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subfolder_0/A Review on Hydrotherapy Practices in Ancient India.txt

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+_____________________________________________________________________________________________________ 
+ 
+# Dean; 
+*Corresponding author: E-mail: [email protected]; 
+ 
+ 
+ 
+Journal of Complementary and Alternative Medical 
+Research 
+ 
+17(1): 22-29, 2022; Article no.JOCAMR.79409 
+ISSN: 2456-6276 
+ 
+                                 
+ 
+ 
+A Review on Hydrotherapy Practices in Ancient 
+India 
+ 
+K. J. Sujatha a*# and N. K. Manjunath b 
+ 
+a Division of Natural Therapeutics, Shri Dharmasthala Manjunatheshwara College of Naturopathy and 
+Yogic Sciences, Ujire, 574240, India. 
+b Director of Research and International affairs, S-VYASA University, India. 
+ 
+Authors’ contributions 
+ 
+This work was carried out in collaboration between both authors. Both authors read and approved the 
+final manuscript. 
+ 
+Article Information 
+ 
+DOI: 10.9734/JOCAMR/2022/v17i130323 
+ 
+Open Peer Review History: 
+This journal follows the Advanced Open Peer Review policy. Identity of the Reviewers, Editor(s) and additional Reviewers,  
+peer review comments, different versions of the manuscript, comments of the editors, etc are available here: 
+https://www.sdiarticle5.com/review-history/79409 
+ 
+ 
+Received 07 November 2021 
+Accepted 10 January 2022 
+Published 12 January 2022 
+ 
+ 
+ABSTRACT 
+ 
+Background: Water being one of the five great elements (pañcamahābhūta), is considered to be 
+the medium of creation and maintenance of life. Hydrotherapy is the application of water in various 
+forms, temperature on the body either internally or externally for the treatment of the diseases and 
+maintenance of health. It has been observed that many of the practices are considered as a part of 
+daily routine before it was developed into a separate treatment modality. Application of water was 
+given utmost importance in Indian traditional texts like Rigveda, yajurveda, atharva veda, as well 
+as caraka samhitä, çuçruta samhitä and añöäìgasangraha of äyurveda. The practice of 
+hydrotherapy was a part of the all performances or rituals like yäga and yajïa. In this study we aim 
+to elaborate the ancient Indian techniques for improving the body immunity through hydrotherapy 
+as mentioned in traditional texts. The traditional references for hydrotherapy technique like bath, 
+affusion, immersion, packs, irrigations, compresses, poultices, etc, in Indian tradition are searched 
+and compiled. The key changes which can happen in the body due to these practices, which 
+confirm the healthy condition is studied and the proper methodology for these procedures are listed 
+as per the Indian texts with upgrading methods.  We observed in this research that, although 
+having a firm foundation of these behaviours listed in all classic books, they are not mandatory in 
+our day-to-day actions.The modern life style has given more liberty to the people about these 
+Review Article 
+ 
+ 
+ 
+ 
+ 
+Sujatha and Manjunath; JOCAMR, 17(1): 22-29, 2022; Article no.JOCAMR.79409 
+ 
+ 
+ 
+23 
+ 
+practices.  Many historical methods have been seen to be unappealing or to fail to persuade 
+others. In this regard we found many of the ready/ easy practices which can reach wider range of 
+people, as an essential method to propagate and train for better living and protection of health to 
+entire humankind. 
+ 
+ 
+Keywords: Water; hydrotherapy; Indian tradition; vedas; naturopathy. 
+ 
+ABBREVATIONS 
+ 
+RV  :  Rigveda  
+YV  
+:  Yajurveda  
+BAU  :  Bruhadäraëyakopanisad  
+TU  
+:  Taittaréya upaniñad  
+CS  : Caraka Samhita 
+AS  
+: Añöäìgasangraha  
+AV  
+: Atherva Veda  
+SS  
+: Sütra Stäna 
+ 
+1. INTRODUCTION 
+ 
+Hydrotherapy is the application of water in 
+various forms and temperature on the body 
+either internally or externally for the treatment of 
+the diseases and maintenance of health [1]. It 
+has been observed that many of the practices 
+are considered as a part of daily routine before it 
+was developed into a separate treatment 
+modality like Hydrotherapy. The practices like 
+washing hands, gargling (throat irrigation), 
+Bathing, water drinking is considered to be the 
+protective measures, then evolved and modified 
+into different procedures [2]. The concept of 
+usage of water for prevention and treatment of 
+disease and promotion of health was well 
+developed in philosophy and medicine of eastern 
+civilization based on river Sindhu [3]. Water or 
+“äpa” was worshipped in reality and symbolically 
+in ancient Indian culture as nature was kept 
+above man [4]. Ancient religious thought is 
+progression from physical to spiritual, from a 
+purely naturalistic to an increasingly ethical and 
+psychological view of nature [5]. Worshipping of 
+water resources has the intention of protection 
+and maintenance of health through water. 
+ 
+Water is one of the five great elements 
+(pañcamahābhūta) namely ether (ākāśa), air 
+(vāyu), fire (teja or agni), water (āpa), and Earth 
+(pṛthivī) [6]. In Vedas and Upanishads, the 
+traditional text books of Indian culture, the 
+process of evolution of five great elements 
+(pañcamahābhūta) 
+is 
+explained 
+very 
+systematically.  The Air is said to have been 
+generated from space, fire from air, water from 
+fire, and earth from water. Fire and water, which 
+are claimed to pervade the whole cosmos, have 
+a tight relationship and are said to be procreative 
+[7]. The five elements constitute the physical 
+universe; Water is regarded as the primordial 
+substance from which the universe came into 
+being as it is mentioned in Rigveda (RV), 
+SBXIV,3,2.13. It is mentioned that water is the 
+source of our lives, i.e, janayathä [8]. In 
+Yajurveda (YV) hymn no-17/36 states that life in 
+universe, by receiving the cosmic water will have 
+the 
+ability 
+to 
+partake 
+it 
+fully 
+[9]. 
+Bruhadäraëyakopanisad 
+(BAU)t 
+in 
+its 
+verse,6.4.1, mentions that the element earth 
+sustains all creatures and the earth is sustained 
+by water. The water gets transformed into herbs 
+and vegetations, they in turn become flowers and 
+then fruits and fruits support the creatures [10]. 
+The respect was shown by taking utmost care of 
+the water sources. There was a warning in 
+Atherva Veda (AV) about maintaining of water 
+and its sources clean. Pollution was mentioned 
+as poisoning and considered as responsible for 
+spreading of diseases.  One who dirties or spoils 
+ponds, lakes, rivers, etc., or cause smell near 
+residential areas was liable to chastisement [11] 
+Waters and herbs should have no poison’ is 
+mentioned in RV saàhitä vi –39-5. ‘Waters are to 
+be freed from defilement’ is according to Atharva 
+Veda Samhita x-5-24. Taittaréya upaniñad (TU) 
+in the verse 5.101 prescribes certain norms for 
+human beings to keep the environment clean. 
+“One should not cause urine and stool in water, 
+should not spit in water; and should not take bath 
+[12]. Yajurveda also cautions against polluting 
+water as well as destroying trees or plants which 
+are the sources of medicine. It is mentioned in 
+padmapuräëa in the verse from 8-13of chapter 
+8of Kriya Yoga Sar that dirtying of water or 
+surroundings of rivers as a sinful act.  This is an 
+excellent mode of preventing the disease. The 
+God who exists in the universe, lives in air, 
+water, in fire and also in trees and herbs, men 
+should have reverence for them”. BAU (3.9.28) 
+[13] in the same manner the subject of water has 
+been 
+related 
+spiritually, 
+philosophically, 
+cosmologically, medically, and poetically in the 
+ancient Indian literature comprising the veda, 
+upaniñad, puräëä and småti. 
+ 
+2. NEED FOR THE STUDY 
+ 
+The knowledge of medicinal property of water 
+was inherited among ancient Indian people and 
+ 
+ 
+ 
+ 
+Sujatha and Manjunath; JOCAMR, 17(1): 22-29, 2022; Article no.JOCAMR.79409 
+ 
+ 
+ 
+24 
+ 
+texts. The use of water as a medicine was not 
+investigated and it remained unearthed. This 
+study referred the ancient Indian literature such 
+as veda and upaniñad, äyurveda and traditional 
+treatment methods, exploring the knowledge of 
+hydrotherapy. It has become a need, especially 
+because hydrotherapy now occupies the majority 
+of treatment modalities as an independent or 
+adjuvant therapy in the present day. We have 
+conducted a study to revive hydrotherapy of 
+ancient India which will be a contribution towards 
+the better understanding in diagnosis, and 
+treatment of the disease. 
+ 
+3. CONCEPT OF MEDICINAL PROPERTY 
+IN WATER  
+ 
+Atharva veda (AV) mentions about beneficial 
+effects of water irrespective of the place where it 
+had been obtained. In verse 11/4, it is said that 
+“In those deserts where water is present, it is 
+available from ponds, the water we fill in 
+pitchers/pots, water available through rains, may 
+all this water be beneficial to us”. The benefit 
+which is mentioned here is health itself to every 
+individual human being [14]. Caraka Samhita 
+(CS) defines health as a condition which is the 
+best source of virtue, wealth, gratification and 
+emancipation while diseases are destroyers of 
+this source of welfare and life itself (CS.Sū.1.15-
+17) [15]. According to çuçruta samhitä, a healthy 
+person is one who has a perfect balance of all 
+body functions in equilibrium with the mind and 
+soul, any deviation from which results in 
+diseases (SS.Sū.15,41) [16]. Añöäìgasangraha 
+(AS) a traditional text on Ayurveda describes that 
+there can be no life without water and world is 
+predominantly watery both in health or in ill 
+health [17]. Kathopanishad refers to this custom 
+stating ‘A learned guest who visits our dwellings 
+is gleaming similar to fire and to appease him get 
+water132’; in other words, guests must be first 
+treated with water to cleanse themselves.[17]. 
+So, providing water to wash hands, legs and 
+giving water to sip is the first line of treatment 
+recommended for the guests especially in Hindu 
+culture. AV in several other hymns like 6.23; 24 & 
+57 specifically mention the medicinal value of 
+waters and as a dispeller of diseases, as a curer 
+of incurable diseases. In the verse-1.161.9., RV 
+recognizes these qualities and state – ‘there 
+exists no better element other than water”. In the 
+verse - 10.9.5. of RV, it is stated that “Water is 
+sovereign 
+of 
+precious 
+treasures, 
+hence 
+requested to act as a healer and remove all ill 
+health”  [18]. The water is considered to be a 
+preservable, precious panacea for the disease 
+condition. 
+4. WATER AS UNIVERSAL REMEDIAL 
+AGENT  
+ 
+The medicinal property of water, uplifts it as a 
+universal remedial agent i. e vishwa bheSaja. 
+Water was known to give strength and vigor as it 
+is mentioned in RV. It is known to relive the 
+weakness or degeneration (kñaya). Water is 
+abundantly filled with Medicinal Herbs; helps to 
+protect body, so that one can live long according 
+to RV [19]. “Water is present in all Medicinal 
+Herbs of the World, as TU explains the same in 
+verse 1.7.1. Thus, water was considered to be 
+the main ingredient of herbs and plants, also all 
+living beings, in particular human beings. In AV 
+water gets first place as a curative medicine, 
+Water gives strength, it is remedial, it expels 
+diseases [20]. AV tells indirectly that water 
+contains nectar, the mythological divine drink 
+which makes Gods (Deva) unageing and 
+immortal. AV feels that water is, as skilled as a 
+physician, even the herbs are medicinal because 
+they are the products of water. The early 
+beginnings of the art of healing and of the 
+knowledge of healing herbs are found in the 
+“kauçika sütra “of the AV [21]. Yajurveda in the 
+verse15.20 elaborates the application of water 
+differently. “Water is the light, the essence, the 
+nectar and the God, the Brahman”. Yajurveda 
+described water is good for eye problems and is 
+energetic. Up till now in day-to-day practices 
+most of the eye problems are removed by rinsing 
+eye with water [22]. Inherent properties of water 
+both Physical and chemical are responsible for 
+the different functions which are carried out by 
+water in both human beings and plants. Water 
+moves from root of the plant till the tip by 
+capillary action.  Capillary action is the ability of a 
+liquid to flow in narrow spaces without the 
+assistance of, and in opposition to external 
+forces like gravity. Water is capable of capillary 
+action due to its properties of adhesion & 
+cohesion [23].  
+ 
+An example of capillary action in human biology 
+is the drainage of constantly produced tear fluid 
+from the eye. This is essential in many parts of 
+the 
+body, 
+especially: 
+(low 
+viscosity 
+and 
+lubricating 
+property) 
+in 
+the 
+thoracic 
+and 
+abdominal cavities where internal organs (e.g., 
+the heart and lungs, and the organs of the 
+digestive system) are located next to each other 
+and slide over one another as the body moves 
+[24]. At synovial joints, structures such as bones, 
+ligaments, and tendons must move smoothly 
+relative to one another without being hampered 
+by friction between the various structures/ 
+ 
+ 
+ 
+ 
+Sujatha and Manjunath; JOCAMR, 17(1): 22-29, 2022; Article no.JOCAMR.79409 
+ 
+ 
+ 
+25 
+ 
+surfaces. Lubrication is required when internal 
+organs/cells come into contact with one another 
+and glide over one another. Organisms Depend 
+on 
+Cohesion. 
+Hydrogen 
+bonds 
+hold 
+the 
+substance 
+together, 
+a 
+phenomenon 
+called 
+cohesion. Cohesion is responsible for the 
+transport of the water column in plants. The 
+existence of hydrogen bond will help water to 
+consider a unique media to treat all the ailment 
+[25]. The physical properties are recognized in 
+rain water as stated in Sütra Stäna (SS) 45.3.   It 
+was stated that water dropping down from sky, 
+has no taste, no odour. It is absolutely pure and 
+beneficial like nectar. it gives and sustains life, 
+quenches thirst, cures wounds by weapons etc. 
+and revives the consciousness of those who faint 
+due to fatigue, gives clear knowledge, removes 
+drowsiness, burning sensation in the body. The 
+concept of water in Rigveda also recognizes 
+these properties of water as divine values. “The 
+water which is created in the universe, the water 
+which flows in the form of river etc, the water 
+which comes from the digging of the wells, 
+canals etc., the water which is self-created in the 
+form of waterfalls etc, who enters into the ocean 
+and who is pure and full of light, who is full of 
+divine characteristics, help me in this world. 
+Thus, Water is being mentioned as the great 
+purifier and help when received [26]. The 
+rejuvenation therapy (rasäyana) originally based 
+on ‘Rasa’ means water only. The rasa or sap of 
+water is known to care like mother. Water is 
+considered as mother who can know to care in 
+the disease process and correct the system. 
+Vedic texts consistently use ‘rasa’ in the sense of 
+water.  “äpam rasaù” is a frequently appearing 
+phrase in the AV. Similarly, in the AV there was 
+frequent praise of water and its virtues such as 
+conferring luster, putting away old age, resisting 
+of diseases and bringing of immortality are 
+emphasized [27]. Thus, in the Vedic age water 
+was regarded as rasäyana and it is said to fulfil 
+all the functions and dispeller of diseases.  
+ 
+5. HEALING PROCESS IN WATER 
+ 
+Healing process in water is categorized into three 
+remedial 
+properties 
+like 
+Absorbing 
+and 
+communicating property, change of state and 
+solvent property [28]. 
+ 
+5.1 Absorbing 
+and 
+Communicating 
+Property 
+ 
+According to the concept of Indian philosophy as 
+explained in Vedic age, water gets divided into 
+minute particles due to the effect of sun rays and 
+wind. Then it ascends to the atmosphere by the 
+capillary of air. It gets condensed there and 
+subsequently falls as rainfall. So, absorption of 
+water by the atmosphere was recognized here. 
+The verse RV,83.4 Rishi Atri prays parjanya in 
+the following words: - “When parjanya (Sun of 
+Heaven) protects the earth with his waters i.e. 
+irrigates the earth, then winds (for rains) are 
+blown, lightning strikes, vegetation sprouts and 
+grows, sky downpours the drops of water and the 
+earth becomes capable for the welfare of the 
+whole 
+world”. This verse mentions about 
+absorption of water by earth helping the 
+vegetation and energy will be gained through this 
+vegetation [29]. Compared with other materials 
+water can absorb or release a relatively large 
+amount of heat energy while only adjusting its 
+own temperature by a relatively small amount. 
+Therefore, the fact that water accounts for a 
+significant proportion of body mass helps the 
+body to cope with environmental temperature 
+variations and maintain the body's temperature 
+within a safe and comfortable range. The specific 
+heat of the body and water help in the amount of 
+heat that must be absorbed or communicated 
+between water and body to be same. SS 
+mentions that Aqua is a major chemical required 
+for digestion of food taken in. It is advisable to sip 
+little water during meals. The water is also said to 
+give nutrition in the verse VII.49.2 of RV. 
+Nutrition of the body is by two processes mainly, 
+absorption of food and communication of heat 
+produced in cellular activity. So, absorption and 
+communication can be very effective through 
+watery medium when it is used internally. 
+ 
+5.2 Change of State 
+ 
+In Linga purana of 1.36.38 and 1.36.39 say that 
+water is never destroyed nor lost, only its state is 
+changed. Verses 1.36.66-67 of the Linga purana 
+says that it changes one state to the other, water 
+(liquid) to Vapour (gas) by sun heat.  Vapour 
+ascends to the sky with the air   and gets 
+converted into cloud. The cloud will be converted 
+into rain fall. These verses indicate that he 
+interchanging of solid, liquid and vapour state of 
+water was known [30]. The tripartite nature of 
+agni has been connected with the three forms of 
+water – celestial, atmospheric, and terrestrial, 
+called by different synonyms in RV. In Verse 
+XII362.4 of Mahabharata, it is explained that sun 
+rays will rain for 4 months and same water will be 
+extracted by the sunrays [31]. The circulation of 
+water in different forms. The change of state of 
+water from solid to liquid and liquid to gas of vice 
+versa provides a wide range of application each 
+state exhibiting unique effect on the body [32]. 
+ 
+ 
+ 
+ 
+Sujatha and Manjunath; JOCAMR, 17(1): 22-29, 2022; Article no.JOCAMR.79409 
+ 
+ 
+ 
+26 
+ 
+5.3 Solvent Property 
+ 
+In 
+cändogya 
+upaniñad 
+verse 
+6.13.1, 
+the 
+dissolving property of water where the son 
+çvetaketu gets the knowledge of Brahman. Water 
+is an excellent solvent that transports many 
+essential molecules and other particles around 
+the body. These include nutrients and waste 
+products from the body's metabolic processes. 
+Ionization, Electronegativity and osmosis in 
+water, helps to flush out toxins and waste 
+products from tissues and ultimately from the 
+body [33]. Elimination by water is mentioned in 
+Veda both from body and mind. Water is said to 
+wash away the wicked tendencies in a person 
+the treacheries burning within and any falsehood 
+of the mind.8.1. RV offers oblations to deities 
+presiding over the flowing waters- “O Water, 
+which we have drunk, becomes refreshing in our 
+body. May you be pleasant to us by driving away 
+diseases and pains – O divine immortal waters” 
+(RV 63). Water is seen as the reservoir of all 
+curative medicines. ‘varuëa’ is a cosmic ruler as 
+well as the deity that dwells in waters, presides 
+over them and is, therefore, prayed to for 
+granting strength and virility to people’. Water is 
+considered to be a purifier, life-giver, and 
+destroyer of evil [34]. 
+ 
+6. TECHNIQUES OF HYDROTHERAPY  
+ 
+Baths, Packs, Compresses and irrigations are 
+the main treatment modalities of hydrotherapy 
+which were practised in ancient India. All these 
+treatments have different action and reaction 
+according to the ability of response in the person, 
+temperature, duration, area of application and 
+mode of application used. The cold receptors will 
+get stimulated gradually but hot receptors 
+suddenly [35]. The series changes can occur in 
+three phases as action, reaction and remote 
+effect. So, hydrotherapy prescription making 
+should be very much subjective. The modalities 
+like cold bath and immersions were practiced by 
+appreciating the beneficial effects. Verse 9.1 of 
+RV mentions about deeply entering to water 
+which will produce shining of skin in person. In 
+RV ponds of varying depths for bathing was 
+mentioned in hymn no10/71/7 [36]. All major 
+religions of India place an emphasis on 
+ceremonial purity, and bathing is one of the 
+primaries means of attaining outward purity. 
+Ancient Indians used elaborate practices for 
+personal hygiene with three daily baths and 
+washing. In Hindu households, any acts of 
+defilement are countered by undergoing a bath 
+and Hindus also immerse in Sarovar as part of 
+religious rites. These are recorded in the works 
+called gruhya sütra and are in practice today in 
+some communities. The gruhya sütra or Vedic 
+domestic rites and rituals for the householders 
+mentions about washing hands, taking bath, 
+wearing wet cloth as in pack and sipping water 
+as part of many rituals [37]. Steam bath and Sun 
+bath, are mentioned in äyurveda as svedana, 
+snehana. They are the pre procedures for 
+Panchakarma [38]. An herbal combination is 
+added sometimes to the steam for medicinal 
+effect. Sea bathing and river bathing were also 
+advised as a hygienic measure in Hinduism.  
+Local baths like ‘Foot bath’ improves eyesight 
+and pacifies the mind. This rejuvenates the 
+circulatory 
+system. 
+The 
+foot 
+bath 
+is 
+recommended 
+for 
+curing 
+acute 
+headache, 
+insomnia, disorders related to blood pressure, 
+etc [39]. 
+ 
+There is clear instruction on drinking water based 
+on a person's nature. When water is consumed, 
+it bestows fortunate divinity on the individual who 
+drinks it.4.1 of RV.  Consuming water about 1.5 
+liters each morning on an empty stomach, as 
+well as throughout the day is called uña käla 
+cikistä. Water therapy is considered to be a 
+material way of taking an "internal bath" [40]. The 
+attributes of rainwater gathered prior to the 
+contact with land are listed by çuçruta in the 45th 
+branch of SS. ‘It beats the disparities caused by 
+vätä, pitta, kapha offers vigor, augments the 
+seven building materials of the body known as 
+saptadhätu which enhances the brain activity’. 
+Once it touches the land its quality changes 
+according to the quality of the terrain. cäëakya 
+néti in the verse 41 mentions that during 
+indigestion the right and suitable food is water 
+only, preferably hot water. CS mentions that 
+Water taken at dawn works like the heavenly 
+nectar, and in the process of assimilation, it 
+bestows strength; water works like poison when 
+taken immediately after food and as a medicine 
+when 
+properly 
+employed 
+during 
+disease 
+condition.  SS talks about the quantity of water to 
+be taken. The food doesn’t get digested and 
+assimilated if water is consumed in very high 
+quantities. The same problem occurs when water 
+is consumed in too low quantities. It is important 
+to drink more water on a regular basis if you want 
+to have a decent appetite. A person suffering 
+from loss of taste, heartburn, oedema, any of the 
+wasting illnesses, poor digestion, abdominal 
+dropsy, skin disorders, fever, diseases affecting 
+the eyes, ulcer, and diabetes mellitus should 
+drink as little water as possible.AS in the verse 5 
+states that water consumed in the middle, at the 
+ 
+ 
+ 
+ 
+Sujatha and Manjunath; JOCAMR, 17(1): 22-29, 2022; Article no.JOCAMR.79409 
+ 
+ 
+ 
+27 
+ 
+end and in the beginning results in a balanced 
+structure, obese structure and a lean structure, 
+respectively. SS warns that water taken before 
+meals 
+will 
+dampen 
+the 
+digestive 
+power 
+(jaöharägni) and dilute the digestive juices, and 
+in the long run, it results in malassimilation 
+(ineffective assimilation). Water, when taken 
+immediately after meal, causes obesity, and 
+hence, it is advisable to take little water in the 
+course of meals.  
+ 
+SS explains about the thirteen types of 
+fomentation as well as their indications and 
+contra indications. At the time of fomentation, it is 
+necessary to protect the body like eyes, heart 
+and testicle. Because these are most delicate 
+parts of the body. Fomentation is to be 
+administered until there is complete recovery 
+from cold, colic pain, stiffness and heaviness of 
+body, or until tenderness and sweating appear 
+there. 
+ 
+SS in the verse 45 explains the use of describes 
+the therapeutic benefits of cold water. Cold water 
+is known to be helpful in treating epilepsy, in 
+summer, in the condition of excessive body heat, 
+the imbalance of pitta, treating blood poisoning, 
+problem associated with excessive consumption 
+of 
+wine, 
+the 
+state 
+of 
+unconsciousness, 
+exhaustion, vertigo or dizziness and nausea. 
+Although 
+cold 
+water 
+is 
+good 
+and 
+is 
+recommended to be used as medicine, its use is 
+not advised under conditions, such as pain at the 
+sides  of the chest,  catarrh, rheumatism, 
+diseases of  the larynx, distention of the stomach 
+by gas or air, cases of undigested faeces, acute 
+stage of fever, just after the exhibition of any 
+emetic or purgative remedy, severe cough and 
+soon after consuming fatty or oily drinks 
+(snehapäna) acute cold, vätä diseases, sore 
+throat, gastritis, constipation, fever immediately 
+after dysentery and nausea, during hiccups and 
+on consuming more of oily food. 
+ 
+7. CONCLUSION 
+ 
+Water is an essential component in the medical 
+field. It is unquestionably a component of treating 
+symptoms and eradicating the underlying cause 
+of the sickness. The word ‘jévanaà ’ is derived 
+from the root verb ‘jéva’ meaning embracing life 
+or ‘präëadhäraëe’. Water is given the word 
+jévanaà jévanaà to show its importance in life. 
+Water is broadly found in scriptures as an utter 
+necessity in bathing, (snaana), drinking (päna), 
+cleansing (çauca), relieving treatment (cikitsä), 
+hospitality (upacära), farming (kruñi), and offering 
+(tarpaëaà). Mahatma Gandhi employed water 
+therapy to effectively heal many people's 
+diseases. Water is consequently understood as 
+the elixir of life. Water is used both in the 
+preparation 
+of 
+medications 
+and 
+in 
+their 
+consumption. 
+Prevention, 
+treatment 
+and 
+maintenance of health through is a divine 
+responsibility of every person. In this regard, the 
+knowledge of ancient scholars on usage of water 
+as medicine water is thought to bring peace, 
+happiness wealth, long life and good health. 
+ 
+NOTE 
+ 
+The study highlights the efficacy of "ayurveda" 
+which is an ancient tradition, used in some parts 
+of India. This ancient concept should be carefully 
+evaluated in the light of modern medical science 
+and can be utilized partially if found suitable. 
+ 
+CONSENT 
+ 
+It is not applicable. 
+ 
+ETHICAL APPROVAL 
+ 
+It is not applicable. 
+ 
+COMPETING INTERESTS 
+ 
+Authors have declared that no competing 
+interests exist. 
+ 
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+_________________________________________________________________________________ 
+© 2022 Sujatha and Manjunath; This is an Open Access article distributed under the terms of the Creative Commons Attribution 
+License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any 
+medium, provided the original work is properly cited. 
+ 
+ 
+ 
+ 
+Peer-review history: 
+The peer review history for this paper can be accessed here: 
+https://www.sdiarticle5.com/review-history/79409 

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+© 2022 Yoga Mīmāṃsā | Published by Wolters Kluwer - Medknow
+Original Article
+A cross-sectional study on impulsiveness, mindfulness, 
+and World Health Organization quality of life in 
+heartfulness meditators
+Dwivedi Krishna1, Deepeshwar Singh1, Krishna Prasanna2
+1Department of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samasthana, Bengaluru, Karnataka, India, 
+ 
+2Welfare Harvesters, Bengaluru, Karnataka, India
+INTRODUCTION
+Meditation is a self-regulated contemplative practice that helps 
+to improve mental functioning and well-being. Patanjali yoga 
+sutra, the ancient yogic text compiled by sage Patanjali defines 
+“meditation as a balanced, continuous and natural flow of attention 
+directed towards the one point or region of meditation” (Chapter 
+III verses 2; PSY[1]). Later, meditation has categorized into 
+different types of meditative practices as described elsewhere.[2,3] 
+However, in any meditation technique, the practitioner tends to 
+continuously focus on the chosen object for a considerable amount 
+of time and that leads to a focused attentive state of mind. Once 
+the practitioner becomes experienced enough to avoid mind 
+wandering and maintain sustained attention for a considerable 
+amount of time, the practitioner gradually enters the state of deep 
+meditation. Last two decades, researchers have been observed that 
+meditation is capable of promoting mental health and wellbeing. 
+Context: Heartfulness meditation (HM) is a heart-based meditation with its unique feature of transmitting energy 
+which may have an impact on mental health and well-being. The present study intends to compare the mental health-
+related outcomes in long-term HM meditators (LTM), short-term HM meditators (STM), and control groups (CTL).
+Materials and Methods: The self-reported measures of mental health and well-being are reported by using 
+State Trait Anxiety Inventory-II, Barratt Impulsive Scale-11, Mindfulness Attention Awareness Scale, Meditation 
+Depth Questionnaire, and World Health Organization Quality of life-BREF. A total of 79 participants (29 females) 
+participated in LTM (n = 28), STM (n = 26), and CTL (n = 25) with age range 30.09 ± 6.3 years.
+Results: The LTM and STM groups showed higher mindfulness along with the depth of meditation, quality of 
+life, and lower anxiety and impulsivity than to CTL group. Our findings suggest that the HM practice enhances 
+mindfulness, reduces anxiety, and regulates impulsivity. The LTM and STM groups showed significant positive 
+trends of mindfulness as compared to CTL. 
+Conclusion: The results indicated that HM practice could be an effective intervention for reducing anxious and 
+impulsive behavior by subsequently improving mindfulness-related mental health and well-being.
+Key Words:  Anxiety, heartfulness meditation, impulsivity, mental well-being, mindfulness, quality of life
+Address for correspondence: 
+Dr. Deepeshwar Singh, Department of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana, No. 19, Eknath 
+Bhavan, Gavipuram Circle, K.G. Nagar, Bengaluru, Karnataka, India.  
+E-mail: [email protected]
+Submitted: 31-Jan-2022  Revised: 03-Apr-2022  Accepted: 11-Apr-2022  Published: ***
+How to cite this article: Krishna D, Singh D, Prasanna K. A cross-
+sectional study on impulsiveness, mindfulness, and World Health 
+Organization quality of life in heartfulness meditators. Yoga Mimamsa 
+2022;XX:XX-XX.
+This is an open access journal, and articles are distributed under the terms of the 
+Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which 
+allows others to remix, tweak, and build upon the work non-commercially, as long as 
+appropriate credit is given and the new creations are licensed under the identical terms.
+For reprints contact: [email protected]
+ym_15_22_R2
+Access this article online
+Quick Response Code:
+Website:
+www.ym-kdham.in
+DOI:
+10.4103/ym.ym_15_22
+Abstract
+[Downloaded free from http://www.ym-kdham.in on Saturday, July 16, 2022, IP: 136.232.192.146]
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+Krishna, et al.: Heartfulness meditation promotes mental health and well-being
+Yoga Mīmāṃsā | Volume 54 | Issue 1 | January-June 2022	
+25
+Scientific investigations reported that the meditation practice helps 
+to reduce anxiety, depression, and emotional dysregulation.[4-8]
+In recent years, meditation has emerged as a preventive and 
+potential therapeutic tool for psychiatric and psychosomatic 
+problems due to the resultant outcome of meditation techniques 
+for reducing stress, anxiety, and depression.[9-11] A disturbed 
+mental state is associated with an inability to regulate an 
+emotional response to perceived threats, and meditation practice 
+strengthens a person’s mental ability to control emotions when 
+anxious.[12] The scientific investigations on meditation have 
+focused on outcome measures such as cognitive functions, health 
+behaviors, psychological effects, and synchronicities.[13] Previous 
+studies have reported that the mindfulness meditation improves 
+behavior control, quality of life, and reduced impulsivity.[14,15] 
+There is a vast literature on mindfulness meditation concerning 
+mental health issues such as impulsive behavior or distress, 
+and emphasis on protective capacities for distress tolerance 
+and resilience.[14,16] Today, meditation is acceptable and readily 
+adaptable to daily lives to promote mental health and well-
+being.[17,18] However, more research is needed to understand the 
+relationship between various mental health with duration and 
+quality of meditation practice.
+The practice of heart-based meditation has been tested as a 
+potential preventive intervention for a wide range of clinical 
+and psychological issues.[19,20] HM, practice is a modified form 
+of Raja Yoga meditation consisted of meditation, cleaning, and 
+prayer. Empirical evidence suggests that Raja yoga has a positive 
+influence on physiological,[19] emotional, and psychological 
+wellbeing.[20] Further, it has a beneficial effect on emotional 
+regulation, pro-social behavior, positive health, and quality of 
+life.[20-23] However, there is no study, to our knowledge, that 
+examined the different duration of HM experience on mental 
+health-related outcomes and quality of life. Hence, we aimed to 
+check the effect of HM on mindfulness, anxiety, impulsiveness, 
+depth of meditation, and quality of life in long-term and short-term 
+meditators with reference to nonmeditators.
+MATERIALS AND METHODS
+Participants
+In the cross-sectional study, 79 participants (29 females) with 
+age ranged between 25 and 45 years were recruited from 
+heartfulness meditation (HM) centers (long-term HM meditators 
+[LTM]: n = 28, short-term HM meditators [STM]: n = 26) and 
+nearby areas (control [CTL]: n = 25). The inclusion criteria 
+were (a) in the LTM group, the participant should have had 
+more than 3 years of HM experience, (b) in the STM group, 
+the participant should have had at least 6–36 months of HM 
+experience, (c) control participants never had the experience 
+of HM in their total life span. The exclusion criteria were (a) 
+presence of any illness, particularly psychiatric disorders, (b) 
+person on any medication, and (c) history of smoking or alcohol. 
+None of the participants were involved in any other ongoing 
+research activity.
+Demographic information
+All participants were asked to provide their demographic 
+information such as age, gender, occupation, education attainment, 
+meditation experience (in years), frequency of meditation 
+practices (every day, 2–4 times a week, once or twice every week, 
+once every week, or rarely), years of meditation, and the average 
+duration of each meditation session in minutes. The characteristics 
+of the participants are given in Table 1.
+This study was approved by the Ethics Committee of the 
+Institution (RES/IEC-SVYASA/164/1/2020). Written informed 
+consent was obtained from each participant after explaining the 
+design and assessment tools of the study.
+Assessment tools
+The trait anxiety of the participants was assessed using the 
+State-Trait Anxiety Inventory (STAI-II).[24] The trait anxiety 
+STAI-II (how individual generally feels-Trait). It consists of 20 
+items emphasizing the intensity of anxiety symptoms. These 
+questionnaires contain excellent psychometric properties. Each 
+question is rated on a 4-point scale (i) almost never, (ii) sometimes, 
+(iii) often, and (iv) almost always. Reversed scoring items are: 1, 
+2, 5, 8, 10, 11, 15, 16, 19, and 20. Scores range from 20 to 90, and 
+the cutoff for high anxiety is 48.[25] The median alpha reliability 
+coefficient for the trait scale is 0.81.
+The dispositional mindfulness was assessed using the Mindful 
+Attention Awareness Scale (MAAS).[26] This tool measures 
+the general tendency to be attentive and aware of present 
+moment experiences in daily life. It measures a unique quality 
+of consciousness related to a variety of well-being constructs, 
+differentiates mindfulness practitioners from others, and is 
+associated with enhanced self-awareness. MAAS has been used 
+for several studies and reported mental health indicators positively 
+associated with mental and physical health. It contains a 15-item 
+self-reported single-factor scale to assess a core characteristic of 
+mindfulness. It is collected on a 6-point Likert scale; (i) Almost 
+always, (ii) Very frequently, (iii) Somewhat infrequently, (iv) Very 
+infrequently, and (v) Almost never. To score the scale, simply 
+compute a mean of the 15 items. Higher scores reflect higher 
+levels of dispositional mindfulness. The internal consistency 
+reliability is 0.74.
+The quality of life of recruited participants was assessed 
+using the World Health Organization Quality of Life-BREF 
+(WHOQOL-BREF).[27] It is a self-assessment tool to measure 
+the individual’s perceptions in the context of their culture 
+and value systems and their personal goals, standards, and 
+concerns. The WHOQOL-BREF instrument comprises 26 
+items; first, two questions contain overall all quality of life 
+and General Health, 24 items are divided into four domains: 
+(i) physical health with 7 items-explaining about pain and 
+discomfort, energy and fatigue, sleep and relaxation, mobility, 
+and daily life activity; (ii) psychological health with 6 items-
+focusing on positive and negative feelings, thinking, learning, 
+memory and concentration, self-esteem, personal beliefs, and 
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+Krishna, et al.: Heartfulness meditation promotes mental health and well-being
+26 	
+Yoga Mīmāṃsā | Volume 54 | Issue 1 | January-June 2022
+spirituality; (iii) social domain-with 3 items-addressing personal 
+relationships, support, social and sexual activity; and (iv) the 
+environment with eight items detecting the physical safety and 
+protection, home environment, financial resources, health, and 
+social care, seeking for wisdom and skill. Each item is rated on 
+a 5-point Likert scale scored from 1 to 5 on a response scale. 
+Each item of the WHOQO-BREF is scored from 0 (worse) and 
+156 (best) on a response scale.[28] Its good internal consistency 
+is α = 0.63.
+Barratt Impulsiveness Scale-11 (BIS-11) was used to assess the 
+personality/behavioral construct of impulsiveness. There are 
+30-items self-reported scales divided into three primary factors of 
+scale: (1) attentional impulsivity (BIS-A) with 8 items; (2) Motor 
+impulsivity (BIS-M) with 11 items; (3) nonplanning (BIS-NP) 
+with 11 items. Participants respond to each item using a 4-point 
+Likert scale: 1 (rarely/never), 2 (occasionally), 3 (often), and 4 
+(almost always/always). Reversed scoring items are: 1, 7, 8, 9, 
+10, 12 13, 15, 20, 29, and 30. The total score ranges from 30 to 
+120 and higher scores indicate greater impulsivity. BIS-11 internal 
+consistency coefficient is 0.74.
+The depth of meditative experiences was assessed using 
+Meditation Depth Questionnaire (MEDEQ). It contains 30 
+items in five different subdomains; (a) hindrance (MEDEQ-H)-
+assesses the boredom, impatience, and problem with motivation 
+and concentration, (b) Relaxation (MEDEQ-R)-emphasizing 
+comfortable feeling, inner peace, and calmness, (c) personal-self 
+(MEDEQ-PS)-explains the experience of being detached from 
+thoughts, having a deep understanding or insight and feeling 
+centred, (d) Transpersonal qualities (MEDEQ-TPQ)-include 
+emotion such as love, devotion, thankfulness, and connectedness, 
+and (e) Transpersonal-self (MEDEQ-TPS)-interprets the 
+disappearance of cognitive process and the experience of the 
+unity of everything.[29] Each item is rated with the scale ranging 
+from 0 (not at all) to 4 (very much). Responses are summed up to 
+a total score for the dimension of meditation depth. The internal 
+consistency of MEDEQ is = 0.81.
+Heartfulness meditation practice
+It is a unique heart-based practice consisting of cleaning, prayer, 
+and meditation is aided by yogic transmission. Meditation is 
+done preferably in the morning on the source of light within the 
+heart. Cleaning is performed in the evening to rejuvenate oneself 
+from the effects of impressions created by the activities during 
+the day. Prayer is silently offered before going to bed connecting 
+ourselves with our inner-self to reinforce the goal of our life. The 
+entire system becomes pure and more capable of receiving yogic 
+transmission which improves the effectiveness of meditation. The 
+process of transmission is facilitated by meditating with the global 
+guide or certified HM trainer.[19]
+Control group participants who had no experience of any form 
+of meditation were asked to complete the same questionnaires.
+Data analysis
+Statistical analysis was done using the SPSS software version, 20 
+Inc. (Chicago, IL, USA) in Windows. The data were checked for 
+normal distribution and homogeneity of variance by applying the 
+Shapiro‑Wilk test and Levene test. One-way analysis of variance 
+(ANOVA) was performed between group analysis for each 
+psychological assessment. This was followed by post hoc analysis 
+with Bonferroni adjustment for multiple comparisons. Statistical 
+significance was considered at p < 0.05. The descriptive statistics 
+included mean values, standard deviations (SDs), significant 
+values, F-value, partial eta square is given in Tables 2 and 3. The 
+relationship between the scores of trait anxiety (STAI-II) and trait 
+mindfulness (MAAS) with other outcomes was analyzed using 
+Pearson’s correlation, as shown in Table 4.
+RESULTS
+The Shapiro–Wilk test showed that data were homogeneous and 
+normally distributed (p > 0.05). The results of one-way ANOVA 
+for all the variables are reported in Table 2.
+The mean and SD values of self-reported questionnaires are given 
+in Table 3. The post hoc analysis with Bonferroni adjustment 
+Table 1: Characteristics of participants
+Characteristics
+LTM (n=28), n (%)
+STM (n=26), n (%)
+CTL (n=25), n (%)
+Gender
+Male
+17
+18
+16
+Female
+11
+8
+9
+Age (years)
+Male
+32.54±6.2
+30±7.5
+28.43±3.3
+Female
+32±6
+29.45±7.5
+28.12±3.2
+Meditation experience (months)
+137.46±27.54
+12.80±6.48
+‑
+Duration of practice/day (min)
+76.07±15.24
+47.5±20.36
+‑
+Education
+Undergraduate
+9 (32)
+10 (38)
+7 (28)
+Postgraduate
+19 (68)
+16 (61)
+17 (68)
+Higher education
+‑
+1 (4)
+Socioeconomic status
+Lower
+8 (29)
+5 (19)
+7 (28)
+Middle
+18 (64)
+20 (77)
+16 (64)
+Higher
+2 (7)
+1 (4)
+2 (8)
+HM, Heartfulness meditation; LTM, Long‑term HM meditators; STM, Short‑term HM meditators; CTL, Control groups
+[Downloaded free from http://www.ym-kdham.in on Saturday, July 16, 2022, IP: 136.232.192.146]
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+Krishna, et al.: Heartfulness meditation promotes mental health and well-being
+Yoga Mīmāṃsā | Volume 54 | Issue 1 | January-June 2022	
+27
+showed a significant higher scores of MAAS (p < 0.001; 
+p < 0.001), MEDEQ-R (p < 0.05; p < 0.001), MEDEQ-PS (p < 
+0.01; p < 0.001), MEDEQ-TPQ (p < 0.001; p < 0.001), MEDEQ-
+TPS (p < 0.001; p < 0.001), WHOQOL-Physical (p < 0.05), 
+WHOQOL-psychological (p < 0.01) and lower score of STAI-
+II (p < 0.001; p < 0.001), BIS-A (p < 0.05; p < 0.001), BIS-M 
+(p > 0.05; p < 0.001), BIS-NP (p < 0.05; p < 0.001), BIS-T 
+(p < 0.001; p < 0.001) and hindrances of meditation depth scale 
+(p < 0.01; p < 0.001) in the LTM as compared to STM and CTL, 
+respectively. Moreover, the STM group has shown significant 
+higher scores in MAAS (p < 0.01), MEDEQ-PS (p < 0.05), 
+MEDEQ-TPQ (p < 0.05), MEDEQ-TPS (p < 0.05) and lower 
+cores in STAI-II (p < 0.05), BIS-A p < 0.05), BIS-M (p < 0.05), 
+BIS-T (p < 0.01), and MEDEQ-H (p < 0.05) compared to CTL.
+Pearson’s correlation [Table 4] shows a significant negative 
+correlation of MAAS with trait anxiety (LTM [r = −0.38, p < 0.05] 
+and STM [r = −0.47, p < 0.05]); BIS-A (r = −39, p < 0.05), BIS-M 
+(r = −0.51, p < 0.01), BIS-NP (r = −0.54, p < 0.01), BIS-T (r 
+= −0.64, p < 0.001), hindrance (LTM [r = −41, p < 0.05], and 
+STM [r = −0.41, p < 0.05]). Moreover, MAAS showed positive 
+correlation with relaxation (r = 0.48, p < 0.01), transpersonal 
+qualities (r = 0.38, p < 0.05), QOL-Physical (r = 0.44, p < 0.05), 
+QOL-Psychological (r = 0.46, p < 0.05), and meditation experience 
+(r = 0.37, p < 0.05) in LTM group. Whereas, STAI-II has shown 
+negative correlation with meditation experience (r = −0.41, p < 
+0.05), relaxation (r = −0.5, p < 0.01), and positive correlation 
+with hindrance (r = 0.45, p < 0.05) in LTM group and positive 
+correlation with hindrance (r = 0.42, p < 0.05) in STM group. A 
+heatmap of Person’s correlation between mindfulness and other 
+outcome measures of LTM group is presented in Figure 1.
+DISCUSSION
+The primary aim of the study was to compare the mindfulness 
+and anxiety among HM meditators and nonmeditators. Moreover, 
+we also assessed other mental health-related outcomes such 
+as impulsivity, trait anxiety, meditation depth, and quality of 
+life. As expected, we found trait mindfulness was higher and 
+anxiety was lower in the LTM group as compared to the CTL 
+group. Similarly, other mental health-related outcomes showed 
+lower impulsive behavior and higher depth of meditation and 
+Table 2: Analysis of variance results of mental 
+outcomes among three different groups
+Variables
+F
+df 
+p
+pη2
+T‑MAAS 
+42.88
+2,76
+<0.001
+0.53
+STAI‑II
+23.38
+2,76
+<0.001
+0.38
+BIS‑A
+14.55
+2,76
+<0.001
+0.27
+BIS‑M
+9.93
+2,76
+<0.001
+0.21
+BIS‑NP
+8.96
+2,76
+<0.001
+0.19
+BIS‑T
+21.09
+2,76
+<0.001
+0.36
+MEDEQ‑H
+34.73
+2,76
+<0.001
+0.48
+MEDEQ‑R
+13.62
+2,76
+0.013
+0.26
+MEDEQ‑PS
+40.44
+2,76
+<0.001
+0.52
+MEDEQ‑TPQ
+69.31
+2,76
+<0.001
+0.65
+MEDEQ‑TPS
+25.85
+2,76
+<0.001
+0.41
+WHOQoL‑Physical
+3.16
+2,76
+0.04
+0.08
+WHOQoL‑Psychological
+8.53
+2,76
+<0.001
+0.18
+WHOQoL‑SR
+2.90
+2,76
+0.061
+0.07
+WHOQoL‑E
+2.72
+2,76
+0.072
+0.07
+T-MAAS, Triat Mindfulness Attention Awareness Scale; BIS, Barratt Impulsive 
+Scale, BIS‑A, Attentional Impulsivity; BIS‑M, Motor impulsivity; BIS‑NP, 
+Nonplanning; BIS-T, Total impulsivity; STAI‑II, State‑Trait Anxiety Inventory; 
+MEDEQ, Meditation Depth Questionnaire; MEDEQ‑H, MEDEQ‑Hindrance; 
+MEDEQ‑R, MEDEQ‑Relaxation; MEDEQ‑PS, MEDEQ‑Personal‑Self; MEDEQ‑TPQ, 
+MEDEQ‑Transpersonal Qualities; MEDEQ‑TPS, MEDEQ‑Transpersonal‑Self; 
+WHOQoL‑BREF
+, World Health Organization Quality of Life; WHOQoL‑SR, Social 
+relationship; WHOQoL‑E, Environmental; df, degree of freedom
+Table 3: Mean and standard deviation of mental health‑related outcome measures of participants in 
+three groups
+Groups/
+variables
+LTM
+STM
+CTL
+CI (95%) 
+Effect size 
+(Cohen’s d)
+T1
+T2
+T3
+T1
+T2
+T3
+MAAS
+63.29±5.18***,$$$ 55.04±6.43$$ 49.04±3.63
+2.07–10.85
+8.00–16.88
+1.46–10.5
+0.88
+1.88
+0.96
+STAI‑II
+31±5.07***,$$$
+37.31±5.52$ 41.64±6.52 −9.98–(−2.97)
+−13.98–(−6.9)
+−7.57–(−0.36) −1.21 −2.05 −0.69
+BIS‑A
+15.78±2.85*,$$$
+18.85±4.33$ 21.64±4.55 −5.63–(−0.48)
+−8.45–(3.25)
+−5.44–(−0.15) −0.84 −1.56 −0.63
+BIS‑M
+19.71±3.92$$$
+21.50±3.13$ 24.16±4.25
+−4.26–0.68
+−6.94–(−1.95)
+−5.2–(0.12)
+−0.5 −1.08 −0.71
+BIS‑NP
+20±3.15*,$$$
+22.85±2.96 24.04±4.25 −5.11–(−0.58)
+−6.33–(−1.75)
+−3.52–1.14
+−0.93 −1.09 −0.33
+BIS‑T
+55.50±6.85***,$$$ 63.19±5.48$$ 69.84±8.78 −12.51–(−2.87) −19.21–(−9.47) −11.61–(−1.69) −1.15 −1.75 −0.91
+MEDEQ‑H
+3.89±2.11**,$$$
+6.19±1.85$
+8.08±2.98
+−3.9–(−0.87)
+−5.57–(2.51)
+−3.21–(−0.09) −1.23 −1.59 −0.68
+MEDEQ‑R
+10.61±1.19*,$$$
+9.38±1.41
+8.44±1.89
+0.35–2.24
+1.32–3.23
+0.01–1.95
+1.08
+1.48
+0.61
+MEDEQ‑PS
+22.39±3.05**,$$$
+17.35±3.19$ 15.12±2.83
+3.37–7.37
+5.57–9.61
+0.17–4.28
+1.69
+2.53
+0.74
+MEDEQ‑TPQ
+26.18±3.93***,$$$
+18.31±3.45$ 15.52±2.78
+5.74–10.21
+8.51–13.02
+0.49–5.09
+2.16
+3.14
+0.88
+MEDEQ‑TPS
+18.79±1.57***,$$$
+15.38±3.43$ 12.92±3.93
+1.45–5.49
+3.89–7.97
+0.38–4.54
+1.32
+2.03
+0.67
+WHOQoL‑ 
+Physical
+55.78±4.99$
+53.31±5.03 52.16±6.13
+−0.47–6.36
+0.64–7.54
+−2.36–4.66
+0.61
+0.76
+0.20
+WHOQoL‑ 
+Psychological
+61.04±5.28$$
+58.15±6.35 55.12±7.18
+−1.21–6.97
+1.78–10.05
+−1.17–7.24
+0.49
+0.95
+0.45
+WHOQoL‑SR
+59.53±7.71
+56.54±6.21 55.76±3.14
+−0.96–6.96
+1.17–9.18
+−1.89–6.25
+0.43
+0.86
+0.44
+WHOQoL‑E
+56.17±5.27
+55±3.17
+53.56±3.29
+−1.47–3.83
+1.26–6.62
+0.03–5.48
+0.27
+0.89
+0.86
+*Compare with STM; $Compare with CTL; * or $p<0.05; ** or $$p<0.01; *** or $$$p<0.001. HM, Heartfulness meditation; LTM, Long‑term HM Meditators; STM, 
+Short‑term HM Meditators; CTL, Control groups; CI, Confidence interval; MAAS, Mindfulness Attention Awareness Scale; BIS, Barratt Impulsive Scale; BIS‑A, Attentional 
+Impulsivity; BIS‑M, Motor Impulsivity; BIS‑NP, Nonplanning; BIS-T, Total impulsivity, STAI‑II, State‑Trait Anxiety Inventory; MEDEQ, Meditation Depth Questionnaire; 
+MEDEQ‑H, MEDEQ‑Hindrance; MEDEQ‑R, MEDEQ‑Relaxation; MEDEQ‑PS, MEDEQ‑Personal‑Self; MEDEQ‑TPQ, MEDEQ‑Transpersonal Qualities; MEDEQ‑TPS, 
+MEDEQ‑Transpersonal‑Self; WHOQoL‑BREF
+, World Health Organization Quality of Life; WHOQoL-SR, Social relationship; WHOQoL-E, Environmental
+[Downloaded free from http://www.ym-kdham.in on Saturday, July 16, 2022, IP: 136.232.192.146]
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+Krishna, et al.: Heartfulness meditation promotes mental health and well-being
+28 	
+Yoga Mīmāṃsā | Volume 54 | Issue 1 | January-June 2022
+quality of life in HM practitioners. It indicates that the frequency 
+of meditation is associated with improvement in alertness, 
+attentiveness, mindful state, and also enhance the ability to cope 
+with anxiety efficiently.[30,31] These outcomes are inferred from 
+the potential differences in LTM when compared to STM and 
+CTL groups. Moreover, significant associations were observed 
+between meditation experience, mindfulness, anxiety, impulsive 
+behavior, and quality of life in LTM and STM groups. The 
+meditation experience is positively associated with mindfulness 
+and meditation depth and negatively correlated with anxiety 
+and impulsiveness. These results support the previous studies 
+on HM and enhance the evidence of HM practice’s effect on 
+mental health and well-being. The experienced HM practitioners 
+showed lower impulsiveness in attention, motor, and nonplanning 
+behavior. It indicates that HM practice may have preventive and 
+therapeutic potentials to reduce impulsivity among individuals. 
+The trait anxiety also showed a lower score in experienced HM 
+practitioners which indicate that HM controls not only impulsive 
+behavior but also anxiety. The previous study supports our findings 
+that meditation increases subjects’ ability to improve motor 
+responses.[32] It was found that lower BIS-11 motor impulsivity and 
+nonplanning impulsivity subscale scores were associated with the 
+medial orbitofrontal cortex and paracingulate gyrus.[14] These brain 
+areas are associated with a mindfulness practice that is negatively 
+correlated with impulsiveness and anxiety in meditators.[14] HM 
+could be a useful therapeutic technique to treat conditions having 
+features of impulsiveness such as attention deficit hyperactive 
+disorders, obsessive-compulsive disorder, and substance abuse.[6,12] 
+Moreover, the depth of meditation was assessed, and meditators 
+reported higher scores for relaxation, personal self, transpersonal 
+qualities, and transpersonal-self with lower hindrances which 
+suggests that the intense meditation may reduce mental fluctuations 
+and improve self-perception.[33] A previous study reported that 
+cognitive function, attention, and self-awareness are enhanced 
+by mindfulness meditation that showed greater cortical thickness 
+in anterior insular cortex.[34] This study is the first to examine the 
+effect of HM on self-reported dispositional mindfulness and other 
+psychological health outcomes. The quality of life particularly, 
+the physical and psychological domain of life, was higher in the 
+meditators group. Moreover, other studies reported that higher 
+Figure 1: Graphical representation of correlation between mindfulness with anxiety, impulsivity, depth of meditation, and quality of life in 
+LTM group. The Pearson’s correlation showed a significant positive relation of mindfulness with relaxation, meditation depth, and quality of 
+life, whereas the negative relation of mindfulness with anxiety and impulsivity. MAAS, Mindful Attention Awareness Scale;  STAI-II, State-
+Trait Anxiety Inventory; BIS, Barratt Impulsive Scale; BIS-A, BIS-Attentional impulsivity; BIS-M, BIS-Motor impulsivity; BIS-NP, BIS-
+Nonplanning; MEDEQ, Meditation Depth Questionnaire; MEDEQ-H, MEDEQ-Hindrance; MEDEQ-R, MEDEQ-Relaxation; MEDEQ-PS, 
+MEDEQ-Personal-Self; MEDEQ-TPQ, MEDEQ-Transpersonal Qualities; MEDEQ-TPS, MEDEQ-Transpersonal-Self; QOL, Quality of life
+[Downloaded free from http://www.ym-kdham.in on Saturday, July 16, 2022, IP: 136.232.192.146]
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+Krishna, et al.: Heartfulness meditation promotes mental health and well-being
+Yoga Mīmāṃsā | Volume 54 | Issue 1 | January-June 2022	
+29
+self-reported mindfulness was positively correlated with better 
+quality of life and psychological well-being.[26,35] The lower trait 
+anxiety of experienced meditators may be due to reduction in 
+hindrances and enhanced relaxation and personal self, as reported 
+in the MEDEQ. Previous mindfulness meditation studies also 
+found significantly lower STAI-II scores.[36,37] Reduced STAI-
+II scores are principally attributed to the anterior cingulate 
+cortex, a brain region that controls thinking and emotion and 
+is functionally tied with the amygdala reactivity to explicit and 
+implicit emotional processing, which could reduce anxiety.[38] 
+The current finding suggests that HM meditation helped to reduce 
+anxiety by regulating self-referential thoughts. Further, higher trait 
+mindfulness is related to lower neuroticism, depression, anxiety, 
+and higher life satisfaction, optimism, and self-esteem.[39] In line 
+with this, we also observed a negative correlation between trait 
+mindfulness with lower anxiety among meditators. The HM 
+practice has potential to influence breathing rhythm and suppress 
+global vagal modulation and enhance sympathetic and baroreflex 
+activity during deep meditation.[40] These outcomes indicated that 
+HM could be considered a therapeutic tool for healthcare providers 
+to ameliorate health-related issues, and enhance wellness.[30]
+Although HM showed significant change among the practitioners, 
+there are limitations to the study. The limitations of the study 
+are (i) the broad age range of the participants, (ii) the data 
+is a self-reported subjective assessment, (iii) the duration of 
+heartfulness practice was self-reported by meditators, and lack of 
+supervision may have its repercussions, and (iv) there is a need 
+to study a more heterogeneous meditation groups with diverse 
+cultures and societies. Finally, the present study paves a path 
+for future exploration with neuroimaging techniques such as 
+electroencephalogram, electrocardiogram, functional magnetic 
+resonance imaging (fMRI), or positron emission tomography to 
+study the structure or functional and cognitive domains of the brain 
+among long-term, novice, and naïve heartfulness practitioners.
+CONCLUSION
+The results indicated that HM practice could be an effective 
+and promising intervention to enhance mindfulness, depth of 
+meditation, and quality of life with reduction of impulsivity and 
+anxiety. The regular practice of this meditation technique may 
+improve the personal self and transpersonal qualities that promote 
+positive emotions and quality of life. Finally, the outcome of the 
+study highlights the preventive and therapeutic potentials of HM 
+for regulating anxiety and impulsiveness in behavioral disorders.
+Financial support and sponsorship
+Nil.
+Conflicts of interest
+There are no conflicts of interest.
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+Variables
+LTM
+STM
+Pearson’s (r)
+p
+Pearson’s (r)
+p
+MAAS
+STAI‑II
+−0.38
+0.043
+−0.47
+0.014
+BIS‑A
+−0.39
+0.035
+0.3
+>0.05
+BIS‑M
+−0.51
+0.005
+0.02
+>0.05
+BIS‑NP
+−0.54
+0.003
+−0.13
+>0.05
+BIS‑T
+−0.64
+<0.001
+−0.11
+>0.05
+Hindrance
+−0.43
+0.022
+−0.41
+0.037
+Relaxation
+0.48
+0.008
+0.25
+>0.05
+TPQ
+0.38
+0.045
+0.2
+>0.05
+QOL‑physical
+0.44
+0.020
+−0.28
+>0.05
+QOL‑psychological
+0.46
+0.013
+0.26
+>0.05
+Med‑experience
+0.37
+0.048
+0.17
+>0.05
+STAI‑II
+Med‑experience
+−0.41
+0.032
+−0.25
+>0.05
+Hindrance
+0.45
+0.015
+0.42
+0.029
+Relaxation
+−0.5
+0.007
+0.12
+>0.05
+The Pearson’s correlation showed a significant positive relation of mindfulness 
+with relaxation, meditation depth, and QOL whereas the negative relation of 
+mindfulness with anxiety and impulsivity. HM, Heartfulness meditation; LTM, 
+Long‑term HM meditators; STM, Short‑term HM meditators; MAAS, Mindfulness 
+Attention Awareness Scale; BIS, Barratt Impulsive Scale; BIS‑A, BIS‑Attentional 
+impulsivity; BIS‑M, BIS‑Motor impulsivity; BIS‑NP, BIS‑Nonplanning; BIS-T, Total 
+impulsivity, STAI‑II, State‑Trait Anxiety Inventory; TPQ, Transpersonal qualities; 
+QOL, Quality of life
+[Downloaded free from http://www.ym-kdham.in on Saturday, July 16, 2022, IP: 136.232.192.146]
+1
+2
+3
+4
+5
+6
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+10
+11
+12
+13
+14
+15
+16
+17
+18
+19
+20
+21
+22
+23
+24
+25
+26
+27
+28
+29
+30
+31
+32
+33
+34
+35
+36
+37
+38
+39
+40
+41
+42
+43
+44
+45
+46
+47
+48
+49
+50
+51
+52
+53
+54
+55
+56
+57
+58
+59
+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
+Krishna, et al.: Heartfulness meditation promotes mental health and well-being
+30 	
+Yoga Mīmāṃsā | Volume 54 | Issue 1 | January-June 2022
+Future directions in meditation research: Recommendations for expanding 
+the field of contemplative science. PLoS One 2018;13:e0205740.
+14.	 Korponay C, Dentico D, Kral TR, Ly M, Kruis A, Davis K, et al. The 
+effect of mindfulness meditation on impulsivity and its neurobiological 
+correlates in healthy adults. Sci Rep 2019;9:11963.
+15.	 Joshi AM, Mehta SA, Pande N, Mehta AO, Randhe KS. Effect of 
+Mindfulness-Based Art Therapy (MBAT) on psychological distress and 
+spiritual wellbeing in breast cancer patients undergoing chemotherapy. 
+Indian J Palliat Care 2021;27:552-60.
+16.	 Nila K, Holt DV, Ditzen B, Aguilar-Raab C. Mindfulness-based stress 
+reduction (MBSR) enhances distress tolerance and resilience through 
+changes in mindfulness. Ment Health Prev 2016;4:36-41.
+17.	 Duprey EB, McKee LG, O’Neal CW, Algoe SB. Stressful life events and 
+internalizing symptoms in emerging adults: The roles of mindfulness 
+and gratitude. Ment Health Prev 2018;12:1-9. [doi: 10.1016/j.
+mhp.2018.08.003].
+18.	 Beccia AL, Dunlap C, Hanes DA, Courneene BJ, Zwickey HL. 
+Mindfulness-based eating disorder prevention programs: A systematic 
+review and meta-analysis. Ment Health Prev 2018;9:1-12.
+19.	 Arya NK, Singh K, Malik A, Mehrotra R. Effect of Heartfulness cleaning 
+and meditation on heart rate variability. Indian Heart J 2018;70 Suppl 
+3:S50-5.
+20.	 Desai K, Gupta P, Parikh P, Desai A. Impact of virtual heartfulness 
+meditation program on stress, quality of sleep, and psychological 
+wellbeing during the COVID-19 pandemic: A mixed-method study. Int 
+J Environ Res Public Health 2021;18:11114.
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+lifestyle through mindfulness in university students: A randomized 
+controlled trial. Nutrients 2020;12:2450.
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+and practice. Can J Psychiatry 2012;57:63-9.
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+Effect of heartfulness meditation on burnout, emotional wellness, and 
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+et al. Meditation experience is associated with increased cortical thickness. 
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+[Downloaded free from http://www.ym-kdham.in on Saturday, July 16, 2022, IP: 136.232.192.146]

subfolder_0/Add-on Yoga Therapy for Social Cognition in Schizophrenia_ A Pilot Study.txt

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+Int J Yoga. 2018 Sep-Dec; 11(3): 242–244.
+doi: 10.4103/ijoy.IJOY_45_17
+PMCID: PMC6134743
+PMID: 30233119
+Add-on Yoga Therapy for Social Cognition in Schizophrenia: A Pilot
+Study
+Ramajayam Govindaraj, Shalini Naik,  NK Manjunath,  Urvakhsh Mehta Mehta,  BN Gangadhar,  and
+Shivarama Varambally
+Department of Psychiatry, NIMHANS Integrated Centre for Yoga, NIMHANS, Bengaluru, Karnataka, India
+Department of Psychiatry, NIMHANS, Bengaluru, Karnataka, India
+Department of Yoga and Life Sciences, S-VYASA, Bengaluru, Karnataka, India
+Address for correspondence: Dr. Ramajayam Govindaraj, Department of Psychiatry, NIMHANS Integrated
+Centre for Yoga, NIMHANS, Hosur Road, Bengaluru - 560 029, Karnataka, India. E-mail:
+[email protected]
+Received 2017 Aug; Accepted 2017 Nov.
+Copyright : © 2018 International Journal of Yoga
+This is an open access journal, and articles are distributed under the terms of the Creative Commons
+Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the
+work non-commercially, as long as appropriate credit is given and the new creations are licensed under the
+identical terms.
+Abstract
+Background:
+Yoga as a mind–body therapy is useful in lifestyle-related disorders including neuropsychiatric
+disorders. In schizophrenia patients, yoga has been shown to significantly improve negative symptoms,
+functioning, and plasma oxytocin level.
+Aim:
+The aim of the study was to study the effect of add-on yoga therapy on social cognition in
+schizophrenia patients.
+Materials and Methods:
+In a single pre-post, study design, 15 schizophrenia patients stabilized on antipsychotic medication for
+6 weeks were assessed for social cognition (theory of mind, facial emotion recognition, and social
+perception [SP]) and clinical symptoms (negative and positive symptoms and social disability) before
+and after twenty sessions of add-on yoga therapy.
+Results:
+There was a significant improvement in the social cognition composite score after 20 sessions of yoga
+(t[13] = −5.37, P ≤ 0.001). Clinical symptoms also reduced significantly after twenty sessions of yoga.
+Conclusion:
+Results are promising to integrate yoga in clinical practice, if proven in well-controlled clinical trials.
+Keywords: Schizophrenia, social cognition, yoga
+1
+2
+1
+1
+1
+1
+2
+Introduction
+Schizophrenia is a severe mental disorder affecting young adults with a lifetime prevalence of 1%. It is
+characterized by three important symptom clusters, namely, positive, negative, and cognitive
+symptoms. Except for the positive symptoms, there are no effective treatments available for the
+negative and cognitive symptoms.[1] In addition, the existing treatments are not free of side effects;
+some causing extrapyramidal side effects and others causing metabolic side effects.[2]
+Unavailability of effective biological treatments for negative and cognitive symptoms adds to the
+already existing burden of socio-occupational dysfunction associated with these symptom clusters.
+Psychosocial interventions are available targeting a few or most of the domains of social cognition with
+or without neurocognition training. However, the majority of them (for example, cognitive
+enhancement therapy and social cognition interaction training) are highly resource intensive and their
+feasibility in developing countries are questionable though they might be effective. Moreover, they
+were developed keeping in mind the Western patient population and their cultural validity in other
+cultures. Hence, there is a need to explore the role of other complementary therapies such as yoga for
+an integrated approach in treating patients with schizophrenia.
+Yoga as a mind–body therapy is useful in lifestyle-related disorders including neuropsychiatric
+disorders.[3,4] In healthy adults and elderly, yoga is found to be efficacious in improving cognitive
+skills.[5] Yoga has been shown to significantly improve negative symptoms and functioning in
+schizophrenia patients.[6,7] In a recent study, along with improvements in functioning, yoga also
+increased oxytocin levels in patients with schizophrenia.[8]
+In this study, we hypothesized that practice of yoga for 1 month would improve social cognition in
+patients with schizophrenia.
+Materials and Methods
+Setting
+The study was conducted in a tertiary care neuropsychiatry hospital in South India in collaboration with
+a Yoga University. The study was approved by the Ethics Committee of both the institutes.
+Study design
+The study design was a single group pre-post design.
+Sample
+Patients with schizophrenia (outpatient n = 7 and inpatient n = 8) stabilized on antipsychotic
+medications for at least 6 weeks, and cooperative for yoga practices were recruited as a part of a larger
+randomized controlled trial after obtaining a written informed consent. Their diagnosis was made by
+their treating psychiatrists and confirmed with the Mini-International Neuro-psychiatric Interview.[9]
+They were of either gender, coming from the age group of 18–45 years with Clinical Global
+Impression-Severity[10] score of 3 or more. Patients with a history of risk of harm to self or others;
+who had received electroconvulsive therapy or yoga therapy in the last 6 months; patients with
+significant neurological disorder or head injury; and patients with substance abuse in the last 1 month
+or dependence in the last 6 months except nicotine were excluded from the study. Out of 15 patients
+recruited, one subject dropped out due to general medical illness (osteoarthritis).
+Intervention
+A trained yoga instructor taught all the participants a validated yoga module for 1 month. Subjects
+attended twenty sessions of yoga over 6 weeks. Each session lasted for 1 h. The yoga module consisted
+of asana, pranayama, and AUM chanting. Details of the module can be found in an earlier publication.
+[11]
+Assessments
+The following assessments were performed at baseline and after twenty sessions of yoga.
+1. Psychopathology was assessed using Scale for Assessment of Negative Symptoms (SANS)[12]
+and Scale for Assessment of Positive Symptoms (SAPS)[13]
+2. Socio-occupational dysfunction was assessed by Groningen social disability scale (GSDS-II)[14]
+3. Social Cognition was assessed using the social cognition rating tool for Indian setting,[15] a
+validated tool for assessing social cognition appropriate for Indian population that captures
+theory of mind and SP, and tool for recognition of emotions in neuropsychiatric disorders[16]
+that assesses facial emotion recognition. Each domain was scored as the proportion of correct
+responses on a scale of 0–100. The proportions of correct answers were converted into a global
+composite score by averaging the individual domain scores as done in earlier studies.[17]
+A trained psychiatry resident performed the clinical assessments, and a trained research scholar
+performed the social cognition assessments. Neither of them was involved in training the subjects with
+yoga. The yoga instructor monitored yoga performances of all subjects.
+Statistical analysis
+Data were tested for outliers and normality. Data were found to be normal, and there was no outlier.
+Paired t-test was applied to detect a difference in pre- and post-measures using Statistical Package for
+the Social Sciences version 24 (IBM Corp. Released 2016. IBM SPSS Statistics for Windows, Version
+24.0. Armonk, NY: IBM Corp.).
+Results
+The sociodemographic details of the subjects are shown in Table 1.
+Table 1
+Sociodemographic details
+SANS, SAPS, and GSDS scores reduced significantly, and social cognition composite score (SCCS)
+improved significantly after 1 month of yoga practice [Table 2]. Effect size (Cohen's d) for SANS,
+SAPS, GSDS, and SCCS is 2.7, 1.5, 1.9, and 1.4, respectively.
+Table 2
+Pre-post measures
+Discussion
+At the end of 1-month add-on yoga therapy, scores on psychopathology and socio-occupational
+dysfunction rating scales reduced significantly and SCCS increased significantly. Previous studies have
+shown efficacy of yoga in reducing psychopathological symptoms, especially the negative symptoms.
+This is one of the first studies exploring the role of yoga in social cognition for patients with
+schizophrenia. Unlike previous studies,[8,16] which have primarily used tasks assessing only facial
+emotion recognition deficits (FERD), this study has included most of the domains of social cognition
+including FERD. A subgroup analysis of the social cognition subdomains revealed significant changes
+in second-order theory of mind (t[13] = −2.45, P = 0.02] and SP (t[13] = −2.35, P = 0.03) but not in
+first-order theory of mind (t[13] = −1.61, P = 0.1). The changes were significant in emotion recognition
+(t[13] = −5.05, P < 0.001) and faux pas indices (t[13] = −8.0, P < 0.001) (considered as higher-order
+theory of mind) as well. Whether the improvement in SCCS is due to improvement in all the individual
+domains or improvement in some other phenomena (like mirror neuron activity) which might be
+common to all the subdomains of social cognition, needs to be explored further. For example, a recent
+pilot study has shown improvement in mirror neuron activity with yoga intervention, measured by
+functional near infra-red spectroscopy.[18] The large effect size with yoga intervention is interesting,
+but it could also be due to the chance detection passing through the threshold of significance which is
+usually kept at 0.05 (type I error). Considering the small sample size, further studies with robust design
+are required for confirming the large effect size following yoga intervention. Yoga could possibly work
+by both bottom-up and top-down approaches-promoting relaxation through asana and pranayama and
+mindfulness through chanting and positive resolution, respectively. This dual effect of yoga might well
+fit in with the dual processing theory of Social Cognition,[19] with mindfulness (yoga mediated)
+promoting controlled (reflective) processing and relaxation modulating the reflexive (automatic)
+processing. Although the results are promising, they should be interpreted with caution as there is no
+control arm in this study and may need confirmation by well-controlled studies.
+Financial support and sponsorship
+Nil.
+Conflicts of interest
+There are no conflicts of interest.
+Acknowledgment
+We thank the NIMHANS Integrated Centre for Yoga and its staffs for the logistic support in conducting
+the yoga sessions.
+We would like to acknowledge the financial support from Wellcome Trust-DBT India Alliance
+(IA/E/12/1/500755) for one of the researchers (RG) during this study period.
+Shivarama Varambally is the recipient of a current Wellcome Trust-DBT India Alliance Intermediate
+Clinical Fellowship (Grant number IA/CPHI/15/1/502026).
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+Publications

subfolder_0/An Ayurvedic basis for using honey to treat herpes.txt

@@ -0,0 +1,188 @@
+PERSONAL USE
+ONLY
+An Ayurvedic basis for using honey to treat herpes
+Comment to:
+Topical honey application vs. acyclovir for the treatment of the 
+recurrent herpes simplex lesions
+Noorie S. Al-Walli
+Med Sci Monit, 2004; 10(8): MT94-98
+Dear Editor,
+Honey was demonstrated to accelerate the healing process of 
+labial and genital herpes lesions with marked improvement 
+in the signs and symptoms of recurrent episodes [1]. This 
+article is an interesting example of the use of the topical ap-
+plication of honey in a viral infection. There are several refe-
+rences to the use of sugar based preparations in traditional 
+medicine, including the Indian system of Ayurveda [2].
+Ayurveda is a compound word i.e., âyus meaning ‘life’ or 
+‘life principle’, and the word veda, which refers to ‘a sys-
+tem of knowledge’. Hence ‘Ayurveda’ roughly translates as 
+the ‘knowledge of life’. The ancient Indian ayurveda texts, 
+Caraka Samhita [circa 200 B.C.] and Susrutha Samhita [circa 
+1200–800 B.C.] describe the separate use of honey and su-
+gar in most ayurvedic preparations, where both of them 
+are used to expel harmful substances from the body [3]. In 
+Susrutha Samhita eight types of honey have been described 
+largely based on the nature of the insect which gathered 
+them, as well as the properties of the honey [4].
+In ayurvedic medicine it is considered that the body consists 
+of three physical humors [doshas] viz, wind [vata], bile [pitta] 
+and phlegm [kapha] [5]. Harmony between the three phy-
+sical humors [doshas] and three mental attributes [gunas] 
+leads to health, whereas disharmony is associated with di-
+sease [6]. The three mental attributes [gunas] are divine 
+[sattva], kingly [rajas] and evil [tamas].
+Also, imbalance within any one of the three physical doshas 
+i.e, vata, pitta or kapha, leads to dysfunction, imbalance and 
+disease, specifi
+ c to the humor involved [7]. Many disorders 
+have been described as being associated with pitta imba-
+lance including pyrexia, hyperacidity, abscesses, stomatitis, 
+aphthous ulcers, and even herpes (described as a condition 
+with painful vesicles) (Caraka Samhita, Chapter 11; Verse 14) 
+[8]. Pitta imbalance is also associated with specifi
+ c symptoms 
+and signs viz, burning, itching, heat, redness and discharge, 
+among others (Caraka Samhita, Chapter 11; Verse 15) [8].
+Honey is one of the remedies recommended to allevia-
+te disorders of pitta (Caraka Samhita, Chapter 27; Verses 
+243–246) [8]. Since pitta imbalance is associated with her-
+pes, this suggests that in ayurvedic medicine there is a ba-
+sis for the use of honey in the treatment of herpes. While 
+there are no published trials on the use of ayurveda in the 
+management of herpes simplex and other conditions re-
+lated to pitta imbalance, honey is used in the treatment of 
+some of these conditions. For example, honey is effective-
+ly used as an adjunct to gargles for aphthous ulcers, sto-
+matitis, and a sore throat [9]. Hence it is worth investiga-
+ting the use of honey in conditions described as being due 
+to pitta imbalance.
+Sincerely,
+Shirley Telles1, Raghuraj Puthige2,
+Naveen Kalkuni Visweswaraiah3
+1 Patanjali Yog Peeth, Haridwar, Uttaranchal, India;
+e-mail: [email protected]
+2 JSS Institute of Naturopathy & Yogic Sciences,
+Ootacamund, Tamil Nadu, India
+e-mail: [email protected]
+3 Patanjali Yog Peeth, Haridwar, Uttaranchal, India
+REFERENCES:
+ 1. Al-Walli NS: Topical honey application vs. acyclovir for the treatment 
+of the recurrent herpes simplex lesions. Med Sci Monit, 2004; 10(8): 
+MT94–98
+ 2. Forrest RD: Development of wound therapy from the Dark Ages to the 
+present. JR Soc Med, 1982; 75(4): 268–73
+ 3. Nakamure T, Endo J, Sakim M: Comparative studies on saccharated 
+preparations in traditional medicine. Yakushigaku Zasshi, 1996; 31(1): 
+12–22
+ 4. Dutt UC: The materia medica of the Hindus. Mittal Publications: New 
+Delhi, India, 1995
+ 5. 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(193): 1–9
+ 6. Mishra L, Singh BB, Dagenais S: Ayurveda: a historical perspective and 
+principles of the traditional healthcare system in India. Altern Ther 
+Health Med, 2001; 7(2): 36–42
+ 7. Chauhan P: Eternal health: the essence of Ayurveda. Jiva Institute: 
+Faridabad, India, 2000
+ 8. Sharma PV: Caraka-Samhita (Volume 1), Chaukhamba Orientalia: 
+Varanasi, India, 1996
+ 9. Graham TJ: Ayurveda materia medica for domestic use. Volume I. Logos 
+Press: New Delhi, India, 2006
+Received: 2007.09.19
+LE17
+Letter to Editor
+WWW.MEDSCIMONIT.COM
+LE
+Current Contents/Clinical Medicine • IF(2006)=1.595 • Index Medicus/MEDLINE • EMBASE/Excerpta Medica • Chemical Abstracts • Index Copernicus
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subfolder_0/Analysis of Telomere Damage by Fluorescence in situ Hybridisation on Micronuclei in Lymph.txt

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+PRECLINICAL STUDY
+Analysis of telomere damage by fluorescence in situ hybridisation
+on micronuclei in lymphocytes of breast carcinoma patients
+after radiotherapy
+Birendranath Banerjee Æ Sanjiv Sharma Æ
+Sridevi Hegde Æ M. Prakash Hande
+Received: 5 October 2006 / Accepted: 24 January 2007 / Published online: 28 February 2007
+
 Springer Science+Business Media B.V. 2007
+Abstract
+Radiotherapy has become an indispensable
+tool in the effective management of most of the cancers.
+There have been efforts earlier to study the differential
+radio-sensitivity patterns in patients undergoing radia-
+tion treatment to correlate with treatment induced
+complications such as tissue injury, cell death, and
+chromosomal aberration frequencies etc. The present
+study is an attempt to correlate the radiation-induced
+damage in the peripheral blood lymphocytes (PBLs) of
+breast cancer patients with the frequency of telomere
+mediated chromosomal damage. Blood samples from
+55 patients with (Gr-II and Gr-III) CA-breast were
+obtained pre- and post-radiotherapy. The patients were
+treated with external beam radiotherapy of 50.4 Gy
+over a period of 6 weeks. Chromosome damage was
+measured by analysing micronucleus (MN) frequency
+in PBLs. The MN-frequency of the irradiated patients
+increased significantly compared to the patients being
+self-controls. The micronuclei were hybridized with
+telomere probes to study the extent of telomere dam-
+age. The fluorescence signals of the telomere regions in
+the first generation of the binucleated cells were
+significantly higher in the post-radiotherapy patients.
+There was also significant correlation observed in the
+patients with higher-grade tumours. Inter-individual
+variability
+was
+observed
+in
+the
+radiation-induced
+MN frequency in lymphocytes of patients after six
+weeks of radiotherapy. There was a significant corre-
+lation
+between
+functionally
+intact
+telomeres
+and
+the cellular response to ionising radiation. Our find-
+ings suggest that fluorescence in situ hybridisation
+on micronuclei could be effectively used as routine
+clinical application to determine the individual sensi-
+tivity to ionising radiation with respect to telomere
+damage.
+Keywords
+Breast cancer 
 Cytokinesis blocked
+micronucleus assay 
 Fluorescence in situ
+hybridisation 
 Radiosensitivity 
 Telomere damage
+Introduction
+Radiotherapy is an important therapeutic modality in
+clinical cancer management. Lately with advent of
+better machines and innovative technology, individu-
+alisation of cancer radiotherapy is gaining greater
+grounds. There have been number of studies done
+earlier to prove the radiosensitivity of different indi-
+viduals undergoing radiotherapy. Fibroblasts are the
+most commonly used in vitro experimental model for
+studying the radiosensitivity of normal tissue. Johansen
+et al. [1, 2] observed a significant correlation between
+the surviving fractions of fibroblasts after 3.5 Gy and
+subcutaneous fibrosis in breast cancer patients. The
+micronucleus (MN) assay is a sensitive tool to assess
+radiation induced cytogenetic damage, though there is
+B. Banerjee 
 S. Hegde
+Department of Medical Genetics, Manipal Hospital,
+Bangalore, India
+B. Banerjee 
 M. P. Hande (&)
+Genome Stability Laboratory Department of Physiology,
+Yong Loo Lin School of Medicine, National University of
+Singapore, Block MD9, 2 Medical Drive, Singapore 117597,
+Singapore
+e-mail: [email protected]
+S. Sharma
+Department of Radiotherapy and Radiation Oncology,
+Manipal Hospital, Bangalore, India
+123
+Breast Cancer Res Treat (2008) 107:25–31
+DOI 10.1007/s10549-007-9530-y
+a variation in the base line frequencies from one lab-
+oratory to others [3]. After exposure to mutagenic
+agents, micronuclei in the cells are derived either from
+acentric fragments or lagging chromosomes [4–6].
+Micronuclei in cytokinesis-blocked peripheral blood
+lymphocytes (PBLs) are one of the most reliable bio-
+markers (indicators) in assessing the chromosome
+damage induced by ionising radiation or exposure to
+chemicals. Oppitz et al. [7] have shown significant
+correlations between in vitro MN frequency and radio-
+sensitivity. In most of the in vitro studies, inconsistent
+results were observed which did not correlate with the
+in vivo conditions. In studies attempted by Johansen
+et al. [1, 2], no significant correlations were found be-
+tween MN frequency of the patients with side effects
+and those without side effects and for the healthy
+control parameters. The difference in the MN fre-
+quency might be due to exposure to various environ-
+mental
+mutagens
+and
+genetic
+diversity
+in
+the
+population. In a recent study, Lee et al. [8] determined
+the occurrence of micronuclei before radiotherapy and
+their persistence after radiotherapy in patients with
+cancers of prostate and breast. However, Lee et al. [8]
+measured the total MN frequency and did not use
+fluorescence in situ hybridisation (FISH) either with
+centromere or telomere probes to determine nature of
+the micronuclei induced. Therefore an attempt has
+been made to study the MN frequencies in individual
+breast cancer patients. The PBLs were isolated from
+the patient and MN frequency was determined. Blood
+was taken from breast cancer patients both pre- and
+post-radiotherapy where the patients act as their own
+self-control thereby eliminating the inter-individual
+variation.
+Telomeres are the ends of the chromosomes, which
+have special nucleoprotein complexes that serve as
+protective caps to the important gene rich sub telo-
+meric regions of the chromosome [9–11]. Telomeres
+are repetitive non-coding DNA at the ends of the lin-
+ear chromosomes ranging in size of 5–15 kb in human
+cells [12]. As a consequence of semi- conservative
+modes of DNA replication, the extreme termini of
+chromosomes are not duplicated completely resulting
+in successive shortening of telomeres with each cell
+division. Telomeres also prevent end-to-end inter-
+chromosomal fusions and take part in efficient DNA
+repair functions under normal conditions [13]. There
+may be a significant link between telomere mainte-
+nance and radio-sensitivity [14]. Radiosensitive cells
+such as cells from A-T patients show significant
+fragmentation and telomere damage establishing the
+link between telomere maintenance and repair defects
+[15]. Telomere maintenance and genome stability is
+associated with a host of repair genes such as BRCA-1,
+ATM, XRCC4, Ku70, Ku80 etc [15–22]. Therefore the
+fact that telomeres play role in protecting the genome
+led us to investigate the correlation between radiation-
+induced DNA damage and telomere breakage. In
+the present study, we set to investigate the extent of
+telomere breakage-damage in PBLs derived from
+breast tumour patients either before or after radiation
+treatment by analysing the presence of telomere sig-
+nals in micronuclei using FISH.
+Materials and methods
+Patient recruitment
+Fifty five female patients with age group of 36–63 years
+were recruited using a random allotment chart that
+fitted with inclusion criteria of Ca-breast low (GrII)
+and high (GrIII and GrIV) without any other serious
+clinical complication apart from the carcinoma breast.
+The patients had all undergone unilateral mastectomy
+and were advised post-operative radiotherapy and
+chemotherapy for 5 weeks and were administered a
+dose of 1.8 Gy per day for a cumulative dose of 50.4 Gy
+(60Co c radiation source). The patients did not have
+any exposure to other mutagens, smoking or alcohol
+for at least 3 months prior to pre-radiation blood
+donation. The patients did not receive chemotherapy
+at the start of radiation and all the patients were
+recruited at the Department of Radiotherapy, Manipal
+Hospital, Bangalore, India. They were all counselled
+and consent forms were taken prior to recruitment
+into the study. The project was approved by Institu-
+tional Review Board (IRB) of the Manipal Hospital,
+Bangalore, India.
+Cytokinesis blocked micronucleus assay (CBMN
+assay)
+Five ml of peripheral blood from breast cancer patients
+(both
+pre-
+and
+post-radiotherapy
+schedule)
+were
+collected by venous puncture vacutainer method. The
+blood samples were coded and despatched to the
+laboratory for blind-analysis. The method essentially
+followed the protocol described by Fenech and Morley
+[23]. Briefly, one ml of freshly collected heparinised
+peripheral blood was added to 5 ml of RPMI-1640
+(Sigma
+Aldrich)
+media
+containing
+10%
+foetal
+bovine serum (Gibco BRL) and 200 ll of 1% phyto-
+haemoagglutinin (Gibco BRL). The culture was incu-
+bated in a CO2 incubator for 69 h. After 44 h of
+culturing, 100 ll of Cytochalasin B (6 lg/ml; Sigma)
+26
+Breast Cancer Res Treat (2008) 107:25–31
+123
+was added to all the cultures and harvested at 69 h post
+culture initiation. Cell suspension was centrifuged at
+1500 RPM for 10 min and supernatant was discarded.
+The pellet was subjected to 0.075 M KCl (hypotonic
+solution). After 10 min, the cells were centrifuged and
+washed twice with Carnoy’s fixative (3:1, Methanol and
+Acetic Acid). The cells were carefully dropped on to
+pre-cleaned slides. Two slides from each sample were
+prepared for Giemsa staining and FISH with telomere
+probes. The Giemsa stained slides were analysed under
+OlympusBX 60 bright field upright microscope. An
+average of 1000–1500 binucleated cells was scored per
+patient, pre- and post-radiotherapy.
+Fluorescence in situ Hybridisation (FISH)
+on Micronuclei
+Slides prepared from PBLs from patients pre- and post-
+radiotherapy were taken and hybridised with PNA
+(Peptide Nucleic Acid) probe from DAKO (cat no
+K532611). The FISH procedure was followed according
+to the manual instruction of DAKO. The counter-
+stained slides were analysed under Zeiss Axoiplan
+Fluorescence microscope with appropriate filters for
+fluorescence imaging. One thousand binucleated cells
+were scored and all the micronuclei containing red
+telomere signals were recorded in the image processing
+software attached with the microscope.
+Statistical analysis
+Karl Pearson��s rank correlation was used to study the
+association of MN frequency and telomere damage
+signals. The statistical analysis was done by SPSS
+software (version10) to study the distribution pattern
+and the regression patterns of the pre- and post-
+radiotherapy samples.
+Results and discussion
+We measured the MN frequency in 55 breast cancer
+patients
+undergoing
+partial-body
+irradiation.
+We
+mainly evaluated the relationship between total MN
+yield and the percentage of MN with telomere damage
+before and after radiation therapy in the patients. The
+MN baseline-yield for the 55 patients before radio-
+therapy is given in Fig. 1. The mean MN frequency in
+the PBLs from breast cancer patients was 22.6 ± 3.21
+(Mean ± S.D) and ranged from 12.5 to 30.2. This value
+is slightly higher than the base line frequency for the
+cancer patients from a study of Lee et al. [8]. We have
+used all 55 patients from the breast cancer cohort while
+Lee et al. [8] have included only 13 patients (9 prostate
+cancers, 3 testicular cancers and 1 breast cancer). The
+discrepancy may be due to the type of cancer studied as
+well as the stage of tumours studied here. The post-
+radiotherapy MN frequency was analysed after a
+cumulative dose of 50.4 Gy which was administered at
+a fractionated dose of 1.8 Gy per day of external beam
+radiotherapy from a 60Co c radiation source. There is a
+high degree of damage in vivo in the lymphocytes of
+breast carcinoma patients post-irradiation. The post-
+radiotherapy MN frequency increased to 283.1 ± 23
+(Mean ± SD; Fig. 2) and ranged from 230 to 350.
+Though the distribution of micronuclei produced after
+radiotherapy was heterogeneous, the data clearly
+indicate the higher damage produced by fractionated
+irradiation. A similar observation was also made by
+Lee et al. [8].
+Slides with CB-MN were subjected to FISH using
+telomere specific PNA probes. A representative image
+is displayed in Fig. 3 showing a typical binucleated cell
+with a micronucleus. Telomere signals could be visible
+in the micronucleus (Fig. 3). Telomere distribution
+patterns for patients before and after radiotherapy in
+Figs. 4 and 5 respectively. FISH analysis revealed that
+there is not much telomere damage in most of the
+patients before radiotherapy (Fig. 4). This was evident
+by the presence of very low number of telomere signals
+Fig. 1 MN frequency distribution in the PBLs of breast cancer
+patients pre-radiation therapy. Note the higher percentage of
+micronuclei detected in G0 lymphocytes from breast cancer
+patients. (Mean 22.6 SD 3.21)
+Breast Cancer Res Treat (2008) 107:25–31
+27
+123
+in the MN. However, the data obtained from the
+patients after radiotherapy showed significant telo-
+mere damage (Fig. 5). Many of the MN displayed
+telomere signals (Mean 40.71 ± 6.06). The difference is
+statistically significant (P < 0.001).
+We
+then
+compared
+the
+mean
+frequency
+of
+micronuclei
+with
+the
+micronuclei
+with
+telomere
+damage to determine whether or not there is a corre-
+lation between micronuclei production and telomere
+dysfunction. The data for patients before radiation
+therapy is presented in Fig. 6. As is displayed, there is
+not much correlation (r2 = 0.45) between telomere
+damage and total MN production in pre-radiotherapy
+patients. However, in post-radiotherapy patients, the
+relationship between MN frequency and MN with
+telomere damage is significantly higher (r2 = 0.68;
+>95% confidence limit) indicating the fact that patients
+following radiotherapy suffered significant telomere
+damage.
+The MN analysis has been proved to be an effective
+tool to quantify radiation damage in both exposed
+population and also the radio sensitivity of various
+individuals [24–26]. In a recent work, Mozdarani et al.
+[24, 27] demonstrated
+that
+there
+is
+an elevated
+spontaneous frequency of MN in breast cancer group
+compared to the control group. They also showed that
+Ca-Breast patients were more sensitive (30%) to ion-
+izing radiation than the age- and sex-matched controls.
+Scott et al. [28–30] showed that there is indeed a sig-
+nificant correlation between carcinoma of the breast
+and increased chromosomal radiosensitivity. Scott et al.
+[28] proved that in ataxia telangiectasia patients there is
+an elevated radiosensitivity observed in lymphocytes. It
+is observed in our study that the MN frequencies in
+carcinoma breast patients had a significant correlation
+with telomeric damage after radiotherapy. Short telo-
+meres or dysfunctional telomeres may contribute to
+elevated radiation sensitivity or carcinogen sensitivity
+[31, 32] (Newman, Banerjee, Hande unpublished). The
+telomeres play crucial role in detection and repair of
+DNA damage and radiation insult [19]. The presence of
+telomere signals in micronuclei might have been the
+result of telomere breakage and/or dysfunctional telo-
+meres in the lymphocytes of breast cancer patients.
+There was an attempt made by Acar et al. [33] to find
+the chromosomal origin in FISH on MN in acute lym-
+phoblastoid leukaemia patients but they did not report
+telomere damage pattern. In another work Norppa
+et al.
+[34]
+tried
+to
+find
+the
+contents
+of
+human
+micronuclei and reported telomeric signals in some MN
+population. Based on previous reports and our data, we
+hypothesise that in CA-breast there is a considerable
+amount of genomic instability in the lymphocytes with
+short telomeres. It is also possible that there is abnor-
+mal telomere maintenance in a sub- population of
+lymphocytes which makes them more radiosensitive.
+Desmaze et al. [35, 36] reported that initially telomere
+Fig. 2 Frequency distribution showing the micronuclei in the Ca
+–Breast patients post radiation therapy. There is very high
+degree of damage in the G0 lymphocytes of Carcinoma Breast
+patients in vivo after a cumulative dose of 50.4 Gy at the rate of
+1.8 Gy per day of external beam radiotherapy from a 60Co
+source. (Mean 253.1 SD 24.21)
+Fig. 3 Cytokinesis-blocked
+binucleated lymphocyte of
+breast cancer patients after
+radiotherapy. FISH with
+telomere specific peptide
+nucleic acid (PNA) probes
+were used to determine the
+presence of telomere signals
+in the micronuclei as pointed
+by arrows
+28
+Breast Cancer Res Treat (2008) 107:25–31
+123
+dysfunction and genomic instability contribute to
+radiation
+susceptibility.
+Slijepcevic
+et al.
+[14,
+37]
+indicated that interstitial breakpoints in chromosome
+contain telomeric signal. It is also suggested that
+telomere maintenance play crucial role in radiation
+susceptibility and radio-resistance [14]. Though we
+have not studied the fate of these micronuclei with
+telomere damage, it is tempting to speculate that such
+telomere loss could lead to chromosome end-to-end
+fusions or chromosome loss ultimately facilitating cells
+to undergo apoptosis (Fig. 7).
+Fig. 5 Frequency distribution showing the telomere damage in
+the Ca-Breast patients post-radiation therapy. There is a
+significant (P < 0.001) increase in telomere damage in the MN
+population and the damage pattern is normally distributed with a
+mean of 40.7 SD 6.06
+Fig. 6 The correlation showing the mean frequency of micronu-
+clei and the telomere damage frequency in lymphocytes from
+breast cancer patients before radiotherapy was initiated. It is
+evident that there is no considerable correlation (r2 = 0.45)
+Fig. 7 The correlation showing the mean frequency of micronu-
+clei and the presence of telomere damage in lymphocytes from
+breast cancer patients after radiotherapy. There is a significant
+association between total MN frequency and the telomere
+damage detected in micronuclei (r2 = 0.68)
+Fig. 4 Frequency distribution showing the telomere damage in
+the micronuclei in PBLs of the breast cancer patients before
+radiotherapy. Note that telomeric damage pre-radiotherapy is
+minimal (Mean 8.0 SD 1.05)
+Breast Cancer Res Treat (2008) 107:25–31
+29
+123
+MN analysis of 55 breast cancer patients following
+radiotherapy
+demonstrates
+heterogeneity
+in
+the
+response to radiation among these individuals. This
+indicates a varied radiosensitivity within this popula-
+tion. We speculate that individual response to radiation
+may differ among the breast cancer patients. This
+observation highlights the fact that it would be
+important to know the radiosensitivity of individual
+patient while administering the radiotherapy to breast
+cancer patients. Our data also suggest that telomere
+damage pattern in micronuclei as detected by FISH
+might indicate the individual radiosensitivity and give a
+brief idea of genome stability status. It might also give
+an indication of radio-resistance in stage-variant cancer
+cells. The varied radiosensitivity of the breast cancer
+patients and the link between telomere damage and
+radiation sensitivity provides a frame work for further
+research that may have an impact in radio-therapeutic
+strategies in cancer.
+Acknowledgements
+We would like to convey our gratitude to
+radiotherapists and radiation physicists especially, Mr. R Holla
+and T R Vivek, from the Department of Radiotherapy, Manipal
+Hospital, Bangalore. The support team of Department of
+Oncology is gratefully acknowledged for providing the blood
+samples. Dr Solomon F.D Paul, HOD, Dept of Genetics Sri
+Ramachandra Medical College, Chennai, India is thanked for his
+guidance and help in image capture and allowing us to the facility
+in his laboratory. The project is supported by a grant from
+Atomic Energy Radiation Board (AERB), Govt. of India. MPH
+acknowledges the support from National Medical Research
+Council, Singapore.
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subfolder_0/Assessment of cardiac autonomic function in patients with Duchenne muscular dystrophy using.txt

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+Original article
+Assessment of cardiac autonomic function in
+patients with Duchenne muscular dystrophy using
+short term heart rate variability measures
+Pradnya Dhargave a, Atchayaram Nalini a, Hulegar Ashok Abhishekh b,
+Adoor Meghana a, Raghuram Nagarathna c, Trichur R. Raju a,
+Talakad N. Sathyaprabha a,*
+a National Institute of Mental Health and Neurosciences, Bangalore, India
+b Bangalore Medical College and Research Institute, Bangalore, India
+c Vivekananda Yoga Research Foundation, Bangalore, India
+a r t i c l e i n f o
+Article history:
+Received 24 September 2013
+Received in revised form
+23 December 2013
+Accepted 30 December 2013
+Keywords:
+Heart rate variability
+Duchenne muscular dystrophy
+Cardia
+Autonomic
+a b s t r a c t
+Background: Duchenne muscular dystrophy (DMD) is a hereditary neuromuscular disorder
+frequently associated with progressive cardiac dysfunction, and is one of the common
+causes of death in these children. Early diagnostic markers of cardiac involvement might
+help in timely intervention. In this study we compared the short term HRV measures of
+DMD children with that of healthy subjects.
+Method: One hundred and twenty-four genetically confirmed boys with DMD and 50 age
+matched controls were recruited. Error-free, electrocardiogram was recorded in all subjects
+at rest in the supine position. HRV parameters were computed in time and frequency
+domains. Time domain measures included standard deviation of NN interval (SDNN), and
+root of square mean of successive NN interval (RMSSD). Frequency domain consisted of
+total, low frequency and high frequency power values. Ratio of low frequency and high
+frequency power values (LF/HF) was determined using customized software.
+Results: HRV parameters were significantly altered in DMD children as compared to healthy
+controls. Following parameters [mean (SD)] were reduced in DMD as compared to controls;
+RMSSD (in ms) [52.14 (33.2) vs 64.64 (43.2); p ¼ 0.038], High frequency component (nu) [38.77
+(14.4) vs 48.02 (17.1); p ¼ 0.001] suggesting a loss of vagal tone. In contrast, measure of
+sympathovagal balance LF/HF [1.18 (0.87) vs 0.89 (0.79); p ¼ 0.020] was increased in DMD
+group.
+Conclusion: In this cross sectional study we have demonstrated alteration in autonomic
+tone in DMD. Loss of vagal tone and an increase in sympathetic tone were observed in DMD
+children. Further prospective studies are required to confirm the utility of these measures
+as predictors of adverse cardiac outcome in DMD.
+ª 2014 European Paediatric Neurology Society. Published by Elsevier Ltd. All rights
+reserved.
+* Corresponding author. National Institute of Mental Health and Neuro Sciences (NIMHANS), Hosur Road, Bangalore 560 029, India. Tel.:
+þ91 80 26995172/73; fax: þ91 80 26564830.
+E-mail address: [email protected] (T.N. Sathyaprabha).
+Official Journal of the European Paediatric Neurology Society
+e u r o p e a n j o u r n a l o f p a e d i a t r i c n e u r o l o g y x x x ( 2 0 1 4 ) 1 e4
+Please cite this article in press as: Dhargave P, et al., Assessment of cardiac autonomic function in patients with Duchenne
+muscular dystrophy using short term heart rate variability measures, European Journal of Paediatric Neurology (2014), http://
+dx.doi.org/10.1016/j.ejpn.2013.12.009
+1090-3798/$ e see front matter ª 2014 European Paediatric Neurology Society. Published by Elsevier Ltd. All rights reserved.
+http://dx.doi.org/10.1016/j.ejpn.2013.12.009
+1.
+Introduction
+Duchenne muscular dystrophy (DMD) is X-lined neurolog-
+ical disorder presenting as a progressive muscular weak-
+ness. Though respiratory failure is the leading cause of
+death in these patients, with advancement in respiratory
+support technology, cardiac disorders are becoming an
+important issue.1 Reduced heart rate variability has been
+shown to be a predictor of adverse cardiovascular events.2
+In particular, decreased vagal function and increased sym-
+pathetic activity is shown to be associated with higher risk
+of cardiovascular disease.3 Several authors have reported
+impairment in electrocardiographic wave morphology and
+QT dispersion.4e6 Yanagisawa et al., in their five year follow
+up
+study
+have
+demonstrated
+higher
+incidence
+of
+arrhythmia with increase in age.5 It has been shown that
+combination therapy of angiotensin converting enzyme in-
+hibitor and beta blockers can reverse signs of congestive
+cardiac failure in DMD patients.7 Thus, early diagnostic
+markers are likely to help in deciding such intervention at
+an early phase.
+Heart rate variability (HRV) is a non invasive tool to
+assess modulation of autonomic function. Several authors
+have used HRV to assess cardiac neural regulation.8e10 In
+DMD
+brain
+dysfunction
+has
+been
+demonstrated
+by
+converging evidences from neuropathological and imaging
+studies11,12. Hence, HRV might be a good tool to study the
+dysfunction in central autonomic network. In this cross
+sectional study, we compared HRV of DMD children with
+healthy controls.
+2.
+Materials and methods
+This study was conducted in National Institute of Mental
+Health and Neurosciences a tertiary care neurology hospital.
+Institutional ethics committee approved the study. It was a
+prospective study from March 2009 to September 2012,
+where in 124 children with genetically confirmed DMD and
+50 age matched normal boys, with no history of any
+neuromuscular symptoms or cardiac illness, were recruited
+after obtaining written assent consent. Our cohort were
+drug naive at the time of evaluation and were recruited for
+the study after genetic testing which was available within
+3e4 weeks after clinical examination. Genetic confirmation
+was done by mPCR method for 30 exons of the DMD gene.
+The assessment protocol consisted of Modified Manual
+muscle testing, joint range of motion, muscular dystrophy
+functional rating scale (MDFRS), timed functional tests, in-
+telligence Quotient with Stanford Binet Kamat Test, pul-
+monary function tests, heart rate variability (HRV), quality
+of life (QOL) with Pediatric quality of life Neuro muscular
+module, and Generic score. All children with DMD were
+started on the recommended daily dose of 0.75 mg/kg of
+prednisolone which was taken by children for about 2e3
+weeks only at time of HRV assessment. The test was con-
+ducted in the autonomic laboratory under standard condi-
+tions as described earlier.8,9,13
+3.
+Data acquisition
+Artifact free, lead II electrocardiogram (ECG) was recorded in
+all subjects at rest in supine position and signals were
+conveyed through analog digital converter (Power Lab, 16
+channels data acquisition system, AD Instruments, Australia)
+with a sampling rate of 1024 Hz. The raw ECG was converted
+into consecutive RR intervals for analysis. The data was
+analyzed offline using an automatic programme that allows
+visual checking of the raw ECG and breathing signals. It was
+ensured that subjects breathed with a respiratory rate of
+12e15 breaths/min.10,14 An error free 5 min ECG segment was
+taken for analysis and time and frequency domain parameters
+were calculated according to the Task force report on HRV.2
+Time domain parameters such as Standard deviation of RR
+intervals (SDNN) in milliseconds, Square root of the mean
+squared differences of successive intervals (RMSSD) in milli-
+seconds, the number of NN intervals differing by > 50 ms from
+the preceding interval (NN 50), the percentage of intervals
+>50 ms different from preceding interval (pNN50) and fre-
+quency domain parameters such as low frequency spectral
+power (LF) in ms2, high frequency spectral power (HF) in ms2,
+also in high frequency normalized units (HF.nu), low fre-
+quency normalized units (LF.nu) and low frequency and high
+frequency ratio (LF/HF) were computed using customized
+software.8e10,13e15
+4.
+Statistical analysis
+Groups were compared using independent sample t-test for
+continuous variables. HRV components obtained were not
+normally distributed and hence had to be square root
+Table 1 e HRV parameters in DMD patients versus
+controls.
+Parameter
+Cases
+[mean (SD)]
+Controls
+[mean (SD)]
+p Value
+Heart rate (BPM)
+100.32 (15.47)
+85.75 (11.45)
+<0.00**
+SDNN (ms)
+53.40 (26.5)
+60.59 (28.9)
+0.095
+RMSSD
+52.14 (33.2)
+64.64 (43.2)
+0.038*
+NN50
+97.04 (77.8)
+121.42 (78.9)
+0.048*
+pNN50
+21.70 (18.81)
+30.3 (21.2)
+0.008*
+Total power (ms2)
+3405.46 (3408.6)
+4430.82 (4810.08)
+0.076
+Low frequency
+power (ms2)
+868.17 (918.07)
+837.67 (650.16)
+0.668
+LF.nu
+36.80 (16.13)
+32.03 (14.9)
+0.088
+High frequency
+power (ms2)
+1201.35 (1660.6)
+2077.09 (3625.3)
+0.015*
+HF.nu
+38.77 (14.4)
+48.02 (17.1)
+0.001**
+LF/HF
+1.18 (0.87)
+0.89 (0.79)
+0.020*
+*denotes p < 0.05. ** denotes p < 0.01.
+Abbreviations: Bpm: beats per minute, HR: heart rate, SDNN:
+standard deviation of NN interval, RMSSD: root of square mean of
+successive NN interval, NN50: number of NN intervals with less
+than 50 ms, pNN50: percentage of number of NN interval with less
+than 50 ms, LF: low frequency power, LF.nu: low frequency power
+normalized unit, HF: high frequency power, HF.nu: high frequency
+power normalized unit, LF/HF: low frequency to high frequency
+ratio.
+e u r o p e a n j o u r n a l o f p a e d i a t r i c n e u r o l o g y x x x ( 2 0 1 4 ) 1 e4
+2
+Please cite this article in press as: Dhargave P, et al., Assessment of cardiac autonomic function in patients with Duchenne
+muscular dystrophy using short term heart rate variability measures, European Journal of Paediatric Neurology (2014), http://
+dx.doi.org/10.1016/j.ejpn.2013.12.009
+transformed to produce normal distributions. Values are
+expressed in [mean (SD)]. Level of significance was kept at
+0.05.
+5.
+Results
+Among the 124 boys recruited, the age ranged from 5 to 10
+years and the mean age at presentation was 7.9  1.5 years
+(range, 5e10 yrs). Mean height was 118.1  8.3 cms (range:
+95e147 cms). Mean weight was 20.6  4.2 Kg (range:11e32 kg).
+Age of onset ranged from 1.5 to 4.0 years and the mean age of
+onset was 2.8  0.6 years (rang1.5e4.0 yrs). Mean duration of
+illness was 5.1  1.5 years (range, 1e8 years). Mean creatinine
+kinase level was 13,365  8727 IU.
+HRV parameters are summarized in Table 1. HRV param-
+eters were significantly altered in DMD patients compared to
+controls. SDNN, RMSSD, NN50, pNN50, total power were
+reduced in DMD patients suggesting overall reduction in
+autonomic regulation of heart. HF power and HF.nu were
+reduced further suggesting loss of vagal tone. LF.nu and LF/HF
+ratio were increased in patient group denoting sympathetic
+predominance (Table 1).
+6.
+Discussion
+To our knowledge this is the first study assessing short term
+HRV parameters in DMD. Current results are consistent with
+previous studies which used long term (24 h) recording.
+Lanza et al. showed that all HRV parameters were lower in
+children with DMD and particularly pNN50 and HF power16
+thus, accounting the marked impairment of cardiac auto-
+nomic function to impairment in the parasympathetic
+branch. Inoue et al. reported that SDNN was frequently
+altered in DMD.17 Few prospective studies have been con-
+ducted assessing the utility of 24 h HRV as a predictor of
+adverse cardiovascular events. Yotsukura et al. in their nine
+year follow up study, observed that at baseline high fre-
+quency power was significantly lower and the ratio of low
+frequency to high frequency was significantly higher in
+patients with DMD than in the normal controls and differ-
+ences became significantly greater with disease progres-
+sion.18 Similarly, a study by Kirchman et al. reported that
+HRV is reduced in 51% of patients.4
+Explanation for the reduced HRV remains speculative at
+this point of time. Several authors have reported persistent
+tachycardia in DMD. Mechanism for this phenomenon re-
+mains elusive. Infiltration of sinoatrial node by fibro fatty
+tissue has been hypothesized to result in automaticity and
+reentry.19 In addition, animal models of cardiomyopathy have
+shown correlation between specific genetic mutation and
+alteration in particular HRV measures although the exact
+mechanism of this phenomenon remains unknown. Dystro-
+phin deficit mice models have shown alteration of nitric oxide
+and vascular endothelial growth factor secretion in the
+myocardium.20e23 Nitric oxide has been shown to play
+important role in cardiac autonomic function modulation. It
+influences vagal tone by direct and agonistic effect in pre-
+ganglionic and postganglionic neurons. Considering all these
+evidences, nitric oxide alteration might play a role in this
+phenomenon.24e26
+Apart from these peripheral mechanisms it is highly
+possible
+that
+central
+autonomic
+dysfunction
+might
+contribute to alteration in HRV. In Positron Emission To-
+mography study in patients with DMD, hypometabolism has
+been documented in temporal gyri, uncus, cerebellum and
+hippocampus.12
+Interestingly,
+cardiac
+gated
+fMRI
+study
+which correlated HRV measures with brain area has shown
+that above areas have prominent influence of autonomic
+modulation.27 In addition, histopathological studies of cor-
+tex of DMD patients have revealed impairments, particu-
+larly
+loss
+of
+neurons,
+gliosis,
+dentritic
+aberration,
+astrocytosis and perinuclear vacuolation11. Thus, central
+autonomic dysregulation might influence the alteration in
+HRV values in DMD.
+Yotusukra et al. in their 9 year follow up study of DMD
+found that time domain values differed significantly between
+those who died and survived.18 In another, 10 year follow up
+study, same authors have demonstrated sequential changes
+in QRS wave morphology and the electric forces tended to
+increase towards rightward direction.6 Thus, these data sug-
+gest that ECG and HRV changes have prognostic significance.
+Compared to 24 h HRV, in short term HRV analysis frequency
+domains measures which are reflection of sympathetic and
+parasympathetic functions are best represented.2 Thus, short
+term HRV analysis is a good tool to investigate DMD children
+for evidence of cardiac autonomic dysfunction. Further
+studies are required to substantiate the predictive properties
+of these short term HRV measures. Future studies should
+evaluate influence of beta blocker and angiotensin converting
+enzyme inhibitors (ACE) on improving cardiac status of these
+patients.
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+dystrophies. Semin Respir Crit Care Med 2002;23:231e8.
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+27. Napadow V, Dhond R, Conti G, Makris N, Brown EN,
+Barbieri R. Brain correlates of autonomic modulation:
+combining heart rate variability with fMRI. Neuroimage
+2008;42:169e77.
+e u r o p e a n j o u r n a l o f p a e d i a t r i c n e u r o l o g y x x x ( 2 0 1 4 ) 1 e4
+4
+Please cite this article in press as: Dhargave P, et al., Assessment of cardiac autonomic function in patients with Duchenne
+muscular dystrophy using short term heart rate variability measures, European Journal of Paediatric Neurology (2014), http://
+dx.doi.org/10.1016/j.ejpn.2013.12.009

subfolder_0/Autonomic changes during ‘OM’ meditation..txt

@@ -0,0 +1,604 @@
+Indian J Physiol Pharmacol
+1995; 39(4): 418-420
+SHORT
+COMMUNICATION
+AUTONOMIC
+CHANGES
+DURING
+"OM" MEDITATION
+SHIRLEY TELLES*, R. NAGARATHNAAND H. R. NAGENDRA
+Vivekananda
+Kendra Yoga Research Foundation,
+Bangalore - 560 018
+( Received
+on July
+19, 1994 )
+Abstract:
+The autonomic and respiratory
+variables
+were studied
+in seven
+experienced meditators
+(with experience ranging from 5 to 20 years). Each
+subject was studied in two types of sessions -
+meditation (with a period of
+mental chanting of "OM")and control (with a period of non-targetted thinking).
+The meditators showed a statistically significant reduction in heart rate during
+meditation compared to the control period (paired 't' test). During both types
+of sessions there
+was a comparable
+increase
+in the cutaneous
+peripheral
+vascular resistance. Keeping in mind similar results of other authors, this was
+interpreted
+as
+a sign
+of increased
+mental
+alertness,
+even
+while
+being
+physiologically relaxed (as shown by the reduced heart rate).
+Key words:
+oxygen consumption
+metabolism
+INTRODUCTION
+Mentally
+chanting
+"OM" was
+shown to
+increase
+the
+efficiency with
+which
+sensory
+information was processed in subjects with more
+than 10 years of meditation experience, whereas
+mentally chanting "one" had the opposite effect
+(1). These
+changes
+occurred
+mainly
+at
+the
+mesencephalic
+or diencephalic level. Another
+study of 7 proficient subjects (3 of whom had 20
+years experience of meditation), revealed that
+mental chanting of "OM"activated higher neural
+centres, i.e. the association cortices (2). Mental
+chanting
+of "OM" leads to a single thought
+state, and a subjective feeling of deep relaxation.
+Hence the present study was carried out to find
+out whether "OM" meditation would also cause
+changes
+in
+the
+autonomic
+and
+metabolic
+functions of the seven experienced meditators
+whose neural responses to the meditation were
+described above (2).
+METHODS
+Subjects,'
+The study was carried' out on 7
+normal,
+healthy
+male volunteers
+in the
+age
+range of 29 to 55 years (mean ± SD, 42.3 ± 9.8
+years). They were all committed meditators with
+experience ranging between 5 and 20 years. The
+yoga
+meditation
+details
+of the
+study
+were
+explained
+to the
+subjects and their signed informed consent was
+taken in accord with the ethical guidelines of
+the Indian Council of Medical Research, New
+Delhi.
+Design of the study,' Each session was of 32
+min duration, of which 20 min were spent in
+meditation, preceded and followed by two 6 min
+periods of sitting
+relaxed,
+with
+eyes closed.
+Subjects were also studied in control sessions
+which
+were
+of the
+same
+duration
+as
+the
+meditation sessions, and similar in design except
+that the 20 min period was spent sitting relaxed
+with eyes closed, and non-targetted
+thinking
+(instead
+of meditation).
+Meditation
+involved
+mental
+chanting
+of "OM", while
+sitting
+comfortably, with eyes closed. Both types
+of
+sessions were repeated on three separate days.
+Parameters studied,' Recordings of autonomic
+and respiratory
+variables were made on a 10
+channel polygraph (MadeIIO, Polyrite, Recorders
+and Medicare systems, Chandigarh, India). EKG
+was recorded using the standard
+limb lead I
+configuration.
+Heart
+rate
+was
+obtained
+by
+counting the number of QRS complexes per 40
+see intervals
+continuously.
+Epochs of 40 see
+were chosen to be able to correlate this data
+*Corresponding
+Author
+Indian J Physiol Pharmacol
+1995; 39(4)
+with that of subjects practicing other meditations
+(3). This has been described in the discussion.
+Palmar skin resistance (SR) was recorded using
+2 silver
+chloride
+disc electrodes
+filled with
+electode jelly (CSR Technocarta,
+Hyderabad,
+India), placed 4 em apart on the palmar surface
+of the right
+hand.
+SR values were sampled
+continuously at 20 see intervals. Skin blood flow
+was
+recorded
+using
+a
+photo-electric
+plethysmograph placed over the left thumb nail.
+The amplitude of six plethysmogram waveforms
+were calculated
+in each minute.
+Two nasal
+thermistors
+placed one at each nostril
+were
+used to record respiration. The number ofbreath
+cycles in each minute was calculated to give the
+respiratory
+rate.
+Oxygen
+consumption
+was
+recorded using the closed circuit Benedict-Roth
+apparatus. In this method, the subject breathed
+into an oxygen tank
+wearing
+a close fitting
+mask, and with a nose clip. The exhaled carbon
+dioxide does not enter the tank, as it is absorbed
+by soda lime. The difference between the initial
+and final volumes of oxygen in the tank is the
+amount of oxygen consumed by the subject in a
+given period of breathing
+(i.e. 5 min). The
+recording laboratory had a temperature
+of 25 ±
+1°C, with relative humidity about 70 percent.
+Autonomic Changes
+during
+Meditation
+419
+The
+values
+were
+corrected
+for
+standard
+temperature
+and pressure.
+The OC recordings were made before and
+after
+meditation,
+but not during
+meditation.
+Polygraphic
+recordings
+were
+made
+before,
+during, and after meditation.
+Values of the 5 variables mentioned above
+were averaged for each of the 3 periods of a
+session viz. before, during and after meditation
+(or the control procedure). Statistical analysis of
+these
+averaged
+values
+was
+done
+to reveal
+significant differences between (a) before versus
+during meditation
+(or control) and (b) during
+meditation versus during control periods, using
+the paired 't' test.
+RESULTS
+All seven meditators
+showed a small but
+statistically
+significant reduction in heart rate
+during meditation compared to the control period
+(P<O.OOl,paired 't' test, Table D. There was a
+significant and comparable decrease in finger
+plethysmogram amplitude, during the meditation
+and control periods compared to the preceding
+periods (P<0.05, paired 't' test, in both cases).
+There
+was
+also
+a non-significant
+trend
+of
+TABLE I: Autonomic and respiratory variables recorded in 7 meditators. Values are Group mean ± S.D.
+Variables
+studied
+I
+Meditation
+session
+Control session
+Pre
+During
+Pre
+During
+Heart rate
+47.00
+46.90**
+47.20
+47.60
+(Beats per 40 see)
+±5.00
+±4.30
+±4.90
+±4.80
+Respiratory
+rate
+10.80
+10.40
+10.50
+11.10
+(Breaths
+per min)
+±3.60
+±3.30
+±3.40
+±3.20
+Skin resistance
+412.90
+446.60
+307.40
+335.70
+(Kilo ohms)
+±129.90
+±107.10
+±123.40
+±113.80
+Finger plethysmogram
+1.00
+0.70*
+1.10
+0.70#
+amplitude
+(rnm)
+±0.20
+±0.20
+0.20
+±0.20
+Oxygen Consumption was recorded immediately before and after the meditation period, but not during.
+Oxygen consumption
+Pre
+Post
+Pre
+Post
+(ml/min STPD)
+454.00
+386.20
+480.30
+483.80
+±192.00
+±68.70
+±153.00
+±232.50
+** P<O.OOl,during meditation versus during control (paired 't' test).
+it P<O.05, before versus during period (paired 't' test).
+420
+Telles
+et al
+reduction in the oxygen consumption following
+meditation (P>O.05, paired 't' test). The group
+average values ± SD for all 5 variables are as
+shown in Table I.
+DISCUSSION
+The present
+study revealed
+a significant
+decrease in heart rate during mental chanting
+of
+-"OM",
+which
+is
+suggestive
+of
+psychophysiological
+relaxation.
+The
+non-
+significant
+trend
+of reduction
+in
+oxygen
+consumption also has a similar interpretation.
+This change is similar to that caused by TM (4),
+though of smaller magnitude.
+However, it is important
+to note that the
+actual
+pre-meditation
+(or control) values
+of
+oxygen consumption of the (senior) meditators
+of the present
+study were noticeably higher
+than those of other meditators
+(4), and of the
+general population. Since it is usually thought
+that
+yoga practitioners
+have
+lower
+oxygen
+consumption values
+than
+those
+who do not
+practise
+yoga, these
+results
+are
+difficult to
+explain. There is a report (5) in the literature
+which demonstrated
+an increase in the basal
+metabolic
+rate
+(BMR)
+with
+six
+weeks
+experience in yoga, compared to the period before
+learning yoga. The BMR decreased, but did not
+return to the initial value after continuing yoga
+practice for six weeks. In contrast to the present
+study,
+the
+subjects
+were
+not
+practising
+meditation, but were practising specific postures
+(yogasanas) and breath regulation (pranayama).
+Hence no direct correlation can be made between
+Indian J Physiol Pharmacol
+1995; 39(4)
+the two studies, and further
+assessments
+are
+necessary to come to a definite conclusion.
+The
+significant
+decrease
+in
+finger
+plethysmogram
+amplitude
+(i.e.
+increased
+peripheral vascular resistance) which occurred
+during both meditation and control periods is a
+sign of increased sympathetic tone and hence is
+also not expected during meditation (4).
+While attempting to explain these seemingly
+contradictory results, it is to be noted that the
+same
+individual
+may
+simultaneously
+show
+changes in two variables
+indicating
+opposite
+states of arousal, e.g. a decrease in heart rate
+along with
+reduced
+skin
+resistance.
+While
+explaining
+similar
+contradictory
+changes
+in
+Ananda
+Marga
+meditators
+(6), the
+authors
+described the reduced
+skin resistance
+as an
+attempt to prevent intrusion of sleep during the
+session. Since reduced skin blood flow is know
+to occur when the subject is alert,
+as while
+solving arithmetic
+problems mentally (7), the
+present study might indicate that chanting "OM"
+mentally
+causes increased
+alertness
+(reduced
+finger plethysmogram amplitude), even though
+the subject was more relaxed (reduced heart
+rate).
+ACKNOWLEDGEMENTS
+This study was designed and carried out
+under the expert guidance of (the late) Dr. T.
+Desiraju
+(NIMHANS,
+Bangalore).
+The
+contributions
+of the
+other
+staff
+of "Project
+Consciousness", are gratefully acknowledged.
+REFERENCES
+l.
+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; 74:87-94.
+2.
+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; [B] 98:237-239.
+3.
+Telles
+S,
+Desiraju
+T.
+Autonomic
+changes
+in
+Bramakumaris
+Raja
+Yoga
+Meditation.
+Int
+J
+Psychophysiol
+1993; 1:147-152.
+4.
+Wallace
+RK, Benson
+H, Wilson
+AF. A wakeful
+hypometabolic physiologic state. Am J Physiol
+1971;
+221:795-799.
+5.
+Dhanaraj
+YH.
+the
+effects
+of yoga
+and
+the
+5BX
+fitness
+plan
+on selected
+physiologic
+parameters.
+In
+Science
+studies
+Yoga.
+Funderburke
+J
+(Ed),
+Illinois,
+Himalayan
+International
+Institute,
+1977.
+6.
+Corby
+JC,
+Roth
+WT,
+Zarcone
+YP,
+Kopell
+BS.
+Psychophysiological
+correlates
+of the
+practice
+of
+Tantric Yoga meditation.
+Arch
+Gen Psych
+1978; 36:
+571-577.
+7.
+Delius
+W, Kellerova
+E.
+Reaction
+of arterial
+and
+venous vessels in the human
+forearm
+and hand
+to
+deep
+breath
+or mental
+strain.
+Clin
+Sci
+1971; 40:
+271-282.

