence 
+and digestion of thoughts. Located in the heart;Bharajaka Pitta - Governs lustre and 
+complexion, temperature and pigmentation of the skin. Located in the skin. Kapha is 
+the body fluid principle which relates to mucus, lubrication, and the carrier of 
+nutrients.the five components of kapha are: Kledaka Kapha - Governs moistening and 
+liquefying of the food in the initial stages of digestion. Located in the upper part of 
+the stomach; Avalambhaka Kapha - Governs lubrication of the heart and lungs. 
+Provides strength to the back, chest and heart. Located in the chest, heart and lungs; 
+Tarpaka Kapha - Governs calmness, happiness and stability. Nourishment of sense 
+and motor organs. Located in the head, sinuses and cerebrospinal fluid. Bodhaka 
+Kapha - Governs perception of taste, lubricating and moistening of food. Located in 
+the tongue, mouth and throat; Shleshaka Kapha - Governs lubrication of all joints. 
+Located in the joints”.[8] 
+ 
+Agni-Food consumed will not provide good health unless it is digested properly.   The 
+digestion of food is carried out in the stomach (jathar) by the subtle bioenergy which 
+is referred to as “digestive fire” (jatharagni).[9]  There are  thirteen   types of fire that 
+operate in the body which are responsible for various metabolic activities [10];these 
+include the master Agni in the stomach, the jaatharagni, seven dhatu Agnis which are 
+responsible for the formation of tissues (dhatus), and five bhuta Agnis that integrate 
+the five elements (panchmahabhutas, the earth, water, air,fire and space ). These 
+Agnis are descriptive categories that are responsible for carrying out the action of 
+different enzymes and metabolic processes. Of the thirteen types of Agnis, the most 
+important is the digestive fire/jatharagni, the collective subtle energy that 
+encompasses the entire process of digestion. The concept of the digestive fire 
+(jatharagni) is significant due to its central role in the digestive processes such as    
+formation of nutritive fluid (ahara rasa), the physiological elements (doshas), tissues 
+(dhatus), and wastes (malas). [11, 12, 13, 14, and 15] 
+Ama-When the agni becomes weak (mandagni), a number of unwanted  unripe 
+byproducts of digestion and metabolism start forming and accumulating in the body at 
+Online International Interdisciplinary Research Journal, {Bi-Monthly}, ISSN2249-9598, Volume-IV, Nov 2014 Special Issue 
+ 
+w w w . o i i r j . o r g                      I S S N  2 2 4 9 - 9 5 9 8  
+Page 24 
+different levels from the gross to the molecular level, from a local gastrointestinal 
+tract (GIT) level to the systemic level in tissues and cells. Such products are 
+collectively called ama and act as toxic and antigenic materials. The systemic signs 
+and symptoms of the ama state are slow digestion, heaviness in the body, lack of 
+appetite, nausea, salivation, distaste, constipation, heaviness in the belly, lethargy etc.  
+Aama is a kind of autotoxin and acts like a foreign body or antigen in the body to 
+which the body reacts immunologically, releasing nonspecific antibodies in the 
+system.The presence of ama renders an ama state (amavastha) in the body, which is 
+characterised by increasing impermeability and sluggishness of the body channels or 
+srotas resulting in srotodusti. [16]    
+Srotasas -For normal functioning of the body, it is essential that these channels 
+(srotas), both the gross and subtle, remain intact and do not get blocked. Diseases are 
+precipitated due to blockage or stagnation of ama and other malas that lead to 
+stagnation of doshas. [17] Hence, it is necessary that these channels are kept clean and 
+competent. Ayurveda emphasises that all diseases are the product of a weak Agni [18] 
+and in turn, the main principle of treatment of all diseases in Ayurveda is to restore 
+and to strengthen the Agni along with the digestion and metabolism. [19]  
+The model of CCINV-Figure.1 
+Chemotherapy causes several distressing symptoms ranging from nausea and 
+vomiting to low blood counts [20] which are understood as disturbances in all these 
+five components of health.  The pathophysiology of chemotherapy induced nausea 
+and vomiting can be holistically explained by Ayurveda by the following model. 
+Ayurveda proposes that chemotherapy induces aggravation of both vaata and pitta 
+doshas [21] Aggravated pitta results in   heightened activity of pachaka pitta situated in 
+the stomach region which is responsible for gastritis and jatharagni mandya (poor 
+gastric fire manifesting as poor appetite).The associated aggravation of vaata dosha 
+contributes to worsening of the jatharagni mandya and also leads directly to 
+aggravation of udana vaata which is located in the chest and causes vomiting. As 
+jatharagni is the master and the functioning of all other Agni’s is controlled by this, 
+jatharagni mandya results in mandya of all the 12 Agni’s i.e.the  7 dhatvagnis and 5 
+bhutagnis.   This systemic Agni mandya causes formation of aama (endo-toxins/ 
+antigens) which leads to obstruction of srotuses all over the body. As the lower part of 
+the annavaha srotus is governed by apaana vaata, obstruction of this srotas and the 
+appana vaata leads difficulty in elimination of wastes/mala resulting in constipation.  
+Further,this obstruction to the free flow of apaana results in the activation of   udaana 
+vaata which is responsible for vomiting. Nausea is the manifestation of the upward 
+force of the suppressed udana vayu.  
+Yoga is defined as voluntary mastery over all functions of the mind [22] through 
+conscious voluntary slowing down of the rate of flow thoughts [23] to achieve balanced 
+functioning of the mind [24] Thus yoga brings balance at all levels by slowing down 
+and rest at all levels. There are several herbs [e.g. pippali, shunthi etc] recommended 
+for reducing jatharaagni mandya . As the excited pitta gets cooled down, the pachaka 
+pitta activity reduces which helps in reducing gastritis. Reduction of excited pachaka 
+pitta activity also improves jatharagni .This in turn improves the functioning of other 
+agnis [Dipana]. This helps in digestion of accumulated aama at all levels. This further 
+clears the srotuses, relieves constipation by normalizing the flow of apaana and udana 
+vayus. A good clearance of the bowel reverses the vaayu flow and stops the nausea 
+and vomiting. Thus the Ayurveda concept proposes a reversibility model of CCINV 
+and emphasizes on correcting the Agni mandya while yoga offers correction of vaata 
+Online International Interdisciplinary Research Journal, {Bi-Monthly}, ISSN2249-9598, Volume-IV, Nov 2014 Special Issue 
+ 
+w w w . o i i r j . o r g                      I S S N  2 2 4 9 - 9 5 9 8  
+Page 25 
+imbalances through breathing techniques that corrects the master vaata, the prana 
+vaata. [25,   26]   
+Apart from chemotherapy the antiemetic medications also may influence the Agni.   
+Antiemetic therapy, in an effort to control vomiting, may worsen the 
+jaatharagnimandya. Hence it appears that use of Agni assessment during the 
+management of CCINV may add value. Though there is evidence for use of 
+nonpharmacological mind body approaches such as Yoga in reducing nausea and 
+emesis induced by chemotherapy [27, 28] there is no study to our knowledge on use of 
+Ayurveda medications or concepts in managing chemotherapy induced nausea and 
+emesis. Pilot randomized controlled studies comparing this with conventional 
+management strategies are necessitated. 
+Figure1. AYURVEDA/YOGA MODEL OF CCINV 
+ 
+Acknowledgement:  
+This study is a part of the author's Doctoral research work. The author gratefully 
+acknowledges DrShridhara. B.S HOD PG studies in Panchakarma Ayurveda medical 
+college Bengaluru for his support. 
+  
+References: 
+[1]  
+Hawkins R, and Grunberg S. (2009) Chemotherapy-induced nausea and 
+vomiting: challenges and opportunities for improved patient outcomes. Clinical 
+journal of oncology nursing. 13(1):54-64. 
+[2] 
+Ballatori E, RoilaF(2003). Impact of nausea and vomiting on quality of life in 
+cancer patients during chemotherapy. Health and quality of life outcomes. 1(1):46. 
+[3]  
+National Cancer Institute: PDQ® Nausea and Vomiting. Bethesda, MD: 
+National Cancer Institute. Available at:  
+http://cancer.gov/cancertopics/pdq/supportivecare/nausea/HealthProfessional.  
+[4] 
+ Andrews PL, Hawthorn J :( 1988. ) The neurophysiology of vomiting. 
+BaillieresClinGastroenterol 2 (1): 141-68,  
+[5]  
+Miller AD, Leslie RA: (1994.)  The area postrema and vomiting. Front 
+Neuroendocrinol 15 (4): 301-20,  
+[6]  
+Schwartz MD, Jacobsen PB, Bovbjerg DH. (1996) Role of nausea in the 
+development of aversions to a beverage paired with chemotherapy treatment in cancer 
+patients. Physiology &behavior.; 59(4):659-63. 
+[7] 
+Vaidya 
+JadavjiTrikamjiAcharya. 
+(Ed.). 
+(1981). 
+SushruthaSamhita 
+of 
+Sushrutacharya, SootraSthana; 1 ed, Chapter 15 Verse 44. NirnayaSagar Press. 
+[8]  
+[Monier-Williams, Sanskrit-English Dictionary, Oxford, 1899; Tripathi S. 
+Ashtanga Sangraha Sutrasthana. Choukhamba Samsrita prasthana , New Delhi, India 
+1993] 
+[9] 
+Akash Kumar Agrawal, C. R. Yadav and M. S. Meena .(2010) .  Physiological 
+aspectsof Agni.Ayu. Jul-Sep; 31(3):395–398.doi:  10.4103/0974-8520.77159PMCID: 
+PMC3221079. (Akash Kumar Agrawal, C. R. Yadav&M. S. Meena,2010). 
+[10] 
+HaridasaSamskrithaGranthamala 106.  AshtangaHrudaya of Vagbhata, 
+SootraSthana; Chapter 11, Verse 34 .Chowkamba Press 
+[11] 
+VaidyaJadavjiTrikamjiAcharya. 
+(Ed.). 
+(1935). 
+CharakaSamhita 
+of 
+Agnivesharevised by Charaka and Dridahabala, ChikitsaSthana;: Chapter 15 Verse 3 
+Bombay: NirnayaSagar Press 1935. 
+[12]  
+Radhakantdev R, (1967) edt..Shabdakalpadruma, Amar Publication Varanasi: 
+ChaukhambaSamskrit Series.:8. 
+Online International Interdisciplinary Research Journal, {Bi-Monthly}, ISSN2249-9598, Volume-IV, Nov 2014 Special Issue 
+ 
+w w w . o i i r j . o r g                      I S S N  2 2 4 9 - 9 5 9 8  
+Page 26 
+[13] 
+HaridasaSamskrithaGranthamala 106.  AshtangaHrudaya of Vagbhata, 
+SootraSthana; Doshadivijnaneedi: Chapter 11, Verse 34 .Chowkamba Press. 
+[14]  
+HaridasaSamskrithaGranthamala 106.  AshtangaHrudaya of Vagbhata, 
+ShareeraSthana; Chapter3, Verse 50-54 Chowkamba Press. 
+[15] 
+VaidyaJadavjiTrikamjiAcharya. (Ed.). (1935). CharakaSamhita of Agnivesha 
+revised by Charaka and Dridahabala, ChikitsaSthana;: Chapter 15 Verse 3 Bombay: 
+NirnayaSagar Press 1935. 
+[16]  Sunita Amruthesh. (2007). Dentistry and Ayurveda-III (basics - ama, 
+immunity, ojas, rasas, etiopathogenesis and prevention). Indian journal of dental 
+research. 18(3):112-119] 
+[17]  
+Haridasa Samskritha Granthamala 106.  Ashtanga Hrudaya of Vagbhata, 
+Sootra Sthana; Doshopakramaniyam: Chapter 13, Verse 25 and Verse 27 Chowkamba 
+Press 
+[18] 
+Amruthesh#ref2 (2007) ; www.ijdr.in/article volume18 issue;0970;9290 [1],[2]    
+[19] 
+Divya K, Tripathi JS, Tiwari SK (2013) Exploring Novel Concept of Agni and 
+its Clinical Relevance. AlternInteg Med 2: 140. doi:10.4172/2327-5162.1000140 
+[20] 
+www.Cancer.org 
+[21] 
+(Metri K1, Bhargav H2, Chowdhury P3, Koka PS. (2014)Ayurveda for chemo-
+radiotherapy induced side effects in cancer patients.  J Stem Cells. 2013;8(2):115-29. 
+doi: jsc..8.2.115.]). 
+[22] 
+Patnajali yoga sutras 
+[23]  
+Yoga vasistha 
+[24]  
+Bhagavadgita chapter 2 verse 48 
+[25]  
+Hata Yoga Pradipika-Asana  Chapter  2 Verse 19 
+[26]  
+Ramachandra Krishna Kulkarni (1982) Dosha Dhatu Mala Vignanam Dosha 
+Vignana Chapter2, Belagave 
+[27]  
+Mundy EA, DuHamel KN and Montgomery GH (2003).The efficacy of 
+behavioral interventions for cancer treatment-related side effects.SeminClin 
+Neuropsychiatry Oct; 8: 253-75. 
+[28] 
+Raghavendra RM, Nagarathna R, Nagendra HR, Gopinath KS, Srinath BS, 
+Ravi BD, et al. (2006) Effects of an integrated yoga programme on chemotherapy - 
+induced nausea and emesis in breast cancer patients. European Journal of cancer care; 
+16(6):462-74. 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+Online International Interdisciplinary Research Journal, {Bi-Monthly}, ISSN2249-9598, Volume-IV, Nov 2014 Special Issue 
+ 
+w w w . o i i r j . o r g                      I S S N  2 2 4 9 - 9 5 9 8  
+Page 27 
+ 
+FIGURE : AYURVEDA/YOGA  MODEL OF CCINV 
+CHEMOTHERAPY 
+  
+YOGA & DEEPANA/PAACHANA 
+HERBS 
+ 
+ 
+  VAATA  
+PITTA 
+ 
+  VAATA  &   PITTA  
+decreased 
+pachaka 
+pitta  
+Jaatharagni Mandya 
+Pachaka 
+pitta 
+Improved jaatharagni 
+Reduced 
+gastritis 
+Systemic agni mandya 
+  
+gastritis 
+Improved systemic agnis 
+ 
+Aama formation 
+Aama digested (deepana) 
+Obstruction of strotases 
+Lower part 
+Clearance of strotases 
+(paachana) 
+Blockage of   annavaha strotas 
+Apaana vata blockage  
+constipation 
+Bowel  Cleared  
+UDANA disturbed  
+Apaana , Samana, udana 
+Vaayu restored 
+NAUSEA VOMITING 
+NO NAUSEA VOMITING 
+  

subfolder_0/Breathing-Focused Yoga Intervention on Respiratory Decline in Chronically Pesticide-Exposed Farmers A Randomized Controlled Trial (1).txt

@@ -0,0 +1,1905 @@
+CLINICAL TRIAL
+published: 11 March 2022
+doi: 10.3389/fmed.2022.807612
+Frontiers in Medicine | www.frontiersin.org
+1
+March 2022 | Volume 9 | Article 807612
+Edited by:
+Hsiao-Chi Chuang,
+Taipei Medical University, Taiwan
+Reviewed by:
+Irma Ruslina Defi,
+Dr. Hasan Sadikin General
+Hospital, Indonesia
+Shu-Chuan Ho,
+Taipei Medical University, Taiwan
+*Correspondence:
+Vijaya Majumdar
+[email protected]
+Specialty section:
+This article was submitted to
+Pulmonary Medicine,
+a section of the journal
+Frontiers in Medicine
+Received: 02 November 2021
+Accepted: 07 February 2022
+Published: 11 March 2022
+Citation:
+Dhansoia V, Majumdar V,
+Manjunath NK, Singh Gaharwar U and
+Singh D (2022) Breathing-Focused
+Yoga Intervention on Respiratory
+Decline in Chronically
+Pesticide-Exposed Farmers: A
+Randomized Controlled Trial.
+Front. Med. 9:807612.
+doi: 10.3389/fmed.2022.807612
+Breathing-Focused Yoga Intervention
+on Respiratory Decline in Chronically
+Pesticide-Exposed Farmers: A
+Randomized Controlled Trial
+Vipin Dhansoia 1, Vijaya Majumdar 1*, N. K. Manjunath 1, Usha Singh Gaharwar 2,3 and
+Deepeshwar Singh 1
+1 Swami Vivekananda Yoga Anusandhana Samsthana, Bengaluru, India, 2 School of Environmental Sciences, Jawaharlal
+Nehru University, New Delhi, India, 3 Swami Shraddhanand College, University of Delhi, Alipur, Delhi
+Background: Occupational exposure to pesticides has been associated with lung and
+cognitive function exacerbations. In the present study, we tested the effectiveness of
+breathing focused yoga intervention on alleviation of adverse respiratory and cognitive
+effects associated with chronic pesticide exposure in farmers.
+Methods: We undertook a parallel, two-armed randomized controlled trial with blinded
+outcome assessors on a chronically pesticide-exposed farming population. The study
+was conducted at district Panipat, State Haryana located in the Northern part of India
+from November 2019 to August 2020. A total of 634 farmers were screened, and 140
+farmers were randomized to breathing-focused yoga intervention (BFY, n = 70) and
+waitlist control arms (n = 65). BFY was delivered weekly in 45-min group sessions over
+12 weeks followed by home-based practice. The primary outcome was the change in
+spirometry-based markers of pulmonary function from baseline expressed as raw values,
+Global Lung Initiative (GLI) percent predicted (pp), and GLI z-scores after 24 weeks of
+intervention. Secondary variables were Trail making tests (TMT A and B), Digit symbol
+substitution (DSST), and WHO Quality of life-BREF (WHOQOL-Bref). Analysis was by
+intention-to-treat. Mediation analysis was done considering oxidative stress markers as
+potential mediators.
+Results: At the end of 6 months of intervention, the overall follow-up in the participants
+was 87.85% (n = 123); 90% (n = 63) in the control group, and 85.71% in the yoga group
+(n = 60). The mean age of the study cohort (n = 140) was 38.75 (SD = 7.50) years.
+Compared with the control group, at 24 weeks post-intervention, the BFY group had
+significantly improved status of the raw sand z scores markers of airway obstruction, after
+adjusting for confounders, FEV1, FVC, FEF25-75 [z score-adjusted mean differences
+(95% CI); 1.66 (1.10–2.21) 1.88 (1.21–2.55), and 6.85 (5.12–8.57), respectively. A fraction
+of FEF25-75 change (mediation percentage 23.95%) was explained by glutathione
+augmentation. There were also significant improvements in cognitive scores of DSST,
+TMT-A and TMT-B, and WHOQOL-Bref.
+Conclusion: In conclusion, regular practice of BFY could improve the exacerbations
+in the markers of airway obstruction in chronically pesticide-exposed farmers and
+Dhansoia et al.
+Yoga and Respiratory Decline
+cognitive variables. A significant mediating effect of glutathione augmentation was also
+observed concerning the effect of the intervention on FEF25-75. These findings provide
+an important piece of beneficial evidence of the breathing-based yoga intervention that
+needs validation across different farming ethnicities.
+Clinical Trial Registration: www.ClinicalTrials.gov, identifier: CTRI/2019/11/021989.
+Keywords: farmers, pesticide exposure, breathing-focused yoga intervention, respiratory decline, cognitive
+decline
+INTRODUCTION
+Pesticide use is an integral measure for agricultural sustainability,
+one of the primary objectives of the sustainable development
+goals (SDG-2) (1). However, the large-scale use of pesticides has
+surfaced as a double-edged sword associated with a varying range
+of detrimental health outcomes (2–15). Prevention of work-
+related respiratory disease constitutes the primary focus of the
+National Institute of Occupational Safety & Health (NIOSH)
+(16). Though the modifiability of occupational exposures
+through educational strategies has grabbed some clinical interest
+as a preventive measure for further exacerbations including
+chronic obstructive pulmonary disease (COPD), and chronic
+bronchitis (17). However, these interventions require changing
+the behavior of farmers which has been notified as a difficult
+outcome to achieve given the observation that many protective
+recommendations are never adopted by farmers (17).
+Adverse respiratory consequences expressed as reductions
+in spirometric variables [forced expiratory volume in 1 s
+(FEV1), forced vital capacity (FVC), and their ratio percentage
+FEV/FVC%] are the most widely reported health concerns
+of chronic pesticide exposure (3–9). These manifestations
+are the established risk factors for fixed airway obstruction
+including chronic obstructive pulmonary disease (6). Several
+lines of evidence support the beneficial effects of yoga-
+based interventions on the respiratory system in various non-
+clinical and clinical settings exacerbations such as COPD and
+asthma (18–25). The improved efficiency of respiratory function
+associated with yoga practice has been attributed to various
+factors including enhanced ventilatory functions, increased
+forced vital capacity, FEV1, maximum breathing capacity and
+breath-holding time, maximal stretching of respiratory muscles,
+efficient use of diaphragmatic and abdominal muscle, blunting of
+excitatory pathways regulating respiratory systems, etc. (20, 22–
+25). Explicitly there is a particular indication of the limited
+effectiveness of the yoga-based intervention to its breathing-
+focused practices as compared to yoga postures against critical
+manifestations such as COPD (19). These respiratory exercises
+are relatively simple, low cost, and could be incorporated
+into the daily lives of farmers. However, there is no clinical
+trial report available addressing the effectiveness of these
+practices in pesticide-exposed farmers with adverse respiratory
+manifestations. Further, given the notion that the efficacy of
+yoga-based interventions depends on the fitness levels of the
+individuals (21), the generalisability of findings from different
+subject populations is limited.
+Cognitive impairment is another major health exacerbation
+of
+chronic
+pesticide
+exposure.
+It
+is
+a
+risk
+factor
+for
+neurodegenerative diseases (13, 14) and could underline
+the reduced well-being of farmers directly linked to the
+sustainability of agriculture (26) and hence, calling for clinical
+attention. Several studies support role of yoga as an effective
+intervention to enhance cognitive function (Hedges’ g = 0.33,
+standard error = 0.08, 95% CI = 0.18–0.48), with the strongest
+effects reported for attention and processing speed (g = 0.29, p
+< 0.001), followed by executive function (g = 0.27, p = 0.001)
+and memory (g = 0.18, p = 0.051) (27, 28). Importantly, these
+domains of cognition also intersect with pesticide exposure-
+induced
+cognitive
+decline,
+we
+thereby
+hypothesized
+that
+farmers with pesticide exposure will benefit cognitively through
+yoga-based interventions.
+In view of the lack of available studies focused on the
+management of adverse chronic health effects in pesticide
+exposed farmers, we conducted a randomized clinical trial to
+test if 24 weeks of regular breathing-focused yoga practice could
+alleviate their adverse respiratory and cognitive manifestations
+against a wait-list control group.
+Over recent years, there has been increased recognition of the
+importance of evaluating hypothesized mediating mechanisms
+in clinical trials (29). Oxidative stress is one of the unanimous
+pathological mechanisms underlying pesticide-induced toxicity
+of various pesticides (30–32), with lipid peroxidation and GSH
+depletion being the critical modulators of airway damage in
+obstructive lung diseases (33). Alleviation of imbalances in
+oxidative stress parameters has been one of the mechanistic
+insights obtained from yoga-based clinical research (34–36).
+Hence, the present trial also aimed to test the mediating role
+of the oxidative stress markers underlying the effectiveness of
+the breathing-focused yoga intervention on the respiratory and
+cognitive outcomes.
+METHODS
+Study Design
+The study was a two-armed, randomized, parallel-group
+clinical trial with breathing-focused yoga intervention and
+the wait-list control groups with blinded outcome assessors
+(Figure 1). Details of the same have been appended in
+the
+study
+protocol
+(Supplementary Material).
+The
+trial
+was conducted at district Panipat, State Haryana located
+in the Northern part of India from November 2019 to
+Frontiers in Medicine | www.frontiersin.org
+2
+March 2022 | Volume 9 | Article 807612
+Dhansoia et al.
+Yoga and Respiratory Decline
+FIGURE 1 | Trial consolidated standards of reporting trials profile. MOCA indicates Montreal Cognitive Assessment.
+August 2020. Farmers were invited to participate and were
+recruited
+during
+the
+meetings
+conducted
+by
+the
+village
+organizations. Only one member from each household was
+randomly
+selected
+to
+avoid
+any
+within-family
+clustering
+effects. After a detailed explanation of the study objectives
+and design, informed consent was obtained from willing
+individuals. The study was conducted following the CONSORT
+statement for non-pharmacological interventions and was
+approved by the Institutional ethics committee. The study
+was also registered with clinical trials of India registration
+number: CTRI/2019/11/021989.
+Participants
+The participants were male farmers of the age group between
+18 and 49 years, naïve to the practice of pranayama or
+other yoga-based practices, and with at least 6 months of
+self-reported spraying operations in the field. Farmers with
+prior exposure to yoga or any other mind-body medicine,
+symptoms of acute pesticide exposure/poisoning, smokers/ex-
+smokers, self-reported diagnosis of respiratory disease (such
+as COPD, asthma, bronchiectasis, pulmonary fibrosis, etc.),
+history of chronic or terminal disorders (such as active
+cancer,
+severe
+heart
+or
+cerebrovascular
+disease),
+or
+any
+limitations that could have led to difficulties in follow-up
+or assessments (such as mental illness or severe cognitive
+impairment, Montreal cognitive assessment, MoCA score <10)
+(37). were excluded from the study. For additional details see
+Supplementary Table 1.
+Randomization and Blinding
+An
+external
+statistician,
+not
+directly
+involved
+in
+the
+implementation of the BFY had randomized the participants
+during their baseline visit in a 1:1 ratio (n = 70, each arm)
+using a sequence randomizer. The allocation sequences were
+sealed and participants were informed about the further process
+immediately after their baseline assessment. Owing to the nature
+of the intervention, blinding was not possible, however, outcome
+measures were blinded for the randomization groups.
+Intervention
+All the participants of the yoga group followed a breathing-
+focused yoga module for 24 weeks. For the initial 12 weeks,
+Frontiers in Medicine | www.frontiersin.org
+3
+March 2022 | Volume 9 | Article 807612
+Dhansoia et al.
+Yoga and Respiratory Decline
+the instructions for the yoga practices were given by certified
+yoga teachers for 45 min for 6 days/week. Following the same,
+participants were advised to do daily home-based practice for
+the next 12 weeks; this was done to integrate the intervention
+into their daily routine settings. The farmers were not restricted
+from doing their routine farm work on fields and thereby
+were obligatorily physically active. The intervention included
+physical practices (loosening practices, breathing practices with
+body movements, asanas), relaxation techniques, pranayama,
+lectures regarding the importance of yoga, lifestyle changes
+through notional corrections, the importance of wearing
+personal protective equipment during pesticide spray. Since
+farmers were involved in physically-demanding routine activities
+and based on the indicative relevance of breathing-focused
+yoga interventions on pulmonary function under various
+settings, the intervention was drafted with special emphasis on
+breathing practices, relaxation techniques, and meditation (20,
+28). Asansa (physical postures) (pavanamuktasana, sukhasana,
+gomukhasana, paschimotanasana, and vakrasana) were included
+only for preparatory requiremrnts for the practice of pranayama.
+Further, under pranayama, Bhastrika pranayama was included
+based on the associated beneficial outcomes on lung function
+as well as on cognitive improvement (20, 28). The pranayama
+session was drafted as a comprehensive respiratory exercise
+regime of 25 min, composed of fast practices Kapalabhati
+interspersed with Surya bedhana (20). Details of intervention are
+presented in Supplementary Table 2 of the Study Protocol.
+Waitlist Control Group
+For inactive control participants, we chose a wait-list design
+as we deemed it as an ethically appropriate alternative to
+provide needed care to the control pesticide-exposed group
+following the trial. Though the subjects in the wait-list group
+participated in no active intervention, while recruitment, they
+were instructed to continue their daily activities (without
+engaging in regular structured exercise) and were also given
+weekly once group lectures focused on the importance of
+wearing personal protective equipment during pesticide spray.
+All subjects received monthly phone calls to assess for any
+subjective changes in health. After the completion of the
+24th week study, these participants received the same yoga-
+based intervention given to the intervention group post their
+data collection.
+Outcomes
+All outcome assessments were done at baseline and 6 months.
+Standard measures of spirometry included forced vital capacity
+(FVC), forced expiratory volume in one second (FEV1), the
+ratio of forced expiratory volume in 1 s to forced vital capacity
+(FEV1/FVC), forced expiratory flow between 25 and 75% of
+the FVC, FEF25–75 and peak expiratory flow rate (PEFR). The
+primary outcome was the adjusted mean difference in lung
+function variables analyzed as spirometric data from baseline
+to the 24th week. The data was presented as raw spirometric
+scores. Additionally, in order to meet the worldwide diagnostic
+standard, free of bias due to age, height, sex and ethnic groups,
+we used the Global Lung Function prediction equations to
+derive percent predicted values and standard deviation (z-) scores
+adjusted for sex, age, and height and ethnicity (38, 39). As specific
+reference ranges do not yet exist for South Asian population,
+the Caucasian equations (i.e., derived from white subjects of
+European origin) were used to derive the Global Lung Function
+Initiative (GLI) based scores. The secondary outcome variables
+were changes in cognitive functions scored through Digit Symbol
+Substitution Test (DSST) and Trail Making Tests part A and
+B (TMT-A and B); and psychological variables scored through
+perceived stress scale (PSS), and World Health Organization
+Quality of Life–BREF (WHOQOL-Bref). The neurocognitive
+tests/domains were selected based on the previous reports on
+neuropsychological outcomes in pesticide exposed farmers (13,
+14). Mitigation of oxidative stress was hypothesized as the causal
+mediation mechanism for the breathing focused yoga and hence,
+the planned mediation analysis included oxidative stress markers;
+Malondialdehyde (MDA), Superoxide dismutase (SOD), and
+Glutathione (GSH).
+Assessments
+Baseline assessments of study outcome measures were performed
+before subjects were randomized. Assessments were repeated
+at the end of 6 months of intervention. The preliminary
+information was obtained from all study subjects which included
+questions on demographic data, and those related to pesticide
+exposure including detailed exposure information, names of the
+pesticides used, mode of application, period, dose, frequency of
+pesticide applications, and personal protective equipment repair
+status, duration used, etc.
+Respiratory Parameters
+A pulmonary function test was performed to assess pulmonary
+impairment in pesticide sprayers by using a spirometer (RMS
+Helios-702, India) following the standards of lung function
+testing of the American thoracic society/European respiratory
+Society (ATS/ERS) (40). Standard measures of spirometry
+included forced vital capacity (FVC), forced expiratory volume
+in 1 s (FEV1), the ratio of forced expiratory volume in 1 s to
+forced vital capacity (FEV1/FVC), forced expiratory flow between
+25 and 75% of the FVC (FEF25–75%) and peak expiratory flow
+rate (PEFR). Participants were instructed to breathe, and three
+reproducible measurements each of FEV1, FVC, and maximal
+mid-expiratory flow were obtained. The highest values were
+documented and used for analysis. Other spirometric variables,
+including forced expiratory flow at 25–75% (FEF25–75) and peak
+expiratory flow (PEF), were obtained from the trial with the
+highest combined FEV1 and FVC. Using the Excel macro for
+GLI, reference values, the lower limit of normal (LLN), Z-scores,
+and percentiles for FEV1, FVC, and the FEV1/FVC ratio were
+calculated for each subject in the reference population available
+from www.lungfunction.org (41, 42). Height and weight at the
+time of spirometry were measured to the nearest 0.1 cm on a
+stadiometer and 0.1 kg on an electronic scale, respectively.
+Neurocognitive Parameters
+The Montreal Cognitive Assessment (MoCA) was used to
+evaluate the overall cognitive abilities of the participants (37).
+Frontiers in Medicine | www.frontiersin.org
+4
+March 2022 | Volume 9 | Article 807612
+Dhansoia et al.
+Yoga and Respiratory Decline
+Cognitive function was assessed using the neuropsychological
+tests, DSST (43, 44) (for executive function, speed of processing,
+attention), and Trail Making Test A/B (TMT-A: speed of
+processing; TMT-B: executive function) (45–48). DSST is a
+component of the Wechsler Adult Intelligence Test with
+high test-retest reliability. This pen and pencil-based test
+has a considerable executive function component, evaluates
+psychomotor speed, attention, and executive function. The
+subject was given a key grid of numbers and matching symbols
+and a test section with numbers and empty boxes. The test
+consists of filling as many empty boxes as possible with a symbol
+matching each number. The score is the number of correct
+number-symbol matches achieved in 90 s. We used the DSST
+scores as a continuous variable. TMT measures scanning and
+visuomotor tracking, divided attention, and cognitive flexibility.
+Two raw scores (time needed to complete TMT A and TMT
+B) and three derived scores (TMT B-A, TMT B/A, and TMT
+(B-A)/A) were calculated for each participant. These tests were
+selected based on the previous reports on neuropsychological
+outcomes in pesticide-exposed farmers.
+Psychological Assessments
+Stress perception was assessed using the perceived stress scale
+(PSS), a 10-item well-validated scale that gauges chronic stress
+on a 40-point scale (49). A total score ranging from 0 to 40 is
+computed by reverse scoring the four positively worded items
+and then summing all the scale items. Higher scores indicate
+greater levels of perceived stress. Though not as diagnostic
+criteria, PSS scores of 0–13, 14–26, and 27–40 points have been
+considered as indicators of low, moderate, and high perceived
+stress, respectively (50).
+The quality of life (QOL) of the participants was assessed
+using the World Health Organization Quality of Life –
+BREF (WHOQOL-Bref) (51), a standardized comprehensive
+instrument comprising 26 items that elicits the perceived physical
+health, psychological health, social relations and environment—
+related QOL in an individual.
+Biomarkers of Oxidative Stress
+Oxidative stress markers, reduced glutathione (GSH) were
+estimated in the whole blood whereas, TBARS (Thiobarbituric
+acid reactive substances), and SOD (Superoxide dismutase)
+were analyzed from the hemolysate. TBARS concentration was
+expressed as serum malondialdehyde (MDA). The plasma and
+the buffy coat were removed from whole blood by centrifugation
+at 2,000 rpm for 10 min at 4◦C. The red cells were washed
+thrice with normal saline and a hemolysate(s) was prepared as
+follows: MDA levels were measured with the method described
+by Ohkawa et al. (52). The plasma and the buffy coat were
+removed from whole blood by centrifugation at 2,000 rpm for
+10 min at 4◦C. The red cells were washed thrice with normal
+saline and a hemolysate(s) was prepared as follows: For the
+estimation, MDA hemolysate was prepared by mixing 1.9 ml of
+cold distilled water with 0.1 ml of packed cell volume (PCV)
+suspension. For estimation of SOD activity: The remaining red
+cells were haemolysed by approximately adding 1.5 volumes.
+Statistical Analysis
+Given the lack of reported minimally clinically significant
+difference suggested for FEV1 defined for clinical trial endpoints
+for occupationally impaired lung function. The calculated sample
+size of n = 140 was based on the reported effect of on FEV1 [effect
+size of 0.54, (123/ml) improvement] 20 for 80% power and a 2-
+sided α = 0.05, with assumed attrition of 20% over 6 months. To
+meet the objective of recruiting 140 subjects, a rough sampling
+frame of 500 households was generated. The distribution of
+continuous variables was analyzed for normal distribution (using
+the Kolmogorov–Smirnov statistic) and for homogeneity of
+variance (Levene’s test). Data for these variables are shown as
+means and standard deviation (SD). Covariates considered were
+age, educational level, BMI, cumulative exposure index (CEI),
+and serum achetylcholinesatse levels. Algorithms for calculation
+of CEI are Given in Supplementary Table 3. All statistical
+analyses were performed blinded to the randomization group and
+results are reported using intention-to-treat analysis. the 2012
+Global Lung Function Initiative (GLI) reference equations were
+used and percent predicted and z-scores were calculated, using
+the open-source GLI R Macro. The GLI Z-score is a standardized
+measure of the positioning of an observed measurement in the
+distribution of the population from which the GLI reference
+values are derived and takes both between-subject and age-
+and height-related variability into account. LLN was defined
+as the lower fifth percentile in the distribution from which
+the GLI reference values are derived, as calculated by the GLI
+Excel macro. Airway obstruction was defined as FEV1/FVC less
+than the lower limit of normal as per the recommendations
+of The American Thoracic Society (ATS)/European Respiratory
+Society (ERS) (53). Linear regression was used to analyze study
+outcomes as adjusted mean differences (AMDs), additionally
+adjusted for their comparable value at baseline and other
+covariates Missing data were minimal. A P-value < 0.05
+was considered to indicate significant differences between
+adjusted means.
+We applied causal mediation method, to investigate if
+oxidative stress could be a causal pathway between intervention
+and the outcome. We fit mediation models to estimate the
+direct and indirect effects of the intervention assuming a
+mediating effect of the oxidative stress markers. Mediation
+analysis was performed using the methods described by Valeri
+and Vanderweele (54) to investigate direct and indirect effects
+of the BFY on study outcomes at 6 months. The PROCESS
+SPSS Macro version 2.13, model four was used to perform
+analysis by fitting a linear regression model to the outcomes
+with yoga yreatment and the mediators included were the
+covariates (described above), and then fitting a regression model
+to the mediator (linear or logistic depending on the mediator)
+including intervention as a covariate. In mediation analysis,
+effects can be broken down into separate paths: the c path
+between the treatment and outcome (without accounting for
+potential mediators), the a path between the intervention and
+the potential mediator; and the b path between the potential
+mediator and the outcome (Supplementary Figure 1). The
+mediating (indirect) pathway is calculated as the product of
+paths a and b (ab). Univariable linear regression models were
+Frontiers in Medicine | www.frontiersin.org
+5
+March 2022 | Volume 9 | Article 807612
+Dhansoia et al.
+Yoga and Respiratory Decline
+fitted to the potential mediators MDA, GSH and SOD to test
+whether there was an association between the BFY and the
+mediators. Since a variable can only be a mediator of treatment
+if there is a significant effect (p < 0.05) of treatment on the
+mediator (path a), Following the sam, linear regression analyses
+were performed to examine the relationships between treatment
+allocation and change in each of the potential mediators, and
+between change in each of the potential mediators and the
+outcome posttreatment scores.
+RESULTS
+Flow of Patients
+The flow of patients into the study is shown in Figure 1. During
+the months of November-January 2019–20, we had screened
+634 farmers from five nearby villages of Panipat district state
+Haryana, India. Out of 634 farmers screened, only 280 fitted
+the eligibility criteria (Figure 1), of which only 140 completed
+the baseline assessments who were randomized into yoga and
+control groups. A total of 130 participants (92.85%) completed
+the post-intervention assessment.
+Demographics at Baseline
+The mean age of the study cohort (n = 140) was 38.75 (SD
+=7.50) years; and their mean BMI was 22.44 (SD = 1.37) kg/m2
+(Table 1). Mean pesticide exposure among sprayers was found
+to be 5.71 (SD = 3.04) years. As compared with participants,
+non-participants were of lower age and had comparatively
+less
+exposure
+to
+pesticides
+(Supplementary Table 4).
+All
+the study subjects belonged to agricultural occupation with
+similar socioeconomic status (data not shown) with mean
+period of education as 3.54 (2.77) years. Aligining with the
+previous observations, farmers seemed to be exposed to
+combination of multiple pesticides, mostly organophosphates
+(see Supplementary Table 5) with mean serum cholinesterase
+levels of 5.37 (SD = 0.88) matching their exposure status (55).
+Table 1 also demonstrates the distribution of the spirometric
+variables following conversion to the GLI z-scores. Notably, the
+median z-score values were well-below zero [FEV1 = −3.39
+(1.36); FVC = −3.07 (1.60); FEV1/FVC = −1.73 (1.76); FEF25–
+75 = −1.73 1.76, mean (SD)]. The median FEV1 z-score was
+less than −1.64, the lower limit of normal and the median
+FVC and FEF25–75 z-scores approached this mark. Almost the
+entire cohort had mild cognitive impairment (98.6%, MOCA
+scores 18–25). At baseline, the distribution of the demographic
+and study variables were found to be fairly even with the non-
+significant differences between the study groups (p > 0.05) (for
+details, see Table 1), except for DSST and TMT scores. However,
+the distribution of global cognition was balanced between the
+groups (MoCA, P = 0.225). The farmers were also exposed to
+a mixture of various pesticides, mostly organophosphate and a
+cumulative effect of pesticides, measured by activity of serum
+cholenesstase activity levels aligned with the range observed
+in previous populations with similar duration of pesticide
+exposure. Though almost the entire cohort exhibited potentially
+unsafe behavior with respect to the use personal protective
+equipments use with 72.85% reported none. There was also a
+significantly skewed distribution of PPE use between the study
+groups
+(Supplementary Table 6),
+however,
+the
+cumulative
+pesticide exposure index was equally distributed between
+the groups.
+Primary Outcomes
+At the end of 6 months of intervention, the overall follow-up
+in the participants was 87.85% (n = 123); 90% (n = 63) in the
+control group, and 85.71% in the yoga group (n = 60). The
+adjusted means of the all spirometric variables and their z-scores
+are presented in Table 2. In the intention-to-treat analysis with
+the raw spirometric data on the 140 randomized patients, BFY
+group had a significantly improvement in FEV1 (L) [AMD, 1.02,
+95% CI (0.75–1.38), p < 0.001)], FVC (L) [AMD, 1.14 95% CI
+(0.79–1.49), p < 0.001], FEF25–75 [AMD, 29.33 95% CI (22.46–
+36.20) p < 0.001], PEFR [AMD, 43.47 95% CI (35.33–51.60), p <
+0.001] as compared to the controls, following adjustment for age,
+height, education level, cumulative pesticide exposure, and serum
+cholineestase levels. However, no significant between group
+difference was observed for FEV1/FVC% (Table 2). Analyses
+of z-scores which are independent of age, and height, gave
+similar results (FEV1 AMD = 1.66 (95% CI = 1.10–2.21),
+FVC AMD = 1.88 (95% CI = 1.21–2.55) FEV1/FVC GLI
+pp AMD = 3.19 (95%CI=−8.68–14.96), and FEF25–75 z-
+score AMD=6.85 (95% CI = 5.12–8.57) following adjustment
+for education level, cumulative pesticide exposure and serum
+cholinesterase levels.
+In exploratory subgroup analyses, greater improvements in
+spirometric variables were noted in farmers with age>39 years
+as compared to those ≤39 years (data not shown).
+Secondary Outcomes
+The secondary variables were the cognitive and psychological
+variables.
+The
+post-intervention
+mean
+scores
+of
+DSST
+[AMD = 11.82 (95% CI, 8.90–14.75)], TMT-A [AMD = −24.60
+(95% CI, −28.14 to −21.05)] and TMT-B [−41.99 (−49.72
+to −34.25)] were significantly improved in the yoga group
+as compared to the control group (Table 2). The influence
+of BFY on the contrive outcomes was not confounded by
+age or education (Table 2). We could also observe significant
+improvement in WHO-BREF scores as compared to the control
+group [AMD = 26.89, (95% CI = 22.82–30.97)]. Concerning
+PSS, positive but non-significant changes in the adjusted
+means were observed between BFY and the control group
+(Table 2).
+Mediation Analysis
+Test of Direct Effect of Treatment on the Mediators
+Concerning the proposed mediators of yoga intervention,
+MDA demonstrated a significant reduction in the yoga group
+as compared to the control group [(AMD = −63.72, 95%
+CI = −91.94– (−35.05)], whereas the anti-oxidative markers
+GSH and SOD indicated a comparative increase in the yoga
+group [AMD; GSH = 1.08, 95% CI = 0.79–1.37; AMD;
+SOD = 0.06, 95% CI = 0.010–0.11] as compared to the
+controls (Table 2). Hence, significant associations could be
+established between BFY and all the potential mediators using
+Frontiers in Medicine | www.frontiersin.org
+6
+March 2022 | Volume 9 | Article 807612
+Dhansoia et al.
+Yoga and Respiratory Decline
+TABLE 1 | Baseline characteristics of study participants.
+Variables
+Overall
+(n = 140)
+Yoga
+(n = 70)
+Control
+(n = 70)
+P-value
+Age (yr)
+38.75 (7.50)
+37.64 (8.31)
+39.86 (6.47)
+0.081
+Height (m)
+1.73 (0.05)
+1.74 (0.05)
+1.73 (0.05)
+0.481
+Weight (Kg)
+67.55 (5.07)
+68.36 (5.51)
+66.74 (4.47)
+0.060
+BMI (Kg/m2)
+22.44 (1.37)
+22.63 (1.45)
+22.25 (1.27)
+0.100
+Education, (years)
+3.54 (2.77)
+3.93 (3.35)
+3.16 (1.99)
+0.100
+Pesticide exposure in years (yr)
+5.71 (3.04)
+6.28(3.93)
+5.15 (3.04)
+0.061
+Serum cholinesterase (KU/ml)
+5.37 (0.88)
+5.30 (0.94)
+5.44 (0.82)
+0.355
+Cumulative pesticide exposure index (CEI)
+8125.13
+(6022.36)
+8670.10
+(5782.09)
+7587.9
+(6244.98)
+0.291
+Adverse respiratory symptoms, n (%)
+Wheezing
+22 (15.7)
+14 (20.0)
+8 (11.4)
+0.164
+Dry cough
+12(8.6)
+9 (12.9)
+3 (4.3)
+0.128
+Productive cough
+106 (75.7)
+54 (77.1)
+52 (74.3)
+0.693
+Dyspnoea
+98 (70)
+57 (81.4)
+41(58.6)
+0.001*
+Airflow obstruction
+79 (56.29)
+44 (62.85)
+35 (49.23)
+0.078
+Lung function characteristics
+FEV1 (L), mean (SD)
+2.06 (0.70)
+2.04 (0.76)
+2.08 (0.64)
+0.691
+FEV1 GLI PP
+54.91 (18.80)
+55.43 (17.11)
+54.34 (20.58)
+0.738
+FVC (L), mean (SD)
+2.92 (0.82)
+2.79 (0.87)
+3.04 (0.74)
+0.065
+FVC GLI PP
+64.27 (18.28)
+66.47 (16.73)
+61.90 (19.68)
+0.147
+FEV1/FVC GLI PP
+85.46 (15.21)
+83.39 (15.23)
+87.69 (15.00)
+0.167
+PEFR Pred (%)
+43.76 (19.02)
+44.03 (21.17)
+43.49 (16.77)
+0.867
+FEF25-75 Pred (%)
+49.71 (23.82)
+45.44 (19.62)
+53.99 (26.85)
+0.03
+Z-Scores
+FEV1 (L) z-score
+−3.39 (1.36)
+−3.36 (1.21)
+−3.41 (1.50)
+0.846
+FVC (L) z-score
+−3.07 (1.60)
+−2.88 (1.46)
+−3.27 (1.73)
+0.158
+FEV1/FVC z-score
+−1.73 (1.76)
+−1.98 (1.66)
+−1.46 (1.84)
+0.090
+FEF25–75% z-score
+17.23 (5.20)
+16.83 (5.25)
+17.66 (5.17)
+0.355
+Cognitive function
+MoCA score
+22.31(1.95)
+22.11(2.10)
+22.51 (1.77)
+0.225
+DSST score (s)
+38.34 (8.38)
+35.63 (7.60)
+41.04 (8.30)
+<0.001*
+TMT-A (s)
+43.92 (18.81.216)
+34.53 (16.44)
+53.31(16.34)
+<0.001*
+TMT-B (s)
+104.72 (42.61)
+92.56 (37.20)
+116.89 (44.43)
+<0.001*
+Secondary variables
+PSS
+22.57 (5.95)
+22.80 (5.89)
+22.34 (6.04)
+0.651
+WHOQOL-Bref
+47.61 (11.11)
+43.97 (11.02)
+51.24 (10.03)
+<0.001*
+Oxidative stress indices
+MDA, nmol/l
+2.57 (7.66)
+2.481(7.36)
+2.66 (7.70)
+0.153
+GSH, mg/ml
+2.51 (0.73)
+2.61 (0.62)
+2.46 (0.80)
+0.083
+SOD (units/min/mg protein)
+0.23 (0.13)
+0.24 (0.13)
+0.22 (0.13)
+0.410
+Continuous variables are represented as means (SD), and categorical variables are represented as number (%); s stands for seconds, t = independent samples t-test statistic; and
+χ2 = Chi-Square test statistic. Cumulative pesticide exposure index CEI; Airflow obstruction was defined as FEV1/FVC less than the lower limit of normal as per the recommendations
+of The American Thoracic Society (ATS)/European Respiratory Society (ERS). defined as FVC, forced vital capacity; FEV1: forced expiratory volume in 1 s; FEF25-75: forced expiratory
+flow; GLI PP
+, percent predicted values of FEV1, FVC and FEV1/FVC derived using Global Lung Function Initiative (GLI) equations; z-scores are standard deviation scores of spirometric
+variables adjusted for sex, age, and height using the Global Lung Function Initiative (GLI)-2012 equations; MOCA, Montreal Cognitive Assessment; DSST, Digit symbol substitution test;
+TMT-A, Trail making test A; TMT-B, Trail making test B; PSS, Perceived stress score; World Health Organization Quality of Life – BREF (WHOQOL-Bref); MDA, Malondialdehyde; GSH,
+Glutathione; Superoxide dismutase, SOD.
+linear regression models (path a, Supplementary Figure 1).
+Therefore,
+further
+mediation
+models
+as
+presented
+in
+Table 3
+were
+fitted
+to
+all
+the
+three
+(SOD,
+MDA,
+and
+GSH) variables.
+Test of the Indirect (Mediating) Effect
+The indirect, direct and total effects of each of the models are
+given in Table 3. The mediation analyses indicated GSH as a
+mediator of the effect of BFY on FEF5-5. As observed in Table 3,
+Frontiers in Medicine | www.frontiersin.org
+7
+March 2022 | Volume 9 | Article 807612
+Dhansoia et al.
+Yoga and Respiratory Decline
+TABLE 2 | Outcome measures (primary and secondary) after 6 months of follow-up.
+Outcomes
+Adjusted means
+(Yoga)
+mean (SE)
+Adjusted means
+(control)
+mean (SE)
+AMD (95% CI)
+F value, partial
+eta square
+Primary
+Lung function
+FEV1 (L)
+3.02 (0.09)
+1.99 (0.09)
+1.02 (0.75–1.29)**
+56.84, 0.33**
+GLIFEV1 PP
+68.80 (3.73)
+48.19 (3.73)
+20.61 (10.05–31.165)**
+14.92, 0.11**
+FVC (L)
+3.81 (0.12)
+2.65 (0.12)
+1.14 (0.79–1.49)**
+41.81, 0.26**
+GLIFVC PP
+72.04 (3.99)
+52.31 (3.99)
+−19.75 (8.40–31.10)*
+11.87, 0.087*
+GLIFEV1/FVCPP
+81.40 (4.15)
+84.54 (4.15)
+3.19 (−8.68–14.96), 0.600
+299.14, 0.002
+FEF25-75 (L.sec-1)
+76.66 (2.43)
+47.34 (2.37)
+29.33 (22.46–36.20)**
+71.46, 0.38**
+PEFR
+93.88(2.88)
+49.81 (2.80)
+43.47 (35.33–51.60)**
+111.91,0.49**
+FEV1 (L) z-score
+−1.38 (0.20)
+−3.03 (0.20)
+1.66 (1.10–2.21)**
+34.61, 0.218**
+FVC (L) z-score
+−1.25 (0.23)
+−3.13 (0.23)
+1.88 (1.21–2.55)**
+31.04, 0.200**
+FEV1/FVC z-score
+−0.59 (0.15)
+−0.59 (0.15)
+0.01 (−0.44–0.45), 0.982P
+0.00, 0.00
+FEF25–75% z-score
+25.75 (0.61)
+18.90 (0.60)
+6.85 (5.12–8.57)**
+62.01, 0.37**
+Secondary
+Cognitive function
+DSST
+49.27 (1.01)
+37.44 (0.98)
+11.82 (8.90–14.75)**
+64.15, 0.36**
+TMT A (s)
+24.18 (1.18)
+49.00 (1.14)
+−24.60 (−28.14–21.05)**
+189.06, 0.62**
+TMT B (s)
+71.68 (2.68)
+113.67 (2.61)
+−41.99 (−49.72– −34.25)**
+115.69, 0.50**
+Psychological well-being
+PSS
+18.77 (0.66)
+20.25 (0.64)
+−1.47 (−3.33–0.38)
+2.45, 0.021, 0.12
+WHOQOL-Bref
+64.45(1.37)
+37.20 (1.34)
+27.25 (23.27–31.23)**
+183.69, 0.62**
+Oxidative stress markers
+MDA, nmol/ml nmol/ml
+1.90 (1.00)
+2.53 (0.98)
+−63.72 (−91.94–35.05)
+20.03, 0.15**
+SOD (units/min/mg protein)
+0.32 (0.02)
+0.26 (0.18)
+0.06 (0.010–0.11)
+5.38, 0.04, 02*
+GSH, mg/ml
+3.55 (0.10)
+2.48 (0.10)
+1.08 (0.79–1.37)
+53.48, 0.32**
+FVC, forced vital capacity; FEV1, forced expiratory volume in 1 s; GLIFEV1PP - indicates Global Lung Function Initiative (GLI) percent predicted of FEV1, FEF25–75, forced expiratory
+flow; FVC, forced vital capacity; FEV1 (L), forced expiratory volume in one second (L indicates liter); FEV1/FVC, ratio of forced expiratory volume in one second to forced vital capacity;
+FEF (25–75), forced expiratory flow between the 25 and 75% of the FVC; PEFR, peak expiratory flow rate; z-scores are standard deviation scores of spirometric variables adjusted
+for sex, age, and height using the Global Lung Function Initiative (GLI)-2012 equations DSST score, Digit symbol substitution test; TMT-A and -B, Trail Making Tests, part A and B;
+PSS, Perceived stress score; WHOQOL-Bref, World Health Organization Quality of Life – BREF; TBARS, Thiobarbituric acid reactive substances; SOD, Superoxide dismutase; MDA,
+Malondialdehyde; GSH, Glutathione. The adjusted means of all variables are presented along with standard errors (SE).
+Adjusted means stand for the mean values of the outcome variables adjusted for covariates age, educational level, BMI, cumulative exposure index (CEI), and serum achetylcholinesatse
+levels for raw spirometric variables. However, for Global Lung Function Initiative (GLI) percent predicted variables, age and BMI adjustments were not done as the data is standardized
+for age, height and ethnicity. AMD: Adjusted mean difference, differences in the adjusted means between the two groups (i.e., adjusted for the covariate). *Indicate P-value < 0.05, and
+**indicate P < 0.01.
+GLI z-scores are independent of age, and height.
+a fraction of FEF25-75 change was partly explained by increases
+in GSH levels (mediation percentage 23.95%).
+DISCUSSION
+In this 24-weeks randomized controlled trial on chronically
+pesticide exposed farmers, BFY practice was significantly more
+observed to be more effective than the wait-list control
+condition in the alleviation of spirometry-based indices of airflow
+limitation, in particular FEV1, FVC, FEV25-75, and PEFR.
+The observed increment in FEV1 by 1.02L over 6 months in
+the BFY group seems relevant against an annual decline by
+13.1 mL (95% CI, 19.1 to 7.1) (7) and a reduction by 140 ml
+observed over an average of 3.4 years of pesticide exposure
+(10). However, given the lack of specific reports on clinical
+interventions with spirometry-based pulmonary outcomes in
+pesticide-exposed populations, there remains an uncertainty in
+the clinical significance of the observed effect sizes. Nonetheless,
+the observed change of ∼1 l in FEV1 is larger than the
+minimal clinically important difference of 100 ml suggested
+for pharmacological trials (56). Our observations accord with
+the previous reports of improvements in pulmonary function
+parameters with regular yoga practice, particularly breathing-
+focused practices (18–20). Additionally, there have been mixed
+findings as well-indicating that the effectiveness of yoga-based
+breathing interventions is influenced by the fitness levels of the
+subjects, with only marginal improvements in lung functions
+observed in the elderly (20) to moderate-but-clinically-significant
+improvements in COPD patients (18). This further explains
+the comparatively larger effect-sizes observed concerning FEV1
+and FEV1 (Pred%) in the present pesticide-exposed cohort
+Frontiers in Medicine | www.frontiersin.org
+8
+March 2022 | Volume 9 | Article 807612
+Dhansoia et al.
+Yoga and Respiratory Decline
+TABLE 3 | Indirect, direct, and total effects of the mediation models on respiratory and cognitive outcomes at 6 months.
+Outcomes
+Mediators
+Indirect effects
+(mediating-effect)
+Direct effect of BFY
+intervention
+on outcome (DE)
+Total effect
+(TE)
+Proportion
+mediated (%)
+FEV(L)
+SOD
+0.02 (−0.03–0.09)
+1.06 (0.67–1.45)**
+1.01 (0.74–1.29)**
+1.98
+MDA
+−0.08 (0.07–0.24)
+7.92
+GSH
+0.01 (0.11–0.21)
+1.00
+FEV z score
+SOD
+0.018 (−0.11–0.15)
+1.90 (1.11–2.69)
+1.78 (1.24–2.33)**
+1.01
+MDA
+−0.15 (−0.50–0.15)
+8.43
+GSH
+0.01 (−0.45–0.48)
+0.56
+GLFEVPP
+SOD
+0.02 (−0.03–0.09)
+47.68 (33.93–61.43)**
+48.64 (38.84–58.44)**
+0.04
+MDA
+1.08 (−3.53–5.83)
+2.22
+GSH
+1.11 (−6.74–8.03)
+2.28
+FVC(L)
+SOD
+0.024 (−0.044–0.11)
+1.30 (0.81–1.80)*
+1.12 (0.76–1.48)*
+2.14
+MDA
+−0.16 (−0.36–0.018)
+14.28
+GSH
+−0.045 (−0.32–0.21)
+4.02
+FVC z score
+SOD
+0.01 (−0.06–1.00)
+2.32 (1.34–3.29)
+2.03 (1.34–2.71)
+2.14
+MDA
+−0.14 (−0.34–0.02)
+14.28
+GSH
+−0.045 (−0.32–0.21)
+4.02
+GLFVCPP
+SOD
+−1.29 (−3.99–0.48)
+49.58 (35.60–63.59)*
+46.47 (36.49–56.45)*
+3.00
+MDA
+−0.92 (−5.83–3.70)
+2.00
+GSH
+0.89 (−8.07–5.46)
+1.91
+FEV1/FVC
+SOD
+0.27 (−0.42–1.22)
+−1.36 (−6.80–4.08)
+2.54 (−1.43–6.50)
+10.63
+MDA
+2.31 (0.68–4.51)
+92.03
+GSH
+1.31 (−1.18–3.82)
+0.52
+GLIFEV1/FVCPP
+SOD
+0.04 (−0.79–0.95)
+−3.15 (−8.54–2.24)
+0.49 (−3.35–4.34)
+8.16
+MDA
+2.96 (0.85–5.38)
+–
+GSH
+0.64 (−2.37–3.48)
+–
+FEV1/FVC z-Score
+GSH
+0.00 (−0.11–0.13)
+−0.55 (−1.24–0.14)
+−0.04 (−0.54–0.45)
+–
+MDA
+0.40 (0.15–0.13)
+–
+GSH
+0.10 (−0.30–0.46)
+–
+FEF25–75%
+SOD
+0.28 (−1.07–2.02)
+18.78 (9.40–28.17)*
+28.39 (21.49–35.29)*
+0.99
+MDA
+2.51 (−0.23–5.75)
+8.84
+GSH
+6.80 (1.51–12.36)
+23.95*
+FEF25–75% z-Score
+SOD
+0.03 (−0.33–0.45)
+4.72 (2.36–7.07)
+6.94 (5.34–8.5)*
+0.004
+MDA
+0.83 (−0.07–1.80)
+11.95
+GSH
+1.60 (0.48–2.90)
+23.50*
+PEFR
+SOD
+1.43(−0.43–4.02)
+43.64 (31.90–55.38)*
+44.47 (36.15–52.79)*
+3.21
+MDA
+1.60 (−1.22–4.95)
+3.59
+GSH
+−0.72 (−6.41–4.90)
+1.62
+DSST
+SOD
+0.11 (−0.69–0.93)
+10.83 (6.74–14.92)*
+11.71 (8.70–14.73)*
+0.94
+MDA
+0.026 (−1.39–1.51)
+0.26
+GSH
+0.71 (−1.23–2.70)
+6.06
+TMT-A
+SOD
+0.24 (−0.76–1.54)
+−24.25 [−28.91 –(19.60)]*
+−24.60 [−28.13– (−21.07)]
+*
+0.99
+MDA
+0.40 (−1.16–1.78)
+8.69
+GSH
+−0.96 (−3.60–1.41)
+3.90
+TMT-B
+SOD
+1.58(−0.39–4.07)
+−44.36 (−54.81– −33.91)*
+−42.40 (−50.28– −34.51)*
+3.73
+MDA
+1.28 (−1.81–4.75)
+3.02
+GSH
+−0.82 (−6.31–4.87)
+1.93
+PSS
+SOD
+−0.06 (−0.63–0.45)
+−3.60 (−6.19– −1.01)
+−1.63 (−3.51–0.25)
+3.92
+MDA
+0.52 (−0.40–1.51)
+31.91
+GSH
+1.46 (0.15–3.02)
+89.57
+WHOQOL-Bref
+SOD
+−0.61 (−1.98–0.25)
+26.07 (20.72–31.41)
+27.61 (23.61–.61.63)*
+2.21
+MDA
+−0.26 (−1.71–1.12)
+0.94
+GSH
+2.41 (−0.57–5.86)
+8.72
+Direct effect (DE) refers to the direct influence of the BFY on the study outcomes that is not mediated by other variables in the model. An indirect (mediated) effect expresses the portion
+of the intervention effect that is mediated through a specific mediator. The total effect (TE) is the sum of the direct and indirect effects of the BFY and of mediators on the study outcomes.
+SOD, Superoxide dismutase; MDA, Malondialdehyde; GSH, Glutathione; FEV, Forced expiraory volume; FVC, Forced vital capacity; PEFR. GLGlobal Lung Initiative (GLI) percent predicted
+(pp), and GLI z-scores, The adjusted means of all variables are presented along with standard errors. Adjusted for age, BMI, and education (yrs), adjusted for respiratory symptoms.
+Frontiers in Medicine | www.frontiersin.org
+9
+March 2022 | Volume 9 | Article 807612
+Dhansoia et al.
+Yoga and Respiratory Decline
+as compared to the meta-analyzed effect-sizes on patients
+with COPD [weighted mean difference (WMD) of 125 ml for
+FEV1(L)20 and 3.95% for FEV (Pred%)] (18). Pesticide exposure
+has been sought as a risk factor for obstructive pulmonary
+diseases marked by an early reduction in FEV1 (57). Our results
+justify the relevance of early intervention in pesticide-exposed
+populations for prevention of manifestations of irreversible
+lung function decline as in COPD (57). Mechanistically, we
+could establish a 24% mediating effect of glutathione increment
+underlying BFY induced improvements in FEF25-75, which
+is another primary spirometry-based marker of the airway in
+abundance in obstruction (4). Glutathione is the principal small
+molecular weight thiol of the antioxidant system abundant
+in the epithelial lining fluid of lungs and serves as a crucial
+protector of alveolar macrophages, pulmonary epithelial cells,
+and pulmonary endothelial cells from oxidative stresses (33).
+Its depletion and disturbed metabolism are key manifestations
+in pesticide exposed tissues under inflammatory settings of
+lung decline including chronic obstructive pulmonary disease
+(COPD). Our findings on GSH augmentation accord with
+prior reports on remarkably increased after yoga practice
+serum total glutathione (GSH) contents, activities of GSH-
+peroxidase, and GSH-transferase (58). The notion BFY could
+serve as a non-pharmacological substitute for GSH augmentation
+deserves attention since supplementation of GSH precursors
+has been considered as the best means of manipulating
+intracellular GSH biosynthesis to combat its depletion noted
+in varied inflammatory settings (59). For other spirometric
+parameters we failed to establish a significant mediating effect
+of alleviation of oxidative stress on BBY intervention. These
+findings indicate the need to explore other alternate markers,
+including inflammation. Altogether, the observed beneficial
+effects of BFY on FEV1 along with other spirometric markers of
+small airway obstruction (FEV25-75% and PEFR) deserve clinical
+attention to combat exacerbations of lung function decline in
+pesticide-exposed populations. These findings deserve clinical
+recognition given the observed poor status of precautionary
+practices in the farming population; most of the farmers
+(n = 102, 72.85%) were not using personal protective equipment.
+Moreover, when analyzed for airflow obstruction, 56.3% had
+airflow obstruction and ∼70% of the farmers reported adverse
+respiratory symptoms.
+Pesticides are known lipophilic neurotoxins and are reported
+to cross and disrupt the blood-brain barrier (60). Long-term
+exposure to these chemicals could lead to neuronal loss in specific
+brain regions and subsequent cognitive impairment (61). In line
+with previous reports on pesticide exposure and global cognitive
+function, the entire cohort of pesticide-exposed farmers had
+the manifestation of mild cognitive impairment (MOCA scores
+18–25) (14, 33). In particular, the TMT-B scores of the study
+cohort were lower as compared to the normative population-
+based scores reported for the matched age and education status,
+indicative of their compromised executive control (61, 62). In
+this backdrop of cognitive decline, BBY intervention was found
+to have significant potential to mitigate neurocognitive decline
+through improvements in the TMT-B scores by 42 s, DSST by
+11 s, and TMT-A by 25 s. Our results are in line with previous
+reports of yoga-based practices, However, no causal inference
+could be established for oxidative stress markers underlying the
+beneficial cognitive effects of the BFY. Inclusion of the objective
+mediators such as structural and functional brain changes could
+aid in unraveling the mediator influences.
+Psychological stress is a well-recognized health concern
+amongst farmers. Though we could find a trend for improvement
+in perceived stress in the BFY group, the difference between
+the groups was not statistically significant. Notably, there was
+a significant improvement in the quality of life in the BFY
+group as compared to the control group, which is a positive
+health marker indicative of improved capacity to function (63).
+and an important factor toward the attainment of sustainable
+agriculture (64).
+This study is limited by the small sample size and use
+of prebronchodilator spirometry. The study was focused on
+early intervention in the high-risk farming population, the
+trial was of a short duration of 6 months, and hence, we
+did not include the outcome of COPD manifestation which
+would be required to get a more realistic insight into the
+preventive potential of BFY. We did not consider statistical
+power requirements for causal analyses which need extended
+validation in larger trials (29). The strength of this study lies
+in the fact that it is the first-ever trial that addressed the need
+for clinical attention to alleviate adverse health conditions in
+the chronically pesticide-exposed farmer population. The present
+trial was conducted in India which is predominantly a rural
+country with 67% of its population engaged in agricultural
+practice (65). In the Indian scenario, farmers mainly live in
+rural areas wherein government hospitals are the major health
+care setups with a preponderance of traditional health experts
+(66). However, originating in India as a comprehensive mind-
+body practice, yoga has become increasingly popular in the West
+as a holistic approach to health and well-being, the popularity
+and practice of yoga-based interventions are not restricted to
+the Indian subcontinent (67, 68). Over recent years, there has
+been a sharp rise in the spread of yoga-based interventions
+across the globe. Given the fact that ethnicity is an important
+factor in lung function, the trial findings need validation over
+different ethnic settings. Overall the study findings are useful
+for establishing preliminary evidence for future larger trials with
+longer follow-ups targeting the prevention of COPD in the high-
+risk population.
+Enhanced respiratory surveillance has been stated as a
+need of the hour for pesticide-exposed farmers. Our findings
+indicate the scope of implementation of cost-effective breathing-
+focused interventions along with respiratory surveillance in
+pesticide exposed farmers. Given the multimodal influence
+of yoga on health, the effects of yoga may be broader
+when explored for other adverse health effects associated
+with pesticide exposure. Overall, the findings support the use
+of yoga-based interventions as a pragmatic strategy against
+exacerbations of respiratory and cognitive health decline in
+farming communities. In this 24-weeks randomized controlled
+trial on chronically pesticide exposed farmers, breathing
+focused yoga intervention was significantly more effective
+than the wait-list control condition in the alleviation of
+Frontiers in Medicine | www.frontiersin.org
+10
+March 2022 | Volume 9 | Article 807612
+Dhansoia et al.
+Yoga and Respiratory Decline
+spirometry-based indices of airflow limitation, in particular
+FEV1, FEV25-75, and PEFR. The study also gave mechanistic
+insights into the understanding of the breathing-focused
+yoga intervention vis GSH augmentation for improvement
+for FEF5-5%. This could serve as a cost-effective substitute
+for GSH supplementation suggested for the management of
+airway inflammation.
+DATA AVAILABILITY STATEMENT
+The raw data supporting the conclusions of this article will be
+made available by the authors, without undue reservation.
+ETHICS STATEMENT
+The study was conducted in accordance with the CONSORT
+statement
+for
+non-pharmacological
+interventions
+and
+was approved by the Institutional Ethics Committee. The
+patients/participants provided their written informed consent to
+participate in this study.
+AUTHOR CONTRIBUTIONS
+VD:
+conceptualization,
+study
+design,
+and
+data
+analysis.
+VM: conceptualization, study design, data analysis, writing
+first draft of manuscript, and revision of manuscript. NM:
+conceptualization, study design, and revision of manuscript. US:
+data analysis. DS: revision of manuscript. All authors contributed
+to the article and approved the submitted version.
+ACKNOWLEDGMENTS
+USG is thankful to the Indian Council of Medical Research
+(ICMR) for providing Research associate fellowship (Sanction
+No. 45/02/2018-NAN/BMS).
+SUPPLEMENTARY MATERIAL
+The Supplementary Material for this article can be found
+online
+at:
+https://www.frontiersin.org/articles/10.3389/fmed.
+2022.807612/full#supplementary-material
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+Conflict of Interest: The authors declare that the research was conducted in the
+absence of any commercial or financial relationships that could be construed as a
+potential conflict of interest.
+Publisher’s Note: All claims expressed in this article are solely those of the authors
+and do not necessarily represent those of their affiliated organizations, or those of
+the publisher, the editors and the reviewers. Any product that may be evaluated in
+this article, or claim that may be made by its manufacturer, is not guaranteed or
+endorsed by the publisher.
+Copyright © 2022 Dhansoia, Majumdar, Manjunath, Singh Gaharwar and Singh.
+This is an open-access article distributed under the terms of the Creative Commons
+Attribution License (CC BY). The use, distribution or reproduction in other forums
+is permitted, provided the original author(s) and the copyright owner(s) are credited
+and that the original publication in this journal is cited, in accordance with accepted
+academic practice. No use, distribution or reproduction is permitted which does not
+comply with these terms.
+Frontiers in Medicine | www.frontiersin.org
+13
+March 2022 | Volume 9 | Article 807612

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+Challenging Case in Clinical Practice:
+Yoga Therapy for Parkinson’s Disease
+Nishitha Jasti, BNYS, MSc, Hemant Bhargav, MD, PhD,
+Harish Babu, BAMS, MD, and R. Nagarathna, MD, FRCP
+Introduction
+Parkinson’s disease (PD) is a common movement disorder
+where the efficacy of yoga has been studied. A review article
+has shown that yoga resulted in improvements in functional
+mobility, balance, and lower limb strength in patients with PD,
+which, in turn, influences gait and postural stability.1 Enhanced
+body flexibility postyoga also positively affects drooped pos-
+ture and rigidity. A study on Iyengar-based hatha yoga showed
+a significant improvement in scores on the Unified Parkinson’s
+Disease rating scale (UPDRS) and the Berg’s Balance Scale
+(BBS). A reduction in falling episodes by 25% and reduction in
+visible tremors were noted lasting for several hours after yoga
+practice.2 A study of power yoga (a vigorous and fitness-based
+variant of yoga) showed significant improvement in upper and
+lower limb bradykinesia scores and rigidity score.3 Improve-
+ment was observed in one repetition maximum (1-RM) and
+peak power on biceps curl, chest press, leg press, hip abduc-
+tion, and seated calf. It also showed significant improvements
+in the activities of daily living and overall score of the Par-
+kinson’s Disease Questionnaire-39 (PDQ-39). Schmid et al.
+demonstrated the role of yoga in reducing the fear of falling
+and improvement in static balance in elderly subjects, which is
+one of the major concerns to be addressed in patients with PD.4
+The effectiveness of yoga for psychosocial well-being in PD
+has also been studied, considering the heightened vulnerability
+to increased stress, mood disorders, and emotional dysregula-
+tion. Positive trends in depression scores and development of
+positive social relationships have been reported after a yoga
+intervention.5 Studies on yoga also showed substantial im-
+provement in quality of sleep in patients with PD.1
+The efficacy of yoga has also been demonstrated in other
+chronic and neurodegenerative disorders where movement is
+compromised. A study reported significant improvements in
+balance, speed, and endurance of walking and fatigability in
+patients with multiple sclerosis.6 Another study reported im-
+provement in static balance and gait parameters, which were
+determined using a stabilometer and a gait trainer, respec-
+tively, in women with chronic musculoskeletal disorders.7 The
+mentioned outcomes demonstrate that yoga therapy can be a
+powerful adjunct for patients with movement disorders in the
+areas of empowering self, reducing symptom severity, im-
+proving functional autonomy, and psychosocial well-being.
+Case Presentation
+Demographic Details and Clinical Presentation
+A 55-year old housewife Mrs. A was admitted to a holistic
+health care center in Bengaluru, India. She was diagnosed with
+stage-5 (Hoehn and Yahr staging)8 idiopathic PD for the past
+eight years by a neurologist and was on medications for the
+same. The patient presented with chief complaints of (1) dis-
+abling resting tremors for the past eight years in the left hand,
+which had later progressed to the right hand and the left leg, (2)
+stiffness and pain in the limbs (more in the upper limbs) for the
+past year, (3) slowing down of movement with difficulty in
+walking for the past year, (4) difficulty in speech, (5) difficulty
+in maintaining sleep for the past month, and, (6) difficulty in
+passing stools for the past six months. Her illness was insidious
+in onset with a gradually progressive course. Her symptoms
+significantly incapacitated her from continuing her daily rou-
+tine. She also reported frequent episodes of falls in the past
+month, which enforced the use of a wheelchair. On neurologic
+examination, the patient was found conscious, oriented, had
+scanning speech, needed support while walking, and displayed
+a festinant gait. She had masked facial expressions, reduced
+cognitive abilities, and emotional lability. Her cranial nerve
+functions, reflexes, and sensory functions were normal. On
+motor system examination, it was observed that there was
+hypertonia in the joints of the upper and lower limbs. Cog-
+wheel rigidity was demonstrable in the upper and lower limbs.
+She was unable to get up from the wheelchair without support
+and needed constant support to walk. Motor coordination was
+impaired with positive finger-to-nose and heel-knee tests—
+with more impairment on the left side. Her bladder function
+was normal. Clinical examination did not reveal any signs of
+significant autonomic dysfunction. She had been taking
+125 mg of syndopa (levodopa1carbidopa) four times a day for
+past two years.
+ALTERNATIVE AND COMPLEMENTARY THERAPIES
+DOI: 10.1089/act.2020.29264.nja 
 MARY ANN LIEBERT, INC. 
 VOL. 26 NO. 2
+APRIL 2020
+57
+Downloaded by University Of Newcastle from www.liebertpub.com at 04/15/20. For personal use only. 
+Assessments
+We assessed her clinical progress using the UPDRS, assessed
+balance on the BBS, short-term memory on the digit span test,
+pain and symptoms on the visual analog scale (VAS), and
+anxiety and mood on the Hamilton Anxiety Rating Scale
+(HAM-A) and Hamilton Depression Rating Scale (HAM-D),
+respectively. We also assessed her yoga performance ability on
+the yoga performance assessment (YPA) scale.9 All the men-
+tioned scales were applied on the day of admission and again
+after four weeks of the yoga-based lifestyle (YBL) modification
+program. Her medications were kept stable for the entire month.
+Her UPDRS scores were assessed on both the ON-state (during
+which the effect of antiparkinsonian medication still exists) and
+the OFF-state (12–14 hours after the antiparkinsonian medica-
+tion was taken) to assess the effect of the YBL program on the
+course of the disorder and the severity of symptoms.
+Intervention
+The patient participated in a YBL program in a residential
+setting, which included a combination of yog

+asana, pr

+an

+ay

+ama,
+meditation, chanting, relaxation techniques, devotional sessions,
+yogic counseling based on yoga philosophy, and dietary modi-
+fications based on yogic principles. The yoga practice involved a
+validated yoga intervention for 60 minutes duration,10 for 6 days
+a week for 4 weeks, which was facilitated by a well-trained yoga
+therapist. The patient also continued the conventional therapy
+for the entire month.
+The details of the validated 60-minute yoga module for PD
+are described below:
+1. First week (to be done with mindfulness and breath syn-
+chronization three times a day)
+i. Whole-body joint loosening sitting on the chair (Sukshma
+Vyayama): (duration—five minutes)
+a. Neck exercises (Ghriva Sithilikarana)—three rounds
+b. Shoulder rotation (Bhuja Sithilikarana)—three rounds
+c. Waist rotation (Kati Sithilikarana)—three rounds
+d. Knee cap tightening (Janu Sithilikarana)—three rounds
+e. Ankle rotation (Gulpha Sithilikarana)—three rounds
+2. Second week (practicing 10 rounds each with holding the
+pose1first week practices)
+i. Breathing exercises (Shvasa kriya sitting on the chair):
+(duration—six minutes)
+a. Hands in and out breathing (Hastashw

+asana kriya)—
+three rounds
+b. Hand
+stretch
+breathing
+(Urdhvahastashw

+asana
+kriya)—three rounds
+c. Moon pose breathing (Shashank

+asana with “M-kara”
+chanting)—three rounds
+ii. Relaxation in corpse pose (Shav

+asana with “A-kara”
+chanting): (duration—three minutes)
+iii. Physical postures (

+asanas) in supine pose: (duration—
+seven minutes)
+a. Bridge pose (Setu Bandh

+asana)—three rounds
+b. Folded leg stretch (Supta Udarakarshan

+asana)—
+three rounds on either side
+c. Half wind releasing pose (Ardha Pavanamukt

+asana)—
+one round on either side
+3. Third week (practicing five rounds each with holding the
+pose for 10 breaths1first- and second-week practices)
+i. Physical postures (

+asanas) in standing pose with wall
+support: (duration—one minute on either side)
+a. Lateral arc pose (Ardha Kati Chakr

+asana)—one
+round on each side
+ii. Physical postures (

+asanas) in prone pose: (duration—
+four minutes)
+a. Serpent pose (Bhujang

+asana)—three rounds
+b. Half locust pose (Ardha Shalabh

+asana)—three rounds
+on either side
+4. Practices that were performed continuously from the first
+week to the fourth week after the physical postures (as they
+could be done in sitting position)
+i. Deep relaxation technique in corpse pose (Shav

+asana):
+(duration—five minutes)
+ii. Controlled breathing techniques (Pr

+an

+ay

+ama): (dura-
+tion—11 minutes)
+a. Skull brightening breath (Kapalbhati)—60 counts
+(counts increased from 20 to 40 and 40 to 60 in the
+first and second weeks, respectively)
+b. Sectional breathing (Vibhagiya Pr

+an

+ay

+ama)
+– Abdominal breathing (three rounds)
+– Thoracic breathing (three rounds)
+– Clavicular/shoulder breathing (three rounds)
+c. Alternate nostril breathing (Nadi Shuddi Pr

+an

+ay

+ama)—
+nine rounds
+d. Humming bee breath (Bhramari Pr

+an

+ay

+ama)—five
+rounds
+iii. Meditative techniques (Dhyana): (duration—10 minutes)
+a. Sound resonance technique (Nadanusandhana)
+– “A-kara” chanting (nine rounds)
+b. OM meditation (OM-kara Dhyana)
+Results
+The patient found the intervention to be safe and feasible.
+She was able to do all the practices. Her yoga performance
+ability improved on the YPA scale from 15 to 32. UPDRS
+scores reduced significantly from 83 to 58 in the ON-state and
+55 in the OFF-state, BBS scores improved from 13 to 23 in
+the ON-state and 26 in the OFF-state, digit span forward test
+scores improved from 4 to 6 and digit span backward scores
+improved from 3 to 4 in both the ON-state and OFF-state.
+UPDRS scores showed improvement in the domains of ac-
+tivities of daily living, bradykinesia, tremors, and rigidity.
+Scores on VAS for pain fell from 7 to 3 and 6 to 3 in both the
+ON-state and OFF-state in the left and right arms, respec-
+tively. The HAM-A score reduced from 10 to 2 in the ON-
+state and to 4 in the OFF-state; HAM-D scores reduced from
+18 to 0 in the ON-state and 4 in the OFF-state. The scores show
+significant improvement in motor and nonmotor symptoms in
+the ON-state and OFF-state.
+58
+MARY ANN LIEBERT, INC. 
 VOL. 26 NO. 2
+ALTERNATIVE AND COMPLEMENTARY THERAPIES 
 APRIL 2020
+Downloaded by University Of Newcastle from www.liebertpub.com at 04/15/20. For personal use only. 
+Discussion
+This case study demonstrates the potential application of a
+YBL modification program in debilitating movement disorders
+such as PD. The patient was not able to practice the whole yoga
+program from day 1. Her therapy started with simple joint
+loosening practices of all the joints in the upper and lower
+limbs three times a day. The joint loosening practices were
+done with mindfulness and breath synchronization. She was
+also given slow pr

+an

+ay

+ama, chanting, and meditative practices
+in the first week along with joint loosening. Yoga practices
+were taught in a way that physical practices are done when the
+patient is in the ON-state so that there is better performance and
+optimal use of the yoga program.
+From the second week, we added slow and gentle

+asanas, which
+required joint movements and which were possible in sitting and
+lying down positions such as straight leg raise breathing, Pa-
+vanmukt

+asana breathing, Setu Bandh

+asana breathing, and so on.
+The practices in the second week were done without maintaining
+the procedure for a long time, but just the number of rounds was
+increased. In the third week, the practices were maintained for 10
+deep breaths and the patient was instructed to be much more
+mindful of the practice with each breath. The patient developed
+confidence. By the fourth week, she was able to do the standing
+poses with minimal wall support. She also started walking slowly
+without support for short distances (in the ON-state as well as in
+the OFF-state) by the end of the fourth week. Her sitting and
+standing postures became better. Her mood and appetite im-
+proved. Constipation resolved as a result of the sattvic diet (fresh
+and wholesome vegetarian food that is easy to digest and rich in
+nutrients) and yoga practices. We expect that improved perfor-
+mance of yoga on the YPA scale has translated into significant
+improvements in clinical symptoms.
+The present case showed persistent improvement in OFF-state
+scores, illustrating the crucial role of yoga therapy in improving
+symptoms and also preventing the worsening of symptoms after
+the effectiveness of the antiparkinsonian medication wears off.
+This also explains the need for incorporation of yoga therapy in
+the treatment regimen to improve symptoms, quality of life, and
+prevent the progression of the disease, as it is already known that
+chronicity of the disease reduces the efficacy of antiparkinsonian
+medication drastically.11
+The improvement we have observed is higher than what is
+usually reported in clinical trials of yoga. We observed that her
+BBS and UPDRS scores improved by *50% and 34%, re-
+spectively. This can be explained by the following logic: (1)
+most of the studies have used only yoga posture and breathing-
+related practices, but the effect of a whole YBL modification
+program, which brings balance at the level of body, breath,
+emotion, intellect, and spirit, has not been tested in this popu-
+lation before. A YBL program may be much more effective
+than simply practicing yoga for one hour and continuing the
+same faulty lifestyle as before; (2) the practice was maintained
+consistently for six days a week. Most of the yoga studies report
+practices being done two to three times a week and not every day.
+Practicing yoga every day may be much more effective than
+practicing intermittently; (3) most importantly, our emphasis was
+on doing the practices mindfully, ultimately aiming at a deeply
+relaxed state of mind. Yoga philosophy advocates that the mind
+plays a very important role in noncommunicable diseases such as
+PD and thus, practices such as yogic counseling and devotional
+sessions might also have contributed to this improvement.
+The yoga therapy utilized in this case was based on the prin-
+ciple of Integrated Approach of Yoga Therapy, which involves a
+holistic approach of looking into an individual at five layers of
+existence (Panca Ko
+sas), namely: physical body, (Annamaya
+Ko
+sa), body of life force (Pr

+an
+_ amaya Ko
+sa), mental body
+(Manomaya Ko
+sa), body of intellect (Vijn
+˜anamaya Ko
+sa), and
+body of bliss (

+Anandamaya Ko
+sa). According to yoga philoso-
+phy, agitations in the mental body from incorrect lifestyle habits
+percolate into the adjacent body of life force and manifests in the
+form of disturbance in the breath and later changes in cellular
+dynamics at the level of physical body to result in a disorder.12
+Thereby, YBL has been designed to involve practices addressing
+each layer. The scientific mechanism of action for yoga might
+include downregulation of the hypothalamo pituitary adrenal
+axis, better autonomic modulation, improved flexibility, and re-
+duced stiffness through improved microcirculation and improved
+mood of the subject due to enhanced mindfulness. Relaxation of
+the mind and better insight into oneself by yogic counseling may
+have allowed resolution of several deep-rooted psychologic
+conflicts, which further enhanced the patient’s relationship with
+herself and with society. All this ultimately manifested as an
+improved clinical picture and better quality of life for this case.
+Conclusion
+Add-on yoga therapy may be useful in reducing tremor,
+bradykinesia, and rigidity and improving balance and quality
+of life in patients suffering from PD. However, uncontrollable
+factors such as the interaction with the therapist and the es-
+tablishment of an empathic bond between the patient and the
+therapist might have influenced the outcomes of the case study,
+which cannot be excluded. These findings need confirmation
+through more research in the future.
+Author Disclosure Statement
+No competing financial interests exist.
+Funding Information
+This research received no grant from any funding agency.
+References
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+treatment of hematopoietic inhibition in HIV-1 infection. J Stem Cells
+2010;5:129–148.
+Nishitha Jasti, BNYS, MSc (Yoga therapy), is from S-VYASA Yoga
+University, in Bangalore, India. Hemant Bhargav, MD, PhD (Yoga), is an
+assistant professor of Yoga in the Department of Integrative Medicine,
+NIMHANS, in Bangalore, India. Harish Babu, BAMS, MD, is an assistant
+professor at Arogydhama Holistic Health Center, S-VYASA Yoga Uni-
+versity, in Bangalore, India. R. Nagarathna, MD, FRCP, is Medical Di-
+rector at Arogydhama Holistic Health Center, S-VYASA Yoga University,
+in Bangalore, India.
+To order reprints of this article, contact the publisher at (914) 740-2100.
+60
+MARY ANN LIEBERT, INC. 
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+ALTERNATIVE AND COMPLEMENTARY THERAPIES 
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+Downloaded by University Of Newcastle from www.liebertpub.com at 04/15/20. For personal use only. 

subfolder_0/Changes in Electrical Activities of the Brain Associated with Cognitive Functions in Type 2 Diabetes Mellitus A Systematic Review.txt

@@ -0,0 +1,1466 @@
+Changes in Electrical Activities of the
+Brain Associated with Cognitive Functions
+in Type 2 Diabetes Mellitus: A Systematic
+Review
+Amit Kanthi1
+, Deepeshwar Singh1
+, N. K. Manjunath1,
+and Raghuram Nagarathna2
+Abstract
+Introduction: Electroencephalogram (EEG) has the potentials to decipher the neural underpinnings of cognitive processes in clin-
+ical and healthy populations. Objective: The current systematic review is intended to examine the functional brain changes under-
+lying cognitive dysfunctions in T2DM patients. Methods: The review was conducted on studies published in the PubMed,
+WebofScience, Cochrane, PsycInfo database till June 2021. The keywords used were electroencephalogram, T2DM, cognitive
+impairment/dysfunction. We considered studies using resting-state EEG and ERP. The preferred reporting items for systematic
+reviews and meta-analysis (PRISMA) guidelines were followed to compile the studies. Results: The search yielded a total of 2384
+studies. Finally, 16 independent studies were included. There was a pattern of a shift in EEG power observed from higher to
+lower frequencies in T2DM patients, though to a lesser degree than Alzheimer’s disease patients. P300 latency was increased
+in T2DM patients mainly over frontal, parietal, and posterior regions. P300 and N100 amplitudes were decreased in T2DM
+patients than in healthy controls. Conclusion: The results indicate that T2DM has consequences for cognitive functions, and it
+finds a place in the continuum of healthy cognition to dementia.
+Keywords
+type 2 diabetes (T2DM), EEG, ERP, cognitive function, cognitive decline
+Received August 16, 2021; revised January 20, 2022; accepted February 22, 2022.
+Introduction
+Diabetes Mellitus (DM) is a significant global health concern. It
+affected approximately 463 million people in 2019 and is esti-
+mated to reach 700.2 million by 2045.1 Around 90% of these
+cases are diagnosed as Type 2 Diabetes Mellitus (T2DM),2,3
+which is a late-onset most common type of diabetes character-
+ized by the reduced capacity of peripheral tissue to regulate
+glucose homeostasis in response to insulin.4 T2DM is known
+for its long-term macrovascular and microvascular complica-
+tions, ultimately affecting brain health that may lead to
+Alzheimer’s disease and vascular dementia.5 To be specific, epi-
+demiological studies suggest that individuals with T2DM have
+an increased risk of cognitive decline (1.5%) and dementia
+(1.6%) than healthy controls.6
+Identifying mechanisms behind this association is crucial to
+tackling cognitive complications of T2DM. Recognizing these
+mechanisms will help address the complications at an earlier
+stage where treatment is more efficient. However, the mecha-
+nisms responsible for cognitive impairments in T2DM patients
+are still poorly understood. Some factors identified so far are
+hypoglycemia, compromised glycemic control, impaired insulin
+signalling and the most important, hyperglycemia.7 Along with
+these, advanced glycation end (AGE) production (mediated by
+hyperglycemia) coupled with oxidative stress can degenerate
+neurons, damage vascular endothelium, and lead to cognitive
+impairment.8
+The information gathered from structural and functional
+brain changes also enables the early detection of cognitive
+problems. Brain structural changes investigated in T2DM
+patients via MRI (Magnetic Resonance Imaging) studies,
+reported the presence of regional atrophy in the hippocampus,
+basal ganglia, orbitofrontal and occipital lobes.9 An increased
+presence of subcortical infarcts and large vessel infarcts were
+1Department of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana
+Samsthana (S-VYASA), Bangalore, India
+2Arogyadhama, Swami Vivekananda Yoga Anusandhana Samsthana (S-VYASA),
+Bangalore, India
+Corresponding Author:
+Deepeshwar Singh, Department of Yoga and Life Sciences, Swami Vivekananda
+Yoga Anusandhana Samsthana (S-VYASA), #19 Eknath Bhavan, Gavipuram
+Circle, K.G. Nagar, Bangalore, KA, India.
+Email: [email protected]
+Review
+Clinical EEG and Neuroscience
+1-13
+© EEG and Clinical Neuroscience
+Society (ECNS) 2022
+Article reuse guidelines:
+sagepub.com/journals-permissions
+DOI: 10.1177/15500594221089106
+journals.sagepub.com/home/eeg
+also reported.10 T2DM patients also exhibited the presence of
+white matter lesions as compared to healthy controls.10,11
+Diffusion Tensor Imaging (DTI) metrics provide indices of
+white matter axonal integrity, tract anatomy, and connectivity
+between brain regions. It demonstrated that microstructural
+white matter abnormalities might contribute to deficits in
+brain structure and function in adults with T2DM.12–14
+Collectively, it can be implicated that structural MRI indices
+provide evidence of localized and widespread brain abnormal-
+ities in T2DM adults.
+Electroencephalogram (EEG) is another approach to study
+the functional brain changes through the brain’s cortical activ-
+ity. It measures the electrical activities of the brain and repre-
+sents the aggregate post-synaptic currents of neurons in the
+brain. EEG has been used to identify different types and sever-
+ities of cognitive impairments. Moreover, it is a cost-effective
+and non-invasive method, accessible in most countries across
+the globe.15 Hence EEG could be a promising tool to extract
+the characteristics of cortical functional brain connective
+related to MCI in T2DM.
+The current systematic review sought to examine the cortical
+activity of the brain underlying cognitive dysfunction in T2DM.
+This review focuses on both the task-based EEG, ie,
+event-related
+potentials
+(ERPs)
+and
+resting-state
+EEG
+(rsEEG) studies, without limiting to any particular kind of anal-
+ysis technique adopted (power spectrum analysis, synchroniza-
+tion, coherence etc) in the studies. To the best of our
+knowledge, this is the first review ever presented, consolidating
+the pieces of evidence of both EEG and ERP studies investigat-
+ing cognitive processes in T2DM patients.
+Methods
+Search Strategy and Study Selection
+Database search was conducted in PubMed, Cochrane, Science
+Direct, and Wiley Online Library from the earliest records till
+Jan 2020. Search terms were entered as follows: Type 2
+Diabetes Mellitus (T2DM) and cognitive dysfunction, T2DM
+and EEG, T2DM and event-related potentials (ERPs), neuro-
+cognitive changes in T2DM, T2DM, and brain functions.
+Studies on humans, published in the English language and
+used only EEG as an assessment tool, were considered for
+the study. Exclusion criteria included animal studies, patients
+with type1 diabetes, and imaging modalities other than EEG.
+The duplicate articles were deleted as the first step of study
+selection. The remaining returns were then evaluated based on
+the title and the abstract and were included only if they: 1) were
+original and empirical studies, 2) analysed cognitive functions
+in T2DM, 3) used only EEG or ERP method to analyse the cog-
+nitive processes. Studies surviving this step of evaluation were
+then searched for full article.
+Figure 1 provides the summary of the search process.
+Quality Assessment and Extracted Information
+NIH Quality assessment tool for case-controlled and cross-
+sectional studies was used to rate the quality of the included
+studies. Information extracted from the studies consists of the
+publication year, country, imaging modality, analysis, and par-
+ticipant demographics, including the number of participants.
+Results
+The search yielded a total of 90 studies. Sixteen studies were
+selected after excluding the irrelevant studies. No overlapping
+of participant samples was seen in any of the studies. The
+studies were of fair to good quality as assessed by the NIH
+quality assessment tool.
+Study Demographics and Details
+The studies were conducted across many different countries
+including Sweden (n = 1), USA (n = 2), Japan (n = 2), India
+(n = 2), Brazil (n = 1), Finland (n = 1) and China (n = 7) being
+the highest. Not all studies reported the average age of the par-
+ticipants. However, the age of the participants ranged from 32
+to 84 years. The disease duration ranged from 1 to 28 years.
+Only three studies reported whether the participants were
+using insulin.16–18 Most of the studies reported groups
+matched for age, gender, and education. Six studies performed
+ERP analysis, and eight studies performed frequency analysis.
+Besides, two studies performed both ERP and frequency
+analysis.
+In summary, eight of the sixteen studies used ERP analysis.
+While four studies performed power spectral analysis, two
+studies did coherence analysis. Synchronization and coupling
+analysis were carried out by one study each.
+The supplementary tables provide study demographics
+details (Tables 1 and 2).
+Resting-State EEG (rsEEG)
+Ten of sixteen studies have analysed the EEG frequencies to
+ascertain the cognitive relevance of the cortical activity in
+T2DM patients. Four studies assessed the spectral power,
+eight studies evaluated the synchronization levels, and one
+study assessed determinism.
+Benwell et al (2020) compared the EEG frequency charac-
+teristics between Alzheimer’s Disease patients (AD), T2DM,
+and healthy controls (HC). A pattern of a shift in EEG power
+was observed from higher to lower frequencies in T2DM
+patients, particularly over temporal regions. AD patients
+showed higher relative (δ + θ) power than T2DM and HC,
+whereas relative (α + β) power was lower for AD than T2DM
+and HC.19 T2DM patients show slowing of EEG rhythms
+with the reduction in alpha and beta band power over the pari-
+etal and central and posterior regions, respectively.18,20 Also,
+T2DM patients had a significantly higher % of θ activity at
+2
+Clinical EEG and Neuroscience 0(0)
+Cz and less power in α at Pz simultaneously. People with dia-
+betes tended to have more power consistently distributed in the
+slower δ and θ EEG bands at all the three recording sites,
+although it was not significant.18 Furthermore, Bian et al
+reported that the ratios of power of theta versus the power of
+alpha [P(θ)/P(α)] in the frontal and left temporal region were
+significantly higher in the T2DM patients having an amnestic
+mild cognitive impairment (aMCI) as compared to the patients
+without aMCI.21
+The synchronization values tend to decrease in T2DM
+patients with amnestic mild cognitive impairment (aMCI) com-
+pared to cognitively healthy T2DM patients, particularly over
+central and occipital regions.22 The decrease was observed in
+all the EEG frequency bands.19 Similar to the power analysis
+observations, the aMCI group had larger coherence values in
+θ and δ frequency bands.23 In addition, α frequency coherence
+values were lower in fronto-posterior, right-temporo posterior
+regions.21,23 Phase lag index (PLI) as a measure of synchroni-
+zation also shows that the global mean PLI in lower α, upper
+α, and β bands were significantly decreased in T2DM patients
+with aMCI.20 However, T2DM patients do not show any differ-
+ence in PLI than healthy controls.3
+Task-Based EEG Studies (Event-Related Potentials)
+There were a total of 8 ERP studies. Majority of the studies
+focused on the P300 component. Six of the studies assessed
+the P300 ERP component, while three studies assessed the
+Figure 1. Result of systematic search.
+Kanthi et al
+3
+Table 1. Studies of Resting State EEG in Type 2 Diabetes Mellitus.
+Study
+Participants
+T2DM
+duration
+Years of
+education
+HbA1c, insulin
+use, HOMA-IR
+Country
+EEG measures
+Results
+EEG correlated with
+neuropsychological test
+performance
+Benwell et al
+(2019)
+T2DM, n = 27 (12
+females, 50-78
+years)
+AD, n = 18, (11
+females, 52-86
+years)
+Heathy Control, n
+= 27, (13 females,
+50-77 years)
+Not reported
+Not
+reported
+HbA1c < 10
+USA
+Power density
+(absolute and
+relative power,
+spectral power
+ratio), peak
+frequency
+• Relative d + θ power higher
+for AD compared to T2DM
+and HC.
+• Relative α + β power were
+lower for AD compared to
+T2DM and HC.
+• Higher relative power in
+lower gamma band in AD
+compared to HC.
+• Relative alpha was lower in
+T2DM in frontal, temporal,
+and posterior regions.
+• Lower alpha in temporal
+region in T2DM
+• An overall relationship between
+the composite
+neuropsychological scores and
+the Spectral power ratio (SPR).
+• Positive association with
+learning and memory, and EFs
+with SPR.
+• Not related with T2DM.
+Bian et al
+(2014)
+(T2DM)
+aMCI, n = 16 (5
+males, 11 females
+mean age 69.7 ±
+8.4
+years, range 52 to
+84 years
+Control, n = 12 (6
+males, 6 females
+mean age 73.3 ±
+4.6
+years, range 63 to
+80 years
+aMCI = 9.3 ±
+2.4
+years, range
+1 to 20 years
+Controls =
+14.0 ± 3.1
+years, range
+1 to 30 years
+aMCI = 12.9
+±
+1.8 years,
+range 6 to
+16 years
+Control =
+13.8 ±
+3.0 years,
+range 9 to
+19 years
+Not reported
+China
+Relative power
+and coherence
+• Relative power not different
+across the groups.
+• Higher ratios of P(theta)/
+P(alpha) in the frontal and left
+temporal regions in aMCI.
+• Lower alpha coherence in
+posterior region (intra
+region) for aMCI group.
+• Higher inter-hemispheric
+coherence in aMCI in delta, a
+lower coherence in the
+theta.
+• P(theta)/P(alpha) negatively
+correlated to MoCA in the
+frontal and left temporal regions.
+• No significant correlation
+between ratios of power and
+neuropsychological tests.
+• Alpha, theta, and delta
+coherences correlated to MoCA
+scores.
+Cooray et al
+(2011)
+T2DM, n = 28
+Age range 50 to
+70 years
+(T2DMi) n = 15
+(T2DMr) n = 13
+Controls, n = 21
+T2DMi = 8.6
+years (1-22)
+T2DMr =
+11.2 years
+(2-28)
+12 (7-20)
+years
+(HbA1c)
+T2DMi = 8%
+(5.8-12.9)
+T2DMr = 8%
+(5.1-10.0)
+(Insulin)
+T2DMi = 80%
+T2DMr = 69%
+Sweden
+Power, phase lag
+index
+• Reduced power in the beta
+band in T2DM. Most
+pronounced reduction over
+central and posterior
+regions.
+• No differences in PLI in the
+theta, alpha or beta band
+between T2DM and
+controls.
+• Increased alpha-power and
+connectivity in alpha and
+Not reported
+(continued)
+4
+Table 1. (continued)
+Study
+Participants
+T2DM
+duration
+Years of
+education
+HbA1c, insulin
+use, HOMA-IR
+Country
+EEG measures
+Results
+EEG correlated with
+neuropsychological test
+performance
+theta across hemispheres in
+T2DMi.
+• Increase in beta band
+connectivity over central
+region in T2DMi.
+Cui et al
+(2016)
+(T2DM), n = 46
+aMCI, n = 26, (10
+male, 16 female)
+Controls, n = 20,
+(12 male, 8 female
+Not reported
+Not
+reported
+Not reported
+China
+Synchronization
+• Decreased synchronization
+in all regions in aMCI.
+• Particularly low in central
+and occipital regions.
+• NWPMI and SNWPMI are
+effective index to estimate
+the synchronization strength.
+• SNWPMI correlated with MMSE
+and semantic fluency
+significantly.
+Cui et al
+(2018)
+(T2DM), n = 35 (14
+males, 21 females)
+Age 69.43 ± 8.79,
+range 43 to 84
+years
+aMCI, n = 18, 6 M,
+12 F
+Controls,
+n = 17, 8 M, 9 F
+Not reported
+aMCI =
+13.44 ±
+3.09
+Controls =
+13.44 ±
+3.09
+Not Reported
+China
+Magnitude
+squared
+coherence for
+synchronization
+• Larger theta and delta
+coherence in aMCI group.
+• Lower Alpha coherence in
+aMCI.
+• Coherence negatively correlated
+with WAIS-DST, AVLT, BNT,
+MoCA.
+• aMCI coherence lower in left
+hemisphere, positively
+correlated with MoCA.
+Cui et al
+(2014)
+(T2DM)
+aMCI = 8, 5 M, 3F
+Age 70 ± 10.784
+years
+Control = 11,
+5 M, 6 F
+Age 74.27 ± 3.349
+years
+Not reported
+aMCI =
+13.88 ±
+3.441
+control =
+13.64 ±
+2.541
+Not Reported
+China
+Synchronization
+• Decreased synchronization
+in aMCI in all bands.
+• Frontal S, SI, and GSI values
+of aMCI group were not
+significantly different.
+• Three synchronization values
+in parietal and temporal
+regions all were different in
+delta and beta2 bands
+between aMCI and control
+group.
+• Occipital theta and beta2
+synchronization more
+significantly different
+between the two groups,
+especially in the beta2 band.
+• Only temporal theta S values,
+Occipital theta S values, and
+Boston Name Testing were
+strictly correlated significantly.
+Cui et al
+(2016)
+(T2DM) n = 32,
+15 M, 17 F
+aMCI, n = 18, 8 M,
+10 F
+Not reported
+aMCI =
+13.72 ±
+2.87
+NC =
+Not reported
+China
+Determinism
+• Determinism of SRP
+(SRP_DET) of aMCI has
+higher values, indicating
+increase of EEG regularity in
+SRP_DET is strictly negatively
+correlated to MoCA and
+memory functions at electrode
+P4.
+(continued)
+5
+Table 1. (continued)
+Study
+Participants
+T2DM
+duration
+Years of
+education
+HbA1c, insulin
+use, HOMA-IR
+Country
+EEG measures
+Results
+EEG correlated with
+neuropsychological test
+performance
+Age 70.28 ± 8.5
+NC, n = 14, 9 M, 5
+F
+Age 63.79 ± 16.9
+12.57 ±
+3.23
+the temporal and occipital
+regions.
+• SRP_DET is more effective
+than PRP_DET in finding the
+correlated EEG deterministic
+characteristic of aMCI in
+T2DM.
+Mooradian
+et al
+(1988)
+(NIDDM) n = 43,
+Age 66.3 ± 0.8
+years
+HC n = 41, Age
+65.3 ± 0.3 years
+13.3 ± 1.8
+years
+Not
+reported
+HbA1c = 109 ±
+36 g/L
+Insulin users =
+20
+Hypoglycemic
+agents = 40
+USA
+Frequency power
+• Slowing of EEG rhythms over
+the central cortex.
+• Significantly higher % of theta
+activity at Cz in diabetics.
+• Significantly less alpha power
+at Pz in diabetics.
+• More power distribution in
+diabetics in slower delta and
+theta EEG bands.
+Not reported.
+Wen et al
+(2016)
+(T2DM), n = 39
+Age 68.95 ± 8.95,
+range 43 to 84
+years
+aMCI, n = 19, 12
+F, 7 M
+NC, n = 20, 11 F,
+9 M
+aMCI = 9.19 ±
+6.29, Range 1
+to 20 years
+NC = 13.60
+± 8.59 years
+Range 1 to
+30 years
+aMCI =
+13.00 ±
+2.94
+NC =
+12.70 ±
+3.40
+Not reported
+China
+Coupling strength
+and
+directionality
+(permutation
+conditional
+mutual
+information)
+• Difference in coupling
+strength and directionality of
+EEG signals between aMCI,
+T2DM and NC in different
+brain regions.
+• PCMI can effectively calculate
+the coupling strength and
+directionality.
+• Coupling strength and
+directionality correlated with
+MoCA but not for all electrode
+pairs.
+Zeng et al
+(2015)
+[T2DM]
+aMCI, n = 16, 5 F,
+11M
+Age = 69.7 ± 8.4
+Controls, n = 12,
+6 F, 6 M
+Age = 73.3 ± 4.6
+aMCI = 9.3 ±
+2.4
+Controls =
+14.0 ± 3.1
+aMCI = 12.9
+± 1.8
+Controls =
+13.8 ± 3.0
+NA
+China
+Synchronization
+(PLI), graph
+analysis
+• Decreased global mean PLI in
+lower alpha, upper alpha, and
+beta bands in aMCI.
+• Lower functional connection
+at a short and long
+intra-hemispheric distance
+on left hemisphere.
+• Clustering coefficient lower
+in aMCI group, and the path
+length significantly increased.
+• Cognitive status measured by
+MoCA had a significant positive
+correlation with cluster
+coefficient and negative
+correlation with path length in
+lower alpha band.
+6
+Table 2. Studies of Task Based EEG (ERP) in Type 2 Diabetes.
+Study
+Participants
+T2DM
+duration
+Years of
+education
+HbA1c, insulin use,
+HOMA-IR
+Country
+Results
+Neurocognitive task and
+Cognitive function assessed
+Kurita et al.
+(1996)
+(NIDDM) n = 60 50.7 ±
+8.9 years, range 32 to 67
+years, 39 men, 21
+women
+(Neurologically healthy)
+n = 20, mean age 49.8 ±
+9.8 years, range 32 to 67
+years,
+110 ± 7.3
+years, range
+1 to 28
+years
+Not
+reported
+HbA1c = 7.4 to
+15.9%, mean 10.9
+± 2.0%
+Insulin users = 26
+Hypoglycaemic
+agents = 18
+Japan
+• The slope of the latency/age regression
+line was 1.51 ms/year.
+• Longer P300 values in diabetics.
+• Mean P3 latency in order of decreasing
+length were HbA1c ≥10%, HbA1c <
+10%, and control subjects.
+• No between P300 values and HbA1c
+levels.
+Auditory Oddball
+Mooradian
+et al,
+(1988)
+(NIDDM) n = 43,
+Age 66.3 ± 0.8 years
+HC n = 41,
+Age 65.3 ± 0.3 years
+13.3 ± 1.8
+years
+Not
+reported
+HbA1c = 109 ±
+36 g/L
+Insulin users = 20
+Hypoglycemic
+agents = 40
+USA
+• No increased P100 latency in controls
+or diabetics at Cz.
+• P3 latency significantly different for
+diabetics and controls.
+• Trend towards longer latencies in
+diabetics at Fz and Cz.
+• The intravenous administration of
+glucose did not alter P300 latency.
+Auditory and visual oddball
+(checkerboard vs diamond
+pattern), as an index of
+attention and information
+processing time.
+Cooray et al
+(2011)
+(T2DM) n = 28
+(HC) n = 21
+Age range 50 to 70 years
+(T2DMi) n = 15
+(T2DMr) n = 13
+T2DMi = 8.6
+years
+(1-22)
+T2DMr =
+11.2 years
+(2-28)
+12 (7-20)
+years
+(HbA1c)
+T2DMi = 8%
+(5.8-12.9)
+T2DMr = 8%
+(5.1-10.0)
+(Insulin)
+T2DMi = 80%
+T2DMr = 69%
+Sweden
+• Lowered N100 amplitude in T2DM.
+• Prolonged P300 latency in T2DM
+patients
+• No difference in N100 peak latency and
+P300 peak amplitude between patients
+and healthy controls.
+Auditory oddball
+Tondon et al
+(1998)
+(NIDDM) n = 30
+Age 43.6 ± 9 years,
+Controls n = 30
+Age 36.73 ± 13.3 years
+2 to 10 years
+Not
+reported
+HbA1c = 9.9 ± 1.0%
+India
+• Higher N200 and P300 peak latencies
+diabetics.
+• No significant correlation between
+latencies of N2 & P3 with height,
+weight, Glucose levels, and diabetes
+duration.
+Auditory oddball
+Mochizuki
+et al (1998)
+(NIDDM) n = 24, mean
+age 56.7 years,
+Controls n = 16, mean
+age 54.9
+Not
+reported
+Not
+reported
+HbA1 = 9.7%
+Japan
+• Longer N200 & P300 latencies in the
+diabetic group.
+• Smaller N200 & P300 amplitudes in
+diabetes patients.
+• Shorter P300 latency after treatment
+than before.
+Auditory oddball
+(continued)
+7
+Table 2. (continued)
+Study
+Participants
+T2DM
+duration
+Years of
+education
+HbA1c, insulin use,
+HOMA-IR
+Country
+Results
+Neurocognitive task and
+Cognitive function assessed
+Hazari et al
+(2011)
+(T2DM)
+Group 1, n = 11, age 52
+± 6
+Group 2, n = 17, age 53
+± 6
+Healthy controls
+N = 18, age 50 ± 7
+(T2DM)
+Group 1 =
+3 ± 2 years
+Group 2 =
+10 ± 4
+years
+Not
+reported
+Insulin users
+Group 1 = 0
+Group 2 = 24%
+India
+• Patients with over 5 years of duration
+had much prolonged P300 latencies in
+contrast to patients with 5 years or less
+disease duration and showed trends
+similar to that of controls.
+• P300 did not differ significantly among
+the groups. Hypertensive diabetics
+showed much prolonged P3 latencies
+compared to normotensive diabetics.
+Novel three stimulus oddball
+paradigms
+Hissa et al
+(2002)
+NIDDM n = 44, 12M, 32 F
+Age 58.84 ± 8.4, Range
+38 to 75
+HC n = 17, 2M, 15F
+Age 56.53 ± 8.09, Range
+43 to 69
+10.52 ± 7.97
+years,
+Range 2 to
+41 years
+Not
+Reported
+NIDDM
+HbA1c 8.28 ± 2.09
+Min-Max 5.1 to
+13.5
+HC
+HbA1c 5.74 ± 0.95
+Min-Max 4.3 to 8.0
+Brazil
+• Higher P300 latency in diabetics.
+• Retinopathy did not influence P300
+latency.
+• Insignificant trend for lower values of
+the P300 latency in patients with no
+hypoglycemic episodes.
+Acoustic ball paradigm
+Vanhanen
+et al (1996)
+NIDDM n = 9, 3M, 6 F
+Age 72.7 ± 2.5 years
+HC n = 9, 4 M, 5 F
+Age 74.6 ± 1.8 years
+8.2 ± 4.8
+years, range
+1 to 15
+years
+NIDDM
+6.1 ± 1.6
+years
+HC 7.1 ±
+1.5 years
+Not reported
+Finland
+• Differences in N100 were spread over
+a wide range of electrodes.
+• Differences in MMN most significant in
+fronto-central areas.
+• Habituation of N1 is decreased in
+diabetics.
+• Shorter N100 latency in central brain
+areas in diabetics.
+• MMN area, was smaller in diabetics.
+• No difference in N2b and P300
+components in both groups. No
+differences in latencies or amplitudes
+between the groups.
+• N100 correlated with delayed recall of
+the wordlist in both the groups.
+• MMN did not correlate with any of the
+neuropsychological tests.
+• FBG or insulin levels did not correlate
+with any ERPs within the groups.
+Oddball in three separate
+behavioural condition.
+8
+N100 ERP component. The P100 & N200 were evaluated only
+by one study.
+Interestingly, all the studies used oddball tasks as a measure
+of ERP. Five of the eight studies have used the classical audi-
+tory oddball task.17,20,24–26 Other remaining studies have used
+a novel three stimuli auditory oddball task.16 Finally, one
+study has employed auditory oddball tasks in three different
+behavioural conditions.27
+Studies using the classic auditory oddball task showed that
+the T2DM patients had longer P300 latencies than healthy con-
+trols.16,18 Studies employing an altered version of the oddball
+task also observed similar results.18,20 The prolonged P300
+latency was visible primarily over the brain’s frontal, central,
+and posterior regions.16 Besides, P100 and N200 latencies
+were also increased in diabetic patients than in healthy con-
+trols.18,25 At the same time, the N100 component has a hetero-
+geneous outcome from showing no difference to significantly
+increased latencies in T2DM patients.20,26
+Kurita et al found mean P300 latencies in the order of
+decreasing length for those with retinopathy, without retinop-
+athy, and control subjects.17 In terms of the HbA1c group,
+P300 latencies in the order of decreasing length were
+HbA1c ≥10%, HbA1c < 10%, and controls. The P300
+latency was also much delayed in hypertensive T2DM
+patients.24 On the contrary, it was found to be unaffected by
+the presence of retinopathy in T2DM patients16 also, the laten-
+cies of P300 and N100 were unchanged with the duration of
+T2DM. Interestingly, only three studies reported the P300
+amplitude, and it tends to decrease in T2DM patients com-
+pared to the control group. T2DM patients had lower N100
+amplitude than controls, mainly over the central and posterior
+regions.20 Likewise, N200 and P300 amplitudes were also
+decreased in T2DM patients than in controls.25 However,
+only four studies reported measuring the amplitude of ERP
+components.
+Neurocognitive Functions
+There were a total of 7 studies assessing various cognitive func-
+tions. Patients with AD performed worse in all tests than the
+T2DM and healthy control.19 For scores on the Digit Symbol
+Substitution Test (DSST), Ray Auditory Verbal Learning
+Test (RAVLT) learning and delayed recognition trials, logical
+memory immediate and delayed recall trials. In semantic
+fluency, TMT time, TMT errors, Digit Span backward,
+RAVLT delayed recall, Boston Naming Test, and GDS, the
+AD patients performed worse than the HC and T2DM
+groups. However, the T2DM and HC groups did not differ
+from each other. Only on the Digit Span forward test was
+there a difference between HC and AD, while T2DM was no
+different from either HC or AD.20,28
+The
+T2DM
+patients
+with
+amnestic
+Mild
+Cognitive
+Impairment (aMCI) tend to have reduced global cognition com-
+pared
+to
+the
+T2DM
+patients
+with
+normal
+cognitive
+functions.15,20,23,28
+Discussion
+The current review aims to understand the neurophysiological
+changes associated with cognitive functions in T2DM patients
+as observed by the rsEEG and ERP studies. Overall, T2DM
+patients show some EEG and ERP characteristics that indicate
+towards cognitive impairment or future cognitive decline.
+However, the findings of the previous studies on cognitive
+impairment in T2DM patients should be carefully interpreted
+because of the diversity of the study design, sample size and
+characteristics, and analysis techniques adopted. We intend to
+discuss the relevant points of the findings hereafter.
+Spectral Power Analysis
+Spectral power analysis is a very well-known method in EEG
+signal processing. It is used for the quantification of the sponta-
+neous electrical activities of the brain. Furthermore, with the
+neuropsychological correlations, the power analysis of the
+EEG series provides valuable information to distinguish
+healthy and impaired brain functions.19
+The power analysis of frequency bands reveal that the
+T2DM patients exhibit a dominance of lower brain frequencies
+over the higher frequencies, which is similar to the characteris-
+tics observed in MCI and AD. Benwell et al, (2020) compared
+ratios of [P(α + β)/P(δ + θ)] in AD and T2DM. The Spectral
+power ratio demonstrated a shifting pattern from higher oscil-
+lating frequency to lower frequency in AD. Apparently, this
+shifting pattern was also present in T2DM patients, but to a
+lesser extent. T2DM patients having aMCI show higher ratio
+of [P(θ)/P(α)] in frontal and left temporal regions as compared
+to cognitively healthy T2DM patients.21 The present observa-
+tions reiterate the findings of the previous studies that have
+demonstrated the dominance of slower brain frequencies in
+AD and MCI.29–36 Moreover, the cortical rhythm correlates
+to the grey matter volume, a candidate biomarker of MCI and
+AD patients. The higher δ sources and lower α sources are
+related to the decreased cortical grey matter volume in MCI
+and AD.37 It means, better cognitive function or better scores
+cognitive tests are directly proportional to the increased grey
+matter volume. Hence, the findings of the current review in con-
+currence with the earlier findings, suggest that the rsEEG activ-
+ity observed in T2DM is strictly
+a pathophysiological
+phenomenon.
+The alpha power is reported to be linked with impairments in
+learning and memory in AD patients and it is also correlated
+with the hippocampal volume.38 It is well known that hippo-
+campal atrophy is associated with cognitive impairment in
+MCI as well as in AD. Recently, the measurement of normal-
+ized hippocampal atrophy has been introduced in the guidelines
+for assessing early AD.39 The decreased magnitude of alpha
+frequency is found to be correlated with progressive hippocam-
+pal atrophy in the parietal, occipital and temporal areas in MCI
+and AD. Hence, future studies should incorporate structural and
+functional neuroimaging techniques to find and identify the
+Kanthi et al
+9
+specific characteristics in T2DM that are indicative of cognitive
+processes. Interestingly, alpha power was shown to be
+increased in a subset of T2DM patients with aMCI after receiv-
+ing a 2-month glycemic control treatment. The increased alpha
+power was associated with improvements in visuospatial and
+semantic memory performance.20 The increased alpha power
+after the intervention suggests that the improved glycemic
+control and early intervention could improve the cognitive per-
+formance. Notably, poor glycemic control is one of the mecha-
+nisms hypothesized to be responsible for cognitive dysfunction
+in T2DM.7 However, more such investigations are required to
+investigate the relationship between the glucose levels and
+oscillatory alpha activity.
+Coherence Analysis
+The nature of EEG signal characteristics is very complex.
+Therefore, different methods have been used to analyse the
+EEG signals from different perspectives. Some of these
+methods
+include
+coherence
+analysis,
+coupling
+analysis,
+mutual information, and synchronization analysis.
+The EEG coherence analysis has been used earlier to evalu-
+ate the functionality of cortical connections and provide infor-
+mation about the synchronization of the regional cortical
+activity.21 The coherence analysis used in T2DM patients
+with aMCI showed a reduction in alpha and theta bands com-
+pared to cognitively healthy T2DM patients. The lower alpha
+band was observed in posterior, fronto-right temporal/fronto-
+posterior/right temporo-posterior regions. On the other hand,
+the theta band was reduced in the left and right sides of the
+central and parietal regions of the brain. In addition, the inter-
+hemispheric coherence reported increased delta band connec-
+tivity in left and right temporal areas as observed in aMCI
+patients.21
+Similar changes in alpha and delta frequency bands were
+also reported in previous studies.40–42 It is suggested that the
+increased inter-hemispheric coherence in temporal region is
+linked to hippocampal atrophy. In contrast the decreased coher-
+ence in fronto-parietal region is linked to the subcortical
+CVD.40 Notably, hippocampal atrophy and CVD also are asso-
+ciated with the cognitive decline.43,44 These outcomes are
+notable, as the microvascular and macrovascular complications
+are one of the hypothesized mechanisms for the cognitive
+impairment in T2DM. In summary, findings indicate that coher-
+ence analysis can be used to deduce some EEG characteristics
+to identify the occurrence and severity of the cognitive impair-
+ment in T2DM patients.
+Event-Related Potentials
+P300 Component. The P300 component is associated with
+detecting novel stimuli, updating working memory, inhibitory
+control, and selective attentional processes.45 Additionally,
+P300 is also characterized by a large amplitude (μV) wave
+and smaller latency (ms) generated by discrimination and
+attentional neural processes.45 The characteristics of P300 com-
+ponent affect differently in healthy and clinical conditions. The
+findings of P300 latency in T2DM patients have been consistent
+across all studies as compared to healthy controls.16–18,20,24–27
+It was also positively correlated with the age, duration, and
+severity of T2DM.16,17,24 The findings are suggestive of a pos-
+sible contribution of microangiopathy or metabolic derange-
+ment in a small part. However, the influence of disease
+duration on P300 latency might be because of the test
+novelty, which increases the workload of the cognitive task
+by presenting stimuli at a higher rate.16 Notably, only P300
+latency could differentiate the groups for their cognitive perfor-
+mance. Most of the studies did not find any difference in P300
+amplitude among the groups. However, in another study, P300
+amplitude was best highlighted only with executive functions
+tasks, while the latency was highlighted even with the
+oddball task.46 The studies included in the current systematic
+review used only the oddball paradigm, indeed with some var-
+iations. The relative uniformity in the tasks used and heteroge-
+neity in the samples and study designs may have led to the
+indifferences in the P300 amplitude.
+N100 Component. The N100 amplitudes were decreased in
+both the studies. The decrease in amplitude might be reflecting
+impaired arousal and probably slight impairment in the ability
+to automatically redirect the attention. Cooray et al, (2008)
+hypothesized that the N100 amplitude reduction in Type 1
+Diabetes Mellitus (T1DM) patients could be caused by a loss
+of nerve impulse synchrony in auditory tracts in the white
+matter. This hypothesis is again supported by the evidence of
+white matter lesions obtained from MRI studies in both
+T1DM and T2DM.11,47,48 Interestingly Vanhanen et al,
+(1996) found shorter latency in diabetic patients as compared
+to controls. The auditory N100 ERP component is suggested
+to signal the detection of acoustic change in the environment.
+Such acoustic changes cause widespread cerebral activation
+as part of orienting reaction.49 The shorter N100 latency in
+T2DM might be due to loss of a non-specific arousal compo-
+nent, which emerges slightly later than N100 generated at audi-
+tory cortical areas. An alternate explanation could suggest
+tonically maintained attention to auditory stimuli and an inabil-
+ity to release underlying processes. Both explanations suggest
+possible impairment in the automatic ability to allocate atten-
+tional resources.
+Limitations and Future Considerations
+The current review involved studies that investigated neuro-
+physiological changes associated with cognitive functions in
+T2DM patients. There are some limitations in the current
+study that must be considered. The studies involved in the
+review varied in design, sample characteristics, and methods
+of assessments. Majority of the studies were cross-sectional,
+and only one study used an intervention protocol. Some
+studies compared T2DM patients with HC, MCI, and AD,
+10
+Clinical EEG and Neuroscience 0(0)
+while some attempted to understand the difference in cortical
+activity within a subgroup of T2DM having aMCI. With the
+varied study designs and analysis methods, it is difficult to
+reach to a common understanding of the results. Some rsEEG
+studies were aimed to explore the significance of the analysis
+techniques in identifying the cognitive characteristics of
+T2DM patients. Hence, the lack of reproducibility of the find-
+ings remains a challenge.
+The information pertaining to the demographic characteris-
+tics of the samples, like the glucose levels, education years,
+and the disease duration were also missing in some studies. It
+is unclear whether the studies failed to report the information
+or not gathered at all in the process of the investigation. The
+age range of the samples was excessively stretched from
+young adult to elderly population. Therefore, it would be diffi-
+cult to ascertain whether the changes in cortical activities
+related to cognition are associated with natural aging or patho-
+logical condition of T2DM.
+The interventional studies assessing cortical activity are rare
+to find. The current review found only one study that provided
+intensified glycemic control treatment and concluded with a
+plausible improvement in cognitive performance as a conse-
+quence of improved glycemic control. Again, reliability of
+the findings remains a challenge as no other interventional
+studies have assessed the association between glycemic
+control and cortical activity in T2DM patients.
+Hence, we suggest that the future studies should try to assess
+the cortical activity along with MRI. Cortical activity accompa-
+nied with MRI assessments will provide a comprehensive
+understanding of the cognitive characteristics in T2DM.
+Moreover, it will help to enhance our knowledge about the cor-
+tical activity related to cognitive functions. For example,
+knowing whether an observed cortical activity provides
+domain-specific information of cognitive functions or indicates
+the severity of the cognitive impairment. Neuropsychological
+studies show that memory, executive functions and information
+processing are mainly affected in T2DM patients. Hence, unlike
+the studies of the current review that used only oddball task,
+future ERP studies may explore the domain-specific cognitive
+processes in T2DM patients.
+Previous studies have demonstrated the possibility of reduc-
+ing the risk of cognitive decline by providing early interven-
+tions to T2DM patients. Hence, developing and identifying
+interventions to prevent or reduce the risk of cognitive
+decline in T2DM patients is equally important. Interventions
+corresponding to alternative and complementary medicines
+have received growing attention because of their holistic
+approach, and yoga therapy is one of the most widely accepted.
+Yoga therapy has shown to be beneficial to improve glycemic
+control and reduce stress levels among diabetic patients.
+Unfortunately, no studies were found that assessed the effect
+of yoga on cognitive processes in T2DM patients. Hence, it
+will be good to explore the effects of yoga practices on cortical
+activities
+related
+to
+cognitive
+functions
+in
+the
+T2DM
+population.
+Conclusion
+With the current review, the EEG emerges as a promising tool
+to investigate the cortical activities associated with cognitive
+functions in T2DM patients. The rsEEG studies demonstrated
+that the T2DM patients show some functional alterations in
+the brain compared to their healthy cohort. These alterations
+are similar to the characteristics of EEG activity in MCI and
+AD or Dementia. The dominance of low frequency power,
+and prolonged latencies and decreased amplitudes of ERP com-
+ponents observed in T2DM patients suggest problems in the
+domains of attention, memory, and executive functions,
+which may have cognitive functioning consequences.
+Acknowledgments
+This study was primarily funded by Ministry of AYUSH, govt. of
+India. (Sanction number - Z.28015/209/2015HPC(EMR)-AYUSH).
+The authors express deep gratitude to the research fellows and
+Anvesana Research Laboratories for their consistent support to accom-
+plish this project.
+Declaration of Conflicting Interests
+The author(s) declared no potential conflicts of interest with respect to
+the research, authorship, and/or publication of this article.
+Funding
+The author(s) received no financial support for the research, author-
+ship, and/or publication of this article.
+Ethical Approval
+Not applicable, because this article does not contain any studies with
+human or animal subjects.
+ORCID iDs
+Amit Kanthi
+https://orcid.org/0000-0001-8968-0273
+Deepeshwar Singh
+https://orcid.org/0000-0002-9867-1405
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+Kanthi et al
+13

