diff --git a/subfolder_0/A SURVEY ON THE NEED FOR DEVELOPING AN AYURVEDA BASED.txt b/subfolder_0/A SURVEY ON THE NEED FOR DEVELOPING AN AYURVEDA BASED.txt new file mode 100644 index 0000000000000000000000000000000000000000..c15c97770d823ab775ae57ced29a7760b8509710 --- /dev/null +++ b/subfolder_0/A SURVEY ON THE NEED FOR DEVELOPING AN AYURVEDA BASED.txt @@ -0,0 +1,845 @@ +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: brramakrishnasvyasa@gmail.com +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 + + diff --git a/subfolder_0/A casework report of social anxiety disorder with anankastic personality disorder a cognitive behavior therapy approach.txt b/subfolder_0/A casework report of social anxiety disorder with anankastic personality disorder a cognitive behavior therapy approach.txt new file mode 100644 index 0000000000000000000000000000000000000000..e69de29bb2d1d6434b8b29ae775ad8c2e48c5391 diff --git "a/subfolder_0/A nonrandomized non-na\303\257ve, comparative study of the effects of kapalabhati and breath awareness on event- related potentials in trained yoga practitioners.txt" "b/subfolder_0/A nonrandomized non-na\303\257ve, comparative study of the effects of kapalabhati and breath awareness on event- related potentials in trained yoga practitioners.txt" new file mode 100644 index 0000000000000000000000000000000000000000..dc526b5be88f3287014522e5b566c83284ec8097 --- /dev/null +++ "b/subfolder_0/A nonrandomized non-na\303\257ve, comparative study of the effects of kapalabhati and breath awareness on event- related potentials in trained yoga practitioners.txt" @@ -0,0 +1,519 @@ +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. +References +1. Ramdev S. Pranayama: Its Philosophy and Practice. Harid- +war, India: Divya Prakashan, 2005. +2. Brown RP, Gerbarg PL. Sudarshan Kriya yogic breathing in +the treatment of stress, anxiety, and depression: Part I— +Neurophysiologic model. J Altern Complement Med 2005; +11:189–201. +3. Sarawati SN. Prana, Pranayama, Pranavidya. Bihar, India: +Yoga Publications Trust, 2002. +4. Stancak A Jr, Kuna M, Srinivasan T, et al. Kapalabhati: Yogic +cleansing exercise. II. EEG topography analysis. Homeost +Health Dis 1991;33:182–189. +5. Raghuraj P, Ramakrishnan AG, Nagendra HR. Effect of two +selected yoga-breathing techniques on heart rate variability. +Indian J Physiol Pharmacol 1998;42:467–472. +6. Fredrickson M, Engel BT. Cardiovascular and electrodermal +adjustments during a vigilance task in patients with border- +line and established hypertension. J Psychosom Res 1985; +29:235–246. +7. Telles S, Raghuraj P, Arankalle D, Naveen KV. Immediate +effect of high-frequency yoga breathing on attention. Indian +J Med Sci 2008;62:20–22. +8. Polich J. P300 in clinical applications. In: Niedermeyer E, +Lopes da Silva F, eds. Electroencephalography: Basic Prin- +ciples, Clinical Applications and Related Fields, 4th ed. Bal- +timore and Munich: Urban and Schwarzenberg, 1999:1073– +1091. +9. Polich J, Conroy M. P3a and P3b from visual stimuli: Gen- +der effects and normative variability. In: Reinvang I, Green- +lee MW, Herrmann M, eds. The Cognitive Neuroscience of +Individual Differences. Delmenhorst, Germany: Hanse In- +stitute for Advanced Study, 2003:293–306. +10. Jasper HH. The ten-twenty electrode system of the Interna- +tional Federation. Electroencephalogr Clin Neurophysiol +1958;10:371–375. +11. Carson R, Goddard PH, Orme-Johnson D. P300 under condi- +tions of temporal uncertainty and filter attenuation: Reduced +latency in long-term practitioner of TM. Psychophysiology +1990;27:S23. +12. Travis F, Miskov S. P300 latency and amplitude during eyes- +closed rest and Transcendental Meditation practice. Psy- +chophysiology 1994;31:S67. +13. Sarang SP, Telles S. Changes in P300 following two yoga- +based relaxation techniques. Int J Neurosci 2006;116:1419– +1430. +14. Naga Venkatesha Murthy PJ, Janakiramiah N, Gangadhar +BN, Subbukrishna DK. P300 amplitude and antidepressant +response to Sudarshan Kriya Yoga (SKY). J Affect Disord +1998;50:45–48. +15. Polich J. Clinical application of P300 event-related brain po- +tential. Phys Med Rehabil Clin North Am 2004;15:133–161. +16. Fox E. Attentional bias in anxiety: Selective or not? Behav +Res Ther 1993;31:487–493. +17. Halgren E, Marnikovic K, Chauvel P. Generators of the late +cognitive potentials in auditory and visual oddball tasks. +Electroencephalogr Clin Neurophysiol 1998;106:156–164. +18. Polich J, Kok K. Cognitive and biological determinants of +P300: An integrative review. Biol Psychol 1995;41:103–146. +19. Saraswati SS. Asana, Pranayama, Mudra, Bandha. Bihar, India: +Yoga Publications Trust, 2008. +20. Khalsa SS, Rudrauf D, Damansio AR, et al. Interoceptive +awareness in experienced meditators. Psychophysiology +2008;45:671–677. +21. Wallace RK, Benson H, Wilson AF. A wakeful hypo-meta- +bolic physiological state. Am J Physiol 1972;227:795–799. +22. Corby JC, Roth WT, Zarcone VP Jr, Kopell BS. Psychophys- +iological correlates of the practice of tantric yoga meditation. +Arch Gen Psychiatry 1978;35:571–577. +23. Lang R, Dehof K, Meurer KA, Kaufmann W. Sympathetic +activity and transcendental meditation. J Neural Transm +1979;44:117–135. +24. Telles S, Desiraju T. Autonomic changes in Brahmakumaris +Raj yoga meditation. Int J Psychophysiol 1993;15:147–152. +25. Stancák A Jr, Kuna M, Srinivasan T, et al. Kapalabhati: Yogic +cleansing exercise. I. Cardiovascular and respiratory +changes. Homeost Health Dis 1991;33:126–134. +26. Manjunath NK, Telles S. Effects of sirsasana (headstand) +practice on autonomic and respiratory variables. Indian J +Physiol Pharmacol 2004;47:34–42. +27. Raghuraj P, Telles S. Immediate effect of specific nostril ma- +nipulating yoga breathing on autonomic and respiratory +variables. Appl Psychophysiol Biofeedback 2008;33:65–75. +Address reprint requests to: +Shirley Telles, Ph.D. +Patanjali Yogpeeth +Maharishi Dayanand Gram +Bahadrabad, Haridwar, Uttarakhand 249408 +India +E-mail: shirleytelles@gmail.com +YOGA BREATHING AND ERPs +285 diff --git a/subfolder_0/A recipe for Policy research in AYUSH educational and research.txt b/subfolder_0/A recipe for Policy research in AYUSH educational and research.txt new file mode 100644 index 0000000000000000000000000000000000000000..d23f17de9e3c35bde4f9091e55bcf4906f66cb5f --- /dev/null +++ b/subfolder_0/A recipe for Policy research in AYUSH educational and research.txt @@ -0,0 +1,277 @@ +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: akshay1anand@rediffmail.com +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 diff --git a/subfolder_0/A self-rating scale to measure states of tridosha in children..txt b/subfolder_0/A self-rating scale to measure states of tridosha in children..txt new file mode 100644 index 0000000000000000000000000000000000000000..309e75a96bf5a478c7f4494b1f7289532403218d --- /dev/null +++ b/subfolder_0/A self-rating scale to measure states of tridosha in children..txt @@ -0,0 +1,356 @@ +3 +© 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: ayursuch@rediffmail.com +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: WKHLRPMedknow_reprints@wolterskluwer.com +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. +6th ed. Varanasi: Chaukamba Orientalia; 2005. +7. +Krishnamurthy KH. Bhavaprakasha: English Commentary. 1st ed. +New Delhi: Chaukamba Vishwabharati; 2000. +8. +Pandit Hariprasad Tripati. Harita Samhita: Hindi Vyakhya. 1st ed. +Varanasi: Chaukamba Krishnadas Academy; 2005. +9. +Vidya Lakshmipati Shastri. Yogaratnakara: Hindi Commentary. 1st ed. +New Delhi: Chaukamba Prakashana; 2007. +10. +Joshi RR. A biostatistical approach to ayurveda: Quantifying the tridosa. +J Altern Complemen Med 2005;11:221‑5. +11. +Hankey A. The scientific value of Ayurveda. J Altern Complement Med +2005;11:221‑5. +12. +Hankey A. A test of the systems analysis underlying the scientific theory +of ayurveda tridosa. J Altern Complement Med 2005;11:385‑90. +13. +Patwardhan B, Joshi K, Chopra A. Classification of human population +based on HLA gene polymorphism and the concept of Prakriti in +ayurveda. J Altern Complement Med 2005;11:349‑53. +14. +Patwardhan  B, Bodeker  G. Ayurvedic genomics: Establishing a +genetic basis for mind‑body typologies. J Altern Complement Med +2008;14:571‑6. +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. +Mishra L, Singh BB, Dagenais S. Healthcare and disease management +in Ayurveda. Altern Ther Health Med 2001;7:44‑50. +17. +Dube KC, Kumar A, Dube S. Personality types in Ayurveda. Am J Chin +Med 1983;11:25‑34. +18. +Endo J, Nakamura T. Comparative studies of the tridosha theory in +Ayurveda and the theory of the four deranged elements in Buddhist +medicine. Kagakushi Kenkyu 1995;34:1‑9. +19. +Mahdihassan  S. A  comparative study of Chinese cosmology +cum‑humorology with eight elements. Am J Chin Med 1990;18:181‑4. +20. +Purvya MC, Meena MS. A review on role of prakriti in aging. Ayu +2011;32:20‑4. +21. +Tripathi PK, Patwardhan K, Singh G. The basic cardiovascular responses +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] diff --git "a/subfolder_0/A statistical model for quantification of Panchako\305\233as of large collective entities.txt" "b/subfolder_0/A statistical model for quantification of Panchako\305\233as of large collective entities.txt" new file mode 100644 index 0000000000000000000000000000000000000000..35340333008c8c53ddcd62162902ad85dea0a952 --- /dev/null +++ "b/subfolder_0/A statistical model for quantification of Panchako\305\233as of large collective entities.txt" @@ -0,0 +1,3987 @@ +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: bltembe@chem.iitb.ac.in +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: reprints@medknow.com +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. +References +1. +Sharvananda S, Upanishad T. Sri Ramakrisnha Math, Chennai +Publications, 1921. +2. +Nagarathna R, Nagendra HR. Integrated Approach of Yoga +Therapy for Positive Health. Swami Vivekananda Yoga +Prakashana, Bangalore; 2008. +3. +Nagarathna R, Nagendra HR. Integrated Approach of Yoga +Therapy for Positive Thinking. Swami Vivekananda Yoga +Prakashana, Bangalore; 2013. +4. +Jagannathan A, Bishenchandra Y. Decoding the integrated +approach to yoga therapy. Int J Yoga 2014;7:166-7. +5. +A large number of M. Sc., M. D. and Ph. D. Dissertations of the +SVYASA University; 2008-2015. +6. +Routledge RN, Standalai N, Dayan P. Dolan RJ. A computational +and neural model of momentary and subjective well-being. Proc +Natl Acad Sci USA 2014;111;12252-7. +7. +Available +from: +http://www.mathsgee.com/2014/10/12/ +mathematicalhappiness-models. [Last accessed on 2015 Oct 31]. +8. +Ura K, Alkire S, Zangmo T. GNH (Gross National Happiness) +and GNH Index, The Centre for Bhutan Studies. Available from: +http://www.ophi.org.uk/wp-content/uploads/Ura-et-al-Bhutan- +Happiness-Chapter.pdf. [Last accessed on 2015 Oct 31]. +9. +Kramer AD. An Unobtrusive Model of Gross National +Happiness, CHI 2010: (ACM Conference on Human Factors in +Computing Systems) Language 2.0 April 10-16 Atlanta, Georgia, +[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 +92 +International Journal of Yoga ‑ Philosophy, Psychology and Parapsychology  ¦  Volume 6  ¦  Issue 2  ¦  July‑December 2018 +USA; 2010. p. 287-90. +10. Available from: http://www.nationsonline.org/oneworld/world_ +population.htm. [on populations]. [Last accessed on 2015 Oct +31]. +11. Available +from: +http://www.en.wikipedia.org/wiki/List_of_ +countries_by_future_population_%28United_Nations,_Low_ +variant%29. [on current population]. [Last accessed on 2015 Oct +31]. +12. Available from: http://www.infoplease.com/world/statistics/life- +expectancy-country.html. [on life expectancy]. [Last accessed on +2015 Oct 31]. +13. Available from: http://www.worldlifeexpectancy.com/cause-of- +death/all-cancers/by-country/[on (WHO) life expectancy/deaths +due to illnesses and suicides]. [Last accessed on 2015 Oct 31]. +14. Available +from: +http://www.data.worldbank.org/indicator/ +AG.LND.AGRI.ZS[on percentages of agricultural areas]; http:// +wdi.worldbank.org/table/3.2. [Last accessed on 2015 Oct 31]. +15. Available +from: +http://www.en.wikipedia.org/wiki/List_of_ +countries_and_dependencies_by_area. [on land areas]. [Last +accessed on 2015 Oct 31]. +16. Available +from: +http://www.en.wikipedia.org/wiki/List_of_ +countries_by_GDP_%28nominal%29. [on GDP]. [Last accessed +on 2015 Oct 31]. +17. Available from: http://www.en.wikipedia.org/wiki/Purchasing_ +power_parity. [on purchasing power parity]. [Last accessed on +2015 Oct 31]. +18. Available from: http://www.tradingeconomics.com/country-list/ +gross-national-product [on GNP]. [Last accessed on 2015 Oct +31]. +19. Available +from: +http://www.en.wikipedia.org/wiki/List_of_ +countries_by_percentage_of_population_living_in_poverty. +[on +poverty index]. [Last accessed on 2015 Oct 31]. +20. Available +from: +http://www.data.worldbank.org/indicator/ +IS.ROD.DNST.K2. [on road lengths]. [Last accessed on 2015 +Oct 31]. +21. Available from: http://www.nationsencyclopedia.com/WorldStats/ +HNP-hospital-beds.html [on hospital beds]. [Last accessed on +2015 Oct 31]. +22. Available +from: +http://www.news.com.au/travel/world-travel/ +countries-with-the-worst-air-pollution-ranked-by-world-health- +organisation/story-e6frfqai-1227040198863. [on air pollution 1]. + +[Last accessed on 2015 Oct 31]. +23. Available from: http://www.statisticbrain.com/countries-ranked- +by-air-pollution. [Last accessed on 2015 Oct 31]. +24. Available from: http://www.epa.gov/airnow/aqi_brochure_02_14. +pdf. [Last accessed on 2015 Oct 31]. +25. Available +from: +http://www.epi.yale.edu/epi/country-rankings. +[on water quality rankings]. [Last accessed on 2015 Oct 31]. +26. Available +from: +http://www.en.wikipedia.org/wiki/List_of_ +countries_by_employment_rate. [on Employment levels]. [Last +accessed on 2015 Oct 31]. +27. Available +from: +http://www.en.wikipedia.org/wiki/List_of_ +countries_by_unemployment_rate. [on unemployment]. [Last +accessed on 2015 Oct 31]. +28. Available +from: +https://www.cia.gov/library/publications/the- +world-factbook/rankorder/2129rank.html. +[on +unemployment +rate]. [Last accessed on 2015 Oct 31]. +29. Available +from: +http://www.en.wikipedia.org/wiki/List_of_ +countries_by_road_network_size. +[on +road +length]. +[Last +accessed on 2015 Oct 31]. +30. Available +from: +http://www.en.wikipedia.org/wiki/List_of_ +countries_by_rail_transport_network_size. [on rail services]. + +[Last accessed on 2015 Oct 31]. +31. Available from: http://www.data.worldbank.org/indicator/IS.AIR. +PSGR. [on air travel data]. [Last accessed on 2015 Oct 31]. +32. Available +from: +http://www.list.wikia.com/wiki/List_of_ +countries_by_number_of_airports. [on no of airports]. [Last +accessed on 2015 Oct 31]. +33. Available +from: +http://www.prokerala.com/travel/airports/ +country-list/. [on air port list]. [Last accessed on 2015 Oct 31]. +34. Available +from: +http://www.en.wikipedia.org/wiki/List_of_ +countries_by_number_of_Internet_users. [Last accessed on 2015 +Oct 31]. +35. Available from: http://www.data.worldbank.org/indicator/IT.NET. +USER.P2. [on internet users]. [Last accessed on 2015 Oct 31]. +36. Available +from: +http://www.en.wikipedia.org/wiki/List_of_ +countries_by_number_of_mobile_phones_in_use. +[on +mobile +numbers in countries]. [Last accessed on 2015 Oct 31]. +37. Available from: http://www.unodc.org/documents/gsh/pdfs/2014_ +GLOBAL_HOMICIDE_BOOK_web.pdf. [on crime rates]. [Last +accessed on 2015 Oct 31]. +38. Available +from: +http://www.en.wikipedia.org/wiki/List_of_ +countries_by_suicide_rate. [on suicide rates]. [Last accessed on +2015 Oct 31]. +39. Available +from: +https://www.transparency.org/cpi2013/results. +[on corruption index]. [Last accessed on 2015 Oct 31]. +40. Available from: http://www.prisonstudies.org/highest-to-lowest/ +prison-population-total?field_region_taxonomy_tid=All. +[on +prison statistics]; http://www.data.worldjusticeproject.org/# Rule +of Law index 2015. [Last accessed on 2015 Oct 31]. +41. Available +from: +http://www.en.wikipedia.org/wiki/Divorce_ +demography. [on divorce statistics]. [Last accessed on 2015 Oct +31]. +42. Available +from: +http://www.indidivorce.com/divorce-rate-in- +india.html. [on divorce rates]. [Last accessed on 2015 Oct 31]. +43. Available from: http://www.economist.com/node/2. [on marriage +age]. [Last accessed on 2015 Oct 31]. +44. Available +from: +http://www.en.wikipedia.org/wiki/School_ +counselor. [on school counselling]. [Last accessed on 2015 Oct +31]. +45. Available from: http://www.world.bymap.org/LiteracyRates.html. +[on literacy rates]. [Last accessed on 2015 Oct 31]. +46. Available from: http://www.russellsage.org/research/chartbook/ +percentage-population-select-countries-bachelors-degrees-or- +higher-age. [on number of graduates]. [Last accessed on 2015 +Oct 31]. +47. Available +from: +http://www.wamu.org/news/morning_ +edition/12/02/21/graduation_rates_increase_around_the_globe_ +as_us_plateaus. [on graduation rates]. [Last accessed on 2015 +Oct 31]. +48. Available +from: +http://www.openaccessweek.org/profiles/ +blogs/the-top-20-countries-for-scientific-output. +[on +research +publications]. [Last accessed on 2015 Oct 31]. +49. Available +from: +http://www.solgelnanophotonics.blogspot. +in/2012/01/top-40-countries-by-number-of-research.html. +[on +research publications]. [Last accessed on 2015 Oct 31]. +50. Available +from: +http://www.en.wikipedia.org/wiki/List_ +of_countries_by_Human_Development_Index. +[on +Human +development Index]. [Last accessed on 2015 Oct 31]. +51. Available from: http://www.theguardian.com/news/datablog/2010/ +sep/08/charitable-giving-country. [on charitywise giving]. [Last +accessed on 2015 Oct 31]. +52. Available +from: +http://www.en.wikipedia.org/wiki/World_ +Giving_Index. [on donations]. [Last accessed on 2015 Oct 31]. +53. Available from: http://www.theguardian.com/news/datablog/2010/ +sep/08/charitable-giving-countryWorld +Giving +Index. +[Last +[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 +93 +International Journal of Yoga ‑ Philosophy, Psychology and Parapsychology  ¦  Volume 6  ¦  Issue 2  ¦  July‑December 2018 +accessed on 2015 Oct 31]. +54. Spiegel M, Schiller J. “Probability and Statistics”, Schaum’s +Outline Series. McGraw Hill Book Company: New Delhi; 2010. +55. Biology. +Standard +XI. +Chennai: +Tamilnadu +Textbook +Corporation; 2005. Available from: http://www.textbooksonline. +tn.nic.in/books/11/std11-biozoo-em.pdf. [Last accessed on 2015 +Oct 31]. +56. McGill VJ. In: Frederick A, editor. The Idea of Happiness. New +York: Praeger Publishers; 1967. +57. Bruni L, Comim F, Pugno M, editors. Capabilities and +Happiness. Oxford: Oxford University Press; 2008. +58. Smeyers P, Smith R, Standish P. The Therapy of Education: +Philosophy, Happiness and Personal Growth. Hampshire, UK: +Palgrave Macmillan; 2011. +59. Natarajan AR. The Ramana Way to Natural Happiness. +Bangalore: Ramana Maharshi Center for Learning; 2002. +60. Alkire S, Foster J. Understandings and misunderstandings +of multidimensional poverty measurement. J Econ Inequal +2011;9:289-314. +61. Noddings N. Happiness and Education. Cambridge, UK: +Cambridge University Press; 2003. +62. Available +from: +http://www.earth.columbia.edu/sitefiles/file/ +Sachs%20Writing/2012/World%20Happiness%20Report.pdf. +(World happiness index). [Last accessed on 2015 Oct 31]. +63. Cantril H. The Pattern of Human Concerns. New Brunswick, NJ: +Rutgers University Press; 1966. +64. Schwartz CE, Sprangers MA. Methodological approaches for +assessing response shift in longitudinal health-related quality-of- +life research. Soc Sci Med 1999;48:1531-48. +65. Burckhardt CS, Anderson KL. The quality of life scale (QOLS): +Reliability, validity, and utilization. Health Qual Life Outcomes +2003;1:60. +66. Horley J, Lavery JJ. The Stability and Sensitivity of Subjective +Well-being measures. Soc Indic Res 1991;24:113-22. +[Downloaded free from http://www.ijoyppp.org on Monday, January 25, 2021, IP: 136.232.192.146] diff --git a/subfolder_0/AUTONOMIC AND RESPIRATORY MEASURES IN CHILDREN WITH IMPAIRED VISION FOLLOWING YOGA AND PHYSICAL ACTIVITY PROGRAMS.txt b/subfolder_0/AUTONOMIC AND RESPIRATORY MEASURES IN CHILDREN WITH IMPAIRED VISION FOLLOWING YOGA AND PHYSICAL ACTIVITY PROGRAMS.txt new file mode 100644 index 0000000000000000000000000000000000000000..29f75f01c575b96c22e6046ab9b5272332cf3af5 --- /dev/null +++ b/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: vkyogas@blr.vsnl.net.in. +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 diff --git a/subfolder_0/AYURVEDA FOR CHEMO-RADIOTHERAPY INDUCED SIDE EFFECTS IN CANCER PATIENTS_unlocked.txt b/subfolder_0/AYURVEDA FOR CHEMO-RADIOTHERAPY INDUCED SIDE EFFECTS IN CANCER PATIENTS_unlocked.txt new file mode 100644 index 0000000000000000000000000000000000000000..a4a530e3eda953416d4a1a7fa69e45058ab46d8d --- /dev/null +++ b/subfolder_0/AYURVEDA FOR CHEMO-RADIOTHERAPY INDUCED SIDE EFFECTS IN CANCER PATIENTS_unlocked.txt @@ -0,0 +1,1695 @@ +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: kgmhetre@gmail.com. + Email: hemant.bhargav1@gmail.com +‡ Email: pkoka@haffkineinstitute.org +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. + +REFERENCES + +[1] +Yadav B, Bajaj A, Saxena M, Saxena AK. In Vitro +Anticancer Activity of the Root, Stem and Leaves of +Withania Somnifera against Various Human Cancer +Cell Lines. Indian J Pharm Sci 2010; 72(5):659–663. +[2] +Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman +D. Global Cancer Statistics.Ca Cancer J Clin 2011; +61:69–90. +[3] +Baliga MS. Triphala, Ayurvedic formulation for treating +and preventing cancer: a review. J Altern Complement +Med 2010; 16 (12):1301-1308. +[4] +Chuai Y, Xu X, Wang A. Preservation of Fertility in +Females Treated for Cancer. International Journal of +Biological Sciences 2012; 8(7):1005-1012. +[5] +Braunward F, Hauser K, Jameson L, et al. Principles of +Cancer Treatment. Harrison's principles of Internal +Medicine 2008; Ed. 17. +[6] +Prasanna PGS, Stone HB, Wong RS, Capala J, +Bernhard EJ, Vikram B, et al. Normal tissue protection +for improving radiotherapy: Where are the Gaps? Transl +Cancer Res 2012; 1(1):35–48. +[7] +Surendiran A, Balamurugan N, Gunaseelan K, Akhtar +S, Reddy KS, Adithan C. Adverse drug reaction profile +of cisplatin-based chemotherapy regimen in a tertiary +care hospital in India: An evaluative study. Indian J +Pharmacol 2010; 42(1):40–43. +[8] +Mukherjee PK, Nema NK, Venkatesh P, Debnath PK. +Changing scenario for promotion and development of +Ayurveda - way forward. J Ethnopharmacol 2012. +[9] +Gupta VKL, Pallavi G, Patgiri BJ, Galib, Prajapati PK. +Critical review on the pharmaceutical vistas of Lauha +Kalpas (Iron formulations). J Ayurveda Integr Med +2012; 3(1):21–28. +[10] +Jayasundar R. Healthcare the Ayurvedic way. Indian J +Med Ethics 2012; 9(3):177-179. +[11] +Patwardhan B, Bodeker G. Ayurvedic genomics: +establishing a genetic basis for mind-body typologies. J +Altern Complement Med 2008; 14(5):571-6. +[12] +Tripathi S. Astang Sangraha Sutrasthana. Choukhamba +Sanskrita Prasthana, New Delhi, India 1993. +[13] +Shastri K, Chaturvedi K. Charka Samhita Chikitsa +sthan. Choukambha Bharat Acedamy Varanasi, India +2006. +[14] +Vyas P, Thakar AB, Baghel MS, Sisodia A, Deole Y. +Efficacy of Rasayana Avaleha as adjuvant to +radiotherapy and chemotherapy in reducing adverse +effects. Ayu 2010; 31(4):417–423. +[15] +Jagetia GC, Baliga MS. The evaluation of the radio- +protective effect of chyavanaprasha (an ayurvedic +rasayana drug) in mice exposed to lethal dose of +gamma-radiation: a preliminary study. Phytother Res +2004; 18(1):14-8. +[16] +Baliga MS. Triphala, Ayurvedic formulation for treating +and preventing cancer: a review. J Altern Complement +Med 2010; 16(12):1301-8. +Ayurveda for Chemo-radiotherapy Induced Side Effects in Cancer Patients +127 +[17] +Sharma P, Parmar J, Sharma P, Verma P, Goyal PK. +Radiation-Induced +Testicular +Injury +and +Its +Amelioration by Tinospora cordifolia (An Indian +Medicinal Plant) Extract. Evid Based Complement +Alternat Me 2011. +[18] +Perboni S, Bowers C, Kojima S, Asakawa A, Inui A. +Growth hormone releasing peptide 2 reverses anorexia +associated with chemotherapy with 5-fluorouracil in +colon cancer cell-bearing mice. World J Gastroenterol +2008; 14(41):6303–6305. +[19] +Aminah J,Yingwei Qi, Glenda K, Ruoxiang J, Sheila M, +Cunningham J, Mandrekar S, Ping Y. The cancer +anorexia/weight loss syndrome: exploring associations +with single nucleotide polymorphisms (SNPs) of +inflammatory cytokines in patients with non-small cell +lung cancer. Support Care Cancer 2010; 18(10):1299– +1304. +[20] +Mishra S. Shangadhara Samhita , madhyam khand 6th +chapter, verse 65-69 page no. 83. Choukhamba +publications Varanasi, India 2001. +[21] +Arbabi-K, +Arbabi +K, +Deghatipour +M, +Ansari +Moghadam A. Evaluation of the Efficacy of Zinc +Sulfate in the Prevention of Chemotherapy-induced +Mucositis: A Double-blind Randomized Clinical Trial. +Arch Iran Med 2012; 15(7):413-7. +[22] +Debabrata D, Agarwal SK, Chandola HD. Protective +effect of Yashtimadhu (Glycyrrhiza glabra) against side +effects of radiation/chemotherapy in head and neck +malignancies. Ayu 2011; 32(2):196–199. +[23] +Sirisinghe RG, Halim AS, Ravichandran M, Al-Shabasi +Y, Shokrional AA. Conference on the Medicinal Uses +of Honey (From Hive to Therapy). Malays J Med Sci +2007; 14(1):101–127. +[24] +Freitas AP, Bitencourt FS, Brito GA, de Alencar NM, +Ribeiro RA, Lima-Júnior RC, et al. Protein fraction of +Calotropis procera latex protects against 5-fluorouracil- +induced oral mucositis associated with downregulation +of +pivotal +pro-inflammatory +mediators. +Naunyn +Schmiedebergs Arch Pharmacol 2012; 14. +[25] +Yoon WS, Kim CY, Yang DS, Park YJ, Park W, Ahn +YC, Kim SH, Kwon GY. Protective effect of triphala on +radiation induced acute intestinal mucosal damage in +Sprague Dawley rats. Indian J Exp Biol 2012; +50(3):195-200. +[26] +Julie L. Ryan, M, Heckler CE, Roscoe JA, Dakhil SR, +Kirshner J, et al. Ginger (Zingiber officinale) reduces +acute chemotherapy-induced nausea: Support Care +Cancer 2012; 20(7):1479–1489. +[27] +Shastri K. Bhavaprakash Uttarardh. 10th chapter, 57th +verse, page no.118. Choukhambha Sanskrita Samsthan +1988. +[28] +Steensma DP, Sloan JA, Dakhil SR, Dalton R, Kahanic +SP, Prager DJ, et al. Phase III, Randomized Study of the +Effects of Parenteral Iron, Oral Iron, or No Iron +Supplementation on the Erythropoietic Response to +Darbepoetin Alfa for Patients With Chemotherapy- +Associated Anemia. J Clin Oncol 2011; 29(1):97–105. +[29] +Ruchi S, Patel IK, Anand IP. Evaluation of Dhatri +Avaleha as adjuvant therapy in Thalassemia (Anukta +Vyadhi in Ayurveda). Ayu 2010; 31(1):19–23. +[30] +Alexander S, Wieland V, Karin J. Chemotherapy- +induced diarrhea: pathophysiology, frequency and +guideline-based management. Ther Adv Med Oncol +2010; 2(1):51–63. +[31] +Francesca I, Francesco C, Capasso R, Valeria A, +Gabriella A, Rocco L, et al. Effect of Boswellia serrata +on intestinal motility in rodents: inhibition of diarrhoea +without constipation. Br J Pharmaco 2006; 148(4):553– +560. +[32] +Grover JK, Khandkar S, Vats V, Dhunnoo Y, Das D. +Pharmacological studies on Myristica fragrans : +Antidiarrheal, hypnotic, analgesic and hemodynamic +(blood pressure) parameters. Methods Find Exp Clin +Pharmacol 2002, 24(10):675 +[33] +Miaskowski C, Paul SM, Cooper BA, Lee K, Dodd M, +West C, et al. Predictors of the Trajectories of Self- +Reported Sleep Disturbance in Men with Prostate +Cancer During and Following Radiation Therapy. +2011; 34(2):171–179. +[34] +McCarthy CG, Alleman RJ, Bell ZW, Bloomer RJ. A +Dietary +Supplement +Containing +Chlorophytum +Borivilianum and Velvet Bean Improves Sleep Quality +in Men and Women. Integr Med Insights. 2011; 7:7–14. +[35] +Galani VJ, Patel BG, Ran DG. Sphaeranthus indicus +Linn.: A phytopharmacological review. Int J Ayurveda +Res. 2010; 1(4):247–253. +[36] +Surendiran A, Balamurugan N, Gunaseelan K, Akhtar +S, Reddy KS, Adithan C. Adverse drug reaction profile +of cisplatin-based chemotherapy regimen in a tertiary +care hospital in India: An evaluative study. Indian J +Pharmacol. 2010; 42(1):40–43. +[37] +Mishra LC. Scientific basis for Ayurvedic therapies. +ISBN 0-8493-1366-X, CRC Pr., Florida. 2003 +[38] +Munshi R, Bhalerao S, Rathi P, Kuber VV, Nipanikar +SU, Kadbhane KP. An open-label, prospective clinical +study to evaluate the efficacy and safety of +TLPL/AY/01/2008 in the management of functional +constipation. J Ayurveda Integr Med. 2011; 2(3):144– +152. +[39] +Waart HV, Stuiver MM, Harten WHV, Sonke GS, Neil +K. Design of the Physical exercise during Adjuvant +Chemotherapy +Effectiveness +Study +(PACES): +A +randomized controlled trial to evaluate effectiveness +and cost-effectiveness of physical exercise in improving +physical fitness and reducing fatigue. BMC Cancer +2010; 10:673. +[40] +Mishra RK, Trivedi R, Pandya MA. A clinical study of +Ashwagandha ghrita and Ashwagandha granules for its +Brumhana and Balya effect. Ayu. 2010; 31(3):355–360. +[41] +Singh N, Bhalla M, de Jager P, Gilca M. An Overview +on Ashwagandha: A Rasayana (Rejuvenator) of +Kashinath Metri, Hemant Bhargav, Praerna Chowdhury et al. +128 +Ayurveda. Afr J Tradit Complement Altern Med. 2011; +8(5S):208–213. +[42] +Janelsins MC, Kohli S, Mohile SG, Usuki K, Ahles TA, +Morrow +GR. +An +Update +on +Cancer +- +And +Chemotherapy-Related Cognitive Dysfunction: Semin +Oncol. 2011; 38(3): 431–438. +[43] +Parle M, Bansal N. Antiamnesic Activity of an +Ayurvedic Formulation Chyawanprash in Mice. Evid +Based Complement Alternat Med. 2011; 2011: 898593. +[44] +Vollala +VR, +Upadhya +S, +Satheesha +Nayak. +Enhancement of basolateral amygdaloid neuronal +dendritic arborization following Bacopa monniera +extract treatment in adult rats. Clinics 2011; 66(4):663- +671. +[45] +Singh N, Bhalla M, de Jager P, Gilca M. An Overview +on Ashwagandha: A Rasayana (Rejuvenator) of +Ayurveda. Afr J Tradit Complement Altern Med. 2011; +8(5S):208–213. +[46] +Stan SD, Hahm ER, Warin R, Singh SV. Withaferin A. +Causes FOXO3a- and Bim-Dependent Apoptosis and +Inhibits Growth of Human Breast Cancer Cells In Vivo. +Cancer Res. 2009; 68(18):7661–7669. +[47] +Shah +JS, +Goyal +RK. +Investigation +of +Neuropsychopharmacological Effects of a Polyherbal +Formulation on the Learning and Memory Process in +Rats. J Young Pharm. 2011; 3(2):119–124. +[48] +Ben-Arye E, Dudai N, Eini A, Torem M, Schiff E, +Rakover Y. Treatment of Upper Respiratory Tract +Infections in Primary Care: A Randomized Study Using +Aromatic Herbs. Evid Based Complement Alternat Med. +2011; 2011: 690346. +[49] +Gutzmer R, Wollenberg A, Ugurel S, Homey B, Ganser +A, Kapp A. Cutaneous Side Effects of New Antitumor +Drugs Clinical Features and Management Dtsch +Arztebl Int. 2012; 109(8):133–140. +[50] +Gardino S, Rodriguez S, Campo-Engelsteinmen L with +cancer. Infertility, cancer, and changing gender norms. J +Cancer Surviv. 2011; 5(2):152–157. +[51] +Shastri K. Bhavaprakashah 72th chapter verse 22th page +no. 816. Choukhambha Sanskrit prakashan Varanasi, +India. 1987. +[52] +Shukla KK, Mahdi AA, Ahmad MK, Jaiswar SP, +Shankwar SN, Tiwari SC. Mucuna pruriens Reduces +Stress and Improves the Quality of Semen in Infertile +Men. Evid Based Complement Alternat Med. 2010; +7(1):137–144. +[53] +Singh S, Nair V, Gupta YK. Evaluation of the +aphrodisiac activity of Tribulus terrestris Linn.in +sexually sluggish male albino rats. J Pharmacol +Pharmacother. 2012; 3(1):43–47. +[54] +Ima +A, +Furu +T. +Chemotherapy-induced female +infertility and protective action of gonadotropin- +releasing hormone analogues. 2007: 27(1):20-24. +[55] +Princy, Palatty L, Pratibha S, Shirke KM, Kamble S, +Ravanakar M. A clinical round up of the female +infertility amongst Indians. Journal clinical diagnostic +research 2012; 4204:2486. +[56] +Savarese DMF, Savy G, Vahdat L, Wischmeyer PE, +Corey B. Prevention of chemotherapy and radiation +toxicity with glutamine. Cancer Treatment Reviews. +2003; 29(6):501–513. +[57] +Samarakoon +SMS, +Chandola +HM, +Shukla +VJ. +Evaluation of antioxidant potential of Amalakayas +Rasayana: A polyherbal Ayurvedic formulation. Int J +Ayurveda Res. 2011; 2(1):23–28. +[58] +Mishra PK, Raghuram GV, Bhargava A, Ahirwar A, +Samarth R, Upadhyaya R, et al. In vitro and in vivo +evaluation +of +the +anticarcinogenic +and +cancer +chemopreventive potential of a flavonoid-rich fraction +from a traditional Indian herb Selaginella bryopteris. Br +J Nutr. 2011; 106(8):1154-68. +[59] +Chatterjee UR, Ray S, Micard V, Ghosh D, Ghosh K, +Shruti S, et al. Interaction with bovine serum albumin of +an +anti-oxidative +pectic +arabinogalactan +from +Andrographis paniculata. Carbohydrate Polymers 2014; +101:342–348. +[60] +Shah KA, Patel MB, Patel RJ, Parmar PK. Mangifera +Indica (Mango). Pharmacogn Rev. 2010; 4(7):42–48. +[61] +Russo A, Izzo AA, Borrelli F, Renis M, Vanella A. Free +radical scavenging capacity and protective effect of +Bacopa monniera L. on DNA damage. Phytother Res. +2003; 17(8):870-875. +[62] +Baliga MS. Triphala, Ayurvedic formulation for treating +and preventing cancer: a review. J Altern Complement +Med. 2010; 16(12):1301-8. +[63] +Das T, Sa G, Saha B, Das K. Multifocal signal +modulation therapy of cancer: ancient weapon, modern +targets. Mol Cell Biochem. 2010; 336(1-2):85-95. +[64] +Chun YS, Laurent A , Maru D, Vauthey JN . +Management of chemotherapy-associated hepatotoxicity +in colorectal liver metastases. The Lancet oncology +2009; 10(3):278–286. +[65] +Hosny M H, Farouk HH. Protective effect of Withania +somnifera against radiation-induced hepatotoxicity in +rats. Ecotoxicol Environ Saf. 2012; 80:14-19. +[66] +Madhavan V, Pandey AS, Murali A, Yoganarasimhan +SN. Protective effects of Capparis sepiaria root extracts +against acetaminophen-induced hepatotoxicity in Wistar +rats. J Complement Integr Med. 2012; 9(1). +[67] +Shah VN, Shah MB, Bhatt PA. Hepatoprotective +activity of punarnavashtak kwath, an Ayurvedic +formulation, against CCl4-induced hepatotoxicity in rats +and on the HepG2 cell line. Pharm Biol. 2011 ; +49(4):408-415. +[68] +Kataria M, Singh LN. Hepatoprotective effect of Liv-52 +and kumaryasava on carbon tetrachloride induced +hepatic damage in rats. Indian J Exp Biol. 1997; +35(6):655-657. +[69] +Hahm ER, Lee J, Kim SH, Sehrawat A, Arlotti JA, +Shiva SS, et al. SV Metabolic Alterations in Mammary +Ayurveda for Chemo-radiotherapy Induced Side Effects in Cancer Patients +129 +Cancer Prevention by Withaferin A in a Clinically +Relevant Mouse Model. J Natl Cancer Inst. 2013. +[70] +Yadav B, Bajaj A, Saxena M, Saxena AK. In Vitro +Anticancer Activity of the Root, Stem and Leaves of +Withania Somnifera against Various Human Cancer +Cell Lines. Indian J Pharm Sci. 2010; 72(5):659–663. +[71] +Widodo N, Priyandoko D, Shah N, Wadhwa R, Kaul +SC. Selective killing of cancer cells by Ashwagandha +leaf extract and its component Withanone involves ROS +signaling. PLoS One. 2010; 5(10). +[72] +Sun C, Nirmalananda S, Jenkins CE, Debnath S, +Balambika R, Fata JE, et al. First Ayurvedic Approach +towards Green Drugs: Anti Cervical Cancer-Cell +Properties of Clerodendrum viscosum Root Extract. +Anticancer Agents Med Chem. 2013. +[73] +Khaw AK, Hande MP, Kalthur G, Hande MP. +Curcumin inhibits telomerase and induces telomere +shortening and apoptosis in brain tumour cells. J Cell +Biochem. 2013; 114(6):1257-1270. +[74] +Shilpa PN, Sivaramakrishnan V, Devaraj NS. Induction +of apoptosis by methanolic extract of Rubia cordifolia +Linn in HEp-2 cell line is mediated by reactive oxygen +species. Asian Pac J Cancer Prev. 2012; 13(6):2753- +2758. +[75] +Choedon T, Shukla SK, Kumar V. Chemopreventive +and anti-cancer properties of the aqueous extract of +flowers of Butea monosperma. J Ethnopharmaco. 2010; +129(2):208-213. +[76] +Baliga MS. Triphala, Ayurvedic formulation for treating +and preventing cancer: a review. J Altern Complement +Med. 2010; 16(12):1301-1308. +[77] +BB, Gehlot P. Inflammation and cancer: how friendly is +the relationship for cancer patients? Current Opinion in +Pharmacology 2009; 9( 4):351–369. +[78] +Kwatra D, Subramaniam D, Anant S, et al. Methanolic +Extracts of Bitter Melon Inhibit Colon Cancer Stem +Cells by Affecting Energy Homeostasis and Autophagy. +Evidence +based +complimentary +and +alternative +medicine. 2013; Volume 2013:14 +[79] +Vayalil PK, Kuttan G, Kuttan R. Rasayanas: Evidence +for the Concept of Prevention of Diseases. Am. J. Chin. +Med. 2002; 30:155. + + + + diff --git a/subfolder_0/An innovative approach in health sciences Yoga for obesity.txt b/subfolder_0/An innovative approach in health sciences Yoga for obesity.txt new file mode 100644 index 0000000000000000000000000000000000000000..b2e81d92a97e24048fe0e1678addbc96dd4bd04e --- /dev/null +++ b/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: rudranath29@gmail.com +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] diff --git a/subfolder_0/Assessment of risk of diabetes by using Indian Diabetic risk score (IDRS) in Indian population.txt b/subfolder_0/Assessment of risk of diabetes by using Indian Diabetic risk score (IDRS) in Indian population.txt new file mode 100644 index 0000000000000000000000000000000000000000..4d6714ee3981cca533636ab817990616ab7b44af --- /dev/null +++ b/subfolder_0/Assessment of risk of diabetes by using Indian Diabetic risk score (IDRS) in Indian population.txt @@ -0,0 +1,1310 @@ +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: rnagaratna@gmail.com (R. Nagarathna), akshay1anand@rediffmail.com (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. +R E F E R E N C E S +[1] IDF I. Diabetes Atlas Update Poster. IDF; 2014. +[2] Harrison TA, Hindorff LA, Kim H, Wines RC, Bowen DJ, +McGrath BB, et al. Family history of diabetes as a potential +public health tool. Am J Prev Med 2003;24:152–9. +[3] Kaushal K, Mahajan A, Parashar A, Dhadwal DS, Jaswal V, +Jaret P, et al. Validity of madras diabetes research foundation: +Indian diabetes risk score for screening of diabetes mellitus +among adult population of urban field practice area, Indira +Gandhi Medical College, Shimla, Himachal Pradesh, India. +Ind J Endocrinol Metabol 2017;21:876. +[4] Abbasi A, Peelen LM, Corpeleijn E, van der Schouw YT, Stolk +RP, Spijkerman AM, et al. Prediction models for risk of +developing type 2 diabetes: systematic literature search and +independent external validation study. BMJ 2012;345 e5900. +[5] Long J, Rozo-Rivera A, Akers T, VanGeest JB, Bairan A, Fogarty +KJ, et al. Validating the utility of the Spanish version of the +American Diabetes Association Risk Test. Clin Nurs Res +2006;15:107–18. +[6] Al-Lawati J, Tuomilehto J. Diabetes risk score in Oman: a tool +to identify prevalent type 2 diabetes among Arabs of the +Middle East. Diabetes Res Clin Pract 2007;77:438–44. +[7] Mohan V, Deepa R, Deepa M, Somannavar S, Datta M. A +simplified Indian Diabetes Risk Score for screening for +undiagnosed diabetic subjects. J Associat Phys India +2005;53:759–63. +[8] Adhikari P, Pathak R, Kotian S. Validation of the MDRF-Indian +Diabetes Risk Score (IDRS) in another south Indian +population through the Boloor Diabetes Study (BDS). J Assoc +Physicians India 2010;58:434–6. +[9] Joshi SR. Indian diabetes risk score. JAPI 2005;53:755–7. +[10] Gupta SK, Singh Z, Purty AJ, Kar M, Vedapriya D, Mahajan P, +et al. Diabetes prevalence and its risk factors in rural area of +Tamil Nadu. Ind J Commun Med: OffiPubl Ind Associat +Prevent Soc Med 2010;35:396. +[11] Mohan V, Anbalagan VP. Expanding role of the Madras +Diabetes Research Foundation - Indian Diabetes Risk Score in +clinical practice. Indian J Endocrinol Metab 2013;17:31–6. +[12] Dudeja P, Singh G, Gadekar T, Mukherji S. Performance of +Indian Diabetes Risk Score (IDRS) as screening tool for +diabetes in an urban slum. Med J Armed Forces India +2017;73:123–8. +[13] Kaushal K, Mahajan A, Parashar A, Dhadwal DS, Jaswal VMS, +Jaret P, et al. Validity of Madras Diabetes Research +Foundation: Indian Diabetes Risk Score for Screening of +Diabetes Mellitus among Adult Population of Urban Field +Practice Area, Indira Gandhi Medical College, Shimla, +Himachal Pradesh. India Indian J Endocrinol Metab +2017;21:876–81. +[14] Bhadoria AS, Kasar PK, Toppo NA. Validation of Indian +diabetic risk score in diagnosing type 2 diabetes mellitus +against high fasting blood sugar levels among adult +population of central India. Biomed J 2015;38:359–60. +[15] Nagarathna R, Rajesh SK, Amit S, Patil S, Anand A, Nagendra +HR. Methodology of Niyantrita Madhumeha Bharata +Abhiyaan-2017, a Nationwide Multicentric Trial on the Effect +of a Validated Culturally Acceptable Lifestyle Intervention for +Primary Prevention of Diabetes: Part 2. Int J Yoga +2019;12:193–205. +[16] Nagarathna R, T +yagi R, Kaur G, Vendan V, Acharya IN, Anand +A, et al. Efficacy of a Validated Yoga Protocol on Dyslipidemia +in Diabetes Patients: NMB-2017 India Trial. Medicines (Basel) +2019;6. +[17] Khan MM, Sonkar GK, Alam R, Mehrotra S, Khan MS, Kumar +A, et al. Validity of Indian Diabetes Risk Score and its +association with body mass index and glycosylated +hemoglobin for screening of diabetes in and around areas of +Lucknow. J Family Med Prim Care 2017;6:366–73. +[18] Mohan V, Sandeep S, Deepa R, Shah B, Varghese C. +Epidemiology of type 2 diabetes: Indian scenario. Indian J +Med Res 2007;125:217–30. +[19] Salinero-Fort MA, de Burgos-Lunar C, Mostaza Prieto J, Lahoz +Rallo C, Abanades-Herranz JC, Gomez-Campelo P, et al. +Validating prediction scales of type 2 diabetes mellitus in +Spain: the SPREDIA-2 population-based prospective cohort +study protocol. BMJ Open 2015;5 e007195. +[20] Rathmann W, Martin S, Haastert B, Icks A, Holle R, Lowel H, +et al. Performance of screening questionnaires and risk +scores for undiagnosed diabetes: the KORA Survey 2000. Arch +Intern Med 2005;165:436–41. +[21] Lindstrom J, Tuomilehto J. The diabetes risk score: a practical +tool to predict type 2 diabetes risk. Diabetes Care +2003;26:725–31. +[22] Glumer C, Carstensen B, Sandbaek A, Lauritzen T, Jorgensen +T, Borch-Johnsen K, et al. A Danish diabetes risk score for +targeted screening: the Inter99 study. Diabetes Care +2004;27:727–33. +[23] Balkau B, Lange C, Fezeu L, Tichet J, de Lauzon-Guillain B, +Czernichow S, et al. Predicting diabetes: clinical, biological, +and genetic approaches: data from the Epidemiological Study +on the Insulin Resistance Syndrome (DESIR). Diabetes Care +2008;31:2056–61. +[24] Schmidt MI, Duncan BB, Bang H, Pankow JS, Ballantyne CM, +Golden SH, et al. Identifying individuals at high risk for +diabetes: the Atherosclerosis Risk in Communities study. +Diabetes Care 2005;28:2013–8. +[25] Hippisley-Cox J, Coupland C, Robson J, Sheikh A, Brindle P. +Predicting risk of type 2 diabetes in England and Wales: +prospective derivation and validation of QDScore. BMJ +2009;338 b880. +[26] Misra A, Pandey RM, Devi JR, Sharma R, Vikram NK, Khanna +N. High prevalence of diabetes, obesity and dyslipidaemia in +urban slum population in northern India. Int J Obes Relat +Metab Disord 2001;25:1722–9. +[27] Ramachandran A, Snehalatha C, Kapur A, Vijay V, Mohan V, +Das AK, et al. High prevalence of diabetes and impaired +glucose tolerance in India: National Urban Diabetes Survey. +Diabetologia 2001;44:1094–101. +[28] Bharati DR, Pal R, Kar S, Rekha R, Yamuna TV, Basu M. +Prevalence and determinants of diabetes mellitus in +Puducherry. South India J Pharm Bioallied Sci 2011;3:513–8. +[29] Dasappa H, Fathima FN, Prabhakar R, Sarin S. Prevalence of +diabetes and pre-diabetes and assessments of their risk +factors in urban slums of Bangalore. J Family Med Prim Care +2015;4:399–404. +[30] Zargar AH, Khan AK, Masoodi SR, Laway BA, Wani AI, Bashir +MI, et al. Prevalence of type 2 diabetes mellitus and impaired +glucose tolerance in the Kashmir Valley of the Indian +subcontinent. Diabetes Res Clin Pract 2000;47:135–46. +[31] Agrawal S, Ebrahim S. Prevalence and risk factors for self- +reported diabetes among adult men and women in India: +findings from a national cross-sectional survey. Public Health +Nutr 2012;15:1065–77. +8 +d i a b e t e s r e s e a r c h a n d c l i n i c a l p r a c t i c e 1 6 2 ( 2 0 2 0 ) 1 0 8 0 8 8 +[32] Gupta OP, Joshi MH, Dave SK. Prevalence of diabetes in India. +Adv Metab Disord 1978;9:147–65. +[33] Gupta RKST, Verma AK, Raina SK. Utility of MDRF-IDRS +(Madras Diabetes Research Foundation-Indian Diabetes +Risk Score) as a tool to assess risk for diabetes-a study from +north-west India. Int J Diabetes Devel Countries +2015;35:570–2. +[34] Ramachandran A. Epidemiology of diabetes in India–three +decades of research. J Assoc Physicians India 2005;53:34–8. +[35] Chowdhury R. MAaKLS, A study on distribution and +determinantsof indian diabetic risk score (idrs) among rural +population of west bengal ISSN: 2249 4995|eISSN: 2277 8810. A +study on distribution and determinantsof indian diabetic risk +score (idrs) among rural population of west bengal. Natl J Med +Res 2012;2:282–6. +[36] Kaveeshwar SA, Cornwall J. The current state of diabetes +mellitus in India. Austral Med J 2014;7(1):45–8. https://doi.org/ +10.4066/AMJ.2013.1979. +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 +9 diff --git a/subfolder_0/Auditory Information Processing During Meditation Based on Evoked Potentials Studies.txt b/subfolder_0/Auditory Information Processing During Meditation Based on Evoked Potentials Studies.txt new file mode 100644 index 0000000000000000000000000000000000000000..64c272172c575509d0701e1493911610089c97ff --- /dev/null +++ b/subfolder_0/Auditory Information Processing During Meditation Based on Evoked Potentials Studies.txt @@ -0,0 +1,1123 @@ +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: shirleytelles@gmail.com +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- +701. +2. Brown DP (1977) A model for the levels of concentrative meditation. Int J Clin +Exp Hypn 25: 236-73. +3. Murata T, Takahashi T, Hamada T, Omori M, Kosaka H, et al. (2004) +Individual trait anxiety levels characterizing the properties of zen meditation. +Neuropsychobiology 50: 189-194. +4. Taimni IK (1994) The Science of Yoga: The Yoga-sutras of Patanjali in +Sanskrit with Transliteration in Roman, Translation and Commentary in +English. Theosophical Publishing House. +5. Telles S, Joseph C, Venkatesh S, Desiraju T (1993) Alterations of auditory +middle latency evoked potentials during yogic consciously regulated breathing +and attentive state of mind. Int J Psychophysiol 14: 189-198. +6. Desiraju T (1979) Electrophysiology of Prefrontal and Dorsolateral Cortex +elucidating the basis and nature of Higher nervous associations in primates. +In: (Ed.) MABB, editor. Brain Mech. Mem. Learn. From single neuron to man, +New York, p. 79-89. +7. Desiraju T (1984) Neurophysiology and Consciousness. An integrated non – +dualist evolutionary theory. In: (Eds.) DG and PIK, editor. Front. Physiol. Res., +Academy of Science, Canberra: Australian Academy of Science, Canberra, +and Cambridge University Press, p. 325-333. +8. Pribram KH, McGuinness D (1992) Attention and para-attentional processing. +Event-related brain potentials as tests of a model. Ann N Y Acad Sci 658: 65- +92. +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 diff --git a/subfolder_0/Ayurveda Perspective of Management of Cancer Chemotherapy.txt b/subfolder_0/Ayurveda Perspective of Management of Cancer Chemotherapy.txt new file mode 100644 index 0000000000000000000000000000000000000000..192e24cb84d57f3025021325df492cb3dfa256fd --- /dev/null +++ b/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 + diff --git a/subfolder_0/Breathing-Focused Yoga Intervention on Respiratory Decline in Chronically Pesticide-Exposed Farmers A Randomized Controlled Trial (1).txt b/subfolder_0/Breathing-Focused Yoga Intervention on Respiratory Decline in Chronically Pesticide-Exposed Farmers A Randomized Controlled Trial (1).txt new file mode 100644 index 0000000000000000000000000000000000000000..23ffec405749bbebcff8eee994efd224269cd9e9 --- /dev/null +++ b/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 +majumdar.vijaya@gmail.com +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 +REFERENCES +1. Gil +JDB, +Reidsma +P, +Giller +K, +Todman +L, +Whitmore +A, +van +Ittersum M. Sustainable development goal 2: improved targets and +indicators for agriculture and food security. Ambio. (2019) 48:685–98. +doi: 10.1007/s13280-018-1101-4 +2. Nicolopoulou-Stamati P, Maipas S, Kotampasi C, Stamatis P, Hens L. +Chemical pesticides and human health: the urgent need for a new concept +in agriculture. Front Public Health. (2016) 4:148. doi: 10.3389/fpubh. +2016.00148 +3. Hu R, Huang X, Huang J, Li Y, Zhang C, Yin Y, et al. Long- and short-term +health effects of pesticide exposure: a cohort study from China. PLoS ONE. +(2015) 10:e0128766. doi: 10.1371/journal.pone.0128766 +4. Hernández AF, Casado I, Pena G, Gil F, Villanueva E, Pla A. Low level of +exposure to pesticides leads to lung dysfunction in occupationally exposed +subjects. Inhal Toxicol. (2008) 20:839–49. doi: 10.1080/08958370801905524 +5. de Jong K, Boezen HM, Kromhout H, Vermeulen R, Postma DS, +Vonk JM. Association of occupational pesticide exposure with accelerated +longitudinal decline in lung function. Am J Epidemiol. (2014) 179:1323– +30. doi: 10.1093/aje/kwu053 +6. Alif +SM, +Dharmage +SC, +Benke +G, +Dennekamp +M, +Burgess +JA, +Perret JL, et al. Occupational exposure to pesticides are associated +with +fixed +airflow +obstruction +in +middle-age. +Thorax. +(2017) +72:990–7. doi: 10.1136/thoraxjnl-2016-209665 +7. Mamane A, Baldi I, Tessier JF, Raherison C, Bouvier G. Occupational +exposure to pesticides and respiratory health. Eur Respir Rev. (2015) 24:306– +19. doi: 10.1183/16000617.00006014 +8. Ratanachina J, De Matteis S, Cullinan P, Burney P. Pesticide exposure and +lung function: a systematic review and meta-analysis. Occup Med. (2020) +70:14–23. doi: 10.1093/occmed/kqz161 +9. Fareed M, Pathak MK, Bihari V, Kamal R, Srivastava AK, Kesavachandran +CN. Adverse respiratory health and hematological alterations among +agricultural +workers +occupationally +exposed +to +organophosphate +pesticides: a cross-sectional study in North India. PLoS ONE. (2013) +8:e69755. doi: 10.1371/journal.pone.0069755 +10. Negatu B, Kromhout H, Mekonnen Y, Vermeulen R. Occupational pesticide +exposure and respiratory health: a large-scale cross-sectional study in +three commercial farming systems in Ethiopia. Thorax. (2017) 72:498– +9. doi: 10.1136/thoraxjnl-2016-208924 +11. Aloizou AM, Siokas V, Vogiatzi C, Peristeri E, Docea AO, Petrakis D, et al. +Pesticides, cognitive functions and dementia: a review. Toxicol Lett. (2020) +326:31–51. doi: 10.1016/j.toxlet.2020.03.005 +12. Kamel +F, +Hoppin +JA. +Association +of +pesticide +exposure +with +neurologic dysfunction and disease. Environ Health Perspect. (2004) +112:950–8. doi: 10.1289/ehp.7135 +13. Muñoz-Quezada MT, Lucero BA, Iglesias VP, Muñoz MP, Cornejo CA, +Achu E, et al. Chronic exposure to organophosphate (OP) pesticides +and neuropsychological functioning in farm workers: a review. Int J +Occup Environ Health. (2016) 22:68–79. doi: 10.1080/10773525.2015.11 +23848 +14. Daghagh +Yazd +S, +Wheeler +SA, +Zuo +A. +Key +risk +factors +affecting +farmers’ +mental +health: +a +systematic +review. +Int +J +Environ +Res +Public +Health. +(2019) +16:4849. +doi: +10.3390/ijerph162 +34849 +15. Kim +JY, +Park +S, +Kim +SK, +Kim +CS, +Kim +TH, +et +al. +Correction: +pesticide +exposure +and +cognitive +decline +in +a +rural +South +Korean +population. PLOS ONE. (2019) 14: e0216310. doi: 10.1371/journal.pone. +0216310 eCollection 2019 +16. Cummings KJ, Johns DO, Mazurek JM, Hearl FJ, Weissman DN. +NIOSH’s respiratory health division: 50 years of and service. Arch +Environ Occup Health. (2019) 74:15–29. doi: 10.1080/19338244.2018.15 +32387 +17. Afshari M, Karimi-Shahanjarini A, Khoshravesh S, Besharati F. Effectiveness +of interventions to promote pesticide safety and reduce pesticide exposure +in agricultural health studies: a systematic review. PLoS ONE. (2021) +16:e0245766. doi: 10.1371/journal.pone.0245766 +18. Liu XC, Pan L, Hu Q, Dong WP, Yan JH, Dong L. Effects of +yoga training in patients with chronic obstructive pulmonary disease: +a systematic review and meta-analysis. J Thorac Dis. (2014) 6:795– +802. doi: 10.3978/j.issn.2072-1439.2014.06.05 +19. Cramer H, Haller H, Klose P, Ward L, Chung VC, Lauche, R. The risks +and benefits of yoga for patients with chronic obstructive pulmonary +disease: a systematic review and meta-analysis. Clin Rehabil. (2019) 33:1847– +62. doi: 10.1177/0269215519860551 +20. Santaella DF, Devesa CR, Rojo MR, Amato MB, Drager LF, Casali KR, +et al. Yoga respiratory training improves respiratory function and cardiac +sympathovagal balance in elderly subjects: a randomised controlled trial. BMJ +Open. (2011) 1:e000085. doi: 10.1136/bmjopen-2011-000085 +Frontiers in Medicine | www.frontiersin.org +11 +March 2022 | Volume 9 | Article 807612 +Dhansoia et al. +Yoga and Respiratory Decline +21. Abel AN, Lloyd LK, Williams JS. The effects of regular yoga practice on +pulmonary function in healthy individuals: a literature review. J Altern +Complement Med. (2013) 19:185–90. doi: 10.1089/acm.2011.0516 +22. Beutler E, Beltrami FG, Boutellier U, Spengler CM. Effect of regular yoga +practice on respiratory regulation and exercise performance. PLoS ONE. +(2016) 11:e0153159. doi: 10.1371/journal.pone.0153159 +23. Makwana K, Khirwadkar N, Gupta HC. Effect of short term yoga +practice +on +ventilatory +function +tests. +Indian +J +Physiol +Pharmacol. +(1988) 32:202–8. +24. 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. doi: 10.4103/0973-6131. +133875 +25. Sodhi C, Singh S, Dandona PK, A study of the effect of yoga training on +pulmonary functions in patients with bronchial asthma. Indian J Physiol +Pharmacol. (2009) 53:169–74. +26. Menne B, Aragon de Leon E, Bekker M, Mirzikashvili N, Morton S, Shriwise +A, et al. Health and well-being for all: an approach to accelerating progress +to achieve the Sustainable Development Goals (SDGs) in countries in +the WHO European region. Eur J Public Health. (2020) 30(Suppl_1):i3– +9. doi: 10.1093/eurpub/ckaa026 +27. Gothe +NP, +McAuley +E. +Yoga +and +cognition: +a +meta-analysis +of +chronic +and +acute +effects. +Psychosom +Med. +(2015) +77:784– +97. doi: 10.1097/PSY.0000000000000218 +28. Sharma +VK. +M +R, +S +V, +Subramanian +SK, +Bhavanani +AB, +Madanmohan, et al. Effect of fast and slow pranayama practice on +cognitive functions in healthy volunteers. J Clin Diagn Res. (2014) +8:10–3. doi: 10.7860/JCDR/2014/7256.3668 +29. Whittle R, Mansell G, Jellema P, van der Windt D. Applying causal +mediation methods to clinical trial data: what can we learn about why our +interventions (don’t) work?. Eur J Pain. (2017) 21:614–22. doi: 10.1002/e +jp.964 +30. Lee KM, Park SY, Lee K, Oh SS, Ko SB. Pesticide metabolite and oxidative +stress in male farmers exposed to pesticide. Ann Occup Environ Med. (2017) +29:5. doi: 10.1186/s40557-017-0162-3 +31. Della Morte R, Villani GR, Di Martino E, Squillacioti C, De Marco L, Vuotto P, +et al. Glutathione depletion induced in rat liver fractions by seven pesticides. +Boll Soc Ital Biol Sper. (1994) 70:185–92. +32. Mecdad AA, Ahmed MH, ElHalwagy MEA, Afify MMM, A study on oxidative +stress biomarkers and immunomodulatory effects of pesticides in pesticide- +sprayers. Egyptian J Forensic Sci. (2011) 1:93–8. doi: 10.1016/j.ejfs.2011.04.012 +33. Drost EM, Skwarski KM, Sauleda J, Soler N, Roca J, Agusti A, et al. Oxidative +stress and airway inflammation in severe exacerbations of COPD. Thorax. +(2005) 60:293–300. doi: 10.1136/thx.2004.027946 +34. Patil SG, Dhanakshirur GB, Aithala MR, Naregal G, Das KK. Effect of yoga on +oxidative stress in elderly with grade-I hypertension: a randomized controlled +study. J Clin Diagn Res. (2014) 8:BC04–7. doi: 10.7860/JCDR/2014/94 +98.4586 +35. Pal R, Gupta N. Yogic practices on oxidative stress and of antioxidant level: a +systematic review of randomized controlled trials. J Complement Integr Med. +(2017) 16:20170079. doi: 10.1515/jcim-2017-0079 +36. Gordon L, McGrowder DA, Pena YT, Cabrera E, Lawrence-Wright +MB. Effect of yoga exercise therapy on oxidative stress indicators +with end-stage renal disease on hemodialysis. Int J Yoga. (2013) 6:31– +8. doi: 10.4103/0973-6131.105944 +37. Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, +Collin I. The montreal cognitive assessment, MoCA: a brief screening +tool for mild cognitive impairment. J Am Geriatr Soc. (2005) 53:695– +9. doi: 10.1111/j.1532-5415.2005.53221.x +38. Quanjer PH, Stanojevic S, Cole TJ, et al. Multi-ethnic reference values +for spirometry for the 3–95-yr age range: the global lung function +2012 equations. Eur Respir J. (2012) 40:1324–43. doi: 10.1183/09031936.00 +080312 +39. Devakumar D, Stocks J, Ayres JG, Kigby J, Yadav SK, Saville NM, et al. +Effects of antenatal multiple micronutrient supplementation on lung function +in mid-childhood: follow-up of a double-blind randomised controlled +trial in Nepal. Eur Respir J. (2015) 45:1566–75. doi: 10.1183/09031936.00 +188914 +40. American Thoracic Society – Standardization of spirometry 1995 update. Am J +respire Crit Care Med. (1995) 152:1107–36. doi: 10.1164/ajrccm.152.3.7663792 +41. Initiative GL. FR Macro. (2012). Available online at: https://wwwers- +educationorg/guidelines/global-lung-function-initiative/spirometry-tools/r- +macroaspx +42. Hall GL, Stanojevic S, GLI Network Executive, Members of the GLI Network +Executive. The Global Lung Function Initiative (GLI) Network ERS Clinical +Research Collaboration: how international collaboration can shape clinical +practice. Eur Respir J. (2019) 53:1802277. doi: 10.1183/13993003.02277-2018 +43. Matarazzo JD, Herman D. Base rate data for the WAIS-R: test-retest +stability and VIQ-PIQ differences. J Clin Neuropsychol. (1984) 6: 351– +66. doi: 10.1080/01688638408401227 +44. Jaeger J. Digit symbol substitution test: the case for sensitivity over specificity +in neuropsychological testing. J Clin Psychopharmacol. (2018) 38:513– +9. doi: 10.1097/JCP.0000000000000941 +45. Bowie +CR, +Harvey +PD. +Administration +and +interpretation +of +the +trail making test. Nat. Protoc. (2006) 1:2277–81. doi: 10.1038/nprot.2 +006.390 +46. Reitan R. Validity of the trail making test as an indicator of organic brain +damage. Percept Mot Skills. (1958) 8:271–6. doi: 10.2466/pms.1958.8.3.271 +47. Olivera-Souza +RD, +Moll +J, +Passman +LJ, +Cunha +FC, +Paes +F, +Adriano +MV, +et +al. +Trail +making +and +cognitive +set-shifting. +Arq +Neuropsiquiatr. (2000) 58(3B):826–9. doi: 10.1590/s0004-282x20000005 +00006 +48. Strauss E, Sherman EMS, Spreen O. A compendium of neuropsychological +tests: administration, norms, and commentary. Arch Clin Neuropsychol. +(2006) 21:819–25. doi: 10.1016/j.acn.2006.09.002 +49. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J +Health Soc Behav. (1983) 24:385–96. +50. Wiriyakijja P, Porter S, Fedele S, Hodgson T, McMillan R, Shephard +M, et al. Validation of the HADS and PSS-10 and a cross-sectional +study +of +psychological +status +in +patients +with +recurrent +aphthous +stomatitis. +J. +Oral +Pathol +Med. +(2020) +49:260–70. +doi: +10.1111/ +jop.12991 +51. Skevington +SM, +Lotfy +M, +O’Connell +KA. +WHOQOL +Group. +The +world +health +organization’s +WHOQOL-BREF +quality +of +life +assessment: +psychometric +properties +and +results +of +the +international field trial. A report from the WHOQOL group. Qual +Life +Res. +(2004) +13:299–310. doi: +10.1023/B:QURE.0000018486. +91360.00 +52. Ohkawa H, Ohishi N, Yagi K. Assay for lipid peroxides in animal +tissues by thiobarbituric acid reaction. Anal Chem. (1979) 95:351– +8. doi: 10.1016/0003-2697(79)90738-3 +53. Quanjer PH, Pretto JJ, Brazzale DJ, Boros PW. Grading the severity of +airways obstruction: new wine in new bottles. Eur Respir J. (2014) 43:505– +12. doi: 10.1183/09031936.00086313 +54. Valeri L, Vanderweele TJ. Mediation analysis allowing for exposure- +mediator interactions and causal interpretation: theoretical assumptions and +implementation with SAS and SPSS macros. Psychol Methods. (2013) 18:137– +50. doi: 10.1037/a0031034 +55. Dhalla AS, Sharma S. Assessment of serum cholinesterase in rural punjabi +sprayers exposed to a mixture of pesticides. Toxicol Int. (2013) 20:154– +9. doi: 10.4103/0971-6580.117258 +56. McGlothlin +AE, +Lewis +RJ. +Minimal +clinically +important +difference: +defining +what +really +matters +to +patients. +JAMA. +(2014) +1:1342– +3. doi: 10.1001/jama.2014.13128 +57. Pourhassan, B, Meysamie, A, Alizadeh, S, Habibian, A, Beigzadeh, Z. Risk +of obstructive pulmonary diseases and occupational exposure to pesticides: +a systematic review and meta-analysis. Public Health. (2019) 174:31– +41. doi: 10.1016/j.puhe.2019.05.024 +58. Lim SA, Cheong KJ. Regular yoga practice improves antioxidant status, +immune function, and stress hormone releases in young healthy people: a +randomized, double-blind, controlled pilot study. J Altern Complement Med. +(2015) 21:530–8. doi: 10.1089/acm.2014.0044 +59. Rahman +I, +MacNee +W. +Lung +glutathione +and +oxidative +stress: +implications +in +cigarette +smoke-induced +airway +disease. +Am +J +Physiol. +(1999) +277:L1067–88. +doi: +10.1152/ajplung.1999.277. +6.L1067 +Frontiers in Medicine | www.frontiersin.org +12 +March 2022 | Volume 9 | Article 807612 +Dhansoia et al. +Yoga and Respiratory Decline +60. Richardson +JR, +Fitsanakis +V, +Westerink +RHS, +Kanthasamy +AG. +Neurotoxicity +of +pesticides. +Acta +Neuropathol. +(2019) +138:343– +62. doi: 10.1007/s00401-019-02033-9 +61. Arbuthnott K, Frank J. Trail making test, part B as a measure of executive +control: validation using a set-switching paradigm. J Clin Exp Neuropsychol. +(2000) 22:518–28. doi: 10.1076/1380-3395(200008)22:4;1-0;FT518 +62. Tombaugh TN. Trail making test A and B: normative data stratified by age +and education. archives of clinical neuropsychology. Arch Clin Neuropsychol. +(2004) 19:203–14. doi: 10.1016/S0887-6177(03)00039-8 +63. Wojewódzka-Wiewiórska A, Kłoczko-Gajewska A, Sulewski P. Between the +social and economic dimensions of sustainability rural areas—in search of +farmers’ quality of life. Sustainability. (2020) 12:148. doi: 10.3390/su12010148 +64. Gladis MM, Gosch EA, Dishuk NM, Crits-Christoph P. Quality of life: +expanding the scope of clinical significance. J Consult Clin Psychol. (1999) +67:320–31. doi: 10.1037//0022-006x.67.3.320 +65. Suryatapa D, Annalakshmi C, Tapan KP. Organic farming in India: a vision +towards a healthy nation. Food Qual Safet. (2020) 4:69–76. +66. Bawaskar +PH, +Bawaskar +PH, +Bawakar +HS. +India– +science +small +progress +in +health +care, +decline +in +rural +service. +Lancet. +(2015) +386:2389. doi: 10.1016/S0140-6736(15)01189-7 +67. Fitogram: yoga-markt in Deutschland. (2016). Avaialble online at: https:// +www.fitogram.pro/blog/yoga-markt-in-deutschland-2016/. +(accessed +September 21, 2018). +68. Cartwright T, Mason H, Porter A, Pilkington K. Yoga practice in +the UK: a cross-sectional survey of motivation, health benefits and +behaviors. BMJ Open. (2020) 10:e031848. doi: 10.1136/bmjopen-2019- +031848 +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 diff --git a/subfolder_0/Challenging Case in Clinical Practice Yoga Therapy for Parkinson_s disease.txt b/subfolder_0/Challenging Case in Clinical Practice Yoga Therapy for Parkinson_s disease.txt new file mode 100644 index 0000000000000000000000000000000000000000..f29f9aeea12a1dfbdf7da3823d8b62886486788a --- /dev/null +++ b/subfolder_0/Challenging Case in Clinical Practice Yoga Therapy for Parkinson_s disease.txt @@ -0,0 +1,396 @@ +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 +1. Roland KP. Applications of yoga in Parkinson’s disease: A systematic +literature review. Res Rev Parkinsonism 2014;4:1–8. +MARY ANN LIEBERT, INC.  VOL. 26 NO. 2 +59 +ALTERNATIVE AND COMPLEMENTARY THERAPIES  APRIL 2020 +Downloaded by University Of Newcastle from www.liebertpub.com at 04/15/20. For personal use only. +2. Colgrove YS, Sharma N, Kluding P, et al. Effect of yoga on motor function +in people with Parkinson’s disease: A randomized, controlled pilot study. J +Yoga Phys Ther 2012;2:112. +3. Ni M, Mooney K, Signorile JF. Controlled pilot study of the effects of +power yoga in Parkinson’s disease. Complement Ther Med 2016;25:126–131. +4. Schmid AA, Van Puymbroeck M, Koceja DM. Effect of a 12-week yoga +intervention on fear of falling and balance in older adults: A pilot study. Arch +Phys Med Rehabil 2010;91:576–583. +5. Boulgarides LK, Barakatt E, Coleman-Salgado B. Measuring the effect of +an eight-week adaptive yoga program on the physical and psychological status +of individuals with Parkinson’s disease. A pilot study. Int J Yoga Therap +2014;24:31–41. +6. Ahmadi A, Nikbakh M, Arastoo A, et al. The effects of a yoga intervention +on balance, speed and endurance of walking, fatigue and quality of life in +people with multiple sclerosis. J Hum Kinet 2010;23:71–78. +7. U +¨ lger O +¨ , Ya +glı NV. Effects of yoga on balance and gait properties in +women with musculoskeletal problems: A pilot study. Complement Ther Clin +Pract 2011;17:13–15. +8. Perlmutter JS. Assessment of Parkinson disease manifestations. Curr +Protoc Neurosci 2009;49:10. +9. Hariprasad VR, Varambally S, Varambally PT, et al. Designing, validation +and feasibility of a yoga-based intervention for elderly. Indian J Psychiatry +2013;55:S344. +10. Kakde N, Metri KG, Varambally S, et al. Development and valida- +tion of a yoga module for Parkinson disease. J Complement Integr Med +2017;14:1–8. +11. Cutson TM, Laub KC, Schenkman M. Pharmacological and non- +pharmacological interventions in the treatment of Parkinson’s disease. Phys +Ther 1995;75:363–373. +12. Bhargav H, Raghuram N, Rao NH, et al. Potential yoga modules for +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.  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. diff --git a/subfolder_0/Changes in Electrical Activities of the Brain Associated with Cognitive Functions in Type 2 Diabetes Mellitus A Systematic Review.txt b/subfolder_0/Changes in Electrical Activities of the Brain Associated with Cognitive Functions in Type 2 Diabetes Mellitus A Systematic Review.txt new file mode 100644 index 0000000000000000000000000000000000000000..6b8f44ddbea4622c11a3b16a2c6d0a52013e9b31 --- /dev/null +++ b/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: deepeshwar.singh@outlook.com +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 +References +1. International Diabetes Federation. IDF Diabetes Atlas; 2019. +2. Macpherson H, Formica M, Harris E, Daly RM. Brain functional +alterations in type 2 diabetes – A systematic review of fMRI +studies. Front Neuroendocrinol. 2017;47:34-46. doi:10.1016/j. +yfrne.2017.07.001 +3. Zeng K, Wang Y, Ouyang G, Bian Z, Wang L, Li X. Complex +network analysis of resting state EEG in amnestic mild cognitive +impairment patients with type 2 diabetes. Front Comput Neurosci. +2015;9. doi:10.3389/fncom.2015.00133 +4. Roberto S, Crisafulli A. Consequence of type 1 and 2 diabetes +mellitus on the cardiovascular regulation during exercise: a brief +review. Curr Diabetes Rev. 2017;13(6):560-565. doi:10.2174/ +1573399812666160614123226 +5. Cheng G, Huang C, Deng H, Wang H. Diabetes as a risk factor for +dementia and mild cognitive impairment: a meta-analysis of lon- +gitudinal studies. Intern Med J. 2012;42(5):484-491. doi:10.1111/ +j.1445–5994.2012.02758.x +Kanthi et al +11 +6. Cukierman T, Gerstein HC, Williamson JD. Cognitive decline and +dementia in diabetes – systematic overview of prospective obser- +vational studies. Diabetologia. 2005;48(12):2460-2469. doi:10. +1007/s00125-005-0023-4 +7. Dik MG, Jonker C, Comijs HC, et al. Contribution of metabolic +syndrome +components +to +cognition +in +older +individuals. +Diabetes Care. 2007;30(10):2655-2660. doi:10.2337/dc06-1190 +8. Yamagishi S-I, Imaizumi T. Diabetic vascular complications: +pathophysiology, biochemical basis and potential therapeutic +strategy. Cur Phar Des. 2005;11(18):2279-2299. +9. Moulton CD, Costafreda SG, Horton P, Ismail K, Fu CHY. +Meta-analyses of structural regional cerebral effects in type 1 +and type 2 diabetes. Brain Imaging Behav. 2015;9(4):651-662. +doi:10.1007/s11682-014-9348-2 +10. Van Harten B, Oosterman JM, Potter Van Loon BJ, Scheltens P, +Weinstein HC. Brain lesions on MRI in elderly patients with type +2 diabetes mellitus. Eur Neurol. 2007;57(2):70-74. doi:10.1159/ +000098054 +11. Van Harten B, de Leeuw F-E, Weinstein HC, Scheltens P, +Biessels GJ. Brain imaging in patients with diabetes: a systematic +review. Diabetes Care. 2006;29(11):2539-2548. doi:10.2337/ +dc-06-1637 +12. Reijmer YD, Brundel M, Bresser J de, et al. Microstructural white +matter abnormalities and cognitive functioning in type 2 diabetes: +a diffusion tensor imaging study. Diabetes Care. 2013;36(1):137. +doi:10.2337/DC12-0493 +13. Hsu J-L, Chen Y-L, Leu J-G, et al. Microstructural white matter +abnormalities in type 2 diabetes mellitus: a diffusion tensor +imaging study. NeuroImage. 2012;59(2):1098-1105. doi:10. +1016/j.neuroimage.2011.09.041 +14. Hoogenboom WS, Marder TJ, Flores VL, et al. Cerebral white +matter +integrity +and +resting-state +functional +connectivity +in +middle-aged +patients +with +type +2 +diabetes. +Diabetes. +2014;63(2):728-738. doi:10.2337/db13-1219 +15. Cui D, Liu J, Bian Z, Li Q, Wang L, Li X. Cortical source multi- +variate EEG synchronization analysis on amnestic mild cognitive +impairment in type 2 diabetes. Sci World J. 2014;2014:523216. +doi:10.1155/2014/523216 +16. Hazari MAH, Ram Reddy B, Uzma N, Santhosh Kumar B. +Cognitive impairment in type 2 diabetes mellitus. Int J Diab +Melli. 2015;3(1):19-24. doi:10.1016/j.ijdm.2011.01.001 +17. Kurita A, Katayama K, Mochio S. Neurophysiological evidence +for altered higher brain functions in NIPPM. Diabetes Care. +1996;19(4):361-364. +18. Mooradian AD, Perryman K, Fitten J, Kavonian GD, Morley JE. +Cortical function in elderly non-insulin dependent diabetic +patients: behavioral and electrophysiologic studies. Arch Int +Med. 1988;148(11):2369-2372. http://archinte.jamanetwork.com/ +19. Benwell CSY, Davila-Pérez P, Fried PJ, et al. EEG Spectral power +abnormalities and their relationship with cognitive dysfunction in +patients with Alzheimer’s disease and type 2 diabetes. Neurobiol +Aging. 2020;85:83-95. doi:10.1016/j.neurobiolaging.2019.10.004 +20. Cooray G, Nilsson E, Wahlin Å, Laukka EJ, Brismar K, Brismar +T. Effects of intensified metabolic control on CNS function in type 2 +diabetes. Psychoneuroendocrinology. 2011;36(1):77-86. doi:10. +1016/j.psyneuen.2010.06.009 +21. Bian Z, Li Q, Wang L, Lu C, Yin S, Li X. Relative power and +coherence of EEG series are related to amnestic mild cognitive +impairment in diabetes. Front Aging Neurosci. 2014;6(11):11. +doi:10.3389/fnagi.2014.00011 +22. Cui D, Pu W, Liu J, et al. A new EEG synchronization strength +analysis +method: +s-estimator +based +normalized +weighted- +permutation mutual information. Neural Netw. 2016;82:30-38. +doi:10.1016/j.neunet.2016.06.004 +23. Cui D, Qi S, Gu G, et al. Magnitude squared coherence method +based on weighted canonical correlation analysis for EEG syn- +chronization analysis in amnestic mild cognitive impairment +of diabetes mellitus. IEEE Trans Neur Sys and Rehab Eng. +2018;26(10):1908-1917. doi:10.1109/TNSRE.2018.2862396 +24. Hissa MN, Artur Costa D’almeida J, Cremasco F, de Bruin VMS. +Event related P300 potential in NIDDM patients without cognitive +impairment and its relationship with previous hypoglycemic epi- +sodes. Neuroendocrinol Lett. 2002;23(3):226-230. https://www. +researchgate.net/publication/11295416 +25. Mochizuki Y, Oishi M, Hayakawa Y, Matsuzakl M, Takasu T. +Improvement of P300 latency by treatment in non-insulin-dependent +diabetes Mellitus. Clin Electroencephalogr. 1998;29(4):194-196. +26. Tandon OP, Verma A, Ram BK. Cognitive dysfunction in +NIDDM: p3 event related evoked potential study. Indian J +Physiol Pharmacol. 1999;43(3):383-388. +27. Vanhanen M, Karhu J, Partanen J, Laakso M, Riekkinen P. ERPs +reveal dificits in automatic cerebral stimulus processing in patients +with NIDDM. Neuroreport. 1996;7(15–17):2767-2771. +28. Wen D, Bian Z, Li Q, Wang L, Lu C, Li X. Resting-state EEG +coupling analysis of amnestic mild cognitive impairment with +type 2 diabetes mellitus by using permutation conditional +mutual information. Clin Neurophysiol. 2016;127(1):335-348. +doi:10.1016/j.clinph.2015.05.016 +29. Babiloni C, Frisoni G, Steriade M, et al. Frontal white matter +volume and delta EEG sources negatively correlate in awake sub- +jects with mild cognitive impairment and Alzheimer’s disease. +Clin +Neurophysiol. +2006;117(5):1113-1129. +doi:10.1016/j. +clinph.2006.01.020 +30. Fraga FJ, Falk TH, Kanda PAM, Anghinah R. Characterizing +Alzheimer’s disease severity via resting-awake EEG amplitude +modulation analysis. PLoS ONE. 2013;8(8):e72240. doi:10. +1371/journal.pone.0072240 +31. Babiloni C, Lizio R, Marzano N, et al. Brain neural synchroniza- +tion and functional coupling in Alzheimer’s disease as revealed by +resting state EEG rhythms. Int J Psycho. 2016;103:88-102. +doi:10.1016/j.ijpsycho.2015.02.008 +32. Babiloni C, Babiloni F, Carducci F, et al. Movement-related elec- +troencephalographic +reactivity +in +Alzheimer +disease. +NeuroImage. 2000;12(2):139-146. doi:10.1006/nimg.2000.0602 +33. Bennys K, Rondouin G, Vergnes C, Touchon J. Diagnostic value +of quantitative EEG in Alzheimer’s disease. Clin Neurophysiol. +2001;31(3):153-160. +34. Johnson JD. The conversational brain: fronto-hippocampal inter- +action and disconnection. Med Hypotheses. 2006;67(4):759-764. +doi:10.1016/j.mehy.2006.04.031 +35. Jelic V, Johansson S-E, Almkvist O, et al. Quantitative electroen- +cephalography +in +mild +cognitive +impairment: +longitudinal +changes +and +possible +prediction +of +Alzheimer’s +disease. +Neurobiol Aging. 2000;21(4):533-540 +36. Neto E, Biessmann F, Aurlien H, Nordby H, Eichele T. +Regularized linear discriminant analysis of EEG features in +dementia patients. Front Aging Neurosci. 2016;8:273. doi:10. +3389/FNAGI.2016.00273 +37. Babiloni C, Carducci F, Lizio R, et al. Resting state cortical electro- +encephalographic rhythms are related to gray matter volume in +12 +Clinical EEG and Neuroscience 0(0) +subjects with mild cognitive impairment and Alzheimer's disease. +Hum Brain Mapp. 2013;34(6):1427-1446. doi:10.1002/hbm.22005 +38. Babiloni C, Frisoni GB, Pievani M, et al. Hippocampal volume +and cortical sources of EEG alpha rhythms in mild cognitive +impairment and Alzheimer disease. NeuroImage. 2009;44- +(1):123-135. doi:10.1016/j.neuroimage.2008.08.005 +39. Dubois B, Feldman HH, Jacova C, et al. Revising the +NINCDS-ADRDA criteria. Lancet Neurol. 2007;6(8):734-746. +doi:10.1016/S1474 +40. Moretti D, Frisoni G, … MP-J group. Cerebrovascular disease and +hippocampal atrophy are differently linked to functional coupling +of brain areas: an EEG coherence study in MCI subjects. J +Alzheimer’s Disease. 2008;14(3):285-299. +41. Jeong J. EEG Dynamics in patients with Alzheimer’s disease. Clin +Neurophysiol. +2004;115(7):1490-1505. +doi:10.1016/j.clinph. +2004.01.001 +42. Babiloni C, Frisoni BG, Pievani M, et al. White-matter vascular +lesions correlate with alpha EEG sources in mild cognitive impair- +ment. Neuropsychologia. 2008;46(6):1707-1720. doi:10.1016/j. +neuropsychologia.2008.03.021 +43. Lanzino G, Lanzino DJ, Wang D. Cerebrovascular disease and +cognitive dysfunction. Neurological Report. 2012;24(4):331-336. +44. Mueller SG, Schuff N, Yaffe K, Madison C, Miller B, Weiner +MW. Hippocampal atrophy patterns in mild cognitive impairment +and Alzheimer’s disease. Hum Brain Mapp. 2010;31(9):1339- +1347. doi:10.1002/hbm.20934 +45. Patel HS, Azzam NP. Characterization of N200 and P300: +selected studies of the event-related potential. Int J Med Sci. +2005;2(4):147-154. +46. Paitel ER, Samii MR, Nielson KA. A systematic review of cogni- +tive event-related potentials in mild cognitive impairment and +Alzheimer’s +disease. +Behav +Brain +Res. +2021;396:112904. +doi:10.1016/j.bbr.2020.112904 +47. Kodl CT, Seaquist ER. Cognitive dysfunction and diabetes +Mellitus. Endocr Rev. 2008;29(4):494-511. doi:10.1210/er. +2007 +48. Jongen C, van der Grond J, Kappelle LJ, Biessels GJ, Viergever +MA, Pluim JPW. Automated measurement of brain and white +matter lesion volume in type 2 diabetes mellitus. Diabetologia. +2007;50(7):1509-1516. doi:10.1007/s00125-007-0688-y +49. Remijn GB, Hasuo E, Fujihira H, Morimoto S. An introduction +to the measurement of auditory event-related potentials +(ERPs). Acoust Sci Technol. 2014;35(5):225-242. doi:10. +1250/ast.35.229 +Kanthi et al +13 diff --git a/subfolder_0/Changes in MIDAS, Perceived Stress, Frontalis Muscle Activity and Non-Steroidal Anti-Inflammatory Drugs Usage in Patients with Migraine Headache wi.txt b/subfolder_0/Changes in MIDAS, Perceived Stress, Frontalis Muscle Activity and Non-Steroidal Anti-Inflammatory Drugs Usage in Patients with Migraine Headache wi.txt new file mode 100644 index 0000000000000000000000000000000000000000..57dc01f9c92f5f6842ce4e9cdbef641227af4084 --- /dev/null +++ b/subfolder_0/Changes in MIDAS, Perceived Stress, Frontalis Muscle Activity and Non-Steroidal Anti-Inflammatory Drugs Usage in Patients with Migraine Headache wi.txt @@ -0,0 +1,1251 @@ +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 karger@karger.com +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. +References +  1 Dodick DW: Review of comorbidities and +risk factors for the development of migraine +complications (infarct and chronic migraine). +Cephalalgia 2009; 29(suppl 3): 7–14. +  2 Dawn CB, Marcia FT, Rupnow T, Richard BL: +Assessing and managing all aspects of mi- +graine: migraine attacks, migraine-related +functional impairment, common comorbidi- +ties, and quality of life. Mayo Clin Proc 2009; +84: 422–435. +  3 Stewart WF, Lipton RB, Whyte J, Dowson A, +Kolodner K, Liberman JN, Sawyer J: An Inter- +national study to assess reliability of the mi- +graine disability assessment (MIDAS) score. +Neurology 1999; 53: 988–994. +  4 Maki K, Vahtera J, Virtanen M, Elovainio M, +Keltikangas-Jarvinen L, Kivimaki M: Work +stress and new-onset migraine in a female em- +ployee population. Cephalalgia 2008; 28: 18–25. +  5 Moon H, Seo JG, Park SP: Perceived stress in +patients with migraine: a case-control study. J +Headache Pain 2017; 18: 73. +  6 Cortelli P, Pierangeli G, Parchi P, Contin M, +Baruzzi A, Lugaresi E: Autonomic nervous +system function in migraine without aura. +Headache 1991; 31: 457–462. +  7 Jensen R, Fuglsang-Frederiksen A, Olesen J: +Quantitative surface EMG of pericranial mus- +cles in headache, a population study. Electro- +encephalogr Clin Neurophysiol 1994; 93: 335– +344. +  8 Leistad RB, Sand T, Westgaard RH, Nilsen KB, +Stovner LJ: Stress-induced pain and muscle +activity in patients with migraine and tension- +type headache. Cephalalgia 2006; 26: 64–73. +  9 Goadsby PJ: Bench to bedside advances in the +21st century for primary headache disorders: +migraine treatments for migraine patients. +Brain 2016; 139: 2571–2577. +10 Jaideep SS, Nagaraja D, Pal PK, Sudhakara D, +Satyaprabha TN: Modulation of cardiac auto- +nomic dysfunction in ischemic stroke follow- +ing Ayurveda (Indian System of Medicine) +Treatment. Evid Based Complement Alternat +Med 2014; 2014: 634695. +11 Peterson CT, Lucas J, John-William L, Thomp- +son JW, Moseley MA, Patel S, Peterson SN, +Porter V, Schadt EE, Mills PJ, Tanzi RE, Do- +raiswamy PM, Chopra D: Identification of al- +tered metabolomic profiles following a pan- +chakarma-based Ayurvedic Intervention in +healthy subjects: The Self-Directed Biological +Transformation Initiative (SBTI). Sci Rep +2016; 6: 32609. +12 Vaidya PB, Vaidya BS, Vaidya SK: Response to +Ayurvedic therapy in the treatment of migraine +without aura. Int J Ayurveda Res 2010; 1: 30–36. +13 Mishra K, Singh P, Bunch SJ, Bunch SJ, Zhang +R: The therapeutic value of yoga in neurolog- +ical disorders. Ann Indian Acad Neurol 2012; +15: 247–254. +14 Sargent J, Solbach P, Coyne L, Spohn H, +Segerson J: Results of a controlled, experi- +mental, outcome study of nondrug treat- +ments for the control of migraine headaches. +J Behav Med 1986; 9: 291–323. +15 International Headache Society: Internation- +al classification of headache disorders. Ceph- +alalgia 2013; 33: 629–808. +16 Cohen S, Williamson GM: Perceived stress in +a probability sample of the United States. Soc +Psychol Health 1988: 31–67. +17 Gada MT: A comparative study of efficacy of +EMG bio-feedback and progressive muscular +relaxation in tension headache. Indian J Psy- +chiatry 1984; 26: 121–127. +18 De Luca CJ: The use of surface electromyog- +raphy in biomechanics. J Appl Biomech 1997; +13: 135–163. +19 Yadunandan U (ed): Ashtanga Hrudayam of +Vagbhata with Vidyotini Hindi commentary, +ed 12. Varanasi, Chaukhambha Sanskrit +Sansthan, 1997, pp 380–474. +20 Rais A, Bhatted S: Clinical study to evaluate +the effect of Virechana karma on serum elec- +trolytes. Ayu 2013; 34: 379–382. +21 Shastri P (ed): Sharangadhara Samhita, Mad- +hyama Khanda. Varanasi, Oriental Publishers +and Distributors, 1985, vol. 2, pp 145–147. +22 Niteshwar K, Vidayanath R: Sahasra Yoga +Churnaprakarana 62. Varanasi, Chaukhamb- +ha Bharati Academy, 2007. +23 Wells RE, Burch R, Paulsen RH, Wayne PM, +Houle TT, Loder E: Meditation for migraines: +a pilot randomized controlled trial. Headache +2014; 54: 1484–1495. +24 Michalsen A, Grossman P, Acil A, Langhorst +J, Ludtke R, Esch T, Stefano GB, Dobos GJ: +Rapid stress reduction and anxiolysis among +distressed women as a consequence of a three- +month intensive yoga program. Med Sci +Monit 2005; 11: 555–561. +25 Basler AJ: Pilot study investigating the effects +of Ayurvedic Abhyanga massage on subjec- +tive stress experience. J Altern Complement +Med 2011; 17: 435–440. +26 Salahuddin L, Cho J, Jeong MG, Kim D: Ul- +trashort term analysis of heart rate variability +for monitoring mental stress in mobile set- +tings. Conf Proc IEEE Eng Med Biol Soc 2007; +4656–4659. +27 Bhimani NT, Kulkarni NB, Kowale A, Salvi S: +Effect of pranayama on stress and cardiovas- +cular autonomic function. Indian J Physiol +Pharmacol 2011; 55: 370–377. +28 Mason H, Vandoni M, deBarbieri G, Codrons +E, Ugargol V, Bernardi L: Cardiovascular and +respiratory effect of Yogic slow breathing in +the Yoga beginner: what is the best approach? +Evid Based Complement Alternat Med 2013; +2013: 743504. +29 Brown RP, Gerbarg PL: Yoga breathing, med- +itation, and longevity. Ann N Y Acad Sci +2009; 1172: 54–62. +30 Thirthalli J, Naveen GH, Rao MG, Varambal- +ly S, Christopher R, Gangadhar BN: Cortisol +and antidepressant effects of yoga. Indian J +Psychiatry 2013; 55: 405–408. +31 deCharms RC, Maeda F, Glover GH, Ludlow D, +John MP, Soneji D, John DE, Gabrieli JD, Mack- +ey SC: Control over brain activation and pain +learned by using real-time functional MRI. Proc +Natl Acad Sci USA 2005; 102: 18626–18631. +32 Grant JA, Courtemanche J, Duerden EG, +Duncan GH, Rainville P: Cortical thickness +and pain sensitivity in Zen meditators. Emo- +tion 2010; 10: 43–53. +33 Grossman P, Niemann L, Schmidt S, Walach +H: Mindfulness-based stress reduction and +health benefits. A meta-analysis. J Psychoso- +mat Res 2004; 57: 35–43. +34 Streeter CC, Gerbarg PL, Saper RB, Ciraulo +DA, Brown RP: Effects of yoga on the auto- +nomic nervous system, gamma-aminobutyr- +ic-acid, and allostasis in epilepsy, depression, +and post-traumatic stress disorder. Med Hy- +potheses 2012; 78: 571–579. +Sharma/Nandi Krishnamurthy/Nagendra +Ann Neurosci 2018;25:250–260 +260 +DOI: 10.1159/000492269 +35 Larsson SE, Larsson R, Zhang Q, Cai H, Oberg +PA: Effects of psychophysiological stress on +trapezius muscles blood flow and electromy- +ography during static load. Eur J Appl Physiol +1995; 71: 493–498. +36 Bhatia R, Dureja GP, Tripathi M, Bhattacha- +rjee M, Bijlani RL, Mathur R: Role of tempora- +lis muscle over activity in chronic tension type +headache: effect of yoga based management. +Indian J Physiol Pharmacol 2007; 51: 333–344. +37 Natsume Y, Neeraj K, Tripathi SM, Nose M, +Bhutani KK: Kalyanaka ghrita: an example of +intertextuality among the Bower manuscript, +Charak samhita, Susruta samhita, Astangahr- +dayam samhita and Ayurvedic Formulary of In- +dia (AFI). Ind J Trad Knowl 2015; 14: 519–524. +38 Peterson CT, Denniston K, Chopra D: Thera- +peutic uses of Triphala in Ayurvedic Medi- +cine. J Altern Complement Med 2017; 23: 607– +614. +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- +pora cordifolia polysaccharide against iron- +mediated lipid damage and gamma-ray in- +duced protein damage. Redox Rep 2002; 7: +137–143. +41 Chua LS: Review on liver inflammation and +anti inflammatory activity of Andrographis +paniculata for hepatoprotection. Phytother +Res 2014; 28: 1589–1598. diff --git a/subfolder_0/Comparison of lymphocyte apoptotic index and qualitative DNA damage.txt b/subfolder_0/Comparison of lymphocyte apoptotic index and qualitative DNA damage.txt new file mode 100644 index 0000000000000000000000000000000000000000..f7246ba1864eac71fee271b230e7d47ebdd21741 --- /dev/null +++ b/subfolder_0/Comparison of lymphocyte apoptotic index and qualitative DNA damage.txt @@ -0,0 +1,558 @@ +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: rnagaratna@gmail.com +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. +REFERENCES +1. +World Health Organization. World health Report factsheet [Internet]. +Factsheet, 2012. Available from: http://www.who.int/mediacentre/factsheets/ +fs297/en/index.html [Last cited on 2012 Apr 24]. +2. +Ferlay J, Shin H, Bray F, Forman D, Mathers C, Parkin D. GLOBOCAN +2008 v1.2, Cancer Incidence and Mortality Worldwide: IARC Cancer Base +No. 10. International Agency for Research on Cancer. 2010. Available from: +http://globocan.iarc.fr [Last cited on 2011 Jun 12]. +3. +Burke MA, Goodkin K. Stress and the development of breast cancer: A +persistent and popular link despite contrary evidence. Cancer 1997;79:1055-  +9. +4. +Janakiramaiah N, Gangadhar BN, Naga Venkatesha Murthy PJ, Harish +MG, Subbakrishna DK, Vedamurthachar A. Antidepressant efficacy of +Sudarshan Kriya Yoga (SKY) in melancholia: A randomized comparison +with electroconvulsive therapy (ECT) and imipramine. J Affect Disord +2000;57:255-9. +5. +Wyllie AH, Kerr JF, Currie AR. Cell death: The significance of apoptosis. Int +Rev Cytol 1980;68:251-306. +6. +Nicholson DW, Ali A, Thornberry NA, Vaillancourt JP, Ding CK, Gallant M, +et al. Identification and inhibition of the ICE/CED-3 protease necessary for +mammalian apoptosis. Nature 1995;376:37-43. +7. +Setlow RB. Repair deficient human disorders and cancer. Nature +1978;271:713-7. +8. +Warner HR. Aging and regulation of apoptosis. Curr Top Cell Regul +1997;35:107-21. +9. +Gajecka M, Rydzanicz M, Jaskula-Sztul R, Wierzbicka M, Szyfter W, Szyfter +K. Reduced DNA repair capacity in laryngeal cancer subjects. A comparison +of phenotypic and genotypic results. Adv Otorhinolaryngol 2005;62:25-37. +10. Tripathi P, Aggarwal A. NF-kB transcription factor : A key player in the +generation of immune response. Curr Sci India 2006;90:519-31. +11. +Piperakis SM, Kontogianni K, Karanastasi G, Iakovidou-Kritsi Z, Piperakis +MM. The use of comet assay in measuring DNA damage and repair efficiency +in child, adult, and old age populations. Cell Biol Toxicol 2009;25:65-71. +12. Kiecolt-Glaser JK, Stephens RE, Lipetz PD, Speicher CE, Glaser R. Distress +and DNA repair in human lymphocytes. J Behav Med 1985;8:311-20. +13. Glaser R, Thorn BE, Tarr KL, Kiecolt-Glaser JK, D’Ambrosio SM. Effects +of stress on methyltransferase synthesis: An important DNA repair enzyme. +Health Psychol 1985;4:403-12. +14. Tomei LD, Kiecolt-Glaser JK, Kennedy S, Glaser R. Psychological stress and +phorbol ester inhibition of radiation-induced apoptosis in human peripheral +blood leukocytes. Psychiatry Res 1990;33:59-71. +15. Kiecolt-Glaser JK, Robles TF, Heffner KL, Loving TJ, Glaser R. Psycho- +oncology and cancer: Psychoneuroimmunology and cancer. Ann Oncol +2002;13:165-9. +16. Kiecolt-Glaser JK, Glaser R. Psychoneuroimmunology: Can psychological +interventions modulate immunity? J Consult Clin Psychol 1992;60:569-75. +17. Kiecolt-Glaser JK, Glaser R, Williger D, Stout J, Messick G, Sheppard S, et +al. Psychosocial enhancement of immunocompetence in a geriatric population. +Health Psychol 1985;4:25-41. +18. Fawzy FI, Kemeny ME, Fawzy NW, Elashoff R, Morton D, Cousins N, et +al. A structured psychiatric intervention for cancer patients. II. Changes over +time in immunological measures. Arch Gen Psychiatry 1990;47:729-35. +19. Fawzy FI, Fawzy NW, Hyun CS, Elashoff R, Guthrie D, Fahey JL, et al. +Figure 2: Difference in Apoptosis% and Comet% for the three cross-sectional +groups (BC, breast cancer; NV, normal; SY: Yoga group) +Ram, et al.: Comparison of lymphocyte AI and QDD in yoga and breast cancer patients: A pilot study +25 +International Journal of Yoga  Vol. 6  Jan-Jun-2013 +Malignant melanoma. Effects of an early structured psychiatric intervention, +coping, and affective state on recurrence and survival 6 years later. Arch Gen +Psychiatry 1993;50:681-9. +20. Vadiraja HS, Raghavendra RM, Nagarathna R, Nagendra HR, Rekha M, +Vanitha N, et al. Effects of a yoga program on cortisol rhythm and mood +states in early breast cancer patients undergoing adjuvant radiotherapy: A +randomized controlled trial. Integr Cancer Ther 2009;8:37-46. +21. 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. +22. Bøyum A. Isolation of lymphocytes, granulocytes and macrophages. Scand +J Immunol 1976;5:9-15. +23. Singh NP. A simple method for accurate estimation of apoptotic cells. +Experimental cell research. 2000;256(1):328-37. +24. Rojas E, Lopez MC, Valverde M. Single cell gel electrophoresis assay: +Methodology and applications. J Chromatogr B Biomed Sci Appl +1999;722:225-54. +25. Andersen BL, Kiecolt-Glaser JK, Glaser R. A biobehavioral model of cancer +stress and disease course. Am Psychol 1994;49:389-404. +26. Clancy S. DNA damage and repair: Mechanisms for maintaining DNA +integrity. In: Moss B, editor. Nature Education. 1st ed. Cambridge: Nature +Publishing Group; 2008. +27. Biswas DK, Shi Q, Baily S, Strickland I, Ghosh S, Pardee AB, et al. NF-kappa +B activation in human breast cancer specimens and its role in cell proliferation +and apoptosis. Proc Natl Acad Sci USA 2004;101:10137-42. +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 +Author Help: Reference checking facility +The manuscript system (www.journalonweb.com) allows the authors to check and verify the accuracy and style of references. The tool checks +the references with PubMed as per a predefined style. Authors are encouraged to use this facility, before submitting articles to the journal. +• +The style as well as bibliographic elements should be 100% accurate, to help get the references verified from the system. 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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 + + Search + +GO +Similar in PUBMED + Search Pubmed for +Krishnappa DT +Sridhar MK +Nagendra H R + Search in Google Scholar +for +Krishnappa DT +Sridhar MK +Nagendra H R + Related articles +%26#256;tman +Brahman +consciousness +hemispheres of the brain +ignorance +knowledge +mind +self +sleep +subconscious +superego +Access Statistics +Email Alert * +Add to My List * +* Registration required (free) + + In this article +Abstract +Mind in Indian P... +The Mind in West... +Feelings and Emo... +The Role of Brai... +Conclusion +References + Article Access Statistics + Viewed +1033 + Printed +48 + Emailed +0 + PDF Downloaded +10 + Comments +[Add] + Click here to view optimized website for mobile devices +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 + diff --git a/subfolder_0/DIFFERENCES BETWEEN CONGENITALLY BLIND AND NORMALLY SIGHTED SUBJECTS.txt b/subfolder_0/DIFFERENCES BETWEEN CONGENITALLY BLIND AND NORMALLY SIGHTED SUBJECTS.txt new file mode 100644 index 0000000000000000000000000000000000000000..f4944ed7be94a7960afee309e3c58ed4bdc5e4a8 --- /dev/null +++ b/subfolder_0/DIFFERENCES BETWEEN CONGENITALLY BLIND AND NORMALLY SIGHTED SUBJECTS.txt @@ -0,0 +1,11 @@ + + + + + + + + + + + diff --git a/subfolder_0/Decoding Beliefs and Obsessions.txt b/subfolder_0/Decoding Beliefs and Obsessions.txt new file mode 100644 index 0000000000000000000000000000000000000000..e69de29bb2d1d6434b8b29ae775ad8c2e48c5391 diff --git a/subfolder_0/Decoding the integrated approach to yoga therapy Qualitative evidence based conceptual framework.txt b/subfolder_0/Decoding the integrated approach to yoga therapy Qualitative evidence based conceptual framework.txt new file mode 100644 index 0000000000000000000000000000000000000000..3e8c8ec3a4cec5c7b772228cdcfe07643c1ba5f3 --- /dev/null +++ b/subfolder_0/Decoding the integrated approach to yoga therapy Qualitative evidence based conceptual framework.txt @@ -0,0 +1,1059 @@ +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: jaganaarti@gmail.com +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 +3DUWLFLSDQW +5HODWHG +)DFWRUV +7KHUDSLVW +5HODWHG +)DFWRUV +7UHDWPHQWUHODWHGIDFWRUV +$LPRI,$<7 +,PSURYHPHQWDQGFKDQJHV +2XWFRPHRI,$<7 +$ELOLW\ +WR +JXLGH +$VVLVWDQFHWR +SDUWLFLSDQWV +([SODQDWLRQ +RIH[HUFLVHV +'XUDWLRQ +RI +WUHDWPHQW +3V\FKLDWULF +D\XUYHGLF +PHGLFDWLRQ +ZLWK\RJD +&RXQVHOOLQJ +$ZDUHQHVV +RIKLVKHU +FRQGLWLRQ +([SHFWDWLRQV +&RRSHUDWLRQRI +SDUWLFLSDQW +8QGHU +VWDQGLQJ +SUHYLRXV +H[SHULHQFH +RI\RJD +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 +Author Help: Reference checking facility +The manuscript system (www.journalonweb.com) allows the authors to check and verify the accuracy and style of references. The tool checks +the references with PubMed as per a predefined style. Authors are encouraged to use this facility, before submitting articles to the journal. +• +The style as well as bibliographic elements should be 100% accurate, to help get the references verified from the system. 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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: deepeshwar.singh@outlook.com + +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 +REFERENCES +1. +Barthelemy +C, +Brilhault +BF. +Autism, +In: +Neuroscience in the 21st Century. New York, NY: +Springer New York; 2016: 3233-3246. +2. +Arora +NK, +Nair +MKC, +Gulati +S. +Neurodevelopmental disorders in children aged 2-9 +years: Population-based burden estimates across five +regions in India. Persson LA, ed. PLoS Med. +2018;15(7):1002615. +3. +Srikantha P, Mohajeri HM. The possible role of the +microbiota-gut-brain-axis +in +autism +spectrum +disorder. Int J Mol Sci. 2019;20(9):2115. +4. +Modabbernia A, Velthorst E, Reichenberg A. +Environmental risk factors for autism: an evidence- +based review of systematic reviews and meta- +analyses. Mol Autism. 2017;8(1):13. +5. +Czeizel AE, Puho EH, Langmar Z, Acs N, Banhidy +F. Possible association of folic acid supplementation +during pregnancy with reduction of preterm birth: a +population-based study. Eur J Obstet Gynecol +Reprod Biol. 2010;10:16. +6. +Zwaigenbaum L, Bauman ML, Choueiri R. Early +identification and interventions for autism spectrum +disorder: Executive summary. In: Pediatrics; 2015. +7. +Schopler E, Reichler RJ, Vellis RF, Daly K. Toward +objective +classification +of +childhood +autism: +Childhood Autism Rating Scale (CARS). J Autism +Dev Disord. 1980;10:1007. +8. +Eyberg SM, Ross AW. Assessment of child +behavior problems: The validation of a new +inventory. J Clin Child Psychol. 1978;10:1080. +9. +Volkmar FR, Cicchetti DV, Dykens E, Sparrow SS, +Leckman JF, Cohen DJ. An evaluation of the autism +behavior +checklist. +J +Autism +Dev +Disord. +1988;18(1):81-97. +10. Lord C, Rutter M, Couteur LA. Autism Diagnostic +Interview-Revised: A revised version of a diagnostic +interview for caregivers of individuals with possible +pervasive developmental disorders. J Autism Dev +Disord. 1994;24(5):659-85. +11. Lord C, Risi S, Lambrecht L. The autism diagnostic +observation schedule-generic: a standard measure of +social and communication deficits associated with +the spectrum of autism. J Autism Dev Disord. +2000;30(3):205-23. +12. Bundzen P, Korotkov KG. Health quality evaluation +on the basis of GDV parameters. In: Human Energy +Field: Study with bioelectrography. In: Bio- +Well.Com. Health quality evaluation on the basis of +GDV parameters. Human energy field: study with +bioelectrography. +Fair +Lawn, +NJ: +Backbone +Publishing Co. 2002:103-7. +13. Korotkov KG, Matravers P, Orlov DV, Williams +BO. Application of Electrophoton Capture (EPC) +Analysis Based on Gas Discharge Visualization +(GDV) Technique in Medicine: A Systematic +Review. +J +Altern +Complement +Med. +2010;16(1):13-25. +14. Wijk VR, Wijk EPA. An introduction to human +biophoton +emission. +Forschende +Komplementarmedizin +und +Klass +Naturheilkd; +2005. +15. Kataoka Y, Cui Y, Yamagata A. Activity- +Dependent Neural Tissue Oxidation Emits Intrinsic +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 1554 +Ultraweak +Photons. +Biochem +Biophys +Res +Commun. 2001;285(4):1007-11. +16. Devaraj B, Usa M, Inaba H. Biophotons: Ultraweak +light emission from living systems. Curr Opin Solid +State Mater Sci; 1997. +17. Hossu M, Rupert R. Quantum Events of Biophoton +Emission Associated with Complementary and +Alternative Medicine Therapies: A Descriptive Pilot +Study. J Altern Complement Med. 2006;12(2):119- +124. +18. Hacker GW, Pawlak E, Pauser G. Biomedical +Evidence of Influence of Geopathic Zones on the +Human Body: Scientifically Traceable Effects and +Ways of Harmonization. Complement Med Res. +2005;12(6):315-27. +19. Korotkov K. The Principles of GDV Analysis. (Piet. +M, +ed.). +Embourg, +Belgium: +Amazon.com +Publishing; 2009. +20. Anufrieva E, Anufriev V, Starchenko M, Timofeev +N. Thought’s Registration by means of Gas- +Discharge Visualization. 2014:1-5. +21. Cohly H, Kostyuk N, Isokpehi R, Rajnarayanan R. +Bio-electrographic method for preventive health +care. In: First Annual ORNL Biomedical Science +and Engineering Conference. IEEE; 2009:1-4. +22. Kostyuk N, Cole P, Meghanathan N, Isokpehi RD, +Cohly HHP. Gas Discharge Visualization: An +Imaging and Modeling Tool for Medical Biometrics. +Int J Biomed Imaging. 2011;2011:1-7. +23. Bhat R, Mavathur R, Srinivasan T. Diabetes mellitus +type 2 and yoga: Electro photonic imaging +perspective. Int J Yoga. 2017;10(3):152. +24. Bhargav +H, +Srinivasan TM, +Varambally +S, +Gangadhar BN, Koka P. Effect of Mobile Phone- +Induced +Electromagnetic +Field +on +Brain +Hemodynamics and Human Stem Cell Functioning: +Possible Mechanistic Link to Cancer Risk and Early +Diagnostic Value of Electronphotonic Imaging. J +Stem Cells. 2015;10(4):287-94. +25. Yakovleva EG, Korotkov KG, Fedorov ED, Ivanova +EV, Plahov RV, Belonosov SS. Engineering +Approach to Identifying Patients with Colon Tumors +on the Basis of Electrophotonic Imaging Technique +Data. Open Biomed Eng J. 2016;10(1):72-80. +26. Aleksandrova E. GDV Analysis of Arterial +Hypertension. Bio-WellEu. 2009:1-9. +27. Deo G, Kumar IR, Srinivasan TM, Kushwah KK. +Cumulative effect of short-term and long-term +meditation practice in men and women on +psychophysiological parameters of electrophotonic +imaging: A cross-sectional study. J Complement +Integr Med. 2016;13(1):73-82. +28. Ming X, Julu POO, Brimacombe M, Connor S, +Daniels ML. Reduced cardiac parasympathetic +activity in children with autism. Brain Dev. +2005;27(7):509-16. +29. Kostyuk N, Rajnarayanan RV, Isokpehi RD, Cohly +HH. Autism from a biometric perspective. Int J +Environ Res Public Health. 2010;7(5):1984-95. +30. Kamal A. Assessment of Autonomic Function in +Children with Autism and Normal Children Using +Spectral Analysis and Posture Entrainment: A Pilot +Study. J Neurol Neurosci. 2015;6(3):2171-6625. +31. Ewen BS. The neurobiology of stress: From +serendipity to clinical relevance. Brain Res; 2000. +32. Bharath R, Moodithaya SS, Bhat SU, Mirajkar AM, +Shetty SB. Comparison of physiological and +biochemical autonomic indices in children with and +without autism spectrum disorders. Med; 2019. +33. Kushki A, Brian J, Dupuis A, Anagnostou E. +Functional autonomic nervous system profile in +children with autism spectrum disorder. Mol +Autism; 2014. +34. Kurth F, Narr KL, Woods RP. Diminished gray +matter within the hypothalamus in autism disorder: +A potential link to hormonal effects. Biol +Psychiatry. 2011;70(3):278-82. +35. Uys JDK, Marais L, Faure J. Developmental trauma +is associated with behavioral hyperarousal, altered +HPA axis activity, and decreased hippocampal +neurotrophin expression in the adult rat. In: Annals +of the New York Academy of Sciences; 2006. +36. Frye RE, Wynne R, Rose S. Thyroid dysfunction in +children with autism spectrum disorder is associated +with folate receptor α autoimmune disorder. J +Neuroendocrinol; 2017. +37. Ishiyama A, Komaki H, Saito T. Unusual exocrine +complication of pancreatitis in mitochondrial +disease. Brain Dev. 2013;35(7):654-9. +38. Borre YE, Keeffe GW, Clarke G, Stanton C, Dinan +TG, Cryan JF. Microbiota and neurodevelopmental +windows: implications for brain disorders. Trends +Mol Med. 2014;20(9):509-18. +39. Rudie JD, Brown JA, Pancer BD. Altered functional +and structural brain network organization in autism. +NeuroImage Clin. 2013;2(1):79-94. +40. Levy SE, Mandell DS, Schultz RT. Autism. Lancet. +2009;374(9701):1627-38. +41. Oyarzabal A, Valencia MI. Synaptic energy +metabolism and neuronal excitability, in sickness +and health. J Inherit Metab Dis. 2019;42(2):220-36. + + + + + + + + + + +Cite this article as: Sankhala SS, Deepeshwar S, +Kotikalapudi S, Chatterjee S. Determining bioenergy +field of autistic and normal healthy children: an +electrophotonic imaging study. Int J Community Med +Public Health 2020;7:1547-54. +View publication stats +View publication stats diff --git a/subfolder_0/Development and feasibility of need-based psychosocial training programme for family caregivers.txt b/subfolder_0/Development and feasibility of need-based psychosocial training programme for family caregivers.txt new file mode 100644 index 0000000000000000000000000000000000000000..8b5668078001f4c72f91d0d4aa31f5d6f4630d70 --- /dev/null +++ b/subfolder_0/Development and feasibility of need-based psychosocial training programme for family caregivers.txt @@ -0,0 +1,777 @@ +This article appeared in a journal published by Elsevier. The attached +copy is furnished to the author for internal non-commercial research +and education use, including for instruction at the authors institution +and sharing with colleagues. +Other uses, including reproduction and distribution, or selling or +licensing copies, or posting to personal, institutional or third party +websites are prohibited. +In most cases authors are permitted to post their version of the +article (e.g. in Word or Tex form) to their personal website or +institutional repository. Authors requiring further information +regarding Elsevier’s archiving and manuscript policies are +encouraged to visit: +http://www.elsevier.com/copyright +Author's personal copy +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: jaganaarti@gmail.com (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 diff --git a/subfolder_0/Development of sushrutha prakriti inventory, an Ayurveda based personality assessment tool.txt b/subfolder_0/Development of sushrutha prakriti inventory, an Ayurveda based personality assessment tool.txt new file mode 100644 index 0000000000000000000000000000000000000000..77b13f5fcc5a6348f66cbb7280747d6682c59901 --- /dev/null +++ b/subfolder_0/Development of sushrutha prakriti inventory, an Ayurveda based personality assessment tool.txt @@ -0,0 +1,1122 @@ +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: + brramakrishnasvyasa@gmail.com +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 + + + + + + + + + + + + + + + + + + + + diff --git a/subfolder_0/Dispositional mindfulness and its relation to impulsivity.txt b/subfolder_0/Dispositional mindfulness and its relation to impulsivity.txt new file mode 100644 index 0000000000000000000000000000000000000000..f874b4ec33e9fb6838d6c44728faea679edff51f --- /dev/null +++ b/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: rajesheskay@svyasa.org +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 +52 diff --git a/subfolder_0/EFFECT OF TWO SELECTED YOGIC BREATHING TECHNIQUES ON HEART RATE.txt b/subfolder_0/EFFECT OF TWO SELECTED YOGIC BREATHING TECHNIQUES ON HEART RATE.txt new file mode 100644 index 0000000000000000000000000000000000000000..a0e7403bed2327126766a0bd28eaa011866314a3 --- /dev/null +++ b/subfolder_0/EFFECT OF TWO SELECTED YOGIC BREATHING TECHNIQUES ON HEART RATE.txt @@ -0,0 +1,17 @@ + + + + + + + + + + + + + + + + + diff --git a/subfolder_0/EFFICACY OF YOGA ON PREGNANCY OUTCOME.txt b/subfolder_0/EFFICACY OF YOGA ON PREGNANCY OUTCOME.txt new file mode 100644 index 0000000000000000000000000000000000000000..30b472ee69f49462cdeacbd4e58583c3ff14cc29 --- /dev/null +++ b/subfolder_0/EFFICACY OF YOGA ON PREGNANCY OUTCOME.txt @@ -0,0 +1,13 @@ + + + + + + + + + + + + + diff --git a/subfolder_0/Effect of 1-week yoga-based residential program on cardiovascular variables of hypertensive patients A Comparative Study.txt b/subfolder_0/Effect of 1-week yoga-based residential program on cardiovascular variables of hypertensive patients A Comparative Study.txt new file mode 100644 index 0000000000000000000000000000000000000000..95cdcb89ee0ce5c01e194fc3fa50899c1449f052 --- /dev/null +++ b/subfolder_0/Effect of 1-week yoga-based residential program on cardiovascular variables of hypertensive patients A Comparative Study.txt @@ -0,0 +1,599 @@ +© 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: kgmhetre@gmail.com +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: reprints@medknow.com +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. diff --git a/subfolder_0/Effect of Integrated Yoga (IY) on psychological states and CD4 counts of HIV-1 infected patients.txt b/subfolder_0/Effect of Integrated Yoga (IY) on psychological states and CD4 counts of HIV-1 infected patients.txt new file mode 100644 index 0000000000000000000000000000000000000000..1553f0e289b5384e7b4afe870b8ce351194e9f93 --- /dev/null +++ b/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: +kgmhetre@gmail.com +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 +REFERENCES +1. Aranda NB. Quality of life in HIV­1 – Positive patient. J Assoc Nurses AIDS Care. 2004;15:20–7. +2. Shacham E, Onen NF, Donovan MF, Rosenburg N, Overton ET. Psychiatric diagnoses among an HIV­infected outpatient clinic population. J Int Assoc +Provid AIDS Care. 2014 pii: 2325957414553846. [PubMed] +3. Masiello A, De Guglielmo C, Giglio S, Acone N. Beyond depression: Assessing personality disorders, alexithymia and socio­emotional alienation in +patients with HIV­1 infection. Infez Med. 2014;22:193–9. [PubMed] +1 +1 +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/ +5/6 +4. Hays RB, Turner H, Coates TJ. Social support, AIDS­related symptoms, and depression among gay men. J Consult Clin Psychol. 1992;60:463–9. +[PubMed] +5. Wagner GJ, Rabkin JG, Rabkin R. A comparative analysis of standard and alternative antidepressants in the treatment of human immunodeficiency +virus patients. Compr Psychiatry. 1996;37:402–8. [PubMed] +6. Bogart LM, Catz SL, Kelly JA, Gray­Bernhardt ML, Hartmann BR, Otto­Salaj LL, et al. Psychosocial issues in the era of new AIDS treatments from +the perspective of persons living with HIV +. J Health Psychol. 2000;5:500–16. [PubMed] +7. Blashill AJ, Bedoya CA, Mayer KH, O’Cleirigh C, Pinkston MM, Remmert JE, et al. Psychosocial syndemics are additively associated with worse +ART adherence in HIV­infected individuals. AIDS Behav. 2015;19:981–6. [PMC free article] [PubMed] +8. Attonito J, Dévieux JG, Lerner BD, Hospital MM, Rosenberg R. Antiretroviral treatment adherence as a mediating factor between psychosocial +variables and HIV viral load. J Assoc Nurses AIDS Care. 2014;25:626–37. [PMC free article] [PubMed] +9. Mulkins AL, Ibáñez­Carrasco F, Boyack D, Verhoef MJ. The living well lab: A community­based HIV/AIDS research initiative. J Complement Integr +Med. 2014;11:213–22. [PubMed] +10. Cramer H, Lauche R, Langhorst J, Dobos G. Yoga for depression: A systematic review and meta­analysis. Depress Anxiety. 2013;30:1068–83. +[PubMed] +11. Shapiro D, Cook IA, Dmitry M, Davydov, Ottaviani C, Leuchter AF, et al. Yoga as a complementary treatment of depression: Effects of traits and +moods on treatment outcome. Evid Based Complement Alternat Med. 2007;4:493–502. [PMC free article] [PubMed] +12. Cheema BS, Marshall PW, Chang D, Colagiuri B, Machliss B. Effect of an office worksite­based Yoga program on heart rate variability: A +randomized controlled trial. BMC Public Health. 2012;11:578. [PMC free article] [PubMed] +13. Uebelacker LA, Epstein­Lubow G, Gaudiano BA, Tremont G, Battle CL, Miller IW. Hatha Yoga for depression: Critical review of the evidence for +efficacy, plausible mechanisms of action, and directions for future research. J Psychiatr Pract. 2010;16:22–33. [PubMed] +14. Gopal A, Mondal S, Gandhi A, Arora S, Bhattacharjee J. Effect of integrated Yoga practices on immune responses in examination stress – A +preliminary study. Int J Yoga. 2011;4:26–32. [PMC free article] [PubMed] +15. Kumar K, Pandya P. A study on the impact on ESR level through Yogic relaxation technique Yoganidra. Indian J Tradit Knowl. 2012;11:358–61. +16. Rao RM, Telles S, Nagendra HR, Nagarathna R, Gopinath K, Srinath S, et al. Effects of Yoga on natural killer cell counts in early breast cancer +patients undergoing conventional treatment. Comment to: Recreational music­making modulates natural killer cell activity, cytokines, and mood states in +corporate employees Masatada Wachi, Masahro Koyama, Masanori Utsuyama, Barry B. Bittman, Masanobu Kitagawa, Katsuiku Hirokawa Med Sci +Monit. 2007;13:CR57–70. Med Sci Monit 2008;14:LE3­4. [PubMed] +17. Visweswaraiah NK, Telles S. Randomized trial of Yoga as a complementary therapy for pulmonary tuberculosis. Respirology. 2004;9:96–101. +[PubMed] +18. Pilkington K, Kirkwood G, Rampes H, Richardson J. Yoga for depression: The research evidence. J Affect Disord. 2005;89:13–24. [PubMed] +19. Cade WT, Reeds DN, Mondy KE, Overton ET, Grassino J, Tucker S, et al. Yoga lifestyle intervention reduces blood pressure in HIV­infected adults +with cardiovascular disease risk factors. HIV Med. 2010;11:379–88. [PMC free article] [PubMed] +20. Koar WH. Meditation, T­cells, anxiety, depression and HIV infection. Subtle Energies Energy Med J Arch. 1995;6:91–7. +21. Available from: https://www.randomizer.org/ . [Last accessed on 2014 Jan]. +22. Bhargav H, Raghuram N, Rao NH, Tekur P, Koka PS. Potential Yoga modules for treatment of hematopoietic inhibition in HIV­1 infection. J Stem +Cells. 2009;5:129–48. [PubMed] +23. Bjelland I, Dahl AA, Haug TT, Neckelmann D. The validity of the hospital anxiety and depression scale. An updated literature review. J Psychosom +Res. 2002;52:69–77. [PubMed] +24. Kandathil AJ, Kannangai R, David S, Nithyanandam G, Solomon S, Balakrishnan P, et al. Comparison of microcapillary cytometry technology and +flow cytometry for CD4+ and CD8+ T­cell estimation. Clin Diagn Lab Immunol. 2005;12:1006–9. [PMC free article] [PubMed] +25. Taylor DN. Effects of a behavioral stress­management program on anxiety, mood, self­esteem, and T­cell count in HIV positive men. Psychol Rep. +1995;76:451–7. [PubMed] +26. Hammen C. Stress and depression. Annu Rev Clin Psychol. 2005;1:293–319. [PubMed] +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/ +6/6 +27. Antoni MH, Schneiderman N, Fletcher MA, Goldstein DA, Ironson G, Laperriere A. Psychoneuroimmunology and HIV­1. J Consult Clin Psychol. +1990;58:38–49. [PubMed] +28. Frank MK, Rebecca BL, Susan M, David WP, Winnie BK. Depression and CD4 cell count among persons with HIV­1 infect Uganda. AIDS Behav. +2006;10:105–11. [PubMed] +29. Ickovics J, Hamburger M, Vlahov D, Schoenbaum E, Schuman P, Boland R, et al. Mortality CD4 cell count decline and depressive symptoms +among HIV­1 – Seropositive women: Longitudinal analysis from HIV­1 epidemiology research study. JAMA. 2001;285:1460–5. [PubMed] diff --git a/subfolder_0/Effect of Surya Namaskar on Sustained Attention in School Children.txt b/subfolder_0/Effect of Surya Namaskar on Sustained Attention in School Children.txt new file mode 100644 index 0000000000000000000000000000000000000000..522fe859dcc7c591f1b22402421bc08704eceed2 Binary files /dev/null and b/subfolder_0/Effect of Surya Namaskar on Sustained Attention in School Children.txt differ diff --git a/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 b/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 new file mode 100644 index 0000000000000000000000000000000000000000..fe9ec9cdecea37f5b4c46e192c80ac5d5ff3be75 --- /dev/null +++ b/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 @@ -0,0 +1,738 @@ +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: aparsaoji@gmail.com (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. +References +[1] K. Choi, J.H. Park, H.K. Cheong, Prevalence of musculoskeletal symptoms related +with activities of daily living and contributing factors in Korean adults, J. Prev. +Med. Public Heal 46 (2013) 39, https://doi.org/10.3961/JPMPH.2013.46.1.39. +[2] J. Kishore, Prevalence of musculoskeletal disorders amongst adult population of +India, Epidemiol. Int 04 (2019) 22–26, https://doi.org/10.24321/ +2455.7048.201915. +[3] S. Hazarika, Prevalence of musculoskeletal pain in relation to age, gender and +anatomical site involved, J. Med. Sci. Clin. Res 04 (2016) 14944–14948, https:// +doi.org/10.18535/JMSCR/V4I12.105. +[4] F. Puntillo, M. Giglio, A. Paladini, G. Perchiazzi, O. Viswanath, I. Urits, C. Sabb` +a, +G. Varrassi, N. Brienza, Pathophysiology of musculoskeletal pain: a narrative +review, Ther. Adv. Musculoskelet. Dis. 13 (2021), https://doi.org/10.1177/ +1759720×21995067. +[5] A. Choobineh, H. Daneshmandi, S. Saraj Zadeh Fard, S. Tabatabaee, Prevalence of +work-related musculoskeletal symptoms among Iranian workforce and job groups, +Int. J. Prev. Med 7 (2016) 130, https://doi.org/10.4103/2008-7802.195851. +[6] M. Ghasemkhani, E. Mahmudi, H. Jabbari, Musculoskeletal symptoms in workers, +Int. J. Occup. Saf. Erg. 14 (2008) 455–462, https://doi.org/10.1080/ +10803548.2008.11076784. +[7] I. Moreira-Silva, J. Azevedo, S. Rodrigues, A. Seixas, M. Jorge, Predicting +musculoskeletal symptoms in workers of a manufacturing company, Int. J. Occup. +Saf. Erg. 27 (2021) 1136–1144, https://doi.org/10.1080/ +10803548.2019.1693112. +[8] J. Malchaire, N. Cock, S. Vergracht, Review of the factors associated with +musculoskeletal problems in epidemiological studies, Int. Arch. Occup. Environ. +Health 74 (2001) 79–90, https://doi.org/10.1007/S004200000212. +[9] M.F. Barbe, A.E. Barr, Inflammation and the pathophysiology of work-related +musculoskeletal disorders, Brain. Behav. Immun. 20 (2006) 423–429, https://doi. +org/10.1016/j.bbi.2006.03.001. +[10] T. Wang, Y.L. Zhao, L.X. Hao, J.G. Jia, Prevalence of musculoskeletal symptoms +among industrial employees in a modern industrial region in Beijing, China, Chin. +Med. J. (Engl. ) 132 (2019) 789, https://doi.org/10.1097/ +CM9.0000000000000165. +[11] N.M. Filho, G.A. Silva, Disability pension from back pain among social security +beneficiaries, Brazil Rev. Saude Publica 45 (2011) 494–502, https://doi.org/ +10.1590/S0034-89102011000300007. +[12] T.M. Ribas, R.M. Teodori, F.F. Mescolotto, M.I.D.L. Montebelo, S.B.S. Baruki, E. +M. Pazzianotto-Forti, Impact of physical activity levels on musculoskeletal +symptoms and absenteeism of workers of a metallurgical company, Rev. Bras. Med. +Do Trab. 18 (2020) 425–433, https://doi.org/10.47626/1679-4435-2020-572. +[13] J. Vinstrup, M.D. Jakobsen, J. Calatayud, K. Jay, L.L. Andersen, Association of +stress and musculoskeletal pain with poor sleep: cross-sectional study among 3,600 +hospital workers, Front. Neurol. 9 (2018), https://doi.org/10.3389/ +fneur.2018.00968. +[14] Z.L. Fragoso, A.K. McGonagle, Chronic pain in the workplace: a diary study of pain +interference at work and worker strain, Stress Heal 34 (2018) 416–424, https:// +doi.org/10.1002/smi.2801. +[15] E. Dean, A. S¨ +oderlund, What is the role of lifestyle behaviour change associated +with non-communicable disease risk in managing musculoskeletal health +conditions with special reference to chronic pain? BMC Musculoskelet. Disord. 16 +(2015) 87, https://doi.org/10.1186/s12891-015-0545-y. +B. Pravalika et al. +Advances in Integrative Medicine xxx (xxxx) xxx +6 +[16] M.D. Jakobsen, E. Sundstrup, M. Brandt, L.L. Andersen, Effect of physical exercise +on musculoskeletal pain in multiple body regions among healthcare workers: +secondary analysis of a cluster randomized controlled trial, Musculoskelet. Sci. Pr. +34 (2018) 89–96, https://doi.org/10.1016/J.MSKSP.2018.01.006. +[17] O.O. Aje, B. Smith-Campbell, C. Bett, Preventing musculoskeletal disorders in +factory workers: evaluating a new eight minute stretching program, Work. Heal. +Saf. 66 (2018) 343–347, https://doi.org/10.1177/2165079917743520. +[18] N. Tani, M. Ohta, Y. Higuchi, J. Akatsu, M. Kumashiro, Lifestyle and subjective +musculoskeletal symptoms in young male Japanese workers: a 16-year +retrospective cohort study, Prev. Med. Rep. 20 (2020), 101171, https://doi.org/ +10.1016/j.pmedr.2020.101171. +[19] A.L. Monson, A.M. Chismark, B.R. Cooper, T.M. Krenik-Matejcek, Effects of yoga +on musculoskeletal pain, J. Dent. Hyg. JDH 91 (2017) 15–22. +[20] S. Biman, S. Maharana, K.G. Metri, R. Nagaratna, Effects of yoga on stress, fatigue, +musculoskeletal pain, and the quality of life among employees of diamond +industry: a new approach in employee wellness, Work 70 (2021) 521–529, https:// +doi.org/10.3233/WOR-213589. +[21] S. Telles, M. Dash, K.V. Naveen, Effect of yoga on musculoskeletal discomfort and +motor functions in professional computer users, Work 33 (2009) 297–306, https:// +doi.org/10.3233/WOR-2009-0877. +[22] N.J. Patil, R. Nagaratna, P. Tekur, P.V. Manohar, H. Bhargav, D. Patil, +A randomized trial comparing effect of yoga and exercises on quality of life in +among nursing population with chronic low back pain, Int. J. Yoga 11 (2018) +208–214, https://doi.org/10.4103/ijoy.IJOY_2_18. +[23] M.G. Garcia, M. Estrella, A. Pe˜ +nafiel, P.G. Arauz, B.J. Martin, Impact of 10-min +daily yoga exercises on physical and mental discomfort of home-office workers +during COVID-19, Hum. Factors (2021), https://doi.org/10.1177/ +00187208211045766. +[24] K.A. Williams, J. Petronis, D. Smith, D. Goodrich, J. Wu, N. Ravi, E.J. Doyle, R. +G. Juckett, M.M. Kolar, R. Gross, L. Steinberg, Effect of Iyengar yoga therapy for +chronic low back pain, Pain 115 (2005) 107–117, https://doi.org/10.1016/j. +pain.2005.02.016. +[25] P. Tekur, C. Singphow, H.R. Nagendra, N. Raghuram, Effect of short-term intensive +yoga program on pain, functional disability and spinal flexibility in chronic low +back pain: a randomized control study, J. Altern. Complement. Med 14 (2008) +637–644, https://doi.org/10.1089/acm.2007.0815. +[26] H.E. Tilbrook, H. Cox, C.E. Hewitt, A.R. Kang’ombe, L.H. Chuang, S. Jayakody, J. +D. Aplin, A. Semlyen, A. Trewhela, I. Watt, D.J. Torgerson, Yoga for chronic low +back pain: a randomized trial, Ann. Intern. Med. 155 (2011) 569–578, https://doi. +org/10.7326/0003-4819-155-9-201111010-00003. +[27] S. Deepeshwar, M. Tanwar, V. Kavuri, R.B. Budhi, Effect of yoga based lifestyle +intervention on patients with knee osteoarthritis: a randomized controlled trial, +Front. Psychiatry 9 (2018) 180, https://doi.org/10.3389/fpsyt.2018.00180. +[28] J. Ebnezar, R. Nagarathna, Y. Bali, H.R. Nagendra, Effect of an integrated approach +of yoga therapy on quality of life in osteoarthritis of the knee joint: a randomized +control study, Int. J. Yoga 4 (2011) 55, https://doi.org/10.4103/0973- +6131.85486. +[29] A.A. Wren, M.A. Wright, J.W. Carson, F.J. Keefe, Yoga for persistent pain: new +findings and directions for an ancient practice. Pain 152 (2011) 477–480, https:// +doi.org/10.1016/j.pain.2010.11.017. +[30] J.W. Carson, K.M. Carson, K.D. Jones, R.M. Bennett, C.L. Wright, S.D. Mist, A pilot +randomized controlled trial of the Yoga of Awareness program in the management +of fibromyalgia. Pain 151 (2010) 530–539, https://doi.org/10.1016/j. +pain.2010.08.020. +[31] B. Yogitha, R. Nagarathna, E. John, H. Nagendra, Complimentary effect of yogic +sound resonance relaxation technique in patients with common neck pain, Int. J. +Yoga 3 (2010) 18, https://doi.org/10.4103/0973-6131.66774. +[32] R. Manocha, D. Black, J. Sarris, C. Stough, A randomized, controlled trial of +meditation for work stress, anxiety and depressed mood in full-time workers, Evid. +-Based Complement. Altern. Med 2011 (2011), https://doi.org/10.1155/2011/ +960583. +[33] E. Della Valle, S. Palermi, I. Aloe, R. Marcantonio, R. Spera, S. Montagnani, +F. Sirico, Effectiveness of workplace yoga interventions to reduce perceived stress +in employees: a systematic review and meta-analysis, J. Funct. Morphol. Kinesiol 5 +(2020), https://doi.org/10.3390/JFMK5020033. +[34] R. Fang, X. Li, A regular yoga intervention for staff nurse sleep quality and work +stress: a randomised controlled trial, J. Clin. Nurs. 24 (2015) 3374–3379, https:// +doi.org/10.1111/jocn.12983. +[35] N. Parajuli, B. Pradhan, M. Jat, Effect of four weeks of integrated yoga intervention +on perceived stress and sleep quality among female nursing professionals working +at a tertiary care hospital: a pilot study, Ind. Psychiatry J. 30 (2021) 136, https:// +doi.org/10.4103/ipj.ipj_11_21. +[36] U. Yamuna, V. Majumdar, A.A. Saoji, Effect of Yoga on homocysteine level, +symptomatology and quality of life in industrial workers with Chronic Venous +Insufficiency: study protocol for a randomized controlled trial, Adv. Integr. Med. 9 +(2022) 119–125, https://doi.org/10.1016/j.aimed.2022.02.002. +[37] A.A. Saoji, Yoga: a strategy to cope up stress and enhance wellbeing among +medical students. N. Am. J. Med. Sci. 8 (2016) 200–202, https://doi.org/10.4103/ +1947-2714.179962. +[38] S. Muktibodhananda Saraswati, S. Satyananda Saraswati, Hatha yoga pradipika = +Light on hatha yoga: including the original Sanskrit text of the Hatha yoga +pradipika with translation in English, (1998) 641. 〈https://www.goodreads.com/w +ork/best_book/193009-hatha-yoga-pradipika〉(Accessed 3 January 2022). +[39] O. Erdinc, K. Hot, M. Ozkaya, Turkish version of the cornell musculoskeletal +discomfort questionnaire: cross-cultural adaptation and validation, Work 39 +(2011) 251–260, https://doi.org/10.3233/WOR-2011-1173. +[40] R. Siqueira Reis, A.A. Ferreira Hino, C. Rom´ +Elio Rodriguez A˜ +Nez, Perceived stress +scale: reliability and validity study in Brazil, J. Health Psychol. 15 (2010) 107–114, +https://doi.org/10.1177/1359105309346343. +[41] M.D. Manzar, J.A. Moiz, W. Zannat, D.W. Spence, S.R. Pandi-Perumal, A. +S. Bahammam, M.E. Hussain, Validity of the pittsburgh sleep quality index in +Indian university students, Oman Med. J. 30 (2015) 193, https://doi.org/10.5001/ +OMJ.2015.41. +[42] P.S. Swathi, A.A. Saoji, R. Bhat, The role of trataka in ameliorating visual strain and +promoting psychological well-being during prolonged use of digital displays: A +randomized controlled trial, Work 71 (2) (2022) 327–333, https://doi.org/ +10.3233/WOR-210834. +[43] A. Loghmani, P. Golshiri, A. Zamani, M. Kheirmand, N. Jafari, Musculoskeletal +symptoms and job satisfaction among office-workers: A Cross- sectional study from +Iran, Acta Medica Academica 42 (1) (2013) 46–54, https://doi.org/10.5644/ +ama2006-124.70. +B. Pravalika et al. diff --git a/subfolder_0/Effect of a Yoga Based Meditation Technique on Emotional Regulation, Self-compassion and Mindfulness in College Students - ScienceDirect.txt b/subfolder_0/Effect of a Yoga Based Meditation Technique on Emotional Regulation, Self-compassion and Mindfulness in College Students - ScienceDirect.txt new file mode 100644 index 0000000000000000000000000000000000000000..479168889f03b632c93976b6bbfd4ace019de710 --- /dev/null +++ b/subfolder_0/Effect of a Yoga Based Meditation Technique on Emotional Regulation, Self-compassion and Mindfulness in College Students - ScienceDirect.txt @@ -0,0 +1,149 @@ +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 +T Barnhofer et al. +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 +Research article +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 +Research article +“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 +Research article +The benefits of yoga in children +Journal of Integrative Medicine, Volume 16, Issue 1, 2018, pp. 14-19 +Show abstract +Research article +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. diff --git a/subfolder_0/Effect of integrated Yoga module on positive and negative emotions in Home Guards in Bengaluru.txt b/subfolder_0/Effect of integrated Yoga module on positive and negative emotions in Home Guards in Bengaluru.txt new file mode 100644 index 0000000000000000000000000000000000000000..9ce234608f6f54873e785289311c81ae756c9e0b --- /dev/null +++ b/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: b_amaranath@yahoo.co.in +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: reprints@medknow.com +[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. +REFERENCES +1. +Goyanka J. Srimad Bhagavad Gita Tattvavivecani. 15th ed. Gorakhpur: Gita +Press; 1999. +2. +Karnataka State HGs Mannual. Karnataka: Karnataka State Government; +1962. +3. +Nagarathna R, Nagendra HR. Integrated Approach of Yoga Therapy for Positive +Health. 3rd ed. Bangalore: Swami Vivekananda Yoga Prakashana; 2006. +4. +Lazarus RS. Coping theory and research: Past, present, and future. Psychosom +Med 1993;55:234‑47. +5. +Carr A. Positive Psychology. Spl Indian Reprint. New York: Routledge; 2008. +6. +Santrock JW. Psychology Essentials. 2nd ed. New York: Tata McGraw‑Hill; +2005. p. 337‑47. +7. +Watson D, Clark LA, Tellegen A. Development and validation of brief +measures of positive and negative affect: The PANAS scales. J Pers Soc +Psychol 1988;54:1063‑70. +8. +Basso MR, Schefft BK, Ris MD, Dember WN. Mood and global‑local visual +processing. J Neuropsychol Soc 1996;2:249‑55. +9. +Lazarus RS. Toward better research on stress and coping. Am Psychol +2000;55:665‑73. +10. Dillon  KM, Minchoff  B, Baker  KH. Positive emotional states and +enhancement of the immune system. Int J Psychiatry Med 1985;15:13‑8. +11. +Folkman S, Moskowitz JT. Positive affect and the other side of coping. Am +Psychol 2000;55:647‑54. +12. Davis CG, Nolen‑Hoeksema S, Larson J. Making sense of loss and benefiting +from the experience: Two construals of meaning. J Pers Soc Psychol +1998;75:561‑74. +13. Ostir GV, Berges IM, Markides KS, Ottenbacher KJ. Hypertension in older +adults and the role of positive emotions. Psychosom Med 2006;68:727‑33. +14. Drossmana  DA, Creedb  FH, Oldenc  KW, Svedlundd  J, Tonere  BB, +Whiteheadf WE. Psychosocial aspects of the functional gastrointestinal +disorders. Gut 1999;45:1125‑30. +15. Kubzansky LD, Sparrow D, Vokonas P, Kawachi I. Is the glass half empty +or half full? A prospective study of optimism and coronary heart disease in +the normative aging study. Psychosom Med 2001;63:910‑6. +16. Tsenkova VK, Dienberg Love G, Singer BH, Ryff CD. Coping and positive +affect predict longitudinal change in glycosylated hemoglobin. Health Psychol +2008;27 2 Suppl: S163‑71. +17. McCaffrey AM, Pugh GF, O’Connor BB. Understanding patient preference +for integrative medical care: Results from patient focus groups. J Gen Intern +Med 2007;22:1500‑5. +18. Greene AM, Walsh  EG, Sirois  FM, McCaffrey A. Perceived benefits +of complementary and alternative medicine: A whole systems research +perspective. Open Complement Med J 2009;1:35‑45. +19. Nahin RL, Byrd‑Clark D, Stussman BJ, Kalyanaraman N. Disease severity is +associated with the use of complementary medicine to treat or manage type‑2 +diabetes: Data from the 2002 and 2007 National Health Interview Survey. +BMC Complement Altern Med 2012;12:193. +20. Lo CB, Desmond RA, Meleth S. Inclusion of complementary and alternative +medicine in US state comprehensive cancer control plans: Baseline data. +J Cancer Educ 2009;24:249‑53. +21. Survey National Centre for Complementary and Alternative Medicine. +Available from: http://www.nccam.nih.gov. [Last cited on 2015 06]. +22. Kubzansky LD, Wright RJ, Cohen S, Weiss S, Rosner B, Sparrow D. +Breathing easy: A prospective study of optimism and pulmonary function in +the normative aging study. Ann Behav Med 2002;24:345‑53. +23. Danner  DD, Snowdon  DA, Friesen WV. Positive emotions in early +life and longevity: Findings from the nun study. J  Pers Soc Psychol +2001;80:804‑13. +24. Ray US, Mukhopadhyaya S, Purkayastha SS, Asnani V, Tomer OS, Prashad R, +et al. Effect of yogic exercises on physical and mental health of young +fellowship course trainees. Indian J Physiol Pharmacol 2001;45:37‑53. +25. Madanmohan, Thombre DP, Balakumar B, Nambinarayanan TK, Thakur S, +Krishnamurthy N, et al. Effect of yoga training on reaction time, respiratory +endurance and muscle strength. Indian J Physiol Pharmacol 1993;37:350‑2. +26. Raghuraj P, Telles S. Muscle power, dexterity skill and visual perception in +community home girls trained in yoga or sports and in regular school girls. +Indian J Physiol Pharmacol 1997;41:409‑15. +27. Chen KM, Tseng WS. Pilot‑testing the effects of a newly‑developed silver +yoga exercise program for female seniors. J Nurs Res 2008;16:37‑46. +28. Solberg EE, Halvorsen R, Sundgot‑Borgen J, Ingjer F, Holen A. Meditation: +A modulator of the immune response to physical stress? A brief report. Br J +Sports Med 1995;29:255‑7. +29. Harinath K, Malhotra AS, Pal K, Prasad R, Kumar R, Kain TC, et al. Effects +of hatha yoga and Omkar meditation on cardiorespiratory performance, +psychologic profile, and melatonin secretion. J Altern Complement Med +2004;10:261‑8. +30. West J, Otte C, Geher K, Johnson J, Mohr DC. Effects of hatha yoga and +African dance on perceived stress, affect, and salivary cortisol. Ann Behav +Med 2004;28:114‑8. +31. Tooley GA, Armstrong SM, Norman TR, Sali A. Acute increases in night‑time +plasma melatonin levels following a period of meditation. Biol Psychol +2000;53:69‑78. +32. Ray US, Sinha B, Tomer OS, Pathak A, Dasgupta T, Selvamurthy W. Aerobic +capacity and perceived exertion after practice of hatha yogic exercises. Indian +J Med Res 2001;114:215‑21. +33. Telles S, Nagrathna R, Nagendra HR. Improvement in visual perception +following yoga training. J Indian Psychol 1995;13:30‑2. +34. Telles S, Ramaprabhu V, Reddy SK. Effect of yoga training on maze learning. +Indian J Physiol Pharmacol 2000;44:197‑201. +35. Manjunath NK, Telles S. Spatial and verbal memory test scores following +yoga and fine arts camps for school children. Indian J Physiol Pharmacol +2004;48:353‑6. +36. Lavey R, Sherman T, Mueser KT, Osborne DD, Currier M, Wolfe R. The +effects of yoga on mood in psychiatric inpatients. Psychiatr Rehabil J +2005;28:399‑402. +37. 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. +38. Vempati RP, Telles S. Yoga‑based guided relaxation reduces sympathetic +activity judged from baseline levels. Psychol Rep 2002;90:487‑94. +39. Motulsky H. Random Number Calculators. Graph Pad Software; 2015. +[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 +43 +International Journal of Yoga • Vol. 9 • Jan-Jun-2016 +Available from: http://www.graphpad.com/quickcalcs/randMenu/. +[Last accessed on 2015 06]. +40. Narasimhan L, Nagarathna R, Nagendra H. Effect of integrated yogic +practices on positive and negative emotions in healthy adults. Int J Yoga +2011;4:13‑9. +41. Nagarathna R, Nagendra HR. Integrated Approach of Yoga Therapy for +Positive Health. 5th ed. Bangalore: SVYP; 2003. +42. Lokeswarananda S, Taittiriya U. The Ramakrishna Mission Institute of +Culture. Calcutta: Ramakrishna Mission Institute of Culture; 1996. p. 136‑80. +43. Nagarathna R, Nagendra HR. Yoga. 2nd ed. Bangalore: SVYP; 2003. +44. Av a i l a b l e f r o m : h t t p : / / w w w. u n i ‑ m a n n h e i n . d e / g p o w e r. +[Last accessed on 2015 06]. +45. Khurana A, Dhar PL. Effect of Vipassana Meditation on Quality of life, +Subjective Well‑being, and Criminal Propensity Among Inmates of Tihar +Jail, Delhi. Final Report Submitted to Vipassana Research Institute; June, +2000. Available from: http://www.geocities.com/pldhar/publications.htm. +[Last cited on 2015 06]. +46. Deshpande S, Nagendra HR, Raghuram N. A randomized control trial of the +effect of yoga on verbal aggressiveness in normal healthy volunteers. Int J +Yoga 2008;1:76‑82. +47. Michalsen A, Grossman P, Acil A, Langhorst J, Lüdtke R, Esch T, et al. +Rapid stress reduction and anxiolysis among distressed women as a +consequence of a three‑month intensive yoga program. Med Sci Monit +2005;11:CR555‑561. +48. Rao  RM, Nagendra  HR, Raghuram  N, Vinay  C, Chandrashekara  S, +Gopinath KS, et al. Influence of yoga on mood states, distress, quality of +life and immune outcomes in early stage breast cancer patients undergoing +surgery. Int J Yoga 2008;1:11‑20. +49. West J, Otte C, Geher K, Johnson J, Mohr DC. Effects of hatha yoga and +African dance on perceived stress, affect, and salivary cortisol. Ann Behav +Med 2004;28:114‑8. +50. Khalsa  SB, Cope  S. Effects of a yoga lifestyle intervention on +performance‑related characteristics of musicians: A preliminary study. Med +Sci Monit 2006;12:CR325‑31. +51. Malathi A, Damodaran A. Stress due to exams in medical students – Role of +yoga. Indian J Physiol Pharmacol 1999;43:218‑24. +52. Michalsen A, Grossman P, Acil A, Langhorst J, Lüdtke R, Esch T, et al. +Rapid stress reduction and anxiolysis among distressed women as a +consequence of a three‑month intensive yoga program. Med Sci Monit +2005;11:CR555‑561. +53. Nagendra HR. The Science of Emotion′s Culture (Bhakti Yoga). 1st ed. +Bangalore: Swami Vivekananda Yoga Prakashana; 2000. +54. Powers DV, Cramer RJ, Grubka JM. Spirituality, life stress, and affective +well‑being. J Psychol Theol 2007;35:235‑43. +[Downloaded from http://www.ijoy.org.in on Wednesday, July 27, 2016, IP: 14.139.155.82] diff --git a/subfolder_0/Effect of integrated Yoga on neurogenic bladder dysfunction in patients with multiple sclerosis.txt b/subfolder_0/Effect of integrated Yoga on neurogenic bladder dysfunction in patients with multiple sclerosis.txt new file mode 100644 index 0000000000000000000000000000000000000000..3e14a9cc46db1f89ba428bd626d0ede1890b9660 --- /dev/null +++ b/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. + diff --git a/subfolder_0/Effect of integrated approach of yoga therapy on male obesity and psychological parameters.txt b/subfolder_0/Effect of integrated approach of yoga therapy on male obesity and psychological parameters.txt new file mode 100644 index 0000000000000000000000000000000000000000..003c96a10c99f211f5e9ae03f6a16b678eeff403 --- /dev/null +++ b/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 + WHO  Global Database on Body Mass Index Available from: http://apps.who.int/ +[1] +bmi/index. [Accessed on 2014 Aug 9]. + WHO Obesity and overweight. World Health Organization;Available from: http:// +[2] +www.who.int/mediacentre/factsheets/fs311/en. Accessed on 2014 Jul 24. +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 +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: +Mr. P.B. Rshikesan, +Research Scholar, 19, Eknath Bhavan, Gavipuram Circle, K.G. Nagar, Bengaluru‑560 019, Karnataka, India. +E-mail: hrishipb@gmail.com +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 + WHO Obesity. World Health Organization; Available from: http://www.who.int/ +[3] +topics/obesity/en/. [Accessed on 2016 Mar 31]. + Prasad D, Dash A, Kabir Z, Das B. Prevalence and risk factors for metabolic +[4] +syndrome in Asian Indians: A community study from urban Eastern India. J +Cardiovasc Dis Res. 2012;3(3):204. + Ramachandran A, Snehalatha C. Rising burden of obesity in Asia. +[5] +J Obes. +2010;2010. + Dhurandhar N. Obesity in India: Opportunities for clinical research. J +[6] + Obes Metab +Res. 2014;1(1):25. + Yadav K, Krishnan A. Changing patterns of diet, physical activity and obesity +[7] +among urban, rural and slum populations in north India. Obes Rev. 2008;9(5):400– +08. + Singh RB, Pella D, Mechirova V, Kartikey K, Demeester F, Tomar RS, et al. +[8] +Prevalence of obesity, physical inactivity and undernutrition, a triple burden of +diseases during transition in a developing economy. The Five City Study Group. +Acta Cardiol 2007;62(2):119–27. + Kalra S, Unnikrishnan A. Obesity in India: The weight of the nation. +[9] +J Med Nutr +Nutraceuticals 2012;1(1):37. + Deepa M, Farooq S, Deepa R, Manjula D, Mohan V. Prevalence and significance +[10] +of generalized and central body obesity in an urban Asian Indian population in +Chennai, India (CURES: 47). Eur J of Clin Nutr. 2009;63:259–67. + Misra A, Chowbey P +, Makkar BM, Vikram NK, Wasir JS, Chadha D, et al. +[11] +Consensus statement for diagnosis of obesity, abdominal obesity and the +metabolic syndrome for Asian Indians and recommendations for physical activity, +medical and surgical management. J Assoc Physicians India. 2009;57:163–70. + Snehalatha C, Viswanathan V, Ramachandran A. Cutoff values for normal +[12] +anthropometric variables in asian Indian adults. Diabetes Care. 2003;26(5):1380– +84. + Mini Sheth NS. The Scientific Way to Managing Obesity. New Delhi: Sterling +[13] +publishers; 2011. + Dehghan M, Akhtar-Danesh N, Merchant AT. Childhood obesity, prevalence and +[14] +prevention. Nutr J. 2005;4:24. + Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 +[15] +years. N Engl J Med. 2007;357:370–79. + Karnik S, Kanekar A. Childhood obesity: a global public health crisis. +[16] +Int J Prev +Med. 2012;3:1–7. + Thayer KA, Heindel JJ, Bucher JR, Gallo MA. Role of Environmental Chemicals in +[17] +Diabetes and Obesity: A National Toxicology Program Workshop. Environmental +Health Perspectives. 2012;120(6):779–89. + Taimini IK. The Science of Yoga. Chennai: The Theosophical Publishing House; +[18] +2010. + Taimini IK. Glimpses into psychology of Yoga.Chennai:Theosophical Publishing +[19] +House; 2007. + Udupa KN. Stress and its management.Delhi: Motilal Banarsidass Publishers Pvt +[20] +Ltd; 2000. + Adam M, Judi B, Jane PE, Mladen G Michael F. Yoga in the Management of +[21] +Overweight and Obesity. Am J Lifestyle Med. 2014; 8(1): 33-41. + Benavides S, Caballero J. Ashtanga yoga for children and adolescents for weight +[22] +management and psychological well being: an uncontrolled open pilot study. +Complement Ther Clin Pract. 2009;15(2):110–14. + Saghaei M. Implementation of an open-source customizable minimization +[23] +program for allocation of patients to parallel groups in clinical trials. J Biomed Sci +Eng. 2011;04(11):734–39. + Altman DG, Bland JM. Treatment allocation by minimisation. +[24] +BMJ. +2005;330:843. + Scott +NW, +McPherson +GC, +Ramsay +CR, +Campbell +MK. +The +method +of +minimization +[25] +for allocation to clinical trials: A review. Control Clin Trials. 2002;23:662–74. + Dhananjai S, Sadashiv, Tiwari S, Dutt K, Kumar R. Reducing psychological +[26] +distress and obesity through Yoga practice. Int J Yoga. 2013;6:66–70. + Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: a flexible statistical power +[27] +analysis program for the social, behavioural, and biomedical sciences. Behav +Res Methods. 2007;39:175–91. + NIN. Dietary Guidelines - a Manual. Hyderabad: National Institute of Nutrition; +[28] +2011. + Kannieappan LM, Deussen AR, Grivell RM, Yelland L, Dodd JM. Developing a +[29] +tool for obtaining maternal skinfold thickness measurements and assessing inter +observer variability among pregnant women who are overweight and obese. +BMC Pregnancy Childbirth. 2013;13:42. + Durnin J V, Womersley J. Body fat assessed from total body density and its +[30] +estimation from skinfold thickness: measurements on 481 men and women aged +from 16 to 72 years. Br J Nutr. 1974;32(1):77–97. + Lee EH. Review of the psychometric evidence of the perceived stress scale. +[31] +Asian Nursing Research. 2012;(6):121–27. + Lillis J, Heyes SC. Measuring avoidance and inflexibility in weight related +[32] +problems. Int journel Behav Consult Ther. 2008;4(1):30-40. + Niemeier H, Leahey T, Reed KP +, Brown RA, Wing RR. An acceptance based +[33] +behavioural intervention for weight loss a pilot study. Behav Ther. 2012;43(2):1- +14. + West J, Manchester B, Wright J, Lawlor DA, Waiblinger D. Reliability of routine +[34] +clinical measurements of neonatal circumferences and research measurements +of neonatal skinfold thicknesses: Findings from the Born in Bradford study. +Paediatr Perinat Epidemiol. 2011;25:164–71. + Dabhadkar KC, Deshmukh A, Bellam N, Tuliani T. Body shape index +[35] +predicts cardiovascular mortality independent of BMI. J Am Coll Cardiol. +2013;61(10):E1364. + Krakauer NY, Krakauer JC. A new body shape index predicts mortality hazard +[36] +independently of body mass index. PLoS One. 2012;7(7):1-10. + Romero-Corral A, Somers VK, Sierra-Johnson J, Thomas RJ, Collazo-Clavell +[37] +ML, Korinek J, et al. Accuracy of body mass index in diagnosing obesity in the +adult general population. Int J Obes (Lond). 2008;32:959–66. + Telles S, Sharma SK, Yadav A, Singh N, Balkrishna A. A comparative controlled +[38] +trial comparing the effects of yoga and walking for overweight and obese adults. +Med Sci Monit. 2014;20:894–904. + Telles S, Naveen VK, Balkrishana A, Kumar S. Short term health impact of a yoga +[39] +and diet change program on obesity. Med Sci Monit. 2010; 16(1): 35–40. + Sarría A, García Llop LA, Moreno LA, Fleta J, Morellón MP +, Bueno M. Skinfold +[40] +thickness measurements are better predictors of body fat percentage than +body mass index in male Spanish children and adolescents. Eur J Clin Nutr +1998;52(8):573–76. + Cohen S. Perceived stress Scale. +[41] +Psychology. 1983;9:1–3. + Niemeier HM, Leahey T, Palm Reed K, Brown RA, Wing RR. An acceptance- +[42] +based behavioural intervention for weight loss: a pilot study. Behav Ther +2012;43(2):427–35. + Gupta N, Khera S, Vempati RP +, Sharma R, Bijlani RL. Effect of yoga based +[43] +lifestyle intervention on state and trait anxiety. Indian J Physiol Pharmacol. +2006;50(1):41–47. + Yoshihara K, Hiramoto T, Sudo N, Kubo C. Profile of mood states and stress- +[44] +related biochemical indices in long-term yoga practitioners. Biopsychosoc Med. +2011;5:6. + Braun TD, Park CL, Conboy LA. Psychological well-being, health behaviours, +[45] +and weight loss among participants in a residential, Kripalu yoga-based weight +loss program. Int J Yoga Therap. 2012;(22):9–22. + Daubenmier J, Kristeller J, Hecht FM, Maninger N, Kuwata M, Jhaveri K, et al. +[46] +Mindfulness intervention for stress eating to reduce cortisol and abdominal fat +among overweight and obese women: An exploratory randomized controlled +study. J Obes. 2011;2011:651936. + Smith JJ, Morgan PJ, Plotnikoff RC, Dally KA, Salmon J, Okely AD, et al. Smart- +[47] +phone obesity prevention trial for adolescent boys in low-income communities: +the ATLAS RCT. Pediatrics. 2014;134(3):723-31. + Aizawa K, Maeda K, Ogawa M, Sato Y, Kasamatsu M, Waki K, et al. +[48] +Comparative Study of the Routine Daily Usability of FoodLog: A Smartphone- +based Food Recording Tool Assisted by Image Retrieval. J Diabetes Sci Technol +2014;8(2):203–08. + González C, Herrero P +, Cubero JM, Iniesta JM, Hernando ME, García-Sáez G, +[49] +et al. PREDIRCAM eHealth platform for individualized telemedical assistance for +lifestyle modification in the treatment of obesity, diabetes, and cardiometabolic risk +prevention: a pilot study (PREDIRCAM 1). J Diabetes Sci Technol 2013;7(4):888– +97. diff --git a/subfolder_0/Effect of integrated yoga on anti-psychotic induced side effects and cognitive functions in patients suffering from schizophrenia.txt b/subfolder_0/Effect of integrated yoga on anti-psychotic induced side effects and cognitive functions in patients suffering from schizophrenia.txt new file mode 100644 index 0000000000000000000000000000000000000000..0dd9d13a6e4fb4524869d58eb5fe4766623fb291 --- /dev/null +++ b/subfolder_0/Effect of integrated yoga on anti-psychotic induced side effects and cognitive functions in patients suffering from schizophrenia.txt @@ -0,0 +1,706 @@ +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: hemant.bhargav1@gmail.com +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 +Download Date | 7/2/18 7:22 AM +Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd +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 +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 +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 +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 +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 +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 +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 +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 +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 +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 +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 +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 +DE GRUYTER +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- +chiatr Ment Health Nurs. 2006;13:730–4. +[4] Sharma T. Cognitive effects of conventional and atypical antipsychotics in schizophrenia. Br J Psychiatry. 1999;174:44–51. +[5] Gallhofer B, Bauer U, Lis S, Krieger S, Gruppe H. Cognitive dysfunction in schizophrenia: comparison of treatment with atypical antipsy- +chotic agents and conventional neuroleptic drugs. Eur Neuropsychopharmacol. 1996;6:13–20. +[6] Meltzer HY, McGurk SR. The effects of clozapine, risperidone, and olanzapine on cognitive function in schizophrenia. Schizophr Bull. +1999;25:233–56. +[7] McEvoy JP +, McCue M, Spring B, Mohs RC, Lavori PW, Farr RM. Effects of amantadine and trihexyphenidyl on memory in elderly normal +volunteers. Am J Psychiatry. 1987;144:573–7. +[8] Feinberg M. The problem of anticholergic adverse effect in older patients. Drug Aging. 1993;3:335–48. +[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 +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 +[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. +[26] Bhatia T, Agarwal A, Shah G, Wood J, Richard J, Gur RE, et al. Adjunctive cognitive remediation for schizophrenia using yoga: an open, +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 +Brought to you by | Göteborg University - University of Gothenburg +Authenticated +Download Date | 7/2/18 7:22 AM diff --git a/subfolder_0/Effect of one-month yoga training program on performance in a mirror tracing task.txt b/subfolder_0/Effect of one-month yoga training program on performance in a mirror tracing task.txt new file mode 100644 index 0000000000000000000000000000000000000000..077f0d9faefc8496ad4beb0798cacebc22660c65 --- /dev/null +++ b/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 : anvesana@gmail.com +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. diff --git a/subfolder_0/Effect of short term intensive yoga prohram for on pain functional disability and spinal flexibility in CLBP.txt b/subfolder_0/Effect of short term intensive yoga prohram for on pain functional disability and spinal flexibility in CLBP.txt new file mode 100644 index 0000000000000000000000000000000000000000..0b6fb6159c9261402138649df9bd28ae5c3cd893 --- /dev/null +++ b/subfolder_0/Effect of short term intensive yoga prohram for on pain functional disability and spinal flexibility in CLBP.txt @@ -0,0 +1,959 @@ +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. +References +1. Franks JW, Kerr MS, Brooker AS, Demano SE. Disability re- +sulting from occupational low back pain: A review of sci- +entific evidence on prevention before disability begins. Spine +1996;21:2908–2917. +2. Andersson GBJ. The epidemiology of spinal disorders. In: +Frymoyer JW, ed. The Adult Spine: Principles and Practice, +2nd ed. Philadelphia: Lippincot-Raven, 1997:93–141. +3. Williamas AC, Nicholas MK, Richardson PH, et al. Evalua- +tion of a cognitive behavioral program for rehabilitating pa- +tients with chronic pain. Br J Gen Pract 1993;43:513–518. +4. Moldofsky H, Lue FA. Disordered sleep, pain, fatigue and +gastrointestinal symptoms in fibromyalgia, chronic fatigue +and irritable bowel syndromes. In: Mayer EA, Raybould HE, +eds. Basic and Clinical Aspects of Chronic Abdominal Pain. +New York. Elsevier Science, 1993:249–255. +5. Fryer G, Morris T, Gibbons P. Paraspinal muscles and in- +tervertebral dysfunction: Part One. J Manipulative Physiol +Ther 2004;27:267–274. +6. Rodríguez-García J, Sánchez-Gastaldo A, Ibáñez-Campos T, +et al. Related factors with the failed surgery of herniated +lumbar disc. Neurocirugia (Astur) 2005;16507–517. +7. Garfinkel MM, Singhal A, Katz WA, et al. Yoga based in- +tervention for carpel tunnel syndrome: A randomized trial. +J Am Med Assoc 1998;280:1601–1603. +8. Haslock I, Monro R, Nagarathna R, et al. Measuring the ef- +fects of yoga in rheumatoid arthritis. Br J Rheumatol +1994;33:787–788. +9. Murugesan R, Govindarajulu N, Bera TK. Effect of selected +yogic practices on the management of hypertension. Indian +J Physiol Pharmacol 2000;44:207–210. +10. Nagarathna R, Nagendra HR. Yoga for bronchial asthma: A +controlled study. BMJ (Clin Rer Ed) 1985;291:1077–1079. +11. Vedanthan PK, Keshavulu LN, Murthy KC, et al. Clinical +study of yoga techniques in university students with asthma: +A controlled study. Allerg Asthma Proc 1998;19:3–9. +12. Taneja I, Deepak KK, Poojary G, et al. Yogic versus con- +ventional treatment in diarrhea-predominant irritable bowel +syndrome: A randomized control study. Appl Psychophys- +iol Biofeedback 2004;29:2919–2933. +13. Singh S, Malhotra V, Singh K, Sharma S. A preliminary report +on the role of yoga asanas on oxidative stress in non-insulin +dependent diabetes. Indian J Clin Biochem 2001;16:216–220. +14. Manchanda SC, Narang R, Reddy KS, et al. Retardation of +coronary atherosclerosis with yoga lifestyle intervention. J +Assoc Physicians India 2000;48:687–694. +15. Woolery A, Myers H, Sternlieb B, Zeltzer L. A yoga inter- +vention for young adults with elevated symptoms of de- +pression. Altern Ther Health Med 2004;10:60–63. +16. Sherman KJ, Cherkin DC, Erro J, et al. Comparing yoga, ex- +ercise, and a self-care book for chronic low back pain: A ran- +domized, controlled trial. Ann Intern Med 2005;143:849–856. +17. Williamas KA, Patrons J, Smith D, et al. Effect of Iyengar +yoga therapy for chronic low back pain. Pain 2005; +115(1–2):107–17. +18. Vidyasagar JVS, Prasad BN, Reddy V, et al. Effects of yoga +practices in nonspecific low back pain. Clin Proc NIMS +1989;4:160–164. +19. Galantino ML, Bzdewka TM, Eissler-Russo JL, et al. The im- +pact of modified Hatha yoga on chronic low back pain: A +pilot study. Altern Ther Health Med 2004;10:56–59. +20. Bijlani RL, Vempati RP, Yadav RK, et al. A brief but com- +prehensive lifestyle education program based on yoga re- +duces risk factors for cardiovascular disease and diabetes +mellitus. J Altern Complement Med 2005;11:267–274. +21. Spitzer WO, LeBlanc FE, Dupis M. Scientific approach to the +assessment and management of activity related spinal dis- +orders: A monograph for clinicians. Spine 1987;12:75. +22. Nagarathna R, Nagendra HR. Yoga for the promotion of +positive health. Bangalore: Swami Vivekananda Yoga +Prakashana, 2000. +23. Telles S, Nagarathna R, Nagendra HR. Autonomic changes +during OM meditation. Indian J Physiol Pharmacol +1995;39:418–420. +24. Nagarathna R, Nagendra HR. Yoga for Back Pain. Banga- +lore: Swami Vivekananda Yoga Prakashana, 2001. +25. Vempati RP, Telles S. Yoga based guided relaxation reduces +sympathetic activity in subjects based on baseline levels. +Psychol Rep 2002;90:487–494. +26. Nagendra HR. Pranayama:—the Art and Science. Bangalore: +Swami Vivekananda Yoga Prakashana, 2000. +27. Chinmayananda S. Mandukya Upanishad. Bombay: Sachin +Publishers, 1984. +28. Nagendra HR, Nagarathna R. New Perspectives in Stress +Management. Bangalore: Vivekananda Kendra Prakashana, +1997. +29. Telles S, Reddy SK, Nagendra HR. Oxygen consumption and +respiration following two yoga relaxation techniques. Ap- +plied Psychophysiol Biofeedback 2000;25:221–227. +30. Swami Lokeswarananda. Taittireya Upanishad. Kolkatta, In- +dia: The Ramakrishna Mission Institute of Culture, 1996. +31. Nagendra HR. Mind Sound Resonance Technique. Banga- +lore: Swami Vivekananda Yoga Prakashana, 1998. +32. Fairbank JC, Pynsent PB. The Oswestry Disability Index. +Spine 2000;25:2940–2952. +33. Brown RP, Gerbarg PL. Sudarshan Kriya Yogic breathing in +the treatment of stress, anxiety, and depression: Part II— +clinical applications and guidelines. J Altern Complement +Med 2005;11:711–717. +34. Telles S, Nagarathna R, Nagendra HR. Breathing through a +particular nostril can alter metabolism and autonomic ac- +tivities. Indian J Physiol Pharmacol 1994;38:133–137. +35. Basler HD, Jakie C, Kroner-Herwig B. Incorporation of cog- +nitive–behavior treatment into the medical care of chronic +low back pain patients: A controlled randomised study in +German pain treatment centers. Patient Educ Couns +1997;31:113–124. +36. Turk DC, Meichenbaum D, Genest M. Pain and Behavioural +Medicine: A Cognitive–Behavioural Perspective. New York: +Guilford Press, 1983. +37. Lipchik GL, Milles K, Covington EC. The effects of multi- +disciplinary pain management treatment on locus of control +and pain beliefs in chronic non-terminal pain. Clin J Pain +1993;9:49–57. +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: p_tekur@yahoo.co.in; rnagaratna@gmail.com +TEKUR ET AL. +644 diff --git a/subfolder_0/Effect of the integrated approach of yoga therapy on platelet count and uric acid in pregnancy.txt b/subfolder_0/Effect of the integrated approach of yoga therapy on platelet count and uric acid in pregnancy.txt new file mode 100644 index 0000000000000000000000000000000000000000..5f182a1edc5e88c5bd267849f6894a37a280e44f --- /dev/null +++ b/subfolder_0/Effect of the integrated approach of yoga therapy on platelet count and uric acid in pregnancy.txt @@ -0,0 +1,312 @@ +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. +References +1 +Robert WP, Lisa MB, Roberta BN, Katheryn MC, Marcia JG, Michael PF, et al. Uric acid concentrations in early pregnancy among preeclamptic women with gestational +hyperuricemia at delivery. Am J Obstet Gynecol 2006;194:160-8. +2 +Richard JJ, Santos EP, Yuri YS, Jacek M, Laura GS, Daniel IF, et al. Hypothesis: Could excessive fructose intake and uric acid cause type 2 diabetes? Endocr Rev +2009;30:96-116. +3 +James DK, Steer PJ, Weiner CP, Gonik B. High-risk pregnancy management options. 3 rd ed. Philadephia, USA: Elsevier; 2006. +4 +Laura BM, Linda A. Anesthesia for fetal intervention and surgery. 1 st ed. Guilford, (USA): McGraw Hill Publishers; 2005. +5 +Takashima M, Yamasaki M, Ohashi M, Morikawa H, Mochizuki M. A trial of low-dose aspirin therapy in high-risk pregnancy. Nihon Sanka Fujinka Gakkai Zasshi 1992;44:845- +52. +6 +Rogers MS, Fung HY, Hung CY. Calcium and low-dose aspirin prophylaxis in women at high risk of pregnancy-induced hypertension. Hypertens Pregnancy 1999;18:165- +72. +7 +Posadzki P, Nel G. Mind-body medicine: A conceptual (re) synthesis? Adv Mind Body Med 2009;24:8-14. +8 +Richard PB, Patricia L. Sudarsharna Kriya yogic breathing in the treatment of stress and anxiety and depression part I: Neurophysiologic model. J Altern Complement Med +2005;11:189-201. +9 +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. +10 +Chuntharapat S, Petpichetchian W, Hatthakit U. Yoga during pregnancy: Effects on maternal comfort, labor pain and birth outcomes. Complement Ther Clin Pract +2008;14:105-15. +11 +Narendran S, Nagarathna R, Narendran V, Gunasheela S, Nagendra HR. Efficacy of yoga on pregnancy outcome. J Altern Complement Med 2005;11:237-44. +12 +Narendran S, Nagarathna R, Narendran V, Gunasheela S, Nagendra HR. Efficacy of yoga in pregnant women with abnormal doppler study of umbilical and uterine arteries. +J Indian Med Assoc 2005;37:165-75. +13 +Kanako S. Studies on prophylaxis of preeclampsia by water exercise during pregnancy. J Aichi Medical University Association 1999;27:103-14. +14 +Kumar PJ, Clark ML. Clinical Medicine. 6 th ed. Edinburgh (NY): Elsevier Saunders Publishers; 2005. +15 +Laupacis A, Sackett DL, Roberts RS. An assessment of clinically useful measures of the consequences of treatment. N Engl J Med 1988;318:1728-33. +16 +El-Sayed MS, Sajad AZ. Exercise and training effects on blood haemostasis in health and disease: An Update. Sports Med 2004;34:181-200. +17 +Boyle JA, Campbell S, Duncan AM, Greig WR, Buchanan WW. Serum uric acid levels in normal pregnancy with observations on the renal excretion of urate in pregnancy. J +Clin Pathol 1966;19:501-03. +18 +Lind T, Godfrey KA, Otun H, Philips PR. Changes in serum uric acid concentrations during normal pregnancy. Br J Obstet Gynaecol 1984;91:128-32. +19 +Powers RW, Bodnar LM, Ness RB, Cooper KM, Gallaher MJ, Frank MP, et al. Uric acid concentrations in early pregnancy among preeclamptic women with gestational +hyperuricemia at delivery. Am J Obstet Gynecol 2006;194:160. +20 +Chohan IS, Nayar HS, Thomas P, Geetha NS. Influence of yoga on blood coagulation. Thromb Haemost 1984;51:196-7. +21 +Patnaik MM, Haddad T, Morton CT. Pregnancy and thrombophilia. Expert Rev Cardiovasc Ther 2007;5:753-65. +22 +McCrae KR. Thrombocytopenia in pregnancy. Hematology Am Soc Hematol Educ Program 2010;2010:397-402. +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 +5/5 +23 +Silver RM, Berkowitz RL, Bussel J. Thrombocytopenia in pregnancy. ACOG Practice Bulletin. No 6. Chicago (USA):1999. +24 +Sica DA, Schoolwerth AC. Renal handling of organic anions and cations and renal excretion of uric acid. In: The Kidney. Brenner BM, editor. 5 th ed. Philadelphia, USA: +Saunders Co.; 1996. p. 607-26. +25 +Richard L. The kidney in preeclampsia. Kidney Int 2005;67:1194-203. +26 +Jeyabalan A, Kirk P. Renal function during normal pregnancy and preeclampsia. Front Biosci 2007;12:2425-37. +27 +De-Weerth C, Buitelaar JK. Physiological stress reactivity in human pregnancy. Neurosci Biobehav Rev 2005;29:295-312. +28 +Mendelson T, Dipietro JA, Costigan AK, Ping Chen P, Henderson LJ. Associations of maternal psychological factors with umbilical and uterine blood flow. J Psychosom +Obstet Gynaecol 2011;32:3-9. +29 +Vanden Bergh B, Mulder E, Mennes M, Glover V. Antenatal maternal anxiety and stress and the neurobehavioral development of the fetus and child: Links and possible +mechanisms, a review. Neurosci Biobehav Rev 2005;29:237-58. +30 +Wong ML, Dong C, Esposito K, Thakur S, Liu W, Robert M, et al. Elevated stress-hemoconcentration in major depression is normalized by antidepressant treatment: +Secondary analysis from a randomized, double-blind clinical trial and relevance to cardiovascular disease risk. PLos One 2008;3:2350. +31 +Thrall G, Lane D, Carroll D, Lip GY. A systematic review of the effects of acute psychological stress and physical activity on haemorheology, coagulation, fibrinolysis and +platelet reactivity: Implications for the pathogenesis of acute coronary syndromes. Thromb Res 2007;120:819-47. +32 +Smith C, Hancock H, Mortimer JB, Eckert K. A randomized comparative trial of yoga and relaxation to reduce stress and anxiety. Complement Ther Med 2007;15:77-83. +33 +McCaffrey R, Ruknui P, Hatthakit U, Kasetsomboon P. The effects of yoga on hypertensive persons in Thailand. Holist Nurs Pract 2005;19:173-80. +34 +Rakhshani A, Maharana S, Nagarathna R, Nagendra HR, Padmalatha V. Effects of integrated yoga on quality of life and interpersonal relationship of pregnant women. Qual +Life Res 2010;19:1447-55. + + +Monday, August 11, 2014 + Site Map | Home | Contact Us | Feedback | Copyright and Disclaimer diff --git "a/subfolder_0/Effectiveness of Yoga Lifestyle on Lipid Metabolism in a Vulnerable Population\342\200\224A Community Based Multicenter Randomized Controlled Trial.txt" "b/subfolder_0/Effectiveness of Yoga Lifestyle on Lipid Metabolism in a Vulnerable Population\342\200\224A Community Based Multicenter Randomized Controlled Trial.txt" new file mode 100644 index 0000000000000000000000000000000000000000..bd6406f09d844cb503b133842389c60719376f19 --- /dev/null +++ "b/subfolder_0/Effectiveness of Yoga Lifestyle on Lipid Metabolism in a Vulnerable Population\342\200\224A Community Based Multicenter Randomized Controlled Trial.txt" @@ -0,0 +1,1280 @@ +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; +dramits90@gmail.com (A.K.S.); ayursuch@gmail.com (S.S.P.); chancellor@svyasa.edu.in (H.R.N.) +2 +Neuroscience Research Lab, Department of Neurology, Postgraduate Institute of Medical Education and +Research (PGIMER), Chandigarh 160012, India; Saurabh.kum1991@gmail.com +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; +acharyaishwar@gmail.com +6 +Yoga Clinic, Bhopal 462026, India; latavk123@gmail.com +7 +Arogya Rasahara Kendra, Bhopal 462024, India; purnimadatey@gmail.com +* +Correspondence: rnagaratna@gmail.com (R.N.); akshay1anand@rediffmail.com (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 +References +1. +Mithal, A.; Majhi, D.; Shunmugavelu, M.; Talwarkar, P.G.; Vasnawala, H.; Raza, A.S. Prevalence of dyslipidemia in adult Indian +diabetic patients: A cross sectional study (SOLID). Indian J. Endocrinol. Metab. 2014, 18, 642–647. [CrossRef] +2. +Rosenson, R.S.; Brewer, H.B.; Ansell, B.; Barter, P.; Chapman, M.J.; Heinecke, J.W.; Kontush, A.; Tall, A.R.; Webb, N.R. Translation +of high-density lipoprotein function into clinical practice: Current prospects and future challenges. Circulation 2013, 128, +1256–1267. [CrossRef] [PubMed] +3. +Frank, A.T.; Zhao, B.; Jose, P.O.; Azar, K.M.; Fortmann, S.P.; Palaniappan, L.P. Racial/Ethnic Differences in Dyslipidemia Patterns. +Circulation 2014, 129, 570–579. [CrossRef] [PubMed] +4. +Pu, J.; Romanelli, R.; Zhao, B.; Azar, K.M.; Hastings, K.G.; Nimbal, V.; Fortmann, S.P.; Palaniappan, L.P. Dyslipidemia in Special +Ethnic Populations. Cardiol. Clin. 2015, 33, 325–333. [CrossRef] +5. +Chandra, K.S.; Bansal, M.; Nair, T.; Iyengar, S.; Gupta, R.; Manchanda, S.C.; Mohanan, P.; Rao, V.D.; Manjunath, C.; Sawh- +ney, J.; et al. Consensus statement on management of dyslipidemia in Indian subjects. Indian Heart J. 2014, 66, S1–S51. [CrossRef] +[PubMed] +6. +Farmer, J.A. Diabetic dyslipidemia and atherosclerosis: Evidence from clinical trials. Curr. Diabetes Rep. 2008, 8, 71–77. [CrossRef] +[PubMed] +7. +Association, A.D. Management of dyslipidemia in adults with diabetes. Diabetes care 2003, 26, s83–s86. +8. +Wilson, P.W.; D’Agostino, R.B.; Parise, H.; Sullivan, L.; Meigs, J.B. Metabolic Syndrome as a Precursor of Cardiovascular Disease +and Type 2 Diabetes Mellitus. Circulation 2005, 112, 3066–3072. [CrossRef] +9. +Joshi, S.R.; Anjana, R.M.; Deepa, M.; Pradeepa, R.; Bhansali, A.; Dhandania, V.K.; Joshi, P.P.; Unnikrishnan, R.; Nirmal, E.; +Subashini, R.; et al. Prevalence of Dyslipidemia in Urban and Rural India: The ICMR–INDIAB Study. PLoS ONE 2014, 9, e96808. +[CrossRef] +10. +Fox, C.S.; Coady, S.; Sorlie, P.D.; D’Agostino, R.B.; Pencina, M.J.; Vasan, R.S.; Meigs, J.B.; Levy, D.; Savage, P.J. Increasing +Cardiovascular Disease Burden Due to Diabetes Mellitus. Circulation 2007, 115, 1544–1550. [CrossRef] +11. +Silverio, A.; Cavallo, P.; De Rosa, R.; Galasso, G. Big Health Data and Cardiovascular Diseases: A Challenge for Research, an +Opportunity for Clinical Care. Front. Med. 2019, 6, 36. [CrossRef] +12. +Saha, S.; Mondal, S.; Kundu, B. Yoga as a therapeutic intervention for the management of type 2 diabetes mellitus. Int. J. Yoga +2018, 11, 129–138. [CrossRef] [PubMed] +13. +Tundwala, V.; Gupta, R.P.; Kumar, S.; Singh, V.B.; Sandeep, B.R.; Dayal, P.; Prakash, P. A study on effect of yoga and various +asanas on obesity, hypertension and dyslipidemia. Int. J. Basic Appl. Med. Sci. 2012, 2, 93–98. +14. +Chandrasekaran, A.M.; Kinra, S.; Ajay, V.S.; Chattopadhyay, K.; Singh, K.; Singh, K.; Praveen, P.A.; Soni, D.; Devarajan, R.; +Kondal, D.; et al. Effectiveness and cost-effectiveness of a Yoga-based Cardiac Rehabilitation (Yoga-CaRe) program following +acute myocardial infarction: Study rationale and design of a multi-center randomized controlled trial. Int. J. Cardiol. 2019, 280, +14–18. [CrossRef] [PubMed] +15. +Kumar, S.; Sudha, S.; Chopra, M.; Khan, F.; Sharma, K. Physical Exercise and Yoga: As an alternative approach towards COVID-19 +management. Curr. Tradit. Med. 2021, 7, 1. [CrossRef] +16. +Yeung, A.C.; Chang, D.H.T.; Bensoussan, A.; Kiat, H. Yoga and cardiac rehabilitation: A brief review of evidence. J. Yoga Phys. +Ther. 2015, 5, 1000207. [CrossRef] +17. +Bali, P.; Kaur, N.; Tiwari, A.; Bammidi, S.; Podder, V.; Devi, C.; Kumar, S.; Sivapuram, M.S.; Ghani, A.; Modgil, S.; et al. +Effectiveness of Yoga as the Public Health Intervention Module in the Management of Diabetes and Diabetes Associated +Dementia in South East Asia: A Narrative Review. Neuroepidemiology 2020, 54, 287–303. [CrossRef] +18. +Pal, D.K.; Bhalla, A.; Bammidi, S.; Telles, S.; Kohli, A.; Kumar, S.; Devi, P.; Kaur, N.; Sharma, K.; Kumar, R.; et al. Can Yoga-Based +Diabetes Management Studies Facilitate Integrative Medicine in India Current Status and Future Directions. Integr. Med. Int. +2017, 4, 125–141. [CrossRef] +19. +Arati, M.; Arpita, P.; Arati, M. Effect of yoga (asana and pranayama) on serum lipid profile in normal healthy volunteers. Int. J. +Contemp. Med. Res. 2015, 2, 1277–1281. +20. +Behar, S.; Graff, E.; Reicher-Reiss, H.; Boyko, V.; Benderly, M.; Shotan, A.; Brunner, D. Low total cholesterol is associated with +high total mortality in patients with coronary heart disease. Eur. Heart J. 1997, 18, 52–59. [CrossRef] +21. +Elmehdawi, R.R. Hypolipidemia: A word of caution. Libyan J. Med. 2008, 3, 84–90. [CrossRef] [PubMed] +22. +Shantakumari, N.; Sequeira, S.; El Deeb, R. Effects of a yoga intervention on lipid profiles of diabetes patients with dyslipidemia. +Indian Heart J. 2013, 65, 127–131. [CrossRef] [PubMed] +23. +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, 633–640. +24. +Innes, K.E.; Selfe, T.K. Yoga for Adults with Type 2 Diabetes: A Systematic Review of Controlled Trials. J. Diabetes Res. 2016, 2016, +1–23. [CrossRef] +25. +Raveendran, A.V.; Deshpandae, A.; Joshi, S.R. Therapeutic Role of Yoga in Type 2 Diabetes. Endocrinol. Metab. 2018, 33, 307–317. +[CrossRef] [PubMed] +26. +Gotto Jr, A.M. Cholesterol management in theory and practice. Circulation 1997, 96, 4424–4430. [CrossRef] +27. +Mahesh, N.K.; Kumar, A.; Bhat, K.G.; Verma, N. Role of yoga therapy on lipid profile in patients of hypertension and prehyper- +tension. Int. J. Adv. Med. 2018, 5, 321. [CrossRef] +Medicines 2021, 8, 37 +15 of 16 +28. +Mohammed, R.; Banu, A.; Irman, S.; Jaiswal, R.K. Importance of yoga in diabetes and dyslipidemia. Int. J. Res. Med. Sci. 2016, 4, +3504–3508. [CrossRef] +29. +Nagendra, H.R.; Nagarathna, R.; Rajesh, S.K.; Amit, S.; Telles, S.; Hankey, A. Niyantrita Madhumeha Bharata 2017, methodology +for a nationwide diabetes prevalence estimate: Part 1. Int. J. Yoga 2019, 12, 179–192. [CrossRef] +30. +Weber, M.B.; Ranjani, H.; Staimez, L.R.; Anjana, R.M.; Ali, M.; Narayan, K.V.; Mohan, V. The Stepwise Approach to Diabetes +Prevention: Results From the D-CLIP Randomized Controlled Trial. Diabetes Care 2016, 39, 1760–1767. [CrossRef] +31. +Nagarathna, R.; Rajesh, S.K.; Amit, S.; Patil, S.; Anand, A.; Nagendra, H.R. Methodology of Niyantrita Madhumeha Bharata +Abhiyaan- 2017, a nationwide multicentric trial on the effect of a validated culturally acceptable lifestyle intervention for primary +prevention of diabetes: Part 2. Int. J. Yoga 2019, 12, 193–205. [CrossRef] +32. +Sattar, N.; Rawshani, A.; Franzén, S.; Rawshani, A.; Svensson, A.M.; Rosengren, A.; McGuire, D.K.; Eliasson, B.; Gudbjörnsdottir, S. +Age at diagnosis of type 2 diabetes mellitus and associations with cardiovascular and mortality risks: Findings from the Swedish +National Diabetes Registry. Circulation 2019, 139, 2228–2237. [CrossRef] +33. +Kaur, N.; Malik, N.; Mathur, D.; Pal, S.; Malik, R.; Rana, S. Mindfulness and yoga halt the conversion of pre-diabetic rural women +into diabetics-a pilot study. Integr. Med. Case Rep. 2020, 1, 8–18. [CrossRef] +34. +Singh, S.; Kyizom, T.; Singh, K.P.; Tandon, O.P.; Madhu, S.V. Influence of pranayamas and yoga-asanas on serum insulin, blood +glucose and lipid profile in type 2 diabetes. Indian J. Clin. Biochem. 