subfolder_0/Barriers to yoga therapy as an add-on treatment for schizophrenia in India.txt

@@ -0,0 +1,384 @@
+International Journal of Yoga  Vol. 5  Jan-Jun-2012
+70
+For this reason, researchers have studied alternative and 
+complementary strategies such as yoga to help patients 
+with schizophrenia. Studies on efficacy of yoga in 
+patients with schizophrenia have shown improvement 
+in cognitive  skills, physiological parameters and 
+psychopathology.[3‑5]
+In this context, a single blind randomized controlled 
+study was conducted in NIMHANS, to assess the 
+effectiveness of yoga as an add‑on treatment for persons 
+with schizophrenia. It was found that in spite of offering 
+yoga, explaining its potential benefits and providing travel 
+support to attend the training, a number of patients were 
+not able to come for the yoga training. In order to make 
+yoga acceptable and available to the patient population, 
+it is essential to understand the possible barriers to yoga 
+therapy for patients with schizophrenia. This paper is an 
+attempt in that direction.
+INTRODUCTION
+Schizophrenia is ranked as the ninth leading cause of 
+disability in people worldwide.[1] Pharmacotherapy 
+is the mainstay in the management of schizophrenia. 
+However, even with the best drugs available to treat 
+schizophrenia, refractoriness, negative symptoms, 
+frequent relapses, and persisting cognitive impairment 
+still persist.[2]
+Aim: To describe the possible barriers to yoga therapy for patients with schizophrenia in India.
+Materials and Methods: In a randomized control trial at NIMHANS, patients with schizophrenia (on stable doses of 
+antipsychotics, 18–60 years of age, with a Clinical Global Impression‑Severity score of 3 or more) were randomized into one of 
+three limbs: Yoga therapy, physical exercise and waitlist. Of 857 patients screened, 392 (45.7%) patients were found eligible for 
+the study. Among them, 223 (56.8%) declined to take part in the trial. The primary reasons for declining were analyzed.
+Results: The primary reasons for declining were (a) distance from the center (n=83; 37.2%); (b) no one to accompany them for 
+training (n=25; 11.2%); (c) busy work schedule (n=21, 9.4%); (d) unwilling to come for one month (n=11; 4.9%), (e) not willing 
+for yoga therapy (n=9, 4.0%); (f) personal reasons (n=3, 1.3%); (g) religious reasons (n=1, 0.4%). In 70 patients (31.6%), no 
+reasons were ascribed. No patient refused citing research nature of the intervention as a reason.
+Conclusion: More than half of the patients eligible for yoga did not consent to the study. Logistic factors, such as the need for 
+daily training under supervision in a specialized center for long periods, are the most important barriers that prevent patients 
+with schizophrenia from receiving yoga therapy. Alternative models/schedules that are patient‑friendly must be explored to 
+reach the benefit of yoga to patients with schizophrenia.
+Key words: Barriers; schizophrenia; yoga.
+ABSTRACT
+Barriers to yoga therapy as an add‑on treatment for 
+schizophrenia in India
+Shubhangi Baspure, Aarti Jagannathan1, Santosh Kumar2, Shivarama Varambally3, Jagadisha Thirthalli3,  
+G Venkatasubramanain3, HR Nagendra4, BN Gangadhar3
+Former Senior Research Fellow (SRF), AYUSH-Yoga Project, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, 
+1Department of Psychiatric Social Work, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, 2Department of 
+Psychiatry, Institute of Human Behaviour and Allied Sciences (IHBAS), New Delhi, 3Department of Psychiatry, National Institute of Mental Health 
+and Neurosciences (NIMHANS), Bangalore, 4Vice-chancellor, Swami Vivekananda Yoga Anusandhana Samasthana (SVYASA), Bangalore, India
+Address for correspondence: Dr. Aarti Jagannathan, 
+House No: 10, ‘JAGRATI’, 5th Cross, M.R Gardens, Vishwanatha Naganahalli, R.T. Nagar Post, Bangalore ‑ 560 032, India. 
+E‑mail: [email protected]
+Short Communication
+Access this article online
+Website: 
+www.ijoy.org.in
+Quick Response Code
+DOI: 
+10.4103/0973-6131.91718
+71
+International Journal of Yoga  Vol. 5  Jan-Jun-2012
+Baspure, et al.: Barriers to yoga therapy as an add‑on treatment for schizophrenia in India
+MATERIALS AND METHODS
+Sample
+In order to achieve the target sample of 120 patients for 
+the larger randomized controlled study (three groups: 
+Yoga group, physical exercise and waitlist group), the 
+researchers screened 857  patients with schizophrenia 
+who presented to NIMHANS outpatient department over a 
+15 month period. To be eligible, the patient was required to 
+have a diagnosis of schizophrenia (diagnosed according to 
+DSM‑IV), an illness severity on clinical global impression 
+≥3, age 18‑60 years and, residing in and around Bangalore. 
+Patients who had co morbid mental retardation, serious 
+neurological illness or epilepsy were also excluded. Out 
+of the total screened patients, 392 were found eligible 
+and 465 not eligible for the study. These 392 patients 
+were offered an option to participate in the current study. 
+Between the period 7th March 2008 and 28th May 2009, 
+119 patients accepted to participate in the study and 223 
+refused [Figure 1].
+Design, tools and procedure
+The current study adopted a descriptive research design. 
+Patients who fulfilled the inclusion criteria were explained 
+about the study design and were invited to participate in 
+the study.
+A log of patients screened for the project was maintained. 
+This log contained details of patient’s name, file number, 
+age, sex, address, contact number and information on 
+whether the patient has agreed to participate in the 
+Screened
+(N= 857) 
+Recruited 
+(N =119) 
+Excluded
+(N = 465) 
+Not Recruited 
+(N= 273) 
+Age >60 
+ (N= 28) 
+Detailed work-up 
+pending
+(N= 7) 
+Proxy
+(N= 11) 
+CGI < 3 
+(N= 221) 
+Not compliant to 
+medications
+(N= 16)
+Comorbid Illness
+(N= 40) 
+Already practicing yoga 
+ (N= 8) 
+Too ill to give consent  
+(N= 5) 
+Medications changed 
+(N= 126) 
+Other parallel treatment 
+(N= 1) 
+Medico-legal 
+(N= 2) 
+Long Distance 
+ (N=83) 
+No one to 
+accompany
+(N=25)
+Cannot come daily 
+(N=11)
+Not willing to do 
+yoga
+ (N=9) 
+Personal Reasons 
+(N=3)
+Going for work 
+(N=21)
+Due to religion 
+(N=1)
+Not known  
+(N=45)
+Undecided
+(N=25)
+Refused
+(N=223)
+Tagged
+(N=25)
+At
+screening 
+(3)
+At 1st 
+Follow-
+up (2) 
+At 2nd 
+Follow-
+up (6) 
+At 3rd 
+Follow-
+up (14) 
+Accepted
+but did not 
+come
+(N=25)
+Figure 1: Sampling procedure
+International Journal of Yoga  Vol. 5  Jan-Jun-2012
+72
+Baspure, et al.: Barriers to yoga therapy as an add‑on treatment for schizophrenia in India
+study. If the patient had refused to participate, the 
+reasons for refusal were recorded verbatim. The first 
+reason that was spontaneously stated was analyzed in 
+the sample.
+RESULTS
+The mean age of patients who refused for the study was 
+34.8 years (10.13 SD) and 38% of them were females. 
+Patients who refused to participate in yoga seemed to 
+be older [34.8 (10.13) years] than patients who agreed 
+to participate [33.2 (9.3) years; P=0.09]. There was no 
+difference in gender distribution of patients who agreed 
+for the study as compared to those who refused.
+The reasons for refusal were (a) staying far away from the 
+center (n=83; 37.2%); (b) no one to accompany patient for 
+training (n=25; 11.2%); (c) patient cannot miss work (n=21, 
+9.4%); (d) unable to come every day for one month (n=11; 
+4.9%); (e) not willing for yoga (n=9, 4.0%); (f) personal 
+reasons (n=3, 1.3%); (g) religious reasons (n=1, 0.4%). In 
+70 patients, no reason was ascribed, though 25 of these had 
+agreed to come but dropped out. No patient refused citing 
+research nature of the intervention as a reason [Table 1].
+DISCUSSION
+The results of the study bring out the barriers to attend 
+yoga therapy such as staying far away from the center, 
+there was no one to accompany patient for yoga, patient 
+was going for work, inability to come daily for yoga for 
+one month, personal reasons and unwillingness to practice 
+yoga due to religious reasons. The above findings need to 
+be understood in the context that, except for a few scientific 
+research studies;[3,5] yoga for schizophrenia is a relatively 
+new treatment methodology. Thus, there is a possibility 
+that both mental health practitioners and patients are 
+skeptical about the effectiveness of this new treatment. 
+There has also been some debate on whether people from 
+faiths other than Hinduism should practice yoga.[6]
+The yoga training especially in the case of treatment of 
+persons with mental illness needs to be given by a trained 
+yoga therapist.[7] Though yoga has its roots from ancient 
+India, it is widely taught as a treatment methodology only 
+in the urban centers where a few trained yoga instructors 
+are available.[8] This could be difficult for those patients 
+who stay far away from the yoga center and find it difficult 
+to avail of the treatment on a daily basis. Reasons of a 
+clinical trial as the reason for refusal did not Figure as the 
+first in the entire sample. However, a sizeable sample did 
+not provide any reasons for their refusal. Hence, the nature 
+of a clinical trial and random allocation to yoga could be 
+one of the reasons in the sample who refused to partake in 
+the study. Patients, who were inhibited to say this as the 
+first reason, may have abstained from stating so.
+Further the treatment of yoga has a different course as 
+against biological treatments like medications, which 
+hardly require a few minutes to administer. The lengthy 
+course of yoga treatment[9] could act as a barrier for patients 
+who are working and cannot take out time every day for 
+the treatment.
+Medication and treatment adherence is a big barrier in 
+treating psychiatric illness like schizophrenia,[10] as most 
+patients do have insight about their illness. Further the 
+nature of schizophrenia itself, where patients experience 
+negative symptoms,[11] may make it difficult for them to 
+attend the yoga treatment consistently for the required 
+period of time. This could explain why some patients, who 
+agreed to participate, did not attend the yoga sessions. It 
+was challenging to motivate out‑patients to regularly attend 
+the yoga classes for one month daily. Routinely patients 
+attend outpatient follow ups once in two months only. 
+Offer of bus fares to patients and their relatives to come 
+for intervention daily produced some effects with regards 
+to treatment adherence. Further, due to the nature of the 
+illness, caregivers often need to accompany the patient to 
+the daily treatment sessions. Caregivers may also have their 
+own personal commitments due to which they may find 
+it difficult to adhere to the yoga treatment regime. Certain 
+other issues that merit discussion are:
+(1)	Yoga as add‑on to conventional treatment: In this 
+study, patients who were on outpatient follow up 
+with stabilized medication status were included. 
+Patients thus had already obtained best benefits from 
+conventional interventions. Follow up medication 
+helped prevent relapses. Though most patients had 
+residual symptoms like negative syndrome, cognitive 
+deficits and poor social functioning (CGI rating ≥3 
+or mean duration of illness was close to 10 years), 
+they were not actively symptomatic at the stage of 
+recruitment for the study. In this context, both patients 
+and their caregivers could have been skeptical of trying 
+any new intervention.
+(2)	User‑friendly yoga intervention: The refusal rate in this 
+study was high. Refusal occurred despite limiting the 
+yoga treatment to only four weeks of daily supervised 
+interventions as well as support to patients and families 
+for bus fares. Among those who did not enter the study 
+Table  1: Reasons for refusal
+Reason for refusal
+n
+%
+Staying far away from yoga center
+83
+37.2
+Reason not given
+45
+20.2
+No one to accompany patient
+25
+11.2
+Accepted but did not come 
+25
+11.2
+Patient going for work
+21
+9.4
+Unable to come every day for one month
+11
+4.9
+Not willing for yoga 
+9
+4.0
+Personal reasons
+3
+1.4
+Due to religious reasons
+1
+0.5
+73
+International Journal of Yoga  Vol. 5  Jan-Jun-2012
+Baspure, et al.: Barriers to yoga therapy as an add‑on treatment for schizophrenia in India
+after being found suitable, one of the reasons was 
+inability to attend yoga sessions daily. Clearly, this 
+demands an alternative and flexible approach. Yoga 
+modules have to be designed that demand fewer days 
+for training. Three days a week program may offset this 
+difficulty and motivate more patients to accept yoga as 
+an add‑on intervention. As follow up patients attend 
+OPD once in one or two months, an intensive training 
+session on that day may be more acceptable. These 
+visits may be used to gradually train the patients in 
+the entire module of yoga over several visits. There is a 
+need to evaluate such unconventional regimens of yoga 
+therapy. Reaching yoga to patients through community 
+yoga program is yet another alternative. More research 
+is needed to develop evidence‑based yoga modules for 
+schizophrenia patients.
+One of the major limitations of the study was its 
+homogeneous sample. Only patients who had Clinical 
+Global Severity rating of 3–5 were chosen for the study, 
+thus excluding a large number of patients who were 
+either recovering from schizophrenia or who were too 
+symptomatic to be recruited into yoga treatment. Further 
+only out‑patients pursuing treatment in one mental hospital 
+were included in the study. Thus the generalizability of 
+the results may be limited.
+CONCLUSION
+Given that yoga may prove to be a cost‑effective addition to 
+the current treatment methods available for schizophrenia, 
+there is a pressing need to understand the barriers to yoga 
+treatment such as daily training under supervision in a 
+specialized center for periods as long as one month. Yoga 
+schedules that may be more user friendly merit testing. 
+The module itself needs to be made more attractive and 
+reachable to patients closer to their residences. Less 
+frequent supervised training, graded increase in duration 
+of sessions by yoga therapists to patients in smaller groups, 
+could help increase the acceptance for yoga. Programs 
+aiming to reach yoga to patients with schizophrenia in the 
+larger community should be cognizant of these difficulties. 
+Further, effective marketing of yoga by all mental health 
+professionals is an important step in making yoga accepted 
+as an add on treatment modality for schizophrenia.
+REFERENCES
+1.	
+Murray CJL, Lopez AD. The global burden of disease; A Comprehensive 
+assessment of Mmortality and disability from diseases, injuries, and risk 
+factors in 1990 and projected to 2020. Cambridge MA: Harvard University 
+Press; 1996.
+2.	
+Kane JM, Honigfeld G, Singer J, Meltzer HY. Clozapine for treatment resistant 
+schizophrenia. Archives of General Psychiatry 1998;45:789‑96.
+3.	
+Nagendra HR, Telles S, Naveen KV. An integrated approach of Yoga therapy 
+for the management of schizophrenia. Final report submitted to the Dept. of 
+ISM and H, Ministry of Health and Family Welfare, New Delhi, 2000.
+4.	
+Lukoff D, Wallace CJ, Liberman RP, Burke K. A holistic program for chronic 
+schizophrenic patients. Schizophr Bull 1986;12:274‑82.
+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.
+6.	
+Miller E. Is hatha yoga religiously neutral? Christian Research Institute. 
+Charlotte, NC, US, 2009. Available from: http://www.equip.org/articles/
+hatha‑yoga‑religiously‑neutral. [Last cited on 2011 Jan 04].
+7.	
+Brown RP, Gerbarg LP. Sudarshan Kriya Yogic Breathing in the treatment of 
+stress, anxiety and depression: Part II—Clinical applications and Guidelines. 
+J Altern Complement Med 2005;11:711‑7.
+8.	
+Ramesh A, Hyma B. Traditional Indian medicine in practice in an Indian 
+metropolitan city. Soc Sci Med Med Geogr 1981;15:69‑81.
+9.	
+Chaya MS, Kurpad AV, Nagendra HR, Nagaratna R. The effect of long term 
+combined yoga practice on the basal metabolic rate of healthy adults. BMC 
+Complement Altern Med 2006;6:28.
+10.	 Thirthalli J, Venkatesh BK, Kishorekumar KV, Arunachala U, 
+Venkatasubramanian G, Subbakrishna DK, et al. Prospective comparison 
+of course of disability in antipsychotic‑treated and untreated schizophrenia 
+patients. Acta Psychiatr Scand 2009;119:209‑17.
+11.	
+Sadock BJ, Sadock VA. Kaplan and Sadock’s synopsis of psychiatry: 
+Behavioral sciences/clinical Psychiatry. North American Edition Philadelphia, 
+Pa, US: Lippincott Williams and Wilkins; 1983.
+How to cite this article: Baspure S, Jagannathan A, Kumar S, 
+Varambally S, Thirthalli J, Venkatasubramanain G, et al. Barriers to 
+yoga therapy as an add-on treatment for schizophrenia in India. Int J 
+Yoga 2012;5:70-3.
+Source of Support: Nil, Conflict of Interest: None declared

subfolder_0/Changes in Bioenergy Field of Children with Autism following.txt

@@ -0,0 +1,816 @@
+Int J Med. Public Health. 2021; 11(1):57-62.
+A Multifaceted Peer Reviewed Journal in the field of Medicine and Public Health
+www.ijmedph.org | www.journalonweb.com/ijmedph
+Original Article
+International Journal of Medicine and Public Health, Vol 11, Issue 1, Jan-Mar, 2021
+57
+Surendra Singh Sankhala, 
+Hongasandra Ramarao 
+Nagendra, Singh 
+Deepeshwar*
+Division of Yoga & Life Sciences, Swami 
+Vivekananda Yoga Anusandhana 
+Samsthana (S-VYASA), Gavipuram 
+Circle, KG Nagar, Bangalore Karnataka, 
+INDIA.
+Correspondence
+Dr. Singh Deepeshwar
+Division of Yoga & Life Sciences, 
+Swami Vivekananda Yoga Anusandhana 
+Samsthana (S-VYASA), Eknath Bhavan, 
+Gavipuram Circle, KG Nagar, Bangalore, 
+Karnataka, INDIA.
+Mobile no: +91 080-22639906
+Email: [email protected]
+History
+• Submission Date: 26-11-2020;
+• Revised Date: 18-12-2020;
+• Accepted Date: 27-01-2021;
+DOI : 10.5530/ijmedph.2021.1.11
+Article Available online 
+http://www.ijmedph.org/v11/i1
+Copyright
+© 2021 Phcog.Net. This is an open-
+access article distributed under the terms 
+of the Creative Commons Attribution 4.0 
+International license.
+Cite this article : Sankhala SS, Nagendra HR, Deepeshwar S. Changes in Bioenergy Field of Children with 
+Autism following Non-pharmacological Interventions: A Randomized Controlled Study. Int J Med Public Health. 
+2021;11(1):57-62.
+ABSTRACT
+Introduction: The effectiveness of integrated approach using complementary therapies 
+for children diagnosed with Autism spectrum Disorder (ASD) is poorly studied. This is due to 
+limited objective assessments and lack of well-designed therapeutic module. Aim: This study 
+examined the effect of yoga and naturopathy interventions on Electrophotonic Imaging (EPI) 
+parameters in children with autism. Methods: This study consisted of three groups i.e., Yoga 
+(YG), combination (Yoga and Naturopathy, YNG) and Control Group (CG) tested a 24 days 
+intervention duration. Yoga group received series of yoga practices and combination groups 
+received both yoga and naturopathy for the same duration. The control group maintained their 
+daily usual activities. The EPI parameters included Activation Coefficient (AC, stress parameter), 
+Integral Area (IA, general health parameter), Integral Entropy (IE, disorderliness parameter) were 
+compared between groups and within group after interventions. Seventy-seven children with 
+autism were randomized and 70 children completed the study with 95% adherence to the yoga 
+and naturopathy interventions. Results: The results of the analysis showed that there was a 
+significant improvement in energy level of YG and YNG in IAL (p<0.01; p<0.001), IEL (p<0.05; 
+p<0.001) and no change in control group. Moreover, there were a significant difference in post 
+assessment of 
+YG and 
+YNG from CG in IAL (p<0.001), IEL (p<0.05) and IAR (p<0.01) parameters 
+of EPI. Conclusion: This study provides evidence that interventions of yoga and naturopathy 
+may be useful to reduce the severity of symptoms and improve energy level that is required for 
+children with autism and other neurodevelopmental disorders.
+Key words: Yoga, Naturopathy, IAYT
+, Neurodevelopmental disorder, Children, Electrophonic 
+imaging.
+Changes in Bioenergy Field of Children with Autism following 
+Non-pharmacological Interventions: A Randomized Controlled 
+Study
+Surendra Singh Sankhala, Hongasandra Ramarao Nagendra, Singh Deepeshwar*
+INTRODUCTION
+Autism Spectrum Disorder (ASD) is a complex 
+neurodevelopmental 
+disorder 
+that 
+includes 
+impaired communication and social skills, that 
+results in the presence of stereotype, repetitive or 
+restricted behaviour. These symptoms may vary 
+across individuals at a different age. A recent WHO 
+report estimated that worldwide one in 160 children 
+has an ASD.1 There is no current epidemiological 
+data available on the prevalence estimation of ASD 
+in India. However, an early report suggests that 
+one in 100 children in the age group of 1-10 years 
+might be affected by ASD in India, which is lower 
+than the global Prevalence.2 Other epidemiological 
+studies have been conducted over the past 50 years, 
+indicating a dramatic increase in ASD globally.3-5
+Scientific studies suggest no evidence or causative 
+theory exists, but few risk factors may be associated 
+with ASD, including environmental and genetic 
+factors.6-8 Therefore, early diagnosis of ASD is 
+challenging and symptoms may appear 3 years of 
+age. Early diagnosis is an important criterion to plan 
+appropriate intervention once ASD is identified. 
+However, inappropriate autism diagnostic tools and 
+limited evidence-based clinical intervention studies 
+on ASD restrict ASD symptoms efficiently. There 
+are many therapies for autism, including behavioral, 
+cognitive,9 selective diet,10,11 mega doses of selected 
+vitamins and nutraceutical,12 complementary and 
+alternative medicine (CAM)13 and mind-body 
+intervention, someway address the symptoms of ASD. 
+CAM’s usefulness was reported 40-62% population 
+of ASD in a recent survey conducted in Germany.14 
+CAM therapy includes acupuncture, physical therapy, 
+yoga, music, etc. with limited evidence for effective 
+treatment of ASD core symptoms and associated 
+comorbidities. Autistic children are mainly affected by 
+behavioral problems, physiological conditions such 
+as gastrointestinal (GI), autonomic abnormalities, 
+impaired motor functions and sensory integration 
+problems.15-18 The severity of autism in children 
+aged 7-15 years was reduced after yoga training and 
+improved sleep quality and GI issues.19,20 The motor 
+Sankhala, et al.: Bioenergy Field and Children with Autism
+58
+International Journal of Medicine and Public Health, Vol 11, Issue 1, Jan-Mar, 2021
+impairment and improper coordination were enhanced by after 8-weeks 
+of yoga training.21
+Further, the behavioral, social and emotional patterns of ASD children 
+were improved following either yoga, dance, or music therapy measured 
+through behavioral scales.22-24 The outcomes of the previous study 
+on Yoga suggests that it may regulate the psychological and psycho-
+physiological states of children with ASD. A study using a biometric 
+tool called electrophotonic imaging (EPI) helps assess the functional 
+state of the organ and organ system of the human body by recoding 
+the physiological process through fingertips.25 Few other studies have 
+been trying to understand ASD’s biological pattern of ASD but limited 
+evidence-based and randomized controlled studies are reported in this 
+area. The parameters of EPI have not been studies after the intervention 
+of yoga or naturopathy in ASD children.
+Therefore, the current study was aimed to explore the efficacy of yoga 
+and naturopathy interventions on the EPI parameters of children with 
+ASD. 
+MATERIALS AND METHODS
+Participants
+Seventy participants aged between 7 to 15 years (mean and SD; 9.12±2.3 
+years) were recruited from specific autism centers in Bangalore and 
+Kolkata, India. This study was conducted between March 2018- August 
+2019. Children diagnosed with mild or moderate ASD by a psychiatrist 
+using the stipulated guidelines in the Diagnostic and Statistical 
+Manual of Mental Disorders (DSM–5) for autism26 were recruited in 
+the present study. The selected children were physically active, able to 
+follow instructions and ready to undergo for yoga and naturopathy 
+interventions. We have excluded children if they have severe behaviour 
+problems, uncontrolled seizures, neurological problems, including visual 
+or auditory impairments. Each child was assessed using the Childhood 
+Rating scale (CRS),27 which demonstrated a mild to moderate autism 
+range. Those who marked a severe range of autism were not accepted 
+into this trial. The CONSORT Flow diagram of the trial is given in 
+
+Figure 1. 
+Ethics approval and informed consent
+The research study was carried out following the Declaration of 
+Helsinki and approved by the Institutional Ethics Committee (IEC) 
+of the University. Further, the course was registered in the Clinical 
+Trial Registry of India (CTRI) [CTRI/2018/08/015267] before the 
+recruitment of participants. The informed consent was obtained from 
+school authority, parents, or guardian of all participants after explaining 
+the nature of the study and were informed about the EPI technique and 
+procedure of data acquisition.
+Randomization
+The autistic children were randomized into either 24-days yoga or yoga 
+and naturopathy interventions or routine physical activity (active control) 
+group. After CRS at baseline, all eligible participants were randomized 
+into three groups using a computer-generated random assignment 
+scheme. Participants were assigned in a 1:1:1 ratio to each group in the 
+block of 10-12 participants. The principal investigator, investigator who 
+acquired data and statisticians were blind to the assigned group. It was 
+not possible to mask the intervention from the subject. 
+Instrumentation
+This study utilized electrophotonic imaging (EPI) tool, model number: 
+FTDI.13.6001.110310 (Kirlionics Technologies International company, 
+Saint Petersburg, Russia), also known as gas discharge visualization, 
+following guidelines of Kirlian effect. EPI allows us to measure the 
+energy field in humans and used as a scientific device in few other studies 
+demonstrated the level of stress, general health and disorderliness 
+through stimulated optoelectronic emission of humans.28-30 The EPI 
+is based on applied physical and Chinese meridian theory to assess 
+subtle bio-energy changes in the body using fingertips. Each fingertip is 
+subdivided into various sectors and was correlated with different organs 
+and organ systems of the body.31 The biophotons can be captured from 
+ten fingertips by placing them on dielectric glass, which is stimulated 
+by high voltage (10kV) and high frequency (1024 Hz) for less than a 
+millisecond. Due the presence of high electric field, the electrons 
+extracted from the surface of skin and can be seen as a luminous glow 
+around the finger and capture using an optical CCD (charge-coupled 
+device) camera.32 The health-related information can be derived from 
+sectors of the fingertip quantified by EPI software. If there is a gap in 
+any sectors shows imbalance in the concerned organ within the body.33 
+Few studies used a specially designed plastic sheet that is placed above 
+the dielectric glass surface before data acquisition (with filter) and then 
+without filter data was collected.25,34 For short duration recording, the 
+EPI parameters were found to be consistent and with filter data are 
+more stronger than without filter data.32,33 Therefore, in the present 
+study we acquired data ‘with filter’
+. This tool provides information about 
+physiological and psychophysiological states through electromagnetic 
+field of human body. The normative data of EPI measurements showed 
+that the healthy individual fall within the range of 4.1-6.6% and highly 
+reliable for different clinical conditions such as cancer, autism, diabetes, 
+sports, mind-body medicine.35,36
+EPI tool enabled four different parameters: (1) activation coefficient 
+(AC), measures the stress level and normal range is 2-4 in healthy people; 
+(2) integral area (IA) from left and right side: measure of general health 
+index with a range of -0.6 to +1 for healthy; (3) integral entropy (IE) from 
+left and right side: measures of human energy filed of disorderliness with 
+a range of 1-2 in healthy people.33
+Procedure for data-acquisition
+Each ASD diagnosed child seated in electrically isolated comfortable 
+chair and asked to place their fingertip on a dielectric glass at 45° angle 
+for a short duration (approx. 15-20 sec). The data collection was done 
+in morning after three hours of food intake. Parents or Guardians were 
+asked to remove metallic items from their children at least one day before 
+data acquisition. The variability in environmental conditions including 
+temperature (26.8°C at Pre and 27.3°C at Post) and humidity (51.8% at 
+Pre and 50.6% at Post) was monitored using Hygrometer (Equinox, EQ 
+310 CTH) because it may affect electrophotonic emission from human 
+Figure 1: CONSORT flow chart of ASD children through study.
+Sankhala, et al.: Bioenergy Field and Children with Autism
+International Journal of Medicine and Public Health, Vol 11, Issue 1, Jan-Mar, 2021
+59
+participants.37 Prior to data collection on EPI, children were exposed to 
+the method of placing their fingertip on a plane glass surface. Once they 
+are comfortable and stable, data was acquired as per the instructions 
+stipulated in the EPI manual. If still the collected data was not clear, it 
+was repeated twice or participant was discarded from the study. None of 
+the potential participants were discarded due to above reason. After data 
+collection from all 10 fingertips, every child underwent for randomly 
+assigned intervention for a period of 24 days. 
+Interventions
+The study intervention was 24-day structured 60 min integrated yoga 
+protocol, yoga and naturopathy in morning and afternoon with the gap of 
+2 hrs of food intake. Integrated yoga was a combination of easy physical 
+postures (sukshma vyayama; asana), yogic breathing (pranayama) and 
+guided relaxation and followed up with mantra chanting that engaged 
+ASD children to be attentive for their body and being present in the 
+moment. The yoga and naturopathy were a combination of above-
+mentioned yoga practices and eight sessions of naturopathy intervention 
+that included abdominal mud pack and enema using lukewarm water, 
+which is therapeutically efficacious and safe.38 Additionally, the diet 
+pattern was advised by a dietician to yoga and naturopathy group 
+children. The intervention protocol is given in Table 1. The yoga practice 
+and yoga and naturopathy interventions were led by an experienced yoga 
+trainer for children from Yoga University, Bangalore, India. The control 
+group participants continued their normal routine as usual without any 
+change.
+Statistical analysis
+Total eighty-four parameters were extracted from left side and right side 
+of EPI data to give a comprehensive energy level description at different 
+organs and organ systems of ASD child. All analyses were conducted 
+using IBM SPSS statistics 24.0 (IBM Corp. Released 2018, IBM SPSS 
+Statistics for Windows, Version 24.0; IBM Corp., Armonk, NY, USA) 
+and JASP 0.10.2. The EPI data is a continuous variables and descriptive 
+statistics were tabulated including the means and standard deviations 
+presented in Table 2. Data analysis was based on the Per-protocol analysis 
+(PPA) method that included all available data in a mixed-model analysis. 
+The EPI parameters were analysed using repeated measures analysis of 
+variance (ANOVA) with two factors i.e., Factor 1: three intervention 
+Groups (YG, YNG and CTL); Factor 2: Time points (Pre and Post). Each 
+EPI parameters were assessed with a Group × Time interaction term. The 
+repeated measures of ANOVAs were carried out followed by post-hoc 
+analysis with Bonferroni corrections, for all the parameters of EPI. 
+RESULTS
+The ANOVA results of within subject and between subject outcomes are 
+given in Table 3.
+Baseline comparison of YG (n=23), YNG (n= 23) and CTL 
+(n=24)
+The 2-way repeated measures of ANOVA showed that there was a 
+significant difference in baseline energy level of IAL, IAR between autism 
+(YG and YNG) and healthy control (p<0.001). After intervention period, 
+the ASD control group showed significant difference in IAL (p<0.05) 
+compared to healthy control group. Similarly, YG showed significant 
+difference with YNG (p<0.05), ASD control (p<0.05) and healthy control 
+(p=0.001). The YNG group showed significant difference with ASD 
+control (p<0.001) and no difference with healthy control (p>0.05). 
+Within group comparisons (pre-post) in groups
+Post hoc analysis with Bonferroni adjustment showed a significant 
+improvement in YG and YNG groups as reported in Table 2. The yoga 
+intervention showed a significant improvement in IAL (p<0.01; Cohen’s 
+d=0.41) and IEL (p<0.05; Cohen’s d= 0.46) when compared with pre. 
+Similarly, YNG showed there were significant improvement from pre to 
+post in IAL (p<0.001; Cohen’s d= 1.50) and IAR (p<0.001; Cohen’s d= 
+1.31) whereas no changes were observed in ASD control group. 
+DISCUSSION
+The aim of the present study was to examine the effect of Yoga and 
+combination of yoga and naturopathy interventions on the important 
+parameters of EPI that measures the pattern of bioenergy field in 
+children with autism. Bioenergy field can be one of the indicators 
+to assess the human health.28 Moreover, it can be also utilized as an 
+important parameter to assess the effectiveness of interventions given 
+to the children with autism, as attempted in the current study.39,40 The 
+autistic children underwent for one-month yoga and combination of 
+yoga and naturopathy interventions that showed promising outcome in 
+the bioenergy field measures through EPI. Both YG and YNG showed 
+improvement in IAL and IAR which is an important indicator of in 
+general health parameter. The IEL and IER reflect the disorderliness 
+in energy pattern. Following the intervention of yoga and naturopathy 
+Table 1: Yoga practices and naturopathy interventions structure and 
+components 
+A: Yoga.
+Name of the practice (Yoga)
+Duration
+(min)
+Starting prayer
+1 min
+Breathing Exercises
+2 min
+Preparatory/Dynamic Practice
+10 min
+Wind Releasing Practices
+5 min
+Sun Salutation (10 step)
+5 min
+Relaxation
+1 min
+Standing asana
+5 min
+Sitting asana
+6 min
+Prone Posture
+2 min
+Supine Posture
+4 min
+Breathing Practices (Pranayama)
+5 min
+Relaxation
+8 min
+Chanting sloka
+5 min
+Ending Prayer
+1 min
+B: Naturopathy 
+Name of Treatment
+Duration of 
+session (min)
+Total number of 
+sessions
+Mud Pack to abdomen
+20
+8
+Enema (lukewarm water)
+10
+8
+Diet
+Diet advise will be 
+given
+(what to eat, how 
+to eat, when to 
+eat)
+Sankhala, et al.: Bioenergy Field and Children with Autism
+60
+International Journal of Medicine and Public Health, Vol 11, Issue 1, Jan-Mar, 2021
+showed improvement in general health and energy pattern throughout 
+the body of children with autism. However, we have not observed any 
+changes in stress level as reflected by AC parameter of EPI. This may be 
+due to ASD children may have delayed self-awareness and struggle with 
+poor insight.41,42
+Children with autism is associated with inattentiveness, overactivity 
+and impulsiveness that constantly affect the metabolic process and 
+replenishing their required energy for normal functioning. This is 
+mainly due to children with ASD have gastrointestinal (GI) symptoms 
+including abdominal pain, constipation and diarrhoea that increases 
+severe rigid-compulsive symptoms.43 This is the first study, where yoga 
+was given with add-on naturopathy intervention that showed beneficial 
+effect on the energy pattern in EPI parameters of children with ASD. 
+The naturopathy intervention included cleansing practices that help to 
+remove toxins from the body and improves the health of gut (enteric) 
+microbiome (GM) in ASD children. The GM play a causative role in 
+ASD44 and can be modified through yoga and naturopathy interventions.45 
+Moreover, yoga practice influence microbiome-gut-brain axis, a complex 
+communication pathway, that has causal effects on brain and behaviour.46 
+The microbiome has intricate communication between the external 
+environment and the human body that influence brain function and 
+behaviour.47 Other few studies demonstrated the effectiveness of yoga on 
+the functional abdominal pain including reduction of pain intensity and 
+frequency and improve the quality of sleep in children.48,49
+The practice of yoga helps to energize the body and bring harmony 
+between body and mind.50 The structured yoga program with continuous 
+repeated sessions increases attentiveness, calmness, with reduction in 
+severity of symptoms.19 Moreover, the repeated sessions enhance recall 
+ability, imitation skills, facial expression and verbal receptive skills 
+in children with ASD. Scientific studies showed that when children 
+imitate repeatedly the body positions and movements guided by a yoga 
+therapist may stimulate mirror neurons system (MNS).51 Activation in 
+MNS in autism improves higher level of cognitive process and social 
+learning behaviour.52 Following yoga practice improves motor abilities 
+including balance, strength and flexibility) and social behaviour in 
+children. However, few other studies reported yoga practices have 
+beneficial effect on physical activity including hyperactivity, self-efficacy 
+and socialization in children with autism.53,54 The results of the previous 
+findings are in agreement with the present study outcome that energy 
+level was improved following yoga and naturopathy interventions in 
+children with autism.
+Despite of encouraging results, the current study has several limitations 
+including development and standardisation of yoga and naturopathy 
+module that may limit the feasibility of the current study. However, 
+the considered module was taken from the previous study.55 The other 
+limitation was not assessing the quality of life of parents though they were 
+also present during the data acquisition and interventions. Future study 
+can be plan on both children and parents using various comprehensive 
+neuropsychological and petrophysical scales for better understanding. 
+A feasibility study can be planned after standardizing and validating 
+yoga and naturopathy module neurodevelopmental disorder including 
+autism. 
+CONCLUSION
+The practice of yoga with naturopathy interventions showed beneficial 
+for children with autism. Yoga can be considered as one of the therapeutic 
+techniques that helps to channelize the energy through the body which 
+helps to reduce the severe of symptoms in autistic children. Moreover, 
+naturopathy intervention can play a major role to reduce the physical 
+complications including constipation, irritable bowel syndrome (IBS) 
+and other GIT related issues in children.
+Table 2: Within group and between group comparisons of electrophotonic imaging (EPI) parameters before and after interventions.
+Variables
+Yoga
+(n=23)
+Cohen’s d
+Yoga and Naturopathy
+(n=23)
+Cohen’s d
+Control
+(n=24)
+Cohen’s 
+d
+Pre
+Post
+Pre
+Post
+Pre
+Post
+AC
+3.01 ±1.62
+3.38±1.58
+0.23
+3.69 ±2.25
+3.36±0.92
+0.19
+3.42±2.03
+3.35±2.01
+0.03
+IAL
+0.17±0.34
+0.29±0.23**$$$
+0.41
+-0.03±0.33
+0.43±0.18***$$$
+1.50
+0.14±0.85
+0.17±0.80
+0.04
+IEL
+1.77±0.22
+1.87±0.21*
+-0.46
+1.78±0.21
+1.84±0.27$
+0.25
+1.79±0.40
+1.79±0.39
+0.00
+IAR
+0.11±0.37
+0.22±0.36$$
+0.30
+-0.06±0.35
+0.43±0.19***$$$
+1.31
+-0.11±0.26
+0.01±0.18
+-0.53
+IER
+1.88±0.15
+1.91±0.17
+0.18
+1.83±0.18
+1.91±0.19
+0.43
+1.81±0.41
+1.84±0.37
+-0.08
+AC: activation coefficient; IAL: integral area left side; IEL: integral entropy left side; IAR: integral area right side; IER: integral entropy right side. * p<0.05; **<0.01; 
+***<0.001; represent significant level in post compared with pre. $<0.05; $$<0.01; $$$<0.001 represent the significant difference from control group.
+Table 3: ANOVA results.
+Measures
+Source
+F (df)
+p-value
+Partial 
+η2
+Observed 
+Power
+AC
+Time Point
+0.004 (1, 65)
+>0.05 
+(NS)
+0.00
+.05
+Time Point 
+× Group
+2.41 (2, 65)
+>0.05 
+(NS)
+0.07
+0.47
+IAL
+Time Point
+24.78 (1,65)
+<0.001 
+0.28
+0.32
+Time Point 
+× Group
+10.70 (2, 65)
+<0.001
+0.25
+0.99
+IEL
+Time Point
+2.29 (1, 65)
+>0.05 
+(NS)
+0.03
+0.32
+Time Point 
+× Group
+0.65 (2,65)
+>0.05 
+(NS)
+0.02
+0.15
+IAR
+Time Point
+28.99 (1,65)
+<0.001
+.31
+1.0
+Time Point 
+× Group
+7.74 (2,65)
+0.001
+.19
+.94
+IER
+Time Point
+2.61 (1,65)
+0.11 
+(NS)
+.04
+.36
+Time Point 
+× Group
+0.30 (2,65)
+>0.05 
+(NS)
+.0.01
+.09
+Sankhala, et al.: Bioenergy Field and Children with Autism
+International Journal of Medicine and Public Health, Vol 11, Issue 1, Jan-Mar, 2021
+61
+ACKNOWLEDGEMENT
+Authors would like to thank Dr. Jayashree from Asha Foundation, 
+Dr. Sridip Chaterjee and his students from Department of Physical 
+Education, Jadavpur University and Dr. Sivakumar, S-VYASA University 
+for helping at different stages of the data collection on children with 
+autism. Also, authors would like to thank all participants and their 
+families to participate and support in the study.
+CONFLICT OF INTEREST
+The authors declare no conflict of interest. 
+ABBREVIATIONS
+ASD: Autism Spectrum Disorder; EPI: Electrophotonic imaging; YG: 
+Yoga Group; YNG: Yoga and Naturopathy; CG: Control Group; AC: 
+Activation Coefficient; IAL and IAR: Integral Area left and right; IEL 
+and IER: Integral Entropy left and right;  IAYT: Integrated approach 
+of yoga therapy; CAM: Complementary and alternative medicine; GI: 
+Gastrointestinal; CRS: Childhood Rating scale; ANOVA: Analysis of 
+variance; MNS: Mirror neurons system; IBS: Irritable bowel syndrome; 
+GIT: Gastro Intestinal Tract.
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subfolder_0/Combined Ayurveda and Yoga Practices for Newly Diagnosed Type 2 Diabetes Mellitus A Controlled Trial.txt

@@ -0,0 +1,1020 @@
+Fax +49 761 4 52 07 14
+[email protected]
+www.karger.com
+Accessible online at: 
+www.karger.com/cmr
+ 
+ 
+  
+  
+Original Article · Originalarbeit
+Complement Med Res
+DOI: 10.1159/000464441
+Combined Ayurveda and Yoga Practices for Newly  
+Diagnosed Type 2 Diabetes Mellitus: A Controlled Trial
+Purnima Datey    Alex Hankey    H.R. Nagendra 
+S-VYASA, Bangalore, India
+Schlüsselwörter
+Yoga · Ayurveda · Typ-2-Diabetes · Prävention ·  
+Wiederherstellung der Gesundheit · Rasahara
+Zusammenfassung
+Hintergrund: Die steigende Häufigkeit des Auftretens von 
+Typ-2-Diabetes in Indien gibt Anlass für nationale Besorgnis, 
+besonders wegen der steigenden Kostenbelastung für den 
+Staat. Als ein Ansatz, um diese Steigerungen aufzuhalten, 
+hat die Yoga-Medizin weitreichenden Einsatz gefunden, mit 
+gleicher Beliebtheit bei allen sozialen Schichten. Hier berich-
+ten wir über eine Studie, die nahelegt, dass eine Behandlung 
+mit frischen Kräutersäften und Yoga die Spiegel von Glu-
+kose und Hämoglobin A1c (HbA1c) im Blut von Menschen 
+mit Diabetesvorstufen verbessern kann. Methoden: Studien-
+design: 3-armige kontrollierte Studie über 3  Monate. Teil-
+nehmer: 157 männliche Strafgefangene mit neu diagnosti-
+zierten hohen Blutzuckerspiegeln im nüchternen Zustand 
+(FBS) und nach einer Mahlzeit (postprandial, PPBS). Grup-
+peninterventionen: 1) Rasahara und Yoga, 2) Yoga, 3) keine 
+Intervention. Messwerte: Die FBS- und PPBS-Spiegel wur-
+den alle 2 Wochen gemessen; die HbA1c- und Blutfettwerte 
+wurden vor und nach der Intervention bestimmt. Ergebnisse: 
+Signifikante Abnahmen ergaben sich für die FBS- (–21,13 ± 
+21,16 mg/dl) und PPBS-Spiegel (–15,02  ± 14,89  mg/dl) in 
+Gruppe 1 (beide p < 0,0001) und für den FBS-Spiegel (20,62 ± 
+32,68 mg/dl) in Gruppe 2 (p = 0,0005), während die Zunah-
+men in Gruppe 3 nur für den PPBS-Spiegel (9,62 ± 21,83 mg/
+dl) (p  = 0,0022) Signifikanz erlangten. Die beobachteten 
+­
+Veränderungen beim HbA1c-Spiegel betrugen: Gruppe 1, 
+–0,044 ± 0,059 mg/dl; Gruppe 2, +0,024 ± 0,456 mg/dl (nicht 
+signifikant); Gruppe 3, +0,365  ± 0,369  mg/dl (p  < 0,0001). 
+Schlussfolgerungen: Diese Studie zu Yoga als Methode zur 
+Behandlung von Diabetes zeigt, dass alle männlichen Straf-
+gefangenen von den Yoga-Programmen des Gefängnisses 
+profitieren können. Die Aufnahme von Yoga-Programmen in 
+staatliche und bundesstaatliche Aktivitäten auf allen Ebenen 
+ist nun eine nationale Maßnahme in Indien. Weiterführende 
+Studien sollten durchgeführt werden, um noch robustere 
+­
+Ergebnisse zu erhalten.
+Keywords
+Yoga · Ayurveda · Type 2 diabetes · Prevention ·  
+Health restoration · Rasahara
+Summary
+Background: The increasing prevalence of type 2 diabetes 
+in India is a cause for national concern, particularly the spi-
+raling cost burden to the country. As one approach to stop 
+its increase, Yoga medicine has been widely implemented, 
+finding popularity with all social strata. Here, we report a 
+study suggesting that treatment with fresh herbal juices and 
+Yoga can improve the levels of blood glucose and hemo-
+globin A1c (HbA1c) in people with pre-diabetes. Methods: 
+Study design: 3-arm controlled trial 3 months in duration. 
+Participants: 157 male prisoners with newly diagnosed, high 
+fasting blood sugar (FBS) and postprandial blood sugar 
+(PPBS) levels. Group interventions: (1) Rasahara and Yoga, 
+(2) Yoga, (3) no intervention. Assessments: FBS and PPBS 
+levels were measured every 2 weeks; HbA1c and blood li-
+pids were determined pre- and post-intervention. Results: 
+Significant decreases occurred in the FBS (–21.13  ± 
+21.16  mg/dl) and PPBS levels (–15.02  ± 14.89  mg/dl) in 
+group 1 (both p  < 0.0001) and in the FBS level (20.62  ± 
+32.68 mg/dl) in group 2 (p = 0.0005), while the increases in 
+group 3 attained significance only for the PPBS level (9.62 ± 
+21.83 mg/dl) (p = 0.0022). Observed changes in HbA1c were: 
+group 1, –0.044 ± 0.059 mg/dl; group 2, +0.024 ± 0.456 mg/dl 
+(not significant); and group 3, +0.365  ± 0.369  mg/dl (p  < 
+0.0001). Conclusions: This study of Yoga for the treatment 
+of diabetes shows that all male prisoners could benefit from 
+the Yoga prison programs. Addition of Yoga programs to 
+state and federal activities at all levels is now national pol-
+icy in India. Follow-up studies should be carried out to ob-
+tain more robust results.
+© 2017 S. Karger GmbH, Freiburg
+Published online: September 29, 2017
+Dr. Alex Hankey
+S-VYASA
+19 Gavipuram Circle, Kempe Gowda Nagar, Bangalore 560019, India
+[email protected]
+© 2017 S. Karger GmbH, Freiburg
+Downloaded by: 
+King's College London                                  
+137.73.144.138 - 12/8/2017 12:49:12 PM
+Datey/Hankey/Nagendra
+Complement Med Res 2017;24:1–8
+Introduction 
+One of the greatest challenges to contemporary health care is 
+type 2 diabetes mellitus (T2DM) [1]. Epidemiological studies of 
+T2DM foresee increases in global health expenditure that are un-
+sustainable [1], particularly in India, where the increasing preva-
+lence of T2DM is a cause for national concern. International Fed-
+eration of Diabetes (IDF) statistics place India’s diabetes preva-
+lence at 9% [2], but urban levels are estimated at 5% [3, 4]. The ris-
+ing incidence in all social classes, from the highest to the lowest 
+class, has created a spiraling cost burden. Rather than universally 
+combating the disease with drugs, which merely palliate the condi-
+tion, India and other countries in South Asia are well placed to 
+counter the challenge with their systems of traditional complemen-
+tary and alternative medicine (TCAM).
+Indian opinion [5] now holds that no single system of medicine is 
+sufficient to take care of the entire health care needs of the nation 
+and that the traditional AYUSH (Ayurveda, Yoga, Unani, Siddha 
+and Homeopathy) systems of medicine have useful roles to play in 
+improving national health care. More specifically, it was hypothe-
+sized [5, 6] that, while modern biomedicine may be more appropri-
+ate for most infectious diseases and conditions requiring surgery 
+and intensive care, India’s TCAM systems may well have distinct 
+advantages for non-communicable diseases and chronic conditions 
+like T2DM, motivating increased research activity and funding for 
+them. In 2014, the Indian government created a separate Ministry 
+for AYUSH updating National Health Policy by launching the Na-
+tional AYUSH Mission to investigate their potential to make signifi-
+cant contributions to national health care [7, 8]. The study reported 
+here, concerning a protocol combining Ayurveda and Yoga, was 
+motivated by these considerations and the need to obtain more data.
+For Yoga, medical applications are increasingly well researched, 
+starting with asthma [9] and extending to areas such as breast can-
+cer survivors [10, 11], where 12 randomized controlled trials 
+(RCTs) have been included in a systematic review and meta-analy-
+sis [12]. Similar numbers of RCTs have been systematically re-
+viewed for such pathologies as lower back pain [13, 14], depression 
+[15, 16], rheumatoid conditions [17], cardiovascular disease [18], 
+and cardiovascular disease risk factors [19]. With regard to diabe-
+tes, a recent review of controlled trials of Yoga [20] for T2DM ana-
+lyzed 12 RCTs and 13 non-RCTs covering 2,170 patients, finding 
+good evidence that Yoga practice can positively affect glycemic con-
+trol, lipid levels, and body lipocyte percentages. Another systematic 
+review and meta-analysis [21] made similar findings. Yoga practices 
+are well validated as a discipline promoting weight reduction [22, 
+23], and since overweight is a major contributing factor to early 
+stages of T2DM, its potential to counteract obesity has been re-
+viewed [24] and found to be a potentially key way to reverse begin-
+nings of the disorder. All such recent studies [20–24] confirming 
+benefits of Yoga for aspects of T2DM support an application pro-
+posed by practitioners of Yoga medicine since the millennium [25].
+Both Yoga and Ayurveda are components of the ancient Indian 
+sciences or Vedas, with estimated origins as early as 7,000 BCE (be-
+fore the Christian era) in the Indus basin [26]. By the beginning of 
+the third millennium BCE, Yoga postures were portrayed in figu-
+rines [26]. The famous Upanishad texts [27] portray Yoga practice 
+as a central component of education of the children of the society’s 
+leaders. The Ayurveda text, Charaka Samhita, suggests that the two 
+disciplines complement each other because sickness of mind will 
+result in sickness of body [28]; use of Yoga is to perfect healthy 
+minds. The Ashtanga Hrdayam [29], one of Ayurveda’s three main 
+texts, states that self-realization, which can only be obtained 
+through Yoga meditation [30], is a preferred treatment for mental 
+disorders [31]. Similarly, Ayurveda’s foremost classic, Charaka 
+Samhita [32], which describes the origins of Ayurveda in its open-
+ing section, also names Yoga as the preferred treatment for prob-
+lems of the mind [33].
+The theory of Ayurveda is based on an integrated formulation of 
+human physiology and etiology [34, 35], now recognized as the most 
+concise integration of the two subjects formulated in the history of 
+medicine [36]. Its theory identifies 3 factors, known as 3 doshas, 
+governing the regulation of the organism’s 3 main systems func-
+tions: Input/Output, Turnover, and Storage [37]. Ayurveda main-
+tains that, when optimally balanced regulation of any of these is lost 
+or degraded, the system becomes open to disease [38]. For diabetes, 
+it states that full-blown T2DM is preceded by urination becoming 
+more frequent, prameha [39], and is then identified by sweetness of 
+the urine, madhu (sweet) meha (urine) [40], recognized by its attrac-
+tion for ants, as the condition now called diabetes. Frequent urina-
+tion suggests that the dosha in charge of the kidneys has been driven 
+out of balance. This dosha, Vata dosha, and more particularly its 
+subdosha related to the kidneys, Apana Vata, is also connected to 
+the hypothalamic-pituitary-adrenal (HPA) axis, meaning that an-
+cient Ayurveda implicitly recognized the acknowledged connection 
+between stress and T2DM. Vata dosha, when out of balance, is said 
+to drive other doshas out of balance as well; so, the general connec-
+tion between stress and disease was recognized by Ayurveda. Yoga 
+with its ability to reduce stress is therefore a natural system to be in-
+corporated into preventive health programs in Ayurveda. A treat-
+ment aiming to reverse slightly elevated blood sugar levels compris-
+ing both Ayurveda herbs and Yoga practice, such as that reported 
+here, is therefore entirely natural in the context of the integrative 
+practice of the traditional Indian AYUSH systems of medicine.
+Methods
+Study Design
+A 3-month, 3-arm, controlled trial invited by the jail administration of the 
+Central Jail, Bhopal, Madhya Pradesh, India (fig. 1), from 8th May to 8th August, 
+2015.
+Participants
+Blood tests for the initial screening of prison inmates was performed at Bho-
+pal Central Jail itself, by the prison doctor on 6th and 7th May, 2015, before the 
+start of the trial. Screening identified 567 men with elevated fasting blood sugar 
+(FBS) levels, who were informed about the trial. Of these, 112 finally agreed to 
+participate (fig. 1). G*power analysis was performed using data from previous 
+studies of Yoga and T2DM at S-VYASA [41]. α and β = 0.05 requirements 
+yielded a required number of participants of n = 30 for each trial arm.
+Downloaded by: 
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+137.73.144.138 - 12/8/2017 12:49:12 PM
+Ayurveda and Yoga Controlled Trial for Type 2 
+Diabetes
+Complement Med Res 2017;24:1–8
+Inclusion Criteria
+FBS level > 100; no previous diagnosis of diabetes risk; age ≤ 70 years; jail 
+sentence extending over the trial duration period; able and willing to participate 
+in Yoga.
+Exclusion Criteria
+Age > 70 years; unable/unwilling to practice Yoga; mental disorder; already 
+with T2DM complications: kidney damage, retinopathy, stroke, or heart attack; 
+body mass index (BMI) < 20.
+Assignment to Groups
+Assignment to groups was performed after 38 potential participants ­
+decided 
+not to continue in the trial. Since the numbers were now known to be less than 
+50 in each group, we were advised that randomization might ­
+produce unwanted 
+initial differences between groups and that a particular variable should be cho-
+sen to remain initially equal (private communication of Dr. Archana Purushot-
+tama). Assignment was therefore performed by assigning each participant se-
+quentially to groups 1, 2, or 3 according to their place in the initial FBS level 
+sequence, to try and ensure that the FBS means and standard deviations were 
+comparable (in the event, this was markedly unsuccessful).
+Interventions for Each Group
+The interventions comprised: (1) supplemented Ayurveda herbal juices and 
+Yoga; (2) Yoga [40]; (3) no intervention. The herbs listed below were selected 
+from experience at the 5 herbal juice clinics in the City of Bhopal, developed with 
+guidance from Vaidya P. Y. (Khadivale) Vaidya, one of Pune’s most respected 
+Ayurvedic doctors. Herbs were prepared daily in the jail after the morning Yoga 
+classes. Amounts prescribed for the whole of group 1 were blended in filtered 
+water, a method commonly used, but not for each herb when juiced individually.
+–	 Amalaki (Emblica officinalis) (50 ml): 8 g dried powder soaked for 12 h;
+–	 Guduchi (Tinospora cordifolia) (50 ml): 15 g stem;
+–	 Vasaka (Adhatoda vasica Nees) (50 ml): 4 g green leaves;
+–	 Wheatgrass (Triticum aestivum L.) (50 ml): 25 g green stems.
+(Herbs with Sanskrit and botanical names are listed in the order of their 
+medicinal importance. Wheatgrass is not an Ayurvedic herb, but see below. 
+Amounts are per participant.)
+ 
+Post  
+assessment 
+Post-intervention 
+assessment 
+Post-intervention 
+assessment 
+Assessments
+every 15 days - 5
+Assessments 
+every 15 days - 5 
+Assessments 
+every 15 days - 5
+Group 1: Rasahara 
+and yoga – 38
+Group 3: 
+controls – 37
+Group 2:  
+yoga – 37 
+Assigned to groups – 112 
+Consented and enrolled in study - 150
+1.  Lack of time – 264 
+Declined: 2.  No reason given – 44 
+3.  Not interested – 109 
+Eligible subjects screened – 567 
+Declined after listening to protocol – 38
+Pre-intervention 
+assessment 
+Pre-intervention 
+assessment 
+Pre-
+assessment 
+Fig. 1. Flow diagram for the Ayurveda and Yoga 
+controlled trial.
+Downloaded by: 
+King's College London                                  
+137.73.144.138 - 12/8/2017 12:49:12 PM
+Datey/Hankey/Nagendra
+Complement Med Res 2017;24:1–8
+The preparation of Amalaki is described below; Guduchi was harvested each 
+evening and stored in a cool dry place overnight; Vasaka and wheatgrass were 
+picked fresh each morning.
+Herbs: their original identification, collection of plant material, and selected 
+western herbal properties relevant to the aims of the study:
+–	 Amalaki [42]: Fresh fruits were bought in Bhopal city markets and then 
+prepared as dried powder according to methods stated by Vaidya P. Y. 
+Vaidya. Included for its anti-hyperglycemic properties, it also has antioxi-
+dant and rejuvenating (Rasayana) effects.
+–	 Guduchi [43]: Plants originally identified and authenticated by Vaidya P. 
+Y. Vaidya were organically grown in a specially prepared area at the first 
+author’s main clinic, harvested fresh each evening, and stored overnight. 
+Guduchi has antihyperglycemic, antistress, antioxidant, and immunomod-
+ulatory effects.
+–	 Vasaka [44]: Plants originally identified and authenticated by Vaidya P. Y. 
+Vaidya were organically grown in a specially prepared area at the first au-
+thor’s main clinic and harvested fresh each morning. Vasaka has antidia-
+betic, antihyperglycemic, antistress, and antioxidant effects.
+–	 Wheatgrass: Organically grown from organic wheat grains at the first au-
+thor’s main clinic. Planted in a clean, airy place in separate lots specially 
+prepared for growing it. 8-day old plants were cut from their roots, washed 
+clean and then blended and strained to prepare the juice. Wheatgrass has 
+antihyperglycemic and hypolipidemic, anti-inflammatory, anti-ageing, and 
+immunomodulatory effects.
+Definitions of juice and methods of preparation are described in Yogaratna-
+kara [45]. In terms of Ayurveda, the first three herbs [42–44] are all recognized 
+to be of value for cases of prameha and madhumeha, as Ayurveda names its 
+own recognized precursor stage to diabetes and the full condition, respectively. 
+Amalaki fruit is a herb held to have remarkable healing properties with specific 
+application to hyperglycemic conditions [46, 47]. Guduchi stem is well known 
+for its immune system-stimulating properties as well as for the treatment of el-
+evated blood sugar levels [48, 49]. Vasaka is known for its antidiabetic activities 
+[50, 51], while wheatgrass [52, 53], which is also anti-hyperglycemic and hy-
+polipidemic, contains nutrients and vitality that assist cure in many conditions. 
+Though not yet in Ayurveda texts, wheatgrass juice is already widely available 
+and popular in Indian cities strongly connected to the West, like Bangalore. It 
+will probably come to be formally recognized and used by Ayurveda, as has 
+been the case with other foreign herbs imported by, e.g., the Arabs, Portuguese 
+and British.
+While Ayurveda tends to individualize herbal treatments according to spe-
+cific dosha imbalances seen in each patient, all the chosen herbs are among 
+those recognized to balance all doshas and to have other valuable activities [48, 
+49, 52] like being antioxidant agents [47, 49, 53]. For these reasons, and consid-
+ering that the participants’ blood sugar levels were only mildly elevated, a uni-
+form herbal treatment for the whole of group 1 was deemed appropriate. The 
+overall prescription was formulated for the practical reasons of each herb being 
+available all year round and easy to prepare. Its medicinal value lies in the ingre-
+dients’ mutual compatibility and complementary values. Each herb contains 
+different chemical complexes with the stated actions, presumably making their 
+synergistic effects more beneficial.
+The Yoga module had been developed using a Delphi round of consultation 
+among experts and tested and validated [40]. It was administered daily to all 
+members of groups 1 (supplemented Ayurveda herbal juices and Yoga) and 2 
+(Yoga only). Yoga classes were held for 60 min daily, 7 days per week, in a com-
+munity hall in the jail; with interruptions, 75 min were often needed. The hall 
+was big enough to accommodate 100 participants, and was kept clean and free 
+of insects and mosquitoes. Classes were run by a fully trained, professional 
+Yoga teacher (MA in Yoga) employed for the purpose, together with a qualified 
+yoga trainer to help participants follow instructions more precisely. The first 
+author was present at every session.
+The Yoga intervention is given in table 1. It comprised: flexion exercises of 
+head and neck, limbs and torso (Sukshma Vyayama, warming muscles and 
+stimulating lymph flow, 10 min); 12-posture sun salutation (Suryanamaskara) 
+(2 rounds – 15 min); cyclic meditation consisting of exercises, yoga postures, 
+and 3 relaxation sequences including a final 7 min in supine posture: 10 rounds 
+of single-nostril pranayama breathing; 10 rounds of Bhramari Pranayama 
+(breathing while making an ‘Mmm…’ sound); finally 2 rounds of Nadanusand-
+hana (separate vocalization of ‘Aaa...’, ‘Uuu...’ and ‘Mmm…’ with 4 ‘mudra’ 
+hand positions). In addition, the pranayama-related techniques were practiced 
+by the participants each evening before going to bed.
+Cyclic Meditation: Participants keep their eyes closed and follow pre-re-
+corded instructions to carry out the practices slowly, with awareness and re-
+laxation. First, a yoga text verse is repeated (40 s), followed by supine isometric 
+contraction of body muscles, ending with rest (instant relaxation technique) 
+(1 min); slowly rising to stand at ease; then centering/balancing weight on al-
+ternate feet (2 min); then a Yoga posture sequence, bending to the right (1: 
+20 min), standing balanced (30 s) with instruction on relaxation and aware-
+ness, bending to the left (1: 20 min), standing balanced (30 s), forward bending 
+(1: 20  min), abdominal breathing in supine posture (quick relaxation tech-
+nique) 5 rounds of 36 s (3 min), standing balanced (30 s), backward bending 
+(1: 20 min), finally, slowly coming to the supine posture with instructions to 
+relax different parts of the body in sequence (7  min) (deep relaxation 
+technique).
+Assessments
+The FBS and postprandial blood sugar (PPBS) levels were measured every 
+15 days beginning on day 1, and the hemoglobin A1c (HbA1c) levels were de-
+termined before and after the intervention (fig. 1).
+Ethical Approval
+SVYASA’s institutional ethical approval committee approved the trial.
+Statistical Analysis
+Raw data were entered into Excel files, initially on a single sheet, divided by 
+different variables and different classes of variables. Miscopying errors were 
+identified and eliminated, as were outliers, particularly for the final assessment 
+of the controls. Means and standard deviations for pre and post data were en-
+tered on the sheet for interest, as well as those for selected post-minus-pre dif-
+ferences. Certain variables, for which such inspection revealed interesting 
+anomalies, were subjected to post-hoc analysis, which will be reported sepa-
+rately. Data were then entered into SPSS-20 for checking for normality and the 
+performance of appropriate tests for statistical significance, i.e. 1-sample t-tests, 
+independent-sample t-tests and, where appropriate, equivalent non-parametric 
+tests.
+Practice
+Flexion  
+exercises
+Surya  
+Namaskara
+Cyclic  
+meditation
+Pranayamaa
+Alternate  
+nostril
+Bhramari
+Vocalize A, U, M
+Amount
+once
+2 rounds
+once
+2 lots of 10 
+rounds
+2 lots of 10 
+rounds
+2 rounds twice 
+daily
+aThe pranayama exercises were given once in the morning, and the participants were instructed to per-
+form them once again by themselves before retiring for the night in the evening.
+Table 1. The yoga practices given to the T2DM 
+participants attending the intervention
+Downloaded by: 
+King's College London                                  
+137.73.144.138 - 12/8/2017 12:49:12 PM
+Ayurveda and Yoga Controlled Trial for Type 2 
+Diabetes
+Complement Med Res 2017;24:1–8
+Results
+Of the 567 male inmates of Bhopal Central Jail screened and in-
+formed about the trial, 417 declined (153 refused or were not inter-
+ested, 264 had time problems), 150 agreed to enroll. However, on 
+being informed of the study intervention and assessment details, 
+38, not having realized possible conflicts with their programs, de-
+mands on their time, or the need to give blood samples, immedi-
+ately withdrew, leaving 112 participants who were assigned to 
+groups: 38, 37, and 37 participants assigned to group 1, 2, and 3, 
+respectively. After this, no further attrition occurred (fig. 1).
+Demographic details are given in table 2, which presents age, 
+weight, height, and BMI means and standard deviations (SDs) for 
+each group and for all participants together. Table 3 presents the 
+changes over 15 days in FBS and PPBS, depicted as graphs in fig-
+ures 2 and 3, respectively. These show that groups 1 and 2 obtained 
+better FBS and PPBS values during and at the end of the interven-
+tion, and that group 1 ended with the lowest values (p < 0.0001). 
+However, the decrease in FBS for group 1, from 113.3 to 90.2 mg/dl 
+(–21.1 mg/dl), was not significantly different from that for group 2, 
+from 121.4 to 100.8 mg/dl (–20.6 mg/dl). For the PPBS, on the 
+other hand, the group 1 final value, 129.4 mg/dl, was significantly 
+different from that of group 2, 140.6 mg/dl. Interestingly, the initial 
+trend over the first 4 readings, from 144.4 to 106.1  mg/dl 
+(–38.3 mg/dl), for group 1 was also significantly greater than the 
+Group variable
+Group 1
+Group 2
+Group 3
+All
+Age, years
+  38.2 ± 10.3a
+  40.7 ± 10.86
+  41.9 ± 12
+  40.8 ± 11.1
+Weight, kg
+  61.5 ± 6.28
+  65.45 ± 8.79
+  64.2 ± 9.32
+  63.7 ± 8.31
+Height, cm
+165.4 ± 5.17
+165.7 ± 4.27
+164.82 ± 5.91
+165.3 ± 5.13
+BMI, kg/m2
+  22.5 ± 1.83
+  23.7 ± 2.81
+  23.6 ± 2.65
+  23.3 ± 2.51
+aMeans ± SD.
+BMI = Body mass index; SD = standard deviation.
+Table 2. Means and standard deviations of the 
+stated demographic variables for the 112 male 
+­
+prisoners involved in the controlled trial of Yoga 
+and diabetes held in Bhopal Central Jail in 2015
+Group 1
+Group 2
+Group 3a
+FBS, mg/dl
+PPBS, mg/dl
+FBS, mg/dl
+PPBS, mg/dl
+FBS, mg/dl
+PPBS, mg/dl
+Day 0
+111.316
+± 12.6835
+144.395
+± 29.5603
+121.459
+± 29.4615
+146.784
+± 46.8414
+117.324
+± 20.5251
+146.811
+± 38.0722
+Day 15
+102.684
+± 13.0303
+120.842
+± 29.4127
+115.730
+± 23.4232
+131.027
+± 45.9417
+116.243
+± 21.5644
+146.324
+± 40.1995
+Day 30
+97.974
+± 14.4736
+114.079
+± 30.0633
+111.324
+± 23.7019
+127.405
+± 44.0527
+113.649
+± 21.3596
+146.432
+± 41.2732
+Day 45
+103.026
+± 11.6607
+106.132
+± 32.9915
+114.514
+± 20.5056
+119.919
+± 48.2444
+124.541
+± 26.6527
+151.838
+± 39.0046
+Day 60
+96.711
+± 11.6941
+129.816
+± 19.7332
+108.189
+± 19.1585
+141.405
+± 43.1345
+120.919
+± 23.6800
+156.622
+± 40.0918
+Day 75
+88.474
+± 18.2827
+129.816
+± 19.7332
+102.243
+± 27.0959
+141.405
+± 43.1345
+121.676
+± 29.2347
+156.622
+± 40.0918
+Day 90
+90.184
+± 21.4172
+129.368
+± 35.7661
+100.838
+± 30.6698
+140.649
+± 50.0079
+142.838
+± 42.0195
+168.432
+± 50.8011
+Pre-post
+21.13
+± 21.16
+15.0
+± 14.89
+20.62
+± 32.68
+6.13
+± 35.30
+–4.36
+± 25.6
+–9.62
+± 21.83
+Significance 
+t / p
+6.15 / 0.0001
+6.2 / 0.0001
+3.83 / 0.0005
+0.30 / 0.15
+1.10 / NS
+3.29 / 0.0022
+The values of groups 1 and 2 decreased during the study period, while those of group 3 increased.
+aThe group 3 data on day 90 was anomalous and is given in italics. Pre-post differences and their significance for group 3 therefore 
+used the day 0 and day 75 data.
+FBS = Fasting blood sugar; PPBS = postprandial blood sugar; NS = not significant.
+Table 3. FBS and 
+PPBS data for groups 
+1–3 taken every 15 days
+ 
+ 
+ 
+ 
+0
+20
+40
+60
+80
+100
+120
+140
+160
+1
+2
+3
+4
+5
+6
+7
+Group 1
+Group 2
+Group 3
+Fig. 2. Changes in FBS measured every 15 days during the intervention. Group 
+1–3 FBS values at the beginning of the intervention and every 15 days thereafter. 
+The values of groups 1 and 2, indicated as series 1 and series 2, respectively, 
+­
+decrease steadily, increasing at point 4. The group 3 values remain relatively flat 
+compared to the other two series, with a similar increase at point 4.
+Downloaded by: 
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+137.73.144.138 - 12/8/2017 12:49:12 PM
+Datey/Hankey/Nagendra
+Complement Med Res 2017;24:1–8
+(p = 0.0002), group 2 was at +0.024 ± 0.456 mg/dl (not significant 
+(NS)), and group 3 at +0.365 ± 0.369 mg/dl (p < 0.0001). Although 
+the group 1 changes were statistically significant and therefore in-
+teresting, they are too small to be of immediate clinical value.
+Table 5 shows group-time interaction comparisons between the 
+3 groups. These attained significance for both group 1 and group 2 
+with respect to group 3 on all variables, but not between groups 1 
+and 2.
+Discussion
+In this Ayurveda and Yoga study of integrative treatments for 
+T2DM, the group-time interaction results indicate that both Ayur-
+veda herbal juices plus Yoga and Yoga alone are beneficial pro-
+grams for controlling blood sugar levels. The difference of 0.09 
+units between groups 1 and 3 in the HbA1c data seems of clinical 
+value. It confirms that regular ingestion of Ayurveda herbal juices 
+would be helpful to prevent an increase of standard markers of 
+T2DM, especially compared to no treatment, and would therefore 
+stop diabetes developing over the long term. This is particularly 
+significant as HbA1c is considered as a more stable and reliable 
+marker for T2DM than the FBS or PPBS. Indeed, the study data 
+showed greater fluctuations in the blood sugar levels, with higher 
+sensitivity to misbehavior, corroborating this idea.
+A striking aspect of the data depicted in figure 2 (FBS) and fig-
+ure 3 (PPBS) are the increases in the values in all 3 groups around 
+day 45 (23rd June) just after cooler wet weather had set in at the 
+beginning of Bhopal’s 2015 monsoon on 20th June. Their interest is 
+sufficient to merit a comment in a separate submission, since they 
+may well be indicative of a natural physiological response to a 
+change in season. Again, differences in behavior between groups 1 
+and 2 suggest that Ayurveda herbal juices were playing a useful ad-
+ditional role.
+Generally, the results agree with experimental hypotheses, namely 
+that 3 months of participation in the Yoga and Ayurveda programs 
+ 
+0
+20
+40
+60
+80
+100
+120
+140
+160
+180
+1
+2
+3
+4
+5
+6
+7
+Group 1
+Group 2
+Group 3
+Fig. 3. Changes in PPBS measured every 15 days during the intervention. 
+Group 1, 2 and 3 PPBS values at the start and after every 15 days of the inter-
+vention. The values of groups 1 and 2, indicated as series 1 and series 2, respec-
+tively, decrease with an increase at point 5, remaining flat thereafter. By com-
+parison, the group 3 values remain relatively flat, increasing slightly between 
+points 3 and 5.
+Group 1: Ayurveda and Yoga
+Group 2: Yoga only
+Group 3: Control
+Pre, mg/dl
+5.59 ± 0.52
+5.88 ± 0.88
+5.58 ± 0.58
+Post, mg/dl
+5.56 ± 0.51
+5.90 ± 0.71
+5.94 ± 0.51
+Decrease, mg/dl
+0.044 ± 0.059
+–0.024 ± 0.456
+–0.365 ± 0.369
+Significance t / p
+4.10 / 0.0002
+0.32 / NS
+6.01 / 0.0001
+While the group 1 mean values decreased significantly and the group 3 mean values increased significantly,  
+no significant change was observed in group 2.
+NS = Not significant.
+Table 4. Pre and post data for Hb1Ac for groups 
+1, 2 and 3 and the corresponding differences and 
+significance t and p values
+Group pairs
+FBS
+PPBS
+HbA1c
+1 and 2
+0.08 / 0.93
+1.42 / 0.15
+0.87 / 0.38
+1 and 3
+8.54 / 0.0001
+8.51 / 0.0001
+6.78 / 0.0001
+2 and 3
+6.75 / 0.0001
+4.09 / 0.0001
+4.01 / 0.0001
+FBS = Fasting blood sugar; PPBS = postprandial blood sugar; HbA1c = hemoglobin A1c.
+Table 5. Significances of the between-group 
+­
+differences over the course of the study, in terms of 
+t and p values for group-time interactions
+decrease for group 2 over the same time period, 146.8 to 119.9 mg/
+dl (–26.9 mg/dl), for group 2. The group 2 pre-post decreases in 
+FBS (20.6  ± 32.7  mg/dl) attained significance (p  = 0.0005), but 
+those for PPBS (6.13 ± 35.30 mg/dl) did not, although the day 45 
+decrease of –26.8  mg/dl when group 2 reached its lowest PPBS 
+value of 119.9  ± 48.24  mg/dl was significant, the decrease of 
+–26.86 ± 37.61 mg/dl yielding 1 sample t = 4.34, p < 0.0001.
+In the case of group 3, gross anomalies in the day 90 FBS data for 
+several group members indicated that the fasting conditions were 
+not uniformly observed for the last data point, with similar, smaller 
+increases for the PPBS data. The day 75 data were therefore consid-
+ered more appropriate for pre-post estimates for the group, espe-
+cially as the values had remained stable for 1 month. Group changes 
+attained significance for PPBS, an increase of 9.62 ± 21.83 mg/dl 
+(p = 0.0022), but not for FBS, an increase of 4.36 ± 25.6 mg/dl.
+Table  4 sets out the results for glycosylated hemoglobin 
+(HbA1c): The group 1 values were reduced by –0.044 ± 0.059 mg/dl 
+Downloaded by: 
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+137.73.144.138 - 12/8/2017 12:49:12 PM
+Ayurveda and Yoga Controlled Trial for Type 2 
+Diabetes
+Complement Med Res 2017;24:1–8
+would have beneficial effects on diabetes markers and that addition 
+of herbal juices would increase effects. The second hypothesis con-
+cerning Ayurveda herbal juices seemed to work well for PPBS and 
+HbA1c levels, but was less supported in the case of FBS assessments, 
+for which both groups 1 and 2 seemed to perform equally well.
+The study results therefore lend weight to research on Yoga 
+conducted over the past 30 years, starting with studies of asthma 
+[8], which have established the efficacy of Yoga for all types of dis-
+ease [9–25]. Systematic application to obesity [22–24], and diabetes 
+[20, 21], is a relatively recent development and has led to the for-
+mation of a nationwide Stop Diabetes Movement in India (see 
+http://svyasa.edu.in/stop-diabetes-movement-sdm), initially moti-
+vated by the success in some cases in a Yoga Medicine Health Cen-
+tre inpatient setting. Particular clients achieved marked benefits, 
+although averages may be rather lower.
+The results also support previous research on Ayurveda indicat-
+ing useful applications of its herbal medicines to T2DM [41, 46–
+51]. Whether patients who would benefit most can be identified by 
+Ayurveda’s rather different assessment of those at risk from T2DM 
+has yet to be determined. It should definitely be investigated.
+Strengths: The study has reported good changes on the variables 
+measured; the interventions show promise for further study and 
+assessment on a larger scale in an RCT.
+Weaknesses: The institutional setting in a jail is unusual, repre-
+senting a possible confounding factor in interpreting the results. 
+The misunderstanding with potential participants that caused high 
+initial attrition considerably reduced the power of the study. Failure 
+to randomize the trial was a cause for regret. There is no a priori 
+reason for believing that the results would necessarily be different, 
+but an RCT would have carried more weight. Another weakness, in 
+terms of traditional medicine, was that Western diagnosis was used 
+for subject selection. The Ayurveda treatments did not follow tradi-
+tional practice, which is to take specific Ayurvedic imbalances into 
+account, and then design personal Ayurveda treatments that at-
+tempt to rectify each person’s specific imbalances. Future studies 
+that do so will provide results of greater value for Ayurveda.
+Outlook for further research: The promising nature of the re-
+sults justifies further follow-up, particularly in light of the tradi-
+tionally recognized ability of Ayurveda and Yoga to reverse imbal-
+ances in physiological function and their consequent potential to 
+cure cases of chronic disease. Also, Ayurveda notes many kinds of 
+prameha that precede diabetes. An important line of further inves-
+tigation would be to assess each patient’s particular kind of 
+prameha in detail, and the efficacy of different Ayurveda and/or 
+Yoga prescriptions for each kind.
+Conclusions
+The trial suggests the potential efficacy of a combination of 
+Ayurveda and Yoga, including strict rules of diet and behavior, i.e. 
+bed and meal times and exercise, for the treatment of newly diag-
+nosed elevated blood sugar levels. It also suggests that Yoga pro-
+grams may be enhanced by the addition of supplemented Ayur-
+veda herbal juice therapy. Together, they represent a cost-effective 
+alternative to long-term prescription of palliative drugs that do not 
+aim to improve the underlying pathology; further studies of these 
+combined modalities of treatment are merited, particularly in rural 
+areas of India, where they should be easy to implement.
+Trial Registration
+CTRI number Ref/2015/03/008680.
+Acknowledgements
+We would like to acknowledge assistance from technicians at the Rasahara 
+Kendra Clinics in preparing the Rasahara herbal juices, Jaiprakash for assis-
+tance in the Yoga training sessions, and Deepeshwar Singh for assistance with 
+the statistical analysis. The cooperation of the prison authorities is also grate-
+fully acknowledged.
+Disclosure Statement
+Purnima Datey is the founder/owner of the Rasahara Kendra Clinics in the 
+city of Bhopal where the study was performed. Costs for the tests not provided 
+by the jail authorities were provided by her as part of her PhD thesis expenses. 
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+137.73.144.138 - 12/8/2017 12:49:12 PM

subfolder_0/Concept and Mechanism of Cognition According to Ancient Indian Texts.txt

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+See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/273439039
+Concept and Mechanism of Cognition
+According to Ancient Indian Texts
+Article · January 2014
+READS
+101
+5 authors, including:
+Suhas Vinchurkar
+Electrical Geodesics Incorporated
+10 PUBLICATIONS   11 CITATIONS   
+SEE PROFILE
+Deepeshwar Singh
+SVYASA Yoga University
+14 PUBLICATIONS   17 CITATIONS   
+SEE PROFILE
+Available from: Deepeshwar Singh
+Retrieved on: 27 July 2016
+International Journal of Literary Studies, 2014, 4(3),  55-58
+Cognition is defined as the set of all mental abilities and processes 
+Perception, Inference and Valid Testimony are the means. By these 
+related to knowledge: attention, memory & working memory, 
+all other means of right cognition too are established (Virupaks -
+judgment& evaluation, reasoning & computation problem solving 
+hananada, 1995). 
+& decision making, comprehension & production of 
+Figure 1:Schematic presentation of mechanism of cognition 
+language(Miller & Wallis, 2009).The concept of cognition and 
+according to Sāṅkhya and Yoga
+perception has a detailed description in all the six Indian 
+philosophies but has slight variations amongst each of the 
+philosophies.All six schools of Vedic philosophy aim to describe 
+the nature of the external world and its relationship to the 
+individual, to go beyond the world of appearances to ultimate 
+Reality, and to describe the goal of life and the means for attaining 
+this goal. Perception and cognition have been described to have 
+key role in the right means of knowledge(Swami, 2001).The sad-
+darshana (six philosophical views) are nyaya (logic), vaisesika 
+(atomic theory), sankhya (analysis of matter and spirit), yoga (the 
+discipline of self- realization), karma-mimamsa (science of 
+fruitive work) and vedanta (science of God realization).
+Concept and mechanism of Cognition according to Sāṅkhya
+Cognition, on the Sāṅkhya account, is a complex process: the 
+senses (such as sight) cognize their respective objects (color and 
+shape) through the physical organs (such as the eye). 
+And these senses are themselves the objects of cognition of the 
+psyche (which in turn is comprised of three facultiesthe mind (manas), 
+the intellect (buddhi), and the ego (ahaṁkāra). The mind for its part 
+internally constructs a representation of objects of the external world 
+with the data supplied by the senses. The ego contributes personal 
+perspective to knowledge claims. The intellect contributes 
+understanding to knowledge. The puruṣa adds consciousness to the 
+result: it is the mere witness of the intellectual processes.
+Concept and Mechanism of Cognition according to Yoga
+According to Patanjali's epistemology(Taimini, 1986), cognition is 
+possible only because citta is coloured by both the object and the mind 
+druñöamanumänamäptavacanaà ca sarvapramäëasiddhatvät |
+itself. Sensory impressions from the external world continually 
+bombard the functions of sight, hearing, smell, taste and touch. As the 
+trividhaà pramäëmiñöaà prameyasiddhi pramäëäddhi || 4 ||
+mind defines the object, so the object defines the mind. Manas then 
+[Sāṅkhya Karika 4]
+registers the objects of cognition and controls the response. It does so 
+by drawing from the memory bank of karma stored in the mind. So, the 
+model of Cognition according Sāṅkhyaand Yoga is almost replicable 
+except for the fact that Buddhi in Yoga is represented by Chitta.
+Ô‚òmnumanmaÝvcn< c svRàma[isÏTvat!,
+iÇivx<àma[imò< àmeyisiÏ>àma[aiÏ. 4.
+Concept and Mechanism of Cognition According to Ancient 
+Indian Texts
+Suhas A. Vinchurkar, Deepeshwar Singh, Naveen K. Visweswaraiah, H.R. Nagendra  and Ramachandra G. Bhat
+Swami Vivekananda Yoga Anusandhana Samsthana (S-VYASA), Bengaluru
+Correspondence should be sent to
+ 
+ Suhas A. Vinchurkar, Swami 
+Vivekananda Yoga Anusandhana Samsthana (S-VYASA),Bengaluru
+Online available at www.iahrw.com
+International Journal of Literary Studies
+ISSN-2231-4652
+Volume 1, Issue 1
+June -2011
+International Journal  of 
+LITERARY STUDIES
+Managing Editor 
+Sunil Saini, Ph.D.
+In addition, Patanjali describes the highest levels of cognition, which 
+not attributable to it, such as when seeing a chili, one knows what it 
+can be attained by Samyama
+would be bitter or hot)
+c. Yogaja (when certain human beings, from the power of Yoga, can 
+perceive past, present and future and may have supernatural 
+abilities)
+grahaëa svarüpäsmitänvayärthavattvasaàyamädindriyajayaù 
+||3|48||
+indriyärthasännikarñatpannaïjïänamavyapadeçyamavyabhicayri 
+vyavasäyätmakaà ÷ pratyakñaà ||1|1|4||
+tato manojavitvaà vikaraëabhävaù pradhänajayaçca ||3|49||
+A perceptual cognition arises by means of the connection between 
+Mastery over the sense organs by performign Samyama on their 
+sense faculty and object, is not dependent on words, is non-
+power of cognition, real nature, egoism, all-pervasiveness and 
+deviating, and is determinate(Chadha, 2001).
+functionsThence, instantaneous cognition without the use of any 
+vehicle and complete mastery over Pradhana.
+Nyāya-sūtraenumerates Six kinds of connection (sannikarṣa) to 
+account for the fact that that we perceive not only substances, but 
+Mastery of the Indriyas(sense organs) enables the Yogi to perceive 
+properties, absences, and so on: (i) conjunction (Samyoga), the 
+anything in the realm of Prakriti without the help of any organized 
+connection between a sense faculty and an object; (ii) inherence in 
+vehicle of consciousness. When the Yogi has obtained mastery over 
+what is conjoined (Saṁyukta-Samavāya), the connection between a 
+the sense-organs through Samyama he can dispense with the aid of 
+sense faculty and a property-trope which inheres in an object; (iii) 
+instruments in preceiveing anything in the manifested Universe. The 
+inherence in what inheres in what is conjoined (Saṁyukta-
+non-instrumental perception is direct and instantaneuos. 
+Samaveta-Samavāya), the connection between a sense faculty and 
+Concept and Mechanism of Cognition according to Nyāya-sūtra
+the universal which is instantiated in a property-trope; (iv) inherence 
+Cognition according to Nyāya (Matilal, 1975)can have several 
+(Samavāya), the kind of connection which makes auditory 
+sources and therefore can be classified as follows:
+perception possible; (v) inherence in what inheres (Samaveta-
+1. Laukika or ordinary cognition as attained through the senses viz., 
+Samavāya), the connection between the auditory faculty and 
+visual by eyes, olfactory by nose, auditory by ears, tactile by skin, 
+universals which inhere within sounds; (vi) qualifier-qualified 
+gustatory by tongue and mental by mind
+relation (Viśeṣya-Viśeṣaṇa-Bhāva), the connection which allows for 
+2. Aluakika or extra ordinary involves 
+the perception of inherence and absence in objects. In all cases, the 
+a. Sämänyalakçana  perceiving generality from a particular object
+perceptual cognition is born of connection between a sense faculty 
+b. Jïänalakçana (when one sense organ can also perceive qualities 
+and an occurring fact or object(Basu, 1913).
+¢h[ SvêpaiSmtaNvyawRvÅvs<ymaidiNÔyjy>.3,48.
+#iNÔYrœwiSÚkARTpÚJnmVypdeymVyiÉcair VyvSYTmk àTy]m! .1,1,4.
+ttae mnaejivTv< ivkr[Éav> àxanjyí.3,49.
+sTs<àyaege pué;SyeiNÔya[a< buiÏjNm! tTàTy] minimÄ< 
+iv*manaeplMÉnTvaÄ!.1,1,4.
+Aperception that results from connection of the sense faculties of 
+a person with that (tat) [same object that appears in the cognition] is 
+true (sat) cognition.
+satsamprayoge puruñasyendriyäëäà buddhijanm tatpratyakña 
+The perception is the knowledge, which one has by the senses 
+manimittaà vidyamänopalambhanatvätt ||1|1|4||
+Figure 2: Schematic presentation of mechanism of cognition according to Nyāya-sūtra
+VINCHURKAR ET AL./CONCEPT AND MECHANISM OF COGNITION ACCORDING
+56
+coming in contact with the soul. It is not the cause of duty by reason 
+of acquiring knowledge of the existing thing.
+Concept and mechanism of Cognition according to Advaita Vedānta
+tatra pramäkaraëaà pramäëam| tatra smrutivyavruttaà 
+According to Advaita Vedānta the defining characteristic of 
+pramätvamanadhigatäbädhitärthaviñayakajïänatvama 
+cognition is the directness of knowledge acquired through 
+smrutisädhäraëantu abädhitärthaviñayakajïänatvam | 
+perception. Vedānta Paribhāṣācites pleasure and pain as instances of 
+nérupasyäpi kälsyendriyaveddyatväbhyupagamena 
+perception that are directly intuited without any sense object 
+dhärävähikabuddherapi purvapurvajïänäviñaya 
+contact(Madhavanadna, 1942). For the Advaitin perception is 
+tattatûçaëaviçeñviñayayakatveana na tattravyäptiù | ûintu 
+simply the immediacy of consciousness; knowledge not mediated by 
+ghatasphurëaà öävdaghatäkäräntaùkaranëavrittirekaiva na tu 
+any instrument. Advaitins regard the role of the sensory connection 
+nänä vrutteù svavirodhivrutyuptiparyantaà 
+as accidental, rather than essential, to the perceptual 
+sthäyitväbhyupagamäta tathäca tatpratiphalitacaitanyarupaà 
+process(Appelbaum, 2002). 
+ghatädijïänamapi tatra tävatkälénamekameva iti nävyäptiçkäpi
+Vedānta Paribhāṣādivides the process of cognition into two 
+[Vedānta Paribhāṣā 5]
+phases and formulates two criteria (Prayojaka), corresponding to the 
+two phases of the process, namely:
+In the case of continous cognition there is no break in knowledge, 
+but so long as there is the cognition of a jar, the mental state that 
+(i)The determination of the perceptual character of cognition 
+assumes the form of the jar is just one and not multiple, for a mental 
+(Jiinnapratyaksatva)
+state is admitted to last till another state opposed to it has arisen. 
+(ii) The determination of the perceptual character of the object 
+Advaita maintains that the antahkarana 'goes out'  through the 
+(Visayapratyaksatva).
+respective sense-organs, say the eye, pervades the object of attention 
+Advaita regards manas to be part of a complex, unifiedinner-organ 
+and transforms itself in the form of the object. The transformation or 
+which is termed antahkarana, literally, 'inner vehicle.' Manas and 
+modification of the antahkaranais technically termed vrtti, 
+antahkarana are sometimes used interchangeably(Bilimoria, 1980). 
+oftenrenderedas"mentalstate." Thespecific 'transformation' or 
+modification (antahkarana vrtti) is the apprehending mental mode, 
+which makes known the object.
+Antahkarana, the inner organ, is the instrument through which the 
+subject acquires perceptual knowledge. Also, the different aspects or 
+functions of antahkaranaare: buddhi(intellect), ahamkara(I notion), 
+citta (memory). 
+SwaiyTva_yupgmat twac tTàit)iltcEtNyép< "taid}anmip tÇ 
+tavTkalInmekmev #it naVyaiÝZkaip
+tÇ àmakr[< àma[m!, tÇ SèuitVyìuÄ< àmaTvmnixgtabaixtawRiv;yk}anTvm 
+Sèuitsaxar[Ntu AbaixtawRiv;yk}anTvm!, nIépSyaip 
+kaLSyeiNÔyveÎ(Tva_yupgmen xaravaihkbuÏerip puvRpuvR}anaiv;y 
+tÄTˆOz[ivzei:v;yykTven n tTÇVyaiÝ>, iˆoNtu "tS)…[¡ 
+qaVd"takaraNt>krN[iìiÄrekEv n tu nana ìuÄe> SvivraeixìuTyuiÝpyRNt< 
+understanding of cognition and also the philosophical concepts of 
+Summary and Conclusion
+Nyāya. According to the modern physiological understanding of 
+The concept and mechanisms of cognition vary across different 
+cognition, brain first perceives a particular object through the 
+Indian philosophies. Under normal circumstances, the senses 
+external senses of sight, touch, smell, taste and sound. In true 
+perceive the object of perception, which is then registered in the 
+physiological sense, brain tries to relate to the experience of 
+brain. This concept conformsto the modern physiological 
+sensation with the one in memory and if there is no memory, it builds 
+Figure 3: Schematic presentation of mechanism of cognition according to Vedānta Paribhāṣā
+International Journal of Literary Studies, 2014, 4(3), 55-58
+57
+a new pathway within brain and registers the current experience into 
+its memory store. So perception and memory are correlated to draw 
+an inference internally regarding the object of sensation. In addition, 
+if the recognition is endorsed by a known individual, it readily 
+accepts it as correct and factual. Therefore, the physiological 
+understanding of cognition very much relates to the philosophical 
+views of the Naiyāyikas in terms of cognition and right knowledge. 
+References
+Bilimoria, P. (1980). Perception (Pratyaksha) in Advaita Vedanta. Philosophy East and 
+West, 30(1), 3544.
+Chadha, M. (2001). Perceptual Cognition: A Nyāya-Kantian Approach. Philosophy 
+East and West, 51(2), 197-209.
+Madhavanadna, S. (1942). Vedanta Paribhasha of Dharmaraja Advarindra (First., p. 
+248). Belur Math, Howrah: The Ramakrishna Mission Sharada Pitha.
+Matilal, B. K. (1975). Causality in the Nyāya-Vaiśeṣika School. Philosophy East and 
+West, 25(1), 4148.
+Miller, E., & Wallis, J. (2009). Executive function and higher-order cognition: definition 
+and neural substrates. Encyclopedia of Neuroscience, 4(99-104).
+Swami, S. (2001). The Six systems of Vedic Philosophy (pp. 180).
+Appelbaum, D. (2002). “A Note on Pratyakṣa in Advaita Vedãnta.” Philosophy East 
+Taimini, I. K. (1986). The science of yoga. Madras: The Theosophical Publishing House.
+and West, 32(2), 201205.
+Virupakshananada, S. (1995). Samkhya Karika of Isvara Krishna (First., p. 135). 
+Mylapore, Madras, India: Sri Ramkrishna Math.
+Basu, B. D. (1913). The Nyāya-sūtra of Gotama (First., p. 176). Allahabad, India: 
+Sudhindranath Vasu.
+VINCHURKAR ET AL./CONCEPT AND MECHANISM OF COGNITION ACCORDING
+58

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+https://doi.org/10.1177/0972753121998496
+Annals of Neurosciences
+27(3-4) 190­
+–192, 2020 
+© The Author(s) 2021
+Reprints and permissions:
+in.sagepub.com/journals-permissions-india
+DOI: 10.1177/0972753121998496
+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
+Cost of Management of Diabetes Mellitus:  
+A Pan India Study
+Raghuram Nagarathna,1 M Madhava,1 Suchitra S. Patil,2 Amit Singh,2 K. Perumal,1 
+Ganga Ningombam,1 and Hongasandra R. Nagendra2
+Abstract
+Background: Diabetes mellitus is a major noncommunicable disease. While mortality rates are increasing, the costs of 
+managing the disease are also increasing. The all-India average monthly expenditure per person (pppm) is reported to be ` 
+1,098.25, which translates to an annual expenditure of `13,179 per person.
+Purpose: While a number of studies have gone into the aspect of the cost of disease management, we do not find any study 
+which has pan-India reach. We also do not find studies that focus on differences (if any) between rural and urban areas, age 
+or on the basis of gender. We planned to report the cost of illness (COI) in diabetes individuals as compared to others from 
+the data of a pan-India trial.
+Methods: Government of India commissioned the Indian Yoga Association to study the prevalence of diabetes mellitus in 
+India in 2017. As part of the questionnaire, the cost of treatment was also captured. Data collected from 25 states and union 
+territories were analyzed using the analysis of covriance (ANCOVA) test on SPSS version 21.
+Results: There was a significant difference (P < .05) between the average expenses per person per month (pppm) of individuals 
+with self-reported known diabetes (`1,357.65 pppm) and others (unknown and/or nondiabetes individuals–` 999.91 pppm). 
+Similarly, there was a significant difference between rural (`2,893 pppm) and urban (`4,162 pppm) participants and between 
+those below (`1,996 pppm) and above 40 years (`5,059 pppm) of age.
+Conclusion: This preliminary report has shown that the COI because of diabetes is significantly higher than others pointing 
+to an urgent need to promote disease-preventive measures.
+Keywords
+Behavior, clinical medicine, function, physiology 
+Received 5 October 2020; accepted 7 October 2020
+2 Division of Yoga and Life Sciences, Swami Vivekananda Yoga 
+Anusandhana Samsthana (SVYASA), Bengaluru, Karnataka, India
+1 Vivekananda Yoga Anusandhana Samsthana (VYASA), Kempegowda 
+Nagar, Bengaluru, Karnataka, India
+Corresponding author
+Raghuram Nagarathna, Vivekananda Yoga Anusandhana Samsthana 
+(VYASA), 19, Eknath Bhavan, Gavipuram Circle, Kempegowda Nagar, 
+Bengaluru, Karnataka 560019, India.
+E-mail: [email protected]
+Introduction
+There are 463 million people living in the world with diabetes 
+today. It is projected that by 2045, 700 million people will 
+have the disease worldwide. In India, from an estimated 50 
+million people in 2010, the count is expected to increase to 
+134 million by 2045.1 Diabetes is responsible for a wide 
+range of neurological manifestations. These can be the result 
+of metabolic disorders or their treatment, or they can represent 
+secondary manifestations.2
+In the USA, the total estimated cost of diagnosed diabetes 
+in 2017 is USD 327 billion including USD 237 billion in 
+direct medical costs and USD 90 billion in reduced 
+productivity.3 This represents a 26% increase between 2012 
+and 2017.3 People with diagnosed diabetes, on average, have 
+medical expenses ∼2.3 times higher than what expenditure 
+would be in the absence of diabetes.3 People with diagnosed 
+diabetes incur average medical expenditure of USD 16,750 
+per year, of which USD 9,600 is attributed to diabetes.3
+Nagarathna et al.	
+191
+In India, the median average annual direct and indirect 
+costs associated with diabetes care were estimated at ` 
+25,391 and ` 4,970, respectively.4 Extrapolating from the 
+Indian population, the annual cost of diabetes was found be 
+USD 31.9 billion in 2010.4
+Over 400 papers have been published over the past 20 
+years.5 The cost of diabetes therapy increases linearly along 
+with the duration of the disease.6 The average life-time cost of 
+all drugs used in diabetes management is estimated at 
+` 19,45,135.6 The average total expenditure per patient per 
+month (pppm) was ` 1,265, out of which medical expenditure 
+was ` 993 and nonmedical expenditure was ` 271.6 The total 
+COI for diabetic care without any complications was ` 22,456 
+per patient per annum and with complication was ` 30,634.7 
+There exists a high burden of missed clinic appointments 
+among diabetes patients in tertiary care government health 
+settings in India.8 This appears to be related to the high cost in 
+terms of both time and money involved in attending 
+appointments for the modest benefit of a dispensation of a 
+15-day drug refill.8 Nearly one-fourth of the income of the 
+patient was spent for diabetic care.9 The total expenditure on 
+diabetes is ` 912 per visit, the direct cost of health care for a 
+diabetic individual was ` 553 and indirect expenditure was ` 
+359.10 The average time lost on each visit was 2.6 h and 
+included travel time, waiting period, and consultation.10
+While a number of studies have been conducted, to the 
+best of our knowledge, there appears to be none which has an 
+All-India sample. There appears to be no studies comparing 
+costs between urban and rural areas. This article is an attempt 
+to bridge the gap.
+Methods
+The Indian Yoga Association was commissioned in 2016 to 
+2017 by the Government of India to conduct this study which 
+was undertaken in two phases (details of the methodology 
+have also been published).11 In brief, phase 1 was to estimate 
+the prevalence of prediabetes and diabetes across the country, 
+and phase 2 was to conduct a randomized controlled trial 
+using a validated yoga lifestyle protocol. A detailed 
+questionnaire was used to collect data on various parameters 
+from the subjects. One of the parameters was the COI which 
+has also been used for analysis in this article. Data was 
+anaylzed by using SPSS (23.0) version.12 
+Results
+Table 1 provides the profile of the participants. Data of 7,055 
+participants is collated in this survey.
+Out of the 7,055 participants from 50 districts of 25 states 
+of India (over 200 villages and urban census enumeration 
+blocks), 2014 reported that they had prior diagnosis of 
+diabetes. The remaining 4,941 included those who marked 
+“No” to the question “Have you ever been told by a health care 
+provider that you have diabetes?” These were placed in the 
+“others” category and included both those who were not aware 
+that they had diabetes and those with no diabetes. Out of the 
+7,055 participants, 3,372 were males and 3,683 were females, 
+and 4,162 were from urban and 2,893 from rural locations.
+Table 2 provides the summary of the analysis of COI.
+For the 7,055 participants, the average monthly health 
+expenditure was calculated as ` 1,098.25, which translates to 
+` 13,179 per annum. Thus, about 17% of the expenditure of 
+the household was spent on health care.
+The average expenditure per month for males was found 
+to be ` 1,120.59 (` 13,447.08/year), while for females it was 
+` 1,077.74 (` 12,932.88/year). The average amount spent in 
+rural areas was ` 1,072.28 (` 12,867.36/year), while that in 
+urban areas was ` 1,135.61 (` 13,627.32/year). For those 
+below the age group of 40 years, the average monthly expense 
+was ` 1,007.63 (` 12,091.56/year), while for those above the 
+age of 40 years it was ` 1,132.90 (` 13,594.80/year).
+Discussion
+This pan-India study looking at self-reported COI for diabetes 
+within one year from the data of a larger study planned for 
+primary prevention of diabetes, covering 50 districts in 25 
+states/union territories, has shown that the average monthly 
+health expenditure was ` 1,357.65 for diabetes and ` 999.91 
+in others. Similarly, the difference between the expenditure in 
+Table 1. Demographic Profile of 7,055 Respondents
+Categories
+Gender
+Location
+Age  
+Categories
+N 
+Known 
+Diabetes
+N  
+Others
+Male
+Female Urban
+Rural
+<40 
+Years
+>40 
+Years
+2,114
+4,941
+3,372
+3,683
+4,162
+2,893
+1,996
+5,059
+Note: N is number of partcipants.
+Table 2. Summary of Results of COI
+Mean Health 
+Expenditure 
+per Month
+Significance 
+P
+Family  
+Expenditure/
+Month
+% of Total 
+Family  
+Expenditure
+Known 
+DM
+1,357.65
+<.001
+7,231.40
+18.7%
+Others
+999.91
+6,400.32
+15.6%
+Male
+1,120.59
+.78
+6,883.60
+16.2%
+Female
+1,077.74
+6,315.57
+17.0%
+Rural
+1,072.28
+.02
+6,415.55
+17.6%
+Urban
+1,135.61
+6,708.27
+16.0%
+Age<40
+1,007.63
+.02
+6,559.16
+15.4%
+Age >40
+1,132.90
+6,595.94
+17.1%
+Note: The COI was 36% (P < .001) higher in diabetes individuals than 
+others.
+192	
+Annals of Neurosciences 27(3-4)
+rural and urban households and the age of the patient are also 
+statistically significant. Those below the age of 40 spend 
+significantly less than those who are above the age of 40.
+Approximately 17% of the total household expenditure 
+was on health care.
+While average monthly expenditure is in line with other 
+studies, we find that the health expenditure goes up 
+significantly for those who are aware of their diagnosis. This 
+is an area that has a potential for further research.
+Limitation
+Analyses of multiple surveys per country or territory show 
+how the estimated share of the household expenditure devoted 
+to health (i.e., health expenditure share) would have varied if 
+survey instruments with different characteristics had been 
+employed.13 The questions in our survey were many and 
+exhaustive, and could have had an impact on the response. 
+The survey was administered by yoga practitioners and there 
+is a possibility that bias of the yoga practitioner could not 
+have been excluded.
+Conclusion
+A 17% share of medical expenses is a very high number and 
+reinforces the belief that the current governmental 
+interventions and medical insurance are highly inadequate. At 
+a national level, the percentage spent on health care as a 
+percentage of GDP is roughly around 1% to 1.5% and the 
+near-term target is to achieve 2.5% of the GDP. Also, there is 
+a need to look at why there is a significant difference in 
+expenditure after diagnosis.
+Author Contribution
+RN: Concept, Design, Definition of Intellectual content, Manuscript 
+preparation, Manuscript editing, Manuscript review, Guarantor. MM: 
+Design, Definition of Intellectual content, Data acquisition, Data 
+analysis, Manuscript preparation, Manuscript editing, Manuscript 
+review. SSP: Design, Data acquisition, Data analysis, Statistical 
+analysis, Manuscript preparation, Manuscript editing, Manuscript 
+review. AS: Concept, Design, Definition of Intellectual content, Data 
+acquisition, Manuscript editing, Manuscript review, Guarantor. PK: 
+Design, Definition of Intellectual content, Literature search, Data 
+acquisition, Data analysis, Statistical analysis. GN: Design, Definition 
+of Intellectual content, Data acquisition, Manuscript review. HRN: 
+Concept, Design, Definition of Intellectual, Literature search, 
+Manuscript editing, Manuscript review.
+Declaration of Conflicting Interests
+The authors declared no potential conflicts of interest with respect to 
+the research, authorship, and/or publication of this article.
+Ethical Statement
+Ethical clearance was obtained by the Ethics Committee of the 
+Indian Yoga Association. The study was registered on CTRI 
+(Registration Number – Trial REF/2018/02/017724).
+This article complies with International Committee of Medical 
+Journal editor’s (ICMJE) uniform requirements for manuscript.
+Funding
+The authors received no financial support for the research, 
+authorship, and/or publication of this article.
+References
+1	 .	 Who Diabetes Atlas. https://diabetesatlas.org/data/en/coun-
+try/93/in.html (accessed on September 11, 2020.
+2.		 Watkins PJ, and Thomas PK., Diabetes mellitus and the nervous 
+system. J Neurol Neurosurg Psychiatry 1998; 65: 620–632.
+3.		 American Diabetes Association. Economic costs of diabetes in 
+the USA in 2017. Diabetes Care May 2018; 41(5): 917–928.
+4.		 Tharkar S, Devarajan A, Kumpatla S, et al. The socioeconom-
+ics of diabetes from a developing country: A population based 
+cost of illness study. Diabetes Res Clin Pract September 2010; 
+89(3): 334–340.
+	 	 https://doi.org/10.1016/j.diabres.2010.05.009
+5.		 Oberoi S, and Kansra P., Economic menace of diabetes in India: A 
+systematic review. Int J Diabetes Dev Ctries June 2020; 17:1–12.
+6.		 Singla R, Bindra J, Singla A, et al. Drug prescription patterns 
+and cost analysis of diabetes therapy in India: Audit of an endo-
+crine practice. Indian J Endocr Metab 2019; 23: 40–45.
+7.		 Acharya LD,  Rau NR,  Udupa N, et al.  Assessment of cost of 
+illness for diabetic patients in South Indian tertiary care hos-
+pital. J Pharm Bioallied Sci  2016; 8: 314. doi: 10.4103/0975-
+7406.199336.
+8.		 Basu S, Garg S, Sharma N, et al. The determinants of out-of-
+pocket health care expenses for diabetes mellitus patients in 
+India: An examination of a tertiary care government hospital in 
+Delhi. Perspect Clin Res 2020; 11: 86–91.
+9.		 Mathew G, Fathima FN, Agrawal T, et al. “DIABETIC TAX”: 
+Cost of care among persons with type 2 diabetes mellitus in an 
+Urban Underprivileged Area of Bengaluru. Indian J Community 
+Med 2019; 44: 113–117.
+10.	 Javalkar R, and Sandhya. The economic burden of health 
+expenditure on diabetes mellitus among urban poor: A cross 
+sectional study. Int J Community Med Public Health February 
+2019; 6(3): 1162–1166. February 2019. ISSN 2394-6040. 
+Available at: https://www.ijcmph.com/index.php/ijcmph/arti-
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+org/10.18203/2394-6040.ijcmph20190604
+11.	 Nagendra HR, Nagarathna R, Rajesh SK, et al. Niyantrita 
+Madhumeha Bharata 2017, Methodology for a Nationwide 
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+12.	 IBM Corp. Released 2012. IBM SPSS Statistics for Windows, 
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subfolder_0/Cumulative effect of shortterm and long-term.txt