subfolder_0/Changes in MIDAS, Perceived Stress, Frontalis Muscle Activity and Non-Steroidal Anti-Inflammatory Drugs Usage in Patients with Migraine Headache wi.txt

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+Original Paper
+Ann Neurosci 2018;25:250–260
+Changes in MIDAS, Perceived Stress, Frontalis Muscle 
+Activity and Non-Steroidal Anti-Inflammatory Drugs 
+Usage in Patients with Migraine Headache without 
+Aura following Ayurveda and Yoga Compared to 
+Controls: An Open Labeled Non-Randomized Study
+M.S. Vasudha    N.K. Manjunath    H.R. Nagendra    
+Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana (S-VYASA)  
+A Deemed to be University, Bengaluru, India
+Received: May 8, 2018
+Accepted: July 19, 2018
+Published online: September 11, 2018
+Dr. Vasudha M. Sharma
+Division of Yoga and Life Sciences, S-VYASA University
+Prashanthi Kutiram, Jigani (Hobli), Anekal (Taluk)
+Bengaluru, Karnataka 560106 (India)
+E-Mail vasudhamsharma @ gmail.com
+© 2018 S. Karger AG, Basel
+E-Mail [email protected]
+www.karger.com/aon
+DOI: 10.1159/000492269
+Keywords
+Integrative medicine · Ayurveda · Yoga therapy ·  
+Migraine · Pain · Disability · Stress
+Abstract
+Background: There has been a significant increase in the use 
+of complementary and integrative medicine to provide long-
+term healing solutions in migraine headache patients. Know-
+ing the limitations of conventional medical approach, the 
+present study evaluated the influence of two Indian tradi-
+tional systems of medicine on migraine-related disability, au-
+tonomic variables, perceived stress, and muscle activity in pa-
+tients with migraine headache without aura. Methods: Thirty 
+subjects recruited to the Ayurveda and Yoga (AY) group un-
+derwent traditional Panchakarma (Bio-purification) using 
+therapeutic Purgation followed by yoga therapy, while 30 
+subjects of control (CT) group continued on symptomatic 
+treatment (non-steroidal anti-inflammatory drugs [NSAID’s]) 
+for 90 days. Migraine disability assessment score, perceived 
+stress, heart rate variability (HRV), and surface electromyog-
+raphy (EMG) of frontalis muscle were measured on day 1, day 
+30, and day 90 in both groups. Results: Significant reduction 
+in migraine disability and perceived stress scores were ob-
+served in the AY group. The low-frequency component of the 
+HRV decreased significantly, the high-frequency component 
+increased and their ratio showed improved sympathovagal 
+balance. The EMG showed decreased activity of the frontalis 
+muscle in the AY group compared to the control group. Con-
+clusion: The integrative approach combining Ayurveda and 
+Yoga therapy reduces migraine-related disability, perceived 
+stress, sympathetic arousal, and muscle tension.
+© 2018 S. Karger AG, Basel
+Introduction
+Migraine headache is a neurological disorder, preva-
+lent across the world and is associated with varied degrees 
+of disability, thereby affecting the work capacity and pro-
+ductivity of an individual. It is associated with comor-
+bidities and modifiable risk factors [1].
+Changes in MIDAS, Perceived Stress, 
+Frontalis Muscle Activity
+251
+Ann Neurosci 2018;25:250–260
+DOI: 10.1159/000492269
+Functional disability associated with migraine can lead 
+to physical, mental, and social consequences [2], and it is 
+commonly measured through the migraine disability as-
+sessment questionnaire (MIDAS) [3]. An episode of mi-
+graine is triggered by several factors including stress 
+which is either physical or mental in nature [4]. The sub-
+jective perception of the impact of stress is measured 
+through perceived stress scale, and studies show a higher 
+incidence of perceived stress in migraineurs [5].
+Stress can induce changes in the autonomic nervous 
+system, which is measured non-invasively through heart 
+rate variability (HRV). Migraine headache is known to 
+induce autonomic imbalance. The sympathetic activity is 
+heightened not only during the attacks but also during 
+headache-free states [6].
+Studies on headache patients also show an increased 
+muscle activity compared to healthy controls [7], and 
+cognitive stress is a known precursor for the same [8]. 
+Conventional medicines used in migraine have always 
+been derived from other class of drugs and showed limi-
+tations in providing satisfactory relief without side effects 
+[9]. The treatment approach, therefore, has to be more 
+than a prescription. Hence, an integrative approach to the 
+management of migraine is essential.
+Ayurveda and Yoga therapy are two ancient Indian 
+systems of medicine which are used effectively in health 
+and disease. Their integration offers a holistic approach, 
+which would promote mind-body medicine in a compre-
+hensive manner. Furthermore, Ayurveda therapies are 
+known to influence physiological processes including au-
+tonomic modulation [10] and metabolic profiles [11]. In 
+case of migraine headache, it was reported earlier that an 
+Ayurveda-based polyherbal formulation administered 
+for 90 days showed a significant decrease in migraine-
+related disability, frequency, and intensity [12]. However, 
+no studies are available till date that demonstrate the un-
+derlying physiological mechanisms. 
+Also, there are more number of studies on Yoga com-
+pared to Ayurveda in stress and pain management. The 
+beneficial effects of Yoga have been attributed to auto-
+nomic balance shifting towards vagal dominance, re-
+duced biochemical markers of stress such as cortisol, re-
+duced anxiety, and improved psychological well-being 
+[13]. The evidence further shows that biofeedback and 
+progressive muscular relaxation were also effective in re-
+ducing frontalis EMG activity in migraine headache pa-
+tients [14]. 
+Keeping in view the limitations of conventional treat-
+ment and the possible beneficial effects of Ayurveda and 
+Yoga therapies, the present study aimed at evaluating the 
+role of an integrated traditional Indian medicine-based 
+intervention in the management of migraine headache. 
+The objective was to comprehensively understand its in-
+fluence on autonomic variables, surface electromyogram 
+(sEMG), perceived stress, and migraine-related disability. 
+Methods
+The subjects were recruited from Samatvam Holistic Health 
+Center, Bengaluru, Karnataka in South India. The study protocol 
+was approved by the Institutional Ethics Committee (RES/IEC-
+SVYASA/23/2013), and the study was conducted between 2015 
+and 2017. The study is registered with the Clinical Trials Registry 
+of India (CTRI/2017/10/010074). A total of 86 individuals who 
+were clinically diagnosed with migraine headache were screened 
+based on inclusion and exclusion criteria, and 60 subjects were se-
+lected for the study. The recruitment was based on self-selection 
+by the subjects to either Ayurveda and Yoga (AY) or Control (CT) 
+groups. Subjects were explained about the study protocol, and a 
+signed informed consent was obtained before recruitment. They 
+were also given the choice to withdraw from the study at any stage. 
+The sample size was calculated using the G Power software from a 
+previous study [12], with an effect size of 1.31, α = 0.05 and pow-
+er = 0.95. The required sample size was 19 subjects in each group. 
+Considering the compliance-related issues, and to improve the sta-
+tistical impact, a sample size of 30 subjects in each group was con-
+sidered. 
+Inclusion criteria: Subjects belonging to both genders, between 
+18 and 46 years of age with a headache history for more than 1 
+year, 5 or more attacks of headache in 3 months, willingness to 
+take oral Ayurveda medicine, practicing Yoga, following the di-
+etary restrictions for 75 days, and completing the headache dairy 
+were included.
+The diagnostic criteria were based on the International Clas-
+sification of Headache Disorders (3rd edition) of the Internation-
+al Headache Society, 2013 [15].
+Exclusion criteria: Subjects with primary psychiatric disorders 
+(depression, anxiety, psychosis), major medical illness like renal, 
+hepatic, neurological and cardiac diseases, pregnancy, pure men-
+strual migraine, subjects on Ayurveda or Yoga intervention for the 
+past 6 months and subjects on conventional prophylactic treat-
+ment were excluded from the study. 
+The present study was a prospective matched controlled trial. 
+Subjects were recruited as and when they approached the physi-
+cian who referred them to an investigator. Subjects willing to un-
+dergo Ayurveda and Yoga interventions were allocated to the AY 
+group, while the others who chose to continue with symptomatic 
+treatment were recruited to the CT group. The groups were 
+matched for age and gender. Subjects of the AY group and CT 
+group were assessed on days 1, 30, and 90. The assessments were 
+carried out in headache-free states and in non-menstrual phase in 
+case of female subjects.
+Assessments
+Migraine Disability Assessment
+MIDAS is a short, self-administered questionnaire used to 
+quantify headache-related disability in a span of 3 months. It has 
+a set of 5 questions, and the total score is based on the number of 
+Sharma/Nandi Krishnamurthy/Nagendra
+Ann Neurosci 2018;25:250–260
+252
+DOI: 10.1159/000492269
+days marked against each question. The grades and respective 
+scores are mentioned in Table 1. The reliability and validity of the 
+questionnaire are assessed and well-established [3]. 
+Perceived Stress Scale 10
+Perceived stress scale 1 (PSS) measures the perceived level of 
+stress as a function of objective stressful events, coping processes, 
+and personality factors. PSS-10 was selected due to its superior 
+psychometric properties [16]. Each item is rated on a 5-point scale 
+ranging from never (0) to almost always (4). Items 4, 5, 7, and 8 are 
+the positively stated items and they were reverse scored. The sum 
+of all 10 items indicated the levels of perceived stress. Scores be-
+tween 0 and 13 were considered as low stress, 14–26 as moderate 
+stress, and 27–40 as high perceived stress. 
+Autonomic Variables and Surface Electromyography
+An 8-channel fully integrated data acquisition system (Power 
+lab 15T) from AD instruments, Australia was used for simultane-
+ous recording of Heart Rate, Respiratory Rate, HRV, and surface 
+electromyography (sEMG). 
+Assessments were done in a dimly lit, sound attenuated room. 
+Subjects were asked to sit on an armless chair with back support 
+by placing their feet on a non-conducting material. During re-
+cordings, they were instructed to close their eyes and maintain 
+normal breathing. Heart rate, respiratory rate, and sEMG were 
+recorded simultaneously for a duration of 3 min during frowning 
+(by raising the eyebrows), which produced voluntary muscle con-
+traction. 
+The electrocardiogram (ECG) was recorded using standard 
+limb lead II configuration by placing clamp ECG electrodes with 
+electrode gel. Data were acquired at a sampling rate of 1,024 Hz. 
+The heart rate variability was derived from ECG by computing the 
+successive RR intervals.
+Respiratory rate was recorded through a piezo respiratory belt 
+transducer. This was used to generate a voltage with a change in 
+thoracic circumference due to respiration. The output range was 
+between 20 and 400 mV, with a sensitivity of 4.5 ± 1 mV/mm. 
+The sEMG of the frontalis muscle was recorded using 2 pre-
+gelled silver chloride electrodes placed on the forehead with a dis-
+tance of 2 cm between them, and approximately 2.5 cm above each 
+eyebrow along with a shared ground electrode [17]. The sEMG was 
+recorded with a sampling rate of 1,000 Hz, bandwidth of 20–500 
+Hz, and a maximum input impedance of 5 Ω. A low pass notch 
+filter was applied at 50 Hz.
+Data Extraction
+Lab Chart 8 software was used to extract the data offline. Heart 
+rate, HRV, respiratory rate, and EMG were derived separately 
+from the data collected on days 1, 30, and 90. 
+The noise-free ECG data excluding ectopic beats were selected 
+for further analysis. Heart rate was obtained as beats per minute, 
+averaging it across 3 min. The Lab chart software also processed 
+the ECG signals by identifying successive RR intervals to extract 
+both frequency domain and time domain measures of HRV. The 
+low frequency (LF), high frequency (HF), and LF/HF ratio ex-
+pressed as normalized units were used as frequency domain mea-
+sures. While, the SD of RR Intervals, the square root of the mean 
+squared differences of successive NN intervals, and the proportion 
+derived by dividing NN50 by the total number of NN intervals 
+(pNN50) were derived as time domain measures. 
+The respiratory rate was derived as the number of breath cycles 
+per minute after averaging it across 3 min by computing successive 
+inspiratory and expiratory cycles.
+The sEMG recording obtained during the 3 min voluntary con-
+traction was used to derive RMS EMG and integral EMG [18].
+Interventions
+Ayurveda treatment of Virechana (therapeutic purgation) fol-
+lowed by Yoga therapy was given to the subjects of the AY group. 
+Following the assessments on day 1, Deepana (Digestive) Hingu-
+vachadi churna (polyherbal powder) [20] was given for the first 
+3 days. From day 4, Abhyantara snehapana (internal oleation) with 
+Kallyanaka Ghrita (a polyherbal preparation made with clarified 
+butter) [19] was administered on empty stomach between 7 and 
+8 a.m. in increasing dosage ranging from 30 to 150 mL for 3–5 days 
+until Samyak Snighdha Lakshanas (adequacy of internal oleation) 
+were seen. Following this, Sarvanga Abhyanga (full body oil appli-
+cation) with Shuddha Tila taila (pure Sesame oil) and Swedana 
+(steam bath) was administered for 3 days. The next day (maximum 
+by day 12), Virechana (therapeutic purgation) was induced by ad-
+ministering Trivrit lehyam (polyherbal paste) [19]. The process of 
+Virechana was reported earlier as safe and efficacious with no im-
+balance in serum electrolyte levels [20]. Samsarjana krama (di-
+etary regimen) for 3–5 days (Day 12–14/16) was specified based on 
+Shuddhi (degrees of cleansing).
+Shamana Oushadhi (oral medication for pacification) was start-
+ed between days 15 and 17 and was continued for a span of 75 days. 
+Pathyakshadhatradi Kashaya (polyherbal decoction) [21], 15 mL, 
+30 min before breakfast and dinner with 45 mL of warm water was 
+advised for oral use. Kachoradi churna (polyherbal powder) [22], 
+topical use as a paste mixed with milk (at room temperature) on 
+the forehead once a day. There was a special mention of Pathya and 
+Apathya (Do’s and Don’ts regarding diet and lifestyle). The com-
+position of each polyherbal formulation and the dosage are men-
+tioned in Table 2. 
+The subjects were allowed to take oral analgesics (Non-steroi-
+dal anti-inflammatory drugs, NSAID), as and when required based 
+on the intensity of pain tolerable to them, and the same was noted 
+in their diary for medication use. 
+Yoga therapy: The specially designed integrated Yoga therapy 
+module for migraine included loosening exercises, breathing exer-
+cises, asanas (postures), pranayama (regulated breathing), relax-
+ation techniques, and chanting. Yoga was practiced for 40 min 
+daily, beginning from day 15 to 17 of the treatment for 7 days as 
+personalized sessions under the supervision of a trained Yoga ther-
+apist. The subjects were asked to practice the same module at 
+home, 5 days a week until day 90. Female subjects were advised not 
+to practice yoga during the first 3 days of menstrual cycle. The yoga 
+therapy module is detailed in Table 3. 
+Table 1. The 4-point grading system for MIDAS questionnaire
+Grade
+Disability
+Score
+I
+Little or no disability 
+0–5
+II
+Mild
+6–10
+III
+Moderate
+11–20
+IV
+Severe
+21+
+Changes in MIDAS, Perceived Stress, 
+Frontalis Muscle Activity
+253
+Ann Neurosci 2018;25:250–260
+DOI: 10.1159/000492269
+a. Hinguvachadi Churna [19]. It is prepared with one part of each 
+of the ingredients mentioned below. They are powdered separately and 
+mixed together. Dosage: 2.5–5 g, 30 min before food with warm water
+Sanskrit name
+Botanical name
+Shuddha Hingu
+(processed with Ghee)
+Ferula asafetida
+Vacha
+Acorus calamus
+Vijaya
+Terminalia chebula
+Pashugandha
+Cleome gynandra
+Dadima
+Punica granatum
+Dipyaja(Ajwain)
+Trachyspermum ammi
+Dhanya
+Coriandrum sativum
+Pata
+Cyclea peltata
+Pushkaramoola
+Inula racemosa
+Shati
+Hedychium spicatum
+Hapusha
+Sphaeranthus indicus
+Agni
+Plumbago zeylanica
+Yavakshar
+Alkali preparation
+made of Hordeum vulgare
+Svarjika kshara
+Sarjika kshara
+Saindava lavana
+Rock salt
+Sauvarchala lavana
+Black salt
+Vida lavana
+Type of black salt
+Shunti
+Zingiber officinalis
+Maricha
+Piper nigrum
+Pippali
+Piper longum
+Ajaji
+Cuminum cyminum
+Chavya
+Piper chaba
+Tintidika
+Rhus parviflora
+Vetasamla(Amlavetasa)
+Garcinia morella
+b. Kallyanaka Ghrita [19]. 12 g each of the below mentioned in-
+gredients are used to make a medicated ghee (clarified butter)
+Sanskrit name
+Botanical name
+Haritaki 
+Terminalia chebula
+Vibhitaki 
+Terminalia bellirica
+Amalaki
+Emblica officinalis
+Vishala
+Citrulus cholocynthis
+Bhadra ela 
+Amomum subulatum
+Devadaru 
+Cedrus deodara
+Elavaluka 
+Prunus avium
+Sariva 
+Hemidesmus indicus
+Haridra 
+Turmeric
+Daruharidra 
+Berberis aristata
+Shalaparni 
+Desmodium gangeticum
+Prishnaparni 
+Uraria picta
+Phalini 
+Callicarpa macrophylla
+Nata 
+Brihati
+Valeriana wallichi
+Solanum indicum
+Sanskrit name
+Botanical name
+Kushta
+Saussurea lappa
+Manjishta
+Rubia cordifolia
+Nagakeshara 
+Mesua ferrea
+Dadimaphalatwak 
+Punica granatum
+Vella
+Embelia ribes
+Talisapatra 
+Abbies webbiana
+Ela 
+Elettaria cardamomum
+Malati
+Jasminum sambac
+Utpala 
+Nymphea stellata
+Danti 
+Baliospermum montanum
+Padmaka 
+Prunus poddum
+Hima 
+Sandalwood -Santalum album
+Sarpi 
+Ghee – 768 g
+Manufacturer – Arya Vaidya Pharmacy, Coimbatore, India, a 
+GMP certified company. 
+c. Trivrit Lehyam [19]. Trivrit – Operculina turpethum. Prepara-
+tion – 25 g of the powder is added with 400 mL of water, boiled and 
+reduced to 100 mL, filtered. To this Trivrit Kashaya, 25 g of Trivrit 
+powder is again added, along with 50 g of sugar and mixed well. 25 
+mL of honey and 5 g each of cinnamon, cardamom, and cinnamon 
+fine powder is added to obtain the sweet paste
+Sl. No.
+Ingredients
+Quantity
+1
+Trivrit Kashaya
+100 mL
+2
+Trivrit Churna
+25 g
+3
+Sugar
+50 g
+4
+Honey
+25 mL
+5
+Cinnamon
+5 g
+6
+Cardamom
+5 g
+7
+Cinnamon leaves powder
+5 g
+Manufacturer – Arya Vaidya Pharmacy, Coimbatore, India, a 
+GMP certified company. 
+d. Pathyakshadhatradi Kashaya [21]. Herbal decoction is prepared 
+from 10 g each of the following herbs
+Sanskrit name
+Botanical name
+Pathya 
+Terminalia chebula
+Aksha 
+Terminalia bellirica
+Dhatri (Amla)
+Emblica officinalis
+Bhunimba  
+Andrographis paniculata
+Nisha (Turmeric)
+Curcuma longa
+Nimba (Neem)
+Azadirachta indica
+Amruta 
+Tinospora cordifolia
+Dosage – 15 mL twice daily before breakfast and dinner mixed 
+with 45 mL of warm water. Manufacturer – Arya Vaidya Pharma-
+cy, Coimbatore, India, a GMP certified company.
+Table 2. List of polyherbal preparations (with their botanical names) used across Ayurveda treatment period and their prescribed quan-
+tity in the formulation
+Sharma/Nandi Krishnamurthy/Nagendra
+Ann Neurosci 2018;25:250–260
+254
+DOI: 10.1159/000492269
+Control Group
+The subjects who agreed to participate in the trial but preferred 
+to continue on oral analgesics (NSAIDs) for symptomatic relief as 
+per the prescription of a general physician or neurologist were in-
+cluded under this group. They were asked not to practice yoga nor 
+follow Ayurveda during the study period. They were given an op-
+tion to undergo the same therapy protocol as given for the AY 
+group after the study period.
+Subjects of both groups were monitored once in 2 weeks over 
+a telephonic call and visited the investigator once a month. The 
+subjects were free to withdraw from the study at any stage if they 
+felt the conditions were not conducive. 
+Data Analysis
+The data were analyzed using Statistical Packages for Social Sci-
+ences (SPSS), version 23. The normality and homogeneity were 
+assessed using Kolmogorov-Smirnov test. The missing values were 
+replaced by intention-to-treat analysis. The data of individual vari-
+ables were analyzed using a repeated measures analysis of variance 
+with one within-subjects factor (Time) and one between subjects 
+factor (Groups). Multiple comparisons were made across mean 
+values using a post-hoc analysis with Bonferroni correction. The 
+values were considered significant if p < 0.05.
+Results
+The AY group comprised 30 (8 male and 22 female) 
+subjects, with an average age ±SD of 33.83 ± 6.84 years. 
+The CT group had an equal number of subjects matched 
+for age and gender, with an average age ± SD of 31.46 ± 
+7.81 years. The demographic and clinical characteristics 
+are detailed in Table 4. There was one drop out in the AY 
+group on day 90 and one each from the CT group on days 
+30 and 90. The RM analysis of variance with post-hoc 
+analysis (with Bonferroni correction) showed significant 
+differences within and between subjects. 
+MIDAS: There was a significant difference in both 
+within-subjects factor (Time, p < 0.001) as well as be-
+tween subjects factor (Groups, p < 0.05). Also, the inter-
+action between Time and Groups was significant (p < 
+0.001). The post-hoc analysis with Bonferroni correction 
+suggested that there was a significant reduction in MIDAS 
+scores for the AY group on days 30 and 90 compared to 
+day 1 values (p < 0.001, for both comparisons; Table 4a).
+When the degree of disability was compared across 
+days 1, 30, and 90, the number of subjects with grade IV 
+(severe disability) decreased from 16 (53.3) to 4 (13.3) to 
+1 (3.3%) subject, whereas those belonging to grade I 
+MIDAS (little or no disability) increased from 6 (20) to 11 
+(36.6) to 20 (66.6%), respectively. The CT group showed 
+no change across three assessment points.
+Perceived Stress Scale 10: There was a significant differ-
+ence in both within-subjects factor (Time, p < 0.001) and 
+between-subjects factor (Groups, p < 0.001). Also, the in-
+teraction between Time and Groups was significant (p < 
+0.001). The post-hoc analysis showed a significant reduc-
+tion in PSS scores for the AY group on days 30 and 90 com-
+pared to the day 1 values (p < 0.01, p < 0.001, respectively). 
+The scores of perceived stress in the AY group changed 
+significantly across the three assessments (days 1, 30, and 
+90). The number of subjects with low stress increased 
+from 3 (10) to 7 (23.3) to 18 (60%), while the number with 
+moderate stress decreased from 25 (83.3) to 22 (73.3) to 
+11 (36.6%), and with high perceived stress decreased from 
+2 (6.6) to 1 (3.3) to 0 subjects (Table 4a). 
+Heart Rate Variability: There was a significant interac-
+tion between time and groups for LF, HF power values in 
+normalized units as well as LF/HF ratio (p < 0.05). The post-
+hoc analysis showed a significant reduction in LF power and 
+LF/HF ratio, while HF power increased in the AY group on 
+day 90 compared to their day 1 and day 30 values (p < 0.01, 
+p < 0.05 respectively). There were no changes observed in 
+the time domain measures of HRV (Table 4b).
+Heart Rate: There was a significant difference in within-
+subjects factor (Time, p < 0.05). The post-hoc analysis with 
+Bonferroni correction showed no significant difference 
+across multiple comparisons for both groups (Table 4c).
+Respiratory Rate: There was no significant difference 
+in both within-subjects factor and between-subjects fac-
+e. Kachoradi churna [22]. Equal quantities of herbal powders mentioned 
+below are used to make the powder
+Sanskrit name
+Botanical name
+Kachora
+Curcuma zedoaria
+Dhatri
+Emblica officinalis
+Manjishta
+Rubia cordifolia
+Yashti
+Glycyrrhiza glabra
+Daru
+Cedrus deodara
+Silajitu
+Asphaltum
+Vedhi
+Ferula foetida
+Rohini
+Andrographis paniculata
+Tintrinisira
+Tamarindus indicus
+Kumkuma
+Crocus sativus
+Indu 
+Camphor
+Varivaha
+Cyperus rotundus
+Rochanam
+Mallotus phillippenensis
+Bala
+Sida cordifolia
+Laja
+Oryza sativa
+Jala 
+Coleus zeylanicus
+Usira 
+Vetiveria zizanioides
+Pushkaramoola
+Innula racemosa
+Dosage – 1/2 tsp to be mixed with milk and applied on the forehead. Ma-
+nufacturer – Arya Vaidya Pharmacy, Coimbatore, India, a GMP certified 
+company.
+Table 2. (continued)
+Changes in MIDAS, Perceived Stress, 
+Frontalis Muscle Activity
+255
+Ann Neurosci 2018;25:250–260
+DOI: 10.1159/000492269
+Table 3. Details of the yoga program specially designed for the migraine patients are listed below. The description includes the category 
+of practices, duration of each practice (s-seconds, min-minutes), number of repetitions, and the sequence of practices
+Sl. No.
+Practices
+Number of rounds 
+Duration
+1.
+Loosening practices (Shithilikarana vyayama)
+5 rounds
+5 min
+Neck up and down movement 
+Neck side to side movement
+Shoulder rotation – clockwise and anti-clockwise
+Shoulder cuff rotation – clockwise and anti-clockwise
+Head rolling – clockwise and anti-clockwise, up and down movement
+2.
+Instant relaxation technique
+1 round
+1 min
+3.
+Breathing practices
+5 rounds each
+5 min
+Ankle stretch breathing
+Shashankasana breathing
+Tiger stretch breathing
+Uttanapadasana breathing – Single leg 
+4.
+Quick relaxation technique 
+1 round
+3 min
+5.
+Postures (Asanas)
+1 round each
+12 min
+5a
+Standing:
+Padahasthasana
+Ardha Chakrasana
+Ardhakati Chakrasana
+Trikonasana
+30 s each
+approximately
+2.5 min
+Relaxation in standing posture
+30 s
+30 s
+5b
+Sitting:
+Janushirasana
+Vajrasana
+Ushtrasana
+Shashankasana
+Suptavajrasana
+Vakrasana
+30 s each
+approximately
+4 min
+Relaxation in sitting posture
+30 s
+30 s
+5c
+Supine:
+Viparita karani/Sarvangasana
+Matsyasana
+Pavanamukthasana
+Naukasana
+Setubandhasana
+30 s each
+2.5 min
+Relaxation in supine position
+30 s
+30 s
+5d
+Prone: 
+Bhujangasana
+Shalabhasana
+Dhanurasana
+30 s each
+1.5 min
+6.
+Deep relaxation technique
+7 min
+7.
+Kriyas Kapalabhati 
+1 min
+8.
+Regulated breathing practices (Pranayama)
+1 min each
+3 min
+Nadishodhana Pranayama
+Bhramari Pranayama 
+Ujjayi Pranayama
+1 min each
+3 min
+9.
+Nadanusandhana (chanting)
+3 min
+Sharma/Nandi Krishnamurthy/Nagendra
+Ann Neurosci 2018;25:250–260
+256
+DOI: 10.1159/000492269
+Table 4. Demographic and clinical characteristics of subjects belonging to the AY and CT groups
+AY 
+CT
+Age, years, mean ± SD
+33.83±6.84
+31.46±7.81
+Gender
+Male
+8
+8
+Female
+22
+22
+Clinical characteristics
+Severity of headache (intensity of pain)
+Moderate
+9
+12
+Severe
+21
+18
+Average duration of attack (in hours)
+27.8
+29.8
+Associated with nausea and/or vomiting (number of subjects)
+30
+30
+Number of subjects using analgesics
+30
+30
+a. MIDAS score and PSS recorded on days 1, 30, and 90 in both AY and CT groups. Values are group mean ± SD
+AY 
+CT
+day 1
+day 30
+day 90
+day 1
+day 30
+day 90
+MIDAS
+25.73±22.07
+10.76±10.39***
+5.48±7.97***, †
+21.00±15.26
+17.58±12.40
+20.24±13.48 
+PSS
+21.20±4.83
+17.03±5.72**
+11.96±4.85***, † † †
+22.30±3.36
+21.34±2.48
+21.51±3.34 
+** p < 0.01, *** p < 0.001, † p < 0.05, † † † p < 0.001, repeated measures ANOVA with post-hoc analysis. 
+* Comparing the day 1 values with respective days 30 and 90 values, † comparing days 30 and 90 values.
+MIDAS, migraine disability assessment; PSS, perceived stress score. 
+b. Frequency domain and time domain measures of heart rate variability recorded on days 1, 30, and 90 in both AY and CT groups. The 
+values are group mean ± SD
+AY
+CT
+day 1
+day 30
+day 90
+day 1
+day 30
+day 90
+LF, nu
+54.86±18.45
+50.72±17.25
+41.26±15.48**, †
+43.51±18.33
+45.77±16.40
+46.04±16.85 
+HF, nu
+45.29±18.22
+48.90±18.15
+58.91±15.43**, †
+56.71±18.30
+54.36±16.37
+54.14±16.87
+LF/HF, ratio
+2.06±2.79
+1.29±0.86
+0.84±0.59†
+1.04±0.97
+1.10±0.98
+1.09±0.89
+SDNN, ms
+34.99±18.86
+33.43±13.65
+34.33±18.47
+34.41±13.23
+33.73±20.27
+34.37±20.20 
+RMSSD, ms
+25.49±19.63
+23.71±14.38
+28.16±24.60
+30.50±20.70
+30.41±26.39
+33.10±27.05
+pNN50, ms
+8.43±14.32
+7.72±12.41
+6.35±10.62
+11.88±18.74
+9.82±14.78
+12.51±19.23
+** p < 0.01, † p < 0.05, repeated measures ANOVA with post-hoc analysis. 
+* Comparing day 1 with day 30 and day 90 values, † comparing day 30 with day 90 values.
+c. The HR and RR recorded on days 1, 30 and 90 in both AY and CT groups. The values are group mean ± SD
+AY
+CT
+day 1
+day 30
+day 90
+day 1
+day 30
+day 90
+HR (BPM)
+82.95±11.53
+84.72±12.63
+78.53±11.12
+86.58±9.74
+87.05±11.93
+84.09±14.24 
+RR (BrPM)
+18.30±3.03
+17.03±2.55
+16±2.59**
+17.76±3.72
+18.03±3.38
+18.41±3.87
+** p < 0.01, Repeated measures ANOVA with post-hoc analysis comparing the day 1 values with days 30 and 90 values. BPM, beats 
+per minute; BrPM, breaths per minute; HR, heart rate; RR, respiratory rate.
+Changes in MIDAS, Perceived Stress, 
+Frontalis Muscle Activity
+257
+Ann Neurosci 2018;25:250–260
+DOI: 10.1159/000492269
+tor. The interaction between time and groups was sig-
+nificantly different (p < 0.05).
+The post-hoc analysis with Bonferroni correction sug-
+gested that there was a significant reduction in respira-
+tory rate in the AY group on day 90 compared to day 1 
+values (p < 0.01; Table 4c).
+Surface Electromyography: The mean RMS EMG 
+showed a significant difference in within-subjects factor 
+(time, p < 0.05), between subjects factor (groups, p < 0.05) 
+and the interaction between time and groups (p < 0.01). 
+The post-hoc analysis showed a significant reduction on 
+day 90 compared to day 1 and day 30 values (p < 0.001and 
+p < 0.05, respectively). 
+Integral EMG (p < 0.001) showed a significant differ-
+ence in the interaction between time and groups (p < 
+0.001). The post-hoc analysis showed a significant reduc-
+tion in integral EMG values in the AY group on day 90 
+compared to day 1 values (p < 0.01).
+The control group showed no significant changes 
+across assessments (days 30 and 90, compared to day 1) 
+for different variables (p < 0.05; Table 4d).
+Medication (NSAID) Use: The analgesic requirement on 
+need basis, which was noticed in all 30 participants of the AY 
+group (100%) on day 1 reduced to 14 participants (46.6%) by 
+day 30 and was noticed in 6 participants (20%) on day 90 
+compared to the CT group where the requirement reduced 
+from 30 participants (100%) on day 1 to 27 participants 
+(90%) on day 30, and to 26 participants (86.66%) on day 90.
+Discussion
+A combined Ayurveda and Yoga therapy intervention 
+for 90 days reduced migraine-related disability, levels of 
+perceived stress, and sympathetic arousal. The foremost 
+treatise of Ayurveda, Charaka Samhita considers Yoga as 
+an integral part of Ayurveda where the balance of Doshas 
+(body humor) is achieved through Ayurveda and psycho-
+logical well-being through Yoga therapy. Hence, we made 
+an attempt to study the combined effect of Yoga and 
+Ayurveda in individuals with migraine headache.
+Migraine is a leading cause, among both men and wom-
+en, for years spent with disability at physical, mental, and 
+social levels [4]. The MIDAS scores which were high in the 
+present study decreased significantly in the AY group. This 
+can primarily be attributed to the reduced severity of pain, 
+frequency of headache, and improved quality of life. Simi-
+lar changes in MIDAS were reported earlier, where Ayurve-
+da medicines were given along with regulated diet and life-
+style. Improved digestive fire (agni) and better acid-alka-
+line balance in the digestive system were the proposed 
+mechanisms [12]. A mindfulness-based stress reduction 
+program along with conventional prophylaxis also showed 
+a significant reduction in migraine-related disability. It 
+was speculated that improved emotional regulation, less 
+pain catastrophizing, and increased pain acceptance are 
+the reasons behind the positive results observed [23]. 
+Stress is considered as an important factor for trigger 
+and perpetuation of migraine headache [5]. The higher 
+perceived stress scores observed in AY and CT groups 
+indicate the impact of stress on the present study popula-
+tion. The severity of perceived stress decreased signifi-
+cantly in the AY group, with more than 60% of the par-
+ticipants moving to low perceived stress levels. Similarly, 
+significant improvement in perceived stress, marked re-
+lief in pain, and reduction in salivary cortisol levels were 
+observed in 24 women with headache or back pain fol-
+lowing the practice of Iyengar Yoga, twice a week for 
+90 min duration [24]. A previous report implied that a 
+single session of Abhyanga reduced subjective stress ex-
+perience, lowered heart rate, and systolic blood pressure 
+[25]. Abhyanga which was part of Ayurveda intervention 
+for 6–8 days in the present study, was expected to relax 
+and rejuvenate an individual physically and mentally.
+The evoked autonomic changes were recorded during 
+the 3-min frowning period. Reduction in the duration of 
+d. The integral EMG and RMS EMG recorded on days 1, 30, and 90 in both AY and CT groups. The values are group mean ± SD
+AY
+CT
+day 1
+day 30
+day 90
+day 1
+day 30
+day 90
+Integral EMG, µV
+11.80±8.49
+8.74±4.85
+6.52±2.77**, † †
+9.31±3.90
+10.96±5.42
+12.04±6.31
+RMS EMG, µV 
+133.43±58.25
+113.99±68.61
+75.44±35.19***, †
+128.50±69.53
+159.41±129.39
+128.31±65.87
+** p <0.01, *** p < 0.001, † p < 0.05, † † p < 0.01, repeated measures ANOVA with post-hoc analysis. * Comparing day 1 with day 30 and day 
+90 values, † comparing day 30 with day 90 values.
+Table 4. (continued)
+Sharma/Nandi Krishnamurthy/Nagendra
+Ann Neurosci 2018;25:250–260
+258
+DOI: 10.1159/000492269
+recording from standard 5 to 3 min was based on the sub-
+jective experience based on our pilot study where subjects 
+expressed discomfort and were anxious about the onset 
+of a migraine attack following frowning for 5 min. One 
+such study validates the short-term HRV [26].
+An increased HF and decreased LF component of HRV 
+along with reduced heart rate and respiratory rate in the 
+present study gives a clear indication of sympathovagal 
+balance shifting towards vagal dominance in the AY group. 
+A previous study on healthy undergraduate medical stu-
+dents showed a significant reduction in stress, decrease in 
+LF component, and increase in HF component of HRV 
+spectrum following 2 months of pranayama practice [27]. 
+The changes were attributed to the inhibitory signals gen-
+erated during the process of pranayama from cardiorespi-
+ratory system leading to modulation of autonomic system 
+resulting in parasympathetic dominance. Heightened 
+baroreflex sensitivity and improved oxygenation have 
+been the proposed underlying mechanisms for the de-
+creased heart rate, systolic blood pressure, and improved 
+oxygen consumption observed in the study [28]. Brown 
+and Gerbarg in a review reported that yoga-breathing in-
+terventions increase HRV, improve sympathovagal bal-
+ance, and promote stress resilience. Coherent breathing 
+and resonant breathing, using a fixed rate of 3 and a half to 
+6 breaths per minute (bpm), have been shown to increase 
+HRV and parasympathetic nervous system activity [29].
+Increased parasympathetic activity may cause reduced 
+firing of the paragigantocellular nucleus of the medulla to 
+locus coeruleus, and decreased stimulation of locus ceruleus 
+could reduce norepinephrine output, resulting in relax-
+ation, quiescence, and reduced respiratory and heart rates 
+[30]. Using real-time functional MRI, attempts were made 
+in healthy volunteers to modulate the activation of their own 
+anterior cingulate cortex to alter their pain experience [31]. 
+The association between increased cortical thickness in 
+pain-related brain regions (including anterior cingulate 
+cortex, bilateral parahippocampal gyrus) and lowered pain 
+sensitivity in Zen meditators compared to non-meditators 
+has added a probable supporting evidence for the underly-
+ing mechanisms [32]. Some meditation types such as mind-
+fulness are associated with enhancements in cognitive con-
+trol, emotional regulation, positive mood, and acceptance. 
+Each of them play a role in pain modulation [33].
+Streeter et al. [34], in a comprehensive review, have 
+reported that asanas, pranayama, and meditation includ-
+ing chanting can shift sympathovagal balance to vagal 
+dominance, enhance activity of the gamma-aminobutyr-
+ic acid system, and reduce allostatic load. The authors 
+have also hypothesized that the regulation of hypothala-
+mo-pituitary-adrenal axis through the practice of yoga is 
+one of the underlying mechanism.
+Furthermore, stress is also known to increase muscle 
+activation. In chronic pain, sympathetic activity due to 
+nociceptive stimulation may cause disturbances of blood 
+flow regulation in the affected muscle and enhance mus-
+cle activation [35]. A previous report on yoga in tension-
+type headache has shown to reduce EMG amplitude at 
+rest and during mental activity [36]. Reduced sympathet-
+ic activity following the practice of yoga is also known to 
+bring down muscle activity.
+Hence, the present study demonstrated that the auto-
+nomic arousal and sEMG activity during frowning were 
+substantially lower on day 90, inferring a positive role of 
+Ayurveda and yoga in an attenuated stress response. 
+Two polyherbal combinations were used in the 
+Ayurveda treatment protocol (Kallyanaka Ghrita for in-
+ternal oleation and Pathyakshadhatryadi kashaya as oral 
+medicine post virechana). Kallyanaka ghrita is one of the 
+combinations mentioned in Bower manuscript and tra-
+ditional Ayurveda texts and also assessed scientifically 
+through HPTLC [37].
+The orally administered decoction (Pathyakshad-
+hatyradi Kashaya) used in this study for 75 days has 
+7 herbs. Triphala (3 herbs) has adaptogenic effects [38], 
+Azadirachta Indica has anti-inflammatory, anti-prolifer-
+ative properties, turmeric with the active ingredient cur-
+cumin has anti-inflammatory effect [39], Tinospora car-
+difolia has anti-oxidant, immunomodulatory properties 
+[40], and Andrographis paniculata has shown hepato-
+protective, antioxidant, and anti-inflammatory proper-
+ties [41]. 
+Hence, the present study illustrates that a combined 
+intervention of traditional Ayurveda and yoga therapies 
+can reduce migraine-related disability and perceived 
+stress by establishing autonomic balance and reduced 
+frontalis muscle activity over the forehead. 
+Limitations and Future Directions
+Self-selection of intervention by the subjects was the 
+major limitation of the study. Bigger sample size with a 
+randomized controlled trial with a longer follow-up 
+would offer more generalized results. 
+Conclusion
+Ayurveda and yoga therapy reduce migraine-related 
+disability by reducing perceived stress, improving auto-
+nomic balance, and reducing muscle tension. 
+Changes in MIDAS, Perceived Stress, 
+Frontalis Muscle Activity
+259
+Ann Neurosci 2018;25:250–260
+DOI: 10.1159/000492269
+Acknowledgments
+We acknowledge the contribution of Dr. Raghavendra Bhat for 
+technical support and Dr. Prajna Shetty for assisting in data collec-
+tion and yoga training.
+Disclosure Statement
+This work received no specific grant from any funding agency, 
+commercial, or not-for-profit sectors.
+Author Contribution
+Dr. Vasudha M. Sharma was involved in conceptualizing the 
+study, reviewing the literature, planning Ayurveda intervention, 
+recruitment of subjects and assessments, data analysis, and pre-
+paring the manuscript. Dr. Manjunath N.K. was involved in 
+conceptualizing and designing the study, planning statisti-
+cal analysis, and preparing the manuscript. Dr. Nagendra H.R. 
+was  instrumental in providing guidance for the whole study, 
+­
+designing the yoga therapy module, and preparing the manu-
+script. 
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+39	 Gupta SC, Patchva S, Aggarwal B: Therapeu-
+tic roles of curcumin: lessons learned from 
+clinical trials. AAPS J 2013; 15: 195–218.
+40	 Subramanian M, Chintalwar GJ, Chattopad-
+hyay S: Antioxidant properties of a Tinos-
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+paniculata for hepatoprotection. Phytother 
+Res 2014; 28: 1589–1598.

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+Volume 6 | Issue 1 | January-June | 2013
+Official Publication of
+Swami Vivekananda Yoga Anusandhana Samsthana University
+Online full text at
+http://www.ijoy.org.in
+IJ Y
+O
+International Journal of Yoga
+Editorial
+From meditation to dhyana
+Original Articles
+Yoga experience as a predictor of psychological wellness in women over 45 years
+Comparison of lymphocyte apoptotic index and qualitative DNA damage in yoga practitioners and breast cancer patients: A pilot study
+Voluntary heart rate reduction following yoga using different strategies
+Effect of yoga exercise therapy on oxidative stress indicators with end-stage rena disease on hemodialysis
+Effect of the integrated approach of yoga therapy on platelet count and uric acid in pregnancy: A multicenter stratified randomized 
+single-blind study
+Yogic practice and diabetes mellitus in geriatric patients
+Contents
+ISSN 0973-6131
+International Journal of Yoga  Vol. 6  Jan-Jun-2013
+20
+Comparison of lymphocyte apoptotic index and qualitative 
+DNA damage in yoga practitioners and breast cancer patients: 
+A pilot study
+Amritanshu Ram, Birendranath Banerjee, Vadiraja S Hosakote, Raghavendra M Rao, Raghuram Nagarathna
+Division of Yoga Life Sciences, SVYASA, Bangalore, India
+Address for correspondence: Dr. Raghuram Nagarathna, 
+ 
+No. 19, Eknath Bhavan, Gavipuram Circle, Kempegowdanagar, 
+ 
+Bangalore - 560 019, India. 
+ 
+E-mail: [email protected]
+Original Article
+cancer.World statistics indicate that in India alone 22.2% 
+of women presently suffer from cancer, which is expected 
+to increase to almost 30% in the next 5 years.[2] Research 
+to understand the etiology and eradicate the tumor burden 
+without harming the host has progressed with many 
+success stories that have resulted in cure (in a few cancers), 
+improved longevity and quality life. In spite of these 
+fascinating advances, treatment of cancer is laden with 
+multiple side effects. Some degree of damage to normal 
+healthy tissues is an expected side effect of both chemo- 
+and radiation therapies. Continuing attempts to reduce 
+these effects have had many success stories, although not 
+yet complete. Radiation therapy is associated with known 
+imbalances that result in increased apoptosis[3] and other 
+chromosomal abnormalities.[4]
+INTRODUCTION
+Cancer appears to be an ever growing disease and a leading 
+cause of death worldwide. It accounted for 7.4 million 
+deaths (or about 13% of all deaths worldwide) in 2008.[1] 
+There has been a constant increase in the incidence of 
+Background: Yoga is found to be effective in reducing stress levels and radiation-induced DNA damage, and improving the 
+quality of life, in breast cancer patients. The present study was aimed at comparing the apoptotic index (AI) and DNA damage 
+of advanced yoga practitioners with those of breast cancer patients.
+Materials and Methods: This cross-sectional pilot study compared three groups (n = 9 each) of age-matched subjects viz. 
+(1) Carcinoma breast patients in stage II or III undergoing radiation therapy after completing three cycles of chemotherapy; 
+(2) Senior yoga practitioners who were practicing asanas, pranayama and meditation daily for more than 10 years; and (3) 
+Normal healthy volunteers. Peripheral blood lymphocytes were isolated, and qualitative DNA damage (QDD) and AI were 
+evaluated by single-cell gel electrophoresis assay. Approximately 500 cells were counted in each case. Number of cells that 
+were normal, undergoing apoptosis, and with DNA damage were categorized and percentages were calculated.
+Results: Data being normally distributed, one-way analysis of variance (ANOVA) showed significant interaction between 
+groups in AI (P = 0.016) and QDD (P = 0.045). On post-hoc analysis using Scheffe test, AI was significantly lower in non-yoga 
+volunteers as compared with the breast cancer group (P = 0.019) and QDD was significantly lower in yoga practitioners when 
+compared with non-yoga volunteers (P = 0.047).
+Conclusion: Cellular dysfunction (QDD) requires restorative mechanisms (AI) to restore the system to a balance. The results 
+of this pilot study show trends, which indicate that in ill-health, there is inadequate restorative mechanisms (AI) although 
+dysfunction (QDD) is high. Through regular practice of yoga, cellular dysfunction can be lowered, thus necessitating reduced 
+restorative mechanisms. AI and QDD could also be useful indicators for predicting the three zones of health viz. disease, 
+health, and positive health.
+Key words: Apoptotic index; breast cancer; comet assay; DNA damage; yoga. 
+ABSTRACT
+Access this article online
+Website: 
+www.ijoy.org.in
+Quick Response Code
+DOI: 
+4103/0973-6131.105938
+Ram, et al.: Comparison of lymphocyte AI and QDD in yoga and breast cancer patients: A pilot study
+21
+International Journal of Yoga  Vol. 6  Jan-Jun-2013
+Apoptosis or programmed cell death in the tissues is 
+a normal phenomenon, which is a very important and 
+inevitable event in the remodeling of tissues during 
+development and aging.[5] It is a crucial process for 
+eliminating cancer cells.[6] Most carcinogens appear to 
+induce tumors by damaging cellular DNA that results 
+in abnormal cells.[7] Apoptosis is one of the protective 
+mechanism by which cells undergo self-suicide in 
+response to DNA damage. Given that faulty DNA repair 
+is associated with an increased incidence of abnormal 
+cells,[7] the processes for repair or destruction of damaged 
+cellular DNA are critical when it comes to defending the 
+body against carcinogens. The studies on liver damage 
+and neoplastic lesions suggest an extremely important 
+role for apoptosis in controlling cancer.[8] It was seen in 
+various studies that DNA damage and apoptosis tended to 
+increase with the grade of the tumor.[9] Key steps crucial 
+to progress of tumor progression are genomic instability 
+and escape from apoptosis.[10] Studies also indicate that 
+the older population shows higher basal levels of DNA 
+damage and more sensitivity to DNA-damaging agents 
+than the younger population.[11]
+The possibility of a linkage between emotional distress and 
+DNA repair was explored in a study using peripheral blood 
+lymphocytes (PBLs) obtained from patients in a psychiatric 
+hospital.[12] The results showed that lymphocytes from 
+psychiatric patients demonstrated greater impairments 
+relative to controls, in their ability to repair damaged 
+cellular DNA, and those who were more depressed showed 
+significantly poorer repair of damaged DNA than their less 
+depressed counterparts. In another study[13] 45 rats, half of 
+which were assigned to a rotational stress condition, were 
+fed a carcinogen. The levels of the DNA repair enzyme 
+(methyltransferase) induced in response to carcinogen 
+damage were significantly lower in the stressed animals’ 
+splenic lymphocytes.[13]
+Research has also documented inhibition of apoptosis 
+by stress,[14] which in turn could result in suppression of 
+immune function. Tomei et al.[14] showed that examination 
+stress in medical students enhanced the inhibition of 
+radiation-induced apoptosis in PBLs. Thus it appears that 
+psychosocial stressors could ultimately lead to progressive 
+accumulation of errors within cell genomes as well as 
+reducing tumor-specific and innate immune responses.[15]
+A number of researchers have shown that stress-reducing 
+interventions can improve immune functions.[16] The first 
+well-controlled demonstration of immune enhancement 
+via behavioral intervention came from a study on normal 
+healthy adults that showed significant enhancement 
+in natural killer (NK) cell activity, with concomitant 
+decreases in distress-related symptomatology after 1 
+month of relaxation training.[17] One of the comprehensive 
+intervention studies in cancer research evaluated both the 
+immediate and longer term effects of a 6-week structured 
+group intervention that consisted of health education and 
+stress management techniques such as relaxation and 
+psychological support[18,19] in patients with stage-I or -II 
+malignant melanoma. A 6-year follow-up showed a trend 
+toward greater recurrence, as well as higher mortality rates, 
+among patients in the control group when compared with 
+the patients in the intervention group.[19] In a randomized 
+control study, Vadiraja et al.[20] compared the effects of an 
+integrated yoga program with brief supportive therapy 
+in 88 breast cancer outpatients undergoing adjuvant 
+radiotherapy and showed decreases in anxiety, depression, 
+perceived stress, 6 a.m. salivary cortisol, and pooled mean 
+cortisol levels in the yoga group compared with controls. 
+We studied the effects of an integrated yoga program in 
+modulating perceived stress levels, anxiety, as well as 
+depression levels and radiation-induced DNA damage, 
+in 68 breast cancer patients undergoing radiotherapy. 
+Radiation-induced DNA damage after radiotherapy was 
+significantly elevated in both the yoga and the control 
+groups, with a trend of a lesser level of DNA damage 
+in the yoga group. There was also significant decrease 
+in perceived stress and negative affect, with increase in 
+positive affect after yoga.[21]
+MATERIALS AND METHODS
+This was a three-armed cross-sectional design that 
+compared the apoptotic index (AI) and qualitative DNA 
+damage (QDD) in three groups of age-matched subjects: (1) 
+Carcinoma breast patients; (2) Advanced yoga practitioners; 
+and (3) Normal healthy volunteers. Recruited for the study 
+were 13 women with breast cancer in stage II or III who 
+were referred to the radiology department for radiation 
+therapy after completing three cycles of chemotherapy at 
+Manipal Hospital and Bangalore Institute of Oncology. The 
+inclusion criteria were (a) adult females in the age range 
+35-70 years with carcinoma of the breast in stage II or III 
+undergoing radiation therapy and (b) performance status 
+of 0-3 on Zubrod’s scale. Those with metastatic breast 
+cancer; those who were on steroids; and those with other 
+major medical conditions such as diabetes, coronary heart 
+disease, and/or a major psychiatric illness were excluded.
+The second group consisted of 11 age-matched (±2 years) 
+individuals from two yoga institutions (VYASA and 
+Yogashree (the yoga wing of Hindu Seva Pratishthana)) 
+with experience in regular practice of yoga for at least 1 
+h per day for more than 10 years. The third group of 10 
+normal healthy volunteers who did not have experience 
+of yoga was selected from the staff of both the hospitals. 
+Those who had any symptoms, illnesses, were on any form 
+of medication, smoked, or consumed alcohol were not 
+included in groups 2 and 3. This study was approved by 
+the institutional ethical review committee and consent was 
+Ram, et al.: Comparison of lymphocyte AI and QDD in yoga and breast cancer patients: A pilot study
+International Journal of Yoga  Vol. 6  Jan-Jun-2013
+22
+sought from all the subjects of the study. Five milliliters 
+of fasting blood was drawn from the antecubital vein 
+into heparinized vacutainers between 8:00 a.m. 10:00 
+a.m. in the hospital premises by a laboratory technician. 
+The samples were coded and analyzed for AI and QDD at 
+Manipal Hospital by a blinded investigator.
+Blinding
+The PBL samples were coded to blind for groups and age.
+Yoga practices
+The advanced yoga practitioners included in this study were 
+all senior yoga teachers who were teaching and practicing 
+yoga daily regularly (5-7 days/week) for several years (>10 
+years). All of them had a routine of doing integrated yoga 
+that included a few asanas, pranayama, and meditation.
+Assessments and data extraction
+The PBLs were isolated from the blood samples by the 
+Ficoll density-gradient method using Histopaque 1077 
+(Sigma Aldrich, St Louis, MO, USA).[22] Single-cell gel 
+electrophoresis or comet assay was conducted according 
+to the prescribed protocol.[23,24] Cells embedded in 
+agarose were lysed, subjected briefly to an electric 
+field, stained with a fluorescent DNA-binding stain, and 
+viewed using a fluorescence microscope. Fragmented 
+DNA migrates farther in the electric field, and the cell 
+then resembles a “comet” with a brightly fluorescent 
+head and a tail region, which increases as damage 
+increases. Slides were treated with the DNA-binding 
+dye propidium iodide (1 mg/ml) (Sigma Aldrich) and 
+viewed with appropriate filters at ´40 [Figure 1]. No 
+standardization was necessary as this was a qualitative 
+test and the comet cells, apoptotic cells, and normal cells 
+were clearly distinguishable by the trained researcher 
+who counted the cells in each of the coded slides. 
+Approximately 500 cells were scored in total for each of 
+the samples. The number of apoptotic cells and comets 
+was expressed as a percentage of the total number of 
+cells counted.
+Data analysis
+Data were cumulated and descriptive statistics were 
+calculated. Data being normally distributed, comparisons 
+were made using one-way analysis of variance (ANOVA) 
+to evaluate the interactions between the three groups. 
+Post-hoc tests (Scheffe test) were conducted to isolate the 
+groups with significant differences.
+RESULTS
+The final numbers available for analysis were nine in 
+each group. Demographic data showed that mean age was 
+46.67 ± 10.79 years in women with breast cancer (BC), 
+48.44 ± 10.91 in senior yoga (SY), and 47.11 ± 9.99 in 
+non-yoga volunteers (NV). The values for QDD and AI 
+were normally distributed. Table 1 shows the mean and 
+standard deviation values for each of the groups followed 
+by one-way ANOVA and Scheffe test for group differences.
+Apoptotic index
+One-way ANOVA showed that there was significant group 
+interaction between the three groups (f(2,24) =4.973, P = 
+0.016). Post-hoc analyses using Scheffe test revealed that 
+percentage apoptosis was significantly lower in the yoga 
+group as compared with non-yoga volunteers (P = 0.019).
+DNA damage
+Percentage of comet cells was highest in the cancer patients 
+and least in the senior yoga practitioners. One-way ANOVA 
+showed significant group interaction between groups (f(2,24) 
+=3.534, P = 0.045). On post-hoc analyses using Scheffe 
+test, significantly lower comet percentages were seen in 
+the senior yoga practitioners as compared with the breast 
+cancer group (P = 0.047) [Table 1].
+Thus, percentage apoptosis and levels of DNA damage 
+showed significant group interactions with significant 
+differences between the yoga and non-yoga groups and 
+the breast cancer and yoga groups for percentage apoptosis 
+and DNA damage, respectively.
+Table 1: Between group comparisons of AI and % comets by one way ANOVA (n=9 in each group)
+Group
+Number of cells counted
+% Apoptosis  
+(AI) ANOVA, P=0.016
+% Comet (QDD)  
+ANOVA, P=0.045
+%
+Post‑hoc* sig.
+%
+Post‑hoc* sig. 
+BC
+406.22±177.23
+10.05±3.24
+BC:SY
+0.687
+3.13±1.74
+BC:SY
+0.047†
+SY
+510.55±49.27
+8.79±3.08
+SY:NV
+0.019†
+1.53±1.00
+SY:NV
+0.313
+NV
+512.88±82.92
+13.17±2.77
+NV:BC
+0.113
+2.47±0.93
+NV:BC
+0.564
+AI: Apoptotic index; ANOVA: Analysis of variance; BC: Breast cancer; NV: Non��yoga volunteers; QDD: Qualitative DNA damage; SY: Senior yoga practitioners 
+*Post‑hoc analysis by Scheffe test † P<0.05 Observations: (1) Significant group interaction in both variables. (2) Least QDD in SY group. (3) Highest AI in NV 
+group 
+Ram, et al.: Comparison of lymphocyte AI and QDD in yoga and breast cancer patients: A pilot study
+23
+International Journal of Yoga  Vol. 6  Jan-Jun-2013
+DISCUSSION
+In this cross-sectional pilot study three groups of subjects 
+viz. senior yoga practitioners (SY) (n = 9), healthy non-
+yoga volunteers (NV) (n = 9), and patients with carcinoma 
+of breast undergoing radiotherapy after three cycles of 
+chemotherapy (BC) (n = 9) were selected. The results 
+showed that the percentage apoptosis and DNA damage 
+were least in the SY group. Percentage apoptosis was 
+highest in the NV group and percentage comet was highest 
+in the breast cancer group. Significant group interactions 
+were observed as tested by one-way ANOVA.
+Apoptosis is a process of genetically programmed 
+alternations of cell structure that leads to failure of 
+proliferation and differentiation, and eventual cell death. 
+Apoptosis is induced by a variety of toxic cellular insults 
+and is crucial for recognition and disposal of toxins and 
+unhealthy cells. It provides an indication of the body’s 
+response to physical and chemical stresses on the tissues. 
+The need for apoptosis arises when regular functions like 
+aging, protein profiles, genetic integrity, and inter-cellular 
+signaling pathways are dysregulated to the extent that 
+it deviates from normal homeostasis. This process may 
+function to protect against the appearance of heritable 
+phenotypic changes in cells and may be a critical factor 
+in normal cellular immune function.[14] Thus AI is an 
+indicator of the rate of toxin build-up at the cellular level. 
+A high AI observed in the NV group indicates that the 
+cellular environment required frequent “housekeeping”. 
+A low AI in the yoga group would therefore indicate that 
+the rate of cellular toxin build-up was low.[25]
+DNA is a repository of genetic information in each living cell, 
+its integrity and stability being essential to life. It is subject 
+to assault from the environment, and the resulting damage, 
+if not repaired, leads to mutation and possibly disease. 
+DNA damage could be the result of excessive exposure 
+to UV radiation, tobacco smoke, mutations during DNA 
+replication, byproducts of metabolism, and oxidative stress 
+amongst others. In the present study, breast cancer patients 
+who underwent therapeutic strategies (radiotherapy and 
+chemotherapy) showed significantly higher DNA damage 
+levels as compared with yoga practitioners. This could be 
+due to treatment-related insult to the DNA. Psychological 
+stress responses affect metabolic byproducts and oxidative 
+stress,[26] which could have contributed to the higher values 
+of DNA damage in this group. The trend of low values 
+of DNA damage in the yoga group as compared with the 
+non-yoga group, although non-significant, could indicate a 
+reversal of these stress-induced physiological and cellular 
+changes. Hence, regular yoga practice may help to keep up 
+the integrity of the DNA in breast cancer patients during 
+conventional treatment modalities.
+The authors have also tried to suggest a model of healthy 
+aging utilizing both values of AI and QDD. This model 
+works on the premise that QDD is an index of ill-health and 
+AI is the ability to restore health in the system. The values 
+for breast cancer patients have high levels of QDD with low 
+values of AI, indicating illness with the inability to heal. In 
+comparison, normal individuals without exposure to yoga 
+show moderate levels of QDD but a high AI, indicating 
+that the system is in a state of “high alert,” with restorative 
+mechanisms at heightened levels. The third group of senior 
+yoga practitioners (SY) however had low values for both 
+AI and QDD, suggesting that regular long-term practice of 
+awareness building and internalization achieved through 
+yoga practice could improve the efficiency of the system. 
+Mindful awareness of yoga brings about stress reduction 
+and hence metabolic and oxidative homeostasis, which 
+would percolate into cellular processes such as preserving 
+the integrity of the DNA, resulting in reduced requirement 
+of restorative mechanisms. This is represented figuratively 
+[Figure 2] as a linear progression from disease, through 
+health, toward positive health.
+In conclusion, we may state that when one adopts a yogic 
+way of life with minimal or no abuse to the body and mind, 
+it tends toward a healthy body, which reflects in the cellular 
+parameters of AI and DNA damage. Regular yoga practice 
+could also be the key to healthy senescence as it could 
+have a buffering effect on age-dependant DNA damage and 
+repair capacity. Thus this pilot study paves the road map 
+Figure 1: (a) Normal cell. (b) Cell with DNA damage, forming comet tail. (c) Apoptotic cell (doi: 10.1016/j.ajodo.2003.09.010)
+c
+b
+a
+Ram, et al.: Comparison of lymphocyte AI and QDD in yoga and breast cancer patients: A pilot study
+International Journal of Yoga  Vol. 6  Jan-Jun-2013
+24
+for designing more robust studies using these variables.
+Limitations of the study
+This was a pilot experiment to look for directional 
+differences between the three cohorts and hence, small 
+yet heterogeneous cohorts were involved. Data from 
+a fourth group consisting of cancer patients who had 
+prolonged exposure to yoga practice would have been more 
+effective in understanding the differences. Also, newly 
+diagnosed and advanced-stage breast cancer groups would 
+have added to the evidence of the hypothesis. Gender 
+differences could have confounded the comparisons, 
+although an attempt was made to match the age between 
+the three groups. The technique of estimating the AI and 
+QDD was manual observation of the morphology of cells at 
+low magnification. More objective and accurate measures 
+are advised if this study is not exploratory in nature.
+Strength of the study
+There are several studies on brain processes in senior 
+meaditators of vipassana, transcendental meditation, 
+etc. But, to the best of our knowledge, this is the first 
+study that has looked at cellular functions like AI in yoga 
+practitioners and compared it with those of cancer patients 
+undergoing radiation. This study provides direction for 
+further investigations in order to understand fundamental 
+differences between health and disease. The results of this 
+study helped us to propose a new hypothesis of disease, 
+health, and positive health, which needs validation by 
+well-designed studies in future.
+Suggestions for future research
+As initiation, progression, and therapy of cancer are laden 
+with many cellular, immunological, and psychological 
+factors, it is important to have a comprehensive set of 
+measures to understand the impact of yoga in cancer. In 
+addition to apoptosis, the role of the complex components 
+of the immune system such as cytokines and their 
+respective transcription factors such as nuclear factor-
+kB (NF-kb)[27] in disease and health are recognized. We 
+propose future studies using a comprehensive battery of 
+these cellular and immune measures. A four-armed study 
+to compare the immune variables and NF-kB in age- and 
+sex-matched patients of breast cancer with and without 
+yoga, and normal volunteers with and without yoga, is 
+presently underway.
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+How to cite this article: Ram A, Banerjee B, Hosakote VS, Rao RM, 
+ 
+Nagarathna R. Comparison of lymphocyte apoptotic index and 
+qualitative DNA damage in yoga practitioners and breast cancer 
+patients: A pilot study. Int J Yoga 2013;6:20-5.
+Source of Support: Nil, Conflict of Interest: None declared
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+ORIGINAL ARTICLE
+Year : 2020  |  Volume : 52  |  Issue : 1  |  Page : 25-28
+Concept of mind in Indian philosophy, Western philosophy, and psychology
+Durga Tanisandra Krishnappa, Melukote Krishnamurthy Sridhar, HR Nagendra
+Division of Yoga and Humanities, SVYASA Yoga University (Deemed to be), Bengaluru, Karnataka, India
+Date of Submission
+23-Dec-2019
+Date of Acceptance
+25-Feb-2020
+Date of Web Publication
+11-Jun-2020
+ 
+ 
+ 
+ 
+Correspondence Address:
+Durga Tanisandra Krishnappa
+SVYASA Yoga University (Deemed to be), 19, Eknath Bhavan, Gavipuram Circle, Kempegowda Nagar, Bengaluru - 560
+019, Karnataka 
+India
+DOI: 10.4103/ym.ym_24_19
+  Abstract
+ 
+This article makes an explorative journey into the concepts of mind as explained in the Indian philosophical traditions
+and Western psychology. The article explains about knowledge domains in the traditions and their distinctive features,
+different connotations and denotations of mind, and the different methods being used in explaining mind. Yet, they may
+not appear to be opposed or conflicting in nature. The article elaborates on the concepts such as mind (manas) and mind
+apparatus (citta) in Indian philosophical traditions and compares with the traditional Western psychology where the
+primary emphasis is given to the mind. The article indicates that in the Indian philosophical tradition, mind helps in
+knowing consciousness, whereas in the Western paradigm, mind becomes the subject as well as the object of knowing.
+Knowing gives an understanding of the truth and could lead to realization. In the Eastern tradition, knowing becomes a
+being and becoming. This knowledge of the self (ātman) helps the individual in attaining happiness (sukha) and welfare
+(abhyudaya) in this world and realization of the supreme reality (Brahman) leading to liberation (mokṣa). Thus, knowing
+and understanding about consciousness become complementary in both the traditions.
+Keywords: Ātman, Brahman, consciousness, hemispheres of the brain, ignorance, knowledge, mind, self, sleep,
+subconscious, superego
+ 
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+How to cite this article:
+Krishnappa DT, Sridhar MK, Nagendra H R. Concept of mind in Indian philosophy, Western philosophy, and
+psychology. Yoga Mimamsa 2020;52:25-8
+How to cite this URL:
+Krishnappa DT, Sridhar MK, Nagendra H R. Concept of mind in Indian philosophy, Western philosophy, and
+psychology. Yoga Mimamsa [serial online] 2020 [cited 2021 Jan 23];52:25-8. Available from: https://www.ym-
+kdham.in/text.asp?2020/52/1/25/286551
+  Mind in Indian Philosophy
+ 
+According to Nyāya Vaiśeṣika philosophy, there are seven kinds of ultimate realities (padārtha). They are substance
+(dravya), quality (guṇa), action or motion (karma), genus or universality (sāmānya), species or specialty (viśeṣa),
+inherence (samavāya), and negation (abhāva). The substances are nine in number. They are earth, air, water, fire, and
+ether, which are objective elements (as we can perceive them by our senses), and time, space, mind (manas), and self
+(ātman) – (Virupakshananda, 2015) Tatra dravyā ṇi pṛthivyaptejovāyvākāśakāladigātmamānāmsi navaiva I Tarka
+Saṃgraha, Ta. Sa, 3.
+The mind becomes the instrument of experience such as happiness (sukha) and unhappiness (dukkha) –
+Sukhadyupalabdhisādhanamindriyam manaha I Tacca pratyātmaniyatatvādanantam paramāṇurūpam nityam ca I, T. S.
+9.). It is also an object of experience like other senses. The self is the basis and substratum of consciousness and
+experience, but in reality, unconsciousness in nature (Prabhavananda, 1977). The self becomes consciousness when it is
+associated with the mind. Birth means the association of the self with body and death means the dissociation of self from
+body. The self is eternal (Jñānādhikara ṇamātmā I T.S. 8). The existence of self is proved by the theory of causation
+(Kārya-kāraṇavāda). The God (Īśvara) becomes the efficient cause of the world.
+Sāṃkhya philosophy consists of two ultimate realities. They are self (puruṣa) and primordial nature (prakṛti). Prakṛti
+consists of three attributes (guṇa-s), namely sattva, rajas, and tamas, which are in a state of equilibrium or
+nonequilibrium. This activity of guṇa-s results in evolution. The first product of evolution is cosmic intelligence
+(buddhi). Ego is also an evolute of primordial nature (prakṛti), and it manifests based on the predominance of three guṇa-
+s.
+In Sāṃkhya philosophy, the mind evolves as a sattva aspect of attributes or guṇa-s. It evolves with the five organs of
+perception (hearing, touch, sight, taste, and smell) and five organs of motion (hands, feet, speech, excretory organ, and
+generative organ). The subtle (rasa tanmātra) or atomic parts of the sense perception evolve with the tamas aspect of
+three attributes. The combination of these with the help of rajas becomes anaspect of mind itself. The mind also carries
+out the order of will (icchā) and become an instrument in the actions of an individual. According to Vijnanabhikshu, a
+commentator of Sāṃkhya Pravachana Sutra, intelligence (buddhi) is the storehouse of all subconsciousness impressions
+(Prabhavananda, 1977). The buddhi consists of all the three guṇa-s and acts upon the individual.
+Yoga deals with the control of thought waves of the mind (yogaḥ cittavṛtti nirodhaḥ IPatanjali Yoga Sūtra [PYS] I.2).
+According to Swami Vivekananda, the mind apparatus (citta) is a combination of three components namely manas,
+buddhi, and ahaṃkāra and sensory organs (indriya-s, Vivekananda, 1976, p. 116). Manas is an aspect of citta which
+receives all the impressions from the outside world. Buddhi is the determinative faculty which distinguishes between
+good and bad and righteous and unrighteous aspects of things and thoughts. Ahaṃkāra is the egoistic aspect of mind and
+personality, which owns the impressions. Even according to yoga, mind is unconscious, and it only reflects the
+consciousness of the self or puruṣa. Thus, the knowledge received as a result of our experience with the outside world is
+only an objective experience and the self is not associated with it at all. The experiences with the outside world are the
+result of objects. Senses contact the external world through perception, mind, ego, and buddhi. Hence, a person suffers
+from joy (sukha), sorrow (dukkha), and delusion (moha) as a result of the creation of thought waves in the mind.
+However, amidst these experiences, the puruṣa remains untouched, pure, enlightened, and free (Kleśakarmavipa kaśair
+aparāmṛṣtaḥ puruṣa viśeṣaĪśwaraḥ I PYS. I.24.). The dormant state of mind is called the samskāra-s (mental
+impressions), which changes the personality of an individual. The samskāra-s gives rise to the thought waves. They are
+like a negative film roll in a camera. They are expressed in one's life based on the actions (karma) of past and present life,
+upbringing, environment, and education. Hence, bad samskāra-s have to be destroyed by the discipline of body and mind
+(samatvam yoga ucchate IBhagavad Gītā, II 48). Swami Vivekananda, based on an ancient Sanskrit verse, says that mind
+is like a maddened monkey, and it should be controlled by practice every day over a period of time “until at last the mind
+will be under perfect control” (Vivekananda, p. 174-5, 1950). This continuous practice leads to concentration (Dhāraṇā)
+defined by Patanjali as holding the mind on to the same object (Deśabandhascittasya Dhāraṇā-PYS, III.1). The practice
+must be undertaken under the strict instruction or supervision of a teacher. Bhoja, the commentator, has discovered five
+types of minds which have an aptitude for yoga. They are scattered mind (kśipta), dull mind (mudhā), average mind
+(vikśipta), one-pointed mind (ekāgra), and concentrated mind (niruddha). People who are having the first three types are
+not suited for higher practices of yoga. Sattva nature of mind predominates in the fourth type and the last type has pure
+and serene nature, in which puruṣa gets absorbed. Then, illumination arises in the mind (Tajjayāt prajñalokaḥ I PYS
+III.5).
+The ignorance of one's own existence brings misery as a result of egoism and prevents a person from experiencing a
+glimpse of consciousness (Avidyāsmitārā gadveṣabhiniveśāha kleśah IPYS II 3.) Mind is only an instrument of
+perception and experience, and it reflects consciousness, whereas puruṣa is the sufferer or enjoys as a result of thought
+waves (Prabhavananda, 1977). The Mīmāmsā philosophy considers self as distinct from the body, senses, and mind.
+Intelligence, will (icchā), and effort (prayatna) are the natural attributes of the self.
+According to the Upaniṣhads, mind cannot be treated as consciousness, as the consciousness or self exists even without
+the mind as explained in an enchanting dialogue between Indra and Prajapati (Chāndogya Up. X.2, XI.1.). Indra guided
+by Prajapati understood that the physical body (deha), senses (indriya), mind (manas), sleep (nidrā), dream (svapnam),
+and dreamless sleep (suṣupti) were not the highest truth, but self (ātmā) was the highest truth, which is distinct from the
+[TAG2]
+[TAG3]
+[TAG4]
+above and whosoever knows the self, meditated upon it, realizes it and will be free from all pains, pleasures, and cycles
+of birth and death (Chāndogya Up. XII.1). Kaṭa Upaniṣhad tells that mind is above the senses, and through the help of
+mind, intellect, and ego, one understands the true self (Kaṭa Up. II. iii. 7-8 Indriyebhyaha parammano manasaḥ
+satvamuttamam I Satvadādhi mahānātmā mahatovyaktamuttamam II Avyaktatastu parah puruṣo vyāpakolinga eva ca I
+Yam jñātvā muccyate janturamṛutatvam ca gachhati II) (Aurobindo, 1953). Whereas in Taittirīya Upaniṣhad -
+(Sarvananda, 1973), mind is treated as the third sheath above food or physical self (annamaya) and psychic breath
+(prāṇamaya). This mental sheath called manomaya koṣa is responsible for all the activities within the body and
+connection with the external world (Anyontara ātmā manomayaḥ I Tenaiṣa pūrṇaḥ I Tai. Up. II. 3.). In the Māndūkya
+Upaniṣhad (5), the mind gets connected with the external world through sensory organs in the waking state (jāgrat), acts
+independently of the sensory organs in the dream state (svapnam), and gets merged in deep sleep state (suṣupti) and
+fourth called turīyā (suṣuptasthāna ek ībhūta prajñānaghana evānadamayo hyānandabhuk cetomukḥ prajñāstṛtīyaḥ
+padaḥ I). According to Shankaracharya, mind, matter, all finite objects of the world, and their inter-relations are a
+misreading of Brahman and nothing more (Prabhavananda, 1977). For Ramanujacharya, free will plays an important role
+in attaining devotion (bhakti) to the supreme lord. Control of passions and internal and external purity of mind enhance
+the free will.
+  The Mind in Western Philosophy
+ 
+James L. Christian, a contemporary American philosopher, raises an important assumption about the Western dilemma
+and the Judo-Christian assumption spanning two millennia with respect to matter, mind, and God. To quote, “What has
+received by the infinite mind cannot be comprehended by finite minds; the mysteries of faith will remain beyond our
+grasp for we see through a glass darkly our purpose in life should not be to analyze the infinite or synthesize life's
+engagements. Rather our goal should be to get into right relationship with God. To do his will through faith and to look
+forward to an eternity which will transcend this mortal existence” (Lee, 1990).
+The Western philosophers from Socrates to Hume faced this dilemma, the problem of matter, mind, and God, and came
+out with their own philosophical explanations. For Rene Descartes, mind and body were separate substances just as
+thought and extension were separate entities, whereas soul in his view was present in the pineal gland of the brain which
+comes into contact with the vital spirits and through which it interacts with the body (Stumpf, 1975), whereas Hobbes
+reduced mind to bodies in motion and achieved the unity of human. Descartes in his famous dictum “Cogito Ergo Sum”(I
+think therefore I am) included sensory perceptions such as feeling. He failed to solve the problem of mind–body
+interaction or unity.
+Whereas for Spinoza, human becomes an innate version of God. He is a mode of God's attributes of thought and
+extension (Stumpf, 1975). For A.N. Whitehead, body and mind became societies or nexus which are sets of actual
+entities. The aggregates of actual entities which were uncreated where patterns and qualities such as shapes and colors of
+qualities or objects (roundness, greenness, courage, etc.) were present. The timeless actual entity was called God by A.N.
+Whitehead. According to him, God is the poet of the world with tender patience leading it by his vision of truth, beauty,
+and goodness (Stumpf, 1975).
+Plato came with the theory of ideas or forms or patterns after which things were made. According to this theory, matter is
+constantly changing and it is only an appearance he assumed that things were ordered by mind and this cosmos became
+the actuality of the world soul in receptacle. The receptacle was a matrix which had to do structure but was capable of
+receiving the structure by a craftsman or demiurge. The world soul was eternal just like the soul in the body of a man
+(Stumpf, 1975). According to Immanuel Kant, mind brings something to the objects it experiences regularly. He
+visualized mind as a very active agent doing something with the objects it experiences. For Kant, thinking involved not
+only receiving impressions through our senses but also making judgments about what we experienced (Stumpf, 1975).
+Sigmund Freud believed that human personality is exhibited through the interaction of three dynamic systems, namely,
+the Id, the Ego, and the Superego. Id was the whole complex of our physical and psychic needs. Driven by emotion, it
+operates on the pleasure principle. Seeking pleasure and avoiding pain. The Superego is our system of moral values
+acquired through interaction with the world. The Ego is a psychic system that operates on the reality principle and
+mediates between Ego and Superego. He said that when Id is in command, individual would get a sense of wholeness,
+effectiveness, and well-being (Lee, 1990). Freud also discovered that there existed the unconsciousness mind apart from
+the conscious mind.
+  Feelings and Emotions in the Field of Psychology
+ 
+The term “emotion” is derived from a Latin word emovere, which means to stir up, agitate, or excite. The emotions
+finally depend on activities of the mind. Their awareness of the significance of situations involves internal and external
+changes. The emotional experience has three dimensions. They are tension–relaxation, pleasantness–unpleasantness, and
+attention–rejection. Pleasantness involves joy, pride, contentment, love, peace, etc., whereas unpleasantness involves fear,
+grief, shame, remorse, guilt, etc.; further, a powerful emotion causes concentration on certain stimuli excluding other
+stimuli. Such persons only concentrate on the positive attributes of a person. Sometimes, this strong emotion enables an
+organism to utilize its maximum strength for achieving a goal. Anger is an emotionally unpleasant accompaniment of
+motivation in many cases. Any motivated behavior that is interrupted may bring about anger. The primary occasion for
+anger is the thwarting of goal-seeking activity. Hence, anger may be the by-product of any interrupted or motivated
+sequences no matter what the motivational content of that sequence may be. J. B. Watson who did a lot of experiments on
+children for scores of years concludes that there were three clear-cut identifications of emotions present at birth which are
+fear, rage, and love and these are inborn, belonging to the original, fundamental nature of human beings.
+  The Role of Brain in the Play of Emotions
+ 
+Now, it is known through neurological experiments that hypothalamus in the brain is the center of emotions and
+emotional activity. Neurologists have observed that any injury to the hypothalamus results in loss of memory. Further, the
+analysis of the umpteen cases of the electroencephalograph recordings shows that tension, apprehension, anxiety, and
+unexpected stimulation by intense stimuli, all tends to disturb the cortical rhythms, and the entire brain plays a role in the
+underplay of emotions.
+  Conclusion
+ 
+In the Indian philosophy, both mind (manas) and matter (dravya) are placed in the same category as they become the
+objects of knowledge. However, in the Western philosophy, both are based on a clear distinction between mind and
+matter. In the Indian philosophical tradition, mind helps in knowing consciousness, whereas in the Western paradigm,
+mind becomes the subject as well as the object of knowing. Knowing gives an understanding of the truth and could lead
+to realization. In the Indian philosophy, knowing becomes a being and becoming. This knowledge of the self (ātman)
+helps the individual in attaining happiness (sukha) and welfare (abhyudaya) in this world and realization of the supreme
+reality (Brahman) leading to liberation (moksha). Thus, knowing and understanding about consciousness become
+complementary in both Indian and Western philosophical and psychological systems.
+Financial support and sponsorship
+Nil.
+Conflicts of interest
+There are no conflicts of interest.[8]
+ 
+  References
+ 
+1.
+Aurobindo, S. (1953). Eight Upanishads, Sri Aurobindo Ashram, Pondicherry.  
+    
+2.
+Lee, C. J. (1990). Philosophy, an introduction to the art of wondering. 5th ed. USA: Holt Rinehart and Winston.
+ISBN 0-03-0300414-8. p. 25.  
+    
+3.
+Prabhavananda, S. (1977). The spiritual heritage of India. India: Sri Ramakrishna Math, Madras. p. 203-205, 17-
+220, 244.  
+    
+4.
+Sarvananda, S. (1973). Taittiriyopanisad. Sri Ramakrishna Math, Madras.  
+    
+5.
+Stumpf, S. E. (1975). Socrates to Sartre, A history of philosophy. USA: McGraw Hill Company. ISBN 0-7062326-
+0. p. 79-82, 255-261, 392-394.  
+    
+6.
+Virupakshananda, S. (2015). Tarka Samgraha. Madras: Sri Ramakrishna Math, Mylapore. Eighth Print November,
+ISBN 81-7120-674-3.  
+    
+7.
+Vivekananda, S. (1932, 1947, 1948, 1950, 1955). The complete works of Swami Vivekananda. Vol. 1-8. Mayavati:
+Advaita Ashrama.  
+    
+8.
+Vivekananda, S. (1976). (Sixteenth Impression), Raja -Yoga or Conquering the internal nature. 10M3C. Calcutta:
+Advaita Ashram.  
+    
+ 
+ 
+ 
+ 
+ 
+  
+Sitemap | What's New | Feedback | Disclaimer
+© Yoga Mimamsa | Published by Wolters Kluwer - Medknow
+Online since 30th July, 2014
+ 

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subfolder_0/Decoding the integrated approach to yoga therapy Qualitative evidence based conceptual framework.txt