2008, 23, 365–368. [CrossRef] [PubMed] +35. +Bijlani, R.L.; Vempati, R.P.; Yadav, R.K.; Ray, R.B.; Gupta, V.; Sharma, R.; Mehta, N.; Mahapatra, S.C. A Brief but Comprehensive +Lifestyle Education Program Based on Yoga Reduces Risk Factors for Cardiovascular Disease and Diabetes Mellitus. J. Altern. +Complement. Med. 2005, 11, 267–274. [CrossRef] +36. +Satyapriya, M.; Nagarathna, R.; Padmalatha, V.; Nagendra, H. Effect of integrated yoga on anxiety, depression & well being in +normal pregnancy. Complement. Ther. Clin. Pr. 2013, 19, 230–236. [CrossRef] +37. +Satyapriya, M.; Nagendra, H.R.; Nagarathna, R.; Padmalatha, V. Effect of integrated yoga on stress and heart rate variability in +pregnant women. Int. J. Gynecol. Obstet. 2008, 104, 218–222. [CrossRef] [PubMed] +38. +Madanmohan, A.B.B.; Sanjay, Z.; Dayanidy, G.; Basavaraddi, I.V. Effect of yoga therapy on reaction time, biochemical parameters +and wellness score of peri and post-menopausal diabetic patients. Int. J. Yoga 2012, 5, 5–10. [CrossRef] +39. +Udupa, K.; Sathyaprabha, T.N.; Telles, S.; Singh, N. Influence of Yoga on the Autonomic Nervous System. In Research-Based +Perspectives on the Psychophysiology of Yoga; IGI Global: Hershey, PA, USA, 2018; pp. 67–85. +40. +Sathyaprabha, T.; Kisan, R.; Adoor, M.; Nalini, A.; Kutty, B.M.; Murthy, B.C.; Sujan, M.; Rao, R.; Raju, T. Effect of Yoga on migraine: +A comprehensive study using clinical profile and cardiac autonomic functions. Int. J. Yoga 2014, 7, 126–132. [CrossRef] +41. +Rao, R.M.; Vadiraja, H.; Nagaratna, R.; Gopinath, K.S.; Patil, S.; Diwakar, R.B.; Shahsidhara, H.; Ajaikumar, B.; Nagendra, H. +Effect of yoga on sleep quality and neuroendocrine immune response in metastatic breast cancer patients. Indian J. Palliat. Care +2017, 23, 253–260. [CrossRef] +42. +Goldstein, J.L.; Brown, M.S. History of Discovery: The LDL receptor. Arterioscler. Thromb. Vasc. Biol. 2009, 29, 431–438. [CrossRef] +43. +Rosenson, R.S.; Brewer, H.B.; Davidson, W.S.; Fayad, Z.A.; Fuster, V.; Goldstein, J.; Hellerstein, M.; Jiang, X.C.; Phillips, M.C.; +Rader, D.J.; et al. Cholesterol efflux and atheroprotection: Advancing the concept of reverse cholesterol transport. Circulation +2012, 125, 1905–1919. [CrossRef] +44. +Pal, R.; Gupta, N. Yogic practices on oxidative stress and of antioxidant level: A systematic review of randomized controlled +trials. J. Complement. Integr. Med. 2017, 16. [CrossRef] [PubMed] +45. +Manna, I. Effects of yoga training on body composition and oxidant-antioxidant status among healthy male. Int. J. Yoga 2018, 11, +105–110. [CrossRef] [PubMed] +46. +Shete, S.U.; Verma, A.; Kulkarni, D.D.; Bhogal, R.S. Effect of yoga training on inflammatory cytokines and C-reactive protein in +employees of small-scale industries. J. Educ. Health Promot. 2017, 6, 76. [CrossRef] [PubMed] +47. +Javalkar, S.R. The economic burden of health expenditure on diabetes mellitus among urban poor: A cross sectional study. Int. J. +Community Med. Public Health 2019, 6, 1162–1166. [CrossRef] +48. +Podder, V.; Srivastava, V.; Kumar, S.; Nagarathna, R.; Sivapuram, M.S.; Kaur, N.; Sharma, K.; Singh, A.K.; Malik, N.; +Anand, A.; et al. Prevalence and Awareness of Stroke and Other Comorbidities Associated with Diabetes in Northwest India. J. +Neurosci. Rural. Pr. 2020, 11, 467–473. [CrossRef] +49. +Kumar, S.; Anand, A.; Nagarathna, R.; Kaur, N.; Sivapuram, M.S.; Pannu, V.; Pal, D.K.; Malik, N.; Singh, A.K.; Nagendra, H.R. +Prevalence of prediabetes, and diabetes in Chandigarh and Panchkula region based on glycated haemoglobin and Indian diabetes +risk score. Endocrinol. Diabetes Metab. 2021, 4, 162. [CrossRef] +50. +Goyal, A.K.; Bhadada, S.; Malik, N.; Anand, A.; Kumar, R.; Bammidi, S.; Tyagi, R.; Modgil, S.; Sharma, K.; Bali, P.; et al. Guinness +world record attempt as a method to pivot the role of Yoga in Diabetes management. Ann. Neurosci. 2019, 26, 21–24. [CrossRef] +51. +Anand, A.; Banik, A.; Thakur, K.; Masters, C.L. The Animal Models of Dementia and Alzheimer’s Disease for Pre-Clinical Testing +and Clinical Translation. Curr. Alzheimer Res. 2012, 9, 1010–1029. [CrossRef] +52. +Sharma, N.K.; Gupta, A.; Prabhakar, S.; Singh, R.; Sharma, S.K.; Chen, W.; Anand, A. Association between CFH Y402H +Polymorphism and Age Related Macular Degeneration in North Indian Cohort. PLoS ONE 2013, 8, e70193. [CrossRef] [PubMed] +Medicines 2021, 8, 37 +16 of 16 +53. +Nagarathna, R.; Tyagi, R.; Kaur, G.; Vendan, V.; Acharya, I.N.; Anand, A.; Singh, A.; Nagendra, H.R. Efficacy of a Validated Yoga +Protocol on Dyslipidemia in Diabetes Patients: NMB-2017 India Trial. Medicines 2019, 6, 100. [CrossRef] [PubMed] +54. +Ved, R.R.; Gupta, G.; Singh, S. India’s health and wellness centres: Realizing universal health coverage through comprehensive +primary health care. WHO South-East Asia J. Public Health 2019, 8, 18–20. [CrossRef] [PubMed] diff --git a/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 b/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 new file mode 100644 index 0000000000000000000000000000000000000000..ddc0066e7606d6470e8680ed7710dceff1c1f10e --- /dev/null +++ b/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 @@ -0,0 +1,1360 @@ +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 +rnagaratna@gmail.com +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 +REFERENCES +1. International Diabetes Federation. Idf Diabetes Atlas. Brussels, Belgium: +International Diabetes Federation (2019). Available at: https://diabetesatlas. +org/upload/resources/material/20200302_133351_IDFATLAS9e-final-web. +pdf (Accessed May 2020). +2. Saeedi P, Petersohn I, Salpea P, Malanda B, Karuranga S, Unwin N, et al. +Global and Regional Diabetes Prevalence Estimates for 2019 and Projections +for 2030 and 2045: Results From the International Diabetes Federation +Diabetes Atlas, 9th Edition. Diabetes Res Clin Pract (2019) 157:107843. doi: +10.1016/j.diabres.2019.107843 +3. Tabák AG, Herder C, Rathmann W, Brunner EJ, Kivimäki M. Prediabetes: A +High-Risk State For Diabetes Development. Lancet (2012) 379:2279–90. doi: +10.1016/S0140-6736(12)60283-9 +4. Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker +EA, et al. Diabetes Prevention Program Research Group. Reduction in the +Incidence of Type 2 Diabetes With Lifestyle Intervention or Metformin. +N Engl J Med (2002) 346:393–403. doi: 10.1056/NEJMoa012512 +5. Pan XR, Li GW, Hu YH, Wang JX, Yang WY, An ZX, et al. Effects of Diet and +Exercise in Preventing NIDDM in People With Impaired Glucose Tolerance. +The Da Qing IGT and Diabetes Study. Diabetes Care (1997) 20:537–44. doi: +10.2337/diacare.20.4.537 +6. Lindström J, Louheranta A, Mannelin M, Rastas M, Salminen V, Eriksson J, +et al. Finnish Diabetes Prevention Study Group. The Finnish Diabetes +Prevention Study (DPS): Lifestyle Intervention and 3-Year Results on Diet +and Physical Activity. Diabetes Care (2003) 26:3230–6. doi: 10.2337/ +diacare.26.12.3230 +7. Kosaka K, Noda M, Kuzuya T. Prevention of Type 2 Diabetes by Lifestyle +Intervention: A Japanese Trial in IGT Males. Diabetes Res Clin Pract (2005) +67:152–62. doi: 10.1016/j.diabres.2004.06.010 +8. Ramachandran A, Snehalatha C, Mary S, Mukesh B, Bhaskar AD, Vijay V. Indian +Diabetes Prevention Programme (Idpp) The Indian Diabetes Prevention +Programme Shows That Lifestyle Modification and Metformin Prevent Type 2 +Diabetes in Asian Indian Subjects With Impaired Glucose Tolerance (IDPP-1). +Diabetologia (2006) 49:289–97. doi: 10.1007/s00125-005-0097-z +9. Weber MB, Ranjani H, Meyers GC, Mohan V, Narayan KM. A Model of +Translational Research for Diabetes Prevention in Low and Middle-Income +Countries: The Diabetes Community Lifestyle Improvement Program (D- +CLIP) Trial. Prim Care Diabetes (2012) 6:3–9. doi: 10.1016/j.pcd.2011.04.005 +10. Weber MB, Ranjani H, Staimez LR, Anjana RM, Ali MK, Narayan KM, et al. The +Stepwise Approach to Diabetes Prevention: Results From the D-CLIP Randomized +Controlled Trial. Diabetes Care (2016) 39:1760–7. doi: 10.2337/dc16-1241 +11. Glechner A, Keuchel L, Affengruber L, Titscher V, Sommer I, Matyas N, et al. +Effects of Lifestyle Changes on Adults With Prediabetes: A Systematic Review +and Meta-Analysis. Prim Care Diabetes (2018) 12:393–408. doi: 10.1016/ +j.pcd.2018.07.003 +12. Kahn R, Davidson MB. The Reality of Type 2 Diabetes Prevention. Diabetes +Care (2014) 37:943–9. doi: 10.2337/dc13-1954 +13. Baker MK, Simpson K, Lloyd B, Bauman AE, Singh MA. Behavioral Strategies +in Diabetes Prevention Programs: A Systematic Review of Randomized +Controlled Trials. Diabetes Res Clin Pract (2011) 91:1–12. doi: 10.1016/ +j.diabres.2010.06.030 +14. Büssing A, Michalsen A, Khalsa SB, Telles S, Sherman KJ. Effects of Yoga on +Mental and Physical Health: A Short Summary of Reviews. Evid Based +Complement Alternat Med (2012) 2012:165410. doi: 10.1155/2012/165410 +15. Gard T, Noggle JJ, Park CL, Vago DR, Wilson A. Potential Self-Regulatory +Mechanisms of Yoga for Psychological Health. Front Hum Neurosci (2014) +8:770. doi: 10.3389/fnhum.2014.00770 +16. Sullivan MB, Erb M, Schmalzl L, Moonaz S, Noggle Taylor J, Porges SW. Yoga +Therapy and Polyvagal Theory: The Convergence of Traditional Wisdom and +Contemporary Neuroscience for Self-Regulation and Resilience. Front Hum +Neurosci (2018) 12:67. doi: 10.3389/fnhum.2018.00067 +17. Ramamoorthi R, Gahreman D, Skinner T, Moss S. The Effect of Yoga Practice +on Glycemic Control and Other Health Parameters in the Prediabetic State: A +Systematic Review and Meta-Analysis. PloS One (2019) 14:e0221067. doi: +10.1371/journal.pone.0221067 +18. Innes KE, Selfe TK. Yoga for Adults With Type 2 Diabetes: A Systematic +Review of Controlled Trials. J Diabetes Res (2016) 2016:6979370. doi: 10.1155/ +2016/6979370 +19. Cramer H, Innes KE, Michalsen A, Vempati R, Langhorst J, Dobos GJ. Yoga +for Adults With Type 2 Diabetes Mellitus (Protocol). Cochrane Database Syst +Rev (2015) 4:CD011658. doi: 10.1002/14651858.CD011658 +20. Kumar V, Jagannathan A, Philip M, Thulasi A, Angadi P, Raghuram N. Role of +Yoga for Patients With Type II Diabetes Mellitus: A Systematic Review and Meta- +Analysis. Complement Ther Med (2016) 25:104–12. doi: 10.1016/j.ctim.2016.02.001 +21. Jyotsna VP. Prediabetes and Type 2 Diabetes Mellitus: Evidence for Effect of +Yoga. Indian J Endocrinol Metab (2014) 18:745–9. doi: 10.4103/2230- +8210.141318 +22. McDermott KA, Rao MR, Nagarathna R, Murphy EJ, Burke A, Nagendra RH, +et al. A Yoga Intervention for Type 2 Diabetes Risk Reduction: A Pilot +Randomized Controlled Trial. BMC Complement Altern Med (2014) 14:212. +doi: 10.1186/1472-6882-14-212 +23. Anjana RM, Shanthi Rani CS, Deepa M, Pradeepa R, Sudha V, Divya Nair H, +et al. Incidence of Diabetes and Prediabetes and Predictors of Progression +Raghuram et al. +Yoga and Prediabetes +Frontiers in Endocrinology | www.frontiersin.org +June 2021 | Volume 12 | Article 664657 +10 +Among Asian Indians: 10-Year Follow-up of the Chennai Urban Rural +Epidemiology Study (Cures). Diabetes Care (2015) 38:1441–8. doi: 10.2337/ +dc14-2814 +24. Nagendra HR, Nagarathna R, Rajesh SK, Amit S, Telles S, Hankey A. +Niyantrita Madhumeha Bharata 2017, Methodology for a Nationwide +Diabetes Prevalence Estimate: Part 1. Int J Yoga (2019) 12:179–92. doi: +10.4103/ijoy.IJOY_40_18 +25. Nagarathna R, Rajesh SK, Amit S, Patil S, Anand A, Nagendra HR. +Methodology of Niyantrita Madhumeha Bharata Abhiyaan-2017, a +Nationwide Multicentric Trial on the Effect of a Validated Culturally +Acceptable Lifestyle Intervention for Primary Prevention of Diabetes: Part +2. Int J Yoga (2019) 12:193–205. doi: 10.4103/ijoy.IJOY_38_19 +26. Mohan V, Anbalagan VP. Expanding Role of the Madras Diabetes Research +Foundation - Indian Diabetes Risk Score in Clinical Practice. Indian J +Endocrinol Metab (2013) 17:31–6. doi: 10.4103/2230-8210.107825 +27. Mohan V, Deepa M, Anjana RM, Lanthorn H, Deepa R. Incidence of Diabetes +and Pre-Diabetes in a Selected Urban South Indian Population (CUPS-19). +J Assoc Physicians India (2008) 56:152–7. +28. American Diabetes Association. Standards of Medical Care in Diabetes. +Diabetes Care (2013) 36(Suppl. 1):S11–66. doi: 10.2337/dc13-S011 +29. Yokota N, Miyakoshi T, Sato Y, Nakasone Y, Yamashita K, Imai T, et al. +Predictive Models for Conversion of Prediabetes to Diabetes. J Diabetes +Complications (2017) 31:1266–71. doi: 10.1016/j.jdiacomp.2017.01.005 +30. Kohn MA, Senyak J. Sample Size Calculators. Available at: https://www. +sample-size.net/ (Accessed 31 March 2021). UCSF CTSI. 26 March 2021. +31. Global Recommendations on Physical Activity for Health. Geneva: World +Health Organization (2010). +32. American Diabetes Association. 4. Lifestyle Management. Diabetes Care +(2017) 40(Suppl 1):S33–43. doi: 10.2337/dc17-S007 +33. Fleiss JL. The Measurement of Interrater Agreement. In: Statistical Methods for +Rates and Proportions. New York: John Wiley & Sons, Inc. (1981). p. 212–36. +34. Janjua NZ, Khan MI, Clemens JD. Estimates of Intraclass Correlation +Coefficient and Design Effect for Surveys and Cluster Randomized Trials on +Injection Use in Pakistan and Developing Countries. Trop Med Int Health +(2006) 11:1832–40. doi: 10.1111/j.1365-3156.2006.01736.x +35. Gupta S. Intention-to-Treat Concept: A Review. Perspect Clin Res (2011) +2:109. doi: 10.4103/2229-3485.83221 +36. Donner A, Klar N. Design and Analysis of Cluster Randomization Trials in +Health Research. London, England: Arnold (2000). +37. Altman DG, Bland JM. Interaction Revisited: The Difference Between Two +Estimates. BMJ (2003) 326:219. doi: 10.1136/bmj.326.7382.219 +38. Snehalatha C, Viswanathan V, Ramachandran A. Cut Off Values for Normal +Anthopometric Variables in Asian Indian Adults. Diabetes Care (2003) +26:1380–4. doi: 10.2337/diacare.26.5.1380 +39. Weyrich P, Stefan N, Häring HU, Laakso M, Fritsche A. Effect of Genotype on +Success of Lifestyle Intervention in Subjects at Risk for Type 2 Diabetes. J Mol +Med (2007) 85:107–17. doi: 10.1007/s00109-006-0134-5 +40. Lindström J, Peltonen M, Eriksson JG, Aunola S, Hämäläinen H, Ilanne- +Parikka P. Determinants for the Effectiveness of Lifestyle Intervention in the +Finnish Diabetes Prevention Study. Diabetes Care (2008) 31:857–62. doi: +10.2337/dc07-2162 +41. Schulze MB. Determinants for the Effectiveness of Lifestyle Intervention in the +Finnish Diabetes Prevention Study: Response to Lindstrom et al. Diabetes +Care (2008) 31:e87. doi: 10.2337/dc08-1138 +42. Chaya MS, Ramakrishnan G, Shastry S, Kishore RP, Nagendra H, Nagarathna +R, et al. Insulin Sensitivity and Cardiac Autonomic Function in Young Male +Practitioners of Yoga. Natl Med J India (2008) 21:217–21. +43. Vijayakumar G, Manghat S, Vijayakumar R, Simon L, Scaria LM, +Vijayakumar A, et al. Incidence of Type 2 Diabetes Mellitus and +Prediabetes in Kerala, India: Results From a 10-Year Prospective Cohort. +BMC Public Health (2019) Jan 3119:140. doi: 10.1186/s12889-019-6445-6 +44. Thankappan KR, Sathish T, Tapp RJ, Shaw JE, Lotfaliany M, Wolfe R, et al. A +Peer-Support Lifestyle Intervention for Preventing Type 2 Diabetes in India: A +Cluster-Randomized Controlled Trial of the Kerala Diabetes Prevention +Program. PloS Med (2018) 15:e1002575. doi: 10.1371/journal.pmed.1002575 +45. Petter J, Reitsma-van Rooijen MM, Korevaar JC, Nielen MM. Willingness to +Participate in Prevention Programs for Cardiometabolic Diseases. BMC Public +Health (2015) 15:44. doi: 10.1186/s12889-015-1379-0 +46. Shi BY. The Importance and Strategy of Diabetes Prevention. Chronic Dis +Transl Med (2016) 202:204–7. doi: 10.1016/j.cdtm.2016.11.013 +47. Unnikrishnan R, Anjana RM, Mohan V. Diabetes in South Asians: Is the +Phenotype Different? Diabetes (2014) 63:53–5. doi: 10.2337/db13-1592 +48. Perreault L, Pan Q, Schroeder EB, Kalyani RR, Bray GA, Dagogo-Jack S, et al. +Diabetes Prevention Program Research Group. Regression From Prediabetes +to Normal Glucose Regulation and Prevalence of Microvascular Disease in the +Diabetes Prevention Program Outcomes Study (Dppos). Diabetes Care (2019) +42:1809–15. doi: 10.2337/dc19-0244 +49. Diabetes Prevention Program Research Group, Knowler WC, Fowler SE, +Hamman RF, Christophi CA, Hoffman HJ, et al. 10-Year Follow-Up of +Diabetes Incidence and Weight Loss in the Diabetes Prevention Program +Outcomes Study. Lancet (2009) 374:1677–86. doi: 10.1016/S0140-6736(09) +61457-4 +50. Forouhi NG, Luan J, Hennings S, Wareham NJ. Incidence of Type 2 Diabetes +in England and its Association With Baseline Impaired Fasting Glucose: The +Ely Study 1990–2000. Diabetes Med (2007) 24:200–07. doi: 10.1111/j.1464- +5491.2007.02068.x +51. The Lancet. Type 2 Diabetes: The Urgent Need to Protect Young People. +Lancet (2018) 392:2325. doi: 10.1016/S0140-6736(18)33015-0 +52. Kilpatrick ES. Haemoglobin A1c in the Diagnosis and Monitoring of Diabetes +Mellitus. J Clin Pathol (2008) 61:977–82. doi: 10.1136/jcp.2007.054304 +53. Hirst JA, Stevens RJ, Farmer AJ. Changes in HbA1c Level Over a 12-Week +Follow-Up in Patients With Type 2 Diabetes Following a Medication Change. +PloS One (2014) 9:e92458. doi: 10.1371/journal.pone.0092458 +54. Yang R, Carter BL, Gums TH, Gryzlak BM, Xu Y, Levy BT. Selection Bias and +Subject Refusal in a Cluster-Randomized Controlled Trial. BMC Med Res +Methodol (2017) 17:94. doi: 10.1186/s12874-017-0368-7 +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 diff --git a/subfolder_0/Effects of Yoga and an Ayurveda preparation on gait, balance and mobility in older persons.txt b/subfolder_0/Effects of Yoga and an Ayurveda preparation on gait, balance and mobility in older persons.txt new file mode 100644 index 0000000000000000000000000000000000000000..e046904f5f66105097fa9e9b3d6cb9dc6de28ce3 --- /dev/null +++ b/subfolder_0/Effects of Yoga and an Ayurveda preparation on gait, balance and mobility in older persons.txt @@ -0,0 +1,243 @@ +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 +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 +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: pyp.research@gmail.com +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. 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This copy is for personal use only - distribu diff --git a/subfolder_0/Effects of Yoga on Utero-Fetal-Placental Circulation in High-Risk Pregnancy A Randomized Controlled Trial.txt b/subfolder_0/Effects of Yoga on Utero-Fetal-Placental Circulation in High-Risk Pregnancy A Randomized Controlled Trial.txt new file mode 100644 index 0000000000000000000000000000000000000000..224b866a298feefbb9645c56672a9906a8d1f904 --- /dev/null +++ b/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; abbas616@gmail.com +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). +References +[1] Y. Khong and I. Brosens, “Defective deep placentation,” Best +Practice and Research: Clinical Obstetrics and Gynaecology, vol. +25, no. 3, pp. 301–311, 2011. +[2] J. Espinoza, R. Romero, M. K. Yeon et al., “Normal and abnor- +mal transformation of the spiral arteries during pregnancy,” +Journal of Perinatal Medicine, vol. 34, no. 6, pp. 447–458, 2006. +[3] V. Chaddha, S. Viero, B. Huppertz, and J. Kingdom, “Devel- +opmental biology of the placenta and the origins of placental +insufficiency,” Seminars in Fetal and Neonatal Medicine, vol. 9, +no. 5, pp. 357–369, 2004. +[4] E. C. M. Nelissen, A. P. A. van Montfoort, J. C. M. Dumoulin, +and J. L. H. Evers, “Epigenetics and the placenta,” Human Repro- +duction Update, vol. 17, no. 3, pp. 397–417, 2011. +[5] M. G. Ross and M. H. Beall, “Adult sequelae of intrauterine +growth restriction,” Seminars in Perinatology, vol. 32, no. 3, pp. +213–218, 2008. +[6] G. S. J. Whitley, P. R. Dash, L.-J. Ayling, F. Prefumo, B. Thil- +aganathan, and J. E. Cartwright, “Increased apoptosis in first +trimester extravillous trophoblasts from pregnancies at higher +risk of developing preeclampsia,” The American Journal of +Pathology, vol. 170, no. 6, pp. 1903–1909, 2007. +[7] S. Narendran, R. Nagarathna, and H. R. Nagendra, Yoga for +Pregnancy, Vivekananda Yoga Research Foundation, Bangalore, +India, 2008. +[8] P. Oswal, R. Nagarathna, J. Ebnezar, and H. R. Nagendra, “The +effect of add-on yogic prana energization technique (YPET) on +healing of fresh fractures: a randomized control study,” Journal +of Alternative and Complementary Medicine, vol. 17, no. 3, pp. +253–258, 2011. +[9] P. Sengupta, “Health impacts of yoga and pranayama: a state- +of-the-art review,” International Journal of Preventive Medicine, +vol. 3, no. 7, pp. 444–458, 2012. +[10] R. Jayashree, A. Malini, R. Nagarathna et al., “Effect of the +integrated approach of yoga therapy on platelet count and uric +acid in pregnancy: a multicenter stratified randomized single- +blind study,” International Journal of Yoga, vol. 6, no. 1, p. 39, +2013. +[11] S. Babbar, A. C. Parks-Savage, and S. P. Chauhan, “Yoga during +pregnancy: a review,” American Journal of Perinatology, vol. 29, +no. 6, pp. 459–464, 2012. +[12] A. Rakhshani, R. Nagarathna, R. Mhaskar, A. Mhaskar, A. +Thomas, and S. Gunasheela, “The effects of yoga in prevention +of pregnancy complications in high-risk pregnancies: a ran- +domized controlled trial,” Preventive Medicine, vol. 55, no. 4, pp. +333–340, 2012. +[13] K. Kanako, “Studies on prophylaxis of preeclampsia by water +exercise during pregnancy,” The Journal of the Aichi Medical +University Association, vol. 27, pp. 103–114, 1999. +[14] S. Narendran, R. Nagarathana, and H. R. Nagendra, Yoga for +Pregnancy, Vivekananda Yoga Research Foundation, Bangalore, +India, 2010. +[15] C. Deane, “Doppler utrasound: principles and practice,” in +Doppler in Obstetrics, K. Nikolaides, G. Rizzo, K. Hecher, and +R. Ximenes, Eds., pp. 4–24, Fetal Medicine Foundation, Dayton, +Ohio, USA, 2002. +[16] P. Factor-Litvak, L. F. Cushman, F. Kronenberg, C. Wade, and +D. Kalmuss, “Use of complementary and alternative medicine +among women in New York City: a pilot study,” The Journal of +Alternative and Complementary Medicine, vol. 7, no. 6, pp. 659– +666, 2001. +[17] T. Field, “Prenatal exercise research,” Infant Behavior and +Development, vol. 35, no. 3, pp. 397–407, 2012. +[18] T. Field, “Yoga clinical research review,” Complementary Thera- +pies in Clinical Practice, vol. 17, no. 1, pp. 1–8, 2011. +[19] A. Khalil, K. Harrington, S. Muttukrishna, and E. Jauniaux, +“Effect of antihypertensive therapy with 𝛼-methyldopa on uter- +ine artery Doppler in pregnancies with hypertensive disorders,” +Ultrasound in Obstetrics and Gynecology, vol. 35, no. 6, pp. 688– +694, 2010. +[20] L. M. Szymanski and A. J. Satin, “Exercise during pregnancy: +fetal responses to current public health guidelines,” Obstetrics +and Gynecology, vol. 119, no. 3, pp. 603–610, 2012. +[21] N. M. Rafla and G. A. Etokowo, “The effect of maternal exercise +on uterine artery velocimetry waveforms,” Journal of Obstetrics +and Gynaecology, vol. 18, no. 1, pp. 14–17, 1998. +[22] S. Roberge, K. H. Nicolaides, S. Demers, P. Villa, and E. +Bujold, “Prevention of perinatal death and adverse perinatal +outcome using low-dose aspirin: a meta-analysis,” Ultrasound +in Obstetrics and Gynecology, vol. 41, no. 5, pp. 491–499, 2013. +[23] C. A. Meads, J. S. Cnossen, S. Meher et al., “Methods of pre- +diction and prevention of pre-eclampsia: systematic reviews of +accuracy and effectiveness literature with economic modelling,” +Health Technology Assessment, vol. 12, no. 6, pp. 1–270, 2008. +[24] K. Rytlewski, R. Olszanecki, R. Lauterbach et al., “Effects of +oral L-arginine on the pulsatility indices of umbilical artery and +middle cerebral artery in preterm labor,” European Journal of +Obstetrics & Gynecology and Reproductive Biology, vol. 138, no. +1, pp. 23–28, 2008. +[25] M. E. Estensen, J. O. Beitnes, G. Grindheim et al., “Altered +maternal left ventricular contractility and function during +normal pregnancy,” Ultrasound in Obstetrics and Gynecology, +vol. 41, no. 6, pp. 659–666, 2013. +[26] K. Curtis, A. Weinrib, and J. Katz, “Systematic review of yoga +for pregnant women: current status and future directions,” +Evidence-based Complementary and Alternative Medicine, vol. +2012, Article ID 715942, 13 pages, 2012. +[27] K. Dhameja, S. Singh, M. D. Mustafa et al., “Therapeutic effect +of yoga in patients with hypertension with reference to GST +10 +Advances in Preventive Medicine +gene polymorphism,” Journal of Alternative and Complementary +Medicine, vol. 19, no. 3, pp. 243–249, 2013. +[28] A. R. Brammarajan, Indian Literature: Verses from Patham Thir- +umurai, 2000. +[29] N. Nagilla, A. Hankey, and H. Nagendra, “Effects of yoga +practice on acumeridian energies: variance reduction implies +benefits for regulation,” International Journal of Yoga, vol. 6, no. +1, pp. 61–65, 2013. +[30] Y. L. Shui, The Biophysics Basis for Acupuncture and Health, +Dragon Eye Press, Pasadena, Calif, USA, 2004. +Submit your manuscripts at +http://www.hindawi.com +Stem Cells +International +Hindawi Publishing Corporation +http://www.hindawi.com +Volume 2014 +Hindawi Publishing Corporation +http://www.hindawi.com +Volume 2014 +MEDIATORS +INFLAMMATION +of +Hindawi Publishing Corporation +http://www.hindawi.com +Volume 2014 +Behavioural +Neurology +Endocrinology +International Journal of +Hindawi Publishing Corporation +http://www.hindawi.com +Volume 2014 +Hindawi Publishing Corporation +http://www.hindawi.com +Volume 2014 +Disease Markers +Hindawi Publishing Corporation +http://www.hindawi.com +Volume 2014 +BioMed +Research International +Oncology +Journal of +Hindawi Publishing Corporation +http://www.hindawi.com +Volume 2014 +Hindawi Publishing Corporation +http://www.hindawi.com +Volume 2014 +Oxidative Medicine and +Cellular Longevity +Hindawi Publishing Corporation +http://www.hindawi.com +Volume 2014 +PPAR Research +The Scientific +World Journal +Hindawi Publishing Corporation +http://www.hindawi.com +Volume 2014 +Immunology Research +Hindawi Publishing Corporation +http://www.hindawi.com +Volume 2014 +Journal of +Obesity +Journal of +Hindawi Publishing Corporation +http://www.hindawi.com +Volume 2014 +Hindawi Publishing Corporation +http://www.hindawi.com +Volume 2014 + +Computational and +Mathematical Methods +in Medicine +Ophthalmology +Journal of +Hindawi Publishing Corporation +http://www.hindawi.com +Volume 2014 +Diabetes Research +Journal of +Hindawi Publishing Corporation +http://www.hindawi.com +Volume 2014 +Hindawi Publishing Corporation +http://www.hindawi.com +Volume 2014 +Research and Treatment +AIDS +Hindawi Publishing Corporation +http://www.hindawi.com +Volume 2014 +Gastroenterology +Research and Practice +Hindawi Publishing Corporation +http://www.hindawi.com +Volume 2014 +Parkinson’s +Disease +Evidence-Based +Complementary and +Alternative Medicine +Volume 2014 +Hindawi Publishing Corporation +http://www.hindawi.com diff --git a/subfolder_0/Effects of a Yoga Program on Cortisol level and mood.txt b/subfolder_0/Effects of a Yoga Program on Cortisol level and mood.txt new file mode 100644 index 0000000000000000000000000000000000000000..42aa533a909349ffccff39f445648248a01de69f --- /dev/null +++ b/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 + +http://ict.sagepub.com/cgi/alerts + +Email Alerts: + +http://ict.sagepub.com/subscriptions + +Subscriptions: + +http://www.sagepub.com/journalsReprints.nav +Reprints: + +http://www.sagepub.com/journalsPermissions.nav +Permissions: + +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: raghav.hcgrf@gmail.com. +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. +References + 1. Derogatis LR, Morrow GR, Fetting J. The prevalence of psy- +chiatric disorders among cancer patients. JAMA. 1983;239: +751-757. + 2. Farber JM, Weinerman BH, Kuypers JA. Psychosocial distress +in oncology outpatients. J Psychosoc Oncol. 1983;2:109-118. + 3. Stefanek ME, Derogatis LP, Shaw A. Psychological distress +among oncology outpatients: prevalence and severity as mea- +sured with the Brief Symptom Inventory. Psychosomatics. 1987; +28:537-539. + 4. de Boer-Dennert M, de Wit R, Schmitz PI, et al. Patient per- +ceptions of the side effects of chemotherapy: the influence of +5HT3 antagonists. Br J Cancer. 1997;76:1055-1061. + 5. Gelber RD, Goldhirsch A, Cavalli F. Quality-of-life-adjusted +evaluation of adjuvant therapies for operable breast cancer. The +International Breast Cancer Study Group. Ann Intern Med. +1991;114:695-697. + at UQ Library on September 22, 2009 +http://ict.sagepub.com +Downloaded from +Yoga for Breast Cancer / Vadiraja et al.    45 + 6. Hughson AV, Cooper AF, McArdle CS, et al. Psychosocial +effects of radiotherapy after mastectomy. Br Med J. 1987;294: +1515-1518. + 7. Aaronson NK, Meyerowitz BE, Bard M, et al. Quality of life +research in oncology: past achievements and future priorities. +Cancer. 1991;67:839-843. + 8. Redd WH, Silberfarb PM, Andersen BL, et al. Physiologic +and psychobehavioral research in oncology. Cancer. 1991;67: +813-822. + 9. Spencer SM, Lehman JM, Wynings C, et al. Concerns about +breast cancer and relations to psychosocial well-being in a mul- +tiethnic sample of early-stage patients. Health Psychol. +1999;18:159-168. +10. Smith MY, Redd WH, Peyser C, et al. Post-traumatic stress +disorder in cancer: a review. Psychooncology. 1999;8:521-537. +11. Chaturvedi SK, Prabha Chandra S, Channabasavanna SM, et al. +Levels of anxiety and depression in depression in patients receiving +radiotherapy in India. Psychooncology. 1996;5:343-346. +12. Wengstrom Y, Haggmark C, Strander H, et al. Perceived symp- +toms and quality of life in women with breast cancer receiving +radiation therapy. Eur J Oncol Nurs. 2000;4:78-88. +13. Vedhara K, Tuinstra J, Miles JN, et al. Psychosocial factors +associated with indices of cortisol production in women with +breast cancer and controls. Psychoneuroendocrinology. 2006; +31:299-311. +14. Thornton LM, Andersen BL, Carson WE III. Immune, endo- +crine, and behavioral precursors to breast cancer recurrence: a +case-control analysis. Cancer Immunol Immunother. 2008;57: +1471-1481. +15. Aragona M, Muscatello MR, Losi E, et al. Lymphocyte number +and stress parameter modifications in untreated breast cancer +patients with depressive mood and previous life stress. J Exp +Ther Oncol. 1996;1:354-360. +16. Van der Pompe G, Duivenvoorrden HJ, Antoni MH, et al. +Effectiveness of a short-term group psychotherapy program on +endocrine and immune function in breast cancer patients: an +exploratory study. J Psychosom Res. 1997;42:453-466. +17. McEwen BS, Sapolsky RM. Stress and cognitive function. Curr +Opin Neurobiol. 1995;5:205-216. +18. Andersen BL, Kiecolt-Glaser JK, Glaser R. A biobehavioral +model of cancer, stress, and disease course. Am Psychol. +1994;49:389-404. +19. Cohen S, Williamson GM. Stress and infectious diseases in +humans. Psychol Bull. 1991;109:5-24. +20. Spiegel D, Sephton SE, Terr AI, et al. Effects of psychosocial +treatment in prolonging cancer survival may be mediated by +neuroimmune mechanisms. Ann N Y Acad Sci. 1998;840: +674-683. +21. Mormont MC, Levi F. Circadian-system alterations during +cancer processes: a review. Int J Cancer. 1997;70:241-247. +22. Chrousos G, Gold PW. A healthy body in a healthy mind—and +vice versa—the damaging power of “uncontrollable” stress +[editorial]. J Clin Endocrinol Metab. 1998;83:1842-1845. +23. Deuschle M, Schweiger U, Weber B, et al. Diurnal activity and +pulsatility of the hypothalamus-pituitary-adrenal system in +male depressed patients and healthy controls. J Clin Endocrinol +Metab. 1997;82:234-238. +24. Sephton SE, Sapolsky RM, Kraemer HC, et al. Diurnal cortisol +rhythm as a predictor of breast cancer survival. J Natl Cancer +Inst. 2000;92:994-1000. +25. Carlson LE, Ursuliak Z, Goodey E, et al. The effects of a mind- +fulness meditation-based stress reduction program on mood +and symptoms of stress in cancer outpatients: 6-month fol- +low-up. Support Care Cancer. 2001;9:112-123. +26. Speca M, Carlson LE, Goodey E, et al. A randomized, wait-list +controlled clinical trial: the effect of a mindfulness meditation- +based stress reduction program on mood and symptoms of stress +in cancer outpatients. Psychosom Med. 2000;62:613-622. +27. Meyer TM, Mark M. Effects of psychosocial interventions with +adult cancer patients: a meta-analysis of randomized experi- +ments. Health Psychol. 1995;1:101-108. +28. Carlson LE, Speca M, Patel KD, et al. Mindfulness-based +stress reduction in relation to quality of life, mood, symptoms +of stress and levels of cortisol, dehydroepiandrosterone sulfate +(DHEAS) and melatonin in breast and prostate cancer outpa- +tients. Psychoneuroendocrinology. 2004;29:448-474. +29. Cruess DG, Antoni MH, McGregor BA, et al. Cognitive- +behavioral stress management reduces serum cortisol by +enhancing benefit finding among women being treated for early +stage breast cancer. Psychosom Med. 2000;62:304-308. +30. Andersen BL. Psychological interventions for cancer patients +to enhance the quality of life. J Consult Clin Psychol. 1992;60: +552-568. +31. Trijsburg RW, van Knippenberg FCE, Rijpma SE. Effects of +psychological treatment on cancer patients: a critical review. +Psychosom Med. 1992;54:489-517. +32. Carlson LE, Speca M, Patel KD, et al. Mindfulness-based +stress reduction in relation to quality of life, mood, symptoms +of stress, and immune parameters in breast and prostate cancer +outpatients. Psychosom Med. 2003;65:571-581. +33. Spiegel D, Bloom JR, Kraemer HC, et al. Effect of psychosocial +treatment on survival of patients with metastatic breast cancer. +Lancet. 1989;2:888-891. +34. Bower JE, Alison Woolery MA, Sternleib B, et al. Yoga for can- +cer patients and survivors. Cancer Control. 2005;12:165-171. +35. Granath J, Ingvarsson S, von Thiele U, et al. Stress manage- +ment: a randomized study of cognitive behavioural therapy and +yoga. Cogn Behav Ther. 2006;35:3-10. +36. Vedamurthachar A, Janakiramaiah N, Hegde JM, et al. +Antidepressant efficacy and hormonal effects of Sudarshana +Kriya Yoga (SKY) in alcohol dependent individuals. J Affect +Disord. 2006;94:249-253. +37. Michalsen A, Grossman P, Acil A, et al. Rapid stress reduction +and anxiolysis among distressed women as a consequence of a +three-month intensive yoga program. Med Sci Monit. 2005;11: +CR555-CR561. +38. Raghavendra RM, Nagarathna R, Nagendra HR, et al. Anxiolytic +effects of a yoga program in early breast cancer patients under- +going conventional treatment: a randomized controlled trial. +Complement Ther Med. In press. +39. Raghavendra RM, Nagarathna R, Nagendra HR, et al. Effects +of an integrated yoga program on chemotherapy-induced nau- +sea and emesis in breast cancer patients. Eur J Cancer Care. +2007;16:462-474. +40. Rao RM, Telles S, Nagendra HR, et al. Effects of yoga on natu- +ral killer cell counts in early breast cancer patients undergoing +conventional treatment. Med Sci Monit. 2008;14:LE3-LE4. +41. Heim C, Ehlert U. The potential role of hypocortisolism in +the pathophysiology of stress-related bodily disorders. +Psychoneuroendocrinology. 2000;25:1-35. + at UQ Library on September 22, 2009 +http://ict.sagepub.com +Downloaded from +46    Integrative Cancer Therapies / Vol. 8, No. 1, March 2009 +42. Pollard TM. Use of cortisol as a stress marker: practical and +theoretical problems. Am J Hum Biol. 1994;6:1-10. +43. Zigmond AS, Snaith RP. The hospital anxiety and depression +scale. Acta Psychiatr Scand. 1983;67:361-370. +44. Herrmann C. International experiences with the Hospital +Anxiety and Depression Scale—a review of validation data and +clinical results. J Psychosomatic Res. 1997;42:17-41. +45. Bjelland I, Dahl AA, Haug TT, et al. The validity of the Hospital +Anxiety and Depression Scale: an updated literature review. J +Psychosomatic Res. 2002;52:69-77. +46. Rodgers J, Martin CR, Morse RC, et al. An investigation into +the psychometric properties of the Hospital Anxiety and +Depression Scale in patients with breast cancer. Health Qual +Life Outcomes. 2005;3:41. +47. Cohen S, Kamarck T, Mermelstein R. A global measure of +perceived stress. J Health Soc Behav. 1983;24:385-396. +48. Pruessner JC, Kirschbaum C, Meinlschmid G, et al. Two formulas +for computation of the area under the curve represent measures +of total hormone concentration versus time-dependent change. +Psychoneuroendocrinology. 2003;28:916-931. +49. Hanson Frost M, Suman VJ, Rummans TA, et al. Physical, +psychological and social well-being of women with breast +cancer: the influence of disease phase. Psychooncology. 2000;9: +221-231. +50. Malathi A, Damodaran A. Stress due to exams in medical +students: role of yoga. Indian J Physiol Pharmacol. 1999;43: +218-224. +51. Bijlani RL. Influence of yoga on brain and behaviour: facts and +speculations. Indian J Physiol Pharmacol. 2004;48:1-5. +52. Kabat-Zinn J, Massion AO, Kristeller J, et al. Effectiveness of a +meditation-based stress reduction program in the treatment of +anxiety disorders. Am J Psychiatry. 1992;149:936-943. +53. Khalsa SB, Cope S. Effects of a yoga lifestyle intervention on +performance-related characteristics of musicians: a preliminary +study. Med Sci Monit. 2006;12:325-331. +54. Taneja I, Deepak KK, Poojary G, et al. Yogic versus conven- +tional treatment in diarrhea predominant irritable bowel +syndrome: a randomized control study. Appl Psychophysiol +Biofeedback. 2004;29:19-33. +55. Woolery A, Myers H, Sternlieb B, et al. A yoga intervention for +young adults with elevated symptoms of depression. Altern +Ther Health Med. 2004;10:60-63. +56. Brown RP, Gerbarg PL. Sudarshan Kriya Yogic breathing in the +treatment of stress, anxiety, and depression: part II—clinical +applications and guidelines. J +Altern Complement Med. 2005;11: +711-717. +57. Hidderley M, Holt M. A pilot randomized trial assessing the +effects of autogenic training in early stage cancer patients in +relation to psychological status and immune system responses. +Eur J Oncol Nurs. 2004;8:61-65. +58. Danhauer SC, Tooze JA, Farmer DF, et al. Restorative yoga for +women with ovarian or breast cancer: findings from a pilot +study. J Soc Integr Oncol. 2008;6:47-58. +59. Schedlowski M, Jung C, Schimanski G, et al. Effects of behav- +ioral intervention on plasma cortisol and lymphocytes in breast +cancer patients: an exploratory study. Psychooncology. 1994;3: +181-187. +60. Turner-Cobb JM, Sephton SE, Koopman C, et al. Social sup- +port and salivary cortisol in women with metastatic breast +cancer. Psychosom Med. 2000;62:337-345. +61. Cohen L, de Moor C, Devine D, et al. Endocrine levels at the +start of treatment are associated with subsequent psychological +adjustment in cancer patients with metastatic disease. Psychosom +Med. 2001;63:951-958. +62. Courneya KS. Exercise interventions during cancer treat- +ment: biopsychosocial outcomes. Exerc Sport Sci Rev. 2001;29: +60-64. +63. Courneya KS, Friedenreich CM. Physical exercise and quality +of life following cancer diagnosis: a literature review. Ann +Behav Med. 1999;21:171-179. +64. Friedenreich CM, Courneya KS, Bryant HE. Relation between +intensity of physical activity and breast cancer risk reduction. +Med Sci Sports Exerc. 2001;33:1538-1545. +65. Telles S, Nagaratna R, Nagendra HR. Breathing through a par- +ticular nostril can alter metabolic and autonomic activities. +Indian J Physiol Pharmacol. 1994;38:133-137. +66. Telles S, Nagaratna R, Nagendra HR. Autonomic changes + +during OM meditation. Indian J Physiol Pharmacol. 1995;39: +418-420. +67. Telles S, Reddy SK, Nagendra HR. Oxygen consumption and +respiration following two yoga based relaxation techniques. +Appl Psychophysiol Biofeedback. 2000;25:221-227. +68. Sugi Y Akutsu K. Studies on respiration and energy metabolism +during sitting in Za Zen. Res J Physiol Educ. 1968;12:190-206. +69. Checkley S. Neuroendocrine mechanisms and the precipitation of +depression by life events. Br J Psychiatry Suppl. 1992;15:7-17. +70. Telch CF, Telch MJ. Group coping skills instruction and sup- +portive group therapy for cancer patients: a comparison of +strategies. J Consult Clin Psychol. 1986;54:802-808. +71. Greer S, Moorey S, Baruch JD, et al. Adjuvant psychological +therapy for patients with cancer—a prospective randomized +trial. Br Med J. 1992;304:675-680. + at UQ Library on September 22, 2009 +http://ict.sagepub.com +Downloaded from diff --git a/subfolder_0/Effects of an integrated Yoga Program on Self-reported Depression Scores in Breast Cancer Patients Undergoing Conventional Treatment.txt b/subfolder_0/Effects of an integrated Yoga Program on Self-reported Depression Scores in Breast Cancer Patients Undergoing Conventional Treatment.txt new file mode 100644 index 0000000000000000000000000000000000000000..805a9851ed9b0d77dc16b066d15212b306522a73 --- /dev/null +++ b/subfolder_0/Effects of an integrated Yoga Program on Self-reported Depression Scores in Breast Cancer Patients Undergoing Conventional Treatment.txt @@ -0,0 +1,885 @@ +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: raghav.hcgrf@gmail.com +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. +REFERENCES +1. +Ferrell B, Grant MM, Funk B, Otis-Green S, Garcia N. Quality of life in + +breast cancer survivors as identifi ed by focus groups. Psychooncology +1997;6:13-23. +2. +Meyerowitz B. Post mastectomy coping strategies and quality of life. Health +Psychol 1983;2:117-32. +3. +Meyerowitz B, Watkins IK, Sparks FC. Psychosocial implications of adjuvant +Table 3: Pearson correlation (r‑values) between depression scores and treatment‑related symptoms +(severity and distress) at various conventional treatment intervals +Post‑surgery +During radiotherapy +During chemotherapy +Symptom severity +Symptom distress +Symptom severity +Symptom distress +Symptom severity +Symptom distress +Post‑surgery +Beck’s depression score +0.73** +0.74** +‑ +‑ +‑ +‑ +During Radiotherapy +Beck’s depression score +‑ +‑ +0.49** +0.77** +‑ +‑ +During chemotherapy +Beck’s depression score +‑ +‑ +‑ +‑ +0.43** +0.71** +**P<0.001, for Pearson correlation coefficients r +180 + Indian Journal of Palliative Care / May-Aug 2015 / Vol 21 / Issue 2 +Rao, et al.: Antidepressant effects of yoga +chemotherapy. A two-year follow-up. Cancer 1983;52:1541-5. +4. +Derogatis L, Morrow GR, Fetting J, Penman D, Piasetsky S, Schmale AM, +et al. The prevalence of psychiatric disorders among cancer patients. JAMA +1983;249:751-7. +5. +Lansky S, List MA, Herrmann CA, Ets-Hokin EG, DasGupta TK, +Wilbanks GD, et al. Absence of major depressive disorder in female cancer +patients. J Clin Oncol 1985;3:1553-60. +6. +Chaturvedi S, Chandra PS, Channabasavanna SM, Anantha N, Reddy BK, +Sharma S. Levels of anxiety and depression in patients receiving radiotherapy +in India. Psychooncology 1996;5:343-6. +7. +Wengström Y, Häggmark C, Strander H, Forsberg C. Perceived symptoms +and quality of life in women with breast cancer receiving radiation therapy. +Eur J Oncol Nurs 2000;4:78-88. +8. +Cassileth B, Lusk EJ, Hutter R, Strouse TB, Brown LL. Concordance of +depression and anxiety in patients with cancer. Psychol Rep 1984;54:588-90. +9. +Glover J, Dibble SL, Dodd MJ, Miaskowski C. Mood states of oncology +outpatients: Does pain make a difference? J Pain Symptom Manage +1995;10:120-8. +10. Umesh SB. Psychosocial aspects of cancers in women. Bangalore: +Department of Psychiatry, NIMHANS; 1998. +11. Cassileth B, Lusk EJ, Miller DS, Brown LL, Miller C. Psychosocial correlates +of survival in advanced malignant disease? New Engl J Med 1985;312:1551-5. +12. Walker L, Heys SD, Ogston K. Psychological factors predict response to +neo-adjuvant chemotherapy in women with locally advanced breast cancer. +Psychooncology 1997;6:242-3. +13. Sephton SE, Sapolsky RM, Kraemer HC, Spiegel D. Early mortality in +metastatic breast cancer patients with absent or abnormal diurnal cortisol +rhythms. J Natl Cancer Inst 2000;92:994-1000. +14. Leigh H, Percarpio B, Opsahl C, Ungerer J. Psychological predictors +of survival in cancer patients undergoing radiation therapy. Psychother +Psychosom 1987;47:65-73. +15. C lassen C, Hermanson KS, Spiegel D. Psychotherapy, stress, and survival +in breast cancer. Oxford: Oxford Medical Publications; 1994. p. 123-62. +16. Meyer TJ, Mark MM. Effects of psychosocial interventions with adult +cancer patients: A meta-analysis of randomized experiments. Health Psychol +1995;14:101-8. +17. Spiegel D. Psychosocial aspects of breast cancer treatment. Semin Oncol +1997;24 (1 Suppl 1):S1-36-47. +18. Targ EF, Levine EG. The efficacy of a mind -body-spirit group for women +with breast cancer: A randomized controlled trial. Gen Hosp Psychiatry +2002;24:238-48. +19. Khalsa SB. Yoga as a therapeutic intervention. Principles Pract Stress Manage +2007;3:449-62. +20. Ray US, Mukhopadhyaya S, Purkayastha SS, Asnani V, Tomer OS, Prashad R, +et al. Effect of yogic exercises on physical and mental health of young +fellowship course trainees. Indian J Physiol Pharmacol 2001;45:37-53. +21. 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. +22. Lavey R, Sherman T, Mueser KT, Osborne DD, Currier M, Wolfe R. The +effects of yoga on mood in psychiatric inpatients. Psychiatr Rehabil J +2005;28:399-402. +23. Sharma VK, Das S, Mondal S, Goswami U, Gandhi A. Effect of Sahaj Yoga +on depressive disorders. Indian J Physiol Pharmacol 2005;49:462-8. +24. Culos-Reed SN, Carlson LE, Daroux LM, Hately-Aldous S. A pilot study +of yoga for breast cancer survivors: Physical and psychological benefits. +Psychooncology 2006;15:891-7. +25. Speca M, Carlson LE, Goodey E, Angen M. A randomized, wait-list +controlled clinical trial: The effect of a mindfulness meditation-based stress +reduction program on mood and symptoms of stress in cancer outpatients. +Psychosom Med 2000;62:613-22. +26. Pilkington K, Kirkwood G, Rampes H, Richardson J. Yoga for depression: +The research evidence. J Affect Disord 2005;89:13-24. +27. Sudarshan M, Petrucci A, Dumitra S, Duplisea J, Wexler S, Meterissian S. Yoga +therapy for breast cancer patients: A prospective cohort study. Complement +Ther Clin Pract 2013;19:227-9. +28. Taso C, Lin HS, Lin WL, Chen SM, Huang WT, Chen SW. The effect of +yoga exercise on improving depression, anxiety, and fatigue in women with +breast cancer: A randomized controlled trial. J Nurs Res 2014;22:155-64. +29. Chandwani K, Perkins G, Nagendra HR, Raghuram NV, Spelman A, +Nagarathna R, et al. Randomized, controlled trial of yoga in women with +breast cancer undergoing radiotherapy. J Clin Oncol 2014;32:1058-65. +30. Joseph CD. Psychological supportive therapy for cancer patients. Indian J +Cancer 1982;20:268-70. +31. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh JK. An inventory for +measuring depression. Arch Gen Psychiatry 1961;4:561-71. +32. Bhaskaran SA. Behavioural management of patients with cancer. Bangalore: +National Institute of Mental Health and Neurosciences; 1996. +33. Telles S, Nagarathna R, Nagendra HR. Autonomic changes while mentally +repeating two syllables-one meaningful and the other neutral. Indian J +Physiol Pharmacol 1998;42:57-63. +34. Telles S, Reddy SK, Nagendra HR. Oxygen consumption and respiration +following two yoga relaxation techniques. Appl Psychophysiol Biofeedback +2000;25:221-7. +35. Goodwin PJ, Leszcz M, Koopmans J, Arnold A, Doll R, Chochinov H, +et al. Randomized trial of group psychosocial support in metastatic breast +cancer: The BEST study. Breast-Expressive Supportive Therapy study. +Cancer Treat Rev 1996;22:91-6. +36. Greer S, Moorey S, Baruch JD, Watson M, Robertson BM, Mason A, et al. +Adjuvant psychological therapy for patients with cancer: A prospective +randomized trial. Br Med J 1992;304:675-80. +37. Telch C, Telch MJ. Group coping skills instruction and supportive group +therapy for cancer patients: A comparison of strategies. J Consult Clin +Psychol 1986;54:802-8. +38. Burish T, Snyder SL, Jenkins RA. Preparing patients for cancer +chemotherapy: Effect of coping preparation and relaxation interventions. +J Consult Clin Psychol 1991;59:518-25. +39. Hopko D, Bell JL, Armento ME, Hunt MK, Lejuez CW +. Behaviour therapy +for depressed cancer patients in primary care. Psychotherapy 2005;42:236-43. +40. Vedamurthachar A, Janakiramaiah N, Hegde JM, Shetty TK, +Subbakrishna DK, Sureshbabu SV, et al. Antidepressant efficacy and +hormonal effects of Sudarshana Kriya Yoga (SKY) in alcohol dependent +individuals. J Affect Disord 2006;94:249-53. +41. Whitley E, Ball J. Statistics review 4: Sample size calculations. Crit Care +2002;6:335-41. +42. Meyer SE, Chrousos GP, Gold PW +. Major depression and the stress system: +A life span perspective. Dev Psychopathol 2001;13:565-80. +43. Luebbert K, Dahme, B, Hasenbring, M. The effectiveness of relaxation +training in reducing treatment-related symptoms and improving emotional +adjustment in acute non-surgical cancer treatment: A meta-analytical review. +Psycho-oncology. 2001;10:490-502. +44. Stokes PE. The potential role of excessive cortisol induced by HPA +hyperfunction in the pathogenesis of depression. Eur Neuropsychopharmacol +1995;5:77-82. +45. Ronson A. Stress and allostatic load: Perspectives in psycho-oncology. Bull +Cancer 2006;93:289-95. +46. DeBerry S, Davis S, Reinhard KE. A comparison of meditation-relaxation +and cognitive/behavioural techniques for reducing anxiety and depression +in a geriatric population. J Geriatr Psychiatry 1989;22:231-47. +47. Spiegel D, Kraemer H, Bloom J, Gottheil E. Effect of psychosocial +treatment on survival of patients with metastatic breast cancer. Lancet +1989;334:888-91. +48. Telles S, Nagarathna R, Nagendra HR, Desiraju T. Physiological changes in +sports teachers following 3 months of training in Yoga. Indian J Med Sci +1993;47:235-8. +49. Harte JL, Eifert GH, Smith R. The effects of running and meditation on + +beta-endorphin, corticotrophin-releasing hormone and cortisol in plasma, +and on mood. Biol Psychol 1995;40:251-65. +50. West J, Otte C, Geher K, Johnson J, Mohr DC. Effects of Hatha yoga and +African dance on perceived stress, affect, and salivary cortisol. Ann Behav +Med 2004;28:114-8. +51. Carey M, Burish TG. Anxiety as a predictor of behavioural therapy outcome +for cancer chemotherapy patients. J Consult Clin Psychol 1985;53:860-5. + Indian Journal of Palliative Care / May-Aug 2015 / Vol 21 / Issue 2 +181 +Rao, et al.: Antidepressant effects of yoga +52. Raghavendra R, Nagarathna R, Nagendra HR, Gopinath KS, Srinath BS, +Ravi BD, et al. Effects of an integrated yoga programme on chemotherapy +induced nausea and emesis in breast cancer patients. Eur J Cancer Care +2007;16:462-74. +53. Goldberg JA, Scott RN, Davidson PM, Murray GD, Stallard S, George WD, +et al. Psychological morbidity in the first year after breast surgery. Eur J Surg +Oncol 1992;18:327-31. +54. Lasry JC, Margolese RG. Fear of recurrence, breast-conserving surgery, +and the trade-off hypothesis. Cancer 1992;69:2111-5. +55. Nelson JC, Mazure CM, Jatlow PI. Does melancholia predict response in +major depression? J Affect Disord 1990;18:157-65. +56. Riessman, F. The “Helper Therapy” Principle in Social Work.1965;10:27-32. +How to cite this article: Rao RM, Raghuram N, Nagendra HR, Usharani MR, +Gopinath KS, Diwakar RB, et al. Effects of an integrated yoga program on +self-reported depression scores in breast cancer patients undergoing conventional +treatment: A randomized controlled trial. Indian J Palliat Care 2015;21:174-81. +Source of Support: Grant from Central Council for Research in Yoga +and Naturopathy (CCRYN), Department of AYUSH, Ministry of Health and +Family Welfare, New Delhi. Conflict of Interest: None declared. diff --git a/subfolder_0/Effects of an integrated yoga program in modulating psychological stress and radiation-induced genotoxic stress in breast cancer patients undergoing radiotherap.txt b/subfolder_0/Effects of an integrated yoga program in modulating psychological stress and radiation-induced genotoxic stress in breast cancer patients undergoing radiotherap.txt new file mode 100644 index 0000000000000000000000000000000000000000..66ae79cce54314b89f94bdce12ae6b2968715a9a --- /dev/null +++ b/subfolder_0/Effects of an integrated yoga program in modulating psychological stress and radiation-induced genotoxic stress in breast cancer patients undergoing radiotherap.txt @@ -0,0 +1,994 @@ +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: phsmph@nus.edu.sg. + 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 +Downloaded from +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 +Downloaded from +Banerjee et al +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. +References +1. +Derogatis LR, Morrow GR, Fetting J, et al. The prevalence of +psychiatric disorders among cancer patients. JAMA. 1983;249: +751-757. +2. +Stefanek ME, Derogatis LP, Shaw A. Psychological distress +among oncology outpatients: prevalence and severity as mea- +sured with the Brief Symptom Inventory. Psychosomatics. 1987; +28:530-539. +3. +Culos-Reed SN, Carlson LE, Daroux LM, Hately-Aldous S. A +pilot study of yoga for breast cancer survivors: physical and +psychological benefits. Psychooncology. 2006;15:891-897. +4. +Fox BH. The role of psychological factors in cancer incidence +and prognosis. Oncology (Williston Park). 1995;9:245-253. +5. +Spiegel D. Essentials of psychotherapeutic intervention for +cancer patients. Support Care Cancer. 1995;3:252-256. +6. +Spiegel D. Psychological distress and disease course for women +with breast cancer: one answer, many questions. J Natl Cancer +Inst. 1996;88:629-631. +7. +Buettner C, Kroenke CH, Phillips RS, Davis RB, Eisenberg DM, +Holmes MD. Correlates of use of different types of comple- +mentary and alternative medicine by breast cancer survivors +in the nurses’ health study. Breast Cancer Res Treat. 2006;100: +219-227. +8. +Cassileth BR, Chapman CC. Alternative and complementary +cancer therapies. Cancer. 1996;77:1026-1034. +9. +Cassileth BR, Chapman CC. Alternative cancer medicine: +a ten-year update. Cancer Invest. 1996;14:396-404. +10. +Brawley LR, Culos-Reed SN. Studying adherence to therapeu- +tic regimens: overview, theories, recommendations. Control +Clin Trials. 2000;21:156S-163S. +11. +Gimbel MA. Yoga, meditation, and imagery: clinical applica- +tions. Nurse Pract Forum. 1998;9:243-255. +12. +Johnson NA, Heller RF. Prediction of patient nonadherence +with home-based exercise for cardiac rehabilitation: the role +of perceived barriers and perceived benefits. Prev Med. 1998; +27:56-64. +13. +Telles S, Nagarathna R, Nagendra HR. Autonomic changes +while mentally repeating two syllables—one meaningful and +the other neutral. Indian J Physiol Pharmacol. 1998;42:57-63. +14. +Nagarathna R, Nagendra HR. Yoga for bronchial asthma: a con- +trolled study. Br Med J (Clin Res Ed). 1985;19(291):1077-1079. +15. +Henderson JW, Donatelle RJ. The relationship between cancer +locus of control and complementary and alternative medicine +use by women diagnosed with breast cancer. Psychooncology. +2003;12:59-67. +16. +Henderson JW, Donatelle RJ. Complementary and alternative +medicine use by women after completion of allopathic treat- +ment for breast cancer. Altern Ther Health Med. 2004;10:52-57. +17. +Solberg EE, Halvorsen R, Sundgot-Borgen J, Ingjer F, Holen +A. Meditation: a modulator of the immune response to phys- +ical stress? A brief report. Br J Sports Med. 1995;29:255-257. +18. +Sainani GS. Non-drug therapy in prevention and control of +hypertension. J Assoc Physicians India. 2003;51:1001-1006. +19. +Schneider RH, Staggers F, Alxander CN, et al. A randomised +controlled trial of stress reduction for hypertension in older +African Americans. Hypertension. 1995;26:820-827. +20. +Walton KG, Pugh ND, Gelderloos P, Macrae P. Stress reduc- +tion and preventing hypertension: preliminary support for a +psychoneuroendocrine mechanism. J Altern Complement Med. +1995;1:263-283. +21. +Jayasinghe SR. Yoga in cardiac health (a review). Eur J Cardiovasc +Prev Rehabil. 2004;11:369-375. +22. +Raub JA. Psychophysiologic effects of Hatha Yoga on muscu- +loskeletal and cardiopulmonary function: a literature review. +J Altern Complement Med. 2002;8:797-812. +23. +Sudsuang R, Chentanez V, Veluvan K. Effect of Buddhist med- +itation on serum cortisol and total protein levels, blood pres- +sure, pulse rate, lung volume and reaction time. Physiol Behav. +1991;50:543-548. +24. +Wenneberg SR, Schneider RH, Walton KG, et al. A controlled +study of the effects of the transcendental meditation program +on cardiovascular reactivity and ambulatory blood pressure. +Int J Neurosci. 1997;89:15-28. +25. +Sahay BK, Sahay RK. Lifestyle modification in management +of diabetes mellitus. J Indian Med Assoc. 2002;100:178-180. +26. +Burstein HJ, Gelber S, Guadagnoli E, Weeks JC. Use of alterna- +tive medicine by women with early-stage breast cancer. N Engl +J Med. 1999;340:1733-1739. +27. +Carlson LE, Ursuliak Z, Goodey E, Angen M, Speca M. The +effects of a mindfulness meditation-based stress reduction +program on mood and symptoms of stress in cancer outpa- +tients: 6-month follow-up. Support Care Cancer. 2001;9:112-123. +Yoga Intervention Modulates Genotoxic Stress Following Radiotherapy +INTEGRATIVE CANCER THERAPIES 6(3); 2007 +249 + at FLORIDA INTERNATIONAL UNIV on December 21, 2014 +ict.sagepub.com +Downloaded from +Banerjee et al +250 +INTEGRATIVE CANCER THERAPIES 6(3); 2007 +28. +Carlson LE, Speca M, Patel KD, Goodey E. Mindfulness-based +stress reduction in relation to quality of life, mood, symptoms +of stress, and immune parameters in breast and prostate can- +cer outpatients. Psychosom Med. 2003;65:571-581. +29. +Carlson LE, Speca M, Patel KD, Goodey E. Mindfulness-based +stress reduction in relation to quality of life, mood, symptoms +of stress and levels of cortisol, dehydroepiandrosterone sul- +fate (DHEAS) and melatonin in breast and prostate cancer +outpatients. Psychoneuroendocrinology. 2004;29:448-474. +30. +Casso D, Buist DS, Taplin S. Quality of life of 5-10 year breast +cancer survivors diagnosed between age 40 and 49. Health Qual +Life Outcomes. 2004;2:25. +31. +Rosenbaum E, Gautier H, Fobair P, et al. Cancer supportive care, +improving the quality of life for cancer patients. A program eval- +uation report. Support Care Cancer. 2004;12:293-301. +32. +Carson JW, Carson KM, Porter LS, Keefe FJ, Shaw H, Miller +JM. Yoga for women with metastatic breast cancer: results +from a pilot study. J Pain Symptom Manage. 2007;33:331-341. +33. +Rao MR, Raghuram N, Nagendra HR, et al. Effects of an inte- +grated yoga program on chemotherapy induced nausea and +emesis in breast cancer patients. Eur J Cancer Care. 2007; +accepted for publication. +34. +Mozdarani H, Mansouri Z, Haeri SA. Cytogenetic radiosensi- +tivity of g0-lymphocytes of breast and esophageal cancer +patients as determined by micronucleus assay. J Radiat Res +(Tokyo). 2005;46:111-116. +35. +Scott D, Barber JB, Levine EL, Burrill W, Roberts SA. Radiation- +induced micronucleus induction in lymphocytes identifies a +high frequency of radiosensitive cases among breast cancer +patients: a test for predisposition? Br J Cancer. 1998;77:614-620. +36. +Banerjee B, Sharma S, Hegde S, Hande MP. Analysis of telo- +mere damage by fluorescence in situ hybridisation on +micronuclei in lymphocytes of breast carcinoma patients after +radiotherapy. Breast Cancer Res Treat. 2007;PMID: 17333339 Feb +28 [Epub ahead of print]. +37. +Epel ES, Blackburn EH, Lin J, et al. Accelerated telomere +shortening in response to life stress. Proc Natl Acad Sci U S A. +2004;101:17312-17315. +38. +Cohen L, Marshall GD Jr, Cheng L, Agarwal SK, Wei Q. DNA +repair capacity in healthy medical students during and after +exam stress. J Behav Med. 2000;23:531-544. +39. +Glaser R, Thorn BE, Tarr KL, Kiecolt-Glaser JK, D’Ambrosio +SM. Effects of stress on methyltransferase synthesis: an impor- +tant DNA repair enzyme. Health Psychol. 1985;4:403-412. +40. +Kiecolt-Glaser JK, Stephens RE, Lipetz PD, Speicher CE, +Glaser R. Distress and DNA repair in human lymphocytes. +J Behav Med. 1985;8:311-320. +41. +Cohen S., Williamson GM. perceived stress in a probability +sample of the United States. In: Spacapan S, Oskamp, S, eds. +The Social Psychology of Health: Claremont Symposium on Applied +Social Psychology. Newbury Park, CA: Sage; 1988:31-67. +42. +Nagendra HR. Yoga: Its Basis and Applications. Prakashana, +India: Swami Vivekananda Yoga Prakashana; 2004. +43. +Poonepalli A, Balakrishnan L, Khaw AK, et al. Lack of poly +(ADP-ribose) polymerase-1 gene product enhances cellular sen- +sitivity to arsenite. Cancer Res. 2005;65:10977-10983. +44. +Epel ES, Lin J, Wilhelm FH, et al. Cell aging in relation to stress +arousal and cardiovascular disease risk factors. Psychoneuro- +endocrinology. 2006;31:277-287. +45. +Hande MP. DNA repair factors and telomere-chromosome +integrity in mammalian cells. Cytogenet Genome Res. 2004;104: +116-122. +46. +Slijepcevic P. The role of DNA damage response proteins at +telomeres—an “integrative” model. DNA Repair (Amst). 2006;5: +1299-1306. +47. +Richardson MA, Sanders T, Palmer JL, Greisinger A, Singletary +SE. Complementary/alternative medicine use in a compre- +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 diff --git a/subfolder_0/Effects of yoga for cardiovascular and respiratory functions a pilot study..txt b/subfolder_0/Effects of yoga for cardiovascular and respiratory functions a pilot study..txt new file mode 100644 index 0000000000000000000000000000000000000000..d0eef5c0a10353268a8e09f35f6e728ce483e40f --- /dev/null +++ b/subfolder_0/Effects of yoga for cardiovascular and respiratory functions a pilot study..txt @@ -0,0 +1,780 @@ +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: + dr.mooventhan@gmail.com +(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/). diff --git a/subfolder_0/Efficacy of yoga and psychosocial training programme for caregivers of persons with schizophrenia.txt b/subfolder_0/Efficacy of yoga and psychosocial training programme for caregivers of persons with schizophrenia.txt new file mode 100644 index 0000000000000000000000000000000000000000..e69de29bb2d1d6434b8b29ae775ad8c2e48c5391 diff --git a/subfolder_0/Efficacy of yoga practices on emotion regulation and mindfulness in type 2 diabetes mellitus patients.txt b/subfolder_0/Efficacy of yoga practices on emotion regulation and mindfulness in type 2 diabetes mellitus patients.txt new file mode 100644 index 0000000000000000000000000000000000000000..2afc39f0dd2f2b7cb527e7051e613969858e19c8 --- /dev/null +++ b/subfolder_0/Efficacy of yoga practices on emotion regulation and mindfulness in type 2 diabetes mellitus patients.txt @@ -0,0 +1,1313 @@ +1 +2 +3 +4 +5 +6 +7 +8 +9 +10 +11 +12 +13 +14 +15 +16 +17 +18 +19 +20 +21 +22 +23 +24 +25 +26 +27 +28 +29 +30 +31 +32 +33 +34 +35 +36 +37 +38 +39 +40 +41 +42 +43 +44 +45 +46 +47 +48 +49 +50 +51 +52 +53 +54 +55 +56 +57 +58 +59 +1 +2 +3 +4 +5 +6 +7 +8 +9 +10 +11 +12 +13 +14 +15 +16 +17 +18 +19 +20 +21 +22 +23 +24 +25 +26 +27 +28 +29 +30 +31 +32 +33 +34 +35 +36 +37 +38 +39 +40 +41 +42 +43 +44 +45 +46 +47 +48 +49 +50 +51 +52 +53 +54 +55 +56 +57 +58 +59 +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: namitsk@gmail.com +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: WKHLRPMedknow_reprints@wolterskluwer.com +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] +1 +2 +3 +4 +5 +6 +7 +8 +9 +10 +11 +12 +13 +14 +15 +16 +17 +18 +19 +20 +21 +22 +23 +24 +25 +26 +27 +28 +29 +30 +31 +32 +33 +34 +35 +36 +37 +38 +39 +40 +41 +42 +43 +44 +45 +46 +47 +48 +49 +50 +51 +52 +53 +54 +55 +56 +57 +58 +59 +1 +2 +3 +4 +5 +6 +7 +8 +9 +10 +11 +12 +13 +14 +15 +16 +17 +18 +19 +20 +21 +22 +23 +24 +25 +26 +27 +28 +29 +30 +31 +32 +33 +34 +35 +36 +37 +38 +39 +40 +41 +42 +43 +44 +45 +46 +47 +48 +49 +50 +51 +52 +53 +54 +55 +56 +57 +58 +59 +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 +[Downloaded free from http://www.ym-kdham.in on Saturday, July 16, 2022, IP: 136.232.192.146] +1 +2 +3 +4 +5 +6 +7 +8 +9 +10 +11 +12 +13 +14 +15 +16 +17 +18 +19 +20 +21 +22 +23 +24 +25 +26 +27 +28 +29 +30 +31 +32 +33 +34 +35 +36 +37 +38 +39 +40 +41 +42 +43 +44 +45 +46 +47 +48 +49 +50 +51 +52 +53 +54 +55 +56 +57 +58 +59 +1 +2 +3 +4 +5 +6 +7 +8 +9 +10 +11 +12 +13 +14 +15 +16 +17 +18 +19 +20 +21 +22 +23 +24 +25 +26 +27 +28 +29 +30 +31 +32 +33 +34 +35 +36 +37 +38 +39 +40 +41 +42 +43 +44 +45 +46 +47 +48 +49 +50 +51 +52 +53 +54 +55 +56 +57 +58 +59 +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 +5 +10 +15 +20 +25 +30 +35 +40 +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] +1 +2 +3 +4 +5 +6 +7 +8 +9 +10 +11 +12 +13 +14 +15 +16 +17 +18 +19 +20 +21 +22 +23 +24 +25 +26 +27 +28 +29 +30 +31 +32 +33 +34 +35 +36 +37 +38 +39 +40 +41 +42 +43 +44 +45 +46 +47 +48 +49 +50 +51 +52 +53 +54 +55 +56 +57 +58 +59 +1 +2 +3 +4 +5 +6 +7 +8 +9 +10 +11 +12 +13 +14 +15 +16 +17 +18 +19 +20 +21 +22 +23 +24 +25 +26 +27 +28 +29 +30 +31 +32 +33 +34 +35 +36 +37 +38 +39 +40 +41 +42 +43 +44 +45 +46 +47 +48 +49 +50 +51 +52 +53 +54 +55 +56 +57 +58 +59 +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 +5 +10 +15 +20 +25 +30 +35 +40 +45 +50 +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 +[Downloaded free from http://www.ym-kdham.in on Saturday, July 16, 2022, IP: 136.232.192.146] +1 +2 +3 +4 +5 +6 +7 +8 +9 +10 +11 +12 +13 +14 +15 +16 +17 +18 +19 +20 +21 +22 +23 +24 +25 +26 +27 +28 +29 +30 +31 +32 +33 +34 +35 +36 +37 +38 +39 +40 +41 +42 +43 +44 +45 +46 +47 +48 +49 +50 +51 +52 +53 +54 +55 +56 +57 +58 +59 +1 +2 +3 +4 +5 +6 +7 +8 +9 +10 +11 +12 +13 +14 +15 +16 +17 +18 +19 +20 +21 +22 +23 +24 +25 +26 +27 +28 +29 +30 +31 +32 +33 +34 +35 +36 +37 +38 +39 +40 +41 +42 +43 +44 +45 +46 +47 +48 +49 +50 +51 +52 +53 +54 +55 +56 +57 +58 +59 +Kanthi, et al.: Emotion regulation and mindfulness in T2DM patients +16 +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. +REFERENCES +1. Hall PA, Rodin GM, Vallis TM, Perkins BA. The consequences of anxious +temperament for disease detection, self-management behavior, and quality +of life in Type 2 diabetes mellitus. J Psychosom Res 2009;67:297-305. +2. Robertson SM, Stanley MA, Cully JA, Naik AD. Positive emotional health +and diabetes care: Concepts, measurement, and clinical implications. +Psychosomatics 2012;53:1-12. +3. Rane K, Wajngot A, Wändell PE, Gåfvels C. Psychosocial problems in +patients with newly diagnosed diabetes: Number and characteristics. +Diabetes Res Clin Pract 2011;93:371-8. +4. Anderson RJ, Grigsby AB, Freedland KE, de Groot M, McGill JB, +Clouse RE, et al. Anxiety and poor glycemic control: A meta-analytic +review of the literature. Int J Psychiatry Med 2002;32:235-47. +5. Katon WJ. The comorbidity of diabetes mellitus and depression. Am J +Med 2008;121 11 Suppl 2:S8. +6. Padala PR, Desouza CV, Almeida S, Shivaswamy V, Ariyarathna K, +Rouse L, et al. The impact of apathy on glycemic control in diabetes: A +cross-sectional study. Diabetes Res Clin Pract 2008;79:37-41. +7. Sagui SJ, Levens SM. Cognitive reappraisal ability buffers against the +indirect effects of perceived stress reactivity on Type 2 diabetes. Health +Psychol 2016;35:1154-8. +8. Nicolucci A, Kovacs Burns K, Holt RI, Comaschi M, Hermanns N, Ishii H, +et al. Diabetes Attitudes, Wishes and Needs second study (DAWN2™): +Cross-national benchmarking of diabetes-related psychosocial outcomes +for people with diabetes. Diabet Med 2013;30:767-77. +9. Park M, Katon WJ, Wolf FM. Depression and risk of mortality in +individuals with diabetes: A meta-analysis and systematic review. Gen +Hosp Psychiatry 2013;35:217-25. +10. Baumeister H, Hutter N, Bengel J. Psychological and pharmacological +interventions for depression in patients with diabetes mellitus and +depression. Cochrane Database Syst Rev 2012;12:CD008381. +11. Das-Munshi J, Stewart R, Ismail K, Bebbington PE, Jenkins R, Prince MJ. +Diabetes, common mental disorders, and disability: Findings from the UK +National Psychiatric Morbidity Survey. Psychosom Med 2007;69:543-50. +12. Gonzalez JS, Fisher L, Polonsky WH. Depression in diabetes: Have we +been missing something important? Diabetes Care 2011;34:236-9. +Table 3: Changes in emotion regulation questionnaire measures and mindfulness after the +intervention +Mean±SD +Within group (pre‑post) +Yoga group (n=27) +Control group +(n=27) +t (df) +Mean difference +Percentage change +Yoga +Control +Yoga +Control +Yoga +Control +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] +1 +2 +3 +4 +5 +6 +7 +8 +9 +10 +11 +12 +13 +14 +15 +16 +17 +18 +19 +20 +21 +22 +23 +24 +25 +26 +27 +28 +29 +30 +31 +32 +33 +34 +35 +36 +37 +38 +39 +40 +41 +42 +43 +44 +45 +46 +47 +48 +49 +50 +51 +52 +53 +54 +55 +56 +57 +58 +59 +1 +2 +3 +4 +5 +6 +7 +8 +9 +10 +11 +12 +13 +14 +15 +16 +17 +18 +19 +20 +21 +22 +23 +24 +25 +26 +27 +28 +29 +30 +31 +32 +33 +34 +35 +36 +37 +38 +39 +40 +41 +42 +43 +44 +45 +46 +47 +48 +49 +50 +51 +52 +53 +54 +55 +56 +57 +58 +59 +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 +diabetes. J Pediatr Psychol 2006;31:818-27. +14. Gullone E, Hughes EK, King NJ, Tonge B. The normative development +of emotion regulation strategy use in children and adolescents: A 2-year +follow-up study. J Child Psychol Psychiatry 2010;51:567-74. +15. Gross JJ. The emerging field of emotion regulation : An integrative review. +??? 1998;2:271-99. +16. Rasmussen NH, Smith SA, Maxson JA, Bernard ME, Cha SS, Agerter DC, +et al. Association of HbA 1c with emotion regulation, intolerance of +uncertainty, and purpose in life in type 2 diabetes mellitus. Primary Care +Diabetes 2013;7:213-21. +17. Fisher L, Hessler D, Polonsky W, Strycker L, Guzman S, Bowyer V, et al. +Emotion regulation contributes to the development of diabetes distress +among adults with type 1 diabetes. Patient Educ Couns 2018;101:124-31. +18. Raveendran AV, Deshpandae A, Joshi SR. Therapeutic role of yoga in +type 2 diabetes. Endocrinol Metab (Seoul) 2018;33:307-17. +19. Balaji PA, Varne RS, Ali SS. Effects of yoga-pranayama practices +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. +22. Singh VP, Khandelwal B, Sherpa NT. Psycho-neuro-endocrine- +immune mechanisms of action of yoga in type II diabetes. Anc Sci Life +2015;35:12-7. +23. Bishop SR. Mindfulness: A proposed operational definition. Clin Psychol +Sci Pract 2004;11:???. +24. Kang Y, Gruber J, Gray JR. Mindfulness and de-automatization. Emot +Rev 2013;5:192-201. +25. Roemer L, Williston SK, Rollins LG. Mindfulness and emotion regulation. +Curr Opin Psychol 2015;3:52-7. +26. Bamber MD, Schneider JK. Mindfulness-based meditation to decrease +stress and anxiety in college students: A narrative synthesis of the research. +Educ Res Rev 2016;18:1-32. +27. Goldin PR, Gross JJ. Effects of mindfulness-based stress reduction +(MBSR) on emotion regulation in social anxiety disorder. Emotion +2010;10:83-91. +28. Nagarathna R, Rajesh SK, Amit S, Patil S, Anand A, Nagendra HR. +Methodology of Niyantrita Madhumeha Bharata Abhiyaan-2017, a +nationwide multicentric trial on the effect of a validated culturally +acceptable lifestyle intervention for primary prevention of diabetes: Part +2. Int J Yoga 2019;12:193-205. +29. Walach KH, et al. Measuring mindfulness-The Freiburg Mindfulness +Inventory Related papers The Difficult y of Defining Mindfulness: +Current Thought and Critical Issues Flavia Straia Changes in Mindfulness +and Emotion Regulat ion in an Exposure-Based Cognitive Therapy for +Depress… he Assessment of Mindfulness with Self-Report Measures: +Existing Scales and Open Issues Measuring mindfulness-the Freiburg +Mindfulness Inventory (FMI); 2006. [doi: 10.1016/j.paid.2005.11.025]. +30. Froeliger B, Garland EL, McClernon FJ. Yoga meditation practitioners +exhibit greater gray matter volume and fewer reported cognitive failures: +Results of a preliminary voxel-based morphometric analysis. Evid Based +Complement Alternat Med 2012;2012:821307. +31. Khoury B, Lecomte T, Fortin G, Masse M, Therien P, Bouchard V, et al. +Mindfulness-based therapy: A comprehensive meta-analysis. Clin Psychol +Rev 2013;33:763-71. +32. Hayes AM, Feldman G. Clarifying the construct of mindfulness in the +context of emotion regulation and the process of change in therapy. ??? +???;???:???. [doi: 10.1093/clipsy/bph080]. +33. Webb TL, Miles E, Sheeran P. Dealing with feeling: A meta-analysis of +the effectiveness of strategies derived from the process model of emotion +regulation. Psychol Bull 2012;138:775-808. +34. Park G, Van Bavel JJ, Vasey MW, Thayer JF. Cardiac vagal tone predicts +attentional engagement to and disengagement from fearful faces. Emotion +2013;13:645-56. +35. Ross A, Thomas S. The health benefits of yoga and exercise: A review of +comparison studies. J Altern Complement Med 2010;16:3-12. +36. Kiecolt-Glaser JK, Christian L, Preston H, Houts CR, Malarkey WB, +Emery CF, et al. Stress, inflammation, and yoga practice. Psychosom +Med 2010;72:113-21. +37. Harinath K, Malhotra AS, Pal K, Prasad R, Kumar R, Kain TC, +et al. Effects of Hatha yoga and Omkar meditation on cardiorespiratory +performance, psychologic profile, and melatonin secretion. J Altern +Complement Med 2004;10:261-8. +38. Vadiraja HS, Raghavendra RM, Nagarathna R, Nagendra HR, Rekha M, +Vanitha N, et al. Effects of a yoga program on cortisol rhythm and mood +states in early breast cancer patients undergoing adjuvant radiotherapy: +A randomized controlled trial. Integr Cancer Ther 2009;8:37-46. +39. Streeter CC, Whitfield TH, Owen L, Rein T, Karri SK, Yakhkind A, +et al. Effects of yoga versus walking on mood, anxiety, and brain GABA +levels: A randomized controlled MRS study. J Altern Complement Med +2010;16:1145-52. +9    +[Downloaded free from http://www.ym-kdham.in on Saturday, July 16, 2022, IP: 136.232.192.146] diff --git a/subfolder_0/Energy medicine.txt b/subfolder_0/Energy medicine.txt new file mode 100644 index 0000000000000000000000000000000000000000..3adfca90721510460c7df168dc250ad2726725d0 --- /dev/null +++ b/subfolder_0/Energy medicine.txt @@ -0,0 +1,59 @@ +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: editor@ijoy.org.in +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 diff --git a/subfolder_0/Enhancement of cancer stem cell susceptibility to conventional treatments through_unlocked.txt b/subfolder_0/Enhancement of cancer stem cell susceptibility to conventional treatments through_unlocked.txt new file mode 100644 index 0000000000000000000000000000000000000000..c1c7215337bc25a52c8e240882af3a7cd8dfa5bb --- /dev/null +++ b/subfolder_0/Enhancement of cancer stem cell susceptibility to conventional treatments through_unlocked.txt @@ -0,0 +1,810 @@ +Journal of Stem Cells + +ISSN: 1556-8539 +Volume 7, Number 4 + +© Nova Science Publishers, Inc. + + + + +Enhancement of Cancer Stem Cell Susceptibility +to Conventional Treatments through Complementary +Yoga Therapy: Possible Cellular and Molecular Mechanisms + + + +Hemant Bhargav1, Kashinath Metri1, +Nagarathna Raghuram1, +Nagendra Hongasandra Ramarao1, +and Prasad S. Koka1,2,3,4* +1Department of Integrative Cell Biology, Swami +Vivekananda Yoga Anusandhana Samsthana (SVYASA) +University, Kempegowda Nagar, Bangalore, India +2Department of Biological Sciences, Poornaprajna +Institute of Scientific Research, Sadashivnagar, +Bangalore, India +3Laboratory of Stem Cell Biology, Torrey Pines Institute +for Molecular Studies, 3550 General Atomics Court, +San Diego, California, USA +4Haffkine Institute, Acharya Donde Marg, Parel, +Mumbai, India + + + + Corresponding Authors: Dr. Hemant Bhargav, MBBS, MD +Phone: ++91 +8762019348 +Email: +hemant. +bhargav1@gmail.com; Dr. Prasad Koka, PhD Email: +pkoka@tpims.org +Abstract + +Cancer stem cells (CSCs) are stem-like tumor populations +that are reported to contribute towards tumor growth, +maintenance and recurrence after therapy. Hypoxia +increases CSC fraction and promotes acquisition of a stem- +cell-like state. Cancer stem cells are critically dependant on +the hypoxia-inducible factor-1 (HIF-1) for survival, self- +renewal, +tumor +growth +and +maintenance +of +their +undifferentiated phenotype. Recent researches show that +stage of differentiation of the tumor cells is predictive of +their susceptibility to natural killer cell (NK) cell mediated +cytotoxicity and cancer stem cells are significant targets of +NK cell cytotoxicity. Studies also show that reversion of +tumor cells to a less-differentiated phenotype can be +achieved by blocking NFκB. +Yoga therapy (yogic lifestyle modifications encompassing +physical postures, breathing practices, relaxation techniques +and meditations) is known to modulate neural, endocrine +and immune functions at the cellular level through +influencing cell cycle control, aging, oxidative stress, +apoptosis and several pathways of stress signaling +molecules. Yoga therapy has also been shown to enhance +natural killer cell activity and modulate stress and DNA +damage in breast cancer patients receiving radiotherapy. +Recent study found that brief daily yogic meditation may +reverse the pattern of increased NFκB-related transcription +of pro-inflammatory cytokines in leukocytes. Thus, yoga +therapy has the potential to reduce cancer stem cell +survival, self -renewal and tumor growth by modifying the +tumor micro-environment through various mechanisms +such as; 1) reducing HIF-1 activity by enhanced +oxygenation, 2) promoting NK cell activity directly (or +indirectly through down regulating NFκB expression), +thereby enhancing NK cell mediated CSC lysis, and 3) by +minimizing the aberrant expressions or activities of various +hormones, cytokines, chemokines and tumor signaling +pathways. Yoga therapy may have a synergistic effect with +conventional modalities of treatment in preventing cancer +progression and recurrences. + +Keywords: cancer stem cells, hypoxia, yoga, breathing +techniques, meditation, NK cells + +Hemant Bhargav, Kashinath Metri, Nagarathna Raghuram et al. + +262 + +Role of Cancer Stem Cells in Cancer +Progression and Recurrence + +Cancer is increasingly being viewed as a stem +cell disease, both in its propagation by a minority of +cells with stem-cell-like properties and in its possible +derivation from normal tissue stem cells [1, 2]. Recent +reports link resistance to conventional therapies and +the metastatic potential of cancer to a stem-cell-like +tumor population, termed cancer stem cells (CSCs) [1, +2-5]. Numerous studies indicate that malignant +transformations of stem cells and their progenitors +into cancer progenitor cells might give rise to several +human cancer types such as those of the breast, blood, +brain, skin, lung, gastrointestinal tract, pancreas, +prostate etc [6-12]. Another study by Heddleston et al +[5] describes that CSCs contribute to tumor growth, +maintenance, and recurrence after therapy through +multiple mechanisms and networks such as their +ability to restrict DNA damage during radiation or +chemotherapy by reduction of ROS (Reactive Oxygen +Species) and enhanced activity of DNA checkpoint +kinases [13, 14]. Thus, the CSC population survives +injury and can continue to propagate the tumor by +preventing DNA damage. On the basis of these +observations, it appears that the elimination of this +minority of cancer progenitor cells with stem cell-like +properties which are responsible for tumor formation +is essential for the development of more effective +curative treatments against cancer. + + +Hypoxia and Cancer Stem Cell Survival + +Hypoxia or decreased oxygenation occurs in a +number of physiological and pathophysiological +settings, particularly when rapid tissue growth +exceeds blood supply. Hypoxia is necessary for Stem +cell survival [15], for e.g., stem cells are abundant in +fetal circulation where the partial pressure of oxygen +(pO2) is low and embryogenesis occurs in a +physiologic “hypoxic” environment (3%–5% O2). +Hypoxia is a common feature of all solid tumors and +is an independent prognostic factor for advanced +disease progression and poor clinical outcome [16- +18]. Hypoxia enhances malignant potential of tumor +cells by facilitation of tumor invasion and metastasis +[19], increased expression of drug resistance genes +[20] and reduced expression of DNA repair genes +[21], and increased genomic instability [22]. Hypoxia- +induced signaling is primarily mediated by the +ubiquitous hypoxia-inducible factor-1 (HIF-1), a +molecular determinant of the response of mammalian +cells to hypoxia and a regulator of O2 homeostasis. +Discovery of HIF-1 has led to the identification of a +“molecular target” of hypoxia suitable for the +development of cancer therapeutics [23]. HIFs +regulate the expression of at least 180 genes involved +in wide range of cellular functions such as +metabolism, cell survival, erythropoiesis, and vascular +remodeling [24]. Study shows that low-oxygen +concentrations may promote survival of stem cell +populations by inhibiting cell death through different +pathways (apoptosis induced factor (AIF)-dependent +cell death and caspase-mediated cell death) [25]. +Heddleston et al [5] demonstrate that CSCs are +critically dependant on the HIFs for their survival, +self-renewal and growth. Presence of hypoxia in +tumors may present challenges for therapy because of +the promotion of CSC phenotypes even upon +successful killing of CSCs [5]. They further provide +experimental evidence that put emphasis on the role +of micro-environmental conditions such as hypoxia +that govern CSCs and suggest that newer therapeutic +modalities should be aimed towards disrupting this +micro-environment of the CSCs [5]. It is also +interesting to note that stem cells are sheltered within +a vascular structure in a tumor that provides specific +and confined microenvironments such as hypoxic +areas that are probably involved in the regulation of +stem-cell renewal and fate which may serve as +possible niches for CSCs [26]. The correlation of +tumor hypoxia to poor patient outcome may be related +to an increase in the presence of cancer stem cells [5]. + + +Yoga and Oxygenation + +Consistent practice of yogic postures (asanas) +and breathing techniques (pranayama) increases the +lung's airflow, air capacity, stamina and efficiency. +Back bending postures open the chest, improving both +lung and heart functions. A study [27] assessed blood +oxygen saturation before, during and after two yoga +breathing techniques; high frequency yoga breathing +(Kapalabhati) and breath awareness in 29 healthy +Enhancement of Cancer Stem Cell Susceptibility to Conventional Treatments through Yoga Therapy + +263 +male volunteers with ages ranging between 17 and 32 +years. They observed a significant increase (P<0.01) +in oxygen saturation during the 33 min session of high +frequency yoga breathing. No changes were seen +during breath awareness. Another study measured the +impact of asanas and pranayama on blood oxygen +saturation level. Participants were divided into three +groups– control, experimental-I and experimental-II +which were randomly assigned to three sessions +namely no treatment, treatment as asanas and +treatment as pranayama respectively. It was observed +from the study that the three groups differed +significantly with increase in oxygenation in the +pranayama group [28]. A study compared oxygen +consumption during the short kumbhak (timed breath +holding) varieties of Ujjayi pranayama, and the other +the long kumbhak varieties of Ujjayi pranayama in +ten healthy volunteers between 28-59 years of age. +The duration of kumbhak phase was on an average +22.2 percent of the respiratory cycle in the short +kumbhak group, and 50.4 per cent in the long +kumbhak group. It was observed that short kumbhak +pranayamic breathing caused a statistically significant +increase (52%) in the oxygen consumption (and +metabolic rate) compared to the pre-pranayamic +baseline period of breathing. In contrast to the above, +the long kumbhak pranayamic breathing caused a +statistically significant lowering of the oxygen +consumption (by 19%) and metabolic rate) [29]. Yoga +practices have been also been shown to improve the +redox status. Another study [30], was conducted on +healthy male volunteers divided into two groups viz. +yoga (n = 34) and control group (n = 08). In addition +to their routine activities, the yoga group practiced +yogasanas, pranayama and meditation for 3 months +and control group followed usual routine. Blood +samples were collected in fasting condition before and +after 3 months of yogic practice. Reduced glutathione +and total antioxidant status increased significantly +(P<0.001) whereas glutathione peroxidase activity (P +< +0.001), +plasma +concentration +level +of +malondialdehyde (P<0.01) and oxidized glutathione +(P<0.01) decreased significantly in yoga group after +completion of 3 months. Peripheral arterial oxygen +saturation also increased in the yoga group at the +same time. Another yogic breathing technique called +Sudarshan kriya (SK), which involves breathing in +three different rhythms [31], has been shown to lower +blood lactate levels and provides better antioxidant +defense [31]. In another study [32], the effect of SK +was studied at the transcriptional level of the +antioxidant enzymes. There was a significant increase +in +expression +of +glutathione-S-transferase +in +practitioners of SK as compared to the normal +controls along with significant increase in anti- +apoptotic Cox-2 and HSP-70. A non-significant +increase was observed in the expression of anti- +oxidant +Cu-Zn +SOD, +Mn +SOD, +Glutathione +peroxidase and Catalase genes in practitioners. +Though aging-related hTERT and anti-apoptotic Bcl- +2 also showed an increasing trend in SK practitioners +but it was not statistically significant [32]. +As per Yoga philosophy, prāna (vital force) is the +basic fabric of the universe and everything here is +governed by prāna [33, 34]. Prāna is the basic life +principle that is responsible for all kind of movements +(of thoughts as well the matter) and has the ability to +expand and contract by itself [33, 34]. Prāna can be +thought of as an interface between energy and +consciousness [35]. Yoga philosophy also appreciates +that mind is subtler and thus more powerful than the +prāna and hence can direct its flow [33-38], which in +turn moves energy and hence the particles in the same +direction. Suitable types of prānayāma (Yogic +breathing techniques) help to remove the random +agitations in prāna flow in the prānamaya kośa [36, +37]. Other hathayoga texts such as Hathyoga +Pradipika (H.Y.P.) [39] and Gheranda Samhita (G.S.) +[40] also describe beneficial effects of various +prānayāma as follows: “Wherever there is affliction +due to disease, filling that region with prāna one +should hold it there” (H.Y.P. 5.23) or “Lying supine +on even ground and extending the body one should +practice prānayāma for alleviation of every kind of +disease (H.Y.P. 5.21)”. For bhastrikā prānayāma it is +described that it removes imbalances of all three +dośas (basic humors according to ayurvedic science); +vāta, pitta and kapha. It also improves body fire +(H.Y.P.2.65) and those who do it thrice daily will +never suffer from any disease (G.S. 5.77). Ujjayī +prānayāma also is considered very important and it is +advised that it should form the core of the practices; it +destroys all the diseases of the nādis (subtle energy +channels through which the prāna moves) dhātus +(sevenfold structural components that support the +body, according to ayurvedic science) & increases +Hemant Bhargav, Kashinath Metri, Nagarathna Raghuram et al. + +264 + +gastric fire (H.Y.P. 2.52). Thus, based on these +ancient yogic principles we may use prānayāma and +conscious mental imagery techniques together to +balance subtle molecular derangements in the micro- +environment of the tumour cells such as tumour +signaling pathways and cytokine or chemokine +expressions and also to enhance the blood flow and +oxygenation to a particular region in the body by +consciously moving and balancing the prāna to that +part, thereby possibly reducing the hypoxia-induced +transcription of HIFs and thus making survival of +CSCs more difficult. One such technique which we +have developed is called as Pranic Energization +Technique (PET), where the mind is focused and +made sensitive to appreciate subtle nerve impulse of +touch +sensation +and +then +vyāna +prāna +is +systematically moved and balanced throughout the +body. This technique of PET is also proposed to be +beneficial in reducing radiation induced side effects +such as DNA damage by reducing oxidative stress in +cancer patients [41, 50]. + +Our Pilot Study Comparing the Effects of Two +High Frequency Yoga Breathings on Blood +Oxygen Saturation + +Method: We assessed the changes in blood +oxygen saturation levels during two high frequency +yoga breathing techniques called Bhastrika and +Kapalabhati on 10 healthy male volunteers in the age +range of 18-30 yrs (group mean ± S.D., 24.4 ± 2.8 +years) who were divided into two groups (five in +each) to perform the two breathing techniques +respectively. They had experience of performing these +breathing practices for at least 3 months. Their +oxygen saturation levels were assessed for 1minute +before, 1 minute during the practice using Mindray +MEC-1200 +(Shenzhen +Mindray +Bio-Medical +Electronics Co., Ltd. China). Pre data was compared +with during data using paired samples t test in both +the groups. +Results: We observed a significant increase in +oxygen saturation during the practices of both +Bhastrika (p= 0.009) and Kapalabhati (p=0.012) as +compared to the baseline values (see Table 1). + + +Table 1. Blood oxygen saturation changes before and during (in action) +two high frequency yoga breathing techniques + + +Pre-breathing (1 min) +During-breathing (1 min) +p value *(pre vs during) +Group 1 (Kapalabhati) +97.40±1.34 +100±00 +0.012 +Group 2 (Bhastrika) +96.6±1.95 +100.2±1.94 +0.009 +*paired samples t test. + +Modulation of Neural, Endocrine and Immune +Functions through Yoga Therapy + +A review by Mimeault and Batra [12] describes +that aberrant expression and activities of hormones, +cytokines and chemokines which include estrogens, +androgens, TGF-Notch etc., and tumorigenic +signaling elements such as telomerase, NF-B and +Myc-1 may enhance cancer stem cell survival and +contribute towards the malignant potential of tumors +[12]. Evidences show that Yoga therapy modulates +neural, endocrine and immune functions towards +homeostasis [42]. Yoga therapy may bring about +moderation and balance in the expression and +activities of various hormones, cytokines and +tumorigenic signaling elements to reduce cancer stem +cell survival and thus may complement conventional +therapies in reducing cancer progression and +recurrence. For e.g., Yoga therapy has been shown to +enhance natural killer cell activity [43], reduce plasma +TNF alpha levels following surgery and modulate +stress and DNA damage during radiotherapy in breast +cancer patients [44]. + + +Yoga – NFkB: Natural Killer Cell Activity +and Cancer Stem Cell Lysis + +Study by Tseng et al [45] demonstrated an +increased lysis of cancer stem cells but not their +differentiated counterparts by NK cells. This lysis was +mediated by increased cytotoxicity as well as +Enhancement of Cancer Stem Cell Susceptibility to Conventional Treatments through Yoga Therapy + +265 +augmented secretion of IFN-γ. In this study, NK cells +were found to lyse human Mesenchymal Stem Cells +(hMSCs), human dental pulp stem cells (hDPSCs) +and human induced pluripotent stem cells (hiPSCs) +significantly +more +than +their +differentiated +counterparts or parental lines from which they were +derived. It was also found that inhibition of +differentiation or reversion of cells to a less- +differentiated phenotype by blocking NFκB or +targeted knock down of COX2 in monocytes +significantly augmented NK cell cytotoxicity and +secretion of IFN-γ. Taken together, these results +suggest that stem cells are significant targets of the +NK cell cytotoxicity [45]. +Many metastatic tumor cells exhibit constitutively +elevated NFκB activity [46]. Studies also show that +inhibition of NFκB in primary oral squamous cell +carcinomas, or in non-tumorigenic oral keratinocytes) +leads to a significant increase in cytotoxicity and +secretion of IFN-γ by the human NK cells [47]. +A study on 45 dementia caregivers showed that +brief daily yogic meditation intervention may reverse +the pattern of increased NF-κB-related transcription +of +pro-inflammatory +cytokines +and +decreased +Interferon +response +factors +(IRF1) +related +transcription of innate antiviral response genes [48], +which may enhance NK cell activity indirectly. Also, +as described above, integrated yoga has already been +shown to increase NK cell activity in breast cancer +patients [43, 49]. Recent pilot study also showed that +regular practitioners of yoga have lower cellular +dysfunctions owing to reduced qualitative DNA +damage and better restorative mechanisms (apoptotic +index) as compared to cancer patients [50]. Thus, +another mechanism through which yoga therapy may +be effective in increasing CSC susceptibility to +conventional treatments is through enhancement of +NK cell functioning (Figure 1). + + + +Figure 1. Interactions between natural killer (NK) cells, tumour cells and cancer stem cells (CSC). Stage of +differentiation of the tumor cells is predictive of their susceptibility to (NK) cell mediated cytotoxicity. +Complementary therapies such as yoga are being shown to enhance natural killer cell activity and also to down +regulate NFkB expression, the figure thus denotes the probable mechanism of action of such therapies. + +Conclusion + +Yoga increases resistance against oxidative stress +and thus plays a protective role against development +of cancer on one hand and on the other side, yogic +therapeutic techniques as a whole and pranayama in +particular have been shown to enhance oxygenation. +Yoga modulates neural, endocrine and immunological +functions at the cellular level and enhances NK cell +functioning in cancer patients; all of which make +survival for CSCs difficult. Yoga has also been shown +to reduce radiation and chemotherapy induced side +Hemant Bhargav, Kashinath Metri, Nagarathna Raghuram et al. + +266 + +effects. Thus, yoga therapy may have a synergistic +effect with conventional modalities of treatment in +preventing cancer progression and recurrences by +increasing the susceptibility of cancer stem cells to +conventional treatment. Future studies should aim at +unraveling the effects of yoga therapy on HIF-1 +levels, NFkB expression, stem-like expressions on +tumor cells and extent of CSC lysis. + + +Acknowledgment + +Dr. +Prasad +Koka +is +supported +by +the +Ramalingaswami +Fellowship +Re-entry +Scheme +funded by the Department of Biotechnology, +Government of India, New Delhi. + + +References + +[1] +Beachy PA, Karhadkar SS, Berman DM. Tissue repair +and stem cell renewal in carcinogenesis. Nature +2004;432:324–331. +[2] +Zhang M, Dias P, Minev B, Koka PS. Induction, +isolation +and +characterization +human +fetal +hematopoietic cancer stem cells in vivo. J Stem Cells +2010; 5(1): 1-7. +[3] +Wagemaker G. Heterogeneity of radiation sensitivity of +hemopoietic stem cell subsets. Stem Cells 1995; +13:257-60. +[4] +Bao S, Wu Q, McLendon RE, Hao Y, Shi Q, +Hjelmeland AB, et al. Glioma stem cells promote +radioresistance by preferential activation of the DNA +damage response. Nature 2006; 444:756-60. +[5] +Heddleston JM, Li Z, Lathia JD, Bao S, Hjelmeland +AB, and Rich JN. Hypoxia inducible factors in cancer +stem cells. Br J Cancer 2010; 102(5): 789–795. +[6] +Liu S, Dontu G, Wicha MS. Mammary stem cells, self- +renewal pathways, and carcinogenesis. Breast Cancer +Res 2005;7:86–95. +[7] +Kim CF, Jackson EL, Woolfenden AE et al. +Identification of bronchioalveolar stem cells in normal +lung and lung cancer. Cell 2005;121: 823–835. +[8] +Fang D, Nguyen TK, Leishear K et al. A tumorigenic +subpopulation with stem cell properties in melanomas. +Cancer Res 2005;65: 9328 –9337. +[9] +Schier S, Wright NA. Stem cell relationships and the +origin of gastrointestinal cancer. Oncology 2005;69:9– +13. +[10] +Wang JC, Dick JE. Cancer stem cells: Lessons from +leukemia. Trends Cell Biol 2005;15:494–501. +[11] +Galderisi U, Cipollaro M, Giordano A. Stem cells and +brain cancer. Cell Death Differ 2006;13:5-11. +[12] +Mimeault M, Brand RE, Sasson AA et al. Recent +advances on the molecular mechanisms involved in +pancreatic cancer progression and therapies. Pancreas +2005;31:301–316. +[13] +Bao S, Wu Q, McLendon RE, Hao Y, Shi Q, +Hjelmeland AB, Dewhirst MW, Bigner DD, Rich JN. +Glioma +stem +cells +promote +radioresistance +by +preferential activation of the DNA damage response. +Nature. 2006a;444:756–760. +[14] +Diehn M, Cho RW, Lobo NA, Kalisky T, Dorie MJ, +Kulp AN, Qian D, Lam JS, Ailles LE, Wong M, Joshua +B, Kaplan MJ, Wapnir I, Dirbas FM, Somlo G, +Garberoglio C, Paz B, Shen J, Lau SK, Quake SR, +Brown JM, Weissman IL, Clarke MF. Association of +reactive oxygen species levels and radioresistance in +cancer stem cells. Nature. 2009;458:780–783. +[15] +Cipolleschi MG, Dello Sbarba P, Olivotto M. The role +of hypoxia in the maintenance of hematopoietic stem +cells. Blood. 1993;82:2031–7. +[16] +Brizel DM, Scully SP, Harrelson JM, Layfield LJ, Bean +JM, Prosnitz LR, et al. Tumor oxygenation predicts for +the likelihood of distant metastases in human soft tissue +sarcoma. Cancer Res 1996; 56:941-3. +[17] +Hockel M, Schlenger K, Aral B, Mitze M, Schaffer U, +Vaupel P. Association between tumor hypoxia and +malignant progression in advanced cancer of the uterine +cervix. Cancer Res 1996; 56:4509-15. +[18] +Young SD, Marshall RS, Hill RP. Hypoxia induces +DNA overreplication and enhances metastatic potential +of murine tumor cells. Proc Natl Acad Sci USA +1988;85:9533-7. +[19] +Subarsky +P, +Hill +RP. +The +hypoxic +tumour +microenvironment and metastatic progression. Clin Exp +Metastasis 2003; 20:237-50. +[20] +Comerford KM, Wallace TJ, Karhausen J, Louis NA, +Montalto MC, Colgan SP. Hypoxia-inducible factor-1- +dependent regulation of the multidrug resistance +(MDR1) gene. Cancer Res 2002; 62:3387-94. +[21] +Mihaylova VT, Bindra RS, Yuan J, Campisi D, +Narayanan L, Jensen R, et al. Decreased expression of +the DNA mismatch repair gene Mlh1 under hypoxic +stress in mammalian cells. Mol Cell Biol 2003;23:3265- +73. +[22] +Koshiji M, To KK, Hammer S, Kumamoto K, Harris +AL, Modrich P, et al. HIF-1alpha induces genetic +instability +by +transcriptionally +downregulating +MutSalpha expression. Mol Cell 2005; 17:793-803. +[23] +Giovanni Melillo. Inhibiting Hypoxia-Inducible Factor +1 for Cancer Therapy. Mol Cancer Res 2006;4(9):601– +5. +[24] +Semenza, G.L. 2000. HIF-1 and human disease: One +highly involved factor. Genes & Dev 2000;14:1983– +1991. +[25] +Clarke L, Kooy DV. Low Oxygen Enhances Primitive +and Definitive Neural Stem Cell Colony Formation by +Enhancement of Cancer Stem Cell Susceptibility to Conventional Treatments through Yoga Therapy + +267 +Inhibiting Distinct Cell Death Pathways. Stem Cells +2009;27:1879–1886. +[26] +Gilbertson RJ, Rich JN. Making a tumour′s bed: +glioblastoma stem cells and the vascular niche. Nat Rev +Cancer. 2007;7:733–736. +[27] +Gupta RK, Telles S, Balkrishna A. 2011. Effect of Two +Yogic Breathing Techniques on Oxygen Saturation. +Indian J Physiol Pharmacol 2011; Vol. 55, No. 5, +Supplement. http://www.appicon2011.org/Documents/ +Page%2041%20-%20336. Pdf +[28] +Ashok C. Impact of asanas and pranayama on blood +oxygen saturation level. Br J Sports Med 2010; 44:i69. +[29] +Telles S, Desiraju T.1991. Oxygen consumption during +pranayamic type of very slow-rate breathing. Indian J +Med Res. ;94: 357-63. +[30] +Pal R, Singh SN, Saha M. 2011. Improvement of Redox +Status through Yoga. Indian J Physiol Pharmacol, Vol. +55, No. 5, Supplement. http://www.appicon2011.org/ +Documents/Page%2041%20-%20336. Pdf +[31] +Sharma H, Sen S, Singh A, Bhardwaj NK, Kochupillai +V, Singh N. Sudarshan Kriya practitioners exhibit better +antioxidant status and lower blood lactate levels. Biol +Psychol. 2003; 63:281-91. +[32] +Singh N, Sharma H, Datta P, Singh A, Sen S, Bhardwaj +NK, Kochupillai V. Gene Expression Profiling in +Practitioners +of +Sudarshan +Kriya. +Journal +of +Psychosomatic research;2008:50-53. +[33] +Praśnopaniśad. Commentary by swami chinmayānanda. +Central +Chinmaya +Mission +Trust, +Sandeepany +Sadhanalaya, Powai Park Drive, Mumbai (Fourth +Edition), 1990. +[34] +Taittarīya +Upaniśad. +With +the +commentary +of +Sankaracharya translated by swami Gambhirānanda. +1986. +Published +byAdvaita +Ashrama. +Mayavati, +Pithoragarh, Himalayas, 1990. +[35] +Taimni IK. The science of yoga: The yoga sūtrās of +Pātañjali. Wheaton, IL: Theosophical Publishing House, +1961. +[36] +The Vision and the Way of Vasistha. Compiled by B.L. +Atreya translated by Samvid, Indian Heritage Trust, +Madras, India, 1993. +[37] +Nagendra H R, Nagaratna R. Yoga for Promotion of +Positive +Health. +Swami +Vivekānanda +Yoga +Publications. Bangalore, India, 2001. +[38] +The Holy Gita commentary by Swami Chinmayānanda, +Chapter 3 verse 42. Central Chinmaya Mission Trust, +Sandeepany Sadhanalaya, Powai Park Drive, Mumbai, +India, 2001. +[39] +Hath Yoga Pradipika: Light on hath yoga- commentary +by Swami Muktibodhānanda under the guidance of +Swami Satyānanda Saraswati. Yoga Publication Trust, +Ganga darshan, Munger, Bihar, India (Third edition), +2002. +[40] +The Gheranda Samhita, translated by Rai Bahadur Srisa +Chandra Vasu. Chaukhamba Sanskrit pratishthan, +Jawaharnagar, Delhi, India. (First edition), 1999. +[41] +AN Pandey. Response 2. Int J Yoga. 2012; 5(1): 76–77 +[42] +Bhargav H, Raghuram N, Ramarao NH, Tekur P, Koka +PS. 2010. Potential Yoga Modules for Hematopoietic +Inhibition in HIV-1 Infection. J Stem Cells; 5(3): 129- +148. +[43] +Rao RM, Telles S, Nagendra HR, Nagarathna R, +Gopinath K, Srinath S, Chandrashekara C.2008. Effects +of yoga on natural killer cell counts in early breast +cancer patients undergoing conventional treatment. Med +Sci Monit; 14(2):LE3-4. +[44] +Rao RM, Nagendra HR, Raghuram N, Vinay C, +Chandrashekara S, Gopinath KS, Srinath BS.2008. +Influence of yoga on postoperative outcomes and +wound healing in early operable breast cancer patients +undergoing surgery. Int J Yoga ;1(1):33-41. +[45] +Tseng HC, Arasteh A, Paranjpe A, Teruel A, Yang W et +al. Increased Lysis of Stem Cells but Not Their +Differentiated Cells by Natural Killer Cells; De- +Differentiation or Reprogramming Activates NK Cells. +PLoS One. 2010; 5(7): e11590. +[46] +Rayet B, Gelinas C. Aberrant rel/nfkb genes and +activity in human cancer. Oncogene. 1999;18(49):6938– +47. +[47] +Jewett A. et al. Inhibition of nuclear factor kappa B +(NFkappaB) activity in oral tumor cells prevents +depletion of cells NK and increases their functional +activation. +Cancer +Immunol +Immunother. +2006;55(9):1052–63. +[48] +Black DS, Cole SW, Irwin MR, Breen E, St Cyr NM, +Nazarian N, Khalsa DS, Lavretsky H.2012. Yogic +meditation +reverses +NF-κB +and +IRF-related +transcriptome dynamics in leukocytes of family +dementia caregivers in a randomized controlled trial. +Psychoneuroendocrinology. 2012 Jul 13. [Epub ahead +of print] +[49] +Nakau M, Imanishi J, Imanishi J, Watanabe S, Imanishi +A, Baba T, Hirai K, Ito T, Chiba W, Morimoto Y. +Spiritual care of cancer patients by integrated medicine +in urban green space: a pilot study. Explore (NY). +2013;9(2):87-90. +[50] +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 Jan;6(1):20-5. + diff --git a/subfolder_0/Evidence for extended age dependent maternal immunity in infected children_unlocked.txt b/subfolder_0/Evidence for extended age dependent maternal immunity in infected children_unlocked.txt new file mode 100644 index 0000000000000000000000000000000000000000..ab46f0d26615309a702f6f9a1fec5f7c0332101e --- /dev/null +++ b/subfolder_0/Evidence for extended age dependent maternal immunity in infected children_unlocked.txt @@ -0,0 +1,3239 @@ +Journal of Stem Cells + +ISSN: 1556-8539 +Volume 7, Number 3 + +© 2012 Nova Science Publishers, Inc. + + + + +Evidence for Extended Age Dependent Maternal Immunity +in Infected Children: Mother to Child Transmission of HIV +Infection and Potential Interventions Including Sulfatides +of the Human Fetal Adnexa and Complementary +or Alternative Medicines + + +Hemant Bhargav1, Vidya Huilgol2, +Kashinath Metri1, I. Birgitta Sundell3, +Satyam Tripathi1Nagaratna Ramagouda4,5, +Mahesh Jadhav4, Nagarathna Raghuram1, +Nagendra Hongasandra Ramarao1, and +Prasad S Koka1,3,6,7,≠, + +1Department of Integrative Cell Biology, +Swami Vivekananda Yoga Anusandhana Samsthana, +Gavipuram Circle, Kempegowda Nagar, +Bangalore, Karnataka State, India +2ICTC and ART Centre, +Belgaum Institute of Medical Sciences, +Ambedkar Road, Belgaum, Karnataka State, India +3Laboratory of Stem Cell Biology, +Torrey Pines Institute for Molecular Studies, +San Diego, California, USA +4Mahesh Foundation-Aadhar, Siddeshwar Nagar, Kanabargi, +Belgaum, Karnataka State, India +5Spandana Network of Positive People, +Matru Pitru Chaya Building, Sadashiv Nagar, +Belgaum, Karnataka State, India +6Division of Biological Sciences, +Poornaprajna Institute of Scientific Research, +Poornaprajnapura, Bidalur, Devanahalli, +Bangalore, Karnataka State, India +7Department of Virology and Immunology, +Haffkine Institute for Training, Research & Testing, Acharya +Donde Marg, Parel, +Mumbai, Maharashtra State, India + +≠Chief Advisor for Stem Cell Biology and Oncolytic Viral +Therapy, Genelux Corporation, San Diego, California, +USA +Corresponding Author: Prasad S Koka, PhD. Mailing +Address: No. 4, 16th Cross, Poornaprajna Institute of +Scientific Research, Sadashivnagar, Bangalore – 560 080, +India. Email: prasad.koka@poornaprajna.org + +Abstract + +The two neighboring southwestern states of India, +Karnataka and Maharashtra, have high incidence of +HIV/AIDS and are among the six most high prevalence +HIV infected states. In Karnataka state, the northern +districts of Bagalkot, Belgaum and Bijapur (the three Bs) +and in Maharashtra state, the southern districts of Sangli, +Satara, and Solapur (the three Ss) are the areas with the +highest incidence of HIV/AIDS. We have evaluated the +incidence of maternal to child transmission (MTCT) of +HIV-1 infection in Belgaum District which is more than +500 kilometers distance by road from the campus in greater +Bangalore (Karnataka State). We have obtained the prenatal +CD4 counts of HIV infected pregnant mothers. We have +also screened the HIV infected children in two orphanages +(rehabilitation centres for HIV infected children) in +Belgaum District. The clinical conditions of these infected +children were assessed for their CD4 counts, anti-retroviral +therapy (ART) intake status, outpatient illnesses and body +composition. We have observed that there is an influence of +the age factor on the CD4 counts of the HIV infected +children. + +Further, in view of the role of our recently found +involvement of sulfatide, -- galactosylceramide, in +inhibition of HIV-1 replication and enhancement of +hematopoiesis which is otherwise inhibited due to such +infection, we have discussed the possible role of sulfatides +that biologically occur in the fetal adnexa (placenta- +trophoblasts /amnion/chorion-umbilical cord), in containing +HIV infection as a potential safer alternative to the ART +regimens currently approved to be clinically practiced. + +Lastly, we have discussed the complementary and +alternative medicine (CAM) therapies such as evidence +based yoga and ayurveda as add-on to ART in potential +elimination of MTCT of HIV infection. + +Out of a total of 150 children delivered by HIV infected +mothers, 13 children were found to be positive as +Hemant Bhargav, Vidya Huilgol, Kashinath Metri et al. + +128 + +determined by the dried blood smear (DBS) for virological +testing, giving an incidence of about 8.66% in the Belgaum +district during the last two years, in spite of the prescription +of currently available ART regimens. All the 13 HIV- +transmitting mothers had normal vaginal deliveries. Though +12% of the total 150 deliveries required lower segment +caesarean section (LSCS), none among them resulted in +MTCT of HIV. Comparison of the prenatal CD4 counts +between transmitting and non-transmitting mothers did not +show significant differences (p=0.25) thus suggesting +indirectly that HIV-1 proviral loads (undetermined / +unavailable) need not necessarily determine the fate of +incidence of vertical transmission. + +The mean age of 44 HIV infected children (14 females, 30 +males) that were screened in two orphanages was 10.8±3.1 +years. Out of these 44 children, 27 were taking ART +(61.36%) with mean duration of consumption being +2.8±2.28 years. Fifty percent (n=22) of the children were +suffering from at least one outpatient illness, out of which +13 were taking ART. Their mean basal metabolic rate +(BMR), body mass index (BMI), muscle mass, fat mass +and fat % were 795.45±106.9, 14.55±1.9 kg/m2, 9.54±3.4 +kg, 3.69±2.24 kg and 15.04±7.8% respectively. Comparison +between the children taking ART (on-ART, n=27) and +those not taking ART (non-ART, n= 17) showed that +though there was no significant difference in the average +age of the two groups, on-ART children had significantly +higher BMR (p=0.05), and muscle mass (p=0.004), than +non-ART. The CD4 counts, BMI, fat mass and fat +percentage did not show significant statistical differences +between the two groups. + +The CD4 counts of the children (both on-ART and non- +ART) of age 8 years and below (n=12) were found to be +significantly higher (p=0.04) than those of age 14 and +above (n=10). All the children in age group of 14 years and +above (n=10) except one child were on ART, whereas 7 out +of 12 children in age group of 8 years and below were on- +ART. In one of the rehabilitation centers called Aadhar, +among non-ART children, a significant correlation was +observed between the age of the child and CD4 counts +(measured separately in the months of June 2011 and +December 2011). Both the CD4 counts measured in June +2011 (n=6; r=-0.82, p= 0.04) as well as in December 2011 +(n=6; r=-0.97, p=0.001) showed a significant decline as the +age progressed. Also, at the same center, among on-ART +children, the CD4 counts in June 2011 (n=7) and December +2011 (n=8) were significantly different between the +children in the age group of 8 below years, and those in the +age group of 14 years and above (p= 0.005). + +As HIV infected children grow in age, they may lose +maternal derived immunity as shown by the decrease in +CD4 counts, irrespective of their ART status. It is to be +expected from these results that the conferred maternal +immunity (possibly primarily humoral and secondarily +cytotoxic immune responses) to the virus acquired at child +birth taper off and eventually overcome by the generation +of mutant HIV strains in the children, as the life spans of +the infected children progress. + +We have discussed safer therapeutic interventions whose +efficacy on HIV/AIDS may be synergistic to or even +substitute the existing treatment strategies. Some of such +interventions may even be customized to help eliminate +MTCT. Further, these virus infected pregnant mother +patient blood / serum samples could prove useful in the +vaccine development against HIV infection. + +Keywords: HIV, vertical transmission, fetal adnexa, +sulfatides, CAM + + +Introduction + +Problem of HIV/AIDS in India and in the State +of Karnataka + +HIV is a global health problem and one of the +major health threats in India [1]. In 2008, an estimated +2.27 million people between the ages of 15-49 years +were living with HIV (PLHIV=people living with +HIV) in India [2]. India is ranked third in the world in +terms of highest number of people living with HIV +infection. In almost 6 percent of cases in 2008, the +route of transmission of infection was from mother to +child (vertical) transmission [1]. +Whereas in 2005-2006 in India, 11,817 pregnant +mothers were detected with HIV infection, the +number increased to 16,860 in 2006-2007, and to +20,250 in 2007-2008, at PPTCT (=prevention of +parent to child transmission) centers. Despite the scale +up in HIV/AIDS health care program, only 20% of +the estimated annual pregnancies out of 27 million +were counseled and tested for HIV/AIDS in 2009. +Further, only 30% of an estimated annual load of +65,000 HIV positive pregnant women was detected in +the same year. India government National AIDS +Control Organisation (NACO) thus aims at new +initiatives for early detection among pregnant women +and eliminate mother to child transmission [2]. +Women account for 39 percent of PLHIV in India, +while children account for 3.8%. While there are no +reliable estimates of ‘affected’ children in the country, +a UNICEF report summarizes that India possibly has +150,000 vertically infected children; 1,500,000 +children orphaned by AIDS; and 7,000,000 children +with HIV-positive parents (either or both). An +Evidence for Extended Age Dependent Maternal Immunity in Infected Children + +129 + +infected child will usually have a positive parent, and +may also be orphaned by AIDS due to the death of +parent(s). Out of over 70,000 children living with +HIV registered in 2009, only approximately one third +received ART [2]. +Around 60% of the PLHIV burden is in the six +high prevalence states of India, where our currently +residing Karnataka state ranks second [2]. Based on +the revised estimates of infected people, an estimated +276,000 people in Karnataka are infected with HIV +[3]. In the general population, data from the antenatal +clinic attendees in Karnataka suggest that the overall +prevalence of HIV in the general population is high: +approximately 0.86% according to the 2007 antenatal +sentinel surveillance and 0.69 in the National Family +Health Survey III (NFHS-3). The sentinel surveillance +data also pegs the HIV prevalence among those +attending sexually transmitted infections (STI) clinics +at 7.15% [2]. Though the antenatal prevalence has +decreased from 1.3 (2005) to 0.86 (2007), prevalence +of HIV exceeds 1% in antenatal clinic attendees in 11 +of the total 27 districts of Karnataka. The prevalence +is relatively higher in the northern districts of the +state, which includes Belgaum district [4]. Overall, in +Karnataka state, the number of HIV infected +individuals is showing a steady increase in the last ten +years. Correspondingly the number of HIV infected +women also is on the rise. As a result, the number of +children born with HIV infection is also on the rise +and it is expected to increase with the number of +infections occurring in women [4]. +A study by Pradhan et al [4] indicated that the +burden of non-hospitalized (outpatient) as well as +hospitalized (inpatient) illnesses is very heavy on HIV +infected households in comparison with non-HIV +households in Karnataka state due to frequency of +clinical and hospital visits. In the age group of 15-59 +years, which consists of the majority of HIV infected +population, the burden on HIV households is nearly +four times that of non-HIV households in respect of +non-hospitalized illnesses and nearly ten times in case +of hospitalized illnesses. +Thus, we planned this study to determine the +incidence of MTCT of HIV infection in the Belgaum +district of Karnataka State, India and conducted a +clinical estimation in two orphanage rehabilitation +centers for HIV infected children (Spandana and +Aadhar) in the same district area. We evaluated the +basic health parameters and the burden of illnesses in +these HIV infected children from these two +orphanages and the impact of various factors such as +age, ART status and overall environment on the +affected children. +Since MTCT involves the fetal adnexa, we have +also been investigating the human host cellular factors +that may play role(s) in HIV-1 infection as they relate +to different stem cells involved in molecular, cellular, +and clinical consequences of HIV-1 infection either in +a direct manner, or more likely in these cases, in an +indirect manner. + + +Mother to Child Transmission of HIV +infection: Role of Placenta + +It is important to study the role of putative +cellular host factors in HIV infection to understand +the mechanisms of HIV pathogenesis. For example, +when the infected T-lymphocytes interact with the +hematopoietic CD34+ progenitor stem cells, this +causes the inhibition of the CD34+ progenitor stem +cell differentiation in an indirect manner [5, 6]. +Similarly, during the process of MTCT of HIV +infection, the host cellular factors may play an +important role when the infected T-lymphocytes +interact with the placental mesenchymal stem cells +(MSCs) and the neighboring trophoblasts, in an +indirect manner with implications to the involvement +of inflammatory cytokines [7], or other unknown +factors, all of which are yet to be determined. +In MTCT, the placental mesenchymal stem cells +(MSCs), and/or its trophoblasts, amnion and chorion +membranes, amniotic fluid, (Figure 1) [8], and +umbilical cord (together known as fetal adnexa) are +naturally expected to play role(s) in the vertical +transmission of HIV infection. +Transmission of HIV during pregnancy increases +the population of HIV infected patients worldwide +and also contributes to infant mortality [9]. +The placental cells play a major role in the +vertical transmission of HIV [10]. An injury to +placenta aggravates and increases the risk of the +vertical transmission. +HIV infected T-lymphocytes when they come +into contact with the placental trophoblasts may +become susceptible to the mother to fetus virus +Hemant Bhargav, Vidya Huilgol, Kashinath Metri et al. + +130 + +transmission during pregnancy [11]. The occurrence +of vertical transmission is higher with increased +number of pregnancies of the mother and chorio- +amnionitis is associated with placental transmission of +human immunodeficiency virus-1 subtype E in the +early gestational period [9], possibly due to maternal +response to the local inflammation of the placental +membranes. + +  +  +Figure 1. The amniotic membrane is the thin innermost layer of placenta, almost fused with the chorion in a way that the two +are one membrane (left panel). Amnion consists of a thin epithelial layer, a thick basement membrane of extra cellular +matrix proteins (ECM) and an avascular stroma. In the amniotic membrane there are two cell types present, they are of +different embryological origin: mesenchymal stem cells (MSC) from mesoderm and epithelial cells from ectoderm. The +chorionic membrane contains fibroblasts and trophoblasts . For mesenchymal stem cell isolation, the two membranes should +be separated prior to enzymatic digestion [6]. +Placental cytokines and its other soluble factors +may then trigger the crossing of the barrier between +the HIV infected T-lymphocytes and the placental +trophoblasts thereby increasing the risk of mother to +fetal virus transmission [11]. +Although the physiological impact is not yet +known, in vitro studies suggest that HIV gene +products can induce directly the activation of T +lymphocytes and macrophages, and the production of +pro-inflammatory cytokines and chemokines. +For instance, the envelope protein gp120 may be +able +to +activate +cells +or +to +enhance +their +responsiveness to activation, even in absence of direct +infection, through binding to or interaction with CD4 +or co-receptors [12-15]. +The accessory protein, Nef, is also able to lead to +lymphocyte activation either directly or through the +infection of macrophages [16]. HIV-1 also causes +immune activation and inflammation through indirect +means. Thus, placental inflammation may also be a +factor in enhancing vertical transmission. +Vertical Transmission of HIV Infection + +131 + + + +Role of Sulfatides and CAM in Enhancement +of the prevention of MTCT of HIV Infection + +In this context, we also discuss the role of our +newly found sulfatide, -- galactosylceramide, in +preventing MTCT of HIV infection [14, 15]. As it has +been shown that sulfatide inhibits HIV-1 replication +and causes increase in the CD4 counts and sulfatide +concentrations, besides enhancing hematopoiesis +which is otherwise inhibited by the virus replication +[14]. Arylsulphatase A (an enzyme that catabolizes +sulfatides) has been extracted and biochemically +determined in human placenta, its chorionic and +amnionic membranes [Figure3], and the umbilical +cord [16]. In the discussion section, we also describe +the scientific evidences which indicate a possible role +for CAM therapies,for the HIV infected mothers, as +an +add-on +to +anti-retroviral +therapy +(ART)in +preventing MTCT of HIV infection.We hypothesize +that by integrating these new safer drug candidates +such as the Sulfatide, coupled with CAM regimens,as +clinical therapeutic alternatives to the currently +prescribed standard ART care of the HIV infected +mother,we may be able to better contain the incidence +of MTCT.These integrative methods may enhance the +possibility of achieving the UNAIDS goal of virtually +eliminating the mother-to-child transmission of HIV +infection by the year 2015. + + +Methods + +Even though HIV type 1 (HIV-1) is known to be +the most prevalent in India, since we have not +determined that the virus type 2 is excluded in these +infections, we are referring to the virus as HIV +infection and not exclusively as HIV-1. +We have detected through dried blood smear +(DBS) the HIV infection status of the delivered child. +Among a total of 150 HIV infected children that were +tested by DBS. All the HIV infected mothers who +came for delivery in the Belgaum Institute of Medical +Science (BIMS) during the last two years were on +standard ART. +ART +was +initiated +according +to +national +guidelines on the basis of immunological and/or +clinical criteria to all the HIV infected pregnant +mothers.Pre-natal CD4 counts were detected using +PARTEC CyFLOW Counter, or Becton Dickinson +Fluorescence Activated Cell Sorter (BD FACS) +instrument. +A total of 44 HIV infected children were screened +in the orphanages and the data was acquired. The +mean age of 44 HIV infected children (14 females, 30 +males) in the two orphanages, Spandana and Aadhar +centers combined was 10.8±3.1 years. The body +composition of the children was measured using +InBody R20 Body Composition Analyzer by +BIOSPACE, Seoul, 135 854 Korea. This device +measures body composition (Weight, Body Fat Mass, +Percentage Body Fat, Body Mass Index, Skeletal +Muscle Mass, Basal Metabolic Rate) using Direct +Segmental Multi-frequency Bioelectrical Impedance +Analysis (DSM-BIA) Method. +Data was found normally distributed by Shapiro- +Wilk test and Independent samples t test was used to +compare the dependent variables using SPSS version +16.0. The prevalence rate of non-hospitalized illnesses +(outpatient) was assessed based on the reporting of +illnesses by the children during the clinical +appointment and examination and based on their +clinical history. + + +Results + +Clinical Data on MTCT of HIV Infection + +Out of a total of 150 children delivered by HIV +infected mothers, 13 children were found to be DBS +positive, giving an incidence of about 8.66% in the +Belgaum district, Karnataka state, India during the +years 2009 to 2011.Out of 150 HIV infected mothers +who delivered the babies, 18 (12%) underwent lower +segment caesarean section (LSCS). All the above 13 +HIV-transmitting +mothers +had +normal +vaginal +deliveries. No LSCS case transmitted the infection to +the child (Table 1). +The average CD4 counts of undetected group +(n=30) was found to be 366.1±236.7, whereas in the +detected group (n=4) the values were 41,238,301 and +324 and respectively. +All the 4 DBS detected cases showed mothers’ +CD4 counts below 350 (Figure 2). The comparison +Hemant Bhargav, Vidya Huilgol, Kashinath Metri et al. + +132 + +between the prenatal CD4 counts of the transmitting +mothers and the non-transmitting mothers did not +show significant statistical differences (p=0.25) +(Figure 2 and Table 2). + +Table 1. This table provides information regarding the incidence of MTCT in a government hospital in a district +belonging to Karnataka state of India. Table 1 shows that among 150 children delivered by HIV positive pregnant +mothers, 13 pregnancies (8.66%) resulted in MTCT of HIV as determined by the dried blood smear (DBS) for +virological testing. Out of which 3 were from outer states and 9 were wet blood smear (WBS) positive. All the +mothers were put on standard ART treatment. All 13 HIV-transmitting mothers had normal vaginal deliveries + +Total DBS done +DBS positive +No of children +150 +13 +Normal deliveries +132 +13 +Caesarean section +18 +0 +Death +NA +1 +WBS positive +NA +9 +Out of state +NA +3 + +  +Figure 2. Incidence of MTCT and comparison to CD4 counts of the HIV infected mothers. This figure shows a scatter +diagram between the perinatal CD4 counts of the HIV infected pregnant mothers who delivered with MTCT of HIV +infection (DBS detected) and those who did not show MTCT (DBS undetected). Statistically the CD4 counts of the +transmitting mothers did not differ significantly from the non-transmitting mothers. +Table 2 - This table provides information +regarding the incidence of MTCT in a government +hospital in a district belonging to Karnataka state of +India. Prenatal CD4 counts were available for 31 HIV +infected mothers (on all MTCT instances, CD4 counts +of the mothers were found to be below 350). +To retain confidentiality and protect the identity, +only the first three letters of the name of the subjects +are disclosed and any speculation of the actual full +Vertical Transmission of HIV Infection + +133 + +given or last name would be misleading. The rows are +filled in increasing order of age of the children born to +HIV +infected +mothers. +Blank +rows +indicate +unavailable data. f=female; m=male; DBS=dried +blood smear for detection of HIV transmission in +child. + +Table 2. Incidence of MTCT (as detected by DBS) and comparison to CD4 counts of the mothers. + +S No + +Child +(first 3 letters) +Gender +(DOB) +MM/DD/YYYY +Age in +months +DBS status +Mother +(first 3 +letters) +CD4 +counts +1 +Sru +f +12/13/2011 +2 +Sar +417 +2 +Pra +f +11/04/2011 +3 +Uma +335 +3 +Arc +f +11/02/2011 +3 +Ruk +805 +4 +Gau +f +11/04/2011 +3 +Lax +369 +5 +Pan +m +10/03/2011 +4 +Nag +74 +6 +Vij +m +10/06/2011 +4 +Sum +210 +7 +Sam +m +10/22/2011 +4 +Dra +307 +8 +Sid +m +08/29/2011 +6 +not detected +Res +351 +9 +Smi +f +07/07/2011 +7 +not detected +Lax +319 +10 +Sup +f +06/23/2011 +8 +Sav +300 +11 +Vit +m +06/17/2011 +8 +Kas +549 +12 +San +m +06/22/2011 +8 +not detected +Kav +262 +13 +Aim +f +06/23/2011 +8 +not detected +Afr +208 +14 +Dee +f +05/10/2011 +9 +Lax +623 +15 +Sam +f +05/19/2011 +9 +not detected +Dee +144 +16 +Man +m +05/04/2011 +9 +not detected +Poo +287 +17 +Shi +f +04/09/2011 +10 +San +185 +18 +Sup +m +03/25/2011 +11 +not detected +San +225 +19 +Gan +m +03/03/2011 +11 +not detected +Bha +20 +Par +m +02/21/2011 +12 +not detected +Ara +499 +21 +Gan +m +02/14/2011 +12 +detected +Mon +238 +22 +Pri +f +01/04/2011 +13 +not detected +Par +23 +Yog +m +01/30/2011 +13 +not detected +Par +523 +24 +Aru +m +12/06/2010 +15 +not detected +Lal +561 +25 +Pra +f +10/25/2010 +17 +not detected +Shr +1217 +26 +Bag +m +10/02/2010 +17 +not detected +Swa +229 +27 +Nan +f +09/29/2010 +18 +Poo +28 +Gaj +m +09/09/2010 +18 +not detected +Sav +283 +29 +Shi +m +09/16/2010 +18 +not detected +Dan +343 +30 +Pra +f +08/29/2010 +19 +not detected +Dee +327 +31 +Pre +f +08/26/2010 +19 +not detected +Lal +32 +Pra +m +08/01/2010 +19 +not detected +Sur +272 +33 +Vij +m +07/20/2010 +20 +not detected +Mal +132 +34 +Kar +m +06/14/2010 +21 +Vid +233 +35 +Dya +m +06/13/2010 +21 +not detected +Bhi +313 +36 +Kar +m +06/14/2010 +21 +not detected +Vid +233 +37 +Kus +m +05/17/2010 +22 +not detected +Bha +307 +Table 2 (continued) + +S No +Child +(first 3 letters) +Gender +(DOB) +MM/DD/YYYY +Age in +months +DBS status +Mother +(first 3 letters) +CD4 +counts +38 +Sha +m +05/14/2010 +22 +detected +Gee +41 +Hemant Bhargav, Vidya Huilgol, Kashinath Metri et al. + +134 + +39 +Man +m +04/29/2010 +23 +not detected +Suv +677 +40 +Vit +m +04/28/2010 +23 +not detected +Sur +670 +41 +Cha +f +03/10/2010 +24 +not detected +Asm +831 +42 +Ais +f +03/20/2010 +24 +not detected +Nir +43 +Sru +f +02/25/2010 +25 +Ann +44 +Jot +m +02/10/2010 +25 +Ruk +250 +45 +Shr +f +02/25/2010 +25 +Anp +46 +Mur +m +01/14/2010 +26 +Mal +47 +Mur +m +01/14/2010 +26 +Mal +48 +Dar +m +12/11/2009 +26 +not detected +Sak +314 +49 +Vij +f +11/19/2009 +27 +Sho +202 +50 +Sam +m +11/12/2009 +27 +detected +Lax +51 +Par +m +11/03/2009 +27 +not detected +Ren +298 +52 +Ali +f +10/10/2009 +28 +not detected +Afr +208 +53 +Aks +f +10/04/2009 +28 +not detected +Mah +237 +54 +Sam +m +10/18/2009 +28 +not detected +Anu +55 +Aru +m +09/12/2009 +29 +Ren +56 +San +m +09/11/2009 +29 +Gee +118 +57 +Sus +m +09/19/2009 +29 +Shr +58 +Nan +f +09/29/2009 +29 +not detected +Poo +59 +Ruk +f +09/29/2009 +29 +not detected +Mah +238 +60 +Lax +f +09/18/2009 +29 +detected +Mal +324 +61 +Suj +m +08/20/2009 +30 +Nut +62 +Vin +m +08/23/2009 +30 +detected +Nag +63 +Pra +m +08/04/2009 +30 +detected +Lax +301 +64 +Suj +m +08/20/2009 +30 +not detected +Nut +65 +Aks +f +06/03/2009 +32 +not detected +Gee +646 +66 +Nam +f +06/07/2009 +32 +not detected +Sum +727 +67 +Sid +m +04/10/2009 +34 +not detected +Yal +110 + +Table 2 provides information regarding the incidence of MTCT in a government hospital in Belgaum district of +Karnataka state in India. Prenatal CD4 counts were available for 27 HIV infected mothers (on all MTCT +instances, CD4 counts of the mothers were found to be below 350). To retain confidentiality and protect the +identity, only the first three letters of the name of the subjects are disclosed and any speculation of the actual full +given or last name would be misleading. The rows are filled in increasing order of age of the children born to +HIV infected mothers. Blank rows indicate unavailable data. f=female; m=male; DBS=dried blood smear, for +detection of HIV transmission in child. + +Clinical data of HIV infected children with and +without ART in Spandana and Aadhar +orphanage rehabilitation centers +The mean age of 44 HIV infected children (14 +females, 30 males) in the two orphanages combined +was 10.8±3.1 years. Out of 44 children, 27 were +taking ART (61.36%) with mean duration of drug +consumption being 2.8±2.28 years. All of them were +attending schools regularly except one child who was +not able to attend routinely because of severe +lethargy, nausea, and drowsiness due to ART. Fifty +percent (n=22) of the children were suffering from a +Vertical Transmission of HIV Infection + +135 + +health related problem out of which 13 were taking +ART and 9 were not on ART. These generally +outpatient illnesses include upper respiratory tract +infections (URIs -25%), skin infections (6.8%), +chronic suppurative otitis media (CSOM - 6.8%), eye +problems, difficulty in seeing (decreased vision- +4.5%), depression (4.5%) and ART related side +effects such as nausea, drowsiness, lethargy and +gastritis (6.8%). Their mean basal metabolic rate +(BMR), body mass index (BMI), muscle mass, fat +mass and fat percent were 795.45±106.9, 14.55±1.9 +kg/m2, 9.54±3.4 kg, 3.69±2.24 kg and 15.04±7.8%, +respectively, all of which suggest high prevalence of +malnutrition in this population (Table 3), which is +caused by decreased food intake due to the side +effects of medications and HIV infection (eg. +opportunistic infections). +All the CD4 counts measured in the year 2011 +were divided into different groups depending on the +age of the children between 4 to 16 years (Tables 4 +and 5; Figures 3-6). The CD4 counts of the age group +of 8 and below (n=12) were found to be significantly +higher (p=0.04) than those of age group 14 and above +(p=0.04) (n=10) (Tables 4 and 5; Figures 3-6) +irrespective of their ART status. All the children in +age group 14 and above (n=10) except one child were +on ART, whereas 7 out of 12 children in the age +group 8 and below were on ART (Figures 3-6). Also, +it was observed that in one of the rehabilitation +centers called Aadhar, there was a significant +correlation between the age of the child and CD4 +counts (measured separately in the months of June +2011 and December 2011), among non-ART children +(Figure 5). Both the CD4 counts measured in June +2011 (n=6; r=-0.82, p= 0.04) as well as in December +2011 (n=6; r=-0.97, p=0.001) showed a significant +decline as the age progressed. Also, at the same +center, among on-ART children (Figure 6), the CD4 +counts in June 2011 (n=7) and December 2011 (n=8) +were significantly different between the children in +the age group of 8 years below, and those in the age +group of 14 years and above (p= 0.005). So, the +observed differences in the CD4 counts with age were +independent of the ART status of the child. + +Table 3. Comparison between the children in Spandana and Aadhar that are taking ART (on-ART) and not taking +ART (non-ART) showed that though there was no significant difference in the average age of the two groups, on- +ART children had significantly higher BMR (p=0.05) and muscle mass (p=0.004) than non-ART children. But these +results may be affected by the fact that the ART group consisted of larger number of children with higher age than +the non-ART group. The CD4 counts, BMI, fat mass and fat % did not show significant differences between the two +(on-ART vs non-ART) groups, (p<0.05). + + +On-ART +Non-ART +Orphanages / Rehabilitation Centers +Aadhar +Spandana +Aadhar +Spandana +Number of Children +8 +19 +6 +11 +Mean Age (Years) +11.6±2.7 +11.1±3.1 +9.5±4.1 +10.3±2.8 +Mean ART Duration (Years) +2.6±1.3 +2.9±2.6 +NA +NA +Mean BMR +838.88±149.1 +812.58±103.3 +748±104.6 +760.18±63.8 +Mean Muscle Mass (kg) +11.97±4.5 +10.13±2.7 +6.9±3.5 +7.96±2.5 +Mean Fat Mass (kg) +3.68±2.6 +3.80±2.1 +2.93±2.1 +3.94±2.2 +Mean BMI (kg/m2) +14.70±1.73 +14.60±1.5 +15.01±2.4 +14.06± +Percent Fat +14.07±8.2 +15.32±7.0 +14.28±9.9 +15.7±8.7 +Mean CD4 Counts(2011) +545.43±339.9 +492.06±242.14 +533.67±229.08 533.9±189.18 +Number of children with health problems +3 +10 +1 +8 +Number of children not attending schools regularly +0 +1 +0 +0 + +Table 4 shows the T-cell CD4 counts of the HIV +infected children in Spandana. The children are +classified into two groups based on their ART status +(On-ART and Non-ART). The data is arranged in +chronological order as per the age of the child. There +was no significant difference in the average age of the +two groups (p=0.9). Also, there was no significant +difference between the CD4 counts of the two groups +(p=0.5). No significant correlation has been observed +between the duration of ART and the CD4 counts in +the HIV infected children who are on ART (r= -0.16; +p=0.5). + +Hemant Bhargav, Vidya Huilgol, Kashinath Metri et al. + +136 + +Table 4. Spandana Orphanage Rehabilitation Center: CD4 Counts + +Non-ART +S No +Age +Sex +ART Status/Duration +CD4 Counts (2011) +1 +4 +F +NO +561 +2 +7 +M +NO +NA +3 +8 +M +NO +286 +4 +11 +F +NO +299 +5 +11 +F +NO +488 +6 +12 +M +NO +649 +7 +12 +F +NO +570 +8 +12 +M +NO +952 +9 +12 +F +NO +527 +11 +12 +M +NO +579 +10 +13 +M +NO +428 +On-ART +1 +6 +M +2 yrs +NA +2 +6 +M +2yrs +686 +3 +6 +F +1yr +986 +4 +7 +M +6 mos +251 +5 +8 +F +5yrs +337 +6 +11 +M +4yrs +493 +7 +11 +M +1yr +603 +8 +11 +M +2yrs +338 +9 +12 +M +4yrs +214 +10 +12 +M +10 yrs +416 +11 +12 +M +1yr +384 +12 +12 +F +2 yrs +791 +`13 +12 +F +3yrs +271 +14 +14 +M + 1yr +166 +15 +14 +M +9 yrs +445 +16 +14 +M +2 yrs +773 +17 +14 +F +3 yrs +274 +18 +15 +F +1 yr +592 +19 +16 +M +3 yrs +837 + +Table 5 - CD4 T-cell counts of the HIV infected +children in Aadhar. The children are classified into +two groups based on their ART status (On-ART and +Non-ART). The data is arranged in chronological +order as per the age of the child. There was no +significant difference in the average age of the two +groups (p=0.2). +There was no significant difference between the +CD4 counts taken in the month of June 2011 (p=0.9) +and the CD4 counts measured in the month of +December 2011 (p=0.3) of the two groups. Also, there +was no significant correlation between the duration of +ART and the CD4 counts measured in June 2011 +(r=0.003; p=0.9), or CD4 counts determined in +December 2011 (r= 0.12; p=0.7), in the HIV infected +children who are on-ART. + + +Hemant Bhargav, Vidya Huilgol, Kashinath Metri et al. +137 +  +Figure 3. A scatter diagram between the age (years) of the HIV infected children who are not taking ART are +denoted on X-axis and their respective CD4 T-cell counts on the Y-axis. No significant correlation was observed +between the age of the child and CD4 counts (r= 0.2; p=0.5). When the CD4 counts of the children between those +having CD4 values below 350 were compared with those with values above 350, we have found a significant +difference (p=0.03). + +  +Figure 4. A scatter diagram between the age (years) of the HIV infected children who are on- (taking) ART are +denoted on X-axis and their respective CD4 T-cell counts on the Y-axis. No significant correlation was observed +between the age of the child and CD4 counts (r= - 0.2; p=0.3).When the CD4 counts of the children between those +having CD4 values below 350 were compared with those with values above 350, we found a significant difference +(p=0.00). +Table 5. Aadhar Orphanage Rehabilitation Center: CD4 Counts + +Non-ART +S No +Age +Sex +ART Status/Duration +CD4 June 2011 +CD4 Dec 2011 +1 +4yr +M +NO +880 +780 +2 +5yr +F +NO +630 +317 +3 +10yr +M +NO +388 +620 +4 +11yr +F +NO +603 +523 +5 +13yr +M +NO +492 +483 +6 +14yr +M +NO +209 +395 +On-ART +1 +7yr +M +4yrs +646 +646 +2 +8yr +M +2yr +349 +575 +3 +11yr +M +4yrs +721 +692 +4 +12yr +M +3yr +1194 +714 +5 +13yr +M +3yrs +390 +662 +6 +14yr +M +4yr +NA +294 +7 +14yr +F +6mos +224 +327 +8 +14yr +M +1 yr +294 +115 +Hemant Bhargav, Vidya Huilgol, Kashinath Metri et al. + +138 + +  +Figure 5. A scatter diagram between the age (years) of the HIV infected children who are not taking ART denoted +on X-axis and their respective T-cell CD4 counts on the Y-axis. A significant correlation was observed between the +age of the child and CD4 counts. Both the CD4 counts measured in June 2011 (r=-0.82; p= 0.04) as well as those +taken in December 2011 (r=-0.97; p=0.001) showed a significant decline in the CD4 counts as the age progressed. +The p value for the difference in the CD4 counts between the age group of 4-5 versus 10-11 years is 0.018; age +group 10-11 versus 14 years, p=0.15; age group 4-5 versus 14 years, p=0.004. +  +Figure 6. A scatter diagram between the age (years) of the HIV infected children who are not taking ART (non- +ART) denoted on X-axis and their respective T-cell CD4 counts on the Y-axis. It has been observed that the CD4 +counts (measured separately in the months of June 2011 and December 2011) were significantly different between +the children in the age group of 8 years below, and those in the age group of 14 years and above (p= 0.005), by +independent samples t test. Thus there is a significant decline in CD4 counts in the HIV infected children who are +taking ART from 7-8 years of age group to those at the age of 14 years. The p value for the difference in the CD4 +counts between the age group of 7-8 versus 14 years is 0.005; age group 11-13 versus 14 years, p=0.004; age group +7-13 versus 14 years, p=0.002. +Hemant Bhargav, Vidya Huilgol, Kashinath Metri et al. +139 +We have compared the body mass composition of +the HIV infected children in Spandana (Tables 3 and +6 and Figures 7-10) and Aadhar (Tables 3 and 7 and +Figures 11-14) centers between those children who +are taking ART (on-ART) and those not taking ART +(non-ART). +Results have shown that though there was no +significant difference in the average age of these two +(drug and non-drug) groups, on-ART children had +significantly higher BMR (p=0.05) and muscle mass +(p=0.004) than non-ART children. +Thus the ART is proving to be beneficial to the +general health of the infected children. But these body +mass composition results may be affected by the fact +that ART group had more children with higher age +than the non-ART group. The CD4 counts, BMI, fat +mass and fat % did not show significant differences +between the two ART and non-ART groups. + + +Table 6. Spandana Orphanage Rehabilitation Center: Demographic Details and Body Mass Composition + +Non-ART +S No +Age +(Yrs) +Sex +Health problems +ART Status +BMR +Muscle +mass +(Kg) +Fat +mass(Kg +) +BMI +(kg/m2) +% Fat +1 +4 +F +URI +NO +630 +4.9 +0.4 +7.7 +3 +2 +7 +M +CSOM +NO +714 +7.3 +2.6 +12.8 +13.9 +3 +8 +M +URI +NO +714 +2.3 +5.9 +16.5 +27 +4 +11 +F +URI +NO +735 +7.9 +6 +15.1 +26.3 +5 +11 +F +Nil +NO +723 +7.6 +2.7 +13.4 +14 +6 +12 +F +URI +NO +802 +8 +0.6 +14.1 +3 +7 +12 +F +URI +NO +765 +8.5 +5.5 +13.9 +23.1 +8 +12 +M +URI +NO +817 +10.1 +3.3 +14.6 +13.7 +9 +12 +M +URI +NO +811 +10 +5.5 +15.6 +9 +10 +12 +M +Nil +NO +799 +9.6 +3.5 +14.7 +14.8 +11 +13 +M +Nil +NO +852 +11.4 +7.4 +16.3 +24.9 +On-ART +1 +6 +M +Nil +2 yrs +659 +7.1 +1.2 +13.5 +8.2 +2 +6 +M +URI +2yrs +751 +8.3 +4 +14.3 +18.4 +3 +6 +F +CSOM +1yr +656 +5.8 +4 +15.7 +23.4 +4 +7 +M +Nil +6 mos +676 +11 +0.4 +13.2 +3 +5 +8 +F +Nil +5yrs +771 +8.9 +5.1 +15.7 +21.6 +6 +11 +M +CSOM +1yr +783 +9.2 +3.6 +13.6 +15.7 +7 +11 +M +URI +2yrs +822 +10.3 +3.9 +15.1 +15.6 +8 +11 +M +Nil +4yrs +823 +10.3 +1.4 +12.3 +6.4 +9 +12 +M +ART Side +effects +(sedation) +4yrs +780 +9 +5.1 +14.9 +21.3 +10 +12 +M +Nil +10 yrs +776 +8.9 +1.6 +13.1 +7.9 +11 +12 +F +Diminished +visual acuity +2 yrs +815 +10.1 +4.1 +14.6 +16.6 +12 +12 +F +Nil +3yrs +865 +11.3 +5.1 +14.9 +18.2 +13 +12 +M +URI +1yr +772 +8.8 +4.9 +14.6 +20.8 +14 +13 +M +URI +1yr +862 +7.4 +5.9 +15.5 +20.6 +15 +14 +M +Nil +9 yrs +1038 +16.4 +1.7 +14.9 +5.2 +16 +14 +F +Skin Infection +3yrs +1045 +16.5 +10.1 +19.6 +29.3 +17 +14yr +M +foot infection, +URI + 2 yrs +130 +850 +25.9 +11.1 +3.2 +18 +15yr +F +Nil +1yr +138 +871 +27.7 +11.7 +4.5 +19 +16yr +M +Nil +3 yrs +136 +824 +23.4 +10.4 +2.4 + +Hemant Bhargav, Vidya Huilgol, Kashinath Metri et al. +140 +Table 6 - Comparison between HIV infected +children who are on-ART and non-ART at Spandana. +A comparative data on the prevalence of different +health problems and body mass composition in HIV-1 +infected children who are on-ART and non-ART. +Body mass composition includes Basal Metabolic +Rate (BMR), Body Mass Index (BMI), Muscle Mass, +Fat Mass and Fat Percent. The analysis of the data +shows significant difference between BMR of the two +groups. BMR in the on-ART group is significantly +higher than in the non-ART group. +This Table also shows common health problems +suffered by these children such as, Upper respiratory +tract infections (URIs), Chronic Suppurative Otitis +Media (CSOM), skin infections, ART related side +effects, etc. + +Table 7 - Comparison between HIV infected +children who are on-ART and non-ART at Aadhar. +This table provides a comparative data on the +prevalence of different health problems and body +mass composition in HIV infected children who are +on-ART and non-ART. Body mass composition +includes Basal Metabolic Rate (BMR), Body Mass +Index (BMI), Muscle Mass, Fat Mass and Fat Percent. +The analysis of the data shows significant difference +between BMR of the two groups. BMR in the ART +group is significantly higher than in the non-ART +group. This Table also shows common health +problems suffered by these children such as Upper +respiratory +tract +infections +(URIs), +Chronic +Suppurative Otitis Media (CSOM), skin infections, +ART related side effects, etc. +  +Figure 7. This scatter plot compares the muscle mass (kg) of the HIV infected children between those who are on-ART and +non-ART. X-axis denotes the serial number of HIV infected children. + +Vertical Transmission of HIV Infection + +141 + +  +Figure 8. This scatter plot compares the basal metabolic rates (BMR) of the HIV infected children between those who are +on-ART and non-ART. X-axis denotes the serial number of HIV infected children. + + +Figure 9. This scatter diagram between T-cell CD4 counts (measured in June 2011 and December 2011) and the body mass +index (BMI) of the HIV infected children at Spandana showed no significant correlation. +Hemant Bhargav, Vidya Huilgol, Kashinath Metri et al. + +142 + +  +Figure 10. This scatter diagram plotted with the age of HIV infected children at Spandanaon Y-axis and their body mass +index (BMI) on the X-axis shows that there was no significant correlation. The average BMI is 14.41±1.8 kg/m2 and the +average age is 10.86±2.9 years. +Table 7. Aadhar Orphanage Rehabilitation Center: Demographic Details and Body Mass Composition + +Non-ART +S No +Age +(yrs) +Sex +Health problems +ART +Status/ +Duration +BMR +Muscle +mass +(Kg) +Fat +mass +(Kg) +BMI +(Kg/m2) +% Fat +1 +4 +M +Nil +NO +603 +4.2 +2.7 +13.5 +20.2 +2 +5 +F +Nil +NO +670 +NA +0.4 +12.3 +3 +3 +10 +M +Nil +NO +782 +9.3 +3.8 +15.1 +16.7 +4 +11 +F +Nil +NO +869 +2.6 +0.7 +19.6 +3 +5 +13 +M +Nil +NO +851 +11.1 +3.7 +14.4 +14.4 +6 +14 +M +URI +NO +713 +7.3 +6.3 +15.2 +28.4 +On-ART +1 +7 +M +Nil +4yrs +677 +6.3 +2.4 +13.7 +14.5 +2 +8 +M +Acidity due to ART +2yrs +707 +7.3 +5.4 +16.2 +25.7 +3 +11 +M +Headache +Diminished visual +acuity +4yrs +747 +17.4 +0.5 +12.3 +3 +4 +12 +M +Nil +3yrs +880 +11.9 +4.9 +15.4 +17.2 +5 +13 +M +Nil +3yrs +806 +9.9 +2.2 +13.7 +9.8 +6 +14 +M +Nil +4yrs +1131 +18.9 +8.1 +17.9 +18.8 +7 +14 +F +Nil +6 mos +804 +9.7 +5.2 +14.2 +20.6 +8 +14 +M +Depression, +Oesophageal +candidiasis +1 yr +959 +14.4 +0.8 +14.4 +3 + +Vertical Transmission of HIV Infection + +143 + +  +Figure 11. This scatter plot compares the muscle mass (kg) of the HIV infected children between those who are on-ART and +non-ART at Aadhar. X-axis denotes the serial number of HIV infected children. + +  +Figure 12. This scatter plot compares the basal metabolic rates (BMR) of the HIV infected children between those who are +on-ART and non-ART at Aadhar. X-axis denotes the serial number of HIV infected children. +Hemant Bhargav, Vidya Huilgol, Kashinath Metri et al. + +144 + +  +Figure 13. This scatter diagram between T-cell CD4 counts (measured in June 2011 and December 2011) and the body mass +index (BMI) of the HIV infected children at Aadhar showed no significant correlation. + + +  +Figure 14. This scatter diagram plotted with the age of 14 HIV infected children at Aadhar on Y-axis and their body mass +index (BMI) on the X-axis shows that there was no significant correlation. The average BMI is 14.85±2 kg/m2 with an +average age of 10.71±3.4 years. +Vertical Transmission of HIV Infection +145 +Discussion + +We  have observed that the rate of incidence of +MTCT of HIV-1 infection in Belgaum District +(Karnataka State) is 8.66% (Table 1) which is +considerably lower than in other parts of India where +it ranged from 24% in Mumbai to as high as 48% in +amongst tribal women [20]. In developing countries, +the MTCT incidence rates were reported to be as high +as 40% [20]. Even in developed countries like the +United States and those of Western Europe, the +MTCT incidence rates were reported to range from +15-20% [20].The sero-prevalence of HIV-2 is low in +India and hence the probability of MTCT of HIV-2 is +even lower than in most other countries [20]. This +suggests that the clinical management of HIV +infection and in particular the MTCT of the virus +(HIV-1 and/or HIV-2) at least in the Belgaum district +is good. For this disease control, the credit may be +deserved for the clinicians and healthcare personnel +including +HIV +infected +volunteers +of +non- +governmental organizations (NGOs) at the district or +state level, and India’s National AIDS Control +Organisation (NACO). + +Children on-ART versus non-ART + +About half (22 out of 44) of the HIV infected +children in the orphanage rehabilitation centers were +suffering from health related problems in this part of +the country (India), out of which 13 were taking ART +and 9 were not on ART. These problems may be due +to the fact that children who are on ART are more +immunodeficient (CD4 counts less than 350) than +those still not started on ART. In fact ART lowers +CD4 counts upon continued administration, age 14 +years (Figure 6) which also supports HIV-1 induced +hematopoietic inhibition and potential synergism of +the effects of both virus infection and drug induced +cytopenias. +But it also becomes evident that apart from ART, +other integrative strategies which can improve the +immunity levels of these children are needed to +address these problems, as stated in the introduction +section of this article. +Children taking ART had higher muscle mass and +BMR than those who were not on ART (non-ART). +This higher metabolic rate may be due to acceleration +of the metabolism due to ART. Though more +immunodeficient children are put on-ART, the higher +muscle mass in the ART group may be due to +increased immunity (CD4 counts) in this group due to +prophylactic ART effects. + + +Declining CD4 Counts with Age of the HIV +Infected Children + +The CD4 counts of the children of age 8 years +and below were found to be significantly higher than +those of age 14 and above (p=0.04). All the children +in 14 and above age group (n=10) except for one child +were on ART, whereas 7 out of 12 children in 8 and +below age group were on ART. +These results suggest that as HIV infected +children grow, they may lose immunity as indicated +by decline in the CD4 counts especially at the age of +14 and thereafter, irrespective of their ART status. + + +Age Dependence of Children’s Maternal +Immunity to HIV Infection + +As it has been proposed that potential exposure to +low dose virus or viral antigens in the presence of +maternal antibody in the infant may only serve to +immunize it and create a long term HIV strain specific +immunity without the necessity of mounting new or +additional humoral and cytotoxic responses by the +childrens’ immune system to attack the generating +mutant virus strains [21].This finding may be due to +the immunization of the children to the viral antigens +in the early years of development, which allows a +specific long term maternally conferred immunity +build up that may last up to 8 years of age and then +gradually start declining thus causing significant +reduction in CD4 counts especially around 14 years of +age and thereafter. We find that this extended +maternal immunity is independent of ART to the +infected child (Figures 5 and 6). +It was previously reported that HIV-1 infection +was cleared in an infant within a year after birth [22] +which supports our findings on the conferment of +maternal immunity to their vertically transmitted HIV +infected children. Whereas we have found that in HIV +infected children due to vertical transmission even +Hemant Bhargav, Vidya Huilgol, Kashinath Metri et al. + +146 + +beyond the age of 4 years and up to 8 years, normal +CD4 counts are maintained whether on-ART or non- +ART (Tables 4 and 5; Figures 3-6), previous reports +state that there was enhanced loss of CD4 cells prior +to attaining an age of 3 years [23]. Despite high +viremia levels in perinatally infected infants, the CD4 +levels also remain higher than in HIV-1 infected +adults with a similar viremia status [24].Thus our +findings on the CD4 levels reveal an extension of +maternally +conferred +immunity +in +vertical +transmission of HIV infection to children of age +levels well beyond the post-delivery dates that were +previously reported. + + +Role of Placental Soluble Factors in Vertical +Transmission + +Placental cytokines and its other soluble factors +trigger the crossing of the barrier between the HIV +infected T-lymphocytes and the placental trophoblasts +thereby increasing the risk of mother to fetal virus +transmission [11]. We have therefore isolated the +mesenchymal stem cells (MSCs) from the placental +membranes [8] to study the role of placental soluble +factors in the vertical transmission of HIV infection. +The amniotic membrane contains the MSCs and the +chorionic membrane contains the trophoblasts. + + +Role of Sulfatides in Prevention of MTCT +of HIV infection + +In addition to ART, we had earlier showedfor the +first time that the sulfatide, -- galactosylceramide, +inhibitsHIV-1 +replication +[17]. +Sulfatide +also +increases CD4+ cells as compared to AZT in HIV-1 +infected SCID-hu mice [17]. Sulfatide concentrations +and arylsulphatase A (an enzyme that catabolizes +sulphatides) have been extracted and biochemically +determined in human placenta, its chorionic and +amnionic membranes (Figure 1) [8], and the umbilical +cord [19].Variations in the sulfatide concentration and +the behavior of arylsulphatase A activity in the +placenta, cord, and membranes of healthy gravidas +(pregnant females) at term pregnancy, following +spontaneous birth have been evaluated [19]. It was +observed that activity of arylsulphatase A decreased +in the cord, in membranes and in the placenta and +sulfatide concentration was found to be maximal in +the placenta and minimal in the cord with +intermediate value in the membranes following +delivery [19]. In the clinic, it is observed that MTCT +tends to be at a greater risk during delivery that is +associated with prolonged labor. The observation that +sulfatide concentration tends to be minimal in the +cord may increase the chances of HIV-1infection +during delivery. So, administration of sulfatides +during delivery in utero may reduce the chances of +such MTCT. Exogenous sulfatide gets incorporated +into the cell membranes and blocks HIV-1 entry into +the CD4 negative cells via the Gal/Cer receptor which +otherwise serves also as an alternative cellular +receptor for HIV-1 entry, in conjunction with the +natural CXCR4 co-receptor for the virus [18].Thus, +our recently found pre-clinical translational efficacy +of sulfatide using the SCID-hu model system [18], +may play an important role in preventing maternal to +fetal transmission of HIV infection during the +delivery, by inhibiting the virus entry and its +replication [17-19]. + + +Complementary and Alternative Medicine +(CAM) Interventions + +HIV infected individuals often use alternative or +complementary therapies to manage side effects of +HIV infection or ART [25-29]. Surveys estimate that +47–74% of HIV infected individuals in the United +States have used some form of alternative- +complementary therapy to improve general health and +well being [29]. + + +Yoga for Prevention of MTCT in HIV Infected +Pregnant Mothers + +Yoga is a safe, low cost, popular intervention that +has shown its efficacy in HIV positive individuals in +reducing psychological distress [30], anxiety and +depression [31], increasing T cell count [31], natural +killer cell activity [32] and buffering CD4+ T +lymphocyte declines [33]. The term “yoga” originates +from Samskrit root “yuj” which means union. Yoga is +a psycho-somatic-spiritual discipline to achieve union +Vertical Transmission of HIV Infection + +147 + +and harmony between mind, body and soul and to +ultimately unite individual consciousness with the +Universal consciousness [34]. As described in an +ancient yogic scripture called Patanjali Yoga Sutra +(P.Y.S. 1.2) [35], yoga is a holistic science, that +chiefly deals with gaining mastery over the mind +through various mind-body techniques such as āsanas +(postures +done +with +awareness), +Prānayāma +(voluntarily regulated nostril breathing), meditations +along withkriyās (purificatory practices), and yoga +nidrā (guided relaxation with imagery) [36]. +Pregnancy is state of physiological stress that +necessitates physical, mental and social adaptation. +HIV diagnosis with the social stigma attached to it, in +itself is a significant stressor. A review by Mulder et +al [37] finds that pregnant women with high stress and +anxiety levels are at increased risk for spontaneous +abortion and pre-term labor and for having a +malformed or growth-retarded baby as indicated by +recent well-controlled human studies [37]. They also +conclude that maternal psychological factors may +significantly contribute to pregnancy complications +and unfavorable development of the (unborn) child. +These problems might be reduced by specific stress +reduction in high anxious pregnant women [37]. +Several maternal factors such as low CD4+ +lymphocyte +counts, +high +viral +load, +immune +responses, advanced disease status, smoking and drug +abuse, have been implicated in an increased risk of +MTCT of HIV infection [37]. Though use of ART +during pregnancy has significantly reduced the rate of +MTCT, selective transmission of ART resistant +mutants has been reported [38]. +Stress, a psycho-physiological process, causes +various biological effects via the pathway of immune- +neuroendocrine axis which may lead to a greater +replication and faster progression of HIV in the +infected subjects [39]. There is substantial evidence +that depression and stress are associated with more +rapid CD4 cell declines and HIV disease progression +[40, 41]. In a large cohort study of women with HIV +by the HIV Epidemiology Research Study (HERS), +women with chronic depressive symptoms had more +rapid declines in CD4 counts, and were two times +more likely to die compared to women with little or +no depressive symptoms, after controlling for other +prognostic factors [42]. Such an increased proviral +burden +depletes +the +CD4 +counts, +inhibits +hematopoiesis [43], and thereby increases the chances +of HIV-1 MTCT [38]. Nair et al [44] have +demonstrated that, the stress hormone, cortisol, +synergizes with HIV-1 gp-120 to induce apoptosis of +normal human peripheral blood mononuclear cells. +Yoga has been proven to reduce stress levels via +decreasing sympathetic activity and causing a state of +parasympathetic dominance. Yoga techniques were +found to be effective in treating phobias, major +depressive disorders, grief, insomnia [45] and +posttraumatic stress disorder [46]. Hatha Yoga (a +form of yoga which chiefly focuses on dynamic body +postures, +cleansing +practices +and +breathing +techniques) practices have also been shown to reduce +perceived stress, negative affect (“Affect” as denoted +here is a psychological term for an observable +expression of emotion)and salivary cortisol levels +[47]. By reducing cortisol levels in HIV patients, yoga +may prevent switching of cytokines from type 1 to +type 2 [48, 49] and thereby affect HIV replication in a +positive manner, which may decrease viral loads in +circulation and consequently improve CD4 counts +thereby preventing MTCT of HIV-1 infection. +Further, the poor response of HIV for a lowering of its +replication and slower CD4 cell increase in some HIV +infected individuals after initiation of HAART is +associated with higher autonomic nervous system +activity as measured by a series of physiological +parameters like palmar skin conductance and EKG +inter-beat interval [50]. Hence interventions that +reduce autonomic nervous system activity could have +beneficial effects in HIV persons who are on +antiretroviral treatment. +Our recent randomized controlled trial on 70 HIV +infected subjects divided into two groups: yoga and +wait list control, demonstrated that 3 months, 1 hour +yoga intervention (5 days a week) improves quality of +life and positive “affect” in HIV infected individuals +and reduces anxiety and depression significantly as +compared to the wait list control group [51]. Also, +there was a non-significant increase in the CD4 cells +(+2.39%), CD8 cells (+3.17%) and reduction in the +viral load (-4.87%) in the yoga group after 3 months, +whereas the control group showed reduction in CD4 +(-8.38%) and CD8 (-2.38%) cells and rise in the viral +load (+87.88%). The intervention included breathing +practices, loosening exercises, āsanas, prānayāmas +and +meditations. +Our +recent +review +provides +Hemant Bhargav, Vidya Huilgol, Kashinath Metri et al. + +148 + +evidences for potential role of yoga therapy modules +in hematopoietic inhibition in HIV infection [52]. +Another study of ours [53], on 122 healthy pregnant +women who practiced integrated yoga daily for 1hr +from 18-20th week of gestation up to the delivery, +showed significant reduction in the perceived stress +and improvement in the adaptive autonomic response +to stress as compared to the control group who +practiced standard prenatal exercises 1-hour daily. +The integrated yoga practice for pregnant mothers +included the following [52, 53]: + + +Lectures on yogic philosophy: Jñana yoga, +Karma yoga, Bhaktī yoga and Rāja yoga +based on the Bhagvad Gīta. + +Breathing practices: Hands in and out +breathing, hand stretch breathing, ankle +stretch breathing, tiger breathing and bridge +posture breathing. + +Postures (āsanas): Tādāsana, ardhakati- +ćakrāsana, +trikonāsana, +vajrāsana, +vakrāsana, siddhāsana, baddha konāsana, +upaviștha-konāsana, +mālāsana, +viparita +karīnī and ardha pavana muktāsana. + +Prānayāma: +Sectional +breathing, +nadishuddhi, sītali and bhrāmari. + +Meditations: +Om +meditation, +nadānu +sandhānum (A. U. M. chanting) + +Relaxation Techniques: Deep relaxation +technique, Yoga nidrā. + +Similarly, in another study [54] on 355 pregnant +women, integrated yoga practices lead to significant +improvement in the birth weight of the babies, +reduction in the preterm labor and Intra-uterine +growth retardation (IUGR) either in isolation or +associated with pregnancy induced hypertension, with +no increased complications in pregnant women who +practiced integrated yoga daily for 1 hr till delivery as +compared to control who followed standard obstetric +advice of a 30 min walk daily. More recently, Beddoe +at al [55] showed that women that start prenatal yoga +early in pregnancy compared to women who practiced +later in pregnancy experience improved sleep patterns +in their second trimester. They also showed that 7 +weeks of mindfulness-based yoga combined with +elements of Iyengar yoga lead to significant reduction +in the physical pain in the pregnant women who +practiced in the second trimester and reduction in +perceived stress and trait anxiety for those who +practiced in the third trimester [56]. +These above yogic practices that comprise of +āsanas, Prānayāmas, meditations, and relaxation +techniques, may help reduce the burden of pregnant +mother and their children in relieving the side effects +of MTCT of HIV infection due to both the virus and +the ART. Thus, yoga therapy may promote health in +HIV infected mother; it may also enhance the efficacy +of ART in preventing MTCT and help in reduction of +ART related side effects. + +Scientific Evidences for Anti-HIV Activity of +Ayurvedicherbal Medications for Prevention of +MTCT of the Virus + +Ayurveda literally means “science of life”. It is a +holistic medical system that emphasizes prevention +and promotion of health through creating balance at +the physical level between the five basic elements +(space, air, fire, water and earth) in the body, at the +mental level between mental elements of inertia +(tamas) and activity (rajas) and at the level of spirit by +enhancing the harmony with nature. +There are many formulations mentioned by in the +ayurvedic texts which are believed to improve the +immune system. +Some of these are studied scientifically, for +example, in a study one of the rasāyanas called +chavanprāsha avaleha (CA), mentioned in the +charaka +samhītā +[57] +in +the +chapter +called +rasāyanādhya (Rasāyana-that which destroys the +disease and old age) was given for 90 days and was +found to improve stress tolerance, endocrine functions +mainly in adrenal and testicles, the serum protein +levels; and to reduce urinary levels of nitrogen, +creatinine, mucopolysaccharide, and hydroxyl proline. +It also showed improvement in the general well being +without the complaint of any physical disorder [58]. +There are many ayurvedic herbs which have been +shown to posses anti-HIV activity, for example, +Punicagranatum (pomegranate = “dādima”) juice has +HIV-1 entry inhibitors in it, which forms a complex +with corn starch that can block HIV binding toits +receptor CD4 and co-receptors CXCR4/CCR5 and +inhibit infection [59]. Another study [60] examined +the safety and effect of an acetone-water neem leaf +Vertical Transmission of HIV Infection + +149 + +(Azadirachta Indica) extract on CD4 cells 60 +HIV/AIDS patients to determine the influence of +neem on immunity and viral load in HIV/AIDS. +Patients were confirmed as HIV -1 or -2 positive, as +having CD4 cell counts less than 300 cells/l, and as +antiretrovirally naïve. They were given oral neem leaf +extract 1.0 g daily for 12 weeks. At the end of 12 +weeks there was significant improvement in the CD4 +counts as compared to the baseline, along with +significant +improvement +in +mean +bodyweight, +hemoglobin +concentration, +and +lymphocyte +differential count. The ESR also reduced along with +significant reduction in the HIV-related pathologies as +compared to the baseline [60]. Mangifera indica +(mango), is another commonly used herb in ayurvedic +medicine. +A recent review by Shah et al [61] shows that +mango possesses anti-diabetic, anti-oxidant, anti-viral, +cardiotonic, +hypotensive, +anti-inflammatory +properties. The review studies show various effects +such as anti-bacterial, anti- fungal, anthelmintic, anti- +parasitic, anti-tumor, anti-HIV, anti-bone resorption, +anti-spasmodic, anti-pyretic, anti-diarrhoeal, anti- +allergic, immune-modulation, hypolipidemic, anti - +microbial, hepato-protective, and gastro-protective.In +vitro, the effect of mangiferin (active ingredient of +mango) was studied against herpes simplex virus type +2 (HSV-2); mangiferin does not directly inactivate +HSV-2 but inhibits the late event in HSV-2 +replication [62]. In vitro, mangiferin was also able to +inhibit HSV-1 virus replication within cells [63] and +to antagonize the cytopathic effects of HIV [64]. +In another study, Glycyrrhizin (GL), a terpenoid +from the roots of Glycyrrhizaglabra, was shown to +have dose dependent inhibitory activity on HIV-1 +replication +in +MOLT-4 +cells +(human +acute +lymphoblastic cell line), in addition to reduction in +protein kinase C (PKC) activity of MOLT-4 cells. +Since, another PKC inhibitor also showed to inhibit +HIV replication in the same study; it was proposed +that PKC inhibition may be one of the mechanisms +through which GL inhibits HIV-1 replication [65]. +Compound GL has also been shown to improve CD4+ +T-cell count, lower active T lymphocyte subset +expression, +inhibit +HIV +and +help +immune +reconstitution in AIDS patients [66]. +Another study compared antiviral effect of +synthesized Glycyrrhizin sulfate (GLS)in vitro with +the parental anti-HIV compound GL on HIV. GLS +was found to be an efficient inhibitor of reverse +transcriptase. The effect of GLS was 4 times stronger +than that of GL in molar terms [67].In addition +Glycyrrhizic acid was shown to have affinity towards +the various surface proteins of HIV-1 [68]. +In one study, fruits of another important +medicinal herb called Terminalia Chebula were +subjected to bioassay, which yielded four kinds of +HIV-1 integrase inhibitors, gallic acid and three +galloyl glucoses [69]. +Phyllantus amarus (Bhunīmbā) is one of the +ayurvedic herbs. One of the studies on its aqueous and +alcohol based extracts found that Bhunīmbāis having +potential inhibiting activity against replication of +HIV-1 in CD4+HeLa cells [70]. +A clinical study [71] on phytochemical (phenolic, +flavonoid and carotenoid) and antibacterial activities +of aqueous and ethanol extracts of Trīphalā (three +fruits +namely +Harītakī +(Termineli +achebula), +Bibhītakī (Termineli abellerica), Amalakā (Embilica +officinalis) and its individual components had shown +antibacterial activity against the bacterial isolates +tested in the HIV/AIDS patients. +The isolated bacteria included in the testing were +among the common opportunistic pathogens in HIV +infection, +such +as, +Pseudomonas +aeruginosa, +Klebsiella pneumoniae, Shigella sonnei, S. flexneri, +Staphylococcus aureus, Vibrio cholerae, Salmonella +paratyphi-B, Escherichia coli, Enterococcus faecalis, +Salmonella typhi, etc. Another study [72] on a +patented compound, poly herbal cream called +Basantwhich contains curcumin (diferuloylmethane), +purified extracts of Amalaki (Gooseberry abundantly +found in India – Emblica officinalisi), purified +saponins from Sapindus mukorossi, aloe vera and rose +water have a strong viricidal property against the +HIV-1NL4.3 in CEM-GFP reporter T and P4 (Hela- +CD4-LTR-Gal). In the same study, Amalakīand aloe +vera have shown their inhibitory property against +transduction of human papilloma virus type 16 (HPV- +16) pseudovirus [72]. +It also inhibited drug resistant strains of Neisseria +gonorrhoeae, Candida glabrata, Candida albicans +and Candida tropicalis which are isolated from +women having vulvo-vaginal candidiasis. + +Hemant Bhargav, Vidya Huilgol, Kashinath Metri et al. + +150 + +Conclusion + +We will use these clinical data and experimental +results to understand the mechanisms of vertical +transmission of HIV infection with particular +reference to the viral strains prevalent in different +parts of India and in general around the globe. We +will continue with the characterization of the role of +placenta which includes the placental mesenchymal +stem cells (MSCs), trophoblasts, amniotic and +chorionic cells, and amniotic fluid (Figure 1) for the +potential infection by HIV and its mother to child +transmission (MTCT). However, since the above cells +that comprise the placenta do not seem to consist of +the HIV-1 target CD4+ cells, we propose to examine +the role of the placental inflammatory sites for +indirect entry of the virus from the mother to the fetus +to cause the occurrence of vertical transmission. This +will set the stage as an important model for the +indirect role of hitherto undetermined host factor +candidates including known cytokines, in placental +mesenchymal stem cell – HIV infected T lymphocyte +interactions specific to mother to infant virus +transmission [7] and may further extend to CD34+ +progenitor stem cell – HIV infected T lymphocyte +interactions that indirectly inhibit hematopoiesis [5]. +We will also investigate whether there is +commonality between these two phenomena with +respect to the host factors. +In this regard, there are two possible mechanisms: +(a) In the case of vertical transmissions it could be +either the infiltration of the HIV infected T +lymphocytes at the sites of inflammation, or indirect +effects of the host factors not excluding the cytokines +[7, 8] besides unknown or undetermined candidate +proteins, molecules, or lipids. (b) In the effects on +CD34+ cell differentiation [5, 6, 43, 73, 74]; the only +route of virus mediated deleterious effects seems to be +the implication of host factors. These mechanisms are +currently being investigated as part of this RF DBT +grant or through other projects. +We also aim to investigate the role of our recent +antiretroviral drug candidate, sulfatide [17, 18], as +well as complementary and alternative medicines +(CAM), in the prevention or near elimination of +maternal to fetal transmission of HIV infection +through inhibition of HIV entry and its replication +with minimal side effects. +Acknowledgments + +This work was supported by Ramalingaswami +Fellowship (also inclusive of contingency grant +funds) awarded to Dr Prasad Koka by the Department +of Biotechnology (DBT), Ministry of Science & +Technology (MST), Government of India (GOI). We +thank the helpful assistance of Ms Venkata Prasanthi +Vallapaneni, Senior Research Fellow who was +supported by this contingency grant funds. Dr Hemant +Bhargav, Junior Research Fellow was also supported +by this contingency grant funds. We are greatly +indebted to the Karnataka State Health Minister Sri +Ramdas and his health ministry officials for their +facilitation and arrangements of the road trip by a +special bus to Belgaum and also the expected +meetings and visits to hospitals, clinics and children’s +orphanages in that city and adjacent townships of +Belgaum district. We are also very much thankful to +the Managing Director, Belgaum Institute of Medical +Sciences (BIMS), Dr M R Chandrasekhar, for +enabling our meetings with the physicians and staff at +this BIMS medical college hospital and its HIV/AIDS +clinics. + +References + +[1] +UNAIDS (United Nations Program on HIV/ Acquired +Immune Deficiency Syndrome) report on the global +AIDS epidemic, 2010. +[2] +UNGASS (United Nations General Assembly Special +Session). Country Progress Report, India. Submitted +March 31, 2010. +[3] +India HIV estimates, NACO (National AIDS Control +Organisation), 2006. +[4] +Pradhan BK, Sundar R, Natesh G. Socio-Economic +Impact of HIV and AIDS in Karnataka, India United +Nations Development Programme, 2006. +[5] +Koka PS, Jamieson BD, Brooks DG, Zack JA. Human +immunodeficiency virus type-1 induced hematopoietic +inhibition is independent of productive infection of +progenitor cells in vivo. J Virol 1999; 73: 9089-9097. +[6] +Koka PS, Kitchen CM, Reddy ST. Targeting c-Mpl for +revival of human immunodeficiency virus type 1- +induced +hematopoietic +inhibition +when +CD34+ +progenitor cells are re-engrafted into a fresh stromal +microenvironment in vivo. J Virol 2004; 78: 11385- +11392. +[7] +Koka PS, Sundell IB. Placental sFlt-1 in mother to child +transmission of HIV-1 infection. Manuscript submitted. +Vertical Transmission of HIV Infection + +151 + +[8] +Sundell IB, Koka PS. Placental Membrane as a Source +of Mesenchymal Stem Cells. J. Stem Cells 2010; 5(2): +83-88. +[9] +Bhoopat L, Khunamornphong S, Sirivatanapa P, +Rithaporn T, Lerdsrimongkol P, Thorner PS, Bhoopat +T. Chorioamnionitis is associated with placental +transmission of human immunodeficiency virus-1 +subtype E in the early gestational period. Modern +Pathology 2005; 18: 1357-1364. +[10] +Al-husaini AM. Role of placenta in the vertical +transmission of human immunodeficiency virus. J +Perinatol 2009; 29: 331-336. +[11] +Derrien M, Faye A, Dolcini G, Chaouat G, Barre- +Sinoussi S, Menu E. Impact of the placental cytokine- +chemokine balance on regulation of cell-cell contact- +induced human immunodeficiency virus type 1 +translocation across a trophoblastic barrier in vitro. J +Virol 2005; 79: 12304-12310. +[12] +Merrill JE, Koyanagi Y, Chen IS. Interleukin-1 and +tumour necrosis factor  can be induced from +mononuclear phagocytes by human immunodeficiency +virus-1 binding to CD4. J. Virol 1989; 63: 4404-4408. +[13] +Koka P, He K, Zack JA, Kitchen S, Peacock W, Fried I, +Tran +T, +Yashar +SS, +Merrill +JE. + + +Human +immunodeficiency virus 1 envelope proteins induce +interleukin 1, tumor necrosis factor , and nitric oxide +in glial cultures derived from fetal, neonatal, and adult +human brain. J Exp Med 1995; 182: 941-952. +[14] +Reickmann P, Poly G, Fox CH, Kehrl JH, Fauci AS. +Recombinant gp120 specifically enhances tumour +necrosis factor alpha and Ig production in B +lymphocytes from HIV infected individuals but not +from seronegative donors. J. Immunol 199; 147: 2922- +2927. +[15] +Lee C , Liu QH, Tomkowicz B, Yi Y, Freedman BD, +Collman RG. Macrophage activation through CCR5- +CXCR4- mediated gp120 elicited signal pathways. J. +Leuk Biol 2003; 74: 676-682. +[16] +Swingler S, Mann A, Jacque J, Brichacek B, Sasseville +VG, Williams K et al. HIV-1 Nef mediates lymphocyte +chemotaxis and activation by infected macrophages. Nat +Med. 1999; 5: 997-1003. +[17] +Sundell IB, Halder R, Zhang M, Maricic I, Koka PS, +Kumar V. Sulfatide administration leads to inhibition of +HIV-1 replication and enhanced hematopoiesis. J. Stem +Cells 2010; 5(1): 33-42. +[18] +Sundell IB, Cortado RV, Koka PS. Sulfatide ~ a new +Candidate for ART treatment in HIV-1 infection. J. +Stem Cells; 2012; 7(1): 61-72. +[19] +Indraccolo U, Traini E, Baldoni E, Indraccolo SR, +Vitaioli L. Arylsulphatase A activity and sulphatide +concentration in placenta, membranes and cord after +delivery. J. Perinat Med. 2009; 37(5): 497-502. +[20] +Kaizad RD, Parikshit DT. Prevention of mother to child +transmission of HIV infection. J. Obst Gynecol 2006; +56(5): 390-395. +[21] +Salk J, Bretscher PA, Salk PL, Clerici M, Shearer GM. +A strategy for prophylactic vaccination against HIV. +Science 1993; 260: 1270-1272. +[22] +Bryson YJ, Pang S, Wei LS, Dickover R, Diagne A, +Chen IS. Clearance of HIV infection in a perinatally +infected infant. N Engl J. Med. 1995; 332(13): 833-838 +[23] +Dickover RE, Dillon M, Gillette SG, Deveikis A, Keller +M, Plaeger-Marshall S, Chen I, Diagne A, Stiehm ER, +Bryson Y. Rapid increases in load of human +immunodeficiency virus correlate with early disease +progression and loss of CD4 cells in vertically infected +infants. J. Infect Dis. 1994; 170(5): 1279-1284. +[24] +Krogstad P, Uittenbogaart CH, Dickover R, Bryson YJ, +Plaeger S, Garfinkel A. Primary HIV infection of +infants: the effects of somatic growth on lymphocyte +and virus dynamics. Clin. Immunol. 