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+Guru Deo*, Itagi R. Kumar, Thaiyar M. Srinivasan and Kuldeep K. Kushwah
+Cumulative effect of short-term and long-term
+meditation practice in men and women on
+psychophysiological parameters of electrophotonic
+imaging: a cross-sectional study
+DOI 10.1515/jcim-2015-0050
+Received July 5, 2015; accepted September 22, 2015;
+previously published online November 5, 2015
+Abstract
+Background: Anapanasati is one of the meditation techni-
+ques discussed in Buddhism. In this meditation, one focuses
+one’s attention on bodily sensations caused by incoming
+and outgoing breath. This study aims to track the cumula-
+tive effect of long-term meditators (LTM) and short-term
+meditators (STM) using electrophotonic imaging (EPI).
+Methods: To execute the current study, 432 subjects (264
+men and 168 women with mean age of 34.36 ± 6.83)
+were recruited from two meditation centers. LTM had
+practiced for more than 60 months (mean of months
+111 ± 47.20, hoursperday 1.71 ± 1.20Þ. STM had practiced
+meditation from 6 months to less than 60 months (mean
+of months 37.17 ± 19.44, hoursperday 2.14 ± 4.99Þ. A cross-
+sectional research design was applied and data was col-
+lected using EPI. Scatter plot and Fisher discriminant model
+were also used for statistical presentation of values and
+interdependency of variables with length of practice
+between groups.
+Results: In both LTM and STM, lower values of stress (acti-
+vation coefficient) were found in woman meditators as
+compared to men. In both groups, highly significant gen-
+der-related differences were observed in integral area para-
+meter, which measures the overall health of an individual.
+Integral entropy (index of disorderliness of subtle energy in
+the body) was fluctuating in both groups in both directions
+for both genders. It was increasing in LTM group and
+decreasing in STM group with increasing length of practice.
+Conclusions: Women of LTM and STM demonstrated les-
+ser stress than men. Both groups showed cumulative
+health-related improvement. Moreover, in gender-related
+analysis woman meditators exhibited more positive
+improvement in EPI parameters than men.
+Keywords:
+anapanasati,
+cumulative,
+disorderliness,
+electrophotonic imaging, gas discharge visualization,
+meditation, stress
+Introduction
+Meditation encompasses specific mental state of con-
+sciousness, which induces physiological and neuropsycho-
+logical changes. Regulation of attention plays a vital role
+in all techniques of meditation [1]. Even short-term medita-
+tion practices have shown beneficial changes on auto-
+nomic and physiological functioning of the body [2–4]. It
+is shown in many studies that long-term meditation prac-
+tices have provided positive effect on the cognitive and
+perceptional
+aspects
+of
+brain
+activity
+[4–9].
+Recent
+research has shown interesting findings how meditation
+reduces aging process and enhances gray matter in the
+brain and brain activity itself [10–18]. Another recent study
+with large sample size (n= 100) presents the potential
+protective effect of long-term meditation on gray matter
+atrophy and concludes that meditation is brain protective
+and reduces deterioration of age-related changes in brain
+tissues [9].
+Traditional anapanasati meditation, which is termed as
+focused attention meditation, is widely studied in scientific
+community. In this meditation, practitioners focus on the
+bodily sensation caused by incoming and outgoing breath
+and if distracted due to any stimulus, they bring back
+attention on the object of contemplation [19]. Anapanasati
+meditation (focused attention meditation) practiced over a
+long period of time induces an effortless concentrative state
+of mind. Studies have also been carried out to observe an
+immediate and comparative effect of short-term versus
+long-term meditation practices [4, 20–22].
+*Corresponding author: Guru Deo, Department of Bioenergy, Division
+of Yoga and Physical Sciences, S-VYASA Yoga University, No. 19,
+Eknath Bhavan, Gavipuram Circle, Kempe Gowda Nagar, Bangalore
+560019, Karnataka, India, E-mail: [email protected]
+http://orcid.org/0000-0003-1506-363X
+Itagi R. Kumar, Thaiyar M. Srinivasan, Kuldeep K. Kushwah,
+Department of Bioenergy, Division of Yoga and Physical Sciences,
+S-VYASA Yoga University, No. 19, Eknath Bhavan, Gavipuram Circle,
+Kempe Gowda Nagar, Bangalore 560019, Karnataka, India
+J Complement Integr Med. 2016; 13(1): 73–82
+Authenticated | [email protected] author's copy
+Download Date | 3/14/16 10:03 AM
+Apart from this angle of observation, there are only
+a few studies to observe any gender-related changes in
+meditation practices. A national survey among the
+population in the United States indicates gender imbal-
+ance in the usages of body–mind therapies including
+meditation (23.8% women and 14.4% men) [23]. In one
+study,
+electroencephalogram
+(EEG)
+coherence
+was
+found different in navigation skill training, wherein
+women exhibit higher activity in the theta band com-
+pared to men [24]. Recently in gender-related studies
+following Quadrato motor training (QMT), it was seen
+theta and alpha intra-hemispheric coherence increases
+in women, indicating enhanced relaxation, heightened
+attention and reduced activity and thought contents as
+compared to men. Gender differences are found in sev-
+eral areas of emotional functioning and cognitive cor-
+relates
+of
+recognition
+abilities
+[25].
+In
+behavioral
+endeavor regarding the role of emotion in visuospatial
+working memory, differences are found in men and
+women related to the brain activity pattern [26]. It is
+reported
+in
+Qigong
+meditation
+treatment,
+women
+showed greater reduction in cravings, anxiety and with-
+drawal
+symptoms
+than
+men
+[27].
+Women
+retrieve
+appearance of others efficiently and have better face
+recognition throughout than men [17, 28]. It is noted
+that women have more experiential and cognitive orien-
+tation toward spirituality than men [29].
+Thus, in the light of findings presented earlier, the
+current study is devised to explore the gender-based
+differences in the cumulative effect of meditation in
+short-term versus long-term meditation practitioners.
+Application of electrophotonic
+imaging
+Electrophotonic imaging (EPI) also known as gas discharge
+visualization (based on Kirlian effect) is used in recording
+human bioelectromagnetic field. It gives potential informa-
+tion about the physiological and psychophysiological con-
+dition of the human body [30]. In measurements using EPI,
+electrons are drawn out from the body. Under different
+psychophysiological conditions, the amount of electron
+emission from the body fluctuates from homeostatic level
+[31]. In EPI, high voltage and high frequency are applied to
+the fingertip for less than a millisecond; the resultant
+response is seen as a luminous glow around the finger
+which is captured using an optical CCD (charge-coupled
+device) camera [32]. The captured image is known as EPI-
+gram. In this way, electrons are extracted from the surface
+of the cutaneous layer of the skin due to the impressed
+electromagnetic field [33]. The captured images can be
+quantified for medical and scientific research. All 10
+images taken from the tip of the fingers of both hands
+give complete information about the possible health status
+of an individual. Every image is divided into a number of
+sectors and analyzed based on acupuncture meridian the-
+ory [34]. If an image has gaps in its sector, this shows an
+imbalance in the concerned organ within the body [35]. The
+image formation changes due to the person’s psychoemo-
+tional state. On EPI applications, images are taken twice:
+with filter and without the filter that show physiological
+and psychophysiological functioning of the human system,
+respectively [32]. A filter is a specially designed plastic
+sheet that is placed while taking an EPI-gram. Since the
+filter absorbs sweat, the values of EPI-gram with filter
+relate physiological conditions while those without filter
+provide values for psychophysiological assessments. The
+variations in EPI measurements in healthy individuals fall
+within a range of 4.1–6.6 % [32]. This instrument is non-
+invasive, safe to use, with quick assessments and has high
+reliability [31, 32, 37]. EPI had been applied to study cardi-
+ovascular disease, autism, cancer, diabetes, sport, healing
+and meditation [31–44].
+EPI parameters
+Activation coefficient
+Activation coefficient (AC) measures the level of stress in
+an individual. The normal range is 2–4 in healthy people.
+These values are derived through taking the difference of
+measurements obtained with and without filter [32].
+Integral area
+Integral area (IA) is a measure of general health index
+with a range of –0.6 to + 1 for healthy people. It indicates
+the presence of structural and functional state in normal
+mind–body activities [32, 45]. This is a ratio between EPI
+background area and area of an ideal image of EPI. The
+mathematics related to this is available elsewhere [32].
+Integral entropy
+Integral entropy (IE) is an evaluation of disorderliness in
+human energy field with normal range of 1–2 in healthy
+people. This is mathematically derived from the uniformity
+74
+Deo et al.: Cumulative effect of short-term and long-term meditation practice in men and women
+Authenticated | [email protected] author's copy
+Download Date | 3/14/16 10:03 AM
+of the EPI-gram and the presence of deficiencies in the
+organs measured [35].
+Materials and methods
+A total number of 482 subjects were recruited from Pyramid Valley
+International,
+Bangalore,
+and
+The
+Pyramid
+Spiritual
+Trust,
+Kailashpuri, Hyderabad, India, including 264 men and 168 women
+(mean age of 34.36 ± 6.83 years). All the 432 subjects were consid-
+ered for analysis after excluding 50 subjects (23 men and 27 women)
+due to four reasons, viz. defective images, only without filter mea-
+surement, ill health issues and having extreme values in the images.
+Subjects were divided into two groups: long-term meditators (LTM)
+practicing
+more
+than
+60
+months
+(mean
+months
+of
+practice
+111 ± 47.20, hoursperday 1.71 ± 1.20Þ and short-term meditators (STM)
+practicing from 6 months to less than 60 months (mean months of
+practice 37.17 ± 19.44, hoursperday 2.14 ± 4.99Þ. There were 184 sub-
+jects in LTM group (mean age 35.28 ± 6.49inyearsÞ consisting of 116
+men and 68 women, 248 in STM (mean age 33.69 ± 7.00Þ consisting
+of 148 men and 100 women. All the subjects gave written informed
+consent for voluntary participation in this research and the study
+received approval from the Institutional Ethical Committee. The
+cross-sectional research design was applied, and data were collected
+using EPI.
+The inclusion criteria were healthy volunteers, age range between
+24 and 45 years, both genders and willing to participate in the study.
+To be included in either LTM or STM group, subjects required to
+have at least 6 months of prior anapanasati meditation experience.
+Subjects with missing fingers or having cut in fingers, smoked or
+taken alcohol on test day, having any disease or on prescription
+drugs were excluded from the study.
+Demographic sheets were served to seek self-reported health sta-
+tus, age and prior meditation experience to assign in either of the
+groups.
+Data acquisition and analysis
+EPI instrument also known as gas discharge visualization produced
+by “Kirlionics Technologies International,” Saint Petersburg, Russia
+(GDV camera Pro with analog video camera, model number:
+FTDI.13.6001.110310), was used to collect data. Raw data from EPI
+program was exported to excel for analysis of the required three
+parameters, namely, AC, IA and IE. R statistical packages (R version
+3.0.1, 2013) by R Foundation for Statistical Computing Platform were
+used to process data for statistical analysis [46]. Parametric inde-
+pendent t-test was performed within each group where a level of
+p < 0.05, p < 0.01 and p < 0.001 were considered as statistically sig-
+nificant, higher significance and highly significant, respectively. To
+account for possible variability in atmospheric temperature and
+humidity, a hygrometer (Equinox, EQ 310 CTH) was used during
+data collection. During data recording at different time intervals,
+mean temperature was 26.63 ± 3.47 and humidity 52.18% measured
+in °C and percent, respectively, to observe atmospheric effect and
+possible variability of electrophotonic emission in human subjects
+[32]. To determine the interdependency among variables, we carried
+out Fisher discriminant function analysis and scatter plots are pre-
+sented for visual representation.
+Results
+Gender-dependent differences within
+LTM group
+Table 1 shows results in LTM group, AC values were
+less in women in comparison to men but this difference
+was not significant. At physiological level (with filter),
+values of IA with filter left side (IAWL) were highly
+significantly lower (p < 0.001) in women. Higher mean
+values
+of
+IA
+with
+right
+side
+(IAWR)
+in
+women
+were found highly significant (p < 0.001) in comparison
+to men.
+At the psychophysiological level (without filter), sig-
+nificant lower values of IANL (IA no filter left) (p = 0.03)
+and IANR (IAN right side) (p = 0.04) were found in
+women as compared to men. Higher value of IENL (IE
+no filter left) was observed in women as compared to men
+but the result was not significant. The mean values of
+IENR (IE no right side) were higher in women than men.
+This difference was statistically significant (p = 0.04) in
+women in comparison to men.
+Gender-related differences within STM group
+Table 2 shows results in STM group, AC values were
+lower in women as compared to men though the result
+was not significant. At the physiological level (with fil-
+ter), there were highly significant (p < 0.001) lower values
+of IAWL found in women as compared to men. Highly
+Table 1: Gender based values of EPI parameters within LTM group.
+Type of
+measurement
+Variable
+Male,
+mean ± SD
+Female,
+mean ± SD
+p-Value
+Physiological (with
+filter)
+AC
+.± .
+.± .
+.
+IAWL
+.± .
+.± .<.b
+IAWR
+.± .
+.± .<.b
+IEWL
+.± .
+.± .
+.
+IEWR
+.± .
+.± .
+.
+Psychophysiological
+(without filter)
+IANL
+.± .
+.± .
+.a
+IANR
+.± .
+.± .
+.a
+IENL
+.± .
+.± .
+.
+IENR
+.± .
+.± .
+.a
+ap < 0.05, bp < 0.001. AC, activation coefficient; IAWL, integral area with
+filter left; IAWR, integral area with filter right; IEWL, integral entropy with
+filter left; IEWR, integral entropy with filter right; IANL, integral area no
+filter left; IANR, integral area no filter right; IENL, integral entropy no
+filter left; IENR, integral entropy no filter right.
+Deo et al.: Cumulative effect of short-term and long-term meditation practice in men and women
+75
+Authenticated | [email protected] author's copy
+Download Date | 3/14/16 10:03 AM
+significant
+(p < 0.001)
+higher
+values
+of
+IAWR
+were
+observed in women in comparison to men.
+At the psychophysiological level (without filter),
+values of IANL were found significantly lower in women
+(p = 0.04) in comparison to men.
+Gender-related comparison of EPI para-
+meters between LTM and STM groups
+In this section, comparison between LTM and STM groups
+were made to observe in mean values of variables. Table 3
+shows the values of AC in men were lower in LTM as
+compared to men in STM. At the physiological level, mean
+values of IAWL and IAWR in LTM were found lower than
+STM in men. However, mean values of IEWL and IEWR were
+higher in LTM men in comparison to STM men.
+At the psychophysiological level, mean values of
+IANL were lower and IANR mean values higher in LTM
+men as compared to STM men. No differences in mean
+values of IENL were found in both groups. Higher mean
+values of IENR were observed in LTM men than STM men.
+The comparative results of LTM and STM men discussed
+above were not statistically significant.
+Women have less values of AC in LTM group as
+compared to women of STM. The result of IAWL
+(p = 0.05) and IAWR (p = 0.04) was statistically signifi-
+cant. The mean value of IEWR was more in LTM women
+than STM.
+At psychophysiological level, mean values of IANL
+and IANR were lower in LTM women in comparison to
+STM but not significant. Higher values of IENL and IENR
+were found in LTM women as compared to STM women
+but not significant.
+LTM
+scatter
+plot
+shows
+(Figure
+1)
+unexpected
+increasing trend in entropy with increase in total
+hours of meditation. This is possibly due to constant
+fluctuation of energy in the body system and washout
+of cumulative effect of meditation at the psychophysio-
+logical level in LTM group. This may also be due to
+participants’ attitude of habituation that sets in due to
+their long-term practice, both of which needs to be
+studied further.
+STM scatter plot demonstrates (Figure 2) with increase
+of total hours of practice, entropy decreases, which is a
+Table 2: Gender-related differences of EPI parameters within STM
+group.
+Type of measurement
+Variable
+Male,
+mean ± sd
+Female,
+mean ± sd
+p-Value
+Physiological (with
+filter)
+AC
+.± .
+.± .
+.
+IAWL
+.± .
+.± .<.b
+IAWR
+.± .
+.± .<.b
+IEWL
+.± .
+.± .
+.
+IEWR
+.± .
+.± .
+.
+Psychophysiological
+(without filter)
+IANL
+.± .
+.± .
+.a
+IANR
+.± .
+.± .
+.
+IENL
+.± .
+.± .
+.
+IENR
+.± .
+.± .
+.
+ap < 0.05, bp < 0.001. AC, activation coefficient; IAWL, integral area
+with filter left; IAWR, integral area with filter right; IEWL, integral entropy
+with filter left; IEWR, integral entropy with filter right; IANL, integral area
+no filter left; IANR, integral area no filter right; IENL, integral entropy no
+filter left; IENR, integral entropy no filter right.
+Table 3: Gender-related values of EPI parameters and comparisons between groups: LTM and STM.
+Type of measurement
+Variable
+Male
+p-Value
+Female
+p-Value
+LTM, mean ± sd
+STM, mean ± sd
+LTM, mean ± sd
+STM, mean ± sd
+Physiological (with filter)
+AC
+.± .
+.± .
+.
+.± .
+.± .
+.
+IAWL
+.± .
+.± .
+.
+.± .
+.± .
+.a
+IAWR
+.± .
+.± .
+.
+.± .
+.± .
+.a
+IEWL
+.± .
+.± .
+.
+.± .
+.± .
+.
+IEWR
+.± .
+.± .
+.
+.± .
+.± .
+.
+Psychophysiological (without filter)
+IANL
+.± .
+.± .
+.
+.± .
+.± .
+.
+IANR
+.± .
+.± .
+.
+.± .
+.± .
+.
+IENL
+.± .
+.± .
+.
+.± .
+.± .
+.
+IENR
+.± .
+.± .
+.
+.± .
+.± .
+.
+ap < 0.05. LTM, long-term meditators; STM, short-term meditators; AC, activation coefficient; IAWL, integral area with filter left; IAWR, integral area
+with filter right; IEWL, integral entropy with filter left; IEWR, integral entropy with filter right; IANL, integral area no filter left; IANR, integral area no
+filter right; IENL, integral entropy no filter left; IENR, integral entropy no filter right.
+76
+Deo et al.: Cumulative effect of short-term and long-term meditation practice in men and women
+Authenticated | [email protected] author's copy
+Download Date | 3/14/16 10:03 AM
+positive change in meditators. This may be due to cumu-
+lative effect of meditation at the psychophysiological level
+in STM group. This may also be due to the initial enthu-
+siasm and commitments of the practitioners.
+Table 4 shows Fisher discriminant function. The
+Fisher discriminant function analysis is performed to
+determine how well a function explains the interdepen-
+dency among EPI variables for LTM and STM groups.
+Overall conclusion of this analysis is that while a dif-
+ference between LTM and STM groups may be suspected,
+Group LTM: Gender: Male
+Figure 1: Scatter plot showing relation-
+ship between IENR and hours of practice
+in LTM group.
+Group STM: Gender: Male
+Figure 2: Scatter plot showing relation-
+ship between IENR and hours of practice
+in STM group.
+Table 4: Fisher’s linear discriminant function model for LTM and STM
+groups to estimate coefficient and interdependency of variables.
+The discriminant function: F
+LTM = –.+ .(AC)-.(IAWL)-.(IAWR) + .
+(IEWL) + .(IEWR)+ .(IANL)+ .(IANR) + .
+(IENL)+ .(IENR).
+STM= –.+ .(AC)-.(IAWL)-.(IAWR) + .
+(IEWL) + .(IEWR) + .(IANL)+ .(IANR)+ .
+(IENL) + .(IENR).
+Deo et al.: Cumulative effect of short-term and long-term meditation practice in men and women
+77
+Authenticated | [email protected] author's copy
+Download Date | 3/14/16 10:03 AM
+Fisher’s linear discriminant function indicates that there is
+no statistical difference between the groups.
+Eigenvalue (Table 5)
+For a good model, the eigenvalue must be > 1. The bigger
+the eigenvalue, the stronger is the discriminating power
+of the function. Our analysis found that the eigenvalue is
+0.03 ( < 1) which shows we could not find any discrimi-
+nant variable to predict the cumulative effect in the
+study.
+Wilks lambda (Table 5)
+In a discriminant analysis, Wilks lambda is used to test
+the significance of discriminant function. In our model,
+we found Wilks lambda = 0.971 and p-value = 0.180. It
+shows that there is no statistical difference (p > 0.05)
+among the EPI variables with respect to LTM and STM
+groups.
+Discussion
+The aim of the current study was to explore the gender-
+related cumulative effect of meditation in short-term and
+long-term practitioners. Mindfulness and other techni-
+ques of meditation are used for health-oriented purposes
+at
+the
+physical
+and
+psychophysical
+levels
+[47–49].
+Studies have been reported to observe the changes in
+long-term,
+short-term,
+immediate
+and
+premeditative
+state of the human brain due to meditation. Application
+of EEG, ECG (electrocardiogram) and fMRI (functional
+magnetic resonance imaging) to detect the effect at neu-
+rophysiological
+and
+psychophysiological
+levels
+has
+drawn the attention of the medical community as well
+[6–9, 18, 20–22, 49, 50].
+Here attempts are carried out to observe cumulative
+changes in men and women at the physiological and
+psychophysiological levels by using EPI. In both STM
+(p = 0.39) and LTM (p = 0.93) groups, lower values of AC
+were found in women as compared to men. But these
+trends were not significant in both groups. This indicates
+more positive improvement due to practice at the physio-
+logical and psychophysiological levels took place in
+women as compared to men. Previous finding also
+reports women benefited more than men during comple-
+mentary and alternative intervention due to more spiri-
+tual orientation in women [29]. Though the result is not
+significant in AC, yet the direction of trend is the
+observed in STM and LTM groups. The lower mean
+value of stress parameter AC found herein using EPI
+measurement is in line with earlier findings in women
+[ < U > 27, 32 < /U > ]. Higher coherence in women reported
+previously exhibits better coordination between hemi-
+spheres [24]. In QMT, a kind of walking meditation,
+increased theta and alpha demonstrate heightened atten-
+tion and enhanced relaxation found in women compared
+to men [51]. In Qigong meditation, findings demonstrate
+women reduced anxiety and withdrawal symptoms sig-
+nificantly more than men [27].
+At the physiological level, the mean values of IAWL
+(parameter of the healthy subject, normal range is 0.6 to
++ 1) [35] were highly significantly lower in women than
+men. In both STM (p< 0.001) and LTM (p< 0.001) groups,
+lesser values of left side IA parameters in women indicate
+overall reserves of high functional energy and good stress
+tolerance in the body [32]. Energy required for the normal
+functioning of the body in day-to-day activities is con-
+stantly replenished due to normal metabolic processes
+[32]. The difference in mean values between female and
+male meditators is found to be 0.08 for IAWL. This shows
+that female meditators are having more stress tolerance
+than male meditators. A previous study concludes that
+longer the duration of meditation more the significant
+changes in physiological parameters observed such as
+heart rate, respiratory rate and blood pressure positively
+[52]. Highly significant larger values of IAWR (STM
+p < 0.001 and LTM p < 0.001) in women as compared to
+men show compensatory process occurring to bring swift
+changes in the system back to the homeostatic state. This,
+in other words, is called the influence of synchronizing
+transmission due to interconnections within the system
+[35]. Interestingly, this pattern of change took place in
+Table 5: Summary of canonical discriminant functions.
+Eigenvalues
+Function
+Eigenvalue
+% of
+variance
+Cumulative
+%
+Canonical
+correlation
+
+.a
+.
+.
+.
+Wilks lambda
+Test of
+function(s)
+Wilks
+lambda
+Chi-
+square
+df
+Sig.
+
+.
+.
+
+.
+aFirst, one canonical discriminant function was used in the analysis.
+df = degree of freedom.
+78
+Deo et al.: Cumulative effect of short-term and long-term meditation practice in men and women
+Authenticated | [email protected] author's copy
+Download Date | 3/14/16 10:03 AM
+both LTM and STM groups. It demonstrates larger physio-
+logical cumulative effect in women than in men.
+The mean values of IEWL (measure of disorderliness
+in the system) were lesser in LTM women as compared to
+STM women. Entropy is a measure of disorder at the
+molecular level in the system. A system having high
+disorder has more entropy values. The system can gen-
+erate entropy but cannot destroy it. It can be increased or
+decreased depending upon the energy exchange from or
+to the system. Mediation reduces sympathetic arousal in
+the system with enhanced parasympathetic activation
+[53]. Meditation is supposed to reduce overall entropy in
+the system. Meditation, if practiced over a long period of
+time, is supposed to give more equilibrium in the system
+at both physiological and neurophysiological levels [20].
+So in the present study, in women, lower values of
+entropy in LTM but not in STM are likely due to the
+cumulative impact of the practice. Though they practiced
+meditation for long period of time, fluctuations in IE
+parameter were observed. This could be due to stress
+experienced by the participants due to unknown mea-
+surement technique. Further, people who are sensitive
+(at the energy level) to high voltage might have instability
+in entropy values. These aspects need further carefully
+monitored studies.
+At the psychophysiological level, in both LTM and
+STM groups, mean values of IANL were significantly
+lower in women as compared to men. Lower values in
+this parameter demonstrate that women of both groups
+are more receptive in benefits from the practice as com-
+pared to men. Earlier finding has shown that STM is
+associated
+with
+physiological
+relaxation
+responses
+with
+significant
+decreased
+galvanic
+skin
+response,
+whereas LTM result was a significant improvement in
+emotional quotients and cognitive performances [6].
+There were positive highly significant lower trends of
+IAWL values in LTM and STM groups for women as
+compared to men. The unexpected higher mean values
+of IAWR in LTM and STM women may be due to higher
+activity of left hemisphere of the brain with logical
+thinking predominating in them while practicing medi-
+tation. The lower mean values of IA at both physiologi-
+cal and psychophysiological levels in LTM women as
+compared to men are possibly due to reduced sympa-
+thetic activation and enhanced parasympathetic arousal
+as seen in LTM study [52]. Previous studies also reported
+measuring some aspects of perception and correlating
+with mechanism of consciousness using EPI [43]. The
+larger value of changes observed in women may be due
+to improved perception and enhanced consciousness in
+female meditators.
+The mean values of IENR were higher in both groups
+showing more existence of disorderliness in women as
+compared to men. In LTM, mean value of IENR was
+significantly more in comparison to STM. This demon-
+strates larger chaos in psychological level in women
+than men though they show better responses at the phy-
+siological level. However, in STM women, the mean value
+of IEWL was more than in men which may be due to
+disorderliness of energy at physiological level.
+Between-group analysis
+In Table 3, comparison was carried out between groups to
+record changes based on gender. In AC (stress parameter,
+normal range 2–4 in healthy individual), IAWL and
+IAWR, lower mean values were found at the physiologi-
+cal level in LTM men as compared to STM men. The
+results support the earlier findings: the longer the dura-
+tion of meditation practice, the more the positive changes
+[20, 52]. Mean values of IEWL and IEWR were higher in
+LTM men as compared to men in STM. This indicates that
+although LTM practitioners have positive effect, yet, at a
+subtle level disorderliness is indicated.
+Lower values of IANL were observed at the psycho-
+physiological level in LTM men in comparison to STM
+men. This is possibly due to dose–effect response of
+practice in long-term practitioners. The mean values of
+IANR and IENR were higher in LTM men in comparison to
+STM. This may be possibly due to the engagement of the
+left hemisphere of the brain [35].
+At the physiological level in LTM women, the trends of
+mean values were lower in AC, IAWL, IAWR and IEWL
+parameters as compared to STM women. LTM women were
+displaying less stress in comparison to STM women.
+Positive significant lower mean values of IAWL and IAWR
+were observed in LTM women in comparison to STM
+women. The lower values in LTM women may be likely
+due to the practice of anapanasati meditation over a long
+period of time. The overall results between groups showed
+that long time practices induce beneficial effect over body
+and mind which is apparent in LTM women.
+At the psychophysiological level, the mean values of
+IANL and IANR were less in LTM women as compared to
+STM women. The lower mean values in LTM are possibly
+due to cumulative effect of longer meditation practice.
+Absence of such trends in values of these variables in
+STM supports the conviction of cumulative effect. These
+results were not statistically significant.
+Unexpected higher values of IEWR at the physiologi-
+cal level, and higher values of IENL and IENR at the
+Deo et al.: Cumulative effect of short-term and long-term meditation practice in men and women
+79
+Authenticated | [email protected] author's copy
+Download Date | 3/14/16 10:03 AM
+psychophysiological level were found in LTM women as
+compared to STM. The correlational trend of entropy with
+hours of practice in LTM and STM groups is demonstrated
+through scatter plots shown in Figures 1 and 2, respec-
+tively. However, these results were not significant. A
+possible reason for these results could be washout effects
+of meditation practice in these variables. As mentioned
+earlier, this may also be due to participants’ attitude of
+habituation and routine attitude to the practice, both of
+which needs to be studied further.
+The Fisher discriminant linear analysis is carried out
+to identify the discriminant variables and interdepen-
+dency in LTM and STM groups. The study concludes
+that there is no significant difference between the groups
+and interrelationship of variables.
+This is the first study reporting gender-dependent
+changes in LTM and STM using EPI. The study presents
+reliability and reproducibility with bigger sample size
+using EPI. Unlike other earlier studies where EPI is used
+with small sample size, bigger sample size was used here
+to find out minute changes in meditators in all three
+parameters, viz. AC, IA and IE.
+The limitations of this study can be summed up as
+follows: (a) self-reporting in demographic sheets on the
+duration of practice by participants; (b) data collection at
+two sites and (c) LTM and STM effects were not measured
+through any other way in this study which is also a
+shortcoming of the study.
+Future study may consider the following points to
+be incorporated while using EPI: (a) include control
+group to compare the results with nonmeditators; (b)
+include one more group to see an immediate effect in
+meditators and lasting effect over long time; (c) equal
+number of men and women and (e) environmental
+entropy should be controlled by taking care of all
+environmental factors.
+Conclusions
+To verify the changes in LTM and STM at the electron
+emission level, a novel technique called EPI is used in
+this study. Gender-related analysis showed that female
+practitioners are more benefited due to meditation prac-
+tice than men. Women of both LTM and STM groups
+demonstrated lesser stress in comparison to men of
+both groups.
+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.
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+Download Date | 3/14/16 10:03 AM

subfolder_0/Depression in Traditional Chinese Medicine high variances in.txt

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+1 
+ 
+TITLE PAGE 
+TYPE OF PAPER: Original Research Article  
+ 
+TITLE: Depression in Traditional Chinese Medicine: high variances in electrodermal 
+conductances at Jing-Well meridian endpoints 
+ 
+AUTHORS:  Kaniyamparambil Baburajan Meenakshy, Alex Hankey, Hongsandra 
+Ramarao Nagendra1 
+ 
+1. Affiliation of all Authors:  
+Swami Vivekananda Yoga AnusandhanaSamsthana (S-VYASA) 
+ 
+ 
+Keywords: Depression, Acugraph, Electrodermal conductance, Jing-Well points, Chi 
+Energy Level 
+ 
+ 
+Corresponding Author:  
+Name:      
+Alex Hankey PhD 
+Address: 
+S-VYASA, Eknath Bhavan,  
+ 
+ 
+19 Gavipuram Circle,  
+ 
+ 
+K.G. Nagar, Bangalore 560019 
+ 
+ 
+India 
+Phone numbers:  
+Mobile: 
++ 91 900 800 8789 
+Landline 
++ 91 80 2263 9961 
+Fax:   
++ 91 80 2660 8645 
+E-mail : 
+[email protected] 
+ 
+ 
+ 
+ 
+ 
+ 
+2 
+ 
+PAPER FOR SUBMISSION  
+SECOND PAGE 
+Authors’contributions: 
+Mennakshy KB. Total involvement in Study as part of PhD course work. Data Collection and 
+Analysis, Writing and submitting paper 
+ 
+Hankey A.  Detailed supervision of research student’s work at all stages. Planning and editing 
+the writing, and chief responsibility for interpretation of results. Selection of Journal and 
+Submission. 
+ 
+Nagendra H.R. Planning of Study and coordination of project, Direction of Data Collection, 
+Supervision of Interpretation and Writing, Final Approval before submission.   
+ 
+ 
+Conflict of Interest: None  
+ 
+ 
+Funding: None  
+ 
+ 
+Further Information: Accepted Studies attached 
+ 
+ 
+3 
+ 
+ Depression in Traditional Chinese Medicine: high variances in  
+electrodermal conductances at Jing-Well meridian endpoints  
+KB Meenakshy, Alex Hankey, and H R Nagendra 
+ 
+ABSTRACT 
+Background: Acugraph3 is an instrument for electrodermal assessment of acupuncture 
+meridian activity in accordance with principles of Traditional Chinese Medical Sciences. It 
+has recently been used to characterize groups of subjects, resulting in the new observation of 
+higher variances in pathology groups than healthy persons. Here we report AcuGraph3 
+assessment of a groups of depression patients and demographically comparable controls 
+yielding similar findings.  
+Aims: To show that Acugraph3 can evaluate acupuncture meridian characteristics of 
+depression subjects, distinguishing them from healthy subjects. 
+Methods:  
+Study Design: Cross sectional design. 
+Subjects: Twenty-seven depression patients, aged 35.05±8.16 years, diagnosed by a qualified 
+psychiatrist, attending a Yoga Medicine hospital, and forty-three ‘healthy’ adults, aged 44.02 
+± 9.80 years attending the same institution for health improvement.  
+Informed consent: was obtained from all subjects; ethical approval was obtained from the 
+institutional review board. 
+Assessment: AcuGraph3 measurements of electro-dermal conductance at Jing-Well 
+acupuncture meridian endpoints.  
+Statistical Analysis: used SPSS-16 software for independent sample t tests between groups. 
+Results: Mean conductance values were much higher in the depression group in all meridians 
+than in the ‘Normal Healthy’ group, for which all values were well below the recommended 
+‘healthy’ value of 100. However, standard deviations of group conductance levels were also 
+significantly larger for the depression group than for the ‘healthy’ controls in all meridians. 
+Both t and F values were significant in all cases. 
+Discussion and Conclusions: These results are not at all expected: group mean conductances 
+for healthy controls should be normal; lower values suggest poor life-style and associated 
+fatigue. Mental conditions should not affect meridian energies, but higher group standard 
+deviations for the depression patients point to fluctuation in meridian energies, suggesting 
+poor system regulation as previously observed in pathology groups.   
+ 
+4 
+ 
+INDRODUCTION 
+In Traditional Chinese Medicine diagnosis usually includes assessment of levels of Qi in 
+different meridians. Voll in Germany1 and Nakatani in Japan2 showed that electrodermal 
+assessment of skin conductance at acupuncture points can be used for this purpose. Many 
+machines making such assessments are now available, for example, Neurometer (Ryodoraku 
+Research Centre Ltd., Tokyo, Japan), Dermatron (Pitterling Electronic, Munich, Germany) 3, 
+and AcuGraph3 (Meridia Technologies, Meridian, Idaho) 4, an instrument designed for use on 
+limited numbers of acupuncture points, the Jing-Well points on the fingers and toes at the end 
+of each meridian (See Figure 1), and the Yuan-Source points slightly higher up each meridian 
+near the wrists and ankles. A reliability study has shown substantial variability in AcuGraph3 
+readings, however5, so it has recently been used to assess groups of patients in order to 
+demonstrate that, despite low reliability of individual readings, it can, by this method, obtain 
+interesting results.  
+Several such Acugraph3 studies have been made on groups. One on 8,637 individuals 
+established North American population norms6, finding lower conductance values for females 
+than males, values for both genders decreasing with age. Several pre-post studies have 
+assessed effects of Yoga therapy courses. 7-9 including a stress reduction course for business 
+executives8. In general, conductance values increase after Yoga practice, and gender 
+differences observed in pre-assessment are usually eliminated in post-assessment7, values for 
+females having increased more than for males.  
+One study assessed inter-operator variation in readings, demonstrating distinct styles of use 
+by different operators. It concluded that large studies involving many operators must take 
+inter-operator variability into account for measured values to be comparable.10 Some studies 
+of groups with particular pathologies, Type 2 Diabetes11 and HIV/AIDS12, have identified 
+meridian energy characteristics for the pathology concerned.  
+5 
+ 
+Among the more interesting results are observations of higher variances in conductance 
+values for groups with a pathology or less experience of Yoga.9 Here we report comparative 
+AcuGraph3 assessment of a group of twenty-seven depression patients attending a Yoga 
+healthcare centre near Bangalore, and a group of forty-three individuals with no identified 
+pathology attending the same institution to promote positive health. Although only intended 
+as a pilot study, the data yielded such definitive results supporting previous findings of 
+increased group variances that they seemed worth reporting in their own right.  
+Depression is a common reporting condition in primary care, and causes considerable burden 
+to health care systems in developed countries e.g. Australia’s incidence of depression is over 
+30%.13 Understanding it more deeply is therefore of importance, so its meridian 
+characteristics are of interest.  
+ACUGRAPH  
+The Acugraph3 Digital Meridian Imaging system has the following components: a ‘probe’ to 
+contact the acupoints, and ‘ground bar’ at zero volts held by the subject, connected by a 
+‘connector cable’ to the monitoring computer, programmed through a software CD, together 
+with a user manual. 5 Data is presented on a 0–200 conductance unit scale. The instrument 
+uses ultra-low, 0-40 μA, currents so as not to exceed participants’ sensitivity thresholds. 
+Experienced operators can obtain about 10 readings per minute, displayed when complete as 
+an onscreen bar graph by the software. A green middle line display’s a person’s average 
+conductance, with high (red) and low (blue) lines on either side. Derivative variables are also 
+calculated. 4 
+ 
+ 
+6 
+ 
+METHODS 
+Study Design: Cross Sectional Design 
+Subjects: Twenty-seven (17 male, 10 female) patients attending a Yoga therapy Health 
+Home (Arogyadhama) in Bangalore, diagnosed by the psychiatrist as having depression, 
+according to criteria from a DSM IV assessment criteria on arrival, and a control group of 
+forty-three healthy adults (28 male, 15 female) attending the same institution for health 
+improvement purposes; all subjects were aged 20-60 years. (Mean and SD of   Depression: 
+35.05±8.16, Healthy Subjects: 44.02 ± 9.80 
+Inclusion Criteria 
+ 
+Depression without further complications 
+ 
+Willing to participate in the study. 
+Exclusion Criteria 
+ 
+More severe form of psychiatric disorder e.g. Schizophrenia, Alcoholism etc. 
+ 
+Any cut, scar or mole on the surface of Jing-Well meridian endpoints. 
+ 
+ Missing any finger or toe. 
+Assessment: Single readings of skin conductance at Jing-Well meridian endpoints were 
+taken using the Acugraph3 Digital Meridian Imaging System during the same daily time 
+period, 11.00 am to 12.00 noon, and in the same place, by a single operator (the first author) 
+in order to reduce environment and measurement variability. When making Acugraph3 
+measurements (Figure 1), the subject sits comfortably on a chair, feet on a mat. First personal 
+information is taken: First / Last Name, age, gender etc. and an ID number is assigned. The 
+subject’s hands are checked for excessive wetness or dryness, which is adjusted using a towel 
+or damp cotton ball, to improve uniformity of acupuncture point surface conductances. The 
+subject then holds a ground bar in one hand with a medium grip, and successive acupuncture 
+points are measured on the opposite side, in the order specified by the computer, Lung, 
+7 
+ 
+Pericardium, Heart, Small Intestine, Triple Warmer, and Large Intestine, (Hand) and Spleen, 
+Liver, Kidney, Bladder, Gall Bladder, and Stomach (Foot).   
+AcuGraph3 should be avoided for subjects with implanted electronic devices like pacemakers 
+or defibrillators, and also for those with skin rashes, lesions, or wounds at acupoints. 4 
+Results displayed by Software: 
+Meridians: Lung (Lu_L, Lu_R) Pericardium (Pc_L, Pc_R) Heart (Ht_L, Ht_R) Small 
+intestine (Si_L, Si_R) Triple warmer (Te_L, Te_R) Large intestine (Li_L, Li_R) Spleen 
+(Sp_L, Sp_R) Liver (Lr_L, Lr_R) Kidney (Ki_L, Ki_R) Bladder (Bl_L, Bl_R) Gall Bladder 
+(Gb_L, Gb_R) Stomach (St_L, St_R). 
+Meridian Groupings: the 16 groupings come in three sections: averages of selected meridians 
+by body region etc. (5); averages according to ‘element’ (5); and important balance / 
+imbalance sets (6). Selectiions of meridians include, Low, Medium, High, Yin and Yang; 
+‘Elements’ are classified under, Wood, Metal, Fire, Water and Earth; Balance/Imbalance 
+Groupings comprise, Personal Integrated Energy (P.I.E.), an index of overall energetic status, 
+Energy Level (mean of all 24 meridians); Energy Stability (E_S) is the range related to the 
+mean; Upper-Lower Imbalance (U_L), mean of upper meridians minus mean of lower 
+meridians; Right-Left Imbalance (R_L), mean of right side meridians minus mean of left side 
+meridians; and Yin-Yang Balance (Y_Y), Yin meridians mean minus Yang meridians mean.    
+Data Analysis: used SPSS 16. Statistical tests included Independent Sample t-test to 
+compare means and Levene’s ‘F’ test to compare SDs for all 24 meridians given in Table 1a 
+and meridian groupings in Table 1b . 
+RESULTS 
+Tables 1a and 1b present group means and SDs of all the individual meridians (Table 1a) and 
+various derived and average variables (Table 1b), also giving t and F test comparison values. 
+8 
+ 
+Table 1a: Group Averages and Standard Deviations for 24 Meridians 
+with Independent Sample t test and Levene’s F test values 
+Group 
+Depression  
+No Pathology 
+Indep. 
+Sample  
+t test 
+p 
+Value  
+Levene’s 
+F 
+Meridian 
+Mean 
+SD 
+Mean 
+SD 
+LU-L 
+111.41 
+38.03 
+77.44 
+19.56 
+4.30 
+0.00 
+13.05 
+LU-R 
+103.56 
+44.62 
+73.21 
+19.91 
+3.33 
+0.00 
+20.07 
+PC-L 
+105.70 
+40.46 
+70.23 
+16.13 
+4.34 
+0.00 
+24.26 
+PC-R 
+99.04 
+39.61 
+69.49 
+17.76 
+3.65 
+0.00 
+13.79 
+HT-L 
+106.89 
+43.65 
+66.70 
+14.67 
+4.62 
+0.00 
+36.36 
+HT-R 
+107.78 
+39.66 
+72.65 
+16.59 
+4.37 
+0.00 
+17.15 
+SI-L 
+96.59 
+44.50 
+71.77 
+15.52 
+2.79 
+0.01 
+17.15 
+SI-R 
+108.00 
+47.46 
+70.33 
+19.68 
+3.92 
+0.00 
+22.15 
+TE-L 
+107.48 
+44.24 
+69.35 
+14.02 
+4.34 
+0.00 
+29.15 
+TE-R 
+109.93 
+45.09 
+70.56 
+18.15 
+4.32 
+0.00 
+29.77 
+LI-L 
+99.63 
+36.50 
+68.60 
+14.42 
+4.22 
+0.00 
+22.81 
+LI-R 
+101.70 
+34.10 
+69.21 
+16.73 
+4.62 
+0.00 
+14.11 
+  SP-L 
+109.85 
+52.82 
+67.95 
+20.43 
+3.94 
+0.00 
+34.04 
+SP-R 
+107.33 
+59.39 
+62.23 
+18.55 
+3.83 
+0.00 
+74.82 
+LR-L 
+116.37 
+55.88 
+71.26 
+19.33 
+4.05 
+0.00 
+33.84 
+LR-R 
+109.63 
+56.24 
+66.47 
+20.98 
+3.82 
+0.00 
+45.72 
+KI-L 
+86.22 
+51.4 
+58.00 
+16.08 
+2.77 
+0.01 
+46.88 
+KI-R 
+86.89 
+51.18 
+57.58 
+20.58 
+2.84 
+0.01 
+21.08 
+BL-L 
+83.11 
+43.17 
+58.56 
+23.9 
+2.71 
+0.01 
+7.67 
+BL-R 
+80.89 
+44.27 
+59.44 
+25.12 
+2.30 
+0.03 
+10.82 
+GB-L 
+94.89 
+52.98 
+63.49 
+21.73 
+2.93 
+0.01 
+23.85 
+GB-R 
+90.67 
+48.68 
+64.84 
+23.24 
+2.58 
+0.01 
+20.45 
+ST-L 
+101.04 
+50.95 
+68.56 
+19.85 
+3.17 
+0.00 
+31.64 
+ST-R 
+104.00 
+55.02 
+67.77 
+21.31 
+3.27 
+0.00 
+38.29 
+Table 1a Caption: Table 1a presents group means and standard deviations for individual meridians for 
+Depression and No Pathology groups. Means for the first are mostly in the ideal range of 90 to 108. In contrast 
+the No Pathology group had far lower means, range 57-77, probably reflecting the average citizen’s high level 
+of disease susceptibility. Group SDs for the Depression group were very high, while those of the No Pathology 
+group were far lower. Differences between means were all highly significant, as shown in the ‘t’ and p value 
+columns; F values were also all highly significant, all p < 0.0001, except for BL_L, p < 0.0003. Meridian 
+properties of the two groups are completely distinct.  
+9 
+ 
+Table 1b: Group Averages and Standard Deviations for Meridian Groupings 
+with Independent Sample t test and Levene’s F test values 
+Group → 
+Depression  
+No Pathology 
+Indep. 
+Sample  
+t test 
+p 
+Value  
+Levene’s 
+F 
+Variable ↓ 
+Mean 
+SD 
+Mean 
+SD 
+LOW 
+84.15 
+32.12 
+56.07 
+11.80 
+4.38 
+0.00 
+21.47 
+MEDIUM 
+97.67 
+34.50 
+67.47 
+13.42 
+4.37 
+0.00 
+20.29 
+HIGH 
+111.41 
+36.86 
+78.95 
+14.16 
+4.40 
+0.00 
+20.52 
+YIN 
+101.07 
+34.62 
+68.56 
+12.19 
+4.74 
+0.00 
+31.03 
+YANG 
+95.44 
+35.40 
+67.37 
+13.95 
+3.94 
+0.00 
+18.47 
+FIRE 
+101.48 
+33.05 
+70.44 
+13.77 
+4.72 
+0.00 
+10.93 
+EARTH 
+102.70 
+45.61 
+67.23 
+5.68 
+3.86 
+0.00 
+36.13 
+METAL 
+101.41 
+31.76 
+72.21 
+14.49 
+4.68 
+0.00 
+15.79 
+WATER 
+81.74 
+42.95 
+57.84 
+19.75 
+2.62 
+0.01 
+16.02 
+WOOD 
+99.15 
+48.00 
+66.81 
+8.45 
+3.29 
+0.00 
+37.95 
+P.I.E. 
+42.74 
+16.92 
+72.53 
+14.55 
+-7.42 
+0.00 
+1.68 
+E_L 
+97.78 
+34.49 
+67.40 
+12.90 
+4.41 
+0.00 
+21.23 
+E_S 
+60.11 
+16.71 
+84.21 
+10.63 
+-6.73 
+0.00 
+10.2 
+U_L 
+23.59 
+16.41 
+15.81 
+14.29 
+2.16 
+0.04 
+1.49 
+L_R 
+9.56 
+9.28 
+4.30 
+3.61 
+2.73 
+0.01 
+16.48 
+Y_Y 
+9.85 
+7.46 
+4.60 
+5.60 
+3.03 
+0.00 
+6.48 
+Table 1b Caption: Table 1b presents group means and standard deviations for meridian groupings for the 
+Depression and No Pathology groups. Selected meridians, rows 1-5 are all low for the no pathology group; for 
+the five ‘element’ meridian groupings, water is low in both groups; of the Balance variables, the No Pathology 
+group was healthier than the Depression in all variables except Energy Level E_L, which was low like the 
+selected meridians and ‘element’ meridians. t tests on all groupings were significant, as were all F tests except 
+P.I.E. and Upper-Lower imbalance, U_L. 
+Table 1a contains the striking result that the depression group’s Means and SD’s are both 
+larger for all meridians (details in Table 2a). This is a highly significant result in toto, apart 
+from the fact that it was highly significant for each meridian individually. These significant 
+differences carry over to the meridian groupings given in Table 1b, where all mean values are 
+larger for the depression group except Personal Integrated Energy (P.I.E.) and Energy 
+Stability (E_S), which were smaller (smaller values in these variables indicate ill-health). For 
+10 
+ 
+the other imbalance variables (U_L, L_R and Y_Y), it is the other way round: larger values 
+indicate health problems.  Although the high values of meridian energies and their principal 
+averages make the depression group seem healthy, problems are masked by the average 
+process and show up in the imbalance variables and the PIE and Energy Stability variables, 
+which make it clear that, in reality, the group is less healthy.  
+To clarify just how different the two groups were, Table 2a displays the ranges of the 
+Meridian Group Means and SD’s for each group. The two pairs of ranges are well separated! 
+Table 2b displays the ranges for the mean and SDs of the 24 meridians for individuals. 
+Table 2a: Ranges of Meridian Group Means and SD’s  
+for No Pathology & Depression Groups 
+GROUP 
+GROUP MEAN  
+GROUP SD 
+NO PATHOLOGY 
+57.58 to 77.44 
+14.02 to 25.12 
+DEPRESSION 
+80.89 to 111.41 
+34.10 to 59.39 
+ 
+Table 2a Caption: Table 2a presents the ranges of the Group Means and Standard Deviations for meridians 
+given in Table 1a. This makes it clear that the ranges of both Means and SD’s for the Depression group are 
+higher than, and clearly separated from, those for the No Pathology group. Both pairs of datasets are distinct 
+with gaps of several units in between them. The two distributions have completely different characteristics. 
+Table 2b: Ranges of Means and SD’s of values for the 24 meridians 
+for individuals in the No Pathology & Depression Groups 
+GROUP 
+INDIVIDUAL 
+MEAN  
+INDIVIDUAL SD 
+NO PATHOLOGY 
+35.67 to 103.92 
+6.22 to 32.45 
+DEPRESSION 
+21.83 to 172.08 
+11.48 to 49.23 
+ 
+Table 2b Caption: Table 2b presents the ranges of the Means and Standard Deviations of values from all 24 
+meridians, for each individual participant. It shows that for the Depression group, means of the 24 meridian 
+values varied over the range, 21 to 172, far greater than, and including, the range for the No Pathology group, 35 
+to 104. The range of  the Depression group’s SD’s was about 44% larger than the No Pathology group’s. 
+11 
+ 
+Table 2a summarizes the data from Table 1a by presenting the range of meridian group mean 
+energies, and standard deviations showing that there was no overlap between the pairs of 
+distributions. Each pair is well separated and completely distinct. The Depression patients 
+had higher group mean electrodermal conductance levels in all meridians,. For the standard 
+deviations, the depression group’s values were all far higher than the control group’s with no 
+overlap at all. This shows that their meridian properties were much less well regulated, and 
+subject to high levels of fluctuation. By comparison, the ‘no pathology’ controls showed 
+considerably lower conductance levels at all meridian Jing-Well points, but also much lower 
+group variances, indicating greater stability. 
+Table 2b presents a similar analysis of data from individual subjects, the ranges of their mean 
+conductance levels (E_L), and the standard deviations of all 24 meridian conductance levels. 
+It shows, first, that the range of the Depression group’s mean conductances include the range 
+of the normal group’s – they are much more variable; and, second, that the standard 
+deviations, or range of variability of individual meridian conductances is about 45% higher.  
+Because of the higher values of the Upper Lower imbalance for the Depression group given 
+in Table 1b, it is not clear that the differences in SD’s between the two groups given in Table 
+2b are due to intrinsic differences in SD or are primarily due to differences between sets of 
+Upper and Lower meridians. We therefore calculated the group total variances of the upper 
+and lower meridian values separately. These are presented in Table 3.  
+Table 3: Mean Variances of Upper and Lower Meridians 
+for the Depression and No Pathology Control Groups 
+ 
+ 
+Table 3 Caption: Table 3 presents the mean variances of the upper and lower 
+meridians for the two groups. 
+MERIDIANS 
+Depression No Pathology 
+Upper 
+666.2 
+109.1 
+Lower 
+904.4 
+184.8 
+12 
+ 
+Table 3 shows that the mean variance for the upper meridians of the depression patients was 
+over five times higher than that of the healthy controls, and almost five times higher for the 
+lower meridians. Depression results in far greater conductance variability at Jing-Well points. 
+Variability in conductance values is therefore far higher for both upper meridians and lower 
+meridians for the Depression group than for the No Pathology group, confirming Table 2b.  
+DISCUSSION AND CONCLUSIONS 
+The above results may at first seem surprising. One unexpected finding was normal levels of 
+group mean conductance for the depression group, since values near 100 are considered a 
+sign of robust physical health. The lower values for the supposedly healthy control group 
+were less surprising. Participants arriving at the Yoga therapy center often present with low 
+mean conductance levels. One to two weeks Yoga therapy usually improves them greatly. 
+One possible reason for generally observed low mean readings is lack of care over physical 
+health, including poor personal lifestyle, which Yoga lifestyle programs are designed to 
+improve. The meridians with lowest values for both groups, kidney (KI) and bladder (BL), 
+offer valuable topics for further study e.g. the relationship between their values, fluid intake, 
+and overall health.  
+A second possibly surprising result is the strong influence of depression on conductances. 
+Each meridian is connected to one of the body’s principle organs, so a mental pathology like 
+depression might not be expected to influence acupuncture point conductance values. The 
+observed influence may be understood as follows: both TCM and Yoga maintain that states 
+of mind influence levels of Qi (or prana). Those with disturbed states of mind, i.e. 
+depression, may therefore be expected to have meridian conductance levels disturbed.   
+As an ancient system of medicine and health care, Traditional Chinese Medicine is one of the 
+oldest, continually practiced, codified systems of medicine in the world.14 It is based on the 
+concept of maintaining balance of the vital energy, or Qi, that flows in specific channels, or 
+13 
+ 
+meridians throughout the body. Diagnosis often incorporates assessment of levels of Qi at 
+various points where a meridian touches the surface (acupuncture points). Components of 
+Chinese medicine include Chinese herbal medicine, and means of stimulating and altering Qi 
+levels in each meridian such as acupuncture, acupressure (Tui Na), moxibustion, massage 
+therapy, and other such subtle techniques like Qigong. 14 
+Classically, acupuncture and moxibustion were used to treat the vast majority of complaints, 
+including acute conditions like rheumatism, gout and neuralgic conditions, abdominal cramps 
+and colic. Both were also recommended in cases of mental disturbance. TCM recognizes that 
+mental disorders are the outcome of poor or inactive energy, or an imbalance between yin and 
+yang.15  
+In developed countries Integrative Medicine has become increasingly popular, usually 
+combining conventional medicine with TCM, including acupuncture and Chinese herbal 
+medicine, because integrative practice of these disciplines is well advanced in China. 
+Accurate use of TCM requires traditional assessment through the Chinese system of pulse 
+analysis, which is challenging and often difficult for western practitioners to learn, requiring, 
+as it does, great sensitivity on the part of the diagnostician. Electrodermal assessment being 
+mechanical is relatively easier to learn.  
+This electrodermal study reveals aspects of patients’ conditions that could not have been 
+inferred without the analysis of AcuGraph3 assessment data for whole groups. It continues a 
+series of analyses of group data of individual pathologies not previously undertaken, 
+characterizing patients’ meridian properties.11,12 Big differences were established between the 
+group of depression patients and those with no overt pathology. Some, like the greater values 
+for AcuGraph imbalance variables, PIE, E_S, U_L, L_R, and Y_Y, were expected, while the 
+much larger standard deviations for Group Means of individual meridians is consistent with 
+previous findings. The other major difference, higher group mean conductances for all 
+14 
+ 
+meridians, had not been anticipated, but the statistical significance and effect size are large 
+enough to make this new observation definite.  
+Tables 2b and 3 continue this investigation of high variabilities for individual patients, 
+yielding the significant result: the size of standard deviation in meridian conductance values 
+is much higher for individual depression patients than for no pathology controls. This finding 
+has practical and theoretical implications: practically, high disease susceptibilities of 
+depression patient. Acugraph readings of healthy organs remain within ±15 units of the mean. 
+High individual variances (Table 3) mean that depression patients have several organs outside 
+this range and are in greater danger of falling ill. High values of group standard deviations 
+(Table 1a and 2a) have similar implications. Now consider the possible cause.   
+Variances increase when regulation and control are less precise. Higher individual and group 
+standard deviations suggest that top-down regulation of meridian energies is compromised. 
+This follows if stress levels are higher, as holds for depression. Results are consistent with the 
+fact that stress is a precondition for most disease.  
+Analysis of conductances therefore agrees with identification of stress as an important factor 
+in etiology. If depression is a manifestation of stress, then as a group, depression patients 
+must be in greater danger of physical illness. The data analysis presented here confirms that 
+conclusion from a completely new, self-consistent perspective. It also points to variability of 
+meridian energies as a factor to consider in understanding individual health. 7,9 
+Indian tradition maintains that regular practice of Yoga and associated techniques like 
+meditation improves overall health.16  For example, the Transcendental Meditation 
+technique17 has been shown to steadily decrease health costs of those who learn18, so that 
+regular meditators’ hospitalization costs are some 50% lower than those of a non- practicing 
+control group 19. Data presented here and in other studies7-9 point to two possible mechanisms 
+15 
+ 
+for this: increases in Qi energy as measured by conductance values, and variance reduction 
+with its implication of better variable control. Improved regulation should, in general, 
+improve health. 20,21 If Yoga practice improves physiological control of meridianenergies7,9 
+i.e. regulation, that should contribute to its generally recognised ability to improve health.22,23  
+The study’s strengths include the very definite nature of the results. (1) Their statistical 
+significance, with consistent, higher values of Groups Averages for individual meridian 
+energy levels and SDs, and measures of imbalances for the Depression group; (2) the 
+confirmed expectations of levels of imbalance, and (3) their extension of observations of 
+large SDs from previous studies. 7,9  
+The limitations of the study include the relatively small number of participants (27 
+Depression, 43 Healthy), and its relatively limited choice of populations. The extent to which 
+it may generalize to other populations may be questioned. Being a cross-sectional study is 
+another limitation, though the statistics offset this.  
+The future of this kind of research is to extend AcuGraph3 classifications to further kinds of 
+pathology, and to larger groups from more varied populations. AcuGraph3 measures of 
+depression patients should also be studied in a specialist mental health institution, where 
+processes of recovery of both in- and out-patients can be followed. 
+In both mental health and other pathologies, it should be possible to test hypotheses about 
+how Yoga brings about cure of otherwise chronic pathologies. For example, previous studies 
+have shown that regular Yoga practice improves meridian stability, suggesting how Yoga 
+may benefit patients with mental disturbance, and fitting the picture that restoration of good 
+regulation restores health.20,21 Yoga practice may thus have the side benefit of preventing 
+physical disease in depression patients, whereas merely relieving symptoms by administering 
+anti-depressants will fail to do so.  This implication is worth further research.  
+ 
+16 
+ 
+REFERENCES  
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+4. Meridia Technologies Inc. AcuGraph3 Digital Meridian Imaging. Meridian Technologies. 
+Meridian, Idaho, 2008. 
+5. Mist SD, Aickin M, Kalnins E, Cleaver J, Batchelor R, Thorne T, Chamberlin S et al. 
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+6. Chamberlin S, Colbert AP, Larsen A. Skin conductance at 24 source (Yuan) Acupoints in 
+8637 Patients: Influence of Age, Gender and Time of Day. J Acupunct Meridian Stud 
+2011; 4:14-23.  
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+Variance reduction implies benefits for regulation. Int J Yoga 2013; 6(1)61-65. 
+doi:10.4103/0973-6131.105948 
+8. Meenakshy KB, Alex Hankey, H R Nagendra Electrodermal Assessment of SMET 
+Program for Business Executives-Voice of Res.2014; 2(4):2277-80. 
+9. Sharma B, Hankey A, Nagilla N, Meenakshy KB, Nagendra HR. Do yoga practices 
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+10. Sharma B, Hankey A, Meenakshy KB, Nagendra HR. Inter-operator variability of 
+electrodermal measure at Jing-Well points using Acugraph3. J Acupunct Merid Studies, 
+2014; 7(1):44-51. Epub: 18.03.2013. 
+17 
+ 
+11. Sharma B, Hankey A, Meenakshy KB, Nagendra HR. Acugraph3 measurements at Jing-
+Well points to identify electrodermal characteristics of Type 2 diabetes patients. In 
+Communication.  
+12. Meenakshy KB. Sharma B, Hankey A. Nagendra HR. An Electrodermal Study 
+Comparing HIV Infected Children with Non Infected Children. Res. React. Resol. 2013; 
+1:4-8.  
+13. Jorm A. F. Christensen H. Griffiths K.M. Changes in Depression Awareness and 
+Attitudes in Australia: The Impact of Beyondblue: The National Depression Initiative. 
+Aust N Z J Psychiatry, 2006; 40(1): 42-46. doi: 10.1080/j.1440-1614.2006.01739. 
+14. Veith I. (Trans.)Yellow Emperor’s Classic of Internal Medicine. University of California 
+Press, Berkeley, 2002. 
+15. Veith I: Acupuncture in traditional Chinese Medicine- An historical review. Calif Med 
+118:70-79, Feb 1973 
+16. Nagarathna R. Yoga in Medicine. Chapter 6 in API Textbook of Medicine, 2001. 
+17. Yogi M.M, Science of Being and Art of Living, Transcendental Meditation. Plume, New 
+York. 2001. 
+18. Herron et al. The Impact of the Transcendental Meditation Programme on Government 
+Payments to Physicians in Quebec. American Journal of Health Promotion, 1996, 10, 3: 
+208-216.  
+19. Orme-Johnson DW. Medical Care Utilisation and the Transcendental Meditation 
+Programme. Psychosomatic Medicine, 1987, 49: 493-507. 
+20. Hankey A. A prophet lays down his pen. J. Altern Complement Med, 2012, 18(2): 103-
+105. doi:10.1089/acm.2011.0960.  
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+Med, 2012; 3(3): 119–123. doi: 10.4103/0975-9476.100170 
+18 
+ 
+22. Nagendra H.R Yoga for Promotion of positive health. Swami Vivekananda Yoga 
+Prakashan, Bangalore 2004.  
+23. Nagendra H.R Yoga for Anxiety and Depression. Swami Vivekananda Yoga Prakashan, 
+Bangalore 2001 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+19 
+ 
+FIGURE 1: Hardware used with AcuGraph Digital Meridian Imaging Software, and 
+Positions of Points Measured 
+ 
+ 
+ 
+Figure 1 Caption: The AcuGraph3 Digital Meridian Imaging System uses the hardware 
+shown: a probe with a flat round end,  which contacts selected acupuncture points, while the 
+subject holds the ‘Ground Bar’ (depicted) n the opposite hand. All such electrical apparatus 
+including the control unit plugs into the controlling computer. This experiment assessed 
+electrodermal conductance at the Jing Well meridian end points in the positions shown at the 
+end of each meridian. On the hands, Lungs (Thumb), Large Intestine (index Finger), 
+Pericardium (Middle Finger), Triple Warmer (Ring Finger), and Heart and Small Intestine 
+(Little Finger), and on the feet,  Spleen and Liver (Big Toe), Stomach (second toe), Gall 
+Bladder (Fourth Toe), and Kidney and Bladder(Pink).    
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 

subfolder_0/Design and validation of Integrated Yoga Therapy module for Antarctic.txt

@@ -0,0 +1,406 @@
+Original Research Article
+Design and validation of Integrated Yoga Therapy module for Antarctic
+expeditioners
+Ragavendrasamy Balakrishnan a, Ramesh Mavathur Nanjundaiah a, *, Mohit Nirwan b,
+Manjunath Krishnamurthy Sharma c, Lilly Ganju b, Mantu Saha b, Shashi Bala Singh d,
+Nagendra Hongasandra Ramarao e
+a Molecular Biosciences Laboratory, Anvesana Research Laboratories, S-VYASA University, Bangalore, India
+b Defence Institute of Physiology and Allied Sciences, New Delhi, India
+c Anvesana Research Laboratories, S-VYASA University, Bangalore, India
+d Life Sciences Research Board, Defence Research and Development Organisation, New Delhi, India
+e S-VYASA University, Bangalore, India
+a r t i c l e i n f o
+Article history:
+Received 20 July 2017
+Received in revised form
+27 October 2017
+Accepted 18 November 2017
+Available online xxx
+Keywords:
+Yoga module
+Antarctica
+Stress
+IAYT
+a b s t r a c t
+Background: Extreme environments are inherently stressful and are characterized by a variety of physical
+and psychosocial stressors, including, but not limited to, isolation, confinement, social tensions, minimal
+possibility of medical evacuation, boredom, monotony, and danger. Previous research studies recom-
+mend adaptation to the environment to maintain optimal function and remain healthy. Different in-
+terventions have been tried in the past for effective management of stress. Yoga practices have been
+shown to be beneficial for coping with stress and enhance quality of life, sleep and immune status.
+Objective: The current article describes preparation of a Yoga module for better management of stressors
+in extreme environmental condition of Antarctica.
+Materials and methods: A Yoga module was designed based on the traditional and contemporary yoga
+literature as well as published studies. The Yoga module was sent for validation to forty experts of which
+thirty responded.
+Results: Experts (n ¼ 30) gave their opinion on the usefulness of the yoga module. In total 29 out of 30
+practices were retained. The average content validity ratio and intra class correlation of the entire
+module was 0.89 & 0.78 respectively.
+Conclusion: A specific yoga module for coping and facilitating adaptation in Antarctica was designed and
+validated. This module was used in the 35th Indian Scientific expedition to Antarctica, and experiments
+are underway to understand the efficacy and utility of Yoga on psychological stress, sleep, serum bio-
+markers and gene expression. Further outcomes shall provide the efficacy and utility of this module in
+Antarctic environments.
+© 2018 The Authors. Published by Elsevier B.V. on behalf of Institute of Transdisciplinary Health Sciences
+and Technology and World Ayurveda Foundation. This is an open access article under the CC BY-NC-ND
+license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
+1. Introduction
+Characteristics
+and
+determinants
+of
+human
+response
+to
+extreme environmental conditions prevailing in the Antarctic
+continent has interested psychologists and physiologists. Extreme
+environments are inherently stressful and are characterised by a
+variety of physical and psychosocial stressors including but not
+limiting
+to
+capsule
+environment,
+isolation,
+social
+tensions,
+boredom, monotony and danger [1]. The international commit-
+tees, COMNAP (The Council of Managers for National Antarctic
+Program) and SCAR (Scientific Committee of Antarctic Research),
+in addition to the organisers of the expedition from individual
+countries, are primarily concerned to enhance the overall well-
+ness of the members sent to the Antarctic stations. Even though
+scientific research is the primary goal of Antarctic expedition,
+equal importance is given to take care of the physical and psy-
+chological health of the expeditioners starting from selection of
+expeditioners to emergency evacuation to involving behavioural
+* Corresponding author.
+E-mail: [email protected] (R.M. Nanjundaiah).
+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.2017.11.005
+0975-9476/© 2018 The Authors. Published by Elsevier B.V. on behalf of Institute of Transdisciplinary Health Sciences and Technology and World Ayurveda Foundation. This is
+an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
+Journal of Ayurveda and Integrative Medicine xxx (2018) 1e4
+Please cite this article in press as: Balakrishnan R, et al., Design and validation of Integrated Yoga Therapy module for Antarctic expeditioners,
+J Ayurveda Integr Med (2018), https://doi.org/10.1016/j.jaim.2017.11.005
+scientist and psychologists to offering periodic support through
+online group or individual psychological counselling sessions for
+helping expeditioners deal with the stress [2].
+Several psychological and physiological changes are observed in
+Antarctic expeditioners. Psychological changes range from behav-
+ioural changes like aggression, mood swings to psychiatric prob-
+lems like depression [3]. Isolation seems to have a considerable
+effect. Isolation and inherent danger associated in Antarctic envi-
+ronment might enhance the extent of repetitive negative thinking
+based on the personality of the individual. Reports suggest an in-
+crease in smoking, loneliness, homesickness and a reduction in
+rapport during the isolated dark winter months [4]. Physiologically,
+decreased immune responsiveness accompanied with variations in
+circulating insulin, thyroid stimulating hormones, testosterone,
+cortisol, melatonin, pro-inflammatory Cytokines, 25-OH-vitamin D
+and a significant increase in total cholesterol have been recorded
+[5e8]. Some studies also suggest that such challenging environ-
+ments also turn to be salutogenic in certain individuals. With
+limited access to health care in the Antarctic environment, strate-
+gies are required to be adopted to promote overall psycho-physical
+wellness of an individual and also the group. Interestingly, Yoga
+practices have been known to be beneficial and promote psycho-
+physiological wellbeing across human cultures.
+Physical postures (asana), voluntarily regulated breathing (pra-
+nayama), and meditation (dhyana) are the three main components
+of Yoga practiced in India over thousands of years. In the past
+decade, Yoga has gained popularity as a fitness strategy and as well
+as an adjunct therapeutic tool in the management of obesity [9],
+diabetes [10], hypertension [11] and even auto-immune disorders
+[12]. Yoga practices have been shown to alleviate anxiety, fear
+[13,14], negative thinking [15], and enhance cardio-pulmonary
+fitness [16], immune status [17,18], and also telomere length [19]
+in regular practitioners. Yoga practices improve the overall sleep
+efficiency and total sleep time [20]. Yoga practice in high altitudes
+showed a lower reduction in oral temperature and lower increase
+in Oxygen consumption and energy expenditure compared to
+physical therapy [21]. Meta-analysis of data on Yoga recommend
+Yoga to be considered as an ancillary treatment option in the
+management of depressive disorders [22].
+A study was conducted on the summer and wintering over
+members of the 35th Indian Scientific Expedition Members to
+Antarctica to understand the role of Yoga practices on facilitating
+human adaptation to extreme climatic conditions. Even though
+Yoga practices are known to be beneficial for individuals irre-
+spective of their health and disease states, it is essential to structure
+specific Yoga practices that are intended to provide most benefits.
+Yoga practices for Antarctica were designed with the following
+objectives:
+i. To regulate mood and alleviate psychological stress caused
+due to isolation
+ii. To enhance physical wellness, overcome fatigue and regulate
+metabolism
+iii. To enable better thermoregulation
+iv. To
+enhance
+better
+sleep
+and
+promote
+interpersonal
+relationship
+The objectives were listed based on the earlier reports on the
+psychological and physiological changes in Antarctic expeditioners.
+Practices identified were compiled together to promote calmness of
+mind and sleep, overcome stress and fatigue, promote overall
+endurance of the body, regulate digestion, metabolism and enable
+better pulmonary functions (supplementary material 1). The cur-
+rent study present the data on the designing and validation of the
+Yoga module that was implemented in the expedition members.
+2. Materials and methods
+The classical and contemporary yoga texts were reviewed to
+develop the content of the Yoga module. Texts on Yoga Sutras of
+Patanjali, Hatha Yoga Pradipika, Shiva Samhitha, Gheranda Samhita,
+Hatharathnavali, Bhagavad Gita, Upanishads, Yoga Vashishta and
+Yogic Sukshma Vyayama were reviewed [23e31]. Practices that
+might be difficult for the expeditioners to practice and those that
+are contra-indicated in common disorders such as hypertension
+and cardiovascular disorders were not included. Similarly, those
+practices that were difficult to objectively verify and certain
+Sükshma vy€
+ay€
+ama (loosening exercise) practices that might not be
+feasible to practice in group inside the Antarctic stations like
+Jangha Shakti vikasaka [31] were not included. The Yoga module
+that was designed consisted of postures with slow movements
+and breath
+awareness, loosening exercises, suryanamaskara,
+asana, pra€
+eayama, relaxation and nadanusandhana. The duration
+of the entire practice is 1 h.
+The Yoga module was sent along with the objectives to forty
+yoga experts out of whom thirty responded with their scores and
+comments. Members with allopathic & AYUSH streams of med-
+icine with post graduate medical degree in Yoga therapy, re-
+searchers with doctoral degree in yoga, and yoga & naturopathic
+physicians with over 7 years of clinical experience were consid-
+ered to be included in the expert panel for validating the Yoga
+module. The experts rated the usefulness of the module on a
+scale of 1e5 (1 not at all useful, 2 a little useful, 3 moderately
+useful, 4 very useful, 5 extremely useful). Content Validity Ratio
+(CVR) for suitability of items was calculated following Lawshe's
+method [32]. Dichotomous (yes/no) responses were obtained to
+determine the duration of the individual practice and the entire
+yoga session.
+2.1. Statistical analysis
+Lawshe's CVR ratio was calculated [32] for each item in the
+module. Items with a CVR of 0.6 and above were considered beyond
+change agreement (p < 0.05, one tailed) for 30 experts. Intra class
+correlation was calculated for inter-rater reliability [33].
+3. Results
+Thirty experts in Yoga therapy and research consented to
+contribute to the content validation of the Yoga module for
+extreme Antarctic environmental conditions. These Yoga experts
+had experience in various traditions of Yoga. The experts age
+ranged from 32 to 50 years (mean 36.3 ± 4.17 years). The average
+experience following formal yoga training was 12.3 years
+ranging between 8 and 26 years. The scores obtained for the
+individual practices and the calculated CVR are shown in the
+supplementary material 2. One practice viparitakarani with CVR
+<0.6 was excluded. The average CVR for the entire Yoga module
+was 0.89. Good agreement is noted for most practices listed in
+the yoga module. Intra Class Correlation [33] for the entire
+module was 0.78.
+All
+the experts opined on the need
+for practicing
+Sur-
+yanamaskara (sun salutation), relaxation and breath awareness
+based practices and pranayama. Most experts agreed on the dura-
+tion of 1 h for the Yoga practices (Table 1). In addition to the
+practices that were asked to be scored by experts, seven experts
+recommended to include vaman dhauti kriya (voluntarily induced
+vomiting after drinking saline water in empty stomach). But, was
+not considered in module due to challenges in water treatment and
+discharge at Antarctica.
+R. Balakrishnan et al. / Journal of Ayurveda and Integrative Medicine xxx (2018) 1e4
+2
+Please cite this article in press as: Balakrishnan R, et al., Design and validation of Integrated Yoga Therapy module for Antarctic expeditioners,
+J Ayurveda Integr Med (2018), https://doi.org/10.1016/j.jaim.2017.11.005
+4. Discussion
+The Yoga module for application in the extreme Antarctic con-
+ditions appears to be acceptable for most of the experts. Similar
+strategy was used in earlier studies for validating yoga modules for
+various pathological conditions [34,35].
+The experts from different schools of yoga were in agreement
+with the contents of the module. Only viparitakarani was not fav-
+oured to be included in the final module as indicated by the CVR
+score (<0.6). Seven experts suggested including vaman dhauti kriya.
+However, with concerns over processing the waste water and
+maintenance in the Antarctic stations and the decision of experts
+not being unanimous, the recommendation was not taken further
+into validation.
+Several interventions like psychiatric counselling, group ther-
+apy, medications and diet are tried on the expeditioners to reduce
+their psycho-physiological stress. Yoga, a widely accepted reliever
+of stress [36], has never been tried in Antarctica until now. Also, the
+strengths of this module is that it consists of simple postures that
+are easy to follow and as the practices are derived from traditional
+yoga texts, yoga instructor following any school of Yoga should be
+able to teach the module. The classical Yoga texts does not describe
+specific symptom based guidelines for their practice e as the pri-
+mary objective of Yoga practices is to gain mastery over mind [26]
+and the observed physical and mental benefits might be actual by-
+product of yoga practice. Therefore, the practices have been
+selected from the texts based on the approximating descriptions of
+mental and physical health benefits of specific Yoga practices and
+that are feasible to be practiced at the Indian Antarctic station. This
+is the first attempt made to administer structured Yoga practices
+with an objective to understand its mechanisms of action in iso-
+lated, stressful and extreme Antarctic conditions. The effect of the
+Yoga intervention will be known when the study on the summer
+[Voyage team] and wintering over [Bharati, Larsemann hills,
+(692402800S 761101400E)] members of the 35th Indian Scientific
+Expedition to Antarctica will be analysed for changes in their psy-
+chological stress, sleep, serum biomarkers, and gene expression
+regulations.
+5. Conclusion
+A comprehensive and traditional text based Yoga module was
+developed as an intervention to facilitate coping up with the psy-
+chological and physiological stressors in the Antarctica. The Yoga
+module was validated by 30 experts who agreed to most of the
+practices. The final module was used as an intervention in the 35th
+Indian Scientific Expedition to Antarctica. Testing of efficacy of the
+intervention on alleviating psycho-physiological stress at genetic
+and molecular level is underway and might prove to be an efficient
+way to deal the stressors associated with the extreme Antarctic
+environments.
+Funding
+This project was funded by Defence Institute of Physiology and
+Allied Sciences, New Delhi (TC/DIP-265/CARS-05/DIPAS/2-15).
+Acknowledgements
+The authors acknowledge all the experts for offering their
+comments and inputs to develop this module.
+Appendix A. Supplementary data
+Supplementary data to this article can be found online at
+https://doi.org/10.1016/j.jaim.2017.11.005.
+References
+[1] Suedfeld P. Applying positive psychology in the study of extreme environ-
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+[2] Suedfeld P, Steel GD. The environmental psychology of capsule habitats. Annu
+Rev Psychol 2000;51. p 227e53.
+[3] Gunderson EKE. Emotional symptoms in extremely isolated groups. Arch Gen
+Psychiatr 1963;9. p 362.
+[4] Bhargava R, Mukerji S, Sachdeva U. Psychological impact of the Antarctic
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+J Ayurveda Integr Med (2018), https://doi.org/10.1016/j.jaim.2017.11.005
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+(10C) in men after six months' practice of yoga exercises. Int J Biometeorol
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+review and meta-analysis. Depress Anxiety 2013;30. p 1068e83.
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+Please cite this article in press as: Balakrishnan R, et al., Design and validation of Integrated Yoga Therapy module for Antarctic expeditioners,
+J Ayurveda Integr Med (2018), https://doi.org/10.1016/j.jaim.2017.11.005

subfolder_0/Designing, validation, and feasibility of integrated yoga therapy module for chronic low back pain_unlocked.txt

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+103
+International Journal of Yoga • Vol. 8 • Jul-Dec-2015
+disability, and reduced health‑related quality of life.[5,6] LBP 
+was identified by the Pan American Health Organization as 
+one of the top three occupational health problems.[7] The 
+complex nature of the CLBP demand multidimensional 
+approach to treatment.[8] There is a wide variety of 
+treatments available for CLBP
+. A pilot study by Eisenberg 
+et al., showed that, multidisciplinary (integrated) approach, 
+which includes conventional care, complementary, and 
+alternative medicines (CAM) or both is promising in the 
+treatment of patients with persistent LBP
+.[9]
+In the recent past yoga has emerged as one of the 
+evidence‑based CAM in CLBP
+, which is widely used across 
+the globe. According to national surveys, yoga practice has 
+increased, with over 10 million Americans practicing yoga 
+for health reasons in 2002 and over 13 million in 2007.[10,11] 
+Popularity of yoga has led to several schools of yoga viz., 
+INTRODUCTION
+Chronic low back pain  (CLBP) defined as back pain 
+lasting >12 weeks. Low back pain (LBP) is a common and 
+costly health problem; 70–80% of adults are afflicted by it at 
+some point of time in their lives,[1,2] expenditures attributed 
+to spine problems were $2580 per person. The CLBP 42% 
+prevalence rate.[3] In addition to the pain, CLBP has also 
+resulted in increased psychological distress,[4] increased 
+Original Article
+Designing, validation, and feasibility of integrated yoga 
+therapy module for chronic low back pain
+Nitin J Patil, Raghuaram Nagarathna1, Padmini Tekur1, Dhanashree N Patil1, Hongasandra Ramarao Nagendra1,  
+Pailoor Subramanya1
+Department of Integrative Medicine, Sri Devaraj Urs University, Tamka, Kolar, 1Division of Yoga and Life Sciences, S-VYASA Yoga University, 
+Bengaluru, Karnataka, India
+Address for correspondence: Dr. Nitin J Patil, 
+Department of Integrative Medicine, Sri Devaraj Urs University, Tamaka, Kolar - 563 101, Karnataka, India. 
+E-mail: [email protected]
+Context: Chronic low back pain (CLBP) is a significant public health problem that has reached epidemic proportions. Yoga 
+therapy has emerged as one of the complementary and alternative therapies for CLBP.
+Aim: The present study reports the development, validation, and feasibility of an integrated yoga therapy module (IYTM) for 
+CLBP.
+Settings and Design: This study was carried out at the SVYASA Yoga University, Bengaluru, South India. The IYTM for CLBP 
+was designed, validated, and later tested for feasibility in patients with CLBP.
+Materials and Methods: In the first phase, IYTM for CLBP was designed based on the literature review of classical texts and 
+recently published research studies. In the second phase, designed IYTM (26 yoga practices) was validated by thirty subject 
+matter (yoga) experts. Content validity ratio (CVR) was analyzed using Lawshe’s formula. In the third phase, the validated 
+IYTM (20 yoga practices) was tested on 12 patients for pain, disability and perceived stress at baseline and after 1‑month of 
+this intervention.
+Results: A total of 20 yoga practices with CVR ≥0.33 were included, 6 yoga practices with CVR ≤0.33 were excluded from the 
+designed IYTM. The feasibility study with validated IYTM showed significant reduction in numerical pain rating scale (P = 0.02), 
+Oswestry disability scale (P = 0.02), and Perceived Stress Scale (P = 0.03).
+Conclusion: The designed IYTM was validated by thirty yoga experts and later evaluated on a small sample. This study has 
+shown that the validated IYTM is feasible, had no adverse effects and was useful in alleviating pain, disability, and perceived 
+stress in patients with CLBP. However, randomized control trials with larger sample are needed to strengthen the study.
+Key words: Chronic low back pain; content validity ratio; integrated yoga therapy module.
+ABSTRACT
+Access this article online
+Website: 
+www.ijoy.org.in
+Quick Response Code
+DOI: 
+10.4103/0973-6131.158470 
+[Downloaded from http://www.ijoy.org.in on Wednesday, July 27, 2016, IP: 14.139.155.82]
+International Journal of Yoga • Vol. 8 • Jul-Dec-2015
+104
+Patil, et al.: Validation of yoga module for low back pain
+Iyengar yoga, Viniyoga, Astanga yoga, Hatha yoga, Laughter 
+yoga, Sudarshana kriya yoga, etc. Stress‑related LBP seems 
+to be an appropriate indication for yoga therapy as large 
+number of literature supports the same.[12] Literature 
+review reveals that, Viniyoga, Hatha yoga, Iyengar yoga, 
+and Integrated yoga are the most commonly used forms 
+to treat LBP
+.[13‑15]
+In a systematic review, Chou and Huffman found that, 
+yoga therapy is effective for sub‑acute or CLBP
+. In a large 
+sample study of 6 weeks, Viniyoga was found to be superior 
+to conventional exercise. In another review by Posadzki 
+and Ernst which included four randomized controlled 
+trials  (RCTs) apart from Chou and Huffman’s review, 
+revealed that the intervention of Iyengar and Viniyoga 
+for the period of 12–24 weeks were beneficial in CLBP
+.[14] 
+Tekur et al., intervened CLBP patients with 7‑day intensive 
+residential integrated yoga and found it beneficial for pain, 
+disability, anxiety, stress, and quality of life in patients with 
+CLBP
+.[15‑17] Another review of Cramer et al., found 12 studies 
+meeting inclusion criteria, reported on Viniyoga, Iyengar 
+yoga, and Hatha yoga interventions for CLBP
+. Ten of these 
+studies were included in the meta‑analysis, which strongly 
+favored over control interventions for reducing pain and 
+disability scores.[18]
+Different schools of yoga have varying proportions of 
+physical, breathing, and mind activities executed through 
+varied practices. Most of these studies found a varied 
+range of positive benefits on CLBP
+. These advances have 
+given us a lead to develop a standardized module by 
+extracting the best yoga practices out of different schools 
+of yoga, as they had a common objective “chitta vritti 
+nirodhah”  (voluntary mastery over the modifications 
+of the mind).[19] The present study report development, 
+validation, and feasibility of validated integrated yoga 
+therapy module (IYTM) for CLBP
+.
+MATERIALS AND METHODS
+The designing, validation, and feasibility of IYTM for 
+CLBP [Figure 1] were carried out in the following steps:
+First phase: Designing of integrated yoga therapy module 
+for chronic low back pain
+Designing the IYTM for CLBP was done by using 
+classical texts,[19‑21] recent books on back pain,[22‑27] 
+peer‑reviewed research publications and other related 
+sources for the development of IYTM for CLBP
+.[14‑18,28‑30] 
+Underlying mechanism of the beneficial effects of 
+each yoga practice yet to be explored. Twenty‑six 
+yoga practices were tabulated under designed IYTM, 
+which had strong support for beneficial effects on 
+CLBP [Table 1].
+Second phase: Validation of integrated yoga therapy 
+module for chronic low back pain
+Validation of designed IYTM‑26 yoga practices [Table 2] 
+was done with the help of subject matter expert 
+raters (SMEs)/experts, viz. Doctor of Medicine in Yoga, 
+Doctorates in Yoga with minimum experience of 5 years 
+in the field of yoga, and yoga therapists with a masters 
+in Yoga having minimum experience of 7  years after 
+post formal education. Thirty SMEs were consented 
+to participate in the evaluation. They marked content 
+validity on a three (0–2) point scale, viz. Not necessary ‑ 0, 
+Useful but not essential ‑ 1, Essential ‑ 2. After validation, 
+data were analyzed using Lawshe’s content validity 
+ratio (CVR).[31]
+Third phase: Feasibility study
+T
+welve patients (5 male and 7 female) with age 36.75 ± 3.79 
+having nonspecific CLBP who consented to participate in 
+the study were recruited from SVYASA Yoga University, 
+Bengaluru, India. The inclusion criteria were (a) History 
+of CLBP of more than 12 weeks (b) pain in the lumbar 
+spine with or without radiation to legs and (c) age between 
+18 and 45 years. Exclusion criteria were, (a) CLBP due to 
+organic pathology in the spine, like malignancy (primary 
+or secondary) or chronic infections investigated by X‑ray 
+of the lumbar spine.[32] The study was approved by the 
+institutional review board and the ethical committee of the 
+Table 1: Designed IYTM for CLBP based on literature 
+review
+Specific practices
+Supta udarakarshanasana (folded leg lumbar stretch)
+Shava udarakarshanasana (crossed leg lumbar stretch)
+Pavanamuktasana (wind releasing pose)
+Setu bandhasana breathing (bridge pose lumbar stretch)
+Instant relaxation technique
+VyaghraSana (tiger breathing)
+Bhujangasana (serpent pose)
+Shalabhasana breathing (locust pose),
+Shashankasana breathing (moon pose)
+Uttanapadasana (straight leg raise pose)
+Quick relaxation techniques
+Ardha kati chakrasana (lateral arc pose)
+Ardha chakrasana (half wheel pose)
+Parivrtta trikonasana (revolved triangle pose)
+Ustrasana (camel pose)
+Vakrasana (twisted pose)
+Viparitakarani (half shoulder stand) with wall support
+Deep relaxation technique
+Vibhagiya pranayama (sectional breathing)
+Nadi shuddhi (alternate nostril breathing)
+Bhramari (humming bee breath)
+Dharana/dhyana (meditation)
+Nadanusandhana (A, U, M, AUM chanting)
+Om dhyana (Om meditation)
+Laghoo shankhaprakshalana (yogic colon cleansing)
+Trataka (yogic gazing)
+IYTM = Integrated yoga therapy module; CLBP = Chronic low back pain
+[Downloaded from http://www.ijoy.org.in on Wednesday, July 27, 2016, IP: 14.139.155.82]
+105
+International Journal of Yoga • Vol. 8 • Jul-Dec-2015
+Patil, et al.: Validation of yoga module for low back pain
+Designing IYTM for CLBP, based on literature review
+(26 Yoga practices)   
+Validation of designed IYTM was done by 30 Yoga experts 
+Lawshe's content validity ratio were calucated for each practices
+(Validated IYTM consists  of 20 yoga pratcies)
+Feasibility study - 12 CLBP patients recruited and consent obtained  
+Intervention with validated IYTM (20 Yoga Practices)
+(5 days a week for one month) 
+Validated IYTM for CLBP
+found Feasible   
+Figure 1: Depicts the steps in the development of the integrated yoga therapy module for chronic low back pain
+University. Signed informed consent was obtained from all 
+patients. All the patients have come with X‑ray/magnetic 
+resonance imaging/computed tomography, none of them 
+had sciatica. They were intervened with the validated 
+IYTM [Table 3] for 1‑month (1 h/day, 5 days a week). 
+Assessed for pain, disability, and perceived stress by 
+using the numerical rating scale (NRS), oswestry disability 
+index (ODI), and perceived stress scale (PSS), respectively 
+at baseline and after 1‑month of the intervention. All the 
+12 patients completed the intervention. There were no 
+adverse effects observed during the study period.
+RESULTS
+Results: Content validity
+30 SMEs validated all the 26 practices of designed IYTM for 
+CLBP
+. Data were analyzed for content validity using Lawshe’s 
+CVR.[31] Lawshe’s formula is CVR = (ne − N/2)/(N/2), where, 
+CVR = Content validity ratio, ne = number of SME panelists 
+indicating “essential,” N = Total number of SME panelists, 
+SME. CVR was calculated for all the 26 practices and 
+tabulated [Table 2]. Among them, 20 yoga practices [Table 3] 
+with CVR ≥0.33 were included, 6 yoga practices [Table 4] 
+with CVR ≤0.33 were excluded from designed IYTM. Mean 
+CVR of validated IYTM was 0.7 ± 0.24. As per the Lawshe’s 
+CVR ratio the minimum value for 30 SMEs is 0.33, it means 
+the CVR ratio achieved to evaluate the content validity of 
+the IYTM is found to be significant and the validated IYTM 
+is valid to be used as an intervention for CLBP patients.
+Results: Feasibility study
+Twelve CLBP patients, who consented to the study, were 
+intervened with validated IYTM, which consisted of 
+20 practices with CVR ≥0.33. Assessments were done at 
+baseline and after 1‑month of intervention. All patients 
+[Downloaded from http://www.ijoy.org.in on Wednesday, July 27, 2016, IP: 14.139.155.82]
+International Journal of Yoga • Vol. 8 • Jul-Dec-2015
+106
+Patil, et al.: Validation of yoga module for low back pain
+completed the intervention; no adverse effects were noticed 
+during the study. Data were analyzed using Wilcox test, 
+which showed a significant reduction in pain (P = 0.02), 
+disability (P = 0.02), and perceived stress (P = 0.03).
+DISCUSSION
+This study was planned in three phases viz. (a) designing 
+of IYTM for CLBP (b) validation of IYTM for CLBP by 
+SMEs (c) feasibility study of validated IYTM.
+•	 In the first phase, integrated yoga module for CLBP 
+was designed based on literature reviews of traditional 
+textual references, recent research publications, and 
+advice from yoga experts. Our comprehensive search in 
+traditional yogic texts did not yield any direct references 
+for yogic practices with the ability of improving the 
+CLBP
+. However, recent Hatha yogic texts[19,20] lay more 
+emphasis on improving health through different yogic 
+practices. In addition to that, recent findings of several 
+schools of yoga in their research studies on CLBP were 
+helped in formulating IYTM for CLBP
+•	 Subject matter (Yoga) experts (SMEs) were involved in 
+the validation process. CVR was calculated for all the 
+26 practices of designed IYTM. CVR was developed 
+by C. H. Lawshe. It is essentially a method for gauging 
+agreement among raters or judges regarding how 
+essential a particular item is. Lawshe (1975) proposed 
+that each of the SMEs on the judging panel responds 
+to the following question for each item: “Is the skill or 
+knowledge measured by this item “essential,” “useful, 
+but not essential” or “not necessary.” According to 
+Lawshe, if more than half of the panelists indicate 
+Table 3: IYTM practices with CVR ≥0.33 need to be 
+retained (validate IYTM)
+Name of the practices
+CVR
+Supta udarakarshanasana (folded leg lumbar stretch)
+0.86
+Shava udarakarshanasana (crossed leg lumbar stretch)
+0.86
+Pavanamuktasana (wind releasing pose)
+0.86
+Setu bandhasana breathing (bridge pose lumbar stretch)
+1.0
+Instant relaxation technique
+0.6
+VyaghraSana (tiger breathing)
+0.6
+Bhujangasana (serpent pose)
+0.8
+Shalabhasana breathing (locust pose)
+0.33
+Uttanapadasana (straight leg raise pose)
+0.33
+Quick relaxation techniques
+0.8
+Ardha kati chakrasana (lateral arc pose)
+0.6
+Ardha chakrasana (half wheel pose)
+0.33
+Deep relaxation technique
+1.0
+Vibhagiya pranayama (sectional breathing)
+0.66
+Nadi shuddhi (alternate nostril breathing)
+1.0
+Bhramari (humming bee breath)
+0.86
+Dharana/dhyana (meditation)
+0.73
+Nadanusandhana (A, U, M, AUM chanting)
+1.0
+Om Dhyana (Om meditation)
+0.53
+Laghoo shankhaprakshalana (yogic colon cleansing)
+0.33
+Mean
+0.7
+SD
+0.24
+IYTM = Integrated yoga therapy module; SD = Standard deviation;  
+CVR = Content validity ratio
+Table 2: Validated IYTM for CLBP with CVR as per Lawshe formula
+Specific practices
+Ne*
+N**
+N/2
+Ne-N/2
+CVR***
+Supta udarakarshanasana (folded leg lumbar stretch)
+28
+30
+15
+13
+0.86
+Shava udarakarshanasana (crossed leg lumbar stretch)
+28
+30
+15
+13
+0.86
+Pavanamuktasana (wind releasing pose)
+27
+30
+15
+12
+0.86
+Setu bandhasana breathing (bridge pose lumbar stretch)
+30
+30
+15
+15
+1.0
+Instant relaxation technique
+24
+30
+15
+09
+0.6
+VyaghraSana (tiger breathing)
+24
+30
+15
+09
+0.6
+Bhujangasana (serpent pose)
+27
+30
+15
+12
+0.8
+Shalabhasana breathing (locust pose)
+20
+30
+15
+05
+0.33
+Shashankasana breathing (moon pose)
+16
+30
+15
+01
+0.06
+Uttanapadasana (straight leg raise pose)
+20
+30
+15
+05
+0.33
+Quick relaxation techniques
+27
+30
+15
+12
+0.8
+Ardha kati chakrasana (lateral arc pose)
+24
+30
+15
+09
+0.6
+Ardha chakrasana (half wheel pose)
+20
+30
+15
+05
+0.33
+Parivrtta trikonasana (revolved triangle pose)
+10
+30
+15
+−05
+−0.33
+Ustrasana (camel pose)
+17
+30
+15
+02
+0.13
+Vakrasana (twisted pose)
+14
+30
+15
+−01
+−0.06
+Viparitakarani (half shoulder stand) with wall support
+10
+30
+15
+−05
+−0.33
+Deep relaxation technique
+30
+30
+15
+15
+1.0
+Vibhagiya pranayama (sectional breathing)
+25
+30
+15
+10
+0.66
+Nadi shuddhi (alternate nostril breathing)
+30
+30
+15
+15
+1.0
+Bhramari (humming bee breath)
+28
+30
+15
+13
+0.86
+Dharana/dhyana (meditation)
+26
+30
+15
+11
+0.73
+Nadanusandhana (A, U, M, AUM chanting)
+30
+30
+15
+15
+1.0
+Om Dhyana (Om meditation)
+23
+30
+15
+08
+0.53
+Laghoo shankhaprakshalana (yogic colon cleansing)
+20
+30
+15
+05
+0.33
+Trataka (yogic gazing)
+09
+30
+15
+−06
+−0.4
+Mean
+22.58
+30
+15
+7.58
+0.61
+SD
+6.53
+0
+0
+6.53
+0.39
+*Ne = Total number of essentials for each practice; **N = Total number of panelists; ***CVR = Content validity ratio; IYTM = Integrated yoga therapy module; 
+CLBP = Chronic low back pain; SD = Standard deviation
+[Downloaded from http://www.ijoy.org.in on Wednesday, July 27, 2016, IP: 14.139.155.82]
+107
+International Journal of Yoga • Vol. 8 • Jul-Dec-2015
+Patil, et al.: Validation of yoga module for low back pain
+that an item is essential, that item has at least some 
+content validity. Greater levels of content validity 
+exist as larger numbers of the panelists agree that a 
+particular item is essential. Using these assumptions, 
+Lawshe developed a formula termed the CVR: Lawshe’s 
+formula is CVR =  (ne−N/2)/(N/2), where the CVR, 
+number of SME panelists indicating “essential,” total 
+number of SME panelists. This formula yields values, 
+which range from +1 to −1; positive values indicate 
+that at least half the SMEs rated the item as essential. 
+The mean CVR across the items may be used as an 
+indicator of overall.
+Content validity ratio was calculated for all the 26 practices of 
+designed IYTM. Among them, 20 practices with CVR ≥0. 33 
+included in the validated IYTM [Table 3]. Other six practices 
+with CVR ≤0.33 viz., Sasankasana breathing (0.06), Parivritta 
+trikonasana (−0.33), Ustrasana/Ardha ustrasana (0.13), 
+Vakrasana/Ardhamastyendrasana (−0.06), Viparitakarani 
+with wall support (−0.33), Trataka (−0.4). These practices 
+were either complimentary poses for an important posture 
+to align the body and mind level. Due to these reasons, most 
+of the experts have not considered them as essential for 
+CLBP
+. Apart from those 6 practices, all other 20 practices 
+were considered to be essential for CLBP; this made the 
+final CVR ratio satisfy the minimum value as per Lawshe’s 
+CVR ratio.
+Twelve patients were intervened by validated IYTM 
+(20 practices), and they were assessed pre‑  and 
+post‑intervention for pain (NRS), disability (ODI), and 
+perceived stress (PSS). All three outcome measures, showed 
+statistically significant (P < 0.005) positive impact of validated
+IYTM on CLBP patients. All 12 patients completed the 
+intervention, there were no adverse effects noticed during 
+the study. In case of nonspecific CLBP
+, validated IYTM 
+may use as complimentary intervention. However, RCT 
+with larger samples are needed to validate its efficacy as 
+a primary intervention.
+CONCLUSION
+Integrated yoga therapy module having 26 practices for 
+CLBP
+, was designed on the basis of literature review, 
+which was validated by 30 Yoga experts. Among 26 yoga 
+practices, 20 were found to be essential (CVR ≥0.33) and 
+6 not essential (CVR ≤0.33) for CLBP
+. Feasibility study 
+showed that validated IYTM was found to be beneficial 
+for pain, disability, and perceived stress in patients with 
+CLBP
+. The present validation brings greater acceptability 
+and better therapy module for CLBP
+.
+LIMITATIONS OF THE STUDY
+In the present study, validated IYTM was only tested on a 
+small sample of 12, however, RCTs with the larger sample 
+can become a curtain raiser for future work.
+ACKNOWLEDGMENT
+We would like to thank the staff of SVYASA Yoga University, 
+Bengaluru, India for their support throughout the study. We 
+would like to thank Dr. Judu I. SVYASA University, Bengaluru 
+for statistical analysis.
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+Table 4: IYTM practices with CVR ≤0.33 need to be 
+deleted/removed
+Name of the practices
+CVR
+Shalabhasana breathing (locust pose)
+−0.06
+Parivrtta trikonasana (revolved triangle pose)
+−0.33
+Ustrasana (camel pose)
+0.13
+Vakrasana (twisted pose)
+−0.06
+Viparitakarani (half shoulder stand) with wall support
+−0.33
+Trataka (yogic gazing)
+−0.4
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+[Downloaded from http://www.ijoy.org.in on Wednesday, July 27, 2016, IP: 14.139.155.82]
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+How to cite this article: Patil NJ, Nagarathna R, Tekur P, Patil DN, 
+Nagendra HR, Subramanya P. Designing, validation, and feasibility of 
+integrated yoga therapy module for chronic low back pain. Int J Yoga 
+2015;8:103-8.
+Source of Support: Nil. Conflict of Interest: None declared.
+Author Help: Online submission of the manuscripts
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+1) 	 First Page File: 
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subfolder_0/Development of a Yoga programme for type-2 diabetes prevention (YOGA-DP) among high-risk people in India.txt

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+ORIGINAL RESEARCH
+published: 17 November 2020
+doi: 10.3389/fpubh.2020.548674
+Frontiers in Public Health | www.frontiersin.org
+1
+November 2020 | Volume 8 | Article 548674
+Edited by:
+Lambert Felix,
+The University of Manchester,
+United Kingdom
+Reviewed by:
+Raj Maturi,
+Indiana University Bloomington,
+United States
+Anju Devianee Keetharuth,
+The University of Sheffield,
+United Kingdom
+*Correspondence:
+Kaushik Chattopadhyay
+kaushik.chattopadhyay@
+nottingham.ac.uk
+Specialty section:
+This article was submitted to
+Public Health Education and
+Promotion,
+a section of the journal
+Frontiers in Public Health
+Received: 03 April 2020
+Accepted: 02 October 2020
+Published: 17 November 2020
+Citation:
+Chattopadhyay K, Mishra P
+,
+Manjunath NK, Harris T, Hamer M,
+Greenfield SM, Wang H, Singh K,
+Lewis SA, Tandon N, Kinra S and
+Prabhakaran D (2020) Development of
+a Yoga Program for Type-2 Diabetes
+Prevention (YOGA-DP) Among
+High-Risk People in India.
+Front. Public Health 8:548674.
+doi: 10.3389/fpubh.2020.548674
+Development of a Yoga Program for
+Type-2 Diabetes Prevention
+(YOGA-DP) Among High-Risk People
+in India
+Kaushik Chattopadhyay 1,2*, Pallavi Mishra 3, Nandi Krishnamurthy Manjunath 4,
+Tess Harris 5, Mark Hamer 6, Sheila Margaret Greenfield 7, Haiquan Wang 1,2, Kavita Singh 3,
+Sarah Anne Lewis 1, Nikhil Tandon 8, Sanjay Kinra 9 and Dorairaj Prabhakaran 3
+1 Division of Epidemiology and Public Health, University of Nottingham, Nottingham, United Kingdom, 2 The Nottingham
+Centre for Evidence-Based Healthcare: A Joanna Briggs Institute Centre of Excellence, Nottingham, United Kingdom,
+3 Centre for Chronic Disease Control, New Delhi, India, 4 Swami Vivekananda Yoga Anusandhana Samsthana, Bengaluru,
+India, 5 Population Health Research Institute, St. George’s University of London, London, United Kingdom, 6 Division of
+Surgery and Interventional Science, Institute Sport Exercise and Health, University College London, London,
+United Kingdom, 7 Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom,
+8 Department of Endocrinology, Metabolism and Diabetes, All India Institute of Medical Sciences, New Delhi, India, 9 London
+School of Hygiene and Tropical Medicine, London, United Kingdom
+Introduction: Many Indians are at high-risk of type-2 diabetes mellitus (T2DM). Yoga is
+an ancient Indian mind-body discipline, that has been associated with improved glucose
+levels and can help to prevent T2DM. The study aimed to systematically develop a
+Yoga program for T2DM prevention (YOGA-DP) among high-risk people in India using a
+complex intervention development approach.
+Materials and Methods: As part of the intervention, we developed a booklet and a
+high-definition video for participants and a manual for YOGA-DP instructors. A systematic
+iterative process was followed to develop the intervention and included five steps: (i) a
+systematic review of the literature to generate a list of Yogic practices that improves
+blood glucose levels among adults at high-risk of or with T2DM, (ii) validation of identified
+Yogic practices by Yoga experts, (iii) development of the intervention, (iv) consultation with
+Yoga, exercise, physical activity, diet, behavior change, and/or diabetes experts about
+the intervention, and (v) pretest the intervention among Yoga practitioners and lay people
+(those at risk of T2DM and had not practiced Yoga before) in India.
+Results: YOGA-DP is a structured lifestyle education and exercise program, provided
+over a period of 24 weeks. The exercise part is based on Yoga and includes Shithilikarana
+Vyayama (loosening exercises), Surya Namaskar (sun salutation exercises), Asana
+(Yogic poses), Pranayama (breathing practices), and Dhyana (meditation) and relaxation
+practices. Once participants complete the program, they are strongly encouraged to
+maintain a healthy lifestyle in the long-term.
+Conclusions: We systematically developed a novel Yoga program for T2DM prevention
+(YOGA-DP) among high-risk people in India. A multi-center feasibility randomized
+controlled trial is in progress in India.
+Keywords: Yoga, prevention, prediabetes, lifestyle, physical activity, diet
+Chattopadhyay et al.
+Yoga for Type-2 Diabetes Prevention
+INTRODUCTION
+India has the second-largest type-2 diabetes mellitus (T2DM)
+population in the world, a disorder with major health and
+socioeconomic consequences (1). More than 77 million Indians
+are at high-risk of T2DM—their blood glucose levels are higher
+than normal but lower than the established threshold for T2DM
+itself (2). These people are more likely to develop T2DM and its
+complications than those with normal blood glucose levels (3).
+Unhealthy lifestyle (i.e., physical inactivity and unhealthy diet)
+is a major risk factor for T2DM (3). Physical activity levels are
+low among Indians (4). Similarly, unhealthy diets, high in fat
+(especially saturated fat) and low in fiber, are more prevalent
+among Indians (5, 6). Screening of people who are at high-risk
+of T2DM, followed by an effective lifestyle intervention is a cost-
+effective approach that can normalize blood glucose levels and
+has other health benefits (3, 7, 8).
+Health interventions should be informed by and compatible
+with the sociocultural expectations of people and their health
+beliefs (9). The prevention and management of chronic diseases
+like T2DM using traditional Indian therapies have been
+prioritized by the Indian government (10). Yoga, an ancient
+Indian mind-body discipline, covers not only physical activity
+but also a healthy diet (11). Many different styles of Yoga
+are undertaken, focusing on similar core elements of physical,
+mental, and spiritual practices. No particular style of Yoga is
+necessarily better or more authentic than the others (12). Indians
+usually have high acceptability of Yoga because it fits their health
+beliefs and culture (13, 14). Generally, it uses a gentle approach, is
+easy to learn, is safe, requires a low to moderate level of guidance,
+is inexpensive to maintain, and can be practiced indoors and
+outdoors (13). It can be practiced by older adults and those with
+a wide range of comorbidities (12, 13). As a form of physical
+activity, some of the Yogic practices are of low-intensity (<3.5
+kcal/min) and some are of moderate-intensity (3.5–7.0 kcal/min)
+(12, 15). For example, Surya Namaskar (sun salutation exercises)
+burns about 3.8–6.7 kcal/min (16, 17). Yoga is also a muscle-
+strengthening activity (12). Thus, it can contribute to the aim of
+routine lifestyle advice given to people at high-risk of T2DM to
+prevent it.
+The beneficial effects of Yoga on T2DM-related risk profiles
+appear to occur via two main pathways. First, by reducing
+the activation and reactivity of the sympathoadrenal system
+and the hypothalamic-pituitary-adrenal axis and by promoting
+the feelings of well-being, Yoga may alleviate the effects of
+stress and foster multiple positive downstream effects on the
+neuroendocrine status, metabolic function, and related systemic
+inflammatory responses (18). Second, by directly stimulating
+the vagus nerve, Yoga may enhance the parasympathetic
+activity and lead to positive changes in the cardiovagal
+function, mood, energy state, and related neuroendocrine,
+metabolic, and inflammatory responses (18). In addition, Yoga
+may lead to weight loss, which itself lowers the risk of
+T2DM (18).
+The beneficial effects of Yoga on T2DM-related outcomes
+in T2DM (as adjuvant therapy) and metabolic syndrome have
+been reported in several systematic reviews of clinical trials
+(19–22). For example, a review of 44 randomized controlled
+trials (RCTs), conducted among T2DM, metabolic syndrome,
+or healthy participants (n = 3,168), found that Yoga improves
+blood glucose levels compared to usual care or no intervention
+(mean difference = −0.45%; 95% confidence interval = −0.87
+to −0.02), without any major safety issues (19). However, most
+of the included studies were short-term (≤3 months) and were
+often associated with considerable methodological limitations,
+such as small sample sizes in treatment groups, resulting in
+lack of statistical power for outcome assessment, and lack of
+blinding of outcome assessors, leading to potential analysis
+bias. In addition, some of the relevant previous studies have
+not described the intervention in detail, and it is difficult
+to replicate successful interventions. Most studies have not
+reported the intervention development process. It is hard to
+know whether these interventions were carefully thought out
+(e.g., their safety and acceptability) and comprehensive in their
+development. Thus, it is difficult to select (and replicate) one
+successful intervention over the other. Another selection barrier
+is their heterogeneous contents (i.e., different Yogic practices
+were included in these interventions), which needed to be
+summarized for utilization in T2DM prevention. Thus, our study
+aimed to address these issues by systematically developing a Yoga
+program for T2DM prevention (YOGA-DP) among high-risk
+people in India.
+MATERIALS AND METHODS
+We followed a systematic iterative process to develop the
+intervention, guided by the UK’s Medical Research Council
+(MRC)
+guidance
+on
+developing
+and
+evaluating
+complex
+interventions and Sherman’s guideline for developing Yoga
+interventions for RCTs (9, 23). The template for intervention
+description and replication (TIDieR) checklist and guide were
+used to report the intervention (24). As part of the intervention,
+we developed a booklet and a high-definition video for
+participants and a manual for YOGA-DP instructors. An external
+filmmaking company was hired to convert the booklet (Yoga
+part) into a video to aid audio-visual learning. It was decided to
+use USB flash drives (having a compressed video—2.08 gigabyte
+(GB) in MPEG-4 Part 14 (MP4) file format) after discussing the
+technological advancements as well as accessibility issues in India
+with the relevant stakeholders (e.g., those in the field of film
+making). All these are available in English and two other Indian
+languages, Hindi and Kannada.
+Figure 1 shows the development process of YOGA-DP, which
+consisted of five steps:
+(1) We conducted a systematic review of scientific literature
+to generate a list of Yogic practices that improves blood
+glucose levels among adults at high-risk of or with T2DM.
+The PROSPERO protocol informed the systematic review
+process (PROSPERO registration number CRD42018097216)
+(25). The process was guided by the Preferred Reporting
+Items for Systematic Reviews and Meta-Analyses (PRISMA)
+documents (26). Two Joanna Briggs Institute (JBI) accredited
+systematic reviewers (KC/HW) were involved in the process
+Frontiers in Public Health | www.frontiersin.org
+2
+November 2020 | Volume 8 | Article 548674
+Chattopadhyay et al.
+Yoga for Type-2 Diabetes Prevention
+FIGURE 1 | Development process of YOGA-DP
+.
+and independently screened the titles and abstracts and full-
+text of studies, assessed the methodological quality of studies,
+and extracted data from the studies. Any disagreements between
+them were resolved through discussion.
+Inclusion and Exclusion Criteria
+Population, intervention, comparator, and outcome: Studies
+targeting adults (≥18 years) at high-risk of or with T2DM were
+eligible. The diagnosis was based on blood glucose levels. Studies
+comparing Yoga intervention to no or any intervention and
+reporting successful Yoga interventions were eligible i.e., Yogic
+practices which improved blood glucose levels. At least one of
+the following needed to be statistically significant in the Yoga
+intervention group as compared to the control group: fasting
+blood glucose (FBG), postprandial blood glucose (PPBG), or
+glycated hemoglobin (HbA1c). Studies reporting at least one
+Yogic practice (i.e., Asana (Yogic pose), Pranayama (breathing
+practice), or Dhyana (meditation) and relaxation practice), based
+on classical Yoga texts, were eligible. Studies were excluded if
+they did not report the Sanskrit name of the Yogic practice.
+No restrictions were made regarding the frequency or duration
+of the Yoga intervention. Studies on multimodal interventions
+that included Yoga amongst others were excluded. Studies
+allowing individual co-interventions were eligible i.e., studies
+allowing participants to continue their individual treatment were
+not excluded as long as all the study groups were allowed to
+do so.
+Study design: Only RCTs were eligible.
+Language
+of
+publication:
+No
+language
+restrictions
+were applied.
+Search Strategy
+(a) Using existing full-text peer-reviewed systematic reviews
+as a starting point for identifying the relevant RCTs (and
+interventions), systematic reviews were searched on PubMed
+from its inception date to 7th May 2018. The systematic review
+authors (reviewers) searched a range of databases, the reference
+list of identified original and review articles, and the table
+of contents of relevant journals, trial registers, proceedings,
+and abstracts from relevant symposiums, conferences, and
+colloquiums. These systematic review authors also approached
+the relevant experts. The search strategy used was: (Yoga[MeSH]
+OR Yoga∗[tiab] OR Yogi∗[tiab] OR Asana∗[tiab] OR Pranayam∗
+[tiab] OR Dhyan∗[tiab]) AND systematic[sb].
+(b) To supplement the above step, we searched on PubMed
+to directly identify any full-text peer-reviewed RCTs that were
+published between 1st January 2015 and 7th May 2018. The
+search strategy used was: (Yoga[MeSH] OR Yoga∗[tiab] OR
+Yogi∗[tiab] OR Asana∗[tiab] OR Pranayam∗[tiab] OR Dhyan∗
+[tiab]) AND random∗[mp] NOT systematic[sb].
+(c) We also searched IndMED and Google Scholar for
+additional systematic reviews and RCTs, using different words
+for Yoga, prediabetes, diabetes, systematic review, and RCT. For
+Google Scholar, the advanced search tool was used (with all of
+the words in the title of the article) and excluded patents and
+citations. The reference list of all the relevant RCTs was also
+screened for additional RCTs.
+Screening and Full-Text Reading
+Following the search, all identified citations were collated and
+uploaded into EndNote X8.2, a reference management software
+(27). Titles and abstracts were screened for eligibility using
+the inclusion and exclusion criteria. The full-texts of studies
+identified as potentially eligible or those without an abstract
+were retrieved and assessed against the inclusion and exclusion
+criteria. The full-texts of studies that did not meet the inclusion
+criteria were excluded, and the reasons for exclusion were
+reported (Supplementary Table 1).
+Frontiers in Public Health | www.frontiersin.org
+3
+November 2020 | Volume 8 | Article 548674
+Chattopadhyay et al.
+Yoga for Type-2 Diabetes Prevention
+Methodological Quality Assessment
+In terms of methodological quality of the included RCTs,
+the following were assessed: randomization method, allocation
+concealment, blinding of outcome assessors, and withdrawals
+and dropouts. The Jadad score was also calculated. The Jadad
+score ranges from zero to five points—two points are given
+for randomization, two points for blinding, and one point for
+dropouts (28). A low-quality study receives a score of two points
+or less, and a high-quality study receives a score of at least three
+points (28). The Jadad score is easy to use, contains many of the
+important elements that have empirically been shown to correlate
+with bias, and has known reliability and external validity (29).
+Data were extracted and synthesized from all the included RCTs,
+regardless of their methodological quality.
+Data Extraction
+Study characteristics of the included RCTs and the intervention
+details were extracted using a standardized data extraction tool.
+Data Synthesis
+Narrative data synthesis was conducted as the aim of the
+systematic review was to generate a list of Yogic practices that
+improves blood glucose levels among adults at high-risk of or
+with T2DM.
+(2) We required at least 40 Yoga experts (41 responders) to
+validate each of the identified Yogic practices, based on Lawshe’s
+content validity ratio (CVR) formula (30). Highly qualified and
+experienced Yoga practitioners and/or Yoga researchers with an
+interest in diabetes (including those with high-level authority)
+were purposively selected in India for this purpose. One of the
+study authors (NKM) is a key person in the field of Yoga, and this
+helped us to gain access to these Yoga experts. A questionnaire
+with all the identified practices was administered electronically
+through email, and they marked the content validity of each
+practice on a three-point scale (zero = not necessary, one =
+useful but not essential, two = essential), taking into account the
+safety aspect. CVR was calculated for each practice but only those
+with CVR ≥0.29 were included in the intervention (30, 31).
+CVR = (ne −N/2)/(N/2)
+Where,
+ne = number of experts indicating “essential”
+N = total number of experts.
+(3) We drafted the intervention, with texts and pictorials. With
+permission, the information on being at high-risk of T2DM and
+how to prevent T2DM by being more physically active, keeping a
+healthy weight, eating less fat (especially saturated fat), and eating
+more fiber was extracted from an existing booklet of Leicester
+Diabetes Centre (UK) and the Diabetes UK website and adapted
+to the Indian context (32, 33). Any traditional advice which is
+based on anecdotal (or contradictory) evidence was not included
+in the intervention e.g., dietary advice to consume ghee, a type
+of clarified butter composed almost entirely of fat, especially
+saturated fat.
+(4) We conducted a consultation on the intervention with 16
+experts in Yoga, exercise, physical activity, diet, behavior change,
+and/or diabetes from India and the UK. Like step number two,
+we used our multidisciplinary team’s contact to approach these
+experts. The intervention was shared with them through email,
+and they further reviewed its structure and content, especially
+from the safety point of view. Their feedback (through email) was
+used to improve it.
+(5) We pre-tested the intervention among eight Yoga
+practitioners (teachers) and six lay people (those at risk of T2DM
+and had not practiced Yoga before) at Swami Vivekananda Yoga
+Anusandhana Samsthana (S-VYASA), India. The objectives were
+to identify any difficulties they had in reading and understanding
+the intervention (i.e., comprehension of content/instructions)
+and to explore the acceptability of the intervention and ways
+to promote its uptake and adherence. In addition, Yoga
+practitioners were asked about the overall sequence and flow
+of the intervention and any difficulties they had in delivering
+the intervention, especially within the intended timeframe. They
+were purposively selected to ensure representation of diversity by
+age and sex. The intervention was shared with them prior to the
+following activities—to enable them to read and understand it in
+their free time:
+(a) Yoga practitioners: A face-to-face meeting was held
+with them.
+(b) Lay people: A Yoga session, based on the intervention, was
+delivered to them by two Yoga practitioners (one male and one
+female). This was followed by a face-to-face meeting with them.
+With consent, the feedback was noted and digitally-recorded.
+Their feedback was used to finalize the intervention.
+RESULTS
+The results describe the outcome of each step of the intervention
+development process.
+(1) A total of nine RCTs were included in our systematic
+review. Supplementary Figure 1 shows the flowchart depicting
+the
+search
+and
+screening
+process
+of
+systematic
+reviews
+and RCTs.
+(a) 501 systematic review records were identified until 7th May
+2018. 468 records were excluded at the title and abstract screening
+stage. The full-texts of 33 systematic reviews were assessed for
+eligibility and 21 were excluded at this stage. The remaining
+12 systematic reviews were included containing potential RCTs
+(19, 21, 22, 34–42). The full-texts of 67 potential RCTs were
+assessed for eligibility and 58 were excluded at this stage. The
+remaining eight RCTs (two similar articles from the same RCT
+were published in two different journals) were included in our
+systematic review (43–51).
+(b) To supplement the above step, 384 RCT records were
+directly identified between 1st January 2015 and 7th May 2018.
+374 records were excluded at the title and abstract screening
+stage. The full-texts of 10 RCTs were assessed for eligibility and
+nine were excluded at this stage. The remaining one RCT was
+included in our systematic review (52).
+Supplementary Tables 2, 3 report the study characteristics
+and critical appraisal of the nine included RCTs, respectively.
+Briefly, all the RCTs were conducted in India. The sample
+size ranged from 30 to 337. Yoga was an adjuvant therapy
+Frontiers in Public Health | www.frontiersin.org
+4
+November 2020 | Volume 8 | Article 548674
+Chattopadhyay et al.
+Yoga for Type-2 Diabetes Prevention
+TABLE 1 | Intervention details of the included RCTs.
+References
+Intervention
+development
+information
+Yoga sessions:
+frequency and
+duration
+Yoga
+sessions:
+delivery
+(place and
+person)
+Shithilikarana
+Vyayama
+Surya
+Namaskar
+Asana
+Pranayama
+Dhyana and
+relaxation practice
+Extra features
+Agrawal et al.
+(43)
+NS
+60 min/day X 5–7
+days/week X 12
+weeks
+At the hospital,
+NS
+Yes
+Yes
+Paschimottanasana,
+Ardhamatsyendrasana,
+Uttanapadasana,
+Sarvangasana, Matsyasana
+Yes (NS)
+Kayotsarga, Preksha
+meditation
+including Anupreksha
+Nagarathna
+et al. (44)
+Developed by
+experts including
+Yoga, based on the
+knowledge culled
+out from Yoga
+scriptures (Patanjali
+Yoga Sutras,
+Bhagavad Gita, and
+Mandukya Karika)
+60 min/day X 5
+days/week X 12
+weeks (and then till
+9 months: 1 session
+(of 120 min)/week
+and 60 min/day X 7
+days/week
+self-practice
+at home)
+NS, by Yoga
+instructor
+Yes
+Yes
+Parivrttatrikonasana,
+Vakrasana,
+Ardhamatsyendrasana,
+Ustrasana, Hamsasana,
+Mayurasana, Bhujangasana,
+Dhanurasana,
+Sarvangasana, Matsyasana,
+Padahastasana,
+Ardhachakrasana,
+Trikonasana,
+Pavanamuktasana,
+Shavasana
+Vibhagiya, Ujjayi,
+Nadishodhana,
+Sheetali, Shitkari,
+Bhramari,
+Kapalbhati
+Nadanusandhana
+(A Kara, U Kara, M
+Kara, and AUM
+chanting)
+Self-reporting of
+Yoga practice at
+home (types and
+min/day),
+pre-recorded Yoga
+instruction
+audiotape
+for participants
+Vaishali et al.
+(45, 46)
+NS
+45–60 min/day X 6
+days/week X 12
+weeks
+At the hospital,
+by Yoga
+instructor
+Vajrasana, Suptavajrasana,
+Tadasana, Padahastasana,
+Trikonasana,
+Paravakonasana,
+Trikonasana, Vakrasana,
+Pavanamuktasana,
+Bhujangasana,
+Shalabhasana, Shavasana
+Ujjayi, Anulom Vilom
+Weekly talks by a
+motivated
+participant on
+perceived benefits
+and personal
+experiences of
+regular Yoga
+practice, followed by
+group discussions
+among participants
+for
+enhancing adherence
+Yadav (47)
+NS
+? X 12 weeks
+NS, NS
+Poornabhujangasana,
+Dhanurasana,
+Baddhapadmasana,
+Kukkutasana, Halasana
+Kumar and
+Kalidasan (48)
+NS
+50 min/day X 6
+days/week X 12
+weeks (morning
+sessions)
+At a Yoga
+center?, by
+Yoga instructor
+Yes
+Tadasana, Konasana,
+Padahastasana, Piraiasana,
+Yoga Mudrasana
+(Padmasana, Vajrasana,
+Sukhasana),
+Janusirsasana, Vakrasana,
+Ustrasana, Makarasana,
+Pavanamuktasana,
+Uttanapadasana,
+Naukasana, Bhujangasana,
+Ardhashalabhasana,
+Poornashalabhasana,
+Dhanurasana, Shavasana
+(Continued)
+Frontiers in Public Health | www.frontiersin.org
+5
+November 2020 | Volume 8 | Article 548674
+Chattopadhyay et al.
+Yoga for Type-2 Diabetes Prevention
+TABLE 1 | Continued
+References
+Intervention
+development
+information
+Yoga sessions:
+frequency and
+duration
+Yoga
+sessions:
+delivery
+(place and
+person)
+Shithilikarana
+Vyayama
+Surya
+Namaskar
+Asana
+Pranayama
+Dhyana and
+relaxation practice
+Extra features
+Kumpatla et al.
+(49)
+Based on earlier
+reports
+30 min/day X 7
+days/week X 12
+weeks (one training
+session in the
+morning and then
+self-practice at
+home)
+At the hospital,
+by Yoga
+instructor
+Vakrasana,
+Paschimottanasana,
+Mandukasana,
+Uttanapadasana,
+Naukasana, Bhujangasana,
+Trikonasana
+Regular phone calls
+for encouraging
+self-practice at
+home, Yoga booklet
+for participants
+Sharma et al.
+(50)
+NS
+45–60 min/day X 5
+days/week X 12
+weeks (morning
+sessions on empty
+stomach)
+At the hospital,
+by Yoga
+instructor
+Trikonasana, Tadasana,
+Sukhasana, Padmasana,
+Mandukasana,
+Paschimottanasana,
+Ardhamatsyendrasana,
+Pavanamuktasana,
+Bhujangasana, Vajrasana,
+Dhanurasana, Shavasana
+Yes (NS)
+Singh et al.
+(51)
+NS
+? min/day X 7
+days/week X 2
+weeks (and then till
+6 months:
+once/month
+supervision at the
+delivery center? and
+self-practice at
+home)
+NS, by Yoga
+instructor
+Yes
+Yes
+Tadasana, Trikonasana,
+Vajrasana, Padmasana,
+Ardhamatsyendrasana,
+Paschimottanasana,
+Bhujangasana,
+Dhanurasana, Halasana,
+Naukasana, Shavasana
+Bhastrika,
+Kapalbhati, Anulom
+Vilom, Bhramari
+Self-reporting of
+Yoga practice at
+home (types/day
+and lapse),
+requesting
+family/carer to
+accompany
+participant during
+sessions and to
+countersign once
+participant finishes
+self-practice at
+home, weekly phone
+call to participant
+and family/carer for
+monitoring
+adherence and
+knowing difficulties,
+Yoga booklet
+for participants
+Keerthi et al.
+(52)
+Formulated in
+accordance with
+guidelines of Morarji
+Desai National
+Institute of Yoga,
+India
+45 min X 3
+days/week X 12
+weeks (and
+self-practice at
+home)
+At the hospital,
+by Yoga
+instructor
+Yes
+Yes
+Padahastasana, Konasana,
+Vakrasana,
+Ardhamatsyendrasana,
+Paschimottanasana,
+Shalabhasana,
+Dhanurasana,
+Pavanamuktasana,
+Ardhahalasana,
+Saralmatsyasana,
+Tadasana, Katichakrasana,
+Shavasana
+Nadishodhana,
+Bhramari,
+Chandranadi
+Nadanusandhana (A
+Kara, U Kara, M
+Kara, and AUM
+chanting), Yoga
+Nidra
+Attendance
+documentation of
+Yoga sessions,
+regular phone calls
+for monitoring
+self-practice at
+home, Yoga booklet
+for participants
+NS, Not specified; ?, Unclear.
+Frontiers in Public Health | www.frontiersin.org
+6
+November 2020 | Volume 8 | Article 548674
+Chattopadhyay et al.
+Yoga for Type-2 Diabetes Prevention
+TABLE 2 | Validation of the identified Yogic practices.
+Yogic practices
+CVR
+Additional reason for exclusion
+Included in the intervention?
+Shithilikarana Vyayama
+0.71
+Yes
+Surya Namaskar
+0.80
+Yes
+Ardhachakrasana
+0.61
+Yes
+Katichakrasana
+0.90
+Yes
+Padahastasana
+0.51
+Part of Surya Namaskar
+No
+Piraiasana
+−0.56
+No
+Tadasana
+0.37
+Yes
+Konasana
+0.90
+Yes
+Paravakonasana
+0.37
+Yes
+Trikonasana
+0.56
+Yes
+Parivrttatrikonasana
+0.27
+No
+Ardhamatsyendrasana
+0.95
+Yes
+Janusirsasana
+0.51
+Yes
+Kukkutasana
+−0.95
+No
+Mandukasana
+0.90
+Yes
+Padmasana
+−0.02
+No
+Baddhapadmasana
+−0.37
+No
+Paschimottanasana
+0.66
+Yes
+Sukhasana
+0.22
+No
+Ustrasana
+0.66
+Yes
+Vajrasana
+0.56
+Yes
+Vakrasana
+1.00
+Yes
+Yoga Mudrasana 1 (Padmasana)
+0.07
+No
+Yoga Mudrasana 2 (Vajrasana)
+0.27
+No
+Yoga Mudrasana 3 (Sukhasana)
+0.12
+No
+Bhujangasana
+0.95
+Part of Surya Namaskar
+No
+Poornabhujangasana
+−0.71
+No
+Dhanurasana
+0.80
+Yes
+Hamsasana
+−0.51
+No
+Makarasana
+0.66
+Yes
+Mayurasana
+−0.51
+No
+Shalabhasana/Poornashalabhasana
+0.32
+Yes
+Ardhashalabhasana
+0.51
+Yes
+Halasana
+0.12
+No
+Ardhahalasana
+0.61
+Yes
+Matsyasana
+0.17
+No
+Saralmatsyasana
+0.37
+Yes
+Naukasana
+0.66
+Yes
+Pavanamuktasana
+0.95
+Yes
+Suptavajrasana
+−0.22
+No
+Sarvangasana
+0.07
+No
+Uttanapadasana
+0.61
+Yes
+Shavasana
+0.90
+Similar to Yoga Nidra
+No
+Anulom Vilom Pranayama
+0.80
+Similar to Nadishodhana Pranayama
+No
+Nadishodhana Pranayama
+0.85
+Yes
+Chandranadi Pranayama
+−0.02
+No
+Bhastrika Pranayama
+0.37
+Yes
+Kapalbhati Pranayama
+0.56
+Yes
+Bhramari Pranayama
+0.80
+Yes
+Sheetali Pranayama
+−0.17
+No
+Shitkari Pranayama
+−0.27
+No
+Ujjayi Pranayama
+−0.17
+No
+Vibhagiya Pranayama
+0.51
+Yes
+Nadanusandhana (A Kara, U Kara, M Kara, and AUM chanting)
+0.76
+AUM chanting removed on religious grounds
+Partially
+AUM chanting
+0.46
+On religious grounds
+No
+Kayotsarga
+0.80
+Part of Yoga Nidra
+No
+Preksha meditation including Anupreksha
+0.32
+Part of Yoga Nidra
+No
+Yoga Nidra
+0.76
+Yes
+Frontiers in Public Health | www.frontiersin.org
+7
+November 2020 | Volume 8 | Article 548674
+Chattopadhyay et al.
+Yoga for Type-2 Diabetes Prevention
+TABLE 3 | Structure of YOGA-DP
+.
+Week
+Group Yoga sessions
+delivered by YOGA-DP instructors
+Self-practice of Yoga at
+home using YOGA-DP booklet
+and a video
+Extra features
+1–4
+(month 1)
+At least two sessions of 45 min per week.
+An attendance register is kept.
+–
+At the first session, the instructor is giving
+participants part one of our program booklet.
+This gives them information about being at
+high-risk of T2DM and how to prevent T2DM
+(i.e., by being more physically active, keeping a
+healthy weight, eating less fat (especially
+saturated fat), and eating more fiber).
+5–12
+(month 2–3)
+At least two sessions of 75 min per week.
+An attendance register is kept.
+–
+At the last session, the instructor is giving
+participants part two of our program booklet
+and a video. These give them information on
+Yoga practice to prevent T2DM. Also, a Yoga
+diary and a non-slippery Yoga mat are provided
+for self-practice of Yoga at home.
+13–24
+(month 4–6)
+At least one session of 75 min every 4
+weeks. An attendance register is kept.
+At least two sessions of 75 min per week.
+Participants are given the Yoga diary to record
+their Yoga practice (types and minutes).
+The instructor is phoning participants every
+week to offer support and help and to
+troubleshoot any problems.
+25+
+(month 7+)
+–
+At least two sessions of 75 min per week.
+Participants are given the Yoga diary to record
+their Yoga practice (types and minutes).
+–
+in all the RCTs—all the RCTs were conducted among T2DM
+patients and one study also included people with prediabetes. The
+improvement in blood glucose levels was measured using FBG,
+PPBG, and/or HbA1c tests. One RCT mentioned that no adverse
+event occurred and four reported limited information on adverse
+events. The Jadad score of only four RCTs was high. Only four
+RCTs mentioned the allocation concealment (two provided only
+limited information). Table 1 reports the intervention details of
+the included RCTs. More specifically, 58 Yogic practices that
+improve blood glucose levels among adults at high-risk of or with
+T2DM were identified.
+(2) Table 2 reports the validation of the identified Yogic
+practices. Out of the 58 identified Yogic practices, 31 were
+included in the intervention, namely, Shithilikarana Vyayama
+(loosening exercises), Surya Namaskar, 22 Asana (six standing
+poses, seven sitting poses, four lying poses-front/prone, and five
+lying poses-back/supine), five Pranayama, and two Dhyana and
+relaxation practices. There was one exception—Ardhaustrasana,
+a simplified form of Ustrasana (a sitting pose included in the
+intervention), was additionally included in the intervention as
+recommended by the Yoga experts during the validation work.
+(3–5) The intervention is for adults (18–74 years) who are at
+high-risk of T2DM and are currently safe to do physical activity,
+determined by the Physical Activity Readiness Questionnaire
+(PAR-Q)/clinician. The intervention is not suitable for pregnant
+women; people with chest pain, a heart condition, or any serious
+or uncontrolled medical condition; or people who have recently
+undergone surgery. People with high blood pressure are required
+to check first with their clinician that their blood pressure is
+well-controlled before taking part in the intervention.
+Tables 3, 4 report the structure of YOGA-DP and structure
+and content of the Yoga sessions, respectively. The intervention
+is a structured lifestyle education and exercise program, provided
+over a period of 24 weeks. The exercise part is based on
+Yoga and includes 32 Yogic practices, namely, Shithilikarana
+Vyayama, Surya Namaskar, 23 Asana (six standing poses, eight
+sitting poses, four lying poses-front/prone, and five lying poses-
+back/supine), five Pranayama, and two Dhyana and relaxation
+practices. Once participants complete the intervention, they are
+strongly encouraged to maintain a healthy lifestyle in the long-
+term, using the intervention booklet and video. It should be
+noted that, initially, we planned 52 supervised center-based
+group sessions (75 min/session X two sessions/week X 26 weeks).
+However, the intervention structure was modified after the
+consultation work to enhance intervention uptake and adherence
+i.e., based on the recommendations of experts in step number
+four. In the first instance, 75 min/session might appear a huge
+amount of time for the participants to commit to, and thus, we
+designed 45 min session in weeks 1–4 to avoid any physical or
+mental exhaustion and to gradually build their fitness. Second,
+to avoid the excessive burden of attending center-based sessions,
+weeks 13–24 comprise of one center-based session every 4 weeks
+and self-practice at home (using the intervention booklet and
+video) is recommended from week 13 onwards. Initial supervised
+center-based sessions are deemed to be appropriate for wider
+use in India due to the low levels of literacy. Similarly, initial
+group sessions are deemed to be appropriate for benefits from
+shared experiences and peer support. To improve intervention
+uptake and adherence, the group Yoga sessions are run locally
+(e.g., at Yoga centers and community centers) and at different
+time points of the day (with evening and weekend sessions), and
+participants can join as per their convenience. Some of their
+local travel costs for attending these sessions are reimbursed. A
+family member or someone close to the participant is invited
+to join them in these sessions. The intervention is delivered by
+YOGA-DP instructors—qualified and experienced Yoga teachers
+Frontiers in Public Health | www.frontiersin.org
+8
+November 2020 | Volume 8 | Article 548674
+Chattopadhyay et al.
+Yoga for Type-2 Diabetes Prevention
+TABLE 4 | Structure and content of the Yoga sessions.
+Yogic practices
+Week 1–4
+Each session should
+last for 45 min with
+the time split as
+follows:
+Week 5+
+Each session should
+last for 75 min with
+the time split as
+follows:
+Details
+Shithilikarana
+Vyayama
+Around 5 min
+Around 5 min
+(1) Neck rotation 30 s
+(2) Shoulder rotation 30 s
+(3) Elbow flexion and extension 30 s
+(4) Wrist rotation 30 s
+(5) Finger movement 30 s
+(6) Waist rotation 30 s
+(7) Knee flexion and extension 1 min
+(8) Ankle rotation 1 min
+(9) Toe movement 30 s
+Surya Namaskar
+–
+Around 15 min
+The below mentioned 12 steps constitute one set of Surya Namaskar. To complete one round
+of Surya Namaskar, participants need to repeat these 12 steps on the other side of their body
+(i.e., by extending their left leg behind in step number 4 and bringing their left leg forward in
+step number 9). Initially, they should practice Surya Namaskar at a slower pace. Only with
+practice over some time, they may try to do 12 rounds of it at a faster pace for around 15 min
+(i.e., a couple of seconds per step).
+(1) Pranamasana (prayer pose)
+(2) Hastauttanasana (raised arms pose)
+(3) Padahastasana (hands to feet pose)
+(4) Ashwa Sanchalanasana (equestrian pose)
+(5) Dandasana (stick pose)
+(6) Ashtanga Namaskara Asana (salute with eight parts)
+(7) Bhujangasana (cobra pose)
+(8) Parvatasana (mountain pose)
+(9) Ashwa Sanchalanasana (equestrian pose)
+(10) Padahastasana (hands to feet pose)
+(11) Hastauttanasana (raised arms pose)
+(12) Pranamasana (prayer pose)
+Asana
+Around 15 min
+Around 30 min
+Two-sided poses (right and left) are to be practiced for about 3 min (1.5 min on each side) and
+central-positioned poses are to be practiced for about 1.5 min. In each session, the Yogic
+poses are selected from the list below to prevent boredom from the similarity of routine.
+Advanced Yogic poses are introduced from week 5 onwards, for example, Konasana (angle
+pose), Trikonasana (triangle pose), Paravakonasana (lateral angle pose), Ardhaustrasana (half
+camel pose), Ustrasana (camel pose), Dhanurasana (bow pose), and Naukasana (boat pose).
+(A) Standing poses
+(1) Tadasana (palm tree pose) 1.5 min
+(2) Ardhachakrasana (half wheel pose) 1.5 min
+(3) Katichakrasana (waist wheel pose) 3 min
+(4) Konasana (angle pose) or Trikonasana (triangle pose) or Paravakonasana (lateral angle
+pose): alternatively 3 min
+(B) Sitting poses
+(1) Vajrasana (adamant pose) 1.5 min
+(2) Mandukasana (frog pose) 1.5 min
+(3) Ardhaustrasana (half camel pose) or Ustrasana (camel pose): alternatively 1.5 min
+(4) Vakrasana (twisted pose) or Ardhamatsyendrasana (half spinal twist pose): alternatively
+3 min
+(5) Paschimottanasana (seated forward bend pose) or Janusirsasana (head to knee pose):
+alternatively 1.5 or 3 min, respectively
+(C) Lying poses- front/prone
+(1) Ardhashalabhasana (half locust pose) or Poornashalabhasana (full locust pose): alternatively
+3 or 1.5 min, respectively
+(2) Dhanurasana (bow pose) 1.5 min
+(3) Makarasana (crocodile pose) 1.5 min
+(D) Lying poses- back/supine
+(1) Uttanapadasana (raised legs pose) or Ardhahalasana (half plow pose): alternatively 1.5 min
+(2) Pavanamuktasana (wind relieving pose) 1.5 min
+(3) Naukasana (boat pose) 1.5 min
+(4) Saralmatsyasana (easy fish pose) 1.5 min
+(Continued)
+Frontiers in Public Health | www.frontiersin.org
+9
+November 2020 | Volume 8 | Article 548674
+Chattopadhyay et al.
+Yoga for Type-2 Diabetes Prevention
+TABLE 4 | Continued
+Yogic practices
+Week 1–4
+Each session should
+last for 45 min with
+the time split as
+follows:
+Week 5+
+Each session should
+last for 75 min with
+the time split as
+follows:
+Details
+Pranayama
+Around 13 min
+Around 13 min
+(1) Vibhagiya Pranayama (sectional breathing) 4 min
+(2) Nadishodhana Pranayama (alternate nostril breathing) 3 min
+(3) Kapalbhati Pranayama (skull shining breathing) or Bhastrika Pranayama (bellow breathing):
+alternatively 3 min
+(4) Bhramari Pranayama (bee breathing) 3 min
+Dhyana and
+relaxation practices
+Around 12 min
+Around 12 min
+In each session, the following Dhyana and relaxation practices are to be done in a
+darkened room.
+(1) A Kara chanting, U Kara chanting, and M Kara chanting 3 min
+(2) Yoga Nidra (Yogic sleep) 9 min
+with formal training provided on the program, and they can
+speak the local languages. Female instructors are available for
+female participants.
+DISCUSSION
+We report the systematic development of a novel Yoga program
+for T2DM prevention (YOGA-DP) among high-risk people in
+India. The duration of our intervention (24 weeks) is longer
+than many other Yoga interventions (43, 45–50, 52). Even after
+formally completing the intervention, participants are strongly
+encouraged to maintain a healthy lifestyle in the long-term, using
+the intervention booklet and video. The long-term maintenance
+of a healthy lifestyle is required, not just for preventing T2DM
+but also for overall health (3). However, lifestyle interventions’
+poor uptake and adherence (especially over the long-term) are
+well-recognized and can negatively affect the effectiveness of
+these interventions (53). This is the reason we incorporated
+multiple strategies to enhance uptake and adherence to our
+intervention. Some of these have already been used in previous
+successful studies (44–46, 49, 51, 52) and some came up during
+the intervention development process (e.g., female YOGA-DP
+instructors for female participants). In fact, as mentioned in the
+results section, the structure of our intervention evolved during
+the development process to enhance its uptake and adherence.
+Similar to many other Yoga interventions, our intervention
+includes Shithilikarana Vyayama, Asana (standing, sitting, and
+lying poses), Pranayama, and Dhyana and relaxation practices
+(43, 44, 52). Surya Namaskar is something additional in our
+intervention which is not always found in Yoga interventions.
+It can help in the prevention of T2DM, as it is considered a
+moderate-intensity activity and burns about 3.8–6.7 kcal/min
+(16, 17). Second, based on the suggestion of Yoga experts,
+AUM chanting (under Dhyana and relaxation practices) was
+not retained on religious grounds. Thus, the acceptance of the
+intervention could be high among people irrespective of their
+religious beliefs.
+Yoga is a complex intervention, and the MRC guidance
+on developing and evaluating complex interventions provided
+the overall framework to develop the intervention (9). In
+fact, intervention development is the first step, and there are
+other steps as well, such as feasibility/piloting, evaluation, and
+implementation. There are questions throughout this guidance
+which helped us to design the study and to follow a systematic
+iterative process. It is not a “one size fits all” guidance but
+a generic one, and thus, not all the questions were relevant
+in our context. A major challenge was to systematically
+integrate traditional and western medical systems for T2DM
+prevention. Any traditional advice which is based on anecdotal
+(or contradictory) evidence was not included in the intervention.
+A similar systematic approach could be used to develop other
+local and cross-cultural health interventions.
+The study has several strengths and weaknesses. This is one
+of the few studies to report the systematic development of a
+Yoga intervention. Another example is a Yoga-based cardiac
+rehabilitation (Yoga-CaRe) program which has been developed
+for secondary prevention of myocardial infarction in India
+(54). The interventions, study participants, and outcomes are
+different in the two studies. We followed a systematic process and
+reviewed the scientific literature as part of the process. In other
+words, we summarized the heterogeneous contents of successful
+and relevant Yoga interventions. The process also helped us
+to reach consensus on this complex intervention. A range of
+stakeholders (including healthcare, medical, and Yoga experts
+and practitioners and the public) were involved to explore issues
+like safety and acceptability of the intervention. The systematic
+review included only those studies that showed evidence of
+effectiveness in one of the prespecified outcomes. It should be
+noted that this was not a typical effectiveness systematic review,
+and the ultimate aim was to develop an intervention based on
+previous successful interventions. We also excluded studies if
+they did not report the Sanskrit name of the Yogic practice.
+Without the Sanskrit name, the English translation could mean
+more than one Yogic practice (and sometimes even modified or
+patented Yoga), and it is difficult to replicate such interventions
+for multiple reasons. There is a chance of missing a relevant
+Yogic practice. However, Yoga experts were involved in the
+next step, and they confirmed the inclusion of all the essential
+Yogic practices. Second, the Jadad score was calculated as part
+of the methodological quality assessment of the included RCTs.
+Apart from its many advantages, as mentioned before, it has
+disadvantages as well. For example, it is over-simplistic and does
+Frontiers in Public Health | www.frontiersin.org
+10
+November 2020 | Volume 8 | Article 548674
+Chattopadhyay et al.
+Yoga for Type-2 Diabetes Prevention
+not take into account many essential methodological issues, such
+as the concealment of treatment allocation (55). Therefore, in
+addition to the Jadad score calculation, we assessed the allocation
+concealment. Third, due to the accessibility issues in India, we
+had to compress the video, which affected its quality. However,
+we have archived the original high-quality video for future use.
+A multi-center feasibility RCT is currently in progress in India
+to determine the feasibility of undertaking the main RCT (56). If
+the feasibility is acceptable, we will design and conduct the main
+RCT. If the intervention is found to be effective, it will be a low-
+cost, acceptable, and local solution for preventing T2DM among
+high-risk people in India and for improving their overall health.
+It will also prevent the future clinical, personal, and economic
+burden of T2DM on patients, their families, the health system,
+and the economy. The advantages of preventing T2DM may
+extend to the prevention of T2DM related complications. More
+evidence-based choices will be available to people for preventing
+T2DM. The intervention will simultaneously empower people
+to manage their health. Given that T2DM and its related
+costs are global concerns and Yoga is popular or is becoming
+popular globally, there will be worldwide interest in this low-
+cost Yoga-based T2DM prevention program, particularly in
+other South Asian countries and in countries with South Asian
+ethnic minorities (57, 58). The intervention could be adapted,
+evaluated, and implemented to prevent T2DM in other settings
+or populations.
+In conclusion, we systematically developed a novel Yoga
+program for T2DM prevention (YOGA-DP) among high-risk
+people in India. A multi-center feasibility RCT is in progress
+in India.
+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 approved by four research ethics committees,
+namely, Faculty of Medicine and Health Sciences, University of
+Nottingham (UK); Centre for Chronic Disease Control (CCDC,
+India); Swami Vivekananda Yoga Anusandhana Samsthana (S-
+VYASA, India); and Bapu Nature Cure Hospital and Yogashram
+(BNCHY, India). The patients/participants provided their written
+informed consent to participate in this study.
+AUTHOR CONTRIBUTIONS
+KC conceptualized, designed, and conducted the study with the
+help of other authors, wrote the first draft of the manuscript,
+and other authors contributed significantly to the revision of the
+manuscript. All authors read and approved the final manuscript.
+FUNDING
+This study was funded by the UK’s DFID/MRC/NIHR/Wellcome
+Trust Joint Global Health Trials (MR/R018278/1). The funding
+agencies had no role in developing the intervention or writing
+the manuscript.
+ACKNOWLEDGMENTS
+We thank all the people who have contributed to the
+development of YOGA-DP, Leicester Diabetes Centre, and
+Diabetes UK.
+SUPPLEMENTARY MATERIAL
+The Supplementary Material for this article can be found
+online
+at:
+https://www.frontiersin.org/articles/10.3389/fpubh.
+2020.548674/full#supplementary-material
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+Frontiers in Public Health | www.frontiersin.org
+12
+November 2020 | Volume 8 | Article 548674
+Chattopadhyay et al.
+Yoga for Type-2 Diabetes Prevention
+54. Chattopadhyay
+K,
+Chandrasekaran
+AM,
+Praveen
+PA,
+Manchanda
+SC, Madan K, Ajay VS, et al. Development of a Yoga-based cardiac
+rehabilitation
+(Yoga-CaRe)
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+myocardial infarction. Evid Based Complement Alternat Med. (2019)
+2019:7470184. doi: 10.1155/2019/7470184
+55. Hempel S, Suttorp MJ, Miles JNV, Wang Z, Maglione M, Morton S, et al.
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+Rockville, MD: Agency for Healthcare Research and Quality (2011).
+56. Chattopadhyay K, Mishra P, Singh K, Tess Harris T, Hamer M, Greenfield SM,
+et al. Yoga programme for type-2 diabetes prevention (YOGA-DP) among
+high risk people in India: A multicentre feasibility randomised controlled
+trial protocol. BMJ Open. (2020) 10:e036277. doi: 10.1136/bmjopen-2019-
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+(2008) 23:1653–8. doi: 10.1007/s11606-008-0735-5
+58. Ding D, Stamatakis E. Yoga practice in England 1997-2008: Prevalence,
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+7:172. doi: 10.1186/1756-0500-7-172
+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 © 2020 Chattopadhyay, Mishra, Manjunath, Harris, Hamer, Greenfield,
+Wang, Singh, Lewis, Tandon, Kinra and Prabhakaran. 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 Public Health | www.frontiersin.org
+13
+November 2020 | Volume 8 | Article 548674