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+International Journal of Yoga • Vol. 7 • Jan-Jun-2014
+22
+Decoding the integrated approach to yoga therapy: Qualitative 
+evidence based conceptual framework
+Maria Del Carmen Villacres, Aarti Jagannathan, Nagarathna R, Jayashree Ramakrsihna1
+Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samasthana, 1Department of Mental Health Education, 
+NIMHANS, Bangalore, India
+Address for correspondence: Dr. Aarti Jagannathan, 
+Swami Vivekananda Yoga Anusandhana Samasthana, 
+ 
+19, Gavipuuram, KG Nagar ‑ 560 019, Bangalore, India. 
+E‑mail: [email protected]
+Original Article
+for imbalances at gross levels (Pranamaya and Annamaya 
+Kosas). IAYT slows down the loop of uncontrolled speed of 
+thoughts (stress) through several techniques that use the 
+principle of “successive stimulations followed by progressive 
+relaxation and the rest” to correct the imbalances, promote 
+“mastery over the mind” and harmonize the disturbances at 
+each of the five levels (Pancha Kosa).[1,2]
+Based on the above Pancha Kosa concept, the IAYT model 
+incorporates varied yogic practices at each level to help 
+patients with different disorders deal with their problems.[3] 
+The Annamaya Kosa practices include: (1) Asana: A stable 
+and comfortable posture, which gives deep relaxation to 
+internal organs by massaging them thoroughly; all organs 
+of the body start functioning in a harmonious manner and 
+the mind becomes tranquil (2) Diet: Simple vegetarian 
+wholesome food that calms down the mind (Sattvic diet) is 
+recommended as it helps to maintain internal harmony in 
+the body as well as mind (3) Loosening exercises: Reduces 
+joint stiffness, strengthens the muscles of the body and 
+increases physical stamina.
+INTRODUCTION
+The integrated approach to yoga therapy (IAYT) model 
+developed by Swami Vivekananda Yoga Anusandhana 
+Samasthana (S‑VYASA)[1] is based on the principle that “the 
+root of all psychosocial illnesses is in the mind; which causes 
+an internal imbalance due to long standing stressful and 
+demanding situations of life.”[1] Intense surges of uncontrolled 
+excessive speed of responses to these demanding situations at 
+an emotional level (Manomaya Kosa), conflicts between value 
+systems (Vijnanamaya Kosha), and strong likes and dislikes 
+at the psychological level (Manomaya Kosa) are responsible 
+Access this article online
+Website: 
+www.ijoy.org.in
+Quick Response Code
+DOI: 
+10.4103/0973-6131.123475
+Aim: The aim of this study was to define, decode, and append to the conceptual frame‑work of the integrated approach to 
+yoga therapy (IAYT).
+Materials and Methods: Four stakeholders who followed two in‑patients with depression over a period of 2 weeks in the 
+residential center “Arogyadhama” (of Swami Vivekananda Yoga Anusandana Samsthana, Bangalore, India) were interviewed 
+before the start of the IAYT treatment and prior to discharge of the patient. The patients were also interviewed pre and post and 
+were observed once during their session. The data from the audio recordings from eight in‑depth interviews were transcribed 
+manually and qualitative analysis was conducted.
+Results: The conceptual frame‑work of IAYT depicts that patient related factors (“co‑operation of patient,” “patients awareness 
+of his/her condition”), therapist related factors (“ability to guide,” the “assistance to the patients,” “explanation of the exercises”) 
+and treatment related factors (“combination of psychiatric or Ayurvedic medication with yoga,” “counseling during the IAYT 
+treatment,” duration of treatment), play an integrated role in reaching the “aim of IAYT” and experiencing “improvements and 
+changes.”
+Conclusion: The IAYT is a holistic program and the ability of the patient to cooperate with and integrate the available 
+factors (therapist related and treatment related) could enable best results.
+Key words: Conceptual; evidence‑based; integrated approach to yoga therapy; qualitative.
+ABSTRACT
+Villacres, et al.: Integrated approach to yoga therapy
+23
+International Journal of Yoga • Vol. 7 • Jan-Jun-2014
+The Pranayama Kosa practices include:  (1) Breathing 
+exercises and cleansing breath: Increases awareness about 
+breathing, clears the lungs, corrects breathing pattern, 
+and increases lung capacity; (2) Pranayama: Slows down 
+breathing rate and restores autonomic balance thereby 
+calming the mind. The Manomaya Kosa practices 
+include: (1) Cyclic meditation: Practices with repeated 
+stimulations and relaxations; (2) Om meditation and mind 
+sound resonance technique (MSRT) for creating awareness 
+and slowing down the mind and (3) Devotional sessions: 
+For emotional culture through “Bhakti Yoga” and The 
+Vijnanamaya Kosa Practices include: (1) Lectures and yogic 
+counseling using yogic concepts of fearlessness for stress 
+management. All the above practices are incorporated 
+with the aim to help a person achieve the final state of 
+self��knowledge, the Anandamaya Kosa (Bliss), a state of 
+blissful silence with awareness, perfect poise and freedom 
+of choice where the mind is not troubled by stressful 
+thoughts and fears.[3]
+Thus, the IAYT can be understood as a holistic model, 
+which corrects the imbalances at physical, mental and 
+emotional levels. All components of the IAYT are mutually 
+exclusive of each other in theory; for the IAYT model to 
+have its desired effect, all the components need to be 
+integrated and provided to have a desired effect on each 
+of the five levels of existence. No component singularly 
+can claim to be the IAYT, nor could possibly have the same 
+effects as the whole model. IAYT has been shown to have 
+complimentary benefits in the treatment of mind body 
+diseases such as bronchial asthma,[4] mental deficiency,[5] 
+arthritis,[6] cancer,[7] and stress during pregnancy.[8]
+To further understand the practical application of 
+the IAYT model, to explore the dynamics and to add to 
+the conceptual frame‑work, the authors of this paper used 
+the qualitative methodology and followed‑up two patients 
+with depression and their treating team who used the IAYT 
+model at S‑VYASA.
+MATERIALS AND METHODS
+This paper is part of a larger study conducted at the 
+S‑VYASA to understand the dynamics of the IAYT for 
+patients with depression. The study was cleared by the 
+Institute Ethics Committee at S‑VYASA, Bangalore.
+Sample
+For this paper, two in‑patients with depression were 
+followed over a period of 2 weeks in the residential center 
+“
+Arogyadhama” (of S‑VYASA Bangalore, India). Though 
+the center admits subjects willing to undergo IAYT for 
+ 
+9 different ailments, the IAYT schedule is the same for all 
+patients‑with modifications only in the Asana practice 
+according to the diagnosed ailment. Hence for the purpose 
+of homogeneity of the sample, patients and their treating 
+team from only one department (Psychiatry) were chosen.
+The two patients were under the supervision of a treating 
+team of 4 members (a professional consultant psychiatrist (P), 
+a psychologist  (PC), a yoga therapist experienced in 
+handling depression cases Yoga therapist (YT) and a senior 
+consultant in Ayurveda Physician (AP). All treating team 
+members and patients gave their consent to participate in 
+the study. The treating team was interviewed whenever 
+a patient got admitted and at the time of their discharge. 
+The patients were observed during one of their sessions 
+in the 2 weeks period of stay and were interviewed before 
+the start and at the end of their IAYT treatment period. The 
+socio demographic data of the patients and treating team 
+of the study was compiled [Table 1].
+In‑depth interview
+The study used the in‑depth interview method of data 
+collection, wherein each interview took between 45 min 
+and 1 h. The primary author (also the primary researcher) 
+interviewed the patients and treating team about their 
+knowledge about yoga, the reasons for opting for this 
+method of treatment and their expectations, efficacy and 
+experiences of the IAYT sessions. This interview was 
+conducted with the help of an interview guide which was 
+developed based on the objectives of the study, literature 
+review and discussion with experts (co‑investigators of 
+this study). It followed a semi‑structured format, using 
+open‑ended questions in a face‑to‑face conversational 
+style. Answers to open questions originated new questions; 
+hence, questions were generated until data saturation 
+was reached. The data saturation point is that stage in 
+the interview when the questions asked stop eliciting any 
+additional information.
+The interview guide’s questions were modified for each 
+new session according to the information given in the 
+previous meeting and also based on prominent answers. 
+The interview guide was flexible facilitating the researcher 
+to modify the questions according to the interviewed 
+previous answers; some direction was given when the 
+Table  1: Sociodemographic sheet of the treating team 
+and participants
+Treating team  (n=4)
+Participants  (n=2)
+Variable
+N  (%)/
+mean  (SD)#
+Variable
+N  (%)/
+mean (SD)#
+Age (years)#
+33 (11.51)
+Age (years)#
+42 (11.31)
+Gender
+Gender
+Male
+2 (50)
+Male
+1 (50)
+Female
+2 (50)
+Female
+1 (50)
+Education (years)#
+18 (2)
+Education (years)#
+16 (1.41)
+Experience of yoga
+Experience of yoga
+Yes
+1 (25)
+Yes
+2 (100)
+SD = Standard deviation
+Villacres, et al.: Integrated approach to yoga therapy
+International Journal of Yoga • Vol. 7 • Jan-Jun-2014
+24
+focus of the interview was lost, and probes were used 
+when necessary. Questions opened up discussions on the 
+personal definition of depression and yoga, experience 
+with yoga, personal information and history of the 
+interviewed person in general. In the interviews, patients 
+were asked on possible knowledge and insight on their 
+symptoms of depression, also on the reasons why they 
+chose yoga as a treatment and on their expectations for 
+the treatment. The biological and cognitive model of 
+depression was considered as the theoretical framework 
+for development of the interview guide.
+Intermediate observation
+An intermediate observations checklist was developed 
+by the researcher based on literature review, previous 
+observations made during yoga practical sessions, from 
+personal experience and with the support of experts. 
+These observations aimed to explore the performance, 
+understanding and adherence of the patient to the yoga 
+treatment. Observations were made during a general 
+pranayama class and during a special technique 
+session [Table 2] in the section for mental disorders.
+The researcher interviewed each of the four members 
+of the treating team and two patients immediately after 
+they started the IAYT treatment for each of the patients. 
+Details of the IAYT treatment practiced are given in Table 2. 
+Intermediate observations on the patient’s performance 
+and adjustment to the practices was made after 1 week 
+of admission to the center; post‑in‑depth interview with 
+treating team and patients was conducted after completing 
+2  weeks of their residential program. The interviews 
+were audio recorded and followed the interview guide. 
+Saturation of data was reached only with some of the 
+stakeholders (PC and YT) and patients in specific themes 
+after case 2. However, due to the completion of the project 
+timeline, the sample size was frozen at two patients and 
+four stakeholders for this study.
+Data analysis
+The data from the audio recordings from eight in‑depth 
+interviews were transcribed manually. The transcripts were 
+reviewed several times and the information was organized, 
+classified and interpreted qualitatively. The selection of 
+the important themes was based on: (1) repetition of the 
+themes (as they were considered important by the treating 
+team), and (2) new themes, which could add light on the 
+experience and concept of IAYT model for depression.
+The information from the intermediate observations 
+that referred to the performance and/or adherence 
+of practices  –  of the patient, and guidance of the 
+practices – from the yoga instructor‑was also transcribed, 
+organized and clubbed in  (1) Observations made on 
+Table  2: IAYT practices program schedule
+Time
+Program
+Description
+05:00
+Om meditation
+Om (AUM) chanting is considered to 
+be the call to God; visualization and 
+internalization of this mantra is made 
+during the meditation.
+05:30
+Special technique 
+for depression
+Combinations and instruction in dynamic 
+yoga with
+Breathing exercises
+Sithilikarana Vyayama (Loosening Exercises)
+Asanas
+Relaxation techniques
+Instant relaxation technique: Body 
+tightening, relaxation
+Quick relaxation technique: Body and 
+breath observation with A‑kara chanting
+Deep relaxation technique: Body 
+observation with A‑U‑M‑kara chanting 
+and visualization
+06:30
+Kriyas (once a 
+week outdoors)
+Desensitizing and purification  
+techniques
+Vamana/Vastra/Danda Dhouti
+Uddiyana/Agnisara, Nauli
+Laghu Sankha Prakasalana
+Viparita karani kriya with asvinimudra 
+(in session only)
+Jala Neti
+Sutra Neti
+Kapalabhati
+Trataka
+07:00
+Maitri Milan
+Gita chanting and main lecture of 
+the day in yogic principles from the 
+Bhagavad‑Gita and other sacred 
+scriptures
+08:00
+Breakfast
+Sattvic principles in the preparation 
+of food, to gain vitality, strength and 
+stamina, health and cheerfulness
+11:00
+Parameters
+Vital signs measurement: BP
+, Pulse Rate, 
+Bhramari chanting, attendance to sessions, 
+weight, FAQ’s. To section in‑charge
+12:00
+Pranayama
+Vubhagiya Pranayama (Sectional 
+breathing with mudras)
+Nadi suddhi
+Cooling breathing: Sitali, Sitkari, Sadanta
+Bhramari
+13:15
+Lunch
+Sattvic food
+14:00
+Lecture
+Talks on yogic philosophy, and positive 
+inputs for lifestyle
+15:00
+Advanced technique
+Mind Sound Resonance Technique: 
+Mind control and relaxation with 
+visualization and A‑U‑M‑kara chanting
+Cyclic meditation: Awareness on body 
+movement combined with Asanas and 
+relaxation techniques
+Pranic Energizing Technique: Prana and 
+body awareness with visualization and 
+relaxation
+16:00
+Special technique
+Same as 05:30
+17:00
+Malt
+Break for snack, walking or resting
+18:30
+Bhajans
+Bhakti Yoga to develop acceptance 
+and humbleness. Bhajans or emotional 
+culture through sacred chanting in 
+devotional sessions
+20:00
+Dinner
+Sattvic food
+21:00
+Happy Assembly 
+(once every 15 days)
+Personal development with public 
+performance and games
+BP = Blood pressure; IAYT = Integrated approach to yoga therapy
+Villacres, et al.: Integrated approach to yoga therapy
+25
+International Journal of Yoga • Vol. 7 • Jan-Jun-2014
+patients and (2) observations made about the instructor 
+student (the yoga class teacher, not part of the interviewed 
+treating team).
+RESULTS
+A detailed description of the each of the cases (patients) 
+and their problems has been deliberately masked in 
+this paper in keeping with the ethical guidelines of 
+confidentiality (during publication). Further the aim of this 
+paper was to put forth a conceptual framework of IAYT, 
+and not to report a case study.
+A number of themes emerged from the in‑depth 
+interviews with the stakeholders and patients. These 
+themes emerged at five data points: (1) Pre‑yoga session 
+in‑depth interview with stakeholders,  (2) post‑yoga 
+session in‑depth interview with stakeholders, (3) pre‑yoga 
+session in‑depth interview with patients, (4) post‑yoga 
+session in‑depth interview with patients and, (5) during 
+intermediate observation.
+Pre‑yoga session in‑depth interview with stakeholders
+The themes that emerged during the pre‑in depth interview 
+with stakeholders were: (1) Aim of IAYT, (2) conditions that 
+accelerate the effect of IAYT, (3) combination of psychiatric 
+or Ayurvedic medication with yoga, and (4) importance of 
+counseling during the IAYT treatment. In the following 
+paragraphs, the above mentioned themes are substantiated 
+with quotes of the patients/treating team.
+Aim of integrated approach to yoga therapy
+The aim of IAYT was to “help the patients” reach each 
+of their “layers of existence” (Panch Kosas), through the 
+therapy process. The unique feature of the IAYT was 
+the need to integrate the principles of yoga therapy in 
+the counseling sessions during the treatment process, 
+to enable patients to understand the process and 
+goal of the IAYT. The counseling is offered by the 
+PC (psychoeducation, supportive therapy) and YT (yogic 
+counseling).
+“We don’t train a subject only physically or …mentally; (we 
+train them in an integrated way): Physically, mentally, 
+intellectually, and spiritually…To move from the basic level 
+step by step to the ultimate state of ananda, the blissful 
+stage… will bring changes in them; and to enhance the 
+anandamaya kosa level we are making them play…yogic 
+games, happy assemble, to bring out the ananda within 
+them (The Pancha Kosas) these are the basic things we 
+explain (through counseling session) to them and when they 
+understand, they can start functioning better…”
+– Stakeholder‑YT
+Conditions that accelerate the efficacy of the integrated 
+approach to yoga therapy
+The duration of treatment, cooperation of the patient 
+and the patient’s awareness of his/her own situation are 
+considered important aspects in accelerating the effect of 
+IAYT. The treating team believed that patients required a 
+minimum of 15 day’s in‑patient stay to experience changes 
+in their symptoms and attitudes.
+•	 Duration of treatment
+	
+
+“In the IAYT it is not like they are taking a pill…The body 
+and mind… we are bringing them into harmony. It takes 
+time to learn things…We need at least 2 weeks to see the 
+changes.”
+– (Stakeholder‑YT)
+	
+
+“I have seen when they stay here for a longer time, I have 
+seen a lot of improvements in their clinical symptoms…”
+– (Stakeholder‑AP)
+•	 Cooperation of the patient
+	
+
+“We need the cooperation from their side… If they are 
+ready to open up … (it is easy to train them)… (Even in) 
+very difficult cases…we train them through counseling 
+sessions and maitri milan.”
+– (Stakeholder‑YT)
+•	 Patient’s awareness of his/her own condition
+	
+
+“(The depressed persons) they may not know that they 
+are depressed.”
+– (Stakeholder‑P)
+	
+
+“They’ll say that they are feeling better after 2 or 
+3 weeks because they practice yoga right away, (and 
+if) they have insight into their depression they will feel 
+even better…
+– (Stakeholder‑PC)
+Integrated approach to yoga therapy and add‑on treatments 
+like antidepressants and Ayurvedic methods
+Another special feature of the IAYT is that it provides room 
+for the amalgamation of the practice of physical and mental 
+yoga with western medical pharmaceutics (antidepressants) 
+or traditional Indian medicine (Ayurveda) in accordance 
+to the demands or needs of the patients.
+“(IAYT) is a holistic approach, so that definitely, put together, 
+will work for (the patients). The medication will help.”
+– (Stakeholder‑PC)
+“(Antidepressants and yoga therapy) they are in a parallel 
+level, they… complement each other to have a positive effect.”
+
+– (P)
+“Yoga plays a very important role…to relax the mind, 
+and Ayurveda takes care of the doshic imbalances, so this 
+combination is very good in managing any kind of mental 
+disorder.”
+– (Stakeholder‑AP)
+Villacres, et al.: Integrated approach to yoga therapy
+International Journal of Yoga • Vol. 7 • Jan-Jun-2014
+26
+Importance of counseling during the integrated approach to 
+yoga therapy treatment
+The counseling process is considered an integral part 
+of the IAYT. It is used by the PC to enable the patient 
+to gain insight of his/her condition and to motivate 
+him/her to continue with the treatment. Further, the YT 
+complemented the PC’s sessions by counseling the patients 
+on the psychology of yoga and its practices to reach higher 
+levels of existence (ananda).
+“We intend to guide the person to move from the basic 
+level (physical) step by step to the ultimate state of ananda (subtle 
+blissfulness). Therefore, we operate in the prana level, the mind 
+level, and the intellectual level…, and bring about the changes. 
+We will explain these basic concepts in yoga therapy and when 
+they understand, they start functioning better; for that also we 
+need to give the patients counseling sessions.”
+– (Stakeholder‑YT)
+Post‑yoga session in‑depth interview with stakeholders
+The main theme during the post‑yoga session in‑depth 
+interview with the stakeholders focused on the improvements 
+and changed observed by them in the patients as a result 
+of undergoing IAYT training for 2 weeks. The stakeholders 
+observed some improvement and changes in the symptoms, 
+attitudes and mood (enthusiasm, optimism, dynamism, 
+socialization, and calmness) of the patients.
+“I see lots of (changes)… they are more cheerful at the time 
+of discharge. Medicine helped her slightly, but the change is 
+mainly because (of) the yoga practiced, and the counseling”
+– (Stakeholder‑PC)
+Pre‑yoga session in‑depth interview with patients
+The themes that emerged from the pre in‑depth interviews 
+with the patients were: (1) Personal definition of yoga, 
+ 
+(2) previous experience with yoga, (3) reasons for yoga 
+being helpful for patient’s condition, and (4) expectations 
+from current treatment.
+Personal definition of yoga
+The patients had a clear idea on what yoga meant and 
+what it can do for them:
+“Yoga brings up inner energy… that is why I came here to 
+learn those things. I want to be myself; I want to come out 
+of my fear now.”
+– (Patient 1)
+“Yoga is a holistic approach, which makes the human being 
+physically fit, mentally stable, socially adjusted. Yoga makes 
+the man to enjoy the harmony in the things, so, makes the 
+man to live a happy life.”
+– (Patient 2)
+Previous experiences with yoga
+Both patients had some previous experiences with yoga. 
+Patient one had practiced Hatha yoga and continued her 
+practice at home for the next 2 years. She openly expressed 
+that the main benefits of yoga for her were feeling very 
+healthy and loss of weight. Patient two had practiced yoga 
+long ago. In spite of the short‑term of practice, he had a 
+positive experience.
+Reasons why yoga might be helpful for the patient’s condition
+Patients were optimistic that yoga would help them feel 
+energetic, happy and also help them concentrate and take 
+decisions better.
+“I feel that I will come out of this situation. I want to be 
+energetic and feel myself. So, I can practice again. So, I 
+want to be more constant again, I want to be happy. So, 
+when the energetic comes inside me, (then) I can practice 
+again, walking and all, (that way) I can keep myself busy 
+also.”
+– (Patient 1)
+“My concentration problem has to be regained, I need 
+decision making capacity; I want to be a good team player, 
+to make me at most time happy.”
+– (Patient 2)
+Expectations from the current yoga treatment
+Patients were aware and optimistic about the possible 
+positive effects of regular practice of yoga;
+“As I got well in 1998 (after yoga), same thing I want to 
+get back. I want to lose my weight; I want to come out of 
+depression and to be energetic.”
+– (Patient 1)
+“I want to come out full from this, health and that; so I am 
+going to go for an alternative thing. So, I want to get rid of 
+this thing.”
+– (Patient 2)
+Post‑yoga session in‑depth interview with patients
+The themes that emerged from the post‑in‑depth 
+interview with the patients were: (1) Experience of IAYT, 
+ 
+(2) improvements and changes and  (3) outcome of 
+ 
+IAYT.
+•	 IAYT Experience
+	
+
+Both patients expressed that they had a positive 
+experience from the IAYT treatment at the home center.
+“… very good actually, I came out of my depression and I 
+am feeling good.”
+
+–(Patient 1)
+Villacres, et al.: Integrated approach to yoga therapy
+27
+International Journal of Yoga • Vol. 7 • Jan-Jun-2014
+“Sometimes I would feel sleepy before entering the class, but 
+my mood was quite alright during the practices”; I would 
+feel fresh after the class.”
+
+– (Patient 2)
+•	 Experience with Asana practice
+Patients felt that Asanas helped to become physical fit 
+and relaxed.
+“Asanas … somehow I felt that this Asanas are also very 
+good. Physically I am feeling light, happy.”
+
+– (Patient 1)
+“I felt freshness and more relaxed.”
+
+– (Patient 2)
+Complications with the practice of Asanas according to 
+the patients were associated with their weight:
+“I couldn’t do (Asanas) because of my weight and my back 
+pain. But I just had 1 week there so I can’t explain because 
+1 week is too short period for me.”
+
+– (Patient 1)
+“Those programmers (referring to the practice of Asanas) 
+…which involve more of bending (I can’t do) because of 
+my tummy as well, it is difficult to bend. Some balancing 
+activities, standing, (that) means, bigger (effort) because of 
+my excessive weight…”
+
+– (Patient 2)
+•	 Experience with pranayama practice
+The benefits with Pranayamas were experienced by both 
+the patients.
+“(It) helped me a lot actually. I am feeling a little energetic and 
+I am keeping myself calm (while doing them).”
+
+– (Patient 1)
+“I went to four pranayama  (sessions). The instructor 
+was taking us slowly, steadily, so, after each and every 
+pranayama (inhalation/exhalation cycle). It had a soothing 
+effect.”
+
+– (Patient 2)
+•	 Experience with meditation practice
+The benefits of Om meditation [Table 2] were parallel to 
+those in pranayama for both patients:
+“Meditation helped me a lot more than these Asanas (in) 
+getting a lot of peace of mind… not getting any (disturbing) 
+thoughts.”
+
+(Patient 1)
+“I went only for 2 classes…; it helps me to get the 
+concentration power (I liked) “cyclic meditation” [Table 2]…
+initially it was theoretically explained, I learned the 
+concepts. And performing these each and every day…; I 
+felt relaxation; initially that is the effect only.”
+
+– (Patient 2)
+•	 Experience with relaxation practice
+For both the patients the benefits from the relaxation 
+techniques were related to sleep and capacity to rest:
+“MSRT [Table 2] with chanting A‑U‑M, those are very good 
+actually (they) are very relaxing; I slept so many times … 
+while doing …M‑kara, U‑kara and these things…”
+
+– (Patient 1)
+“I went to sleep (during the relaxation technique). It helped 
+me to sleep.” 
+
+– (Patient 2)
+•	 Experience with Kriyas sessions
+The benefits with the Kriyas for the patients were related 
+to cleansing of their breathe and bowel movements.
+“It was good actually! The first kriya I did very well …
+breathing better.”
+“The first Kriya is pouring the nose watering coming from 
+“this thing”. The second Kriya is using the catheter (I was 
+not) able to do the “catheter”. My stomach was clear, after 
+finishing the Kriyas.”
+•	 Experience with Bhajans sessions
+The patients felt benefited from the devotional chanting 
+hour. Though patient two came from a different cultural 
+background he was pleased to have had an experience in 
+which everyone was together for the same devotional aim:
+“I felt every time very happy, I was happy there.”
+“Whereas for bhajans I am having my own faith of God, 
+ok? So, the language of here what they use is Sanskrit my 
+mother tongue is Tamil, (if it were in) my own way, my faith, 
+language means it will be more useful (In general), this 
+experience means is (for me) social harmony (because) it 
+gives the opportunity to the people to get together and treat 
+the God without talking of other topic.”
+•	 Physical discomforts during the IAYT practices in general
+While patient one reported experiencing drowsiness 
+due to the medications, as a physical discomfort during 
+IAYT practice, Patient two reported inability in practicing 
+bending Asanas.
+“When you feel drowsier, go and sleep‑Just take rest; I was 
+told. So, 1 or 2 sessions I missed like that only and I slept 
+there after… I was happy. I got very good sleep at nighttime”
+
+– (Patient 1)
+“Bending forward exercises.”
+
+– (Patient 2)
+•	 Emotional discomforts during the IAYT practices in 
+general
+Initially, both patients did not want to stay at the home 
+center. However, after day 3, their attitude toward yoga 
+seemed to change and they started feeling positive toward 
+the whole treatment.
+Villacres, et al.: Integrated approach to yoga therapy
+International Journal of Yoga • Vol. 7 • Jan-Jun-2014
+28
+“(Happiness from practices would last) for some time, but 
+slowly after 3 days; the first 2 days I didn’t want to stay there, 
+I wanted to go back actually. However, from 3rd day when I 
+started making friends with others, and I started enjoying the 
+prayers and the pranayama, then I felt very happy. Then, I 
+slowly came out of my loneliness and my depression.”
+
+– (Patient 1)
+Improvements and changes
+•	 Physical changes noticed with the yoga practice
+“The Asanas for back ache helped me a lot; my back pain (is) 
+almost gone”
+
+– (Patient 1)
+•	 Emotional changes noticed with the yoga practice
+The patient expressed that the IAYT helped her to build up her 
+inner strength. She said it was not possible to explain exactly 
+the “good feeling” she had experienced from the practices:
+“I used to cry for all small things usually now I am not that 
+much (With the practice of the IAYT) I got inner strength 
+and the mental peace also (While been there), I felt happy, 
+energetic; now I am just happy. I cannot explain what is 
+that (she laughs).”
+
+– (Patient 1)
+Outcomes of integrated approach to yoga therapy
+•	 Fulfillment on health expectations with IAYT
+The outcomes of the practices for the condition of the 
+patient were effective. In spite of this, both agreed that 
+they would need more time to complete her goals.
+“I joined to come out of my loneliness and depression, and 
+to feel healthy also. But 1 week is not sufficient for me. My 
+experience is that I want to continue another 1 week or 
+10 days.”
+
+– (Patient 1)
+“It enhanced my health. I want to be happy in my mind, 
+my dullness should go out. Somehow it had helped me until 
+now I have not even completed 1 week. I can also relate 
+that it is a gradual steady process.”
+• General insights after the treatment
+Patient 1 expressed that time is an important factor to 
+reach a deeper insight level with the practice of the IAYT. 
+However, she concurred that her emotional attitude had 
+changed since she started again practicing yoga:
+“I told you 1 week is not sufficient for me. I think that I have 
+to come and join again, and I have to take more classes. 
+I am sure I may come and join again. The only thing is that, 
+mentally, I am not worrying nowadays. I am feeling much 
+better. However, 1 week is not sufficient for me. I think I 
+have to come and join again” 
+
+– (Patient 1)
+•	 Essential message assimilated during IAYT treatment
+The short time of her stay only let her realize that yoga is 
+beneficial for one’s health:
+“Essential message that I got there is that “practicing yoga 
+is very good”, that is all. Whatever the practicing methods, 
+whatever they have taught while we do the practices, it 
+really helps” 
+
+– (Patient 1)
+•	 Capacity on practicing alone in the future
+Patient 1 was did not feel capable about going on with 
+the practice alone, whereas Patient two was confident of 
+practicing yoga alone at home.
+“No… I need more instructions also. I need to come and 
+join again”
+
+– (Patient 1)
+“I want to practice in the evenings, nearly 1½ h; I think that 
+through the life I am going to practice”
+
+– (Patient 2)
+Themes emerged during intermediate observation
+The results of the intermediate observations of the patients 
+reiterated the importance of “discipline” and extended 
+duration of practice. Observing the student‑instructors 
+revealed that the “ability to guide,” the “assistance to 
+patients” and the “explanation of the exercises” were 
+3 important factors/themes in the enabling patients to 
+understand and internalize the IAYT.
+Ability to guide
+The instructor gave clear explanations of the practices 
+at the beginning of the session. He used clear and 
+correct English words and phrases. Correct tone of voice 
+ 
+and volume was also used. The instructor continuously 
+asked the participants if they had understood his 
+indications.
+Assistance to the patients
+The instructor took care of the participants in general by 
+changing their position in the hall, in case she saw that they 
+were not comfortable. She corrected the spine alignment of 
+the participant of the study. However, she did not correct 
+the alignment of the head and arms of participants during 
+relaxation time when they were lying on the floor.
+Explanation of exercises
+The instructor explained the meaning and benefits of 
+some practices and its timings. She also explained the 
+contraindications and gave alternative practices for the 
+exercises given at that moment. She gave proper guidance 
+for the relaxation techniques with visualizations. There 
+were no explanations of mantras.
+Villacres, et al.: Integrated approach to yoga therapy
+29
+International Journal of Yoga • Vol. 7 • Jan-Jun-2014
+DISCUSSION
+It can be noticed from the qualitative analysis that the 
+success (outcome) of IAYT as a holistic treatment depends 
+on a number of factors, which are inter‑twined and also 
+independently important in the implementation of the 
+IAYT. For example: The patient’s expectations from the 
+treatment are based on his/her understanding of yoga, 
+his/her previous experience with yoga and awareness of 
+his/her condition; this in turn affects his/her co‑operation 
+to the treatment. Patient’s co‑operation to IAYT is also 
+influenced by the therapist’s ability to guide, assist and 
+explain the IAYT practices. The data depicts that if the 
+therapist is able to motivate the patient to co‑operate with 
+IAYT process long enough with the help of counseling 
+and medication, desired aim and outcome of IAYT can 
+be achieved.
+The results of the qualitative analysis thus put forth the 
+conceptual framework of IAYT; which depicts that patient 
+related factors (expectation/co‑operation of patient, patients 
+awareness of his/her condition, understanding/previous 
+experience of yoga), therapist related factors (“ability to 
+guide,” the “assistance to the patients,” “explanation of 
+the exercises”) and treatment related factors (“combination 
+of psychiatric or Ayurvedic medication with yoga,” 
+“counseling during the IAYT treatment,” “duration of 
+treatment”), play an integrated role in reaching the 
+“aim of IAYT” and experiencing “improvements and 
+changes” [Figure 1].
+The authors believe that the strength of the IAYT is its 
+ability to integrate and advocate the importance of patient, 
+therapist, and treatment related factors in helping the 
+patient experience improvement in his/her condition. 
+This is a challenging task as each therapist (treating team 
+member coming from different professional backgrounds) 
+could have a different theoretical orientation, diagnosis and 
+intervention program for the patient. However, in spite of 
+these professional differences, the mutual understanding 
+and appreciation of the differing perspectives is key to the 
+integration that is of paramount importance to achieve the 
+aim of the IAYT.
+In principle, in most schools of yoga in the world, yoga 
+is equivalent to “
+Asana, pranayama and/or meditation 
+practice.” Hence, the success of their program is mostly 
+ascribed to patient or/and therapist related factors. Very few 
+schools of yoga aim to provide a holistic approach (such 
+as the IAYT), which focuses not just on the patient or 
+therapist, but also on the treatment factors that play an 
+integral role in the effectiveness of the program. Further, 
+the IAYT approach is considered as a way of life where 
+Asanas and pranayama comprise only a minuscule part 
+of the entire program [Table 2].
+Certain other features of the IAYT worth discussion are:
+•	 Patient cooperation during the IAYT treatment 
+entails not just practicing the Asanas or pranayama 
+techniques as per the instructions of the therapist 
+correctly, but also attending all lectures and 
+counseling (entire IAYT program). Here, the authors 
+would like to clarify that “co‑operation of the patient” 
+entails not just co‑operating with the IAYT schedule 
+but also being an “active patient” in each of the 
+activities/programs.
+•	 “Co‑operation of the patient” and “being an active 
+patient” also chiefly depends on the insight 
+level (“awareness of the patient about his condition”) 
+of the patient. Only if the patient is aware that he is in 
+need of the treatment/the treatment is good for him/
+her, does he/she co‑operate and participate actively in 
+the treatment. In this study, case 1 had insight about 
+her disorder and co‑operated better with the treatment 
+process (according to the treating team) as compared 
+to case 2 who did not have insight about his disorder. 
+This component of insight (awareness of the patient 
+about his condition) is important as IAYT requires an 
+active patient who attends various didactic sessions, 
+learns skills (exercises) and develops commitment (to 
+continue diet, meditation etc.)
+Figure 1: Conceptual frame-work of integrated approach to yoga therapy
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+Villacres, et al.: Integrated approach to yoga therapy
+International Journal of Yoga • Vol. 7 • Jan-Jun-2014
+30
+•	 Antidepressant medication or Ayurveda is considered 
+as an add‑on treatment to the IAYT; contrary to certain 
+studies where yoga is considered as an add‑on treatment 
+to medications.[9‑12] Interview with the patients also 
+brought out that side‑effects of the anti‑depressant 
+medications (e.g.: Increased sleep) often disturbed their 
+ability to participate fully in the IAYT schedule. Case 
+2 especially requested for a shift from anti‑depressant 
+medication to Ayurveda for the same reason. However, 
+due to the severity of his symptoms, he was advised 
+to continue with both the medications (after adjusting 
+the dosages antidepressants and Ayurveda medication), 
+with primary emphasis on IAYT
+•	 Counseling during the IAYT treatment entails 
+motivating the patient to continue with the treatment 
+and enabling insight facilitation about his/her 
+condition. The simultaneous lectures and sessions 
+by the YT further acts as non‑formal counseling 
+sessions where the principles of yoga psychology 
+and philosophy are imparted that is how the patient 
+can move from one level of existence (Pancha Kosha) 
+to another by following the varied practices of the 
+IAYT. This empowers patients to combine theory with 
+practice for improved results. Further, integration 
+between the treating team and their interventions/
+sessions could be brought about if all the treating team 
+incorporates the principles of IAYT in their practice/
+sessions. For this all the treating team involved, may 
+need to go through a basic IAYT course to understand 
+its principles and integrate it into their practice
+•	 The “improvements and changes” observed as an outcome 
+of the IAYT differ from those found in other studies.[9,12‑14] 
+The capacity of the patient to integrate the IAYT as his/
+her daily practice/way of life (even after discharge); 
+and not mere symptom reduction‑is considered as 
+“improvement and changes”. This integration is possible 
+if the patient commits and cooperates for longer duration 
+of treatment (as the effect of yoga is usually observed 
+over a period of time and patients require time to adopt 
+new schedules to their way of life). Thus, the authors 
+believe that the themes of “cooperation of patient (patient 
+related factors) and “duration of treatment” (treatment 
+related factors) are inter‑related and can ultimately have 
+a bearing on the effectives of the IAYT.
+These results of this study need to be discussed in the 
+context; that the sample of the study was of only two patients. 
+Further language difficulties experienced by the patients and 
+treating team in expressing their thoughts need to be taken 
+into account while understanding their testimonies. The data 
+collected from the in‑depth interviews in this study thus 
+requires to be taken as a useful preliminary (pilot) step in 
+understanding the conceptual frame‑work of IAYT. Further, 
+as IAYT necessarily requires integration of patient, therapist, 
+and treatment related factors, it could be challenging to adopt 
+it in an out‑patient setting.
+In spite of the above limitations, the proposed conceptual 
+frame‑work can be considered as a useful stepping stone in 
+understanding the dynamics of IAYT‑for (1) researchers in 
+knowledge/theory building and future research, (2) clinicians/
+therapists in developing holistic IAYT interventions, (3) yoga 
+advocates in propagating IAYT as a way of life.
+CONCLUSION
+The IAYT is a working example of an attempt to treat 
+the “whole” patient with the integration of various types 
+of therapy and requires active continuing collaboration 
+between the various therapists and the patient for desired 
+treatment outcomes. This continued collaboration helps 
+the patient to achieve the aim of IAYT and adopt it as a 
+way of life to deal with his/her problem.
+ACKNOWLEDGMENTS
+The authors would like to thank Dr. HR Nagendra, Vice Chancellor 
+of Swami Vivekananda Anusandhana Samsthana (S‑VYASA) 
+for providing them the opportunity to conduct this study. They 
+would also like to thank all patients and treating team, for their 
+individual and collective contribution in completing this study.
+REFERENCES
+1.	
+Nagarathna R, Nagendra H. Integrated Approach of Yoga Therapy for Positive 
+Health. Bangalore: Swami Vivekananda Yoga Prakashana; 2008. p. 8‑20.
+2.	
+Patanjali Yoga Sutra, 1.2, 1.3. In: Krishnamoorthy S, editor. Concept of 
+Anxiety According to Ancient Indian Scriptures. SYASA, Bangalore: 
+M.Sc (Yoga)‑ Dissertation; 2007.
+3.	
+Nagarathna R, Nagendra HR. Integrated Approach of Yoga Therapy for 
+Positive Health. Bangalore: Swami Vivekanand Yoga Prakashana; 2004.
+4.	
+Nagarathna R, Nagendra HR. Yoga for bronchial asthma: A controlled study. 
+Br Med J (Clin Res Ed) 1985;291:1077‑9.
+5.	
+Uma K, Nagendra HR, Nagarathna R, Vaidehi S, Seethalakshmi R. The 
+integrated approach of yoga: A therapeutic tool for mentally retarded children: 
+A one‑year controlled study. J Ment Defic Res 1989;33:415‑21.
+6.	
+Haslock I, Monro R, Nagarathna R, Nagendra HR, Raghuram NV. Measuring 
+the effects of yoga in rheumatoid arthritis. Br J Rheumatol 1994;33:787‑8.
+7.	
+Banerjee B, Vadiraj HS, Ram A, Rao R, Jayapal M, Gopinath KS, et al. 
+Effects of an integrated yoga program in modulating psychological stress 
+and radiation‑induced genotoxic stress in breast cancer patients undergoing 
+radiotherapy. Integr Cancer Ther 2007;6:242‑50.
+8.	
+Satyapriya M, Nagendra HR, Nagarathna R, Padmalatha V. Effect of integrated 
+yoga on stress and heart rate variability in pregnant women. Int J Gynaecol 
+Obstet 2009;104:218‑22.
+9.	
+Uebelacker LA, Tremont G, Epstein‑Lubow G, Gaudiano BA, Gillette T, 
+Kalibatseva Z, et al. Open trial of Vinyasa yoga for persistently depressed 
+individuals: Evidence of feasibility and acceptability. Behav Modif 
+2010;34:247‑64.
+10.	 Sharma VK, Das S, Mondal S, Goswami U, Gandhi A. Effect of Sahaj Yoga 
+on neuro‑cognitive functions in patients suffering from major depression. 
+Indian J Physiol Pharmacol 2006;50:375‑83.
+11.	
+Sharma VK, Das S, Mondal S, Goswampi U, Gandhi A. Effect of Sahaj Yoga 
+on depressive disorders. Indian J Physiol Pharmacol 2005;49:462‑8.
+12.	 Shapiro D, Cook IA, Davydov DM, Ottaviani C, Leuchter AF, Abrams M. Yoga 
+as a complementary treatment of depression: Effects of traits and moods on 
+treatment outcome. Evid Based Complement Alternat Med 2007;4:493‑502.
+Villacres, et al.: Integrated approach to yoga therapy
+31
+International Journal of Yoga • Vol. 7 • Jan-Jun-2014
+13.	 Bennett SM, Weintraub A, Khalsa SB. Initial evaluation of the Life Force 
+Yoga Program as a therapeutic intervention for depression. Int J Yoga Therap 
+2008;18:49‑57.
+14.	 Javnbakht M, Hejazi Kenari R, Ghasemi M. Effects of yoga on depression 
+and anxiety of women. Complement Ther Clin Pract 2009;15:102‑4.
+How to cite this article: Villacres MC, Jagannathan A, Nagarathna 
+R, Ramakrsihna J. Decoding the integrated approach to yoga 
+therapy: Qualitative evidence based conceptual framework. Int J Yoga 
+2014;7:22-31.
+Source of Support: Nil, Conflict of Interest: None declared
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+Determining bioenergy field of autistic and normal healthy children: an
+electrophotonic imaging study
+Article · April 2020
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+                                 International Journal of Community Medicine and Public Health | April 2020 | Vol 7 | Issue 4    Page 1547 
+International Journal of Community Medicine and Public Health 
+Sankhala SS et al. Int J Community Med Public Health. 2020 Apr;7(4):1547-1554 
+http://www.ijcmph.com 
+pISSN 2394-6032 | eISSN 2394-6040 
+Original Research Article 
+Determining bioenergy field of autistic and normal healthy children:   
+an electrophotonic imaging study 
+Surendra Singh Sankhala1, Singh Deepeshwar1*, Shivakumar Kotikalapudi1, Sridip Chatterjee2  
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+INTRODUCTION 
+Autism 
+spectrum 
+disorder 
+(ASD) 
+is 
+a 
+set 
+of 
+neurodevelopmental 
+disorders 
+(NDDs), 
+including 
+restricted, repetitive behavioral, communication and 
+social 
+impairments. 
+During 
+past 
+decades, 
+the 
+epidemiological studies showed an increase in the 
+prevalence of autism worldwide.1 An autism survey in 
+India estimated about 1 in 100 children under age 10 
+years have autism.2 Research studies reported that 
+children with ASD have unclear pathophysiology and 
+may be associated with several risk factors including 
+alterations of gut microbiota, genetic, environmental 
+toxicants  and nutritional factor.3-5 Further, few other 
+associated risk factors are age, gender, parental education 
+and behavior. Apart from core symptoms of ASD, such as 
+socialization, communication and repetitive behavior, the 
+clinical symptoms are usually present by the age of 3 
+years. The symptoms may worsen in delayed diagnosis 
+and initiation of ASD-specific intervention. However, the 
+timing and developmental course of ASD symptoms vary 
+across children.6  
+ABSTRACT 
+ 
+Background: Currently assessment of autistic behavior is done based on learning disabilities, personal observation of 
+behavioral patterns and standard autistic scales. Electrophotonic imaging (EPI) instrument is used to assess health 
+status based on bio-energy field of various organ and organ system of human body. And can be useful to determine 
+the early diagnosis of autistic symptoms and degree of improvement for any therapeutic intervention given to these 
+autistic children on a regular basis. This study aimed to investigate the differences of EPI parameters of autistic 
+children and healthy children of the same age group.  
+Methods: This study was carried out by taking the EPI images of 33 autistic and 36 healthy children of age group 4 to 
+14 years from an autistic center and nearby school in Bangalore. The statistical analysis on acquired data were done 
+using IBM SPSS Version 20.0.  
+Results: The variables activation coefficient, integral area, sacrum, hypothalamus, thyroid gland, pancreas and 
+coronary vessels showed a significant statistical difference in their mean value for autistic and healthy children 
+(p<0.05).  
+Conclusions: The EPI parameters for autistic and healthy children open up the possibility of using EPI based 
+instrument for early diagnosis. Deeper analysis of the differing parameters gave us more insight into the type of 
+intervention to be selected for improving the health of autistic children.  
+ 
+Keywords: Electrophotonic imaging, Autism spectrum disorder, Gas discharge visualization, Autistic children  
+1Division of Yoga and Life Science, Swami Vivekananda Yoga Anusandhana Samsthana (S-VYASA), Bangalore, 
+Karnataka, India 
+2Department of Physical Education, Jadavpur University, Kolkata, West Bengal, India.  
+  
+Received: 08 January 2020 
+Revised: 12 February 2020 
+Accepted: 28 February 2020 
+ 
+*Correspondence: 
+Dr. Singh Deepeshwar, 
+E-mail: [email protected] 
+ 
+Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under 
+the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial 
+use, distribution, and reproduction in any medium, provided the original work is properly cited. 
+DOI: http://dx.doi.org/10.18203/2394-6040.ijcmph20201472 
+Sankhala SS et al. Int J Community Med Public Health. 2020 Apr;7(4):1547-1554 
+                                International Journal of Community Medicine and Public Health | April 2020 | Vol 7 | Issue 4    Page 1548 
+An early and reliable diagnosis and appropriate 
+interventions may reduce the progressive symptom 
+development in ASD children. There are various 
+screening 
+methods 
+developed 
+by 
+clinicians 
+and 
+psychiatrists across the world and come up with a 
+common underlying criterial for ASD given in the 
+diagnostic and statistical manual fourth edition (DSM-
+IV). Apart from DSM-IV, many clinicians have been 
+using self-screening methods such as childhood autism 
+rating scale (CARS), behavior problems inventory-short 
+form (BPI-S), autism behavior checklist (ABC), autism 
+diagnostic interview-revised (ADI-R), autism diagnostic 
+observation schedule (ADOS) to assess individual with 
+ASD.7-11 These scales are having suitable validity and 
+sensitivity but criticized due to more number of items, 
+time-consuming, and scoring methods. Therefore, leading 
+medical experts and psychiatrists across the world 
+seeking a specific screening method to identify autistic 
+traits in their early stages and subsequently, necessary 
+medication can be provided without delay.  
+Electrophotonic imaging (EPI), is a non-invasive user-
+friendly 
+biometric 
+device 
+to 
+assess 
+the 
+human 
+bioelectromagnetic 
+field 
+under 
+different 
+psycho-
+physiological and pathophysiological conditions.12,13 
+Generally, a living system emits spontaneous biophoton 
+that is linked to the endogenous states of biological 
+processes.14 These biophotons are ultra-low rate emission 
+of 
+electromagnetic 
+energy 
+associated 
+with 
+cell 
+functioning 
+including 
+cell 
+metabolism, 
+growth, 
+phagocytosis, neural activity, and oxidative stress.15-17 
+EPI instrument captures coronal discharges from the 
+fingertips induced by applying underside high voltage 
+(10-15 kV) and high frequency (1024 Hz) for less than a 
+millisecond. The dielectric glass plate of EPI accelerates a 
+high electric field, generating electronic avalanches which 
+cause glow in the surrounding of fingertips. This can be 
+captured as an image by using an optical charge-coupled 
+camera (CCD) placed underneath the glass place.18 The 
+image will be captured from all 10 fingertips of both 
+hands through the EPI software. Based on Chinese 
+acupuncture meridians theory, each fingertip is divided 
+into sectors that represent different organs and human 
+systems.19 The acquired image formation may change due 
+to the mental state and psychic energy of the individual.20 
+The EPI parameters successfully reported a balanced or 
+disturbed state of the organ and organ system.  
+There are a few studies that have demonstrated the 
+usefulness of EPI for early diagnosis than conventional 
+methods.13,21 The psycho-emotional state of children with 
+the autistic disorder can be diagnosed through EPI that 
+concomitantly improves the interventional strategy for 
+symptoms control.22 Few other studies reported the 
+usefulness of EPI in the screening and early diagnosis of 
+diabetes, 
+asthma, 
+cancer, 
+autism 
+and 
+clinical  
+conditions.22-26 The parameters of EPI showed high 
+functional energy reserve in meditators which reflect 
+better psycho-physiological levels following anapanasati 
+meditation.27 There have been very few studies in 
+capturing EPI parameters related to autism. The study of 
+these parameters could pave way for coming up with a 
+yogic exercise that could facilitate in improving any of 
+those parameters to bring about a positive change in 
+autistic children for their cognitive development.  
+There is a dearth of data reporting the difference in EPI 
+parameters of autistic children matched with the age-
+gender healthy control group. Therefore, the present study 
+aimed to capture the EPI image of autistic and healthy 
+children of the same age and gender. 
+METHODS 
+Participants 
+A total of 69 children were recruited, during September 
+2018 to April 2019 in the study. Thirty-three previously 
+diagnosed autistic children who were diagnosed with 
+Indian scale for assessment of autism (ISAA) from 
+various autistic centers in Bangalore. Another group of 36 
+healthy children recruited from nearby schools as control. 
+However, the mean age of autistic (8.9±3.6 years) and 
+healthy control (9.3±2.8 years) was not significantly 
+different.  
+Inclusion criteria 
+Only those children were recruited whose teachers and 
+parents given their consent for participation. The autistic 
+children receiving stable medication or behavioural 
+interventions. They all were able to understand and 
+followed the instructions. The age range were 7 years to 
+14 years.  
+Exclusion criteria 
+Children with significant behaviour problems, auditory or 
+impairments, severe neurological or physical deformities 
+were excluded from the study.  
+Study design 
+A cross-sectional study design was adopted, where two 
+groups i.e., autistic children and healthy controls were 
+compared using selected parameters of EPI. Each child 
+had to keep all the ten fingers one by one on the glass 
+surface of the EPI equipment and data were recorded. 
+Ethical approval 
+All participants were explained about the nature of the 
+study and were given basic information about the EPI 
+technique as well as the procedure for assessment. This 
+study was approved by the institutional ethical committee 
+of the university and registered in the clinical trial registry 
+of India (CTRI).  
+Sankhala SS et al. Int J Community Med Public Health. 2020 Apr;7(4):1547-1554 
+                                International Journal of Community Medicine and Public Health | April 2020 | Vol 7 | Issue 4    Page 1549 
+Informed consent was obtained from the teachers and 
+parents of the participants after explanation about the 
+nature of the study and were given basic information 
+about the EPI technique as well as the procedure for 
+assessment.  
+Instruments and procedure for data collection 
+The reading from 10 fingers of each child was collected 
+using EPI technology developed by Saint-Petersburg, 
+Russia (GDV camera pro with an analog video camera, 
+model number: FTDI.13.6001.110310). Data collection 
+was done in the morning with a gap of 3 hours from meal. 
+All data were recorded as per the stipulated guidelines for 
+EPI measurements that helped to maintain the reliability 
+and reproducibility of the acquired data. Each participant 
+was asked to remove all metallic objects from their body 
+24 hours before data collection. Calibration of the 
+equipment was carried out before acquiring data. Further, 
+during data collection, participants stood on an 
+electrically isolated surface and placed their fingertip on 
+the dielectric glass to capture the image. After each 
+recording, the dielectric glass surface was cleaned by an 
+alcoholic 
+solution. 
+Atmospheric 
+temperature 
+and 
+humidity were monitored by hygrometer (Equinox, EQ 
+310CTH) and it was maintained 26.8°C and 52.2%, 
+respectively.  
+Parameters analyzed 
+The captured EPI Images were loaded into the EPI 
+software and the coronal discharges corresponding to the 
+organs and organ systems were exported into a 
+spreadsheet. Each record had 82 variables (parameters) 
+per subject. The parameters were: (a) activation 
+coefficient (AC): measure the level of stress and range 
+between 2-4 in healthy people; (b) integral area, measure 
+of general health index with a range of -0.6 to +1, that 
+indicate the presence of structural and functional state of 
+mind-body of healthy people; (c) integral entropy: 
+evaluate the disorderliness in human energy field with 
+normal range 1-2 and indicate the presence of 
+deficiencies in the organs measured in healthy people. 
+The above parameters correspond to different organ 
+system including kidney, liver, immune system, pancreas, 
+cerebral and coronary vessels. 
+Data analysis 
+Data analysis was done using IBM SPSS software version 
+21.0. The parameters of acquired data were segregated for 
+autistic and healthy children and tested for normality. A 
+parametric independent sample t-test was carried out 
+between EPI parameters of autistic and non-autistic 
+children. All statistical analyses were computed at 
+p≤0.05. The Pearson correlation was done between age 
+and EPI parameters. 
+RESULTS 
+The statistical analysis of autistic and control children 
+data is given in (Table 1). The independent sample t-test 
+and effect size (Cohen’s d) of selected parameters 
+demonstrated 
+a 
+statistically 
+significant 
+difference 
+(p<0.05) for the meridians associated with sacrum, 
+pancreas, liver, thyroid, hypothalamus, left eye and 
+coronary vessels. Also, there were significantly different 
+(p<0.05) values in RMS of integral area for both the right 
+and left side of the body. The autistic children showed a 
+statistically higher value in the activation coefficient than 
+healthy control children (p<0.01). The effect sizes were 
+measured using the Cohen’s d; if effect size 0.2 is 
+considered small, 0.6 is medium and 0.8 is large.  
+The Pearson’s correlation showed that there was a 
+statistically positive correlation between healthy children 
+age and scores of integral area, r = 0.51, p<0.001, RMS of 
+integral area, r = 0.38, p<0.001, sacrum, r=0.28, p<0.02, 
+thyroid gland, r=0.3, p<0.05, left eye = 0.29, p<0.05, 
+liver, r = 0.32, p<0.01, pancreas, r = 0.24, p<0.05. In 
+contrast, the autistic children showed marginal correlation 
+in integral area, r=0.39, p<0.05 and liver, r=0.347, p<0.05 
+with age as shown in Table 2 (autistic children) and Table 
+3 (healthy children). Since all correlations were having 
+similar graphs, a subsample of correlation graph between 
+age and integral area is presented in (Figure 1).  
+Table 1: Electrophotonic imaging parameters (EPI) analysis using independent sample t-test. Value are mean, 
+standard deviation, and effect size. 
+S. 
+no. 
+Variables of 
+EPI 
+Group 
+t value 
+df 
+P value 
+95% confidence 
+interval of the 
+difference 
+Cohen’s 
+d 
+Healthy 
+control 
+(n=36) 
+Autistic 
+(n=33) 
+Lower 
+Upper 
+1 
+Activation 
+coefficient 
+2.95±1.36 
+3.73±2.22 
+-1.77 
+67 
+0.081 
+0.66 
+2.70 
+-0.427 
+Left hand 
+ 
+2 
+RMS of integral 
+area 
+0.31±0.08 
+0.39±0. 11 
+3.12 
+67 
+0.002 
+0.12 
+0.03 
+0.76 
+3 
+Sacrum 
+0.52±0. 33 
+0.80±0.72 
+2.10 
+67 
+0.04 
+0.54 
+0.01 
+0.51 
+4 
+Hypothalamus 
+0.47±0.21 
+0.33±0.23 
+2.59 
+67 
+0.01 
+0.03 
+0.25 
+0.63 
+5 
+Thyroid gland 
+0.34±0. 26 
+0. 51±0. 26 
+2.82 
+67 
+0.006 
+0.30 
+0.05 
+0.68 
+Continued. 
+Sankhala SS et al. Int J Community Med Public Health. 2020 Apr;7(4):1547-1554 
+                                International Journal of Community Medicine and Public Health | April 2020 | Vol 7 | Issue 4    Page 1550 
+S. 
+no. 
+Variables of 
+EPI 
+Group 
+t value 
+df 
+P value 
+95% confidence 
+interval of the 
+difference 
+Cohen’s 
+d 
+Healthy 
+control 
+(n=36) 
+Autistic 
+(n=33) 
+Lower 
+Upper 
+Right hand  
+ 
+6 
+RMS of integral 
+area 
+0.29±0. 07 
+0.35±0. 09 
+2.92 
+67 
+0.005 
+0.10 
+0.02 
+-0.703 
+7 
+Left eye 
+0.60±0.29 
+0.79±0.40 
+2.18 
+67 
+0.03 
+0.35 
+0.02 
+-0.526 
+8 
+Liver 
+0.66±0.44 
+0.89±0.40 
+2.26 
+67 
+0.02 
+0.43 
+0.03 
+-0.544 
+9 
+Pancreas 
+0.37±0.40 
+0.63±0.60 
+2.13 
+67 
+0.03 
+0.50 
+0.02 
+-0.512 
+10 
+Coronary 
+vessels 
+0.31±0.25 
+0.44±0.15 
+2.57 
+67 
+0.01 
+0.23 
+0.03 
+-0.618 
+ 
+ 
+Figure 1: A subsample of correlation graph between age and integral area of normal healthy children. 
+DISCUSSION 
+The aim of study was to investigate whether EPI 
+parameters can be used for the diagnostic purpose of 
+autistic children. The selected parameters were compared 
+with healthy children outcomes. The results showed a 
+significant difference between EPI parameters of children 
+with autistic and healthy. The autistic children showed a 
+higher activation coefficient (AC) when compared with 
+healthy control which suggests the resting cardiac vagal 
+tone was less in autistic children. The outcome of AC can 
+be speculated that autistic children have elevated 
+sympathetic tone suggesting autonomic abnormality.28 
+The outcome of AC is concomitant with other findings 
+which suggest that the autonomic nervous system is 
+impaired in children with autism, mainly decreased 
+parasympathetic activity revealed by auto power and 
+coherence spectra analysis.29,30 
+Apart from AC, other parameters of EPI on left and right 
+side showed significant different in autistic and healthy 
+children. The left and right side of RMS integral area 
+showed positively lower energy level in healthy children 
+and significantly higher in autistic children. The higher 
+energy values in integral area in autistic children suggests 
+high load on physiological system, this may be due to 
+poor 
+adaptation.31 
+The 
+healthy 
+children 
+showed 
+physiological flexibility which may be helpful for acute 
+stress adaptation in healthy children and impaired in 
+autism children.32 The poor adaptation is associated with 
+dysregulation of the autonomic activity, particularly 
+sympathetic and parasympathetic outflow that outflows 
+via brainstem and sacral spinal region. In the present 
+study, sacrum showed high level of energy in children 
+with autism compared to normal healthy. Previous 
+evidence suggests that ASD may be associated with 
+hyper-arousal of the ANS in ASD children.33 The hyper-
+arousal behavior altered hypothalamic-pituitary-adrenal 
+(HPA) axis and diminished grey matter within the 
+hypothalamus in autism disorder34,35 that can be 
+correlated with marked lower energy level in autistic 
+compare to normal healthy children. The grey matter in 
+the hypothalamus linked with social interaction, restricted 
+and stereotyped pattern of behavior as reported in autistic 
+children.34 The hypothalamus synthesizes behavior 
+associated 
+hormones 
+like 
+oxytocin 
+and 
+arginine 
+vasopressin. The energy level is higher in thyroid gland, 
+that may suggest ASD is related to thyroid dysfunction, 
+common in children with ASD.36 
+Sankhala SS et al. Int J Community Med Public Health. 2020 Apr;7(4):1547-1554 
+                                International Journal of Community Medicine and Public Health | April 2020 | Vol 7 | Issue 4    Page 1551 
+Table 2: Correlation analysis of autistic children. 
+   
+Age  
+Activation 
+coefficient  
+Integral 
+area  
+RMS of 
+integral 
+area  
+Sacrum  
+Hypothalamus  
+Thyroid 
+gland  
+Left eye  
+Liver  
+Pancreas  
+Coronary 
+vessels  
+Age  
+Pearson's r 
+ 
+— 
+ 
+   
+   
+ 
+   
+   
+   
+   
+   
+p value  
+—  
+ 
+   
+   
+   
+   
+   
+   
+   
+   
+Activation coefficient  
+Pearson's r  
+0.111  
+—  
+   
+   
+   
+   
+   
+   
+   
+   
+p value  
+0.537  
+—  
+   
+   
+   
+   
+   
+   
+   
+   
+Integral area  
+Pearson's r  
+0.390  
+*0.210 
+—  
+ 
+ 
+   
+   
+   
+   
+   
+p value  
+0.025  
+ 
+0.241  
+—  
+   
+   
+   
+   
+   
+   
+   
+RMS of integral area  
+Pearson's r  
+0.290  
+0.048  
+0.268  
+—  
+   
+   
+   
+   
+   
+   
+p value  
+ 
+0.791  
+0.132  
+—  
+   
+   
+   
+   
+   
+   
+Sacrum  
+Pearson's r  
+0.250  
+-0.015  
+0.347  
+*0.478  
+** —  
+   
+   
+   
+   
+   
+p value  
+0.161  
+0.935  
+0.048  
+0.005  
+—  
+   
+   
+   
+   
+   
+Hypothalamus  
+Pearson's r  
+0.096  
+0.194  
+0.526  
+** -0.016  
+0.178  
+—  
+   
+   
+   
+   
+p value  
+0.594  
+0.278  
+0.002  
+0.928  
+0.322  
+—  
+   
+   
+   
+   
+Thyroid gland  
+Pearson's r  
+0.267  
+0.119  
+0.345  
+*0.284  
+0.324  
+0.265  
+—  
+   
+   
+   
+p value  
+0.133  
+0.508  
+0.050  
+0.109  
+0.066  
+0.136  
+—  
+   
+   
+   
+Left eye  
+Pearson's r  
+0.227  
+0.321  
+0.518  
+**0.029  
+0.082  
+0.329  
+0.066  
+—  
+   
+    
+p value  
+0.205  
+0.069  
+0.002  
+0.871  
+0.650  
+0.062  
+0.716  
+—  
+   
+   
+Liver  
+Pearson's r  
+0.347  
+*0.257  
+0.393  
+*0.323  
+0.585   
+***0.127  
+0.305  
+0.193  
+—  
+ 
+p value  
+0.048  
+0.149  
+0.024  
+0.067  
+<0.001  
+0.481  
+0.084  
+0.282  
+—  
+   
+Pancreas  
+Pearson's r  
+0.270  
+-0.034  
+0.226  
+0.412  
+*0.564  
+***0.163  
+0.749  
+***0.133  0.322  
+—  
+p value  
+0.129  
+0.850  
+0.206  
+0.017  
+<0.001  
+0.365  
+<0.001  
+0.461  
+0.068  
+—  
+Coronary vessels  
+Pearson's r  
+-0.191  
+-0.065  
+0.164  
+-0.341  
+-0.035  
+0.177  
+0.123  
+0.318  
+0.055  
+0.051  
+ 
+p value  
+0.288  
+0.720  
+0.360  
+0.052  
+0.846  
+0.324  
+0.496  
+0.071  
+0.762  
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+Sankhala SS et al. Int J Community Med Public Health. 2020 Apr;7(4):1547-1554 
+                                International Journal of Community Medicine and Public Health | April 2020 | Vol 7 | Issue 4    Page 1552 
+Table 3. Correlation analysis of healthy children. 
+   
+   
+Age  
+Activation 
+coefficient  
+Integral 
+area  
+RMS of 
+integral 
+area  
+Sacrum  
+Hypothalamus  
+Thyroid 
+gland  
+Left eye  
+Liver  
+Pancreas  
+Coronary 
+vessels  
+Age  
+Pearson's r  
+—  
+   
+   
+   
+   
+   
+   
+   
+   
+   
+   
+p value  
+—  
+   
+   
+   
+   
+   
+   
+   
+   
+   
+   
+Activation 
+coefficient  
+Pearson's r  
+-0.135  
+—  
+   
+   
+   
+   
+   
+   
+   
+   
+   
+p value  
+0.268  
+—  
+   
+   
+   
+   
+   
+   
+   
+   
+   
+Integral area  
+Pearson's r  
+0.51  
+***-0.160  
+—  
+   
+   
+   
+   
+   
+   
+   
+   
+p value  
+<0.001  
+0.189  
+—  
+   
+   
+   
+   
+   
+   
+   
+   
+RMS of 
+integral area  
+Pearson's r  
+0.378  
+ 
+** -0.284  
+* 0.335  
+** —  
+   
+   
+   
+   
+   
+   
+   
+p value  
+0.001  
+0.018  
+0.005  
+—  
+   
+   
+   
+   
+   
+   
+   
+Sacrum  
+Pearson's r  
+0.280  
+ 
+*-0.101  
+0.349  
+**0.473  
+ 
+*** —  
+   
+   
+   
+   
+   
+   
+p value  
+0.020  
+0.407  
+0.003  
+<0.001  
+—  
+   
+   
+   
+   
+   
+   
+Hypothalamus  
+Pearson's r  
+0.104  
+0.156  
+0.565  
+***-0.074  
+0.098  
+—  
+   
+   
+   
+   
+   
+p value  
+0.396  
+0.200  
+<0.001  
+0.544  
+0.424  
+—  
+   
+   
+   
+   
+   
+Thyroid gland  
+Pearson's r  
+0.300  
+ 
+*-0.191  
+0.448  
+***0.286  
+ 
+*0.308  
+**0.239  
+ 
+* —  
+   
+   
+   
+   
+p value  
+0.012  
+0.116  
+<0.001  
+0.017  
+0.010  
+0.048  
+—  
+   
+   
+   
+   
+Left eye  
+Pearson's r  
+0.278  
+ 
+*0.105  
+0.479  
+***0.012  
+0.072  
+0.382  
+ 
+** 0.108  
+—  
+   
+   
+   
+p value  
+0.021  
+0.391  
+<0.001  
+0.922  
+0.558  
+0.001  
+0.377  
+—  
+   
+   
+   
+Liver  
+Pearson's r  
+0.317  
+ 
+**-0.052  
+0.361  
+**0.395  
+ 
+***0.532  
+***0.169  
+0.208  
+0.108  
+—  
+   
+   
+p value  
+0.008  
+0.674  
+0.002  
+<0.001  
+<0.001  
+0.165  
+0.086  
+0.378  
+—  
+   
+   
+Pancreas  
+Pearson's r  
+0.242  
+ 
+*-0.233  
+0.323  
+**0.380  
+ 
+**0.511  
+***0.165  
+0.772  
+***0.128  
+0.310  
+** —  
+   
+p value  
+0.045  
+0.054  
+0.007  
+0.001  
+<0.001  
+0.176  
+<0.001  
+0.294  
+0.010  
+ 
+   
+Coronary 
+vessels  
+Pearson's r  
+0.001  
+-0.170  
+0.388  
+***-0.147  
+0.090  
+0.277  
+ 
+*0.241  
+*0.331  
+ 
+**0.042  
+0.179  
+—  
+p value  
+0.992  
+0.161  
+<0.001  
+0.227  
+0.462  
+0.021  
+0.046  
+0.006  
+0.735  
+0.140  
+—  
+* p < .05, ** p < .01, *** p < .001. 
+ 
+ 
+ 
+ 
+Sankhala SS et al. Int J Community Med Public Health. 2020 Apr;7(4):1547-1554 
+                                International Journal of Community Medicine and Public Health | April 2020 | Vol 7 | Issue 4    Page 1553 
+The autistic children also showed gastrointestinal (GI) 
+dysfunction including chronic constipation and diarrhea 
+as well as mitochondrial disorder that leads to pancreatic, 
+liver and coronary insufficiency.37 These changes affect 
+the GI system as well as alter the gut microbiome in 
+developing infant that is associated with ASD.38 The 
+alteration in gut microbiota is related to GI problems that 
+may be due to overproduction of bacterial metabolites or 
+altered brain structure and associated functions.3,39 Few 
+other studies reported that ASD is a highly genetic and 
+multifactorial disease that may affect synaptic maturation 
+and neural effect of gene expression.40 The synaptic 
+energy support cell metabolism and cell function that is 
+associated with health and disease.41 The energy level of 
+the pancreas, liver and coronary vessels showed a 
+significant difference between autistic and healthy 
+children. These outcomes can be possibly correlate with 
+other psychological scales of autism in future studies.  
+However, the findings of EPI parameters are positively 
+correlated with symptoms at organ level as showed in 
+previous findings associated with Autism. Therefore, EPI 
+biometric tool has the potential to identify a dysfunctional 
+state from normal functional state at an early stage in 
+real-time as shown in the present study. It measures the 
+biological and behavioral patterns by biophotons emitted 
+by a living organism that corresponds to the organ and 
+organ system behavior and health. There are other few 
+studies that have been trying to understand the biological 
+pattern specific to the disease. Further, this device is a 
+completely non-invasive, less time consuming and safe 
+method where the electric current flow through a pulse 
+current in microamps that does not affect any cell and 
+tissue or other physiological changes.  
+CONCLUSION  
+This study pointed out the significance of using the EPI 
+instrument for assessing the psycho-physiological and 
+functional state of organ and organ system in autistic and 
+normal healthy children. Further investigation could help 
+use this device as a possible diagnostic tool for the 
+diagnosis of ASD. The changes in EPI parameters can be 
+further explored in coming up with an effective 
+interventional strategy to correct the corresponding EPI 
+parameters. However, further study is required to 
+investigate more autistic children and correlate with other 
+quantitative methods to identify the prognosis of autism 
+in children.  
+Funding: No funding sources 
+Conflict of interest: None declared 
+Ethical approval: The study was approved by the 
+Institutional Ethics Committee 
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+Author's personal copy
+Development and feasibility of need-based psychosocial training programme for
+family caregivers of in-patients with schizophrenia in India
+Aarti Jagannathan a,*, Ameer Hamza a, Jagadisha Thirthalli b, H.R. Nagendra c, B.N. Gangadhar b
+a Department of Psychiatric Social Work, National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bangalore 560029, India
+b Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bangalore 560029, India
+c Swami Vivekananda Yoga Anusandhana, Samsthana (SVYASA), Bangalore, India
+1. Introduction
+Family members of patients with schizophrenia have extensive
+needs. The major needs of the caregivers include gaining education
+about the illness, ways of coping with the patient’s bizarre and
+assaultive behaviour, obtaining support, lack of enough opportu-
+nities to relieve the burden imposed on them, reducing risks to
+their own wellbeing and promoting the wellbeing of the mentally
+ill (Chafetz and Barnes, 1989; Angermeyer et al., 2000; Chien and
+Norman, 2003). Studies using scales to assess caregiver-needs have
+focused on specific needs such as educational needs (Chien and
+Norman, 2003) or on groups of needs such as counseling and
+support services, education and financial entitlements (Wancata
+et al., 2006; Barrowclough et al., 1998).
+There have been no systematic scientific Indian studies to
+assess the needs of caregivers; however various opinions have
+been expressed. Some of the needs opined are the need for
+awareness on the nature and outcome of mental illnesses in the
+community, need for primary psychiatric and other professional
+treatment,
+and
+psychosocial
+rehabilitation
+(Goswami,
+2006;
+Janardhan, 2006). Unmet needs of the patients have also been
+found to be significantly related to caregiver’s burden (Cleary et al.,
+2005). Meeting these needs would help to enhance the level of
+functioning of the patient (Soloman and Draine, 1994) as well as to
+decrease the emotional problems of family members (Johnson,
+1994).
+Needs
+vary
+across
+cultures
+and
+hence
+to
+develop
+any
+programme to cater to the needs of caregivers, an in-depth
+assessment in a cultural context is essential. Further, schizophre-
+nia outcome in India differs from the West, perhaps due to
+difference in family values, expectations, expressed emotions,
+family structure and stigma associated with the illness. In lieu of
+the above discussion, needs assessment of 30 caregivers of
+inpatients with schizophrenia, using focus group discussion
+(FGD) was conducted at NIMHANS, Bangalore (Jagannathan
+et al., 2011). The main needs of the caregivers that emerged
+were: (1) managing the behaviour of the patients, (2) managing
+social-vocational problems of patients, (3) health of the caregivers,
+(4) education about illness, (5) rehabilitation, and (6) managing
+sexual and marital problems of patients. These findings provide a
+Asian Journal of Psychiatry 4 (2011) 113–118
+A R T I C L E
+I N F O
+Article history:
+Received 21 August 2010
+Received in revised form 30 January 2011
+Accepted 5 February 2011
+Keywords:
+Need
+Psychosocial programme
+Family caregivers
+Schizophrenia
+A B S T R A C T
+Objectives: To develop and test the feasibility of a need-based psychosocial training programme for
+family caregivers of in-patients with schizophrenia in India.
+Method: Six topics for the psychosocial training programme were identified. Each day’s programme was
+based on a theoretical approach and involved a combination of methodologies. A structured
+questionnaire eliciting
+comments on
+each
+day’s topic,
+content and methodology was
+given
+independently to 11 experienced mental health professionals for validation. The final version of the
+programme based on the feedback given by the experts was pilot tested on a group of six caregivers to
+check for feasibility.
+Results: Experts gave an average score of ‘4’ (very much – on a 5 point Likert scale) when asked whether
+the overall psychosocial programme will achieve its objective of helping the caregiver reduce their
+burden. They independently approved the theoretical approach and methodology used for each day’s
+topic and suggested many changes. In the pilot study, quantitative and qualitative feedback of the
+caregivers further endorsed the feasibility and usefulness of the programme.
+Conclusion: The developed psychosocial training programme was found acceptable to the caregivers of
+in-patients with schizophrenia.
+ 2011 Elsevier B.V. All rights reserved.
+* Corresponding author at: Psychiatric Social Work, 1st Floor, Dr. Govindswamy
+Memorial Centre, National Institute of Mental Health and Neurosciences (NIMHANS),
+Bangalore 560029, India. Tel.: +91 94 48150690; fax: +91 80 26576465.
+E-mail address: [email protected] (A. Jagannathan).
+Contents lists available at ScienceDirect
+Asian Journal of Psychiatry
+journal homepage: www.elsevier.com/locate/ajp
+1876-2018/$ – see front matter  2011 Elsevier B.V. All rights reserved.
+doi:10.1016/j.ajp.2011.02.001
+Author's personal copy
+strong ground for the development of a culturally specific need
+based psychosocial programme for caregivers of Indian families.
+Different psychosocial models have proven to be effective in
+helping caregivers deal with their family member’s illness. Family
+management interventions such as crisis-oriented family therapy,
+behaviour family therapy, family psycho-education, multiple
+family group intervention, relatives groups, and family consulta-
+tion have shown positive outcomes both for patients and their
+families (Barbato and D’Avanzo, 2000; Gabi Pitschel-Walz, 2004;
+Pharoah et al., 2000; Pekkala and Merinder, 2004; Shinde, 2005).
+However, the significant number of cultural differences discussed
+above necessitates the development of a culturally suitable need-
+based intervention package for caregivers to enable them to handle
+their relative with schizophrenia in the Indian setting.
+Unfortunately, there are hardly any research studies which
+discuss
+the
+development
+and
+effectiveness
+of
+standardized
+psychosocial programme based on the assessed needs of caregivers
+of persons suffering from schizophrenia in India. The current paper
+aims to detail the development of a psychosocial training
+programme; based on the results of a recently concluded study
+on the assessed needs of inpatients’ family caregivers of persons
+with schizophrenia.
+2. Methodology
+The study was reviewed and approved by the Institute’s Ethics
+Committee. Written informed consent of the mental health
+professionals who helped in validation of the programme and
+family caregivers who participated in the pilot study was obtained.
+A socio-demographic sheet eliciting information on their age,
+occupation, monthly income and marital status was filled up by the
+researcher for both the mental health professionals and family
+caregivers.
+The qualitative research methodology was used to develop and
+test the feasibility of the psychosocial programme. Qualitative data
+during the validation phase was collected using the method of in-
+depth interviews.
+The development of the psychosocial programme was con-
+ducted in two phases. Phase-1 involved development of the
+content and methodology for the psychosocial programme. Phase-
+2 involved face and content validation of the programme. The
+feasibility of the programme was tested in Phase-3 of the study
+where the programme was pilot-tested and feedback from the
+caregivers who participated in the programme was elicited. The
+process involved in each phase of the development and feasibility
+testing of the programme is delineated below (Fig. 1):
+2.1. Phase-1: programme development
+The framework of the psychosocial programme was based on
+the six broad categories of needs elucidated from the results of the
+recently concluded study on the assessment of needs of family
+caregivers of schizophrenia inpatients in India (Jagannathan et al.,
+2011). Depending on the number of concepts under each category
+of needs, one or more session was assigned for its discussion. In-
+depth literature review in conjunction with expert opinion was
+elicited to decide on the appropriate theoretical approach and
+methodology to conduct each day’s session, covering different
+needs (category and concepts). The outcome was a 10-day group
+training programme which addressed the above studied six needs.
+Each day’s programme was based on a theoretical approach, with a
+combination of techniques and required the caregivers to complete
+some homework assignments (Table 1).
+2.2. Phase-2: face and content validation
+For
+the
+purpose
+of
+face
+and
+content
+validation
+of
+the
+programme, in-depth interviews were conducted with the help
+of a structured interview guide to elicit qualitative comments on
+each day’s topic, content and methodology. Eleven experienced
+mental health professionals (3 psychiatrists, 3 psychiatric social
+workers, 2 psychologists and 2 psychiatric nurses and 1 mental
+health educationalist) were approached individually and the
+researcher presented the details of the programme to them using
+the medium of power point presentation. The average number of
+years of experience (SD) of the experts after their formal
+qualification was 19.5 (7.7) years. After presenting the details of
+one day’s session, the researcher requested the mental health
+professionals to fill in their comments in the structured question-
+naire on how applicable was the approach used and contents
+described for that day’s session – before proceeding to the next
+day’s session details. Through this methodology of content –
+[(Fig._1)TD$FIG]
+Categories of needs idenfied
+Concepts under each category used to develop components of each day’s session
+Skills, techniques and approach of each day’s session decided
+Programme validated by 11 experts (face, content and consensual validity)
+Validated Programme pilot tested on 6 caregivers and Finalized
+Fig. 1. Process of inductive method of programme development.
+Table 1
+Contents of the preliminary 10-day group training programme.
+Day
+Topic
+Approach/model
+Content
+1
+Myths about illness
+Psycho-education
+11 myths discussed
+2
+Information about schizophrenia
+Psycho-education
+Definition, magnitude, identification, symptoms, causes, treatment,
+relapse prevention, role of family
+3
+Patient’s behaviour
+Problem solving
+Analyzing patient related problems through problem-solving:
+advantages–disadvantages approach
+4
+Socio-occupation
+Behaviour modification
+Activity scheduling, improving social skills
+5
+Marital and sexual
+SWOT analysis
+Weighing the strengths, weakness, opportunities, threats of marital
+and sexual problems, patient’s understanding of marriage/role and
+responsibilities, laws related to marriage
+6
+Socio-economic benefits
+Psycho-education
+Employment, education, social security, affirmative action. Family support
+groups and laws related to schizophrenia
+7
+Health of caregivers
+Supportive
+Managing negative emotions, social support network
+8
+Health of caregivers
+Supportive
+Time chart analysis, planning for future, decision making, being physically
+fit (exercise, diet, sleep)
+9
+Homework revision
+–
+–
+10
+Role play (summary)
+–
+–
+A. Jagannathan et al. / Asian Journal of Psychiatry 4 (2011) 113–118
+114
+Author's personal copy
+validation the researcher accumulated a list of comments for
+incorporating into each day’s session.
+For face validation of the programme, each of the mental health
+professionals was asked to rate the likelihood of the programme
+achieving its objective of reducing caregiver burden and stress (on
+a five point Likert scale).
+To arrive at a consensus on the contents and methodology of the
+psychosocial programme, three rounds of iteration was conducted
+among the mental health professionals – i.e. the researcher made
+changes to the programme based on comments given by the
+mental health professionals and went back (iteration) to the same
+professionals for their further inputs on the modified programme.
+The programme was modified and presented to the professionals
+three times before all the 11 experts agreed on the contents and
+methodology of the programme.
+2.2.1. Data analysis
+Data collected from the in-depth interviews was analyzed using
+the method of content analysis and recursive abstraction (without
+coding, datasets were summarized; those summaries were then
+further summarized, and so on. The end result was a more compact
+and accurate summary of the qualitative data collected – that
+would have been difficult to achieve without the preceding steps of
+summarization).
+A standardized script of the final version of the revised 7 days
+psychosocial programme was developed on incorporating the
+comments of the 11 experts. The script followed a semi-structured
+format; using open-ended discussion and questions in a face-to-
+face ‘conversational’ style rather than a formal question-answer
+format (the script is available from the authors on request). The
+script included discussion, therapeutic activities and/or brain-
+storming on each day’s topic.
+2.3. Phase-3: pilot study and feasibility
+2.3.1. Sample
+The final version of the programme was pilot-tested on a group
+of six in-patient family caregivers who were residing at National
+Institute of Mental Health and Neuro Sciences (NIMHANS) in
+Bangalore, India (NIMHANS has a 900-bed teaching hospital with
+training and research facilities in psychiatry and other neuros-
+ciences) during the period of the study (April 2009). The aim of
+pilot study was to test the feasibility of the psychosocial training
+programme. Caregivers of patients with a diagnosis of schizophre-
+nia were included in the study if they were to continue to provide
+care for them following discharge. Caregivers with psychiatric or
+neurological disorders and those caring for another relative with
+psychiatric illness were excluded.
+Out of the eight caregivers approached to be a part of pilot
+study, two caregivers dropped out; hence the total sample of
+caregivers attending the psychosocial group was six. One caregiver
+dropped out because her patient was very symptomatic and there
+was no one to care for her back in the ward; the other did not seem
+to understand the importance and need of training (psychosocial)
+and hence was not motivated enough to attend the sessions. Both
+caregivers felt that it was the patient who was ill and required
+training.
+The sample contained members from different socio-eco-
+nomic backgrounds, different states of India and from different
+caregiver roles. The mean age (SD) of the caregivers was 54.7
+(5.8) years. They had completed an average of 14.7 (4.7) years of
+education.
+Three
+of
+them
+were
+females
+and
+four
+of
+the
+caregivers were parents. The average (SD) duration of illness
+of their patients was 6.7 (10.5) years and four of them had not
+received any prior structured training on how they should take
+care of their patient.
+2.3.2. Procedure
+Socio-demographic details of consenting caregivers were taken
+before providing them the psychosocial training programme.
+Participants in the psychosocial group received training in skills by
+a qualified psychiatric social worker, to enable them to handle a
+person suffering from schizophrenia (script for the psychosocial
+programme
+was
+developed
+in
+Phase-2
+of
+the
+study).
+The
+intervention programme included sessions of about 1 h daily for
+a period of seven days. During the entire period of the study, the ill
+relative continued to receive the routine treatment prescribed by
+the doctors at NIMHANS. At the end of the 7-day programme, the
+caregivers were asked to fill a structured feedback form on their
+overall rating of the programme, trainer and the handouts
+distributed during the sessions.
+2.3.3. Data analysis
+Descriptive analysis of the quantitative (Likert ratings) feed-
+back and content analysis of the qualitative feedback received from
+the caregivers was conducted. Each and every comment was given
+importance and the researcher tried to accommodate all of it into
+the psychosocial programme. The modified final version of the
+psychosocial was distributed among the researcher’s three guides
+for their inputs and validation.
+3. Results
+As the main objective of the study was to develop and test the
+feasibility of a need based psychosocial training programme for
+inpatient caregivers, the results reflect the qualitative data acquired
+at two levels: at the validation stage and at the pilot stage.
+3.1. At validation stage
+For content validation, based on Table 1 (presented in the
+previous section), 11 experts gave their opinion on whether the
+approach/model used for a particular topic in the programme was
+appropriate:
+ Nine out of the 11 experts (82%) agreed that each topic in the
+programme used an appropriate approach/model to convey the
+contents of the session. Following is the feedback given by the
+two experts (18%) who disagreed with the approach used for
+some sessions:
+1. Expert 9 felt that the approach/model used for the session ‘Day
+6 – dealing with marital and sexual problems of patient’
+should be one of strengths, liability and problem solving and
+not a SWOT analysis approach, as illiterate/less literate people
+would find it difficult to understand the SWOT analysis
+approach.
+2. Expert 11 felt that the approach/model used for the session
+‘Day 8 – managing your health’ should employ a behavioural
+and educational model instead of a supportive approach, as
+apart
+from
+ventilation,
+caregivers
+would
+require
+some
+concrete suggestions and interventions to help them deal
+with their health needs – which could be satisfied only
+through the behavioural and educational approach.
+ Nine out of the 11 experts (82%) agreed that the contents of each
+day’s session were appropriate. The feedback given by the two
+experts (18%) who felt that the contents of some sessions were
+inappropriate was:
+1. Expert 6 felt that for the session ‘Day 1 – myths about the
+illness’ myths relevant to the Indian socio-cultural context
+needs to be incorporated. She suggested that the relevant
+myths could be elicited by interviewing experienced clinicians
+about common myths encountered in their practice. Further
+for ‘Day 5 – motivating patient to indulge in activities and
+A. Jagannathan et al. / Asian Journal of Psychiatry 4 (2011) 113–118
+115
+Author's personal copy
+socialize’ she suggested that the content of social skills
+required to be modified according to socio-cultural context
+with less use of jargon, so that even illiterate caregivers are
+able to understand and implement the skills.
+2. Expert 9 felt that for ‘Day 6 – dealing with marital and sexual
+problems of patient’ the contents of the session required to
+change in accordance with a change in the approach/model
+used in the session (strengths, liabilities and problem solving
+approach instead of SWOT analysis).
+A summary of the comments given by all 11 mental health
+professionals is given in Table 2.
+For face validation, on asking whether the overall psychosocial
+programme would achieve its objective of helping the caregivers
+reduce their burden and stress, nine out of the 11 experts (81.8%)
+gave a rank of 4 or 5 (very much or extremely useful). The feedback
+given by the two experts (18%) who felt that the programme would
+help caregivers only moderately was:
+1. Expert 9 felt that the psychosocial programme would only
+indirectly help in reducing stress; however would directly help
+in improving knowledge of the caregivers.
+2. Expert 10 felt that (1) the duration of each session in view of the
+vast content and group size was too tight; (2) caregivers may not
+be able to assimilate across all sessions and spacing between
+sessions could help them assimilate what was taught in the
+session; (3) education level of the caregiver within a group
+would determine the effectiveness of the group session; and (4)
+explicitly encouraging informal group dialogues after every
+session could help tackle some of the above challenges.
+The overall comments of some of the experts about the
+programme have been delineated below:
+ ‘‘Great effort. I am sure it will be helpful to caregivers.’’ (Expert 1).
+ ‘‘The current initiative will help the caregivers develop insight, be
+optimistic in their thinking and make use of the already available
+welfare measures to improve the quality of life of the patients and
+the caregivers.’’ (Expert 5).
+ ‘‘Very good attempt. . . Good luck.’’ (Expert 11).
+Based on comments of experts several changes were made to
+the programme:
+ The programme was shortened to seven days, as majority of the
+experts felt that all the six needs could be covered in one session
+each. The 7th day was provided for making a summary of the
+programme, revision of homework assignments and feedback.
+ Approaches like SWOT and problem solving were modified as
+experts believed that very few caregivers who entered the
+programme would have high educational attainment and good
+cognitive abilities to understand and self analyze and implement
+the SWOT or problem solving approach. Thus a more directive
+approach to solving problems where the possible problems faced
+by caregivers with probable solutions were incorporated in the
+Day 2 of the psychosocial programme.
+ Contents on myths about schizophrenia and social skills were
+made more culturally relevant – as most of the content on myths
+about schizophrenia and social skills that were borrowed from
+Western literature were not applicable to the Indian culture.
+Thus certain portions of the texts in the above mentioned two
+topics had to be either deleted or modified to suit the Indian
+caregivers.
+ Handouts of each session and sessions that used the psycho-
+education approach were prepared using power point for audio–
+visual effect in four local Indian languages: Kannada, Tamil, Hindi
+and English. This was done so that all the caregivers are able to
+participate, understand and implement the skills and strategies
+discussed in the session better, irrespective of their language.
+For consensual validation of the psychosocial programme, three
+rounds of iteration was conducted among the mental health
+professionals – i.e. the researcher made changes to the programme
+based on comments given by the mental health professionals and
+went back (iteration) to the same professionals for their further
+inputs on the modified programme. The programme was modified
+and presented to the professionals three times before all the 11
+experts
+agreed
+on
+the
+contents
+and
+methodology
+of
+the
+programme.
+3.2. At pilot stage
+Out of the six caregivers who underwent the psychosocial
+training programme, five of them assigned a score of 4 or 5 (on a 5-
+point likert scale, 5 being extremely useful) for the overall
+programme, handouts distributed and performance of the trainer.
+Qualitative feedback of the caregivers further endorsed the
+feasibility and usefulness of the programme. The following quotes
+of the caregivers reflect usefulness of participating in the 7 day
+group programme:
+‘‘The programme helps one to know better about the illness of
+schizophrenia, how one should conduct themselves and also about
+the legal and welfare benefits provided by the government. Overall
+Table 2
+Comments of experts on each day’s contents in training programme.
+Day
+Topic
+Comments by experts
+1
+Myths about illness
+Include culturally relevant myths, use of flip charts
+2
+Information about schizophrenia
+Use visual medium, add course and outcome of illness
+3
+Managing patient’s behaviour
+Use appropriate–not appropriate technique of problem solving. To be more directive with less
+educated people as they will not understand steps of problem solving, use of role play for learning skills
+4
+Social-occupational of patient
+Modify expectations of caregivers, utilization of family resources for social-vocation aspects,
+add culturally relevant social skills, include daily living skills
+5
+Marital-sexual problems of patient
+Add genetic counseling, avoid SWOT use merits demerits approach,
+6
+Welfare benefits for caregivers/patient
+To prepare booklet and have more discussion in session, include information about family support
+groups (examples), socio-legal aid services
+7
+Managing caregiver’s health
+(negative emotions and social support)
+Include discussion of stigma, Club Days 8 and 9 into one day, diet-sleep can be given as handout. Add about
+sharing care giving activities and perceived barriers to self care
+8
+Managing caregiver’s health
+(time-chart analysis, being physically fit)
+–
+9
+Homework assignments
+Should be done daily at beginning of every session.
+10
+Summary of sessions + role plays
+Add bibliotherapy (books they can read), check education level of caregivers before imparting skills.
+A. Jagannathan et al. / Asian Journal of Psychiatry 4 (2011) 113–118
+116
+Author's personal copy
+the programme is useful and educative.’’ (Mr. PM, 64 year old
+uncle of patient).
+‘‘This training programme is essential for all caregivers of patients
+suffering from schizophrenia. It is a fantastic programme and there
+should be a method to reach out this programme to many other
+caregivers in the community, i.e. either through manuals or
+webcast.’’ (Mr. SKL, 51 year old father of patient).
+‘‘The programme was excellent and I value the programme as it
+provided useful and valuable information on how caregivers should
+deal with and manage their patients. Addition of practical training
+exercises to deal with the patient should also be incorporated.’’ (Mr.
+SP, 55 year old father of patient).
+‘‘The programme was very informative, useful and practical.’’ (Mrs.
+PJ, 59 year old mother of patient).
+Certain suggestions given by the participants were:
+‘‘Practical training to deal with the patients should be incorporated.
+Most of the skills taught are difficult to implement with the
+patient.’’(Mr. SP, 55 year old father of patient).
+The above suggestion was incorporated in the final psychoso-
+cial programme, by adding more examples on how to apply the
+skills on the patients and by including homework assignments. The
+final programme was then revalidated by the three co-authors of
+the researcher for the main study.
+4. Discussion
+The challenges faced by caregivers in dealing with their relative
+who is suffering from schizophrenia are varied and extensive. Thus
+there is a need toenablecaregiverstodeal withthe burden andstress
+of caring. A number of psychosocial interventions offered to family
+members with patients of schizophrenia have been developing with
+increasing sophistication and cost efficacy. The current study in an
+attempt to develop a psychosocial training programme (based on the
+results of a recently concluded study on the assessment of needs of
+family caregivers of schizophrenia inpatients) describes the steps
+involved in the programme development, content and face valida-
+tion and pilot testing of the programme.
+The major strength of this programme was that it was need-
+based. There are hardly any research studies, which discuss the
+development and effectiveness of standardized training pro-
+grammes (multi-component psychosocial intervention) based on
+the assessed needs of caregivers of persons suffering from
+schizophrenia in India. This attempt to develop a structured
+intervention programme based on the holistic coverage of all the
+needs of the family caregivers – via a participatory approach (i.e.
+the caregivers themselves opined their needs and areas they
+required training in which was incorporated to develop the
+programme) is thus of significant importance.
+This programme incorporated varied approaches and strategies
+to deal with multiple topics of need to the caregivers – a multi-
+component programme as against specific programmes such as
+supportgroups, psycho-educationandcounseling. Ametaanalysis of
+specificintervention strategiesdesignedtohelp caregiverscopewith
+the burden of caregiving showed that collectively the interventions
+had no effect on caregiver burden – only multi-component
+interventions significantly reduced caregiver burden (Acton and
+Kang, 2001). Health education groups (a multi-component group
+program) for caregivers was found to be more effective than usual
+care in reducing depression, maintaining social integration, increas-
+ing effectiveness in solving pressing problems,increasing knowledge
+of community services and how to access them, changing caregivers’
+feelings of competence, and the way they respond to the care giving
+situation (Toseland et al., 2001). Schizophrenia Patient Outcomes
+Research Team (PORT) has also recommended that all families in
+contact with their relative who have a mental illness be offered a
+multi-component family psychosocial intervention programme
+spanning nine months (Lehman et al., 1998).
+In India, a majority of the persons with schizophrenia stay with
+their families, and more so in joint families (Thara et al., 1998).
+Further as mentioned earlier – schizophrenia outcome differs from
+the West, due to difference in family values, expectations,
+expressed emotions, family structure and stigma associated with
+the illness. Culturally relevant models in the Indian setting require
+clinicians to include the family members (who are majority of the
+time the primary caregivers of the patients) as important
+stakeholders in the treatment process. The strong community,
+family and social support available in India also helps the patient to
+rehabilitate faster and better into the society. In this context,
+acknowledging and incorporating the significant cultural differ-
+ences between the West and India in the development of a
+culturally suitable intervention package for caregivers, gains
+further importance.
+Any psychosocial intervention for caregivers of patients of
+schizophrenia requires facilitation by professional psychiatric social
+workers, who are very few in number compared to the crores of
+persons and families who suffer from schizophrenia in India. As it is
+difficult to cater to the needs of all the caregivers through individual
+psychosocial intervention – due to lack of manpower and resources,
+a group intervention to address psychosocial needs of the caregivers
+proves to be much more beneficial in the Indian scenario.
+The programme was developed using a sound methodology of
+inductive enquiry approach. Qualitative feedback from the experts
+(that each topic in the programme had an appropriate theoretical
+content in keeping with the aim of the study) as well as results of the
+needs assessment,furtheraddedtothevalidationoftheprogramme.
+The final programme had consensual validation of all the experts
+that it would prove to be useful in reducing the burden of caregivers.
+The feasibility of the programme analyzed from the qualitative
+feedback of the caregivers endorsed the feasibility and usefulness
+of the programme. Majority of the caregivers who underwent the
+programme
+opined
+that
+the
+overall
+programme,
+handouts
+distributed and performance of the trainer was helpful in training
+them to better manage their patient. The fact that the caregivers
+were able to understand the contents of the 7 days programme and
+implement the skills taught to them in the programme in their
+management of the patient, indicates that the programme was
+effective to empower the caregivers.
+Certain methodological issues of this study need mention. Some
+of the members were hesitant to talk in a group situation –
+especially sharing sensitive issues. Caregivers may have expressed
+other needs if they had been individually counselled. To counter
+some of these methodological limitations, informed consent of the
+members to participate in a psychosocial programme was taken
+before the start of the intervention. Those members who were not
+comfortable in talking in a group situation were not taken for the
+study. Caregivers who refused to be part of the pilot study, were
+still provided appropriate counseling as part of the treatment
+process as and when required by their treating team.
+5. Conclusion
+This study is one of the first studies to use a scientifically
+researched inductive enquiry model for the development of a
+A. Jagannathan et al. / Asian Journal of Psychiatry 4 (2011) 113–118
+117
+Author's personal copy
+need-based psychosocial programme for caregivers of in-patients
+with
+schizophrenia
+in
+India.
+Further
+this
+programme
+has
+components that impart skills and techniques in accordance with
+the felt needs of caregivers. Finally these findings are highly
+indicative and future studies could test the efficacy of the
+programme with a larger quantitative sample to reconfirm the
+validity, reliability and generalization of the programme. The
+researchers plan to test the efficacy of this validated psychosocial
+programme for family caregivers of inpatients with schizophrenia
+in India in a larger randomized control trial, as an outcome of this
+study.
+Contributors
+All authors gave their ideas, and contributed to the analysis and
+writing paper. AJ, JT and BNG contributed to the accessing
+resources. AJ contributed to data collecting.
+Role of funding source
+None. The study was conducted as part of the academic
+requirement for the doctoral (PhD) degree programme under the
+Department of Psychiatric Social work and in collaboration with
+the Department of Psychiatry, NIMHANS, Bangalore 560029. India.
+Conflict of interest
+None. None of the authors have any actual or potential conflict
+of interest including any financial, personal or other relationships
+with other people or organizations within three (3) years of
+beginning the work submitted that could inappropriately influ-
+ence, or be perceived to influence, their work.
+Acknowledgement
+None.
+References
+Acton, G.J., Kang, J., 2001. Interventions to reduce the burden of caregiving for an
+adult with dementia: a meta analysis. Research in Nursing and Health 24 (5),
+349–360.
+Angermeyer, M.C., Diaz Ruiz de Zarate, J., Matschinger, H., 2000. Information and
+support needs of the family of psychiatric patients. Gesundheitswesen 62 (10),
+483–486.
+Barbato, A., D’Avanzo, B., 2000. Family interventions in schizophrenia and related
+disorders: a critical review of clinical trials. Acta Psychiatrica Scandinavia 102,
+81–97.
+Barrowclough, C., Marshall, M., Lockwood, A., Quinn, J., Sellwood, W., 1998. Asses-
+sing the needs of the relatives for psychosocial interventions in schizophrenia: a
+relatives’ version of cardinal needs schedule (RCNS). Psychological Medicine 28,
+531–542.
+Chafetz, L., Barnes, L., 1989. Issues in psychiatric caregiving. Archives Psychiatric
+Nursing 3 (2), 61–68.
+Chien, W.T., Norman, I., 2003. Educational needs of families caring for Chinese
+patients with schizophrenia. Journal of Advanced Nursing 44 (5), 490–498.
+Cleary, M., Freeman, A., Hunt, G.E., Walter, G., 2005. What patients and carers want
+to know: an exploration of information and resource needs in adult mental
+health services. Australian and New Zealand Journal of Psychiatry 39, 507–513.
+Gabi Pitschel-Walz, 2004. The effect of family interventions on relapse and re-
+hospitalization in schizophrenia: a meta-analysis. Focus 2, 78–94.
+Goswami, M., 2006. From a family care-giver to a care-giver at the community level
+– ‘‘Ashadeep model’’. In: Murthy, R.S (Ed.), Mental Health by the People. Peoples
+Action for Mental Health (PAMH), Bangalore, pp. 150–159.
+Jagannathan, A., Thirthalli, J., Hamza, A., Nagendra, H.R., Hariprasad, V.R., Gang-
+adhar, B.N., 2011. A qualitative study on the needs of caregivers of in-patients
+with schizophrenia in India. International Journal of Social Psychiatry 57 (2),
+180–194.
+Janardhan, N., 2006. Community mental health and development model evolved
+through consulting people with mental illness. In: Murthy, R.S (Ed.), Mental
+Health by the People. Peoples Action for Mental Health (PAMH), Bangalore, pp.
+261–281.
+Johnson, D.L., 1994. Current issues in family research: Can the burden of mental
+illness be relieved. In: Lefley, H.P., Wasow, M. (Eds.), Helping Families Cope
+with Mental Illness. Harwood Academic, Newark, NJ, pp. 309–328.
+Lehman, A.F., Steinwaches, D.M., PORT co-investigators, 1998. At issue: translating
+research into practice: The Schizophrenia Patient Outcomes Research Team
+(PORT) treatment recommendations. Schizophrenia Bulletin 24 (1), 1–10.
+Pekkala, E., Merinder, L., 2004. Psychoeducation for schizophrenia. Cochrane Data-
+base of Systematic Reviews (1).
+Pharoah, F.M., Mari, J.J., Streiner, D., 2000. Family intervention for schizophrenia
+(Cochrane Review). The Cochrane Library, Issue 3. Update Software, Oxford.
+Shinde, S., 2005. Short term effects of family psycho-education in schizophrenia.
+Thesis in MD Psychiatry, NIMHANS, Bangalore, India.
+Soloman, P., Draine, J., 1994. Examination of Adaptive Coping Among Individuals
+with a Serious Mentally Ill Relative, Unpublished paper. Hanerman University,
+Department of Psychiatry and Mental Health Science, Philadelphia, PA.
+Thara, R., Padmavathi, R., Kumar, S., Srinivasan, L., 1998. Burden assessment
+schedule: instrument to assess burden on caregivers of chronically mentally
+ill. Indian Journal of Psychiatry 40, 21–29.
+Toseland, R.W., McCallion, P., Smith, T., Huck, S., Bourgeois, P., Garstka, T.A., 2001.
+Health education groups for caregivers in an HMO. Journal of Clinical Psychol-
+ogy 57 (4), 551–570.
+Wancata, J., Krautgartner, M., Berner, J., Scumaci, S., Freidl, M., Alexandrowicz, R.,
+Rittamannsberger, H., 2006. The ‘‘carers’ needs assessment for schizophrenia’’.
+Social Psychiatry and Psychiatric Epidemiology 41, 221–229.
+A. Jagannathan et al. / Asian Journal of Psychiatry 4 (2011) 113–118
+118

subfolder_0/Development of sushrutha prakriti inventory, an Ayurveda based personality assessment tool.txt