1999; 92(1): 25-33. +[25] +De Visser R, Ezzy D, Bartos M. Alternative or +Complementary? +Nonallopathic +Therapies +for +HIV/AIDS. Altern Ther Health Med. 2000; 6: 44–52. +[26] +Duggan J, Peterson WS, Schutz M, Khuder S, +Charkraborty J. Use of Complementary and Alternative +Therapies in HIV-Infected Patients. AIDS Patient Care +STDS. 15: 159–167. +[27] +Knippels HM, Weiss JJ. 2000. Use of alternative +medicine in a sample of HIV-positive gay men: an +exploratory study of prevalence and user characteristics. +AIDS Care. 2001; 12: 435-446. +[28] +Ozsoy M, Ernst E. How effective are complementary +therapies for HIV and AIDS? - A systematic review. +Int.J STD AIDS. 1999; 10: 629-635. +[29] +Cho M, Ye X, Dobs A, Cofrancesco J. Prevalence of +complementary and alternative medicine use among +HIV patients for perceived lipodystrophy. J. Alt Compl +Med. 2006; 12(5): 475-482. +[30] +Bormann JE, Gifford AL, Shively M, Smith TL, +Redwine L, Kelly A, et al. Effects of spiritual mantram +repetition on HIV outcomes: a randomized controlled +trial. J. Behav Med 2006; 29(4): 359-376. +[31] +Koar W. Meditation, T-cells, anxiety, depression and +HIV infection. Subtle Energies and Energy Medicine +Journal 1995; 6(1): 1995-2008. +[32] +Robinson FP, Mathews HL, Witek-Janusek L. Psycho- +endocrine-immune response to mindfulness-based stress +reduction in individuals infected with the human +immunodeficiency virus: a quasi-experimental study. J. +Alt Compl Med 2003; 9(5): 683-694. +[33] +Creswell, J. D., Myers, H. F., Cole, S. W., and Irwin, M. +R. Mindfulness meditation training effects on CD4+ T +lymphocytes in HIV-1 infected adults: a small +randomized controlled trial. Brain Behav Immun 2009; +23(2): 184-188. +[34] +Madanmohan. Introducing Yoga to Medical Students- +The JIPMER Experience: Advanced Centre for Yoga +Therapy, Education and Research, 2008. +Hemant Bhargav, Vidya Huilgol, Kashinath Metri et al. + +152 + +[35] +Four Chapters on Freedom. Commentary on the Yoga +Sutras of Patanjali by Swami Satyānanda Saraswati. +Yoga Publications Trust. Munger, Bihar, India 2002. +[36] +Innes KE, Vincent HK. The influence of yoga-based +programs on risk profiles in adults with type 2 diabetes +mellitus: a systematic review. Evid. Based Compl Alt. +Med. 2007; 4: 469-486. +[37] +Mulder EJ, Robles de Medina PG, Huizink AC, Van +den Bergh BR, Buitelaar JK, Visser GH. Prenatal +maternal stress: effects on pregnancy and the (unborn) +child. Early Hum. Dev. 2002; 70(1-2): 3-14. +[38] +Ahmad N. Molecular mechanisms of HIV-1 mother-to- +child transmission and infection in neonatal target cells. +Life Sci 2011; 88(21-22): 980-6. +[39] +Antoni MH, S. N., Fletcher MA, Goldstein DA, Ironson +G, LaPerriere A. Psychoneuroimmunology and HIV-l. J +Consult. Clin.Psychol 1990; 1(5): 38-49. +[40] +Leserman J, Jackson E, Petitto J, Golden R, Silva S, and +Perkins D, et al.. Progression to AIDS: The effects of +stress, depressive symptoms and social support. +Psychosomatic Med 1999; 61: 397-406. +[41] +Burack JH, Barrett DC, Stall RD, Chesney MA, +Ekstrand, ML, Coates, TJ. 1993. Depressive symptoms +and CD4 lymphocyte decline among HIV-infected men. +JAMA 1993; 270: 2568-2573. +[42] +Ickovics J, Hamburger M, Vlahov D, Schoenbaum E, +Schuman P, Boland R, Moore J. 2001. Mortality CD4 +cell count decline and depressive symptoms among +HIV-seropositive women: Longitudinal analysis from +HIV Epidemiology Research Study. JAMA 2001; 285: +1460-1465. +[43] +Koka PS, Fraser JK, Bryson Y, Bristol GC, Aldrovandi +GM, +Daar +ES, +Zack +JA. +1998. +Human +immunodeficiency virus type 1 inhibits multi-lineage +hematopoiesis in vivo. J. Virol. 1998; 72: 5121-5127. +[44] +Nair MPN, Mahajan S, Hou J, Sweet AM, Schwartz +SA. 2000. The stress hormone, cortisol, synergizes with +HIV-1 gp-120 to induce apoptosis of normal human +peripheral blood mononuclear cells. Cell Mol Biol +(Noisy-le-grand) 2000; 46(7): 1227-1238. +[45] +Khalsa, S. B. Yoga as a therapeutic intervention: a +bibliometric analysis of published research studies. +Indian J. Physiol.Pharmacol 2004; 48(3): 269-285. +[46] +Descilo T, Vedamurtachar A, Gerbarg PL, Nagaraja D, +Gangadhar BN, Damodaran B, et al. Effects of a yoga +breath intervention alone and in combination with an +exposure therapy for post-traumatic stress disorder and +depression in survivors of the 2004 South-East Asia +tsunami. Acta Psychiatr. Scand. 2010; 121(4): 289-300. +[47] +West J, Otte C, Geher K, Johnson J, Mohr DC. Effects +of Hatha yoga and African dance on perceived stress, +affect, and salivary cortisol. Ann Behav Med. 2004; +28(2): 114-118. +[48] +A Bhansali, RJ Dash, A Sud, S Bhadada, S Sehgal, BR +Sharma. A preliminary report on basal and stimulated +plasma +cortisol +in +patients +with +acquired +immunodeficiency syndrome patients. Indian J. Med. +Res. 2000; 112: 173-7. +[49] +Vago T, Clerici M, Norbiato G. 1994. 5 Glucocorticoids +and the immune system in AIDS. Baillière's Clinical +Endocrinology and Metabolism 1994; 8(4): 789-802. +[50] +Cole SW, Naliboff BD, Kemeny ME, Griswold MP, +Fahey JL, Zack JA . 2001. Impaired response to +HAART in HIV-infected individuals with high +autonomic nervous system activity. Proc Natl Acad Sci +USA. 2001; 98: 12695-12700. +[51] +Deb U, Nagendra HR, Nagarathna R, Raghvendra Rao +M, Satish KS, Sangamitra I. Efficacy of yoga +intervention on HIV seropositive subjects – a +randomized waitlist controlled trial. Unpublished +observations. +[52] +Bhargav H, Raghuram N, Nagendra HR, Tekur P, Koka +PS. Potential Yoga Modules for Hematopoietic +Inhibition in HIV-1 Infection. J. Stem Cells 2011; 5(3): +129-148. +[53] +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(3): 218-222. +[54] +Narendran S, Nagarathna R, Narendran V, Gunasheela +S, Nagendra HR. Efficacy of yoga on pregnancy +outcome. J. Alt. Compl Med 2005; 11(2): 237-244. +[55] +Beddoe AE, Lee KA, Weiss SJ, Kennedy HP, Yang CP. +Effects of mindful yoga on sleep in pregnant women: a +pilot study. Biol Res. Nurs 2010; 11(4): 363-370. +[56] +Beddoe AE, Paul Yang CP, Kennedy HP, Weiss SJ, Lee +KA.The effects of mindfulness-based yoga during +pregnancy on maternal psychological and physical +distress. J. Obstet Gynecol Neonatal Nurs 2009; 38(3): +310-319. +[57] +Kashinathshastri, +Gorakhanathchaturvedi, +Charakasamhitachikitsasthana. Chapter 1, verse 69, pg +17. Chaukhamba Bharati Academy, Varanasi, India, +2006. +[58] +Udupa KN, Singh RH. Clinical and Experimental +Studies on Rasayana Drugs and Panchkarma Therapy +(monograph), Central Council for Research in Ayurveda +and Siddha, New Delhi, India, 1993. +[59] +Neurath AR, Strick N, Li YY, Debnath AK. +Punicagranatum (pomegranate) juice provides an HIV-1 +entry inhibitor and candidate topical microbicide. Ann N +Y Acad. Sci 2005; 1056: 311-327. +[60] +Mbah AU, Udeinya IJ, Shu EN, Chijioke CP, Nubila T, +Udeinya F, Muobuike A, Mmuobieri A, Obioma MS. +2007. Fractionated neem leaf extract is safe and +increases CD4+ cell levels in HIV/AIDS patients. Am. +J. Ther 2007; 14(4): 369-374. +[61] +Shah KA, Patel MB, Patel RJ, Parmar PK. 2010. +Mangifera Indica (Mango). Pharmacogn Rev. 2010; +4(7): 42-48. +[62] +Zhu XM, Song JX, Huang ZZ, Whu YM, Yu MJ. +Antiviral activity of mangiferin against herpes simplex +Vertical Transmission of HIV Infection + +153 + +virus type 2 in vitro. Zhongguo Yao Li Xue Bao. 1993; +14: 452-454. +[63] +Zheng MS, Lu ZY. Antiviral effect of mangiferin and +isomangiferin on herpes simplex virus. Chin Med J. +1990; 103: 160–165. +[64] +Guha S, Ghosal S, Chattopadyay U. Antitumor, +immunomodulatory and anti-HIV effect of mangiferin: +A naturally occurring glucosylxanthone. Chemotherapy. +1996; 42: 443-451. +[65] +Ito M, Sato A, Hirabayashi K, Tanabe F, Shigeta S, +Baba M, De Clercq E, Nakashima H, Yamamoto N. +Mechanism of inhibitory effect of glycyrrhizin on +replication of human immunodeficiency virus (HIV). +Antiviral Res. 1988; 10(6): 289-298. +[66] +Yao WH, Zhao W, Wu YW, Zhao H, Wei HX, Cheng C +et al. Effect of compound glycyrrhizin on peripheral T- +lymphocyte subset in AIDS patients. Zhonghua Nan Ke +Xue 2006; 12: 598-601. +[67] +Nakashima H, Matsui T, Yoshida O, et al. A new anti- +human immunodeficiency virus substance, glycyrrhizin +sulfate; endowment of glycyrrhizin with reverse +transcriptase-inhibitory +activity +by +chemical +modification. Jpn J. Cancer Res. 1987; 78(8): 767-771. +[68] +Il'ina TV, Fediuk NV, Bachinskiĭ AG, TumanovaOIu, +Kuvshinov +VN, +Il'ichev +AA, +Pokrovskiĭ +AG. +Determination of glycyrrhizic acid binding sites by a +phage display method. Mol Biol (Mosk). 2003; 37(5): +861-867. +[69] +Ahn MJ, Kim CY, Lee JS, Kim TG, Kim SH, Lee CK et +al. Inhibition of HIV-1 integrase by galloyl glucoses +from Terminaliachebula and flavonol glycoside gallates +from Euphorbia pekinensis. Planta Med. 2002; 68(5): +457-459. +[70] +Notka F, Meier GR, Wagner R.Inhibition of wild-type +human +immunodeficiency +virus +and +reverse +transcriptase +inhibitor-resistant +variants +by +Phyllanthusamarus. Antiviral Res. 2003; 58(2): 175- +186. +[71] +Srikumar +R, +Parthasarathy +NJ, +Shankar +EM, +Manikandan S, Vijayakumar R, Thangaraj R et al. +Evaluation of the growth inhibitory activities of +Triphala against common bacterial isolates from HIV +infected patients. Phytother Res.2007; 21(5): 476-480. +[72] +Talwar GP, Dar SA, Rai MK, Reddy KV, Mitra D, +Kulkarni SV et al.A novel polyherbalmicrobicide with +inhibitory effect on bacterial, fungal and viral genital +pathogens. Int. J. Antimicrob. Agents 2008; 32(2): 180- +185. +[73] +Zhang M, Poh TY, Louache F, Sundell IB, Yuan J, +Evans +S, +Koka +PS. +Rescue +of +multi-lineage +hematopoiesis during HIV-1 Infection by human c-mpl +gene transfer and reconstitution of CD34+ progenitor +cells in vivo. J Stem Cells 2009; 4(3): 161-177. +[74] +Zhang M, Evans S, Yuan J, Ratner L, Koka PS. HIV-1 +determinants of thrombocytopenia at the stage of +CD34+ progenitor cell differentiation in vivo lie in the +viral envelope gp120 V3 loop region. Virology 2010; +401(2): 131-136. + + diff --git a/subfolder_0/HEALTHY LIFE-STYLE PRESCRIPTIONS FOR DIFFERENT PERSONALITY TYPES (TRIDOSHA PRAKRITI).txt b/subfolder_0/HEALTHY LIFE-STYLE PRESCRIPTIONS FOR DIFFERENT PERSONALITY TYPES (TRIDOSHA PRAKRITI).txt new file mode 100644 index 0000000000000000000000000000000000000000..8d37344f75837d2220bafa74d7081f54f4d6b43b --- /dev/null +++ b/subfolder_0/HEALTHY LIFE-STYLE PRESCRIPTIONS FOR DIFFERENT PERSONALITY TYPES (TRIDOSHA PRAKRITI).txt @@ -0,0 +1,871 @@ +Jour. of Ayurveda & Holistic Medicine +Volume-II, Issue-VII +30 + + +HEALTHY LIFE-STYLE PRESCRIPTIONS FOR DIFFERENT PERSONALITY TYPES +(TRIDOSHA PRAKRITI) + Ramakrishna B R1 Kishore K R2 Vaidya Vasudeva3 Nagendra H R4 + +INTRODUCTION: +The whole world, particularly the developed and developing +countries,iscursed with non-communicable diseases (NCDs) +(WHO Fact sheet updated March 2013), also known as non- +infectious epidemics, which are due to impaired lifestyle +practices(WHO Global status report on Non-communicable +diseases 2010). The western system of medicine is striving to +manage this progressive, alarming problem and looking to +complementary and alternative systems of medicine +(CAMs).In this endeavour, Ayurveda and Yoga, the age old +natural systems of health care that primarily focus on +prevention of diseases through life style modifications and +interventions based on the fundamental concepts of +Tridoshas[1] and Prakriti, play an important role. According to +Ayurveda, Tridoshas, namely Kapha, Vata and Pitta, the three +functional humours [2], are responsible for three universal +functions in the body, namely generation (anabolism), +organization (metabolism) and destruction (catabolism) +respectively[1]. They contribute to both the physical and +psychological personality development from the time of +zygote formation, exhibiting a very specific structure- +function-behaviour pattern and trait of a person known as +Prakriti. [1] +Ayurveda classic texts say that Prakriti is formed due to the +predominant doshas (functional entities) during fertilization +and remains unchanged throughout the life span of an +individual, manifesting very specific characteristic features in +physical, psychological, intellectual, spiritual and social +domains of a person[2]. A person remains healthy if his life +style is in tune with his/ her Prakriti to maintain the dynamic +equilibrium of all the three doshas. The doshas get vitiated if +the life style does not suit his/ her inborn Prakriti. Hence, an +abnormality in this equilibrium can be reversed through +suitable life style modifications to prevent or cure diseases +and promote wellness. (Samyak Ahara-Vihara and Vichara). +According to Ayurveda there are seven types of Prakritis[1], +namely Vatala, Pittala, Kaphala, Vata Pittala, Vata Kaphala, +Kapha Pittala, and Sama Prakriti. Three have single dosha +ABSTRACT: +Intense efforts to offer life style modification programs are underway to prevent the increasing incidence of non- +communicable diseases (NCD). Accumulating evidence for the beneficial effects of complementary and alternative +systems of medicine in NCDs have popularised Yoga and Ayurveda systems because of the emphasis on elaborate life +style modification. The life style modifications of Ayurveda include Ahara (food and drinks), Vihara (practises and +habits) and Vichara (thoughts) that vary according to the type of the personality/Prakriti (physic – physio - +psychological) of an individual and also the environment (Ritucharya-seasonal regimens). In this study, specific life style +prescriptions with regard to different Prakriti were compiled from classical texts of Ayurveda by the researcher. The +prepared list was sent to the participants of a focus group of five Ayurveda experts who had signed an informed +consent for this validation study. After obtaining their feedback, the revised list was sent to them again and the group +met for an intensive interactive session in the library to refer to the classical texts before finalising the table of +prescriptions. The result of this study offers tables of suitable prescriptions of life style changes for normal adults for +the prevention of NCDs based on the Ayurvedic concept of Prakriti. The life style prescription comprises of three major +aspects namely Ahara, Vihara and Vichara. The Ahara prescription contains eleven items, Vihara contains five items +and Vichara contains four items. The study also reveals that the Ahara, Vihara and Vichara recommended for each of +the Prakriti are totally different and specific. This validated module based on the Tridosha theory of Ayurveda helps the +modern medical system to individualize life style prescriptions that vary widely according to different Prakriti and +Ayurveda and Yoga systems for promotion of positive health and prevention of diseases. +Key Words: Life style, Tridosha Prakruti, Ahara, Vihara. +1PhD (Yoga) scholar, +4Chancellor, 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). +Corresponding author email address: +brramakrishnasvyasa@gmail.com +Access this article online: www.jahm.in +Published by Atreya Ayurveda Publications, Ilkal-587125 (India) all +rights reserved. +Received on: 03/08/14, Revised on: 20/08/14, Accepted on: +26/08/14 +Jour. of Ayurveda & Holistic Medicine +Volume-II, Issue-VII +31 + +predominance, three have dual dosha predominance, and +one is a balance of all the three doshas.These seven types +vary widely in the characteristics of different domains of +health, such as immunity against communicable and non- +communicable diseases, vulnerability to particular diseases, +behaviour , personality, intellect, lifespan etc. One’s type is +based on the predominant physical and physiological +properties, described as Gunas of Tridoshas, established +during the manifestation of Prakriti during fertilization[1] +Hence, Ayurveda provides elaborate advice on life style +practices that include Ahara, Vihara and Vichara suitable to +the individual’s Prakriti that helps in maintaining a balance of +the three doshas, and prevents exaggeration/vitiation of any +one dosha. The selection criterion is also clearly laid down as +Viruddha Guna (select those items of food or practices that +have qualities which can oppose the dominant Guna +(cravings) of the individual.) Thus, specific life style +injunctions for each of the Prakriti types are available in +classical texts of Ayurveda[2]. +• +Rakta Shali [red rice] has been attributed with sheetha +[cold] and snigdha [unctuous] properties [3] and indicated +in vathapithaja prakriti persons. +• +Shastika shali [a variety of rice which yields in 60 days] is +attributed with sheetha, snigdha and laghu [light] +properties [3] is indicated in Pitta prakriti persons +• +Godhuma [wheat] with snigdha and guru properties[3] is +indicated in Vata prakriti persons. +• +Shimbi dhanyas [pulses/dicotyledons] with rooksha +[dryness], laghu [lightness] and sheetha properties [3] is +not indicated in Vata prakriti persons. +• +Tila [sesame] with snigdha and ushna properties [3] is +indicated in Vata prakriti person. +• +Kukkuta mamsa [chicken meat] with laghu and ushna +[hot] properties [3] is indicated in Kapha prakriti persons. +• +Matsya [fish] with snigdha, guru and ushna properties [3] +is indicated in vata prakriti persons. +• +Vyayama [exercise] with laghu property, is indicated in +Kapha prakriti persons. +• +Abhyanga [oil massage] with snigdha property is +indicated in Vata prakriti persons. +The present study was aimed at preparing the table of +suitable life style prescriptions for different Prakriti types, in +present day context, based on the recommendations by the +classical texts. This would be a very useful addition to the +present knowledge of life style modification recommended +by WHO for NCDs. +METHODS: +The concept of life style management is referred to in the +authoritative +literature +of +Ayurveda, +namely +the +Bruhathrayees. The list of recommendations for Ahara (food +and drinks), Vihara (habits and practices) and Vichara +(thoughts) for the three dominant Prakriti types was +prepared using the concept of Viruddha Dharma (opposite +qualities) as recommended by these texts. The items +compiled from the texts were translated from Sanskrit to +English language. These prescriptions for each of the Dosha +Prakriti were then modified to suit the current scenario of life +style without deviating from the basic concepts portrayed in +the classical texts. This list was sent to the participants of a +focus group of five Ayurveda experts who had signed an +informed consent for this validation study. After obtaining +their feedback, the revised list was sent to them again and +the group met for an intensive interactive session in the +library to refer to the classic texts of Ayurveda before +finalising the table of prescriptions. +RESULTS: + The compilation included qualitative information with +respect to the concept of Gunas of: +a. Ahara: staple food grains (rice, wheat etc.) and millets, +cereals and pulses, fruits and vegetables, milk and milk +products, sugarcane and its products, drinks and +beverages, spices and aromatics, meat and prepared +food items, honey, liquors and different sources of +drinking water; +b. Vihara: daily & seasonal regimens, exercise, sleep and +sex, daily bath and weekly oil bath, job and profession, +relaxation and meditation; +c. +Vichara: teaching and self-studies, debates and +discussions, prayer and rituals. +Following are the important Lifestyle observations noticed in +the present study for administration to each of the dosha +Prakriti for maintenance of harmony. +Table 1: Showing lifestyle for Vata Prakriti +Items +Recommendations +Ahara +Groups + Suitable Items – V1 +Not Suitable Items – V2 +Food and +drinks +Tastes / Rasa +Sweet, sour, and salt taste. +Pungent, astringent and bitter taste food and +drinks. +Cereals +Rice, wheat, red rice, navara rice, Thai +rice, black rice, navane [neevara], +Millets- ragi, corn, maize, oats, +barley, rye, sajje,maida, +Pulses +Tuvar dal [lentils], black gram, soya +bean, green gram, ground nut, horse +gram . +Horse gram, red lentils, dry peas, soya, bengal +gram, +Fats/oils +All types of oils and ghee particularly- +sesame,olive, badam [almond], +mustard, sun flower, ground nut, +coconut, rice bran, wheat bran, palm, +Grape seed oil, all fried and roasted food, bakery +products, burgers and pizzas, chocolates, ice +cream, honey,junkfood- (potato chips, puffs and +samosas ,pastas) +Jour. of Ayurveda & Holistic Medicine +Volume-II, Issue-VII +32 + +linseed, soya + +Fruits +Seasonal all fruits- mangos, sweet +apples, +bananas, red banana, papaya, oranges, +citron, citrus medica,tamarind, cocum, +amlavethasa, lemon, cherry, sweet +pears, cranberry, figs, plums, +pineapple,butterfruit, peaches, kiwi +Unseasonal and unripe fruits, berries and cherries, +guava, grapes, dates, jack fruit, jamoon fruit, +tomatoes, melons. + +Nuts & Seeds +All kinds of nuts, dry fruits & oil seeds. +Preferably ground nuts, almonds, +cashews, pista, apricot, acrods, sesame, +poppy seeds, linseeds, pumpkin seeds. +All roasted nuts and seeds, spiced nuts, popcorns, +dry roasted grams. + +Vegetables +Baked and fried vegetables with ghee +and oil- particularly dodi +[jeevanthi],drumstick, onions, +ashgaurd, asparagus, amarphophilus, +radish, bamboo sprouts, +carrots, +Half-baked and raw vegetables, baked and roasted +without oil & ghee, particularly- peas,potatos, +sweetpotatos, beet root, country peas, +legumes, bitter taste vegetables-bittergaurd, +snakegaurd, ridgegaurd, pumpkin, navilkol, +capsicum, brinjal, kalang, arrowroot, half ripened +bananas, green leafy vegetables, cabbages, beans, +cauliflower, sprouts. + +Spices +Spices – ginger, asafoetida, garlic, mint, +cumin, dill, coriander, cinnamon, +pudina, clove, nutmeg, pepper, +mustard, curcuma, cardamom, rock +salt, blacksalt,tamalapatra,allspice, +curry leaves, mango ginger, pulao +spices. +Too much of spices, red and green chillies of any +kind. + + +Milk and milk +products +Fresh and warm milk with cream, fresh +cheese, ghee, spiced +buttermilk,paneer. +Butter, buttermilk, yogurt, curds, old cheese, Lassi. + +Drinks beverages & +others +Warm water, lemon juice, ginger lemon +tea, pudina-mint tea... +Cold water, aerated soft drinks &beverages, +alcoholic drinks, tobacco, coffee, tea, + + +Meat +Chicken, goat, deer, lamb, pigeon. +Red meat, sheep, fish and seafood, eggs. +Vihara / +Habits + +Bathing and +Massage + + +Warm water bath/shower, +Oil bath / oil massage at regular +intervals, steam bath, sauna bath +Cold water bath; river,pond, well and waterfalls +bath +Exercise +Light exercise, warm water swimming, +loosening exercise. + +Heavy exercises, long walking, exposure to cold +breeze, tread mill, cycling, trekking, hiking skying, +skating, jogging, horse riding, heavy vehicle driving +and racing, outdoor play. +Sexual act +Less practice +Frequent / daily practice +Sleep + +7-8 hours at night only +Day time sleeping, keeping awake in the night. + +Rejuvenatingtherapy +Seasonal Panchakarma (Basti) therapy +during Varsharuthu [August & +September]. + +Vichara / +Thoughts +Profession +Office job, less travelling, other than +roaming jobs. +Monotonous working, travelling and touring, +marketing profession, in depth studies and +focussed work. +Self-study +Spiritual and moral literature. +Novels, adventure scripts. + +Spiritual practices +Bhajans,prayers, holy assembly + +Jour. of Ayurveda & Holistic Medicine +Volume-II, Issue-VII +33 + +Yoga practices +Yoga asanas, Pranayamas- Anuloma +viloma, Ujjai, Bhramari, Sukshma +vyayama and meditation. +Dynamic yoga, power yoga,Bikram yoga + +Table 2: Showing lifestyle for Pitta Prakriti. +Items +Recommendations +Ahara +Groups + Suitable Items – P1 +Not Suitable Items –P2 +Food and +drinks +Tastes / +Rasa +Bitter, astringent and sweet taste food +& drinks. +Pungent, sour and salt taste food and drinks. +Cereals +White rice, wheat, barley , oats, +sprouted grains, navara, ragi, +Millets, rye, brown rice, red rice, buck wheat & +corn +Pulses +Green gram, thuvardal [lentils], pulses, +gram sprouts. +Horse gram, black gram, red lentils, dry peas, soya, +Bengal gram. +Fats/oils +Oils like olive oil, soya oil, grape seed +oil, wheat and rice bran oils, +food items prepared with moderate +ghee, +Mustard oil, coconut oil, sesame oil, sunflower oil, +almond oil, palm oil, +All deep oil fried and roasted foods. + +Fruits +All sweet fruits, preferably- bananas, +sweet mangos, sweet melons, avocado, +figs, pears, sweet grapes, raisins, +cherry, pineapple, plums, sweet +oranges, citrons, citrus medica, sweet +berries , juice fruit, bhelfruit, +cranberry, +All sour fruits, particularly tamarind, orange, sour +apples, sour berries, sour cherries, sour plums, sour +grapes, lemons, peach, papaya, olives, apricots + +Nuts&Seeds +Dates( fresh], pumpkin seeds, melon +seeds, +Cumin seeds, dill seeds, sowa seeds- +ajwain and sompf seeds. +All dry fruits and nuts, particularly +ground nuts, cashew, almonds, acrodes, , +Pistachio, dry coconut +, salted and spiced nuts. +Seeds like sesame, linseed, poppy seeds. + +Vegetables +All kinds of leafy vegetables, lentil +salads, spinach, cabbage, cauliflower, +broccoli, celery, fennel, onions, bitter +vegetables, +cluster beans, dried sprouts, carrots, +banana flower, dodi [jeevanthi], agase, +ashgaurd, asparagus, +Capsicum, radish, beetroot, carrot, drumstick, +corns, amorphophelus, +Tomatoes, bamboo sprouts, gonguru, brinjal. + + +Spices +Spices like cumin, coriander, fennel, +saffron, cardamom, cinnamon, +turmeric, fresh ginger, +Spices like black pepper, dry ginger, all kinds of +chilies, cloves, mustard seeds, +Salts, asafoetida, garlic, pulao spices. + + +Milk and Milk +products +Fresh and warm milk with cream, fresh +cheese, ghee, buttermilk, paneer. +Sour milk products, sour creams. + + +Drinks Beverages +& others +Tender coconut water, candy sugar +drinks, wines, beer, vodka +plenty of water, lemon water with +honey, +Fresh herbal juices-Amla, Pomegranate, +Centella, Grape, Jamoon Fruit and +Sauces. milk icecream and candies. +Coffee, tea, alcoholic beverages,jaggery, brown +sugar, sugar cane juice, honey, molasses, soda +water, packed & preserved juices, jams, ketchups, +chocolates, and roasted and spiced grams, chips, +pizzas and burgers, cocoa, salty and hot foods, +tobacco in any form. + + +Meat +Low fat meat (gout, legs, thighs) with +less spice, sweet water fish, seafood +with less spice, rabbit, pork, gout. +Meat of animals, chicken, sea fish, eggs, red meat, +sheep, broiler chicken. +Vihara / +Habits + +Bathing and +Massage + + +Warm / cold water bath/shower, +Sauna bath, warm water Jacuzzi and +tub bath, oil bath and massage without +steam. + +Hot water- bath/shower/swimming, +Steam bat sunbath, Jacuzzi and sauna +Exercises +Light exercise, micro exercise, all types +of exercise with moderate effort, early +morning and late evening walking in +Heavy exercises, long walking, exposure to hot air, +tread mill, cycling, trekking, skating, jogging, horse +riding, heavy vehicle driving and racing, outdoor +Jour. of Ayurveda & Holistic Medicine +Volume-II, Issue-VII +34 + +gardens and parks, skewing +play +Sexual act +Moderate +Regular and frequent +Sleep +Moderate +Day sleep except during summer +Rejuvenating +therapy +Seasonal Panchakarma (Virechana) +therapy during sharadrutu (October- +November) + +Vichara / +Thoughts +Profession +Less intellectual jobs, routine and +casual work, less focussed fields. +Monotonous working, travelling and touring, +marketing profession, intellectual and focussed +work. +Self-study +Spiritual and sober literature +Exciting and temptation-causing books + +Spiritual practices +Bhajans prayers, holy rituals and +practices, divine practices and service +oriented acts. + +Yoga practices +Yoga asana, Pranayama – +Chandranuloma viloma, sheetali- +sheetkari-sadanta, Bhramari +meditation. +Dynamic yoga, power yoga,, Bikram yoga, +Pranayama – Suryaranuloma viloma. + +Table 3: Showing lifestyle for Kapha Prakriti +Items +Recommendations +Ahara +Groups + Suitable Items –K1 +Not Suitable Items –K2 +Food and +drinks +Tastes / +Rasa +Pungent, bitter and astringent taste +foods and drinks, warm and hot, dry & +less fatty foods. +Sweet, sour and salty taste food and drinks, cold and +chilled foods, fatty foods. +Cereals +Wheat, white and stored rice, millets – +ragi, jawar, corn buckwheat, oats, barley. +Brown rice, red rice, new rice, new wheat, +Basmati rice, navane. +Pulses +All types of grams and pulses- thuvar dal +[lentil], Green gram, black gram, horse +gram, Bengal gram, red dal, Kaboolchana. +Soya beans and soya products, white and red beans +Fats/oils +Sunflower oil, sesame oil, margarine oil, +linseed oil, groundnut oil, mustard oil, +olive oil, almond oil, coconut oil, small +quantity of ghee. +Rice and wheat bran oils, +Grape seed oil, palm oil. + +Fruits + Papaya, pears, berries, cherries, +mangoes, peaches, dry fruits. +Bananas, apples, grapes, jack fruit, guava, +butter fruits, citrus fruits, lemon, melons, +Pineapples, avocado, sapotas and kiwi. + +Nuts and Seeds +All dry nuts and seeds preferably: dry +dates, almonds, cashew nuts, apricots, +pumpkin seeds, sunflower seeds, +cucumber seeds,ground nuts, sesame +seeds, copra, sesame, poppy seeds, +linseeds,. +Pistachio, fresh dates, poppy seeds. + +Vegetables +All kinds of leafy vegetables, lentil salads, +spinach, cabbage, cauliflower, broccoli, +celery, fennel, asparagus, radish, onions, +capsicum, amarphophilus, bamboo +sprouts, bitter vegetables. +Potatoes, cucumber, pumpkin, tomatoes, peas, white +beans, onion salads, ladies finger, ash guard, ridge +guard, bananas, banana stems, beet roots, sweet +potatoes , +centella leaves, bottle gourd, + +Spices +All spices in moderate quantity,- ginger, +black and white pepper, clove, cinnamon, +turmeric, cardamom, long pepper, +coriander, jeera [cumin], allspices, +cinnamon leaves, camphor, saffron. + + +Milk and Milk +products +Low fat milk, spiced buttermilk +Butter, buttermilk, yogurt, curds, aged cheese, lassi, +ghee and pannier +Jour. of Ayurveda & Holistic Medicine +Volume-II, Issue-VII +35 + + +Drinks +,Beverages& +others +Warm water, lemon juice, ginger lemon +tea, coffee, herbal tea, – pudina-mint +tea... ginger-tulsi [bassllicum], ginger- +lemon, honey- lemon, coffee and tea. +Alcoholic drinks- whiskey, brandy, rum in +small dose. +Cold water, aerated soft drinks &beverages, +Alcoholic drinks – wines, beers, vodka, and tobacco in +different forms. + +Meat +Chicken meat, goat meat. +Red meat, sheep, fish and seafoods, eggs, pork and +beef. +Vihara / +Habits + +Bathing and +Massage + + +Hot water bath/shower, swimming and +tub bath, oil bath and body massage with +steam, +hot powder massage [udvarthana], +herbal powder massage +[churnapindasweda], foot massage +[padaghatha], +Cold water bath, shower, swimming and tub bath. +Exercises +Dynamic exercises, +Power yoga, brisk walking, running, +jogging, skiing, hiking, wrestling, +swimming, horse riding, skating, cycling +and treadmill. + Indoor games and sedentary sports. +Sexual act +Preferred + +Sleep +4-6 hours at night only. +Day time sleeping, +Rejuvenating +therapy +Seasonal panchakarma therapy during +Vasanta rutu [ April & May] + + +Profession +All marketing professions, driving, sports +Sedentary work +Vichara/ +Thoughts +Self-study +Exciting and temptation creating +literature. +Casual and sober literature, in-depth study. +Spiritual +practices +Divine dances, loud bhajans and prayers, +yajna, homa, Havana rituals, upavasa. + +Yoga practices +Yoga-dynamic asana, practice of +Sooryanulomaviloma Pranayama [right +nostril breathing]. + +Chandranuloma viloma Pranayama [left nostril +breathing], cooling Pranayama – +Sheethali, Sheethkari and Sadantha Pranayama, +relaxation techniques. +These prescriptions are to be suitably integrated and +administered to those who have Prakriti with two doshas. +For Vatapittaprakriti persons, the lifestyles of Vata should be +advised during cloudy [monsoon] and rainy season, a Pitta +lifestyle should be advised during hot [summer & autumn] +season and combination of both during other seasons[2]. +For Pittakaphaprakriti persons, the lifestyles of Pitta should +be advocated during hot [summer & autumn] season, and the +lifestyles of Kapha should be advised during cold [winter & +spring] season and combination of both should be given +during other seasons[2]. +For Vatakapha Prakriti persons, the lifestyle of Vata should +be advised during monsoon and rainy season, lifestyles of +Kapha should be advised during winter and spring season and +combination of both should be given during other seasons [2]. +Samaprakriti, also known as Tridosha Prakriti, persons are +advised to follow the normal life style with a note that +nothing should be taken or practiced in excess and everything +should be in moderation[2]. + +Table 4: FGD to validate the contents of Life style prescription based on Ayurvedic concepts + +Lifestyle +prescription +Expert +1 +Expert +2 +Expert +3 +Expert +4 +Expert +5 +Remarks +V1 +1 +2 +1 +2 +1 + +V2 +2 +1 +1 +2 +1 + +P1 +1 +2 +1 +2 +1 + +P2 +1 +1 +1 +1 +2 + +K1 +2 +1 +2 +2 +1 + +K2 +2 +1 +1 +2 +2 + +Jour. of Ayurveda & Holistic Medicine +Volume-II, Issue-VII +36 + +1 - Most appropriate, 2 - Appropriate, 3 - Less appropriate, 4 - Not appropriate. +V1- Take & Practice more for Vata prakriti, V2- Take & Practice less for Vata prakriti, P1- Take & Practice more for Pitta +prakriti, P2- Take & Practice less for Pitta prakriti, K1- Take & Practice more for Kapha prakriti, K2- Take & Practice less for +Kapha prakriti + +DISCUSSION: +It is seen from the study that the classification of lifestyle +comprising of food, habits and practices is purely based on +the concept of Gunas [properties derived and inherited from +the five basic elements of the universe namely Prithvi (earth), +Aap (water), Tejas (fire), Vayu (air) & Akasha (ether)[4] The +Prakriti management through lifestyle modifications is based +on the concept of Gunas which has ten pairs of mutually +opposite properties and are designated in the texts as +Gurvadi Vimshathi Gunas [twenty physical proprieties][4]. +Based on the proposition those for management of Prakriti +with particular dosha dominance, the lifestyle of the opposite +qualities need to be administered to maintain harmony[4]. +Vatha prakriti needs sneha [unctuous], guru [heavy], ushna +[hot], mrudu [soft], sthoola [gross] and sthira [firm] +properties which are the opposite of the qualities of Vata[4]. +Pitta prakriti needs rooksha [dry], manda [slow], sheetha +[cold], sandhra [dense] and ghana [solid] which are the +opposite qualities of Pitta[4]. +Kapha prakriti needs laghu [light], tikshna [potent], ushna +[hot], rooksha [dry], vishada [transparent] and khara [rough] +properties which are the opposite qualities of Kapha[4]. +This entire concept is based on the fundamental doctrine of +Samanya and Vishesha Siddhanta – “The Similar things +produce similarity & dissimilar things produce variability. In +order to maintain the harmony of a particular type of Prakriti +which is manifested due to the predominance of a particular +dosha or doshas we need to administer the life style +possessing opposite qualities, otherwise it results in +disharmony. In addition, one of the main concepts of +Ayurvedic therapeutics, namely shadvidha upakrama, which +comprises of snehan, rookshana, brihmana, langhana, +svedana +and +stambhana +(lubricating, +anti-lubricating, +growth-promoting, lightness, diaphoretic binding), is purely +based on the concept of guna only. In the life style +management of Ayurveda these specialities of therapeutics +are invariably used to maintain the harmony of Tridoshas. +Based on these doctrines and concepts we can provide +Ayurvedic rationality for the present day modern lifestyles in +the management of the Prakriti and its harmony, whereas +the modern life style methods do not dissect the effect based +on their inherent qualities and hence, cannot provide +individual-oriented life style practices which are mandatory +to promote health and prevention of disease on an individual +basis. +Limitations of the study: +The present study is limited to compile and analyse the +information on lifestyle prescriptions documented among the +classical texts of Ayurveda and present through a table form +involving the three basic aspects of life style, namely Ahara, +Vihara and Vichara. + +Strengths of the study: +This study has shown that the Ayurvedic lifestyle has three +major aspects and twenty life style practises. There is a +concept in lifestyle prescription, and it is essentially based on +the personality of an individual. +Recommendations: +Based on the observations of this study it is recommended +that, in the absence of any validated healthy lifestyle +prescription based on Prakriti, this life style prescription can +be used for the promotion of positive health and prevention +of diseases after the assessment of Prakriti of an individual +using a scientifically developed and validated tool. Otherwise +the whole exercise of Prakriti assessment becomes futile. +Suggestions for future work: +Based on the results and observations of this study it is +suggested that the validated healthy life style prescription +should be used on a greater number of samples of different +types of Prakriti to further validate its role and utility, and an +increased number of experimental studies on the efficacy of +the healthy life style prescriptions based on Prakriti in +promoting positive health and prevention of diseases by +using and comparing different tools. +REFERENCES: +1. +Shastry K.A Sushruta samhita. Varanasi: chowkambha Sanskrit +samsthana. 1997. +2. +Dash B, and Sharma, R.K CarakaSamhita. Chowkamba Sanskrit +series office. Varanasi. 1995 +3. +Chunekar K C, Pandey G S,. Bhavaprakasha nighantu of Sri +Bhavamishrachowkamba Bharati academy. Varanasi. 1986 +4. +Anna Moreshwar Astanga hrudaya. Varanasi: Chowkambha +publications. 1993. +5. +Chopra D Positive health. New York: Crown publishers, 1994. +6. +Lad V,.An Introduction to Ayurveda. Altern Ther Health Med, +1995;1(3): 57-63. +7. +Endo J, Nakamura T. Comparative studies of the tridosha theory +in Ayurveda and the theory of the four derangedelements in +Buddhist medicine. Kagakushi Kenkyu, 1995; 34(193): 1-9. +8. +Kurup RK & Kurup PA. Hypothalamic digoxin, hemispheric +chemical dominance, and the tridosha theory. Int J Neurosci, +2003;113(5):657-81. +9. +Joshi RR. A biostatistical approach to Ayurveda: quantifying the +tridosha. J Altern Complement Med, 2004;10(5):879-89. +10. Hankey A. (2005) A tests of the systems analysis underlying the +scientific theory of Ayurveda Tridosha. J Altern Complement +Med, 11(3): 385-90. +Cite this article as: Ramakrishna B R, Kishore K R, Vaidya Vasudev, +Nagendra H R. Healthy life-style prescriptions for different +personality types (tridosha prakriti). J of Ayurveda and Hol Med +(JAHM); 2014;2(7):30-36. +Source of support: Nil, Conflict of interest: None Declared diff --git a/subfolder_0/Heart rate variability changes during and after the practice of bhramari pranayama.txt b/subfolder_0/Heart rate variability changes during and after the practice of bhramari pranayama.txt new file mode 100644 index 0000000000000000000000000000000000000000..aac299ba3b05a5b05a7bd16d4b19430218becd57 --- /dev/null +++ b/subfolder_0/Heart rate variability changes during and after the practice of bhramari pranayama.txt @@ -0,0 +1,469 @@ +© 2017 International Journal of Yoga | Published by Wolters Kluwer ‑ Medknow +99 +Introduction +Yoga is an ancient Indian science as well as +the way of life, which includes the practice +of specific posture (asana) and regulated +breathing (pranayama). Pranayama is one +of the most important yogic practices.[1] +Different types of pranayama were reported +to +produce +different +cardiovascular[2] +and autonomic responses[3] in healthy +individuals.[2,3] +Bhramari pranayama (humming bee breath) +is one of the common pranayama practice, +which involves inhaling through both +nostrils and while exhaling produce sound +of humming bee.[1] +A previous study stated that “the practice +of +Bhramari +pranayama +influences +the +parasympathetic +dominance +on +cardiovascular system due to its effect in +reducing systolic blood pressure  (SBP), +diastolic BP  (DBP), and mean arterial +pressure (MAP).”[4] +There are several methods available to +measure cardiac autonomic nervous system, +Address for correspondence: +Dr. Nivethitha L, +Department of Research +and Development, S‑VYASA +University, Bengaluru, +Karnataka, India. +E‑mail: dr.nivethithathenature@ +gmail.com +Abstract +Background: Yoga is an ancient Indian science as well as the way of life. Pranayama is one of the +most important yogic practices. Bhramari pranayama was shown to produce a reduction in blood +pressure after the practice and thus reported to produce parasympathetic activity. However, there are +no known studies reported the heart rate variability (HRV) changes either during or after the practice +of Bhramari. Hence, this study aims at evaluating the HRV changes during and after the practice. +Materials and Methods: Sixteen (9 males, 7 females) healthy volunteers with the mean ± standard +deviation age of 23.50 ± 3.01 years were recruited. All the subjects performed Bhramari pranayama +for the duration of 5 min. Assessments were taken before, during, and immediately after the practice +of pranayama. Statistical analysis was performed using students paired samples t‑test, Wilcoxon +signed‑ranks test and repeated measures of analysis of variance and Post‑hoc analysis with Bonferroni +adjustment for multiple comparisons. Results: Results of this study showed a significant increase in +HR and low frequency spectrum of HRV and a significant reduction in high frequency spectrum of +HRV during the practice of Bhramari which revert to normal after the practice. Conclusion: Results +of this study suggests that there might be a parasympathetic withdrawal during the practice of +Bhramari. However, further studies are required to warrant the findings of this study. +Keywords: Bhramari pranayama, blood pressure, heart rate variability +Heart Rate Variability Changes During and after the Practice of Bhramari +Pranayama +Short Communication +Nivethitha L, +Manjunath NK, +Mooventhan A +Department of Research +and Development S‑VYASA +University, Bengaluru, +Karnataka, India +of which heart rate variability  (HRV) +has been established as a noninvasive +tool. Classical spectral analysis of HRV +signals distinguishes sympathetic from the +parasympathetic activity.[5] +Many studies have reported the HRV +of pranayama practices before and after +the practice but only very few studies +have +reported +the +HRV +during +the +pranayama practices such as alternate +nostril breathing[6] and Kapalbhati.[7] Since, +Bhramari pranayama was reported to +produce parasympathetic activity without +assessing autonomic measures, we had +a research question as “Does Bhramari +pranayama +produce +parasympathetic +activity?.” +Based +on +the +previous +study observations and reports,[4,8] we +hypothesized that Bhramari pranayama +may produce parasympathetic activity and +hence, this present study aims at evaluating +HRV (a noninvasive tool used to find +sympathetic and parasympathetic activity)[5] +changes during and after the practice of +Bhramari pranayama. +Access this article online +Website: www.ijoy.org.in +DOI: 10.4103/0973-6131.205518 +Quick Response Code: +How to cite this article: Nivethitha L, Manjunath NK, +Mooventhan A. Heart rate variability changes during +and after the practice of bhramari pranayama. Int J +Yoga 2017;10:99-102. +Received: September, 2016. Accepted: November, 2016. +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: reprints@medknow.com +Nivethitha, et al.: HRV changes during and after Bhramari +100 +International Journal of Yoga | Volume 10 | Issue 2 | May‑August 2017 +Materials and Methods +Subjects +Sixteen (9 males, 7 females) healthy volunteers with the +mean  ±  standard deviation age of 23.50  ±  3.01  years +were recruited from a residential yoga university, +South India. Subjects aged 18  years and above +experienced in practicing yoga for more than 1 year and +willingness to participate in the study were included. +Subjects with the history of any systemic and mental +illness, regular use of medication for any diseases, +chronic smoking, and alcoholism were excluded from +this study. The study protocol was approved by the +Institutional Ethics Committee and a written informed +consent was obtained from each subject. +Of 40 subjects assessed for eligibility, 22 subjects did not +fulfill the inclusion criteria and hence, did not include +in the study. Recruited 18 subjects underwent Bhramari +pranayama practice. Demographic variables of the study +subjects were shown in Table 1. +The design of the study +This is a single group repeated measures study, in which +all the subjects were asked to perform Bhramari pranayama +for the duration of 5  min. Assessments were performed +before, during, and after the intervention. +Assessment +HR and HRV: HR and HRV were assessed before, +during, and after the intervention using a four‑channel +polygraph  (Polyrite D, Recorders and Medicare Systems, +Chandigarh, India). The Ag/AgCl pregelled electrodes were +placed according to the standard limb lead II configuration +for recording electrocardiogram (ECG). Data were acquired +at the sampling rate of 1024 Hz.[9] +BP: SBP and DBP were assessed before and after the +intervention using sphygmomanometer. +Data extraction +Frequency domain and time domain analysis of the +HRV data were carried out at baseline, during and +post‑intervention  (5  min recordings for each). The data +recorded were visually inspected off‑line, and only +noise‑free data were included for the analysis. The data +were analyzed with an HRV analysis software  (Kubios +HRV version 2.0, Biomedical Signal Analysis Group, +Department of physics, University of Kuopio, Finland).[10] +The energy in the HRV series in the following specific +frequency bands was studied: Low frequency  (LF) +band (0.04–0.15  Hz), and high‑frequency (HF) band +(0.15–0.4 Hz). LF/HF ratio was also calculated.[11] +The LF and HF band values were expressed as normalized +units. The following components of the time domain HRV +were analyzed:  (1) the mean of the intervals between +adjacent QRS complexes or the instantaneous HR (RR +Intervals), (2) standard deviation of RR Intervals (SDNN) +(3) HR, (4) the square root of the mean of the sum of the +squares of differences between adjacent normal-to-normal +(NN) intervals (RMSSD),  (5) the number of interval +differences of successive NN intervals >50 ms (NN50), and +(6) the proportion derived by dividing NN50 by the total +number of NN intervals  (pNN50).[8] Assessments such as +pulse pressure  (PP), MAP were derived using following +formulas. PP was calculated as  (SBP  −  DBP); MAP +as (DBP + ⅓ PP).[12] +Intervention +All the subjects were asked to perform Bhramari pranayama +by inhaling through both nostrils and while exhaling +produced the sound of humming bee for the duration of +5 min at the rate of 6 breath/min.[1] +Data analysis +Of 18 subjects, 2  female subjects RRInterval could not +be extracted from the ECG due to “T” wave elevation +and hence, these data were not included in the statistical +analysis. Rests of the data were checked for the normality +using Shapiro–Wilk test. Statistical analysis for BP was +performed using Student’s paired samples t‑test  (data that +were normally distributed) and Wilcoxon signed‑ranks +test (data that were not normally distributed) and HRV +data were analyzed using repeated measures of analysis of +variance and Post‑hoc analysis with Bonferroni adjustment +for multiple comparisons with the use of Statistical Package +for the Social Sciences (SPSS) for Windows, Version 16.0. +Chicago, SPSS Inc. P  <  0.05 was considered statistically +significant. +Results +Results of this present showed a significant increase in +HR and LF spectrum of HRV and a significant reduction +in HF spectrum of HRV during the practice of Bhramari, +and it reverts back to normal during the recovery period +after the practice. It also showed a significant reduction in +SBP, DBP, and MAP after the practice and such significant +changes were observed in rest of the variables [Table 2]. +Discussion +HR is influenced by physical, emotional, and cognitive +activities. Physiological oscillations that lead to variable +Table 1: Demographic variables of the study +group (n=16) +Variables +Study group (n = 16) +Age (years) +23.50±3.01 +Gender +Female (n=7), male (n=9) +Height (cm) +165.44±12.86 +Weight (kg) +60.56±8.91 +BMI (kg/m2) +22.16±2.35 +BMI = Body mass index +Nivethitha, et al.: HRV changes during and after Bhramari +101 +International Journal of Yoga | Volume 10 | Issue 2 | May‑August 2017 +beat‑to‑beat fluctuations in HR are known as HRV. Hence, +HR and HRV are the most sensitive and easily accessible +indicators of sympathetic and parasympathetic activity and +autonomic regulation. The time domain analysis of HRV +mainly reflects parasympathetic outflow and frequency +domain analysis reflects overall autonomic balance and is +the most widely used tool to investigate HRV and involves +decomposition of sequential RRIntervals into sinusoidal +components of different amplitude and frequency. Just as +HF band power is related to parasympathetic activity, LF +band power is often related to sympathetic activity, yet the +interpretation and clinical significance of HRV in the LF +band have aroused intense controversy. The relationship +between the LF band and sympathetic activity has been +disputed because LF band power has been shown to be +partly under parasympathetic control.[11] HF band power is +mainly under parasympathetic control.[5] +Results of this present showed a significant increase in +HR and LF spectrum of HRV and a significant reduction +in HF spectrum of HRV during the practice of Bhramari +compared to its baseline, and it reverts back to normal +during the recovery period after the practice. This effect +might be possibly through its slow breathing techniques +because slow yoga breathing practices were reported to +increase HR fluctuations in the LF band with simultaneous +increases in HR; or breathing at 4.5 and 6.5/min frequency +or other rhythmical stimulation at this frequency such as +rhythmical skeletal muscle contraction were reported to +reflect in large increases in the LF band and simultaneous +decreases in the HF band. Such resonance effects were +also reported with yoga slow breathing practices, mantra +chanting, and some meditative practices.[11] +A comprehensive review reported as the large amplitude +HR oscillations occurring in the LF range resulting from +breathing at an optimal frequency may reflect resonance, also +known as “coherence” occurring due to entrainment between +HR, BP, and the relaxation response rather than sympathetic +tone.[11] And since, the time domain variables of HRV and +the HF band power of frequency domain are mainly the +indicative of the parasympathetic activities, the insignificant +reduction in these variables such as RRI, SDNN, RMSSD, +NN50, pNN50  (time domain), and significant reduction in +HF band power  (Frequency domain) along with significant +increase in HR during the practice of Bhramari pranayama, +we believe that there might be a parasympathetic withdrawal +while practicing Bhramari pranayama. +Due to the reduction in the BP level after the practice +of Bhramari pranayama, previous studies has stated that +“Bhramari pranayama induces parasympathetic dominance +on cardiovascular system”[4,8] whereas, findings of this +present study is contradicting the statement of the previous +studies. At the same time, the previous study’s findings +such as significant reduction in SBP, DBP, MAP,[4,8] and +mild fall in HR after the Bhramari pranayama were similar +to this present study findings.[4] Hence, reduction in the BP +might not attribute to the increased level of parasympathetic +activity, but it might attribute to other mechanisms which +are unclear and need to be evaluated in the future studies. +Strengths of the study +The first study evaluating the HRV during the practice +of Bhramari pranayama. Standard equipment was used +for assessments. Although the BP was assessed using +sphygmomanometer, the assessment was performed by the +intern who was not in the part of the study. +Limitations of the study +The study was conducted in the healthy volunteers, hence +limiting the application of its findings to pathological +conditions. Additional assessments, such as continuous BP +monitoring, baroreceptor sensitivity, photoplethysmography, +and galvanic skin resistance would have given a better +understanding of the state of the autonomic nervous system. +The present study assessed only the HRV and BP changes +in one group and did not have the control group and also +did not assess its underlying mechanisms. Hence, further +studies are required  (i.e.,  randomized controlled trials) +engaging a larger sample size, using advanced techniques, +and taking place over a greater period, to evaluate its +precise physiological effects and underlying mechanisms. +Table 2: Baseline, during, and postassessments of study +group (n=16) +Variables +Study group (n=16) +Baseline +During +Post +SBP (mmHg)† +115.50±7.75 +‑ +110.50±8.56* +DBP (mmHg)† +76.88±6.28 +‑ +72.38±5.94* +PP (mmHg)# +38.63±4.36 +‑ +38.13±4.59 +MAP (mmHg)† +89.75±6.49 +‑ +85.08±6.58* +RR Intervals +(ms)¶ +736.27±81.44 +727.23±82.10 +745.20±64.73 +SDNN (ms)¶ +52.92±16.69 +50.39±17.37 +58.58±16.01 +HR (b/min)¶ +83.18±7.98 +87.35±6.40* +81.80±6.63 +RMSSD (ms)¶ +39.33±16.92 +37.38±19.04 +40.57±13.08 +NN50 (count)¶ +61.75±47.26 +51.56±28.65 +57.69±52.83 +pNN50 (%)¶ +15.69±12.59 +12.64±7.27 +14.49±13.16 +LF (n.u)¶ +60.75±23.63 +81.75±13.04* +71.12±22.84 +HF (n.u)¶ +39.20±23.55 +18.19±13.00* +28.74±22.62 +LF/HF (ms2)¶ +3.05±3.07 +9.33±8.52 +5.18±4.83 +All values are in mean±SD. †Student paired samples‑t‑test, +#Wilcoxon signed ranks test, ¶Repeated measures of analysis of +variance, *P<0.05. SBP = Systolic blood pressure, DBP = Diastolic +blood pressure, PP = Pulse pressure, MAP = Mean arterial +pressure, RR Intervals = The intervals between adjacent QRS +complexes or the instantaneous HR, SDNN = Standard deviation +of RR Intervals, HR = Heart rate, RMSSD = The square root of +the mean of the sum of the squares of differences between adjacent +NN intervals, NN50 = The number of interval differences of +successive NN intervals greater than 50 ms, pNN50 = Proportion +derived by dividing NN50 by the total number of NN intervals, LF += Low frequency, HF = High frequency, LFHF ratio = Ratio of low +frequency to high frequency, SD = Standard deviation +Nivethitha, et al.: HRV changes during and after Bhramari +102 +International Journal of Yoga | Volume 10 | Issue 2 | May‑August 2017 +Conclusion +Results of this study suggest that there might be a +parasympathetic withdrawal during the practice of Bhramari +that revert back to normal after the practice. However, +further studies are required to warrant the findings of this +study. +Acknowledgment +We would like to thank Mr. V. Loganathan, Mr. K.P. +Aruchunan +and +the +staffs +of +Anvesana +Research +Laboratories, S‑VYASA University, Bengaluru for their +moral support. +Financial support and sponsorship +Nil. +Conflicts of interest +There are no conflicts of interest. +References +1. +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. +2. +Sharma VK, Trakroo M, Subramaniam V, Rajajeyakumar M, +Bhavanani AB, Sahai A. Effect of fast and slow pranayama +on perceived stress and cardiovascular parameters in young +health‑care students. Int J Yoga 2013;6:104‑10. +3. +Raghuraj P, Telles S. Immediate effect of specific nostril +manipulating yoga breathing practices on autonomic and +respiratory +variables. +Appl +Psychophysiol +Biofeedback +2008;33:65‑75. +4. +Pramanik T, Pudasaini B, Prajapati R. Immediate effect of a slow +pace breathing exercise Bhramari pranayama on blood pressure +and heart rate. Nepal Med Coll J 2010;12:154‑7. +5. +Muralikrishnan +K, +Balakrishnan +B, +Balasubramanian +K, +Visnegarawla F. Measurement of the effect of Isha Yoga on +cardiac autonomic nervous system using short‑term heart rate +variability. J Ayurveda Integr Med 2012;3:91‑6. +6. +Telles S, Sharma SK, Balkrishna A. Blood pressure and heart rate +variability during yoga‑based alternate nostril breathing practice +and breath awareness. Med Sci Monit Basic Res 2014;20:184‑93. +7. +Telles S, Singh N, Balkrishna A. Heart rate variability changes +during high frequency yoga breathing and breath awareness. +Biopsychosoc Med 2011;5:4. +8. +Kuppusamy M, Kamaldeen D, Pitani R, Amaldas J. Immediate +effects of Bhramari pranayama on resting cardiovascular parameters +in healthy adolescents. J Clin Diagn Res 2016;10:CC17‑9. +9. +Mooventhan A, Nivethitha L. Effects of ice massage of the head +and spine on heart rate variability in healthy volunteers. J Integr +Med 2016;14:306‑10. +10. Tarvainen MP, Niskanen JP, Lipponen JA, Ranta‑Aho PO, +Karjalainen PA. Kubios HRV  –  Heart rate variability analysis +software. Comput Methods Programs Biomed 2014;113:210‑20. +11. Tyagi A, Cohen M. Yoga and heart rate variability: +A  comprehensive review of the literature. Int J Yoga +2016;9:97‑113. +12. Mooventhan A. Immediate effect of ice bag application to head +and spine on cardiovascular changes in healthy volunteers. Int J +Health Allied Sci 2016;5:53‑6. +Reproduced with permission of copyright owner. +Further reproduction prohibited without permission. diff --git a/subfolder_0/IMPROVEMENT IN STATIC MOTOR PERFORMANCE FOLLOWING YOGIC TRAINING OF SCHOOL CHILDREN.txt b/subfolder_0/IMPROVEMENT IN STATIC MOTOR PERFORMANCE FOLLOWING YOGIC TRAINING OF SCHOOL CHILDREN.txt new file mode 100644 index 0000000000000000000000000000000000000000..e5e686e057d91c91d36f44d3df214d4441026f28 --- /dev/null +++ b/subfolder_0/IMPROVEMENT IN STATIC MOTOR PERFORMANCE FOLLOWING YOGIC TRAINING OF SCHOOL CHILDREN.txt @@ -0,0 +1,12 @@ + + + + + + + + + + + + diff --git a/subfolder_0/Immediate Effects of Yoga Breathing with Intermittent Breath Retention on the Autonomic and Cardiovascular Variables amongst Healthy Volunteers.txt b/subfolder_0/Immediate Effects of Yoga Breathing with Intermittent Breath Retention on the Autonomic and Cardiovascular Variables amongst Healthy Volunteers.txt new file mode 100644 index 0000000000000000000000000000000000000000..27a5bd395046c561b0b14c616518180b0cd5cb71 --- /dev/null +++ b/subfolder_0/Immediate Effects of Yoga Breathing with Intermittent Breath Retention on the Autonomic and Cardiovascular Variables amongst Healthy Volunteers.txt @@ -0,0 +1,1078 @@ +See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/322499060 +Immediate Effects of Yoga Breathing with Intermittent Breath Retention on +the Autonomic and Cardiovascular Variables Amongst Healthy Volunteers +Article  in  Indian journal of physiology and pharmacology · January 2018 +CITATION +1 +READS +281 +3 authors, including: +Some of the authors of this publication are also working on these related projects: +Neurocognitive and Psychophysiological Changes Following Yogic Breath Holding View project +Evidence based Naturopathy and Yoga Therapy View project +Apar Saoji +SVYASA Yoga University +19 PUBLICATIONS   23 CITATIONS    +SEE PROFILE +All content following this page was uploaded by Apar Saoji on 15 January 2018. +The user has requested enhancement of the downloaded file. +Indian J Physiol Pharmacol 2018; 62(1) +Autonomic and Cardiovascular Changes With Yogic Breathing +41 +Original Article +Immediate Effects of Yoga Breathing with Intermittent Breath +Retention on the Autonomic and Cardiovascular Variables +Amongst Healthy Volunteers +Apar Avinash Saoji*, B. R. Raghavendra +and N. K. Manjunath +Division of Yoga and Life Sciences, +Swami Vivekananda Yoga Anusandhana Samsthana, +19, Eknath Bhavan, Gavipuram Circle, +KG Nagar, Bangalore 19 +Abstract +Background: Though breath retention is an important part of Yoga, not much is known about the physiological +changes occurring following yogic breath retention. We examined the effects of 20 minutes regulated yogic +breathing with intermittent breath retention (experimental session) at a frequency of 3 breaths per minute +on the cardiovascular and autonomic functions. +Methods: Thirty-nine volunteers (22 females) with age-range 18 to 30 years (group mean±SD, 20.6±1.82 +years) were recruited. Heart rate variability and cardiovascular variables were assessed through non-invasive +blood pressure monitoring system before and after the experimental session or breath awareness (control +session). The subjects were randomly assigned to either experimental or control session. +Results: There were significant reductions observed in the heart rate, stroke volume and cardiac output +following the intervention. The Baroreflex Sensitivity (BRS) increased significantly following the experimental +session, whereas no changes were observed following the control session. The time domain components of +HRV indicated an enhanced heart rate variability following experimental session. Similar trends were observed +following the control session. An increase in low frequency and decrease in high frequency components of +HRV were observed following the experimental session. There was no significant change in frequency domain +components following the control session. +Conclusion: The current study indicates differential autonomic modulation with enhanced BRS amongst +healthy practitioners of yoga. Such yoga breathing may be useful for prevention of various metabolic disorders. +The time domain components of heart rate variability suggest improvement following yoga breathing with +intermittent breath retention. +Indian J Physiol Pharmacol 2018; 62(1) : 41–50 +*Corresponding author : +Apar Avinash Saoji, Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana, 19, EknathBhavan, +Gavipuram Circle, KG Nagar, Bangalore 19; Email : aparsaoji@gmail.com +(Received on August 1, 2017) +42 +Saoji, Raghavendra and Manjunath +Indian J Physiol Pharmacol 2018; 62(1) +breath retention for a short duration. In contrast, +lowered oxygen consumption was observed with +prolonged breath retention (16). Since the practice +of ANB and Ujjayi Pranayama are found to influence +the autonomic functions even without the practice of +breath retention (10, 17, 18), the effects of +intermittent breath retention remain unclear. +The physiological effects of breath retention among +underwater divers have been explored. The most +common physiological response of the body to +voluntary breath retention is to utilize the oxygen +available optimally. Such response include +bradycardia, reduction in stroke volume, cardiac +output, and peripheral vasoconstriction. The initial +phase of breath retention alters the physiology +maximally, whereas the hemodynamic changes +stabilize in the later part of extended breath holding +(19–21). Breath retention also leads to cerebral +vasodilation and increased sympathetic tone in +response to hypoxia and hypercapnia (22, 23). +Further, it is demonstrated that the physiological +impact of breath retention depends on the +psychological status of an individual (24). +Although breath retention is practiced by both +underwater divers and yoga practitioners, there are +fundamental differences in the way it is practiced. +Amongst the underwater divers, breath retention is +performed for a maximal duration following the +completion of inhalation. Yoga prescribes retention +in three ways – following inhalation (antarkumbhaka), +following exhalation (bahyakumbhaka) and naturally +occurring breath-retention (kevalakumbhaka). It is +also prescribed to be practiced for various durations +depending on the nature of the practice of pranayama +(13, 25). +Considering the importance of breath retention in the +traditional yoga texts and lack of scientific +understanding of its effects, the current study was +undertaken to evaluate the effect of slow yogic +breathing with intermittent breath retentions on +autonomic activity, cardiovascular functions including +baroreflex sensitivity (BRS) through modulation of +the cardiorespiratory pathways. +Introduction +Human respiration forms the bridge between +autonomic and voluntary nervous systems since it is +the only physiological system controlled by both the +divisions. The impact of modulation of breathing on +the autonomic and cardiovascular functions is well +documented (1–4). +Breath regulation or Pranayama is one of the eight +limbs of (Ashtanga Yoga) of Patanjali (5). Various +techniques of Pranayama are described in Hatha +Yoga texts (6). The texts also describe the profound +effects of yoga breathing on the mind-body complex. +The yoga breathing techniques include modulation +of the pace of breathing, manipulation of nostrils, +chanting of humming sounds, retention of breath +etc. There has been growing interest in the inquiry +of physiological effects of yoga and especially +yogic breathing techniques in recent years (7). +Several studies indicate the differential effects of +various Yoga breathing techniques on autonomic +functions. +In general, the practice of yoga has been found to +bring balance in the autonomic functions with a trend +towards parasympathetic dominance (7, 8). Various +yoga breathing techniques are known to modify the +cardiovascular functions (9), Baroreflex Sensitivity +(10) and autonomic responses (11, 12). +Although the traditional texts of yoga emphasize on +the practice of intermittent breath retention (5, 6, +13), such practice has sought very limited scientific +attention. The proposed multiple health benefits of +intermittent yogic breath retention include an increase +in hemoglobin by increasing erythropoietin, increase +in vascular endothelial growth factor leading to the +formation of collaterals, reduction in blood pressure +and resistance to cellular damage and thereby +delayed ageing (14). A study demonstrated reduced +pulse rate and increased galvanic skin resistance, +following alternate nostril breathing (ANB) with +intermittent breath retention (15). Another study +demonstrated a significant increase in oxygen +consumption while performing Ujjayi Pranayama with +Indian J Physiol Pharmacol 2018; 62(1) +Autonomic and Cardiovascular Changes With Yogic Breathing +43 +Methods +Participants +Thirty-Nine volunteers (17 males + 22 females) with +their ages ranging from 18 to 30 years (group +mean±SD, 20.6±1.82 years) were recruited for the +study. They were selected from a population of 160 +students, studying various long-term courses in a +Yoga University situated in South India. They had +experience of practicing yoga ranging from 1 to 4 +years (group mean±SD, 2.92±1.75 years). +Experienced yoga practitioners were chosen for the +study since breath retention is an advanced yoga +practice and is not recommended to be practiced by +people naïve to yoga practice. Their training in yoga +included understanding yoga philosophy and practice +of yoga postures (asanas), voluntarily regulated +breathing (pranayama) and meditation techniques. All +the participants included in the study were trained in +the breathing practice assessed in the present study +for 20 min/day, 6 days a week, for 8 weeks prior to +the assessment. This 8 weeks of supervised training +was conducted to ensure uniformity of breathing +practices amongst all the participants. +Sample size +The sample size was calculated based on the effect +size obtained from a previous study (26) which +assessed changes in blood pressure following the +practice of pranayama. It was calculated using +G*Power software, Version 3.1.9.2 (27), where the +Power was 0.95, α = 0.05, the effect size (Cohen’s +d) was 1.018 and the recommended sample size +resulted in being 31 participants in each group. +Allowing a 20-30% attrition rate, we concluded to +include 40 participants to the study. +The physical health of the subjects was assessed +through routine clinical examination by a trained +physician who otherwise had no role in the trial. The +subjects with a history of any major illness in past +6 months especially any cardiac or respiratory +disorders, consumption of any medications, tobacco, +alcohol or substance abuse in any form were excluded +from the study. The demographic data of the +participants are presented in Table I. +Ethical consideration +The study was approved by the institutional ethics +committee of the Swami Vivekananda Yoga +Anusandhana Samsthana. A signed informed consent +was obtained from all the participants. +Design +Following the 8-week training, the subjects were +randomly assigned for the practice of yoga breathing +with intermittent breath holding (experimental +session) and breath awareness (control session). Half +of the subjects had the experimental session on day +1 and control session on day 2 and for the rest, the +order was reversed. The random allotment of the +sessions was done using a web-based computer +program (www.randomizer.org). Both experimental +and control sessions lasted for 20 min each, which +was preceded and followed by 5 min of assessment +periods. The assessments were performed before and +immediately following the experimental and control +sessions. The time of the day was kept constant for +each subject on both days. Female participants were +assessed during the luteal phase of menstrual cycle +(10 to 16 days after the onset of menstruation) to +minimize the effect of menstrual cycle on autonomic +functions (28). +A s s e s s m e n t s +Electrocardiogram (ECG) and respiration were +recorded using 16-channel human physiology system +(PowerLab 16/35, ADInstruments, Australia) and +blood pressure (BP) were monitored using Finapres +Continuous Non-Invasive Blood Pressure (NIBP) +Systems (Finapres Medical Systems B.V., +Netherlands). The ECG was acquired using limb Lead +TABLE I : +Demographic data of the volunteers. +Male +Female +Total +Sample size (n) +17 +22 +39 +Age (years) +20.88±1.93 +20.39±1.75 +20.6±1.82 +Height (cm) +168.65±6.92 +158.56±6.25 +162.85±8.19 +Weight (Kg) +59.06±6.74 +51.30±6.53 +54.6±7.60 +BMI (Kg/m2) +20.73±1.74 +20.36±1.86 +20.52±1.80 +Years of Yoga +3.82±2.67 +4.00±2.86 +3.92±2.75 +experience +44 +Saoji, Raghavendra and Manjunath +Indian J Physiol Pharmacol 2018; 62(1) +II system i.e., the electrodes were placed on the +right arm and both legs (29). A standard finger cuff +was connected to the left middle finger, in between +the interphalangeal joints. Brachial correction was +made at regular intervals as per the standard +operating procedure of the instrument. The accuracy +of NIBP by Fianpress Medical Systems has been +standardized through comparable experiments with +Intra-arterial blood pressure measurements (30, 31). +Bitscope Easy v 2.0 software (Finapres Medical +Systems B.V., Netherlands) was used for the +recordings of NIBP. The digitized ECG data was +analyzed offline to obtain the heart rate variability +(HRV) spectrum. Respiration was recorded using a +volumetric pressure transducer fixed around the trunk +about 8 cm below the lower costal margin while the +participants sat erect. +Heart rate variability +The ECG was recorded using a standard bipolar limb +lead II configuration, which was digitized using a 16 +bit analog to digital converter at a sampling rate of +1 KHz and was analyzed offline to obtain the HRV +spectrum. Frequency domain and time domain +analysis of HRV data were carried out using Lab +Chart 8 (AD instruments, Australia) program, which +uses Lomb-Scargle Periodogram algorithm. +Intervention +Experimental session +The experimental session included the regulated +yogic breathing for 20 minutes incorporating phases +of inhalation (puraka), internal retention of breath +(antarkumbhaka), exhalation (recaka) and external +retention of breath (bahyakumbhaka) in a ratio of +1:1:1:1 for 6 seconds each. The classic yoga texts +suggest breath retention in varying ratios. The ratio +for the intervention was chosen since it is considered +ideal for subjects who are naïve to the practice of +breath retention. The intervention was derived from a +classical training methodology of pranayama +suggested in the ancient text of Yoga (13). The +intervals of 6 seconds were decided based on a +previous study which used the similar duration of +phases of breath retention along with Nadisuddhi +Pranayama (15). The duration of 6 seconds was +ensured through verbal cues in a pre-recorded audio +track. +Control session +During the control session, the participants were +seated erect, performing normal breathing with breath +awareness for the same duration of 20 min in the +same test environment, including the audible cues. +There were no adverse events reported during either +the training of participants in yoga breathing with +intermittent breath retention or during the recordings. +Test conditions +The recording room in the research laboratory was +sound attenuated and air-conditioned in order to avoid +thermal, visual or auditory disturbance. The +temperature of the recording room was maintained +at 25±1°C. The relative humidity during the time of +the study was on average 52%. During both practice +and assessments, the participants were seated +comfortably, keeping the spine erect on a soft chair +with backrest. +Data extraction +The following data were extracted from the 16-channel +polygraph. The heart rate in beats per minute was +calculated by counting the R waves of the QRS +complex in the ECG. Frequency domain and time +domain analysis of HRV data were performed. The +energy in the HRV series in the following specific +frequency bands were studied viz., Low frequency +(LF) band (0.04–0.15 Hz) and highfrequency (HF) +band (0.15–0.5 Hz). According to guidelines, LF and +HF band values were expressed as normalized units. +The LF/HF ratio was also calculated. The following +components of time domain HRV were analyzed: (i) +SDNN (the standard deviation of NN intervals), (ii) +the square root of the mean of the sum of the squares +of differences between adjacent NN intervals +(RMSSD), (iii) the proportion derived by dividing +NN50 by the total number of NN intervals (pNN50). +The respiratory rate in cycles per minute (cpm) +was calculated by counting the total breath +cycles. +Indian J Physiol Pharmacol 2018; 62(1) +Autonomic and Cardiovascular Changes With Yogic Breathing +45 +Brachial artery systolic (SBP) and diastolic pressures +(DBP) were extrapolated from finger arterial pressure +through the use of a height correction unit and +waveform filtering and level correction methods. Mean +arterial pressure (MAP), SBP and DBP were +expressed in mmHg. The computed measurements +of Stroke volume (SV), cardiac output (CO) from the +arterial BP and HR has been found reliable when +compared to Modelflow-derived CO (32). The Total +Peripheral resistance (TPR) estimation from the +computed CO was also found to be valid (33). Another +variable of interest, Baroreflex Sensitivity (BRS) was +estimated from the spontaneous HRV and BP +variability (BPV) measured by the Finapress method +(34). +Data analysis +The data were analyzed by the statistician using +Statistical Package R version 3.2.4 (www.r- +project.org). Repeated measures analyses of variance +(RM-ANOVA) were performed with two Within- +Subjects factors, i.e., (i) Sessions with two levels; +intervention and control and (ii) States with two levels, +pre and post intervention. +Results +The results are presented as the group mean and +standard deviation for the autonomic and the +cardiovascular variables (Table II). +Following the experimental session, an increase in +SDNN, RMSSD, pNN50 of the time domain variables +of HRV was observed. A significant increase was +also noted in LFnu, Total Peripheral Resistance and +Baroreflex Sensitivity following the experimental +session. We also found a reduction in HFnu, MAP, +SV and CO in the experimental session. The heart +rate reduced following both experimental and control +sessions. After control session, an increase in +RMSSD, pNN50, SBP and SV was noted. A reduction +was observed in CO following the control session. +No changes were observed in the frequency domain +variables of HRV and Baroreflex Sensitivity following +the control session. Although there was reduction +noted in the respiratory rate in both groups, the +changes were non-significant. Also, Pre-Post breath +rates were incidentally observed to be similar for +both the sessions. +Repeated measures analysis of variance +The significant changes in the components of HRV +and cardiovascular variables are presented in Table +III. +Post hoc analyses with Bonferroni adjustment +There was a significant reduction in HR (P<0.001, +TABLE II : +Changes in the Heart Rate Variability and Cardiovascular variables before and following the experimental and control sessions. +Experimental session +Control session +Pre +Post +Pre +Post +Heart rate (beats/min) +78.54±10.54 +74.92±9.25*** +76.67±9.58 +73.94±9.29** +SDNN (ms) +64.47±6.27 +74.76±29.20** +65.67±28.02 +70.84±28.57 +RMSSD (ms) +45.98±22.90 +52.39±24.96*** +49.23±23.22 +54.81±23.93* +pNN50 (% units) +21.26±16.65 +24.99±16.49** +25.20±17.78 +30.67±17.75** +LFnU +61.72±17.55 +67.51±15.77* +57.38±18.96 +55.56±20.55 +HFnU +38.53±17.16 +32.65±15.27* +42.48±18.57 +43.71±19.65 +LF:HF +2.58±2.72 +3.10±2.70 +2.07±1.96 +2.11±2.59 +Respiratory Rate (cycles/min) +15.42±3.46 +14.63±4.03 +16.18±3.71 +15.38±4.11 +Systolic BP (mmHg) +102.10±12.21 +101.04±11.39 +104.44±10.91 +106.83±11.86*** +Diastolic BP (mmHg) +59.33±8.76 +58.49±.30 +60.88±8.46 +60.61±8.23 +Mean Arterial pressure (mmHg) +77.88±10.12 +76.35±9.54* +79.52±9.10 +79.59±8.99 +Stroke Volume (ml) +68.35±15.83 +66.20±15.75* +70.36±12.04 +72.22±11.41*** +Cardiac output (l/min) +5.27±1.20 +4.88±1.05*** +5.32±0.85 +5.26±0.81** +Total Peripheral Resistance +0.99±0.37 +1.04±0.39*** +1.07±0.70 +0.99±0.36 +Baroreflex Sensitivity (ms/mmHg) +14.56±.55 +15.81±5.71** +16.24±8.83 +16.50±7.75 +Repeated Measures Analyses of Variance with post hoc Bonferoni adjustment, *=p<0.05, **=p<0.01, ***=p<0.001 +SDNN: standard deviation of NN intervals; RMSSD: root of the mean of the sum of the squares of differences between +adjacent NN intervals; pNN50: proportion derived by dividing NN50 by the total number of NN intervals. +46 +Saoji, Raghavendra and Manjunath +Indian J Physiol Pharmacol 2018; 62(1) +post hoc analyses following ANOVA), HFnu (P<0.05), +MAP (P<0.05), SV (P<0.05), CO (P<0.001), whereas +increase was noted in LFnu (P<0.05), SDNN +(P<0.001), RMSSD (P<0.01), pNN50 (P<0.01) TPR +(P<0.001) and BRS (P<0.01) following the +experimental session. Reductions in HR (P<0.01), +CO (P<0.01) and TPR (P<0.001) whereas increase +in RMSSD (P<0.05), pNN50 (P<0.01), SBP (P<0.001) +and SV (P<0.001) were observed following the control +session. +Discussion +This study investigated the effect of yoga breathing +with intermittent breath holding on frequency and time +domain variables of heart rate variability (HRV) and +cardiovascular functions in healthy yoga practitioners. +To the best of our knowledge, this is the first attempt +to scientifically explore the effects of isolated yoga +breathing with breath retention among healthy +volunteers. The earlier studies where yogic breath +retention was used, it was in combination with other +yoga breathing techniques (15, 16, 35). +HRV is the physiological phenomenon of variation in +the time interval between heartbeats. It is measured +by the variation in the beat-to-beat intervals (36). +HRV is widely utilized to interpret the cardiac +autonomic regulation following various yoga practices +(7). HRV is the pattern of several overlapping +oscillatory frequency components. Three components +of the frequency domain analyses of HRV have been +identified viz., the high frequency (0.15–0.4 Hz), low +frequency (0.05–0.15 Hz), and very low frequency +(0.005–0.05 Hz). In general, LF component is +correlated with the activity of sympathetic and +parasympathetic nervous system whereas HF +component with parasympathetic activity. The +physiological interpretation of VLF component is +unclear (36). It is also observed that, high-amplitude +peaks in the LF range during rhythmical slow +breathing may reflect resonance characteristics of +the cardiovascular system where respiratory sinus +arrhythmia interacts with the baroreflex (37). +Breathing at such resonant frequency may increase +HRV and be reflected in large increases in the LF +band and simultaneous decreases in the HF band. +The findings of the spectral analysis of HRV of the +current study indicate an increase in LF and a +corresponding reduction in HF, with enhanced +baroreflex sensitivity. These changes, thus, may be +attributed to breathing at a very slow rate of 2.5 Hz. +TABLE III : Summery of the Repeated Measures Analysis of Variance (RM-ANOVA) showing statistically significant results. +Variables +Factor +F Value +df +Level of significance +LFnu +Sessions +13.81 +1, 38 +0.01 +HFnu +Sessions +13.61 +1, 38 +0.01 +LF/HF ratio +Sessions +6.17 +1, 38 +0.05 +pNN50 +Sessions +5.17 +1, 38 +0.05 +Systolic BP +Sessions +81.20 +1, 38 +0.001 +Diastolic BP +Sessions +213.62 +1, 38 +0.001 +Mean arterial pressure +Sessions +18.84 +1, 38 +0.001 +Cardiac output +Sessions +612.38 +1, 38 +0.001 +Stroke volume +Sessions +6.81 +1, 38 +0.05 +Total peripheral resistance +Sessions +581.17 +1, 38 +0.001 +Heart rate +States +37.96 +1, 38 +0.001 +RMSSD +States +15.79 +1, 38 +0.001 +pNN50 +States +16.77 +1, 38 +0.001 +SDNN +States +13.04 +1, 38 +0.01 +Systolic BP +States +81.33 +1, 38 +0.001 +Diastolic BP +States +732.29 +1, 38 +0.001 +Mean arterial pressure +States +343.79 +1, 38 +0.001 +Cardiac output +States +13.83 +1, 38 +0.01 +Stroke volume +States +22.67 +1, 38 +0.001 +Total peripheral resistance +States +580.45 +1, 38 +0.001 +HFnu +Sessions x states +4.12 +1, 38 +0.05 +Systolic BP +Sessions x states +81.31 +1, 38 +0.001 +Diastolic BP +Sessions x states +1030.13 +1, 38 +0.001 +Mean arterial pressure +Sessions x states +292.73 +1, 38 +0.001 +Cardiac output +Sessions x states +14.07 +1, 38 +0.01 +Total peripheral resistance +Sessions x states +617.01 +1, 38 +0.001 +Indian J Physiol Pharmacol 2018; 62(1) +Autonomic and Cardiovascular Changes With Yogic Breathing +47 +The findings are similar to earlier yoga studies +demonstrating an increase in LF with slow yoga +breathing (38). Breathing at such slow rate imitating +the resonant frequency is found to influence the heart +rate and blood pressure oscillations and thus enhance +the overall HRV (39) and subsequent reduction in +heart rate and blood pressure (40). Yet, the blood +pressure changes were nonsignificant in the current +study. No changes in the frequency components of +HRV were observed following the control session. +Among the time-domain variables, SDNN is an +indicator of overall heart rate variability, whereas +RMSSD and pNN50 are associated with vagal tone +(36). The changes in the time domain components +of the HRV were similar following both experimental +and control sessions with an increase in SDNN, +RMSSD and pNN50, thus indicating an enhanced +HRV. Yet, the magnitude of change was higher +following the experimental session. However, the +reason for the change following the experimental +session remain unclear, whether it was due to +intermittent breath retention or slow breathingalone. +Since, the participants were long-term yoga +practitioners, and performing breath awareness during +the control session, they might have entered a +meditative state and thus modulating the HRV. Such +enhanced HRV is common among long-term yoga +practitioners (7). Similar changes in time-domain +variables of HRV were observed in a previous study +in participants practicing breath awareness (41). +We also found a significant increase in the Baroreflex +Sensitivity following the 20 min experimental session. +Our findings are consistent with earlier studies +elucidating the influence of yogic breathing techniques +on Baroreflex Sensitivity in healthy (10) as well as +Clinical population with essential hypertension (42) +and chronic heart failure (43). Such gain in the +baroreflex sensitivity may also be due to slow +breathing in the experimental session at the resonant +frequency of about 2.5 Hz. Also, the earlier studies +attribute the gain in Baroreflex Sensitivity to +increased vagal tone, indicated by a gain in RMSSD +and pNN50 as well as reduced heart rate. Arterial +baroreceptor activity and respiratory sinus arrhythmia +are interrelated (44) and therefore the increase in +Baroreflex Sensitivity could be attributed to enhanced +HRV following the experimental session. Jerath et. +al. propose the action of inhibitory signals and +hyperpolarizing current within neural and non-neural +tissue activation of slowly adapting stretch receptors, +responsible for modulation of the activity of the +cardiorespiratory centers (45). +Reduced heart rate variability and baroreflex +sensitivity is found to be a risk factor for +cardiovascular diseases (46, 47), diabetes mellitus +(48, 49) and various metabolic syndromes (50). The +enhanced heart rate variability and baroreflex +sensitivity observed following the yoga breathing +assessed in the present study may indicate its role +in preventing such disorders. Future studies may +incorporate clinical population to assess the effect +of yoga breathing with intermittent breath retention +on the cardiac autonomic regulation. +We also found an increase in the total peripheral +resistance and LFnu indicative of a possible +sympathetic shift in the autonomic activity. These +changes may be due to the very nature of the +intervention, which includes focused attention on the +verbal cues and constant synchronization of the +breathing with it. The nature of intervention needed +constant attention, which may be responsible for the +selective sympathetic arousal. An earlier study of +yoga breathing with breath-retention for short duration +indicated an increase in oxygen consumption, which +might be considered similar to the results of the +present study (16). Also, intermittent hypoxia created +in the experimental session would contribute to +enhanced sympathetic tone (23). Despite the +sympathetic arousal, the gain in baroreflex sensitivity +may be attribute to inhibition of chemoreflex +mechanisms due to slow breathing (51). Also, long +term yoga practitioners demonstrate a generalized +reduction in chemoreceptor sensitivity (52). Slow +breathing possibly leads to a generalized attenuation +in the excitatory pathways for respiratory and +cardiovascular systems. Both respiratory and +cardiovascular systems share similar control +mechanisms, thus alterations in breathing may be +responsible for the cardiovascular changes (53). +The reduction in cardiac output and stroke volume +may be a result of body’s compensatory mechanism +48 +Saoji, Raghavendra and Manjunath +Indian J Physiol Pharmacol 2018; 62(1) +due to intermittent breath retention along with very +slow breath. Also breathing at resonant frequency +has been shown to enhance the gaseous exchange +and oxygen saturation (54), thereby reducing the +overall circulatory load.The changes observed in the +current study following the intervention are similar to +those found following voluntary breath retention in +swimmers and divers, which include bradycardia, +reduction in stroke volume, cardiac output, and +peripheral vasoconstriction (19). However, in the +current study, the practice of breath-retention was +intermittent and short term instead of the maximal +breath retention as practiced by the divers. +Although we could demonstrate differential changes +in the autonomic and cardiovascular activity following +yoga breathing with intermittent breath retention, the +examination of the exact underlying mechanisms was +beyond the scope of the study. Assessments during +the practice of yoga breathing with intermittent +retention may bring clarity on the underlying +mechanisms. Lung volume and the partial pressure +of CO2 (PaCO2) are known to influence the HRV +spectrum in conscious subjects (55). We could not +control the lung volume as well as assess the PaCO2 +in the current study. Thus, future studies may be +planned to assess the effects of lung volume and +PaCO2 in yoga breathing techniques. Future studies +may also include neuroimaging techniques focusing +on the neural centers for the vagus nerve to +understand the underlying mechanisms. We did not +examine the long-term effects of the practice of yoga +breathing with intermittent breath retention. Our study +population was limited to healthy young volunteers, +with training in yoga. Future studies may be designed +to understand the effects of yoga breathing with breath +retention in different populations and clinical setting. +Conclusion +The current study indicates differential autonomic +modulation with enhanced Baroreflex Sensitivity along +with selective sympathetic activation amongst healthy +practitioners of yoga. The time domain components +of heart rate variability suggest improvement following +yoga breathing with intermittent breath retention and +a similar trend following normal breathing with breath +awareness. Such yoga breathing may be useful for +prevention of various metabolic disorders including +heart diseases and diabetes mellitus. Further studies +using neuroimaging techniques in different +populations could be used to understand the exact +mechanisms involved in the practice of yogic breath +retention and its specific effects. +Compliance with ethical standards +Disclosure of potential conflicts of interest: The +authors declare no conflict of interests. +Research involving Human Subjects: The study has +been approved by the institutional ethics committee +and have been performed in accordance with the +ethical standards as laid down in the 1964 +Declaration of Helsinki and its later amendments or +comparable ethical standards. +Informed consent: Written informed consent was +obtained from all the participants. +References +1. +Grossman P. Respiration, Stress, and Cardiovascular +Function. Psychophysiology 1983 May; 20(3): 284–300. +2. +Pinna GD, Maestri R, La Rovere MT, Gobbi E, Fanfulla F. +Effect +of +paced +breathing +on +ventilatory +and +cardiovascular variability parameters during short-term +investigations of autonomic function. AJP Hear Circ +Physiol 2005 Aug 12; 290(1): H424–H433. +3. +Hirsch J a, Bishop B. Respiratory sinus arrhythmia in +humans: how breathing pattern modulates heart rate. +Physiology 1981; 241(4): H620–H629. +4. +Song H-S, Lehrer PM. The Effects of Specific Respiratory +Rates on Heart Rate and Heart Rate Variability. Appl +Psychophysiol Biofeedback 2003; 28(1): 13–23. +5. +Taimni I. The Science of Yoga: The Yoga-sûtras of +Patañjali in Sanskrit with Transliteration in Roman, +Translation and Commentary in English. Theosophical +Publishing House; 1999. +6. +Muktibodhananda S. Hatha Yoga Pradipika: Light on Hatha +Yoga. 2nd ed. Bihar: Yoga Publication Trust; 2002. +7. +Tyagi A, Cohen M. Yoga and heart rate variability: A +comprehensive review of the literature. Int J Yoga 2016; +9(2): 97–113. +8. +Peter R, Sood S, Dhawan A. Spectral Parameters of HRV +In Yoga Practitioners, Athletes And Sedentary Males. +Indian J Physiol Pharmacol 2015; 59(4): 380–387. +9. +Shannahoff-Khalsa DS, Sramek BB, Kennel MB, Jamieson +Indian J Physiol Pharmacol 2018; 62(1) +Autonomic and Cardiovascular Changes With Yogic Breathing +49 +SW. Hemodynamic observations on a yogic breathing +technique claimed to help eliminate and prevent heart +attacks: a pilot study. J Altern Complement Med 2004 +Oct; 10(5): 757–66. +10. Mason H, Vandoni M, Debarbieri G, Codrons E, Ugargol V, +Bernardi L. Cardiovascular and respiratory effect of yogic +slow breathing in the yoga beginner: what is the best +approach? Evid Based Complement Alternat Med 2013 +Jan; 2013: 743504. +11. Pal GK, Velkumary S, Madanmohan. Effect of short-term +practice of breathing exercises on autonomic functions in +normal human volunteers. Indian J Med Res 2004 Aug; +120(2): 115–121. +12. Sharma VK, Trakroo M, Subramaniam V, Rajajeyakumar +M, Bhavanani AB, Sahai A. Effect of fast and slow +pranayama on perceived stress and cardiovascular +parameters in young health-care students. Int J Yoga +2013 Jul; 6(2): 104–110. +13. Saraswati SN. Prana Pranayama Prana Vidya. 2nd ed. +Munger: Yoga Publications Trust; 2002. +14. Malshe PC. Nisshesha rechaka pranayama offers benefits +through brief intermittent hypoxia. Ayu 2011 Oct; 32(4): +451–457. +15. Turankar A V., Jain S, Patel SB, Sinha SR, Joshi AD, +Vallish BN, et al. Effects of slow breathing exercise on +cardiovascular functions, pulmonary functions & galvanic +skin resistance in healthy human volunteers - a pilot +study. Indian J Med Res 2013 May; 137(5): 916–921. +16. Telles S, Desiraju T. Oxygen consumption during +pranayamic type of very slow-rate breathing. Indian J +Med Res 1991 Oct; 94(i): 357–363. +17. Lee Cm, Ghiya S. Influence of alternate nostril breathing +on heart rate variability in non-practitioners of yogic +breathing. Vol. 5, International Journal of Yoga. 2012. +p. 66. +18. Bhavanani AB, Ramanathan M, Balaji R, Pushpa D. +Differential effects of uninostril and alternate nostril +pranayamas on cardiovascular parameters and reaction +time. Int J Yoga 2014 Jan; 7(1): 60–65. +19. Costalat G, Coquart J, Castres I, Tourny C, Lemaitre F. +Hemodynamic adjustments during breath-holding in trained +divers. Eur J Appl Physiol 2013 Oct; 113(10): 2523– +2529. +20. Joulia F, Lemaitre F, Fontanari P, Mille ML, Barthelemy P. +Circulatory effects of apnoea in elite breath-hold divers. +Acta Physiol (Oxf). 2009 Sep; 197(1): 75–82. +21. Lemaître F, Bernier F, Petit I, Renard N, Gardette B, Joulia +F. Heart rate responses during a breath-holding +competition in well-trained divers. Int J Sports Med 2005; +26(6): 409–413. +22. Molinari F, Liboni W, Grippi G, Negri E. Relationship +between oxygen supply and cerebral blood flow assessed +by transcranial Doppler and near-infrared spectroscopy +in healthy subjects during breath-holding. J Neuroeng +Rehabil 2006 Jan 1; 3(17): 16. +23. Spicuzza L, Porta C, Bramanti A, Maffeis M, Casucci G, +Casiraghi N, et al. Interaction between central-peripheral +chemoreflexes and cerebro-cardiovascular control. Clin +Auton Res 2005 Dec; 15(6): 373–381. +24. Laurino M, Menicucci D, Mastorci F, Allegrini P, Piarulli A, +Scilingo EP, et al. Mind-body relationships in elite apnea +divers during breath holding: a study of autonomic responses +to acute hypoxemia. Front Neuroeng 2012 Jan; 5:4. +25. Nagendra HR. Pranayama-The Art and Science. Bangalore: +Swami Vivekananda Yoga Prakashana; 2007. +26. Raghuraj P, Telles S. Immediate effect of specific nostril +manipulating yoga breathing practices on autonomic and +respiratory variables. Appl Psychophysiol Biofeedback +2008 Jun; 33(2): 65–75. +27. Faul F, Erdfelder E, Lang A-GG, Buchner A. G*Power 3: +a flexible statistical power analysis program for the social, +behavioral, and biomedical sciences. Behav Res Methods +2007; 39(2): 175–191. +28. Leicht AS, Hirning DA, Allen GD. Heart rate variability and +endogenous sex hormones during the menstrual cycle in +young women. Exp Physiol 2003 May; 88(3): 441–446. +29. Ashley E, Niebauer J. Conquering the ECG. In: Cardiology +Explained. London: Remedica; 2004. +30. Imholz BP, Wieling W, Langewouters GJ, van Montfrans +GA. Continuous finger arterial pressure: utility in the +cardiovascular laboratory. Clin Auton Res 1991 Mar; 1(1): +43–53. +31. Porter KB, O’Brien WF, Kiefert V, Knuppel RA. Finapres: +a noninvasive device to monitor blood pressure. Obstet +Gynecol 1991 Sep; 78(3.1): 430–433. +32. Hill L, Sollers Iii J, Thayer J. Evaluation of a simple +estimation method for the derivation of cardiac output +from arterial blood pressure and heart rate. Biomed Sci +Instrum 2012; 48: 165–170. +33. Hill LK, Sollers Iii JJ, Thayer JF. Resistance reconstructed +estimation +of +total +peripheral +resistance +from +computationally derived cardiac output. Biomed Sci +Instrum 2013; 49: 216–223. +34. Swenne CA. Baroreflex sensitivity: mechanisms and +measurement. Netherlands Hear J 2013 Feb 23; 21(2): +58–60. +35. Villien F, Yu M, Barthélémy P, Jammes Y. Training to yoga +respiration selectively increases respiratory sensation in +healthy man. Respir Physiol Neurobiol 2005 Mar; 146(1): +85–96. +36. Task Force of The European Society of Cardiology and +The North American Electrophysiology S of P and. Heart +rate variability: standards of measurement, physiological +interpretation and clinical use. Task Force of the European +Society of Cardiology and the North American Society of +Pacing and Electrophysiology. Circulation 1996 Mar 1; +93(5): 1043–1065. +37. Berntson GG, Bigger JT, Eckberg DL, Grossman P, +Kaufmann PG, Malik M, et al. Heart rate variability: origins, +methods, and interpretive caveats. Psychophysiology 1997 +Nov; 34(6): 623–648. +38. Peng CK, Mietus JE, Liu Y, Khalsa G, Douglas PS, Benson +H, et al. Exaggerated heart rate oscillations during two +meditation techniques. Int J Cardiol 1999 Jul 31; 70(2): +101–107. +39. Lehrer PM, Vaschillo E, Vaschillo B. Resonant frequency +biofeedback training to increase cardiac variability: +rationale and manual for training. Appl Psychophysiol +Biofeedback 2000 Sep; 25(3): 177–191. +40. Wang S-Z, Li S, Xu X-Y, Lin G-P, Shao L, Zhao Y, et al. +Effect of slow abdominal breathing combined with +biofeedback on blood pressure and heart rate variability +in prehypertension. J Altern Complement Med 2010 Oct; +16(10): 1039–1045. +41. Telles S, Sharma SK, Balkrishna A. Blood Pressure and +Heart Rate Variability during Yoga-Based Alternate Nostril +50 +Saoji, Raghavendra and Manjunath +Indian J Physiol Pharmacol 2018; 62(1) +Breathing Practice and Breath Awareness. Med Sci Monit +Basic Res 2014; 20. +42. Joseph CN, Porta C, Casucci G, Casiraghi N, Maffeis M, +Rossi M, et al. Slow Breathing Improves Arterial Baroreflex +Sensitivity and Decreases Blood Pressure in Essential +Hypertension. Hypertension 2005 Oct 1; 46(4): 714–718. +43. Bernardi L, Porta C, Spicuzza L, Bellwon J, Spadacini G, +Frey AW, et al. Slow Breathing Increases Arterial +Baroreflex Sensitivity in Patients With Chronic Heart +Failure. Circulation 2002 Jan 15; 105(2): 143–145. +44. Piepoli M, Sleight P, Leuzzi S, Valle F, Spadacini G, Passino +C, et al. Origin of Respiratory Sinus Arrhythmia in +Conscious Humans/: An Important Role for Arterial Carotid +Baroreceptors. Circulation 1997 Apr 1; 95(7): 1813–1821. +45. Jerath R, Edry JW, Barnes VA, Jerath V. Physiology of +long pranayamic breathing: neural respiratory elements +may provide a mechanism that explains how slow deep +breathing shifts the autonomic nervous system. Med +Hypotheses 2006 Jan; 67(3): 566–571. +46. Thayer JF, Yamamoto SS, Brosschot JF. The relationship +of autonomic imbalance, heart rate variability and +cardiovascular disease risk factors. Int J Cardiol 2010 +May; 141(2): 122–131. +47. Rovere MT La, Bigger JT, Marcus FI, Mortara A, Schwartz +PJ. Baroreflex sensitivity and heart-rate variability in +prediction of total cardiac mortality after myocardial +infarction. Lancet 1998 Feb; 351(9101): 478–484. +48. França da Silva AK, Penachini da Costa de Rezende +Barbosa M, Marques Vanderlei F, Destro Christofaro DG, +Marques Vanderlei LC. Application of Heart Rate Variability +in Diagnosis and Prognosis of Individuals with Diabetes +Mellitus: +Systematic +Review. +Ann +Noninvasive +Electrocardiol 2016 May; 21(3): 223–235. +49. Frattola A, Parati G, Gamba P, Paleari F, Mauri G, Di +Rienzo M, et al. Time and frequency domain estimates of +spontaneous baroreflex sensitivity provide early detection +of autonomic dysfunction in diabetes mellitus. Diabetologia +1997 Nov 25; 40(12): 1470–1475. +50. Stuckey MI, Tulppo MP, Kiviniemi AM, Petrella RJ. Heart +rate variability and the metabolic syndrome: a systematic +review of the literature. Diabetes Metab Res Rev 2014 +Nov; 30(8): 784–793. +51. Bernardi L, Gabutti A, Porta C, Spicuzza L. Slow breathing +reduces +chemoreflex +response +to +hypoxia +and +hypercapnia, and increases baroreflex sensitivity. J +Hypertens 2001 Dec; 19(12): 2221–2229. +52. Spicuzza L, Gabutti A, Porta C, Montano N, Bernardi L. +Yoga and chemoreflex response to hypoxia and +hypercapnia. Lancet (London, England). 2000 Oct 28; +356(9240): 1495–1496. +53. Somers V, Mark A, Abboud F. Interaction of baroreceptor +and chemoreceptor reflex control of sympathetic nerve +activity in normal humans. J Clin Investig 1991; 87: 1953– +1975. +54. Lehrer P, Woolfolk R, Sime W. Principles and Practice of +Stress Management. New York: Guilford Press; 2007. +55. Pöyhönen M, Syväoja S, Hartikainen J, Ruokonen E, Takala +J. The effect of carbon dioxide, respiratory rate and tidal +volume on human heart rate variability. Acta Anaesthesiol +Scand 2004 Jan; 48(1): 93–101. +View publication stats +View publication stats diff --git a/subfolder_0/Impact of yoga and physical exercise on psychological wellbeing among substance abusers a randomized controlled trial.txt b/subfolder_0/Impact of yoga and physical exercise on psychological wellbeing among substance abusers a randomized controlled trial.txt new file mode 100644 index 0000000000000000000000000000000000000000..e69de29bb2d1d6434b8b29ae775ad8c2e48c5391 diff --git a/subfolder_0/Influence of Yoga & Ayurveda on self-rated sleep in a geriatric.txt b/subfolder_0/Influence of Yoga & Ayurveda on self-rated sleep in a geriatric.txt new file mode 100644 index 0000000000000000000000000000000000000000..6cf15397d8db794b72b57fd1757db5ba363a325f --- /dev/null +++ b/subfolder_0/Influence of Yoga & Ayurveda on self-rated sleep in a geriatric.txt @@ -0,0 +1,795 @@ +Indian J Med Res 121, May 2005, pp 683-690 +683 +Older adults spend more time in bed relative to +time spent asleep1. This is due to longer time taken to +fall asleep, more periods of wakefulness during the +night, and time spent lying awake before rising in the +morning. It is well recognized that the function of sleep +in everyday life is crucial to an individual’s sense of +wellbeing, with a strong relationship between the +quality of sleep and psychological symptoms2. Hence, +it is also desirable for older persons to get an adequate +sleep at night, though the expectations should be based +Influence of Yoga & Ayurveda on self-rated sleep in a geriatric +population +N.K. Manjunath & Shirley Telles +Swami Vivekananda Yoga Research Foundation, Bangalore, India +Received April 20, 2004 +Background & objectives: Sleep in older persons is characterized by decreased ability to stay +asleep, resulting in fragmented sleep and reduced daytime alertness. Pharmacological treatment +of insomnia in older persons is associated with hazardous side effects. Hence, the present study +was designed to compare the effects of Yoga and Ayurveda on the self rated sleep in a geriatric +population. +Methods: Of the 120 residents from a home for the aged, 69 were stratified based on age (five- +year intervals) and randomly allocated to three groups i.e., Yoga (physical postures, relaxation +techniques, voluntarily regulated breathing and lectures on yoga philosophy), Ayurveda (a herbal +preparation), and Wait-list control (no intervention). The groups were evaluated for self- +assessment of sleep over a one week period at baseline, and after three and six months of the +respective interventions. +Results: The Yoga group showed a significant decrease in the time taken to fall asleep +(approximate group average decrease: 10 min, P<0.05), an increase in the total number of hours +slept (approximate group average increase: 60 min, P< 0.05) and in the feeling of being rested in +the morning based on a rating scale (P<0.05) after six months. The other groups showed no +significant change. +Interpretation & conclusion: Yoga practice improved different aspects of sleep in a geriatric +population. +Key words Ayurveda - geriatric population - self-rated sleep - yoga +684 +INDIAN J MED RES, MAY 2005 +on realistic ideas of the sleep requirement and +inevitable age-related changes in the sleep structure3. +Pharmacological treatment of insomnia in older +persons has been found to be associated with +hazardous side effects such as states of confusion, +psychomotor performance deficits, nocturnal falls, +dysphoric mood, impaired intellectual functioning, and +daytime sleepiness4. During the last two decades, a +number of well documented behavioural principles for +good sleep have been described and particular forms +of short-term behavioural and psychological therapies +have become available5. Clinical interest in the +possible effectiveness of such approaches has been +stimulated by the fact of high co-morbidity between +insomnia and other conditions which respond to +psychological approaches. These therapeutic +approaches can be mainly classified into three +categories: behaviour based educative methods (e.g., +avoiding large amounts of coffee or heavy food just +before bedtime)6; relaxation techniques (e.g., +progressive muscular relaxation, briefer forms of +autogenic training, and various forms of self- +hypnosis); and formal psychotherapy. +Yoga is an ancient Indian science and way of life +which brings about relaxation and also induces a +balanced mental state7. Yoga techniques include +physical postures (asanas), voluntarily regulated +breathing +(pranayamas), +meditation, +and +philosophical principles which help to reach a +balanced mental state. A closely related ancient Indian +discipline, Ayurveda (the ‘Science of Life’, in +Sanskrit), provides comprehensive knowledge about +diverse aspects of health8,9. Wide ranges of health +measures are covered including massage and herbal +preparations. The latter are used for healthy persons +(‘rejuvenating preparations’ or rasayanas) and for +therapy. In the present study on persons over the age +of 60 yr we compared the effects of yoga with those +of an ayurveda herbal preparation (intended to +promote positive health in aged persons) on different +aspects of sleep, based on their self-assessment. This +comparison of the effects of two related disciplines +was planned to understand their effects individually, +so as to use them with better efficiency as +complementary systems, which is how these have been +traditionally described8. +Material & Methods +Subjects: The subjects were persons of both sexes, +over the age of 60 yr in a residential home for the +aged in Bangalore city, south India. The total number +of residents was 120; 30 of them were ill or bed-ridden. +The remaining 90 persons were told about the trial. +All of them expressed their willingness to participate +in the trial. The protocol was approved by the ethical +committee of the institution and the signed informed +consent of each subject was taken. They were screened +using the electrocardiogram (all leads), fasting blood +glucose, and blood pressure measurements, as well +as a detailed clinical examination. +Subjects with the following health problems were +excluded from the study: uncontrolled diabetes (seven +participants), uncontrolled hypertension (four), +neurological disorders (three), dementia (one), hearing +impairment (five), and a detected case of non-infective +Hansen’s disease. Sixty nine subjects were included +for the study after this screening. +Randomization: The 69 subjects were stratified +according to age [five-year intervals, between 60 and +65 yr (lower limit), and between 90 and 95 yr (upper +limit)]. Within a particular five-year age range, +subjects of each gender separately, were randomized +as three groups (groups 1, 2 and 3) using a standard +random number table. Allocation of a group to a +particular intervention was carried out by the lottery +method, as follows: The three interventions ‘Yoga’, +‘Ayurveda’ or ‘Wait-list control’ were written on three +similar pieces of paper which were folded. A person +who had no other part in the trial, picked up and +opened the folded papers. The first intervention to be +picked up was assigned to group 1, and accordingly +for groups 2 and 3. Following stratified sampling and +random allocation, there were 23 subjects in each +group (including seven males in the Yoga group and +six males each in Ayurveda and Wait-list control +groups) with average ages (± SD) of 70.1 ± 8.3, 72.1 +± 9.0, and 72.3 ± 7.4 yr, respectively. +The Ayurveda group was selected so as to +independently evaluate the effects of a system of +treatment (and of lifestyle) which is complimentary +to Yoga. The idea was to evolve a comprehensive +685 +programme with some aspects each from Yoga and +Ayurveda, for a geriatric population. The Wait-list +control group was selected to study the retest effect +(as assessments were made thrice) on subjects who +were equally motivated to receive Yoga or Ayurveda +if the interventions were allocated to them. +Study protocol: All three groups were assessed for +self rating of specific aspects of sleep at baseline, and +after three and six months of the interventions (Yoga, +Ayurveda, or Wait-list control) using a sleep rating +questionnaire. There were seven questions, which +subjects were asked to answer based on their +experience during the week prior to assessment. +Asking them to recall their quality and amount of sleep +in the week prior to assessment was important, as +recall over longer periods is especially likely to be +influenced by anamnesis in older persons10. The +questionnaire consisted of seven questions. The +questions were either dichotomous (i.e., two options: +yes/no; Questions 5 and 6) or open questions (i.e., +Questions 1, 2, 3, 4 and 7). +The questions were: +1. Approximately how long (in min) does it take you +to fall asleep? +2. How many hours do you sleep each night? +3. How many times (if any) do you wake up during +the night? +4. What are the usual reasons for wakening up, if +you do so? +5. Do you feel rested in the morning (yes/no)? +6. Do you sleep in the day time (yes/no)? +7. If your answer to Question 6 was ‘yes’, for how +long do your day time naps last (in min)? +The sleep rating questionnaire has been evaluated +for its reliability and validity based on standard +criteria. Reliability was ascertained based on (i) +temporal stability, and (ii) internal consistency. To +assess temporal stability the correlation coefficients +were calculated using the data of the ‘no intervention’, +Wait-list control group with two correlations being +made, viz.: (i) baseline with three months, and (ii) +baseline with six months. Of the five variables for +which the correlations were made, the temporal +stability was demonstrated for four (Table I). In order +to evaluate internal consistency the correlation +between two variables, which assessed an equivalent +aspect of sleep, was calculated. The two variables +were the number of hours slept each night and the +feeling of being rested in the morning. The values for +the three groups were as follows: Yoga (r = 0.643), +Ayurveda (r = 0.578) and Wait-list control (r = 0.699). +Validity was inferred based on the content and +indirectly based on the test for internal consistency +described above. +To eliminate the possibility of bias the examiner +was kept unaware of the group to which the subject +belonged. +Interventions +Ayurveda - The Ayurveda group received a herbal +preparation i.e., a ‘rejuvenating tonic’ (Rasayana +Kalpa in Sanskrit). The participants were given 10 g +(1 tablespoon, approximately) of Rasayana Kalpa, +twice a day, once in the morning (0600) and again in +the evening (1800). After both doses they were asked +to drink 200 ml of skimmed milk, as is prescribed in +Ayurveda texts8. Though the prescribed dose was 48 +g per day11, the present dose was suggested by +Ayurveda experts who were consultants for the project. +This preparation (10 g) consisted of the following +herbs (the Sanskrit names are given in parenthesis): +Withania somnifera (ashwagandha roots, 2 g), +Emblica officinalis (amalaki, 1 g), Sida cordifolia +(bala, 0.25 g), Terminalia arjuna (arjuna, 0.25 g), +Piper longum (pippali, 0.5 g). The other contents +were: sugar (4 g), honey (2 g), water and clarified +butter (ghee) in the amount required to get the correct +semi-solid consistency. +Yoga training: The Yoga session was planned to +include: physical activity, relaxation, regulated +breathing and philosophical aspects. This was an +integrated approach of yoga, derived from principles +in ancient texts which emphasize that yoga should +promote health at all levels12. The session was for sixty +minutes daily, for six days a week. Subjects practiced +breathing exercises (10 min), loosening exercises +(shithilikarana vyayama, 5 min), physical postures +MANJUNATH & TELLES: YOGA, AYURVEDA & GERIATRIC PERSONS' SLEEP +686 +INDIAN J MED RES, MAY 2005 +(20 min) [i.e., tadasana (mountain posture) +padahasthasana +(hand- +to-foot +posture), +ardhakatichakrasana (lateral arc posture), +ardhachakrasana +(half +wheel +posture), +viparithakarani (half shoulder stand posture), +matsyasana (fish posture), bhujangasana (cobra +posture), shalabhasana (locust posture), makarasana +(crocodile posture), vakrasana (sitting sideward twist +posture), paschimothanasana (back-stretching +posture), ushtrasana (camel posture), shashankasana +(moon posture), vajrasana (diamond posture), (ardha) +padmasana (half lotus posture), shavasana (corpse +posture)], voluntarily regulated breathing +(pranayama, 10 min) such as: nadishudhi (alternate +nostril breathing), brahmari (bumble bee breathing), +surya anuloma viloma (right nostril yoga breathing), +and chandra anuloma viloma (left nostril yoga +breathing) and yoga-based guided relaxation (15 min), +which has been described elsewhere13. There was an +additional session in the evening which consisted of +devotional songs (bhajans, 15 min) and lectures on +theory and philosophy of yoga alternating with ‘cyclic +meditation’. The last technique is derived from another +ancient Indian text (the Mandukya Upanishad) and +involves alternating cycles of physical postures and +supine rest14. +Statistical analysis: Data were analyzed using the +statistical package (SPSS Version 10.0). The data at +baseline, and at three and six months of all three +groups were assessed with tests for normality +distribution using both graphic presentations (box plot +and stem and leaf plot) as well as Kolmogorov- +Smirnov test. +Repeated measures Analysis of Variance (ANOVA) +was used to test for (i) significant differences between +the assessments (baseline, three and six months) of +all three groups i.e., within-subjects factor, and (ii) +differences between the groups (Ayurveda, Yoga and +Wait-list control) i.e., between-subjects factor. The +‘t’ test for paired data was used to compare data at +three and six months with those at baseline for each +group, separately. These parametric tests were used +even though the data were found to be not normally +distributed as it has been shown that analyses of +variance and t tests are usually robust enough to +perform well even if the data deviate somewhat from +the requirements of normality and homoscedasticity15. +Since the ‘feeling of being rested in the morning’ +was dichotomously scored, the data were binary. +Hence, a nonparametric statistical test, McNemar test +was used to compare data at three and six months +with those at baseline for each group, separately. +Results +The 69 were older persons were staying in an +institution for the aged. At the beginning of the study, +most of them reported sleep difficulties. These were: +(i) difficulty in falling asleep (55 out of 69), (ii) periods +Table I. Correlation coefficient for temporal stability in Wait-list control group +Variable studied +Comparisons + Baseline versus 3 months +Baseline versus 6 months +Correlation +P value +Correlation +P value +coefficient +(two tailed) +coefficient +(two tailed) +Time taken to fall asleep +0.495 +.027 +0.561 +.010 +Number of hours slept +0.455 +.001 +0.361 +.001 +each night +Feeling of being rested in +0.204 +.388 +0.167 +.482 +the morning +Number of awakenings in +0.781 +.001 +0.645 +.002 +the night +Number of minutes slept +0.851 +.001 +0.744 +.001 +each afternoon +687 +of wakefulness during the night (58 out of 69), and +(iii) reduced number of hours slept each night (42 out +of 69). +The data of baseline, three and six months of all +three groups were found to be not normally distributed +based on the Kolmogorov-Smirnov test. In the Yoga +group the time taken to fall asleep was reduced +significantly at three (P<0.05) and six months +(P<0.01), and duration of sleep each night increased +significantly at six months (P<0.05). Other groups +showed no significant change (Table II). +The repeated measures ANOVA showed that there +was a significant interaction between the factors +(Assessments and Groups; P<0.05) for the ‘time taken +to fall asleep’, while other variables showed no +significant difference (Table III). +The paired ‘t’ test showed that there was a +significant decrease in the time taken to fall asleep in +the Yoga group at both three months (P<0.05) and +six months (P<0.01) when compared with the baseline +values. Also, there was a significant increase in the +total number of hours slept each night in the Yoga +group for the comparisons made between the values +at six months with (i) those at baseline (P<0.05) and +(ii) at three months (P<0.05). +The McNemar test for the “feeling of being rested +in the morning” showed that there was a significant +increase in the ‘feeling of being rested in the morning’ +in the Yoga group at six months (N=18, P<0.05) +compared with the baseline values, while other groups +showed no significant change. +Discussion +Problems with sleep organization in the elderly +include difficulty in falling asleep, less time spent in +the deeper stages of sleep, early morning awakening, +and less total sleep time16. A variety of factors may +influence the sleep in older persons, such as acute and +chronic illnesses, medication effects, psychiatric +Table II. Self-rated sleep assessment scores at baseline and after three and six months for all three groups (Yoga, Ayurveda and +Wait-list control) +Yoga +Ayurveda +Wait-list control +Baseline +Three +Six months Baseline +Three +Six months +Baseline +Three +Six months +months +months +months +(n = 23) +(n = 20) +(n = 18) +(n = 23) +(n = 15) +(n = 12) +(n = 23) +(n = 20) +(n = 20) +Time taken to fall asleep +36.30 +29.00* +25.83** +39.40 +39.60 +28.30 +36.70 +39.70 +40.70 +(min) +± 11.00 +± 12.30 +± 11.70 +± 21.70 +± 25.50 +± 15.60 +± 22.10 +± 18.40 +± 23.10 +Duration of sleep each night 5.78 +6.25 +6.88* +6.13 +6.13 +6.50 +6.43 +6.30 +6.45 +(h) +± 0.95 +± 0.78 +± 0.96 +± 1.05 +± 1.55 +± 1.24 +± 1.16 +± 0.86 +± 1.09 +Number of awakenings +2.50 +2.00 +2.00 +2.30 +1.90 +2.00 +2.30 +2.30 +2.40 +in the night (number +± 0.90 +± 0.70 +± 0.70 +± 1.20 +± 1.10 +± 1.00 +± 1.20 +± 1.20 +± 1.20 +of times) +Feeling of being rested +0.26 +0.45 +0.66† +0.48 +0.53 +0.50 +0.61 +0.50 +0.57 +in the morning (0=not +± 0.04 +± 0.51 +± 0.48 +± 0.50 +± 0.51 +± 0.52 +± 0.5 +± 0.51 +± 0.5 +rested, +1 = well rested) +sleep in the afternoon +35.80 +28.50 +31.60 +22.20 +22.00 +23.70 +31.30 +30.00 +27.70 +(min) +± 27.70 +± 21.70 +± 22.30 +± 18.00 +± 20.30 +± 16.20 +± 20.60 +± 19.40 +± 21.30 + + +*P<0.05, **P<0.01, t-test for paired data comparing the values at three or six months versus baseline; †P<0.05, McNemar test, +comparing the values at six months versus baseline +Values are mean±SD +MANJUNATH & TELLES: YOGA, AYURVEDA & GERIATRIC PERSONS' SLEEP +688 +INDIAN J MED RES, MAY 2005 +disorders and primary sleep disorders17,18. However, +the subjects studied here were screened to exclude +these factors. Hence any sleep disorganization +observed in them may be attributed to psychological +factors associated with ‘assorted life changes such as +loss of loved ones, leaving a familiar home to live in a +more supervised setting’16, as well as financial strain19. +In the present study the improvement in sleep +following yoga was in agreement with earlier reports20. +The practice of yoga has been shown to reduce signs +of physiological arousal in normal volunteers based +on measurements of autonomic and respiratory +variables and oxygen consumption13,14, as well as a +decrease in plasma catecholamine levels21. A similar +benefit of reduced physiological arousal following +yoga was also seen in persons with higher than usual +arousal to begin with, related to their social +circumstances22 or to physical impediments23. +While the above studies have shown that the +practice of yoga decreases psychophysiological +arousal, it has also been shown that subjects who +practiced yoga breathing (pranayama) for a two-year +period could achieve higher work rates with reduced +oxygen consumption per unit work and without an +increase in blood lactate levels24. In addition, yoga +practice was shown to help in adapting to unusual +environmental demands25 and to bring about a shift in +balance, in cases of abnormal functioning as evidenced +by changes in the electroencephalograph frequencies +in epileptics following six months of Sahaja yoga26. +Hence, yoga may have reduced the time taken to +fall asleep and increased the total sleep time by +reducing physiological arousal, manifestations of +anxiety and improving the ability to physiologically +adapt in this group of institutionalized, older persons. +Difficulty in falling asleep has been found to be higher +in groups with physiologic and somatoform +disorders27. Also, complaints of nocturnal awakening +were higher in persons with anxiety and physiologic +disorders. In the present study, most often the +participants woke up because of nycturia, occasional +cough, and non-specific aches. +Rasayana Kalpa has been believed to promote +positive health in older persons and contains, among +other constituents, the roots of Withania somnifera +(aswagandha)8. The roots of Withania somnifera are +traditionally used to promote physical and mental +health, to provide defence against disease and adverse +environmental factors and to arrest aging. Withania +somnifera is also used to stabilize the mood in persons +with behavioural disturbances. The anxiolytic and +antidepressive +effects +of +the +bioactive +glycowithanolides isolated from Withania somnifera +roots were compared with those of the benzodiazepine, +lorazepam and the tricyclic antidepressant, +imipramine, respectively, in rats28. The herbal +preparation exhibited an antidepressant effect +comparable with that induced by imipramine, +supporting the use of this preparation as a mood +stabilizer. +The absence of change in the Ayurveda group may +be related to the fact that the number of subjects at +six months was reduced to 12, versus 18 in the Yoga +group. The main reason was that the preparation was +followed by milk (as prescribed in Ayurveda texts), +hence, they chose to give up their customary intake of +coffee. This was not a required restriction but though +the participants chose to give it up, they were +uncomfortable about it. +Sleep disorders have been shown to be related to +depressive symptoms, poor physical activity, +Table III. Analysis of variance for “time taken to fall asleep” +Source +df +MS +F +P value +(two tailed) +Within subjects factor +1.785 +510.7 +3.02 +0.060 +(Assessments) +Between subjects factor +2 +1060.958 +1.334 +0.273 +(Groups) +Interaction +3.569 +455.5 +2.694 +0.042 +(assessments subjects)* +Error +83.876 +169.08 +(Within subjects factor) +Error +47 +795.576 +(Between subjects factor) +*Greenhouse-Geisser epsilon = 0.892, hence df, MS, F and P +values are noted taking Greenhouse-Geisser epsilon into +account +689 +medication and bad self-rated health29. As already +described, yoga is known to reduce anxiety while +physical activity is increased23. In addition, the +philosophical aspects of yoga may have been +important to reduce depressive symptoms in these +institutionalized older persons30. The subjective +assessment of the participants was that singing +devotional songs was the most enjoyable part of the +yoga programme. This devotion was “bhakti yoga” +or the science of emotion culture31. Hence an integrated +approach of yoga including the mental and +philosophical aspects in addition to the physical, was +especially useful. +The present results suggest that yoga practice, +which includes physical activity, relaxation with +awareness, and inputs about philosophical and +emotional stability33, improved the sleep and increased +the feeling of being refreshed on awakening in +institutionalized older persons. Since it is known that +changes in sleep are inevitable as age advances34, any +intervention, which makes this process free from +difficulties, is a useful addition to the routine of older +persons. Since the assessments were done using a +questionnaire, which was subjective in nature, the +findings of the study should be regarded as a +preliminary observation rather than a substantiated +view. In order to objectively understand the changes +in sleep architecture underlying these improvements, +further research with polysomnographic recordings +would be required. +Acknowledgment +Authors acknowledge the Department of Indian Systems of +Medicine and Homeopathy, Ministry of Health and Family +Welfare, Government of India, New Delhi, India, for financial +support, and Asaktha Poshaka Sabha, Bangalore, and The +Government Ayurveda Medical College, Bangalore, India, for +technical support. +References +1. +Bliwise NG. Factors related to sleep quality in healthy +elderly women. Psychol Aging 1992; 7 : 83-8. +2. +Hays JC, Blazer DG, Foley DJ. Risk of napping: excessive +daytime sleepiness and mortality in an older community +population. J Am Geriatr Soc 1996; 44 : 693-8. +3. +Hoch C, Buysse DJ, Monk TH, Reynolds CF. Sleep +disorders and aging. In: Birren JE, Sloane RB, Cohen GD, +editors. Handbook of mental health and aging, 2nd ed. +New York: Academic Press; 1992 p. 557-8. +4. +Engle-Friedman M, Bootzin RR. Insomnia as a problem +for the elderly. In: Wisocki PA, editor. Handbook of +clinical behavioral therapy with the elderly client. New +York: Plenum Press; 1991 p. 273-98. +5. +Nielson HG, Nordhus IH, Kvale G. Insomnia in older +adults. In: Nordhus IH, Vandenbos GH, Berg S, Fromholt +P, editors. Clinical geropsychology. Washington DC: +American Psychological Association; 1998 p. 167-76. +6. +Morin CM. Insomnia: Psychological assessment and +management. New York: Guildford Press; 1993. +7. +Taimini IK. The Science of Yoga. Madras: The +Theosophical Publishing House; 1986. +8. +Sharma RK, Dash B. Charaka Samhita. Varanasi: +Chowkhamba Sanskrit Series Office; 1998. +9. +Dev S. Ancient–modern concordance in Ayurvedic plants: +some examples. Environ Health Perspect 1999; 107 : 783-9. +10. +Kayed K. [Insomnia and hypnotica]. Tidsskr Nor +Laegeforen 1995; 115 : 1087-90. +11. +Sharangadhara. Madhyama Khanda. In: Shastri P, editor. +Sharangadhara Samhita, Adhamalla Teeka. Varanasi: +Oriental Publishers & Distributors; 1985. +12. +Swami Gambhirananda. Taittiriya Upanishad. Calcutta: +Advaita Ashrama; 1986. +13. +Vempati RP, Telles S. Yoga based guided relaxation +reduces sympathetic activity judged from baseline levels. +Psychol Rep 2002; 90 : 487-94. +14. +Telles S, Reddy SK, Nagendra HR. Oxygen consumption +and respiration following two yoga relaxation techniques. +Appl Psychophysiol Biofeedback 2000; 25 : 221-7. +15. +Zar JH, editor. Biostatistical analysis. New Jersey: +Prentice-Hall, Inc.; 1999. +16. +Neubauer DN. Sleep problems in the elderly. Am Fam +Physician 1999; 59 : 2551-60. +17. +Bliwise DL. Sleep in normal aging and dementia. Sleep +1993; 16 : 40-81. +18. +Neubauer DN, Smith PL, Earley CJ. Sleep disorders. In: +Barker LR, Burton JR, Zieve PD, editors. Principles of +ambulatory medicine. 5th ed. Baltimore: Williams & +Wilkins; 1999 p. 1314-28. +MANJUNATH & TELLES: YOGA, AYURVEDA & GERIATRIC PERSONS' SLEEP +690 +INDIAN J MED RES, MAY 2005 +19. +Roberts RE, Shema SJ, Kaplan GA, Strawbridge WJ. Sleep +complaints and depression in an aging cohort: A prospective +perspective. Am J Psychiatry 2000; 157 : 81-8. +20. +Long L, Huntley A, Ernst E. Which complementary and +alternative therapies benefit which conditions? A survey +of the opinions of 223 professional organizations. +Complement Ther Med 2001; 9 : 178-85. +21. +Udupa KN, Singh RH, Yadav RA. Certain studies on +psychological and biochemical responses to the practice +of Hatha Yoga in young normal volunteers. Indian J Med +Res 1973; 61 : 237-44. +22. +Telles S, Narendran S, Raghuraj P, Nagarathna R, +Nagendra HR. Comparison of changes in autonomic and +respiratory parameters of girls after yoga and games at a +community home. Percept Mot Skills 1997; 84 : 251-7. +23. +Telles S, Srinivas RB. Autonomic and respiratory measures +in children with impaired vision following yoga and +physical activity programs. Int J Rehabil Health 1999; 4 : +117-22. +24. +Raju PS, Madhavi S, Prasad KVV, Reddy MV, Reddy ME, +Sahay BK, et al. Comparison of effects of yoga & physical +exercise in athletes. Indian J Med Res 1994; 100 : 81-6. +25. +Rao S. Oxygen consumption during yoga-type breathing +at altitudes of 520m and 3,800m. Indian J Med Res 1968; +56 : 701-5. +26. +Panjwani U, Selvamurthy W, Singh SH, Gupta HL, +Thakur L, Rai UC. Effect of Sahaja yoga practice on +seizure control & EEG changes in patients of epilepsy. +Indian J Med Res 1996; 103 : 165-72. +27. +Okuji Y, Matsuura M, Kawasaki S, Kometani S, +Shimoyama T, Sato M, et al. Prevalence of insomnia in +various psychiatric diagnostic categories. Psychiatry Clin +Neurosci 2002; 56 : 239-40. +28. +Bhattacharya SK, Bhattacharya A, Sairam K, Ghosal S. +Anxiolytic-antidepressant activity of Withania somnifera +glycowithanolides: an experimental study. Phytomedicine +2000; 7 : 463-9. +29. +Zanocchi M, Ponzetto M, Spada S, Risso R, Aimer T, +Maero B, et al. Sleep disorders in the aged. Minerva Med +1999; 90 : 421-7. +30. +Nagarathna R, Nagendra HR. Yoga practices for anxiety +and depression. Bangalore: Swami Vivekananda Yoga +Prakashana; 2001. +31. +Nagendra HR. The science of emotion culture (Bhakti +Yoga). Bangalore: Swami Vivekananda Yoga Prakashana; +2000. +32. +Swami +Sivananda. +Narada +bhakti +sutras. +Shivanandanagar, Uttar Pradesh: The Divine Life Society; +1997. +33. +Nagendra HR. Yoga - Its basis and applications. +Bangalore: Swami Vivekananda Yoga Prakashana; 2000. +34. +Vitiello MV. Effective treatment of sleep disturbances in +older adults. Clin Cornerstone 2000; 2 : 16-27. +Reprint requests: Dr Shirley Telles, Swami Vivekananda Yoga Research Foundation, City office, No.19, +Eknath Bhavan, Gavipuram Circle, K.G. Nagar, Bangalore 560019, India +e-mail: anvesana@vsnl.com diff --git a/subfolder_0/Integrated Approach of Yoga Therapy towards Chronic Low Back Pain.txt b/subfolder_0/Integrated Approach of Yoga Therapy towards Chronic Low Back Pain.txt new file mode 100644 index 0000000000000000000000000000000000000000..d4c78652b62ca9702a74960b25a2f6d4269c1701 --- /dev/null +++ b/subfolder_0/Integrated Approach of Yoga Therapy towards Chronic Low Back Pain.txt @@ -0,0 +1,581 @@ +www.jimcr.com +INTEGRATIVE MEDICINE CASE REPORTS  VOLUME 2  NUMBER 1  JANUARY 2021 +15 +IMCR +CASE REPORT +Integrated Approach of Yoga Therapy towards Chronic Low Back Pain: +A Case Report +Reshma P +. Jogdand1*, Shekhar Mukhiya Sunuwar2, Amit Singh3 and R. Nagrathna4 +Department of Life Sciences, SVYASA University, Bangalore1,3,4 +The School of Yoga and Naturopathic Medicine, SVYASA University, Bangalore2 +ABSTRACT +This case report represents the patient of lower back pain (LBP) who visited Arogyadhama +(SVYASA University, Bangalore). Patient was suffering from low back pain and multiple joint pain +at the time of visit and 14 days Yoga intervention was provided to the patient for pain man- +agement, which helped the patient in relieving the pain and improving the muscular strength +and quality of life significantly. The present case study is an attempt to provide IAYT (Integrated +approach of Yoga therapy) practices in combination with naturopathy and physiotherapy for the +maintenance of LBP profile and symptoms. +doi: 10.38205/imcr.020115 +KEY WORDS +Lower back pain +Yoga therapy +Naturopathy +Physiotherapy +Quality of life +*Corresponding Author: +Reshma P. Jogdand +Department of Life Sciences, +SVYASA University, Bangalore +Contact no: +91-9449164937 +E-mail: reshma.bnys@gmail.com +Introduction +Chronic low back pain (CLBP) is a chronic pain syndrome of +the lower back region lasting at least for 3 months. It is the +most common musculoskeletal condition affecting the adult +population. Many authors define CLBP as pain that lasts be- +yond the expected period of healing (1). CLBP is a main cause +of physical disability worldwide and needs significant gov- +ernment assistance and financial help to resolve the issue (2). +Non-specific LBP does not have any recognizable pathology +(such as infection, tumor, osteoporosis, rheumatoid arthritis, +fracture, or inflammation) and traits (3).  +Commonness of incessant LBP IS 4.2% among the adults +in the age group of 24 to 39 years and 19.6% among 20 to +59 years (5). Among nine investigations, six show preva- +lence of LBP in about 3.9%–10.2% people aged 18 or more, +whereas other three investigations shows prevalence range +of the same between 13.1% and 20.3%. LBP predominance +was noticed 25.4% among Brazilian population while it was +15 to 45% in French human services laborers. Pervasiveness +of CLBP is evaluated to be 5.91% in Italy (2). The prevalence +of acute and CLBP in adults doubled in the last decade and +continues to increase dramatically in the aging population, + +affecting both men and women in all ethnic groups (6). +Side effects, pathology, and radiological appearances are +ineffectively associated with CLBP. Intensity of pain is indefi- +nite in about 85% of individuals suffering from CLBP. About +4% of individuals with CLBP in essential consideration has +pressure breaks, and about 1% are known to be associated +with tumor. The commonness of prolapsed intervertebral +plate among individuals with CLBP is about 1% to 3%, while +Ankylosing spondylitis and spinal diseases are more uncom- +mon. These findings can’t be used for an authoritative conclu- +sion on incessant LBP. Different factors, other than physical, +may be associated with progression of CLBP which includes +hazard factors such as substantial physical work, bowing, +turning, lifting and Psychosocial chance elements, such as +nervousness, gloom, and mental worry, at work. Having a past +history of LBP and a more extended span of critical hazard +factors for chronicity. One efficient survey of described that +some mental components such as trouble, burdensome state +of mind, and somatization are related with an expanded dan- +ger of constant LBP. Working environment and individual +factors are also thought to be associated with the progress of +interminable LBP (4). +Case presentation +Recruitment of patient +A 51 year old female from Telengana who visited Prashanti +Kutiram (Arogyadhma) SVYASA for treatment of her CLBP +was enrolled as a participant for this case study after taking +her written consent and explaining her about the treatment +regimen. She was kept in section ‘E’, which deals with spinal +disorders and back pain. She resided in the campus for a pe- +riod of 14 days (6th March, 2020 to 19th March, 2020). Yoga +therapy, which included loosening practices (Table 1), Pra- +nayams (Table 2), breathing practices (Table 3) and asanas +INTEGRATIVE MEDICINE CASE REPORTS  VOLUME 2  NUMBER 1  JANUARY 2021 +www.jimcr.com +16 +IMCR +CASE REPORT +(Table 4) was combined with Naturopathy (Table 5) and Phys- +iotherapy (Table 6)s for her CLBP treatment. Specific diet plan + +(Table 7) was also followed by participant. Below is a treat- +ment regimen that was provided to the patient during her +stay in SVYASA. +IAYT Protocol +Treatment Regimen +Loosening Practice (7) +Table 1: Loosening practices followed by participant +S. +No. +Practice +Duration +per session +Frequency +per day +Duration of +intervention +1 +Ankle movement +10 times +2 times a day 2 weeks +2 +Feet movement +inward-outward +10 times +2 times a day 2 weeks +3 +Ankle rotation +10 times +2 times a day 2 weeks +4 +Butterfly +20 times +2 times a day 2 weeks +5 +St. leg raising +5 times +2 times a day 2 weeks +6 +Shoulder +Rotation +10 times +2 times a day 2 weeks +7 +Upper arm +stretch +10 times +2 times a day 2 weeks +8 +Vertical stretch +of knee +10 times +2 times a day 2 weeks +9 +Neck movement +10 times +2 times a day 2 weeks +10 +Side leg raising +10 times +2 times a day 2 weeks +11 +Alternate foot +knee +10 times +2 times a day 2 weeks +12 +Sideward +bending +10 times +2 times a day 2 weeks +13 +Cross leg L.S +10 times +2 times a day 2 weeks +14 +Hip stretch +10 times +2 times a day 2 weeks +15 +Back stretch with +alternate leg +10 times +2 times a day 2 weeks +16 +Full butterfly +10 times +2 times a day 2 weeks +17 +Alternate & both +leg raising +10 times +2 times a day 2 weeks +18 +Side leg raising +10 times +2 times a day 2 weeks +Pranayama (8) +Table 2: Pranayams followed by participant +Pranayama +Duration of +procedure +Frequency +Duration of +Intervention +1 Nadishuddhi +Pranayama +27 Rounds +for each +nostril +4 times a day 2 weeks +2 Brahmari +9 Rounds +2 times a day 2 weeks +3 Naadaanusandhna +5 Rounds +2 times a day 2 weeks +Deep Relaxation Technique (10–15 minutes) (9) +Each session of passive exercise, pranayama was completed +with D.R.T. (Deep Relaxation Technique). Deep Relaxation +Technique (D.R.T.) is a deeper and more intense form of relax- +ation. For making participant comfortable during relaxation +session, DRT was done in Savasana (Corpse Pose) because it +is generally done for 15 minutes. +Breathing Practices (10) +Table 3: Breathing practices followed by participant +S. +No. +Breathing +Practices +Duration of +procedure +Frequency +Duration of +Intervention +1 +Hand Stretch +Breathing +2 minutes +2 times a day 2 weeks +2 +Hands In and +Out Breathing +2 minutes +2 times a day 2 weeks +3 +Ankle stretch +Breathing +2 minutes +2 times a day 2 weeks +4 +Tiger Breathing 2 minutes +2 times a day 2 weeks +Yogasana (11) +Table 4: Asanas followed by participant +Yogasanas +Duration of +procedure +Frequency +Duration of +Intervention +Standing Position +1 sasankasana +2 minutes +2 times a day 2 weeks +2. Dorsal stretch +(naukasana) +2 minutes +2 times a day 2 weeks +3 Pavanmuktasanakriya +(without lifting the +head) +2 minutes +2 times a day 2 weeks +4. Bhujanagasana +2 minutes +2 times a day 2 weeks +5 Dorsal stretch +1 minute +2 times a day 2 weeks +6 salabhasana +2 minutes +2 times a day 2 weeks +7 Walking +2 times a day 2 weeks +8 Side leg raising +1 minute +2 times a day 2 weeks +Naturopathy (12) +Table 5: Naturopathy treatment followed by participant +S. +No. +Treatments +Duration +(minutes) +Frequency +Periods +1 +Mud pack +15 +1 time a day +1 week +2 +Salt water bath +45 +1 time a day +1 week +3 +Mustard pack +30 +1 time a day +1 week +4 +Hot fomentation +15 +1 time a day +1 week +5 +Vibro massage +15 +1 time a day +1 week +www.jimcr.com +INTEGRATIVE MEDICINE CASE REPORTS  VOLUME 2  NUMBER 1  JANUARY 2021 +17 +IMCR +CASE REPORT +Physiotherapy (13)(14) +Table 6: Physiotherapy treatment followed by participant +S. +No. +Treatments +Duration +(minutes) +Frequency +Periods +1 +ix. IFT +5 +1 time a day +1 week +2 +x. Ultrasound +5 +1 time aday +1 week +Diet Protocol (8) +The participant was advised to take naturopathic diet con- +secutively for 14 days of her stay in Prashanti kuteeram. The +pattern was as follows. +Lunch: (boiled diet) 1 chapati, 1 cup adl, 1 cup rice, butter- +milk, 100 gm boiled vegtables (beans + pumpkin + beetroot + +methi + spinach + knolkhol) +Dinner: (Raw diet) 2–3 slices fruits (papaya + watermelon ++ pomegranate/muskmelon), Vegetable salad (cucumber + +pomegranate + beetroot + carrot), Butter milk. +Diagnosis +Reduction of low back pain was noticed. +Table 8: Score of different parameters before and after the treatment +regimen +Parameters +DOA +DOD +Pulse Beats/min +80 bpm +74 bpm +BP in mmHg +130/70 mm/Hg +148/98 mm/Hg +Respiratory Cycles/min +17 cpm +11 cpm +Bhramari Time (Sec) +15 sec +15 sec +Symptoms score +03 +01 +Straight leg raising +Lt/Rt in degree +80/80 +90/90 +Sit and reach +46 cm +47 cm +Pain Scale Reading +09 +05 +Discussion +It was observed that the patient was able to maintain a healthy +living by adopting IAYT which may have helped improving the +patient’s overall health. During her stay she had undergone +Table 7: Weekly diet plan followed by participant +8:00 am +10:00 am +12:00 pm +2:00 pm +5:00 pm +7:30 pm +8:30 pm +Saturday +Ash gourd juice +Barley water +Lunch +Buttermilk +Ash gourd juice +Dinner +Kashayam +Sunday +Carrot juice +Watermelon +Lunch +Buttermilk +Carrot juice +Dinner +Kashayam +Monday +Bottle gourd juice +Musk melon +Lunch +Buttermilk +Bottle gourd juice +Dinner +Kashayam +Thuesday +Bottle gourd + Watermelon +Lunch +Buttermilk +Bottle gourd +Dinner +Kashayam +Wednesday +Ash guard juice +Carrot juice +Lunch +Buttermilk +Ash guard juice +Dinner +Kashayam +Thursday +Carrot juice +Ash guard +Lunch +Buttermilk +Dinner +Kashayam +Friday +Breakfast +– +Pongal + buttermilk Buttermilk +– +Dinner +– +Fig. 1: Bars represent the intensity of different parameters diagnosed during treatment period of 14 days. +0 +10 +20 +30 +40 +50 +60 +70 +80 +90 +100 +Pulse rate +Respiratory +rate +Bhramari +rate +Symptoms +score +straight leg +raising +sit and reach Pain Scale +Reading +Chart Title +Pre +Post +INTEGRATIVE MEDICINE CASE REPORTS  VOLUME 2  NUMBER 1  JANUARY 2021 +www.jimcr.com +18 +IMCR +CASE REPORT +above mentioned yoga practice, meditation, relaxation tech- +niques, Naturopathy treatments and Physiotherapy practices. +There was marked positive changes in all vitals including +Blood pressure, Respiratory rate and there was significant im- +provement in symptoms score and good number of reduction +in straight leg raising and sit and reach scale. +Conclusion +Overall treatment of Yoga combined with physiotherapy, na- +turopathy and specific diet plan helped her to reduce LBP and +symptom score such as difficulty in performing day to day +activities and disturbed sleep due to pain and helped her to +maintain the better quality of life. Above mentioned integrat- +ed treatment can be recommended to the patients with CLBP. +Acknowledgement +First of all, I bestow in front of Lord Dhanavantari and ex- +press deepest gratitude to the almighty. In addition I would +like to acknowledge the following people who played an in- +strumental role in the completion of this project. I express my +appreciation to the blessings of my gurus and salutations to +my parents and all my teachers. I am grateful to Dr. Nagarath- +na and Dr. Amit Singh of research for sharing their thoughts +with other people. Special thanks to a person who motivated +me for this work is Dr. Amit singh, his guidance and support +makes me more strong and confident to study in this area. +I am appreciative to section therapist for their guidance +and allowing me to provide Yoga therapy to their patients and +their immense support in my presented work. My love and +regards goes to my loving parents for their endless support +and encouragement finally, my hearted thank to my husband +Mr. Sumit Aundhekar for extending his support through out +my work. I express my gratitude to all the Participants, as they +were the true inspiration and purpose. +Authorship contribution +RJ and SM has written Article. +RN guided to write article. +AS has contributed in a treatment planning. +Informed consent +Yes. +Source of funding +Nil. +Conflict of interest +Nil. +Received Date: 04-07-20; Revised Date: 24-08-20 +Accepted Date: 15-09-20 +References +1. +Johannes CB, Le TK, Zhou X, Johnston JA, Dworkin RH. The prevalence of +chronic pain in United States adults: results of an Internet-based sur- +vey. The Journal of Pain. 2010 Nov 1;11(11):1230–9. +2. +Allegri M, Montella S, Salici F, Valente A, Marchesini M, Compagnone C, +­ +Baciarello M, Manferdini ME, Fanelli G. Mechanisms of low back pain: +a guide for diagnosis and therapy. F1000Research. 2016;5. +3. +Andersson GB. Epidemiological features of chronic low-back pain. The lan- +cet. 1999 Aug 14;354(9178):581–5. +4. +Chou R, Huffman LH. Nonpharmacologic therapies for acute and chronic +low back pain: a review of the evidence for an American Pain Society/ +American College of Physicians clinical practice guideline. Annals of +internal medicine. 2007 Oct 2;147(7):492–504. +5. +Meucci RD, Fassa AG, Paniz VM, Silva MC, Wegman DH. Increase of chronic +low back pain prevalence in a medium-sized city of southern Brazil. +BMC musculoskeletal disorders. 2013 Dec;14(1):1–1. +6. +Meucci RD, Fassa AG, Faria NM. Prevalence of chronic low back pain: sys- +tematic review. Revista de saude publica. 2015 Oct 20;49:73. +7. +Ebnezar J, Nagarathna R, Bali Yogitha HR. Effect of integrated yoga therapy +on pain, morning stiffness and anxiety in osteoarthritis of the knee +joint: a randomized control study. International Journal of Yoga. 2012 +Jan;5(1):28. +8. +Macphail K. C-reactive protein, chronic low back pain and, diet and life- +style. International Musculoskeletal Medicine. 2015 Apr 1;37(1): +29–32. +9. +Blödt S, Pach D, Roll S, Witt CM. Effectiveness of app-based relaxation for +patients with chronic low back pain (Relaxback) and chronic neck +pain (Relaxneck): study protocol for two randomized pragmatic tri- +als. Trials. 2014 Dec;15(1):1–9. +10. Smith MD, Russell A, Hodges PW. Disorders of breathing and continence +have a stronger association with back pain than obesity and phys- +ical activity. Australian Journal of Physiotherapy. 2006 Jan 1;52(1): +11–6. +11. Tilbrook HE, Cox H, Hewitt CE, Kang'ombe AR, Chuang LH, Jayakody S, +Aplin JD, Semlyen A, Trewhela A, Watt I, Torgerson DJ. Yoga for chron- +ic low back pain: a randomized trial. Annals of internal medicine. +2011 Nov 1;155(9):569–78. +12. Konrad K, Tatrai T, Hunka A, Vereckei E, Korondi I. Controlled trial of bal- +neotherapy in treatment of low back pain. Annals of the rheumatic +diseases. 1992 Jun 1;51(6):820–2. +13. Hurley DA, Minder PM, McDonough SM, Walsh DM, Moore AP, Baxter DG. +Interferential therapy electrode placement technique in acute low +back pain: a preliminary investigation. Archives of physical medicine +and rehabilitation. 