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+© 2017 International Journal of Yoga | Published by Wolters Kluwer ‑ Medknow
+152
+Introduction
+Diabetes poses a great threat to the 
+world. With the changes in lifestyle in the 
+developing and the developed countries, 
+people are prone to this disorder. Coupled 
+with genetic dispositions of Asians, people 
+in those countries are predisposed to this 
+disorder.[1] India has a major problem; the 
+disease is spreading faster than anticipated 
+earlier. It is shifting from older people 
+to young adults.[2,3] The magnitude is so 
+severe that by 2025–2030 India is expected 
+to be the diabetic capital of the world.[4,5] 
+The knowledge regarding this problem is 
+known from earlier times and is mentioned 
+in the ancient literature on Indian medical 
+system like Ayurveda.[6] Modern medicine 
+facilitated 
+diagnosis 
+and 
+management 
+of 
+disease 
+through 
+advancement 
+in 
+pharmacology and research but the cure 
+still remains a distant dream.[7] The disease 
+is lethal in action and spreads to almost all 
+Address for correspondence: 
+Dr. Romesh Kumar Bhat, 
+Anvesana Research 
+Laboratories, Swami 
+Vivekananda Yoga 
+Anusandhana Samsthana 
+Yoga University, No. 19, 
+Eknath Bhavan, Gavipuram 
+Circle, Kempe Gowda 
+Nagar, Bengaluru ‑ 560 019, 
+Karnataka, India. 
+E‑mail: romesh112005@ 
+yahoo.co.in
+Abstract
+Background: Yoga is the most popular form of alternative medicine for the management of diabetes 
+mellitus type 2. The electro‑photonic imaging (EPI) is another contribution from alternative medicine 
+in health monitoring. Aim: To evaluate diabetes from EPI perspective. Objectives: (1) Compare 
+various EPI parameters in normal, prediabetic and diabetic patients.  (2) Find difference in 
+controlled and uncontrolled diabetes. (3) Study the effect of 7 days diabetes‑specific yoga program. 
+Materials and Methods: For the first objective, there were 102  patients  (normal 29, prediabetic 
+13, diabetic 60). In the second study, there were 60  patients  (controlled diabetes 27, uncontrolled 
+diabetes 33). The third study comprised 37 patients. EPI parameters were related to general health 
+as well to specific organs. Results: In the first study, significant difference was observed between 
+(1) Diabetics and normal: average intensity 5.978, form coefficient 3.590, immune organs 0.281 all 
+P < 0.001; (2) Diabetics and prediabetics: average intensity 6.676, form coefficient 4.158, immune 
+organs 5.890 P  <  0.032;  (3) Normal and prediabetes: immune organs  (−6.171 P  =  000). In the 
+second study, remarkable difference was in the immune organs (0.201, P = 0.031). In the pre‑ and 
+post‑study, the mean difference was: area 630.37, form coefficient 1.78, entropy 0.03, liver  0.24, 
+pancreas 0.17, coronary vessels 0.11, and left kidney 29, with all P < 0.02. Conclusion: There is a 
+significant difference in EPI parameters between normal, prediabetics and diabetics, the prominent 
+being average intensity, form coefficient, and immune organs. Between controlled and uncontrolled 
+diabetes, immune organs show significant change. Intervention of yoga results in change in most 
+parameters.
+Keywords: Diabetes, electro‑photonic imaging, parameter
+Diabetes Mellitus Type 2 and Yoga: Electro Photonic Imaging 
+Perspective
+Original Article
+Romesh  
+Kumar Bhat, 
+Ramesh Mavathur1, 
+TM Srinivasan1
+Departments of Bio energy, 
+Anvesana Research Laboratories 
+and 1Yoga and Life Sciences, 
+Swami Vivekananda Yoga 
+Anusandhana Samsthana 
+Yoga University, Bengaluru, 
+Karnataka, India
+vital organs of the body. Early detection 
+and management would greatly help in 
+arresting the spread of disease. The serious 
+repercussions of the disease could thus be 
+avoided or deferred.[8] Stress is found to be 
+one of the main causes of diabetes. This 
+is in line with the philosophy of Yoga and 
+Ayurveda. As per both, the source of all the 
+diseases is mind. Disturbances in the mind 
+cause systemic problems and ultimately 
+settle at the organ level. The cause and 
+effect is known by the terms “Aadhi” and 
+“Vyadhi,” respectively.[9,10] The modern 
+medical system till recently was focused on 
+the physical organs and systems for disease 
+management. It is realized lately, that for 
+all gross manifestations, there is a subtle 
+undercurrent. The medicine now focuses on 
+mind and the body rather than body only. 
+Yoga is one blessing to the mankind which 
+helps to calm down mind and rejuvenate the 
+body. It is a recognized spiritual philosophy 
+with immense health benefits and very 
+Access this article online
+Website: www.ijoy.org.in
+DOI: 10.4103/0973-6131.213469 
+Quick Response Code:
+How to cite this article: Bhat RK, Mavathur R, 
+Srinivasan TM. Diabetes mellitus type 2 and yoga: 
+Electro photonic imaging perspective. Int J Yoga 
+2017;10:152-9.
+Received: June, 2016. Accepted: September, 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: [email protected]
+Bhat, et al.: IJOY: EPI perspective of DM 2 and yoga
+153
+International Journal of Yoga | Volume 10 | Issue 3 | September‑December 2017
+effective in treating stress.[11,12] Thus, a holistic medicine 
+is evolving, where wisdom of traditional practices and the 
+modern medicine is offered simultaneously for the welfare 
+of mankind.[13] India is taking a big lead in this direction.[14] 
+Modern system is well supported by organized research 
+and other systems are also trying to develop on these 
+lines. One such system on which research has been going 
+on for decades is electro‑photonic imaging (EPI) based on 
+Kirlian photography. This equipment is based on applied 
+physics and tries to investigate subtle bio‑energy changes 
+in the body. The principle of working of EPI instrument is 
+very simple. Tip of the ten fingers is placed on dielectric 
+glass one by one, a high‑voltage short duration pulse of 
+10 kV and frequency 1024 Hz is applied and electrons 
+are extracted from the finger. Due to the presence of high 
+electric field, the electrons collide with air molecules in the 
+surroundings and photons are released around the finger. 
+A  camera fitted in the EPI captures this image which is 
+analyzed with the help of software.[15] The captured image 
+parameters depend on the state of health of an individual. 
+The ten fingers represent various organs and systems as 
+per the Chinese system of acupuncture.[16‑18] So, EPI in 
+the real sense is a fusion of modern physics and ancient 
+philosophy. The software that is used for the analysis of 
+image gives various energy diagrams and parameters. 
+These parameters are indicative of the general state of 
+health and the state of various organs and systems. In 
+Russia, EPI is used in medical sciences, biometrics, sports, 
+forensic, human behavior, etc. Healers use it for observing 
+changes after the administration of an intervention.[19] At the 
+moment it is a good tool in the hands of healers and those 
+practicing alternative medicine. They can find the impact of 
+intervention by comparing pre‑ and post‑conditions.[20]
+Aim and objectives
+The aim is to study diabetes mellitus  (DM) type  2 with 
+the help of EPI parameters. The objectives are to find the 
+changes in EPI parameters in normal, prediabetic, and 
+diabetic patients, compare controlled and uncontrolled 
+diabetes, and evaluate the effect of 7‑day practice 
+of yoga camp in connection with the stop diabetes 
+movement  (SDM) campaign of Swami Vivekananda Yoga 
+Anusandhana Samsthana  (S‑VYASA) Yoga University, 
+Bengaluru, India.
+Materials and Methods
+The study was conducted on the participants of the yoga 
+camps held in connection with SDM campaign and 
+Arogyadham  (a residential health center) of S‑VYASA 
+Yoga University. After the scrutiny of 250 participants, 
+following number of patients were selected for the 
+different studies. (a) One hundred and two patients (mean 
+age 51 ± 11) for the first objective. Out of these, 52 were 
+males  (mean age 54  ±  11) and rest females  (mean age 
+47  ±  10). The total patients comprised 29 normal  (mean 
+age 44 ± 11), 13 prediabetic (mean age 51.2 ± 12.3) and 
+60 diabetic (mean age 54 ± 9.6). (b) Sixty patients (mean 
+age 53.8 ± 9.62) for the second objective. Out of these, 35 
+were males (mean age 56.83 ± 8.72) and 25 females (mean 
+age 49.56  ±  9.38). The total patients were divided into 
+controlled diabetes n  =  27  (mean age 56.04  ±  9.28) and 
+uncontrolled diabetes n = 33 (mean age 51.97 ± 9.65). (c) 
+Thirty‑seven patients (mean age 54.46 ± 7.21) comprising 
+24 males (mean age 57.46 ± 7.35) and 13 females (mean 
+age 54.62 ± 6.83). The dropouts from the initial scrutiny 
+were on account of (1) incomplete images (2) withdrawal 
+from the camp (3) either of the images was not available 
+in case of pre‑  and post‑study. EPI images were taken 
+on the first day of the camp and in case of pre‑  and 
+post‑intervention study; the images were taken on the 
+conclusion of the camp also. The categorization was 
+based on fasting blood sugar  (FBS). As per the criteria, 
+<100 mg/dl was normal, between 100 and 125 mg/dl 
+prediabetic and >126 mg/dl diabetic. This is as per the 
+American Diabetes Association score.[21] Controlled and 
+uncontrolled diabetics were classified on the basis of 
+above scale from the participants who were confirmed 
+diabetics from the medical history and reports. Participants 
+who had FBS >126 mg/dl for more than 3 months, in spite 
+of being on anti diabetes medicine, were classified as 
+uncontrolled diabetics.[22,23] They were on medication for 
+the management of their diabetes. The intervention was 
+administered by yoga trainers and therapists. The EPI 
+parameters selected for analysis were area, intensity, form 
+coefficient, entropy, and fractality which pertain to general 
+health.[15] Further there were parameters which were 
+organ specific such as liver, immune organs, pancreas, 
+coronary vessels, cerebral vessels, left kidney and right 
+kidney. The organ‑specific parameters were selected on 
+the basis of modern medical literature.[24‑27] The average 
+of the values of the left‑  and right‑hand fingers was 
+considered for the EPI parameters. The EPI parameters 
+were obtained through the software EPI diagram, EPI 
+screening, and EPI scientific laboratory. Participants in 
+the age range of 18–75  years, male or female and those 
+willing to volunteer for study were selected. As diabetes 
+is spreading to younger people and the study was 
+broad‑based covering normal, prediabetics, and diabetics, 
+we decided for a broader range of age. All participants 
+had to give blood for FBS test on the inaugural day of 
+camp or have a recent blood report. Consent was taken 
+from willing participants, and only 5 ml of blood was 
+collected from each participant for the testing purpose. 
+This study was cleared by the Institutional Ethics 
+Committee at S‑VYASA Yoga University, Bengaluru, 
+India; vide RES/1EC‑SVYASA/66/2015.
+Exclusion criteria
+Patients 
+with 
+comorbidities 
+such 
+as 
+hypertension, 
+dyslipidemia, and fatty liver disease and those taking any 
+medicine in the case of normal and prediabetic participants; 
+diabetic patients taking medicines apart from diabetes; 
+Bhat, et al.: IJOY: EPI perspective of DM 2 and yoga
+154
+International Journal of Yoga | Volume 10 | Issue 3 | September‑December 2017
+patients suffering from any infectious or contagious 
+disease; physically handicapped and those having missing 
+fingers were excluded from the study. Females having 
+menstruation or pregnancy on the day of measurement 
+were also excluded from the study.
+Sampling time
+The data were taken in the morning hours with a gap of 
+at least 3 h from the last meal. The data in the camps 
+were mostly taken on the inaugural day of the camp. Data 
+at Aroghyadham  (residential hospital) were taken in the 
+morning as well in the evening but ensuring gap of 3 h 
+from the last meal. The requirement from participants was 
+to follow yogic way of life in the matter of exercise, mental 
+relaxation, and diet. This was monitored through regular 
+feedbacks in the camps and records in Aroghyadham  (for 
+residential participants). EPI was calibrated each time 
+the place of taking measurement changed or as required. 
+Informed consent was taken from all the participants before 
+conducting the study. The study was approved by the 
+University’s Ethics Committee.
+Instrument
+GDV Camera Pro with analog video camera, model 
+number: FTDI.13.6001.110310  (Kirlionics Technologies 
+International company, Saint‑Petersburg, Russia) was used 
+for the assessment purpose. Along with the EPI software, 
+it provided various features such as EPI screening, EPI 
+scientific laboratory, and EPI diagram. These are different 
+software programs for analysis and data extraction. EPI 
+screening allows evaluating particular sectors of different 
+fingers related to body systems as well as to different 
+organs. EPI scientific laboratory gives the data for each 
+finger and the average of parameters related to general 
+health.
+Parameters analyzed
+From EPI software the following parameters were 
+analyzed: Total area is an absolute value and is measured 
+as the number of pixels in the image having brightness 
+above a preset threshold. Area of glow is in proportion 
+to quantity of electrons; average intensity is evaluation 
+of light intensity averaged over the area of image; form 
+coefficient and fractality are measures of irregularity in 
+the image’s external contour; entropy reflects the level 
+of nonuniformity of image, in other words, the level of 
+stability of the energy field. It is a measure of energy 
+disturbance in the body. From EPI screening/EPI diagram, 
+integral area of liver, pancreas, immune organs, coronary 
+vessels, cerebral vessels, left kidney and right kidney 
+were analyzed. Integral area is relative value and shows 
+the extent to which the EPI gram deviates from an ideal 
+model. For evaluation of the functional state of particular 
+systems and organs, these parameters are calculated for the 
+whole EPI gram or for the sectors of particular zones. It is 
+indicative of general health.
+Data analysis
+Data analysis was carried out with the help of Microsoft 
+Office Excel 2007.lnk and R‑studio version  3.2.0 along 
+with R Cmdr version  2.1‑7. Statistical tests: Independent 
+sample t‑test and paired t‑test were used to compare the 
+means.
+Intervention
+The intervention was yoga program based on SDM module 
+of S‑VYASA. It comprises asanas, pranayama, meditation, 
+practices on stress management, lectures on the disease 
+and diet regulations and the modification in lifestyle. The 
+yoga sessions was held from 5:00 h to 7:00 h every day for 
+7 days under the guidance of experienced yoga trainers and 
+therapists.
+Results
+In 
+the 
+first 
+study, 
+we 
+observed 
+significant 
+difference in means of average intensity  (diabetes 
+and 
+normal 
+= 
+5.978 
+[P 
+= 
+0.0001], 
+diabetes 
+and 
+prediabetes 
+= 
+6.676 
+[P 
+= 
+0.0169]); 
+form 
+coefficient  (diabetes and normal = −3.590  [P  =  0.0007], 
+diabetes and prediabetes = −4.158 [P = 0.0315]); immune 
+organs  (diabetes and normal  =  0.281  [P  =  0.0004], 
+diabetes and prediabetes = −5.890  [P  =  0.0001], normal 
+and prediabetes = −6.171  [P  =  0.0001])  [Tables  1‑3]. 
+Besides, there were small differences (but very significant) 
+observed in many other parameters as seen in Table  4. 
+The second study observation was pertaining to immune 
+organs  (difference in means 0.201, P  = 0.0319)  [Table  5]. 
+In the third, i.e. pre‑ and post‑study, the noticeable changes 
+were in area  (mean difference 630.465, P  =  0.0004); 
+form coefficient  (mean difference  −  1.783, P  =  0.0001); 
+entropy (mean difference − 0.029, P = 0.0012); liver (mean 
+difference 0.247, P  =  0.0001); pancreas  (mean difference 
+0.176, P  =  0.0250); coronary vessels  (mean difference 
+0.142, P  =  0.0001); cerebral vessels  (mean difference 
+0.192, P  =  0.0002); left kidney  (mean difference 0.157, 
+P  =  0.0042); right kidney  (mean difference 0.248, 
+P = 0.0001) [Table 6].
+Discussions
+The purpose of this study was to evaluate whether the 
+parameters of EPI can be used for diagnostic aspects 
+of DM type  2. In the first study three stages of diabetes 
+were 
+considered, 
+namely, 
+normal, 
+prediabetes 
+and 
+diabetes. Independent t‑test between diabetes and normal, 
+diabetes and prediabetes, normal and prediabetes showed 
+significant results. There is a remarkable difference in 
+the parameters between diabetes and normal and the 
+difference is highly significant. Average intensity, entropy, 
+liver, pancreas, immune organs coronary vessels, cerebral 
+vessels, left kidney, right kidney all are more imbalanced 
+in diabetic state than in the normal. This is on expected 
+lines as higher values are indicative of disorder. Fractality 
+Bhat, et al.: IJOY: EPI perspective of DM 2 and yoga
+155
+International Journal of Yoga | Volume 10 | Issue 3 | September‑December 2017
+and form coefficient which are measures of irregularity in 
+the external contour have negative values as the images 
+are more regular in normal condition than the diabetic 
+and have a higher value in normal condition. This is in 
+line with the theory of EPI that the average intensity and 
+entropy are high with aging and progression of disease, 
+Table 1: Independent sample t‑test; normal-prediabetes
+Parameter
+Normal
+PD
+t
+df
+P
+Mean
+Area
+11,487.860
+11,597.770
+−0.231
+23.045
+0.819
+109.910
+Intensity
+78.087
+77.388
+0.273
+17.527
+0.788
+0.698
+FC
+14.934
+15.502
+−0.298
+19.020
+0.769
+−0.567
+EN
+1.862
+1.770
+1.567
+20.849
+0.132
+0.092
+FR
+1.923
+1.987
+−1.362
+32.524
+0.183
+−0.064
+LI
+−0.045
+0.105
+−1.187
+32.350
+0.244
+−0.150
+IM organs
+−0.196
+5.975
+−16.375
+12.585
+7.362e-10
+−6.171
+PA
+−0.261
+0.096
+−2.315
+34.320
+0.027
+−0.357
+CO
+−0.131
+−0.050
+−0.849
+34.314
+0.402
+−0.081
+CE
+−0.021
+−0.007
+−0.138
+21.550
+0.892
+−0.014
+Left kidney
+−0.049
+0.053
+−0.740
+25.851
+0.466
+−0.102
+Right kidney
+−0.092
+−0.062
+−0.244
+22.019
+0.809
+−0.031
+P level of significance, <0.5 considered statistically significant; Student’s t‑test. df = Degree of freedom, FC = Form coefficient, 
+EN = Entropy, FR = Fractality, LI = Liver, IM = Immunity, PA = Pancreas, CO = Coronary, CE = Cerebral, PD = Prediabetes
+Table 2: Independent sample t‑test; diabetes-normal
+Parameter
+Diabetes
+Normal
+t
+df
+P
+Mean
+Area
+12,003.320
+11,487.860
+1.596
+56.675
+0.116
+515.460
+Intensity
+84.065
+78.087
+4.075
+70.164
+0.0001194
+5.978
+FC
+11.344
+14.934
+−3.651
+40.784
+0.001
+−3.590
+EN
+1.965
+1.862
+2.821
+55.251
+0.007
+0.103
+FR
+1.848
+1.923
+−2.271
+30.317
+0.030
+−0.075
+LI
+0.274
+−0.045
+2.868
+62.216
+0.006
+0.319
+IM organs
+0.085
+−0.196
+3.699
+66.439
+0.000441
+0.281
+PA
+0.220
+−0.261
+3.691
+50.377
+0.001
+0.481
+CO
+0.213
+−0.131
+4.295
+48.965
+8.259e-05
+0.344
+CE
+0.263
+−0.021
+4.052
+65.358
+0.0001376
+0.284
+Left kidney
+0.258
+−0.049
+3.072
+53.868
+0.003
+0.307
+Right kidney
+0.242
+−0.092
+3.732
+69.411
+0.004
+0.334
+P level of significance, <0.5 considered statistically significant; Student’s t‑test. df = Degree of freedom, FC = Form coefficient, 
+EN = Entropy, FR = Fractality, LI = Liver, IM = Immunity, PA = Pancreas, CO = Coronary, CE = Cerebral
+Table 3: Independent sample t-test; diabetes and prediabetes
+Parameter
+Diabetes
+Prediabetes
+t
+df
+P
+Mean
+Area
+12,003.320
+11,597.770
+1.658
+17.811
+0.114
+405.550
+Intensity
+84.065
+77.388
+2.655
+16.611
+0.017
+6.676
+FC
+11.344
+15.502
+−2.399
+13.519
+0.032
+−4.158
+EN
+1.965
+1.770
+3.571
+16.307
+0.002
+0.195
+Fractality
+1.848
+1.987
+−4.041
+12.922
+0.001
+−0.139
+FR
+0.274
+0.105
+1.477
+27.664
+0.151
+0.169
+IM organs
+0.085
+5.975
+−15.681
+12.421
+1.479e-09
+−5.890
+PA
+0.220
+0.096
+0.968
+23.075
+0.343
+0.124
+CO
+0.213
+−0.050
+3.344
+22.295
+0.003
+0.263
+CE
+0.263
+−0.007
+2.752
+18.912
+0.013
+0.270
+Left kidney
+0.258
+0.053
+1.658
+18.679
+0.114
+0.205
+Right kidney
+0.242
+−0.062
+2.504
+20.437
+0.021
+0.304
+P level of significance, <0.5 considered statistically significant; Student’s t‑test. df = Degree of freedom, FC = Form coefficient, 
+EN = Entropy, FR = Fractality, LI = Liver, IM = Immunity, PA = Pancreas, CO = Coronary, CE = Cerebral
+Bhat, et al.: IJOY: EPI perspective of DM 2 and yoga
+156
+International Journal of Yoga | Volume 10 | Issue 3 | September‑December 2017
+form coefficient and fractality are lesser. Similarly, there 
+is highly significant difference in the selected parameters 
+in diabetic and prediabetic. However, the differences in 
+the integral area of liver, pancreas, and left kidney are not 
+significant. This could be due to the fact that these organs 
+are affected at the prediabetic stage itself as they would 
+be at the diabetic stage. Another important aspect is with 
+respect to energy in immune organs. Results indicate that 
+immune organs get more compromised at the prediabetic 
+stage which paves the way for disease to progress and 
+become devastating, the body becomes vulnerable to 
+multiple problems.[28‑30] The first study has revealed 
+noticeable differences in the three stages, i.e.,  normal, 
+prediabetes, and diabetes. In the second study we 
+considered controlled diabetes and uncontrolled diabetes. 
+The controlled diabetes as per the American Diabetes 
+Association was considered as FBS  <126 mg/dl and 
+above this as uncontrolled. There was small noticeable but 
+significant difference in the immune organs. It is a negative 
+difference in line with the earlier argument that immune 
+organs are compromised much earlier than the extreme 
+manifestation of the disease in this case of DM type  2. 
+In rest of the parameters there is no significant change. It 
+perhaps shows the state of these organs in the diabetics 
+whether the diabetes is controlled or uncontrolled. In the 
+pre‑  and post‑study, we observed significant differences 
+in many parameters by the paired t‑test. These are total 
+area, form coefficient, entropy, coronary vessels, cerebral 
+vessels, pancreas, left kidney and right kidney. The 
+intervention of yoga makes the change. As mentioned 
+earlier, area increases with the aging and the disturbed state 
+of health. Reduction in the area indicates improvement. 
+Entropy is indicative of stability of energy field and 
+negative sign shows that a correction has happened in 
+poststate. Results show that stability is more and hence the 
+disturbance is less in the poststate.[15] Similarly, there is an 
+increase in form coefficient and hence the improvement 
+in irregularity of the image. Liver, pancreas coronary 
+vessels, cerebral vessels, and kidneys are the organs that 
+are affected by diabetes. We observe a reduction in the 
+integral area of these parameters taking them towards 
+the normal values after yoga intervention. Thus, 7‑day 
+practice of yoga related to diabetes brings general feeling 
+Table 5: Independent sample t‑test controlled‑uncontrolled diabetes
+Parameter
+Controlled
+Uncontrolled
+t
+df
+P
+Difference of means
+Area
+11,919.310
+12,071.670
+−0.412
+57.855
+0.6819
+−152.36
+CE
+0.273
+0.255
+0.2136
+57.045
+0.8316
+0.019
+CO
+0.279
+0.158
+1.5316
+54.857
+0.1314
+0.121
+EN
+1.977
+1.954
+0.57251
+50.813
+0.5695
+0.023
+FC
+10.747
+11.833
+−1.2867
+53.368
+0.2038
+−1.085
+FR
+1.840
+1.855
+−1.0802
+53.726
+0.2849
+−0.014
+IM
+0.196
+−0.006
+2.2044
+52.786
+0.03188
+0.201
+Intensity
+85.721
+82.710
+1.5403
+55.54
+0.1292
+3.011
+LI
+0.373
+0.192
+1.334
+57.739
+0.1874
+0.181
+Left kidney
+0.338
+0.192
+1.3318
+58
+0.1881
+0.145
+PA
+0.297
+0.156
+1.026
+56.992
+0.3092
+0.141
+Right kidney
+0.394
+0.118
+2.4989
+55.651
+0.01544
+0.276
+P level of significance, <0.5 considered statistically significant; Student’s t‑test. FC = Form coefficient, EN = Entropy, FR = Fractality, 
+LI = Liver, IM = Immunity, PA = Pancreas, CO = Coronary, CE = Cerebral, df = Degree of freedom
+Table 4: Combined highly significant results of 
+independent sample t-test
+Parameter Group 
+t
+df
+P
+Mean of 
+differences
+AI
+DAI, NAI
+4.075
+70.164 0.0001194
+5.978
+DAI, PDAI
+2.655
+16.611
+0.017
+6.676
+FC
+DFC, NFC
+−3.651
+40.784
+0.001
+−3.590
+DFC, PDFC
+−2.399
+13.519
+0.032
+−4.158
+EN
+DEN, NEN
+2.821
+55.251
+0.007
+0.103
+DEN, PDEN
+3.571
+16.307
+0.002
+0.195
+FR
+DFR, NFR
+−2.271
+30.317
+0.030
+−0.075
+DFR, PDFR
+−4.041
+12.922
+0.001
+−0.139
+LI
+DLI, NLI
+2.868
+62.216
+0.006
+0.319
+IM organs DIM, NIM
+3.699
+66.439
+0.000441
+0.281
+DIM, PDIM
+−15.681 12.421 1.479e‑09
+−5.890
+NIM, PDIM
+−16.375 12.585 7.362e‑10
+−6.171
+PA
+DPA, NPA
+3.691
+50.377
+0.001
+0.481
+NPA, PDPA
+−2.315
+34.320
+0.027
+−0.357
+CO
+DCO, NCO
+4.295
+48.965 8.259e‑05
+0.344
+DCO, PDCO
+3.344
+22.295
+0.003
+0.263
+CE
+DCE, NCE
+4.052
+65.358 0.0001376
+0.284
+DCE, PDCE
+2.752
+18.912
+0.013
+0.270
+Left 
+kidney
+DLT, NLT
+3.072
+53.868
+0.003
+0.307
+Right 
+kidney
+DRT, NRT
+3.732
+69.411
+0.004
+0.334
+DRT, PDRT
+2.504
+20.437
+0.021
+0.304
+P level of significance, <0.5 considered statistically significant; 
+Student’s t-test. D = Diabetes, PD = Prediabetes, N = Normal, 
+AI = Average intensity, FC = Form coefficient, EN = Entropy, 
+FR = Fractality, LI = Liver, IM = Immunity, PA = Pancreas, 
+CO = Coronary, CE = Cerebral, df = Degree of freedom
+Bhat, et al.: IJOY: EPI perspective of DM 2 and yoga
+157
+International Journal of Yoga | Volume 10 | Issue 3 | September‑December 2017
+of well‑being and some changes at the organ level. The 
+broad clue taken from all these studies is that EPI does 
+indicate changes at the general level as well organ/system 
+level in the different conditions of diabetes. There is direct 
+evidence of progressive change in most of the selected 
+parameters from normal to prediabetes to diabetes as seen 
+in Table 7 and Figure 1. These findings if properly applied 
+by the practitioners can help them to know regarding onset 
+of the disease and advise therapy and monitor the effect of 
+therapy.
+Limitations of the study
+The changes in different states/conditions need to be 
+corroborated with the modern medicine diagnostics. 
+At the moment there is no technology in the modern 
+science that can notice changes at the subtle level as the 
+EPI.
+Strength of the study
+This is the exclusive study on various aspects of diabetes. The 
+difference in three states, i.e., normal, prediabetic, and diabetic 
+is demonstrated through EPI. Effect of yoga in diabetics and 
+the changes in controlled and uncontrolled diabetes has been 
+presented. This study shows the changes and effects in the right 
+direction which strengthens the confidence in EPI technology.
+Further research
+Further research should be carried out on large sample sizes 
+with funding from national/international medical institutes. 
+This should be in conjunction with the practitioners/
+scientists of modern medicine and instrumentation. An 
+important area is to find whether small significant changes 
+in the general/organ‑specific parameters produce noticeable 
+changes at the physical level and correlate how much 
+change is the desired change for the desired effect.
+Conclusion
+This study was meant to look at diabetes from the perspective 
+of EPI. From the three situations considered, we infer from 
+the first study that values of intensity, form coefficient, and 
+immune organs can broadly classify a person into normal, 
+prediabetic, and diabetic. From the second study, we can 
+differentiate between controlled and uncontrolled diabetes 
+through the EPI parameters of Immune organs. In the 
+uncontrolled diabetes immune organs get compromised. 
+A  7‑day yoga camp on diabetes control and management 
+produces changes which can be seen through EPI in a large 
+number of parameters for both general and organ specific.
+Acknowledgments
+We would like to thank Dr. Guru Deo for data acquisition 
+and review. Dr.  Kuldeep K Kushwaha was extremely 
+helpful during collection of data. The support from SDM 
+team and Aroghyadham of S‑VYASA was highly valuable.
+Table 6: Pre-and post-results by paired t‑test
+t
+df
+P
+Mean of differences
+Total Area
+3.8737
+36
+0.0004
+630.4649
+AI
+−0.6810
+36
+0.5002
+−0.3887
+FC
+−4.3354
+36
+0.0001
+−1.7830
+EN
+−3.5140
+36
+0.0012
+−0.0297
+FR
+−0.4084
+36
+0.6854
+−0.0020
+Liver
+4.5659
+36
+5.614e-05
+0.2467
+IM
+0.9274
+36
+0.3599
+0.0517
+PA
+2.3382
+36
+0.0250
+0.1763
+CO vessels
+4.3967
+36
+9.331e-05
+0.1422
+CE vessels
+4.1166
+36
+0.0002
+0.1924
+Left kidney
+3.0564
+36
+0.0042
+0.1567
+Right kidney
+4.3051
+36
+0.0001
+0.2481
+P level of significance, <0.5 considered statistically significant; 
+Student’s t‑test. FC = Form coefficient, EN = Entropy, 
+FR = Fractality, LI = Liver, IM = Immunity, PA = Pancreas, 
+CO = Coronary, CE = Cerebral, AI = Average intensity, 
+df = Degree of freedom
+Table 7: One-way ANOVA
+Diabetes
+Normal
+Prediabetes
+df
+P
+F
+Mean
+SD
+Mean
+SD
+Mean
+SD
+Area
+12,003.320
+1451.203
+11,487.860
+1416.931
+11,597.770
+1425.588
+2
+<1
+1.410
+Intensity
+84.065
+7.616
+78.087
+5.862
+77.388
+8.346
+2
+<0.001
+9.029
+FC
+11.344
+3.239
+14.934
+4.792
+15.502
+6.064
+2
+<0.001
+10.270
+EN
+1.965
+0.160
+1.862
+0.161
+1.770
+0.182
+2
+<0.001
+9.371
+FR
+1.848
+0.050
+1.923
+0.174
+1.987
+0.121
+2
+<0.001
+10.820
+LI
+0.274
+0.532
+−0.045
+0.469
+0.105
+0.329
+2
+<0.05
+4.152
+IM organs
+0.085
+0.380
+−0.196
+0.312
+5.975
+1.342
+2
+<0.001
+612.800
+PA
+0.220
+0.533
+−0.261
+0.595
+0.096
+0.387
+2
+<0.001
+7.862
+CO
+0.213
+0.320
+−0.131
+0.369
+−0.050
+0.240
+2
+<0.001
+12.040
+CE
+0.263
+0.347
+−0.021
+0.290
+−0.007
+0.314
+2
+<0.001
+8.976
+Left kidney
+0.258
+0.431
+−0.049
+0.446
+0.053
+0.397
+2
+<0.01
+5.265
+Right kidney
+0.242
+0.461
+−0.092
+0.359
+−0.062
+0.380
+2
+<0.01
+7.212
+SD = Standard deviation, FC = Form coefficient, EN = Entropy, FR = Fractality, LI = Liver, IM = Immunity, PA = Pancreas, 
+CO = Coronary, CE = Cerebral, df = Degree of freedom
+Bhat, et al.: IJOY: EPI perspective of DM 2 and yoga
+158
+International Journal of Yoga | Volume 10 | Issue 3 | September‑December 2017
+Figure 1: 1-12: Graphical representation of various parameters in normal, pre-diabetic and diabetic state
+Bhat, et al.: IJOY: EPI perspective of DM 2 and yoga
+159
+International Journal of Yoga | Volume 10 | Issue 3 | September‑December 2017
+Financial support and sponsorship
+Nil.
+Conflicts of interest
+There are no conflicts of interest.
+References
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+Reproduced with permission of copyright owner.
+Further reproduction prohibited without permission.

subfolder_0/EFFECT OF INTEGRATED YOGA MODULE ON PERCEIVED STRESS.txt

@@ -0,0 +1,1759 @@
+ 
+ 
+ 
+www.jahm.in 
+(ISSN-2321-1563) 
+ 
+ 
+21 
+ 
+ORIGINAL RESEARCH ARTICLE 
+EFFECT OF INTEGRATED YOGA MODULE ON PERCEIVED STRESS, VERBAL AGGRESSION AND 
+SATISFACTION WITH LIFE IN HOME GUARDS IN BANGALORE – A WAIT LIST RANDOMIZED CONTROL 
+TRIAL 
+B. AMARANATH AMARANATH1 NAGENDRA H.R.2 DR.SUDHEER DESHPANDE3  
+ 
+ABSTRACT 
+Introduction:  Although the modern medical science and technology is helping us to cope up with the external 
+injuries, the stress created in interaction with individuals and public events is taking toll on us.  This is more 
+prominent in Home Guards(HGs), who have to work in the field to maintain law and order in public events.  
+This study is to observe the role of Yoga to reduce the stress, verbal aggression and  increase the satisfaction 
+in life. Objective: To study the efficacy of Integrated Yoga Module (IYM) on PSS, VAS and SWL in HGs. 
+Methods: Five HGs who attended introductory lectures, 148 HGs of both sexes, who satisfied the inclusion 
+and exclusion criteria were randomly allocated into two groups. The Yoga group(YG) practiced in an IYM that 
+included Asanas, Pranayama, meditation and lectures. The control group(CG)  was not given any Yoga practice 
+but they were performing their routine work. The experimental group had supervised practice sessions for 
+one hour daily, six days a week for eight weeks. Perceived Stress, Verbal Aggression and Satisfaction in Life 
+was assessed before and after 8 weeks using the self-administered PSS, VAS and SWL Scale. Results: There 
+was a significant decrease in PSS,VAS level in the YG and a significant increase in the CG. PSS, VAS was also 
+found significant in between groups, similarly there was a significant increase in SWL level in YG with a 
+significant decrease in the CG. SWL was also found significant in between groups. Conclusions: This study has 
+showed that 8 week intervention of IYM reduced Perceived Stress Level, Verbal aggression in the YG and it 
+increased in the CG. Also Satisfaction in Life level increased in YG and decreased in CG.  
+Keywords: Home Guards, Perceived Stress, Verbal Aggression & Satisfaction with Life, Yoga. 
+ 
+ 
+1Ph.D. Scholar, 2Chancellor, 3Former Registrar S-VYASA University, Bangalore, India. 
+Corresponding author email: [email protected]   
+Access this article online: www.jahm.in 
+Published by Atreya Ayurveda Publications under the license CC-by-NC. 
+Jour. of Ayurveda & Holistic Medicine 
+Volume-III, Issue-V  
+ 
+22 
+ 
+INTRODUCTION: 
+Home Guard services now a days has become 
+one of the most challenging and stressful 
+services in India in general and Karnataka in 
+particular. They have to deal with angry mobs, 
+counter-insurgency operations, traffic control, 
+VIP security, political rallies, religious festival 
+crowd control, and various other law and 
+order duties without losing their composure 
+and sensitivity. They have to face potentially 
+hazardous situations that can result in physical 
+or mental trauma or even death in the line of 
+duty. HGs work in Home Guards Organization 
+(HGO). HGO is an independent disciplined and 
+uniformed body of volunteers constituted 
+under Karnataka HGs Act, 1962 under 
+Karnataka Home Department.[1]  The HGs 
+normally share their duty with the security and 
+police personnel. The major problem for all 
+the above is basically stress. 
+One of the best methodologies to combat 
+stress and improve the satisfaction in life is 
+Yoga. Yoga which encompasses several 
+techniques 
+including 
+physical 
+postures, 
+breathing 
+techniques 
+(Pranayama) 
+and 
+meditation has become very popular for its 
+applications in health starting from better 
+physical fitness[2] to a better quality of life in 
+cancer patients.[3] Yoga has been used 
+effectively for stress reduction that has 
+resulted in biochemical [4] and physiological [5] 
+changes. Several studies have highlighted the 
+psychological benefits of integrated Yoga 
+practices such as anxiety, neurosis[6,7] and 
+depressive illness[8,9] The mood benefits of 
+Hatha Yoga and swimming compared in 
+college students showed that Yoga was as 
+effective as swimming in decreasing anxiety, 
+confusion, tension and depression, and that 
+the 
+acute 
+decreases 
+after 
+Yoga 
+were 
+significantly greater than after swimming for 
+men who were personally selected to 
+participate.[10]    Similar results have also been 
+noted in psychiatric patients with a reduction 
+in negative emotions factor in Profile of mood 
+states, including tension-anxiety, depression-
+dejection, anger-hostility, fatigue-inertia, and 
+confusion-bewilderment after Yoga.[11]     
+Although there are several studies on the 
+efficacy of Yoga on different measures of 
+emotional states in police, there are no studies 
+on any measure of stress and the coping 
+strategies in HGs. Hence, the aim of the 
+current study was to investigate whether 
+Integrated Yoga Module (IYM) can provide 
+benefits to HG in reducing stress and 
+increasing satisfaction in life. 
+OBJECTIVEs 
+ To study the efficacy of Integrated Yoga 
+Module (IYM) on PSS, VAS and SWL in HGs. 
+METHODS 
+Jour. of Ayurveda & Holistic Medicine 
+Volume-III, Issue-V  
+ 
+23 
+ 
+Subjects: Subjects were selected from 500 
+field working HGs from Bangalore Rural 
+District who attended motivational lectures 
+given by deputed instructors. 148 who 
+volunteered to join the study were randomly 
+divided into YG (n=75) and CG (n=73) using a 
+Random 
+number 
+calculators 
+[Internet], 
+random number table was generated. [12]     
+Inclusion criteria: (a) Men or woman, (b) 
+normal healthy field working HGs and(c) age 
+between 20-45 years. 
+Exclusion criteria: (a) Any ailment, (b) 
+Consuming alcohol and smoking, and (c) Those 
+already practicing Yoga. 
+Informed Consent: Informed consent was 
+taken from all the subjects before enrolling 
+them in the study.  The institutional ethical 
+committee of S-VYASA approved the study 
+proposal.  
+Study Design: This was a prospective, 
+randomized, single-blind, control study to 
+measure and compare the personality (Gunās) 
+of the HGs allotted to YG and CG.  Gruha 
+Rakshaka Bhavan (HG Administrative office at 
+Bangalore, Karnataka was the venue for Yoga 
+classes). 
+Both groups continued performing routine 
+work such as maintaining law and order, 
+managing traffic and the public in different 
+government organization like RTO, Vidhana 
+Soudha, etc.,. Both groups participated in 
+weekly mandatory parades as per HG 
+schedules.   
+In addition to normal routine work the YG also 
+did one hour of IYM practices, six days a week 
+for eight weeks. Daily attendance was taken 
+for all the subjects, Yoga trained experts 
+taught Yoga to YG. The CG only did their 
+normal routine work, but its participants were 
+given the option to join Yoga classes after 
+study completion. 
+Intervention: The YG HGs besides doing their 
+normal routine work participated in IYM. The 
+Integrated Yoga module was selected from the 
+integrated set of Yoga practices used in earlier 
+studies on effects of IYM on positive 
+health.[13] The basis of developing the 
+integrated 
+approach 
+is 
+ancient 
+Yoga 
+texts[14] for total physical, mental, emotional, 
+social and spiritual levels developments.[15] 
+Techniques 
+include 
+physical 
+practices  (Kriyas, Asanas, 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 IYM (appended in Table No. 1) for 2 
+months,60 minutes of practice daily, 6 days 
+per week. 
+Table 1 - Details of the practices 
+Jour. of Ayurveda & Holistic Medicine 
+Volume-III, Issue-V  
+ 
+24 
+ 
+Sl 
+no. 
+Duration 
+Names 
+                   Benefits  
+1 
+5 minutes 
+Breathing practices, Hands in and 
+out breathing, Dog breathing,Tiger 
+breathing,Straightlegsraise 
+breathing. 
+  
+Brings into action all the lobes of the lungs 
+for 
+full 
+utilization. 
+Normalizes 
+the 
+breathing rate Makes the breathing 
+uniform, continuous and rhythmic. 
+2 
+ 
+5 minutes 
+ 
+Loosening ExercisesJogging, 
+Forward and backward bending 
+Side bending, 
+Prepares the joints for better flexibility  to 
+move on to postures 
+Twisting 
+Pavanamuktasana kriya 
+3 
+25 minutes 
+Asanas : 
+Standing:Ardha cakrasana, 
+Pada hastasana. 
+Sitting: Vajrasana,Supta vajrasana 
+Halasana or Mayurasana. 
+Prone postures:Dhanurasana 
+Supine postures:Sarvaingasana, 
+Matyasana,ArdhaSirsasana or 
+ Sirsasana 
+Balance and harmony. Great speed in 
+movement due to agility 
+Makes 
+body 
+flexible,improves 
+concentration, Relaxation in action and 
+hence conservation of energy.Tranquility 
+of mind and clarity of thought 
+4 
+5 minutes 
+Deep Relaxation Technique 
+Deep rest to cells,Stress reduction 
+Rejuvenates the tissues,Unfolds the latent 
+impressions 
+buried 
+within 
+the 
+subconscious mind. 
+ 
+5 
+10 minutes 
+Pranayama: 
+Vibhageya 
+pranayama,Nadicuddhi 
+Pranyama,Çitale, Setkari, Sadanta 
+Pranayama,Bhramari Pranayama 
+Nadanusandhana 
+      OR 
+  Brings mastery over Prana 
+ 
+   6 
+ 
+Meditation –  Om Meditation 
+Provides deep rest to the system,calms 
+down the mind. Reduces metabolic rate,  
+blissful awareness,freshness, lightness 
+Jour. of Ayurveda & Holistic Medicine 
+Volume-III, Issue-V  
+ 
+25 
+ 
+expansion at mental level, improves 
+concentration, memory, and creativity. 
+ 
+7 
+10 minutes 
+Lectures 
+Cultures the emotions. 
+Removes ignorance and wrong notions.  
+Stable personality. 
+8           
+Kapalabhati 
+Cleanses the body removes the toxins.  
+It desensitizes the possible hyper 
+sensitivity. 
+ 
+Assessments: The Perceived Stress Scale was 
+developed to measure the degree to which 
+situatioŶs iŶ oŶe’s life are appraised as stressful. 
+Psychological stress has been defined as the extent 
+to which persons perceive (appraise) that their 
+demands exceed their ability to cope.  
+The Perceived Stress scale was developed by 
+Sheldon Cohen and his colleagues.[16] The PSS 
+was published in 1983,[16] and has become 
+one of the most widely used psychological 
+instruments for 
+measuring 
+nonspecific 
+perceived stress. 
+Assessing the PSS score: The PSS score was 
+determined by the following method: First, by 
+reversing the scores for questions 4, 5, 7 and 
+8. On these 4 questions, the scores could 
+change from: 0 = 4, 1 = 3, 2 = 2, 3 = 1, 4 = 0. 
+Then, the scores were added up for each item 
+to get the total. The total score was 
+represented as the stress score: The individual 
+scores on the PSS could range from 0 to 40, 
+ǁhiĐh ǁere grouped iŶto ϯ groups. • Loǁ 
+stress: Scores ranging from 0-ϭϯ. • Moderate 
+stress: Scores ranging from 14-ϭ9. • High 
+perceived stress: Scores ranging from 20-40.  
+The Verbal Aggressiveness Scale (VAS) is an 
+interpersonal model and measure. The VAS 
+developed by Infante and Wigley contains 20 
+items scored on a 5-point linear rating format 
+with reverse scoring on ten out of 20 items 
+(questions: 1, 3, 5, 8, 10, 12, 14, 15, 17, 
+20).[17]  The scores can range from 20 to 100. 
+The VAS gives a single overall score that 
+describes the disposition of an individual 
+towards low, moderate, or high level verbal 
+aggressiveness. Scores from 20-46 suggest low 
+verbal 
+aggressiveness, 
+47-73 
+suggest 
+moderate verbal aggressiveness and 74-100 
+suggest high verbal aggressiveness. 
+Validity: This scale is stable across time. The 
+reported test-retest reliability is 0.82 for a four 
+week period. Further, cross-culture reliability 
+has been supported in a number of studies 
+[8] . 
+Jour. of Ayurveda & Holistic Medicine 
+Volume-III, Issue-V  
+ 
+26 
+ 
+The Satisfaction in Life Scale is a short 5-item 
+instrument designed to measure global 
+cognitive judgments of satisfaction with one's 
+life and it is developed by Ed Diener, Emmons, 
+Larsen and Griffin, 1985.[17] 
+The Satisfaction in Life Scale (SWLS) has been 
+used heavily as a measure of the life 
+satisfaction component of subjective well-
+being. Scores on the SWLS have been shown 
+to correlate with measures of mental health, 
+and be predictive of future behaviors such as 
+suicide attempts. In the area of health 
+psychology, the SWLS has been used to 
+measure the subjective quality of life of people 
+experiencing serious health concerns. 
+A 5-item scale designed to measure global 
+ĐogŶitiǀe judgŵeŶts of oŶe’s life satisfaĐtioŶ. 
+Participants indicate how much they agree or 
+disagree with each of the 5 items using a 7-
+point scale that ranges from 7 strongly agree 
+to 1 strongly disagree. 
+Satisfaction in life scale scores 5to9 are 
+considered extremely dissatisfied, scores 10 to 
+14 are considered as moderately dissatisfied, 
+score 20 are considered as neutral, scores 21 
+to 25 are considered as slightly satisfied, 
+scores 26 to 30 are considered as satisfied and 
+scores 31 to 35 are considered as extremely 
+satisfied.[18]  The coefficient alpha for the 
+scale has ranged from .79 to .89, indicating 
+that the scale has high internal consistency. 
+The scale was also found to have good test-
+retest correlations (.84, .80 over a month 
+interval).[19] 
+Evaluation: The tests were administered by 
+examiners before and after eight 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 
+evaluated 
+the 
+coded 
+QRSs.  
+Another person blind to group membership 
+decoded the QRSs only after noting the scores 
+both before and after data was completed. 
+Data extraction: The data was extracted as per 
+the instructions in the PSS, VAS and SWL 
+manual.  
+Statistical analysis: Data was analyzed using R-
+Studio statistical software. Based on a 
+previous study, [20]  the effect size was 
+calculated using G power.[21]   Data at baseline 
+was assessed for normal distribution using 
+Shapiro-Wilk's test for both the groups. The 
+data was  normally distributed for PSS (p ч 
+0.05) ,  VAS( p ч Ϭ.Ϭϱ) and  SWL(p ч Ϭ.ϬϱͿ . 
+Independent sample t –tests were performed 
+to assess significance of differences between 
+the groups and paired samples t-tests for 
+within group changes. 
+Data analysis: Data was analyzed using R- 
+Statistical software. Data at baseline was 
+Jour. of Ayurveda & Holistic Medicine 
+Volume-III, Issue-V  
+ 
+27 
+ 
+assessed for normal distribution using Shapiro-
+Wilk's 
+test 
+in 
+both 
+the 
+groups. 
+The 
+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: The 75 participants in YG 
+and 73 participants in CG had age ranges 
+between 20 and50 years.  Between 20 to 30 
+years 36 in YG and 41 in CG, between 30 to 40 
+years 28 in YG and 20 in CG, above 40 years 
+11in YG and 12 in CG. In gender, 36 in YG were 
+female, and 31 in CG, 39 in YG, were male and 
+42 in CG.  In marital status 49 were married in 
+both YG and CG;26 in YG were unmarried ,and 
+24 
+in 
+CG. 
+PartiĐipaŶts’ 
+educational 
+qualifications were upto SSLC, SSLC to PUC and 
+graduates. 49 in YG and 37 in CG are SSLC, 20 
+in YG and 24 in CG are PUC and 6 in YG and 12 
+in 
+CG 
+are 
+Degree.
+Table 2 Perceived Stress level 
+ 
+Yoga Group 
+Controlled Group 
+Between Group 
+ 
+PSS 
+Pre 
+Post 
+p value 
+Pre 
+Post 
+p value 
+t 
+P value 
+20.52±4.57 
+17.04±5.04 
+0.001 
+19.87±4.73 
+21.45±5.37 
+0.044 
+5.14 
+0.001 
+ 
+Graph no. 1 Perceived Stress Level 
+ 
+In general the stress level in Yoga group has 
+significantly 
+;pчϬ.ϬϱͿ 
+deĐreased 
+froŵ 
+20.52±4.57 to 19.87±4.73 whereas it has 
+increased 
+significantly 
+;pчϬ.ϬϱͿ 
+from 
+19.87±4.73 to 21.45±5.37 in control group. 
+Between the group is also significant ;pчϬ.ϬϱͿ. 
+(Appended in Table No. 2A,). Perceived Stress 
+Level Scores around 13 are considered 
+average, scores 14 to 19 are considered as 
+moderate stress and  Scores of 20 or higher 
+are considered high stress. 
+Table no. 3 Perceived Stress Level 
+Scores 
+ 
+Yoga Group 
+Control Group 
+0
+5
+10
+15
+20
+25
+Yoga Group
+Control Group
+Perceived Stress Level 
+pre
+post
+Jour. of Ayurveda & Holistic Medicine 
+Volume-III, Issue-V  
+ 
+28 
+ 
+ 
+ 
+Before 
+After 
+Before 
+After 
+<13 
+Average 
+5 
+23 
+10 
+2 
+14to19 
+Moderately  
+24 
+28 
+24 
+27 
+>20 
+High 
+46 
+24 
+39 
+44 
+ 
+There were 5 people who were in average 
+stress and increased to 23 in Yoga group 
+where as it has decreased from 10 to 2 in 
+control group. 24 people who were in the 
+category of moderate stress have increased to 
+28 people in Yoga where as in control group it 
+has increased from 24 to 27 people (same 
+trend). 46 people who were in the category of 
+high stress have decreased to 24 in Yoga 
+group whereas it has increased in control 
+group from 39  to 44 persons. 
+Graph no. 2- Change in PSS 
+ 
+Table no. 4- Change in Perceived Stress Level: 
+Scores 
+ 
+Yoga Group 
+Control Group 
+ 
+ 
+Before 
+yoga 
+Shifting of  people 
+to different stress 
+group . 
+After 
+yoga  
+Before  
+Shifting of  people 
+to different stress 
+group . 
+After  
+<13 
+Average 
+5 
+ 3 to <13 
+2 to 14-19 
+23 
+10 
+1 to <13 
+ 5 to 14-19 
+4 to >20 
+2 
+14to1
+9 
+Moderately  24 
+7 to <13 
+12 to 14-19 
+5 to >20 
+28 
+24 
+ 9 to 14-19 
+15 to >20 
+27 
+>20 
+High 
+46 
+13 to <13 
+14 to 14-19 
+24 
+39 
+1 to <13 
+13 to 14-19 
+44 
+0
+10
+20
+30
+40
+50
+Before
+After
+Before
+After
+Yoga Group
+Controll Group
+Change in PSS 
+<13 Average
+14to19 Moderately
+>20 High
+Jour. of Ayurveda & Holistic Medicine 
+Volume-III, Issue-V  
+ 
+29 
+ 
+19 to >20 
+25 to >20 
+Average Stress: PSSчϭϯ is ĐoŶsidered as 
+average stress. There were 5 people who were 
+in average stress, 3 people remain in average 
+and 2 move to moderate stress level  in Yoga 
+group where as 10 people who were in 
+average stress, 1 remain in average and 5 
+move to moderate stress level and 4 people 
+move to high stress level in control group.   
+Moderate stress: PSS score 14 to 19 are 
+considered as moderate stress level. There 
+were 24 people who were in moderate stress, 
+7 people move to average and 12 move to 
+moderate stress level and 5 move to high 
+stress level in Yoga group where as 24 people 
+who were in moderate stress, 9 move to 
+moderate stress level and 15 people move to 
+high stress level in control group.   
+High stress: PSSшϮϬ is considered as high 
+stress level. There were 46 people who were 
+in high stress, 13 people move to average, 14 
+move to moderate stress level and 19 remain 
+in high stress level in Yoga group where as out 
+of 39 people who were in high stress, 1 person 
+move to average stress level , 13 people to 
+moderate stress and 25 people move to high 
+stress level in control group.   
+Table no. 5- Verbal Aggression 
+ 
+Yoga Group 
+Controlled Group 
+Between Group 
+ 
+VAS 
+Pre 
+Post 
+p value 
+Pre 
+Post 
+p value 
+t 
+P value 
+58.89±8.05 
+55.73±7.87 
+0.01 
+58.87±6.83 
+62.31±6.93 
+0.004 
+5.39 
+0.001 
+In general the Verbal Aggression in Yoga group 
+has 
+sigŶifiĐaŶtlLJ;pчϬ.ϬϱͿ 
+deĐreased 
+froŵ 
+58.89±8.05 to 55.73±7.87 whereas it has 
+iŶĐreased 
+sigŶifiĐaŶtlLJ;pчϬ.ϬϱͿ 
+ 
+froŵ 
+58.87±6.83 to 62.31±6.93 in control group. 
+BetǁeeŶ the group is also sigŶifiĐaŶt;pчϬ.ϬϱͿ. 
+(Appended in Table No. 2B,). 
+Graph no. 3- Verbal Aggression Level 
+ 
+2. Gender:- Males and Females:-Both males 
+(58.17±8.70 
+to 
+56.35±8.77) 
+and 
+females 
+(59.66±7.33 to 55.05±6.83) have shown decrease 
+in verbal aggression in yoga group  whereas it has 
+increased  in Males (59.16±6.639 to 64.50±7.02) 
+and  considerably increase in Females (58.22±7.14 
+50
+55
+60
+65
+Yoga Group
+Control Group
+Verbal Aggression Level 
+pre
+post
+Jour. of Ayurveda & Holistic Medicine 
+Volume-III, Issue-V  
+ 
+30 
+ 
+to 60.03±9.01) in control group. (appended in 
+Table No. 2B) 
+3. Marital status:  Both married (60.06±8.19 to 
+55.60±7.63) and unmarried people (56.56±7.38 to 
+56.0±8.49) shown decrease in verbal aggression in 
+Yoga group whereas it had increased in married 
+(58.26±7.27 to 61.73±7.15) and unmarried people 
+(60.12±5.77 to63.50±6.44)  in control group 
+.(appended in Table No. 2B). 
+4. Education: - Further the groups were divided 
+according to their educational qualification high 
+school or below, Pre-University and Degree. The 
+two groups SSLC or below (58.89±7.51 to 
+56.44±7.77) ,PUC (58.25±9.22 to 55.70±7.79) and 
+degree (61.0±9.40 to 50.00±7.97 have shown 
+decrease in verbal aggression in yoga group. In 
+controlled group Degree category shown increase 
+in verbal aggression but other two categories slight 
+decrease in verbal aggression level. (appended in 
+Table No. 2B) 
+5.  Age: - The data was analyzed based on the ages. 
+The age groups between 20 to 29 years 
+(59.50±7.26 to 56.02±9.00), 30 to 39 years 
+(58.53±9.17 to 55.92±6.35) and above 40 years 
+(57.81±8.06 to 54.27±7.97)  have shown  decrease 
+in verbal aggression level whereas the HGs 30 to 
+39 have shown increase in verbal aggression  
+(58.40±6.2 to 62.25±8.01) but slight decrease in 
+other categories in the control group. (appended 
+in Table No. 2B) 
+Table no. 6- Change in Verbal Aggression  Level: 
+Scores 
+ 
+Yoga Group 
+Control Group 
+ 
+ 
+Before 
+After 
+Before 
+After 
+20-46 
+Low Verbal Aggression 
+5 
+14 
+3 
+1 
+47-73 
+Moderately Verbal Aggression 
+68 
+61 
+69 
+66 
+74-100 
+High Verbal Aggression 
+2 
+0 
+1 
+6 
+There were 5 people who were Low Verbal 
+Aggression and increased to 14 in Yoga group 
+where as it has decreased from 3 to 1 in control 
+group. 68 people who were in the category of 
+moderate verbal aggression have decreased to 61 
+people in Yoga where as in control group also it 
+has increased from 69 to 66 people. 2 people who 
+were in the category of high verbal aggression 
+have become nil in Yoga group whereas it has 
+increased in control group from 1 to 6 persons. 
+Graph no.4 –Change in Verbal Aggression Level 
+ 
+Table no.7- Satisfaction with Life Scale 
+0
+20
+40
+60
+80
+pre
+Post
+pre
+post
+Yoga Group
+Control Group
+Change in Verbal Aggression Level 
+20-46 Low Verbal Aggression
+47-73 Moderately Verbal
+Aggression
+74-100 High Verbal Aggression
+Jour. of Ayurveda & Holistic Medicine 
+Volume-III, Issue-V  
+ 
+31 
+ 
+ 
+Yoga Group 
+Controlled Group 
+Between Group 
+ 
+SWL 
+Pre 
+Post 
+p value 
+Pre 
+Post 
+p value 
+t 
+P value 
+25.34±4.79 
+27.57±3.49 
+0.0001 
+25.01±5.03 
+19.80±6.88 
+0.0001 
+-8.61 
+0.0001 
+Graph no. 5- Satisfaction with life 
+ 
+In general the Satisfaction in life in Yoga group has 
+sigŶifiĐaŶtlLJ;pчϬ.ϬϱͿ iŶĐreased froŵ Ϯϱ.ϯϰ±ϰ.79 to 
+27.57±3.49 
+ 
+whereas 
+it 
+has 
+decreased 
+sigŶifiĐaŶtlLJ;pчϬ.ϬϱͿ 
+froŵ 
+Ϯϱ.Ϭϭ±ϱ.Ϭϯ 
+to 
+19.80±6.88 in control group .Between the group is 
+also sigŶifiĐaŶt;pчϬ.ϬϱͿ. ;AppeŶded iŶ Taďle No. 
+2C,).  
+Improvement in Satisfaction with Life Scale  
+Table- Satisfaction with life scale scores 5to9 are 
+considered extremely dissatisfied, scores 10 to 14 
+are considered as moderately dissatisfied, score 20 
+are considered as neutral, scores 21 to 25 are 
+considered as slightly satisfied, scores 26 to 30 are 
+considered as satisfied and scores 31 to 35 are 
+considered as extremely satisfied.  
+Graph no.6- Change in Satisfaction with life
+Improvement in Satisfaction with Life Scale 
+shows Moderately and Slightly dissatisfied  
+level 
+in 
+participants 
+have 
+reduced 
+to 
+completely nil in Yoga group where as it has 
+increased in Control group. Slightly satisfied, 
+satisfied and extremely satisfied has increased 
+in yoga group where as in control group 
+except slightly satisfied both satisfied and 
+extremely 
+satisfied 
+has 
+decreased 
+substantially. 
+ 
+ 
+0
+10
+20
+30
+Yoga Group
+Control Group
+Satisfaction with life 
+pre
+post
+0
+10
+20
+30
+40
+pre
+Post
+pre
+post
+Yoga Group
+Control Group
+Change in Satisfaction with life 
+5 to 9 Extremely
+dissatisfied
+10 to 14 Moderately
+dissatisfied
+15 to 19 Slightly
+dissatisfied
+20 Neutral
+Jour. of Ayurveda & Holistic Medicine 
+Volume-III, Issue-V  
+ 
+32 
+ 
+Table no. 8- Change in Satisfaction with life level: 
+Scores 
+ 
+Yoga Group 
+Control Group 
+ 
+ 
+Before 
+Shifting of  
+people to 
+different 
+satisfaction scale 
+After 
+Before 
+Shifting of  
+people to 
+different 
+satisfaction scale 
+After 
+5-9 
+Extremely 
+dissatisfied 
+- 
+ 
+- 
+- 
+ 
+9 
+10-14 
+Moderately 
+dissatisfied 
+1 
+1 to 26-30 
+0 
+1 
+ 1 to 21-25 
+10 
+15-19 
+Slightly dissatisfied 
+11 
+5 to 21-25 
+3 to 26-30 
+3 to 31-35 
+0 
+9 
+ 1 to 5-9 
+6 to 21-25 
+2 to 31-35 
+10 
+20 
+Neutral 
+- 
+ 
+ 
+4 
+ 1 to 5-9 
+1 to 10-14 
+2 to 21-25 
+2 
+21-25 
+Slightly Satisfied 
+24 
+8 to 21-25 
+11 to 26-30 
+5 to 31-35 
+ 
+29 
+22 
+ 3 to 5-9 
+2 to 10-14 
+3 to 15-19 
+1 to 20 
+8 to 21-25 
+5 to 26-30 
+30 
+26-30 
+Satisfied 
+26 
+10 to 21-25 
+9 to 26-30 
+7 to 31-35 
+28 
+27 
+ 3 to 5-9 
+3 to 10-14 
+7 to 15-19 
+ 1 to 20 
+9 to 21-25 
+4 to 26-30 
+10 
+31-35 
+Extremely satisfied 
+13 
+6 to 21-25 
+4 to 26-30 
+3 to 31-35 
+18 
+10 
+ 1 to 5-9 
+4 to 10-14 
+4 to 21-25 
+1 to 26-30 
+2 
+ 
+There were 12 people who were in different 
+dissatisfied and Neutral level, 5 people move 
+to slightly satisfied level,4 people move to 
+satisfied and other 3 moved to extremely 
+satisfied level in Yoga group where as 12 
+people who were in different dissatisfied and 
+neutral levels, 3 remain in dissatisfied level 
+Jour. of Ayurveda & Holistic Medicine 
+Volume-III, Issue-V  
+ 
+33 
+ 
+and other 9 move to satisfied  level in control 
+group. 
+Similarly 63 people who were in different 
+satisfied level ,  24 people move to dissatisfied 
+level and other 57 people move to satisfied  
+and highly satisfied level in Yoga group where 
+as out of 62 people who were in different 
+satisfied levels, 28 people move to different 
+dissatisfied level and only 34 people remain in 
+satisfied level  in control group 
+DISCUSSION: 
+This is a randomized control prospective study 
+in HGs comparing the efficacy of Yoga on 
+Perceived stress level, Verbal Aggression and 
+Satisfaction 
+in 
+life. 
+This 
+study 
+has 
+demonstrated 
+that 
+an 
+eight 
+weeks 
+intervention of an integrated Yoga module 
+(IYM) 
+has 
+reduced 
+stress 
+level 
+Verbal 
+aggression level and increased the satisfaction 
+in life in the Yoga group compared to control 
+group.  
+In this study, average 70% of the Home Guards 
+in the sample were found to be suffering from 
+psychological stress, which is consistent with 
+the stress reported by Rao et al. in 28.8% of 
+CISF personnel.[22] Other studies such as that 
+done by Geetha et al. a Bengaluru police 
+personnel found high stress levels in 60% of 
+population,[23]  Deb et al. also found high 
+stress in 79.4% of traffic constables in Kolkata. 
+The higher levels of stress reported by these 
+studies as compared to the present study 
+could be because of socio-demographic and 
+methodological differences in the studies. 
+Several 
+international 
+studies 
+in 
+police 
+personnel have also reported stress levels 
+ranging 40–50% of the sample, but contrary to 
+the present study, these studies have found 
+higher psychological stress in female police 
+persons. [24, 25, 26] The reason for this could 
+be that the number of females in the current 
+study sample was very less compared to 
+males, with an M: F ratio of 9:1. As the ratio of 
+females in Indian police is quite less as 
+compared to males, a bigger sample size is 
+required to get a true representation of their 
+stress levels and other study parameters. 
+According to the most widely used scriptural 
+reference on Yoga, the sage Patanjali [27]   
+defines Yoga as a technique for developing 
+mastery over the modifications of the mind 
+and goes on to highlight many techniques that 
+help in achieving this mastery. They are 
+classified under eight major streams including 
+injunctions for social and personal behavior 
+(Yama, Niyama), body postures (Asanas), 
+breathing 
+(Pranayama), 
+and 
+meditation 
+(Pratyahara, Dharana, Dhyana, and Samadhi) 
+techniques that lead to mastery over any of 
+the modifications in the mind. Furthermore, 
+the sage Vasishta [28] in his famous work, Yoga 
+Vasishta, defines Yoga as a technique to slow 
+Jour. of Ayurveda & Holistic Medicine 
+Volume-III, Issue-V  
+ 
+34 
+ 
+down or calm the mind directly through deep 
+internal 
+awareness. 
+Hence, 
+it 
+was 
+hypothesized that stress level, one of the 
+manifestations of an uncontrolled fast mind 
+has decreased by the techniques of Yoga. 
+A study on the relationship between verbal 
+aggressiveness and state of anxiety in sports 
+by Alexandra et al[29] showed that male 
+basketball players were more affected by 
+verbal 
+aggressiveness 
+of 
+their 
+coaches 
+compared to female basketball players as 
+assessed by VAS administered immediately 
+after the game. In their study, they also 
+observed a positive correlation between their 
+anxiety and VAS scores in male players. It is 
+known that Yoga with its holistic approach 
+uses several techniques to calm down the 
+mind and reduce the anxiety state. Our earlier 
+studies have shown that in community home 
+girls 
+and 
+congenitally 
+blind 
+children, 
+sympathetic tone reduced after Yoga practices 
+which resulted in significant decrease in 
+resting heart rates and breath rates, thus 
+reducing fear and anxiety.[30] The sympathetic 
+tone reduction could be a valuable treatment 
+modality for reduction of anxiety. Another 
+study on PT teachers also showed that Yoga 
+reduced their sympathetic activity after three 
+months of Yoga practices. [31]  A significant 
+reduction in anxiety scores was observed in 
+patients with anxiety neurosis [32]  after a Yoga 
+program. Based on these observations, we 
+may 
+suggest 
+that 
+the 
+reduction 
+in 
+aggressiveness in the present study could be 
+due to the reduction in their baseline anxiety 
+and sympathetic reactivity. 
+In summary, this randomized, prospective, 
+single-blind, comparative study has shown the 
+efficacy 
+of 
+Yoga 
+in 
+decreasing 
+verbal 
+aggressiveness and stress and improving 
+satisfaction with life level. Hence, Yoga may be 
+recommended to Security forces to deal with 
+the problem of violence among themselves 
+and with others, which is still a live issue in all 
+parts of the world 
+The strength of our design is the integrated 
+Yoga module for HGs. It is first test of its kind 
+in Home Guards where they have been 
+exposed to IYM practice which has shown 
+beneficial effect to home guards 
+CONCLUSION:  
+In summary, this randomized, prospective, 
+single-blind, comparative study has shown the 
+efficacy of Yoga in decreasing the stress level, 
+verbal aggression level and increasing the 
+satisfaction in life. Hence, Yoga may be 
+recommended to Security forces to deal with 
+the problem of violence among themselves 
+and with others, which is still a live issue in all 
+parts of the world. Further Yoga is very cost 
+effective and recommended to home guards. 
+Hence, this study is a solution to HGs to 
+reduce the stress, verbal aggression and 
+Jour. of Ayurveda & Holistic Medicine 
+Volume-III, Issue-V  
+ 
+35 
+ 
+improve their life satisfaction. By this  service 
+to public will improve and in turn the image of 
+the Department will also go up. 
+ 
+REFERENCES: 
+1. Karnataka 
+State 
+HGs 
+Mannual. 
+karnataka: 
+Karnataka State Government; 1962 
+2. Telles S, Hanumanthaiah BH, Nagarathna R NH. 
+Plasticity of motor control systems demonstrated 
+by Yoga training. Indian J PhysiolPharmacol 
+1994;38:143–4. 
+3. Bower JE, Woolery A, Sternlieb B GD. Yoga for 
+cancer patients and survivors.  Cancer 
+Control. 
+Cancer Control 2005;12:165–71. 
+4. Selvamurthy W, Ray US, Hegde KS SR. Physiological 
+respoŶses to Đold ;ϭϬ° CͿ iŶ ŵeŶ after sidž ŵoŶths’ 
+practice of Yoga exercises. Int J Biometeorol . 
+2005;32:188–93. 
+5. Vempati RP TS. Baseline occupational stress levels 
+and physiological responses to a two day stress 
+management 
+program. 
+J 
+Indian 
+Psychol.2000;18:33–7. 
+6. Brown RP, Gerbarg PL. SudarshanKriya Yogic 
+Breathing in the Treatment of Stress, Anxiety, and 
+Depression: Part I—Neurophysiologic Model. J 
+Altern ComplementMed. 2005 Feb;11(1):189–201. 
+7. Shannahoff-khalsa DS, Beckett LR. Clinical Case 
+Report: Efficacy of Yogic Techniques in the 
+Treatment of Obsessive Compulsive D Isorders. 
+IntJNeurosci.1996;85:1–17. 
+8. Jorm 
+AF, 
+Christensen 
+H, 
+Griffiths 
+KM 
+RB. 
+Effectiveness of complementary and self-help 
+treatments 
+for 
+depression. 
+Med 
+J 
+Aust. 
+2002;176:S84–96. 
+9. Janakiramaiah N, Gangadhar BN, Naga Venkatesha 
+Murthy 
+PJ, 
+Harish 
+MG, 
+Subbakrishna.  
+DK,Vedamurthachar A. Antidepressant efficacy of 
+Sudarshan Kriya Yoga (SKY) in melancholia: a r  
+andomized comparison with electroconvulsive 
+therapy (ECT) and imipramine. J Affect Disord 
+2000;57:255–9.  
+10. Berger BG, Owen Dr. Mood Alteration with Yoga 
+and Swimming-Aerobic Exercise May not be 
+necessary. Percept Mot Skills 1992;75:1331–43.  
+11. Lavey R, Sherman T, Musser KT, Osbrne DD, Currier 
+M WR. The effects of Yoga on moods in psychiatric 
+inpatients. PsychiatrRehabil J. 2005;28:399–402. 
+12. Motulsky H. Random number calculators 2015. 
+13. Nagarathna R, Nagendra HR. Integrated Approach 
+of Yoga Therapy for Positive Health.5th ed. SVYP: 
+Bangalore;2003. 
+14. S Loleswarananada. Taittiriya U. Calcutta: The 
+Ramakrishna Mission Institute of Culture;1996. 
+15. Narasimhan L, Nagarathna R, Nagendra H R. Effect 
+of integrated yogic practices on positive and 
+negative emotions in healthy adults. Int J Yoga 
+2011;4:13-9. 
+16. Cohen, S., Kamarck, T., Mermelstein, R.A global 
+measure of perceived stress. Journal of Health and 
+Social Behavior.  1983:24:385-396. 
+17. Infante DA, Wigley CJ. Verbal aggressiveness: An 
+interpersonal model and measure.  Commun 
+Monogr. 1986;53:61–9. 
+18. Pavot, W., & Diener, E. (2008). The Satisfaction 
+With Life Scale and the emerging construct  of life  
+satisfaction. Journal of Positive Psychology, 3, 137–
+152. 
+19. Ramesh Bhat M, Sameer MK, Ganaraja B. Journal of 
+Clinical and Diagnostic Research.  2011 November 
+(Suppl-2), Vol-5(7): 1331-1335. 
+20. VivekKumar 
+Sharma, 
+Madanmohan 
+Trakroo, 
+Velkumary Subramaniam, M.Rajajeyakumar,Anan B 
+Bhavanani, Ajit Sahai.Int J Yoga .2013:6:104-110. 
+21. Faul F. G*Power Version 3.0.10 2008. 
+22. Rao GP, Moinuddin K, Sai PG, Sarma E, Sarma A, 
+Rao AS. A study of stress and psychiatri  morbidity 
+Jour. of Ayurveda & Holistic Medicine 
+Volume-III, Issue-V  
+ 
+36 
+ 
+in central industrial security force. Indian J Psychol 
+Med. 2008;30:39–47. 
+23. Geetha PR, Subbakrishna DK, Channabasavanna 
+SM. 
+Subjective 
+well 
+being 
+among 
+police 
+personnel. Indian J Psychiatry. 1998;40:172–9.  
+24. Collins 
+PA, 
+Gibbs 
+ACC.Stress 
+in 
+police 
+officers:Astudy of the origins, prevalence & severity 
+of stress-related symptoms within a county police 
+force. Occupation Med. 2003;53:256–64.  
+25. Lipp ME. Stress and quality of life of senior Brazilian 
+police officers. Span J Psychol.2009;12:593–603. 
+26. Costa M, Junior HA, Oliviera J. Stress: Diagnosis of 
+Military Police Personnel in a Brazilian City. Rev 
+Panam Salud Publication. 2007;21:217–22.  
+27. Taimini IK. The science of Yoga: The Yoga-Sutras of 
+Patanjali in Sanskrit Quest Books; 1999.   
+28. Nagarathna R, Nagendra HR. Yoga, 2nd ed. SVYP: 
+Bangalore; 2003. 
+29. Bekiari A, Pantazis S, Apostolou M, Nonnati A SK. 
+The relationship between verbal aggressiveness 
+and state anxiety in sport settings. 2005;12:165–8. 
+30. 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 Motor Skills 
+1997;84:251-7.  
+31. Telles S, Nagarathna R, Nagendra HR, Desiraju T. 
+Physiological changes in sports  teacher following 3 
+months of training in Yoga. Indian J Med Sci 
+1993;10:235-8.    
+32. Sahasi G, Mohan D, Kacker C. Effectiveness of yogic 
+techniques in the management of     anxiety. J 
+Personality Clinical Studies 1989;5:51-5.  
+Cite this article as: B. Amaranath amaranath, Nagendra 
+H.R, Sudheer Deshpande. Effect of integrated yoga 
+module on perceived stress, verbal aggression and 
+satisfaction with life in home guards in Bangalore – a wait 
+list randomized control trial, J of Ayurveda and Hol 
+Med (JAHM).2015;3(5):21-38 
+Source of support: Nil, Conflict of interest: None 
+Declared 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+Table 2A - Pre and Post data of Perceived Stress Level status in all the categories: 
+Sl.
+No
+. 
+ 
+Yoga Group 
+Control  Group 
+Pre 
+Post 
+t 
+p 
+Pre 
+Post 
+t 
+P 
+1 
+Pss 
+ 
+20.52±4.57 
+17.04±5.04 
+-5.06 
+0.001 
+19.87±4.73 
+21.45±5.37 
+2.04 
+0.044 
+                                                                          Marital Status  
+Married 
+21.30±4.01 
+17.57±5.15 
+-4.08 
+0.001 
+19.63±5.13 
+19.95±4.38 
+0.37 
+0.710 
+Unmarried 
+19.03.±5.24 
+16.01±4.76 
+-3.01 
+0.005 
+20.37±3.95 
+24.50±5.98 
+2.92 
+0.007 
+Jour. of Ayurveda & Holistic Medicine 
+Volume-III, Issue-V  
+ 
+37 
+ 
+                                                                           Gender 
+Male  
+19.20±4.67 
+15.41±4.68 
+-4.55 
+0.001 
+19.80±4.89 
+22.28±5.89 
+2.35 
+0.023 
+Female 
+21.94±4.05 
+18.80±4.81 
+-2.80 
+0.008 
+19.96±4.66 
+20.32±4.51 
+0.32 
+0.750 
+                                                            Educational Qualification 
+< SSLC 
+21.42±3.96 
+17.40±4.79 
+-4.48 
+0.001 
+19.18±4.99 
+20.51±5.43 
+1.23 
+0.224 
+PUC 
+19.15±5.39 
+17.50±5.28 
+-1.36 
+0.187 
+20.58±5.14 
+21.29±4.94 
+0.47 
+0.638 
+Degree 
+17.66±4.71 
+12.50±4.76 
+-3.27 
+0.022 
+20.58±2.87 
+24.66±5.17 
+2.79 
+0.017 
+                                                                                     Age 
+Age 20-29 
+20.13±4.73 
+16.63±5.24 
+-3.57 
+0.001 
+20.82±4.20 
+22.63±5.74 
+1.72 
+0.091 
+Age 30- 39 
+20.82±4.83 
+17.78±4.82 
+-2.76 
+0.010 
+18.35±5.47 
+19.80±4.54 
+0.97 
+0.342 
+Age >40 
+21.01±3.49 
+16.45±5.12 
+-2.17 
+0.054 
+19.16±4.93 
+20.16±4.60 
+0.52 
+0.613 
+ 
+Table 2B - Pre and Post data of Verbal Aggression Level in all the categories: 
+Sl. 
+No. 
+ 
+Yoga Group 
+ 
+ 
+Control Group 
+Between Group 
+Pre 
+Post 
+t 
+p 
+Pre 
+Post 
+t 
+P 
+1 
+vas 
+ 
+58.89±8.05 
+55.73±7.87 
+-2.5 
+0.011 
+58.87±6.83 
+62.31±6.93 
+2.97 
+0.004 
+Marital status 
+Married 
+60.06±8.19 
+55.60±7.63 
+-2.96 
+0.004 
+58.26±7.27 
+61.73±7.15 
+2.31 
+0.02 
+Unmarried 
+56.56.±7.38 
+56.0±8.49 
+-0.277 
+0.783 
+60.12±5.77 
+63.50±6.44 
+1.88 
+0.07 
+Gender 
+Male  
+58.17±8.70 
+56.35±8.77 
+-0.95 
+0.347 
+59.16±6.69 
+64.50±7.02 
+3.15 
+0.003 
+Female 
+59.66±7.33 
+55.05±6.83 
+-3.16 
+0.003 
+58.43±7.09 
+59.35±5.67 
+0.63 
+0.53 
+Educational Qualification 
+< SSLC 
+58.89±7.51 
+46.99±7.24 
+-1.93 
+0.058 
+58.51±5.55 
+62.72±6.80 
+3.20 
+0.002 
+PUC 
+58.25±9.22 
+55.70±7.79 
+-0.87 
+0.391 
+60.45±7.82 
+60.45±6.34 
+0 
+1 
+Degree 
+61.0±9.40 
+50.00±7.97 
+-2.05 
+0.095 
+56.83±8.04 
+64.75±8.02 
+2.07 
+0.06 
+Age (Years) 
+Age 20-29 
+59.50±7.26 
+56.02±9.00 
+-1.91 
+0.063 
+59.63±6.29 
+63.36±6.94 
+2.47 
+0.01 
+Age 30- 39 
+58.53±9.17 
+55.92±6.35 
+-1.32 
+0.195 
+57.55±6.56 
+61.25±6.14 
+1.96 
+0.06 
+Age >40 
+57.81±8.06 
+54.27±7.97 
+-1.07 
+0.306 
+58.50±9.02 
+60.50±8.01 
+0.53 
+0.61 
+ 
+Table 2C - Pre and Post data of Satisfaction in Life status in all the categories 
+Jour. of Ayurveda & Holistic Medicine 
+Volume-III, Issue-V  
+ 
+38 
+ 
+ 
+ 
+ 
+ 
+Sl.No. 
+ 
+Yoga Group 
+Control Group 
+Pre 
+Post 
+t 
+p 
+Pre 
+Post 
+t 
+p 
+1 
+SWL 
+ 
+25.34±4.79 
+27.57±3.47 
+3.20 
+0.001 
+25.01±5.03 
+19.80±6.88 
+-4.67 
+0.001 
+                                                                          Marital Status  
+Married 
+25.32±5.09 
+28.14±3.66 
+3.06 
+0.003 
+24.19±5.15 
+21.79±6.00 
+-2.41 
+0.019 
+Unmarried 
+25.38.±4.26 
+26.50±2.94 
+1.12 
+0.270 
+25.20±4.88 
+15.75±6.89 
+-5.02 
+0.001 
+                                                                           Gender 
+Male  
+25.61±4.68 
+26.87±3.32 
+1.51 
+0.137 
+25.47±4.54 
+18.78±7.70 
+-4.27 
+0.001 
+Female 
+25.05±4.95 
+28.33±3.56 2.92 
+0.005 
+24.38±5.64 
+21.19±5.40 
+-2.20 
+0.034 
+                                                            Educational Qualification 
+< SSLC 
+25.01±4.98 
+27.48±3.19 
+2.69 
+0.009 
+24.04±5.56 
+21.94±5.95 
+-1.32 
+0.194 
+PUC 
+25.50±4.17 
+27.00±3.89 
+1.21 
+0.231 
+25.41±4.50 
+18.54±7.05 
+-4.20 
+0.003 
+Degree 
+27.66±5.20 
+30.16±4.35 
+1.61 
+0.166 
+27.16±3.71 
+15.75±7.37 
+-4.71 
+0.006 
+                                                                                     Age 
+Age 20-29 
+25.33±4.48 
+26.66±3.15 
+1.31 
+0.198 
+25.17±4.79 
+18.46±7.09 
+-4.53 
+0.001 
+Age 30- 39 
+25.39±5.05 
+28.67±3.60 
+2.62 
+0.010 
+25.10±6.23 
+22.10±5.46 
+-1.38 
+0.181 
+Age >40 
+25.27.±5.57 
+27.90±4.01 
+1.82 
+0.091 
+24.33±3.82 
+20.58±7.65 
+-1.39 
+0.191 

subfolder_0/EFFECT OF YOGA BASED AND FORCED UNINOSTRIL BREATHING ON THE AUTONOMIC NERVOUS SYSTEM.txt

@@ -0,0 +1,6 @@
+ 
+ 
+ 
+ 
+ 
+ 

subfolder_0/Effect Of Yoga On Cognitive Abilities In Schoolchildren From A Socioeconomically Disadvantaged Background.txt

@@ -0,0 +1,33 @@
+Effect Of Yoga On Cognitive Abilities In Schoolchildren From 
+A Socioeconomically Disadvantaged Background: 
+Arandomized Controlled Study. 
+Chaya MS1, Nagendra H, Selvam S, Kurpad A, Srinivasan K. 
+ABSTRACT 
+The objective of this study was to assess the effect of yoga, compared to physical activity on 
+the 
+cognitive 
+performance 
+in 
+7-9 
+year-oldschoolchildren 
+from 
+a 
+socioeconomic disadvantaged background. 
+DESIGN: 
+Two hundred (200) schoolchildren from Bangalore, India, after baseline assessment 
+of cognitive functioning were randomly allocated to either a yoga or a physical-activity 
+group. Cognitive functions (attention and concentration, visuo-spatial abilities, verbal ability, and 
+abstract thinking) were assessed using an Indian adaptation of the Wechsler Intelligence Scale for 
+Children at baseline, after 3 months of intervention, and later at a 3-month follow-up. 
+RESULTS: 
+Of the 200 subjects, 193 were assessed at 3 months after the study, and then 180 were assessed at 
+the 3-month follow-up. There were no significant differences in cognitive performance between 
+the two study groups (yoga versus physical activity) at postintervention, after controlling for grade 
+levels. Improvement in the mean scores of cognitive tests following intervention varied from 0.5 
+(Arithmetic) to 1.4 (Coding) for the yoga group and 0.7 (Arithmetic) to 1.6 (Vocabulary) in the 
+physical-activity group. 
+CONCLUSIONS: 
+Yoga was as effective as physical activity in improving cognitive performance in 7-9 year 
+old schoolchildren. Further studies are needed to examine the dose-response relationship 
+between yoga and cognitive performance 
+ 

subfolder_0/Effect of 6 months intense Yoga practice on lipid profile, thyroxine medication and serum TSH level in women suffering from hypothyroidism.txt

@@ -0,0 +1,474 @@
+Savithri Nilkantham, Kashinath G. M.*, Nagaratna R. and Nagendra H. R.
+Effect of 6 months intense Yoga practice on lipid
+profile, thyroxine medication and serum TSH level
+in women suffering from hypothyroidism: A pilot
+study
+DOI 10.1515/jcim-2014-0079
+Received December 31, 2014; accepted February 23, 2016
+Abstract
+Background: A significant number of women in India are
+suffering from hypothyroidism. Hypothyroidism is charac-
+terized by elevated lipid profiles and thyroid stimulation
+hormone (TSH). It leads many comorbid conditions such
+as coronary artery disease, obesity, depression, osteoporo-
+sis, sleep apnea, and etc. Yoga is proven to be effective in
+reducing weight, dyslipidemia, depression and it brings the
+balance in autonomous nervous system. We aimed to study
+the effect of 6 months yoga practice on lipid profile, thyrox-
+ine requirement and serum TSH in women suffering from
+hypothyroidism.
+Objective: To practice on
+study the effect of 6 months
+yoga practice on lipid profile, thyroxine requirement and
+serum TSH in women suffering from hypothyroidism.
+Methods: Twenty-two household women suffering from
+hypothyroidism between the age range of 30 and 40
+(mean± SD; 36.7± 3.2) years, with average 4± 1.12-year his-
+tory of hypothyroidism were included in this study. Subjects
+with known cardiac issues, hypertension, history, recent sur-
+gery, slip disc and low back pain were excluded from this
+study. None of the subjects were on any other medication
+except thyroxine which was kept during the intervention
+phage (mean 65.78± 22.74 mcg). All the subjects underwent
+6 months of yoga practice 1 h daily for 4 days a week. Lipid
+profile, thyroxine dosage and serum TSH level were assessed
+beforeand afterintervention.Datawas analyzed using paired
+sample t test & Wilcoxon’s signed rank test.
+Results: The paired sample t-test showed significant
+reduction in total cholesterol (p = 0.006; –8.99 %), low-
+density
+lipoprotein
+(LDL)
+(p = 0.002;
+–9.81 %)
+and
+triglycerides (p = 0.013; –7.6 %), and there was a signifi-
+cant improvement in high-density lipoprotein (HDL)
+(p = 0.02; + 9.65 %) along with nonsignificant reduction
+in TSH level (p = 0.452; –9.72 %). Wilcoxon signed-rank
+test showed significant reduction in thyroxine medication
+score (p = 0.029; –15.30 %) from.
+Conclusion: 6 months practice of yoga may help in
+improving cholesterol level, serum TSH, may also help
+in reducing the thyroxine requirement in female patients
+suffering from hypothyroidism. However, further rando-
+mized controlled studies need to be conducted to confirm
+the present finding.
+Keywords: cholesterol, hypothyroidism, thyroid stimula-
+tion hormone (TSH), thyroxine requirement, yoga.
+Introduction
+Hypothyroidism is one of the most common health con-
+ditions characterized by hypo-functioning of the thyroid
+gland [1]. It is believed to be a common health issue in
+India and worldwide. The prevalence of hypothyroidism
+is quite high, affecting approximately one in 10 out of 35
+adults [2]. It is more prevalent in females and elder
+population [3].
+Hypothyroidism is characterized by increased level
+of thyroid stimulation hormone (TSH) [4], triglycerides,
+low-density lipoprotein (LDL) and reduced high-density
+lipoprotein (HDL). Hence hypothyroidism is associated
+with increased risk of atherosclerosis [5]. Management
+of dyslipidemia, TSH level and thyroxine dosage is the
+goal of conventional management of hypothyroidism in
+order to reduce the complications and comorbidities.
+Studies reported that thyroid hormone therapy leads
+to a decrease in bone mineral density, which may lead to
+increased chances of fractures [6]. This can also cause
+spinal osteopenia [7].
+Yoga is one of the most ancient sciences, which was
+practiced by ancient Indians for the higher purposes like
+self-realization Samadhi and gaining the higher powers
+*Corresponding author: Kashinath G. M., Department of Yoga and
+Life Sciences, S-VYASA University, Bangalore, Karnataka 560019,
+India, E-mail: [email protected]
+Savithri Nilkantham, Nagaratna R., Nagendra H. R., Department of
+Yoga and Life Sciences, S-VYASA University, Bangalore, Karnataka
+560019, India
+J Complement Integr Med. 2016; aop
+Authenticated | [email protected] author's copy
+Download Date | 4/8/16 12:34 PM
+called siddhis. Many scientific studies have been con-
+ducted on different components of yoga like asana
+(yogic physical postures), pranayama (yogic breathing
+practices), meditation and yoga-based relaxation techni-
+ques since last few decades. Studies reported health ben-
+efitting effects of yoga in many diseased conditions like
+diabetes, hypertension, asthma [8], depression, anxiety
+[9] and etc.
+Previous studies on yoga reported that yoga helps in
+reducing the body mass index (BMI), total cholesterol
+and free fat mass in obese individuals [10]; it also
+reduces the triglycerides and improves HDL and overall
+well-being. Hence, it has a potential role as add-on to
+the modern medical management of hypothyroidism. In
+earlier studies, yoga is found to be effective in improv-
+ing the quality of life [3] and lung function [11] in
+hypothyroidism subjects. In present study, we aimed to
+see the effect of 6 months yoga practice on lipid profile,
+thyroxine medication and TSH level in women with
+hypothyroidism.
+Materials and methods
+Twenty-two household women with hypothyroidism within the age
+range of 30–40 (mean± SD; 36.7± 7.2 years), with 3–5 (mean± SD;
+4 ± 1.12)-year history of hypothyroidism were included in this study.
+All the subjects were residents of Springfield Apartment, Sarjapur
+Road, Bangalore, India.
+Subjects with known cardiac disease, hypertension, history of
+recent surgery, slip disc and low back pain were excluded from
+this study. Thyroxine dosage was constant with an average dose
+of 65.78 ± 22.74 mcg during the intervention phase. All the partici-
+pants underwent 6 months of intense yoga practice, which included
+asana (yogic physical postures), Suryanamaskar (Sun salutations),
+pranayama (yogic breathing practice), yoga-based relaxation techni-
+ques and meditation (see Table 2).
+Lipid profile, serum TSH and thyroxine requirement were assessed
+before and at the end of 6-month intervention. Thyroxine dosage
+was reduced based on the serum TSH level by family endocrinolo-
+gists for the respective subjects at the end of 6 months (see Table 1).
+A written informed consent was obtained before the intervention
+and subjects were explained in detail about the study in their
+mother tongue.
+Assessments
+The pre–post-design was followed and lipid profile (total choles-
+terol, triglycerides, HDL and LDL) and TSH level were assessed
+before and after the intervention. Thyroxine dosage was changed
+by endocrinologists on the basis of serum TSH levels at the end of 6
+months.
+All blood tests were done in the authentic laboratory.
+Intervention
+All the subjects underwent 6 months of yoga intervention, 1 h daily for 4
+days in a week. Each class consists of opening prayer, loosening
+practice asanas, Suryanamaskar (Sun salutation), pranayama, relaxa-
+tion techniques and meditation (see Table 2).
+All the practices included in this module were mainly focused on
+weight reduction and enhancement of physical and mental well-
+being. Physical postures, Suryanamaskar,
+and
+dynamic yogic
+breathing practices like Bhastrika and Kapalabhati pranayama help
+in increasing the physical activity and metabolic rate, and slow
+breathing practices like Nadi Shuddhi pranayama, Ujjayi pranayama,
+Bhramari pranayama and so on help in the enhancement of physical
+and mental relaxation and enhance the deep relaxation at physical
+and mental levels.
+Results
+Data analysis was done using Statistical Package for
+Social Sciences (SPSS) version 10. Baseline data of all
+variables were found to be normally distributed by
+Shapiro–Wilk test, except thyroxine medication score.
+The paired sample t-test showed significant reduction
+in total cholesterol (p = 0.006; –8.99 %), LDL (p = 0.002;
+–9.81 %) and triglycerides (0.013; –7.6 %), and there
+was a significant increase in HDL (p = 0.02; + 9.65 %).
+Wilcoxon signed-rank test showed significant reduction
+in thyroxine medication score (p = 0.029; –15.30 %)
+from baseline. There was a reduction in TSH level
+(p = 0.452; –9.72 %) which was not statistically signifi-
+cant (Table 3).
+Discussion
+In this study, we observed a significant reduction in total
+cholesterol
+(8.99 %),
+LDL
+(9.81 %)
+and
+triglycerides
+(7.65 %), and significant improvement in HDL cholesterol
+(9.65 %). The mean thyroxine medication score was
+Table 1: Demographic details of subjects.
+Subject, n
+Age
+(mean ± SD),
+years
+Disease
+since
+(mean ± SD),
+years
+Thyroxine
+dosage
+(mean ± SD),
+mcg
+Comorbid
+conditions
+(females)
+.± .
+± .
+.± .
+Obesity,
+disturbed
+sleep,
+dyslipidemia
+2
+Savitri et al.: Yoga and hypothyroidism
+Authenticated | [email protected] author's copy
+Download Date | 4/8/16 12:34 PM
+significantly reduced by 15.30 %, where no significant
+reduction was seen in serum TSH.
+Out of 22 subjects, seven subjects could be able to reduce
+their thyroxine medication dosage, no increase in thyroxine
+0
+50
+100
+150
+200
+250
+Total cholesterol
+Triglycerides
+HDL
+LDL
+Mean scores
+Lipid profile
+Pre
+Post
+Figure 1: Pre- and post-changes
+in mean and SD in lipid profile after
+6 months of yoga intervention.
+0
+1
+2
+3
+4
+5
+6
+Pre
+Post
+Mean serum TSH level
+(mIU/L)
+Serum TSH
+Pre
+Post
+Figure 3: Pre- and post-changes
+in mean and SD in serum TSH levels
+after 6 months of yoga intervention.
+0
+20
+40
+60
+80
+100
+Pre
+Post
+Mean thyroxine dose
+(mcg)
+Thyroxine medication score
+Pre
+Post
+Figure 2: Pre- and post-changes
+in mean and SD in thyroxine medication
+after 6 months of yoga intervention.
+Table 2: List of the practices given.
+Starting prayer
+Sukshma Vyayama–Sithilikarna Vyayama
+Hands in and out breathing, hands stretch breathing, Kapola Shakti Vikasaka
+(for cheeks/mouth), Griva Shakti Vikasaka (for Neck), Anguli Shakti Vikasaka
+(for fingers), etc. []
+Suryanamaskar sets followed by deep relaxation techniques (DRT) []
+Special techniques
+Mind, sound resonance technique []/cyclic meditation [] once in a week
+Balancing postures
+Bakasana, Vrikshasana, Sirsasana, Natarajasana, Ujjayi pranayama, Ardha
+Matsyendrasana twist, Vashishtasana twist, Ardha Padmasana twist,
+Bhujangasana,
+Shalabhasana,
+Dhanurasana,
+Halasana,
+Matsyasana,
+Simha Mudra, Shashankasana
+Pranayama and Kriyas
+Nadi Shuddhi pranayama, Vibhagya pranayama, Bhastrika, Kapalabhati,
+Bhramri, Ujjayi pranayama []
+Closing prayer
+Table 3: Pre- and post-changes in lipid profile, TSH and thyroxine
+medication score after 6 months of yoga intervention.
+Variables
+Pre (Mean ± SD)
+Post (Mean ± SD)
+p Value
+change, %
+TL
+.± .
+.± .
+.**
+–.
+TR
+.± .
+.± .
+.**
+–.
+HDL
+.± .
+.± .
+.*
+.
+LDL
+.± .
+.± .
+.
+–.
+TSH
+.± .
+.± .
+.
+–.
+Thyroxine
+.± .
+.± .
+.*
+–.
+TL-Total Cholesterol, TR-Triglycerides, HDL- High Density lipoprotein,
+LDL-Low
+density
+lipoprotein,
+TSH-Thyroid
+Stimulating
+Hormone;
+*p < 0.05 level, p** < 0.001 level.
+Savitri et al.: Yoga and hypothyroidism
+3
+Authenticated | [email protected] author's copy
+Download Date | 4/8/16 12:34 PM
+medication was observed in any of the subjects at the end of
+the study.
+Previously, two studies have looked into the efficacy
+of yoga in hypothyroidism. In a study on 20 hypothyroid-
+ism women, 1 month of yoga practice showed significant
+improvement in the quality of life [3], and in another
+study, 6 months of pranayama (yogic breathing) practice
+improved forced expiratory volume in lung function test
+of women with hypothyroidism [10]. These studies are
+suggestive of positive role of yoga practice in hypothyr-
+oidism. Similarly, in our pilot study we observed the
+positive effect of yoga practice in hypothyroidism.
+In earlier studies, 12 weeks of yoga intervention in
+elderly women with diabetes showed significant reduc-
+tion in triglycerides, total cholesterol, LDL and improved
+HDL [15]. In another randomized control trial, 6 months
+of yoga nidra (yogic relaxation method) practice was
+shown to reduce the serum TSH level in females with
+menstrual abnormalities [16].
+In our study also we found similar results as that of
+the previous one.
+The exact mechanism behind these finding is not
+known. One of the possible mechanisms could be
+increased physical activity due to Suryanamaskar and
+physical postures might have helped in reducing trigly-
+cerides, total cholesterol, LDL and increased HDL choles-
+terol [17]. The pranayama, relaxation practices and
+meditation are known to reduce stress and modulate the
+hypothalamo-pituitary–adrenal axis [18]. Similarly, yoga
+practice might influence the hypothalamo-pituitary–thyr-
+oid axis and lead to decrease in serum TSH.
+This study shows the potential role of yoga in the
+management of hypothyroidism and preventions of car-
+diac disease due to hypothyroidism.
+Strengths
+The strengths of the study are as follows: (i) to the best of
+our knowledge this is the first study that assessed the
+effect of yoga intervention on objective tools like TSH and
+thyroxine medication score, and lipid profile in hypothyr-
+oidism; (ii) long-term intervention; and (iii) good adher-
+ence rate.
+Limitations
+This study has a few limitations: (i) lack of control group;
+(ii) small sample size; and (iii) uni-gender, which restricts
+the generalization.
+Future studies should include the randomized con-
+trolled design with a larger sample size and other objec-
+tive
+variables
+like
+BMI,
+cardiovascular
+parameters,
+psychological variable along with thyroid hormones.
+Conclusions
+Long-term practice of yoga may help in improving cho-
+lesterol level, serum TSH and thyroxine requirement in
+female patients suffering from hypothyroidism. However,
+further randomized controlled studies need to be con-
+ducted to confirm the present finding.
+Acknowledgments: The authors are thankful to all the
+subjects who have participated in this study without
+whose cooperation this study would not have been com-
+pleted. We are grateful to all the endocrinologist who
+have helped in monitoring the thyroxine medication in
+the study.
+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
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+hypothyroidism. Int J Health Sci Res 2013;3:29–32.
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+Authenticated | [email protected] author's copy
+Download Date | 4/8/16 12:34 PM

subfolder_0/Effect of Heartfulness Meditation Among Long-Term, Short-Term and Non-meditators on Prefrontal Cortex Activity of Brain.txt