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+Jour. of Ayurveda & Holistic Medicine 
+Volume-II, Issue-VIII  
+ 
+6 
+ 
+ 
+DEVELOPMENT OF SUSHRUTHA PRAKRITI INVENTORY, AN AYURVEDA 
+BASED PERSONALITY ASSESSMENT TOOL 
+Ramakrishna B R1  Kishore K R2   VaidyaV3  Nagaratna R4  Nagendra H R5 
+ 
+ 
+INTRODUCTION: 
+Human being is a social animal and a product of social 
+circumstances. Society influences his life and he influences 
+the society. In the process of interaction between man and 
+society, a kind of characteristics emerge in man, which can be 
+considered as his way of behavior and subsequently that 
+becomes the pattern of his life which is called personality / 
+Prakriti. There are many ways of understanding and 
+interpreting these characteristics and from time to time many 
+scholars have tried to define personality.  
+Definition of personality  
+Theories, speculations and hypothesis have been developed 
+across the globe, defining and assessing human behavior in 
+terms of his unique traits and types. According to Allport, 
+personality is the dynamic organization within the individual 
+of those psychophysical systems that determine his unique 
+adjustments to his environment. [1]Personality includes three 
+aspects of an individual viz. the psychological, biological and 
+environmental. 
+It 
+encompasses 
+those 
+enduring 
+characteristics which make each one unique and directs the 
+behavior in a predictable manner in different situations and 
+also during stressfully demanding situations. The biological 
+aspects 
+consisting 
+of 
+genetic, 
+neurophysiologic, 
+neurochemical and endocrinological components predispose 
+the individual for a particular behavior that he / she may 
+exhibit. This, in interaction with socio-cultural components 
+such as learning, language, religion and society influences the 
+development of personality.[2] 
+Classification of types of personality 
+Different cultures and schools of thoughts have put forth 
+their concepts of personality through scientific and empirical 
+studies.Hippocrates classified people on the basis of four 
+bodily humours – blood, phlegm, black bile and yellow bile.[3]. 
+Later, Sigmund Freud the father of psychoanalysis viewed 
+personality on three aspects, i.e. the structural, dynamic and 
+psychosexual.[4]The structural aspects of personality include 
+the id, ego and the super ego. The dynamic aspects contain 
+ABSTRACT: 
+Background: Assessment of human population based on Prakriti (constitution) is the first step in Ayurveda practice.  
+Our survey amongst practicing Ayurveda doctors had established the need for a standardized Prakriti assessment tool. 
+Aim: To develop a comprehensive tool for assessment of Prakrti. Settings and design: The tool was developed at 
+Sushrutha Ayurveda Medical College, Bengaluru by checking (a) Content/ consensual validity by focussed group 
+discussions (FGD) after item generation, (b) reliability by field trial on 300 healthy volunteers, correlations between 
+subjective and objective assessment, Cronbach’salpha and (c) test retest reliability on 30 subjects. Methods: 
+Characteristics of   Vata, Pitta and Kapha personalities from ten authentic classics of Ayurveda were compiled. Twelve 
+Ayurveda experts and two psychologists formed the focussed group for validation at different steps. Reliability test was 
+done on 300 healthy volunteers; of these 30 subjects were assessed independently by 5 experts; 75 of these were 
+retested after one month.  Results: A total number of 861 features were pooled. By applying Edward’scriteria  it 
+reduced to 490 and by applying Jackson’s criteria it reduced to  99 for part 1 (self-administered) and  60 for part 2 
+(clinician’s assessment). The version(90+60 items) that evolved after content / consensual validation by 12 experts had 
+Cronbach’s alpha between 0.61 to 0.80.Pearson’s correlations of subjective vs objective assessment was > 0.95 and 
+Test-retest reliability was>0.95 for all three Prakritis. Conclusion: This study has yielded a scientifically standardized tool 
+called SPI with two parts, SPI-A with 90 questions and SPI-B with 60 items, to assess the Prakriti of an individual.  
+Key Words: Sushrutha, Prakriti, Inventory, Assessment. 
+1Ph.D.(Yoga) scholar, 4Medical Director, 5Chancellor. Swami 
+Vivekananda 
+Yoga 
+Anusandhana 
+Samsthana 
+(S-VYASA) 
+University, Bengaluru. 
+2Research officer, National Ayurveda Dietetics Research 
+Institute, Jayanagar, Bengaluru. 
+3Deputy medical superintendent, Sushrutha Ayurveda Medical 
+College and Hospital, Bengaluru. 
+Corresponding author email address: 
+ [email protected] 
+Access this article online: www.jahm.in 
+Published by Atreya Ayurveda Publications under the license 
+CC-by-NC. 
+Received on: 26/09/14, Revised on: 18/11/14, Accepted on: 
+23/11/14 
+Jour. of Ayurveda & Holistic Medicine 
+Volume-II, Issue-VIII  
+ 
+7 
+ 
+the conscious, unconscious and defence mechanisms. The 
+psychosexual aspect is understood in terms of the child’s 
+development in five subsequent stages. They are oral, anal, 
+phallic, lateen and genital. Sheldon and Kretschmerweretwo 
+scholars who classified personality on the basis of physic.[5]). 
+Kretschmer classified people as pyknic who are fat and 
+short.[6] Asthenic who are bony and lean and athletic who are 
+muscular.  Sheldon gave a more complex and valid 
+classification of personality. He found the relationship 
+between body build and temperament. He typed individuals 
+into 
+endomorphic, 
+mesomorphicand 
+ectomorphic.In 
+psychology, the Big Five personality traits are five broad 
+domains or dimensions of personality that are used to 
+describe human personality. The theory based on the Big Five 
+factors is called the five-factor model.[7] The five factors are 
+openness, conscientiousness, extraversion, agreeableness, 
+and neuroticism. According to yoga, the personality is 
+determined by three gunas namely the satva, rajas and 
+tamas, which are also the basic dynamic materials with which 
+the universe is made of. 
+Ayurveda describes personality as Prakriti, a Sanskrit word 
+that means nature or natural form of constitution of an 
+individual.Ithas propounded a distinctive way of classifying 
+the human population based on the concept ofPrakriti.The 
+different variants of Prakriti are based on the principles of 
+tridoshas namelyVata (motion), Pitta (metabolism) and 
+Kapha (structure) This concept had so far remained elusive 
+and was looked upon as esoteric. But the work by 
+Patwardhan et al.[8] has opened up great interest by Modern 
+biomedical scientists after they demonstrated a correlation 
+between HLA alleles and Prakriti type. Prakriti is formed in 
+the womb of the mother at the time of conception due to the 
+predominant dosha/doshas and it determines the true nature 
+of an individual with respect to physical, physiological and 
+psychological dimensions for the whole life. Prakriti of an 
+individual remains intact and cannot be changed throughout 
+life but can be modified by changing one’s life-style (Ahara-
+food and drinks, Vihara-habits and practices – Vichara- 
+thoughts the basic components of Yoga) in a positive 
+(positive health) or negative way(vikrti) 
+Prakriti is of seven types namely Vatala, Pittala, Kaphala, 
+VataPittala, VataKaphala, PittaKaphala and Sama Prakriti 
+based on the predominance of doshas. A study by Bhushan 
+and Kalpana.[8] has demonstrated a correlation between the 
+tissue type HLA and Prakriti types to support this. Joshi et. 
+al.[8]found  a  biostatical approach to compute quantitative 
+estimates of tridoshas in terms of accuracy of estimation with 
+statistical confidence level above 90% that could be used for 
+the scientific establishment of Ayurveda in a new light. 
+Tools  
+Although the traditional training of all Ayurveda physicians 
+and students does include Prakriti assessment as the first and 
+the most important step in treating a patient, there is no 
+standardized tool available to assess Prakriti.There have been 
+preliminary attempts to develop clinical tools to identify 
+these Prakriti types. A few such attempts are worth 
+mentioning: Chopra, [9] published a brief version to help 
+common man to assess one’s own personality that has three 
+sections i.e. Vata, Pitta and Kapha. The data extractable from 
+this tool seems linear where as there is coupling seen in the 
+presentations of these Prakriti. The data extractable from 
+Kasture’s(22) questionnaire does not seem to have sufficient 
+stress on the higher mental predispositions. A Software that 
+intends 
+to 
+measure 
+Prakriti 
+called 
+AyuSoft,[10]has 
+inconsistencies in terms of close ended questionsand has too 
+manyquestions compromising on its user friendliness. 
+Further, these tools have not been subjected to standard 
+tests of validity and reliability. Our survey revealed that most 
+of the Ayurvedic physicians use Prakriti assessment in their 
+practice; many do not knowthe availability of standardized 
+tools, have expressed an urgent need for such a tool and also 
+willingness to use it. With this background the present study 
+was planned to develop a comprehensive, user friendly, non-
+linear clinical instrument. 
+METHODS: 
+A group of 12 Ayurveda experts with MD and/or PhD in 
+Ayurveda from different specialties were invited to 
+participatein the study. Two psychologists who had 
+experience in developing inventories were also a part of this 
+group. Guidance was also sought from one statistician at 
+different stages. After a signed informed consent, these 
+experts met for focused group discussions (FGD) at each step 
+of the study in the library of Sushrutha Ayurveda Medical 
+College, Bengaluru, to enable referring to different texts.  
+In the first step of ‘Item generation’  all words and sentences 
+referring to the characteristics of the three doshas were 
+compiled by the researcher from ten authentic Ayurveda 
+classical texts viz. Charaka Samhita, Sushrutha Samhita, 
+Ashtanga Sangraha, Ashtanga Hrudaya, Bhela Samhita, 
+Kashyapa Samhita, Haritha Samhita, Sharngadhara Samhita, 
+Bhavaprakasha Samhita and Yogaratnakara. 
+In the second step of ‘Item reduction’,the number of items 
+was reduced to 490 by deleting all repeated words as per 
+Edward’scriteria.Then the items were divided into two sets 
+namely physical features (175) used for part 2 of the SPI and 
+the non-physical features (315) used for construction of 
+questions for the part 1 as a questionnaire. The discussions 
+for the third step of ‘content validity’ to apply Jackson’s 
+criteria of deleting words with the same meaning resulted in 
+99 questions (33 each for Vata, Pitta and Kapha) and 60 
+items for physical checklist (20 each for Vata, Pitta and 
+Kapha). Then the researcher sat with the two psychologists 
+for reconstruction of the questions in acceptable English 
+language. To establish the consensual validity the group of 
+experts scored all these 99+60 questions on a four point scale 
+i.e. most appropriate (score 1), appropriate (2), not 
+appropriate   (3) and  not at all appropriate (4). The response 
+bias was taken care of by avoiding interaction  between the 
+experts during  validation.  
+After this, the initial SPI consisting of two parts, SPI-Q 
+(Sushrutha Personality Inventory- Questionnaire), a self-
+administered questionnaire with 99 items that included all 
+non-physical characteristics to be answered by the subject 
+and, SPI-C (Sushrutha Personality Inventory Check-list) with 
+60 items that included all  physical characteristics to be filled 
+by the observer was available. 
+In the next step of reliability testing, a field study was carried 
+out by administering the test to healthy volunteer students of 
+both genders (139 females and 161 males) in the age range of 
+Jour. of Ayurveda & Holistic Medicine 
+Volume-II, Issue-VIII  
+ 
+8 
+ 
+19 to 24 years who consented to participate in the study. 
+They completed the self-administered SPI –Q while seated in 
+a class room with enough gaps between them to avoid 
+interaction. 
+The 
+researcher, 
+an 
+Ayurveda 
+physician, 
+interviewed each one of them individually to complete the 
+second part, the SPI-C, which took about ten minutes for 
+each student. 
+In the next step after analyzing the results of the field study 
+and the feed back from the FGD necessary language 
+corrections in the sentences were made with a further 
+reduction in the number of items. Thus the final SPI evolved 
+with part 1, (SPI-Q) consisting of 90 questions (30 each for 
+Vata, Pitta and Kapha) and part 2 (SPI-C) consisting of 60 
+items (20 each for Vata, Pitta and Kapha). 
+Expert validation was done on 75 subjects (40 females and 35 
+males), randomly selected from the group of 300 students 
+assessed during field testing.   Five experts who were blind to 
+the scores of SPI carried out Prakriti assessment of these 75 
+subjects independently  (without any interaction between 
+the experts) based  on their own experience and the result 
+sheet was kept away confidentially for  correlations with the 
+objective scores of SPI-Q and  SPI-C that were already 
+available from the initial field testing data base. 
+Test retest validity was checked by administering the final 
+test material to 30 subjects randomly selected from the 
+original population of 300 students after four weeks in the 
+same setting. 
+Data analysis  
+Data was analysed by using SPSS-15 software. Descriptive 
+statistics was used to obtain the percentage of students in 
+different categories of Prakritis. Normality of data was 
+checked by Kolmogorov Spirnov test. Since all data were 
+normally distributed, percentile distribution was used to 
+describe the number of students in Vata, Pitta or Kapha 
+groups. Pearson’s correlations test was used to check 
+correlations. Cronbach’s Alpha was applied to know the 
+consistency / Reliability of items in Vata, Pitta and Kapha. 
+RESULTS: 
+Fig. 1 shows the results of the steps of development and 
+validation. Phase 1 of the process of Scale Development for 
+SPI 
+included 
+the 
+following 
+steps. 
+(i) 
+Item 
+Generation/Construction that yielded 856 items, (ii)Item 
+Reduction (conceptual validity ) reduced it to 490 items, and 
+(iii) content/consensual validity as assessed by 12 experts 
+(deleted all those items with scores 3 and 4) which reduced it 
+to 90 + 60 items.  
+Phase 2 checked the validity and reliability by (i) field testing 
+on 300 subjects, (ii) looking at correlation between subjective 
+assessments by 5 experts and the scores obtained from SPI 
+on 75 subjects, (iii) Test and retest reliability by administering 
+SPI-Q once again 4 weeks after the initial test to 30 (15 males 
+and 15 females) selected from the original group, and (iv) 
+calculating Cronbach’s alpha for standardized and un-
+standardized data set from 300 samples.     
+Item generation: 
+Table-1 shows the number of items under each of the three 
+dosha characteristics from a total of 861 itemsgenerated 
+from 10 classical texts of Ayurveda.  
+Content validation 
+Applying Edward’s criteria, [11] the items that had same words 
+from the ten texts were removed and 490 items were 
+retained. Applying Jackson’s criteria,[12] the words that had 
+similar words with same meaning were replaced by the most 
+suitable word. The 108 items that remained were scored by 
+12 experts (E1 to E12 - Tables in supplementary file) on a 
+scale of 4 (most appropriate, appropriate, not applicable and 
+not at all applicable) independently without interaction 
+between them to avoid response bias. Ninety nine items of 
+SPI-Q that had scores 1 or 2 as marked by 12 experts were 
+retained and those marked 3 (not appropriate) or 4 (not at all 
+appropriate) were deleted. Items 1 to 33 were descriptions of 
+Vata of which items 31 and 29 were marked 3 or 4 and hence 
+were deleted. Items number 40, 52 and 61 had to be deleted 
+from 33 of the Pitta questions; question number 74, 88 and 
+91 were deleted from the questions depicting Kapha. All 60 
+items of SPI-C were retained as there was consensus for all 
+with scores of 1 or 2. 
+Phase 2- validity and reliability tests 
+Table 2. shows the results of the field study on 300 students 
+(139 females and 161 males) in age range of 19 to 24 
+years.The mean and SD, and the range of the values for the 
+three doshas are tabulated. 
+Among the 30 questions of Vata of SPI-Q, the lowest value 
+was 2.0 and 3.0 for males and females respectively, and the 
+highest was 19.0(M) and 20.0(F). Among the 30 questions of 
+Pitta of SPI-Q, the lowest value was 4 for both males and 
+females, and the highest values were 27.0(M) and 21.0(F). 
+Among the 30 questions of Kapha of SPI-Q, the lowest value 
+was 6.0 for males and7.0 for females, and the highest values 
+were 24.0(M) and 24.0(F).  
+Subjective vs. objective reliability 
+Results of reliability test that compared the subjective 
+assessments by 5 experts on 75 randomly selected subjects 
+from the pool of  the original sample of  300  (used for field 
+study) also showed highly significant correlations (r 
+values≥0.98)  for V, P and K on both SPI-Q and SPI-C.  
+Cronbach’s α test 
+Cronbach α (Table 3) was applied to know the consistency / 
+Reliability of items in V, P and K.  The reliability score for 
+unstandardized items was 0.708 whereas the reliability score 
+for standardized items was 0.734. The reliability was 
+determined based on the following valuesof Cronbach’s α: 
+Not reliable = 0 to 0.40, Moderate reliability = 0.41 to 0.60 , 
+Good reliability = 0.61 to 0.80and very High reliability = 0.81 
+to 1.00. Thus the present study the Cronbach’s α obtained 
+was between 0.61 to 0.80 giving good reliability of the SPI-Q 
+inventory. 
+Test–retest reliability  
+Results of test–retest reliability statistics using Pearson’s 
+correlations on 30 randomly selected subjects (15 males and 
+15 females) showed r values ≥0.98 for V, P and K on both SPI-
+Q and SPI-C 
+Normative values of SPI 
+ 
+The data of 300 normal subjects in age range of 19 to 24 
+years were compiled by combining the scores of both parts of 
+Jour. of Ayurveda & Holistic Medicine 
+Volume-II, Issue-VIII  
+ 
+9 
+ 
+the inventory and they were categorized as low, medium and 
+high scores for the three Prakrititypes. These values were 
+derived by computing the reference ranges as shown in table-
+Fig 1:  Flow chart of the steps of development and validation of SPI. 
+ 
+Step1 
+Content generation 
+Items from 10Ayurveda classics. 
+Vata-277,  Pitta-272,  Kapha-312.Total-861 
+ 
+ 
+Step 2 
+Item reduction( Edward’s Criteria) 
+Vata-157,Pitta 142,Kapha-191,Total-490 
+Physical-175   non- physical- 315 
+ 
+ 
+Step 3 
+Content validity(Jackson’s criteria) 
+Part 1  -99 
+V-33, P-33, K-33 
+Part 2- 60 
+V-20, P-20, K-20 
+Fig. 2: 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+Phase 2 
+Reliability – field testing - 300 healthy volunteers 
+Test retest reliability – 75 from the same set 
+Expert validation  - 30 from the same set 
+Cronbach’s alpha 
+ 
+ 
+Phase 3 
+Normative values of V,P, K, for males and females 
+ 
+ 
+Step 4 
+Consensual validity- 12 experts 
+Scoring  on 4 point scale 
+Final Part 1 - SPI-A 
+V-30, P-30.K-30 
+Final Part 2 - SPI-B 
+V-20,P-20,K-20 
+Jour. of Ayurveda & Holistic Medicine 
+Volume-II, Issue-VIII  
+ 
+10 
+ 
+ 
+Table 1: Number of features of different types of Prakriti from  10 Ayurveda classics 
+No. 
+Authors 
+Vata 
+Pitta 
+Kapha 
+Total 
+1 
+Charaka samhita 
+58 
+54 
+38 
+150 
+2 
+Sushrutha samhita 
+33 
+32 
+38 
+103 
+3 
+Astanga hridaya 
+51 
+55 
+80 
+186 
+4 
+Astanga sangraha 
+55 
+61 
+71 
+187 
+5 
+Sharangadhara samhita 
+06 
+05 
+05 
+16 
+6 
+Bhavaprakasha samhita 
+09 
+08 
+06 
+23 
+7 
+Harita samhita 
+18 
+14 
+21 
+53 
+8 
+Bhela samhita 
+19 
+21 
+29 
+69 
+9 
+Yogaratnakara 
+17 
+11 
+13 
+41 
+10 
+Kashyapa samhita 
+11 
+11 
+11 
+33 
+ 
+Total 
+277 
+272 
+312 
+861 
+ 
+Table  2 : Range and mean values for V,P K in 300 healthy volunteers  
+Test  
+Groups 
+Category 
+VATA 
+PITTA  
+KAPHA  
+SPI-A 
+ 
+ 
+Total 
+Range 
+5.60-20.64 
+4.38-20.72 
+4.93-20.69 
+Mean ±SD 
+10.17± 3.85` 
+12.83 ± 4.00 
+15.56 ± 3.84 
+Males 
+Range 
+2.54-17.77  
+5.60-20.64 
+8.47-22.78 
+Mean ±SD 
+10.16 ± 3.88  
+13.12 ± 3.84 
+15.63 ± 3.65 
+ 
+Normality (P) 
+0.302 
+ 
+0.135 
+0.529 
+ 
+ 
+Range 
+2.68-17.71 
+4.38-20.72 
+7.58-23.40 
+Females 
+Mean ±SD 
+10.19 ± 3.83 
+12.55 ± 4.17 
+15.49 ± 4.04 
+Normality (P) 
+ 
+0.076 
+0.194 
+ 
+0.228 
+ 
+ 
+Table 3:    Reference range for V , P and K  based on SPI-A (30 each for V, P, K) and SPI-B (20 each for V, P, K)   
+ 
+VATA 
+PITA 
+KAPHA 
+Sample size 
+300 
+300 
+300 
+Lowest  value 
+2.0 
+6.0 
+8.0 
+Highest value 
+30.0 
+32.0 
+39.0 
+Mean 
+14.29 
+17.28 
+23.1 
+Median 
+14.00 
+17.00 
+23.0 
+SD 
+4.62 
+4.97 
+5.57 
+Co-efficient of Skewness 
+0.45 
+0.22 
+-0.015 
+Jour. of Ayurveda & Holistic Medicine 
+Volume-II, Issue-VIII  
+ 
+11 
+ 
+Co-efficeint of kurtosis 
+0.50 
+0.31 
+-0.038 
+D`Agastino Pearson test for Normal distribution 
+0.002** 
+0.154 
+0.958 
+Normality 
+Not Normal 
+Normal 
+Normal 
+90% Reference Interval 
+7.50-22.00 
+9.10-25.5 
+13.8-32.2 
+Interpretation 
+Low 
+<7.50 
+<9.1 
+<13.8 
+Medium 
+7.50-22.00 
+9.1-25.5 
+13.8-32.2 
+High 
+>22.0 
+>25.5 
+>32.2 
+ 
+Based on the values for low (L), medium (M) and high (H) 
+scores for V, P and K, classification of these 300 subjects was 
+done with 27 combinations (table 3). 70% (210 subjects) of 
+the population had Medium V, P and K indicating that these 
+were completely normal and the remaining 30% (90 subjects) 
+had variations in Prakriti distributed amongst other 26 
+combinations. Among 139 males and 161 females (100%), 96 
+males and 114 females (70%) werein the Medium V,P and K  
+and remaining 42 males and 48 females (30%) were in other 
+categories of Prakriti. A few examples of the percentage of 
+subjects in different combinations are: (i)  0% in category Low 
+Vata (VL) + low Pitta (PL) + low Kapha (KL)  (ii) 0.7% in 
+category VL+ PL + KM ; (iii) 0% in category VL + PM + KH  ;(iv) 
+0.3% in VL + PM + KL ;(v) 3.0% in VL + PM + KM;  (vi) 0.3% in 
+VL + PM + KH; (vii) 0.0  % in VL + PH + KL; (viii) 0.7% VL + PH + 
+KM. 
+DISCUSSION: 
+In this study, ten authentic classics of Ayurvedawere selected 
+as the source for item generation. Focussed group 
+discussions by 12 Ayurveda experts and two psychologists 
+was carried out to evolve a standardized tool called SPIwith 
+two parts, namely SPI-Q with 90 questions that includes the 
+Physiological, Psychological, Social, Intellectual and Spiritual 
+domains and SPI-C with 60items to assess the physical 
+characteristics of Prakriti. A strong reliability was found 
+between SPI-Qwith experts’ subjective assessment scores for 
+>0.95; correlations between SPI-C and experts’ subjective 
+assessment score were also highly significant with r values > 
+0.95. There was also highly significant Test – retest 
+reliability.Chronbach’s alpha was also highly significant with α 
+values >0.95for V,P,K of both SPI-Qand SPI-C. 
+Comparisons 
+The literary survey of the selected classics revealed that there 
+are significant differences among the authors to describe 
+different features of Prakriti with respect to different 
+domains. Charaka being the authority of medicine has not 
+given any features of Prakriti in relation to the spiritual 
+domain, Sushruta and Vagbhata have given importance 
+toanalogieswhile describing the features of Prakritias they 
+seemed to believe that Upamana (analogy) is the best 
+method of understanding the highest truth. All the authors 
+have given due importance to physical ,physiological and 
+psychological 
+domains. 
+Harita, 
+Sharanghadhara, 
+Bhavaprakash and Kashyapa have not considered the social 
+domain while Sharangadhara and Kashyapa have not given 
+any consideration to spiritual domain. This may be due to the 
+fact that the Kashyapa has been an expertise on paediatrics 
+and Sharanghadhara has been an authority on pharmacy and 
+pharmaceuticals.The table 7below gives the details of the 
+number of items available in different texts on different 
+domains. 
+ 
+Table 4: Items available in classical texts under  different domains  
+Sl. no 
+Domains 
+Number of items obtained  from   ten classical texts 
+1* 
+CS 
+2 
+SS 
+3 
+AH 
+4 
+AS 
+5 
+BS 
+6 
+HS 
+7 
+BpS 
+8 
+SdS 
+9 
+YR 
+10 
+KS 
+Total 
+1 
+Physical  
+57 
+40 
+56 
+60 
+22 
+20 
+11 
+7 
+9 
+6 
+288 
+2 
+Physiological 
+67 
+15 
+53 
+57 
+14 
+9 
+5 
+2 
+7 
+25 
+254 
+3 
+Psychological  
+18 
+26 
+46 
+48 
+24 
+21 
+5 
+4 
+13 
+2 
+207 
+4 
+Intellectual 
+4 
+9 
+8 
+9 
+5 
+0 
+1 
+3 
+5 
+0 
+44 
+Jour. of Ayurveda & Holistic Medicine 
+Volume-II, Issue-VIII  
+ 
+12 
+ 
+5 
+Spiritual 
+0 
+3 
+9 
+6 
+2 
+3 
+1 
+0 
+2 
+0 
+26 
+6 
+Social 
+4 
+7 
+10 
+7 
+2 
+0 
+0 
+0 
+5 
+0 
+35 
+7 
+Analogies 
+0 
+3 
+4 
+0 
+0 
+0 
+0 
+0 
+0 
+0 
+7 
+ 
+Total  
+150 
+103 
+186 
+187 
+69 
+53 
+23 
+16 
+41 
+33 
+861 
+Abbreviations: CS - Charaka Samhita, SS - Sushrutha Samhita, AH - Astanga Hridaya, AS - Astanga Sangraha, BS - Bhela Samhita, HS - Haritha 
+Samhita, BpS - Bhavaprakasha Samhita, SdS - Sharangadhara Samitha , YR - Yogaratnakara, KS - Kashyapa Samhita. 
+Comparisons of tools in English language  
+There are a few existing tools in English language that are 
+available which are very popular. Chopra, in his popular book 
+‘Perfect health’ published a brief version of Prakriti 
+assessment tool to help common man to assess one’s own 
+personality that has three sections i.e. Vata, Pitta and Kapha. 
+The data presented inthis tool islinearand not clear in the 
+presentations of thePrakrtis. The data extractable from 
+Kasture’s (1997) questionnaire, although non-linear, it does 
+not seem to have sufficient stress on the higher mental 
+predispositions. Athavale (2004) seems to have just listed the 
+attributes of Prakriti which cannot be effectively used as a 
+tool. A software that intends to measure Prakriti called 
+AyuSoft, seems to have inconsistencies in terms of close 
+ended questions and there are too many questions 
+compromising on the user friendliness of the instrument. 
+Further, these tools have not been subjected to any of the 
+standard tests of validity and reliability.  The table below 
+gives a comparison of all available tools. Table 16 below gives 
+a comprehensive comparison of all available tools  
+ 
+Table 5: Comparison of different tools available for assessment of Prakriti 
+Sl . no. 
+Title and reference 
+ 
+ Total number  and aspects covered  
+Comments 
+1 
+Development and standardization of Mysore  
+psychological Tridosha scale 
+(2011)(16) 
+The authors have developed a 
+personality scale to assess Tridoshas i.e. 
+Vata, Pitta, and Kapha from 
+psychological perspective in human 
+beings. 
+Physical and physiological 
+components are ignored 
+ 
+3 
+Development and validation of  a Prototype 
+Prakriti Analysis Tool (PPAT); Inference from 
+pilot study (Ayu, april 2012)(17) 
+The present study aims to develop a 
+prototype Prakriti analysis tool and its 
+evaluation on inter-rater validity 
+grounds. The study observes that Vata 
+and Pitta constructs of Prakriti 
+identification in Ayurveda have a 
+significant inter-rater correlation (P < 
+0.001 and P < 0.01), whereas Kapha has 
+less (P < 0.02) correlation. 
+A pilot prototype study, 
+study is confined to only 
+Charaka- Samhita 
+4 
+Diets based on Ayurvedic   constitution-
+potential for weight management 
+ (Alternther health med .2009) (18) 
+A retrospective study was conducted to 
+determine the effectiveness 
+ofAyurvedic constitution-based diets on 
+weight loss patterns of obese adults.: 
+Records of 200 obese adults, both male 
+and female, who had completed 3 
+months of the diet therapy at Ayurvedic 
+clinics, were examined and data 
+collated 
+Not used  a standardized tool 
+5 
+EGLN1 involvement in high altitude 
+adaptation revealed through genetic analysis 
+of extreme constitution types defined in 
+Ayurveda (19) 
+ In the present study, a link between 
+high-altitude adaptation and common 
+variations rs479200 (C/T) and rs480902 
+(T/C) in the EGLN1 gene. Furthermore, 
+the TT genotype of rs479200, which was 
+more frequent in Kapha types and 
+correlated with higher expression of 
+EGLN1, was associated with patients 
+suffering from high-altitude pulmonary 
+edema, 
+Research oriented study 
+Jour. of Ayurveda & Holistic Medicine 
+Volume-II, Issue-VIII  
+ 
+13 
+ 
+ 
+CONCLUSION: 
+This study has resulted in an administrable tool (SPI-Q and 
+SPI-C) comprising both subjective(90 questions) and objective 
+(60 checklist) methods for assessment of Prakriti based on 
+the concept of tridosha, the most fundamental theory of 
+Ayurveda. It depicts the real nature of different types of 
+Prakriti postulated by different authors.  
+Limitations of the study 
+The reliability test in phase two has used healthy volunteers 
+from one age group in one area of India. Hence the 
+normative values may not be applicable for all populations. 
+The focussed group of experts could have included 
+consultants from modern medicine. 
+Suggestions for future work 
+ Studies to define the normative values in different age 
+groups and in different cultures need to be planned. Factor 
+analysis to define different domains of the tool is 
+recommended. Future work to define the disturbances in 
+Prakriti in different disease states is the next step to 
+understand the scriptural knowledge in the light of modern 
+medicine. Development of tools for assessment of Agniand 
+Aama status in health and disease will provide more 
+authentic and holistic assessments to pave way to developing 
+standardized therapeutic protocols ofAyurveda. 
+Strengths of the study 
+This tool developed by using modern methods of validation 
+and standardisation is the first attempt that has offered 
+6 
+Whole genome expression and biochemical 
+correlates of extreme constitutional types 
+defined in Ayurveda(20) 
+ 
+ 
+Prakriti analysissoftwarewith 23 
+questions in 5 domains.  
+80% concordance between 
+clinical and software analysis.  
+No 
+items 
+for 
+objective 
+assessments   
+ No standardization    
+7 
+Self -rating Ayusoft software and developed 
+by BhushanPatwardhan and team with 
+collaboration from CDAC( 2006) 
+With C-DAC, Dr. Patwardhan has 
+conceptualized an innovative project 
+named AyuSoft, which has been 
+supported by the Ministry of 
+Information Technology. The first 
+version of  
+AyuSoft as a decision support system
+ 
+ 
+No  standardization 
+8 
+Deepak chopra’s body type questionnaire, 
+(21) (1994) 
+20 Q each for vata pitta kapha - 
+Not standardized 
+9 
+Self- rating Kasture’s Prakriti(textbook) 
+1991(22) 
+22 Q, combined for V, P & K, 
+No distinct subjective and 
+objective measures No  
+standardization 
+10 
+ 
+Prakriti software by FRLHT 
+http://www.frlht.org/clinic/index.htm.  
+ 
+A software developed by FRLHT 
+No   standardization 
+11 
+Development of Dhanavantari personality 
+inventory based on tridosha with respect to 
+Ahara,Vihara and Vichara(23) (2006) 
+ 
+60 questions combined for V, P & 
+Kexternal validity; content validity; 
+cross validity; test retest reliability 
+checked. 
+No items for objective 
+assessment. 
+Significant validity and 
+reliability demonstrated. 
+No inter-rater reliability. 
+Unpublished 
+12 
+The human constitution by  Vasant 
+Lad5(1998) 
+Has 20 subjects with three  columns for 
+VPK 
+Not standardized  
+13 
+A Biostatical Approach to Ayurveda: 
+Quantifying the Tridosha8(2004) 
+ 
+Questionnaire for statistical 
+modelling of Ayurvedic diagnostic 
+factors   
+Has 28 items with 3 options for 
+each(VPK).   
+No evidence of 
+standardization  
+14 
+Prakriti pareeksha -RGUHS syllabus (1992) 
+Has 26 items with 3 columns (VPK) 
+Included in the curriculum of 
+BAMS degree No evidence of 
+standardization 
+15 
+Tridosha questionnaire – Vivekananda 
+Yoga Anusandhana Arogyadhama (2000) 
+Has 60 questions (V20, P20 & K20) with 
+triple scoring pattern 
+Scoring pattern is not 
+uniform 
+No   standardization 
+16 
+Diagnostic test for Prakriti - Ayurveda 
+Holistic online.com(AICBS,inc. (2006) 
+Has 4 parts with 58 items with 3 options   No  standardization 
+17 
+ 
+Ayurvedic Constitution Chart – David 
+Frawley(24)(2001) 
+A table of 29 items with 3 options for 
+VPK questions in statement form  
+No   standardization 
+Jour. of Ayurveda & Holistic Medicine 
+Volume-II, Issue-VIII  
+ 
+14 
+ 
+authentic toll for use by the medical professionals in general 
+and the Ayurveda community in particular.   Determining the 
+personality based on Tridoshas adds new dimensions to 
+modern system of medicine to recommend specific life-style 
+changes with/ without medications for prevention and cure 
+of diseases and promotion of positive health. 
+REFERENCES: 
+1. 
+Ian Nicholson, Inventing Personality: Gordon Allport and the 
+Science of Selfhood, American Psychological Association, 
+2003, ISBN 1-55798-929-X 
+2. 
+Singer, MiltonLeVine, R.A.2001 Culture and Personality Studies 
+1918-1960. Journal of Personality. 69:6, 803-818 
+3. 
+Hippocrates Collected Works I. Hippocrates. W. H. S. Jones. 
+Cambridge. Harvard University Press. 1868. 
+4. 
+Sigmund Freud and Lou Andreas-Salome; Letters, Publisher: 
+Harcourt Brace Jovanovich; 1972, ISBN 978-0-15-133490-2 
+5. 
+Sheldon, William H. The Varieties of Human Physique (An 
+Introduction to Constitutional Psychology) ♦ Harper & Brothers, 
+1940 
+6. 
+Authur S. Reber- Dictionary of Psychology, Penguin p.690 
+(1995) (FFM).[2014] 
+7. 
+Bradshaw, S. D. (1997). Impression management and the NEO 
+five factor inventory: Cause for concern? Psychological Reports, 
+80, 832-834. 
+8. 
+Joshi RR. Abiostatistical approach to Ayurveda:quantifying the 
+tridosha. J Altern Complement Med, (2004) 10(5):879-8 
+9. 
+Chopra D Positive health. New York: Crown publishers.1994 
+10. Bhushan. Patwardhan vAyusoft software;   CDAC( 2006 
+11. Arora D, Kumar M.Food allergies-leads from Ayurveda. Indian J 
+med sci, .(2003)57(2): 59-63. 
+12. Jackson(1970,1971,1973,1984:Jackon and Reddon1987) 
+13. Sharma S, Puri S, Agarwal T, Sharma V.D diets based on 
+Ayurvedic 
+constitution--potential 
+for 
+weight 
+management.Alternther health mdcn2009 Jan-Feb;15(1):44-7. 
+14. AggarvalsNegi S, Jha P, Singh PK, Stobdan T, Pasha MA, Ghosh 
+S, Agrawal A; Indian Genome Variation Consortium, Prasher 
+B, Mukerji MEGLN1 involvement in high-altitude adaptation 
+revealed through genetic analysis of extreme constitution types 
+defined in Ayurveda. "ProcNatlAcadSci U S A."[jour] 2010 Nov 
+2;107(44):18961-6. doi: 10.1073/pnas.1006108107. Epub 2010 
+Oct 18. 
+15. Shilpiagaval, sapnanegi, Bhavana Prasher   genomics and 
+molecular medicine, institute of genomics and integrative 
+Biology, CSIR, Newdelhi;Whole genome expression and 
+biochemical correlates of extreme constitutional types defined 
+in AyurvedaJtrans Medicine.2008 
+16. H.S. Kasture.  ; PrakritiShree BaidyanathAyurvedaBhavan, 1991 
+- Health - 210 pages 
+17. Vaidya V; Self rating subjective questionnaire MSc thesis 
+submitted to SVYASA,     (2007) 24)   
+18.  David Frawley , Sandra Summerfield Kozak, Yoga for your Type 
+(2001) 
+ 
+Cite this article as: Ramakrishna B R, Kishore K R,   VaidyaV, 
+Nagaratna R, Nagendra H R. Development of Sushrutha 
+Prakriti Inventory, an Ayurveda based personality assessment 
+tool. J of Ayurveda and Hol Med (JAHM).2014;2(8):6-14. 
+Source of support: Nil, Conflict of interest: None Declared 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 

subfolder_0/Dispositional mindfulness and its relation to impulsivity.txt

@@ -0,0 +1,343 @@
+International Journal Of Yoga
+Philosophy, Psychology and Parapsychology
+Official Publication of
+Swami Vivekananda Yoga Anusandhana Samsthana University
+IJOY-PPP
+Vol. 1 | Issue 1 | January-June, 2013
+ISSN: 2347-5633
+diagnosis of various psychiatric disturbances: Substance 
+abuse, suicidal behaviors, antisocial personality disorders, 
+aggression, bipolar, obsessive  –  compulsive spectrum 
+disorders and pathological gambling.[1,3,4] Higher impulsivity 
+is also associated with increased likelihood of taking to 
+smoking or becoming a heavy drinker.[5] Further, prospective 
+evidence from a large non‑clinical population suggests that 
+high impulsivity could be a risk factor for depression in 
+healthy adults.[6] A trait impulsivity model identifies three 
+components: Attentional impulsivity, or lack of cognitive 
+persistence with an inability to tolerate complexity; motor 
+impulsivity, or acting on the spur of the moment; and 
+non‑planning impulsivity, or lack of a sense of the future (or 
+the past).[7]
+Mindfulness is conceptualized as a state of attentiveness 
+to present events and experiences that is unmediated by 
+discursive or discriminating cognition.[8,9] Mindfulness 
+INTRODUCTION
+Impulsivity has been defined as a predisposition toward 
+unplanned reactions to internal or external stimuli, without 
+regard to the negative consequences.[1] It is characterized 
+by deficits in self‑control, expressed as a repeated failure 
+of self‑discipline, self‑regulation, or sensitivity to the 
+immediate rewards.[2] Impulsivity is a fundamental 
+component, consistently associated with understanding and 
+Dispositional mindfulness and its relation to impulsivity in 
+college students
+Sasidharan K  Rajesh, Judu V Ilavarasu, Srinivasan TM1
+Department of Psychology, 1Division of Yoga and Physical Sciences, Swami Vivekananda Yoga Anusandhana Samsthana, Bengaluru, 
+Karnataka, India
+Address for Correspondence: Mr. Sasidharan K Rajesh, 
+Swami Vivekananda Yoga Anusandhana Samsthana, Yoga Univeristy, #19 Eknath Bhavan, 
+ No. 19, Gavipuram Circle, K. G. Nagar, Bengaluru ‑ 560 019, Karnataka, India. 
+E‑mail: [email protected]
+Access this article online
+Website: 
+www.ijoyppp.org
+Quick Response Code
+DOI: 
+10.4103/2347-5633.123292
+Brief Report
+Context: Impulsivity is a fundamental component, consistently associated with understanding 
+and diagnosis of various neurologic and neuropsychiatric disorders. Aims: The aim of this study 
+is to examine the relationship between self‑reported dispositional mindfulness and impulsivity in 
+a sample of college students. Settings and Design: This is a correlational study using a sample 
+of 370 undergraduate students (226 females and 144 males) from three colleges, in Kerala, India. 
+Participants age ranged from 18 to 26 years with a mean age of 19.47 years (standard deviation = 1.46). 
+Subjects and Methods: Participants were given questionnaire packets including demographic details, 
+mindful attention awareness scale, Barratt Impulsiveness Scale version 11 (BIS‑11) and General Health 
+Questionnaire‑12. Statistical Analysis Used: Pearson correlations were used to examine the association 
+between mindfulness and Impulsivity. Partial correlations were examined between impulsivity and 
+mindfulness measures while controlling for psychological distress. Results: Dispositional mindfulness 
+was negatively correlated with psychological distress (r = −0.40, P < 0.01) and BIS‑11 scores (BIS total: 
+r = 0.50; attentional: r = 0.44; motor: r = −0.23 non‑planning: r = 0.25, P < 0.01). Relationship remained 
+significant between mindfulness and impulsivity while after controlling for psychological distress. 
+Conclusions: Dispositional mindfulness related to the ability to refrain from impulsive behavior in the 
+presence of psychological distress
+Key words: Impulsivity, mindfulness, psychological distress
+ABSTRACT
+49
+International Journal of Yoga - Philosophy, Psychology and Parapsychology  Vol. 1  Jan-Jun-2013
+Rajesh, et al.: Mindfulness and its relation to impulsivity
+International Journal of Yoga - Philosophy, Psychology and Parapsychology  Vol. 1  Jan-Jun-2013
+50
+is a positive dispositional trait inherent to all of us even 
+to those who do not practice mindfulness meditation.[10] 
+Mindfulness training has shown promise in the treatment for 
+smoking cessations and substance use disorders.[11,12] Further 
+dispositional mindfulness was related to higher dispositional 
+self‑control.[13] Furthermore it is reported that mindfulness 
+skills help to abstain from maladaptive impulsive behavior 
+in the presence of negative affect or distress.[14]
+There is a dearth in data in this area as most studies in the 
+area were conducted in other parts of the world. Hence, the 
+aim of this study was to examine the relationship between 
+dispositional mindfulness and impulsivity in a sample of 
+college student in India.
+SUBJECTS AND METHODS
+Participants
+A total of 376 undergraduate students from three colleges 
+affiliated to Mahatma Gandhi University, in Kerala, India 
+were participated in this study. Due to missing data, 
+6 participants were removed, leaving a final sample of 
+226 females and 144 males. Participants age ranged from 
+18 to 26 years with a mean age of 19.47 years (standard 
+deviation = 1.46). Participants were not provided with any 
+incentives for their participation.
+Procedure
+Each participant read and signed an informed consent 
+document. All the procedures were reviewed and accepted 
+by the appropriate institutional review board. Participants 
+were given questionnaire packets including demographic 
+details and self‑report measures. Each packet was assigned 
+an arbitrary code number so that confidentiality could 
+be maintained. We tested approximately 20 participants 
+per session. The average completion time for sessions 
+was 35 min. After participants completed the packet of 
+questionnaires, they were debriefed about the study.
+Measures
+The Mindful Attention Awareness Scale (MAAS) was used 
+to measure dispositional mindfulness. MAAS is a 15‑item, 
+6‑point Likert scale (1 = almost always to 6 = almost 
+never) measure that assesses the quality of attention and 
+awareness that individuals apply to their daily lives. All 
+items of the MAAS are worded in a negative. Participants’ 
+responses to each item are summed to create a total score. 
+A high score indicates a high degree of mindfulness. The 
+Cronbach’s alpha coefficient for the MAAS has been 
+recorded as 0.81.[8]
+The Barratt Impulsiveness Scale version 11 (BIS‑11) is a 
+30‑item questionnaire, which has been extensively used 
+in research on impulsivity and impulse control disorders. 
+Previous research found increased scores on the BIS‑11 in 
+a number of impulsive populations. It was standardized 
+in college students; further, substance abusers showed 
+significantly different group scores in comparison to 
+the student group. All items are measured on a 4‑point 
+scale (1 = Rarely/Never; 2 = Occasionally; 3 = Often; 
+4 = Almost Always/Always). In general four indicates 
+the most impulsive response, but some items are scored 
+in reverse order to avoid a response bias. Eight items are 
+used to measure the attentional impulsiveness dimension, 
+composed of attention and cognitive instability factors. 
+11 items measure motor impulsiveness and perseverance 
+factors in the motor impulsiveness dimension. 11 items 
+measure the participant’s self‑control and cognitive 
+complexity in the non‑planning impulsiveness. The 
+items are summed and the higher the BIS‑11 total score, 
+the higher the impulsiveness level. Total BIS‑11 scores 
+are strongly correlated with other self‑report measures 
+of impulsivity. The BIS‑11 total score demonstrates good 
+internal consistency in undergraduates (α =0.82).[7]
+The General Health Questionnaire (GHQ‑12) is a subset of 
+the GHQ‑28 and is a screening questionnaire for detecting 
+current, independently verifiable forms of psychiatric 
+illness, including depression, anxiety, social impairment 
+and hypochondriasis. The GHQ‑12 has been used 
+extensively world‑wide as a valid and reliable measure 
+for non‑specific psychological distress. The scale contains 
+an equal number of positively and negatively worded 
+questions. Positively worded items have four possible 
+responses, namely “better than usual,” “same as usual,” 
+“less than usual” and “much less than usual.” Responses 
+to negatively worded items are “not at all,” “no more 
+than usual,” “rather more than usual” and “much more 
+than usual.” Each item in response category was coded 
+0‑0‑1‑1, with a total score ranging from 0 to 12 points. High 
+scores indicate greater psychological distress. Previous 
+studies reported that the GHQ‑12 has good psychometric 
+properties.[15] A recent study with a non‑clinical college 
+undergraduate sample has shown an adequate Cronbach’s 
+alpha of 0.87.[16]
+RESULTS
+All statistical analyses were performed using the 
+Statistical Package for Social Sciences  (version  16.0). 
+Pearson correlations were used to examine the association 
+between mindfulness and Impulsivity. Partial correlations 
+were examined between impulsivity and mindfulness 
+measures while controlling for psychological distress. 
+Descriptive statistics for all variable, zero‑order and partial 
+correlation are summarized in Table  1. Psychological 
+distress was significantly and negatively correlated with 
+mindfulness  (r = −0.40, P  <  0.01) and significantly 
+positively correlated with BIS‑11 scores (BIS total: r = 0.35, 
+Rajesh, et al.: Mindfulness and its relation to impulsivity
+51
+International Journal of Yoga - Philosophy, Psychology and Parapsychology  Vol. 1  Jan-Jun-2013
+P < 0.01; attentional: r = 0.36, P < 0.01; non‑planning: 
+r = 0.25, P < 0.01) except the motor impulsivity subscale. 
+As hypothesized, all the correlations between mindfulness 
+and impulsivity were negative and significant. Relationship 
+remained significant between mindfulness and impulsivity 
+while after controlling for psychological distress.
+DISCUSSION
+This study sets out to examine the relationship between 
+dispositional mindfulness and impulsivity among college 
+students. Participants in this study had no formal training 
+in mindfulness techniques. The significant relationship 
+between dispositional mindfulness and different domains 
+on the impulsivity confirmed our primary hypothesis. Even 
+when controlling for the influence of psychological distress, 
+the relationship between dispositional mindfulness and 
+impulsivity scores remained significant. Dispositional 
+mindfulness had strongest relationships to attentional 
+impulsivity domain and these correlations persisted 
+regardless of the extent of psychological distress. This 
+study supports the emerging literature on the benefits of 
+mindfulness construct.
+This finding is consistent with a previous research 
+reporting a negative relationship between mindfulness 
+and impulsiveness.[14] Potential mechanisms by which 
+dispositional mindfulness inhibit the impulsive behavior 
+may be effective self‑regulated behavior and positive 
+emotional states through present movement awareness and 
+non‑reactivity.[8] When combined with previous studies, 
+impulsive tendencies are often lacking in self‑control; 
+however, dispositional mindfulness is positively correlated 
+with self‑control.[17]
+There are some limitations to this study that need to 
+be considered. The sample consisting entirely of young 
+adults may limit the generalization. Future research 
+should examine our findings in more diverse populations. 
+However, the causal direction of this relation is uncertain 
+in these studies due to cross‑sectional design. Longitudinal 
+and experimental studies on mindfulness training may 
+provide causal relationships between mindfulness 
+and impulsivity. Further self‑report measures may be 
+compromised by response biases. Future work should 
+explore the use of comprehensive behavioral and 
+physiological measures.
+Despite these limitations, the present study confirmed 
+our primary hypothesis; dispositional mindfulness is 
+negatively correlated with impulsive behavior. To the 
+best of our knowledge, this may be the first study in an 
+Indian sample to understand the relationship between 
+dispositional mindfulness and impulsivity. Mindfulness 
+can be enhanced by training. Individuals participated in 
+mindfulness meditation leads to increases in dispositional 
+mindfulness, which in turn leads to reduction in clinical 
+symptoms and improved well‑being.[18] Further brief yoga 
+intervention exhibited significant impact on the trait 
+mindfulness.[19] Our study suggests that development of 
+mindfulness in younger populations and understanding 
+possible mechanisms linking mindfulness and impulsivity 
+may be a fruitful avenue for future research.
+ACKNOWLEDGMENT
+We acknowledge all subjects in this study for their participation 
+and college principals who granted permission.
+REFERENCES
+1.	
+Moeller FG, Barratt ES, Dougherty DM, Schmitz JM, Swann AC. Psychiatric 
+aspects of impulsivity. Am J Psychiatry 2001;158:1783‑93.
+2.	
+Strayhorn JM Jr. Self‑control: Theory and research. J Am Acad Child Adolesc 
+Psychiatry 2002;41:7‑16.
+3.	
+Gvion Y, Apter A. Aggression, impulsivity, and suicide behavior: A review 
+of the literature. Arch Suicide Res 2011;15:93‑112.
+4.	
+Liu W, Lee GP, Goldweber A, Petras H, Storr CL, Ialongo NS, et al. 
+Impulsivity trajectories and gambling in adolescence among urban male 
+youth. Addiction 2013;108:780‑8.
+5.	
+Granö N, Virtanen M, Vahtera J, Elovainio M, Kivimäki M. Impulsivity 
+as a predictor of smoking and alcohol consumption. Pers Individ Dif 
+2004;37:1693‑700.
+6.	
+Granö N, Keltikangas‑Järvinen L, Kouvonen A, Virtanen M, Elovainio M, 
+Vahtera J, et al. Impulsivity as a predictor of newly diagnosed depression. 
+Scand J Psychol 2007;48:173‑9.
+7.	
+Patton  JH, Stanford  MS, Barratt  ES. Factor structure of the Barratt 
+impulsiveness scale. J Clin Psychol 1995;51:768‑74.
+8. 
+Brown KW, Ryan RM. The benefits of being present: Mindfulness and its 
+role in psychological well‑being. J Pers Soc Psychol 2003;84:822‑48.
+9.	
+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.
+10.	 Hollis‑Walker L, Colosimo K. Mindfulness, self‑compassion, and happiness 
+in non‑meditators: A theoretical and empirical examination. Pers Individ Dif 
+2011;50:222‑7.
+11.	
+Bowen S, Chawla N, Collins SE, Witkiewitz K, Hsu S, Grow J, et al. 
+Mindfulness‑based relapse prevention for substance use disorders: A pilot 
+efficacy trial. Subst Abus 2009;30:295‑305.
+12.	 Brewer JA, Mallik S, Babuscio TA, Nich C, Johnson HE, Deleone CM, et al. 
+Mindfulness training for smoking cessation: Results from a randomized 
+controlled trial. Drug Alcohol Depend 2011;119:72‑80.
+13.	 Lakey CE, Campbell WK, Brown KW, Goodie AS. Dispositional mindfulness 
+Table 1: Zero‑order and partial correlations (controlling 
+for psychological distress) between mindfulness and 
+impulsivity scores (N=370)
+Measure
+Mean
+SD
+MAAS*
+BIS total
+69.35
+7.34
+−0.50 (−0.42)
+Attentional impulsivity
+18.89
+3.30
+−0.44 (−0.35)
+Motor impulsivity
+24.77
+3.70
+−0.23 (−0.21)
+Non‑planning impulsivity
+25.68
+4.15
+−0.33 (−0.26)
+MAAS
+57.53
+10.45
+‑
+Partial correlations are in parentheses. BIS total=Barratt impulsiveness scale 
+total impulsiveness score, MAAS=Mindfulness attention awareness scale, 
+*P<0.01
+as a predictor of the severity of gambling outcomes. Pers Individ Dif 
+2007;43:1698‑710.
+14.	 Peters JR, Erisman SM, Upton BT, Baer RA, Roemer L. A preliminary 
+investigation of the relationships between dispositional mindfulness and 
+impulsivity. Mindfulness 2011;2:228‑35.
+15.	 Goldberg DP, Gater R, Sartorius N, Ustun TB, Piccinelli M, Gureje O, et al. 
+The validity of two versions of the GHQ in the WHO study of mental illness 
+in general health care. Psychol Med 1997;27:191‑7.
+16.	 Masuda A, Price M, Anderson PL, Wendell JW. Disordered eating‑related 
+cognition and psychological flexibility as predictors of psychological health 
+among college students. Behav Modif 2010;34:3‑15.
+17.	 Bowlin SL, Baer RA. Relationships between mindfulness, self‑control, and 
+psychological functioning. Pers Individ Dif 2012;52:411‑5.
+How to cite this article: Rajesh SK, Ilavarasu JV, Srinivasan TM. 
+Dispositional mindfulness and its relation to impulsivity in college 
+students. Int J Yoga - Philosop Psychol Parapsychol 2013;1:49-52.
+Source of Support: Swami Vivekananda Yoga Anusandhana 
+Samsthana University, Bengaluru, India, Conflict of Interest: None 
+declared
+18.	 Carmody  J, Baer  RA. Relationships between mindfulness practice 
+and levels of mindfulness, medical and psychological symptoms and 
+well‑being in a mindfulness‑based stress reduction program. J Behav Med 
+2008;31:23‑33.
+19.	 Shelov DV, Suchday S, Friedberg JP. A pilot study measuring the impact of 
+yoga on the trait of mindfulness. Behav Cogn Psychother 2009;37:595‑8.
+Announcement
+Android App
+A free application to browse and search the journal’s content is now available for Android based mobiles and 
+devices. The application provides “Table of Contents” of the latest issues, which are stored on the device 
+for future offline browsing. Internet connection is required to access the back issues and search facility. The 
+application is compatible with all the versions of Android. The application can be downloaded from https://
+market.android.com/details?id=comm.app.medknow. For suggestions and comments do write back to us.
+Rajesh, et al.: Mindfulness and its relation to impulsivity
+International Journal of Yoga - Philosophy, Psychology and Parapsychology  Vol. 1  Jan-Jun-2013
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+© 2018 International Journal of Yoga | Published by Wolters Kluwer ‑ Medknow
+170
+Introduction
+Essential hypertension (HTN) is one of the 
+most common public health problems and 
+a leading cause of morbidity and mortality 
+worldwide. It is a modifiable and an 
+independent risk factor for stroke, cardiac 
+disease, and chronic kidney disease[1,2] HTN 
+is responsible for 57% deaths due to stroke 
+and 24% deaths due to coronary artery 
+disease.[3]
+Evidence suggests the growing trends in 
+HTN prevalence worldwide. In China, 
+the prevalence of HTN is reported to 
+be 27%.[4] A survey conducted in 2003 
+in the US, Europe, and Canada reported 
+28% (lowest) prevalence of HTN in the US 
+countries and 44% (highest) in the European 
+countries.[1] In India, highest prevalence of 
+HTN in urban population is men 44% and 
+Address for correspondence: 
+Dr. Kashinath G Metri, 
+School of Yoga and Life 
+Sciences, Swami Vivekananda 
+Yoga Anusandhana 
+Samsthana University, 
+Bengaluru, Karnataka, India. 
+E‑mail: [email protected]
+Access this article online
+Website: www.ijoy.org.in
+DOI: 10.4103/ijoy.IJOY_77_16
+Quick Response Code:
+Abstract
+Introduction: Hypertension  (HTN) is an important public health concern and a leading cause of 
+morbidity and mortality worldwide. Yoga is a form of mind–body medicine shown to be effective in 
+controlling blood pressure  (BP) and reduces cardiac risk factors in HTN. Integrated approach of Yoga 
+therapy (IAYT) is a residential yoga‑based lifestyle intervention proven to be beneficial in several health 
+conditions. Aim: To study the efficacy of 1  week of residential IAYT intervention on cardiovascular 
+parameters in hypertensive patients. Methodology: Twenty hypertensive individuals  (7  females) within 
+age range between 30 and 60  years  (average; 46.62  ±  9.9  years), who underwent 1  week of IAYT 
+treatment for HTN, were compared with age‑ gender‑matched non‑IAYT group (5 females; average age; 
+47.08 ± 9.69 years) in terms of systolic BP (SBP), diastolic BP (DBP), mean arterial pressure (MAP), 
+cardiac output (CO), stroke volume  (SV), baroreflex sensitivity  (BRS), and total peripheral vascular 
+resistance  (TPVR), IAYT program consisted of sessions of asanas, breathing practices, meditation and 
+relaxation techniques, low salt, low‑calorie diet, devotional session, and counseling. Individuals in 
+non‑IAYT group followed their normal routine. All the variables were assessed before and after one week. 
+Data were analyzed using SPSS version 16. RM-ANOVA was applied to assess within group and between 
+group changes after intervention. Results: There was a significant improvement in SBP  (P  =  0.004), 
+DBP  (P  =  0.008), MAP  (0.03), BRS  (P  <  0.001), and TPVR (P  =  0.007) in IAYT, group whereas in 
+control group, we did not find significant difference in any of the variables. Between‑group comparison 
+showed a significant improvement in SBP  (P  =  0.038), BRS  (P  =  0.034), and TPVR  (P  =  0.015) in 
+IAYT group as compared to non‑IAYT group. Conclusion: One‑week IAYT intervention showed an 
+improvement in baroreflex sensitivity, systolic BP, and total peripheral vascular resistance in hypertensive 
+patients. However, further randomized control trials need to be performed to confirm the present findings.
+Keywords: Baroreflex sensitivity, blood pressure, hypertension, integrated approach of Yoga 
+therapy, peripheral vascular resistance, Yoga
+Effect of 1‑Week Yoga‑Based Residential Program on Cardiovascular 
+Variables of Hypertensive Patients: A Comparative Study
+Short Communication
+Kashinath G Metri, 
+Balaram Pradhan, 
+Amit Singh, 
+Nagendra HR
+Division of Yoga and Life 
+sciences, School of Yoga 
+and Life Sciences, Swami 
+Vivekananda Yoga Anusandhana 
+Samsthana, Yoga University, 
+Bengaluru, Karnataka, India
+How to cite this article: Metri KG, Pradhan B, 
+Singh A, Nagendra HR. Effect of 1-week yoga-based 
+residential program on cardiovascular variables of 
+hypertensive patients: A comparative study. Int J 
+Yoga 2018;11:170-4.
+Received: December, 2016. Accepted: April, 2017.
+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]
+women 45% found in Mumbai (survey 
+report reported in years 1999) and lowest 
+14% in Chennai  (survey report reported in 
+years 2000).[5]
+Cause of HTN is believed to be the complex 
+interaction between genetic and environmental 
+factors. Environmental factor includes urban 
+lifestyle characterized by sedentary job, 
+psychological stress, junk food consisting of 
+high‑calorie, salt and less fiber food.[2]
+These 
+causes 
+contribute 
+to 
+autonomic 
+imbalance, characterized by reduced vagal 
+tone and increased sympathetic activity. As 
+the lifestyle is a major cause of HTN and 
+lifestyle modification, intervention plays a 
+major role in management and cure of HTN.
+Yoga is a holistic science, discovered and 
+developed by ancient Indian sages around 
+Metri, et al.: IAYT for hypertension
+171
+International Journal of Yoga | Volume 11 | Issue 2 | May‑August 2018
+5000  years back. It is a tradition of lifestyle, health, and 
+spirituality.[6] Yoga consists of several mind–body practices 
+including physical postures, breathing techniques, and 
+meditation. Several scientific investigations have demonstrated 
+the health benefiting effects of yoga practice in healthy and 
+diseased conditions. Yoga improves cardiovascular variables 
+such as blood pressure (BP), heart rate (HR), HR variability, 
+and baroreflex sensitivity  (BRS).[7,8] Practice of yoga has 
+shown to be effective in improving BP control, HR, and HR 
+variability in hypertensive individuals.[9] A comprehensive 
+review by Innes et  al. reported that yoga practice enhances 
+the parasympathetic activity and reduces sympathetic tone 
+by decreasing activation of hypothalamic‑pituitary‑adrenal 
+axis.[10] Damodaran et  al. demonstrated the potential role of 
+yoga in improving cardiac risk factors.[11]
+Integrated approach of Yoga therapy  (IAYT) is a 
+residential yoga‑based lifestyle intervention program for 
+various chronic health conditions, conducted by SVYASA 
+University, Bengaluru. IAYT consists of several mind–body 
+practices, which include repeated sessions of yoga practice, 
+breathing practices and cleaning techniques (designed for 
+specific health conditions), low salt and low‑calorie diet, 
+devotional session, and turning to nature.
+Previous 
+scientific 
+investigations 
+on 
+IAYT 
+have 
+demonstrated its beneficial in chronic low back pain,[12] 
+anxiety,[13] osteoarthritis,[14] constipation,[15] etc.
+None of the earlier studies on IAYT have looked into its 
+efficacy in HTN.
+With this background, the present study was designed 
+to study the impact of 1‑week IAYT intervention on 
+cardiovascular parameters in individuals with HTN.
+Methodology
+Subjects
+Forty hypertensive individuals (20 IAYT and 20 non‑IAYT 
+group) within the age range 30–60 years with a history of 
+minimum 5 years of HTN were enrolled in this study.
+Source of subjects
+Integrated approach of Yoga therapy group
+Hypertensive individuals who visited SVYAS university 
+campus to attend 1‑week IAYT program for HTN and who 
+fulfill study criteria were included in IAYT group.
+Nonintegrated approach of Yoga therapy group
+Hypertensive individuals from a local area nearby SVYASA 
+University campus who were regular antihypertensive 
+medication were included in non‑IAYT group.
+We included hypertensive individuals  (1) within age 
+range 30–60  years,  (2) of any gender, and  (3) willing to 
+participate in the study. We excluded the individuals if 
+they (1) had diabetes mellitus, (2) had psychiatric problem 
+or are on any antipsychotic medication,  (3) had any kind 
+of surgery recently, (4) had cardiac arrhythmia, and (5) had 
+previous exposure to any form of yoga in the last 1 year.
+Assessments
+Individuals were assessed in the morning between 11 and 
+12 PM, in a silent room, seated on a chair, in a relaxed 
+state. Noninvasive continuous BP monitoring method was 
+used adopting Finapres Medical Systems  (FinaPress) to 
+assess the cardiac variables.[16]
+Data acquisition
+BP signals were converted from analog to digital at 
+100  Hz  (BeatScope 1.1, TNO‑body mass index  [BMI]) 
+for off‑line analysis. Cardiac stroke volume  (SV) was 
+calculated with the use of BeatScope 1.1 software. 
+Mean arterial pressure  (MAP) was the integral over one 
+heartbeat, and HR was the inverse of the pulse interval. 
+Cardiac output  (CO) was SV times HR. Total peripheral 
+resistance  (TPR) was MAP divided by CO, and pulse 
+pressure was systolic minus diastolic pressure. SV, CO, and 
+TPR are expressed relative to sitting in a chair.[17]
+Outcome measures
+•	
+HR
+•	
+Systolic BP (SBP), diastolic BP (DBP), and MAP
+•	
+Cardiac output
+•	
+SV
+•	
+Total peripheral vascular resistance (TPVR)
+•	
+BRS.
+Intervention
+Integrated approach of Yoga therapy group
+Individuals in IAYT group underwent 1‑week residential 
+IAYT intervention consisting of repeated sessions of 
+asana, pranayama, relaxation techniques designed for 
+HTN (the module was being used for more than 20 years); 
+individuals followed satvika diet consisted of low salt, low 
+calorie, and high fiber food and devotional and counseling 
+sessions. Individuals in the control group followed normal 
+daily routines and were on antihypertensive medication.
+Data extraction and analysis
+SBP, DBP, and MAP were extrapolated from finger arterial 
+pressure through the use of a height correction unit and 
+waveform filtering and level correction methods, supplied 
+by the BeatScope software package  (Finapres Medical 
+Systems B.V., 184 Netherlands).
+MAP, SBP, and DBP were expressed in mmHg. SV, CO, 
+TPR, and BRS were also extrapolated from the standard 
+formulae using BeatScope Easy version 2.0 (Smart Medical 
+- Cotswold Business Village - Moreton in Marsh - - United 
+Kingdom)  computer based program. The obtained data 
+were transformed to excel sheet for data analysis. Data 
+were analyzed using SPSS version 10 (IBM Corporation 1 
+New Orchard Road Armonk, New York, United States).
+Metri, et al.: IAYT for hypertension
+172
+International Journal of Yoga | Volume 11 | Issue 2 | May‑August 2018
+Results
+There were no significant difference found between the groups 
+in terms of age, gender distribution, and BMI [Table 1].
+Within‑group comparison
+There was a significant decrease in SBP  (P  =  0.004), 
+DBP (P = 0.008), MAP (P = 0.03), BRS (P < 0.001), and 
+TPVR (P = 0.007) after 1 week of IAYT intervention group 
+compared to baseline, whereas in control group, we did not 
+find significant difference in any of the variables [Table 2].
+Between group comparison
+Between‑group 
+comparison 
+showed 
+a 
+significantly 
+better improvement SBP  (P  =  0.038), BRS  (P  =  0.034), 
+and TPVR  (P  =  0.015) in IAYT group as compared to 
+non‑IAYT group [Table 2].
+Discussion
+This study was aimed to see the efficacy of 1  week of 
+residential IAYT intervention on cardiovascular variables 
+in hypertensive patients. We observed a significant 
+improvement in SBP, SBP, MAP, BRS, and TPVR in 
+intervention as compared to non‑IAYT group.
+IAYT is a residential yoga setup at SVYASA University 
+campus. IAYT was designed by Dr.  Nagaratna R, 
+Medical Consultant, with experience in yoga therapy. 
+Previous studies on IAYT showed its potential role in the 
+management of various chronic health problems such as 
+chronic low back pain, osteoarthritis, asthma, and anxiety. 
+This study is the first attempt to assess the efficacy of 
+IAYT in HTN.
+Yoga intervention has shown to be effective in improving 
+various cardiovascular parameters in hypertensive and 
+cardiac conditions.
+A systematic review by Hagins et  al., 2013, reported that 
+yoga is an effective intervention in reducing BP in HTN.[9] 
+In our study, we also found significant improvement in BP 
+after 1 week of IAYT.
+Very few studies have assessed efficacy of yoga on BRS 
+in HTN. An immediate effect study showed that slow 
+breathing at 6 breaths/min improves BRS in healthy 
+volunteers.
+In another study by Bowman et al., 1997, 6 weeks of yoga 
+intervention improved BRS in elderly persons, whereas 
+practice of aerobic exercises for the same duration in similar 
+population did not improve BRS.[18] Similarly, we also 
+found a significant improvement in BRS, but the duration 
+of intervention was shorter in our study than previous study 
+and previous studies were of healthy persons.
+In another study by Parshad, 2011, 64 healthy students of 
+average age 21.3 years underwent 6 weeks of yoga practice 
+(1 session/week); postintervention, a significant decrease in 
+SBP, DBP, MAP, CO, SV, and TPVR was observed.[19]
+In our study, we also observed a significant reduction in 
+TPVR, but we did not find improvement in CO and SV, 
+probably because 1  week of intervention may not be 
+sufficient to bring an improvement in left ventricular 
+hypertrophy due to which there was no improvement 
+in CO and SV. The intervention period was lesser in our 
+study and the previous study was in healthy students. To 
+ 
+Table 1: Baseline characteristics of the groups
+Variables
+IAYT
+Non‑IAYT
+P
+Number of subjects (n=20)
+Female
+5
+7
+NS
+Male
+15
+13
+Age (mean), years
+46.62±9.9
+47.08±9.69
+NS
+BMI (kg/m2)
+25.45±5.86
+26.27±4.15
+NS
+IAYT = Integrated approach of Yoga therapy, BMI = Body mass 
+index, NS = Not significant
+Table 2: Pre‑post changes in variables in both the groups
+Groups
+IAYT group
+Non‑IAYT group
+Between‑group 
+comparison (P)
+Mean±SD
+Mean 
+difference
+P
+Mean±SD
+Mean 
+difference
+P
+Pre
+Post
+Pre
+Post
+Heart rate (beats/min)
+78.21±2.45
+77.11±2.20
+2.510
+0.665
+76.64±2.18
+75.51±1.799
+1.131
+0.72
+0.579
+SBP (mmHg)
+135.23±5.27 122.73±3.92
+−12.500
+0.004**
+130.72±3.51
+138.62±5.89
+−7.878
+0.12
+0.038**
+DBP (mmHg)
+77.38±3.177 71.45±2.537
+−5.927*
+0.008**
+74.14±1.917
+76.16±2.13
+2.017
+0.36
+0.095
+MAP (mmHg)
+100.02±3.98 91.722±3.11
+−8.299*
+0.003**
+96.060±2.50
+149.60±3.1
+53.541
+0.34
+0.298
+Cardiac 
+output mL/min
+6.55±0.43
+6.76±0.38
+−0.211
+0.460
+6.09±0.25
+6.19±0.31
+0.094
+0.75
+0.557
+Stroke volume 
+mL/stroke
+84.95±5.74
+85.98±4.67
+1.032
+0.826
+80.61±3.39
+83.88±4.88
+3.274
+0.50
+0.785
+Baroreflex sensitivity
+6.30±0.74
+8.97±0.92
+2.673*
+<0.001**
+6.43±0.60
+6.61±0.57
+0.184
+0.65
+0.034**
+Peripheral 
+vascular resistance 
+mmHg/min/mL
+1427.24±166 1036.94±135
+−390.29
+0.007** 1495.73±156.8 1347.01±934.8
+−148.72
+0.19
+0.015**
+SBP = Systolic blood pressure, SD = Standard deviation, IAYT = Integrated approach of Yoga therapy, DBP = Diastolic blood pressure, 
+MAP = Mean arterial pressure. *Significant at the level of o.o1; **Significance at the level 0.001
+Metri, et al.: IAYT for hypertension
+173
+International Journal of Yoga | Volume 11 | Issue 2 | May‑August 2018
+the best of our knowledge, none of the earlier studies have 
+assessed the efficacy of yoga in improving TPR in HTN 
+[Figure 1].
+The exact mechanism behind these findings is not 
+known. However, the possible mechanism could be; 
+change in the lifestyle or following IAYT intervention in 
+terms of increased physical activity,[20] reduced routine 
+psychological 
+stressors,[21] 
+and 
+repeated 
+practice 
+of 
+relaxation and breathing practices[22] which are known 
+to reduce sympathetic activity by downregulation of 
+cortical‑hypothalamic‑pituitary‑adrenal axis.[23] Decreased 
+sympathetic activity is associated with reduction in the 
+BP and peripheral vascular resistance and enhancement of 
+BRS.[24,25] In a study practice of 20  min relaxation, every 
+day has shown a significant reduction in BP.[26]
+Strengths of the study
+(1) To the best of our knowledge, it the first study to assess 
+the effect of yoga on BRS and TPVR in patients with 
+HTN. (2) It is the first study to assess the effect of IAYT on 
+cardiovascular parameters in HTN.  (3) No adverse effects 
+were observed during the IAYT intervention suggesting 
+the feasibility of IAYT in HTN. (4) As intervention was a 
+residential setup, adherence rate was 100%. (4) IAYT is a 
+comprehensive yoga lifestyle.
+Limitations of the study
+The limitations of the study are (1) lack of proper control 
+group and randomization,  (2) small sample size, (3) short 
+intervention, and  (4) IAYT intervention is difficult to 
+follow with daily routine.
+Suggestions for future studies
+Future studies should be carried out using randomized 
+controlled design,  (2) other cardiac autonomic functions 
+such as HR variability and biochemical variables should be 
+assessed. (3) Duration of the intervention should be larger 
+and follow‑up should be done.
+Conclusion
+One‑week IAYT intervention showed an improvement 
+in baroreflex sensitivity, systolic BP, and total peripheral 
+vascular resistance in hypertensive patients. However, 
+further randomized control trials need to be performed to 
+confirm the present findings.
+Financial support and sponsorship
+Nil.
+Conflicts of interest
+There are no conflicts of interest.
+References
+1.	
+Wolf‑Maier  K, Cooper  RS, Banegas  JR, Giampaoli  S, 
+Hense HW, Joffres M, et al. Hypertension prevalence and blood 
+pressure levels in 6 European countries, Canada, and the United 
+States. JAMA 2003;289:2363‑9.
+2.	
+World Health Organization. A  global brief on hypertension: 
+Silent killer, global public health crisis. Geneva, Switzerland: 
+World Health Organization; 2016.
+3.	
+Murray CJ, Lopez AD. Mortality by cause for eight regions of the 
+world: Global Burden of Disease Study. Lancet 1997;349:1269‑76.
+4.	
+Gu  D, Reynolds  K, Wu  X, Chen  J, Duan  X, Muntner  P, et  al. 
+Prevalence, awareness, treatment, and control of hypertension in 
+china. Hypertension 2002;40:920‑7.
+5.	
+Gupta R. Trends in hypertension epidemiology in India. J  Hum 
+Hypertens 2004;18:73‑8.
+6.	
+Jayasinghe SR. Yoga in cardiac health (a review). European Journal 
+of Cardiovascular Prevention and Rehabilitation 2004;11:369-75.
+7.	
+Bernardi  L, Sleight  P, Bandinelli  G, Cencetti  S, Fattorini  L, 
+Wdowczyc‑Szulc  J, et  al. Effect of rosary prayer and yoga 
+mantras on autonomic cardiovascular rhythms: Comparative 
+study. BMJ 2001;323:1446‑9.
+8.	
+Appel  LJ, Moore  TJ, Obarzanek  E, Vollmer  WM, Svetkey  LP, 
+Sacks FM, et al. A clinical trial of the effects of dietary patterns 
+on blood pressure. DASH Collaborative Research Group. N Engl 
+J Med 1997;336:1117‑24.
+9.	
+Hagins M, States R, Selfe T, Innes K. Effectiveness of yoga for 
+hypertension: Systematic review and meta‑analysis. Evid Based 
+Complement Alternat Med 2013;2013:649836.
+10.	 Innes  KE, Bourguignon  C, Taylor  AG. Risk indices associated 
+with the insulin resistance syndrome, cardiovascular disease, and 
+possible protection with yoga: A systematic review. J Am Board 
+Fam Pract 2005;18:491‑519.
+11.	 Damodaran  A, Malathi  A, Patil  N, Shah  N, Marathe  S. 
+Therapeutic 
+potential 
+of 
+yoga 
+practices 
+in 
+modifying 
+cardiovascular risk profile in middle aged men and women. 
+J Assoc Physicians India 2002;50:633‑40.
+12.	 Tekur  P, Singphow  C, Nagendra  HR, Raghuram  N. Effect of 
+short‑term intensive yoga program on pain, functional disability 
+and spinal flexibility in chronic low back pain: A randomized 
+Figure 1: Hypothalamo-pituitary Adrenal Axis (HPA-Axis): Diagram showing 
+mechanism of increase in blood pressure following sympathetic over 
+activity through HPA axis over activation
+Sympathetic activation
+Activation of Cortico-
+hypothalamic path
+Corticotrophin
+releasing hormone
+Pituitary gland
+Corticotrophin
+hormone
+Adrenal gland
+Corticosols, Adrenalin
+and nor-adrenalin
+Increased
+cardiac
+out-put 
+Increased blood
+pressure, total
+peripheral
+vascular
+resistance 
+Sodium retention
+Increased blood
+volume
+Metri, et al.: IAYT for hypertension
+174
+International Journal of Yoga | Volume 11 | Issue 2 | May‑August 2018
+control study. J Altern Complement Med 2008;14:637‑44.
+13.	 Dhansoia  V, Bhargav  H, Metri  K. Immediate effect of mind 
+sound resonance technique on state anxiety and cognitive 
+functions in patients suffering from generalized anxiety disorder: 
+A self‑controlled pilot study. Int J Yoga 2015;8:70‑3.
+14.	 Ebnezar  J, Nagarathna  R, Yogitha  B, Nagendra  HR. Effect of 
+integrated yoga therapy on pain, morning stiffness and anxiety in 
+osteoarthritis of the knee joint: A randomized control study. Int J 
+Yoga 2012;5:28‑36.
+15.	 Rao  J, Metri  KG, Singh  A, Nagaratna  R. Effect of integrated 
+approach of Yoga therapy on chronic constipation. Voice of 
+Research 2016;5:23-26.
+16.	 Lemson  J, Hofhuizen  CM, Schraa  O, Settels  JJ, Scheffer  GJ, 
+van der Hoeven  JG. The reliability of continuous noninvasive 
+finger blood pressure measurement in critically ill children. 
+Anesth Analg 2009;108:814‑21.
+17.	 van Lieshout JJ, Toska K, van Lieshout EJ, Eriksen M, Walløe L, 
+Wesseling  KH. Beat‑to‑beat noninvasive stroke volume from 
+arterial pressure and Doppler ultrasound. Eur J Appl Physiol 
+2003;90:131‑7.
+18.	 Bowman  AJ, Clayton  RH, Murray  A, Reed  JW, Subhan  MM, 
+Ford  GA. Effects of aerobic exercise training and yoga on 
+the baroreflex in healthy elderly persons. Eur J Clin Invest 
+1997;27:443‑9.
+19.	 Parshad  O, Richards  A, Asnani  M. Impact of yoga on 
+haemodynamic function in healthy medical students. West 
+Indian Med J 2011;60:148‑52.
+20.	 Warburton DE, Nicol CW, Bredin SS. Health benefits of physical 
+activity: The evidence. CMAJ 2006;174:801‑9.
+21.	 Mezzacappa  ES, Kelsey  RM, Katkin  ES, Sloan  RP. Vagal 
+rebound and recovery from psychological stress. Psychosom 
+Med 2001;63:650‑7.
+22.	 Herbert Benson  MD, Klipper  MZ. The Relaxation Response. 
+New York: Harper Collins; 1992.
+23.	 Streeter  CC, Gerbarg  PL, Saper  RB, Ciraulo  DA, Brown  RP. 
+Effects 
+of 
+yoga 
+on 
+the 
+autonomic 
+nervous 
+system, 
+gamma‑aminobutyric‑acid, 
+and 
+allostasis 
+in 
+epilepsy, 
+depression, and post‑traumatic stress disorder. Med Hypotheses 
+2012;78:571‑9.
+24.	 Reid  IA. Interactions between ANG II, sympathetic nervous 
+system, and baroreceptor reflexes in regulation of blood pressure. 
+Am J Physiol 1992;262(6 Pt 1):E763‑78.
+25.	 Guyenet PG. The sympathetic control of blood pressure. Nat Rev 
+Neurosci 2006;7:335‑46.
+26.	 Bali  LR. Long‑term effect of relaxation on blood pressure and 
+anxiety levels of essential hypertensive males: A controlled 
+study. Psychosom Med 1979;41:637‑46.
+Reproduced with permission of copyright owner. Further reproduction
+prohibited without permission.

subfolder_0/Effect of Integrated Yoga (IY) on psychological states and CD4 counts of HIV-1 infected patients.txt

@@ -0,0 +1,240 @@
+3/1/2017
+Effect of Integrated Yoga (IY) on psychological states and CD4 counts of HIV­1 infected patients: A randomized controlled pilot study
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4728960/
+1/6
+Effect of Integrated Yoga (IY) on psychological states and CD4 counts of HIV-1 infected patients: A
+randomized controlled pilot study
+Rosy Naoroibam, Kashinath G Metri, [...], and HR Nagendra
+Abstract
+Background:
+Human immunodeficiency virus (HIV) infected individuals frequently suffer from anxiety and depression. Depression has been associated with
+rapid decline in CD4 counts and worsened treatment outcomes in HIV­infected patients. Yoga has been used to reduce psychopathology and
+improve immunity.
+Aim:
+To study the effect of 1­month integrated yoga (IY) intervention on anxiety, depression, and CD4 counts in patients suffering from HIV­1
+infection.
+Methods:
+Forty four HIV­1 infected individuals from two HIV rehabilitation centers of Manipur State of India were randomized into two groups: Yoga
+(n = 22; 12 males) and control (n = 22; 14 males). Yoga group received IY intervention, which included physical postures (asanas), breathing
+practices (pranayama), relaxation techniques, and meditation. IY sessions were given 60 min/day, 6 days a week for 1 month. Control group
+followed daily routine during this period. All patients were on anti­retroviral therapy (ART) and dosages were kept stable during the study.
+There was no significant difference in age, gender, education, CD4 counts, and ART status between the two groups. Hospital anxiety and
+depression scale was used to assess anxiety and depression, CD4 counts were measured by flow cytometry before and after intervention.
+Analysis of variance – repeated measures was applied to analyze the data using SPSS version 10.
+Results:
+Within group comparison showed a significant reduction in depression scores (F [1, 21] =4.19, P < 0.05) and non­significant reduction in
+anxiety scores along with non significant increment in CD4 counts in the yoga group. In the control group, there was a non­significant increase
+in anxiety and depression scores and reduction in CD4 counts. Between­group comparison revealed a significant reduction in depression scores
+(F [1, 21] =5.64, P < 0.05) and significant increase in CD4 counts (F [1, 21] =5.35, P < 0.05) in the yoga group as compared to the control.
+Conclusion:
+One month practice of IY may reduce depression and improve immunity in HIV­1 infected adults.
+Keywords: Anxiety, CD4 count, depression, human immunodeficiency virus, yoga
+INTRODUCTION
+Human immunodeficiency virus (HIV) infection is a communicable disease leading to significant morbidity, mortality, and poor quality of life.
+Approximately, 2.5 million individuals were found to be infected with HIV­1 infection in the 2009 survey. Though anti­retroviral therapy
+(ART) has significantly increased the life span and treatment outcome in HIV­infected patients, social stigma, depression, substance abuse, and
+wrong cultural beliefs significantly impair their quality of life.[1] Mental disorders such as major depressive disorder, generalized anxiety, and
+agoraphobia are commonly found in patients with HIV.[2] Out of all these, depression is the most prevalent comorbid mental disorder with a
+prevalence of 22–38% among HIV­infected patients.[3,4,5] Unemployment, lack of health insurance, low CD4+ cell counts, not having a
+partner, and poor quality of social support are significant contributors for depression in HIV­infected patients.[6] Depression is found to be
+associated with poor adherence to ART,[7] and also influences CD4 counts and viral loads (VLs) negatively.[8] Antidepressant medications are
+helpful, but they are not free from side effects.
+Complementary and alternative medicine is becoming popular as rehabilitation measures in patients living with HIV/AIDS.[9] Yoga is the most
+commonly used mind–body intervention.[10] It is cost­effective and easy to implement and offers benefit for emotional, psychological, and
+physical health.[11] Yoga encompasses asanas (Yogic postures), pranayama (Yogic breathing practices), yoga­based relaxation techniques, and
+meditation.
+Many studies demonstrated the broad positive impact of yoga in health and many disease conditions.[12] Yoga can augment current treatment
+modalities of HIV infection.[13] Yoga helps in many psychological conditions such as anxiety, depression, and schizophrenia. It improves
+3/1/2017
+Effect of Integrated Yoga (IY) on psychological states and CD4 counts of HIV­1 infected patients: A randomized controlled pilot study
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4728960/
+2/6
+overall well­being and quality of life in many chronic medical illnesses. Earlier studies reported the potential role of yoga in resisting the
+impairment of cellular immunity.[14] In a study in healthy volunteers, Yoganidra (a yogic relaxation technique) practice given for 30 min daily
+for 6 months showed a significant reduction in erythrocyte sedimentation rate than the control group.[15] In another study, yoga practice
+improved natural killer cell activity in early breast cancer patients.[16] In a randomized control trial on pulmonary tuberculosis patients, 2
+months of yoga practice helped in reducing the infection.[17]
+Yoga is proven to be safe and effective in reducing depression and anxiety.[18] In a study, yoga helped reduction of blood pressure in pre­
+hypertensive HIV­1 infected subjects.[19] Earlier, meditation and Qigong practice had been found useful in reducing anxiety and depression,
+and increasing T­cell count in HIV­infected patients.[20] But, this study was done on a small sample of HIV­infected patients and lacked
+control group. Hence, there is a need for exploration of this area with a better design. Therefore, present study was planned with an intention to
+assess the effect of a month­long Integrated Yoga (IY)intervention on psychological health and CD4 counts of HIV­1 infected individuals using
+a randomized controlled design.
+METHODS
+Forty­four HIV­1 infected patients from two HIV rehabilitation centers in Manipur, were selected in this study; subjects were randomly
+divided into a yoga group (n = 22) and control group (n = 22) using online random number generator software.[21] Subject with active
+infection, severe weakness, and those under psychiatric medications were excluded from the study. All the participants were educated at least
+up to 12  standard [Table 1].
+Table 1
+Demographic data of subjects
+Intervention
+All the subjects in the yoga group performed asanas (Yogic postures), pranayama (Yogic breathing techniques), and yoga­based relaxation
+techniques [Table 2] 1 h daily, 6 days in a week for 1 month. Control group followed their normal routine activity. Regular attendance was
+monitored by maintaining attendance register and subjects who attended <70% of sessions were excluded from the study. The yoga module
+implemented in this study followed typical IAYT session module and details of these practices were given elsewhere.[22]
+Table 2
+List of the practices given to the yoga group
+Assessments
+Hospital anxiety and depression scale Both groups were administered hospital anxiety and depression scale (HADS), before and after 1 month of
+yoga intervention. HADS is considered as a valid tool to assess symptom severity and cases of anxiety disorders and depression in both somatic,
+psychiatric, and primary care patients and in the general population.[23]
+CD4 counts Whole blood samples were collected from all 44 HIV­infected individuals from HIV rehabilitation centers in Manipur for their
+CD4+ T­cell estimation. To avoid any diurnal variation in the T­cell subset counts, all the samples were collected between 8:00 am and 10:00
+am in K /K  EDTA vacutainer tubes (Becton Dickinson, Franklin Lakes, NJ, USA) after obtaining an informed consent. The most common
+technique for measuring CD4 counts in developed country settings is flow cytometry. Flow cytometers use lasers to excite fluorescent antibody
+probes specific for various cell surface markers, such as CD3, CD4, and CD8, which distinguish one type of lymphocyte from another. We used
+FACSCount system (Becton Dickinson, San Jose, USA) for CD4 T enumeration. The enumeration of the T cell subsets by the FACSCount
+system was performed using respective reagents (liquid format). Reagents were maintained at a temperature range of 2–8°C. Strict cold chain
+was maintained throughout the procedure. The technical details of the procedure are provided elsewhere.[24]
+Data analysis
+All data were found to be normally distributed by Shapiro–Wilk test. Analysis of variance – repeated measures with Bonferroni's correction
+was performed to analyze the data using SPSS (IBM, Pvt Ltd) version 10.
+RESULTS
+th
+2
+3
+3/1/2017
+Effect of Integrated Yoga (IY) on psychological states and CD4 counts of HIV­1 infected patients: A randomized controlled pilot��study
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4728960/
+3/6
+Yoga group
+In the yoga group, at the baseline, out of 22, 12 (50%) suffered from clinical anxiety (HADS scores >11) and 9 (40.9%) suffered from clinical
+depression (HADS scores >11). After 1 month of IY, number of subjects with clinical anxiety came down to 9 (40.9%) and those with clinical
+depression reduced to 2 (9.09%).
+Within­group comparison showed significant reduction in depression (P = 0.04, −13.39%), a nonsignificant improvement in CD4 count (P =
+0.42, +6.4%), and a nonsignificant reduction in anxiety scores (P = 0.13, −8.2%) in the yoga group [Table 3 and Graphs 1­3].
+Table 3
+Within­group comparisons of both the groups (yoga and control) showing mean and SD of anxiety, depression, and CD4
+counts before and after
+Graph 1
+Pre­ and post­changes in mean and standard deviation in anxiety scores in yoga and control group before and after the study
+Graph 3
+Pre­ and post­changes in CD4 counts in yoga and control group before and after the study
+Graph 2
+Pre­ and post­changes in mean depression scores in yoga and control group before and after the study
+Control group
+At the baseline, out of 22, 8 (36.3%) suffered from clinical anxiety (HADS scores >11) and 5 (22.7%) suffered from clinical depression
+(HADS scores >11). After 1 month, 5 (22.7%) had clinical anxiety and 7 (31.81%) had clinical depression.
+Nonsignificant increase both in anxiety scores (P = 0.06, +12.91%) and CD4 count (P = 0.41, −6.9%) was observed in control group.
+Between-group
+There was significant reduction in depression scores (F [1,21] =5.65, P = 0.02) and significant improvement in CD4 counts (F [1,21] =5.35, P
+= 0.04) in yoga group as compared to control group at the end of one month yoga intervention [Table 4].
+Table 4
+Between­group comparison for anxiety, depression, and CD4 counts before and after one­month IY intervention
+DISCUSSION
+The aim of this study was to observe the effect of 1 month IY intervention on depression, anxiety, and CD4 counts in patients living with HIV­1
+infection. Significant reduction in depression and improvement in CD4 counts was observed at the end of 1 month of IY practice, as compared
+to the control group.
+To the best of our knowledge, present work is the first attempt to explore the effect of IY intervention on anxiety, depression, and CD4 counts
+in HIV­infected individuals. Previously, Koar (1995) assessed the effect of 3­month Qigong practice on anxiety, depression, and CD4 counts of
+26 HIV­infected patients in his pilot work.[20] At the end of 1 month, there was an improvement in anxiety by 0.65%, depression by 19.82%,
+and CD4 counts by 10.89%. We observed an improvement in anxiety, depression, and CD4 counts by 8.2%. 13.39%, and 6.4%, respectively.
+3/1/2017
+Effect of Integrated Yoga (IY) on psychological states and CD4 counts of HIV­1 infected patients: A randomized controlled pilot study
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4728960/
+4/6
+Higher percentage improvement in CD4 counts in the previous study[20] as compared to that found by us may be due to longer duration of
+intervention (3 months) than compared to our study (1 month). Similarly, in another controlled study, 1 month of stress management program
+(biweekly sessions of progressive muscle relaxation, biofeedback, meditation, and hypnosis) reduced anxiety, improved mood, self­esteem, and
+T cell counts in 20 HIV­positive individuals and found it to be effective in improving all the variables measured.[25] These results are similar
+to our findings. This suggests an important role of stress management through various mind–body interventions in the clinical care of HIV­
+infected individuals.
+At the baseline, we observed that out of 44 subjects who participated in the study, 20 (45.4%) had scores on HADS above 11, which suggests
+clinical anxiety and 20 (45.4%) had scores of depression above 11 suggesting clinical depression. Stress and depression are clearly linked and
+stress may precipitate or exacerbate depressive symptoms and depression.[26] Psychological stress due to HIV­1 diagnosis, social stigma, poor
+health, and ART medication are the basic causes of depression and anxiety in HIV­1 infected patients. Stress not only leads progression of
+HIV­1, but also suppress the immunity by affecting immune­neuroendocrine axis.[27] Depression is common among HIV­1 infected patients
+and it is associated with low CD4 cell counts,[28] presence of depression brings a rapid decline in CD4 counts.[29] Probably, the reduction in
+depression that we observed in this study is because of reduction in stress levels through yoga. Reduction in depression would have led to
+increase in the CD4 counts as well.
+Strength of the present study includes a randomized controlled design, implementation of a specific validated yoga protocol, and important
+assessment tools. Major limitations are relatively small sample size, lack of objective assessments tools such as VLs, bio­markers of
+depression, or imaging techniques.
+In future, studies should be planned with large sample size using important biochemical (VLs, markers of inflammation) and radiological
+variables. Future studies should also assess the effect of long­term IY intervention on these variables.
+CONCLUSION
+Regular practice of yoga helps to improve psychological well­being by reducing depression and improves immunity by increasing CD4 counts in
+patients suffering from HIV1. Hence, yoga can be a useful adjuvant in the conventional management of HIV­1 infection.
+Financial support and sponsorship
+Nil.
+Conflicts of interest
+There are no conflicts of interest.
+Article information
+Int J Yoga. 2016 Jan-Jun; 9(1): 57–61.
+doi:  10.4103/0973-6131.171723
+PMCID: PMC4728960
+Rosy Naoroibam, Kashinath G Metri, Hemant Bhargav, R Nagaratna,  and HR Nagendra
+School of Yoga and Life Sciences, S-VYASA University, Bengaluru, Karnataka, India
+Holistic Health Center, S-VYASA University, Bengaluru, Karnataka, India
+Address for correspondence: Dr. Kashinath G Metri, Division of Yoga and Life Sciences, S-VYASA University, Bengaluru, Karnataka, India. E-mail:
+[email protected]
+Copyright : © International Journal of Yoga
+This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-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.
+Articles from International Journal of Yoga are provided here courtesy of Medknow Publications
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subfolder_0/Effect of Yoga on musculoskeletal pain and discomfort, perceived stress, and quality of sleep in industrial workers Study protocol for a randomized controlled trial.txt

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+Advances in Integrative Medicine xxx (xxxx) xxx
+Please cite this article as: B. Pravalika, Advances in Integrative Medicine, https://doi.org/10.1016/j.aimed.2022.11.003
+Available online 24 November 2022
+2212-9588/© 2022 Elsevier Ltd. All rights reserved.
+Effect of Yoga on musculoskeletal pain and discomfort, perceived stress, 
+and quality of sleep in industrial workers: Study protocol for a randomized 
+controlled trial☆ 
+B. Pravalika a, U. Yamuna a, Apar Avinash Saoji b,* 
+a Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana (S-VYASA Yoga University), Bengaluru, Karnataka, India 
+b School of Yoga and Naturopathic Medicine, Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana (S-VYASA Yoga University), 
+Bengaluru, Karnataka, India   
+A R T I C L E  I N F O   
+Keywords: 
+Yoga 
+RCT 
+Occupational Health 
+Musculoskeletal pain and discomfort 
+CMDQ 
+Stress 
+Sleep 
+A B S T R A C T   
+Background and objectives: Musculoskeletal pain and discomfort at the workplace are closely associated with 
+prolonged, repetitive, continuous, and unnatural movements. Yoga as mind-body medicine has been shown to 
+reduce pain and disability. The current study aims to assess the effect of yoga on musculoskeletal pain and 
+discomfort among industry workers. 
+Materials and methods: Ninety industrial workers with self-reported pain symptoms will be randomly assigned to 
+Yoga and wait-list control groups following an equal allocation ratio. Yoga group will receive a specially 
+designed Integrated Yoga module five days a week for eight weeks. The control group will be given lifestyle 
+suggestions, and they will be offered the same Yoga module after the post-assessment. Musculoskeletal pain and 
+discomfort scores, perceived stress, and quality of sleep will be assessed at baseline, after four and eight weeks. 
+Statistical analyses: Normality and appropriate statistical tests will be done after data collection to assess the 
+differences between and within the groups. 
+Expected outcomes: Specifically designed Yoga module will help reduce subjective pain, stress and improve sleep 
+quality in industrial workers.   
+1. Introduction 
+1.1. Background and rationale 
+1.1.1. Musculoskeletal symptoms 
+Musculoskeletal symptoms are defined as any pain in the muscles, 
+tendons, and nerves arising from repetitive, continuous, and unnatural 
+movements [1]. Prevalence of musculoskeletal pain/discomfort range 
+between 6.92 % and 76.8 % in the Indian adult population, with sig­
+nificant rural-urban differences [2]. A study on the Indian population of 
+musculoskeletal pain shows 55.2 % prevalence, 60 % males and 40 % 
+females showing male predominance in an adult population ranging 
+from 31 to 40 years, and the common anatomical site involved was low 
+back (54.1 %) [3]. A narrative review depicts different mechanisms 
+associated with pain. Pain is in a complex interplay with emotional 
+status and cognition, where they can either decrease or increase pain 
+perception [4]. Pain is not only due to physiological causes but also 
+closely associated with the behavioral and psychosocial aspects of an 
+individual. 
+1.1.2. Occupation and musculoskeletal symptoms 
+Work-related musculoskeletal symptoms are found to be the most 
+common cause of occupational injury and physical disability. The 
+highest prevalence was observed in healthcare professionals, followed 
+by manufacturing industries [5]. Centre for Disease Control and Pre­
+vention 1997 (last reviewed Feb 2020) defines work-related musculo­
+skeletal disorders as the condition in which the work environment and 
+performance of work for a prolonged period contribute to the condition 
+and its worsening. 
+Prevalence of musculoskeletal symptoms is strongly associated be­
+tween years worked and pain in the lower back (44 %), shoulders (33.3 
+%), and neck (32 %) [6]. Age and work category seems to be found 
+☆Trial Registration Number: CTRI/2022/03/040894 
+* Corresponding author. 
+E-mail address: [email protected] (A.A. Saoji).  
+Contents lists available at ScienceDirect 
+Advances in Integrative Medicine 
+journal homepage: www.elsevier.com/locate/aimed 
+https://doi.org/10.1016/j.aimed.2022.11.003 
+Received 15 July 2022; Received in revised form 5 November 2022; Accepted 21 November 2022   
+Advances in Integrative Medicine xxx (xxxx) xxx
+2
+associated with the high prevalence of occurrence in the lower back, 
+wrist/hand, neck, shoulder, and ankle/feet regions in full-time em­
+ployees of manufacturing industries [7]. 
+Occupational musculoskeletal symptoms are often associated with 
+perceived physical and mental stress, sensation of fatigue, and dizziness 
+[8]. Repetitive, continuous, forceful task performance leads to me­
+chanical tissue injury and microtraumas causing inflammation [9]. 
+Musculoskeletal pain development and disability are found to have an 
+association with the psychological aspect of workplace activity (e.g.; 
+perceived job dissatisfaction, job strain, and boredom with actual work), 
+education, and socioeconomic status of workers [4]. Studies have 
+claimed that musculoskeletal symptoms in industrial workers are asso­
+ciated with factors like gender, age, lack of exercise, nightshift work, 
+longer job tenure, reduced access to health information and health care, 
+and a negative attitude towards seeking healthcare [10]. 
+Work-related musculoskeletal diseases are reported to cause 
+different degrees of functional incapacity, main cause of absenteeism 
+which increases company expenses representing the major cause to 
+retirement among men [11,12]. A study to quantify the association of 
+stress and musculoskeletal pain with poor sleep among hospital workers 
+concluded that there exists a clear dose-response relationship between 
+perceived stress and poor sleep as well as between pain intensity and 
+poor sleep [13]. The pain interference is a stressor for individuals at the 
+workplace, ultimately leading to negative affect and end-of-workday 
+emotional exhaustion [14]. Exercise and other effective interventional 
+measures are essential to manage and prevent musculoskeletal symp­
+toms of pain and discomfort in working population. 
+1.1.3. Lifestyle factors for pain management 
+Pain has been found to have relationship with various health be­
+haviors like smoking, unhealthy diet and weight, physical inactivity, 
+poor sleep, and mental stress [15]. Supervised group-based exercise at 
+work and motivational coaching sessions are found effective for workers 
+on musculoskeletal pain intensity and pressure pain threshold [16]. 
+Another study on physical activity in metallurgic industries concluded 
+that leisure-time physical activity and physical exercise helped to reduce 
+absenteeism [12]. Workers committed to a customized set of in­
+terventions like preshift stretching program, produce significant, 
+evidence-based health promotion outcomes [17]. A retrospective lon­
+gitudinal study highlighted four important lifestyle factors (life satis­
+faction, hours of sleep, exercise habits, and physical fitness) in workers 
+to reduce their risk of subjective musculoskeletal symptom occurrence 
+[18]. These lifestyle behavioral changes help an individual to cope with 
+pain perception and associated stressors in their work environment. 
+1.1.4. Yoga in the management of Musculoskeletal Pain, Stress, and Sleep 
+Quality 
+Yoga, as a holistic therapy is a form of complementary and alterna­
+tive medicine considering ’body as whole’. Yoga has its impact on 
+musculoskeletal pain in various workplace settings like hygiene pro­
+fession [19], diamond industry [20], professional computer users [21, 
+42], nursing population in hospital settings [22], home-office workers 
+[23], metallurgic company [12], etc. Previous studies on Yoga have 
+shown its association with a reduction in pain-related disability [24], 
+improvement in flexibility [25], functional capacity and mobility [26], 
+muscular strength [27] and quality of life [28] in individuals with 
+different musculoskeletal disorders. 
+A review paper has highlighted the potential role of yoga in pain 
+management for a range of conditions that can be chronically painful. 
+Yoga is speculated to produce physiological, behavioral, and psycho­
+logical changes in pain management. It is found to alter the pain expe­
+rience by decreasing sympathetic activity, reducing inflammatory 
+markers and stress markers, increase in muscular strength, flexibility, 
+and cardiorespiratory capacity [29]. Yoga dealing with the mind and 
+psychological status helps to cultivate a healthy acceptance in 
+decreasing emotional distress and willingness to learn from pain and 
+other stressful experiences [30]. Yoga aims to recondition and rejuve­
+nate the neuromuscular system by lubricating the joints, muscles, and 
+ligaments, strengthening periarticular muscles, and improving the co­
+ordination of joint movements [27]. 
+Yogic meditation and relaxation have been shown to play a signifi­
+cant role in reducing pain, tenderness, disability, and state anxiety and 
+improving flexibility in patients with common neck pain [31]. Mental 
+silence in the form of meditation called Sahaja Yoga has helped to 
+reduce work stress and depressed mood in full-time workers [32]. A 
+meta-analysis has quantified that workplace yoga interventions have 
+been effective in reducing perceived stress among employees when 
+compared to no-treatment [33]. Integrative yoga has also shown its 
+beneficial effect in improving the quality of sleep in individuals, thereby 
+improving their overall health and quality of life [34,35]. 
+1.1.5. Rationale for the present study 
+In workplace population, due to their heavy workload, prolonged 
+standing, manual continuous repetitive handling of materials, and un­
+natural movements, make them prone to get musculoskeletal ailments. 
+Few studies on exercise at work and motivational coaching sessions have 
+been found effective in the reduction of pain intensity and absenteeism 
+associated with their work [12,16]. Stress and sleep disturbance due to 
+their change in shift work also has adverse health effects on their body 
+and mind. There are many studies of yoga on specific musculoskeletal 
+disorders, but very minimal are on musculoskeletal health in industrial 
+workers. A study on Workplace Yoga has shown its effectiveness in 
+reducing stress, musculoskeletal pain, fatigue, and quality of life among 
+diamond industry employees [20]. In this study, we will try to under­
+stand the efficacy of Yoga as integrative therapy in reducing Musculo­
+skeletal pain in manufacturing industrial workers and thereby lower 
+their associated discomfort, perceived stress and improve quality of 
+sleep. 
+2. Objectives 
+The main objective of this study is to investigate the efficacy of in­
+tegrated yoga on musculoskeletal pain and its associated discomfort, 
+perceived stress, and sleep quality in industrial workers. 
+3. Materials and methods 
+3.1. 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. 
+3.2. Participants, interventions, and outcomes 
+3.2.1. Study setting 
+The research study will be conducted in manufacturing Industries 
+located in Bangalore from February 2022 to February 2023. 
+3.2.2. Eligibility criteria 
+The participants will be selected based on the inclusion and exclusion 
+criteria as depicted in Table 1. 
+3.2.3. Intervention 
+The specific yoga intervention developed for industrial workers [36] 
+will be administered for 60 min/day five days a week for eight consec­
+utive weeks. An integrated yoga module validated on industrial workers 
+will be used. The set of practices includes loosenings, strengthening, 
+gentle stretches, relaxation techniques, breathing techniques with 
+awareness, and different series of asana for lowering physical bodily 
+stress. Pranayama and physical postures (asana) maintenance for a 
+B. Pravalika et al.                                                                                                                                                                                                                              
+Advances in Integrative Medicine xxx (xxxx) xxx
+3
+prolonged time with breathing and awareness also work on lowering 
+stress associated with pain and discomfort. This addition of breath 
+component in Yoga makes it more special than other exercises and 
+physical activities. Meditation and relaxation, as in previous studies 
+have shown to have beneficial effects in improving sleep quality, quality 
+of life, and mood, reduction of stress and anxiety as compared to no 
+treatment and other treatments [32,35,37,38]. 
+Details of validated yoga module for industrial workers are described 
+in Table 2 [36]. 
+3.2.4. Incentives 
+There won’t be any financial or other incentives given to participants 
+to take part in this study. 
+3.2.5. Outcomes 
+Demographic and anthropometric details includes age, alcohol use, 
+smoking status, education, marital status, sleep quality, and dietary 
+habits, will be documented during the process of screening the partici­
+pants. Anthropometrical variables include height, weight, and BMI will 
+be included. Other variables in the survey are nature/designation of 
+employment, work experience, number of working hours/day (<8hrs/ 
+>8hrs), work time (shift/day work), posture at work (standing/sitting/ 
+standing with substantial movement) and hours of sitting/standing in a 
+working day. This study will assess all variables at 3-time points: Base­
+line, after four and eight weeks. 
+3.2.5.1. Primary outcome measure: Musculoskeletal pain and discomfort. 
+Cornell Musculoskeletal Discomfort Questionnaire (CMDQ) is a self- 
+rating questionnaire containing body mapdiagram, and it addresses 
+the frequency, severity, and work interference of musculoskeletal 
+discomfort on three scales across 20 body parts during the previous 
+week. The level of discomfort with work is scored from 0 to 2, and the 
+total discomfort score was calculated by using the following formula: 
+frequency × discomfort × interference = discomfort score. Visual 
+Analogue Scale (VAS) has been found to have a positive correlation with 
+the severity scores of CMDQ. Validity kappa coefficients between the 
+responses given on the VAS and on the CMDQ frequency scale ranged 
+between 0.62 and 0.92 across body parts [39]. 
+3.2.5.2. Secondary outcome measures: perceived stress and quality of 
+sleep. Perceived Stress Scale (PSS-10) questions are of general nature; it 
+is to enquire about feelings and thoughts to measure the "degree to 
+which situations in one’s life/life events are appraised as stressful" 
+during the previous month. It comprises ten items, out of which six items 
+are negatively worded, and the remaining four are positively worded 
+with reverse coding. All the scale items are summed up; the total score 
+ranges from 0 to 40. Higher the total score denoted greater perceived 
+stress. Reliability coefficients for PSS were 0.83 (Factor 1), 0.77 (Factor 
+Fig. 1. Trial Profile.  
+Table 1 
+Eligibility Criteria for the participants [43].  
+Inclusion criteria 
+Exclusion criteria 
+Industrial workers aged 18–60 years 
+with minimum 6 months of work 
+experience at industry 
+Participants who had any previous illness 
+and/or injuries that may have contributed 
+to musculoskeletal discomfort or disorder 
+. 
+Participants with self-reported pain 
+symptoms and only males will be 
+included in the study 
+Partcipants with any chronic lifestyle 
+disorders like Diabetes or Hypertension 
+Voluntary partipants with no prior 
+exposure to yoga and able to perform 
+yogic practices 
+Individuals who underwent any recent 
+surgery since past six months will be 
+excluded from the study.  
+B. Pravalika et al.                                                                                                                                                                                                                              
+Advances in Integrative Medicine xxx (xxxx) xxx
+4
+2), and 0.86 (total score) by the two-stage translation procedure [40]. 
+Pittsburgh Sleep Quality Index (PSQI) consists of 7 components to 
+assess particular clinical aspects of sleep, measuring subjective sleep 
+quality and sleep disturbances. Total scoring ranges from 0 to 21, in 
+which a higher score represents poor or worse sleep quality, and a score 
+of 5 indicates significant sleep disturbance. In a study on Indian uni­
+versity students, the Cronbach’s alpha for the PSQI was found to be 
+0.736 [41]. 
+3.2.5.3. Assessment of the safety of the intervention. There is no antici­
+pation of any adverse side effects during and after yoga practices or 
+during assessment because participants’ self-reported pain symptoms is 
+taken as reference. Safety precautions will be taken during the study, 
+providing first aid and emergency services if required. 
+3.2.6. Participant timeline 
+Recruitment of participants for the study will be based on the eligi­
+bility criteria. The assessment of all variables will be done at three time 
+points baseline, four, and eight weeks. Following random allocation, 
+participants will be assigned to Yoga and control groups. Yoga group 
+will be administered the intervention for eight weeks, and the control 
+group will be given lifestyle suggestions. Table 3 presents the timeline 
+for participant assessment. 
+3.2.7. Sample size 
+The computed sample size obtained using G power software (3.1.9.4) 
+is 36 in each group with α-0.05, power-0.8, effect size-0.67, where 
+dropout estimation is 25 %. Therefore the considered sample size for this 
+study is 90 (Yoga=45, Control=45) [21]. 
+3.2.8. Recruitment 
+We will screen male workers in the manufacturing industries in 
+Bengaluru for self-reported pain symptoms. A representative sample of 
+ninety will be recruited for the RCT study. 
+3.3. Assignment of interventions 
+3.3.1. Randomization 
+Participants will be randomly assigned using computer-generated 
+random numbers (www.randomizer.org), which will be concealed 
+using sealed envelopes. 
+3.3.2. Blinding 
+We will use single blinding method, wherein the researcher will be 
+blinded for the screening process and during the assessment of the data. 
+Participants are actively involved in the study intervention; hence not 
+possible to blind them. 
+3.4. Data collection, management, and analysis 
+3.4.1. Data collection methods 
+Demographic, socioeconomic, and anthropometrical data will be 
+collected through a survey questionnaire during the screening process. 
+The primary variable - musculoskeletal pain and discomfort and sec­
+ondary variables - stress and sleep quality will be assessed using vali­
+dated and reliable questionnaires. 
+3.4.2. Data management 
+Data from participants will be kept in separate department folders. 
+The study coordinator and principal investigator will have access to the 
+information, and it will not be disclosed to others. For participant 
+identification certain codes will be given to their names. The principal 
+Table 2 
+Yoga intervention module for industrial workers.  
+Sl. 
+no 
+Intervention 
+Time, 
+minutes 
+1 
+Loosening exercises   
+1.1 
+Neck movements, Shoulder rotation, Shoulder shrugs  
+3 
+1.2 
+Elbow movements, Wrist movements  
+2 
+1.3 
+Knee rotation and tightening  
+1 
+1.4 
+Ankle rotation, Feet movements  
+2 
+1.5 
+Toe and Heel walking  
+1 
+1.6 
+Side lying leg lifts  
+1 
+2 
+Relaxation techniques   
+2.1 
+Instant Relaxation Technique (IRT)  
+1 
+2.2 
+Quick Relaxation Technique (QRT)  
+2 
+2.3 
+Deep Relaxation Technique (DRT)  
+2 
+3 
+Breathing exercises   
+3.1 
+Hand stretch breathing, Hands in and out breathing  
+1 
+3.2 
+Ankle stretch breathing  
+1 
+3.3 
+setubandhasana breathing, bhujangasana breathing, Tiger 
+breathing  
+2 
+3.4 
+Alternate leg raise  
+1 
+4 
+Strengthening exercises   
+4.1 
+Hip abduction and adduction in supine  
+1 
+4.2 
+Hamstring stretch with rope support in supine  
+1 
+4.3 
+Quadriceps stretch with wall support  
+1 
+4.4 
+Single and both legs raising with maintenance at 10, 30, 45, 
+60 and 90 degree  
+1 
+4.5 
+Single straight leg raise to 90 degree followed by rotation of 
+the same leg  
+1 
+5 
+Asana   
+5.1 
+Ardhachakrasana  
+1 
+5.2 
+Trikonasana, parivritta trikonasana  
+2 
+5.3 
+Padahasthasana  
+1 
+5.4 
+Veerabhadrasana 
+vrikshasana 
+garudasana  
+3 
+5.5 
+Utkatasana  
+1 
+5.6 
+Gomukhasana  
+1 
+5.7 
+Vakrasana, ardhamatsyendrasana  
+2 
+5.8 
+Baddhakonasana, upavishta konasana  
+2 
+5.9 
+Pavanamuktasana  
+1 
+5.10 
+Sarvangasana 
+Vipareetakarani  
+2 
+5.11 
+Matsyasana  
+1 
+5.12 
+Bhujangasana 
+Shalabhasana 
+Dhanurasana  
+3 
+6 
+Pranayama and other practices   
+6.1 
+Nadishuddhi pranayama  
+3 
+6.2 
+Bhramari pranayama  
+3 
+6.3 
+Uddiyana bandha  
+1 
+6.4 
+Nadanusandhana  
+3 
+7 
+OM meditation  
+5  
+Table 3 
+Timeline for the participant assessment.  
+Overview of outcomes time points  
+Pre 
+study 
+Baseline 
+after 4 
+weeks 
+after 8 
+weeks 
+Age (yrs) 
+x    
+Height (m) 
+x    
+Weight (kg) 
+x    
+BMI (kg/m2) 
+x    
+Blood pressure, in mmHg 
+x    
+Smoking status (yes/no) 
+x 
+x 
+x 
+x 
+Alcohol intake (yes/no) 
+x 
+x 
+x 
+x 
+Education 
+x    
+Dietary habits 
+x    
+Sleep quality 
+x 
+x 
+x 
+x 
+Work experience (in days/months/ 
+years) 
+x    
+Posture at work (standing/sitting/ 
+standing with substantial 
+movement) 
+x    
+Posture at work (hrs/day) 
+x    
+Work time (shift/day) 
+x    
+Musculoskeletal pain 
+x 
+x 
+x 
+x 
+Stress  
+x 
+x 
+x  
+B. Pravalika et al.                                                                                                                                                                                                                              
+Advances in Integrative Medicine xxx (xxxx) xxx
+5
+investigator will enter the data, and it will be encrypted with a passcode. 
+3.4.3. Statistical methods 
+Data extraction will be based on manual and scoring keys. The 
+Shapiro Wilk test will be used to determine the normal of the data. 
+Musculoskeletal pain and discomfort scores will be the primary 
+outcome. Other variables of perceived stress and quality of sleep will be 
+defined as secondary outcomes. Based on data distribution, appropriate 
+statistical tests will be used. Categorical data analyses will be done using 
+the Chi-square test. To analyze mean differences (between and within 
+groups) analysis of variance (ANOVA) will be used. And correlation 
+analysis will be used to quantify the degree of relationship between the 
+outcomes. 
+3.5. Monitoring 
+3.5.1. Data monitoring 
+Monitoring of data will be done by the principal investigator. No 
+other external committee (DMC) will be allowed to do so. 
+3.6. Ethics and dissemination 
+3.6.1. Research ethics approval 
+The trial has been reviewed and approved by the Institutional Ethics 
+Committee (IEC) of Swami Vivekananda Yoga Anusandhana Samsthana, 
+Bengaluru on 12th February 2022. Also, the trial has been registered in 
+the Clinical Trials Registry-India (CTRI) with trial registration number: 
+CTRI/2022/03/040894. 
+3.6.2. Consent 
+At the assessment time of participants, written and oral informed 
+consent will be taken for their voluntary participation. Detailed infor­
+mation about research, objectives, methods, and procedures will be 
+given in the consent form. They can leave the study at any time point, 
+and they will not be forced against their choice. 
+3.6.3. Confidentiality 
+Participants’ identities will be concealed in the research. Personal 
+data of participants will be kept confidential other than the researchers 
+involved in the study. Coded keys will be used instead of their names. 
+The coding used in the study will be encrypted with a passcode and will 
+be known only to the primary investigator. 
+3.6.4. Declaration of interests 
+No financial or competing interests exist. 
+3.6.5. Access to data 
+The final dataset will only be accessed by the principal investigator 
+of the study. 
+3.6.6. Dissemination policy 
+General meetings will be held to share the knowledge of this study 
+with the participants. Private and confidential information will not be 
+disclosed. Results of the data will be published in a peer-reviewed sci­
+entific journal and presented at national/international conferences to 
+share the findings with other interested participants. 
+IEC Reference number 
+RES/IEC-SVYASA/230/2022. 
+Grant support or other sources of funding 
+NO. 
+Declarations of any conflicts of interest 
+NO. 
+Other disclaimers, if any 
+NO. 
+Trial status 
+Recruitment in progress. 
+Funding 
+No funding is yet received for the trial. 
+Authors’ contributions 
+BP: Writing – original draft and revised draft, review & editing. UY: 
+Writing – original draft and revised draft, review & editing. AAS: 
+Conceptualization; Data curation; Formal analysis; Investigation; 
+Methodology; Project administration; Supervision; Validation; Visuali­
+zation; Writing – original and revised draft, review & editing. 
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subfolder_0/Effect of a Yoga Based Meditation Technique on Emotional Regulation, Self-compassion and Mindfulness in College Students - ScienceDirect.txt

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+EXPLORE
+Volume 14, Issue 6, November 2018, Pages 443-447
+Brief Report
+Effect of a Yoga Based Meditation Technique on Emotional Regulation,
+Self-compassion and Mindfulness in College Students
+Naresh Kumar Patel , L. Nivethitha , A. Mooventhan 
+Show more
+https://doi.org/10.1016/j.explore.2018.06.008 ↗
+Get rights and content ↗
+Background
+Emotion regulation is often a challenge for the college students. Yoga practice has been shown to reduce
+stress and improve mindfulness that is related to emotion regulation. Mastering emotions technique
+(MEMT) is one of the yoga-based meditation techniques that are designed to control emotions among
+practitioners. However, to the best of our knowledge, there is no known study reporting its scientific
+evidence-based effects on emotion and its related variables. Thus, this study was conducted to evaluate the
+effect of MEMT on emotion regulation, self-compassion, and mindfulness in college students.
+Materials and methods
+Seventy-two subjects with the age varied from 18 to 25 years were recruited from a residential college. All
+the subjects underwent MEMT for the duration of 45 min a day for a period of 2 weeks. Assessments such as
+Emotional Regulation Questionnaire (ERQ), The Positive and Negative Affect Schedule (PANAS), Self-
+Compassion Scale (SCS), and Mindful Attention Awareness Scale (MAAS) were taken before and after the
+intervention.
+Results
+Results of this study showed a significant increase in the scores of cognitive reappraisal, positive affect, self-
+compassion, and MAAS along with a significant reduction in the scores of negative affect, and expressive
+suppression after the practice of MEMT compared to its respective baseline.
+Conclusions
+Results of this study suggest that practice of MEMT is effective in improving emotion regulation, positive
+affects, self-compassion, and mindfulness while in reducing negative affects among college students.
+Section snippets
+1
+2
+2
+Share
+Cite
+Background
+Emotion regulation is defined as “the extrinsic and intrinsic processes that are responsible for monitoring,
+evaluating, and modifying emotional reactions, especially their intensive and temporal features, to
+accomplish one's goals.” It is influenced by a range of systems including neurophysiological, physical,
+cognitive, behavioural, and social systems. Research in the field of emotion regulation among adolescent is
+steadily increasing over the past decade.  Reappraisal and suppression are the …
+Subject
+Seventy-two healthy female volunteers with the age varied from 18 to 25 years were recruited from a
+residential college in Odisha, India, based on the following inclusion and exclusion criteria. Healthy female
+subjects with the age of 18 years and above, who is willing to participate in the study, were included in the
+study. Subjects with the history of any systemic and mental illness, under regular medication for any
+disease, chronic smoking, chronic alcoholism, during menstruation, pregnancy, …
+Result
+Of 100 subjects, 28 subjects did not fulfil the criteria and thus not included in the study. Recruited 72
+subjects were undergone 2 weeks of MEMT practice and completed the study. Results of this study showed
+a significant increase in the cognitive reappraisal of ERQ, positive affect of PANAS, MAAS, and self-
+compassion scores; and a significant reduction in the expressive suppression of ERQ, and negative affect of
+PANAS scores after the practice of MEMT compared to its baseline (Fig. 1).…
+Discussion
+The emotional imbalance is quite common and challenging in college students. Evidence suggests that yoga
+practice improve emotion regulation among school students.  MEMT is a yoga-based meditation technique
+developed to regulate the emotions among the regular practitioners. However, there is a lack of scientific
+evidence reporting the effect of MEMT on emotional regulation in college students. Hence, the present study
+was conducted to evaluate the effect of MEMT on emotional regulation in…
+Conclusion
+Results of this study suggest that practice of MEMT is effective in improving emotional regulation, positive
+affects, self-compassion, and mindfulness while in reducing negative affects among college students.…
+Source of funding
+Nil.…
+References (12)
+EL Merz et al.
+Psychometric properties of Positive and Negative Affect Schedule (PANAS) original and short
+forms in an African American community sample
+J Affect Disord (2013)
+1
+1
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+Dispositional mindfulness moderates the relation between neuroticism and depressive
+symptoms
+Pers Individ Dif (2011)
+LA Daly et al.
+Yoga and Emotion regulation in high school students: a randomized controlled trial
+Evid Based Complement Alternat Med (2015)
+JJ. Gross
+Emotion regulation: affective, cognitive, and social consequences
+Psychophysiology (2002)
+A Mooventhan et al.
+Effect of Bhramari pranayama and OM chanting on pulmonary function in healthy individuals: a
+prospective randomized control trial
+Int J Yoga (2014)
+R Nagarathna et al.
+Yoga for Cancer
+(2014)
+There are more references available in the full text version of this article.
+Cited by (24)
+Contemplating library instruction: Integrating contemplative practices in a mid-sized academic
+library
+2021, Journal of Academic Librarianship
+Citation Excerpt :
+…Two recent controlled trials report a modest reduction in student stress following the use of mobile app-based
+mindfulness meditation (Flett et al., 2020; Huberty et al., 2019). Numerous descriptive studies involving college students
+report a range of positive psychological effects, including reducing stress, depression or anxiety, or improving other
+mental health outcomes (e.g. Carpena et al., 2019; Cheli et al., 2020; Crowley & Munk, 2017; Gorvine et al., 2019; Kinser
+et al., 2016; Liu & Lin, 2019; Miller et al., 2018; Newton & Ohrt, 2018; Patel et al., 2018; Saul & Fish, 2019; Schlumpf, 2017;
+Schwind et al., 2017; Thomas, 2017; Vidic & Cherup, 2019; Wetzel, 2017; Witry et al., 2020; Zollars et al., 2019). While
+their methodology is typically less rigorous than those referenced above, these positive findings add weight to the
+argument that CP can be effective in reducing stress and improving student mental health.…
+Show abstract
+Ambidextrous habitude in physical education: A vital life-skill
+2023, Life Skills in Contemporary Education Systems: Critical Perspectives
+Pilot Study About the Effects of the Soma Experiencing Motion (Soma e-Motion) Program on
+Interoceptive Awareness and Self-Compassion
+2023, Psychiatry Investigation
+A cross-sectional analysis of yoga experience on variables associated with psychological well-
+being
+2023, Frontiers in Psychology
+The Effectiveness of Mindfulness-Based Stress Reduction Intervention for Cognitive Emotion
+Regulation and Cognitive Reactivity in Patients with Epilepsy
+2022, International Journal of Cognitive Therapy
+Mindfulness-based online intervention increases well-being and decreases stress after Covid-19
+lockdown
+2022, Scientific Reports
+View all citing articles on Scopus
+Recommended articles (6)
+Research article
+Modern postural yoga as a mental health promoting tool: A systematic review
+Complementary Therapies in Clinical Practice, Volume 31, 2018, pp. 248-255
+Show abstract
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+The effect of movement-focused and breath-focused yoga practice on stress parameters and
+sustained attention: A randomized controlled pilot study
+Consciousness and Cognition, Volume 65, 2018, pp. 109-125
+Show abstract
+Research article
+Mindfulness and avoidance mediate the relationship between yoga practice and anxiety
+Complementary Therapies in Medicine, Volume 40, 2018, pp. 89-94
+Show abstract
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+“Yoga resets my inner peace barometer”: A qualitative study illuminating the pathways of how
+yoga impacts one’s relationship to oneself and to others
+Complementary Therapies in Medicine, Volume 40, 2018, pp. 215-221
+Show abstract
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+Journal of Integrative Medicine, Volume 16, Issue 1, 2018, pp. 14-19
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+Effects of acute aerobic exercise or meditation on emotional regulation
+Physiology & Behavior, Volume 186, 2018, pp. 16-24
+Show abstract
+View full text
+© 2018 Elsevier Inc. All rights reserved.
+Copyright © 2023 Elsevier B.V. or its licensors or contributors.
+ScienceDirect® is a registered trademark of Elsevier B.V.

subfolder_0/Effect of integrated Yoga module on positive and negative emotions in Home Guards in Bengaluru.txt