2001 Apr 1;82(4):485–93. +14. Ebadi S, Henschke N, Nakhostin Ansari N, Fallah E, van Tulder MW. Thera- +peutic ultrasound for chronic low-back pain. Cochrane Database Syst +Rev. 2014 Mar 14;(3):CD009169. diff --git a/subfolder_0/Integrating Yoga in Cancer Care_ Scope and Challenges.txt b/subfolder_0/Integrating Yoga in Cancer Care_ Scope and Challenges.txt new file mode 100644 index 0000000000000000000000000000000000000000..4a4ba684ebf945613028916825b8fe839a45ae9b --- /dev/null +++ b/subfolder_0/Integrating Yoga in Cancer Care_ Scope and Challenges.txt @@ -0,0 +1,84 @@ +Indian J Palliat Care. 2017 Jul-Sep; 23(3): 223–224. +doi: 10.4103/IJPC.IJPC_103_17 +PMCID: PMC5545944 +PMID: 28827922 +Integrating Yoga in Cancer Care: Scope and Challenges +HR Nagendra +Chancellor, Swami Vivekananda Yoga Anusandhana Samsthana University, Bengaluru, Karnataka, India +Address for correspondence: Dr. HR Nagendra, Chancellor, Swami Vivekananda Yoga Anusandhana +Samsthana University, Bengaluru, Karnataka, India. E-mail: hrnagendra1943@gmail.com +Copyright : © 2017 Indian Journal of Palliative Care +This is an open access article distributed under the terms of the Creative Commons Attribution- +NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non- +commercially, as long as the author is credited and the new creations are licensed under the identical terms. +We see an increasing burden of cancer in the country today probably attributed to rise in lifestyle- +related noncommunicable diseases and better detection of cancer. Coupled with this increasing burden +are also high mortality rates for cancers in the country. Although treatment modalities for detection and +treatment of cancer are improving, the lack of awareness, accessibility to quality care, and affordability +are hampering good outcomes. Majority of the cancer centers are located in urban cities with people +having to travel long distances and be away from work indirectly increasing the cost of care. Although +government schemes have helped offer subsidized care to the people, the survivorship and care +continuity are nonexistent with people not having access to care in their towns and villages following +first line of treatment. As a result, studies have shown that more than 90% of patients die at their homes +without any access to palliative care. Only 0.4% of the cancer patients have any access to palliative +care in the country. The cost of cancer care in the country though low in comparison to west is still +beyond the reach of common man. A large percentage of population afflicted with cancer are thrust +into poverty with people selling off homes, land for their treatment, people being incapacitated from +work with loss of earnings due to long treatment schedules, and treatment-related morbidity. It is +therefore important to explore local healing traditions and mind-body interventions such as in AYUSH +systems of medicine Ayurveda, Yoga and Naturopathy, Unani Siddha, and Homeopathy to reduce +treatment-related morbidity, improve quality of life, and identify any novel plant-derived drug targets +against cancer. +Cancer care has been under the purview of conventional medicine in the country and AYUSH +interventions exist only as a last resort or are sought for symptom mitigation. However, many patients +take recourse to these therapies both as a first line and in their survivorship period with an intent to +reduce side effects of conventional treatment and improve anticancer immunity. Whether these +interventions are beneficial or not is a question that needs to be answered through systematic research. +Studies should look at the safety efficacy and cost-effectiveness of these therapies if these are to be +integrated with mainstream medicine. +Sඋ඗඘ඍ ඗ඎ Y඗ඏඉ +Yoga as a mind-body intervention has been increasingly used in cancer patients. However, in the last +decade, several large phase III studies on yoga and cancer have shown light on the beneficial effects +and cost-effectiveness of these interventions. Integrating these interventions into cancer care for +symptom mitigation and quality of life may also reduce duration of hospital stay and costs. Further +research is warranted in the area. Second, we need to identify and create feasible and safe yoga +protocols for cancer patients. Setting goals of care, plan of care, and objectives will help rationalize use +of yoga interventions in cancer patients. Identifying clinical situations where certain yoga interventions +can pose significant risk is also warranted. For example, a patients receiving radiation for a lung lesion +should not do hyperventilation practices such as Kapalabhati and Bhastrika for fear of causing +pneumothorax. Studies have shown that it is a very feasible to implement a yoga program at bedside in +an oncology practice setting. Multiple hospital admissions and daily radiotherapy present an +opportunity to engage the patients in regular yoga practice during their treatment visits. Nurses in +hospitals can be taught to impart yoga intervention to patients during their +surgery/chemotherapy/radiotherapy. Yoga can also be taught to the caregivers to reduce their burnout +as well as to reinforce these practices among the patients. Home care team to manage pain can use yoga +for morphine-induced constipation, fatigue, nausea and vomiting, headache and other stress, and +vasomotor symptoms. Training AYUSH doctors in palliative care will help meet the unmet need for +home-based palliative care services and rural palliative care services in the country. No doubt, these +practices are known to help improve quality of life of cancer patients and reduce symptom burden. +Whether this translates to reduced duration of hospital stay and cost reduction needs more evidence. +Studies should look at the efficacy of these services in reducing cost. Insurance companies should +encourage hospitals to adopt these interventions to mitigate costs and reduce hospital visits. +Cඐඉඔඔඍඖඏඍඛ +While beneficial effects of yoga are quite well known, its adoption by the oncology medical +community is still wanting. Most of them still perceive “Yoga” as an “Asana” or as some form of body +contortion, which can expose the patient to unnecessary risk of musculoskeletal injuries. Their +concerns are genuine as we also need to educate the yoga practitioners on the medical condition of +cancer patients and their vulnerability to fractures and pain. We need to use services of organizations +such as Indian association of palliative care and Indian Naturopathy Yoga graduates’ Medical +Association to bridge this divide. Oncologists need to be exposed to beneficial effects of yoga +intervention and educated about “What really is Yoga.” Yoga as per Sage Vasistha is a science of +calming down the mind. Sage Pathanjali explains this systematically through eight-fold steps called +Astanga Yoga which uses ethics, disciplines, postures, regulated breathing, or breath control, to control +the mind followed by concentration and meditation. These series of practices are known to identify the +inherent stress responses and help cope with them through altered perception, controlled appraisal, +sublimed emotions, nonexpectation, and detachment. Yoga helps patients cope with uncertainty of +illness and more importantly reduces fear. +Our studies on cancer patients in India and abroad are promising. We need to formulate think tank on +formulating the way forward for Integrating Yoga and AYUSH streams into oncology care. We need to +identify priority and thrust areas wherein these interventions can be used in clinical settings. We need +to encourage government to set up center for excellence in yoga and oncology to develop the evidence +and setup integrative wellness centers in all regional cancer centers across India. Large multicenter +studies are needed before yoga interventions become a reality in oncology. +Articles from Indian Journal of Palliative Care are provided here courtesy of Wolters Kluwer -- Medknow +Publications diff --git a/subfolder_0/Integrating evidence-based treatments for common mental disorders in routine primary care.txt b/subfolder_0/Integrating evidence-based treatments for common mental disorders in routine primary care.txt new file mode 100644 index 0000000000000000000000000000000000000000..0636cb13c1a07d29920cfb456f3a5f88bed00fb0 --- /dev/null +++ b/subfolder_0/Integrating evidence-based treatments for common mental disorders in routine primary care.txt @@ -0,0 +1,807 @@ +39 +Integrating evidence-based treatments for common +mental disorders in routine primary care: +feasibility and acceptability of the MANAS +intervention in Goa, India +RESEARCH REPORT +SUDIPTO CHATTERJEE1,2, NEERJA CHOWDHARY1, SULOCHANA PEDNEKAR1, ALEX COHEN3, GRACY ANDREW1, +RICARDO ARAYA4, GREGORY SIMON5, MICHAEL KING6, SHIRLEY TELLES8, HELEN WEISS2, HELENA VERDELI7, +KATHLEEN CLOUGHERTY7, BETTY KIRKWOOD2, VIKRAM PATEL1,2 +1Sangath Centre, 841/1 Alto-Porvorim, Goa 403521, India +2London School of Hygiene and Tropical Medicine, Keppel Street, Bloomsbury, London, WC1E 7HT, UK +3Department of Social Medicine, Harvard Medical School, Boston, MA, USA +4Division of Psychiatry, University of Bristol, UK +5Centre for Health Studies, Group Health Cooperative, Seattle, WA, USA +6University College, London, UK +7Columbia University, New York, NY, USA +8Swami Vivekananda Yoga Research Foundation, Bangalore, India +Depressive and anxiety disorders, also referred to as com- +mon mental disorders (CMD), are widely prevalent in pri- +mary care settings in low- and middle-income countries +(LAMIC)(1) and are associated with significant levels of dis- +ability, increased health care costs and reduced economic +productivity (2-4). Although substantial proportions of pri- +mary care attenders in LAMIC suffer from a CMD – esti- +mates vary from 10 to 30% (1,5) – the vast majority of pa- +tients do not receive effective treatments (6). This treatment +gap persists even as a growing evidence base demonstrates +that there are efficacious treatments that are feasible in +LAMIC settings (7-10). To address this treatment gap, inte- +gration of mental health services into primary care is widely +acknowledged as the most feasible strategy (11). While we +now have encouraging evidence that specific treatments for +CMD work in LAMIC, the challenge is to integrate these in +a comprehensive intervention package within routine pri- +mary care systems. This is one of the key research priorities +for CMD in LAMIC (12). +A recent review of evidence from high-income countries +highlighted the components that are necessary for the effec- +tive integration of services for depression in primary care set- +tings (13). These were the routine screening of patients, ed- +ucation for primary health care staff, skilled mental health +providers delivering a stepped-care intervention and the ac- +tive collaboration of mental health specialists in the pro- +gramme. +The adaptation of these principles in LAMIC primary +care settings presents several challenges. These include lim- +ited skilled mental health resources, vastly different social +and cultural contexts and an already constrained primary +care system (14-16). Other barriers to possible integration +include the low recognition rates of CMD by primary care +doctors (17), limited primary health care staff and large +numbers of patients, infrequent and/or inadequate use of +antidepressants (18) and the frequent use of medications +such as vitamin injections which are prescribed for their +supposedly ”restorative” properties (19). Low adherence to +medication regimens further minimizes the gains of treat- +ment. In addition, few patients receive psychosocial treat- +ments, typically because of a scarcity of personnel with the +time and skills to deliver these (20). +The MANAS project is an effectiveness trial of a multi- +component, comprehensive intervention to integrate the +treatment of CMD in primary care facilities in Goa, a state +on the West coast of India which has been the setting for a +Common mental disorders, such as depression and anxiety, pose a major public health burden in developing countries. Although these +disorders are thought to be best managed in primary care settings, there is a dearth of evidence about how this can be achieved in low re- +source settings. The MANAS project is an attempt to integrate an evidence based package of treatments into routine public and private +primary care settings in Goa, India. Before initiating the trial, we carried out extensive preparatory work, over a period of 15 months, to +examine the feasibility and acceptability of the planned intervention. This paper describes the systematic development and evaluation of +the intervention through this preparatory phase. The preparatory stage, which was implemented in three phases, utilized quantitative and +qualitative methods to inform our understanding of the potential problems and possible solutions in implementing the trial and led to +critical modifications of the original intervention plan. Investing in systematic formative work prior to conducting expensive trials of the +effectiveness of complex interventions is a useful exercise which potentially improves the likelihood of a positive result of such trials. +Key words: Depression, anxiety, low-income countries, primary care, effectiveness of interventions +(World Psychiatry 2008;7:39-46) +IMP. 39-46 23-01-2008 17:10 Pagina 39 +40 +World Psychiatry 7:1 - February 2008 +number of studies on the epidemiology and treatment of +CMD (21-23). The original intervention plan was based on +two principles: first, the treatments selected would be +based on evidence from published trials in LAMIC and, +thus, include psychoeducation (24,25), antidepressants +(7,9) and group interpersonal therapy (IPT) (8,10); and, +second, the intervention would address the challenges +highlighted earlier and be based on the best global evi- +dence available (13). The intervention would involve a re- +configuration of both the human resources and the princi- +ples of care delivery in primary care. The personnel would +comprise a low cost, skilled mental health care provider +working in the clinics (the “health counselor”), who, along +with the existing primary care doctor, would detect and +provide treatments for CMD with the support and supervi- +sion of a visiting psychiatrist. The treatments provided +would be matched to the needs of the patient (stepped +care) (7), including brief psychoeducation as the first step, +with the more intensive treatments (antidepressants and +IPT) being available for those with more severe problems +(Table 1). We refer to this collaborative, stepped care inter- +vention as the MANAS intervention. As a word, MANAS +means “humanity” in the local Konkani language. It is al- +so an acronym for MANAShanty Sudhar shodh (“project +to promote mental health”). +Our aim is, ultimately, to evaluate the MANAS interven- +tion in a cluster randomized controlled trial in primary care +settings in Goa, India. This trial is now in progress. In this +paper, we describe the preparatory stage (October 2005 - De- +cember 2006), in which the feasibility and acceptability of +the intervention was evaluated systematically, in keeping +with the current recommendations for the conduct of com- +plex intervention trials (26). The preparatory stage had three +distinct phases: a) consultation with stakeholders; b) form- +ative research to evaluate key components of the interven- +tion; and c) piloting of the entire intervention. Each stage is +described sequentially, with a focus on the methods and key +findings, and questions which arose which were then ad- +dressed in the subsequent stage. +CONSULTATION PHASE +Objectives and methods +The objective of this phase was to consult with local, na- +tional and international stakeholders from the public, pri- +vate and academic sectors about the feasibility of the pro- +posed intervention. A total of 14 consultation meetings were +held at primary health care centres and conference venues +with the local stakeholders. A total of 145 doctors from the +Directorate of Health Services and private practitioners par- +ticipated, in addition to the primary health care staff. Dur- +ing these meetings, a key member of the team described the +MANAS intervention. Group exercises were undertaken to +get feedback on the relevance and need of the programme +in primary care, on the feasibility of implementing the in- +tervention and on the specific problems and solutions that +were likely to occur in these settings. A meeting of national +and international collaborators involved with the trial was +held in early 2006, during which results of the previous con- +sultations were presented and further inputs of this group +were considered. +Results +Doctors suggested that the routine screening results for +detection of CMD be presented to them in a simple manner +that would also be of assistance in providing feedback to pa- +tients. Psychoeducation (Step 1) should be brief, emphasize +the connection between the stressors and the symptoms, +and be delivered in an empathic manner. The health coun- +selor should avoid using terms that could be stigmatizing. +Public sector doctors wanted the antidepressant to be +made available free of cost, in keeping with usual care prac- +tices and in order to improve adherence rates. The partici- +pants suggested that the group psychological intervention +be delivered either in primary health care centres or in com- +munity locations (e.g., temple courtyards or local schools), +Table 1 The collaborative stepped care intervention framework for the MANAS project +Steps of care +Objective +Responsible health workers +Intervention +Recognition +Sensitive and specific detection of CMD +Health counselor +Use of screening questionnaire +Step 1 +Provision of health promotion advice +Health counselor +Psychoeducation +and education about symptoms +Step 2 +Provision of evidence-based pharmacotherapy +Primary health care centre +Antidepressant (fluoxetine 20-40 mg/day +or psychotherapy to patients who +doctor and health counselor +for at least 6 months) +do not respond to Step 1 +OR interpersonal psychotherapy +Step 3 +Provision of both treatments for patients who +Primary health care centre doctor +Antidepressant plus interpersonal +do not respond to Step 2 +and health counselor +psychotherapy; intensive adherence +management +Step 4 +Management of treatment resistant cases +Psychiatrist (visiting) +Referral (either through phone discussion +or suicidal patients +or face to face evaluation in primary health +care centre) +CMD – common mental disorders +IMP. 39-46 23-01-2008 17:10 Pagina 40 +41 +for men and women separately and in the evenings to max- +imize attendance. Furthermore, concerns were expressed +that many patients would not find group sessions accept- +able or convenient, and that an individual treatment format +should also be offered as a choice. +Many of the participants felt that including yoga as one +of the group activities would make the intervention more +culturally acceptable. It was agreed that a set of yoga tech- +niques, selected on the basis of their efficacy for anxiety and +depression, would be utilized in the MANAS intervention. +It was proposed that the yoga sessions be available to all pri- +mary health care attendees and staff, in addition to the pa- +tients receiving the intervention, so as to destigmatize the +overall program. +According to the original formulation of the program, +doctors would provide patients with a choice of antide- +pressants or psychological treatments. However, the stake- +holders felt that, in the context of the strong medical mod- +el in current care, this would lead to most patients receiv- +ing antidepressants. It was recommended that the effec- +tiveness and appropriateness of psychological treatments +be emphasized in the training of doctors, to make the +process of choice more balanced. Furthermore, doctors felt +there should be a distinction in guidelines for mildly ill pa- +tients from those who are severely ill (based either on +screening questionnaire data or clinical assessment), so +that the latter can be moved straight to a higher step on +their first presentation. Considering the multiple responsi- +bilities of the health counselor, the decision was made to +separate the roles of screening and intervention delivery. +Thus, two additional full-time staff would be based in fa- +cilities, one to screen and, where needed, to register pa- +tients (whom we refer to as the “health assistant”) and one +to be the case manager for the MANAS intervention (the +health counselor). The health counselor was seen as the +most important human resource of the program, and most +of the participants were of the opinion that she should be +a woman, be fluent in the local languages, have excellent +communication skills and be available for consultations on +a regular basis in the clinics. Many also wanted her to be +called the ”salagar” (advisor), to reflect local understand- +ings and improve her acceptability. +FORMATIVE PHASE +Objectives and methods +The objective of the formative phase was to evaluate the +feasibility and acceptability of the specific treatments in the +intervention. +The formative research was conducted over 16 weeks +(April - July 2006) in four primary health care centres and +four private general practice facilities. The primary health +care centres, which were staffed by 3-5 doctors backed up +by nursing and administrative personnel, offered outpatient +care 6 days a week, as well as limited inpatient facilities. The +private general practice clinics were in urban and rural ar- +eas and were run by a single doctor with or without inpa- +tient facilities in single rooms or in small hospitals referred +to locally as ”nursing homes”. None of these facilities had +counsellors or health educators and specialty mental health +care was accessible only through referrals. +In keeping with the recommendations made during the +consultation phase, 10 women (4 health counselors and 6 +health assistants) were recruited. The health counselors were +trained to deliver the various treatments, including counsel- +ing skills, psychoeducation, yoga and IPT; their training was +based on a draft manual developed for the intervention. The +health assistants were trained in the use of the screening in- +strument chosen for the trial. The final training exercise for +the doctors was conducted either individually or in small +groups. This focused on the recognition and management +of CMD, with a particular emphasis on the rational use of +antidepressants and avoidance of non-evidence based med- +ications. A set of materials were developed for patients and +program staff, including a “patient card” for the reporting of +the screening results to the doctor, handouts for various +symptom management strategies and a doctor’s guide on +the use of antidepressants. The health counselor and health +assistant were then placed in facilities where they imple- +mented the specific treatments. +Two types of data were collected for the assessment of the +formative phase: +Process indicators. These were the total number of at- +tendees in each facility; the number who were excluded from +undergoing screening on the basis of a priori exclusion cri- +teria (<18 years old, inability to speak any of the local lan- +guages, in need of urgent medical care, attending the clinic +within 2 weeks of the initial screening and therefore not el- +igible for screening at this contact, refusal to answer); the +number who screened as having possible CMD; the num- +ber who met the health counselor after consulting the doc- +tor during their initial visit; and the number who returned +for follow-up sessions. These data were collected on a dai- +ly basis by the health counselor and collated weekly; analy- +sis was carried out using the SPSS14 package. +Qualitative data. In-depth, semi-structured interviews +with key stakeholders (doctors, facility staff, health coun- +selors and patients) were conducted to document their per- +spectives about the feasibility, utility and acceptability of +various aspects of the intervention. Since we wanted to elic- +it specific information from each of the groups, different in- +terviews were developed for each group. For example, the +interviews for patients focused on their recollection of the +process of the intervention and their opinion about the util- +ity of the treatments; the interviews for primary care physi- +cians elicited their perceptions of the feasibility of the in- +tervention and the individual treatments as well as their role +in the overall process. The thematic method of analysis of +qualitative data was used to generate results. +IMP. 39-46 23-01-2008 17:10 Pagina 41 +42 +World Psychiatry 7:1 - February 2008 +Results +A total of 7473 patients attended the primary care facili- +ties during the formative phase (Table 2). Of those who were +screened, 899 (31.6%) were positive for CMD. Of these +cases, 70.6% were women; the average age was 41 years (SD +13.5). Among them, 53% actually received the first session +of psychoeducation and only 24.3% of those who had re- +ceived the initial session returned for further follow-up ap- +pointments. IPT was offered (all opted for the individual for- +mat) to 16 patients, 11 of whom (68%) attended at least four +sessions and only 3 (19%) completed six or more sessions. +A total of 89 interviews were completed with doctors +(n=10), patients (n=50), staff in the facilities (n=17) and the +intervention team (n=12). Clinic and programme staff spoke +of problems in providing counselors with work space that of- +fered an acceptable level of privacy, especially in the smaller +general practice clinics. Facility staff and the counselors con- +sistently suggested that a systematic mapping of the physical +infrastructure and the personnel in the facility be conducted +prior to implementing the intervention. This would orient +counselors to the usual care processes in their clinics, and +help them identify any potential difficulties in positioning the +intervention. Doctors and staff in the facilities also men- +tioned the need for counselors to be visible members of the +facility. Several strategies to achieve this goal were suggest- +ed, including meetings between the counselors and the doc- +tors every day before and after the outpatient clinic, regular +meetings with other facility staff, and counselors’ atten- +dance at the scheduled monthly review meetings with the +field staff of the primary health care centres. There was near +unanimity in stakeholder groups that women with excellent +communication skills were the ideal choice for being effec- +tive health counselors. +A majority of patients reported screening to be a useful +process, as they were asked about emotional problems, +which were not otherwise usually assessed. Most patients +felt that the duration of the screening was acceptable, and +the clinic staff did not feel that the new procedure adversely +impacted on the usual care processes. The 30 minute psy- +choeducation session was described as useful by most pa- +tients, with the majority able to recall the contents of the ses- +sion. Most endorsed the role of stress in contributing to their +health problems, and were practicing the suggested tech- +niques to improve their symptoms. In particular, the breath- +ing exercises, and advice about sleep and diet, were felt to be +the most useful components of the psychoeducation session; +this was also endorsed by the health counselors. The efforts +to deliver IPT met with limited success, as users cited a vari- +ety of problems in returning for treatment on a weekly basis, +in particular the loss of wages and the cost of repeated trav- +el to the clinic. Another important barrier, specific to the +group format, was concerns about confidentiality, given the +personal nature of the issues being discussed and that other +members of the groups who lived in the same community +might gossip about their problems to others. +In conclusion, the formative research suggested that, +with the exception of the group IPT component, specific +treatments of the MANAS intervention were feasible and +acceptable to patients and providers. We were reassured +that the locally recruited and trained health counselors +(who had no prior mental health experience) could provide +the intervention consistently. We agreed that facilities that +lacked a private space for the health counselor office could +not participate in the program. A “running-in period” be- +fore starting service delivery was accepted as an important +exercise for the team to become familiar with the physical +layout of the clinic, the staff and usual procedures. Though +patients felt that the intervention was acceptable, the poor +follow-up rates indicated that non-adherence would be a +major obstacle to the successful implementation of the in- +tervention. To generate an appropriate and effective adher- +ence management strategy, it was felt that an in depth un- +derstanding of the reasons for non-adherence from the ser- +vice user perspective was essential. Another concern was +the large number of patients who did not meet the health +counselor after being screened and seen by the doctor, and +were lost to the program. Greater attention to minimize this +attrition by initiating changes to the care pathway in the +clinic became an immediate priority. +PILOTING PHASE +Objectives and methods +The objectives of the pilot phase were to implement and +evaluate the intervention, and to understand the reasons for +Table 2 Salient process indicator data in the formative and piloting phases of the MANAS intervention +Total +Total +Reasons for exclusion +Total cases +% receiving +% returned +attenders +screened +identified +psycho- +for follow-up +education +Formative phase +7473 +2846 (38.0%) +1530 (41.0%) <18 years +899 (31.6%) +53.0% +24.3% +1165 (12.8%) acutely ill +1214 (17.4%) attending specialist unit +Pilot phase +7194 +2530 (35.1%) +1711 (38.7%) <18 years +854 (33.7%) +65.8% +43.8% +1497 (11.2%) acutely ill +1167 (26.4%) repeat attenders in <2 weeks +IMP. 39-46 23-01-2008 17:10 Pagina 42 +43 +non-adherence while implementing efforts to improve fol- +low-up rates. +The intervention was piloted in four primary health care +centres between August and November 2006. In this phase, +the MANAS intervention, as originally proposed, was con- +siderably modified in the following ways: a structured ad- +herence management protocol was developed; the role of +the health counselors was broadened so that they would al- +so provide advice for practical social difficulties (e.g., by +keeping a referral register of community agencies for social +problems); the focus of IPT was switched from group to in- +dividual formats; a structured protocol for the supervision +of the health counselor by the visiting psychiatrist (clinical +specialist) was produced. Finally, a list of process indicators +that would enable the clinical specialist to effectively sup- +port and monitor the progress of the intervention was de- +veloped (Table 3). +Quantitative and qualitative data were collected during +this phase by using the above-mentioned process indicators +and by administering semi-structured interviews to patients +who provided consent to describe their experiences of the in- +tervention and reasons for adherence or non-adherence. Pur- +posive, random sampling generated two groups of partici- +pants who were interviewed in their homes: 50 who were ad- +herent and 50 who were not (attended two or less sessions +and not following-up). A guide took each participant through +the process of the MANAS intervention and explored his/her +reasons for adherence or non-adherence. Feedback was also +sought on the participants’ views about the utility of the ad- +herence management strategies. The qualitative data were +compiled and analysed by using thematic analysis tech- +niques. +Results +A total of 7194 patients attended the primary health care +centres during the piloting phase and, of these, 854 (33.7%) +were identified as possible cases. Of the patients identified +by screening, 68.3% were women, and the average age was +40 years (SD 12.8). The adherence management procedures +improved both the rates of patients receiving the first psy- +choeducation session and those attending follow-up for fur- +ther consultation (Table 2). When reminder letters and tele- +phone calls were feasible, the response was also encourag- +ing and suggested that these would be important adherence +management aids during the main trial. +Our attempts to provide IPT in a group format were again +not successful. Problems in finding mutually convenient +times and inadequate local transportation facilities made it +impossible to form ongoing groups of a minimum of 3-4 pa- +tients. However, while the health counselors were, with su- +pervision, able to confidently deliver IPT in an individual for- +mat, adherence remained a major challenge. Out of 12 pa- +tients who were offered IPT, only 7 (58%) attended the first +session, of whom only 2 completed all of the sessions. +Health counselors conducted a total of 7 yoga courses (5 +daily sessions each) in the selected primary health care cen- +tres: four of them were for the staff of the centres, while +three were conducted for patients and members of the local +community. All yoga courses were well attended and most +participants continued for the full 5 days of the course. +Data on the use of antidepressant medication (fluoxetine) +were collated across the formative and the pilot phases. Of +1753 patients who had screened positive, 598 (34.1%) were +prescribed fluoxetine. Of those who received the medica- +tion, only 148 (24.7%) returned for a repeat supply. This is +possibly an underestimate, because some patients pre- +scribed antidepressants in the later part of the phase are like- +ly renew their medication supply after the end of the colla- +tion of process indicators. +Of the 100 patients selected for the study of reasons for +adherence, 77 could be interviewed. The most frequent rea- +sons for not being interviewed were that the user was not at +home (61%) and the evaluation team did not have the cor- +rect address (22%). +The results of this study are reported in Tables 4 and 5. The +most frequently cited reason for not returning to meet the +health counselor was economic: patients were daily wage +earners and could not come to the clinic during the working +week. Other reasons for non-adherence included child care +obligations and annoyance with waiting for long periods to +see the doctor and health counselor. Feeling better after re- +ceiving and practicing treatments like the breathing exercise +was a reason for adherence. The importance of proactively +reminding patients to return for follow-up emerged as a key +factor influencing adherence. In contrast to the patients who +were adherent with treatment (three quarters of whom re- +ported the reminder as a reason for adherence), the major- +ity of non-adherent patients (61%) reported that they had +not been sent any reminders. Patients who were adherent +reported that one of the most important reasons for coming +back was that their problems were understood by the inter- +vention team, who talked to them in a sympathetic manner +within a confidential relationship. Adherent patients also +Table 3 Process indicators to monitor progress of MANAS inter- +vention +- The number/proportion of patients screened as having CMD who received the +first psychoeducation session +- The number/proportion of patients with moderate/severe CMD (based on +screening questionnaire score) who were started on step 2 treatments (antide- +pressant/interpersonal psychotherapy) on the initial visit +- The number/proportion of patients in the program who attended scheduled +follow-up appointments +- The number/proportion of patients receiving interpersonal psychotherapy +- The proportion of patients started on antidepressant who completed 3 months +of treatment +- The proportion of patients started on interpersonal psychotherapy who com- +pleted 6 sessions +- The number/proportion of patients who have been discharged from the pro- +gram +CMD – common mental disorder +IMP. 39-46 23-01-2008 17:10 Pagina 43 +44 +World Psychiatry 7:1 - February 2008 +reported being supported by the social network of their im- +mediate family, friends and other relatives. +Respondents in both the adherent and non-adherent +groups had adequate recall of the process of the program, +and there were few differences in the way they perceived the +acceptability of the interventions. For example, most re- +spondents identified the screening process as being useful +in helping them gain an understanding of their problems, +especially endorsing the concept of “tension”. The majority +of patients remembered the content of the initial psychoed- +ucation session with the health counselor, and reported that +advice on the breathing exercise, improving the quality of +sleep and diet problems was the most useful. Most adher- +ent patients appreciated that they had an active role to play +in getting better, which reinforced their sense of mastery +and control over their symptoms. +In conclusion, the principal outcome of the piloting +phase was the confirmation of the feasibility of the MAN- +AS intervention, in general, and of the adherence manage- +ment and supervision protocols, in particular. However, a +number of modifications were still needed: a) the inclusion +of an adherence management protocol in the initial assess- +ment of the patient, exploring possible risk factors for non- +adherence and guiding the development of a careful plan to +improve adherence at every step of the process of care de- +livery; b) replacing group IPT with individual IPT; c) con- +firming the use of yoga, in a course of 5 sessions delivered +over consecutive weekdays, as a component of the inter- +vention (since it was a culturally acceptable mental health +promotion activity, yoga could also improve the overall ac- +ceptability of the intervention); d) the use of structured sen- +tinel indicators to enable supervision and monitoring of the +program by the visiting psychiatrist. +DISCUSSION +To the best of our knowledge, this is the first systematic +effort in a low-income country to develop a complex inter- +vention for integrating the care of CMD into routine pri- +mary care. These studies were carried out prior to testing the +effectiveness of the MANAS intervention in a cluster ran- +domized trial. We used a three-phase method for the devel- +opment of the intervention. This method provided a sys- +tematic framework, while at the same time being sufficient- +ly flexible to ensure that outputs from each stage raised +questions and informed the design of the subsequent stage. +We believe that such preparation is critical in ensuring the +feasibility and acceptability of complex interventions, and +serves to identify a number of challenges which need to be +addressed before conducting an effectiveness trial. +Each of the three phases was a rich learning experience +and resulted in incremental improvements in the develop- +ment of the final intervention. We have been able to demon- +strate the need for such an intervention, by confirming that +about 12% of all primary care attendees are suffering from a +CMD. Although the final intervention protocol continues to +use the same specific treatments that we had originally en- +visaged, there have been a number of key modifications to +improve their feasibility and acceptability. Eight examples +are considered in this discussion. First, we had initially con- +ceptualized IPT as a group intervention with 8-12 sessions, +based on the evidence available from the trial in Uganda (8). +However, we discovered that the group format and number +of sessions were likely to be impractical in the social context +of primary care in Goa; thus, we have had to reformat the +IPT to be delivered in an individual format over 6 to 8 ses- +sions. Second, adherence management moved from being a +peripheral component of the intervention to becoming a +central feature, running across the intervention from the first +psychoeducation session onwards, with a proactive set of +strategies. Third, we had originally anticipated that the health +counselor would carry out both screening and delivery of +the intervention. This proved to be unfeasible and we added +an additional, low-cost, human resource (the health assis- +tant) to administer the screening instrument. Fourth, the +scope of the health counselors’ role expanded to include a +range of additional activities, such as managing adherence +and being a link between the health centre and existing re- +sources in the community. Fifth, we had anticipated no se- +Table 4 Commonly cited reasons for adherence with the MANAS +intervention (n=41) +- Felt problems were understood by doctor and health counselor +38 (92%) +- Belief in the beneficial effects of treatment +37 (90%) +- Confidence in the ability of doctor and health counselor to handle +problems +37 (90%) +- Felt better with treatment +36 (87%) +- Given an active role and hence a sense of control in treatment +33 (80%) +- Treated with empathy and respected by the team +32 (78%) +- Treatment for these problems was being provided in the centre +31 (75%) +- Flexible follow-up appointment given +30 (73%) +- Reminders sent for appointment (postcard/phone) +30 (73%) +- Treatment was provided free of charge +26 (63%) +- Family was supportive about practicing techniques like breathing +exercise at home +24 (58%) +- Ease of transport facilities +23 (56%) +- Family encouraged continuation of treatment +22 (53%) +- Family believed that subject has an illness that needs regular +consultation at health facilities +14 (34%) +- Short waiting period to meet the doctor and health counselor +13 (31%) +Table 5 +Commonly cited reasons for non-adherence with the +MANAS intervention (n=36) +- Engaged in work – cannot find time to get to treatment +18 (50%). +- Have become better and saw no need to follow-up +7 (19%). +- Caring for children or other family members +7 (19%). +- Long wait to meet the doctor and health counselor +6 (16%). +- Side effect of medication +3 (8.3%) +- Difficult transport facilities +3 (8.3%) +- Change in health status, i.e. developed other illness +3 (8.3%) +- Distance of home from clinic +2 (5.5%) +- Expense of transportation +2 (5.5%) +- Feeling worse since last consultation and did not feel advice +was useful +2 (5.5%) +- Family emergency +2 (5.5%) +IMP. 39-46 23-01-2008 17:10 Pagina 44 +45 +lection criterion for facilities, apart from consent of the fa- +cility. However, we accepted that the lack of a minimum pri- +vate space for the health counselor was a non-negotiable +criterion for a facility to be eligible. Sixth, the important role +of yoga was affirmed as a means to both promote mental +health and possibly destigmatize the MANAS intervention. +Seventh, we learnt that the intervention should have a run- +ning-in phase, during which the team employs a structured +mapping process to familiarize itself with the primary health +care centre and, thus, to identify and address potential phys- +ical and logistic barriers. Finally, the process indicators al- +lowed us to set realistic and appropriate targets for the deliv- +ery and monitoring of the intervention. +The preparatory phase also provided critical feedback re- +garding the content and structure of the training for the +team members, as well as the content and format of the ma- +terials used for the intervention. We have not described our +findings in detail in this paper due to space considerations, +but these are available from the authors. +We wish to re-emphasize the importance of a preparato- +ry phase as a crucial step before conducting clinical trials of +complex interventions in mental health. In our experience, +the MANAS intervention has been improved significantly, +at least in terms of its feasibility and acceptability, as a con- +sequence of this work. We hope that these modifications +will help enhance the overall effectiveness of the interven- +tion, currently being conducted in its first phase in 12 pri- +mary health care centres in Goa. +In conclusion, complex interventions for CMD are best +delivered by teams who are adequately skilled, motivated +and have in place structured supervision and strong leader- +ship to improve their practice. This involves a clear delin- +eation of the roles of each member of the team and mecha- +nisms to manage and resolve conflicts. The preparatory +phase has given us the opportunity to develop a framework +that will streamline the safety, quality and comprehensive- +ness of the subsequent program. +Acknowledgements +The MANAS project is entirely supported by the Wellcome +Trust through a senior clinical research fellowship awarded to +Vikram Patel. The project is implemented through a collabo- +ration between the London School of Hygiene and Tropical +Medicine and three Goan institutions: Sangath, the Direc- +torate of Health Services (Government of Goa) and the Vol- +untary Health Association of Goa. +References +1. Patel V +. The epidemiology of common mental disorders in South +Asia. NIMHANS Journal 1999;17:307-27. +2. Chisholm D, Sekar K, Kumar KK et al. Integration of mental health +care into primary care. Demonstration cost-outcome study in In- +dia and Pakistan. Br J Psychiatry 2000;176:581-8. +3. Lopez A, Mathers CD, Ezzati M et al (eds). Global burden of dis- +ease and risk factors. Washington: Oxford University Press and the +World Bank, 2006. +4. Ustun TB, Sartorius N (eds). Mental illness in general health care: +an international study. Chichester: Wiley, 1995. +5. Ormel J, Von Korff M, Ustun TB et al. Common mental disorders +and disability across cultures. Results from the WHO Collaborative +Study on Psychological Problems in General Health Care. JAMA +1994;272:1741-8. +6. Ustun T, Von Korff M. Primary mental health services: access and +provision of care. In: Ustun TB, Sartorius N (eds). Mental illness +in general health care: an international study. Chichester: Wiley, +1995:347-60. +7. Araya R, Rojas G, Fritsch R et al. Treating depression in primary +care in low-income women in Santiago, Chile: a randomised con- +trolled trial. Lancet 2003;361:995-1000. +8. Bolton P, Bass J, Neugebauer R et al. Group interpersonal psy- +chotherapy for depression in rural Uganda: a randomized con- +trolled trial. JAMA 2003;289:3117-24. +9. Patel V +, Chisholm D, Rabe-Hesketh S et al. Efficacy and cost-ef- +fectiveness of drug and psychological treatments for common men- +tal disorders in general health care in Goa, India: a randomised, +controlled trial. Lancet 2003;361:33-9. +10. Verdeli H, Clougherty K, Bolton P et al. Adopting group interper- +sonal psychotherapy for a developing country: experience in rural +Uganda. World Psychiatry 2003;2:114-20. +11. World Health Organization. Mental health: new understanding, +new hope. The world health report 2001. Geneva: World Health +Organization, 2001. +12. The Lancet Mental Health Group. Scale up services for mental dis- +orders: a call for action. Lancet (in press). +13. Bower P, Gilbody S, Richards D et al. Collaborative care for de- +pression in primary care. Making sense of a complex intervention: +systematic review and meta-regression. Br J Psychiatry 2006;189: +484-93. +14. Abas M, Baingana F, Broadhead J et al. Common mental disorders +and primary health care: current practice in low-income countries. +Harv Rev Psychiatry 2003;11:166-73. +15. Cohen A. The effectiveness of mental health services in primary +care: the view from the developing world. Geneva: World Health +Organization, 2001. +16. Petersen I. From policy to praxis: rethinking comprehensive inte- +grated primary mental health care. Unpublished PhD thesis, Uni- +versity of Cape Town, 2000. +17. Patel V +. Recognition of common mental disorders in primary care +in African countries: should “mental” be dropped? Lancet 1996; +347:742-4. +18. Patel V +., Andrade C. Pharmacological treatment of severe psychi- +atric disorders in the developing world: lessons from India. CNS +Drugs 2003;17:1071-80. +19. Linden M, Lecrubier Y, Bellantuono C et al. The prescribing of psy- +chotropic drugs by primary care physicians: an international col- +laborative study. J Clin Psychopharmacol 1999;19:132-40. +20. Saxena S, Sharan P, Garrido Cumbrera M et al. World Health Or- +ganization’s Mental Health Atlas 2005: implications for policy de- +velopment. World Psychiatry 2006;5:179-84. +21. Patel V +, Kirkwood BR, Pednekar S et al. Gender disadvantage and +reproductive health risk factors for common mental disorders in +women: a community survey in India. Arch Gen Psychiatry 2006; +63:404-13. +22. Patel V +, Kirkwood BR, Pednekar S et al. Risk factors for common +mental disorders in women. Population-based longitudinal study. +Br J Psychiatry 2006;189:547-55. +23. Patel V +, Kirkwood BR, Weiss H et al. Chronic fatigue in develop- +ing countries: population based survey of women in India. BMJ +2005;330:1190. +24. Ali BS, Rahbar MH, Naeem S et al. The effectiveness of counsel- +IMP. 39-46 23-01-2008 17:10 Pagina 45 +ing on anxiety and depression by minimally trained counselors: a +randomized controlled trial. Am J Psychother 2003;57:324-36. +25. Lara MA, Navarro C, Navarrete L et al. Seguimento a dos anos de +una intervencion psicoeducativa para mujeres con sintomas de de- +presion, en servicios de salud para poblacion abierta. Salud Men- +tal 2003;26:27-36. +26. Campbell NC, Murray E, Darbyshire J et al. Designing and evalu- +ating complex interventions to improve health care. BMJ 2007;334: +455-9. +46 +World Psychiatry 7:1 - February 2008 +IMP. 39-46 23-01-2008 17:10 Pagina 46 diff --git a/subfolder_0/Integrative Medicine as a Panpharmacon for COVID-19 Pandemic A Call for Global Advocacy.txt b/subfolder_0/Integrative Medicine as a Panpharmacon for COVID-19 Pandemic A Call for Global Advocacy.txt new file mode 100644 index 0000000000000000000000000000000000000000..aee97b08f457e6373a25d75a56150a4357ce38a7 --- /dev/null +++ b/subfolder_0/Integrative Medicine as a Panpharmacon for COVID-19 Pandemic A Call for Global Advocacy.txt @@ -0,0 +1,235 @@ +Commentary +Annals of Neurosciences +1–3 +© The Author(s) 2020 +Reprints and permissions: +in.sagepub.com/journals-permissions-india +DOI: 10.1177/0972753120950052 +journals.sagepub.com/home/aon + +The COVID-19 infection has become a pandemic with +no sight of standard therapy for cure. About 183,020 new +cases and 4,743 deaths were reported on June 21, 2020, +the International Day of Yoga (IDY).1 Although the virus +is appreciably less virulent given the lower fatality, it +remains catastrophic due to the huge population of India +thereby posing a threat to the public health and economy. +Interestingly, the global lockdown, as a mitigation strategy to +prevent spread of COVID-19, coincided with the sixth IDY’s +theme of “Yoga at Home, Yoga with Family.” Ironically, this +acted as a recourse to the vulnerable population, reeling under +increased cases of domestic violence and impending economic +crisis, experiencing unprecedented fear and anxiety, and +psychological stress. The current times are often termed as +the “generational challenge” of our era as even the health care +workers are overwhelmed by the gravity of the health crisis. At +this time, one of India’s largest Medical Institute, PGIMER, +Chandigarh, with its Journal Integrative Medicine Case +Reports,2 began to systematically broadcast the need, theory +and practice of mindfulness, Yoga and Ayurveda, through its +Facebook page “Yoga scholars PGIMER” with the help of +world experts for public and physicians, empowering both +with coping skills, resilience, and philosophy. This 3-month +continuous educational series culminated with Professor +Jagat Ram, Director, PGIMER announcing the plenary talk +by Dr David Frowley on the occasion of PGI’s IDY 2020. +This session, which was broadcasted from Department of +Telemedicine’s server, sought to profile the “Common Yoga +Protocol” approved by Ministry of AYUSH. Dr Frowley gave +an inspiring talk on “Yoga and Ayurveda Psychology,” which +was well attended by faculty, residents, staff, and students +within and outside Chandigarh. This set the tone of paradigm +shift in the manner in which the practice of Medicine has so +far been perceived and practiced. Insights of this development +are presented in the following commentary. + +Interplay Between Risk Reduction of +COVID-19 and Traditional Medicine + +Health can be expounded as a holistic well-being achieved +by maintaining the physical, mental, social, and spiritual +homeostasis as referenced by Tiattiriya Upanishad,3 which +was later redefined by WHO as “ONE” health paradigm, +aptly cited by Professor Jagat Ram in his IDY 2020 welcome +address. The unprecedented infection caused by severe +acute respiratory syndrome coronavirus 2 (SARS-CoV-2) +has deteriorated both physical and mental health added +with the economic crisis. Preliminary studies have reported +an intensified fatality of those nursing noncommunicable +diseases (NCDs), including cardiovascular diseases, diabetes +mellitus, respiratory diseases, and cancer.4 At the same time, +the current situation of social isolation, complete/partial +lockdown, restricted travel, coupled with closure of community +resources, has entailed faulty dietary habits, physical +inactivity, paradigm shift in the psychosocial relations, poor +health monitoring further exacerbating the existing NCDs +that might increase its incidence and prevalence in future. +Temporary halt in the activities of preventive medicine and +rehabilitation departments has further brought rehabilitation +of NCDs to a grinding halt. Physical activity in the current +situation is confined to indoors and requires resources, +which itself is a barrier for individuals living in the low- and +middle-income countries. In this context, advocacy for ONE +health paradigm alluded in the PGI’s IDY deliberations call +for an urgent need for installation of Integrative Medicine +(IM). This may foster evidence-based physical, spiritual, and +psychological well-being of not only the health care workers +but also patients. + +Unequivocally, the trends of NCDs will be heightened +in the aftermath of COVID-19 outbreak and may cumber +the path of achieving the sustainable development and +reduction of premature death goals set by the World Health +Organization (WHO).5 Thus, there is an acute need of holistic +mind-body medicine system not only because of current +health policy but also as an emergent need in response to +achieving postpandemic solutions. +1 +Center for Integrative Medicine and Research, All India Institute of Medical +Sciences, New Delhi, India. +2 +S-VYASA, Prashanti Kutiram, Bangalore, Karnataka, India. +3 +Department of Biophysics, PGIMER, Chandigarh, India. +Corresponding author: +Sriloy Mohanty, Center for Integrative Medicine and Research, All India +Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India. +E-mail: sriloy21@gmail.com + +Integrative Medicine as a Panpharmacon +for COVID-19 Pandemic: A Call for Global +Advocacy + +Sriloy Mohanty1 +, Amit Singh2, and Promod Avti3 +2 +Annals of Neurosciences +Integrative Medicine (IM) for ONE Health +IM brings conventional and complementary approaches +together in a coordinated fashion such that it is grounded in +the definition postulated by WHO, addressing the full range +of physical, psychological, social, and spiritual well-being of +a person’s health. Yoga, a composite ancient Indian technique +can aid in achieving wellness, harmony, and social order. +It is gaining popularity as a major component of IM across +the globe. Professor Jagat Ram cited Tiattiriya Upanishad, +explaining the concept of Panchkosha as a narrative of mind- +body connection, pointing out that the “mind-body medicine” +being the proposed Joint flagship program of Ministry of +AYUSH and MOHFW, New Delhi. He even quoted from +second sutra of Patanjali’s yoga sutras6 the Yoga Chitta Vritti +Nirodhah arguing that Yoga provides the tools and techniques +to alleviate the perturbations of the mind. “If mental +perturbations remain unaddressed, chronic psychological +and psychosomatic disorders might follow,” he mentioned, +indicating the manner in which practice of medicine has to +transform itself. It is well known that yoga and mindfulness +interventions not only improve psychological health by +reducing stress, anxiety, and depressive symptoms7 but it may +also enhance the lung capacity if practiced under supervision. +Professor Ram’s advocacy for Yoga’s integration with the +conventional medicine bridges the chasm that had prevented +the harmonization of physical, spiritual, and psychological +health. His vision that this may reduce the risks associated +with age and comorbidities in a cost-effective manner, +earlier advocated by Ministry of AYUSH, was never flagged +effectively as evident from his welcome address on IDY 2020. +Integrative Medicine for Knowledge +Economy +WHO’s global action plan for the prevention of +noncommunicable +diseases +advocates +harnessing +the +potential of traditional and complementary therapies +because of their potentially lower costs and greater cultural +acceptability. India’s potential in acquiring global leadership +in IM is inspired by the known susceptibility of the vulnerable +population to COVID-19. Professor GD Puri’s concluding +remarks on the aforementioned PGI’s IDY program that not +only acknowledged David Frowley’s Yoga and Ayurveda +Psychology prescription for post COVID-19 era but also +qualified it by highlighting the abundant evidence that +showed how neurochemicals influence disease and health +outcome. It is also writ large that having practices of such +integrative methods could be one of the effective ways of +handling unexpected and unwarranted pandemic situations. +PGI’s IDY advocacy paves the way for national framework +of “Integrative Medicine Departments” in the country, as +alluded by Professor Jagat Ram. All India Institute of Medical +Sciences (AIIMS), New Delhi, has already established the +Center for Integrative Medicine and Research (CIMR) with +support of Ministry of AYUSH, and able guidance of Dr HR +Nagendra, the Chancellor of S-VYASA. The new AIIMS +units have followed suit. Other institutions like NIMHANS, +Medanta, Manipal University have already taken early lead +providing an inclusive and collaborative environment for +mutual learning, research, and clinical practice. The model +of IM calls for a new paradigm of integration, ranging from +active participation of funding agencies like Department +of Biotechnology (DBT), Council for Scientific and +Industrial Research (CSIR) to educational reforms by the +University Grants Commission (UGC) and National Medical +Commission (NMC) to installation of appropriate governing +bodies and deans of mentor institutions. This will ensure that +evidence-based integration is entrepreneurial, sustainable, and +caters to knowledge economy by integrating the technology +component of IM. +Author’s Contribution +Conceptualization was done by Sriloy Mohanty and Amit Singh. +Methodology was done by Pramod Avti and Sriloy Mohanty. Vali- +dation was done by Amit Singh and Pramod Avti. Resources were +done by Pramod Avti and Sriloy Mohanty. Writing—original draft +preparation was done by Sriloy Mohanty. Writing—review and ed- +iting was done by Pramod Avti and supervision was done by Amit +Singh. All authors have read and agreed to the published version of +the manuscript. +Declaration of Conflicting Interests +The authors declared no potential conflicts of interest with respect to +the research, authorship, and/or publication of this article. +Funding +The authors received no financial support for the research, +authorship, and/or publication of this article. +ORCID iDs +Sriloy Mohanty + https://orcid.org/0000-0001-6981-9178 +Promod Avti + https://orcid.org/0000-0001-5603-4523 +References +1. +Romanov +BK. +WHO +situation +report: +coronavirus +disease COVID-2019. Vol. 8. Geneva: WHO, 2020. +DOI:10.30895/2312-7821-2020-8-1-3-8 +2. +Anand A. J Integr Med Case Rep Published http://jimcr.com/. +(2020, accessed June 28, 2020). +3. +Gambhirananda S. Taittiriya Upanishad. Howrah: Advaita +Ashrama, 2010. +Mohanty et al. +3 +4. +Wu Z and McGoogan JM. Characteristics of and important +lessons from the coronavirus disease 2019 (COVID-19) +outbreak in China. JAMA 2020; 323(13): 1239–1242. +DOI:10.1001/jama.2020.2648 +5. +World Health Organization. NCD deaths—probability of dying +between 30 and 70 years from one of the 4 main NCDs, %, +2012*. In Global NCD target reduce premature deaths from +NCDs. Geneva: WHO, 2016. +6. +Saraswati SS. Four chapters on freedom: commentary on the +Yoga Sutras of Patanjali. Bihar: Yoga Publication Trust, Bihar +School of Yoga, 2008. +7. +Tellhed U, Daukantaitė D, Maddux RE, et al. Yogic breathing +and mindfulness as stress coping mediate positive health +outcomes of yoga. Mindfulness (N Y) 2019; 10(12): 2703– +2715. DOI:10.1007/s12671-019-01225-4 diff --git a/subfolder_0/Job satisfaction, job stress and psychosomatic health problems in software professionals in India_unlocked.txt b/subfolder_0/Job satisfaction, job stress and psychosomatic health problems in software professionals in India_unlocked.txt new file mode 100644 index 0000000000000000000000000000000000000000..c11bbf9ea874fec42cff3e2d70263eeb506e1ec9 --- /dev/null +++ b/subfolder_0/Job satisfaction, job stress and psychosomatic health problems in software professionals in India_unlocked.txt @@ -0,0 +1,926 @@ +153 +Indian Journal of Occupational and Environmental Medicine - December 2014 - Volume 18 - Issue 3 +153 +Job satisfaction, job stress and +psychosomatic health problems in +software professionals in India +Sahukar Madhura, +Pailoor Subramanya, +Pradhan Balaram +Swami Vivekananda +Yoga Anusandhana +Samsthana, Bengaluru, +Karnataka, India +For correspondence: +Ms. Sahukar Madhura, +Sorab Road, Anavatti, +Shivamoga Dist, Kar- +nataka, +India - 577 413. +Email: csmadhura@ +gmail.com +INTRODUCTION +Hundreds of research studies have been conducted on the +stress associated with job satisfaction and jobstress working +in various occupations around the world. Studies on muscular +skeletal disorders in information systems occupation has also +been studied around the world and also in Indian computer +professionals. Individual Spirituality at Work and Its Relationship +with Job Satisfaction has been studied among sales professionals. +However, the effect of spirituality (recent growth in the field +of Yoga) on job satisfaction, stress, and health in software +professionals in India has not been included in these studies. +Retaining an adequate and qualified workforce is a prerequisite +for a well‑functioning organization, but is sometimes difficult +to realize when conditions, such as a good economic situation, +a tight labor market and an aging workforce, tend to increase +the turnover of the workforce. It can be hypothesized that +job satisfaction could function as a buffer against conditions +favoring a high turnover, because a small but significant +relationship exists between a low level of job satisfaction +and turnover. Moreover, job satisfaction could also buffer +against other negative influences in the workplace, such as +occupational stress. For these reasons, attention paid to job +satisfaction of employees may prevent staff shortages in the +future and may even cut costs. +Several studies have tried to +determine the link between stress +and job satisfaction. Job satisfaction +and job stress are the two hot focuses +in human resource management +researches. It has a direct impact in +employee’s health and consequently +impacts work performance. Stress +leads to psychosomatic disorders +such as asthma, diabetes mellitus, +back pain, hypertension, anxiety and +depression and arthritis. These are +referred as Adhija Vyadhi in yogic +texts. Most of the software engineers +suffer from back pain, eye disorders, +headache, breathing problems and +so on. Indian software professionals +are exposed to the new culture of +work, employment, organization, +and management. With globalization, +there are transformations in their +lifestyle, sociality, and identity. At +the same time, most Indian software +professionals have the strong +influence of Indian culture and values. +Many software professionals have +realized the impact of change in their +lifestyle and its implications, which +has attracted them to yoga and other +spiritual practices. The aim is to +analyze the impact of these practices +on job satisfaction, stress, and health +of software professionals. +LITERATURE REVIEW +Review of studies on job +satisfaction and stress +Stress, Job Satisfaction, and Customer +Satisfaction in a Transport Company +has been examined[1] and the results +show that there is an opposite +relationship of stress and job +satisfaction among bus hostesses. +This negative relationship ultimately +Access this article online +Website: www.ijoem.com +DOI: +10.4103/0019-5278.146917 +Quick Response Code: +Abstract +This questionnaire based study investigates correlation +between job satisfaction, job stress and psychosomatic +health in Indian software professionals. Also, examines +how yoga practicing Indian software professionals cope +up with stress and psychosomatic health problems. +The sample consisted of yoga practicing and non-yoga +practicing Indian software professionals working in +India. The findings of this study have shown that there is +significant correlation among job satisfaction, job stress +and health. In Yoga practitioners job satisfaction is not +significantly related to Psychosomatic health whereas +in non-yoga group Psychosomatic Health symptoms +showed significant relationship with Job satisfaction. +Key words: Job satisfaction, job stress, psychosomatic +health, Indian software professionals, yoga, psychological +stress, occupational stress +Brief +Communication +[Downloaded free from http://www.ijoem.com on Friday, July 29, 2016, IP: 14.139.155.82] +Sahukar, et al.: Job satisfaction and Indian software professionals +154 +Indian Journal of Occupational and Environmental Medicine - December 2014 - Volume 18 - Issue 3 +154 +effects the customer satisfaction. The study of relationship +between employee motivation, job satisfaction and corporate +culture in marketing Research Company in South Africa[2] +found linear relationships. A  study has been made on +association between job stress, social support, job satisfaction, +and absenteeism among offshore oil personnel.[3] Results +of the study of relationship between Job Stress and Job +Satisfaction among University Staff in Malaysia[4] show a +negative relationship between the two. +A survey of job satisfaction, sources of stress, and psychological +symptoms among general practitioners in Leeds[5] has +identified low job satisfaction and significant problems in +the physical and mental wellbeing of general practitioners. +Findings of examination of employee’s Work Stress, Job +Satisfaction, and Organizational Commitment among Public +Employees before Privatization[6] indicate that satisfied and +committed workforce is not a guarantee to have low level of +work stress and vice versa. +Review of studies on factors of job satisfaction +There have been studies on various factors such as age, salary, +and physiological and psychological stress, which impact job +satisfaction. +The findings of the study “the effect of age on occupational +stress and job satisfaction among managers of different age +groups,”[7] reveals higher levels of job stress and less job +satisfaction among managers of 25–35 years age than their +counterparts in the middle age (36–45 years) and the old +age groups (46–55 years). The study also found that the age +found to be negatively correlated with occupational stress +and positively with job satisfaction. A study has examined +the relationship between physiological stress and job +satisfaction and the relationship between psychological stress +and job satisfaction.[8] Statistically, the result demonstrates +that the level of physiological stress has decreased job +satisfaction, and the level of psychological stress has not +decreased job satisfaction. Furthermore, the study confirms +that occupational stress does act as a partial determinant +of job satisfaction in the occupational stress models of the +organizational sector sample. +A study explored the relationship among job performance, +satisfaction, and stress: A conceptual framework of Malaysian +higher learning institutions,[9] which provides some ideas +on how these three theories or relationships will influence +one another. There are three suggestions highlighted here. +The first is that lower level of job stress will lead to a higher +level of job satisfaction and job performance among the +employees. Second is a greater emphasis on a higher level +of job satisfaction, such as lower level of job stress will lead +to a better employee’s job performance. Finally, these are +the vital roles played by the proposed moderators in each +of the relationships in the quest to enhance employee’s +job performance, which will ultimately lead to an improved +organizational performance. +Review of Studies on Health +A study investigated occupational stress, Type A behavior +pattern, work attitudes, health symptoms, and health +behaviors among information systems personnel[10] Type A +behavior pattern was found to be a significant moderator +for some of the stressor–criterion associations. The findings +suggest that more managerial understanding of person– +environment fit in general and the individual employee’s +predisposition toward the Type A behavior pattern specifically +may be beneficial in attempting to initiate, nurture, and sustain +a productive and healthy work atmosphere. +Stress causing psychosomatic illness has been examined +among nurses[11] and results imply psychosomatic disorders, +such as acidity, back pain, stiffness in neck and shoulders, +forgetfulness, anger, and worry, significantly increased in +nurses having higher stress scores. +Review of studies on Indian software professionals +A Comparative Analysis of Stress and Management Problems +with Reference to Gujarat State has been done,[12] which +proves a positive correlation between stress and managerial +problems. “Role stress among women in the Indian +information technology sector”[13] investigates the intensity +of organizational role stress among women informational +technology professionals in the Indian private sector. The +research finds differences in the level of stress between +married and unmarried employees on several role stressors. +However, level of education does not emerge as a significant +differentiator of stressors. +The impact of different dimensions of pay satisfaction‑related +issues of software professionals in India on intent to leave has +been explored.[14] +Review of studies on Indian software professionals +and health +A study on Occupational Stress and Psychological Fitness in +Information Technology Sector in Mumbai Area[15] reveals that +occupational stress affects the mental fitness of employees +working in the IT sector and creates hazard for organizational +and employee productivity. However, no statistical techniques +are used to analyze the data. The findings recorded are +mere assumptions/perceptions of the respondents about +relationship between corporate stress and psychological +fitness. +An examination of Work style Risk Factors for Work Related +Musculoskeletal Symptoms among Computer Professionals +[Downloaded free from http://www.ijoem.com on Friday, July 29, 2016, IP: 14.139.155.82] +Sahukar, et al.: Job satisfaction and Indian software professionals +155 +Indian Journal of Occupational and Environmental Medicine - December 2014 - Volume 18 - Issue 3 +155 +in India[16] concluded that Work style seems to be a mediating +factor for musculoskeletal pain, discomfort, and loss of +productivity. +The Effect of New Technologies on Job Satisfaction and +Psychosomatic Complaints[17] investigated the effects of +new technologies, specifically visual display units, on +psychosomatic complaints and job satisfaction. Attention +was focused on the influences of the work situation (job +contents, employee participation) of attitudes and individual +differences. +Review of studies on the impact of Indian culture +and spirituality +The results of “Exploratory study among sales professionals’ +individual spirituality at work and its relationship with job +satisfaction, propensity to leave, and job commitment[18] reveal +that sales professionals’ spirituality at work is positively +related to job satisfaction and job commitment, and negatively +related to propensity to leave. +The study paper “Work, culture, and sociality in the Indian +IT industry: A sociological study,”[19] documented the social +and cultural transformations that have been set in motion +by the rapid growth of the IT and ITES industries in India, +and through this to shed some light on wider processes of +globalization. The study focused on the creation of the IT +workforce; the new forms of work, employment, organization, +and management, and the new cultures of work that have +emerged in this industry, and on the transformations in +lifestyle, sociality, and identity that are taking place within +this new global workforce. +A qualitative Research on Advantages of Vipassana Meditation +on Psychosomatic, Professional, and Managerial development +of Business Graduates[20] concludes that Vipassana Meditation +Process has high importance in orientation of students with +better physique, psychosocial state that helps them to become +good professionals with focused managerial aptitude. +As one gets more and more established in the practice of +meditation, there are fewer mental problems, and even +psychosomatic disorders such as hypertension, peptic +ulcer, irritable bowel syndrome, asthma, and eczema get +ameliorated Dileep Kumar M. (2005). Vipassana meditation, +therefore, leads to better health and a happy, blissful mind. +There is less mental tension and confusion, and with such +a clear and calm mind, one is able to deal easily with one’s +problems, thus living a merry and joyful life. +A study on workplace spirituality, organizational emotional +ownership, and job satisfaction as moderators in coping with +job stress[21] in information technology professionals in India +revealed that workplace spirituality, organizational emotional +ownership, and job satisfaction are negatively correlated with +job stress. The study also found that workplace spirituality +emerged as the strongest predictor to cope up with job stress. +AIMS AND OBJECTIVES +Aims of the study +• To study the relationship between job satisfaction, job +stress, and health in Indian software professionals +• To compare job satisfaction, stress, and health between +yoga practicing and non–yoga practicing Indian software +professionals group. +Rationale for selecting the variables studied +Job Satisfaction +Retaining an adequate and qualified workforce is a prerequisite +for a well‑functioning organization, but is sometimes difficult +to realize when conditions, such as a good economic situation, +a tight labor market, and an aging workforce, tend to increase +the turnover of the workforce. It can be hypothesized that +job satisfaction could function as a buffer against conditions +favoring a high turnover, because a small but significant +relationship exists between a low level of job satisfaction +and turnover. Moreover, job satisfaction could also buffer +against other negative influences in the workplace, such as +occupational stress. For these reasons, attention paid to job +satisfaction of employees may prevent staff shortages in the +future and may even cut costs. +Stress +Several studies have tried to determine the link between stress +and job satisfaction. Job satisfaction and job stress are the +two hot focuses in human resource management researches. +It has a direct impact in employee’s health and consequently +impacts work performance. +Psychosomatic Ailments +Stress leads to psychosomatic disorders such as asthma, +diabetes mellitus, back pain, hypertension, anxiety and +depression, and arthritis. These are referred as Adhija Vyadhi +in yogic texts. Most of the software engineers suffer from back +pain, eye disorders, headache, breathing problems, and so on. +Software Professionals In India +Indian software professionals are exposed to the new culture +of work, employment, organization, and management. With +globalization there are transformations in their lifestyle, +sociality, and identity. At the same time most Indian software +professionals have the strong influence of Indian culture and +values. +Yoga And Other Spiritual Practices +Many software professionals have realized the impact of +change in their lifestyle and its implications, which has +[Downloaded free from http://www.ijoem.com on Friday, July 29, 2016, IP: 14.139.155.82] +Sahukar, et al.: Job satisfaction and Indian software professionals +156 +Indian Journal of Occupational and Environmental Medicine - December 2014 - Volume 18 - Issue 3 +156 +attracted them to yoga and other spiritual practices. The aim +is to analyze the impact of these practices on job satisfaction, +stress, and health of software professionals. +Hypothesis +• Hypothesis 1: There is a negative correlation between job +satisfaction and job stress +• Hypothesis 2: There is a positive correlation between job +satisfaction and health +• Hypothesis3: There is a negative correlation between job +stress and health +• Hypothesis 4: There is a relationship between spiritual +practices and job satisfaction +• Hypothesis 5: There is a relationship between spiritual +practices and job stress +• Hypothesis 6: There is a relationship between spiritual +practices and health. +MATERIALS AND METHODS +Sample +Indian software professionals living in Bengaluru, India, +working with various companies in Bengaluru were randomly +selected. Online survey questionnaire was sent to 320 +people. One hundred and forty‑one (44%) people completed +the questionnaire and responded. One hundred and two +respondents (72.3%) were male and 39 respondents (27.7%) were +female. The mean age of the responders was 30 years (standard +deviation = 5.19 years, range 21–years). +Inclusion Criteria +Indian software professionals in the age group 20–55 years +living and working in Bengaluru, India, were included. Both +service‑based and product‑based company professionals +were included. +Exclusion Criteria +Subjects from India but living and working abroad were +excluded. +Ethical Considerations +To maintain ethical neutrality, details about the company +are not published. Confidentiality is assured as part of the +research process. +Design of the Study +A cross‑sectional survey design was used. Email questionnaire +survey of software professionals in Bangalore, India, was +done. The main outcomes of measures include quantitative +measures of job satisfaction, job stress, psychosomatic +health symptoms, and effect of yoga and Indian culture. +Measures +Job satisfaction was measured using general job satisfaction +survey questionnaire having 10 questions with five‑point +Likert scale to rate dimensions of job satisfaction. The total +score was made by adding the items. A high score indicated +higher job satisfaction. Cronbach’s alpha = 0.864. A detailed +job satisfaction questionnaire is available in Appendix 1. +Job stress was measured using a tailor‑made questionnaire +for symptoms of job stress, which included 16 questions with +five‑point Likert scale to rate dimensions of job stress. Total +score was made by adding the items. A high score indicated +higher job stress. Cronbach’s alpha = 0.903. Detailed job +stress questionnaire is available in Appendix 2. +Psychosomatic health symptoms Questionnaire was designed +with five‑point scales of symptom severity. A detailed health +symptoms Questionnaire is available in Appendix 3. Total +score was made by adding the items. +Questions related to the belief in God, leisure activities (visits +to temples, charity work, meeting family friends, bhajans, +and so on). Type of any practices such as yoga, meditation +techniques, or relaxation techniques were asked. Software +professionals who practiced one or more of yoga practices +among asanas, pranayama, breathing awareness, meditation, +and any relaxation techniques were grouped as yoga group. +Similarly, those who spend their leisure time with one or +more spiritual activities among reading books on philosophy +and/or religion, participate in Bhajans or Satsang, visiting +temples or pilgrimage, charity work or selfless service or +helping the needy, and meditation were grouped as spiritual +leisure group. +Data analysis +The data analysis was carried out with the SPSS 18.0 program. +First, descriptive statistics (eg, means, standard deviations, +and mode) were used to explore the data. +Normality of Data—This study involves a relatively large +sample (141) and therefore, the Central Limit Theorem could +be applied and hence there is no question on normality of +the data. +Reliability—Cronbach’s alpha coefficients (α) were used +to assess the internal consistency of the measuring +instruments[22] for job satisfaction and job stress. +Correlation—Pearson’s product–moment correlation +coefficients were used to specify the relationships between +the variables. +Independent sample t test was used to compare yoga and +nonyoga group scores on variables. The differences among +yoga and nonyoga software professionals on job satisfaction, +job stress and health variables were investigated through +[Downloaded free from http://www.ijoem.com on Friday, July 29, 2016, IP: 14.139.155.82] +Sahukar, et al.: Job satisfaction and Indian software professionals +157 +Indian Journal of Occupational and Environmental Medicine - December 2014 - Volume 18 - Issue 3 +157 +independent sample t test. Also, differences of variables on +spiritual leisure activity and nonspiritual leisure activity were +calculated through independent sample t test. +RESULTS +One hundred and forty‑one people completed the questionnaire +and responded (44%). One hundred and two respondents (72.3%) +were male and 39 respondents  (27.7%) were female. +The mean age of responders was 30  years  (standard +deviation = 5.19 years, range 21–51 years). +One hundred and twenty‑one people believed in the existence +of God or supreme Power (85.8%). Twenty (20) people did not +believe in God (14.2%). +Acceptable Cronbach’s alpha coefficients were obtained +on all measuring instruments. Cronbach’s alpha for the +questionnaires used are in table 1. +Hypotheses 1, 2, and 3 results +Pearson’s product moment correlation coefficients are listed +in table 2. +• Hypothesis 1 Job stress showed significant negative +relationship with job satisfaction (t = −0.486, N = 141, +P = 0.001). That means that employees who were more +satisfied with their organization are less stressed. The +ability to cope with stress and meeting the challenges of +this competitive business environment can be enhanced +by increasing job satisfaction +• Hypothesis 2 Psychosomatic health symptoms score +showed significant negative relationship with job +satisfaction (r = −0.328, N = 141, P < 0.001). That +means employees who were more satisfied scored less +psychosomatic health symptoms score, which means +they were healthier. Psychosomatic ailments are better +managed with increased job satisfaction +• Hypothesis 3 J o b s t r e s s s h o w e d s i g n i f i c a n t +positive relationship with Psychosomatic Health +symptoms (r = 0.506, N = 141, P = 0.000). With increased +job stress, employees showed higher psychosomatic +health symptoms score. +Hypotheses 4, 5, and 6 results +Tables 3 and 4 provide descriptive statistics for the two pair +of groups that were compared. +Yoga Group Versus Nonyoga Group +Seventy‑six respondents were in the yoga group (54%) and 65 +were under nonyoga group (46%). +• Hypothesis 1 Both in yoga group and nonyoga group, +job stress showed significant negative relationship +with job satisfaction (yoga group r = −0.369, N = 76, +P  <  0.01 and nonyoga group r =  –.596, N  =  65, +P < 0.01). However, mean of job satisfaction score of +yoga group (33.23) is slightly higher than the nonyoga +group (31.41) +• Hypothesis 2 In yoga group, job satisfaction is not +significantly related to psychosomatic health (r = –0.188, +N = 76, P > 0.01), whereas in nonyoga group stress +psychosomatic health symptoms showed significant +relationship with job satisfaction (r = −0.445, N = 65, +P < 0.01). That possibly means psychosomatic disorders +are well managed in yoga group irrespective of job +satisfaction +• Hypothesis 3 Job stress showed significant positive +relationship with psychosomatic health symptoms in +both yoga (r = 0.554, N = 76, P < 0.01) and nonyoga +groups  (r  =  0.433, N  =  65, P  <  0.01). However, +psychosomatic health symptoms score in yoga +group (4.59) is slightly lesser than that in the nonyoga +group (6.26) +• Hypothesis 4 There was no significant difference +between the two groups on job satisfaction (f = 0.159, +P  =  0.690). Also, the mean of job satisfaction score +of yoga group (33.23) is slightly higher than nonyoga +group (31.41) +• Hypothesis 5 t Test showed that yoga practice found +to have significant difference in job stress (f = 0.585, +P = 0.446). That means yoga group were coped up with +stress better than nonyoga group +• Hypothesis 6 t‑  Test showed that yoga found to +have significant difference in psychosomatic health +symptoms (f = 4.217, P = 0.042). That means psychosomatic +ailments are managed better with yoga. +DISCUSSION +A moderate level of stress or “Eustress” is an important +motivating factor and is considered normal and necessary. +If stress is intense, continuous, and repeated, it becomes +a negative phenomenon or “Distress,” which can lead +to physical illness and psychological disorders.[23] +Matter‑based approach and increased dependency on +science and technology for modern lifestyle among +software professionals has increased stress, which is +expressed as social unrest, increasing health hazards, +and so forth.[24] +This study of stress level and job satisfaction among Indian +software professionals confirms the negative correlation +between job stress and job satisfaction. This result is +consistent with similar studies by Ahsan et  al. among +University Staff in Malaysia, study by Ismail, et al. (2009) +in Malaysia,[8] Roos and Van Eeden (2008), and a study by +Appleton et al. (1998). +[Downloaded free from http://www.ijoem.com on Friday, July 29, 2016, IP: 14.139.155.82] +Sahukar, et al.: Job satisfaction and Indian software professionals +158 +Indian Journal of Occupational and Environmental Medicine - December 2014 - Volume 18 - Issue 3 +158 +This study evaluated relationship between psychosomatic +health symptoms and job satisfaction and seen significant +relationship between the two. +Psychosomatic health symptoms showed a positive correlation +with job stress. This result is in consistent with earlier +research by Kane (2009) titled “Stress causing psychosomatic +illness among nurses in India.” Increasing stress and lesser job +satisfaction can negatively influence software professionals’ +emotional and physical health. +Stress management techniques can help individuals +manage their physical and emotional health. A study by +Chawla, et al. (2010) shows a positive relationship between +job satisfaction and spirituality at work among sales +professionals, which provide the relevance of spirituality at +work to salespeople. Kumar’s[20] study reveals the importance +of Vipassana meditation to orient the students with better +physique and psychosocial state that helps them to become +good professionals with focused managerial aptitude. +Yoga being holistic approach for stress management not +only brings fitness and vigor to the physical body but also +harness our emotions and expands our power of insight, +vision, and analysis.[24] The main focus of this study was +to evaluate the influences of yoga, spiritual and cultural +aspects of Indians on job satisfaction, job stress, and +psychosomatic health. +In the nonyoga group, job satisfaction, stress, and +psychosomatic symptoms were correlated. In the yoga group, +job stress showed significant negative relationship with job +satisfaction and positive correlation with psychosomatic +health symptoms. However, yoga group showed no significant +relationship between job satisfaction and psychosomatic +health symptoms. Also, yoga group scored significantly low in +job stress and health compared with nonyoga group. Further +study needs to be carried out with a detailed questionnaire, +which evaluates various factors of yoga practicing such as +the duration and frequency, the techniques practiced, and +mindfulness during working hours and leisure activities, +spiritual aspects, belief, and values to determine which +factors of yoga have a relationship with job satisfaction. +CONCLUSION +The study was set out to explore the correlation among job +satisfaction, job stress, and health and to compare yoga +and nonyoga practicing groups score of job satisfaction, job +stress, and health. The study also sought to know how the +Indian spirituality influences these parameters. The study +sought to answer the following questions: +1. Does job satisfaction have an impact on job stress and +psychosomatic health? +2. Does yoga have an impact on job satisfaction? +3. Do software professionals practicing yoga cope better with +stress and have better health? +The findings of this study have shown that there is a +significant correlation among job satisfaction, job stress, +and health. Job stress is negatively related to health and +job satisfaction. Software professionals with higher job +satisfaction scored less job stress score and psychosomatic +ailments score. +This study found out that yoga did not show a significant +impact on job satisfaction. However, in yoga practitioners, +job satisfaction is not significantly related to psychosomatic +health, whereas in the nonyoga group psychosomatic +health symptoms showed a significant relationship with +job satisfaction. That means psychosomatic disorders are +well managed in yoga practicing software professionals +irrespective of job satisfaction. +The yoga group had scored significantly lower in job +stress and psychosomatic symptoms score compared +with the nonyoga group. That implies yoga is a tool for +software professionals to cope up with their stress and +psychosomatic disorders. +This study encountered limitations in assessing spiritual +beliefs of Indian software professionals. The study could +not evaluate impact of spiritual leisure activities. Influence +of confounding variables were not controlled. The study +considered practices among asana, pranayama, breath +awareness, meditation and any relaxation techniques. +Further work needs to be done to look into other aspects +of yoga practicing, including duration and frequency of the +techniques practiced and mindfulness during working hours +and leisure activities, spiritual aspects, belief and values. +Taken together, this study recommends software professionals +to manage their stress and health by practicing yoga. +REFERENCES +1. +Malik MI, Safwan MN, Sindhu AG. Examining Stress, Job Satisfaction +and Customer Satisfaction in a Transport Company‑A Case from +Pakistan. Int J Bus Soc Sci 2011;2:81‑5. +2. +Roos  W, Van Eeden  R. The Relationship between Employee +Motivation, Job Satisfaction and Corporate Culture. S Afr J Ind Psychol +2008;1:54‑63. +3. +Ulleberg P, Rundo T. Job stress, social support, job satisfaction and +absenteeism among offshore oil. Work Stress 1997;11:215‑28. +4. +Ahsan N, Abdullah Z, Gun Fie DY, Shah Alam S. A Study of Job Stress +on Job Satisfaction among. University Staff in Malaysia: Empirical +Study. Eur J Soc Sci 2009;8:121‑31. +5. +Appleton K, House A, Dowell A. A survey of job satisfaction, sources +of stress and psychological symptoms among general practitioners in +Leeds. Br J Gen Pract 1998;48:1059‑63. +[Downloaded free from http://www.ijoem.com on Friday, July 29, 2016, IP: 14.139.155.82] +Sahukar, et al.: Job satisfaction and Indian software professionals +159 +Indian Journal of Occupational and Environmental Medicine - December 2014 - Volume 18 - Issue 3 +159 +6. +Bytyqi F, Reshani V, Hasan V. Work Stress, Job Satisfaction and +Organizational Commitment among Public Employees before +Privatization. Eur J Soc Sci 2010;18:156‑62. +7. +Chandraiah K, Agrawal SC, Marimuthu P, Manoharan N. Occupational +Stress and Job Satisfaction among Managers. Indian J Occup Environ +Med 2003;7:6‑11. +8. +Ismail A, Yao A, Yunus. Relationship between Occupational Stress +and Job Satisfaction: An Empirical Study in Malaysia. The Romanian +Economic Journal 2009;34:3-30. +9. +Ma VA, Koh  HW, Kuek. Exploring the relationship among Job +Performance, Satisfaction and Stress: A Conceptual Framework of +Malaysia Higher Learning Institutions. 2nd International Conference on +Management Proceeding: 2012. 346‑57. +10. +Ivancevich JM, Napier HA, Wetherbe JC. An empirical study of +occupational stress, attitudes and health among information systems +personnel. Int J Manpow 2002;9:77‑85. +11. +Kane PP. Stress causing psychosomatic illness among nurses, Indian J +Occup Environ Med 2009;13:28‑32. +12. +Jani, Jyotindra M. A Comparative Analysis of stress and management +problems (With Reference to Gujarat State), thesis PhD, Gujarat, India: +Saurashtra University; 2009. +13. +Aziz M. Role stress among women in the Indian information technology +sector, Women Manage Rev 2004;19:356‑63. +14. +Bhal KT, Gulati N. Pay Satisfaction of Software Professionals in India. +Vikalpa 2007;32:9‑21. +15. +Akhtar K. Occupational Stress And Psychological Fitness – Study Of +Information Technology Sector In Mumbai Area. Int J Manage Res Rev +2012;2:61‑73. +16. +Sharan D, Parijat P, Sasidharan AP, Ranganathan R, Mohandoss M, +Jose J. Workstyle risk factors for work related musculoskeletal symptoms +among computer professionals in India. J Occup Rehabil 2011;21:520‑5. +17. +Korunka C, Weiss A, Huemer KH, Karetta B. The Effect of New +Technologies on Job Satisfaction and Psychosomatic Complaints. Appl +Psychol Int Rev 1995;44:123‑42. +18. +Chawla V, Guda S. Individual Spirituality at Work and Its Relationship +with Job Satisfaction, Propensity to Leave and Job Commitment: +An Exploratory Study among Sales Professionals. J Hum Values +2010;16:157‑67. +19. +Upadhya C, Vasavi AR. Work, Culture, And Sociality In The Indian It +Industry: A Sociological Study, Indo‑Dutch Programme for Alternatives +in Development, School of Social Sciences, National Institute of +Advanced Studies, Bangalore, India. India: Indian Institute of Science +Campus; 2006. +20. Kumar DM. Advantages of Vipassana Meditation on Psychosomatic, +Professional and Managerial development of Business Graduates a +qualitative Research, Sinhgad Business School, Sinhgad Technical +and Educational Society, Kusgaon, Lonavla, Maharashtra, India. 2005. +21. +Chand P, Koul H. Workplace Spirituality, Organizational Emotional +Ownership and Job Satisfaction as Moderators in Coping with Job +Stress. Bangkok: International Conference on Humanities, Economics +and Geography (ICHEG’2012), March 17‑18, 2012., +22. +Clark LA, Watson D. Construct validity: Basic issues in objective scale +development. Psychol Assess 1995;7:309‑19. +23. +McVicar A. Workplace stress in nursing: A literature review. J Adv Nurs +2003;44:633‑42. +24. +Nagarathna R, Nagendra HR. New Perspectives in Stress Management. +1st  ed. Bangalore, Karnataka, India: Swami Vivekananda Yoga +Prakashana; 1986. +Cite this article as: Madhura S, Subramanya P, Balaram P. +Job satisfaction, job stress and psychosomatic health problems +in software professionals in India. Indian J Occup Environ Med +2014;18:153-61. +Source of Support: Nil, Conflict of Interest: None declared. +APPENDIX – I Job Satisfaction Questionnaire +Please rate the following items +1 = Strongly Disagree +2 = Disagree + 3 = Don’t know +4 = Strongly Agree +5 = Agree +I receive recognition for a job well done. +I feel close to the people at work. +I feel good about working at this +company +I feel secure about my job. +I believe management is concerned +about me. +On the whole I believe work is good for +my physical health. +My Salary is good. +All my talents and skills are used at +work. +I get along well with supervisors +I feel good about my job. +[Downloaded free from http://www.ijoem.com on Friday, July 29, 2016, IP: 14.139.155.82] +Sahukar, et al.: Job satisfaction and Indian software professionals +160 +Indian Journal of Occupational and Environmental Medicine - December 2014 - Volume 18 - Issue 3 +160 +Job satisfaction score interpretation: +42–50: Very high satisfaction +39–41: High satisfaction +32–38: Average satisfaction +27–31: Low satisfaction +10–26: Very low satisfaction. +APPENDIX – 2 JOB STRESS QUESTIONNAIRE +Please rate the following items in terms of how often the +symptom is true for you during the last three months. +0=Never 1=Occasionally 2=somewhat often 3=Frequently +4=Almost always +1. I feel tired even with adequate sleep. +2. I feel frustrated in carrying out my responsibilities at work. +3. I am moody, irritable, or impatient over small +inconveniences. +4. I want to withdraw from the constant demands on my time +and energy. +5. I feel negative, futile, or depressed about my job. +6. My decision‑making ability seems less than usual. +7. I think that I am not as efficient as I should be. +8. The quality of my work is less than it should be. +9. I feel physically, emotionally, or spiritually depleted. +10. My resistance to illness is lowered. +11. I am eating more or less, drinking more coffee, smoking +more cigarettes, or using more alcohol or drugs to cope +with my job. +12. I am feeling emotionally callous about the problems and +needs of others. +13. I am having difficulty concentrating. +14. I am easily bored. +15. I feel a sense of dissatisfaction, of something wrong or +missing. +16. When I ask myself why I get up and go to work, the only +answer that occurs is “the money.” +Job Stress Score interpretation: +0–21: You are probably coping adequately with your job. +21–30: You are suffering from job stress and need to take +preventative action. +30–40: You need to take preventative action to avoid job +burnout. +41–64: You are burning and must develop a comprehensive +job stress management plan. +APPENDIX 3: HEALTH QUESTIONNAIRE +Please check all that apply to you: +A P P E N D I X 4 S P I R I T UA L P R A C T I S E S +QUESTIONNAIRE +1. Do you believe in God or existence of supreme power? Yes/ +No +2. Do you spend your leisure hours by +(a) visiting friends and family. +(c) Reading books on philosophy and/or religion. +(d) participate in Bhajans/Satsang? Frequency weekly/ +monthly/fortnight. +(e) Visiting temple. Reason: Routine/like the vibration/to +worship/to pray and fulfil your desires/feel secure and +comfortable/bhakthi and attachment toward God/feel +relaxed, light and fresh. +(f) Charity work/selfless service/helping the needy. +(g) Meditation. +(h) Listening to classical/devotional music. +(g) None of the above. +0 - No +symptoms +1 - Mild +Does not disturb +daily routine +2 - Moderate +Disturbs +daily routine +3 - High (Have been +taking off because +of the symptom) +4 - Severe +Bed ridden because +of the complaint +Head ache/migraine +Asthma (bronchial asthma, nasal allergy, chronic bronchitis) +Back pain +Neck pain +Eye problems (dryness, itching) +Hypertension +Anxiety and depression +Gastrointestinal disorder (gastritis, peptic ulcer, irritable bowel +syndrome, or ulcerative colitis) +Gynecological problems (infertility/impotence/fibroids/ovarian cysts) +Diabetes mellitus +Menstrual disorders +[Downloaded free from http://www.ijoem.com on Friday, July 29, 2016, IP: 14.139.155.82] +Sahukar, et al.: Job satisfaction and Indian software professionals +161 +Indian Journal of Occupational and Environmental Medicine - December 2014 - Volume 18 - Issue 3 +161 +Table 1: Reliability test results of the measuring instruments– +Cronbach’s alpha coefficients +Questionnaire name +Cronbach’s alpha +Number of items +Job satisfaction questionnaire +0.864 +10 +Job stress questionnaire +0.903 +16 +Health questionnaire +0.805 +10 +Table 2: Pearson’s product moment correlation coefficients and +descriptive statistics of variables +Variable +Mean +Standard +deviation +Pearson’s product moment +correlation coefficients +Job +satisfaction +Job +stress +Health +symptoms +Job satisfaction +32.39 +7.23 +1 +Job stress +19.29 +11.20 +−0.486** +1 +Health symptoms +5.36 +4.63 +−0.328** +0.506* +1 +Significant at *P<0.05, **P<0.01) +Table 3: Group statistics +Yoga Nonyoga Spiritual leisure +activities +Nonspiritual +leisure activities +N +76 +65 +74 +67 +Job satisfaction +Mean +33.23 +31.41 +33.25 +31.44 +Standard deviation +7.44 +6.09 +7.53 +6.81 +Job stress +Mean +17.17 +21.78 +18.04 +20.68 +Standard deviation 10.34 +11.733 +10.36 +11.98 +Health symptoms +Mean +4.59 +6.26 +5.31 +5.41 +Standard deviation 4.066 +5.11 +4.69 +4.61 +Table 4: Independent sample t test in the yoga and nonyoga +groups +f value +Significance +Job satisfaction +0.159 +>0.5 +Job stress +0.585 +<0.5 +Health symptoms +4.217 +<0.05 +3. Do you practice any of the following? Yoga asanas/ +pranayama/meditation/relaxation techniques/breath +awareness. +APPENDIX 5 TABLES +[Downloaded free from http://www.ijoem.com on Friday, July 29, 2016, IP: 14.139.155.82] diff --git a/subfolder_0/Long Latency Auditory Evoked Potentials During Meditation.txt b/subfolder_0/Long Latency Auditory Evoked Potentials During Meditation.txt new file mode 100644 index 0000000000000000000000000000000000000000..c5484f7a7fb76d26820a2cfac18494577e847bab --- /dev/null +++ b/subfolder_0/Long Latency Auditory Evoked Potentials During Meditation.txt @@ -0,0 +1,1162 @@ +Original Article + +Long Latency Auditory Evoked Potentials +During Meditation +Shirley Telles1,2, Deepeshwar Singh2, K. V. Naveen2, and Subramanya +Pailoor2 +Abstract +The auditory sensory pathway has been studied in meditators using midlatency and short latency auditory evoked potentials. +The present study evaluated long latency auditory evoked potentials (LLAEPs) during meditation. Sixty male participants +aged between 18 and 31 years (group mean ± SD, 20.5 ± 3.8 years), were assessed in 4 mental states based on descriptions +in the traditional texts. They were (a) random thinking, (b) nonmeditative focusing, (c) meditative focusing, and (d) +meditation. The order of the sessions was randomly assigned. The LLAEP components studied were P1 (40-60 ms), N1 (75- +115 ms), P2 (120-180 ms), and N2 (180-280 ms). For each component, the peak amplitude and peak latency were measured +from the prestimulus baseline. There was a significant decrease in the peak latency of the P2 component during and after +meditation (P < .001; analysis of variance and post hoc analysis with Bonferroni adjustment). The P1, P2, and N2 +components showed a significant decrease in peak amplitudes during random thinking (P < .01; P < .001; P < .01, +respectively) and nonmeditative focused thinking (P < .01; P < .01; P < .05, respectively). The results suggest that meditation +facilitates the processing of auditory information in the auditory association cortex, whereas the number of neurons recruited +was less in random thinking and non meditative focused thinking at the level of the secondary auditory cortex, auditory +association cortex and anterior cingulate cortex respectively. +Keywords +meditation, long latency auditory evoked potentials, yoga +Received February 17, 2014; revised May 27, 2014; accepted June 28, 2014. + +Introduction +Meditation is a self-regulated conscious process and mental +training.1 The functional changes in the brain during +meditation have been studied with various techniques that +have different spatial and temporal resolutions.2 +Evoked potentials have been used in meditation studies, +since the correlation between the different components of +evoked potentials and the underlying neural generators are +fairly well known.3 Evoked potentials also allow changes in +a sensory pathway to be understood, from the periphery +through brainstem evoked potentials, to central areas with +long latency auditory evoked potentials (LLAEPs). +Brainstem auditory evoked potentials (BAEPs) have +been studied in Transcendental Meditation4 and in +practitioners of meditation on OM.5 Midlatency auditory +evoked potentials (MLAEPs) have been studied in different +meditations, including the eyes-open Brahmakumaris Raj +Yoga Meditation,6 meditation on OM,5-9 and Sahaja Yoga, +which involves mental silence and awareness devoid of any +thought.10 The study of short latency AEPs in OM +meditators (n = 30; meditation experience 6 months; +Cohen’s d = 0.50) suggested that the auditory information +transmission was delayed at the inferior collicular level +during meditation with focusing.11 The report on +transcendental meditators (n = 5; meditation experience 5 +years; Cohen’s d = 0.35) showed enhanced auditory +information +transmission +following +Transcendental +Meditation. In trancendental meditation, participants +consciously reorient12(p208) their attention to the given +mantra, whereas in OM meditation the attention is allowed +to wander.5 The MLAEPs with Sahaja Yoga meditation10 (n += 32; meditation experience 6 months; Cohen’s d = 0.41) +and OM meditation9 (n = 60; meditation experience 6 +months; Cohen’s d = 0.47) showed there was a delay in +auditory information transmission during meditation at the +level of the medial geniculate and primary auditory cortex +1Patanjali Research Foundation, Haridwar, India +2ICMR Center for Advanced Research in Yoga and Neurophysiology, +S-VYASA University, Bengaluru, India + +Corresponding Author: +Shirley Telles, Patanjali Research Foundation, Patanjali Yogpeeth, +Haridwar, Uttarakhand 249405, India. +Email: shirleytelles@gmail.com +Clinical EEG and Neuroscience +1–12 +© EEG and Clinical Neuroscience +Society (ECNS) 2014 +Reprints and permissions: +sagepub.com/journalsPermissions.nav +DOI: 10.1177/1550059414544737 +eeg.sagepub.com + +Telles et al +2 + +during meditation whereas Brahmakumaris Raja Yoga +Meditation (n = 16; meditation experience 5 years; +Cohen’s d = 0.61) showed reduction in conduction time.6 +Sahaja Yoga Meditation involves cleansing practices and +meditation to reach a state of thoughtless awareness.13 +Brahmakumaris Raja Yoga Meditation is practiced with the +attention focused on a series of meaningful thoughts.14(p96) +For both brainstem and midlatency evoked potentials, the +results have differed with each meditation technique. The +results of a single study on LLAEPs in Transcendental +Meditation are detailed below.15 Transcendental meditators +showed no changes in LLAEPs. LLAEPs assess the higher +auditory processing capabilities in central and cortical +components of the auditory pathway given the scarcity of +data on LLAEPs in meditation the present study was +designed to evaluate LLAEPs in practitioners during +meditation practiced as described in the ancient texts. +A possible reason for the differences in results with +different meditation techniques, even though they all aim at +facilitating spiritual evolution, is that they differ in the +methods used.16(p448),17 Most of these techniques have +evolved in the past 200 years. This is relatively recent +compared to the ancient texts (eg, Patanajli’s Yoga Sutras; +circa 900 BC). The present study has attempted to overcome +the possible cause for differences by assessing the effects of +meditation when practiced as described in traditional yoga +texts.5 +The first, most recent and comprehensive compilation of +descriptions in the ancient texts is the Patanjali’s Yoga +Sutras (circa 900 BC). There are 2 meditative states +described here. The first is meditative focusing (called +dharana in Sanskrit) during which the mind is confined to +a fixed and defined area of functioning. This is often +considered a preparatory phase (Patanjali’s Yoga Sutra, +chapter III, verse 1). The second state is considered the +actual meditation (called dhyana in Sanskrit), characterized +by effortless, mental expansion (Patanjali’s Yoga Sutra, +chapter III, verse 2). During this stage there is an +uninterrupted flow of the mind toward the object of +meditation. +When not in meditation, it is said that the mind may be +in 2 other states. These are random thinking (called +cancalata in Sanskrit; Bhagavad Gita, chapter VI, verse 34; +circa 400-600 BC) and nonmeditative focused thinking +(called ekagrata in Sanskrit; Bhagavad Gita, chapter VI, +verse 12). +Brainstem and midlatency auditory evoked potentials +have been recorded during these four states with an +encouraging degree of intersubject consistency.5,9 +LLAEPs have not been studied in these 4 states. In fact +there is just one study on LLAEPs during Transcendental +Meditation.15 In that study, LLAEPs were recorded in 8 +experienced meditators (meditation experience 6 years; +Cohen’s d = 0.18), before during and after meditation and +also during light sleep. No consistent changes were noted +between baseline and meditation auditory evoked +potentials or between meditation and sleep. +Hence the present study was designed to assess the +LLAEPs during the 4 mental states described above, to +determine whether the differences in mental states would +cause changes in the LLAEP components based on changes +in the underlying neural generators. +Materials and Methods +Participants +Sixty males with ages between 18 and 31 years (group +mean ± SD, 20.5 ± 3.8 years) were recruited as +participants by announcements in the university +newsletter and flyers on the notice boards. Statistical +calculation of the sample size was not done prior to the +experiment. However, post hoc analyses showed that for +the present study, with the sample size as 48 used for +final analysis, in each session (selected from the 60, as +mentioned below), and with the Cohen’s d = 0.70, the +power was 0.95.18 Cohen’s d was obtained from the P2 +component peak latency in the meditation session when +“during” values were compared with “pre” values. +Participants were all students of a yoga university in +south India. Twelve participants were excluded from the +study because of motion artifact in the signals or because +of high electrode impedance during the recordings. +Hence, the data from 48 participants with ages ranging +from 17 to 30 years (group mean age ± SD, 19.3 ± 2.6 +years) were included for the final analysis. To be +included in the trial, participants had to meet the +following criteria: (a) have normal health based on a +routine clinical examination; (b) male volunteers alone +were studied as auditory evoked potentials are known to +vary with the phases of the menstrual cycle19; (c) have a +minimum experience of meditation on the Sanskrit +syllable OM, for 30 minutes each day, for 5 days in a +week; and (d) the participants had to have meditation +practice for a minimum of 3 months (with a group +average experience ± SD of 20.9 ± 14.2 months). The +exclusion criteria were (a) persons on any medication or +herbal remedy; (b) presence of any illness, particularly +psychiatric or neurological disorders; and (c) any +auditory deficit. None of the participants were excluded +based on these criteria. The baseline characteristics of +participants are given in Table 1. +The project was approved by the ethics committee of the +university. The study protocol was explained to the +participants and their signed informed consent was +obtained. Participants were not given any incentive to take +part in the study. + +Table 1. Characteristics of 48 Participants. +Telles et al +3 + +Characteristics + +Age in years (group mean ± SD) +19.3 ± 2.6 +Years of education, n (%) + 17 +17 (35.4) + Up to 15 +23 (47.9) + Up to 12 +8 (16.7) +Type of meditation +Meditation on the Sanskrit +syllable OM +Experience of meditation practice in months, n (%) + 6-12 +23 (48.9) + 13-24 +9 (19.2) + 25-36 +7 (14.9) + 37-48 +6 (12.8) + 48-60 +2 (4.3) +Socioeconomic status,36 n (%) +High-income group +9 (18.7) +Mid-income group +33 (68.7) +Low-income group +6 (12.5) +Design of the Study +Despite the fact that participants had prior experience of +OM meditation, all participants were given a 3-month +orientation program guided by an experienced meditation +teacher. The purpose of this orientation was for all +participants to practice the 2 different states of meditation, +namely, meditative focusing and effortless meditation, +based on specific instructions following a uniform method. +Each participant was assessed in 4 sessions, to which +they were assigned randomly. The sessions were +randomized using a standard random number table. Two of +them were meditation sessions. These were (a) meditative +focusing (dharana in Sanskrit) and (b) meditation without +focusing or effortless meditation (dhyana in Sanskrit). The +other 2 sessions were nonmeditation sessions. They were +(a) nonmeditative focused thinking (ekagrata in Sanskrit) +and (b) random thinking (cancalata in Sanskrit). All 4 +sessions consisted of 3 states: before (5 minutes), during (20 +minutes), and after (5 minutes). The design is presented +schematically in Figure 1. +Assessment Procedure +Recording Conditions. Long latency auditory evoked +potentials were assessed in the 4 sessions, that is, random +thinking (cancalata), nonmeditative focused thinking +(ekagrata), meditative focusing (dharana), and meditation +(dhyana). Participants were seated in a sound attenuated, +dimly lit cabin with sound level 26 dB normal hearing level +and monitored on a closed circuit television to detect if they +moved or fell asleep during a session. Instructions were +given through a 2-way intercom, so that participants could +remain undisturbed during a session. The LLAEPs were +recorded with eyes closed and participants seated at ease. +The temperature in the recording room was maintained at +24.0C  1.0C. The average humidity was 56% on the days +the experiments were conducted. LLAEPs were recorded in +the 250-ms, poststimulus time period without any +prestimulus delay, using a 4-channel system (Nicolet +Biomedical Inc, Madison, WI). +Electrode Positions. Ag/AgCl disk electrodes were fixed +with electrode gel (10-20 conductive EEG paste) at the +vertex (Cz) with reference electrodes on linked earlobes +(A1-A2) and with the ground electrode on the forehead +(FPz). Electrode placements were based on the international +10-20 electrode placement system.20 The electrode +impedance was kept less than 5 kohm. +Amplifier Settings. Standard settings for LLAEP recording +were used.21 The EEG activity was amplified with a +sensitivity of 100 V. The low cut filter was 0.1 Hz and the +high cut filter was 30.0 Hz. LLAEPs were averaged in 500 +trial sweeps in the 0 to 500 ms range. Rejection was set at +90% of the full-scale range of the analog-to-digital +converter. +Stimulus Characteristics. Binaural click stimuli of 100-s +duration and alternating polarity at the rate of 5.0 Hz were +delivered +through +acoustically +shielded +earphones +(Amplivox, Kidlington, UK).21 The threshold of hearing +was noted for each participant to verify that their hearing +was normal. The threshold of hearing was checked as +follows (a) decreasing the intensity in 5-dB steps until the +participant could no longer hear the clicks and (b) +increasing the intensity in 5-dB steps until the clicks were +audible. The click threshold was taken as the midpoint +between the intensities at which the clicks could and could +not be heard. This procedure was repeated twice. The +thresholds ranged between 15 and 25 dB normal hearling +level (nHL). The average threshold of hearing was 14.03 ± +2.98 dB nHL. The intensity was kept at 70 dB nHL. +Participants had 100% compliance to the meditation +orientation program and for the recordings. +Interventions +Random Thinking (Cancalata). Participants were asked to +allow their thoughts to wander freely as they listened to a +compiled audio CD consisting of brief periods of +conversation, announcements, advertisements, and talks on +diverse topics recorded from a local radio station +transmission. These conversations were not connected and +hence it was thought that listening to them could induce a +state of random thinking. +Nonmeditative Focused Thinking (Ekagarta). Participants +listened to a prerecorded lecture on the process of +meditating and the object of meditation, that is, the Sanskrit +syllable OM. This was intended to induce a state of +nonmeditative focusing. +Telles et al +2 + + + +Figure 1. Schematic representation of the study design of the 4 sessions. The long latency auditory evoked potentials (LLAEPs) were +recorded before, during and after the intervention. Periods of recording are shown as stippled and periods of intervention are shown as +hatched. + +Meditative Focusing (Dharana). Participants were asked +to open their eyes and gaze at the syllable OM as it is +written in Sanskrit. During this time guided instructions +required them to direct their thoughts to the physical +attributes of the syllable, that is, the shape and color, and +then to close their eyes and continue to visualize the +syllable mentally. The main emphasis during meditative +focusing was that thoughts are consciously brought back +(if they wander) to the single thought of OM. +Meditative +Defocusing +or +Effortless +Meditation +(Dhyana). During this session participants were +instructed to keep their eyes closed and dwell on thoughts +of OM, without any effort, particularly on the subtle +(rather than physical) attributes and connotations of the +syllable. This would gradually allow the participants to +experience brief periods of silence, which they reported +after the session. +Data Extraction +Long latency auditory evoked potential components, +namely, P1, N1, P2 and N2 waves were measured from a +zero DC baseline. Peak latency was measured from the +time of click delivery. The peak latencies and peak +amplitudes of the following components were measured, +the P1 wave between 40 and 60 ms, is the maximum +positive peak preceding the N1 wave which is a negative +component between 80 and 115 ms. The P2 wave is a +positive component between 140 and 180 ms. It is also +the first maximum positive component preceding the N2 +wave component, which is between 200 and 280 ms.22 +Components of LLAEPs and their neural generators are +described in Table 2. + +Original Article + +Table 2. Components of Long Latency Auditory Evoked Potentials (LLAEPs) and Their Neural Generators. +LLAEP Components +Latency (ms) +Neural Generator +P1 +40-60 +Secondary auditory cortex in the lateral Heschl’s gyrus +N1 +80-115 +Bilateral parts of the auditory superior cortex +P2 +140-180 +Mesencephalic reticular activating system (RAS) +N2 +200-280 +Anterior cingulate cortex + + +Figure 2. A single sample of a long latency auditory evoked potentials waveform before meditation and after meditation. + +Data Analysis +Statistical analysis was done using SPSS (version 16.0). +Data were tested for normality by the Kolmogorov– +Smirnov test. Since the participants of the experimental +group were assessed in repeat sessions on separate days (ie, +random +thinking, +nonmeditative +focused +thinking, +meditative focusing and meditation), the repeated-measures +analysis of variance (ANOVA) was used. Repeated- +measures ANOVAs were performed with 2 “within +subjects” factors, that is, factor 1—sessions such as random +thinking, nonmeditative focused thinking, meditative +focusing, and meditation, and factor 2—states, that is, +Before, During (1-4), and After. Repeated-measures +ANOVAs were carried out for each wave of LLAEPs +separately, for both peak latencies and peak amplitudes. +This was followed by a post hoc analyses with Bonferroni +adjustment for multiple comparisons between the mean +values of different states (“During” and “After”) and all +comparisons were made with the respective “Before” state. +Results +The group mean values ± SD for the peak latencies +(milliseconds) and peak amplitudes (V) of P1, N1, P2, and +N2 components of LLAEPs in 4 sessions (random thinking, +nonmeditative focused thinking, meditative focusing, and +meditation) in Before, During, and After states are given in +Table 3 (peak latencies) and Table 4 (peak amplitude). A +sample LLAEPs waveform is shown in Figure 2. +Repeated-Measures Analysis of Variance +The ANOVA values for the Within-Subjects factor (States), +Between-Subjects factor (Sessions) and interaction between +the 2 for the different components of LLAEPs are provided +in Table 5. A significant interaction between Sessions and +States for any component suggests that the 2 are +interdependent. +Sessions + +States +interaction +was +significant for P1 and P2 amplitude; and N1, N2 and P2 +latency +components +of +LLAEPs. +This +significant +interaction is graphically presented in Figures 3 and 4. +Post Hoc Analyses With Bonferroni Adjustment +Post hoc analyses with Bonferroni adjustment were +performed and all comparisons were made with respective +“Before” states. There was a significant decrease in the +amplitude of P1, P2, and N2 waves during random + + +Table 3. Peak Latencies of Long Latency Auditory Evoked Potential (LLAEP) Components for 4 Sessions. +Components +Sessions +Latency, Mean  SD +Cohen’s d +States +Before +D1 +D2 +D3 +D4 +After +P1 component +Random thinking +46.48  7.92 +47.69  9.54 +47.52  7.78 +46.71  7.53 +45.92  7.51 +48.48  8.26 +0.247 +Nonmeditative +focused thinking +47.33  8.34 +47.75  7.76 +46.50  7.68 +46.04  6.38 +46.17  7.33 +48.44  8.13 +0.135 +Meditative focused +thinking +48.15  9.70 +47.96  8.23 +47.71  7.62 +47.69  8.25 +47.69  8.87 +50.44  9.03 +0.244 +Meditation +48.69  9.46 +46.48  7.20 +47.13  7.22 +46.31  6.91 +46.96  7.36 +47.79  7.90 +0.103 +N1 component +Random thinking +98.67  14.64 +100.65  15.13 +97.58  16.34 +95.06  15.73 +97.25  18.48 +100.52  15.81 +0.121 +Nonmeditative +focused thinking +97.48  15.22 +101.75  15.31 +101.98  14.81 +99.63  15.61 +97.73  15.44 +103.33  15.09 +0.386 +Meditative focused +thinking +98.23  15.15 +99.98  16.80 +98.31  16.19 +97.15  15.46 +100.94  15.33 +101.10  15.11 +0.190 +Meditation +98.85  14.18 +99.71  16.51 +100.46  16.82 +98.44  16.26 +98.52  16.18 +100.85  15.71 +0.134 +P2 component +Random thinking +154.88  13.54 +158.17  15.05 +155.02  14.90 +152.85  12.75 +153.40  13.85 +154.98  12.37 +0.008 +Nonmeditative +focused thinking +155.67  10.38 +154.90  12.34 +154.29  9.85 +156.27  14.75 +156.58  12.69 +156.60  11.50 +0.085 +Meditative focused +thinking +157.73  14.16 +154.79  11.18 +154.88  12.31 +150.81  12.80 +157.73  12.03 +153.90  11.54 +0.296 +Meditation +158.23  9.24 +151.71  11.83** +153.58  10.36 +154.90  10.30 +153.15  13.20 +151.81  9.06** +0.702 +N2 component +Random thinking +221.63  3.13 +222.48  7.42 +222.19  2.76 +221.94  2.90 +221.92  2.84 +222.58  3.74 +0.275 +Nonmeditative +focused thinking +222.29  3.72 +221.79  3.72 +222.88  3.22 +222.50  4.78 +222.60  3.55 +222.31  3.54 +0.080 +Meditative focused +thinking +223.21  6.04 +221.33  4.11 +222.85  3.37 +221.35  4.51 +222.13  2.91 +222.04  3.40 +0.239 +Meditation +223.10  5.65 +223.42  6.32 +223.73  7.09 +222.29  4.52 +222.88  3.08 +223.00  5.58 +0.018 +aValues are group means  SD. Cohen’s d is calculated for the maximum difference in the post–pre or during–pre comparisons. +**P < .01; repeated-measures analysis of variance with Bonferroni adjustment comparing During and Post values with Pre values. + + +Telles et al +2 + +Table 4. Peak Amplitude of Long Latency Auditory Evoked Potential (LLAEP) Components for 4 Sessions. +Component +Sessions +Amplitude Mean  SD +Cohen’s d +States +Before +D1 +D2 +D3 +D4 +After +P1 component +Random thinking +1.19  1.01 +0.85  0.62 +0.65  0.51** +0.82  0.54 +0.74  0.61* +1.04  0.67 +0.675 +Nonmeditative focused +thinking +1.05  0.80 +0.79  0.59 +0.79  0.58* +0.69  0.54** +0.69  0.50*** +0.99  0.74 +0.540 +Meditative focused +thinking +1.19  0.97 +1.02  0.69 +0.97  0.86 +0.97  0.60 +1.01  0.67 +1.06  0.78 +0.202 +Meditation +0.96  0.66 +0.84  0.61 +0.90  0.60 +0.87  0.72 +0.90  0.80 +0.97  0.64 +0.015 +N1 component +Random thinking +0.56  0.51 +0.44  0.38 +0.44  0.40 +0.40  0.29 +0.41  0.34 +0.50  0.38 +0.346 +Nonmeditative focused +thinking +0.40  0.31 +0.36  0.28 +0.38  0.33 +0.45  0.38 +0.34  0.25 +0.42  0.38 +0.058 +Meditative focused +thinking +0.43  0.43 +0.46  0.41 +0.44  0.47 +0.44  0.46 +0.44  0.35 +0.54  0.46 +0.247 +Meditation +0.31  0.43 +0.37  0.36 +0.69  1.84 +0.43  0.45 +0.46  0.39 +0.40  0.36 +0.227 +P2 component +Random thinking +0.95  0.83 +0.57  0.42** +0.51  0.46*** +0.59  0.51** +0.61  0.40* +0.84  0.57 +0.656 +Nonmeditative focused +thinking +0.82  0.47 +0.66  0.45 +0.58  0.47** +0.56  0.47* +0.56  0.37** +0.78  0.47 +0.615 +Meditative focused +thinking +0.87  0.65 +0.71  0.47 +0.66  0.62 +0.78  0.54 +0.72  0.50 +0.86  0.60 +0.331 +Meditation +0.80  0.57 +0.69  0.52 +0.68  0.47 +0.64  0.41 +0.70  0.58 +0.80  0.47 +0.322 +N2 component +Random thinking +0.39  0.36 +0.39  0.33 +0.35  0.34 +0.31  0.26 +0.30  0.26** +0.42  0.40 +0.679 +Nonmeditative focused +thinking +0.41  0.30 +0.36  0.25 +0.36  0.27 +0.34  0.31 +0.26  0.23* +0.34  0.28 +0.561 +Meditative focused +thinking +0.38  0.36 +0.42  0.33 +0.40  0.37 +0.39  0.38 +0.34  0.26 +0.43  0.29 +0.153 +Meditation +0.39  0.33 +0.38  0.34 +0.35  0.29 +0.39±  0.35 +0.39  0.48 +0.28  0.25 +0.376 +a.Values are group means  SD. Cohen’s d is calculated for the maximum difference in the post–pre or during–pre comparisons. +*P < .05, **P < .01, ***P < .001; repeated-measures analysis of variance with Bonferroni adjustment comparing During and Post values with Pre values. + +8 +Clinical EEG and Neuroscience + + +Table 5. Summary of the Repeated-Measures Analysis of Variance Showing Statistically Significant Results. +Component +Factor +F Value +df +Hyunh-Feldt  +Level of +Significance + +P1 wave amplitude +Session +4.08 +(2.52, 118.6) +0.893 +P < .05 +0.080 +N2 wave latency +Session +1.69 +(2.19, 102.8) +0.766 +P < .05 +0.035 +P1 wave latency +State +3.76 +(3.77, 177.04) +0.827 +P < .01 +0.074 +P1 wave amplitude +State +10.72 +(2.76, 129.57) +0.589 +P < .001 +0.186 +N1 wave latency +State +2.86 +(4.14, 194.54) +0.918 +P < .05 +0.057 +P2 wave amplitude +State +9.74 +(4, 187.98) +0.884 +P < .001 +0.172 +P1 wave amplitude +Session  State +2.08 +(9.59, 450.57) +0.816 +P < .05 +0.043 +N2 wave latency +Session  State +0.83 +(7.59, 356.64) +0.613 +P < .05 +0.017 +P2 wave latency +Session  State +1.93 +(10.17, 478.16) +0.880 +P < .05 +0.039 +P2 wave amplitude +Session  State +4.02 +(9.9, 464.54) +0.849 +P < .001 +0.079 + + +Figure 3. Graphical representation of the interaction between Sessions × States for the amplitude. Dependent variable (peak amplitude in +V) on the Y axis, one of the independent variables (States) on the X axis, and the other independent variable (Sessions) as separate lines +on the graph. + +2 +p +η +Telles et al +9 + + + +Figure 4. Graphical representation of the interaction between Sessions × States for the amplitude. Dependent variable (peak latency in +milliseconds) on the Y axis, one of the independent variables (States) on the X axis, and the other independent variable (Sessions) as +separate lines on the graph. +Telles et al +11 + + +thinking (P < .01; P < .001; P < .01, respectively) and +nonmeditative focused thinking (P < .01; P < .01; P < .05, +respectively) and a decrease in the peak latency of the P2 +wave during and after meditation (P < .001). All +comparisons were made with the “Pre” state. Cohen’s d +values were calculated and are provided in Table 3 (peak +latencies) and Table 4 (peak amplitude) for the 4 sessions at +Cz. +Discussion +Long latency auditory evoked potentials are generated by +thalamocortical and corticocortical auditory pathways, the +primary auditory cortex and the association cortical areas.21 +The present study assessed LLAEPs during 4 mental states. +During meditation the peak latency of the P2 component +significantly reduced. A decrease in peak latency is +suggestive of a facilitation of auditory sensory transmission +because of increased speed of conduction in the underlying +neural generators.23(p278) +At present the functional significance of the P2 +component is not as clear as that of components generated +more peripherally. The P2 wave partly reflects auditory +output of the mesencephalic activation system.24,25 +Myoelectrography (MEG) studies have attempted to locate +the neural generators of the P2 component. Both MEG data +and EEG data from depth electrodes implanted in the +auditory cortex were collected in the same patients.26-29 It +was found that generators for the P2 component were +localized in the planum temporale as well as Brodmann area +22 (the auditory association complex). Other reports have +speculated that the P2 component may receive contributions +from cortical areas in the depth of the Sylvian fissure.30 +Hence, it remains possible that the P2 component arises +from multiple sources with a center of activity close to +Heschl’s gyrus.30 The present results suggest that the +practice of meditation improves information transmission in +areas concerned with complex processing of auditory +stimuli as the auditory association cortices are possibly +involved. +During the 2 mental states that were considered for +comparison, that is, random thinking and non meditative +focusing, the peak amplitudes of the P1, P2, and N2 +components reduced. A decrease in amplitude suggests that +the number of neuronal involvement recruited is less than +in the Pre state. The neural generators of the P2 component +have been mentioned above. The neuronal sources of the P1 +component are difficult to localize due to low signal-to- +noise ratio. Also the brain response which generates the P1 +component is preceded and followed in time within 10 to 15 +ms by several EP components, which arises from sources +other than those generating P1.31 Studies on animal models +suggested that neuronal activity in the hippocampus might +contribute to sensory gating32; however, this was not proved +in human recordings.33 MEG studies have shown that there +may be a temporal lobe generator for P1 especially, located +bilaterally in the superior temporal gyrus.34 In addition, the +frontal lobe is involved in auditory sensory gating and this +activity may contribute to the P1 component. However, the +maximum contribution to the P1 activity is from the +temporal lobe.35 The N2 component of auditory evoked +potentials helps to evaluate the cognitive processes involved +in stimulus classification.36 The amplitude of the N2 +component is directly related to changes in the left superior +temporal gyrus and bilateral medial temporal lobe areas.37 +However, this description does not exclude the involvement +of other cortical areas in the genesis of the N2 component. +In random thinking and nonmeditative focusing sessions, a +decrease in amplitude of the P1 and N2 components +suggests that the overall neuronal activation and number of +neurons recruited in the neural generators underlying these +components was less. Other studies reported that the P2 and +N2 components decrease in amplitude with a reduction in +attention.38 Since random thinking did not involve focusing +of attention, the reduction in amplitude in P2 and N2 +components is not surprising. In contrast, the reduction in +amplitude in non meditative focusing is surprising as (a) +participants were asked to focus during the session and (b) +the nature of focusing was obviously different from +meditative focusing as meditative focusing did not reduce +P2–N2 amplitudes. The P2 amplitude is also sensitive to +shifts in consciousness during the stages of sleep.39 Based +on (a) the self-report of the meditators, (b) observation of +the raw EEG recorded, and (c) observation of the +participants on the closed circuit TV. Hence, the reduced +amplitude of the three components during random thinking +and nonmeditative focusing may reflect a decrease in the +number of neurons recruited. +The present results are different from the early study +conducted on practitioners of Transcendental Meditation. +This could be due to differences in the method of meditation +and sample size. The sample size was 8 with Cohen’s d = +0.18 whereas in the present study the sample size was 48 +with Cohen’s d = 0.68. +Hence, evaluating the effect of meditation based on +descriptions in the traditional texts has yielded a significant +result for long latency auditory evoked potentials. The main +difference being, as was already mentioned, that the +traditional practices started approximately over 1000 years +BC, whereas other techniques have evolved in the past 200 +years. +The most important finding was the reduced latency of +the P2 component during meditation. +While the findings are reasonably straightforward, the +study has the following limitations: (a) The evaluation of +the quality of practice was based on a self reported visual +analog scale (VAS) and hence was subjective. (b) Random +thinking and nonmeditative focusing were the control +Telles et al +11 + +conditions. There was no control without any intervention. +(c) While the participants had been trained to switch +between the 4 states, the possibility that they did get into the +meditative state inadvertently cannot be ruled out. (d) The +transcultural generalizability of the results remains to be +determined, by conducting similar studies on a non-Indian +population. This suggests an area for future research. +Conclusion +The present results suggest that (a) meditation facilitates the +processing of auditory information in the auditory +association +cortex +and +(b) +random +thinking +and +nonmeditative focusing resulted in fewer neurons being +recruited in auditory association areas. +Declaration of Conflicting Interests +The author(s) declared no potential conflicts of interest with +respect to the research, authorship, and/or publication of this +article. +Funding +The author(s) disclosed receipt of the following financial support +for the research, authorship, and/or publication of this article: The +authors gratefully acknowledge the funding from the Indian +Council of Medical Research (ICMR), Government of India, as +part of a grant for a Center for Advanced Research in Yoga and +Neurophysiology (CAR-Y&N), (Project No. 2001-05010). +References +1. Murata T, Takahashi T, Hamada T, et al. Individual trait +anxiety levels characterizing the properties of Zen meditation. +Neuropsychobiology. 2004;50:189-194. +2. Mishra U, Kalita J. Clinical Neurophysiology: Nerve +Conduction, Electromyography and Evoked Potentials. New +Delhi, India: B.I. Churchill Livingstone; 1999. +3. Woods DL, Clayworth CC. Click spatial position influences +middle latency auditory evoked potentials (MLAEPs) in +humans. +Electroencephalogr +Clin +Neurophysiol. +1985;60:122-129. +4. McEvoy TM, Frumkin LR, Harkins SW. Effects of meditation +on brainstem auditory evoked potentials. Int J Neurosci. +1980;10:165-170. +5. Kumar S, Nagendra H, Manjunath N, Naveen K, Telles S. +Meditation on OM: relevance from ancient texts and +contemporary science. Int J Yoga. 2010;3:2-5. +6. Telles S, Naveen KV. Changes in middle latency auditory +evoked +potentials +during +meditation. +Psychol +Rep. +2004;94:398-400. +7. Telles S, Nagarathna R, Nagendra HR, Desiraju T. Alterations +in auditory middle latency evoked potentials during meditation +on a meaningful symbol—”Om”. Int J Neurosci. 1994;76:87- +93. +8. Telles S, Desiraju T. Recording of auditory middle latency +evoked potentials during the practice of meditation with the +syllable “OM”. Indian J Med Res. 1993;98:237-239. +9. Telles S, Raghavendra BR, Naveen KV, Manjunath NK, +Subramanya P. Mid-latency auditory evoked potentials in 2 +meditative states. Clin EEG Neurosci. 2012;43:154-160. +10. Panjwani U, Selvamurthy W, Singh SH, Gupta HL, +Mukhopadhyay S, Thakur L. Effect of Sahaja yoga meditation +on auditory evoked potentials (AEP) and visual contrast +sensitivity +(VCS) +in +epileptics. +Appl +Psychophysiol +Biofeedback. 2000;25:1-12. +11. Kumar S, Nagendra H, Naveen K, Manjunath N, Telles S. +Brainstem auditory-evoked potentials in two meditative +mental states. Int J Yoga. 2010;3:37-41. +12. Russell P. The TM Technique: An Introduction to +Transcendental Meditation and the Teachings of Maharishi +Mahesh Yogi. Las Vegas, NV: Elf Rock Productions; 2002. +13. Shri Mataji Nirmala Devi. Sahaja Yoga Book One. 2nd ed. +Australia: Nirmala Yoga; 1989. +14. PBKI Vishva-Vidyalaya. Raja Yoga Meditation: A General +Introduction. Mt Abu, India: Raja Yoga Centre; 1989. +15. Barwood TJ, Empson JA, Lister SG, Tilley AJ. Auditory +evoked +potentials +and +Transcendental +Meditation. +Electroencephalogr Clin Neurophysiol. 1978;45:671-673. +16. Taimni IK. The Science of Yoga: The Yoga-sūtras of Patañjali +in Sanskrit With Transliteration in Roman, Translation and +Commentary in English. Chennai, India: Theosophical +Society; 1999. +17. Saraswati M, Swami G. Bhagavad Gita. Kolkata, India: +Advaita Ashrama; 1998. +18. Erdfelder E, Faul F, Buchner A. GPOWER: A general power +analysis program. Behav Res Methods Instrum Comput. +1996;28(1):1-11. +19. Yadav A, Tandon OP, Vaney N. Auditory evoked responses +during different phases of menstrual cycle. Indian J Physiol +Pharmacol. 2002;46:449-56. +20. Jasper H. The ten-twenty electrode system of the International +Federation. +Electroencephalogr +Clin +Neurophysiol. +1958;10:371-375. +21. Ventura LMP, Alvarenga KDF, Costa Filho OA. Protocol to +collect late latency auditory evoked potentials. Braz J +Otorhinolaryngol. 2009;75:879-883. +22. Ponton CW, Eggermont JJ, Kwong B, Don M. Maturation of +human central auditory system activity: evidence from multi- +channel evoked potentials. Clin Neurophysiol. 2000;111:220- +236. +23. Malhotra A. Auditory Evoked Responses in Clinical Practice. +New York, NY: Springer-Verlag; 1997:278. +24. Woods DL, Knight RT, Scabini D. Anatomical substrates of +auditory +selective +attention: +behavioral +and +electro- +physiological effects of posterior association cortex lesions. +Brain Res Cogn Brain Res. 1993;1:227-240. +25. Picton TW, Alain C, Woods DL, et al. Intracerebral sources of +human +auditory-evoked +potentials. +Audiol +Neurootol. +1999;4:64-79. +26. Hari R, Pelizzone M, Mäkelä JP, Hällström J, Leinonen L, +Lounasmaa O V. Neuromagnetic responses of the human +auditory cortex to on- and offsets of noise bursts. Audiology. +1987;26:31-43. +27. Pantev C, Hoke M, Lütkenhöner B, Lehnertz K. +Neuromagnetic evidence of functional organization of the +auditory cortex in humans. Acta Otolaryngol Suppl. +1991;491:106-114. +Telles et al +12 + +28. Sams M, Paavilainen P, Alho K, Näätänen R. Auditory +frequency +discrimination +and +event-related +potentials. +Electroencephalogr Clin Neurophysiol. 1985;62:437-448. +29. Rif J, Hari R, Hämäläinen MS, Sams M. Auditory attention +affects two different areas in the human supratemporal cortex. +Electroencephalogr Clin Neurophysiol. 1991;79:464-472. +30. Crowley KE, Colrain IM. A review of the evidence for P2 +being an independent component process: age, sleep and +modality. Clin Neurophysiol. 2004;115:732-744. +31. Korzyukov O, Pflieger ME, Wagner M, et al. Generators of +the intracranial P50 response in auditory sensory gating. +Neuroimage. 2007;35:814-826. +32. Freedman R, Adler LE, Myles-Worsley M, et al. Inhibitory +gating of an evoked response to repeated auditory stimuli in +schizophrenic and normal subjects. Human recordings, +computer simulation, and an animal model. Arch Gen +Psychiatry. 1996;53:1114-1121. +33. Grunwald T, Boutros NN, Pezer N, et al. Neuronal substrates +of sensory gating within the human brain. Biol Psychiatry. +2003;53:511-519. +34. Huang MX, Edgar JC, Thoma RJ, et al. Predicting EEG +responses using MEG sources in superior temporal gyrus +reveals source asynchrony in patients with schizophrenia. Clin +Neurophysiol. 2003;114:835-850. +35. Weisser R, Weisbrod M, Roehrig M, Rupp A, Schroeder J, +Scherg M. Is frontal lobe involved in the generation of +auditory evoked P50? Neuroreport. 2001;12:3303-3307. +36. O’Donnell BF, Shenton ME, McCarley RW, et al. The +auditory N2 component in schizophrenia: relationship to MRI +temporal lobe gray matter and to other ERP abnormalities. Biol +Psychiatry. 1993;34:26-40. +37. Shenton ME, Kikinis R, Jolesz FA, et al. Abnormalities of the +left temporal lobe and thought disorder in schizophrenia. A +quantitative magnetic resonance imaging study. N Engl J Med. +1992;327:604-612. +38. Hansen JC, Hillyard SA. Endogenous brain potentials +associated +with +selective +auditory +attention. +Electroencephalogr Clin Neurophysiol. 1980;49:277-290. +39. Colrain IM, Di Parsia P, Gora J. The impact of prestimulus +EEG frequency on auditory evoked potentials during sleep +onset. Can J Exp Psychol. 2000;54:243-254. + diff --git a/subfolder_0/Long-term effect of yogic practices on diurnal metabolic rates.txt b/subfolder_0/Long-term effect of yogic practices on diurnal metabolic rates.txt new file mode 100644 index 0000000000000000000000000000000000000000..9b50ff0057adfe36d86668c7769fcb337fd6ba15 --- /dev/null +++ b/subfolder_0/Long-term effect of yogic practices on diurnal metabolic rates.txt @@ -0,0 +1,724 @@ +27 +International Journal of Yoga + +! + +Vol. 1:1 + +! + +Jan-Jun-2008 +Long-term effect of yogic practices on diurnal metabolic rates +of healthy subjects +Chaya M S, Nagendra H R1 +Department of Life Sciences, Vivekananda Yoga Anusandhana Samsthana (VYASA), Bangalore, India. +1Vyasa (Swami Vivekananda Yoga University), Prasanti Kuteeram, Jigani, Bangalore Dist-560 019, India. +Original Article +Correspondence to: Dr. M. S. Chaya +Department of life sciences, +Vyasa (Vivekananda Yoga Anusandhana Samsthana) +(A Deemed Yoga University), #45/3, KV layout, 2nd cross, + 4th block east, Jayanagar, Bangalore 560019, India. +E-mail: chayapu@hotmail.com / chayams@gmail.com +Background: The metabolic rate is an indicator of autonomic activity. Reduced sympathetic arousal probably resulting in +hypometabolic states has been reported in several yogic studies. +Aim: The main objective of this study was to assess the effect of yoga training on diurnal metabolic rates in yoga practitioners +at two different times of the day (at 6 a.m. and 9 p.m.). +Materials and Methods: Eighty eight healthy volunteers were selected and their metabolic rates assessed at 6 a.m. and 9 +p.m. using an indirect calorimeter at a yoga school in Bangalore, India. Results and conclusions: The results show that the +average metabolic rate of the yoga group was 12% lower than that of the non-yoga group (P < 0.001) measured at 9 p.m. +and 16% lower at 6 a.m. (P < 0.001). The 9 p.m. metabolic rates of the yoga group were almost equal to their predicted basal +metabolic rates (BMRs) whereas the metabolic rate was signifi + cantly higher than the predicted BMR for the non-yoga group. +The 6 a.m. metabolic rate was comparable to their predicted BMR in the non-yoga group whereas it was much lower in the +yoga group (P < 0.001). The lower metabolic rates in the yoga group at 6 a.m. and 9 p.m. may be due to coping strategies for +day-to-day stress, decreased sympathetic nervous system activity and probably, a stable autonomic nervous system response +(to different stressors) achieved due to training in yoga. +Key words: Basal Metabolic Rate (BMR); decreased arousal response; yoga; yoga training. +ABSTRACT +An understanding of metabolism at different times of the +day has significant implications due to its link to sleep, +health, stress and fatigue, ultimately determining the +quality of life. BMR is the lowest (basal) metabolic rate +measured just after waking from a night’s sleep.[1] It is +well known that sleep is a restorative process wherein +the body synthesizes its necessary chemicals for growth, +maintenance and development. Rejuvenation and repair +take place during sleep.[2] Sleep generally brings down the +metabolic rate by about 10%.[1,3] Low basal metabolic rates +of yoga practitioners have been reported.[4] Hypometabolic +states have been reported in yogic studies[5-8] wherein +short and immediate effects of meditation and relaxation +were observed. +Yoga which is a way of life is characterized by balance, +health, harmony and bliss.[9] In yoga lore, three normal +states of consciousness have been identified[10]—they are +wakeful state (jagratha), dream or rapid eye movement +(REM, swapna or dream state) and deep sleep without +dreams (sushupti). Meditation is a part of yoga which +is the seventh limb of Astanga yoga[11]—a state of alert +rest as stated by Maharshi Mahesh Yogi.[12] This leads to +superconsciousness or the fourth state of consciousness +called the Samadhi, which is beyond the deep sleep state +in terms of metabolism.[5,6] +Practice of yoga brings about changes such as slowing +of the breath, calming of the mind and relaxation of +the body leading to efficiency/balance or homeostasis. +[9] The earliest study on metabolism by Anand et al.[13] +has demonstrated that a yogi could reduce oxygen +consumption while sealed in an airtight box for nearly +ten hours, thus changing metabolism at will. Studies +on meditation have demonstrated that Transcendental +meditation (TM),[5,6] Zen Meditation,[8] Om Meditation[7] +[Downloaded free from http://www.ijoy.org.in on Tuesday, January 06, 2009] +International Journal of Yoga + +! + +Vol. 1:1 + +! + +Jan-Jun-2008 +28 +Chaya M S and Nagendra H R +and Yogic Relaxation[14] reduce oxygen consumption, +respiratory and heart rates and spontaneous Galvanic Skin +Response (GSR).[15,16] The above changes are attributed +mainly to reduced sympathetic activity / arousal response +and decreased mental and muscular activities. +Studies done on a certain type of Pranayama (breathing +technique) called UJJAYI demonstrated a 19% increase in +oxygen consumption.[17] Right nostril breathing increased +oxygen consumption by 28%.[18] Practice of Asanas or specific +postures also increased oxygen consumption.[19,20] All these +changes have been seen as the immediate acute effect of +yoga practices. There is no literature report as to how long +these changes last or the influence these practices have on +the diurnal metabolic rates measured at two different times +of the day in experienced yoga practitioners. +A typical yoga capsule usually consists of Asana, +Pranayama and deep relaxation or meditation, which has +a combined effect but ultimately leads to deep relaxation +and reduced oxygen consumption.[4] It is believed that all +these must have some permanent effect on metabolism +when practised over a period of time, leading to efficiency +and relief from stress, thereby resulting in certain changes +in the diurnal metabolism, BMR and sleep. +Wallace et al. have reported the effect of acute practices +resulting in the reduction in metabolic rate in meditation +as compared to sleep.[5,6] The present study examines +whether there is also a long-term effect of the combined +practices. +With this background, the present study was conducted to +know: (1) Is there any difference in the diurnal metabolic +rate at two different times of the day (6 a.m. and 9 p.m.) +of trained yoga subjects compared to those in the non- +yoga group? (2) To compare the metabolic rate at 6 a.m. +with that of the subjects’ BMR values predicted by the +1985 Food and Agricultural Organization/World Health +Organization/United Nations University (FAO/WHO/UNU) +equations.[21] +SUBJECTS AND METHODS +The study was conducted at VYASA, a residential yoga +research foundation near Bangalore. Out of 140 subjects +screened, 88 (39 women, 49 men) normal, healthy subjects +(as assessed by clinical examination) were selected for the +study. These subjects were not taking any medication and +did not have any sleep disorder. They were in the age range +of 20–55 years (mean age = 33 yrs ± 9.88) with a mean +weight of 58.36 ± 8.94 kg, mean height of 1.48 meters ± +0.23 and a mean body mass index (BMI) of 21.59 ± 3.09). +The yoga group consisted of 27 men and 24 women who +were trained in yoga for a minimum period of six months +and who had been practising yoga for at least two hours +a day, five days a week for 25 days a month (Appendix +A). The non-yoga control group consisted of 22 men and +15 women who did not practice yoga but were staying +in the same yoga institute under similar environmental +conditions performing day-to-day activities of the center. +Both the groups had similar activity profiles (other than +yoga) and took the same simple vegetarian meal. The two +groups were matched for weight, age and BMI [Table 1]. +All subjects had an early, simple, non-spicy vegetarian +dinner at 6 p.m. The assessments were made early in the +morning at around 6 a.m. and between 8.30 and 9 p.m. +to eliminate the thermic effect of food on metabolism. +The subjects were randomized for assessment, 50% of +them being assessed at 9 p.m. and the other 50% at 6 +a.m. Assessments were made in the morning only after +the subjects had reported that they had slept for about +seven hours. +The subjects were made to rest in a supine position for +20–30 minutes before the assessments were made twice for +Table 1: Age and anthropometrical characteristics of men and women of Yoga and Non-Yoga groups +Groups + +Total +Men +Women + +n +51 +27 +24 +Yoga +Age (y)ns +33.44± 10.17 +33.96±9.1 +32.92±11.24 + +Weight (kg)ns +58.23± 8.53 +60.59±8.89 +55.88±8.18 + +Height (m)ns +1.49±3.4 +1.55±0.23 +1.43±0.21 + +BMI (kg/m2)ns +21.61±3.40 +21.02±3.03 +22.21±3.78 + +n +37 +22 +15 +Non-Yoga +Age (y)ns +33.75± 9.59 +34.18±9.65 +33.33±9.53 + +Weight (kg)ns +58.5±9.34 +61.73±9.43 +55.27±9.26 + +Height (m)ns +1.48± 0.24 +1.55±0.25 +1.42±0.24 + +BMI (kg/m2)ns +21.58±2.78 +21.12±2.77 +22.04±2.79 +Values are mean ± 1 standard deviation. +ns: Non-Significant between groups (Independent t test.) +m: Meters, BMI: Body mass index +[Downloaded free from http://www.ijoy.org.in on Tuesday, January 06, 2009] +29 +International Journal of Yoga + +! + +Vol. 1:1 + +! + +Jan-Jun-2008 +Yoga and metabolism +15 min each with a gap of 15 minutes. The measurements +were made in thermoneutral conditions at approximately +25ºC in quiet surroundings and the average of two +readings was taken. +The assessments were done by indirect calorimetry using +OXYCON PRO from JAEGER, Germany. The instrument +was calibrated daily for flow volume and gas analysis by +using certified gases (mixture of 5.2% CO2 in nitrogen and +atmospheric air, BOC, UK). VO2 (volume of oxygen), VCO2 +(volume of carbon dioxide), VE (Ventilation), BF (Breath +Flow), EE (Energy Expenditure) and RQ (Respiratory +Quotient) were measured by triple V sensors-fast response +gas analyzer based on the differential paramagnetic +principle using a face mask. The gas analyzer is designed +to analyze gases with a speed of 10 msec (100 Hz) with a +breathing level of up to 80 breaths per minute. +The 1985 FAO/WHO/UNU equations (26) were used +to predict values of BMR based on age, sex and body +weight. +Statistical analysis +The data was analyzed using independent t test for +comparing the yoga and non-yoga groups, paired t test for +analyzing the intragroup effects. Analysis of co-variance +was used to adjust the BMR for differences in body weights +between the groups. SPSS 10 package was used for all the +analyses. Differences were considered significant at P < +0.05 for all statistical procedures. The data is presented +as mean ± standard deviation (SD). +RESULTS +Table 2 gives the details of energy expenditure of the yoga +and non-yoga groups and their predicted values of two +different assessments taken at 6 a.m. and 9 p.m. The yoga +group showed significantly lower metabolic rates both +at 6 a.m. and at 9 p.m. when compared to the non-yoga +group (P < 0.001, P < 0.05). The 9 p.m. measurements +of the yoga group were almost equal to their predicted +values (before sleep). On the other hand, the non-yoga +group had significantly higher metabolic rates before sleep +and basal metabolic rates (SMR and BMR) comparable to +their predicted values at 6 a.m. The EE/kg body weight +values were also significantly lower in the yoga group at +6 a.m. and 9 p.m. (P < 0.01) when compared to the non- +yoga group. The yoga group had significantly lowered +values in other measured parameters as well such as +VO2 (P < 0.03), VCO2 (P < 0.05), heart rate (P < 0.01) at +9 pm when compared with the non-yoga group and had +lower values in VO2 (p<0.001), VCO2 (p< 0.05), Breath +rate (p <0.05). +Gender differences in energy expenditure and VO2 +continued even after adjusting for body weight in the yoga +group whereas no gender differences existed in the non- +yoga group after adjusting for body weight (Ancova). +DISCUSSIONS +The main result of this study is that the yoga group had +significantly lower metabolic rates at two different times +of the day, i.e., 6 a.m. and 9 p.m. when compared to the +non-yoga group. The yoga training had a beneficial effect +on metabolism in general as seen in the lowered metabolic +rate of the yoga group at 9 p.m. and reduced EE/kg body +weight suggesting greater metabolic efficiency. +An earlier study by Anand et al.[13] on a yogi shut in an +airtight box for ten hours showed reduced metabolic rate +at the end of this period. However, the basal metabolic +rate of the yogi had been within the normal range. +Wallace et al.[5,6] has shown that the practice of +transcendental meditation leads to hypometabolic states +(lowered metabolic rates) and proposed to call it the +fourth state of consciousness, different from sleep yet +metabolically equivalent or even below metabolic rates +seen during sleep. He observed a 17% reduction in oxygen +consumption during 20 min of transcendental meditation +whereas after sleep, the metabolic rate was usually +reduced by 10%.[2,3] Our study demonstrates that the acute +effects of yoga practiced over a period of time, will have +long-term effects on metabolism, leading to metabolic +efficiency (as seen in the lowered EE/kg body weight). +High-intensity exercises increase the basal metabolic +rates in subjects aged between 59–77[22] years whereas low +and moderate intensity exercises do not have any effect +on these rates.[23,24] All these exercises are mainly related +Table 2: Energy Expenditure of Yoga and Non-yoga +groups at 9 p.m. and 6 a.m. +Metabolic rate at two +Yoga +Non-Yoga +different times of the day +n = 51 +n = 37 +9 p.m. MR (Kcal.d-1) +1413.79±402.2* +1604.17±326.86 +6 a.m. MR (Kcal.d-1) +1200.57±242.41**‡ +1415.17±278.22 +6 a.m. MR (Kcal.d-1.kg-1) +20.61±4.16*‡ +24.19±4.76 +Predicted BMR (Kcal.d-1) +1385.36±165.24 +1399.51±159.94 +Predicted BMR (Kcal.d-1.kg-1) +23.79±2.84 +23.92±2.73 +Values are expressed as mean ± 1 SD. +MR: Metabolic Rate, BMR: basal metabolic rate +2. Significant at P < 0.05 comparisons between yoga and non-yoga +groups, independent t test +** Significant at P < 0.001 using 9 p.m. values as covariate (Ancova), +adjusted for body weight. +‡ Significant at P < 0.001 comparisons between yoga and non-yoga +groups. + +Independent t test compared with measured energy expenditure using +predicted values. +ns Not Significant +[Downloaded free from http://www.ijoy.org.in on Tuesday, January 06, 2009] +International Journal of Yoga + +! + +Vol. 1:1 + +! + +Jan-Jun-2008 +30 +Chaya M S and Nagendra H R +to central or sympathetic activation[25] whereas yoga is +reported to bring down sympathetic activity.[5,8,14] However, +Yoga Asana (physical posture) is an energy expenditure +activity[19,20] and hence, it was hypothesized that it would +increase the resting metabolic rate. Contrary to this +hypothesis, our study shows that Asanas when practised +along with pranayama and meditation over a period of +time actually reduce the metabolic rate. This may be due +to alterations in autonomic nervous functions leading +to autonomic stability as observed by Orme-Johnson,[15] +who found that those practising TM showed stability in +the rate of habituation, number of multiple responses +and spontaneous GSR when compared to non-meditators. +Silverman et al.[16] also observed low levels of sympathetic +activity which have been correlated with greater resistance +to stresses such as sensory deprivation. This deprivation +can be attributed to decreased arousal response (reduced +sympathetic activation) after TM meditation. +There are other yoga techniques such as Om meditation,[7] +Zen meditation,[8] Cyclic meditation[14] and certain +pranayamas (breathing techniques),[17,26] in which +decreased metabolic rate, heart rate, reduction in Oxygen +consumption, carbon dioxide elimination, breath rate, +breath volume and pulse rate were observed as acute effects +(pre- compared to post- levels). Electroencephalograms +(EEGs) recorded by Banquet et al.[27] showed predominant +alpha wave activities with increased amplitude and +frequency but few theta waves during the practice of +Transcendental meditation. Our study not only endorses +this view but also adds that the integrated approach of +yoga training can convert these short-term changes into +more permanent expressions as noticed in the changes +in metabolic rates of the yoga group at 6 a.m. and 9 p.m. +and the changes in EE/kg body weight. +The BMR which includes the cost of arousal, represents +the activation of the central and sympathetic nervous +systems from sleep to basal levels[28] and may be +influenced by various factors including control over the +state of one’s mind.[9] +The lower 6 a.m. metabolic rate of the yoga group +suggests that the combined practice of yoga has an +Table 3: Genderwise comparison of BMR of Yoga and Non-Yoga groups along with their predicted values + +Yoga +Non-Yoga +Metabolic rates at two +Women +Men +Women +Men +different times of the day +n = 24 +n = 15 +n = 27 +n = 22 +9 p.m. MR (Kcal.d-1) +1141.71±299.87ns +1639.78±265.4§ +1358.16±340.02ns +1781.51±234.35 +9 p.m. (Kcal.d-1.kg-1) +20.75±5.47 +24.32±4.8 +27.06±5.61 +28.86±3.8 +6 a.m. MR (Kcal.d-1) +1045.57±201.9**‡ +1324.62±226.16**‡ +1283.90±207.32ns +1510.67±273.92ns +6 a.m. MR (Kcal.d-1.kg-1) +18.99±3.61**‡ +22.07±4.09*‡ +23.37±3.42 +24.76±4.44 +Predicted BMR Kcal.d-1) +1242.14±93.36 +1505.96±108.77 +1256.06±90.92 +1504.9±103.24 +Values are in mean ± 1 SD +MR = Metabolic rate +** Significant at P < 0.005 comparisons between yoga and non-yoga groups +2. Significant at P < 0.05 comparisons between yoga and non-yoga groups, multivariate analysis using 9 p.m. values as covariate +‡ Significant at P < 0.001 compared to predicted values +ns Not Significant when compared with predicted values. +Table 4: Genderwise comparison of yoga and non-yoga groups in all parameters other than energy expenditure + +Yoga +Non-Yoga +Ventilatory parameter and +Women +Men +Women +Men +heart rate +n = 24 +n = 15 +n = 27 + n = 22 +9 p.m. VE [l/min] +6.15±1.64 +7.96±1.83 +6.56±1.55 +8.53±1.11 +6 a.m. VE [l/min] +5.35±1.03ns +6.17±1.00** +6.22±1.25 +7.4±1.46 +9 p.m. BF [1/min] +17.52±10.54 +14.44±4.57 +19.50±2.38 +14.8±4.13 +6 a.m. BF [1/min] +14.49±3.52* +12.43±3.72** +17.86±2.14 +14.38±3.09 +9 p.m. VO2 [ml/min] +166.15±38.83 +237.44±45.17 +195.99±37.74 +253.28±33.65 +6 a.m. VO2 [ml/min] +153.35±26.23** +195.46±27.62* +186.47±31.93 +216.29±38.8 +9 p.m. VCO2 [ml/min] +154.07±38.22 +220.00±47.09 +174.52±31.86 +238.16±30.5 +6 am VCO2 [ml/min] +140.36±25.08* +173.21±26.92** +161.81±26.41 +198.87±36.31 +9 pm HR [beats/min] +69.06±9.32 +68.16±9.06 +78.63±8.56 +72.62±8.29 +6 am HR [beats/min] +69.64±8.99ns +65.09±9.9ns +72.09±5.76 +67.84±12.45 +Values mean ± SD, ** Significant at P <0.005 genderwise comparison between yoga and non-yoga groups, multivariate analysis using 9 p.m. values as +covariate. +2. Significant at P < 0.05 genderwise comparison between yoga and non-yoga groups, multivariate analysis using 9 p.m. values as covariate +ns: Not Significant, VE: Ventilation, BF: Breath flow, VO2: Volume of oxygen +VCO2: Volume of carbon dioxide, HR: Heart rate. +[Downloaded free from http://www.ijoy.org.in on Tuesday, January 06, 2009] +31 +International Journal of Yoga + +! + +Vol. 1:1 + +! + +Jan-Jun-2008 +Yoga and metabolism +overall calming effect and is manifested as decreased +sympathetic activity.[6,7,14] Orme Johnson[15] has further +demonstrated that greater the regularity of practice, +greater was the increase in autonomic stability. This is +also amply demonstrated by the lowered metabolic rates +of the yoga group both at 6 a.m. and 9 p.m. compared +to the metabolic rates of the non-yoga group in our +study. These lower metabolic rates can be attributed to +the decreased sympathetic tone and decreased arousal +response in general and a greater ability to recover from +stressful conditions quickly. This is evident when we +look at the differences in the yoga and non-yoga groups +at 9 p.m., which existed even after adjusting for body +weight (using Ancova). +Furthermore, studies on the long-term effects of yoga +on the BMR of normal healthy volunteers have shown +that yoga groups had lower BMR compared to non-yoga +groups[4] which has also been confirmed by our study. +There are however, contradictory reports about gender +differences in SMR/BMR, a few claiming that the +differences do not exist when adjusted for Body weight, +Fat mass or Fat-Free Mass[28-30] while others claim that +gender differences exist even after accounting for these +parameters.[31,32] In our study, gender differences although +not found in the non-yoga group, existed in the yoga +group. This suggests that training in yoga may have +different effects on men and women as women respond +differently to stress.[33,34] A further detailed study on the +effect of training on gender differences along with a +detailed analysis of body composition (Fat mass, Fat-free +mass and Fat distribution) may be necessary to determine +the precise cause of these differences. +We conclude that the long-term practice of yoga leads +to lower metabolic rates and probably greater metabolic +efficiency mainly due to reduced sympathetic activity and +/ or stabilized nervous system. The main limitation of this +study is that it is not a prospective randomized control +study and hence, conclusions can not be drawn based +on these results. However, the results are consistent with +expectations based on other studies and thus, encouraging +to conduct further investigations. +APPENDIX A +Details of yoga practices done by the yoga group selected +for the study +All the subjects practise a 60–90 min capsule consisting +of Asana, Pranayama and Meditation daily for six days +a week. +Breathing +1. +Hands in and out +2. +Ankle stretch +3. +Tiger +4. +Rabbit +Loosening +1. +Heals touching +2. +Tadasana techniques +Asana Practices: Standing posture +1. +Trikona asana +2. +Parivrutha trikonasana +3. +Ardha kati Chakrasana +4. +Ardha Chakrasana +Sitting Asanas +1. +Paschimothanasan +2. +Ushtrasana +3. +Vakrasna/Matyendrasana +Supine postures +1. +Halasana +2. +Chakrasana +3. +Sarvangasana +4. +Matsyasana +Prone postures +1. +Bhujanghasana +2. +Shalabhasana +3. +Dhanurasana +Pranayama +1. +Kapala Bhathi. +2. +Nadi shuddi +3. +Omkar chanting +Meditation 5–10 minutes +REFERENCES +1. +Robinson CH, Lawler MR, Chenoweth WL, et al. Normal and therapeutic +Nutrition. 7th ed. Mc Milan Publishing Co: New York; 1986. p. 103. +[Downloaded free from http://www.ijoy.org.in on Tuesday, January 06, 2009] +International Journal of Yoga + +! + +Vol. 1:1 + +! + +Jan-Jun-2008 +32 +2. +Adam K. Sleep as a restorative process and a theory to explain why. Prog +Brain Res 1980;53:289-305. +3. +Bijlani RL. Understanding medical physiology. 2nd ed. Jaypee Brother’s +Medical Publishers: New Delhi; 1977. p. 421. +4. +Chaya MS, Kurpad AV, Nagendra HR, Nagarathna R. The effect of long term +combined yoga practice on the basal metabolic rate of healthy adults. BMC +Complement Altern Med 2006;6:28. +5. +Wallace RK, Benson H. The physiology of meditation. In: Altered States of +awareness. Readings from scientifi + c American. WH Freeman and Co: San +Francisco; 1972. p. 2. +6. +Wallace RK, Benson H, Wilson AF. A Wakeful hypo metabolic physiologic +state. Am J Physiol 1971;221:795-9. +7. +Telles S, Nagaratna R, Nagendra HR. Autonomic changes during OM +meditation. Indian J Physiol Pharmacol 1995;39:418-20. +8. +Sugi Y Akutsu K. Studies on respiration and energy metabolism during sitting +in Za Zen. Res J Physiol Educ 1968;12:190-206. +9. +Nagendra HR, Nagaratna R. New perspective in stress management. +Vivekananda Kendra Prakashana: Bangalore India; 1977. +10. Swami Nikhilananda. Mandokya Upanishad with Gaudapada Karika and +sankara’s commentary. Advaitha Ashram: Calcutta; 1995. +11. +Taimini LK. The science of yoga, The Theosophical Publishing House: +Madras, India; 1961. +12. Maharshi Mahesh Yogi. The science and art of living Los Angeles. +International SRM Publications: New York; 1972. +13. Anand BK, Chhina GS, Singh B. Studies on Shri Ramanada Yogi during his +stay in an air tight box. Indian J Med Res 1961;49:82-9. +14. Telles S, Reddy SK, Nagendra HR. Oxygen consumption and respiration +following two Yoga based relaxation techniques. Appl Psychophysiol +Biofeedback 2000;25:221-7. +15. Orme-Johnson DW. Autonomic stability and transcendental meditation. +Psychosom Med 1973;35:341-9. +16. Silverman AJ, Cohen SI, Shmavonian BM. Psycho physiologic investigation +in sensory deprivation. Psychosomat Med 1961;23:48-62. +17. Miles WR. Oxygen consumption during 3-yoga type breathing pattern. J Appl +Physiol 1964;19:75-82. +18. Telles S, Nagaratna R, Nagendra HR. Breathing through a particular nostril +can alter metabolic and autonomic activities. Indian J Physiol Pharmacol +1994;38:133-7. +19. Rai L, Ram K. Energy expenditure and ventilatory responses during Siddasana: +A yogic seated posture. Indian J Physiol Pharmocol 1994;38:29-33. +20. Rai L, Ram K. Energy expenditure and ventilatory responses during veerasana +a yogic standing posture. Indian J Physiol Pharmacol 1993;37:45-50. +21. FAO/WHO/UNU expert consultation. Energy and protein requirements. WHO +tech rep ser: 1985. p. 724. +22. Williamson DL, Kirwn JP. A single bout of concentric resistance exercise +increases basal metabolic rate in 48 hours after exercise in healthy 59-77 yrs +old men. J Gerontol A Biol Sci Med Sci 1997;52:M352-5. +23. Gilliat-Wimberly M, Manore MM, Wooly K, Swan PD, Carrrol SS. Effects of +habitual activity on resting metabolic rates and Body composition of women +aged 35-50 yrs. J Am Diet Assoc 2001;101:1181-8. +24. Ribeyre J, Fellmann N, Montaurier C, Delaitre M, Vernet J, Coudert J, +et al. Daily energy expenditure and its main components as measured by +indirect calorimetry in athletes and non-athletic adolescents. Br J Nutr +2000;83:355-62. +25. McArdle WD, Katch FI, Katch VL. Exercise physiology, 4th ed. Williams +and Wilkins: Baltimore; 1996. p. 339-55. +26. Telles S, Desi Raju T. Oxygen consumption during pranayama type of very +slow rate breathing. Indian J Med Res 1991;94:357-63. +27. Banquet JP. Spectral analysis of the EEG in meditation. Electroencephalogr +Clin Neurophysiol 1973;35:143-51. +28. Fontvielle AM, Ferraro RT, Rising R, Larsol DE, Ravussine E. Energy cost +of arousal: Effect of sex race and obesity. Int J Obes Relat Metab Disord +1993;17:705-9. +29. Goldberg GR, Prentice AM, Davies HL, Murgatroyd PR. Overnight and basal +metabolic rate in men and women. Eur J Clin Nutr 1988;42:137-44. +30. Seal JL, Conway JM. Relationship between overnight energy expenditure +and BMR measured in a room sized calorimeter. Eur J Clin Nutr +1999;53:107-11. +31. Ferro-Luzzi A, Petrachi C, Kurian R, Kurpad AV. Basal metabolism of +weight-stable chronically undernourished men and women: Lack of metabolic +adaptation and ethnic differences. Am J Clin Nutr 1997;66:1086-93. +32. Kanady AN, Gokhale MK, Rao S. Energy costs of standard activities among +Indian adults. Eur J Clin Nurt 2001;55:708-13. +33. al’Absi M, Wittermers LE Jr. Enhanced adreno cortical responses to stress +in hyper tension prone men and women. Ann Behav Med 2003;25:25-33. +34. Traustadottir T, Bosch PR, Matt KS. Gender differences in cardiovascular +and hypothalamic-pituitary-adrenal axis responses to psychological stress in +healthy older adult men and women. Stress 2003;6:133-40. +Chaya M S and Nagendra H R +[Downloaded free from http://www.ijoy.org.in on Tuesday, January 06, 2009] diff --git a/subfolder_0/Measures of mindfulness and anxiety.txt b/subfolder_0/Measures of mindfulness and anxiety.txt new file mode 100644 index 0000000000000000000000000000000000000000..5fd45b4200b4e212c20f91b63645f7ab49970eef --- /dev/null +++ b/subfolder_0/Measures of mindfulness and anxiety.txt @@ -0,0 +1,627 @@ +An Official Publication of SciBiolMed.Org +ISSN: Online 2230-8598 +www.journalonweb.com/ijmedph +Vol 4 | Issue 1 | Jan-Mar 2014 +www.ijmedph.org +SciBiolMed.Org - A non-profit private organization dedicated to +Research in the field of Science, Biology and Medicine. It provides +high quality, accurate and required information to enhance re­ +search and innovative concepts in scholarly publishing. +Editor : Dr. Subhankar Chakraborty (USA) +The journal is indexed with CAB Abstracts, Chemical Abstracts, DOAJ, + +Genamics JournalSeek, Google Scholar, Index Copernicus, National +Science Library, OpenJGate and Ulrich’s International Periodical Directory. +Vol 4, Issue 1, Jan-Mar 2014 +International Journal of +Medicine and Public Health +Online Manuscript Submission +www.journalonweb.com/ijmedph +CONTENTS +Dengue research in India: A scientometric +analysis of publications, 2003-12 +Liver disorders: A scientometric study of +publication outputs from India during +2003-2012 +Privatization of medical education in India: +A health system dilemma +Mapping the health indicators of +Chhattisgarh: A public health perspective +Reviving community medicine in India: The +need to perform our primary role +Evolution of quality in maternal health in +India: Lessons and priorities +Mobile-health technology: Can it +Strengthen and improve public health +systems of other developing countries as +per Indian strategies? A systematic review +of the literature +more in this issue....... +110 +International Journal of Medicine and Public Health | Jan-Mar 2014 | Vol 4 | Issue 1 +Deepeshwar Singh, +Ashok Vinchurkar Suhas, +Kalkuni Visweswaraiah +Naveen, Hongasandra +Ramarao Nagendra +Division of Yoga and Life +Sciences, Swami Vivekananda +Yoga Anusandhana Samsthana +(S-VYASA), SVYASA, Bengaluru, + +Karnataka, India +Address for the Correspondence: +Dr. Deepeshwar Singh, +Swami Vivekananda Yoga +Anusandhana Samsthana, +# 19 Eknath Bhavan, Gavipuram +Circle, KG Nagar, Bengaluru, +Karnataka - 560 018, India. +E-mail: deepeshwar.singh@ +gmail.com +Measures of mindfulness and anxiety +in OM meditators and non-meditators: +A cross-sectional study +Original Article +INTRODUCTION +Mindfulness meditation is an ancient concept, grounded in a wide range of spiritual and religious +traditions, including Yoga, Tai Chi, Buddhism, Zen, Taoism, Hinduism, etc. In Buddhist literature, +mindfulness is described as the awareness that emerges through paying attention, on purpose, in +the present moment, and non-judgmentally to the unfolding of experience moment by moment.[1] +Meditation can be defi + ned as the intentional self-regulation of attention from moment to moment +through which mindfulness is cultivated.[2] In the Indian yogic tradition ‘Om’ is one of the fundamental +symbol of meditation. It is the symbol of reality from which arises the three letters; namely, A, U, +and M.[3] ‘Om’ meditation helps to enhance the awareness or mindfulness to all incoming sensations, +emotions, and thoughts from moment to moment without focusing on any of them.[4] +During the last decade, scientific interest in meditation and mindfulness practice has an explosive +and unprecedented surge. Long-term practice of meditation has been found to improve sustained +attention, general well-being, mental health, enhance potency of positive feelings, and reduce anxiety.[5,6] +Additionally, meditation training has been shown to improve levels of mindfulness attention, working +memory, and creativity.[7] Practicing meditation may reduce psychophysiological arousal, improve +concentration, selective attention, and visual scanning abilities compared to resting in a supine +posture.[8,9] Mental chanting of Om (with experience of 5-20 years) showed an increase in the effi + ciency +with which sensory information was processed as revealed by activated higher neural centers, that is, +the association cortices leading to a single thought state, and a subjective feeling of deep relaxation.[10] +A cyclical combination of yoga postures and supine rest in cyclic meditation (CM) improved memory +scores immediately after the practice and decreased state anxiety more than rest in a classical yoga +Background: Meditation has been shown to be an effective practice of mindfulness +and psychological health. The aim of the study was to explore this relationship +and to investigate the role of meditation on mindfulness skills and psychological +health. Materials and Methods: Sixty-seven long-term ‘Om’ meditation practitioners +and equal number of normal healthy subjects matched to the meditators on age +(meditators: 23.96 ± 3.25 years; non-meditators: 21.72 ± 3.44 years), years of +education (meditators: 15.13 ± 1.57 years: non-meditators: 14.12 ± 1.76 years) +participated in the study. Anxiety and mindfulness were measured by the State-Trait +Anxiety Inventory (STAI) and Freiburg Mindfulness Inventory (FMI), respectively. +Statistical analyses were carried out using the Statistical Package for Social Sciences +(SPSS) software version 18.00 (SPSS Inc., Chicago, USA). The mindfulness and +state and trait anxiety scores were analyzed using one-way analysis of variance +(ANOVA) and independent t-test. Results: The meditator group showed signifi + cantly +lower state (P < 0.001) and total anxiety (P < 0.001) as compared to the non- +meditation group. ‘Om’ meditation practice was positively correlated to mindfulness +(P < 0.001), acceptance (P < 0.001), and presence (P < 0.05); and negatively +correlated to state (P < 0.01) and total anxiety (P < 0.001). Conclusions: The +practice of meditation was associated with higher levels of mindfulness and lower +levels of psychological anxiety. +Key words: Anxiety, mindfulness, Om meditation, state and trait +Abstract +Access this article online +Website: www.ijmedph.org +DOI: 10.4103/2230-8598.127170 +Quick response code: +Singh, et al.: Meditation and mindfulness and anxiety +111 +International Journal of Medicine and Public Health | Jan-Mar 2014 | Vol 4 | Issue 1 +relaxation posture (shavasana).[9] Mindfulness meditation and gentle +yoga improve mood and affective processes and are associated with +improvements in immune system functioning, stress, and emotional +regulation.[11] Meditation practice stabilizes the mind and decrease +mental proliferation which are helpful to cultivate the ethical +qualities, that is, compassion, mindfulness, loving kindness, and +forgiveness. Practicing open monitoring meditation techniques try +to enlarge the attentional focus to all incoming sensations, emotions, +and thoughts from moment to moment without focusing on any +of them is associated with increased theta activity.[12] A recent study +found that 3 days of meditation training was effective at reducing +pain ratings and sensitivity, as well as anxiety scores when compared +to baseline and other manipulations, such as relaxation and a math +distracter task. A similar training regimen improved mood and +reduced heart rate when compared to a sham meditation and control +group.[13] Finally, meditation is defi + ned as a family of complex +emotional and attentional regulatory strategies developed for various +ends, including the cultivation of well-being and emotional balance. +There are no previous studies reporting mindfulness levels of +individuals practicing meditation on the syllable ‘Om’. Therefore, +the present study was designed to measure the levels of mindfulness +and correlate the same to state and trait anxiety scores. +MATERIALS AND METHODS +Subjects +Sixty-seven Om meditators whose age ranged from 19 to 27 (23.96 ± +3.25 years) were recruited for the study. An equal number of normal +healthy male participants (n = 67) matched for their age, gender, and +years of education were selected. G power (two-tailed) was used to +calculate the sample size. With alpha set to 0.05 and power at 0.95, +to get an effect size of 0.8, the calculated sample size was 42 in each +group.[14,15] The non-meditator group had no previous experience +of any form of meditation. All participants were recruited from +Swami Vivekananda Yoga Anusandhana Samsthana (S-VYASA)—a +Yoga University, Bangalore, India. These participants were recruited +by announcements in the University newsletter and fl + yers on the +notice boards. The inclusion criteria were as follows: i) No any +chronic illness, particularly psychiatric, or neurological disorders; +ii) male volunteers alone; iii) all meditators had been practicing +meditation on the Sanskrit syllable, ‘Om’ for 30-200 min each day, +for 5 days in a week; and iv) had a minimum of 1 year experience +in meditation. None of the potential participants were excluded +using these conditions. The demographic indices of meditators and +non-meditators are outlined in Table 1. Signed informed consent +was obtained from all participants following a detailed explanation +of the study. The study was approved by the Institutional Ethics +Committee of the S-VYASA University. +Assessments +This cross-sectional survey aimed to collect data concerning +mindfulness and state and trait anxiety using the Freiburg +Mindfulness Inventory (FMI) and State-Trait Anxiety Inventory +(STAI), respectively. +The description of measurements are given below. +The FMI +We used one-dimensional 14-item short version of FMI which +was found to be semantically robust and psychometrically stable +(Cronbach’s alpha = 0.83).[16] All items were scored on a 4-point +Likert scale (0: rarely; 1: occasionally; 2: fairly often; 3: almost always). +Scores range from 8 to 32, with higher scores indicating higher levels +of mindfulness. The FMI measures trait mindfulness and has been +shown to have good psychometric properties including a high internal +consistency (alpha of 0.86 in an initial validation study), and it has been +shown to correlate positively with health indicators.[17] Furthermore, the +scale was able to differentiate between mindfulness practitioners and +non-practitioners. The two proposed subfacets of the FMI, presence +(items 1,2,3,5,7,10), and acceptance (items 4,6,8,9,11,12,14) was then +tested separately. This scale is semantically independent from a Buddhist +or meditation context and is applicable to all population groups. +State and Trait Anxiety Scale +The anxiety levels were assessed using a questionnaire ‘State-Trait +Anxiety Inventory’ (STAI).[18] This is a self-report assessment +anxiety scale, which includes separate measures of state and trait +anxiety. State anxiety (S-anxiety) is defi + ned as a transitory emotional +state characterized by consciously perceived feeling of tension +and apprehension. Trait anxiety (T-Anxiety) refers to relatively +stable individual differences in anxiety proneness. Depending on +the characteristics of the stressful stimulus conditions, individuals +experience differential levels of state anxiety as a function of their +level of trait anxiety. The STAI consists of two separate subscales +that contain 20 items each. The items are in the form of statements +people used to describe themselves. The essential qualities evaluated +are feelings of apprehension, tension, nervousness, and worry. Both +subscales (S-Anxiety and T-Anxiety) use a 4-point Likert scale to +allow the subject to show how often or how much each question +applies to them in both situations. It has high internal consistency +with Cronbach’s alpha of 0.73. Also, the test is designed to take +only 20 min at the maximum to reduce the amount of fl + uctuations +in S-Anxiety that could become apparent if the test was to go for +a long period of time. +Table 1: Mean group differences of two groups +and standard deviations +Characteristics +Mean ± SD +Mean age +Meditators +23.6 ± 3.25 +Non-meditators +21.72 ± 3.44 +Years of education +Meditators +15.13 ± 1.57 +Non-meditators +14.12 ± 1.76 +Meditation experience (years) +Meditators +7.85 ± 2.37 +Singh, et al.: Meditation and mindfulness and anxiety +112 +International Journal of Medicine and Public Health | Jan-Mar 2014 | Vol 4 | Issue 1 +These questionnaires were showing the relations among mindfulness +and anxiety in participants of meditator and non-meditator groups. +Data collection +Each participant was assessed in 2 consecutive days at the same +time. Participants were requested to use any necessary visual aids +(i.e., glasses and contact lenses). On the day 1, participants in each +group carried out the FMI fi + rst followed by the STAI on the day 2 at +a time. To ensure each item was carefully considered and participants +were advised they had an unlimited amount of time to complete +the questionnaire. Participants received a recording blank with +the front page on top and a pencil without an eraser. Participants +were instructed as per the instructions stipulated on the manual of +the questionnaires. Testing began once participants had confirmed +they understood the given instructions. Participants were advised to +provide answer as honestly and spontaneously as possible for every +statement. The scoring was done by a person who was unaware +when the assessment was made and whether the assessment was +meditation group or control group. +Statistical analysis +The scores were analyzed using one-way analysis of variance +(ANOVA). One-way ANOVA compared mindfulness and state and +trait anxiety scores and independent t-test were used to compare +mindfulness and anxiety of the data in ‘Om’ meditators and non- +meditators. Partial correlation (r) with meditation experience and +anxiety and mindfulness is given in Table 1. All statistical analyses +were computed at P ≤ 0.05, two-tailed, using PASW Statistics 18.00 +(SPSS Inc., Chicago). +RESULTS +The age and years of education status were reported no signifi + cant +difference in the meditation and non-meditation groups. An +independent sample t-test and one-way ANOVA were performed +to assess the difference in state and trait anxiety, and mindfulness in +both the groups. The groups mean values ± SD, Cohen’s d (effect +size) for age, years of education, FMI mindfulness (mindfulness, +acceptance, and presence), and STAI scores (state, trait, and total +scores) are given in Table 2. The analysis on the FMI scores showed +that participants in meditation group reported higher mindfulness +scores in all three factors, mindfulness (F = 3.85, P > 0.001, t = +5.01), acceptance (F = 7.152, P < 0.001, t = 4.78), and presence +(F = 1.85, P =0.038, t = 2.10) compared to the participants in the +non-meditation group. The non-meditation group shows higher +anxiety as their state scores of STAI were higher than participants +in the meditation group. Results showed that ‘Om’ meditation group +have signifi + cantly higher mindfulness and less state anxiety compared +to non-meditator group in the age-matched control group. +Partial Correlation (r) with meditation experience +and anxiety and mindfulness +As shown in Table 2, the STAI scale and FMI strongly correlated +with years of meditation experience. There was negative correlation +found between meditation experience and STAI scores (state, trait, +and total anxiety), while there was a strong positive correlation +between years of meditation practice and FMI mindfulness scores +(acceptance and presence). There was also a positive correlation +between years of meditation with age and years of education. +DISCUSSIONS +In the present study, long-term meditators reported signifi + cantly +lower state anxiety and total anxiety scores of STAI and higher +level of total mindfulness scores, acceptance, and presence of FMI +compared to the non-meditators. There was a strong, positive, +partial correlation between experience of meditation with the total +scores of mindfulness, acceptance, and presence; while there was +a negative correlation with state and total anxiety. The acceptance +component of the mindfulness scale is related to the nonjudgmental +acceptance of the situation, while mindfulness presence is related +to the experience of the moment and a cognitive reelection of all +actions.