@@ -0,0 +1,502 @@
+Review began 11/08/2022 
+Review ended 02/11/2023 
+Published 02/14/2023
+© Copyright 2023
+Shrivastava et al. This is an open access
+article distributed under the terms of the
+Creative Commons Attribution License CC-
+BY 4.0., which permits unrestricted use,
+distribution, and reproduction in any
+medium, provided the original author and
+source are credited.
+Effect of Heartfulness Meditation Among Long-
+Term, Short-Term and Non-meditators on
+Prefrontal Cortex Activity of Brain Using Machine
+Learning Classification: A Cross-Sectional Study
+Anurag Shrivastava  , Bikesh K. Singh  , Dwivedi Krishna  , Prasanna Krishna  , Deepeshwar Singh 
+1. Biomedical Engineering, National Institute of Technology, Raipur, Raipur, IND 2. Yoga Life Sciences, Swami
+Vivekananda Yoga Anusandhana Samsthana (S-VYASA), Bengluru, IND 3. Welfare Harvesters, Banglore, IND 4. Yoga
+and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana (S-VYASA), Bangalore, IND
+Corresponding author: Bikesh K. Singh, [email protected]
+Abstract
+Background
+Meditation is a mental practice with health benefits and may increase activity in the prefrontal cortex of the
+brain. Heartfulness meditation (HM) is a modified form of rajyoga meditation supported by a unique feature
+called “yogic transmission.” This feasibility study aimed to explore the effect of HM on
+electroencephalogram (EEG) connectivity parameters of long-term meditators (LTM), short-term meditators
+(STM), and non-meditators (NM) with an application of machine learning models and determining
+classifier methods that can effectively discriminate between the groups.
+Materials and methods
+EEG data were collected from 34 participants. The functional connectivity parameters, correlation
+coefficient, clustering coefficient, shortest path, and phase locking value were utilized as a feature vector for
+classification. To evaluate the various states of HM practice, the categorization was done between (LTM,
+NM) and (STM, NM) using a multitude of machine learning classifiers.
+Results
+The classifier's performances were evaluated based on accuracy using 10-fold cross-validation. The results
+showed that the accuracy of machine learning models ranges from 84% to 100% while classifying LTM and
+NM, and accuracy from 80% to 93% while classifying STM and NM. It was found that decision trees, support
+vector machines, k-nearest neighbors, and ensemble classifiers performed better than linear discriminant
+analysis and logistic regression.
+Conclusion
+This is the first study to our knowledge employing machine learning for the classification among HM
+meditators and NM The results indicated that machine learning classifiers with EEG functional connectivity
+as a feature vector could be a viable marker for accessing meditation ability.
+Categories: Other
+Keywords: classifiers, functional connectivity, machine learning, electroencephalograph (eeg), heartfulness
+meditation (hm)
+Introduction
+Meditation practice can be used for exercising the brain and therefore became a field of interest among
+researchers [1]. There are various meditation practices known globally, but HM and its effects have not been
+evaluated by neuroimaging techniques. HM is the modified form of raja yoga meditation which involves
+focusing on the heart rather than concentrating on breathing. The HM has a unique feature of yogic
+transmission which facilitates even a new practitioner to feel the effect of meditation in a very short
+duration. In HM, a practitioner is allowed to perform meditation along with the trainer (guru), who initiates
+the transmission as per procedure [2]. Research shows the benefits of HM in moderating vital heart
+parameters Heart rate, respiration rate, Systolic blood pressure [3], and stress level [4-6]. Studies carried out
+on HM during the COVID-19 pandemic situation indicate that HM helps to regulate overall anger, mood,
+depression [4], stress, and sleep quality [5]. In HM practice, participants are allowed to sit comfortably with
+their eyes closed and asked to contemplate the source of light within the heart. If the mind of the
+participants gets distracted, then they are advised to gently redirect their focus to the heart again. This
+meditation is more straightforward as participants do not have to focus on the breath or chant the mantras,
+which is a mandatory tool in several other forms of meditation [7]. There is very limited research examining
+1
+1
+2
+3
+4
+ 
+Open Access Original
+Article
+ DOI: 10.7759/cureus.34977
+How to cite this article
+Shrivastava A, Singh B K, Krishna D, et al. (February 14, 2023) Effect of Heartfulness Meditation Among Long-Term, Short-Term and Non-
+meditators on Prefrontal Cortex Activity of Brain Using Machine Learning Classification: A Cross-Sectional Study. Cureus 15(2): e34977. DOI
+10.7759/cureus.34977
+the effect of HM on brain signals. Various forms of meditation studies explored the changes in different
+lobes of the brain using electroencephalogram (EEG). EEG is a non-invasive but powerful technique used for
+the analysis of the brain’s activity. It is captured from the scalp's surface with the help of electrodes which
+measure electrical signals generated by various actions of the brain. Traditionally, EEG signals are
+categorized into four frequency bands: delta (0-4 Hz), theta (4-8 Hz), alpha (8-12 Hz), and beta (12-30 Hz).
+Each band is a reflection of different activity patterns of the brain. EEG has a high temporal resolution, is
+relatively low cost, and is portable, therefore popular among researchers [8,9]. Functional connectivity is
+currently one of the most pertinent areas of study for neurological responses using EEG signal analysis.
+Understanding how information is processed can be gained by examining the modifications in node
+interactions brought about by meditation. In functional connectivity analysis, several features are calculated
+and stored in the matrix, representing the connectivity between each pair of nodes [10]. Functional
+connectivity can be used for analyzing cognitive activity [11], disorders like schizophrenia [12],
+depression [13], chronic pain [14], yoga, and meditation [15-17]. Therefore, we have used functional
+connectivity parameters in the present study such as Pearson correlation (r) [18], phase locking value
+(PLV) [19], clustering coefficient (CC), and shortest path (SP) [20]. Previous meditation reported an increase
+in functional connectivity of the brain during meditation as compared to the resting state [21].
+Numerous studies indicate that connectivity increases in the brain's prefrontal cortex in experienced
+meditators compared to the non-meditators [22,23]. This study, therefore, focused on the prefrontal cortex.
+Different classifiers, including decision tree (DT), support vector machine (SVM), k-nearest neighbor (KNN),
+and ensemble classifier (EC), are employed in the meditation study to distinguish meditative and non-
+meditative states. [24]. Therefore, the purpose of this study is to make an objective measurement of HM by
+computing functional connectivity characteristics as a feature and selecting the best classifier that could
+distinguish between LTM, STM, and NM.
+Materials And Methods
+The objective of the study has been explained in PICO (population-intervention-comparison-outcome)
+format as shown in Table 1.
+Population
+Intervention
+Comparison
+Outcome
+Meditators (long term and short term) and
+non-meditators  
+Heartfulness
+meditation
+Between meditators (long term and short term)
+and non-meditators
+Machine learning
+classifiers accuracy
+TABLE 1: PICO elements of the study
+PICO: population-intervention-comparison-outcome
+Participants
+In total 45 (30 males and 15 female) participants in the age group between 20 and 45 years were recruited
+from Heartfulness Center, Bengaluru, India. Based on experience, participants were categorized into three
+groups: long-term meditator (LTM) having experience greater than five years, short-term meditator (STM)
+having experience less than three years, and non-meditator (NM) without meditation experience. The study
+was approved by the institutional ethics committee, Swami Vivekananda Yoga Anusandhana Samsthana
+(SVYASA), Bengaluru, India. Participants' demography characteristics are given in Table 2.
+S.no
+Demographics
+Gender
+Long-term meditators
+Short-term meditators
+Non -meditators
+1
+Gender
+Male
+9
+7
+7
+Female
+4
+4
+3
+2
+Age (years) 
+Male
+32.54 ± 6.2
+30 ± 7.5
+28.43 ± 3.3
+Female
+32.01 ± 6.4
+29.45 ± 7.5
+28.12 ±3.2
+3
+Meditation experience ( months)
+Male+Female
+98.71 ± 32.35
+12.80 ± 6.48
+----
+4
+Duration of practice/day  (minutes)
+Male+Female
+76.07 ± 15.24
+47.5 ± 20.36
+----
+TABLE 2: Demographics of participants
+2023 Shrivastava et al. Cureus 15(2): e34977. DOI 10.7759/cureus.34977
+2 of 12
+Participants between the age of 20 and 45 years were included in the study. All the participants are mentally
+and physically healthy. People practicing other forms of meditation and diagnosed with mental and physical
+health issues were excluded from the study. Also, the participants selected are non-alcoholic, non-smokers,
+and not under any type of medication.
+Experiment design
+The present study was an age-matched cross-sectional design. All participants' EEG data was collected and
+analyzed in the following stages as shown in Figure 1.
+FIGURE 1: Flow diagram of EEG signal analysis
+EEG: electroencephalogram, LTM: long-term meditators, STM: short-term meditators, NM: non-meditaors, PLV:
+phase-locking value
+EEG Acquisition and Segmentation
+The recording occurs at the cognitive neuroscience lab, SVYASA, Bengaluru, India. Each participant was
+assessed using 128 channels EEG system, (EGI geodesic transcranial electrical neuromodulation sensor
+GSN300), and data were recorded using EGI netstation (version 4.5.6) software. The sampling frequency was
+250 Hz. The EEG recording took place in four states: Baseline state (5 minutes), where participants were
+instructed to relax with closed eyes. The second state was the meditation state (10 minutes), where
+participants were instructed to initiate HM practice, In the third state was transmission (10 minutes)
+participants were allowed to continue HM practice, and at the same time, an expert meditator (guru) starts
+the transmission to aid the practitioner, and the last state was post state (5 minutes) where participants were
+instructed to end meditation practice and relax.
+Preprocessing and Band Extraction
+2023 Shrivastava et al. Cureus 15(2): e34977. DOI 10.7759/cureus.34977
+3 of 12
+Preprocessing of the EEG signal was carried out in the EEGLAB toolbox (version 2021) [25]. The direct
+current noise was removed by applying a clean line. Further noises (muscular, ocular, and head
+movement) were removed by visual inspection and by applying Independent Component Analysis. The next
+stage after preprocessing was the segmentation of prefrontal cortex EEG signals into the left and right
+hemispheres. The electrodes corresponding to the prefrontal lobe were selected for this study (Figure 2).
+After segmentation, EEG bands (delta (0.3 - 4 Hz), theta (4-8 Hz), alpha (8-12 Hz), and beta (12-30 Hz)) were
+extracted using a bandpass filter. Functional connectivity was calculated for 20 electrodes. Prefrontal left
+and right 10 electrodes each.
+FIGURE 2: Electrode placements in prefrontal lobe of the brain
+Feature Selection
+Functional connectivity features between each inter-region (left and right) electrode pair were calculated for
+classification. The features selected are, correlation coefficient (r), phase locking value (PLV), shortest path
+(SP), and clustering coefficient (CC).
+Correlation coefficient (r): It is one of the basic features to measure the functional connectivity of the brain
+by accessing the degree of similarity between the pair of electrodes. It is the ratio of covariance between two
+signals and their respective variances. The correlation is calculated from equation below.
+ 
+Where Cov(i,j) is the cross-spectral density between two signals, and Var(i)and Var(j) are the auto spectral
+densities for signals i and j, respectively. The correlation value lies between +1 to -1, where +1 indicates that
+signals are perfect positive correlation, -1 indicates a perfect negative correlation, and 0 indicates that the
+two signals are perfectly uncorrelated [18,26] .
+Phase-locking value (PLV): The PLV measures the phase synchronization between pair of electrodes in a
+functional brain network. The Hilbert transform will obtain the phase of the corresponding signals, and after
+that phase difference between the two signals will be calculated. The rage lies from +1 to 0, where + 1
+represents perfect phase synchronization. [10] . For the electrode pair (i,j), the phase difference can be
+calculated from equation below.
+ 
+Where 
+ represents phase difference between electrodes i and j [19,27-28].
+Characteristic path length (PL)/shortest path (SP): It is the measure of global efficiency calculated by the
+average of the shortest path between the nodes. Global efficiency is inversely proportional to the average
+shortest path. It represents the number of intermediate edges between pairs of electrodes that are
+responsible for information flow. There is more than one path possible between electrode pairs. Only the
+shortest path is taken into account because it is the fastest way for information transfer. It is used to
+measure functional connectivity [27] . The shorter path length represents better functional connectivity. The
+shortest path calculation was based on Dijkstra's algorithm. [29].
+2023 Shrivastava et al. Cureus 15(2): e34977. DOI 10.7759/cureus.34977
+4 of 12
+Clustering coefficient (CC): It measures the local segregation in a complex brain network by accessing the
+possibility of nodes from the cluster. Assuming there are three nodes, j, k, and l.suppose node j and k is
+connected to l, then the clustering coefficient reflects the probability of connection between j and k to form
+a triangle in a network. The clustering coefficient measures the speed of information processing and
+transmission within a network [26-27,29] .The clustering coefficient is calculated by equation below.
+Where ki is the degree of node and w jk ,wkl, wlm are the weights between nodes j and k, k and l, l and m,
+respectively [30].
+Classification
+The classification of selected features was performed by the classifier learner application in MATLAB
+R2018a. Further k-fold cross-validation method was used for system evaluation by segmenting the data set
+into training and testing data sets.
+k-fold cross validation: It splits the data set into k groups. After that, it selects one group as the testing
+group and the other k-1 group as the training group. In this technique, each group will get a chance to
+become a testing group. In this study, 10-fold cross-validation is used for system evaluation. This means 10
+times training and testing of data set is involved.
+Classifiers and features: In this study, we have considered classification based on the meditation states
+(baseline, meditation, transmission) and classification based on the EEG signal band (delta, theta, alpha,
+beta, and gamma). The classification was performed for LTM vs NM and STM vs NM groups. Functional
+connectivity parameters are used as features given in Table 3.
+Classification
+group: state
+wise
+Classifiers
+Features
+  LTM vs NM 
+Decision tree, linear discriminate
+analysis, logistic regression, support
+vector machine, k nearest neighbor
+and ensemble
+Correlation coefficient -(delta, theta, alpha,beta), phase locking value-(delta,
+theta, alpha,beta), shortest path- (delta, theta, alpha,beta) and clustering
+coefficient- (delta, theta, alpha,beta)
+  STM vs NM
+Classification
+group: band
+wise
+Classifiers
+Features
+  LTM vs NM 
+Decision tree, linear discriminate
+analysis, logistic regression, support
+vector machine, k nearest neighbor
+and ensemble
+Correlation coefficient -(baseline, meditation, transmission, post), phase locking
+value-(baseline, meditation, transmission, post), shortest path- (baseline,
+meditation, transmission, post) and clustering coefficient- (baseline, meditation,
+transmission, post)
+  STM vs NM
+TABLE 3: List of classifiers and features
+LTM: long-term meditators, STM: short-term meditators, NM: non-meditators
+Results
+The results obtained from functional connectivity analysis of the prefrontal cortex along with the
+significance level for between-group comparison are shown in Figures 3-6. The graph indicates an increase
+in the value of r, PLV, CC, and decrement in SP in the meditation and transmission states, respectively, as
+compared to the baseline, which is an indicator of enhanced functional connectivity during meditation and
+transmission. In this study, these functional connectivity features were used to classify meditative and non-
+meditative states.
+2023 Shrivastava et al. Cureus 15(2): e34977. DOI 10.7759/cureus.34977
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+FIGURE 3: Average r values of EEG bands for different meditation states
+*compares NM group, *P<0.05, **P<0.01, and ***P<0.001. r: correlation coefficient, EEG: electroencephalogram,
+LTM: long-term meditators, STM: short-term meditators, NM: non-meditators
+2023 Shrivastava et al. Cureus 15(2): e34977. DOI 10.7759/cureus.34977
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+FIGURE 4: Average PLV values of EEG bands for different meditation
+states
+ *compares NM group, *P<0.05, **P<0.01, and ***P<0.001. PLV: phase-locking value, EEG:
+electroencephalogram, LTM: long-term meditators, STM: short-term meditators, NM: non-meditators
+2023 Shrivastava et al. Cureus 15(2): e34977. DOI 10.7759/cureus.34977
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+FIGURE 5: Average CC values of EEG bands for different meditation
+states
+*compares NM group, *P<0.05, **P<0.01, and ***P<0.001. CC: clustering coefficient, EEG:
+electroencephalogram, LTM: long-erm meditators, STM: short-term meditators, NM: non-meditators
+2023 Shrivastava et al. Cureus 15(2): e34977. DOI 10.7759/cureus.34977
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+FIGURE 6: Average SP values of EEG bands for different meditation
+states
+*compares NM group and $compares STM. *$P<0.05, **$$P<0.01, and ***$$$P<0.001. SP: shortest path, EEG:
+electroencephalogram, LTM: long-term meditators, STM: short-term meditators, NM: non-meditators 
+The participants were categorized into three groups (LTM-13, STM-11, and NM-10), and six classifiers
+(Decision tree, Linear discriminate analysis, Logistic regression, Support vector machine, K nearest
+neighbor, and Ensemble) were compared based on their accuracy. The result of the percentage accuracy of
+various classifiers for state-wise classification is shown in Figures 7A, 7B. While performing state-wise
+classification between NM and LTM groups, the baseline achieved the highest accuracy for decision tree and
+ensemble classifiers of 100% and 95%, respectively. The meditation achieved the highest accuracy of 91%
+both for SVM and KNN. SVM and KNN classifiers during transmission achieved the highest accuracy of 99%
+and 97%, respectively. In contrast, the accuracy of LD and LR was lower during all the states.
+2023 Shrivastava et al. Cureus 15(2): e34977. DOI 10.7759/cureus.34977
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+FIGURE 7: Group performance of classifiers (state wise and band wise)
+LD: linear discriminant, LR: logistic regression, DT: decision tree, SVM: support vector machine, KNN: k-nearest
+neighbor, LTM: long-term meditators, STM: short-term meditators, NM: non-meditators
+The results of state-wise classification for the NM vs STM group reveal that for the baseline state, the highest
+accuracy was achieved for the ensemble classifier with an accuracy of 88%. The meditation state achieved
+the highest accuracy for SVM and KNN classifiers with an accuracy of 93% and 92%, respectively, and for the
+transmission state highest accuracy of 89% and 88% was achieved by employing SVM and KNN classifiers.
+Now considering the band-wise classifier performance for STM vs NM group, the accuracy achieved by
+classifiers in the delta band was 100% for the decision tree, SVM, KNN, and ensemble classifiers, for theta
+band KNN, Ensemble, and SVM classifier shows the accuracy of 100%, 97%, and 95%, respectively. The SVM,
+ensemble, and KNN classifiers are in the alpha band. The performance of classifiers in the beta band was not
+satisfactory, with the highest accuracy of 76% achieved by KNN classifiers.
+The result of band-wise classifier performance for the LTM vs NM group reveals that the highest accuracy
+achieved by the classifier in the delta band was 90% and 87% for SVM and KNN, respectively. The highest
+accuracy of 82% and 80% in the theta band was achieved by the SVM and KNN classifiers, respectively. In the
+alpha band, the SVM and ensemble classifiers achieved an accuracy of 90% each and the KNN classifier
+showed an accuracy of 85%. In this group also the performance of classifiers is not so satisfactory, with the
+highest accuracy of 76% achieved by the ensemble classifier. Figures 7C, 7D show the band-wise
+performance of classifiers.
+Discussion
+This is the first study on HM employing machine learning to classify meditators and non-meditators. This
+study effectively categorizes participants into different classes, i.e., LTM, STM, and NM, using connectivity
+features. The connectivity feature results indicate an increase in value of the r, PLV, CC, and decrement in
+SP in the meditation and transmission states, respectively as compared to the baseline state, which is an
+indicator of enhanced functional connectivity during meditation and transmission. This result is aligned
+with the findings of [31-34], where focused attention (FA) meditation and integrative body-mind
+training and relaxation training respectively, enhance the connectivity features (r, PLV, and CC) while
+reducing SP thereby increasing global efficiency. The classifier results indicate that functional connectivity
+features were better for identifying the changes due to meditation. The comparison results among classifiers
+show that LTM vs NM was classified with higher accuracy as compared to STM vs NM. The results also
+indicated that SVM, KNN, DT, and Ensemble classifiers perform with better accuracy in most cases as
+compared to LDA and LR. DT performs better with the accuracy of 100% only in delta and baseline states
+while classifying LTM vs NM. The accuracy range of LTM vs NM ranges from 84% to 100%, whereas STM vs
+NM ranges from 80% to 93%.
+2023 Shrivastava et al. Cureus 15(2): e34977. DOI 10.7759/cureus.34977
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+The first limitation of this study is the small sample size for all three groups, which limits the generalization.
+The second limitation is the discomfort to the meditator during the EEG setup. Some other factors that can
+affect the results, such as heterogeneity in practice, and clinical history, were not taken into account in this
+study. Further study could use other neuro-imaging techniques with increased sample sizes for all the groups
+(LTM, STM, and NM) to support the findings of our study. Furthermore, a cardiovascular study employing an
+electrocardiogram (ECG) analysis technique can be incorporated to signify the coordination between the
+heart and brain while performing HM.
+Conclusions
+This is the first study to our knowledge employing machine learning in HM. The shreds of
+evidence demonstrated a methodological pipeline for classification among meditators (LTM, STM) and
+NM to assess the impact of HM. The classifiers are compared based on their computational accuracy. The
+findings demonstrated the viability of DT, SVM, KNN, and Ensemble classifier with EEG functional
+connectivity as feature vectors for accessing meditation ability and their capability to accurately distinguish
+between meditative and non-meditative states. These classifiers can quantify meditation experience and
+meditation state effectively. The unique feature of HM 'Transmission' revealed distinct alterations in the
+prefrontal cortex of meditators. Furthermore, this study can be extended with different features and other
+classification techniques.
+Additional Information
+Disclosures
+Human subjects: Consent was obtained or waived by all participants in this study. Institutional Ethics
+Committee, SVYASA, Bengaluru issued approval RES/IECSVYASA/164/1/2020. Animal subjects: All authors
+have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In
+compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services
+info: All authors have declared that no financial support was received from any organization for the
+submitted work. Financial relationships: All authors have declared that they have no financial
+relationships at present or within the previous three years with any organizations that might have an
+interest in the submitted work. Other relationships: All authors have declared that there are no other
+relationships or activities that could appear to have influenced the submitted work.
+Acknowledgements
+We gratefully acknowledge that this study was partially funded by Heartfulness Institute and executed in the
+Cognitive Neuroscience Laboratory at Swami Vivekananda Yoga Anusandhana Samsthana (S-VYASA),
+Bangalore. The authors would like to thank Dr. J Krishnamurthy, Mr. Anil Jamadagani and Mr. Parthasarathy
+Patel for supporting this study at different stages.
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+12 of 12

subfolder_0/Effect of Integrated Yoga Program on Energy Outcomes as a Measure of Preventive Health Care in Healthy People.txt

@@ -0,0 +1,685 @@
+61
+Vol. 12, No. 4/2015
+Central European Journal of Sport Sciences and Medicine | Vol. 12, No. 4/2015:  61–71 | DOI: 10.18276/cej.2015.4-07
+Effect of Integrated Yoga Program on Energy Outcomes  
+as a Measure of Preventive Health Care in Healthy People
+Kuldeep Kumar Kushwah,a, b, c, d Hongasandra Ramarao Nagendra,a, d  
+Thaiyar Madabusi Srinivasana, d
+S-VYASA University, Bangalore, India 
+A	Study Design; B Data Collection; C Statistical Analysis, D Manuscript Preparation
+Address for correspondence:
+Kuldeep Kumar Kushwah, Ph.D. Scholar 
+Swami Vivekananda Yoga Anusandhana Samsthana 
+# 19, ‘Eknath Bhavan’, Gavipuram Circle, Kempe Gowda Nagar, Bengaluru – 560 019, India
+E-mail: [email protected]
+Abstract. The aim of this study was to measure the changes in stress, general health index and disorderliness in human energy pattern 
+through Integrated Yoga Practices (IYP). Ninety four healthy volunteers (male 55 and female 39), age (mean ± sd 26.70 ±8.58) were 
+assessed before and after four weeks of IYP. The experiment was conducted four times and the assessment was done by utilizing 
+the Electro Photonic Imaging (EPI) technique. Comparisons were made to ascertain whether energy homeostasis diverges based 
+on genders. The parameters considered for analysis were Activation Coefficient (AC), Integral Area (IA) and Integral Entropy (IE). 
+Reduction in stress levels (AC), increase in general health index (IA) and decrease in disorderliness (IE) on the left side parameters were 
+found reproducible in all four experiments. The results also revealed a highly significant reduction in stress levels and highly significant 
+improvement in the health indices at the psycho-physiological level. The subgroup analysis of both male and female demonstrated 
+a significant reduction in stress levels and significant improvement in health index (psycho-physiological). Baseline comparisons 
+between males and females showed significant difference in general health index at both psychophysiological and physiological levels. 
+In conclusion, IYP regulates, improves and prolongs energy homeostasis of an organism. Therefore, it helps in prevention of ill health 
+and also preserves health. The EPI outcomes are reproducible. Further, the present study also found that the energy pattern differs with 
+gender. Hence, it is suggested that studies with male and female participants may be conducted separately.
+Key words: Integrated Yoga Program IYP, Electro Photonic Imaging Technique EPI, Gas Discharge Visualization GDV, Stress, General 
+Health Index and Disorderliness
+Introduction
+Health and its care have become a global concern. The fast pace of life, sedentary lifestyle, immoderation 
+in diet, activities, recreation and sleep are the factors responsible for stressful living which ultimately manifest 
+in diseases (Bijlani et al. 2005; Sivananda 2008a; Smaldone et al. 2007; Waxman 2005) like obesity, diabetes 
+mellitus, heart diseases, hyperlipidaemia, respiratory infections and cancer (Segasothy and Phillips 1999; Sharma 
+and Majumdar 2009). They affect daily work and quality of life of individuals (Van Nieuwenhuizen et al. 2015). 
+62
+Central European Journal of Sport Sciences and Medicine
+Kuldeep Kumar Kushwah, Hongasandra Ramarao Nagendra, Thaiyar Madabusi Srinivasan
+Thus, there is a need for change in lifestyle in most populations to prevent ill health and promote good health. 
+Since energy is the foundation of electrophysiological and biochemical processes, it is necessary to measure and 
+correlate the energy through available technology known as electro photonic imaging technique (EPI).
+Yoga, an ancient Indian lifestyle-related discipline has been scientifically proven and shown to improve 
+physical, mental, and emotional wellbeing (Buffart et al. 2012; Gard et al. 2014) through all its components which 
+include Kriya (cleansing techniques), Asana (yogic postures), Pranayama (breathing practices), Dhyana (meditation) 
+and diet. These techniques correct energy imbalances, and restores energy homeostasis in humans (Lynton at al. 
+2007). This energy which is subtle known as Prana (Srinivasan 2014). It is considered to be the vital energy that 
+regulates all cellular processes and keeps a person healthy. As per the Ayurvedic texts, Prana (Traditional Chinese 
+Medicine counterpart, Qi), is believed to be responsible for health of every cell in the body (Sancier and Hu 1991). 
+Availability of cellular electrons is closely related to the health of cells (Szent-Gyorgyi 1978). We conceptually tried 
+to relate Prana (the fundamental febric of subtle energy) with electrons (the fundamental aspect of matter) and 
+expect that both will converge closely. Through this, we tried to derive our operational definitions of various abstract 
+constructs. The conceptual relationship between Prana and electrons seems to be quite evident, however, more 
+empirical evidence is needed to support this concept. We operationally define Prana as the intensity of electro 
+photonic emission patterns as obtained in a form of EPI-gram. Homeostasis of Prana is operationally defined as 
+uniformity of electro photonic emission patterns in a form of EPI-gram as obtained by EPI instrument. Electron 
+availability is operationally defined as the intensity of electro photonic patterns obtained from EPI-grams.
+However, when this homeostasis level of Prana is disturbed, it leads to pain and somatic diseases later as 
+postulated in yoga (Srinivasan 2014; Srinivasan 2013). All the animate beings require steady conditions inside 
+for their survival, such as internal temperature, body pH, metabolic rate and energy expenditure versus energy 
+consumption; similarly, energy (Prana) homeostasis is required for healthy functioning of all systems within the 
+body. The health and disease concept of yoga enables us to better understand the root cause of diseases and 
+disorders (Vyadhi) which are believed to emerge from the disrupted mind (leading to Adhi). The disturbed mind 
+leads to stress and further creates imbalances in Prana, finally manifest as disease or disorder at the physical level 
+(Nagarathna and Nagendra 2009), especially in those systems and organs which have either deficient or disturbed 
+Prana. This understanding of disease manifestation suggests that if this hindrance in energy (Prana) could be 
+prevented or corrected, then we could probably succeed in preventing diseases and also reverse the progress of 
+manifested diseases.
+Earlier research on short-term lifestyle modification and stress management education program based on 
+Yoga has shown remarkable improvement in subjective well-being scores of the subjects (Sharma et al. 2008). This 
+could therefore make a considerable contribution to early prevention as well as management of lifestyle diseases.
+The present evidence convinced us to attempt research on yoga based lifestyle-related program in healthy subjects 
+to prevent ill health and promote health.
+Therefore, the present single-arm prospective study was undertaken to study the potential effect of an 
+integrated yoga program on energy parameters, namely; Activation Coefficient (a measure of stress), Integral 
+Area (a measure of general health), and Integral Entropy (a measure of disorderliness) as measured through EPI 
+technique. The study also attempts to find out the reproducibility of EPI outcomes and also to check whether energy 
+outcomes differ gender-wise.
+63
+Vol. 12, No. 4/2015
+IYP as a Preventive Health Care
+Material and Methods
+Subjects
+A total of 152 volunteers were assessed before and after four weeks of a one month Yoga Instructor Course 
+(YIC) at Swami Vivekananda Yoga Anusamdhana Samsthana (S-VYASA, Yoga University), Bengaluru, Karnataka, 
+India. All volunteers were selected from four batches of YIC (Months – May 2014, n = 43, June 2014, n = 52, July 
+2014, n = 38 and August 2014, n = 19).
+Inclusion criteria
+Healthy volunteers, age ranging 18 to 60 years, both male and female, willing to participate in the study and 
+having post hoc Integral Area value between –0.6 to +1 (IA, normal health index range in European Popultion in the 
+EPI technique) were included in the study.
+Exclusion criteria
+Volunteers who had cuts in the fingers, missing fingers, having any health-related issues and substance 
+abuse were excluded from the study.
+Ethical consideration
+The study protocol was approved by the Institutional Ethics Committee. A written informed consent was 
+obtained from all the volunteers who were willing to participate in the study before the assessment, and the 
+confidentialities of their data and information were maintained.
+Yoga intervention
+Residential Integrated Yoga Program (IYP) for four weeks.
+The program comprises of Kriya (cleansing techniques), Asana (Physical postures), Pranayama (Breathing 
+practices), Dhyana (meditation), Bhajan (devotional songs), Krida Yoga (Yoga games), spiritual discourses and 
+lectures on yoga and philosophy. The program starts daily at 4.30 am till 10.00 pm and the diet is vegetarian (yogic 
+food). 
+Assessments
+EPI technique
+Electro Photonic Imaging (EPI) technique also known as Gas Discharge Visualization (GDV) has been 
+used in a number of studies as a scientific device to evaluate stress, general health and disorderliness based on 
+a measure of stimulated optoelectronic emission of humans (Korotkov et al. 2010; Korotkov et al. 2012; Deo et al. 
+2015; Kushwah et al. 2015).This emission takes place when the finger tips are exposed to a short electric pulse 
+of high voltage (10 kv), with high frequency (1024 Hz) and low current in micro amps for less than a millisecond 
+(Ciesielska 2009). Emission is captured in the form of an image by a CCD-camera placed under a dielectric plate 
+in the EPI system (Hacker et al. 2005). Further, the acquired 10 EPI images are divided into various sectors, which 
+64
+Central European Journal of Sport Sciences and Medicine
+Kuldeep Kumar Kushwah, Hongasandra Ramarao Nagendra, Thaiyar Madabusi Srinivasan
+correlate with diverse organs and systems within the body (Korotkov et al. 2012; Hacker et al. 2011; Korotkov 2011) 
+This correlation of EPI image sectors with different organs of the body is mostly based on empirical findings and 
+also supported by both acupuncture and meridian system of Sujok (Korotkov 2002). Recently, meridian system 
+has been scientifically supported by a newly found circulatory system called Bonghan system. It is a thread like 
+structure found on the superficially inside blood or lymph vessels, on the surface of internal organs, and also in the 
+brain ventricles (Soh 2009). It provides a possible connection between the EPI sectors from finger tips’ images and 
+with the organs and systems within the body. EPI assessment is done in two ways; namely, with filter and without 
+filter (Korotkov et al. 2012). A filter is a plastic film specially designed to be used in between the finger tips and the 
+dielectric plate to eliminate the sympathetic response which results in sweat and cooling sensations of fingers and 
+to register the information which is more of physiological in nature. Measurements using filter provides physiological 
+and without filter provides psycho-physiological information (Korotkov 2002).
+EPI Parameters
+1. Activation Coefficient (AC), 2. Integral Area, left and right side (IAL and IAR) and 3. Integral Entropy, left 
+and right side (IEL and IER).
+AC parameter is an estimation of stress level acquired by comparing the reading with and without filter. Hence, 
+it is the difference between sympathetic and parasympathetic responses. It ranges from 0–10 where 2–4 is an 
+indication of normal quiescent state. Below 2 – is a state of relaxed and calm people. This could be because of the 
+two possible reasons, deep meditation or chronic depression. AC above 4 indicates exited state and towards higher 
+levels of stress. IA, left and right parameter is a magnitude of general health index of a person being investigated and 
+ranges from [–0.6 to +1] and is an indicative of good health condition. IE, left and right parameter is a determinant of 
+disorderliness in the human energy system. A range of [1 to 2] indicates a healthy pattern of entropy in an organism 
+(Korotkov 2002; Cioca et al. 2004; Kostyuk et al. 2011).
+Further, the EPI provides a non-invasive, objective and painless method, which is used for quick evaluation 
+of health abnormalities in the human energy system (Korotkov 2011; Korotkov et al. 2010). Therefore, it is gaining 
+high significance in the field of medicine and energy dimensions. From the reliability point of view, EPI parameters 
+have a variation of 4.1% on a daily average, whereas, on 10 minute average it varies only 6.6% shows high reliability 
+of the technique (Korotkov 2011). In the present study, EPI Pro and EPI Compact devices, produced by Kirlionics 
+Technologies International, Saint-Petersburg, Russia were used in the assessment processes. 
+Procedure
+The experiments were carried out four times on four different YIC programs in order to find out the 
+reproducibility of EPI outcomes. All subjects were assessed before and after four weeks of their YIC course. 
+The readings were taken from all 10 fingers in two ways, namely without filter and with filter. In order to obtain 
+a reliable and reproducible data, an established guideline (Alexandrova et al. 2002) was followed. The data was 
+collected after three hours of food intake. The subjects were asked to remove all metallic items which they do not 
+wear for 24 hours in a day. Further, they were also provided an electrically isolated surface to stand on during the 
+measurements and were instructed to place the finger on the dielectric glass plate at 45° angle. A distance of 3 feet 
+between the EPI camera and the computer system was maintained; the calibration of the instrument was performed 
+routinely, and an alcoholic solution was used to clean the glass plate after the assessment of each individual.
+65
+Vol. 12, No. 4/2015
+IYP as a Preventive Health Care
+Temperature and humidity measurements
+To check the variability in the environmental condition during measurement time, we used a Thermo/
+Hygrometer – Equinox, EQ 310 CTH. This dimension is necessary to quantify and check as the variation in this 
+environmental factors influence the electro photonic emission pattern, especially if the changes are greater than 
+±2.5% (Korotkov 2011). The average temperature observed during all four experiments was (mean ± sd) pre 29.10 
+±1.06ºC and post 29.20 ±2.39ºC and humidity pre 59% and post 59%.
+Data extraction and analysis
+The GDV diagram program was used to extract the raw data from the EPI system into Excel. This program 
+provides all parameters which were taken into consideration for analysis, namely Activation Coefficient, Integral 
+Area and Integral Entropy. Further, data analysis was carried out using ‘R statistical package for data analyses’ 
+(R Development Core team 2014) and Microsoft Excel program. Paired sample t-test was used for evaluating 
+pre and post readings and independent sample t-test for cross sectional comparisons between male and female 
+subgroups.
+Results
+Out of 152 volunteers, a total of 94 healthy subjects (male 55 and female 39, age, mean ± sd 26.70 ±8.58) who 
+were eligible as per the inclusion and exclusion criteria were only considered in the analysis. Table 1 presents the 
+participants’ characteristics of subgroups as males and females and as a whole. There is no difference in between 
+the age and BMI of both the genders.
+Table 1. Participants’ Characteristics
+Variables
+Male (n = 55)
+Female (n = 39)
+Total (n = 94)
+Age (year)
+26.93 ±9.12
+26.36 ±7.87
+26.70 ±8.58
+Height (cm)
+169.16 ±9.96
+159.31 ±6.08
+165.07 ±8.19
+Weight (kg)
+65.05 ±12.99
+57.79 ±10.12
+62.04 ±12.36
+BMI (kg/m2)
+22.70 ±3.92
+22.78 ±3.82
+22.73 ±3.86
+The observations in all four experiments (psycho-physiological level) showed a decreasing trend of AC, 
+increase in IA, left and right and decrease in IE left. Whereas, IE right was found increasing in three of four 
+experiments and decreased only in one experiment. This suggests that there exist a reproducibility of stress 
+reduction and health improvement through Integrated Yoga Practices. Table 2 presents results from all four groups 
+combined into one, where the decrease in AC value turned highly significant (p < 0.001, d = 0.59). The results at the 
+psycho-physiological level showed a highly significant increase in both IA, left and right (IA left p < 0.001, d = 0.39 
+and IA right p < 0.001, d = 0.48). The IE left values decreased from higher to lower (IE left 1.88 ±0.17, to 1.84 ±0.15, 
+p = 0.07, d = 0.18), but not significantly. The mean values of IE right side shifted towards higher, but marginally not 
+significantly (IE right 1.85 ±0.24 to 1.88 ±0.17, p = 0.30, d = 0.1). Whereas, the results at the physiological level were 
+found very stable except IE Left, which showed a shift of a marginal increase within the normal range.
+66
+Central European Journal of Sport Sciences and Medicine
+Kuldeep Kumar Kushwah, Hongasandra Ramarao Nagendra, Thaiyar Madabusi Srinivasan
+Table 2. Pre-post changes at both psycho-physiological and physiological levels (n = 94)
+Levels 
+Variables
+Pre
+mean ± sd
+Post
+mean ± sd
+t-value
+p-value
+AC
+3.28 ±1.21
+2.56 ±0.60
+5.75
+<0.001***
+Without 
+filter
+IAL
+–0.002 ±0.24
+0.11 ±0.15
+–3.78
+<0.001***
+IAR
+–0.01 ±0.21
+0.10 ±0.16
+–4.57
+<0.001***
+IEL
+1.88 ±0.17
+1.84 ±0.15
+1.86
+0.070
+IER
+1.85 ±0.24
+1.88 ±0.17
+–1.05
+0.300
+With 
+filter
+IAL
+0.39 ±0.16
+0.39 ±0.12
+–0.14
+0.890
+IAR
+0.39 ±0.15
+0.39 ±0.13
+–0.04
+0.960
+IEL
+1.91 ±0.15
+1.95 ±0.15
+–1.92
+0.060
+IER
+1.94 ±0.15
+1.94 ±0.15
+–0.21
+0.830
+Abbreviations: AC – Activation Coefficient; IAL – Integral Area Left side; IAR – Integral Area Right side; IEL – Integral 
+Entropy Left side; IER – Integral Entropy Right side. Significant level, *p < 0.05, **p < 0.01, ***p < 0.001.
+Table 3. Pre and post results of sub groups at both psycho-physiological and physiological levels
+Levels
+Variables
+Pre male
+Post male
+t-value
+p-value
+Pre female
+Post female
+t-value
+p-value
+mean ± sd  
+(n = 55)
+mean ± sd  
+(n = 55)
+mean ± sd  
+(n = 39)
+mean ± sd  
+(n = 39)
+AC
+3.09 ±1.06
+2.58 ±0.55
+3.25
+0.002**
+3.55 ±1.36
+2.52 ±0.66
+5.13
+<0.001***
+Without 
+filter
+IAL
+0.07 ±0.19
+0.13 ±0.13
+–1.96
+0.050*
+–0.11 ±0.25
+0.07 ±0.16
+–3.36
+0.002**
+IAR 
+0.04 ±0.19
+0.12 ±0.15
+–2.71
+0.009**
+–0.08 ±0.21
+0.08 ±0.16
+–3.78
+<0.001***
+IEL 
+1.88 ±0.17
+1.83 ±0.16
+1.66
+0.100
+1.88 ±0.17
+1.85 ±0.14
+0.90
+0.370
+IER 
+1.85 ±0.22
+1.90 ±0.18
+–1.10
+0.270
+1.84 ±0.27
+1.85 ±0.17
+–0.27
+0.790
+With
+filter
+IAL 
+0.42 ±0.13
+0.42 ±0.11
+0.25
+0.800
+0.35 ±0.20
+0.36 ±0.13
+–0.31
+0.760
+IAR 
+0.43 ±0.12
+0.41 ±0.11
+0.91
+0.360
+0.35 ±0.19
+0.37 ±0.15
+–0.58
+0.570
+IEL 
+1.92 ±0.14
+1.95 ±0.16
+–1.19
+0.240
+1.89 ±0.15
+1.95 ±0.14
+–1.53
+0.130
+IER 
+1.96 ±0.15
+1.91 ±0.15
+2.35
+0.020*
+1.92 ±0.16
+1.99 ±0.14
+–2.35
+0.020*
+Abbreviations: AC – Activation Coefficient; IAL – Integral Area Left; IAR – Integral Area Right; IEL – Integral Entropy Left side; IER – Integral Entropy Right side. Significant level, 
+ 
+*p < 0.05, **p < 0.01, ***p < 0.001.
+Both groups demonstrated significant reduction in stress levels and significant improvement in general 
+health index after IYP at the psycho-physiological level. However, integral entropy parameter at (NF) level did 
+not show any change. At physiological level, IE right side decreased significantly in the male group, whereas it 
+significantly increased in the female group. Other parameters at the physiological level in both the groups did not 
+reveal significant changes.
+The baseline comparisons between both groups showed higher mean values of AC in females than males 
+(AC, females 3.55 ±1.36 and males 3.09 ±1.06, p = 0.06). The magnitude of mean values of IA, left and IA right 
+side (NF) readings were found significantly higher in males (IA left p < 0.001 and IA right p < 0.01) than females, 
+whereas, no significant difference was found from IE left and IE right values between the groups. Further, the 
+magnitude of IA left and IA right values (WF) were significantly higher in males than females (IA left p = 0.04 and IA 
+right p = 0.02). However, no significant difference was found from IE left and IE right (WF) in between the genders. 
+67
+Vol. 12, No. 4/2015
+IYP as a Preventive Health Care
+Table 4. Cross sectional results (between males and females) at both psycho-physiological and physiological levels
+Levels
+Variables
+Pre male
+Pre female
+t-value
+p-value
+Post male
+Post female
+t-value
+p-value
+mean ± sd  
+(n = 55)
+mean ± sd  
+(n = 39)
+mean ± sd  
+(n = 55)
+mean ± sd  
+(n = 39)
+AC
+3.09 ±1.06
+3.55 ±1.36
+1.88
+0.060
+2.58 ±0.55
+2.52 ±0.66
+–0.47
+0.640
+Without 
+filter
+IAL
+0.07 ±0.19
+–0.11 ±0.25
+–3.67
+<0.001***
+0.13 ±0.13
+0.07 ±0.16
+–2.06
+0.040*
+IAR 
+0.04 ±0.19
+–0.08 ±0.21
+–2.93
+<0.010**
+0.12 ±0.15
+0.08 ±0.16
+–1.26
+0.210
+IEL 
+1.88 ±0.17
+1.88 ±0.17
+–0.12
+0.900
+1.83 ±0.16
+1.85 ±0.14
+0.36
+0.720
+IER 
+1.85 ±0.22
+1.84 ±0.27
+–0.24
+0.810
+1.90 ±0.18
+1.85 ±0.17
+–1.29
+0.200
+With
+filter
+IAL 
+0.42 ±0.13
+0.35 ±0.20
+–2.10
+0.040*
+0.42 ±0.11
+0.36 ±0.13
+–2.28
+0.020*
+IAR 
+0.43 ±0.12
+0.35 ±0.19
+–2.38
+0.020*
+0.41 ±0.11
+0.37 ±0.15
+–1.66
+0.100
+IEL 
+1.92 ±0.14
+1.89 ±0.15
+–0.78
+0.440
+1.95 ±0.16
+1.95 ±0.14
+–0.11
+0.910
+IER 
+1.96 ±0.15
+1.92 ±0.16
+–1.23
+0.220
+1.91 ±0.15
+1.99 ±0.14
+2.90
+0.005**
+Abbreviations: AC – Activation Coefficient; IAL – Integral Area Left; IAR – Integral Area Right; IEL – Integral Entropy Left side; IER – Integral Entropy Right side. Significant level, 
+*p < 0.05, **p < 0.01, ***p < 0.001.
+Post of male and female data indicated improvement in all parameters except IE right (WF), which showed 
+a significant shift towards higher values in the females group, though this increase was in the normal range of the 
+entropy parameter.
+Discussion
+Compared with the previous research in the field of yoga, the present study is first of its kind to 
+measure the effect of Integrated Yoga Program (IYP) on healthy volunteers, makes an attempt to find out 
+whether  EPI  parameters  differ  gender-wise and tries to establish the reproducibility of the EPI outcomes by 
+conducting four different experiments.
+The results from all four experiments (psycho-physiological level) were found reproducible except for IE 
+right side which exceptionally increased in three of four experiments. There was a highly significant decrease in 
+activation coefficient and highly significant improvement in integral area, left and right side (psycho-physiological 
+level) after four weeks of IYP. Similar changes were also observed from subgroups of male and female. Further, the 
+baseline comparisons between the genders have also demonstrated the significant difference in IA, left and right 
+side from both without filter and with filter readings.
+Psycho-physiological level
+Activation coefficient (stress parameter)
+A number of studies have evidence of the phenomenon that regular practice of integrated yoga reduces stress 
+in various populations (Buffart et al. 2012; McDermott et al. 2014; Michalsen 2008; Rao et al. 2008; Yoshihara et al. 
+2014). The results from the present study also show that integrated yoga practice on a regular basis reduces stress 
+significantly (p < 0.001) in healthy people. This may be due to the yoga practices which work on autonomic nervous 
+system (Streeter 2012) and restore balance between sympathetic and parasympathetic responses. Development of 
+a coherence zone between both SNS and PNS responses may regulate, unify and correct the imbalances in the flow 
+of Prana in the body. This may be confirmed by the uniformity throughout the EPI image glow area which increases 
+68
+Central European Journal of Sport Sciences and Medicine
+Kuldeep Kumar Kushwah, Hongasandra Ramarao Nagendra, Thaiyar Madabusi Srinivasan
+after the yoga practice. Earlier, this phenomenon was noticed in a pilot study by other researchers. It was found that 
+during progression of relaxation, the sensitive stress marker Salivary Alpha Amylase (sAA) (Van Stegeren 2006) 
+decreased, whereas, the EPI image glow area increased (Hacker 2011). It suggests that significant reduction in AC 
+leads to prevention of any abnormality in the Pranic energy distribution which could lead to prevention of diseases.
+Integral Area (IA, general health index)
+It is well known that yoga components, i.e., physical postures, breathing techniques, meditation, cleansing 
+techniques, and diet practices improve health and well-being in individuals (Jagannathan et al. 2014; Cabral et al. 
+2011; Gomes-Neto et al. 2014; Buffart et al. 2012). The present study also showed a highly significant increase in 
+IA left (p < 0.001) and right (p < 0.001) which suggest improvement in general health of the participants. It may be 
+due to reduction in stress level leading towards harmony and improved Pranic circulation, indicating improvement 
+in psycho-physiological health. 
+Integral Entropy (IE, disorderliness)
+The integrated practices of yoga improve and regulate the vital energy called Prana (Sharma et al. 2014). 
+Keeping harmonious homeostasis of this energy is a key essence of yoga practice, which keeps one healthy and 
+promotes positive health (Nagarathna and Nagendra 2009). Loss of homeostasis of the energy produces entropy, 
+which is otherwise known as disorderliness in the human energy systems (Korotkov 2002) and high or low entropy 
+may lead to diseases in the body. The shift of IE left higher to lower values and IE right toward higher may be an 
+adjustment towards balance in both. It indicates better energy homeostasis through IYP, which is an indication of 
+prevention of ill health.
+Physiological level
+Present study results at the physiological level have demonstrated the strength of regular practice of yoga, 
+which helps in sustaining the homeostasis level of energy by keeping both mind and body in harmony. That is 
+a unique outcome from the study suggesting that yoga is a boon for the health. The finding showed that the mean 
+values of IA left, right and IE right was same before and after the IYP. Although, the IE left showed a shift of an 
+increase within the normal range, but was negligible and not significant.
+Gender-wise comparisons
+Subgroup analysis of males and females showed a clear significant difference of energy parameters at 
+the baseline. One of the previous studies reported that women experience more stress than men (Matud 2004). 
+The findings of our present study are also similar, showing that magnitude of the stress parameter is higher in 
+females than males as found from the baseline comparisons of both males and females. After the intervention, 
+both male and female groups showed a significant reduction in stress level. It is a well-known fact that high-stress 
+levels affect the health of individuals. According to a report by American Psychological Association, women are 
+more prone to the stress-related health problems such as hypertension, depression, anxiety, and obesity (Herscher 
+2014) than men. The present study findings showed significantly lower level of the IA values in females than males 
+at both physiological and psycho-physiological levels in baseline comparison. This suggests that females are more 
+69
+Vol. 12, No. 4/2015
+IYP as a Preventive Health Care
+susceptible to develop health issues than males. After the IYP, IA values showed significant improvement in both 
+the groups, but the magnitude of improvement was more in females than males as compared with pre scores. 
+Studies have reported that socio economic and cultural factors influence the health of females, whereas the work 
+responsibilities influence males (Annette 2001; American Psychological Associantion 2015). Baseline comparisons 
+of the IE, left and right values at both psycho-physiological and physiological levels indicated no difference between 
+males and females. However, after the intervention IE right side (WF) decreased significantly in the male group 
+indicating reduction in disorderliness, whereas, an exception of significant increase was observed in IE right values 
+in the female group, but it was within the normal range. Moreover, these findings suggest that gender has an 
+influence on energy patterns which needs to be studied separately with more data to substantiate the findings.
+Strength
+The findings of reproducible EPI outcomes, highly significant reduction in stress, highly significant improvement 
+in general health indices (psycho-physiological level) and the baseline comparisons of males and females, which 
+showed significant difference in general health indices (psycho-physiological and physiological level) provide the 
+strength for the study.
+Limitations
+Absence of a control group may have posed a threat to the internal validity of the study; however, we estimate 
+that this would at the maximum obscure the measured magnitude of the effects but not the direction of effect. 
+A further confirmatory study may be done to better estimate the effect sizes. 
+Suggestions for future study and Implication of the study
+From the findings of significant difference in energy trend between the males and females, it is suggested that 
+males and females should be studied separately. Further, it is also suggested that future study should attempt to 
+follow the subjects after the completion of study in order to find out prolonging effects of yoga practices. Moreover, 
+IYP can be implemented for the prevention of ill health and promotion of health in individuals.
+Conclusions
+Present study achieved the reproducible results of stress, general health and disorderliness parameters in 
+all four experiments at the psycho-physiological level except IE right side. Outcomes of the study also suggest that 
+the energy parameters differ gender-wise and hence needs to be studied separately with more data to substantiate 
+the findings. Further, the findings from the investigations also suggest that IYP can be used to regulate, improve 
+and sustain the energy homeostasis of an organism. This, in essence, is important in the field of prevention and 
+sustenance of health. 
+Acknowledgments
+The authors would like to thank Dr. Judu V. Ilavarasu (PhD) for reviewing the draft and Mr. Guru Deo 
+(PhD scholar), Dr. Padamavati Maharana (PhD), Dr. T. Indira Rao (PhD), and Mr. Kuntal Ghosh (PhD Scholar) for 
+their consistent assistance in data collection.
+70
+Central European Journal of Sport Sciences and Medicine
+Kuldeep Kumar Kushwah, Hongasandra Ramarao Nagendra, Thaiyar Madabusi Srinivasan
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+61–71.

subfolder_0/Effect of Pyramids and their Materials on Emergence and Growth of Fenugreek.txt

@@ -0,0 +1,358 @@
+Research Journal of Agricultural Sciences 2011, 2(3): 629-631 
+ 
+Effect of Pyramids and their Materials on Emergence and Growth of 
+Fenugreek 
+ 
+Itagi Ravi Kumar and H R Nagendra  
+Swami Vivekananda Yoga Anusandhana Samsthana,  
+Eknath Bhavan, 19, Gavipuram Circle, Bangalore – 560 019, Karnataka, India 
+e-mail: [email protected] 
+ 
+A B S T R A C T 
+Investigation has been carried out to find out the influence of square pyramidal structure and its material 
+on the radical emergence and seedling vigor. Two pyramid models were used, one made of plywood and 
+other of fiber glass with both having square base. The control sample was kept in open air. The results 
+have shown that there is a significant influence on the radical emergence when the seeds are kept in 
+plywood square pyramid (PLSP) model. The higher effect was also shown in the seedling vigor growth 
+when kept in the plywood square pyramid (PLSP) compared to fiberglass square pyramid (FGSP). There 
+was increase in temperature by 3oC to 5oC inside PLSP compared to the other model and outside the 
+model. 
+ 
+Key words: Pyramids, Radical Length, Seedling vigor, Emergence, Tantra, Yantra 
+Pyramids are strong structures, the polygonal base 
+and sloping triangular sides meeting in an apex. 
+According to Indian philosophy the primary elements of 
+Universe are earth, water, fire, air and ether (Vasu 
+1974). Shape of pyramid contains four triangles joining 
+each other at the centre, the concept of four basic tattvas 
+– earth, water, fire and air are merging together with the 
+power of the ether to form a centre of power generator 
+that combines the universal energy with the nature 
+(David 1999). Tantra is a technique to achieve 
+materialistic and spiritual goal. The major components 
+of tantra are mantra and yantra. The Mantra is the 
+sound aspect and yantra is shape aspect. The yantra 
+involving points, lines, triangles and squares represent 
+energies in various modes to exert its influence in the 
+desired manner. In yantra the triangular shape 
+represents the universal energy and the inverted triangle 
+represent sakti, the process of creativity (Venugopalan 
+2003). 
+The effects of a model pyramid of Egyptian-type 
+on plants, aqueous solutions and solids. It was found 
+that a pre-sowing holding of dry barely seeds in the 
+pyramid stimulated the growth of the plants (Narimanov 
+1999). There are hardly any investigations to state the 
+property of the pyramids of capturing the cosmic energy 
+from the surroundings and in turn influence on both 
+living and non-living matter in the pyramid. Hence, the 
+present investigation was undertaken on a scientific 
+basis to study whether pyramids and its material have 
+any influence on the germination and growth of 
+fenugreek. 
+ 
+MATERIALS AND METHODS 
+Two following pyramids were used for the 
+experiments, a plywood square pyramid (PLSP) with a 
+square of length 315 mm and height 200 mm; a 
+fiberglass square pyramid (FGSP) with square of length 
+315 mm and height 200 mm (Fig 1). The fenugreek 
+seeds were procured from seed technology information 
+center, University of Agricultural Sciences (GKVK), 
+Bangalore. Pyramids and control samples were kept in 
+the same room. The pyramids were kept with one of the 
+sides being oriented in the magnetic North-South 
+direction.  
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+Fig 1 Pyramid models 
+ 
+Total of 240 seeds were used for each pyramid and 
+control. Seeds were selected randomly from pool of 
+seeds. Seeds are not stored in the pyramids before used
+                                                                           629                                                www.rjas.info 
+ 
+Elevation 
+Elevation 
+Plain 
+Plain 
+315 mm 
+315 mm 
+200 mm 
+200 mm 
+315 mm 
+315 mm 
+Plywood Square Pyramid (PLSP) Fiberglass Square Pyramid (FGSP) 
+ 
+ 
+ 
+ 
+ 
+Fig 2 Radical length (cm) of fenugreek on day 2 
+ 
+ 
+Fig 3 Seedling vigor in terms of length (cm) of fenugreek on 
+day 4 
+ 
+for testing and here seeds are used to find out the effect 
+of pyramids and their materials on its emergence and 
+growth. Seeds were soaked in distilled water for 30 
+minutes and placed on germination paper wetted with 
+distilled water and sandwiched with another wet paper 
+and covered top and bottom with plastic sheet and made 
+into rolls. Total of 18 rolls were made with 80 seeds in 
+each roll. Six rolls were kept at the base of each of the 
+two pyramids and another set of 6 rolls kept outside as 
+control. Seed emergence was determined on day 2 by 
+taking three rolls at random from each of the model 
+pyramids and three rolls from control; counted number 
+of seeds showing emergence and percent emergence 
+calculated. The radical emergence was measured by 
+taking the length of the radical, fresh and dry weight of 
+the radical recorded. Emergence was recorded and 
+determined seedling vigor on day 4 with remaining 
+three rolls from each of the two pyramids and as well as 
+from control. Counted number of seed showing 
+emergence and percent emergence calculated. Seedling 
+vigor determined in terms of length, fresh and dry 
+weight of the seedling recorded. The temperature was 
+recorded at every four hours interval both inside and 
+outside the pyramids. 
+ 
+Table 1 Influence of pyramid model on root emergence in fenugreek on day 2 
+Treatment 
+% 
+Emergence 
+Radical Emergence 
+Radical Fresh 
+Weight 
+Radical Dry 
+Weight 
+Average 
+Temperature 
+Mean 
+(cm) 
+Std 
+Dev 
+Mann-
+Whitney 
+Weight 
+(gm) 
+% change Weight 
+(gm) 
+% 
+change 
+Control 
+92 
+1.03 
+0.57 
+- 
+7.38 
+- 
+2.01 
+- 
+26°C 
+PLSP 
+95 
+1.36 
+0.84 
+0.000 
+7.86 
+6.50 
+2.13 
+5.97 
+31°C 
+FGSP  
+93 
+1.15 
+2.01 
+0.147 
+7.44 
+0.81 
+2.04 
+1.49 
+28°C 
+Total seeds in each treatment are 240 nos.; PLSP sample has maximum percentage emergence; PLSP shows maximum mean radical length; 
+PLSP shows significant radical length; PLSP sample has maximum total fresh and dry weight 
+ 
+RESULTS AND DISCUSSION 
+The pyramid samples show greater mean radical 
+length compared to control sample but PLSP sample 
+shows significant difference and FGSP sample shows 
+non-significant difference with respect to control 
+sample as found from Mann-Whitney test. PLSP and 
+FGSP samples have more fresh weight and dry weight 
+of radical emergence compared to control but PLSP 
+sample shows higher value compared to FGSP (Table 
+1). 
+The pyramid samples show higher percentage 
+emergence compared to control samples. PLSP sample 
+shows 4% more emergence to control sample and 3 % 
+more to FGSP sample. Results indicated that pyramid 
+samples have higher seedling vigor measured in terms 
+of length in cm compared to control sample. PLSP 
+sample has significant mean value to control sample as 
+found from Man-Whitney test but FGSP sample has no 
+significant mean value to control sample (Table 2).  
+PLSP and FGSP samples have more fresh weight 
+and dry weight of seedling vigor compared to control 
+but PLSP sample shows higher value compared to 
+FGSP. Samples of PLSP and FGSP show higher 
+percentage emergence, radical emergence in mean 
+length, higher fresh weight and dry weight of radical, 
+higher seedling vigor measured in terms of length, 
+higher fresh weight and dry weight of seedling vigor 
+compared to control sample, this indicates that 
+pyramidal shape has an influence on these parameters 
+and can be speculated that pyramidal shapes are 
+effective in capturing cosmic radiation and manifest as 
+life energy, which helps to accelerate the emergence, in
+Kumar and Nagendra 
+Radical Length (cm) of Fenugreek on Day 2
+0
+5
+10
+15
+20
+25
+1
+8
+15 22 29 36 43 50 57 64 71 78 85 92 99 106 113 120 127 134 141 148 155 162 169 176 183 190 197 204 211 218 225 232 239
+Seed
+Length (cm)
+Control
+PLSP
+FGSP
+Seedling Vigor in terms of Length (cm) of Fenugreek on Day 4
+0
+2
+4
+6
+8
+10
+12
+14
+16
+1
+8
+15 22
+29 36 43
+50 57 64 71
+78 85 92
+99 106 113 120 127 134 141 148 155 162 169 176 183 190 197 204 211 218 225 232 239
+Seed
+Seedling Vigor (cm)
+Control
+PLSP
+FGSP
+                                                                           630                                                www.rjas.info 
+ 
+Table 2 Influence of pyramid model on germination and seedling vigor on day 4 
+Treatment 
+% 
+Germination 
+Seedling Vigor 
+Seedling Vigor 
+Fresh Weight 
+Seedling Vigor 
+Dry Weight  
+Average 
+Temperature 
+Mean 
+(cm) 
+Std 
+Dev 
+Mann-
+Whitney 
+Weight 
+(gm) 
+% 
+change 
+Weight 
+(gm) 
+% 
+change 
+Control 
+93 
+7.02 
+2.51 
+- 
+13.29 
+- 
+2.25 
+- 
+27°C 
+PLSP 
+97 
+8.09 
+3.11 
+0.000 
+15.21 
+14.45 
+2.61 
+16 
+31°C 
+FGSP  
+94 
+7.46 
+2.43 
+0.040 
+13.44 
+1.13 
+2.28 
+1.33 
+29°C 
+Total seeds in each treatment are 240 nos.; PLSP sample has maximum percentage emergence; PLSP shows maximum mean radical length; 
+PLSP shows significant radical length; PLSP sample has maximum total fresh and dry weight 
+ 
+growth of radical emergence in length and seedling 
+vigor which was measured in terms of percentage 
+emergence and length (Kumar et al. 2010). 
+The higher average temperature in the pyramids as 
+compared to outside might also indicate that pyramids’ 
+shapes create a different energy field inside which is 
+different from outside which may cause in accelerating 
+the growth of radical and higher seedling vigor 
+compared to control sample (Table 1 & 2). 
+The PLSP sample accelerates significant radical 
+emergence and seedling vigor compared to FGSP 
+sample and with respect to control sample, this may be 
+because of PLSP has an opaque surface and not 
+allowing to dissipate energy field created inside but 
+FGSP is of transferring surface. This indicates that 
+pyramid made out of plywood material is more 
+effective in creating energy field in the pyramid space.  
+This investigation shows that pyramidal structures 
+exhibit a positive influence on the emergence, growth of 
+radical emergence and seedling vigor in terms of length 
+compared to control sample. Plywood pyramidal 
+structure is more effective than fiberglass structure. 
+ 
+LITERATURE CITED 
+David F. 1999. Tantric Yoga and the Wisdom of goddesses. Motilal Banarasidas Publishers Private Limited, Delhi. 
+Kumar I R, Swamy N V C and Nagendra H R. 2005. Effect of Pyramids on Micro-organisms. Indian Journal of 
+Traditional Knowledge 4(4): 373-379.   
+Kumar I R, Swamy N V C, Nagendra H R and Radhakrishna. 2010. Influence of Pyramids on Germination and 
+Growth of Fenugreek. Indian Journal of Traditional Knowledge 9(2): 347-349. 
+Narimanov A A. 1999. Pyramid Effect. Science, December 3, 1999: pp286 (5446). 
+Vasu S C. 1974.  Brahma Sutra. The Vedantasutras of Badarayana. Reprint, New York: AMS Press. 
+Venugopalan R. 2003. Soul Searchers. Healing Power of Pyramid, B. Jain Publishers (P) Ltd. New Delhi. 
+ 
+Pyramids and their Materials on Emergence and Growth of Fenugreek 
+                                                                           631                                                www.rjas.info 
+ 

subfolder_0/Effect of a yoga program on glucose metabolism and blood lipid levels in adolescent girls with polycystic ovary syndrome.txt

@@ -0,0 +1,815 @@
+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
+CLINICAL ARTICLE
+Effect of a yoga program on glucose metabolism and blood lipid levels in adolescent
+girls with polycystic ovary syndrome
+Ram Nidhi a,⁎, Venkatram Padmalatha b, Raghuram Nagarathna a, Amritanshu Ram a
+a Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana (SVYSA) University, Bengaluru, India
+b Rangadore Memorial Hospital, Bengaluru, India
+a b s t r a c t
+a r t i c l e
+i n f o
+Article history:
+Received 19 October 2011
+Received in revised form 24 January 2012
+Accepted 21 March 2012
+Keywords:
+Adolescents
+Insulin resistance
+Lipid levels
+Polycystic ovary syndrome
+Yoga
+Objective: To assess the efficacy of yoga therapy on glucose metabolism and blood lipid values in adolescent girls
+with polycystic ovary syndrome (PCOS). Methods: A prospective, randomized, interventional controlled trial
+recruited 90 adolescents aged between 15 and 18 years who met the Rotterdam criteria for PCOS. A yoga group
+practiced suryanamaskara, asanas, pranayama, and meditation 1 hour per day each day for12 weeks while
+another group practiced conventional physical exercises. The Mann–Whitney U test was used to compare score
+changes between the 2 groups. Results: The changes in fasting insulin, fasting blood glucose, and homeostasis
+model assessment of insulin resistance were significantly different in the 2 groups (Pb0.05). Except for high-
+density lipoprotein cholesterol, the changes in blood lipid values were also significantly different (Pb0.05). The
+changes in body mass index, waist circumference, hip circumference, and waist-to-hip ratio, however, were not
+significantly different (P>0.05). Conclusion: Yoga was found to be more effective than conventional physical
+exercises in improving glucose, lipid, and insulin values, including insulin resistance values, in adolescent girls
+with PCOS independent of anthropometric changes.
+Central Trial Registry of India No.: REFCTRI-2008 000291.
+© 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
+1. Introduction
+Polycystic ovary syndrome (PCOS) is a clinically heterogeneous
+endocrine disorder with a prevalence estimated to range from 2.2% to as
+high as 26%, depending on age and ethnicity [1,2]. In a recent survey, we
+found a 9.13% prevalence of PCOS in south Indian adolescent girls [3].
+Although medical care is usually sought for the clinical signs of PCOS,
+the syndrome is associated with many asymptomatic but serious
+conditions that include insulin resistance (IR), type 2 diabetes mellitus,
+and dyslipidemia.
+The prevalence of metabolic syndrome is as high as 40% among
+women younger than 30 years who have PCOS [4]. Moreover, studies in
+adolescent girls with PCOS reveal that IR is present early in the course of
+the syndrome, and that IR develops more frequently among those
+experiencing premature pubarche [5]. Moreover, elevated levels of
+triglycerides, very-low-density lipoprotein (VLDL) cholesterol, and low-
+density lipoprotein (LDL) cholesterol, with decreased levels of high-
+density lipoprotein (HDL) cholesterol, have all been noted in young and
+adult patients with PCOS [6]. It is thus necessary to diagnose and treat
+adolescents as early as the condition is recognized to prevent health
+risks in the long term.
+Insulin-sensitizing agents such as metformin and thiazolidine-
+diones have been used extensively in the treatment of PCOS, although
+with mixed results. The benefits have been short term and accompa-
+nied by adverse effects such as nausea, diarrhea, and abdominal
+cramps [7]. These drawbacks have triggered researchers and patients
+to seek help through nonpharmacologic therapies. Intervention
+studies have shown that in women with PCOS, short-term weight
+loss induced by dieting decreased abdominal fat volume [8,9], signs of
+hyperandrogenemia [8], and blood lipid levels [9] while it improved
+insulin sensitivity [8,9].
+A study by Thomson et al. [10] showed that a calorie-restricted diet
+combined with aerobic exercises, alone or with resistance exercises,
+improved body composition in overweight and obese women with
+PCOS, but had no effect on their IR and blood lipid values. A more recent
+review of all exercise therapies—whether aerobic, based on resistance
+exercises, or both���showed that the most consistent benefits were
+reduced IR, improved ovulation, and weight loss [11].
+Although yoga has not been studied as a form of therapy for
+PCOS, increased insulin sensitivity was shown to be associated with a
+less marked relationship between high body weight and poor insulin
+sensitivity in healthy men who had been practicing yoga for 1 year
+or longer [12]. Another study has shown that yoga improved fast-
+ing blood levels of glucose and lipids in persons with obesity and
+diabetes [13].
+The present study was designed to investigate the effect of yoga
+therapy in adolescent girls with PCOS.
+International Journal of Gynecology and Obstetrics 118 (2012) 37–41
+⁎ Corresponding author at: 19 Eknath Bhavan, Gavipuram Circle, Kempegowdanagara,
+Bengaluru 560 019, India. Tel.: +91 80 2661 1182; fax: +91 80 2660 8645.
+E-mail address: [email protected] (R. Nidhi).
+0020-7292/$ – see front matter © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
+doi:10.1016/j.ijgo.2012.01.027
+Contents lists available at SciVerse ScienceDirect
+International Journal of Gynecology and Obstetrics
+journal homepage: www.elsevier.com/locate/ijgo
+Author's personal copy
+2. Materials and methods
+The study was carried out with adolescent girls aged between 15
+and 18 years who attended a residential school in Anantpur, Andhra
+Pradesh, India. Those who showed at least two-thirds of the features
+listed in the Rotterdam criteria for PCOS were included in the study
+[14]. The features were oligomenorrhea or amenorrhea (an absence
+of menstruation for 45 or more days and/or fewer than 8 menses per
+year); clinical hyperandrogenism (a score of 6 or higher on the
+modified Ferriman–Gallwey scale); biochemical hyperandrogenism
+(serum testosterone level higher than 82 ng/dL in the absence of
+other causes of hyperandrogenism); polycystic ovaries (presence of
+more than 10 cysts 2 to 8 mm in diameter, usually combined with
+an ovarian volume greater than 10 cm3 and echo-dense stroma
+on ultrasound).
+The exclusion criteria were having followed a hormonal treatment
+or used oral contraceptives or insulin-sensitizing agents in the
+previous 6 weeks; smoking; a history of hyperprolactinemia; thyroid
+abnormalities; nonclassic adrenal hyperplasia; and a prior experience
+of yoga.
+The study was approved by the Institutional Ethical Committee
+of Swami Vivekananda Yoga Anusandhana Samsthana University.
+Signed Informed consent was obtained from college authorities, the
+students, and one of their parents.
+A sample size of 80 participants was found to be adequate for an
+effect size of 0.63, an α level of 0.05, and a power of 0.80. The mean
+fasting insulin (FI) value for each group at the end of the intervention,
+and the difference between the 2 values, were first calculated. Then, as
+no yoga studies were available, the effect size was determined by
+dividing the mean difference between the FI values by the pooled
+standard deviation for FI reported in a previously published randomized
+trial that studied the effects of 3 months of structured exercises in
+young women with PCOS [15].
+The present prospective, randomized, interventional controlled trial
+was started after its purpose and design were clearly defined and all
+informed consent forms were signed. All adolescents with oligomenor-
+rhea and/or hirsutism were asked to come for an ultrasound and blood
+tests. Of those who satisfied the Rotterdam criteria for PCOS, 90 were
+randomly selected and assigned to 1 of 2 groups, one in which yoga
+would be practiced (group 1) and the other in which conventional
+physical exercises would be practiced for the same duration (group 2).
+Anthropometric measurements, endocrine hormone levels, and men-
+strual frequency were recorded.
+Both groups went through their respective set of practices 1 hour per
+day each day for12 weeks under the supervision of trained instructors,
+for a total of 90 sessions. Double blinding was not possible because the
+trial was interventional. The medical officer, the ultrasound specialist,
+and the laboratory staff were blinded to the groups, and the statistician
+who performed the randomization and the final analysis was blinded to
+the data source.
+The primary outcomes were changes in levels of serum FI, fasting
+blood glucose (FBG), and serum lipids. The secondary outcomes were
+changes in body mass index (BMI, calculated as weight in kilograms
+divided by the square of height in meters) and waist-to-hip ratio (WHR).
+Since none of the adolescents had testosterone values higher than the
+normal range, testosterone level was not included as an outcome
+variable. Because it was not possible to obtain consent for transvaginal
+scans, transabdominal pelvic scans were performed using a Philips HD
+11XE ultrasound system (Philips, Best, the Netherlands), with special
+attention to the ovaries.
+A 10-mL sample of fasting venous blood was drawn from each
+adolescent between 6:00 and 8:00 AM for baseline measurements.
+Another sample of fasting venous blood was drawn at the end of the
+trial, after the adolescents had abstained from performing their practices
+for 5 days. At both times the serum was separated by centrifugation and
+stored at –20 °C until it was analyzed at certified laboratories.
+Fasting insulin level was assessed by solid-phase radioimmunoassay
+(intra-assay coefficient of variation [CV], 2.2%; interassay CV, 6.1%;
+specificity, 4 ng/mL). Levels of total cholesterol (TC) (intra-assay CV,
+0.8%; interassay CV, 1.7%), triglycerides (intra-assay CV, 1.5%; interassay
+CV, 1.8%), and FBG (intra-assay CV, 0.9%; interassay CV, 1.8%) were
+measured using the enzymatic calorimetric method. Levels of high-
+density lipoprotein (HDL) cholesterol (intra-assay CV, 2.9%; interassay
+CV, 3.6%) were measured using a homogenous calorimetric assay,
+whereas levels of low-density lipoprotein (LDL) cholesterol (intra-assay
+CV, 0.9%; interassay CV, 2.0%) were measured by means of a homoge-
+nous turbidimetric assay.
+Two parallel training modules, one for each group, were developed
+by a team of experts that included a psychiatrist, a gynecologist, and a
+yoga therapy physician. Care was taken to coordinate the lectures,
+practical classes, and types of relaxation techniques used in the modules.
+The concepts for group 1 were taken from traditional yoga texts
+(Patanjali yoga sutras, Upanishads, and Yoga Vasishtha) that place
+emphasis on a holistic approach to health management at the physical,
+mental, emotional, and intellectual levels [16]. The practices consisted
+of asanas (yoga postures), pranayama, relaxation techniques, and
+meditation, along with lectures on yogic lifestyle and yogic counseling
+for stress management. All adolescents received at least 1 session,
+lasting about 1 hour, of individualized counseling aiming at cognitive
+restructuring based on yoga philosophy.
+Table 1 details the hour-long module used in group 2. In this group
+the exercises consisted of a set of physical movements and safe non-
+yogic breathing followed by supine rest (without instructions), and
+these activities paralleled those in group 1. The adolescents in this group
+also received 1 counseling session. Care was taken by the counselors not
+to introduce any of the yogic concepts during these sessions.
+All statistical analyses were performed using SPSS software, version
+17.0 (IBM, Armonk, NY, USA). The Kolmogorov–Smirnov test was used
+to check for normal distribution. Our objective was to compare changes
+after practicing yoga or conventional physical exercises, but the data
+were not normally distributed. Nonparametric analysis was therefore
+done, using the Mann–Whitney U test to compare difference scores
+(or Δ changes) between the 2 groups. The difference scores were
+calculated by subtracting post-intervention changes from baseline
+values for each variable.
+3. Results
+The trial flowchart is shown in Fig. 1. Of 986 adolescents who
+agreed to the clinical examination, 154 with oligomenorrhea and/or
+hirsutism underwent the ultrasound and blood tests. Of these, 85
+satisfied the Rotterdam criteria for PCOS and were randomized but 14
+became ineligible (7 in each group) because of an attendance of less
+than 75%. The final analysis was done with 71 participants, 35 in
+group 1 and 36 in group 2.
+The demographic data appear in Table 2. Of the adolescents
+recruited, 83.53% were of normal weight, with a BMI between 18.5
+and 23, and only 16.47% were overweight, with a BMI higher than 23;
+63.53% had a WTH ratio greater than 0.8; 43.53% had a menstrual
+cycle of 90 or more days; 32.4% (9 in group 1 and 14 in group 2) had a
+homeostasis model assessment of IR (HOMA-IR) score (calculated as
+fasting glucose level in mmol/L multiplied by fasting insulin level in
+μU/mL and divided by 22.5) of 2 or higher (2.0 being considered the
+cutoff value for PCOS). A high majority (90%) of the participants had
+opted for scientific curricula in their academics.
+The Mann–Whitney U test showed that the mean±SD changes in
+difference scores for FBG in group 1 and group 2 were significantly
+different (–4.26±6.97 vs. 0.64±7.94; Pb0.01). The Wilcoxon signed
+rank test revealed a significant reduction in FBG levels in group 1
+(Pb0.001) but not in group 2 (P>0.05). Changes in difference scores
+for FI were significantly different in the 2 groups (–1.30±4.65 vs.
+1.60±8.19; Pb0.05), but there was a baseline difference in FI levels;
+38
+R. Nidhi et al. / International Journal of Gynecology and Obstetrics 118 (2012) 37–41
+Author's personal copy
+and within-group analysis showed a significant decrease in FI levels
+group 1 (Pb0.001) and a significant increase in group 2 (Pb0.001).
+The changes in HOMA-IR scores were significantly different in group
+1 and group 2 (0.38±0.92 vs. 0.29±1.56; Pb0.05), as a significant
+reduction occurred in group 1 (Pb0.05) but not in group 2 (P>0.05).
+The Mann–Whitney U test showed that the mean changes in
+difference scores were significantly different in group 1 and group 2
+for serum levels of triglycerides (12.94±10.72 vs. 6.44±10.80), LDL
+(8.20±9.83 vs. 2.85±15.14), VLDL 2.40±1.97 vs. 1.34±2.23), and
+TC (9.37±11.30 vs. 2.86±17.75) (Pb0.05 for each). The changes in
+difference scores for the TC/HDL ratio were also significantly different
+in the 2 groups (0.33±0.25 vs. 0.19±0.33; Pb0.01), but those for
+HDL were not (P>0.05). In both groups, within-group analysis
+showed significant decreases in triglyceride levels, VLDL levels, and
+the TC/HDL ratio (Pb0.01), as well as a significant increase in HDL
+levels (Pb0.01). The decrease in TC level, however, was significant
+only in group 1 (Pb0.001).
+The changes for BMI, WC, HC, and WHR were nonsignificant both
+within and between the groups.
+Table 1
+Exercises practiced in parallel in the 2 groups.
+Group 1
+Time, min
+Group 2
+Time, min
+Group lecture: cognitive restructuring based on the
+spiritual philosophy underlying yogic concepts.
+8
+Group lecture: modern conventional concepts about
+a healthy lifestyle that includes diet and exercise.
+15
+Surya namaskara (sun salutation)
+10
+Brisk walk
+15
+Prone asanas
+Prone exercises
+Cobra pose (bhujangasana)
+1
+Prone head lift
+1
+Locust pose (salabhasana)
+1
+Prone leg rising
+1
+Bow pose (dhanurasana)
+1
+Tiger leg stretch
+1
+Standing asanas
+Standing exercises
+Triangle pose (trikonasana)
+1
+Spread leg side bending
+1
+Twisted angle pose (parsva-konasana)
+1
+Spread leg twisted bending
+1
+Spread leg intense stretch (prasarita padottanasana)
+1
+Spread leg forward bend
+1
+Supine asanas
+Supine exercises
+Inverted pose (viparita karni)
+1
+Straight leg raising
+1
+Shoulder stand (sarvangasana)
+1
+Straight leg supine twist
+1
+Plough pose (halasana)
+1
+Cycling with bended knee and crunches
+1
+Sitting asanas
+Sitting exercises
+Sitting forward stretch (paschimottanasana)
+1
+Spread leg forward bend
+1
+Fixed angle pose (baddha-konasana)
+1
+Spread leg alternate toe touching
+1
+Garland pose (malasana)
+1
+Squat pose
+1
+Guided relaxation (savasana)
+10
+Supine rest
+10
+Breathing techniques (pranayama)
+Normal breathing
+8
+Sectional breathing (vibhagiya-pranayama)
+4
+Forceful exhalation (kapala bhati)
+2
+Right nostril breathing (suryanuloma viloma)
+2
+Alternate nostril breathing (nadi suddhi)
+2
+Om meditation (om dhyana)
+10
+Screened(n=986)
+Unsuitable (n=832)
+Randomized (n=85)
+Control (n=43)
+Yoga (n=42)
+Completed (n=35)
+Completed (n=36)
+Dropout (n=7)
+Dropout (n=7)
+Excluded (n=69)
+Presence of clinical symptoms (n=154)
+Clinical Examination
+Laboratory Evaluation
+Fig. 1. Trial flowchart.
+Table 2
+Demographic, anthropometric, and metabolic characteristics at baseline.a
+Variable
+Group 1
+Group 2
+P value
+(n=42)
+(n=43)
+Age, y
+16.22±1.13
+16.22±0.93
+0.15
+Height, m
+1.54±0.06
+1.56±0.05
+0.24
+Weight, Kg
+47.92±6.20
+51.14±7.39
+0.04
+BMI
+20.30±1.92
+21.22±2.99
+0.54
+Girls with BMI≤23
+37
+34
+Girls with BMI >23
+5
+9
+WC, m
+0.67±0.06
+0.69±0.07
+0.14
+HC, m
+0.87±0.07
+0.90±0.08
+0.07
+WHR
+0.01±0.0005
+0.008±0.0005
+0.59
+Girls with WHR ≥0.8
+16
+15
+Girls with WHR b0.8
+26
+28
+FI, pmol/L
+60.31±22.93
+75.91±35.10
+0.02
+FBG, mmol/L
+4.30±0.37
+4.19±0.34
+0.23
+HOMA-IR score
+1.68±0.74
+2.05±0.99
+0.07
+Girls with HOMA-IR score ≥2)
+10
+20
+Girls with HOMA-IR score b2)
+32
+23
+TRIG, mmol/L
+14±0.20
+1.10±0.20
+0.25
+TC, mmol/L
+4.22±0.47
+4.04±0.51
+0.06
+HDL, mmol/L
+1.06±0.06
+1.05±0.07
+0.47
+LDL, mmol/L
+2.65±0.40
+2.48±0.41
+0.06
+VLDL, mmol/L
+0.52±0.08
+0.51±0.09
+0.39
+TC/HDL
+3.99±0.38
+3.85±0.37
+0.04
+Menstrual frequency, mo
+1.41±0.8
+1.47±0.87
+0.48
+Girls with cycle of 45 to b59 d
+9
+9
+Girls with cycle of 60 to b90 d
+14
+16
+Girls with cycle of ≥90 d
+19
+18
+Girls with O+H
+5
+4
+Girls with H+PCO
+3
+5
+Girls with O+PCO
+25
+26
+Girls with O+H+PCO
+9
+8
+Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by the
+square of height in meters); FI, fasting Insulin; FBG, fasting blood glucose; H,
+hyperandrogenism; HC, hip circumference; HDL, High-density lipoprotein; HOMA-IR,
+Homeostasis Model Assessment, insulin resistance; LDL, low-density lipoprotein; O,
+oligomenorrhea; PCO, polycystic ovaries; TC, total cholesterol; TRIG, triglycerides;
+VLDL, very-low-density lipoprotein; WC, Waist Circumference; WHR, waist-to hip
+ratio.
+a Values are given as mean±SD or number unless otherwise indicated.
+39
+R. Nidhi et al. / International Journal of Gynecology and Obstetrics 118 (2012) 37–41
+Author's personal copy
+4. Discussion
+There were highly significant differences in the FBG changes
+observed in each group after the 12-week intervention program
+(Table 3). There was a noticeable reduction in difference scores (–4.26)
+in group 1 and an increase in difference scores in group 2 (+0.64)
+(Pb0.001). We also report a 5.4% reduction in FBG blood concentration
+after the yoga program, which is greater than the 1% reduction observed
+at the end of a structured exercise program in a study by Vigorito et al.
+[14], or the 0.4% observed after metformin therapy in a study by Bridger
+et al. with Canadian girls with PCOS [17].
+The baseline FI levels were significantly different in the 2 groups.
+However, the difference in the changes observed in each group following
+the intervention were also significant, with a drop in difference scores
+(–1.30) in group 1 and a rise (+1.60) group 2 (Pb0.05). The 14.9%
+reduction in FI blood concentration at the end of the yoga program is
+greater than the 9% reduction after 3 months of exercise reported by
+Vigorito et al [15]. Likewise, the changes in HOMA-IR score were
+significantly different in the 2 groups, with a reduction (–0.38) in
+difference scores in group 1 and an increase (+0.29) in group 2
+(Pb0.05) This 22.49% reduction at the end of the yoga program is much
+greater than the 18% reduction after metformin therapy reported by
+Bridger et al. [17].
+It is interesting to note that the group that practiced physical
+exercises showed no reduction in FBG levels, FI levels, or HOMA-IR
+scores 5 days after the program ended. We propose that the effect of
+acute exercise had already dissipated when the post-intervention blood
+sample was collected. This suggestion is supported by observations on
+the effect of exercise detraining (i.e. ceasing to exercise) in a study by
+Mikines et al. [18], who showed that the training-induced improve-
+ments in insulin sensitivity were significantly reduced after 5 days of
+not exercising, and by a study by Segal et al. [19] who, after controlling
+for the effects of the last exercise session, did not find that aerobic
+exercise improved insulin sensitivity.
+The mean baseline lipid values in the present study are similar to
+those in previously published studies with girls affected by PCOS
+[20,21]. The 5.72% reduction in TC blood concentration and the 7.95%
+reduction in LDL blood concentration at the end of the yoga program
+are greater than the 1.31% and 4.06% after 3 months of exercise
+reported by Vigorito et al. [15].
+Most of the exercise studies showing a positive association between
+reductions in FBG and FI concentrations and lower BMI and WHR values
+have been carried out with obese women with PCOS. In the present
+study, 84% of the adolescents were of normal weight, with a BMI
+between 18.5 and 23, and there were no significant anthropometric
+changes in either group at the end of the study. The lack of weight loss
+after a 12-week yoga program successful in reducing FBG, FI, and lipid
+levels may indicate that the hypothalamic–pituitary–adrenal axis and
+sympatho-adrenal pathways, rather than the exercises the program
+entailed, may be responsible for these reductions.
+It has been shown that PCOS, which includes hyperandrogenemia,
+hyperinsulinemia, and IR, and the related metabolic syndrome are
+both associated with disturbed activity of the sympathetic nervous
+system [22]. Increased sympathetic and decreased parasympathetic
+activity has been documented in women with PCOS by assessing
+heart rate variability (a measure of cardiac autonomic control) [23],
+and through direct intraneural recordings [24].
+There is evidence that regularly practicing yoga lowers cortisol
+levels [25] and stress arousal threshold by modulating sympathetic
+nerve activity [26] in the general population. We hypothesize that, in
+addition to the beneficial effects of physical activity, practicing yoga
+may lead to significant improvement in glucose and lipid metabolism
+by stabilizing the hypothalamic–pituitary–adrenal axis and promot-
+ing autonomic balance in girls with PCOS.
+Strengths of the study included a specifically designed holistic
+yoga program based on subtle yogic concepts; the supervision of both
+groups as the participants practiced the required exercises on the
+same days for the same number of days; and a detraining interval of
+5 days between the end of the intervention and the post-intervention
+blood collection. The participants were a “captive” population, how-
+ever, and of a highly selective age group, and the study's findings may
+not be generalizable.
+It would be interesting to correlate the effects of yoga on PCOS
+symptoms with those on the biochemical markers of PCOS. By including
+objective and subjective measures of stress, future studies with a longer
+follow-up may also help in understanding the mechanisms involved in
+the etiology of PCOS and the therapeutic benefits of yoga. Finally, it
+would be interesting to know whether the degree of IR and the effects of
+yoga are associated with the severity of structural changes observed in
+women with polycystic ovaries.
+Acknowledgments
+The Central Council for Research in Yoga and Naturopathy,
+Ministry of Health, Government of India, funded the project.
+Conflict of interest
+The authors have no conflicts of interest.
+Table 3
+Changes in both groups after the intervention.a
+Variable
+Group 1
+(n=35)
+Group 2
+(n=36)
+P value c
+Pre
+Post
+Difference scores
+P value b
+Pre
+Post
+Difference scores
+P value b
+FI
+60.62±23
+51.58±17.53
+9.04±32.31
+b0.001
+70.31±33.09
+81.4±47.59
+11.09±56.85
+b0.001
+b0.05
+FBG
+4.34±0.36
+4.1±0.18
+0.24±0.39
+b0.001
+4.17±0.32
+4.21±0.34
+0.04±0.44
+0.47
+b0.01
+HOMA-IR
+1.69±0.75
+1.31±0.44
+0.38±0.92
+b0.05
+1.88±0.94
+2.16±1.28
+0.29±1.56
+0.19
+b0.05
+TRIG
+1.15±0.18
+1.01±1
+0.15±0.12
+b0.001
+1.07±0.19
+1±0.11
+0.07±0.12
+b0.001
+b0.05
+TCHL
+4.24±0.4
+4±0.34
+0.24±0.29
+b0.001
+4±0.53
+3.92±0.42
+0.07±0.46
+0.15
+b0.01
+HDL
+1.05±0.52
+1.08±0.06
+0.03±0.04
+b0.001
+1.04±0.59
+1.08±0.07
+0.03±0.58
+b0.01
+0.65
+LDL
+2.67±0.34
+2.46±0.29
+0.21±0.25
+b0.001
+2.47±0.43
+2.39±0.35
+0.07±0.39
+0.13
+b0.05
+VLDL
+0.52±0.08
+0.46±0.05
+0.06±0.05
+b0.001
+0.49±0.09
+0.46±0.05
+0.03±0.06
+b0.001
+b0.05
+TC/HDL
+4.05±0.35
+3.72±0.26
+0.33±0.25
+b0.001
+3.83±0.38
+3.65±0.3
+0.19±0.33
+b0.001
+b0.01
+BMI
+20.22±1.65
+20.11±1.74
+0.11±0.51
+0.32
+21.28±3.05
+21.59±2.78
+0.31±1.63
+0.66
+0.39
+WC
+0.66±0.04
+0.64±0.03
+0.01±0.03
+0.06
+0.69±0.07
+0.69±0.06
+0.006±0.005
+0.89
+0.27
+HC
+0.86±0.06
+0.84±0.05
+0.01±0.04
+0.19
+0.90±0.08
+0.89±0.06
+0.01±0.06
+0.45
+0.81
+WHR
+0.77±0.05
+0.76±0.04
+0.01±0.05
+0.53
+0.77±0.05
+0.78±0.05
+0±0.05
+0.42
+0.21
+For abbreviations, please see Table 2.
+a Values are given as mean±SD unless otherwise indicated.
+b By the Wilcoxon signed rank test for the changes in measured values.
+c By the Mann–Whitney U test for the changes in difference scores.
+40
+R. Nidhi et al. / International Journal of Gynecology and Obstetrics 118 (2012) 37–41
+Author's personal copy
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subfolder_0/Effect of hot arm and foot bath on heart rate variability and blood pressure in healthy volunteers.txt

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+Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd
+DE GRUYTER
+Journal of Complementary and Integrative Medicine. 2019; 20180181
+Samruddhi Chintaman Vyas1 / A. Mooventhan2 / N.K. Manjunath3
+Effect ofhot arm and foot bath on heart rate
+variability and blood pressure in healthy
+volunteers
+1 Department of Yoga and Naturopathy, Division of Yoga and Life Sciences, The School of Yoga and Naturopathic Medicine,
+S-VYASA a Deemed to be University, Bengaluru, India, E-mail: [email protected]
+2 Department of Naturopathy, Government Yoga and Naturopathy Medical College, Arumbakkam, Chennai-600106, Tamil-
+nadu, India, E-mail: [email protected]
+3 Department of Research and Development, Division of Yoga and Life Science, S-VYASA a Deemed to be University, Ben-
+galuru, Karnataka, India, E-mail: [email protected]
+Abstract:
+Background: Though hot arm and foot bath (HAFB) is widely used, a precise physiological response is not
+reported. Hence, the present study was conducted to evaluate the effect of HAFB on heart rate variability (HRV)
+and blood pressure (BP) in healthy volunteers.
+Materials and Methods: Sixteen healthy male volunteers’ aged 23.81 ± 5.27 (mean ± standard deviation) years
+were recruited. All the subjects underwent only one session of HAFB (104-degree Fahrenheit) for the duration
+of 20 min. Assessments such as Electrocardiography and BP were taken before and after the intervention.
+Results: Results of this study showed a significant reduction in systolic-BP (SBP), diastolic-BP (DBP), mean
+arterial pressure (MAP), the mean of the intervals between adjacent QRS complexes or the instantaneous heart
+rate (RR interval), the number of interval differences of successive NN intervals greater than 50 ms (NN50), the
+proportion derived by dividing NN50 by the total number of NN intervals (pNN50), and high frequency (HF)
+band of HRV along with a significant increase in heart rate (HR), low-frequency (LF) band of HRV and LF/HF
+ratio compared to its baseline.
+Conclusions: Results of this study suggest that 20 min of HAFB produce a significant increase in HR and a
+significant reduction in SBP, DBP, and MAP while producing parasympathetic withdrawal.
+Keywords: blood pressure, heart rate variability, hot arm and foot bath, hydrotherapy
+DOI: 10.1515/jcim-2018-0181
+Received: September 25, 2018; Accepted: March 14, 2019
+Background
+Hydrotherapy is one of the important naturopathic treatment modalities that uses water in its various forms
+(water, ice, steam) for health promotion or treatment of various diseases [1]. Hot baths are the common hy-
+drotherapic measures that are employed in treating many conditions such as pain, chronic rheumatism, men-
+strual disorders, bronchial asthma, bronchitis, and obesity [2]. Hot arm and foot bath (HAFB) is one of the
+important hot baths used in various naturopathic hospitals in India. In previous studies, head-out water im-
+mersions in various temperatures were shown to produce various effects [3]. For example, immersion in cold
+water produces a significant increase in heart rate (HR) and blood pressure (BP) [1], while immersion in hot
+water produces a significant increase in HR and a decrease in systolic BP (SBP) and diastolic BP (DBP) [4].
+Cardiovascular functions are controlled by temperature, hormones, and neural factors [5]. HR is influenced
+by physical, emotional and cognitive activities. Heart rate variability (HRV) is defined as a beat-to-beat varia-
+tion in the HR due to physiological changes. HR and HRV are the most sensitive and easily accessible indicators
+of sympathetic and parasympathetic activity and autonomic regulation [6]. There are studies reporting cardio-
+vascular effects of head-out immersion bath [1]. But, though HAFB is widely used, the precise physiological
+responses have not been explored. To the best of our knowledge, there is no known study reporting the effect
+of HAFB on HRV and BP in healthy individuals. Hence, the present study was conducted to evaluate the effect
+of HAFB on HRV and BP in healthy individuals.
+A. Mooventhan is the corresponding author.
+© 2019 Walter de Gruyter GmbH, Berlin/Boston.
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+DE GRUYTER
+Materials and methods
+Subjects
+Sixteen healthy male volunteers’ aged 23.81 ± 5.27 (mean ± standard deviation) years were recruited from a res-
+idential college, South India. Male subjects with the age 18 years and above and who were willing to participate
+in the study were included in the study. Subject with the history of any systemic and mental illness, on medica-
+tion for any diseases, chronic smoking and alcoholism were excluded from the study. The study protocol was
+approved by the institutional ethics committee and informed consent was obtained from all the subjects.
+Design of the study
+This is a single group pre-test and post-test pilot study, in which all the subjects underwent only one session of
+HAFB for the duration of 20 min. Assessments were taken before and after 20 min of intervention.
+Assessment
+Baseline and post intervention assessments of HR, HRV, and BP were taken in the evening between 4:00 and
+6:00 pm while subject was sitting on a comfortable chair [7]. All the subjects were advised to avoid alcohol,
+cigarette smoking, coffee/tea, food, and exercise for at least 30 min prior to their assessments [8]. They were
+also instructed to maintain with their normal breath and avoid limbs [9] and other body movements to avoid
+the movement artifacts [10].
+Heart rate and heart ratevariability
+The electrocardiography was measured before and after the intervention using Zephyr BioHarness (Nether-
+land), the lightweight, wearable monitor while it was attached around the chest. Data were acquired at the
+sampling rate of 250 Hz. In offline, data were manually inspected and the noise free data were included for
+analysis.
+Blood pressure
+SBP and DBP were assessed before and after the intervention using sphygmomanometer.
+Intervention
+All the subjects were asked to immerse their both (right and left) upper limbs (Fingers, hands, wrist joints,
+forearms and elbow joints) and both (right and left) lower limbs (Toes, foot, ankle joints and half of the legs [i. e.
+till the origin of the Achilles tendon]) in the specially prepared tub filled with hot water (38–40 °C) [2] for the
+duration of 20 min. The intervention was in the evening (between 6 pm and 7:30 pm). There were mild variations
+in the amount of water used among the subjects, because the amount of water has been chosen based on the
+following criteria: water which was sufficient enough to immerse the desired parts (i. e. upper limbs [till elbow
+level] and lower limbs [till the origin of the Achilles tendon]). The temperature of the water was checked for
+every 5 min interval using water thermometer. If, reduction in temperature was found below 38 °C, addition of
+hot water was employed (only one time between 10th and 15th min of intervention) to maintain the temperature
+within the desired range.
+Data extraction
+Time domain and frequency domain analysis of the HRV data were carried out at baseline (5 min recording),
+and post-intervention (5 min recording). The data were analyzed with an HRV analysis software (Kubios HRV
+version 2.0) developed by the Biomedical Signal Analysis Group (University of Kuopio, Finland) [11]. The time
+2
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+DE GRUYTER
+Vyas et al.
+domain variables of HRV such as (1) the mean of the intervals between adjacent QRS complexes or the instan-
+taneous HR (RRI), (2) HR, (3) the square root of the mean of the sum of the squares of differences between
+adjacent NN intervals (RMSSD), (4) the number of interval differences of successive NN intervals greater than
+50 ms (NN50), and (5) the proportion derived by dividing NN50 by the total number of NN intervals (pNN50)
+[5] and the frequency domains of HRV such as low-frequency (LF) band (0.04–0.15 Hz), and high-frequency
+(HF) band (0.15–0.4 Hz) and LF/HF ratio were studied [6]. The LF and HF band values were expressed as nor-
+malized units. Assessments such as pulse pressure (PP), mean arterial pressure (MAP) were derived using the
+following formulas. PP was calculated as (SBP − DBP); and MAP as (DBP + ￿PP) [12].
+Statistical analysis
+All the data were checked for normality using Kolmogorov–Smirnov test. Statistical analysis was performed
+using students paired samples-t-test (data that were normally distributed) and Wilcoxon signed ranks test (data
+that were not normally distributed) using Statistical Package for the Social Sciences (SPSS) for Windows, Version
+16.0. Chicago, SPSS Inc. p-value <0.05 was considered as significant.
+Results
+Of 20 subjects recruited to the study, 4 subjects’ data were not proper due to poor signal and hence, did not
+include in the study. Demographic variables of the study group have been given in Table 1. Results of this
+study showed a significant reduction in SBP, DBP, MAP, RRI, NN50, pNN50, HF band of HRV and a significant
+increase in HR, LF band of HRV and LF/HF ratio compared to its baseline Table 2.
+Table 1: Demographic variables of the study group (n=16).
+Variables
+Study Group (n=16)
+Age, Years
+23.81 ± 5.27
+Genders
+16 Males
+Height, cm
+164.06 ± 8.05
+Weight, kg
+57.38 ± 7.75
+Body Mass Index, kg/m2
+21.31 ± 2.49
+Table 2: Baseline and post-test assessments of study group (n=16).
+Variables
+Baseline
+Post
+t/z value
+p value
+SBP, mmHga
+112.75 ± 7.83
+108.88 ± 7.83
+3.467
+0.003
+DBP, mmHgb
+76.38 ± 7.56
+73.63 ± 6.12
+2.571
+0.010
+PP, mmHga
+36.38 ± 10.39
+35.25 ± 7.93
+0.676
+0.509
+MAP, mmHga
+88.50 ± 5.88
+85.38 ± 5.61
+6.334
+<0.001
+RRI, msa
+802.16 ± 113.45
+735.38 ± 116.31
+4.996
+<0.001
+HR, b/minta
+76.91 ± 11.36
+84.57 ± 13.19
+4.443
+<0.001
+RMSSD, msb
+67.94 ± 36.93
+60.88 ± 66.24
+1.758
+0.079
+NN50, counta
+86.69 ± 50.38
+52.69 ± 41.40
+5.210
+<0.001
+pNN50, %a
+23.88 ± 14.44
+13.47 ± 11.05
+4.969
+<0.001
+LF, n.ua
+55.99 ± 17.70
+65.72 ± 17.55
+2.167
+0.047
+HF, n.ua
+43.70 ± 17.60
+34.11 ± 17.53
+2.151
+0.048
+LFHF ratioa
+1.67 ± 1.04
+2.83 ± 2.04
+3.131
+0.007
+All values are in Mean ± Standard Deviation. aPaired samples-t-test; bWilcoxon signed ranks test; SBP, Systolic blood pressure; DBP,
+Diastolic blood pressure; PP, Pulse pressure; MAP, Mean arterial pressure; RRI, the intervals between adjacent QRS complexes or the
+instantaneous heart rate; HR, Heart rate; RMSSD, The square root of the mean of the sum of the squares of differences between adjacent
+NN intervals; NN50, The number of interval differences of successive NN intervals greater than 50 milliseconds; pNN50, Proportion
+derived by dividing NN50 by the total number of NN intervals; LF, Low frequency band of the HRV; HF, High frequency band of the
+HRV; LFHF ratio, Ratio of low frequency to high frequency.
+3
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+Vyas et al.
+DE GRUYTER
+Discussion
+BP is one of the indicators of cardiovascular health. HR and HRV are the indicators of sympathetic and parasym-
+pathetic activity and autonomic regulation. Results of this study showed a significant reduction in SBP, DBP,
+MAP, and a significant increase in HR compared with its baseline. The significant reduction in SBP and DBP in
+this study suggests that 20 min of HAFB might be useful in reducing BP. Since BP is directly related to periph-
+eral resistance [12], this effect could be possibly through increased peripheral circulation due to a reduction in
+peripheral vascular resistance. Because HABF is mentioned to produce dilatation of blood vessels of arms and
+legs [2]. Moreover, in a previous study on thermal therapy, the reduction in BP has reported to be associated
+with the reduction in total peripheral resistance and improvement in peripheral circulation [13]. The reduction
+in the MAP could be possibly through the reduction in SBP and DBP.
+A significant increase in HR in this study could be possibly to increase cardiac output (CO) (HR × Stroke
+volume=CO) [12] in order to prevent the further reduction of the BP due to strong vasodilatory effect of the hot
+application in the periphery (i. e. could be a kind of compensatory mechanism to the reduction in the BP). This
+hypothesis is supported by previous reports like in a review, water immersion to shoulder level at 40 °C was
+reported to produce a considerable increase in cardiac output [1]; and in a study on sauna bathing reduction in
+the BP was reported along with the increase in HR and CO [13]. The results of the present study (i. e. reduction
+in SBP, DBP, and increase in HR) are supported by a previous study on hot water immersion bath [4].
+The time domain variables of HRV and the HF band power of frequency domain have been recognized as
+stronger predictors of vagal modulation [5, 6]. And thus, a significant reduction in these variables such as RRI,
+NN50, pNN50 (Time domain) and HF band power of HRV (Frequency domain) along with significant increase
+in HR (Time domain), LF band power of HRV, and LF/HF ratio (Frequency domain) after HAFB, suggests the
+presence of parasympathetic withdrawal.
+Strengthsof the study
+The first study evaluating effect of HAFB on HRV and BP in healthy individuals. Though the BP was assessed
+using sphygmomanometer, the assessment was performed by the intern who was not in the part of the study.
+Limitations ofthe study
+Study was conducted in the healthy male volunteers, hence limiting the application of its findings to the females
+and pathological conditions. Since, ECG was assessed using a Bio-Harness that was attached around the chest,
+we thought it would be difficult to get the cooperation from the female subjects and thus not included them in
+the study. Since it is a pilot study, we the small sample size was kept small and we did not calculate the sample
+size based on any previous study. Additional assessments, such as stroke volume, cardiac output, baroreceptor
+sensitivity, peripheral vascular resistance would have provided a better understanding of the reduction in SBP
+and DBP. The present study assessed only the immediate effect of HAFB on HRV and BP in one group and did
+not have the control group and also did not assess the long-term effect. Hence, further studies are required (i. e.
+randomized controlled trials) engaging a larger sample size, using advanced techniques in order to evaluate its
+precise physiological effects and underlying mechanisms.
+Conclusion
+Results of this study suggest that 20 min of HAFB produce a significant reduction in both SBP and DBP while
+producing parasympathetic withdrawal. Further studies are required to warrant the findings of this study.
+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.
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+DE GRUYTER
+Vyas et al.
+Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis,
+and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.
+References
+[1] Mooventhan A, Nivethitha L. Scientific evidence based effects of hydrotherapy on various systems of the body. North Am J Med Sci
+2014;6:199–209.
+[2] Kellogg JH. Rational hydrotherapy, 2nd ed. Pune: National Institute of Naturopathy, 2005.
+[3] Srámek P
+, Simecková M, Janský L, Savlíková J, Vybíral S. Human physiological responses to immersion into water of different tempera-
+tures. Eur J Appl Physiol 2000;81:436–42.
+[4] Digiesi V, Cerchiai G, Mannini L, Masi F, Nassi F. Hemorheologic and blood cell changes in humans during partial immersion with a thera-
+peutic method, in 38 °C water. Minerva Med 1986;77:1407–11.
+[5] 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.
+[6] Tyagi A, Cohen M. Yoga and heart rate variability: A comprehensive review of the literature. Int J Yoga 2016;9:97–113.
+[7] Koenig J, Jarczok MN, Warth M, Ellis RJ, Bach C, Hillecke TK, et al. Body mass index is related to autonomic nervous system activity as
+measured by heart rate variability - a replication using short term measurements. J Nutr Health Aging 2014;18:300–2.
+[8] Chen J, Dongfeng G, Jaquish CE, Chen CS, Rao DC, Depei, et al. Association between blood pressure responses to cold pressor test and
+dietary sodium intervention in the Chinese population. Arch Intern Med 2008;168:1740–6.
+[9] Herrera E, Sandoval MC, Camargo DM, Salvini TF. Motor and sensory nerve conduction are affected differently by ice pack, ice massage,
+and cold water immersion. Phys Ther 2010;90:581–91.
+[10] Telles S, Joshi M, Somvanshi P
+. Yoga breathing through a particular nostril is associated with contralateral event-related potential
+changes. Int J Yoga 2012;5:102–7.
+[11] 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.
+[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.
+[13] Iiyama J, Matsushita K, Tanaka N, Kawahira K. Effects of single low-temperature sauna bathing in patients with severe motor and intel-
+lectual disabilities. Int J Biometeorol 2008;52:431–7.
+5
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subfolder_0/Effect of integrated yoga module on personality of home guards in Bengaluru_ A randomized control trial.txt

@@ -0,0 +1,247 @@
+3/1/2017
+Effect of integrated yoga module on personality of home guards in Bengaluru: A randomized control trial
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4910290/
+1/6
+Effect of integrated yoga module on personality of home guards in Bengaluru: A randomized control trial
+B. Amaranath, H.R. Nagendra, and Sudheer Deshpande
+Abstract
+Background
+Home Guards Organization is an independent disciplined and uniformed body of volunteers. All categories of home guards (HGs), who work in
+the field, experience varied emotions and are required to cope with varied situations. Yoga practices may be helpful to master such emotions
+and should lead to improvement in personality.
+Objective
+To study the efficacy of integrated yoga module (IYM) on personality (Gunās) (yogic personality measure) of HGs.
+Methods
+Of 500 HGs who attended introductory lectures, 148 HGs of either gender, who satisfied the inclusion and exclusion criteria and who consented
+to participate in the study were randomly allocated to two groups. The yoga group (YG) practiced an IYM for 1 h daily, 6 days a week for 8
+weeks along with their routine work. The control group (CG) remained on routine work. Personality was assessed before and after 8 weeks
+using the self­administered Vedic Personality Inventory.
+Results
+Baseline scores for all domains for both groups did not differ significantly (P > 0.05, Shapiro Wilk's test). Sattva score in YG significantly
+increased from 39.87 ± 2.02 to 47.14 ± 7.22, where as it decreased significantly from 43.66 ± 4.39 to 37.74 ± 10.26 in CG. Rajas score in YG
+significantly decreased from 29.15 ± 0.98 to 27.46 ± 4.38, where as it increased significantly from 28.60 ± 3.55 to 32.74 ± 5.37 in CG. Tamas
+score in YG significantly decreased from 30.98 ± 1.04 to 25.40 ± 5.11, where as it significantly increased from 27.74 ± 4.43 to 30.51 ± 5.50 in
+CG.
+Conclusions
+Results indicate that IYM can profitably be suggested for HGs as a cost­effective means to help them cope with stressful situations.
+Keywords: Guna, Home guards, Rajas, Sattva, Tamas, Yoga
+1. Introduction
+Security and police personnel played very important roles in controlling law and order in society and protected the country even in ancient days.
+Today, the Home Guards Organization (HGO) shares the above duty with security and police personnel. The HGO is an independent,
+disciplined, and uniformed body of personnel constituted under Karnataka Home Guards (HGs) Act, 1962, under the Karnataka Home
+Department. HGs' services have become indispensable during fairs, festivals, sports, elections, and for daily traffic control.
+Normally, HGs work in stressful situations; hence, facing the realities of life is tough for them. All categories of field working HGs,
+experience varied emotions and have to cope with various tough situations in their day to day duties.
+Yoga has been gaining popularity as a tool for developing both physical and mental faculties and reducing stress. People around the globe
+recognize yoga's efficacy as a tool to develop body and mind during the last century; people in India have been practicing yoga for several
+centuries to promote positive health and well­being [1].
+Yoga pacifies the restless mind and offers relief to the sick [2]. It can also be used to develop physical fitness for which even common folks
+hanker [3]. Many use yoga for developing memory, intelligence, and creativity [4]. With its manifold benefits, yoga is becoming a part of
+school education [5]. Specialists use it to unfold deeper layers of consciousness to attain spiritual perfection [6]. Growing scientific evidence,
+demonstrates that yoga is an important promoter of physical and mental health and a behavior­modifying practice. Several studies have
+demonstrated its beneficial effects on health behavior for many lifestyle­related somatic (body­related) problems such as hypertension [7],
+bronchial asthma [8], diabetes [9], and few psychiatric conditions such as anxiety neurosis [10] and depressive illness [11].
+The philosophy of yoga holds that somatic problems are manifestations of imbalance between the three Gunas (Sattva, Rajas, and Tamas) that
+manifest in the body­mind complex of an individual [12]. Further, the famous scriptural text, the Bhagavad Gita tells that Gunas indicate
+specific behavioral styles. Purity, wisdom, bliss, love of knowledge, spiritual excellence, and other noble and sublime qualities and serenity
+3/1/2017
+Effect of integrated yoga module on personality of home guards in Bengaluru: A randomized control trial
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4910290/
+2/6
+associated with Sattva. Egoism, activity, restlessness, and hankering after mundane things, such as wealth, power, valor, and comforts,
+symbolize Rajas. Tamas relates to qualities such as bias, heedlessness and inertia, perversion in taste, thought, and action [13]. Ill health occurs
+when Rajas or Tamas dominate Sattva and the individual habitually responds to them. Furthermore, after a detailed mind analysis, the Bhagavad
+Gita says that when the set of two Gunas dominate, the person loses mastery over the internal dialog and its speeded­up loops of sentences,
+which show up as upsurges of emotions and impulsive behavior. Humans in perfect health are completely free to respond to Sattva, Rajas, or
+Tamas. Hence, a tool that can grade the set three patterns of behavioral some a sures the degree of positive health [13]. The Vedic Personality
+Inventory (VPI) is a valid and reliable inventory that can measure the three patterns of behavior [14].
+Many studies have been carried out on the role of integrated yoga module (IYM), but this study on personality and coping strategies in HGs is
+completely original.
+2. Methods
+2.1. Participants
+The participants were selected from 500 fields working HGs from Bangalore rural district who attended motivational lectures given by deputed
+instructors. A total of 148 who volunteered to join the study were randomly divided into yoga group (YG) (n = 75) and control group (CG)
+(n = 73) using a random number calculators (internet), random number table was generated [15].
+2.2. Inclusion criteria
+(a) Men or woman, (b) normal healthy field working HGs, and (c) age between 20 and 45years.
+2.3. Exclusion criteria
+(a) Any ailment, (b) consuming alcohol and smoking, and (c) those already practicing yoga.
+2.4. Informed consent
+The Institutional Ethical Committee of S­Vyasa Yoga University approved the study proposal. Informed consent was taken from all participants
+before enrolling them in the study.
+2.5. Study design
+This was a prospective, randomized, single­blind, control study to measure and compare the personality (Gunās) of the HGs allotted to YG and
+CG. Gruha Rakshaka Bhavan (HG administrative office at Bengaluru, Karnataka) was the venue for yoga classes.
+Both groups continued performing routine work such as maintaining law and order, managing traffic and the public in different government
+organizations. Both groups participated in weekly mandatory parades as per HG schedules.
+In addition to normal routine work, the YG also did 1 h of IYM practices, 6 days a week for 8 weeks. Daily attendance was taken for all the
+participants; yoga trained experts taught yoga to YG. The CG only did their normal routine work, but its participants were given the option to
+join yoga classes after study completion.
+2.6. Intervention
+The YG HGs besides doing their normal routine work participated in IYM. The IYM was selected from the integrated set of yoga practices
+used in earlier studies on effects of IYM on positive health [16]. The basis of developing the integrated approach is ancient yoga texts [17] for
+total physical, mental, emotional, social, and spiritual levels developments [18]. Techniques include physical practices (Kriyas and Asanas),
+breathing practices with body movements and Pranayama, meditation, lectures on yoga, and stress management through notional corrections for
+blissful awareness under all circumstances (action in relaxation). Qualified yoga teachers taught IYM [Table 1] for 2 months, 60 min of
+practice daily, 6 day/week.
+Table 1
+Details of the IYM practices.
+2.7. Masking
+3/1/2017
+Effect of integrated yoga module on personality of home guards in Bengaluru: A randomized control trial
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4910290/
+3/6
+The invigilators coded and saved the answered questionnaires response sheets (QRS) for scoring latter. A psychologist not involved in group
+formation or class supervision evaluated the coded QRSs. Another person blind to group membership decoded the QRSs only after noting the
+scores both before and after data was completed.
+2.8. Assessments
+The tests were administered by examiners before and after 8 weeks of IYM in a disturbance free quiet room. VPI developed by Wolf VPI in
+1998 [17] assesses the Vedic concept of the three personality types or Gunās. It is a “psychological construct” to assess three personality
+patterns expounded in the Vedas­the ancient Indian scriptures; hence, the name VPI. It measures levels of the three Gunās viz., Sattva, Rajas,
+and Tamas using acceptable psychometric properties. The original 90 criteria were shortened to 56 in 1999 after a reliability and validity
+analysis [19]. It now contains 15 Sattva, 19 Rajas, and 22 Tamas (total 56) questions.
+The 56 item VPI is adequate for group research and perhaps also for individual assessment. With regards to reliability, each item of the VPI
+contributes positively to the reliability of its subscale and also has a corrected item­total correlation with its subscale >0.50. These statistics
+suggest strong subscales, meaning that the elements of the subscales correlate strongly with each other [14].
+The questionnaire was self­administered with a time of 30 min for answering. A7­point Likert­type scale was chosen as a balance between
+convenience for the participant and researcher, and statistical power; also to minimize the chances of spurious out comes, especially in factor
+analysis. Gunā' scores were obtained by totaling scores of items' responses for each Guna and dividing it by the number of items for that Guna.
+For each subscale, a higher score indicated a greater predominance of that Guna. Minimum and maximum scores for each thus range from 1 to
+7. The VPI has been used extensively during the past 15 years and is accepted as a valid and reliable tool. A variety of studies has shown it to
+be very effective in understanding personality.
+2.9. Data extraction
+The data were extracted as per the instructions in the VPI manual.
+2.10. Statistical analysis
+Data were analyzed using R Studio statistical software (R Foundation for Statistical Computing).
+Based on a previous study [19], the effect size was calculated to be 0.8. With a power of 0.8 and alpha set to 0.05, the minimum sample size
+was found to be 164. This calculation was done using G power [20].
+Data at baseline were assessed for normal distribution using Shapiro–Wilk's test for both the groups. The data were not normally distributed for
+Sattva (P = 0.0001), but it was so distributed for Rajas (P = 0.0001) and Tamas (P = 0.0001).
+Independent sample t­test was performed to assess the significance of differences between the groups and paired samples t­test for within
+group changes.
+3. Results
+3.1. Demographic data
+The 75 participants in YG and 73 participants in CG had age ranges between 20 and 50 years.
+Between 20 and 30 years, 36 in YG and 41 in CG; between 30 and 40 years, 28 in YG and 20 in CG; above 40 years, 11 in YG and 12 in CG.
+In gender, 36 in YG were female and 31 in CG; 39 in YG were male and 42 in CG. In marital status, 49 were married in both YG and CG; 26
+in YG were unmarried, and 24 in CG. Participants' educational qualifications were upto SSLC, SSLC to PUC, and graduates. Forty­nine in
+YG and 37 in CG are SSLC, 20 in YG and 24 in CG are PUC, and 6 in YG and 12 in CG are degree.
+3.2. Mean difference after integrated yoga module
+Within group difference was significant for all three Guna in both the groups.
+When data analysis was analyzed for various subsets (as post­hoc multiple comparisons) with gender, marital status, educational qualification,
+and age all categories, it showed similar trends as observed collectively for respective Guna in both the groups.
+3/1/2017
+Effect of integrated yoga module on personality of home guards in Bengaluru: A randomized control trial
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4910290/
+4/6
+4. Discussion
+This is a randomized controlled prospective study of normal HGs assessing the efficacy of an IYM for 8 weeks on 148 normal adults to change
+their personality (Guna) as assessed by VPI. Results showed that there was an increase in Sattva level (P < 0.001) in YG and decrease in CG.
+There were significant decreases in Rajas and Tamas in YG and increases in CG. When data analysis was sub divided by gender, educational
+qualification, and age all categories showed similar trends as expected according to the yogic literature.
+A study by Das [21] conducted using the Mahamantra in a three­armed, randomized prospective, control study on 62 volunteers showed that the
+Mahamantra group increased Sattva and decreased Tamas with no significant change in Rajas scores on��the VPI questionnaire after chanting of
+Mahamantra, 20 min daily for 4 weeks. However, in addition to increase in Sattva and decrease in Tamas, the present study observed a
+significant decrease in Rajas not observed after Mahamantra. This difference could be because of the addition of Asanas and Pranayama to the
+meditation technique used in this present study as compared to the Mahamantra.
+The behavior of a human being is an expression of a combination of different Gunās. Tamas (meaning darkness) is the grossest aspect of our
+personality characterized by excessive sleep, laziness, depression, procrastination, a feeling of helplessness, impulsivity, anger, and arrogance
+(packed up with vital energy). When we reduce Tamas through mastery over the mind, we become dynamic, sensitive, and sharp to move
+toward Rajas (the shining one) characterized by intense activity, ambitiousness, competitiveness, high sense of self­importance, desire for sense
+gratification, little interest in spiritual elevation, dissatisfaction with one's position, envy of others, and a materialistic cleverness [22]. With
+further growth and mastery, one moves into Sattva dominance which includes the qualities of truthfulness, stability, discipline, sense of control,
+sharp intelligence, preference for vegetarianism, truthfulness, gravity, dutifulness, detachment, respect for superiors and staunch determination,
+and stability in the face of adversity and also conscious action. Thus, we can see that although both Rajas and Tamas have both positive and
+negative qualities; they are the manifestation of a violent state of mind in which a person lacks mastery over personality or the ability to
+improve components of general health. The IYM increased Sattva. Hence, IYM which is more related to traditional practices in India and is
+cost effective can be recommended for its additional benefits of promoting personality development.
+Another study conducted by Deshpande et al. [19] compared the effects yoga and physical exercise (PE) on Gunas and general health. Yoga
+was observed to give better effects on the Sattva than PE, with a larger effective size, the main difference seemed to be in the effect on Rajo
+guna. Reduction in this Guna was significantly higher in PE group than Y group. Thus, it was concluded that both physical activity (to reduce
+Rajas and Tamas) and yoga (to improve Sattva) may be recommended for harmonious development of personality. However, the present study
+observed that giving IYM decreased Rajas significantly in YG as compared to CG.
+The yogic techniques such as breathing practices, Asanas, pranayama, meditation, and lecture have helped the HGs to increase their level of
+confidence, and hence it has become easy for them to overcome Tamas and increase Sattva.
+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, that means relaxation in action and efficiency in outcome.
+Further studies can be done with various populations such as police, military, and other security­related agencies for increasing the level of
+confidence with yoga intervention.
+The strength of our design is IYM for HGs. The HGs work in very stressful situations during elections, when managing traffic and in other
+crowded places. It is essential in the present day circumstances that they can manage their personalities (Gunās) and cope with stressful
+situations. Most of them succumb to smoking and drinking to overcome their stress. Hence, training them to calm their minds is an immediate
+need and to enable them to increase Sattva and decrease Rajas and Tamas. An interesting observation was that HGs in YG who were graduates
+showed increase in Rajas, where as all others in YG showed reductions. This may possibly be because only six people were in that category,
+and should be further studied with a larger number of HGs.
+This study demonstrates the utility of the VPI as a tool for measuring the subtle dimensions of Gunās described in traditional texts of yoga as a
+measure of steps of individual growth.
+Limitation of this study: we have taken only subjective parameter such as questionnaire, objective parameter such as blood pressure and electro
+cardiogram would have given more information.
+5. Conclusion
+The results have shown that IYM has improved the personality of HGs by increasing their Sattva Guna and reducing their Rajas and Tamas.
+Further, yoga is cost­effective and recommended to HGs. Hence, this study suggests a solution to train HGs to calm their mind and help them to
+increase their Sattva Guna. By this, their service to public will improve and in turn the image of the department will also go up.
+Source of support
+Nil.
+3/1/2017
+Effect of integrated yoga module on personality of home guards in Bengaluru: A randomized control trial
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4910290/
+5/6
+Conflict of interest
+No.
+Acknowledgments
+Our grateful acknowledgments for all those who helped us in this project. We are grateful to S­VYASA for supporting this study. We thank the
+volunteers, teachers, and supporters who participated in this study.
+Footnotes
+Peer review under responsibility of Transdisciplinary University, Bangalore.
+Article information
+J Ayurveda Integr Med. 2016 Mar; 7(1): 44–47.
+Published online 2016 May 24. doi:  10.1016/j.jaim.2015.11.002
+PMCID: PMC4910290
+B. Amaranath,  H.R. Nagendra, and Sudheer Deshpande
+Yoga & Life Science, S-VYASA Yoga University, Bengaluru, Karnataka, India
+B. Amaranath: [email protected]
+Corresponding author. No. 33/04, First Floor, Gangappa Complex, DVG Road, Basavangudi, Bengaluru 560004, Karnataka, India.No. 33/04First Floor, Gangappa
+Complex, DVG Road, BasavangudiBengaluruKarnataka560004India ; Email: [email protected]
+Received 2015 Jul 28; Revised 2015 Nov 19; Accepted 2015 Nov 24.
+Copyright © 2016 Transdisciplinary University, Bangalore and World Ayurveda Foundation. Publishing Services by Elsevier B.V.
+This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
+Articles from Journal of Ayurveda and Integrative Medicine are provided here courtesy of Elsevier
+References
+1. Ross A., Thomas S. The health benefits of yoga and exercise: a review of comparison studies. J Altern Complement Med. 2010;16:3–12. [PubMed]
+2. Ganpat T.S., Nagendra H.R. Integrated yoga therapy for improving mental health in managers. Ind Psychiatry J. 2011;20:45–48. [PubMed]
+3. Kejriwal A., Krishnana V
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+10. Brown R.P., Gerbarg P.L. Sudarshan Kriya yogic breathing in the treatment of stress, anxiety, and depression: part I­neurophysiologic model. J Altern
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+3/1/2017
+Effect of integrated yoga module on personality of home guards in Bengaluru: A randomized control trial
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4910290/
+6/6
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subfolder_0/Effect of integrated yoga therapy on pain morning stiffness and.txt