@@ -0,0 +1,1058 @@
+35
+© 2016 International Journal of Yoga | Published by Wolters Kluwer - Medknow
+Effect of integrated Yoga module on positive and negative 
+emotions in Home Guards in Bengaluru: A wait list 
+randomized control trial
+B Amaranath, Hongasandra R Nagendra, Sudheer Deshpande
+Department of Yoga and Life Science, S-VYASA Yoga University, Bengaluru, Karnataka, India
+Address for correspondence: Mr. B Amaranath, 
+No.33/04, Gangappa Complex, DVG Road, Basavangudi, Bengaluru ‑ 560 004, Karnataka, India. 
+E‑mail: [email protected]
+traffic control. Nowadays, Bengaluru HGs assist Bengaluru 
+city Traffic Police, Regional Transport Office, Bangalore 
+University, Food Corporation of India, Karnataka State Road 
+Transport Corporation, and many more organizations.[2]
+Normally, the HGs work in stressful situations; hence, facing 
+the realities of life is tough for them. Stress is not viewed as 
+a singular event, but as a transaction between an individual 
+and the environment that makes demand on all available 
+INTRODUCTION
+Security and police personnel are playing a very important 
+role in controlling law and order in the society and protected 
+the country even in ancient days.[1] Today, Home Guards 
+Organization (HGO) shares the above duty with the security 
+and police personnel. HGO is an independent disciplined and 
+uniformed body of volunteers constituted under Karnataka 
+Home Guards (HGs) Act, 1962, under Karnataka Home 
+Department. HGs’ Services have become indispensable 
+during fairs, festivals, sports, elections, and for daily 
+Original Article
+Background: The beneficial aspect of positive emotions on the process of learning and the harmful affect of negative emotions 
+on coping with stress and health are well‑documented through studies. The Home Guards (HGs) are working in a very stressful 
+situation during election, managing traffic and other crowded places. It is quite essential in present day circumstances that 
+they have to manage their emotions and cope up with different stressful situations.
+Objective: To study the efficacy of integrated Yoga module (IYM) on emotions (positive and negative affect [PA and NA]) of HGs.
+Methods: A total of 148 HGs both males and females who qualified the inclusion and exclusion criteria were randomly divided 
+into Yoga group (YG) and control groups (CG). The YG had supervised practice sessions (by trained experts) for 1 h daily, 
+6 days a week for 8 weeks along with their regular routine work whereas CG performing their routine work. Positive affect 
+negative affect scale (PANAS) was assessed before and after 8 weeks using a modified version of PANAS.
+Results: PA in YG had significantly increased (P < 0.05) whereas it had decreased significantly (P < 0.05) in CG. Other positive 
+effect in YG had significantly increased (P < 0.001), whereas it had decreased significantly (P < 0.001) in CG. NA in YG had 
+significantly decreased (P < 0.001), whereas it had significantly increased (P < 0.001) in CG. Other NA in YG had significantly 
+decreased (P < 0.001), whereas it had significantly increased (P < 0.01) in CG.
+Conclusions: The results suggested that IYM can be useful for HGs to improve the PA and to decrease NA score. Moreover, 
+IYM is cost‑effective and helps HGs for coping up with emotions in stressful situations.
+Key words: Home Guards; negative affect; positive affect; Yoga.
+ABSTRACT
+Access this article online
+Website: 
+www.ijoy.org.in
+Quick Response Code
+DOI: 
+10.4103/0973-6131.171719 
+How to cite this article: Amaranath B, Nagendra HR, Deshpande S. 
+Effect of integrated Yoga module on positive and negative emotions in 
+Home Guards in Bengaluru: A wait list randomized control trial. Int J Yoga 
+2016;9:35-43.
+This is an open access article distributed under the terms of the Creative 
+Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows 
+others to remix, tweak, and build upon the work non‑commercially, as long as the 
+author is credited and the new creations are licensed under the identical terms.
+For reprints contact: [email protected]
+[Downloaded from http://www.ijoy.org.in on Wednesday, July 27, 2016, IP: 14.139.155.82]
+Amaranath, et al.: A wait list randomized control trial on Home Guards
+International Journal of Yoga • Vol. 9 • Jan-Jun-2016
+36
+coping resources of the body‑mind complex. This involves 
+cognitive appraisal and coping processes. When these 
+resources are taxed, and the responses exceed the coping 
+abilities, it can result in distressful negative emotions.[3] 
+These precipitate aggressive behaviors such as anger, fear, 
+distress, and irritability. Stress and coping are closely related 
+to affect or emotions because they are affected by cognitive 
+appraisal.[4] Thus the heightened stress responses that result 
+in negative affect (NA) and distress, are reflections of an 
+inability to cope with demanding situations.[5]
+An emotion is defined as a mental and physiological state 
+associated with a wide variety of feelings, thoughts, and 
+behaviors. It is a prime determinant of the sense of subjective 
+well‑being and appears to play a central role in many human 
+activities.[6] Watson et al. measured these emotions under 
+two major categories namely positive and NA. Pleasant 
+emotions of different intensities may be grouped as “positive 
+affectivity” (PA) and unpleasant emotions under “NA
+”.[7]
+Negative affect
+NA can be termed as a state of aversive mood and 
+subjective distress. It is seen that self‑esteem of a person 
+is affected, and the quality of relationship with others gets 
+deteriorated.[8] This not only leads to the cause of anxiety 
+and depression but also narrows down the attention. The 
+fear leads to withdrawal behavior where the situation 
+demands for survival[8] depending on the capacity to cope 
+up with different situations.[9] The characteristics of low 
+NA[7] are calmness and contentment.
+Positive affect
+It is observed that people who are having tendencies 
+to cope up through humor will have greater positive 
+mood and have also shown increased levels of salivary 
+immunoglobulin A, a vital immune system protein.[10] 
+Positive emotions such as hope does contribute to over 
+health benefits accrued by dispositional optimists.[5]
+Remedial measures
+The coping strategies in respect of occurrence and 
+responding with positive emotions  (e.g.,  positive 
+reappraisal, problem‑focused coping, and infusing every 
+event with positive meaning) do help buffering against 
+stress and depressed mood.[11] Such strategies will help the 
+individuals to emerge from critical moments with all new 
+coping skills establishing closer relationship and showing 
+greater appreciation toward life. All such strategies predict 
+an increase in psychological well‑being.[12]
+Through studies, the benefits of PA in prevention and 
+rehabilitation of stress‑related diseases such as hypertension,[13] 
+gastrointestinal disorders,[14] coronary heart disease,[15] 
+and diabetes have been established. It is also established 
+through studies that the higher PA has shown lower levels 
+of glycosylated hemoglobin in normal people, indicating the 
+beneficial effect of PA on diabetic parameters.[16]
+The studies have also shown that individuals often adopt 
+complementary health approaches to improve their health 
+and well‑being[17,18] or to get relieved from symptoms 
+associated with chronic diseases or the side‑effects of use 
+of conventional medicine.[19,20]
+Yoga
+The ancient Yoga from India dating back to thousands of 
+years is now getting the popularity all over the world as 
+a practice of mind‑body medicine. Its practices have the 
+potential to promote PA. In the recent survey conducted 
+by the National Center for Complementary and Alternative 
+Medicine in 2015 has shown that overall 34% of adults 
+used complementary and alternative therapies and Yoga 
+in 2012.[21] The whole of person’s life including physical, 
+mental, emotional, and spiritual aspects are addressed 
+by Yoga for prevention of disease and overall well‑being 
+of the person. It is also observed that the practice of Yoga 
+do benefit the individual for overcoming his negative 
+emotions, which in turn will improve the quality of life 
+of healthy people with increased immunity,[10] better 
+pulmonary functions,[22] and increased life‑span.[23]
+Yoga and physical health
+It was observed that practice of Yoga improved joint flexibility,[24] 
+respiratory endurance, and strengthening of muscles[25] in 
+young. Yoga practice also improved the dexterity in students.[26] 
+The other documented physical health benefits of Yoga are 
+reduction in body fat, improved shoulder flexibility in elderly 
+females,[27] improvement in immunological tolerance,[28] 
+noticeable and favorable changes in neuro‑endocrine functions 
+including melatonin and cortisol secretions,[29‑31] lower 
+perceived exertion after exhaustive exercise.[32]
+Yoga for positive mental health
+Continued practice of Yoga for 10–30 days has shown 
+increased visual perception,[33] better learning skills,[34] 
+and increased spatial and verbal memory.[35] The integrated 
+practice of Yoga has also shown improved cognitive 
+functions in children and adults.
+Yoga for positive emotional health
+In the studies made for assessing the emotional states 
+of the individual by “Profile of Mood States” after 
+practice of Yoga have shown significant improvements 
+in negative emotions such tension, anxiety, depression, 
+dejection, anger, hostility, fatigue, inertia, confusion, and 
+[Downloaded from http://www.ijoy.org.in on Wednesday, July 27, 2016, IP: 14.139.155.82]
+Amaranath, et al.: A wait list randomized control trial on Home Guards
+37
+International Journal of Yoga • Vol. 9 • Jan-Jun-2016
+bewilderment.[36] 10 h practice of Iyengar Yoga has shown 
+improvement in the emotional states of the individual with 
+regard to depression, anxiety, negative mood, and fatigue 
+in young adults[37] as reported by the practitioners. In the 
+study to compare African dance and Hatha Yoga, showed 
+reduced perceived stress and NA with both these practices 
+but the Hatha Yoga showed reduced cortisol levels also.[30] 
+Hence, the benefits of Yoga practice is that it improves 
+mood and differential effects which may be related to its 
+influence on physiological states of arousal[30] through 
+establishing stable autonomic balance.[38]
+Thus, reducing NA and increasing PA is one of the main 
+concerns in management of emotions.
+In the present study, we examined the positive and NA 
+outcomes HGs who attended integrated Yoga module (IYM) 
+for 2 months; daily 60 min of practice; 6 days a week.
+METHODS
+Subjects
+Five hundred HGs attended motivational lectures. 148 
+of them volunteered to be in study group. The subjects 
+were randomly divided into Yoga group (YG) (n = 75) and 
+control groups (CG) (n = 73) using random number table.[39] 
+The subjects were selected from field working HGs from 
+various parts of Bangalore Rural District.
+Based on a previous study,[40] the effect size was calculated 
+as 0.456, fixing alpha = 0.05, power = 0.95 and hence the 
+sample size of this study was (n = 75). This calculation 
+was done using G power.
+We have included the subjects of both gender, normal healthy 
+field working HGs and age between 20 and 45 years. Similarly, 
+we have excluded the subjects with any ailments, consuming 
+alcohol, and smoking and those who already practicing Yoga.
+The Institutional Ethical Committee of S‑VYASA approved 
+the study proposal. The informed consent was taken from 
+all subjects before enrolling them in the study.
+Design
+This is a prospective, randomized, single‑blind, control 
+study to measure and compare the positive and NA 
+thereby anxiety and depression of the HGs allotted 
+to YG and CG. The researcher deputed instructors to 
+deliver introductory lectures to the HGs for motivating 
+them to join the study. Gruha Rakshaka Bhavan  (HG 
+Administrative office at Bengaluru, Karnataka, was the 
+venue for Yoga classes).
+Both the groups  (YG and CG) were performing their 
+routine work such as maintaining law and order, 
+managing the traffic and public in different government 
+organization such as RTO and Vidhana Soudha and 
+participated in weekly mandatory parades as per HG 
+schedules.
+The YG besides doing their normal routine work also did 
+1 h of IYM practices, 6 days a week for 8 weeks. Daily 
+attendance was taken for all the subjects; Yoga trained 
+experts taught IYM to YG. The CG did their normal routine 
+work. The CG was given an option to join Yoga classes after 
+the study completion.
+Evaluation
+The tests were self‑administered by examiners before and 
+after 8 weeks of IYM in a disturbance free quiet room.
+Masking
+The invigilators coded and saved the answered 
+questionnaires response sheets (QRS) for scoring latter. 
+A psychologist not involved in group formation or class 
+supervision valued the coded QRSs. Another person 
+decoded the QRSs only after noting the scores both before 
+and after data was completed.
+Assessments
+Assessment was done using the positive affect negative 
+affect scale (PANAS) questionnaire developed by Watson 
+et al.[7] The PANAS is a 20‑item questionnaire designed 
+to measure PA and NA. It has ten questions each to 
+measure positive and negative emotions, referred to 
+as PA and NA. The internal reliability  (Cronbach’s 
+coefficient alpha) is 0.86–0.96 for PA and 0.84–0.87 for 
+NA of the PANAS.[7] Narasimhan et al. in her study has 
+added nine (four positive and five negative) questions 
+for his study, which are referred as other PA (OPA) and 
+other NA (ONA).[40] The PANAS, OPA, and ONA domain 
+scores were analyzed and interpreted separately since the 
+questions that were added had not been tested earlier for 
+validity and reliability.
+Data extraction
+The participants rated all questions on a 5‑point scale 
+of 0–4. (0‑not at all, 1‑a little, 2‑moderately, 3‑quite a 
+bit, and 4‑extremely) reflecting the extent to which they 
+experienced the emotion during the past 1 week. All 29 
+questions were intermixed in the questionnaire. They were 
+carefully isolated for obtaining the individual scores for 
+the four domains, i.e. PA, NA, OPA, and ONA. Incomplete 
+answer sheets were discarded.
+[Downloaded from http://www.ijoy.org.in on Wednesday, July 27, 2016, IP: 14.139.155.82]
+Amaranath, et al.: A wait list randomized control trial on Home Guards
+International Journal of Yoga • Vol. 9 • Jan-Jun-2016
+38
+Intervention
+Yoga group
+The YG HGs besides doing their routine work participated 
+in Yoga practice also. They were given IYM from the 
+integrated set of Yoga practices used in earlier studies 
+on the effects of Yoga for positive health.[41] The basis of 
+developing the integrated approach is ancient Yoga texts[42] 
+for total physical, mental, emotional, social, and spiritual 
+levels[43] developments. The techniques include physical 
+practices (Kriyās, A-sanās, a healthy Yogic diet), breathing 
+practices with body movements and Pranayama, meditation, 
+lectures on Yoga, stress management, and life‑style change 
+through notional corrections for blissful awareness under all 
+circumstances (action in relaxation). Qualified Yoga teachers 
+taught Yoga. They taught the group the IYM [Table 1] for 
+2 months; daily 60 min of practice; 6 days a week.
+Control group
+The CG did no Yoga practice but did their routine work 
+only. However, the CG subjects could opt for Yoga classes 
+as part of the study after study duration.
+Statistical analysis
+Data were analyzed using R‑Statistical software. This 
+calculation was done using G power.[44]
+Data at baseline were assessed for normal distribution 
+using Shapiro–Wilk’s test in both the groups. The 
+Table 1: Details of the IYM practices
+Duration
+Names
+Benefits
+5 minutes
+Breathing practices
+Brings into action all the lobes of the lungs for full utilization
+Hands in and out breathing
+Dog breathing
+Normalizes the breathing rate
+Tiger breathing
+Makes the breathing uniform, continuous and rhythmic
+Straight legs raise breathing (alt. Both)
+5 minutes
+Loosening exercises
+Prepares the joints for better flexibility to move on to postures
+Jogging
+Forward and backward bending
+Side bending
+Twisting
+Pavanamuktasana kriya
+25 minutes
+Asanas
+Balance and harmony
+Standing
+Great speed in movement due to agility
+Ardha cakrasana
+Flexible body
+Pada hastasana
+Supple but stone hard when the need arises
+Sitting
+Relaxation in action and hence conservation of energy
+Vajrasana
+Supta vajrasana
+Tranquility of mind and clarity of thought
+Halasana or Mayurasana
+Prone postures
+Dhanurasana
+Supine postures
+Sarvaingasana
+Matyasana
+Ardha Sirsasana or Sirsasana
+5 minutes
+Deep relaxation technique
+Deep rest to cells
+Stress reduction
+Rejuvenates the tissues
+Unfolds the latent impressions buried within the subconscious mind
+10 minutes
+Pranayama
+Brings mastery over Prana
+Vibhagey Pranayama
+Naoicuddhi Pranyama
+Çitale, Setkari, Sadanta Pranayama
+Bhramare Pranayama
+Nadanusandhana
+OR
+Cleanses the body removes the toxins
+Kapalabhati
+It desensitizes the possible hyper sensitivity
+Meditation – Om Meditation
+Provides deep rest to the system
+Calms down the mind
+Reduces metabolic rate, blissful awareness freshness, lightness expansion at 
+mental level.. emotional equipoise improves concentration, memory, and creativity
+10 minutes
+Lectures
+Cultures the emotions
+Removes ignorance and wrong notions
+Stable personality
+IYM = Integrated Yoga module, DRT = Deep relaxation technique
+[Downloaded from http://www.ijoy.org.in on Wednesday, July 27, 2016, IP: 14.139.155.82]
+Amaranath, et al.: A wait list randomized control trial on Home Guards
+39
+International Journal of Yoga • Vol. 9 • Jan-Jun-2016
+independent sample t‑test was performed to assess the 
+significant difference between the groups and paired 
+samples t‑test for within the group.
+RESULTS
+Demographic data
+There were 75 subjects in YG and 73 subjects in CG. 
+The age range was between 20 and 50 years. They were 
+36 females in YG and 31 in CG, 39 males in YG and 42 
+in CG. There were 49 married people in both YG and CG. 
+There were 26 unmarried in YG and 24 in CG.
+The educational qualification of the subjects were up to 
+SSLC, SSLC to PUC, and graduates [Table 2].
+Changes in positive affect negative affect scale after Yoga 
+in Yoga group
+There was a significant improvement in PA after yoga 
+at a P < 0.01 and P < 0.001 showing 5.53% and 22.86% 
+changes in PA and OPA, respectively. The NA decreased 
+after yoga at a P  <  0.001, with 22.23% and 24.92% 
+reduction in NA and ONA, respectively.
+Changes in positive affect negative affect scale in control 
+group
+There was a significant reduction in PA after yoga at a 
+P < 0.05 and P < 0.001 showing 7.83% and 18.50% changes 
+Table  2: Demographic data of subjects
+Particulars
+YG
+CG
+Number of participants (n)
+75
+73
+Age (range)
+20-30
+36
+41
+30-40
+28
+20
+>40
+11
+12
+Gender
+Females
+36
+31
+Males
+39
+42
+Marital status
+Married
+49
+49
+Unmarried
+26
+24
+Educational qualifications
+SSLC
+49
+37
+PUC
+20
+24
+Degree
+6
+12
+YG = Yoga group, CG = Control group
+in PA and OPA, respectively. There was a significant 
+increase in NA and ONA P < 0.001, P < 0.01 with 23.23% 
+and 11.71% improvement in NA and ONA, respectively.
+Positive affect
+In general, the PA in YG has significantly increased 
+from 19.92 ± 3.89 to 21.02 ± 3.76 (P < 0.01), whereas 
+it has decreased significantly from 19.79  ±  3.88 to 
+18.24 ± 6.38 (P < 0.05) in CG [Table 2a and Figure 1].
+Other positive affect
+The OPA in YG has significantly increased from 8.44 ± 2.42 
+to 10.37 ± 2.86 (P < 0.001), whereas it has decreased 
+significantly from 9.97 ± 2.48 to 8.17 ± 3.27 (P < 0.001) 
+in CG [Table 2a and Figure 2].
+Negative affect
+In general, the NA in YG had significantly decreased 
+from 16.76 ± 7.71 to 13.03 ± 6.63 (P < 0.001), whereas 
+it had increased significantly from 17.86  ±  5.29 to 
+22.01  ±  7.53  (P  <  0.01) in controlled group 
+[Table 2a and Figure 3].
+Other negative affect
+In general, the ONA in Yoga has significantly decreased 
+from 10.07 ± 3.85 to 7.56 ± 3.95 (P < 0.001), whereas 
+it has increased significantly from 10.84  ±  2.82 to 
+12.11 ± 3.76 (P < 0.01) in CG [Table 2a-d and Figure 4].
+Further individual question in the PANAS was analyzed.
+This table shows the changes in individual items of 
+PA domains  (PA and OPA). There was an increase 
+ranging from 0% to 20.73% in the individual items of 
+PA with a negative change  −  3.35% in the question 
+“Proud.” There was 5.32–39.29% increase in the OPA 
+scores. Question number 15 (“content”) indicating the 
+degree of contentment showed the highest degree of 
+improvement (39.29%) in YG. However, in CG, there was 
+a decrease ranging from 0% to 24.30% in the individual 
+items of PA with a positive change 14.45% in the question 
+“Strong.” There was 14.38–39.07% decrease in the OPA 
+Table  2a: Pre‑  and post‑data of PA, OPA, NA, and ONA in YG and CG
+PANAS
+YG  (mean±SD)
+t
+P
+CG  (mean±SD)
+t
+P
+Between group
+Pre
+Post
+Pre
+Post
+t
+P
+PA
+19.92±3.89
+21.02±3.76
+2.45
+0.016**
+19.79±3.88
+18.24±6.38
+−2.04
+0.0443*
+−3.21
+0.0016***
+OPA
+8.44±2.42
+10.37±2.86
+−5.11
+0.0001***
+9.97±2.48
+8.17±3.27
+4.33
+0.0001***
+−4.33
+0.0001***
+NA
+16.76±7.71
+13.03±6.63
+−5.11
+0.0001***
+17.86±5.29
+22.01±7.53
+4.49
+0.0001***
+7.70
+0.0001***
+ONA
+10.07±3.85
+7.56±3.95
+−5.45
+0.0001***
+10.84±2.82
+12.11±3.76
+2.49
+0.0150**
+7.17
+0.0001***
+Significant level, *P<0.05 and **P<0.01 ***P<0.001, The independent sample t‑test was performed to assess the significant difference between the groups and paired 
+samples t‑test for within the group. SD = Standard deviation, YG = Yoga group, CG = Control group, PANAS = Positive affect negative affect scale, OPA = Other 
+positive affect, ONA = Other negative affect, PA = Positive affect, NA = Negative affect
+[Downloaded from http://www.ijoy.org.in on Wednesday, July 27, 2016, IP: 14.139.155.82]
+Amaranath, et al.: A wait list randomized control trial on Home Guards
+International Journal of Yoga • Vol. 9 • Jan-Jun-2016
+40
+with utter ease and effortlessness. Yoga is considered as a 
+special skill of action in relaxation. This was observed with 
+Yoga practices in musicians with the relative reduction 
+in performance anxiety, musculoskeletal conditions, and 
+mood and flow experience.[50] Yoga practices prior to exams 
+scores. Question number 8 “pleased” with positive 
+improvement.
+In YG, it is noteworthy that the degree of changes in the NA is 
+better, in the range of 11.14–38.01%, than the increase in the 
+items on PA. The ONA descriptor “Disappointed” showed the 
+maximum reduction of 38.01%. There is a positive change 
+in questions Jittery, Guilty, and Hostile in YG.
+In CG, there is an increase in NA range of 4.19–42.15%, 
+descriptor “Jittery” showed the maximum increase of 
+42.15%. The ONA also increase with a range of 0.52–38.40%, 
+with a “Miserable” showed maximum increase 38.40%.
+DISCUSSION
+The descriptive of negative emotions, “Distressed” and 
+“Disappointed” showed 37.40% and 38.01% reduction, 
+respectively, in YG. Since the HGs are volunteers and they 
+do not have job security, they were in a mood of distress 
+and disappointment. The beneficial effect of the IYM in 
+unwinding the distress and disappointed feeling in HG’s 
+that too within a short period of time may be considered 
+as an important contribution of this study.
+IYM meant to develop better mastery over the modifications 
+of the mind through introspective awareness to calm down 
+the mind may have increased their level of confidence to 
+make a resolve to change their lifestyle and approached to 
+their life to overcome their guilt, shame, and the related 
+complexes. Similar changes have been reported in a study 
+after Vipassana meditation in Tihar Jail. The inmates of the 
+jail showed reduced hostility, anxiety, and depression with 
+improved sense of well‑being and hope for the future in 
+those with or without psychiatric problems.[45] Reduction 
+in aggressive behavior has been demonstrated in normal 
+young volunteers after 12 weeks of integrated Yoga program 
+similar to the practices used in this study.[46]
+In this study, it has been noticed that negative emotions such 
+as fear, hatredness, and nervousness, which are other forms 
+of anxiety, which leads to stress have reduced drastically. 
+Many studies have shown the stress reducing effect of 
+Yoga,[47‑49] which supports the observations of our study. 
+The relaxation response after yoga may offer the ability to 
+face the situations in a relaxed state of mind and perform 
+Table  2b: Results of integrated yoga practices in YG and CG
+Variables
+YG
+CG
+Mean±SD
+Pre‑post
+P
+Percentage 
+changes in YG
+Mean±SD
+Pre‑post
+P
+Percentage 
+changes in CG
+Preyoga
+Postyoga
+Pre
+Post
+PANAS positive
+19.92±3.89
+21.02±3.76
+0.016**
++5.53
+19.79±3.88
+18.24±6.38
+0.0443*
+−7.83
+Other positive
+8.44±2.42
+10.37±2.86
+0.0001***
++22.86
+9.97±2.48
+8.17±3.27
+0.0001***
+−18.50
+PANAS negative
+16.76±7.71
+13.03±6.63
+0.0001***
+−22.23
+17.86±5.29
+22.01±7.53
+0.0001***
++23.23
+Other negative
+10.07±3.85
+7.56±3.95
+0.0001***
+−24.92
+10.84±2.82
+12.11±3.76
+0.0150**
++11.71
+SD = Standard deviation, YG = Yoga group, CG = Control group; PANAS = Positive affect negative affect scale. *P<0.05,**P<0.001 and ***P<0.001
+Table  2c: Changes in individual items of PA
+Question 
+number
+PANAS PA
+Descriptor
+Percentage change 
+(increase) in YG
+Percentage change 
+(decrease) in CG
+PA
+2
+Attentive
+13.11
+−17.13
+3
+Interested
+0.0
+−24.30
+7
+Excited
+20.73
+0.65
+10
+Strong
+0.43
+14.45
+11
+Enthusiastic
+4.63
+−15.69
+17
+Determined
+5.33
+−14.22
+18
+Proud
+−3.35
+−3.96
+22
+Inspired
+11.17
+−23.26
+25
+Active
+9.85
+−6.86
+29
+Alert
+11.82
+1.55
+OPA
+1
+Happy
+5.32
+−39.07
+8
+Pleased
+25.35
+5.52
+15
+Content
+39.29
+−14.38
+26
+Glad
+26.99
+−15.54
+YG = Yoga group, CG = Control group, PANAS = Positive affect negative 
+affect scale, OPA = Other positive affect, PA = Positive affect
+Table  2d: Changes in individual items of NA
+Question 
+number
+PANAS NA
+Descriptor
+Percentage change 
+(decrease) in YG
+Percentage change 
+(increase) in CG
+NA
+4
+Afraid
+−26.90
+10.07
+6
+Distressed
+−37.40
+4.19
+9
+Upset
+−30.06
+8.77
+12
+Jittery
+0.93
+42.15
+14
+Guilty
+5.33
+40.63
+16
+Nervous
+−26.23
+15.32
+20
+Scared
+−17.46
+32.06
+21
+Hostile
+6.67
+108.06
+24
+Ashamed
+−24.75
+7.30
+28
+Irritable
+−29.87
+26.03
+ONA
+5
+Disappointed
+−38.01
+3.14
+13
+Sad
+−28.57
+0.52
+19
+Unhappy
+−25.16
+26.14
+23
+Troubled
+−11.14
+0.61
+27
+Miserable
+−16.26
+38.40
+YG = Yoga group, CG = Control group, PANAS = Positive affect negative 
+affect scale, ONA = Other negative affect, NA = Negative affect
+[Downloaded from http://www.ijoy.org.in on Wednesday, July 27, 2016, IP: 14.139.155.82]
+Amaranath, et al.: A wait list randomized control trial on Home Guards
+41
+International Journal of Yoga • Vol. 9 • Jan-Jun-2016
+in medical students showed improved concentration, 
+improved efficiency, increased attentiveness, and significant 
+reduction in number of failures.[51]
+“Disappointed, upset, irritable, hostile” are different facets 
+of anger resulting from unsatisfied desires or the inability 
+to cope. All this is described in the Bhagavadgita as violent 
+speed of mind resulting in anxiety or depression. These have 
+shown reduction in this study. Benefits of Yoga practices 
+for rapid stress reduction and anxiolysis among distressed 
+women,[52] betterment of mood in psychiatric inpatients,[36] 
+and reduction in symptoms of depression[37] are reported.
+The perception of vigor “
+Active” and “Pleased” (q. 25, 8) 
+have increased by 9.85% and 25.35%, respectively. The 
+feeling of wellness was contributed by Asanas and loosening 
+exercises, which increases spinal flexibility,[24] dexterity,[26] 
+and stamina.[25]
+The integrated Yoga program taught in this camp included 
+lectures and practice of bhakti Yoga (devotional sessions) 
+that are meant for direct handling of emotions by nurturing 
+the positive emotions of pure love and surrender to the 
+divine as tools for stress reduction and positive health.[53] 
+Similar thinking is expressed by a study, which said that 
+spirituality (faith, selfless service, and pure love) promotes 
+a healthier coping style.[54] An increase in PA “contentment” 
+by 39.29% reflects the calming effect of yoga.
+The increase in PA and decrease in NA in YG may be 
+due to better mastery over modification of the mind 
+and calming down of the mind. The yogic techniques 
+have helped the HGs to increase their level of 
+confidence and hence it has become easy for them to 
+overcome NAs.
+The other aspect of yoga is relaxation which might have 
+given the ability to the HGs to face the situation in the field 
+in a relaxed state of mind and perform duty in relaxed and 
+effectiveness way, which means relaxation in action and 
+efficiency in outcome.
+The results obtained in our study is almost similar to the 
+results of one of the earlier studies Narasimhan et al.[40] The 
+other 9 questions OPA and ONA, which was taken from 
+Narasimhan et al.[40] variable can be validated.
+The strength of our design is the IYM for HGs. It is 
+first test of its kind in HGs where they have been 
+exposed to IYM practice, which shown the beneficial 
+effect to HGs.
+CONCLUSION
+The results have shown that IYM has increased the PA 
+in HGs and reduced the NA. Further Yoga is very cost 
+effective and recommended to HGs. Hence, this study 
+is a solution to train HGs to calm their mind and help 
+them to increase their positive thinking and decrease 
+negative mindset. By this, their service to public will 
+improve and in turn the image of the Department will 
+also go up.
+Figure 3: Changes in negative affect
+0
+5
+10
+15
+20
+25
+Yoga Group
+Control Group
+Negative Affect
+pre
+post
+Figure 4: Changes in other negative affect
+0
+2
+4
+6
+8
+10
+12
+14
+Yoga Group
+Control Group
+Other Negative Affect
+pre
+post
+Figure 1: Changes in positive affect
+16
+17
+18
+19
+20
+21
+22
+Yoga Group
+Control Group
+Positve Affect
+pre
+post
+Figure 2: Changes in other positive affect 
+0
+2
+4
+6
+8
+10
+12
+Yoga Group
+Control Group
+Other Positive Affect
+pre
+post
+[Downloaded from http://www.ijoy.org.in on Wednesday, July 27, 2016, IP: 14.139.155.82]
+Amaranath, et al.: A wait list randomized control trial on Home Guards
+International Journal of Yoga • Vol. 9 • Jan-Jun-2016
+42
+This study is the continuation and suggestion given one 
+of the earlier studies done by Lakshmi et al. There was no 
+control in that study and it was suggested to have a CG in 
+future study, which was carried out in our study.
+Acknowledgments
+Our grateful acknowledgments for all who have helped 
+us in this project particularly Dr.  Judo Ilavarasu and 
+ 
+Mr. Kuldeep Kumar Kushwah. We are grateful to 
+S‑VYASA for supporting this study. We thank the 
+volunteers, teachers, and supporters who participated 
+in this study.
+Financial support and sponsorship 
+Nil.
+Conflicts of interest
+There are no conflicts of interest.
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subfolder_0/Effect of integrated Yoga on neurogenic bladder dysfunction in patients with multiple sclerosis.txt

@@ -0,0 +1,36 @@
+Effect of integrated Yoga on neurogenic bladder dysfunction in p
+atients with multiple sclerosis-
+A prospectiveobservational case series. 
+Patil NJ1, Nagaratna R, Garner C, Raghuram NV, Crisan R. 
+ABSTRACT 
+BACKGROUND: 
+Neurogenic bladder dysfunction (NBD) is a common distressful symptom in multiple sclerosis 
+(MS) affecting quality of life. Yoga has been widely used in treating various symptoms 
+of patients with MS. 
+OBJECTIVES: 
+To evaluate the effect of integrated Yoga for NBD in patients with MS as an adjunct to standard 
+medical care. 
+DESIGN: 
+This open arm, pre-post study design assessed the outcome measures at base line and after 21 days 
+of integrated Yoga intervention. 
+SETTING: 
+study was conducted at the center for neurological rehabilitation at KWA-Klinik Stift Rottal in 
+Bad Griesbach, Germany. Eleven MSpatients with NBD (mean age 46.7±11.24 years) with mean 
+duration 17.2 years volunteered to participate in the study. 
+INTERVENTIONS: 
+integrated Yoga which includes preparatory yogic loosening and breathing practices, Nadishuddi 
+pranayama (alternate nostril breathing), moola bandha (anal lock), kapalbhati (rapid nostril 
+breathing) and deep relaxation technique was given for 2h per day for continuous 21 days. 
+OUTCOME MEASURES: 
+ultrasound scanning for post void residual urine volume (PVR), micturition check list (MCL), 
+incontinence impact questionnaire-7 (IIQ-7) andurogenital distress inventory-6 (UDI-6) were 
+used. 
+RESULTS: 
+Paired sample t-test showed significant improvement in post void residual urine (62.34%, p<0.05), 
+scores on micturition frequency checklist (25%, p<0.05), incontinence impact questionnaire-7 
+(32.77%, p<0.05) and uro-genital distress inventory-6 (26.33%, p<0.05). 
+CONCLUSION: 
+This study points to the safety and effectiveness of integrated Yoga for bladder symptoms as an 
+adjunct to standard care in multiplesclerosis patients with neurogenic bladder dysfunction in 
+Germany. Further trails are necessary to confirm these findings. 
+ 

subfolder_0/Effect of integrated approach of yoga therapy on male obesity and psychological parameters.txt

@@ -0,0 +1,1158 @@
+Journal of Clinical and Diagnostic Research. 2016 Oct, Vol-10(10): KC01-KC06
+1
+DOI: 10.7860/JCDR/2016/21494.8727
+Original Article
+Introduction
+Obesity/overweight is a serious disorder and this is becoming 
+severe worldwide [1-3]. It is increasing in urban population in 
+India and other south Asian countries [4]. The new solutions 
+for prevention and control of obesity is to be evolved. Effective 
+methods are needed for controlling obesity in India [5,6]. Also, 
+studies showed that non-communicable diseases like obesity 
+are originating from factors of lifestyle and urbanization [7]. Study 
+showed that obesity is a public health problem in some cities of 
+India including Mumbai [8]. Sedentary behaviour due to greater 
+economic development in metro cities also have link to obesity. 
+Obesity is a root cause for many diseases including metabolic 
+syndrome and type-2 diabetes mellitus in India [9].
+Study showed that among Indians, both abdominal and central 
+obesity are present in male and female [10]. Generalized obesity 
+is more in male and abdominal obesity in female.  Also, studies 
+showed that Asian Indians have some special features of obesity 
+regarding effect of excess body fat [11]. The limits of normal 
+Body Mass Index (BMI) are reduced in Asian Indians than in white 
+Caucasians considering percentage body fat. The obesity is 
+generally measured by BMI. BMI greater than or equal to 25 kg/
+m2 is considered as overweight and greater than or equal to 30 
+kg/m2 is obesity by WHO. However, for Asian population the BMI 
+cut-off points are much lesser and BMI between 23 to 25 kg/m2 
+is considered as overweight and above 25 kg/m2 is considered as 
+obese [12,13].
+Generally obesity is considered as unbalance of energy intake and 
+energy expenditure. The excessive intake of sugar and junk food 
+causes deposition of fat [14]. Obesity is also linked to behavioural 
+changes and social networks [15]. The mechanism of development 
+of obesity is not completely understood but causes are many like 
+stress, environmental, behavioural, lifestyle, genetic factors etc., 
+[16,17].
+The present solutions for reduction and prevention of obesity 
+are limited and have adverse effects [6]. Hence, it is prudent to 
+explore the treatments from alternative therapies like yoga, pilate, 
+tai-chi, etc. The psychological stress will be reduced by yoga as 
+per its definition in the Patanjali yoga sutras [18]. Yoga is defined 
+as inhibition of modification of thoughts [19]. The mental stress 
+is closely related to psychosomatic diseases and yoga practice 
+is useful for reduction of stress [20]. Also earlier studies showed 
+that Yoga will help to increase awareness on satiety and sense 
+of overeating [21]. There are short term studies showing the 
+usefulness of Yoga practices for weight reduction [22]. However 
+studies of the long term yoga training for weight reduction along 
+with weight related psychological parameters were not found. The 
+aim of the present study was to find out the effect of 14 weeks 
+Integrated Approach of Yoga Therapy (IAYT) practice on male 
+obesity parameters in urban setting.
+Materials and methods
+Participants
+The study was a parallel group study with yoga and control groups. 
+The yoga group was given the intervention of yoga training.
+Keywords: Body mass index, Obesity, Perceived stress scale, Waist circumference
+Complementary/alternative 
+Medicine Section
+Effect of Integrated Approach of 
+Yoga Therapy on Male Obesity and 
+Psychological Parameters-A Randomised 
+Controlled Trial
+P
+.b. Rshikesan1, Pailoor Subramanya2 
+ABSTRACT
+Introduction: Obesity is a growing global epidemic and cause 
+of non-communicable diseases. Yoga is one of the effective 
+ways to reduce stress which is one of the causes of obesity.
+Aim: To assess the effect of Integrated Approach of Yoga 
+Therapy (IAYT) yoga module on adult male obesity in an urban 
+setting. 
+Materials and Methods: RCT (Randomized Controlled Trial) 
+was conducted for 14 weeks on obese male subjects with yoga 
+and control groups. Total number of subjects were 72 and they 
+were randomized into two groups (Yoga n=37, Control n=35).The 
+subjects were from an urban setting of Mumbai and were doing 
+yoga for the first time. Special yoga training of IAYT was given 
+to yoga group for one and half hour for 5 days in a week for 14 
+weeks. The control group continued regular physical activities 
+and no specific physical activity was given. The assessments 
+were anthropometric parameters of weight,  Body Mass Index 
+(BMI), MAC (Mid Upper Arm Circumferences) of Left and Right 
+Arm,  Waist Circumference (WC), HC (Hip Circumference), WHR 
+(Waist Hip Ratio), SKF(Skin Fold Thickness of Biceps, Triceps, 
+Sub scapular, suprailiac and cumulative), Percentage body fat 
+based on SKF and Psychological Questionnaires of Perceived 
+Stress Scale (PSS) and AAQW (Acceptance and Action 
+Questionnaire for Weight Related Difficulty). These were taken 
+before and after intervention for both yoga and control groups. 
+Within and between group analysis & correlation of differences 
+from post to pre readings among the variables, were carried out 
+using SPSS 21.
+Results: The anthropometric and psychological parameters 
+were improved in both the groups but changes were significant 
+in yoga group.
+Conclusion: Incorporating the IAYT for obese male in urban 
+setting will be effective for obesity treatment and for reducing 
+the obesity related problems.
+P
+.B. Rshikesan and Pailoor Subramanya, Yoga and Male Obesity	
+www.jcdr.net
+Journal of Clinical and Diagnostic Research. 2016 Oct, Vol-10(10): KC01-KC06
+2
+Part No 
+Yoga Practice
+Duration (minutes)
+1
+Lecture & Counselling
+10
+2a
+Warm Up
+10
+2b
+Suryanamaskara
+10
+3
+Asana
+30
+4
+Pranayama
+15
+5
+Meditation
+15
+Total duration
+90
+[Table/Fig-2]: The five  part iayt intervention.
+There were total 120 subject who showed desire for joining the 
+research when contacted through advertisement. The subjects 
+were living in Mumbai. They were mostly employees or family 
+members of employees near Anushaktinagar of Mumbai. Total 
+80 enrolled based on selection criteria. Randomization with 
+minimization of co-factors was done. Total 40 subjects were 
+assigned in yoga group and 40 in control group. The minimization 
+was done using open source software of Minim Py to have balance 
+between groups [23,24]. It is reported that minimization is effective 
+and is desirable in RCTs [25]. These were groups of age (18 to 40 
+and 41 to 60) and groups of education (up to graduates and post-
+graduates/ above). The trial profile is given in [Table/Fig-1].
+Intervention
+The IAYT consisting of Asanas, Pranayama, Relaxation and 
+Meditation techniques were introduced in a slow step by step 
+manner. Each session of the intervention was for 90 minutes for 
+five days in a week for 14 weeks. Details of the yoga intervention 
+are provided in [Table/Fig-2]. 
+No specific physical activity was given to control group but asked 
+to continue their regular physical activities which they have been 
+practicing. The intervention was done during March to June in 
+2015.
+Components across both the groups:- Participants received 
+their respective measurement values and a food log format and 
+basic sample meal plan for sedentary male adults based on 
+guidelines of NIN (National Institute of Nutrition Hyderabad) [28].
+Assessments 
+The assessments were wt.(Body Weight), BMI (Body Mass Index), 
+MAC (Mid Upper Arm Circumference) for both right and left upper 
+arms, WC (Waist Circumference), HC (Hip Circumference), WHR 
+(Waist Hip Ratio), ABSI (A Body Shape Index), SKF (Skin Fold 
+Thickness) at 4 body points applicable for male [29]. These were at 
+right upper arm biceps (SKFraf) right upper arm triceps (SKFrab), 
+sub scapular (SKFshob), suprailiac (SKFstof). Percentage body 
+fat was based on cumulative skin fold thickness SKF from table 
+applicable for male [30].
+The PSS (Perceived Stress Scale) and AAQW (Acceptance and 
+Action Questionnaire in Weight related difficulties) were assessed 
+[31-33]. The same scales were used for pre and post assessments. 
+The weight was measured using electronic weighing scale. For 
+height inelastic measuring tape and ruler were used and subjects 
+stood against the wall. Waist circumference was measured at the 
+midway between the lowest rib margin and iliac crest and hip 
+circumference at the widest trochanters, with inelastic tape. The 
+standard skin fold caliper was used to measure skin fold thickness 
+[29,34].
+statistical Analysis 
+The data was analysed using SPSS software 21 version. Normality 
+test was done using Shapiro wilk test. The paired sample t-test 
+was done for pre-post for both groups on all the variables which 
+were found normally distributed. For not normally distributed 
+parameters, Wilcoxon signed ranks test was done. Between 
+groups analysis was done using independent sample t-test for the 
+post values of the groups. Correlation of differences from post 
+to pre readings, among the variables was carried out. A value of 
+p<0.05 was considered statistically significant. 
+Results
+The baseline demographic data of age and height of the yoga and 
+control group are given in [Table/Fig-3]. Results of within group 
+analysis of the anthropometric and psychological parameters are 
+given in [Table/Fig-4a,b]. Between group analysis results are given 
+in [Table/Fig-5]. The pre-post change in each variable was co 
+related with each other and given in [Table/Fig-6].
+The minimum age in yoga group was 26 and maximum 60 whereas 
+in control group minimum was 21 and maximum was 58 years. The 
+BMI of yoga group ranged from 25.33 to 34.84 with the mean ±SD 
+28.7±2.35. BMI of control group ranged from 25.01 to 33.64 with 
+the mean ±SD 27.70±2.05. The demographic, educational and 
+Sample Size
+The sample size was calculated based on previous study using 
+G*Power software [26,27]. Out of four primary outcomes variable 
+HC (hip circumference) had lowest effect size and this was 
+considered to calculate sample size in the current study and got 
+minimum sample size as 29.
+Ethical Clearance 
+Approval of institutional ethical committee was obtained. 
+Informed Consent
+Informed consent was taken from participants prior to 
+recruitment.
+Screening 
+Screening for obesity was done based on BMI as per selection 
+criteria. Selection criteria was BMI from 23 Kg/m2 to 35 Kg/
+m2, Gender male, age 18 to 60years  and having normal 
+health conditions except obesity. Each individual was given an 
+alphanumeric code and removing personal identifiers. 
+Variable
+Yoga  group n=37
+Control Group  n=35
+Pre
+95%  CI
+Pre
+95%  CI
+Age
+40.03±8.74
+(37.12-42.94)
+42.20±12.06
+(38.76-46.89)
+Height
+169.45±7.35
+(167.00-171.90)
+169.29±6.37
+(167.17-171.65)
+[Table/Fig-3]: Baseline data of age and height.
+ 
+ 
+[Table/Fig-1]: Trial profile of RCT.
+www.jcdr.net	
+P
+.B. Rshikesan and Pailoor Subramanya, Yoga and Male Obesity
+Journal of Clinical and Diagnostic Research. 2016 Oct, Vol-10(10): KC01-KC06
+3
+groups decreased after the intervention. The weight (wt) reduction 
+in yoga group was significant (p<0.004) and reduction in control 
+group was not significant. 
+The MACs of both left and right arm were reduced in both Yoga 
+and Control groups. In yoga group left mac change was significant 
+(p<0.02) and in control group it was not significant. Similarly right 
+MAC of yoga group was reduced and change was significant 
+(p<0.02) and change in control group was not significant. 
+The WC, Right arm front side SKF, WHR and Percentage body fat 
+based on SKF were not normally distributed. The Bicep SKF and 
+the percentage body fat reduced in yoga group and WHR reduced 
+in control group but were not significant. 
+The WC in both groups were significant (Yoga p<0.04 & Control 
+p<0.001). The reduction HC was significant in both groups (Yoga 
+p<0.001 and Control p<0.001).
+The BMI was reduced in both groups but reduction was significant 
+in yoga (p<0.01). The body shape index ABSI was also calculated 
+based on WC height and BMI [35-37].  
+The change in cumulative skin fold thickness was significant in 
+Yoga group alone (p<0.05). However, among the 4 separate 
+measurements of SKF, in yoga group alone, suprailiac SKF change 
+(reduction) was significant (p<0.002). In both groups all the 4 SKF 
+values were reduced except that in control group the sub scapular 
+skin fold thickness and Biceps Raf  increased. Also, percentage 
+body fat reduced only in Yoga group (p=0.051) and in control 
+group it was increased but not significant.
+Psychological Parameters
+The PSS score improvement was significant (p<0.001) in Yoga 
+group alone and in Control group score was improved but change 
+was not significant.
+In Yoga group, AAQW score improvement was significant (p<0.001) 
+and in Control group score was improved but not significant.
+anthropometric data were similar in both groups. In each group, 
+out of 40 subjects, 20 were between 10th standard to graduates 
+and 20 were post graduates or higher qualified. In each group 
+number of subjects with age between 18 to 40 was 20 and age 
+between 41 to 60 was 20. In each group all the subjects were 
+working and all were having BMI above 25 Kg/m2.
+The yoga group attended yoga training for 14 weeks and average 
+attendance percentage was 66, 61, 53 and 49 at the completed 
+weeks of 6, 8, 12 and 14 respectively. The control group continued 
+their physical activities.
+Anthropometric Parameters
+The pre and post-data of the anthropometric parameters were 
+compared. It was found that the weight of the yoga and control 
+Variables 
+Yoga  group  n=37
+Control group  n=35
+ Pre
+ Post
+t 
+Sig
+Pre
+Post
+t 
+Sig
+Weight- wt
+82.63±10.05
+81.51±10.00
+3.1
+0.004
+79.45±8.85
+79.22±8.93
+0.94
+0.353
+MAC left arm -macl
+29.98±2.02
+29.42±1.92
+2.53
+0.016
+32.53±16.53
+28.10±1.70
+1.61
+0.118
+MAC right arm - macr
+30.18±2.04
+29.64±2.04
+2.48
+0.018
+32.47±16.73
+28.10±1.85
+1.57
+0.125
+ Hip circumference-HC
+103.50±5.71
+101.29±4.95
+5.39
+<0.001
+104.28±6.60
+101.38±6.13
+4.54
+<0.001
+Triceps-SKF right arm back 
+side- Rab
+19.05±7.01
+17.87±5.05
+0.89
+0.379
+13.70±6.57
+13.22±4.24
+0.45
+0.652
+Suprailiac-SKF at stomach 
+front side- Stof
+32.45±7.82
+28.04±5.45
+3.29
+0.002
+27.46±9.37
+25.57±7.06
+1.15
+0.259
+Sub scapular-SKF shoulder 
+back side-Shob
+27.87±6.97
+26.91±5.23
+0.86
+0.396
+21.76±7.11
+22.28±4.98
+-0.38
+0.707
+BMI
+28.7±2.35
+28.33±2.42
+2.82
+0.008
+27.70±2.05
+27.61±2.01
+1.04
+0.306
+ABSI
+0.08±0.00
+0.08±0.00
+0.97
+0.337
+0.08±0.00
+0.08±0.00
+4.02
+<0.001
+SKF cumulative
+93.93±22.56
+85.52±13.38
+2.23
+0.032
+73.65±20.61
+72.17±14.55
+0.4
+0.693
+PSS
+16.51±6.12
+12.59±6.65
+3.83
+<0.001
+14.29±6.51
+13.51±5.95
+0.69
+0.493
+AAQW-aaqw
+81.24±17.35
+71.54±14.62
+3.9
+<0.001
+73.11±14.80
+69.71±16.28
+1.24
+0.224
+[Table/Fig-4a]: Within group analysis results.
+Variables 
+Yoga group  n=37
+Control group  n=35
+Pre
+Post
+Z score
+Sig asymp. sig 
+(2-tailed)
+Pre
+Post
+Z score
+Sig asymp. 
+sig (2-tailed)
+wc
+99.58±7.37
+98.25±7.12
+-2.06b
+0.039
+99.28±6.82
+95.79±8.33
+-3.71b
+<0.001
+Biceps-Raf
+14.55±7.19
+12.70±5.02
+-1.42b
+0.156
+10.72±5.00
+11.10±3.69
+-0.672c
+0.502
+WHR
+0.96±0.04
+0.97±0.05
+-1.82c
+0.069
+0.95±0.06
+0.94±0.06
+-0.82b
+0.413
+Percentage Body Fat (Pfc)
+30.78±4.37
+29.66±3.30
+-1.96b
+0.051
+27.55±5.17
+27.58±5.29
+-0.03c
+0.98
+[Table/Fig-4b]: Within group analysis results-Non parametric.
+a-Wilcoxon signed ranks test	
+b-based on positive ranks 	 	
+c- based on negative ranks
+Variable
+Yoga - Post- 
+Mean Std 
+dev
+n=37
+Control 
+Post- Mean 
+Std dev
+n=35
+t
+Sig (t 
+tailed)
+Diff. in Mean 95% 
+CI lower/Upper
+Wt
+81.51±10.00
+79.22±8.93
+1.02
+0.31
+2.29 (-2.17- 6.76)
+MACL
+29.42±1.92
+28.10±1.70
+3.07
+0.003
+1.32 (0.46-2.17)
+Macr
+29.64±2.04
+28.10±1.85
+3.35
+0.001
+1.54 (0.62- 2.46)
+HC
+101.29±4.95 101.38±6.13
+-0.07
+0.945
+-0.09 ( -2.70 – 2.52)
+Triceps-Rab
+17.87±5.05
+13.22±4.24
+4.22
+<0.001
+4.65 (2.42- 6.85)
+Suprailiac-
+Stof
+28.04±5.45
+25.57±7.06
+1.66
+0.101
+2.47 ( -0.49 -5.42)
+Sub scapular-
+Shob
+26.91±5.23
+22.28±4.98
+3.85
+<0.001
+4.63 (2.23 -7.04)
+Bmi
+28.33±2.42
+27.61±2.01
+1.37
+0.175
+0.72 ( -0.33 -1.77)
+Cumulative 
+skin fold-Skft
+85.52±13.38 72.17±14.55
+4.06
+<0.001
+13.35 (6.79 – 19.91)
+Pss
+12.59±6.65
+13.51±5.95
+-0.62
+0.539
+-0.92 ( -3.89 -2.05)
+Aaqw
+71.54±14.62 69.71±16.28
+0.5
+0.618
+1.83 (-5.44-9.09)
+[Table/Fig-5]: Between group analysis.
+P
+.B. Rshikesan and Pailoor Subramanya, Yoga and Male Obesity	
+www.jcdr.net
+Journal of Clinical and Diagnostic Research. 2016 Oct, Vol-10(10): KC01-KC06
+4
+Regarding relative improvements among the variables, weight was 
+positively correlated with HC (r =0.234, p<0.02), WC(r=0.366, 
+p<0.01), SKF suprailiac (r=0.12, p<0.16), PSS score (r= 
+0.18,p<0.07)and AAQW score (r=0.15, p<0.10). The left MAC was 
+negatively correlated with PSS (r=-0.28, p<0.01) but there was no 
+significant correlation with AAQW.
+Also, right MAC was negatively correlated with PSS (r=-0.29, 
+p<0.01) and there was no correlation with AAQW.
+SKF suprailiac and SKF sub scapular had positive correlation 
+(r=0.46, p<0.001), triceps and sub scapular skin fold had positive 
+correlation (r=0.28, p<0.01). BMI and HC had positive correlation 
+(r=0.23, p<0.03). PSS was correlated positively with AAQW scores 
+(r=0.22, p<0.04).
+In the between group analysis, changes in weight, HC, suprailiac, 
+BMI, PSS and AAQW difference in scores were not significant. 
+The left & right MAC, triceps skin fold thickness, sub scapular skin 
+fold thickness, cumulative skin fold thickness were significant. All 
+values of control group were lesser than yoga group except HC 
+& PSS. None of the subjects reported adverse events during the 
+intervention. This was asked during each session.
+Discussion
+Most of the  anthropometric parameters and all the psychological 
+parameters were improved in Yoga group. Also, in the control 
+group there was improvement. The weight reduction in yoga group 
+was significant (p<0.004) but not in control group. The MACs were 
+reduced in both the groups but reduction was significant in yoga 
+group (p<0.02). The WC (p<0.04) and HC (p<0.001) were reduced 
+in yoga group. 
+In an earlier study of a two week residential yoga intervention, 
+improvement was noted in the anthropometric parameters on 
+obese male and female participants [38]. The BMI, WC, HC were 
+reduced and reductions were significant. The WHR was not 
+changed in this study and also in another short term yoga and 
+diet change study, on obesity [38,39]. This showed that there was 
+no difference in reduction of fat in the waist and hip. In the current 
+study WHR showed increasing trend, but the change was not 
+significant. 
+This shows that in the current study, the reduction of fat in Yoga 
+group resulted in more reduction in hip area than in waist area and 
+in Control group more reduction in waist than in Hip. The yoga 
+practices were containing practices for reduction of fat in both 
+waist and hip areas. This included warm up and suryanamaskara 
+as given in the part 2a &2b of the 5 part IAYT yoga module 
+intervention [Table/Fig-2]. The control group also continued to do 
+physical activities which might have resulted in improvement in 
+their anthropometric parameters. They were asked to continue 
+their regular physical activities and also they were given their 
+respective assessment readings and sample food plan details. 
+The reduction in MAC of both left and right upper arm was 
+significant in Yoga group. The previous studies on obesity and 
+yoga on adults also included the MAC measurement as a part of 
+anthropometric parameters [39]. But in the current study both left 
+as well as right MAC were measured.
+In the current study control group MAC was reduced but not 
+significant. In earlier study of short duration, found decrease in 
+MAC and concluded that the reduction may be due to reduction in 
+muscle or skin layer as muscle circumference was not measured 
+separately [39]. In previous study the MAC reduction was significant 
+in control group alone [38]. This could be due to the short duration 
+of 2 weeks intervention among other factors if any. In the current 
+study, in Yoga group for both left and right MACs were improved 
+with significance which shows the effectiveness of the module of 
+Asanas involving arms and shoulder.
+In the current study the cumulative skin fold thickness SKF 
+(involving 4 measurements) reduction was significant in yoga 
+group and in Control group there was decrease but not significant. 
+Further the SKF of biceps and triceps were reduced in yoga group 
+but these values were not significant. In both groups all the 4 skin 
+fold thickness values were reduced except in Control group sub 
+scapular and biceps raf were increased. This may be due to lack 
+of physical activities involving hand and shoulder muscles by the 
+Control group. It is also noted that anthropometry and skin fold 
+thickness are best predictors for obesity assessments [40]. SKF 
+reduction was significant in suprailiac [stomach side] of Yoga group 
+alone, out of all 4 SKFs. Also in Yoga group alone the percentage 
+body fat reduced and with significance (p=0.051). This shows that 
+the IAYT yoga intervention is effective in reducing the fat and also 
+reduction at different sites for male.
+In psychological instruments PSS and AAQW were used. There 
+was difference in stress levels in PSS and AAQW base values 
+of groups. The PSS is one of the widely used validated scales 
+to assess the psychometric properties evaluated mostly using 
+college students or workers [31]. In the current study all subjects 
+wt
+macl
+macr
+wc
+HC
+raf
+rab
+stof
+shob
+bmi
+whr
+skft
+pfc
+pss
+aaqw
+wt
+1.00
+macl
+-0.03
+1.00
+macr
+-0.02
+0.995**
+1.00
+wc
+0.366**
+0.10
+0.10
+1.00
+hc
+0.234*
+0.08
+0.08
+0.396**
+1.00
+raf
+0.00
+-0.03
+-0.04
+0.05
+-0.02
+1.00
+rab
+-0.11
+-0.07
+-0.07
+-0.05
+-0.05
+0.691**
+1.00
+stof
+0.12
+-0.01
+-0.03
+0.08
+0.04
+0.420**
+0.18
+1.00
+shob
+0.07
+-0.04
+-0.03
+0.09
+0.02
+0.352**
+0.277**
+0.456**
+1.00
+bmi
+0.993**
+-0.03
+-0.02
+0.359**
+0.231*
+-0.01
+-0.10
+0.11
+0.06
+1.00
+whr
+0.201*
+0.04
+0.05
+0.770**
+-0.275**
+0.06
+-0.03
+0.04
+0.07
+0.196*
+1.00
+skft
+0.04
+-0.05
+-0.06
+0.06
+0.00
+0.813**
+0.697**
+0.735**
+0.708**
+0.03
+0.05
+1.00
+pfc
+0.12
+-0.04
+-0.05
+0.11
+0.02
+0.736**
+0.630**
+0.727**
+0.714**
+0.11
+0.09
+0.953**
+1.00
+pss
+0.18
+-0.279**
+-0.281**
+0.01
+0.09
+-0.02
+-0.08
+-0.01
+0.05
+0.17
+-0.05
+-0.02
+-0.06
+1.00
+aaqw
+0.15
+-0.01
+0.01
+0.06
+-0.02
+0.00
+0.03
+-0.07
+0.09
+0.15
+0.06
+0.01
+-0.01
+0.215*
+1.00
+[Table/Fig-6]: Correlations among (n=72) variable.
+*. Correlation is significant at the 0.05 level (1-tailed).	
+	
+**. Correlation is significant at the 0.01 level (1-tailed).
+wt: weight	
+macl: Mid arm circumference left 	
+macr: Mid arm circumference right 	
+wc: Waist circumference 	 	
+hc: Hip circumference	
+raf: Biceps skin fold thickness
+rab: Triceps skin fold thickness	
+stof: Suprailiac skin fold thickness	
+shob: Sub scapular skin fold thickness	 bmi: body mass index	
+whr: Waist hip ratio
+skft: Cumulative skin fold thickness	
+pfc: Percentage body fat 	 	
+pss: Perceived stress scale score	
+aaqw: Action and weight relayed difficulty score
+www.jcdr.net	
+P
+.B. Rshikesan and Pailoor Subramanya, Yoga and Male Obesity
+Journal of Clinical and Diagnostic Research. 2016 Oct, Vol-10(10): KC01-KC06
+5
+were working. The PSS is used for measuring perception of stress 
+[41]. In the current study the PSS reduced in both groups but 
+reduction was significant in yoga group alone. The yoga practices 
+were shown to reduce psychological distress in obese in earlier 
+studies [26]. The current study is one of the earliest studies, 
+combining components of anthropometric PSS and AAQW [33]. 
+The AAQW is a 22 item questionnaire for assessing experience 
+based avoidance and psychological inflexibility associated with 
+obesity and obesity factors such as food. The score was reduced 
+in both the groups. Earlier study (both male/female) of 24 weeks 
+showed that greater decrease in weight related experiential 
+avoidance was linked to more weight loss [42]. The current study 
+of only male subjects, also confirms this point. In the current study, 
+the decrease of AAQW score is significant in Yoga group. Hence 
+after the IAYT intervention the experiential avoidance is reduced 
+in Yoga group which also confirms the reduction of stress levels 
+including acceptance of difficult emotions of obese.
+Earlier studies showed that 10 days of short term yoga 
+interventions involving Asana, Pranayama, Relaxation techniques 
+give anxiety reduction [43]. Also, previous studies showed that the 
+long term, 2 years yoga practices reduce the mood changes and 
+stress related bio chemical indices [44]. Also, previous residential 
+weight reduction yoga study did not show significance in mood 
+disturbance, when assessed at 3 month follow-up [45]. In current 
+study, improvement in scores in both PSS and AAQW were 
+significant in Yoga group. This may be due to the effect of different 
+relaxation techniques used in intervention namely MSRT (Mind 
+Sound Resonance Technique), OM meditation Cyclic meditation 
+and Savasana.
+This is one of the studies exclusively on male population and more 
+than 3 months in an urban setting. The psychological stress is found 
+to increase cortisol secretion and abdominal fat in an exploratory 
+RCT on female [46]. The mindfulness training improves the eating 
+pattern and reduces the fat. The current study also support that 
+the reduction of abdominal fat on male is consistent with reduction 
+in perceived stress. The suprailiac skin fold (stomach front side fat) 
+reduction was significant in yoga group but not in control group. 
+The between group analysis, (significance on cumulative SKF, 
+triceps, sub scapular, MACs) showed the improvement in the fat 
+reduction in the respective areas in yoga group. 
+It was found that PSS and weight related psychological inflexibility 
+are positively correlated. In previous study with n=272 & both male 
+and female, weight was positively correlated with HC (r=0.21, 
+p<0.01) where as in current study (r =0.234, p<0.02) [26].This 
+supports that weight and HC in male alone also similarly correlated. 
+The weight and WC are positively correlated WC (r=0.366, p<0.01) 
+in current study whereas in earlier study correlation is (r=0.22, 
+p<0.0001) [26]. This supports the higher positive correlations of 
+body weight with HC & WC in male obesity similar to previous 
+mixed studies. Also, it is found that there is positive correlation of 
+weight with SKF suprailiac. The SKF suprailiac and sub scapular 
+are positively correlated. This may be due to the similar increase in 
+fat deposition in trunk portion.
+Strengths limitations and future 
+scopes
+This is an exclusive study on urban male obesity with psychological 
+parameters. 
+This 
+study 
+has 
+compared 
+the 
+variable 
+of 
+anthropometric 
+and scores of PSS and AAQW together. It is found that IAYT is 
+effective for reducing obesity and problems related to avoidance 
+and inflexibility among obese. 
+Large age variation of subjects was found as a limitation which was 
+considered initially to get more sample size for the longer duration 
+of intervention. However, the urban environment of life style such 
+as easy availability of junk food, occupational stress (all subjects 
+were working) etc., were common for all the subjects. Further both 
+the groups were having similar age variation as minimization of co 
+factors was done. Blinding on the intervention was not possible 
+since the sample were mostly from same locality and once the 
+intervention started the control group were aware of the yoga 
+programme though subtle practical details were not known to 
+them. Also the individual assessment parameters including the 
+food log format and sample food plan were available with control 
+group also. This might have also given them some motivation to 
+do regular physical exercise and walking activities. This might have 
+improved their anthropometric and psychological parameters.
+In Yoga group dropouts were minimum due to interactions and 
+lecture sessions as part of the IAYT module. Lecture was on the 
+designated topics of IAYT module with chance for clarifying the 
+doubts to participants. 
+It was reported that people with interest and some belief in benefit 
+of yoga are more likely to join the yoga studies than who are 
+indifferent to yoga [21]. This may be applicable In the current study 
+also, since subjects were having initial interest and enthusiasm in 
+joining yoga training.
+There is scope for future research with different cross-sections 
+of male obesity with adolescence, middle age and beyond, as 
+separate groups. Also overweight and different grades of male 
+obesity in the urban setting can be studied. In the current study on 
+urban setting of Mumbai, the subjects had commonality of food 
+habits, easy availability of junk food, and economic capability since 
+all were working. The social economic and the city environment 
+affects positively to obesity and different grades of obesity can be 
+taken for different studies.
+The  maintenance  of accurate food log plays a vital role in controll­
+ing eating. Food monitoring and control affect the obesity and 
+the smart phone or web based such methods will be easier than 
+hand written food log [47,48]. Earlier studies also shows keeping 
+accurate food log is difficult even in web based systems [49]. In the 
+current study we asked participants to write and maintain food log 
+and reminded about that periodically in the class once in a week. 
+More control on food log may give further weight reduction. 
+Current study confirms that the one and half hour IAYT is an 
+effective alternative measure in this urban setting for different 
+sectors of male obesity. The different sectors can be researched 
+for the relative effectiveness and tailor made usability, in future.
+Conclusion
+The IAYT yoga training is effective in improving the anthropometric 
+parameters of male obesity in urban setting. The weight, BMI, 
+waist circumference and skinfold measurements were decreased. 
+The psychological stress related to body weight difficulties and 
+perceived stress was also reduced by practice of yoga for fourteen 
+weeks. The findings suggest the usefulness of yoga for obesity 
+treatment. 
+Trial Registration
+The trial was registered with the Clinical Trials registry of India 
+CTRI/2015/01/005433
+Acknowledgements 
+The authors acknowledge with thanks Dr Ram Nidhi, Asst. Prof, 
+Swami Vivekananda Yoga Anusandhana Samsthana (SVYASA)
+for the initial guidance for the study. The authors are thankful to 
+yoga circle Anushaktinagar Mumbai for the help in conducting the 
+specified IAYT Yoga class. 
+References
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+.B. Rshikesan and Pailoor Subramanya, Yoga and Male Obesity	
+www.jcdr.net
+Journal of Clinical and Diagnostic Research. 2016 Oct, Vol-10(10): KC01-KC06
+6
+	
+	
+PARTICULARS OF CONTRIBUTORS:
+1.	
+Research Scholar, Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana, Bengaluru, Karnataka, India.
+2.	
+Associate Professor, Division of Yoga and Life Sciences, #19 S-VYASA Yoga University, Gavipuram Circle, K.G. Nagar, Bengaluru, Karnataka, India.
+NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:
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+Research Scholar, 19, Eknath Bhavan, Gavipuram Circle, K.G. Nagar, Bengaluru‑560 019, Karnataka, India.
+E-mail: [email protected]
+Financial OR OTHER COMPETING INTERESTS: None.
+Date of Submission: May 18, 2016
+Date of Peer Review: Jul 02, 2016
+ Date of Acceptance: Aug 01, 2016
+Date of Publishing: Oct 01, 2016
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subfolder_0/Effect of integrated yoga on anti-psychotic induced side effects and cognitive functions in patients suffering from schizophrenia.txt

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+Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd
+DE GRUYTER
+Journal of Complementary and Integrative Medicine. 2018; 20170155
+Short Communication
+Meghnath Verma1 / HemantBhargav2 / ShivaramaVarambally3 / NagarathnaRaghuram1 /
+Gangadhar BN3
+Effect ofintegratedyoga on anti-psychotic
+inducedside effectsand cognitive functions in
+patients suffering fromschizophrenia
+1 School of Yoga and Life Sciences, S-VYASA Yoga University, No.19, EknathBhavan, Gavipuram circle, Kempegowda Nagar,
+Bangalore 560019, Karnataka, India
+2 NIMHANS, Integrate Centre for Yoga, Department of Psychiatry, National Institute of Mental Health and Neuro Sciences
+(NIMHANS), Hosur Road, Lakkasandra, Bengaluru 560029, India, E-mail: [email protected]
+3 Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Hosur Road, Lakkasandra,
+Bengaluru 560029, Karnataka, India
+Abstract:
+Background: Twenty one (12 females) subjects, diagnosed with schizophrenia by a psychiatrist using ICD-10, in
+the ages 52.87 + 9.5 years and suffering since 24.0 ± 3.05 years were recruited into the study from a schizophrenia
+rehabilitation center in Bengaluru.
+Methods: All subjects were taking anti-psychotic medications and were in stable state for more than a month.
+Psychiatric medications were kept constant during the study period. Assessments were done at three points of
+time: (1) baseline, (2) after one month of usual routine (pre) and (3) after five months of validated Integrated
+Yoga (IY) intervention (post). Validated 1 h Yoga module (consisting of asanas, pranayama, relaxation tech-
+niques and chantings) was practiced for 5 months, five sessions per week. Antipsychotic-induced side effects
+were assessed using Simpson Angus Scale (SAS) and Udvalg for Kliniske Undersogelser (UKU) side effect rat-
+ing scale. Cognitive functions (using Trail making Test A and B), clinical symptoms and anthropometry were
+assessed as secondary variables. Comparisons between “pre” and “post” data was done using paired samples
+t-tests after subtracting baseline scores from them respectively.
+Results: At the end of five months, significant reduction in drug-induced Parkinsonian symptoms (SAS score;
+p=0.001) and 38 items of UKU scale was observed along with significant improvement in processing speed,
+executive functions and negative symptoms of schizophrenia patients. No side effects of Yoga were reported.
+Conclusions: The present study provides preliminary evidence for usefulness of Integrated Yoga intervention
+in managing anti-psychotic-induced side effects.
+Keywords: anti-psychotic medications, cognition, integrated yoga, positive and negative symptoms, schizophre-
+nia
+DOI: 10.1515/jcim-2017-0155
+Received: November 16, 2017; Accepted: May 2, 2018
+Introduction
+Anti-psychotic medications (APM) are the mainstay in the management of schizophrenia. Traditional or first-
+generation antipsychotics are clearly effective in the treatment of the positive symptoms of psychosis such as
+hallucinations and delusions but they commonly cause extra-pyramidal side effects (EPS) such as drug-induced
+Parkinsonism, dystonic reactions and akathisia at clinically effective dosages [1]. These side effects can be highly
+distressing and disabling to the patients [2]. The second-generation anti-psychotics cause less EPS but they lead
+to weight gain, dyslipidemia and insulin resistance (metabolic syndrome) [3]. Maintaining cognitive functions
+is another difficult task in schizophrenia. Impaired cognitive function (especially selective attention, processing
+speed, executive memory and reasoning) is both a feature of schizophrenia and a side effect of conventional
+neuroleptics. Some anti-psychotics may worsen negative symptoms and/or cognitive functions of schizophre-
+nia patients [4–6]. Anti-cholinergics (e.g. trihexiphenidyl) are commonly used to manage EPS in conjunction
+with APMs [7]. But these medications may in turn cause their own side effects such as constipation, dry mouth
+HemantBhargav is the corresponding author.
+© 2018 Walter de Gruyter GmbH, Berlin/Boston.
+1
+Brought to you by | Göteborg University - University of Gothenburg
+Authenticated
+Download Date | 7/2/18 7:22 AM
+Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd
+Verma et al.
+DE GRUYTER
+and indigestion [8]. Evidences also suggest that anti-cholinergic medications may contribute as much as one-
+third to two-thirds of the memory deficit typically seen in patients with schizophrenia [9]. Thus, there is a
+need for further exploration on ways to manage anti-psychotic-induced side effects in patients with chronic
+psychoses.
+Yoga has recently emerged as an effective and safe complementary mind–body intervention in variety of
+psychiatric disorders such as depression, anxiety and schizophrenia [10, 11]. Addition of yoga therapy to con-
+ventional psychiatric medications in schizophrenia has been found useful in potentiating the effects of APMs.
+Yoga had been especially useful in reducing negative symptoms and enhancing cognition in schizophrenia [12–
+17]. Yoga has also been found effective in treating Parkinson’s disease as well as type 2 diabetes and metabolic
+syndrome [18, 19]. Previously, a single blind randomized controlled trial found that weekly session of yoga for
+8 weeks were more effective in improving balance of chronic schizophrenia patients as compared to regular
+day-care program [20]. Our literature survey didn’t reveal any study which used standard psychometric tools
+to assess anti-psychotic-induced side effects while imparting a long-term yoga intervention in schizophrenia
+patients. Hence, current study was planned as a preliminary attempt to assess effect of 5 months Integrated
+Yoga intervention on anti-psychotic-induced side effects, cognitive functions, positive and negative symptoms
+and anthropometric measures in chronic schizophrenia patients. Present study shall also be useful in providing
+an estimate of effect size for future studies in this area.
+Materials and methods
+Subjects
+Twenty one (12 females) subjects in the age range of 52.87 ± 9.5 years from a schizophrenia rehabilitation cen-
+ter in Bengaluru with an established diagnosis of schizophrenia (as diagnosed by a psychiatrist using ICD-10
+criteria) and mean duration of illness of 27.75 ± 7.68 years were recruited into the study after obtaining written
+informed consent from the patients as well as the guardian or relatives. All subjects had achieved a stable state
+for last one month or more and antipsychotic medications were kept constant during the course of the study.
+Table 1 provides demographic details of the subjects.
+Table 1: Demographic data.
+Characteristics
+n Means ± SD
+n
+21
+Male
+9
+Female
+12
+Age (years)
+52.87 ± 9.50
+Duration of illness (years)
+24.0 ± 3.05
+Education (years)
+13.75 ± 2.68
+Level of Education
+Below SSLC
+0
+SSLC
+4
+PUC
+10
+Graduate
+4
+Post Graduate
+3
+Marital status
+Single
+14
+Married
+2
+Divorced
+5
+Type of antipsychotic drugs
+Trihexiphenidyl Hydrochloride
+11
+Resperidone
+8
+Aripipirazole
+1
+Olanzapine
+7
+Clozapine
+1
+Chlorpromazine
+1
+Lorazepam
+1
+Citalopram
+1
+2
+Brought to you by | Göteborg University - University of Gothenburg
+Authenticated
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+DE GRUYTER
+Verma et al.
+Haloperidol
+2
+Fluoxetine
+1
+Sulpitac
+2
+Abbreviations: SSLC: Secondary School Leaving Certificate; PUC: Pre University Course
+Design
+Assessment were done at three points of time within the group i.e. 0 (baseline), after 1 month (pre intervention)
+and after 5 months (post intervention). After baseline, subjects followed their usual routine for 1 month and pre
+assessments were done. Then 1-h integrated yoga session was added in their daily routine for 5 days a week
+for the next 5 months and then post assessments were done. Table 2 depicts the design of the study.
+Table 2: Design of the study (Single group Pre minus Baseline – Post minus Baseline).
+Baseline
+assessment
+Pre intervention
+assessment
+Post
+intervention
+assessment
+SAS UKU side
+effects rating
+Scale
+Normal routine
+without Yoga for
+1 month
+SAS UKU side
+effects Rating
+scale
+Yoga intervention: 1 h per session, 5
+sessions per week for 5 months
+SAS UKU
+side effects
+Rating scale
+TMT-A
+TMT-A
+TMT-A
+TMT-B
+TMT-B
+TMT-B
+BPRS
+BPRS
+BPRS
+SAPS
+SAPS
+SAPS
+SANS
+SANS
+SANS
+SBP
+SBP
+SBP
+DBP
+DBP
+DBP
+BMI
+BMI
+BMI
+WC
+WC
+WC
+HC
+HC
+HC
+SBP: systolic blood pressure; DBP: diastolic blood pressure; WC: waist circumferences; HC: hip circumferences; BMI: body mass index;
+TMT-A: trail making test – Part A; TMT-B: trail making test – Part B; BPRS: brief psychiatric rating scale; SAPS: scale for assessment of
+positive symptoms; SANS: scale for the assessment of negative symptoms; SAS: Simpson–Angus scale; Udvalg for Kliniske Undersogelser
+(UKU)-side effect rating scale.
+Assessments
+Assessments were done for antipsychotic-induced side effects using standardized psychometric tools: (1) Simp-
+son Angus Scale (SAS) [21] and (2) Udvalg for Kliniske Undersogelser (UKU) [22] rating scale (Primary vari-
+ables).
+Secondary variables were: (a) Trail making test (TMT A and B): Literature review shows that although trail
+making tests are very simple, they reflect a wide variety of cognitive processes including attention, visual search
+and scanning, sequencing and shifting, psychomotor speed, abstraction, flexibility, ability to execute and mod-
+ify a plan of action, and ability to maintain two trains of thought simultaneously [23]; (b) clinical symptoms
+using Scale for assessment of positive symptom (SAPS) & scale for assessment of negative symptoms (SANS)
+[24] and anthropometric measurements (Waist and Hip circumferences, Body Mass Index).
+Intervention
+We used a validated Integrated Yoga module for Schizophrenia [25]. Details of Yoga program are given in Table
+3. The module consisted of loosening practices, breathing exercises, suryanamaskāra, yogāsana, prāṇayāma,
+relaxation technique as followed in National Institute of Mental Health and Neuroscience (NIMHANS) and
+SVYASA Yoga University, Bangalore, India. The intervention was imparted in the form of 1 h IY sessions, taught
+5 days a week for 5 months. Initial, 1 month the yoga sessions were conducted by a trained yoga professional and
+simultaneously two subjects from the study (who had better grasping power and ability to perform yoga and
+3
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+Verma et al.
+DE GRUYTER
+conduct yoga sessions) were trained to conduct yoga sessions. Next 1 month, the trained subjects conducted the
+yoga sessions under supervision of the yoga professional. And then next 3 months unsupervised sessions were
+conducted by trained subjects. The warden of the rehabilitation center monitored the sessions and conducted
+attendance for each session. Yoga professional visited the rehabilitation center once every month to supervise
+the sessions from third month to fifth month.
+Table 3: Yoga based intervention module for schizophrenia (duration: 60 min).
+S. no.
+Practices
+Timing
+1.
+Loosening exercises
+– Jogging
+– Twisting
+– Forward & backward bending
+– Sideward bending
+5 min
+2.
+Breathing exercises
+– Hand stretch breathing
+– Tiger breathing
+– Śaśāṁkāsana breathing
+5 min
+3.
+Surya Namaskāra
+4 rounds slow 4 rounds fast
+10 min
+4.
+Yogāsanas
+Sitting posture
+– Vakrāsana
+– Ardha usṭrāsana
+Prone posture
+– Bhujaṁgāsana
+– Śalabhāasana
+– Dhanusrāsana
+Supine posture
+– Viparītakaraṇīāsana
+– Matsyāsana
+20 min
+5.
+Prāṇayāma
+– Bhastrikā
+– Nāḍīshuddhi
+9 min
+6.
+Chanting
+– A,U,M chanting (9 rounds each) in Śavāsana (with open
+eyes)
+10 min
+7.
+Ending prayer
+1 min
+Data analysis
+SPSS (IBM Pvt Ltd) version 10.0 was used to analyze the data. Data were found normally distributed using
+Kolmogrov-Smirnov test. Baseline scores (at the start of recruitment) were subtracted from pre intervention
+score (after 1 month of usual routine following baseline assessments) and post intervention score (after 5 months
+of Yoga intervention following pre assessments) data, respectively, to generate “pre-diff” (Pre minus baseline)
+and “post-diff” (Post minus baseline) scores, respectively. Then, comparisons were done between “pre-diff” and
+“post-diff” scores using paired-samples t-test. Alpha of 0.05 was considered as a cut-off for significance.
+Results
+A total of 30 subjects were screened, of whom 26 satisfied the inclusion criteria and consented for the study.
+Baseline assessments were performed on 26 subjects. At the end of 1 month, 26 subjects were available for
+pre data collection. During the 5 month yoga intervention period, 5 subjects dropped out of the study and 21
+subjects were available for post data collection after 5 months. The reasons for drop out were: one subject expired
+due to cardiac arrest, one subject was hospitalized due to infection and three subjects left the rehabilitation
+center due to personal reasons.
+4
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+DE GRUYTER
+Verma et al.
+At the end of the study, it was observed that there was a significant reduction in drug-induced Parkinso-
+nian symptoms on SAS scale (p=0.000). Of 48 items in the UKU, 38 items showed significant reduction: (1)
+psychological side effects (sleep, memory, dream activity concentration, etc.) (p=0.004); (2) neurological side
+effects (tone, rigidity, tremor, etc.) (p=0.035); and (3) other side effects (like headache, rashes, pigmentation,
+etc.) (p=0.000) at the end of 5 months as compared to the pre-data (Table 4).
+5
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+DE GRUYTER
+Table 4: Showing comparison of pre-diff (pre scores minus baseline) scores with post-diff (post scores minus baseline) scores within the group.
+S no.
+Variables
+Baseline Scores
+(Mean ± SD)
+Pre intervention
+scores (Mean ± SD)
+Post intervention
+scores
+(Mean ± SD)
+Pre-diff scores(Pre
+minus Basline)
+(Mean ± SD)
+Post-diff scores (Post
+minus Baseline)
+(Mean ± SD)
+Confidence interval
+paValue(Pre
+–diff
+vs.Post-
+diff)
+Lower
+bound
+Upper
+bound
+1
+SBP
+115.71 ± 9.45
+113.9 ± 13.77
+119.18 ± 11.35
+−1.50 ± 9.89
+2.06 ± 10.32
+−9.582
+2.457
+0.226
+2
+DBP
+75.42 ± 9.96
+73.52 ± 9.99
+73.21 ± 7.66
+−2.13 ± 10.62
+−2.50 ± 10.92
+−5.681
+6.431
+0.897
+3
+WC
+96.5 ± 9.97
+96.72 ± 11.68
+96.81 ± 11.57
+1.42 ± 3.26
+−0.41 ± 5.35
+−0.444
+4.106
+0.107
+4
+HC
+104.14 ± 11.29
+104.01 ± 11.89
+103.81 ± 9.81
+0.84 ± 2.53
+−0.87 ± 6.99
+−1.935
+5.373
+0.332
+5
+BMI
+26.78 ± 4.26
+26.50 ± 4.16
+26.03 ± 4.79
+−0.28 ± 1.51
+−0.64 ± 1.97
+−0.242
+0.977
+0.218
+6
+TMT-A
+70.85
+71.15 ± 45.93
+57.6 ± 21.63
+−1.13 ± 25.78
+−11.5 ± 25.35
+1.743
+18.882
+0.022b
+7
+TMT-B
+130.95 ± 80.43
+109.4 ± 49.94
+94.28 ± 53.78
+−15.5 ± 41.95
+−36.5 ± 53.15
+7.739
+34.36
+0.004c
+8
+BPRS
+38.85 ± 14.07
+36.95 ± 12.16
+31.25 ± 14.68
+−2.00 ± 8.36
+−6.81 ± 6.10
+0.324
+9.301
+0.037b
+9
+SAPS
+26.04 ± 32.68
+22.19 ± 27.83
+17.81 ± 30.20
+−5.00 ± 7.11
+−9.56 ± 10.98
+−0.168
+9.293
+0.058
+10
+SANS
+32.28 ± 21.33
+31.61 ± 21.42
+19.93 ± 15.15
+−0.69 ± 8.23
+−12.69 ± 13.25
+4.063
+19.937
+0.006c
+11
+SAS
+9.28 ± 4.99
+8.76 ± 4.51
+4.8125 ± 3.83
+−0.19 ± 4.40
+−4.19 ± 3.92
+2.652
+5.348
+0.000c
+12
+UKU –
+PS
+(ITEM-1)
+8.61 ± 4.68
+8.52 ± 10.19
+5.56 ± 3.24
+−0.50 ± 2.22
+−3.13 ± 3.96
+0.999
+4.251
+0.004c
+13
+UKU -
+NS
+(ITEM-
+2)
+4.0 ± 2.21
+3.42 ± 2.25
+2.81 ± 1.72
+−0.50 ± 1.09
+−1.25 ± 2.32
+0.062
+1.438
+0.035b
+14
+UKU -
+AS
+ITEM-3
+3.61 ± 3.18
+2.76 ± 2.40
+1.93 ± 1.87
+−0.69 ± 1.35
+−1.44 ± 2.42
+−0.04
+1.54
+0.061
+15
+UKU -
+NS
+ITEM-4
+7.14 ± 5.62
+6.57 ± 3.24
+4.0 ± 1.59
+−0.31 ± 4.84
+−3.06 ± 5.10
+1.452
+4.048
+0.000c
+16
+PDF
+ITEM-5
+1.57 ± 0.92
+1.04 ± 0.21
+1.12 ± 0.88
+1.25 ± 0.77
+−0.44 ± 0.892
+1.312
+2.063
+0.000c
+17
+Drug
+Dose
+ITEM-6
+1.0 ± 0.77
+1.09 ± 0.53
+1.06 ± 0.77
+0.19 ± 0.911
+0.13 ± 1.025
+−0.469
+0.594
+0.806
+6
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+DE GRUYTER
+Verma et al.
+aPaired Samples t test.
+bp<0.05, cp<0.01.
+Pre-diff scores: Pre intervention scores (after one month of normal routine) minus baseline (before normal routine) scores; Post-diff
+scores: Pre intervention scores (after 5 months of Yoga Intervention) minus baseline (before normal routine); SBP: systolic blood pressure;
+DBP: diastolic blood pressure; WC: waist circumferences; HC: hip circumferences; BMI: body mass index; TMT-A: trail making test – part
+A; TMT-B: trail making test – part B; BPRS: brief psychiatric rating scale; SAPS: scale for assessment of positive symptoms; SANS: scale for
+the assessment of negative symptoms; SAS: Simpson–Angus scale; Udvalg for Kliniske Undersogelser (UKU)-side effect rating scale
+(ITEM 1: Psychic side effects; ITEM 2: Neurologic side effects; ITEM 3:Autonomic side effects; ITEM 4:Other side effects; ITEM 5:Patient
+daily Performance; ITEM 6:Drug Dose).
+7
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+DE GRUYTER
+There was a significant improvement in TMT-A (p=0.022) and TMT-B scores (p=0.004) after Integrated Yoga
+intervention. Clinically, scores on SANS (p=0.006) and brief psychiatric rating scale (BPRS) (p=0.037) also re-
+duced significantly.
+Scores on SAPS, waist circumference, hip circumference, Body Mass Index (BMI), diastolic blood pressure
+and scores on 10 items of UKU side effect rating scale didn’t change significantly as compared to the pre values
+(Table 4).
+We did not find any significant difference between the genders in their response to Yoga intervention.
+Discussion
+In this preliminary study, we observed that at the end of 5 months of IY intervention there was a significant
+reduction in drug-induced Parkinsonian symptoms along with significant improvement in cognitive functions
+and negative symptoms of schizophrenia patients.
+Previously, Ikai et al. [20] conducted a single blind randomized controlled trial on 49 outpatients with
+schizophrenia or related psychotic disorder investigating the effect of weekly sessions of yoga therapy (60-
+min per week) for 8 weeks in addition to their ongoing treatment on postural instability. In the control group,
+the subjects received a weekly regular day-care program. They observed that at the end of 8 weeks, there were
+significant improvements in a total length of trunk motion, the Romberg ratio and anteflexion in standing in
+the yoga group, while there were no significant changes in the control group. However, those clinical gains re-
+turned to the baseline level at Week 16. The intervention given by Ikai et al. was short term, and the assessments
+were not focused on typical side effects of psychotropic drugs. The present study used standard psychometric
+tools to assess anti-psychotic-induced side effects and imparted a long-term (6-month) yoga intervention in
+contrast to most previous such studies.
+A previous randomized controlled study (RCT) which used the same yoga module for 16 weeks found that
+it was effective in reducing positive and negative symptoms of patients with schizophrenia [13]. Another RCT
+found similar yoga intervention to be useful in reducing negative and positive symptoms and depressive symp-
+toms in in-patients with functional psychosis [14]. Other RCTs have used yoga intervention (daily 1 h) for 8
+weeks and 16 weeks, respectively, and found useful reduction in positive and negative symptoms of patients
+suffering from schizophrenia [15, 16]. Another RCT on 43 schizophrenia patients demonstrated significant im-
+provement of oxytocin levels along with improved socio-occupational functioning with 4 weeks of Integrated
+Yoga intervention [17]. Our results are in line with these studies as we have also observed significant reduction
+in negative symptoms, improvement in visuo-perceptual ability (TMT A) and executive functions (TMT-B) as
+well as some reduction in positive symptoms. We observed much higher improvement in TMT A and TMT B
+performances as compared to previous studies. This may be due to the longer duration of yoga intervention in
+the current study. The reduction in positive symptoms may not have reached significance due to the fact that
+the subjects were already stabilized with medications and had minimal positive symptoms at baseline. Most
+previous studies have used PANSS (Positive and Negative Syndrome Scale) for assessment of clinical symp-
+toms but we found similar result using SAPS and SANS, which allows for better characterization of individual
+positive and negative symptoms. The long-term intervention used in our study as compared to other previous
+studies (varies from 4 weeks to 8 weeks) suggests that the benefits of yoga therapy are maintained for at least
+5 months.
+For some of the variables such as: scores on SAPS, waist circumference, hip circumference, BMI, diastolic
+blood pressure and scores on 10 items of UKU side effect rating scale, there was no significant change at the
+end of 5 months after intervention as compared to the pre-intervention values (Table 4). This may be explained
+based on the following reasons: (1) the participants were relatively elderly in the present study (mean ± SD
+age: 52.87 ± 9.5 years) as compared with those in the previous RCTs that evaluated the effectiveness of yoga in
+schizophrenia (mean ± SD age: 32.5 ± 7.9, 37.4 ± 13.6 and 32.8 ± 10.0 years, respectively) [13, 15, 16]. Furthermore,
+this study included very chronic patients with a mean duration of illness of 24.0 ± 3.05 years who showed
+persistent psychopathology. These factors might have limited the ability of the subjects to practice the given
+intervention with the same intensity as in previous studies; (2) the sample size of the study was low to achieve
+desirable effect sizes for these variables.
+We observed good adherence in this long-term study. As discussed under results section, only 5 patients
+dropped, out of 26 recruited, during the study period of 5 months. The dropout rate in the present study was
+19.23%, which is comparable to the dropout rates in previous RCTs (17–21%) [13, 15, 16]. But duration of most
+previous RCTs being lesser than the current study (average 6–8 weeks as compared to 20 weeks), this dropout
+rate is still lower. These are several potential reasons for such a low rate of withdrawal in this study. First, the
+study was conducted in a residential setup and travel to the yoga center (the major barrier for adherence) was
+8
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+Verma et al.
+avoided. Second, practice was given regularly (5 days a week) under supervision of yoga teacher and/or warden
+of the rehabilitation center for the whole intervention period of 5 months.
+Probable mechanisms of action of IY may include: (1) increase in the oxytocin levels; regular yoga practice
+for 4 weeks has been found useful in enhancing oxytocin levels in subjects with schizophrenia [17]. Oxytocin
+is associated with increased social bonding, better emotional well-being and cognitive functions [26]; (2) Yoga
+breathing had also been shown to affect pre-frontal oxygenation in schizophrenia patients [27], which may have
+a cognition enhancing effect; (3) Yoga practices have been shown to increase the activity of GABA (gamma-
+amino butyric-acid) system [28]; and BDNF (brain-derived neurotrophic factor) which are directly related to
+antidepressant effects [29].
+Strengths of current study are: (1) longer duration of intervention, (2) better adherence by the subjects, (3)
+exploration of a clinically important area which has global implications. Present study also has several limita-
+tions: (1) small sample size; (2) lack of control group and (3) lack of objective measures of assessment. Current
+work is a preliminary attempt to plan for future studies with larger sample size and more robust design.
+Conclusions
+This study suggests that Integrated Yoga intervention of 5 months may be useful in reducing drug-induced
+Parkinsonism and other antipsychotic-induced side effects. These findings need confirmation from studies with
+larger sample size and randomized controlled design.
+Acknowledgments:
+We are thankful to Dr Ranganathan for his support and to all the patients who cooperated during this research.
+Author contributions: All the authors have accepted responsibility for the entire content of this submitted
+manuscript and approved submission.
+Research funding: None declared.
+Employment or leadership: None declared.
+Honorarium: None declared.
+Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis
+and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.
+References
+[1] Arana GW. Overview of side effects caused by typical anti-psychotics. J Clin Psychiatry. 2000;61:5–11.
+[2] Fakhoury WK, Wright D, Wallace M. Prevalence and extent of distress of adverse effects of antipsychotics among callers to a United King-
+dom National Mental Health Helpline. Int Clin Psychopharmacol. 2001;6:153–62.
+[3] Usher K, Foster K, Park T. The metabolic syndrome and schizophrenia: the latest evidence and nursing guidelines for management. J Psy-
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+[4] Sharma T. Cognitive effects of conventional and atypical antipsychotics in schizophrenia. Br J Psychiatry. 1999;174:44–51.
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+, McCue M, Spring B, Mohs RC, Lavori PW, Farr RM. Effects of amantadine and trihexyphenidyl on memory in elderly normal
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+[9] Minzenberg MJ, Poole JH, Benton C, Vinogradov S. Association of anticholinergic load with impairment of complex attention and mem-
+ory in schizophrenia. Am J Psychiatry. 2004;161:116–24.
+[10] Woolery A, Myers H, Sternlieb B, Zeltzer L. A yoga intervention for young adults with elevated symptoms of depression. Altern Ther
+Health Med. 2004;10:60–3.
+[11] Vancampfort D, Vansteelandt K, Scheewe T, Probst M, Knapen J, De Herdt A, et al. Yoga in schizophrenia: a systematic review of ran-
+domised controlled trials. Acta Psychiatr Scand. 2012;126:12–20.
+9
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+Authenticated
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+Verma et al.
+DE GRUYTER
+[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;116:226–32.
+[13] Varambally S, Gangadhar BN, Thirthalli J, Jagannathan A, Kumar S, Venkatasubramanian G, et al. Therapeutic efficacy of add-on yo-
+gasana intervention in stabilized outpatient schizophrenia: randomized controlled comparison with exercise and waitlist. Indian J Psy-
+chiatry. 2012;54:227.
+[14] Manjunath RB, Varambally S, Thirthalli J, Basavaraddi IV, Gangadhar BN. Efficacy of yoga as an add-on treatment for in-patients with
+functional psychotic disorder. Indian J Psychiatry. 2013;55:374.
+[15] Visceglia E, Lewis S. Yoga therapy as an adjunctive treatment for schizophrenia: a randomized, controlled pilot study. J Altern Comple-
+ment Med. 2011;17:601–7.
+[16] Thirthalli J, Duraiswamy G, Varambally S, Nagendra HR, Gangadhar BN. Yoga as an add-on treatment in the management of
+schizophrenia: a randomized controlled trial. Ann Gen Psychiatry. 2006;5:84.
+[17] Jayaram N, Varambally S, Behere RV, Venkatasubramanian G, Arasappa R, Christopher R, et al. Effect of yoga therapy on plasma oxytocin
+and facial emotion recognition deficits in patients of schizophrenia. Indian J Psychiatry. 2013 Jul;55:S409.
+[18] Hall E, Verheyden G, Ashburn A. Effect of a yoga program on an individual with Parkinson’s disease: a single-subject design. Disabil
+Rehabil. 2011;33:1483–9.
+[19] Innes KE, Bourguignon C, Taylor AG. Risk indices associated with the insulin resistance syndrome, cardiovascular disease, and possible
+protection with yoga: a systematic review. J Am Board Fam Pract. 2005;18:491–519.
+[20] Ikai S, Uchida H, Suzuki T, Tsunoda K, Mimura M, Fujii Y. Effects of yoga therapy on postural stability in patients with schizophrenia-
+spectrum disorders: a single-blind randomized controlled trial. J Psychiatr Res. 2013;47:1744–50.
+[21] Janno S, Holi MM, Tuisku K, Wahlbeck K. Validity of Simpson-Angus Scale (SAS) in a naturalistic schizophrenia population. BMC Neurol.
+2005 Mar 17;5:5.
+[22] Lingjaerde O, Ahlfors UG, Bech P
+, Dencker SJ, Elgen K. The UKU side effect rating scale: a new comprehensive rating scale for psy-
+chotropic drugs and a cross‐sectional study of side effects in neuroleptic‐treated patients. Acta Psychiatr Scand. 1987;76:1–00.
+[23] Zalonis I, Kararizou E, Triantafyllou NI, Kapaki E, Papageorgiou S, Sgouropoulos PE, et al. A normative study of the trail making test A
+and B in Greek adults. Clin Neuropsychol. 2008 Sep 1;22:842–50.
+[24] Norman RM, Malla AK, Cortese L, Diaz F. A study of the interrelationship between and comparative interrater reliability of the SAPS,
+SANS and PANSS. Schizophr Res. 1996 Mar 31;19:73–85.
+[25] Govindaraj R, Varambally S, Sharma M, Gangadhar BN. Designing and validation of a yoga-based intervention for schizophrenia. Int Rev
+Psychiatry. 2016;28:323–6.
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+non‐randomised trial. Acta Neuropsychiatr. 2012;24:91–100.
+[27] Bhargav H, Nagendra HR, Gangadhar BN, Nagarathna R. Frontal hemodynamic responses to high frequency yoga breathing in
+schizophrenia: a functional near-infrared spectroscopy study. Front Psychiatry. 2014;5:29
+[28] Streeter CC, Gerbarg PL, Saper RB, Ciraulo DA, Brown RP
+. Effects of yoga on the autonomic nervous system, gamma-aminobutyric-acid,
+and allostasis in epilepsy, depression, and post-traumatic stress disorder. Med Hypotheses. 2012;78:571–9.
+[29] Naveen GH, Thirthalli J, Rao MG, Varambally S, Christopher R, Gangadhar BN. Positive therapeutic and neurotropic effects of yoga in
+depression: a comparative study. Indian J Psychiatry. 2013;55:S400.
+10
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subfolder_0/Effect of one-month yoga training program on performance in a mirror tracing task.txt

@@ -0,0 +1,427 @@
+INTRODUCTION
+A mirror tracing task requires reversal
+ability, eye-hand coordination and motor
+learning (1). The practice of yoga techniques
+have been shown to improve a number of
+motor abilities.
+Following ten days of yoga practice the
+static motor performance or hand steadiness
+improved in school children (2) and in young
+adults 
+(3). 
+An 
+improvement 
+in 
+hand
+steadiness suggests better eye-hand co-
+ordination, concentration, and decreased
+anxiety. Yoga practice for a month improved
+performance in a repetitive motor task (i.e.,
+finger tapping) implying a decrease in
+fatigability (4), and in a task requiring skill
+and speed (i.e., the O’Connor tweezer
+dexterity task) (5).
+The 
+present 
+study 
+was 
+aimed 
+at
+evaluating the effects of yoga practice on
+performance in a mirror star tracing task.
+This aim was to understand (i) whether yoga
+practice influences mirror star tracing and
+(ii) whether the performance in the task
+changes if a volunteer repeats it after a
+month (with no specific intervention in-
+between). The control group served to
+SHORT 
+COMMUNICATION
+EFFECT OF A ONE-MONTH YOGA TRAINING PROGRAM ON
+PERFORMANCE IN A MIRROR-TRACING TASK
+SHIRLEY TELLES*, P. PRAGHURAJ, ABHIJIT GHOSH
+AND H. R. NAGENDRA
+Swami Vivekananda Yoga Research Foundation,
+Bangalore – 560 019
+( Received on May 20, 2005 )
+Abstract : The performance in a mirror star tracing task was assessed
+in two groups of volunteers (yoga and control) with 26 people in each
+group, and age range between 18 and 45 years. The star to be traced was
+six pointed and the outline was made up of 60 circles (4 mm in diameter).
+At the end of one month the yoga group showed a significant improvement
+in terms of an increase in the number of circles crossed (P<0.001, Wilcoxon
+paired signed ranks test) for both hands and a decrease in the number of
+circles left out for the right hand (P<0.05). The control group showed a
+significant increase in number of circles crossed for the left hand alone
+(P<0.05) at the end of a month attributed to re-test. The study suggests
+that one month of yoga improved reversal ability, eye-hand co-ordination,
+speed and accuracy which are necessary for mirror star tracing.
+Key words : mirror tracing task
+yoga
+reversal ability
+speed
+accuracy
+Indian J Physiol Pharmacol 2006; 50 (2) : 187–190
+*Corresponding Author :
+Swami Vivekananda Yoga Research Foundation, #19, Eknath Bhavan, Near
+Gavipuram Circle, K.G. Nagar, Bangalore – 560 019, India. Ph.: 91-80-26612669;
+Fax : 91-80-26608645; E-mail : [email protected]
+188
+Telles  et  al
+Indian J Physiol Pharmacol 2006; 50(2)
+answer the second question, i.e., whether
+mirror star tracing is influenced by re-
+testing. Hence this is not a randomized
+controlled trial and the control group served
+solely to understand the re-test effect.
+METHODS
+S u b j e c t s
+There 
+were 
+two 
+groups, 
+Yoga 
+and
+Control. The yoga group consisted of 26
+subjects (12 female) who had elected to join
+a 
+one-month 
+residential 
+yoga 
+training
+program. Their ages ranged between 18 and
+45 
+years 
+(group 
+average 
+age ± S.D.,
+25.7 ± 7.1 years). The control group of 26
+subjects (11 female), were within the same
+age range as the yoga group. All subjects
+had normal health based on a routine
+clinical examination and were right hand
+dominant 
+based 
+on 
+the 
+Edinburgh
+handedness inventory (6). The two groups
+were not matched in any other way. Hence
+the control group served to assess the re-
+test effect on performance in the task. The
+volunteers of both groups had all completed
+their graduation (minimum) and were all
+office (‘white collar’) workers.
+D e s i g n
+Assessments were made at the beginning
+(initial) and end (final) of a thirty day period
+during which the yoga group received
+training in yoga while the control group
+carried on with their routine activities.
+For both groups the testing (pre and post)
+was between 10.00 a.m. and 12 noon. The
+project was reviewed and approved by the
+Institutional Ethics Committee.
+A s s e s s m e n t
+The task involved filling in the outline
+of a six-pointed star while looking in a
+mirror to observe the movements of the hand
+(7). A shield prevented the subject from
+looking directly at the pattern which was
+placed on a board and was visible in the
+mirror (Anand Agencies, Pune, India). The
+outline of the star consisted of 60 circles,
+each circle approximately 4 mm in diameter.
+The star was placed so that two points faced
+up or down and one point faced right or left.
+Alternate subjects were asked to begin
+tracing with either the right hand or with
+the left hand. This order was kept the same
+at the final assessment. Tracing with either
+hand began from mid-way between the two
+lower points, and then proceeded either
+clockwise (with the left hand) or anti-
+clockwise (with the right hand).
+The volunteers were asked to trace the
+outline of the star passing through as many
+circles as possible within one minute. Hence
+the total number of circles crossed in one
+minute need not be 60, i.e., they may not
+have been able to pass through all the circles
+in one minute. The numbers of circles crossed
+and left out were calculated from the point
+of starting till the end-point, i.e., the circle
+reached at the end of one minute. In the
+process of moving along the outline volunteers
+would (i) cross circles which is what they
+are meant to do, and (ii) leave out circles -
+which is considered as an error. The
+variables noted were: (i) number of circles
+crossed, and (ii) number of circles left out.
+Training in yoga
+The yoga group received training in
+physical postures (asanas, 90 minutes),
+cleansing practices (kriyas, 30 minutes),
+yoga 
+voluntarily 
+controlled 
+breathing
+(pranayama, 60 minutes), meditation (60
+minutes), devotional sessions (90 minutes)
+Indian J Physiol Pharmacol 2006; 50(2)
+Yoga Improves Mirror-Tracing
+189
+and lectures on the theory of yoga (60
+minutes).
+The 
+asanas 
+which 
+were 
+practiced
+every day included: ardhacati cakrasana,
+ardha 
+cakrasana, 
+padahastasana, 
+ardha
+matsyendrasana, 
+paschimottanasana,
+ustrasana, matsyasana, salabhasana, and
+cakrasana. The kriyas were: trataka (daily)
+and jala neti and vaman dhauti (twice in a
+week). The pranayama practices included
+brahmari, nadisuddhi, sitali, sitkari, and
+sadanta pranyamas, as well as sectional
+breathing (with attention shifting from the
+abdomen, to the chest, and to the clavicular
+(upper) part.
+Data 
+analysis
+The 
+non-parametric 
+Wilcoxon 
+paired
+signed ranks test was used for Initial-Final
+comparisons of the data of the two groups.
+This test was selected as the data did not
+have equal variance and a normal distribution.
+RESULTS
+The Yoga group showed a significant
+increase in number of circles crossed for both
+the right and the left hands at the final
+assessment compared to the initial values
+(P<0.001, in both cases). The Yoga group also
+showed a significant decrease in the number
+of circles left out when using the right hand,
+at the final assessment (P<0.05). The Control
+group showed a significant increase in the
+number of circles crossed using the left hand
+at final assessment compared to the initial
+assessment (P<0.05). There was no change
+for the right hand or for the number of
+circles missed (for both hands) at the final
+assessment compared to the initial values.
+There was no significant difference between
+the initial values of the two groups (P>0.05,
+for all comparisons, Mann-Whitney U test).
+The group average values ± S.D. are given
+in Table I.
+DISCUSSION
+The Yoga group showed a significant
+improvement in the performance in a mirror
+tracing task at the end of a one-month
+program, in terms of an increase in the
+number of circles crossed (when using either
+hand) and a decrease in the number of
+circles left out using the right hand. The
+control group showed an increase in the
+number of circles crossed using the left hand
+at the end of thirty days.
+There has been no study on the effect of
+TABLE I :
+Number of circles traced and missed in one minute during a mirror star tracing task
+before and after a month in yoga and control groups. Values are group Mean±S.D.
+Number of circles traced
+Number of circles missed
+Groups
+Right hand
+Left hand
+Right hand
+Left hand
+Before
+After
+Before
+After
+Before
+After
+Before
+After
+Yoga
+18.7±12.4
+36.2±15.5***
+22.7±13.4
+42.7±18.8***
+0.4±0.7
+0.1±0.3*
+1.0±1.4
+0.9±1.2
+(n=26)
+Control
+19.3±10.2
+23.1±9.6
+21.9±12.5
+27.3±12.6*
+1.5±3.6
+1.0±1.3
+1.7±3.3
+2.0±2.0
+(n=26)
+*P<0.05, ***P<0.001, Wilcoxon paired signed ranks test, for ‘After’ values compared to ‘Before’.
+190
+Telles  et  al
+Indian J Physiol Pharmacol 2006; 50(2)
+yoga practice on performance in a mirror
+tracing task. However mirror tracing was
+used not as a motor task but as one of three
+laboratory 
+stressors 
+in 
+practitioners 
+of
+transcendental meditation (TM), and the
+salivary cortisol levels were measured (8).
+The practice of TM was associated with
+lower 
+plasma 
+cortisol 
+suggesting 
+that
+meditation reduced the ‘stress’ associated
+with performing the mirror tracing task.
+The fact that the control group also
+showed an improvement (though of a lesser
+magnitude) in the task performance can be
+explained as a beneficial effect of practice
+on testing. This was also shown in an earlier
+study where the improvement seen in a
+mirror tracing task over twelve repeat
+sessions was retained four months later (9).
+Also, the initial improvement (i.e., after 1
+or 2 trials) was greater for the non-dominant
+hand. The fact that the non-dominant hand
+improves with re-testing may explain why
+the 
+left 
+hand 
+performance 
+showed 
+an
+improvement in the control group. The
+control group consisted of office workers in
+offices and factories close to the yoga center.
+There is no reason to expect that their
+routine activities at work or at home could
+have influenced their performance in the
+mirror star tracing task. However it has to
+be emphasized that since a detailed account
+of their activities was not noted hence this
+possibility cannot be ruled out.
+The yoga group showed an increase in
+the number of circles traversed in a minute
+suggesting an improvement in speed. The
+other change following yoga was a decrease
+in the number of circles left out during the
+one-minute traverse. This reduction suggests
+an improvement in accuracy.
+In a previous study the motivation to
+learn yoga was found to influence the
+performance in a tweezer dexterity task (5).
+Hence higher motivation levels in yoga-
+learners may have also contributed to the
+improved performance in the mirror tracing
+task.
+In summary, the present results suggest
+that a month of yoga training brings about
+an improvement in a mirror tracing task The
+motivation to learn yoga may have also
+influenced the results. However further
+studies using a randomized controlled design
+could substantiate these preliminary findings.
+REFERENCES
+1.
+Edelstein K, Dennis M, Copeland K, Frederick J,
+Francis D, Hetherington R, Brandt ME, Fletcher
+JM. Motor learning in children with spina bifida:
+dissociation 
+between 
+performance 
+level 
+and
+acquisition rate. J Int Neuropsychol Soc 2004;
+10(6): 877–887.
+2.
+Telles 
+S, 
+Hanumanthaiah 
+B, 
+Nagarathna 
+R,
+Nagendra 
+HR. 
+Improvement 
+in 
+static 
+motor
+performance following yogic training of school
+children. Percept Mot Skills 1993; 76: 1264–1266.
+3.
+Telles 
+S, 
+Hanumanthaiah 
+B, 
+Nagaratha 
+R,
+Nagendra HR. Plasticity of motor control systems
+demonstrated by yoga training. Indian J Physiol
+Pharmacol 1994; 38(20): 143–144.
+4.
+Dash M, Telles S. Motor speed based on a finger
+tapping task following yoga. Indian J Physiol
+Pharmacol 1999; 43(3); 458–462.
+5.
+Manjunath NK, Telles S. Factors influencing
+changes in tweezer dexterity scores following yoga
+training. Indian J Physiol Pharmacol 1999; 43(2):
+225–229.
+6 .
+Oldfield 
+RC. 
+The 
+assessment 
+and 
+analysis
+of 
+handedness: 
+the 
+Edinburgh 
+inventory.
+Neuropsychologia 1971; 9: 97–114.
+7.
+Whipple GM. Manual of mental and physical tests
+(3rd Ed.). Baltimore: Warwick & York Inc. 1924.
+8 .
+Maclean CRK, Walton KG, Wanneberg SR, Levitsky
+DK, Mandarino JP, Wazin R, Hillis SL, Schneider
+RH. Altered responses of cortisol, growth hormone,
+thyroid stimulating hormone and testosterone to
+acute stress after four months’ practice of TM.
+Ann New York Acad Sci 1994; 746: 381–384.
+9.
+Marks 
+S. 
+Ipsilateral 
+and 
+contralateral 
+skill
+acquisition following random practice of unilateral
+mirror-drawing. Percept Mot Skills 1996; 83(3 pt
+1): 715–722.

subfolder_0/Effect of short term intensive yoga prohram for on pain functional disability and spinal flexibility in CLBP.txt