[19] Meditation aims to teach more accepting relationship of +one’s thought rather than emphasizing the creating of more positive +or adaptive thoughts. Longer meditation experience reported more +frequent meditation with higher mindfulness and lower psychological +distress. However, meditation techniques effectively showed, reduce +self-reported state and trait anxiety.[5] +Several studies of meditation to date have reported correlations +between self-reported mindfulness and psychological health. For +example, Lykins and Baer (2009)[20] reported significantly higher +Table 2: Means and standard deviations, analysis of variance (ANOVA), and partial correlations (control +age and years of education) for FMI and STAI scores for meditator and non-meditator groups +Characteristic +Meditators +Non-meditators +F +Percentage +change (%) +Cohen’s d +(effect size) +Partial correlation +(r) with meditation +experience +State-Trait +Anxiety Inventory +(STAI) +S-STAI +26.24±10.21 +32.75±8.29 +16.29*** +24.81 +0.700 +–0.329*** +T-STAI +31.12±10.02 +33.44±7.36 +2.29 (NS) +7.46 +0.263 +–0.114 (NS) +Total-STAI +57.36±9.87 +65.69±10.57 +22.01*** +14.52 +0.815 +–0.0363*** +Freiburg +Mindfulness +Inventory (FMI) +Mindfulness +45.42±5.22 +40.34±6.42 +25.05*** +11.18 +0.868 +0.355*** +Acceptance +24.53±4.21 +20.81±4.75 +22.86*** +15.17 +0.829 +0.328*** +Presence +20.89±3.49 +19.54±3.94 +4.42* +6.46 +0.363 +0.176* +*P < 0.05, ***P < 0.001 signifi + cance level, NS = Not signifi + cant +Singh, et al.: Meditation and mindfulness and anxiety +113 +International Journal of Medicine and Public Health | Jan-Mar 2014 | Vol 4 | Issue 1 +levels of mindfulness, self-compassion, and overall sense of +wellbeing; and significantly lower levels of psychological symptoms, +rumination, thought suppression, fear of emotion, and difficulties +with emotion regulation in meditators compared to non-meditators, +and changes in these variables were linearly associated with extent +of meditation practice. Linehan (1993)[21] describes the development +of mindfulness skills as a central goal of several behavior therapy, +a leading mindfulness-based intervention. There was a strong +consistency between extent of meditation practice with trait +mindfulness as well as and other outcome variables, including fear +of emotions, rumination, and behavioral correlations.[22] Moreover, +participants in the meditation group showed more mindfulness and +were also more likely to cope with stress in adaptive ways, particularly +using less avoidant-oriented strategies in stress situations.[23] +Mindfulness meditation has been found to regulate anxiety. In +a recent study on mindfulness meditation reported signifi + cant +reduction in state anxiety scores after meditation session.[24] In the +present study, we reported a strong positive correlation between +experience of meditation and state anxiety and total anxiety; but +there was no signifi + cant relation with trait anxiety. Our fi + ndings are +consistent with previous studies that have found an inverse relation +between mindfulness, stress, and state anxiety. +The trait anxiety represents a generalized tendency to be fearful, +worried, and apprehensive about the future. It also reflects +individual differences in the frequency and intensity with which +anxiety states have been manifested in the past. The stronger trait +anxiety may report more intense elevations in state anxiety in a +threatening situation. There was no signifi + cant difference in trait +anxiety of meditators and non-meditators in the present study +because participants in both the groups were young and healthy. The +immediate effect of a 30 min practice of a meditation technique +called CM on state and trait anxiety was measured in normal healthy +volunteers, which showed signifi + cantly better reduction in state +anxiety after the CM and improve memory.[9] +Feldman et al., (2010)[25] compared the immediate effects of +mindful breathing to alternative stress management techniques +(progressive muscle relaxation and loving-kindness meditation) +in novice meditators, demonstrated greater decentering when +compared to those receiving the two alternative interventions; there +was also reduced frequency of repetitive thoughts and negative +reactions to thoughts. These fi + ndings provide further evidence +that cognitive aspects of meditation (e.g., mindful breathing) may +create changes in cognitive processes[26] associated with depression +and anxiety (e.g., rumination) that are distinct from other validated +stress management approaches. Mindfulness meditation is also +documented to contribute for better coping in individuals in high +stress work environments, such as medical students[5] or business +executives, and community members enrolled in a wellness +program. +Although studies on neurophysiological changes reported the +positive impact of meditation training on brain regions responsible +for constructs that are often dysregulated in individuals with +depression and anxiety disorders. Recently, majority of functional +neuroimaging studies investigated brain regions like the anterior +cingulate cortex (ACC) and the insula were shown to be involved +in the development and maintenance of anxiety disorders.[27] +Meditation-related anxiety relief was associated with activation +of the ACC, ventromedial prefrontal cortex, and anterior insula. +Meditation-related activation in these regions exhibited a strong +relationship to anxiety relief. During meditation, those who +exhibited greater default-related activity (i.e., posterior cingulate +cortex (PCC)) reported greater anxiety, possibly refl + ecting an +inability to control self-referential thoughts. Meditation showed +changes in activation of prefrontal cortex (PFC) and the Anterior +Cingulate Cortex (ACC), as well as signifi + cant increases in alpha +and theta activity.[28] In addition, theta activity was found to be +more common in experienced meditators, suggesting that greater +meditation expertise may result in improved ability to self-regulate +a state of deep relaxation.[29] These fi + ndings are important to +demonstrate a neurobiological impact of meditation on brain +structures and regions (i.e., PFC, hippocampus, and limbic system) +that are well-known to be affected in individuals with anxiety and +depression. Several other studies show that meditation can reverse +some abnormalities, like depression, anxiety, attention defi + cit, and +posttraumatic stress disorder; producing salutary functional and +structural changes in the brain. The mindfulness programs reported +positive impact on symptoms of anxiety and depression,[30] as +well as improvements in sleep patterns and sustained attention.[31] +After several researches on meditation and mindfulness; however, +clear mechanisms of change have yet to be identifi + ed. There are +different behavioral, psychological, and biological pathways which +have suggested how enhanced mindfulness may displace stress and +anxiety-related illness and enhancing adaptive coping processes. +In summary, the present study suggested that, the intense practice +of meditation on the symbol ‘Om’ may enhance mindfulness and +reduce anxiety. Meditation techniques have been used to regulate +the mind, emotions, and the responses in adverse psychological +conditions. Therefore, meditation would be a mind body medicine +which helps in the modulation of expectations, inner engagement, +anxiety, and self-awareness. +CONCLUSION +In conclusion, the results suggest that mindful person may be less +prone to anxiety-related problem. Mindfulness practice will help to +increase awareness and problem solving strategies of the present +moment which would facilitate effective processing as a means to +enhance mental health and well-being. Further study of meditation +and mindfulness may help to better disclose how the quality and +depth of meditation infl + uence mindfulness and enhancing adaptive +strategies for anxiety and its related problems. Also, additional +research is needed to clarify the mechanisms of change that +are responsible for the benefi + cial effects of meditation on both +psychological and physical health. +Singh, et al.: Meditation and mindfulness and anxiety +114 +International Journal of Medicine and Public Health | Jan-Mar 2014 | Vol 4 | Issue 1 +ACKNOWLEDGMENTS +The present study was supported by Swami Vivekananda Yoga Research +Foundation (S-VYASA) is gratefully acknowledged. +REFERENCES +1. +Kabat-zinn J. Mindfulness-based interventions in context : Past, present, +and future. Clin Psychol (New York) 2003;10:144-56. +2. +Corsini RJ. Handbook of innovative therapy. Volume 204 of Wiley Series +on Personality Processes. Ed. 2, illustrated, the University of Michigan: +Wiley; 2001. +3. +Sivananda S. Japa yoga: A comprehensive treatise on mantra-sastra. +Shivanandanagar India: Divine Life Society; 1972. +4. +Lutz A, Slagter HA, Rawlings NB, Francis AD, Greischar LL, Davidson +RJ. Mental training enhances attentional stability: Neural and behavioral +evidence. J Neurosci 2009;29:13418-27. +5. +Shapiro SL, Schwartz GE, Bonner G. Effects of mindfulness-based +stress reduction on medical and premedical students. J Behav Med +1998;21:581-99. +6. +Wachholtz AB, Pargament KI. Is spirituality a critical ingredient of +meditation? Comparing the effects of spiritual meditation, secular +meditation, and relaxation on spiritual, psychological, cardiac, and pain +outcomes. J Behav Med 2005;28:369-84. +7. +Orme-Johnson D, Granieri B. The effects of the age of enlightenment +governor training courses on fi + eld independence, creativity, intelligence, +and behavioral fl + exibility. Scientifi + c research on the Transcendental +Meditation Program: Collected papers. Vol. 1. [Bad Bellingen, Germany]: +Maharishi European Research University Press, 1977. +8. +Sarang SP, Telles S. Immediate effect of two yoga-based relaxation +techniques on performance in a letter-cancellation task. Percept Mot +Skills 2007;105:379-85. +9. +Subramanya P, Telles S. Effect of two yoga-based relaxation techniques +on memory scores and state anxiety. Biopsychosoc Med 2009;3:8. +10. +Telles S, Desiraju T. Recording of auditory middle latency evoked +potentials during the practice of meditation with the syllable “OM”. Indian +J Med Res 1993;98:237-9. +11. +Davidson RJ, Kabat-Zinn J, Schumacher J, Rosenkranz M, Muller D, +Santorelli SF, et al. Alterations in brain and immune function produced by +mindfulness meditation. Psychosom Med 2003;65:564-70. +12. +Mu Y, Han S. Neural oscillations involved in self-referential processing. +Neuroimage 2010;53:757-68. +13. +Zeidan F, Johnson SK, Gordon NS, Goolkasian P. Effects of brief and +sham mindfulness meditation on mood and cardiovascular variables. +J Altern Complement Med 2010;16:867-73. +14. +van den Hurk PA, Wingens T, Giommi F, Barendregt HP, Speckens AE, +van Schie HT. On the relationship between the practice of mindfulness +meditation and personality—an Exploratory Analysis of the Mediating +Role of Mindfulness Skills. Mindfulness (N Y) 2011;2:194-200. +15. +Erdfelder E, Faul F, Buchner A. GPOWER: A general power analysis +program. Behav Res Methods Instrum Comput 1996;28:1-11. +16. +Baer RA, Smith GT, Lykins E, Button D, Krietemeyer J, Sauer S, et al. +Construct validity of the fi + ve facet mindfulness questionnaire in meditating +and nonmeditating samples. Assessment 2008;15:329-42. +17. +Leigh J, Bowen S, Marlatt GA. Spirituality, mindfulness and substance +abuse. Addict Behav 2005;30:1335-41. +18. +Spielberger CD, Gorsuch RL, Lushene R, Vagg PR, Jacobs GA. Manual +for the state-trait anxiety inventory. PaloAlto: Consulting Psychologists +Press; 1983. +19. +Kohls N, Sauer S, Walach H. Facets of mindfulness - Results of an online +study investigating the Freiburg Mindfulness Inventory. Pers Individ Dif +2009;46:224-30. +20. +Lykins EL, Baer RA. Psychological functioning in a sample of long-term +practitioners of mindfulness meditation. J Cogn Psychother 2009;23:226-41. +21. +Linehan M. Skills Training Manual for Treating Borderline Personality +Disorder. Diagnosis and Treatment of Mental Disorders. Illustrated, +Guilford Publication; 1993. +22. +Josefsson T, Larsman P, Broberg AG, Lundh LG. Self-reported +mindfulness mediates the relation between meditation experience and +psychological well-being. Mindfulness 2011;2:49-58. +23. +Chang VY, Palesh O, Caldwell R, Glasgow N, Abramson M, Luskin F, +et al. The effects of a mindfulness-based stress reduction program on +stress, mindfulness self-effi + cacy, and positive states of mind. Stress +Health 2004;20:141-7. +24. +Zeidan F, Martucci KT, Kraft RA, McHaffi + e JG, Coghill RC. Neural +correlates of mindfulness meditation-related anxiety relief. Soc Cogn +Affect Neurosci 2013. +25. +Feldman G, Greeson J, Senville J. Differential effects of mindful +breathing, progressive muscle relaxation, and loving-kindness meditation +on decentering and negative reactions to repetitive thoughts. Behav Res +Ther 2010;48:1002-11. +26. +Ramel1 W, Goldin PR, Carmona PE, McQuaid JR. The effects of +mindfulness meditation on cognitive processes and affect in patients with +past depression. Cognit Ther Res 2004;28:433-55. +27. +Holzschneider K, Mulert C. Neuroimaging in anxiety disorders. Dialogues +Clin Neurosci 2011;13:453-61. +28. +Cahn BR, Polich J. Meditation states and traits: EEG, ERP, and +neuroimaging studies. Psychol Bull 2006;132:180-211. +29. +Chiesa A, Serretti A. Mindfulness-based interventions for chronic pain: A +systematic review of the evidence. J Altern Complement Med 2011;17:83-93. +30. +Baer RA. Mindfulness training as a clinical intervention: A conceptual and +empirical review. Clin Psychol (New York) 2003;10:125-43. +31. +Jha AP, Krompinger J, Baime MJ. Mindfulness training modifi + es +subsystems of attention. Cogn Affect Behav Neurosci 2007;7:109-19. +How to cite this article: Singh D, Suhas AV, Naveen KV, Nagendra +HR. Measures of mindfulness and anxiety in OM meditators and +non-meditators: A cross-sectional study. Int J Med Public Health +2014;4:110-4. +Source of Support: Nil, Confl + ict of Interest: None declared. diff --git "a/subfolder_0/Measuring the tridosha symptoms of unm\304\201da (psychosis)_a preliminary study.txt" "b/subfolder_0/Measuring the tridosha symptoms of unm\304\201da (psychosis)_a preliminary study.txt" new file mode 100644 index 0000000000000000000000000000000000000000..f6a5d74ba687f205a20513215ba8924d8e443bef --- /dev/null +++ "b/subfolder_0/Measuring the tridosha symptoms of unm\304\201da (psychosis)_a preliminary study.txt" @@ -0,0 +1,709 @@ +Measuring the Tridosha Symptoms of Unma +¯da (Psychosis): +A Preliminary Study +Sureshrao P. Suchitra, M.Sc., +1 Honagalli S. Devika, M.Sc., +1 Bangalore N. Gangadhar, M.D., +2 +Raghuram Nagarathna, M.D., F.R.C.P.(Edin), +1 Hongasamudra R. Nagendra, Ph.D., +1 +and Ravi Kulkarni, Ph.D. +1 +Abstract +Objective: This is a preliminary report on the development of a scale to measure the symptoms of unma +¯da +(psychosis) attributable to tridos +.a (metabolic principles) by using the concepts of Ayurvedic medicine. +Design: The 67-item unma +¯da specific symptom scale was developed on the basis of translation of Sanskrit verses +describing va +¯taja (V), pittaja (P), and kaphaja (K) unma +¯da (specific symptoms of psychosis due to the imbalances of +metabolic components) and by taking the opinions of experts (15 Ayurveda experts, 5 psychiatrists, and 5 +psychologists). +Settings: The setting for this study was Spandana Psychiatric Nursing Home Bangalore, India. +Subjects: The scale was administered by an unblinded assessor to 30 consecutive patients with nonaffective +psychotic disorders. +Results: The unma +¯da specific symptom scale was associated with excellent internal consistency. The Cronbach’s a +for V, P, and K scales were 0.98, 0.98, and 0.97, respectively. The split-half reliability for V, P, and K scales were +0.97, 0.97, and 0.88 respectively. Scores on va +¯taja, pittaja, and kaphaja scales were inversely correlated, suggesting +that they are mutually exclusive. The three subgroups of psychoses—paranoid schizophrenia, schizophrenia +(unspecified), and unspecified nonorganic psychosis—had significantly different loadings on the three scores, +having high scores on va +¯taja, pittaja, and kaphaja, respectively. +Conclusions: The tridoshas in psychotic disorders can be measured reliably by this instrument. The scores on each +of these dos +¸as help in differentiating three types of psychosis (according to A +¯ yurveda) that have good corre- +spondence with prevailing classification. However, this scale must also be applied to the other 28 separate +subcategories of the psychoses that are identified in the International Statistical Classifications of Diseases +(version 10) and to the 10 variants of psychosis as defined by the American Psychiatric Association Diagnostic +and Statistical Manual-IV-R to help better understand the true utility for use here with the various subcategories +of schizophrenia. +Introduction +A +yurveda, the science of life, is essentially based on the +principles of tridosha: va +¯ta, pitta, and kapha. Tridoshas are +metabolic principles (va +¯ta is responsible for movement, pitta is +responsible for metabolism, and kapha is responsible for +binding) that determine the physical and mental constitution +of an individual.1–4 A genetic basis for tridosha constitution +has been suggested.5 Ayurveda classics state1: ‘‘Rogastu dosha +vaishamyam, dosha sa +¯myam arogata’’ [vitiation of doshas is dis- +ease and balance of doshas gives health]. In Ayurveda, +psychosis is described as unma +¯da.1–4 Furthermore, these +scriptures have proposed three distinct types (va +¯taja, pittaja +and kaphaja) in unma +¯da (psychosis) determined by the corre- +sponding doshas. These types of unma +¯da carry etiological, +pharmacological, and prognostic importance. Accordingly, +classic Ayurvedic texts explain the different types of treat- +ments including the diet for each dosha-related disorder. +Several literary studies6–9 are available in the area of +concepts of mental illness in Atharva Veda and A +¯ yurveda +classics. Studies also explain about the traditional classifica- +tion of mental illnesses as described in the ancient texts of +A +¯ yurveda. The possible correlation with the modern classi- +fication has also been explained. +A +study, +proposing +independent +scientific +evidence +for the identification of the dosha, is available.10 Studies on +1Department of Life Sciences, SVYASA University, Bangalore, India. +2Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India. +THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE +Volume 16, Number 4, 2010, pp. 457–462 +ª Mary Ann Liebert, Inc. +DOI: 10.1089=acm.2009.0296 +457 +quantification of tridoshas are available (e.g., a questionnaire +to assess the constitution of an individual developed on the +basis of classical description and opinions of the experts is +available11). A preliminary version of model interview to +identify the doshas has been published.12 +A simple and standardized instrument to measure the types +of psychoses according to Ayurvedic concepts is not available. +Hence, the present investigation was carried out to develop +and evaluate an unma +¯da-specific symptom scale (USS). +Methods +USS was developed based on 75 Sanskrit statements +(items) from available, authoritative, and ancient texts de- +scribing symptoms typical of va +¯taja, pittaja, and kaphaja unma +¯da +(psychosis). Translated into English, these items were pre- +sented to 5 Ayurveda experts, they were asked about cor- +rectness of each statement, and to check whether any of the +items were repeated. Of these, 72 items agreed on by all +5 experts were retained. The three items dropped had similar +meanings. Ten (10) independent senior Ayurveda doctors +examined each item further to indicate whether (1) the +symptoms of va +¯taja, pittaja, and kaphaja unma +¯da selected for +the scale are correct, and (2) it is an acceptable translation of +the Sanskrit statements in the original texts. On their sug- +gestions, some items were refined. +Items were then presented to 5 psychiatrists. For each +item, they were asked to indicate whether these statements +can be presented to patients with psychotic disorders and +informants. All 72 items were found suitable. Five (5) inde- +pendent psychologists reviewed the format of this scale and +recommended a two-point scoring (0 and 1), which was +adopted in the final USS. +Description of final scale +The USS has 72 items: 25 items for va +¯taja unma +¯da, 24 items +for pittaja unma +¯da, and 23 items for kaphaja unma +¯da subscales. +A clinician (using scripted interview) administered the scale +and marked the presence or absence of each feature as 0 or 1 +on the basis of responses of both the patient and the infor- +mant. The score of each subscale is the sum of all positive +responses (Appendix 1). +Subjects +The patients in this study were outpatients from Spandana +Psychiatric Nursing Home in Bangalore. Consecutive con- +senting patients of both sexes (15 males) with an age range of +22–55 years (mean  standard deviation age ¼ 38.6  10.2 +years) formed the sample (n ¼ 30). A senior psychiatrist, S. +Srinivas, with 25 years of experience with clinical interviews, +diagnosed these patients as paranoid schizophrenia (n ¼ 17), +schizophrenia, unspecified (n ¼ 7), and unspecified nonor- +ganic psychosis (n ¼ 6) according to International Classifi- +cation of Diseases, 10th Revision (ICD-10). All these patients +were under treatment for 6 months or longer and were ac- +companied with an informant who had lived with the pa- +tient since the onset of the disease or longer. +The 72-item USS was administered and rated by an author +(S.P.S.) based on the information from the patient and the +informant. The Statistical Package for Social Sciences (SPSS- +10) was used for data analysis. +The item difficulty level was first assessed. The data were +next analyzed for reliability. The split-half and Cronbach’s a +tests were applied for reliability analysis. Pearson’s correla- +tion analysis was done to check the degree of association +between va +¯ta, pitta, and kapha scores. The differences in mean +scores of each diagnostic group were analyzed, using the +Kruskal-Wallis test. +Results +Content validity +Of the 10 A +¯ yurveda experts, who served as judges, 6 of +them agreed on all 72 items of the USS. Three (3) judges +agreed on 95% and 1 on 85% of the items. +Item difficulty level +This is defined as the presence of a said symptom ex- +pressed as the percentage of patients who score positive to +that item.13 Items that had poor difficulty level (absent in +>50% of patients) were V5 and V6 (absent in 70%), P24 +(absent in 89.5%), and K9 and K10 (absent in 89.5%). Data +analysis was carried out after deleting the five items with +low difficulty level. Final analysis was done on 67 items of +the scale. +Internal consistency +The Cronbach’s alpha for V, P and K scales were 0.98, 0.98, +and 0.97, respectively. The split-half reliability for V, P, and K +scale were 0.97, 0.97, and 0.88, respectively. This shows that +the three scales have good internal consistency.14 +Correlations +The subscales correlated significantly (negatively) with +each other: +V vs. P ¼ 0.55 p < 0.05, V vs. K ¼ 0.53 p < 0.05, and P vs. +K ¼ 0.35 p < 0.05 +Typological validation +To determine whether USS differentiated different types +of psychoses (paranoid, schizophrenia, unspecified and un- +specified nonorganic psychosis), comparisons of mean scores +were done. Nearly all patients (16=17) with paranoid +schizophrenia scored above the 75th percentile of the va +¯taja +score. Likewise, all patients with schizophrenia, unspecified +scored above the 75th percentile of the pittaja score and all +patients with unspecified nonorganic psychosis scored above +the 75th percentile of the kaphaja score (Table 1). +Discussion +This preliminary study has described the development of +a 67-item (symptoms of three doshas in unma +¯da), interview- +based, unma +¯da specific symptom scale (USS) as an instru- +ment for measuring tridosha (va +¯taja, pittaja, and kaphaja) in +psychotic disorders. +Items of USS were generated from Sanskrit statements +described in available, authoritative texts of Ayurveda. +Content validity from 15 Ayurveda experts, and the opinion +of 5 psychiatrists and 5 psychologists were used to refine the +items in the scale. The subscales were constructed mainly on +the basis of theoretical and psychometric considerations. +458 +SUCHITRA ET AL. +Primary empirical analysis indicated that the items selected +were appropriate to constructs. After item analysis, 67 items +were retained. Correlation between va +¯taja, pittaja, and kaphaja +scale scores was negative, suggesting discriminative validity +(Table 2). The reliability of subscales of USS was supported +by the Cronbach’s a coefficient and the split-half analysis. +This provided the evidence of stability over items. +Applying the scale to the patients with psychosis further +validated these three dimensions of doshas. Nearly all pa- +tients of (F20.0) paranoid schizophrenia scored above the +75th percentile of the va +¯ta dosha subscale, all patients of +(F20.9) schizophrenia unspecified scored above the 75th +percentile of the pitta dosha subscale, and all patients of (F29.) +unspecified nonorganic psychosis scored above the 75th +percentile of the kapha dosha subscale (Table 1). +Though the study provides evidence of categorizing pa- +tients on the basis of doshas, diagnosis of three categories was +not established by using standard instruments or methods. +Additional studies are required to confirm these findings in a +similar set of patients and with those blinded to the con- +ventional diagnoses. This tridosha scale has inherent limita- +tions. As its name indicates, it can classify individuals into +three subtypes, va +¯ta, pitta, and kapha. To examine its utility in +classifying patients with psychotic disorder, we had a sam- +ple of 30 patients with functional psychotic disorder at- +tending the outpatient clinic. It is a coincidence that the +diagnoses in this unselected sample were only three. Psy- +chotic disorders have been classified into many other types. +ICD-10 lists 28 more diagnostic subtypes as can be subsumed +under functional psychoses. Therefore, the sample studied +cannot be considered representative. Also, the diagnoses +were made on ICD-10.15 (Appendix 2 provides other sub- +categories of schizophrenia in ICD-10). Yet another widely +used diagnostic system, DSM-IV-TR (Diagnostic and Statistical +Manual for Psychiatric Diagnosis, 4th edition, text revision)16 +was not used in the study. However, paranoid schizophre- +nia, schizophrenia unspecified, and unspecified nonorganic +psychosis categories of ICD-10 correspond to paranoid +schizophrenia (295.30), schizophrenia undifferentiated type +(295.9), and psychosis not otherwise specified (298.90), re- +spectively, according to DSM-IV-TR classification. However, +diagnosis corresponding to the other 10 categories of DSM- +IV-TR, namely: disorganized schizophrenia (295.10), cata- +tonic schizophrenia (295.20), residual type of schizophrenia +(295.60), schizophreniform disorder (295.40), schizoaffective +disorder (295.70), delusional disorder (297.1), brief psychotic +disorder (298.8), shared psychotic disorder (297.3), psychotic +disorder due to general medical condition with delusions +(293.81), psychotic disorder due to general medical condition +with hallucinations (293.82) were not included in the study. +Furthermore, it remains to be seen whether the tridosha +scale can classify the corresponding diagnoses in DSM-IV- +TR, which is a diagnostic system that has been developed by +the American Psychiatric Association (1992). These limita- +tions demand a study on this scale to include a larger and +representative sample that has been diagnosed on both di- +agnostic systems using a structured instrument. Such a study +can indicate which diagnostic subtypes are included in each +of the tridosha types. +The raters in this study were not blinded to the original +diagnosis. There is also a need to demonstrate inter-rater +reliability, test–retest reliability, criterion validity, construct +validity, and treatment effects on this scale. +In the current psychiatric practice, all three subtypes of +psychoses would have received antipsychotic drugs. No +guide is available to match each of these diagnoses with a +drug. On the other hand, the tridosha profile differentiates +these psychoses subtypes. A +¯ yurveda provides different +matched management plans for each dosha (viz., diet). The +instrument reported here may thus have a potential use in +clinical practice to help treatment matching in Ayurveda. +Conclusions +The results here suggest that the Unma +¯da Specific Scale +merits serious further study as an instrument to measure +tridoshas symptoms of psychotic disorders. +The scores of patients from three diagnostic categories on +each of the subscales (Va +¯ta, Pitta, and Kapha) help in sub- +classifying unma +¯da, which has good correspondence with +prevailing classification of psychosis. However, this is a +preliminary result. Larger studies employing blinded re- +viewers are necessary to help confirm the validity of the scale +and its overall use for diagnosis and treatment of the psy- +choses. A tridosha measure may point to a better choice of +treatment options using Ayurveda. +Table 1. Scores of All Subjects in Three Dos +¸a Scales +Scale +Mean +SD +Range +>75%a +Va +¯ta (V) +13.96 +9.66 +1–23 +16 +Pitta (P) +7.66 +8.25 +2–23 +7 +Kapha (K) +5.00 +7.07 +1–21 +6 +The percentile scores of all the subjects in three subscales are +shown. +aSixteen (16) subjects who scored above 75 percentile of the va +¯taja +score belonged to the paranoid schizophrenia category. Likewise, +subjects (n ¼ 7) who scored above 75 percentile of the pittaja score +were the patients with schizophrenia not otherwise specified (NOS) +scored and subjects (n ¼ 6) who scored above the 75th percentile of +the kaphaja score were the patients with psychosis NOS. +SD, standard deviation. +Table 2. Mean  Standard Deviation Dosha Scores for Three Different Diagnostic Groups +Dos +.a ? diagnosis ; +Va +¯taja +Pittaja +Kaphaja +Siga +Paranoid schizophrenia (n ¼ 17) +21.76  1.52 +3.52  1.12 +1.52  1.00 +p < 0.001 +Schizophrenia unspecified (n ¼ 7) +3.574  98 +22.42  0.79 +1.00  0.0 +p < 0.001 +Unspecified nonorganic psychosis (n ¼ 6) +2.83  1.94 +2.83  1.16 +20.5  1.22 +p < 0.001 +Bolding shows that three groups scored differently in different scales. +aKruskal-Wallis test. +Sig, significance. +TRIDOSHA SYMPTOMS OF UNMA +¯DA (PSYCHOSIS) +459 +Acknowledgments +We thank Dr. Srinivas, Director, Spandana Psychiatric +Nursing Home, Dr. Kishore, Ph.D. scholar, the National In- +stitute of Mental Health and Neurosciences, and Ayurveda +experts in Government A +¯ yurveda College, Bangalore for +their support and participation in the study. +Disclosure Statement +No competing financial interests exist. +References +1. Tripati R. Ashtanga Sangraha: Hindi Commentary, 2nd ed. +New Delhi: Choukamba Publications, 2001. +2. Tripati B. Ashtanga Hradaya: Hindi Commentary, 2nd ed. +New Delhi: Choukamba Publications, 1997. +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. Patwardhan B, Joshi K, Chopra A. Classification of human +population based on HLA gene polymorphism and the +concept of Prakriti in Ayurveda. J Altern Complement Med +2005;11:349–353. +6. Balodhi JP, Chowdhary JR. Psychiatric concepts in Atharva- +veda Veda: A Review. Indian J Psychiatry 1986;28:63–68. +7. Varma LP. Psychiatry in Ayurveda. Indian J Psychiatry +1965;5:292–312. +8. Venkoba R. A psychiatric thought in Ancient India. Indian J +Psychiatry 1978;20:107–119. +9. Weiss MG, Sharma SD, Gaur RK, et al. Traditional concepts +of mental disorder among Indian psychiatric patients: Pre- +liminary report of work in progress. Social Sci Med +1986;23:379–386. +10. Hankey A. A test of the systems analysis underlying the +scientific theory of Ayurveda Tridosa. J Altern Complement +Med 2005;11:385–390. +11. Joshi RR. A biostatistical approach to Ayurveda: Quantify- +ing the tridosa. J Altern Complement Med 2005;11:221–225. +12. Weiss MG, Desai A, Jadhar S, et al. Humoral concepts of +mental illness in India. Social Sci Med 1988;27:471–477. +13. Anastasi A, Urbina S. Psychological Testing, 7th ed. New +Delhi: Pearson Education, 2005. +14. Nunnaly JC. Psychometric Theory, 2nd ed. New York: +McGraw-Hill, 1978. +15. World Health Organization. International Classification of +Diseases. 10th ed. Geneva: WHO, 1992. +16. American Psychiatric Association. Diagnostic and Statistical +Manual of Mental Disorders. 4th ed, text revision. New +Delhi: Jaypee Brothers Medical Publishers, 2000. +Address correspondence to: +Sureshrao P. Suchitra, M.Sc. +Department of Life Sciences +Swami Vivekananda Yoga Anusandhana Samsthana (SVYASA) +Eknath Bhavan, No. 19 +Gavipuram Circle, Kempegowda Nagar +Bangalore 560043 +India +E-mail: svyasablr@yahoo.com +(Appendix follows ?) +460 +SUCHITRA ET AL. +Appendix 1. Unma +¯da Specific Symptom Scale +Va +¯taja unma +¯da +1. Parisaran +. +.amjasram (running about without ceasing) +2. Satatamaniyanam ca gira +¯ (continues irregular speech) +3. Abhiks +´n +.asmitahasitanrtyagı +¯tava +¯di +(frequent +excessive +smiling, laughing, singing, and dancing in improper +situation) +4. Vı +¯n +.as +´ankhas +´a +¯myata +¯ls +´abda +¯nukaranamsa +¯mna (opposite imi- +tation of vı +¯na, flute, s +´ankha, etc.) +5. Ya +¯namya +¯nai (riding a vehicle that is not meant for riding) +6. Alankaran +.amanalankarikairdravai (doing make-up with +the things not meant for make-up) +7. Lobhas +´cbhyavyavaharais +´valabdhes +´u ca +¯vamanastı +¯vram (de- +siring for the things not available, disrespecting the +things available) +8. Ma +¯tsarya (jealousy) +9. Ka +¯rs +´ya (emaciation) +10. Pa +¯rus +¸ya (harshness of body) +11. Utpindit +.a +¯runaks +´ata (protruded eyeball) +12. Rodana (crying) +13. Arunas +´a +¯rı +¯ra (redness of the body) +14. Jı +¯rnebalam (increases after digestion) +15. Ru +¯ks +´achavi (dryness of the body) +16. Parus +.ava +¯k (coarse voice) +17. Dhamanı +¯tata (prominent veins) +18. S +´ı +¯ta +¯tura (Affected by the cold things) +19. Sphutita anga sandhi (crackling sound in joints and +body) +20. Aasphot +.ati (trembling) +21. At +.ati (wandering) +22. Vikros +´a (abusing) +23. Bhrama (to go astray) +24. A +¯ kros +´a (loud cry) +25. Bahubha +¯s +.ita (excessive talking) +Pittaja unma +¯da +1. Amars +.a (impatience) +2. Krodha (anger) +3. Samrambhas +´cha +¯stha +¯ne (violence) +4. S +´a +¯stralos +.t +.raka +¯shaka +¯s +¸thamus +¸t +¸ibhirabhihananam (beating by +weapon,stone, wood, hand) +5. Abhidravan +.am (attacking) +6. Praccha +¯yas +´ı +¯todaka +¯nna +¯bhilas +¸a (desiring for shadow, cold +food, and water) +7. Santa +¯ps +´ca +¯tivelam (feeling hot in cold season also) +8. Ta +¯mraharitaha +¯ridrasamrabdha +¯ks +´ata (red, yellow, green, +inflamed eyes) +9. Vinagnabha +¯va (moving nakedly) +10. Santarjana (threatening) +11. Atidravan +.am (excessive running) +12. Us +.n +.a (hot) +13. Ros +.a (raised temper) +14. Pı +¯ta ca (yellowishness of body) +15. Tris +.n +.abahula (excessive thirst) +16. Swedabahula (excessive sweat) +17. Da +¯habahula (excessive burning sensation) +18. Bahubhukh (excessive hunger) +19. Vinidra (less sleep) +20. Hima +¯nilajala +¯nta viha +¯ra sevi (wants to go river banks) +21. Tı +¯ks +.n +.a (sharp, strong) +22. Hima +¯mbunicayeapi sa vanhis +´ankhi (suspects fire in snow) +23. Diva +¯ nabhasi pas +´yati ta +¯raks +´aca (sees stars in daytime) +24. Santa +¯pa (fever) +Kaphaja unma +¯da +1. Stha +¯namekades +´e (sitting in one place) +2. Tu +¯rs +.nibhava (silence, without speaking) +3. Alpacankraman +.a (less walking) +4. La +¯las +´inghanaka sravanam (excessive secretion of saliva +and mucus) +5. Ananna +¯bhilas +.a (not desiring food) +6. Rahaska +¯mata (wants loneliness) +7. Bhı +¯bhatsatvam (feeling disgusting) +8. S +´oucadwes +.a (hating cleanliness) +9. Swapnanityata (sleeping all the time) +10. S +´wyatura +¯nane (swelling of the face) +11. S +´uklastimitamalopadigdha +¯ks +´atvam (white, dirty, stilled +eyeball) +12. Arocaka (not feeling like eating) +13. Na +¯riviviktapriyata (desiring sex) +14. Chardi (vomiting) +15. Nakha +¯dis +´ouklyam (whiteness of nails, etc.) +16. Agnisa +¯da (reduced appetite) +17. Ka +¯sa (cough) +18. Alpamati (dull) +19. Alpa praca +¯ra (less wandering) +20. Alpa kathana (doesn’t like to mingle with people) +21. Alpa bhukh (eating less) +22. Us +.n +.asevi (desires for hot things) +23. Ra +¯trou bhrs +´am (aggravates at night) +TRIDOSHA SYMPTOMS OF UNMA +¯DA (PSYCHOSIS) +461 +Appendix 2. List of Schizophrenia Subcategories +According to International Classification +of Diseases,10th Revision +(F20.0) Paranoid schizophrenia +(F20.1) Hebephrenic schizophrenia +(F20.2) Catatonic schizophrenia +(F20.3) Undifferentiated schizophrenia +(F20.4) Postschizophrenic depression +(F20.5) Residual schizophrenia +(F20.6) Simple schizophrenia +(F20.8) Other schizophrenia (cenesthopathic schizophrenia, +schizophreniform disorder NOS, schizophreniform psychosis +NOS) +(F20.9) Schizophrenia, unspecified +(F21.) Schizotypal disorder +(F22.) Persistent delusional disorders +(F22.0) Delusional disorder +(F22.8) Other persistent delusional disorders (delusional +dysmorphophobia, involutional paranoid state, paranoia +querulans) +(F22.9) Persistent delusional disorder, unspecified +(F23.) Acute and transient psychotic disorders +(F23.0) Acute polymorphic psychotic disorder without +symptoms of schizophrenia +(F23.1) +Acute +polymorphic +psychotic +disorder +with +symptoms of schizophrenia +(F23.2) Acute schizophrenia-like psychotic disorder +(F23.3) Other acute predominantly delusional psychotic +disorders +(F23.8) Other acute and transient psychotic disorders +(F23.9) Acute and transient psychotic disorder, unspecified +(F24.) Induced delusional disorder ( folie deux, induced +paranoid disorder, induced psychotic disorder) +(F25.) Schizoaffective disorders +(F25.0) Schizoaffective disorder, manic type +(F25.1) Schizoaffective disorder, depressive type +(F25.2) Schizoaffective disorder, mixed type +(F25.8) Other schizoaffective disorders +(F25.9) Schizoaffective disorder, unspecified +(F28.) Other nonorganic psychotic disorders, chronic hal- +lucinatory psychosis +(F29.) Unspecified nonorganic psychosis +462 +SUCHITRA ET AL. diff --git a/subfolder_0/Meditative states based on yoga texts and their effects on performance of a cancellation task..txt b/subfolder_0/Meditative states based on yoga texts and their effects on performance of a cancellation task..txt new file mode 100644 index 0000000000000000000000000000000000000000..26d78d120c2ebf435637e4b376da352405c6f5fc --- /dev/null +++ b/subfolder_0/Meditative states based on yoga texts and their effects on performance of a cancellation task..txt @@ -0,0 +1,533 @@ +Perceptual and Motor Skills, 2009, 109, 3, 679-689. © Perceptual and Motor Skills 2009 +DOI 10.2466/PMS.109.3.679-689 +ISSN 0031-5125 +MEDITATIVE STATES BASED ON YOGA TEXTS AND THEIR EFFECTS +ON PERFORMANCE OF A LETTER-CANCELLATION TASK1 +SANJAY KUMAR AND SHIRLEY TELLES +Indian Council of Medical Research, Centre for Advanced Research +in Yoga and Neurophysiology, SVYASA, Bangalore, India +Summary.—Performance in a six-letter cancellation task was studied in 35 male +experienced meditators with experience ranging from 6 to 12 months. Each par­ +ticipant was studied in four sessions, two Meditation and two Control sessions. +The Control sessions were (i) Cancalata or nontargeted thinking and (ii) Ekagrata or +focusing on a single topic, in this case, meditation. The Meditation sessions were +(i) Dharana or focusing on the symbol “OM” and (ii) Dhyana or an effortless single- +thought (of OM) state. Ekagrata and dharana differ in that the former involves fo­ +cusing with multiple thoughts whereas the latter involves focusing with a single +thought, i.e., the significance of OM. The net scores on the six-letter cancellation +task were significantly higher after a session of Dharana and lower after the Canca­ +lata session, while there was no significant change after Ekagrata and Dhyana ses­ +sions. Focusing on the symbol OM in Dharana may favorably influence selective +attention, concentration, visual scanning abilities, and a repetitive motor response +compared to other sessions. +Meditation has been described as training in awareness, which when +practiced over a period of time produces definite changes in perception, +attention, and cognition (Brown, 1977). During meditation, a state charac­ +terized by deep relaxation and increased internalized attention is reached +(Murata, Takahashi, Hamada, Omori, Kosaka, Yoshida, et al., 2004). From +the late 1960s there have been many studies on the effect of practicing +meditation in both inexperienced as well as experienced meditators. These +are too numerous to cite here, though two early and often cited studies on +the effects of Transcendental Meditation2 were by Wallace (1970) and Wal­ +lace, Benson, and Wilson (1971). Many of these early studies showed that +meditation practice is associated with reduced sympathetic activity and +in some cases increased parasympathetic nervous system activity. Howev­ +er, for Transcendental MeditationTM, Zen meditation, and Ananda Marga +meditation techniques, findings have been contradictory. +In the case of Transcendental MeditationTM, Wallace, et al., (1971) re­ +ported that 36 volunteers with an average of 29.4 mo. experience in Tran­ +scendental MeditationTM showed a decrease in oxygen consumption, re­ +duced heart and breath rates, decreased blood lactate, and an increase in +1Address all correspondence to Shirley Telles, Ph.D., Patanjali Yogpeeth, Maharishi Day­ +anand Gram, Bahadrabad, Haridwar, 249402, Uttarakhand, India, or e-mail (shirleytelles@ +gmail.com). +2Service mark registration number in the USA:1082923, www.uspto.gov. +S. KUMAR & S. TELLES +680 +slow alpha and occasional theta in the EEG. Another early study suggest­ +ed that Transcendental MeditationTM was associated with greater auto­ +nomic stability based on the rate of galvanic skin resistance habituation, +as well as a decrease in the number of responses and spontaneous fluctua­ +tions in the skin resistance (Orme-Johnson, 1973). These are examples of +the majority of studies on Transcendental MeditationTM, suggesting that +the practice is associated with autonomic stability and sympathetic with­ +drawal. In contrast, a single report suggested that meditators with greater +experience of Transcendental MeditationTM had higher sympathetic ner­ +vous system activity (Lang, Dehof, Meurer, & Kaufmann, 1979). In this +study, long-term meditators (with 2 to 3 years of experience in Transcen­ +dental MeditationTM) had lower 24-hr. urinary catecholamines compared +to those with more experience of Transcendental MeditationTM, described +as advanced meditators, whose average experience of Transcendental +MeditationTM was 4.1 yr. +There have been fewer studies of Zazen meditation; inconsistent ef­ +fects were reported for this eyes-open technique. Hirai (1960) described +an increase in heart rate during meditation, while Sugi and Akutsu (1968) +found a decrease in oxygen consumption in meditators practicing Zazen. +Similarly, two contradictory reports were also found for Ananda Marga +meditation, which involves concentration and attention directed to an in­ +ward or outward focus. In one report, basal skin conductance increased +during meditation (Corby, Roth, Zarcone, & Kopell, 1978). Based on these +findings, the authors challenged the relaxation model of meditation, in +spite of an earlier published report of Ananda Marga meditation which +showed an increase in galvanic skin resistance, a decrease in breath rate, +and a more stable EEG with increased alpha and theta activity (Elson, +Hauri, & Cunis, 1977). +Hence, these early studies on Transcendental MeditationTM, Zazen +meditation, and Ananda Marga meditation do not support a single model +of meditation as being either activating or relaxing. In these studies, medi­ +tators were compared to nonmeditating controls. A subsequent study as­ +sessed the same individual in meditation and non-meditation sessions, +each repeated three times on separate days (Telles & Desiraju, 1993). For +the group as a whole, different subdivisions of the sympathetic nervous +system (e.g., cardiac, sudomotor, and cutaneous vasomotor subdivisions) +modified variously in meditation. Efferent sympathetic nerves can bring +about changes suggestive of both increased and decreased activity in dif­ +ferent parts of the body simultaneously. This also did not support the idea +that meditation is associated with reduced sympathetic activity. Based on +such studies, meditation is increasingly considered a state of alert rest. +This is particularly the case as recent neuroimaging studies have shown +that mindfulness meditation is associated with increased activation in +CANCELLATION TASK: PERFORMANCE IN MEDITATIVE STATES +681 +parts of the brain related to attention (Brefczynski-Lewis, Lutz, Schaefer, +Levinson, & Davidson, 2007). +Interestingly, this concept of meditation being a state of increased +attention differs from descriptions in ancient yoga texts, assumed to be +written by expert practitioners. In Patanjali’s Yoga Sutras (circa 900 BC), +two meditative states are described (Taimini, 1986). The first is dharana +(or focusing with effort), confining of the mind within a limited mental +area (“desha-bandhash chittasya dharana,” Patanjali’s Yoga Sutras, Chapter +3, Verse 1). The next stage is dhyana or effortless expansion (“tatra pra­ +tyayaikatanata dhyanam,” Patanjali’s Yoga Sutras, Chapter 3, Verse 2), the +uninterrupted flow of the mind toward the object chosen for meditation. +The practice of dharana is supposed to precede the practice of dhyana. Fol­ +lowing this logic, it may be speculated that in studies which reported that +meditation increased sympathetic activity, meditators were in the dharana +stage, since increased sympathetic activity is associated with increased at­ +tention and vigilance (Fredrikson & Engel, 1985). Likewise, reports of re­ +duced sympathetic activity in meditators practicing the same meditation +technique could indicate that meditators were in the dhyana stage at the +time. Basing hypotheses on ancient texts that could be misinterpreted is +entirely speculative, but such hypotheses are testable. Such research can +provide insights into the meanings of these texts and the process of medi­ +tation itself. +There have been no studies so far which have attempted to assess the +effects of the two stages of meditation separately. This is mainly because +meditators pass from one stage to another during meditation, with no +change in behavior marking their shift from one stage to the next. In the +present study, participants were specially trained to practice dharana and +dhyana separately. Dharana and dhyana are, in fact, the last two of four stag­ +es, which form a continuum in the process and practice of meditation. The +first two stages are cancalata (Bhagavad Gita, Chapter 6, Verse 34; Saraswati +& Swami, 1998), which is a stage of random thinking. This is followed by +ekagrata (Bhagavad Gita, Chapter 6, Verse 12), during which the attention is +directed to a series of associated thoughts. These thoughts are preferably +related to meditation, to facilitate the next two stages, dharana and dhyana. +The present study used a simple letter-cancellation task to measure +attention and concentration in individuals before and after (a) a cancala­ +ta (or random thinking session), (b) an ekagrata session with attention di­ +rected to several thoughts related to meditation, (c) dharana, focusing on +thoughts about the object of meditation, and (4) dhyana, a stage without +focusing but contemplating the object of meditation. A control group of +non-meditators was used for comparison. It was thought that this would +help to understand whether the descriptions of meditation as a state of +S. KUMAR & S. TELLES +682 +alert rest or improved attention may be better understood if the effects of +dharana and dhyana practice on an attentional task were studied separately. +Method +Participants +The study was carried out on 70 normal male volunteers from Swami +Vivekananda Yoga Research Foundation, Bangalore, South India. Health +status was verified by a routine case history and clinical examination. +None of them were taking any medications. Thirty-five participants were +meditators with an age range of 22 to 38 years (M age = 28.0, SD = 3.8). The +control group consisted of 35 male volunteer nonmeditators with an age +range of 22 to 38 years (M age = 27.3, SD = 3.3). All meditators had been +practicing OM meditation for 30 min. per day, 4 days each week, with ex­ +perience ranging from 6 to 12 months. Meditation on OM was practiced as +the states of dharana and dhyana. Their meditation practice was based on +self-report as well as (where possible) consultations with the meditation +teacher (guru). All participants expressed willingness to participate in the +experiment. The project was approved by the Institutional Ethics Commit­ +tee. The study protocol was explained to the subjects and their signed in­ +formed consent was obtained. +Procedure +Thirty-five meditators were assessed in four sessions each (i.e., Eka­ +grata, Dharana, Dhyana, and Cancalata) and 35 nonmeditators were as­ +sessed in one Control session. A session consisted of 20 min. of practice. +The details of the yoga techniques are explained below. +The assessments were made on four different days, not necessarily +on consecutive days, but at the same time of day. Each volunteer was as­ +sessed in four separate sessions and the control group of non-meditators +was assessed at the beginning and end of a single session during which +they were asked to sit and relax for 20 min. in the same posture as that of +the meditators. The allocation of meditators to the four sessions was ran­ +domized. This was done to minimize the influence of exposure to the lab­ +oratory for the first time. Assessments were made immediately before and +after each session. +Assessments +The procedure for testing has been described earlier (Sarang & Telles, +2007) and is detailed below. +The six-letter cancellation task was presented on a worksheet which +specified the six target letters to be cancelled; below that was a working +section composed of letters of the alphabet arranged randomly in 22 col­ +umns and 14 rows. The participants were asked to cancel as many of the +CANCELLATION TASK: PERFORMANCE IN MEDITATIVE STATES +683 +six target letters as possible in the specified time of 90 sec. They were told +that there were two possible strategies, i.e., marking out all six letters at +one pass, or selecting one target letter to cancel, making multiple passes. +Participants were asked to choose whichever strategy suited them. They +were also told that they could follow a horizontal, vertical, or a random +path according to their choice (Natu & Agarwal, 1997). +The scoring was done by a person who was unaware when the assess­ +ment was made and whether the assessment was before or after the ses­ +sion. Each cancelled letter was scored as 1 irrespective of whether it was +correctly or incorrectly cancelled. The total number of cancellations and +errors (wrong cancellations) was counted. Net scores were calculated by +deducting the number of errors from the total cancellations. As this test +was administered before and immediately after the intervention, to avoid +the test-retest effects, parallel worksheets were prepared for each session +by changing the target letters and the sequence of letters in the working +section. The reliability and validity of the task have been established for +use in an Indian population (Agarwal, Kalra, Natu, Dadich, & Deswal, +2002). +Yoga Techniques +Throughout all sessions, participants kept their eyes closed and fol­ +lowed prerecorded instructions. The instructions emphasized carrying +out the practice slowly, with awareness and relaxation. The meditators +who participated in the study underwent a month of orientation sessions +where they practiced separately the two stages which normally form a +continuum in meditation (dharana and dhyana) as described above, as two +distinct sessions. The four sessions were Cancalata, or nontargeted think­ +ing; Ekagrata, listening to a lecture on meditation, with multiple, yet as­ +sociated thoughts; Dharana, meditative focusing on the symbol OM; and +Dhyana, an effortless single-thought state. +During the Cancalata session (nontargeted thinking), the participants +were directed to allow their thoughts to wander freely as they listened to a +prerecorded general conversation from a local radio station transmission. +During the Ekagrata practice, participants listened to a lecture on medita­ +tion. The Dharana session consisted of meditative focusing on the meaning +of the Sanskrit syllable OM, a symbol for the entire universe, represent­ +ing that which sustains everything (Mandukya Upanishad; Chinmayanan­ +da, 1984). The Dhyana session consisted of meditation with supposed ef­ +fortless absorption with the object of meditation. For the two meditation +sessions (Dharana and Dhyana) and the other two sessions (Cancalata and +Ekagrata), participants were given guided instructions using an audio re­ +cording relevant to the respective sessions. The control session consisted +of sitting and relaxing in the same posture as that of the meditators. All +S. KUMAR & S. TELLES +684 +sessions (Dharana, Dhyana, Cancalata, Ekagrata, and Control) constituted a +practice of 20-min. duration. +Data Analysis +Statistical analysis was done using SPSS Version 10.0. The total net +scores were analyzed using repeated-measures analysis of variance +(ANOVA). These four ANOVAs compared performance on the letter-can­ +cellation task for the groups participating in the four meditation sessions +with the control group. For each ANOVA, there was one between-subjects +factor (Groups: Meditation, Control) and one within-subjects factor (Time: +Presession, Postsession). Post hoc analyses compared the performances be­ +fore and after a session, and compared the performance after each medi­ +tation session with the control session. All comparisons were Bonferroni +adjusted from p < .05. +Results +The groups’ means and standard deviations were compared for to­ +tal scores, error scores, and net scores before and after Cancalata, Ekagrata, +Dharana, Dhyana and Control sessions (see Table 1). +The repeated-measures ANOVA on performance after the sessions +showed a significant interaction between Group and Time in Dharana and +Control sessions for total scores (F1,68 = 14.54, p < .001, Huynh-Feldt epsi­ +lon = 1.00; η2 = 0.18) and net scores (F1,68 = 11.67, p < .001, Huynh-Feldt ep­ +silon = 1.00; η2 = 0.15). There was a significant effect of Time after Canca­ +lata and Control sessions for total scores (F1,68 = 49.8, p < .001, Huynh-Feldt +epsilon = 1.00; η2 = 0.42 ), net scores (F1,68 = 40.6, p < .001, Huynh-Feldt ep­ +silon = 1.00; η2 = 0.37), and error scores (F1,68 = 4.2, p < .05, Huynh-Feldt ep­ +silon = 1.00; η2 = 0.06). There was a significant interaction between Group +and Time after Cancalata and Control sessions for total scores (F1,68 = 14.42, +p < .001, Huynh-Feldt epsilon = 1.00; η2 = 0.16) and net scores (F1,68 = 10.94, +p < .01, Huynh-Feldt epsilon = 1.00; η2 = 0.14). There was a significant ef­ +fect of Time after Dhyana and Control sessions for total scores (F1,68 = 4.47, +p < .05, Huynh-Feldt epsilon = 1.00; η2 = 0.06), for net scores (F1,68 = 5.08, +p < .05, Huynh-Feldt epsilon = 1.00; η2 = 0.07), and for error scores (F1,68 = 4.2, +p < .05, Huynh-Feldt epsilon =  1.00; η2 = 0.01). +Total and net scores were significantly higher after the Dharana ses­ +sion compared to before (ps < .02), whereas after the Cancalata as well as +the Control sessions these scores were significantly lower (ps < .0001, .05, +respectively). No significant change was observed from before to after the +other sessions for the letter-cancellation task. Total scores after Cancalata +(p < .01) and Dharana (p < .01) sessions were significantly different from to­ +tal scores after the Control session. The net scores after the Dharana ses­ +sions were significantly higher compared to net scores after the Control +session (p < .05). +CANCELLATION TASK: PERFORMANCE IN MEDITATIVE STATES +685 +TABLE 1 +Total Scores, Net Scores, and Error Scores in Letter-cancellation Task Before and After +Sessions of Cancalata, Ekagrata, Dharana, and Dhyana Meditation and Control Relaxation +Variables and Time +Cancalata (n = 35) +Ekagrata (n = 35) +Dharana (n = 35) +Dhyana (n = 35) +Control (n = 35) +M +SD +M +SD +M +SD +M +SD +M +SD +Total Scores +Before +35.26 +9.87 +31.54 +9.20 +32.60 +8.90 +36.96 +11.43 +34.40 +9.19 +After +26.60‡aa +6.82 +31.69 +9.39 +37.49†aa +11.78 +35.11 +9.23 +31.80* +7.03 +Net Scores +Before +34.11 +10.44 +30.97 +8.71 +32.60 +8.79 +36.46 +11.46 +34.03 +9.19 +After +26.17‡ +6.86 +31.23 +9.54 +36.94†a +12.31 +34.51 +9.55 +31.51* +7.07 +Error Scores +Before +1.14 +2.05 +0.57 +1.44 +0.23 +0.60 +0.23 +0.60 +0.37 +0.88 +After +0.40* +0.60 +0.46 +1.15 +0.29 +0.79 +0.60 +1.58 +0.29 +0.58 +Note.—*p < .05, †p < .01, ‡p <  .001, ANOVA with Bonferroni adjustment: comparisons of performance before and after sessions. Ap < .05, AAp < .01, +ANOVA with Bonferroni adjustment, comparing performance after cancalata, ekagrata, dharana, and dhyana meditation with performance after +control relaxation. +S. KUMAR & S. TELLES +686 +Discussion +The present study assessed the performance in a letter-cancellation +task before and after meditative focusing (dharana), meditative defocusing +or an effortless single-thought stage (dhyana), nontargeted thinking (can­ +calata), listening to a lecture on meditation (ekagrata), and a Control ses­ +sion. The net scores were higher after meditative focusing (dharana) alone, +while the net scores were lower after nontargeted thinking (cancalata) and +after the Control session. +Several studies have shown an improvement in the efficiency of ex­ +ecutive or orientational processing following meditation (“orientation to +specific objects in the attentional field”; Chan & Woollacott, 2007). There +are also reports of changes associated with increased concentration and +attention. For example, in Zen meditators an increase in both sympathet­ +ic and parasympathetic indices during the appearance of frontal midline +theta rhythm compared to control periods has been reported (Kubota, +Sato, Toichi, Murai, Okada, Hayashi, et al., 2001). The frontal midline the­ +ta rhythm is a distinct theta activity which reflects mental concentration +associated with a low anxiety state. This finding suggests that meditation +brought about a relaxed state with heightened internalized attention and +concentration. +The contingent negative variation (CNV) is an event-related potential +occurring between a warning stimulus and an imperative stimulus requir­ +ing a response (Walter, Cooper, Aldridge, McCallum, & Winter, 1964). A +study of the contingent negative variation amplitude was the basis of as­ +sessing the effect of meditation on attention to external objects (Travis, +Tecce, Arenander, & Wallace, 2002). The effects of transcendent experi­ +ences occurring during the practice of Transcendental MeditationTM on the +contingent negative variation amplitude, rebound, and distraction effects +were studied by Travis, et al. (2002). The observed changes suggested that +transcendent experiences could enhance cortical responses and executive +functioning. +Another event-related potential, P300, was shown to change follow­ +ing the practice of a meditation technique called cyclic meditation (Sarang +& Telles, 2006a). Cyclic meditation consists of cycles of “stimulating” and +“calming” practices. The P300 peak latency was reduced to a greater ex­ +tent following cyclic meditation compared to an equal-duration period of +supine rest. The P300 latency reflects the speed of stimulus classification +and is an index of stimulus processing, rather than response generation +(Polich, 2004). The P300 peak latency is negatively correlated with mental +function in normal persons; shorter latencies are associated with superior +cognitive performance in tasks for attention and immediate memory. +In two separate studies, following yoga breathing techniques (Telles, +CANCELLATION TASK: PERFORMANCE IN MEDITATIVE STATES +687 +Raghuraj, Maharana, & Nagendra, 2007) and following cyclic meditation, +there was an improvement in performance in a letter-cancellation task +(Sarang & Telles, 2007). Since the letter-cancellation task assesses selec­ +tive attention and concentration (Uttl & Pilkenton-Taylor, 2001), these re­ +sults support the idea of improved attention following cyclic meditation. +The cancellation task also showed correlation with other tasks for cogni­ +tive ability and sustained attention (Amador-Campos & Kirchner-Nebot, +1999). Cyclic meditation practice also was associated with a decrease in +oxygen consumption (Telles, Reddy, & Nagendra, 2000; Sarang & Telles, +2006c) and changes in the heart rate variability suggestive of vagal domi­ +nance and/or sympathetic withdrawal (Sarang & Telles, 2006b). Hence cy­ +clic meditation—as mentioned earlier for Zen Meditation (Kubota, et al., +2001)—was characterized by both relaxation and alertness. There is a sim­ +ilarity between dharana meditation and cyclic meditation, despite many +dissimilarities in the practices, as there is a focusing of attention in both of +them. In dharana meditation the attention is directed to the object of medi­ +tation (in this case, the syllable OM), whereas in cyclic meditation the at­ +tention is directed toward sensations occurring in the body during the +practice. +In the present study, attention alone was measured using a cancella­ +tion task. There was no attempt to assess objective indicators of relaxation +and arousal simultaneously. The present results suggest that meditative +focusing (dharana) may be the phase during which attention improves. +This study was an attempt to assess the two stages of meditation described +in an ancient yoga text, the Patanjali’s Yoga Sutras (Patanjali, circa 900 BC). +When the effects of these two stages were assessed separately, the first +stage called dharana was associated with improved performance on an at­ +tention task, whereas the second stage, dhyana, did not change the perfor­ +mance on the same task. The fact that the performance was reduced after +relaxation in the group of nonmeditator controls, and following nontar­ +geted thinking by meditators (Cancalata session), suggests that the Eka­ +grata and the Dhyana sessions influence performance so that the reduction +seen after the Control session was not seen after the Ekagrata or Dhyana +sessions. The reason for this is not known. +One of the main limitations of the study is that the participants were +volunteers who also were experienced in meditation. The volunteers may +have had their own ideas about the effects of dharana and dhyana medita­ +tion, and these ideas, as well as their interest in and enthusiasm for medi­ +tation, may have influenced the outcome of the study. Apart from this the +fact that the participants were volunteers may make it less possible to gen­ +eralize the findings. The Control group may have felt deprived of the ad­ +ditional attention from or interaction with the yoga instructor; this could +S. KUMAR & S. TELLES +688 +possibly be associated with poor motivation for the task. Additional care +(in this case, interaction with the yoga instructor) is known to have psy­ +chological benefits (Delbanco, 1993). Further studies using other objective +measurements would substantiate these findings and help to understand +the mechanisms involved. +REFERENCES +Agarwal, A. K., Kalra, R., Natu, M. V., Dadich, A. P., & Deswal, R. S. (2002) Psycho­ +motor performance of psychiatric inpatients under therapy: assessment by paper +and pencil tests. Human Psychopharmacology: Clinical & Experimental, 17, 91-93. +Amador-Campos, J. A., & Kirchner-Nebot, T. (1999) Correlations among scores on +measures of field dependence–independence cognitive style, cognitive ability, +and sustained attention. Perceptual and Motor Skills, 88, 236-239. +Brefczynski-Lewis, J. A., Lutz, A., Schaefer, H. S., Levinson, D. B., & Davidson, R. J. +(2007) Neural correlates of attentional expertise in long-term meditation practi­ +tioners. Proceedings of the National Academy of Sciences of the United States of America, +104, 11,483-11,488. +Brown, D. P. (1977) A model for the levels of concentrative meditation. International +Journal of Clinical and Experimental Hypnosis, 25, 236-273. +Chan, D., & Woollacott, M. (2007) Effects of level of meditation experience on at­ +tentional focus: is the efficiency of executive or orientation networks improved? +Journal of Alternative and Complementary Medicine, 13, 651-658. +Chinmayananda, S. (1984) Mandukya Upanishad. Bombay, India: Sachin. +Corby, J. C., Roth, W. T., Zarcone, V. P. J. R., & Kopell, B. S. (1978) Psychophysi­ +ological correlates of the practice of Tantric Yoga meditation. Archives of General +Psychiatry, 35, 571-577. +Delbanco, T. (1993) The healing roles of doctor and patient. In B. Moyers (Ed.), Heal­ +ing and the mind. New York: Doubleday. Pp. 7-23. +Elson, B. D., Hauri, P., & Cunis, D. (1977) Physiological changes in yoga meditation. +Psychophysiology, 14, 52-57. +Fredrikson, M., & Engel, B. T. (1985) Cardiovascular and electrodermal adjustments +during a vigilance task in patients with borderline and established hypertention. +Journal of Psychosomatic Research, 29, 235-246. +Hirai, T. (1960) Electroencephalographic study on the Zen Meditation (ZAZEN)–EEG +changes during concentrated relaxation. Psychiatry Neurology Japan, 62, 76-105. +Kubota, Y., Sato, W., Toichi, M., Murai, T., Okada, T., Hayashi, A., & Sengoku, A. +(2001) Frontal midline theta rhythm is correlated with cardiac autonomic ac­ +tivities during the performance of an attention demanding meditation procedure. +Cognitive Brain Research, 11, 281-287. +Lang, R., Dehof, K., Meurer, K. A., & Kaufmann, W. (1979) Sympathetic activity and +Transcendental Meditation. Journal of Neural Transmission, 44, 117-135. +Murata, T., Takahashi, T., Hamada, T., Omori, M., Kosaka, H., Yoshida, H., & Wada, Y. +(2004) Individual trait anxiety levels characterizing the properties of Zen medi­ +tation. Neuropsychobiology, 50, 189-194. +Natu, M. V., & Agarwal, A. K. (1997) Testing of stimulant effects of coffee on the +psychomotor performance: an exercise in clinical pharmacology. Indian Journal of +Pharmacology, 29, 11-14. +CANCELLATION TASK: PERFORMANCE IN MEDITATIVE STATES +689 +Orme-Johnson, D. W. (1973) Autonomic stability and Transcendental Meditation. +Psychosomatic Medicine, 35, 341-349. +Polich, J. (2004) Clinical application of P300 event-related brain potential. Physical +Medicine and Rehabilitation Clinics of North America, 15, 133-161. +Sarang, S. P., & Telles, S. (2006a) Changes in P300 following two yoga-based relax­ +ation techniques. The International Journal of Neuroscience, 116, 1419-1430. +Sarang, S. P., & Telles, S. (2006b) Effects of two yoga-based relaxation techniques on +heart rate variability. International Journal of Stress Management, 13, 460-475. +Sarang, S. P., & Telles, S. (2006c) Oxygen consumption and respiration during and +after two yoga relaxation techniques. Applied Psychophysiology and Biofeedback, 31, +143-153. +Sarang, S. P., & Telles, S. (2007) Immediate effect of two yoga-based relaxation tech­ +niques on performance in a letter-cancellation task. Perceptual and Motor Skills, +105, 379-385. +Saraswati, M., & Swami, G. (1998) Bhagavad Gita. Himalaya, India: Advaita Ashrama. +Sugi, Y., & Akutsu, K. (1968) Studies on respiration and energy-metabolism during +sitting in Zazen. Research Journal of Physical Education, 12, 190-206. +Taimini, I. K. (1986) The science of yoga. Madras, India: Theosophical Publishing House. +Telles, S., & Desiraju, T. (1993) Autonomic changes in Brahmakumaris raja yoga +meditation. International Journal of Psychophysiology, 15, 147-152. +Telles, S., Raghuraj, P., Maharana, S., & Nagendra, H. R. (2007) Immediate effect +of three yoga breathing techniques on performance on a letter-cancellation task. +Perceptual and Motor Skills, 104, 1289-1296. +Telles, S., Reddy, S. K., & Nagendra, H. R. (2000) Oxygen consumption and respira­ +tion following two yoga relaxation techniques. Applied Psychophysiology and Bio­ +feedback, 25, 221-227. +Travis, F., Tecce, J., Arenander, A., & Wallace, R. K. (2002) Patterns of EEG coher­ +ence, power, and contingent negative variation characterize the integration of +transcendental and waking states. Biological Psychology, 61, 293-319. +Uttl, B., & Pilkenton-Taylor, C. (2001) Letter cancellation performance across the +adult life span. Clinical Neuropsychology, 15, 521-530. +Wallace, R. K. (1970) Physiological effects of Transcendental Meditation. Science, 167, +1751-1754. +Wallace, R. K., Benson, H., & Wilson, A. F. (1971) A wakeful hypometabolic physi­ +ologic state. American Journal of Physiology, 221, 795-799. +Walter, W. G., Cooper, R., Aldridge, V. J., McCallum, W. C., & Winter, A. L. +(1964) Contingent negative variation: an electric sign of sensorimotor associa­ +tion and expectancy in the human brain. Nature, 203, 380-384. +Accepted September 23, 2009. diff --git a/subfolder_0/Mind_ The Source of Wellness and Illness.txt b/subfolder_0/Mind_ The Source of Wellness and Illness.txt new file mode 100644 index 0000000000000000000000000000000000000000..57f478b966dcce7c474eec93c3f2a73360a578e6 --- /dev/null +++ b/subfolder_0/Mind_ The Source of Wellness and Illness.txt @@ -0,0 +1,165 @@ +Check + +Users Online: 145 +Home About +us +Editorial +board +Search +Ahead +of +print +Current +issue +Archives Submit +article Instructions Subscribe Contacts Login + + + + +EDITORIAL +Year : 2020 | Volume : 8 | Issue : 2 | Page : 39-40 +Mind: The Source of Wellness and Illness +HR Nagendra +Chancellor, Swami Vivekananda Yoga Anusandhana Samsthana, 19, Eknath Bhavan, Gavipuram Circle, K. G. Nagar, +Bengaluru - 560 019, Karnataka, India +Date of Submission +25-Jun-2020 +Date of Acceptance +14-Jul-2020 +Date of Web Publication +21-Aug-2020 + + + + +Correspondence Address: +Dr. H R Nagendra +Chancellor, Swami Vivekananda Yoga Anusandhana Samsthana, 19, Eknath Bhavan, Gavipuram Circle, K. G. Nagar, +Bengaluru - 560 019, Karnataka +India +Source of Support: None, Conflict of Interest: None +DOI: 10.4103/2347-5633.277013 + +How to cite this article: +Nagendra H R. Mind: The Source of Wellness and Illness. Int J Yoga - Philosop Psychol Parapsychol 2020;8:39-40 +How to cite this URL: +Nagendra H R. Mind: The Source of Wellness and Illness. Int J Yoga - Philosop Psychol Parapsychol [serial online] +2020 [cited 2021 Jan 23];8:39-40. Available from: https://www.ijoyppp.org/text.asp?2020/8/2/39/277013 +All of us desire a good health and well-being. This is even more sought during this current COVID pandemic. While the +mind–body evolution had been always a puzzle, there are some useful insights that we can draw from ancient wisdom. +According to the classical yoga text, Yoga Vasishta, the world evolves from the primordial cause, Consciousness. +Consciousness is all pervasive, beyond space and time as enunciated by Goswami.[1] Patanjali states consciousness as +beyond the mind called svarupa.[2] From this svarupa of pure consciousness called Purusha emerges the five Koshas – +Annamaya, Pranamaya, Manomaya, Vijnanamaya, and Anandamaya koshas. The fully evolved state of consciousness is +called as Samsara or Jagat (the world) and is made of Citta or mind according to Yoga Vasishta.[3] + + Search + +GO +Similar in PUBMED + Search Pubmed for +Nagendra H R + Search in Google Scholar +for +Nagendra H R +Access Statistics +Email Alert * +Add to My List * +* Registration required (free) + + In this article + References + Article Tables + Article Access Statistics + Viewed +1095 + Printed +49 + Emailed +0 + PDF Downloaded +119 + Comments +[Add] +[TAG2] +[TAG3] +[TAG4] +jāyatee mana eeveeha mana eeva vivardhatee | +samyagdarśana dṛñöyā tu mana eeva hi mucyate || +(Upashama Prakaranam, Canto 5, Verse 11) +Whatever is born and evolved is nothing but the mind.[4] Patanjali defines mind as a conglomeration of thoughts called +Citta vrittis. Moreover, the five modifications of the mind are Pramana (the right knowledge), Viparyaya (wrong +knowledge), Vikalpa (distracted), Nidraa (sleep), and Smriti (memory). With this background information, let us now +analyze the mind as the cause for wellness and illness. +The unmanifest and nondual state of mind called Avyakta is the causal state form where the manifest stages of mind +emerge. Much before consciousness grossifies itself to Annamaya kosha as its final evolute; mind starts its manifestation +of duality in Vijnanamaya kosha, the sheath of Wisdom. This state of mind with fullest knowledge of all creation having +almost no Ajnana is a state of perfect health. +As presented in an earlier Editorial,[5] the next is the Manomaya kosha featured by Ajnana (ignorance) manifesting in the +form of Viparyaya or wrong knowledge which can percolate at the level of Prana going in wrong directions. Pranamaya +kosha further grossifies to Annamaya Kosha, and pranic wrong directional flows can bring similar imbalances in the +physical body, including cellular and neuronal levels. Then, it can percolate to immune system causing diabetes or cancer +and even to gene level, resulting in genetic challenges. These diseases in the form of noncommunicable diseases are +considered as a big challenge to the Modern medical world. +Yet, another way by which Ajnana manifests in the Manomaya kosha is Vikalpa, in the form of excessive uncontrollable +speed of mind and distractions. This may lead to neuroticism, epileptic attacks, etc., at the brain level as well as +hypertension, Ischemic Heart Disease (IHD), etc., at the physical level. This uncontrollable speed of mind, as depicted in +the following verses of Bhagavat Gita, can result in the form of violent emotions. +dhyāyato viñayānpuàsaù saìgasteñūpajāyate | +saìgātsaïjāyate kāmaù kāmātkrodho'bhijāyate || B. G. 2-62|| +krodhādbhavati sammohaù sammohātsmṛtivibhramaù | +smṛtibhraàçād buddhināço buddhināçātpraëaçyati || B.G. 2-63|| +These emotions can emerge as strong sensual attractions and repulsions, leading to wrong habits such as consumption of +unhealthy food, smoking, and even psychedelic drugs. These ill habits cause digestive disorders, respiratory problems, +and many other NCDs, ultimately shattering the whole life. +The next in sequence is Nidraa (sleep), which is the manifestation of tamas, may cause depression, mental retardations, +etc. This further percolates to the Smriti or memory level causing loss of memory, and discrimination, taking us to animal +level and even to coma and death. [Table 1] summarizes the expressions of mind in different koshas and further illustrates +how by right approach mind can be a cause for wellness and if not managed properly can lead to be a source of illness. +Table 1: Expression of mind in different koshas +Click here to view +Hence, according to Patanjali, mind is the basic fabric of the whole creation. Creation of matter is also by mind. Svarupa +is pure consciousness called as Ishvara beyond all changes. Mind is known as Prakriti or nature and Purusha the +consciousness. Purusha is featured by infinite knowledge, power, bliss, and freedom. However, Prakriti is at several +levels – causal, subtle, and grosser levels – and is powered by the Purusha. The whole objective of Yoga is to purify +ourselves by gaining mastery over the mind. Thereby, we manifest more and more of consciousness – bliss, power, +knowledge, and freedom. We can move from afflicted to unafflicted state of mind freeing ourselves from slavery, +bondage, misery, stresses, to blissful, energetic, dynamic, knowledgeable, more and more efficient stages of life, to +ultimately become totally free to merge with Svarupa or Ishvara called as Kaivalya. From creation to the very source of +creation, from Prakriti to Purusha. + + References + +1. +Goswami A. The Self-Aware Universe: How Consciousness Creates the Material World. New York: Penguin; +1995. + +2. +Taimini IK. The Science of Yoga. Madras, India: The Theosophical Publishing House; 1986. + +3. +Jnanananda B. The Essence of Yogavāsistha. 1st ed. Pondicherry: Samata Books; 1982. + +4. +Murthy KV. Musings on Yogavaasishta – Part V The Calm Down; 2016. Available from: +http://www.advaita.org.uk/discourses/downloads/yogavasishta_v.pdf. [Last accessed on 2020 Jun 28]. + +5. +Nagendra HR. Seeing the truth: Yoga for health and harmony. Int J Yoga-Philosop Psychol Parapsychol 2019;7:1- +2. + + + + Tables + [Table 1] + + + + + + +Sitemap | What's New | Feedback | Disclaimer +© International Journal of Yoga, Philosophy, Psychology and Parapsychology | Published by Wolters Kluwer - Medknow +Online since 30th Sep, 2013 + diff --git a/subfolder_0/Neurophysiological Changes in Meditation Correlated with Descriptions from the Ancient Texts.txt b/subfolder_0/Neurophysiological Changes in Meditation Correlated with Descriptions from the Ancient Texts.txt new file mode 100644 index 0000000000000000000000000000000000000000..2f4f8eb5e3548cf243a1e527caedbdcc64e8f260 --- /dev/null +++ b/subfolder_0/Neurophysiological Changes in Meditation Correlated with Descriptions from the Ancient Texts.txt @@ -0,0 +1,427 @@ +SPECIAL ISSUE +Neurophysiological Changes in Meditation Correlated +with Descriptions from the Ancient Texts +Shirley Telles, PhD,1 and Bhat Ramachandra Raghavendra, MSc2 +1Patanjali Research Foundation, Haridwar, India; 2ICMR Center for Advanced Research in Yoga and Neurophysiology, SVYASA, Bengaluru, India +Keywords: meditation, autonomic changes, evoked potentials, neuroimaging, attention task +Meditation is currently considered to be associated with +increased awareness. In ancient yoga texts, two separate +meditative states have been described. These are medita- +tive focusing (dharana) and a state of mental expansiveness +(dhyana). Two more mental states are described in another +yoga text. These are random thinking (cancalata) and +focusing while not in meditation (ekagrata). The physio- +logical effects of these states have been assessed using +autonomic variables, evoked potentials, functional mag- +netic resonance imaging, and performance in a cancellation +task. The findings suggest that dhyana is associated with +reduced sympathetic activity and increased vagal tone, +whereas dharana does indeed improve performance in an +attention task. Hence, correlating findings from ancient +texts with contemporary science can be useful. +Meditation was described early on as a training in +awareness, which when practiced for some time leads to +changes in perception, attention, and cognition (Brown, +1977). More recently, meditation has been recognized as +a state of consciousness in which deep relaxation and +increased +internalized +attention +exist, +simultaneously +(Murata et al., 2004). Perhaps this is the reason why the +concepts of directing and regulating attention are consid- +ered inherent parts of different meditation techniques +(Davidson & Goleman, 1977). +The concepts of meditation described in ancient yoga +texts are rather different, as meditation is not supposed to +be associated with heightened attention or even of being +aware of the experience as it happens. This is most clearly +mentioned in the aphorisms (sutras) of the sage, Patanjali +(ca. 900 B.C.). According to Patanjali, there are eight stages, +which are to follow each other in sequence to lead to a stage +of ultimate realization (Taimini, 1986). These eight stages +are (i) and (ii) rules for good conduct (yamas and niyamas), +(iii) physical postures (asanas), (iv) voluntarily regulated +breathing (pranayamas), (v) withdrawal, particularly from +external sensations (pratyahara), (vi) focused thinking +(dharana), (vii) a defocused state of mental expansiveness +(dhyana), and (viii) an experience of transcendence or +ultimate realization (samadhi). While the ideal yoga +practice would involve going from one stage to the other +in sequence, there have been reports of benefits when +novices to yoga practice begin with practicing yoga postures +(Khattab, Khattab, Ortak, Richardt, & Bonnemeier, 2007) +or +voluntarily +regulated +breathing +(Telles, +Gaur, +& +Balkrishna, 2009). This also applies to meditation (Tang +et al., 2007). The sixth (dharana) and seventh (dhyana) +stages described by Patanjali are both meditative states. +The sixth stage (dharana) fits in with the known +descriptions of meditation (Brown, 1977). Dharana means +confining the mind within a limited mental area (‘‘desha- +bandhashchittasya +dharana’’; +Patanjali’s +Yoga +Sutras, +Chapter 3, Verse 1). The description of dharana fits in with +the contemporary categorization of meditation practices as +two main styles (Telles, Naveen, & Balkrishna, 2010). This +categorization is based on how attention is directed (Lutz, +Slagter, Dunne, & Davidson, 2008). One category is called +focused attention (FA), during which attention is sustained +and focused on a given object. The second category is called +open monitor meditation, where meditators are required not +to react, while monitoring the content of ongoing experi- +ence. This style is a method by which the practitioner is +aware of all mental content from one moment to the next. +Both types of meditation styles require mental activity, +though the nature of the activity is different. Specifically +‘‘open monitor meditation’’ does not involve a specific +attentional focus, but involves brain regions that are active +in disengaging attention from ongoing experience. Hence, +while dharana does include the current descriptions of +meditation, dhyana does not fit either category. Unlike +dharana, which requires special effort, during dhyana there +is no special focusing or effort. The description of dhyana, is +as an uninterrupted flow of the mind toward the object +chosen for meditation (‘‘tatra pratyayaikatanata dhya- +nam’’; Patanjali’s Yoga Sutras, Chapter 3, Verse 2). +A series of experiments have been carried out to +understand whether the physiological effects of dharana +Biofeedback +Volume 39, Issue 2, pp. 56–59 +DOI: 10.5298/1081-5937-39.2.08 +EAssociation for Applied Psychophysiology & Biofeedback +www.aapb.org +56 +Summer 2011 | Biofeedback +and dhyana are distinct and different. In these experiments, +two more mental states described in another yoga text (the +Bhagavad Gita, which was compiled ca. 500 B.C.) were +considered as control sessions. The first was cancalata +(Bhagavad Gita, Chapter 6, Verse 34; Sarasvati & Swami, +1998), which is a stage of random thinking. The second +state was ekagrata (Bhagavad Gita, Chapter 6, Verse 12), +during which the attention is directed to a number of +associated thoughts. If a person chooses thoughts related to +meditation, it would be easier for them to practice dharana +and dhyana. +These studies were carried out on healthy male volunteers +whose ages ranged between 20 and 55 years (group mean age +6 SD, 29.0 6 6.8 years). All of them were residing at a yoga +center in South India and were actively engaged in studying +yoga. Their normal health status was based on a routine case +history and chemical examination. +While they were practicing other yoga techniques as +well, all of them had a minimum of 6 months experience of +meditation on the Sanskrit syllable, Om (group average +experience 6 SD, 22.5 6 17.5 months). This meditation +technique can be separately practiced as dharana (focusing +on thoughts of Om) and dhyana (where the practitioner +does not focus on Om but reaches an expansive mental +state where all thoughts are about Om, but no effort is +involved). Participants can be trained to practice the two +techniques (dharana and dhyana) separately and at will. 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 dharana, dhyana, ekagrata and 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. +The assessments included (i) autonomic variables and +the breath rate, (ii) brainstem auditory evoked potentials, +(iii) functional magnetic resonance imaging, and (iv) +performance in a letter cancellation task. Each of these +assessments and the results obtained will be discussed +below in detail. +Autonomic Variables and the Breath Rate +The autonomic variables assessed included the heart rate, +heart rate variability (for both time and frequency domain +analysis), skin resistance, finger plethysmogram amplitude, +and the +breath +rate. +Assessment were made +before +(5 minutes), during (20 minutes), and after (5 minutes), +the four practices. These were: (i) dharana, (ii) dhyana, (iii) +cancalata, and (iv) ekagrata, practiced on four separate +days. Data were analyzed using a repeated measure +ANOVA and Bonferroni adjusted post hoc analysis. Most +of the significant changes were observed during dhyana. +These were an increase in the finger plethysmogram +amplitude, a decrease in heart rate, breath rate, and changes +in both the frequency and time domain analyses of the +heart rate variability (HRV) (Indian Council of Medical +Research Project Report, 2009). Frequency domain analysis +of the HRV resulted in a significant decrease in low +frequency (LF) power, an increase in high frequency (HF) +power, and decrease in the LF/HF ratio during dhyana. +Time domain analysis of the HRV resulted in an +increase in the NN50 count and the pNN50 during dhyana. +During dharana there was a significant increase in the skin +resistance level, with no other change during the practice. +During ekagrata there was a significant increase in the skin +resistance level, LF power, and a decrease in the HF power +of the HRV. During cancalata the skin resistance level +increased, as did the breath rate and LF power of the HRV. +In all four sessions there was an increase in the skin +resistance level. However, apart from this, the changes +during ekagrata and cancalata suggested increased sym- +pathetic activity, whereas all the changes seen in dhyana +were suggestive of reduced sympathetic activity and a shift +towards vagal dominance. The decrease in the breath rate +during dhyana is in keeping with this state being associated +with increased relaxation. +Brainstem Auditory Evoked Potentials +Evoked potentials are used in meditation studies since the +correlation between different evoked potential components +and the underlying neural generators is fairly well worked +out (Woods & Clayworth, 1985). Another reason is that +the cerebral cortex is actively involved in meditation (Lazar +et al., 2005). Hence cortico-efferent gating may occur with +changes at subcortical relay centers (Napadow et al., 2008). +Brainstem auditory evoked potentials (BAEPs) provide an +objective physiological index of auditory functions subcor- +tically. BAEPs were recorded with binaural click stimuli (of +50 ms duration, 40 Hz frequency, and 80 dB nHL intensity), +averaged for 1,500 stimuli (Kumar, Nagendra, Manjunath, +Naveen, & Telles, 2010). +The peak latency of a specific component, the wave V, +increased significantly during dharana, ekagrata, and +cancalata sessions, but there was no change during the +practice of dhyana. An increase in the latency of an evoked +potential component is understood to suggest that sensory +information processing at the level of the underlying +Telles and Raghavendra +Biofeedback | Summer 2011 +57 +neural generator is delayed (Subramanya & Telles, 2009). +Wave V is considered to correspond to the inferior colliculi, +located in the tectum (midbrain) (McEvoy, Frumkin, & +Harkins, 1980). The present results suggest that dhyana +practice alone does not delay auditory sensory transmission +at the brainstem level, whereas dharana practice is +associated with a delay, as are the practices of ekagrata +and cancalata. +Functional Magnetic Resonance Imaging +Functional magnetic resonance imaging (fMRI) measures +hemodynamic changes related to neural activity in the +brain or spinal cord (Deyoe, Bandettini, Neitz, Miller, & +Winans, 1994). A 3.0 T scanner (Philips) was used to obtain +echo-planar images (Indian Council of Medical Research +Project Report, 2009; Dawn, Telles, George, & Naveen, +2010). For this experiment, participants switched among +cancalata, ekagrata, dharana, and dhyana phases, spending +one minute in each stage. The sequence was then repeated +once more. All comparisons were made with respect to the +cancalata phase, which was taken as the control phase. +During ekagrata there was bilateral activation of the +middle temporal gyrus, (whose exact function is not +known, but is believed to be connected with recognition +of faces), contemplating distance related to spatial orienta- +tion, and accessing meanings of words during reading +(Duara et al., 2008). The left parahippocampal gyrus +activated +in +ekagrata, +which +is +concerned +with +the +formation of spatial memory. There was also bilateral +fusiform gyri activation, which is correlated with face and +body recognition, recognition of numbers and words, and +abstraction of concepts (Thomaes et al., 2009). The bilateral +activation of the cerebellum during ekagrata may suggest a +certain level of involvement in regulation of tone and +posture, which may be related to the fact that ekagrata is +associated with paying greater attention (in this case) to the +auditory information supplied. +Dharana is like ekagrata, a mental state characterized +by increased attention. During dharana the increased +activation of the anterior cingulate is suggestive of +enhanced cognitive and attentional processing (Leroux +et al., 2009). The bilateral activation of the dorsolateral +prefrontal cortex suggests that dharana would facilitate +functions known to be subserved by the prefrontal cortex, +such as planning, cognitive behavior, and various functions, +which come under the broad category of ‘‘executive +functions’’ (Bertolino et al., 2009). +In dhyana (compared to cancalata) the changes were +more complex. White matter hyperintensities were seen in +the frontal region. White matter hyperintensities in the +frontal region have been correlated with reduced frontal +rCMRgle (regional glucose metabolism) and low executive +scores (Tullberg et al., 2004). Dhyana was also associated +with increased activation in the right orbitofrontal cortex, +a region of the association cortex involved in cognitive +processes such as decision making, as well as being involved +in emotion regulation and reward. +Performance in a Letter Cancellation Task +The letter cancellation task assesses selective attention +and concentration (Uttl & Pilkenton-Taylor, 2001). The +performance in a six-letter cancellation task was assessed +before and after each of the four practices separately +(Kumar & Telles, 2009). There was also a control group +of non-meditators, for comparison. All assessments were +made before and after the practices. The net scores in +the task were significantly higher after the dharana +session and lower after the cancalata session. The +results suggest that focusing on the symbol Om in +dharana sessions may have a favorable effect on selective +attention, concentration, visual scanning abilities, and a +repetitive motor response, all of which are involved in a +cancellation task. The absence of change after the +ekagrata session suggests that non-meditative focusing +did not have this effect. +Summary +Objective assessments of autonomic variables, brainstem +auditory evoked potentials, functional magnetic resonance +imaging, and performance in a cancellation task, showed +differences +between +dharana +and +dhyana +meditative +sessions. The findings were mainly in keeping with the +descriptions of these two meditative states mentioned in +ancient yoga texts. It is also interesting to speculate that +even if a particular meditation technique requires focusing +(hence, resembling dharana), meditators may inadvertent- +ly +enter +the +dhyana +phase. +Accordingly, +differences +observed in a group may occur because participants are in +different stages (i.e., dharana or dhyana) of meditation. +These observations suggest that knowing the descriptions +of these practices in the ancient texts may help in +understanding contemporary research findings. +Acknowledgment +The authors gratefully acknowledge the funding from +Patanjali Research Foundation, Haridwar and 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 Neuro- +physiology (CAR-Y&N). +Meditation in Ancient Texts and Contemporary Science +58 +Summer 2011 | Biofeedback +References +Bertolino, A., Fazio, L., Di Giorgio, A., Blasi, G., Romano, R., +Taurisano, P., et al. (2009). Genetically determined interaction +between the dopamine transporter and the D2 receptor on +prefronto-striatal activity and volume in humans. Journal of +Neuroscience, 29, 1224–1234. +Brown, D. P. (1977). A model for the levels of concentrative +meditation. The International Journal of Clinical and Exper- +imental Hypnosis, 25, 236–273. +Davidson, R. J., & Goleman, D. J. (1977). The role of attention in +meditation and hypnosis: A psychobiological perspective on +transformations of consciousness. The International Journal of +Clinical and Experimental Hypnosis, 25, 291–308. +Dawn, R., Telles, S., George, L., & Naveen, K. V. (2010). Blood +oxygen level changes during meditation: An exploratory fMRI +study. Proceedings of the International Conference on Brain, +Mind & Soul—Integrating the Interface. +Deyoe, E. A., Bandettini, P., Neitz, J., Miller, D., & Winans, P. +(1994). Functional magnetic resonance imaging (fMRI) of the +human brain. Journal of Neuroscience Methods, 54, 171–187. +Duara, R., Loewenstein, D. A., Potter, E., Appel, J., Greig, M. T., Urs, +R., et al. (2008). Medial temporal lobe atrophy on MRI scans and +the diagnosis of Alzheimer disease. Neurology, 71, 1986–1992. +Indian Council of Medical Research Project Report. (2009). +Neurophysiological correlates of phases of wakefulness and +sleep in meditators. Bangalore, India: ICMR Center for +Advanced Research in Yoga and Neurophysiology. +Khattab, K., Khattab, A. A., Ortak, J., Richardt, G., & Bonnemeier, H. +(2007). Iyengar yoga increases cardiac parasympathetic nervous +modulation among healthy yoga practitioners. Evidence-Based +Complementary and Alternative Medicine, 4, 511–517. +Kumar, S., & Telles, S. (2009). Meditative states based on yoga +texts and their effects on performance of a cancellation task. +Perceptual and Motor Skills, 109, 679–689. +Kumar, S., Nagendra, H. R., Manjunath N. K., Naveen K. V., & Telles, +S. (2010). Meditation on Om: Relevance from ancient texts and +contemporary science. International Journal of Yoga, 3, 3–5. +Lazar, S. W., Kerr, C. E., Wasserman, R. H., Gray, J. R., Greve, D. N., +Treadway, M. T., et al. (2005). Meditation experience is associated +with increased cortical thickness. Neuroreport, 16, 1893–1897. +Leroux, G., Spiess, J., Zago, L., Rossi, S., Lubin, A., Turbelin, +M. R., et al. (2009). Adult brains don’t fully overcome biases +that lead to incorrect performance during cognitive develop- +ment: An fMRI study in young adults completing a Piaget-like +task. Developmental Science, 12, 326–338. +Lutz, A., Slagter, H. A., Dunne, J. D., & Davidson, R. J. (2008). +Attention regulation and monitoring in meditation. Trends in +Cognitive Sciences, 12, 163–169. +McEvoy, T. M., Frumkin, L. R., & Harkins, S. W. (1980). Effects +of meditation on brainstem auditory evoked potentials. +International Journal of Neuroscience, 10, 165–170. +Murata, T., Takahashi, T., Hamada, T., Omori, M., Kosaka, H., +Yoshida, H., et al. (2004). Individual trait anxiety levels +characterizing the properties of Zen meditation. Neuropsycho- +biology, 50, 189–194. +Napadow, V., Dhond, R., Conti, G., Makris, N., Brown, E. N., & +Barbieri, R. (2008). Brain correlates of autonomic modulation: +Combining heart rate variability with fMRI. Neuroimage, 42, +169–177. +Sarasvati, M., & Swami, G. (1998). Bhagavad Gita. Calcutta, +India: Advaita Ashrama. +Subramanya, P., & Telles, S. (2009). Changes in midlatency +auditory evoked potentials following two yoga-based relaxa- +tion techniques. Clinical EEG and Neuroscience, 40, 190–195. +Taimini, I. K. (1986). The science of yoga. Madras, India: The +Theosophical Publishing House. +Tang, Y. Y., Ma, Y., Wang, J., Fan, Y., Feng, S., Lu, Q., et al. +(2007). Short-term meditation training improves attention +and self-regulation. Proceedings of the National Academy +of Sciences of the United States of America, 104, 17152– +17156. +Telles, S., Gaur, V., & Balkrishna, A. (2009). Effect of a yoga +practice session and a yoga theory session on state anxiety. +Perceptual and Motor Skills, 109, 924–930. +Telles, S., Naveen, K. V., & Balkrishna, A. (2010). Meditation and +attention: A comment on a recent article. Perceptual and +Motor Skills, 111, 918–920. +Thomaes, K., Dorrepaal, E., Draijer, N. P., de Ruiter, M. B., +Elzinga, B. M., van Balkom, A. J., et al. (2009). Increased +activation of the left hippocampus region in Complex PTSD +during encoding and recognition of emotional words: A pilot +study. Psychiatric Research, 171, 44–53. +Tullberg, M., Fletcher, E., DeCarli, C., Mungas, D., Reed, B. R., +Harvey, D. J., et al. (2004). White matter lesions impair frontal +lobe function regardless of their location. Neurology, 63, 246– +253. +Uttl, B., & Pilkenton-Taylor, C. (2001). Letter cancellation +performance across the adult life span. The Clinical Neuro- +psychologist, 15, 521–530. +Woods, D. L., & Clayworth, C. C. (1985). Click spatial position +influences middle latency auditory evoked potentials (MLAEPs) +in humans. Clinical Electroencephalography, 60, 122–129. +Shirley Telles +Bhat Ramachandra +Raghavendra +Correspondence: Shirley Telles, PhD, Patanjali Research Foundation, Patanjali +Yogpeeth, Maharishi Dayanand Gram, Bahadrabad, Haridwar, Uttarakhand +249408, India, email: shirleytelles@gmail.com. +Telles and Raghavendra +Biofeedback | Summer 2011 +59 diff --git a/subfolder_0/Normative data for the letter-cancellation task in school.txt b/subfolder_0/Normative data for the letter-cancellation task in school.txt new file mode 100644 index 0000000000000000000000000000000000000000..f47916fa4d2c6b3602304adf7e56f4a1c3adcdb1 --- /dev/null +++ b/subfolder_0/Normative data for the letter-cancellation task in school.txt @@ -0,0 +1,572 @@ +International Journal of Yoga + +! + +Vol. 1:2 + +! + +Jul-Dec-2008 +72 +Normative data for the letter-cancellation task in school +children +Balaram Pradhan, Nagendra H R +Division of Yoga & Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana, Bangalore, India +Aims: To establish the norms for the letter-cancellation task—a psychomotor performance task. +Materials and Methods: Eight hundred nineteen school students were selected in the present study in an age range between +nine and 16 years (M = 12.14; SD = 1.78 years). Subjects were assessed once for the cancellation task. +Results: Both age and sex infl + uenced performance on the SLCT; therefore, correction scores were obtained on the basis of +these factors. +Conclusions: The availability of Indian normative data for the SLCT will allow wider application of this test in clinical +practice. +Key Words: Attention; cancellation; information processing speed; psychomotor task; sustained. +Original Article +Correspondence to: Dr. Nagendra H R +Swami Vivekananda Yoga Anusandhana Samsthana, +# 19, K.G. Nagar, Bangalore 560 019, India. +E-mail: hrnagendra@rediffmail.com +ABSTRACT +INTRODUCTION +Cancellation tests have a long history in neuropsychological +assessment. Most commonly, they are administered as +paper-and-pencil tests that are normally used to assess +a person’s ability to visually search for an identifiable +target and to either cancel or circle all such target items +in an array. They vary widely in their complexity from +long letter strings, such as the “H” Test[1] and “ +A +” Test[2] or +number strings like the “2 and 7 Cancellation” Test.[3] They +may include symbols that are quite simple as in the “Star +Cancellation,”[4] Teddy Bear Cancellation,[5] and Symbol +Cancellation tests.[6] +However, they have also been utilized in neuropsychological +test batteries for the assessment of the effectiveness of +treatment for adult patients with anorexia nervosa and +bulimia nervosa,[7] and for the assessment of illiterate +individuals to determine if education affected performance +in a neuropsychological battery.[8] They have also been +employed to assess cognitive impairments in alcoholic +cirrhotic patients,[9] and to evaluate target detection +deficits in patients who have undergone frontal lobectomy +surgery.[10] +An individual's performance on cancellation tests often +depends on their vigilance, motivation, and arousal +as they visually scan the array and select appropriate +responses while suppressing inappropriate ones.[10] +These tasks are assigned as measures of the capacity for +sustained attention, concentration, visual scanning, and +rapid response activation and inhibition.[11] For others, +they are measures of efficiency and speed of visual +scanning,[12] or selective attention.[13,14] For yet others, they +are administered primarily to assess potential hemispatial +inattention and visual neglect,[15,16] or motor perseverative + +behaviour.[17] A recent study on the symbol cancellation +test provides a measure of neglect, the organizational +process, and attention.[18] Hence, the main objective of the +present study was to derive normative data for the newly +developed letter cancellation test.[19] +MATERIALS AND METHODS +Subjects +Eight hundred nineteen school students were selected in +the present study in an age range between 9 and 16 years +(M = 12.14; SD = 1.78 years). All of them were healthy +and proficient in English. Participants were excluded +from the study if they indicated that they had a history of +neurological or psychiatric disturbance, and were using +[Downloaded free from http://www.ijoy.org.in on Tuesday, January 06, 2009] +73 +International Journal of Yoga + +! + +Vol. 1:2 + +! + +Jul-Dec-2008 +medication with central nervous system problems, or +had a history of any learning disability. After completely +describing the study to the participants, written informed +consent was obtained. +Instrument +The six letter cancellation task consisted of a test +worksheet which specified the six target letters to be +cancelled and had a ‘working section’ which consisted +of letters of the alphabet arranged randomly in 22 rows +and 14 columns. The participants were asked to cancel as +many of the six target letters as possible in the specified +time, i.e., 1 min, 30 sec. They were told to choose from two +possible strategies, i.e., (i) doing all six letters at a time or +(ii) to selective any one target letter out of the six. They +were also told that they could follow a horizontal, vertical, +or a random path, according to their choice.[10] The total +number of cancellations and wrong cancellations were +scored and the net scores were calculated by deducting +wrong cancellations from the total cancellations attempted. +Tests were administered by five trained assistants in the +neuropsychological test laboratory. +Data analysis +The normative procedure for net six letter cancellation +scores (NSLCT) involved the fitting of multiple linear +regression models adjusted for age (in years) and +sex. The core assumptions of regression analysis +(homoscedasticity, normal distribution of the residuals, +absence of multicollinearity, and the absence of ‘influential +cases’) were tested for each model. Homoscedasticity +was evaluated by visual inspection of the scatter plots +of the residuals on the predicted values. The normal +distribution of the residuals was investigated by visual +inspection of the histograms and the normal probability +plots. The occurrence of multicollinearity was checked +by calculating the Variance Inflation Factors (VIFs), which +should not exceed 10.[20] Cook’s distances were computed +to identify any possible influential cases. Normative data +can then be obtained by calculating the residuals for the +NSLCT scores (ei = observed score – predicted score). The +residuals are then standardized (Zi = ei / SD [residual]). All +analyses were performed by using the SPSS 10.0 version +software package. +RESULTS +Linear multiple regression models were fitted for the +SLCT scores. The residuals were sufficiently normally +distributed and no heteroscedasticity was observed. VIFs +of the predictors in the regression models had a maximum +value of 1.001, which is well below the cut-off value of +10. The outliers had virtually no effect (maximum Cook’s +distance 0.04). Table 1 presents the mean and standard +deviation stratified by age and sex. Table 2 represents the +regression models. Age and sex had a significantly positive +and negative (P < 0.001) influence on the predicted SLCT +scores. +Combining these regression models with the standard +deviations of the residuals provides normative data. +First, the predicted values of the scores (predicted yi) for +the SLCT are calculated by inserting the coded values +of the predictor variables in the regression models +[Table 2]. Next, the residuals of both scores are calculated +(ei = observed yi – predicted yi) and then standardized (Zi += ei / SD (residual). The SD (residual) equals 7.82 for the +SLCT scores. +Multiple linear regressions provided a multiple R value of +0.538 with a corresponding R2 determination index of 0.29, +indicating that 29% of the score variance was explained by +the combination of age and sex. The model equation was: +SLCT score = -4.307 + 2.545 × Age – 4.25 × Sex. This +indicates that for each progressive year of age, the SLCT +scores increase, on average, by 2.545 and decrease by -4.25 +for each sex. These coefficients allowed us to calculate the +correction scores to apply to individual subjects to consider +the effects of age and sex. Table 3 provides normative SLCT +data based on the regression models in Table 3, stratified +by age and sex with percentile values. +Reliability and validity +The Six Letter Cancellation test retest reliability was found +(r = 0.781, P = 0.002).[21] This test is directly related to +attention measurement. This test has been used in earlier +studies in an Indian population.[22-24] Hence, this test had +been validated for the present study. +DISCUSSIONS +The results found higher scores with an increase in the +age of both sexes; females had higher scores than males +in the cancellation task performance. Previous studies +on 50 psychiatic inpatients who had been diagnosed +Table 1: Mean and standard deviation of net six letter +cancellation task scores stratified by age and sex + + Female + Male +AGE (years) +n +Mean ± SD +n +Mean ± SD +9 +10 +16.2±6.36 +17 +13.06±5.03 +10 +71 +20.73±7.1 +88 +16.9±6.31 +11 +41 +23.41±6.7 +84 +20.62±6.21 +12 +49 +24.35±7.96 +118 +22.43±8.09 +13 +66 +31.23±9.33 +74 +23.7±7.63 +14 +31 +30.81±7.53 +69 +26.25±8.38 +15 +37 +34.54±9.13 +43 +29.93±9.87 +16 +9 +34.67±6.18 +12 +29.75±12.52 +Total +314 +26.73±9.54 +505 +22.37±8.71 +Psychomotor performance task in school children +[Downloaded free from http://www.ijoy.org.in on Tuesday, January 06, 2009] +International Journal of Yoga + +! + +Vol. 1:2 + +! + +Jul-Dec-2008 +74 +with substance-related disorder, schozophenia, bipolar, +depressive, or anxiety disorders, showed that these +patients had lower scores than normal volunteers[22] and +also after coffee stimulant scores was increase.[23] To our +knowledge, a prior study on the SLCT reported a general +description of performance but did not provide means or +standard deviations of performance on this measure for +children. Moreover, the effect of demographic variables +on SLCT performance had not been previously examined. +However, examination of percentile ranks revealed an +unstable pattern of SLCT performance across age and +gender groups. Age was a stronger predictor than sex for +the SLCT. This study was limited to children and uneven +cell sizes across derived age and sex. Further research +with larger samples is needed to clarify this relation, +perhaps in an adult population. Nonetheless, these +results permit quantitative evaluation of performance +on the SLCT in healthy school children. As the SLCT +is easy to administer in short duration of time and +potentially useful in the assessment of attention, neglect, +and psychomotor ability, it is hoped that these normative +data will increase the use of SLCT in clinical pediatric +populations. +Hence, one possible mechanism can be that the posterior +parietal cortex is known to be important in normal eye +movement control, visuospatial attention, and peripheral +vision—all important components of reading.[25] Attention +tasks that depend on parietal cortex functioning: spatial +attention task,[26] perceptual grouping,[27] and visual search. +[28] It is clear that many of these attention-related functions +contribute to reading. Indeed, selective attention to a word +or string of words requires concentrated focal attention +and controlled shift of attention. +REFERENCES +1. +Laurent-Vannier A, Chevignard M, Pradat-Diehl P, Abada G, De Agostini +M. Assessment of unilateral spatial neglect in children using the Teddy Bear +Cancellation Test. Dev Med Child Neurol 2006;48:120-5. +2. +Ruff RM, Evans RW, Light RH. Automatic detection vs controlled search: A +paper and pencil approach. Percept Mot Skills 1986;62:407-516. +3. +Halligan PW, Wilson B, Cockburn J. A short screening test for visual neglect +in stroke patients. Int Disabil Stud 1990;12:95-9. +4. +Lowery N, Ragland JD, Gur RC, Gur RE, Moberg PJ. Normative data for +the symbol cancellation test in young healthy adults. Appl Neuropsychol +2004;11:218-21. +5. +Lowery N, Ragland JD, Gur RC, Gur RE, Moberg PJ. Normative data for +the symbol cancellation test in young healthy adults. Appl Neuropsychol +2004;11:218-21. +6. +Lauer CJ, Gorzewski B, Gerlinghoff M, Backmund H, Zihl J. +Neuropsychological assessment before and after treatment in patients with +anorexia nervosa and bulimia nervosa. J Psychiatr Res 1999;33:129-38. +7. +Rosselli M, Ardila A, Rosas P. Neuropsychological assessment in illiterates. +Brain Cogn 1990;12:281-96. +8. +Kapczinski F, Curran HV, Przemioslo R, Williams R, Fluck E, Fernandes C, +et al. Cognitive impairments of alcoholic cirrhotic patients: Correlation with +endogenous benzodiazepine receptor ligands and increased afÞ + nity of platelet +receptors. J Neurol Neurosurg Psychiatry 1996;60:676-80. +9. +Richer F, Decary A, Lapierre MF, Rouleau I, Bouvier G, Saint-Hilaire JM. +Target detection deÞ + cits in frontal lobectomy. Brain Cogn 1993;21:203-11. +10. Sandson TA, Bachna KJ, Morin MD. Right hemisphere dysfunction in +ADHD: Visual hemispatial attention and clinical subtype. J Learn Disabil +2000;33:83-90. +11. +Lezak MD. Neuropsychological assessment. 3rd ed. New York: Oxford +University Press; 1995. +12. Geldmacher DS. Effect of stimulus number, and target-to-distractor ratio, +on the performance of random array letter-cancellation tasks. Brain Cogn +1996;32:405-15. +13. Amieva H, Lafont S, Dartigues JF, Fabrigoule C. Selective attention in +Alzheimer’s disease: Analysis of errors in Zazzo’s cancellation task. Brain +Cogn 1999;40:26-9. +14. Casco C, Tressoldi PE, Dellantonio A. Visual selective attention and reading +efÞ + ciency are related in children. Cortex 1998;34:531-46. +15. Adair JC, Na DL, Schwarz RL, Heilman KM. Analysis of primary and +secondary inß + uences on spatial neglect. Brain Cogn 1998;37:351-67. +16. Aglioti S, Smania N, Barbieri C, Corbetta M. Inß + uence of stimulus salience +and attentional demands on visual search patterns in hemispatial neglect. +Brain Cogn 1997;34:388-403. +17. Na DL, Adair JC, Kang Y, Chung CS, Lee KH, Heilman KM. Motor +perseveration behavior on a line cancellation task. Neurology 1999;52: +1569-76. +18. Lowery N, Ragland JD, Gur RC, Gur, RE. Moberg PJ. Normative data for +Table 2: Multiple linear regression models of the SLCT scores with age and sex as predictors +Variables +B +Std. error +t +P values +Standardized B +VIF +R[2] +SD (residuals) +Constant +-4.307 +1.932 +-2.229 +0.026 +- +- +- +- +Age +2.545 +0.154 +16.498 +< 0.001 +0.487 +1.000 +0.289 +7.82 +Sex +-4.250 +0.563 +-7.554 +< 0.001 +-0.223 +1.000 +- +- +Table 3: Net six letter cancellation tasks stratified by age and sex of raw percentile scores + + + + Female +age in years + + + + + + + Male age in years + +Age +9 +10 +11 +12 +13 +14 +15 +16 +9 +10 +11 +12 +13 +14 +15 +16 + +5 +5 +8.6 +9.7 +10.5 +18.35 +17.6 +22.7 +26 +7 +7 +12 +10 +12 +13.5 +13 +10 + +10 +5.7 +11 +16 +13 +20.7 +18 +24.6 +26 +7 +9 +13.00 +12.90 13.50 15.00 +17 +11.2 + +25 +12 +16 +19 +19 +25 +25 +29.5 +30 +8 +13 +16 +18 +19 +21 +22 +21 + +50 +16 +20 +22 +24 +29.5 +32 +33 +35 +13 +16 +20.5 +22 +23 +26 +29 +25 + +75 +23.25 +27 +29 +31.5 +38 +34 +38.5 +38 +17 +22 +24 +27 +29 +32.5 +35 +41.75 + +90 +24.9 +30 +31 +34 +44 +41.6 +46.4 +. +21 +26 +30 +31.1 +35 +36 +43.2 +46.5 + +95 +. +31.8 +35.6 +38 +47.65 +43.6 +54.4 +. +. +28 +33.75 +36 +36.75 +39 +48.8 +. +Percentiles +Pradhan B and Nagendra H R +[Downloaded free from http://www.ijoy.org.in on Tuesday, January 06, 2009] +75 +International Journal of Yoga + +! + +Vol. 1:2 + +! + +Jul-Dec-2008 +the symbol cancellation test in young healthy adults. Appl Neuropsychol +2004;11:218-21. +19. Natu MV, Agarawal AK. Testing of stimulant effects of coffee on the +psychomotor performance: An exercise in clinical pharmacology. Indian J +Physiol Pharmacol 1997;29:11-4. +20. Belsley DA, Kuh E, Welsch RE. Regression diagnostics: Identifying the +inß + uential data and source of collinearity. New York: Wiley; 1980. +21. Sarang PS, Telles S. Comparison of psychological effect of two yoga +relaxation techniques, Ph.D. Thesis; 2006. +22. Agarwal AK, Kalra R, Natu MV, Dadhich AP, Deswa RS. Psychomotor +performance of psychiatric inpatients under therapy: Assessment by paper +and pencil test. Hum Psycopharmacol Clin Exp 2002;172:91-93. +23. Natu MV, Agarawal AK. Testing of stimulant effects of coffee on the +psychomotor performance: An exercise in clinical pharmacology. Indian J +Physiol Pharmacol 1997;29:11-4. +24. Sarang SP, Telles S. Immediate effect of two yoga-based relaxation techniques +on performance in a letter-cancellation task. Percept Mot Skills 2007;105: +379-85. +25. Stein J, Walsh V. To see but not to read: The magnocellular theory of dyslexia. +Trends Neurosci 1997;20:147-51. +26. Brannan J, Williams MC. Allocation of visual attention in good and poor +readers. Percept Psychophys 1987;41:23-28. +27. Williams MC, Bologna N. Perceptual grouping in good and poor readers. +Percept Psychophys 1985;38:367-74. +28. Casco C, Prunetti E. Visual search in good and poor readers: Effect +with single and combined features targets. Percept Mot Skills 1996;82: +1155-67. +Psychomotor performance task in school children +[Downloaded free from http://www.ijoy.org.in on Tuesday, January 06, 2009] diff --git a/subfolder_0/OXYGEN CONSUMPTION AND RESPIRATION DURING AND AFTER TWO YOGA RELAXATION TECHNIQUES.txt b/subfolder_0/OXYGEN CONSUMPTION AND RESPIRATION DURING AND AFTER TWO YOGA RELAXATION TECHNIQUES.txt new file mode 100644 index 0000000000000000000000000000000000000000..2a17f29efa72b2824eaa3e32dc5e939e785b5a28 --- /dev/null +++ b/subfolder_0/OXYGEN CONSUMPTION AND RESPIRATION DURING AND AFTER TWO YOGA RELAXATION TECHNIQUES.txt @@ -0,0 +1,30 @@ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + diff --git a/subfolder_0/PHYSIOLOGICAL CHANGES IN SPORTS TEACHERS FOLLOWING 3 MONTHS OF TRAINING IN YOGA.txt b/subfolder_0/PHYSIOLOGICAL CHANGES IN SPORTS TEACHERS FOLLOWING 3 MONTHS OF TRAINING IN YOGA.txt new file mode 100644 index 0000000000000000000000000000000000000000..30b472ee69f49462cdeacbd4e58583c3ff14cc29 --- /dev/null +++ b/subfolder_0/PHYSIOLOGICAL CHANGES IN SPORTS TEACHERS FOLLOWING 3 MONTHS OF TRAINING IN YOGA.txt @@ -0,0 +1,13 @@ + + + + + + + + + + + + + diff --git a/subfolder_0/PRANAYAMA INCREASES GRIP STRENGTH WITHOUT LATERALIZED EFFECTS.txt b/subfolder_0/PRANAYAMA INCREASES GRIP STRENGTH WITHOUT LATERALIZED EFFECTS.txt new file mode 100644 index 0000000000000000000000000000000000000000..c4c02190eceae5f8432850f5274844e1043a0725 --- /dev/null +++ b/subfolder_0/PRANAYAMA INCREASES GRIP STRENGTH WITHOUT LATERALIZED EFFECTS.txt @@ -0,0 +1,14 @@ + + + + + + + + + + + + + + diff --git a/subfolder_0/Physiological Measures of Right Nostril Breathing.txt b/subfolder_0/Physiological Measures of Right Nostril Breathing.txt new file mode 100644 index 0000000000000000000000000000000000000000..4f4e9cba355b453dda52061e544d9a6caeb56970 --- /dev/null +++ b/subfolder_0/Physiological Measures of Right Nostril Breathing.txt @@ -0,0 +1,603 @@ +THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE +Volume 2, Number 4, 1996, pp. 479^84 +Mary Ann Liebert, Inc. +Physiological Measures of Right Nostril Breathing +SHIRLEY TELLES Ph.D., R. NAGARATHNA, M.R.C.P., and H.R. NAGENDRA, Ph.D. +ABSTRACT +This study was conducted to assess the physiological effects of a yoga breathing practice that +involves breathing exclusively through the right nostril. This practice is called surya anuloma +viloma pranayama (SAV). Twelve volunteers (average age 27.2 years ± 3.3 years, four males) +were assessed before and after test sessions conducted on two consecutive days. On one day +the test session involved practicing SAV pranayama for 45 minutes (SAV session). During +the test period of the other day, subjects were asked to breathe normally for 45 minutes (NB +session). For half the patients (randomly chosen) the SAV session was on the first day and +the NB session on the next day. For the remaining six patients, the order of the two sessions +was reversed. After the SAV session (but not after the NB) there was a significant (P < .05, +paired t test) increase in oxygen consumption (17%) and in systolic blood pressure (mean in- +crease 9.4mm Hg) and a significant decrease in digit pulse volume (45.7%). The latter two +changes are interpreted to be the result of increased cutaneous vasoconstriction. After both +SAV and NB sessions, there was a significant decrease in skin resistance (two factor ANOVA, +Tukey test). These findings show that SAV has a sympathetic stimulating effect. This tech- +nique and other variations of unilateral forced nostril breathing deserve further study re- +garding therapeutic merits in a wide range of disorders. +INTRODUCTION +inant stage was correlated with the activity phase +of the basic rest-activity cycle (BRAC) and with +T +he nasal cycle is an ultradian rhythm with a +an increase in the sympathetic tone (Wemtz, +periodicity of about two to eight hours, dur- +Bickford, Bloom & Shannahoff-Khalsa, 1983). The +ing which the right and left nares are alternately +left nostril dominant stage was correlated with +patent (Keuning, 1968). Forced right nostril +the resting phase of the BRAC and with parasym- +breathing occluding the left nostril was found to +pathetic dominance. +increase blood glucose levels (Backon, 1988) and +Some varieties of yoga breathing (pranayama) +heart rate (Shannahoff-Khalsa & Kennedy, 1993). +involve inhalation and exhalation through one +In a detailed review (Shannahoff-Khalsa, 1991) a +nostril exclusively. These yoga practices provide +number of other physiological and psychological +an opportunity to study the effects of selective +effects of right nostril breathing were suggested, +nostril breathing for prolonged periods. Some of +such as generalized sympathetic tonus, increased +the physiological effects of a month of right nos- +temperature and metabolic rate, and improved +tril breathing +pranayama +(surya +anuloma +verbal performance. Left nostril breathing had re- +viloma or SAV), practiced for ten minutes four +verse effects. Based on this, the right nostril dom- +times in a day, were found to be significantly +Vivekananda Kendra Yoga Research Foundation, Bangalore, India +479 +480 +TELLES ET AL. +different from the effects of a left nostril breath- +MATERIAL AND METHODS +ing pranayama (chandra anuloma viloma or +CAV) and an alternate nostril breathing Subjects +pranayama (nadisuddhi or NDS), when all three +Twelve volunteers, (four males), age range +techniques were practiced for the same fre- +21 to 33 years (age mean (SD), 27.2 (3.3) years) +quency and duration (Telles, Nagarathna & participated in the study. None had a history +Nagendra, 1994). SAV caused a significant in- +^f major illnesses, and on a routine medical ex- +crease m oxygen consumption (37%), whereas +amination they were all found to be of normal +both left and alternate nostril breathing caused +health. All twelve subjects resided for approx- +a nonsignificant increase in oxygen consump- +ij^ately three months prior to testing at the +tion (24% and 19%, respectively). With all three +j ^ ^ ^ ^^ere the tests were held. This allowed +practices there was a sigmficant decrease in +^^^^ ^-^^ ^^^ schedule (e.g., meal times and +body weight. This reduction was comparable for +^-^^ ^f ^^]^- +^r sleeping) to be kept con- +SAV and CAV (2.3 kg) and less for NDS (1.5 kg). +^^^^^ ^^ ^j^^ ^ +before testing and on the two +With CAV alone there was a significant decrease +^ +^f assessment. The subjects had all been +m volar skin resistance, interpreted as a reduc- +acticing different yoga techniques (asanas +tion in sympathetic tone. While both SAV and +^^^ pranayamas, excluding SAV) for approxi- +CAV were accompanied by a reduction in body +^^^ , ^.^^^y minutes every day, during the +weight, SAV alone significantly increased the +^^^^^ ^^^^^^ +^^^ to the study. The subjects +oxygen consumption. The increase in OC (albeit +^-^ „^^ +^-^^ ^j^^ +techniques during the +not significant) following CAV cou d mean that +^ +^f ^^^ ^^^ +-^ ^^^^^ ^^ ^^^^^^ ^^^ ^1^^^^^ +CAV practice is not actually "cooling" as de- +^^ ^^e short-term effects of these practices mod- +scribed by the ancient yoga texts, but more ac- +-fy- +^he effects of the pranayama practice +curately less stimulating than SAV. Of course, +^-^^ g^y) that was studied, +the mcrease m skin resistance following CAV +practice shows that this practice does reduce +Design of the study +sympathetic activity at least in some divisions +of innervation. +Assessments were made on two separate days +The comparable reduction in body weight +^^ soon as the subjects woke up in the morning, +with both SAV and CAV suggests a possible +between 4:15 AM and 5:30 AM. Assessments +therapeutic application in obesity for both +were taken, followed by the test period (45 min- +these practices. However, the maximum in- +^^^s), at the end of which assessments were re- +crease in oxygen consumption following SAV +Plated. On day one the test period involved +makes this practice preferable to CAV, partic- +practicing surya anuloma viloma pranayama +ularly in view of the fact that the resting meta- +^^^^^ ^^^ ^^ minutes. This involves breathing +bolic rate (RMR) in kcal/kg/hour is lower in +exclusively through the right nostril. On day 2, +the obese and is negatively correlated with the +during the 45-minute test period, subjects were +body mass index (BMI) (Dudani, Bijlani, Gupta, +^^^^ed to breathe normally. This was called the +Manoch & Nayar, 1986). +^ ^ session. Half the subjects (selected on a ran- +Obesity is well known to be associated with +^^"^ ^^^^^^ ^ere given SAV sessions first, fol- +a variety of diseases, particularly hypertension +^o^ed by NB sessions on the next day. The six +and coronary heart disease (Mayer, 1980). +remaining subjects had NB sessions on day one +Hence, the present shidy was designed to as- +^^^ ^^^ sessions the next day. +sess the immediate effects of 45 minutes of SAV +pranayama on blood pressure (BP), digit pulse +^^sesswenfs +volume, heart rate, breath rate, skin resistance. +The sequence of assessment was the same for +and oxygen consumption. This information +the recordings made before and after the test pe- +was considered necessary to understand any riods of both SAV and NB. The sequence was as +possible therapeutic merits (and limitations) of +follows: Subjects were asked to rest for 5 min- +this breathing technique. +utes, seated at ease. Oxygen consumption (OC) +EFFECTS OF A YOGA BREATHING PRACTICE +481 +was recorded for 5 minutes using the closed cir- +Pressure Dry (STPD), according to the accepted +cuit Benedict-Roth apparatus. Recordings were +procedure (Report of the International Union +made almost immediately after waking up in the +of Physiological Sciences Commission +on +morning. This was followed by a 10-minute +Teaching Physiology, 1991). Heart rate (HR) in +recording of polygraph data viz. heart rate +beats per minute (bpm) was obtained by con- +through EKG, skin resistance, respiration, and +tinuously counting the QRS complexes in suc- +digit pulse volume as detailed below. The blood +cessive 60 = second periods. The skin resis- +pressure (BP) was recorded once at the end of +tance (SR) trace was sampled every 30 seconds, +the 10-minute recording. This sequence was re- +The amplitude of the digit pulse volume (DPV) +peated at the end of the test period. +was sampled from the peak of pulse wave at +Oxygen consumption (OC) was recorded for +30-second intervals and converted to millivolts +5 minutes using the closed circuit Benedict- +(mV) (Roy & Steptoe, 1991). +Roth apparatus. Recordings were made almost +The data were analyzed using the 2-factor +immediately after waking up in the morning. +ANOVA, the multiple comparison Tukey test. +Poly +graphic recordings were made using a 10- +and the paired t test. The ANOVA was used to +channel +polygraph +(Model +10, +Polyrite, +determine whether there was a significant dif- +Recorders and Medicare, Chandigarh, India), +ference between SAV and NB sessions (Factor +The EKG was recorded using standard limb +A), the readings before the test period corn- +lead I configuration. The skin resistance (SR) +pared to the readings obtained after it (Factor +was recorded using specially contoured metal +B), and interaction between Factors (A X B). The +electrodes +smeared +with +electrode +jelly +multiple comparison Tukey test was used to +(Medicon, Madras, India) and placed in contact +check the least significant difference between +with the volar surfaces of the distal phalanges +different pairs of means. As a second level +of the index and middle fingers of the left hand, +analysis, the t test for paired data was used to +A fixed current of lOuA was passed between +compare the initial and final data of SAV and +the electrodes. Respiration was recorded using +NB sessions separately, +a volumetric pressure transducer fixed around +the trunk about 8 cm below the lower costal +_. +/n A^TX +J +I T +^ - +/KTT^\ +^T +1 • ^ +^ +^ +A +T. +i. +Pranayama (SAV) and normal breathinQ (NB) +margm as the subject sat erect. A photo- +^ +"^ +plethysmograph was placed on the volar sur- +During both surya anuloma viloma prana- +face of the distal phalanx of the left thumb to +yama (SAV) and normal breathing (NB), sub- +record the digit pulse volume (DPV). +jects sat either in padmasana (lotus posture) +The blood pressure was recorded with a +or sukhasana (sitting cross-legged at ease), +standard mercury sphygmomanometer, aus- +with their eyes closed. Surya anuloma viloma +cultating over the right brachial artery. The di- +pranayama (SAV) involves breathing exclu- +astolic pressure was noted as the reading at +sively through the right nostril, while the left +which the Korotkoff sounds appeared muffled, +nostril is kept occluded with gentle pressure +Recordings were made of the (subjective) feel- +from the ring and little finger of the right hand +ings the subjects experienced at the end of both +(Nagendra, Mohan & Shriram, 1988). During +sessions. Subjects were shown how to monitor +normal breathing (NB) there was no voluntary +their nasal airflow using a method described +manipulation of the nostrils, +earlier (Klein, Pilon, Prossner & Shannahoff- +During the three months prior to the study, +Khalsa, 1986), by breating on a glass slide and +the subjects practiced the following yoga tech- +noting which patch of mist was smaller and / or +niques: +faded more quickly. +1. Asanas: ardha cakrasana/ lateral arc posture +(left and right side), ardha cakrasana/ half-wheel +posture, padahastasana/ forward-bend posture. +Data acquisition and analysis +^^^^ +matsyendrasana/ half-twist posture, us- +The OC was calculated in ml/min and con- +trasana/ camel posture, pascimatanasana/ poste- +verted to ml/min Standard Temperature and +rior stretching, bhujangasana/ serpent posture. +482 +TELLES ET AL. +salabhasana/ locust posture/ dhanurasana/ bow +posture, sarvangasana/ shoulder-stand, mat- +syasana/ fish posture, and savasana/ corpse pos- +ture. +2. Pranayamas: sectional breathing, nadisud- +dhi (purification of subtle perception paths), uj- +jayi (hissing pranayama), and bhrahmari (bee- +sounding pranayama). +RESULTS +The group mean values ± SD for all the pa- +rameters have been given in Table 1. +Two Factor ANOVA +The two factor ANOVA revealed a signifi- +cant difference between the 'l^efore" and "af- +ter" values of skin resistance—^SR (viz Factor +B = before test period versus after test period), +[F - 8.54, F 0.02 (2) 1,44 = 7.24 hence P < 0.02], +here (as well as below) the "F" value for DF 44 +has been derived by linear interpolation (Zar, +1984) from the values for DF = 40 and DF = 45, +given in a standard table. The multiple com- +parison Tukey test revealed a significant dif- +ference between the mean SR value after SAV +compared to the mean value before SAV (q — +3.91, where q .05 (2) 4, 40 = 3.79, hence P < +TABLE 1. AUTONOMIC VARIABLES BEFORE AND AFTER +SURYA ANULOMA PRANAYAMA (SAV) +AND NORMAL +BREATHING (NB) VALUES ARE GROUP MEAN ± +SD, +NUMBER OF SUBJECTS = 12 +Parameter +Heart +Rate (bpm) +Respiration +Rate (cpm) +Skin Resist- +-ance (KOhms) +Digit Pulse +Volume (mm) +Systolic +BP (mm Hg) +Diastolic +BP (mm Hg) +Oxygen +Consumption +(ml/min STPD) +1 +Before +67.7 +±10.0 +13.9 +±5.4 +461.3 +±312.0 +7.0 +±2.8 +100.6 +±9.8 +74.7 +±11.5 +257-4 +±54.0 +SAV +After +66.0 +±11.0 +13.5 +±4.8±4.4 +183.0** +±159.2® +3.8* +±1.8 +110.0* +±9.6 +72.5 +±9.8 +301.1* +±51.1 +NB +Before +65.0 +±8.1 +12.8 +±5.2 +444.0 +±280.0 +6.6 +±4.6 +104.5 +±10.1 +71.2 +±7.3 +251.6 +±40.0 +After +64.5 +±9.0 +12.1 +306.0** +±205.7 +6.7 +±5.0 +101.7 +±10.9 +69.8 +±7.5 +205.3 +±59.2 +*p < 0.05, paired t test, "after" compared to "before." +**p < 0.001 paired t test, "after" compared to "before." +@p < 0.05, Tukey test. +0.05). Here 40 is the next value listed on the +standard table where 44 is not listed. +For the systolic BP, interaction between +Factor A (SAV versus NB) and Factor B (before +versus after), i.e., A X B was significant [F = +4.54, F 0.05 (1) 1, 44 = 4.06, hence P < 0.05]. +However, there was no significant effect of ei- +ther Factors A or B independently (P > 0.2, in +both cases, DF as described above). There was +no significant effect of either of the Factors (A +or B) or of the interaction between them (A X +B) for the remaining parameters (P > 0.2 in all +cases, DF as described above). The multiple +comparison Tukey test did not reveal a signif- +icant difference in the comparison of the group +mean values for these parameters (for all para- +meters q < 2.50, DF as described above for SR, +hence P > 0.1). +Paired t test +The paired t test revealed a significant de- +crease (45.7%) in digit pulse volume (DPV) fol- +lowing SAV (P < 0.05), with no significant +change after NB. There was a significant (P < +0.05) increase of 17% in the oxygen consump- +tion (OC) after SAV and in the systolic blood +pressure after SAV sessions by an average of +9.4 mm HG (P < 0.05), but not after NB ses- +sions. The skin resistance (SR) was significantly +reduced after both SAV and NB sessions (P < +0.001, in both cases). The change was greater +after SAV sessions (60%), compared to a 31% +decrease after NB sessions. However, this dif- +ference was not statistically significant [q = += +1.72, where q 0.5 (2) 4, 40 = 1,996, hence P > +0.5]. +There were no significant changes in the +other parameters after either SAV or NB ses- +sions, compared to before (P > 0.1) in all cases). +DISCUSSION +The present study has demonstrated a sig- +nificant (paired t test) increase in OC (17%), sys- +tolic BP (9.4 mm of Hg on an average), and a +significant decrease in digit pulse volume +(45.7%), after SAV, with no change in these +measurements after NB. After both SAV and +NB there was a significant decrease (two Factor +ANOVA, Tukey test) in SR. +EFFECTS OF A YOGA BREATHING PRACTICE +483 +The immediate effects of SAV on oxygen con- +It was interesting to note that at the end of +sumption shown in the present study are sim- +the SAV test session, nine of twelve subjects re- +ilar to the changes in baseline status reported +ported feeling more relaxed, while at the end +after a month of SAV practice (Telles et al., +of the NB session eight subjects felt greater re- +1994). This increase in oxygen consumption +laxation. Among these subjects there were six +was considered especially interesting with a +who reported feeling relaxed after both ses- +possible application in the obese who are +sions. In the present study the subjects had +known to have a lower Resting Metabolic Rate +practiced yoga for three months prior to the +(RMR) in Kcal/kg/hour than the nonobese (the +study. The practice of yoga has been shown to +RMR is negatively correlated with the body +reduce anxiety and increase quietitude (Hjelle, +mass index, or BMI) (Dudani et al, 1986). This +1974). Hence, the earlier practice of yoga in the +effect is indeed in keeping with the name +subjects of the present study may have added +('surya anuloma viloma pranayama'), which +to the sympathetic stimulating effects of SAV, +means "heat generating breathing practice" +so that subjects felt more relaxed, though phys- +(Nagendra et al., 1988). In this context it may +ically they showed signs of sympathetic stim- +be mentioned that in the earlier study (Telles +ulation. However, it is important to note that +et al., 1994) the practice of CAV (''chandra an- +the subjects' prior experience of yoga could be +uloma viloma pranayama" or "heat dissipat- +expected to condition their autonomic nervous +ing" breathing practice) also increased the OC, +systems, so that their response to SAV may not +though the increase was not significant and +be the same as that of naive subjects who have +was of a lesser naagnitude than that caused by +no prior experience of yoga. +SAV (24% versus 37%). Hence the name ("heat +The way in which breathing through either +dissipating") breathing practice may be mainly +nostril can influence autonomic functions is not +relative to SAV. +well understood. A study of the electrographic +Apart from the effects on OC, the practice of +activity generated by nasal (as opposed to oral) +SAV for a month caused an increase in heart +breathing (Kristof, Servit & Manas, 1981), +rate, suggestive of increased cardiac sympa- +showed that this activating effect could also be +thetic tone and/or reduced vagal tone (Telles +produced by nasal insufflation without inflat- +et aL, 1994). In the present study, immediately +ing the lung. This neural reflex was abolished +after SAV there was a significant reduction in +after injecting local anesthesia into the nasal +skin resistance (SR) and in digit pulse volume +mucosa. The afferents arising from the mucosa +(DPV), both indicative of an increase in sym- +are believed to be connected to both the hypo- +pathetic tone (to palmar sudomotor glands and +thalamus (hence the autonomic nervous sys- +cutaneous vasculature, respectively). These re- +tem) and the cerebral cortex; however, these +suits support those of previous studies which +pathways have not been anatomically defined, +have demonstrated the sympathetic stimulat- +In summary the practice of SAV may be of +ing effect of forced right nostril breathing +benefit in obesity, but in view of the increase +(Backon, 1988; Shannahoff-Khalsa & Kennedy, +in systolic BP and cutaneous vasoconstriction, +1993). The increase in systolic BP observed here +it may be best to avoid this practice in obese +was probably due to cutaneous vasoconstric- +patients who are also hypertensive, +tion (as shown by the decrease in digit pulse +volume). Both SAV and NB sessions caused a +significant reduction in the SR. The reduction +REFERENCES +in SR after NB sessions could indicate an in- +crease in the sympathetic activity in subjects +Backon J. Changes in blood glucose levels induced by dif- +Sixty minutes after waking, as a "wearing off" +ferential forced unilateral nostril breathing, a technique +of the increased SR known to occur during +which affects both brain hemisphericity and autonomic +sleen (Tart 1967) All subiects—irrespective of +^^^^'^- ^^^ ^"^""^"^ ^^' 1988;16:1197-1199. +Sleep uart, i^b/). An suDjects +irrespective or +^^^^. +^^ ^..j^^. ^^ ^^^^^ ^^^ Manoch S, Nayar U. +which nostril was dominant at the start of the +Metabolic rate at rest and after meals with varying fiber +test session—showed these effects, suggestive +content in obese and nonobese women. Indian J Med +of sympathetic stimulation. +Res 1986;84:74-82. +484 +TELLES ET AL. +Hjelle CA. Transcendental Meditation and psychological +health. Percept Mot Skills 1974;39:623-628. +Keuning J. On the nasal cycle. J Int Rhinol 1968;6:99-136. +Klein R, Pilon D, Prossner S, Shannahoff-Khalsa D. Nasal +airflow asymmetries and human performance. Biol +Psychol 1986;23:127-137. +Kristof M, Servit Z, Manas K. Activating effect of nasal +airflow on epileptiform electrographic abnormalities in +the human EEG. Evidence for the reflex origin of the +phenomenon. Physiol Bohemoslov 1981;30:73-77. +Mayer J. Obesity. In: Modern Nutrition in Health and +Disease. Goodhart RS, Shils ME (eds.). Philadelphia: +Lea & Febiger, 1980. p 733. +Nagendra HR, Mohan T, Shriram A. Yoga in Education. +Bangalore: Vive-kananda Kendra Yoga Anusandhana +Samsthan, 1988. p 120. +Report of the International Union of Physiological Sciences +Commission on Teaching Physiology Singapore: World +Scientific, 1991, p. 87. +Roy M, Steptoe A. The inhibition of cardiovascular re- +sponses to mental stress following aerobic exercise. +Psychophysiol 1991;28:689-699- +Shannahoff-Khalsa D. Lateralized rhythms of the central +and autonomic nervous system. Int J Psychophysiol +1991;11:222-251. +Shannahoff-Khalsa D, Kennedy B. The effects of unilat- +eral forced nostril breathing on the heart. Int J Neurosci +1993;73:47^0. +Tart C. Pattern of basal skin resistance during sleep. +Psychophysiol 1967;4:35-39- +Telles S, Nagarathna R, Nagendra HR. Breathing through +a particular nostril can alter metabolism and autono- +mic activities. Indian J Physiol Pharmacol 1994;38:133- +137. +Werntz DA, Bickford RG, Bloom FE, Shannahoff-Khalsa +D. Alternating cerebral hemispheric activity and the lat- +eralization of autonomic nervous function. +Hum +Neurobiol 1983;2:39^3. +Zar JH. Biostatistical analysis. Second edition. New Jersey: +Prentice-Hall, 1984. p 477. +Address reprint requests to: +Shirley Telles, Ph.D. +Vivekanando Kendra Yoga Research Foundation +"Eknath Bhavan" +19 Gavipuram Circle +Bangalore, 560 019 India diff --git a/subfolder_0/Positive impact of cyclic meditation on subsequent.txt b/subfolder_0/Positive impact of cyclic meditation on subsequent.txt new file mode 100644 index 0000000000000000000000000000000000000000..a86845bc78e232ef5cc1bfd35dd68d2deb67163e Binary files /dev/null and b/subfolder_0/Positive impact of cyclic meditation on subsequent.txt differ diff --git a/subfolder_0/Potential role of yoga in management of the ominous octet Adding a new facet to type 2 diabetes management and prevention.txt b/subfolder_0/Potential role of yoga in management of the ominous octet Adding a new facet to type 2 diabetes management and prevention.txt new file mode 100644 index 0000000000000000000000000000000000000000..70ed048bfeb26700ef2f30f1cd6149a6e0a4b0a6 --- /dev/null +++ b/subfolder_0/Potential role of yoga in management of the ominous octet Adding a new facet to type 2 diabetes management and prevention.txt @@ -0,0 +1,871 @@ +© 2020 Journal of Diabetology | Published by Wolters Kluwer ‑ Medknow +10 +Review Article +Introduction +The prevalence and incidence of diabetes mellitus is increasing +worldwide at an alarming pace. The number of adults with +diabetes was 194 million in 2006 and was predicted to reach +333 million by 2025.[1] But already, an estimated 425 million +adults have diabetes and another 352.1 million adults have +impaired glucose tolerance (IGT).[2] +Our knowledge and understanding of the pathophysiology of type 2 +diabetes mellitus (T2DM) is ever expanding. The two common +pathophysiological abnormalities observed in T2DM are insulin +resistance and impaired β‑cell function. The pathophysiology of +T2DM is believed to commence with insulin resistance, which +leads to glucotoxicity and decreased β‑cell function.[3] However, +according to the ‘β‑cell centric’ approach,[4] β‑cell dysfunction +is the primary defect in T2DM which in turn leads to insulin +resistance. Apart from insulin resistance (in muscles and liver) +and β‑cell dysfunction, the ‘ominous octet’ model of DeFronzo[5] +refers to the involvement of brain, adipose tissue, gastrointestinal +hormones, kidney and α‑cells in the pathophysiology of T2DM +and emphasises the need for a multiple drug combination to rectify +the underlying pathophysiological defects and not simply aim at +reducing the HbA1C levels. +A recent systematic review demonstrated that lifestyle +interventions are better at reducing the incidence of T2DM than +usual medical care in populations across different ethnicities +and cultures.[6,7] Lifestyle interventions are also effective in +secondary prevention of diabetes as shown in the Da Qing +study, where participants in the lifestyle group had a 47% +lower risk of diabetic retinopathy at 20‑year follow‑up.[8] +Abstract +Global increase in the prevalence of diabetes places a huge economic burden upon health systems due to costs of management, especially in those +with co‑morbidities. Epidemiological studies show lifestyle interventions to be cost‑effective in type 2 diabetes prevention and management. +Exercise is a major component in these lifestyle interventions. However, exercise is contraindicated in advanced complications of diabetes +such as proliferative retinopathy and also has increased risk of hypoglycaemia. Yoga is a form of low‑to‑moderate intensity physical activity, +emerging as a widely practised form of complementary therapy in the management of various medical conditions. It is also believed to be a +safe and cost‑effective mode of physical activity in the primary and secondary prevention of type 2 diabetes. The ‘ominous octet’ model of +DeFronzo puts forth the eight major pathophysiological abnormalities observed in type 2 diabetes. The current review explores the mechanism +and ‘potential’ role of yoga in management of this ominous octet. +Keywords: Management, mechanism, ominous octet, type 2 diabetes mellitus, yoga +Access this article online +Quick Response Code: +Website: +www.journalofdiabetology.org +DOI: +10.4103/jod.jod_6_18 +Address for correspondence: Dr. Venugopal Vijayakumar, +4, Conran Smith Road, Gopalapuram, Chennai ‑ 600 086, + +Tamil Nadu, India. + +E‑mail: dr.venu@svyasa.org +This is an open access journal, and articles are distributed under the terms of the Creative +Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to +remix, tweak, and build upon the work non-commercially, as long as appropriate credit +is given and the new creations are licensed under the identical terms. +For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com +How to cite this article: Vijayakumar V, Mavathur R, Raguram N, +Ranjani H, Anjana RM, Mohan V. Potential role of yoga in management of +the ominous octet: Adding a new facet to type 2 diabetes management and +prevention. J Diabetol 2021;12:10-7. +Potential Role of Yoga in Management of the Ominous Octet: +Adding a New Facet to Type 2 Diabetes Management and +Prevention +Venugopal Vijayakumar1,2, Ramesh Mavathur3, Nagarathna Raguram3, Harish Ranjani4, Ranjit Mohan Anjana5, Viswanathan Mohan5 +1Department of Yoga, Govt. Yoga & Naturopathy Medical College, Chennai, 2Department of Yoga and Physical Activity, Madras Diabetes Research Foundation, +Chennai, 3Department of Yoga and Life sciences, Swami Vivekananda Yoga Anusandhana Samsthana (S-VYASA University), Bengaluru, 4Translational Research +Department, Madras Diabetes Research Foundation, 5Madras Diabetes Research Foundation & Dr. Mohan’s Diabetes Specialities Centre, Chennai, India +Received: 05-February-2018, Revised: 23-March-2018, Accepted: 09-April-2018, +Published: 25-December-2020 +[Downloaded free from http://www.journalofdiabetology.org on Saturday, January 23, 2021, IP: 136.232.192.146] +Vijayakumar, et al.: Yogic management of the ominous octet +Journal of Diabetology  ¦  Volume 12  ¦  Issue 1  ¦  January-March 2021 +11 +Dietary modifications and exercise recommendations are the +conventional lifestyle interventions recommended for the +prevention and management of T2DM. Increase in moderate +physical activity is associated with multiple benefits such +as, improved insulin sensitivity, better glycemic control, +reduced body mass index, improvement in lipid profile and +other risk factors associated with diabetes such as obesity +and hypertension.[9,10] However, physical exercise may need +to be done with caution in patients with increased risk of +cardiovascular events and comorbidities associated with +microvascular and macrovascular complications such as +diabetic neuropathy and proliferative retinopathy, which +could worsen with intensive exercise programs.[11] Although +the beneficial effects of physical activity are well established, +adherence rate remains poor, as patients seem not to engage +in regular physical activities for different reasons.[12‑14] There +is growing interest in alternative and holistic models to T2DM +management which could possibly improve adherence. +Yoga is a mind/body practise based on traditional Indian +philosophy, depicting the ideal way of life and is more than just +a physical activity.[15] In terms of energy expenditure, it is similar +to mild‑to‑moderate intensity exercise.[16] In addition to the +physical movements (asanas), yoga commonly involves multiple +other components such as controlled respiration (pranayama), +relaxation and meditation (dhyana). Many studies are emerging +on the benefits of yoga in various diseases.[17] Findings from +extensive studies suggest yoga to have multiple benefits in the +etiopathogenesis of T2DM and associated complications such +as improved glycemic control, lipid profile, improved cognition, +nerve conduction velocity, weight loss, reduced inflammation,[18,19] +oxidative stress,[20] and cardiovascular risk factors in T2DM +patients.[21‑23] Comparative studies on yoga versus exercise suggest +that yoga is as effective if not superior to physical exercise in +health‑related outcome measures such as blood glucose, lipids, +salivary cortisol and oxidative stress which are of greater +significance in the primary and secondary prevention of T2DM, +with additional benefits of improving subjective measures such +as fatigue, sleep, pain and quality of life (QoL).[24,25] +The role of physical exercise as a part of the lifestyle +intervention in the prevention and management of diabetes +is well established.[26] The current narrative review aims at +exploring the ‘ominous octet’ involved in the etiopathogenesis +of T2DM and the potential role of yoga in correcting these +pathological defects for an effective primary and secondary +prevention of T2DM [Figure 1]. +Yogic Management of the Ominous Octet +β‑cell dysfunction +The defects in β‑cell dysfunction primarily involve three +components. First, the secretion timing disorder, where there +is a reduction in the initial acute phase insulin release (AIR). +Autonomic nervous system is attributed for >70% of the AIR.[27] +AIR is generally abolished by vagotomy in rats[28] and by atropine +in humans[29] which is suggestive of the pivotal role of vagal +activity in AIR. Second is the quantitative disorder, in which there +is an increase or decrease in the second phase insulin release. +Third, the qualitative disorder, in which there is an increase in +the proinsulin‑to‑insulin ratio.[30] An increase in the amount of +proinsulin in circulation, which is attributed to the impaired +cleavage capacity of the β‑cells, is observed irrespective of the +diabetes duration, suggesting that β‑cell dysfunction need not +necessarily occur after insulin resistance and might possibly +precede the onset of clinically overt T2DM.[30] +Patients with T2DM have higher levels of oxidative stress. +Subtle increases in the physiological concentration of the +reactive oxygen species  (ROS) might mimic a number +of insulin‑like effects, including increase in glucose +transporters (GLUT) translocation, lipogenesis, decreased +lipolysis,[31] and an increase in the glucose‑stimulated insulin +secretion.[32] However, chronic oxidative stress and free radical +damage observed in T2DM plays an important role in inducing +β‑cell dysfunction, as β‑cells possess limited defence against +excess ROS production due to low levels of ROS‑detoxifying +enzymes.[33,34] Increase in oxidative stress leads to decreased +transcription of the insulin gene by decreasing PDX1 and +MafA binding.[35,36] Similarly, protein misfolding and resultant +ER stress in the human β‑cells is a major pathophysiological +event in T2DM which is also associated with oxidative stress.[3] +Yoga studies showed a reduction in oxidative stress and increased +anti‑oxidant defence, by improving superoxide dismutase, +glutathione, malondialdehyde, Vitamin C and Vitamin E +profile.[37,38] γ‑aminobutyric acid (GABA) induces membrane +depolarisation and proliferation in β‑cells, and thus increases +insulin secretion.[39] A study comparing the effects of yoga +with walking, found yoga to improve GABA levels better than +walking.[40] Yoga reduces sympathetic activation and enhances +parasympathetic activity through direct stimulation of the +vagus nerve.[41,42] The positive impact of yoga on the autonomic +Figure 1: Pathways involved in the yogic management of type 2 diabetes +mellitus +[Downloaded free from http://www.journalofdiabetology.org on Saturday, January 23, 2021, IP: 136.232.192.146] +Vijayakumar, et al.: Yogic management of the ominous octet +Journal of Diabetology  ¦  Volume 12  ¦  Issue 1  ¦  January-March 2021 +12 +nervous system would possibly help overcome insulin secretion +timing disorder as well. With improved antioxidant defence, +GABA secretion and autonomic balance, yoga appears to have +the potential to play multiple roles in preserving β‑cell function +associated with T2DM and metabolic syndrome. +Insulin resistance +Skeletal muscle is one of the major sites for disposal of ingested +glucose in healthy individuals with normal glucose tolerance. +Postprandial hyperglycaemia induces insulin secretion and the +resultant increase in plasma insulin concentration stimulates +glucose uptake in skeletal muscles.[43] Meanwhile, glucose uptake +into skeletal muscles is stimulated through insulin‑independent +mechanisms as well, that are activated by muscle contractions, +hypoxia and nitric oxide, all of which are shown to increase +membrane translocation of glucose transporter 4 (GLUT 4).[44,45] +In the insulin‑resistant state (e.g., in T2DM and metabolic +syndrome), the insulin‑dependent glucose disposal in skeletal +muscle is markedly impaired;[46] however, the capacity for the +insulin‑independent Adenosine 5’‑monophosphate‑activated +protein kinase (AMPK)‑mediated glucose uptake is still intact +in the muscle cells of patients with T2DM.[47] +Yoga – asanas and pranayama have shown to improve insulin +sensitivity in T2DM.[48] Insulin sensitivity is found to be +significantly higher in regular practitioners of yoga.[49] The +observed increase in glucose sensitivity could be attributed to +the possible activation of AMPK through muscle contractions +involved during yoga postures.[50] +Adipose tissue and inflammation +Increase in the pro‑inflammatory markers and decrease in the +anti‑inflammatory markers are often observed in T2DM and +prediabetes.[51] Adipocytes are now known to be the key regulators +of glucose homeostasis. Adipokines play an integral role in the +etiopathogenesis of T2DM and modulation of adipocytes could +therefore be a useful therapeutic strategy in T2DM.[52] +Reduction in the pro‑inflammatory markers such as tumor +necrosis factor α, interleukin‑6, C‑reactive protein (CRP) and +high‑sensitivity CRP, and increase in the anti‑inflammatory +markers such as adiponectin are consistently reported +through various studies on yoga.[53‑55] Adiponectin activates +AMP kinase of liver and thereby help reduce hepatic glucose +production  (HGP).[56] Role of adiponectin on improving +endothelial nitric oxide synthetase (eNOS) and resultant +increase in endothelial nitric oxide production is well +established,[57,58] which is beneficial in the prevention of +neuropathy, cardiovascular complications and improve delayed +wound healing in diabetes. A systematic review on the effect of +exercise on adiponectin states that moderate‑intensity exercise +programs have significant impact on the adiponectin levels.[59] +This was ably supported by a study which found regular yoga +practise to increase adiponectin levels.[53] +Brain +In 1854, the renowned physiologist Claude Bernard observed +that a lesion in the floor of fourth‑cerebral ventricle could +induce diabetes and postulated that brain plays a central role +in glucose homeostasis and diabetes pathogenesis. The notion +remained popular up until the discovery of insulin by Banting +and Best in 1921, and the identification of liver, muscle and +adipose tissue as the principal target organs of insulin on glucose +metabolism.[60] Furthermore, a strong evolutionary link is +observed between neurons and the insulin‑producing β‑cells in +various animals.[61,62] Even in higher animals, the hypothalamus +senses blood glucose levels, in a similar way as the β‑cells.[63] +The available literature clearly suggests a high degree of +association between brain and glucose metabolism. There are +many glucose‑sensing neurons in the brain, particularly in +hypothalamus (arcuate, ventromedial and paraventricular nuclei) +which helps in systemic glucose homeostasis.[60,64] Injecting +smaller doses of glucose or insulin into these discrete areas of the +brain can lower blood glucose levels and increase liver insulin +sensitivity, independent of the amount of insulin in circulation.[65] +Administration of leptin into the third ventricle reverses insulin +resistance and diabetes phenotypes in lipodystrophic mouse +at doses too low to have any effect outside the brain and is +ineffective otherwise when administered peripherally.[66] +Conversely, deletion of receptors for either insulin or leptin from +certain specific hypothalamic neurons causes systemic insulin +resistance and glucose intolerance, indicating the physiological +role of these neurons on systemic glucose metabolism.[67,68] +brain‑derived neurotrophic factor (BDNF) prevents apoptosis +and preserves insulin‑secreting capacity of β‑cells.[69] Similarly, +serotonin is also reported to increase β‑cell proliferation.[70] +Some yoga studies have reported improvement in the BDNF +and serotonin levels following practise of yoga.[71,72] Conversely, +disturbances in the glucose metabolism also affect the brain. +HbA1C of more than 7% increases the risk of developing mild +cognitive impairment by 4‑fold.[73] T2DM is associated with +a 1.5–2.5‑fold increased risk of cognitive dysfunction.[74,75] +A cognitive decline is observed very early, during IGT and +metabolic syndrome.[76‑78] +Bromocriptine is a sympatholytic D2‑dopamine agonist +approved for use as antihyperglycemic medication.[79] The +mechanism of action of which is attributed to its dopaminergic +activity in the brain and subsequent inhibition of sympathetic +tone, thereby improving both insulin release and insulin +sensitivity.[80] Yoga, in addition to reduction in the sympathetic +tone and increase in parasympathetic tone, has also shown +to increase dopamine levels.[81] A landmark study in yoga +demonstrated that meditation facilitates cortical plasticity, +and regular practitioners of meditation are observed to have +increased cortical thickness, especially in areas associated with +somatosensory, cognitive and emotional processing.[82] An +improvement in cognitive brain functions of T2DM patients +is also observed with regular yoga practise.[83] Further studies +on yoga had shown increased gray matter in the limbic system, +cerebral lobes and cerebellum, improved cerebral blood flow +and activation of midbrain close to the hypothalamus.[84] Yoga, +thus might play an important role in enhancing the brain +regulated glucose homeostasis mechanism, possibly through +[Downloaded free from http://www.journalofdiabetology.org on Saturday, January 23, 2021, IP: 136.232.192.146] +Vijayakumar, et al.: Yogic management of the ominous octet +Journal of Diabetology  ¦  Volume 12  ¦  Issue 1  ¦  January-March 2021 +13 +hypothalamic–pituitary–adrenal axis and potentially improve +cognitive dysfunction associated with T2DM, albeit, more +studies are required. +Glucagon +Elevated glucagon levels and hyperfunction of α‑cells were +demonstrated in individuals with T2DM in 1970. Indeed, the +importance of α‑cells in diabetes was observed way back in +1947, when Rodriquez‑Candela reported that alloxan‑induced +diabetes of dogs could be ameliorated by removal of pancreatic +α‑cell remnants.[85] A more recent study with an animal model +demonstrated that, even in complete insulin deficiency, blocking +of glucagon action could possibly prevent the metabolic +and clinical derangements seen in type 1 diabetic mice,[86] +highlighting the importance of glucagon suppression in the +pathogenesis of diabetes. Elevated fasting plasma glucagon +levels lead to increase in the HGP[87] and decreased insulin +sensitivity in animal models.[86] Similarly, the capacity of the liver +to synthesise triglycerides (which independently causes insulin +resistance) is enhanced during stress which is partly due to the +action of glucagon through the cyclic adenosine monophosphate +pathway.[88] GABA induces membrane hyperpolarisation in +α‑cells, resulting in suppression of glucagon secretion,[89] and +as mentioned earlier, yoga improves GABA levels.[90,91] +Glucagon‑like peptide‑1 +Glucagon‑like peptide‑1 (GLP‑1) is a potent incretin hormone, +acting more like a ‘master switch’ in glucose metabolism by +operating through multiple pathways such as increased glucose +uptake of muscle and liver, inhibiting glucagon secretion, +while promoting insulin and somatostatin secretion and +delayed gastric emptying.[92] The gene encoding the GLP‑1, +the proglucagon gene has three known sites of expression, +namely, α‑cells, L cells of the large intestine and the nucleus +tractus solitarius in the hindbrain, which is the nucleus of +vagus nerve as well.[93] The role of vagus in the regulation of +GLP‑1 secretion has been clearly demonstrated in animal model. +Bilateral subdiaphragmatic vagotomy in conjunction with gut +transection and selective hepatic branch vagotomy completely +abolishes the fat‑induced and exogenous GIP‑induced GLP‑1 +release, respectively, while stimulation of the distal end of the +celiac branch of the subdiaphragmatic vagus nerve significantly +increases the release of GLP‑1.[94] GLP‑1 inhibits gastric +emptying and acts through the vagal afferent‑mediated central +mechanism,[95] which could positively be influenced by yoga +due to its known property of vagal activation. However, this is +purely speculative based on the known effects of yoga on the +autonomic nervous system and robust studies are needed to +establish the impact of yoga specifically on GLP‑1 secretion. +Liver +The liver is the major organ of glucose metabolism and HGP +and the main source of fasting hyperglycaemia, contributing +to approximately 80% of diurnal hyperglycemia in T2DM.[96] +An increase in the circulating blood glucose levels releases +insulin and inhibit HGP, but this negative feedback is +dysfunctional in T2DM. Increased flux of free fatty acids to +liver and accumulation of liver fat are the major determinants +of the decreased sensitivity of endogenous HGP to insulin.[97] +Glucagon,[86] central nutrient and hormone‑sensing in the +hypothalamus, together plays a central role in regulating +peripheral glucose homeostasis and mediate in the reduction +of HGP through vagal nerve efferent signaling to the liver.[98] +Various meta‑analysis and systematic reviews on the effect of +yoga on T2DM consistently report a higher reduction in the +FPG (fasting plasma glucose) levels, than PPG (post‑prandial +plasma glucose) levels, which suggests a reduction in the +HGP.[11,99] Although the effect of yoga on HGP has not +been measured directly so far, one could speculate that the +aforementioned positive impact of yoga on glucagon and +adiponectin would have an influence in reducing the HGP. +An improvement in the lipid profile through yoga is attributed +to the increased hepatic lipase activity, which affects the +lipoprotein metabolism and increases uptake of triglycerides +by adipose tissue.[91] +Glucose reabsorption +The kidney plays an important role in regulating glucose +homeostasis. The inhibition of renal glucose reabsorption is +one of the novel and effective strategies in the management of +T2DM.[100] β‑cell dysfunction could upregulate sodium‑glucose +cotransporter 2 (SGLT2) protein in the kidney of patients with +T2DM. Both SGLT2 and glucose transporter 2 (GLUT2) +are expressed more in the proximal convoluted tubules cells +of T2DM patients than in healthy individuals, resulting +in elevated renal glucose uptake and further worsening of +hyperglycaemia.[101] Hypothalamic pro‑opiomelanocortin +deficiency improves glucose tolerance in mouse models, +by increasing glycosuria and reduced sympathetic nervous +system  (SNS) activity which is attributed to observed +glycosuria and improved glucose tolerance.[102] Likewise, +the SNS activity reducing property of yoga might also help +reduce renal glucose reabsorption, facilitating improved +glucose tolerance and better glycemic control [Figure 2]. This +is obviously an area for future yoga research. +Other Physiological and Metabolic Effects of +Yoga +The blood glucose lowering effect of yoga could be attributed +to the stretching and contraction movements often performed +during physical asana postures in yoga, as muscle contraction +improves glucose sensitivity and reduce blood glucose.[48,49] +However, randomised controlled trials (RCTs) done in the +past have found yoga to be as effective if not superior to +physical exercises[20,21,103] and the benefits are not just restricted +to the physical movements involved in yoga. For instance, +yoga nidra (‘yogic sleep’) is a yogic technique which involves +complete body relaxation without any physical movements. +A 3‑month study exploring the efficacy of yoga nidra in +patients with T2DM found a significant reduction in the blood +glucose levels when compared to the control group.[104] The +study indicated that the reduction in blood glucose might not +[Downloaded free from http://www.journalofdiabetology.org on Saturday, January 23, 2021, IP: 136.232.192.146] +Vijayakumar, et al.: Yogic management of the ominous octet +Journal of Diabetology  ¦  Volume 12  ¦  Issue 1  ¦  January-March 2021 +14 +only be due to the physical movements involved but also +through a possible reduction in the stress hormones or due to +increased vagal activity.[105] Decreased vagal tone contributes to +the etiopathogenesis of T2DM in multiple ways.[26,106] Reduced +breathing rate increases vagal activation and decreases the +influence of sympathetic branch of the autonomic nervous +system, measured by an increase in heart rate variability and +baroreceptor sensitivity.[107] Some studies report betterment +of the complications associated with diabetes, like improved +nerve conduction velocity,[108] cognition,[82] and QoL.[109] +Autonomic dysfunction associated with T2DM is reported to +be stabilised following yoga.[105,110] It is of interest that a couple +of studies have reported a reduction in the medication score and +insulin intake of T2DM patients,[111,112] suggesting a possible +improvement in β‑cell dysfunction, insulin resistance or any +of the pathological abnormalities in the above‑mentioned +ominous octet, which was not observed with the control group +on exercise‑based lifestyle intervention.[112] Thus, yoga shows +promising insights of becoming an effective complementary +therapy in the prevention and management of T2DM. +Quality of Studies +Methodological flaws and bias are being reported in the +systematic reviews of the past, on yoga studies in patients with +diabetes.[18,19] Unlike drug trials, blinding might not be possible +in yoga studies, providing a very low score while assessing +the available RCT for bias. But still, high‑quality RCTs, +taking into account of the bias in study design, selection bias +and publication bias are lacking and are very much essential +to concretise the evidence available on the beneficial effects +of yoga in diabetes. Meanwhile, the available evidence from +RCTs and comparative studies are in line with the findings of +nonrandomised and uncontrolled studies, thus indicative that +the positive findings observed with yoga are not simply due +to poor study design alone. +Admittedly, there are a few studies reporting yoga not to be +beneficial as popularly ‘claimed’, on various dimensions of +diabetes such as glycemic control,[9] inflammation,[22] and blood +pressure.[113] Looking into the methodologies of these studies, +it was observed that the duration of yoga intervention given +was either once or twice a week, in comparison with the other +yoga trials where the participants generally practise yoga three +to five times a week. Yoga is more a way of life, to be practised +ideally every day for health and well‑being. Even if considered +as just a form of physical activity, it should be practised 5 days +a week to get the desired benefits.