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+International Journal of Yoga  Vol. 5  Jan-Jun-2012
+28
+women >60 years.[2] In India OA is the second most common 
+rheumatologic problem and has a prevalence rate of 22 to 
+39.[3] Clinically it presents as pain in and around the joint, 
+joint stiffness usually after rest, crepitation and restricted 
+joint movements associated with muscle weakness.[4] 
+The strongest risk factors for OA are age[5] and genetics.[6] 
+Other risk factors include female gender, obesity, cigarette 
+smoking, intra‑articular fractures, chondrocalcinosis, 
+crystals in joint fluid/cartilage, prolonged immobilization, 
+joint hypermobility, instability, peripheral neuropathy, 
+prolonged occupational or sports stress.[7]
+Chrousos and Gold observed that the development of 
+age‑related diseases occurs at different rates in different 
+INTRODUCTION
+Patients with osteoarthritis (OA) of knee are characterized 
+primarily by articular cartilage degeneration and a 
+secondary peri‑articular bone response.[1] Worldwide, 
+the prevalence rate of OA is 9.6% for men and 18% for 
+ 
+Aim: To study the effect of integrated yoga on pain, morning stiffness and anxiety in osteoarthritis of knees.
+Materials and Methods: Two hundred and fifty participants with OA knees (35–80 years) were randomly assigned to yoga 
+or control group. Both groups had transcutaneous electrical stimulation and ultrasound treatment followed by intervention 
+(40 min) for two weeks with follow up for three months. The integrated yoga consisted of yogic loosening and strengthening 
+practices, asanas, relaxation, pranayama and meditation. The control group had physiotherapy exercises. Assessments were 
+done on 15th (post 1) and 90th day (post 2).
+Results: Resting pain (numerical rating scale) reduced better (P<0.001, Mann–Whitney U test) in yoga group (post 1=33.6% 
+and post 2=71.8%) than control group (post 1=13.4% and post 2=37.5%). Morning stiffness decreased more (P<0.001) in 
+yoga (post 1=68.6% and post 2=98.1%) than control group (post 1=38.6% and post 2=71.6%). State anxiety (STAI‑1) reduced 
+(P<0.001) by 35.5% (post 1) and 58.4% (post 2) in the yoga group and 15.6% (post 1) and 38.8% (post 2) in the control group; 
+trait anxiety (STAI 2) reduced (P<0.001) better (post 1=34.6% and post 2=57.10%) in yoga than control group (post 1=14.12% 
+and post 2=34.73%). Systolic blood pressure reduced (P<0.001) better in yoga group (post 1=−7.93% and post 2=−15.7%) 
+than the control group (post 1=−1.8% and post 2=−3.8%). Diastolic blood pressure reduced (P<0.001) better in yoga group 
+(post 1=−7.6% and post 2=−16.4%) than the control group (post 1=−2.1% and post 2=−5.0%). Pulse rate reduced (P<0.001) 
+better in yoga group (post 1=−8.41% and post 2=−12.4%) than the control group (post 1=−5.1% and post 2=−7.1%).
+Conclusion: Integrated approach of yoga therapy is better than physiotherapy exercises as an adjunct to transcutaneous 
+electrical stimulation and ultrasound treatment in reducing pain, morning stiffness, state and trait anxiety, blood pressure and 
+pulse rate in patients with OA knees.
+Key words: Anxiety; osteoarthritis; pain; stiffness; yoga.
+ABSTRACT
+Effect of integrated yoga therapy on pain, morning stiffness 
+and anxiety in osteoarthritis of the knee joint: A randomized 
+control study
+John Ebnezar, Raghuram Nagarathna1, Bali Yogitha2, Hongasandra Ramarao Nagendra3
+Department of Orthopedics, Ebnezar Orthopaedic Centre, Parimala Speciality Hospital, Bangalore, 1Division of Yoga and Life‑Sciences, Swami 
+Vivekananda Yoga Research Foundation (SVYASA), 2Department of Orthopedics, Ayurveda Surgeon and Yoga Therapist, Ebnezer Orthopaedic 
+Centre, Parimala Speciality Hospital, Bangalore, 3Vice Chancellor, Swami Vivekananda Yoga Anusandhana Samastana (SVYASA), Bangalore, India
+Address for correspondence: Dr. Raghuram Nagarathna, 
+Division of Yoga and Life‑Sciences, Swami Vivekananda Yoga Research Foundation (SVYASA), Bengaluru, India. 
+E‑mail: [email protected]
+Original Article
+Access this article online
+Website: 
+www.ijoy.org.in
+Quick Response Code
+DOI: 
+10.4103/0973-6131.91708
+29
+International Journal of Yoga  Vol. 5  Jan-Jun-2012
+Ebnezar, et al.: Integrated yoga therapy for osteoarthritis of knees
+individuals and psychological distress appears to be an 
+important factor promoting earlier onset of age‑related 
+diseases.[8] Aging being a strong risk factor for OA, psycho 
+emotional stresses would also have a contributory role 
+in initiation and aggravation of degenerative changes of 
+OA. It has been suggested that the presence of depressive 
+symptoms predicts future musculoskeletal disorders but 
+not vice versa.[9] Linton S.J reviewed the psychological risk 
+factors in back and neck pain which indicated a clear link 
+between psychological variables with neck and back pain. 
+Stress, distress or anxiety as well as mood and emotions, 
+cognitive dysfunction and pain behavior were found to be 
+significant factors.[10]
+Relieving pain and stiffness and improving physical 
+function are the important goals of present day therapy 
+for OA.[11] Non‑opioid analgesics such as acetaminophen 
+and non‑steroidal anti‑inflammatory drugs (NSAIDs), 
+including cyclo‑oxygenase II inhibitors have been the 
+mainstay of drug treatment.[12] They reduce both pain 
+and inflammation quite effectively, but their long‑term 
+use is associated with increased risk for gastrointestinal 
+bleeding,[13] hypertension[14] congestive heart failure,[15] renal 
+insufficiency and other adverse effects.[16] Before deciding 
+on specific non‑pharmacologic and pharmacologic options, 
+it is important to understand the degree of the patient’s 
+symptoms, concerns, disability, and what the arthritis means 
+to him or her.[17] Emotional responses are a component of 
+any pain and hence the first step in osteoarthritis pain 
+management is to respect pain, treat it intensively and 
+address the psyche. Inadequately treated pain can lead 
+to other serious co‑morbidities, including depression, 
+sleep disturbances, anxiety, fatigue, impaired ambulation, 
+decreased socialization and poor quality of life.[18]
+Yoga is an ancient Indian science and way of life which 
+talks about the origin of diseases.[19] The texts describe 
+the mechanism of how the suppressed emotions (called 
+adhis) percolate into the physical body manifesting as 
+diseases (adhija vyahdis). These texts go on to describe 
+the conceptual basis for reversibility of mind body disease 
+(prasava‑pratiprasava model) and offer the necessary 
+principles to design specific postures, breathing and 
+meditation techniques for different diseases.[20] Hence, 
+yoga is fast advancing as an effective therapeutic tool in 
+physical, psychological and psychosomatic disorders.
+Several studies point to the psychological benefits of 
+yoga during health and disease. In a study on healthy 
+adults, Vempati et al. showed that the yoga‑based guided 
+relaxation can reduce the sympathetic activity as measured 
+by autonomic parameters, oxygen consumption and 
+breath volume.[21] Medical and pre‑medical students 
+showed lesser anxiety and stress during an examination 
+period after eight weeks of meditation.[22] The relaxation 
+component of yoga has shown significant reduction in 
+heart rate and blood pressure in different conditions.[23] 
+Transcendental meditation (TM) was compared to muscle 
+relaxation in its effectiveness in controlling stress with 
+significantly better reduction in blood pressure in the TM 
+group.[24] Yogitha et al. showed reduction in blood pressure, 
+pulse rate and state anxiety levels in patients with common 
+neck pain after integrated yoga.[25]
+Yoga therapy has shown significant reduction in pain, 
+functional disability with improved strength, balance 
+and gait, when used as an adjunct in the management of 
+rheumatoid arthritis,[26] hand OA[27] and OA knees.[28,29] 
+Although we know that the psychological components 
+such as depression and anxiety are important aspects to 
+be addressed in pain management and yoga has shown 
+its contributory role, there are no yoga studies that have 
+looked at the relationship between anxiety and pain in 
+patients with OA knees. Hence the present study was 
+planned.
+MATERIALS AND METHODS
+Patients with OA knees from the outpatient department 
+of Ebnezar Orthopedic Center, Bengaluru were recruited 
+for the study. A sample size of 250 was obtained on G 
+power software by fixing the alpha at 0.05 powered at 
+0.8 and an effect size of 0.38 considering the mean and 
+SD of an earlier study.[30] Two hundred and fifty patients, 
+76 males and 174 females in the age group of 35 to 80 years 
+ 
+(yoga −59.56 ± 9.54) and (control −59.42 ± 10.66) 
+with OA knees(one or both joints) satisfying the ACR 
+Guidelines[31] for diagnosis were included. The inclusion 
+criteria were (i) persistent pain for three months prior to 
+recruitment, (ii) moderate to severe pain on walking, (iii) 
+Kellegren and Lawrence[32] radiological grading of II to IV 
+in X‑rays taken within six months prior to entry, and (iv) 
+those fully ambulant, literate and willing to participate in 
+the study. Those with (i) grade I changes in X‑ray (ii) acute 
+knee pain, (iii) secondary osteoarthritis due to rheumatoid 
+arthritis, gout, septic arthritis, tuberculosis, tumor, trauma 
+or hemophilia were excluded. The study was approved by 
+the institutional review board (IRB) and ethical committee 
+of SVAYSA university. Signed informed consent was 
+obtained from all the participants.
+Design
+This was a prospective randomized parallel active 
+control study on patients with OA knees in the age range 
+of 35 to 80  years. After the initial screening, patients 
+who fulfilled the entry criteria were assigned to either 
+yoga or control group. A computer generated random 
+number table (www.randomizer.org) was used for 
+randomization. Numbered envelopes were used to conceal 
+the sequence until the intervention was assigned. Both 
+International Journal of Yoga  Vol. 5  Jan-Jun-2012
+30
+Ebnezar, et al.: Integrated yoga therapy for osteoarthritis of knees
+groups were given the conventional physiotherapy using 
+transcutaneous electrical stimulation and ultrasound 
+followed by supervised practices at the center for 40 min 
+daily (6 days/week) for two weeks. The study group was 
+taught integrated yoga and the control group the non‑yogic 
+physiotherapy exercises by certified therapists. After this, 
+they were asked to practice only the supervised practices 
+of 40  min daily at home for the next three months. 
+Compliance was supervised by telephone calls once in 
+three days and a weekly review class at the center. All 
+patients were asked to tick the practices daily after the 
+home practice in the diary provided for the purpose; at 
+every visit their clinical progress and therapy received on 
+the day were documented. All assessments were carried 
+out on 1st, 15th and 90th days.
+Blinding and masking
+As this was an interventional study, double blinding was 
+not possible. The answer sheets of the questionnaires 
+were coded and analyzed only after the study was 
+completed. The statistician who did the randomization 
+and data analysis and the researcher who carried out the 
+assessments were blinded to the treatment status of the 
+subjects.
+Intervention for yoga group
+The daily routine practiced at the center in the yoga group 
+included 40 min of integrated yoga therapy practice after 
+20 min of physiotherapy with transcutaneous electrical 
+stimulation and ultrasound for 15 days. The integrated 
+yoga therapy practice included shithilikarana vyayamas 
+(loosening practices), sakti vikasaka (strengthening 
+practices) followed by yogasanas and relaxation techniques 
+with devotional songs. Later patient was advised to 
+continue the integrated yoga therapy practice of 40 min 
+at home for the next three months.
+The concepts used to develop a specific module of an 
+integrated approach to yoga therapy (IAYT) for knee 
+pain were taken from the traditional yoga scriptures 
+(Patanjali Yoga Sutras, Yoga vasishtha and Upanishads) 
+that highlight a holistic life style for positive health at 
+physical, mental, emotional and intellectual levels.[33] 
+Yoga is defined as mastery over the modifications of mind 
+(Chitta Vritti Nirodhah‑definition of yoga by Patanjali). It 
+helps to remove the unnecessary surges of neuromuscular 
+activation resulting from heightened stress responses that 
+may contribute to aging[34] The daily routine included a 1 h 
+practice as follows [Table 1]:
+•	 Yogic sukshma vyayamas (loosening and strengthening 
+practices): These are safe rhythmic repetitive stretching 
+movements synchronized with breathing. These 
+practices mobilize the joints and strengthen the 
+periarticular muscles.
+Table  1: Yoga module for osteoarthritis of knees
+Conventional physiotherapy was carried out 
+only at the center for 15 days which included
+•  
+TENS‑ 10 min
+•  
+Ultrasound‑ 10 min
+20.0 min
+Integrated yoga practice‑ This was made 
+to practice by the patient at the center for 
+40 min for 15 days after the conventional 
+physiotherapy and later advised to continue 
+at home for the next three months. This 
+included the following practices:
+40.0 min
+Shithilikarana vyayama (loosening exercises):
+10.0 min
+1.  
+Foot and ankle loosening practices
+•  
+Passive rotation of each toe 
+(clockwise and anticlockwise)
+10 rounds
+1.0 min
+•  
+Toe bending
+10 rounds
+0.5 min
+•  
+Passive rotation of ankle  
+(clockwise and anticlockwise) 
+10 rounds
+0.5 min
+•  
+Ankle bending
+10 rounds
+0.5 min
+•  
+Ankle rotation  
+(clockwise and anti‑clockwise) 
+10 rounds
+0.5 min
+2.  
+Knee loosening practices
+•  
+Bending the knee in prone position
+1.0 min
+•  
+Knee bending – both sides
+10 rounds
+0.5 min
+•  
+Knee rotation – both sides
+10 rounds
+0.5 min
+•  
+Passive patella rotation
+0.5 min
+3.  
+Hip and waist loosening practices
+•  
+Half butterfly
+10 rounds
+0.5 min
+•  
+Full butterfly 
+10 rounds
+0.5 min
+•  
+Hip rotations  
+(both internal and external)
+10 rounds
+0.5 min
+4.  
+Upper limbs loosening practices
+•  
+Finger loosening 
+10 rounds
+0.5 min
+•  
+Wrist loosening
+10 rounds
+0.5 min
+•  
+Wrist rotation  
+(clockwise and anticlockwise)
+10 rounds
+0.5 min
+5.  
+Neck loosening practices
+•  
+Forward and backward bending
+10 rounds
+1.0 min
+•  
+Neck rotation  
+(both clockwise and anticlockwise)
+10 rounds
+0.5 min
+6.  
+Instant relaxation technique‑ is a 17 step 
+practice of tightening the entire body 
+from toes to the head and letting it go.
+1.0 min
+7.  
+Strengthening exercises (sakti vikaasaka 
+suksma vyayama)
+5.0 min
+•  
+Back exercises (kati sakti vikaasaka)
+5 rounds
+0.5 min
+•  
+Thigh exercises (jangha sakti vikaasaka)
+5 rounds
+0.5 min
+•  
+Straight leg raise breathing‑ single 
+and both legs 
+10 rounds
+1.5 min
+•  
+Knee cap tightening – single and 
+both legs
+10 rounds
+2.0 min
+•  
+Ankle tightening exercises 
+5 rounds
+0.5 min
+8.  
+Quick relaxation technique (QRT) consists 
+of 3 phase of observing the abdominal 
+movements, synchronizing it with 
+breathing and chanting of ‘U kara.
+3.0 min
+9.  
+Yogasanas
+10.0 min
+A. Standing asanas
+•  
+Tadasana 
+•  
+Ardha Kati Chakrasana 
+•  
+Ardha Chakrasana 
+•  
+Prasarita padahastasana 
+B. Lying Asanas
+•  
+Bhujangasana
+•  
+Shalabasana
+•  
+Dhanurasana
+contd...
+31
+International Journal of Yoga  Vol. 5  Jan-Jun-2012
+Ebnezar, et al.: Integrated yoga therapy for osteoarthritis of knees
+•	 Relaxation techniques: Three types of guided relaxation 
+techniques were interspersed between the physical 
+practices of sukshmavyayamas and asanas.
+•	 Asanas (physical postures): Asanas are featured by 
+effortless maintenance in the final posture by internal 
+awareness. We selected asanas in standing and supine 
+position that would relax and strengthen the knee joints.
+•	 Pranayama: The practice of voluntary regulated 
+breathing while the mind is directed to the flow of 
+breath is called Pranayama. These practices promote 
+autonomic balance through mastery over the mind.[35]
+•	 Meditation: Patanjali defines meditation (dhyana) as 
+effortless flow of a single thought in the mind without 
+distractions (pratyaya ekataanata dhyanam). This has 
+been shown to offer physiological benefits through 
+alertful rest to the mind body complex.[36]
+•	 Lectures and Counseling: Yogic concepts of health and 
+disease, yama, niyama, bhakti yoga, Jnana yoga and 
+karma yoga were presented in the theory classes. These 
+sessions were aimed at understanding the need for life 
+style change, weight management and prevent early 
+aging by yogic self management of psychosocial stresses.
+Intervention for control group
+The daily routine practiced at the center in the control 
+group included 40 min of a therapeutic exercise practice 
+after 20  min of physiotherapy with transcutaneous 
+electrical stimulation and ultrasound for 15 days. The 
+therapeutic physical exercises (40 min) included loosening 
+and strengthening practices for the hands, elbows, arms 
+and shoulders followed by a brief period of rest and specific 
+knee practices followed by supine rest with light music. 
+Later patient was advised to continue the therapeutic 
+exercise practice of 40 min at home for the next three 
+months [Table 2].
+Measurements
+a.	 Numerical pain rating scale (NRS): Pain at rest was 
+recorded by the patient on numerical pain rating scale 
+prepared for the purpose by drawing a 10 cm line in 
+the center of a white sheet with ‘0’ as nil pain and ‘10’ 
+as worst possible pain.[37‑39] Separate sheets were used 
+at each assessment time.
+10. 
+Deep relaxation technique (DRT) is 
+a guided relaxation technique with 
+relaxation from toes to the head, 
+feeling of letting go, chanting OM and 
+feeling of limitless expansion through 
+visualization.
+5.0 min
+11. 
+Nadi Shudi Pranayama (With Nasik 
+Mudra) ‑ Nadishuddhi Pranayama is 
+a slow rhythmic technique of alternate 
+nostril breathing involving the phases of 
+inhalation and exhalation using nasika 
+mudra.
+3.0 min
+12. 
+OM meditation is done seated in any 
+comfortable meditative posture repeating 
+the syllable OM mentally.
+2.0 min
+Table  1: contd/-
+Table  2: Control module for osteoarthritis of knees
+Conventional physiotherapy was carried out 
+only at the center for 15 days which included
+•  
+TENS‑ 10 min
+•  
+Ultrasound‑ 10 min
+20.0 min
+Therapeutic practices‑ This was made to 
+practice by the patient at the center for 
+40 min for 15 days after the conventional 
+physiotherapy and later advised to continue 
+at the home for next three months. This 
+included the following practices:
+40.0 min
+Loosening exercises 
+10 min
+1.  Foot and ankle 
+•  
+Passive rotation of the toes  
+(each toe clockwise and anticlockwise) 
+10 rounds
+0.5 min
+•  
+Passive rotation of the ankle  
+(both clockwise and anticlockwise)
+10 rounds
+0.5 min
+•  
+Toe bending
+10 rounds
+0.5 min
+•  
+Ankle bending
+10 rounds
+0.5 min
+•  
+Ankle rotation (clockwise and 
+anti‑clockwise both sides)
+10 rounds
+0.5 min
+2.  Knee
+•  
+Knee bending – both sides	
+10 rounds
+0.5 min
+•  
+Knee rotation – both sides	
+10 rounds
+0.5 min
+3.  Hip and waist loosening practices
+•  
+Half butterfly
+10 rounds
+0.6 min
+•  
+Full butterfly 
+10 rounds
+0.6 min
+•  
+Hip rotations  
+(both internal and external)
+10 rounds
+0.5 min
+4.  Upper limbs loosening practices
+•  
+Finger loosening
+10 rounds
+0.6 min
+•  
+Wrist loosening
+10 rounds
+0.6 min
+•  
+Wrist rotation  
+(both clockwise and anticlockwise)
+10 rounds
+0.5 min
+•  
+Elbow loosening
+5 rounds
+0.5 min
+•  
+Arm loosening‑forward and backward 
+movements
+10 rounds
+0.5 min
+5.  Neck loosening practices
+•  
+Forward and backward bending
+10 rounds
+0.5 min
+•  
+Sideward bending
+10 rounds
+0.5 min
+•  
+Sideward tilting
+5 rounds
+0.5 min
+•  
+Neck rotation  
+(both clockwise and anticlockwise)
+5 rounds
+0.5 min
+6.  Quick pause 
+2.0 min
+7.  Strengthening exercises
+5.0 min
+•  
+Palm exercises
+5 rounds
+0.5 min
+•  
+Elbow exercises
+10 rounds
+0.5 min
+•  
+Arm exercises
+5 rounds
+0.5 min
+•  
+Back exercises 
+5 rounds
+0.5 min
+•  
+Thigh exercises 
+5 rounds
+0.5 min
+•  
+Calf exercises 
+5 rounds
+0.5 min
+8.  Rest
+3 min
+9.  Specific knee practices
+15.0 min
+•  
+Flexion and extension with and 
+without resistance 
+3 min
+•  
+Knee cap tightening‑ self and against 
+small pillow 
+3 min
+•  
+Straight leg raising – single and both 
+– 30/60/90 degrees 
+5 min
+•  
+Cycling 
+4 min
+10. Supine rest 
+5.0 min
+International Journal of Yoga  Vol. 5  Jan-Jun-2012
+32
+Ebnezar, et al.: Integrated yoga therapy for osteoarthritis of knees
+b.	 Early morning stiffness in minutes as reported by the 
+patients during clinical interview was documented.
+c.	 State and trait anxiety inventory (STAI‑1 and STAI‑2): 
+STAI developed by Spielberger et al.,[40] consisting of 
+2 forms each comprising of 20 items rated on a four 
+point scale (0‑3) was used for assessing the anxiety 
+levels. Form STAI‑1 assesses the state anxiety which 
+is defined as ‘a transitory emotional state that varies 
+in intensity, fluctuates over time and characterized by 
+feelings of tension and apprehension and by heightened 
+activity of the autonomic nervous system’. It evaluates 
+how respondents feel ‘right now’ at this moment. Form 
+STAI‑2 evaluates trait anxiety, which is defined as ‘a 
+relatively stable individual predisposition to respond 
+to situations perceived as threatening’. It assesses how 
+the respondents feel most of the time. The scores for 
+each of the forms range from 20 to 80, with high scores 
+indicating presence of high levels of anxiety. We used 
+both Y1 and Y2 in our study.
+	
+Quek et al.,[41] have reported a high degree of internal 
+consistency for STAI with Cronbach’s alpha of 0.38 
+to 0.89 for each of the 40 items and 0.86 for the total 
+scores. test‑retest correlation coefficients for the 
+40  items score were highly significant. Intra‑class 
+correlation coefficient was also high (ICC=0.39 to 0.89).
+d.	 Blood pressure (BP): BP was measured using a mercury 
+sphygmomanometer (Diamond Company) on day one, 
+15th day and on 90th day.
+e.	 Pulse rate (PR) ‑ Pulse rate was counted manually for 
+1 min on first, 15th day and on 90th days.
+It was ensured that the BP and pulse were recorded after 
+completing the intervention in both groups at all points 
+of time.
+Statistical methods
+The data were analyzed using SPSS Version 16. The base 
+line values of the two groups were checked for normal 
+distribution by using Shapiro‑Wilk’s test. The baseline 
+values were not normally distributed. Hence Wilcoxon’s 
+signed ranks test and Mann –Whitney U test were used 
+to compare means within and between the two groups 
+respectively. Spearman’s Rho test was used to observe the 
+correlations between all variables at all three points in time 
+(pre, 15th and 90th days). Figure 1 shows the trial profile. 
+7 patients dropped out in the yoga group and 8 in the 
+control group. Table 3 denotes the demographic data. There 
+was no significant difference between groups at baseline on 
+all variables (P>0.05, Mann–Whitney test for pre values).
+RESULTS
+Table 4 shows the results within yoga group and between 
+the groups. Table 5 shows the results within control group 
+and between the groups after 15th and 90th days.
+Resting pain
+Mann–Whitney U test showed a significant difference 
+between and within groups in resting NRS (Wilcoxon’s, 
+P<0.001) after the intervention on 15th and 90th day with 
+higher effect sizes in yoga than control group.
+Early morning stiffness
+There was a significant difference in early morning 
+stiffness within groups (Wilcoxon’s, P<0.001) and between 
+groups (Mann–Whitney, P<0.001) after the intervention at 
+223 Self Referred 
+73 Referred by the 
+Physicians
+Number screened 
+296
+Number satisfied selection 
+criteria (Randomly assigned) 
+250
+Yoga group 
+125
+Control group 
+Final Analysis on 118 
+(YOGA GROUP) 
+Final Analysis on 117 
+(CONTROL GROUP) 
+Drop outs
+Yoga group 
+(7) 
+2-got relief on the 
+10
+th day and 
+discontinued the 
+treatment 
+3-Discontinued 
+due to 
+emergencies at 
+home 
+2-Office calls 
+Drop outs
+Control
+group
+(8)
+3-
+Respiratory
+tract 
+infections 
+2-Had
+relief and 
+discontinued
+1-Due to 
+emergencies
+at home 
+2-Pain
+became 
+severe 
+and could 
+not 
+continue the
+treatment 
+hence
+advisedbe
+125
+Figure 1: Trial profile
+Table  3: Demographic data
+Characteristics
+Yoga (n=125)
+Control (n=125)
+Age
+(Mean±SD)
+59.56 ± 9.54
+59.42 ± 10.66
+Sex
+Males
+Females
+37
+88
+39
+86
+Occupation
+Skilled workers
+Semi‑skilled workers
+Unskilled workers
+Others
+28
+34
+3
+60
+32
+31
+5
+57
+Associated diseases
+Diabetes
+Hypertension
+Overweight/obesity
+Osteoporosis
+Others
+22
+30
+98
+78
+26
+16
+19
+73
+67
+30
+33
+International Journal of Yoga  Vol. 5  Jan-Jun-2012
+Ebnezar, et al.: Integrated yoga therapy for osteoarthritis of knees
+both points in time with higher effect sizes in yoga than 
+control group.
+State and trait anxiety scores
+There was better reduction in both state and trait 
+anxiety scores (Wilcoxon’s, P<0.001) and between 
+groups (Mann–Whitney, P<0.001) in the yoga 
+group with significant differences within and 
+between yoga and control groups at two weeks and three 
+months.
+Systolic and diastolic blood pressure
+There was significant difference within (Wilcoxon’s, 
+P<0.001) and between groups (Mann–Whitney, P<0.001) 
+in the systolic and diastolic blood pressure in the two 
+groups with better reduction in yoga group.
+Pulse rate
+There was significant reduction in both groups 
+with (Wilcoxon’s, P<0.001) and between groups 
+ 
+Table  4: Results within yoga group
+VB
+Pre and post
+Mean ± SD
+95% CI
+ES
+% change
+LB
+UB
+Resting pain
+Pre
+6.89 ± 0.69
+8.15
+8.48
+3.74
+Po1
+4.53 ± 0.92 (*+)
+4.74
+5.13
+5.37
+−33.6
+Po2
+1.94 ± 1.11 (*+)
+1.81
+2.24
+4.20
+−71.8
+Early morning stiffness
+Pre
+16.47 ± 5.22
+15.51
+17.42
+2.41
+Po1
+5.17 ± 3.97 (*+)
+4.44
+5.89
+3.13
+−68.6
+Po2
+0.31 ± 1.27 (*+)
+0.07
+0.54
+1.35
+−98.1
+Systolic blood pressure
+Pre
+138.48 ± 16.1
+135.52
+141.43
+1.64
+Po1
+127.49 ± 12.50 (*+)
+125.19
+129.77
+2.24
+−7.93
+Po2
+116.72 ± 11.06 (*+)
+114.69
+118.744
+2.04
+−15.7
+Diastolic blood pressure
+Pre
+86.96 ± 7.17
+85.64
+88.27
+1.56
+Po1
+80.27 ± 6.37 (*+)
+79.10
+81.44
+2.74
+−7.6
+Po2
+72.63 ± 7.50 (*+)
+71.25
+74.00
+1.69
+−16.4
+Pulse rate
+Pre
+79.41 ± 5.29
+78.44
+80.37
+2.87
+Po1
+72.73 ± 4.89 (*+)
+71.84
+73.62
+3.18
+−8.41
+Po2
+69.56 ± 4.67 (*+)
+68.71
+70.41
+0.99
+−12.4
+STAI‑1
+Pre
+62.39 ± 6.82
+61.15
+63.63
+3.01
+Po1
+40.19 ± 4.49 (*+)
+39.37
+41.01
+4.28
+−35.5
+Po2
+25.96 ± 4.80 (*+)
+25.08
+26.83
+2.74
+−58.39
+STAI‑2
+Pre
+62.20 ± 6.07
+60.10
+61.42
+2.54
+Po1
+40.63 ± 4.54 (*+)
+38.20
+40.22
+3.20
+−34.6%
+Po2
+26.68 ± 5.71 (*+)
+24.10
+25.50
+1.55
+−57.10
+Po1 ‑ Post (15th day); Po2 ‑ (90th day), SD ‑ Standard deviation, CI ‑ Confidence interval, LB ‑ Lower bound, UB ‑ Upper bound, ES ‑ Effect size, % ‑ Percentages. 
+*P<0.01 for Wilcoxon’s test (within groups). +P<0.01 for Mann–Whitney ‘U’ test (between groups)
+Table 5: Results within control group
+VB
+Pre and post
+Mean ± SD
+95% CI
+ES
+% change
+LB
+UB
+Resting pain
+Pre
+6.68 ± 0.70
+8.01
+8.35
+1.77
+Po1
+5.78 ± 1.12 (*+)
+5.70
+6.15
+2.24
+−13.4
+Po2
+4.17 ± 1.51 (*+)
+4.01
+4.61
+2.18
+−37.5
+Early morning stiffness
+Pre
+16.53 ± 5.45
+15.53
+17.53
+1.93
+Po1
+10.14 ± 5.40 (*+)
+9.15
+11.13
+3.11
+−38.6
+Po2
+4.68 ± 4.63 (*+)
+3.83
+5.53
+2.18
+−71.6
+Systolic blood pressure
+Pre
+133.13 ± 12.68
+130.78
+135.47
+1.24
+Po1
+130.64 ± 12.12
+128.40
+132.88
+1.58
+−1.8
+Po2
+128.05 ± 12.28
+125.78
+130.32
+1.20
+−3.8
+Diastolic blood pressure
+Pre
+84.49 ± 6.93
+83.20
+85.76
+0.68
+Po1
+82.68 ± 6.81
+81.41
+83.93
+1.24
+−2.1
+Po2
+80.24 ± 6.99
+78.95
+81.53
+0.71
+−5.0
+Pulse rate
+Pre
+79.30 ± 4.23
+78.52
+80.07
+1.65
+Po1
+75.23 ± 4.66
+74.38
+76.08
+1.84
+−5.1
+Po2
+73.66 ± 4.94
+72.75
+74.56
+0.96
+−7.1
+STAI‑1
+Pre
+62.37 ± 8.93
+60.73
+64.00
+1.18
+Po1
+52.62 ± 8.70(*)
+51.02
+54.21
+2.23
+−15.6
+Po2
+38.17 ± 5.88(*)
+37.09
+39.25
+1.59
+−38.8
+STAI‑2
+Pre
+60.17 ± 9.35
+59.73
+64.00
+1.00
+Po1
+51.67 ± 8.19 (*)
+52.02
+53.21
+1.80
+−14.12
+Po2
+39.27 ± 5.88 (*)
+40.09
+42.25
+1.43
+−34.73 
+Po1 ‑ Post (15th day), Po2 ‑ (90th day), SD ‑ Standard deviation, CI ‑ Confidence interval, LB ‑ Lower bound, UB ‑ Upper bound, ES ‑ Effect size, 
+% ‑ Percentages.*‑P<0.01 for Wilcoxon’s test (within groups). +‑P<0.01 for Mann–Whitney ‘U’ test (between groups)
+International Journal of Yoga  Vol. 5  Jan-Jun-2012
+34
+Ebnezar, et al.: Integrated yoga therapy for osteoarthritis of knees
+(Mann–Whitney, P<0.001) significantly better reduction 
+in yoga than control group at 15th and 90th days.
+Correlations
+There was a significant positive correlation (Spearman’s 
+Rho test) between early morning stiffness and pain at 
+2 weeks (P<0.001, r=0.35). Pulse rate also showed positive 
+correlation with pain (P=0.05, r=0.18) at 2 weeks. State 
+anxiety (STAI‑1) was positively correlated with pain 
+(P<0.001, r=0.34) at 90th day; Trait anxiety also showed 
+a positive correlation with pain (P=−0.013. r=0.23) at 
+90 days.
+DISCUSSION
+This randomized two armed parallel control trial 
+on 250  patients with osteoarthritis of knees of both 
+genders (F=175) in the age range of 35 to 80  years 
+showed significantly better improvement in yoga 
+than control group on all variables (P<0.001, Mann–
+Whitney) including resting pain, early morning stiffness, 
+state and trait anxiety scores, blood pressure and pulse 
+rate.
+Resting pain
+In a pilot study on OA of knees, Kolasinski et al.,[28] used 
+a specific sequence of asanas based on the teachings of 
+Iyengar for eight weeks. They measured only the pain 
+and physical functions by WOMAC with a significant 
+reduction (P=0.04) in pain by 46.7%. In another pilot 
+study on yoga for OA knees, Ranjita et al.,[42] used a set 
+of integrated yoga therapy program in a non‑residential 
+camp set up for one week without any physiotherapy 
+intervention. She showed a 40% reduction in resting pain 
+after yoga. In our study, we added yoga after the standard 
+physiotherapy which showed a reduction in resting pain 
+scores by 33.6 and 71.8% after 15 and 90 days respectively. 
+Looking at the degree of changes in all the three yoga 
+studies which is similar (37‑47%), we may speculate that 
+yoga is beneficial when used with or without a session 
+of physiotherapy.
+Early morning stiffness
+Haslock et al.,[26] showed the beneficial effects of specific 
+integrated yoga practices in patients with rheumatoid 
+arthritis who had secondary OA in several joints. They 
+observed better increase in hand grip strength (63%, left, 
+66% right) in yoga group than non yoga controls (8% left 
+and 5% right) indicating reduced stiffness. Our study 
+showed a reduction in early morning stiffness scores by 
+69 and 98% after 15 and 90 days respectively. None of 
+the other yoga studies have noted morning stiffness as an 
+outcome variable.
+State trait anxiety
+There was better reduction in state and trait anxiety scores 
+in the yoga group with significant differences within and 
+between yoga and control groups at two weeks and three 
+months. In our earlier study on patients with chronic neck 
+pain,[25] we had observed significant 19.3% reduction in 
+STAI‑1 scores as compared to 8.2% in control group within 
+10 days of intervention. In the present study, we used both 
+state and trait anxiety measures since this was a long‑term 
+follow up of three months. The reduction in anxiety scores 
+after yoga in both STAI‑1 (36% ‑post 1 and 58% ‑post 2) 
+and STAI‑2 scores (post  1‑35% and post  2‑57%) were 
+much higher in these patients with chronic knee pain as 
+compared to those with neck pain.
+Blood pressure and pulse rate
+In a randomized controlled study in patients with chronic 
+neck pain, we observed a reduction in both systolic and 
+diastolic blood pressure by 16% after ten days’ of add ‑on 
+IAYT for neck pain.[25] In the present study also, we 
+observed similar reduction of 16% in both systolic and 
+diastolic BP after 90 days of intervention. The pulse rate 
+reduced by 10% in the chronic neck pain study which is 
+similar to the present study with 12.4% reduction after 
+90 days of IAYT for knee pain. A significant correlation 
+observed in this study between pain and early morning 
+stiffness after yoga points to the global improvement in 
+the patient’s condition. Again, a significant correlation 
+between pulse rate and anxiety with pain shows the mind 
+body interaction.[43] We know that there exists an etiological 
+relationship between an aging disease such as OA and life 
+style, obesity and stress.[5] Whether this positive correlation 
+has an etiologically predictable relationship needs to be 
+studied in future studies.
+There are some studies that have looked at anxiety and 
+autonomic variables in normal healthy volunteers after 
+yoga for promotion of positive heath. Raghuraj et al.,[44] 
+observed significant reduction in heart rate variability 
+and blood pressure immediately after 20 min practice of 
+alternate nostril breathing (nadishuddhi pranayama).
+In a study by Vempati et  al.,[21] in healthy adults, the 
+yoga‑based guided relaxation was shown to reduce the 
+sympathetic activity as measured by reduced heart rate 
+and skin conductance, oxygen consumption and breath 
+volume. Reduction in heart rate has also been observed 
+after meditation.[36,45]
+The immediate effect of a 30 min practice of a meditation 
+technique called cyclic meditation on STAI  1 was 
+measured in normal healthy volunteers, which showed 
+significantly better reduction in state anxiety after the 
+cyclic meditation session as compared to a session of 
+35
+International Journal of Yoga  Vol. 5  Jan-Jun-2012
+Ebnezar, et al.: Integrated yoga therapy for osteoarthritis of knees
+supine rest. Studies on different types of meditation have 
+consistently shown increased mental alertness even while 
+the patients are physiologically relaxed. These autonomic 
+changes of reduced sympathetic arousal, reduced anxiety 
+and alertful rest points to stress reduction after yoga both 
+in health and disease which seems to be the inner healer.[36]
+Mechanisms
+The experience of pain in OA patients is not only due to 
+activation of sensory nociceptive fibers in the arthritic joint 
+but it is compounded by other factors such as affective, 
+behavioral and cognitive factors.[17] Stress reducing effect 
+of yoga seems to be a major mechanism of its efficacy 
+in pain management in patients with OA knees.[46] The 
+multi‑factorial approach of yoga includes not only 
+physical practices (asanas) but also has the components 
+of breathing (pranayama), meditation (dharana and 
+dhyana), introspective intellectual (jnana yoga) and 
+emotional (bhakti yoga) practices. These practices help 
+in bringing about mastery over the modifications of the 
+mind (chittavritti nirodhah) which is the definition of 
+yoga according to Patanjali.[21] This may contribute to a 
+consistent change in behavior and life style that can reduce 
+anxiety and the resultant effect on pain reduction.
+Baser et al.[47] have shown the association between cognitive 
+behavioral therapy (CBT) with physical, psychological and 
+social well being. The concepts in philosophy of yoga are 
+similar to those of CBT which says that chronic pain is not 
+simply a neurophysiologic state but is influenced by the 
+way a person sees the world and attributes meaning to the 
+events. Lip chick et al.,[48] showed that the increased sense 
+of personal control over pain following a pain management 
+program of CBT was accompanied by a reduction in 
+negativity. Thus the present study gives evidence to the 
+relationship between reduction in pain, anxiety and 
+sympathetic tone after yoga in patients with OA knees. 
+This may offer preliminary evidence to the reversibility 
+theory of yoga in a degenerative disease.
+Strengths of the study
+Good sample size, randomized control design, active 
+supervised intervention for the control group for the same 
+duration as the experimental group and follow up for 
+three months with good compliance (6% dropout) are the 
+strengths of this study. The result of this study that has 
+shown marked differences between groups on all variables 
+offers strong evidence for incorporating this module of 
+IAYT for OA knees by the clinicians.
+Limitations of the study
+The study was on a selected group who presented to a 
+specialty orthopedic center and hence not generalizable.
+Suggestions for future work
+A longer follow up of ≥12 months is necessary to check 
+the long‑term efficacy and acceptability. Studies using 
+MRI and biochemical variables may throw light on the 
+mechanisms.
+CONCLUSIONS
+Adjunctive program of integrated approach of yoga therapy 
+for OA knees reduces ‘rest pain’, early morning stiffness, 
+anxiety, and blood pressure and pulse rate. Yoga offers a 
+good value addition as a non‑pharmacological intervention 
+in management of OA knees.
+ACKNOWLEDGEMENTS
+We are thankful to Dr. Ravi Kulkarni for his help in statistical 
+analysis. We thank Mr. Zafar, the physiotherapist, and also Mrs. 
+Pragati Oswal and Mr. Rangaji, the Yoga therapists, for their 
+enthusiastic participation in the study. We gratefully acknowledge 
+the help of all the staff of SVYASA and Parimala Health Care 
+Services for their co‑operation in conducting and funding this 
+study.
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+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.
+How to cite this article: 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.
+Source of Support: Nil, Conflict of Interest: None declared

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+International Journal of Yoga • Vol. 7 • Jan-Jun-2014
+76
+Effect of repetitive yogic squats with specific hand 
+position (Thoppukaranam) on selective attention and 
+psychological states
+Angelica Chandrasekeran, Sasidharan K Rajesh, TM Srinivasan1
+Department of Psychology, 1Division of Yoga and Physical Sciences, Swami Vivekananda Yoga Anusandhana Samsthana, 
+Kempegowda Nagar, Bengaluru, Karnataka, India
+Address for correspondence: Mr. Sasidharan K Rajesh, 
+#19 Eknath Bhavan, No. 19, Gavipuram Circle, Kempegowda Nagar, Bengaluru - 560 019, Karnataka, India. 
+E-mail: [email protected]
+While practicing Thoppukaranam, devotees hold earlobes 
+between thumb and forefinger with hands crossed in 
+front of chest and perform repetitive squats. This is done 
+18 or 108 or 1008 times. General belief is Thoppukaranam 
+will bestow success in all endeavors. Further, it has been 
+used as a form of punishment in schools. Even though 
+not mentioned in any Vedic scriptures, it has been passed 
+down as narration and is followed even today with great 
+faith. Further, in Chinese Acupuncture therapy and Indian 
+Ayurveda, earlobe is believed to contain energy meridians 
+which correspond to the head. Moreover, in auricular 
+therapy, ear is believed to correspond to whole body in 
+shape of an inverted fetus curled in womb and the earlobe 
+stands for the head.[2]
+Testimonial on super brain yoga−a similar practice using 
+the thumb and a finger to apply pressure to each earlobe 
+INTRODUCTION
+In the Indian tradition, the elephant-headed deity 
+Ganapati, is worshipped as the remover of obstacles, 
+bestower of knowledge and success.[1] Intrinsically, 
+his blessings are sought before the commencement of 
+any endeavor. Yogic squats with specific hand position 
+(Thoppukaranam), a physical act of worshiping the deity, 
+are practiced throughout India (especially in the South). 
+Context:  Research on the effect of Thoppukaranam is limited despite it being practiced as a form of worship to 
+the elephant-headed deity Lord Ganapati and punishment in schools.
+Aims: The purpose of this study was to examine the effect of Thoppukaranam on selective attention and psychological states 
+in a sample of young adults.
+Settings and Designs: A randomized self-as-control within subjects design was employed. Thirty undergraduate 
+students (4  females and 26  males) from a residential Yoga University in Southern India were recruited for this study 
+(group mean age ± standard deviation, 20.17 ± 2.92).
+Materials and Methods: The d2 test, State Anxiety Inventory-Short Form and State Mindful Attention Awareness Scale 
+(SMAAS) were used to measure cognitive performance and psychological states. Assessments were made in three sessions: 
+Baseline, control (squats), and experimental (Thoppukaranam) on 3 separate days.
+Statistical analysis used: Data were analyzed using one-way repeated measures analyses of variance between three 
+sessions, that is, baseline, squat, and Thoppukaranam.
+Results: There was a significant improvement in all measures of the d2 test of attention (TN, E, TN‑E, E%, and 
+concentration performance) and state mindfulness after Thoppukaranam. Further state anxiety reduced significantly after the 
+experimental session.
+Conclusions: These findings indicate Thoppukaranam results in enhancement of cognitive functioning and psychological states.
+Key words: Mental Concentration; selective attention; state anxiety; state mindfulness; squats; Thoppukaranam
+ABSTRACT
+Access this article online
+Website: 
+www.ijoy.org.in
+Quick Response Code
+DOI: 
+10.4103/0973-6131.123497
+Short Communication
+[Downloaded from http://www.ijoy.org.in on Thursday, March 02, 2017, IP: 14.139.155.82]
+Chandrasekeran, et al.: Thoppukaranam on selective attention and psychological states
+77
+International Journal of Yoga • Vol. 7 • Jan-Jun-2014
+while doing knee bends and taking breaths−shows 
+increased class participation, concentration, improved 
+quality of academic performance and social skills in 
+a sample of US school students.[3] To our knowledge, 
+there is no study to date using Thoppukaranam. Hence, 
+current study examines the effect of traditional practice 
+of Thoppukaranam on cognitive and psychological states 
+in healthy individuals.
+MATERIALS AND METHODS
+Participants
+A total of 36 undergraduate students from a residential Yoga 
+University in Southern India were recruited for this study. 
+The final sample comprised 30 volunteers (86.66% male), 
+due to drop out. The reasons for dropout (a) not completed 
+the orientation, (b) ill health and, (c) personal reason. 
+Participants’ age ranged from 17 to 29 years with a mean 
+age of 20.17 years (standard deviation =2.92). All reported 
+having a normal or corrected vision. Those who had 
+any history of psychological illness, heart disease, renal 
+failure, recent surgery, joint pain, or any other debilitating 
+condition, and unwillingness to participate in the study 
+were excluded.
+Design
+This was a randomized self as control within-subjects 
+design. Participants were assessed on 3 separate days 
+in neuropsychology laboratory of the above university. 
+Participants were counterbalanced randomly into three 
+sessions: Baseline, control (squats), and yogic squats 
+(Thoppukaranam) to minimize the order effect.
+ASSESSMENTS
+Sociodemographic questionnaire
+A sociodemographic checklist was developed to document 
+participants’ basic information such as name, gender, age, 
+level of education, and experience in yoga.
+d2 attention test
+The d2 attention test is a timed test of selective attention 
+and mental concentration.[4] The one-page test consists 
+of 14 lines, each comprising of 47 characters of letters 
+“d” and “p” with one to four dashes, arranged either 
+individually or in pairs above and below the letters. The 
+subject is required to scan across each line to identify and 
+cross out all “d’s” with two dashes. The subject is allowed 
+20 s per line. All other combinations of letters and dashes 
+are considered irrelevant. In a series of tests-retests, 
+and intervals of up to 40 months, d2 test indices, total 
+number of items processed (TN), total performance 
+(TN-E, where E is error), and concentration performance 
+(CP) demonstrate satisfactory to good reliability (r > 70). 
+Further, over a 5-h interval in adults, the test has shown 
+good test-retest reliability.[4]
+State trait anxiety inventory-short form
+The state trait anxiety inventory-short form (STAI-SF) 
+consists of two questionnaires of 20 items each. The first 
+questionnaire measures state anxiety (how one feels at 
+the moment); the second, trait anxiety (how one generally 
+feels).[5] A standardized, short-form of STAI has been used 
+for this study. STAI-SF consists of six items assessing the 
+extent to which patients feel ‘‘calm,’’ ‘‘tense,’’ ‘‘upset,’’ 
+‘‘relaxed,’’ ‘‘content,’’ and ‘‘worried’’ on a 4-point scale 
+ranging from ‘‘not at all’’ to ‘‘very much.’’ Items consist 
+of equal numbers of anxiety-present and anxiety-absent. 
+Three items are scored in reverse order to avoid a response 
+bias. The items were summed to produce a total score in 
+which higher scores are related to greater anxiety. The six 
+items STAI-SF demonstrated good reliability coefficient 
+(r > 82).[6]
+State mindful attention awareness scale
+The SMAAS is a valid tool for measuring state mindfulness.[7] 
+The scale is designed to assess the short-term or current 
+expression of a core characteristic of mindfulness; this 
+is a receptive state of mind and sensitive awareness of 
+observing the present moment. The SMAAS draws items 
+drawn from the trait form of the MAAS (e.g., “I’m finding 
+it difficult to stay focused on what’s happening in the 
+present”). SMAAS has shown excellent psychometric 
+properties (Cronbach’s alpha = 92).
+Procedure
+Participants were briefed on the purpose and nature of the 
+study. Confidentiality was assured as part of the research 
+process. Eligible participants were briefed on the study 
+and informed consent approved by the institutional ethics 
+committee was obtained. Eligible participants underwent 
+familiarization on the practice of Thoppukaranam and 
+squats for a period of 10 days. They were also familiarized 
+with procedure of assessment tools. During baseline 
+session, participants completed the psychological state 
+and attention test.
+Experimental session (Thoppukaranam)
+Participants practiced 108 rounds of Thoppukaranam. 
+The procedure for Thoppukaranam was to squat with 
+specific hand position. The procedure for squat was a 
+modified form of the Mayo Clinic’s practice.[8] Instructions 
+are as follows: Stand with your feet slightly apart, greater 
+than shoulder width and toes pointing ahead. The hands 
+[Downloaded from http://www.ijoy.org.in on Thursday, March 02, 2017, IP: 14.139.155.82]
+Chandrasekeran, et al.: Thoppukaranam on selective attention and psychological states
+International Journal of Yoga • Vol. 7 • Jan-Jun-2014
+78
+difference between baseline and squats. Error scores are 
+related to attentional control, rule compliance, accuracy of 
+visual scanning, and quality of performance, carefulness 
+and cognitive flexibility.[4] Mean total error differed 
+statistically significantly between sessions [F (6.79), 
+P  <  0.001]. Results indicate significant reduction in 
+total error scores compare to baseline and squat following 
+the practice of Thoppukaranam. The mean E% indicates 
+accuracy, quality of work, and degree of carefulness by 
+subjects on the test.[4] The results show that mean E% 
+scores differed statistically significantly between sessions 
+[F (9.18), P < 0.001]. Statistically significant reduction in 
+E% scores following Thoppukaranam compared to baseline 
+and squats sessions. The CP is a highly reliable measure 
+of coordination of speed and accuracy performance on 
+the test.[4] Mean CP differed statistically significantly 
+between sessions [F (17.98), P < 0.001]. Results showed a 
+statistically significant increase in CP scores from baseline 
+and squat following the practice of Thoppukaranam. 
+Further mean TN-E [F (17.32), P  <  0.001] scores also 
+indicate statistically significant increases between 
+sessions. TN-E score showed significant improvement after 
+the practice of Thoppukaranam compared to baseline and 
+squat. Results indicate that Thoppukaranam enhanced 
+attentional and inhibitory control.
+State anxiety and state mindfulness
+The results show that the state anxiety was significantly 
+affected [F (4.80), P  >  0.01] by the type of sessions. 
+Further state anxiety score showed significant reduction 
+immediately following the practice of Thoppukaranam 
+compared to baseline. Further STAI-SF score did not change 
+statistically comparing baseline and squats. The present 
+moment awareness scores [F (3.01), P < 0.05] indicated 
+statistical significance between sessions. Results show that 
+immediately after the practice of Thoppukaranam, there 
+was a significant increase in state mindfulness compared to 
+baseline. Further, SMAAS score did not change statistically 
+comparing baseline and squats.
+DISCUSSION
+The purpose of this study was to assess the effect 
+of Thoppukaranam on selective attention, mental 
+concentration, state mindfulness, and state anxiety in a 
+sample of young adults. Findings suggest that the practice 
+of Thoppukaranam has an immediate effect on selective 
+attention and CP compared to baseline and squats. Further, 
+Thoppukaranam session shown enhanced mindfulness 
+and reduced state anxiety compare to baseline. As per 
+our knowledge, there is no previous report specific to 
+Thoppukaranam on cognitive function and psychological 
+states for comparison. But the findings are consistent 
+with anecdotes regarding the effect of super brain yoga, a 
+similar practice.[3]
+cross over each other (left over right), maintaining a gentle 
+pressure holding the earlobes throughout with thumb in 
+front and the finger to the back. Slowly descend, bending 
+through hips, knees, and ankles, and stopping when knees 
+reach a 90°angle. Then return to the starting position. Keep 
+the back in a neutral position and abdominal muscles tight. 
+Do not flatten the curve of the lower back or arch back. 
+Keep knees centered over feet while going down. Do not 
+let knees roll inward or outward. Keep movements smooth 
+and controlled with normal breathing.
+Control session (squats)
+Subjects practiced 108 rounds of squats with the same 
+instructions as Thoppukaranam but with variation in 
+hand positions. The hands are kept crossed over the chest 
+(left over right), holding onto the opposite shoulder instead 
+of holding the earlobes.
+RESULTS
+Data were extracted from the completed tests as per test 
+manuals and scoring keys. Statistical analysis was carried 
+out using the Statistical Package for Social Sciences 
+(version  16.0). Data were analyzed using one-way 
+repeated-measures analyses of variance between three 
+sessions, that is, Baseline, squat, and Thoppukaranam. 
+The group mean and standard deviation of scores obtained 
+in the d2 test of attention and psychological states are 
+presented in Table 1.
+d2 test of selective attention
+TN is a highly reliable measure of attentional allocation 
+(selective and sustained), processing speed, amount of 
+work completed, and motivation.[4] A one-way repeated 
+measures analysis of variance revealed a mean TN differed 
+statistically significantly between sessions [F (14.52), 
+P < 0.001]. Thoppukaranam session showed a significantly 
+higher TN score when compared to the baseline and squat. 
+However, TN score did not show a statistically significant 
+Table  1: Scores on the d2 test of attention, state 
+mindfulness, and state anxiety between sessions 
+(baseline, squat, and Thoppukaranam)
+Mean  (SD)
+Baseline
+Squat
+Thoppukaranam
+d2 Test
+TN
+505.83 (82.78)
+505.13 (85.27)
+556.07 (73.44)*†
+E
+44.23 (43.90)
+38.13 (42.97)
+27.63 (30.26)*†
+E %
+8.83 (8.50)
+7.33 (7.43)
+4.88 (4.97)*†
+TN‑E
+461.60 (91.26)
+467.00 (84.72)
+528.43 (72.95)*†
+CP
+177.17 (54.15)
+182.70 (47.39)
+215.70 (44.28)*†
+STAI‑SF
+1.79 (0.53)
+1.67 (0.42)
+1.53 (0.42)*
+SMAAS
+4.37 (1.03)
+4.51 (1.06)
+4.82 (1.14)*
+*P<0.05 compared with baseline, †P<0.05 compared with squat, 
+TN = Total number processed; E = Error; CP = Concentration performance; 
+STAI‑SF = State trait anxiety inventory ‑ Short Form; 
+SMAAS = State mindful attention awareness scale; SD = Standard deviation
+[Downloaded from http://www.ijoy.org.in on Thursday, March 02, 2017, IP: 14.139.155.82]
+Chandrasekeran, et al.: Thoppukaranam on selective attention and psychological states
+79
+International Journal of Yoga • Vol. 7 • Jan-Jun-2014
+The positive effect of physical activity on attention has 
+been reported in previous research.[9] Studies also indicate 
+that coordinated exercise increases one’s attention.[10] 
+The aspect of physical activity was consistent in both 
+squats and Thoppukaranam. The component of holding 
+the earlobes seen only in the practice of Thoppukaranam 
+may account for the significant improvement in attention 
+scores. Overall, the reduction in state anxiety and increased 
+present moment awareness may be cited as a possible 
+mechanism for the improved performance. Further, the 
+role of stimulating acupuncture points on earlobes may 
+enhance attention performance.
+While this study resulted in important findings, 
+the results have to be considered in light of several 
+limitations. Representation of males and females ratio 
+was not equal and small sample size does not allow for 
+generalization of the findings to a realistic population. 
+Moreover, neither physiological measurements nor the 
+lasting effect of intervention was assessed. Furthermore, 
+the study used a mix of novice and long-term yoga 
+practitioners who were part of an on-going residential 
+yoga course. Therefore, it is unclear what effect the yoga 
+practice had in influencing the participants’ performance 
+and psychological states.
+Though Thoppukaranam has been practiced throughout 
+India, there has been no formal research studies carried 
+out to understand the effect of the practice to date. This is 
+the first attempt to study the effect of the practice. Future 
+studies could measure physiological parameters using 
+brain imaging techniques to understand the mechanism 
+and fallout period of the effects. It is also recommended to 
+include comparison of unguided individual practice across 
+various age groups with varying needs such as students in 
+primary, secondary, or tertiary level educational institutes 
+as well as those with special needs, developmental and 
+behavioral disorders.
+ACKNOWLEDGMENT
+We are especially grateful to S-VYASA Yoga University, Bengaluru, 
+Karnataka for financial support.
+REFERENCES
+1.	
+Chinmayananda, Swami. Glory of Ganesha. Bombay: Central Chinmaya 
+Mission Trust;1987.
+2.	
+Nogier, P. Handbook of Auriculotheraphy. Maisonneuve, Moulins-les-Metz, 
+France, 1981.
+3.	
+Superbrain Yoga [Internet] 2007. Available from http://www.superbrainyoga.
+com. [Last cited on 2012 June 10].
+4.	
+Brickenkamp R, Zillmer E. The d2 test of attention. Seattle: Hogrefe and 
+Huber Publishers;1998.
+5.	
+Spielberger CD. Manual for the State–Trait Anxiety Inventory (Form Y). 
+Palo Alto: Mind Garden;1983.
+6.	
+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.
+7. 
+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.
+8.	
+Mayo Clinic [Internet] 2010 http://www.mayoclinic.com/health/squat/
+MM00724 Video: [Last cited on 2012 Aug 27].
+9. 
+Hillman CH, Castelli DM, Buck SM. Aerobic fitness and neurocognitive 
+function in healthy preadolescent children. Med Sci Sports Exerc 
+2005;37:1967-74.
+10.	 Budde H, Voelcker-Rehage C, Pietrabyk-Kendziorra S, Ribeiro P, Tidow G. 
+Acute coordinative exercise improves attentional performance in adolescents. 
+Neurosci Lett 2008;441:219-23.
+How to cite this article: Chandrasekeran A, Rajesh SK, Srinivasan 
+TM. Effect of repetitive yogic squats with specific hand position 
+(Thoppukaranam) on selective attention and psychological states. Int 
+J Yoga 2014;7:76-9.
+Source of Support:S-VYASA University, Conflict of Interest: None 
+declared
+[Downloaded from http://www.ijoy.org.in on Thursday, March 02, 2017, IP: 14.139.155.82]

subfolder_0/Effect of uninostril yoga breathing on brain hemodynamics_ A functional near-infrared spectroscopy study.txt

@@ -0,0 +1,323 @@
+3/1/2017
+Effect of uninostril yoga breathing on brain hemodynamics: A functional near­infrared spectroscopy study
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4728953/
+1/7
+Effect of uninostril yoga breathing on brain hemodynamics: A functional near-infrared spectroscopy study
+Karamjit Singh, Hemant Bhargav, and TM Srinivasan
+Abstract
+Objectives:
+To measure the effect of the right and left nostril yoga breathing on frontal hemodynamic responses in 32 right handed healthy male subjects
+within the age range of 18–35 years (23.75 ± 4.14 years).
+Materials and Methods:
+Each subject practiced right nostril yoga breathing (RNYB), left nostril yoga breathing (LNYB) or breath awareness (BA) (as control) for 10
+min at the same time of the day for three consecutive days, respectively. The sequence of intervention was assigned randomly. The frontal
+hemodynamic response in terms of changes in the oxygenated hemoglobin (oxyHb), deoxygenated hemoglobin (deoxyHb), and total hemoglobin
+(totalHb or blood volume) concentration was tapped for 5 min before (pre) and 10 min during the breathing practices using a 16 channel
+functional near­infrared system (FNIR100­ACK­W, BIOPAC Systems, Inc., U.S.A.). Average of the eight channels on each side (right and
+left frontals) was obtained for the two sessions (pre and during). Data was analyzed using SPSS version 10.0 through paired and independent
+samples t­test.
+Results:
+Within group comparison showed that during RNYB, oxyHb levels increased significantly in the left prefrontal cortex (PFC) as compared to
+the baseline (P = 0.026). LNYB showed a trend towards significance for reduction in oxyHb in the right hemisphere (P = 0.057). Whereas BA
+caused significant reduction in deoxyHb (P = 0.023) in the left hemisphere. Between groups comparison revealed that oxyHb and blood volume
+in the left PFC increased significantly during RNYB as compared to BA (oxyHb: P =0.012; TotalHb: P =0.017) and LNYB (oxyHb: P =0.024;
+totalHb: P =0.034).
+Conclusion:
+RNYB increased oxygenation and blood volume in the left PFC as compared to BA and LNYB. This supports the relationship between nasal
+cycle and ultradian rhythm of cerebral dominance and suggests a possible application of uninostril yoga breathing in the management of
+psychopathological states which show lateralized cerebral dysfunctions.
+Keywords: Blood flow, functional near­infrared spectroscopy, nasal cycle, unilateral nostril breathing, yoga breathing
+INTRODUCTION
+The alternate congestion­decongestion response of the erectile tissue of nasal turbinate and septum of two nostrils leads to altered unilateral
+nasal resistance. Thus, the air flow through one nostril is greater than next at any given point of time which later switches to another. This is
+called nasal cycle.[1] The nasal cycle which lasts for 25 min to 2–3 h is closely related to the ultradian rhythm of cerebral dominance that lasts
+for 1.5–3 h.[1,2] The dominance of nasal cycle is inversely correlated to the alternating dominance in the cerebral hemispheres; this is
+regulated by a common mechanism mediated through the autonomic nervous system.[3] Electroencephalogram (EEG) studies have shown that
+integrated EEG amplitudes are greater over the cerebral hemisphere contralateral to the dominant nostril.[4,5] This rhythm of cerebral
+dominance plays an important role in cognitive performance, memory processes, mood, and behavior.[2,6]
+Pranayama refers to voluntarily regulated rhythmic yoga breathing technique. Slow yogic breathings through a particular nostril have been
+shown to be effective in improving cardio­respiratory functions, autonomic imbalances, and psychological stress.[7,8,9,10] Studies have
+observed that left nostril yoga breathing (LNYB) enhanced performance in the right hemisphere dominant tasks such as spatial memory
+scores[7,8] and right nostril yoga breathing (RNYB) improved left hemisphere dominant tasks such as letter­cancellation and verbal memory
+scores.[9] An ancient yogic treatise in Samskrit called Shivaswarodaya describes that breathing through a particular nostril affects cognitive
+activities and emotions of an individual.[11] This has recently been verified by scientific research as well.[12]
+Study by Telles et al.[13] showed that right nostril breathing facilitates the left hemisphere activity through a significant reduction in P300
+evoked potential latency. The neuroelectric events that underlie P300 generation arise from the interaction between frontal lobe, hippocampal,
+and temporoparietal function.[13] Thus, researches on uninostril yoga breathing increasingly point towards its activating effect on contralateral
+brain hemispheres (especially the frontals) in terms of: (a) enhancement of cognitive task performances and (b) greater integrated EEG
+amplitudes.
+3/1/2017
+Effect of uninostril yoga breathing on brain hemodynamics: A functional near­infrared spectroscopy study
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4728953/
+2/7
+Functional near­infrared spectroscopy (fNIRS) is a noninvasive optical method that can measure the real time change in oxygenated
+hemoglobin (oxyHb), deoxygenated hemoglobin (deoxyHb), and their sum that is, total hemoglobin (totalHb) or blood volume in different brain
+regions including bilateral prefrontal cortices (PFCs). Basics of the NIRS device are described elsewhere.[14] Though the spatial resolution of
+the fNIRS device is coarse, its temporal resolution is excellent and fNIRS results are physiologically comparable to fMRI results.[15] A recent
+study used fNIRS to study the effect of yoga breathing technique called Kapalabhati (KB) on blood flow changes in PFCs of 18 healthy
+individuals and 18 schizophrenia patients. There was a significant increase in bilateral prefrontal oxyHb (in µMol/L) in healthy subjects during
+the practice of KB.[16] This suggests probable effect of yoga breathing on brain hemodynamics and necessitates deeper exploration.
+Thus, in order to understand the mechanism through which the nasal cycle relates to ultradian rhythm of cerebral dominance, present study was
+planned to understand the effect of yoga breathing through a particular nostril on oxygenation and blood flow changes in bilateral prefrontal
+cortices in healthy individuals using fNIRS.
+MATERIALS AND METHODS
+Subjects
+Thirty­two male subjects with ages ranging between 18 and 35 years (group mean ± standard deviation [SD], 23.75 ± 4.14 years) and average
+education of 15.78 ± 2.88 (mean ± SD) years were included in the study. Demographic details of the subjects are provided in Table 1. Sex
+differences have been documented in structure, function, and chemistry of the brain, and different phases of menstrual cycle have been shown
+to influence the cerebral blood flow,[17,18] hence the study included only male participants. The subjects were students of graduation and
+postgraduation studies from a Yoga University. They had an experience of practicing the three yoga breathing techniques that are, RNYB,
+LNYB and breathe awareness (BA) ranging between 3 and 36 months (group mean ± SD, 12.5 ± 8.6 months). All of them had completed a
+residential training course in yoga which was for 1­month. In addition to this, all the subjects included in the study were given week long
+training in the breathing practices assessed in the present study for 30 min each day for a week before starting the study. This 1­week of
+supervised practice was to ensure the uniformity among all the subjects. All subjects were checked for their health using general health
+questionnaire (GHQ) and those with GHQ score ≥7 were excluded. None of them had a history of smoking or respiratory ailments including
+nasopharyngeal abnormalities. They were all right handed dominant based on their response to the Edinburgh handedness inventory.[19] Also,
+none of them was taking medication and they did not use any other wellness strategy. The variables to be recorded and the study design were
+described to the subjects after which their signed consent to participate in the study was obtained. None of them was aware of the hypothesis of
+the study. The project had the approval of the Institutional Review Board.
+Table 1
+Demographic data of the subjects
+Assessment
+Each subject performed single intervention on each day at the same time, empty stomach, but the intervention was randomized using slips
+numbered from 1 to 3.
+Recorded audio­tape of instructions was played during the time of the experiment for RNYB, LNYB, and BA, respectively. Assessment
+schedule is provided in Table 2. The inhalation and exhalation ratio was 2:3, the duration of inhalation was 6 s and exhalation was 9 s.
+Therefore, the breathing time was 15 s for a single breath, approximately 4 breaths in a minute and 80 breaths in the total duration of 10 min.
+Each session lasted for 15 min where the first 5 min was for baseline recording (pre) than any one of yogic breathing was performed for 10
+min. The intervention of RNYB, LNYB, and BA was practiced for 10 min continuously without any interval. The oxy­hemoglobin (oxyHb) and
+deoxy­hemoglobin (deoxyHb) concentration were assessed over the left and right hemisphere. Recordings were taken only when the subject
+performed the practice correctly and comfortably. A chest pressure transducer was used to monitor the technique of breathing objectively.
+Table 2
+Assessment schedule of the study
+General health questionnaire
+GHQ was used to establish healthy status. It has 28 questions with four different sub scales to assess the physical fitness, anxiety and insomnia,
+social dysfunction, and depression. It gives the information about the recent mental status and general health. The questioner has acceptable
+psychometrics and has intimae consistency and reliability with Cronbach's alpha of 0.85 and validity of 0.76.[20]
+3/1/2017
+Effect of uninostril yoga breathing on brain hemodynamics: A functional near­infrared spectroscopy study
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4728953/
+3/7
+Functional near-infrared spectroscopy device
+The system (FNIR100­ACK­W, BIOPAC Systems, Inc., U.S.A.) is a continuous wave device which measures changes in attenuation at 2
+wavelengths (730 and 850 nm, ±15 nm), sampling at 25 kHz and allows for the differentiation of two dynamic absorbers (oxyHb and deoxyHb).
+It has 4 light emitting and 10 detector probes with 16 channels that can be measured quasi simultaneously. Concentration changes in oxyHb and
+deoxyHb were calculated based on a modified Beer–Lambert approach.[14] The optodes were affixed to a probe set with an inter­optode
+distance of 2.5 cm covering an area of ∼6 cm × 18 cm. The probe set was fastened to the participant's head by elastic straps. The head band
+was placed on the forehead and covered with a black cloth. The recording was made in a dark sound attenuated cabin. For horizontal fixation,
+the lower edge of the probe set was fixed 1 cm above the nasion.
+Data analysis
+Sample size was calculated using two­tailed G power (calculated sample size = 32; effect size 1.05, alpha = 0.05, power = 0.80). The
+calculated sample size came out to be 32. The waveforms of oxyHb and deoxyHb changes in bilateral PFC were acquired from all the subjects
+in all 16 channels, and the data was averaged according to the task condition (pre, during and post). The average of the oxyHb, deoxyHb, and
+totalHb levels on both right (channels 1–8) and left side (channels 9–16) of the brain[16] was taken. Thereby, one mean value of each condition
+(pre and during) for each side of the brain (right and left) was obtained for each participant. The data were analyzed by the statistician using
+Statistical Package for Social Sciences version 10.0 (IBM India Private Limited). Shapiro–Wilk's test was used to check the normality of the
+data. As the data was found to be normally distributed, paired samples t­test was used to measure the changes in oxyHb, deoxyHb, and totalHb
+levels, respectively, during RNYB, LNYB, and BA practices from the baseline (pre) levels in all the subjects and independent samples t­test
+was used for between group comparisons. Alpha (P value) <0.05 was considered to be statistically significant.
+RESULTS
+Oxygenated hemoglobin changes
+Within group comparisons [Table 3 and Figure 1] revealed that during RNYB oxyHb levels increased significantly in the left PFC as compared
+to the baseline (P = 0.026), whereas no significant change was observed in the right hemisphere (P = 0.654). During LNYB, we observed a
+trend towards significance for a reduction in oxyHb in the right hemisphere (P = 0.057). In the left PFC, there was no significant change in
+oxyHb levels as compared to the baseline (P = 0.854). The control intervention BA did not show any significant changes in the levels of oxyHb
+in bilateral PFC (left PFC: [P = 0.145]; right PFC [P = 0.061]).
+Table 3
+Comparison within the group before and during RNYB, LNYB and BA groups for changes in oxy­Hb, deoxy­Hb, total­Hb
+Figure 1
+Changes in oxygenated hemoglobin levels before and during right nostril yoga breathing, left nostril yoga breathing and
+breath awareness in left and right hemispheres. OxyHb = Oxygenated hemoglobin; RNYB = Right nostril yoga breathing;
+LNYB = Left nostril ...
+For oxyHb levels, comparison between RNYB and BA showed that oxyHb increased significantly in the left PFC during RNYB as compared to
+BA [P = 0.012, Table 4]; with no significant difference between them in right PFC [P = 0.972, Table 4]. Similarly, the comparison between
+the oxyHb levels during RNYB and LNYB revealed a significant increase in oxyHb in left PFC during RNYB [P = 0.024, Table 5] as
+compared to LNYB, with no such difference in right PFC [P = 0.589, Table 5]. No significant differences were observed between oxyHb
+levels during LNYB and BA in both the PFC [Table 5].
+Table 4
+Comparison between RNYB and BA groups for changes in oxy­Hb, deoxy­Hb, total­Hb during the intervention
+3/1/2017
+Effect of uninostril yoga breathing on brain hemodynamics: A functional near­infrared spectroscopy study
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4728953/
+4/7
+Table 5
+Comparison between RNYB and LNYB groups for changes in oxy­Hb, deoxy­Hb, total­Hb during the intervention
+Deoxygenated hemoglobin changes
+During RNYB, we did not observe any significant change in deoxyHb levels in the left as well as right PFC, respectively, as compared to the
+baseline [left PFC (P = 0.289); right PFC (P = 0.443); Table 3 and Figure 2]. Similar results were seen during LNYB as well (left PFC: [P =
+0.359; Table 3]; right PFC: [P = 0.808; Table 3]). Practice of BA also revealed no significant changes during the practice in both the
+hemispheres but after the practice of BA, there was a significant reduction in deoxyHb in the left PFC [P = 0.023, Table 3].
+Figure 2
+Changes in deoxygenated hemoglobin levels before and during right nostril yoga breathing, left nostril yoga breathing and
+breath awareness in left and right hemispheres. OxyHb = Oxygenated hemoglobin; RNYB = Right nostril yoga breathing;
+LNYB = Left nostril ...
+Comparison between deoxyHb levels during RNYB and BA, RNYB and LNYB, or LNYB and BA did not show any significant differences in
+both the hemispheres, respectively [Table 4].
+Total hemoglobin (blood volume) changes
+Though within group comparison of totalHb levels did not show significant change from the baseline during all the three interventions in both
+the hemispheres, respectively [Table 3 and Figure 3], between group comparisons revealed a significant increase in blood volume in the left
+PFC during RNYB as compared to BA [P = 0.017, Table 4]. A significant increase in blood volume was seen during RNYB as compared to
+LNYB as well [P = 0.034, Table 5]. Other between the group comparisons for change in blood volume did not reveal any significant change on
+both the PFC [Table 5].
+Figure 3
+Changes in total hemoglobin levels before and during right nostril yoga breathing and left nostril yoga breathing and breath
+awareness in left and right hemispheres. OxyHb = Oxygenated hemoglobin; RNYB = Right nostril yoga breathing; LNYB =
+Left nostril ...
+DISCUSSION
+The present study was planned to see the effects of yoga breathing through a particular nostril on the hemodynamic changes in the bilateral PFC
+on 32 healthy male volunteers. We found that RNYB lead to a significant increase in the level of oxyHb and totalHb in the left PFC in
+comparison to BA or LNYB, also, there was a trend toward significant reduction in oxyHb in right PFC during LNYB and BA, respectively.
+Increase in totalHb and oxyHb and a reciprocal decrease in deoxyHb are expected to be observed in activated areas of the brain in NIRS
+measurements which indicates an increase in the blood flow,[14] though researchers have found activation of a brain region when there is: (1)
+No change in totalHb alongside an increase in oxyHb and a reciprocal decrease in deoxyHb and (2) an increase or no change in deoxyHb
+accompanying increases in totalHb and oxyHb.[14,21] OxyHb is considered as the most sensitive indicator of changes in regional cerebral blood
+flow in NIRS measurements.[21] We found an increase in both oxyHb and totalHb with no change in deoxyHb in the left PFC during RNYB.
+Thus, the present study suggests activation or increase in the blood flow in the left PFC during RNYB and trend towards deactivation of right
+PFC during LNYB and BA, respectively.
+These results support the relationship between nasal cycle and ultradian rhythm of cerebral dominance and point toward change in the blood
+flow and oxygenation in contralateral brain regions as one of the mechanisms underlying this relationship. Present study also explains: (1)
+Better performance in the left hemisphere dominant tasks such as verbal memory scores and letter­cancellation task and (2) increased
+integrated EEG amplitudes and reduced P300 latency in left hemisphere observed immediately after RNYB respectively.[6,13]
+We also observed a trend toward the significant decrease in oxyHb [P = 0.053; Table 3 and Figure 1] along with no change in deoxyHb or
+totalHb in right PFC during LNYB. This suggests a probable deactivating or relaxing effect of LNYB on right PFC. But studies have observed
+the better performances in right hemisphere dominant tasks and higher integrated EEG amplitudes in the right hemisphere after LNYB. Thus,
+why we did not get activating effects on right hemisphere following LNYB or in contrast why our results show a deactivating or relaxing trend
+is difficult to explain and more detailed studies to understand the underlying mechanisms are needed in future. Here one important aspect is the
+traditional ancient yogic view on uninostril yogic breathing where LNYB also known as Chandra anulomaviloma is believed to produce the
+3/1/2017
+Effect of uninostril yoga breathing on brain hemodynamics: A functional near­infrared spectroscopy study
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4728953/
+5/7
+calming and relaxing effect on the body in contrast to RNYB or Surya anulomaviloma which is more activating and energizing.[11] Results in
+the present study support this view. Previously, similar diverging effects of RNYB and LNYB have been observed on autonomic nervous
+system, where RNYB lead to higher sympathetic activity but LNYB, on the other hand, brought parasympathetic dominance.[22]
+The exact mechanism through which uninostril breathing influences cerebral blood flow is not known. PFC receives serotonergic input from
+dorsal raphe nucleus of the brainstem, as well as noradrenergic input from another brainstem nucleus, the locus coeruleus (LC). A large
+number of studies have shown that these two neurotransmitter systems (serotonin and nordrenaline) modulate the functional properties of the
+PFC in both humans and animal models. Studies have revealed that breathing through a particular nostril can alter metabolism and autonomic
+activites.[22] The mechanical receptors in the nasal mucosa are activated with airflow into the nostrils, and this signal is unilaterally
+transmitted to the hypothalamus thereby altering the autonomic functions mediated via hypthalamo­pituitary­adrenal (HPA) axis.[1] Telles et al.
+found that regular practice of RNYB for a month leads to a significant increase of 37% in baseline oxygen consumption. The authors attributed
+this increase in metabolism to increased sympathetic discharge mediated by increased output of adrenaline from the adrenal medulla.[22]
+Interestingly, LC has been identified as an upstream component of circuitry providing for dorsal medial PFC modulation of emotional stress­
+induced (HPA) activation.[23] Thus, uninostril yoga breathing may influence PFC through HPA­LC mediated noradrenaline release. Another
+neurotransmitter which may play an important role in mediating PFC activation is serotonin. In order to understand the neuro­physiological
+mechanisms involved in Zen meditation, another study used 24­channel near­infrared spectroscopy during a 20­min session of abdominal
+(Tanden) breathing in 15 healthy volunteers. They found a significant increase in the level of oxyHb in anterior PFC during Tanden breathing,
+accompanied by a reduction in feeling of negative mood compared to the baseline. They also observed changes in EEG such as increased alpha
+band activity and decreased theta band activity during Tanden breathing and EEG changes were correlated with a significant increase in whole
+blood serotonin (serotonin) levels. Thus, the author concluded that Tanden breathing lead to the activation of the anterior PFC and serotonin
+system. This may be responsible for the improvement of negative mood and EEG signal changes observed during Tanden breathing.[24]
+Another study assessed three primary lines of evidence that comprised of the effects of serotonin and noradrenaline on impulsivity, cognitive
+flexibility, and working memory and found supporting evidence toward the activating effect of serotonin and deactivating effect of
+noradrenaline on PFC.[25] Improvement in mood and EEG changes have been observed with RNYB,[13] as these changes are correlated with
+serotonin level as well and serotonin has an activating effect on PFC, it appears probable that RNYB may be mediating its PFC activating
+effect via increased serotonin release from the dorsal raphe nucleus in the brainstem. Now the question arises, what makes RNYB specifically
+engage the dorsal raphe nucleus pathway? It is well known that right and LNYB have diverging effects on the autonomic nervous system,
+where RNYB causes sympathetic activation and LNYB leads to parasympathetic dominance. These effects are exerted via autonomic neurons
+in the paraventricular nucleus of the hypothalamus.[22] RNYB stimulates the paraventricular nucleus and may selectively increase
+corticotrophin releasing hormone (CRH) and cortisol by modulation of HPA axis. CRH is the stress neurotransmitter which plays an important
+role in the activation of the central sympathetic and serotonergic systems and release of serotonin from dorsal raphe nucleus has been shown to
+be mediated by the release of CRH.[26] Thus, it is hypothesized that RNYB causes prefrontal activation through HPA­CRH­dorsal raphe
+nucleus mediated serotonin release. LNYB, on the other hand, leads to parasympathetic dominance by suppressing the activation of the
+paraventricular nucleus and thereby decreasing CRH and cortisol secretion. This may exert opposing effects. It is known that neural
+connections exist between the CRH neurons in the paraventricular nucleus of the hypothalamus and noradrenergic neurons in LC.[27] Also,
+increased parasympathetic response (as observed after LNYB) could result in a decrease in both heart rate and respiration that may lead to the
+stimulation of LC by the paragigantocellular nucleus.[28] Thus, two breathing techniques may follow different pathways to cause the activation
+or deactivation of contralateral hemispheres [Figure 4]. A hypothetical mechanism can be postulated to explain the activating and deactivating
+effects of RNYB and LNYB as observed in our study: This involves HPA­LC mediated noradrenaline release to cause PFC deactivation and
+HPA­CRH­dorsal raphe nucleus mediated serotonin release to cause PFC activation [Figure 4].
+Figure 4
+Pathway showing hypothetical mechanism of action of uninostril yoga breathing on brain hemodynamics. CRH =
+Corticotrophin releasing hormone; PFC = Prefrontal cortex; RNYB = Right nostril yoga breathing; LNYB = Left nostril yoga
+breathing
+Present study has several limitations. A randomized controlled design would have been better, but this could not be achieved in the present study
+due to limited subject availability. Second, we did not assess the post­breathing baseline. The main objective of present study was to understand
+the mechanism through which uninostril yoga breathing affects cognition. Thus, this preliminary study was planned to see the effect during the
+breathing process on PFC activation. In future, we plan to assess the post­breathing effects as well to find out the duration for which the effect
+lasts after the breathing technique. Future studies should also use other comprehensive imaging techniques such as fMRI to confirm these
+findings and should observe the effect of uninostril breathings on other brain areas as well. Effect of uninostril yoga breathing on neuro­
+chemicals should also be assessed in future studies to understand the mechanism behind activation or deactivation of PFCs.[25] Future studies
+should also apply and observe the effects of uninostril yoga breathing on individuals with various psychopathologies where lateralized cerebral
+dysfunctions are prominent, viz., attention deficit hyperactivity disorder, alzheimer's disease, depression, obsessive compulsive disorder etc.[29]
+CONCLUSION
+3/1/2017
+Effect of uninostril yoga breathing on brain hemodynamics: A functional near­infrared spectroscopy study
+https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4728953/
+6/7
+Yoga breathing through a particular nostril was found to have an effect on contralateral frontal hemodynamics. This may be the probable
+mechanism behind the cognitive changes induced by uninostril yoga breathing. These findings support the relationship between nasal cycle and
+ultradian rhythm of cerebral dominance.
+Financial support and sponsorship
+Nil.
+Conflicts of interest
+There are no conflicts of interest.
+Article information
+Int J Yoga. 2016 Jan-Jun; 9(1): 12–19.
+doi:  10.4103/0973-6131.171711
+PMCID: PMC4728953
+Karamjit Singh, Hemant Bhargav, and TM Srinivasan
+Division of Yoga and Life Science, Anvesana Research Laboratories, S-VYASA Yoga University, Bengaluru, Karnataka, India
+Address for correspondence: Dr. Hemant Bhargav, S-VYASA Yoga University, Bengaluru, Karnataka, India. E-mail: [email protected]
+Copyright : © International Journal of Yoga
+This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix,
+tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
+Articles from International Journal of Yoga are provided here courtesy of Medknow Publications
+REFERENCES
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+functional near­infrared spectroscopy study. Front Psychiatry. 2014;5:29. [PMC free article] [PubMed]
+17. Krejza J, Siemkowicz J, Sawicka M, Szylak A, Kochanowicz J, Mariak Z, et al. Oscillations of cerebrovascular resistance throughout the menstrual
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+22. Telles S, Nagarathna R, Nagendra HR. Breathing through a particular nostril can alter metabolism and autonomic activities. Indian J Physiol
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subfolder_0/Effect of yoga on quality of life of CLBP patients a randomizd control study.txt

@@ -0,0 +1,899 @@
+International Journal of Yoga  Vol. 3  Jan-Jun-2010
+10
+Original Article
+Effect of yoga on quality of life of CLBP patients:  
+A randomized control study
+Padmini Tekur, Singphow Chametcha, Ramarao Nagendra Hongasandra, Nagarathna Raghuram
+Division of Yoga and Life Sciences, Swami Vivekananda Yoga Research Foundation (SVYASA), Bangalore, India
+Address for correspondence: Ms. Padmini Tekur,
+Division of Yoga and Life Sciences, Swami Vivekananda Yoga Research 
+ 
+Foundation (A Yoga University), # 19, Eknath Bhavan, 
+ 
+Gavipuram Circle, K.G. Nagar, Bangalore - 560 019, India. 
+E-mail: [email protected]; [email protected]
+DOI: 10.4103/0973-6131.66773
+INTRODUCTION
+In recent years, quality of life (QOL) has become a key 
+concept in the medical community where health care 
+places dual emphasis on treatment and quality of care. 
+The World Health Organization (WHO) defines QOL as 
+an ‘individual’s perception of his/her position in life in 
+the context of culture and value system in which they 
+live and in relation to their goals, expectations, standards 
+and concerns’.[1] It depends on a patient’s physical, 
+psychological and social responses to a disease and its 
+treatment.[2]
+One per cent of the US population is chronically disabled 
+due to CLBP
+.[3] Studies on QOL in chronic diseases including 
+CLBP point to factors such as chronicity, seriousness of the 
+episode, stress and depression that reduce the QOL.[4] CLBP 
+in women seems to be associated with the lowest quality of 
+life amongst many types of non-malignant chronic pains as 
+was observed in a survey carried out in a multidisciplinary 
+pain clinic in Netherlands.[5] 
+In CLBP, the reduction in quality of life could be 
+attributed to sleep disturbances, fatigue, medication 
+abuse[6] functional disability[7] and stress. Amongst these, 
+psychological factors such as depression, anxiety, fear 
+and anger seem to have a greater impact than biomedical 
+or biomechanical factors on CLBP related disability and 
+QOL.[8] Regression analysis in a group of 1208 chronic pain 
+patients showed that pain catastrophizing had stronger 
+association with quality of life than the intensity of 
+ 
+pain.[5] Similarly, in patients with fibromyalgia[9] and 
+Context: In two of the earlier Randomized Control Trials on yoga for chronic lower back pain (CLBP), 12 to 16 weeks of 
+intervention were found effective in reducing pain and disability.  
+Aim: To study the efficacy of a residential short term intensive yoga program on quality of life in CLBP.
+Materials and Methods: About 80 patients with CLBP (females 37) registered for a week long treatment at SVYASA Holistic 
+Health Centre in Bengaluru, India. They were randomized into two groups (40 each). The yoga group practiced a specific 
+module for CLBP comprising of asanas (physical postures), pranayama (breathing practices), meditation and lectures on yoga 
+philosophy. The control group practiced physical therapy exercises for back pain. 
+Perceived stress scale (PSS) was used to measure baseline stress levels. Outcome measures were WHOQOL Bref for quality 
+of life and straight leg raising test (SLR) using a Goniometer.
+Results: There were significant negative correlations (Pearson’s, P<0.005, r>0.30) between baseline PSS with all four domains 
+and the total score of WHOQOLBref. All the four domains’ WHOQOLBref improved in the yoga group (repeated measures 
+ANOVA P=0.001) with significant group*time interaction (P<0.05) and differences between groups (P<0.01). SLR increased 
+in both groups (P=0.001) with higher increase in yoga (31.1 % right, 28.4 % left) than control (18.7% right, 21.5 % left) group 
+with significant group*time interaction (SLR right leg P=0.044).
+Conclusion: In CLBP, a negative correlation exists between stress and quality of life. Yoga increases quality of life and spinal 
+flexibility better than physical therapy exercises. 
+Key words: Chronic low back pain; flexibility; quality of life; stress; yoga.
+ABSTRACT
+www.ijoy.org.in
+[Downloaded from http://www.ijoy.org.in on Thursday, March 03, 2011, IP: 117.211.90.10]
+11
+International Journal of Yoga  Vol. 3  Jan-Jun-2010
+CLBP
+,[10] the degree of pain, perceived disability and QOL 
+were influenced more by their mental health status than 
+the degree of physical impairment.    
+Multidisciplinary biopsychosocial rehabilitation has been 
+shown to be better than usual care in improving QOL with 
+reduction in pain and functional disability in patients with 
+chronic back pain.[11] Yoga, with its holistic approach to 
+improve overall quality of life, offers several self regulatory 
+practices that aim at correcting these psychological factors 
+that contribute to low QOL. An integrated approach to 
+yoga therapy (IAYT) that includes practices at physical, 
+breathing, mental, intellectual and emotional levels has 
+been shown to be effective in improving the QOL in several 
+chronic conditions such as fibromyalgia,[12] rheumatoid 
+arthritis[13] and cancer.[14] Our recent randomized control 
+study on patients with CLBP has shown that an intensive 
+residential short term program of IAYT can reduce the 
+intensity of pain and disability and improve spinal 
+flexibility.[15] 
+Objective
+This study was planned to: (i) compare the effect of 
+yoga with physical therapy exercises on QOL in patients 
+undergoing a short term intensive residential program for 
+CLBP (ii)  study the baseline correlations between QOL 
+and stress scores. 
+Hypothesis
+QOL in yoga group would be better than control (physical 
+exercise) as yoga is a multi-dimensional treatment modality 
+that caters to all the levels of existence.
+MATERIALS AND METHODS
+Subjects 
+A total of 160 patients with CLBP admitted to a holistic 
+health home in Bengaluru (South India) from April 2005 
+to June 2006 were screened. Of these, 80 who satisfied the 
+inclusion criteria were recruited. Statistical calculation 
+using G power software yielded a sample size of 35 per 
+group for an effect size of 0.89 (calculated from our earlier 
+interventional pilot study) with an alpha at 0.05 powered 
+at 0.8. The inclusion criteria were (a) history of CLBP of 
+more than three months (b) pain in lumbar spine with or 
+without radiation to legs and (c) age between 18 to 60 years. 
+Exclusion criteria were, (a) CLBP due to organic pathology 
+in the spine such as malignancy (primary or secondary), or 
+chronic infections checked by X ray of lumbar spine.[16] The 
+study was approved by the institutional review board and 
+the ethical committee of the university. A signed informed 
+consent was obtained from all patients.
+Study design
+In this randomized control study, 80 subjects who 
+satisfied the inclusion criteria were allotted to two 
+ 
+groups by a computer generated random number table 
+(www.randomizer.org). Numbered opaque envelopes were 
+used to implement the random allocation to conceal the 
+sequence until interventions were assigned. Magnetic 
+resonance Imaging (MRI) scans of all patients were 
+reviewed and X-ray pictures of lumbar spine (antero 
+posterior and lateral view) were obtained. Demographic 
+details vital clinical data, personal, family and stress 
+history were documented before starting the intervention. 
+Outcome variables were recorded on the first and seventh 
+day. The experimental group trained under the yoga-based 
+program whereas the control group received physical 
+therapy exercise based program. The control group went 
+on to the yoga group in the second week. Both groups had 
+the same daily routine with matched intervention [Table 1].
+Blinding and masking
+The statistician, who randomized and analysed data, and the 
+researcher who carried out the assessments were blind to the 
+subject’s group. The psychologist scored the coded answer 
+sheets of the questionnaires after completion of the study.
+Intervention
+Yoga intervention
+The specific ‘integrated yoga therapy module for low back 
+pain’ was developed by a team of two yoga experts and a 
+physiatrist. The concepts of the modules were taken from 
+traditional yoga scriptures (patanjali yoga sutra, and yoga 
+vasishtha) that highlight a holistic approach to health 
+management at physical, mental, emotional and intellectual 
+levels.[17] The practices consisted of asanas for back pain 
+(yoga postures), pranayama, relaxation techniques, 
+meditation, and lectures on yogic lifestyle, devotional 
+sessions and stress management through yogic counseling. 
+The physical practices (back pain special techniques 
+ 
+[Table 2], included simple yogic movements and 
+maintenance in the final posture of asanas that provide 
+stretch and relaxation. The safety of the practices 
+was ensured by avoiding acute forward or backward 
+movements of the spine and jerky movements while 
+designing the module.[18]
+Pranayama included yogic breathing practices to achieve 
+a slow rhythmic pattern of breathing. The instructions for 
+this included (a) slow down the breath rate, (b) exhalation 
+to be made longer than inhalation, and (c) develop an 
+internal awareness. A prolonged easy, slow exhalation is 
+the safest way to get mastery over the mind.[19] 
+Yoga in back pain
+[Downloaded from http://www.ijoy.org.in on Thursday, March 03, 2011, IP: 117.211.90.10]
+International Journal of Yoga  Vol. 3  Jan-Jun-2010
+12
+Tekur, et al. 
+Table 1: Time table for two groups for week-long residential program daily schedule of practices for yoga and 
+control group
+Time
+Yoga group
+Control group
+05.00-05.30 am
+OM meditation – 30 minutes 
+Walking - 30 minutes
+05.30-06.30 am
+Yoga based special technique – 60 minutes
+Exercise based special technique - 60 minutes
+06.30-07.30 am
+Bath and wash
+Bath and wash
+07.30-08.15 am
+Chanting of yogic hymns – 45 minutes
+Video show (on nature) – 45 minutes
+08.15-08.45 am
+Breakfast
+Breakfast
+08.45-10.00 am
+Rest
+Rest
+10.00-11.00 am
+Lecture (on yogic lifestyle) – 60 minutes
+Lecture (on healthy lifestyle) – 60 minutes
+11.00-12.00 noon
+Pranayama (yogic breathing) – 60 minutes
+Non yogic breathing practice ��� 60 minutes
+12.00-01.00 pm
+Yoga based special technique – 60 minutes
+Exercise based special technique – 60 minutes
+01.00-02.00 pm
+Lunch(vegetarian diet)
+Lunch (vegetarian diet)
+02.00-02.30 pm
+Deep relaxation technique – 30 minutes
+Rest at room – 30 minutes
+02.30-04.00 pm
+Assessments and counseling
+Assessments and counseling
+04.00-05.00 pm
+Cyclic meditation – 60 minutes
+Listening to music – 60 minutes
+06.15-06.45 pm
+Divine hymns session (Bhajan) – 30 minutes
+Video show (on nature) – 30 minutes
+06.45-07.45 pm
+Meditation with yogic chants (Mind sound resonance 
+technique) – 45 minutes
+Walking – 45 minutes
+07.45-08.30 pm
+Dinner (vegetarian diet)
+Dinner (vegetarian diet)
+08.30-10.00 pm
+Self study
+Self study
+Hour to hour matching for the type of practices for the two groups was ensured
+Table 2: 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
+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
+Meditation, considered to be a part of yoga, (antaranga 
+yoga) is a valuable tool to calm down uncontrollable surge 
+of negative emotions. Since most patients with CLBP have 
+a component of psychological stress that may contribute to 
+poor quality of life, meditation and devotional sessions are 
+relevant to correct the problem in a holistic way. Lectures 
+and individual yogic counseling for stress management 
+to bring about a notional correction were focused on 
+‘happiness analysis’.[20]
+This analysis helps the patient (a) cognize the source 
+and pattern of their emotional responses, (b) restore 
+freedom to change the emotional responses to chronic 
+pain and  demanding life situations and (c) learn to stay 
+on in the blissful bed of inner silence  achieved during 
+all joyful moments of life. Thus the IAYT for back pain 
+had a multidimensional approach to promote positive 
+mood and well being through techniques for physical 
+relaxation, breath manipulation to calm down the mind 
+and counseling sessions for cognitive change. 
+Control intervention	
+The practices consisted of a set of physical movements 
+(certified by the senior physiatrist – Table 3), non-yogic 
+safe breathing exercises, lectures on scientific information 
+including (a) causes of back pain, (b) stress, QOL and CLBP 
+and (c)  benefits of physical exercises. For the experimental 
+group, video shows on animals, plants, nature etc. were 
+used as placebo to engage them during the time when the 
+yoga group had video shows on yoga or going through 
+yogic counseling.
+Outcome variables
+Quality of life
+WHOQOL-BREF is a standardized comprehensive 
+instrument for assessment of QOL comprising of 26 items 
+and was developed by the WHO. The scale provides a 
+measure of an individual’s perception of quality of life 
+for the four domains: (1) physical health (seven items) (2) 
+psychological health (six items) (3) social relationships 
+(three items) and (4) environmental health (eight items). 
+In addition, it also includes two questions for ‘overall 
+quality of life’ and ‘general health’ facets. The domain 
+scores are scaled in a positive direction (i.e., higher 
+scores denote higher quality of life). The range of scores 
+is 4-20 for each domain. The internal consistency of 
+WHOQOL-BREF ranged from 0.66-0.87 (Chronbach’s 
+[Downloaded from http://www.ijoy.org.in on Thursday, March 03, 2011, IP: 117.211.90.10]
+13
+International Journal of Yoga  Vol. 3  Jan-Jun-2010
+alpha co-efficient). The scale has been found to have good 
+discriminant validity.[1] It has good test retest reliability and 
+is recommended for use in health surveys and to assess the 
+efficacy of any intervention at suitable intervals according 
+to the need of the study.
+Perceived stress scale
+The perceived stress scale (PSS) measures a global 
+perception of stress response on a continuum from mild 
+to severe.[21] It has 10 items asking the subject to rate how 
+often they have perceived an event in their life over the 
+last month. The measure has good reliability, validity and 
+internal consistency with a Cronbach’s alpha of 88. It has 
+been widely used, is general in nature, and brief. We have 
+used it only for baseline correlations with QOL and not 
+after the intervention as it cannot be administered before 
+one month for retest.
+Straight leg raising test[22]
+A goniometer (Anand Agencies, Pune) that has two scales 
+fixed at one end to a compass (calibrated in degrees), was 
+used to measure straight leg raising (SLR). It was placed 
+with the stationary arm parallel to the edge of the table, the 
+moving arm along the lateral midline of the thigh and the 
+axis over the superior half of the greater trochanter. Then 
+the leg was raised passively until the patient reported pain. 
+The angle between the two scales is read on the compass. 
+The procedure is repeated on both sides
+Other measurements taken in this group of patients to assess 
+disability, spinal flexibility, severity of pain,[15] anxiety and 
+depression have been reported (under revision) as different 
+publications 
+Data extraction
+PSS was assessed using a five-point scale (0=never; 
+4=very often). The scores on four items that were worded 
+in the opposite direction were reverse-scored as per the 
+instructions in the manual. The sum of the scores on all 
+10 items was the total PSS score.[21]
+WHOQOLBref: After scoring, the mean values for total and 
+individual domains were computed. These were multiplied 
+by four to obtain the final score comparable to WHOQOL 
+100 as indicated in the manual.[1]
+Data analysis
+Data was analyzed using SPSS version 10.0. Statistical tests 
+used included Kolmogorov–Smirnov’s test for normality 
+of baseline data, independent samples ‘t’ for baseline 
+matching of the two groups, repeated measures ANOVA 
+for group*time interaction followed by post hoc analysis 
+for within and between group differences and Pearson’s 
+correlation test for correlations.
+RESULTS
+Figure 1 shows the study profile. There were no drop outs as 
+this was a residential short term program. The two groups, 
+yoga and control (40 each), were similar with respect to 
+socio-demographic and medical characteristics [T
+able 4]. The 
+baseline data for all variables were normally distributed and 
+did not differ significantly between groups (P>0.05). T
+able 5 
+shows the results of all variables. There were no adverse events.
+Perceived stress scale
+PSS was used only for baseline assessments and correlations 
+with QOL. The mean scores of PSS for the whole group 
+ 
+(n=80) was higher (18.80 plus/minus 6.22) than the 
+normative mean value (14.1) for normal adult Indians.[21] 
+There were 60 patients (31 in yoga and 29 in control) who had 
+scores greater than 14. Correlations between scores of PSS 
+and total WHOQOL Bref in the whole group (n=80) showed 
+Experimental Group 40
+Control Group 40
+Final Analysis on 40
+Control group
+Final Analysis on 40
+Experimental group
+80 Satisfied selection criteria
+Randomly Assigned
+126 interested in participation
+120 Self Referred
+40 Referred by physicians
+Figure 1: Trial profile
+Yoga in back pain
+Table 3: 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
+[Downloaded from http://www.ijoy.org.in on Thursday, March 03, 2011, IP: 117.211.90.10]
+International Journal of Yoga  Vol. 3  Jan-Jun-2010
+14
+significant negative correlations at r=0.59, (P=0.01). The 
+correlations between PSS and the four domains were as 
+follows. physical r=0.31, (P=0.005); psychological r=0.48 
+(P<0.001); social r=0.46 (P<0.001) and environmental 
+r=0.39, (P<0.001).
+WHOQOL BREF 
+T
+able 5 shows the results after the intervention in the two 
+groups. There was significant group*time interaction and 
+difference between groups on all domains at P<0.01. Within 
+group analysis showed significant improvement in yoga group 
+and non-significant change in control group on all domains.
+Straight leg raising 
+There was significant increase in SLR in both groups at 
+P<0.001 with significant group*time interaction for SLR 
+right side at P=0.04. 
+DISCUSSION
+This randomized control study on 80 patients with CLBP
+, 
+who underwent a residential intensive training program 
+for one week, showed that there was significant negative 
+correlation in the baseline values of PSS with all domains 
+of WHOQOL. There was significantly better (P<0.01) 
+improvement in quality of life on all domains of WHO 
+QOL and SLR (right) in yoga than control group. 
+About 75% (60/80) of this group of patients with CLBP 
+had stress levels above 14.1 (limiting value for Indians).[21] 
+The negative correlation observed in this study supports 
+earlier observations of ‘higher the stress levels lower the 
+QOL’ (1). Subjective experience of one’s own life in the 
+light of altered external stressors such as financial strain 
+or family responsibilities[23] can lead to fear of uncertainty 
+of the future[24] resulting in a viscous loop contributing to 
+poor quality of life.[25] 
+A study on the relationship between chronic pain and 
+health related quality of life (HRQOL) showed that 58% of 
+patients had depression and anxiety with severe reduction 
+in physical, psychological and social well-being.[26] 
+A predictable relationship between HRQOL with functional 
+status and psychological factors has also been documented.[27,28]
+Several non-pharmacological interventions including 
+‘back school program’,[29] mindfulness based meditation,[30]
+cognitive behavior modification[7] and multidisciplinary 
+programs[31] have been shown to be effective in reducing 
+Table 4: Demographic data
+Variables
+Yoga
+Control
+Number of participants
+40
+40
+Males (M)
+19
+25
+Females (F)
+21
+15
+Age (mean ± SD)
+49 ± 3.6
+48 ± 4
+Education
+a) High school
+M-3, F-11
+  M-5, F-3.
+b) College
+M-10, F-8
+ M-13, F-10
+c) Post graduate
+  M-6, F-2
+  M-7, F-2
+Males
+Working-sedentary
+14
+16
+Working-non sedentary
+5
+8
+Females
+Working
+6
+7
+Housewives
+15
+8
+CLBP
+< 1 year
+10
+11
+1-5 years
+9
+11
+5-10 years
+11
+10
+> 10 years
+10
+8
+Cause
+Lumbar spondylosis (LS)
+6
+5
+Prolapsed intervertebral
+6
+7
+LS with PID
+19
+15
+Muscle spasm
+9
+13
+Tekur, et al. 
+Table 5: Results of all variables post intervention (Repeated measures ANOVA)
+Within groups
+Between 
+groups
+Yoga
+Control
+Variable
+Mean ± SD
+95% CI
+ES
+% 
+change
+P 
+values
+Mean ± SD
+95% CI
+ES
+% 
+change
+P 
+values
+ES
+P 
+value
+PHY
+Pre
+11.87 ± 2.5
+11.07 to 12.67
+1.19
+27.55 <0.001 12.49 ± 2.26
+11.76 to 13.21
+0.25
+4.96
+0.113 0.253 0.001
+Post
+15.14 ± 1.56 14.64 to 15.64
+13.11 ± 2.17
+12.42 to 13.81
+PSYCH
+Pre
+13.15 ± 2.34
+12.40 to 13.9
+0.85
+15.82 <0.001 13.12 ± 2.42
+12.34 to 13.89
+0.08
+1.75
+0.588 0.085 0.001
+Post
+15.23 ± 1.34 14.81 to 15.66
+13.35 ± 2.71
+12.48 to 14.22
+SOC
+Pre
+13.43 ± 3.32 12.38 to 14.49
+0.43
+10.17
+0.001
+13.50 ± 3.30
+12.44 to 14.56
+0.47
+3.45
+0.291
+0.60 0.004
+Post
+14.80 ± 2.71 13.93 to 15.67
+13.03 ± 3.16
+12.02 to 14.04
+ENV
+Pre
+13.45 ± 2.2
+12.75 to 14.15
+0.54
+8.77
+0.001
+13.44 ± 2.32
+12.70 to 14.18
+0.03
+0.45
+0.811 0.036 0.017
+Post
+14.63 ± 1.6
+14.11 to 15.14
+13.50 ± 2.16
+12.81 to 14.19
+SLRR
+Pre
+57.95 ± 20.23 51.48 to 64.42
+1.14
+31.14
+0.001
+57.68 ± 24.65
+49.79 to 65.56
+0.99
+18.67
+0.001 0.407 0.04
+Post 76.00 ± 16.38 70.76 to 81.24
+68.45 ± 20.48
+61.90 to 75.00
+SLR L
+Pre
+59.00 ±18.54 53.07 to 64.93
+1.19
+28.38
+0.001
+56.30 ± 23.71
+48.72 to 63.88
+0.70
+21.45
+0.001 0.430 0.16
+Post 75.75 ± 15.04 70.94 to 80.56
+68.38 ± 19.03
+62.29 to 74.46
+PHY = Physical health, PSYCH = Psychological health, SOC = Social health, ENV = Environment, area domains of WHOQOL Bref. SLRR = Straight leg raising 
+right side, SLRL = Straight leg raising left side, CI = Confidence interval, ES = Effect size
+[Downloaded from http://www.ijoy.org.in on Thursday, March 03, 2011, IP: 117.211.90.10]
+15
+International Journal of Yoga  Vol. 3  Jan-Jun-2010
+pain, disability and improving QOL in CLBP
+. There are no 
+studies on effect of yoga on QOL in CLBP
+. 
+Deshpande et al. have shown the beneficial effect of a non-
+residential integrated yoga program that assessed the QOL 
+using WHO QOL100 on 184 normal volunteers in south 
+India.[32] We have used these scores for comparison with 
+our scores on WHOQOL Bref in CLBP patients. 
+Physical health
+The baseline scores for this domain (mean 11.9) in CLBP 
+(present study) patients were lower than the scores (mean 
+13.8) in normal volunteers.[32] After yoga it increased to 
+14.5 in normal volunteers and 15.14 in patients with CLBP 
+pointing to the normalizing effect of yoga on physical QOL. 
+This domain of WHOQOLBref deals with features such 
+as mobility, fatigue, pain, sleep, work capacity etc The 
+observed improvement can be attributed to reduction in 
+pain and disability with improvement in spinal flexibility.[15] 
+Other studies on integrated yoga in healthy children and 
+adults have shown better physical stamina[33] dexterity and 
+eye hand coordination.[34] Better quality and duration of 
+sleep after yoga has been reported in the elderly.[35]
+Psychological health
+There was a significant (20%) improvement in yoga 
+group with non- significant change in control group. The 
+baseline values were much lower (mean 13.0) than normal 
+volunteers (14.7) and increased (15.2 in CLBP) similar to 
+normal volunteers (15.5) after yoga. The improvement 
+seen in this domain that deals with questions relating 
+to feelings, self esteem, spirituality, thinking, learning, 
+memory etc. may be attributed to reduction in anxiety 
+and depression. Several studies have shown the effect 
+of yoga in reducing anxiety[36] depression[37] and stress[38] 
+with enhanced mental health as observed by improved 
+perceptual sharpness,[39] memory[40] and better information 
+processing at the thalamic level.[41]
+Social health
+The mean scores changed from 13.0 to 14.8 in CLBP 
+patients and 14.8 to 15.2 in normal volunteers. This 
+domain has questions relating to problems in interpersonal 
+relationships, social support etc which could be the 
+main source of stress contributing to spinal pain. They 
+were addressed during lectures and at a personal level in 
+yoga counseling sessions. They were aimed at achieving 
+an introspective cognitive change by recognizing the 
+psychological freedom ‘to react, not to react or change 
+the usual pattern of reaction to situations’ highlighted 
+in yoga texts.[17] This would have resulted in reversal of 
+the biochemical processes and opened up the connective 
+tissue plasticity.[42]
+Environmental health
+The mean value in this domain which was lower (12.8) than 
+normal (14.5) improved significantly to reach normalcy 
+(14.6) after yoga and not after physical exercises. This 
+domain has questions that deal with problems relating to 
+financial resources, physical safety, physical environment 
+such as pollution, noise, climate etc. One of the definitions 
+of yoga (Bhagavad-Gita) says that yoga results in equanimity 
+and balance (samatavam) that can help in better tolerance 
+to environmental changes (sheeta ushna samah-tolerence 
+to heat or cold). Studies have shown that yoga changes 
+the physiological responses to stressors by improving 
+autonomic stability with better parasympathetic tone in 
+normal adults[43] and reducing sympathetic arousal with 
+improved performance in congenitally blind children[44] 
+and community home girls.[45]
+Yoga texts explain how integrated yoga techniques help 
+in improving the quality of life. Voluntary reduction 
+in violence and aggressiveness[46] during emotional 
+reactions of anxiety[47] or depression[37] is achieved through 
+restful awareness during all the practices in general and 
+meditation in particular.[48] This mastery over emotional 
+surges leads to controlled and need based physiological 
+responses to stressfully demanding situations instead of 
+uncontrolled overtones of HPA axis[49,50] during chronic 
+pain. 
+CONCLUSION
+This randomized control study has shown that patients 
+with CLBP had high stress levels with a negative 
+correlation with QOL. A week long residential intensive 
+yoga program increased the QOL and spinal flexibility 
+better than physical therapy exercises for CLBP
+. 
+Limitations of the study include
+(i)	
+Since both groups were in the same campus, the 
+possibility of some interaction and exchange of 
+ideas could not be ruled out, although special 
+care was taken to keep the groups engaged 
+independently
+(ii)	
+Short term intervention of one week may be 
+considered a major limitation. A follow-up of 
+patients who were asked to continue the practices 
+daily (one hour) with the help of video and audio 
+instructions is planned
+Suggestions for future work
+(i)	
+Generalization of this program for different cultures 
+needs to be assessed
+(ii)	
+Objective measures such as EMG may be included
+(iii)	
+Three arm studies that combine yoga during 
+physiotherapy may show synergistic effects
+Yoga in back pain
+[Downloaded from http://www.ijoy.org.in on Thursday, March 03, 2011, IP: 117.211.90.10]
+International Journal of Yoga  Vol. 3  Jan-Jun-2010
+16
+ACKNOWLEDGMENTS
+We are thankful to Dr. Kulkarni R and Mr. Pradhan B who helped 
+with the statistical analysis of data. Our thanks are due to 
+ 
+Dr. Usha Rani, for her help in scoring the questionnaires. We thank 
+all the staff of SVYASA for their cooperation in conducting the 
+program, the director of Jubilee Camdarc institute for taking the 
+X-rays and Dr. E. John, who gave his second opinion on the X-rays. 
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+Gopinath KS, et al. Influence of yoga on mood states, distress, quality of 
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+intensive yoga program on pain, functional disability and spinal flexibility 
+in chronic low back pain: A randomized control study. J Altern Complement 
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+Mission Institute of Culture; 1996.
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+22.	 Hsieh CY, Walker JM, Gillis K. Straight-leg-raising test: Comparison of three 
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+ 
+et al. Why do doctors find some patients difficult to help? Quarterly J Med 
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+malignant pain patients referred to a Danish multidisciplinary pain centre. 
+Pain 1997;73:393-400.
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+Predicting health-related quality of life in patients with low back pain. Spine 
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+predictors of health-related quality of life and health service utilisation in 
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+31.	 Sjöström R, Alricsson M, Asplund R. Back to work-evaluation of a 
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+32.	 Deshpande S. Influence of yoga on quality of life a randomized control study 
+[PhD, Thesis]. Bengaluru: Swami Vivekananda Yoga University; 2007.
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+in community home girls trained yoga or sports and in regular school girls. 
+Indian J Physiol Pharmacol 1997;41:409-15.
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+in a mirror tracing task. Indian J Physiol Pharmacol 2006;50:187-90.
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+in a geriatric population. Indian J Med Res 2005;121:683-90.
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+stress reduction and anxiolysis among distressed women as a consequence 
+of a three-month intensive yoga program. Med Sci Monit 2005;11:555-61.
+37.	 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.
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+39.	 Telles S, Nagarathna R, Nagendra HR. Improvement in visual perception 
+following yoga training. J Indian Psychol 1995;13:30-2.
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+particular nostril increases spatial memory scores without lateralized effects. 
+Psychol Rep 1997;81:555-61.
+41.	 Telles S, Joseph C, Venkatesh S, Desiraju T. Alterations of auditory middle 
+latency evoked potentials during yogic consciously regulated breathing and 
+attentive state of mind. Int J Psychophysiol 1993;14:189-98.
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+can alter metabolism and autonomic activities. Indian J Physiol Pharmacol 
+1994;38:133-7.
+44.	 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.
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+17
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+45.	 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. Perceptual Motor Skills 1997;84:251-7.
+46.	 Deshpande S, Nagendra HR, Nagarathna R. A randomized control trial of 
+the effect of yoga on verbal aggressiveness in normal healthy volunteers. Int 
+J Yoga 2008;1:76-82.
+47.	 Miller JJ, Fletcher K, Kabat-Zinn J. Three-year follow-up and clinical 
+implications of a mindfulness meditation-based stress reduction 
+Yoga in back pain
+intervention in the treatment of anxiety disorders. Gen Hosp Psychiatry 
+1995;17:192-200.
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+[Downloaded from http://www.ijoy.org.in on Thursday, March 03, 2011, IP: 117.211.90.10]

subfolder_0/Effect of yoga relaxation techniques on performance of DLST by teenagers.txt

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+International Journal of Yoga 
+ 
+ 
+ 
+Vol. 2:1 
+ 
+ 
+ 
+Jan-Jun-2009
+30
+Effect of yoga relaxation techniques on performance of  
+digit–letter substitution task by teenagers
+	
+Balaram Pradhan, Nagendra H R
+Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana, Bangalore, India
+Address for correspondence: Dr. Nagendra H. R., 
+ Vice Chancellor of Swami Vivekananda Yoga Anusandhana Samsthana, 
+ 
+# 19, K.G. Nagar, Bangalore – 560 019, India. 
+ 
+E-mail: [email protected]
+DOI: 10.4103/0973-6131.43293
+Original Article
+Background/Aims: Memory and selective attention are important skills for academic and professional performance. Techniques 
+to improve these skills are not taught either in education or company training courses. Any system which can systematically 
+improve these skills will be of value in schools, universities, and workplaces.  Aims:To investigate possible improvements in 
+memory and selective attention, as measured by the Digit–Letter Substitution Task (DLST), due to practice of Cyclic Meditation 
+(CM), a yoga relaxation technique, as compared to Supine Rest (SR).
+Materials and Methods: Subjects consisted of 253 school students, 156 boys, 97 girls, in the age range 13–16 years, who 
+were attending a 10-day yoga training course during summer vacation. The selected subjects had English as their medium 
+of instruction in school and they acted as their own controls. They were allocated to two groups, and tested on the DLST, 
+immediately before and after 22.5 minutes practice of CM on one day, and immediately before and after an equal period of SR 
+on the other day. The first group performed CM on day 9 and SR on day 10. For the second group, the order was reversed. 
+Results: Within each group pre-post test differences were significant for both the relaxation techniques. The magnitude of net 
+score improvement was greater after SR (7.85%) compared to CM (3.95%). Significance levels were P < 0.4 x 10-9 for SR and 
+P < 0.1 x 10-3 for CM. The number of wrong attempts also increased significantly on both interventions, even after removing 
+two outlier data points on day 1 in the SR group.
+Conclusions: Both CM and SR lead to improvement in performance on the DLST. However, these relaxation techniques 
+lead to more wrong cancellation errors. 
+Key words: DLST; yoga; relaxation; meditation. 
+Abstract
+introduction
+Over the past thirty years or more, yoga and associated 
+meditation techniques have come to be accepted as important 
+means of reducing effects of stress.[1] A wide variety of 
+studies in these fields have been done,[2-4] and in one of 
+them different techniques such as progressive muscular 
+relaxation, biofeedback, relaxation, and mental imagery 
+were compared by meta-analysis.[5] One study concluded 
+that different techniques produce different spectrum of 
+effect sizes for different tasks.[6] The early hypothesis by 
+Benson[7] that there is a universal ‘relaxation response’ that 
+is same for any technique has been convincingly refuted.[8] 
+Rather it is recognized that each technique produces effects 
+in specific brain regions, and that precise magnitude of 
+benefits for a particular task depends on the extent to which 
+that brain region is used in task performance. 
+Today, the most effective of these techniques are well 
+accepted as being of substantial benefit for stress in 
+the workplace and in other aspects of life, and are 
+widely taught as specific coping skills, particularly for 
+professionally incurred stress. These stress-reduction 
+techniques have been found useful in reducing a 
+variety of stress-related symptoms, such as anxiety, 
+neuroticism, depression, and hypertension. For example, 
+‘Deep Breathing Meditation Exercises’ have been 
+reported to decrease anxiety, nervousness, self-doubt, 
+and concentration loss.[9] They have also been found 
+to improve measures of emotional intelligence.[10] Such 
+techniques are most effective when practiced daily for 
+an extended period of time.[11]
+In addition to reduction in stress symptoms, beneficial 
+[Downloaded free from http://www.ijoy.org.in on Thursday, March 04, 2010]
+31
+International Journal of Yoga 
+ 
+ 
+ 
+Vol. 2:1 
+ 
+ 
+ 
+Jan-Jun-2009
+effects of various relaxation techniques include: feeling 
+of well-being, sense of calmness and relaxation in activity, 
+improved sleep, less emotional reactivity, increased inner 
+directedness (self-awareness), and improved self-care.[12] 
+Improved performance has also been found on a variety 
+of psychological tests, such as IQ,[13] Tower of London 
+Test,[13,14] Baddley Tests of Verbal and Spatial Memory,[15,16] 
+Six Letter Cancellation Test (SLCT),[17] and so on. 
+In this study, the influence of yoga relaxation techniques 
+on performance of the Digit–Letter Substitution Task 
+(DLST) was investigated. The DLST depends on selective 
+attention and memory. It is easily understood and 
+performed and suitable for subjects of all ages, including 
+school students. It was therefore given to participants in 
+a 10-day personality development camp held for early 
+teenage school students during their summer vacation. 
+The two techniques chosen were the easily performed 
+Cyclic Meditation (CM) developed at sVYASA,[18] and 
+the Supine Rest (SR) position known as ‘sleep posture’ 
+(shavasana), generally done at the end of yogasana 
+practice. The reasons are as follows. 
+Shavasana has been found to reduce physiological 
+arousal,[19] and to be effective in helping practitioners 
+cope with stress manifestations, for example, Bera et al. 
+found recovery from induced physiological stress was 
+significantly faster for supine posture with additional 
+progressive relaxation, compared to resting, sitting in 
+a chair, or plain shavasana (SR).[20] In another study, 
+a significant decrease in breath rate was noted after 
+performance of the yoga-based Isometric Relaxation 
+Technique (IRT), when compared to SR.[21] IRT forms an 
+integral part of the CM, which we now describe in detail. 
+CM combines ‘stimulating’ and ‘calming’ practices. Such 
+yoga practice is described in the Mandukya Karika, 
+a text associated the Mandukya Upanishad, which 
+suggests that such a combination is helpful in attaining 
+mental equilibrium. CM consists of the practice of yoga 
+postures (asanas) interspersed with periods of relaxation 
+in shavasana. After the period of practice, significant 
+reductions in oxygen consumption occur, compared 
+to an equal period of shavasana.[22,23] CM has been 
+found particularly effective in relieving stress, and is 
+ 
+widely applied in professional stress management programs. 
+Recent studies on CM suggest that during the yoga posture 
+phase, predominantly sympathetic activation occurs, 
+whereas after CM, the parasympathetic nervous system 
+becomes dominant.[24] The overall result is a greater 
+reduction in energy expenditure than in SR.[25] CM has 
+also been found to enhance the P300 wave in the evoked 
+potential,[26] a fundamental cognitive process involving 
+attention and immediate memory.[27] 
+Since the DLST involves memory and selective attention, 
+it was hypothesized that CM would increase performance 
+on the test. For convenience of subject availability, it 
+was decided to study changes on DLST scores after 
+performance of CM, compared to SR, in school students 
+attending one of sVYASA's summer vacation 10-day 
+personality development camps. 
+MATERIALS AND METHODS
+Subjects
+The subjects in the study were school students attending 
+a 10-day yoga training course during their summer 
+vacation. Since the protocol for the DLST is given in 
+English, subjects were selected first, for being between 
+ages 13 and 16; and second, for English being their 
+medium of instruction in school. Exclusion criteria 
+included: first, any history of neurological or psychiatric 
+disturbance; second, use of any medication affecting the 
+central nervous system; third, any history of learning 
+disability; and last, insufficient proficiency in English to 
+understand how to take the test. Twelve further students 
+were eliminated when they made excessive numbers of 
+wrong substitutions on a preliminary test. (Two further 
+subjects were eliminated for similar reasons after the first 
+test, see data analysis.) Of more than 300 students in the 
+correct age range attending the yoga training camp, 253 
+(156 boys and 97 girls) were selected. The mean age for the 
+group was 13.95 ± 0.99 years [Table 1]. Study participants 
+were given a complete description of the study, following 
+which they were asked to give written informed consent. 
+Since the comparison study protocol required two equal 
+groups with the order of the two interventions reversed, 
+the 253 subjects were allocated to two groups of 133 (80 
+boys and 53 girls) and 120 (76 boys and 44 girls). 
+Procedure
+As participants in the yoga personality development camp, 
+all the subjects were trained in the practice of both CM and 
+SR over the 7-day period preceding the start of the study. 
+Rather than being a random control design, the study was 
+self-controlled, with all study participants being measured 
+before and after a period of CM, and before and after a 
+similar period of SR. The two sets of measurements took 
+place on successive days at the end of the yoga camp, 
+days 9 and 10. In order to allow for any possible learning 
+process that might have resulted from the first day’s tests, 
+Table 1: Age group mean ± standard deviation of 
+study subjects
+	
+Mean  ±  SD	
+n
+Girls	
+14.02 ± 1.02	
+97
+Boys	
+13.91 ± 0.97	
+156
+Total	
+13.95 ± 0.99	
+253
+Mental speed task performance task in children
+[Downloaded free from http://www.ijoy.org.in on Thursday, March 04, 2010]
+International Journal of Yoga 
+ 
+ 
+ 
+Vol. 2:1 
+ 
+ 
+ 
+Jan-Jun-2009
+32
+the subjects were allocated to two equal-sized groups, 
+with the first group doing CM on day 9 and SR on day 10, 
+and the second group with the order reversed. Subjects 
+were tested on the DLST, immediately before and after a 
+session of CM of 22.5 minutes duration on one day, and 
+immediately before and after an equal period of SR on 
+the other day. 
+Instrument 
+The DLST worksheet consists of a 8 rows x 12 columns 
+array of random digits 1–9. Subjects are seated with the 
+worksheet upside down until the start of the test. They 
+were also given a coding sheet naming the specific letter 
+to substitute for each digit 1–9 in that particular test, the 
+same coding applying to an entire test group. Subjects 
+were instructed to make their own choice of letter 
+substitution strategy, whether horizontally, vertically, or 
+selecting each particular digit randomized in the array one 
+at a time. They were told to substitute as many target digits 
+as possible in the specified time of 90 seconds. Finally, 
+they were instructed to turn over the worksheet and start 
+the test. Each test was timed on a standard stopwatch. 
+Because the tests were administered with such a short 
+intervening time interval, immediately before and after an 
+intervention of only 22.5 minutes, different worksheets 
+and coding were used for each test, with different digit–
+letter pairing in the key and differently randomized arrays 
+of digits on the worksheet.
+Scoring the DLST counts both the total number of 
+substitutions attempted, and the number of wrong 
+substitutions. Net score is obtained by deducting the 
+latter from the former. Scoring was carried out by persons 
+unaware of when the assessment was made, whether it 
+was ‘before’ or ‘after’ the intervention, or whether the 
+subject was engaged in CM or SR on that day. 
+The use of this DLST protocol to study immediate effects 
+has already been validated for the Indian population.[28] 
+Intervention
+Subjects were instructed to keep their eyes closed 
+throughout the time periods of practice of both CM and 
+SR. CM used prerecorded instructions, which emphasized 
+the need to carry out the practice slowly, with awareness 
+and relaxation. The practice starts with subjects lying on 
+their backs in shavasana and consists of the following 
+sequence: 
+•	 Repetition of a verse from the Mandukya Upanishad[29] 
+(0:40 minutes). 
+•	 Isometric contraction of the muscles of the body ending 
+with supine rest (1:00 minutes).
+•	 Slowly coming up from the left side and standing at 
+ease (tadasana), ‘balancing’ the weight on both feet, 
+called centering (2:00 minutes). 
+•	 The first stretching posture, bending to the right 
+(ardhakatichakrasana) (1:20 minutes). 
+• Tadasana with instructions about relaxation and 
+awareness (1:10 minutes). 
+• Ardhakatichakrasana bending to the left (1:20 
+minutes). 
+• Tadasana as previously (1:10 minutes). 
+•	 Forward bending (padahastasana) (1:20 minutes). 
+• Tadasana as previously (1:10 minutes). 
+•	 Backward bending (ardhachakrasana) (1:20 minutes). 
+•	 Slowly coming down into the supine posture 
+(shavasana) with instructions to relax different parts 
+of the body in sequence (10:00 minutes). 
+All postures are practiced slowly, with instructions to be 
+aware of all felt sensations. Total duration of practice is 
+22.5 minutes.[18]  
+During the sessions of SR, subjects lie on their back in 
+sleep posture (shavasana) with eyes closed, legs apart, and 
+arms away from the sides of the body. This practice was 
+also given for 22.5 minutes, the same as for CM, timed 
+on a stopwatch.
+To allow for any possible learning effect, the two groups 
+received the two interventions in reverse order.
+Data analysis
+Statistical analysis was done using SPSS (version 10.0). 
+The Kolmogorov test of normality showed that the total 
+scores and net score data were normally distributed, but 
+that wrong substitutions data were not (Kolmogorov–
+Smirnov test, P < 0.05). Hence, Student’s paired ‘t’ test 
+was used for total and net scores, and the nonparametric 
+Wilcoxon signed ranks test was used for the analysis of 
+wrong substitutions, specifically for within group pre-
+post comparisons for both CM and SR. The first day 
+SR group contained two outliers with 9 and 10 wrong 
+substitutions, respectively. Since these were over five 
+standard deviations from the mean, they were removed, 
+and the data analyzed without them included. 
+RESULTS
+Mean values and standard deviation for total scores, 
+wrong substitutions, and net scores on all tests are given 
+in Table 2. 
+There were significant differences on DLST net scores 
+between sessions for the same group, and between groups 
+for the same session. For the whole group of 253 students, 
+Pradhan and Nagendra
+[Downloaded free from http://www.ijoy.org.in on Thursday, March 04, 2010]
+33
+International Journal of Yoga 
+ 
+ 
+ 
+Vol. 2:1 
+ 
+ 
+ 
+Jan-Jun-2009
+the increase in net score means were 7.85% after SR, 
+and 3.95% after CM; both were highly significant: P < 
+0.4 x 10–9 for SR and P < 0.1 x 10–3 for CM. In addition, 
+both groups made more errors after the interventions, 
+118.18% after SR and 166.31% after CM, with Wilcoxon 
+signed ranks test significances of P < 0.5 x 10–2 and P 
+< 0.4 x 10–2, respectively. The SR wrong substitutions 
+data contained two further outliers, who were removed 
+and the data reanalyzed. Group performance on wrong 
+substitutions data is significant in its implications for 
+the wakeful alertness of subjects after these forms of yoga 
+relaxation. Finally, the scores of the two subgroups were 
+analyzed for the first time they took the test on both days. 
+This revealed very significant learning to have taken place, 
+vindicating the protocol’s use of a reverse order for the 
+delivery of the two interventions to the two subgroups on 
+the two days of testing. 
+DISCUSSION
+A study by Patil and Telles[30] assessed performance on 
+the related SLCT immediately before and after CM and 
+SR. Protocol design was similar with two subgroups 
+doing both interventions in opposite order. Net scores 
+were significantly higher after both practices, though the 
+magnitude was more after CM than SR (24.9 vs 13.6%). 
+Wrong cancellation scores decreased after CM, but not after 
+SR – controls showed no change. CM seems to improves 
+some of the skills used in SLCT performance – selective 
+attention, concentration, visual scanning abilities, and 
+repetitive motor response.[16] This suggests that DLST 
+performance should also improve after performing both 
+kinds of relaxation.
+It was therefore not unexpected that DLST performance 
+should improve immediately after both types of yoga-
+based relaxation sessions. However, results were different 
+from SLCT: in contrast, for DLST, SR sessions produced 
+better performance than did CM. Pre-post improvements 
+on net scores were almost twice as much for SR as for CM 
+(7.85 vs 3.95%). 
+In addition, the changes in wrong substitution scores after 
+CM and SR suggest that subjects may have become drowsy 
+by the end of the intervention period. 
+The differences almost certainly arose because the 
+DLST depends on different components of psychomotor 
+performance from the SLCT, namely: (a) sensory 
+information processing ability; (b) central integration 
+of learning and memory, and (c) motor function and 
+coordination.[31] The DLST was developed from Digit 
+Symbol Substitution Test (DSST), one of the subsets of 
+the Wechsler intelligence scale.[32] Substitution tests are 
+essentially speed-dependent tasks that require the subject 
+to match particular signs – symbols, digits, or letters – to 
+other signs within a specified time period. The DLST 
+has the advantage of using letters and digits, signs that 
+are already well-known to those taking the test.[33] Thus, 
+there is no question of a need to learn new symbols 
+while being tested. Such learning ability is definitely 
+not one of the aptitudes on trial. For this reason, the 
+DLST was used instead of the DSST.[34] Substitution tasks 
+involve visual scanning, mental flexibility, sustained 
+attention, psychomotor speed, and speed of information 
+ 
+processing.[35,36] Our finding, that both CM and SR enhance 
+task performance, suggests that one of more of these skills 
+is being improved, probably sustained attention.
+Previous results also show that CM practice reduces 
+physiological arousal (decreases in oxygen consumption 
+and minute ventilation are observed),[22,23] increases 
+parasympathetic dominance,[24] and decreases energy 
+expenditure.[25] These changes occur together with 
+decreased latency and increased amplitude in the 
+ 
+P300.[26] P300 event-related potentials (EPR) reflect 
+fundamental cognitive events requiring attention and 
+immediate memory processes.[27] They also reflect cognitive 
+brain functions like sequential information processing, 
+stimulus discrimination, and short-term memory.[37] 
+Increases in EPR amplitude with attention suggest greater 
+cognitive processing capacity.[38] Neuropsychological tests 
+assessing how rapidly attentional resources are allocated 
+for memory processing[39,40] associate shorter EPR latency 
+with improved cognitive performance. Altogether, these 
+results suggest that CM reduces physiological arousal, 
+simultaneously improving performance on tasks requiring 
+attention. Further studies are required to understand 
+which mechanisms improve task performance. For 
+example, anxiety is known to affect performance on tasks 
+requiring attention.[41] Anxiety reduction during CM and 
+Table 2: Mean values and standard deviation for digit–letter substitution task total score, net score, and wrong 
+substitution score 
+Variables	
+	
+                           Sessions	
+	
+                            Cyclic meditation (N = 253)	                          Supine rest (N = 253)	
+	
+	
+Pre	
+Post	
+Pre	
+Post
+Total score for substitution	
+60.13±10.98	
+62.53±13.2***	
+57.04±12.24	
+61.67±12.55***
+Score for wrong substitution	
+0.08±0.29	
+0.2±0.65**	
+0.11±0.46	
+0.24±0.75**
+Net score for substitution	
+59.93±11.03	
+62.3±13.21***	
+56.95±12.26	
+61.42±12.55***
+***P < 0.001, student’s paired ‘t’ test, posts cores compared with respective prescores, **P < 0.01, Wilcoxon signed ranks test, posts cores compared with 
+respective pre scores 
+Mental speed task performance task in children
+[Downloaded free from http://www.ijoy.org.in on Thursday, March 04, 2010]
+International Journal of Yoga 
+ 
+ 
+ 
+Vol. 2:1 
+ 
+ 
+ 
+Jan-Jun-2009
+34
+SR practice may have contributed in some way to the 
+observed improvements in performance. The effects of 
+varying age and gender, and lengthening training program 
+duration could also be investigated. 
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+28. 	 Natu MV, Agarwal AK. Testing of stimulant effects of coffee on the 
+psychomotor performance: An exercise in clinical pharmacology. Indian J 
+Physiol Pharmacol 1997;29:11-4.
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+sounds after cochlear implant: A case report. Laryngoscope 1991;101:905-7.
+38. 	 Sommer W, Matt J, Leuthold H. Consciousness of attention and expectancy 
+as reflected in event-related potentials and reaction times. J Exp Psych Learn 
+Mem Cogn 1990;16:902-15. 
+39. 	 Polich J, Howard L, Starr A. P300 latency correlates with digit span. 
+Psychophysiology 1983;20:665-9.
+40. 	 Reinvang I. Cognitive event-related potentials in neuropsychological 
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+1993;31:487-93.
+Pradhan and Nagendra
+[Downloaded free from http://www.ijoy.org.in on Thursday, March 04, 2010]

subfolder_0/Effects of Yoga in Managing Fatigue in Breast Cancer Patients_ A Randomized Controlled Trial.txt