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+THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE
+Volume 14, Number 6, 2008, pp. 637–644
+© Mary Ann Liebert, Inc.
+DOI: 10.1089/acm.2007.0815
+Effect of Short-Term Intensive Yoga Program on Pain,
+Functional Disability, and Spinal Flexibility in Chronic Low
+Back Pain: A Randomized Control Study
+Padmini Tekur, M.B.B.S. (Ph.D.Cand.),1 Chametcha Singphow, M.Sc.,1
+Hongasandra Ramarao Nagendra, M.E., Ph.D.,2 and 
+Nagarathna Raghuram, M.B.B.S., M.D., F.R.C.P. (Edin)1
+Abstract
+Objective: The aim of this study was to compare the effect of a short-term intensive residential yoga program
+with physical exercise (control) on pain and spinal flexibility in subjects with chronic low-back pain (CLBP).
+Design: This was a wait-list, randomized controlled study.
+Setting: The study was conducted at a residential integrative health center in Bangalore, South India.
+Subjects: Eighty (80) subjects (females, n  37) with CLBP, who consented were randomly assigned to receive
+yoga or physical exercise if they satisfied the selection criteria.
+Intervention: The intervention consisted of a 1-week intensive residential yoga program comprised of asanas
+(physical postures) designed for back pain, pranayamas (breathing practices), meditation, and didactic and in-
+teractive sessions on philosophical concepts of yoga. The control group practiced physical exercises under a
+trained physiatrist and also had didactic and interactive sessions on lifestyle change. Both of the groups were
+matched for time on intervention and attention.
+Outcome measures: Pain-related outcomes were assessed by the Oswestry Disability Index (ODI) and by spinal
+flexibility, which was assessed using goniometer at pre and post intervention. Data were analyzed using re-
+peated measures analysis of variance (RMANOVA).
+Results: Data conformed to a Gaussian distribution. There was a significant reduction in ODI scores in the yoga
+group compared to the control group (p  0.01; effect size 1.264). Spinal flexibility measures improved signif-
+icantly in both groups but the yoga group had greater improvement as compared to controls on spinal flexion
+(p  0.008; effect size 0.146), spinal extension (p  0.002; effect size 0.251), right lateral flexion (p  0.059; effect
+size 0.006); and left lateral flexion (p  0.006; effect size 0.171).
+Conclusions: Seven (7) days of a residential intensive yoga-based lifestyle program reduced pain-related dis-
+ability and improved spinal flexibility in patients with CLBP better than a physical exercise regimen.
+637
+Introduction
+C
+hronic low-back pain (CLBP) is the most common cause
+contributing to a large number of lost work days and dis-
+ability claims.1 About 1% of the U.S. population (both men and
+women) is chronically disabled as a result of low-back pain.2
+Functional disability,3 sleep disturbances, fatigue, and med-
+ication abuse4 are seen in people suffering from CLBP. Several
+studies point to the role of a sedentary lifestyle that includes
+(1) mechanical factors such as prolonged wrong postures lead-
+ing to wasting and weakness of postural muscles and (2)
+chronic muscle spasm resulting from psychologic stress in the
+etiology of CLBP. Increased paraspinal electromyographic
+(EMG) activity has been observed in subjects with CLBP that
+may be the result of both voluntary and nonvoluntary changes
+in motor control in response to perceived stress.5
+Unexpected failures and recurrences after physical and
+surgical therapies have been documented. One (1) of 3 pa-
+tients operated for herniated lumbar discs presented with
+failed disc surgery with persistent pain, fatigue, exhaustion,
+and emotional problems that interfered with their jobs, and
+only 2 of 3 patients, who were active before the operations,
+1Division of Yoga and Life Sciences, Swami Vivekananda Yoga Research Foundation (SVYASA), Bangalore, India.
+2SYVASA, Bangalore, India.
+returned to work.6 This has led to research in nonpharma-
+cologic therapies including yoga. Yoga offers a self-correc-
+tive, holistic approach to health and has been shown to 
+be effective in several chronic lifestyle-related diseases 
+(via well-designed trials) such as osteoarthritis,7 rheumatoid
+arthritis (RA),8 essential hypertension,9 bronchial asthma,10,11
+irritable bowel syndrome,12 diabetes,13 coronary artery dis-
+ease,14 and depression.15 Yoga has also been used in patients
+with CLBP. Two (2) recent randomized control trials (RCTs)
+on yoga for CLBP using Viniyoga16 and Iyengar yoga ther-
+apy17 showed reduction in pain and functional disability
+with nonsignificant changes in the control groups. Among
+other studies on yoga for CLBP, 1 study lacked a control
+group18 and the other was not powered to reach statistical
+significance.19 These RCTs have demonstrated the efficacy
+of yoga done for 3–6 months, in an outpatient setting. The
+present study was planned to observe the effect of an inte-
+grated yoga program with a hypothesis that changes in pain
+and flexibility can be achieved in a short-term intensive res-
+idential yoga program. Bijlani et al.20 reported favorable
+metabolic effects after 9 days of a yoga-based lifestyle change
+program in patients with hypertension and diabetes melli-
+tus.
+Thus, the aim of the present randomized controlled study
+was to determine the efficacy of yoga on disability caused
+by pain and spinal flexibility in patients with CLBP in a
+short-term, week-long intensive residential program.
+Methods
+Subjects
+Among 160 patients who were admitted to a health home
+in Bangalore (South India), for management of low-back
+pain, 80 who satisfied the selection criteria were recruited
+for the study after initial assessments by the chief investiga-
+tor, who had experience in rheumatology after earning a
+medical postgraduate degree. All of these patients were from
+upper and lower middle classes from all over the country,
+including urban, semiurban, and rural regions of India. The
+breakdown of the patients’ educational backgrounds from
+primary school to post graduation is shown in the demo-
+graphic table (Table 1). The sample size was determined af-
+ter calculating the effect size from a previous study. The 
+patients were recruited by advertisements, newsletters, self-
+referrals, word-of-mouth, or referrals by medical practition-
+ers. Patients came with earlier magnetic resonance imaging
+(MRI) scans at the time of admission and new X-rays were
+taken and opinions of 2 experts, a radiologist, and an ortho-
+pedic surgeon were obtained to rule out any organic cause
+of CLBP. The inclusion criteria were: (1) history of CLBP of
+more than 3 months; (2) pain in the lumbar spine with or
+without radiation to legs21; and (3) age between 18 to 60
+years. Exclusion criteria were: (1) CLBP caused by organic
+pathology in the spine, such as malignancy (primary or sec-
+ondary), or chronic infections checked by an X-ray of lum-
+bar spine; (2) severe obesity; and (3) critical illness.
+The study was approved after a critical evaluation by the
+institutional review board (IRB) of the institution; the board
+consisted of unaffiliated impartial members as per the crite-
+ria for an IRB spelled out by the Indian council for medical
+research. Signed informed consent was obtained from all pa-
+tients.
+Study design
+In this randomized control study, 80 subjects who satis-
+fied the study criteria were allotted to 2 groups, experimen-
+tal and control, by a computer-generated random number
+table (obtained from www.randomizer.org). Numbered con-
+TEKUR ET AL.
+638
+TABLE 1. DETAILS OF DEMOGRAPHIC DATA OF THE STUDY PARTICIPANTS
+Step
+number
+Variables
+Yoga group
+Control group
+1
+Number of participants
+40
+40
+2
+Males (M)
+19
+25
+3
+Females (F)
+21
+15
+4
+Age (mean  standard deviation)
+49  3.6
+48  4
+5
+Education
+High school
+M  3, F  11
+M  5, F  3
+College
+M  10, F  8
+M  13, F  10
+Postgraduate
+M  6, F  2
+M  7, F  2
+6
+Working patterns
+Males
+Working—sedentary
+14
+16
+Working—nonsedentary
+5
+8
+Females
+Working
+6
+7
+Housewives
+15
+8
+7
+CLBP
+ 1 year
+10
+11
+1–5 years
+9
+11
+5–10 years
+11
+10
+ 10 years
+10
+8
+8
+Cause
+Lumbar spondylosis (LS)
+6
+5
+Prolapsed intervertebral
+disc (PID)
+6
+7
+LS with PID
+19
+15
+Muscle spasm
+9
+13
+tainers were used to implement the random allocation to con-
+ceal the sequence until interventions were assigned. A semi-
+structured interview was used to obtain demographic de-
+tails; vital clinical data; and personal, family, and stress
+histories. Outcome variables were recorded on the first and
+seventh days before the beginning of the day’s schedule. The
+experimental group received a yoga-based program whereas
+the control group received a nonyogic physical exercise–
+based intervention and went on to the yoga group in the sec-
+ond week. A set of physical exercise practices for low-back
+pain developed by a physiatrist was used for the control
+group. The physiatrist was a clinician with a Master’s degree
+in physical medicine with experience in treating back pains
+with exercise therapies, and he was not affiliated with the
+yoga center. He was confident that these exercises were use-
+ful and safe. They was not meant to be a placebo but were
+designed to help the patients.
+Both groups had the same daily routine, a vegetarian diet,
+and hour-to-hour matched interventions. Table 2 shows the
+daily routine.
+Blinding and masking
+The statistician who did the randomization and analysis
+of data and the researcher who enrolled the subjects, as-
+signed them to groups, and carried out the assessments were
+blinded to the subjects’ treatment status. Because this was an
+interventional study, double-blinding was not possible.
+Coded answer sheets of the questionnaires were analyzed
+only after completion of the study.
+Intervention
+Yoga intervention
+The concepts used to develop a specific module of an “in-
+tegrated approach to yoga therapy (IAYT)” for back pain
+were taken from traditional yoga scriptures (the Patanjali
+yoga sutras, Upanishads, and Yoga Vasishtha) that highlight a
+holistic approach to health management at physical, mental,
+emotional, and intellectual levels.22 The daily routine in-
+cluded the practices as follows (Table 3):
+• Om meditation—In this meditation, the syllable Om is used
+to achieve a state of alert rest.23 The person seated in any
+comfortable meditative postures repeats the syllable Om
+mentally, leading to an effortless flow of a single thought
+in the mind (pratyaya eka taanata dhyam) for 10 minutes.
+• Yoga-based special technique—The yogic physical practices
+(back-pain special techniques; Table 3) progressed from
+initial safe movements to final yoga postures to provide a
+tractionlike effect. They included practices (1) to relax the
+spinal muscles by stretching as in I-5, 6 and by deep rest-
+ing via breath awareness as in III, and conscious guided
+relaxation of all parts of the body as in VI; (2) a traction
+effect as in I-1, IV-1 and 2, V-1, 2; and 3; (3) strengthening
+the back muscles as in I-4 and II-1 and 2; and (4) strength-
+ening the abdominals as in I-1, 2, and 3. Safety of the prac-
+tices was ensured by consultation with a senior physia-
+trist. Special care while designing the module was taken
+to avoid acute forward or backward movements and jerky
+movements of the spine.24
+• Yogic hymns—These involved guided chanting (with
+meaning) of verses from the Bhagavadgita (the most pop-
+ular Indian scripture) that describes the definition and the
+streams of yoga to arrive at the concept of lifestyle change
+via self-mastery, self-surrender, self-analysis, and aware-
+ness in action. Divine-hymn sessions of singing were
+meant to replace suppressed emotions and open up the
+gentle emotions to move toward a stress-free joyful state
+of mind. Because most patients with CLBP have a com-
+ponent of psychologic stress, these practices are relevant
+to correct the problem in a holistic way.
+• Lectures—These were tailor-made to provide the entire
+philosophical model of thorough self-corrective tech-
+YOGA IN BACK PAIN
+639
+TABLE 2. TIMETABLE FOR THE YOGA AND CONTROL GROUPS: DAILY SCHEDULE
+Step
+number
+Time
+Yoga group
+Control group
+1
+05.00–05.30 AM
+Om meditation—30 minutes
+Walking—30 minutes
+2
+05.30–06.30 AM
+Yoga-based special technique—60 minutes
+Exercise-based special technique—60 minutes
+3
+06.30–07.30 AM
+Bath and wash
+Bath and wash
+4
+07.30–08.15 AM
+Chanting of yogic hymns—45 minutes
+Video show (on nature)—45 minutes
+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 minutes
+Lecture (on healthy lifestyle)—60 minutes
+8
+11.00–12.00 noon
+Pranayama (yogic breathing)—60 minutes
+Non yogic breathing practice—60 minutes
+9
+12.00–01.00 PM
+Yoga-based special technique—60 minutes
+Exercise based special technique—60 minutes
+10
+01.00–02.00 PM
+Lunch (vegetarian diet)
+Lunch (vegetarian diet)
+11
+02.00–02.30 PM
+Deep relaxation technique—30 minutes
+Rest at room—30 minutes
+12
+02.30–04.00 PM
+Assessments and counseling
+Assessments and counseling
+13
+04.00–05.00 PM
+Cyclic meditation—60 minutes
+Listening to music—60 minutes
+14
+06.15–06.45 PM
+Divine hymns session (Bhajan)—30 minutes
+Video show (on nature)—30 minutes
+15
+06.45–07.45 PM
+Meditation with yogic chants (mind sound 
+Walking—45 minutes
+resonance technique)—45 minutes
+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.
+niques for healing. There were talks on the yogic approach
+to health, and the physiologic effects of different yoga
+practices were taught to the subjects.
+• Deep relaxation technique—This is a guided relaxation tech-
+nique that lasts for 10 minutes and is done in 3 phases: (1)
+relaxation from the tip of the toes to the head mentioning
+each part of the body specifically; (2) letting the body “col-
+lapse” on the ground with a feeling of “letting go,” while
+chanting Om; and (3) inducing a feeling of expansion by
+visualization of the limitless sky or ocean.25
+• Yogic breathing practices—Pranayama is a state of voluntar-
+ily regulated breathing while the mind is directed to the
+flow of breath or prana. A typical cycle of the slow type
+pranayamic breathing involves the phases of inhalation and
+exhalation. There are different kinds of pranayamas, vary-
+ing according to the durations of the phases in the breath-
+ing cycles and the nostrils used. Yogic breathing practices
+were included to bring about a slow rhythmic breathing
+pattern to reduce the breath rate, with internal awareness
+of the touch of the flow of air through the air passages,
+which is an effective way to achieve mastery over the
+mind.26
+• Cyclic meditation—This is based on traditional texts.27 The
+technique includes a combination of both stimulating and
+relaxing or calming practices.28 Studies of this meditation
+have shown that this technique, which is a combination
+of yoga postures interspersed with relaxation, reduces
+arousal more than relaxation alone.29
+• Counseling—Individual yogic counseling for stress man-
+agement was focused on “happiness analysis” from an an-
+cient text called Taitteriya Upanishad,30 which is similar to
+the CBT used in modern psychotherapy. This was used to
+help the patient with CLBP to become aware of the emo-
+tional responses and restore their freedom to change these
+responses to chronic pain resulting in stress reduction.
+• Mind sound resonance technique—Perception of the internal
+resonance of all tissues of the body during prolonged slow
+chanting of vedic syllables (a, u, m and Om, etc.) at a very
+low pitch can help achieve a deep meditative state. Re-
+peated practice of these syllables has been incorporated
+into this 30-minute practice.31
+Control intervention
+The practices consisted of a set of physical movements (cer-
+tified by the senior physiatrist (Table 4) as well as nonyogic
+safe breathing exercises and lectures on scientific information
+including: (1) causes of back pain; (2) stress and CLBP; and
+(3) the benefits of physical exercises. Video shows on animals,
+plants, nature, et cetera, were used as placebos to engage the
+subjects during the time when there were video shows on
+yoga or yogic counseling for the experimental group.
+Outcome variables
+Spinal mobility. Spinal mobility was measured using a dial-
+type goniometer (Anand Agencies, Pune, India). This in-
+strument has a dial with a calibration from 0° to 360° that is
+tied around the waist. The value for the range of the move-
+ment (ROM) is read on the dial and noted in degrees.
+Functional Disability Index. The Oswestry low-back pain Dis-
+ability Index (ODI), a self-administered questionnaire, devel-
+oped by Jones and Hunt, in England,32 was used to measure
+disability. This index has 5 graded questions for assessing the
+degree of pain in 10 different areas of living such as walking,
+standing, social life, et cetera. Total score for ODI ranges from
+0 to 100. The scores for each of the 10 sections of ODI are
+added and the final score is expressed as “% disability.” Grad-
+ing of the disability is described as (1) minimal disability
+(0%–20%), when a patient can cope with most living activi-
+ties; (2) moderate disability (21%–40%), when patient may be
+disabled from work and reports more pain and difficulty with
+sitting, lifting, and standing; (3) severe disability: (41%–60%),
+when pain remains the main problem; (4) crippled (61%–80%),
+when pain affects all aspects of the patient’s life; and (5) bed-
+bound or exaggerating (81%–100%).
+Statistical analysis
+The data were analyzed by the statistician, using the Sta-
+tistical Package for Social Sciences (SPSS), version 10.0 
+TEKUR ET AL.
+640
+TABLE 3. 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 4. 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
+for PC Windows 2003 (Chicago, IL). The Kolmogorov–
+Smirnov’s test was used to check the normality of baseline
+data, an independent samples t-test was used to check for
+matching of the groups, and repeated measures analysis
+of variance (RMANOVA) were used to compare the means
+within and between groups. Effect sizes were also calcu-
+lated.
+Results
+Figure 1 shows the study profile. There were no dropouts
+as this was a residential short-term program. The groups
+were similar with respect to sociodemographic and medical
+characteristics (see Table 1). The baseline data for all vari-
+ables were normally distributed and did not differ signifi-
+cantly between groups (p  0.05). Table 5 shows the results
+after 7 days of intervention. For the design of this study (1
+within-subjects and 1 between-subjects factor), there were no
+ancillary analyses.
+Oswestry Disability Index
+RMANOVA showed a significant difference between
+groups (p  0.001). The total disability scores in the yoga
+group decreased (p  0.001) from 36.50  14.22 to 18.70 
+11.55, indicating a shift from moderate to mild disability.
+The effect size was 1.144 with a 48.76% reduction in dis-
+ability. There was a nonsignificant reduction in ODI scores
+in the control group (p  0.19). Subgroup analysis of the
+section 1 of the ODI, which is a measure of pain, also
+showed significant reduction in pain in patients who re-
+ceived yoga (p  0.001) with a nonsignificant reduction in
+the control group and a significant difference between the
+groups (p  0.001).
+Spinal flexibility
+Spinal flexion increased in both groups with a significant
+difference between groups (p  0.008) with a higher effect
+size (1.305) in the yoga group.
+Spinal extension increased in both groups (p  0.001). The
+improvement in the yoga group was significantly higher
+than in the control group (p  0.002; effect size 0.251).
+Right lateral flexion increased significantly in both groups
+(p  0.001). The improvement in the yoga group was mar-
+ginally higher than in the control group (p  0.059; effect size
+0.006).
+Left lateral flexion improved significantly in both groups
+(p  0.001). The yoga group was significantly better than
+control group (p  0.006; effect size 0.171).
+Discussion
+This was a wait-list, randomized, two-armed control study
+on 80 patients with CLBP of more than 3 months’ duration.
+RMANOVA showed significant difference between groups
+in the ODI with reduction in disability (p  0.001) in the yoga
+group. ODI section 1 (measure of pain) also showed signif-
+icant difference between groups. Spinal flexion, extension,
+right lateral flexion, and left lateral flexion increased in both
+groups with a significant difference between groups and
+higher effect sizes in the yoga group than the control group.
+No adverse events or side-effects seen in either of the groups.
+A 49% reduction in disability with a significant increase
+in spinal flexibility after this short-term intensive yoga pro-
+gram is noteworthy. In an earlier, well-planned, three-
+armed, randomized control study on Viniyoga, back-related
+functions and symptom reductions were superior in the yoga
+group compared to the self-care book and exercise groups
+after 12 and 26 weeks of intervention; no objective measures
+were used in the study. Another randomized control trial on
+Iyengar yoga also showed significant reduction in pain and
+functional disability, after 16 and 32 weeks of yoga (3 classes
+per week), with no significant improvement in degree of
+spinal flexibility. The present study although of only 7 days’
+duration, showed significant changes not only in pain and
+disability but also in objective measures of spinal flexibility.
+The difference in these remarkable observations of the pres-
+ent study as compared to earlier ones seems to be because:
+(1) The frequency of the daily practice was intensive and
+continuous under active supervision, whereas, in other
+studies there was a long gap between 2 sessions.
+(2) The duration of practices of yoga in the present study
+was 8 hours per day for 7 days, whereas in the other
+study with the Iyengar module, the practice was a 1.5-
+hour class per week with 30 minutes of practice at home
+for 5 days for 16 weeks, and the Viniyoga module had a
+75-minute class with a 3 hours of practice at home per
+week for 12 weeks apart from the follow-up period.
+YOGA IN BACK PAIN
+641
+120 – Self-Referred,
+40 – Referred by 
+Physician
+Dropouts
+Office Calls
+Emergencies
+at Home
+Dropouts
+Respiratory
+Tract Infections
+Emergencies
+at Home
+5 
+2 
+3 
+6 
+3 
+3 
+126 – Interested
+in Participation
+Experimental
+n 
 45
+Control
+n 
 46
+Final Analysis of 40
+Experimental Group
+Final Analysis of 40
+Control Group
+91 – Satisfied Selection
+Criteria and Randomly Assigned
+FIG. 1.
+Trial profile.
+TABLE 5. RESULTS OF ALL VARIABLES POSTINTERVENTION (RMANOVA)
+Within-groups
+Between-
+Yoga
+Control
+groups
+t-values
+Variable
+Pr & Po
+Mean  SD
+95% CI
+ES
+% change
+value
+Mean  SD
+95% CI
+ES
+% Change
+t-values
+ES
+F-value
+ODI
+Pr
+36.5  14.22
+13.05 to 22.54
+1.14
+48.76
+7.23
+38.9  13.27
+1.59 to 7.89
+0.21
+8.09
+1.37
+1.26
+18.89
+Po
+18.70*  11.55
+35.75  15.19
+ODI Section1
+Pr
+5.80  6.94
+0.8 to 6.7
+0.42
+60.34
+5.01
+4.96  3.29
+0.45 to 2.01
+0.20
+15.6
+1.79
+0.23
+7.61
+Po
+2.31*  4.50
+4.18*  3.48
+SF
+Pr
+52.48  23.63
+18.21 to 11.49
+1.30
+28.3
+8.26
+56.00  19.97
+11.70 to 4.99
+0.84
+14.91
+5.34
+0.14
+7.43
+Po
+67.33*  21.99
+64.35*  18.55
+SE
+Pr
+9.90  6.83
+6.26 to 3.93
+5.1
+51.52
+9.54
+10.93  5.68
+3.58 to 1.26
+0.61
+22.14
+3.86
+0.25
+10.51
+Po
+15.00*  7.30
+13.35*  5.74
+RLF
+Pr
+16.50  7.51
+5.67 to 3.02
+4.35
+26.36
+7.22
+18.35  8.54
+3.87 to 1.22
+0.55
+13.9
+3.53
+0.006
+3.66
+Po
+20.85*  7.77
+20.90*  8.50
+LLF
+Pr
+14.43  8.23
+7.09 to 4.20
+5.65
+39.15
+6.96
+16.05  8.10
+4.19 to 1.30
+0.68
+17.13
+4.36
+0.17
+7.94
+Po
+20.08*  8.07
+18.80*  6.84
+There were significant differences between groups: *p < 0.01 within-group difference; +p  0.01 between-group difference.
+(RMANOVA), repeated measures analysis of variance; Pr, pre; Po, Post; SD, standard deviation; CI, confidence interval; ES, effect size, ODI, Oswestry Disability Index; SF, spinal flexion; SE, spinal ex-
+tension; RLF, right lateral flexion; LLF, left lateral flexion.
+(3) The integrated yoga module used in this study included
+Om meditation, cyclic meditation, a deep-relaxation tech-
+nique, a mind-sound resonance technique, yogic hymns,
+and devotional sessions in addition to the practices that
+were common to the 3 studies (i.e., physical postures,
+breathing practices, and lectures).
+It appears from these factors that the cumulative effect of in-
+tensive daily practices is more effective than those spread
+out with longer gaps, which may not be as effective.
+Mechanisms
+Deep relaxation of the spinal muscles achieved during safe
+body movements with mindful awareness may form the ba-
+sis of improvement observed in flexibility and pain within
+this short period of intervention. This is supported by ear-
+lier observations of increased paraspinal electromyographic
+(EMG) activity in subjects with CLBP.5 The component of
+back-pain special techniques (physical practices) of IAYT in-
+cluded in this program to relax the spinal muscles was the
+pavanamuktasana (wind-releasing pose) series (Table 3).
+These stretches practiced with mindful awareness may also
+act in a manner similar to that of intermittent spinal traction
+in reducing spinal muscle spasm. Maintenance of the final
+posture of asanas, such as bhujangasana (cobra posture) and
+shalabhasana (locust posture), contributes to improved flexi-
+bility.
+Mechanical factors, such as prolonged wrong postures
+during a sedentary lifestyle leading to wasting and weak-
+ness of postural muscles, also play an important role in func-
+tional disability and chronicity of pain.5 Setubandhasana
+breathing (bridge posture), ekapadasana (straight leg raising),
+and ardha navansana (half boat posture) were the practices in-
+corporated in this module to strengthen both the spinal and
+abdominal muscles. These were repeated under supervision
+in the special technique sessions.24
+All other practices taught during the day were meant to
+release stress via calmness of mind to achieve better coping
+abilities. Yogic breathing is a unique method for balancing
+the autonomic nervous system.33 Research done at our in-
+stitute has shown that specific pranayama practices can have
+a relaxing effect on the sympathetic nervous system thereby
+reducing stress levels.34
+Studies of different types of meditation have consistently
+shown increased mental alertness even while subjects are
+physiologically relaxed. The Om meditation that was used
+in this study has also been shown to provide this psy-
+chophysiologic rest.23
+Basler et al. observed that control over pain via cognitive-
+behavioral (CBT) was associated with physical, psychologic,
+and social well-being.35 The yogic counseling and lecture ses-
+sions that were based on the philosophy of yoga used as a
+part of the intervention appear to be similar to the cognitive
+behavioral perspective that chronic pain is not simply a neu-
+rophysiologic state but is influenced by the way the indi-
+vidual views the world and assigns meaning to events. The
+contributing factors to the experience of pain include many
+aspects, such as sensory, affective, behavioral and cognitive
+factors.36 Thus, these lectures and yogic counseling (jnana
+yoga) sessions were designed (1) to help patients understand
+the sources and patterns of their emotional responses to pain,
+(2) to restore their freedom to change the responses to these
+situations as well as to the chronic pain, and (3) learn to touch
+the blissful bed of inner silence during all joyful moments.
+Lipchik et al.,37 showed that the increased sense of per-
+sonal control over pain following a pain-management pro-
+gram of CBT was accompanied by a reduction in negativity.
+The divine hymn sessions (bhakti yoga) were meant to fos-
+ter an understanding that devotion and surrender to the Di-
+vine unfolds the subtle emotions of pure love, which help in
+moving toward positive emotional affective states and clear-
+ing the negative affect in order to enhance healing and pain
+management.
+The science of yoga and Vedanta22 has a systematic
+methodology to train a person to be established in the ex-
+periential knowledge of one’s true nature, which is a state
+of unchanging state of bliss (sacchidananda). This is the ma-
+jor cognitive behavioral change that makes the participant
+stable under all demanding situations (samatvam) that man-
+ifests as improved quality of life.
+The strengths of this study were (1) the randomized con-
+trol design with the control group also receiving a super-
+vised hour-to-hour matched intervention in a residential
+setup, and (2) significant results seen in objective measures
+(spinal flexibility) apart from pain and disability within 7
+days. This encourages acceptability of the program in pres-
+ent-day fast-paced life.
+Limitations of the study were: (1) Because both groups
+were on the same campus, the possibility of some interac-
+tion and exchange of ideas could not be ruled out, although
+special care was taken to keep the groups engaged inde-
+pendently on the campus for the practice sessions. (2) Short-
+term follow up of only 1 week may be considered a major
+limitation. A follow-up of patients who were asked to con-
+tinue the practices daily (1 hour) with the help of a video
+and audio presentation with instructions has been planned.
+We are following up subjects who continue to do the yoga
+practices although this follow-up will not be a control study
+as this study was a wait-list control. We hope to report this
+follow-up in a different paper. We have noted so far that the
+improvements are steady in subjects who are practicing
+yoga, and the results appear to be encouraging although we
+have not yet completed the follow-up and done the statisti-
+cal analysis.
+Conclusions
+Several suggestions for future work include: (1) including
+measures for assessment of anxiety, depression, and stress;
+(2) having a longer duration of follow-up with continued
+home practice for about 6 months; (3) using more objective
+measures such as X-rays, MRIs of the spine, and EMG stud-
+ies before and after; (4) expanding the generalizability of this
+program to different cultures that can be assessed by stud-
+ies in different ethnic groups; and (5) combining these in-
+terventions with physiotherapy to looks for synergistic ef-
+fects.
+Acknowledgments
+We are thankful to Ravi Kulkarni, Ph.D., who helped with
+the statistical analysis of the data. Our thanks are also due
+to Usha Rani, B.A., M.S., and a M.Sc. student, Raghavendra
+Rao, Ph.D., Ritu Chakum, Ph.D., and Pradhan Bahram, a
+YOGA IN BACK PAIN
+643
+Ph.D. student, for their help with scoring the results and with
+preparing the manuscript; to all the staff members of
+SVYASA for their cooperation in conducting the program;
+to the Jubilee Camdarac Institute for taking the X-rays; and
+John Ebnezar, M.B.B.S., D.Ortho, D.N.B. student, who gave
+his second opinion on the X-rays.
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+Address reprint requests to:
+Padmini Tekur, M.B.B.S. (Ph.D.Cand.)
+Division of Yoga and Life Sciences
+Swami Vivekananda Yoga Research Foundation
+#19, Eknath Bhavan, Gavipuram Circle
+K.G. Nagar, Bangalore 560019
+India
+E-mail: [email protected]; [email protected]
+TEKUR ET AL.
+644

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+8/12/2014
+Effect of the integrated approach of yoga therapy on platelet count and uric acid in pregnancy: A multicenter stratified randomized single-blind study :[PAU…
+http://www.ijoy.org.in/printarticle.asp?issn=0973-6131;year=2013;volume=6;issue=1;spage=39;epage=46;aulast=Jayashree
+1/5
+ORIGINAL ARTICLE
+Year : 2013  |  Volume : 6  |  Issue : 1  |  Page : 39--46
+Effect of the integrated approach of yoga therapy on platelet count and uric acid in pregnancy: A multicenter stratified randomized
+single-blind study
+R Jayashree1, A Malini1, A Rakhshani1, HR Nagendra1, S Gunasheela2, R Nagarathna1,  
+1 Faculty of Division of Yoga and Life Sciences, Vivekananda Yoga Research Foundation (VYASA), Eknath Bhavan, Gavipuram Circle, K.G. Nagar, Bangalore, India
+2 Gunasheela Surgical and Maternity Hospital, Basavanagudi, Bengaluru, India
+Correspondence Address:
+R Nagarathna
+Vivekananda Yoga Research Foundation (VYASA), Eknath Bhavan, Gavipuram Circle, K.G. Nagar, Bangalore - 560019, Karnataka 
+India
+Abstract
+Background: Yoga improves maternal and fetal outcomes in pregnancy. Platelet Count and Uric acid (Ua) are valuable screening measures in high-risk pregnancy. Aim: To examine
+the effect of yoga on platelet counts and serum Ua in high-risk pregnancy. Materials and Methods: This stratified randomized controlled trial, conducted by S-VYASA University at St.
+John«SQ»s Medical College Hospital and Gunasheela Maternity Hospital, recruited 68 women with high-risk pregnancy (30 yoga and 38 controls) in the twelfth week of pregnancy.
+The inclusion criteria were: Bad obstetrics history, twin pregnancies, maternal age < 20 or > 35 years, obesity (BMI > 30), and genetic history of pregnancy complications. Those with
+normal pregnancy, anemia (< 10 grams%dl), h/o clotting disorders; renal, hepatic or heart disease; seizure disorder; or structural abnormalities in the pelvis, were excluded. The
+yoga group practiced simple meditative yoga (three days / week for three months). Results: At baseline, all women had normal platelet counts (> 150×10 9 /L) with a decrease as
+pregnancy advanced. Ua (normal at baseline) increased in both groups. No one developed abnormal thrombocytopenia or hyperuricemia. Healthy reduction in platelet count (twelfth
+to twentieth week) occurred in a higher (P < 0.001, Chi 2 test) number of women in the yoga group than the control group. A similar trend was found in uric acid. Significantly lesser
+number of women in the yoga group (n = 3) developed pregnancy-induced hypertension (PIH) / pre-eclampsia (PE) than those in the control group (n = 12), with absolute risk
+reduction (ARR) by 21%. Conclusion: Antenatal integrated yoga from the twelfth week is safe and effective in promoting a healthy progression of platelets and uric acid in women with
+high-risk pregnancy, pointing to healthy hemodilution and better physiological adaptation.
+How to cite this article:
+Jayashree R, Malini A, Rakhshani A, Nagendra H R, Gunasheela S, Nagarathna R. Effect of the integrated approach of yoga therapy on platelet count and uric acid in pregnancy: A
+multicenter stratified randomized single-blind study.Int J Yoga 2013;6:39-46
+How to cite this URL:
+Jayashree R, Malini A, Rakhshani A, Nagendra H R, Gunasheela S, Nagarathna R. Effect of the integrated approach of yoga therapy on platelet count and uric acid in pregnancy: A
+multicenter stratified randomized single-blind study. Int J Yoga [serial online] 2013 [cited 2014 Aug 11 ];6:39-46 
+Available from: http://www.ijoy.org.in/text.asp?2013/6/1/39/105945
+Full Text
+ Introduction
+Pregnancy is a very precious and important event in a woman's life and one of the happiest periods in the life of a woman. Good prenatal care with proper nutrition and medical
+supervision has gone a long way in reducing infant and maternal mortality in both developed and developing countries. The complications in high-risk pregnancies include
+premature labor, intrauterine growth restriction, pregnancy induced hypertension (PIH), pre-eclampsia (PE), eclampsia, thrombocytopenia, and so on. Several markers have been
+identified that have a predictive value and are included in antenatal screening for prevention of these complications. Studies point to serum uric acid as one such marker, as
+hyperuricemia is associated with PIH or pre-eclampsia / eclampsia. It has been shown that women with hyperuricemia, combined with gestational hypertension, were more
+disposed to having a shorter gestation period, smaller birth weight, and an increased risk of pre-term or pre-mature labor. [1] Normally a small quantity of uric acid (3.0-7.0 mg/dL) is
+produced, which serves as a strong antioxidant and a strong reducing substance. Although its clinical utility has been actively debated, [2] it is useful to include it in routine screening
+in high-risk pregnancies.
+Platelet count is another measure that is of value in screening high-risk pregnancies. Benign Thrombocytopenia of Pregnancy (BTP) is a physiological change, with no pathological
+consequences, [3] which helps in preventing placental thrombosis and infarctions, as pregnancy is basically a hypercoagulable state. [4] BTP during normal pregnancy is
+considered to be due to hemodilution that produces maternal plasma volume expansion as an important physiological adaptive mechanism, to meet the greater circulatory needs of
+the placenta and fetus. [3] The conventional treatment recommended for prevention of pregnancy complications (PIH or pregnancy loss) in high-risk pregnancy is low-dose aspirin,
+as it suppresses the aggregation of platelets in microvascular circulation. [5],[6] To date, several studies have provided evidence of the beneficial effects of many mind-body
+interventions, suggesting better psycho-physiological adaptability. [7],[8] In pregnancy, yoga has been found to be beneficial in preventing complications, with better psychological
+and autonomic stability, [9] and improved maternal comfort. Other benefits included lesser Cesarian sections, shorter duration of labor, [10] reduced pre-term delivery, higher birth
+weight, and better Apgar scores of the infant. [11] 
+There is only one earlier study by Narendran et al.[12] that points to the benefits of yoga in high-risk pregnancy. There are no studies that have looked at the uric acid or platelet levels
+(as indication of better physiological adaptation) of women who practiced yoga for high-risk pregnancy. Hence, we planned to look at the platelet count and uric acid levels in
+pregnant women who practiced yoga from the twelfth to the twenty-eighth week, with a hypothesis that yoga promotes healthy progression of benign thrombocytopenia and uric acid
+levels, which may indicate better physiological adaptation during pregnancy.
+ Materials and Methods
+Design and setting 
+8/12/2014
+Effect of the integrated approach of yoga therapy on platelet count and uric acid in pregnancy: A multicenter stratified randomized single-blind study :[PAU…
+http://www.ijoy.org.in/printarticle.asp?issn=0973-6131;year=2013;volume=6;issue=1;spage=39;epage=46;aulast=Jayashree
+2/5
+This multicenter-stratified, randomized, single-blinded controlled trial was conducted by the Vivekananda Research Foundation at the Obstetric Unit of St. John's Medical College and
+Hospital (SJMCH) and the Gunasheela Maternity Hospital, in Bengaluru, India.
+Subjects 
+This study on platelet counts and uric acid levels was a part of a larger funded project to investigate the efficacy of yoga in high-risk pregnancy. The required sample size was
+calculated from an earlier Japanese study, [13] on yoga in pregnancy. Using the ratios for occurrences of preeclampsia and the event rates between two independent groups with <
+at 0.05 powered at 0. 8 and a probability of type I error of 0.01 (formula provided at CUHK web site: http://department.obg.cuhk.edu.hk), a minimum sample size of 27 per group was
+obtained. We had 68 participants (30 yoga and 38 controls) for final analysis.
+Selection criteria 
+All women were recruited in twelfth week of pregnancy. As the aim of this larger funded project was targeted at high-risk pregnancy, those with (a) bad obstetrics history, (b) twin
+pregnancies, (c) maternal age below 20 or above 35, (d) obesity (BMI greater than 30), and (e) a history of pregnancy complications among blood relatives, (sister, mother and/or
+grandmother) were included in the study. Those with (a) normal pregnancies without high risk, (b) a history of clotting disorders, (b) anemia (<10 grams/dl), (c) chronic renal, hepatic,
+or heart disease, (d) seizure disorders, and (e) structural abnormalities in the reproductive system were excluded from the study.
+Ethical clearance was obtained from the Institutional Ethical Committee of both the S-VYASA University and St. John's Medical College Hospital. All qualified subjects signed the
+informed consent form before enrollment in the study.
+Randomization 
+An online random number generator by Graph Pad Software (http://graphpad.com/quickcalcs/randomize1.cfm) was used to randomize subjects into groups. For each of the five
+subgroups, random number tables for randomization into two groups were generated. The group name (either yoga or control) was written on a slip of paper, folded several times,
+and placed in sequentially marked opaque envelopes, sealed, stamped, and kept away in a safe locker. Thus, there were five sets of sealed envelopes that had the name of the
+subgroups on the outside with the group name inside. When a subject belonging to one of these subgroups was recruited, she was asked to pick up one of the envelopes from the
+set presented to her. Following this, the research staff opened the envelope, informed the subject of the group she had been randomized into, and recorded her ID in the study log.
+Permitting the subjects to pick an envelope randomly, offered a second level of randomization and reduced the chances of dissatisfaction.
+Blinding and masking 
+This was a single-blind study. The physicians, laboratory technicians, and hospital staff were blinded to the group selection. The subject could not be blinded about the practices
+they were taught as this was an interventional study.
+Procedure 
+After randomization and obtaining a signed informed consent, the sociodemographic data were recorded. The yoga group was taught a set of carefully selected simple safe
+meditative yoga exercises that included yogic body movements followed by breathing practices, physical exercises, pranayama, deep relaxation with guided imagery, meditation
+using visualization, and sound resonance. These practices were taught in the hospital premises three days/week for three months by a trained yoga instructor, followed by home
+practice using audio CDs. Patients in the control group were given the conventional antenatal training program offered at these two private hospitals specialized in high-risk obstetric
+practice (St. John's and Gunasheela) in Bengaluru, India. All assessments were made in the twelfth, twentieth and twenty-eighth weeks of pregnancy. Blood pressure, weight, urine
+albumin, and blood glucose levels were measured routinely at each antenatal visit.
+Venous blood was drawn carefully at the antecubital vein using a vacutainer by a qualified technician and the platelet count was assessed immediately on an electronic platelet
+apparatus. The uric acid level was assessed in the serum using the 'Modified Uricase Method'.
+Intervention 
+The integrated meditative yoga module for high risk pregnant women developed by a team consisting of two senior yoga faculties of the Yoga research foundation (VYASA) and an
+obstetrician with knowledge of yoga, was used [Table 1]. This one hour daily practice started with a prayer followed by a short session (3-5 minutes) of theory that was aimed at
+giving an understanding of the holistic approach of yoga. The practices were aimed at achieving a state of deep alertful rest at physical and mental level that may promote rapid
+adaptation to physiological or emotional challenges. The module consisted of a few preparatory loosening body movements and breathing practices, safe asanas in supine
+position, deep relaxation with guided imagery, pranayama and meditation using visualization and sound resonance [Table 1].{Table 1}
+The control group received standard care plus prenatal exercises offered by the hospital. Walking for half an hour morning and evening was the standard exercise prescribed
+routinely. Standard care offered to both groups included:
+Prenatal interventions offered by the two hospitals,pamphlets about diet and nutrition during pregnancy,frequent visits at regular intervals to the hospital, andbi-weekly follow up by
+our staff.
+Data analysis 
+Statistical analysis was conducted with the help of the Statistical Package for Social Sciences (SPSS)-16. The Shapiro Wilk's Test was used to test the normality of the data. As the
+data were normally distributed, group time interaction was checked by using repeated measures ANOVA. Between and within groups, comparisons were done using post hoc
+analysis with Bonferroni corrections. Subgroup analysis on the number of subjects was done by the Chi square test. Absolute risk reduction (RR = control event rate - experimental
+event rate) and number needed to treat (NNT = 1/Control event rate-Experimental Event Rate) for the events of HT and PIH in yoga and control groups were also calculated.
+ Results
+[Figure 1] shows the trial profile. All new registrations (n = 1934) at the antenatal clinics of the two hospitals during the study period were screened. Three hundred and forty-nine met
+the inclusion criteria. Of these, five were excluded, as they had one of the conditions listed in the exclusion criteria. Ninety-three subjects, who consented for the study were
+randomized into two groups, namely, yoga and control. The reasons for non-consent were: Twenty-three did not have time; 75 lived too far away to be able to attend classes; 35 could
+not get the approval of their husbands or families to join the study; 37 were planning to relocate from the Bangalore metropolitan area; 71 were not interested in involvement in any
+form of research; 31 were fearful that the Doppler scanning could harm their babies, and the physicians could not convince them otherwise.{Figure 1}
+There were twenty five dropouts (sixteen from the yoga group and nine from the control group) during the course of the study. Reasons for dropout from the yoga group were: Six
+moved to a different town, four did not adhere to the intervention schedule, one was advised strict bed rest by the obstetrician, and four lost interest in the study. In the control group:
+One subject aborted, three moved away, and five did not show up for follow-up measurements. Only those who completed the assessment at the twenty-eighth week of pregnancy
+were included in the final data analysis. Accordingly 30 in the yoga group and 38 in the control group were available for final analysis.
+8/12/2014
+Effect of the integrated approach of yoga therapy on platelet count and uric acid in pregnancy: A multicenter stratified randomized single-blind study :[PAU…
+http://www.ijoy.org.in/printarticle.asp?issn=0973-6131;year=2013;volume=6;issue=1;spage=39;epage=46;aulast=Jayashree
+3/5
+[Table 2] shows the demographic details. The mean age of the subjects in both groups was 27 years. More than 45% of the women had college and higher education. The mean
+scores on the socioeconomic status was 37.37 (11.28) in the yoga group and 36.05 (8.86) in the control group, indicating that both groups were in the upper middle class.There
+were no significant baseline differences between the two groups in any of the demographic or clinical variables.{Table 2}
+Platelet count 
+All the subjects, in both groups, had normal platelet counts [mean = 263.92 (67.01)x10 9 /L] at baseline (Normal range: 150 - 450), [14] although they were all in the high-risk
+category. There was a decline in platelet count as the pregnancy advanced in both groups, with a trend of a better decline in the yoga group, with no significant difference between the
+groups at the twentieth or twenty-eighth weeks [Table 3], [Figure 2].{Figure 2}
+A subgroup analysis on the number of subjects who had increased platelet or decreased platelet counts in the two groups showed that the number of women with reduced platelet
+count (within normal range) was significantly higher in the yoga group than in the control group, at the twentieth (P = 0.016, Chi 2 = 8.32) and also in twenty-eighth week (P=0.004,chi
+2 = 8.09).{Table 3}
+Uric acid 
+None of the women in either group had high levels (Normal 2.0 - 6.5 mg / dl) of uric acid at baseline (twelfth week). There was an increase in the mean uric acid level as the
+pregnancy advanced, in both groups, with no significant difference between groups (P > 0.05). None of them rose above the normal upper limit of 6.5 mg / dl. There was a trend (P =
+0.09) of a lesser degree of increase in uric acid between the twelfth and twentieth week in the yoga group. The number who had a rise in the third trimester was lesser, although the
+P values did not show any significant differences between the groups [Table 4], [Figure 3]. Also, there were no cases of hyperuricemia in those who developed PIH / PE in either
+group. The number of women who had increased uric acid toward the twenty-eighth week appeared to be higher in the control group than in the yoga group.{Figure 3}{Table 4}
+Pregnancy-induced hypertension / pre-eclampsia 
+There were 12 (37.7%) cases of PIH / PE in the control group, while only 3 (10.3%) in the yoga group, resulting in a highly significant difference between the means (P = 0.018, chi 2 )
+[Table 5]. The number needed to treat (NNT) was 4.76 (i.e. needed to treat five cases of yoga to reduce one event of PIH / PE) and absolute risk reduction (ARR) was 21%, with an
+odds ratio of 0.24. Two of the four cases of pre-eclampsia in the control group developed eclampsia with none in the yoga group. NNT for eclampsia was 5.99 and ARR was 16.7%.
+[15]{Table 5}
+Subjective reports by participants: All those in the experimental group reported that they had a feeling of positive energy, relaxation, and well-being throughout the day after the yoga
+practice. They would make phone calls to the therapists whenever they felt any discomfort, such as, mild back pain, low mood, stress, or anxiety (about the progress of pregnancy), to
+check on the specific yoga practice to overcome these, indicating that they were keen to continue the practices regularly at home, and had experienced positive benefits in every
+session. There were no adverse effects reported during or after the practice of yoga.
+ Discussion
+This multicenter, stratified, randomized, prospective control study on yoga in high-risk pregnancy has shown that there is a progressive reduction in platelets and increase in uric
+acid levels as pregnancy advances, in both groups. None of the cases developed hyperuricemia or abnormal thrombocytopenia. The number of women who had reduction in platelet
+count (within normal range) at the twentieth week was significantly (P < 0.001, Chi 2 test) higher in the yoga group; the number who had an increase of uric acid in the third trimester
+(although within normal range) was significantly higher (P < 0.001, Chi 2 test) in the control than the yoga group. The baseline mean systolic and diastolic blood pressures were
+normal. A significantly lesser number of women in the yoga group developed PIH / PE, when compared with the control group.
+Although the effect of yoga on hemorheological and hemostatic variables has not been studied in pregnancy, several studies have looked at these variables after moderate and
+intense physical training in normal volunteers. Available evidence suggests that the platelet count increases after short-term exercise, with favorable effects on platelet aggregation
+and activation, in both men and women. [16]
+It is known that, as a part of the physiological response, the uric acid level decreases by approximately 25 to 35 percent throughout normal pregnancy. [17] The values are
+significantly low by eight weeks and start increasing from the twenty-fourth week, to reach values greater than the pre-pregnancy values by term, and remain elevated until at least 12
+weeks after delivery. [18] We have observed that the values in our study group followed the same trend of lower values in twelfth week, which went on to increase as the pregnancy
+progressed. It is interesting to note that the curve of progression on uric acid followed the reference pattern in the yoga group, while the control group showed a steep initial rise,
+giving a diamond shape. It would have been useful to see whether the lines would intersect or move parallel in the third trimester and after delivery, if the data were available beyond
+28 weeks of gestation.
+The mean values in our study were much lower at all stages of pregnancy [Figure 2] when compared with American women with high risk. [19] These differences may be due to the
+fact that Indian women consume lesser quantities of animal protein than American women, and there are no published data on uric acid levels in Indian women during normal or
+high-risk pregnancy.
+Yoga is known to induce beneficial effects on the physiological, biochemical, psychological, and cognitive functions, with a significant influence on blood coagulation and other
+metabolic processes. Chohan et al.[20] looked at blood coagulation in normal adults, who underwent a combination of yogic exercises for one hour daily for four months, and noted
+that yoga induced a state of blood hypocoagulability. The changes that occur during pregnancy create a hypercoagulable milieu, which is thought to be protective especially at the
+time of labor, for preventing excessive hemorrhage. [21] A physiological fall in platelet count first becomes apparent in the mid-second to third trimester of pregnancy. The reason for
+this benign physiological thrombocytopenia, although not clear, appears to be relative due to the increased plasma volume resulting from hemodilution. [22] Increased platelet
+consumption by the physiological hypercoagulability [23] or decreased platelet production [22] seem to be the other contributory factors.
+The serum concentration of uric acid is determined by several factors during pregnancy, including dietary intake of purines, metabolic production of uric acid by the mother, fetus, and
+placenta, as well as renal and gastrointestinal excretion. [24] The decrease in uric acid levels during early pregnancy has been attributed to: (a) Hemodilution [25] and (b) increased
+glomerular filtration rate, which goes up by as much as 50% by the beginning of the second trimester [26] and / or (c) reduced proximal tubular reabsorption. [26]
+De-Weerth et al.[27] observed that psychological stresses dampen the physiological adaptation during pregnancy. It is proposed that the endocrine and inflammatory responses to
+psychological stress results in poor pregnancy outcomes, due to alteration of blood flow in the maternal-fetal compartment, primarily as a result of vasoconstriction. [28]
+Psychological stress leads to stress-hemoconcentration, which is possibly due to a decrement in plasma volume, as observed in patients with mild-to-moderate depression. [29]
+Wong et al.[30] also showed that these measures of stress-hemoconcentration improved after antidepressant treatment. Stress induces thrombogenesis that can result in many
+detrimental effects. A systematic review by Thrall et al.[31] has reported that psychological stress and high levels of physical activity are associated with robust changes that lead to
+hypercoagulable states.
+Several studies have shown the stress-reducing effects of yoga. [32],[33] In a randomized controlled trial (RCT) that looked at the effect of integrated yoga in normal pregnancy,
+reduction in stress levels with better quality of life has been observed. [34] We [10] have also shown an increased sensitivity of the autonomic nervous system through heart rate
+variability, which showed that the immediate parasympathetic response to a guided yogic deep relaxation practice in the third trimester, in women who practiced yoga, was
+significantly better than those who practiced only antenatal exercises.
+8/12/2014
+Effect of the integrated approach of yoga therapy on platelet count and uric acid in pregnancy: A multicenter stratified randomized single-blind study :[PAU…
+http://www.ijoy.org.in/printarticle.asp?issn=0973-6131;year=2013;volume=6;issue=1;spage=39;epage=46;aulast=Jayashree
+4/5
+We hypothesize that the favorable changes in platelet counts (within normal range) and uric acid levels, with better pregnancy outcome (lesser PIH / PE / E) observed in the yoga
+group, was due to improved physiological adaptability resulting in improved physiological hemodilution of pregnancy and better blood flow. This may explain the lesser degree of rise
+in uric acid (although not significant) and lesser number of cases of PIH/PE in the yoga group, as compared to the control group.
+Strength of the study 
+The major strength of the study was the design with stratified randomization, with rater blinding, as the staff involved with the assessments were blind to the group treatment status.
+This is the first study that has shown the safety of yoga in high-risk pregnancy and its influence on platelets and uric acid values, hinting at understanding the mechanism.
+Validity and implications 
+Monitoring platelet counts and uric acid levels in high-risk pregnant women is useful to predict the appearance of complications. As indirect indicators of hemodilution, these
+measurements help in understanding how yoga can help in better pregnancy outcomes. The results of this study seems to provide the first ever scientific evidence for the efficacy of
+yoga in improving hemodilution (healthy progression of benign thrombocytopenia and uric acid levels), as an indicator of better physiological adaptation. This study is another
+evidence, after Narendran's study, [12] which points to the benefits of yoga in high-risk pregnancy. We recommend inclusion of this safe module of integrated yoga in all antenatal
+training programs for high-risk pregnancies.
+Limitations of the study 
+The limitations of the study were: (1) The higher number of dropouts in the yoga (n = 16) than in the control group (n = 9). Several subjects from both groups had to go to their native
+places (unplanned) from time-to-time; this accounted for much larger dropouts in the yoga group (four subjects) than in the control group. (2) It was expected that subjects would
+practice the yoga taught in the intervention sessions at home, at least once a day. However, as there were no checks to supervise the patient, the possibility of lack of adherence
+(although our team made regular phone calls) could not be ruled out. (3) Subjects were selected on the basis of high risks, but not on the basis of their platelet counts or uric acid
+levels. Recruitment of subjects with thrombocytopenia or abnormal uric acid levels would have been a better design to study the effect of yoga on these variables. (4) The data on
+platelets and uric acid were not recorded after the twenty-eighth week of gestation or after delivery.
+Suggestions for future studies 
+Future studies may be designed to study the effect of yoga in those with hyperuricemia which may also include a battery of other measures, including Doppler studies to understand
+the holistic mechanism of yoga. Suitable studies may be designed in future to look at the effect of yoga on uric acid and platelet counts at term and after delivery.
+ Conclusion
+This RCT provides evidence that a cost-effective module of integrated yoga is safe and useful in promoting normal physiological adaptation in women with high-risk pregnancy, as
+indicated by the healthy progression of platelet and uric acid levels that has reflected as lesser incidence of PIH/PE.
+ Acknowledgments
+We are thankful to the Central Council for Research in Yoga and Naturopathy, Department of AYUSH, Ministry of Health and Family Welfare, Government of India, New Delhi, India, for
+funding the project. We thank Dr. Kulkarni R. and Dr. Pradhan B. for their assistance in statistical analysis. We thank the Gunasheela IVF Center and St. John's Hospital for their
+collaboration.
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+ 
+Monday, August 11, 2014
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+medicines
+Article
+Effectiveness of Yoga Lifestyle on Lipid Metabolism in a
+Vulnerable Population—A Community Based Multicenter
+Randomized Controlled Trial
+Raghuram Nagarathna 1,*,†,‡, Saurabh Kumar 2,†
+, Akshay Anand 2,3,4,*,‡, Ishwara N. Acharya 5,
+Amit Kumar Singh 1, Suchitra S. Patil 1, Ramesh H Latha 6, Purnima Datey 7 and Hongasandra Ramarao Nagendra 1
+



+

+Citation: Nagarathna, R.; Kumar, S.;
+Anand, A.; Acharya, I.N.; Singh, A.K.;
+Patil, S.S.; Latha, R.H; Datey, P.;
+Nagendra, H.R. Effectiveness of Yoga
+Lifestyle on Lipid Metabolism in a
+Vulnerable Population—A
+Community Based Multicenter
+Randomized Controlled Trial.
+Medicines 2021, 8, 37. https://
+doi.org/10.3390/medicines8070037
+Academic Editors: Roberto Anichini
+and Piergiorgio Francia
+Received: 1 April 2021
+Accepted: 29 June 2021
+Published: 13 July 2021
+Publisher’s Note: MDPI stays neutral
+with regard to jurisdictional claims in
+published maps and institutional affil-
+iations.
+Copyright: © 2021 by the authors.
+Licensee MDPI, Basel, Switzerland.
+This article is an open access article
+distributed
+under
+the
+terms
+and
+conditions of the Creative Commons
+Attribution (CC BY) license (https://
+creativecommons.org/licenses/by/
+4.0/).
+1
+Swami Vivekananda Yoga Anusandhana Samsthana (S-VYASA), Bengaluru 560105, India;
+[email protected] (A.K.S.); [email protected] (S.S.P.); [email protected] (H.R.N.)
+2
+Neuroscience Research Lab, Department of Neurology, Postgraduate Institute of Medical Education and
+Research (PGIMER), Chandigarh 160012, India; [email protected]
+3
+Centre for Mind Body Medicine, PGIMER, Chandigarh 160012, India
+4
+Centre for Cognitive Science and Phenomenology, Panjab University, Chandigarh 160014, India
+5
+Central Council for Research in Yoga & Naturopathy (CCRYN), Delhi 110058, India;
+[email protected]
+6
+Yoga Clinic, Bhopal 462026, India; [email protected]
+7
+Arogya Rasahara Kendra, Bhopal 462024, India; [email protected]
+*
+Correspondence: [email protected] (R.N.); [email protected] (A.A.)
+†
+Equal first authors.
+‡
+Corresponding author: Raghuram Nagarathna; Co-corresponding author: Akshay Anand.
+Abstract: Background: Dyslipidemia poses a high risk for cardiovascular disease and stroke in
+Type 2 diabetes (T2DM). There are no studies on the impact of a validated integrated yoga lifestyle
+protocol on lipid profiles in a high-risk diabetes population. Methods: Here, we report the results
+of lipid profile values of 11,254 (yoga 5932 and control 5322) adults (20–70 years) of both genders
+with high risk (≥60 on Indian diabetes risk score) for diabetes from a nationwide rural and urban
+community-based two group (yoga and conventional management) cluster randomized controlled
+trial. The yoga group practiced a validated integrated yoga lifestyle protocol (DYP) in nine day camps
+followed by daily one-hour practice. Biochemical profiling included glycated hemoglobin and lipid
+profiles before and after three months. Results: There was a significant difference between groups
+(p < 0.001 ANCOVA) with improved serum total cholesterol, triglycerides, low-density lipoprotein,
+and high-density lipoprotein in the yoga group compared to the control group. Further, the regulatory
+effect of yoga was noted with a significant decrease or increase in those with high or low values
+of lipids, respectively, with marginal or no change in those within the normal range. Conclusion:
+Yoga lifestyle improves and regulates (lowered if high, increased if low) the blood lipid levels in both
+genders of prediabetic and diabetic individuals in both rural and urban Indian communities.
+Keywords: diabetes yoga protocol; diabetes; prediabetes; dyslipidemia; lipid regulation
+1. Introduction
+Dyslipidemia (altered blood lipids) is as a contributing risk factor for various macrovas-
+cular complications in type-2 diabetes mellitus (T2DM) patients [1]. Dyslipidemia is
+characterized by high levels of triglycerides (≥150 mg/dL), high low-density lipoprotein
+(LDL ≥130 mg/dL), low high-density lipoprotein (HDL < 40 mg/dL for men; <50 mg/dL
+for women) [2] and high levels of total cholesterol (≥200 mg/dL) [3,4]. It is difficult to
+define the cut-off range for dyslipidemia, as it varies from study to study due to the dif-
+ference in methodologies used. Studies suggest that Indian and migrant Asian Indians
+tend to show increased triglycerides and decreased HDL serum levels than western resi-
+dents [5]. In comparison, serum cholesterol levels tend to be similar to the US population
+Medicines 2021, 8, 37. https://doi.org/10.3390/medicines8070037
+https://www.mdpi.com/journal/medicines
+Medicines 2021, 8, 37
+2 of 16
+and lower than the UK population [5]. A high volume of blood cholesterol is associated
+with greater chances of developing cardiovascular disease, including stroke, peripheral
+vascular disease, and coronary heart disease (CHD) [6]. This is a major cause of cardiac
+morbidity and mortality, especially in the aged and in patients with T2DM [6]. According
+to the American Diabetes Association (ADA), T2DM is associated with a two- to four-fold
+increased risk of developing CHD and increased triglycerides. Decreased HDL levels
+are common in patients with T2DM [7,8]. The Indian Council of Medical Research study
+revealed a high prevalence of dyslipidemia in India, with 79% of the studied population
+showing an abnormality in at least one lipid parameter [9]. The study found a higher
+prevalence of abnormal lipids in females than in males. The middle-aged group population
+(35–64 yrs) showed higher lipid abnormalities than the younger group (20–24 yrs) [9].
+The increasing burden of heart disease and T2DM [10], despite billions of dollars spent
+on research and the use of lipid-lowering drugs over the years, has posed a big challenge for
+health expenditure [11], and there is an urgent need to investigate cost-effective alternative
+approaches. Yoga is one of the popular mind-body approaches developed in India [12].
+Yoga is known to exert positive physiological changes, which have wide-ranging scientific
+significance [13,14] as research findings have described the benefits of yoga in managing
+stress, anxiety, and negative sentiments [12,15]. Yoga may exert cardiovascular changes
+by acting on neurological pathways like the autonomic nervous system (ANS), sympatho-
+adrenal medullary (SAM), or hypothalamic pituitary adrenal (HPA) [16]. It is also believed
+that yoga postures like pranayama (breathing) and asanas improve cardiovascular and
+respiratory activity by increasing nitric oxide (NO) and antioxidant levels in the blood.
+Further, the HPA/SAM are hypothesized to reduce the over-production or activation
+of catecholamines, corticosteroids (glucocorticoids), and subsequent cytokines that are
+pro-inflammatory, increasing CHD risk [16,17]. β-cell sensitivity in response to glucose
+metabolism and insulin secretion is improved by these yoga postures [18].
+Hypercholesterolemia, hypertriglyceridemia, and hyperlipidemia are significant risk
+contributors for coronary heart disease. Both prevention and control of coronary heart
+disease with its associated diseases are essential and can be achieved by modifying the
+lipid profile [19]. There are many reports on the adverse effects of an increased volume
+of bad cholesterol (LDL, triglycerides) and reduced volume of good cholesterol (HDL)
+and on drugs to reduce LDL and increase HDL levels. Some studies have shown the
+detrimental effects (increased mortality in coronary heart disease) of lowering the levels of
+cholesterol (<160 mg/dL), which calls for the integration of an effective evidence-based
+non-pharmacological approach (Cir and EHJ) [20,21]. Mahajan et al. conducted a yoga-
+based study on the lipid profiles of subjects with coronary artery disease and reported the
+effectiveness of yoga in risk modification [22]. Another study reported yoga exerted its
+therapeutic potential in subjects with mild-to-moderate hypertension by reducing the risk
+of cardiovascular diseases [23]. A systemic review conducted by Innes et al. evaluated
+the effects of yoga-based controlled trials and found yoga to be effective in managing the
+blood lipids along with glycemic control [24]. Similarly, Raveendran et al. [25] suggested
+that daily yoga practice helps maintain overall body growth [25]. Hence, it appears that
+maintaining the lipid levels within the normal range is essential [26], which can be achieved
+by integrating yoga with usual care.
+There are a few studies on lipid profiles in T2DM patients [27,28], but there are none
+that have examined the normalizing effect of yoga on lipid values. This requires a large
+sample size from diverse community cohorts, which is challenging. Hence, the present
+paper planned to look at the lipid normalizing effect of the yoga lifestyle change program
+in a trial that was designed as a nationwide multicenter two-armed control trial for primary
+and secondary prevention of diabetes named Niyantrita Madhumeha Bharata Abhiyaan (NMB-
+2017). The sampled population is vulnerable (high risk) to diabetes with scores ≥60 on the
+Indian Diabetes Risk Score (IDRS).
+Medicines 2021, 8, 37
+3 of 16
+2. Materials and Methods
+2.1. Sample Size Calculation
+The sample size for the trial was calculated for the primary prevention of diabetes,
+which was the primary objective of the study. The details of the sample size calculation
+are provided in our earlier publication [29]. In brief, we used the values of relative risk-
+reduction after lifestyle intervention in prediabetes subjects, as observed in an earlier
+study [30], which had an annual conversion rate of 11.1% in the control and 7.8% in the
+intervention group; based on this we obtained a total sample size of 5320, i.e., 2660/group
+at α = 0.05 and 1 −β = 0.80.
+2.2. Screening and Recruitment
+The screening was carried out after getting permission from the Institutional Ethics
+Committee of the Indian Yoga Association (IYA) (Reference no: RES/IEC-IYA/001) and
+obtaining the signed informed consent by all participants. Details of the methodology
+are communicated in an earlier publication [31]. This was multi-level randomization
+starting from the randomization of districts, towns, and census enumeration blocks (urban)
+and villages (rural) depicted in the map (Figures 1 and S1) [31]. The study was a cluster
+randomization design in order to overcome the barriers of contamination. For this reason,
+we included the entire block or village for yoga intervention or control as the case may
+be. The yoga and control clusters were separated by 5–10 km. We randomly identified
+the group as an intervention group, i.e., 2 out of 4 villages and 1 or 2 out of 2 or 4 census
+enumeration blocks (CEBs) were identified in the selected ward, while the other was
+assigned as the waitlisted control group. Phase 2 included administering the yoga lifestyle
+protocol for diabetes developed by an expert committee through the Delphi method in the
+randomly allocated clusters.
+Figure 1. CONSORT diagram of the study.
+2.3. Randomization and Allocation Concealment
+Details of randomization have been published in our earlier publication [29]. In
+brief, a 4-stage randomization approach was implemented using a multi-level stratified
+cluster sampling method. The study was planned to be in two phases. Phase 1 involved a
+cross-sectional survey from the entire country using the National Family Health-3 (NFH-3)
+sampling process. The twenty-nine (95% of India’s population from 2011 census) most
+populous states/union territories of India were grouped under seven geographical zones
+(Northwest, North, Northeast, West, Central, East, and South) based on their cultural
+Medicines 2021, 8, 37
+4 of 16
+similarities (Figure S1); random selection process was applied for selecting 65 districts, four
+rural villages and two census enumeration blocks in an urban town. In brief, this was a
+trial on randomly selected rural and urban community clusters. Phase 1 was door-to-door
+screening for IDRS in these randomly selected clusters of rural (villages) and urban (CEBs)
+locations, followed by blood tests in high-risk (≥60 on IDRS) individuals.
+2.4. Selection Criteria for Phase 2 (RCT)
+In phase 2, two villages and one CEB were randomly selected for yoga intervention,
+and two villages and one CEB formed waitlist control. Adults (20 years) of both genders
+with IDRS Score ≥60 and those with known diabetes (any score on IDRS) were included.
+Those with reported psychiatric problems, major diabetes complications (nephropathy,
+retinopathy, coronary artery disease, history of cerebrovascular accidents) were excluded.
+Pregnant women, lactating mothers, and those who had any surgery within 12 months
+were also excluded. Information about medication was taken. Individuals taking drugs
+were excluded from the study. The lipid values of those who had reported that they had
+practiced yoga regularly within the last three months before the camp were not included in
+this analysis.
+2.5. Blinding and Masking
+Since it was a community-based interventional cluster-randomized trial, the partici-
+pants, instructors, and other individuals involved in the study were not blinded. Masking
+was ensured at different levels. The researchers in the central office provided the names of
+the randomly selected names of clusters to the field Senior Research Fellows (SRFs), and
+hence the selection bias was avoided. The central laboratory that carried out the blood
+investigations on the coded samples, the data operator who checked the accuracy of the
+data obtained online from the field researchers, and the statistician who analyzed the data
+were blinded.
+2.6. Assessments
+Zonal coordinators, yoga volunteers, and SRFs visited the campsites for formal inter-
+action with the leaders of the towns/villages and conducted door-to-door screening using
+the IDRS parameters. Those eligible based on the inclusion/exclusion criteria were invited
+to the blood camp. Two phlebotomists drew the blood samples in coded label vacutainers.
+The sample was processed for plasma separation, stored and transported in cold containers
+to the nearest laboratory, and was processed for biochemical analysis within 6 h of blood
+withdrawal. Data was collected by SRL labs. For storing, the sample standard method was
+applied. These estimations were carried out by the same NABL accredited laboratory (SRL)
+on fasting blood samples collected on day one and after three months of the trial in both
+yoga and control groups. Serum from the fasting venous blood sample was used for the
+estimation of lipids and glycated hemoglobin (A1c) on an auto-analyzer (Beckman Coulter-
+Auto-analyzer model 2700/480); the cholesterol esterase oxidase-peroxidase-amidopyrine
+method for TC, the glycerol phosphate oxidase-peroxidase-amidopyrine method for TG
+and polyethylene glycol-pretreated enzymes for HDL [29,31]. The criteria for diabetes and
+prediabetes were based on A1c values. ADA guidelines recommend A1c based screening
+as the most practical measure to segregate the population into healthy (A1c < 5.3%), pre-
+diabetes (A1c: 5.3–6.4%), and diabetes (A1c ≥6.5%) considering the impending practical
+challenges in screening a large population.
+2.7. Quality Assurance and Training
+Each zone had a zonal coordinator, 35 SRFs (approximately 1 per 2 districts), 1200
+certified yoga volunteers, and 2 research associates. The zonal training program organized
+in different zones trained the SRFs in organizing the camps, data acquisition, volunteer
+training, using the mobile app, maintaining logbooks, conducting regular meetings, etc.
+Medicines 2021, 8, 37
+5 of 16
+These SRFs further trained the volunteers in their respective areas. We used both paper
+and mobile apps to capture the data, collated by deep learning and big data analysis.
+2.8. Intervention
+Both groups were given the standard medical advice on lifestyle for the prevention
+and management of diabetes under the doctor’s supervision from the local medical center.
+The advice on lifestyle through detailed interactive group lectures included (a) advice
+on a healthy diet for diabetes; (b) regular and timely exercise (walking for more than
+20 min daily); (c) habits (sleep, hygiene, tobacco, alcohol, mobile addiction etc.); and (d)
+stress management.
+Diabetes Yoga Protocol
+The yoga group received a validated diabetes yoga lifestyle protocol (DYP) developed
+by an expert committee of 16 professionals (yoga masters, yoga researchers, and diabetol-
+ogist) with two rounds of interaction using the Delphi technique with a CVR > 0.7. The
+reliability of the protocol was tested by cluster analysis with an interclass coefficient value
+of 0.05. The details of the expert committee are published earlier [29].
+The 60-min yoga protocol (Table S1) for prediabetes and uncomplicated diabetes
+consisted of yoga postures, breathing practices, relaxation, pranayama, meditation, and
+lectures on yogic lifestyle for behavioral modification (diet, sleep, stress management
+through conceptual correction using jnana yoga, bhakti yoga and karma yoga). During the
+initial 9-day introductory camps, daily feedback for any adverse effect was recorded. After
+this period, they were asked to do the practices at home using handbooks and/or DVDs;
+adverse effects were discussed and documented during the weekly follow-up classes of
+2 h for three months. Fidelity data was documented through the attendance sheet and
+regular follow-up calls on the phone; individual pictures and videos were also recorded
+and archived in a retrievable format. No financial incentive was given to the participants.
+Any adaptation was decided locally by the trained instructors, which was done based on
+individual cases and not for the area as a whole. The standard protocol was implemented
+in all places uniformly by trained, certified instructors, e.g., some patients who could not
+squat on the floor for physical postures were taught a modified version of the postures to
+be done sitting in a chair. This was included and taught to the instructors in their 5-day
+orientation programs (5 days each in 20 orientation camps in different zones) [31].
+2.9. Statistical Analysis
+Data were analyzed using SPSS version 21.0. The matching of data from different
+sources and different time points was checked by fuzzy logic. Independent samples t-test
+was used to compare baseline characteristics of the two groups. Paired samples t-test was
+used for pre-post comparison within groups. Pre-post comparisons between yoga and
+control groups were checked by the ANCOVA test. The difference in deference analysis was
+done by multinomial regression. A mixed linear model was used to check the differences
+between subcategories of lipid values in 3 subgroups of A1c.
+3. Results
+Figure 1 shows the consort diagram. In the first phase of pan-India screening from
+seven zones (Figure S1), data on IDRS and known diabetes were available on 162,330 indi-
+viduals from the randomized urban (52%) and rural (48%) clusters. Of these, 69,717 individ-
+uals at high risk and who had known diabetes were invited for detailed assessments, and
+48,102 responded. Based on A1c values, 6094 were found to be newly diabetic (A1c ≥6.5),
+7920 were in the prediabetes range, and 13,597 were in the normoglycemia range and
+were invited for intervention in phase 2 of the trial. Of the 12,466 who participated in the
+trial, 6531 were in the yoga clusters and 5935 in the control clusters from all zones. The
+main reason for non-response, although they were interested in participation, was time
+constraints due to family or occupational commitments. Of these, follow-up data were
+Medicines 2021, 8, 37
+6 of 16
+available on 11,254 (5932 yoga and 5322 control; 9% drop out) at three months; analysis of
+pre-post lipid profile data was done on 8116 (3933 yoga and 4183 control) individuals after
+excluding extreme values.
+The baseline characteristics (Table 1) revealed a non-significant difference between
+groups in the age and gender distribution (independent samples t-test) between the yoga
+and control groups. The mean (SD) age (years) of the yoga and control groups was
+48.70 ± 10.64 of 48.41 ± 10.22, respectively. In the yoga group, the percentage of the male
+population was 42.8%, and in the control group, it was 40.9%. In the yoga group, the
+proportion of the rural population was 31.5%, while in the control, it was 47.3%. There
+were 4896 subjects in urban (2693 yoga and 2203 control) and 3220 subjects in rural locations
+(1240 yoga and 1980 control). By profession, most of the recruited participants were clerical
+or shop owners, followed by skilled workers. A total of 502 (n) participants in the yoga
+group and 616 (n) in the control group were aware of their diabetes status/that they had
+diabetes for the last five years. Many participants were newly diagnosed with diabetes
+(1105 in the yoga group and 2145 in the control group) (Table 1).
+Table 1. Demographic details of yoga and control groups.
+Demographic Details
+Yoga
+Control
+p Value
+Age (years)
+Mean ± SD
+48.7 ± 10.64
+48.41 ± 10.22
+0.03
+Gender
+Male N (%)
+1682 (42.8%)
+1710 (40.9%)
+<0.001
+Female N (%)
+2251 (57.2%)
+2473 (59.1%)
+Area
+Urban N (%)
+2693 (69.5%)
+2203 (52.7%)
+<0.001
+Rural N (%)
+1240 (31.5%)
+1980 (47.3%)
+Occupation
+Profession
+594
+778
+0.05
+Semi-Profession
+106
+130
+Clerical, Shop owner
+1415
+1405
+Skilled worker
+1321
+1345
+Semi-skilled worker
+90
+95
+Unskilled worker
+153
+170
+Diabetes status
+Self-declared
+Known DM
+<5 yrs
+502
+616
+<0.001
+5–10 yrs
+163
+220
+>10 yrs
+160
+209
+Newly diagnosed DM
+1105
+2145
+Pre-diabetes
+806
+678
+No DM, only high risk on IDRS
+1197
+315
+The group analysis (Table 2) showed that TC was reduced significantly (p < 0.001 paired
+t-test) from 181.80 ± 39.75 mg/dL to 176.64 ± 38.59 mg/dL after yoga, while there was
+an increase in the control group from 183.44 ± 40.33 mg/dL to 193.27 ± 47.27 mg/dL. A
+marginal increase (153.51 ± 72.88 mg/dL) in TG was observed in the yoga group after three
+months, whereas in the control group, the mean value increased from 155.86 ± 79.40 mg/dL
+to 191.12 ± 107.44 mg/dL. We found a significant reduction in LDL in the yoga group
+from 103.54 ± 34.09 mg/dL to 98.65 ± 33.67 mg/dL; the control group instead showed an
+increase in LDL from 103.99 ± 33.00 mg/dL to 108.01 ± 40.4 mg/dL. Blood HDL showed
+a reduction in both groups; the yoga group reduced marginally from 49.30 ± 11.48 mg/dL
+to 48.61 ± 11.55 mg/dL; similarly, the control decreased from 48.92 ± 11.53 mg/dL to
+44.62 ± 12.15 mg/dL. Similar changes were found in TG, LDL, and HDL (Table 2).
+Analysis of covariance (Table 2) between groups showed that there was a significantly
+better improvement in the yoga than the control group in TC, TG, LDL, and HDL (p < 0.001
+Medicines 2021, 8, 37
+7 of 16
+ANCOVA). There was a significant difference between groups (p < 0.001 Mixed Linear
+Model analysis) in two subgroups (Table 3) of A1c, i.e., in individuals in the diabetic and
+prediabetic ranges. There was a non-significant difference between the yoga and control
+groups in the normoglycemic subgroup.
+An interesting observation emerged in the yoga group when we looked at the three
+subcategories of baseline lipid values, i.e., those with less than, more than, or within the
+normal range (Table 3, Figure S2). In diabetics (A1c ≥6.5) with baseline levels of TC above
+the normal range, there was a significant reduction, and for those below the normal range,
+there was a significant increase with a non-significant change in those within the normal
+range. Looking at TG, LDL, and HDL, there was a significant reduction in those within and
+above normal ranges with an increase in those below the normal range. This phenomenon
+of a shift towards normalcy was not seen in the control group. Although there was a
+significant increase in those below normal values, there was a significant increase in those
+with average and high TC, TG, LDL, and HDL values. Sub-group analyses showed that
+there were no significant differences between males and females, urban and rural areas,
+or young (<40 yrs) and old (>40 yrs) age groups (p > 0.05 ANCOVA) in any of the lipid
+variables (Table 4).
+Medicines 2021, 8, 37
+8 of 16
+Table 2. Changes in lipid variables before and after three months in the two groups. N = 8116 (Yoga-3933, Control-4183).
+Group
+TC_Pre (mg/dL)
+TC_Post (mg/dL)
+TG_Pre (mg/dL)
+TG_Post (mg/dL)
+LDL_Pre (mg/dL)
+LDL_Post
+(mg/dL)
+HDL_Pre (mg/dL)
+HDL_Post
+(mg/dL)
+Yoga
+181.80 ± 39.75
+176.64 ± 38.59 *†
+150.42 ± 70.52
+153.51 ± 72.88 *†
+103.54 ± 34.09
+98.65 ± 33.67 *†
+49.30 ± 11.48
+48.61 ± 11.55 *†
+Control
+183.44 ± 40.33
+193.27 ± 47.27 *
+155.86 ± 79.40
+191.12 ± 107.44 *
+103.99 ± 33.00
+108.01 ± 40.4 *
+48.92 ± 11.53
+44.62 ± 12.15 *
+There were significantly better reductions in TC, TG and LDL and increases in HDL in the yoga group than the control. * Paired sample t-test significance p < 0.001. † ANCOVA p < 0.001. TC: total cholesterol, TG:
+triglycerides, LDL: low-density lipoprotein, HDL: high-density lipoprotein.
+Table 3. Comparison of three subgroups (lesser than, within, and above normal range) of baseline lipid values in control and yoga groups of individuals with high risk for diabetes after
+three months of intervention. TC: Total Cholesterol; TG: Triglyceride; LDL: low-density lipoprotein; HDL: high-density lipoprotein.
+Groups
+Lipid
+Categories
+Diabetes A1c (≥6.5)
+Prediabetes (A1c 5.3–6.4)
+with Diabetes High Risk (IDRS ≥60)
+Normoglycemia (A1c <5.3)
+with Diabetes High Risk (IDRS ≥60)
+Pre, mg/dL
+Post, mg/dL
+Diff (%)
+Pre, mg/dL
+Post, mg/dL
+Diff (%)
+Pre, mg/dL
+Post, mg/dL
+Diff (%)
+Yoga
+TC (<150)
+131.35 ± 15.76
+167.62 ± 37.67
+−36.27 *† (27.6%)
+130.25 ± 16.20
+160.94 ± 37.02
+−30.69 * (23.5%)
+131.80 ± 15.30
+163.83 ± 39.55
+−32.03 *
+(24.3%)
+TC (150–200)
+175.32 ± 14.18
+176.61 ± 38.97
+−1.29 (0.73%)
+174.25 ± 13.93
+174.92 ± 36.88
+−0.67† (0.38%)
+175.61 ± 13.72
+174.50 ± 35.34
+1.11 (0.63%)
+TC (>200)
+228.71 ± 24.20
+185.83 ± 37.61
+42.87 *† (18.7%)
+230.24 ± 25.64
+187.10 ± 39.79
+43.14 *† (18.7%)
+232.64 ± 27.93
+187.55 ± 39.07
+45.09 *(19.3%)
+TG (<150)
+104.97 ± 26.33
+147.60 ± 71.72
+−42.62 *† (40.6%)
+105.63 ± 25.70
+143.61 ± 67.49
+−37.98 *† (35.9%)
+104.96 ± 25.49
+148.03 ± 70.88
+−43.07 *
+(41.0%)
+TG (150–200)
+173.51 ± 14.58
+155.25 ± 71.17
+18.26 *† (10.5%)
+171.58 ± 14.19
+155.81 ± 61.34
+15.77 *† (9.19%)
+173.06 ± 14.55
+169.29 ± 81.49
+3.77 (2.17%)
+TG (>200)
+266.78 ± 56.77
+164.65 ± 74.78
+102.18 *† (38.3%)
+267.97 ± 60.35
+173.76 ± 81.09
+94.21 *† (35.1%)
+262.82 ± 55.22
+168.69 ± 80.60
+94.13 * (35.8%)
+LDL (<100)
+76.68 ± 15.96
+95.04 ± 34.41
+−18.36 *† (23.9%)
+76.55 ± 16.76
+92.66 ± 33.15
+−16.11 * (21.0%)
+76.56 ± 17.02
+92.19 ± 31.17
+−15.37 *
+(20.0%)
+LDL (100–130)
+113.79 ± 8.53
+101.32 ± 31.96
+12.47 *† (10.9%)
+113.06 ± 8.18
+98.34 ± 31.88
+14.72 *† (13.0%)
+113.91 ± 8.27
+100.67 ± 31.93
+13.23 * (11.6%)
+LDL (>130)
+152.75 ± 20.71
+107.06 ± 35.31
+45.68 *† (29.9%)
+154.14 ± 21.15
+108.14 ± 35.04
+46.0 *† (29.8%)
+155.41 ± 24.62
+108.25 ± 35.03
+47.15 * (30.3%)
+HDL (<45)
+38.69 ± 5.26
+47.01 ± 11.43
+−8.31 *† (21.4%)
+38.48 ± 5.17
+45.98 ± 11.34
+−7.5 (19.4%)
+38.70 ± 5.24
+46.34 ± 11.32
+−7.64 *
+(19.7%)
+HDL (45–60)
+52.12 ± 4.14
+49.39 ± 11.54
+2.72 *† (5.2%)
+52.25 ± 4.28
+50.12 ± 11.40
+2.13 *† (4.0%)
+52.07 ± 4.21
+49.22 ± 11.06
+2.85 * (5.4%)
+HDL (>60)
+67.86 ± 6.74
+51.36 ± 11.51
+16.49 *† (24.3%)
+67.66 ± 6.94
+51.25 ± 11.56
+16.41 *† (24.2%)
+69.07 ± 9.11
+50.84 ± 12.40
+18.23 * (26.3%)
+Medicines 2021, 8, 37
+9 of 16
+Table 3. Cont.
+Groups
+Lipid
+Categories
+Diabetes A1c (≥6.5)
+Prediabetes (A1c 5.3–6.4)
+with Diabetes High Risk (IDRS ≥60)
+Normoglycemia (A1c <5.3)
+with Diabetes High Risk (IDRS ≥60)
+Pre, mg/dL
+Post, mg/dL
+Diff (%)
+Pre, mg/dL
+Post, mg/dL
+Diff (%)
+Pre, mg/dL
+Post, mg/dL
+Diff (%)
+Control
+TC (<150)
+130.65 ± 15.57
+170.51 ± 40.59
+−39.86 * (30.5%)
+130.40 ± 14.89
+167.51 ± 37.52
+−37.10 * (28.4%)
+128.57 ± 14.05
+180.68 ± 52.30
+−52.11 *
+(40.5%)
+TC (150–200)
+175.53 ± 14.17
+182.58 ± 41.71
+−7.05 * (4%)
+175.82 ± 13.77
+182.46 ± 40.62
+−6.63 * (3.8%)
+173.26 ± 14.12
+181.01 ± 42.40
+−7.74 *
+(4.46%)
+TC (>200)
+228.75 ± 27.34
+224.04 ± 44.16
+4.70 * (2.0%)
+227.27 ± 24.48
+221.15 ± 40.59
+6.11 * (2.7%)
+229.43 ± 25.02
+225.69 ± 40.98
+3.74 * (1.63%)
+TG (<150)
+104.76 ± 25.95
+162.69 ±
+102.67
+−57.93 * (55.2%)
+106.41 ± 26.33
+174.32 ±
+111.57
+−67.90 * (63.8%)
+106.68 ± 27.13
+164.42 ±
+100.67
+−57.73 *
+(54.1%)
+TG (150–200)
+173.09 ± 14.65
+158.38 ± 80.19
+14.71 * (3.18%)
+173.60 ± 15.59
+167.25 ± 86.19
+6.34 * (3.6%)
+177.69 ± 16.44
+165.00 ± 88.74
+12.69 (7.1%)
+TG (>200)
+278.24 ± 64.15
+287.10 ± 75.54
+−8.85 * (3.1%)
+274.04 ± 64.22
+284.63 ± 74.75
+−10.59 * (3.8%)
+278.12 ± 67.55
+288.13 ± 75.20
+−10.01 *
+(4.5%)
+LDL (<100)
+76.79 ± 16.08
+95.78 ± 33.91
+−18.98 * (24.7%)
+76.71 ± 16.03
+100.65 ± 36.26
+−23.94 * (31.2%)
+75.95 ± 16.96
+98.89 ± 34.74
+−22.94 *
+(30.2%)
+LDL (100–129)
+114.44 ± 8.47
+99.44 ± 34.25
+14.99 * (13.0%)
+113.98 ± 8.61
+100.90 ± 38.79
+13.08 * (11.4%)
+114.78 ± 8.68
+94.11 ± 34.02
+20.67 * (18.0%)
+LDL (>130)
+151.63 ± 18.93
+146.32 ± 37.31
+5.31 * (3.5%)
+149.74 ± 16.28
+143.78 ± 18;25
+5.96 * (3.98%)
+151.70 ± 18.68
+145.87 ± 39.92
+5.82 (3.8%)
+HDL (<45)
+38.86 ± 5.00
+38.21 ± 7.53
+0.44 (1.1%)
+38.13 ± 4.98
+37.03 ± 7.13
+1.10 * (2.8%)
+37.90 ± 4.64
+38.25 ± 6.61
+−0.34 (0.89%)
+HDL (45–60)
+51.96 ± 4.13
+48.68 ± 12.81
+3.28 * (6.3%)
+51.62 ± 4.28
+48.85 ± 13.44
+2.76 * (5.2%)
+51.67 ± 3.89
+49.11 ± 13.18
+2.55 * (4.9%)
+HDL (>60)
+67.90 ± 6.08
+51.45 ± 11.88
+16.44 * (24.2%)
+68.24 ± 6.21
+49.75 ± 11.85
+18.48 * (27.0%)
+67.28 ± 5.00
+50.92 ± 11.66
+16.35 * (24.3%)
+* Paired sample t-test significance p < 0.001, * 2 Paired sample t-test significance p = 0.041, † ANCOVA p < 0.001. NORMALIZING EFFECT OF YOGA there was a significant increase in those with low baseline
+values; non-significant changes in those in the normal range; and a reduction in those with abnormally high baseline values.
+Medicines 2021, 8, 37
+10 of 16
+Table 4. Changes in lipid profile in two groups after three months in gender, area (rural/urban), and age subgroups.
+Groups
+TC (mg/dL)
+TG (mg/dL)
+LDL (mg/dL)
+HDL (mg/dL)
+Y/C
+Pre
+Post
+Df
+Pre
+Post
+Df
+pre
+Post
+Df
+pre
+Post
+df
+Gender
+Male
+Y
+181.96 ± 39.77
+177.44 ± 38.43
+4.52
+150.02 ± 69.88
+154.33 ± 73.82
+−4.31
+103.5 ± 34.72
+98.73 ± 33.36
+4.78
+49.3 ± 11.53
+48.90 ± 11.83
+0.48
+C
+181.24 ± 39.63
+192.73 ± 47.73
+−11.49
+153.74 ± 77.62
+189.80 ± 108.57
+−36.06
+104.88 ± 32.90
+109.07 ± 41.25
+−4.19
+49.30 ± 11.55
+44.77 ± 12.26
+4.52
+Female
+Y
+181.68 ± 39.74
+176.03 ± 38.70 *
+5.64
+150.73 ± 71.01
+152.89 ± 72.17
+−2.16
+103.56 ± 33.61
+98.59 ± 33.90 *
+4.96
+49.24 ± 11.44
+48.39 ± 11.34
+0.84
+C
+184.96 ± 40.75
+193.65 ± 46.95
+−8.68
+157.34 ± 80.60
+192.04 ± 106.65
+−34.69
+103.37 ± 33.05
+107.28 ± 39.88
+−3.90
+48.66 ± 11.51
+44.51 ± 12.08
+4.15
+Location
+Urban
+Y
+181.30 ± 39.74
+176.66 ± 38.74
+4.63
+150.16 ± 7070.62 153.87 ± 73.05
+−3.70
+103.07 ± 34.11
+98.54 ± 33.84 *
+4.53
+49.41 ± 11.39
+48.66 ± 11.64
+0.75
+C
+183.30 ± 40.00
+193.99 ± 47.13 *
+−10.69
+154.43 ± 79.19
+188.01 ± 105.64
+−33.58
+104.35 ± 33.18
+107.7 ± 40.14 *
+−3.41
+49.00 ± 11.67
+44.94 ± 12.40 *
+4.06
+Rural
+Y
+182.89 ± 39.77
+176.58 ± 38.39 *
+6.31
+150.99 ± 70.33
+152.72 ± 72.51
+−1.72
+104.55 ± 34.04
+98.88 ± 33.31 *
+5.66
+49.07 ± 11.67
+48.51 ± 11.37
+0.56
+C
+183.59 ± 40.70
+192.48 ± 47.42
+−8.8
+157.45 ± 79.63 *
+194.56 ± 109.32
+−37.11 103.5 ± 32.79 *
+108.2 ± 40.80 *
+−4.69
+48.83 ± 11.37
+44.26 ± 11.87 *
+4.57
+Age
+groups
+<40
+Y
+180.80 ± 38.78
+177.0 ± 38.38 *
+3.78
+149.63 ± 73.17
+150.10 ± 70.10
+−0.46
+102.28 ± 33.28
+99.62 ± 33.40
+2.65
+49.33 ± 11.16
+48.83 ± 11.21
+0.50
+<40
+C
+182.42 ± 40.51
+195.43 ± 46.12
+−11.00
+155.05 ± 78.79
+191.03 ± 109.61
+−35.98
+104.28 ± 32.65
+107.91 ± 40.93
+−3.63
+49.30 ± 11.52
+44.88 ± 12.46
+4.42
+>40
+Y
+182.18 ± 39.93
+176.49 ± 38.85 *
+5.68
+150.71 ± 69.49
+154.90 ± 73.79 *
+−4.18
+103.92 ± 34.33
+98.28 ± 33.92 *
+5.64
+49.34 ± 11.54
+48.55 ± 11.54 *
+0.79
+>40
+C
+183.10 ± 40.27
+192.53 ± 47.65 *
+−9.43
+156.14 ± 79.63
+191.15 ± 106.70 * −35.00
+103.89 ± 33.12
+108.0 ± 40.29 *
+−4.15
+48.79 ± 11.53
+44.53 ± 12.05 *
+4.26
+*p < 0.001 paired samples T test (pre-post within groups). There were no significant differences between males and females, urban and rural, or young and old age groups. (ANCOVA between the two subgroups).
+Medicines 2021, 8, 37
+11 of 16
+4. Discussion
+4.1. Yoga as an Effective Tool
+After three months of intervention, there was a noteworthy decline in the blood lipid
+(TC, TG, LDL) of subjects with diabetes, prediabetes, and non-diabetes. Interestingly, the
+values in all three groups showed a similar trend with a significant increase in those with
+low levels and a decrease in high values in the yoga group, e.g., there was a significant
+increase in those with HDL <45 mg/dL, while the levels decreased in those with high
+values of ≥60 mg/dL. A similar regulating effect was seen in TC, TG, and LDL, pointing
+to the regulatory effect of yoga in normalizing the values to reach a healthy status, i.e.,
+increasing if it was low and decreasing if it was high, which has not been reported earlier.
+Similar effects were observed in the case of both males and females. After three
+months of intervention, a reduction in the vital lipid parameters such as TC and LDL
+was observed for both the subgroups (male and female). However, TG was found to
+be elevated in both genders. Rural and urban populations differ in some of the basic
+characteristics such as relative pollution, lifestyle, diet, and stress. It was observed that
+yoga induced the same level of changes in biochemical markers in urban populations as in
+rural populations. Age is one of the important contributing risk factors associated with
+diabetes [32]. We categorized the study population into two groups based on age, i.e.,
+below or above 40 years. Analysis on the basis of this categorization revealed that yoga is
+as effective in the aged population (>40 yrs) as in the younger population (<40 yrs).
+Several studies have shown the positive effects of yoga in T2DM, although none had
+used a national consensus protocol [33]. A study on the effect of pranayama and yogasanas
+on blood glucose and lipid profile in a two-armed design on 60 patients of T2DM between
+35–60 yrs with diabetes recruited from the diabetes clinic of a hospital in Delhi, India, had
+shown a significant reduction in serum insulin, blood glucose (fasting and postprandial),
+LDL, TG, and VLDL with an increase in HDL, with insignificant changes in the control
+group after 45 days [34]. A short-term study based on asanas, relaxation, and pranayama
+had also shown a reduction in the lipid profile within nine days of intervention [35]. A
+systematic review of original studies on the metabolic and clinical effects of yoga in adults
+with T2DM summarized the beneficial effects of several variables, including anthropomet-
+ric, blood pressure, glucose tolerance, insulin sensitivity, etc. This study concluded that
+to realign the global focus towards yoga, better quality studies using standardized yoga
+programs are required to validate the effects in populations with T2DM [24].
+The lipid regulating effect of the integrated yoga lifestyle module has been highlighted
+in this study as noted by the significantly higher number of subjects shifting from high or
+low values to the normal range. The state of health, as cited in yoga literature, is defined as
+a state of dynamically changing functioning of the tissues to achieve a balance (samatvam
+yoga) under varying internal (psychological or biochemical) or external (environmental)
+situations [36]. Yoga masters evolved several techniques to achieve mastery over the mind
+(chittavrittinirodhaha) that monitors lifestyle behavior through mindfulness [37]. Healing
+during disease is through restoring this (samatvam) harmony or homeostasis. Yoga offers
+several techniques for correcting the imbalance at mental, emotional, and physical levels,
+which are postulated to manifest in biochemical changes [38]. Several studies on yoga have
+shown a similar harmonizing effect. For example, an improved autonomic balance was
+seen in healthy volunteers [39] and those with heightened sympathetic tone [40]. Studies
+have also shown restoration of diurnal cortisol rhythm in patients [41].
+The efficacy of yoga in achieving this metabolic biochemical homeostasis through
+lipid normalizing effect opens up several research questions about the mechanism of yoga.
+Future studies are imperative at the cellular level to examine whether yoga improves LDL
+receptor sensitivity or receptor-mediated endocytosis and receptor recycling based on the
+feedback regulation of receptors [42]. Whether the regulatory effect of yoga on HDL is
+mediated through a reverse cholesterol transport mechanism [43] that includes macrophage
+cholesterol efflux in arteries or an antioxidant or anti-inflammatory effect [44–46] mediated
+by NO promoting activity needs to be evaluated [43]. The increased number of diabetes
+Medicines 2021, 8, 37
+12 of 16
+cases in the Indian population creates a substantial economic burden [47–50] and poses a
+threat to having age-related disorders [51–53]. Therefore, the study may be extrapolated
+to other populations based on the varied acceptability of yoga protocol as its perceived
+benefits, barriers, and compliance may vary from one country to another. However, the
+generalizability of the yoga protocol to the other parts of the country may also depend
+on the availability and acceptability of certified yoga practitioners. Besides, it is difficult
+to predict the sustainability of the intervention for which long-term studies are required,
+although the benefits experienced by the participants are likely to attract them in long-term
+practice. With the establishment of 150,000 wellness centers in the country [54], the long-
+term sustainability and generalizability to other populations of the intervention may also
+depend on the extent to which it is integrated with modern medicine and prescribed by
+physicians or public health enthusiasts.
+4.2. Strengths
+This is the first multicenter nationwide study in both rural and urban populations on
+the effect of yoga lifestyle on lipid levels. Additionally, this intervention involved certified
+yoga therapists (checked by inter-rater reliability testing) from several member institutions
+of the IYA. There were no adverse/serious events reported during the intervention period
+of three months. However, a few incidents of minor events like pain in the knee or spine
+or generalized body pain, or issues related to digestion were reported. These issues were
+handled by the yoga instructors by correcting their postures and advising on relaxation or
+counter postures.
+4.3. Limitations of the Study
+As this was an interventional study, double-blinding was not possible as the instructor
+and the participant did know that they were doing yoga as a therapy. The post values
+of lipid profile were not available in all those who participated due to various reasons:
+(a) dropouts from the study after recruitment because of time constraints; (b) left the
+residence in the recruited cluster zone for business or change of jobs although they had
+participated in 80% of the sessions; (c) blood samples were corrupted (hemolyzed) in a
+few cases; (d) post data could not be collected due to local conditions such as weather
+(heavy snowfall (Kashmir valley), extremes of temperature (50 ◦C in Odisha), heavy rainfall
+(western ghats of Karnataka) etc.).
+Although efforts were made to ensure reliability by several levels of supervision to pro-
+mote punctuality and uniformity of the intervention, we could not ensure perfect monitoring
+due to weather conditions (Odisha and Kashmir), local political disturbances (election drive
+in UP), state-level agitation (Manipur), transfer of yoga volunteers (Kerala and Goa), etc.
+5. Conclusions
+The data presented in this study prompts more detailed investigations, including
+molecular genetics and cell culture approaches, to understand the mechanism of yoga
+protocols on lipid metabolism in general. The results indicate a non-redundant impact of
+yoga intervention, calling for its integration in medical institutes, further increasing the
+scope of convenience sampling through larger interdisciplinary studies on patients with
+dyslipidemia and diabetes. Further, with the launch of 150,000 wellness centers by the
+Government of India, these trained instructors could be used to provide daily modules of
+DYP, assisted by ASHA and multipurpose workers. Their services could also be utilized for
+screening and control of other non-communicable diseases. In this manner, regular yoga
+sessions in each district could lead to health promotion, prevention, and management of
+diabetes. As these centers will represent a triage of modern medicine, AYUSH, and science
+investigators, such integration could further lead to increased acceptance and incorporation
+into the NPCDCS in an evidence-based manner through new protocols for cancer palliative
+care, cardiovascular disease, and stroke prevention.
+Medicines 2021, 8, 37
+13 of 16
+Supplementary Materials: The following are available online at https://www.mdpi.com/article/10.339
+0/medicines8070037/s1, Figure S1: Map of India showing the geographic spread of the intervention sites
+(reusing the figure after permission (Nagendra et al., 2019), Figure S2: Graphs showing the normalizing
+effect of yoga, Table S1: Validated yoga lifestyle protocol for prediabetes and uncomplicated diabetes.
+Author Contributions: R.N.: proposal writing, planning, monitoring, conducting, review, analysis
+and editing; S.K.: original writing; A.A.: concept of manuscript; I.N.A.: concept, review; A.K.S.:
+planning, monitoring, data management and quality assurance; S.S.P.: data segregation and analysis;
+R.H.L.: data collection, monitoring, quality assurance; P.D.: data collection, monitoring, quality
+assurance; H.R.N.: vision, concept, proposal, planning, monitoring, advice, problem solving, editing.
+All authors have read and agreed to the published version of the manuscript.
+Funding: We thank Ministry of Health and Family and Ministry of AYUSH (through CCRYN),
+Govt. of India for funding this project. The funding was received via grant letter number F.No.
+16-63/2016-17/CCRYN/RES/Y&D/MCT/dated 15.12.2016.
+Ethical Compliance: Screening and recruitment were carried out after getting the permission from
+IEC, reference no RES/IEC-IYA/001 dated 16th Dec 2016. Written informed consent was taken before
+the assessment. The study was primarily done by S-VYASA under IYA.
+Institutional Review Board Statement: The study was conducted according to the guidelines of the
+Declaration of Helsinki, and ap-proved by the Ethics Committee of Indian Yoga Association (protocol
+code RES/IEC-IYA/001 and date of approval 16-12-2016).
+Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
+Data Availability Statement: All the associated data is available within the manuscript/Supplementary
+Materials.
+Acknowledgments: We are thankful to (a) the funding by the Ministry of health and family welfare
+and the Ministry of AYUSH routed through Central Council for Research in Yoga and Naturopathy,
+Govt, of India for their timely support of this project (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 volunteers and (d)
+the members of the research advisory board of NMB for their inputs at all stages of the study.
+Conflicts of Interest: The authors declare no conflict of interest.
+Abbreviations
+DYP
+Diabetes yoga lifestyle protocol
+NMB
+Niyantrita Madhumeha Bharata Abhiyaan
+NABL
+National Accreditation Board for Testing and Calibration Laboratories
+A1c
+Glycated hemoglobin
+TC
+Total cholesterol
+TG
+Triglyceride
+LDL
+Low-density lipoprotein
+HDL
+High-density lipoprotein
+VLDL
+Very-low-density lipoprotein
+T2DM
+Type-2 diabetes mellitus
+CHD
+Coronary heart disease
+ADA
+American Diabetes Association
+ANS
+Autonomic nervous system
+SAM
+Sympatho-adrenal medullary
+HPA
+Hypothalamic pituitary adrenal
+NO
+Nitric oxide
+IDRS
+Indian diabetes risk score
+IYA
+Indian Yoga Association
+CEB
+Census enumeration blocks
+SRF
+Senior research fellows
+ASHA
+Accredited social health activists
+IEC
+Institutional ethics committee
+Medicines 2021, 8, 37
+14 of 16
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subfolder_0/Effectiveness of a yoga-based lifestyle protocol (YLP) in preventing diabetes in a high-risk Indian cohort a multicenter cluster-randomized controlled trial (NMB-trial).txt