[10] Therefore, yoga might +have a dose‑dependent effect on glycemic control in T2DM. +Future studies on yoga should be designed so as to remove +the bias in methodology and reporting, with the recommended +duration or ‘dosage’ of three to five times a week. +Cost‑effectiveness of yoga interventions +A cost‑effective and sustainable intervention for the primary +and secondary prevention of diabetes would help increase the +QoL, diabetes‑free years of life, improved life expectancy, and +on top, cost savings, reducing the economic burden in growing +economy of many developing countries where the prevalence +of T2DM is on the rise. Yoga would be one such cost‑effective +intervention where the cost involved is a onetime investment, +where the patients learn yoga once under the direct supervision +of a suitably qualified and experienced yoga professional and +can practise on their own after getting sufficient training. +Moreover, the adherence rate of yoga is found to be higher than +other forms of physical activity, making it a more acceptable +and simpler form of physical activity for T2DM.[114] +Figure 2: Summary of the hypothesised role of yoga in management of the ‘Ominous octet’ defects of diabetes (Adapted from Defronzo 2009) +[Downloaded free from http://www.journalofdiabetology.org on Saturday, January 23, 2021, IP: 136.232.192.146] +Vijayakumar, et al.: Yogic management of the ominous octet +Journal of Diabetology  ¦  Volume 12  ¦  Issue 1  ¦  January-March 2021 +15 +Future Directions +Few advantages of using yoga as a form of physical activity +in T2DM are the relatively low cardiovascular demands when +compared to other forms of exercises. Low impact makes it an +easier and more simpler physical activity to practicse for people +who are contraindicative for exercise. Unlike many ‘traditional’ +therapies, yoga may be applicable to a larger population of +T2DM patients as it appears to be safe and inexpensive.[115,116] +The strength of most available research evidence on yoga +is modest and necessitates more robust research design and +unbiased reporting in the future. Nevertheless, the potential +role of yoga in the primary and secondary prevention of T2DM +is worth considering. Yoga could be a safe and cost‑effective +modality to prevent and manage T2DM. +Financial support and sponsorship +Nil. +Conflicts of interest +There are no conflicts of interest. +References +1. International Diabetes Federation. IDF Diabetes Atlas 2006. 3rd  ed. +Brusssels: International Diabetes Federation; 2006. +2. International Diabetes Federation. IDF Diabetes Atlas 2017. 8th  ed. +Brusssels: International Diabetes Federation; 2017. +3. Chang‑Chen KJ, Mullur R, Bernal‑Mizrachi E. Beta‑cell failure as a +complication of diabetes. Rev Endocr Metab Disord 2008;9:329‑43. +4. Schwartz SS, Epstein S, Corkey BE, Grant SF, Gavin JR 3rd, Aguilar RB, +et  al. The time is right for a new classification system for diabetes: +Rationale and implications of the β‑cell‑centric classification schema. +Diabetes Care 2016;39:179‑86. +5. Defronzo  RA. Banting lecture. From the triumvirate to the ominous +octet: A new paradigm for the treatment of type 2 diabetes mellitus. +Diabetes 2009;58:773‑95. +6. +Balk EM, Earley A, Raman G, Avendano EA, Pittas AG, Remington PL, +et al. Combined diet and physical activity promotion programs to prevent +type 2 diabetes among persons at increased risk: A systematic review for the +community preventive services task force. Ann Intern Med 2015;163:437‑51. +7. Weber MB, Ranjani H, Staimez LR, Anjana RM, Ali MK, Narayan KM, +et al. The stepwise approach to diabetes prevention: Results from the +D‑CLIP randomized controlled trial. Diabetes Care 2016;39:1760‑7. +8. Hu FB. Globalization of diabetes: The role of diet, lifestyle, and genes. +Diabetes Care 2011;34:1249‑57. +9. Pischke  CR, Marlin  RO, Weidner  G, Chi  C, Ornish  D. The role of +lifestyle in secondary prevention of coronary heart disease in patients +with type 2 diabetes. Can J Diabetes 2006;30:1‑7. +10. Aune D, Norat T, Leitzmann M, Tonstad S, Vatten LJ. Physical activity +and the risk of type 2 diabetes: A systematic review and dose‑response +meta‑analysis. Eur J Epidemiol 2015;30:529‑42. +11. Zinman  B, Ruderman  N, Campaigne  BN, Devlin  JT, Schneider  SH. +Physical activity/exercise and diabetes. Diabetes Care 2004;27:S58‑62. +12. Skoro‑Kondza  L, Tai  SS, Gadelrab  R, Drincevic  D, Greenhalgh  T. +Community based yoga classes for type  2 diabetes: An exploratory +randomised controlled trial. BMC Health Serv Res 2009;9:33. +13. Karjalainen  JJ, Kiviniemi AM, Hautala AJ, Piira  OP, Lepojärvi ES, +Perkiömäki JS, et al. Effects of physical activity and exercise training on +cardiovascular risk in coronary artery disease patients with and without +type 2 diabetes. Diabetes Care 2015;38:706‑15. +14. Anjana  RM, Ranjani  H, Unnikrishnan  R, Weber  MB, Mohan  V, +Narayan  KM, et  al. Exercise patterns and behaviour in Asian +Indians: Data from the baseline survey of the diabetes community +lifestyle improvement program  (D‑CLIP). Diabetes Res Clin Pract +2015;107:77‑84. +15. Kumar V, Jagannathan A, Philip M, Thulasi A, Angadi P, Raghuram N, +et al. Role of yoga for patients with type II diabetes mellitus: A systematic +review and meta‑analysis. Complement Ther Med 2016;25:104‑12. +16. McDermott  KA, Rao  MR, Nagarathna  R, Murphy  EJ, Burke  A, +Nagendra  RH, et  al. A  yoga intervention for type  2 diabetes risk +reduction: A  pilot randomized controlled trial. BMC Complement +Altern Med 2014;14:212. +17. 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. +18. Innes KE, Vincent HK. The influence of yoga‑based programs on risk +profiles in adults with type 2 diabetes mellitus: A systematic review. +Evid Based Complement Alternat Med 2007;4:469‑86. +19. Aljasir B, Bryson M, Al‑Shehri B. Yoga practice for the management +of type II diabetes mellitus in adults: A systematic review. Evid Based +Complement Alternat Med 2010;7:399‑408. +20. Sinha S, Singh SN, Monga YP, Ray US. Improvement of glutathione +and total antioxidant status with yoga. J  Altern Complement Med +2007;13:1085‑90. +21. Schmidt T, Wijga A, Von Zur Mühlen A, Brabant G, Wagner TO. Changes +in cardiovascular risk factors and hormones during a comprehensive +residential three month kriya yoga training and vegetarian nutrition. +Acta Physiol Scand Suppl 1997;640:158‑62. +22. Wolff  M, Memon AA, Chalmers  JP, Sundquist  K, Midlöv P. Yoga’s +effect on inflammatory biomarkers and metabolic risk factors in a high +risk population – A controlled trial in primary care. BMC Cardiovasc +Disord 2015;15:91. +23. Siu PM, Yu  +AP, Benzie IF, Woo J. Effects of 1‑year yoga on cardiovascular +risk factors in middle‑aged and older adults with metabolic syndrome: +A randomized trial. Diabetol Metab Syndr 2015;7:40. +24. Gordon  LA, Morrison  EY, McGrowder  DA, Young  R, Fraser  YT, +Zamora  EM, et  al. Effect of exercise therapy on lipid profile and +oxidative stress indicators in patients with type  2 diabetes. BMC +Complement Altern Med 2008;8:21. +25. Ross A, Thomas S. The health benefits of yoga and exercise: A review of +comparison studies. J Altern Complement Med 2010;16:3‑12. +26. Colberg  SR, Sigal  RJ, Yardley  JE, Riddell  MC, Dunstan  DW, +Dempsey PC, et al. Physical activity/exercise and diabetes: A position +statement of the American Diabetes Association. Diabetes Care +2016;39:2065‑79. +27. Ahrén B, Holst  JJ. The cephalic insulin response to meal ingestion +in humans is dependent on both cholinergic and noncholinergic +mechanisms and is important for postprandial glycemia. Diabetes +2001;50:1030‑8. +28. Berthoud  HR, Bereiter  DA, Trimble  ER, Siegel  EG, Jeanrenaud  B. +Cephalic phase, reflex insulin secretion neuroanatomical and +physiological characterization. Diabetologia 1981;20:393‑401. +29. Teff KL, Townsend RR. Early phase insulin infusion and muscarinic +blockade in obese and lean subjects. Am J Physiol 1999;277: +R198‑208. +30. Pfützner A, Forst  T. Elevated intact proinsulin levels are indicative +of beta‑cell dysfunction, insulin resistance, and cardiovascular risk: +Impact of the antidiabetic agent pioglitazone. J Diabetes Sci Technol +2011;5:784‑93. +31. Le Lay  S, Simard  G, Martinez  MC, Andriantsitohaina  R. Oxidative +stress and metabolic pathologies: From an adipocentric point of view. +Oxid Med Cell Longev 2014;2014:908539. +32. Acharya JD, Ghaskadbi SS. Islets and their antioxidant defense. Islets +2010;2:225‑35. +33. Prentki M, Nolan CJ. Islet beta cell failure in type 2 diabetes. J Clin +Invest 2006;116:1802‑12. +34. Tiedge  M, Lortz  S, Drinkgern  J, Lenzen  S. Relation between +antioxidant enzyme gene expression and antioxidative defense status of +insulin‑producing cells. Diabetes 1997;46:1733‑42. +35. Olson LK, Redmon JB, Towle HC, Robertson RP. Chronic exposure of +HIT cells to high glucose concentrations paradoxically decreases insulin +gene transcription and alters binding of insulin gene regulatory protein. +J Clin Invest 1993;92:514‑9. +36. Olson  LK, Sharma  A, Peshavaria  M, Wright  CV, Towle  HC, +Rodertson  RP, et  al. Reduction of insulin gene transcription in +[Downloaded free from http://www.journalofdiabetology.org on Saturday, January 23, 2021, IP: 136.232.192.146] +Vijayakumar, et al.: Yogic management of the ominous octet +Journal of Diabetology  ¦  Volume 12  ¦  Issue 1  ¦  January-March 2021 +16 +HIT‑T15 beta cells chronically exposed to a supraphysiologic glucose +concentration is associated with loss of STF‑1 transcription factor +expression. Proc Natl Acad Sci U S A 1995;92:9127‑31. +37. Hegde  SV, Adhikari  P, Kotian  S, Pinto  VJ, D’Souza  S, D’Souza  V, +et  al. Effect of 3‑month yoga on oxidative stress in type  2 diabetes +with or without complications: A controlled clinical trial. Diabetes Care +2011;34:2208‑10. +38. Mahapure HH, Shete SU, Bera TK. Effect of yogic exercise on super +oxide dismutase levels in diabetics. Int J Yoga 2008;1:21‑6. +39. Purwana  I, Zheng  J, Li  X, Deurloo  M, Son  DO, Zhang  Z, et  al. +GABA promotes human β‑cell proliferation and modulates glucose +homeostasis. Diabetes 2014;63:4197‑205. +40. Streeter CC, Whitfield TH, Owen L, Rein T, Karri SK, Yakhkind A, +et al. Effects of yoga versus walking on mood, anxiety, and brain GABA +levels: A randomized controlled MRS study. J Altern Complement Med +2010;16:1145‑52. +41. Vaishali  K, Kumar  KV, Adhikari  P, Unnikrishnan  B. Effects of +yoga‑based program on glycosylated hemoglobin level serum lipid +profile in community dwelling elderly subjects with chronic type  2 +diabetes mellitus  – A randomized controlled trial. Phys Occup Ther +Geriatr 2012;30:22‑30. +42. Singh S, Malhotra V, Singh KP, Madhu SV, Tandon OP. Role of yoga in +modifying certain cardiovascular functions in type 2 diabetic patients. +J Assoc Physicians India 2004;52:203‑6. +43. Abdul‑Ghani MA, DeFronzo RA. Pathogenesis of insulin resistance in +skeletal muscle. J Biomed Biotechnol 2010;2010:476279. +44. Henriksen  EJ. Invited review: Effects of acute exercise and exercise +training on insulin resistance. J Appl Physiol (1985) 2002;93:788‑96. +45. Zierath JR, Krook A, Wallberg‑Henriksson H. Insulin action and insulin +resistance in human skeletal muscle. Diabetologia 2000;43:821‑35. +46. Kahn SE, Hull RL, Utzschneider KM. Mechanisms linking obesity to +insulin resistance and type 2 diabetes. Nature 2006;444:840‑6. +47. Koistinen HA, Galuska D, Chibalin AV, Yang J, Zierath JR, Holman GD, +et  al. 5‑amino‑imidazole carboxamide riboside increases glucose +transport and cell‑surface GLUT4 content in skeletal muscle from +subjects with type 2 diabetes. Diabetes 2003;52:1066‑72. +48. Singh  S, Kyizom T, Singh  KP, Tandon  OP, Madhu  SV. Influence of +pranayamas and yoga‑asanas on serum insulin, blood glucose and lipid +profile in type 2 diabetes. Indian J Clin Biochem 2008;23:365‑8. +49. Chaya  MS, Ramakrishnan  G, Shastry  S, Kishore  RP, Nagendra  H, +Nagarathna R, et al. Insulin sensitivity and cardiac autonomic function +in young male practitioners of yoga. Natl Med J India 2008;21:217‑21. +50. Zhang BB, Zhou G, Li C. AMPK: An emerging drug target for diabetes +and the metabolic syndrome. Cell Metab 2009;9:407‑16. +51. Hotamisligil  GS. Inflammation and metabolic disorders. Nature +2006;444:860‑7. +52. Rosen ED, Spiegelman BM. Adipocytes as regulators of energy balance +and glucose homeostasis. Nature 2006;444:847‑53. +53. Kiecolt‑Glaser  JK, Christian  LM, Andridge  R, Hwang  BS, +Malarkey WB, Belury MA, et al. Adiponectin, leptin, and yoga practice. +Physiol Behav 2012;107:809‑13. +54. Sarvottam K, Yadav RK. Obesity‑related inflammation & cardiovascular +disease: Efficacy of a yoga‑based lifestyle intervention. Indian J Med +Res 2014;139:822‑34. +55. Vijayaraghava  A, Doreswamy  V, Narasipur  OS, Kunnavil  R, +Srinivasamurthy N. Effect of yoga practice on levels of inflammatory +markers after moderate and strenuous exercise. J  Clin Diagn Res +2015;9:CC08‑12. +56. Combs  TP, Berg AH, Obici  S, Scherer  PE, Rossetti  L. Endogenous +glucose production is inhibited by the adipose‑derived protein acrp30. +J Clin Invest 2001;108:1875‑81. +57. Hattori  Y, Suzuki  M, Hattori  S, Kasai  K. Globular adiponectin +upregulates nitric oxide production in vascular endothelial cells. +Diabetologia 2003;46:1543‑9. +58. Chen  H, Montagnani  M, Funahashi  T, Shimomura  I, Quon  MJ. +Adiponectin stimulates production of nitric oxide in vascular endothelial +cells. J Biol Chem 2003;278:45021‑6. +59. Simpson  KA, Singh  MA. Effects of exercise on adiponectin: +A systematic review. Obesity (Silver Spring) 2008;16:241‑56. +60. Schwartz  MW, Seeley  RJ, Tschöp MH, Woods  SC, Morton  GJ, +Myers  MG, et  al. Cooperation between brain and islet in glucose +homeostasis and diabetes. Nature 2013;503:59‑66. +61. Arntfield  ME, van der Kooy  D. Β‑cell evolution: How the pancreas +borrowed from the brain: The shared toolbox of genes expressed by +neural and pancreatic endocrine cells may reflect their evolutionary +relationship. Bioessays 2011;33:582‑7. +62. Davidson JK, Falkmer S, Mehrotra BK, Wilson S. Insulin assays and +light microscopical studies of digestive organs in protostomian and +deuterostomian species and in coelenterates. Gen Comp Endocrinol +1971;17:388‑401. +63. Lam TK, Gutierrez‑Juarez R, Pocai A, Rossetti L. Regulation of blood +glucose by hypothalamic pyruvate metabolism. Science 2005;309:943‑7. +64. Elmquist  JK, Coppari  R, Balthasar  N, Ichinose  M, Lowell  BB. +Identifying hypothalamic pathways controlling food intake, body +weight, and glucose homeostasis. J Comp Neurol 2005;493:63‑71. +65. Obici  S, Zhang  BB, Karkanias  G, Rossetti  L. Hypothalamic insulin +signaling is required for inhibition of glucose production. Nat Med +2002;8:1376‑82. +66. Asilmaz E, Cohen P, Miyazaki M, Dobrzyn P, Ueki K, Fayzikhodjaeva G, +et al. Site and mechanism of leptin action in a rodent form of congenital +lipodystrophy. J Clin Invest 2004;113:414‑24. +67. Jordan SD, Könner AC, Brüning JC. Sensing the fuels: Glucose and +lipid signaling in the CNS controlling energy homeostasis. Cell Mol +Life Sci 2010;67:3255‑73. +68. Hill JW, Elias CF, Fukuda M, Williams KW, Berglund ED, Holland WL, +et al. Direct insulin and leptin action on pro‑opiomelanocortin neurons +is required for normal glucose homeostasis and fertility. Cell Metab +2010;11:286‑97. +69. Bathina  S, Srinivas  N, Das  UN. BDNF protects pancreatic β +cells  (RIN5F) against cytotoxic action of alloxan, streptozotocin, +doxorubicin and benzo(a)pyrene in vitro. Metabolism 2016;65:667‑84. +70. Kim H, Toyofuku Y, Lynn FC, Chak E, Uchida T, Mizukami H, et al. +Serotonin regulates pancreatic beta cell mass during pregnancy. Nat +Med 2010;16:804‑8. +71. Lee  M, Moon  W, Kim  J. Effect of yoga on pain, brain‑derived +neurotrophic factor, and serotonin in premenopausal women with +chronic low back pain. Evid Based Complement Alternat Med +2014;2014:203173. +72. Naveen  GH, Varambally  S, Thirthalli  J, Rao  M, Christopher  R, +Gangadhar BN, et al. Serum cortisol and BDNF in patients with major +depression‑effect of yoga. Int Rev Psychiatry 2016;28:273‑8. +73. Yaffe  K, Blackwell  T, Whitmer  RA, Krueger  K, Barrett Connor  E. +Glycosylated hemoglobin level and development of mild cognitive +impairment or dementia in older women. J  Nutr Health Aging +2006;10:293‑5. +74. Cukierman  T, Gerstein  HC, Williamson  JD. Cognitive decline and +dementia in diabetes – Systematic overview of prospective observational +studies. Diabetologia 2005;48:2460‑9. +75. Strachan MW, Reynolds RM, Marioni RE, Price JF. Cognitive function, +dementia and type 2 diabetes mellitus in the elderly. Nat Rev Endocrinol +2011;7:108‑14. +76. Awad  N, Gagnon  M, Messier  C. The relationship between impaired +glucose tolerance, type 2 diabetes, and cognitive function. J Clin Exp +Neuropsychol 2004;26:1044‑80. +77. Ruis  C, Biessels  GJ, Gorter  KJ, van den Donk  M, Kappelle  LJ, +Rutten GE, et al. Cognition in the early stage of type 2 diabetes. Diabetes +Care 2009;32:1261‑5. +78. Dik  MG, Jonker  C, Comijs  HC, Deeg  DJ, Kok  A, Yaffe  K, et  al. +Contribution of metabolic syndrome components to cognition in older +individuals. Diabetes Care 2007;30:2655‑60. +79. Defronzo  RA. Bromocriptine: A  sympatholytic, d2‑dopamine agonist +for the treatment of type 2 diabetes. Diabetes Care 2011;34:789‑94. +80. White JR Jr. A brief history of the development of diabetes medications. +Diabetes Spectr 2014;27:82‑6. +81. Kjaer  TW, Bertelsen  C, Piccini  P, Brooks  D, Alving  J, Lou  HC, +et  al. Increased dopamine tone during meditation‑induced change of +consciousness. Brain Res Cogn Brain Res 2002;13:255‑9. +82. Lazar SW, Kerr CE, Wasserman RH, Gray JR, Greve DN, Treadway MT, +et  al. Meditation experience is associated with increased cortical +thickness. Neuroreport 2005;16:1893‑7. +[Downloaded free from http://www.journalofdiabetology.org on Saturday, January 23, 2021, IP: 136.232.192.146] +Vijayakumar, et al.: Yogic management of the ominous octet +Journal of Diabetology  ¦  Volume 12  ¦  Issue 1  ¦  January-March 2021 +17 +83. Kyizom T, Singh S, Singh KP, Tandon OP, Kumar R. Effect of pranayama +and yoga‑asana on cognitive brain functions in type 2 diabetes‑P3 event +related evoked potential (ERP). Indian J Med Res 2010;131:636‑40. +84. Hazari  N, Sarkar  S. A  review of yoga and meditation neuroimaging +studies in healthy subjects. Altern Complement Ther 2014;20:16‑26. +85. Unger RH, Aguilar‑Parada E, Müller WA, Eisentraut AM. Studies of +pancreatic alpha cell function in normal and diabetic subjects. J Clin +Invest 1970;49:837‑48. +86. Lee Y, Wang MY, Du XQ, Charron MJ, Unger RH. Glucagon receptor +knockout prevents insulin‑deficient type 1 diabetes in mice. Diabetes +2011;60:391‑7. +87. Baron  AD, Schaeffer  L, Shragg  P, Kolterman  OG. Role of +hyperglucagonemia in maintenance of increased rates of hepatic glucose +output in type II diabetics. Diabetes 1987;36:274‑83. +88. Brindley DN, Rolland Y. Possible connections between stress, diabetes, +obesity, hypertension and altered lipoprotein metabolism that may result +in atherosclerosis. Clin Sci (Lond) 1989;77:453‑61. +89. Xu E, Kumar M, Zhang Y, Ju W, Obata T, Zhang N, et al. Intra‑islet +insulin suppresses glucagon release via GABA‑GABAA receptor +system. Cell Metab 2006;3:47‑58. +90. Streeter CC, Jensen JE, Perlmutter RM, Cabral HJ, Tian H, Terhune DB, +et al. Yoga asana sessions increase brain GABA levels: A pilot study. +J Altern Complement Med 2007;13:419‑26. +91. Mccall MC. How might yoga work? An overview of potential underlying +mechanisms. Yoga Phys Ther 2013;3:1‑6. +92. Cervera  A, Wajcberg  E, Sriwijitkamol  A, Fernandez  M, Zuo  P, +Triplitt C, et al. Mechanism of action of exenatide to reduce postprandial +hyperglycemia in type  2 diabetes. Am J Physiol Endocrinol Metab +2008;294:E846‑52. +93. Kieffer  TJ, Habener  JF. The glucagon‑like peptides. Endocr Rev +1999;20:876‑913. +94. Rocca AS, Brubaker PL. Role of the vagus nerve in mediating proximal +nutrient‑induced glucagon‑like peptide‑1  secretion. Endocrinology +1999;140:1687‑94. +95. Imeryüz N, +Yeğen BC, Bozkurt  +A, Coşkun T, Villanueva‑Peñacarrillo ML, +Ulusoy  NB, et  al. Glucagon‑like peptide‑1 inhibits gastric emptying +via vagal afferent‑mediated central mechanisms. Am J Physiol +1997;273:G920‑7. +96. Riddle  M, Umpierrez  G, DiGenio  A, Zhou  R, Rosenstock  J. +Contributions of basal and postprandial hyperglycemia over a wide +range of A1C levels before and after treatment intensification in type 2 +diabetes. Diabetes Care 2011;34:2508‑14. +97. Seppälä‑Lindroos  A, Vehkavaara  S, Häkkinen AM, Goto  T, +Westerbacka  J, Sovijärvi A, et  al. Fat accumulation in the liver is +associated with defects in insulin suppression of glucose production +and serum free fatty acids independent of obesity in normal men. J Clin +Endocrinol Metab 2002;87:3023‑8. +98. Carey M, Kehlenbrink S, Hawkins M. Evidence for central regulation of +glucose metabolism. J Biol Chem 2013;288:34981‑8. +99. Cui J, Yan JH, Yan LM, Pan L, Le JJ, Guo YZ, et al. Effects of yoga +in adults with type  2 diabetes mellitus: A  meta‑analysis. J  Diabetes +Investig 2017;8:201‑9. +100. +Chao EC, Henry RR. SGLT2 inhibition – A novel strategy for diabetes +treatment. Nat Rev Drug Discov 2010;9:551‑9. +101. +Rahmoune H, Thompson PW, Ward JM, Smith CD, Hong G, Brown J, +et al. Glucose transporters in human renal proximal tubular cells isolated +from the urine of patients with non‑insulin‑dependent diabetes. Diabetes +2005;54:3427‑34. +102. +Chhabra KH, Adams JM, Fagel B, Lam DD, Qi N, Rubinstein M, et al. +Hypothalamic POMC deficiency improves glucose tolerance despite +insulin resistance by increasing glycosuria. Diabetes 2016;65:660‑72. +103. +Shinde N, Shinde KJ, Khatri SM, Hande D. A comparative study of yoga +and aerobic exercises in obesity and its effect on pulmonary function. +J Diabetes Metab 2013;4:2. +104. +Amita  S, Prabhakar  S, Manoj  I, Harminder  S, Pavan  T. Effect of +yoga‑nidra on blood glucose level in diabetic patients. Indian J Physiol +Pharmacol 2009;53:97‑101. +105. +Rajesh P, Gurumurthy Sastry M, Parvathi G. Effect of yoga therapy on +anthropometry, metabolic parameters and cardiac autonomic function +tests in type 2 diabetes mellitus patients. Int J Biomed Res 2013;4:330‑8. +106. +Qatanani  M, Lazar  MA. Mechanisms of obesity‑associated insulin +resistance: Many choices on the menu. Genes Dev 2007;21:1443‑55. +107. +Hägglund E, Hagerman I, Dencker K, Strömberg A. Effects of yoga +versus hydrotherapy training on health‑related quality of life and +exercise capacity in patients with heart failure: A randomized controlled +study. Eur J Cardiovasc Nurs 2017;16:381‑9. +108. +Malhotra V, Singh S, Tandon OP, Madhu SV, Prasad A, Sharma SB, +et  al. Effect of yoga asanas on nerve conduction in type  2 diabetes. +Indian J Physiol Pharmacol 2002;46:298‑306. +109. +Jyotsna VP, Joshi A, Ambekar S, Kumar N, Dhawan A, Sreenivas V, +et al. Comprehensive yogic breathing program improves quality of life +in patients with diabetes. Indian J Endocrinol Metab 2012;16:423‑8. +110. +Jyotsna VP, Ambekar S, Singla R, Joshi A, Dhawan A, Kumar N, et al. +Cardiac autonomic function in patients with diabetes improves with +practice of comprehensive yogic breathing program. Indian J Endocrinol +Metab 2013;17:480‑5. +111. +Agrawal RP, Aradhana R, Hussain S, Sabir M, Kochar DK, Kothari RP. +Influence of yogic treatment on quality of life outcomes, glycemic +control and risk factors in diabetes mellitus. Int J Diabetes Dev Ctries +2003;23:130‑4. +112. +Nagarathna  R, Usharani  MR, Rao  AR, Chaku  R, Kulkarni  R, +Nagendra HR. Efficacy of yoga based life style modification program +on medication score and lipid profile in type 2 diabetes – A randomized +control study. Int J Diabetes Dev Ctries 2012;32:122‑30. +113. +Wolff M, Sundquist K, Larsson Lönn S, Midlöv P. Impact of yoga on +blood pressure and quality of life in patients with hypertension  – A +controlled trial in primary care, matched for systolic blood pressure. +BMC Cardiovasc Disord 2013;13:111. +114. +Cramer  H, Haller  H, Dobos  G, Lauche  R. A  systematic review and +meta‑analysis estimating the expected dropout rates in randomized +controlled trials on yoga interventions. Evid Based Complement +Alternat Med 2016;2016:5859729. +115. +Kerr  D, Gillam  E, Ryder  J, Trowbridge  S, Cavan  D, Thomas  P. An +eastern art form for a western disease: Randomised controlled trial of +yoga in patients with poorly controlled insulin‑treated diabetes. Pract +Diabetes Int 2002;19:164‑6. +116. +Venugopal V, Rathi A, Raghuram N. Effect of short‑term yoga‑based +lifestyle intervention on plasma glucose levels in individuals with +diabetes and pre‑diabetes in the community. Diabetes Metab Syndr +2017;11 Suppl 2:S597‑9. +[Downloaded free from http://www.journalofdiabetology.org on Saturday, January 23, 2021, IP: 136.232.192.146] diff --git a/subfolder_0/Prevalence of Obesity in India and Its Neurological Implications A Multifactor Analysis of a Nationwide Cross-Sectional Study.txt b/subfolder_0/Prevalence of Obesity in India and Its Neurological Implications A Multifactor Analysis of a Nationwide Cross-Sectional Study.txt new file mode 100644 index 0000000000000000000000000000000000000000..67ef9f7e9d7b112961e7ebfccfd480e20759273e --- /dev/null +++ b/subfolder_0/Prevalence of Obesity in India and Its Neurological Implications A Multifactor Analysis of a Nationwide Cross-Sectional Study.txt @@ -0,0 +1,1047 @@ +Annals of Neurosciences +27(3-4) 153­ +–161, 2021 +© The Author(s) 2021 +Reprints and permissions: +in.sagepub.com/journals-permissions-india +DOI: 10.1177/0972753120987465 +journals.sagepub.com/home/aon +Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution- +NonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-Commercial use, reproduction and +distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https:// +us.sagepub.com/en-us/nam/open-access-at-sage). +Original Article +Prevalence of Obesity in India and Its +Neurological Implications: A Multifactor +Analysis of a Nationwide Cross-Sectional Study +Murali Venkatrao,1 Raghuram Nagarathna,1 Vijaya Majumdar,1 Suchitra S. Patil,1 +Sunanda Rathi1 and Hongasandra Nagendra1 +Abstract +Background: India is undergoing a rapid epidemiological transition, from underweight to overweight/obese population. +Obesity is a major risk factor in type 2 diabetes and cardiovascular diseases, and is also implicated as a factor in neurological +diseases such as Alzheimer’s disease. A robust, pan-Indian estimate of obesity is not yet available. +Purpose: This study estimates the pan-Indian prevalence of obesity, stratified across nonmodifiable (age and gender) and +modifiable (education and physical activity levels) factors, and across zones and urban/rural. +Methodology: Data for 1,00,531 adults from a nationwide randomized cluster sample survey (Niyantrita Madhumeha Bharata +2017, phase 1) were analyzed. Obesity was determined using body mass index, and cross-tabulations were calculated across +zones, age, gender, education, physical activity, and area. To determine statistical significance, t-tests were used. The odds of +obesity within each category of the various factors were calculated using binary logistic regression. +Results: Prevalence of obesity in India is 40.3%. Zonal variations were seen as follows: south highest at 46.51% and east +lowest at 32.96%. Obesity was higher among women than men (41.88% vs. 38.67%), urban than rural (44.17% vs. 36.08%), +and over 40 than under 40 (45.81% vs. 34.58%). More education implied a higher obesity (44.6% college vs. 38% uneducated), +as did lowered physical activity (43.71% inactive vs. 32.56% vigorously active). The odds ratio for physical activity was 3.83, +stronger than age (1.58), education (1.4), urban (1.3), and gender (1.2). +Conclusion: Obesity levels in India are very high, across all zones. The odds of being obese increases with age, and is higher +among women and among urban dwellers. Obesity is the highest among aging urban men and women who are college educated +and are sedentary. Physical activity and aging are the strongest determinants of obesity. Given the high cost of obesity in terms of +type 2 diabetes, cardiovascular diseases, and Alzheimer’s disease, urgent public health measures are necessary to reduce its impact. +Keywords +Obesity, alzheimer, NMB, diabetes, obesity prevalence +Received 18 September 2020; accepted 7 October 2020 +1 Division of Yoga and Life Sciences, SVYASA University, Prashanti +Kutiram, Jigani, Bengaluru, Karnataka, India +Corresponding author: +Murali Venkatrao, Division of Yoga and Life Sciences, SVYASA University, +Prashanti Kutiram, Vivekananda Road, Kalluballu Post, Jigani, Bengaluru, +Karnataka 560015, India. +E-mail: mvenkatrao@gmail.com +Introduction +Obesity is a condition characterized with an increase in the +size and amount of fat cells in the body. It is a chronic disorder +that is officially classified as a disease by the World Health +Organization (WHO), and also by several other national and +international organizations.1 Although an easily recognizable +condition by specialists and laypersons alike, there does not +yet exist a widely accepted clinical definition of obesity. The +definition of the term by the Obesity Medicine Association +captures both its complex etiology and diverse consequences: +“a chronic, relapsing, multi-factorial, neurobehavioral +disease, wherein an increase in body fat promotes adipose +tissue dysfunction and abnormal fat mass physical forces, +resulting +in +adverse +metabolic, +biomechanical +and +psychosocial health consequences.”2 According to the WHO, +obesity is a major risk factor for noncommunicable diseases +such as heart disease, stroke, type 2 diabetes, certain cancers +(endometrial, breast, ovarian, prostate, liver, gallbladder, +kidney, and colon), and osteoarthritis.3 Obesity is also +Annals of Neurosciences +27(3-4) 153­ +–161, 2020 +© The Author(s) 2021 +Reprints and permissions: +in.sagepub.com/journals-permissions-india +DOI: 10.1177/0972753120987465 +journals.sagepub.com/home/aon +154 +Annals of Neurosciences 27(3-4) +associated with unemployment, social disadvantages, and +reduced socioeconomic productivity.4 +The worldwide prevalence of obesity is reaching pandemic +proportions. The WHO had estimated that in 2016, more than +1.9 billion adults worldwide (39%) were overweight, and +over 650 million (13%) were obese.3 Furthermore, researchers +from the NCD Risk Factor Collaboration reported that the +obesity prevalence increased in every country between 1975 +and 2016; the greatest increases were noted in South Asia, +Southeast Asia, the Caribbean, and Southern Latin America.5 +The current trajectory of prevalence acceleration would result +in almost half of the world’s population being overweight or +obese by 2030.6 +Obesity is commonly studied as a risk factor for type 2 +diabetes and/or cardiovascular morbidities. However, both +the causes for, and the effect of, obesity have a neurological +component as well. For example, recent studies have +suggested that an impaired appetite regulation in obese +individuals is because of cerebral insulin resistance, leading +to both an increased hepatic glucose production and a reduced +muscle glucose intake, thus implicating the brain directly in +the pathogenesis of the metabolic syndrome, and making it +one of the members of the so-called ominous octet.7 The +effects of obesity on the brain are an area of intense +investigative activity. New evidence is emerging which +indicates that obesity without type 2 diabetes results in a +three-fold increase in the risk of developing Alzheimer’s +disease (AD).8 Furthermore, because of the strong correlation +between AD and impairments in insulin and insulin-like +growth factor gene expression and signaling in the brain, AD +may represent a brain-specific form of diabetes, sometimes +referred to as “type 3 diabetes.”9 +Not surprisingly, obesity is associated with huge personal, +social, and economic costs. It is estimated that obesity is +responsible for 5% of all global deaths. The worldwide +economic impact of obesity is estimated to be US$2 trillion, +putting it in the same category as smoking and armed conflict. +There is also growing evidence that socioeconomic +productivity is undermined by obesity.10 It is to be noted that +these estimates do not include the neurological aspect of +obesity, so the true cost is likely to be higher. +As noted before, the South Asian region—which includes +India—has one of the fastest growing obesity rates in the +world. It is estimated that there are 135 million obese +individuals in India.11 The Indian National Family Health +Survey-4 reported that in the 10-year period from 2005 and +2006 to 2015 and 2016, obesity among women between the +ages of 15 and 49 years increased from 13% to 21%; during +the same time period, obesity among men between the ages of +15 and 49 years increased from 9.3% to 19%.12 +It is, therefore, clear that India is experiencing a very rapid +epidemiological +transition. +Undernutrition +and +the +accompanying outcome of an underweight population are +now being replaced by an overweight and obese population. +Because obesity is a major risk factor for most +noncommunicable diseases, a critical component of public +health policy is the prevention and management of this +epidemic. However, as noted by the WHO, obesity is one of +the most neglected public health problems.13 While there are +several studies reporting localized obesity prevalence in +specific states, zones, communities, cities, and locales, there +is no collective data across the country as a whole. The best +prevalence estimate available comes from a pooled analysis +of 14 individual studies.14 +There is an urgent need to quantify the scale of the +problem—that is, to get a robust estimate of the prevalence of +obesity in India—so that a proper public policy can be shaped +to handle the problem. The present study analyzes data from +a large pan-India study conducted in 2017, the Niyantrita +Madhumeha Bharata Abhiyaan (Diabetes Free India), or +NMB-201715,16 to determine obesity prevalence. +Methodology +Study Design +Niyantrita Madhumeha Bharata (Control of Diabetes in +India) 2017, or NMB-2017, was a two-phased study +undertaken across 29 most populous states/union territories +in India. The twin objectives of the study were as follows. +1. +Phase 1—a rapid survey to estimate the prevalence of +obesity, +diabetes, +prediabetes, +and +high-risk +population simultaneously in all zones of India in +2017. +2. +Phase 2—to conduct an randomized controlled trial +(RCT) using a validated yoga lifestyle protocol. +Because this study is focused on data from phase 1 of +NMB-2017, the details of phase 2, which have been reported +elsewhere,16 will not be elaborated further. +Phase 115 was a nationwide randomized cross-sectional +survey using a multilevel stratified cluster sampling technique +with random selection among urban and rural populations +covering 65 districts of the most populous states (25) and +union territories (4) of the country. In a door-to-door survey, +researchers used a short questionnaire to collect data on +diabetes status and diabetes risk. +Sampling was done at four levels: (a) zones, (b) states, (c) +districts, and (d) villages (rural) or towns (urban), with a +randomized cluster sampling of census enumeration blocks +(CEBs) in each town. The states and union territories were +grouped into seven geographical regions based on their +sociocultural similarities with a small deviation from the +grouping available in the national directory.17 Table 1 shows +the composition of each zone. +The districts in the state were the first level of sampling. In +accordance with the sampling plan, it was decided to select +10% of the total number of districts in the country, and +correspondingly 10% of the districts in each state. For states +with ≤10 districts, one district was chosen, and for states with +10 to 30 districts, two districts were chosen. To ensure that +Venkatrao et al. +155 +the district samples within a state were not clustered, we +grouped the state into geographical regions and chose a +district from each region (e.g., if a state needed three districts, +it was grouped into north, south, and central). +A statistician selected two districts randomly within the +group (i.e., double the number needed); after a review of local +conditions within the chosen district, one of the two districts +was purposively sampled. +Each district was also grouped into four geographical +regions (north, east, south, and west). +1. +Rural—within each region, a statistician randomly +chose two villages with a population of around 500. +After a review of local conditions, one of the two +villages was purposively sampled. This resulted in +four villages with a population of around 2,000. +2. +Urban—within each region, a statistician chose one +town/city. From this list of four towns/cities, one city +was purposively chosen after a review of local +conditions. Within the chosen town/city, a ward was +randomly selected. The selected ward was grouped +into four geographical regions (north, east, south, and +west). Depending on the size of the CEBs (which are +either 500 people or 1,000 people), either two or four +wards were randomly selected ensuring that each +CEB came from a different geographical region. +All individuals ≥20 years of age in each household of the +selected CEB were screened. +Participants +Those individuals in the survey from whom the following +data were available were included in the study: height, weight, +gender, area (urban or rural), education level, physical activity +level, and age. +Data Collection +A total of 2 research associates, 7 zonal coordinators, 35 +senior research fellows, and 1,200 data collectors were +involved in data collection. Each group was given training on +their respective duties. +A questionnaire was presented to each individual surveyed, +which asked for the following information. +1. +Demographic: age, gender, marital status, education +level, socioeconomic status, and occupation. +2. +Diabetes risk: family history, physical activity, and +prior diagnosis of diabetes (and for how long). +3. +Yoga practice, if any, and details of the practice. +The following anthropometric data was also collected: +height, weight, and hip/waist circumference. Two blood +pressure readings were taken at 5-min intervals. +Criteria for Determining Obesity +The body mass index (BMI) cutoffs proposed by the WHO +expert group for Asian populations18 have been used, which +are given in Table 2. +Outcome Variables +The outcome was the proportions of obese (BMI ≥ 25) and +not obese (BMI < 25) individuals in various populations: +zones, areas (rural/urban), educational levels, physical +activity levels, gender, and age (under or over 40 years). +Analysis +Because the survey design involved stratified sampling +techniques, the study population was weighted19 to account +for sample selection (design weight) and response rate, which +was further calibrated using data from the 2011 Census of +India, to yield the final weights. Weighting was calculated for +each of the seven regions which formed the units of stratified +sampling. Final weights were used as the estimates of all +population variables. These variables were expressed as +proportions, and t-tests were used to calculate P-values. Odds +ratios (OR) were calculated from a binary logistic regression +analysis to examine the association between various factors +(age, gender, education level, physical activity level, and +urban/rural) and the outcome (obesity). A P-value less than +0.5 was deemed to be significant. +Python v3.7 Pandas v0.23 was used to import data, +calculate weighting, obesity levels, and all descriptive +statistics. SPSS V.26 was used to calculate OR, P-values, and +to do the binary regression analysis. +Table 1. States and Union Territories in Each Zone for NMB- +2017 +Zone +States/Union T +erritories +North- +west +Jammu and Kashmir, Ladakh +Northeast Arunachal Pradesh, Assam, Manipur, Tripura, Meghalaya +North +Delhi, Punjab, Chandigarh, Haryana, Uttarakhand, Ut- +tar Pradesh, Himachal Pradesh +West +Rajasthan, Gujrat, Maharashtra +Central +Madhya Pradesh, Jharkhand +East +Bihar, Chhattisgarh, West Bengal, Odisha +South +Karnataka, Goa, Kerala, Tamil Nadu, Andhra Pradesh, +Telangana, Pondicherry, Andaman and Nicobar +Table 2. Classification of Weight by BMI +Classification +BMI +Underweight +Not obese +<18.5 +Normal +18.5–22.9 +Overweight +23–24.9 +Obese +Obese +≥25 +156 +Annals of Neurosciences 27(3-4) +Results +Description of Data +A total of 1,00,531 individuals participated in the study. Table +3 and Figures 1 to 6 show participant characteristics. +Table 3. Participant Characteristics and Core Measures +Age +(years) +Height +(cm) +Weight +(kg) +BMI (kg/ +m2) +µ ± SD +41.20 ± +13.81 +157.89 ± +9.98 +61.64 ± +12.91 +24.79 ± +5.06 +Min +18 +96 +35 +9.90 +Max +93 +210 +160 +59.56 +Figure 1. Zonal Distribution by Gender. +Figure 2. Zonal Distribution by Age. +Figure 3. Zonal Distribution by Urban/Rural. +Figure 4. Education Levels by Gender. +Figure 5. Physical Activity by Gender. +Venkatrao et al. +157 +Prevalence of Obesity Across Various Populations +Table 4 shows the weighted prevalence of obesity in each +zone, stratified by age, gender, and urban/rural. The overall +prevalence of obesity across India was 40.3% (P < .001). +Among regions, obesity was the highest in the south (46.51%) +and the lowest in the east (32.96%). Across the country as a +whole, obesity tended to be higher among women (41.88%) +as compared to men (38.67%), higher in urban regions +(44.17%) as compared to rural regions (36.08%), and higher +among people over 40 years of age (45.81%) as compared to +those under 40 years (34.58%). +We analyzed how obesity varied with physical activity +levels and education levels. It was found (the “Total” row in +Table 5) that increased education levels were related with +increased obesity—university educated individuals tended to +be more obese (44.6%) when compared to those with no +education (38.4%). Not surprisingly, populations with +vigorous physical activity had lower obesity rates (32.56%) +than populations that were inactive (43.71%). +We also analyzed how obesity varied when nonmodifiable +factors—age and gender—were combined with modifiable +factors—physical activity and education levels (Table 5). It +was found that in general the effects of modifiable factors +exacerbated the effects of nonmodifiable factors. Thus, men +with university education had higher levels of obesity than +men who were uneducated (55.2% vs. 38.4%). Similarly, +among people over 40 years of age, the university educated +subpopulation had 55.2% obesity while the uneducated +subpopulation had 38.4% obesity. +The final part of the analysis was to determine if the increase +in obesity with each of these factors was statistically significant. +This was done by running a binary logistic regression analysis +on each factor—age, area, educational category, physical +activity levels—and determining the OR, along with the +associated P-values and CIs. This is shown in Table 6. +Discussion +Phase 1 of NMB-2017 is the only pan-Indian study of obesity, +prediabetes, and diabetes. A comparable study, the Indian +Council of Medical Research-India Diabetes (ICMR- +INDIAB),20 though quite large, was still limited to 15 states, +representing only 51% of India’s adult population. Also +notable is the fact that several of the extant large-scale reports +of obesity prevalence in India12,21 use the WHO international +guidelines3 for BMI cutoffs to determine obesity, which +defines obesity when BMI ≥ 30. However, these guidelines +are based on studies of Caucasians who have, when compared +with age-matched Asian Indians, lesser total, truncal, intra- +abdominal subcutaneous, and ectopic tissue fat at a given +level of BMI. It is thus more representative of the Indian +Figure 6. Physical Activity by Age +Table 4. Weighted Regional Prevalence of Obesity Across Gender, Area, and Age (P < .001 for Each Proportion, Student’s t-test) +IndiaF +Central +East +Northwest +North +Northeast +South +West +Not +Obese Obese +Not +Obese Obese +Not +Obese Obese +Not +Obese Obese +Not +Obese Obese +Not +Obese Obese +Not +Obese Obese +Not +Obese Obese +Gen- +der +Female +58.12 +41.88 +63.66 +36.34 +66.7 +33.3 +52.79 +47.21 +51.52 +48.48 +62.81 +37.19 +51.95 +48.05 +56.43 +43.57 +Male +61.33 +38.67 +63.22 +36.78 +67.39 +32.61 +60.94 +39.06 +59.7 +40.3 +61.71 +38.29 +55.36 +44.64 +54.93 +45.07 +Area +Rural +63.92 +36.08 +68.36 +31.64 +74.4 +25.6 +60.56 +39.44 +58.35 +41.65 +65.02 +34.98 +57.94 +42.06 +59.31 +40.69 +Urban +55.83 +44.17 +58.43 +41.57 +60.57 +39.43 +53.86 +46.14 +48.07 +51.93 +59.27 +40.73 +50.38 +49.62 +52.54 +47.46 +Age +Under +40 +65.42 +34.58 +70.17 +29.83 +71.35 +28.65 +62.33 +37.67 +63.03 +36.97 +67.31 +32.69 +58.07 +41.93 +65.12 +34.88 +Over +40 +54.19 +45.81 +56.99 +43.01 +62.3 +37.7 +51.73 +48.27 +46.46 +53.54 +57.15 +42.85 +49.12 +50.88 +48.51 +51.49 +Total +59.68 +40.32 +63.42 +36.58 +67.04 +32.96 +56.7 +43.3 +54.67 +45.33 +62.27 +37.73 +53.49 +46.51 +55.73 +44.27 +158 +Annals of Neurosciences 27(3-4) +Table 5. Weighted Prevalence of Oobesity Across Nonmodifiable (Gender and Age) and Modifiable (Education Level and Physical +Activity) Factors (P < .001 for Each Proportion, Student’s t-test) +Education Level +Physical Activity Level +None +School +University +Vigorous +Moderate +Mild +Inactive +Not +Obese +Obese +Not +Obese +Obese +Not +Obese +Obese +Not +Obese +Obese +Not +Obese +Obese +Not +Obese +Obese +Not +Obese +Obese +Gender +Female +58.45 +41.55 +58.11 +41.89 +57.75 +42.25 +67.42 +32.58 +61.22 +38.78 +55.29 +44.71 +53.91 +46.09 +Male +68.30 +31.70 +63.28 +36.72 +53.68 +46.32 +67.45 +32.55 +63.85 +36.15 +57.99 +42.01 +59.02 +40.98 +Age +Under +40 +65.12 +34.88 +66.91 +33.09 +62.04 +37.96 +72.08 +27.92 +67.47 +32.53 +62.65 +37.35 +62.77 +37.23 +Over +40 +60.13 +39.87 +54.58 +45.42 +44.80 +55.20 +62.41 +37.59 +57.34 +42.66 +51.11 +48.89 +50.67 +49.33 +Total +61.6 +38.4 +60.66 +39.34 +55.4 +44.6 +67.44 +32.56 +62.5 +37.5 +56.54 +43.46 +56.29 +43.71 +Table 6. Odds Ratio (OR) for Obesity Among Levels of Various Factors +Factor +Level +OR +95% CI for OR (Lower, Upper) +P-Value +Age +Under 40 +1.0 +Above 40 +1.567 +(1.530, 1.605) +<.001 +Area +Rural +1.0 +Urban +1.302 +(1.272, 1.332) +<.001 +Gender +Male +1.0 +Female +1.202 +(1.175, 1.230) +<.001 +Education level +None +1.0 +Highschool +1.121 +(1.084, 1.158) +<.001 +University +1.398 +(1.344, 1.455) +<.001 +Physical activity +Vigorous +1.0 +Moderate +3.155 +(2.502, 3.978) +<.001 +Mild +3.839 +(3.045, 4.840) +<.001 +Inactive +3.833 +(3.036, 4.839) +<.001 +population when obesity is determined at the lower cutoff +levels as recommended by the WHO expert group.13 Our +study provides the first pan-Indian obesity prevalence +estimate based on these lower BMI cutoffs. As noted in a +consensus statement from more than 100 Indian medical +experts representing reputed medical institutions, hospitals, +government-funded research institutions, and policy-making +bodies in 2009,22 the lower cutoffs are going to result in +additional 10% to 15% of the Indian population to be labeled +as overweight/obese. However, they also noted that the +application of these guidelines will result in a “deceleration +effect on the escalating problem of type 2 diabetes and +cardiovascular disease.”23 +Our results have shown that obesity is a highly prevalent +condition across the country, with 40.32% of the estimated +weighted prevalence among adults 18 to 80 years of age. +Southern India (46.51%) shows the highest prevalence, while +eastern India shows the lowest (32.96%). Among other +regions, north, west, and northwest are all well above the +national average, showing a respective prevalence of 45.33%, +44.27%, and 43.3%; while northeast and central regions are +well below the national average, with a respective prevalence +of 37.73% and 36.58%. +Levels of urbanization can be the reason for the lower +prevalence in the east, northeast, and central regions as +compared to the others.24,25 As seen in Table 6, urban +populations have 1.3 times higher odds of being obese +compared to their rural counterparts. East, northeast, and +central are the three least urbanized regions in India.26 Our +results show that the urban population is markedly more +obese than the rural population—44.17% vs. 36.08%. These +findings are just as true at the zonal level as they are at the +national level. In fact, our results show that even in zones +where obesity is markedly less than the national average, the +Venkatrao et al. +159 +urban population exhibits a high prevalence of obesity. For +example, the eastern zone whose overall prevalence is 32.96% +has an urban prevalence of 39.43%, which is very close to the +national average. This provides public health authorities +many opportunities for evolving effective policies, for +instance through adult education, early intervention in urban +schools, etc. +Our study results highlight the importance of both +nonmodifiable (age and gender) and modifiable (education +levels and physical activity levels) factors for determining +obesity. The population above 40 years of age are more obese +(45.81%) while those under 40 years are less so (34.58%). In +addition to age, gender is another determinant of obesity, with +women showing a higher prevalence (41.88%) as compared +to men (38.67%). +Obesity is higher among the educated than among the +uneducated: 44.6% among those with college education as +compared to 38.4% among those with no education. This is +contrary to the findings in other regions of the world. For +example, researchers have reported decreasing obesity with +the number of years of education in Australia, Canada, and +England.27 But, as noted by Cohen et al.,28 this inverse +relationship between educational attainment and obesity has +only been documented in higher-income countries; they point +out that lower-income countries have the opposite relationship, +with higher educational attainment being related to increased +levels of obesity. The cause of this “education penalty” in +lower-income countries is likely to be multifactorial in nature +and needs further research. At any rate, the education penalty +is more pronounced in the urban population (46.65% of urban +adults with university-level education are obese) as compared +to the rural population (35.71% of rural adults with university- +level education are obese). +Not unexpectedly, we find that physical activity is a strong +determinant of obesity (32.56% among people who do +vigorous physical activity vs. 43.71% among those who do +not do any physical activity). Animal models on obesity and +other problems may also need to be tested and explored.29–43 +While the percentages are certainly compelling, we see the +efficacy of physical activity even more clearly when we look +at the OR data. As seen in Table 6, the odds of being obese +increases by a factor of 3.8 in inactive persons as compared to +those who do vigorous activity. In fact, Table 6 also +demonstrates that the level of physical activity is the strongest +determinant of whether one is obese or not, even stronger +than age (OR = 1.6). +Finally, we note that these factors—age, gender, urban/ +rural, education level, and physical activity level—combine +to exacerbate the prevalence of obesity. For example, obesity +is at 58.1% among inactive urban dwellers with university- +level education who are over 40 years of age, while it is +25.38% among vigorously active rural dwellers with school- +level education who are under 40 years of age. These findings +will be of great help in forming very targeted public policies +aimed at very specific subpopulations for efficiently +addressing the obesity crisis. +The strengths of our study are the pan-Indian nature, a +very large representative population, and a multifactorial +analysis of obesity. A major limitation of the study is that it +did not take diet and stress into account. However, the large +sample size and the sophisticated randomization built into the +study design have ensured that these factors, though not part +of the analysis, are nonetheless unlikely to confound these +results. Additionally, many other resources and herbs need to +be explored and incorporated for people’s well-being,25,44–47 +which may help interventions to be cost-effective. +Conclusion +The high prevalence of obesity found by this study makes the +observation by the WHO that “obesity is one of the most +neglected public health problems”13 even more applicable to +India. The cost of this rapid epidemiological transition is not +limited to the comorbidities of type 2 diabetes and +cardiovascular disease. Given the new evidence indicative of +a three-fold increase in the risk of developing AD among +obese populations without type 2 diabetes,8 and a potential +modeling of AD itself as a brain-specific form of diabetes— +the so-called type 3 diabetes,9 this represents a potentially +large neurological dimension to the malady of obesity. Given +the high cost of obesity in terms of type 2 diabetes, +cardiovascular diseases, and AD, urgent public health +measures are necessary to reduce its impact. +Acknowledgments +We are thankful to (a) the funding by the Ministry of Health and +Family Welfare and Ministry of AYUSH routed through Central +Council for Research in Yoga and Naturopathy, Government of +India for their timely support 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 +1,200 volunteers; and (d) the members of the research advisory +board of NMB for their inputs at all stages of the study. +Author Contribution +Murali Venkatrao conceptualized stratified analysis methodology, +performed sample analysis, and wrote the manuscript. Dr Raghuram +Nagarathna being the primary investigator and the guarantor of this +study had full access to all data in the study and taken responsibility +for the integrity of the data and its analysis. Dr Suchitra Patil +performed additional analysis. Dr Vijaya Majumdar and Dr Sunanda +Rathi oversaw the planning, data collection, and participant +supervision at the study sites. Dr Hongasandra Nagendra +conceptualized the study and monitored its execution. +Declaration of Conflicting Interests +The authors declared no potential conflicts of interest with respect to +the research, authorship, and/or publication of this article. +Ethical Statement +Ethical clearance was obtained by the Ethics Committee of the +Indian Yoga Association. The study was registered on CTRI +160 +Annals of Neurosciences 27(3-4) +Funding +Funding for the study was provided by the Ministry of Health +and Family Welfare and Ministry of AYUSH routed through +Central Council for Research in Yoga and Naturopathy, +Government of India. +ORCID iD +Murali Venkatrao + https://orcid.org/0000-0002-6677-045X +References +1. +Müller, MJ, and Geisler, C. Defining obesity as a disease. Eur J +Clin Nutr 2017; 71: 1256–1258. +2. +Bays, HE, McCarthy, W, Christensen, S et al. Obesity algo- +rithm, presented by the Obesity Medicine Association, 2020. +https://obesitymedicine.org/obesity-algorithm/ (accessed April +12, 2021). +3. +Organization., World Health WHO factsheet on obesity and +overweight: World Health Organization fact sheet, 2020. +https://www.who.int/news-room/fact-sheets/detail/obesity-and- +overweight (accessed April 12, 2021). +4. +Obesity:, Blüher M. Global epidemiology and pathogenesis. +Nat Rev Endocrinol 2019; 15: 288–298. +5. +Bentham, J, Di Cesare, M, Bilano, V et al. Worldwide trends in +body-mass index, underweight, overweight, and obesity from +1975 to 2016: A pooled analysis of 2416 population-based mea- +surement studies in 128.9 million children, adolescents, and +adults. Lancet December 16, 2017; 390(10113): 2627–2642. +6. +Kelly, T, Yang, W, C-S, Chen et al. Global burden of obesity +in 2005 and projections to 2030. Int J Obes September 2008; +32(9): 1431–1437. +7. +Defronzo, RA. From the triumvirate to the ominous octet: A +new paradigm for the treatment of type 2 diabetes mellitus. +Diabetes 2009; 58(4): 773–795. +8. +Whitmer, R, Gunderson, E, Quesenberry, C et al. Body mass +index in midlife and risk of Alzheimer’s disease and vascular +dementia. Curr Alzheimer Res April 3, 2007; 4(2): 103–109. +9. +De La Monte, SM, Tong, M, Lester-Coll, N et al. Therapeutic +rescue of neurodegeneration in experimental type 3 diabetes: +Relevance to Alzheimer’s disease. J Alzheimer’s Dis 2006; +10(1): 89–109. +10. obesity:, McKinsey Global Institute. Overcoming An initial +economic analysis, 2014. https://www.mckinsey.com/indus- +tries/health +care-systems-and-services/our-insights/how-the- +world-could-better-fight-obesity# (2014, accessed September +12, 2020). +11. Pradeepa, R, Anjana, RM, Joshi, SR et al. Prevalence of gen- +eralized and abdominal obesity in urban and rural India: The +ICMR-INDIAB study (phase-I) [ICMR-INDIAB-3]. Indian J +Med Res August 1, 2015; 142: 139–150. +12. National Family Health Survey (NFHS-4) 2015-16 India, 2015. +http://www.rchiips.org/nfhs (accessed September 12, 2020). +13. World Health Organization.Obesity:, Preventing and managing +the global epidemic. World Health Organ Tech Rep Ser 2000; +894: 7–9. +14. Ahirwar, R and Mondal, PR. Prevalence of obesity in India: A +systematic review. Diabetes Metab Syndr: Clin Res Rev 2019; +13: 318–321. +15. Nagendra, HR, Nagarathna, R, Rajesh, S et al. Niyantrita +Madhumeha Bharata 2017, methodology for a nationwide diabe- +tes prevalence estimate: Part 1. Int J Yoga 2019; 12(3): 179–192. +16. Nagarathna, R, Rajesh, SK, Amit, S et al. Methodology of +Niyantrita Madhumeha Bharata Abhiyaan-2017, a nationwide +multicentric trial on the effect of a validated culturally accept- +able lifestyle intervention for primary prevention of diabetes: +Part 2. Int J Yoga 2019; 12(3): 193–205. +17. Wikipedia. Administrative divisions of India, https:// +en.wikipedia.org/wiki/Administrative_divisions_of_India +(accessed May 27, 2020) +18. Inoue, S, Zimmet, P, Caterson, I et al. WHO Western Pacific +Region. The Asia-Pacific perspective: Redefining obesity and +its treatment. World Health Organization, 2000. +19. Rao, JNK, and Wu, CFJ. Resampling inference with complex +survey data. J Am Stat Assoc March 1988; 83(401): 231. +20. Anjana, RM, Deepa, M, Pradeepa, R et al. Prevalence of dia- +betes and prediabetes in 15 states of India: Results from the +ICMR-INDIAB population-based cross-sectional study. Lancet +Diabetes Endocrinol August 1, 2017; 5(8): 585–596. +21. National Family Health Survey. 2020. http://rchiips.org/NFHS/ +factsheet.shtml (accessed September 15, 2020). +22. Mahajan K and Batra A. Obesity in adult Asian Indians: The +ideal BMI cut-off. Indian Heart J 2018; 70: 195. +23. Misra, A, Chowbey, P, Makkar, BM et al. Consensus statement +for diagnosis of obesity, abdominal obesity and the metabolic +syndrome for Asian Indians and recommendations for physical +activity, medical and surgical management. J Assoc Physicians +India February 2009; 57: 163–170. +24. Podder, V, Srivastava, V, Kumar, S et al. Prevalence and aware- +ness of stroke and other comorbidities associated with diabetes in +Northwest India. J Neurosci Rural Pract July 2020; 11(3): 467. +25. Raghuram, N, Bali, P, Srivastava, V et al. Prevalence of diabe- +tes and its determinants in young adult Indian population. Front +Endocrinol 2020; 11: 846. +26. Census of India. 2014. Office of the Registrar General and Census +Commissioner, India. https://censusindia.gov.in/2011census/ +population_enumeration.html (accessed September 15, 2020). +27. Devaux, M, Sassi, F, Church, J et al. Exploring the relationship +between education and obesity. OECD J: Econ Stud 2011 ; 2011(1). +28. Cohen, AK, Rai, M, Rehkopf, DH et al. Educational attainment +and obesity: A systematic review. Obes Rev 2013; 14: 989–1005. +29. Sharma, NK, Gupta, A, Prabhakar, S et al. CC chemokine +receptor-3 as new target for age-related macular degeneration. +Gene July 1, 2013; 523(1): 106–111. +30. Anand, A, Saraf, MK, and Prabhakar, S. Antiamnesic effect of +B. monniera on L-NNA induced amnesia involves calmodulin. +Neurochem Res 2010; 35(8): 1172–1181. +31. Anand, A, Banik, A, Thakur, K et al. The animal models of +dementia and Alzheimer’s disease for preclinical testing and +clinical translation. Curr Alzheimer Res November 1, 2012; +9(9): 1010–1029. +(Registration Number—Trial REF/2018/02/017724). This article +complies with International Committee of Medical Journal Editors’ +(ICMJE) uniform requirements for manuscript. +Venkatrao et al. +161 +32. Anand, A, Gupta, PK, Sharma, NK et al. Soluble VEGFR1 +(sVEGFR1) as a novel marker of amyotrophic lateral sclero- +sis (ALS) in the North Indian ALS patients. Eur J Neurol May +2012; 19(5): 788–792. +33. Goyal, K, Koul, V, Singh, Y et al. Targeted drug delivery to +central nervous system (CNS) for the treatment of neurodegen- +erative disorders: Trends and advances. Cent Nerv Syst Agents +Med Chem April 1, 2014; 14(1): 43–59. +34. Sharma, NK, Gupta, A, Prabhakar, S et al. Single nucleotide +polymorphism and serum levels of VEGFR2 are associated +with age related macular degeneration. Curr Neurovascular Res +November 1, 2012; 9(4): 256–265. +35. 35. Anand, A, Saraf, MK, Prabhakar, S. Sustained inhibition +of brotizolam induced anterograde amnesia by norharmane and +retrograde amnesia by l-glutamic acid in mice. Behav Brain Res +August 22, 2007; 182(1): 12–20. +36. Singh, T, Prabhakar, S, Gupta, A et al. Recruitment of stem +cells into the injured retina after laser injury. Stem Cells Dev +February 10, 2012; 21(3): 448–454. +37. Gupta, PK, Prabhakar, S, Abburi, C et al. Vascular endothe- +lial growth factor-A and chemokine ligand (CCL2) genes are +upregulated in peripheral blood mononuclear cells in Indian +amyotrophic lateral sclerosis patients. J Neuroinflammation +December 1, 2011; 8(1): 114. +38. Vinish, M, Prabhakar, S, Khullar, M et al. Genetic screen- +ing reveals high frequency of PARK2 mutations and reduced +Parkin expression conferring risk for Parkinsonism in North +West India. J Neurol Neurosurg Psychiatry February 1, 2010; +81(2): 166–170. +39. Anand, A, Tyagi, R, Mohanty, M et al. Dystrophin induced cog- +nitive impairment: Mechanisms, models and therapeutic strate- +gies. Ann Neurosci April 2015; 22(2): 108. +40. Banik, A, Brown, RE, Bamburg, J et al. Translation of preclini- +cal studies into successful clinical trials for Alzheimer’s dis- +ease: What are the roadblocks and how can they be overcome? +J Alzheimer’s Dis January 1, 2015; 47(4): 815–843. +41. Anand, A, Sharma, NK, Gupta, A et al. Single nucleotide poly- +morphisms in MCP-1 and its receptor are associated with the +risk of age related macular degeneration. PLoS One November +21, 2012; 7(11): e49905. +42. Sharma, K, Sharma, NK, Anand, A. Why AMD is a disease of +ageing and not of development: Mechanisms and insights. Front +Aging Neurosci July 10, 2014; 6: 151. +43. Sharma, NK, Gupta, A, Prabhakar, S et al. Association between +CFH Y402H polymorphism and age related macular degeneration +in North Indian cohort. PLoS One July 29, 2013; 8(7): e70193. +44. Mathur, D, Goyal, K, and Koul, V et al. The molecular links of +reemerging therapy: A review of evidence of Brahmi (Bacopa +monniera). Front Pharmacol 2016; 7: 44. +45. Anand, A, Thakur, K, and Gupta, PK. ALS and oxidative stress: +The neurovascular scenario. Oxidative Med Cell Longevity +October 2013; 2013. +46. English, D, Sharma, NK, and Sharma, K et al. Neural stem +cells: Trends and advances. J Cell Biochem April 2013; 114(4): +764–772. +47. Sharma, NK, Prabhakar, S, Gupta, A et al. New biomarker for +neovascular age-related macular degeneration: Eotaxin-2. DNA +Cell Biol November 1, 2012; 31(11): 1618–1627. diff --git a/subfolder_0/Regenerative potential of meditation An integrated module for enhancement of regeneration.txt b/subfolder_0/Regenerative potential of meditation An integrated module for enhancement of regeneration.txt new file mode 100644 index 0000000000000000000000000000000000000000..be5c3ca6c8068131dd4c996e755b3c501624e7a4 --- /dev/null +++ b/subfolder_0/Regenerative potential of meditation An integrated module for enhancement of regeneration.txt @@ -0,0 +1,38 @@ +November 12-14, 2012 Hilton San Antonio Airport, USA +International Conference on +Regenerative & Functional Medicine +Volume 2 Issue 5 +Page 69 +J Stem Cell Res Ther 2012 +ISSN: 2157-7633 JSCRT, an open access journal +Regenerative Medicine-2012 +November 12-14, 2012 +A +s per the traditional vedic texts of India, meditation is a practice during which there is no focusing but an expansive mental +state is reached effortlessly, leading to absolute silencing of the mind which transcends the realms of time and space. These +traditional texts describe various occasions where the advanced meditation-masters could regenerate any organ of the body at +will, and that even diseases which are present since birth could be cured through realization of this state of existence. In this +review, we explored the ancient vedic literature of India, to collect all the information related to the process of regeneration and its +relation to the cognitive phenomena taking place in the mind of the mediators. We also reviewed the available scientific literature +to understand the probable mechanisms of action of these cognitive-behavioral techniques at the cell biological level. For e.g., it +has been shown in many studies that meditative states slow down the metabolic processes in the body (suspended animation) +which includes reduction in the breathing rate, ECG (electro-cardiogram) and EEG (electro-encephalogram) activities, and the +blood flow respectively. This reduces tissue oxygenation and promotes hypoxia in the cellular micro-environment throughout +the body. Hypoxia-induced signaling is primarily mediated by the hypoxia-inducible factor-1 (HIF-1), a molecular determinant +of the response of mammalian cells to hypoxia and a regulator of O2 homeostasis. It is well known that stem cells are critically +dependant on hypoxic environment and HIFs for survival, self-renewal and growth. Thus, meditation may enhance stem cell +functioning. Another mechanism through which meditation may help regeneration and healing is through the enhanced +release of an extremely important pleiotropic substance called melatonin, which is produced by the body (the pineal gland, the +bone marrow, circulating immune cells, and other sources) and has anti-inflammatory, immune-stimulating, anti-oxidant and +regeneration-enhancing properties. Studies also show that meditation may have salutary effects on telomere length by reducing +cognitive stress and stress arousal and increasing positive states of mind and hormonal factors that may promote telomere +maintenance and thereby slow down the rate of cellular ageing. Thus, finally, through this exploration into the traditional and +modern scientific literature we come up with evidence based integrated module to enhance the process of regeneration further, +towards the future of regenerative medicine. +Hemant Bhargav, J Stem Cell Res Ther 2012, 2:5 +http://dx.doi.org/10.4172/2157-7633.S1.005 +Regenerative potential of meditation: An integrated module for enhancement of +regeneration process towards the future of regenerative medicine +Hemant Bhargav +Swami Vivekananda Yoga Anusandhana Samsthana, India +urs.aatmiya@gmail.com diff --git a/subfolder_0/Remedial yoga module remarkably improves symptoms in irritable.txt b/subfolder_0/Remedial yoga module remarkably improves symptoms in irritable.txt new file mode 100644 index 0000000000000000000000000000000000000000..ac1b7d9c717fb94a0c89d8b9e901943bd8ca9463 --- /dev/null +++ b/subfolder_0/Remedial yoga module remarkably improves symptoms in irritable.txt @@ -0,0 +1,1829 @@ +Research paper +Remedial yoga module remarkably improves symptoms in irritable +bowel syndrome patients: A 12-week randomized controlled trial$ +Vijaya Kavuria,b,1, Pooja Selvana,1, Ariel Malamudc,2, Nagarathna Raghuramb,3, +Senthamil R. Selvana,b,* +a Vivekananda Yoga Research Foundation, Norwalk, CA, USA +b Swami Vivekananda Yoga University (SVYASA), Bangalore, Karnataka, India +c White Memorial Medical Center, Los Angeles, CA, USA +A R T I C L E +I N F O +Article history: +Received 29 August 2015 +Received in revised form 2 November 2015 +Accepted 3 November 2015 +Keywords: +Yoga +IBS +IBS-SSS +IBS-QOLp +Anxiety +Depression +A B S T R A C T +Introduction: Irritable bowel syndrome (IBS) is very common [252_TD$DIF]disorder, with various associated symptoms +and affects quality of life. Alternatives to Western medication are often sought. Previous research has +suggested that Yoga practice could have a positive impact on alleviating these symptoms. The aim was to +evaluate a comprehensive Remedial Yoga Module (RYM) for use as an intervention for IBS. +Methods: IBS patients (diagnosed according to Rome III criteria) were randomized into 3 groups[253_TD$DIF]: +Yoga + limited conventional treatment, Combination (Yoga + conventional treatment[254_TD$DIF]) and Wait-list +Control groups. Yoga and Combination groups received RYM sessions, three times a week, for 12 weeks, +and [25_TD$DIF]the Wait-list Control group maintained their current lifestyle. Primary endpoints were IBS-Symptom +Severity Scales (IBS-SSS) and IBS Quality of Life (IBS-QOL). Secondary endpoints were Hospital Anxiety +and Depression [310_TD$DIF]Scale (HADS), Autonomic Symptom Score (ASS), IBS Global Assessment of Improvement +(IBS-GAI), Medicine and Supplement Use, physical flexibility, and autonomic functions. +Results: 97 patients were randomized and 78 patients completed the study with high adherence (90%) to +RYM sessions. There were significant improvements in IBS-SSS and IBS-QOL scores in Yoga (n = 25; +p < 0.001) and Combination groups (n = 26; p < 0.001) when compared to Wait[249_TD$DIF]-list Control group (n = 27). +Also, HADS, ASS, IBS-GAI, physical flexibility, and autonomic functions were significantly improved [256_TD$DIF]which +correlated with a reduction in the amount of Medicine and Supplement Use in the Yoga and Combination +groups. +Conclusion: A 12-week RYM intervention could be a feasible stand-alone treatment or an integrative +option within conventional treatment for IBS patients with addressing IBS and associated conditions. +ã 2015 The Authors. Published by Elsevier GmbH. This is an open access article under the CC BY license +(http://creativecommons.org/licenses/by/4.0/). +1. Introduction +Irritable bowel syndrome (IBS) is the most prevalent functional +gastrointestinal +(GI) +disorder +in +which +patients +experience +abdominal pain or discomfort that occurs in association with +altered bowel habits over a period of at least three months, in the +absence of any detectable organic cause [1,2]. IBS is classified as +either diarrhea predominant (IBS-D), constipation predominant +(IBS-C), or alternating stool pattern of mixed diarrhea and +constipation (IBS-M) [3]. The incidence rates range from 9 to [257_TD$DIF] +23% worldwide and 10–15% in the USA [4]. Though the primary +cause and effect are not established, these patients suffer from a +host of secondary symptoms such as depression, anxiety, head- +aches, fibromyalgia, migraines, and chronic fatigue syndrome [5,6]. +Also, the quality of life (QOL) is affected to a greater extent in IBS +patients compared to organic GI disorders [7]. Stress impacts the +$ Trial Registration: ISRCTN; 42102754. +* Corresponding author at: Research Director, Vivekananda Yoga Research +Foundation (VYRF), 11722 Farina Street, Norwalk, CA 90650, USA. +E-mail addresses: vijaya_kavuri@yahoo.com (V. Kavuri), +poojaselvan93@gmail.com (P. Selvan), malabur@yahoo.com (A. Malamud), +rnagaratna@gmail.com (N. Raghuram), senthamils59@gmail.com (S.R. Selvan). +1 Vivekananda Yoga Research Foundation, 11722 Farina Street, Norwalk, CA +90650, USA. +2 White Memorial Medical Center, 1701 E. Cesar Chavez Ave, #100, Los Angeles, +CA 90033, USA. +3 School of Yoga Life Sciences, Swami Vivekananda Yoga University (SVYASA), 19 +Eknath +Bhavan, +Gavipuram +Circle, +Kempegowda +Nagar, +Bangalore +560019, +Karnataka, India. +http://dx.doi.org/10.1016/j.eujim.2015.11.001 +1876-3820/ã 2015 The Authors. Published by Elsevier GmbH. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). +European Journal of Integrative Medicine 7 (2015) 595–608 +Contents lists available at ScienceDirect +European Journal of Integrative Medicine +journal homepage: www.elsevier.com/eujim +gut physiology leading to brain-gut axis dysfunction and influences +the development and exacerbation of IBS [8]. Autonomic imbal- +ance, either sympathetic excess or parasympathetic dominance, +was found in IBS patients [9,10]. +IBS in the United States is estimated to cost more than $20 +billion annually, in direct and indirect [258_TD$DIF]expenditures [11,12]. The +pharmacological treatment options address targeted-symptomatic +relief and most of these treatments have side effects such as [31_TD$DIF] +nausea, headaches, dry mouth, cramping, constipation, blurred +vision[312_TD$DIF]. Thus, these patients remain inadequately treated and +dissatisfied with their QOL. About 50% of IBS patients often seek +alternative treatments like, probiotics, Chinese herbal therapy, +Yoga, +acupuncture[260_TD$DIF], +and +hypnosis +[13]. +Recent +reviews +on +complementary and alternative medicine (CAM) on IBS have all +concurred [261_TD$DIF]that various CAM modalities could benefit IBS patients +in improving their symptoms and QOL [13–15]. +Yoga has been shown to improve headaches, anxiety, depres- +sion, chronic fatigue, and fibromyalgia [16–20]. In a report of IBS +and current treatment options, Ducrotte had suggested that Yoga +postures targeting the lower abdomen would help in relieving the +symptoms of IBS by enhancing energy circulation in and around +the intestines [21]. +Only four studies (3 on adolescents and 1 on adults) have +previously explored the effects of Yoga postures on IBS patients. +Even though, all these studies reported improvements in the Yoga +group, the regimens of Yoga practices, and durations of the +intervention varied. The sequence of the postures or the length of +time involved in each posture was not mentioned in detail. Two of +the studies had supervised instruction, and two others were self- +instructed [22–25]. There are few other studies that investigated +meditation in IBS patients [26–28]. +In the present randomized trial, a comprehensive Remedial +Yoga Module (RYM) as an intervention for IBS was assessed. The +Yoga module importantly included all primary facets of Yoga, +body-breath-mind (postures, regulated breathing[262_TD$DIF], and meditation) +to be practiced three times a week, supervised by an instructor +[29]. The study investigated the efficacy of RYM on IBS-Symptom +Severity Scales (IBS-SSS) and IBS-QOL. The secondary objectives +were to evaluate the impact of RYM on psychological symptoms, +autonomic nervous system function, and physical flexibility. +2. Materials and methods +2.1. Subjects +The principal recruitment strategy was to publicize the clinical +trial to all gastroenterology clinics, primary care physicians[263_TD$DIF], and +psychiatry offices around White Memorial Medical Center, Los +Angeles, California, USA. It was calculated that a total of 75 subjects +would be needed for the study. Assuming 30% attrition, it was +planned that 99 subjects should be enrolled into the study. Ethical +approval was obtained prior to the commencement of the trial. +A total of 120 patients were referred to the study from the +physicians’ offices in Los Angeles, California, USA. All male and +female subjects [264_TD$DIF]from the ages of 18 years and above with a +diagnosis of IBS using Rome III criteria were considered eligible. +The inclusion criteria were (i) patients that did not practice Yoga in +the last 6 months, (ii) not enrolled in any other alternative +medicine programs and (iii) patients committed to three months of +Yoga, three times a week. The exclusion criteria were (i) patients +with pregnancy, (ii) physical or mental disability to do Yoga, (iii) +history of drug, alcohol, or chemical abuse within 6 months prior to +screening, (iv) patients with any organic bowel disease, and (v) +inability to comply with study and follow-up procedures. +2.2. Study design +All subjects upon signing an informed consent form were +randomized +(parallel) +into +three +groups—Yoga +group +(Yoga +intervention with limited conventional treatment of three days +a week), Combination group (Yoga intervention and Conventional +Treatment), +and +Wait[249_TD$DIF]-list +Control +group +(current +care +and +lifestyle), and the allocation was 1:1:1. The Yoga group and [265_TD$DIF] +Combination group were planned to differentiate between the +effects of Yoga alone and Yoga with medication on IBS symptoms. +All three groups were assessed at three time points, at Week 0 (Pre- +intervention), at Week 6 (Mid-intervention) and [26_TD$DIF]at Week 12 (Post- +intervention), which would allow us to determine the ideal +duration of Yoga intervention required for IBS patients. +2.3. Randomization +In order to ensure allocation of an equal number of patients to +all three groups, randomization was carried out in blocks of six +patients, and the patients were asked to pull out numbers from an +envelope [30]. The random numbers were generated using online +software by a research team member not involved with data +collection [31]. The randomization process was concealed from +research team that was collecting data and the outcome assessors. +Ninety seven patients, both male (n = 13; median age 46 years; +median weight 157 pounds) and female (n = 84; median age, 45 +years; median weight 157 pounds), meeting the inclusion and +exclusion criteria, were enrolled in the study between September +2012 and June 2014. Data collection was from November 2012 to +September 2014. +2.4. Intervention +i) Yoga group. Intervention with RYM for IBS, one hour long [313_TD$DIF]three +days a week for 12 weeks, was provided under the guidance of +Table 1 +Mean and median age and weight of randomized subjects. +Groups +Total enrolled/female/male +Age in years/weight in lbs (Mean  SD) +Median age in years/weight in lbs +Yoga +33/31/2 +44.06  13.42/155.48  26.39 +45/156 +44.06  13.42/155.48  26.39 +45/156 +45.80  12.71/159.00  29.95 +42/147 +Combination +33/28/5 +44.27  13.59/159.36  29.88 +46/157 +44.27  13.59/159.36  29.88 +46/157 +41.18  12.75/159.68  34.62 +42.5/155 +[248_TD$DIF]Wait-list Control +31/25/6 +45.08  13.28/168.61  31.00 +46/165 +44.07  13.68/169.77  32.65 +46/165 +45.77  12.88/167.73  31.52 +46/164 +596 +V. Kavuri et al. / European Journal of Integrative Medicine 7 (2015) 595–608 +certified Yoga instructors. The Yoga group was advised to +voluntarily reduce their medications (prescription and supple- +ment use if any) for IBS to three days a week. There was a +gastroenterologist available in case of aggravated symptoms +due to reduction in the medications. Patients were excluded +from analysis but not from attending Yoga sessions if they were +using medication more than three times a week. +ii) Combination group. Patients continued with their medications[267_TD +$DIF], if any, under the guidance of their physician, and attended +Yoga classes three times a week for 12 weeks along with the +Yoga group. +iii) Wait[249_TD$DIF]-list control group. Patients continued their medications +if any, under the guidance of their physician, and were +suggested to maintain their lifestyle. The research staff had +advised [268_TD$DIF]these controls to walk for 60 min three times a +week during their waiting period of 12 weeks. The [269_TD$DIF]Wait-list +Controls were contacted and were reminded one week +before their next assessment interval at Week 6 and 12. After +12 weeks of waiting, [270_TD$DIF]they were offered the same Yoga +intervention. The mean and median age, and weight of patients +[271_TD$DIF]as a result of randomization into the three groups is given in +Table 1. +2.5. Yoga sessions +Six certified Yoga instructors were trained, instructed[272_TD$DIF], and +monitored by the lead Yoga instructor and overseen by study +principal investigator. This was to ensure that the module was +followed exactly and [273_TD$DIF]that there were no differences in the +intervention +received +by +the +patients +from +different +Yoga +instructors. The Yoga instructors were concealed to the group +allocation of the patients. The Yoga session for the intervention +was followed as listed in Table 2 and as depicted in Supplementary +Fig. 1. +Each [314_TD$DIF]one hour Yoga session had a gradual space and started +with simple breathing practices, loosening practices[315_TD$DIF], and simple +postures with relaxation [316_TD$DIF]in between. The session ended with +regulated breathing and meditation. Occasionally the sessions +lasted an extra 5–10 min as some new patients required more +attention. The Yoga sessions were held three days a week +(evening) and one weekend morning class, which served as an +alternate option/makeup class. Adherence to the Yoga module +was monitored by research staff regularly, and there were no +deviations noted from the protocol. All patients received free Yoga +mats. A remuneration of $20 was paid to [276_TD$DIF]Wait-list Controls for +Table 2 +Protocol of one hour [309_TD$DIF]Remedial Yoga Module used for IBS. +Name of Yoga practice +Number of rounds +Duration (minutes) +Starting affirmation (A-U-M, sound three times, OM, three times) +2 min +Breathing practices +5 min +1 +Hands-stretch breathing +5  3 +2 min +2 +Vyaghrasana/tiger pose breathing +5 +1 min +3 +Shashankasana/moon pose breathing +5 +1 min +4 +Padottanasana/straight leg raise breathing (supine position, both legs) +5 +1 min +Savaasana/instant relaxation +2 min +Sithilikarana Vyayama/loosening exercises +6 min +1 +Forward and backward bending +20 +2 min +2 +Side bending +10 +1 min +3 +Twisting +10 +1 min +4 +Pavanamuktasana Kriya/wind relieving pose with leg rotation +5 + 5  2 +2 min +Savaasana/quick relaxation +3 min +Asanas/postures-standing, sitting, prone, supine +18 min +1 +Ardhakati cakrasana/half-waist wheel pose +1 + 1 +2 min +2 +Ardha cakrasana/Half wheel pose +1 +1 min +3 +Padahastasana/hands to feet pose +1 +1 min +4 +Trikonasana/triangle pose +1 + 1 +2 min +5 +Parivritta trikonasana/revolved triangle pose +1 + 1 +2 min +6 +Vrikshasana/tree pose +1 + 1 +2 min +7 +Vakrasana/half spinal twist +1 + 1 +2 min +8 +Pascimottanasana/seated forward bend pose +1 +1 min +9 +Bhujangasana/cobra pose +1 +1 min +10 +Shalabhasana/locust pose +1 +1 min +11 +Sarvangasana/shoulder stand +1 +1 min +12 +Viparitakaraniwith wall support/legs up the wall +1 +1 min +13 +Matsyasana/fish pose +1 +1 min +Savaasana/deep relaxation +6 min +Kriyas/cleansing and Pranayama/regulated +breathing +11 min +1 +Uddiyana Bandha and Agnisara/abdominal lock and rigorous movement of +abdomen +3 (30 count) +2 min +2 +Kapalabhati/forceful exhalation +1 (60 count) +1 min +3 +Vibhagiya Svasana/sectional breathing +5 +1 min +4 +NadiShuddhi pranayama/alternate nostril breathing +9 +3 min +5 +Sitali/cooling pranayama +5 +1 min +6 +Sitkari/cooling pranayama +5 +1 min +7 +Bhramari/M-chanting +5 +1 min +Dhyana/meditation +6 min +1 +Nadanusandhana/Yoga of sound +(A-U-M) +9 +3 min +2 +OM meditation (OM) +9 +3 min +Closing affirmation—OM three times +1 min +5  3—Three positions of hand stretch; 5 + 5  2—5 rounds each clock wise and anti clock wise each leg; 1 + 1—on both sides. +V. Kavuri et al. / European Journal of Integrative Medicine 7 (2015) 595–608 +597 +attending each measurement, and Yoga and Combination groups +were paid $5 for the same. All the Yoga sessions and appraisals +were held in the research center [27_TD$DIF](in a temperature and noise +controlled suite) of White Memorial Medical Center, Los Angeles, +USA. +2.6. Primary outcome assessments +2.6.1. Irritable Bowel Syndrome-Severity Scoring System (IBS-SSS) +IBS-SSS is a self-reported questionnaire regarding pain severity, +frequency, abdominal distension/bloating, bowel habit satisfac- +tion, and interference in life. The score for each of the questions +ranged from 0 to 100 with a visual analog scale. The total score was +500 points. A reduction of 50 points was considered to be adequate +for clinical improvement [32]. +2.6.2. Irritable Bowel Syndrome Quality of Life (IBS-QOL) +IBS-QOL is a self-reported tool designed to assess various +aspects of quality of life in IBS patients. The questionnaire +consisted of a 5 point rating of 34 items inquiring into the +emotional well-being and interference with activity, body image, +health worry, food avoidance, social reaction, sex, and relation- +ships. The scores (reverse scoring) ranged from 34 to 170, with, +higher score indicating better quality of life. An increment of 14 +points (when transformed to 0–100 range) was considered to be +clinically significant improvement [33]. +2.7. Secondary outcome assessments +2.7.1. Hospital Anxiety and Depression Scale (HADS) +Hospital Anxiety and Depression Scale is a 14 item self- +reported questionnaire, 7 items for anxiety and 7 items for +depression. This questionnaire used a 4 point rating (0–3) and +was divided into two subscales. Each subscale score ranged from 0 +to 21 [278_TD$DIF]– scores of 0–7 indicate normal levels[279_TD$DIF], 8–10 indicate +borderline[280_TD$DIF], and 11–21 suggest abnormal levels of anxiety and +depression [34]. +2.7.2. IBS-Global Assessment of Improvement Score (IBS-GAI) +Patients were asked to provide a global assessment of their IBS +at 0, 6, and 12 weeks using the question, “Compared with your IBS +symptoms six weeks ago, are you now: terrible, worse, slightly +worse, no change, slightly better, better or excellent”. Minimum +score was 1 (terrible) and maximum score was 7 (excellent), higher +score meaning improvement [35]. +2.7.3. Autonomic Symptom Score +Autonomic Symptom Score is a 10 item self-reported scale, with +a score of 1 for presence and 0 for absence. Maximum score was 10 +and minimum was 0 [25]. +2.7.4. Medicine and supplement use +Subjects were interviewed about use of IBS symptom relieving +medications: prescription, non-prescription, herbal or dietary +supplements and were recorded at week 0. Changes in the drug +consumption from baseline were evaluated at week 6 and at week +12. If the subject changed a drug regimen that was equivalent to +baseline drug regimen with respect to medication class and/or +dosing period, and expected to yield a similar response, the drug +usage was considered unchanged. Changing the dosage or stopping +one or more components of multiple drug regimens was also +considered +alteration +in +drug +usage. +Final +outcomes +were +measured in frequency intervals of success (decrease in dosage +or cessation of medication) and failure (no change or increase in +dosage) [36]. +[317_TD$DIF]2.8. Autonomic function testing +To assess sympathetic and parasympathetic reactivity before +and after intervention in the present study, a battery of four +cardiovascular reflex tests (two sympathetic tasks and two +parasympathetic +tasks) +were +conducted. +Electrocardiogram +(ECG) and respiration were acquired with a two channel Biopac +MP 45 Data Acquisition System, (BIOPAC, CA, USA). An automatic +blood pressure apparatus and hand grip dynamometer were used +in sympathetic reactivity tests [37]. +[318_TD$DIF]2.9. Sympathetic reactivity tests +[319_TD$DIF]2.9.1. Handgrip test +Changes in diastolic blood pressure while undergoing handgrip +test [281_TD$DIF]measured the sympathetic reactivity [37]. An electronic hand +grip dynamometer (Camry EH 101, Guangdong, China) and a +noninvasive automatic blood pressure monitor (Omron HEM 7121, +Kyoto, Japan) were used for this isometric test. The subjects were +directed to grip the hand-grip dynamometer with their dominant +hand and contract to the maximum extent possible for five +seconds. The maximum reading (in lbs) was taken as the maximum +volumetric contraction (MVC). The subject was then asked to +contract the dynamometer continually at 30% of the MVC for 4 min. +The changes in diastolic blood pressure were measured in the +contra lateral arm at 1, 2, and 4 min. +[320_TD$DIF]2.9.2. Mental arithmetic test +A five minute mental arithmetic test was used to induce +cognitive stress and elicit sympathetic reactivity [37]. Subjects +were given a three digit number and asked to perform serial +subtraction using number 7 or 3. Subjects answered verbally, and +in case of a wrong answer, error message was given before a new +number was read. The heart rate was monitored by continuous ECG +and blood pressure was monitored by automatic blood pressure +machine at 1, 2, and 5 min of the test. +[321_TD$DIF]2.10. Parasympathetic reactivity tests +[32_TD$DIF]2.10.1. Heart-rate variability in deep breathing test +The deep breathing was conducted with the patient resting in [282_TD$DIF] +the +supine +position +for +5 min, +connected +to +the +standard +electrocardiogram (ECG) leads [37]. Before beginning the test, +patients were taught to breathe at a rate of 6 respiration cycles per +one minute. The ECG was recorded at a speed of 25 mm/s for 180 s +while the patient breathed as instructed. Heart Rate Variability was +extracted using the Kubios (version 2.2, Finland) software. +[323_TD$DIF]2.10.2. 30–ratio (Supine to upright position). +Using the body’s physiological response upon moving from a +supine to an upright posture, parasympathetic measurements +were obtained [37]. The “30–15” ratio was used to provide a +measure of vagus nerve function. The patients were asked to +remain in supine position for 5 min (until their heart rate has +stabilized), and then were instructed to move from the supine to an +upright posture. From the continuous ECG recording, after the +patient has stabilized in the upright posture, the R–R interval at +30th beat and 15th beat was obtained, and the “30–15” ratio was +calculated. +[324_TD$DIF]2.11. Measurements +2.11.1. Weight and height +Weight was measured to the nearest 0.1 lb (Detecto FH 133/11/ +CH, Webb city, Missouri) and height was measured with a Seca +stadiometer (Seca 222, Chino, CA) to the nearest 0.1 inches (in.). +598 +V. Kavuri et al. / European Journal of Integrative Medicine 7 (2015) 595–608 +Body Mass Index (BMI) was calculated using a BMI calculator (Seca +491, Chino, CA). +[325_TD$DIF]2.11.2. Hip and trunk flexibility +Hip and trunk flexibility was measured with a sit and reach box +(Baseline Corporation, Golden, Colorado) [38]. Patient was asked to +sit on the floor, shoes off and legs stretched with soles of the feet +against the sit and reach box, [283_TD$DIF]with back straight. The subject was +then asked to place one hand over the other on the measuring stick +(stretch indicator), and with knees straight, reach as far as possible +by moving the measuring stick. Best of three tries was recorded to +the nearest 0.1 cm. +[326_TD$DIF]2.11.3. Shoulder flexibility +Flexibility of both shoulders was measured with a standard +goniometer (Baseline corp., Golden, Colorado) in centimeters (cm) +[39]. The patient was asked to stand straight, raise their right hand +over the shoulder and reach down their back as far as possible +while the left hand reached up the middle of the back behind the +waist, trying to bring fingers of both hands together. The distance +between the extended middle fingers of both hands was measured +and recorded to the nearest cm for the right shoulder. The same +procedure was followed for the left shoulder. +[327_TD$DIF]2.11.4. Definition of a responder +Responders were identified for the two primary endpoints. +(i) IBS-SSS: a responder was defined as patient whose overall +symptom severity on the IBS-SSS improved 50 points from +baseline to Week 6 and Week 12 [40] and (ii) IBS-QOL: a responder +was defined as patient whose quality of life had a meaningful +change of 14 points, from baseline to Week 6 and Week 12 [41]. +[328_TD$DIF]2.12. Data analysis and statistics +The primary end points were between group differences in the +changes of IBS-SSS and IBS-QOL scores from week 0 compared to +week 6 and week 12 visits. The secondary end points were to assess +whether changes in HADS, Autonomic Symptom Scores, IBS-GAI, +Medicine and Supplement use, BMI, physical flexibility, and +autonomic +function +tests +differed +between +the +groups. +[(Fig._1)TD$FIG] +27 completed Week 6 +(Mid assessment) +29 completed Week 6 +(Mid assessment) +27 completed Week 6 +(Mid assessment) +0 lost to post-assessment +3 lost to post-assessment +2 Family emergencies +1 Fractured foot at home +2 lost to post-assessment +1 Family emergency +1 Other diagnosis (Flu) +25 completed Week 12 +(Post-assessment) +26 completed Week 12 +(Post-assessment) +27 completed Week 12 +(Post-assessment) +6 Lost to Mid assessment +2 Change in work schedules +2 Non-compliance +1 Family emergency +1 Breast Cancer +4 Lost to Mid assessment +1 Felt Yoga session was +Difficult +1 Non-compliance +1 Moved; 1 Surgery +4 Lost to Mid assessment +3 Lost to follow up +1 Deceased (cardiac event) +Wait-list control group (WG) +n = 31 +(Week 0, Pre-assessment) +Combination group (CG) +n = 33 +(Week 0, Pre-assessment) +Yoga group (YG) +n = 33 +(Week 0, Pre-assessment) +Began Yoga Intervention +Maintain life style +23 subjects not included +5 Did not meet inclusion criteria +2 Already in Yoga, +2 Physically disabled and +1 Pregnant +18 Declined to participate +12 Length of intervention too +long +6 Time conflict with Yoga +sessions +Assessed for eligibility +n = 120 +Randomized +n = 97 +Fig. 1. Flowchart of patients—randomization to completion. +V. Kavuri et al. / European Journal of Integrative Medicine 7 (2015) 595–608 +599 +Questionnaires +were +scored +by assessors +blinded +to group +allocation and not directly involved in the research. +Within-group comparisons were also performed for explorato- +ry reasons. A per-protocol analysis of data obtained from patients +completing the study was performed. Also, an intention-to-treat +analysis, that included all randomized patients, was carried out. +Statistical analysis was carried out using SPSS (Scientific +Packages for Social Sciences, IBM Corporation, NY, version 20.0). +Initial tests of normality showed there were no baseline differences +between groups on demographic and clinical variables, such as age, +weight, and duration of IBS. The baseline data of all the +assessments were tested for normality and all data were normal. +Repeated measures Analyses of Variance (ANOVAs) were per- +formed for each assessment with 2 factors[284_TD$DIF]: (1). Groups: Yoga +group, Combination group and Control group; and (2) Time points: +Week 0 (pre-intervention), Week 6 (mid-intervention) and Week +12 (post-intervention). Repeated measures ANOVAs were carried +out separately followed by post hoc analyses with Bonferroni +correction, for all the primary and secondary end points, for +multiple comparisons between the mean values of different Time +points. All comparisons were made with respective Week 0 (pre- +intervention) values. McNemar’s test and t-test were used to +analyze the nominal data of Medicine and Supplement Use, and +responders. For “Intention To Treat” (ITT) analysis, missing values +were analyzed with multiple imputation method. +3. Results +3.1. Subjects +A total of 97 IBS patients fulfilled the inclusion and exclusion +criteria and were randomized into the trial. Overall, 8 patients in +the Yoga and 7 patients in the Combination groups discontinued +the study, either due to family emergencies (4 patients), other +conditions (4 patients) or time conflicts (3 patients). There were 3 +non-compliant patients [285_TD$DIF]who were excluded from the analysis and +not from the study. There were 4 dropouts in the Wait-list Control +group, 3 were lost to follow-up, and one [286_TD$DIF]died. Fig. 1 shows the flow +of subjects from [329_TD$DIF]randomization to completion. +A total of 78 patients, of the 97 enrolled, completed the study +and were included in the per-protocol analysis. Subjects comprised +of IBS-C (n = 28, median age 43 years; 35.9% of total completed), +IBS-D (n = 23, median age 45 years; 29.5% of total completed), and +IBS-M (n = 27, median age 45 years; 34.6% of total completed). The +median duration of IBS from diagnosis before enrolling into the +trial was five years and medications used were two years. Details of +the demographic data are shown in Table 3. +3.2. Yoga practice +It was required that both Yoga and Combination groups attend +at least 75% (27 out of 36) of the Yoga sessions, and on an average, +the subjects +attended 33 classes in 12 weeks, about 90% +attendance. +3.3. Per-protocol analysis +Repeated measures ANOVA were performed for each assess- +ment with two factors: Time points (Week 0, Week 6 and Week 12) +and groups. Significant main effects of time points and groups; and +the interaction between time points, groups and assessments are +given in Supplement Table 1. +Table 3 +Characteristics of 78 total subjects that completed the study. +Total (78) +Yoga group (25) +Combination group (26) +Wait[249_TD$DIF]-list (Control) group (27) +Marital status +Married/cohabitant +44 (56.4%) +17 (68.0%) +12 (46.2%) +15 (55.6%) +Single +26 (33.3%) +6 (24.0%) +11 (42.3%) +9 (33.3%) +Divorced +7 (9.0%) +1 (4.0%) +3 (11.5%) +3 (11.1%) +Widowed +1 (1.3%) +1 (4.0%) +0 +0 +Ethnicity +Hispanic +56 (71.8%) +15 (60.0%) +19 (73.1%) +22 (81.5%) +Non-hispanic +22 (28.2%) +10 (40.0%) +7 (26.9%) +5 (18.5%) +Education +Middle school +4 (5.1%) +2 (8.0%) +1 (3.9%) +1 (3.7%) +High School +33 (42.3%) +5 (20.0%) +11 (42.3%) +17 (63.0%) +College +41 (52.6%) +18 (72.0%) +14 (53.8%) +9 (33.3%) +Employment +Full-time +51 (65.4%) +19 (76.0%) +14 (53.9%) +18 (66.7%) +Part-time +15 (19.2%) +1 (4.0%) +8 (30.8%) +6 (22.2%) +Home-maker +3 (3.9%) +1 (4.0%) +1 (3.8%) +1 (3.7%) +Unemployed +4 (5.1%) +2 (8.0%) +1 (3.8%) +1 (3.7%) +Retired +5 (6.4%) +2 (8.0%) +2 (7.7%) +1 (3.7%) +Economic status +<30 k +39 (50.0%) +9 (36.0%) +15 (57.7%) +15 (55.6%) +30–60 k +26 (33.3%) +10 (40.0%) +8 (30.8%) +8 (29.6%) +60–100 k +9 (11.6%) +5 (20.0%) +2 (7.7%) +2 (7.4%) +>100 k +4 (5.1%) +1 (4.0%) +1 (3.8%) +2 (7.4%) +IBS subgroups +IBS—constipation +28 (35.9%) +8 (32.0%) +10 (38.5%) +10 (37.0%) +IBS—diarrhea +23 (29.5%) +10 (40.0%) +6 (23.0%) +7 (26.0%) +IBS—mixed +27 (34.6%) +7 (28.0%) +10 (38.5%) +10 (37.0%) +Percent in parentheses represents value of the total in a given category. +600 +V. Kavuri et al. / European Journal of Integrative Medicine 7 (2015) 595–608 +3.4. Primary outcome assessments—IBS-SSS +Post hoc analysis with Bonferroni correction of IBS—SSS showed +a significant improvement in Yoga and Combination groups when +compared to Control group. Fig. 2 illustrates the changes between +groups and time points. There was a significant difference between +Yoga and Control groups at Week 6 (p < 0.001), and at Week 12, the +mean difference was 226.31 16.8; [185.17, 267.44], (p < 0.001). +There was a significant difference between Combination and +Control groups at Week 6 (p < 0.001) and at Week 12, the mean +difference was 189.72 16.63 [149.01, 230.44], (p < 0.001). There +were no significant differences between Yoga and Combination +groups. +The five sub-scales of IBS-SSS were analyzed in detail (Fig. 3). +Significant improvements were observed in all five categories in +Yoga +(p < 0.001) +and +Combination +groups +(p < 0.001) +when +compared to [287_TD$DIF]the Wait-list Control group. Within group changes +of Yoga and Combination showed significant improvements at +Week 6 (p < 0.001) and at Week 12 (p < 0.001) when compared to +Week 0. +3.5. IBS-QOL +Fig. 4 illustrates the changes between groups and time points. +There was a significant difference between Yoga and [251_TD$DIF]Wait-list +Control group at Week 6 (p < 0.001), and at week 12, the mean +difference was 56.53  5.71 [42.56, 70.5]; (p < 0.001). Similarly, a +significant difference between Combination and Control group at +Week 6 (p < 0.001) as well as at Week 12, the mean difference was +47.95  5.65 [34.12, 61.77]; (p < 0.001), was observed. +A similar detailed analysis of eight dimensions of IBS—Quality +of Life assessments was carried out. As shown in Fig. 5, there was a +significant difference between Yoga and [297_TD$DIF]Wait-list Control group +(p < 0.001) and Combination and [30_TD$DIF]the Wait-list Control group +(p < 0.001) in all eight dimensions. Within group changes were +observed in dimensions of one to six and eight in Yoga and +Combination groups at Week 6 (p < 0.001) and at Week 12 +(p < 0.001) when compared to Week 0. +3.6. Secondary outcome assessments—Hospital Anxiety and +Depression [310_TD$DIF]Scale (HADS), Autonomic Symptom Score, and IBS-global +assessments of improvement (IBS-GAI) +Fig. 6 depicts the comparison of all these assessments, between +group differences and within group changes from Week 0 to Week +6 and Week 12. There were significant improvements in both Yoga +and Combination groups in HADS and IBS-GAI assessments when +compared to Control group, at Week 6 (p < 0.001) and at Week 12 +(p < 0.001). In the assessment of [289_TD$DIF]the Autonomic Symptom Score, a +significant difference between Yoga and Control groups (p < 0.01); +Combination and Control groups (p < 0.05) at Week 12 was +observed. +3.7. Medicine and supplement use +At the baseline appraisal, Medication/Supplements for relieving +IBS symptoms were used by 19 out of the 25 subjects in the Yoga +group, 21 out of the 26 in the Combination group and 22 out of the +27 in the Control group. There were a total of 16 subjects (6 in Yoga[290_TD$DIF], +5 in Combination and 5 in Control group) that did not use any +medication/supplements. Most commonly used medication/sup- +plements (by all the groups) were Dicyclomine, Bentyl, amitiza, +Linzess, Loperamide, psyllium, fiber drinks, herbal teas and +probiotics. Medicine and Supplement usage reported during Week +6 assessment decreased significantly in the Yoga and Combination +groups compared to the Control group (p < 0.001). Upon comple- +tion of the intervention of 12 weeks, significant differences +between groups (p < 0.001) continued and almost all of the Yoga +and Combination group subjects reported either stopping or +reducing the medications. There were no significant differences +between Yoga and Combination groups (Table 4). +4. Measurements +4.1. BMI and physical flexibility +There were no changes observed in the Body Mass Index +(Supplement Fig. 2A) in any of the groups. Between group analyses +[(Fig._2)TD$FIG] +0 +100 +200 +300 +400 +500 +YOGA COMBINATION CONTROL +Pre Mid Post Pre Mid Post +Pre Mid Post +IBS-SS Score, Mean ± SD +*** +§§§ +Pre Mid Post Pre Mid Post +Pre Mid Post +IBS-SS Score, Mean ± SD +*** +§§§ +*** +§§§ +*** +§§§ +*** +§§§ +WAIT-LIST +Fig. 2. Changes in IBS-SSS in IBS patients enrolled in the randomized controlled trial of Yoga Therapy. Comparison of IBS-SSS at Week 6 (Mid-intervention) and Week 12 (Post- +intervention) to Week 0 (Pre-intervention). Data were analyzed using Repeated Measures of ANOVA followed by Post hoc analysis with Bonferroni [306_TD$DIF]correction. *: Represents +mean change Within groups when compared to Week 0; ***p < 0.001; x: Represents Between group differences when compared to Control group; xxxp < 0.001. +V. Kavuri et al. / European Journal of Integrative Medicine 7 (2015) 595–608 +601 +showed no differences between Yoga and Combination groups in [291_TD$DIF] +physical flexibility. There was a significant difference between +Yoga and [251_TD$DIF]Wait-list Control groups in the hip-trunk flexibility, +(p < 0.001), right (p < 0.05) and left shoulder flexibility (p < 0.05) at +Week 12. When Combination and [251_TD$DIF]Wait-list Control groups were +compared, there were significant differences in the trunk flexibility +(p < 0.001), right (p < 0.01), and left shoulder flexibility (p < 0.05), +at Week 12. Hip-trunk flexibility (Supplement Fig. 2B), [292_TD$DIF]and right +and left shoulder flexibility showed significant improvements in +the Yoga and Combination groups at Week 6 and at Week 12 +(p < 0.001) when compared to Week 0 (Supplement Fig. 2C1 and +C2). There were no improvements in the physical flexibility of the [293_TD$DIF] +Wait-list Control group. +[(Fig._3)TD$FIG] +(A) +(B) +(C) +(D) +(E) +*** +§§§ +*** +§§§ +*** +§§§ +*** +§§§ +0 +20 +40 +60 +80 +100 +Yoga Group +Combinaon Group +Wait-list Group +Pain Severity (Mean ± SD) +Pre +Mid +Post +*** +§§§ +*** +§§§ +*** +§§§ +*** +§§§ +0 +20 +40 +60 +80 +100 +120 +Yoga Group +Combinaon Group +Wait-list Group +Duraon of Pain (Mean ± SD) +Pre +Mid +Post +*** +§§§ +*** +§§ +*** +§§§ +*** +§§§ +0 +20 +40 +60 +80 +100 +Yoga Group +Combinaon Group +Wait-list Group +Abdominal Distension (Mean ± SD) +Pre +Mid +Post +*** +§§§ +*** +§§§ +*** +§§§ +*** +§§§ +0 +20 +40 +60 +80 +100 +120 +Yoga Group +Combinaon Group +Wait-list Group +Bowel Sasfacon (Mean ± SD) +Pre +Mid +Post +*** +§§§ +*** +§§§ +*** +§§§ +*** +§§§ +0 +20 +40 +60 +80 +100 +Yoga Group +Combinaon Group +Wait-list Group +Interference with Life (Mean ± SD) +Pre +Mid +Post +Fig. 3. Changes in five sub-scales of IBS-SS in IBS patients enrolled in the randomized controlled trial of Yoga Therapy. (A) Pain Severity, (B)Duration of Pain, (C)Abdominal +distension, (D)Bowel Satisfaction and (E) Interference with life at Week 6 (Mid-intervention) and Week 12 (Post-intervention) from Week 0 (Pre-intervention). Data were +analyzed using Repeated Measures of ANOVA followed by Post hoc analysis with Bonferroni [306_TD$DIF]correction. *: Represents mean change Within groups when compared to Week 0; +***p < 0.001; x: Represents Between group differences when compared to Control group; xxp < 0.01; xxxp < 0.001. +602 +V. Kavuri et al. / European Journal of Integrative Medicine 7 (2015) 595–608 +5. Autonomic function tests +5.1. Sympathetic reactivity tasks +In the sympathetic reactivity [31_TD$DIF]tasks, there were no changes +within the group or between the groups in the diastolic blood +pressure (measured in handgrip task), heart rate and blood +pressure (measured in mental arithmetic task). However, handgrip +strength increased significantly within Yoga and Combination +groups at Week 12 (p < 0.001) when compared to Week 0, but there +were no significant differences observed between the three groups +(Supplement Fig. 3A). +Significant improvements in speed (measured by number of +attempted responses) and accuracy (measured by number of +correct responses) were observed at Week 12 in Yoga (p < 0.05) and +in Combination groups (p < 0.001). There were no differences +observed between groups (Supplement Fig. 3B). +5.2. Parasympathetic reactivity tasks +In the parasympathetic reactivity [32_TD$DIF]task of deep breathing, +(Supplement Fig. 4 A1–A4), there were no changes or differences +within or between groups in the time domain of heart rate +variability of deep breathing. In the frequency domain of heart rate +variability, there was no difference between Yoga and [297_TD$DIF]Wait-list +Control groups, but there were significant differences between +Combination and [251_TD$DIF]Wait-list Control groups at Week 12, in LF +(p < 0.05), HF (p < 0.01) and LF/HF ratio (p < 0.01). Combination +group showed decreased LF (p < 0.001), increased HF (p < 0.001) +and [3_TD$DIF]increased LF/HF ratio (p < 0.01) at Week 12 when compared to +Week 0. +In the supine to upright posture (30–15 ratio), there were no +differences between the three groups at the end of intervention. +There were no changes within Combination group when compared +to Week 0. However, in the Yoga group, there were significant +improvements in the parasympathetic dominance at Week 6 +(p < 0.01) and at Week 12 (p < 0.01) when compared to Week 0 +(Supplement Fig. 4B). +[34_TD$DIF]6. Intention-to-treat analysis +All randomized patients (97, Yoga = 33; Combination = 33; [296_TD$DIF]Wait- +list Control = 31) were included in this analysis. There were 19 +dropouts who attended the baseline measurements and 5 of them +also attended the mid-intervention (Week 6) appraisal. The +missing data were analyzed with multiple imputation method. +The values below represent pooled means  S.D. [min, max values]. +The significant changes found in per-protocol analysis were also +found in the intention-to-treat analysis. There was a significant +difference in the improvement in the IBS-SS score between Yoga +and [297_TD$DIF]Wait-list Control group at Week 6 (p < 0.001) and at Week 12 +(p < 0.001); and Combination and [251_TD$DIF]Wait-list Control groups (p +< 0.001) at both time points. There were no differences between +Yoga group and Combination group (p = Not Significant). The Yoga +group changed from 321.73  62.71 [181, [35_TD$DIF]445] at Week 0, to +81.23  51.89 [0,199] at Week 12 (p < 0.001). The Combination +group changed from 334.27  72.63 [202, [36_TD$DIF]485] at Week 0 to +111.78  65.15 [0, 277] at Week 12 (p < 0.001). Control group +changed +from +303.81 70.87 +[171, +433] +at +Week +0 +to +305.64  58.91 [177, 430] at Week 12 (p = Not significant). There +was a significant difference between Intervention groups and +Control group at both time points of mid-intervention and post- +intervention (p < 0.001) in the quality of life assessment. Quality of +Life improved in Yoga group from 98.06  26.94 [44, [37_TD$DIF]149] at Week 0 +to 154.81 11.65 [117, [38_TD$DIF]170] at Week 12 (p < 0.001). Combination +group showed an increased QOL from 95.82  28.91 [39_TD$DIF][44,149] at +Week 0 to 146.32  20.36 [95, 170] [340_TD$DIF]at Week 12 (p < 0.001). In +contrast, +Control group +did +not improve, +it +changed +from +98.35  25.41 [53, 154] [341_TD$DIF]at Week 0 to 98.55  24.09 [42, 149] [342_TD$DIF]at +Week 12 (p = Not Significant). Similar trends of between group +differences were observed in all the assessments. In autonomic +function tasks, there were no differences observed between [343_TD$DIF]the +Yoga, Combination and [34_TD$DIF]Wait-list Control groups. +6.1. Responder analysis +78 patients were included in the responder analysis. In the +assessment of IBS-SSS, 65% were responders (50 point improve- +ment) at Week 6, and 73% at Week 12. The intervention groups +[(Fig._4)TD$FIG] +0 +50 +100 +150 +200 +Pre Mid Post +Pre Mid Post +Pre Mid Post +YOGA COMBINATION CONTROL +IBS-QOL Score, Mean ± SD +*** +§§§ +*** +§§§ +*** +§§§ +*** +§§§ +WAIT-LIST +Fig. 4. Changes in IBS-QOL in IBS patients enrolled in the randomized controlled trial of Yoga Therapy. Comparison of IBS-QOL at Week 6 (Mid-intervention) and Week 12 +(Post-intervention) to Week 0 (Pre-intervention). Data were analyzed using Repeated Measures of ANOVA followed by Post hoc analysis with Bonferroni [306_TD$DIF]correction. *: +Represents mean change Within groups when compared to Week 0; ***p < 0.001; x: Represents Between group differences when compared to Control group; xxxp < 0.001. +V. Kavuri et al. / European Journal of Integrative Medicine 7 (2015) 595–608 +603 +[(Fig._5)TD$FIG] +*** +§§§ +*** +§§§ +*** +§§§ +*** +§§§ +10 +15 +20 +25 +30 +35 +40 +Yoga Group +Combinaon Group +Wait-list Group +Interference with Acvity +(Mean ± SD) +Pre +Mid +Post +(A) +(B) +(C) +(D) +(E) +(F) +*** +§§§ +*** +§§§ +*** +§§§ +*** +§§§ +15 +20 +25 +30 +35 +40 +45 +Yoga Group +Combinaon Group +Wait-list Group +Dysphoria (Mean ± SD) +Pre +Mid +Post +*** +§§§ +*** +§§§ +*** +§§§ +*** +§§§ +0 +5 +10 +15 +20 +25 +Yoga Group +Combinaon Group +Wait-list Group +Body Image (Mean ± SD) +Pre +Mid +Post +*** +§ +*** +*** +§§§ +*** +§§§ +0 +5 +10 +15 +Yoga Group +Combinaon Group +Wait-list Group +Food Avoidance (Mean ± SD) +Pre +Mid +Post +** +§ +*** +§§§ +** +§§§ +0 +2 +4 +6 +8 +10 +12 +Yoga Group +Combinaon Group +Wait-list Group +Sexual (Mean ± SD) +Pre +Mid +Post +§§ +*** +§§§ +*** +§§§ +*** +§§§ +*** +§§§ +0 +2 +4 +6 +8 +10 +12 +14 +16 +18 +Yoga Group +Combinaon Group +Wait-list Group +Health Worry (Mean ± SD) +Pre +Mid +Post +(G) +(H) +*** +§ +*** +§§ +*** +§§§ +*** +§§§ +0 +5 +10 +15 +20 +25 +Yoga Group +Combinaon Group +Wait-list Group +Social Reacon (Mean ± SD) +Pre +Mid +Post +*** +§§§ +*** +§§§ +*** +§§§ +*** +§§§ +5 +7 +9 +11 +13 +15 +17 +Yoga Group +Combinaon Group +Wait-list Group +Relaonships (Mean ± SD) +Pre +Mid +Post +Fig. 5. Changes in eight dimensions of IBS-QOL in IBS patients enrolled in the randomized controlled trial of Yoga Therapy. (A) Dysphoria, (B) [307_TD$DIF]Interference with Activity, (C) +Body Image, (D) [308_TD$DIF]Health Worry, (E) Food Avoidance, (F) Sexual Relations, (G) Social Reaction, and (H) Relationships at Week 6 (Mid-intervention) and Week 12 (Post- +intervention) from Week 0 (Pre-intervention). Data were analyzed using Repeated Measures of ANOVA followed by Post hoc analysis with Bonferroni [306_TD$DIF]correction. *: Represents +mean change within groups when compared to Week 0; **p < 0.01; ***p < 0.001; x: Represents Between group differences when compared to Control group; xp < 0.05; +xxp < 0.01; xxxp < 0.001. +604 +V. Kavuri et al. / European Journal of Integrative Medicine 7 (2015) 595–608 +[(Fig._6)TD$FIG] +Fig. 6. Changes in secondary assessments in IBS patients enrolled in the randomized controlled trial of Yoga Therapy. (A) HADS (anxiety and depression); (B)Autonomic +Symptom Score; and (C) IBS-GAI at Week 6 (Mid-intervention) and Week 12 (Post-intervention) from Week 0 (Pre-intervention). Data were analyzed using Repeated +Measures of ANOVA followed by Post hoc analysis with Bonferroni [306_TD$DIF]correction. *: Represents mean change Within groups when compared to Week 0; ***p < 0.001; x: +Represents between group differences when compared to Control group; xp < 0.05; xxp < 0.01; xxxp < 0.001. +V. Kavuri et al. / European Journal of Integrative Medicine 7 (2015) 595–608 +605 +(n = 51) had 94% responders at Week 6 and 100% at Week 12. The +Wait-list Control group had 22% responders at Week 6 and at Week +12. Baseline IBS-SSS score for all patients was (317.75 70.29). +There was a significant improvement in the responders of IBS-SSS +from Week 6 (175.22 75.38), to Week 12 (117.82  82.82; +p < 0.001). There were no changes observed in non-responders +at the two time points. +In IBS-QOL, 47% were responders (14% improvement) at Week +6, and 64% at Week 12. The intervention groups (n = 51) had 64% +responders at Week 6, and 92% at Week 12. The Wait-list Control +group had 15% and 11% responders at Week 6 and Week 12, +respectively. +Baseline +IBS-QOL +score +for +all +patients +was +(98.68  28.08). A significant change was observed in the quality +of life of responders from Week 6 (134.27 19.25) to Week 12 +(149.02 18.74; p < 0.001). There were no changes observed in the +non-responders at both time points. +[345_TD$DIF]6.2. Adverse events +Participants were encouraged to contact study investigators/ +staff regarding any potential problems/concerns. Three patients, +two in Yoga group and one in Combination group had complained +of low back pain that was aggravated. The instructors took special +care in monitoring and suggesting certain modified practices for +these three patients. All of them reported being relieved of back +pain within a week and completed the program. These complaints +were not recorded as adverse events. There were other reported +adverse events such as flu, cataract surgery, and other diagnoses, +which prompted the patients to discontinue the study. These +events were self-limited and deemed by the investigators and the +data safety monitoring board to not be serious. Death of a Wait[30_TD$DIF]-list +control group patient was also reported, 4 weeks after his baseline +measurements, due to massive cardiac arrest and happened at +home while in sleep. +[346_TD$DIF]7. Discussion +In the present study, a 12 week intervention of RYM showed +significant decreases in the severity of IBS symptoms, improved [347_TD$DIF] +QOL, and lowered Anxiety, Depression, and Autonomic symptom +scores in both Yoga and Combination groups. Also, significant +improvements were observed in physical flexibility and Medicine +and Supplement Use in the intervention groups when compared to +Wait-list Control group (results of the RYM intervention for the +Wait-list Control group are reported in Phase 2, page—this issue). +There was a reduction in the sympathetic dominance in the +Combination group when compared to Yoga and Control groups. +Similarly, changes in all of the five IBS-SS sub-scales and eight +dimensions of QOL were observed at Week 6 and improvements +continued at Week 12 suggesting that all components of RYM— +postures, regulated breathing, and meditation are a superior +alternative than just meditation [26–28] or postures alone [22,23]. +It is recommended that adults engage in moderate physical activity +of 20–60 min a day for 3–5 days of the week, to promote/maintain +health [42,43]. Usual range of dropouts in any physical exercise +intervention trials is 25–50% and adherence rates of about 66% +[44]. RYM with about 22% attrition (24% in Yoga and 21% in +Combination groups[301_TD$DIF]) mainly owing to time constraints and family +issues and adherence of about 90% could be proposed as an +effective intervention. +Our results of IBI-GAI and bowel symptom score are parallel to +an earlier report involving another Yoga strategy on adolescents +and +young +adults +[24]. +The +autonomic +symptom +score +is +significantly improved than that reported in another Yoga study +carried out on IBS adult male patients [25]. When compared to +earlier reports on Meditation for IBS (that measured IBS-SSS, IBS- +QOL, HADS), RYM intervention exhibited significant improvements +in all three assessments at Week 6 that continued to the end of +study period [26,27]. +Our study concurs with the conclusion of a review by Ross and +Thomas, that Yoga may be as effective as or better than exercise in +improving a variety of health related outcome measures [45]. +Johannesson and co-workers investigated 12 weeks of physical +activity as an intervention for IBS patients, and reported a +reduction of 51 points in IBS-SSS, significant improvements in a +few dimensions of IBS-QOL, and no improvement in HADS and BMI +[43]. Results of our study were significantly higher (120 point +reduction in IBS-SSS; a 23% increase in IBS-QOL) in all of the above +assessments, except for BMI which was not impacted by 12 weeks +of RYM. In the present study, about 60% of the patients in both Yoga +and Combination groups have reported of either no headaches +(part of autonomic symptom score) or less frequent and less severe +episodes which are in line with the observation by John et al. [46]. +The results of lowered/[302_TD$DIF]cessation of Medication and Supplement +Use by Yoga and Combination groups, are in concurrence with a +report of Yoga for treatment of low back pain [36]. +The +significant +improvements +observed +in +the +handgrip +strength of the present study are comparable to another study +[47]. In the mental arithmetic task, both Yoga and Combination +groups had elevated levels of speed and accuracy, and are +consistent with the results of an investigation by Field et al. +[48]. In a 15-week Yoga study, Hagins et al. found that the heart +rate and blood pressure are unchanged during the mental +arithmetic task, and our study observed similar statistically +non-significant trend [49]. +Several studies have concluded that there is an autonomic +imbalance toward sympathetic dominance and vagal withdrawal +in IBS patients [9,50,51]. In the present study, the parasympathetic +dominance increased, during deep breathing (Combination group) +and the orthostatic test of 30:15 (Yoga group), suggesting that Yoga +Table 4 +Comparison of changes in IBS Medication and Supplement Usage in the Yoga, Combination and Control groups at Week 6 and Week 12 assessments. +Assessment +Outcome +Groups +P-Value +Yoga +Combination +[250_TD$DIF]Wait-list Control +Week 6 +(mid-intervention) +Success +19 +20 +4 +*** xxx +Failure +0 +1 +18 +No medication used +6 +5 +5 +Week 12 +(post-intervention) +Success +19 +20 +7 +*** xxx +Failure +0 +1 +15 +No medication used +6 +5 +5 +Success—stopped or decreased medication use; failure—no change or increased medication use; no medication used: was not using any medication at baseline. +Data were analyzed using McNemar’s test. +*: Represents significant differences between Yoga and Control groups; ***p < 0.001; x: represents significant differences between Combination and [251_TD$DIF]Wait-list Control groups; +xxxp < 0.001. +606 +V. Kavuri et al. / European Journal of Integrative Medicine 7 (2015) 595–608 +intervention could have improved the autonomic imbalance in IBS +patients. +Three groups and three measurements were designed in this +randomized trial to distinguish between different intervention +groups and [297_TD$DIF]Wait-list Control group; and optimal duration of +intervention. In the subjective assessments, Yoga group fared +better than Combination group. In the objective assessments, both +Yoga and Combination groups showed increased parasympathetic +tone. The results observed at Week 6 of RYM intervention, showed +favorable changes in all symptoms associated with IBS, but the +autonomic system changes were observed mostly at Week 12. This +could imply that 12 weeks of RYM, three times a week, would be +optimal intervention duration for IBS. The subjects in the [293_TD$DIF]Wait-list +Control group showed no changes in any of the primary or +secondary variables from Week 0 to Week 12. +Our study presented the first one hour RYM as a treatment +modality for IBS in adults that included both genders and all +subgroups of IBS, with predominant women IBS sufferers. The +patients reported improvements in their IBS condition, and +developed group support in the Yoga sessions. Almost all patients +reiterated that the Yoga program was highly enjoyable and +benefited their lives. About 80% of the patients self-reported that +they had better energy levels, and better sleep, associating with +Yoga sessions (Supplement Table 2). +Limitations of the present study include the inability of blinding +the subjects which was not possible due to the nature of the +intervention, and [348_TD$DIF]the lack of an active control group. With +adequate funding, gastric motility tests could be undertaken. IBS +subgroups (IBS-C, D or M) were not assessed separately as the +numbers were too small in each group. Future studies could +investigate the benefits of RYM on each subgroup of IBS separately. +Due to inherent challenge with adherence to special dietary +guidelines (especially in the expected majority of study partic- +ipants), we did not emphasize [349_TD$DIF]diet. However, a combination of +RYM and diet; with a detailed Medicine and Supplement Use and +the safety of RYM when compared to other intervention also could +be explored. Large multicenter clinical trials may be conducted in +future to explore the benefits of RYM in IBS sufferers from various +social backgrounds. +In conclusion, RYM could be a valuable, effective and a viable +treatment option for IBS. With RYM intervention, both Yoga and +Combination groups have shown similar improvements in all of +the assessments. It is worth noting that Combination group had +voluntarily reduced their Medicine and Supplement Use. A Yoga +module with precise number of rounds and duration of each +practice was presented. We believe the given module would allow +other researchers to replicate the study. The group setting could +have facilitated group dynamics and support amongst the patients +motivating them to adhere to the program (90% attendance). RYM +was found to be a safe intervention without any major adverse +events associated with the intervention. The overall outcome of +this study suggests that supervised Yoga sessions could be a better +option to motivate the participants, as well as to monitor the +patients and prevent any injuries. RYM could be recommended to +IBS sufferers without prior exposure to Yoga, since our sample size +consisted largely of Hispanic population who were naïve to Yoga. +Conflict of interest +The authors have declared that no conflict of interest exists. +Funding +Vivekananda Yoga Research Foundation (VYRF aka VYASA-LA), +Norwalk, CA, USA. +Study approval +A signed informed consent was obtained from all eligible +patients willing to enroll after a detailed explanation of the study. +The study protocol was approved by the Institutional Review Board +of White Memorial Medical Center, Los Angeles, USA, 20120012. +The clinical trial was registered with ISRCTN, 42102754. As the +study is being part of Ph.D. thesis, the protocol was also approved +by +the +Institutional +Ethics +Committee +of +SVYASA +(Swami +Vivekananda Yoga University, Bangalore, India) IEC-SVYASA-010- +2011. +Specific author’s contributions +All research [350_TD$DIF]was done by the authors. Vijaya Kavuri participated +in the planning of the clinical trial, contributed in designing the +Yoga module, carried out the study, collected and analyzed the +data, and drafted and contributed to the revision of the manuscript. +Pooja Selvan contributed to the administration of assessments, +acquisition of data and editing of the manuscript. Ariel Malamud, +M.D., contributed to the planning and conducting of the study, and +recruiting patients for the clinical trial. Nagarathna Raghuram, M. +D., advised on the design of the Yoga module, contributed in the +planning of clinical trial protocol, and revision of the manuscript. +Senthamil R. Selvan, Ph.D. directed the study including the +planning, execution, design of the Yoga module and clinical trial, +supervising data collection and analysis, evaluating and interpret- +ing the data, and writing and critically revising the manuscript. +Financial support +This study was funded by [305_TD$DIF][246_TD$DIF]Vivekananda Yoga Research Founda- +tion (VYRF aka VYASA-LA), Norwalk, CA, USA. +Acknowledgements +The authors thank the patients who participated in the Yoga +trial, physicians and their staff who referred the patients (Dr. +Alireza Tabesh, Dr. Sandhya Gudapati, Dr. Rangarao Panguluri, Dr. +Pinal Shah, and Dr. Ibarra), Yoga teachers (Yvonne Kim, Kruthi +Gandhi, +Lalli +Venkat, +Mansukh +Kaneria, +Ana +Pimental +and +Chakrapani Kallur), Hema Raja and Jana Rajan, Preethi Selvan +and Viviana Vazquez for their assistance with data collection, Dr. +Gowri Selvan, Dr. Deepeshwar Singh, Dr. Balaram Pradhan, Dr. Judu +Ilavarasu, Dr. Raghavendra Bhat for assistance with analyzing the +data, Dr. Subbaramaiah Kavuri, Michael Jordan and R&D staff of +White Memorial Medical Center for facilitating and providing +necessary facilities for conducting this research. +Appendix A. Supplementary data +Supplementary data associated with this article can be found, in +the online version, at http://dx.doi.org/10.1016/j.eujim.2015.11.001. +References +[1] L.J. Brandt, W.D. Chey, A.E. Foxx-Orenstein, L.R. Schiller, P.S. Schoenfeld, B.M. +Spiegel, et al., An evidence-based position statement on the management of +irritable bowel syndrome, Am. J. Gastroenterol. 104 (Suppl) (2009) S1–35. +[2] M.W. Schmulson, L. Chang, Diagnostic approach to the patient with irritable +bowel syndrome, Am. J. Med. 107 (1999) 20S–26S. +[3] K.B. Holten, A. Wetherington, L. Bankston, Diagnosing the patient with +abdominal pain and altered bowel habits: is it irritable bowel syndrome? Am. +Fam. Phys. 67 (2003) 2157–2162. +[4] E.M.M. Quigley, H. Abdel-Hamid, G. Barbara, S.J. Bhatia, G. Boeckxstaens, G. De, +R. iorgio, et al., A global perspective on irritable bowel syndrome: a consensus +statement of the World Gastroenterology Organisation Summit Task Force on +irritable bowel syndrome, J. Clin. Gastroenterol. 46 (2012) 356–366. +V. Kavuri et al. / European Journal of Integrative Medicine 7 (2015) 595–608 +607 +[5] W.E. Whitehead, O. Palsson, K.R. Jones, Systematic review of the comorbidity +of irritable bowel syndrome with other disorders: what are the causes and +implications? Gastroenterology 122 (2002) 1140–1156. +[6] J.A. Cole, K.J. Rothman, H.J. Cabral, Y. Zhang, F.A. Farraye, Migraine, +fibromyalgia, and depression among people with IBS: a prevalence study, BMC +Gastroenterol. 6 (2006) 26. +[7] M. Simrén, J. Svedlund, I. Posserud, E.S. Björnsson, H. Abrahamsson, Health- +related quality of life in patients attending a gastroenterology outpatient +clinic: functional disorders versus organic diseases, Clin. Gastroenterol. +Hepatol. 4 (2006) 187–195. +[8] P.C. Konturek, T. Brzozowski, S.J. Konturek, Stress and the gut: +pathophysiology, clinical consequences, diagnostic approach and treatment +options, J Physiol Pharmacol 62 (2011) 591–599. +[9] P. Karling, H. Nyhlin, U. Wiklund, M. Sjöberg, B.O. Olofsson, P. Bjerle, Spectral +analysis of heart rate variability in patients with irritable bowel syndrome, +Scand. J. Gastroenterol. 33 (1998) 572–576. +[10] O. Punyabati, K.K. Deepak, M.P. Sharma, S.N. Dwivedi, Autonomic nervous +system reactivity in irritable bowel syndrome, Indian J. Gastroenterol. 19 +(2000) 122–125. +[11] D. Hulisz, The burden of illness of irritable bowel syndrome: current +challenges and hope for the future, J. Manage. Care Pharm.10 (2004) 299–309. +[12] NIDDK Scientists Irritable Bowel Syndrome | National Institute of Diabetes and +Digestive and Kidney Diseases (NIDDK) 2014. http://www.niddk.nih.gov/ +health-information/health-topics/digestive-diseases/ibs/Pages/facts. +[13] Y.-H.A. Shen, R. Nahas, Complementary and alternative medicine for treatment +of irritable bowel syndrome, Can. Fam. Phys. 55 (2009) 143–148. +[14] O. Grundmann, S.L. Yoon, Complementary and alternative medicines in +irritable bowel syndrome: an integrative view, World J. Gastroenterol. 20 +(2014) 346–362. +[15] S.L. Yoon, O. Grundmann, L. Koepp, L. Farrell, Management of irritable bowel +syndrome (IBS) in adults: conventional and complementary/alternative +approaches, Altern. Med. Rev. 16 (2011) 134–151. +[16] R.E. Wells, S.M. Bertisch, C. Buettner, R.S. Phillips, E.P. McCarthy, +Complementary and alternative medicine use among adults with migraines/ +severe headaches, Headache 51 (2011) 1087–1097. +[17] K.K.F. Rocha, A.M. Ribeiro, K.C.F. Rocha, M.B.C. Sousa, F.S. Albuquerque, S. +Ribeiro, et al., Improvement in physiological and psychological parameters +after 6 months of yoga practice, Conscious Cogn. 21 (2012) 843–850. +[18] C.C. Streeter, P.L. Gerbarg, R.B. Saper, D.A. Ciraulo, R.P. Brown, Effects of yoga on +the autonomic nervous system, gamma-aminobutyric-acid, and allostasis in +epilepsy, depression, and post-traumatic stress disorder, Med. Hypotheses 78 +(2012) 571–579. +[19] T. Oka, T. Tanahashi, T. Chijiwa, B. Lkhagvasuren, N. Sudo, K. Oka, Isometric +yoga improves the fatigue and pain of patients with chronic fatigue syndrome +who are resistant to conventional therapy: a randomized, controlled trial, +BioPsychoSoc. Med. 8 (2014) 27. +[20] S.D. Mist, K.A. Firestone, K.D. Jones, Complementary and alternative exercise +for fibromyalgia: a meta-analysis, J. Pain Res. 6 (2013) 247–260. +[21] P. Ducrotté, Irritable bowel syndrome: current treatment options, Presse Med. +36 (2007) 1619–1626. +[22] L. Kuttner, C.T. Chambers, J. Hardial, D.M. Israel, K. Jacobson, K. Evans, A +randomized trial of yoga for adolescents with irritable bowel syndrome, Pain +Res. Manage. 11 (2006) 217–223. +[23] M.M.M.G. Brands, H. Purperhart, J.M. Deckers-Kocken, A pilot study of yoga +treatment in children with functional abdominal pain and irritable bowel +syndrome, Complement. Ther. Med. 19 (2011) 109–114. +[24] S. Evans, K.C. Lung, L.C. Seidman, B. Sternlieb, L.K. Zeltzer, J.C.I. Tsao, Iyengar +yoga for adolescents and young adults with irritable bowel syndrome, J. +Pediatr. Gastroenterol. Nutr. 59 (2014) 244–253. +[25] I. Taneja, K.K. Deepak, G. Poojary, I.N. Acharya, R.M. Pandey, M.P. Sharma, Yogic +versus conventional treatment in diarrhea-predominant irritable bowel +syndrome: a randomized control study, Appl. Psychophysiol. Biofeedback 29 +(2004) 19–33. +[26] D.J. Kearney, K. McDermott, M. Martinez, T.L. Simpson, Association of +participation in a mindfulness programme with bowel symptoms, +gastrointestinal symptom-specific anxiety and quality of life, Aliment. +Pharmacol. Ther. 34 (2011) 363–373. +[27] S.A. Gaylord, O.S. Palsson, E.L. Garland, K.R. Faurot, R.S. Coble, J.D. Mann, et al., +Mindfulness training reduces the severity of irritable bowel syndrome in +women: results of a randomized controlled trial, Am. J. Gastroenterol. 106 +(2011) 1678–1688. +[28] K.A. Zernicke, T.S. Campbell, P.K. Blustein, T.S. Fung, J.A. Johnson, S.L. Bacon, +et al., Mindfulness-based stress reduction for the treatment of irritable bowel +syndrome symptoms: a randomized Wait-list controlled trial, Int. J. Behav. +Med. 20 (2012) 385–396. +[29] V. Kavuri, N. Raghuram, A. Malamud, S.R. Selvan, Irritable bowel syndrome: +yoga as remedial therapy, Evid.-Based Complement. Altern. Med. 2015 (2015) +1–10. +[30] E. Johannesson, G. Ringström, H. Abrahamsson, R. Sadik, Intervention to +increase physical activity in irritable bowel syndrome shows long-term +positive effects, World J. Gastroenterol. 21 (2015) 600–608. +[31] Randomization n.d. www.graphpad.com/quickcalcs/randomize/cfm. +[32] C.Y. Francis, J. Morris, P.J. Whorwell, The irritable bowel severity scoring +system: a simple method of monitoring irritable bowel syndrome and its +progress, Aliment. Pharmacol. Ther. 11 (1997) 395–402. +[33] D.L. Patrick, D.A. Drossman, I.O. Frederick, J. DiCesare, K.L. Puder, Quality of life +in persons with irritable bowel syndrome: development and validation of a +new measure, Dig. Dis. Sci. 43 (1998) 400–411. +[34] A.S. Zigmond, R.P. Snaith, The hospital anxiety and depression scale, Acta +Psychiatr. Scand. 67 (1983) 361–370. +[35] W. Atkinson, T.A. Sheldon, N. Shaath, P.J. Whorwell, Food elimination based on +IgG antibodies in irritable bowel syndrome: a randomised controlled trial, Gut +53 (2004) 1459–1464. +[36] K.A. Williams, J. Petronis, D. Smith, D. Goodrich, J. Wu, N. Ravi, et al., Effect of +Iyengar yoga therapy for chronic low back pain, Pain 115 (2005) 107–117. +[37] A. Zygmunt, J. Stanczyk, Methods of evaluation of autonomic nervous system +function, Arch. Med. Sci. 6 (2010) 11–18. +[38] A. Barlow, Effect of massage of the hamstring muscle group on performance of +the sit and reach test, Br. J. Sports Med. 38 (2004) 349–351. +[39] R.E. Rikli, C.J. Jones, Senior Fitness Test Manual, 2nd ed., Human Kinetics, +Champaign, IL, 2012. +[40] M.C.F. Passos, A.J. Lembo, L.A. Conboy, T.J. Kaptchuk, J.M. Kelly, M.T. Quilty, +et al., Adequate relief in a treatment trial with IBS patients: a prospective +assessment, Am. J. Gastroenterol. 104 (2009) 912–919. +[41] V. Lorenzo-Zúñiga, I.31, a new combination of probiotics, improves irritable +bowel syndrome-related quality of life, World J. Gastroenterol. 20 (2014) 8709. +[42] C.E. Garber, B. Blissmer, M.R. Deschenes, B.A. Franklin, M.J. Lamonte, I.-M. Lee, +et al., American College of Sports Medicine position stand. Quantity and +quality of exercise for developing and maintaining cardiorespiratory, +musculoskeletal, and neuromotor fitness in apparently healthy adults: +guidance for prescribing exercise, Med. Sci. Sports Exercise 43 (2011) 1334– +1359. +[43] E. Johannesson, M. Simrén, H. Strid, A. Bajor, R. Sadik, Physical activity +improves symptoms in irritable bowel syndrome: a randomized controlled +trial, Am. J. Gastroenterol. 106 (2011) 915–922. +[44] S.E. Linke, L.C. Gallo, G.J. Norman, Attrition and adherence rates of sustained vs. +intermittent exercise interventions, Ann. Behav. Med. 42 (2011) 197–209. +[45] A. Ross, S. Thomas, The health benefits of yoga and exercise: a review of +comparison studies, J. Altern. Complement. Med. 16 (2010) 3–12. +[46] P.J. John, N. Sharma, C.M. Sharma, A. Kankane, Effectiveness of yoga therapy in +the treatment of migraine without aura: a randomized controlled trial, +Headache 47 (2007) 654–661. +[47] M. Dash, S. Telles, Improvement in hand grip strength in normal volunteers +and rheumatoid arthritis patients following yoga training, Indian J. Physiol. +Pharmacol. 45 (2001) 355–360. +[48] T. Field, M. Diego, M. Hernandez-Reif, Tai chi/yoga effects on anxiety, heartrate, +EEG and math computations, Complement. Ther. Clin. Pract. 16 (2010) 235– +238. +[49] M. Hagins, S.C. Haden, L.A. Daly, A randomized controlled trial on the effects of +yoga on stress reactivity in 6th grade students, Evid.-Based Complement. +Altern. Med. 2013 (2013) . +[50] W.S. Waring, M. Chui, A. Japp, E.F. Nicol, M.J. Ford, Autonomic cardiovascular +responses are impaired in women with irritable bowel syndrome, J. Clin. +Gastroenterol. 38 (2004) 658–663. +[51] S. Pellissier, C. Dantzer, F. Canini, N. Mathieu, B. Bonaz, Psychological +adjustment and autonomic disturbances in inflammatory bowel diseases and +irritable bowel syndrome, Psychoneuroendocrinology 35 (2010) 653–662. +608 +V. Kavuri et al. / European Journal of Integrative Medicine 7 (2015) 595–608 diff --git "a/subfolder_0/Response to \342\200\234trataka and cognitive function\342\200\235_unlocked.txt" "b/subfolder_0/Response to \342\200\234trataka and cognitive function\342\200\235_unlocked.txt" new file mode 100644 index 0000000000000000000000000000000000000000..3ec1563ddaf3c051ec36f8ab95a327c26f4a6144 --- /dev/null +++ "b/subfolder_0/Response to \342\200\234trataka and cognitive function\342\200\235_unlocked.txt" @@ -0,0 +1,87 @@ +83 +International Journal of Yoga • Vol. 8 • Jan-Jun-2015 +Response to “trataka and cognitive function” +that the trataka procedure as used in this study is feasible, +safe and can be practiced by the elderly without worsening +their eyesight problems. +Shubhada Talwadkar, Aarti Jagannathan, Nagarathna R +Division of Yoga and Life Sciences, + +Swami Vivekananda Yoga Anusandhana Samasthana, + Bengaluru, Karnataka, India +Address for correspondence: + Dr. Aarti Jagannathan, + Swami Vivekananda Yoga Anusandhana Samasthana, + 19, Gavipuuram, KG Nagar, + +Bengaluru ‑ 560 019, Karnataka, India. + +E‑mail: jaganaarti@gmail.com +REFERENCES +1. +Tin  SS, Wiwanitkit V. Trataka and cognitive functions. Int J Yoga +2015;8:82. +2. +Talwadkar S, Jagannathan A, Raghuram N. Effect of trataka on cognitive +functions in the elderly. Int J Yoga 2014;7:96‑103. +3. +Niranjanananda SS. Gheranda Samhita‑Commentary on the Yoga Teachings +of Maharshri Gheranda. Munger: Yoga Publications Trust; 2012. +4. +Muktibodhananda S, Saraswati SS. Hatha Yoga Pradipika. Munger: Yoga +Publications Trust; 2000. +5. +Ramachandra K, Anupama N, Subbalakshmi NK, Sadashiva PM. Effect of +jyotirtrataka on intraocular pressure in normal subjects. Thai J Physiol Sci +2008;21:8‑13. +6. +Niranjanananda SS. Dharanadarshan‑Yogic, Tantric and Upanishadic Practices +of Concentration and Visualizations. 2nd ed. Munger, Bihar: Yoga Publications +Trust; 2003. +7. +Nagendra HR, Vaidehi S, Nagarathna R. Integrated approach of yoga therapy +for ophthalmic disorders. Institutional report VKYOCTAS/84/015. Bengaluru: +Vivekananda Kendra Yoga Therapy and Research Center; 1984. +Dear Sir, +We are thankful to Tin and Wiwanitkit for their observation[1] +on our article “effect of trataka on cognitive functions in +the elderly.”[2] +In response to their observation, we would like to quote +that authentic traditional texts of yoga describe the +benefits of trataka on a whole range of physiological and +cognitive functions.[3,4] Physiologically trataka relieves +various eye ailments such as eye strain and headache, +myopia, astigmatism, glaucoma[5] and even early stages +of cataract.[6] There are different methods of practicing +trataka serving different purposes. Different objects of +awareness are used in the practice of trataka, depending +on the purpose of practicing or taking condition of a +subject practicing into consideration. Certain practices +are to be done only under guidance, such as sun trataka +if not done properly can damage the retina or can lead to +other eye ailments. +The trataka procedure used in this study has been +developed and used by Swami Vivekananda Yoga +Anusandhana Samasthana for the past many years and +has found to be effective with nil adverse effects. The +procedure was thus further modified to suit elderly +individuals in our study where time of gazing at the +flame was only 10 s to begin with, which was gradually +increased to 1-2 min; there were different components +including focusing, defocusing, internal focusing, with +sufficient relaxation in between to reduce possible strain +to the eyes. Within 7  days, subjects reported having +reduced eyestrain, and no any adverse effects were noted. +Similar positive effects of trataka along with other yoga +practices have been shown to reduce visual strain in +persons with progressive myopia.[7] +Thus, the trataka practice can be modified depending on +the error of refraction. The authors would thus like to state +Access this article online +Website: +www.ijoy.org.in +Quick Response Code +DOI: +10.4103/0973-6131.146075 +Letters to Editor +[Downloaded from http://www.ijoy.org.in on Wednesday, July 27, 2016, IP: 14.139.155.82] diff --git a/subfolder_0/Role of Yoga and Its Plausible Mechanism in the Mitigation of.txt b/subfolder_0/Role of Yoga and Its Plausible Mechanism in the Mitigation of.txt new file mode 100644 index 0000000000000000000000000000000000000000..e69de29bb2d1d6434b8b29ae775ad8c2e48c5391 diff --git a/subfolder_0/Role of yoga for patients with type II diabetes mellitus A systematic review and meta-analysis.txt b/subfolder_0/Role of yoga for patients with type II diabetes mellitus A systematic review and meta-analysis.txt new file mode 100644 index 0000000000000000000000000000000000000000..f604a1852217f6dc9ddb8f7dd12b305f6edcd959 --- /dev/null +++ b/subfolder_0/Role of yoga for patients with type II diabetes mellitus A systematic review and meta-analysis.txt @@ -0,0 +1,1398 @@ +Accepted Manuscript +Title: Role of yoga for patients with type II diabetes mellitus: +A systematic review and meta-analysis +Author: Vinod Kumar Aarti Jagannathan Mariamma Philip +Arun Thulasi Praveen Angadi Nagarathna Raghuram +PII: +S0965-2299(16)30010-3 +DOI: +http://dx.doi.org/doi:10.1016/j.ctim.2016.02.001 +Reference: +YCTIM 1535 +To appear in: +Complementary Therapies in Medicine +Received date: +21-6-2015 +Revised date: +19-1-2016 +Accepted date: +2-2-2016 +Please cite this article as: Kumar Vinod, Jagannathan Aarti, Philip Mariamma, Thulasi +Arun, Angadi Praveen, Raghuram Nagarathna.Role of yoga for patients with type II +diabetes mellitus: A systematic review and meta-analysis.Complementary Therapies in +Medicine http://dx.doi.org/10.1016/j.ctim.2016.02.001 +This is a PDF file of an unedited manuscript that has been accepted for publication. +As a service to our customers we are providing this early version of the manuscript. +The manuscript will undergo copyediting, typesetting, and review of the resulting proof +before it is published in its final form. Please note that during the production process +errors may be discovered which could affect the content, and all legal disclaimers that +apply to the journal pertain. +1 + + + +TITLE PAGE + +Title: Role of yoga for patients with type II diabetes mellitus: A systematic review and meta- +analysis. + +Running Head: Yoga for type II diabetes mellitus + +Authors: +1. Dr. Vinod Kumar, MD; Swami Vivekananda Yoga Anusandhana Samsthana (SVYASA), +Bengaluru, India. Email: vinoddrvinod@gmail.com +2. Dr. Aarti Jagannathan, PhD; National Institute of Mental Health and Neurosciences +(NIMHANS), Bengaluru, India. Email: jaganaarti@gmail.com +3. Dr +Mariamma +Philip, +PhD; +NIMHANS, +Bengaluru, +India. +Email: +dr.mariammaphilip@gmail.com +4. Dr.Arun Thulasi, MD; Samatvam Healthcare Pvt Limited, Bengaluru, India. Email: +arunthulli@gmail.com +5. Dr. Praveen Angadi, MD; SVYASA, Bengaluru, India. Email: drpavi9@gmail.com +6. Dr. Nagarathna Raghuram, MD; SVYASA, Bengaluru, India. Email: +rnagaratna@gmail.com + +Name & Address of Department and Institution to which work is attributed: +Division of Yoga & Life Sciences, +Swami Vivekananda Yoga Anusandhana Samsthana (S-VYASA Deemed University) +University Campus: Prashanti Kuteeram +Vivekananda Road, Kalluballu post, Jigani, Anekal +2 + + + +Bengaluru – 560105 +Ph: 080-2263 9961/9963/9984/9995 +Corresponding Author: +Name: Dr. Aarti Jagannathan +Address: National Institute of Mental Health & Neuro Sciences (NIMHANS), Hosur Road, +Lakkasandra, Bengaluru-560029, Karnataka, India. +Phone number: +91-9448150690 +E-mail address: jaganaarti@gmail.com +Sources of Support in form of grants: Nil +Highlights: + 17 RCTs were identified in the systematic review and meta-analysis. + Meta-analysis showed yoga caused a significant reduction in FBS, PPBS and HbA1c. + Yoga is an effective complementary treatment for type II DM in short term. + Adherence to yoga, non-blood glucose assessment tools to be considered in future research +to test efficacy of yoga +Summary +To understand the role and efficacy of yoga in the management of type 2 diabetes mellitus, +this meta-analysis was conducted. Electronic data bases searched were PubMed/Medline, +ProQuest, PsycINFO, IndMED, CENTRAL, Cochrane library, CamQuest and CamBase till +December 17, 2014. Eligible outcomes were fasting blood sugar (FBS), post prandial blood +sugar (PPBS) and glycosylated haemoglobin (HBA1C). Randomized controlled trials and +controlled trials were eligible. Studies focussing only on relaxation or meditation or +multimodal intervention were not included. A total of 17 RCTs were included for review. +Data from research articles on patients, methods, interventions- control and results were +extracted. Mean and standard deviations were utilized for calculating standardized mean +difference with 95% confidence interval. Heterogeneity was assessed with the help of I2 +statistics. χ2 was used to rule out the effects of heterogeneity due to chance alone. Beneficial +3 + + + +effects of yoga as an add-on intervention to standard treatment in comparison to standard +treatment were observed for FBS [Standardized Mean Difference (SMD) -1.40, 95%CI -1.90 +to -0.90, p˂0.00001]; PPBS [SMD -0.91, 95%CI -1.34 to -0.48, p˂0.0001] as well as HBA1C +[SMD -0.64, 95%CI -0.97 to -0.30, p˂0.0002]. But risk of bias was overall high for included +studies. With this available evidence, yoga can be considered as add-on intervention for +management of diabetes. +Key words +Yoga, type II diabetes mellitus, meta-analysis. +4 + + + +Text +1. Introduction: +Type II diabetes mellitus is a multifactorial chronic metabolic disorder characterized +by persistent hyperglycemia due to improper functioning or secretion of insulin hormone from +the pancreas.1 The number of people with diabetes in the world was 387 million in 2014 and is +expected to increase to 592 million by 2035 for all forms of diabetes. According to International +Diabetes Federation, a total 65∙1 million people were suffering from type II diabetes in India +in the age group of 20 to 79 years in 2013.2 India thus has been found to have the highest +prevalence of diabetes in comparison to Chinese and Japanese subjects,3 though the highest +number of people with diabetes is considered to be still present in China.2 Management of +diabetes include control of hyperglycemia, hyperlipidemia, body weight and also long term +planning for prevention and/or early detection of complications.4 +There are several complementary and alternative treatment options which have been +used by patients with diabetes for better control of their sugar levels.5 Some of these are dietary +supplements, acupuncture, massage therapy, hydrotherapy, medicinal herbs and yoga. Yoga is +one among the six ancient Indian philosophical systems which depicts the ideal way of living +life.6 A few systematic reviews depicting the efficacy of yoga for type II diabetes have shown +promising results of this intervention on blood glucose levels, insulin sensitivity, oxidative +stress, lipid profile, anthropometric measures, pulmonary measures, nerve conduction and +quality of life.7-9 However since the publication of these reviews, a considerable number of +new studies have been published that warrant an update. Thus, the aim of this review is to +systematically evaluate and meta-analyze the available data on efficacy of yoga in improving +blood glucose parameters in people with diabetes. +2. Methods: +5 + + + +The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analysis)10 +guidelines and Cochrane collaboration11 recommendations provided the basis for reporting this +review study. +2.1. Search strategy and selection criteria +Randomized controlled trials (RCTs), and controlled trials were eligible. Studies published in +English language were considered for this meta-analysis. Studies with exercise or any other +supervised practice for control group were not included in review. Studies which had a yoga +intervention in form of asana, pranayama, meditation were considered for the review. Studies +which included only breathing practice (pranayama) or only asana were also considered. +Studies focussing only on relaxation or meditation were not included, as all but one study +focused on mindfulness as an intervention12, which the authors believed could not be +considered under the ambit of yoga (as it came from the Buddhist tradition).13 Studies with +multimodal intervention were also not included. There was no restriction regarding yoga +tradition, duration and frequency of intervention. Blood glucose levels and/or glycosylated +haemoglobin were the mandatory parameters for inclusion of study in review process and were +primary outcome measures. Type II diabetes being an asymptomatic disorder in majority of the +cases,4 symptoms of diabetes was not considered as outcome measure. Research articles were +also reviewed for adverse effects or side-effects of the intervention. +Electronic data bases which were searched for the purpose of this review were +PubMed/Medline, ProQuest, PsycINFO, IndMED, CENTRAL, Cochrane library, CamQuest +and CamBase. Papers published till Dec 17th, 2014 was considered. Reference list of all +relevant review articles and randomized controlled trials was also screened for any missing +article. The literature review was planned with search terms such as “yoga and DM”, “yoga +and diabetes”, “yoga and DM”, “yoga and diabetes mellitus”, “yoga and type 2 diabetes”, +6 + + + +“asana and type 2 diabetes mellitus”, “yoga and metabolic disorders”, “asana and DM”, +“asana and diabetes”, “asana and diabetes mellitus”, “asana and type 2 diabetes”, “asana +and type 2 diabetes mellitus”, “asana and metabolic disorders”, “ pranayama and DM”, +“pranayama and diabetes”, “pranayama and diabetes mellitus”, “pranayama and type 2 +diabetes”, “pranayama and type 2 diabetes mellitus”, “pranayama and metabolic disorders”, +“meditation and DM”, “meditation and diabetes”, “meditation and diabetes mellitus”, +“meditation and type 2 diabetes”, “meditation and type 2 diabetes mellitus”, “meditation and +metabolic disorders”, “breathing practices and DM”, “breathing practices and diabetes”, +“breathing practices and diabetes mellitus”, “breathing practices and type 2 diabetes”, +“breathing practices and type 2 diabetes mellitus”, “breathing practices and metabolic +disorders”, “breathing techniques and DM”, “breathing techniques and diabetes”, “breathing +techniques and diabetes mellitus”, “breathing techniques and type 2 diabetes”, “breathing +techniques and type 2 diabetes mellitus”, “breathing techniques and metabolic disorders”, +“Yogic practices and DM”, “Yogic practices and diabetes”, “Yogic practices and diabetes +mellitus”, “Yogic practices and type 2 diabetes”, “Yogic practices and type 2 diabetes +mellitus”, “Yogic practices and metabolic disorders”[Appendix 1]. Screening of abstracts and +final selection of article was done by two researchers independently (AJ and VK). Relevant +articles were thoroughly read by two researchers. The final decision about selection of the +articles for this review, in case of disagreement between the above two researchers was settled +with help of a third researcher (MP). As per the requirement, authors of certain studies selected +for this review were contacted for acquiring full texts of their articles/ raw data and/or for +clarifications about the results of their study. +2.2.Data extraction +7 + + + +Two researchers (AJ and VK) independently extracted data from the research articles on +patients (e.g. age, gender), methods (e.g. randomization and allocation concealment), +interventions and control intervention (e.g. yoga, duration, frequency, control), outcome +(outcome measures, and timing and frequency of outcome measures), results and status of +funding with help of pre-planned excel spreadsheet. Disagreements between the above two +researchers on data extraction were also sorted out with help of the third researcher (MP). +2.3.Assessment of Risk of Bias (ROB) +Screening for Risk of bias was done by two researchers (AJ and VK) independently with +Cochrane ROB tool for assessment of risk of bias.11 This tool rules out risk for bias at seven +levels: random sequence generation, allocation concealment, blinding of participants and +personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and +other sources of bias. Other sources of bias were assessed based on: (1) sampling procedure +used in the study (random or non-random) and (2) baseline matching of data between groups. +For all these criteria, risk of bias was assessed as low, unclear or high. Discrepancies between +the above two researchers on assignment of Risk of Bias status for each study were sorted out +with help of the third researcher (MP). +2.4.Statistical Analysis +Meta-analysis was done with the help of software Review Manager (version 5.3.4; The Nordic +Cochrane Centre, Copenhagen, Denmark). Random-effects model using inverse variance +method was followed. The outcome variables involved in this study were continuous in nature +and the standardized mean differences (SMD) with 95% confidence intervals (CIs) were +determined by division of difference of means between groups by pooled standard deviation +(SD). Wherever SDs were not available, Standard Errors (SEs) were used for calculation.11 +8 + + + +A negative SMD was indicative of the beneficial effects of yoga for diabetes. These beneficial +effects were interpreted only in terms of control in blood glucose levels. +2.5.Assessment of Heterogeneity +Heterogeneity was assessed with the help of I2 statistics. I2 of 0% to 24% was considered low; +I2 of 25% to 49% moderate; I2 of 50% to 74% substantial; and I2 of 75% to 100% was taken as +significant heterogeneity.11,14 χ2 was used to rule out the effects of heterogeneity due to chance +alone.11 +2.6.Subgroup and Sensitivity Analyses +A subgroup was identified on the basis of difference in intervention. This subgroup was having +breathing practices and/or pranayama as the only intervention. Rest of the studies included +yoga intervention in form of combination of practices such as asana, pranayama and +meditation. Standard care was the intervention for the control group in all studies. Further to +check for the strength of the significance, sensitivity analyses for the following domains of +Risk Of Bias (ROB) was conducted: selection bias (Random Sequence Generation), detection +bias (Blinding of Outcome Assessment) and attrition bias (Incomplete Outcome Data). +ROB across studies +Funnel plots were generated using RevMan 5.3.4 which were helpful in assessment of +publication bias. Symmetrical funnel plots were considered to be suggestive of low risk of +publication bias and asymmetrical suggesting high risk.11 +3. Results: +3.1.Literature results +9 + + + +The literature research revealed 106 articles after sorting out duplication. The number further +came down to 75 after removal of review papers (thirteen), unavailability of full texts (ten) and +conference proceedings/case studies/articles (eight). Total 75 full texts were reviewed. Out of +74 articles, 23 RCT were identified for final review and meta-analysis. Texts focussing on +multimodal intervention, non-RCT, and self as control trials were also excluded. Five more +trials were excluded15-19 wherin three of them, relevant data (mean and SD) were not +available,17-19 one study had no absolute control group15 and another had discrepant information +between the abstract and the main text, which was not clarified by the authors.16 Two articles +were found to be coming from one clinical trial. So, final number came down to 17 RCTs. +Flowchart of the above literature search has been depicted in Figure I. +3.2.Study Characteristics +Characteristics of the 17 RCTs included in the study are elaborated in table I. The sample size +of the participants in all 17 studies put together, ranged from 21 to 231. Age range of the +participants in all the 17 studies was 30 to 75 years with only one study targeting patients above +the age of 60 years.20 +In majority of the studies, the intervention provided to the experimental group was a mixture +of asana, pranayama, relaxation, and meditation techniques with minor variation in the +duration of practice. Three studies emphasized independently only on either pranayama or +breathing technique or focused more on breathing techniques with minor additions of asanas.21- +23 Out of these three studies, two studies followed the Sudarshan Kriya Yoga (SKY) technique +and one study used the diaphragmatic breathing intervention. Another three articles specified +Hatha Yoga as their intervention while the remaining studies did not mention any specifications +of the interventions used. Duration (days) of the yoga intervention provided in the studies +varied from 40 days to six months and the frequency of classes were slated at once to twice +10 + + + +weekly or five to seven days per week. Indian studies emphasized more on frequent supervised +practice sessions,24-26 while studies done in other countries advocated for one to two sessions +of supervised practice with home practice advice.27,28 Duration of each yoga sessions varied +from 45 minutes to 120 minutes with majority of the studies having 60-90 minutes duration of +sessions. The diaphragmatic breathing session was conducted and advised for 15-20 minutes, +twice daily.23 Similarly, Sudarshan Kriya Yoga sessions were taught for three to six days before +advising for home practice.22 +Further it was observed that of the 17 RCTs included in the study, 15 studies were from +India20-25, 29-36 one study from United Kingdom28 and one trial from Republic of Cuba.27,37 +Three of the studies, detailed clearly the RCT design used20,21,28 six of them were observed to +have used a matched controlled design for their study23,24,27,29,30,34,37 and the remaining eight +studies did not mention anything about the design. Out of the 17 studies reviewed, three +studies24,27,33,37 followed specified guidelines for diagnosis of type II diabetes, however the +method of diagnosis of the people with diabetes remained unclear for the other studies. A total +of six studies23-25,29,30,33 kept the dosage of medicines fixed for the whole duration of study +while one study clearly mentioned about the changes made to the treatment as per need and +requirement of the participants.34 Eight of the seventeen studies mentioned that patients were +on medication,20-22,26-28,32,35,37 however specific details of the medication taken were omitted; +only two studies did not mention about the medication status of the participants.31,36 +3.3.Outcome measures +It was observed that a wide variety of outcomes measures were reported in the studies along +with the common biochemical parameters used in assessment of diabetes such as fasting blood +sugar, post-prandial blood sugar, and glycosylated haemoglobin. Out of 18 articles (17 trials), +17 reported fasting blood sugar, nine reported post-prandial blood sugar levels and 13 reported +11 + + + +the glycosylated haemoglobin levels as their primary outcome parameters (Table I). As +diabetes is not generally associated with any symptoms4 hence, symptoms were not considered +for outcome measures for this study and were also not reported in majority of trials considered +for this review. None of the 17 studies reported for any adverse events or side-effects of the +yoga intervention. For these reasons, primary outcome measures considered for this review +were all biochemical parameters. +3.4.ROB in individual studies +Risk of bias for individual studies has been represented in Table II. All the studies have low +risk of bias for reporting (Selective Reporting). However, as blinding of yoga intervention is +not feasible, risk of bias for performance (Blinding of Participants & Personnel) was high in +all the studies. Risk of Bias for Selection (Allocation Concealment) and Detection (Blinding +of Outcome Assessment) was unclear for majority of studies. Nine studies had low risk of bias +for attrition. Other biases (sampling procedures and matching of baseline parameters) were also +unclear for majority of studies. Selection bias (Random Sequence Generation) was also unclear +or high for majority of the studies. +3.5.Analysis of overall effect – Blood sugar levels +The meta-analysis revealed that yoga is beneficial in control of blood sugar levels in +comparison to standard care. Beneficial effects were observed for all the three outcome +measures: Fasting blood sugar, Post-Prandial Blood Sugar and Glycosylated haemoglobin +(HbA1c, Table III). Heterogeneity was found to be high. +3.6.Subgroup analyses +Three RCTs were identified which focused on breathing intervention.21-23 On subgroup +analysis, no effect of breathing intervention as compared with the standard care was found for +12 + + + +fasting blood glucose (SMD, -0∙62; 95%CI -1∙46 to 0∙23; p=0∙15), post-prandial blood glucose +(SMD, -0∙49; 95%CI -1∙10 to 0∙12; p=0∙12) and glycosylated haemoglobin (SMD, -0∙05; 95% +CI -0∙32 to 0∙22; p=0∙71). As mentioned earlier, results were significant for all three outcome +measures when cumulative analysis was conducted. +3.7.Sensitivity analyses. +In RCTs with low risk of selection bias (Random Sequence Generation),20,21,28 three studies +were located. No significant effect of yoga in comparison to standard care was observed for all +three outcome measures. As is case of allocation concealment which is a very important source +of bias, most of the studies except one had high/unclear ROB. This could possibly imply that +the results were not clearly distinguishable from potential bias. In RCTs with low risk of +detection bias (Blinding of Outcome Assessment),27,29,37 two studies (three articles) were +located. Significant effects in yoga in comparison with standard care were observed only for +glycosylated haemoglobin (SMD: -0∙50; 95%CI -0∙82 to -0∙18; p=0∙002). In RCTs with low +risk of attrition bias (Incomplete Outcome Data),20,21,23,27-29,33,34,37 eight studies (nine articles) +were identified. Results of yoga in comparison to standard care were significant for FBS (FBS: +SMD -1.40; 95%CI -2.29 to -0.51; p=0.002) and HBA1C (HBA1C: SMD -0.57; 95%CI -1.03 +to -0.11 p=0.01) and non-significant for PPBS (PPBS: SMD -0.39, 95%CI -0.81 to 0.04; +p=0.07). + +3.8.ROB Across Studies +The funnel plots for the blood sugar levels and Glycosylated haemoglobin were asymmetrical, +indicating publication bias. + +4. Discussion: +13 + + + +In this review of 17 studies, evidence in favour of yoga as an effective complementary +treatment for patients with type II diabetes mellitus in comparison to standard care is evident, +though its robustness cannot be emphasized due to high risk of bias and possibility of +publication bias. The review also brought forth that yoga encompassed asanas, pranayama, +breathing techniques and relaxation and not just breathing intervention which independently +on sub-group analysis showed no effect as compared with the standard care on all three blood +glucose parameters. +Majority of studies included in this review were of Indian origin with an exception of +three studies. Further two, out of these three studies, came out from a single trial.27,37 One +another study was conducted with a very small sample size.28 In this context, favourable effects +of yoga on outcome parameters in the sample population could be considered as an outcome +of yoga being a part of the Indian tradition and culture leading to the ease in understanding the +intervention, leading to better performance and results. Cramer et al., (2015) have argued that +the possible reasons for the positive results in Indian trials could be that yoga interventions are +more intense in Indian trials than Non-Indian trials. In our review too it can be observed that +Indian trials have provided intervention for 6 days a week in majority of cases while trials done +outside focused on 2 days per week intervention. Difference in skills of the yoga trainer trained +and practicing in India as compared to the West also can be considered as reason for positive +results in Indian yoga studies.38 +Another aspect that needs to be taken into consideration while interpreting these results +is that in treatment of diabetes, pharmaceutical treatment is proven to have a large and +immediate effect and effects of any add on interventions like yoga are difficult to assess and +can be observed only over a long term period. In this context, it is difficult to predict if the +effect or no-effect is due to the pharmaceutical treatment or the adjunct yoga treatment. All the +studies we have reviewed in this paper also, have adopted yoga as an add-on intervention to +14 + + + +pharmacological intervention. To observe these adjunct effects, larger sample sizes need to be +taken or yoga needs to be provided as an alternative treatment to pharmaceutical treatment to +those participants with diabetes who clinically can undergo non-drug treatment (who have no +complications of diabetes or drug-naïve patients/ freshly diagnosed patients of diabetes). Only +in this scenario we can clearly state whether pharmaceutical treatment or yoga treatment had +an effect or no-effect on the blood glucose levels. Further scientist may argue, ‘Why Yoga’ and +why not other exercises such as swimming jumping etc. Or why does yoga need to be given, if +pharmaceutical treatment itself is able to provide control of blood sugar. In this context, future +randomized controlled studies could consider providing yoga as an alternative treatment to +either severe cases of diabetes who have not improved with pharmaceutical treatment, or to +mild-moderate cases of diabetes who have shown to be more sensitive to the blood glucose +changes than the severe cases.39 +Another argument is that Fasting Blood Sugar (FBS) and Post Prandial Blood Sugar (PPBS) +may not be the ideal outcome parameters to test the effect of yoga on blood glucose levels, as +both these parameters are highly sensitive to pharmaceutical intake and stabilize with +medications. Further with variations in blood glucose between laboratories and within +individuals over a period of time, HbA1c or diabetes complications (such as neuropathy, +nephropathy) may be more reliable outcome parameters of blood glucose levels. None of the +studies reviewed reported for adverse effects or side-effects associated with the intervention, +and hence it was not possible to comment on the safety of the yoga intervention, though the +literature proposes that yoga intervention per se is considered safe.40-45 Further, as diabetes is +not generally associated with any symptoms,4 it was not reported in majority of trials +considered for this review and hence was also not considered as an outcome measure for this +study. Though a number of secondary parameters such as lipid profile, anthropometric +measures, cardiac autonomic functions, oxidative stress, cognitive brain functions, quality of +15 + + + +life etc. were considered in the 17 studies reviewed, the authors believe that they are justified +in not considering them in this review; as they were indicative of only management of +complications arising out of diabetes and not as a direct measures of management of diabetes. +As observed in the prior systematic reviews, the lack of methodological rigour +employed in yoga related RCT’s is well observed in this review, through the lens of Risk of +Bias (ROB). Overall ROB for of the trials included for the review was unclear or high. +Selection bias for majority of studies was also either unclear or high. There was just one study +with low ROB for allocation concealment. This poor methodological quality where smaller +studies were possibly conducted and analyzed with less methodological rigor than larger +studies, and trials of lower quality also tended to show larger intervention effects, possibly was +one of the reasons for large heterogeneity. This is in-spite of the fact that often only statistically +significant results suggesting a beneficial effect are more likely to be published than non- +significant results indicating the possibility of publication bias in yoga studies conducted in +India.38 +4.1.Strengths & Limitations +This meta-analysis paper depicts the efficacy of yoga as a complementary intervention +on blood glucose parameters in the management of type II diabetes. The inclusion of subgroup +and sensitivity analyses further adds to the strength of this review. Language restriction for +literature search, publication bias and post hoc definition of primary outcome measures are +however some of the limitations of the study. Almost all effects were not robust against the +risk of bias. Publication bias, the poor methodology of RCTs, small sample sizes, and small +duration of the studies (none more than six months) does not enable us to conclusive state that +short term effects of yoga interventions can be generalized to the long term management of +type II diabetes mellitus and can only be considered preliminary. +16 + + + +Future RCTs should make sure that the methodology followed is robust with ample +sample size. Long term follow-up and yoga adherence over the period of the study can further +strengthen the evidence in favour of yoga. +5. Conclusion +Yoga can be considered as an effective complementary treatment for patients with type II +diabetes mellitus for short term. However, to advocate and establish yoga as effective +intervention for management of diabetes in long term, further methodological rigorous studies +considering aspects such as adherence to yoga, non-blood glucose tools of data collection with +yoga as an alternative intervention to pharmacology need to be undertaken. + +17 + + + +Acknowledgements +VK acquired and analysed data, wrote manuscript; AJ designed study, analysed data, drafted +and edited manuscript; MP designed study, analysed data and reviewed manuscript; AT & PA +helped in literature search and acquisition of data; NR conceived idea, designed study, and +edited manuscript. +AJ is also guarantor for this work and, as such, had full access to all the data in the study and +takes responsibility for integrity of data and accuracy of data analysis and also that no important +aspects of the study have been omitted. +The authors are thankful to Dr DK Subbakrishna, Professor and Head of Department of +Biostatistics and Dr Jagadisha Thirthalli, Additional Professor, Department of Psychiatry +National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru for their +expert inputs for the study. +Declaration of conflicting interests & funding acknowledgement: +The authors declare that there is no conflict of interest. This project was not funded by any +institute or private or government body. + +18 + + + +1. Tripathy B, Chandalia H. Definition, diagnosis and classification. In: RSSDI textbook of +diabetes in India.; 2008:137–160. +2. Anon. Diabetes: Facts and Figures. IDF Diabetes Atlas Sixth Ed. Updat. Int. Diabetes Fed. +2014. Available at: http://www.idf.org/worlddiabetesday/toolkit/gp/facts-figures. +3. Qiao Q, Hu G, Tuomilehto J, et al. Age- and sex-specific prevalence of diabetes and +impaired glucose regulation in 11 Asian cohorts. Diabetes Care. 2003;26(6):1770–80. +Available at: http://www.ncbi.nlm.nih.gov/pubmed/12766108. Accessed August 24, 2014. +4. Fauci A, Braunwald E, Kasper D, et al. Harrison’s Priciples of Internal Medicine. 