@@ -0,0 +1,447 @@
+Indian J Palliat Care. 2017 Jul-Sep; 23(3): 247–252.
+doi: 10.4103/IJPC.IJPC_95_17
+PMCID: PMC5545948
+PMID: 28827926
+Effects of Yoga in Managing Fatigue in Breast Cancer Patients: A
+Randomized Controlled Trial
+HS Vadiraja, Raghavendra Mohan Rao,  R Nagarathna, HR Nagendra,  Shekhar Patil,  Ravi B Diwakar,
+H P Shashidhara,  K S Gopinath,  and BS Ajaikumar
+Department of Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana, Bengaluru, Karnataka,
+India
+Department of Complementary Alternative Medicine, Health Care Global Enterprises Ltd., Bengaluru,
+Karnataka, India
+Department of Research and Development, Swami Vivekananda Yoga Anusandhana Samsthana, Bengaluru,
+Karnataka, India
+Department of Medical Oncology, HCG Bangalore Institute of Oncology Specialty Center, Bengaluru,
+Karnataka, India
+Department of Surgical Oncology, HCG Bangalore Institute of Oncology, Bengaluru, Karnataka, India
+Department of Radiation Oncology, HCG Bangalore Institute of Oncology, Bengaluru, Karnataka, India
+Address for correspondence: Dr. Raghavendra Mohan Rao, Healthcare Global Enterprises Ltd., No. 8, HCG
+Towers, P Kalinga Rao Road, Sampangiramnagar, Bengaluru - 560 027, Karnataka, India. E-mail:
+[email protected]
+Copyright : © 2017 Indian Journal of Palliative Care
+This is an open access article distributed under the terms of the Creative Commons Attribution-
+NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-
+commercially, as long as the author is credited and the new creations are licensed under the identical terms.
+Abstract
+Background:
+Cancer-related fatigue is widely prevalent in cancer patients and affects quality of life in advanced
+cancer patients. Fatigue is caused due to both psychologic distress and physiological sequel following
+cancer progression and its treatment. In this study, we evaluate the effects of yogic intervention in
+managing fatigue in metastatic breast cancer patients.
+Methods:
+Ninety-one patients with metastatic breast cancer were randomized to receive integrated yoga program
+(n = 46) or supportive therapy and education (n = 45) over a 3-month period. Assessments such as
+perceived stress, fatigue symptom inventory, diurnal salivary cortisol, and natural killer cell counts
+were carried out before and after intervention. Analysis was done using an intention-to-treat approach.
+Postmeasures for the above outcomes were assessed using ANCOVA with respective baseline measure
+as a covariate.
+1
+2
+3
+3
+3
+4
+5
+1
+2
+3
+4
+5
+Results:
+The results suggest that yoga reduces perceived stress (P = 0.001), fatigue frequency (P < 0.001),
+fatigue severity (P < 0.001), interference (P < 0.001), and diurnal variation (P < 0.001) when compared
+to supportive therapy. There was a positive correlation of change in fatigue severity with 9 a.m.
+salivary cortisol levels.
+Conclusion:
+The results suggest that yoga reduces fatigue in advanced breast cancer patients.
+Keywords: Cortisol, fatigue, stress, supportive therapy, yoga
+Iඖගක඗ඌඝඋගඑ඗ඖ
+The diagnosis and treatment of cancer can pose serious side effects and distress in cancer patients. This
+is more so when the cancer is at an advanced stage.[1] Among these manageable treatment-related
+symptoms associated with distress include menopausal/vasomotor symptoms, pain, fatigue, and sleep
+disturbance. There is a wide prevalence in fatigue symptoms among breast cancer patients ranging
+from 70% to 100%.[2,3] Cancer-related fatigue is perceived as being of greater magnitude,
+disproportionate to activity or exertion, and not completely relieved by rest, leaving the patient with an
+overwhelming and sustained sense of exhaustion.[4] Fatigue is an umbrella term used to describe
+various sensations or feelings, and a variety of expressions of reduced capacity at physical, mental,
+emotional, or social levels.[5]
+Both physiological and psychosocial factors play a part in the development of fatigue. The
+physiological reasons for fatigue have been attributed to anemia, cancer therapy, nutritional deficiency,
+electrolyte disturbances, pain, neuropathy, sarcopenia, and cachexia. The biopsychosocial model
+attributes fatigue to psychologic distress that is known to exacerbate fatigue due to other causes as well.
+Cancer-related fatigue is associated with psychosocial factors, such as anxiety and depression,[6,7]
+difficulty in sleeping,[8] full-time employment status,[9] and low degrees of physical functioning.[10]
+However, whether it is a cause or an effect of these factors is unknown. Fatigue is also linked to high
+amounts of other unmanaged symptoms, especially pain.[11]
+Perceived stress has been shown to be related to fatigue and treatment-related distress in cancer
+survivors.[12] Several others studies have shown a direct link between stress, insomnia, fatigue, and
+diurnal salivary cortisol rhythms.[13,14,15,16] Studies have shown that diurnal cortisol slope is an
+important predictor of survival in advanced breast cancer patients and is directly linked to depression.
+[17] Peak cortisol levels are also known to cause soft tissue pains and fatigue as seen in fibromyalgia.
+The hypothalamo-pituitary axes dysregulation is known to cause this change in rhythm as seen in both
+fibromyalgia patients and those with cancer due to chronic stress and allostatic load.[15,18]
+Evidence suggests that pain, fatigue, and depression are frequently undertreated. Patients and health-
+care providers have reported depression and persistent lack of energy as the aggressiveness of therapy
+has been increased and/or the underlying malignancy has worsened.[19] Cancer symptom management
+would benefit if an integrated intervention plan existed for a cluster of symptoms based on a clear
+understanding of which symptoms are likely to cluster, when clustering is likely to occur, and how a
+symptom cluster affects patient outcomes at different stages of treatment. Most of these symptom
+clusters are influenced by patients’ perception, awareness, education, mood states, and can be
+explained through various biologic, psychological, behavioral, and sociocultural mechanisms that
+constitute a symptom interaction network and symptom experience.[20] The experience of multiple
+simultaneous symptoms has a synergistic effect on symptom distress.[21]
+Management of symptoms, therefore, requires a holistic approach that integrates behavioral and mind–
+body strategies, this is more so emphasized in earlier studies that have shown several stress reduction
+and mind–body approaches to reduce distressful symptoms and mood states in cancer patients.
+Several studies have shown psychotherapeutic interventions such as supportive therapy, counseling,
+social support, and cognitive behavior therapy to reduce fatigue in cancer patients.[14,22,23,24,25]
+Several other studies have shown exercise, physical activity, and energy conservation therapy to reduce
+fatigue in cancer survivors.[10,26,27] Mind–body interventions such as yoga have been shown to
+reduce fatigue in early breast cancer survivors during treatment.[28,29,30] Our earlier studies with
+yoga showed reduction in fatigue in early breast cancer patients undergoing radiotherapy.[31,32]
+Earlier studies with yoga intervention are varied with different types of yogic intervention and duration.
+However, there is a paucity of studies showing effects of yogic intervention in reducing fatigue in
+advanced breast cancer patients.[33,34]
+In this study, we evaluated the effects of an integrated yoga program versus supportive therapy on
+perceived stress, fatigue in patients with advanced breast cancer. We also evaluated the relationship
+between fatigue and cortisol rhythms in metastatic breast cancer.
+Mඍගඐ඗ඌඛ
+In this study, 91 patients with metastatic breast cancer were recruited to participate in a trial comparing
+integrated yoga program with education and supportive therapy sessions from January 2004 to June
+2007. Institutional Review Board of the participating institution approved the study. The participants
+were recruited if they satisfied the selection criteria and gave written consent to participate in the study.
+Patients were included in the study if they were diagnosed to have metastatic breast cancer and were
+between 30 and 70 years of age and had adequate performance status (ambulatory >50% of time).
+Patients were excluded from the study if they had brain metastases, underwent chemotherapy treatment
+with exception of bisphosphonate therapy, were pregnant or lactating, on hydrocortisone medications,
+participated in clinical trials involving investigational new drugs, etc., This was a prospective, two-arm,
+randomized controlled study comparing integrated yoga program with supportive therapy with
+randomization done using computer-generated random numbers and opaque envelopes with group
+assignments. More details regarding study procedure are mentioned elsewhere.
+Sample size
+The sample size was calculated based on an earlier study with Mindfulness Based Stress Reduction
+Program (MBSR) that had shown a modest effect size (ES = 0.38) on EORTC QLC30 global quality of
+life measure.[35] Based on an ES of 0.38 for ANOVA between factor effects with α = 0.05 and β = 0.2,
+the sample size thus required was 44 in each group. Considering dropouts, we recruited 46 patients in
+each group.
+There were 65 study completers of yoga (n = 42) and supportive therapy (n = 33) in the study.
+Interventions
+The intervention group received “integrated yoga program” and the control group received “supportive
+counseling sessions” both imparted as individual sessions over a 3-month period. We developed an
+integrated yoga module comprising various practices that include asana (postures), pranayama
+(regulated nostril breathing), yogic relaxation in supine (shavasana), meditation, self-appraisal, and
+counseling. Practices such as pranic energization technique (positron emission tomography - observing
+the flow of energy or prana through the body), cyclic meditation - combination of postures and
+relaxation techniques done keeping eyes closed, and mind sound resonance technique (chanting of
+mantras verbally and mentally) were some of the specific techniques used in cancer patients. Details of
+both the interventions are given elsewhere (Raghavendra et al., 2009).[36,37]
+Outcome 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. The outcome measures ascertained could be grouped into the following
+categories:
+Perceived stress scale
+Perceived stress levels were assessed using perceived stress scale[38] questionnaire. This self-rated
+scale includes 14 items scored on a 5-point scale. This scale was used to assess the degree to which
+participants appraise their daily life as unpredictable, uncontrollable, and overwhelming over the last
+month. This has a reliability of 0.85.[38]
+Fatigue symptom inventory
+The fatigue symptom inventory (FSI), developed in the United States in 1998, is a 14-item self-report
+measure designed to assess the intensity (4 items), daily pattern (1 item), and duration of fatigue (2
+items), as well as its impact on quality of life (7 items).[39,40] Twelve items consist of 11-point Likert-
+type scale (0 = not at all fatigued; 10 = extremely fatigued) and 1 item is composed of the number of
+days in the past week the patients felt fatigued. However, one item related to daily pattern of fatigue
+provides qualitative information and is not included in the total fatigue score. The higher the total
+fatigue score, the more severe the level of fatigue. The scale development process involved a review of
+literature on fatigue in cancer patients and on chronic fatigue in general. Thus, the scale was intended
+to be used to compare fatigue in various groups of patients and normal healthy populations. Based on
+two previous studies, Cronbach's alpha coefficients of the subscale of FSI of impact on quality of life
+ranged from 0.93 to 0.95.[39,40] The FSI has also demonstrated test–retest reliability, construct
+validity, divergent validity, convergent validity, and discriminant validity.[39]
+Rඍඛඝඔගඛ
+Ninety-one metastatic breast cancer survivors (group mean age: 50.54 years ± 8.53 years) registered in
+hospital-based cancer registry of Bangalore Institute of Oncology were recruited for this study. The
+sociodemographic characteristics of the study sample were similar across groups.
+Fatigue severity
+Analysis of covariance on postmeasures using baseline fatigue severity score as a covariate showed a
+significant difference between groups with better decrease in fatigue severity in yoga compared to
+control group [F(1,61) = 32.55, P < 0.001, ES - 1.4, Percentage change (PC) - 61.15%]. Paired-sample
+t-test done to assess within-group change showed a significant decrease in fatigue severity in yoga
+group only (t = 6.7, P < 0.001) and not in the control group (t = −0.05, P = 0.96) [Table 1].
+Table 1
+Comparison of fatigue symptom inventory scores using GLM repeated measures ANOVA
+between yoga and control groups
+Fatigue frequency
+Analysis of covariance on postmeasures using baseline fatigue frequency score as a covariate showed a
+significant difference between groups with better decrease in fatigue frequency in yoga compared to
+control group [F(1,61) = 17.81, P < 0.001, ES - 1.1, PC - 52.64%]. Paired-sample t-test done to assess
+within-group change showed a significant decrease in fatigue frequency in yoga group only (t = 5.8, P
+< 0.001) and not in the control group (t = 0.33, P = 0.74) [Table 1].
+Fatigue interference
+Analysis of covariance on postmeasures using baseline fatigue interference score as a covariate showed
+a significant difference between groups with better decrease in fatigue interference in yoga compared to
+control group [F(1,61) = 28.36, P < 0.001, ES - 1.3, PC - 72.6%]. Paired-sample t-test done to assess
+within-group change showed a significant decrease in fatigue interference in yoga group only (t = 5.5,
+P < 0.001) and not in the control group (t = −0.36, P = 0.72) [Table 1].
+Fatigue diurnal variation
+Analysis of covariance on postmeasures using baseline fatigue diurnal variation score as a covariate
+showed a significant difference between groups with better decrease in fatigue diurnal variation in yoga
+compared to control group [F(1,61) = 13.65, P < 0.001, ES - 0.9, PC - 52.33%]. Paired-sample t-test
+done to assess within-group change showed a significant decrease in fatigue diurnal variation in yoga
+group only (t = 3.8, P < 0.001) and not in the control group (t = −1.18, P = 0.24) [Table 1].
+Perceived stress score
+Nonparametric Mann–Whitney test done to assess between-group changes showed significant
+difference between groups with better decrease in self-report perceived stress in yoga compared to
+control group (z = −2.49, P = 0.01, ES - 1.4, PC - 32.57%). Nonparametric Wilcoxon test done to
+assess within-group change showed significant decrease in self-reported perceived stress in yoga group
+only (z = −3.46, P = 0.001) not in the control group (z = −0.62, P = 0.54) [Table 2].
+Table 2
+Comparison of scores for anxiety, depression, and perceived stress scores using ANCOVA
+between yoga and control groups with respective baseline measure as a covariate
+Bivariate relationships
+There was a significant positive correlation between changes in fatigue severity with change in 9 a.m.
+cortisol levels, indicating the stress reduction benefits of yogic intervention [Table 3].
+Table 3
+Bivariate relationships between changes in measures of stress, fatigue, salivary cortisol, and
+natural killer cell counts following intervention in yoga group using Pearson's correlation
+analysis
+Dඑඛඋඝඛඛඑ඗ඖ
+The results from this study demonstrate a significant reduction in fatigue frequency, severity,
+interference, and diurnal fatigue variability in yoga group compared to supportive therapy intervention.
+There was also a significant decrease in perceived stress in yoga group compared to supportive therapy
+group. These findings are similar to earlier observations in early breast cancer patients with
+mindfulness-based[29] stress reduction and Iyengar yoga.[33]
+Perceived stress
+The results suggest an overall decrease in perceived stress scores with time in both the studies. In our
+study, yoga intervention reduced perceived stress by 32.6% (ES = 1.4) compared to control group.
+There is growing evidence that perceived stress has a major impact on the initiation and progression of
+disease, i.e., cardiovascular disease and chronic pain syndromes[41,42] by downregulating the immune
+system, it is observed that greater perceived stress positively predicted salivary cortisol levels.[43]
+Fatigue symptom inventory
+In this study, there was a significant decrease in fatigue (61.2%, ES = 1.4), fatigue frequency (52.6%,
+ES = 1.5), fatigue interference (72.6%, ES = 1.3), and diurnal variation (52.3%, ES = 0.9) in yoga
+group compared to controls on FSI. Our results are in contrast to earlier studies that have shown a
+modest decrease in fatigue (5.7% following MBSR intervention on Profile of Mood States–fatigue
+subscale[35] and 6.4% on Functional Assessment of Chronic Illness Therapy fatigue scale in a study by
+Moadel et al.[44] This could be because of inadequacy of the subscale to measure various dimensions
+of fatigue[35] and use of yogic intervention in early-stage cancer patients where fatigue would not have
+been a main concern[44] contrary to our study where fatigue was measured in advanced breast cancer
+patients using a specific FSI. Fatigue is an important symptom in cancer patients that directly affects
+functional quality of life. Apart from clinical conditions that affect fatigue such as infections, anemia,
+and pain, progressive disease itself causes fatigue as a part of cancer cachexia through release of
+inflammatory cytokines. Therefore, managing fatigue is also an indication of clinical improvement in
+the patient's condition. The decrease in fatigue seen with our study and consequent reductions in
+morning salivary cortisol and improvement in natural killer (NK) cell counts support this
+understanding.
+Adherence to intervention and outcomes
+Adherence to intervention was good in our study with 80% attending 24 supervised sessions. There
+was a significant improvement in quality of life and decrease in 9 p.m. cortisol level in individuals with
+good adherence to intervention (attending >20 classes). Adherence to intervention in control group was
+100%, as they had to invariably meet the counselors before appointment with their oncologists. This
+also explains why earlier studies did not have similar effects, as the number of sessions was very
+limited (9–12 sessions).[45,46]
+It may be hypothesized from these results that distress decreases with time in cancer patients, use of
+stress reduction interventions only augments this process and that, patients with initially high distress
+and high cortisol levels would probably take a longer time for attenuation of such high cortisol levels
+than those with lesser distress or cortisol profiles. These observations are important as hypothalamic-
+pituitary-adrenal (HPA) axes dysregulation in terms of diurnal salivary cortisol rhythm was found to be
+an important predictor for survival in advanced breast cancer patients.[17] The changes in stress
+response patterns and appraisal could have contributed to reductions in cortisol and distress seen with
+our intervention. The reduction in perceived stress seen with our intervention further offers support for
+this mechanism. An elevated level of cortisol is known to have immunosuppressive effects and is
+largely responsible for the downregulation of immune function because of stress. Reduction seen in
+cortisol levels in our study offers further support for improvements in immune functioning (NK cell
+counts) seen in our study in yoga group (32.4%, ES = 0.5) as also seen with our earlier study.[47] The
+combination of physical postures, breathing exercises, relaxation, and meditation could have helped
+attenuate cortisol levels through stress reduction and exercise effect as earlier studies have documented
+quality of life and biological benefits in cancer patients after moderate exercise.[48,49] Various
+components of yoga intervention are known to have a calming effect and correct the autonomic
+imbalance[50,51,52] and HPA axes disturbances[35] that prelude stress responses. Overall, the reduced
+psychological stress and cortisol following yoga program could be attributed to stress reduction rather
+than mere social support and education in conformity with earlier studies.[53]
+The ability to “unwind” after stressful encounters, i.e., the ability to return to ones neuroendocrine
+baseline influences the total burden that the stressors place on the individual.[54] Decrement in NK cell
+counts has been found to be an important predictor for survival in advanced breast cancer.
+Catecholamines and glucocorticoids have been shown to rapidly and markedly affect the distribution of
+NK cells among different immune compartments (e.g., spleen, liver, lungs, circulating blood,
+marginating pool of blood, etc.),[55,56] and it may be hypothesized that changes in these hormone
+levels and NK cell counts could be one of the mechanisms of action of our intervention.
+Larger randomized controlled trials are needed to further validate the findings and effects of yoga
+intervention on HPA axes dysregulation.
+C඗ඖඋඔඝඛඑ඗ඖ
+In summary, our yoga-based intervention was effective in reducing psychological morbidity, distressful
+symptoms, toxicity, and improving the quality of life in early breast cancer patients undergoing
+conventional cancer treatments. This was probably facilitated through stress reduction and helping the
+cancer patients to cope better with their illness at various stages of their conventional treatment.
+However, larger randomized controlled trails with structured psychiatric interventions as controls are
+needed to further validate our findings.
+Financial support and sponsorship
+This study was supported with grants from the Central Council for Research in Yoga and Naturopathy,
+Ministry of AYUSH, Government of India.
+Conflicts of interest
+There are no conflicts of interest.
+Ackowledgments
+Central Council for Research in Yoga and Naturopathy, Ministry of AYUSH, Govt of India
+Rඍඎඍකඍඖඋඍඛ
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+Publications

subfolder_0/Effects of a Yoga Program on Health, Behavior and Learning Ability in School Children A Single Arm Observational Study.txt

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+See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/318765291
+Effects of a Yoga Program on Health, Behaviour and Learning Ability in School
+Children: A Single Arm Observational Study
+Article · January 2017
+DOI: 10.15406/ijcam.2016.05.00138
+CITATIONS
+0
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+252
+1 author:
+Some of the authors of this publication are also working on these related projects:
+Evaluation of Yoga in Breast Cancer patients undergoing conventional treatment View project
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+Raghavendra M Rao
+Central Council for Research in Yoga and Naturopathy
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+International Journal of Complementary & Alternative Medicine
+Effects of a Yoga Program on Health, Behaviour and 
+Learning Ability in School Children: A Single Arm 
+Observational Study
+Submit Manuscript | http://medcraveonline.com
+Introduction
+Educators, researchers, and health care providers working 
+with children have long been interested in understanding what 
+causes children with average intelligence to suffer from academic 
+underachievement, particularly when these academic difficulties 
+are not the result of physical, social and environmental factors. 
+Behavioural problems in children including mood disorders, 
+emotional distress, peer pressures, learning disorders and 
+adjustment problems are all said to contribute towards academic 
+underachievement [1]. For example emotional distress, disrupted 
+cognitive functioning, and deterioration in academic performance 
+have all been theorized to be possible results of depressive 
+moods that have resulted from peer pressures, family conflicts, 
+and having to contribute to financial needs of the family [2]. 
+School dropout rates have also been attributed to learning 
+difficulty and poor academic performance [3]. Schemes like 
+mid-day meals have failed to improve classroom attendance 
+[4]. Dropout rates in Karnataka according to national sample 
+survey statistics is around 7.9% in rural areas and 3.1% in urban 
+areas with marginally more dropout rates in males compared to 
+females. Specific clinical features of depression such as reduced 
+attention span, lethargy, poor concentration and memory, as well 
+as abridged task perseverance are all factors that have emerged 
+as obstacles to effective learning. Furthermore, poor academic 
+performance has been associated with an increase in social and 
+behavioral problems [5]. Though overt clinical depression is 
+seen in a few a majority of they express depressive mood swings 
+that are usually seen in adolescents. The stress to perform and 
+its accompanying physiological and behavioural stress response 
+can result in mood swings, emotional distress, loss of sleep 
+and cognitive impairment. Poor classroom performance is 
+consistently demonstrated in children with depressive symptoms 
+when no other intervening learning disability is present [6]. 
+Negative correlations between severity of depressive symptoms 
+and intelligence scores, particularly by adolescence, have also 
+been reported [7,8]. Similarly, a weaker performance on a variety 
+of measures assessing cognitive functioning has been observed 
+in cohorts of children with symptoms of depression [8]. These 
+children have also exhibited a weaker performance on academic 
+achievement measures including mathematics and knowledge 
+clusters [5-9] and reading abilities [10]. In addition, behavioural 
+manifestations of depression including attention difficulties 
+[8,11-14]. 
+ 
+Volume 5 Issue 1 - 2017
+ 
+1Swami Vivekananda Yoga, Anusandhana Samsthana, India
+2Healthcare Global Enterprises ltd, India
+*Corresponding author: Raghavendra Rao M, PhD, Senior 
+Scientist and Head CAM program, - 5 Healthcare Global 
+Enterprises ltd, No 8, P Kalinga Rao Rd, Sampangiramnagar, 
+Bengaluru- 560027, Tel: +919916488864; Email:
+Received: December 26, 2016 | Published: January 03, 
+2017
+Research Article
+Int J Complement Alt Med 2017, 5(1): 00138
+Abstract
+Background: Learning difficulties, Stress and behavioural problems are 
+widely prevalent in high school children that contribute to dropouts and poor 
+performance. Yoga as a mind body intervention has been shown to improve 
+performance in pilot studies. In this large observational study we assess the 
+impact of yoga intervention on learning, cognitive abilities, behaviour and health 
+in high school children. 
+Methods: Seven hundred and sixty eight schools across fifty talukas in Karnataka 
+with around seven thousand six hundred and one children were assessed on 
+improvements in learning, cognition, behaviour and health following two months 
+of yoga intervention. Physical education teachers from these schools were trained 
+to impart yoga intervention over two months to students of both higher primary 
+and high school. Assessments were done by class teachers and parents of students 
+who were not involved in imparting intervention. 
+Results: There was a significant improvement in health, learning ability, cognitive 
+ability, behaviour, and positive emotions and decrease in negative emotions (all 
+p’s<0.001). The effect size of change was modest for emotions, behaviour and 
+cognitive ability and large for learning ability and health. 
+Conclusion: The results suggest beneficial effects of yoga intervention in higher 
+primary and high school children. 
+Keywords: Yoga; Performance; Learning; Cognition; Adolescents; School children
+Citation: Vhavle S, Rao MR, Manjunath NK, Ram AR (2017) Effects of a Yoga Program on Health, Behaviour and Learning Ability in School Children: A 
+Single Arm Observational Study. Int J Complement Alt Med 5(1): 00138. DOI: 10.15406/ijcam.2017.05.00138
+Effects of a Yoga Program on Health, Behaviour and Learning Ability in School Children: 
+A Single Arm Observational Study
+2/7
+Copyright:
+©2017 Vhavle et al.
+It has been reported that student fatigue also markedly 
+increases from elementary school to junior high school [15]. 
+Identifying fatigue-related factors is thus important for preventing 
+increased levels of fatigue during this transition period. 
+Exercises and play have helped students learn ways to cope 
+with emotional, social and mental stressors they endure as 
+teenagers [16]. Exercise, group activities and play have been 
+known to improve self-esteem that’s needed to overcome the 
+emotional upheavals during the adolescence age [17]. Regular 
+physical activity and exercise is known to produce strong healthy 
+bones and muscles, reduce risk of obesity and chronic diseases, 
+reduce feelings of anxiety and promote psychologic wellbeing [18]. 
+Moreover, obesity is a growing problem in teens and participation 
+in physical activity decreases as age or grade in school increases 
+further contributing to this problem [17]. Physical activity can 
+improve self-image, self-confidence, mood, relieve stress tension 
+and premenstrual tension, increased alertness, increased energy 
+and increased ability to cope with stress [19]. Yoga is one such 
+mind body intervention that uses postures or asanas, breathing 
+exercises and pranayama (regulated nostril breathing) that has 
+similar metabolic effects as an exercise [20]. Studies have shown 
+that while breathing through right nostril facilitates increase 
+in basal metabolic rate and reduces obesity [21], left nostril 
+breathing has anxiolytic effects [22] Pranayama also influences 
+tidal volume [23]. Similarly as an as are known to improve 
+strength, flexibility [24], and heart rate variability [25] that 
+enhances cardio protective effects [25], performance, endurance 
+and stamina in children [26]. Yoga has also been shown to improve 
+self esteem and promote mental health in adolescents [27]. In this 
+study we evaluated the effects of two months yoga intervention in 
+primary and high school students across all districts in Karnataka. 
+In this study teachers from each selected taluk from each 
+district in Karnataka trained in yoga will evaluate the effects of 
+two months of yoga in adolescent school children studying in 
+higher primary and high school in rural districts of Karnataka on 
+executive functions and their performance. 
+Study Objectives
+i.	 To integrate yoga into rural education in higher primary and 
+high schools in each selected taluk of different districts in the 
+state.
+ii.	 To evaluate the effects of yoga on abilities of learning, 
+cognition, behaviour and health in higher primary and high 
+school children.
+a.	 Hypothesis: Yoga will improve abilities of learning, cognition, 
+behaviour and health in higher primary and high school 
+children following two months of intervention. 
+Methods
+Subjects
+All School children in higher primary (6th – 7th grade) and high 
+school (8th -9th grade) enrolled in schools that were selected for 
+participation in the yoga education program by the education 
+department were assessed before and after two months of yoga 
+intervention. The program was carried out over a period of two 
+consecutive years during the period between Novembers to 
+February in both years. Assessments in this study were carried 
+out by respective class teachers who were not involved in 
+imparting the intervention. The yoga intervention was impacted 
+by physical education teachers who had undergone an intensive 
+residential training program. This was a state program that 
+enrolled teachers and students of schools from all thirty districts. 
+A total of six thousand fifty seven schools were selected for the 
+program covering five lakh six thousand nine hundred seventy 
+four students. Among these only schools with adequate teacher 
+to student ratio and different teachers for specific grades were 
+selected to participate. Only those students were selected that 
+satisfied the selection criteria.
+Selection criteria for subjects
+Inclusion criteria: a) Higher primary and high school children of 
+both sexes. b) Age between 12- 15 years.
+Exclusion criteria: a) Those with h/o congenital heart disease, 
+motor and mental retardation. b) Those with h/o epilepsy, 
+severe exercise induced asthma. c) Fevers or infection at time of 
+screening and recruitment. 
+Outcome measures: a) Student checklist filled by both teachers 
+and their parents [27].
+Intervention
+Yoga program: The Yoga intervention comprised a series of 
+asanas, pranayama, meditation and relaxation given over a one 
+hour period daily 6 days a week for 2 months. The classes started 
+with loosening stretches, breathing exercises followed by eight 
+asanas intersped with yogic relaxation. This was followed by 
+pranayama (regulated nostril breathing). Similar program had 
+been used earlier in school students that showed improvement in 
+spatial and verbal memory scores [28,29]. 
+Data analysis: Data was analysed using SPSS 18.0 for Windows. 
+Mean scores for learning ability, cognition, health, behaviour and 
+emotions were compared before and after intervention using 
+paired t test. The effect sizes of change were determined for each 
+variable.
+Results
+The mean age of the study population was …….. Years. The 
+number of schools that participated in the program and its 
+geographical location is given under Table 1. Number of schools 
+selected for assessments is given in Table 2. Among the eligible 
+9547 students around 7601 students were assessed.
+Learning abilities
+There was a significant improvement in learning abilities such 
+as oral comprehension (p<0.001), listening (p<0.001), reading 
+(p<0.001) and writing (p<0.001) following yoga intervention (See 
+Table 3, Figure 1.
+Health
+There was a significant improvement in eyesight (p<0001), 
+sports activities (p<0001), sickness prevention (p<0001) and 
+health (p<0001) following yoga intervention (Table 4 and Figure 
+2). 
+Citation: Vhavle S, Rao MR, Manjunath NK, Ram AR (2017) Effects of a Yoga Program on Health, Behaviour and Learning Ability in School Children: A 
+Single Arm Observational Study. Int J Complement Alt Med 5(1): 00138. DOI: 10.15406/ijcam.2017.05.00138
+Effects of a Yoga Program on Health, Behaviour and Learning Ability in School Children: 
+A Single Arm Observational Study
+3/7
+Copyright:
+©2017 Vhavle et al.
+Table 1: List of schools, students selected in district and taluks to undergo Yoga assessments.
+Sl. No
+District
+2011-
+2012
+Taluks
+2012-
+2013 
+Taluks
+Selected 
+Taluks
+Total Schools
+(11-12& 
+12-13)
+Selected 
+Schools
+Total 
+Students
+Trained in 
+Yoga
+Total 
+Students
+Eligible for 
+Assessment
+Selected 
+Students for 
+Assessment
+1
+Bagalkote
+2
+3
+5
+386
+47
+13526
+1140
+663
+2
+Belgaum
+3
+3
+2
+417
+17
+31771
+38
+23
+3
+Bijapur
+0
+2
+2
+175
+43
+17318
+792
+792
+4
+Chitradurga
+2
+1
+3
+235
+132
+14640
+745
+235
+5
+Dharawad
+0
+4
+2
+338
+19
+43543
+159
+159
+6
+Davangere
+0
+2
+2
+165
+29
+10326
+531
+505
+7
+Gadag
+0
+3
+1
+271
+16
+35501
+225
+210
+8
+Yadgiri
+1
+1
+2
+136
+15
+15015
+300
+114
+9
+Bellary
+2
+1
+1
+230
+20
+16011
+504
+490
+10
+Koppala
+0
+1
+1
+70
+09
+5625
+153
+153
+11
+Raichur
+1
+1
+1
+188
+25
+17755
+500
+363
+12
+Bidar
+1
+1
+1
+144
+10
+4551
+112
+111
+13
+Gulbarga
+1
+2
+1
+273
+6
+43838
+150
+147
+14
+Madikeri
+0
+1
+1
+89
+14
+10348
+182
+176
+15
+Mandya
+0
+2
+2
+120
+32
+17181
+639
+628
+16
+Mysore
+2
+4
+6
+464
+77
+31518
+1032
+633
+17
+Hassan
+1
+2
+1
+227
+03
+38806
+21
+21
+18
+Ramanagar
+1
+2
+2
+241
+50
+16879
+629
+567
+19
+Chamarajnagar
+0
+1
+1
+69
+5
+4485
+70
+69
+20
+Tumkur
+0
+2
+1
+160
+13
+22239
+237
+217
+21
+Kolar
+1
+1
+1
+121
+19
+6300
+165
+146
+22
+Chikkamagalur
+2
+1
+1
+186
+05
+10220
+90
+89
+23
+D.K.Mangalore
+0
+1
+1
+57
+09
+2730
+90
+90
+24
+Karwar
+1
+6
+4
+556
+16
+14182
+250
+240
+25
+Haveri
+0
+2
+2
+139
+38
+9815
+200
+185
+26
+Shimoga
+1
+1
+1
+90
+12
+8620
+298
+290
+27
+Udupi
+0
+3
+2
+235
+47
+6931
+295
+285
+28
+Chikkaballapura
+0
+1
+0
+22
+0
+1320
+0
+0
+29
+Bangalore
+(urban)
+0
+1
+0
+93
+0
+18600
+0
+0
+30
+Bangalore(r)
+0
+1
+0
+86
+0
+17200
+0
+0
+TOTAL
+22
+55
+50
+6057
+728
+506794
+9547
+7601
+Table 2: Number of schools selected for assessments.
+Year
+No of 
+Schools
+Students trained in 
+Yoga
+No of Taluks
+Sample of Assessments
+Selected Taluks
+Selected Schools
+Selected Students
+2011-12
+1832
+124278
+22
+50
+728
+7601
+2012-13
+4225
+382516
+55
+Total
+6057
+506794
+77
+50
+728
+7601
+Citation: Vhavle S, Rao MR, Manjunath NK, Ram AR (2017) Effects of a Yoga Program on Health, Behaviour and Learning Ability in School Children: A 
+Single Arm Observational Study. Int J Complement Alt Med 5(1): 00138. DOI: 10.15406/ijcam.2017.05.00138
+Effects of a Yoga Program on Health, Behaviour and Learning Ability in School Children: 
+A Single Arm Observational Study
+4/7
+Copyright:
+©2017 Vhavle et al.
+Table 3: Learning abilities following yoga intervention.
+Learning Abilities
+PRE
+POST
+Oral
+2.85±0.87
+3.52±0.68
+Listening
+2.83±0.88
+3.53±0.66
+Reading
+2.82±0.93
+3.54±0.67
+Writing
+2.84±0.92
+3.53±0.66
+Table 4: Health before and after yoga intervention.
+Health
+PRE
+POST
+Eyesight
+3.02±0.91
+3.62±0.62
+Sports
+2.89±0.94
+3.57±0.63
+Sickness
+2.95±0.89
+3.61±0.62
+Health
+3.00±0.88
+3.64±0.59
+Cognitive abilities
+There was a significant improvement in concentration 
+(p<0.001), intellect (p<0.001), memory (p<0.001), intelligence 
+(p<0.001), learning (p<0.001), reasoning (p<0.001), interaction 
+(p<0.001), direct speech (p<0.001), and attention (p<0.001), 
+following yoga intervention (Table 5 and Figure 3). 
+Table 5: Cognitive abilities following yoga intervention.
+Cognitive Abilities
+Pre
+Post
+Intellect
+2.82±0.84
+3.49±0.65
+Memory
+2.74±0.87
+3.45±0.66
+Concentration
+2.75±0.91
+3.50±0.66
+Intelligence
+2.85±0.91
+3.52±0.65
+learning
+2.85±0.89
+3.48±0.67
+Reasoning
+2.75±0.91
+3.44±0.69
+Interaction
+2.75±0.92
+3.42±0.71
+Direct speech
+1.98±0.71
+2.52±0.61
+Attention
+2.06±0.70
+2.60±0.57
+Negative emotions
+There was a significant decrease in negative emotions 
+(p<0.001) such as being unhappy (p<0.001), fear (p<0.001), 
+stubborn (p<0.001), being reserved (p<0.001), impulsive 
+(p<0.001), feeling laziness (p<0.001) and loneliness (p<0.001) 
+(Table 6 and Figure 4). 
+Table 6: Negative emotions before and after yoga intervention.
+Negative Emotions
+PRE
+POST
+Unhappy
+.91±0.76
+.66±0.84***
+Fear
+.91±0.76
+.48±0.64***
+Stubborn
+.81±0.75
+.41±0.63***
+Reserved
+.90±0.72
+.47±0.64***
+Impulsive
+.88±0.74
+.46±0.63***
+Loneliness
+.77±0.74
+.39±0.60***
+Laziness
+.80±0.75
+.41±0.63***
+***p<0.001 on Wilcoxons signed rank test
+Figure 1: Change in learning ability following yoga intervention 
+(Learning Change).
+Figure 2: Health change following yoga intervention (Health Change).
+Figure 3: Cognition Change following yoga intervention.
+Citation: Vhavle S, Rao MR, Manjunath NK, Ram AR (2017) Effects of a Yoga Program on Health, Behaviour and Learning Ability in School Children: A 
+Single Arm Observational Study. Int J Complement Alt Med 5(1): 00138. DOI: 10.15406/ijcam.2017.05.00138
+Effects of a Yoga Program on Health, Behaviour and Learning Ability in School Children: 
+A Single Arm Observational Study
+5/7
+Copyright:
+©2017 Vhavle et al.
+Positive emotions
+There was a significant improvement in positive emotions 
+such as discipline (p<0.001), accommodating (p<0.001), 
+respect (p<0.001), organization capacity (p<0.001), being social 
+(p<0.001) and obedient (p<0.001) (Table 7 and Figure 5).
+Table 7: Positive emotions before and after yoga intervention.
+Positive Emotions
+PRE
+POST
+Discipline
+2.93±0.92
+3.58±0.62
+Accommodating
+2.10±0.69
+2.63±0.54
+Respect
+2.16±0.69
+2.64±0.54
+Organization capacity
+2.01±0.68
+2.55±0.58
+Social
+2.12±0.68
+2.63±0.55
+Obedience
+2.14±0.69
+2.62±0.55
+Effect size
+Effect size was large for learning and health and moderate for 
+cognition and emotions See Table 8.
+Overall results
+The implementation of yoga education program and yoga in 
+schools in various districts of Karnataka showed improvements 
+in all indices of learning and cognitive function in primary and 
+high school students. The results showed beneficial finding with 
+yoga with maximum change being observed in listening, reading, 
+writing indicating better attention and sports indicating healthy 
+physically active lifestyle. There was also an overall improvement 
+in concentration, memory, mathematical ability, discipline and 
+overall personality development following this program.
+Improvements in Individual domains in overall sample:
+There was a significant (all p’s < 0.001) suggesting improvement 
+in all domains in the total sample of 7601 students. Those who 
+fared poor, below average and average in pre assessment showed 
+improvement at post assessment with many of them faring 
+average and good on these domains. Learning (Oral and written 
+expression, mathematical ability) behaviour, cognitive functions 
+(attention, memory, concentration, IQ) improved significantly 
+indicating overall personality development in children. 
+Discussion
+The results of our study suggest an improvement in learning 
+and health, significant reduction in negative health behaviours, 
+improvement in cognition and positive emotions. The effect 
+sizes for improvement were largest for learning and health and 
+moderate for cognition, positive and negative emotions and 
+behaviour. Though the high effect sizes could be due to absence 
+of a control group, they nevertheless show benefit finding on the 
+above measures.
+The intervention was carried out in early teen population 
+where in behavioural changes are profound due to influence of sex 
+hormones in this growth period. Surveys have shown prevalence 
+of psychosocial problems in this age group to be around 10-40% 
+[30-32]. This is an age wherein teens experience externalizing 
+behavioural problems such as confusion, personality conflicts, 
+educational difficulties, substance abuse, hyperactivity, or 
+internalizing emotional upheavals such as anxiety or depression 
+[32-34]. This coupled with transition stress of moving from 
+primary school to high school can add to the prevailing 
+psychosocial disturbance [32]. 
+Our results are similar to earlier observations that have 
+shown yoga to help improve learning, self-esteem, reduce 
+anxiety, depression, aggression, impulsiveness, shyness and other 
+negative emotions seen in teenagers [35,29]. These observations 
+are similar to those gained by using physical education (exercise) 
+and activity that have shown improvements in self-esteem, 
+performance and learning on these measures [36]. 
+Yoga is training in internal awareness and relaxation and 
+teens can appreciate their endurance with postures, flexibility, 
+and strength and internalize their self-progress over time in a 
+non-competitive environment [37]. This aspect of yoga could 
+help facilitate adherence to being physically active and adhere to 
+a planned physical regimen. Salutatory effects of exercise could 
+have helped reduce aggressiveness, reduce emotional upheavals, 
+laziness, and improve mood and wellbeing [38]. This could have 
+brought about a decrease in stress, improved memory, attention 
+span, and learning [39].
+Figure 4: Negative Emotions Change following yoga intervention.
+Figure 5: Positive Emotions Change following yoga intervention.
+Citation: Vhavle S, Rao MR, Manjunath NK, Ram AR (2017) Effects of a Yoga Program on Health, Behaviour and Learning Ability in School Children: A 
+Single Arm Observational Study. Int J Complement Alt Med 5(1): 00138. DOI: 10.15406/ijcam.2017.05.00138
+Effects of a Yoga Program on Health, Behaviour and Learning Ability in School Children: 
+A Single Arm Observational Study
+6/7
+Copyright:
+©2017 Vhavle et al.
+Table 8: Effect sizes following yoga intervention.
+Learning and Health
+Cognition
+Positive Emotions 
+and Behaviours
+Negative 
+Emotions and 
+Behaviors
+Post-Pre
+Effect 
+Size
+Post-Pre
+Effect 
+Size
+Post-Pre
+Effect Size
+Post-Pre
+Effect Size
+Oral change
+1.48
+Intellect change
+0.65
+Discipline change
+0.65
+Unhappy change
+-0.21
+Listening change
+0.99
+Memory change
+0.73
+Accommodating 
+change
+0.66
+Fear change
+-0.47
+Reading change
+1.09
+Concentration change
+0.74
+Respect change
+0.60
+Stubborn change
+-0.43
+Writing change
+1.12
+Intelligence change
+0.65
+Organization 
+capacity change
+0.66
+Reserved change
+-0.48
+Eyesight change
+1.12
+Learning change
+0.61
+Social change
+0.62
+Impulsive change
+-0.46
+Sports change
+1.02
+Reasoning change
+0.65
+Obedience change
+0.59
+Loneliness change
+-0.43
+Digestion change
+1.12
+Interaction change
+0.64
+Self-confidence 
+change
+0.64
+Laziness change
+-0.43
+Sickness change
+1.10
+Direct speech change
+0.64
+Health change
+1.12
+Attention change
+0.63
+One of the major limitations in our study was the results may 
+be prone for bias as this was a state sponsored program and 
+improvements could have been shown by the teacher as benefits 
+of this program. However we had a part of scoring done by class 
+teacher who was not the trained yoga instructor and part of the 
+study about health and behaviour was also scored by the parents 
+to obfuscate this problem. Secondly, having a comparator arm 
+could have delineated the effects of yoga clearly from physical 
+exercise. Third, the questionnaire was more or less subjective 
+and objective valuation of benefit could not be ascertained. 
+Fourth, having participated in a group yoga program could have 
+facilitated group bonding and support that could have contributed 
+to increased wellbeing. However, despite these limitations the 
+geographical extent and diversity and size of study of population 
+add significant credibility and power to this observational study. 
+Further randomized control trials with exercise as a control 
+intervention are needed to validate these findings in a controlled 
+sample population. 
+Conclusion
+The results offer support for beneficial effects of yoga 
+intervention in improving learning, cognitive abilities, health and 
+behaviour in high school children. The results also suggest that 
+imparting yoga in school is a feasible option and can be integrated 
+with the routine physical education. Further randomized 
+controlled trials are needed to validate this intervention.
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+View publication stats
+View publication stats

subfolder_0/Effects of a Yoga Program on Mood States, Quality of Life, and Toxicity in Breast Cancer Patients Receiving Conventional Treatment_ A Randomized Controlled Trial.txt

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+Indian J Palliat Care. 2017 Jul-Sep; 23(3): 237–246.
+doi: 10.4103/IJPC.IJPC_92_17
+PMCID: PMC5545947
+PMID: 28827925
+Effects of a Yoga Program on Mood States, Quality of Life, and Toxicity
+in Breast Cancer Patients Receiving Conventional Treatment: A
+Randomized Controlled Trial
+Raghavendra Mohan Rao, Nagaratna Raghuram,  Hongasandra Ramarao Nagendra,
+Gopinath S Kodaganur,  Ramesh S Bilimagga,  HP Shashidhara,  Ravi B Diwakar,  Shekhar Patil,  and
+Nalini Rao
+Department of Complementary and Alternative Medicine, Healthcare Global Enterprises Ltd., Bengaluru,
+Karnataka, India
+Department of life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana, Bengaluru, Karnataka,
+India
+Department of Research and Development, Swami Vivekananda Yoga Anusandhana Samsthana,, Bengaluru,
+Karnataka, India
+Department of Surgical Oncology, Swami Vivekananda Yoga Anusandhana Samsthana, Bengaluru,
+Karnataka, India
+Department of Radiation Oncology, HCG Bangalore institute of Oncology Specialty Center, Bengaluru,
+Karnataka, India
+Department of Medical Oncology, HCG Bangalore institute of Oncology Specialty Center, Bengaluru,
+Karnataka, India
+Address for correspondence: Dr. Nagarathna Raghuram, Department of Life Sciences, Swami Vivekananda
+Yoga Anusandhana Samsthana, No. 19, Eknath Bhavan, Gavipuram Circle, K.G Nagar, Bengaluru - 560 019,
+Karnataka, India. E-mail: [email protected]
+Copyright : © 2017 Indian Journal of Palliative Care
+This is an open access article distributed under the terms of the Creative Commons Attribution-
+NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-
+commercially, as long as the author is credited and the new creations are licensed under the identical terms.
+Abstract
+Aims:
+The aim of this study is to compare the effects of yoga program with supportive therapy counseling on
+mood states, treatment-related symptoms, toxicity, and quality of life in Stage II and III breast cancer
+patients on conventional treatment.
+Methods:
+Ninety-eight Stage II and III breast cancer patients underwent surgery followed by adjuvant
+radiotherapy (RT) or chemotherapy (CT) or both at a cancer center were randomly assigned to receive
+yoga (n = 45) and supportive therapy counseling (n = 53) over a 24-week period. Intervention consisted
+1
+2
+3
+4
+5
+5
+5
+4
+1
+2
+3
+4
+5
+of 60-min yoga sessions, daily while the control group was imparted supportive therapy during their
+hospital visits. Assessments included state-trait anxiety inventory, Beck's depression inventory,
+symptom checklist, common toxicity criteria, and functional living index-cancer. Assessments were
+done at baseline, after surgery, before, during, and after RT and six cycles of CT.
+Results:
+Both groups had similar baseline scores. There were 29 dropouts 12 (yoga) and 17 (controls) following
+surgery. Sixty-nine participants contributed data to the current analysis (33 in yoga, and 36 in controls).
+An ANCOVA, adjusting for baseline differences, showed a significant decrease for the yoga
+intervention as compared to the control group during RT (first result) and CT (second result), in (i)
+anxiety state by 4.72 and 7.7 points, (ii) depression by 5.74 and 7.25 points, (iii) treatment-related
+symptoms by 2.34 and 2.97 points, (iv) severity of symptoms by 6.43 and 8.83 points, (v) distress by
+7.19 and 13.11 points, and (vi) and improved overall quality of life by 23.9 and 31.2 points as
+compared to controls. Toxicity was significantly less in the yoga group (P = 0.01) during CT.
+Conclusion:
+The results suggest a possible use for yoga as a psychotherapeutic intervention in breast cancer patients
+undergoing conventional treatment.
+Keywords: Cancer, depression, meditation, quality of life, yoga
+Iඖගක඗ඌඝඋගඑ඗ඖ
+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.[1,2,3] The literature on psychosocial
+treatment for breast cancer patients provides uniform evidence for an improvement in mood, coping,
+adjustment, vigor, and a decrease in distressing symptoms.[4,5,6] This was seen in women who
+assumed a sense of self-control and responsibility[1,2] 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. There is a growing desire among cancer patients to assume a
+proactive role and responsibility in their personal care, with most of them evincing an interest in using
+complementary and alternative medicine and mind-body therapies.[7,8]
+Yoga as a complementary and mind-body therapy is being practised increasingly in both Indian and
+Western populations. It is an ancient Indian science that has been used for therapeutic benefit in
+numerous health-care concerns such as diabetes,[9] asthma,[10] hypertension,[11] cardiorespiratory
+illnesses,[12] anxiety,[13] musculoskeletal disorders,[14] and cancer[15] in which mental stress was
+believed to play a role. These techniques not only bridge psychosocial and somatic aspects of care but
+also address the subject's spiritual needs. Yoga techniques such as asanas (postures done with
+awareness), pranayama (voluntarily regulated nostril breathing), yoga nidra (guided relaxation with
+imagery) and meditation, promote physical well-being, and mental calmness. Practitioners have to be
+actively involved in the practice with a sense of self-control and mindful awareness. Such awareness
+combined with relaxation and attention of mental phenomena will alter the perceptions and mental
+responses to both external and internal stimuli, slow down reactivity, and responses to such stimuli and
+instil a greater control over situations. This could be particularly useful in cancer patients who perceive
+cancer as a threat. In addition, cancer patients find these healthcare alternatives to be more congruent
+with their own values, beliefs, and philosophical orientations toward health and life.[16]
+Various components of yoga such as meditation, breathing exercises, and asanas have also been used in
+cancer patients with promising results. Several of these studies have shown to improve psychosocial
+outcomes such as improved affective states, decrease in mood disturbance, stress symptoms and
+improved quality of life, and spiritual well-being in breast cancer[15,17,18] and in conferring
+immunological benefits in early breast and prostate cancer patients.[19] Most of these studies have
+methodological problems with design, some are not randomized[19] and lack effective controls and
+involve heterogeneous cancer population, with varying stages of their disease and treatment.[17] These
+studies also do not address the issues of the effect of conventional treatment on psychological
+morbidity, treatment-related side effects, and quality of life. Moreover, all of these studies on cancer
+patients were conducted in Western populations. There are no published studies until date evaluating
+the effect of yoga interventions on cancer patients in India. Yoga being an ancient Indian philosophy
+and science has a mass appeal and following in India and evaluating its efficacy in Indian cancer
+patients will help us understand any cross-cultural differences in its impact.
+The purpose of the current trial was to study whether a support intervention based on the use of a
+widely used mind/body and psychospiritual intervention such as yoga would be a viable alternative to
+standard “supportive therapy and counseling” sessions in breast cancer outpatients undergoing
+conventional treatment. We, therefore, hypothesized that an integrated yoga-based stress reduction
+program would help the cancer patients to better cope with their disease and treatment actively, reduce
+treatment-related symptoms, distress and toxicity, and improve the quality of life during conventional
+cancer treatment.
+In this study, we compared the effects of a 24-week “integrated yoga program” with “supportive
+therapy” control intervention in operable breast cancer patients undergoing conventional treatment.
+Pඉගඑඍඖගඛ ඉඖඌ Mඍගඐ඗ඌඛ
+This randomized controlled trial was conducted between 2000 January to June 2004 by two
+institutions, Swami Vivekananda Yoga Anusandhana Samsthana and Bangalore Institute of Oncology
+in Bangalore. The institutional review boards of both the institutions approved the study. Ninety-eight
+recently diagnosed women with stage II and III operable breast cancers (group mean age 49.1 ± 9.45
+years) were recruited from Bangalore Institute of Oncology, over a 2½ year period from January 2000
+to June 2002. 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 (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 before their surgery. A total of 69 patients contributed
+data to the current analyses at the second assessment (postsurgery-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 illness [See trial profile; Figure 1].
+However, the order of adjuvant treatments following surgery differed among the subjects with some
+receiving RT followed by CT, and others vice versa and with some receiving partial CT-3 cycles
+followed by RT and again 3 cycles of CT. There were four to six assessments depending on the
+treatment regimen. Irrespective of their treatment regimen, the assessments were scheduled at pre- and
+post-surgery, pre mid and post-RT and CT. Even though there was heterogeneity with respect to the
+treatment regimen, this was homogenous when both the groups were compared. Moreover, all
+participants in the study received the same dose of radiation (50 cGy over 6 weeks) and prescribed
+standard CT schedules (CMF or FAC).
+Open in a separate window
+Figure 1
+Trial profile
+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. Standard self-report questionnaires such as the state-trait anxiety inventory
+(STAI),[20] Beck's depression inventory (BDI),[21] and functional living index of cancer (FLIC)[22]
+were imparted to the participants during the study. 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 were evaluated previously in a similar breast cancer
+population.[23] Finally, treatment-related toxicity and side effects were objectively analyzed by the
+investigators using the World Health Organization Toxicity Criteria[24] during CT.
+Randomization
+Consenting participants were randomly allocated to either yoga or supportive therapy groups using
+random numbers generated by a random number table at a different site by a person who had no part in
+the trial. 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. The order of randomization was verified with the hospital date of admission
+records before surgery at study intervals to make sure that field personnel had not altered the sequence
+of randomization to suit allocation of consenting participants into 2 study arms. 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.
+Interventions
+The intervention group received “integrated yoga program” and the control group received “supportive
+counseling sessions” both imparted as individual sessions. The objectives of this yoga intervention as
+described to participants were (i) to develop an opportunity to understand one's personal responses to
+daily stress and explore ways and means to cope with them (ii) to learn concepts and techniques which
+bring about stress reduction and change in appraisal, and (iii) to enable the participants to take an active
+part in their self-care and healing.
+The yoga practices consisted of a set of asanas (postures done with awareness) breathing exercises,
+Pranayama (voluntarily regulated nostril breathing), meditation, and yogic relaxation techniques with
+imagery. These practices were based on the principles of attention diversion, awareness, and relaxation
+to cope with stressful experiences.
+The sessions began with didactic lectures and interactive sessions on philosophical concepts of yoga
+and importance of these in managing day-to-day stressful experiences (10 min) beginning every
+session. This was followed by a preparatory practice (20 min) with few easy yoga postures, breathing
+exercises and pranayama, and yogic relaxation. The subjects were then guided through any one of these
+meditation practices for the next 30 min. This included focusing awareness on sounds and chants from
+Vedic texts[25] 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 with relaxation while supine, thus achieving a combination of both
+“stimulating” and “calming,” practice.[26] In meditation, participants try to develop clarity in their
+thinking, learn to observe their own mind, decrease negative mind states, and develop positive mind
+states and maintain equipoise in their emotions. On the theistic side, the use of chants and mantras
+helped them to connect with the divine spiritually. These sessions were followed by informal individual
+counseling sessions that focused on problems related to impediments in home practice, clarification of
+participant's doubts, motivation, and supportive interaction with spouses. The participants were also
+informed about the practical day-to-day application of awareness and relaxation to attain a state of
+equanimity during stressful situations and were given homework in learning to adapt to such situations
+by applying these principles.
+The subjects were given booklets and instructions on these practices and were encouraged to pursue
+relevant themes and gain greater depth through proficiency in practice. Subjects were provided
+audiotapes of these practices for home practice using the instructor's voice so that a familiar voice
+could be heard on the cassette.
+The subjects underwent four such in-person sessions during their pre- and post-operative period and
+were asked to undergo three in-person sessions every week for 6 weeks during their adjuvant RT
+treatment in the hospital with self-practice as homework on the remaining days. During CT subjects
+underwent in-person sessions during their hospital visits for CT administration (once in 21 days) and
+were also imparted in person sessions by their trainer once a week. The subjects were asked to practice
+daily for an hour for 6 days/week as homework.
+Their homework was monitored on a day-to-day basis by their instructors through telephone calls and
+weekly house visits. Participants were also encouraged to maintain a daily log listing the yoga practices
+done, use of audiovisual aids, duration of practice, experience of distressful symptoms, intake of
+medication, and diet history. There were two instructors in all one being a physician in naturopathy and
+yoga and other a trained and certified therapist in yoga from the yoga institute. They together
+supervised and imparted the yoga and supportive therapy intervention with help from trained social
+workers and counselors at the hospital.
+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. Subjects and their caretakers were invited
+to participate in an introductory session lasting 60 min before starting any conventional treatment
+wherein they were given information about each conventional treatment and management of its related
+side effects, dietary advice, providing information about a variety of common questions, and showing a
+patient coping successfully. This counseling was extended over the course of their adjuvant RT and CT
+cycles during their hospital visits (once in 10 days, 15 min sessions), and participants were encouraged
+to meet their counselor whenever they had any concerns or issues to discuss. Subjects in the supportive
+therapy group also completed daily logs or dairies on treatment-related symptoms, medication, and diet
+during their CT cycles. Similar supportive sessions have been used successfully as a control
+comparison group to evaluate psychotherapeutic interventions[27,28] and similar coping preparations
+have been effective in controlling CT-related side effects[29] 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.
+Statistical methods
+Data were analyzed using Statistical procedures were conducted using SPSS version 10 (Sun Micro
+solutions, Gujarat, India for PC Windows 2000). Study participants underwent Surgery, RT, and CT
+and interventions were compared for each of these treatments. Mean scores for STAI-state and trait,
+BDI, symptom checklist, FLIC, and toxicity were calculated for the complete sample. Since order of
+their adjuvant treatment differed with some receiving RT followed by CT and others receiving CT
+followed by RT, outcome measures for these groups were therefore compared using analysis of
+covariance at follow-up intervals with their respective baseline measures as a covariate. Alternatively,
+intent to treat (ITT) analyses was conducted as repeated measures analyses using SAS institute for
+advance analytics. These mixed-model analyses use data from all participants who were initially
+randomized regardless of whether they had observations at each time point. Here estimates of the
+missing subjects follow-up data based on the observed values of the completers were used to assess the
+potential impact of the missing data on the results. Subjects were gauged for their regularity of practice
+during surgery, RT, and CT. This regularity of practice was classified as a category variable, and
+ANCOVA using baseline measure as covariates was performed to compare effects of regularity of yoga
+practice with outcome measures during surgery, RT, and CT.
+Rඍඛඝඔගඛ
+The age, stages of disease, grade, and node status were similar in the yoga and supportive therapy
+(control) groups [Table 1].
+Table 1
+Demographic characteristics
+State-trait anxiety inventory - state and trait scores
+Participants reported higher levels of anxiety at baseline (before surgery) as compared to other time
+points. Analysis of covariance using baseline anxiety states as a covariate showed significant decrease
+in anxiety states following surgery (F [66] = 4.22, P = 0.04], before RT (F [63] = 8.32, P = 0.005), and
+during RT (F [63] = 7.37, P = 0.009) in the yoga group as compared to controls. Following RT, there
+was a profound decrease in anxiety states (F [63] = 13.68, P < 0.001), and these effects were
+maintained during CT (F [58] = 3.84, P < 0.001) and following CT (F [58] = 3.84, P < 0.001). As
+described in the methods, we also performed repeated measure ITT analyses at follow-up intervals on
+all randomized subjects with estimates of mixing data elements. ITT analyses showed significant
+decrease in anxiety states only during CT (t [96] = −2.13, P = 0.04) and following CT (t [96] = −2.11,
+P = 0.04) compared to controls in the intervention group [Tables 2 and 3].
+Table 2
+Comparison of mean scores using independent samples t-tests and posttest scores adjusted for
+baseline scores between groups (yoga-control) using ANCOVA for anxiety, depression, and
+quality of life at various stages of conventional treatment
+Table 3
+Estimates of mean between yoga (n=45) and control (n=53) groups (Y-C) on mixed model
+intention to treat analyses using all randomized subjects (all completers and noncompleters,
+n=98) at follow-up assessments
+STAI-trait scores were high in yoga group initially in the period between diagnosis and surgery as
+compared to controls. ANCOVA using baseline anxiety trait score showed significant decrease in
+anxiety trait scores following surgery, (F [66] = 9.10, P = 0.004), following RT (F [62] =12.96, P =
+0.001), and following CT (F [58] = 9.42, P = 0.003) in yoga group as compared to controls. However,
+ITT analyses performed on all randomized subjects at these follow-up intervals showed no significant
+changes.
+Beck depression scores
+Both the groups reported decrease in their depression with time. 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). However, an ITT analyses on all
+randomized subjects showed yoga intervention to significantly reduce depression only during RT (t
+[96] = −1.98, P = 0.05) and CT (t [96] = −3.12, P = 0.002) [Tables 2 and 3].
+Symptom Scores on symptom checklist
+Symptom scores on symptom checklist assessed total no of symptoms, severity of symptoms and total
+distress experienced. The analysis of covariance using baseline symptom scores as a covariate showed
+significant decreases in symptom severity (F [66] = 14.11, P < 0.001) and distress (F [66] = 13.40, P =
+0.001) following surgery in yoga group as compared to controls. There was also a significant decrease
+in symptom number (F [63] =7.24, P = 0.009), severity (F [63] = 17.45, P < 0.001), and distress (F
+[63] = 14.25, P < 0.001) during RT. The intervention effects were more profound during CT showing a
+significant decrease in number of symptoms (F [58] = 9.43, P = 0.003), severity of symptoms (F [58] =
+13.61, P < 0.001), and distress experienced (F [58] = 23.12, P < 0.001) in the yoga group as compared
+to controls. Following CT, the intervention effects were significant for decrease in symptom number (F
+[58] = 9.36, P = 0.003), severity (F [58] = 10.27, P = 0.002), and distress (F [58] = 13.79, P < 0.001) in
+yoga group as compared to controls. ITT analyses showed only a significant decrease in distress
+following surgery (t [96] = −2.19, P = 0.03) and significant decrease in number (t [96] = −1.97, P =
+0.05), (t [96] = −2.65, P = 0.009); severity of symptoms (t [96] = −2.32, P = 0.002), (t [96] = −2.82, P
+= 0.005) and distress (t [96] = −2.83, P = 0.006), (t [96] = −4.22, P = 0.001) during RT and CT [Tables 
+3 and 4].
+Table 4
+Comparison of mean scores using independent samples t-tests and posttest scores adjusted for
+baseline scores between groups (yoga-control) using ANCOVA for number of distressful
+symptoms, severity of symptoms, and distress at various stages of conventional treatment
+Functional living index of cancer-global quality of life scores
+The quality of life scores changed considerably at various stages of treatment. Analysis of covariance
+using baseline quality of life scores as a covariate showed significant improvements in quality of life
+following surgery (F [66] = 12.34, P = 0.01) in yoga group as compared to controls. The intervention
+effects showed more profound improvements in quality of life during RT (F [63] = 22.31, P < 0.001)
+and CT (F [58] = 40.59, P < 0.001) in the yoga group as compared to controls when controlled for
+baseline score as a covariate. A repeated measure ITT analyses on all randomized subjects showed
+similar significant improvements in the quality of life during all the follow-up assessments [Tables 2
+and 3].
+Common toxicity criteria
+Common toxicity criteria guidelines were used to evaluate the CT-induced systemic and organ toxicity
+with individual toxicity scores graded from zero to four and overall toxicity score extrapolated as a sum
+of these scores. Independent samples t-test showed yoga group with significantly reduced overall
+toxicity score as compared to controls (t [58] = −3.873, P = 0.01) (95% confidence interval −5.8 to
+−0.85).
+Regularity of practice
+Participants in the intervention group were gauged for regularity of practice (classified into four
+categories of group variables) based on their frequency/average number of days of yoga practice per
+week. Their regularity of practice was categorized as (i) occasionally (practiced once a week), (ii) often
+(practice 2–3 times/week), (iii) not so regularly (home practice 4–5 times/week) to (iv) regularly (6 or
+more times/week) during various stages of conventional treatment. Following surgery, ANCOVA was
+performed on outcome measures using their baseline scores as a covariate to see the effects of the
+regularity of practice in the yoga group. Regularity of practice was related to significant decrease in
+depression scores (F [32] = 6.43, P = 0.017), symptom severity (F [32] = 10.85, P = 0.003) and
+improvements in quality of life (F [32] = 5.08, P = 0.03) postsurgery. ANCOVA was performed on all
+outcome measures using baseline measures as a covariate to gauge the effect of the regularity of
+practice during RT and CT in the yoga group. Subjects who were regular in their yoga practices
+showed significant decreases for depression (F [29] = 4.44, P = 0.04) and symptom severity (F [31] =
+7.33, P = 0.01) during RT. The changes were more profound with continuation of practice with further
+decrease following RT in depression scores (F [29] = 5.20, P = 0.03), number of symptoms (F [31] =
+5.31, P = 0.03), distress (F (31) = 9.86, P = 0.004), and improvements in quality of life (F [31] = 5.91,
+P = 0.02). However, regularity of practice during CT did not have sufficient power to detect any
+significant differences with outcome measures during CT [Tables 5 and 6].
+Table 5
+Regularity of practice of yoga in the intervention group during various stages of conventional
+treatment
+Table 6
+Mean change scores of outcome measures adjusted for baseline differences between
+intervention subjects practicing yoga regularly versus not so regularly during surgery and
+radiotherapy
+Dඑඛඋඝඛඛඑ඗ඖ
+The previous studies using meditation and yoga in cancer patients have shown beneficial effects in
+improving mood states, sleep, and quality of life in heterogeneous cancer patients with varying stages
+of disease and treatment. This is the first randomized controlled study comparing the efficacy of two
+supportive interventions, yoga with supportive therapy counseling sessions in Stage II and III breast
+cancer patients undergoing conventional cancer treatment. In the present study, 98 recently diagnosed
+breast cancer patients were randomly allocated to receive either yoga or supportive therapy before
+surgery and were followed up with their respective interventions during RT and CT. Following yoga
+intervention, breast cancer patients showed a significant decrease in reactive and chronic anxiety,
+depression and distressful symptoms, and improvement in their quality of life during various stages of
+conventional treatment compared to the control group.
+Anxiety state and trait
+Participants enrolled in our study had high levels of anxiety state before their surgery as compared to
+other stages of treatment. Both interventions seemed to reduce anxiety states subsequently. Yoga
+intervention reduced the anxiety state scores by 10% following surgery, 10.1% and 11.6% during and
+following RT, and 16.2% and 16.8% during and following CT from their baseline means (adjusted for
+baseline differences) than the control group indicating that effects of yoga intervention was better than
+supportive therapy and also when intervention was sustained for a longer duration. Our results are
+consistent with other studies using meditation and relaxation for generalized anxiety.[4]
+Depression
+Our study has shown that depression tended to decrease more with time in the yoga group as compared
+to controls. Yoga intervention decreased depressive symptoms more than the controls by from their
+baseline means (adjusted for baseline differences) by 19.2% following surgery, 42.4% and 39.7%
+during and following RT, and 56.5% and 31% during and following CT. 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 (16). Another important factor to note was that our
+intervention was effective in reducing mild-to-moderate levels of depression and would have been
+more effective in participants with higher scores for depression.
+Quality of life
+Our yoga intervention was effective in improving overall quality of life following surgery by 11.2%,
+compared to supportive therapy from their baseline means (adjusted for baseline differences). The
+quality of life improved by 22.68% and 30.1% during RT and CT in yoga group compared with
+supportive therapy. Similarly, yoga helped in reducing self-reported symptoms by 27% and 35%,
+severity of symptoms by 46.4% and 65.2% and self-reported distress by 42.3% and 82.9% during RT
+and CT than the control group. The severity and distressful symptoms were more during RT and CT
+than following their treatment due to treatment-related toxicity and decrease in treatment-related
+toxicity by yoga intervention could have contributed to decrease in severity and distressful symptoms
+and consequent improvement in the quality of life. Our results indicate that practising regularly and
+gaining proficiency in practice could confer greater benefits in these patients.
+Conventional treatment-related toxicity
+Even though one Grade 4 toxicity cannot be equated to four Grade 1 toxicities, the fact that a
+composite score is different between the treatment groups still suggests that the overall severity of
+toxicity is lower in the yoga group indicating that yoga intervention could be of some benefit in
+reducing the severity of conventional treatment-related toxicity.
+Results indicate that yoga intervention did confer some benefit finding, but it was difficult to delineate
+which aspects of yoga intervention were more beneficial. However, the facets of the yoga-based stress
+reduction program such as relaxation, meditation, asana, pranayama, social support, opportunity to
+assume active role in their own care, self-responsibility, and control over ones lives may have been
+beneficial. Overall, these beneficial effects can be conferred on yoga practices that helped in stress
+reduction rather than on mere social support and education consistent with other behaviorally oriented
+programs that have shown better results with stress reduction than purely supportive interventions.
+[4,30] It is in this context that our study has been able to elucidate the effects of a yoga-based stress
+reduction program clearly.
+The emotional distress, anxiety, depression, and concerns of cancer patients vary with time, age, stage
+of disease, duration of illness, and treatment and as such psychosocial interventions should be tailored
+to the needs of the study population. It is in this context that the homogeneity of support groups has to
+be maintained to evaluate the effects of structured psychosocial interventions that address specific
+needs and concerns of the support group.[31,32] Earlier studies with meditation in cancer patients have
+worked on heterogeneous cancer population varying in age, type and, stages of cancer and treatment as
+compared to the present study which is a homogenous group with respect to their age, disease status,
+and treatment. One of the major contributions of this study is the longitudinal and prospective follow-
+up of a homogenous group of breast cancer patients with similar clinical and demographic
+characteristics undergoing conventional cancer treatment.
+We chose to have individual yoga therapy and supportive counseling sessions as compared to group
+therapy sessions as a group setting could have instilled a sense of community wherein patients could
+model successful coping and gain self-esteem and motivation in their ability to help others in a group.
+This could have contributed to improvement in outcome measures thereby, confounding the benefits
+conferred by our intervention.[33,34] Moreover, these individual sessions also helped to understand the
+specific needs and concerns of participants and monitor individual progress in practice.
+Some of the major limitations to the study are, first, that the participants received conventional
+therapies (radiation, surgery, and CT) in different combinations reflect the usual practices of current
+breast cancer treatments. Although this introduced heterogeneity into the conventional treatment, there
+were not significant differences in the frequency of treatment combinations received by the yoga and
+control groups. It is possible that the yoga therapy worked more effectively for women receiving
+certain sequences of conventional treatment than others. We were not able to assess this possibility due
+to the limited sample sizes of these subgroups. The heterogeneity of conventional treatment, to the
+extent that it might affect yoga therapy, is likely to introduce variability in outcomes that would make it
+more difficult to show a benefit from yoga. However, the finding that yoga therapy was of benefit in a
+population receiving different sequences of conventional therapy should increase the generalizability of
+results, as the benefits are unlikely to be restricted to a specific sequence of conventional treatment.
+Second, the conclusions following this study can be limited by the fact that although the trail was
+randomized, many patients chose to participate because they were either willing or hoping to be
+assigned to the yoga program. This may also be the reason for a greater percentage of dropouts in the
+control group. In an Indian setting, the enthusiasm among the community for these traditional therapies
+is so great that it is very difficult to do controlled studies in this area. Third, even though the control
+group had been given supportive counseling and education only, it is possible that they also had access
+to information and treatment of similar mind-body therapies elsewhere in the community. Fourth, the
+contact hours and duration of the yoga intervention was more as compared to supportive therapy and
+counseling as is with any yoga intervention, and this could have conferred more benefits. However, it
+should be noted that supportive therapy interventions were used only with an intention of negating the
+confounding variables such as social support, instructor-patient interaction and education, which were
+known to improve the psychological and social functioning in cancer patients.[28] 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.
+Fifth, because of the desire to incorporate support and education in the yoga program, it is not clear
+whether a yoga program without support and education would have conferred the same benefits. Our
+study had an attrition rate of 29%, which is in concordance with other studies that have compared
+similar stress reduction interventions such as guided relaxation and imagery to standard education and
+support intervention[35] or standard psychotherapy. The attrition rates being high in this study the
+actual beneficial effects accrued by the intervention on intention to treat analyses were less when
+compared to analyses done only on the completers. It is in this context that the results of the
+intervention have to be viewed with caution.
+Our findings are similar to earlier findings, which envisage a greater role for psychological distress in
+modulating treatment outcomes in terms of toxicity and quality of life.[36] Even though the mood
+disturbances decrease substantially with time,[17,37] yoga group reported better affective states during
+different phases of treatment than the control group. Our observations are similar to those observed by
+a structured psychiatric intervention with decrease in affective states and improved methods of
+coping[7] and meditation in breast cancer patients showing a decrease in mood disturbance, distress,
+and improved the quality of life.[15,17] In summary, our yoga-based intervention was effective in
+reducing psychological morbidity, distressful symptoms, toxicity, and improving the quality of life in
+early breast cancer patients undergoing conventional cancer treatments. This was probably facilitated
+through stress reduction and helping the cancer patients to cope better with their illness at various
+stages of their conventional treatment. However, larger randomized controlled trails with structured
+psychiatric interventions as controls are needed to further validate our findings.
+Financial support and sponsorship
+The Central Council for Research in Yoga and Naturopathy under the Department of AYUSH, Govt. of
+India, provided financial Support for the present study.
+Conflicts of interest
+There are no conflicts of interest.
+Acknowledgments
+We are thankful to Dr. Jayashree, Mrs. Anupama for imparting the yoga intervention. We are grateful to
+Dr. Frederick Hecht, MD, Director, Research, OCIM, UCSF, for his advice in editing this paper and Dr.
+Michael Acree, PhD for guidance on statistical methods.
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+Publications

subfolder_0/Effects of two yoga based relaxation techniques on HRV.txt

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+subscription.
+APA PROOFS
+Effects of Two Yoga Based Relaxation Techniques
+on Heart Rate Variability (HRV)
+Patil Sarang and Shirley Telles
+Swami Vivekananda Yoga Research Foundation
+Heart rate variability (HRV) was studied in cyclic meditation (CM) and
+supine rest (SR). CM included yoga postures followed by guided relaxation.
+Forty-two male volunteers were assessed in CM and SR sessions of 35
+minutes, where CM or SR practice was preceded and followed by 5 minutes
+of SR. During the yoga postures of CM and after CM, low frequency power
+and the low frequency to high frequency power ratio decreased, whereas
+high frequency power increased. Heart rate increased during the yoga
+postures and decreased in guided relaxation and after CM. There was no
+change in SR. Hence, it appeared that predominantly sympathetic activation
+occurred in the yoga posture phases of CM while parasympathetic domi-
+nance increased after CM.
+Keywords: heart rate variability, cyclic meditation, supine rest, autonomic balance
+Meditation is a specific state of consciousness characterized by deep
+relaxation and internalized attention (Murata, et al., 2004). Different medi-
+tation techniques and their physiological effects have been studied using a
+range of variables. Transcendental meditation (TM) involves mentally re-
+peating a string of words (a mantram) with eyes closed and returning
+attention to it whenever attention wanders. In 15 college students, 30 minutes
+of TM practice caused a reduction in heart rate, breathing rate, and oxygen
+consumption and an increase in galvanic skin resistance suggesting a reduc-
+tion in sympathetic arousal (Wallace, 1970). A subsequent study showed a
+similar trend of reduction in heart rate, total ventilation, and oxygen con-
+sumption and a greater stability of the electrodermal response (Wallace,
+Patil Sarang and Shirley Telles, Swami Vivekananda Yoga Research Foundation, Ban-
+galore, India.
+The authors gratefully acknowledge H.R. Nagendra, who derived the CM technique from
+ancient yoga texts, and Ravi Kulkarni, for assistance with the statistical analysis.
+Correspondence concerning this article should be addressed to Shirley Telles, Swami
+Vivekananda Yoga Research Foundation, #19, Eknath Bhavan, Gavipuram Circle, K. G. Nagar,
+Bangalore - 560 019, India. E-mail: [email protected]
+International Journal of Stress Management
+Copyright 2006 by the American Psychological Association
+2006, Vol. 13, No. 4, 000–000
+1072-5245/06/$12.00 DOI: 10.1037/1072-5245.13.4.1
+1
+tapraid1/str-str/str-str/str00406/str2003d06g
+enterlis
+S
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+14:45
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+AQ: 1
+AQ: 6
+APA PROOFS
+Benson, & Wilson, 1971). Based on these changes, TM came to be described
+as a ‘wakeful hypo-metabolic physiologic state’ with reductions in mass
+sympathetic discharge during meditation.
+By contrast, when a study was conducted on 18 Brahmakumaris Raja
+yoga meditators using the self-as-control design (all subjects were studied in
+both meditation and nonmeditation sessions), it was found that both auto-
+nomic activation (based on a consistent increase in the heart rate) and
+relaxation (an increase in skin resistance and finger plethysmogram ampli-
+tude) occurred simultaneously, suggesting selective activation in different
+subdivisions of the sympathetic nervous system during meditation (Telles &
+Desiraju, 1993). Hence, a single model of sympathetic activation or overall
+relaxation was thought inadequate to describe the physiological effects of
+meditation.
+Similar differential activity in the different subdivisions of the autonomic
+nervous system was observed during repeat meditation sessions in seven
+experienced “Om” meditators (Telles, Nagarathna, & Nagendra, 1995).
+There was a simultaneous reduction in heart rate (possibly related to in-
+creased vagal tone with reduced cardiac sympathetic activity) and finger
+plethysmogram amplitude (decreased sympathetic vasomotor activity).
+The changes which occur during different phases of a meditation practice
+have also been studied. In mindfulness meditation (Vipassana), changes in
+the heart rate variability spectrum (as an indicator of the sympathovagal
+balance) were evaluated during different phases of meditation in 14 volun-
+teers (Telles, Mohapatra, & Naveen, 2005). The 30 minutes of meditation
+practice consisted of three 10-minute phases. The first phase was for breath
+awareness; the next phase was for awareness of sensations from the rest of
+the body; and, during the last phase, the subjects were given specific philo-
+sophical concepts to think about mentally (, e.g., relating to feelings of
+universality and good will). A decrease in low frequency (LF) power and in
+the low frequency to high frequency power (LF/HF) ratio, with a trend
+toward an increase in high frequency (HF) power, was seen during the breath
+awareness phase of Vipassana meditation. This suggested a shift in the
+autonomic balance toward vagal dominance during the breath awareness
+phase of Vipassana meditation.
+Hence, whether there is an overall reduction in sympathetic activity (as
+seen in TM) or differential activity in different subdivisions of sympathetic
+activity (as seen in Brahmakumaris Raja yoga meditation and in Om medi-
+tation) or reduced sympathetic activity in some phases of meditation (as in
+Vipassana), there is evidence that meditation is associated with reduced
+sympathetic activity (in some, if not all sympathetic subdivisions).
+In contrast to meditation, yoga postures (asanas) have been associated
+with increased sympathetic activity. In a study of 21 volunteers, an increase
+in heart rate and respiratory rate (RR) was observed during the practice of a
+2
+Sarang and Telles
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+APA PROOFS
+yoga technique that included a series of 12 yoga postures practiced in
+sequence, known as Surya Namaskar (Sinha, Ray, Pathak, & Selvamurthy,
+2004). In another study, in which 20 volunteers experienced in practicing the
+headstand (Sirsasana) were compared with 20 volunteers who had less
+experience, there was an increase in sympathetic activity in different sym-
+pathetic subdivisions such as cardiac (based on heart rate variability), sudo-
+motor (based on skin resistance), and vasomotor (based on finger plethys-
+mogram amplitude) in both groups of practitioners (Manjunath, & Telles,
+2003).
+Understanding the difference between the physiological effects of med-
+itation and yoga postures (asanas) is of interest, as there exists a technique of
+moving meditation, which combines the practice of yoga postures with
+guided meditation. This has been called cyclic meditation (CM) and is based
+on concepts derived from an ancient yoga text, the Mandukya Upanisad. The
+practice of this technique was found to reduce oxygen consumption and
+breath frequency, but to increase tidal volume in 40 male volunteers (between
+20 and 47 years of age), as compared to a comparable period of supine rest
+(SR) in the corpse posture, that is, Shavasana (Telles, Reddy, & Nagendra,
+2000).
+To extend previous research, the present study was designed to evaluate
+changes in heart rate variability (HRV) in CM, compared with a comparable
+period of SR. HRV has been widely used as a measure of vagal activation in
+physiological, psychological, and clinical investigations (Martinmaki, Rusko,
+Kooistra, Kettunen, & Saalasti, 2006), even though this measure can be
+influenced by extraneous factors (Grossman & Kollai, 1993; Grossman,
+Wilhelm, & Spoerle, 2004). In the present study, HRV was used to evaluate
+the changes in autonomic activity in CM and SR sessions.
+METHOD
+Subjects
+Forty-two male volunteers participated in the study, aged 18 to 48 years
+(M 
 27.1, SD 
 6.3 years). Participants were residing at a yoga center. Male
+subjects alone were studied, as autonomic variables have been shown to vary
+with the phases of the menstrual cycle (Yildirir, Kabakci, Akgul, Tokgozo-
+glu, & Oto, 2002). All of them were in normal health, based on a routine
+clinical examination. None of them were taking any medication and they did
+not use any other wellness strategy. The electrocardiogram (ECG) recording
+of all volunteers was free of extra systoles. The volunteers had experience
+practicing CM for more than 3 months (M 
 15.3, SD 
 13.3 months). The
+3
+Yoga Relaxation and HRV
+tapraid1/str-str/str-str/str00406/str2003d06g
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+aims and methods of the study were explained to the meditators and all of
+them gave their informed consent to participate.
+Design
+The meditators were assessed in two separate sessions, CM and SR. For
+half the subjects, the CM session took place on one day, with the SR session
+the next day. The remaining subjects had the order of the sessions reversed.
+Subjects were alternately assigned to either schedule to prevent the order of
+the sessions influencing the outcome. The subjects were unaware about the
+hypothesis of the study. Recordings were made throughout a session. Each
+session lasted for 35 minutes, of which 22 Minutes 30 seconds were spent in
+the practice of either CM or SR, preceded and followed by five minutes of SR.
+Assessments
+The ECG was acquired using Ag/AgCl solid adhesive pregelled elec-
+trodes (Bio Protech Inc., Korea) fixed on the prominant part of the clavicle
+on both sides to simulate Limb Lead I configuration (Thakor & Webster,
+1985). These electrode positions were selected as they eliminated movement
+artifact. The ECG was recorded using an ambulatory ECG system (Niviqure,
+Bangalore, India) at the sampling rate of 1024 Hz and was analyzed offline.
+The data were acquired in five minute epochs in the pre, during, and post
+periods. The data were visually inspected offline; noise-free data were
+included for analysis. The R waves were detected to obtain a point event
+series of successive response-response intervals, from which the beat-to-beat
+heart series were computed. The data were analyzed with an HRV analysis
+program developed by the Biomedical Signal Analysis Group (Niskanen,
+Tarvainen, Ranta-aho, & Karjalainen, 2004).
+Breath rate was assessed simultaneously with the subjects breathing
+ambient air while wearing a mask, using an open circuit apparatus (Oxycon
+Pro system, Model, 2001, Jaeger, Germany). These data were collected as
+part of another study (unpublished data).
+Interventions
+Cyclic Meditation (CM)
+CM lasted for 22 minutes, 30 seconds. Throughout the practice, subjects
+kept their eyes closed and followed instructions from an audiotape. The
+4
+Sarang and Telles
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+APA PROOFS
+instructions emphasized carrying out the practice slowly, with awareness and
+relaxation. The five phases of CM consisted of the following practices.
+Phase 1 (5 minutes): The practice began by repeating a verse (1 minute)
+from the yoga text, the Mandukya Upanishad (Chinmayananda, 1984);
+followed by isometric contraction of the muscles of the body ending with SR
+(1 minute, 30 seconds); slowly coming up from the left side and standing at
+ease, called tadasana, and balancing the weight on both feet, called centering
+(2 minute, 30 seconds).
+Phase 2 (5 minutes): Then the first actual posture, bending to the right
+(ardhakatichakrasana, 1 minute, 20 seconds); a gap of 1 minute, 10 seconds
+in tadasana with instructions about relaxation and awareness; bending to the
+left (ardhakaticakrasana, 1 minute, 20 seconds); a gap of 1 minute, 10
+seconds in tadasana.
+Phase 3 (5 minutes): Forward bending (padahastasana, 1 minute, 20
+seconds); another gap (1 minute. 10 seconds); backward bending (ardha-
+cakrasana, 1 minute. 20 second); a gap of 1 minute. 10 seconds in tadasana.
+Phase 4 (5 minutes): Slowly coming down to a supine posture for rest
+with instructions to relax different parts of the body in sequence.
+Phase 5 (5 minutes): Supine relaxation and a prayer for 2 minutes, 30
+seconds; followed by SR for 2 minutes, 30 seconds (Telles, Reddy, &
+Nagendra, 2000).
+Supine Rest (SR)
+During the 22 minutes, 30 seconds of SR, subjects lay with eyes closed
+in the corpse posture (shavasana) with their legs apart and arms away from
+the sides of the body. The state of SR was considered for analysis in five
+phases to make it comparable to the practice of CM during the CM session.
+However, throughout the five phases the subjects lay in the same posture.
+Data Extraction
+Frequency domain analysis of HRV data was carried out for 5-minute
+recordings in the following epochs for each session (CM and SR): pre, during
+1 (D1), during 2 (D2), during 3 (D3), during 4 (D4), during 5 (D5), and post.
+The HRV power spectrum was obtained using Fast Fourier Transform
+analysis (FFT). The energy in the HRV series in the following specific
+frequency bands was studied: the very low frequency band (0.0–0.05 Hz),
+low frequency band (0.05–0.15 Hz), and high frequency band (0.15–0.50
+Hz). According to guidelines, the low frequency and high frequency band
+5
+Yoga Relaxation and HRV
+tapraid1/str-str/str-str/str00406/str2003d06g
+enterlis
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+APA PROOFS
+values were expressed as normalized units (Task Force of the European
+Society of Cardiology and the North American Society of Pacing & Elec-
+trophysiology, 1996).
+Data Analysis
+Statistical analysis was done using SPSS (Version 10.0). Repeated mea-
+sures analyses of variance (ANOVA) were performed with two Within
+Subjects Variables: Sessions with two levels (CM and SR), and States with
+seven levels (pre, D1, D2, D3, D4, D5, and post. Post hoc tests (with
+Bonferroni adjustment for multiple comparisons) were used to detect signif-
+icant differences between mean values.
+RESULTS
+There was a significant difference between States for LF power, F(4.03,
+161.40) 
 3.29, p  .001, where P is corrected for sphericity violation,
+Huynh-Feldt E
+´√
 .673, and in the interaction between Sessions and States,
+F(5.02, 201.03) 
 6.46, p  .001, Huynh-Feldt E
+´√
 .838. The significant
+interaction between states and sessions means that the effect of one of them
+is not independent of the other factor (Zar, 2005). Post hoc tests for multiple
+comparisons of states with their respective baseline or pre values showed a
+significant increase in LF power in the D2 phase (of yoga postures) compared
+to the pre phase (p  .05) for the CM, and a significant CM compared to the
+pre phase (p  .001). There was no significant change in the SR session. The
+comparison of the two sessions (CM and SR) at each state showed LF power
+was significantly higher in the D2 phase of the CM session compared to the
+D2 phase of the SR session (p  .001). The trend of change in the LF power
+has been shown in Figure 1A.
+There was a significant difference between States for HF power, F(4.33,
+173.48) 
 6.89, p  .001, Huynh-Feldt E
+´√
 .167, and in the interaction
+between Sessions and States, F(5.71, 288.61) 
 7.28, p  .001, Huynh-Feldt
+E
+´√
 .953. The significant interaction between states and sessions means that
+the effect of one of them is not independent of the other. Post hoc tests for
+multiple comparisons of states with their respective baseline or pre values
+showed a significant reduction in the D2 phase (of yoga postures) compared
+to the pre phase, and a significant increase after CM compared to the pre
+phase (p  .001). There was no significant change in the SR session. The
+comparison of the two sessions (CM and SR) at each state showed HF power
+(text continues on page xxx)
+6
+Sarang and Telles
+tapraid1/str-str/str-str/str00406/str2003d06g
+enterlis
+S
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+14:45
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+AQ: 4
+F1
+APA PROOFS
+A.  Low frequency (LF) power
+STATES
+Post
+During5
+During4
+During3
+During2
+During1
+Pre
+Power (normalized unites)
+76
+74
+72
+70
+68
+66
+64
+62
+SESSIONS
+CM
+SR
+B. High frequency (HF) power
+STATES
+Post
+During5
+During4
+During3
+During2
+During1
+Pre
+Power (normalized unites)
+38
+36
+34
+32
+30
+28
+26
+24
+22
+SESSIONS
+CM
+SR
+    C. LF/HF ratio
+STATES
+Post
+During5
+During4
+During3
+During2
+During1
+Pre
+Power (normalized unites)
+3.5
+3.0
+2.5
+2.0
+1.5
+SESSIONS
+CM
+SR
+Figure 1. Changes in low frequency power (LF), high frequency power (HF), LF/HF ratio, very
+low frequency power (VLF), heart rate (HR), and respiratory rate in cyclic meditation (CM) and
+supine rest (SR) sessions.
+tapraid1/str-str/str-str/str00406/str2003d06g
+enterlis
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+APA PROOFS
+D. Very low frequency (VLF) power
+STATES
+Post
+During5
+During4
+During3
+During2
+During1
+Pre
+Power (milliseconds square)
+400000
+380000
+360000
+340000
+320000
+300000
+280000
+260000
+240000
+SESSIONS
+CM
+SR
+       E. Heart rate
+STATES
+Post
+During5
+During4
+During3
+During2
+During1
+Pre
+Beats per minute
+90
+80
+70
+60
+50
+SESSIONS
+CM
+SR
+F. Respiratory rate
+STATES
+Post
+During5
+During4
+During3
+During2
+During1
+Pre
+Cycles per minute
+19
+18
+17
+16
+15
+14
+13
+SESSIONS
+CM
+SR
+Figure 1. (Continued)
+tapraid1/str-str/str-str/str00406/str2003d06g
+enterlis
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+14:45
+Art: 021606
+APA PROOFS
+was significantly lower in the D2 phase of the CM session compared to the
+D2 phase of the SR session (p  .001). The trend of change in the HF power
+has been shown in Figure 1B.
+There was a significant difference between States for LF/HF ratio,
+F(4.52, 180.85) 
 10.86, p  .001, Huynh-Feldt E
+´√
 .167, and in the
+interaction between Sessions and States, F(5.25, 210.27) 
 9.16, p  .001,
+Huynh-Feldt E
+´√
 .876. The significant interaction between states and
+sessions means that the effect of one of them is not independent of the other.
+Post hoc tests for multiple comparisons of states against their respective
+baseline or pre values showed a significant increase in the LF/HF ratio in the
+D2 phase (of yoga postures) compared to the pre phase and a decrease after
+CM compared to the pre phase (p  .001). There was no significant change
+in the SR session. The comparison of the two sessions (CM and SR) at each
+state showed the LF/HF ratio was significantly higher in the D2 phase of the
+CM session compared to the D2 phase of the SR session (p  .001) and was
+significantly lower after the CM session when compared to after the SR
+session (p  .05). The trend of change in the LF/HF rate is shown in Figure 1C.
+For very low frequency (VLF) power there were significant differences
+between Sessions, F(1, 41 
 25.32, p  .001, Huynh-Feldt E
+´√
 1.00;
+States, F(3.93, 157.18) 
 36.59, p  .001, Huynh-Feldt E
+´√
 .591; and the
+interaction between Sessions and States, F(3.21, 141.16) 
 37.88, p  .001,
+Huynh-Feldt E
+´√
 .536. Post hoc tests for multiple comparisons of states
+with their respective baseline or pre values showed a significant decrease in
+VLF power in the D1, D2, and D3 phases (p  .001) compared to the pre
+phase for the CM session (p  .001). There was no significant change in the
+SR session. The comparison of the two sessions (CM and SR) at each state
+showed that VLF power was significantly lower in the D1, D2, and D3 phases
+of the CM session compared to the respective phases of the SR session (p 
+.001). The trend of change in VLF power has been shown in Figure 1D.
+For heart rate (HR) there were significant differences between Sessions,
+F(1, 41) 
 83.37, p  .001, Huynh-Feldt E
+´√
 .167; States, F(3.61,
+144.60) 
 138.93, p  .001, Huynh-Feldt E
+´√
 .167; and the interaction
+between Sessions and States, F(3.40, 136.05) 
 136.66, p  .001, Huynh-
+Feldt E
+´√
 .567. Post hoc tests for multiple comparisons of states against
+their respective baseline or pre values showed a significant increase in HR in
+the D1, D2, and D3 phases (p  .001) compared to the pre values for the CM
+session, whereas it was significantly reduced after CM compared to the pre
+phase (p  .001). There was no significant change in the SR session. The
+comparison of the two sessions (CM and SR) at each state showed that HR
+was significantly higher in the D1, D2, and D3 phases of the CM session
+compared to the respective phases of the SR session (p  .001) and was
+significantly lower after the CM session compared to after the SR session
+(p  .001). The trend of change in the heart rate is shown in Figure 1E.
+9
+Yoga Relaxation and HRV
+tapraid1/str-str/str-str/str00406/str2003d06g
+enterlis
+S
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+APA PROOFS
+For RR there were significant differences between Sessions, F(1, 41) 

+36.23, p  .001, Huynh-Feldt E
+´√
 1.00; States, F(3.86, 154.49) 
 28.90,
+p  .001, Huynh-Feldt E
+´√
 .644; and the interaction between Sessions and
+States, F(3.93, 157.18) 
 36.11, p  .001, Huynh-Feldt E
+´√
 .655. Post hoc
+tests for multiple comparisons of states against their respective baseline or
+pre values showed a significant increase in the RR in the D2, D3, (p  .001),
+and D4 phases (p  .05), compared to the pre phase for the CM session and
+a decrease after the CM compared to the pre phase (p  .001). There was no
+significant change in the SR session. The comparison of the two sessions
+(CM and SR) at each state showed that RR was significantly higher during
+D1, D2, D3, D4 (p  .001), and D5 (p  .05) phases of the CM session,
+compared to the respective phases of the SR session The trend of change
+in the LF power is shown in Figure 1F. The group mean values and SDs
+of LF power, HF power, LF/HF ratio, VLF power, HR, and RR are given
+in Table 1.
+DISCUSSION
+The present study evaluated changes in HRV before, during, and after the
+practice of CM compared to a comparable period of SR (Shavasana). The
+practice of CM was considered in five phases, of which the first three
+included the actual practice of yoga postures, while the fourth and fifth
+phases consisted of guided relaxation.
+Table 1. LF Power, HF Power, LF/HF Ratio, VLF Power, HR, and
+RR in CM and SR Sessions
+Variables
+Sessions
+Phases
+Pre
+During1
+LF (n.u.)
+CM
+66.71  9.05
+66.57  9.54
+SR
+65.06  12.44
+64.19  10.9
+HF (n.u.)
+CM
+33.53  9.00
+33.43  9.54
+SR
+34.94  12.44
+35.76  10.01
+LF/HF ratio
+CM
+2.22  0.90
+2.23  0.88
+SR
+2.27  1.30
+2.05  0.95
+VLF (ms2)
+CM
+381,836.78  76,315.70
+283,394.49***  66,898.74
+SR
+386,165.22  79,165.36
+387,836.10  86,180.09
+HR bpm
+CM
+59.79  6.18
+71.19***  7.97
+SR
+58.89  5.98
+59.26  6.30
+RR cpm
+CM
+15.35  2.41
+15.73  2.89
+SR
+14.75  2.46
+14.14  2.72
+Note.
+Values are group means  SDs. LF 
 low frequency; HF 
 high frequency; VLF 

+very low frequency; HR 
 heart rate; RR 
 respiratory rate; CM 
 cyclic meditation; SR 

+supine rest.
+* p  0.05.
+*** p  0.001. (post-hoc tests with Bonferroni adjustment, compared with
+respective pre values)
+10
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+APA PROOFS
+LF power and the LF/HF ratio increased in the second phase of CM and
+was reduced after the practice by comparison with the baseline (pre phase).
+In contrast, HF power was reduced in the second phase and increased after
+the practice of CM, compared to the pre phase. HR showed an increase in the
+first three phases of CM and was reduced in the fifth phase with a further
+reduction after the practice of CM. In the SR session, there was no significant
+change in the LF power, HF power, LF/HF ratio, and HR.
+The LF band of the HRV is mainly related to sympathetic modulation
+when expressed in normalized units (Task Force of the European Society of
+Cardiology and the North American Society of Pacing & Electrophysiology,
+1996), and efferent vagal activity is a major contributor to the HF band. The
+LF/HF ratio is correlated with sympathovagal balance (Malliani, Pagani,
+Lombardi, & Cerutti, 1991).
+CM is a moving meditation technique in which physical postures are
+interspersed with SR (Telles, Reddy, & Nagendra, 2000). The second phase
+of CM practice consists of a sideward bending posture (ardhaka-
+tichakrasana) and a forward bending posture (padahastasana). The increase
+in LF power and LF/HF ratio and reduction in HF power during this phase
+of CM suggests sympathetic activation and decreased cardiac vagal (i.e.,
+parasympathetic) tone. These results are similar to the changes observed
+during the practice of an inverted posture known as the headstand or Sir-
+sasana (Manjunath & Telles, 2003), which also resulted in changes sugges-
+tive of sympathetic activation. However, changes in autonomic tone are not
+the only factors that can vary LF.
+Phases
+During3
+During4
+During5
+75.70*  7.30
+67.04  8.41
+65.70  10.09
+64.79  12.80
+66.91  10.80
+66.39  10.20
+24.28***  7.30
+32.95  8.41
+34.30  10.09
+34.99  12.72
+33.08  10.80
+33.60  10.20
+3.45***  1.19
+2.26  0.93
+2.19  1.00
+2.20  1.03
+2.35  1.05
+2.27  1.02
+261,083.76***  57,685.64
+301,392.98***  57,311.10
+382,935.27  69,370.48
+383,616.00  86,377.02
+376,016.73  85,184.72
+381,002.95  86,870.62
+81.95***  9.21
+77.73***  7.91
+58.36  6.40
+60.24  6.28
+59.86  6.29
+60.11  6.40
+18.21***  3.40
+18.31***  3.51
+16.07*  2.31
+14.47  2.97
+14.29  2.93
+14.69  2.58
+11
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+Respiratory sinus arrhythmia (RSA) is a commonly employed noninva-
+sive measure of cardiac vagal control (Wilhelm, Grossman, & Coyle, 2004).
+Respiratory variables such as tidal volume and breath rate have been shown
+to change with no change in tonic vagal activity. Hence, concurrent moni-
+toring of respiration and physical activity are considered likely to enhance
+HRV accuracy to predict autonomic control. This is supported by acute
+increases in low frequency and total spectrum HRV and in vagal baroreflex
+gain, corrected with slow breathing during biofeedback periods (Lehrer, et
+al., 2003). It was earlier shown that biofeedback training to increase the
+amplitude of respiratory sinus arrhythmia maximally increases the amplitude
+of heart rate oscillations only at approximately 0.1 Hz. (Lehrer, Vaschillo, &
+Vaschillo, 2000). To achieve this, breathing is slowed to a point at which
+resonance occurs between respiratory-induced oscillations and oscillations
+that naturally occur at this rate. In the present study, changes in LF and HF
+power were correlated with changes in breath rate (monitored simulta-
+neously). Breath rate increased significantly during the second, third, and
+fourth phases of CM and decreased after CM. The increase in breath rate
+during the practice of yoga postures (second and third phase) was more than
+during guided relaxation (fourth phase). This suggests that the shift to LF
+activity in the second phase of CM resulted from changes in autonomic
+balance and was not due to a change in breath rate to the low-frequency
+range.
+The decrease in the LF power and the LF/HF ratio after the practice of
+CM suggests a shift toward vagal dominance. This is similar to HRV changes
+Table 1. (Continued)
+Variables
+Sessions
+Phases
+During5
+Post
+LF (n.u.)
+CM
+64.65  10.18
+64.04***  8.89
+SR
+64.38  9.99
+65.25  11.14
+HF (n.u.)
+CM
+35.35  10.18
+36.18***  8.64
+SR
+35.61  9.99
+34.75  11.14
+LF/HF ratio
+CM
+2.08  0.94
+1.88***  0.80
+SR
+2.04  0.89
+2.16  0.94
+VLF (ms2)
+CM
+382,453.83  76,046.83
+384,493.17  82,098.71
+SR
+377,139.39  85,073.20
+378,404.29  85,180.11
+HR bpm
+CM
+59.32  5.32
+57.42***  5.61
+SR
+60.80  7.08
+60.51  6.74
+RR cpm
+CM
+15.19  2.14
+14.42***  2.33
+SR
+14.47  2.54
+14.74  2.66
+12
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+following a low velocity, low impact technique involving movements, called
+Wai Tan Kung. Wai Tan Kung is a traditional Taiwanese conditioning
+exercise. The effect of Wai Tan Kung was studied on autonomic nervous
+modulation in elderly volunteers (Lu & Kuo, 2003). The immediate effect of
+practicing Wai Tan Kung was to enhance vagal modulation and to suppress
+sympathetic modulation.
+In the present study, VLF power decreased during the first, second, and
+third phases of CM, which involved practicing yoga postures. VLF power
+accounts for more than 90% of the total power in the 24-hour heart rate power
+spectrum, but the physiological mechanisms for VLF power have not been
+identified (Hadase, et al., 2004). VLF power in part reflects thermoregulatory
+mechanisms, fluctuation in activity of the renin-angiotensin system, and the
+function of peripheral chemoreceptors (Malliani, Pagani, Lombardi, &
+Cerutti, 1991; Parati, Saul, Di Rieuzo, & Mancia, 1995). Also, both the
+respiratory pattern and level of physical activity modulate VLF power
+(Bernadi, Valle, Coco, Calciati, & Sleight, 1996; Mortara, et al., 1997). In
+summary, the physiological mechanisms for VLF power are not fully under-
+stood (although this measure is currently considered to be a possible predictor
+of cardiac events in patients with cardiac disease; Hadase, et al., 2004).
+Hence, in the present study, there was no attempt to discuss the physiological
+significance of changes in VLF power during CM.
+The increase in HR while practicing yoga postures during CM is not
+unexpected. The reduction in HR in the fifth phase of CM with a further
+decrease after the practice of CM suggests that the practice was followed by
+a period of parasympathetic dominance based on the HRV and heart rate.
+Changes in the HR during yogic practices are well known (Telles, et al.,
+2004). The present results, suggesting a shift toward parasympathetic dom-
+inance after the practice of CM, are compatible with those of an earlier study
+on the effects of CM, which showed a reduction in RR and oxygen con-
+sumption immediately after the practice of CM to a greater degree than after
+SR (Telles, Reddy & Nagendra, 2000).
+The exact mechanism by which CM brings about a state of relaxation
+needs to be understood. It may be related to the fact that CM practice includes
+yoga postures (which involve stretching) and guided relaxation. When a
+body-mind training program, which included meditative stretching and
+guided relaxation, was practiced by persons with chronic toxic encephalop-
+athy for eight weeks, they showed improved physical and mental relaxation
+as indicated by lower electromyograph activity, higher alpha percentage, and
+reduced state anxiety (Engel & Andersen, 2000).
+When attempting to understand HRV changes that have occurred during
+CM, it is important to understand the factors involved in the practice. During
+CM, yoga postures are practiced with awareness, relaxation, and instructions
+to breathe normally. During the practice of a sitting yoga posture (virasana)
+13
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+there was an increased metabolic rate and increased sympathetic activity,
+which suggested that this practice is a “form of mild exercise” (Rai & Ram,
+1973). Similarly the yoga postures may have caused an increase in LF power,
+as the immediate effect of (mild) exercise (Mourot, Bouhaddi, Tordi, Rouil-
+lon, & Regnard, 2004). The decrease in LF power and LF/HF ratio after CM
+to a lower level than the pre value and the value after the SR session suggests
+that the combination of yoga postures followed by guided relaxation is
+effective in modifying LF activity. Guided relaxation has been shown to be
+more effective in reducing physiological arousal than a control session of SR
+(Sakakibara, Takeuchi, & Hayano, 1994). Specifically yoga based guided
+relaxation (as used in CM) decreased LF power and increased HF power, a
+pattern that did not occur during a period of SR of the same duration
+(Vempati & Telles, 2002). Guided relaxation has several components, such
+as visual imagery and muscle relaxation that may contribute to the effect.
+However, the exact mechanism is not known. CM also includes awareness of
+the breath and of other sensations in the body. Zen meditation, in which deep
+relaxation and increased internalized attention coexist, increasing HF power,
+and decreasing the LF/HF ratio during the meditation (Murata, et al., 2004).
+Also, during the breath awareness phase of Vipassana mindfulness medita-
+tion, there was a decrease in the LF/HF ratio (Telles, Mohapatra, & Naveen,
+2005). Hence, the changes (decrease in LF power, LF/HF ratio) after CM
+may be related to the effects of imagery and muscle relaxation (during guided
+relaxation) and of awareness (throughout CM practice). The fact that the
+change occurred after CM (and not during the phases of guided relaxation)
+suggests that it is the combination of yoga postures followed by guided
+relaxation that is effective. However, further studies are required to under-
+stand the exact mechanisms involved.
+REFERENCES
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+Chinmayananda, S. (1984). Mandukya Upanishad. Bombay, India: Sachin Publishers.
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+Hadase, M., Azuma, A., Zen, K., Asada, S., Kawasaki, T., Kamitani, T., Kawasaki, S., et al.
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+APA PROOFS
+(2004). Very low frequency power of heart rate varibility is a powerful predictor of
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+Lehrer, P. M., Vaschillo, E., & Vaschillo, B. (2000). Resonant frequency biofeedback training
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+Lehrer, P. M., Vaschillo, E., Vaschillo, B., Lu, S. E., Eckberg, D. L., Edelberg, R., et al. (2003).
+Heart rate variability biofeedback increases baroreflex gain and peak expiratory flow.
+Psychosomatic Medicine, 65(5), 796–805.
+Lu, W. A., & Kuo, C. D. (2003). The effect of Wai Tan Kung on autonomic nervous modulation
+in the elderly. Journal of Biomedical Science 10(6, Pt 2), 697–705.
+Malliani, A., Pagani, M., Lombardi, F., & Cerutti, S. (1991). Cardiovascular neural regulation
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+Manjunath, N. K., & Telles, S. (2003). Effects of sirsasana (headstand) practice on autonomic
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+Martinmaki, K., Rusko, H., Kooistra, L., Kettunen, J., & Saalasti, S. (2006). Intraindividual
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+Mortara, A., Sleight, P., Pinna, G. D., Maestri, R., Prpa, A., & La Rouver, M. T. (1997).
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+chobiology, 50(2), 189–194.
+Niskanen, J. P., Tarvainen, M. P., Ranta-aho, P. O., & Karjalainen, P. A. (2004). Software for
+advanced HRV analysis. Computer Methods and Programs in Biomedicine, 76, 73–81.
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+Rai, L., & Ram, K. (1973). Energy expenditure and ventilatory responses during virasana a
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+evaluation of the ability to voluntarily reduce the heart rate after a month of yoga practice.
+Integrative Physiological & Behavioral Science, 39(2), 119–125.
+Telles, S., Mohapatra, R. S., & Naveen, K. V. (2005). Heart rate variability spectrum during
+Vipassana mindfulness meditation. Journal of Indian Psychology, 22(2), 215–219.
+Telles, S., Nagarathna, R., & Nagendra, H. R. (1995). Autonomic changes during “OM”
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+enterlis
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+APA PROOFS
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+following two yoga relaxation techniques. Applied Psychophysiology and Biofeedback,
+25(4), 221–227.
+Thakor, N. V., & Webster, J. G. (1985). Electrode studies for the long-term ambulatory ECG.
+Medical and Biological Engineering and Computing, 23, 1–7.
+Vaschillo, E., Lehrer, P., Rishe, N., & Konstantinov, M. (2002). Heart rate variability biofeed-
+back as a method for assessing baroreflex function: A preliminary study of resonance in
+the cardiovascular system. Applied Psychophysiology and Biofeedback, 27(1), 1–27.
+Vempati, R. P., & Telles, S. (2002). Yoga-based guided relaxation reduces sympathetic activity
+judged from baseline levels. Psychological Reports, 90, 487–494.
+Wallace, R. K. (1970). The physiological effects of transcendental meditation. Science, 167,
+1751–1754.
+Wallace, R. K., Benson, H., & Wilson, A. F. (1971). A wakeful hypo metabolic physiological
+state. American Journal of Physiology, 227, 795–799.
+Wilhelm, F. H., Grossman, P., & Coyle, M. A. (2004). Improving estimation of cardiac vagal
+tone during spontaneous breathing using a paced breathing calibration. Biomedical Sci-
+ences Instrumentation, 40, 317–324.
+Yildirir, A., Kabakci, G., Akgul, E., Tokgozoglu, L., & Oto, A. (2002). Effects of menstrual
+cycle on cardiac autonomic innervation as assessed by heart rate variability. Annals of
+Noninvasive Electrocardiology, 7(1), 60–63.
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+Ltd.
+16
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+AQ: 5
+JOBNAME: AUTHOR QUERIES PAGE: 1 SESS: 1 OUTPUT: Fri Oct 6 05:15:58 2006
+/tapraid1/str
str/str
str/str00406/str2003d06g
+AQ1: Author: APA style is to define abbreviations at first mention and use the abbreviation
+throughout the rest of the article. Please check all abbreviations for accuracy (some words
+have been changed to the abbreviated form since they are already defined.
+AQ2: Author: Is this a direct quote? If so, please add double quotes and the citation. Thanks.
+AQ3: Author: “prominent” meant instead of “prominant”?
+AQ4: Author: Please define SPSS.
+AQ5: Author: Vaschillo et al, 2002, is not cited in your text. Please delete from your ref list or add
+to your article.
+AQ6: Author: Please supply departmental affiliation if applicable.
+AQt1: Author: Please define n.u., bpm, and cpm.
+AUTHOR QUERIES
+AUTHOR PLEASE ANSWER ALL QUERIES
+1