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+Effectiveness of a Yoga-Based
+Lifestyle Protocol (YLP) in Preventing
+Diabetes in a High-Risk Indian
+Cohort: A Multicenter Cluster-
+Randomized Controlled Trial
+(NMB-Trial)
+Nagarathna Raghuram 1*, Venkat Ram 2, Vijaya Majumdar 3, Rajesh SK 3, Amit Singh 3,
+Suchitra Patil3, Akshay Anand4, Ilavarasu Judu3, Srikanta Bhaskara5, Jagannadha Rao Basa6
+and Hongasandra Ramarao Nagendra3
+1 Vivekananda Yoga Anusandhana Samsthana, Bengaluru, India, 2 Apollo Medical College, Hyderabad, India, 3 Division of Life
+Sciences, Swami Vivekananda Yoga University, Bengaluru, India, 4 Neuroscience Research Lab, Department of Neurology,
+Postgraduate Institute of Medical Education and Research, Chandigarh, India, 5 Ekisaan Foundation, Bengaluru, India,
+6 International School of Engineering, Hyderabad, India
+Introduction: Though several lines of evidence support the utility of yoga-based
+interventions in diabetes prevention, most of these studies have been limited by
+methodological issues, primarily sample size inadequacy. Hence, we tested the
+effectiveness of yoga-based lifestyle intervention against diabetes risk reduction in
+multicentre, large community settings of India, through a single-blind cluster-
+randomized controlled trial, Niyantrita Madhumeha Bharat Abhiyan (NMB).
+Research Design and Methods: NMB-trial is a multicentre cluster-randomized trial
+conducted in 80 clusters [composed of rural units (villages) and urban units (Census
+Enumeration Blocks)] randomly assigned in a 1:1 ratio to intervention and control groups.
+Participants were individuals (age, 20–70 years) with prediabetes (blood HbA1c values in
+the range of 5.7–6.4%) and IDRS ≥60. The intervention included the practice of yoga-
+based lifestyle modification protocol (YLP) for 9 consecutive days, followed by daily home
+and weekly supervised practices for 3 months. The control cluster received standard of
+care advice for diabetes prevention. Statistical analyses were performed on an intention-
+to-treat basis, using available and imputed datasets. The primary outcome was the
+conversion from prediabetes to diabetes after the YLP intervention of 3 months
+(diagnosed based upon HbA1c cutoff >6.5%). Secondary outcome included regression
+to normoglycemia with HbA1c <5.7%.
+Results: A total of 3380 (75.96%) participants were followed up at 3 months. At 3 months
+post-intervention, overall, diabetes developed in 726 (21.44%) participants. YLP was
+found to be significantly effective in halting progression to diabetes as compared to
+standard of care; adjusted RRR was 63.81(95% CI = 56.55–69.85). The YLP also
+Frontiers in Endocrinology | www.frontiersin.org
+June 2021 | Volume 12 | Article 664657
+1
+Edited by:
+Andrea Icks,
+Heinrich Heine University of
+Düsseldorf, Germany
+Reviewed by:
+Burkhard Haastert,
+mediStatistica, Germany
+Hanna Kampling,
+Universitätsklinikum Gießen, Germany
+*Correspondence:
+Nagarathna Raghuram
+[email protected]
+Specialty section:
+This article was submitted to
+Clinical Diabetes,
+a section of the journal
+Frontiers in Endocrinology
+Received: 05 February 2021
+Accepted: 23 April 2021
+Published: 11 June 2021
+Citation:
+Raghuram N, Ram V, Majumdar V,
+SK R, Singh A, Patil S, Anand A,
+Judu I, Bhaskara S, Basa JR and
+Nagendra HR (2021) Effectiveness
+of a Yoga-Based Lifestyle Protocol
+(YLP) in Preventing Diabetes
+in a High-Risk Indian Cohort: A
+Multicenter Cluster-Randomized
+Controlled Trial (NMB-Trial).
+Front. Endocrinol. 12:664657.
+doi: 10.3389/fendo.2021.664657
+ORIGINAL RESEARCH
+published: 11 June 2021
+doi: 10.3389/fendo.2021.664657
+accelerated regression to normoglycemia [adjusted Odds Ratio (adjOR) = 1.20 (95% CI,
+1.02–1.43)]. Importantly, younger participants (≤40 years) were found to regress to
+normoglycemia more effectively than the older participants Pinteraction<0.001.
+Conclusion: Based on the significant risk reduction derived from the large sample size,
+and the carefully designed randomized yoga-based intervention on high-risk populations,
+the study is a preliminary but strong proof-of-concept for yoga as a potential lifestyle-
+based treatment to curb the epidemic of diabetes. The observed findings also indicate a
+potential of YLP for diabetes prevention in low/moderate risk profile individuals that needs
+large-scale validation.
+Trial Registration: Clinical Trial Registration Number: CTRI/2018/03/012804.
+Keywords: type 2 diabetes, prediabetes, India, HbA 1c, yoga-based lifestyle intervention
+INTRODUCTION
+The recent estimates by the International Diabetes Federation
+(IDF) report a 9.3% prevalence of diabetes, which indicates 463
+million adults of 20 to 79 years suffering from the disease across
+the globe (1, 2). India tops the second rank as a diabetes capital,
+with 77 million adults with diabetes (1, 2). By 2030, India will
+continue to remain on the top list, with an estimated number of
+101 million people with diabetes (1, 2). Findings of large-scale
+intervention studies indicate that lifestyle modifications could be
+one of the most effective strategies to harness diabetes at its
+biological precursor stage, termed prediabetes (3–10). These
+lifestyle modification trials considered the cornerstone strategy
+for diabetes prevention, include interventions on diet control,
+and/or physical activity (11, 12). Robust behavioral change
+strategies also serve as an integral part of efficient lifestyle
+modifications and underlie the ensured sustenance of clinical
+outcomes (13). Yoga-based intervention is an emerging
+integrative healthcare practice comprised of asanas (physical
+exercises), pranayama (breathing techniques), and meditation
+(14). It also includes a strong behavioral component of self-
+regulation derived from ethical concepts of yamas and niyamas
+(ethical concepts) (15, 16). The ethical principles of yoga have
+also been proposed to enhance the integration of physical and
+mental sensations (interoception) for the fostering of
+physiological and affective states (15, 16).
+Several lines of evidence support the efficacy of yoga on the
+amelioration of modifiable metabolic disease risk factors (fasting
+blood glucose (FBG), and glycosylated hemoglobin A1c (HbA1c)
+and the lipid levels) in general, high risk as well as the population
+with type 2 diabetes manifestation as compared to usual care or
+no intervention (17–21). Most of the meta-analyses reports have
+highlighted several methodological limitations in the reported
+studies, mainly about the adequacy of sample size, improper
+randomizations, allocation concealment, lack of intention-to-
+treat analyses, and missing blinding of at least outcome assessors
+(17–20). A recent meta-analysis on 12 randomized control trials
+and 2 non-randomized control trials, reported the efficacy of
+yoga intervention towards the improvement of fasting blood
+glucose (FBG) [Standard Mean Difference (SMD, −0.064 mg/dl
+(95% CI, −0.201 to 0.074)] (17) and other metabolic parameters
+in population groups under high risk for diabetes. The authors
+recommended yoga as a comprehensive and alternative
+approach to preventing type 2 diabetes (17) and indicated the
+need for testing the notion with adequately powered well-
+designed RCTs. Given the potential efficacy of yoga as a
+lifestyle modification strategy against diabetes risk reduction,
+trials conducted in large community settings would aid in real-
+world clinical translation of the intervention (21, 22). Towards
+the same, the high estimates of prediabetes prevalence in India
+[10·3% (95% CI 10·0–10·6)] provide a relevant clinical window to
+halt the propagation of diabetes (23). Hence, we performed a
+large multicentre, cluster-randomized, controlled, two-armed,
+yoga-based lifestyle intervention-based diabetes prevention trial
+[Niyantrita Madhmeha Bharata Abhiyaan (NMB-trial)]. The
+trial aimed to assess the efficacy of yoga-based lifestyle
+modification protocol (YLP) as a prevention strategy for
+diabetes among high diabetes risk individuals with the
+manifestation of prediabetes, in a large community setting (24, 25).
+METHODS
+NMB-trial is a large, multicentre, cluster-sampled research trial
+to assess the efficacy of yoga-based lifestyle modification protocol
+(YLP) as a prevention strategy for diabetes risk reduction in high
+diabetes risk Indians (24, 25). The cluster-randomized approach
+was used to minimize the exposure of the control group to the
+intervention effects. A cost-effective methodology based on the
+Indian Diabetes Risk Score was adopted for large-scale screening
+for individuals at high risk of diabetes (26, 27). The screening
+was followed by the diagnosis of prediabetes based on blood
+HbA1c levels (range, 5.7–6.4%) as per the guidelines of the
+American diabetes association (ADA) (28). Choice of HbA1c
+over other standard measures of diagnosis [fasting plasma
+glucose (FPG) and/or impaired glucose tolerance (IGT)] was
+guided by the logistical and practical advantages for this large-
+scale screening (28). The screening strategy was modeled to
+obtain an IDRS filter-enriched, high-risk cohort Indian cohort
+with prediabetes, with high conversion potential for diabetes in a
+Raghuram et al.
+Yoga and Prediabetes
+Frontiers in Endocrinology | www.frontiersin.org
+June 2021 | Volume 12 | Article 664657
+2
+short duration of the intervention (3 months) (29). The data
+were collected, and outcomes were assessed at two time points,
+baseline and the end of the intervention (3 months). An
+International Research Advisory Committee with subject
+experts guided all stages of the study. Figure 1 details
+inclusion and exclusion at each step of enrollment. The study
+was registered in Clinical Trials Registry- India (CTRI) Trial
+Registration Number: CTRI/2018/03/012804).
+Participants
+The trial included individuals (age, 20–70 years) with prediabetes
+(blood HbA1c values in the range of 5.7–6.4%) and IDRS ≥60.
+Individuals with diabetes (known and newly diagnosed), severe
+obesity [Body Mass Index (BMI) >40 kg/m2], history of
+uncontrolled hypertension, coronary artery disease, renal
+disease, diabetes retinopathy, head injury, tuberculosis,
+reported psychiatric problems, major surgery, pregnancy in
+case of women, those planning to move out of the area within
+the next 3 months and those who had already done yoga for ≥3
+months just before the dates of recruitment were excluded from
+the study. Newly diagnosed diabetes was diagnosed in subjects
+who exceeded the upper limit of the criteria (HbA1c > 6.4 %) and
+had not taken any diabetic medications before the screening.
+Written informed consent was obtained from all the participants
+before screening and randomization. Prescription of medication
+(metformin) for diabetes prevention is not the standard of care at
+the study site for either the intervention or the control group.
+Details of the recruitment of participants have been discussed in
+detail in earlier reports, and the supplementary protocol and
+earlier publications (24, 25). In brief, using the random cluster
+sampling method, a four-stage strategy (zones®states®
+districts®urban/rural locations) was adopted for identifying
+and enlisting study sites across pan India (24). The sampling
+strategy was adopted from the National Family Health Survey
+(NFH3-3) protocol. Based on the cultural heterogeneity of the
+country, the zonal selection was derived from the 7 geographical
+zones of the country (Jammu and Kashmir, north, northeast,
+west, central, east, and south). The lists of rural and urban areas
+were obtained from the Census 2011. The clusters were villages
+or census enumeration blocks with an adult population of about
+FIGURE 1 | NMB trial profile.
+Raghuram et al.
+Yoga and Prediabetes
+Frontiers in Endocrinology | www.frontiersin.org
+June 2021 | Volume 12 | Article 664657
+3
+500 representing around 100–175, selected from 65 districts of 29
+states/union territories of India. Recruitment of eligible
+households was capped at n = 100 per cluster. Households
+within each cluster were screened sequentially for eligibility;
+only one eligible adult per family was randomly selected as an
+index case to measure the change in the outcomes of interest in
+the study. The screening was implemented across 240 clusters/
+sites with demographic and anthropometry-based
+questionnaires, including evaluation for their IDRS with its 4
+factors (age, family history of diabetes, waist circumference, and
+physical activity) validated for the Indian population. For
+secondary camp-based screening, participants with high IDRS
+values ≥60 were invited for detailed demography and baseline
+assessment of their HbA1c status.
+Sample Size
+We based the sample size calculation of the present trial on the
+clinically significant reduction in relative risk by 30% in the
+proportion of subjects with incident diabetes after 3 months of
+trial. We used the Indian Diabetes Prevention Programme-1
+(IDPP-1) estimate of 18.3% of annual diabetes incidence in the
+control group (8). The derived rates of conversion from
+prediabetes to type 2 diabetes over 3 months were 4.57% and
+3.0% (8), respectively for control and intervention groups. The
+required sample size for the present study was estimated to be
+2241 for each group with a at 0.05 and (1- b error) at 0.80 using a
+web calculator (30) Factoringattrition of 10%, the final sample
+size was estimated to be 4930 individuals with prediabetes. The
+estimated sample size of 4930 provided us an estimate of 164,333
+individuals to screen above 20 years of age (Supplementary
+Protocol). We did not adjust the sample size for ICC estimates;
+however, cluster-adjusted sample size estimation would have
+been necessary. The post-hoc estimation yielded an ICC value of
+0.05 for diabetes incidence (see Supplementary Table 4) and an
+inflation factor of 3.7 for the adjusted sample size. Since the effect
+size of the study, the difference in the diabetes conversion rates
+between the YLP and the control group (20.8%) was much higher
+than the assumed difference of 1.57% used for sample size
+calculation, it rules out the underpowering of the trial.
+Outcomes
+The primary outcome was the conversion from prediabetes to
+diabetes after the YLP intervention of 3 months (diagnosed based
+upon HbA1c cutoff >6.5%). Secondary outcome included
+regression to normoglycemia with HbA1c <5.7%. The study
+outcomes were based upon a single-time point assessments of
+blood HbA1c levels.
+Assessments at baseline and after three months included study
+questionnaires, anthropometric measurements, and blood draw.
+Blood pressure was measured in the right hand in a sitting position
+using a mercury sphygmomanometer [Omron co.2016 Model
+HEM7120] across all locations. BMI was calculated using the
+formula (weight in kg/height in meter2). HbA1c was assessed by
+high-pressure liquid chromatography using the Variant™II
+Turbo machine (Bio-Rad, Hercules, CA) certified by the
+National Glycohemoglobin Standardization Program. The intra-
+and inter-assay coefficients of variation for the biochemical assays
+ranged within the target goals set by ADA’s Standards of Medical
+Care. Lab standardization processes were assured by conducting
+the blood tests in all parts of the country by the laboratories
+accredited by the National Accreditation Board for Testing and
+Calibration Laboratories (NABL).
+IDRS was used as a validated instrument for baseline
+screening of high diabetes risk individuals with scores ranging
+from 0 to 90 (26). IDRS is a scoring tool derived from a multiple
+logistic regression model developed by Mohan et al. to identify
+undiagnosed diabetes in Indian individuals. The tool involves a
+combination of four non-biochemical parameters; age, family
+history of diabetes, waist circumference, and physical activity.
+The individuals are classified as having high risk (score ≥60),
+moderate risk (score 30–50), and low risk (score <30) out of a
+total score of 90 (26).
+Details of self-reported physical activity were collected using
+recall interviews including mean minutes of weekly activities
+were estimated based on the questions on frequency and
+duration of exercise sessions. Participants were asked to recall
+the amount of time spent performing moderate-intensity
+activities (activities that make them breathe somewhat harder
+than normal), vigorous-intensity activities (activities that make
+them breathe much harder than normal), and mild activities
+including walking/bicycling. The levels of physical activity were
+categorized based on the weekly engagement of at least 150
+minutes of moderate-intensity physical activity, or 75 minutes of
+vigorous-intensity physical activity or mild activity including
+bicycling/walking according to guidelines of the World Health
+Organization (31). Details of any adverse reactions or events
+were recorded including the time of occurrence, the severity,
+and duration.
+Randomization and Blinding
+Overall 80 clusters (n = 4450) were randomly assigned in a 1:1
+ratio to the control or the YLP groups by an independent
+statistician using a computer-generated randomization
+sequence. An overall equivalent ratio of rural and urban
+location distributions was maintained (44 rural and 36 urban
+centers). Group allocation was concealed to the participants until
+the completion of the baseline assessment. Based on the nature of
+the YLP, other than the statisticians and the baseline data
+collection staff, the study participants or the field intervention
+yoga therapists or other investigators could not be blinded.
+Intervention
+The intervention included the practice of YLP for 9 consecutive
+days, followed by daily home and weekly supervised practices for
+3 months. All participants in the YLP group received core
+initiation camps of 2-hours daily for 9 days. The YLP was
+developed by a team of 16 members including senior yoga
+experts from different yoga traditions (member institutions of
+Indian Yoga Association [IYA]), yoga researchers, and
+diabetologists (24). The YLP was comprised of selected
+practices for lifestyle diseases, extracted from traditional
+sources (see Supplementary Table 1). The YLP module was
+consistent with the American Diabetes Association
+recommendations for lifestyle change for the prevention of
+Raghuram et al.
+Yoga and Prediabetes
+Frontiers in Endocrinology | www.frontiersin.org
+June 2021 | Volume 12 | Article 664657
+4
+diabetes (Supplementary Table 2) (32). It included 30 minutes
+of physical postures (sun salutation and asanas) equivalent to
+mild to moderate physical activity and 30 minutes of breathing
+practices (kapalabhati kriya and pranayama), meditation and
+relaxation techniques. The YLP group also received educational
+advice that emphasized the role of adherence to the intervention
+to prevent diabetes. Further, evidence-based dietetic advice was
+also provided to promote healthy choices, rich in fiber and lower
+in fat and carbohydrate content (Supplementary Table 3).
+Group/individual lectures on concepts of ethical principles
+(yamas and niyamas), stress, and nutrition for diabetes
+management were also held for 20 minutes. The control cluster
+received standard of care advice for diabetes prevention.
+The roles and responsibilities of the study staff were
+discerned. The YLP was conducted at the study sites by the
+volunteers designated as yoga volunteers for diabetes movement
+(YVDM). These YVDMs were certified yoga instructors from
+different member organizations of IYA. After these core
+intervention camps, participants were asked to continue self-
+practice (group or individual) daily for 3 months. Supervised
+weekly follow-up classes for 2-hours were also conducted. After 3
+months, post data was collected from both groups. The YVDMs
+planned and conducted weekly 2-hours Sunday morning group
+classes where yoga camps were conducted and social media
+groups were also created. This facilitated the communications
+on interactive review follow−up classes, monitoring their
+compliance with daily practices, and their health-related issues.
+The control cluster received standard of care advice for
+diabetes prevention. Participants assigned to the control group
+received standard of care through printed handouts and one-day
+interactive group presentation on structured lifestyle (diet
+physical activity, tobacco cessation, etc) change for diabetes
+prevention, by a team of physician, dietitian, and a fitness
+trainer. This was followed by weekly visits to the site by the
+volunteers to interact and answer queries by the control
+group participants.
+Statistical Analysis
+The statistical analysis was conducted using Statistical Product
+and Service Solutions (SPSS version 21.0; IBM Corp., Armonk,
+NY, USA) and R statistical software package (version 3.5.1). A
+two-sided P value <0.05 was considered statistically significant
+for all analyses. We performed comparative analyses at
+individual level using collective data from YLP and control
+groups with the Chi-Square test, or an independent samples t-
+test. The ICCs were calculated using the method described by
+Fleiss, 1981 (33). For ICC calculation,we obtained within‐ and
+between‐components of variations using analysis of variance for
+the variables, ordinal and binary variables. We performed
+ANOVA in SPSS version 23.0. We calculated the estimates of
+ICC through a Microsoft Excel worksheet by using the
+expressions provided by Fleiss, 1981 (please refer to
+Supplementary Methods for details). (33, 34) In accord with
+the recommendations of the CONSORT eHealth statement, we
+conducted intention-to-treat (ITT) analyses for the primary
+study outcome with multiple imputed data (35). The multiple
+imputations of missing outcomes was carried out based on the
+assumption of missing at random, using multivariate imputation
+via chained equations (MICE) to replace the outcome missing
+values, and performing 50 imputation models with 50 iterations
+per model. In the multiple imputation procedure, the missing
+values at 12-month follow-up were imputed, the model included
+analysis-model covariates (age, gender, location, baseline BMI,
+and physical activity levels). Bootstrapping methods were used to
+produce confidence intervals (CIs) following imputations
+Sensitivity analyses were performed with adjustment of
+clustering effect and primary endpoints derived from imputed
+and non-imputed datasets were compared.
+We assessed the effect of the YLP on the relative risk
+reduction of diabetes using the multivariable logistic regression
+generalized linear mixed models (GLMMs). To avoid serious
+underestimation of variances due to neglected ICC adjustments
+in the case of large cluster sizes (36), Cluster adjustments were
+considered and were adjusted as random effects in GLMMs.
+Treatment group (YLP vs. control), and other categorical
+predictors; gender and location were entered as fixed effects.
+Covariates used were age, gender, baseline values of BMI and
+physical activity (selected a priori for inclusion due to being a
+known confounder). Models were additionally adjusted for post
+BMI data, to check if reductions in BMI could have led to the
+group differences regarding incidence of diabetes. For generation
+of relative risk ratios, expanded logistic models were used.
+Intervention adherence was assessed by evaluating (a) class
+attendance and (b) regularity of practice of yoga during the
+period of study. For secondary outcome, conversion from
+prediabetes to normoglycemia, GLMM was used and Odds
+Ratios were reported with 95% CIs.
+For the analysis of heterogeneity of treatment effects,
+subgroup analyses were done; tests of interaction (z test) were
+conducted as described by Altman (37) with ratios of the relative
+risks, and odds ratios. Age stratification was done based on the
+median value of 40 years; location categories were rural and
+urban; BMI categorization was done based upon the Asian cut
+offs of overweight/obesity, BMI (>23 kg/m2) (38). The sub-group
+analysis-models were adjusted for all the main model covariates
+other than the categorizing variable.
+RESULTS
+Study Enrollment and Follow-Up
+Overall the community-level recruitment in phase 1 of the
+screening for IDRS values included 240 clusters with 155,933
+adult respondents. Out of 155,933 recruited individuals, 106,707
+individuals were excluded based on the eligibility criteria [(IDRS
+scores <60 or age not within the proposed range (20–70 years)];
+only 49,226 individuals from 130 clusters were eligible. Among
+these 27,611 individuals responded to biochemical assessments,
+and 7920 were in the prediabetes range of HbA1c (5.7–6.49%).
+Individuals from the cluster with <50 eligible individuals n =
+2300 were excluded, and 1170 eligible individuals with
+prediabetes declined or did not respond for participation
+during enrollments. The comparative demographic analyses of
+Raghuram et al.
+Yoga and Prediabetes
+Frontiers in Endocrinology | www.frontiersin.org
+June 2021 | Volume 12 | Article 664657
+5
+these non-respondents indicated younger age, higher female
+prevalence, overweight/obese (BMI>23 kg/m2) body
+composition, but comparatively active lifestyle, and lower
+mean HbA1c levels compared to the study participants (see
+Supplementary Table 5). Due to 24% attrition, the follow-up
+numbers were 3380; 1712 in YLP, and 1686 in the control group
+(Figure 1). Missingness analysis indicated significant differences
+for baseline characteristics including age, location and between
+drop-out and non-drop-out groups. Overall, drop-outs were of
+higher age, from rural locations, females, and reported sedentary
+lifestyle at the baseline as compared to non-drop-outs
+(Supplementary Table 6). There were significant differences in
+the number of drop-outs between the YLP (n = 604) and control
+groups (n = 466), which could have led to attrition bias
+(Supplementary Table 7) (c2 = 10.95, P-value < 0.001). The
+reasons for drop-out were mostly time constraints and
+unavailability of the participants due to constraints related to
+their work or weather conditions. Mean class attendance were
+65.19% (SD = 22.14) vs. 63.98% (SD = 22.48), for YLP and
+control groups respectively, p-value = 0.09.
+Baseline Characteristics
+The mean age of the study cohort was 48.58 (SD = 10.34) years;
+60.00% (n = 2670) were females, and the mean BMI was 26.57
+(SD = 4.55) kg/m2 (Table 1). The mean HbA1c level was 5.97%
+(SD = 0.23). Self-reported physical activity levels of the participants
+ranged from 19.78% (vigorous) to 25.92% (mild); 34.52% of the
+cohort was sedentary with no self-reported physical activity. At
+baseline, the distribution of the demographic and clinical
+characteristics was found to be fairly even with the non-
+significant difference between the study groups (p>0.05) (for
+details, see Table 1). Cluster sizes ranged between 35 and 101 and
+the average cluster size was 55.62 (SD = 14.09) (Supplementary
+Table 8). There were no significant differences in average cluster
+sizes between YLP and control groups [57.90 (SD = 13.99) vs. 53.35
+(SD = 13.99), p = 0.15)]. ICC for the baseline variables were age,
+0.002; gender, 0.005; location, 0.024; BMI, −0.002; physical activity,
+0.018; and HbA1c, −0.003 (Supplementary Table 4). The baseline
+demography of the clusters has been reported in (for details see
+Supplementary Table 8). Significant heterogeneity was found
+among clusters for physical activity levels, location-wise, and
+gender. (p>0.05, F-test and Chi-square test).
+Primary Outcome: Conversion From
+Prediabetes to Diabetes
+At 3 months post-intervention, overall, diabetes developed in
+726 (21.44%) participants. A significantly smaller proportion of
+the intervention YLP group developed diabetes (n = 192, 11.21%)
+compared to the control group (n = 534, 32.01%), with a
+difference in the incidence of 20.80%, p<0.001 (Table 2). The
+intervention group exhibited a reduced relative risk of
+conversion from prediabetes to type 2 diabetes by 63.20% as
+compared to the control group [RRR = 63.20% (95% CI, 54.79–
+70.04] (Table 2). This clustering-adjusted RRR was based on
+complete case analysis was 63.20 (95% CI, 54.79–70.04). Due to
+the substantial and differential loss to follow-up in YLP and
+control groups (26.08 vs. 21.84%, respectively) and attrition bias,
+we used multiple imputations of the missing data to supplement
+the records to assess under an intention-to-treat basis (Table 2).
+However, similar RRR was observed using multiple imputations
+(RRR 63.81, 95% CI, 56.55–69.85) which was considered as the
+primary outcome under intention-to-treat analysis.
+Though heterogeneity of treatment effects analyses of cluster-
+adjusted RRRs did not indicate any significant influence of age,
+gender, location, BMI, and physical activity on the efficacy of
+YLP (Pinteraction>0.05) (Table 2). However, there were trends in
+differences in RRRs by baseline BMI, location, and physical
+activity levels. A trend for a decrease in RRRs across increasing
+levels of physical activity was observed. Participants with no
+baseline physical activity had the strongest RRR as compared to
+TABLE 1 | Baseline data for trial participants.
+Characteristics
+Overall (n = 4450)
+YLP (n = 2316)
+Control (n = 2134)
+Test statistic
+Average cluster size, mean (SD)
+55.62 (14.09)
+57.90 (13.99)
+53.35 (13.99)
+t = 1.45
+Age years, mean (SD)
+48.58 (10.34)
+48.61 (10.61)
+48.55 (10.07)
+t = 0.22
+Gender, n (%)
+Female
+2670 (60.00)
+1414 (61.05)
+1256 (58.86)
+c2 = 2.23
+Male
+1780 (40.00)
+902 (38.95)
+878 (41.14)
+Location, n (%)
+Rural
+1916 (43.06)
+1013 (43.74)
+903 (42.31)
+c2 = 0.92
+Urban
+2534 (56.94)
+1303 (56.26)
+1231 (57.68)
+BMI, kg/m2 n (%)
+26.57 (4.55)
+26.62 (4.22)
+26.52 (4.87)
+t = 0.58
+≤23
+3370 (75.73)
+1737 (75.00)
+1633 (76.52)
+c2 = 1.42
+>23
+1080 (24.27)
+579 (25.00)
+501 (23.48)
+Physical activity, n (%)
+c2 = 4.89
+No activity
+1534 (34.52)
+763 (33.03)
+771 (36.15)
+Mild
+1152 (25.92)
+615 (26.61)
+537 (25.17)
+Moderate
+879 (19.78)
+469 (20.29)
+410 (19.22)
+Vigorous
+879 (19.78)
+464 (20.08)
+415 (19.46)
+HbA1c%, mean (SD)
+5.97 (0.23)
+5.96 (0.23)
+5.97 (0.22)
+t = 0.377
+Continuous variables are represented as means (SD), and categorical variables are represented as number (%); t = independent samples t-test statistic, and c2 = Chi-Square test statistic.
+YLP, yoga-based lifestyle protocol; BMI, Body mass index. None of the p-values were significant (<0.05). Self-reported recalls on weekly engagement of physical activity were grouped into
+different levels; at least 150 minutes of moderate-intensity physical activity, or 75 minutes of vigorous-intensity physical activity or mild activity including bicycling/walking.
+Raghuram et al.
+Yoga and Prediabetes
+Frontiers in Endocrinology | www.frontiersin.org
+June 2021 | Volume 12 | Article 664657
+6
+those with mild, moderate, and vigorous activity levels. Similarly,
+RRRs were stronger among overweight/obese (BMI, kg/m2>23)
+and rural participants than their counter subgroups. RRRs were
+also computed with additional adjustment of post-BMI levels,
+however, differences could not be established for the values of
+RRR, 63.95; 95% CI, 56.96–69.81.
+Secondary Outcome: Conversion From
+Prediabetes to Normoglycemia
+At 3 months of follow-up, the YLP was observed to enhance the
+rate of conversion from prediabetes to normoglycemia (52.80%
+in intervention vs. 59.47% in the control group, P = 0.005). YLP
+TABLE 2 | Effect of the YLP on the diabetes prevention at 3-month follow-up.
+Imputed data-based analyses
+Subgroups
+Conversion from prediabetes to
+diabetes, number of events, n (%)
+Test
+statistic
+(c2)
+Unadjusted RRR
+(95% CI)
+RRR-adjusted
+for covariates (95% CI)
+Cluster-adjusted
+RRR (95% CI)
+Pinteraction
+YLP
+(n = 2316)
+Control (n = 2134)
+Overall, n = 4450
+266 (11.48)
+669 (32.01)
+264.09
+63.36 (58.31–67.81)
+64.19 (57.22–64.19)
+63.81 (56.55–69.85)
+#64.24 (58.09–69.49)
+# 63.95 (56.96–69.81)
+≤40 years
+58 (9.45)
+143 (26.48)
+57.97
+64.33 (52.69–73.10)
+64.47 (56.01–71.30)
+64.76 (50.70–74.82)
+0.99
+>40years
+208 (12.22)
+526 (32.99)
+205.29
+62.97 (57.17–67.97)
+62.92 (44.13–75.39)
+64.64 (57.71–70.44)
+Gender
+Male
+87 (9.64)
+260 (29.61)
+113.03
+58.92 (41.94–70.94)
+59.99 (46.03–70.33)
+61.10 (49.35–70.12)
+0.80
+Female
+208 (14.71)
+526 (41.88)
+153.46
+64.59 (53.85–72.84)
+66.01 (57.46–72.84)
+62.40 (46.19–73.73)
+Location
+Rural
+108 (10.66)
+301 (33.33)
+146.16
+69.29 (60.49–76.13)
+68.40 (60.06–75.00)
+62.04 (36.73–77.22)
+0.62
+Urban
+158 (12.13)
+368 (29.90)
+121.50
+41.03 (11.10–60.88)
+54.78 (39.03–66.46)
+55.71 (42.65–65.80)
+BMI, kg/m2
+≤23
+198 (11.40)
+505 (30.93)
+194.38
+63.19 (57.18–68.27)
+64.47 (56.01–71.30)
+59.08 (40.58–71.82)
+0.72
+>23
+68 (11.74)
+164 (32.73)
+70.16
+64.12 (53.65–72.53)
+63.21 (73.48–48.97)
+63.53 (49.95–73.43)
+Physical activity
+No
+95 (12.45)
+246 (31.91)
+83.70
+64.49 (49.40–75.08)
+66.47 (53.98–75.57)
+66.66 (56.56–74.41)
+Mild
+70 (11.38)
+161 (29.98)
+62.49
+69.02 (55.88–78.24)
+66.55 (49.73–77.75)
+64.58 (51.45–74.16)
+0.73
+Moderate
+46 (9.81)
+137 (33.41)
+74.43
+53.02 (27.90–69.40)
+53.66 (30.05–69.31)
+45.22 (4.02–71.16)
+0.89
+Vigorous
+55 (11.85)
+125 (30.12)
+45.10
+60.73 (47.61–70.56)
+66.55 (49.73–77.75)
+46.66 (33.85–78.07)
+0.99
+Complete case records analyses
+Subgroups
+Conversion from prediabetes to
+diabetes, number of events, n (%)
+Test
+statistic
+(c2)
+Unadjusted RRR (95% CI)
+RRR-adjusted
+for covariates (95% CI)
+Cluster-adjusted
+RRR (95% CI)
+Pinteraction
+YLP
+(n = 1712)
+Control (n = 1668)
+Overall, n = 3380
+192 (11.21)
+534 (32.01)
+216.65
+64.97 (59.28–64.97)
+63.03 (54.45–69.99)
+63.20 (54.79–70.04)
+62.98 (54.38–69.96)
+#63.16 (54.74–70.02)
+Age, years
+64.62 (57.70-70.42)
+≤40 years
+40 (8.26)
+120 (26.67)
+55.63
+69.01 (56.72–69.01)
+64.78 (44.57–77.62)
+66.79 (48.81–78.46)
+0.90
+>40 years
+152 (12.38)
+414 (33.99)
+160.59
+63.58 (56.92–63.58)
+62.13 (51.97–70.15)
+62.31 (52.22–70.26)
+Gender
+Male
+68 (10.00)
+210 (30.30)
+86.82
+66.86 (57.35–66.86)
+58.92 (41.94–70.94)
+59.75 (43.28–71.44)
+0.90
+Female
+124 (12.01)
+324 (33.33)
+131.05
+63.95 (56.52–63.95)
+64.59 (53.85–72.84)
+64.89 (54.39–72.97)
+Location
+Rural
+40 (8.06)
+282 (33.73)
+146.16
+75.98 (67.18–75.98)
+69.29 (60.49–76.13)
+69.48 (60.78–76.24)
+0.36
+Urban
+152 (12.50)
+252 (30.0)
+121.50
+58.93 (50.79–58.93)
+52.38 (46.42–57.68)
+44.30 (17.19–62.53)
+BMI, kg/m2
+≤23
+109 (.27)
+410 (31.67)
+130.16
+64.40 (56.77–64.40)
+62.59 (49.83–72.11)
+63.07 (53.12–70.90)
+0.90
+>23
+35 (11.59)
+124 (33.24)
+43.46
+65.14 (50.87–65.14)
+64.00 (44.00–76.86)
+64.35 (45.37–76.74)
+Physical activity
+No
+62 (11.78)
+228 (32.29)
+70.43
+63.50 (52.80–63.50)
+64.49 (49.40–75.08)
+64.82 (50.04–75.23)
+Mild
+63 (11.75)`
+157 (30.13)
+54.16
+61.00 (49.10–61.00)
+69.02 (55.88–78.24)
+69.14 (56.11–78.31)
+0.89
+Moderate
+39 (10.10)
+127 (34.14)
+64.00
+70.41 (58.86–70.41)
+53.02 (27.90–69.40)
+54.04 (29.73–69.94)
+0.85
+Vigorous
+28 (10.61)
+22 (31.88)
+19.41
+66.74 (45.62–66.74)
+46.95 (23.50–77.21)
+49.61 (17.19–78.33)
+0.86
+The Chi-Square test was used to calculate c2 values, and t-values were derived from independent samples t-test result. Relative risk reduction (RRR) was calculated by mixed-effects
+logistic regression models. Models were adjusted for all the covariates age, gender, location, baseline BMI levels, and physical activity levels except for the categorizing variables. Clusters
+were entered as random effects and the RRRs were separately presented under sensitivity analyses. Interaction between YLP and subgroups was calculated as per the statistical notes
+reported by Altman and Bland, 2003, results are mentioned in terms of Pinteraction Assessments were also done on the imputed datasets generated by conducting 50 iterations under
+intention-to-treat basis. #RRRs were additionally adjusted for post-BMI levels.
+Raghuram et al.
+Yoga and Prediabetes
+Frontiers in Endocrinology | www.frontiersin.org
+June 2021 | Volume 12 | Article 664657
+7
+was associated with ~1.2-fold significantly higher chances of
+conversion to normoglycemia [OR = 1.20 (95% CI 1.05–1.50)]
+(Table 3) as compared to the control group. When stratified by
+age, the conversion to normoglycemia after YLP was significantly
+better in the younger age group (≤40 years) than those above 40
+years, with OR = 2.17(95% CI 1.53–3.07) and OR = 1.04(95% CI
+0.84–1.29), respectively) (Table 3). When stratified by gender,
+and BMI, the OR s for conversion to normoglycemia were only
+significant in females and overweight/obese subjects (BMI>23
+Kg/m2), however, Pinteractions were not significant.
+Adverse Effects
+There were no major adverse events or mortality during these 3
+months of follow−up. However, some participants reported mild
+pain in the lumbar or dorsal region during the yoga classes which
+was relieved by the end of the core practice session after
+practicing corrective posture (pavanamuktasana, lumbar
+stretch for back pain), deep relaxation in supine posture,
+pranayama (nadisuddhi and bhramari) and meditation.
+DISCUSSION
+The NMB-trial provides strong evidence towards the
+effectiveness of YLP in reducing the incidence of type 2
+diabetes in high-risk individuals (RRR = 63.81%) compared to
+the control group. The primary aim of the NMB-trial was to
+provide a piece of preliminary evidence on the efficacy of YLP in
+harnessing the progression of diabetes and using a rapid study
+design in community settings of India, the second diabetes
+capital across the globe. Among the previous reported lifestyle-
+based diabetes prevention trials, a varied range of RRRs have
+been reported; 28.5% in the Indian Diabetes Prevention
+Programme-IDPP with 3 years follow-up (8); 32% in Diabetes
+Community Lifestyle Improvement Program (D-CLIP) with 3
+years follow-up (10); 42% in Da Qing IGT and Diabetes Study
+with 6 years follow-up (5), 58% in the Finnish Diabetes
+Prevention Study (DPS)with 3 years follow-up (6); and 67.4%
+in the Japanese lifestyle intervention trial, with 6 years follow-up
+on IGT males (7). These longitudinal trials incorporated various
+combinations of physical activity and diet-control regimes aimed
+at reducing the incidence of diabetes (5–10). The variances in the
+reported RRR values could be ascribed to various reasons such as
+the inclusion criteria of prediabetes populations, the varying
+baseline risk of the study cohorts based on their demography,
+duration of follow-ups, and genetic variability in responsivity to
+lifestyle-based interventions (4–10, 39–41). The RRR of the
+present short-term 3 months NMB-trial (63.81%) is at par
+with those of the lengthy and large-scale lifestyle modification-
+based trials (28.5–67.4%) (9) Mechanistically, yoga-based
+interventions have been reported to harmonize metabolism via
+reducing the negative influence of stress and dampening the
+reactivity and activation of the HPA axis and the
+sympathoadrenal system (19, 20). The high efficacy of YLP
+could be attributed to these reported harmonizing aspects of
+Yoga on physiology and neuroendocrine system and increased
+insulin sensitivity at target tissues (19, 20, 42). Body composition
+and genetic variations have also been reported to affect the
+response to lifestyle-based interventions (40, 41). The strong
+results could be influenced by the high responsivity of Asian
+Indians to yoga-based interventions (17, 40, 41), plausibly
+underlined by their genetic makeup and the highly enriched
+risk profile of the study cohort (IDRS score>60). We speculate
+that self-regulation, one of the behavioral components of yoga,
+TABLE 3 | Generalized linear mixed model analyses for conversion from prediabetes to normoglycemia in the YLP and the control groups at 3 months of follow-up.
+Conversion to normoglycemia
+Logistic regression
+Pinteraction
+YLP
+Control
+Test statistic (c2)
+Adjusted Odd’s Ratio (95% CI)
+p-value
+Overall, n (%)
+904 (55.55)
+630 (59.47)
+4.09*
+1.20 (1.02–1.43)
+0.030
+#1.21 (1.02–1.44)
+0.029
+Age
+Age ≤40 years, n (%)
+264 (54.54)
+138 (30.67)
+23.60*
+2.17 (1.53–3.07)
+<0.001
+<0.001
+Age>40 years, n (%)
+640 (52.11)
+492 (40.39)
+0.56
+1.04 (0.84–1.29)
+0.69
+Gender
+Females, n (%)
+520 (57.27)
+342 (52.78)
+3.09*
+1.32 (1.05–1.67)
+0.018
+0.319
+Males, n (%)
+384 (62.74)
+288 (59.26)
+1.39
+1.13 (0.85–1.51)
+0.386
+Area
+Rural, n (%)
+228 (50.00)
+360 (64.52)
+21.70**
+1.57 (1.19–2.07)
+<0.001
+0.063
+Urban, n (%)
+676 (63.52)
+270 (46.87)
+42.49**
+2.08 (1.65–2.62)
+<0.001
+BMI
+≤23 kg/m2, n (%)
+510 (59.44)
+505 (57.06)
+1.03
+1.14 (0.93–1.40)
+0.196
+0.251
+>23 kg/m2, n (%)
+158 (59.18)
+125 (50.20)
+4.19*
+1.72 (1.17–2.53)
+0.002
+Physical activity
+No (n = 942)
+904 (59.47)
+630 (55.55)
+0.70
+1.13 (0.85–1.50)
+0.410
+Mild (n = 837)
+285 (60.25)
+206 (56.59)
+1.14
+1.19 (0.88–1.61)
+0.256
+0.95
+Moderate (n = 592)
+206 (59.36)
+138 (56.32)
+0.54
+1.32 (0.93–1.89)
+0.123
+0.86
+Vigorous (n = 283)
+150 (63.56)
+28 (59.57)
+0.27
+1.20 (0.16–9.04)
+0.859
+0.99
+Pearson’s chi-square test, *p < 0.05, **p < 0.001 Odd’s ratio calculated by logistic regression, Models used clusters as random effects and were adjusted for all the covariates age, gender,
+location, baseline BMI levels and physical activity levels except for the categorizing variables. Pinteraction values were calculated as per the statistical notes reported by Altman and Bland,
+2003; #additionally adjusted for post BMI levels.
+Raghuram et al.
+Yoga and Prediabetes
+Frontiers in Endocrinology | www.frontiersin.org
+June 2021 | Volume 12 | Article 664657
+8
+defined as a conscious ability to maintain the stability of the
+physiological system by managing or altering adverse
+physiological or psychological states (15, 16), could have also
+contributed significantly towards the achievement of the
+observed substantial glycemic control.
+We observed alarmingly high prediabetes to the diabetes
+conversion rate of ~30% in the control group. Though the
+observed rate of diabetes incidence accords with the accelerated
+pace of diabetes conversion in Indians as compared to other
+ethnicities, it is substantially higher as compared to the reported
+annual estimates of diabetes incidence in the Indian population
+(2.9–13.4%) (23, 43, 44). Incidence rates of diabetes have been
+reported to be influenced by the population characteristics and the
+definition used to define diabetes and prediabetes (2). The NMB-
+trial design used a “high IDRS filter” to select the cohort with a high
+baseline risk profile, with the combined presence of age, waist
+circumference, physical inactivity, and family history of type 2
+diabetes. When compared with non-respondents, a higher
+proportion of study participants were found to be sedentary
+(34.50 vs. 9.10%), this probably indicates motivated participation
+of subjects with an increased awareness of their unhealthy lifestyle
+and poor health in the YLP (45) that could have further led to
+significant efficacy of the trial. Approximately 20% of the eligible
+individuals declined to participate or could not respond to the study.
+This selective inclusion of the individuals with a pre-existing
+inclination for yoga-based practices could have biased the study
+outcome. Moreover, the diagnosis of diabetes and prediabetes in the
+present study are derived from HbA1c values unlike most of the
+reports on diabetes incidence [derived from fasting blood glucose or
+Oral glucose tolerance tests] (6–10).
+Targeted reduction in obesity appears to take center stage
+when it comes to lifestyle modification delaying the onset of
+diabetes (46). However, we observed an equivalent propensity of
+conversion from prediabetes to diabetes in the normal weight
+and overweight/obese control group subjects. These findings
+could be explained by the peculiar Indian phenotype, wherein
+even lean individuals with low BMI are also at high risk of
+metabolic disorders (46, 47). Interestingly, we observed an
+overall high efficacy of YLP for diabetes prevention irrespective
+of baseline BMI and RRR for diabetes reduction was also not
+found to be influenced by BMI changes. This finding could be an
+important aspect of the generalisability of the YLP across
+different community and population settings.
+Regression from prediabetes to normoglycemia is associated
+with a lower prevalence of diabetes-associated complications,
+ascribed to reduced glycemic exposure (48). Varying efficacies of
+lifestyle and pharmacological interventions have been documented
+for regression to normoglycemia, ranging from 23% conversion rate
+in the DPP trial to 55–80% in England-based study with 10-years of
+follow-up (49, 50). In the present study, YLP was found to
+significantly accelerate the regression to normoglycemia OR of
+1.20. At the end of 3 months, half of the intervention cohort
+(52.8%) was found to revert to normoglycemia as compared to
+37.8% of the control group. The observed findings support the
+notion that yoga cultivates resilience by providing the ability to
+“bounce back” and adapt in response to adverse physiological states,
+such as impaired glycemic control (16).
+When stratified by baseline age, the beneficial effect of YLP
+towards reversion to normoglycemia was observed to be higher
+in the younger cohort. Young adults exhibit a more complex and
+aggressive pathophysiology of diabetes, poorer response to
+glucose-lowering medications, and a higher overall risk of
+lifetime complications (51). Hence, this differential age-specific
+modality of YLP could bear significant relevance from the Indian
+perspective, based on the high diabetes susceptibility of this
+population at a younger age (23).
+The study findings favor the utility of HbA1c based outcomes for
+short-term intervention effects of 3 months. The results stand against
+the current clinical practice belief that negates the utility of repeated
+HbA1c tests within two or three months to address the influence of
+interventions (52). Hirst et al. have even reported a shorter duration
+of the 8-week interval to be effective for demonstrating medication-
+induced changes in HbA1c levels. Authors have further
+recommended the need to conduct randomized trials to test an 8-
+week testing interval compared with usual care in people with
+uncontrolled diabetes (52, 53).
+Diabetes is a long-term disease with a prior reported annual
+incidence of 11.1% in the Indian population (9). The study is limited
+by the very short duration model of intervention and follow up
+assessments for diabetes incidence as compared to the prior reports
+on lifestyle-based diabetes prevention. The findings need rigorous
+long-term evaluation before clinical translation. The trial is further
+limited by its cluster-randomized trial design with methodological
+issues of selection bias for participant recruitment (54). The
+observed follow-up rate of 76% for diabetes a long-term disease,
+necessitates further investigation on attrition in long-term follow-
+ups. The comparatively higher loss to follow up in the YLP group
+requires additional research to determine how adherence could be
+further enhanced in the YLP group. Sensitivity analyses were done
+using multiple imputations, which lead to almost similar results to
+those in the complete case analyses leading to no major changes in
+the interpretation of the study findings.
+In conclusion, this first nationwide multicenter randomized
+controlled trial shows that lifestyle change, through a yoga
+lifestyle protocol that included ethical precepts, asanas,
+pranayama, meditation, and diet is an effective method for
+preventing or delaying diabetes in adults with prediabetes. The
+observed findings also indicate a potential of YLP for low/
+moderate risk profile for diabetes that needs large-scale
+validation. Collectively, these findings highlight the pressing
+need for continuing the implementation of the YLP to
+effectively halt the progression of the diabetes epidemic.
+However, further research is needed to evaluate the sustenance
+of the effects of the intervention in longer follow-ups.
+DATA AVAILABILITY STATEMENT
+The raw data supporting the conclusions of this article will be
+made available by the authors, without undue reservation.
+Raghuram et al.
+Yoga and Prediabetes
+Frontiers in Endocrinology | www.frontiersin.org
+June 2021 | Volume 12 | Article 664657
+9
+ETHICS STATEMENT
+The studies involving human participants were reviewed and
+approved by Ethics Committee of the Indian Yoga Association
+(ID: RES/IEC-IYA/001). The patients/participants provided
+their written informed consent to participate in this study.
+AUTHOR CONTRIBUTIONS
+NR is the primary investigator, contributed to the study design,
+acquisition, analysis, and drafting of the manuscript. NR takes
+the responsibility for the integrity of the data. HN conceptualized
+the study, monitored its execution and drafting of the
+manuscript. VR reviewed the article. VM drafted and revised
+the manuscript. AS, AA, and RS contributed to research design,
+data collection and revision of final draft. IJ, SP, and JB
+conducted the statistical analyses and interpreted the data. SB
+was responsible for acquisition of data. All authors contributed
+to the article and approved the submitted version.
+FUNDING
+This work was funded by the Ministry of Health and Family
+Welfare and Ministry of AYUSH [Govt. of India, New Delhi],
+grant number [16-63/2016-17/CCRYN/RES/Y&D/MCT].
+ACKNOWLEDGMENTS
+Major field support was provided by the volunteers of the
+member institutions of Indian yoga association, India.
+SUPPLEMENTARY MATERIAL
+The Supplementary Material for this article can be found online at:
+https://www.frontiersin.org/articles/10.3389/fendo.2021.664657/
+full#supplementary-material
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+Conflict of Interest: The authors declare that the research was conducted in the
+absence of any commercial or financial relationships that could be construed as a
+potential conflict of interest.
+Copyright © 2021 Raghuram, Ram, Majumdar, SK, Singh, Patil, Anand, Judu,
+Bhaskara, Basa and Nagendra. This is an open-access article distributed under the
+terms of the Creative Commons Attribution License (CC BY). The use, distribution or
+reproduction in other forums is permitted, provided the original author(s) and the
+copyright owner(s) are credited and that the original publication in this journal is
+cited, in accordance with accepted academic practice. No use, distribution or
+reproduction is permitted which does not comply with these terms.
+Raghuram et al.
+Yoga and Prediabetes
+Frontiers in Endocrinology | www.frontiersin.org
+June 2021 | Volume 12 | Article 664657
+11

subfolder_0/Effects of Yoga and an Ayurveda preparation on gait, balance and mobility in older persons.txt

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+PERSONAL USE
+ONLY
+Effects of Yoga and an Ayurveda preparation on gait, balance 
+ 
+and mobility in older persons
+Comment to: 
+Effect of combined Taiji and Qigong training on balance mecha-
+nisms: A randomized controlled trial of older adults
+Yang Yang, Jay V. Verkuilen, Karl S. Rosengren, Scott A. Grubisich, 
+Michael R. Reed, Elizabeth T. Hsiao-Wecksler
+Med Sci Monit, 2007; 13(8): CR339-348
+Dear Editor,
+Six months of a combination of Taiji and Qigong training im-
+proved the balance in 33 healthy older adults compared to 
+16 others in a wait-list control group [1]. While evaluating 
+the changes in sensory and biomechanical balance mechani-
+sms, it was inferred that Taiji-Qigong improves balance thro-
+ugh better vestibular inputs and wider stance.
+Yoga is another Oriental practice which was shown to im-
+prove the hip extension, increase the stride length and de-
+crease anterior pelvic tilt, hence improving the gait in ol-
+der adults [2].
+The present randomized controlled trial evaluated the in-
+fl
+ uence of (i) Yoga and (ii) a poly-herbal Ayurveda prepa-
+ration on measures of gait, balance and mobility in older 
+people staying in a home. Sixty-nine older persons were stra-
+tifi
+ ed based on age (5 year intervals from 60 to 95 years) and 
+gender. They were randomly allocated to three groups i.e., 
+Yoga, Ayurveda and a Wait-list control group. There were 23 
+subjects in each group (with seven males in the Yoga group 
+and six males each in Ayurveda and Wait-list control gro-
+ups) with average ages (±S.D.) of 70.1±8.3 years, 72.1±9.0 
+years and 72.3±7.4 years, respectively.
+All three groups were assessed at baseline and after six mon-
+ths for (i) gait and balance using the Tinetti balance and gait 
+evaluation test [3] and (ii) mobility using the timed up and 
+go (TUG) test [4]. The Tinetti test has different maneuvers 
+related to balance (9 items) and gait (7 items). The test was 
+scored using a three point ordinal scale. A score of 0 repre-
+sented maximum impairment, while a score of 2 represented 
+none. A score for gait and another score for balance was ob-
+tained for each person. For the TUG test participants sat in 
+a chair placed 3 m from a wall. They were instructed to rise 
+from the chair, walk at their normal pace to the wall, turn 
+around, return to the chair, and sit down. This task was ti-
+med and the number of steps taken was noted. Lower sco-
+res indicated higher levels of functioning.
+The yoga session was for 75 minutes daily, for 6 days a week. 
+It included loosening exercises (sithilikarana vyama, 5 mi-
+nutes), breathing exercises (10 minutes), physical postu-
+res (asanas, 20 minutes), voluntarily regulated breathing 
+(pranayama, 10 minutes), yoga-based guided relaxation (15 
+minutes) and devotional songs (bhajans, 15 minutes). This 
+is an integrated approach of yoga, derived from principles 
+in ancient yoga texts which described yoga as promoting 
+health at all levels [5].
+The Ayurveda group received a poly-herbal preparation 
+(Rasayana Kalpa [i.e., a ‘rejuvenating tonic’] in Sanskrit) 
+which was not specifi
+ cally targeted at improving balance. 
+The dose was 10g twice a day [6]. It contained the follo-
+wing herbs (the Sanskrit names are given in parenthesis): 
+Withania Somnifera (ashwagandha roots, 2 g), Phyllanthus 
+Emblica (amalaki, 1 g), Sida Cordifolia (bala, 0.25 g), Terminalia 
+Arjuna (arjuna, 0.25 g) and Piper Longum (pippali, 0.5 g). 
+The other contents were: sugar (4 g), honey (2 g), water 
+and clarifi
+ ed butter (ghee) in the amount required to get 
+the correct semi-solid consistency.
+The wait-list control group continued with their normal ro-
+utine which included reading, watching television, playing 
+indoor games and talking to friends.
+The data were analyzed using a repeated measures analy-
+sis of variance (ANOVA) followed by post-hoc analyses with 
+Bonferroni adjustment. All three groups had comparable 
+baseline values with respect to measures of gait and balance 
+as well as mobility. At the end of six months, the Yoga group 
+(n=18 at follow-up) showed a signifi
+ cant increase in the ove-
+rall scores for gait (p <0.001) and balance (p<0.01), while the 
+Ayurveda (n=12 at follow-up) and Wait-list control (n=20 at 
+follow-up) groups showed no signifi
+ cant change (p>0.05). 
+For the TUG test both Yoga and Ayurveda groups showed 
+a signifi
+ cant decrease in the number of steps taken to com-
+plete the test (p<0.001 and p<0.01, respectively).
+Normal gait and balance depends on several factors including 
+free joint mobility, appropriate timing and intensity of musc-
+le action as well as normal sensory input [7]. Yoga practice 
+improved the joint mobility in rheumatoid arthritis patients 
+[8]. In persons with normal health there was an improvement 
+LE19
+Letter to Editor
+WWW.MEDSCIMONIT.COM
+LE19
+LE
+Current Contents/Clinical Medicine • IF(2006)=1.595 • Index Medicus/MEDLINE • EMBASE/Excerpta Medica • Chemical Abstracts • Index Copernicus
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+opy is for personal use only - distribution prohibited.     This copy is for personal use only - distribution prohibited.     This copy is for personal use only - distribution prohibited.     This copy is for personal use only - distribution prohibited.     This copy is for personal use only - distribu
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+ONLY
+in the muscle strength [9], visual perceptual sensitivity [10] 
+and the ability to balance on a stabilometer [11].
+The changes in the present study may be attributed to the 
+benefi
+ cial effects of yoga mentioned above, while the chan-
+ges in the Ayurveda group could be related to improved 
+muscle strength and better sensory perception as hypothe-
+sized in traditional Ayurveda texts [6].
+Sincerely,
+Manjunath N.K1, Shirley Telles2,
+1 Swami Vivekananda Yoga Research Foundation, No. 19,
+K.G. Nagar, Bangalore 560 019, India,
+2 Patanjali Yogpeeth, Maharishi Dayanand Gram,
+Bahadrabad, Haridwar, Uttarakhand 249402, India,
+e-mail: [email protected]
+REFERENCES:
+ 1. Yang Y, Verkuilen JV, Rosengren KS et al: Effect of combined Taiji and 
+Qigong training on balance mechanisms: a randomized controlled trial 
+of older adults. Med Sci Monit, 2007; 13(8): CR339–48
+ 2. DiBenedetto M, Innes KE, Taylor AG et al: Effect of a gentle Iyengar 
+yoga program on gait in the elderly: an exploratory study. Arch Phys 
+Med Rehabil, 2005; 86(9): 1830–37
+ 3. Tinetti ME: Assessment of mobility. Am J Ger Soc, 1986; 34: 119–26
+ 4. Podsiadlo D, Richardson S: The timed “Up & Go“ A test of basic func-
+tional mobility for frail elderly persons. J Am Geriatr Soc, 1991; 39(2): 
+142–48
+ 5. Gambhirananda S: Taittiriya Upanishad. Calcutta: Advaita Ashrama, 
+1986
+ 6. Shastri P: Sharangadhara Samhita, Adhamalla teeka. Varanasi: Oriental 
+Publishers & Distributors, 1985
+ 7. Woollacott MH, Shumway-Cook A, Nashner L: Postural refl
+ exes and 
+aging. In: Mortimer J, Pirozzolo FJ, Maletta G, eds. The Aging Motor 
+System. New York: Praeger, 1982; 98–119
+ 8. Haslock I, Monro R, Nagarathna R et al: Measuring the effects of yoga 
+in rheumatoid arthritis. Br J Rheumatol, 1994; 33(8): 788
+ 9. Raghuraj P, Nagarathna R, Nagendra HR et al: Pranayama increases 
+grip strength without lateralized effects. Indian J Physiol Pharmacol, 
+1997; 41(2): 129–33
+ 10. Ramana Vani P, Nagarathna R, Nagendra HR et al: Progressive incre-
+ase in critical fl
+ icker fusion frequency following yoga training. Indian 
+J Physiol Pharmacol, 1997; 41(2): 71–74
+ 11. Dhume RR, Dhume RA: A comparative study of the driving effects of 
+dextroamphetamine and yogic meditation on muscle control for the 
+performance of balance on balance board. Indian J Physiol Pharmacol, 
+1991; 35(3): 191–94
+Received: 2007.11.13
+LE20
+Electronic PDF security powered by IndexCopernicus.com
+opy is for personal use only - distribution prohibited.     This copy is for personal use only - distribution prohibited.     This copy is for personal use only - distribution prohibited.     This copy is for personal use only - distribution prohibited.     This copy is for personal use only - distribu
+PERSONAL USE
+ONLY
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subfolder_0/Effects of Yoga on Utero-Fetal-Placental Circulation in High-Risk Pregnancy A Randomized Controlled Trial.txt

@@ -0,0 +1,1181 @@
+Research Article
+Effects of Yoga on Utero-Fetal-Placental Circulation in
+High-Risk Pregnancy: A Randomized Controlled Trial
+Abbas Rakhshani,1 Raghuram Nagarathna,1 Rita Mhaskar,2 Arun Mhaskar,2
+Annamma Thomas,2 and Sulochana Gunasheela3
+1SVYASA University, 19 Eknath Bhavan, Gavipuram Circle, KG Nagar, Bangalore 560 019, India
+2St. John’s Medical College and Hospital, Sarjapur Road, Bangalore 560 034, India
+3Gunasheela Surgical & Maternity Hospital, Building No. 1/2, Dewan Madhava Rao Road, Basavanagudi,
+Bangalore, Karnataka 560004, India
+Correspondence should be addressed to Abbas Rakhshani; [email protected]
+Received 1 July 2014; Revised 22 December 2014; Accepted 23 December 2014
+Academic Editor: Masaru Shimada
+Copyright © 2015 Abbas Rakhshani et al. This is an open access article distributed under the Creative Commons Attribution
+License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
+cited.
+Introduction. Impaired placentation and inadequate trophoblast invasion have been associated with the etiology of many pregnancy
+complications and have been correlated with the first trimester uterine artery resistance. Previous studies have shown the benefits
+of yoga in improving pregnancy outcomes and those of yogic visualization in revitalizing the human tissues. Methods. 59 high-risk
+pregnant women were randomized into yoga (n = 27) and control (n = 32) groups. The yoga group received standard care plus yoga
+sessions (1 hour/day, 3 times/week), from 12th to 28th week of gestation. The control group received standard care plus conventional
+antenatal exercises (walking). Measurements were assessed at 12th, 20th, and 28th weeks of gestation. Results. RM-ANOVA showed
+significantly higher values in the yoga group (28th week) for biparietal diameter (P = 0.001), head circumference (P = 0.002), femur
+length (P = 0.005), and estimated fetal weight (P = 0.019). The resistance index in the right uterine artery (P = 0.01), umbilical
+artery (P = 0.011), and fetal middle cerebral artery (P = 0.048) showed significantly lower impedance in the yoga group. Conclusion.
+The results of this first randomized study of yoga in high-risk pregnancy suggest that guided yogic practices and visualization can
+improve the intrauterine fetal growth and the utero-fetal-placental circulation.
+1. Introduction
+Impaired placentation and fetoplacental hypoxia have been
+associated with the etiology of a number of pregnancy
+complications [1]. Proper placentation involves extensive
+vascular remodeling of the uteroplacental arteries, which play
+a major role in delivery of maternal blood to the intervillous
+space [2]. Failure of adequate trophoblast invasion to achieve
+this transformation of the spiral arteries has been associated
+with preeclampsia, preterm delivery, IUGR, and being small
+for gestational age [3, 4]. Conversely, it has been argued that
+improved uteroplacental and fetoplacental blood circulation
+could prevent these complications and also chronic diseases
+later in the life of the neonate [5]. The trophoblast invasion
+is completed by the 20th week of gestation [6]. It has been
+demonstrated that there is a close correlation between the first
+trimester uterine artery resistance and abnormal trophoblast
+invasion [6].
+The word “yoga” is derived from the Sanskrit verb yuj,
+which means union. This refers to the union of the individual
+consciousness with that of the Universal Divine Conscious-
+ness that can be achieved by a wide variety of practices
+that range from certain postures (yoga asanas), breathing
+exercises (pranayama), hand gestures (mudras), cleansing
+exercises (kriyas), relaxation, and meditation techniques.
+The latter two include a wide range of practices, including
+visualization, guided imagery, and sound resonance prac-
+tices. The rational for using these techniques requires a brief
+introduction on prana and its movements in the body.
+The rationale for using techniques requires a brief intro-
+duction on prana and its movement in the body. According
+to the yogic sciences, beyond the physical body is the more
+subtle, pranic body, where the prana flows, and the mental
+body, where our thoughts are processed [7]. The frequency
+of our thoughts in the mental body influences the flow of
+Hindawi Publishing Corporation
+Advances in Preventive Medicine
+Volume 2015, Article ID 373041, 10 pages
+http://dx.doi.org/10.1155/2015/373041
+2
+Advances in Preventive Medicine
+prana in the pranic body, which in turn affects our health [7].
+The idea of using visualization and guided imagery is to give
+order to our uncontrolled thoughts and in doing so regulate
+the flow of prana and improve the health of the physical
+organs. Consequently, it has been argued that visualization
+and guided imagery revitalize the tissues by activating the
+subtle energies (prana) within the body [8].
+Being over 5000 years old, the science of yoga has been
+shown to impact a variety of physical and psychological
+health conditions, including anxiety, depression, metabolic
+syndrome, cancer, and cardiovascular, musculoskeletal, and
+pulmonary disorders [9, 10]. Additionally, yoga has been
+shown to improve the outcomes in low-risk [11] and high-
+risk pregnancies [12]. A study to investigate the effect of
+yoga in high-risk pregnancy was planned (funded by the
+Department of AYUSH, Ministry of Health and Family
+Welfare, Government of India) and the results showed
+significantly fewer pregnancy induced hypertension (PIH),
+preeclampsia, gestational diabetes (GDM), and intrauterine
+growth restriction (IUGR) cases in the yoga group (𝑃=
+0.018, 0.042, 0.049, and 0.05, resp.) and significantly fewer
+small-for-gestational-age (SGA) babies and newborns with
+low APGAR scores (𝑃= 0.006) in the yoga group (𝑃= 0.033)
+[12]. Ultrasound measurements of the fetal development and
+utero-feto-placental blood flow were also included in the
+same study. The present paper reports the effect of yoga on
+these parameters with the hypothesis that the benefits in
+high-risk pregnancy are due to improved placental blood flow
+after yoga. However, the sample sizes for the outcome paper
+[12] are not consistent with those of the present paper due to
+a slightly higher attrition rate in the Doppler data.
+2. Methods
+2.1. Sample-Size Calculations. Using the event ratios (0.185
+in the experimental group and 0.506 in the control group)
+reported in a Japanese study, with 𝛼set at 0.05, probability of
+type I error at 0.01, powered at 0.8, a minimum sample size
+of 27 per group was obtained. As there were no published
+studies on yoga in high-risk pregnancies at the time of
+designing this study, we used the event ratios from the closest
+study by Kanako [13] on simple water exercises to prevent
+preeclampsia. We recruited a total of 93 subjects and the final
+analysis was made on 27 subjects in the yoga group and 32 in
+the control group.
+2.2. Design and Settings. This was a randomized controlled
+prospective stratified single-blind trial. “Single-blind” refers
+to the fact that gynecologists, obstetricians, radiologists, and
+laboratory staff were blinded to the group selection. The trial
+was conducted at the Obstetric Unit of St. John’s Medical
+College and Hospital (SJMCH) and Gunasheela Maternity
+Hospital (GMH) in Bengaluru, India.
+2.3. Selection Criteria
+Inclusion Criteria. Pregnant women within 12 weeks of
+gestation and with any of the following risk factors were con-
+sidered qualified for the study: (1) history of poor obstetrical
+outcomes (pregnancy induced hypertension, preeclampsia,
+eclampsia, and intrauterine growth restriction); (2) twin
+pregnancies; (3) extremes of age: maternal age below 20
+or above 35 years; (4) obesity: maternal body mass index
+of above 30; and/or (5) family history of poor obstetrical
+outcomes among blood relatives, that is, sister, mother, or
+grandmother. Groups were stratified at recruitment based on
+risk factors and the numbers were equal for each risk factor.
+However missing data during the study did not permit us to
+keep the groups matched for the analysis. Exclusion criteria:
+(1) Severe renal, hepatic, gallbladder, or heart disease; (2)
+structural abnormalities in the reproductive system; (3)
+hereditary anemia; (4) seizure disorders; (5) sexually trans-
+mitted diseases, or (6) any medical conditions that prevented
+the subject from safely and effectively practicing the inter-
+ventions. While we did not exclude women with diabetes or
+essential hypertension, none of the participants enrolled in
+the study were ever diagnosed with these conditions prior to
+this pregnancy.
+2.4. Recruitment and Randomization. Subjects within the
+12th week of gestation were approached by a research staff
+at the reception of the Obstetrics Department of SJMCH
+or GMH and introduced to the project. Those who were
+interested were escorted by a staff to an annex room
+in the outpatient department itself, where the study was
+explained in detail, and then were screened using a written
+protocol. Qualified subjects were given the opportunity to
+sign the informed consent form in order to complete the
+recruitment and begin the randomization process. We used
+an online random number generator by GraphPad Soft-
+ware (www.graphpad.com/quickcalcs/randomize1.cfm, last
+accessed on June 16, 2013) to randomize a set of numbers into
+two groups. The selections (yoga or control) were then written
+on paper slips and placed in opaque envelopes, sealed, num-
+bered, and kept in a locked cabinet. Recruited participants
+were assigned an ID and were permitted to pick one of the
+available envelopes to determine their group selection.
+2.5. Ethical Clearance and Informed Consent. The Ethical
+Committee of SJMCH provided clearance for this study and
+approved its informed consent form before its commence-
+ment. All participants were required to sign this consent form
+in order to enroll in the study.
+2.6. Interventions. The intervention set for each group was
+administered from the beginning of the 13th week to the
+end of the 28th week of gestation (a total of 28 sessions).
+The yoga group received standard care plus one-hour yoga
+session three times a week at the center and were instructed
+to practice the same routines at home. The control group
+received standard care plus walking for half an hour mornings
+and evenings (the routine antenatal exercise advised by the
+hospitals). The subjects in both groups were asked to keep
+a diary of their practices and daily physical activities, which
+was checked by the research staff during each of their visits
+to the antenatal department. The yoga classes were conducted
+by trained certified postgraduate yoga therapists, who used an
+instruction manual to conduct the classes at a reserved room
+Advances in Preventive Medicine
+3
+within the premises of SJMCH/GMH. Standard care offered
+to both groups included the following: (1) pamphlets about
+diet and nutrition during pregnancy, (2) regular checkups by
+the obstetrician, and (3) biweekly follow-ups by the research
+staff. The purpose of these biweekly telephone follow-ups was
+to check if the subjects were adhering to their intervention
+practices and routine hospital check-ups.
+The yoga intervention was selected very carefully from
+three categories: (1) yogic postures, (2) relaxation and breath-
+ing exercises, and (3) visualization with guided imagery. The
+yogic postures were chosen to reduce the physical side effects
+of pregnancy, such as edema, and strengthen the perineal
+muscles for delivery. The relaxation and breathing exercises
+were aimed at reducing the maternal stress. The visualization
+with guided imagery exercises were the backbone of this
+study and the rationale for their use is discussed in detail
+in Discussion. They were designed to test two hypotheses:
+(1) when attention moves in an area of the body, it causes
+the prana in that area also to move and (2) better movement
+of prana in an area of the body implies better circulation in
+that area. Table 1 outlines the exercises practiced by the yoga
+group.
+Due to the importance of these visualization and guided
+imagery practices in this study, a brief explanation of them
+is warranted. In the initial visualization and guided imagery
+session, the subjects were asked to focus their attention on
+the place between the nostrils and the upper lip where the
+air is felt during inhalation and exhalation. In the following
+visualization and guided imagery sessions, the subjects were
+asked to visualize the fetus in the uterus and the umbilical
+cord connecting the fetus to the placenta. Then the partici-
+pants were guided to visualize healthy blood flow from the
+mother’s heart into the placenta, through the umbilical cord,
+and bringing nourishment to the fetus.
+2.7. Data Analysis. For data analysis, PASW Statistics (for-
+merly known as SPSS) version 18.0.3 for Mac was used.
+Shapiro-Wilk’s test was used to test the normality of data.
+For Doppler and fetal parameters with three measurements
+in time, repeated measures ANOVA (RM-ANOVA) was
+performed. However, if the difference between the baseline
+data of the two groups was statistically significant (fetal heart
+rate parameter in this study), then ANCOVA test was used,
+while keeping the baseline data as covariate. When there were
+only two measurements in time, Independent Samples 𝑡-test
+was used for variables that followed a Gaussian distribution
+at baseline and Mann-Whitney nonparametric test for those
+that did not. Chi-Square test was used to test significance
+between groups when frequencies were used.
+3. Results
+3.1. Recruitment and Retention. The consort diagram is pre-
+sented in Figure 1. There was none with multiple risk factors
+among the recruited subjects.
+3.2. Socioeconomic and Demographic Data. A self-reported
+questionnaire was used to collect demographic data, which
+included the subjects’ age, weight, height, socioeconomics,
+education, and religion. The financial status of the subjects
+was measured in two ways: (1) subjectively, by recording the
+monthly household income (in Indian rupees) reported by
+the subjects, and (2) objectively, by having the subjects com-
+plete a socioeconomic status (SES) form, used by other Indian
+research groups at SJMCH, which scored the possessions and
+household features and produced a total score ranging from
+0 to 60. These demographic data are listed in Table 2. The
+majority of the subjects in both groups were between 20 and
+35 years of age (only 3 in each group were below 20 years and
+1 in the yoga group and 2 in the control group were above 35).
+3.3. Fetal Measurements. The ultrasound fetal measurements
+are shown in Table 3. The biparietal diameter, head circum-
+ference, femur length, heart rate, and estimated fetal weight
+showed highly significant improvements in the yoga group
+(<0.001, 0.002, 0.005, 0.006, and 0.019 𝑃values, resp.). As
+the baseline fetal heart rate (FHR) was significantly different
+(𝑃= 0.036) in the two groups, we used ANCOVA test keeping
+the baseline values as covariate, which showed significantly
+lower FHR in the yoga group after 8 weeks (𝑃= 0.012) and
+16 weeks (𝑃= 0.001) of intervention.
+3.4. Uteroplacental Circulation. Systolic over diastolic ratio
+(S/D ratio), pulsatility index (PI), resistance index (RI),
+and diastolic notch were measured in right and left uterine
+arteries at the 12th, 20th, and 2nd weeks of gestation. These
+results are listed in Table 4. In the right uterine artery, RI
+showed significantly less resistance in the yoga group (𝑃=
+0.01, RM-ANOVA) and near significance results for the PI
+(𝑃= 0.07, RM-ANOVA). In the left uterine artery, near
+significant result was obtained for RI (𝑃
+=
+0.08, RM-
+ANOVA) and PI (𝑃
+=
+0.08, RM-ANOVA). At baseline
+(12 weeks of gestation), the right uterine artery diastolic
+notch was detected in 22.6% of the subjects in the yoga
+group compared to 18.4% in the control group (𝑃= 0.67).
+In the left uterine artery, the percentages were 32.3% and
+21.1%, respectively (𝑃= 0.29). The number of cases with
+diastolic notch in the uterine arteries was reduced in both
+groups as the pregnancy progressed and the interventions
+were administered. There were much fewer cases in the yoga
+group compared to the control group, though the differences
+were not statistically significant.
+3.5. Fetoplacental Circulation. The S/D ratio, the PI, and the
+RI parameters of the umbilical and fetal middle cerebral
+arteries were assessed at the 20th and 28th weeks of gestation
+through ultrasound Doppler velocimetry. It was not possible
+to measure these parameters at the 12th week of gestation.
+All the parameters, except for the RI of the umbilical artery,
+which showed near significant results, were significantly
+improved in the yoga group at the 28th week of gestation. All
+the parameters for the umbilical artery were significantly bet-
+ter in the yoga group even at the 20th week of gestation. The
+results for the fetoplacental circulation are listed in Table 5.
+No cases with diastolic notch were detected in either group
+for umbilical artery or fetal middle cerebral artery.
+4
+Advances in Preventive Medicine
+Analysis
+Follow-up
+Allocation
+Enrollment
+Assessed for eligibility (n = 1938)
+Excluded (n = 2117)
+∙Not meeting inclusion criteria (n = 1568)
+∙Declined to participate (n = 272)
+∙Other reasons (n = 5)
+Analysed (n = 27)
+Allocated to intervention (n = 46)
+∙Received allocated intervention (n = 46)
+∙Did not receive allocated intervention (n = 0)
+Lost to follow-up (n = 15): 1 aborted, 3 moved
+Discontinued intervention (n = 0)
+Allocated to intervention (n = 47)
+∙Received allocated intervention (n = 47)
+∙Did not receive allocated intervention (n = 0)
+Analysed (n = 32)
+∙Excluded from analysis (n = 0)
+∙Excluded from analysis (n = 0)
+Randomized (n = 93)
+Lost to follow-up (n = 15): 6 moved away, 1
+Discontinued intervention (n = 4): did
+not adhere to the intervention schedule
+wrongly recruited, 1 was on bed rest, 4 lost interest,
+3
+did not show for measurements
+away, 11 did not show for measurements
+Figure 1: Consort diagram for trial profile.
+4. Discussion
+The arterial resistance index (RI) has been defined to be a
+measure of pulsatile blood flow that reflects the resistance
+to blood flow caused by microvascular bed distal to the site
+of measurement [15]. A resistive index of 0 corresponds to
+continuous flow; a resistive index of 1 corresponds to systolic
+but no diastolic flow; and a resistive index greater than 1
+corresponds to reversed diastolic flow. Pulsatility index (PI) is
+a measure of the variability of blood velocity in a vessel, equal
+to the difference between the peak systolic and minimum
+diastolic velocities divided by the mean velocity during the
+cardiac cycle [15]. In contrast, systolic/diastolic (S/D) ratio is a
+simple ratio of the two. High impedance in the uterine arteries
+at 20–24 weeks of gestation has been shown to be associated
+with up to 80% higher risk of developing early onset of
+preeclampsia [2]. There is also a correlation between RI and
+development of small-for-gestational-age fetuses [2]. Hence
+the resistance index (RI) was closely followed up in this study.
+This randomized control study on yoga-based visual-
+ization and relaxation in high-risk pregnancy has shown
+significantly better uteroplacental and fetoplacental blood
+flow velocity in the yoga group compared to the control
+group. The RI in the right uterine artery was significantly
+better in the yoga group (𝑃= 0.01), while it reached near
+significance (𝑃= 0.08) values for the left uterine artery. Also,
+the RI in the umbilical artery was significantly better in the
+study group after 8 weeks of intervention (the 20th week of
+measurement) and in the fetal MCA after 16 weeks (28th week
+of measurement) of interventions. Furthermore, significantly
+fewer occurrences of pregnancy induced hypertension (PIH),
+preeclampsia, gestational diabetes (GDM), and intrauterine
+growth restriction (IUGR) cases were observed in the yoga
+group (𝑃= 0.018, 0.042, 0.049, and 0.05, resp.) [12]. Sig-
+nificantly fewer small-for-gestational-age (SGA) babies were
+born in the study group (𝑃= 0.033) [12]. Also, APGAR scores
+within 1 and 5 minutes of delivery were significantly higher in
+the yoga group (𝑃= 0.006) [12]. As far as the fetal measure-
+ments are concerned, there were significant improvements in
+the biparietal diameter (𝑃< 0.001), the head circumference
+(𝑃= 0.002), the femur length (𝑃= 0.005), and the estimated
+fetal weight (𝑃= 0.019) in the yoga group.
+Interestingly, the umbilical RI was highly significant at the
+20th week of measurement (𝑃= 0.01) and not significant
+at the 28th week (𝑃= 0.091). The reading may have been
+influenced by the growing uterus. If so, the increase in MCA
+flow in the 28th week may indicate that the blood flow to the
+fetus was still improved in the yoga group although it did
+not show in the umbilical artery. This hypothesis is further
+supported by the fact that, in the yoga group, most fetal
+measurements were significantly improved and significantly
+fewer complications were observed.
+Advances in Preventive Medicine
+5
+Table 1: Yoga interventions.
+Practices1
+Duration
+Guided relaxation with visualization and imagery
+5 min.
+Hasta ¯
+ayama ´
+svasanam (hands in and out breathing)
+1 min.
+Hastavist¯
+ara ´
+svasanam (hands stretch breathing)
+2 min.
+Gulphavist¯
+ara ´
+svasanam (ankles stretch breathing with wall support)
+1 min.
+Kat
+.iparivartana ´
+svsanam (side twist breathing)
+1 min.
+Guided relaxation with visualization and imagery
+5 min.
+Utt¯
+anap¯
+ad¯
+asana ´
+svasanam (leg raise breathing)
+1 min.
+Setubandh¯
+asana ´
+svasanam (hip raise breathing)
+1 min.
+P¯
+adasa˜
+nc¯
+alanam (cycling in supine pose)
+1 min.
+Supta udar¯
+akars
+.an
+. asana ´
+svasanam (supine abdominal stretch breathing)
+1 min.
+Vy¯
+aghr¯
+asana ´
+svasanam (tiger stretch breathing)
+1 min.
+Guided relaxation with visualization and imagery
+5 min.
+Gulphag¯
+uran
+. am (ankle rotation)
+2 min.
+J¯
+anuphalak¯
+akars
+.an
+. am (kneecap contraction)
+1 min.
+Ardh¯
+atitali¯
+asana (half butterfly exercise)
+3 min.
+Poorn¯
+atitali¯
+asana (full butterfly exercise)
+1 min.
+Guided relaxation with visualization and imagery
+5 min.
+Jyotitr¯
+at
+.aka (eye exercises)
+2 min.
+N¯
+ad
+.¯
+ı´
+suddhi pranayam (alternate nostrils breathing)
+2 min.
+Deep relaxation in matsyakr¯
+ıd
+. ¯
+asana (lateral shavasana)
+10 min.
+1Except for the visualization and guided imagery, all the practices are part of the book [14].
+Use of complementary and alternative (CAM) therapies
+during pregnancy has been on the rise globally [16]. Yoga,
+due to its ability to lower blood pressure and stress, has been
+particularly popular [17, 18]. This is important because phar-
+macological solution for hypertension related complications
+of pregnancy has shown limited effectiveness in reducing
+the uterine artery resistance to blood flow [19]. In spite of
+these findings, clinical research in pregnancy involving CAM
+therapies are still very few and in between. We were able
+to find only one Doppler study using yoga interventions,
+which also reported fewer complications of pregnancy and
+significantly higher birth weight in the yoga group (𝑃<
+0.018). However, this study was not randomized and did not
+report any data on the resistance indices. We could not find
+any published Doppler study involving tai chi or qi gong in
+pregnancy. But use of exercise in pregnancy has been widely
+studied and the overall results support moderate-to-vigorous
+intensity exercises during pregnancy [20]. Furthermore, it has
+been shown that exercise in the second half of pregnancy
+appears to cause a transient increase in the maternal uterine
+artery pulsatility index without causing any harmful effects
+on maternal uterine blood flow [21].
+Antiplatelet agents, primarily low-dose aspirin [22], and
+calcium supplementation [23] have been shown to reduce the
+risk of adverse pregnancy outcomes; however their impact
+on the uterine artery blood flow is not very clear. Other
+supplementation, such as the amino acid L-arginine, has been
+shown to significantly reduce the pulsatility index of the
+uterine arteries and significantly increase those of the middle
+cerebral fetal artery and the umbilical artery in women with
+threatened preterm labor [24].
+The sample size for this study is too small to draw any
+definite conclusion on the mechanism of action of yoga on
+the reproductive blood flow during pregnancy. Nonetheless,
+we can examine potential previously argued hypothesis for
+the results that were observed in this study. Pregnancy itself is
+a stressful period in a woman’s life and it is now believed that
+it exerts a larger load on the cardiovascular system than previ-
+ously assumed [25]. In contrast, it is now widely accepted that
+practices of yoga do reduce stress [26]. Therefore, it is possible
+that yoga interventions in this study had a positive impact on
+the maternal stress and have reduced the sympathetic tone,
+which in turn relaxed the uterine arteries and resulted in a
+better blood flow. Yoga has been found to decrease blood
+pressure as well as the levels of oxidative stress in patients with
+hypertension [27]. This could have led to better trophoblast
+perfusion and less resistance in the uterine arteries.
+Finally, the yoga intervention used in this study was
+designed with emphasis on the yogic visualization and guided
+imagery, which, as previously stated, intended to test the
+hypothesis that when attention is moved to an area of the
+body, it causes prana to move in that area, which in turn
+improves circulation in the surrounding tissues. These are
+not exactly new ideas. Tirumular, an 8th century South
+Indian saint, once said, “Where the mind goes, the prana
+follows” [28]. Using ultraviolet photography, it has also
+been shown that when acupuncture points in a particular
+meridian are stimulated, the acceleration movement of qi
+6
+Advances in Preventive Medicine
+Table 2: Demographic data and maternal characteristics at baseline.
+Groups
+𝑃values
+Yoga (𝑛= 24)c
+Control (𝑛= 29)c
+Subjects educational profile1
+8th grade
+1
+2
+10th grade
+7
+5
+12th grade
+0
+4
+0.19a
+Junior college
+0
+3
+Bachelor degree
+11
+11
+Master degree
+5
+4
+Living arrangement
+Independent2
+13
+13
+With parents
+8
+13
+0.70a
+With relatives or friends
+3
+3
+Religion
+Hindu
+20
+22
+Moslem
+0
+2
+0.42a
+Christian
+4
+5
+Age
+Mean (SD)
+27.2 (4.8)
+27.5 (5.5)
+0.84b
+95% CI
+25.1–29.2
+25.4–29.5
+Household monthly income3
+Mean (SD)
+35.4 (28.9)
+36.9 (36.4)
+0.87b
+95% CI
+22.9–47.8
+22.8–51.0
+Socioeconomic4
+Mean (SD)
+35.4 (7.8)
+36.5 (9.4)
+0.67b
+95% CI
+32.1–38.7
+32.9–40.0
+Maternal weight (kg)
+Mean (SD)
+61.8 (13.0)
+62.7 (14.6)
+0.82b
+95% CI
+56.4–67.3
+57.1–68.3
+Maternal height (m)
+Mean (SD)
+1.57 (0.05)
+1.58 (0.06)
+0.96b
+95% CI
+1.55–1.59
+1.55–1.59
+Maternal BMI
+Mean (SD)
+25.1 (4.8)
+25.4 (4.9)
+0.84b
+95% CI
+23.1–27.1
+23.5–27.2
+Maternal systolic BP
+Mean (SD)
+108.3 (12.9)
+104.1 (8.3)
+0.18b
+95% CI
+102.7–113.9
+100.9–107.3
+Maternal diastolic BP
+Mean (SD)
+67.5 (9.5)
+64.2 (7.6)
+0.18b
+95% CI
+63.4–71.6
+61.3–67.1
+1No subject had education below 8th standard.
+2Independent: lived with her husband and children, if any.
+3Family’s monthly income in thousands of Indian rupees as reported by the subject.
+4Socioeconomic status: measured by a standard questionnaire.
+aCalculated using Chi-Square test.
+bCalculated using Independent Samples 𝑡-square test.
+cThere were three subjects in each group that did not complete the demographic questionnaire, which resulted in missing data, hence the lower 𝑛values.
+Remarks: no statistically significant difference was observed between the mean values of socioeconomic parameters of the two groups.
+Advances in Preventive Medicine
+7
+Table 3: Ultrasound fetal measurements between groups.
+Parameters
+Gestational age
+Mean ± SD
+𝑃values1
+Yoga (𝑛= 27)
+Control (𝑛= 32)
+Biparietal diameter (BPD)
+12th wk
+20.2 ± 4.0
+19.5 ± 2.4
+<0.001
+20th wk
+50.6 ± 5.4
+46.9 ± 2.4
+28th wk
+72.5 ± 2.9
+70.4 ± 2.3
+Head circumference (HD)
+12th wk
+75.4 ± 9.4
+74.3 ± 8.6
+0.002
+20th wk
+181.0 ± 7.9
+173.7 ± 7.9
+28th wk
+268.6 ± 8.7
+262.4 ± 8.2
+Abdominal circumference (AC)
+12th wk
+62.3 ± 8.5
+60.7 ± 6.2
+0.099
+20th wk
+150.0 ± 10.6
+149.1 ± 8.9
+28th wk
+243.7 ± 13.9
+236.4 ± 11.1
+Femur length (FL)
+12th wk
+9.2 ± 1.9
+9.3 ± 1.7
+0.005
+20th wk
+33.1 ± 2.1
+31.5 ± 1.9
+28th wk
+55.0 ± 2.6
+53.0 ± 2.3
+Heart rate (HR)
+12th wk
+163.5 ± 9.4
+157.8 ± 9.4
+0.006a
+20th wk
+149.3 ± 7.6
+143.0 ± 9.9
+28th wk
+145.0 ± 11.6
+141.3 ± 7.2
+Estimated fetal weight (EFW)
+12th wk
+0.065 ± 0.02
+0.066 ± 0.01
+0.019
+20th wk
+0.362 ± 0.05
+0.329 ± 0.04
+28th wk
+1.275 ± 0.15
+1.188 ± 0.13
+1Calculated using RM-ANOVA.
+aANCOVA keeping the baseline data as covariate.
+Remarks: significant improvement was observed in all fetal parameters except for AC, which was near significance.
+Table 4: Measures of uteroplacental circulation between groups.
+Arteries
+Gestational age
+Mean ± SD or count (%)
+𝑃values
+Yoga (𝑛= 27)
+Control (𝑛= 32)
+Right uterine artery
+Systolic/diastolic ratio
+12th wk
+3.2 ± 1.4
+3.1 ± 1.1
+0.17a
+20th wk
+2.3 ± 0.4
+2.7 ± 1.1
+28th wk
+2.0 ± 0.3
+2.4 ± 0.7
+Pulsatility index
+12th wk
+1.4 ± 0.5
+1.4 ± 0.5
+0.07a
+20th wk
+0.8 ± 0.2
+1.0 ± 0.5
+28th wk
+0.7 ± 0.1
+0.9 ± 0.4
+Resistance index
+12th wk
+0.65 ± 0.1
+0.64 ± 0.1
+0.01a
+20th wk
+0.52 ± 0.1
+0.58 ± 0.1
+28th wk
+0.46 ± 0.1
+0.55 ± 0.1
+Diastolic notch
+12th wk
+7 (22.6%)
+7 (18.4%)
+0.67b
+20th wk
+2 (6.1%)
+3 (7.9%)
+0.76b
+28th wk
+1 (3.6%)
+1 (2.9%)
+0.87bb
+Left uterine artery
+Systolic/diastolic ratio
+12th wk
+3.5 ± 1.5
+3.6 ± 1.6
+0.15a
+20th wk
+2.1 ± 0.3
+2.6 ± 1.1
+28th wk
+1.9 ± 0.3
+2.3 ± 1.2
+Pulsatility index
+12th wk
+1.5 ± 0.6
+1.5 ± 0.8
+0.08a
+20th wk
+0.8 ± 0.2
+1.0 ± 0.5
+28th wk
+0.7 ± 0.1
+1.1 ± 1.8
+Resistance index
+12th wk
+0.69 ± 0.15
+0.66 ± 0.12
+0.08a
+20th wk
+0.52 ± 0.06
+0.57 ± 0.11
+28th wk
+0.47 ± 0.07
+0.59 ± 0.24
+Diastolic notch
+12th wk
+10 (32.3%)
+8 (21.1%)
+0.29b
+20th wk
+1 (3.0%)
+6 (15.8%)
+0.07b
+28th wk
+1 (3.6%)
+3 (8.6%)
+0.42b
+aCalculated using RM-ANOVA. bCalculated using Chi-Square test.
+Remarks: right uterine artery RI was significantly improved in the yoga group, while the PI was near significance along with the RI and PI of left uterine artery.
+8
+Advances in Preventive Medicine
+Table 5: Fetoplacental circulation between groups.
+Gestational age
+Mean ± SD
+𝑃values
+Yoga (𝑛= 27)
+Control (𝑛= 32)
+Umbilical artery
+Systolic/diastolic ratio
+20th wk
+2.7 ± 0.41
+3.3 ± 1.1
+0.001a
+28th wk
+2.6 ± 0.5
+2.9 ± 0.6
+0.031a
+Pulsatility index
+20th wk
+1.01 ± 0.18
+1.37 ± 0.34
+0.001b
+28th wk
+0.87 ± 0.18
+1.05 ± 0.23
+0.001b
+Resistance index
+20th wk
+0.65 ± 0.05
+0.70 ± 0.09
+0.011b
+28th wk
+0.63 ± 0.08
+0.66 ± 0.06
+0.091b
+Fetal middle cerebral artery
+Systolic/diastolic ratio
+20th wk
+5.02 ± 1.47
+5.77 ± 2.04
+0.537b
+28th wk
+5.05 ± 1.64
+6.62 ± 2.26
+0.01b
+Pulsatility index
+20th wk
+1.86 ± 0.45
+2.18 ± 0.67
+0.151b
+28th wk
+1.74 ± 0.53
+2.28 ± 1.10
+0.013b
+Resistance index
+20th wk
+0.77 ± 0.07
+0.80 ± 0.07
+0.22b
+28th wk
+0.80 ± 0.08
+0.85 ± 0.08
+0.048b
+aCalculated using Independent Samples 𝑡-test.
+bCalculated using Mann-Whitney test.
+Remarks: S/D ratio, PI, and RI parameters of umbilical and fetal middle cerebral arteries were significantly improved in the yoga group after 16 weeks of
+intervention, except for the RI of umbilical artery, which was near significance.
+(equivalent to prana in acupuncture [29]) in that meridian
+results in improved circulation in the tissues surrounding that
+meridian [29, 30]. But this concept was never investigated
+scientifically with yoga and certainly not in pregnancy. While
+the sample size of this study is too small to draw a concrete
+conclusion, the results point to the important role that yoga
+can play in high-risk pregnancy.
+In our earlier publication, we have shown that the yoga
+group had lesser number of complications than the control
+group which could be related to this improved blood flow.
+Significantly fewer occurrences of pregnancy induced hyper-
+tension (𝑃= 0.018), preeclampsia (𝑃= 0.042), gestational
+diabetes (𝑃= 0.049), and intrauterine growth restriction
+(𝑃= 0.05) were observed in the yoga group. Significantly
+fewer number had small-for-gestational-age (SGA) babies in
+the study group (𝑃= 0.033) [12]. Also, APGAR scores within
+1 and 5 minutes of delivery were significantly higher in the
+yoga group (𝑃= 0.006).
+Three participants in the yoga group experienced PIH and
+none suffered from preeclampsia or eclampsia. In the control
+group, there were 11 subjects with PIH, 4 with preeclampsia,
+and 2 with eclampsia [12]. Only one of the four participants
+with preeclampsia had a uterine artery diastolic notch at the
+12th week of Doppler measurement and another at the 20th
+week of measurement. Therefore, our sample size was not
+sufficient to detect the predictability of the diastolic notch
+before 24 weeks of gestation as several other past studies have
+confirmed.
+5. Limitations of the Study
+The sample size was too small to draw any conclusion on
+the potential effects of yoga on the diastolic notch of uterine
+arteries. The high-risk nature of the population for this study
+contributed to the lower sample size by increase of dropouts
+due to pregnancy complications. Another reason could have
+been our strict inclusion criteria that made recruitment more
+difficult. Furthermore, some of the subjects delivered in
+their hometowns and we were not able to collect all the
+necessary data required by the study from the corresponding
+institutions. This resulted in missing data. In addition, the
+other hospitals may have used different protocols in delivery,
+performing C-section or administrating medications during
+the delivery that could have impacted the outcome data but
+not the Doppler data that is the focus of this paper. Finally,
+one of the objectives of this pilot study was to gain knowledge
+for the design of a larger and more comprehensive follow-up
+study. We plan to include collection of other parameters, such
+as gravidity and parity, in the future studies.
+6. Strengths of the Study
+A great deal of efforts was spent in adhering to high standards
+of randomization and blinding. The data was very carefully
+entered, double-checked, and analyzed. Also, the sample
+profile matched closely that of the Bengaluru metropolitan
+population.
+7. Future Direction
+We recommend a follow-up multicenter RCT with larger
+sample size powered by the data from this study. We also
+suggest three groups for such a trial, one control group
+(walking) and two study groups. One of the study groups will
+do only the visualizations and guided imagery while the other
+study group practices the rest of the interventions alone.
+8. Conclusion
+The result of this randomized controlled trial of yoga in
+high-risk pregnancy has shown that yogic visualization and
+guided imagery can significantly reduce the impedance in the
+Advances in Preventive Medicine
+9
+uteroplacental and fetoplacental circulation. This pilot data
+can be used to power larger studies to confirm these results
+and elaborate on the mechanism of action.
+Disclosure
+Raghuram Nagarathna, Rita Mhaskar, Arun Mhaskar, An-
+namma Thomas, and Sulochana Gunasheela are coauthors.
+Conflict of Interests
+The authors declare that there is no conflict of interests
+regarding the publication of this paper.
+Acknowledgment
+This study was funded by a grant from the Central Council for
+Research in Yoga & Naturopathy (CCRYN) of Department of
+AYUSH within the Ministry of Health of the Government of
+India (Grant no. 13-1/2010-11/CCRYN/AR-90).
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+Dragon Eye Press, Pasadena, Calif, USA, 2004.
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subfolder_0/Effects of a Yoga Program on Cortisol level and mood.txt

@@ -0,0 +1,1294 @@
+http://ict.sagepub.com
+Integrative Cancer Therapies 
+DOI: 10.1177/1534735409331456 
+ 2009; 8; 37 originally published online Feb 3, 2009; 
+Integr Cancer Ther
+B.S. Srinath, M.S. Vishweshwara, Y.S. Madhavi, B.S. Ajaikumar, Bilimagga S. Ramesh, Rao Nalini and Vinod Kumar 
+Rao M. Raghavendra, H.S. Vadiraja, Raghuram Nagarathna, H.R. Nagendra, M. Rekha, N. Vanitha, K.S. Gopinath,
+ 
+Undergoing Adjuvant Radiotherapy: A Randomized Controlled Trial
+Effects of a Yoga Program on Cortisol Rhythm and Mood States in Early Breast Cancer Patients
+http://ict.sagepub.com/cgi/content/abstract/8/1/37
+ 
+The online version of this article can be found at:
+ 
+Published by:
+http://www.sagepublications.com
+ 
+can be found at:
+Integrative Cancer Therapies 
+Additional services and information for 
+ 
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+http://ict.sagepub.com/cgi/content/refs/8/1/37
+ 
+Citations
+ at UQ Library on September 22, 2009 
+http://ict.sagepub.com
+Downloaded from 
+37
+Although anxiety and depression are some of the most 
+common psychiatric problems seen in cancer patients, 
+many of these problems are not detected, diagnosed, or 
+treated.1 Patients with breast cancer undergoing radiation 
+treatment also report anxiety and depression before, dur-
+ing, and after treatment.11,12 One study found the preva-
+lence of anxiety and depression in Indian cancer patients 
+undergoing radiation treatment to be 64% and 50%, 
+respectively,11 more than that seen in Western popula-
+tions. Both anxiety and depression can affect treatment-
+related distress by leading patients to perceive cancer as a 
+threat, increasing attentiveness to somatic symptoms, and 
+causing aversive symptoms.
+These affective states and distress have been found to 
+contribute to hypothalamic-pituitary-adrenal (HPA) axis 
+dysregulation in cancer patients.13,14 Cortisol, a stress hor-
+mone and an end-product of the HPA axis, has been 
+reported to be elevated in breast cancer patients both prior 
+to and following treatment.15-17 Both elevated levels of 
+cortisol and flattened high levels or erratic diurnal fluctua-
+tions of cortisol have been shown to cause down-regulation 
+P
+sychological distress and morbidity are common 
+sequelae to diagnosis and treatment in early breast 
+cancer patients,1-3 given that the majority of patients 
+report symptoms of depression, anxiety, social dysfunc-
+tion, and inability to work.4-6 These symptoms, coupled 
+with cancer-related intrusive thoughts such as fear of 
+radiation and surgery and image problems, can heighten 
+women’s risk for psychological distress.7-9 This distress 
+been shown to affect cancer-related outcomes in terms of 
+quality of life, mood states (anxiety and depression), tox-
+icity, treatment response, and prognosis.10 
+Objectives. This study compares the effects of an integrated yoga 
+program with brief supportive therapy in breast cancer outpa-
+tients undergoing adjuvant radiotherapy at a cancer center. 
+Methods. Eighty-eight stage II and III breast cancer outpatients 
+are randomly assigned to receive yoga (n = 44) or brief support-
+ive therapy (n = 44) prior to radiotherapy treatment. Assessments 
+include diurnal salivary cortisol levels 3 days before and after 
+radiotherapy and self-ratings of anxiety, depression, and stress 
+collected before and after 6 weeks of radiotherapy. Results. 
+Analysis of covariance reveals significant decreases in anxiety 
+(P < .001), depression (P = .002), perceived stress (P < .001), 
+6 a.m. salivary cortisol (P = .009), and pooled mean cortisol 
+(P = .03) in the yoga group compared with controls. There is a 
+significant positive correlation between morning salivary corti-
+sol level and anxiety and depression. Conclusion. Yoga might 
+have a role in managing self-reported psychological distress and 
+modulating circadian patterns of stress hormones in early 
+breast cancer patients undergoing adjuvant radiotherapy.
+Keywords:  yoga; breast cancer; meditation; cortisol; stress
+From the Department of Yoga Research, Swami Vivekananda Yoga 
+Anusandhana Samsthana, Bangalore, India (HSV, RN, HRN, MR, NV, 
+VK); Departments of Complementary and Alternative Medicine, Surgical 
+Oncology and Radiation Oncology, Bangalore Institute of Oncology, 
+Bangalore, India (RMR, KSG, BSS (MS), BSR, RN); and Department 
+of Radiation Oncology, Bharath Hospital Institute of Oncology, Mysore, 
+India (MSV, YSM, BSA). 
+Address correspondence to: Rao M. Raghavendra, PhD, Bangalore 
+Institute of Oncology, No. 8, P Kalinga Rao Road, Sampangiramnagar, 
+Bangalore-560027 India; e-mail: [email protected].
+Integrative Cancer Therapies
+Volume 8 Number 1
+March 2009  37-46
+© 2009 Sage Publications
+10.1177/1534735409331456
+http://ict.sagepub.com
+hosted at
+http://online.sagepub.com
+Effects of a Yoga Program on Cortisol  
+Rhythm and Mood States in Early Breast  
+Cancer Patients Undergoing Adjuvant  
+Radiotherapy: A Randomized Controlled Trial
+H. S. Vadiraja, BNYS, Rao M. Raghavendra, PhD, Raghuram Nagarathna, MD,  
+H. R. Nagendra, PhD, M. Rekha, MSc, N. Vanitha, BNYS, K. S. Gopinath, MS, B. S.  
+Srinath, MS, M. S. Vishweshwara, MD, Y. S. Madhavi, MD, B. S. Ajaikumar, MD,  
+Bilimagga S. Ramesh, MD, Rao Nalini, MD, and Vinod Kumar, MSc
+ at UQ Library on September 22, 2009 
+http://ict.sagepub.com
+Downloaded from 
+38    Integrative Cancer Therapies / Vol. 8, No. 1, March 2009
+of the immune response as a result of stress.18-20 Such 
+aberrations of cortisol rhythms are attributable to both 
+the physical stress of having cancer21 and psychological 
+stress.22,23 Flattened diurnal salivary cortisol rhythms 
+predict early recurrence14 and mortality from metastatic 
+breast cancer.24
+Various psychotherapeutic interventions such as 
+cognitive behavioral therapy, social support, and stress 
+management have shown beneficial effects in reducing 
+psychological distress25-27 and HPA axis dysregulation 
+associated with cancer.28,29 Studies have shown these 
+inter­
+ventions to reduce distress, anxiety, and depressed 
+mood and enhance quality of life among women with 
+breast cancer in adjuvant settings.30,31 Studies have 
+also shown improvement in HPA axis dysregulation,28 
+immune responses,32 and survival33 following such 
+interventions. 
+Yoga is among the stress reduction mind–body 
+approaches that have been practiced widely in both 
+Indian and Western populations. Various components 
+and types of yoga practices have shown beneficial effects 
+in reducing distressful symptoms and improving sleep, 
+mood, and quality of life in cancer patients.34 Results 
+from randomized controlled studies have shown 
+decreases in cortisol levels in noncancer populations fol-
+lowing yoga intervention.35-37 Our earlier studies with 
+yoga intervention have shown decreases in anxiety 
+states,38 reduction in chemotherapy-induced nausea and 
+vomiting,39 and improvement in immune response40 in 
+early breast cancer patients. These findings offer further 
+support for the stress reduction effects of yoga. It may 
+be speculated that these effects are facilitated by reduc-
+tions in stress hormones that constitute the HPA axis. It 
+is becoming increasingly clear from the accumulating 
+evidence that a mere “elevated,” in vivo cortisol level 
+may insufficiently define “stress” and that changes in its 
+circadian patterns are also important.41,42 However, 
+results from a mindfulness-based stress reduction inter-
+vention show inconclusive evidence for changes in sali-
+vary cortisol rhythms.28 This may be because a 
+heterogeneous cancer population was studied and the 
+duration of the intervention was insufficient to affect 
+salivary cortisol rhythms. 
+We hypothesized that a yoga intervention would 
+help calm the mind and reduce stress, thereby attenu-
+ating HPA axis dysregulation and resulting in normal 
+salivary cortisol levels and circadian rhythms in stage II 
+and III breast cancer patients undergoing adjuvant 
+radiotherapy.
+In this study, we compared the effects of a 6-week 
+integrated yoga program with the effects of a brief 
+ 
+supportive therapy as a control intervention in early 
+operable breast cancer patients undergoing adjuvant 
+radiotherapy.
+Methods
+Subjects
+This is a randomized controlled trial wherein 88 women 
+diagnosed with stage II and III breast cancer were 
+recruited over a 2½-year period at 2 comprehensive can-
+cer care centers. The institutional ethics committees of 
+the recruiting cancer centers approved the study. Patients 
+were eligible to participate in this study if they met the 
+following selection criteria at the study start: (a) were 
+recently diagnosed with operable breast cancer; (b) had 
+been prescribed adjuvant radiotherapy; (c) were between 
+30 and 70 years of age; (d) were assessed as Zubrod’s 
+performance status 0-2 (ambulatory >50% of time); 
+ 
+(e) had a high school education; and (f) consented to 
+participate in the study. Subjects were excluded if they 
+(a) had any concurrent medical condition that was likely 
+to interfere with treatment; (b) had a major psychiatric 
+illness, neurological illness, or autoimmune disorder; 
+ 
+(c) had any known metastases; or (d) were prescribed 
+concurrent chemotherapy cycles during radiotherapy.
+Each study participant was prescribed adjuvant radio-
+therapy with a cumulative dose of 50.4 Gy with fraction-
+ations spread over 6 weeks. The details of the study were 
+explained to the participants, and their informed consent 
+was obtained in writing before they started adjuvant 
+radiotherapy and intervention.
+Randomization
+Of 103 eligible participants, 88 (85.4%) consented to 
+participate and were randomized, via computer-generated 
+random numbers, to receive yoga (n = 44) or supportive 
+therapy (n = 44) before intervention (prior to radiother-
+apy). Randomization was performed using opaque enve-
+lopes with group assignments. Personnel who had no part 
+in the trial performed randomization. The envelopes were 
+opened sequentially in the order of assignment during 
+recruitment, with the names and registration numbers of 
+the participants written on the covers. The order of ran-
+domization was verified with the hospital date of admis-
+sion records for radiotherapy at study intervals to make 
+sure that field personnel had not altered the sequence of 
+randomization to suit the allocation of consenting par-
+ticipants into 2 study arms.
+Among the 88 participants, 75 (yoga n = 42, control 
+n = 33) completed their prescribed radiation therapy of 
+6 weeks and follow-up assessment. However, only 63 par-
+ticipants provided saliva samples at the study start and 
+only 56 provided saliva samples during postintervention 
+assessment. There were 13 dropouts in the study (see trial 
+profile, Figure 1). The reasons for dropping out were 
+transfer to other hospitals (n = 4), use of other comple-
+mentary therapies (eg, homeopathy or ayurveda, n = 2), 
+ at UQ Library on September 22, 2009 
+http://ict.sagepub.com
+Downloaded from 
+Yoga for Breast Cancer / Vadiraja et al.    39
+refusal to continue the study (n = 2), time constraints 
+ 
+(n = 4), and concurrent illnesses such as infections that 
+delayed radiotherapy and intervention (n = 1). 
+Measures
+During the initial visit, demographic information was 
+obtained, including age, marital status, education, occupa-
+tion, obstetric and gynecological history, medical history, and 
+intake of medications; clinical data on the history of breast 
+cancer were abstracted. The following self-report question-
+naires were imparted to the subjects during the study:
+Hospital Anxiety and Depression Scale. Participants 
+were assessed for anxiety and depression using the 
+Hospital Anxiety and Depression Scale (HADS).43 It is a 
+widely used self-report instrument designed to assess the 
+dimensions of anxiety and depression in nonpsychiatric 
+populations.44,45 This 14-item questionnaire consists of 
+ 
+Figure 1.  Trial profile. CAM, complementary and alternative medicine.
+Number of patients screened (n = 165) 
+Eligible patients (n = 103) 
+Number consented and
+randomized (n = 88)  
+Supportive counseling
+(n = 44)  
+Yoga intervention
+(n = 44)  
+Post assessment (n = 42) 
+Post assessment (n = 33) 
+n = 2 
+     Study drop outs           n = 11 
+Reasons for drop outs 
+    0 
+Migration to other hospital    4
+    0      Use of other CAM 
+           2
+    1      Refusal to continue study     1
+    1      Time constraints 
+          3
+    0      Concurrent illness 
+          1
+Subjects providing saliva for
+cortisol, n = 27  
+Subjects providing saliva for
+cortisol, n = 29  
+ at UQ Library on September 22, 2009 
+http://ict.sagepub.com
+Downloaded from 
+40    Integrative Cancer Therapies / Vol. 8, No. 1, March 2009
+2 subscales of 7 items designed to measure levels of anxi-
+ety and depression. Each item is rated on a scale from 0 
+(“not at all”) to 3 (“very much”). The reliability of HADS 
+(all 14 items) and the HADS-A and HADS-D subscales is 
+0.85, 0.79, and 0.87, respectively.46
+Perceived Stress Scale. Perceived stress levels were 
+assessed using the Perceived Stress Scale (PSS).47 This 
+self-rated scale includes 14 items scored on a 5-point 
+scale. This scale assesses the degree to which participants 
+appraise their daily life as unpredictable, uncontrollable, 
+and overwhelming (eg, “In the last week, how often have 
+you felt that you were unable to control the important 
+things in your life?”). This scale has a reliability of 0.85.
+Diurnal Salivary Cortisol
+Participants were asked to give saliva samples 3 times a 
+day for 3 consecutive days before and after adjuvant 
+radiotherapy.
+Saliva collection and storage. Participants were trained 
+to collect their saliva by chewing on a cotton swab and 
+drooling the saliva into a plastic holder resting inside a 
+sterile centrifuge tube. Samples were collected at 6 a.m., 
+9 a.m., and 9 p.m. for 3 consecutive days. The samples 
+were stored in a refrigerator and delivered to study per-
+sonnel after 3 days. Samples were then centrifuged to 
+remove mucous, frozen, and stored at –70° in Eppendorf 
+tubes for analysis. 
+Assay procedure. The samples were thawed and centri-
+fuged at 2500 rpm for 15 minutes, and the supernatant 
+was used for cortisol assessment. Salivary cortisol levels 
+were assessed using an enzyme immunoassay (EIA) method 
+with kits manufactured by Salimetrics Inc (State College, 
+Pa). The tests were run for all the 9 samples collected 
+on 3 consecutive days for each study participant. The 
+tests were standardized under controlled laboratory con-
+ditions using standards and positive and negative controls 
+provided by the manufacturer. The detection range with 
+these kits was 0.012 to 3.0 µg/dL. The intra-assay coeffi-
+cient ranged from 3.35% to 3.65% and interassay coeffi-
+cient from 3.75% to 6.41% with these samples. 
+Mean cortisol levels for specific time points over a 
+3-day period were extrapolated. The diurnal cortisol 
+response was evaluated by calculating the area under the 
+curve (AUC) for 6 a.m., 9 a.m., and 9 p.m. using zero as 
+a reference point. We used AUC, a frequently used 
+method in endocrinology research, to collect information 
+that is contained in repeated measurements over time. 
+This helps to limit the amount of statistical comparisons 
+between groups to minimize 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 2 AUC formulas, AUCb 
+for baseline diurnal cortisol measurements and AUCi for 
+the increase in the AUC with respect to AUCb for the 
+postintervention measure using the trapezoidal method,48 
+we could assess different aspects of the time course of the 
+repeated measurements. 
+Interventions
+Interventions were conducted over a 6-week period for 
+both the groups during the course of their adjuvant radio-
+therapy with one group receiving an integrated yoga pro-
+gram and the other brief supportive therapy as individual 
+sessions. The yoga intervention consisted of a set of asa-
+nas (postures done with awareness), breathing exercises, 
+pranayama (voluntarily regulated nostril breathing), med-
+itation, and yogic relaxation techniques with imagery 
+(mind sound resonance technique and cyclic meditation). 
+Goals of the program were to develop a sense of calmness 
+and relaxation with a perceptible change in coping with 
+day-to-day stressful life experiences. Participants were 
+required to attend a minimum of 3 in-person sessions per 
+week for 6 weeks during their adjuvant radiotherapy treat-
+ment in the hospital and to practice at home on the 
+remaining days. Each in-person session lasted 1 hour and 
+was administered by a trained yoga therapist either before 
+or after radiotherapy. The control intervention consisted 
+of brief supportive therapy with education that is rou-
+tinely offered to patients as a part of their care in this 
+center. We chose to have this as a control intervention 
+mainly to control for the nonspecific effects of the yoga 
+program that may be associated with factors such as 
+attention, support, and a sense of control as described in 
+our earlier study.39 Subjects and their caretakers under-
+went counseling by a trained social worker (15-minute 
+sessions once every 10 days) during their hospital visits 
+for adjuvant radiotherapy. The control group received 3 or 
+4 such counseling sessions during a 6-week period, 
+whereas the intervention group received between 18 and 
+24 yoga sessions. Although the goals of the yoga interven-
+tion were stress reduction and appraisal of changes, the 
+goals of supportive therapy were education, reinforcing 
+social support, and coping preparation.
+Data Analysis
+Data were analyzed using SPSS version 16.0 (SPSS Inc, 
+Chicago, Ill). Descriptive statistics were used to assess 
+normality and homogeneity. The data were found to be 
+normally distributed. Paired-sample t test was used to 
+assess the within-group changes, and analysis of covari-
+ance (ANCOVA) using baseline value as a covariate was 
+used to determine the between-group changes. Data were 
+analyzed for mean saliva collection at 6 a.m., 9 a.m., and 
+9 p.m. and mean for all 3 together (pooled mean diurnal 
+salivary cortisol) as well as for AUCb and AUCi between 
+groups. Relationships between changes in psychological 
+ at UQ Library on September 22, 2009 
+http://ict.sagepub.com
+Downloaded from 
+Yoga for Breast Cancer / Vadiraja et al.    41
+variables to changes in cortisol were assessed using 
+Pearson correlation analysis.
+Results
+The mean age of participants was 46 ± 9.13 years in yoga 
+and 48.45 ± 10.21 years in control groups. All patients 
+had mastectomy as primary treatment, 20 subjects 
+received radiotherapy following mastectomy, and 68 sub-
+jects received radiotherapy following mastectomy and 3 
+cycles of chemotherapy. Participants in both groups were 
+comparable with respect to sociodemographic and medi-
+cal characteristics (Table 1). 
+Diurnal Salivary Cortisol Levels
+Paired-samples t test to assess within-group change fol-
+lowing intervention showed a significant decrease in 
+mean salivary cortisol levels at 6 a.m. (t = 4.21, P < .001) 
+and pooled diurnal mean cortisol in the yoga group (t = 
+2.79, P = .01) but not in the control group (t = 0.34, P < 
+.74, and t = –0.04, P = .96). We used ANCOVA to assess 
+between-group differences using baseline cortisol value 
+(for the corresponding time) as a covariate. There was a 
+significant decrease in mean salivary cortisol level at 6 
+a.m. in the yoga group compared with the control group 
+(F1, 56 = 7.45, P = .009). There was also a significant 
+decrease in pooled mean diurnal salivary cortisol level in 
+the yoga group compared with controls (F1, 53 =5.14, P = 
+.03). There was no significant change between and within 
+groups in salivary cortisol for 9 a.m., 9 p.m., and AUC 
+with respect to baseline (AUCb) and increase (AUCi) 
+(Table 2). Furthermore, we classified patients as having 
+high or low distress by taking the baseline pooled mean 
+diurnal cortisol (0.254 µg/dL) as a cutoff. Subjects in 
+both groups (intervention and control) with pooled diur-
+nal mean cortisol 0.25 µg/dL or less were classified as a 
+low-distress subgroup and those with cortisol greater than 
+0.25 µg/dL were classified as a high-distress subgroup at 
+baseline. Analysis for effects of intervention (yoga vs sup-
+portive therapy) was carried out separately for both sub-
+groups (high-distress and low-distress subgroups). 
+Analysis 
+of covariance using baseline cortisol value for the corre-
+sponding time as a covariate in the low-distress subgroup 
+showed a significant decrease in 6 a.m. mean salivary 
+cortisol in the yoga group compared with controls (F1, 28 = 
+4.48, P = .04). Similarly, there was a significant decease 
+in pooled diurnal mean cortisol levels in the yoga group 
+compared with controls (F1, 28 = 4.93, P = .03). However, 
+Table 1.    Demographic and Medical Characteristics of the Initially Randomized Sample
+	
+All Subjects (N = 88)	
+Yoga Group (N = 44)	
+Control Group (N = 44)
+	
+n	
+%	
+n	
+%	
+n	
+%
+Stage of breast cancer	
+	
+	
+	
+	
+	
+    I	
+5	
+5.7	
+2	
+4.5 	
+3	
+6.8
+    II	
+18	
+20.4	
+11	
+25.0	
+7	
+15.9
+    III	
+65	
+73.9	
+31	
+70.5	
+34	
+77.3
+Grade of breast cancer	
+	
+	
+	
+	
+	
+    I	
+1	
+1.1	
+1	
+2.3	
+0	
+0
+    II	
+33	
+37.5	
+21	
+51.1	
+10	
+22.7
+    III	
+54	
+61.4	
+22	
+47.7	
+34	
+77.3
+Menopausal status	
+	
+	
+	
+	
+	
+    Pre	
+48	
+54.5	
+26	
+59.1	
+23	
+52.3
+    Post	
+40	
+45.5	
+18	
+40.9	
+21	
+47.7
+Histopathology type	
+	
+	
+	
+	
+	
+    IDC	
+72	
+81.8	
+37	
+84.1	
+35	
+39.7
+    ILC	
+7	
+7.9	
+2	
+4.5	
+5	
+11.4
+    IPC	
+3	
+3.4	
+2	
+4.5	
+1	
+2.2
+    DCI	
+2	
+2.2	
+2	
+4.5	
+0	
+0
+    CC	
+2	
+2.2	
+1	
+2.3	
+1	
+2.2
+    PC	
+2	
+2.2	
+0	
+0	
+2	
+4.5
+Regimen	
+	
+	
+	
+	
+	
+    S+CT3+RT	
+68	
+77.3	
+32	
+72.7	
+37	
+84
+    S+RT	
+20	
+22.7	
+12	
+27.3	
+7	
+15.9
+Marital status	
+	
+	
+	
+	
+	
+    Single	
+2	
+2.2	
+1	
+2.3	
+1	
+2.2
+    Married	
+86	
+97.8	
+43	
+97.7	
+43	
+97.8
+NOTES: IDC =  infiltrating ductal carcinoma; ILC, = infiltrating lobular carcinoma; IPC = infiltrating papillary carcinoma; DCI =  ductal carcinoma in situ; CC = 
+comedo carcinoma; PC = papillary carcinoma, S+CT3+RT =  adjuvant radiotherapy after mastectomy followed by 3 cycles of chemotherapy; S+RT =  adjuvant radio-
+therapy after mastectomy.
+ at UQ Library on September 22, 2009 
+http://ict.sagepub.com
+Downloaded from 
+42    Integrative Cancer Therapies / Vol. 8, No. 1, March 2009
+although there was a trend for a decrease in cortisol levels 
+in the high-distress subgroup, the effects of the interven-
+tion were not significant (Table 3).
+Anxiety Scores (HADS-A)
+Paired-samples t test done to assess within-group change 
+showed a significant decrease in self-report anxiety scores 
+in the yoga group (t = 7.24, P < .001) and control group 
+(t = 2.15, P = .04) following intervention. Analysis of 
+covariance on postintervention measures using baseline 
+anxiety as a covariate showed a significant decrease in self-
+report anxiety in the yoga group compared with controls 
+(F1, 73 = 15.4, P < .001) (Table 4).
+Depression Scores (HADS-D)
+Paired-samples t test done to assess within-group change 
+showed a significant decrease in self- report depression 
+within the yoga (t = 6.26, P < .001) and control groups 
+(t = 3.23, P = .01). Analysis of covariance on postinterven-
+tion measures using baseline depression scores as a 
+covariate showed a significant decrease in self-report 
+depression in the yoga group compared with controls 
+(F1, 73 = 10.7, P = .002) (Table 4).
+Perceived Stress Score
+Paired-samples t test done to assess within-group change 
+showed a significant decrease in perceived stress in the 
+yoga group (t = 5.5, P < .001) but not in the control group 
+(t = 1.42, P = .17). Analysis of covariance on postinterven-
+tion measures using baseline perceived stress score as a 
+covariate showed a significant decrease in perceived stress 
+in the yoga group compared with controls (F1, 72 =18.05, 
+P < .001) (Table 4). Bivariate relationships between salivary 
+cortisol rhythms and psychological variables were deter-
+mined using pearson correlation analysis. There was a sig-
+nificant negative correlation between 0600 hrs salivary 
+cortisol with anxiety, and depression states (Table 5).
+Table 2.    Comparison of Mean Values of Diurnal Salivary Cortisol Levels Using  
+Paired t Test and Analysis of Covariance (ANCOVA) 
+	
+Yoga (n = 27), Mean (SD)	
+Control (n = 29), Mean (SD)	
+	
+	
+	
+	
+	
+Effect Size 
+ 
+Outcome Variables	
+Pre 	
+Post 	
+Pre 	
+Post 	
+(Cohen’s f)
+    6 a.m.	
+0.33 (0.17)	
+0.22 (0.15)ab	
+0.38 (0.31)	
+0.36 (0.24)	
+0.24
+    9 a.m.	
+0.26 (0.16)	
+0.19 (0.14)	
+0.24 (0.23)	
+0.24 (0.23)	
+0.21
+    9 p.m.	
+0.19 (0.14)	
+0.16 (0.16)	
+0.16 (0.15)	
+0.16 (0.14)	
+0.14
+Mean pooled diurnal cortisol	
+0.25 (0.13)	
+0.19 (0.13)ab	
+0.25 (0.21)	
+0.25 (0.18)	
+0.27
+    6 a.m. AUCb	
+1.14 (0.76)	
+0.98 (0.63)	
+0.69 (0.38)	
+0.56 (0.38)	
+0.27
+    9 a.m. AUCb	
+3.25 (2.17)	
+2.97 (2.22)	
+1.85 (1.15)	
+1.58 (0.88)	
+0.19
+    9 p.m. AUCb	
+4.39 (2.84)	
+3.96 (2.77)	
+2.54 (1.44)	
+2.15 (1.18)	
+0.19
+    6 a.m. AUCi	
+–0.19 (0.24)	
+–0.13 (0.33)	
+–0.12 (0.26)	
+–0.11 (0.16)	
+0.05
+    9 a.m. AUCi	
+–2.11 (2.07)	
+–1.49 (2.41)	
+–1.37 (1.94)	
+–1.12 (1.52)	
+0.11
+    9 p.m. AUCi	
+–2.31 (2.28)	
+–1.62 (2.72)	
+–1.49 (2.17)	
+–1.23 (1.65)	
+0.11
+NOTES: AUCb =  area under the curve for baseline; AUCi =  area under the curve for increase in cortisol with respect to baseline.
+aP < .05 for within group change using paired t test.
+bP < .05 for between group change using analysis of covariance.
+Table 3.    Comparison of Diurnal Cortisol Levels Between Yoga and Controls in the Initially Low-Distress  
+(Mean Cortisol ≤0.25 µg/dL) and High-Distress (Mean Cortisol >0.25 µg/dL) Subgroups Using  
+Analysis of Covariance With Baseline Measure as a Covariate
+	
+Low-distress Subgroup	
+High-distress Subgroup
+	
+Yoga (n = 13)	
+Control (n = 18)	
+Yoga (n = 14)	
+Control (n = 11)
+	
+Pre	
+Post	
+Pre	
+Post	
+Pre	
+Post	
+Pre	
+Post
+6 a.m.	
+0.23 ± 0.11	
+0.17 ± 0.12	
+0.21 ± 0.13	
+0.27 ± 0.16	
+0.42 ± 0.16	
+0.27 ± 0.16	
+0.65 ± 0.34	
+0.51 ± 0.28
+9 a.m.	
+0.18 ± 0.08	
+0.13 ± 0.07	
+0.12 ± 0.07	
+0.16 ± 0.11	
+0.36 ± 0.16	
+0.25 ± 0.17	
+0.44 ± 0.25	
+0.38 ± 0.31
+9 p.m.	
+0.11 ± 0.08	
+0.09 ± 0.06	
+0.08 ± 0.08	
+0.10 ± 0.09	
+0.26 ± 0.14	
+0.22 ± 0.20	
+0.27 ± 0.18	
+0.26 ± 0.18
+Mean pooled cortisol	
+0.16 ± 0.06	
+0.13 ± 0.05	
+0.13 ± 0.07	
+0.17 ± 0.09	
+0.35 ± 0.10	
+0.24 ± 0.16	
+0.46 ± 0.22	
+0.39 ± 0.20
+aP < .05 for analysis of covariance between groups (yoga vs controls).
+ at UQ Library on September 22, 2009 
+http://ict.sagepub.com
+Downloaded from 
+Yoga for Breast Cancer / Vadiraja et al.    43
+Discussion
+This study evaluated the effects of a 6-week integrated yoga 
+program with supportive therapy in stage II and III breast 
+cancer outpatients undergoing adjuvant radiotherapy. The 
+results suggest significant decreases in self-reported anxi-
+ety, depression, and perceived stress and in 6 a.m. and 
+pooled mean cortisol levels in the yoga group compared 
+with controls. There was a tendency for a decrease in the 
+above measures in both yoga and control groups following 
+radiotherapy, consonant with the usual symptom trajec-
+tory of cancer patients during and after treatment.49 
+However, decrements were profound in the yoga group 
+compared with controls, supporting the stress reduction 
+benefits of yoga program. 
+The effect sizes were more for decreases in anxiety and 
+perceived stress and less for salivary cortisol. This reduc-
+tion in anxiety is consistent with our earlier study using 
+the same support intervention as a control.38 However, 
+the decrements in our study are less compared with ear-
+lier studies that lacked control interventions and showed 
+large effect sizes (Cohen’s d > 0.8) for anxiety reduction 
+on a number of self-report scales.50-55 Our results for 
+reduction in self-reported symptoms of depression are 
+similar to earlier observations using yoga in cancer and 
+noncancer populations.26,56-58 The large effect size 
+observed in our study could be attributed to the fact that 
+the period of diagnosis and active treatment is often asso-
+ciated with greater distress49; given that we had a homog-
+enous study population and better contact duration and 
+exposure to intervention compared with the above stud-
+ies, it is reasonable to see these differences. 
+The decrease in morning salivary cortisol levels sug-
+gests possible stress reduction benefits with our yoga 
+intervention. This is similar to earlier observations with 
+yoga interventions in both noncancer35-37 and cancer16,29,59 
+populations. Although these earlier studies measured 
+1-time plasma cortisol, we chose to assess the diurnal 
+levels of free salivary cortisol because change in the rate 
+of cortisol secretion over a day is considered a robust 
+measure compared with 1-time cortisol assessment.24,60 
+Earlier studies with similar stress reduction interventions 
+such as mindfulness-based stress reduction (MBSR) also 
+showed decrements in cortisol in breast cancer patients 
+who had initially high cortisol levels, suggesting that more 
+distressed patients tend to benefit from stress reduction 
+interventions.28 We similarly divided our sample by initial 
+mean daily cortisol levels and compared the degree of 
+change in subsequent cortisol levels. We found that those 
+people with initially low cortisol levels (below initial mean 
+cutoff) showed significant decreases in 6 a.m. cortisol 
+and mean diurnal cortisol following intervention com-
+pared with those with higher initial levels, who in fact 
+displayed a tendency for a decrease in cortisol levels, con-
+trary to earlier findings. Although our intervention showed 
+reductions in anxiety, depression, and perceived stress in 
+both subgroups, these decrements in psychological dis-
+tress did not translate into significant reductions in corti-
+sol in the high-cutoff group. 
+Table 4.    Comparison of Scores for Anxiety, Depression, and Perceived Stress Between Yoga and Control Groups Following 
+Intervention Using Analysis of Covariance With Baseline Measure as a Covariate 
+	
+Yoga (n=42), Mean (SD)	
+Control (n=33), Mean (SD)
+	
+	
+	
+	
+	
+Effect Size 
+ 
+Outcome Variables	
+Pre 	
+Post 	
+Pre 	
+Post 	
+(Cohen’s f)
+HADS-Anxiety	
+8.05 (3.87)	
+4.88(3.34)ab 	
+9.35 (3.98)	
+8.12c (3.80)	
+0.31
+HADS-Depression	
+7.57 (4.02)	
+4.14(3.45)ad 	
+8.00 (3.47)	
+6.53e (3.78)	
+0.31
+Perceived stress	
+20.78 (6.10)	
+15.17 (4.83)ab	
+21.41 (6.22)	
+20.12 (5.87)	
+0.36
+aP values < .001 for within-group change using paired t test. 
+bP values < .001 for between-group change using analysis of covariance.
+cP values < .05 for within-group change using paired t test. 
+dP values < .01 for between-group change using analysis of covariance. 
+eP values < .01 for within-group change using paired t test. 
+Table 5.    Pearson Correlation (r Values) Between Anxiety, 
+Depression, Perceived Stress Scores, and Cortisol Values
+	
+	
+	
+Perceived 
+ 
+Variables	
+Anxiety	
+Depression	
+Stress
+Cortisol	
+	
+	
+    6 a.m.	
+0.24a	
+0.40b	
+–0.04
+    9 a.m.	
+0.16	
+0.08	
+0.09
+    9 p.m.	
+0.02	
+0.03	
+–0.15
+    Pooled mean 	
+0.22	
+0.24	
+–0.06
+Cortisol AUCb	
+	
+	
+    6 a.m.	
+0.19	
+0.18	
+0.06
+    9 a.m.	
+0.004	
+0.10	
+0.01
+    9 p.m.	
+0.05	
+0.12	
+0.03
+Cortisol AUCi	
+	
+	
+    6 a.m.	
+–0.14	
+–0.11	
+0.13
+    9 a.m.	
+–0.22	
+–0.13	
+0.04
+    9 p.m.	
+–0.21	
+–0.13	
+0.05
+NOTES: AUCb = area under the curve for baseline; AUCi = area under the curve 
+for increase in cortisol with respect to baseline.
+aP values < .05 for Pearson correlation.
+bP values < .01 for Pearson correlation.
+ at UQ Library on September 22, 2009 
+http://ict.sagepub.com
+Downloaded from 
+44    Integrative Cancer Therapies / Vol. 8, No. 1, March 2009
+It may be hypothesized from these results that distress 
+decreases with time in cancer patients, that the use of 
+stress reduction interventions only augments this process, 
+and that patients with initially high distress and high corti-
+sol levels would probably take longer for attenuation of 
+such high cortisol levels than those with lesser distress or 
+cortisol profiles. Our observations differ from earlier study 
+by Carlson et al,28 probably attributable to the differences 
+in cancer populations being studied, differences in type of 
+interventions (MBSR vs yoga), lack of a control arm in the 
+former, and the fact that patients in our study were under-
+going active treatment throughout the study period.
+These observations are important because HPA axis 
+dysregulation in terms of diurnal salivary cortisol rhythm 
+is an important predictor of survival in advanced breast 
+cancer patients.24 Modulating cortisol levels at an earlier 
+stage would help reduce distress in the future61 and pos-
+sibly improve survival in these patients. The changes in 
+stress response patterns and appraisal could have contrib-
+uted to reductions in cortisol and distress seen with our 
+intervention. The reduction in perceived stress seen with 
+our intervention further supports for this mechanism. An 
+elevated level of cortisol is known to have immunosup-
+pressive effects and is largely responsible for the down-
+regulation of immune function because of stress. Reductions 
+seen in cortisol levels in our study further support for 
+improvements in immune functioning (natural killer cell 
+counts) seen with our earlier study in early breast cancer 
+patients undergoing conventional treatment (surgery, 
+radiotherapy, and chemotherapy).40 The combination of 
+physical postures, breathing exercises, relaxation, and 
+meditation could have helped attenuate cortisol levels 
+through stress reduction and exercise effects, given that 
+earlier studies documented quality of life and biological 
+benefits for cancer patients with moderate exercise.62,63 
+Being physically active (walking and household tasks) has 
+also been shown to reduce the risk for development of 
+breast cancer.64 Various components of yoga intervention 
+are known to have a calming effect and to correct auto-
+nomic imbalances65-68 and HPA axis disturbances28 that 
+precede stress responses. This can help reduce perceived 
+stress and maladaptive stress arousal patterns, which are 
+known to cause heightened distress or depressive symp-
+toms69 in these patients. 
+The reduced psychological stress and cortisol levels 
+that we found following the yoga program could be attrib-
+uted to stress reduction rather than mere social support 
+and education, as found in earlier studies.33 The first 
+major limitation in our study is the inequality in contact 
+duration of interventions. Supportive therapy interven-
+tions were used only with the intention of negating the 
+confounding variables such as instructor–patient interac-
+tion, education, and attention.70 Inequality in contact 
+duration of this intervention could have affected its effec-
+tiveness because successes of such interventions depend 
+mainly on contact duration and content. Similar supportive 
+sessions have been used successfully as a control com-
+parison to evaluate psychotherapeutic interventions70,71 
+and have been effective in controlling chemotherapy- 
+related side effects. Second, the duration of the intervention 
+was only 6 weeks, and we were not able to assess the 
+chronic long-term effects of these interventions on corti-
+sol rhythms. Third, it was not possible to conduct dexam-
+ethasone challenge in these participants or measure 
+awakening-related cortisol peaks, which are among the 
+standard tests for assessing HPA axis dysregulation.
+Conclusion
+Our study confirmed previous findings of reductions in 
+anxiety and depression following a yoga program. The 
+reduction in perceived stress and cortisol levels further 
+offers support for the stress reduction benefits of our 
+program. However, larger randomized controlled trials 
+with standard behavioral approaches as controls are 
+needed to validate our findings. Future studies should 
+unravel the putative neuroendocrine mechanisms of these 
+interventions and assess stress appraisal following these 
+interventions using laboratory stressors. 
+Acknowledgments
+This study was supported through a grant from Central 
+Council for Research in Yoga and Naturopathy, Ministry 
+of Health and Family Welfare, Government of India. We 
+are thankful to Gopal Krishna for assisting with labora-
+tory tests, K. N. Jayalakshmi for leading the yoga inter-
+vention, and Dr Ravi Kulkarni for assisting with statistical 
+methods. We thank all staff of Bangalore Institute of 
+Oncology and Bharath Hospital Institute of Oncology for 
+their support throughout the project. We thank all patients 
+and their spouses who participated in this study.
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+ at UQ Library on September 22, 2009 
+http://ict.sagepub.com
+Downloaded from 