17th +Editi. Mcgraw-hill; 2008. +5. Pandey A, Tripathi P, Pandey R. Alternative therapies useful in the management of +diabetes : A systematic review. 2011;3(4):504–512. +6. Sengupta P. Health Impacts of Yoga and Pranayama: A State-of-the-Art Review. Int. J. +Prev. Med. 2012;3(7):444–58. Available at: +http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3415184&tool=pmcentrez&rende +rtype=abstract. Accessed August 24, 2014. +7. Kumar SP. Biopsychosocial Effects of Yoga in Patients with Diabetes : A Focused +Review. 2011;4(1):5–11. +8. Alexander GK, Taylor AG, Innes KE, Kulbok P, Selfe TK. NIH Public Access. +2008;31(3):228–239. +9. Aljasir B, Bryson M, Al-Shehri B. Yoga Practice for the Management of Type II Diabetes +Mellitus in Adults: A systematic review. Evid. Based. Complement. Alternat. Med. +2010;7(4):399–408. Available at: +http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2892348&tool=pmcentrez&rende +rtype=abstract. Accessed August 13, 2014. +10. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic +reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and +elaboration. BMJ. 2009;339:b2700. Available at: +http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2714672&tool=pmcentrez&rende +rtype=abstract. Accessed July 10, 2014. +11. Higgins J, Green S. Cochrane Handbook for Systematic Reviews of Interventions Higgins +J, Green S, eds. Available at: www.cochrane-handbook.org. +12. Maras ML, Rinke WJ, Stephens CR, Boehm TM, Maras ML. Effect of Meditation on +Insulin Dependent Diabetes Mellitus. 1984. +13. Kirmayer L. Mindfulness in cultural context . 2015;52(4):2015. +14. Higgins J, Thompson S, Deeks J, Altman D. Measuring Inconcistency in Meta-analyses. +BMJ. 2003;327:557–560. +19 + + + +15. Nagarathna R, Usharani M, Rao R, et al. Efficacy of yoga based life style modification +program on medication score and lipid profile in type 2 diabetes - A randomized control +study. Int. J. Diabetes Dev. Ctries. 2012;32(3):122–130. +16. Malhotra V, Singh S, Sharma S, et al. The Status Of NIDDM Patients After Yoga +Asanas: Assessment Of Important Parameters. J. Clin. Diagnostic Res. 2010;(4):2652–2667. +17. Rast D, Hojjati Z, Shabani R. The effect of yoga training on lipid profile and blood +glucose in type II diabetic females. Ann. Biol. Res. 2013;4(8):128–133. +18. Jyotsna VP, Joshi A, Ambekar S, et al. Comprehensive yogic breathing program +improves quality of life in patients with diabetes. Indian J. Endocrinol. Metab. +2012;16(3):423–8. Available at: +http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3354853&tool=pmcentrez&rende +rtype=abstract. Accessed July 29, 2014. +19. Skoro-Kondza L, Tai SS, Gadelrab R, Drincevic D, Greenhalgh T. Community based +yoga classes for type 2 diabetes: an exploratory randomised controlled trial. BMC Health +Serv. Res. 2009;9(1410):33. Available at: +http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2652459&tool=pmcentrez&rende +rtype=abstract. Accessed July 15, 2014. +20. Vaishali K, Kumar KV, Adhikari P, UnniKrishnan B. Effects of Yoga-Based Program on +Glycosylated Hemoglobin Level Serum Lipid Profile in Community Dwelling Elderly +Subjects with Chronic Type 2 Diabetes Mellitus–A Randomized Controlled Trial. Phys. +Occup. Ther. Geriatr. 2012;30(1):22–30. Available at: +http://informahealthcare.com/doi/abs/10.3109/02703181.2012.656835. Accessed July 15, +2014. +21. Jyotsna VP, Ambekar S, Sreenivas V. Cardiac autonomic function in patients with +diabetes improves with practice of comprehensive yogic breathing program Abstract +Background : Materials and Methods : Results : Conclusion : :5–12. +22. Agte V V, Tarwadi K. Sudarshan Kriya Yoga for Treating Type 2 Diabetes A Preliminary +Study. :220–222. +23. Hegde S V, Adhikari P, Subbalakshmi NK, et al. Diaphragmatic breathing exercise as a +therapeutic intervention for control of oxidative stress in type 2 diabetes mellitus. +Complement. Ther. Clin. Pract. 2012;18(3):151–3. Available at: +http://www.ncbi.nlm.nih.gov/pubmed/22789789. Accessed July 29, 2014. +24. Kyizom T, Singh S, Singh KP, Tandon OP, Kumar R. Effect of pranayama & yoga-asana +on cognitive brain functions in type 2 diabetes-P3 event related evoked potential (ERP). +Indian J. Med. Res. 2010;131(May):636–40. Available at: +http://www.ncbi.nlm.nih.gov/pubmed/20516534. +25. Balaji PA, Diab PG, Nlsiu P, Bnys SRV, Ali SS. Effects of yoga - pranayama practices +on metabolic parameters and anthropometry in type 2 diabetes. Int. Multidiscip. Res. J. +2011;1(10):1–4. +20 + + + +26. Bindra M, Nair S, Darotiya S. Influence of pranayamas and yoga-asanas on blood +glucose, lipid profile, and HBA1C in type 2 diabetes. Int. J. Pharma Bio Sci. 2013;4(1):169– +172. +27. Gordon LA, Morrison EY, McGrowder DA, et al. Effect of exercise therapy on lipid +profile and oxidative stress indicators in patients with type 2 diabetes. BMC Complement. +Altern. Med. 2008;8:21. Available at: +http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2390515&tool=pmcentrez&rende +rtype=abstract. Accessed July 29, 2014. +28. Monroe R, Power J, Comer A, Nagarathna R, Dona PD. Yoga Therapy for NIDDM; a +controlled trial. J. Complement. Med. Res. 1992;6(2):66–68. +29. Beena RK, Sreekumaran E. Yogic practice and diabetes mellitus in geriatric patients. Int. +J. Yoga. 2013;6(1):47–54. +30. Hegde S V, Adhikari P, Kotian S, et al. Effect of 3-month yoga on oxidative stress in type +2 diabetes with or without complications- A controlled clinical trial. Diabetes Care. +2011;34:2208–2210. +31. Kumar K. A Study on the Effect of Yogic intervention on serum glucose level on +Diabetics. Int. J. Yoga Allied Sci. 2012;1(1):68–72. +32. Pardasany A, Shenoy S, Sandhu JS. Comparing the efficacy of tai chi chuan and hatha +yoga in type 2 diabetes mellitus patients on parameters of blood glucose control and lipid +metabolism. Indian J. Physiother. Occup. Ther. 2010;4(3):11–16. +33. Shantakumari N, Sequeira S, Eldeeb R. Effect of a yoga intervention on hypertensive +diabetic patients. 2012;01(02):60–63. +34. Aggarwal RP, Aradhana, Hussain S, et al. Influence of yogic treatment on quality of life +outcomes, glycemic control and risk factors in diabetes mellitus. Int. J. Diabetes Dev. Ctries. +2003;23:130–134. +35. Mahapure HH, Shete SU, Bera TK. Effect of yogic exercise on super oxide dismutase +levels in diabetics. Int. J. Yoga. 2008;1(1):21–6. Available at: +http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3144605&tool=pmcentrez&rende +rtype=abstract. Accessed July 29, 2014. +36. Yadav S. Effect of 12-week yogic therapy on diabetic patients. Int. J. Phys. Educ. Sport. +Sci. 2013;8:92–100. +37. Gordon L, Morrison EY, Mcgrowder DA, et al. Changes in clinical and metabolic +parameters after exercise therapy in patients with type 2 diabetes. 2008. +38. Cramer H, Lauche R, Langhorst J, Dobos G. Are Indian yoga trials more likely to be +positive than those from other countries ? A systematic review of randomized controlled +trials. Contemp. Clin. Trials. 2015;41:269–272. Available at: +http://dx.doi.org/10.1016/j.cct.2015.02.005. +21 + + + +39. Thulasi A, Kumar V, Jagannathan A, et al. Development, validation and feasibility teting +of yoga program for patients with type 2 diabetes mellitus. BMC Complement. Altern. Med. +40. Cramer H, Ward L, Saper R, et al. The Safety of Yoga : A Systematic Review and Meta- +Analysis of Randomized Controlled Trials . 2015;182(4):2015. +41. Cramer H, Krucoff C, Dobos G. Adverse Events Associated with Yoga : A Systematic +Review of Published Case Reports and Case Series. 2013;8(10). +42. Holton MK, Berry AE. Do side-effects / injuries from yoga practice result in discontinued +use ? Results of a national survey. 2014:133900. +43. Matsushita T, Oka T. A large-scale survey of adverse events experienced in yoga classes. +2015;9(9). +44. Penman S, Cohen M, Stevens P. Yoga in Australia : Results of a national survey. +2012;5(2):92–101. +45. Mikkonen J, Pedersen P, McCarthy PW. A Survey of Musculoskeletal Injury among +Ashtanga Vinyasa Yoga Practitioners. Int. J. Yoga Therap. 2008;(18):59. + + + + + + + + + + + + + + + + + +Figure I: Flowchart of the results of the literature search +193 Records were found for yoga +and diabetes through database +searching +- +66 PubMEd/Medline +- +20 ProQuest +- +9 CamQuest +106 records after removal of +31 Articles removed +- +13 Review papers +- +10 Full text not available +75full texts reviewed +70 additional records +identified through +reference list of review +papers /RCTs and +23 RCT identified for +qualitative and quantitative +Meta-analysis done finally for: +22 + + + + + + + + + +Table I: Characteristics of Included Studies +S +No +. +Reference +Patients, No/age group, +y/mean age, y/female, +%/white, % +Co- +intervention +Program length, frequency and +duration by intervention group +Assessme +nt time +points +Outcome +measures +Treatment +Control +1 +Aggarwal +RP et al, +2003[32] +200(154 completed study) +(82Y and 72C)(22 F,60 +M)Y, (24F,48 M)C; +53.00+7.98Y, +49.90+10.98C +Life style +modification +and diet +control +Yoga; 3 months, 7 +days a week or at +least 5 days a week +Medicines +and +unsupervised +exercises at +home +0 and 3 +months +FBS, HBA1C, +Lipids, BMI, +W/H ratio, +QOL, Diabetes +QOL, SEQ +2 +Agte VV +et al, +2004[20] +87 (57Y and 30C)(28 +males and 29 females in +yoga group)(13 males and +17 females in control +group)(22 dropouts in yoga +group and none in control +group); (54.6 ± 11.8Y) +(55.7 ± 5.8C) 45-65 years +Sessions on +stress free +living, and +eating fresh +vegetables +and fruits +SKY including +asana, pranayama, +and meditation4 +months, 6 days of +training and then +home practice +Conventional +treatment +0 and 4 +months +FBS, PPBS, +HBA1C Lipids, +Hemoglobin +3 +Balaji PA +et al, +2011[23] +44 (22Y and 22C)(22Y = +16T1 on oral drugs + 6T2 +on oral drugs and insulin), +40-55 years +Standard +treatment +Asana and +pranyama, 3 months +(90 days approx), 7 +days per week, 1 +hour per day per +class, 7 am - 8am. +Standard +treatment +0 and 3 +months +FBS, PPBS, +HBA1C, +Lipids, BMI, +W/H ratio, wt +4 +Beena RK +et al, +2013[27] +143 (73Y and 70 C), 60-70 +years +None +Yoga practice, 90 +days (3 months), 6 +days per week for 90 +days, 90 minutes +Routine +walking and +other non- +specific +activities +0 and 90 +days +FBS, Lipids, +HBA1C, +Catalase +activity, MDA +5 +Bindra M +et al, +2013[24] +100 (50Y and 50C), +35-65 years +Conventional +medicines +Yoga practice, 90 +days +Conventional +medicines +0 and 90 +days +FBS, HBA1C, +Lipids +6 +Gordan +LA et al, +2008[25] +231 (77y+77pt+77c), +(62f+15m y & c)/ 40- +70years/64.0y, 63.9pt, +63.6c/ + +Training in +diabetes +education, +and +instruction, +exercise, diet +and +medication +Hatha yoga, 6 +months, 24 classes, +one class per week, +each class 2 hours, +and at home 3- +4days/week +Treatment +plan as +recommende +d by +physician +and no active +exercise of +any type +0, 3 and 6 +months +FBG, Lipids, +MDA, PLA2, +POX, SOD, +Catalase, +Gordan +LA et al, +2008[35] +HBA1C, BMI, +Microalbuminu +ria, creatinine +7 +Hegde SV +et al, +2011[28] +123 (60Y and 63C), +59.8 ± 9.9Y, 57.5 ± 8.9C; +40-75 years +Standard +care +Asana, pranayama, +relaxation, 3 months +(90 days +approximately), 7 +days per week +Standard care +0 and 3 +months +FBG, PPBG, +MDA, SOD, +HBA1C, Waist, +bmi, +Glutathione, +Vitamin C & E, +W/H ratio +8 +Hegde SV +et al, +2012[21] +123(60Y and 63C) (2 +dropouts in yoga group); +(60.0 ± 10.4)Y, 57.5 ± +8.9C; 40-75 years +Standard +care +Diaphragmatic +breathing in supine +position, 3 months +(Daily)(Minimum 4 +days/week), 15-20 +minutes twice daily, +morning and +evening +Standard +medical care +along with +written +dietary and +exercise +advice +0 and 3 +months +FBS, PPBS, +HBA1C, MDA, +SOD, Waist, +BMI, W/H +ratio, +Glutathione, +Vitamin C & E, +SBP & DBP +9 +Jyotsna et +al, +2013[19] +64(36y+28c)/35- +72years/49.25±10.02y/47.5 +3±11.41c/ +Standard +therapy +SKY (12h over 3 +days), regular +practice at home +Standard +therapy- +brisk walking +45 minutes, +diet, OHA +0, 3 and 6 +months +FBS, PPBS, +HBA1C, +Cardiac +autonomic +functions +23 + + + +10 +Kamakhya +K, +2012[29] + +50Y and 50C, 30-60 years + +Light meals +when +practicing +yoga +Asana, pranayama, +SN; 40 days +(classes), 7 days per +week, half an hour +daily +Nothing +mentioned +0 and 40 +days +FBS, PPBS +11 +Kyizom T +et al, +2010[22] +60 (30Y and 30C), +, 52.90 ± 6.87C , 35-60 +years (Information of mean +age missing for yoga +group) +Conventional +treatment +Asana & +pranayama, 45 +classes, daily for +initial five days, and +then they were +regularly called +weekly +Conventional +treatment +0 and 45 +days +FBS, PPBS, +cognitive brain +function, +12 +Mahapure +HH et al, +2008[33] +40 [30Y (21male and nine +female)and 10C(6 male +and 4 female)] +(40-55 years for males and +40-50 years for females)Y; +(40-58 years for males and +45-54 years for females)C +OHA +Asana, pranayama, 6 +weeks (36 Classess), +6 days a week +except Sunday, 60 +minutes +OHA +0 and 6 +weeks +FBS, HBA1C, +SOD +13 +Monroe R +et al, +1992[26] + +21 (10Y and 11C) + +Medication +and diet +Asana, pranayama, 3 +months, 60 classes, +5 classes per week, +each class for 90 +minutes (Most +attended one or two +classes per week and +practiced one or +more time per week +at home) +Medication +and diet +0 and 12 +weeks +FBS, HBA1C +14 +Pardasany +A et al, +2010[30] +45(28m+17f) +(15tc+15y+15c); 40- +60years +Oral +hypoglycemi +cs +12 asanas and 6 +pranayama, for 12 +weeks +Oral +hypoglycemi +cs, no +exercise +1st day +and at end +of 12th +week +FBS,PPBS, +HBA1C, LDL, +Cholesterol +15 +Yadav S, +2013[34] +30 (males) (15y+15c)(30- +55 years) +Nothing +mentioned +12 weeks yoga (5 +asanas) +Nothing +mentioned +Pre test +and post +data +FBS +16 +Shantakum +ari N et al, +2012[31] +100 (50Y and +50C)(26males and 24 +females in each group), +45.51+8.89Y, +44.46+7.98C; 35-55 years +OHA +Yoga practices, 90 +classes (3 months), 7 +days per week, one +hour session daily, +25 students in each +class +OHA +0 and 3 +months +FBS, PPBS, +SBP, DBP +17 +Vaishali K +et al, +2012[18] + +60(27Y and 30C) (14 +male+13 female)Y and +(22male+8female)C; 3 +drop-out in yoga group +because of comorbid and +diabetic complications, +65.8 ± 3.2Y, 64.4 ± 3.8C, +All participants above 60 +years +Education +Asana & +pranayama, 72 +classes (12 weeks), +6 days per week, 45- +60 minutes +Educational +group +(standard +care) +0 and 12 +weeks +FBG, Lipids, +HBA1C +Abbreviations used: Y-Yoga, C-Control, F-Female, M-Male, OHA-Oral hypoglycaemic agents, FBS-Fasting blood sugar, PPBS-Post +prandial blood sugar, HBA1C-Glycosylated haemoglobin, BMI- Body mass index, W/H ratio-Waist hip ratio, QOL-Quality of life, SE-Self +evaluation, MDA-Malondialdhehyde, PLA2-Phospholipase A2, POX-Protein oxidation, SOD- Superoxide dismutase, SBP-systolic blood +pressure, DBP-Diastolic blood pressure, LDL-Low density lipoprotein, FBG-Fasting blood glucose + +Table II: Risk of bias assessment of the included studies using the Cochrane risk of bias Tool + + + + +24 + + + + + + + + + + + + + +S +No +. +Reference +Random +Sequence +Generatio +n +(selection +bias) +Allocation +Concealmen +t (selection +bias) +Blinding of +Participants +& Personnel +(performanc +e bias) +Blinding of +Outcome +Assessmen +t (detection +bias) +Incomplet +e +Outcome +Data +(attrition +bias) +Selective +Reporting +(Reportin +g bias) +Other +Bias +1 +Aggarwal +2003 +Unclear +Unclear +High +Unclear +Low +Low +Low +2 +Agte 2004 +Unclear +Unclear +High +Unclear +Unclear +Low +Unclea +r +3 +Balaji 2011 +Unclear +Unclear +High +Unclear +Unclear +Low +Unclea +r +4 +Beena 2013 +High +Unclear +High +Low +Low +Low +Unclea +r +5 +Bindra 2013 +Unclear +Unclear +High +Unclear +Unclear +Low +Unclea +r +6 +Gordon +2008a; +Gordon +2008b +High +Unclear +High +Low +Low +Low +Unclea +r +7 +Hegde 2011 +High +Unclear +High +Unclear +Unclear +Low +Unclea +r +8 +Hegde 2012 +High +High +High +Unclear +Low +Low +Unclea +r +9 +Jyotsna 2013 +Low +Unclear +High +Unclear +Low +Low +Unclea +r +10 +Kamakhya +2012 +Unclear +Unclear +High +Unclear +Unclear +Low +Unclea +r +11 +Kyizom 2010 +High +Unclear +High +Unclear +Unclear +Low +Unclea +r +12 +Mahapure +2008 +High +Unclear +High +Unclear +Unclear +Low +Unclea +r +13 +Monroe 1992 +Low +Unclear +High +Unclear +Low +Low +Unclea +r +14 +Pardasany +2010 +Unclear +Unclear +High +Unclear +Unclear +Low +Low +15 +Yadav S, +2013 +Unclear +Unclear +High +Unclear +Unclear +Low +Unclea +r +16 +Shantakumar +i 2012 +High +High +High +Unclear +Low +Low +Unclea +r +17 +Vaishali 2012 +Low +Low +High +Unclear +Low +Low +Unclea +r +25 + + + + +Table III – Effects of Yoga on Blood Glucose Parameters +Outcome +No. of +Studies +No. of +Patients +Standardized Mean +Difference (95% +Confidence Interval) +P (Overall +Effect) +Heterogeneity, I2/χ2/P +FBS +17 +1358 +-1.40 [-1.90, -0.90] +˂ 0.00001 +94%/259.34/˂0.00001 +PPBS +9 +659 +-0.91 [-1.34, -0.48] +˂ 0.0001 +85%/52.94/˂0.00001 +HBA1C +13 +1097 +-0.64 [-0.97, -0.30] +0.0002 +85%/80.22/˂0.00001 +FBS: Fasting blood sugar; PPBS: Post prandial blood sugar; HBA1C: Glycosylated +hemoglobin + + + + + + + diff --git a/subfolder_0/Schizophrenia Patient or Spiritually Advanced Personality A Qualitative Case Analysis.txt b/subfolder_0/Schizophrenia Patient or Spiritually Advanced Personality A Qualitative Case Analysis.txt new file mode 100644 index 0000000000000000000000000000000000000000..2c53e0638c1642382f2b66e47a07253267372899 --- /dev/null +++ b/subfolder_0/Schizophrenia Patient or Spiritually Advanced Personality A Qualitative Case Analysis.txt @@ -0,0 +1,819 @@ +PHILOSOPHICAL EXPLORATION +Schizophrenia Patient or Spiritually Advanced +Personality? A Qualitative Case Analysis +Hemant Bhargav • Aarti Jagannathan • Nagarathna Raghuram • +T. M. Srinivasan • Bangalore N. Gangadhar + Springer Science+Business Media New York 2014 +Abstract +Many aspects of spiritual experience are similar in form and content to +symptoms of psychosis. Both spiritually advanced people and patients suffering from +psychopathology experience alterations in their sense of ‘self.’ Psychotic experiences +originate from derangement of the personality, whereas spiritual experiences involve +systematic thinning out of the selfish ego, allowing individual consciousness to merge into +universal consciousness. Documented instances and case studies suggest possible confu- +sion between the spiritually advanced and schizophrenia patients. Clinical practice contains +no clear guidelines on how to distinguish them. Here we use a case presentation to help +tabulate clinically useful points distinguishing spiritually advanced persons from schizo- +phrenia patients. A 34-year-old unmarried male reported to our clinic with four main +complaints: lack of sense of self since childhood; repeated thoughts questioning whether he +existed or not; social withdrawal; and inability to continue in any occupation. Qualitative +H. Bhargav (&)  A. Jagannathan  N. Raghuram +Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana (S-VYASA) +University, No. 19, Eknath Bhavan, Gavipuram Circle, Kempegowda Nagar, +Bangalore 560019, Karnataka, India +e-mail: hemant.bhargav1@gmail.com +A. Jagannathan +e-mail: jaganaarti@gmail.com +N. Raghuram +e-mail: rnagaratna@gmail.com +T. M. Srinivasan +Division of Yoga and Physical Sciences, Swami Vivekananda Yoga Anusandhana Samsthana +(S-VYASA) University, No. 19, Eknath Bhavan, Gavipuram Circle, Kempegowda Nagar, +Bangalore 560019, Karnataka, India +e-mail: tmsrini@gmail.com +B. N. Gangadhar +National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Hombegowda +Nagar, Bangalore 560029, Karnataka, India +e-mail: bng@nimhans.kar.nic.in +123 +J Relig Health +DOI 10.1007/s10943-014-9994-0 +case analysis and discussions using descriptions from ancient texts and modern psychology +led to the diagnosis of schizophrenia rather than spiritual advancement. +Keywords +Spirituality  Sense of self  Yoga  Mental illness  Psychopathology  +Schizophrenia +Introduction +In psychology, the word ‘self’ is defined as the totality of the individual, consisting of all +characteristic attributes, conscious and unconscious, mental and physical (Vander 2007). A +person can refer to ‘self’ either as the regulator of behavior or as the pivot of perception– +cognition–action at the core of personality. It is the essence of individuality—being. Self +psychology has provided a comprehensive theory of psychopathology and treatment. It +identified a new group of developmental needs and transferences: mirroring, idealizing, +and alter ego (Kohut and Wolf 1978). Kohut emphasized that a person becomes more +prone to personality disorders should these three developmental needs not be adequately +met by parental empathy during infancy and childhood. Such disorders arise from sub- +sequent failure to develop intra-psychic structures that reliably regulate self-esteem and +calm the self. Treatment of such disorders of self requires careful understanding of early +failures and creation of an environment in which the intra-psychic structures may effec- +tively develop (Baker and Baker 1987). Studies have depicted disturbances of self in +various psychiatric disorders such as personality disorders (Kohut and Wolf 1978), psy- +choses (Salvatore et al. 2012; Heinisch et al. 2013), bipolar disorder (Lam et al. 2005), +eating disorders (Strober 1991), and somatoform disorders (Kohut and Wolf 1978). +Schizophrenia as a Disorder of Self +As a chronic, severe, and disabling mental illness, schizophrenia is characterized by distur- +bances of thought, perception, affect, and social activity (Van and Kapur 2009). Common +symptoms include positive symptoms (such as disorganization, delusions, or hallucinations) +and negative symptoms (anhedonia, decreased emotional expression, impaired concentra- +tion, and diminished social engagement) (Van and Kapur 2009). Onset is typically seen in late +adolescence with a global lifetime prevalence of about 0.3–0.7 % (Van and Kapur 2009) and +average annual incidence of approximately 15 per 100,000 (Tandon et al. 2008). +Increasing numbers of empirical studies show that disturbances in the ‘sense of self’ or self- +experience are characteristic of schizophrenia (Raballo 2012; Boulanger et al. 2013; de Vries +et al. 2013). Imaging studies attribute this disturbed ‘sense of self’ to deficits in the right brain +(Hecht 2010) and lack of functional connectivity between cortical midline structures (Shad +et al. 2012; Zhao et al. 2014). Disturbed ‘sense of self’ is believed to contribute to the +development of schizophrenia and its associated lack of insight that makes it so hard to treat +(Salvatore et al. 2012; Heinisch et al. 2013). Considering schizophrenia to be a ‘self’ disorder +may helpidentifyhigh-riskpatients,differentiate schizophreniaspectrumdisordersfromother +psychoses, and enhance efficacy of interventions (Akroyd 2013; Nelson et al. 2012, 2013). +Alterations of the Sense of Self in Spirituality +Those in advanced spiritual states also experience alterations in the ‘sense of self’ (Grof +and Grof 1986, 1989). Ancient Yoga texts such as Bhagavad Gita +¯ (Tapasyananda 2005, +J Relig Health +123 +p. 71) and Patanjali’s Yoga Sutra (Saraswati 2002, p. 42) state that transcendence of ego +and consequent diminishing of the ‘sense of self’ are signs of high spiritual attainment. +However, this has to be interpreted with caution, since these texts distinguish strongly +between the ‘selfish’ sense of ‘small self,’ i.e., the little ego, and the vastly expanded sense +of greater ‘Self’ that replaces it as the individual progresses down the path to ‘Self +Realization’. +Spirituality is an integral part of most religious philosophies providing value systems for +most people and enhancing their well-being. In recognition of this, during the 37th World +Health Assembly in 1984, WHO stated that a person’s spiritual well-being is an important +determinant of health (Basu 1995). +Spiritual experience may include such states as ecstatic mood, a sense of newly gained +knowledge, diminishing of sense of doership, and complete surrender to the higher force in +life for one’s own needs (Lukoff 2005). One of the most comprehensive expressions of +such an advanced, integrated, and self-realized experience is given by A +¯di Shan- +kara +¯cha +¯rya: ‘I am verily the ultimate existence, the source-energy of being, which is +equanimous, +tranquil, +silent, +self-existent, +self-aware, +joyously +well, +unchanging, +unformed, undecaying, healthy, real, beyond-appearances, non-vacillating, pervasive, +unspecified, restful, enduring, ever-free, stable, pure, quiescent, unlimited, and free from +fear of ageing and death. I am not a mere representation of a body. This is the true insight +into self’ (Vimuktananda 1938). Grof et al. described six forms of spiritual awakening: +awakening of the serpent power (Kundalini energy), shamanic journey, psychological +renewal through activation of the central archetype, psychic opening, emergence of a +karmic pattern, and possession state, details of which are given elsewhere (Grof and Grof +1986). For example, according to the ancient Indian sciences, Kundalini energy resides at +the base of the spine. When aroused, it can rise through psychic centers situated along the +spine from the tailbone to the top of the head, creating physical symptoms ranging from +sensations of heat and tremors to involuntary laughing or crying, talking in different +languages, nausea, diarrhea or constipation, rigidity or limpness, and animal-like move- +ments and sounds (Sanella 1978). +Psychopathology Versus Spiritual Advancement +Spiritual experiences and psychotic symptoms have many aspects of form and content in +common. Hansen (1995) describes two cases considered mentally ill by relatives, and who +had been diagnosed as schizophrenic by their psychiatrists, but who had in fact been going +through a spiritual crisis, known in the Eastern spiritual tradition as raising the Kundalini. +Hansen explained that the cases recovered completely when that process was allowed to +progress to completion and that it then led to better psychological balance, maturity and +strength afterward. Similarly, in several well-documented cases, spiritually advanced saints +were considered mentally ill by those around them, and professional help was sought. For +example, Swami Rama, the well-known Himalayan spiritual master, wrote in his biography +that he was awakened again and again in the night by the visions of his spiritual master. +This disturbed his parents and they thought it to be a mental health problem. They con- +sulted many doctors, priests, and astrologers but the problem did not resolve with any +therapy. It vanished automatically when Swami Rama met his master (Rama 1999, p. 25). +Another example is that of Swami Paramhamsa Yogananda who describes in his autobi- +ography how, because of his spiritual beliefs and surrendering attitude, he was neglected +by teachers and called a ‘Mad Saint’ by his classmates during his higher secondary edu- +cation (Yogananda 2009, p. 311). Similarly, Swami Ramakrishna Paramhamsa, Guru of +J Relig Health +123 +Swami Vivekananda, was known as ‘the mad priest of Dakshineshwar’ by the people, +because he used to speak to the idol of Goddess Kali (Nikhilananda 1980, p. 831). Similar +instances, where spiritual gestures appear very similar to symptoms of psychopathology, +are found in other faiths and traditions also. Examples are given below. +Christian Mysticism +Egan (1998) writes in his book that ‘Jesus Christ is the foundation of all Christian Mys- +ticism… Jesus claimed that, ‘‘No one knows the Son except the Father, and no one knows +the Father except the Son and anyone to whom the Son chooses to reveal him.’’ (Matthew +11:27). In this and other places in the New Testament (John 7:29; 8:55), Jesus spoke of his +intimate, full personal, loving knowledge of his Father. He knew that he came from the +Father (John 5:30) and would return to him (John 8:14). The Oneness he enjoyed with his +Father dominated his consciousness. He heard his word (John 8:26), knew his will (John +5:30), and had seen him working (John 5:19).’ This clearly suggests that Jesus Christ saw +God, whom he called his Father and spoke to Him. Such spiritual beliefs and extra-sensory +perceptions might be confused with delusions, and auditory or visual hallucinations, +respectively, by psychiatrists. +Islamic Mysticism (Sufism) +Sufipractices form an important part of the belief system of an increasingly large number +of people both in the Muslim world and outside. Nicholson (2007) describes in his book +that a Sufimystic follows a step-by-step methodology toward higher Sufiexperiences of +annihilation in the ultimate reality and eternal existence. Experiences such as transcen- +dence, tranquility, sense of pleasure, and detachment occur more frequently in the fol- +lowers of Sufipractices. Self-mortification is a practice performed by advanced Sufis +which is understood as moral transmutation of the inner man. Apart from influencing the +belief system, this practice may lead to significant changes in the practical life, which +needs to be understood in proper perspective. Nicholson (2007) claims that when they say, +‘Die before you die’, they do not mean to assert that the lower self can be completely +destroyed, but that it can be cleansed of evil attributes such as ignorance, pride, envy, etc. +Another practice in Sufism called ‘‘trust in God (tawakkul)’ involves complete eradication +of self-will. ‘Trust in God’ involves renunciation of every personal initiative and wish; +total passivity like that of a corpse; complete indifference toward anything that is even +remotely connected with one’s self. The Sufiwho has eradicated self-will is said, in +technical language, to have reached the ‘stages’ of ‘acquiescence’ or ‘satisfaction’ (rida) +(Nicholson 2007). Such spiritual practices may behaviorally affect a person and may lead +to professional diagnosis of nihilistic delusions and/or catatonia, if proper spiritual +understanding is lacking. +Although these kinds of spiritual experience have multi-cultural historical precedents, +their similarities to symptoms of psychosis lead authorities to treat what should be con- +sidered mystical states as pathology. Considering the difficulties faced by professionals in +differentiating these two classes of conscious experience, a new diagnostic category +entitled religious or spiritual problem has been included in the fourth edition of the +Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) under ‘other conditions.’ +This category contributes significantly to the greater cultural sensitivity incorporated into +DSM-IV (Turner et al. 1995). Still, clear guidelines in clinical practice are lacking, and the +J Relig Health +123 +issue needs further exploration (Pierre 2001). Listing clinically relevant points distin- +guishing spiritual advancement from psychopathology would therefore be appropriate. +In this context, based on Bronfenbrenner’s socio-ecological theory (Bronfenbrenner +1979), we are presenting a case analysis that will help illustrate the mechanisms, simi- +larities and differences at each socio-ecological level between a person suffering from +schizophrenia and one who is spiritually advanced. Since the case had a number of +challenges at the levels of microsystem (activities, roles, and interpersonal relationships), +family and society, and also at the level of ideologies, beliefs and values, Bronfenbrenner’s +socio-ecological classification was considered appropriate to discuss it. +Illustrative Case +Mr. X, a 34-year-old unmarried male from a semi-urban upper-middle background, with +11 years of formal education, reported to a residential holistic treatment center. His chief +complaints were lack of realization of his self since childhood, repeated thoughts about his +existence, inability to mix with people, worries about others’ opinion of him, low confi- +dence levels, and inability to concentrate on work. The symptoms were almost always +present in spite of regular intake of antipsychotics, and there were no obvious precipitating +factors. He experienced delusions as well as frequent cognitions such as, ‘I can’t exist,’ +‘The word ‘‘existence’’ is not made for me,’ ‘I have no self at all.’ +The patient had appropriate affect, but experienced anxiety in interpersonal situations +and tasks. He remained withdrawn and socially isolated. His self-care was intact. He stated +that he had felt such nihilistic thoughts since childhood (pre-morbidly). His typical dec- +larations included ‘I am not this body,’ ‘I have no thoughts, no mind,’ or ‘I don’t do +anything, I am nothing, I am a blank space, I don’t exist, I am zero.’ Mr. X’s psychosocial +functioning was significantly impaired due to this loss of sense of self. He repeatedly kept +asking similar questions: Am I also a man? Is this a body? Is this mine? Should I start +believing that this body is mine? And do I have a mind? He had a sedentary lifestyle and +had increased appetite and gained weight for the two previous years. He used to sleep for +around 10 h a day, go to bed late at night, and get up late in the morning. His father +reported that he kept asking these questions repeatedly (obsessive ruminations) and was +unable to study or work at all. The patient had strong delusions that the person in the mirror +was not him; although he recognized his own face, he did not feel the emotional contact +normally associated with looking at oneself. He also revealed that during his higher sec- +ondary education he started believing that he was not himself, but his batch mate, so that, +when asked his name, he would reply by saying his batch mate’s. This history was sug- +gestive of the presence of delusional misidentification syndromes such as Capgras syn- +drome. The patient also had affective blunting, was socially withdrawn, and experienced +cognitive decline in terms of reduced attention span and ability to plan. He could not +complete his education and had not been able to pursue any occupation, because of these +dysfunctions. There was no history of organic brain disease or drug-related intoxication, +dependence or withdrawal. Presence of true delusions ruled out the diagnosis of schizo- +typal disorder. Non-episodic course of illness and absence of symptoms suggestive of +mood disorder (mania or depression) with or without schizophrenic symptoms indicated a +negative history for affective or schizo-affective disorders, respectively. Thus, based on the +presence of inappropriate affect, negative symptoms such as social withdrawal, cognitive +deficits, occupational dysfunction, and persistent nihilistic and misidentification delusions, +the patient had been diagnosed by his psychiatrist (using ICD-10, version 2010) as +J Relig Health +123 +suffering from schizophrenia with obsessive thoughts (due to his repeatedly asking the +same questions). The patient had visited a number of psychiatrists and was on antipsy- +chotic treatment for 2 years following his initial diagnosis. After 2 years, he started feeling +that his diagnosis by his doctor as schizophrenic had been wrong, so he had stopped taking +medication. His psychiatrist then referred him for Yoga therapy. +Written informed consent was obtained from both the patient and his carers to record +this case study, which was then approved by the Institutional Ethics Committee. +Case Analysis +Being from a university conducting research in the field of Yoga, complementary medi- +cine, and spirituality, the authors have been exposed to personalities of both types, patients +with schizophrenia and advanced spiritual practitioners. Here, we present a particular case +from two perspectives, bio-medical (psychiatry) and that of the ancient system of yoga +(spirituality). The case is analyzed from both perspectives under the broad framework of +Bronfenbrenner’s socio-ecological theory (Bronfenbrenner 1979) (Fig. 1; Table 1), which +considers personal interactions in the contexts of microsystem, mesosystem, exosystem, +and macrosystem, which we now present. +Microsystem +Bronfenbrenner’s concept of microsystem represents the pattern of activities, roles, and +interpersonal relationships experienced by a developing person when faced by another specific +individual. It encompasses all physical and material features as well as the other person’s +specific characteristics (Bronfenbrenner 1979). The microsystem perspective offers the fol- +lowing parameters to differentiate the spiritually advanced from those with schizophrenia. +History of Practice or Search for Truth +A spiritually advanced personal usually has a history of involvement in spiritual disciplines. +For example, Sri Ramakrishna Paramahamsa practiced advanced meditation for a long time. +Fig. 1 Conceptual framework differentiating between spiritually advanced personality and patient with +psychosis at different socio-ecological levels +J Relig Health +123 +Table 1 Differentiating points between spiritually advanced personality and schizophrenia patient based on Bronfenbrenner’s socio-ecological theory +Socio- +ecological +level +Differentiating trait +Spiritually advanced +Schizophrenia +How to differentiate +Microsystem +History of spiritual +practice +Present +Usually absent +Asking history about past spiritual practices +Appetite and +recreation +Moderate to less +More or less; toward the extremes +Sleep +Moderate to less +More or less; toward the extremes +Dressing +May be poorly dressed +Poorly dressed +Asking the reason for such appearance +Facial expression +Calm and composed +Anxious, fearful, neutral +Eyes +Glowing bright eyes +No change +Voice +Gentle, soothing voice +No change +Reduced +psychomotor +activity +Meditation or trance +Catatonia +1. Presence of spiritual cue +2. Feelings that others get +3. What happens afterward +Increased +psychomotor +activity +Spiritual ecstasy +Positive symptoms +Same as above +Speech +Would like to speak only on spiritual +issues; tone, tempo and volume may +vary appropriately +May not like to speak on spiritual +issues; tone, tempo and volume may +vary inappropriately +Same as above +Thought +Faith +Delusions +By asking justification behind the belief and +assessing the effect of this belief on socio- +occupational functioning +Perception +Extra-sensory perception—speaking to +God +Hallucinations +Verifying the content of hallucinations; whatever +the case declares, whether in future it comes out +to be true or not +Mesosystem +Socialization +Equanimity +Social withdrawal +Affected by presence or absence of others or not +Occupation +Works with joy and enthusiasm, does +not care for results +Occupationally handicapped, excess +worries about the consequences +J Relig Health +123 +Table 1 continued +Socio- +ecological +level +Differentiating trait +Spiritually advanced +Schizophrenia +How to differentiate +Exosystem +Effect of socio- +political forces +Not much affected +Affected more +Botheration for +human welfare +Every action and thought is directed +toward human welfare +Does not bother about others; pre- +occupied with his own problems +Macrosystem +Influence of beliefs, +values and culture +in society +Decisions are free from societal +influences +Affected more by societal influences +J Relig Health +123 +He also followed the paths of Shaktas, Vaishnavas, and Vedantins (Nikhilananda 1980, +p. 129). Such a history may or may not be present in the case of a schizophrenia patient, but it +does constitute a definite indication of being on the spiritual path. Our case (whom we shall +refer to as ‘Mr. X’) did not have any history of following a spiritual discipline. +Appetite and Recreation +Mentally ill patients often experience reduced or increased appetite, whereas the spiritually +advanced normally observe moderation in eating and recreation (Tapasyananda 2005, +p. 174). In spiritually advanced states, the individual may remain completely healthy even +when consuming very little food (Muktibodhananda 1998, p. 58). Mr. X had been gaining +weight over the previous 4–5 years, due to his sedentary lifestyle and level of appetite. +Sleep +Aspiring yogis observe moderation in sleep and wakefulness (Tapasyananda 2005, p. 174); +in advanced stages, they even go beyond the bondage of sleep and wakefulness (Muk- +tibodhananda 1998, p. 594). Thus, a spiritually advanced personality would never complain +of disturbed or excessive sleep. On the other hand, disturbance in sleep and excessive +sleeping are common problems in schizophrenia. Mr. X slept long hours, going to bed late +at night, and getting up late in the morning, but his sleep was disturbed. +Physical Appearance +Both personality types may dress poorly and appear unconcerned about their belongings, +but for different reasons: the mentally ill, due to lack of self-esteem or insight; spiritually +advanced personalities, because they no longer identify with the mind–body complex, so +that, meta-cognitively, they perceive themselves as mere witnesses to activity (Tapasya- +nanda 2005, p. 174; Saraswati 2002, p. 149). Clinically, the two possibilities can be +differentiated by identifying the reasons behind their manner of dressing. A schizophrenia +patient might not be able to give a rationale, but a spiritually advanced person would +typically declare that he is more concerned about a subtler level reality than physical body +and material possessions (Saraswati 2002, p. 147). Mr X dressed poorly, and when asked +why, he replied, ‘I want to dress well, and be like other people but I can’t, because I am not +able to extricate myself from a loss of self existence.’ +Similarly, facial expressions of the two tend to be different; spiritually advanced people +often have calm and composed facial expressions (Tapasyananda 2005, p. 68; Saraswati 2002, +p.208),whileschizophreniapatientstendtoappearfearful,anxious,orirritable(VanandKapur +2009).Theeyesofspirituallyadvancedpeopleappearliquid,soft,clear,andsparkling;thereisa +glow in their eyes, (Yogananda 2009, p. 366; Muktibodhananda 1998, p. 79), their speech is +gentle, soothing, and penetrating (Yogananda 2009, p. 366); schizophrenia patients do not have +such characteristics. In the case in question, Mr. X had an anxious look, his eyes were dull and +sunken, and his voice was jarring, especially when expressing his anxiety. +Psychomotor Activity +Both personality types may show reduced psychomotor activity under certain circumstances +and increased psychomotor activity in others. With respect to the aspect of reduced +J Relig Health +123 +psychomotor activity, confusion may develop while differentiating a schizophrenia patient +sitting dull and withdrawn or even in catatonia (Van and Kapur 2009) from a spiritually +advanced person deeply engrossed in meditation; entering stable and life-enhancing trance +states (Muktibodhananda 1998, p. 593; Tapasyananda 2005, p. 173). In this case, the two can +be clinically differentiated through three observations. First, a spiritual cue such as some +spiritual image, sound, or atmosphere would be present for a spiritually advanced person to +enter into this state (Nikhilananda 1980, p. 232). Such spiritual cues are not necessarily +needed by schizophrenia patient to become withdrawn; instead, they do so in response to +psychological stress (Lodge and Grace 2011). Secondly, during such states, the facial +expressions of the spiritually advanced appear calm, quiet, and blissful (Nikhilananda 1980, +p. 89; Muktibodhananda 1998, p. 593), but a schizophrenia patient’s facial expressions may +appear irritable, anxious, fearful, or neutral (Van and Kapur 2009). Also, during these states, +people around a spiritually advanced person tend to feel a sense of calmness and comfort +(Nikhilananda 1980, p. 109; Yogananda 2009, p. 115), whereas those surrounding a +schizophrenia patient tend to feel stressful and uncomfortable (Vitaliano and Katon 2006). +Thirdly, after coming out of this state, a spiritually advanced person is more loving, accepting, +and insightful, and functions more efficiently (Muktibodhananda 1998, p. 593; Saraswati +2002, p. 108), whereas schizophrenia symptoms increase (Kleinhaus et al. 2012). +Similarly, the increased psychomotor activity seen in schizophrenia patients is com- +monly regarded as a positive symptom (Van and Kapur 2009). Spiritually advanced people +also become more energetic, ecstatically showering love on one and all, following spiritual +experiences (Tapasyananda 2005, p. 90). Here again, distinguishing points are similar to +those listed above: first, the need for a spiritual cue; second, the feelings that others get in +their presence; and third, the sequel. +After a manic episode, a patient suffering from mania or bipolar disorder may become +exhausted, or enter into the depression phase, but a spiritually advanced person does not feel +exhausted or low after such spiritual experiences, but appears calmer and more composed +(Tapasyananda 2005, p. 208). In our case, when Mr. X had low psychomotor activity (in the +absence of any spiritual cue), his behavior was socio-occupationally handicapped, and those +around him, including his relatives, tended to feel dejected and frustrated. +Speech +Both personalities show both high and low speech volume, tone, and tempo. But as described +above, changes in a spiritually advanced person’s speech are associated with spiritual cues, +feelings of calmness in people around him (Nikhilananda 1980, p. 109) and contentment in +listening to him (Nikhilananda 1980, p. 89); further, no exhaustion or dejection is experienced +after speaking, during or after experiencing a spiritually advanced state. A spiritually +advanced person maintains coherent, fluent speech, or a blissful spontaneous silence, like that +of Sri Raman Maharshi (Nikhilananda 1980, p. 89). Also, spiritually advanced personalities +tend to speak about God and Truth, rather than worldly matters (Nikhilananda 1980, p. 119). +In our case, Mr. X had a normal volume, tone, and tempo of speech, but was not interested in +speaking about God or other higher-order matters. +Delusions or Faith? +Both types of personality can hold firm beliefs, which they may not be able to prove +objectively. For example, Mr. X had nihilistic delusions of non-existence of his own self +and that the body and mind did not belong to him. Similarly, importance of faith is stated +J Relig Health +123 +by great sages (Nikhilananda 1980, p. 252). In contrast, in cases where sages such as +Shankaracharya and Gautam Buddha have declared that ‘I am not the body, nor the mind +or the senses’ (Sharma et al. 2009), it is possible to make clear clinical distinctions between +the two. When questioned regarding the reasons behind their statements, spiritually +advanced personalities justify their statements by giving references from authentic spiritual +texts or from their life experience (Tapasyananda 2005, p. 406); schizophrenia patients, on +the other hand, are not able to give authenticated explanations for their statements. When +our team asked Mr. X about the reasons behind his nihilistic conceptions he replied, ‘I +don’t know why. From my childhood I have been like this!’ +Another important aspect of such ideas is their impact on the person’s life. A spiritually +advancedpersonfunctionsbetterbothsociallyandoccupationally(Tapasyananda2005,p.62);in +contrast, such ideas compromise functionality of schizophrenia patients, as in the case of Mr. X. +Hallucinations or Extra-Sensory Perceptions? +Both personalities may claim to hear voices, see phenomena, or feel sensations, which +others do not. For example, auditory hallucinations are quite a common schizophrenia +symptom (Van and Kapur 2009). Sri Ramakrishna Paramhamsa, Paramhamsa Yoga- +nanda, and many other sages have described communication with god (Nikhilananda 1980, +p. 831; Yogananda 2009, p. 76). Differentiating between these two becomes critically +important. One possibility is when content of extra-sensory perception becomes realized in +events in the future. For example, Paramhamsa Yogananda writes in his book that after +intense prayer to the Divine Mother requesting for a Guru to guide, he heard a divine +feminine voice saying ‘Thy Master cometh today!’ Later, that prediction came true: Pa- +ramhamsa Yogananda actually met his Guru the same day (Yogananda 2009, p. 89)! +However, few claims or declarations of schizophrenia patients come true in future: Clin- +ically speaking, hallucinations are false sensory perceptions. Secondly, during such per- +ceptions, spiritually advanced personality remains calm, quiet and blissful (Yogananda +2009, p. 469), whereas schizophrenia patients become irritated and agitated. In our case, +Mr. X did not report any kind of sensory hallucinations. +Mesosystem +A mesosystem consists of two or more microsystems, in which the person concerned +participates i.e., a mesosystem is a system of microsystems (Bronfenbrenner 1979). The +following points may apply to them. +Social Withdrawal or Equanimity +The negative symptoms of schizophrenia include mental apathy, lethargy, and loss of +interest in socio-occupational activities (Van and Kapur 2009). Superficially, these seem +very similar to those resulting from practice of non-attachment and contentment by the +spiritually advanced (Muktibodhananda 1998, p. 54). +But spiritually advanced personalities have no fear and, because they love everyone +unconditionally, may appear impartial to people (Tapasyananda 2005, p. 90). They have +neither attachment nor hatred toward anyone, but are concerned about the welfare of all +(Tapasyananda 2005, p. 68), nor are they affected by someone’s presence or absence. A +schizophrenia patient, on the other hand, has strong likes and dislikes and could become +J Relig Health +123 +indifferent because he is unable to generate appropriate emotions (Rowland et al. 2012). +Thus, clinically speaking, a spiritually advanced person will be less affected by the pre- +sence or absence of others, while a person with schizophrenia will tend to be affected by +such concerns. Mr. X developed anxiety whenever he was interacting with people, so he +tended to remain socially withdrawn and isolated. +Occupational History +A schizophrenia patient is not able to work at his occupation efficiently because of poor +concentration and attention span (Van and Kapur 2009); worries about the consequences of +their actions prevent initiation of further work. Spiritually advanced personalities, on the +other hand, will perform any work assigned to them with interest and enthusiasm (Tap- +asyananda 2005, p. 61), without concern for personal advantage from the results, but only +that their actions contribute to universal well-being. In our case, Mr. X was able to neither +function properly at any job nor undertake a course of study, because of lack of motivation +and ability to concentrate. +Exosystem +The exosystem consists of one or more settings that do not involve the developing person +as an active participant, but in which events occur that affect or are affected by what +happens in that setting (Bronfenbrenner 1979). +Effect of Unemployment, Poverty, Natural Crises +Due to their socio-occupational dysfunction, schizophrenia patients are affected by exo- +system situations such as unemployment, poverty, natural crises. much more than spiri- +tually advanced personalities (Van and Kapur 2009). They are therefore more dependent +on family and society for survival. A spiritually advanced personality is not a burden to +anybody; on the contrary, their actions tend to reduce burdens on family and society +(Tapasyananda 2005, p. 119; Yogananda 2009, p. 109). Mr. X was not employed, was not +able to study properly, and was a burden on family and society, making them more +vulnerable to exosystemic events. +Human Welfare +Every action of spiritually advanced personalities supports the welfare of humanity as a +whole (Tapasyananda 2005, p. 179). They perceive the same divinity in the heart of all +creatures and think and act for the welfare of all (Tapasyananda 2005, p. 180). Such are not +the usual concern of schizophrenia patients, who tend to indulge in talking about them- +selves and their concerns and appear thoroughly ego-centric (Van and Kapur 2009). Mr. X +was hardly concerned about what was happening to others; his main interest was his own +health, he was desperate to get relieved of his problems. +Macrosystem +The macrosystem refers to the overriding beliefs, values, ideology, practices, and policies +within a cultural group (Bronfenbrenner 1979). +J Relig Health +123 +Effect of Beliefs, Ideology, Values, and Practices +A schizophrenia patient is affected by the nature of beliefs, ideologies, and values that +persist in his cultural milieu (Aguilera et al. 2010). On the other hand, spiritually advanced +personalities have risen above the beliefs and dogmas of their society, and thus, their +intellect has full freedom in making decisions; also, they are indifferent to other people’s +opinions of their actions (Tapasyananda 2005, p. 60). Established in a higher reality +principle, their discriminative power is clear and unaffected by social influences (Tap- +asyananda 2005, p. 6). Our unfortunate Mr. X was profoundly affected by social ideolo- +gies, had an inferiority complex, and suffered from his inability to lead a normal life in +society. +Discussion +Cases at each of Bronfenbrenner’s socio-ecological levels illustrate the inherent differ- +ences between spiritually advanced persons and schizophrenia patients. At the microsys- +tem level, they differ in terms of their history of spiritual practices, appearance, +psychomotor activity, speech, thought, perception, appetite, and sleep. At the mesosystem +level, they differ in their social and occupational functioning. At the exosystem level, they +differ in the way that socio-political events in their environment affect them. Lastly, at +macrosystem level, they differ in the way that their society’s beliefs, ideologies, and +thoughts influence them. +Previously, few researchers have attempted to differentiate psychopathology from +spiritually advanced states. A computerized content analysis of written passages from +subjects describing schizophrenia, hallucinogenic drug experiences, and mystical experi- +ences with autobiographical accounts as controls was conducted by Oxman et al. (1988). +They found that schizophrenic subjects emphasized illness/deviance themes; hallucino- +genic accounts emphasized altered sensory experience; mystical accounts focused on +religious/spiritual issues; and normal control subjects emphasized adaptive and interper- +sonal themes. Ballentine and Ajaya (1976) proposed that seemingly similar euphoric +psychotic states and experiences of higher consciousness are distinguished chiefly on the +basis of the fragmented nature of the psychotic experience. The euphoria associated with +psychotic states may abruptly reverse itself and become a horrific vision of the psychotic as +a sinner in hell. On the other hand, the mystic is able to integrate the sometimes contra- +dictory inner world into an expanded consciousness. Wilber (1980, p. 156) writes that both +a psychotic patient and a mystic may experience similar psychic realms, but, unlike the +psychotic patient, the mystic is mastering those realms rather than being overwhelmed by +them. He further writes, ‘The mystic seeks progressive evolution. He trains for it. It takes +most of a lifetime—with luck—to reach permanent, mature, transcendent and unity +structures. At the same time, he maintains potential access to ego, logic, membership, +syntax, etc. He follows a carefully mapped out path under close supervision. He is not +contacting past and infantile experiences, but present and prior depths of reality.’ +Concepts discussed in the ancient yogic texts can be used to further understand the +above differences. Deshmukh (2008) describes how the self-process can be oriented in +three complementary modes of being-in-existence, namely (a) an egocentric, object- +avoidant mode; (b) an allocentric, object-approach-and-explore mode; and (c) an ecosys- +temic, non-interactive, globally oriented, conflict-free, existential mode. The first two are +interactive modes of reflective consciousness, which is subject–object duality, whereas the +J Relig Health +123 +non-interactive, pre-reflective consciousness is restful, spontaneous, non-dual, and exis- +tential. A concept is available in Bhagwad Gita (Tapasyananda 2005) wherein a mecha- +nism of development of delusions and severe mental illness is described. It explains that +those who live their life mostly in ego-centric or duality modes develop a strong sense of +identity with their mind–body complex. They keep thinking about sense objects again and +again and slowly, because of these repeated thought patterns, they develop longing or +inclination for those sense objects. With continuing imagination about the objects, incli- +nation turns into desire and when this desire is not fulfilled it begets anger (Tapasyananda +2005, p. 67). Anger generates delusion, and delusion results in loss of memory. Loss of +memory brings about the destruction of the discriminative intelligence, and loss of dis- +criminative intelligence spells ruin to the person (Tapasyananda 2005, p. 68). This concept +helps us understand how a patient suffering from mental illness becomes more and more +bound by his thoughts. His intellect completely covered by emotions makes him slave to +his body and senses (see Fig. 2). According to Patanjali’s Yoga Sutra (Saraswati 2002), the +basic error lies in forgetting one’s ‘true nature’ and thus, there develops an entity called +ego which is nothing but identification of the unlimited universal consciousness with the +limited mind–body complex. The more an individual identifies himself with the mind– +body complex, the stronger are his likes and dislikes. This leads to fear, fear of getting +what one does not like and of not getting what one likes. This fear becomes an important +factor in altering the perception of the personality. He starts developing paranoid ideations +and everything in life becomes an object of fear (Tapasyananda 2005, p. 67). This fear +slowly starts deranging the ego, thereby altering the ‘sense of the self.’ This becomes the +basis for manifestation of various psychiatric symptoms such as delusions, hallucinations, +social withdrawal, and ultimately the loss of insight and control over mind and senses +(Tapasyananda 2005, p. 67). This concept provides a comprehensive view on deep psy- +chological issues through which psychiatric illnesses emerge and attributes the basic cause +of mental afflictions to fear generated from strong desires (see Fig. 2). +On the other hand, personalities who live their life mostly in third ecosystemic-non-dual +mode of existence (Deshmukh 2008) over a period of time become more and more +expanded in their awareness, thereby showing minimal attachment to the mind–body +Fig. 2 Development of mentally ill patient and spiritually advanced personality +J Relig Health +123 +complex, and minimal likes and dislikes for material things, persons or events (Yogananda +2009, p. 109). Brihadaranyaka Upanishad says, ‘If there is nothing else but me, what am I +afraid of? It is from a second entity that fear comes’ (Madhavananda 2009, p. 66). Thus, +this mode of existence removes the very basis of fear. As Sri Raman Maharshi said, ‘For a +Self-realized person, there are no others.’ A spiritually advanced person becomes more and +more fearless as he/she starts seeing one universal unifying principle in the heart of +everyone, including themselves, and then as they grow further, they see everything as +being projected on one holistic reality principle (Tapasyananda 2005, p. 179). This process +of dissolving the limited-ego into a higher unlimited-Self is known as ego-effacement. This +is achieved by a person on the journey to self-realization through systematic practice, and +then mastery over switching to and from different modes of existence, i.e., such people +shift efficiently from the dual to non-dual mode of existence without conflict. They can +thus lose their ego boundaries without any fear, or psychiatric problems such as delusions, +social withdrawal or loss of insight. When needed, they can once again switch to ego- +centric mode of existence and manage their socio-occupational roles without creating +chaos in their surroundings. As a result of merging with the higher reality principle, these +spiritually advanced personalities develop faculties for extra-sensory perception, intuition, +and creativity (Saraswati 2002, p. 254). All their actions are directed toward the welfare of +the humanity (Tapasyananda 2005, p. 180) (see Fig. 2). +Although Mr. X sounded similar to a spiritually advanced personality in some ways, in +actuality, he was not one, for the following reasons: (a) He was desperate to have a sense of +self, (b) he would compare himself to others and complain, ‘Why am I not like others who +are normal?’, (c) his face looked dull, sad, and anxious, (d) he was neither content nor +peaceful, (e) he was neither working nor studying, (f) he experienced both increased +appetite and disturbed sleep, (g) he wanted to avoid people, (h) he was a burden to his +family, surroundings, and society, (i) he was not able to contribute anything to uplift his +family or society, and finally, (j) he was a source of disharmony and misery for his family +and surroundings. With his prominent delusions of non-existence, disturbed sense of self, +social withdrawal, and repeated questioning about whether he existed, his final diagnosis +was paranoid schizophrenia with obsessive compulsive disorder. +The strength of the study is development of a thorough protocol based on both modern +psychiatric and the ancient yogic perspectives. The study compares and contrasts two dia- +metrically opposed systems of bio-medicine and spirituality. It enables mental health pro- +fessionals understand mental illness from a new perspective, that is of Indian psychology. +Table 2 offers a model which differentiates these two overlapping categories of per- +sonality—seemingly in their external manifestation. The model is based on definitions of +aspects of mind enunciated in Pathanjali’s Yoga Sutras: Mind has five distinct modes of +Table 2 A model for distinguishing schizophrenia and spirituality based on ancient yogic philosophy +Modes of mind +Definition +Schizophrenia +Spirituality +1. Citta +Regurgitation of memory +Fully operating +Not operational +2. Manas +Thought constructs +Active with imagination +Not active +3. Buddhi +Discrimination +Non-active +Active +4. Ahamkara +Ego +Active with self doubt +Non-active +5. Purusha +Real nature +Not known +Fully realized +J Relig Health +123 +operation, Citta, Manas, Buddhi, Ahamkara, and Purusha. The last, Purusha, is the Unity +Consciousness that all living beings are endowed with. Purusha is the eternal principle that +transcends time and space; to realize this is the ultimate goal of Yoga. Ahamkara is the +same as individual self, the ego that gets in the way of realization. Yoga provides with a +framework for transcending this individual ‘self’ to reach the Self or Purusha. In Table 2, +the difference in the mind that is self-centered and self-transcended can be seen based on +the Yoga model. +Conclusion +When a person has an altered sense of self, it becomes important to understand and be able +to differentiate tendencies to schizophrenia from spiritually advancement. This may be +achieved by assessing their predominant mode of existence: egocentric-dual versus eco- +systemic-non-dual, the ability to shift from one mode of existence to another without +confusion, the extent of likes and dislikes toward the material world, persons or events, as +well as the extent to which fear dominates their life. Although there may appear to be +superficial similarities on a gross clinical level, the two differ in their intentions in subtle +ways at all socio-ecological levels listed by Bronfenbrenner. In schizophrenia, alterations +of ‘sense of self’ involve weakening of the ego leading to its derangement and loss of +control over mind and senses. In spiritually advanced personalities, the ego is not deran- +ged; rather, by surrendering to the higher Being, it undergoes a gradual merging into a +higher unlimited-Self (ego-effacement) (Tapasyananda 2005, p. 71). Such a person, in fact, +becomes more aware of his ego and, by developing mastery over it, gains the freedom to +use it or let it go (Saraswati 2002, p. 147). Hopefully, these distinguishing points will help +psychologists and psychiatrists better diagnose such cases. +Conflict of interest +We hereby declare that there are no conflicts of interest in submitting this manuscript. +References +Aguilera, A., Lo +´pez, S. R., Breitborde, N. J., Kopelowicz, A., & Zarate, R. (2010). Expressed emotion and +sociocultural moderation in the course of schizophrenia. Journal of Abnormal Psychology, 119(4), 875. +Akroyd, M. J. (2013). You can’t spell schizophrenia without an ‘I’: How does the early intervention in +psychosis approach relate to the concept of schizophrenia as an ipseity disturbance? Early Intervention +in Psychiatry, 7(3), 238–246. +Baker, H. S., & Baker, M. N. (1987). Heinz Kohut’s self psychology: An overview. American Journal of +Psychiatry, 144(1), 1–9. +Ballentine, R., & Ajaya, S. (1976). Yoga and psychotherapy: The evolution of consciousness. Honesdale: +Himalayan Institute Press. +Basu, S. (1995). How the spiritual dimension of health was acknowledged by the world health assembly—A +report. New Approaches Medicinal Health, 3, 47–51. +Boulanger, M., Dethier, M., Gendre, F., & Blairy, S. (2013). Identity in schizophrenia: A study of trait self- +knowledge. Psychiatry Research, 209(3), 367–374. +Bronfenbrenner, U. (1979). The ecology of human development, experiments by nature and design. Cam- +bridge: Harvard University Press. +de Vries, R., Heering, H. D., Postmes, L., Goedhart, S., Sno, H. N., & de Haan, L. (2013). Self-disturbance +in schizophrenia: A phenomenological approach to better understand our patients. The Primary Care +Companion for CNS Disorders. doi:10.4088/PCC.12m01382. +Deshmukh, V. D. (2008). The multistream self: Biophysical, mental, social, and existential. The Scientific +World Journal, 8, 331–341. +Egan, H. D. (1998). Christian mysticism: The future of a tradition. Eugene: Wipf and Stock Publishers. +J Relig Health +123 +Grof, C., & Grof, S. (1986). Spiritual emergency: The understanding and treatment of transpersonal crises. +Revision, 8(2), 7–20. +Grof, S., & Grof, C. (1989). Spiritual emergency: When personal transformation becomes a crisis. Los +Angeles: Tarcher press. +Hansen, G. (1995). Schizophrenia or spiritual crisis? On’’ raising the kundalini’’ and its diagnostic classi- +fication. Ugeskrift for Laeger, 157(31), 4360–4362. +Hecht, D. (2010). Schizophrenia, the sense of ‘self’ and the right cerebral hemisphere. Medical Hypotheses, +74(1), 186–188. +Heinisch, C., Wiens, S., Gru +¨ndl, M., Juckel, G., & Bru +¨ne, M. (2013). Self-face recognition in schizophrenia +is related to insight. European Archives of Psychiatry and Clinical Neuroscience, 263(8), 655–662. +Kleinhaus, K., Harlap, S., Perrin, M. C., Manor, O., Weiser, M., Harkavy-Friedman, J. M., & Malaspina, D. +(2012). Catatonic schizophrenia: A cohort prospective study. Schizophrenia Bulletin, 38(2), 331–337. +Kohut, H., & Wolf, E. S. (1978). The disorders of the self and their treatment: An outline. International +Journal of Psychoanalysis, 59, 413–425. +Lam, D., Wright, K. I. M., & Sham, P. A. K. (2005). Sense of hyper-positive self and response to cognitive +therapy in bipolar disorder. Psychological Medicine, 35(01), 69–77. +Lodge, D. J., & Grace, A. A. (2011). Developmental pathology, dopamine, stress and schizophrenia. +International Journal of Developmental Neuroscience, 29(3), 207–213. +Lukoff, D. (2005). Spiritual and transpersonal approaches to psychotic disorders. In S. G. Mijares & G. +S. Khalsa (Eds.), The psychospiritual clinician’s handbook: Alternative methods for understanding and +treating mental disorders (pp. 233–257). New York: Haworth Reference Press. +Madhavananda, S. (2009). The Brhadaranyaka Upanishad. Kolkata: Advaita Ashrama Publication +Department. +Muktibodhananda, S. (1998). Hatha yoga pradipika. Munger, Bihar: Yoga Publication Trust. +Nelson, B., Thompson, A., & Yung, A. R. (2012). Basic self-disturbance predicts psychosis onset in the ultra +high risk for psychosis ‘‘prodromal’’ population. Schizophrenia Bulletin, 38(6), 1277–1287. +Nelson, B., Thompson, A., & Yung, A. R. (2013). Not all first-episode psychosis is the same: Preliminary +evidence of greater basic self-disturbance in schizophrenia spectrum cases. Early Intervention in +Psychiatry, 7(2), 200–204. +Nicholson, A. R. (2007). The mystics of Islam. California: Murine Press. +Nikhilananda, S. (1980). The Gospel of Sri Ramakrishna. Chennai: Sri Ramakrishna Math Publication. +Oxman, T. E., Rosenberg, S. D., Schnurr, P. P., Tucker, G. J., & Gala, G. (1988). The language of altered +states. The Journal of Nervous and Mental Disease, 176, 401–408. +Pierre, J. M. (2001). Faith or delusion? At the crossroads of religion and psychosis. Journal of Psychiatric +Practice, 7(3), 163–172. +Raballo, A. (2012). Self-disorders and the experiential core of schizophrenia spectrum vulnerability. Psy- +chiatria Danubina, 24(3), 303–310. +Rama, S. (1999). Living with the Himalayan masters. Honesdale: Himalayan Institute Press. +Rowland, J. E., Hamilton, M. K., Vella, N., Lino, B. J., Mitchell, P. B., & Green, M. J. (2012). Adaptive +associations between social cognition and emotion regulation are absent in schizophrenia and bipolar +disorder. Frontiers in Psychology. doi:10.3389/fpsyg.2012.00607. +Salvatore, G., Lysaker, P. H., Gumley, A., Popolo, R., Mari, J., & Dimaggio, G. (2012). Out of illness +experience: Metacognition-oriented therapy for promoting self-awareness in individuals with psy- +chosis. American Journal of Psychotherapy, 66(1), 85–106. +Sanella, L. (1978). Kundalini: Psychosis or transcendence. San Francisco: H. R. Dakin. +Saraswati, S. S. (2002). Four chapters on freedom: Commentary on the yoga sutras of Patanjali. Munger: +Yoga Publications Trust. +Shad, M. U., Keshavan, M. S., Steinberg, J. L., Mihalakos, P., Thomas, B. P., Motes, M. A., et al. (2012). +Neurobiology of self-awareness in schizophrenia: An fMRI study. Schizophrenia Research, 138(2), +113–119. +Sharma, P., Charak, R., & Sharma, V. (2009). Contemporary perspectives on spirituality and mental health. +Indian Journal of Psychological Medicine, 31(1), 16. +Strober, M. (1991). Disorders of the self in anorexia nervosa: An organismic-developmental paradigm. New +York City: Guilford Press. +Tandon, R., Keshavan, M. S., & Nasrallah, H. A. (2008). Schizophrenia, ‘‘just the facts’’ what we know in +2008. 2. Epidemiology and etiology. Schizophrenia Research, 102(1), 1–18. +Tapasyananda, S. (2005). Srimad Bhagavad Gita: The scripture of mankind. Chennai: Sri Ramakrishna +Math Publication. +Turner, R. P., Lukoff, D., Barnhouse, R. T., & Lu, F. G. (1995). A culturally sensitive diagnostic category in +the DSM-IV. The Journal of Nervous and Mental Disease, 183(7), 435–444. +J Relig Health +123 +Van, O. J., & Kapur, S. (2009). Schizophrenia. Lancet, 374(9690), 635–645. +Vander, G. R. (2007). Dictionary of psychology. Washington DC: American Psychological Association. +Vimuktananda, S. (1938). Aparokshanubhuti or self-realization of Sri Shankaracharya. Holistic health and +medicine (8th ed.). Calcutta: Advaita Ashram. +Vitaliano, P. P., & Katon, W. J. (2006). Effects of stress on family caregivers: Recognition and management. +Psychiatric Times, 13(7), 24–28. +Wilber, K. (1980). The atman project. Wheaton, IL: Theosophical Pub. House. +Yogananda, P. (2009). Autobiography of a Yogi. Kolkata: Yogoda Satsang Matha. +Zhao, Y., Zhang, D., Tan, S., Song, C., Cui, J., Fan, F., et al. (2014). Neural correlates of the abolished self- +referential memory effect in schizophrenia. Psychological Medicine, 44(03), 477–487. +J Relig Health +123 diff --git a/subfolder_0/Seeing the truth Yoga for health and harmony.txt b/subfolder_0/Seeing the truth Yoga for health and harmony.txt new file mode 100644 index 0000000000000000000000000000000000000000..450b4546057f66915ce0d0140adbd8e0bb3f6a94 --- /dev/null +++ b/subfolder_0/Seeing the truth Yoga for health and harmony.txt @@ -0,0 +1,114 @@ +1 +© 2018 International Journal of Yoga - Philosophy, Psychology and Parapsychology | Published by Wolters Kluwer - Medknow +Seeing the Truth: Yoga for Health and Harmony +Even though this erroneous perception  (viparyaya) +appears to be a universal phenomenon, it does obscure +the way we see our world around us, including the +people, place, and events. A  very few seekers of truth +would actually venture into finding the reality and +coming out of the illusory world of perceptions. The +only solution to this problem of viparyaya is to cognize +and experience things as they are. Shankara strongly +emphasizes that the root cause of the problem, the +illusory perception must cease first before the actual +truth is experienced as they are. Yoga also attempts to +achieve this same goal. Yoga highlights that the ultimate +goal is to get established in the inner Self, overcoming +all the modifications of the mind. Mastery over the +mind by the systematic practice of Yoga will meet the +challenge. At the practical level, to the extended sense +of I‑ness  (asmita), attachment  (raga), hatred  (dwesha) +are overcome, to that extent we weaken the field for +viparyaya to flourish. This can be effectively practiced +through selfless service and love. Staying in the state of +awareness and conducting our daily activities can further +support this practice of overcoming viparyaya. It is not +only dissociating with all sources of wrong knowledge, +and associating with the right knowledge, but also +going beyond them both so that no mental modification +can ever affect the established inner Self. This is the +ultimate state of being that the Yoga philosophy suggests +a seeker to follow. +Concluding this discussion, we can clearly observe that +an earnest attempt to see only the truth, things as they +are brings in great clarity and peace and can take us +out of our eternal misery. When such an ideal is lived +every day the very same essence percolates into our +whole being, even to the smallest cell of our body and +opens the gateway of abundant health, happiness, and +harmony. +HR Nagendra +Chancellor, Swami Vivekananda Yoga Anusandhana +Samsthana, 19, Eknath Bhavan, Gavipuram Circle, K.G. Nagar, +Bengaluru ‑ 560 019, Karnataka, India. + +E‑mail: chancellor@svyasa.edu.in +References +1. +Taimini  IK. The Science of Yoga. Madras, India: The +Theosophical Publishing House; 1986. +Editorial +According to Patanjali, there are five modifications of +mind: pramana, the right knowledge; viparyaya, wrong +knowledge; vikalpa, distracted mind; nidra, deep state +sleep without dreams; and smriti, memory.[1] Viparyaya +is erroneous perception or misapprehension arising out +of wrong knowledge and causes illusion and distraction +of mind. In the Sankhya philosophy, which is considered +as the basis of Yoga, it is said that viparyaya is caused +by ignorance  (avidya), sense of I‑ness  (asmita), +attachment (raga), hatred (dwesha), and deep attachment +toward the life  (abhinivesha). Wrong knowledge is a +false conception of an object, and that mental conception +does not match with the actual reality. +One time or the other, we all have experienced erroneous +perception. The train that we are in appears to be moving +while in reality the adjacent train moves. While the boat +appears to be still and the shore seems to be moving, +but it is the other way around. When we see a rope as +a snake in a dimly lit room, viparyaya is said to have +happened. Different blind men touch and describe an +elephant as they have perceived exemplifies viparyaya. +If a person with Jaundice thinks that the whole world +has become yellow, it is viparyaya. Hence, viparyaya is +said to happen when our perception and cognition do not +match with the actual nature of reality of the object of +perception. They all are wrong knowledge or distorted +knowledge. +Interestingly, in our body also something similar +appears to happen at psychological and cellular levels. +Schizophrenia is a manifestation of viparyaya thinking +that I am fine, nothing is wrong in me; so, no treatment +is needed, and wrong things are with others. Like a +person with Jaundice thinks that the whole world has +become yellow, a person with Schizophrenia perceives +the world in his own way assuming it to be the reality. +In Diabetes the immune system thinks that insulin is an +enemy and starts preventing it to reach the bloodstream. +In cancer, the immune system thinks that cancer cells +borne in our body are good friends and allows them to +grow. The root of all these is viparyaya. Abandoning +viparyaya at all levels can be the mantra for effective +conflict resolution and thereby overcoming all sources +of tension and stress.[2] However, how do we overcome +this viparyaya which appears to be a very common +phenomenon? +[Downloaded free from http://www.ijoyppp.org on Saturday, January 23, 2021, IP: 136.232.192.146] +Nagendra: Truth through yoga +2 +International Journal of Yoga ‑ Philosophy, Psychology and Parapsychology  ¦  Volume 7  ¦  Issue 1  ¦  January‑June 2019 +2. +Nagendra  HR, Nagarathna  R. New Perspectives in Stress +Management. Bangalore, India: Swami Vivekananda Yoga +Prakashan; 1997. +Access this article online +Quick Response Code: +Website: www.ijoyppp.org +DOI: 10.4103/2347-5633.255080 +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. +How to cite this article: Nagendra HR. Seeing the truth: Yoga for health +and harmony. Int J Yoga - Philosop Psychol Parapsychol 2019;7:1-2. +[Downloaded free from http://www.ijoyppp.org on Saturday, January 23, 2021, IP: 136.232.192.146] diff --git a/subfolder_0/Shorter latencies of middle latency auditory evoked potentials in congenitally blind compared to normal sighted subjects.txt b/subfolder_0/Shorter latencies of middle latency auditory evoked potentials in congenitally blind compared to normal sighted subjects.txt new file mode 100644 index 0000000000000000000000000000000000000000..04db6d8a4f725acacae077bd42824020a8ed47a5 --- /dev/null +++ b/subfolder_0/Shorter latencies of middle latency auditory evoked potentials in congenitally blind compared to normal sighted subjects.txt @@ -0,0 +1,437 @@ +lnrern J. Neuroscience, 1998, Vol. 95, pp. 173-181 +Reprints available directly from the publisher +Photocopying permitted by license only +1998 OPA (Overseas Puhlishers Association) N.V. +Published hy liceme under +the Gordon and Breach Science +Publishers imprint +Printed in India +SHORTER LATENCIES OF COMPONENTS +OF MIDDLE LATENCY AUDITORY +EVOKED POTENTIALS IN CONGENITALLY +BLIND COMPARED TO NORMAL +SIGHTED SUBJECTS +N. K. MANJUNATH, R. SRINIVAS, K. S. NIRMALA, +H. R. NAGENDRA, ARUN KUMAR and SHIRLEY TELLES* +Vivekanandu Kendra Yoga Research Foundation, Bangalore, India and Department +of Neurology, M.S. Ramaiah Medical Teaching Hospital, Bangalore, India +(Received 14 April 1998) +A previous study which reported shorter latencies of the N b component of AEP-MLRs in +congenitally blind compared to normal sighted subjects, formed the basis for the present study. +The blind subjects had received a rehabilitation program from the age of 4 years onwards, +which may have influenced auditory function. Hence the present study was designed to compare +the AEP MLRs of normal sighted subjects with age-matched blind subjects who had not +undergone early rehabilitation. Auditory evoked potentials (0 to 100 +ms. range) were recorded +in 10 congenitally blind subjects (average age = 22.4 *4.9 yrs.) and an equal number of age- +matched subjects with normal vision. There were two repetitions per subject. The peak latencies +of both the Pa (maximum positive peak between Na and 35 ms.) and Nb (maximum negative +peak between 38 and 52 ms.) waves was significantly shorter in congenitally blind compared to +normal sighted subjects. Since the Pa and Nb waves are believed to be generated by the superior +temporal cortex (Heschl’s gyrus), it appears that processing at this neural level occurs more +efficiently in the blind. Also, in spite of the absence of an early rehabilitation program the +present subjects showed the same auditory changes as those reported earlier. +Keywords: Middle latency auditory evoked potentials; congenitally blind; normal-sighted; +primary auditory area; auditory inputs for rehabilitation +Impaired vision during early development has been shown to give rise to +compensatory changes in the auditory system. Auditory perceptual +*Address for Correspondence: Vivekananda Kendra Yoga Research Foundation, No. 19, +Eknath Bhavan, K. G. Nagar, Bangalore 560 019. India. +173 +Int J Neurosci Downloaded from informahealthcare.com by Universitat de Girona on 11/11/14 +For personal use only. +174 +N. +K. MANJUNATH et al +sensitivity was modified in the congenitally blind, enabling them to use +echoes to perceive spatial positions of objects (Strelow and Brabyn, 1982). +Development of such abilities may be related to changes in auditory +processing. For example, the long latency event related potential waves (Nl, +P2, and P3) were found to have shorter latencies and higher amplitudes in +early blind humans compared to those with normal vision (Niemeyer and +Starlinger, 1981). The Nb component of AEP-MLR (average peak latency +44.3 ms) had a significantly shorter latency in congenitally blind persons +(Naveen, Srinivas, Nirmala, Nagendra and Telles, 1997). This suggested +that auditory information processing at the level of the posteromedial part +of the primary auditory cortex, the known generator of the Nb wave +(Likgeois-Chauvel, Musolino, Badier, Marquis and Chauvel, 1994) was +more efficient in the blind. +Based on investigations of somatosensory information in the blind it was +thought that adaptive changes may be enhanced by experience, such as +Braille reading (Sadato, Pascual-Leone, Grafman, Ibanez, Deiber, Dold and +Hallett, 1996). In the study on AEP-MLRs cited above (Naveen et al., +1997), the subjects were all participating in a systematic education and +rehabilitation program from the age of four years till the time of the study, +when the group average age was 14.3 f +1.4 years. The program included +learning based on Braille reading and auditory inputs. This gave rise to the +speculation that the rehabilitation program may have contributed to the +adaptations seen in auditory functioning. +Hence the present study was designed to determine the changes in +auditory function (measured through middle latency auditory evoked +responses, AEP-MLRs) in congenitally blind subjects who had minimal, +or no formal rehabilitation. +METHOD +Subjects +Two groups were studied with 10 subjects in each group, i.e., congenitally +blind and normal vision. The congenitally blind subjects (group average age +5 SD, 22.4 i +4.9 years) had a diagnosed peripheral visual deficit from birth +and no other abnormality. Blindness was confirmed by the absence of visual +evoked responses. The normal vision group was matched for age (exact +matching) and sex. They all had normal visual evoked responses elicited by +light flashes. The congenitally blind group received no formal rehabilitation +Int J Neurosci Downloaded from informahealthcare.com by Universitat de Girona on 11/11/14 +For personal use only. +EVOKED POTENTIALS IN CONGENITALLY BLIND +175 +(i.e., standard education using Braille or auditory cues) till the age of sixteen +years, when they started to receive vocational training (e.g., weaving). +Design of the Study +Subjects were assessed in a single sitting with two consecutive assessments +(Rl, +R2) of the AEP-MLR, to estimate the reproducibility of the recordings. +This was followed by a recording of Visual Evoked Potentials. +Recording of Evoked Potentials +Auditory middle latency evoked potentials were recorded in the looms. +poststimulus time period, from the vertex referenced to the right earlobe, +with the ground electrode on the forehead. The preamplifier band width +(Nihon Kohden, Neuropack 8, Japan) was set at 10 to 1500 +Hz. Altogether +1500 responses were averaged for each assessment. The rejection level was +expressed as a percentage of the full scale range of the analog-to-digital +convertor. This level was set at 85%. The number of sweeps was displayed +on the monitor. Click stimuli of 40 usec. duration and alternating polarity at +the rate of 5 Hz, were delivered binaurally through acoustically shielded +earphones (Elga DR-531, Japan). The intensity was kept at 85dB for all +assessments. The threshold of hearing was noted. +Visual evoked potentials were recorded in the 200 msec. time period from +Oz, referenced to the right earlobe, with the ground electrode on the +forehead. The preamplifier band width was set at I to l00Hz and 100 +responses were averaged for each period. The method for artifact rejection +was the same as for AEP-MLR, as described above. Light flashes were given +binocularly, using a LED visual stimulator (Nihon Kohden SLS 3500). +AEP-MLRs Components +Peak amplitudes of short latency wave V, +and middle latency Na, Pa and Nb +waves were measured from the baseline existing at the beginning of the +sweep. Peak latency was measured from the time of click delivery. Also the +peak amplitudes of AEP-MLR cortical components (i.e., Pa and Nb) +recorded from the conventional site (i.e., vertex) were compared with +recordings made from the occiput. +The auditory evoked response components were described as follows: +wave V was the maximum positive peak between 5 and 8 ms, the Na wave +was the maximum negative peak between 10 and Isms, the maximum +Int J Neurosci Downloaded from informahealthcare.com by Universitat de Girona on 11/11/14 +For personal use only. +176 +N. K. MANJUNATH et al. +positive peak between Na and 35 ms was described as the Pa wave, and the +maximum negative peak between 38 and 52ms was described as the Nb +wave. These descriptions are similar to other descriptions of AEP +components (Erwin and Buchwald, 1986; McPherson, Tures and Starr, +1989; Naveen et al., 1997). +Data Analysis +Comparison of peak latencies between congenitally blind subjects and those +with normal vision. The data were analyzed using two factor analyses of +variance (ANOVA), with Factor A = groups, i.e., congenitally blind versus +normal vision and Factor B = repeat recordings (Rl, R2). The Tukey +multiple comparison test was used to detect significant differences between +group mean values. +Similar analyses (as mentioned above) were done for the peak amplitudes. +The peak amplitudes of the cortically generated Pa and Nb components +recorded from Cz and Oz, were compared using two factor analyses of +variance, Factor A = groups (congenitally blind, normal sighted) and +Factor B = sites of recording (Cz, Oz). For these analyses the data of R1 +and R2 were pooled. +RESULTS +Comparison of peak latencies of congenitally blind and normal sighted +subjects showed significant differences between (i) Pa wave (the maximum +positive peak between Na and 35ms) and (ii) Nb wave (the maximum +negative peak between 38 and 52ms) peak latencies. The latencies of both +components were shorter in the congenitally blind compared to subjects +with normal vision. However, with the Tukey test for multiple comparisons +between mean values the peak latencies of Pa and Nb waves were not +significantly different between congenitally blind and normal sighted +subjects ( p +> +.lo, for both comparisons]. With the ANOVA, for Pa wave +peak latency [F for Factor A (two groups) = 5.64, since F0.05 (2) +1, +36 = 5.47, hence p < 0.051 and for Nb wave, [ F for Factor A (two +groups) = 4.70, since F0.05 (1) 1, 36 = 4.11, hence p < 0.051. The peak +latencies of wave V and Na wave did not show a significant difference +between groups or repeat recordings and also interaction between factors, +i.e., A x B (p > 0.50). The F value for df = 1,36 has been derived by linear +Int J Neurosci Downloaded from informahealthcare.com by Universitat de Girona on 11/11/14 +For personal use only. +EVOKED POTENTIALS IN CONGENITALLY BLIND +1 +1 +1 + +interpolation from the d +f + = 1,30 and d +f + = 1,40 from the standard table as +described (Zar, 1984). +Out of the 10 pairs of subjects studied: (1) in 5 blind subjects both Pa and +Nb waves had shorter latencies than those of the matched, sighted subjects, +(2) in another 3 blind subjects the Pa wave had a longer latency while Nb +wave was shorter than the matched normal sighted, there were also (3) 2 +blind subjects who had a shorter Pa wave latency and longer Nb wave +latency when compared to the corresponding normal sighted subjects. +Examples of 1, 2 and 3 have shown in Figure 1. +There were no significant differences between the peak amplitudes of the +AEP-MLR components of congenitally blind and normal sighted groups +AEP-MLR IN CB AND NV GROUPS +FIRST RECORDING +t +SECOND RECORDING +CB +NV +3 +CB +Nv +lOmsec +FIGURE 1 +Three examples of AEP-MLRs recorded in congenitally blind (CB) and subjects +with normal vision (NV), with two recordings each. The first example (1) shows shorter +latencies of Pa and Nb is CB compared to NV for both recordings. In the second example (2), +Pa latency is shorter (first recording) or the same (second recording) in CB compared to NV. +while N b latency is longer. The third example shows longer Pa latency and shorter Nb latency in +CB compared to NV, for both recordings. +Int J Neurosci Downloaded from informahealthcare.com by Universitat de Girona on 11/11/14 +For personal use only. +178 +N. K. MANJUNATH et at +recorded at Cz (Two factor ANOVA, Factor A = groups, p > 0.50 for all +comparisons, Factor B = repeat recordings, p > 0.50, and interaction +between factors ( A +x B), p > 0.50. +The peak amplitudes of congenitally blind and normal sighted subjects +showed significant differences in the Pa and Nb wave amplitudes recorded at +Cz and Oz. For Pa [ +F for Factor B = sites of recording (Cz, Oz) = 27.2, +since F0.001(2) 1, 76 = 13.24, hence p < 0.0011, and for Nb wave peak +amplitude [ F for Factor B = 10.6 since F0.002(2) 1, 76 = 9.8, hence +p < 0.0021. The Tukey test for multiple comparisons between the peak +amplitudes showed a significant difference between the mean value at Cz +and at Oz, but not between the groups. The Pa peak amplitude recorded at +Cz was significantly higher than that recorded at Oz for both congenitally +blind [q = 4.40, since q at probability level 0.025, for d +f + = 76, 4 = 4.14, +hence p < 0.0251 and normal sighted subjects [q += 6.04, since q at +probability level 0.001, for d f = 76, 4 = 5.60, hence p < 0.001]. With the +Tukey multiple comparison test the amplitudes of the Nb wave recorded at +Oz and Cz were not significantly different for both congenitally blind and +normal sighted subjects ( +p + > 0.50). +The group average values of peak amplitudes and latencies of the four +components studied, for the congenitally blind and normal sighted subjects +are given in Table I. +DISCUSSION +In the present study, congenitally blind subjects had significantly shorter +peak latencies of two middle latency auditory evoked potential components, +viz, Pa wave (the maximum positive peak between Na and 35ms) and Nb +wave (the maximum negative peak between 38 and 52ms was described as +TABLE I +normal vision (NV) groum. n = 10 each +Peak latencies and peak amplitudes of AEP-MLRs in congenitally blind (CB) and +Wave v +Nu wave +Pa wave +Nb wave +CB +N V +CB +N V +CB +N V +CB +N V +Peak +5.4 +5.4 +14.4 +14.0 +27.7 ** 30.1 +43.3 * +45.9 +latency (ms) ++0.4 +f 0 . 4 ++1.4 +52.0 +f 4 . 3 +i 2 . 8 +4r3.1 +*3.8 +Peak amplitude +0.9 +0.9 +0.8 +0.8 +0.7 +0.8 +0.7 +0.8 +(uV) at Cz +5 0 . 3 +f 0 . 3 +f 0 . 4 +10.5 +f 0 . 3 +5 0 . 5 +f 0 . 4 +f 0 . 5 +Peak amplitude +0.7 +0.7 +0.7 +0.9 +0.3 +0.2 +0.5 +0.7 +(uV) at Oz +f 0 . 3 +f 0 . 3 +f 0 . 4 +50.6 +1 0 . 3 +5 0 . 5 +h0.3 +h0.5 +~~ +~ +*p < 0.05 (one tailed); **p < 0.05 (two tailed); two factor ANOVA; CB versus NV +Int J Neurosci Downloaded from informahealthcare.com by Universitat de Girona on 11/11/14 +For personal use only. +EVOKED POTENTIALS IN CONGENITALLY BLIND +179 +the Nb wave) compared to age matched subjects with normal vision. In +blind subjects there was no difference between the amplitudes of the +cortically generated components (ie., +Pa and Nb) recorded over the vertex +(Cz) compared to those recorded from the occipital region (Oz). +Intracerebral recording in man has shown that the neural generator of the +Nb wave is relatively localized in the dorsoposterior medial part of the +Heschl’s gyrs, i.e., the primary auditory cortex (Likgeois-Chauvel, Muso- +lino, Badier, Marquis and Chauvel, 1994). The pa wave is related to +simultaneous activation of both supratemporal auditory cortices (Deiber, +Ibanez, Fischer, Perrin and Maugikre, 1988) and changes in Pa wave latency +have been regarded as due to modifications in the auditory pathways +between the midbrain and cortex (Morlet, Bertrand, Salord, Boulieu, +Pernier and Fischer, 1997). Hence in the present study subjects who had no +formal rehabilitation with no special programs based on auditory inputs +showed similar differences compared to normal sighted subjects, as blind +subjects who had undergone a formal rehabilitation program (Naveen et a/., +1997). In addition there was a shorter latency of the Pa wave, a possible +reason is discussed below. The absence of change in the wave V and Na +wave suggests that brainstem and diencephalic areas, which are known +generators of these waves (Deiber et al., 1988), appear unchanged. +A previous report comparing AEP-MLR components of congenitally +blind and normal sighted subjects, showed that blind subjects had a +significantly shorter Nb wave peak latency, similar to the results reported in +the present study, though in the earlier study there was no significant +difference between the peak latencies of the Pa component, between the two +groups. Normal sighted subjects of the two groups had exactly the same +peak latencies of wave V and Na waves. The Pa wave peak latency of +normal sighted subjects of the present study was 1.2 +ms longer than that of +the normal sighted subjects, studied earlier. In contrast, the Nb wave peak +latency of normal sighted subjects of the present study was 2.0ms shorter +than that of the normal sighted subjects, studied earlier. These differences +were not significant (t-test for unpaired data). It is possible that the longer +peak latency of the normal sighted subjects of the present study compared to +the normal sighted subjects studied earlier may have contributed to the +present result, viz the significantly shorter Pa peak latency in the blind +subjects. There was another difference between the subjects of the earlier +study (Naveen et al., 1997) and those of the present study, viz they belonged +to different age groups: for the earlier study, group average age was 14.3 +years with a range of 13 to 16 years, whereas subjects of the present study +had a group average age of 22.4 years with a range of 18 to 30 years. AEP +Int J Neurosci Downloaded from informahealthcare.com by Universitat de Girona on 11/11/14 +For personal use only. +180 +N. K. MANJUNATH et al. +MLRs were found to be significantly different between subjects of 20-40 +years age range and those with an age range of 60-80 years (Woods and +Clayworth, 1986). There are no reports available comparing AEP MLRs for +the much smaller age difference between the present and earlier studies. +However since the differences in peak latency were not significant, any +explanation based on the differences may be misleading. +A previous study (Alho, Kujala, Paavilainen, Summala and Naatanen, +1993), had described a larger processing negativity to attended tones at +occipital scalp sites in congenitally blind subjects compared to those with +normal vision. In the present study smaller amplitudes of Pa and Nb waves +of AEP-MLRs were recorded over Oz compared to Cz, in the congenitally +blind and normal sighted subjects. Hence there was no evidence of the +occipital cortices contributing to cortically generated AEP-MLRs in the +blind. +The results hence suggest that irrespective of early rehabilitation +programs, there is facilitation of processing of auditory information at the +level of the primary auditory cortex. However, the occipital area does not +play a role in auditory information processing at primary cortical areas, in +the congenitally blind. +References +Alho, K., Kujala, T., Paavilainen, P., +Summala, H. & Naatanen, R. (1993) Auditory processing +in visual brain areas of the early blind: evidence from event-related potentials, +Electroencephalography and Clinical Neurophysiology, 86, 41 +8 - +421. +Deiber, M. P., Ibanez, V., Fischer, C., Perrin, F. & Mauguitre, F. (1988) Sequential mapping +favors the hypothesis of distinct generators for Na and Pa middle latency auditory evoked +potentials, Electroencephalography and Clinical Neurophysilogy, 71, 181- 197. +Erwin, R. & Buchwald, J. S. (1986) Midlatency auditory evoked responses: differential recovery +cycle characteristics, Electroencephalography and Clinical Neurophysiology, 64, 41 +I +- +423. +Litgeois-Chauvel, C., Musolino, A., Badier, J. M., Marquis, P. & Chauvel, P. (1994) Evoked +potentials recorded from the auditory cortex in man: evaluation and topography of the +middle latency components, Electroencephalography and Clinical Neurophysiology, 92, +204 +- +21 +4. +McPherson, D. L., Tures, C. & Starr, A. (1989) Binaural interaction of the auditory brain-stem +potentials and middle latency auditory evoked potentials in infants and adults, +Electroencephalography and Clinical Neurophysiology, 74, 124- 130. +Morlet, D., Bertrand, O., Salord, F., Boulieu, R., Pernier, J. & Fischer, C. (1997) Dynamics of +MLAEP changes in midazolam-induced sedation, Electroencephalography and Clinical +Neurophysiology, 104, 431 +-446. +Naveen, K. V., Srinivas, R., Nirmdla, K. S., +Nagendra, H. R. & Telles, S. (1997) +Middle latency +auditory evoked potentials in congenitally blind and normal slighted subjects, International +Journal of Neuroscience, 90(1- 2), I05 +- +1 1 +1. +Niemeyer, W. & Starlinger, I. (1981) I. Do the blind hear better? Investigations on auditory +processing in congenital or early acquired blindness. 11. Central functions. Audiology, 20, +510-515. +Int J Neurosci Downloaded from informahealthcare.com by Universitat de Girona on 11/11/14 +For personal use only. +EVOKED POTENTIALS IN CONGENITALLY BLIND +181 +Sadato, N., Pascual-Leone, A., Grafman, J., Ibanez, V., Deiber, M. P., Dold, G. & Hallett, M. +(1996) Activation of the primary visual cortex by Braille reading in blind subjects, Nature, +380, 526-528. +Strelow, E. R. & Brabyn, J. A. (1982) Locomotion of the blind controlled by natural sound +cues, Perception, 11, 635-640. +Woods, D. L. & Clayworth, C. (1986) Age-related changes in human middle latency auditory +evoked potentials, Electroencephalography and Clinical Neurophysiology, 65, 297 +~ 303. +Zar, J . H. (1984) Biostatisticdl analysis. (2nd ed.) p. 477 (Prentice-Hall International Edition, +London). +Int J Neurosci Downloaded from informahealthcare.com by Universitat de Girona on 11/11/14 +For personal use only. diff --git a/subfolder_0/The Effect of One Month Yoga Intervention on Perceived Stress and Anxiety in Pregnant Women.txt b/subfolder_0/The Effect of One Month Yoga Intervention on Perceived Stress and Anxiety in Pregnant Women.txt new file mode 100644 index 0000000000000000000000000000000000000000..88deee7b4ae4e197faf98890c37200d09bdf6ac2 --- /dev/null +++ b/subfolder_0/The Effect of One Month Yoga Intervention on Perceived Stress and Anxiety in Pregnant Women.txt @@ -0,0 +1,438 @@ +a SciTechnol journal +Research Article +Bapat et al., J Womens Health, Issues Care 2016, 5:3 +http://dx.doi.org/10.4172/2325-9795.1000233 +All articles published in Journal of Women’s Health, Issues & Care are the property of SciTechnol, and is protected by +copyright laws. Copyright © 2016, SciTechnol, All Rights Reserved. +Journal of Women’s +Health, Issues & Care +International Publisher of Science, +Technology and Medicine +The Effect of One Month Yoga +Intervention on Perceived Stress +and Anxiety in Pregnant Women +Rashmi A Bapat*, SonyKumari and Nagendra HR +Abstract +The effect of one month yoga intervention on state anxiety and +perceived stress in pregnant women (n=40) was examined. The +participants were divided into two groups- yoga and control group. +Yoga group was given one month yoga intervention of asanas, +relaxation technique, praṇayama, and AUM meditation (thirty +minutes) for one hour every alternate day. Results indicated that +yoga intervention based AUM meditation contributed significantly to +reduce the perceived stress and anxiety in pregnant women. +Keywords +Pregnant women; State anxiety; Perceived stress; One month +yoga; Aum meditation +*Corresponding author: Rashmi Bapat, Swami Vivekananda Yoga Research +Foundation and University, Banglore-560011 India, Tel: 09870489477, +09742060024; E-mail: rashmibapat29@gmail.com +Received: March 4, 2015 Accepted: January 25, 2016 Published: January 29, +2016 +Introduction +Pregnancy is a very precious and important event in a woman’s +life. It is a state of physiological stress that necessitates physical, +mental and social adaptation. Human pregnancy is the most studied +of all mammalian pregnancies. With recent advances in obstetrics +the little life inside the womb can be visualized from the very first +day of fetal life, from the moment of conception until birth. It is +indeed artistic, accurate and awesome; the new life taking shape and +becoming active inside the mother to be so vivid and complex [1,2]. +Today’s urbanization and hectic life style pattern have increased risk +of complications during pregnancy. Emotional stress among all is +found to be more in urbanized population [1,3]. +It is true that the development of the baby is affected by several +maternal as well as several fetal factors. Hypertension, diabetes, +malnutrition, high stress levels in life style can cause harmful effects +on the fetus. Similarly chromosomal abnormalities in embryo +and infections in mother can cause several birth defects. These are +prone to several complications in new born period and even later in +childhood. Apart from these psychological stresses, fear, anxiety in +mother can cause serious problems resulting in poor outcome [1,4,5]. +It is now well-recognized that stress causes psycho-neuro- +immunological changes in the body leading to pregnancy +complications. It can lead to irregular, in coordinate uterine +contractions causing distress ending in operative surgery. +Hypersensitivity of mother leads to intolerance to pain, requiring +heavy dosage of pain killers which are not safe for unborn [6]. Prenatal +stress and outcomes-maternal stress and anxiety during pregnancy +have been associated with: Shorter gestation & higher incidence of +preterm birth. Smaller birth weight and length, increased risk of +miscarriage. Prospective studies have shown that maternal stress and +anxieties during pregnancy are related to infant outcomes; such as +Temperamental problems and increased fussiness, problems with +attention, attention regulation, and emotional reactivity, lower scores +on measures of mental development [1,5]. +Our ancient teachings and techniques from Yoga and Ayurveda +are found to be more effective. There can be many yogic relaxation +techniques that can be used to minimize emotional stress and to +create harmonious environment for coming child [6-9]. +An ancient holistic Indian science, yoga, has been used for +centuries for stress reduction and health promotion [10,11]. Positive +effects of integrated yoga modules have been demonstrated in women +with high- risk pregnancies [1,10,12] but no studies have looked the +effect of one month yoga intervention based on AUM meditation on +perceived stress and anxiety (Tables 1 and 2). The objective of the present +study was to assess the effect of one month yoga intervention. AUM +based meditation on perceived stress and anxiety in pregnant women. +Material and Methods +A total (n=40) forty pregnant women receiving antenatal care at +various obstetrics units in THANE and Mumbai, India were selected +for yoga intervention. The selected women, who were aged between 25 +years to 35 years and between 20th weeks to 28th weeks of pregnancy, +were randomized to the yoga or control group. Yoga group (n=20) +twenty and control group (n=20) twenty were divided randomly. +Both the groups were assessed for the pre and post physiological +parameters blood pressure, weight, pulse rate tests and psychological +PSS, STAI (form –X) tests. They were not informed about the hypothesis +of the study. Informed consent was obtained from them all. +Measures +The State- Anxiety Inventory (STAI) is a psychological inventory. +It was developed by psychologists Charles Spielberg, et al. in 1964. +Their goal in creating the inventory was to create a set of questions +that could be applied towards assessing different types of anxiety. Several +items on the STAI were reversed coded (Items 1, 2, 5, 8, 11, 15, 16, 19, and +20). State Trait Anxiety Inventory (STAI) was used to assess the anxiety +level of the pregnant woman in the initial stage and end stage of both 30 +days of control and 30 days of experimental group +The Perceived Stress Scale was developed to measure the degree +to which situations in one’s life are appraised as stressful. This was +measured before (1day) yoga intervention and after (30th day) for +both the groups. It contain 10 questions that would applied towards +assessing perceived stress level. Several items on PSS were reverse +coded (items 4, 5, 7, 8) High psychological Stress is associated with +high blood pressure, higher BMI, larger waist to hip ratio, shorter +Telomere length, higher cortisol levels, suppressed immune function, +decreased sleep, and Increased alcohol consumption. +Procedure +PSS and STAI (form -X) and parameters like blood pressure, +Citation: Bapat RA, Kumari S, Nagendra HR (2016) The Effect of One Month Yoga Intervention on Perceived Stress and Anxiety in Pregnant Women. J +Womens Health, Issues Care 5:3. +• Page 2 of 3 • +doi:http://dx.doi.org/10.4172/2325-9795.1000233 +Volume 5 • Issue 3 • 1000233 +weight, pulse rate were assessed before and after yoga intervention. +From Table 1, Yoga intervention includes of AUM meditation +sessions 30 minutes and yogic practices, set of loosening of joints, +breathing techniques, asanas, and pranayam alternately one hour for +four week [13,14]. +From Table 2, AUM meditation is a type of meditation in which +the person experience love and peace attune with the fetal movements, +journey within. Everyday life is interaction between the senses and the +outer world [15]. It is a technique for withdrawing the senses from +the outer world and bringing them together (fetus and mother, union +with cosmic soul). The union between you and your bigger self gives +the seat for creativity and peace [16]. Aum meditation decreases +oxygen consumption and heart rate and significant decrease in skin +resistance level. It produces a state of alert full rest [17,18]. +Result and Discussion +Means and SD, percentage, p value of the Measure of variables +by Yoga and Control groups before and after intervention is shown +in Table 3. +The performances of the control and yoga intervention +groups on the measure of PSS, STAI and other variables are shown +in Table 3. A close perusal of the scores reveals considerable gain by +the intervention group. The mean (M) and SD value of PSS, STAI, +pulse rate (PR), systolic blood pressure (Systolic B.P), diastolic blood +pressure (Diastolic B.P), of yoga group has reduced whereas in +control group value increased. The weight increased both in yoga and +control group. The percentage change of PSS & STAI was significant +within the group, whereas control groups shows no significance +expect weight. +As the scores were not normally distributed, Wilcoxon’s +Signed Rank Test was used. Table 4 shows that, there were reduced +percentage change of PSS & STAI value in yoga group (69.8%, +47.9%)compared with control group (88.7%, 61.04%)respectively +and p value<0.05 of PSS & STAI (0.019 & 0.006 ) were significant +within the group. This was supporting to the previous studies +based on only IAYT intervention given for pregnant women. +1 +2 +3 +4 +5 +6 +7 +8 +9 +10 +11 +12 +13 +Hasta yam śvasanam (Hands In and Out Breathing- ‘A’kar, ‘U ’kar,’M kar’ chanting)- 1 min +Hastavistāra śvasanam (Hands Stretch Breathing-‘A’kar, ‘U ’kar,’M kar’ chanting) - 2 min +Ka iparivartanaśvsanam (Side Twist Breathing) -1 min +Vajrasana -5min +Deep Relaxation- 15 min +Uttānapādāsana śvasanam (Leg Raise Breathing) -1 min +Setubandhāsana śvasanam (Hip Raise Breathing) -1 min +Vyāghrāsana śvasanam (Tiger Stretch Breathing) -1 min +Quick Relaxation techniocque ( “U”kar chant 5 times)-5min +Gulphagūra am (Ankle Rotation) -2 min +Jānuphalakākar a am (Kneecap Contraction) -1 min +Ardhātitaliāsana (Half Butterfly Exercise) -3 min +Poornātitaliāsana (Full Butterfly Exercise) -1 min +Table 1: Yogic practice. +1. Opening prayer +Sitting position ; vajrasana,sukhasana,sidhayoni asana +2.PURIFICATION: kapalbhati here avoided. Abdominalbreathing with “U”KARchantings -5times. +3.PREPARATION: +i. +Nadishodhan pranayama: 5 rounds ( linear awareness) +ii. +Shitali pranayama: 5 rounds ( surface aware ness) +iii. +Sitkari pranayama: 5 rounds ( surface awareness) +iv. +Brhamari pranayama: 5 rounds((3D-Three dimensional awareness) +4.Dharana:this is holding the same action.one is dharana on rupa “the form”,second is the wave “shabdda”. +(Dharana of chakras:from muladhar to sahastradal chakra) +5. Chanting of chakra mantras and AUM bijamantra repeatedly with the fast speed. +6. Slow down the speed of mantra chanting. +7. MERGING INTO SILENCE. +8. Closing prayer +Table 2: AUM meditation. +Yoga( n=20) +Control (n=20) +variables +pre +post +% +P value +pre +post +% +P value +M +SD +M +SD +M +SD +M +SD +Weight +60.455 +12.75 +63.460 +11.90 +44.51 +0.000* +51.1 +7.40 +54.5 +7.59 +55.55 +0.000* +Sys. B.P +117.3 +12.63 +114.2 +5.67 +19.94 +0.404 +116.2 +10.07 +114.9 +5.2 +17.31 +0.598 +Dia. B.P +77.4 +10.59 +78.15 +7.24 +67.30 +0.551 +75.8 +7.40 +78.8 +8.2 +28.15 +0.130 +PR +76.6 +8.82 +74.65 +8.2 +20.7 +0.090 +73.6 +3.96 +73.6 +3.6 +26.4 +0.638 +PSS +19.85 +4.28 +17.8 +3.22 +69.8 +0.019* +20.3 +4.6 +22.0 +3.19 +88.07 +0.107 +STAI +46 +5.7 +43.2 +5.66 +47.9 +0.006* +41.6 +6.49 +42.7 +7.69 +61.04 +0.123 +Note: (*significant) +Table 3: Means and SD, percentage, p value of the Measure of variables by Yoga and Control groups before and after intervention. +Citation: Bapat RA, Kumari S, Nagendra HR (2016) The Effect of One Month Yoga Intervention on Perceived Stress and Anxiety in Pregnant Women. J +Womens Health, Issues Care 5:3. +• Page 3 of 3 • +doi:http://dx.doi.org/10.4172/2325-9795.1000233 +Volume 5 • Issue 3 • 1000233 +Group +PSS +STAI +(P)value +%change +(P)value +%change +YOGA +0.019* +69.8 +0.006* +47.9 +CONTROL +0.107 +88.07 +0.123 +61.04 +Table 4: Wilcoxon’s signed Ranked Test. +Note: (*significant) +VARIABLES +WT +SYS. B.P +DIA. B.P +PR +PSS +STAI +PRE +0.021 +0.799 +0.820 +0.718 +0.383 +0.015 +POST +0.013 +0.989 +0.904 +0.314 +0.000* +0.602 +Table 5: Mann- Whitney Tests. +Table 5 presents the result of Mann Whitney test. Results of Mann +Whitney Test shows that there is a significant change in only the post +data PSS value in yoga group rather than control group, the other +variables shows no significant change. On the basis of these results we +can conclude that there is a significant difference between Yoga and +Control group (p<0.05). +The present study clearly indicates that AUM meditation based +one month yoga intervention given during 20th week to 28th week of +first pregnancy period of the average age group between 30-35years +contributed to better reducing perceived stress and state anxiety (PSS +and STAI) levels in pregnant women on Indian population and also +it is safe. +In general the participating reported improvement in alert +fullness. In addition they have experienced other benefits like +reduction in blood pressure, clarity in thinking, and relaxed feeling in +action. Earlier research on integrated yoga on Pregnancy experience +anxiety, and depression in normal pregnancy State (STAI I) anxiety +(decreased 15.65% in yoga, increased 13.76% in control), (2013) +this study lends further support to previous studies based on IAYT +intervention. However, there is need for a more detailed study on diet +based yoga intervention given for pregnant women. +References +1. Narendran S, Nagarathana R, Nagendra HR (2008) Garbhopanishad. Yoga +for pregnancy. SVYP, Banglore, India. +2. Satyapriya M, Nagarathna R, Padmalatha V, Nagendra HR (2013) +Effect of integrated yoga on anxiety, depression & well-being in normal +pregnancy. Complement Ther Clin Pract 19: 230-236. +3. Babbar S, Parks-Savage AC, Chauhan SP (2012) Yoga during pregnancy: a +review. Am J Perinatol 29: 459-464. +4. Chan KP (2014) Effects of parental meditation on pregnant Chinese women +in Hong Kong: A randomized controlled trial. Journal of Nursing Education +and Practice 5: 1. +5. Chang SC, Chen CH (2005) Effects of music therapy on women’s physiologic +measures, anxiety, and satisfaction during cesarean delivery. Res Nurs +Health 28: 453-461. +6. Ulkanatu (2005) Effect of yogic practices in pregnancy depicted by doppler +velocimetry studies of uterine arteries, umbilical artery and middle cerebral +artery of the fetus. +7. Cohen S, Kamarck T, Mermelstein R (1983) A global measure of perceived +stress. J Health Soc Behav 24: 385–396.  +8. Curtis K, Weinrib A, Katz J (2012) Systematic review of yoga for pregnant +women: current status and future directions.  Evid Based Complement +Alternat Med 715942. +9. Tambe B (2002) Ayurvedic garbhasanskar the art and science of pregnancy. +Nashik, India. +10. Borkar +A +(1941) + +Garbhasaàskära +udayäcyä +budhdimäana +va +ärogyyasampanna santatisäaöhé. Mehta publications, Pune, India. +11. Narendran S, Nagarathna R, Gunasheela S, Nagendra H R (2005) Efficacy of +yoga in pregnant women with abnormal doppler study of umbilical and uterine +arteries. J Indian Med Assoc 103: 12-14. +12. Pra na joçé (1892) Agnipurana. Manohar Joshi Prasad Publication, Pune, +India. +13. Sharma PV (2010) Cuçruta saàhitäa zuïut sihta. Volume 2, Vishawabharati +Oriental Publishers, Varanasi, India. +14. Rakhshani A, Nagarathna R, Mhaskar R, Mhaskar A, Thomas A, et al. (2012) +The effects of yoga in prevention of pregnancy complications in high-risk +pregnancies: A randomized controlled trial. Prev Med 55: 333-340. +15. Thavare PK (2001) Manunya yoni praapta jhaalelya jevaacya gatece vareana. +Shrimad Bhagawat Mahapurana Gitapress, Gorakhpur, India. +16. Sivananda SS (2000) Bhagavad Gita. Divine Life Society, Himalayas, India. +17. Sridevi V (2013) We make brilliant child through proper training from foetus. +Garbha vidhya. +18. Telles S, Nagarathna R, Nagendra HR (1998) Autonomic changes while +mentally repeating two syllables--one meaningful and the other neutral. Indian +J Physiol Pharmacol 42: 57-63. +Author Affiliations + + + Top +Swami Vivekananda Yoga Anusandhana Samsthana University, Bangalore, +India +Submit your next manuscript and get advantages of SciTechnol +submissions +™ +™ +50 Journals +™ +™ +21 Day rapid review process +™ +™ +1000 Editorial team +™ +™ +2 Million readers +™ +™ +Publication immediately after acceptance +™ +™ +Quality and quick editorial, review processing +Submit your next manuscript at ● www.scitechnol.com/submission diff --git a/subfolder_0/The first direct experimental evidence correlating ayurveda based tridoshaprakriti with western constitutional psychology somatotypes.txt b/subfolder_0/The first direct experimental evidence correlating ayurveda based tridoshaprakriti with western constitutional psychology somatotypes.txt new file mode 100644 index 0000000000000000000000000000000000000000..06800870c91214baf5183ac6cd38b753be42e2b6 --- /dev/null +++ b/subfolder_0/The first direct experimental evidence correlating ayurveda based tridoshaprakriti with western constitutional psychology somatotypes.txt @@ -0,0 +1,45 @@ +Anc Sci Life. Dec 2012; 32(Suppl 1): S25. +PMCID: PMC3800902 +OA01.25.The first direct experimental evidence correlating ayurveda based +tridosha prakriti, with western constitutional psychology somatotypes +Kashinath G Metri, Dr., Hemant Bhargav, Nagendra Hongasandra Ramarao, Rizzo-Sierra, Ramakrishna R Basavakatti, +and From 5th World Ayurveda Congress 2012 Bhopal, Madhya Pradesh, India. 7-10 Dec 2012 +Division of Yoga and Life Sciences, Sw ami Vivekanda Yoga Anusandhana Samsthana University, 19 Ekanath Bhavan, Gavipuram Circle, +Kempegow da Nagar, Bangalore, Karnataka, India +Sushruta Ayurvedic Medical College, Bangalore, Karnataka, India +Copyright : © 2012 Kashinath G Metri; licensee Ancient Science of Life. +This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), +w hich permits unrestricted use, distribution, and reproduction in any medium, provided the original w ork is properly cited. +Abstract +Purpose: +Ayurveda is one of the most ancient systems of medical health care. The basic principles, diagnosis of the diseases and +their treatment are based on individual prakriti (constitutional type). Ayurveda further classifies the prakriti of an individual +on the basis of a set of psychosomatic attributes of personality, depending on whether this individual belongs to Vata, +Pitta, or Kapha prakriti, or any combination of them (Patwardhan et al., 2005). The appropriate prakriti assessment is +done by several means including questionnaires (Rastogi, 2012; Shilpa and Venkatesha-Murthy, 2011). We aimed to +obtain experimental evidence correlating Ayurveda based tridosha-prakriti with western constitutional psychology +somatotypes (Rizzo-Sierra, 2011). +Method: +We employed our Tridosha-prakriti questionnaire (Ramakrishna and Nagendra, 2012), and compared its results with a +set of body composition parameters: Height, body weight, body mass index (BMI), muscle mass, fat mass, and fat +percentage in normal healthy volunteers (25 males and 25 females, mean age was 26 (± 4) and 25 (± 6) years +respectively). Moreover, two-tailed Pearson's correlations were investigated to match the extreme prakriti types with the +western constitutional psychology somatotypes, through the mentioned body composition measures. +Result: +Significant negative correlations were observed between the percentage of Vata attributes as per the questionnaire in the +individuals and their BMI, body weight and fat mass respectively (p<0.05). Similarly, there was a significant positive +correlation between the percentage of Pitta attributes with the height, body weight, and muscle mass respectively. Also, a +significant positive correlation was observed between the percentage of Kapha attributes with fat mass and fat +percentage, along with a negative correlation with height. +Conclusion: +We provide evidence-linking Ayurveda to modern constitutional psychology. In this way, a concept such as prakriti is +suggested to lie behind the body mass composition of an individual, and deserves attention within the scientific +community. +1 +1 +1 +1 +2 +1 +2 +Articles from Ancient Science of Life are provided here courtesy of Medknow Publications diff --git a/subfolder_0/Therapeutic efficacy of add-on yogasana intervention in stabilized outpatient schizophrenia.txt b/subfolder_0/Therapeutic efficacy of add-on yogasana intervention in stabilized outpatient schizophrenia.txt new file mode 100644 index 0000000000000000000000000000000000000000..268f49b19ac7faa3ea26d7fd26b77c10f8286b23 --- /dev/null +++ b/subfolder_0/Therapeutic efficacy of add-on yogasana intervention in stabilized outpatient schizophrenia.txt @@ -0,0 +1,286 @@ +8/12/2014 +Therapeutic efficacy of add-on yogasana intervention in stabilized outpatient schizophrenia: Randomized controlled comparison with exercise and waitlist +http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3512358/ +1/7 +Therapeutic efficacy of add-on yogasana intervention in stabilized outpatient schizophrenia: +Randomized controlled comparison with exercise and waitlist +Shivarama Varambally, B. N. Gangadhar, [...], and H. R. Nagendra +Abstract +Background: +Schizophrenia is a highly disabling illness. Previous studies have shown yoga to be a feasible add-on therapy in schizophrenia. +Aims: +The current study aimed to test the efficacy of yoga as an add-on treatment in outpatients with schizophrenia. +Settings and Design: +The study done at a tertiary psychiatry center used a single blind randomized controlled design with active control and waitlist +groups. +Materials and Methods: +Consenting patients with schizophrenia were randomized into yoga, exercise, or waitlist group. They continued to receive +pharmacological therapy that was unchanged during the study. Patients in the yoga or exercise group were offered supervised +daily procedures for one month. All patients were assessed by a blind rater at the start of the intervention and at the end of 4 +months. +Results: +Kendall tau, a nonparametric statistical test, showed that significantly more patients in the yoga group improved in Positive and +Negative Syndrome Scale (PANSS) negative and total PANSS scores as well as social functioning scores compared with the +exercise and waitlist group. Odds ratio analysis showed that the likelihood of improvement in yoga group in terms of negative +symptoms was about five times greater than either the exercise or waitlist groups. +Conclusion: +In schizophrenia patients with several years of illness and on stabilized pharmacological therapy, one-month training followed by +three months of home practices of yoga as an add-on treatment offered significant advantage over exercise or treatment as usual. +Yoga holds promise as a complementary intervention in the management of schizophrenia. +Keywords: Add-on treatment, schizophrenia, yoga +INTRODUCTION +Schizophrenia affects persons in the productive age group and the majority of the affected have a chronic course. Consequently, +the disorder ranks in the top ten causes of disease-related disability in the age group 15 to 44 years.[1] Despite best antipsychotic +medications, residual symptoms particularly in the form of negative and cognitive symptoms, produce significant disability.[2] +Treatment strategies, individually or in combination, are hence aimed at containing these symptoms. +Some of these include rehabilitation, behavior modification, and other psychosocial therapies, which produce variable benefits. +Cognitive retraining has been shown to have salutary effects on cognition and global functioning in patients with schizophrenia. +[3] Yoga has emerged as an attractive add-on intervention. Cognitive benefits have been obtained with addition of Yoga in +8/12/2014 +Therapeutic efficacy of add-on yogasana intervention in stabilized outpatient schizophrenia: Randomized controlled comparison with exercise and waitlist +http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3512358/ +2/7 +patients with schizophrenia residing in an institutional setting.[4] Most patients with schizophrenia, however, can remain on +outpatient follow up, though they may have residual symptoms. Duraiswamy et al.[5] evaluated a yogasana regimen against +comparable duration of non-yoga exercises as an add-on therapy to outpatients with schizophrenia “stabilized” on +antipsychotics. Both groups of patients improved with respect to negative symptoms and social functions over four months, +more so in the yogasana group. The authors concluded that yogasana and, if not available, exercise should be added to the +therapy for patients with schizophrenia. However, it is not known if this benefit observed was due to the time lag alone. +Therefore, the present study was designed to control for this nonspecific time-lag effect. Efficacy of add-on yogasana was +compared with exercise and a waitlisted group in three groups of outpatients with schizophrenia, with the hypothesis that Yoga +would be more efficacious than physical exercise, which in turn would be better than waitlist. +MATERIALS AND METHODS +The study was conducted at the National Institute of Mental Health and Neurosciences, a large psychiatric hospital with both +inpatient and outpatient services. The Institute's ethics review committee approved the study. +Patients attending outpatient services on follow-up with a diagnosis of schizophrenia were screened for the following: (a) +receiving antipsychotic medication without change in dosages in the last three months, (b) rated as moderately symptomatic with +a score of 3 or more on clinical global impression,[6] and (c) not received Electro Convulsive Therapy (ECT) in the past three +months. They were initially invited to participate in this three-group randomized study. They received detailed explanation +about the procedures and were told that they had a right to withdraw the consent during the study. Permission was also obtained +from the treating consultants that patients will be randomized and followed up for assessments in the next four months without +change of medication status unless absolutely needed. Where possible, their caregivers were also contacted. They were explained +about the nature of study and their consent to accompany patients to therapy and follow-up sessions was obtained. A psychiatrist +confirmed the diagnosis of schizophrenia according to Diagnostic and Statistical Manual IV (DSM-IV)[7] criteria before +allocating the random number. +Random allocation +One investigator (JT) uninvolved in the treatments or assessments generated random numbers for 120 patients to be allocated to +three groups of approximately equal numbers. A subject's allocation to one of these groups was kept concealed and was +ascertained only after he/she consented and when he/she was to be randomized. Only the social worker and the yoga therapist in +the study were informed to start the corresponding intervention. The rest of the research team was unaware of the current group +allocation. The three groups allocated were yogasana (n=47), exercise (n=37), and waitlist (n=36). Assessments began after +allocation. +Assessments +A trained clinician rated the patients on the following instruments: (a) Positive and Negative Syndrome Scale (PANSS),[8] (b) +Social and Occupational Functioning Scale (SOFS),[9] and (c) Extra Pyramidal Symptoms.[10] These assessments were conducted +before staring the interventions and four months thereafter. Variable number of patients (not all) also attended scheduled follow- +up visits at the end of the supervised yoga therapy and a month thereafter, but we have used the data of only the baseline and 4 +month's assessment data. The rater was unaware of group allocation. Interventions of the research were initiated following first +assessment. +Improvement +Drop in scores between baseline and 4 month assessment were computed as arithmetic difference to operationally define +improvement in a given patient as follows: a drop of 15 for PANSS total score, a drop of 7 each for PANSS negative and +positive scores, and a drop of 14 for SOFS total score. +Yogasana +th +th +8/12/2014 +Therapeutic efficacy of add-on yogasana intervention in stabilized outpatient schizophrenia: Randomized controlled comparison with exercise and waitlist +http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3512358/ +3/7 +This included a set of procedures detailed elsewhere.[5] The regimen included certain postures and breathing patterns. No +component of meditation was included. A certified yoga teacher taught these to all patients in the first month. Each session was +of 45-minute duration. They were expected to attend 25 sessions in the first month. +Exercise +The procedures were drawn from a standard package as described elsewhere.[5] Each session lasted for 45 minutes and like in the +yogasana group, about 25 sessions were offered in one month. +Waitlist +These patients received treatment as usual, similar to the two other groups, but neither yoga nor exercise. This group was offered +one month of either of the two as they preferred but only after study period (4 months). Fourteen patients chose to receive +yogasana for a month after the study period. +Participation incentive +No patient was offered any incentive to participate in the study. However, to facilitate the participation, bus fare or bus pass was +provided to the patient and the relative to travel between their residence and the yoga center. +Dropouts +In both the two active intervention groups, variable number of patients failed to complete 75% attendance (defined as adequate) +to the sessions. Likewise, some did not turn up at the 4 month follow-up and therefore the final sample was smaller; 39, 22, and +34 in yogasana, exercise, and waitlist groups, respectively. +Practice at home +Patients who learnt yogasana or exercise were expected to practice the same at home. The relative who accompanied the patient +during the one-month training was requested to encourage the patient to practice these at home. Patients were given a log book +to verify the regularity of practice and bring the same at their monthly follow-up visits. This latter was poorly followed by +patients; negligible number brought the books at follow-up. It is difficult, therefore, to authenticate the home-practice. +Analyses +The data were managed by one investigator (JT) uninvolved with the treatment, follow-up, or assessments. This investigator +generated and maintained the random sequence and ensured allocation concealment. The three groups were compared at baseline +as regards the variables using ANOVA or chi-square test as was relevant. The baseline variables on PANSS and SOFS did not +follow normal distribution (Shapiro-Wilk test of normality; P<0.001), and hence subsequent analyses were nonparametric. To +compare the change from baseline to 4 month assessments in each of the three treatment groups, Wilcoxon sign rank test was +used for four variables (PANSS negative, positive, and total as well as SOFS). Accordingly, Bonferroni correction for each +variable's alpha values was applied (i.e., alpha value was set at P<0.05/3=0.016). To test the hypothesis that yoga therapy is +more efficacious than physical exercise, which is in turn is more efficacious than waitlist, Kendall's Tau statistic was used. Odds +ratios with 95% confidence intervals were computed to compare the proportion of patients showing improvement across +individual interventions with one another. Primary outcome variable was PANSS scores and the secondary outcome variable was +SOFS scores. +RESULTS +In a period of about 20 consecutive months, 941 patients were screened for the study. The consenting patients (n=119) in the +three groups were comparable with regard to demographic variables [Table 1]. At 4 month follow-up, 24 patients were +unavailable (four from yoga, 14 from exercise, and three from waitlist groups). The 24 patients who dropped out were not +th +th +th +8/12/2014 +Therapeutic efficacy of add-on yogasana intervention in stabilized outpatient schizophrenia: Randomized controlled comparison with exercise and waitlist +http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3512358/ +4/7 +significantly different from the 95 who completed on age (t=1.40; P=0.16), sex (chi-square=0.14; P=0.80), level of education +(chi-square=2.20; P=0.33), and PANSS scores at baseline (PANSS positive, t=-0.71, P=0.48; PANSS negative, t=-1.06, P=0.29; +PANSS total, t=-1.24, P=0.56). Among the 95 patients who completed (39 in yoga, 22 in exercise, and 34 in waitlist groups), +baseline clinical variables were comparable [Table 2]. +Table 1 +Demographic variables across the three groups at baseline +Table 2 +Baseline clinical variables of patients who completed the trial +Reductions occurred in the PANSS (negative and total scores) and SOFS scores between baseline and 4 month assessments, and +remained significant after Bonferroni correction in the Yogasana group [Table 3]. Subjects in the exercise group also obtained +significant reduction in SOFS score, but neither the exercise nor the waitlisted groups obtained any significant reductions in any +of the other outcome variables. The proportions of patients who obtained “improvement” in PANSS negative, PANSS total, and +SOFS scores were higher in the yogasana group as compared with exercise or waitlisted groups [Table 4]. Odds ratio statistic +indicated that Yogasana produced a 5-fold increase in the chance of obtaining improvement in PANSS negative scores as +compared with either exercise (Odds ratio=5.000; 95% CI=1.01 – 24.74) or waitlist (Odds ratio=5.167; 95% CI=1.32 - 20.1). +The likelihood of improvement in yoga group in terms of total PANSS score was about six times greater than in the waitlist +group (Odds ratio=6.576; 95% CI=1.69 – 25.66). The interventions had no effect on drug-induced extrapyramidal ratings (data +not presented). +Table 3 +Psychopathology and socio-occupational functioning scores at baseline and after 4 months +Table 4 +Number and percentage of patients who showed improvement at 4 months in psychopathology and socio-occupational +functioning scores +DISCUSSION +In this sample of antipsychotic-stabilized schizophrenia patients who had an average illness duration of 10 or more years, add-on +intervention of Yogasana was better than another add-on intervention (exercise) or mere wait listing. The patients learnt +yogasana for one month and were advised to practice the same in the next three months at home. This resulted in significant +reductions in not only the PANSS scores, but also improved social function ratings. Changes in the exercise or waitlisted groups +of patients were not significant. More patients in the Yogasana group were improved as compared with the other two groups on +these scales. +The findings confirmed the beneficial effects of add-on yogasana intervention in schizophrenia.[5] The present study is an +improvement in the design over this previous study by way of having a no-add-on-intervention group (waitlist). Unlike a +th +8/12/2014 +Therapeutic efficacy of add-on yogasana intervention in stabilized outpatient schizophrenia: Randomized controlled comparison with exercise and waitlist +http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3512358/ +5/7 +previous study in institutionalized schizophrenia patients,[4] those attending outpatient services were investigated. This was done +as the latter category of patients represents a prototype patient of schizophrenia needing help. The present study was also aimed +at investigating the effects of Yogasana that can be offered with less rigorous but practical once-a-day yoga sessions. This +method of offering an add-on Yogasana intervention produced benefits. +The benefits though were significant statistically, may be clinically less so. The magnitude of difference was small. It must be +realized, however, that on PANSS, their scores were at the lower end to begin with, and scope for further reduction may be +smaller. At the end of 4 months, about a third could become “improved,” as defined operationally in the Yogasana group as +against less than 10% in the other two groups. Therefore, the changes seen in these four months cannot be merely brushed aside +as a spontaneous variations in the course of a long-standing disorder. Instead, credit should be given to Yogasana intervention. +The magnitude of differences between the present study and the one published from the same center[5] are comparable. Also, the +benefits obtained in negative symptoms have been replicated. This aspect of the illness is generally considered to be less +amenable for corrections.[11,12] Yogasana and not merely exercise conferred advantage in reducing negative symptoms. It may +be noted that a recent Cochrane review has pointed to benefits of physical exercise in patients with schizophrenia.[13] +It is not clear how each of these postures produce a psychobiological effect that is conducive for therapeutic effect. While +practicing yogasana, attention needs to be paid on breathing pattern for attaining each posture. Cognitive remediation procedures +use attention-enhancing procedures and have been found beneficial in schizophrenia.[14] It is likely that Yogasana intervention +could be providing this benefit in addition to that provided by physical postures and hence may be better than mere exercise. +Yogasana postures without emphasis on attention to breathing may hence have to be compared with postures alone as regards to +effects in schizophrenia. A sample from this study was also tested on an emotion-recognition task and the Yogasana group +differentially benefitted compared with the other two groups.[15] This benefit on social cognition could be a result of the +attentive component of Yogasana and indirectly also benefited the negative symptoms. The role of Yogasana on drug-induced +extrapyramidal side effects was lacking and hence this explanation cannot be invoked for the benefits observed. +Would the Yogasana intervention have produced better clinical results than merely statistically significant ones? The practices +were limited to asanas and pranayama variants only. Had the patients practiced all components of Ashtanga yoga, would the +benefits have been more striking? The answer is a guarded “yes,” with some caveats. Yama and Niyama border on faith-related +practices and hence can have variable effects. Also, Dhyana (meditation) has a risk of exacerbating psychosis. Some have +highlighted the risk of activation of psychosis during meditation.[16] Also, Dhyana, Dharana, Pratyahara, and Samadhi +procedures (also called Antaranga yoga, higher states of yoga practice) cannot be objectively verified. In patients who have +schizophrenia, a good proportion of whom suffer from motivational defects, ensuring these more mindful practices poses a +challenge. Once patients perfect asanas and pranayama, and provided they are under close supervision by both yoga and mental +health specialists, other elements of yoga should be gradually introduced. This will ensure both a longer term Yogasana practice +and also graduation to other elements of yoga that could be beneficial. +The rigor with which they may have practiced Yogasana at home is even more questionable. This cannot be verified as few +patients adhered to the request of bringing the log/diary at follow-up assessment. As patients lived with their families (unlike in +some other societies) and reported to follow up with a family member, the latter's version, if the patient practiced these +procedures (Yogasana/exercise), could be verified within the limits of certainty. It may also be noted that patients were subsidized +as regards their travel expenses for the participation in the study. Yet, a substantial proportion did not adhere to the study needs. +It is likely that some form of community Yogasana practice closer to the patients’ residences can facilitate adherence and +benefits thereof. Alternatively, practices needing fewer days or lesser frequency of supervised training may make the +intervention more patient-friendly and deserve evaluation. Introducing yogasana early in course of illness may have some +advantages. The families as well as the patients are likely to become better motivated and the intervention may hence be more +effective. +CONCLUSIONS +In summary, moderately symptomatic patients with schizophrenia who were on stabilized medications on outpatient follow-up +th +8/12/2014 +Therapeutic efficacy of add-on yogasana intervention in stabilized outpatient schizophrenia: Randomized controlled comparison with exercise and waitlist +http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3512358/ +6/7 +obtained benefits from yogasana practices. Baseline to 4 month PANSS scores and social dysfunction ratings significantly +dropped in the yoga group, but not in the waitlisted group. The exercise group patients showed a drop in social dysfunction scores +only. Improvement occurred in about 35% of patients of Yoga group in contrast to fewer than 10% in the other two groups. As +regards positive symptoms, no such benefit occurred with any interventions. The study is an improvement over an earlier one as +regards the methodology, inclusion of a third group of waitlisted patients. The findings confirm previous study in that yoga +produces significant, albeit modest, reductions in negative symptoms. This result should encourage adding of Yoga as a +complementary therapy for patients with schizophrenia. +ACKNOWLEDGMENTS +Data quoted are from an EMR Research project funded by the Department of AYUSH, Govt. of India, through the Central +Council for Research in Yoga and Naturopathy, New Delhi, to Dr. B. N. Gangadhar. +Footnotes +Source of Support: EMR Research project funded by the Department of AYUSH, Govt. of India +Conflict of Interest: None declared +Article information +Indian J Psychiatry. 2012 Jul-Sep; 54(3): 227–232. +doi: 10.4103/0019-5545.102414 +PMCID: PMC3512358 +Shivarama Varambally, B. N. Gangadhar, Jagadisha Thirthalli, Aarti Jagannathan, Santosh Kumar, G. Venkatasubramanian, D. Muralidhar, D. K. +Subbakrishna, and H. R. Nagendra +Department of Psychiatry, Psychiatric Social Work, and Biostatistics, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, +India +Director, Swami Vivekanananda Yoga Anusandhana Samsthana (SVYASA), Bangalore, Karnataka, India +Address for correspondence: Dr. Shivarama Varambally, Department of Psychiatry, National Institute of Mental Health and Neurosciences, Hosur Road, +Bangalore-560 029, Karnataka, India. E-mail: ssv.nimhans@gmail.com +Copyright : © Indian Journal of Psychiatry +This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits +unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. +This article has been cited by other articles in PMC. +Articles from Indian Journal of Psychiatry are provided here courtesy of Medknow Publications +REFERENCES +1. Murray CJL, Lopez AD. The Global Burden of Disease; A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and +Risk factors in 1990 and projected to 2020. Cambridge, MA: Harvard University Press; 1996. +2. McGurk SR, Moriarty PJ, Harvey PD, Parrella M, White L, Friedman J, et al. Relationship of cognitive functioning, adaptive life skills, and +negative symptom severity in poor-outcome geriatric schizophrenia patients. J Neuropsychiatry Clin Neurosci. 2000;12:257–64. [PubMed] +3. Hegde SR, Raguram A, Gangadhar B N. Addition of cognitive retraining to improve global functioning in schizophrenia. Schizophr Bull. +2009;35(Suppl 1):295. +4. Nagendra HR, Telles S, Naveen KV. An integrated approach of Yoga therapy for the management of schizophrenia. New Delhi: Final Report +submitted to Dept. of ISM and H, Ministry of Health and Family Welfare, Government of India; 2000. Contract No.: Document Number. +th +1 +1 +8/12/2014 +Therapeutic efficacy of add-on yogasana intervention in stabilized outpatient schizophrenia: Randomized controlled comparison with exercise and waitlist +http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3512358/ +7/7 +5. Duraiswamy G, Thirthalli J, Nagendra HR, Gangadhar BN. Yoga therapy as an add-on treatment in the management of patients with +schizophrenia--a randomized controlled trial. Acta Psychiatr Scand. 2007;116:226–32. [PubMed] +6. Guy W. ECDEU Assessment Manual for Psychopharmacology. Maryland: US Department of Health, Education and Welfare, NIMH Publication; +1976. Clinical Global Impression (CGI) +7. American PA. Diagnostic and statistical manual of mental disorders. 4th ed. Washington DC: American Psychiatric Press; 1994. +8. Kay SF, Opler R. The positive and negative syndrome scale for schizophrenia (PANSS) Schizophr Bull. 1987;13:261–76. [PubMed] +9. Saraswat N, Rao K, Subbakrishna DK, Gangadhar BN. The Social Occupational Functioning Scale (SOFS): A brief measure of functional status +in persons with schizophrenia. Schizophr Res. 2006;81:301–9. [PubMed] +10. Simpson GM. A rating scale for extra-pyramidal side effects. Acta Psychiatr Scand Suppl. 1970;(Suppl 212):11–9. [PubMed] +11. Leucht S, Pitschel-Walz G, Abraham D, Kissling W. Efficacy and extrapyramidal side-effects of the new antipsychotics olanzapine, quetiapine, +risperidone, and sertindole compared to conventional antipsychotics and placebo. A meta-analysis of randomized controlled trials. Schizophr Res. +1999;35:51–68. [PubMed] +12. Buckley PF, Stahl SM. Pharmacological treatment of negative symptoms of schizophrenia: therapeutic opportunity or cul-de-sac? Acta Psychiatr +Scand. 2007;115:93–100. [PubMed] +13. Gorczynski P, Faulkner G. Exercise therapy for schizophrenia. Cochrane Database Syst Rev. 2010:CD004412. [PubMed] +14. Lewandowski KE, Eack SM, Hogarty SS, Greenwald DP, Keshavan MS. Is cognitive enhancement therapy equally effective for patients with +schizophrenia and schizoaffective disorder? Schizophr Res. 2011;125:291–4. [PubMed] +15. Behere RV, Arasappa R, Jagannathan A, Varambally S, Venkatasubramanian G, Thirthalli J, et al. Effect of yoga therapy on facial emotion +recognition deficits, symptoms and functioning in patients with schizophrenia. Acta Psychiatr Scand. 2010;123:147–53. [PubMed] +16. Walsh R, Roche L. Precipitation of acute psychotic episodes by intensive meditation in individuals with a history of schizophrenia. Am J +Psychiatry. 