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+174 	
+ Indian Journal of Palliative Care / May-Aug 2015 / Vol 21 / Issue 2
+INTRODUCTION
+Psychosocial morbidity is common in breast cancer 
+patients after mastectomy and increased during 
+radiotherapy (RT) and chemotherapy (CT), wherein 
+the majority of  patients reported some degree of 
+depression, anxiety, social dysfunction, and inability to 
+work.[1‑3] Anxiety and depression are the commonest 
+psychiatric problems encountered in cancer patients. It 
+has been repeatedly acknowledged that many psychiatric 
+disorders in cancer patients are not detected, diagnosed, 
+or treated.[4] The prevalence of depression in cancer 
+patients ranges from 4.5 to 58%.[5] Patients with breast 
+cancer undergoing radiation treatment also report anxiety 
+and depression before, during, and after the treatment.[6,7] 
+Original Article
+Effects of an integrated Yoga Program on Self-reported 
+Depression Scores in Breast Cancer Patients Undergoing 
+Conventional Treatment: A Randomized Controlled Trial
+Raghavendra Mohan Rao, Nagarathna Raghuram1, HR Nagendra1,  
+MR Usharani, KS Gopinath2, Ravi B Diwakar3, Shekar Patil3,  
+Ramesh S Bilimagga4, Nalini Rao4
+Department of Complementary and Alternative Medicine, 1Swami Vivekananda Yoga Anusandhana Samsthana, 
+2Department of Surgical Oncology, 3Department of Medical  Oncology, 4Department of Radiation Oncology, 
+Healthcare Global Enterprises Ltd, Bangalore, Karnataka, India
+Address for correspondence: Dr. Raghavendra Rao Mohan; E-mail: [email protected]
+ABSTRACT
+Aim: To compare the effects of yoga program with supportive therapy on self-reported symptoms of depression 
+in breast cancer patients undergoing conventional treatment.
+Patients and Methods: Ninety-eight breast cancer patients with stage II and III disease from a cancer 
+center were randomly assigned to receive yoga (n = 45) and supportive therapy (n = 53) over a 24-week 
+period during which they underwent surgery followed by adjuvant radiotherapy (RT) or chemotherapy (CT) 
+or both. The study stoppage criteria was progressive disease rendering the patient bedridden or any physical 
+musculoskeletal injury resulting from intervention or less than 60% attendance to yoga intervention. Subjects 
+underwent yoga intervention for 60 min daily with control group undergoing supportive therapy during their 
+hospital visits. Beck’s Depression Inventory (BDI) and symptom checklist were assessed at baseline, after 
+surgery, before, during, and after RT and six cycles of CT. We used analysis of covariance (intent-to-treat) 
+to study the effects of intervention on depression scores and Pearson correlation analyses to evaluate the 
+bivariate relationships.
+Results: A total of 69 participants contributed data to the current analysis (yoga, n = 33, and controls, n = 36). 
+There was 29% attrition in this study. The results suggest an overall decrease in self-reported depression with 
+time in both the groups. There was a significant decrease in depression scores in the yoga group as compared 
+to controls following surgery, RT, and CT (P < 0.01). There was a positive correlation (P < 0.001) between 
+depression scores with symptom severity and distress during surgery, RT, and CT.
+Conclusion: The results suggest possible antidepressant effects with yoga intervention in breast cancer patients 
+undergoing conventional treatment.
+Key words: Behavioral intervention, Cancer, Depression, Relaxation, Yoga
+Access this article online
+Quick Response Code:
+Website: 
+www.jpalliativecare.com
+DOI: 
+10.4103/0973-1075.156486
+ Indian Journal of Palliative Care / May-Aug 2015 / Vol 21 / Issue 2	
+175
+Rao, et al.: Antidepressant effects of yoga
+The prevalence of anxiety and depression in Indian cancer 
+patients in Bangalore undergoing radiation treatment was 
+64 and 50%, respectively.[6] There is a very high correlation 
+between anxiety and depression in cancer patients.[8]
+Many factors that contribute to development of 
+depression are related to cancer itself. This includes 
+reaction to disfigurement or mutilating surgeries, for 
+example, mastectomy vs lumpectomy patients, several 
+somatic symptoms such as pain,[9] medications, and 
+chemotherapeutic agents.[10] Although recent clinical 
+studies have not found a relationship between depression 
+and cancer outcome.[11] Studies show that depression 
+influences treatment‑related distress in cancer patients[8] 
+and warrant clinical attention because of their clear adverse 
+effects on the quality of life of cancer patients. Other 
+studies have shown depression to be related to prognostic 
+indicators of clinical and pathological response to CT,[12] 
+decreased survival age, abnormal diurnal cortisol rhythms 
+in metastatic breast cancer patients,[13] and predictor of 
+lower mortality.[14]
+Various behavioral interventions have been used 
+successfully to alleviate depression in these patients. 
+Possible explanations for effects of these interventions 
+in improving quality of life (Qol) outcomes and reducing 
+treatment‑related distress in these patients have been 
+attributed to: (i) Decrease in anxiety and affective states,[15] 
+(ii) resorting to more active–behavioral and active–cognitive 
+coping lifestyles,[16] and (iii) reinforcement of social support 
+and stress reduction.[17] While standard psychotherapy 
+approaches such as cognitive behavioral techniques or 
+supportive expressive group therapy encourage problem 
+solving, sharing, and support; they do not include 
+noncognitive resources such as body and breath awareness, 
+postures, meditation, or spiritual exploration. It is here that 
+complementary and alternative medicine approaches such 
+as yoga may be helpful.[18]
+Yoga as a complementary and mind body therapy is 
+being practiced increasingly in both Indian and western 
+populations. It is an ancient Indian science that has been 
+used for therapeutic benefit in numerous healthcare 
+concerns in which mental stress was believed to play a 
+role.[19] Earlier studies have shown beneficial effects with 
+yoga intervention in modulating depression in both healthy 
+volunteers[20,21] and those with established psychiatric 
+diagnoses of depression.[22,23] However, results from breast 
+cancer patients are mixed.[24,25]
+Though most of these studies lack effective controls, have 
+small sample size, use different types of yoga intervention, 
+and depression scales; they nevertheless show beneficial 
+antidepressant effects with yoga intervention.[26‑28]
+In an earlier study of yoga in a population of cancer 
+patients in India[29,30] undergoing radiation treatment; there 
+was an overall improvement in quality of life with patients 
+reporting increased appetite, improved sleep, improved 
+bowel habits, a feeling of peace, and tranquility. However, 
+in this study, yoga was integrated with psychotherapy 
+and this study lacked effective controls and involved 
+heterogeneous cancer population. Yoga with strong cultural 
+and traditional roots in India has a mass appeal. The 
+purpose of the current trial was to study whether a support 
+intervention based on use of a widely used mind/body 
+and psychospiritual intervention such as yoga would be a 
+viable alternative to standard “supportive therapy” sessions 
+in breast cancer outpatients undergoing conventional 
+treatment. We therefore hypothesized that an integrated 
+yoga‑based stress reduction program would help reduce 
+patient’s self‑reported depression during conventional 
+cancer treatment.
+PATIENTS AND METHODS
+This randomized controlled trial evaluated the effects of 
+yoga intervention versus supportive therapy in 98 newly 
+diagnosed stage II and III breast cancer patients undergoing 
+surgery followed by adjuvant RT and/or CT. Ethical 
+committee of the recruiting cancer center approved this 
+study. Patients were included if they met the following 
+criteria: (i) Women with recently diagnosed operable breast 
+cancer, (ii) age between 30 and 70 years, (iii) Zubrod’s 
+performance status 0–2 (ambulatory > 50% of time), 
+(iv) high school education, (v) willingness to participate, and 
+(vi) treatment plan with surgery followed by either or both 
+adjuvant RT and CT. Patients were excluded if they had (i) 
+a concurrent medical condition likely to interfere with the 
+treatment, (ii) any major psychiatric, neurological illness, 
+or autoimmune disorders, and (iii) secondary malignancy. 
+The details of the study were explained to the participants 
+and their informed consent was obtained.
+Baseline assessments were done on 98 patients prior to their 
+surgery. Sixty‑nine patients contributed data to the current 
+analyses at the second assessment (post‑surgery‑4 weeks 
+after surgery), 67 patients during and following RT, and 
+62 patients during and following CT. 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 illnesses. However, the order of 
+176 	
+ Indian Journal of Palliative Care / May-Aug 2015 / Vol 21 / Issue 2
+Rao, et al.: Antidepressant effects of yoga
+adjuvant treatments following surgery differed among 
+the subjects [Table 1]. There were four to six assessments 
+depending on the treatment regimen. The assessments 
+were scheduled at pre‑ and post‑surgery; pre‑, mid‑, and 
+post‑RT, and CT. Moreover, all participants in the study 
+received the same dose of radiation (50c Gy over 6 weeks) 
+and prescribed standard CT schedules (cyclophosphamide, 
+methotrexate, and fluororacil  (CMF) or fluroracil, 
+adriamycin, and cyclophosphamide (FAC).
+Measures
+At the initial visit before randomization demographic 
+information, medical history, clinical data, intake of 
+medications, investigative notes, and conventional 
+treatment regimen were ascertained from all consenting 
+participants. Participants completed the Beck’s 
+Depression Inventory (BDI) that consists of a set of 
+21 questions.[31] The questionnaire was translated to 
+local language (Kannada) and the same was validated. 
+This is a self‑report measure used to assess behavioral 
+manifestations of depression having reliability between 
+0.48 and 0.86 and a validity of  0.67 with diagnostic 
+criteria.
+Subjective symptom checklist was developed during the 
+pilot phase to assess treatment‑related side effects, problems 
+with sexuality and image, and relevant psychological and 
+somatic symptoms related to breast cancer. The checklist 
+consisted of  31 such items each evaluated on two 
+dimensions; severity graded from no to very severe (0–4), 
+and distress from not at all to very much (0–4). These scales 
+measured the total number of symptoms experienced, 
+total/mean severity and distress score, and was evaluated 
+previously in a similar breast cancer population.[32]
+Randomization
+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. Participants 
+were randomized at the initial visit before starting 
+any conventional treatment. Following randomization 
+participants underwent surgery followed by either RT 
+or CT or both and was followed‑up with their respective 
+interventions.
+Interventions
+The intervention group received “integrated yoga program” 
+and the control group received “supportive therapy” both 
+imparted as individual sessions. 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.
+The yoga practices consisted of a set of asanas,[8] breathing 
+exercises, Pranayama  (voluntarily regulated nostril 
+breathing), meditation, and yogic relaxation techniques 
+with imagery.
+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, pranayama, and yogic 
+relaxation. The subjects were then guided through any 
+one of these meditation practices for next 30 min. This 
+included focusing awareness on sounds and chants from 
+Vedic texts,[33] or breath awareness and impulses of touch 
+emanating from palms and fingers while practicing yogic 
+mudras, or a dynamic form of meditation which involved 
+practice with eyes closed of four yoga postures interspersed 
+Table 1: Demographic characteristics
+All subjects
+Yoga group
+Control group
+N
+(%)
+n
+(%)
+n
+(%)
+Stage of breast cancer
+II
+31
+45
+17
+54.83
+14
+45.16
+III
+38
+55
+16
+42.1
+22
+57.89
+Grade of breast cancer
+I
+1
+1
+1
+100
+0
+0
+II
+8
+12
+6
+75
+2
+25
+III
+60
+87
+26
+43
+34
+57
+Menopausal status
+Pre
+33
+48
+20
+61
+13
+39
+Post
+33
+48
+11
+33
+22
+67
+Peri
+1
+1
+1
+100
+0
+0
+Post hysterectomy
+2
+3
+1
+50
+1
+50
+Histopathology type
+IDC
+52
+75
+28
+54
+24
+46
+ILC
+9
+13
+3
+33
+6
+67
+IPC
+6
+9
+2
+33
+4
+67
+IDC‑P
+2
+3
+0
+0
+2
+100
+Treatment regimen
+S+RT+CT
+38
+55.1
+18
+54.5
+20
+55.6
+S+CT+RT
+4
+5.8
+2
+6.1
+2
+5.6
+S+CT3+RT+CT3
+17
+24.6
+7
+21.2
+10
+27.8
+S+CT
+3
+4.4
+1
+3.0
+2
+5.6
+S+RT
+7
+10.1
+5
+15.2
+2
+5.6
+Stressful life events past 2 years
+Yes
+19
+28
+8
+42
+11
+58
+No
+50
+72
+25
+50
+25
+50
+Control group‑supportive therapy group. IDC: Invasive ductal carcinoma, ILC: Invasive 
+lobular carcinoma, IPC: Invasive papillary carcinoma, S: Surgery, RT:  Radiotherapy, 
+CT: Chemotherapy, IDC-P: Invasive ductal carcinoma - Papillary
+ Indian Journal of Palliative Care / May-Aug 2015 / Vol 21 / Issue 2	
+177
+Rao, et al.: Antidepressant effects of yoga
+with relaxation while supine, thus achieving a combination 
+of both “stimulating” and “calming,” practice.[34] 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.
+Subjects were provided audiotapes of these practices for 
+home practice using the instructors voice so that a familiar 
+voice could be heard on the cassette. Subjects underwent 
+in person sessions during their hospital visits and stay 
+and were asked to practice at home on remaining days. 
+Their instructors through telephone calls, weekly house 
+visits, and daily logs monitored their home practice on a 
+day‑to‑day basis. The subjects were required to practice 
+yoga for 1 h at least thrice a week. One yoga therapist and 
+one trained counselor were involved in imparting their 
+respective interventions. Both had master’s degree in their 
+respective fields.
+The control intervention consisted of supportive‑expressive 
+therapy with education as a component.[35] Supportive 
+counseling sessions as control intervention 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. The supportive‑expressive 
+therapy as a control intervention involved creating a 
+supportive environment to facilitate the patients to 
+express their problems, strengthen their relationships 
+in the family and community, and find meaning 
+in their lives. The intervention was unstructured, 
+with therapists trained to facilitate discussion of 
+the following themes in an emotionally expressive 
+rather than a didactic format: (i) Addressing concerns 
+regarding fears of toxicity, image change, resulting from 
+treatment;(ii) improving support and communication 
+with family and friends; (iii) integrating a changed self 
+and body image; and (5) improving communication with 
+physicians;(6) allaying fears of recurrence, progression, 
+and death and learning to cope with them.
+We chose to have this as a control intervention mainly 
+to control for nonspecific effects of the yoga program 
+that may be associated with adjustment such as attention, 
+support, and a sense of control. This counseling was 
+imparted during their hospital visits and was extended over 
+the course of their adjuvant RT and CT cycles (once in 
+10 days, 30 min sessions) and participants were encouraged 
+to contact their counselor whenever they had any concerns 
+or issues to discuss. Similar supportive sessions have been 
+used successfully as a control comparison group to evaluate 
+psychotherapeutic interventions[36,37] and similar coping 
+preparations have been effective in controlling CT‑related 
+side effects.[38]
+The investigating team did not have any role in imparting 
+intervention. The yoga therapists were not involved in 
+taking assessments.
+Statistical methods
+Earlier studies have reported large effect sizes (>1) for 
+depressive symptoms with both yoga and behavioral 
+interventions.[39,40] We therefore chose to have a conservative 
+estimate of effect size (standardized difference d) of 0.8 
+for our study. The sample size needed in our study was 
+based on formula; n = number of groups/d2 × C p, power, 
+where, d is the standardized difference and C p, power is a 
+constant defined by values chosen for P value and power. 
+Considering P at 0.05 and 80% power, the C p, power 
+value is 7.9[41] and standardized difference d as 0.8; going 
+by the formula we have n = 2/0.8 2 × 7.9 = 25 subjects 
+in each arm. Taking into consideration a dropout rate of 
+25% and considering that intervention was for a different 
+population (cancer patients) with a control intervention, 
+we chose to have approximately 55 subjects in each arm.
+Data were analyzed using Statistical Package for Social 
+Sciences version  20.0 for PC windows 2000. Study 
+participants underwent surgery, RT, and CT and interventions 
+were compared for each of these treatments. Mean scores 
+for Beck’s depression scores was calculated for the complete 
+sample. Since order of their adjuvant treatment differed, an 
+analysis of covariance (ANCOVA) was done to compare 
+groups at each follow‑up assessment using the baseline pre 
+surgery measure as a covariate. There were 12 dropouts 
+in yoga and 17 in control group, the reasons for dropouts 
+are given in trial profile. Alternatively, intent‑to‑treat (ITT) 
+analyses were done using the initially randomized sample 
+where in the baseline value of noncompleters was carried 
+forward to replace their missing values at subsequent 
+assessments. This was done to assess the potential impact of 
+the missing data on the results. Simple Pearson correlation 
+analyses was used to study the bivariate relationships 
+between depression scores and treatment related symptom 
+severity and distress at various conventional treatment 
+intervals (post‑surgery/mid RT/mid CT).
+RESULTS
+The groups were similar with respect to sociodemographic 
+and medical characteristics. Though there was heterogeneity 
+178 	
+ Indian Journal of Palliative Care / May-Aug 2015 / Vol 21 / Issue 2
+Rao, et al.: Antidepressant effects of yoga
+with respect to treatment regimen, this distribution did not 
+differ across groups [Table 1]. There were no dropouts due 
+to injuries due to their participation in the study.
+Beck’s depression scores
+Both the groups reported decrease in their depression with 
+time. Analysis of covariance was done comparing follow‑up 
+measures between yoga and control groups controlling for 
+baseline differences. Analysis of covariance using baseline 
+depression scores as a covariate showed significant decrease 
+in depression following surgery (F (65) =7.06, P = 0.01), 
+before RT  (F  (62) =7.77, P  = 0.007), and following 
+RT (F (62) =17.35, P < 0.001) in the yoga group as 
+compared to controls. The yoga group also showed 
+decrease in depression score before CT (F (57) =6.02, 
+P = 0.02), and after CT (F (57) =10.90, P = 0.002) as 
+compared to controls. The decrease in depression became 
+more evident during treatment with significant decrease 
+during RT (F (62) =13.32, P = 0.001) and CT (F (57) =22.3, 
+P < 0.001) [Table 2].
+ITT analyses done on the initial randomized sample 
+showed significant decreases in depression scores before 
+(F (1, 91) =6.67, P = 0.01) and during RT (F (1, 91) =6.28, 
+P = 0.01) and before (F (1, 86) =3.88, P = 0.05) and during 
+CT (F (1, 86) =12.8, P = 0.001) only.
+There was a positive significant correlation between 
+depression scores with symptom severity and distress 
+following surgery, during RT and CT [Table 3].
+DISCUSSION
+We compared the effects of a 24‑week yoga program with 
+supportive therapy in 98 recently diagnosed breast cancer 
+outpatients undergoing surgery, RT, and CT. The results 
+suggest an overall decrease in depression scores with time 
+in both the groups. Yoga intervention decreased depressive 
+symptoms more than the controls from their baseline 
+means by 42% following surgery, 28.1 and 28.5% during 
+and following RT, respectively, and 39.5 and 29.2% during 
+and following CT, respectively. Our results are consistent 
+with other studies using relaxation techniques and adjuvant 
+psychological therapy that have shown a similar decrease 
+in depression in these populations.[36] The effect size for 
+decrease in self‑reported depressive symptoms using BDI 
+in our study was large (>0.8). In the earlier study using 
+mindfulness‑based stress reduction (MBSR) in cancer 
+patients the effect size for depression was 0.3 using the 
+subscale of Profile of Mood States (POMS).[25] However, 
+earlier studies using behavioral therapy[39] and yoga[40] 
+have reported large effect sizes (>1) for their respective 
+interventions. This large effect size could partly be due to 
+the fact that, BDI has limitations in subjects with physical 
+health problems and has less test retest reliability on 
+repeated measurements.[42] Irrespective of the magnitude 
+of effect size, our study shows that yoga is beneficial 
+in reducing self‑reported symptoms of depression and 
+numerous studies have reported beneficial antidepressant 
+effects with similar stress reduction interventions such as 
+relaxation training in cancer patients.[41]
+Stress has been implicated in the pathogenesis of 
+depression[43] and an extensive literature has documented 
+the association of  depression with elevated cortisol 
+levels;[44] various conceptual models have been proposed 
+such as the allostatic load model and posttraumatic 
+phenomenology to explain the relationships between stress 
+and neuroendocrine dysregulation.[45]
+Overall, the antidepressant effects of yoga program could 
+be attributed to stress reduction rather than mere social 
+support and education. This is consistent with earlier 
+studies that have shown better results with stress reduction 
+than purely supportive interventions.[46,47]
+Table 2: Comparison of posttest BDI scores adjusted for baseline scores between groups (yogacontrol) 
+using ANCOVA at various stages of conventional treatment
+Pre surgery
+Post surgery
+During radiotherapy
+During chemotherapy
+Pre RT
+Mid RT
+Post RT
+Pre CT
+Mid CT
+Post CT
+Outcome measures
+Y (n=33), C (n=36)
+Y (n=32), C (n=35)
+Y (n=28), C (n=34)
+BDI (Mean (SD))
+Yoga
+12.1±6.4
+11.6±4.5
+9.8±4.7
+5.5±3.5
+3.7±3.2
+7.5±5.8
+6.6±4.6
+3±3.4
+Control
+15.1±7.3
+15.1±5.3
+13.3±4.9
+11.11±7.7
+8.9±6.3
+12.2±7.5
+14.2±6.6
+7.6±6.1
+ô Adjusted mean
+(Y−C)
+−2.63**
+−3.35**
+−5.74***
+−5.38***
+−3.96*
+−7.25***
+−4.36**
+(95% CI)
+−4.6 to−0.65
+−5.8 to−0.95
+−8.9 to−2.6
+−7.9 to−2.8
+−7.2 to−0.73
+−10.3 to−4.2
+−7.0 to−1.7
+*P <0.05, **P <0.01, ***P <0.001. ôPosttest scores (Y−C) adjusted for their baseline scores between yoga and control groups with 95% CI and using ANCOVA for P values Y: 
+Yoga, C: Control/supportive therapy group, SD: Standard deviation, CI: Confidence interval, ANCOVA: Analysis of covariance, BDI: Beck’s Depression Inventory, RT: Radiotherapy, 
+CT: Chemotherapy
+ Indian Journal of Palliative Care / May-Aug 2015 / Vol 21 / Issue 2	
+179
+Rao, et al.: Antidepressant effects of yoga
+The antidepressant effects of yoga intervention could be 
+explained by reduction in the levels of psychophysiological 
+arousal such as decrease in sympathetic activity,[20] balance 
+in the autonomic nervous system responses,[48] alterations 
+in neuroendocrine arousal,[49,50] and decrease in morning 
+cortisol.[40]
+Scores on self‑reported symptoms of depression correlated 
+directly with symptom severity and distress at various stages 
+of conventional treatment further supporting the idea 
+that reductions in stress could contribute to decrements 
+in treatment related distress, outcomes, and depression in 
+cancer patients.[51] We have shown earlier that yoga has been 
+helpful in reducing both post CT nausea and anticipatory 
+nausea and vomiting. This has been attributed to stress 
+reduction effects of yoga intervention.[52]
+In our study, depression scores of subjects varied with 
+treatment intervals and time similar to earlier observations 
+in cancer patients.[53,54]
+One of the major limitations of the study was not tailoring 
+the control intervention to that of Yoga intervention. 
+While yoga group underwent intervention at least three 
+times a week, the control group had intervention only 
+once in 10 days. It may be argued that yoga group received 
+more attention than the supportive therapy group and 
+this could have contributed towards a placebo effect. 
+However, unlike other studies using waitlisted controls, 
+the control group here also received supportive therapy 
+sessions. These sessions were used only with an intention 
+of  negating the confounding variables such as social 
+support, instructor–patient interaction, education, and 
+attention that are known to improve the psychological 
+and social functioning in cancer patients.[37] Another 
+objective of using social support as a control was with 
+a view of analyzing and identifying the effects of stress 
+reduction conferred by yoga intervention versus a purely 
+supportive intervention on outcome measures. Yoga is 
+a mind body intervention and as such it is difficult to 
+tailor an active comparator arm for this intervention. 
+Moreover, earlier studies have also demonstrated that 
+placebo effects caused due to attention is unfounded in 
+subjects with melancholia.[55] We chose to have individual 
+therapy sessions as against group practice, as individual 
+sessions also helped to understand the specific needs and 
+concerns of participants and monitor individual progress 
+in practice, thereby reducing the confounding effects of 
+being in a group.[56]
+Secondly, some of the symptoms on BDI also mimic 
+symptoms of cancer disease and treatment like feeling 
+down, lack of energy or fatigue, anorexia, weight loss, 
+etc., which could have contributed to increased scores on 
+BDI. However, since all patients underwent conventional 
+treatment, any increase in BDI could have had a floor effect 
+across the entire study group.
+CONCLUSION
+Overall, the study shows benefit finding for reducing 
+self‑reported depression scores in operable breast cancer 
+patients undergoing cancer directed treatment. However, 
+future studies should assess role of yoga in managing 
+clinical depression in this population.
+ACKNOWLEDGEMENT
+This study is funded with grants from Central Council for 
+Research in Yoga and Naturopathy, Dept of AYUSH, Ministry 
+of Health and Family Welfare, Govt of India. We are thankful 
+to them for their support.
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+Gopinath KS, Diwakar RB, et al. Effects of an integrated yoga program on 
+self-reported depression scores in breast cancer patients undergoing conventional 
+treatment: A randomized controlled trial. Indian J Palliat Care 2015;21:174-81.
+Source of Support: Grant from Central Council for Research in Yoga 
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+Family Welfare, New Delhi. Conflict of Interest: None declared.

subfolder_0/Effects of an integrated yoga program in modulating psychological stress and radiation-induced genotoxic stress in breast cancer patients undergoing radiotherap.txt

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+242
+INTEGRATIVE CANCER THERAPIES 6(3); 2007 pp. 242-250
+Effects of an Integrated Yoga Program in
+Modulating Psychological Stress and Radiation-
+Induced Genotoxic Stress in Breast Cancer
+Patients Undergoing Radiotherapy
+Birendranath Banerjee, MSc, H. S. Vadiraj, BNYS, Amritanshu Ram, MSc,
+Raghavendra Rao, BNYS, PhD, Manikandan Jayapal, MSc,
+Kodaganur S. Gopinath, MBBS, MS, B. S. Ramesh, MBBS, MD, Nalini Rao, MBBS, MD,
+Ajay Kumar, MBBS, DNB, Nagarathna Raghuram, MD, MRCP, FRCP,
+Sridevi Hegde, MBBS, DCh, PhD, H. R. Nagendra, PhD, and M. Prakash Hande, PhD
+Effects of an integrated yoga program in modulating per-
+ceived stress levels, anxiety, as well as depression levels
+and radiation-induced DNA damage were studied in 68
+breast cancer patients undergoing radiotherapy. Two psy-
+chological questionnaires—Hospital Anxiety and Depression
+Scale (HADS) and Perceived Stress Scale (PSS)—and DNA
+damage assay were used in the study. There was a significant
+decrease in the HADS scores in the yoga intervention group,
+whereas the control group displayed an increase in these
+scores. Mean PSS was decreased in the yoga group, whereas
+the control group did not show any change pre- and postra-
+diotherapy. Radiation-induced DNA damage was signifi-
+cantly elevated in both the yoga and control groups after
+radiotherapy, but the postradiotherapy DNA damage in the
+yoga group was slightly less when compared to the control
+group. An integrated approach of yoga intervention modu-
+lates the stress and DNA damage levels in breast cancer
+patients during radiotherapy.
+Keywords:
+yoga; meditation; radiotherapy; stress; DNA damage
+Breast cancer is a profoundly stressful disease posing
+both physical and psychological threats to the patient.
+Moreover, patients with breast cancer normally receive
+multimodal treatment over a long period. Psycholo-
+gical distress and trauma are commonly associated with
+the diagnosis of cancer.1-3 Uncertainty about the prog-
+nosis of cancer and social isolation, along with physical
+symptoms or functional losses resulting from the dis-
+ease or its treatment, are the most important factors.
+Due to these various difficulties,4-6 many patients believe
+that stress, including that which is caused by their
+cancer experience, may contribute to poor coping as
+well as recurrence or progression of their disease. In the
+past decade, there has been a growing interest among
+cancer survivors in the use of various complementary
+therapies as adjuvants to conventional treatment in the
+anticipation of reducing the burden of stress and
+better coping with the treatment.7-9 There is a consid-
+erable use of these therapies in recent times in associa-
+tion with cancer treatment; therefore, there is a need
+to understand the links between social, psychological,
+and physiological determinants of health.10 Yoga is an
+ancient Eastern practice that has been used for thera-
+peutic benefits worldwide and is being scientifically
+studied by many clinicians.11 It has been suggested that
+“gentler” physical activities, such as yoga or tai chi, may
+help to promote regular participation in exercise, espe-
+cially in chronic disease populations who face addi-
+tional barriers to engaging in active lifestyles.10,12 There
+have been a number of studies including random-
+ized trials that reported positive therapeutic out-
+comes following yoga programs, including our group.13
+A wide range of benefits have been reported includ-
+ing improvements in asthma,14 immune function,15-17
+hypertension,18-20 cardiovascular effects,12,21,22 blood
+pressure,23,24 diabetes,25 and serum cortisol levels.23
+The use of complementary and alternative medicine
+(CAM) as an adjuvant therapy in breast cancer patients
+Yoga Intervention Modulates Genotoxic Stress Following Radiotherapy
+DOI: 10.1177/1534735407306214
+BB, MJ, and MPH are at the Genome Stability Laboratory, Depart-
+ment of Physiology, Y
+ong Loo Lin School of Medicine, National
+University of Singapore, Singapore. BB and SH are in the Depart-
+ment of Medical Genetics, Manipal hospital, Bangalore, India. BB,
+HSV, AR, RR, NR, and HRN are in the Department of Life Sciences,
+Swami Vivekananda Yoga Research Foundation, SVYASA
+University, Bangalore, India. KSG, BSR, and NR are in the Depart-
+ment of Radiation and Surgical Oncology, Bangalore Institute of
+Oncology, Bangalore, India. AK is at the Bharath Cancer Hospital,
+Mysore, India.
+Correspondence: M. Prakash Hande, PhD, Department of Phy-
+siology, Yong Loo Lin School of Medicine, National University 
+of Singapore, #02-12, Block MD9, 2 Medical Drive, Singapore
+117597; Republic of Singapore; e-mail: [email protected].
+ at FLORIDA INTERNATIONAL UNIV on December 21, 2014
+ict.sagepub.com
+Downloaded from 
+Yoga Intervention Modulates Genotoxic Stress Following Radiotherapy
+INTEGRATIVE CANCER THERAPIES 6(3); 2007
+243
+has attracted the attention of many researchers world-
+wide.7 Burstein et al26 reported that newly diagnosed
+early-stage breast cancer patients who were using CAM
+showed psychosocial stress and had low mental health
+scores 3 months after diagnosis. Meditation was origi-
+nally used as a religious or spiritual practice; it has now
+been accepted worldwide as an effective tool to calm
+the mind and harmonize the physiological and psy-
+chological parameters.13 Meditation-based relaxation
+programs have been implemented in a number of ran-
+domized and pilot studies, particularly those done by
+Carlson et al,27-29 that reported reductions in total
+mood disturbance and specific symptoms of anxiety,
+depression, anger, and confusion. In all these studies,
+the main aim was to improve the quality of life of either
+breast cancer survivors or those who were undergoing
+treatment. There have been reports of improvement of
+quality of life (QOL) in breast cancer patients who
+underwent yoga-based programs or supportive coun-
+seling along with relaxation and imagery.30,31
+Inspired by the favorable outcome of these inter-
+ventional studies, Carson et al32 recently reported sig-
+nificant improvement in pain as well as psychological
+parameters of metastatic breast cancer patients. Another
+recent study showed no physical improvement in
+breast cancer survivors over control patients after yoga
+intervention but a significant improvement in the
+global QOL scores and mood disturbance scores.3 In
+our recent study, Raghavendra et al33 reported that
+breast cancer patients in a yoga program had signifi-
+cant improvement in chemotherapy-induced nausea
+and emesis in quality of life. The current study exam-
+ines the effect of an intensive and integrated yoga
+program that is customized for breast cancer patients
+in modulating psychological and physiological stress.
+It is known that radiation causes DNA damage 
+to peripheral blood lymphocytes (PBLs) of patients
+undergoing radiotherapy treatment.34,35 We also
+reported a significant increase in radiation-induced
+DNA damage in breast cancer patients undergoing
+radiotherapy.36 DNA damage in the form of telomere
+shortening has been linked to increased stress in a pop-
+ulation of caregivers.37 DNA repair capacity is also asso-
+ciated with psychological and physiological stress.38-40
+Therefore in view of the fact that breast cancer patients
+are under stress and that they also undergo consider-
+able radiation-induced DNA damage, we investigate 
+in the present study the effect of an intensive yoga
+program on psychological parameters (Hospital Anxiety
+and Depression Scale [HADS] and Perceived Stress
+Scale [PSS]) as well as radiation-induced DNA damage
+in the PBLs derived from the breast cancer patients
+pre- and post-radiotherapy, using both an intervention
+and a supportive counseling group.
+Methods
+Patients Recruitment
+A randomized controlled study was initiated and 
+a convenience sampling strategy was used to enroll
+patients in the study. The patients were recruited from
+3 cancer hospitals in India, Bangalore Institute of
+Oncology (BIO), Manipal Hospital, Bangalore, India,
+and Bharat Cancer Hospital, Mysore, India. Clinical
+staff were informed of the study and invited to refer
+patients. Posters and leaflets announcing the study
+and inviting patient participation were posted in
+public areas of the clinic. A total of 68 patients were
+recruited from January 2004 until December 2005
+who met the inclusion criteria of (1) recently oper-
+ated breast cancer, (2) age between 30 and 70 years, 
+(3) Zubrod’s performance status 0-2 (ambulatory 
+> 50% of time), (4) high school education, (5) treat-
+ment plan of radiotherapy or both adjuvant radiother-
+apy and chemotherapy, and (6) consent to participate
+in the study. Participants were excluded if they had any
+concurrent medical condition likely to interfere with
+the treatment; major psychiatric, neurological illness,
+or autoimmune disorders; cardiovascular illness; and
+any known metastases. The patients must not have
+had any exposure to other mutagens, smoking, or
+alcohol for at least 3 months prior to preradiation
+blood donation.
+Of the 68 participants randomized to yoga and sup-
+portive therapy initially at the start of the study, 58 par-
+ticipants (yoga n = 35 and control n = 23) completed
+their prescribed radiotherapy treatment of 6 weeks and
+received a cumulative dose of 50.4 Gy. There were 
+10 dropouts either immediately after random assign-
+ment or in the course of the study in the control group
+who did not attend the yoga sessions (Figure 1). The
+reasons for dropouts were attributed to migration to
+other hospitals, use of other complementary therapies
+(eg, homeopathy or ayurveda), lack of interest or other
+concurrent interest, and chemotherapy-induced severe
+discomfort.
+Randomization
+Randomization was performed using a computer-
+generated random numbers table with group assign-
+ments that was sent to the clinics of the 3 recruiting
+hospitals, which was used sequentially to order group
+assignments during recruitment. The order of random-
+ization was verified with the hospital date of admission
+ at FLORIDA INTERNATIONAL UNIV on December 21, 2014
+ict.sagepub.com
+Downloaded from 
+Banerjee et al
+244
+INTEGRATIVE CANCER THERAPIES 6(3); 2007
+records for radiotherapy at intervals to make sure that
+field personnel had not altered the sequence of ran-
+domization to suit allocation of consenting participants
+into the 2 study arms. Of the 58 remaining patients in
+the study group, 35 were randomly assigned to the yoga
+intervention group and 23 patients were assigned to
+the supportive counseling group. Patients were all
+counseled, and consent was obtained prior to recruit-
+ment into the study. The project was approved by the
+institutional review boards of all 3 recruiting hospi-
+tals and SVYASA University India.
+Blood Collection
+Five milliliters of peripheral blood pre- and post-
+scheduled radiotherapy were collected by venipunc-
+ture vacutainer method. The blood samples were
+coded prior to the dispatch to the laboratory.
+During the initial visit, demographic information
+including age, marital status, education, occupation,
+obstetric and gynecologic history, medical history,
+and intake of medications were obtained, and clinical
+data were abstracted, including the history of breast
+cancer, investigative notes, and radiotherapy and
+chemotherapy treatment regimen.
+Questionnaires
+The patients were asked to complete questionnaires
+at various assessment points and were assisted by the
+field personnel if they sought any clarification. The
+research assistants were trained in imparting ques-
+tionnaires.
+Hospital Anxiety and Depression Scale
+This is a 14-item questionnaire developed by Snaith
+and Zigmond and used for screening for depression
+and anxiety in hospital patients. It has a high relia-
+bility of .62 to .8 and correlates strongly with DSM-IV
+criteria for depression and anxiety. The Depression
+subscale and the Anxiety subscale both have maxi-
+mum scores of 21 points.
+Figure 1. Flow chart of study recruitment, randomization, and trial procedure. HADS = Hospital Anxiety and Depression Scale; PSS =
+Perceived Stress Scale.
+68 patients recruited
+who gave voluntary consent
+35 patients (yoga group)
+completed study
+23 patients (control group)
+completed study
+Psychological questionnaires taken
+pre-and postradiotherapy:
+HADS and PSS
+Psychological questionnaires taken
+pre-and postradiotherapy:
+HADS and PSS
+5 mi of peripheral blood drawn
+pre-and postradiotherapy for
+DNA damage analysis
+Yoga Group 
+(n = 35)
+5 mi of peripheral blood drawn
+pre-and postradiotherapy for
+DNA damage analysis
+Supportive Counseling Group
+(n = 33)
+Integrated yoga program was conducted
+in groups with counseling 
+for a period of 6 weeks
+Supportive counseling was given
+instead of yoga program 
+for 6 weeks
+ at FLORIDA INTERNATIONAL UNIV on December 21, 2014
+ict.sagepub.com
+Downloaded from 
+Yoga Intervention Modulates Genotoxic Stress Following Radiotherapy
+INTEGRATIVE CANCER THERAPIES 6(3); 2007
+245
+Perceived Stress Scale41
+The 10-item version of the PSS, which was designed
+for use with community samples, is now the most
+widely used self-report measure of psychological
+stress. Participants respond how often during the
+past month they experienced thoughts and feelings
+such as “felt that you were unable to control the
+important things in your life,” “felt that things were
+going your way,” or “been unable to control irrita-
+tions in your life.” The maximum score on the PSS is
+40 points.
+DNA Damage Study
+Alkaline Single-Cell Gel 
+Electrophoresis (Comet) Assay
+Peripheral blood lymphocytes were isolated by density
+gradient method from the blood collected from the
+patients before and after radiotherapy. The cells were
+washed in ice-cold 1× PBS, and resuspended in Hanks
+balanced salt solution with 10% dimethyl sulfoxide
+with ethylenediamine tetra-acetic acid. The cells were
+then suspended in (0.75%) molten low melting point
+agarose (at 37°C) and immediately pipetted onto the
+comet slides (Trevigen, Gaithersburg, MD). Electro-
+phoresis was done as per the vendor’s suggestions.
+After electrophoresis, slides were briefly rinsed in neu-
+tralization buffer (500 mmol/L Tris-HCl, pH 7.5), air-
+dried, and stained with propidium iodide dye. Three
+hundred to 400 randomly chosen comets were ana-
+lyzed per sample. The extent of DNA damage observed
+was expressed as number of comets analyzed per 100
+cells, which corresponded to the fraction of the DNA
+damage in the peripheral blood lymphocytes of the
+patients, and the data were compared using suitable
+statistics (SPSS software version 10) between pre-
+and postradiotherapy in the yoga and control groups
+of patients. The comet slides were coded and ana-
+lyzed blinded. The slides were decoded after the
+analysis.
+Integrated Yoga Program42
+The randomly assigned intervention group was
+trained under a group of expert yoga trainers for 6
+weeks. In the beginning, only meditative practice as
+well as slow stretching and loosening exercises were
+taught to the patients. They were motivated and
+counseled at the beginning, and the various postures
+(asanas) were meticulously taught. The special tech-
+niques designed for the cancer patients included
+guided imagery of cancer cells, positive thought provo-
+cation, and chanting of various sounds according to
+the respective religious beliefs of the patients. During
+the middle period of the trial, group awareness
+practices were given. They were also provided with
+the audio and video tools to practice at home and
+were followed up via telephone during weekends to
+ensure continuity of practice. Special care was taken
+for patients who suffered from surgery-associated
+side effects such as numbness or pain. The patients
+were familiarized with various breathing practices
+called Pranayama (voluntary regulated nostril breath-
+ing). Each session was of 90 minutes duration, with
+full-time breath awareness and complete relaxation.
+At the end of each session, deep relaxation was given
+in the form of soothing sound vibrations and guided
+imagery called yoga nidra. These practices are
+thought to build inner awareness and attention of
+mental phenomena. This is known to alter the per-
+ceptions and mental responses to both external and
+internal stimuli, slow down reactivity and responses
+to such stimuli, and instill a greater control over
+stressful situations, which promotes physical well-
+being and mental calmness. Control-group patients
+were given supportive counseling and advised to
+take light exercise.
+Results
+A total of 58 patients completed the study (Table 1).
+Among the entire study population, 30 (52%) did
+not undergo chemotherapy immediately after
+surgery. Patients underwent a total of 28 cycles of
+radiotherapy; 5 (9%), 16 (28%), and 7 (11%) under-
+went 1, 2, and more than 2 cycles of chemotherapy,
+respectively. In the study cohort, 26 patients (45%)
+had stage II breast cancer, and 32 (55%) had stage III
+breast cancer, whereas 27 (46%) had histological
+grade II breast tumors, and 31 (54%) had grade III
+breast tumors. Thirty-four women (59%) were men-
+struating, and 24 (41%) had attained menopause,
+whereas 5 (9%) had undergone a hysterectomy. Four-
+teen (24%) had a history of stressful events in the
+past, whereas the majority (44, 76%) did not report
+any stressful or traumatic experience in the past.
+Anxiety and Depression Scores
+There was a significant decrease in the anxiety levels
+in the yoga intervention group from a mean of 8.5
+(SD = 1.6) at baseline to a mean of 4.1 (SD = 1.0)
+(48.2%) after the 6 weeks of the yoga program
+(Figure 2, Table 2). In the control group, the mean
+anxiety score increased from 8.2 (SD = 1.1) to 10.5
+(SD = 1.8) (28%) (Figure 3). Based on repeated mea-
+sures ANCOVA, controlling for baseline values of
+each dependent variable, the change in anxiety was
+significantly different between the groups (P < .001).
+The postradiotherapy depression score for the inter-
+vention group decreased from a mean of 8.0 (SD = 1.9)
+ at FLORIDA INTERNATIONAL UNIV on December 21, 2014
+ict.sagepub.com
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+Banerjee et al
+246
+INTEGRATIVE CANCER THERAPIES 6(3); 2007
+at baseline to a mean of 3.4 (SD = 0.5) (57.5%) after
+the yoga program (Figure 2, Table 2). In the control
+group, the score increased from 7.8 (SD = 0.9) at base-
+line to 9.7 (SD = 1.2) (24%) (Figure 3, Table 2). Based
+on repeated measures ANCOVA, controlling for
+baseline values of each dependent variable, the change
+in depression was significantly different between the
+groups (P < .001).
+Stress Scores
+In the yoga group (Figure 4, Table 2), the mean 
+perceived stress score (PSS) decreased from 20.4 
+(SD = 2.8) at baseline to 14.9 (SD = 2.4) postradio-
+therapy (26.9%), whereas the control group (Figure
+5, Table 2) showed no change pre- and postradio-
+therapy (mean = 19.0 [SD = 2.1] at baseline and mean
+= 20.4 [SD = 2.5] postradiation).
+DNA Damage
+The extent of radiation-induced DNA damage was 
+estimated by alkaline single-cell gel electrophoresis
+(Figure 6). The DNA damage due to radiation was sig-
+nificantly elevated in both the yoga and control groups
+after radiotherapy. The postradiotherapy DNA damage
+Table 1.
+Demographic Particulars of the Patients Included in the Clinical Trial.
+Table 2.
+Comparative Scores of HADS, PSS, and DNA Damage of the Yoga and Control Groups (Mean ± SD)
+All Patients 
+Yoga group
+Control Group
+Age Mean = 44 yrs (SD = 1.3)
+Age Mean = 47 yrs ( SD = 1.1) Age Mean = 43 yrs ( SD = 1.5)
+N = 58
+%
+N = 35
+%
+N = 23
+%
+Cycles of chemotherapy
+None
+30
+52
+14
+40
+16
+70
+1
+5
+9
+3
+9
+2
+9
+2
+16
+28
+12
+34
+4
+17
+> 2
+7
+11
+6
+17
+1
+4
+Stage of breast cancer
+II
+26
+45
+16
+46
+10
+43
+III
+32
+55
+19
+54
+13
+57
+Grade of breast tumor
+II
+27
+46
+17
+48
+10
+43
+III
+31
+54
+18
+52
+12
+57
+Menopausal status
+Pre
+34
+59
+18
+51
+16
+69
+Post
+24
+41
+17
+49
+7
+31
+Stressful events in life
+Yes
+14
+24
+10
+28
+4
+17
+No
+44
+76
+25
+72
+19
+83
+Posthysterectomy
+5
+9
+3
+8
+2
+9
+Data were abstracted on the history of breast cancer, investigative notes, and radiotherapy and chemotherapy treatment regimen.
+HADS-A
+HADS-D
+PSS
+DNA Damage
+Group
+Pre
+Post
+Pre
+Post
+Pre
+Post
+Pre
+Post
+Yoga, n = 35  
+(Mean) 
+8.5
+4.1*
+8.0
+3.4*
+20.4
+14.9*
+2.6
+24.3*
+SD
+1.6
+1.0
+1.9
+0.5
+2.8
+2.4
+0.4
+1.70
+Control, n = 23 
+Mean 
+8.2
+10.5*
+7.8
+9.7*
+19.0
+20.4*
+2.8
+28.8*
+SD
+1.1
+1.8
+0.9
+1.2
+2.1
+2.5
+0.4
+0.9
+HADS = Hospital Anxiety and Depression Scale; PSS = Perceived Stress Scale.
+*P < .001 (P values for ANCOVA scores).
+Demographic Particulars
+Radiation Dose 
+50.4 Gy (28 cycles)
+ at FLORIDA INTERNATIONAL UNIV on December 21, 2014
+ict.sagepub.com
+Downloaded from 
+Yoga Intervention Modulates Genotoxic Stress Following Radiotherapy
+INTEGRATIVE CANCER THERAPIES 6(3); 2007
+247
+was lower by 14.5% (mean = 24.3 [SD = 1.7]) in the
+yoga group when compared to the control group
+(mean = 28.8 [SD = 0.90]). Based on repeated mea-
+sures ANCOVA, controlling for baseline values of each
+dependent variable, the differential in DNA damage
+in the 2 groups was significantly different (P < .001).
+The baseline DNA damage was mean = 2.6 (SD = 0.4)
+and mean = 2.8 (SD = 0.4) for the yoga and control
+groups, respectively, which was significantly correlated
+(Pearson’s correlation coefficient = .97) with postra-
+diotherapy values (SPSS version 10).
+Discussion
+The results of our study suggest that the patients who
+were recruited into the yoga group and the wait-listed
+control group both had significant degrees of back-
+ground stress and anxiety at the beginning of the
+study (Figure 7). These data correlate with the previ-
+ous reports by other groups such as Carlson et al27-29
+and Carson et al.32 The recruitment and randomization
+processes resulted in 2 groups whose general equiva-
+lence was confirmed by analysis of demographic fac-
+tors and preintervention test scores. More patients in
+the yoga group, however, underwent 2 or more cycles
+of chemotherapy than in the control group, which
+would tend to dispose them toward greater levels of
+DNA damage. The background anxiety and depres-
+sion levels can be attributed to the severe traumatic
+experience of cancer as a disease as well as the antici-
+pation of end of life as a crisis situation.4,6 The decrease
+in the anxiety and depression levels can be attributed
+to the relaxation response gained from the integrated
+yoga approach, which had lowered the stress-induced
+arousal in traumatized patients.
+Figure 2. Mean Hospital Anxiety and Depression Scale (HADS)
+scores of the yoga intervention group. The HADS sub-
+scale scores showed significant decreases after the 6-
+week intervention. The total HADS score also showed
+decrease from the baseline (P < .001, repeated mea-
+sures ANCOVA).
+Figure 3. Perceived Stress Scores (PSS) and mean DNA dam-
+age frequency of the yoga intervention group. PSS
+scores showed significant decrease after the 6-week
+intervention. DNA damage showed significant increase
+after the radiation treatment (P < .001, repeated mea-
+sures ANCOVA).
+Figure 4. Mean Hospital Anxiety and Depression Scale (HADS)
+scores of the control group. HADS subscale scores
+showed significant increases after the 6-week wait-
+ing period. The total HADS score also showed an
+increase from the baseline (P < .001 repeated mea-
+sures ANCOVA).
+Figure 5. Mean Perceived Stress Score (PSS) and mean DNA
+damage frequency of the control group. The baseline
+score of PSS showed significant increase after the
+6-week waiting period. The DNA damage showed
+significant increase after the radiation treatment (P < .001
+repeated measures ANCOVA).
+ at FLORIDA INTERNATIONAL UNIV on December 21, 2014
+ict.sagepub.com
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+248
+INTEGRATIVE CANCER THERAPIES 6(3); 2007
+The perceived stress was also reduced significantly
+in the intervention group when compared to the
+control cohort. This is also similar to the findings of
+Casso et al,30 Rosenbaum et al,31 and Carson et al.32
+Although there were a few patients in the control
+population who reported improvement in their sleep
+quality and anxiety levels, the depression scale
+increased over the period of the study in the control
+group. Radiation-induced DNA damage has been
+widely studied and reported by many, including our
+previous study.36 In another work, Mozdarani et al34
+showed that there was an elevated spontaneous fre-
+quency of micronuclei in a breast cancer group com-
+pared to a control group. They also showed that
+breast cancer patients were 30% more sensitive to
+ionizing radiation than the age- and sex-matched
+control population. Scott et al35 reported that breast
+cancer patients displayed radiation susceptibility
+when compared to control. We have reported signifi-
+cant genomic instability in breast cancer patients who
+underwent radiotherapy.36
+In the present study, an effort has been made to
+investigate radiation-induced DNA damage as a
+genotoxic stress and its correlation with the psycho-
+logical stress levels of the patients. Alkaline gel elec-
+trophoresis technique (comet assay) was used as
+described by Poonepalli et al.43 Comet assay is a very
+sensitive tool to study DNA damage.45 In another
+study, Epel et al37 reported a significant correlation
+with telomere length in the PBLs and psychological
+stress in controlled study. Subsequently, Epel et al44
+reported a significant correlation with telomere 
+dysfunction and stress in cardiovascular disease. In
+our previous work,36 we also reported a significant
+correlation between radiation-induced DNA damage
+and telomere dysfunction in breast cancer patients.
+Telomere maintenance is strongly associated with
+DNA damage and repair.45,46 Psychological stress is
+also associated with faulty DNA repair capacity in
+lymphocytes.39,40 Later, Cohen et al38 showed reduced
+DNA repair capacity in anxious students.
+We speculate that the reduced DNA damage in the
+intervention group as compared to the control group
+may be linked to lower psychological stress. The back-
+ground DNA damage levels in both the control group
+and the intervention group may be associated with
+the varied dose of chemotherapy and increased levels
+of anxiety. There is a converging link between the psy-
+chological (QOL, anxiety, depression, mood distur-
+bances, perceived stress )3,27-33 and physiological stress
+at the molecular level such as cortisol levels, cate-
+cholamines, DNA damage, telomere length, and DNA
+repair capacity.34-40,44-46 Buettner et al7 reported in a
+large-scale survey of more than 2000 patients under-
+going various complementary treatments that yoga
+was the most effective among all the CAMs in decreas-
+ing anxiety and depression and improving the QOL
+of breast cancer patients. In the current study, we
+investigated the possible link of stress at the molecu-
+lar level. Much work remains to be done to substantiate
+the findings of the above-mentioned groups, including
+our study.
+Limitations of our study include the small popula-
+tion size, also faced by other groups.28,30-32 In the hos-
+pital clinical outpatient setting, it is difficult to conduct
+large patient trials with physiological parameters such
+as DNA damage involved. No specific data were
+obtained on compliance with the yoga program while
+patients were at home. In addition, the number of
+Figure 7. Representative image of a comet from a postradiother-
+apy treated leukocyte nuclei of a patient stained with
+propidium iodide dye and showing considerable tailing,
+indicating DNA damage.
+Figure 6. Comparative Hospital Anxiety and Depression Scale
+(HADS), Perceived Stress Score (PSS), and DNA dam-
+age frequency scores of the yoga intervention and the
+control group. Baseline HADS, PSS, and DNA damage
+did not differ significantly in the yoga and control groups.
+In comparison to the control group, the yoga group
+showed significant decreases in the anxiety, depression,
+and the perceived stress scores when compared to the
+preintervention baseline. Although both groups showed
+increased DNA damage, the yoga group showed signifi-
+cantly less damage when compared to the control group.
+0.00
+5.00
+10.00
+15.00
+20.00
+25.00
+30.00
+35.00
+Hads A pre
+Hads A post
+Hads D pre
+Hads D post
+Total Hads pre
+Total Hads post
+Pss pre
+Pss post
+DNA damage pre
+DNA damage post
+Mean score
+Yoga
+Control
+ at FLORIDA INTERNATIONAL UNIV on December 21, 2014
+ict.sagepub.com
+Downloaded from 
+dropouts from the control group was large, and the
+control group lacked activities that would account for
+the effects of time and attention from medical per-
+sonnel and yoga instructors received by the yoga
+group. The supportive counseling group does, how-
+ever, account for any gradual reduction in stress scores
+due to natural adjustment to the diagnosis and the
+treatment situation. Larger and more specific trials in
+the future may prove effective in deciphering the
+mechanistic link between emotional trauma and psy-
+chological and physiological stress.
+In summary, our study showed preliminary data to
+support the influence of stress on the coping route at
+the molecular level. Along with earlier studies,16,47 the
+present study highlights the potential of an outpa-
+tient yoga-based program and supportive counseling
+to reduce adverse effects of the conventional treat-
+ment modality and to benefit cancer patients overall.
+Acknowledgments
+We convey our gratitude to the support team of the
+Department of Oncology of BIO, Bharat Cancer
+Hospital, and Manipal Hospital, Bangalore, India,
+for providing the blood samples. The team of radio-
+therapists and radiation physicists from the Depart-
+ment of Radiotherapy, Manipal Hospital, Bangalore,
+is gratefully acknowledged, especially Mr R. Holla
+and T. R. Vivek. The radiation biology work was sup-
+ported partially by a grant from the Atomic Energy
+Radiation Board (AERB), Government of India.
+The yoga program was conducted as a part of grant
+support from SVYASA University Bangalore, India.
+Ms Jayalakshmi, Dr Jayashree, Dr Rekha, and 
+Dr Vanitha are thanked for imparting the yoga
+program to the intervention group. MPH acknowl-
+edges the support from the National Medical
+Research Council, Singapore.
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+hensive cancer center and the implications for oncology. J Clin
+Oncol. 2000;18:2505-2514.
+ at FLORIDA INTERNATIONAL UNIV on December 21, 2014
+ict.sagepub.com
+Downloaded from 

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+Integrative
+ Medicine
+ Research
+ 8
+ (2019)
+ 180
+Contents
+ lists
+ available
+ at
+ ScienceDirect
+Integrative
+ Medicine
+ Research
+j
+ o
+ ur
+ nal
+ ho
+ mepage:
+ www.imr-journal.com
+Letter
+ to
+ Editor
+Effects
+ of
+ yoga
+ for
+ cardiovascular
+ and
+respiratory
+ functions:
+ a
+ pilot
+ study
+Cardiovascular
+ diseases
+ (CVDs)
+ are
+ the
+ leading
+ cause
+ of
+ death
+worldwide.1
+Lifestyle
+ modifications
+ are
+ important
+ factors
+ in
+the
+ treatment,
+ prevention,
+ and
+ rehabilitation
+ of
+ CVDs.2 Yoga
+ is
+an
+ important
+ lifestyle
+ modification
+ consist
+ of
+ specific
+ postures
+(asanas),
+ regulated
+ breathings
+ (pranayamas)
+ etc.3 Though
+ yoga
+ has
+shown
+ to
+ improve
+ cardiovascular4 and
+ respiratory
+ functions3 in
+healthy
+ individuals,3,4 there
+ is
+ a
+ lack
+ of
+ studies
+ in
+ reporting
+ the
+difference
+ that
+ exist
+ in
+ cardiovascular
+ and
+ respiratory
+ functions
+between
+ yoga
+ group
+ (YG)
+ and
+ normal
+ healthy
+ group
+ (NHG).
+Thirteen
+ healthy
+ yoga
+ practitioner
+ (over
+ 1
+ year
+ practice)
+ and
+13
+ age-matched
+ normal
+ healthy
+ individuals
+ were
+ recruited
+ on
+the
+ volutary
+ basis
+ from
+ a
+ residential
+ university,
+ South
+ India
+ (aged
+between
+ 18
+ and
+ 40
+ years).
+ Subject
+ with
+ the
+ history
+ of
+ any
+ systemic
+and
+ mental
+ illness,
+ chronic
+ smoking/alcoholism
+ were
+ excluded.
+Study
+ protocol
+ was
+ approved
+ by
+ the
+ institutional
+ ethics
+ committee
+and
+ a
+ written
+ informed
+ consent
+ was
+ obtained
+ from
+ each
+ subject.
+Breath
+ holding
+ time
+ (BHT)
+ and
+ cardiovascular
+ functions
+ were
+assessed
+ at
+ one
+ point
+ in
+ time
+ as
+ follows:
+ All
+ the
+ subjects
+ were
+ asked
+to
+ take
+ a
+ deep
+ inhalation
+ through
+ both
+ nostrils
+ and
+ hold
+ their
+ breath
+as
+ long
+ as
+ possible,
+ while
+ the
+ nose
+ clipped.
+ BHT
+ was
+ assessed
+ using
+a
+ stop
+ watch.5 Cardiovascular
+ functions
+ were
+ assessed
+ in
+ sitting
+position
+ using
+ a
+ non-invasive
+ blood
+ pressure
+ monitoring
+ sys-
+tem
+ (Finapres
+ Continuous
+ Non-Invasive
+ Blood
+ Pressure
+ Systems,
+Netherlands).
+ Statistical
+ analysis
+ was
+ performed
+ using
+ indepen-
+dent
+ samples-t-test
+ with
+ the
+ use
+ of
+ SPSS
+ (Ver.16.0).
+YG
+ showed
+ a
+ significantly
+ higher
+ BHT
+ (p
+ <
+ 0.01),
+ lower
+ sys-
+tolic
+ blood
+ pressure
+ (p
+ <
+ 0.01),
+ pulse
+ pressure
+ (p
+ <
+ 0.01),
+ and
+ mean
+arterial
+ pressure
+ (p
+ <
+ 0.05)
+ compared
+ to
+ NHG
+ (Table
+ 1).
+ Yoga
+ may
+Table
+ 1
+Demographic
+ and
+ Cardio-respiratory
+ Outcomes
+ of
+ Yoga
+ and
+ Normal
+ Healthy
+ Groups
+Variables
+ 
+Yoga
+ group
+(n
+ =
+ 13)
+Normal
+ healthy
+group
+ (n
+ =
+ 13)
+Age
+ (years)
+ 
+23.6
+ ±
+ 3.6
+ 
+22.7
+ ±
+ 4.1
+Gender
+ (M/F)
+ 
+12/1
+ 
+13/0
+Body
+ mass
+ index
+ (kg/m2)
+ 
+20.9
+ ±
+ 2.3
+ 
+21.3
+ ±
+ 3.3
+Breath
+ holding
+ time
+ (s)
+ 
+84.1
+ ±
+ 17.3
+ 
+41.4
+ ±
+ 18.4**
+Systolic
+ blood
+ pressure
+ (mmHg)
+ 
+113.7±
+ 10.1
+ 
+129.7
+ ±
+ 14.7**
+Diastolic
+ blood
+ pressure
+ (mmHg)
+ 
+70.7
+ ±
+ 7.7
+ 
+77.0
+ ±
+ 11.0
+Pulse
+ pressure
+ (mmHg)
+ 
+43.1
+ ±
+ 6.9
+ 
+52.7
+ ±
+ 8.5**
+Mean
+ arterial
+ pressure
+ (mmHg)
+ 
+87.7
+ ±
+ 8.5
+ 
+97.2±
+ 11.6*
+Heart
+ rate
+ (beats/mint)
+ 
+80.9
+ ±
+ 7.9
+ 
+77.4
+ ±
+ 8.5
+Stoke
+ volume
+ (mL)
+ 
+69.6
+ ±
+ 14.3
+ 
+79.7
+ ±
+ 16.0
+Cardiac
+ output
+ (L/mint)
+ 
+5.6
+ ±
+ 1.3
+ 
+6.1
+ ±
+ 1.0
+Pulse
+ Interval
+ (ms)
+ 
+755.6
+ ±
+ 83.1
+ 
+801.3
+ ±
+ 86.2
+Total
+ peripheral
+ resistant
+ (mmHg
+ min/L)
+ 1.0
+ ±
+ 0.3
+ 
+1.1
+ ±
+ 0.4
+Note:
+ All
+ values
+ are
+ in
+ mean
+ ±
+ standard
+ deviation.
+* p
+ <
+ 0.05.
+** p
+ <
+ 0.01.
+improve
+ the
+ strength
+ of
+ expiratory
+ and
+ inspiratory
+ muscles
+ and
+regular
+ inspiration
+ and
+ expiration
+ for
+ longer
+ duration
+ may
+ increase
+in
+ the
+ voluntary
+ BHT.
+ This
+ results
+ may
+ suggest
+ that
+ the
+ potential
+usage
+ of
+ yoga
+ to
+ prevent
+ cardiovascular
+ and
+ respiratory
+ diseases.
+However,
+ the
+ limitations
+ including
+ small
+ sample
+ size
+ and
+ non-
+randomized
+ study
+ prevent
+ the
+ firm
+ conclusion.
+ More
+ rigorous
+ study
+should
+ be
+ done
+ to
+ confirm
+ this
+ result.
+Funding
+None.
+Conflict
+ of
+ interest
+The
+ authors
+ declare
+ no
+ conflict
+ of
+ interest.
+Data
+ availability
+Data
+ will
+ be
+ made
+ available
+ on
+ request.
+References
+1.
+ Chaddha
+ A.
+ Slow
+ breathing
+ and
+ cardiovascular
+ disease.
+ Int
+ J
+ Yoga
+ 2015;8:142–3,
+http://dx.doi.org/10.4103/0973-6131.158484.
+2.
+ Muralikrishnan
+ K,
+ Balakrishnan
+ B,
+ Balasubramanian
+ K,
+ Visnegarawla
+ F.
+ Mea-
+surement
+ of
+ the
+ effect
+ of
+ Isha
+ Yoga
+ on
+ cardiac
+ autonomic
+ nervous
+ system
+ using
+short-term
+ heart
+ rate
+ variability.
+ J
+ Ayurveda
+ Integr
+ Med
+ 2012;3:91–6,
+ http://dx.
+doi.org/10.4103/0975-9476.96528.
+3.
+ Mooventhan
+ A,
+ Khode
+ V.
+ Effect
+ of
+ Bhramari
+ Pranayama
+ and
+ OM
+ chanting
+ on
+pulmonary
+ function
+ in
+ healthy
+ individuals:
+ a
+ prospective
+ randomized
+ control
+trial.
+ Int
+ J
+ Yoga
+ 2014;7:104–10,
+ http://dx.doi.org/10.4103/0973-6131.133875.
+4.
+ Ankad
+ RB,
+ Herur
+ A,
+ Patil
+ S,
+ Shashikala
+ GV,
+ Chinagudi
+ S.
+ Effect
+ of
+ short-term
+pranayama
+ and
+ meditation
+ on
+ cardiovascular
+ functions
+ in
+ healthy
+ individuals.
+Heart
+ Views
+ 2011;12:58–62,
+ http://dx.doi.org/10.4103/1995-705X.86016.
+5.
+ Pal
+ R,
+ Saha
+ M,  Chatterjee
+ A,
+ Halder
+ K,
+ Tomer
+ OM,
+ Pathak
+ A,
+ et
+ al.
+ Anaerobic
+ power,
+muscle
+ strength
+ and
+ physiological
+ changes
+ in
+ physically
+ active
+ men
+ following
+yogic
+ practice.
+ Biomed
+ Hum
+ Kinet
+ 2013;5:113–20.
+Nivethitha
+ Loganathan a
+Mooventhan
+ Aruchunan
+a,∗
+a Department
+ of
+ Naturopathy,
+ Government
+ Yoga
+ and
+Naturopathy
+ Medical
+ College,
+ Tamilnadu,
+ India
+Nandi
+ Krishnamurthy
+ Manjunath b
+a Division
+ of
+ Yoga
+ and
+ Life
+ Sciences,
+ Swami
+Vivekananda
+ Yoga
+ Anusandhana
+ Samsthana
+(S-VYASA)
+ Karnataka,
+ India
+∗Corresponding
+ author
+ at:
+ Department
+ of
+Naturopathy,
+ Government
+ Yoga
+ and
+ Naturopathy
+Medical
+ College,
+ Arumbakkam,
+ Chennai
+ 600106,
+Tamilnadu,
+ India.
+E-mail
+ address:
+ [email protected]
+(M.
+ Aruchunan)
+11
+ January
+ 2019
+Available
+ online
+ 6
+ June
+ 2019
+https://doi.org/10.1016/j.imr.2019.05.004
+2213-4220/©
+ 2019
+ Korea
+ Institute
+ of
+ Oriental
+ Medicine.
+ 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/).

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+12 	
+© 2022 Yoga Mīmāṃsā | Published by Wolters Kluwer - Medknow
+Original Article
+Efficacy of yoga practices on emotion regulation and 
+mindfulness in type 2 diabetes mellitus patients
+Amit Kanthi, Singh Deepeshwar, Chidananda Kaligal
+Department of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana, Bengaluru, Karnataka, India
+INTRODUCTION
+Type 2 diabetes mellitus (T2DM) is a chronic metabolic disorder 
+(T2DM) that results in excessive blood glucose circulation.[1] 
+Individuals with T2DM are at high risk of decreased psychological 
+well-being.[2-4] It inflicts stress, depression, apathy in the absence of 
+depression, or anxiety.[5-7] An international survey of diabetic people 
+across four continents shows that around 13.8% and 44.6% of people 
+reported having depression and diabetes distress (DD), respectively.[8]
+Previous studies have focused on the relationship between 
+depression and diabetes.[9,10] However, sub-syndromal depressive 
+and mild conditions, such as dysthymia, anxiety, stress, and 
+distress, are more prevalent than depressive disorders.[11] Emotion 
+regulation (ER) is one such psychological factor that needs to be 
+addressed as emotions and emotional experiences are associated 
+with health outcomes.[12,13]
+ER includes extrinsic and intrinsic processes responsible for 
+monitoring, evaluating, and modifying emotional reactions to 
+accomplish one’s goals.[14] It is defined as “attempts individuals 
+make to influence which emotions they have when they have 
+them, and how these emotions are expressed.”[15] The burden of 
+Introduction: Poor emotion regulation (ER) is linked to diabetes distress and depression that may contribute to 
+uncontrolled glycemic levels among type 2 diabetes mellitus (T2DM) patients. As ER can adversely affect the 
+physiological and psychological health of patients with T2DM, holistic management of the disease is essential. 
+Yoga therapy is one such method that can positively impact both the mental and physical health of T2DM patients.
+Methods: Individuals with T2DM (n = 54) were recruited for the study and were randomly allocated to the intervention 
+(yoga) group and control (conventional treatment) group. Cognitive reappraisal (CR) and expressive suppression 
+(ES) were assessed as ER skills, and mindfulness was evaluated before and after the intervention. The intervention 
+was provided for 3 months.
+Results: Participants of the yoga group showed an improved ER ability with increased CR and decreased ES. 
+However, these changes were not statistically significant. ES was significantly reduced (p < 0.05) in the control 
+group. In addition, the yoga group showed significantly increased (p < 0.05) mindfulness and was decreased in 
+the control group.
+Conclusion: Yoga therapy positively affects the psychological well-being of T2DM patients.
+Key Words: Emotion regulation, mindfulness, Type 2 diabetes mellitus, yoga
+Address for correspondence:
+Amit Kanthi, Department of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana, No. 19, Eknath Bhavan, 
+Gavipuram Circle, K.G. Nagar, Bengaluru - 560 019, Karnataka, India. 
+E-mail: [email protected]
+Submitted: 09-Jan-2022  Revised: 24-Mar-2022  Accepted: 26-Mar-2022  Published: ***
+How to cite this article: Kanthi A, Deepeshwar S, Kaligal C. Efficacy of 
+yoga practices on emotion regulation and mindfulness in type 2 diabetes 
+mellitus patients. Yoga Mimamsa 2022;XX:XX-XX.
+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]
+ym_1_22_R2
+Access this article online
+Quick Response Code:
+Website:
+www.ym-kdham.in
+DOI:
+10.4103/ym.ym_1_22
+Abstract
+[Downloaded free from http://www.ym-kdham.in on Saturday, July 16, 2022, IP: 136.232.192.146]
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+Kanthi, et al.: Emotion regulation and mindfulness in T2DM patients
+Yoga Mīmāṃsā | Volume 54 | Issue 1 | January-June 2022	
+13
+adherence to restrictive lifestyle and self-care and its relationship 
+to awareness, expression, and modulation of feelings, makes 
+ER an important psychological variable of interest in T2DM 
+management.[16] ER is also important because of its impact on 
+self-help compliance and health behavior in general.[1] Moreover, 
+a recent study reported the contribution of poor ER in increasing 
+DD among type 1 diabetes patients.[17] Thus, it is imperative that 
+psychological constructs such as ER are addressed, and all the 
+possible interventions are explored and developed to improve the 
+psychological health of T2DM individuals.
+Yoga therapy is a widely known and accepted intervention 
+method for T2DM across the globe. It is exceptionally beneficial 
+in preventing and managing T2DM.[18]
+In addition, the practice of yoga has a multitude of benefits for 
+T2DM patients, including glycemic control, insulin resistance, 
+lipid profile, blood pressure, stress, anxiety, and depression.[19-22]
+One of the ways that yoga might impact the psychological health 
+of T2DM patients is mindfulness, as it is an essential element 
+of the yoga practice. Conceptually, mindfulness contains two 
+elements: awareness of the present moment and the quality of 
+that awareness.[23] In the clinical context, it is described as a 
+nonelaborative and nonjudgmental awareness of present moment 
+experience. Developing the ability of mindfulness is thought to 
+promote objective and adaptive strategies of responding to emotional 
+or cognitive triggers.[24] Consequentially, many researchers have 
+proposed a link between mindfulness and adaptive ER.[25] Moreover, 
+mindfulness has shown to be effective in ER, reducing stress and 
+anxiety.[26,27] Therefore, it is important to investigate if yoga practice 
+can help in improving ER with increased mindfulness.
+With the increasing cases of T2DM, the risk of associated 
+complications also increases. It is important to utilize therapeutic 
+approaches that benefit the management of both T2DM and related 
+complications. One such approach is yoga therapy, and the present 
+study attempts to assess the efficacy of yoga practice on ER skills 
+and mindfulness in T2DM patients.
+METHODS
+Participants
+T2DM patients with ages ranging between 37 and 65 years were 
+recruited from different parts of Bengaluru city. The participants 
+were randomly allocated to the yoga group (n = 27) and the 
+wait-list control group (n = 27). These participants were recruited 
+through newsletter writings and advertisements. The participants 
+included in the study met the following criteria: no presence of 
+complications including neuropathy, nephropathy, retinopathy, 
+and other cardiovascular disorders, absence of neurological or 
+neuropsychiatric disorders, and are familiar with the English 
+language. In addition, none of the participants were advised to 
+stop their conventional medical treatment. The CONSORT flow 
+diagram presents participant selection and allocation details 
+[Figure 1].
+Ethical considerations
+The study was approved by the Institutional Ethics Committee 
+(IEC) of Swami Vivekananda Yoga Anusandhana Samsthana 
+(S-VYASA) University (No. RES/IEC-SVYASA-03/020/2016) 
+and was registered in the Clinical Trial Registry (CTRI) of 
+Government of India. The study protocol was informed to the 
+participants and their informed consent was obtained.
+Study design
+The study is a randomized, parallel group design. Recruited 
+participants were T2DM patients who were randomly divided 
+into two groups, i.e., the yoga group with the intervention of 
+recommended common yoga protocol for T2DM patients and the 
+wait-list control group without any form of yoga interventions. 
+Both groups consisted of 27 participants and were assessed on 
+day 1 and day 90.
+Intervention
+The yoga intervention protocol adopted in the study was a common 
+yoga protocol recommended for T2DM patients by the Indian 
+Yoga Association,[28] which includes Asanas (yoga postures), 
+pranayama (breathing practice), and relaxation techniques. The 
+duration of the yoga intervention was 60 min and was administered 
+for 5 days a week for 3 months. The detailed protocol of the yoga 
+intervention is provided in Table 1.
+OUTCOME MEASURES
+Emotion Regulation Questionnaire
+Emotion Regulation Questionnaire (ERQ) assesses ER tendencies 
+using two different strategies, reappraisal, and suppression. 
+Reappraisal is an antecedent-focused strategy that involves 
+changing the way one thinks about emotional stimuli in an 
+attempt to alter the emotional response before it is fully activated. 
+Suppression is a response-focused strategy that involves attempts 
+to lessen the emotional impact of events by inhibiting emotionally 
+expressive behavior once the emotional response is in full effect. 
+The 10-item ERQ includes six reappraisal and four suppression 
+items, forming two respective subscales.
+Freiburg Mindfulness Questionnaire
+The Freiburg Mindfulness Questionnaire (FMI), short form is 
+intended to measure the general factor of mindfulness and is highly 
+correlated (r=0.95) with the long form. It consists of 14 items and 
+is rated on a 4-point Likert scale with answer options ranging 
+from 1 (rarely) to 4 (almost always). Although the scale measures 
+mindfulness as a general context that has some interrelated facets, 
+“Mindfulness presence,” “Nonjudgmental acceptance,” “openness 
+to Experience,” and “Insight” are the tentative factors identified.[29]
+Data analysis
+Statistical analysis was performed using a statistical analysis 
+software package named SPSS (Version 21, IBM Corporation, 
+USA). The normality of data was assessed using the Shapiro‑Wilk 
+test. Within-group and between-group differences were assessed 
+using paired sample t-test and independent sample t-test, 
+4
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+Kanthi, et al.: Emotion regulation and mindfulness in T2DM patients
+14 	
+Yoga Mīmāṃsā | Volume 54 | Issue 1 | January-June 2022
+respectively. Pre- and post-mean values were compared for 
+each outcome measure. The results were considered statistically 
+significant if the p ≤ 0.05.
+RESULTS
+The demographic characteristics of the patients are given in 
+Table 2. The cognitive reappraisal (CR) was increased in the yoga 
+group and decreased in the control group after the intervention. 
+Expressive suppression (ES) was found to be reduced in the 
+yoga group and increased in the control group. None of these 
+changes was statistically significant except ES in the control group 
+(p < 0.05). Mindfulness was significantly improved (p < 0.05) 
+in the yoga group after the intervention, whereas it reduced in 
+the control group. Mindfulness was also correlated positively 
+(r = 0.47, p = 0.01) with CR and negatively (r = −0.48, p = 0.01) 
+with ES in the yoga group. The details of the changes in ERQ and 
+mindfulness are given in Table 3.
+DISCUSSION
+The present study was intended to investigate the efficacy of yoga 
+practices on mindfulness and ER skills. The ER skills assessed in 
+the current study are CR and ES. Both mindfulness and ER skills 
+were improved after the intervention. Therefore, the findings of the 
+current study exhibit the potential of yoga therapy in the holistic 
+management of T2DM.
+The nature of the yoga practice might shed some light on how it 
+helps improve mindfulness and ER skills. Mindfulness, however, 
+is also a core feature of yoga practice and can be defined as a 
+present-focused state where the mind attunes to moment-by-
+moment sensations rather than “wandering” or dwelling on the 
+past or future.[30] Furthermore, the concentration required to 
+balance and coordinate the movements of a posture synchronizing 
+breath patterns may also facilitate attentional enhancement[30] that 
+eventually might cultivate the habit of being aware of the present 
+moment. This ultimately may contribute to increased mindfulness.
+Increased mindfulness has cognitive and psychological effects in 
+terms of improved attention, executive function, reduced stress, 
+and anxiety levels. One of the pathways, mindfulness is thought 
+to yield these psychological benefits is through the facilitation 
+of adaptive ER.[31] Moreover, mindfulness correlated positively 
+Assessed for eligibility (n = 72)
+Excluded (n = 18)
+• Not meeting inclusion criteria (n = 17)
+• Declined to participate (n = 1)
+• Other reasons (n = 0)
+Randomized (n = 54)
+Allocation
+Enrollment
+Allocated to intervention (n = 27)
+• Received allocated intervention (n = 27)
+• Did not receive allocated intervention
+(give reasons) (n = 0)
+Allocated to conventional treatment (n = 27)
+• Received allocated intervention (n = 27)
+• Did not receive allocated intervention
+(give reasons) (n = 0)
+Lost to follow-up (give reasons) (n = 0)
+Discontinued intervention (give reasons)
+(n = 0)
+Lost to follow-up (give reasons) (n = 0)
+Discontinued intervention (give reasons)
+(n = 0)
+Analysed (n = 27)
+• Excluded from analysis (give reasons) (n = 0)
+Analysed (n = 27)
+• Excluded from analysis (give reasons) (n = 0)
+Follow-Up
+Analysis
+Figure 1: CONSORT flow diagram
+0
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+Pre
+Post
+Yoga
+Control
+ 
+Figure 2: Between group difference for cognitive reappraisal
+[Downloaded free from http://www.ym-kdham.in on Saturday, July 16, 2022, IP: 136.232.192.146]
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+Kanthi, et al.: Emotion regulation and mindfulness in T2DM patients
+Yoga Mīmāṃsā | Volume 54 | Issue 1 | January-June 2022	
+15
+with CR and negatively with ES. It indicates that the increase 
+in mindfulness enables an individual to reinterpret an emotion-
+eliciting situation in a manner that alters its meaning and changes 
+its emotional impact.
+Participants in the current study showed improved CR ability than 
+ES after the intervention, suggesting that yoga practice has assisted 
+in improving ER. As mentioned earlier, one must be attentive 
+and be aware while practicing yoga. As a result, the internal 
+distractions are reduced due to continued focus and awareness 
+of the practice, which could be a potential factor contributing to 
+the improved ER.
+Table 1: Common yoga protocol for type 2 
+diabetes mellitus
+Name of the practice
+Duration 
+(min)
+Starting prayer: Asatoma Sat Gamaya
+2
+Preparatory SukshmaVyayamas and Shithilikarana 
+Practices
+Urdhva‑hasta Shvasana (hand stretch breathing 3 
+rounds at 90°, 135°, 180° each)
+Kati‑Shakti Vikasaka (3 rounds each)
+Forward and backward bending
+Twisting
+Sarvanga Pushti (3 rounds clockwise, 3 rounds 
+counterclockwise)
+6
+Surya Namaskara – SN
+10 step fast SN 6 rounds
+12 step slow SN 1 round (to be avoided by those 
+with knee pain, cardiac problems, renal problem, 
+low back pain, retinopathy and the elderly who are 
+weak and not flexible; instead they can do Chair SN) 
+modified version Chair SN: 7 rounds
+9
+Asanas (1 min per asana)
+Standing (1 min per asana)
+Trikonasana, Pravritta Trikonasana, Prasarita 
+pada‑hastasana
+Supine
+Jathara Parivartanasana, Pavanamuktasana, 
+Viparitakarani
+Prone
+Bhujangasana, Dhanurasana followed by 
+Pavanmuktasana
+Sitting
+Mandukasana, Vakrasana/Ardhamatsyendrasana, 
+Paschimatanasana, ArdhaUshtrasana
+At the end, relaxation with abdominal breathing in 
+supine position (vishranti), 10–15 rounds (2 min)
+15
+Kriyas
+Agnisara: 1 min
+Kapalabhati (at 60 breaths per minute for 1 min 
+followed by rest for 1 min)
+3
+Pranayama
+Nadishuddhi (for 6 min, with Antarkumbhaka and 
+Jalandharbandha for 2 s)
+Bhramari (3 min)
+9
+Meditation (for stress management for deep 
+relaxation and silencing the mind) cyclic meditation 
+(those who are willing to practice techniques of 
+relaxation evolved by their own institutes may do so)
+15
+Resolve (I am completely healthy)
+1
+Closing prayer: Sarvebhavantu Sukhinah
+1
+Total
+60
+SN: Sun salutation
+Table 2: Demographic details
+Participants
+Yoga (n=27)
+Control 
+(n=27)
+Gender (males) ‑ 42 (77.77%)
+Male (age, years)
+21 (49±8.3)
+21 (53±8.7)
+Female (age, years)
+6 (59.5±2.42)
+6 (52±5.9)
+HbA1c (%)
+7.90±1.36
+8.04±1.21
+Disease duration (years), 
+mean±SD
+6.61±4.99
+10.33±6.89
+SD: Standard deviation, HbA1c: Hemoglobin A1c
+0
+5
+10
+15
+20
+25
+Pre
+Post
+Yoga
+Control
+Figure 3: Between group difference for expressive suppression
+11
+0
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+15
+20
+25
+30
+35
+40
+45
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+Pre
+Post
+Yoga
+Control
+Figure 4: Between group difference for mindfulness
+11
+Figure 5: Correlation between mindfulness and ER (CR and ES) in 
+yoga group. FMI, Freiburg mindfulness inventory; CR, Cognitive 
+reappraisal; ER, Emotion regulation; ES, Expressive suppression
+10
+b
+a
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+Yoga Mīmāṃsā | Volume 54 | Issue 1 | January-June 2022
+It is noted that mindfulness affects ER differently at the different 
+stages of practice. Initially, it reduces stress and may subsequently 
+enhance an open experience of emotion that promotes new 
+emotional learning and reestablishes adaptive ER strategies.[32] 
+Webb et al. even categorize mindfulness as a reappraisal strategy 
+suggesting that mindfulness involves a reappraisal of an emotional 
+response.[33]
+Some studies report that people with low heart rate variability 
+show greater orientation toward negative emotion and slower 
+attentional disengagement from negative stimuli. It suggests that 
+the worse regulation of cardiac vagal tone negatively interacts 
+with the bottom-up and top-down processing of emotions.[34] Yoga 
+practices have shown to downregulate the sympathetic nervous 
+system activity and hypothalamic-pituitary-adrenal axis response 
+to stress.[35] For example, sympathetic activation and heart rate 
+are found to be reduced after the yoga practice,[36,37] In addition, 
+a reduction was reported in anxiety scores that correlated with 
+increased GABA levels and reduced morning cortisol levels post 
+yoga intervention.[38,39] Similar interesting finding was a positive 
+correlation between melatonin levels and well-being scores in 
+participants receiving 3-month yoga intervention.[37] Notably, 
+melatonin attenuates the sympathetic activity in response to stress. 
+These findings suggest that the yoga practice seems to affect ER 
+through the regulation of autonomic and endocrine systems.
+Broadly, these findings are in line with the previous studies 
+demonstrating the psychological benefits of yoga practices. 
+However, the current study also directs the attention toward the 
+psychological constructs underlying yoga practice’s benefits. 
+This line of inquiry may open new avenues in thinking about and 
+measuring the impact of yoga practices.
+CONCLUSION
+In the current study, yoga practice has helped T2DM patients 
+in improving ER and mindfulness. However, the increased 
+mindfulness itself might have contributed to the improved ER 
+skills. These results are encouraging as improved ER skills might 
+reduce or prevent DD in T2DM patients that in turn is associated 
+with glycemic control. Furthermore, better ER might enable 
+individuals to improve their health behaviors for the effective 
+management of T2DM. Thus, yoga practice is an effective 
+intervention to improve ER skills and mindfulness in patients 
+with T2DM.
+Acknowledgment
+This study was primarily funded by Ministry of AYUSH, 
+Government of India. (Sanction number - Z.28015/209/2015HPC 
+[EMR]-AYUSH). The authors express deep gratitude to the 
+research fellows and Anvesana Research Laboratories for their 
+consistent support to accomplish this project.
+Financial support and sponsorship
+The funding source is reported.
+Conflicts of interest
+There are no conflicts of interest.
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+Control group 
+(n=27)
+t (df)
+Mean difference
+Percentage change
+Yoga
+Control
+Yoga
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+ERQ – Reappraisal
+30.2±6.34 31.5±4.95 30.4±6.69 28.5±6.80
+1.17 (26) 1.22 (26)
+1.33
+1.93
+3.44
+6.2
+ERQ – Suppression
+15.6±5.23 15.7±4.88 15.3±5.23 17.3±4.62* 0.107 (26) 2.21 (26)
+0.11
+2.03
+0.64
+13.07
+FMI – Mindfulness
+37.9±7.40 39.9±7.21 36.7±7.14 36.2±6.08# 1.79 (26) 0.52 (26)
+2.00
+0.48
+5.27
+1.36
+*p<0.05 (within the group), #p<0.05 (between‑group). ERQ, Emotion Regulation Questionnaire; FMI, Frieberg Mindfulness Questionnaire; SD: Standard deviation
+[Downloaded free from http://www.ym-kdham.in on Saturday, July 16, 2022, IP: 136.232.192.146]
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+48
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+50
+51
+52
+53
+54
+55
+56
+57
+58
+59
+Kanthi, et al.: Emotion regulation and mindfulness in T2DM patients
+Yoga Mīmāṃsā | Volume 54 | Issue 1 | January-June 2022	
+17
+13.	 Beveridge RM, A Berg C, J Wiebe D, L Palmer D. Mother and adolescent 
+representations of illness ownership and stressful events surrounding
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+on metabolic parameters and anthropometry in type 2 diabetes. Int
+Multidiscip Res J 2011;1:01-4.
+20.	 Hegde S, Adhikari P, Kotian S, Pinto VJ, D’souza S, D’souza V. Effect 
+of 3-month yoga on oxidative stress in type 2 diabetes with or without
+complications A controlled clinical trial. Diabetes Care 2011;34:2208-210.
+21.	 Sharma M, Knowlden AP. Role of yoga in preventing and controlling
+type 2 diabetes mellitus. J Evid Based Complement Alternat Med
+2012;17:88-95.
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+immune mechanisms of action of yoga in type II diabetes. Anc Sci Life
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+acceptable lifestyle intervention for primary prevention of diabetes: Part 
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+Inventory Related papers The Difficult y of Defining Mindfulness:
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+Mindfulness-based therapy: A comprehensive meta-analysis. Clin Psychol 
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+et al. Effects of Hatha yoga and Omkar meditation on cardiorespiratory
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+9												
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subfolder_0/Energy medicine.txt

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+4/5/2017
+Energy medicine
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2952118/
+1/2
+Energy medicine
+TM Srinivasan
+Energy Medicine is a word coined by three researchers who gathered at Boulder, Colorado, USA in the late 1980s. This is defined as any
+energetic or informational interaction with a biological system to bring back homeostasis in the organism. Meanwhile, in the late 1990s, the
+National Institutes of Health, the official arm of health policy and implementation in the United States of America defined areas within
+Complementary and Alternative Medicine through five subdivisions. They are: 1. Mind–Body Medicine, 2. Biologically based practices, 3.
+Energy Medicine, 4. Manipulative and Body­based practices, and 5. Whole Medical Systems. While these divisions are not arbitrary, it is still
+breaking up a holistic area into disparate entities. At the core of all this is the concept of subtle energy, which seems to sustain and promote life
+processes in the biological system.
+Thus, subtle energy is another term used along with Energy Medicine. Here the energies activating a person are subtle or of very low intensity.
+Such low levels may not be measurable at this time. This statement implies that the energies we are talking about are of a physical kind. There
+are four basic types of energies enumerated in Physics; they are strong and weak forces at the nuclear level, gravitational, and electromagnetic
+forces. Of these, electromagnetic (or, its equivalent, acoustic) is the only one that is easily manipulated at the present time. Acoustic energy
+could be transformed into electromagnetic or vice versa through a material property known as piezoelectricity. Many tissues of the body are
+known to be piezoelectric; hence, any electromagnetic input to the body is transformed into acoustic and any acoustic input could be
+transformed into electromagnetic energy. Thus, the body is bathed in both electromagnetic and acoustic energies of various frequencies and
+intensities.[1,2]
+There is yet another notion of subtle energy; that is, the energy may not be a physical one. This statement raises many questions: if not physical,
+what is it? Can it be measured? Is there a physical manifestation of the non­physical energy? Take for example, prayer or non­contact
+therapeutic touch. In these examples, there is no measurable physical energy that seems to be taking part in the interactions. Although the
+effects of prayer and therapeutic touch are well­investigated and reported, the energy type and hence the mechanism of action can only be
+surmised. The energy of chi (or, qi) or prana is not measurable; however, the interaction of chi or prana with the biological system may be
+deduced. For example, with the appropriate flow of prana, the tissues are healthy; thus, chi gong or yoga may be thought of as stabilizing the
+flow of prana in the body.
+The question arises if subtle energies could at all be measured. Direct measurement of subtle energies is not possible at present as the physical /
+psychological / spiritual aspects of these energies are not clearly understood in modern terminology. However, indirect measurement of subtle
+energy in the body is possible through certain physiological correlates that are emerging. Instruments to measure acupuncture activity and
+electrical discharge photography popularly known as Kirlian photography are the two main contenders for subtle energy monitoring.
+Acupuncture instruments are based on the observation that acupuncture points have special electrical characteristics; the points have lower
+resistance to electrical current flow as compared to the surrounding tissues. As each meridian is associated with one or more organs inside the
+body, the electrical activity of the acupoint seems to be related to the organ function.
+In the second kind of instrument, based on Kirlian photography, a high voltage, low current is applied to the finger pads. The colorful discharge
+that is observed is analyzed in a computer and is related to organ function. Sophisticated instruments are presently available based on these
+principles and we shall discuss these in more detail in the forthcoming issues. Needless to say, the instruments are undergoing many trials and
+clinical evaluation, so that their use is acceptable in medical diagnostics and therapy.
+Several interesting articles are presented in this issue. It is a privilege for me to be the Editor of IJOY and with all your cooperation, I am sure
+we can bring the best of scientific investigations in Yoga to many readers around the world.
+Article information
+Int J Yoga. 2010 Jan-Jun; 3(1): 1.
+doi:  10.4103/0973-6131.66770
+PMCID: PMC2952118
+TM Srinivasan
+Swami Vivekananda Yoga Anusandhana Samsthana (A Yoga University), No.9, Appajappa Agrahara Chamarajpet, Bangalore - 560 018, India. E-mail: [email protected]
+Copyright © International Journal of Yoga
+This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in
+any medium, provided the original work is properly cited.
+Articles from International Journal of Yoga are provided here courtesy of Medknow Publications
+4/5/2017
+Energy medicine
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2952118/
+2/2
+REFERENCES
+1. Robert Becker, Gary Selden. “The Body electric: Electromagnetism and the Foundations of life”. William Morrow Publ, N. Y; 1985.
+2. Richard Gerber. “A Practical Guide to Vibrational Medicine: Energy Healing and Spiritual Transformation” HarnerCollins, N. Y
+. 2001