1979;136:1085–6. [PubMed] diff --git a/subfolder_0/Traditional practices and recent advances in NadiPariksha a comprehensive review..txt b/subfolder_0/Traditional practices and recent advances in NadiPariksha a comprehensive review..txt new file mode 100644 index 0000000000000000000000000000000000000000..6364089680eaeda01565f4108912402cc04e95b8 --- /dev/null +++ b/subfolder_0/Traditional practices and recent advances in NadiPariksha a comprehensive review..txt @@ -0,0 +1,956 @@ +Review Article +Traditional practices and recent advances in Nadi Pariksha: +A comprehensive review +P. Venkata Giri Kumar a, *, Sudheer Deshpande b, H.R. Nagendra c +a Division of Yoga and Physical Sciences, S-VYASA Yoga University, Bengaluru, Karnataka, India +b VYASA, Eknath Bhavan, Bengaluru, Karnataka, India +c S-VYASA Yoga University, Bengaluru, Karnataka, India +a r t i c l e +i n f o +Article history: +Received 4 May 2017 +Received in revised form +12 October 2017 +Accepted 16 October 2017 +Available online 10 August 2018 +Keywords: +Gati +Kathinya +Pulse wave velocity +a b s t r a c t +The significance of Nadi Pariksha is well understood and effectively used by Ayurveda practioners for +assessing Tridoshas and various physiological and psychological states of the patient. The traditional texts +Sarangadhara Samhita, Yoga Ratnakara, Basavarajeeyam and Bhavaprakasha have discussed the details of +Nadi Pariksha in succinct set of slokas. Ayurveda has thousands of years of rich experience in Nadi Par- +iksha with strong literature support but is subjective in nature and the need for studying nadi with a +scientific approach is well understood. Recently, pulse wave velocity has gained significant research +interest as it is considered to be a strong indicator of cardiovascular disease; however, the relevance of +pulse wave analysis to Nadi Pariksha has not been studied. In this review, traditional methods of Nadi +Pariksha as defined in Ayurveda classics and the recent advances in pulse wave analysis are discussed. As +per classical texts, qualities or properties of pulse such as pulse movement (gati), speed of the pulse +(vega), stability of the pulse (sthiratva) and hardness of the artery (kathinya) play major role in Nadi +Pariksha and in the current review these properties were analyzed and compared with the modern pulse +parameters namely pulse wave velocity, pulse rate variability and arterial stiffness. The significance of +pulse wave velocity in cardiovascular studies is discussed and the need for extending these studies to +Ayurveda is highlighted. +© 2017 Transdisciplinary University, Bangalore and World Ayurveda Foundation. Publishing Services by +Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ +licenses/by-nc-nd/4.0/). +1. Introduction +Ayurveda is well known for Nadi Pariksha and classical texts +have emphasized its significance in assessment of Tridoshas which +are the basis of disease diagnosis and prognosis [1e4]. There is a +precise description of dosha predominance in the texts which can +be sensed from specific locations on radial artery and accordingly +vata dosha is felt at the root of the thumb which can be sensed with +index finger, next to it is pitta dosha which can be sensed with +middle finger followed by kapha dosha sensed by ring finger. As per +ayurveda balanced Tridoshas represent the sound health and viti- +ated doshas lead to diseases. According to Yoga Ratnakara all the +diseases can be diagnosed from Nadi and it was compared with +strings of veena playing all the ragas which signifies the importance +of Nadi Pariksha [3]. The speed, stability and gati of the pulse vary +with the aggravated doshas and assessing such variations with Nadi +Pariksha is an art and science of its own. The traditional ayurvedic +practitioners were adept in pulse based diagnosis and used to di- +agnose the diseases effectively by just placing fingers on the radial +artery. +Ayurveda has rich experience in pulse based diagnosis but it is +subjective in nature and is highly dependent on skill of the physi- +cian. In recent past there is a growing research interest in acquiring +the pulse from Tridosha locations and analyzing the pulse wave +forms scientifically in the context of ayurveda. The pulse patterns of +vata, pitta and kapha doshas were studied in detail by Upadhyaya as +part of the clinical and experimental studies on Nadi Pariksha using +Dudgeon Sphygmograph [5]. It was a detailed study covering the +systematic review of ayurvedic literature, hemodynamics and sta- +tistical analysis of pulse patterns representing vata, pitta and kapha +doshas of normal and diseased persons. The mean pulse rate and +mean pulse pressure were studied across vata, pitta and kapha +doshas and the significance of pulse parameters rate, rhythm, +* Corresponding author. +E-mail address: girikumar.pv@gmail.com (P.V.G. Kumar). +Peer review under responsibility of Transdisciplinary University, Bangalore. +Contents lists available at ScienceDirect +Journal of Ayurveda and Integrative Medicine +journal homepage: http://elsevier.com/locate/jaim +https://doi.org/10.1016/j.jaim.2017.10.007 +0975-9476/© 2017 Transdisciplinary University, Bangalore and World Ayurveda Foundation. Publishing Services by Elsevier B.V. This is an open access article under the CC +BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). +Journal of Ayurveda and Integrative Medicine 10 (2019) 308e315 +volume, force, tension, character and hardness of the artery were +analyzed in the context of ayurveda. In similar lines Vasant has +analyzed the physiological significance of pulse parameters gati +(movement), vega (rate), tala (rhythm), bala (force), tapamana +(temperature), akruti (volume and tension) and kathinya (consis- +tency of the vessel wall) across vata, pitta and kapha doshas [6]. +These initial studies accentuated the importance of the pulse +parameters in analyzing Tridoshas in more scientific way compared +to qualitative analysis. In this review the pulse measuring locations +used in Tridosha analysis were highlighted and qualities or prop- +erties of Nadi as explained in ayurveda classics were discussed. The +physiological significance of qualities of Nadi was analyzed and +compared them with the modern pulse parameters which includes +pulse wave velocity, arterial stiffness and pulse rate variability. +Recent advances in pulse wave analysis were highlighted and the +relevance of pulse wave analysis techniques to Nadi Pariksha was +underscored. As part of the review various pulse measuring in- +struments used in current research and its application to Tridosha +analysis were discussed. Traditional practices in Nadi Pariksha were +manual and there were no instruments available for measuring the +pulse whereas modern pulse wave analysis makes use of in- +struments both in clinical and research applications. In this review +the role of modern instruments in studying the traditional pulse +parameters was discussed. +The ancient texts of ayurveda were included in the study of Nadi +Pariksha. The ayurveda texts included were Sarangadhara Samhita, +Yoga Ratnakara, Basavarajeeyam and Bhavaprakasha. Nadi Vijnana +by Upadhyaya and Secrets of the Pulse by Vasant were also included +in the study of traditional practices of Nadi Pariksha. A detailed +search was undertaken using key words Nadi, Nadi Pariksha in +pubmed, google scholar, science direct and google. The search +yielded only six papers which discussed Nadi Pariksha [7e13] as per +classical texts and there were no papers discussing the relevance of +recent advances in pulse wave analysis to Nadi Pariksha which +underlines the need for a comprehensive review of Nadi Pariksha. +2. Pulse parameters +Traditionally Nadi Pariksha was done by sensing the pulse at +three locations on radial artery and assessing doshas from palpation +of the pulse. The qualities or properties of the Nadi are vital in +assessing doshas as part of Nadi Pariksha. The classical texts have +emphasized the significance of gati, a unique quality of the pulse, as +part of Nadi Pariksha and as per texts gati plays a key role in disease +diagnosis [1e4]. There is no equivalent term for gati in modern +medicine and pulse movement is the closely matching term in +modern medicine which can be associated to gati. There are many +other qualities of pulse apart from gati (pulse movement) which +texts have highlighted and in this review the gati and other quali- +ties of pulse were discussed in detail. +As per Ashtanga Hridayam guru (heavy), manda (slow), hima +(cold), snigdha (unctuous), slakshna (smooth), sandra (solid), mridu +(soft), sthira (stable), sukshma (subtle), visada (non slimy) and their +opposites laghu (light), tikshna (quick, fast), usna (hot), ruksha (dry), +khara (roughness) drava (liquid), kathina (hard), cala (moving), +sthula (big), picchila (slimy) are twenty qualities or gunas which +play key role in disease diagnosis and specifically in assessing +doshas [14]. The qualities of pulse also need to be understood from +these properties and the review of classical texts revealed that the +texts have used the terms manda (slow), vega (fast), sthira (stable), +capala (unstable), kathina (hard), sukshma (subtle) and picchila +(slimy) while explaining the qualities of pulse [1e4]. The texts have +explained the significance of the pulse properties, but in qualitative +manner which is subjective in nature and the need for quantitative +description of these properties is well understood in the light of +evidence based research. This necessitates the review of pulse +properties defined in classical texts with a view to understand the +physiological significance of the pulse and identify the modern +pulse parameters which can be associated to the traditional pulse +properties. +The qualities manda (slow), vega (fast), sthira (stable), capala +(unstable) and kathina (hard) are of research significance as these +qualities or properties are measurable and can be associated to +modern pulse parameters. The terms manda (slow) and vega (fast) +correspond to the speed or velocity of the pulse and in Sar- +angadhara Samitha while explaining Nadi Pariksha vidhi the term +vega is used for increased pulse rate and ksheena and manda are the +terms used for decreased pulse rate [4]. The term vega can be +closely associated to speed of velocity of the pulse and can be +associated to modern pulse parameters such as pulse rate and pulse +wave velocity. +The stability of the pulse has been dealt with in detail in the +texts while explaining Nadi Pariksha and the texts have used terms +sthir (stable) and capal (unstable) while explaining the stability of +the pulse [3,4]. The stability is referred as sthiratva in doshadi vij- +naniya +adhyaha +(sutrasthana) +of +Ashtanga +Hridayam +while +explaining prakruta dosha karma [14]. The texts have not used the +term sthiratva while explaining Nadi Pariksha but this term can be +used to represent the stability of the pulse and can be closely +associated to modern parameter pulse rate variability. As stable +pulse is more rhythmic in nature the term tala which corresponds +to rhythm can also be used to represent stability of the pulse and +Vasant has used the term tala in Secrets of the Pulse [6]. In this re- +view the term sthiratva has been used to represent the stability of +the pulse as it is used in most of the classical texts. +The texts have used the term kathinya to explain the hardness of +the artery and reference to kathinya is available only in Basavar- +ajeeyam. In dviteeya prakarana of Basavarajeeyam while explaining +the signs of mrityu nadi the term kathinya has been used and in +triteeya prakarana of Basavarajeeyam the term kathinya is used to +explain the nature of kapha [1]. The term kathin (hard) represented +as kathinya corresponds to hardness of the artery and can be closely +associated to modern pulse parameter arterial stiffness. Vasant [6] +has used the term consistency of the vessel wall to explain kathi- +nya whereas Upadhyaya [5] has used the term condition of the +vessel wall for the same. In this review the term hardness of the +artery is used to represent kathinya and is associated to arterial +stiffness which is measurable and has research significance. +In summary gati (pulse movement), vega (speed of the pulse), +sthiratva (stability of the pulse) and kathinya (hardness of the ar- +tery) are identified as measurable qualities of Nadi which can be +closely associated to modern pulse parameters pulse movement, +pulse wave velocity, pulse rate variability and arterial stiffness +respectively. In this review the qualities of Nadi have been dis- +cussed in line with the modern pulse parameters with a view to +bring out the physiological significance behind Nadi Pariksha. +2.1. Gati (pulse movement) +The dosha predominance can be well assessed with gati which is +a very unique way of diagnosis in ayurveda wherein the movement +of the pulse has been compared with the movement of animals, +birds and reptiles. According to the texts the movement of vata +pulse, well known as sarpa gati, will be curved resembling move- +ment of snake (sarpa) and leech (jaluka). The curved and zigzag +nature of movement is the significance of vata pulse and in Basa- +varajeeyam the vata pulse has been explained to be of vakra and +kutil in nature which signifies the curved movement [1]. Bhavap- +rakasha has not compared the gati with the movement of animals +or birds but similar to Basavarajeeyam explained it to be of vakra in +P.V.G. Kumar et al. / Journal of Ayurveda and Integrative Medicine 10 (2019) 308e315 +309 +nature [2]. The movement of pitta pulse, well known as manduka +gati, was compared with the movement of frog which will be +hopping and jumping in nature and was explained with the words +capal and utplutya which signifies the jumping nature. The slow +movement (manda gati) is the significance of kapha pulse, well +known as hamsa gati, which has been compared with the move- +ment of swan. The ayurveda texts have explained the gati of the +pulse when more than one dosha is present and according to the +texts gati will be of sarpa and manduka in nature if both vata and +pitta doshas are in aggravation, similarly it will be of sarpa and +hamsa in nature if vata and kapha doshas are in aggravation and will +be of manduka and hamsa in nature if pitta and kapha doshas are in +aggravation. It is quite evident from the texts that gati plays a sig- +nificant role in assessing the dosha predominance and traditional +ayurveda doctors were adept in assessing gati from nadi. +2.1.1. Pulse movement +The traditional practice of assessing gati has been in practice for +thousands of years but it is very subjective in nature and in the +current context of evidence based research it is important to assess +the nature of gati in scientific manner with a clear understanding of +its physiological significance. Upadhyaya as part of his clinical and +experimental studies on Nadi Pariksha discussed the physiological +significance of gati from rate, volume and character of the pulse and +according to him vata pulse signifies the rate of the pulse to be fast, +volume to be small and character to be curvilinear resembling sarpa +gati, if the rate is slow, volume to be high and character is of +jumping in nature it resembles pitta pulse and slow rate with vol- +ume in between vata and pitta resembles kapha pulse [5]. In +another study by Joshi, nadi patterns of healthy and diseased per- +sons were analyzed using computational models with promising +results [12]. These initial studies highlight the physiological sig- +nificance of gati but needs thorough validation to establish the +physiological significance of gati and its nature across Tridoshas in +various states of the health. As it is quite evident from the texts that +gati plays an important role in assessing dosha, it is utmost +important that current research in ayurveda should focus on the +ways of validating gati in a measurable way. +2.2. Vega (speed of the pulse) +The speed of the pulse is another aspect which ayurveda has laid +much importance in understanding various physiological, psycho- +logical and pathological states of the person. According to Sar- +angadhara and Bhavaprakasha [2,4], the increase in lust and anger +result into fast nadi and on the other hand nadi will be slow due to +the increase in sorrow and fear. Sarangadhara has related the speed +of the nadi to digestive fire and said nadi will be fast when the +digestive fire is active and will be slow when the digestive fire is +weak. Traditionally ayurveda doctors used to assess speed of the +pulse from nadi but now with the advent of bio medical in- +struments measuring the speed of pulse has become simple and +sophisticated. The pulse rate is well known measure of the speed of +pulse and has been widely used in clinical practice which gives +initial assessment of state of the health but warrants the need for +further investigations to diagnose the disease. Pulse wave velocity +is another parameter with significant research interest and can be +associated to vega and there is a need to study this parameter in the +context of ayurveda. +2.2.1. Pulse wave velocity +The blood flows faster in aorta compared to peripheral network +and the speed varies from meters per second in aorta to mm per +second in peripheral network. The velocity of the pulse wave is +termed as pulse wave velocity (PWV) and normally ranges from 5 +to 15 m/s. In the recent past pulse wave velocity (PWV) is consid- +ered as an indicator of cardiovascular risk and has gained signifi- +cant research interest [15]. The longitudinal studies have shown +that aortic PWV is a strong predictor of future cardiovascular events +and all cause mortality [16]. The longitudinal studies on aortic and +carotid stiffness in predicting the cardio-vascular disease are listed +in Table 1 [17]. The European Society of Hypertension and European +Society of Cardiology has suggested a threshold exceeding 12 m/s as +a conservative estimate of significant alterations in aortic function +of hypertensive patients and later the threshold has been adjusted +to 10 m/s considering the true anatomical distance traveled by +pulse wave [18]. The studies on the subjects with hypertension, end +stage renal disease and geriatrics have confirmed the predictive +value of aortic PWV especially in assessing the cardiovascular +events [19e21]. +The studies have shown significant results with pulse wave +velocity in modern medicine and in the context of ayurveda the role +of PWV in Tridosha analysis need to be explored. The pulse wave +velocity may not be directly related to vega defined in traditional +text but can be closely associated to it and the variations in doshas +can be studied by measuring the pulse wave velocity. The dosha +predominance has been discussed in classical texts of ayurveda and +according to the texts kapha dominance can be seen in childhood, +pitta dominance in middle age and vata dominance in old age. +Secondly as per ayurveda nature of vata corresponds to fastness, +pitta corresponds to medium speed and kapha corresponds to +slowness. The studies have shown that the pulse wave velocity +measured using carotid femoral technique increases with age and +hence pulse wave velocity can be considered as an important pulse +parameter in studying dosha dominance and classifying doshas. +Carotid femoral technique is gold standard and as a first step it can +be used to study the pulse wave velocity in the context of Tridosha +analysis. +2.3. Sthiratva (stability of the pulse) +The ayurveda classics have discussed the stability of the pulse in +detail with a mention of intermittent nadi which will be sometimes +slow, sometimes fast and sometimes stops in between. Basavar- +ajeeyam has used the term sthitva sthitva to explain the intermittent +pulse while explaining the qualities of sannipatha nadi [1]. As per +the texts nadi which is intermittent in nature and is sensed in the +locations other than the specified place indicates to be fatal which +may lead to early death of the patient. Basavarajeeyam [1] and Yoga +Ratnakara [3] have termed it as asadhya nadi and as per Basavar- +ajeeyam it is the nature of mrityu nadi also. The stability of the pulse +Table 1 +Longitudinal studies on aortic and carotid stiffness. +Measurement site +Type of patient (Reference) +Follow +up (years) +Mean +age +Aortic PWV (Regional +arterial stiffness) +End Stage Renal Disease [19] +6 +51 +Hypertension [21] +9.3 +50 +Elderly (>70) [20] +2.5 +87 +End Stage Renal Disease [48] +5.2 +55 +Hypertension [29] +5.7 +51 +Impaired Glucose Tolerance [49] +10.7 +51 +Hypertension [50] +7.9 +51 +Elderly [51] +4.6 +74 +General Population [15] +10 +64 +General Population [52] +9.4 +55 +Elderly [53] +4.1 +72 +Ascending aorta +(invasive) +Recurrent acute Coronary Heart +Disease [54] +3 +55 +Carotid stiffness +(local stiffness) +End Stage Renal Disease [55] +2.1 +58 +End Stage Renal Disease [56] +7.9 +43 +P.V.G. Kumar et al. / Journal of Ayurveda and Integrative Medicine 10 (2019) 308e315 +310 +also depends on various physiological and psychological states of +the person. According to Sarangadhara Samhita nadi will be strong +and steady in healthy persons and the nadi of a hungry person will +be irregular when compared to that of a person who has just taken +the food [4]. +2.3.1. Pulse rate variability +Traditionally rhythm of the pulse is felt from the palpation of the +pulse which is more qualitative in nature but with instruments it is +possible now to acquire the pulse as time series enabling the +rhythm of the pulse to be analyzed in quantitative manner. In the +recent past there is a growing research interest in studying pulse +rate variability (PRV) as surrogate marker of heart rate variability +(HRV) [22e24]. There are no equivalent terms in traditional texts +which can be compared with PRV but intermittent nadi can be +closely associated to PRV as the nature of intermittent nadi can be +well understood by looking into pulse rate variability and missing +peaks, beat to beat alterations in pulse interval are some of the +important parameters which can explain the intermittent nadi. The +beat to beat alterations of the pulse wave acquired using Nadi +Tarangini showed significant variations across different age groups +and disorders [25]. The arterial pulse intervals (API), analyzed +across time domain, frequency domain and non linear measures +showed significant variations across age and disorders [26]. The +stability or rhythm of the pulse has a significant role in Nadi Par- +iksha but there was no detailed description in the texts about its +association with Tridoshas. As the pulse acquisition has become +much more sophisticated there is a need to study the association of +pulse rate variability with Tridoshas. An indepth study of inter- +mittent nadi is the need of the day as it is considered to be serious +as per the texts and extending PRV analysis to Tridoshas can be a +significant step in Nadi Pariksha. +2.4. Kathinya (hardness of artery) +The hardness of the artery is closely associated to kathinya and +only Basavarajeeyam has discussed the nature of kathin nadi in +detail [1]. As per Basavarajeeyam vata nadi will be hard and the +hardness of the artery has been explained with the words kathor +and kathin whereas the hardness of the artery due to pitta and +kapha doshas was not mentioned. The hardness (kathin) and +roughness (khara) of the artery corresponds to vata dosha as per +ayurveda and Basavarajeeyam compared vata nadi with string of +veena which signifies the hardness of the vata nadi. The blood flow +in hardened arteries will be fast compared to normal arteries which +implies that vata pulse will be fast which is in agreement with +ayurveda. According to Basavarajeeyam if nadi is kathin, very slow +moving in a curved manner, if it is displaced from its original po- +sition then it is considered as mrityu nadi and is an indicator for +early death of the patient. +2.4.1. Arterial stiffness +The arteries stiffen due to age and atherosclerosis and recently +the arterial stiffness measured from pulse wave velocity (PWV) has +gained significant research importance as it is considered to be +strong predictor of cardio-vascular events [16,27] and Alberto et al. +have discussed in detail the role of arterial pulse wave analysis in +cardiovascular risk assessment [28]. A longitudinal study by Bou- +touyrie provides the first direct evidence that the aortic stiffness is +an independent predictor of primary coronary events in hyper- +tensive patients [29] and in another independent study by Laurent, +the aortic stiffness is confirmed to be in an independent predictor +of all cause and cardiovascular mortality in hypertensive patients +[21]. The pulse wave velocity, a surrogate measure of arterial +stiffness, closely corresponds to the description of mrityu nadi. +The stiffness index (SI) is a measure of arterial stiffness and is +measured from radial artery which closely corresponds to the +volume pulse measured using photoplethysmograph (PPG). The SI +measured from digital volume pulse (DVP) of PPG is strongly +associated to cardiovascular risk score emphasizing the significance +of its utility in cardiovascular risk stratification [30]. In our previous +study we have seen that the SI measured from radial artery using +Nadi Tarangini, a pulse acquisition system, has shown significantly +high values at vata location for diabetes compared to non-diabetes +and SI was negatively correlated to fasting plasma glucose in non +diabetes subjects [31]. The study has shown SI at pitta location was +significantly high compared to vata and kapha locations which +might be due to the fact that the average age of the subjects both in +diabetes and non-diabetes groups is around 50 years a pitta +dominant age. Nadi Tarangini has three linearly placed pressure +transducers which can be placed on the Tridosha locations of radial +artery and the pulse will be acquired from vata, pitta and kapha +locations. The advantage of such a system is that the arterial stiff- +ness measured from three locations can be analyzed simulta- +neously and initial studies with Nadi Tarangini have shown that the +arterial stiffness varies significantly across vata, pitta and kapha +locations. The pressure wave as it propagates from central to pe- +ripheral arteries gets amplified at peripheral artery due to multiple +reflections from various reflection sites and the reflection sites are +closer to peripheral arteries when compared to central arteries. As a +result due to the pulse amplification, peripheral arteries do not give +accurate results in cardiovascular studies and hence the arterial +stiffness measured from peripheral arteries was not used as a sur- +rogate for aortic and carotid stiffness [17] and there are very limited +cardiovascular studies with radial artery. As radial artery plays a +major role in ayurveda, SI measured from radial artery can be +considered as significant parameter in Tridosha analysis. As the +significance of arterial stiffness is well understood from the texts of +ayurveda and also from the recent studies, there is a need to study +the arterial stiffness in the context of Tridosha analysis. +3. Pulse locations +Ayurveda has laid much emphasis on sensing the pulse at radial +artery primarily to assess doshas but it has not limited the pulse +location to just radial artery but has clearly defined that the pulse +can be sensed from eight locations. The classical text Basavar- +ajeeyam has mentioned about eight locations to sense nadi and +accordingly there are two at radial artery, two at ankle, two at neck +region and two at nasal region [1]. It is also mentioned that the +knowledge of vata, pitta and kapha doshas can be obtained from +radial artery and Nadi Pariksha based on radial artery has been +widely practiced as it is important to assess Tridoshas for any dis- +ease diagnosis and treatment. Though radial artery plays a major +role in disease diagnosis and treatment, nadi at neck and nasal +regions was also considered as important nadi in diagnosis and +prognosis of disease. The fear, sorrow, anger, lust and fever are +some of the symptoms which can be sensed from the nadi at neck +and similarly the diseases pertaining to head, eyes and ears can be +diagnosed from the nadi at nose. The status of life and health, fever +and its relief are sensed from nadi at ankle. It is evident from the +literature of Ayurveda that nadi pariksha has a major role in disease +diagnosis and is not limited to radial artery but extended to other +arteries. +As per modern physiology pulse is palpated at radial, carotid, +femoral, brachial and ankle arteries and this is in line with the +description in ayurveda except that there was no mention of +femoral artery in ayurveda and arteries at nasal region in modern +physiology are not highlighted. The significance of radial artery +based pulse diagnosis is well understood in ayurveda and has been +P.V.G. Kumar et al. / Journal of Ayurveda and Integrative Medicine 10 (2019) 308e315 +311 +widely practiced but the nadi at other locations are not explored +much. On the other hand the radial artery has a very limited role in +modern medicine and is limited to just measuring the pulse rate +whereas they have given much emphasis on carotid, femoral, +brachial and ankle arteries which were widely used in measuring +the pulse wave velocity. +4. Pulse measurement techniques and instruments +The pulse parameters and their analysis play key role in disease +diagnosis in both ayurveda and modern medicine. In the evidence +based research, pulse measurement techniques and the in- +struments used for such measurements are very critical. There are +multiple pulse measurement techniques for assessing arterial +stiffness from central and peripheral arteries. The pulse wave ve- +locity and stiffness index are measures of arterial stiffness and +techniques are developed to assess arterial stiffness from pulse +wave velocity and stiffness index. The standard pulse wave velocity +measurement techniques are carotid femoral pulse wave velocity +(cfPWV) and brachial ankle pulse wave velocity (baPWV). The ca- +rotid and femoral arteries are used for pulse wave velocity mea- +surement in carotid femoral pulse wave velocity (cfPWV) technique +whereas brachial and ankle arteries are used for pulse wave ve- +locity measurement in brachial ankle pulse wave velocity (baPWV) +technique. Stiffness Index (SI) is measured from the radial artery. In +this section pulse measurement techniques and instruments used +for measurement were discussed. +4.1. Carotid femoral pulse wave velocity (cfPWV) technique +The measurement of pulse wave velocity using carotid femoral +pulse wave velocity is the standard technique and is considered to +be non invasive, robust and reproducible method for assessing the +arterial stiffness [32]. The carotid femoral pulse wave velocity +(cfPWV) has gained significant research interest in the recent past +and the pulse wave velocity measured with cfPWV technique is +considered as gold standard [18]. In cfPWV technique pulse wave +will be obtained at carotid and femoral arteries and the distance +between these two arteries will be recorded. The pulse wave ve- +locity, a surrogate measure of arterial stiffness, is considered as the +ratio of distance between carotid and femoral arteries to the time +taken for the pulse to travel from carotid to femoral arteries [32]. +Pulse Wave Velocity ¼ Distance/pulse transit time from carotid to +femoral +The advantage with the cfPWV is that it is a gold standard but +the process of measuring the arterial stiffness requires good +amount of skill in acquiring the pulse [33]. The cfPWV technique is +a non invasive, robust and reproducible method and is widely used +in epidemiological studies [32]. +The pulse transit time and measurement of distance between +carotid and femoral arteries need to be understood while assessing +pulse wave velocity using cfPWV. The pulse transit time is +measured using foot to foot method wherein foot is considered to +be the end of the diastole. The distance between carotid and +femoral arteries is measured physically and is considered as an +estimate of the true distance traveled by the pulse wave but the +inaccuracies in the distance measured may lead to errors in the +absolute value of PWV. As the true distance traveled by the pulse is +critical for PWV it is recommended that the distance from carotid +artery to sternal notch is subtracted either from the total distance +between carotid and femoral arteries or from the distance between +sterna notch to femoral artery [32]. +4.2. Carotid femoral pulse wave velocity (cfPWV) measuring +instruments +There are number of devices available today to measure the pulse +wave velocity using cfPWV technique. Complior from Alam Medical, +SphygmoCor from Atcor Medical, PulsePen from Dia Tecne, Vasera +from Fucuda Denshi Co Ltd, Vicorder from Skidmore Medical Ltd are +some of the instruments used for measuring the pulse wave velocity +[34]. Complior and SphygmoCor are widely used in PWV based +studies [35] and the way pulse transit time and distance between +arteries are computed varies between these two devices. +The Complior (Alam-Medical, France) is based on pressure +transducers and the pulse at carotid and femoral arteries is ac- +quired simultaneously. The correlation algorithm is applied be- +tween the two simultaneous pulse recordings to determine the +pulse transit time. The distance traveled by pulse is obtained by +directly measuring the distance between carotid and femoral ar- +teries [32,35]. +In the SphygmoCor system (Artcor, Sydney, Australia) high fi- +delity applanation tonometers are used for pulse acquisition and +the pulse is acquired at carotid artery along with the ECG recording +followed by femoral pulse acquisition with simultaneous ECG +recording. The pulse transit time is computed by subtracting the +time difference between ECG and carotid pulse peak from the time +difference between ECG and femoral pulse peak. The distance +traveled by the pulse is computed by subtracting the distance be- +tween sternal notch to carotid artery from the distance between +sternal notch to femoral artery [32,35]. +The PulsePen [34] is another device which uses two methods in +assessing the pulse wave velocity. In the first method two tonom- +eters are used and the pulse is acquired simultaneously at both +carotid and femoral arteries. This is similar to the method used in +Complior. In the second method only one tonometer is used +wherein pulse is acquired from carotid and femoral arteries sepa- +rately and synchronized with ECG. This method is similar to +SphygmoCor. +The Vasera [34] uses cardio-ankle vascular index (CAVI) as an +index for arterial stiffness measurement but this device needs +further validation. The Vicorder [34] is similar to Complior but the +algorithms used are not clear and this device also needs further +validation. +There are many other devices and methods used in assessing +arterial stiffness and the abridged version of expert consensus +document on arterial stiffness has summarized them [32]. Apart +from the standard non imaging techniques the ultrasound and +Magnetic Resonance Imaging (MRI) are the imaging methods used +in assessing pulse wave velocity using which the path length can be +directly measured which is the biggest advantage but is very +expensive solution [36]. Recently many devices have come to the +market but it is important to verify the scientific validity of such +instruments before using them in research [34]. +4.3. Brachial ankle pulse wave velocity (baPWV) technique +The brachial ankle pulse wave velocity (baPWV) is another +technique introduced in Japan in 2000 to measure the pulse wave +velocity from brachial and ankle arteries [37] The complexities +involved in arterial stiffness measurement with cfPWV technique +have been addressed in baPWV. The pulse wave velocity is +measured in baPWV by connecting volume plethysmographic +sensors to the cuffs connected to brachial and ankle locations. The +pulse wave velocity is computed as the ratio of virtual arterial +length between these two arteries to the pulse transit time from +brachial to ankle arteries [37]. The virtual arterial length is +P.V.G. Kumar et al. / Journal of Ayurveda and Integrative Medicine 10 (2019) 308e315 +312 +estimated from the height of the subject which eliminates the need +for physically measuring the distance between arteries [38]. +The virtual arterial length is computed as shown below. +Path length from heart to brachium (Lb) ¼ 0.2195*height of the person +(cm)  0.20734 +Path length from heart to ankle (La) ¼ 0.8129*height of the person +(cm) þ 12.238 +Virtual arterial path length ¼ La  Lb +The pulse acquisition and physical distance measurement have +been extremely simplified in baPWV due to which it has gained +significant clinical interest but there are number of questions and +concerns on the measurement of arterial stiffness using baPWV +which Sugawara has addressed thoroughly in his review [37]. The +height based arterial path length computation grossly over- +estimates the actual path length resulting in overestimation of +PWV values when compared with the arterial path length +measured using MRI [39] but height based path length can be +converted to actual length with an adjustment factor as PWV +measured from height based path length is linearly correlated to +PWV measured from actual path length [37]. As the baPWV tech- +nique is simple to use and pulse wave velocity is strongly correlated +to pulse wave velocity measured using cfPWV, it has gained much +of clinical and research interest and number of studies have been +done using this technique [37,40e42]. +4.4. Brachial ankle pulse wave velocity (baPWV) measuring +instruments +There are not many devices available for measuring pulse wave +velocity using baPWV technique and AT-form PWV/ABI (Colin, +Kamaki, Japan) and VP-2000 (Colin, Kamaki, Japan) are the devices +widely used by researchers for measuring pulse wave velocity. The +baPWV measuring devices consist of volume plethysmographic and +oscillometric sensors, electrocardiogram and phonocardiogram. The +volume pulse is measured using volume plethysmographic sensors, +blood pressure is measured using oscillometric sensors, electrocar- +diogram is used to synchronize pulse at brachial and ankle arteries +and phonocardiogram is used to detect the heart sound. In baPWV +pulse wave velocity is measured by connecting volume plethysmo- +graphic sensors to the cuffs connected to brachial and ankle [40]. +4.5. Stiffness index from radial artery +The arterial stiffness can be measured from radial artery also but +the mechanism to measure +the stiffness +is different when +compared to cfPWV and baPWV techniques. The pulse wave ac- +quired from radial artery is composed of forward and reflected +waves as shown in Fig. 1 wherein a peak appears in the forward +wave during systolic phase of the pulse and a peak corresponding +to reflected wave appears in diastolic phase of the pulse. The time +taken for diastolic peak from the systolic peak depends on the +stiffness of the arteries and height of the person. Hence stiffness +index (SI) is measured as the ratio of height of the person to the +time difference between systolic and diastolic peaks [43]. The pulse +wave measured from radial artery is closely associated to the digital +volume pulse measured from PPG and is related to it by a transfer +function [44]. Hsein-Tsai have demonstrated the significant corre- +lation between the stiffness index measured using PPG and radial +artery [43]. Initial studies have shown promising results with radial +artery but the significance of arterial stiffness measured from radial +artery yet to be established. As per ayurveda kathinya is closely +associated to arterial stiffness and there is a need to extend the +studies on arterial stiffness to Tridosha analysis. +4.6. Stiffness index from radial artery +The sensor and semiconductor technologies have advanced +further and precise pulse acquisition systems are available to +measure the pulse at radial artery which resulted in resurgence of +traditional Tridosha analysis in a more scientific manner. Nadi Tar- +angini [45], Nadi Yantra [46] and Nadi Pariksha Yantra [47] are some +of the instruments available to acquire the pulse at Tridosha loca- +tions simultaneously. Nadi Tarangini is a pulse based acquisition +system based on linearly spaced pressure transducers which con- +verts the pulse pressure to electrical signal and provides the pulse +wave in the form of time series [45]. The pulse wave acquired using +Nadi Tarangini is similar to digital volume pulse from PPG with clear +systolic and diastolic peaks in place. +As pulse measurement is well established and studies have +shown significant results there is a need to extend these techniques +and devices to the studies of ayurveda with a view to bring the +physiological significance of Nadi Pariksha to limelight. The pulse +wave velocity, pulse rate variability and arterial stiffness are some +of the parameters which can be studied in the context of ayurveda +and the scope can be increased further to analyze various other +parameters which can add value to Nadi Pariksha. +5. Conclusion +Ayurveda has thousands of years of experience in Nadi Pariksha +and classical texts have emphasized the significance of Nadi in +disease diagnosis and prognosis. The texts have explained the na- +ture of nadi and its variations in a very qualitative manner using the +traditional parameters gati, vega, sthira, capala and kathinya. The +traditional parameters are closely associated to the modern pa- +rameters such as pulse wave velocity, pulse rate variability and +hardness of the artery which was discussed in this review thor- +oughly. It is important to study these modern parameters in the +context of ayurveda to bring the hidden secrets of Nadi Pariksha to +limelight. There is a dire need for extending the recent advance- +ments in pulse measurement techniques and instruments to +develop the framework for Nadi Pariksha and bring the scientific +approach to pulse based diagnosis which is the need of the day. +Fig. 1. Pulse wave acquired using Nadi Tarangini, representing various peaks and time +periods of the radial pulse. P1 ¼ pulse amplitude at systolic peak; P2 ¼ pulse ampli- +tude at inflection point; P3 ¼ pulse amplitude at dicrotic notch; P4 ¼ pulse amplitude +at Diastolic Peak; Time periods T1, T2, T3, T4 are measured from start of the systolic +phase. T1 ¼ time period at systolic peak; T2 ¼ time period at inflection point; +T3 ¼ time period at dicrotic notch; T4 ¼ time period at diastolic peak. SI ¼ height of the +person (cm)/(T4  T1]. +P.V.G. Kumar et al. / Journal of Ayurveda and Integrative Medicine 10 (2019) 308e315 +313 +Sources of funding +None. +Conflict of interest +None +Acknowledgments +We express our sincere thanks to S-VYASA in supporting this +study. +References +[1] Basavarajeeyam Rangacharya V. Central council of research in ayurveda and +siddha, New Delhi. 2007. +[2] Murthy. Bhavaprakasa of Bhavamisra, vol. I. Varanasi: Chowkambha Krish- +nada Academy; 2008. +[3] SSB M. Yoga Ratnakara. 2nd ed.vol. I. Varanasi: Chowkhamba Sanskrit Series +Office; 2011. +[4] Murthy PHC.  +S +arṅgadhara Samhita of  +S +arṅgadharac +arya. 2nd ed. Varanasi: +Chowkhamba Sanskrit Series Office; 2007. +[5] Upadhyaya. Nadi Vijnana. Delhi: Chaukhamba Sanskrit Pratishthan; 2009. +[6] Vasant Dattatray L. Secrets of the pulse. New Delhi: Motilal Banarsidass +Publishers; 2007. +[7] Venkat Shivudu. A critical review on ayurvedic diagnostic methods 2015;6(2): +134e49. +[8] Dadhich NK, Pooja S. A comprehensive knowledge +on Nadi Pariksha +2016;1(2):190e5. +[9] Gaddam DA. Survey on Nadi Pareeksha for early detection of several diseases +& computational models using nadi patterns. Int J Comput Sci Inf Technol +[Internet] 2015;6(4):3424e5. Available from: www.ijcsit.com. +[10] Gouda DHP, Raju G, MB S. Sharangadhara's Nadi Pareeksha and its implica- +tions in ayurveda. J Ayurveda Integr Med Sci [Internet] 2016;1(3). Available +from: http://www.jaims.in/index.php/jaims/article/view/66. +[11] Shashirekha HK, Sukumar BS. An interpretation of Nadi Pariksha with refer- +ence to Kala 2014;2. +[12] Joshi RR. Diagnostics using computational nadi patterns. Math Comput Model +2005;41(1):33e47. +[13] Prasad GP, Bharati K, Swamy RK. Some important aspects of nadipariksha +from basavarajiyam. Anc Sci Life [Internet] 2004;24(1):27e9. Available from: +http://www.ncbi.nlm.nih.gov/pubmed/22557147%5Cnhttp://www. +pubmedcentral.nih.gov/articlerender.fcgi?artid¼PMC3330914. +[14] Murthy KRS. Astanga Hridayam. Varanasi: Krishnadas Academy; 2007. +[15] Shokawa T, Imazu M, Yamamoto H, Toyofuku M, Tasaki N, Okimoto T, et al. +Pulse wave velocity predicts cardiovascular mortality: findings from the +Hawaii-Los Angeles-Hiroshima study. Circ J [Internet] 2005;69(3):259e64. +Available from: http://www.ncbi.nlm.nih.gov/pubmed/15731528. +[16] Vlachopoulos C, Aznaouridis K, Stefanadis C. Prediction of cardiovascular +events and all-cause mortality with arterial stiffness. A systematic review and +meta-analysis. J Am Coll Cardiol. Elsevier Inc. 2010;55(13):1318e27. +[17] Laurent S, Cockcroft J, Van Bortel L, Boutouyrie P, Giannattasio C, Hayoz D, +et al. Expert consensus document on arterial stiffness: methodological issues +and clinical applications. Eur Heart J 2006;27(21):2588e605. +[18] Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A, B€ +ohm M, et al. 2013 +ESH/ESC guidelines for the management of arterial hypertension: the task +force for the management of arterial hypertension of the European Society of +Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur +Heart J 2013;34(28):2159e219. +[19] Blacher J, Guerin AP, Pannier B, Marchais SJ, Safar ME, London GM. Impact of +aortic stiffness on survival in end-stage renal disease. Circulation [Internet] +1999;99(18):2434e9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/ +10318666. +[20] Meaume S, Benetos A, Henry OF, Rudnichi A, Safar ME. Aortic pulse wave +velocity predicts cardiovascular mortality in subjects >70 years of age. Arte- +rioscler Thromb Vasc Biol 2001;21(12):2046e50. +[21] Laurent S, Boutouyrie P, Asmar R, Gautier I, Laloux B, Guize L, et al. Aortic +stiffness is an independent predictor of all-cause and cardiovascular mortality +in hypertensive patients. Hypertension (Dallas, Tex 1979) 2001;37(5): +1236e41. +[22] Constant I, Laude D, Murat I, Elghozi JL. Pulse rate variability is not a surrogate +for heart rate variability. Clin Sci (Lond) 1999;97(4):391e7. +[23] Hayano J, Barros AK, Kamiya A, Ohte N, Yasuma F. Assessment of pulse rate +variability by the method of pulse frequency demodulation. Biomed Eng +Online 2005;4:62. +[24] Mirza M, Lakshmi ANR. A comparative study of pulse rate variability and heart +rate variability in healthy subjects. Int J Biomed Adv Res [Internet] 2012;3(8): +640e4. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22350367. +[25] Joshi A, Chandran S, Jayaraman VK, Kulkarni BD. Arterial pulse system: modern +methods for traditional Indian medicine. Conf Proc Annu Int Conf IEEE Eng Med +Biol Soc IEEE Eng Med Biol Soc Annu Conf [Internet] 2007 Jan;2007:608e11. +Available from: http://www.ncbi.nlm.nih.gov/pubmed/18002029. +[26] Joshi AJ, Chandran S, Jayaraman VK, Kulkarni BD. Arterial pulse rate variability +analysis for diagnoses. 2008 19th Int Conf Pattern Recognit [Internet]. Ieee +2008 +Dec:1e4. +Available +from: +http://ieeexplore.ieee.org/lpdocs/epic03/ +wrapper.htm?arnumber¼4761757. +[27] Zoungas S, Asmar RP. Arterial stiffness and cardiovascular outcome. Clin Exp +Pharmacol Physiol 2007;34(7):647e51. +[28] Avolio AP, Butlin M, Walsh A. Arterial blood pressure measurement and pulse +wave analysisetheir role in enhancing cardiovascular assessment. Physiol +Meas [Internet] 2010 Jan;31(1):R1e47. Available from: http://www.ncbi.nlm. +nih.gov/pubmed/19940350 [cited 2016 May 31]. +[29] Boutouyrie P, Tropeano AI, Asmar R, Gautier I, Benetos A, Lacolley P, et al. +Aortic stiffness is an independent predictor of primary coronary events in +hypertensive patients: a longitudinal study. 2002;10e15. +[30] Gunarathne A, Patel JV, Hughes EA, Lip GYH. Measurement of stiffness index by +digital volume pulse analysis technique: clinical utility in cardiovascular disease +risk stratification. Am J Hypertens [Internet] 2008 Aug;21(8):866e72. Available +from: http://www.ncbi.nlm.nih.gov/pubmed/18551104 [cited 2016 May 31]. +[31] Kumar PVG, Deshpande S, Joshi A, More P, Nagendra HR. Association of +arterial stiffness measured from Tridoshas with diabetes e a cross sectional +study 2016;2(6):218e23. +[32] Laurent S, Cockcroft J, Van Bortel L, Boutouyrie P, Giannattasio C, Hayoz D, +et al. Abridged version of the expert consensus document on arterial stiffness. +Artery Res 2007;1(1):2e12. +[33] Butlin M, Qasem A, Battista F, Bozec E, McEniery CM, Millet-Amaury E, et al. +Carotid-femoral pulse wave velocity assessment using novel cuff-based +techniques: +comparison +with +tonometric +measurement. +J +Hypertens +[Internet] 2013;31(11):2237e43. Available from: http://www.ncbi.nlm.nih. +gov/pubmed/24077246 [discussion 2243]. +[34] Rajzer MW, Wojciechowska W, Klocek M, Palka I, Brzozowska-Kiszka MM, +Kawecka-Jaszcz K. Comparison of aortic pulse wave velocity measured by +three techniques: Complior, SphygmoCor and Arteriograph. J Hypertens +2008;26(10):2001e7. +[35] Salvi P. Pulse waves how vascular hemodynamics affects blood pressure +[Internet]. Springer; 2012. Available from: www.springer.com. +[36] Pereira T, Correia C, Cardoso J. Novel methods for pulse wave velocity mea- +surement. J Med Biol Eng 2015;35(5):555e65. +[37] Sugawara J, Tanaka H. Brachial-ankle pulse wave velocity : myths, mis- +conceptions, realities 2015;8566:106e13. +[38] Tseng Y, Lin Y, Hsu J. Association of brachial-ankle pulse wave velocity with +atherosclerosis and presence of coronary artery disease in older patients. +2015. p. 1369e75. +[39] Sugawara J, Hayashi K, Tanaka H. Arterial path length estimation on brachial-ankle +pulse wave velocity: validity of height-based formulas. J Hypertens [Internet] +2014;32(4). Available from: http://journals.lww.com/jhypertension/Fulltext/2014/ +04000/Arterial_path_length_estimation_on_brachial_ankle.25.aspx. +[40] Yamashina A, Tomiyama H, Takeda K, Tsuda H, Arai T, Hirose K, et al. Validity, +reproducibility, and clinical significance of noninvasive brachial-ankle pulse +wave velocity measurement. Hypertens Res 2002;25(3):359e64. +[41] Wu N, Cai X, Ye K, Li Y, He M, Zhao W, et al. Association between Brachial- +Ankle pulse wave velocity and cardiac autonomic neuropathy in type 2 dia- +betes. Diabetol Metab Syndr [Internet] 2014;6(1):82. Available from: http:// +www.pubmedcentral.nih.gov/articlerender.fcgi? +artid¼4132900&tool¼pmcentrez&rendertype¼abstract. +[42] Katakami N, Osonoi T, Takahara M, Saitou M, Matsuoka TA, Yamasaki Y, et al. +Clinical utility of brachial-ankle pulse wave velocity in the prediction of cardio- +vascular events in diabetic patients. Cardiovasc Diabetol [Internet] 2014;13(1): +128. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25186287. +[43] Wu HT, Lee CH, Liu AB, Chung WS, Tang CJ, Sun CK, et al. Arterial stiffness +using radial arterial waveforms measured at the wrist as an indicator of +diabetic control in the elderly. IEEE Trans Biomed Eng 2011;58(2):243e52. +[44] Millasseau SC, Guigui FG, Kelly RP, Prasad K, Cockcroft JR, Ritter JM, et al. +Noninvasive assessment of the digital volume pulse. Comparison with the +peripheral pressure pulse. Hypertension 2000;36(6):952e6. +[45] Joshi A, Kulkarni A, Chandran S, Jayaraman VK, Kulkarni BD. Nadi Tarangini: a +pulse based diagnostic system. Conf Proc IEEE Eng Med Biol Soc [Internet] +2007 +Jan;2007:2207e10. +Available +from: +http://www.ncbi.nlm.nih.gov/ +pubmed/18002428. +[46] Abhinav Sareen M, Kumar M, Anand S, Salhan A, Santhosh J. Nadi Yantra: a +robust system design to capture the signals from the radial artery for non- +invasive diagnosis. 2nd Int Conf Bioinforma Biomed Eng iCBBE 2008 +2008;2009(November):1387e90. +[47] Roopini N. Design & development of a system for Nadi Pariksha 2015;4(6): +465e70. +[48] Shoji T, Emoto M, Shinohara K, Kakiya R, Tsujimoto Y, Kishimoto H, et al. +Diabetes mellitus, aortic stiffness, and cardiovascular mortality in end-stage +renal disease. J Am Soc Nephrol [Internet] 2001;12(10):2117e224. Available +from: http://www.ncbi.nlm.nih.gov/pubmed/11562410. +[49] Cruickshank K, Riste L, Anderson SG, Wright JS, Dunn G, Gosling RG. Aortic +pulse-wave velocity and its relationship to mortality in diabetes and glucose +intolerance: +an +integrated +index +of +vascular +function? +Circulation +2002;106(16):2085e90. +P.V.G. Kumar et al. / Journal of Ayurveda and Integrative Medicine 10 (2019) 308e315 +314 +[50] Laurent S, Katsahian S, Fassot C, Tropeano AI, Gautier I, Laloux B, et al. Aortic +stiffness is an independent predictor of fatal stroke in essential hypertension. +Stroke 2003;34(5):1203e6. +[51] Sutton-Tyrrell K, Najjar SS, Boudreau RM, Venkitachalam L, Kupelian V, +Simonsick EM, et al. Elevated aortic pulse wave velocity, a marker of arterial +stiffness, predicts cardiovascular events in well-functioning older adults. +Circulation 2005;111(25):3384e90. +[52] Hansen TW, Staessen JA, Torp-Pedersen C, Rasmussen S, Thijs L, Ibsen H, et al. +Prognostic value of aortic pulse wave velocity as index of arterial stiffness in +the general population. Circulation 2006;113(5):664e70. +[53] Mattace-Raso FUS, Van Der Cammen TJM, Hofman A, Van Popele NM, Bos ML, +Schalekamp MADH, et al. Arterial stiffness and risk of coronary heart disease +and stroke: the Rotterdam Study. Circulation 2006;113(5):657e63. +[54] Stefanadis +C, +Dernellis +J, +Tsiamis +E, +Stratos +C, +Diamantopoulos +L, +Michaelides A, et al. Aortic stiffness as a risk factor for recurrent acute coro- +nary events in patients with ischaemic heart disease. Eur Heart J [Internet] +2000;21(21):390e6. Available from: http://www.idealibrary.com. +[55] Blacher J, Pannier B, Guerin AP, Marchais SJ, Safar ME, London GM. Carotid +arterial stiffness as a predictor of cardiovascular and all-cause mortality in +end-stage renal disease. Hypertension [Internet] 1998;32(3):570e4. Available +from: http://hyper.ahajournals.org/cgi/doi/10.1161/01.HYP.32.3.570. +[56] Barenbrock M, Kosch M, J€ +oster E, Kisters K, Rahn K-H, Hausberg M. Reduced +arterial distensibility is a predictor of cardiovascular disease in patients after +renal transplantation. J Hypertens [Internet] 2002;20(1). Available from: +http://journals.lww.com/jhypertension/Fulltext/2002/01000/Reduced_arterial_ +distensibility_is_a_predictor_of.12.aspx. +P.V.G. Kumar et al. / Journal of Ayurveda and Integrative Medicine 10 (2019) 308e315 +315 diff --git a/subfolder_0/Use of strengths perspective to treat persons suffering from mental illness in India..txt b/subfolder_0/Use of strengths perspective to treat persons suffering from mental illness in India..txt new file mode 100644 index 0000000000000000000000000000000000000000..ba25499f2dfea177f396471e523cc74132ac270e --- /dev/null +++ b/subfolder_0/Use of strengths perspective to treat persons suffering from mental illness in India..txt @@ -0,0 +1,771 @@ +Aarti Jaganathan and Sekar, K. +Use of Strengths Perspective to Treat Persons… +Use of Strengths Perspective to Treat +Persons Suffering from Mental Illness in +India +A Case Analysis +AARTI JAGANATHAN AND SEKAR, K. +Over the past few years, a few practicing psychiatric social workers in India are +adopting the strengths-based perspective in the case management of people suffering +from mental illness. This paper illustrates and analyses a case report depicting the +benefits and challenges of a strengths based perspective in psychiatric social work +intervention in India. The authors also discuss how familial and cultural mores, beliefs +and rituals, can act both as strengths and threats in working with clients. +Dr. Aarti Jagannathan is a Psychiatric Social Worker and Dr. Sekar K. is Professor +and Head of the Department of Psychiatric Social Work, National Institute of Mental +Health and Neurosciences (NIMHANS), Bangalore, India. +THE STRENGTHS PERSPECTIVE +Psychiatric social work intervention in a mental health facility, entails +dealing with the mental and emotional problems of clients, through the +methods of social work practice—case work, group work and community +organisation. Most psychiatric social workers in mental health settings in +India ascribe and use the disease model in dealing with mental health prob- +lems and mental illnesses. The tenets of the disease model of diagnosing +the deficits are used to prescribe pharmacology and psychosocial treat- +ment, to help persons with mental illness cope with their problems. How- +ever, over the past few years, some practicing psychiatric social workers in +India are adopting the strengths-based perspective to case management of +people suffering from mental illness. This shift in perspective from the di- +agnostic approach to a more functional approach, that is, using a +strengths-based approach to case management of people with severe +IJSW, 72(3), 27–42, July 2011 +Use of Strengths Perspective to Treat Persons… +27 +Tata Institute +of +Social Sciences +THE +INDIAN JOURNAL +OF +SOCIAL WORK +Volume 72, Issue 3 +July 2011 +mental illness has also emerged in other parts of the world (Saleebey, 1992; +Sullivan and Rapp, 1994; Weick, Rapp, Sullivan and Kisthardt, 1989). +The strengths approach attempts to understand clients on the basis of +their strengths. This involves systematically examining survival skills, +abilities, knowledge, resources and desires that can be used in some way to +help meet client goals (Saleebey, 1996). The helping process from initial +contact, goal identification, assessment and intervention to evaluation has +the underlying assumptions that human beings have the capacity for +growth and change (Weick, 1992), knowledge about one’s situation (Early +and GlenMaye, 2000), resilience (Garmezy, 1994) +and membership +(Walzer, 1983). The major focus is on collaboration and partnership be- +tween social workers and clients. Other methods include environment +modification and advocacy (Early and GlenMaye, 2000). The method has +not only emerged as an approach to case management for people with se- +vere mental illness (Saleebey, 1992; Sullivan and Rapp, 1994; Weick, +Rapp, Sullivan and Kisthardt, 1989), but is now also used with other client +groups. +In India, familial and cultural mores, beliefs and rituals, can act both as +strengths and threats while working with clients. Some of the strengths and +challenges inherent in the Indian subculture are: +1. +Strong Family system: Strong family support system is seen as the +most important source of strength for an individual in India. The joint +family system, where the couple stays with their parents and relatives, +acts as a primary and secondary support system for the members of the +family (Madan, 1987). Families observe various rituals like family +prayers, family dinners and cultural festivals, which help keep the +family bond and cultural fabric intact. Dysfunctional families, with a +range of expressed/unexpressed emotions and ambiguous communi- +cation systems put severe challenges and limitations to members of the +family. +2. +Religion and Prayer: In the eastern part of the world, especially in +countries like India, belief in God or a greater power helps individuals +feel secure and cope better with problems. Reading scriptures like the +Bhagawat Geeta helps people to surrender themselves and their prob- +lems to the unknown. A spiritual component in a person’s life acts as a +calming force and creates a context for prayer, meditation and affirma- +tion (Koenig and others, 1992; Koenig and others, 1997; McIntosh +and others, 1993). Thus practice of one’s religion and prayer are seen +IJSW, 72(3), 27–42, July 2011 +28 +Aarti Jaganathan and Sekar, K. +as a way of life for most people in India. People who do not adhere to +their religion or subscribe to any form of spirituality are not favorably +looked upon. +3. +Marriage: Marriage is an important event in an individual’s life +and deemed essential in an Indian family. The Hindu scriptures +mark +the +event +as +a +transition +to +adulthood +(from +Bhramhacharyashram to Grihastashram). It sets the tone for fulfill- +ing new social obligations, establishing new kinship bonds, observ- +ing varied traditional values, creation and depletion of economic +resources and also the possibility of givng rise to desirable and un- +desirable sentiments. Majority of the marriages are arranged by +family members and the in-laws home becomes the primary support +system for the bride after marriage. After entering her marital +home, she takes on the onus of taking care of her in-laws as well as +performing household duties (Madan, 1987). +4. +Lineage: Begetting a child, especially a male child, who will carry on +the family lineage, is viewed as auspicious and blessed. The child is +also seen as one who will ultimately take care of and support the par- +ents in their old age. However, a bride who is unable to beget a child is +viewed unfavorably by her family and society. +The above mentioned cultural and familial processes act as strengths +and support systems for the individuals. On the contrary any malfunction- +ing in the familial and cultural environment, can pose a challenge for the +same individual. Though the strengths approach, with its emphasis on +growth and change, collaborative relationship, and the centre of change lo- +cated in the client, is diametrically opposite to the pathology based ap- +proach used in treating mental illness; it still shows promise in improving +the well being, coping and quality of life of persons with mental illness +(Saleebey, 1996). Also, a culturally sensitive strengths approach, in keep- +ing with the familial and cultural mores, beliefs and rituals of a particular +region, can be used as an effective method of therapy in working with the +clients of the region. This paper illustrates and analyses a case report de- +picting the benefits and challenges of using the strengths based perspective +in psychiatric social work intervention in India. The case presented here is +of a married woman who approached the Psychiatric Social Worker for +help at the National Institute of Mental Health and Neuro Sciences +(NIMHANS) Bangalore, India. +IJSW, 72(3), 27–42, July 2011 +Use of Strengths Perspective to Treat Persons… +29 +CASE ILLUSTRATION +Mrs. S, a 26 year old married female was educated upto the 12th standard. +She belonged to a semi-urban middle income socioeconomic background +and was diagnosed with dysthymia, marital discord and primary infertility. +Her complaints included negative cognitions, suicidal ideations, reduced +sleep and appetite, vague sensations in the body, abnormal beliefs that she +will beget a child, negative feelings towards in-laws, husband and +unresolved feelings towards her inability to beget a child and her religious +affiliation. Psychotropic medications helped her to control her suicidal +ideations and depressed cognitions. She then underwent therapy with a +psychiatric social worker affiliated with the National Institute of Mental +Health and Neurosciences (NIMHANS), Bangalore, India. +A detail intake of Mrs S’ case showed that her marital subsystem was not +formed properly. Even after 6 years of marriage, the interaction between +the spouses, was minimal and need based and Mrs S was unable to +conceive. The result of the infertility test showed that the patient had a +weak uterus and her husband had low sperm count. She also expressed +her inability to efficiently carry out the household activities according to +the expectations of her in-laws. +Mrs S changed her religion to Christianity, as she was told that Lord Jesus +would help her beget a child. She told everybody that Jesus had visited her +and had told her that she would beget a child. However, her pregnancy test +turned out to be negative and she did not give birth to a child on the assigned +date. All through the nine months of assumed pregnancy she kept making +people believe that her stomach was bulged and used to treat herself as a +pregnant lady. In the last six months, before the delivery date, the client +reported having severe body sensations and depressed cognitions, which +troubled her and prompted her to attempt suicide multiple times. +CASE ANALYSIS +In the backdrop of familial and cultural mores, beliefs and rituals practiced in +Indian society, the authors analyse the case of Mrs S by (i) comparing the fam- +ily dynamics existing in her family of origin and the family of procreation (See +Table 1) and (ii) presenting a conceptual framework of her strengths and +weaknesses (internal); opportunities and threats (external) (see Figure 1). +Table 1, describes the dynamics of the patient’s family of origin as com- +pared to her family of procreation. The presenting dynamics and relation- +ships existing in the two families were completely different. The family of +origin was very close knit, wherein the patient was pampered and given +IJSW, 72(3), 27–42, July 2011 +30 +Aarti Jaganathan and Sekar, K. +very few household responsibilities. On the other hnd, in the family of pro- +creation, there were strained relationships between the in-laws and the hus- +band over losses in his business. The mother-in-law was critical of her son +and his wife (the patient), as she felt both of them were not dispersing their +IJSW, 72(3), 27–42, July 2011 +Use of Strengths Perspective to Treat Persons… +31 +STRENGTHS +SUPPORT FROM FAMILY OF ORIGIN +SYSTEM OF INDIAN MARRIAGE +OPPORTUNITIES +THREATS +WEAKNESS +INNER RESILIENCE +SUPPORT OF CHURCH +Anxiety and +depression +symptoms +experienced +by Mrs. S. +Inability to do +household chores/ +meet marital +expectations +Lack of +support +from +in-laws +Primary +infertility +MARITAL +DISCORD +FIGURE 1: Conceptual Framework in Context of Core Constructs of +Strengths Perspective +responsibilities effectively. The in-laws were ignorant of the nature of the +patient’s illness. Communication patterns between them was poor. +TABLE1: Comparison of ‘Family Dynamics’ of Family of Origin and Family +of Procreation +Family +Dynamics +Family of Origin +Family of Procreation +Members +Father, mother, brother +Father-in-law, mother-in-law, +sister-in-law, husband +Boundary +Enmeshed. Parents and children +were very close and emotionally +involved in each other’s lives +Closed. No warmth between the +family members. +Subsystem +Parent-child system well formed +Marital sub-system not properly +formed. +Family +developmental +stage +Family launching young adults +(Stage 6 of Family Life Cycle; +Duvall, 1988) +Married Couple stage (Stage 1 +of Family Life Cycle; Duvall, +1988) +Leadership +Father was nominal and +functional leader of the house. +Mother-in-law: functional +leader; father-in-law: nominal +leader. +Role structure +and +functioning +Father and brother manage +outside house activities; mother +in charge of household +activities. Patient given few +household responsibilities +Household work divided +between mother-in-law and +patient. Sister-in-law not +involved in household activities. +Communication +Direct and clear. Low noise +level (fights). +High expressed emotions +(hostility and criticality) +between husband and patient, +husband and his parents. +Reinforcement +Positive reinforcement: verbal +appraisals and material gifts. +No positive reinforcement +Cohesiveness +Very cohesive and high bonding +Disengaged relationships +Family Rituals +Prayers, visiting places of +worship +Family visits religious places of +different faiths. +Adaptive +patterns +Adequate problem solving and +coping strategies. +No conflict resolution. Conflicts +are left unattended +As seen in the conceptual framework (Refer to Figure 1) in the context +of core constructs of the strengths perspective, the weaknesses of the pa- +tient and threats from the environment have been instrumental in +IJSW, 72(3), 27–42, July 2011 +32 +Aarti Jaganathan and Sekar, K. +increasing her symptoms. The issue of primary infertility and her inability +to manage marital/ household responsibilities has not just worsened her +marital discord but also increased her anxiety and depression. Lack of sup- +port from her in-laws has also lead to her current state of symptoms. Her +strengths and opportunities (support from family of origin, religious affili- +ation, system of Indian marriage and inner resilience) on the other hand, +has acted as a protective cover to help her cope with her mental state and +family problems. The following paragraphs detail the patient’s strengths, +weaknesses, opportunities and perceived threats. +Weaknesses +1. +Primary infertility: Biological limitations (weak uterus and low sperm +count in husband), were responsible for the patient’s inability to con- +ceive even after 6 years of marriage. The helplessness of the situation +affected her mental state (anxiety and depression) and family life +(marital discord, high expressed emotions by in-laws). In her village, +not begetting a child was considered to be an ill omen for the family. +Poor insight of marital/household responsibilities: Married at the +young age of 20 years, the patient had a fairy tale concept of marriage +as depicted in Indian movies, where the hero and heroine got married, +reciprocated their love for each other and lived happily ever after. +With such an unrealistic and immature concept of marriage and with +no exposure or training in household chores/responsibilities (she was +given very few responsibilities in her family of origin), Mrs. S found it +difficult to adjust to the demands of her marital home. +Threats +1. +Lack of support from in-laws: The lack of support from her in-laws in- +creased her psychological distress. She was unfavorably looked upon +and isolated for not begetting a child. Changing her religion added to +her woes. Further, her inability to meet the expectations of her +mother-in-law while carrying out the household duties, resulted in se- +vere criticism from her mother-in-law. Constant negative feedback +and lack of support from her husband and in-laws increased her anxi- +ety and depression and impinged on her performance of normal rou- +tine activities. +2. +Marital discord: Constant criticism from in-laws and husband led to +frequent quarrels and affected her marital and personal life. Her +IJSW, 72(3), 27–42, July 2011 +Use of Strengths Perspective to Treat Persons… +33 +husband was suspicious and quarrelsome. There was no positive ver- +bal or non verbal communication in the relationship and communica- +tion of feelings was absent. The bond between the couple had +weakened over the years. +Opportunities +1. +Support from family of origin: The patient received tremendous physi- +cal, emotional and financial support from her parental family in times +of need. The entire family was in the hospital when the patient was get- +ting treatment as they were very concerned for her. They also helped +the patient’s husband with finance to start his business. +2. +System of marriage: The patient, her husband, parental family and +in-laws strongly believed in the sanctity of the Indian marriage sys- +tem. In spite of the various challenges, the client never thought of ter- +minating her marital relationship. Her in-laws and her husband too +wanted a resolution to the problems faced by the patient and not termi- +nation of the marriage. This was one of the reasons for Mrs S continu- +ing with her marriage for a period of 6 years. +Strengths +1. +Religious affiliation: Considering her predicament, Mrs S’ conversion +to Christianity can be viewed as a coping strategy to deal with the ex- +pectations of her in-laws and husband. She compensated her lack of pri- +mary support by garnering tertiary support for self from the church; +instances of her ability to go on with life in spite of critical factors in her +life (Rutter, 1985; Wolin & Wolin, 1993). As begetting a boy child for +family lineage was very important, her in-laws and husband were ready +to condone her, if conversion would actually enable her to conceive. +The strengths approach ascribes that people need to be citizens—re- +sponsible and valued members in a viable group or community. Mrs S +felt that she did not fit into the membership or role of a perfect daugh- +ter-in-law or wife and thus felt alienated, at risk of marginalisation and +oppression from her in-laws (Walzer, 1983). Collectively and individ- +ually as a member of the Christian faith, she began to realise her poten- +tial and cope with the problems in her marital life. This validates the +fact that as people begin to discover the pride in having survived and +overcome their difficulties, more and more of their capacities come +into the work and play of daily life (Saleebey, 1996). +IJSW, 72(3), 27–42, July 2011 +34 +Aarti Jaganathan and Sekar, K. +2. +Inner resilience: The various cultural and social challenges faced by +the client, illustrates that apart from having many capabilities, abilities +and strengths, individuals also have the capacity for growth and +change. The range of experiences, characteristics and roles, contribute +to who the person is and how he/she copes with the problem +(Saleebey, 1997a; Weick, Rapp, Sullivan and Kisthardt, 1989). In case +of Mrs S, her range of experiences from a protected daughter to a sub- +missive daughter-in-law, lack of primary support from in-laws to re- +ceiving support from the tertiary institution of the church and her +inability to conceive to her illusions of child birth, all give us a per- +spective of how the client changed and adapted herself to deal with +critical factors in her life. In keeping with the growing body of re- +search documents on resilience, Mrs S’ case showed that in spite of her +environment continually presenting demands (as a wife, daugh- +ter-in-law), and challenges (inability to conceive), she was able to use +her ongoing and developing fund of energy and skill to face her cur- +rent struggles (Anthony and Cohler, 1987; Garmezy, 1993; Haggerty, +Sherrod, Garmezy and Rutter, 1994). +INTERVENTION +According to Saleeby (1997a), the psychiatric social worker, individuals +are experts on their lives, their strengths, resources and capacities and these +help to create the dialogue of strength. Interventions based on the strengths +approach gives a perspective that the individual already is doing something +to better his/her situation and it is the psychiatric social workers job to help +the individual identify the strengths and continue working as per the goals +and vision envisaged. +Process of Intervention +Step 1: Helping client to assess her strengths +Literature states that strengths assessment focuses on identifying on what +the client is doing to make things better, what works, what will facilitate +the continuation of desired behaviours and situations. Primary focus of as- +sessment is on what the client is doing ‘right’ in relation to goals and vision +(Early and GlenMaye, 2000). A strengths assessment asks the ques- +tion—what kind of life does the client want? It focuses on the client’s capa- +bilities and aspirations in all areas of life’s functioning (Ronnau and +Poertner, 1993; Weick and others, 1989). +IJSW, 72(3), 27–42, July 2011 +Use of Strengths Perspective to Treat Persons… +35 +In order to assess Mrs S’ strengths, the psychiatric social worker used +the technique of ‘conversation’ with the individual and family members, to +hear the client’s story about how she has survived so far, what she wants, +and how she thinks things are going in various areas of life (Cowger, +1997). According to Mrs S, her goal was to indulge in activities in keeping +with the expectations of her in-laws, husband and self as a wife. This was a +step towards her vision of improving her relationship with her husband and +in-laws and living a better marital life. +Mrs S was not comfortable in thinking of herself or others in terms of +strengths or as having emerged from scarring events with something useful +and redemptive (de Shazer, 1991; Lee, 1994). Having been diagnosed as +having a mental illness, she considered herself as deficient and needy +(Holmes & Saleebey, 1993). One of the main presenting complaints of the +client was the experience of vibrations in the body, as a result of which, she +was unable to carry out any of her household activities. In a session with +the client, the social worker found that the client experienced maximum vi- +brations (or anxiety symptoms) only when performing certain household +tasks, interacting with relatives or when talking about her marital life. The +maximum anxiety was observed in the morning as the client was apprehen- +sive of being able to carry out her daily household chores efficiently. Anxi- +ety was heightened by the fact that she had to meet the expectations of her +in-laws; and also ensure that cordial relationships were maintained. +Step II: Insight facilitation +An insight of the relation between her anxiety and her performance as a +wife, made the client realise that in spite of her anxiety she was able to +complete the household activities in the day. Also her innate coping mech- +anisms helped her to maintain her marital relationship for six years; in spite +of discord. Her attempt to convert to Christianity was reflected back to her +as a coping strategy to deal with the lack of social support (GlenMaye, +1998). In this way, through the sessions with the social worker, Mrs S was +able to understand and identify her strengths: psychological (coping strate- +gies to deal with unfavourable family atmosphere), physiological (physical +capacity to carry out household activities in the day with anxiety) and envi- +ronmental (support of church) strengths (Cowger, 1997). +Step III: Adoption of different techniques in therapy: +Collaborative exploration of strategies with focus on identifying internal, +external, created and naturally occurring resources becomes essential in +IJSW, 72(3), 27–42, July 2011 +36 +Aarti Jaganathan and Sekar, K. +choosing interventions for the client. For tailoring the intervention towards +client-defined goals, mutual strategising by the therapist and client around +building on strengths, skills, knowledge and desires is needed (Early & +GlenMaye, 2000). +A total of 30 individual sessions between Mrs S and her therapist were +conducted. +The +initial +sessions +focused +on +establishing +trust, +psychoeducation and setting treatment goals. Mrs S’ treatment goals were +(a) reduction of anxiety, (b) to perform household activities effectively and +efficiently and (c) to improve communication with her husband. +Behaviour Modification +The client believed in the power of prayer and meditation and reported +feeling less anxious after prayer. It was thus decided that the client would +pray and meditate at regular intervals, especially before starting her work +in the mornings, to reduce her anxiety levels in the day. Also regular visits +to the church, taking a break from her household activities were discussed. +To improve her performance of household activities, the therapist helped +the client plan her day and prepare an activity schedule. The importance of +structuring her day and time management to complete all household activi- +ties effectively and efficiently was discussed with the client. +Communication Enhancement +The importance of communication in forming a relationship was explained +to the patient. To improve her communication with her husband, Mrs S was +taught basic communication strategies (to change negative, ambiguous, +paradoxical communication to direct communication; the importance of +tone, tempo and volume of an individual in a communication and its resul- +tant connotation) and was asked to take initiative in conversation, commu- +nication and clarifying misunderstandings instead of waiting for others to +do so. The importance of the husband as her strength and support system in +times of distress was discussed. +Environment Modification +Working collaboratively with family members to identify strengths and +goals of the patient is a helpful strategy in environment modification (Early +& GlenMaye, 2000). Mrs S’ therapist, after meeting individually with her, +convened sessions with the available family members in the hospital—her +mother, father and brother in order to identify her strengths and coping +IJSW, 72(3), 27–42, July 2011 +Use of Strengths Perspective to Treat Persons… +37 +patterns and help her in modifying her environment. The parents offered to +invite their daughter and son-in-law to stay with them, in times of need and +provide emotional support to their daughter if she felt alone and distressed. +They also agreed to be non-critical of her religious affiliations. +Psychoeducation +Though the marital system was the main source of problem for the patient, +the therapist could not work with the in-laws, as they were not informed +about the nature of her illness—due to fear of been stigmatised and ostra- +cised. After a lot of effort, the therapist was successful in conducting only +one session with the husband. The husband was educated about the nature +of the patient’s illness in the context of the dysfunctional marital relation- +ship. Initially, the husband denied any marital problems. He stated that the +patient had a physical and not a mental ailment, which required to be +treated with black magic and not psychiatric medication. Through +psychoeducation, the therapist tried to slowly and indirectly improve the +marital participation, support and involvement of the husband, by solicit- +ing husband’s initiative in communication and listening to personal stories +and narratives of the client in her times of distress (Saleebey, 1997b). By +involving the husband, the therapist tried to indirectly influence the cli- +ent’s environment to become more accepting and helpful (Sullivan, 1992). +This also could be viewed as a resilience building strategy where the pri- +mary focus was to strengthen the protective factors (husband) of the client +(Fraser and Galinsky, 1997). +Evaluation and Outcomes +The strengths approach includes survivor pride (Benard, 1994; Wolin & +Wolin, 1993), hope for the future, the ability to understand another’s needs +and perspectives, and the ability to identify and make choices about indi- +vidual and family goals. Thus evaluation of the strengths approach would +include whether goal attainment is continuously defined and redefined +from the client’s perspective (Early and GlenMaye, 2000). +In the 6 monthly follow-up, the client reported 75% improvement in her +health status. She was able to carry out the household activities with less +anxiety and complete her daily chores as per the schedule she had set for +herself. She practiced prayer and meditation regularly and sought the help +of her parents and the church in times of distress. A year later, the client re- +ported that the relationship between her husband and herself had improved +IJSW, 72(3), 27–42, July 2011 +38 +Aarti Jaganathan and Sekar, K. +dramatically. The client expressed that her husband was much more ap- +proachable and she was able to communicate her distress to him in times of +need. Though her in-laws criticised her less about her work, Mrs S reported +that they were not very reciprocal in their relationship with her. In view of +the changing scenario at home, Mrs S felt more confident of coping with +her marital life in the future. +LIMITATIONS OF THE STUDY +• The current case report depicts the history of a client with mild +mental illness. Similar interventions and outcomes of the strengths +approach on severe mentally ill clients is however questionable. +Thus, the success of the intervention cannot be generalised to all +groups of clients suffering from mental illness. +• A minority percentage of the Indian population lives in urban cities +and has the opportunity for higher levels of education. Urban +educated clients are more liberal in their outlook towards marriage, +family and lineage. As Mrs S was from a semi-urban background and +belong to less educated family her case study cannot be generalised to +all the other socio-economic groups residing in India. +• Each caste and religious group in India has its own mores, beliefs, +customs and rituals. Thus, the customs, mores and beliefs presented +in this case study cannot be generalised to all caste and religious +groups prevalent in India. +CONCLUSION +The strengths perspective is beneficial in dealing with clients with mental +illness, as long as it takes into account the cultural sensitivities of the cli- +ent’s background. Psychiatric social workers need to be equipped in under- +standing and using the prevalent socio-cultural systems of the client as +strengths. They also need to be adept in identifying the socio-cultural cus- +toms and norms that pose a threat to the client and help them deal with +them, keeping in mind the socio-cultural fabric of the community. +REFERENCES: +Anthony E.J. and +: +Cohler, B.J. (Eds.) +1987 +The Invulnerable Child, New York: Guilford Press. +IJSW, 72(3), 27–42, July 2011 +Use of Strengths Perspective to Treat Persons… +39 +Benard, B. +: +1994 +Applications of Resilience. Paper presented at the conference on +the Role of Resilience in Drug Abuse, Alcohol Abuse and +Mental Illness, Washington DC. +Cowger, C. +: +1997 +Assessing +Client’s +Strengths: +Assessment +for +Client +Empowerment. In D. Saleebey (Ed.), The Strengths Perspective +in Social Work Practice, New York: Longman, 59–73. +de Shazer, S. +: +1991 +Putting Difference to Work, New York: W.W. Norton. +Early, T.J. and +: +GlenMaye, L.F. +2000 +Valuing Families: Social Work Practice with Families from a +Strengths Perspective, Social Work, 45 (2),118–130. +Fraser, M.W., and +: +Galinsky, M.J. +1997 +Toward a Resilience-based Model of Practice. In M.W Fraser +(Ed.), Risk and Resilience in Childhood: An +Ecological +Perspective, Washington DC: NASW Press, 265–275. +Garmezy, N. +: +1994 +Reflections +and +Commentary +on +Risk, +Resilience +and +Development. In R.J. Haggerty, L.R. Sherrod, N. Garmezy and +Rutter, M. (Eds), Stress, Risk and Resilience in Children and +Adolescents: +Process, +Mechanisms +and +Interventions, +Cambridge: Cambridge University Press, 1–18. +Garmezy, N. +: +1993 +Children in Poverty: Resilience Despite Risk, Psychiatry, 56, +127–136. +GlenMaye, L. +: +1998 +Empowerment of Women. In L. Gutierrez, R. Parsons, and E. +Cox (Eds.), Empowerment in Social Work Practice: A +Sourcebook Pacific Grove, California: Brooks/Cole, 29–51. +Haggerty R.L., +: +Sherrod, L.R., +Garmezy, N., and +Rutter, M. +1994. +Stress, Risk and Resilience in Children and Adolescents: +Process, Mechanisms and Interventions, London :Cambridge +University Press. +Holmes, G., and +: +Saleebey, D. +1993 +Empowerment and the Politics of Client Hood, Journal of +Progressive Human Services, 4, 61–78. +Koenig, H.G., +: +Cohen, H.J., and +Blazer, D.G. +1992 +Religious Coping and Depression in Hospitalized, Medically Ill +Men, American Journal of Psychiatry, 149, 1693–1700. +Koenig, H.G., +: +Weiner, D.K., +Peterson, B.L., +Meador, K.G., and +Keefe, F.J. +1997 +Religious Coping in a Nursing Home: A Biopsychosocial +Model, International Journal of Psychiatric Medicine, 27, +3645–376. +Madan, G.R. +: +1987 +Indian Sociology, New Delhi: Allied Publishers Private Ltd. +IJSW, 72(3), 27–42, July 2011 +40 +Aarti Jaganathan and Sekar, K. +McIntosh, D.N., +: +Silver, R.C., and +Wortman, C.B. +1993 +Religion’s Role in Adjustment to a Negative Life Event: Coping +with the Loss of a Child, J Pers Soc Psychol, 65, 812–821. +Lee, J.A.B +: +1994 +The Empowerment Approach to Social Work Practice, New +York: Columbia University Press. +Park, K. +: +2000 +Preventive and Social Medicine, Banarsidas Bhanot Publishers. +Pinto, R.M. +: +2006 +Using Social Network Interventions to Improve Mentally Ill +Clients’ Well-being, Clinical Social Work Journal, 34(1), +83–100. +Ronnau, J., and +: +Poertner, J. +1993 +Identification and Use of Strengths: A Family Systems +Approach, Children Today, 22, 20–23. +Rutter, M. +: +1985 +Resilience in the Face of Adversity: Protective Factors and +Resistance +to +Psychiatric +Disorder, +British +Journal +of +Psychiatry, 147, 598–611. +Saleebey, D. +: +1997a +Introduction : Power in the People. In D. Saleebey (Ed.), The +Strengths Perspective in Social Work Practice +(2nd ed.), +(pp.1–18). White plains, NY: Longman. +1997b +: The Strengths Approach to Practice. In D. Saleebey (Ed.), The +Strengths Perspective in Social Work Practice, New York: +Longman, 49–57. +1996 +: The Strengths Perspective in Social Work Practice: Extension +and Cautions, Social Work, 41(3), 296–305. +1992 +: The Strengths Perspective in Social Work Practice, New York: +Longman. +Sullivan, W.P. +: +1992 +Reclaiming the Community: The Strengths Perspective and +Deinstitutionalization, Social Work, 37, 204–209. +Sullivan, W.P., and +: +Rapp, C.A. +1994 +Breaking Away: The Potential and Promise of a Strengths-based +Approach to Social Work Practice. In R.G. Meinert, J.T. +Pardeck, and W.P. Sullivan (Eds.), Issues in Social Work: A +Critical Analysis, Westport: Auburn House, 83–104. +Walzer, M. +: +1983 +Spheres of Justice, New York: Basic Books. +Weick, A., Rapp, C., +: +Sullivan, W.P., and +Kisthardt, W. +1989 +A Strengths Perspective for Social Work Practice, Social Work, +34, 350–354. +Wolin, S.J., and +: +Wolin, S. +1993 +The Resilient Self: How Survivors of Troubled Families Rise +Above Adversity, New York: Villard. +IJSW, 72(3), 27–42, July 2011 +Use of Strengths Perspective to Treat Persons… +41 diff --git a/subfolder_0/YOGA AND PSYCHOSIS RISKS AND THERAPEUTIC POTENTIAL.txt b/subfolder_0/YOGA AND PSYCHOSIS RISKS AND THERAPEUTIC POTENTIAL.txt new file mode 100644 index 0000000000000000000000000000000000000000..6be30bcbb91a507f0e9b4e319dccd4c360090c99 --- /dev/null +++ b/subfolder_0/YOGA AND PSYCHOSIS RISKS AND THERAPEUTIC POTENTIAL.txt @@ -0,0 +1,6 @@ + + + + + + diff --git a/subfolder_0/Yoga for High-Risk Pregnancy_ A Randomized Controlled Trial.txt b/subfolder_0/Yoga for High-Risk Pregnancy_ A Randomized Controlled Trial.txt new file mode 100644 index 0000000000000000000000000000000000000000..9e07438ece255c4e5df15bae17ef9f73037910b4 --- /dev/null +++ b/subfolder_0/Yoga for High-Risk Pregnancy_ A Randomized Controlled Trial.txt @@ -0,0 +1,267 @@ +8/11/2014 +Yoga for High-Risk Pregnancy: A Randomized Controlled Trial +http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3793436/ +1/6 +Go to: +Ann Med Health Sci Res. 2013 Jul-Sep; 3(3): 341–344. +doi: 10.4103/2141-9248.117933 +PMCID: PMC3793436 +Yoga for High-Risk Pregnancy: A Randomized Controlled Trial +CS Deshpande, A Rakshani, R Nagarathna, TS Ganpat, A Kurpad, R Maskar, HR Nagendra, DC Sudheer, R Abbas, N +Raghuram, K Anura, M Rita, and NH Ramarao +Yoga and Life Sciences, S-VYASA University, Bangalore, India +St. John's Medical College and Hospital, Bangalore, India +Department of OBG, S-VYASA University, Bangalore, India +International Journal of Yoga and Vice Chancellor, S-VYASA University, Bangalore, India +Address for correspondence: Dr. Tikhe Sham Ganpat, S-VYASA University, Bangalore, India. E-mail: rudranath29@gmail.com +Copyright : © Annals of Medical and Health Sciences Research +This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, w hich +permits unrestricted use, distribution, and reproduction in any medium, provided the original w ork is properly cited. +Abstract +Background: +Improvements in technology have increased the chances of survival for the micro-premature infant and the very low birth- +weight infant but have significantly increased the financial burden of health care organizations. This economic burden has a +significant impact on third-party payers and on society in general. +Aim: +The study was designed to assess yoga therapy (YT) module on maternal stress level in high risk pregnancy. +Subjects and Methods: +In the present study, sixty-eight pregnant women (38 in the control group with standard antenatal care and 30 in the YT +group) with 27.2 (5.2) years of mean age recruited from the outpatient services of medical college and hospital in +Bangalore, South India, were participated. The study was a single-blind randomized controlled clinical trial. Perceived +stress scale (PSS) was measured during the 12 , 20 , and 28 weeks of pregnancy. SPSS version 16.0 (Chicago, IL, +USA) was used for all data analysis. When the data were found to be normally distributed, the RMANOVA were used +to assess the PSS scores between the yoga and control groups. Significant values were set at P < 0.05. +Results: +There was a significant difference in the PSS level of the YT group with significantly reduced scores at the second follow- +up (28 week of pregnancy) compared to the control group (P = 0.02). Women who took part in the YT module +reported significantly fewer pregnancy discomforts decrease in PSS (P = 0.02) than the control group where the stress +level was increased (RMANOVA test using SPSS-16). +Conclusion: +The present study suggests that the YT module can decrease the stress level during high-risk pregnancy complications. +Thus, practicing YT during high-risk pregnancy is not only a cost-effective option but also a feasible and safe option. +Additional well-designed studies are needed before a strong recommendation can be made. +1 +2 +3 +1 +2 +3 +th +th +th +th +8/11/2014 +Yoga for High-Risk Pregnancy: A Randomized Controlled Trial +http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3793436/ +2/6 +Go to: +Go to: +Keywords: High-risk pregnancy, Maternal stress level, Yoga therapy module +Introduction +There are no clearly identified criteria to distinguish between a “high”- or “low”-risk pregnancy; however, pregnancies in +which the maternal and/or fetal condition pose a threat to life of the mother or fetus are considered as “high risk.”[1] +Maternal conditions most commonly associated with adverse prenatal outcomes include conditions such as diabetes +(chronic and gestational), hypertensive disorders (chronic hypertension, and preeclampsia) and cardiac, renal, +autoimmune, and thrombophiliac disorders.[2,3,4] Fetal conditions associated with high-risk pregnancy (HRP) include +fetal growth restriction, and placental insufficiency.[5,6,7] Sound theoretical knowledge about various complicated +conditions and diseases that may interfere with childbearing is essential in the care of pregnant women at high risk. +Pregnant women at risk want to be treated as normal and help her get through pregnancy and birth with as little sickness +and complication as possible[8] Improvements in technology have increased the chances of survival for the micro- +premature infant and the very low birth-weight infant but have significantly increased the financial burden of health care +organizations. This economic burden has a significant impact on third-party payers and on society in general. Of the +annual U.S. 10.2 billion dollars spent on newborn care alone, 57% is disproportionately consumed by the 10% of infants +who are born preterm.[9] Therefore, it is important to take into consideration the economical and social dimension of +woman when directing treatment during pregnancy. +Studies have shown that fetuses of exercising women may tolerate labor better than those of nonexercisers.[10] It has +been suggested that regular physical activities may protect against preeclampsia by intervening at three key stages in the +disease process: (1) enhanced placental growth and vascularity (protection against abnormal placental development), (2) +reduction of oxidative stress, and (3) reversal of endothelial dysfunction.[11] Yoga, an ancient science of holistic living +has been used for centuries in stress reduction and health promotion[12] and its positive effects have been demonstrated +even in women with HRP complications.[13] An integrated approach to yoga during pregnancy improved birth weight, +decreases preterm labor, and decreases intra uterine growth retardation (IUGR) either in isolation or associated with +pregnancy-induced hypertension, with no increased complications.[14] +With these promising benefits of yoga, we could hypothesize that yoga therapy (YT) module may play a vital role in +prevention of HRP. But, there was insufficient evidence for the role of the YT module in a randomized control trial for +prevention of HRP. Hence, the present study was designed to assess the efficacy of the YT module in reduction of +maternal stress in HRP, with the hypothesis that it is possible to select safe stress reducing practices. +Subjects and Methods +Patients with a diagnosis of HRP, who were on regular follow-up and willing to give consent for the study, were recruited +from the outpatient services of the Medical College and Hospital in Bangalore, South India. A total of 68 patients were +included in the study with their age ranging from 19 to 31 [mean (SD), 27.4 (5.1)] years. The reasons for exclusion of 42 +women from the study were as follows: moved away (n = 20), drop out (n = 5) and irregular attendance (n = 17). There +were 18 (8 yoga, 10 control) women with bad obstetric history, 14 (6 yoga, 8 control) with age factor, 14 (6 yoga, 8 +control) with genetics, 13 (6 yoga, 7 control) with obesity, 8 (4 yoga, 4 control) with multiple pregnancy, and 1 (control) +with diabetes. Signed informed consent was obtained from all subjects before randomization and the project had +received clearance from the ethical committee of University in Bangalore, South India prior to recruitment of the subjects. +Furthermore, the project was approved by the Institutional Ethical Review Board and the registration number was +IERB/1/861/08. The project was also registered with Clinical Trial Registration of India (CTRI) with registration number +as CTRI/2011/10/002096. Patients with a diagnosis of HRP were selected using following criteria: +Inclusion criteria +Pregnant women with (1) hypertension at the time of recruitment/prior to this pregnancy, (2) diabetes at the time of +recruitment/prior to this pregnancy, (3) past history of pregnancy complications such as pregnancy-induced hypertension +8/11/2014 +Yoga for High-Risk Pregnancy: A Randomized Controlled Trial +http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3793436/ +3/6 +Go to: +(PIH), gestational diabetes mellitus (GDM), pre-eclampsia (PE) or eclampsia (E), intrauterine growth restriction (IUGR), +placental abruption (PA), and fetal death (FD), (4) multiple pregnancies, (5) extremes of age, i.e., <20 or > 35 years, (6) +BMI > 30, (7) family history (sister, mother, and/or grandmother) of pregnancy complications (PIH, GDM, PE or E, +IUGR, PA, FD). +Exclusion criteria +Pregnant women with (1) major medical (cardiac, renal or neurological diseases) or mental illnesses (psychosis, neurosis, +addictions, etc.) or with any structural abnormality of reproductive system and (2) normal pregnancy. +The present study was a single-blind randomized controlled clinical trial. Using computer-generated random numbers, 68 +patients were allocated to two treatment groups: Yoga (n = 30), control (n = 38) at their 12 week of pregnancy (end +of the first trimester). The power analysis (alpha = 0.01, power = 0.8, effect size = 0.81) had yielded 27 subjects per +group. +The YT module used in this study was selected carefully by the investigators based on previous studies.[13,15] This +module was a holistic approach to well-being at physical, mental, emotional, intellectual, and spiritual levels and was +designed to reduce chronic psychological stress experienced during HRP. The practices for the control group involved +standard simple prenatal stretching exercises approved by the Society of Obstetricians and Gynecologists of Canada +(SOGC) Clinical Practice Obstetrics Committee, the Executive and Council of SOGC, and the Board of Directors of the +Canadian Society for Exercise Physiology.[16] +The outcome measure was the perceived stress scale (PSS) scores. The PSS is a widely used valid psychological +instrument for measuring perception of stress in the Indian population with a Cronbach's α for reliability of 0.84.[17,18] +This questionnaire consists of 10 questions about experiencing stress during the previous month and coping with the +stress, and has a 5-point scoring system from 0 to 4 with reverse scoring for 4 positive items (the 4 , 5 , 7 , and 8 +questions).[19] The final score is a sum of the scores for all 10 items. The PSS questionnaire was administered at the +baseline, i.e., 12 week of pregnancy, 20 week of pregnancy (1 follow-up), and 28 week of pregnancy (2 +follow-up). +Randomization was carried out using a computer-generated random number table and all baseline data were collected +prior to the starting of prenatal treatment (YT module). The fact that there was no baseline differences in the yoga and +control groups helped to compare the data at follow-up without adjusting for the means at baseline. This study was a +single-blind, randomized controlled clinical trial where only the patients, the medical staff, and the yoga instructor knew +the treatment group. The people involved in the assessments were blind to the group treatment status. +Statistical software SPSS version 16.0 (Chicago IL.USA) was used for all data analysis. When the data were found to +be normally distributed by a Kolmogorov–Smirnov test (P > 0.05), the RMANOVA were used to assess the PSS +scores between the yoga and control groups. +Results +The trial profile shows the selections process of the subjects for the study [Figure 1]. The socio-demographic data +showed that there was no significant difference in any of the demographic or clinical variables in both the yoga and +control groups [Table 1]. The independent sample t-test showed that there was no significant difference in the PSS +scores between the yoga and control groups at baseline. This showed that the sample in both the groups were +comparable at the same PSS score level at the start of the study. There was also no significant difference in the PSS +scores between the groups at the first follow-up (20 week of pregnancy). However, a significant difference in the PSS +scores (P = 0.02) of the yoga group with reduced scores at the second follow-up (28 week of pregnancy) compared +to the control group was observed [Table 2]. Since PSS scores were collected at three time periods, i.e., baseline (12 +week of pregnancy), first follow-up (20 week of pregnancy), and second follow-up (28 week of pregnancy) across +two groups (yoga and control), the RMANOVA was conducted to assess PSS scores across the groups over the period +th +th +th +th +th +th +th +st +th +nd +th +th +th +th +th +8/11/2014 +Yoga for High-Risk Pregnancy: A Randomized Controlled Trial +http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3793436/ +4/6 +Go to: +Go to: +Go to: +Go to: +of time. The results of the RMANOVA showed that there was a significant decrease (P = 0.02) in the PSS scores of the +yoga group compared to the control group [Figure 2]. +Figure 1 +Trial profile +Table 1 +Demographic dat +Table 2 +Perceived stress scale scores at baseline, first and second follow-up +Figure 2 +RMANOVA graph depicting effect of yoga between groups across the period +of 4 months +Discussion +Many women would like to avoid pharmacological or invasive methods of pain management in labor and this may +contribute toward the popularity of complementary methods of pain management. In this connection, it has been reported +that relaxation and yoga may have a role with reducing pain, increasing satisfaction with pain relief, and reducing the rate +of assisted vaginal delivery.[20] Previous study on yoga showed that yoga is a noninvasive, economical, and easy-to- +learn solution to improve the quality of life of pregnant women, improve their abilities to perform their social roles, and +potentially prevent adverse obstetrics outcomes. Pregnancy is a very special time in women's life and yoga can give her +the opportunity and tools to enjoy this miraculous period to the fullest.[15] It was demonstrated that meditation, +breathing, and relaxation techniques which are the essential components of yoga have a direct and positive impact on the +activities of the autonomic nervous system in a pregnant women.[14,21] The present study is consistent with these +findings, indicating that systematic and safe adoption of the YT module can be effective in reducing the stress levels in +HRP. Although, the present study was mainly focused on the prevention of HRP complications (we were forced to +recruit very limited number of subjects in each high-risk category), it would be interesting and extremely useful to find out +what would be the long-term benefits of the YT module on the mother and the child in pregnancies at high risk. The +enhanced oxygenation in maternal blood, better circulation to and from placenta, and reduced maternal stress are certain +to have long-term positive impacts on the health of the mother and the child. +Conclusion +The present study suggests that the YT module can decrease the stress level during HRP complications. Thus, practicing +the YT module during HRP complications is not just a noninvasive and economical option but also a feasible and safe +option. Additional well-designed studies are needed before a strong recommendation can be made. +Acknowledgement +This project was funded by Central Council of Research on Yoga and Naturopathy (CCRYN), Department of AYUSH, +Government of India. We thank CCRYN, SJMC and H and S-VYASA University for supporting the project. +Footnotes +8/11/2014 +Yoga for High-Risk Pregnancy: A Randomized Controlled Trial +http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3793436/ +5/6 +Go to: +Source of Support: This project was funded by Central council of Research on yoga and Naturopathy (CCRYN). +Conflict of Interest: None declared. +References +1. Alfirevic Z, Stampalija T, Gyte GM. Fetal and umbilical Doppler ultrasound in high-risk pregnancies. Cochrane +Database Syst Rev. 2010;1:CD007529. [PubMed] +2. Alfirevic Z, Roberts D, Martlew V. How strong is the association between maternal thrombophilia and adverse +pregnancy outcome? A systematic review. Eur J Obstet Gynecol Reprod Biol. 2002;101:6–14. [PubMed] +3. Roos-Hesselink JW, Duvekot JJ, Thorne SA. Pregnancy in high risk cardiac conditions. Heart. 2009;95:680–6. +[PubMed] +4. Westergaard HB, Langhoff-Roos J, Lingman G, Marsál K, Kreiner S. A critical appraisal of the use of umbilical +artery Doppler ultrasound in high-risk pregnancies: Use of meta-analyses in evidence-based obstetrics. Ultrasound +Obstet Gynecol. 2001;17:466–76. [PubMed] +5. Ashworth A. Effects of intrauterine growth retardation on mortality and morbidity in infants and young children. Eur J +Clin Nutr. 1998:52. [PubMed] +6. Bernstein IM, Horbar JD, Badger GJ, Ohlsson A, Golan A. Morbidity and mortality among very-low-birth-weight +neonates with intrauterine growth restriction. The Vermont Oxford Network. Am J Obstet Gynecol. 2000;182:198–206. +[PubMed] +7. Miskovic B, Vasilj O, Stanojevic M, Ivanković D, Kerner M, Tikvica A. The comparison of fetal behavior in high risk +and normal pregnancies assessed by four dimensional ultrasound. J Matern Fetal Neonatal Med. 2010;23:1461–7. +[PubMed] +8. Berg M, Dahlberg K. Swedish midwives’ care of women who are at high obstetric risk or who have obstetric +complications. Midwifery. 2001;17:259–66. [PubMed] +9. Hawkins MR. The impact of a high-risk disease management program on perinatal outcomes in a managed care +organization. Case Manager. 2005;16:59–63. [PubMed] +10. Paisley TS, Joy EA, Price RJ., Jr Exercise during pregnancy: A practical approach. Curr Sports Med Rep. +2003;2:325–30. [PubMed] +11. Weissgerber TL, Wolfe LA, Davies GA. The role of regular physical activity in preeclampsia prevention. Med Sci +Sports Exerc. 2004;36:2024–31. [PubMed] +12. Collins C. Yoga: Intuition, preventive medicine, and treatment. J Obstet Gynecol Neonatal Nurs. 1998;27:563–8. +[PubMed] +13. 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. [PubMed] +14. Narendran S, Nagarathna R, Narendran V, Gunasheela S, Nagendra HR. Efficacy of Yoga on pregnancy outcome. +J Altern Complement Med. 2005;11:237–44. [PubMed] +15. Rakhshani A, Maharana S, Raghuram N, Nagendra HR, Venkatram P. Effects of integrated Yoga on quality of life +and interpersonal relationship of pregnant women. Qual Life Res. 2010;19:1447–55. [PubMed] +16. Davies GA, Wolfe LA, Mottola MF, MacKinnon C, Arsenault MY, Bartellas E, et al. Exercise in pregnancy and the +postpartum period. J Obstet Gynaecol Can. 2003;25:516–29. [PubMed] +8/11/2014 +Yoga for High-Risk Pregnancy: A Randomized Controlled Trial +http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3793436/ +6/6 +17. Hewitt PL, Flett GL, Mosher SW. The Perceived Stress Scale: Factor structure and relation to depression +symptoms in a psychiatric sample. J Psychopathol Behav Assess. 1993;14:247–57. +18. Chattha R, Nagarathna R, Padmalatha V, Nagendra HR. Effect of Yoga on cognitive functions in climacteric +syndrome: A randomised control study. BJOG. 2008;115:991–1000. [PubMed] +19. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;24:385–96. +[PubMed] +20. Smith CA, Levett KM, Collins CT, Crowther CA. Relaxation techniques for pain management in labour. Cochrane +Database Syst Rev. 2011:12. [PubMed] +21. Kim HH, Nava-Ocampo AA, Kim SK, Kim SH, Kim YJ, Han JY, et al. Is prenatal childbirth preparation effective +in decreasing adverse maternal and neonatal response to labor? A nested case-control study. Acta Biomed. +2008;79:18–22. [PubMed] +Articles from Annals of Medical and Health Sciences Research are provided here courtesy of Medknow +Publications diff --git a/subfolder_0/Yoga module for heart disease.txt b/subfolder_0/Yoga module for heart disease.txt new file mode 100644 index 0000000000000000000000000000000000000000..60729a8ebe40822608bb03edde45b8f716b3854b --- /dev/null +++ b/subfolder_0/Yoga module for heart disease.txt @@ -0,0 +1,401 @@ +© 2015 Journal of Mahatma Gandhi Institute of Medical Sciences | Published by Wolters Kluwer - Medknow +Yoga module for heart disease +Shukla Isha, Sudheer Deshpande, Tikhe Sham Ganpat, Hongasandra Ramarao Nagendra +Introduction +Patients with heart disease (HD) such as congestive +heart failure (CHF) have clinically signifi + cant +depression at a rate 2- to 3-times higher than those of +the general population, and depression creates barriers +to successful CHF treatment (may be more frequent +adverse clinical events and hospitalizations, twice +the risk of mortality).[1] Patients with coronary artery +disease (CAD) (coronary heart disease [CHD]) who +suffer a myocardial infarction or undergo coronary +artery bypass grafting often develop depression +(16-20%),[2-5] and those with depression and CAD +have a diminished quality of life, an increased rate of +cardiac-related morbidity, and premature mortality. +[6] The CAD is thought to be the cause of CHF in +nearly 65% of patients.[7] Moreover, CHD is the +major cause of early morbidity and mortality in most +developed countries. Secondary prevention aims to +prevent repeat cardiac events and death in people +with established CHD. Lifestyle modifi + cations play +an important role in secondary prevention. Yoga +has been regarded as a kind of physical activity as +Department of Yoga and Management Studies, Swami Vivekananda Yoga Anusandhana Samsthana University +(Prashanti Kutiram), Bengaluru, Karnataka, India +Address for correspondence: +Prof. Tikhe Sham Ganpat, Swami Vivekananda Yoga Anusandhana Samsthana University (Prashanti Kutiram), 19, Eknath +Bhavan, Gavipuram Circle, Kempegowda Nagar, Bengaluru - 560 019, Karnataka, India. E-mail: rudranath29@gmail.com +ABSTRACT +Background: Heart disease (HD) is the major cause of early morbidity and mortality in most developed +countries. Secondary prevention aims to prevent repeat cardiac events and death in people with established HD. +Lifestyle modifi + cations play an important role in secondary prevention. Yoga has been regarded as a kind of +physical activity as well as stress management strategy. Growing evidence suggests the benefi + cial effects of yoga +on various ailments. The aim was to develop a validated Integrated Yoga Module (IYM) for HD. Materials and +Methods: The content validity of IYM for HD was assessed by a panel of 40 yoga experts. The IYM protocol +was developed in the form of a tailor-made yoga practices that were supported by classical texts and research +evidence. Each item in the questionnaire was discussed and rated as (i) not essential, (ii) useful, but not essential, +(iii) essential and the content validity ratio (CVR) was calculated using the formula developed by Lawshe. +Results: The data analysis showed that out of 39 IYM practices, 32 indicated signifi + cant content validity (cut +off value 0.29 as calculated by applying Lawshe’s formula for CVR). Conclusion: The IYM for HD suggests +good validation for managing HD. Clinical trials are needed before any recommendation can be made. +KEYWORDS: Content validity, heart disease, yoga +Access this article online +Quick Response Code: +Website: +www.jmgims.co.in +DOI: +10.4103/0971-9903.164241 +Original Article +How to cite this article: Isha S, Deshpande S, Ganpat TS, +Nagendra HR. Yoga module for heart disease. J Mahatma Gandhi +Inst Med Sci 2015;20:153-6. +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: reprints@medknow.com +[Downloaded free from http://www.jmgims.co.in on Wednesday, July 27, 2016, IP: 14.139.155.82] +Isha, et al.: Validating yoga module for heart diseases +Journal of Mahatma Gandhi Institute of Medical Sciences +September 2015 | Vol 20 | Issue 2 +154 +well as stress management strategy.[8] A signifi + cant +positive effect was observed in the form of reduction +in body mass index, waist circumference, systolic +and diastolic blood pressure, and heart rate (P < 0.05) +when yoga therapy was used as an adjunct in patients +with CAD.[9] It was reported that 12-week yoga +therapy signifi + cantly improved the parasympathetic +activity and decreased the sympathetic activity in +heart failure patients.[10] A systematic review and +meta-analysis on effects of yoga on HD revealed +evidence for clinically important effects of yoga +on most biological cardiovascular disease risk +factors with weak recommendations of ancillary +use of yoga for patients with CHD, heart failure, +and cardiac dysrhythmia.[11,12] However, the strong +recommendations for using yoga in HD suggested +in many of previous studies were not confi + rmed +with well-designed and validated yoga module. The +objective of this study was to develop a validated +Integrated Yoga Module (IYM) for HD. +Materials and Methods +Different yoga experts talk about different ways for +the treatment of HD in general. At the same time text +books available from schools of yoga also contemplate +on few pose that can be exclusively advocated for HD. +Therefore, to develop an overall protocol for HD, we +have followed the following steps. +Step 1 (compilation of literary research on HD): +Exhaustive literary search from the Vedas, text books +and research paper/thesis available in yoga was done +for HD, zooming into HD and it was combined with +modern scientifi + c view on HD. +Step 2 (sorting of literary research on HD): The +compiled literature has been put together in a tabular +form to get a common and unique features described in +each text. Then, the studies done on different practices +and published in the journal as a scientifi + c background +were extracted. This gave a scientifi + c back up to the +literary search. +Step 3 (preparing treatment protocol based on literary +research on HD): A minute wise treatment protocol is +developed in the form of tailor made practice that is +supported by classical texts and research evidence. +Step 4 (validation by experts): This complete module +was presented for validation in front of yoga experts +with clinical experience (≥5 years). These experts +were requested to participate for evaluating the content +validity for the proposed instrument on a three point +scale: +1. Not essential, +2. Useful, but not essential, +3. Essential. +An expert panel including 40 health educationists, +environmental health specialists, cardiac electro +physiologist, heart failure specialists, thoracic and +cardiovascular surgery specialists and cardiologists +with ≥5 years of yoga therapy experience examined +the content validity. In this study, experts with yoga +therapy and clinical experience (≥5 years) were +considered as yoga expert. The experts selected +for the present study (both males and females) +were all Indians with age ranging from 45 to 72 +years and following different yoga traditions like +Kaivalyadham Yoga, Satyananda Yoga, Sivananda +Yoga, Vivekananda Yoga and Iyengar Yoga. The +expert panel was asked to comment on the necessity +and relevance of the items in order to calculate the +content validity ratio (CVR) and the content validity +index (CVI), respectively. +Following the experts’ assessments, the CVR for a +total scale was computed. According to Lawshe, if +more than half of the panelists indicate that an item is +essential, then that item has the least content validity.[13] +Here, the CVR for the scale ≥0.29 was considered +satisfactory. The CVI was estimated by experts’ ratings +of items relevancy, simplicity, and clarity on a 4-point +Likert scale. The CVI of each statement was calculated +and recommended values of ≥0.80 were considered +acceptable.[14,15] +Statistical analysis +The cut-off value of 0.29 was calculated by applying +Lawshe’s formula for CVR. According to Lawshe +formula, we have CVR = (Ne — N/2)/N/2, where +CVR, Ne = total number of essentials for each practice, +N = total number of panelists. The Microsoft Offi + ce +Excel 2007 was used for analysis. +Results +The data analysis showed that out of 39 IYM +practices, 32 indicated signifi + cant content validity +[Tables 1-3]. This result was based on the frequency, +length, intensity of the program, teacher qualifi + cation, +and setting that were rated and made blinded for its +validity. +[Downloaded free from http://www.jmgims.co.in on Wednesday, July 27, 2016, IP: 14.139.155.82] +Isha, et al.: Validating yoga module for heart diseases +September 2015 | Vol 20 | Issue 2 +Journal of Mahatma Gandhi Institute of Medical Sciences +155 +Discussion +There is growing evidence that yoga may offer a safe +and cost-effective intervention for HD. However, +systematic, standardized and validated yoga program in +populations with HD is needed to confi + rm and further +elucidate the effects of yoga.[16,17] Findings from the +present study indicate that IYM for HD is appealing to +yoga experts. The HD educators may be able to support +maintenance by discussing specifi + c strategies with +individuals who express interest in yoga practice.[18] An +ideal yoga module like any other exercise prescription +may consist of mode (type), frequency, intensity, +duration, and progression. Determining the appropriate +mode depends upon patient preference and safety +issues regarding the state of HD or other conditions. +Frequency, intensity, and duration are specifi + c to the +type of activity and should be tailored to the patient’s +abilities to perform the activity safely.[19-22] +Conclusion +Based on the fi + ndings from the present study, the IYM +for HD suggests good validation for managing HD. +Clinical trials are needed before any recommendation +can be made. +Acknowledgment +Authors +acknowledge +Swami +Vivekananda +Yoga +Anusandhana Samsthana (S-VYASA) University for +granting permission to carry out this work. +Financial support and sponsorship +Nil. +Confl + icts of interest +There are no confl + icts of interest. +References +1. +Rustad JK, +Stern TA, Hebert KA, Musselman DL. Diagnosis +and treatment of depression in patients with congestive +heart failure: A review of the literature. Prim Care Companion +CNS Disord 2013:15. +2. +Frasure-Smith N, Lespérance F +, Talajic M. Depression +following myocardial infarction. Impact on 6-month survival. +JAMA 1993;270:1819-25. +3. +Schleifer SJ, Macari-Hinson MM, Coyle DA, Slater WR, +Kahn M, Gorlin R, et al. The nature and course of depression +following +myocardial +infarction. +Arch +Intern +Med +1989;149:1785-9. +4. +Thombs BD, Bass EB, Ford DE, Stewart KJ, Tsilidis KK, +Patel U, et al. Prevalence of depression in survivors of acute +myocardial infarction. J Gen Intern Med 2006;21:30-8. +5. +Connerney I, Shapiro PA, McLaughlin JS, Bagiella E, Sloan RP. +Relation between depression after coronary artery bypass +surgery and 12-month outcome: A prospective study. Lancet +2001;358:1766-71. +6. +Celano CM, Huffman JC. Depression and cardiac disease: +A review. Cardiol Rev 2011;19:130-42. +7. +Gheorghiade M, Sopko G, De Luca L, Velazquez EJ, +Parker JD, Binkley PF, et al. Navigating the crossroads of +coronary artery disease and heart failure. Circulation +2006;114:1202-13. +8. +Lau HL, Kwong JS, Yeung F +, Chau PH, Woo J. Yoga for +secondary prevention of coronary heart disease. Cochrane +Database Syst Rev 2012;12:CD009506. +9. +Pal A, Srivastava N, Narain VS, Agrawal GG, Rani M. Effect +of yogic intervention on the autonomic nervous system in +the patients with coronary artery disease: A randomized +controlled trial. East Mediterr Health J 2013;19:452-8. +Table 1: Selected IYM practices (breathing +practices) by yoga experts with their CVR +Name of the IYM practices +CVR +Loosening of fi + ngers +0.5 +Loosening of wrist +0.5 +Shoulder rotation +0.65 +Leg movement +0.65 +Drill walking +0.35 +Hands stretch breathing +0.85 +Hand in and out breathing +0.95 +Ankle stretch breathing +0.8 +Tiger breathing +0.55 +Straight leg raising +0.35 +Quick relaxation technique +1 +IYM = Integrated yoga module, CVR = Content validity ratio +Table 2: Selected IYM practices (postures) by yoga +experts with their CVR +Name of the IYM practices +CVR +Half wheel pose +0.55 +Tree pose +0.7 +Eagle pose +0.45 +Half spinal twist +0.4 +Cow pose +0.5 +Half camel pose +0.55 +Bhujangasana +0.95 +Deep relaxation technique +0.5 +Cleansing techniques: Jala Neti +0.3 +IYM = Integrated yoga module, CVR = Content validity ratio +Table 3: Selected IYM practices (Pranayama +and meditation) by yoga experts with their CVR +Name of the IYM practices +CVR +Sukha pranayama +0.9 +Vibhagiya pranayama +1 +Ujjayi +0.45 +Candra anuloma viloma pranayama +0.75 +Nadi Shuddhi +0.9 +Cooling pranayama +0.6 +Bhramari +1 +Nada anusandhana +0.95 +OM meditation +0.85 +Cyclic meditation +0.85 +Bhajans +0.95 +Counseling and lectures +1 +IYM = Integrated yoga module, CVR = Content validity ratio +[Downloaded free from http://www.jmgims.co.in on Wednesday, July 27, 2016, IP: 14.139.155.82] +Isha, et al.: Validating yoga module for heart diseases +Journal of Mahatma Gandhi Institute of Medical Sciences +September 2015 | Vol 20 | Issue 2 +156 +10. Krishna BH, Pal P, G K P, J B, E J, Y S, et al. Effect of yoga +therapy on heart rate, blood pressure and cardiac autonomic +function in heart failure. J Clin Diagn Res 2014;8:14-6. +11. Cramer H, Lauche R, Haller H, Dobos G, Michalsen A. A systematic +review of yoga for heart disease. Eur J Prev Cardiol 2014. +12. Cramer H, Lauche R, Haller H, Steckhan N, Michalsen A, Dobos G. +Effects of yoga on cardiovascular disease risk factors: A systematic +review and meta-analysis. Int J Cardiol 2014;173:170-83. +13. Lawshe CH, Nagle BF +. A note on the combination of ratings +on the basis of reliability. Psychol Bull 1952;49:270-3. +14. Kasmel A, Tanggaard P. Evaluation of changes in individual +community-related empowerment in community health +promotion interventions in Estonia. Int J Environ Res Public +Health 2011;8:1772-91. +15. Araban M, Tavafian SS, Motesaddi Zarandi S, Hidarnia AR, +Gohari MR, Prochaska JM, et al. Introducing a new measure +for assessing self-efficacy in response to air pollution hazards +for pregnant women. J Environ Health Sci Eng 2013;11:16. +16. Yoga could be good for heart disease. Simultaneous focus +on body, breathing, and mind may be just what the doctor +ordered. Harv Heart Lett 2010;21:5. +17. Kubo A, Hung YY, Ritterman J. Yoga for heart failure patients: +A feasibility pilot study with a multiethnic population. Int J +Yoga Therap 2011:77-83. +18. Yogendra J, Yogendra HJ, Ambardekar S, Lele RD, Shetty S, +Dave M, et al. Beneficial effects of yoga lifestyle on +reversibility of ischaemic heart disease: Caring heart project +of International Board of Yoga. J Assoc Physicians India +2004;52:283-9. +19. Manchanda SC, Narang R. Yoga and coronary artery disease. +Indian Heart J 1998;50:227-8. +20. Telles S, Naveen KV. Yoga for rehabilitation: An overview. +Indian J Med Sci 1997;51:123-7. +21. Schmidt T, Wijga A, Von Zur Mühlen A, Brabant G, Wagner TO. +Changes in cardiovascular risk factors and hormones +during a comprehensive residential three month kriya yoga +training and vegetarian nutrition. Acta Physiol Scand Suppl +1997;640:158-62. +22. Lakshmikanthan +C, +Alagesan +R, +Thanikachalam +S, +Ramamurthi B, Elangovan D, Viswanathan TR, et al. Long +term effects of yoga on hypertension and/or coronary artery +disease. J Assoc Physicians India 1979;27:1055-8. +[Downloaded free from http://www.jmgims.co.in on Wednesday, July 27, 2016, IP: 14.139.155.82] diff --git a/subfolder_0/Yoga therapy for sustained attention.txt b/subfolder_0/Yoga therapy for sustained attention.txt new file mode 100644 index 0000000000000000000000000000000000000000..d81d21e400f353b20226cb8ede16484ceaecaadf --- /dev/null +++ b/subfolder_0/Yoga therapy for sustained attention.txt @@ -0,0 +1,352 @@ +70 +© 2018 Archives of Medicine and Health Sciences | Published by Wolters Kluwer ‑ Medknow +Original Article +Introduction +Sustained attention (SA) is the capacity to attend to a task in +hand for a required period. It is closely associated with task +difficulty or complexity.[1] It is closely associated with the +mental effort required by the task in hand.[2] The capacities +to study and listen to a lecture for an extended length of time +are examples of SA. The six letter cancellation task (SLCT) +requires SA, as well as the ability to shift attention. The +availability of the Indian normative data for the SLCT +allowed wider application of this test in clinical practice for +studying SA. Yoga comprises a wide range of mind/body +practices from postural and breathing techniques to deep +relaxation and meditation. Yoga therapy (YT) tailors these +to the health needs of the individual. Similarly, YT helps +to promote all‑round positive health, as well as assisting +particular medical conditions such as depression, stress, +and anxiety.[3] Particularly, it is more appropriate for many +chronic conditions that persist despite conventional medical +treatment.[4] Moreover, YT helps in empowering individuals +to progress toward improved health, happiness and well‑being +through the application of the teachings and practices of +Yoga.[5] The present study was designed to obtain preliminary +estimates of the effectiveness and safety of YT compared with +a control group in healthy volunteers. +Materials and Methods +Subjects +Sixty healthy volunteers, 48.75 ± 3.86 years of mean age +were participated in the present study. Thirty volunteers +selected from Swami Vivekananda Yoga Anusandhana +Samsthana (S‑VYASA) University, Bengaluru, India were +practiced YT training for 7 days. They were compared with +a control group of 30 healthy volunteers selected from Sri +Devaraj Urs Medical College, Kolar, India matched for +duration of the study, age, gender, and socioenvironmental +Yoga Therapy for Sustained Attention +V. Vineetha, S. Vinutha, K. Karthiyanee, A. Kumar, H. R. Nagendra1, Tikhe Sham Ganpat2 +Departments of Physiology, Sri Devaraj Urs Medical College, Kolar, Karnataka, 1Swami Vivekananda Yoga Anusandhana Samsthana University, Bengaluru, Karnataka, +2Department of Yoga, Sanchi University of Buddhist‑Indic Studies, Bhopal, Madhya Pradesh, India +Background: Sustained attention (SA) is a vital function mediated by the right frontal‑parietal cortex. The six letter cancellation task (SLCT) +measures SA. Assessment of SA in volunteers undergoing Yoga therapy (YT) training compared to control group is the theme of the present +study. Materials and Methods: Sixty healthy volunteers, 48.75 ± 3.86 years of mean age were participated in the present study. Thirty +volunteers selected from Swami Vivekananda Yoga Anusandhana Samsthana University, Bengaluru, India were practiced YT for 7 days. They +were compared with a control group of 30 healthy volunteers from Sri Devaraj Urs Medical College, Kolar, India matched for the duration of +the study, age, gender, and socioeconomic background that were not exposed to YT training but continued their usual college routine during +that period. All volunteers were assessed for SA using SLCT. Results: The YT group showed 18.06% significant increase (P = 0.010, paired +samples t‑test) in total attempted (TA) score on SLCT. Similarly, there was 19.03% significant increase (P = 0.008, paired samples t‑test) in net +score (NS). However, there was 26.32% decrease in wrongly attempted (WA) score which was statistically not significant (P = 0.637, paired +samples t‑test). There was no significant change in control group. Increase in TA and NS and decrease in WA is related with enhancement of +SA. Conclusion: The results suggest that YT enhances SA in healthy volunteers. Additional well‑designed trial with long‑term follow‑up is +needed before a strong recommendation can be made. +Keywords: Healthy volunteers, net score, six letter cancellation task, sustained attention, yoga +Access this article online +Quick Response Code: +Website: +www.amhsjournal.org +DOI: +10.4103/amhs.amhs_50_17 +Abstract +Address for correspondence: Dr. Tikhe Sham Ganpat, +2nd Floor, Atal Bihari Vajpayee Institute of Good Governance and Policy +Analysis, Bhadbhada Square, Bhopal ‑ 462 003, Madhya Pradesh, India. +E‑mail: rudranath29@gmail.com +How to cite this article: Vineetha V, Vinutha S, Karthiyanee K, Kumar A, +Nagendra HR, Ganpat TS. Yoga therapy for sustained attention. Arch Med +Health Sci 2018;6:70-2. +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: reprints@medknow.com +[Downloaded free from http://www.amhsjournal.org on Monday, January 25, 2021, IP: 136.232.192.146] +Vineetha, et al.: Yoga for sustained attention +71 +Archives of Medicine and Health Sciences  ¦  Volume 6  ¦  Issue 1  ¦  January‑June 2018 +background that were not exposed to YT training but continued +their usual college routine during that period. +• +Inclusion criteria – Both healthy male and females +• +Exclusion criteria – Learning disabilities and cognitive +deficits, neurological or psychological disturbances and +under medication for health problem. +Design +Pretest‑Posttest with control group study. +Source +S‑VYASA University, Bengaluru and Sri Devaraj Urs Medical +College, Kolar, India. +Informed consent +Informed consent was obtained from all the participants. +The institutional review board approval +The study was approved by the institutional review board of +S‑VYASA University, Bengaluru and Sri Devaraj Urs Medical +College, Kolar, India. +Intervention +The YT[6] for 7 days was practiced by YT group [Table 1]. +The YT consists of Kriya (cleansing techniques) Sithilikarana +Vyayama (loosening and stretching practice), Suryanamaskara +(practice of salutation to sun), Asana (posture), Pranayama +(breathing practice), and Dhyana (meditation). They were +compared with a control group of 30 healthy volunteers +(medical college staff) selected from Sri Devaraj Urs Medical +College, Kolar, India matched for the duration of the study, +age, gender, and socioeconomic background that were not +exposed to YT training. +The following Āsanas were used during YT training: +Prārthanā (prayer), Suryanamaskāra (Salutations to the sun), +Tādāsana  (palm tree pose), Tiryaka Tādāsana  (swaying +palm tree pose), Kati Chakrāsana (waist rotating pose), +Trikonāsana (triangle pose), Vajrāsana (sleeping thunderbolt +pose), Ushtrāsana (camel pose), Shashānkāsana (pose of the +moon or hare pose), Supta Vajrāsana (sleeping thunderbolt +pose), Bhujangāsana (cobra pose), Dhanurasana (bow pose), +Yogamudrāsana (psychic union pose), Matsyāsana (fish +pose), Chakrāsana  (wheel pose), Śavāsana  (deep +relaxation technique), Prānāyāma  (breathing practices), +and Prārthanā (prayer). The total duration of YT was for +90 min. +Assessment +The SLCT consists of a test worksheet which specifies +six target letters to be cancelled, and a “working section” +consisting of a 22 × 14 array of randomly arranged letters +of the alphabets. Study participants were asked to cancel as +many of the six target letters in the array as possible in the +allotted time of 1:30 min. Participants were told that there +are two possible strategies: (i) Canceling all six letters at +once or (ii) selecting one target letter out of the six at a time. +They were asked to choose whichever strategy suited them. +They were also told that they could follow a horizontal, +vertical, or a random path according to their choice. Scoring +was carried out by a person blind to the details of the data. +The total number of cancellations and wrong cancellations +were scored and the net score (NS) calculated by subtracting +wrong cancellations from total cancellations.[7] Each +component measures a different quantity. The total number +of cancellations is a measure of motor skill combined with +cognitive function. The number of wrong cancellations is a +measure of lack of focused attention and mental distractions. +NS is a measure of SA. +Statistical analysis +The data were entered into Excel sheet. The level of significance +was conducted using P  value. P  ≤ 0.05 was considered +statistically significant. Statistical analysis was performed +using SPSS version 10 (Sun Micro solutions, Gujarat, India +for PC Windows 2000). The results were expressed as +mean ± standard deviation. The Kolmogorov–Smirnov test +showed that the data were normally distributed. Hence, paired +samples test was used to compare means of the data collected +before and after the YT. +Results +The YT group showed 18.06% significant increase +(P < 0.01), paired samples t‑test) in total attempted (TA) +score on SLCT. Similarly, there was 19.03% significant +increase (P = 0.008, paired samples t‑test) in NS. However, +there was 26.32% decrease in wrongly attempted (WA) score +which was statistically not significant (P = 0.637, paired +samples t‑test) [Table 2] whereas there was no significant +change in the control group in regard to TA, NS, and WA +[Table 3]. +Table 1: Yoga therapy +Āsana +Time (min) +Prārthanā (prayer) +03 +Suryanamaskāra (salutations to the sun) +15 +Tādāsana (palm tree pose) +01 +Tiryaka Tādāsana (swaying palm tree pose) +01 +Kati Chakrāsana (waist rotating pose) +01 +Trikonāsana (triangle pose) +01 +Vajrāsana (sleeping thunderbolt pose) +01 +Ushtrāsana (camel pose) +01 +Shashānkāsana (pose of the moon or hare pose) +01 +Supta Vajrāsana (sleeping thunderbolt pose) +01 +Bhujangāsana (cobra pose) +01 +Dhanurasana (bow pose) +01 +Yogamudrāsana (psychic union pose) +01 +Matsyāsana (fish pose) +01 +Chakrāsana (wheel pose) +01 +Śavāsana (deep relaxation technique) +25 +Prānāyāma (breathing practices) +30 +Prārthanā (prayer) +04 +Total time of the YT session +90 +YT: Yoga therapy +[Downloaded free from http://www.amhsjournal.org on Monday, January 25, 2021, IP: 136.232.192.146] +Vineetha, et al.: Yoga for sustained attention +72 +Archives of Medicine and Health Sciences  ¦  Volume 6  ¦  Issue 1  ¦  January‑June 2018 +Discussion +Cancellation tasks require visual selectivity and a repetitive +motor response.[8] They not only require SA but also visual +scanning and activation and inhibition of rapid responses. The +present study found a significant increase in SA scores after +the YT whereas there was no significant change in control +group in regard to TA, NS, and WA. Previous study on SLCT +reported cyclic meditation brings about a greater improvement +in task performance (NS = 26%, P < 0.001) than supine +rest (NS = 14%, P < 0.001).[9] +The significant increase in NS for the YT group on the SLCT +suggests that the yoga improves functioning of the right +frontal‑parietal cortex mediating SA.[6] Similarly, the significant +increase in TA by the IYT group suggests improvement in +the frontal association areas, where the cognitive function +guiding motor skills are located.[10] Decrease in WA suggests +that yoga improves functions in the orbitofrontal area of the +prefrontal cortex, which is hypothesized to mediate distraction +avoidance.[11] Reduced anxiety can improve performance on +tasks requiring SA[12] and yoga’s anxiety‑reducing effects[13] +could also have facilitated this. Increase in TA and NS and +decrease in WA was related with enhancement of SA[14] and +several components in the YT could have contributed to the +increase in the YT group’s SA scores. Any kind of rhythmic +resonance has the power to make the mind more relaxed and +peaceful[15] and so improve attention span. Vedic mantras +are highly rhythmic and uniformly filled with resonance. +Their daily chanting by the YT group may have been partly +responsible for the observed increase in the group’s SA scores. +Conclusion +The practice of YT enhances SA in healthy volunteers +compared to control group. Additional well‑designed +randomized control trial with long‑term follow‑up is needed +before a strong recommendation on wider acceptance and +application of the YT module can be made. +Acknowledgment +Authors would like to acknowledge Swami Vivekananda +Yoga Anusandhana Samsthana (S‑VYASA) University and +Sri Devaraj Urs Medical College, Tamaka, Kolar, Karnataka, +India for granting permission to carry out this work. +Financial support and sponsorship +Nil. +Conflicts of interest +There are no conflicts of interest. +References +1. Rangan R, Nagendra HR, Bhatt R. Effect of yogic education system and +modern education system on sustained attention. Int J Yoga 2009;2:35‑8. +2. Posner MI. Chronometric explorations of mind. In: Hillsdale NJ, editor. +Lawrence Erlbaum Associates;1978. p. 269. +3. Büssing A, Michalsen A, Khalsa SB, Telles S, Sherman KJ. Effects of +yoga on mental and physical health: A short summary of reviews. Evid +Based Complement Alternat Med 2012;2012:165410. +4. Cramer  H, Lauche  R, Langhorst  J, Dobos  G. Yoga for depression: +A  +systematic +review +and +meta‑analysis. +Depress +Anxiety +2013;30:1068‑83. +5. Ross A, Friedmann E, Bevans M, Thomas S. National survey of yoga +practitioners: Mental and physical health benefits. Complement Ther +Med 2013;21:313‑23. +6. Lezak MD. Neuropsychological Assessment. 3rd ed. New York, USA: +Oxford University Press; 1995. +7. Agarwal AK, Kalra R, Natu MV, Dadhich AP, Deswal RS. Psychomotor +performance of psychiatric inpatients under therapy: Assessment by +paper and pencil tests. Hum Psychopharmacol 2002;17:91‑3. +8. Sarang  SP, Telles  S. Immediate effect of two yoga‑based relaxation +techniques on performance in a letter‑cancellation task. Percept Mot +Skills 2007;105:379‑85. +9. Rueckert L, Grafman J. Sustained attention deficits in patients with right +frontal lesions. Neuropsychologia 1996;34:953‑63. +10. Fuster  JM. The Prefrontal Cortex Anatomy, Physiology and +Neurophysiology of the Frontal Lobe. 2nd ed. New York: Raven Press; +1989. +11. Rao LS, Subbakrishna DK, Gopukumar K. Nimhans Neuro‑Psychology +Battery‑2004 Manual. The National Institute of Mental Health and +Neurosciences; 2004. +12. Saltz  E. Manifest anxiety: Have we missed the data? Psychol Rev +1970;77:568‑73. +13. Wallace  RK, Benson  H, Wilson  AF. A  wakeful hypometabolic +physiologic state. Am J Physiol 1971;221:795‑9. +14. Kumar  S, Telles  S. Meditative states based on yoga texts and their +effects on performance of a letter‑cancellation task. Percept Mot Skills +2009;109:679‑89. +15. Yogitha B, Nagarathna R, John E, Nagendra H. Complimentary effect +of yogic sound resonance relaxation technique in patients with common +neck pain. Int J Yoga 2010;3:18‑25. +Table 2: Six letter cancellation task scores before and +after the yoga therapy +SLCT +scores +YT +(↑) % increase +(↓) % decrease +P +Before +After +TA +29.53±11.43 +34.87±10.48 +↑18.06 +0.010* +WA +0.63±1.52 +0.47±1.20 +↓26.32 +0.637 +NS +28.90±11.42 +34.40±10.33 +↑19.03 +0.008** +*Significant at P<0.05, **Significant at P<0.01 (paired samples test) +SLCT: Six letter cancellation task, TA: Total attempted, WA: Wrongly +attempted and NS: Net score, YT: Yoga therapy +Table 3: Six letter cancellation task scores before and +after the control +SLCT +scores +Before +After +(↑) % increase +(↓) % decrease +P +TA +34.91±14.28 +45.59±14.45 +↑ 30.61 +0.281 +WA +0.40±1.21 +0.07±0.39 +↓ 81.58 +0.246 +NS +34.52±14.40 +45.52±14.47 +↑ 31.87 +0.233 +TA: Total attempted, WA: Wrongly attempted, NS: Net score, SLCT: Six +letter cancellation task +[Downloaded free from http://www.amhsjournal.org on Monday, January 25, 2021, IP: 136.232.192.146] diff --git a/subfolder_0/heart rate alterations in different types pranayamas.txt b/subfolder_0/heart rate alterations in different types pranayamas.txt new file mode 100644 index 0000000000000000000000000000000000000000..2c6edd9944763ad5aa47d4386b87c8fc919ddef7 --- /dev/null +++ b/subfolder_0/heart rate alterations in different types pranayamas.txt @@ -0,0 +1,5 @@ + + + + + diff --git a/subfolder_0/improvement in spatial and temporal measures of visual perception following yoga training.txt b/subfolder_0/improvement in spatial and temporal measures of visual perception following yoga training.txt new file mode 100644 index 0000000000000000000000000000000000000000..98bf907428b089ca0b77d6bdd5f79bd22cafd7c4 --- /dev/null +++ b/subfolder_0/improvement in spatial and temporal measures of visual perception following yoga training.txt @@ -0,0 +1,19 @@ + + + + + + + + + + + + + + + + + + + diff --git a/subfolder_0/measuring the effect of yoga in rheumatoid arthritis.txt b/subfolder_0/measuring the effect of yoga in rheumatoid arthritis.txt new file mode 100644 index 0000000000000000000000000000000000000000..b7ec413173dfaf911284a9de91a5225e7fa21bf3 --- /dev/null +++ b/subfolder_0/measuring the effect of yoga in rheumatoid arthritis.txt @@ -0,0 +1,3 @@ + + + diff --git a/subfolder_0/middle latency auditory evoked potentials in congenitally blind band normal sighted subjects.txt b/subfolder_0/middle latency auditory evoked potentials in congenitally blind band normal sighted subjects.txt new file mode 100644 index 0000000000000000000000000000000000000000..0e70f9eb88442d42936df5a1a91baa77e8de3222 --- /dev/null +++ b/subfolder_0/middle latency auditory evoked potentials in congenitally blind band normal sighted subjects.txt @@ -0,0 +1,15 @@ + + + + + + + + + + + + + + + diff --git "a/subfolder_0/yurveda Body\342\200\223Mind Constitutional Types and Role of Yoga Intervention Among Type 2 Diabetes Mellitus Population of Chandigarh and Panchkula Regions.txt" "b/subfolder_0/yurveda Body\342\200\223Mind Constitutional Types and Role of Yoga Intervention Among Type 2 Diabetes Mellitus Population of Chandigarh and Panchkula Regions.txt" new file mode 100644 index 0000000000000000000000000000000000000000..9ddfacca7e984daa1db93751fc3565456c9e53a2 --- /dev/null +++ "b/subfolder_0/yurveda Body\342\200\223Mind Constitutional Types and Role of Yoga Intervention Among Type 2 Diabetes Mellitus Population of Chandigarh and Panchkula Regions.txt" @@ -0,0 +1,1340 @@ +https://doi.org/10.1177/09727531211000040 +Annals of Neurosciences +27(3-4) 214­ +–223, 2020 +© The Author(s) 2021 +Reprints and permissions: +in.sagepub.com/journals-permissions-india +DOI: 10.1177/09727531211000040 +journals.sagepub.com/home/aon +Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution- +NonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-Commercial use, reproduction and +distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https:// +us.sagepub.com/en-us/nam/open-access-at-sage). +Original Article +Ayurveda Body–Mind Constitutional Types +and Role of Yoga Intervention Among Type 2 +Diabetes Mellitus Population of Chandigarh +and Panchkula Regions +Madhava Sai Sivapuram1 +, Vinod Srivastava2, Navneet Kaur3, Akshay Anand4,5,6 +, +Raghuram Nagarathna7, Suchitra Patil7, Saranga Biman7, Ishwar Chander8, Saras Jyoti9 +and Hongasandra Ramarao Nagendra7 +Abstract +Background: Type 2 diabetes needs a better understanding of etiological factors and management strategies based on +lifestyle and constitutional factors, given its high association rate with many cardiovascular, neurological disorders, and +COVID-19 infection. +Purpose: The present study was undertaken to investigate the effect of Diabetes-specific integrated Yoga lifestyle Protocol +(DYP) on glycemic control and lipid profiles of diabetic adults. Along with the DYP intervention, the individuals residing in +Chandigarh and Panchkula union territories in the northern part of India were assessed for Ayurveda-based body–mind +constitutional type. Ayurveda describes body–mind constitution as “prakriti,” which has been discussed from two angles, +namely physiological and psychological as body and mind are correlated. +Methods: Cluster sampling of waitlist control study subjects was used as the sampling method for the study. A total of +1,215 registered subjects (81 diabetic) responded in randomly selected clusters in Chandigarh and Panchkula. Ayurveda +physicians did Ayurveda body–mind constitutional assessment called prakriti assessment (physiological body–mind constitution +assessment) in 35 participants (23 diabetic, 12 prediabetic) as a part of the study. +Results: A group of 50 subjects was randomly selected for yoga intervention out of 81 diabetes mellitus adults, and 31 +subjects were enrolled as waitlist controls. A significant decrease in the glycosylated hemoglobin levels from 8.49 ± 1.94% +to 7.97 ± 2.20% in the intervention group was noticed. The lipid profiles of the DYP intervention and control groups were +monitored. Three-month follow-up results of lipid profile diagnostic tests in intervention and control groups showed a +significant difference between the two groups (P < 0.05). Most diabetic and prediabetic individuals were found to have pitta +dosha (pitta controls all heat, metabolism, and transformation in the mind and body) as dominant constitution type. +Conclusion: The study results demonstrated significant positive effects of yoga in diabetic individuals. This study has +indicated the evidence for the safety and efficacy of the validated DYP for community-level interventions to prevent maladies +like brain damage and stroke. +Keywords +Diabetes-specific integrated Yoga lifestyle Protocol (DYP), Diabetes mellitus (DM), Glycosylated hemoglobin (A 1 c), Lipid +profile, Prakriti +Received 15 December 2020; revised 11 January 2021; accepted 11 January 2021 +9 Department of AYUSH, Haryana Yoga Council, Haryana, India +8 Apoorv Ayurved Clinic, Nangal, Punjab, India +7 Department of Yoga and Life Sciences, Swami Vivekananda Yoga +Anusandhana Samsthana, Bengaluru, Karnataka, India +4 Department of Neurology, Neuroscience Research Lab, Postgraduate +Institute of Medical Education and Research, Chandigarh, India +5 Collaborative Centre for Mind Body Intervention through Yoga, +Postgraduate Institute of Medical Education and Research, Chandigarh, India +2 Department of Social Work, College of Health and Behavioral Sciences, +Fort Hays State University, Hays, USA +1 Department of General Medicine, Dr Pinnamaneni Siddhartha Institute +of Medical Sciences and Research Foundation, Chinna-Avutapalli, Andhra +Pradesh, India +Corresponding author: +Raghuram Nagarathna, Swami Vivekananda Yoga Anusandhana Samsthana, +Bengaluru, Karnataka 560105, India. +E-mail: rnagaratna@gmail.com +Co-Corresponding author: +Dr Akshay Anand, Neuroscience Research Lab, Department of +Neurology, PGIMER, Chandigarh, India +E-mail: akshay1anand@rediffmail.com +3 Department of Physical Education, Panjab University, Chandigarh +6 Centre for Cognitive Sciences and Phenomenology, Panjab University, +Chandigarh, india +Sivapuram et al. +215 +Introduction +Diabetes mellitus (DM) is a metabolic disorder, and it has +become an epidemic with about 463 million people (20 to 79 +years) affected as per 2019 estimates, which represents 9.3% of +the total world’s population. It has an expected prevalence of 700 +million by 2045 globally.1 The International Diabetes Federation +2019 report revealed that 1 in every 11 adults (20 to 79 years +age) has diabetes, and 79% of them belong to low- and middle- +income countries. The high mortality rate (4.2 million in 2019) +associated with DM has been a growing concern and has created +a global pandemic.2 The most affected nations are China, India, +and the USA. In India alone, there are approximately 77 million +individuals who are affected by diabetes. The total global health +expenditure on DM is nearly about USD 760 billion (10% of +total healthcare expenditure).3 The total number of deaths is +alarming in different regions such as South-East +Asia (1,150,300), +Europe (465,900), Middle East and North Africa (418,900), +North America and the Caribbean (301,700), South and Central +America (243,200; 9.4%), and Western Pacific (1,265,100).1 In a +developing country like India, where there is a shortage of +resources, it is expected that the number of DM patients will +increase by 134.2 million by the end of 2045. +The apex body in India for biomedical research, the Indian +Council of Medical Research (ICMR), conducted a phase I +study and projected that there are 62.4 million individuals +affected by diabetes, and 77.2 million people have been living +with prediabetic conditions in India.4 +The current global prevalence and mortality rate associated +with DM indicate the burgeoning socioeconomic burden on +society. Complications of diabetes range from microvascular, +such as neuropathy, nephropathy, and retinopathy,5 to +macrovascular +complications +involving +cardiovascular +diseases and others.6 American Diabetes Association +classified diabetes into type 1 (insulin-dependent), type 2 +(noninsulin-dependent), gestational DM, and diabetes from +other causes.7 Metformin is the most common antidiabetic +agent but is associated with increased homocysteine levels +and vitamin B12 deficiency because of vitamin B12 +malabsorption on prolonged use.8 +Despite the proven benefits of oral drugs and/or insulin, +there are several adverse drug reactions, metabolic complexities +in patients, and economic ramifications that cannot be +overlooked. DM, being a chronic disease, requires long-term +compliance with the medications. A meta-analysis report +indicated that exercise, both aerobic and resistance, positively +increased insulin sensitivity, improved glycemic level, and +decreased cardiovascular risks in diabetic patients.9 However, +many studies have indicated that people with restricted joint +mobility and those who are either overweight or lead the +sedentary lifestyle are unable to participate in the conventional +physical exercise regimen despite being aware of the benefits +of exercise in managing diabetes. There are several studies that +have documented the benefits of yoga on DM and indicate +practicing evidenced-based yoga could be possible cost- +effective interventions suited particularly to those who have +difficulty engaging in physical exercise, remaining active, and +utilizing community resources for the management of DM.10 +Yoga is a mind–body practice that originated from +ancient India and focused on the sequence and combination +of different asanas (postures) synergizing with breath and +mind control.11,12 These asana/postures are not merely +practicing physical movements but exert a coordinated +positive impact on health and lifestyle.13 Yoga, through the +neuroendocrine mechanism, has been proven to be +associated with the decrease in the glycemic status14 and +lipid profile of the individuals.15 +Prakriti (Pra = primary, Kriti = creation), or human being’s +physiological personality, is an essential Ayurveda construct +that explains an individual’s biological variability that is +distinguishable based upon genetic specificity and epigenetic +effects.16 Accordingly, a person’s prakriti is determined by the +dominance of one or more of the three doshas (vata, pitta, and +kapha). Dosha is considered a condition in the body caused by +certain substances, and different combinations of its elements +interfere with physiological activities. Vata refers to wind, +energy, or all movements inside the body; pitta designates bile +and its functioning; and kapha refers to phlegm and other +problems in nose, ear, and throat in modern science, and their +balance and imbalance refer to different Ayurveda personalities. +An individual’s physiological strengths and weaknesses, +mental status, and susceptibility to various illnesses can be +explained by the prakriti type of an individual.17 Several +Ayurveda texts give directions for a personalized healthy living +based upon one’s prakriti type. Therefore, a unique aspect of +this study was the inclusion of an analysis of prakriti type on a +small subset of individuals in a randomized waitlisted +controlled research on yoga for the primary prevention of +diabetes in Chandigarh and Panchkula in India. +Methodology +Subjects +This study was a part of a multicenter randomized control pan- +India study with the primary goals of the prevention of +diabetes. The results of the larger study have been +published.18,19 In the present study, the data of yoga +interventions conducted in Chandigarh and Panchkula have +been included for analyses considering homogeneity in the +population of the identified areas. A total of 1,215 individuals +were screened for identifying the high-risk diabetic population +using the Indian Diabetes Risk Score (IDRS). The survey +conducted the door-to-door survey in the randomly selected +rural and urban clusters by trained field volunteers. Of these, a +total of 444 participants were identified at high risk on IDRS +(>60) and were invited for detailed assessments. There were +154 participants with glycosylated hemoglobin (A1c) level +greater than 6.5%, who were identified as the diabetic group. +The prediabetic group constituted 142 participants whose A1c +was between 5.7% and 6.4%, whereas 148 participants with +A1c less than or equal to 5.6% were considered a healthy +216 +Annals of Neurosciences 27(3-4) +population. All 154 diabetic group participants (both males +and females) were requested to participate in the free Diabetes- +specific integrated Yoga lifestyle Protocol (DYP) intervention +camps organized by the Indian Yoga Association. Because of +time constraints, 73 subjects denied participating in yoga +interventions. Of the remaining 81 participants, 50 subjects +received yoga intervention, and 31 subjects constituted waitlist +control clusters, following four levels of randomizations. The +follow-up period was three months, and the waitlist control +group was trained with the same DYP after the collection of +the data (Figure 1). Both the intervention and the control +groups were on the antidiabetic medications. +DYP Intervention +The intervention group comprised of 50 subjects and were +categorized as known diabetes and newly diagnosed groups +based on A1c (>6.5%). They were trained by qualified yoga +instructors of the Indian Yoga Association on validated DYP. +The training was conducted initially in camps at local +community centers for nine days following 2-h daily practice +of yoga either in the morning or in the evening. The yoga +practice was followed by counseling on using instruction +charts and DVDs to continue yoga at home for one hour daily. +The subjects were monitored once a week by the yoga +instructor, and the same instructor performed a 2-h review +session for three months. Attendance and feedback on daily +home practice were maintained during the weekly visits as +well as through phone calls and WhatsApp messages. +Control Group +The control group comprised of 31 subjects who were +screened and diagnosed as DM and consented to serve as +waitlist controls. +Diabetes-Specific Integrated Yoga Lifestyle +Protocol (DYP) +The validated DYP was designed by the expert committee +consisting of yoga scholars from the member institution of +the Indian Yoga Association that included diabetologists. The +protocols included lectures and materials on lifestyle and +behavior change (diet, physical activity, abstinence from +tobacco, and yoga-based stress coping skills) apart from +asana (physical postures), pranayama, meditation, and +relaxation techniques (Table 1). Table 2 shows the effect of +each asana/procedure used in this study.20,21 +Figure 1. The Study Profile of Chandigarh and Panchkula +Table 1. Diabetes-Specific Integrated Yoga Lifestyle Protocol +(DYP) +S. +No. +Name of the Practice +Duration +(in min) +1 +Opening prayer: Asatoma sat gamaya +(from ignorance lead me to truth) Taаaso +maаjyotir–gаtаyа (from darkness lead me to +light) Mrtyor-maa amrtamgamaya (from death +lead me to immortality) Om shaantih shaantih +shaantih (om peace, peace, peace) +2 +2 +Loosening exercises (preparatory sukshma +vyayamas and shithililarna practices) Urdha- +vahastashvasan (upward tree position; hand +stretching breathing three rounds at 90°, +135°, and 180° each) Kati-shakti vikasaka +(three rounds) (a) Forward and backward +bending; (b) twisting sarvangapushti (devel- +oping entire body; three rounds clockwise, +three rounds anticlockwise) +6 +3 +Surya Namaskara (SN) (sun salutation)10 +step fast SN (fast sun salutation) six rounds +12 step slow SN (slow sun salutation) one +round Modified version chair SN seven +rounds +9 +4 +Asanas (pose/posture; 1 min per asana [pose/ +posture])1. Standing Position (1 min per +asana) Trikonasana (extended triangle pose), +parvritta trikonasana (revolved triangle pose), +prasarita padhastasana (wide-legged forward +bend) 2. Supine Position Jatara parivartana- +sana (master revolved abdomen pose), pawa- +nmuktasana (wind-relieving pose), viparitaka- +rani (upside-down pose) 3. Prone Position +Bhujangasana (cobra pose), dharuasana (bow +pose), followed by pawanmuktasana (wind-re- +lieving pose) 4. Sitting Position Mandukasana +(frog pose), vakrasana/ardhamatsayendrasana +(half spinal twist pose), paschimatanasana +(seated forward bend), ardha ushtrasana +(half camel pose) At the end, relaxation with +abdominal breathing in the supine position +(vishranti), 10 to 15 rounds (2 min) +15 +5 +Kriya (outward physical manifestation) Ag- +nisara (abdomen churning): 1 min, kapalab- +hati (skull shining breathing technique) (60 +breaths per minute for 1 min followed by +rest for 1 min) +3 +6 +Pranayama (breathing techniques) Nadishud- +dhi (alternate nostril breathing; for 6 min, +with antarkumbhak (internal breath reten- +tion) and jalandhar bandh (chin lock; for 2 s) +Bhramari (humming bee breathing) 3 min +9 +(Table 1 continued) +Sivapuram et al. +217 +Assessments +Biochemical Analyses +Fasting blood sugar (FBG), postprandial blood glucose +(PPBG), A1c, and lipid profile were assessed from the blood +samples using standard laboratory procedures in an NABL +accredited lab.22 The blood samples were collected after 10 to +12 hours of overnight fasting and also 2 hours after breakfast, +on day 1 and on day 90. +Prakriti Analysis +Out of the total number of participants from the door-to-door +survey, 23 diabetic subjects and 12 prediabetic subjects, and +5 normal subjects consented and were evaluated for the +prakriti analysis by Ayurveda acharyas, senior physicians of +the Indian system of medicine. There were three methods of +examining +a +person +(pareeksha), +namely +darshana +(inspection), sparshana (palpation), and prashna (history +taking) pareeksha. Each of the three types of pareeksha has +10 items with 3 choices for each of the three doshas (health +constitutional traits), namely vata, pitta, and kapha.17 Thus, +each item had 10 scores constituting a total score of 30. +The score for each dosha was calculated based on the +cumulative score of doshas from the three types of pareeksha. +Based on this result, the characterization resulted in six +different constitutional types—vata-pitta, vata-kapha, pitta- +kapha, pitta-vata, kapha-vata, and kapha-pitta. The +cumulative score of one dosha being greater than 20 +(darshana + sparshana + prashna) was defined as a single +dominant dosha (vata, pitta, or kapha) constitutional type. If +the total score on any dosha did not reach 20, it was +characterized as belonging to one of the combined +personalities based on the order of the scores (Table 3). The +questionnaire that is mentioned in Table 3 and being used for +assessing the prakriti of an individual is a structured +nonstandardized questionnaire. +Data Analysis +The biochemical data generated from the treatment and +control subjects, before and after the intervention, was +recorded in the Microsoft Excel version 10. The statistical +analyses were performed using the SPSS software version +21.0. The recorded data was compared using a paired t-test +following the normal distribution curve. A P-value of less +than .05 was set as the significance level. +Results +Baseline Characteristics +All 81 (50 yoga and 31 control) subjects recruited in the study +had diabetes and were on antidiabetic medications. Table 4 +shows the characteristics of yoga and control group subjects. +S. +No. +Name of the Practice +Duration +(in min) +7 +Meditation (for stress relief, deep relaxation, +and silencing of mind) cyclic meditation +15 +8 +Resolve (I am completely healthy) +1 +9 +Closing prayer: Sarvebhavantu Sukhina (let all +be happy) Sarve Santu Nirāmayaah (free from +diseases) Sarve Bhadrani Paāyantu (let all align +with reality) Maa Ka Scid-Duhkha-Bhag-Bhavet +(let no one suffer from miseries) Om Šāntih +Šāntih Šāntih (om peace, peace, peace) +1 +Total duration +60 +(Table 1 continued) +Table 2. The Effect of Each Asana or Practice/Procedure +S. No. +Asana/Practice/Pro- +cedure +Effect +1. +Surya Namaskara +Subcutaneous tissue fat +is removed because of +extensive muscle workouts; +harmonizing effect at prana +level. +2. +Asana +Standing posi- +tion +Limbs, buttocks, and +abdominal region fat reduc- +tion; apana opening. +Sitting position +Abdominal region fat re- +duction; apana opening. +Supine posi- +tion +Abdominal region fat +reduction; apana dislodge- +ment. +Prone position +Fat reduction at buttock +and shoulder level; prana +balancing. +3. +Kriya +Developing deep internal +awareness; Titiksha, stamina +building; activating and re- +vitalizing the organs; toning +up their functions; desen- +sitization; development of +deep internal awareness; +releases locks and vital life +force in the body. +4. +Relaxation +Alertful rest through stress +reduction (sympathetic +activity decreased). +5. +Pranayama +Regulation of breath; +removes the random +agitations in prana flows; +dominant parasympathetic +activity; stress reduction. +6. +Meditation +Mental alertness increases +and so does physiologi- +cal relaxation with the +reduced heart rate. +218 +Annals of Neurosciences 27(3-4) +Table 3. Questionnaire for Prakriti (Ayurveda Personality) Analysis +Darshana Pareeksha (Inspection) +S. No. +Characteristics +Vata +Y/N +Pitta +Y/N +Kapha +Y/N +1 +Height +Short +  +Normal +  +Tall +  +2 +Weight +Underweight +  +Normal +  +Overweight +  +3 +Complexion +Brown +  +Wheatish +  +Fair +  +4 +Gait +Fast +  +Normal +  +Slow +  +5 +Voice +Harsh +  +Thin +  +Heavy +  +6 +Hair color +Grey +  +Very black +  +Normal +  +7 +Iris color +Blue/Dark brown +  +Black +  +Brown +  +8 +Activities +Fast +  +Normal +  +Slow +  +9 +Personal grooming +Unmanageable +  +Normal +  +Manageable +  +10 +Body parts +Short +  +Normal +  +Big +Sparshana Pareeksha (Palpation) +S. No. +Characteristics +Vata +Y/N +Pitta +Y/N +Kapha +Y/N +1 +Skin +Dry +  +Normal +  +Oily/Moist +  +2 +Pulse +Uncertain/Fast +  +Normal +  +Normal/Slow +  +3 +Hair +Dry +  +Wheatish +  +Oily/Moist +  +4 +Muscle +Thin +  +Normal +  +Fat +  +5 +Nails +Dry +  +Thin +  +Oily/Moist +  +6 +Tendon reflex +Fast +  +Very black +  +Slow +  +7 +Pain on pressing +Maximum +  +Black +  +Low +  +8 +Tongue +Dry/Pale +  +Normal +  +Moist/Thick +  +9 +Bones +Thin, fragile +  +Normal +  +Thick and strong +  +10 +Pulse +Leech, snake +  +Normal +  +Pigeon/Swan +Prashna Pareeksha (History +Taking) +S. No. +Characteristics +Vata +Y/N +Pitta +Y/N +Kapha +Y/N +1 +Favorite juice +Sweet +  +Salty +  +Bitter +  +2 +Sleep +Less +  +Normal +  +Over +  +3 +Favorite season +Rainy +  +Winter +  +Summer +  +4 +Favorite color +Brown or grey +  +Red and dark +  +White or light +  +5 +Dreams +Vacuum places, +sky +  +Fire +  +Hilly areas +  +6 +Voice (quality of +speech) +Dry +  +Thin and sweet +  +Heavy and sweet +  +7 +Appetite +Irregular +  +Excessive +  +Moderate +  +8 +Temperament +Firm in decisions +  +Angry in decisions +  +Constant in deci- +sions +  +9 +Feeling of pain +Highly tolerant +  +Moderately toler- +ant +  +Low tolerance +  +10 +Power +Less +  +Normal +  +High +Note: Scoring key: yes 1; no 0. Total possible score 10 × 3 = 30. Vata personality ≥20 in vata total score; pitta personality ≥ 20 in pitta total score; kapha +personality ≥ 20 in kapha total score. +Result: No. of diabetic subjects: pitta = 20; pitta-kapha = 2; vata-pitta = 1. +Sivapuram et al. +219 +changes. Furthermore, the mean blood glucose (MBG) level +decreased significantly (P < 0.01) in the intervention group +from 197.02 ± 55.81 to 182.10 ± 63.17. In the control group, +there was a nonsignificant change from 200.26 ± 52.87 to +186.69 ± 61.12 (Table 5). +Effect of DYP on Lipid Profile +A comparison of lipid profile parameters after three months +of DYP in the intervention group showed statistically +significant differences in the total cholesterol (TC), +triglycerides (TG), low-density lipoprotein (LDL), high- +density lipoprotein (HDL), and very-low-density lipoprotein +(VLDL) levels. In contrast, in the control group, no +statistically significant results are seen (Table 5). +When compared between the intervention and the control +groups, no statistically significant difference was noted +(Table 5). +Prakriti Analysis +Based on darshana, sparshana, and prashna pareeksha, +total scores on vata, pitta, and kapha were obtained. +Table 4. Baseline Characteristics of Both the Treatment and the +Control Subjects +Demographic Details +Yoga +Control +Sample size (n = 81) +50 +31 +Age (years) M ± (SD) +58.86 ± 24.73 +53.31 ± 7.71 +Height (cm) M ± (SD) +67.98 ± 11.51 +70.40 ± 13.55 +Weight (kg) M ± (SD) +26.51 ± 4.18 +28.51 ± 5.11 +BMI M ± (SD) +97.42 ± 9.14 +99.78 ± 11.34 +Hip circumference (cm) M +± (SD) +96.26 ± 10.60 +97.51 ± 11.55 +Waist circumference (cm) +M ± (SD) +67.98 ± 11.51 +70.40 ± 13.55 +Effect of DYP on A1c and Mean Plasma Glucose (MPG) +The intervention group was receiving antidiabetic medications +and participated in the DYP, whereas the control group was +on antidiabetic medicines only. The A1c levels in the treatment +group, after completion of the yoga intervention, showed a +significant (P < 0.01) decrease from 8.49 ± 1.94% to 7.97 ± +2.20%. In the control group, there were no significant +Table 5. The Pre and Postbiochemical Parameters in the Interventional Group and the Control Group +Variables +Intervention Group +P- +Value +Control Group +Between +Group +P-Value +Number of +Participants +Preinter- +vention +Postinter- +vention +Number +of Par- +ticipants +Preinter- +vention +Postinter- +vention +P- +Value +Mean ± SD +(SE) +Mean ± SD +(SE) +Mean ± SD +(SE) +Mean ± SD +(SE) +Fasting blood +glucose (FBG) +50 +167.46 ± +58.22 +169.01 ± 84.6 +<0.02 +31 +176.51 ± +64.09 +173.00 ± 73.39 +0.25 +0.80 +Postprandial +blood glucose +(PPBG) +28 +259.14 ± +92.46 +231.53 ± +128.13 +<0.01 +28 +259.25 ± +96.89 +224.50 ± +111.37 +<0.01 +0.96 +A1c +50 +8.49 ± 1.94 +7.97 ± 2.20 +<0.01 +31 +8.60 ± 1.84 +10.22 ± 1.66 +0.49 +0.03 +Mean plasma +glucose +(MPG) +50 +197.02 ± +55.81 +182.10 ± 63.17 <0.01 +31 +200.26 ± +52.87 +186.69 ± 61.12 <0.01 +0.13 +Total choles- +terol (TC) +50 +175.16 ± +47.88 +186.02 ± 37.80 <0.01 +31 +181.22 ± +41.05 +176.83 ± 47.88 <0.01 +0.40 +Triglycerides +(TG) +50 +169.68 ± +109.38 +192.92 ± +128.23 +<0.01 +31 +196.19 ± +99.62 +212.77 ± +100.35 +<0.01 +0.60 +High-density +lipoprotein +(HDL) +49 +43.83 ± 9.35 +45.36 ± 10.94 +<0.01 +31 +41.64 ± 10.82 +42.16 ± 11.69 +<0.01 +0.30 +Low-density +lipoprotein +(LDL) +49 +99.91 ± 33.60 102.10 ± 30.53 <0.01 +31 +98.51 ± 38.07 +92.16 ± 41.22 +<0.01 +0.26 +Very-low- +density +lipoprotein +(VLDL) +46 +31.15 ± 15.41 +34.40 ± 17.58 +<0.01 +17 +31.82 ± 9.67 +36.9 ± 13.80 +<0.04 +0.25 +Chol/HDL +ratio +50 +4.08 ± 1.54 +4.30 ± 1.42 +<0.01 +31 +4.52 ± 1.13 +4.32 ± 1.01 +<0.01 +0.13 +HDL/LDL +ratio +50 +2.30 ± 0.95 +2.33 ± 0.83 +<0.01 +31 +2.49 ± 0.89 +2.19 ± 0.78 +<0.01 +0.12 +220 +Annals of Neurosciences 27(3-4) +Ayurveda physicians categorized the participants as pitta, +pitta-kapha, and vata-pitta in the study sample. In 23 +diabetic people, 87% of people (20 people) scored high in +pitta total score (>17) and 25% scored high in pitta-kapha +scores (11, 12). Among 12 prediabetic subjects, 75% scored +high in pitta total score (<17) and 25% scored high in pitta- +kapha scores (11, 12; Table 6). +The statistical analysis results of the studied population +indicated that diabetic and prediabetic subjects were more of +pitta prakriti than the vata-pitta. However, the association +between prakriti scores and the status of diabetes (based on +A1c levels) was not significant. +Discussion +There is a growing body of evidence that supports yoga as a +cost-effective adjunct therapy for DM. With regard to +practicing DYP, each practice/procedure has its clinical +significance, which helps in the control of DM as an adjuvant +to the medications in a more effective way (Table 2 shows the +significance of each asana/practice/procedure). This study +investigated the influence of practicing DYP in diabetic +patients for a period of three months. The biochemical +analysis results of these patients showed a statistically +significant reduction in A1c and MBG levels after the +intervention of DYP. The results of this study support the +beneficial effect of early yoga interventions corresponding to +the evidence in the literature. The nonsignificant differences +in the control group indicate the effectiveness of the +intervention protocols of the study. +Yoga and glycemic control have been studied earlier +among adults with DM patients. In a meta-analysis, Thind + +et al., studied the effects of yoga interventions among adults +with type 2 DM. They found that yoga participants had +significantly decreased levels of A1c, FBG, and PPBG +compared to controls,23 suggesting the biochemical effects of +yoga on the glycemic control of DM in the adult population. +In our study, it was also noted that the MBG along with A1c +decreased and were statistically significant after DYP +intervention in diabetic patients. However, in that meta- +analysis, most of the included studies had a nonuniform +protocol, and different studies used different yoga protocols. +In the present study, DYP, a protocol designed specifically for +diabetic patients, was used for the specified period of three +months. This is consistent with current reports that showed +the yoga group had significantly decreased FBG, PPBG, A1c, +and lipid profile.24 However, our study did not examine +glycemic control based on duration, other comorbidity +conditions, or DM with other complications. +Despite the known benefits of long-term adherence to +physical exercises, such as jogging, walking, swimming, +and other outdoor exercises, patients have reported +several barriers to commitment.25 It is pertinent to note that +diabetic patients often have abnormal lipid profiles because +several steps in lipid metabolism are regulated by insulin,26 +and hence the lipid metabolism follows a typical pattern +called diabetes dyslipidemia.27 Dyslipidemia in individuals +with diabetes is a major risk factor for cardiovascular disease, +and its prevention requires a holistic approach that will +control both glycemic and lipid profile abnormality. Studies +have shown that regardless of the treatment types, good +glycemic control is associated with improved lipid profiles. +For example, Shantakumari et al., studied the effect of yoga +on dyslipidemia among type 2 DM patients for three +months and found improvement in TC, TG, and LDL.26 +Our study investigated the influence of practicing DYP on +lipid profiles among diabetic patients for three months and +found statistically significant results similar to those +found in the literature. Another study has shown +significantly reduced levels of TC and TG after 12 weeks +of postyoga practices, but in that study, yoga training +regimens recommended for weight reduction were also +used (three sets of specific yoga protocol, which was +changed every month).29 In our study, the mean age (years) +of the study participants was 58.86 years in the yoga group. +Ferrara et al., indicated that TC and LDL levels show an +increasing trend until the age of 65 years, and the levels fall +progressively after 65 years.30 Another study analyzed the +correlation between age and plasma TG levels among men +and found a strong correlation between aging and increased +fasting TG plasma concentration,32 suggesting the influence +of aging on lipid profiles. The findings in our study provide +evidence that DYP can help in glycemic control; however, it +should be standardized to cover both diabetes and +hyperlipidemia because they can increase the risk of many +diseases such as cardiovascular diseases and stroke. This may +require the development of new protocols for the management +of DM. +Diabetes in Ayurveda is considered as kapha dominant +metabolic disorder where “agni” (digestive power) both at +the gastrointestinal level and at the tissue level is disturbed. +This eventually leads to a state of improper digestion. The +imbalance in digestion and metabolism is associated with +disturbed glycemic control and lipid profile. This can be of +three types according to the predominant dosha in causative +factors, that is, vata type, pitta type, and kapha type. In a +study reported by Govindaraj et al., the genome-wide analysis +correlates with prakriti analysis.32 Prakriti analysis basically +describes the biological specificity operating at cellular and +genomic level.33 +Table 6. Tridosha Characterization in the Subjects +Diabetes Category +Pitta +Pitta- +Kapha +Vata- +Pitta +T +otal +Prediabeticsub- +jects +N +9 +3 +0 +12 +% +75.0% +25.0% +0.0% +Diabetic sub- +jects +N +20 +2 +1 +23 +% +87.0% +8.7% +4.3% +Sivapuram et al. +221 +Tridosha balance and prakriti analysis being the core +philosophy of the Ayurveda system of medicine are shown to +be linked with chronic diseases, metabolic pathways, and +genotypes, which throws light on its potential applicability of +the concepts in personalized medicine and personalized +preventive healthcare.17 For example, in a diabetic patient, a +better understanding of a complex interaction between an +individual’s prakriti and genomic pathways may enable +instituting +personalized +prevention +and +management +strategies that can lower the susceptibility of an individual to +high-risk vulnerabilities. Each of the doshas in the prakriti +has a set of metabolic tendencies that determine an individual’s +mind and bodily reactions to a confronted stimulus. The +disturbances in equilibrium of any doshas can cause certain +diseases, depending on the prakriti of the person. +In our retrospective prakriti analysis, based upon the +established scoring system, we assessed the types of prakriti +which were more prone to DM in this population. Prakriti +analysis in the diabetic population of Chandigarh and +Panchkula showed pitta prakriti preponderance based on our +nonstandardized +structured +questionnaire. +This +was +inconsistent with other studies that investigated the profiling +of prakriti in diabetic patients, showing an association of +vata-kapha or vata prakriti with diabetes.34 This deviation +may be because of a small sample size was taken in our study, +however much larger sample studies are needed to make apt +conclusion. A study conducted in an Indian Ayurvedic +research institute found that approximately 65% of diabetic +individuals had kapha only or kapha-vata or kapha-pitta +prakriti compared to 35% comprising only  pitta or only +kapha or only vata dominant prakriti type.32 Another study +conducted by Mahalle et al., reported a significant association +of DM, hypertension, and dyslipidemia with vata-kapha +prakriti.33 Every individual has a natural predominance of +one dosha or a combination of two doshas that marks the +uniqueness of their physical, physiological, and psychological +functions. In our study, pitta predominance in the diabetic +population could be because of the fact that pitta prakriti +governs metabolism, thermal regulation, and homeostasis in +the body, and people living in this northern territory of India +may have unique features of heightened metabolism.17 A +study conducted by Tiwari et al., found that individuals with +vata-pitta prakriti in the DM exercise group showed a +statistically significant decrease in the PPBS after exercising +compared to the control group. This indicates that blood sugar +may be well controlled in vata-pitta prakriti individuals.36 +It should be noted that diabetes is a risk factor for +cardiovascular diseases, stroke, neuropathy, and retinopathy, +but the prakriti analysis for diseases was not carried out earlier +including our own published work in respect of the risk factor +analysis of age-related macular degeneration,37–40 dementia,41 +and others. However, there are studies showing that DM acts +as a protective factor by delaying the motor symptoms and the +cognitive functions become worse in patients with amyotrophic +lateral sclerosis.42–44 Ayurvedic practices, such as prakriti +analysis included in this paper, should be included as a part of +the research, when studying various diseases and conducting +human experiments. Such integration of Ayurvedic framework +with modern medicine will be useful for an integrative health +and patient-centered approach. +Limitations +This study did not assess glycemic control and lipid +parameters by stratifying study participants based on gender, +risk factors, and diabetes-associated complications. Small +sample size and sample dropouts remain the major challenge. +This study also could not assess glycemic control in long- +standing cases of diabetes with other comorbid conditions +and did not investigate the effect on other parameters of +metabolic syndrome. +Conclusion +After three months of DYP, the yoga group showed promising +results in terms of glycemic control and a good lipid profile. +The study findings provide promising evidence for the effect +of yoga, particularly DYP, on type 2 diabetes management, +providing insights into the sensitivity of the given protocol +that may not be efficient in improving the lipid profile. +Therefore, the protocol should be customized for both +diabetes and hyperlipidemia. Prakriti analysis in the diabetic +population of Chandigarh and Panchkula showed pitta +prakriti preponderance. Long-term follow-ups should be +performed to assess glycemic control in diabetic individuals. +An extended protocol of DYP should also be structured and +examined on patients with both DM and hyperlipidemia. +Author Contribution +The conceptualization of the project was done by RN, IC, HRN; the +conceptualization of the manuscript was by AA, RN, HRN; the +literature search was done by MSS, SJ, VS; The data acquisition was +done by NK, RN, IC, SP, SB, HRN; the data analysis was by NK, +RN, SP, SB; the statistical analysis was by RN, SB, SP; the +manuscript preparation was by MSS, AA, RN, SJ; the manuscript +editing was by MSS, VS, RN, AA; and the manuscript review was +by MSS, VS, RN, AA, IC. +Declaration of Conflicting Interests +The authors declared no potential conflicts of interest with respect to +the research, authorship, and/or publication of this article. +Ethical Statement +Ethical clearance was obtained from the ethical committee of the +Indian Yoga Association (vide Res/IEC-IYA/001 dt 16.12.16) +constituted as per the ICMR guidelines. Informed consent was +obtained from all the participants. +222 +Annals of Neurosciences 27(3-4) +Funding +The authors would like to acknowledge the Ministry of Health and +Family Welfare and Ministry of AYUSH (through CCRYN), +government of India for funding the project (grant number: +16-63/2016-17/CCRYN/RES/Y&D/MCT/ dated 15.12.2016), and +Indian Yoga Association for overall project implementation. +ORCID IDs +Madhava Sai Sivapuram + https://orcid.org/0000-0003-2022-9630 +Akshay Anand + https://orcid.org/0000-0001-7947-5209 +References +1. International Diabetes Federation. IDF Diabetes Atlas, 9th edn, +2019. Brussels, Belgium. +2. Ferlay J, Colombet M, Soerjomataram I, et al. Estimating the +global cancer incidence and mortality in 2018: GLOBOCAN +sources and methods. Int J Cancer 2019; 144(8): 1941–1953. +3. Yuen L, Saeedi P, Riaz M, et al. Projections of the prevalence of +hyperglycaemia in pregnancy in 2019 and beyond: Results from +the International Diabetes Federation Diabetes Atlas. Diabetes +Res Clin Pract 2019; 157: 107841. +4. Anjana RM Pradeepa R Deepa M, et al. Prevalence of diabetes +and prediabetes (impaired fasting glucose and/or impaired glu- +cose tolerance) in urban and rural India: Phase I results of the +Indian Council of Medical Research–INdia DIABetes (ICMR– +INDIAB) study. Diabetologia 2011; 54: 3022–3027. +5. Pantalone KM Misra-Hebert AD Hobbs TM, et al. Effect of +glycemic control on the Diabetes Complications Severity Index +score and development of complications in people with newly +diagnosed type 2 diabetes. J Diabetes 2018; 10: 192–199. +6. Fowler MJ. Microvascular and macrovascular complications of +diabetes. Clin Diabetes 2008; 26: 77–82. +7. American Diabetes Association. Classification and diagnosis of +diabetes. Diabetes Care 2017; 40: S11–S24. +8. Correia S Carvalho C Santos MS Seiça R   Oliveira CR   Moreira +PI. Mechanisms of action of metformin in type 2 diabetes and +associated complications: An overview. Mini Rev Med Chem +2008; 8: 1343–1354. +9. Thent ZC Das S Henry LJ. Role of exercise in the management +of diabetes mellitus: The global scenario. PloS One 2013; 8: +e80436. +10. Pal DK Bhalla A Bammidi S, et al. Can yoga-based diabetes +management studies facilitate integrative medicine in India cur- +rent status and future directions. Integr Med Int 2017; 4: 125– +141. +11. Salmon P Lush E Jablonski M Sephton SE. Yoga and mindful- +ness: Clinical aspects of an ancient mind/body practice. Cogn +Behav Pract 2009; 16: 59–72. +12. Bali P Kaur N Tiwari A, et al. Effectiveness of yoga as the pub- +lic health intervention module in the management of diabetes +and diabetes associated dementia in South East Asia: A narra- +tive review. Neuroepidemiology 2020; 54: 287–303. +13. Muthuselvi K Dhanalakshmi S Abhishek G. Effect of yoga on +glycosylated hemoglobin levels in diabetic subjects. Indian J +Clin Anat Physiol 2017; 4: 238–240. +14. Singh S Kyizom T Singh KP Tandon OP   and Madhu SV. +Influence of pranayamas and yoga-asanas on serum insulin, +blood glucose and lipid profile in type 2 diabetes. Indian J Clin +Biochem 2008; 23: 365–368. +15. Bali HK. Yoga: An ancient solution to a modern epidemic. +Ready for prime time?. Indian Heart J 2013; 65: 132–136. +16. Rastogi S. Development and validation of a Prototype Prakriti +Analysis Tool (PPAT): Inferences from a pilot study. Ayu +2012; 33: 209–218. +17. Dey S Pahwa P. Prakriti and its associations with metabolism, +chronic diseases, and genotypes: Possibilities of new born +screening and a lifetime of personalized prevention. J Ayurveda +Integr Med 2014; 5: 15–24. +18. Nagendra HR Nagarathna R Rajesh SK Amit S Telles S +and Hankey A. Niyantrita Madhumeha Bharata 2017, method- +ology for a nationwide diabetes prevalence estimate: Part 1. Int +J Yoga 2019; 12: 179–192. +19. Nagarathna R Rajesh SK Amit S Patil S Anand A Nagendra +HR. +Methodology +of +Niyantrita +Madhumeha +Bharata +Abhiyaan-2017, a nationwide multicentric trial on the effect of +a validated culturally acceptable lifestyle intervention for pri- +mary prevention of diabetes: Part 2. Int J Yoga 2019; 12(3): +193–205. +20. Singh AK, Kaur N, Kaushal S, et al. Partitioning of radiologi- +cal, stress and biochemical changes in pre-diabetic women sub- +jected to Diabetic Yoga Protocol. Diabetes Metab Syndr. 2019; +13(4): 2705-2713. +21. Nagarathna R, Tyagi R, Kaur G, et al. Efficacy of a validated +yoga protocol on dyslipidemia in diabetes patients: NMB-2017 +India Trial. Medicines (Basel). 2019 Oct 11; 6(4): 100. +22. Knopfholz J, Disserol CC, Pierin AJ, et al. Validation of the +friedewald formula in patients with metabolic syndrome. +Cholesterol 2014; 2014: 261878. +23. Thind H Lantini R Balletto BLet al. The effects of yoga among +adults with type 2 diabetes: A systematic review and meta-anal- +ysis. Prev Med 2017; 105: 116–126. +24. Cui J Yan JH Yan LM Pan L  Le JJ Guo YZ. Effects of yoga in +adults with type 2 diabetes mellitus: A meta-analysis. J Diabetes +Invest 2017; 8(2): 201–209. +25. Garcia-Perez LE Álvarez M Dilla T Gil-Guillén V  and Orozco- +Beltrán D. Adherence to therapies in patients with type 2 diabe- +tes. Diabetes Ther 2013; 4: 175–194. +26. Rivellese AA Vaccaro O Patti L. The pathophysiology of lipid +metabolism and diabetes. Int J Clin Pract 2004; 58: 32–35. +27. Solano MP Goldberg RB. Lipid management in type 2 diabetes. +Clin Diabetes 2006; 24: 27–32. +28. Shantakumari N Sequeira S El deeb R. Effects of a yoga inter- +vention on lipid profiles of diabetes patients with dyslipidemia. +Indian Heart J 2013; 6: 127–131. +29. Malarvizhi V Elangovan R. Effects of yogic practices on +total cholesterol and triglyceride among obese women. Yoga +Mimamsa 2015; 47(1): 10–14. +30. Ferrara A Barrett-Connor E Total Shan J. LDL and HDL cho- +lesterol decrease with age in older men and women: The Rancho +Bernardo Study 1984–1994. Circulation 1997; 96: 37–43. +31. Greenfield MS Kraemer F Tobey T Reaven G. Effect of age on +plasma triglyceride concentrations in man. Metabolism 1980; +29: 1095–1099. +32. Govindaraj P Nizamuddin S Sharath Aet al. Genome-wide anal- +ysis correlates Ayurveda Prakriti. Sci Rep 2015; 5: 15786. +33. Hankey A. The scientific value of Ayurveda. J Altern +Complement Med 2005; 11(2): 221–225. +34. Vaidya AD. Prakruti genomics and prameha-proclivity: +Relevance to metabolic syndrome. Mol Cytogenet 2014; 7: 1. +Sivapuram et al. +223 +35. Mahalle NP Kulkarni MV Pendse NM Naik SS. Association of +constitutional type of Ayurveda with cardiovascular risk fac- +tors, inflammatory markers and insulin resistance. J Ayurveda +Integr Med 2012; 3: 150–157. +36. Tiwari S Gehlot S Tiwari SK Singh G. Effect of walking (aero- +bic isotonic exercise) on physiological variants with special ref- +erence to Prameha (diabetes mellitus) as per Prakriti. Ayu 2012; +33: 44–49. +37. Anand A Sharma NK Gupta A, et al. Single nucleotide poly- +morphisms in MCP-1 and its receptor are associated with the +risk of age related macular degeneration. PLoS One. 2012; +7(11): e49905. +38. Sharma NK Gupta A Prabhakar S, et al. Association between +CFH Y402H polymorphism and age related macular degenera- +tion in North Indian cohort. PLoS One 2013; 8(7): e70193. +39. Sharma NK Prabhakar S Gupta A, et al., New biomarker for +neovascular age-related macular degeneration: Eotaxin-2. DNA +Cell Biol 2012; 31(11): 1618–1627. +40. Sharma NK Gupta A Prabhakar S Singh R Sharma S Anand A. +Single nucleotide polymorphism and serum levels of VEGFR2 +are associated with age related macular degeneration. Curr +Neurovasc Res 2012; 9(4): 256–265. +41. Anand A Banik A Thakur K Masters CL. The animal models +of dementia and Alzheimer’s disease for preclinical testing and +clinical translation. Curr Alzheimer Res 2012; 9(9): 1010–1029. +42. Anand A Thakur K Gupta PK. ALS and oxidative stress: The neu- +rovascular scenario. Oxid Med Cell Longev 2013; 2013: 635831. +43. Gupta PK Prabhakar S Abburi C Sharma NK Anand A. +Vascular endothelial growth factor-A and chemokine ligand +(CCL2) genes are upregulated in peripheral blood mononu- +clear cells in Indian amyotrophic lateral sclerosis patients. J +Neuroinflammation 2011; 8: 114. +44. Anand A Gupta PK Sharma NK Prabhakar S. Soluble VEGFR1 +(sVEGFR1) as a novel marker of amyotrophic lateral sclerosis +(ALS) in the North Indian ALS patients. Eur J Neurol 2012; +19(5): 788–792.