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+22 | Voice of  Research, Vol. 6 Issue 1, June 2017, ISSN 2277-7733
+Ageing is a natural and unavoidable part every living being
+which is characterized by variety of physical and mental changes.
+Evidences reported that approximately more than 88% of
+elderly people suffer from one or more chronic health problems
+(Hoffman et al, 1996). In a survey report 82% of elderly had
+one or more chronic health problems and 65% had multiple
+health problems (Wolff et al, 2002). Osteoarthritis, diabetes,
+Parkinson’s disease, stroke, musculoskeletal disorders,
+cardiovascular disorders, dementia, etc. are the most common
+chronic problems reported by elderly (Cathleen et al, 2006;
+Nanette et al, 1992). Chronic health problems in elderly, often
+affects the physical, mental, and social life of elderly. It is evident
+that chronic problem in elderly are strongly associated with to
+poor sleep quality, impairment of mental health and reduced
+QoL (Foley, et al, 2004). Presence of chronic health problems
+in elderly, make them more dependent on care givers; feel
+lonely, and depressed. Several cross-sectional studies have
+shown that 9-23% of elderly people having a chronic disorder
+suffer from depressive disorders (Felton, et al, 2010). Suicide
+rate among the elderly is almost double compared to general
+population and 80% of the suicidal cases in elderly known to
+have depressive syndromes (Conwell et al, 1996). There is
+strong association of ageing with sleep problems (Haimov et
+al, 1994). Sleep problem includes the symptoms such as
+difficulty in falling asleep; waking up; awaking too early; needing
+to nap; and not feeling rested. A longitudinal study among
+9000 elderly persons after three years of follow up, reported a
+more than 50% of elderly subjects had at least one of the
+symptoms of sleep problem frequently (Foley et al, 1995).
+Chronic health problem is considered to be one of the
+contributing factors for sleep problems in elderly (Foley, 1995).
+A Longitudinal study has reported the association of sleep
+problem and increased mortality rate among elderly persons
+(Pollak et al, 1990).
+Yoga
+Yoga is a form of mind-body intervention and a popular
+alternative and complementary therapy. Scientific evidence
+recommends the yoga practice in several physical and mental
+health conditions (Lin et al, 2011). Several scientific
+investigations have shown the effectiveness of yoga improving
+sleep quality (Chen 2009), quality of life (Mareles et al, 2006)
+and mental health (Bussing, 2012) in various chronic health
+conditions. Yoga practice shown to be effective in enhancing
+QoL in several chronic health conditions such as breast cancer,
+osteoarthritis, chronic low back pain etc. the Yoga is one among
+the most ancient sciences (Telles, and Naveen, 1997). Practice
+of yoga by persons suffering from chronic disease shown to
+improve symptoms and disease progression in many diseases
+like diabetes, hypertension, Parkinson’s disease, multiple
+sclerosis etc (Alijasir et al, 2010). There are evidences for
+usefulness of yoga practice in elderly individuals. A randomized
+controlled trial study showed significant improvement in QoL
+following three months of yoga intervention in healthy elderly
+living in old age homes. It improves cardiac autonomic
+function, cardio respiratory fitness, nerve conduction, and it
+also improves cognitive functions and psychological health
+(Tran MD et al, 2001). A significant number of scientific studies
+proved the safety and efficacy of yoga in an elderly population
+(Hariprasad et al, 2013). It is proved to be effective in physical,
+physiological and psychological domains in an elderly
+population (Gonçalves LC et al, 2011). To the best of our
+knowledge no previous studies have looked into effects of
+yoga on mental health, sleep quality and quality of life in elderly
+with chronic health problems. With this background, this pilot
+study was planned to see the impact of one yoga practice on
+physiological parameters, psychological health, sleep and quality
+of life of elderly people.
+Methodology
+Participants: We screened 50 elderly persons within age group
+between 60-80 years, who were residents of local community
+apartments of south Bangalore, India for study criteria.
+Inclusion criteria and exclusion criteria: We selected the elderly
+persons; of any gender; within the age range 60 to 80 years;
+who did not had exposure to any form of yoga practice in the
+last one year; who had at least one chronic health condition.
+EFFECTS OF YOGA ON CARDIAC HEALTH SLEEP QUALITY, MENTAL HEALTH
+AND QUALITY OF LIFE OF ELDERLY INDIVIDUALS WITH CHRONIC AILMENTS: A
+SINGLE ARM PILOT STUDY
+Ashwinin Hegde, Kashianth Metri, Promila Chwadhary, Natesh Babu and H R Nagendra
+Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana, Bangalore
+Abstract
+There is a high prevalence of chronic health problems in elderly persons which significantly affects their mental health, sleep quality and quality of
+life (QoL). Practice of  yoga known to enhance physical and mental health. Present pilot study intended to evaluate the effects of  Integrated Yoga
+(IY) practice on sleep quality, mental health and QoL of elderly individuals suffering from chronic health condition(s). Twenty-eight elderly persons
+residents of Bangalore, India (13 males) within the age range 65-80 years (with group mean±SD; 68.8±5.4 yrs) having chronic health problem(s)
+underwent 1 month of  IY, 60 minutes/day for 6 days/week. We excluded the subjects if  they; had compromised cardiac functioning; were on sleep
+medication; underwent abdominal surgery; were on anti-psychotic medications; had exposure to any form of  yoga in past one year. All the subjects
+were assessed for cardiac variables, mental health parameters, sleep quality and quality of life at baseline after one month. It was observed a significant
+decrease in pulse rate (p<.001), respiratory rate (p<.001), Systolic BP (p=.001), Diastolic BP (P<.001), perceived stress (p<.001), fasting sugar
+(p<.001, -11.97%), anxiety (p<.001), depression, (p<.001), along with significant improvements in sleep quality (p<.001) and quality of life
+(p<.002) after one month of IY intervention compared to baseline.
+Keywords: Elderly, Yoga, Quality of  life, Sleep, Anxiety, Depression
+YOGA AND SLEEP, CARDIAC HEALTH AND QoL IN ELDERLY
+Voice of  Research
+Volume 6, Issue 1
+June 2017
+ISSN 2277-7733
+23 | Voice of  Research, Vol. 6 Issue 1, June 2017, ISSN 2277-7733
+We excluded the subjects if they had; history of recent surgery;
+any kind psychiatric problems; compromised cardiac
+functioning; been on psychotic medication or sleep medication.
+Procedure: We followed convenient sampling method.
+Advertisement was carried out through newspapers and flyers
+in different local nearby apartments in south Bangalore, India.
+35 subjects fulfilled eligible criteria among these 4 declined for
+participation and 3 discounted in the middle of study due to
+some personal reasons. Finally Twenty-eight elderly (13 males;
+group average age±SD= 68.8±5.4 yrs) completed the study
+successfully.
+Outcome measures: All the following variables were done at
+baseline and after one month of yoga intervention.
+Cardiac variables- Systolic BP, diastolic BP, heart rate (using
+Omran BP monitoring system), Fasting blood glucose level
+using Gluconorm glucometer
+Psychological variables - Anxiety and depression (using
+Hopsital Anxiety Depression Scale-HADS), Perceived stress
+(using Cohen’s Perceived stress Scale-PSS), Quality of life -
+Using Quality of life and Life satisfaction scale, Sleep quality
+(using Pittsburg sleep quality index)
+Assessment tools: - Hospital Anxiety Depression Scale
+(HADS)-Hospital Anxiety Depression Scale Questionnaire:
+Depressive and anxiety symptoms were measured using this
+questionnaire. HADS Questionnaire has 14 items, seven items
+related to anxiety symptoms and seven item related to
+depressive symptoms. A score greater than or equal to 11
+shows that the subjects have a significant number of
+symptoms of anxiety or depression corresponding to confirm
+cases (Straat et al, 2013). Perceived stress- Cohen’s perceived
+stress scale (CPSS) (Cohen et al, 1983). It is one of the most
+frequently used tools for measuring psychological stress. It is
+a self-reported questionnaire that was designed to measure
+“the degree to which individuals appraise situations in their
+lives as stressful” (Rao et al, 2017). Sleep quality- Sleep quality
+was assessed using Pittsburg sleep quality index. Pittsburg
+sleep quality index: is an effective instrument useful for
+measuring subjective sleep quality and sleep disturbances in
+older people. A score of five and above indicated clinically
+significant sleep disturbances. Numerous studies using the
+PSQI in a variety of the older adult population internationally
+have supported high validity and reliability (Carole et al, 2012).
+Quality of Life Quality of Life Enjoyment and Satisfaction
+Questionnaire- This is one of the most widely used
+instruments to assess psychological distress. The Q-LES-Q is
+a self-report instrument designed to measure satisfaction and
+enjoyment in various domains of functions like physical
+health, work, household duties etc. (Lee et al., 2014).
+Intervention: All the subjects underwent one month of yoga
+practice (detailed in table 1). The practices included in the
+module were chosen from the interventions in previous
+studies. Daily Yoga session was consisted of  loosening
+practices, yoga postures-asanas breathing practices-pranayama,
+yogic relaxation techniques and meditation-dhyana. Yoga
+session was total 60 minutes every day from 6am -7am, 6 days
+a week for 1 month.
+Analysis: Scoring of all self reported questionnaires were done
+following the instructions mentioned in the manual of the
+respective questionnaire. Data was analyzed using SPSS version
+10. Paired sample t test and Wilcoxon’s signed rank test were
+used assess prepost changes.
+Results: Cardiac variables: There was significant decrease in
+pulse rate (p<.001-6.44%), respiratory rate from (p<.001,-
+19.23%), Systolic BP (p<.001, -8.57%), Diastolic BP (p<.001,-
+6.58%), Fasting Sugar (p<.001,-11.97%) in post intervention
+assessments compared to baseline.
+Psychological variables : We observed a significant reduction
+in perceived Stress (p<.001,-41.73%), anxiety (p<.001,-
+51.83%), depression (p<.001,-60.95%), along with a significant
+improvement in sleep quality (p<.001,-55.56%), QoL
+(p<0.001, 14.96), life satisfaction (p=.002, 11.30%) in post
+intervention compared to baseline.
+Table1 - Shows Pre-post changes in all variables after one month
+of yoga practice
+Graph 1 - Pre-post changes in all physiological variables after
+one month of yoga practice
+SL
+No
+Variables
+Pre [Mean
+± SD]
+Post [Mean
+± SD]
+%
+Change
+df
+P
+values
+1
+Pulse rate
+77.11
++7.05
+72.14 +
+6.20
+-6.44
+27
+<.001**a
+2
+Respiratory rate
+20.43 +
+4.26
+16.50 +
+4.56
+-19.23
+27
+<.001**a
+4
+Systolic BP
+144.18 +
+19.49
+131.82 +
+17.35
+-8.57
+27 =0.001*a
+5
+Diastolic  BP
+84. 07 +
+9.97
+78.54 +
+7.98
+-6.58
+27
+<.001**a
+6
+Fasting sugar
+111.04 +
+19.45
+97.75 +
+14.09
+-11.97
+27 <.001**b
+7
+Anxiety
+5.86 +
+3.76
+2.82 +
+2.40
+-51.83
+27 <.001**b
+8
+Depression
+3.75 +
+3.38
+1.46 +
+1.53
+-60.95
+27 <.001**b
+9
+Sleep quality
+index
+6.43 +
+3.66
+2.86 +
+1.86
+-55.56
+27 <.001**b
+10 PSS
+13.18 +
+5.19
+7.68 +
+3.79
+-41.73
+27
+<.001**a
+11 Pain analog scale
+3.50 +
+3.11
+1.07 +
+1.49
+-69.39
+27 <.001**b
+12 Quality of life
+73.54+
+10.54
+84.54 +
+8.78
+14.96
+27
+<.001**a
+14 Satisfaction scores
+4.11+
+0.74
+4.57+
+0.50
+11.30
+27
+=.002*b
+YOGA AND SLEEP, CARDIAC HEALTH AND QoL IN ELDERLY
+24 | Voice of  Research, Vol. 6 Issue 1, June 2017, ISSN 2277-7733
+Graph 2 - Pre-post changes in all psychological variables after
+one month of yoga practice
+Graph 3 - Pre-post changes in all sleep quality after one month
+of yoga practice
+Discussion: This study intended to evaluate the effect of one
+month yoga practice on cardiac variables, sleep quality, mental
+health and QoL of elderly persons suffering from chronic
+health problems. We observed a significant improvement in
+cardio-respiratory fitness parameters (by improved heart rate,
+systolic BP, diastolic BP and respiratory rate), mental health
+(reduction in perceived stress, anxiety and depression), sleep
+quality (by Pittsburgh’s sleep quality Index- PSQI) and QoL
+after one month of yoga intervention compared to baseline.
+These results are supported by various earlier studies done in
+the same population. Previously a study by Bowmen (1997)1
+assessed effect of 6 weeks of yoga training on heart rate and
+blood pressure in healthy elderly people. There was a significant
+decrease in heart rate and no significant change was reported in
+systolic blood pressure. In the present study we observed
+significant decrease in heart and systolic and diastolic BP
+following 4 weeks of yoga intervention this difference in the
+results of these two studies could be difference in the forms
+of yoga. Another study by Kuei-Min Chen (2009), studied
+the effects of six months silver yoga practice on sleep quality,
+depression, and self-perception of health status of 62
+community dwelling elderly and compared it with control
+group (n=62). This study reported a significant improvement
+in mental health components, sleep quality and quality of life.
+Similarly, results of our study are in supports of previous
+study results. However duration and form of yoga, used and
+subjects in both the study are different. In our study we found
+significant improvement in one month of integrated yoga
+intervention however our study was single group prepost
+design. In randomized controlled trial by Hariprasad (2013)
+assessed the effect of six month yoga intervention on sleep
+quality and QoL in elderly people living in old age homes. In
+this study significant improvement in sleep quality and
+environmental domain of QoL was observed in yoga group
+and no improvement was noticed in control group. Similarly
+in results of present study is supported by previous study
+(Hariprasad et al, 2013). However subjects in our study were
+elderly persons had chronic health problems and were living
+with their family also duration of the yoga intervention was
+one month, whereas in previous study (Hariprasad et al, 2013)
+elderly persons were health subjects, living in old-age homes
+and duration of yoga intervention was six month. Our study
+reported a significant improvement in sleep and QoL even
+with such short term intervention as compared to previous
+study (Hariprasad et al, 2013) the reason could be subjects
+with type of yoga practice and subjects with chronic health
+problems are more sensitive to such interventions compared
+to control group. Goncalvas (2011) assessed effect of 14 weeks
+yoga intervention (twice weekly) on flexibility and QoL these
+results support the findings of the resent study. This study
+reported significant improvement QoL. In the present study
+we also found significant improvement in QoL following one
+month yoga intervention. Previously, Manjunath and Telles,
+2005, assessed the effects of yoga and Ayurveda combined
+therapy on sleep quality and quality of life in geriatric population
+in this they found significant improvement in sleep quality.
+Similarly in our study also we observed significant
+improvement in sleep quality.
+Mechanism
+Possible mechanism behind these findings could be; Practice
+of Yoga is known to reduce sympathetic tone (Sengupta et al,
+2012) through down regulation of the hypothalamus-
+pituitary- adrenal axis and enhances the deep physical and
+psychological rest 33, which helps in reducing the heart rate
+and blood pressure 34 practice of yoga improves the physical
+activity 35 (Field et al., 2013), psychological wellbeing 36.
+Different kinds of yogic relaxation techniques 37, different
+types of yogic breathing practices might have helped them to
+reduce anxiety 38. This study is having few limitations such as
+1) Lack of control group 2) small sample sizes
+Conclusion
+This pilot study suggests a potential role of yoga practice in
+improving sleep quality, mental health and QoL of elderly
+individuals with chronic ailments. However, further
+randomized controlled studies need to be performed to
+confirm the present findings.
+Conflict of Interest: None
+YOGA AND SLEEP, CARDIAC HEALTH AND QoL IN ELDERLY
+25 | Voice of  Research, Vol. 6 Issue 1, June 2017, ISSN 2277-7733
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+YOGA AND SLEEP, CARDIAC HEALTH AND QoL IN ELDERLY

subfolder_0/Effects of yoga on prakrti in children – a pilot study..txt

@@ -0,0 +1,240 @@
+SENSE, 2012, Vol. 2 (2), 293-298 
+ 
+ 
+ 
+            
+ 
+        UDC: 233.852.5Y:2-455 
+© 2012 by the International Society for  
+ 
+ 
+            
+ 
+        Original Scientific Paper 
+Scientific Interdisciplinary Yoga Research 
+ 
+ 
+ 
+Effects of Yoga on Prakrti in Children – a Pilot Study 
+ 
+S.P. Suchitra, H.R. Nagendra 
+Vivekananda University  
+Bangalore, India 
+ 
+Abstract: Effect of Yoga on the personality of children and trigunas have been proven. But there 
+are no available studies on the effect of yoga on tridoshas, which may contribute to the 
+restoration of positive health. Objective  of the study was to understand the effect of Integral 
+Yoga module on the Prakrti of children. 
+The study was single group pre-post design. During th period of three months, 30 children aged 
+8-12 yrs, selected from Maxwell public school practiced Integral Yoga module including asanas, 
+pranayama, nadanusandhana, chanting and games. Ayurveda child personality inventory was 
+administered before and after. Paired sample T-test was applied. Vata was decreased 
+significantly and Pitta increased significantly. Increase in Kapha was not significant. Integral 
+Yoga Module has the significant effect on the tridoshas in children. 
+ 
+Key words: tridosha, prakriti, vāta, pitta, kapha 
+ 
+Introduction  
+ 
+Western psychology proclaims personality of an individual determined by the psychodynamic 
+systems id, ego, super-ego and unconscious principle. It defines personality as “the dynamic 
+organization within the individual of those psychophysical systems that determine his 
+characteristic behavior and thought” (Misched, 1971). Indian psychology conceptualizes that the 
+personality is determined by tridosha  (metabolic principles - Vāta, Pitta, Kapha) and trigunas 
+(Sattva. Rajas, Tamas-representing harmony, passion, ignorance) (Brahmananda, 1994). 
+Āyurveda classics illustrate 7 types of Doshaja Prakrti and sixteen types of mental constitution 
+formed at the time of conception (Brahmananda, 1994). Accordingly, they affirm persons with 
+predominance of single dosha, and two dosha are susceptible to somatic diseases and 
+psychological illness. 
+ 
+Concepts of Indian psychology about our past-life actions (samskaras) determine our character. 
+Patanjali quotes that birth, experiences, actions depend upon past-life impressions. He also 
+emphasizes that practice of astanga yoga will help in clearing the impressions, thus changing the 
+character of an individual (Vivekananda, 2006; Tapasyananda, 2006). Thus perfect health can be 
+attained (Brahmananda, 1994). Similarities between Āyurveda concept and modern gestalt theory 
+and the correspondence of 16 types of personalities with 16 types of psychological disorders have 
+been discussed (Dube, Kumar, Dube, 1983). 
+  
+A study have reported significant changes in sattva, rajas, tamas by integral yoga practice on 
+subjects of age group 17-63 (Khemka, Ramaro, Hankey, 2011). A randomized controlled study 
+has shown the influence of yoga on gunas and self esteem in comparison to physical exercise  
+                                                 
+ Corresponding author: [email protected] 
+(Berger, Silver, Stein, 2009). Another study have reported changes in well being of children after 
+yoga (Rangan, Nagendra, Bhat, 2009). The GES  educational program, based around integrated 
+yoga modules is proven effective in enhancing visual and spatial memory (Krishnan, Sripriya, 
+2006). Simplified kundalini yoga have showed significant effect on personality and achievement 
+(Deshpande, Nagendra, Nagarathna, 2009). Yoga has proven more effective than physical 
+exercise in attention deficit hyperactive disorder (Haffner, Roos, Goldstein, Parzer, Resch, 2006). 
+Relaxation and yoga exercise have reduced anxiety of children and adolescent group (Platania-
+Solazzo, Field, Blank, Seligman, Kuhn, Schanberg, Saab, 1992). The efficacy of integral yoga 
+module as an effective therapeutic tool in the management of mentally retarded children has been 
+proven (Smith, Greer, Sheets, Watson, 2011). 
+ 
+Improvement of the physical and mental health and promotion of well-being by six months of 
+yoga practice in adults has been proved (Uma, Nagendra, Nagarathna, Vaidehi, Seethalakshmi, 
+1989). Improvement of cognitive function and quality of life in women who practiced yoga has 
+been addressed (Hadi, Hadi, 2007).  A study has proved reduction of somatic stress by muscle 
+relaxation (Oken, Zajdel, Kishivama, Flegal, Dehen, Has, Kraemer, Lawrence, Levya, 2006). 
+Higher scores in life satisfaction and lower scores in excitability, aggressiveness, openness, 
+emotionality and somatic complaints was followed by hatha-yoga practice (Khasky, Smith, 1999). 
+ 
+As there was  no published  studies  available on the effect of yoga on tridosha and prakrti, need 
+was felt for the present study to be carried out.  
+ 
+Methods 
+ 
+The study was single group pre-post design. Examinees practiced integral yoga module for three 
+months. They practiced twice a week with yoga teahcer and they were asked to practice at home 
+every day by themselves. Āyurveda child personality inventory was administered at the beginning 
+and at the end of three months. Vata, pitta, kapha mean scores were analyzed, significance was 
+analyzed by Paired sample T-test. 
+ 
+Ayurveda child personality inventory which was based on Sanskrit verses quoted in nine texts 
+had three subscales: vata (A), pitta (B), kapha (C). Associated with the Cronbach’s alpha for A, B 
+and C scales were 0.77, 0.55 and 0.84 respectively. The Split-Half reliability scores  were 
+0.66.0.39 and 0.84 respectively. Factor validity coefficient Scores on each items was above 0.5. 
+ 
+Subjects 
+ 
+Thirty children of the age group 8-12 years old from Maxwell Public School, Bangalore were 
+included in the study. Children with attention deficit hyperactive disorder, autism, psychosis and 
+mentally challenged were excluded from the study. 
+ 
+Integral Yoga Module 
+ 
+Yoga practices included breathing exercises like ankle stretch breathing, hand-stretch  breathing, 
+dog breathing, rabbit breathing, dynamic exercises like jogging, forward-backward bending, 
+Surya namaskara, asanas - vrkshasana, veerabhadra-asana,  ustrasana, padahastasana, ostrich 
+pose, blossom, pavanamuktasana kriya, pranayama techniques - nadishuddhi, bhramari, yogic 
+breathing, nadanusandhana, yogic games like search engine, find the leader, along with the 
+stories, vedic chanting, Bhagavad Gita chanting. 
+ 
+ 
+Table 1: Demographic data 
+ 
+Sample 
+N/Mean 
+%/ SD 
+Gender 
+12 boys/N-30 
+40% 
+Age 
+9.5 
+1.4 
+Education 
+5.2 
+1.7 
+ 
+ 
+Results 
+ 
+Table 2:  Paired sample T-test results of ACPI 
+ 
+Tridosha 
+Before Yoga 
+After Yoga 
+Significance 
+Vata 
+19.4±7.29 
+15.4±4.28 
+.002 
+Pitta 
+19.7±6.1 
+23.0±1.6 
+.011 
+Kapha 
+21.4±9.7 
+22.8±4.1 
+.416 
+ 
+ 
+Discussion 
+ 
+Children who scored high in vata and pitta before yoga, scored high in pitta and kapha after 
+yoga. Children who scored high in kapha before practice, scored high in pitta and kapha after 
+yoga. Children, who scored high in vata, scored high in vata nad pitta after yoga. Totally, vata 
+was reduced significantly, pitta increased significantly, while  increase in kapha was not 
+significant. 
+ 
+Sweating reduces vata according to Ayurveda classics (Brahmananda, 1994). A study has shown 
+sweat loss after yoga practice (Schell, Allolio, Schonecke, 1994). Vata is associated with rajas and 
+tamas. Earlier studies have shown rajas and tamas decreases after yoga (Deshpande, Nagendra, 
+Nagarathna, 2009). The present study found that vata has reduced after yoga. 
+ 
+Pitta has the characteristic of heat. If body temperature increases, pitta increases (Brahmananda, 
+1994). Earlier studies have discussed the effect of yoga on body temperature and 
+thermoregulation (Madanmohan, Mahadevan, Balakrishnan, Gopalakrishnan, Prakash, 2008). 
+This study have determined that pitta have increased by integral yoga practice. 
+ 
+Kapha is predominant is jalamahabhuta, which is associated with sattva and tamas guna 
+(Brahmananda, 1994). Earlier research work (Telles, Singh, 2011) has discussed kapha correlates 
+with sattva guna. Earlier studies have shown sattva guna increases after yoga (Rangan, 
+Nagendra, Nagarathna, 2009; Deshpande, Nagendra, Nagarathna, 2009).  This investigation has 
+proved the increase in kapha by yoga. 
+ 
+Conclusions 
+ 
+The strength of this study is the first attempt to explore the effect of yoga on prakrti of children. 
+While, Ayurveda quotes, persons with predominance of single or double doshas will always be 
+diseased and equilibrium state of tridosha is health. The present result may point, that yoga helps 
+to move towards positive health by changing the states of doshas.  
+ 
+Although yoga module resulted in significant changes in tridosha (except kapha), sample size 
+was small, yoga practices were not monitored regularly. Sample was not randomly assigned. 
+Future studies are required on random-controlled sample. And yoga practices should be 
+monitored continuously.  
+ 
+The present study have showed, integrated module of yoga have significant effect on vata and 
+pitta and not necessarily on kapha for children of the age group 8-12 years.  
+ 
+ 
+References: 
+ 
+1. Berger, D.L., Silver, E.J. & Stein, R.E. (2009). Effects of yoga on inner-city children's well-being: a pilot 
+study:Altern Ther Health Med.;15(5):36-42. 
+2. Brahmānanda, T. (1994). Caraka samhitā: Hindivyākhyā.Third edition. New Delhi: Choukhambā publications 
+3. Deshpande, S., Nagendra, H.R. & Nagarathna, R. (2009). A randomized control trial of the effect of yoga on Gunas 
+(personality) and Self esteem in normal healthy volunteers:Int J Yoga.;2(1):13-21. 
+4. Dube, K.C., Kumar, A. & Dube, S. (1983). Personality types in Ayurveda; Am J Chin Med.;11(1-4):25-34 
+5. Hadi, N. & Hadi, N. (2007). Effects of hatha yoga on well-being in healthy adults in Shiraz, Islamic Republic of 
+Iran: East Mediterr Health J.;13(4):829-37. 
+6. Haffner, J., Roos, J., Goldstein, N., Parzer, P. & Resch, F. (2006). The effectiveness of body-oriented methods of 
+therapy in the treatment of attention-deficit hyperactivity disorder (ADHD): results of a controlled pilot study: Z Kinder 
+Jugendpsychiatr Psychother.;34(1):37-47. 
+7. Khasky, A.D. & Smith, J.C. (1999). Stress, relaxation states, and creativity: Percept Mot Skills.;88(2):409-16 
+8. Khemka, S.S., Ramarao, N.H. & Hankey, A. (2011). Effect of integral yoga on psychological and health variables 
+and their correlations:Int J Yoga.;4(2):93-9. 
+9. Krishnan, S. (2006). Personality development through Yoga practices: IJTK, Vol.05(4)  
+10. Madanmohan, Mahadevan, S.K., Balakrishnan, S., Gopalakrishnan, M. & Prakash, E.S. (2008). Effect of six weeks 
+yoga training on weight loss following step test, respiratory pressures, handgrip strength and handgrip endurance in 
+young healthy subjects: Indian J Physiol Pharmacol.;52(2):164-70. 
+11. Misched, W. (1971). Introduction to Personality: New York: Holt. Rinehart and Winston.Inc 
+12. Oken, B.S., Zajdel, D., Kishiyama, S., Flegal, K., Dehen, C., Haas, M., Kraemer, D.F., Lawrence, J. & Leyva, J. 
+(2006). Randomized, controlled, six-month trial of yoga in healthy seniors: effects on cognition and quality of life: 
+Altern Ther Health Med.;12(1):40-7 
+13. Platania-Solazzo, A., Field, T.M., Blank, J., Seligman, F., Kuhn, C., Schanberg, S. & Saab, P. (1992) Relaxation 
+therapy reduces anxiety in child and adolescent psychiatric patients: Acta Paedopsychiatr.;55(2):115-20. 
+14. Rangan, R., Nagendra, H., Bhat, G.R. (2009). Effect of yogic education system and modern education system on 
+memory: Int J Yoga.;2(2):55-61. 
+15. Schell, F.J., Allolio, B. & Schonecke, O.W. (1994). Physiological and psychological effects of Hatha-Yoga exercise 
+in healthy women: Int J Psychosom.;41(1-4):46-52. 
+16. Smith, J.A., Greer, T., Sheets, T. & Watson, S. (2011). Is there more to yoga than exercise?: Altern Ther Health 
+Med.;17(3):22-9. 
+17. Suchitra, S.P. & Nagendra, H.R. Measuring the manasika prakrti of the children (In press) 
+18. Tapasyananda, S. (2003). Shrimad Bhagavad Gita: Mylapore:Sri Ramakrishna Math 
+19. Telles, S. & Singh, N. (2011). High frequency yoga breathing increases energy -expenditure from carbohydrates. 
+Comment to: Assessment of sleep patterns, energy expenditure and circadian rhythms of skin temperature in patients 
+with acute coronary syndrome: Med Sci Monit.;17(9):LE7-8. 
+20. Uma, K., Nagendra, H.R., Nagarathna, R., Vaidehi, S. & Seethalakshmi, R. (1989). The integrated approach of 
+yoga: a therapeutic tool for mentally retarded children: a one-year controlled study. J Ment Defic Res.;33 ( Pt 5):415-21 
+21. Vivekananda, S. (2006). Raja Yoga. Kolkata:Advaita Ashrama 
+ 
+ 
+Received: July 2, 2012 
+Accepted: August 2, 2012 
+ 
+ 
+ 
+ 
+ 

subfolder_0/Effects of yogic breath regulation A narrative review of scientific evidence..txt

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+Review Article
+Effects of yogic breath regulation: A narrative review of scientific
+evidence
+Apar Avinash Saoji*, B.R. Raghavendra, N.K. Manjunath
+Swami Vivekananda Yoga Anusandhana Samsthana (S-VYASA Yoga University), Bangalore, India
+a r t i c l e i n f o
+Article history:
+Received 31 May 2017
+Received in revised form
+4 July 2017
+Accepted 9 July 2017
+Available online xxx
+Keywords:
+Yoga
+Yogic breathing
+Pranayama
+Physiological effects
+Health benefits
+a b s t r a c t
+Pranayama or breath regulation is considered as an essential component of Yoga, which is said to in-
+fluence the physiological systems. We present a comprehensive overview of scientific literature in the
+field of yogic breathing.
+We searched PubMed, PubMed Central and IndMed for citations for keywords “Pranayama” and “Yogic
+Breathing”. The search yielded a total of 1400 references. Experimental papers, case studies and case
+series in English, revealing the effects of yogic breathing were included in the review.
+The preponderance of literature points to beneficial effects of yogic breathing techniques in both
+physiological and clinical setups. Advantageous effects of yogic breathing on the neurocognitive, psy-
+chophysiological, respiratory, biochemical and metabolic functions in healthy individuals were elicited.
+They were also found useful in management of various clinical conditions. Overall, yogic breathing could
+be considered safe, when practiced under guidance of a trained teacher. Considering the positive effects
+of yogic breathing, further large scale studies with rigorous designs to understand the mechanisms
+involved with yogic breathing are warranted.
+© 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
+Yoga is a traditional practice from the ancient Indian culture and
+is considered to be the science of holistic living. Various practices
+involved in the tradition of Yoga include disciplined lifestyle (Yama
+and Niyama), cleansing procedures (Kriya), physical postures
+(Asana), breath regulation (Pranayama), concentration (Dharana)
+and meditation (Dhyana) [1,2]. In recent years, there has been
+greater interest in exploring the benefits of various practices
+described in Yoga [3,4]. There have been scientific studies on the
+effects of individual Yoga practices or their combinations on
+healthy individuals as well as in people suffering from various ail-
+ments [5]. Pranayama or breath regulation has been greatly
+emphasized in Yoga and has drawn special attention from the sci-
+entific community. Breath regulation includes modulation of the
+pace of breathing, viz. slowing down or pacing the breath,
+manipulation of nostrils, chanting of humming sounds, retention of
+breath etc. Various Yoga breathing practices described in classical
+text of hathayoga are enlisted in Table 1 [2]. The current review was
+undertaken with an objective of presenting an overview of the
+available scientific evidences on Yogic Breathing.
+2. Methodology
+The online database, PubMed, PubMed Central and IndMed
+were searched for citations for keywords “Pranayama” and “Yogic
+Breathing”. The search yielded a total of 1400 references from the
+date of inception of the databases till July 2017. Experimental pa-
+pers, case studies and case series in English, revealing the effects of
+yogic breathing were included in the review. The studies that had
+used yogic breathing in combination with other Yoga practices
+were excluded. Studies in languages other than English, and whose
+abstracts were unavailable were excluded from the review. After
+applying the inclusion and exclusion criteria and removing the
+duplicates, a total of 68 studies were selected for the final review.
+The studies included in the review were classified into two
+major categories, physiological and clinical. They were sub-
+classified based on the major findings of the study. The physio-
+logical measures assessed with various yogic breathing practices
+are the neurocognitive assessments, psychophysiological changes,
+* Corresponding author.
+E-mail address: [email protected] (A.A. Saoji).
+Peer review under responsibility of Transdisciplinary University, Bangalore.
+Contents lists available at ScienceDirect
+Journal of Ayurveda and Integrative Medicine
+journal homepage: http://elsevier.com/locate/jaim
+http://dx.doi.org/10.1016/j.jaim.2017.07.008
+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 xxx (2017) 1e9
+Please cite this article in press as: Saoji AA, et al., Effects of yogic breath regulation: A narrative review of scientific evidence, J Ayurveda Integr
+Med (2017), http://dx.doi.org/10.1016/j.jaim.2017.07.008
+respiratory, biochemical and metabolic variables. Studies have also
+been conducted to understand the impact of yogic breathing in
+patients with hypertension, cardiac arrhythmias, bronchial asthma,
+pulmonary tuberculosis, cancer, diabetes mellitus, mental retar-
+dation, stroke rehabilitation, withdrawal from smoking, anxiety
+and pain.
+3. Results
+3.1. Neurocognitive effects of yogic breathing
+Ancient Indian texts on Yoga describe, “As the breath moves, so
+does the mind, and mind ceases to move as the breath is stopped.”
+[2] Thus, evaluating the impact of yogic breathing on neuro-
+cognitive abilities has sought special attention from the scientific
+community. An early review indicates that yogic breathing prac-
+tices could influence the brain activity in different ways [6].
+3.1.1. Changes due to pace of breathing
+The earliest studies reported assessing the effects of yogic
+breathing on neurocognitive abilities evaluated the effect of 15 min
+of high frequency yogic breathing, described as Kapalabhati on EEG
+activity [7]. The study demonstrated increased alpha activity during
+the initial 5 min of Kapalabhati. Theta activity was observed to be
+enhanced, mostly in the occipital region during later stages of
+15 min Kapalabhati compared to the pre-exercise period. Beta 1
+activity increased during the first 10 min of Kapalabhati in occipital
+and to a lesser degree in parietal regions. Another study assessing
+the cognitive abilities demonstrated increase in the number of er-
+rors following 1 and 5 min of practice of Kapalabhati, in a letter
+cancellation task [8].
+The impact of another rapid paced Pranayama called Bhastrika,
+described in Hathayoga as bellow's breath, on reaction time was
+studied by Telles et al. They found a reduction in anticipatory re-
+sponses following 18 min of practice of Bhastrika [9]. Auditory (ART)
+and visual reaction time (VRT) reduced significantly in school
+children following just 9 rounds of Mukha Bhastrika, in 22 healthy
+school children [10]. This phenomenon was further exploited clin-
+ically in mentally challenged adolescents, who have higher reaction
+time. A study done by same authors has shown immediate
+reduction in VRT and ART among 34 mentally challenged adoles-
+cents [11]. A study comparing the effects of slow and fast paced
+Pranayama reported effects of 35 min/day of fast and slow Pra-
+nayama practiced for 10 weeks. Executive functions, perceived
+stress scale (PSS) and reaction time improved significantly in both
+fast and slow Pranayama groups, except reverse digit span, which
+showed an improvement only in fast Pranayama group [12].
+3.1.2. Changes with Bhramari Pranayama
+A form of yogic breathing called Bhramari (female honeybee
+humming breath), which is said to modify the brain responses
+through resonance produced by the humming sound, has shown to
+cause non-epileptic paroxysmal gamma waves in the EEG [13]. A
+study has shown that the practice of Bhramari for 10 min enhances
+inhibition and reaction time in the stop signal task that involves
+cognitive inhibition, in 31 healthy male individuals [14].
+3.1.3. Changes due to manipulation of nostrils
+Uninostril and alternate nostril breathing has been of special
+significance in Yoga, since the nostrils are said to represent the
+subtle energy channels known as Nadis [2,15]. Right nostril corre-
+sponds to Pingala Nadi, and the left to Ida, respectively. Breathing
+through a single specific nostril is said to affect the human system
+differently. A study involving 51 volunteers demonstrated that the
+performance in a spatial task was significantly enhanced during left
+nostril breathing in both males and females, whereas non-
+significant increase was noted in the verbal task performance
+[16]. Another study compared alternate nostril breathing with
+breath awareness. A significant increase was noted in the P300
+peak amplitudes at different scalp sites along with a decrease in the
+peak latency at frontal scalp region, following alternate nostril Yoga
+breathing. Following breath awareness there was a significant in-
+crease in the peak amplitude of P300 at vertex region alone [17].
+Healthy experienced Yoga practitioners demonstrated an increase
+in Na-wave amplitude and decrease in latency during the period of
+Pranayama practice, whereas no alterations were observed in the
+Pa-wave. The Pranayama practice in the study involved consciously
+controlled rhythmic breathing with breath holding [18]. A three
+arm randomized controlled trial done on patients with essential
+hypertension, comparing the effects of Nadishuddhi Pranayama and
+Table 1
+Procedures of various yogic breathing practices.
+Name of the practice
+Method of practice
+Kapalabhati
+Sitting with back and neck erect, one should inhale through
+both nostrils and exhale rapidly by flapping the abdomen during
+each exhalation at a pace of 60e120 breaths/min.
+Bastrika (Bellow's breath)
+One should inhale and exhale quickly and forcefully without
+straining by flapping the abdomen. This should be practiced
+for up to 100 breaths.
+Nadishodhana/Nadishuddhi (Alternate nostril breathing)
+With the right thumb, close the right nostril and inhale through
+left nostril. Closing the left nostril, exhale through right, following
+which inhalation should be done through right nostril. Closing the
+right nostril, breath out through left nostril. This is one round. The
+procedure is repeated for desired number of rounds.
+Suryanuloma Viloma (Right uninostril breathing)
+Closing the left nostril, both inhalation and exhalation should be done
+through right nostril, without altering the normal pace of breathing.
+Chandranuloma Viloma (Left uninostril breathing)
+Procedure similar to Suryanuloma Viloma, breathing is done through left nostril alone, by
+closing the right nostril.
+Suryabhedana (Right nostril initiated breathing)
+Closing the left nostril, inhalation should be done through right nostril. At
+the end of inhalation, close the right nostril and exhale through the left
+nostril. This is one round. The procedure is repeated for desired number of rounds.
+Ujjayi (Psychic Breath)
+Inhalation and exhalation are done through the nose at normal pace, with
+partial contraction of glottis, which produce light snoring sound. One should
+be aware of the passage of breath through the throat during the practice.
+Bhramari (Female honeybee humming breath)
+After a full inhalation, closing the ears using the index fingers, one should
+exhale making a soft humming sound similar to that of a female honeybee.
+A.A. Saoji et al. / Journal of Ayurveda and Integrative Medicine xxx (2017) 1e9
+2
+Please cite this article in press as: Saoji AA, et al., Effects of yogic breath regulation: A narrative review of scientific evidence, J Ayurveda Integr
+Med (2017), http://dx.doi.org/10.1016/j.jaim.2017.07.008
+breath awareness with control session for 10 min elucidated
+reduction in systolic and diastolic blood pressure following
+Nadishuddhi and improvement in Purdue pegboard task perfor-
+mance with both hands and right hand. The Purdue pegboard task
+assesses manual dexterity and eyeehand co-ordination. Breath
+awareness group demonstrated reduction in systolic blood pres-
+sure when compared with control activity like reading magazine
+[19]. The practice of uninostril breathing was also used clinically in
+cases of stroke, where practice of uninostril breathing for 10 weeks
+reduced anxiety in 11 post stroke cases and improved language
+measures in individuals with aphasia due to stroke [20]. Another
+case series on the use of forced uninostril breathing along with
+speech therapy for post stroke aphasia showed improvement in
+correct information unit and word productivity [21].
+Thus, most yogic breathing techniques are found to influence
+the neuro-cognitive abilities positively and some of which were
+even used in clinical settings with beneficial effects. The neuro-
+cognitive effects of yogic breathing are summarized in Table 2.
+3.2. Psychophysiological effects of yogic breathing
+Human respiration is the only physiological system that is under
+both autonomic and voluntary nervous control and thus it is also
+given special emphasis in yogic texts. The effects of yogic breath
+regulation on modulation of autonomic functions (AFT) have been
+studied extensively. The studies on yogic breathing assessing the
+AFT include various assessment measures like blood pressure (BP) e
+systolic (SBP) and diastolic (DBP), heart rate (HR), heart rate vari-
+ability (HRV), respiratory rate (RR), galvanic skin resistance (GSR),
+pulse rate (PR), etc. Both short and long term effects of yogic
+breathing have been assessed using AFT.
+3.2.1. Changes due to nostril manipulation
+A study performed on 8 healthy volunteers demonstrated an
+increase in HR following right forced uninostril breathing (UNB)
+indicating the sympathetic activation following right UNB [22]. A
+three-arm RCT using HRV as the measure of autonomic activity,
+showed sympathetic arousal in the right UNB group, whereas
+indices representing parasympathetic activity were increased in
+left UNB group following 6-week nostril breathing [23]. A pilot RCT
+performed on 12 individuals found that 20 min of alternate nostril
+breathing increased GSR, which denotes parasympathetic activity.
+Though there was no significant change in the BP or pulmonary
+function tests, the study demonstrated efficacy of the yogic
+breathing in bringing a parasympathetic shift in the autonomic
+functions within a short span of one week [24]. Another study
+illustrating the ability of ANB in bringing the parasympathetic shift
+in the autonomic functions uses 30:15 ratio and expiration:inspi-
+ration ratio as measures of autonomic functions [25]. Nadishuddhi
+Pranayama at the rate of one breath per min was found to enhance
+sinus arrhythmia and reduction in low frequency component of
+HRV [26]. It also decreased the average breath rate, confirming the
+Table 2
+The neurocognitive effects of yogic breathing.
+Sl No.
+Author
+Year
+Sample size
+Variables studied
+Findings
+1
+Stanc

+ak et al.
+1991
+11
+EEG
+Alpha activity was increased during the initial 5 min of
+Kapalabhati (KPB). Theta activity was increased during
+later stages of 15 min KPB mostly in the occipital region,
+compared to the pre-exercise period. Beta 1 activity
+increased during the first 10 min of KPB in occipital and
+to a lesser degree in parietal regions.
+2
+Telles et al.
+1993
+11
+Middle Latency Auditory Evoked
+Potential
+Na-wave amplitude increased and latency decreased
+during the period of pranayamic practice, whereas the
+Pa-wave was not significantly altered.
+3
+Jella & Shannahoff-Khalsa
+1993
+51
+Spatial and verbal task performance
+Spatial task performance was significantly enhanced
+during left nostril breathing. Verbal task performance
+non-significantly increased during right nostril
+breathing.
+4
+Bhavanani et al.
+2003
+22
+Visual reaction time (VRT) and auditory
+reaction time (ART)
+VRT and ART reduced significantly in school children
+following 9 rounds of Mukha Bhastrika.
+5
+Vialatte et al.
+2008
+8
+EEG
+Non-epileptic paroxysmal gamma waves were
+generated during the practice of Bhramari Pranayama.
+6
+Bhavanani et al.
+2012
+34
+VRT and ART
+There was reduction in VRT and ART following 9 rounds
+of Mukha Bhastrika among mentally challenged
+children.
+7
+Telles et al.
+2013
+90
+Blood pressure (BP) and Purdue
+pegboard task
+There was reduction in systolic (SBP) and diastolic blood
+pressure (DBP) following Nadishuddhi and
+improvement in Purdue pegboard task performance
+with both hands and right hand. Breath awareness
+group demonstrated reduction in SBP.
+8
+Telles et al.
+2013
+20
+P300
+There was a significant increase in the P300 peak
+amplitudes at different scalp sites and a significant
+decrease in the peak latency at frontal scalp region,
+following alternate nostril Yoga breathing. Following
+breath awareness there was a significant increase in the
+peak amplitude of P300 at Vertex region.
+9
+Pradhan
+2013
+36
+Digit Letter Substitution Task (DLST), Six
+Letter Cancellation Test (SLCT)
+KPB practice for 1 and 5 min had no significant impact
+on SLCT and DLST scores, but there was increase in
+errors following the practice.
+10
+Telles et al.
+2013
+70
+Reaction time
+Following 18 min of Bhastrika Pranayama there was a
+statistically significant reduction in number of
+anticipatory responses compared to before the practice.
+11
+Rajesh et al.
+2014
+31
+Stop Signal Task
+Reduction in stop signal reaction time was found with
+10 min of practice of Bhramari Pranayama. There was
+increase in go Reaction time in Bhramari group when
+compared to deep breathing group for equal duration.
+A.A. Saoji et al. / Journal of Ayurveda and Integrative Medicine xxx (2017) 1e9
+3
+Please cite this article in press as: Saoji AA, et al., Effects of yogic breath regulation: A narrative review of scientific evidence, J Ayurveda Integr
+Med (2017), http://dx.doi.org/10.1016/j.jaim.2017.07.008
+parasympathetic shift of ANS. Another study demonstrated that
+Nadishuddhi Pranayama for 15 min/day for 4 weeks increased PEFR
+and pulse pressure and decrease in PR, RR, DBP in healthy subjects
+[27]. Training in Nadishuddhi Pranayama along with breath holding
+for 4 weeks elucidated reductions in baseline HR, SBP and DBP,
+which was attributed to increased vagal tone and reduced sym-
+pathetic discharge [28]. 6 variations of nostril breathings on car-
+diovascular parameters and reaction time in 20 experienced
+subjects demonstrated that 9 rounds of Nadishuddhi, left nostril
+breathing and left initiated breathing lead to reduction in BP and
+HR, whereas right nostril breathing and right initiated breathing
+showed an increase in the same. There were no changes found with
+normal breathing. The reaction time was lowered following the
+practice of right nostril breathing and right initiated breathing. The
+changes were attributed to the nostril used for inspiration than that
+for expiration [29].
+3.2.2. Changes due to modulation of pace of breathing
+The pace of breathing also modifies psychophysiological re-
+sponses. A pilot study evaluating the effect of very slow breathing
+at 1 breath/min for 20 min on cardiovascular risk factors showed
+dramatic changes in hemodynamic variables like stroke index, HR,
+cardiac index, end diastolic index, peak flow, ejection fraction,
+thoracic fluid index, index of contractility, ejection ratio, systolic
+time ratio, acceleration index, and systolic, diastolic, and mean
+arterial pressures, left stroke work index and stroke systemic
+vascular resistance index. These changes indicate that breathing at
+a slow pace with internal breath hold could influence brainstem
+cardiorespiratory center regulating the Mayer wave patterns [30].
+Another study done on 17 naïve subjects demonstrated an in-
+crease in baroreflex sensitivity (BRS) following slow breathing
+with or without Ujjayi Pranayama. The decrease in the BP and
+increase in the BRS was maximal when the subjects practiced
+slow breathing with equal inspiration and expiration at the rate of
+6 breaths/minutes [31]. A study comparing the training in fast and
+slow
+Pranayama
+for
+3
+months
+elucidated
+increased
+para-
+sympathetic activity and decreased sympathetic activity in the
+slow breathing group at the end of intervention period, whereas
+no significant change in autonomic functions was observed in the
+fast breathing group [32]. A three armed RCT involving 90 young
+healthcare students, which compared the effects of training in
+slow and fast Pranayama for 3 months, showed reduction in
+perceived stress in both fast and slow Pranayama group. The
+cardiovascular variables viz. HR, SBP and DBP reduced only in slow
+Pranayama group. The fast Pranayama group did not show sig-
+nificant changes in the cardiovascular variables [33]. Hand grip
+strength (HGS) and hand grip endurance (HGE) increased with the
+training of fast Pranayama, whereas only HGS increased following
+slow Pranayama training for 12 weeks [34]. Fast paced Kapalabhati
+was shown to increase the LF power and LF:HF ratio and lower the
+HF power in HRV, indicating the sympathetic arousal [35]. A
+concurrent result was found in another study that demonstrated
+an increase in HR, SBP and DBP following Kapalabhati. The study
+performed on 17 individuals also elucidated reduced BRS during
+practice of Kapalabhati [36]. A study demonstrating the effect of
+training in Mukha Bhastrika, involving rapid breathing for 12
+weeks, reduced basal HR, increase in valsalva ratio and deep
+breathing difference in HR. It was also found to reduce the fall in
+BP on variation of posture. All the findings were indicative of
+increased parasympathetic activity following long term training in
+the practice of Mukha Bhastrika [37]. To understand the underly-
+ing pathways for the modulation of cardiovascular parameters
+following slow paced Bhastrika Pranamayama, a study compared
+the effect of 5 min of Bhastrika on HR and BP, with and without
+oral administration of hyoscine-N-butylbromide (Buscopan), a
+parasympathetic blocker drug. Fall in SBP, DBP and HR were noted
+in the group which practiced Bhastrika for 5 min without
+administration of the drug whereas subjects following the
+administration of the drug did not show significant changes in BP
+or HR. Thus the study concluded that the modulation of ANS due
+to practice of slow pace Bhastrika is attributed to the enhanced
+parasympathetic activity [38].
+3.2.3. Changes due to other yogic breathing techniques
+A recent study using HRV demonstrated parasympathetic
+withdrawal during the practice of Bhramari Pranayama, which
+reverted back to normalcy after the completion of practice [39].
+Medical students showed reduced stress levels following practice
+of a combination of Pranayama practices for 1 h a day, 5 days per
+week for 2 months. HRV demonstrated reduction in VLF and LF and
+increase in HF component, indicative of a parasympathetic shift of
+the autonomic activity [38]. The relaxation attained through prac-
+tice of Pranayama was exploited to ease the test anxiety and
+improve test scores in 107 postgraduate students. An RCT demon-
+strated that following the practice of Pranayama for a semester,
+only 33% participants experienced high test anxiety, compared to
+66.67% among the control group. Participants in the Pranayama
+group also had higher scores in the test performance than controls
+[40].
+We observed that, most yogic breathing techniques are found to
+have profound effects on autonomic functions. Most yogic breath-
+ing practices lead to parasympathetic shift of the ANS activity,
+except high frequency Yoga breathing (Kapalabhati) [41]. The ef-
+fects of yogic breathing on psychophysiological variables are sum-
+marized in Table 3.
+3.3. Effects of yogic breathing on respiratory system
+The training in yogic breathing is found to be an effective means
+of enhancing the pulmonary functions. Slow breathing at 6 breaths/
+min showed an increase in vital capacity (VC) after 2 and 5 min, and
+increase in forced vital capacity after 2 min, and increase in forced
+inspiratory vital capacity and peak inspiratory flow rate after 2, 5
+and 10 min [42]. Another study where the effects of 12 week
+training in slow and fast Pranayama on PFT were compared,
+revealed that slow Pranayama group, PEFR and FEV25 improved
+significantly, whereas in the fast Pranayama group, FEV1/FVC, PEFR,
+FEF25-75 improved significantly [43]. A recent study demonstrated
+beneficial effect of one month training in combination of yogic
+breathing on pulmonary functions in competitive swimmers [44].
+Thus, the limited available evidence on effects of yogic breathing on
+respiratory system indicates a positive trend of change in the res-
+piratory physiology.
+3.4. Effects of yogic breathing on biochemical and metabolic
+variables
+Curiosity of what causes the changes that are observed
+following the practice of yogic breathing, led to a study which
+examined the changes in arterial blood gas levels following the
+practice of Pranayama. No significant changes were observed in
+arterial blood oxygenation following Pranayama, thus speculating
+neural mechanisms for changes due to Pranayama [45]. Another
+study observed a decrease in blood urea, and an increase in
+creatinine and tyrosine after 1 min of Kapalabhati. It was attrib-
+uted to decarboxylation and oxidation mechanisms, which may
+be responsible for a reduction in the activity of respiratory cen-
+ters [46].
+A.A. Saoji et al. / Journal of Ayurveda and Integrative Medicine xxx (2017) 1e9
+4
+Please cite this article in press as: Saoji AA, et al., Effects of yogic breath regulation: A narrative review of scientific evidence, J Ayurveda Integr
+Med (2017), http://dx.doi.org/10.1016/j.jaim.2017.07.008
+3.4.1. Changes in oxygen consumption with yogic breathing
+Oxygen consumption is used as a means to understand the
+metabolic activity of the body. A study exploring the effects of Ujjayi
+Pranayama along with short and prolonged Kumbhaka (breath
+hold) elucidated an increase in oxygen consumption with short
+Kumbhaka
+and
+reduction
+with
+prolonged
+breath
+hold
+[47].
+Breathing through right nostril was observed to increase the oxy-
+gen consumption and thereby the overall metabolic status, when
+compared to the left nostril and alternate nostril breathing for the
+same duration [48,49]. These studies have indicated right nostril
+breathing in conditions with lower metabolic rates, like obesity,
+though caution must be taken, as the practice of right uninostril
+breathing was found to increase the BP [50].
+3.4.2. Yogic breathing and oxidative stress
+Yogic breathing was also found to be an effective means to
+combat oxidative stress. It was found to lower the free radical load
+and increase the superoxide dismutase (SOD) among healthy vol-
+unteers, when compared to a control population [51]. Athletes
+often suffer from fatigue due to oxidative stress following the bouts
+Table 3
+Summary of the psychophysiological changes following yogic breathing.
+Sl No. Author
+Year
+Sample size Variables studied
+Findings
+1
+Stanc

+ak et al.
+1991 17
+BP, ECG and respiration
+Increase of Heart rate (HR), SBP and DBP during
+Kapalabhati. BRS reduced during Kapalabhati.
+2
+Raghuraj et al.
+1998 12
+HRV
+Increase in low frequency (LF) power and LF/HF ratio
+while high frequency (HF) power was significantly
+lower following KPB. There were no significant changes
+following Nadishuddhi.
+3
+Pal et al.
+2004 60
+Autonomic Function tests
+The increased parasympathetic activity and decreased
+sympathetic activity were observed in slow breathing
+group after 3 months, whereas no significant change in
+autonomic functions was observed in the fast breathing
+group.
+3
+Shannahoff-Khalsa et al. 2004 4
+Cardiovascular variables
+Following breathing at 1 breath/min with ratio of
+20:20:20 s, there are dramatic variations in
+hemodynamic variables.
+4
+Veerabhadrappa et al.
+2011 50
+Cardiovascular autonomic reactivity
+Mukh Bhastrika training showed an increase in
+parasympathetic activity i.e., reduced basal HR, increase
+in Valsalva ratio and deep breathing difference in HR;
+and reduction in sympathetic activity i.e., reduction in
+fall of SBP on posture variation.
+5
+Bhimani et al.
+2011 59
+HRV, Stress questionnaire
+There was reduction in stress levels with a combination
+of Pranayama practices. HRV demonstrated reduction in
+VLF and LF and increase in HF component.
+6
+Ghiya & Lee
+2012 23
+HRV
+lnTP, lnLF and lnHF were greater during both post-
+Alternate Nostril Breathing and post-Paced Breathing
+compared to PRE. Mean Arterial Pressure (MAP) and
+lnLF/lnHF did not significantly differ between
+conditions
+7
+Mason et al.
+2013 17
+BRS
+BRS increased with slow breathing techniques with or
+without expiratory Ujjayi except with
+inspiratory þ expiratory Ujjayi. The maximal increase in
+BRS and decrease in blood pressure were found in slow
+breathing with equal inspiration and expiration.
+8
+Sinha et al.
+2013 25
+Expiration: inspiration ratio, 30:15 ratio
+Alternate nostril breathing for 5 min/day, for 6 weeks
+increased parasympathetic tone.
+9
+Adhana et al.
+2013 30
+Electromyogram (EMG), GSR, Finger tip temperature (FTT),
+HR and RR. SBP and DBP
+Slow yogic breathing lead to reduction in SBP and DBP.
+Significant modifications were also found in HR RR,
+EMG, GSR and rise in FTT.
+10
+Turankar et al.
+2013 12
+BP, Pulmonary function tests (PFT), GSR
+Practice of Anulom Vilom Pranayama with breath
+holding was found to increase GSR in Pranayama group.
+No significant changes in BP or PFT were noted.
+11
+Sharma et al.
+2013 90
+Perceived stress scale (PSS), HR, BP
+PSS scores reduced in both fast and slow Pranayama
+group, whereas HR, DBP and RPP reduced only in slow
+Pranayama group.
+12
+Pal et al.
+2014 85
+HRV
+HRV indices representing sympathetic activity were
+increased in the Right nostril breathing group and
+indices representing parasympathetic activity were
+increased in Left Nostril Breathing group.
+13
+Bhavanani et al.
+2014 20
+Reaction time, HR, BP
+BP reduced following Chandara Nadi Pranayama,
+Chandrabhedana and Nadishuddhi and increased
+following Surya Nadi Pranayama and Suryabhedana.
+Reduction in reaction time was observed with SN and
+SB.
+14
+Goyal et al.
+2014 50
+BP, HR, Rate pressure product
+Pranayama along with antihypertensive medications
+reduced BP significantly compared to medications
+alone. RPP reduced significantly in the Pranayama group
+15
+Hakked et al.
+2017 27
+Spirometry
+Training in Yogic Breathing for one month enhance lung
+functions in professional swimmers.
+16
+Nivethitha et al.
+2017 16
+HRV
+HF component of HRV reduced during the practice of
+Bhramari Pranayama along with an increase in LF
+component and HR. The changes normalized after the
+conclusion of the practice.
+A.A. Saoji et al. / Journal of Ayurveda and Integrative Medicine xxx (2017) 1e9
+5
+Please cite this article in press as: Saoji AA, et al., Effects of yogic breath regulation: A narrative review of scientific evidence, J Ayurveda Integr
+Med (2017), http://dx.doi.org/10.1016/j.jaim.2017.07.008
+of exercise, therefore requiring antioxidant supply [52]. Yogic
+breathing for 1 h was found to effectively enhance the antioxidant
+defense status in athletes following an exhaustive exercise bout
+compared to control group who practiced quiet sitting. It was
+correlated to lower levels of cortisol and enhanced melatonin
+levels. The authors therefore suggest that rhythmic yogic breathing
+can protect the athletes from long term complications of free rad-
+icals [53].
+3.4.3. Molecular changes with yogic breathing
+The modifications in stress levels, physiological variables and
+cognition due to yogic breathing have been established through
+several studies quoted. The need for understanding the molecular
+biomarkers suggesting the pathways involved prompted a recent
+study, in which salivary proteomes were analyzed during 20 min of
+yogic breathing practice. The study revealed that the biomarkers
+called Deleted in Malignant Brain Tumor-1 (DMBT1) and Ig lambda-
+2 chain C region (IGLC2) were differentially expressed in yogic
+breathing group. DMBT1 was elevated in 7 of yogic breathing group
+by 10-fold and 11-fold at 10 and 15 min, respectively, whereas it
+was undetectable in the time-matched control group. IGLC2 also
+showed significant increase in the yogic breathing group when
+compared to controls [54]. This study was the first to indicate the
+feasibility of acute practice for the stimulation and detection of
+salivary protein biomarkers.
+The studies indicate modulation of metabolism and modifica-
+tions of biochemical markers with the practice of yogic breathing.
+These changes could be correlated to the traditional understanding
+of the flow of Prana (vital energy) controlling the physical functions
+in the body. Also, the studies confer the excitatory effect of right
+nostril breathing described in ancient Indian literature. Table 4 il-
+lustrates the biochemical and metabolic changes following yogic
+breathing.
+3.5. Health benefits of yogic breath regulation
+3.5.1. Yogic breathing in cardiovascular diseases
+The physiological effects of yogic breathing practices observed
+through various experiments correlating with the traditional
+textual understanding, have been used in various clinical setups.
+Few studies were conducted to understand the immediate effect
+of yogic breathing techniques in hypertensive subjects. Following
+Sukha Pranayama for 5 min at 6 breaths per min, there was sig-
+nificant reduction in HR, SBP, pulse pressure, mean arterial
+pressure, rate-pressure product, and double product with an
+insignificant fall in diastolic pressure [55]. The practice of Pranava
+Pranayama demonstrated similar effects. Following 5 min of
+Pranava Pranayama, there was a reduction in SBP, HR and pulse
+pressure [56]. Another study showed immediate reduction in HR,
+SBP and pulse pressure in hypertensive patients following 27
+rounds of left UNB [57]. A study showing the effect of 3 months
+regular practice of slow breathing for 5 min/day maintaining 2:1
+ratio of exhalation:inhalation demonstrated significant reduction
+in SBP, DBP, HR, RR and increased fingertip temperature [58].
+Another study involving 6 weeks training in Pranayama along
+with
+antihypertensive
+medications
+reduced
+BP
+significantly
+compared to medication alone. Rate pressure product reduced
+significantly in the Pranayama group [59]. A study demonstrated
+the beneficial effects of the practice of Pranayama in patients with
+cardiac arrhythmia, demonstrating improvement in QTd, QTc-d,
+JTd, and JTc-d in the ECG following the Pranayama session, indi-
+cating reduction in the indices of ventricular repolarization
+dispersion [60].
+3.5.2. Yogic breathing in respiratory disorders
+The effects of yogic breathing in respiratory disorders were also
+evaluated. A study assessed the effect of yogic breathing in asth-
+matics, in which patients were made to breathe through a Pink City
+Lung exerciser at 1:2 ratio of inhalation: exhalation for 2 weeks,
+15 min/day. At the end of 2 weeks, mean forced expiratory volume
+in 1 s (FEV1), peak expiratory flow rate, symptom score, and inhaler
+use improved in the experimental group, when compared to con-
+trols who were breathing through a placebo device. As an indicator
+of airway reactivity, the dose of histamine needed to provoke a 20%
+reduction in FEV 1 (PD 20) was assessed, which increased signifi-
+cantly during Pranayama breathing but not with the placebo device
+[61]. Subsequent studies show stability [62,63] and improvement
+[64] of symptoms in patients with asthma. There was also
+Table 4
+Biochemical and metabolic changes following yogic breathing.
+Sl No.
+Author
+Year
+Sample size
+Variables studied
+Findings
+1
+Pratap et al.
+1978
+10
+Arterial blood gas
+No significance changes in arterial blood gases were
+noted after Pranayama. Possibility of mental effects of
+this practice was proposed due to neural mechanisms.
+2
+Desai & Gharote
+1990
+12
+Blood Urea, Creatinine, tyrosine
+Decrease in blood urea, increase in creatinine and
+tyrosine after 1 min of Kapalabhati
+3
+Telles & Desiraju
+1991
+10
+Oxygen consumption
+An increase in oxygen consumption was noted in Yoga
+breathing with short kumbhaka and a reduction with
+prolonged kumbhaka.
+4
+Telles et al.
+1994
+48
+Oxygen consumption, GSR
+Baseline oxygen consumption increased following right
+nostril breathing, which was more than alternate nostril
+breathing and increase with left nostril breathing. GSR
+increased with left nostril breathing.
+5
+Telles et al.
+1996
+12
+Oxygen consumption, blood pressure,
+digit pulse volume, GSR
+Following the right nostril breathing, there was an
+increase in oxygen consumption and SBP and reduction
+in digit pulse volume. Right nostril as well as normal
+breathing reduced GSR.
+6
+Bhattacharya et al.
+2002
+60
+SOD,
+Free radicals
+The free radicals were decreased significantly following
+practice of Pranayama but the SOD was increased
+insignificantly as compared to the control group.
+7
+Balasubramanian et al.
+2015
+20
+Salivary Proteome eDMBT1 and
+IGLC2.
+DMBT1 was elevated in yogic breathing group by 10-
+fold, whereas it was undetectable in the time-matched
+controls. IGLC2 also showed a significant increase in
+Yogic Breathing group.
+A.A. Saoji et al. / Journal of Ayurveda and Integrative Medicine xxx (2017) 1e9
+6
+Please cite this article in press as: Saoji AA, et al., Effects of yogic breath regulation: A narrative review of scientific evidence, J Ayurveda Integr
+Med (2017), http://dx.doi.org/10.1016/j.jaim.2017.07.008
+improvement noted in FEV1 and peak expiratory flow rate (PEFR) in
+asthmatics [64]. A recent study also shows enhanced FEV1, FVC and
+FEV1:FVC ratio following 10 min practice of Kapalabhati in patients
+with asthma [65].
+Pranayama was used to aid people trying to undergo cigarette
+withdrawal. Practice of 10 min of yogic breathing helped in
+reducing the craving measures than breathing video controls, viz.
+strength of urge, cigarette craving and desire to smoke. No effect
+was found on mood or physical symptoms [66]. A case reported
+beneficial changes in a patient with pulmonary tuberculosis (PTB),
+who performed Bhramari Pranayama for 45 min per day, 3 days a
+week for 8 weeks. There were significant improvements noted in
+the body weight, body mass index, symptom scores, pulmonary
+function and health related quality of life with conversion of posi-
+tive to negative FME for acid fast bacilli [67].
+3.5.3. Yogic breathing in diabetes mellitus
+Diabetes is a major healthcare burden in recent years that causes
+loss of quality of life (QoL) and requires lifestyle modifications.
+There was significant improvement in the QoL and a non-
+significant trend toward improvement in glycemic control in the
+group practicing the comprehensive yogic breathing program
+Table 5
+Effects of yogic breathing in various clinical population.
+Sl No.
+Author
+Year
+Sample
+size
+Disorder
+Variables studied
+Findings
+1
+Singh et al.
+1990
+18
+Br. Asthma
+Airway reactivity, airway caliber
+Increase in the need of histamine for reduction in
+Forced expiratory volume in 1 s (FEV1) with Pranayama
+in ratio of 1:2 for inhalation: exhalation than control
+group.
+2
+Cooper et al.
+2003
+90
+Br. Asthma
+Symptom scores, FEV1
+At 3rd and 6th month, symptoms remained stable in
+Pranayama group, whereas decrease in symptoms was
+noted in Buteyko breathing. No between group
+difference in FEV1 were noted.
+3
+Saxena & Saxena
+2009
+50
+Br. Asthma
+Peak Expiratory Flow Rate (PEFR),
+FEV1, Symptoms
+A combination of slow breathing, Bhramari and Omkara
+significantly improved symptoms, FEV1 and PEFR in
+patients with Bronchial Asthma.
+4
+Prem et al.
+2013
+120
+Br. Asthma
+Asthma Quality of life, PFT
+Buteyko breathing showed better trends of
+improvement in quality of life and asthma control than
+the group performing the Pranayama.
+5
+Raghavendra et al.
+2016
+60
+Br. Asthma
+FEV1, FVC, FEV1:FVC
+10 min of practice of Kapalabhati enhances FEV1, FVC
+and FEV1:FVC ratio in patients with mild to moderate
+Asthma, when compared to control who performed
+deep breathing.
+6
+Dabhade et al.
+2012
+15
+Cardiac
+Arrhythmias
+ECG
+In patients with cardiac arrthymias, there was
+improvement in QTd, QTc-d, JTd, and JTc-d following
+the Pranayama session, indicating reduction the indices
+of ventricular repolarization dispersion.
+7
+Dhruva et al.
+2012
+16
+Cancer
+Cancer related Symptoms,
+quality of life
+Improved quality of sleep, quality of life and reduced
+anxiety following Pranayama between 2 chemotherapy
+sessions.
+8
+Chakrabarty et al.
+2015
+160
+Cancer
+Cancer related fatigue
+Scores of Cancer related fatigue reduced following
+practice of Pranayama along with radiation therapy (RT)
+than RT alone.
+9
+Jyotsna et al.
+2012
+49
+Type 2 Diabetes
+Mellitus
+WHOQoL BREF, FBS, PPBS, HbA1C
+There was significant improvement in the QOL and a
+non-significant trend toward improvement in glycemic
+control in the group practicing the yogic breathing
+program than standard treatment alone.
+10
+Jyotsna et al.
+2013
+64
+Type 2 Diabetes
+Mellitus
+Cardiac autonomic functions
+Pranayama along with standard therapy improved
+sympathetic functions in diabetics than those who were
+on standard therapy alone.
+11
+Bhavanani et al.
+2012
+22
+Hypertension
+Heart rate, blood pressure
+Immediate reduction in heart rate, systolic pressure,
+pulse pressure following Chandra Nadi Pranayama was
+noted
+12
+Bhavanani et al.
+2012
+29
+Hypertension
+Heart rate, blood pressure
+Reduction in systolic pressure, pulse pressure and heart
+rate in hypertensive patients was observed following
+Pranava Pranayama.
+13
+Marshall et al.
+2013
+11
+Stroke
+Attention, language, spatial abilities,
+depression, and anxiety
+Uninostril breathing practice reduced anxiety in post
+stroke cases and improved language measures in
+individuals with aphasia due to stroke.
+14
+Marshall et al.
+2015
+3
+Stroke
+Western Aphasia Battery-R (WAB-R)
+and Communication Abilities of
+Daily Living-2 (CADL-2)
+In 2 out of 3 cases of stroke induced aphasia, Forced
+Uninostril breathing along with speech therapy showed
+improvement in correct information unit and word
+productivity.
+15
+Nemati.
+2013
+107
+Test Anxiety
+Sarason's test anxiety scale,
+test performance
+Following practice of Pranayama for a semester, fewer
+participants experienced high test anxiety, compared to
+the control group. Participants in the Pranayama group
+also had higher scores in the test performance than
+controls.
+16
+Mooventhan et al.
+2014
+1
+Pulmonary
+Tuberculosis
+Weight, body mass index, symptom
+scores, pulmonary function and health
+related quality of life with conversion
+of positive to negative FME for acid
+fast bacilli
+There were significant changes in weight, body mass
+index, symptom scores, pulmonary function and health
+related quality of life with conversion of positive to
+negative FME for acid fast bacilli, when the patient of
+Pulmonary Tuberculosis
+A.A. Saoji et al. / Journal of Ayurveda and Integrative Medicine xxx (2017) 1e9
+7
+Please cite this article in press as: Saoji AA, et al., Effects of yogic breath regulation: A narrative review of scientific evidence, J Ayurveda Integr
+Med (2017), http://dx.doi.org/10.1016/j.jaim.2017.07.008
+compared with the group that was following standard treatment
+alone [68]. Diabetic patients also are known to have sympathovagal
+imbalance. Practice of Pranayama for 6 months along with standard
+therapy improved sympathetic functions in diabetics than those
+who were on standard therapy alone [69].
+3.5.4. Yogic breathing in other diseases
+A controlled study evaluating the effect of slow Pranayama
+breathing compared to normal breathing on pain perception
+demonstrated reduced ratings of pain intensity and unpleasant-
+ness, particularly for moderately versus mildly painful thermal
+stimuli with slow breathing [70]. A pilot RCT comparing effects of
+Pranayama as an ancillary technique to usual care for patients
+receiving chemotherapy demonstrated improved quality of sleep,
+QoL and reduced anxiety with the practice of Pranayama between 2
+chemotherapy sessions [71]. An RCT involving 160 cancer patients
+undergoing radiotherapy demonstrated significant difference in
+protein thiols and serum glutathione in patients who practiced
+combination of Nadishuddi, Bhramari and Shitali Pranayama for
+30 min/day, twice daily/5 days a week, when compared to controls
+who received radiotherapy alone [72]. Pranayama as an adjunct
+therapy to radiotherapy was also found to be beneficial to reduce
+the cancer related fatigue [73].
+Table 5 summarizes the health benefits of yogic breath regula-
+tion in various clinical population.
+3.6. Complications of yogic breathing
+The practice of Pranayama is generally considered safe and we
+could find only one case report reporting an adverse effect of yogic
+breathing during our review of literature. A case of spontaneous
+pneumothorax caused due to a Yoga breathing technique called
+Kapalabhati was reported [74]. A review also denoted cases of
+rectus sheath hematoma and pneumomediastinum due to practice
+of unspecified Pranayama [75].
+4. Conclusion
+Pranayama or yogic breathing practices were found to influence
+the neurocognitive abilities, autonomic and pulmonary functions as
+well as the biochemical and metabolic activities in the body. The
+studies in the clinical populations, show the effects of yogic
+breathing in modulating cardiovascular variables in patients with
+hypertension and cardiac arrhythmias, relieving the symptoms and
+enhancing the pulmonary functions in bronchial asthma, as an
+ancillary aid to modify the body weight and symptoms of pulmo-
+nary tuberculosis, to enhance mood for patients withdrawing from
+cigarette smoking, to reduce the reaction time in specially abled
+children, to manage anxiety and stress in students, to modulate the
+pain perception, improve the QoL and sympathetic activity in pa-
+tients with diabetes, reduce the cancer related symptoms and
+enhancing the antioxidant status of patients undergoing radio-
+therapy and chemotherapy for cancer. Thus the cost effective and
+safe practices of yogic breathing could aid in prevention and
+management of various non-communicable diseases. They may
+also play a role in management of communicable diseases such as
+pulmonary tuberculosis.
+The limitations of the current review include limiting the search
+to free online databases, which might limit the access to actual
+research work done in the field. Also, the current review is limited
+to narration of the current available scientific literature on yogic
+breathing and no attempt was made to establish the statistical
+validity of the data presented in the literature.
+Overall, we found the practice of yogic breathing safe, when
+practiced under guidance of a trained teacher. Though several
+studies are available elucidating the effects of yogic breathing, they
+lack methodological rigor. Considering the positive effects of yogic
+breathing, further large scale studies with better methodological
+designs to understand the mechanisms involved with yogic
+breathing are warranted.
+Sources of funding
+None.
+Conflict of interest
+None.
+References
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+9
+Please cite this article in press as: Saoji AA, et al., Effects of yogic breath regulation: A narrative review of scientific evidence, J Ayurveda Integr
+Med (2017), http://dx.doi.org/10.1016/j.jaim.2017.07.008

subfolder_0/Estimation of yoga postures using machine learning techniques..txt

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+© 2022 International Journal of Yoga | Published by Wolters Kluwer ‑ Medknow
+137
+Introduction
+Yoga is an ancient Indian science and a 
+way of living that includes the adoption of 
+specific bodily postures, breath regulation, 
+meditation, 
+and 
+relaxation 
+techniques 
+practiced 
+for 
+health 
+promotion 
+and 
+mental relaxation. In recent years, yoga 
+has been adopted internationally for its 
+health benefits. Among several techniques, 
+physical 
+postures 
+have 
+become 
+very 
+popular in the Western world. Yoga is not 
+only about the orientation of the body parts 
+but also emphasizes breathing and being 
+mindful.[1] The traditional Sanskrit name 
+for Yoga postures is asanas. During the 
+pandemic, many people have used yoga to 
+keep themselves physically and mentally 
+fit.[2] Many people practice fine forms of 
+asanas, without a teacher to guide them: 
+either because no trained yoga instructors 
+are available or due to unwillingness to 
+engage one. Nevertheless, it is important to 
+perform asanas correctly, so the practitioner 
+does not sustain injury.[3] Furthermore, 
+asanas should be practiced systematically, 
+paying attention to the orientation of 
+the limbs and the breathing. Improper 
+stretching 
+or 
+performing 
+inappropriate 
+Address for correspondence: 
+Mr. D. Mohan Kishore, 
+Swami Vivekananda Yoga 
+Anusandhana Samsthana 
+(S-VYASA), Jigani, 
+Bengaluru – 560105,  
+Karnataka, India. 
+E‑mail: mohankishorejain@
+svyasa.edu.in
+Access this article online
+Website: www.ijoy.org.in
+DOI: 10.4103/ijoy.ijoy_97_22
+Quick Response Code:
+Abstract
+Yoga is a traditional Indian way of keeping the mind and body fit, through physical postures (asanas), 
+voluntarily regulated breathing  (pranayama), meditation, and relaxation techniques. The recent 
+pandemic has seen a huge surge in numbers of yoga practitioners, many practicing without proper 
+guidance. This study was proposed to ease the work of such practitioners by implementing deep 
+learning‑based methods, which can estimate the correct pose performed by a practitioner. The study 
+implemented this approach using four different deep learning architectures: EpipolarPose, OpenPose, 
+PoseNet, and MediaPipe. These architectures were separately trained using the images obtained from 
+S‑VYASA Deemed to be University. This database had images for five commonly practiced yoga 
+postures: tree pose, triangle pose, half‑moon pose, mountain pose, and warrior pose. The use of 
+this authentic database for training paved the way for the deployment of this model in real‑time 
+applications. The study also compared the estimation accuracy of all architectures and concluded that 
+the MediaPipe architecture provides the best estimation accuracy.
+Keywords: Artificial intelligence, deep learning, machine learning techniques, pose estimation 
+techniques, skeleton and yoga
+Estimation of Yoga Postures Using Machine Learning Techniques 
+D. Mohan Kishore,
+S. Bindu1,
+Nandi
+Krishnamurthy
+Manjunath
+Division of Yoga and Life 
+Sciences, Swami Vivekananda 
+Yoga Anusandhana Samsthana 
+(S-VYASA), 1Department of 
+Electronics and Communication 
+Engineering, B N M Institute 
+of Technology, Bengaluru, 
+Karnataka, India
+How to cite this article: Kishore DM, Bindu S, 
+Manjunath NK. Estimation of yoga poses using machine 
+learning techniques. Int J Yoga 2022;15:137-43.
+Submitted: 29‑May‑2022              
+Accepted: 15‑Jun‑2022--
+Revised: 13‑Jun‑2022 
+Published: 05‑Sep‑2022
+asanas and breathing inappropriately when 
+exercising can be injurious to health. 
+Improper postures can lead to severe pain 
+and chronic problems.[4] Hence, a scientific 
+analysis of asana practice is all important. 
+The present work was developed, with this 
+in mind.
+Pose estimation techniques can be used to 
+identify the accurate performance of yoga 
+postures.[5] 
+Pose 
+estimation 
+algorithms 
+have been used to mark the key points 
+and draw a skeleton on the human body 
+for real‑time images and used to determine 
+the best algorithm for comparing the poses. 
+Posture estimation tasks are challenging as 
+they require creating datasets from which 
+real‑time postures can be estimated.[6]
+This study estimated the five asanas 
+performed by the participant using four 
+different 
+deep 
+learning 
+architectures: 
+EpipolarPose, OpenPose, PoseNet, and 
+MediaPipe. 
+These 
+architectures 
+are 
+especially suitable for pose estimation. 
+Deep learning architectures were trained 
+for the abovementioned five asanas. The 
+training was carried out on an authentic 
+database at S‑VYASA Deemed to be 
+University, hence suitable for real‑time and 
+practical applications. The dataset consisted 
+This 
+is 
+an 
+open 
+access 
+journal, 
+and 
+articles 
+are 
+distributed under the terms of the Creative Commons 
+Attribution‑NonCommercial‑ShareAlike 4.0 License, which 
+allows others to remix, tweak, and build upon the work 
+non‑commercially, as long as appropriate credit is given and 
+the new creations are licensed under the identical terms.
+For reprints contact: WKHLRPMedknow_reprints@wolterskluwer
+.com
+Original Article
+[Downloaded free from http://www.ijoy.org.in on Thursday, January 5, 2023, IP: 103.39.126.58]
+Kishore, et al.: Yoga posture estimation
+International Journal of Yoga | Volume 15 | Issue 2 | May-August 2022
+138
+of about 6000 images of the above five postures, of which 
+75% of the dataset was used in training the model, whereas 
+25% was used for testing.
+Human Body Modeling
+Human body modeling is essential to estimate a human 
+pose by locating the joints in the body skeleton from 
+an image. Most methods use kinematic models where 
+the body’s kinematic structure and shape information is 
+represented by its joints and limbs.[7] Different types of 
+human body modeling are shown in Figure 1.
+The 
+human 
+body 
+can 
+be 
+modeled 
+using 
+a 
+skeleton‑based (kinematic) model, a planar (contour‑based) 
+model, or a volumetric model, as shown in Figure  1. The 
+skeleton‑based model represents a human body having 
+different key points showing the positions of the limb with 
+orientations of the body parts.[8,9]
+However, the skeleton‑based model does not represent the 
+texture or shape of the body. The planar model represents 
+the human body by multiple rectangular boxes yielding a 
+body outline showing the shape of a human body.[10] The 
+volumetric model represents a three‑dimensional  (3D) 
+model of well‑articulated human body shapes and 
+poses.[11] The challenges involved in human pose estimation 
+are that the joint positions could change due to diverse 
+forms of clothes, viewing angles, background contexts, 
+and variations in lighting and weather,[12] making it a 
+challenge for image processing models to identify the 
+joint coordinates and especially difficult to track small and 
+scarcely visible joints.
+Human Pose Estimation
+Computer vision is used to estimate the human pose by 
+identifying human joints as key points in images or videos, 
+for example, the left shoulder, right knee, elbows, and 
+wrist.[13] Pose estimation tries to seek an exact pose in the 
+space of all performed poses. It can be done by single 
+pose or multipose estimation: a single object is estimated 
+by the single pose estimation method, and multiple objects 
+are estimated by multipose estimation.[14] Human posture 
+assessment can be done by mathematical estimation called 
+generative strategies, also pictorially named discriminative 
+strategies.[15] Image processing techniques use AI‑based 
+models, such as convolutional neural networks  (CNNs) 
+which can tailor the architecture suitable for human pose 
+inference.[16] An approach for pose estimation can be done 
+either by bottom‑up/top‑down methods.
+In the bottom‑up approach, body joints are first estimated 
+and then grouped to form unique poses, whereas top‑down 
+methods first detect a boundary box and only then estimate 
+body joints.[17]
+Pose estimation with deep learning
+Deep learning solutions have shown better performance 
+than classical computer vision methods in object detection. 
+Therefore, deep learning techniques offer significant 
+improvements in pose estimation.[18,19]
+The pose estimation methods compared in this research 
+include EpipolarPose, OpenPose, PoseNet, and MediaPipe.
+EpipolarPose
+The EpipolarPose constructs a 3D structure from a 2D 
+image of a human pose. The main advantage of this 
+architecture is that it does not require any ground truth 
+data.[20] A 2D image of the human pose is first captured, 
+and then an epipolar geometry is utilized to train a 3D pose 
+estimator.[21] Its main disadvantage is requiring at least two 
+cameras. The sequence of the steps for training is shown in 
+Figure  2. The upper row of the Figure 2 (orange) depicts 
+the inference pipeline and the bottom row (blue) shows the 
+training pipeline.
+The input block consists of the images of the same 
+scene  (human pose) captured from two or more cameras. 
+These images are then fed to a CNN pose estimator. The 
+same set of images are then fed to the training pipeline, 
+and after triangulation, the 3D human pose obtained (V) is 
+fed back to the upper branch. Hence, this architecture is 
+self‑supervised.
+OpenPose
+The OpenPose is another 2D approach for pose 
+estimation.[22] The OpenPose architecture is shown in 
+Figure  3a‑c. Input images can also be sourced from a 
+webcam or CCTV footage. The advantage of OpenPose 
+is the simultaneous detection of body, facial, and limb 
+key points.[23] Figure  3a shows VGG‑19, a trained CNN 
+architecture from the Visual Geometry Group. It is 
+used to classify images using deep learning. It has 16 
+convolutional layers along with 3 fully connected layers, 
+altogether making 19 layers and the so‑called VGG‑19. 
+The image extract of VGG‑19 is fed to a “two‑branch 
+multistage CNN,” as shown in Figure  3b. The top part 
+of Figure 3c predicts the position of the body parts, and 
+the bottom part represents the prediction of affinity fields, 
+Figure 1: Human body modeling
+[Downloaded free from http://www.ijoy.org.in on Thursday, January 5, 2023, IP: 103.39.126.58]
+Kishore, et al.: Yoga posture estimation
+International Journal of Yoga | Volume 15 | Issue 2 | May-August 2022
+139
+i.e., the degree of association between different body 
+parts. By these means, the human skeletons are evaluated 
+in the image.
+PoseNet
+The PoseNet can also take video inputs for pose estimation; 
+it is invariant to image size; hence, it gives a correct 
+estimation even if the image is expanded or contracted[24,25] 
+and can also estimate single or multiple poses.[26] The 
+architecture shown in Figure 4 has several layers with each 
+layer having multiple units. The first layer includes input 
+images to be analyzed; the architecture consists of encoders 
+that generate visual vectors from the image. These are then 
+mapped onto a localization feature vector. Finally, two 
+separated regression layers give the estimated pose.
+MediaPipe
+This is an architecture for reliable pose estimation. It takes 
+a color image and pinpoints 33 key points on the image. 
+The architecture is shown in Figure 5.
+A two‑step detector–tracker ML pipeline is used for pose 
+estimation.[27] Using a detector, this pipeline first locates 
+the pose region‑of‑interest  (ROI) within the frame. The 
+tracker subsequently predicts all 33 pose key points from 
+this ROI.[28]
+Methodology Adopted
+Initially, the image of a yoga practitioner performing an 
+asana was captured by a camera and fed separately to the 
+four deep learning architectures, which then estimate the 
+V
+Input
+Learnable
+CNN
+Volumetric
+Heatmaps
+Soft
+Argmax
+3D Pose
+Supervision
+Frozen
+CNN
+Triangulation
+2D
+Pose
+Input
+Volumetric
+Heatmaps
+Soft
+Argmax
+Figure 2: The architecture of the EpipolarPose involved during training
+Figure 3: (a) VGG‑19 Convolution Neural Network (C‑Convolution, P‑Pooling). (b) Convolution layer branches. (c) OpenPose architecture
+c
+a
+b
+[Downloaded free from http://www.ijoy.org.in on Thursday, January 5, 2023, IP: 103.39.126.58]
+Kishore, et al.: Yoga posture estimation
+International Journal of Yoga | Volume 15 | Issue 2 | May-August 2022
+140
+pose performed by the practitioner by comparing it with 
+the pretrained model. If it does not match any of the five 
+asanas, an error was shown.
+Twenty practitioners in the age group of 18–60  years 
+performing different postures in real time were captured 
+and fed separately to the proposed architectures, and a 
+comparison of the estimated accuracy was done.
+Results
+Pose estimation for five yoga postures was done using 
+different proposed techniques. The results of pose 
+estimation were shown for each of the five asanas for all 
+the four architectures used. For simplicity, the images of 
+the same individual were shown  (after taking consent) 
+for all estimations and comparisons. The five yoga poses 
+considered for posture estimation are as follows:
+a.	 Ardha Chandrasana/half‑moon pose,
+b.	 Tadasana/mountain pose,
+c.	 Trikonasana/triangular pose,
+d.	 Veerabhadrasana/warrior pose
+e.	 Vrukshasana/tree pose.
+Results of pose estimation using EpipolarPose
+The pose estimation results obtained for five yoga postures 
+using an EpipolarPose are shown in Figure 6.
+Results of pose estimation using OpenPose
+The pose estimation results obtained for five yoga postures 
+using OpenPose are shown in Figure 7.
+Results of pose estimation using PoseNet
+The pose estimation results obtained for five yoga postures 
+using PoseNet are shown in Figure 8.
+Results of pose estimation using MediaPipe
+The pose estimation results obtained for five yoga postures 
+using MediaPipe are shown in Figure 9.
+Pose estimation of the five yoga postures was done for 
+different methods, as shown in Figures 6‑9. After validation 
+of the model, 20 sample images were captured in real time 
+and were fed individually to the model, and the posture 
+accuracy was estimated. The average value of accuracy 
+is summarized in Table  1. Here, the method used for 
+calculating the accuracy is the classification score, which 
+is the ratio of the number of correct predictions (CP) made 
+to the total number of predictions  (TP)  (i.e., total number 
+of predictions  =  the sum of CP and the number of wrong 
+predictions (WP))
+CP
+TP = CP + WP
+It is observed that the accuracy of prediction using 
+EpipolarPose was around 50%. This is because the 
+EpipolarPose is generally suited for describing and 
+analyzing multicamera vision systems dealing with two 
+viewpoints of the same points in a pair of images.[29] As this 
+work involves capturing the image from only one camera, 
+the accuracy of the pose is less and also may be observed 
+that the number of key points detected is less [Figure 6a].
+It is observed that the accuracy of prediction using 
+OpenPose was around 70%. OpenPose is preferred for 
+2D pose detection for multiperson system, which includes 
+body, facial, foot, and hand key points.[30] It is reported to 
+have been used for vehicle detection as well. This method 
+of pose estimation suffers estimating the poses when the 
+ground truth has nontypical postures and also in estimating 
+poses in crowded images, leading to the overlapping of key 
+points. The number of key points detected is more than 
+the EpipolarPose, yet during computation, the accuracy 
+is compromised  [Figure  7a] as Graphics processing units 
+(GPU)‑powered systems were not used.
+It has been reported that after using the fully connecting 
+layer to detect the features using PoseNet, the results have 
+worsened as the network was likely to overfit to the training 
+data. In our work, PoseNet methods gave an accuracy of 
+about 80%. Figure  8 shows the key point detection by 
+PoseNet.
+However, MediaPipe has better accuracy as compared to 
+EpipolarPose, OpenPose, and PoseNet. It may be observed 
+Figure 4: PoseNet architecture
+Figure 5: Human pose estimation pipeline overview
+[Downloaded free from http://www.ijoy.org.in on Thursday, January 5, 2023, IP: 103.39.126.58]
+Kishore, et al.: Yoga posture estimation
+International Journal of Yoga | Volume 15 | Issue 2 | May-August 2022
+141
+from Table  1 that the reason for less accuracy for other 
+methods could also be due to pose estimation using a 
+single camera.
+The background light and contrast also have an influence 
+on the accuracy values; it is clear that MediaPipe provides 
+better results and can estimate postures more accurately 
+than other methods, and hence, it is the most suitable 
+technique for pose classification. It is also observed that the 
+accuracy of a few postures in the MediaPipe is also less 
+because the MediaPipe does not detect the neck key point.
+The accuracy of each of these could be increased further 
+with an increase in the training dataset; but nevertheless, it 
+clearly illustrates the comparative study between different 
+pose estimation methods.
+The present study used four different deep learning 
+architectures, i.e., EpipolarPose, OpenPose, PoseNet, 
+and MediaPipe, which are suitable for pose estimation to 
+evaluate yoga postures, and the results support the fact 
+that MediaPipe has better accuracy compared to the other 
+methods despite using a single camera.
+Further research would be needed to expand this technique 
+for other advanced postures for pose estimation and 
+correction using the same methodology which involves 
+simple tools with better accuracy to assist individuals 
+practicing yoga postures as a self‑evaluation as well as a 
+biofeedback mechanism.
+Discussion
+The present study used four different deep learning 
+architectures, i.e., EpipolarPose, OpenPose, PoseNet, 
+and MediaPipe, which are suitable for pose estimation to 
+evaluate yoga postures, and the results support the fact 
+that MediaPipe has better accuracy compared to the other 
+methods despite using a single camera.
+Muhammed et  al.[21] in their work used a self‑supervised 
+EpipolarPose pose estimation model which does not 
+need 3D ground‑truth data or camera parameters. During 
+training, a 3D pose is obtained using the geometry of a 2D 
+pose estimated from multiview images and used to train a 
+3D pose estimator. Furthermore, Yihui et al.[32] proposed a 
+differentiable epipolar transformation model where 2D is 
+Table 1: Comparison of postures with accuracy (%) of 
+prediction
+Postures
+Accuracy of 
+EpipolarPose
+Accuracy 
+of 
+OpenPose
+Accuracy 
+of 
+PoseNet
+Accuracy 
+of 
+MediaPipe
+Ardha 
+Chandrasana
+37.5
+72.22
+75
+78.78
+Tadasana
+51.25
+55.55
+87.5
+90.9
+Trikonasana
+58.75
+66.66
+81.25
+85.75
+Veerabhadrasana
+62.5
+72.22
+81.25
+81.81
+Vrukshasana
+56.25
+77.77
+87.5
+88.81
+Figure 6: Key point detection by EpipolarPose. (a) Ardhachandrasana. (b) 
+Tadasana. (c) Trikonasana. (d) Veerabhadrasana. (e) Vrukshasana
+d
+c
+b
+a
+e
+Figure 7: Key point detection by OpenPose. (a) Ardhachandrasana. (b) 
+Tadasana. (c) Trikonasana. (d) Veerabhadrasana. (e) Vrukshasana
+d
+c
+b
+a
+e
+Figure  8: Key point detection by PoseNet.  (a) Ardhachandrasana.  (b) 
+Tadasana. (c) Trikonasana. (d) Veerabhadrasana. (e) Vrukshasana
+d
+c
+b
+a
+e
+Figure 9: Key point detection by MediaPipe. (a) Ardhachandrasana. (b) 
+Tadasana. (c) Trikonasana. (d) Veerabhadrasana. (e) Vrukshasana
+d
+c
+b
+a
+e
+[Downloaded free from http://www.ijoy.org.in on Thursday, January 5, 2023, IP: 103.39.126.58]
+Kishore, et al.: Yoga posture estimation
+International Journal of Yoga | Volume 15 | Issue 2 | May-August 2022
+142
+detected to leverage 3D‑aware features to improve 2D pose 
+estimation.
+Haque et  al.[33] used CNN to estimate the human pose 
+present in a 2D image with an accuracy of 82.68, and 
+Dushyant et  al.[34] reported on techniques using CNN to 
+estimate 2D and 3D pose features using an architecture 
+called SelecSLS Net and then predicted a skeletal model 
+fit. Jose and Shailesh[35] used 3D CNN architecture; a 
+modified version of C3D architecture was used for pose 
+estimation which gave an accuracy of 91.5%. Santosh 
+Kumar et  al.[36] in their work reported an accuracy of 
+99.04% for using CNN for feature extraction and LSTM 
+for temporal prediction.
+Yoga is a form of physical exercise demands performing it 
+accurately. Anilkumar et al.[37] reported on a yoga monitoring 
+system which is implemented to estimate and analyze the 
+yoga posture where the user is notified of the error in the 
+posture through a display screen or a wireless speaker. 
+The inaccurate body pose of the user can be pointed out 
+in real time, so that the user can rectify the mistakes. In 
+this work, the nose is assumed to be the origin, so that all 
+calculations are done with respect to the location of the nose 
+in the image. An imaginary horizontal line passes through the 
+nose’s coordinates. This is the X-axis of all the angles and 
+are calculated with respect to this horizontal line.  However, 
+in our work, we have divided the image into quadrants and 
+compared the key points. Deepak and Anurag[38] uploaded a 
+photo of the user performing the pose and compared it with 
+the pose of the expert, and the difference in angles of various 
+body joints was calculated. Based on this difference of angles, 
+feedback is provided to the user to improve the pose.
+Chen et al.[39] proposed a yoga posture recognition system 
+using Microsoft kinetics to detect joints of the human body 
+and to extract the skeleton and then calculated various 
+angles to estimate the poses confirming accuracy of 96%. 
+Chiddarwar et  al.[40] reported a technique for android 
+application discussing the methodology used for yoga 
+pose estimation. However, the present study demonstrated 
+that MediaPipe has better accuracy compared to the other 
+methods despite using a single camera.
+Further research would be needed to expand this technique 
+for other advanced postures for pose estimation and 
+correction using the same methodology which involves 
+simple tools with better accuracy to assist individuals 
+practicing Yoga postures as a self‑evaluation as well as a 
+biofeedback mechanism.
+Conclusions
+The human pose estimation can be effectively used in 
+the health and fitness sector. Pose estimation for fitness 
+applications is particularly challenging due to the wide 
+variety of possible poses with large degrees of freedom, 
+occlusions as the body or other objects occlude limbs as seen 
+from the camera, and a variety of appearances or outfits. 
+This work estimates the accuracy of different postures and 
+compares them with four different architectures. Based 
+on the results, the study concludes that the MediaPipe 
+architecture provides the best estimation accuracy.
+Acknowledgment
+The authors would like to thank B N M Institute of 
+Technology and SVYASA Deemed to be University for 
+jointly collaborating toward the completion of this research 
+work.
+Ethical clearance
+ The study was approved by the Institutional Ethics 
+Committee of Swami Vivekananda Yoga Anusandhana 
+Samsthana (S-VYASA), Bengaluru (Approval Letter No: 
+RES/IEC-SVYASA/193/2021.). 
+The 
+study 
+procedure 
+was explained and signed consent was obtained from the 
+participants.
+Financial support and sponsorship
+Nil.
+Conflicts of interest
+There are no conflicts of interest.
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+Supplementary Table 1: Summary of yoga interventions 
+in Ashtanga yoga and general yoga arm
+Practice
+Duration
+Asanas
+Tiryaktadasana (swaying palm tree pose)
+3 min
+Trikonasana (triangle pose)
+3 min
+Konasana (angle pose)
+3 min
+Padahastasana (hand to foot pose)
+1 min
+Ardhahalasana (half plow pose)
+3 min
+Padavrttasana (cyclical leg pose)
+6 min
+Dwicakriasana (cycling pose) repetitive
+3 min
+Markatasana (monkey pose)
+6 min
+Bhujangaasana (cobra pose)
+3 min
+Salabhasana (locust pose)
+1 min
+Chakkiasana (mill churning pose)
+3 min
+Sthitta konaasana (static angle pose)
+3 min
+Sthitta konaasana (static angle pose)
+1 min
+Paschimottanasana (seated forward bend pose)
+1 min
+Pranyamas
+Ujjayi (victorious breathing)
+3 min
+Anulom‑vilom (alternative nostril breathing)
+6 min
+Brahmari (humming breath)
+3 min
+Meditation
+Nadanusandan (A‑U‑M chanting)
+30 min/once 
+per week
+Relaxation
+Guided relaxation technique
+3 min
+Asanas are repeated 5-10 times within the stipulated duration with 
+holding time of 10-15 s. Apart from these, the AY arm received 
+an Ashtanga yoga‑based orientation (eight limbs of yoga) which 
+included discussions on Yama, Niyama, Asana, Pranayama, 
+Pratyahara, Dharana, Dhyana, and Samadhi. The investigators 
+explained the role of each component of Ashtanga yoga in 
+maintaining good health and live a meaningful life. AY=Ashtanga 
+yoga
+Supplementary Table 2: Overview of the points 
+discussed in orientation program
+Limbs of 
+yoga
+Superficial 
+meaning
+Points discussed
+Yama
+Moral 
+disciplines
+How to build self‑discipline that will be 
+beneficial to others around us and how 
+that can help in calming/toning the mind
+Niyama
+Positive 
+observances
+Discussed on the duties towards one’s 
+self and how it will help in navigate in 
+life
+Asana
+Postures
+How to align the participants’ postures 
+and win over the body
+Pranayama Breathing 
+techniques
+How to achieve freedom over breath 
+and regulate emotional breathing
+Pratyahara Withdrawal 
+of senses
+The importance of control over senses 
+to achieve higher state of mind
+Dharana
+Focused 
+concentration
+How to utilize the first five limbs of 
+yoga on building focus
+Dhyana
+Absorption
+How to meditate on one‑self and stay 
+away from interruptions
+Samadhi
+Bliss
+How to cultivate the habit of staying 
+above likes, dislikes, hatred, love, and 
+treat everything equally
+[Downloaded free from http://www.ijoy.org.in on Thursday, January 5, 2023, IP: 103.39.126.58]

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subfolder_0/Guinness world record attempt as a method to pivot the role of Yoga in Diabetes management.txt

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+www.annalsofneurosciences.org 
+ANNALS OF NEUROSCIENCES VOLUME 26 NUMBER 1 JANUARY 2019
+21
+ANNALS
+RES ARTICLE
+Guinness world record attempt as a method to pivot the role of Yoga in 
+Diabetes management
+Atul Kumar Goyala, Sanjay Bhadadab, Neeru Malikc, Abhilasha Anandd, Raman Kumare,  
+Sridhar Bammidif, Rahul Tyagif, Shweta Modgilf, Kaushal Sharmaf, Parul Balif, Deepak Kumar Palf, 
+Saurabh Kumarf, Navneet Kaurg, Sushant Kaushalf, Abha Tiwarif, Jyoti Sainif, Vinod Bhattf,  
+Amit Chahalg, Sharmila Ranig, Jyoti Tiwarig, Jagdeep Singhg, Sudhir Kumarg, Jaspreet Kaurg,  
+Arti Tiwarig, Mandeep Kaurg, Gagandeep Kaurg, Kiran Sharmag, Parminder Singhh,  
+Akshay Anandf*, R. Nagarathnai, H R Nagendrai
+a Department of Otolaryngology and Head & Neck Surgery (ENT), PGIMER, Chandigarh, India
+b Department of Endocrinology, PGIMER, Chandigarh, India
+c Smaj College of Education, Chandigarh
+d Healing Hospital, Chandigarh, India
+e Yoga Federation of India
+f Neuroscience Research lab, Department of Neurology, PGIMER-Chandigarh, India
+g Department of Physical Education, Panjab University, Chandigarh, India
+h Yoga Association, India
+i Directorate of Sports, Panjab University, Chandigarh, India 
+j Division of Yoga and Physical Sciences, S-VYASA, Bengaluru.
+ABSTRACT
+Background: Attempts for Guinness world record have continued worldwide but these at-
+tempts were rarely aimed to promote public health. Diabetes is one of the rapidly growing life-
+style disorders in India which requires awareness reinforcements among the local population. In 
+recent studies, Yoga has proved to be useful in lifestyle modification and Diabetes management. 
+However, most individuals from rural and urban localities in the country are unaware of this fact. 
+Purpose: The purpose was to organizing a nationwide attempt under the Niyantrit Madhumeh 
+Bharat (NMB) programme to break the world record to be the largest Diabetes lesson, to spread 
+awareness among general population. 
+Methods: Present article represents the perspective of the Chandigarh chapter of NMB pro-
+gramme and its experience in Guinness world record attempt. Diabetes awareness lesson was 
+organized in the city as per the standards defined by the Guinness Book and outcomes of the 
+entire campaign were assessed at the end of the campaign.
+Result: Total 498 individuals participated in the campaign. Among them, 268 participants were 
+questioned at the end of the campaign about the role of Yoga in Diabetes. 247 participants 
+(92%) were agreed that Diabetes can be modified by Yoga and 9 participants (3%) disagreed. 
+The remaining 12 participants (5%) did not give any response. 
+Conclusion: We noticed that most of the participants became aware of the role of Yoga in Diabetes.
+doi : 10.5214/ans.0972.7531.260105
+KEY WORDS 
+Health
+lifestyle
+Yoga
+exercise
+obesity
+Diabetes
+*Corresponding Author:
+Akshay Anand, Professor
+Neuroscience Research Lab  
+Department of Neurology
+Postgraduate Institute of Medical  
+Education and Research, Chandigarh 
+India
+Contact no +91 9914209090
+E-mail: [email protected]
+Introduction
+Growing interest towards in setting world records has result-
+ed in increased number of applications which Guinness book 
+of world records receives every year across the world. To date, 
+many new world records have been made and the previous ones 
+have been surpassed [1] with a few attempts centered towards 
+ 
+the promotion of public health. In 2014, new Guinness world 
+record for largest hand hygiene campaign was made in which a 
+total 277 participants performed hand hygiene before two offi-
+cials and a few witnesses [1]. Diabetes is one of the most com-
+mon lifestyle disorder rapidly growing in India [2] and recent 
+studies on Yoga intervention have shown that Diabetes could 
+be modified by practising Yoga [3]. However, general aware-
+ness needs to be spread among local population [4] before any 
+cost-effective intervention or policy, for its nationwide imple-
+mentation, is considered.
+The “Niyantrit Madhumeha Bharat (NMB)” or control 
+­
+Diabetes campaign was a nationwide research-based diabetes 
+prevention program implemented in rural and urban parts of 
+­
+India [5]. Under the NMB program,the Diabetes screening camps 
+were organized followed by Yoga sessions for those identified 
+as pre-diabetics or diabetics at initial screening phase [5]. The 
+Yoga Volunteers for Diabetes Management (YVDM) were the 
+ANNALS OF NEUROSCIENCES VOLUME 26 NUMBER 1 JANUARY 2019
+www.annalsofneurosciences.org
+22
+ANNALS
+RES ARTICLE
+Yoga volunteers who were trained for the implementation of 
+standardized Yoga protocol for Diabetes, as a national effort [5]. 
+YVDMs conducted the Yoga sessions at various locations across 
+the country. At the end of NMB campaign, a nationwide attempt 
+was made to create a new world record on Diabetes awareness 
+on the International Day of Yoga i.e. June 21, 2017. Under this 
+world record attempt, a 35-minute Diabetes awareness lesson 
+was organized all over the country. The individuals who partic-
+ipated in this country wide-world record attempt were listed. 
+The present case study represents the Chandigarh chapter of 
+that nationwide world record attempt.
+We organized a Guinness world record campaign in 
+Chandigarh as a part of the nationwide campaign. The aim of 
+this campaign was to spread the awareness among the local 
+population about the role of Yoga in Diabetes management. At 
+the end of the campaign, participants were questioned about 
+the possible benefits of Yoga in Diabetes. The responses were 
+compiled and are represented in the current article.
+Methods
+Propaganda
+The campaign was conducted at the Gymnasium Hall, Panjab 
+University, Chandigarh on 21st June 2017. The event was pub-
+licized in the whole city through the social media and local 
+publicity means. A media release was also given to ensure 
+more individuals were made aware of the event.
+Inclusion/exclusion criteria
+Individuals within the age range of 18 to 60 years were in-
+cluded in the campaign. Although the entry to the campaign 
+was free and open for everyone, only those individuals who 
+willingly agreed to witnessthe whole session were permitted 
+to attend the campaign. 
+Entry to the campaign
+The entry of participants was made on the basis of entry 
+tickets which were distributed a day before as well as on 
+the day of the campaign. One steward was assigned to each 
+group of 50 participants. The entry of the participants be-
+gan following a statement and the entry of their respective 
+steward was duly recorded by videography. Each group of 
+the 50 participants sat with their respective stewards in 
+anassigned block.
+Counting Method
+For counting of participants, the Gymnasium venue hall was 
+divided into 20 blocks. Each block was designed in such a way 
+that 50 participants could sit and be supervised by one stew-
+ard (Figure 1). Entry tickets counterfoils were also counted in 
+order to match the number of participants.
+Whistle
+The session was started by the guest speaker after the 3 
+whistles were made by a certified individual who was qual-
+ified by an authorized agency in order to do the same. The 
+end of the lesson was marked by 3 whistles announced by 
+the same individual.
+Time Keeping
+Two individuals, who were qualified from an authorized agen-
+cy for timekeeping in National of International events, were 
+present in the event. They recorded the timing of the session 
+by using a calibrated stopwatch.
+Witnesses
+Two officially approved witnesses were invited to the premis-
+es before the start of the program and before the entry of par-
+ticipants and remained present throughout the session. One 
+of the witnesses was a medical professional with registration 
+to practice medicine and the other witnesses were a Gazett-
+ed officer. The witnesses noted the empty premises, the start 
+of entry of participants, the number of people present in the 
+session, the talk and its duration, timekeepers as well as the 
+stewards. All the procedures were documented, duly counter 
+signed by the witnesses. 
+Video Recording
+Three video cameras and one still camera were used to capture 
+the whole session. The first camera man recorded the session 
+inside the premises. The second camera man initially record-
+ed the empty premisesand then recorded the statement of two 
+witnesses. After that, the second cameraman recorded the en-
+try of all participants. The entry gate was closed soon after the 
+entry of all participants but the recording continued throughout 
+the session. After completion of the session, when participants 
+started leaving the venue, the second cameraman recorded the 
+exit gate until all the participants had left. The third camera 
+man recorded the session from the rooftop. One photographer 
+was also present during the whole session who captured the 
+still pictures of the session from vantage points (Figure 1). The 
+whole session was continuously recorded without switching off 
+any cameras in order to minimize the scope for editing.
+Fig. 1: Map designed for the campaign location representing the 
+ 
+20 blocks () with 50 volunteers (•) and one steward in each block, 
+locations of entry/exit gates, video cameras and witnesses.
+www.annalsofneurosciences.org 
+ANNALS OF NEUROSCIENCES VOLUME 26 NUMBER 1 JANUARY 2019
+23
+ANNALS
+S
+RES ARTICLE
+Diabetes lesson
+The Diabetes lesson was conveyed by a Professor of Endo-
+crinology in Hindi and the duration of the lesson was of 35 
+minutes. The contents of the lesson included a definition of 
+Diabetes, updated on the methods for treatment, the recom-
+mendations for diet, the need for self-monitoring of blood 
+glucose levels, the use of medical devices and role of Yoga in 
+Diabetes. The lesson was given in accordance with the current 
+national and international guidelines and it was also consis-
+tent with the health authority’s recommendations.
+End of the campaign
+After the lesson was over, all the participant’s exit was main-
+tained from a singular exit door. The speaker, timekeepers, and 
+the whistle person provided their closing statements. In the 
+end, the video of the empty hall was recorded and the event 
+ended with the closing statement of two witnesses.
+Questionnaire
+At the end of the campaign and before the exit of participants, 
+they were asked about their views on the role of Yoga in Di-
+abetes management. Out of 498 participants, the responses 
+of only 268 participants could be recorded due to time con-
+straints described above.
+Data Analysis
+The initial count of participants was obtained by the counting 
+the entry ticket counterfoils. Initial count was then verified by 
+the count of official witnesses to obtain the final count. The 
+final count was then duly validated by counting the number of 
+participant’s through video recording and still photography. 
+Responses of participants through questionnaire were docu-
+mented in form number and percentage.
+Results
+A total of 498 participants attended the campaign. Out of those 
+498, responses from 268 participants were collected therefore 
+the data from 268 participants is presented in results. Among 
+268 participants, 144 participants were males (54%) and 124 
+participants (46%) were females (Figure 2). 212 participants 
+(79%) were belonging to the urban area while 56 participants 
+(21%) were from the rural localities (Figure 3). Participants be-
+longing to different age groups ranging from 20–60 years and 
+education level was varied from illiterate to postgraduates and 
+doctorate fellows. 247 individuals (96%) agreed that Diabetes 
+could be prevented by Yoga whereas 9 individuals (4%) dis-
+agreed with it while remaining 12 individuals did not give any 
+response (Figure 4).
+Discussion
+Yoga has been shown to be helpful in dealing with many 
+ 
+lifestyle disorders [6,7] including Diabetes [3]. There-
+fore, attempts to break world record on International Day 
+of Yoga by organising the Diabetes awareness lesson is a 
+unique method of academic social responsibility. In this 
+Fig. 3: Number of rural and urban participants in the campaign.
+Fig. 2: Number of males and females participated in the campaign.
+Fig. 4: Number of individual agreements towards the role of yoga in 
+diabetes management.
+present campaign a total of 498 individuals participated 
+which is significantly higher than the previous Guinness 
+record attempt on hand hygiene in which total 227 indi-
+viduals had participated [1]. The sex ratio of the partici-
+pants was almost equal but a number of participants from 
+ANNALS OF NEUROSCIENCES VOLUME 26 NUMBER 1 JANUARY 2019
+www.annalsofneurosciences.org
+24
+ANNALS
+RES ARTICLE
+the urban area were more when compared to rural which 
+indicates the need for an awareness campaign in rural 
+ 
+localities of the country. The result of the study was con-
+sistent with the previous study in which increased aware-
+ness among participants was noticed after the world record 
+ 
+attempt. In that particular study, the increase in hand hygiene 
+compliance was identified after world record attempt [1]. Sim-
+ilarly, in our study, we found an increased level of awareness 
+among participants about the role of Yoga in Diabetes man-
+agement which is indicated by the fact that 96% participants 
+ 
+acknowledged Yoga as a means of Diabetes management. 
+As a limitation of the present study, we were not able to 
+verify the attention span of the audience when the lecture 
+was being given as our main focus was on the number of 
+participants. Another limitation of our assessment is the 
+ 
+observational before-after design, which limits the strength 
+of evidence.
+Conclusion
+By present campaign, the general public was found to be mo-
+tivated to adopt a healthy lifestyle by introducing Yoga into 
+their daily routine. Increased awareness about Diabetes and 
+Yoga can be generated by engaging people in world record 
+attempts that can be used as an important tool for creating 
+awareness. The data can be used to integrate Yoga through 
+forthcoming wellness centers for the management of lifestyle 
+disorders, which lacks the established treatment.
+Authorship contribution
+AKG wrote the manuscript, SB gave diabetic lessons, AA was 
+referee in the study, NM, RK, SB, RT, SM, K­
+S, PB, DK, SK, NK, SK, 
+A­
+T, JS, VB, AC, SR, JT, JS, ­
+SK, JK, AT, MK, GK, KS participated in 
+the study, PS provided premises to the study, AA conceptual-
+ize and edited the manuscript, Nagarathna was the principal 
+investigator of the study and HRN envisioned the concept.
+Ethical statement
+The written informed consents were obtained from partici-
+pants in the study.
+Source of funding
+Not applicable
+Conflict of interest
+No conflict of interest
+Received Date : 05-12-18; Revised Date : 13-02-19;  
+Accepted Date : 19-02-19
+References
+1.	
+Seto WH, Li K-H, Cheung CWY, Ching PTY, Cowling BJ. Breaking a Guin-
+ness World Record on Hand Sanitizing Relay, initiating a call for vital 
+research in overcoming campaign fatigue for hand hygiene. F1000 
+Research. 2014;3.
+2.	
+Tripathy JP, Thakur J, Jeet G, Chawla S, Jain S, Pal A, et al. Prevalence and 
+risk factors of diabetes in a large community-based study in North 
+India: results from a STEPS survey in Punjab, India. Diabetology & 
+metabolic syndrome. 2017; 9(1): 8.
+3.	
+Pal DK, Bhalla A, Bammidi S, Telles S, Kohli A, Kumar S, et al. Can 
+ 
+Yoga-Based Diabetes Management Studies Facilitate Integrative Med-
+icine in India Current Status and Future Directions. Integrative Medi-
+cine International. 2017; 4(3–4): 125–41.
+4.	
+Singh A, Acharya AS, Dhiman B. Awareness regarding diabetes and its com-
+plications in adults: A cross-sectional study in an urban resettlement 
+colony of east Delhi. Indian Journal of Medical Specialities. 2017.
+5.	
+Anand A. Narendra Modi’s Citizen-Centered Yoga for Diabetes Management 
+Program: Will the Indian State Install Integrative Medicine in Premier 
+Institutes. Integrative Medicine International. 2017; 4(1–2): 66–8.
+6.	
+Anand A, Goyal AK, Bakshi J, Sharma K, Vir D, Anita BK: Yoga as an integra-
+tive approach for prevention and treatment of oral cancer. Interna-
+tional Journal of Yoga. 2018; 11(3): 177–185.
+7.	
+Goyal AK, Bakshi J, Rani S, Anita BK, Anand A: Is rajyoga helpful in main-
+taining patient’s biochemical and hematological profile during breast 
+cancer treatment? Journal of Complementary and Integrative Medi-
+cine. 2019; 16(3): 1–7.

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subfolder_0/Hemodynamic responses on prefrontal cortex related to meditation and attentional task.txt

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+SYSTEMS NEUROSCIENCE
+ORIGINAL RESEARCH ARTICLE
+published: 17 February 2015
+doi: 10.3389/fnsys.2014.00252
+Hemodynamic responses on prefrontal cortex related to
+meditation and attentional task
+Singh Deepeshwar*, Suhas Ashok Vinchurkar, Naveen Kalkuni Visweswaraiah and
+Hongasandra RamaRao Nagendra
+ANVESANA Research Laboratory, Department of Yoga and Life Sciences, Swami Vivekananda Yoga Research Foundation, Bangalore, Karnataka, India
+Edited by:
+Mikhail Lebedev, Duke University,
+USA
+Reviewed by:
+José M. Delgado-García, University
+Pablo de Olavide, Seville, Spain
+Laura Marzetti, University “G.
+d’
+Annunzio” of Chieti-Pescara, Italy
+*Correspondence:
+Singh Deepeshwar, ANVESANA
+Research Laboratory, Department
+of Yoga and Life Sciences, Swami
+Vivekananda Yoga Research
+Foundation, #19 Eknath Bhavan,
+Gavipuram Circle, K.G. Nagar,
+Bangalore – 560019,
+Karnataka, India
+e-mail: deepeshwar.singh@
+gmail.com
+Recent neuroimaging studies state that meditation increases regional cerebral blood
+flow (rCBF) in the prefrontal cortex (PFC). The present study employed functional near
+infrared spectroscopy (fNIRS) to evaluate the relative hemodynamic changes in PFC during
+a cognitive task. Twenty-two healthy male volunteers with ages between 18 and 30
+years (group mean age ± SD; 22.9 ± 4.6 years) performed a color-word stroop task
+before and after 20 min of meditation and random thinking. Repeated measures ANOVA
+was performed followed by a post hoc analysis with Bonferroni adjustment for multiple
+comparisons between the mean values of “During” and “Post” with “Pre” state. During
+meditation there was an increased in oxy-hemoglobin (1HbO) and total hemoglobin
+(1THC) concentration with reduced deoxy-hemoglobin (1HbR) concentration over the
+right prefrontal cortex (rPFC), whereas in random thinking there was increased 1HbR
+with reduced total hemoglobin concentration on the rPFC. The mean reaction time (RT)
+was shorter during stroop color word task with concomitant reduction in 1THC after
+meditation, suggestive of improved performance and efficiency in task related to attention.
+Our findings demonstrated that meditation increased cerebral oxygenation and enhanced
+performance, which was associated with activation of the PFC.
+Keywords: meditation, attention task, Stroop task, fNIRS, cerebral blood flow
+INTRODUCTION
+Meditation is a complex mental process that aims to calm
+the fluctuations of the mind and improve cognitive functions.
+Several meditation techniques from diverse traditions (e.g.,
+Transcendental meditation, Buddhists, Zen, Yoga, Vipassana,
+Brahmakumari, Mindfulness-based stress reduction (MBSR)
+etc.,) demonstrated that regular practice of meditation develops
+awareness to the contents of subjective experience, including
+thoughts, sensations, intentions, and emotions (Saggar et al.,
+2012). It is considered as a voluntary means of mental training
+to achieve greater control of higher mental functions. Traditional
+yoga texts like Patanjali’s Yoga Sutras (the Sage Patanjali’
+, Circa 900
+B.C.) and Bhagavad Gita (Circa 400–600 B.C.) very well describe
+the connection between meditation and mental modifications.
+Traditionally, two states of meditation have been described, viz.,
+(i) focused meditation (dharana in Sanskrit, Patanjali’s Yoga
+Sutras, Chapter III, Verse 1), and this state is supposed to lead to
+the next stage of effortless mental expansion i.e., (iii) meditation
+(dhyana in Sanskrit; Patanjali’s Yoga Sutras, Chapter III, Verse 2).
+When not in meditation, it is said that the mind may be in two
+other states (Telles et al., 2012). These are (i) random thinking
+(cancalata in Sanskrit; Bhagavad Gita, chapter VI, verse 34);
+and (ii) non-meditative focused thinking (ekagrata in Sanskrit;
+Bhagavad Gita, chapter VI, verse 12) (Telles et al., 2014).
+In recent years, there have been a number of neuroimaging
+studies showing that meditation improves cognitive performance
+as signified by behavioral and neurophysiological measures (Tang
+et al., 2007; Lutz et al., 2009). Previous studies have shown
+that the practice of meditation enhances behavioral performance
+viz., perceptual discrimination and sustained attention during
+visual discrimination task (MacLean et al., 2010). Meditation
+practice develops the ability to engage the attention onto an
+object for extended periods of time (Carter et al., 2005; Jha
+et al., 2007; Lutz et al., 2008). It improves the control over the
+distribution of limited brain resources in the temporal domain,
+as measured by the attentional blink task (van Leeuwen et al.,
+2009; Slagter et al., 2011). Long term meditation practice has been
+found to enhance cognitive performance (Cahn and Polich, 2006),
+attentional focus, alerting (Jha et al., 2007), processing speed
+(Lutz et al., 2009; Slagter et al., 2009), and overall information
+processing (van Vugt and Jha, 2011). In a study, Buddhist
+meditation practitioners showed mindfulness meditation was
+positively correlated with sustained attention, when compared
+to non-meditation practitioners (Moore and Malinowski, 2009).
+Improvements in sustained attention and attentional error
+monitoring demonstrated a positive correlation with increased
+activation in executive attention networks in meditators (Short
+et al., 2010). Other studies have shown that meditation is
+associated with improved conflict scores on the attention
+network test (Tang et al., 2007), reduced interference (Chan
+and Woollacott, 2007) and enhanced attentional performance
+during the stroop task compared to meditation-naïve control
+Frontiers in Systems Neuroscience
+www.frontiersin.org
+February 2015 | Volume 8 | Article 252 | 1
+Deepeshwar et al.
+Hemodynamic changes in meditation and attention
+group (Moore and Malinowski, 2009). These studies provide
+significant evidence of meditation promoting the higher-
+order cognitive processing (Zeidan et al., 2010), particularly,
+the features of conflict monitoring and cognitive control
+processes.
+The stroop task is one of the most frequently used models
+of the conflict processing (Sz"
+ucs et al., 2012) in cognitive
+neuroscience. Stroop color word task performance evaluates
+flexibility in the purview of cognitive processes and behavior
+which requires both attention and impulse control. The
+simultaneous presentation of the prime color and a written
+word stimulus will either facilitate (when the color and word
+stimuli are congruent, e.g., “b-l-u-e” written in the color
+blue) or interfere (the incongruent stroop trial, e.g., “blue”
+written in red) with color naming (MacLeod, 1991; Peterson
+et al., 1999). Previous studies on stroop test have consistently
+shown that responses in naming the ink color of incongruent
+color word are much slower than in naming the ink color
+of neutral (Zysset et al., 2007), and responses are often,
+but not always, faster when color and word are congruent
+than in the neutral condition. It supports the hypothesis
+that, both the task relevant and task irrelevant dimensions
+of stroop task activate the same response in the congruent
+condition, in contrast, these dimensions stimulate opposing
+response tendencies in the incongruent condition (Morton
+and Chambers, 1973; Posner and Snyder, 1975; Sz"
+ucs et al.,
+2012).
+Recent studies reported that regular practice of meditation
+may alter brain structure and function related to attention (Lazar
+et al., 2005; Holzel et al., 2011; Kozasa et al., 2012). A study
+on 20 experienced participants of extensive Insight meditation,
+that involves focused attention to internal experiences, reported
+increased cortical thickness in prefrontal cortex (PFC) and
+right anterior insula associated with attention, interoception and
+sensory processing in meditation participants compared with
+matched controls (Lazar et al., 2005).
+In order to examine neuronal activity and hemodynamic
+changes in the brain regions during meditation, the application
+of different neuroimaging techniques (viz., fMRI and MEG)
+would be beneficial. The neuronal activity during meditation
+has been reported in several electroencephalography (EEG)
+and
+magnetoencephalography
+(MEG)
+studies.
+Experienced
+meditators showed an increased EEG power in lower frequency
+bands (theta, delta and alpha) (Kubota et al., 2001; Takahashi
+et
+al.,
+2005)
+compared
+to
+controls.
+An
+EEG
+study
+on
+Transcendental Meditation, showed intermittent prominent
+bursts of frontally dominant theta activity at an average maximal
+amplitude of 135 µV in 21 practitioners (Hebert and Lehmann,
+1977). Zen meditators showed fast theta and slow alpha power
+during meditation (Takahashi et al., 2005) demonstrating
+enhanced automatic memory and reduction in conceptual
+thinking following meditation (Faber et al., 2014). In a single
+MEG study on twelve long term Buddhist meditators were
+assessed in two distinct types of self-awareness, i.e., “narrative”
+and “minimal” in mindfulness-induced selflessness awareness
+(Dor-Ziderman et al., 2013). It was found that there was a
+reduction in gamma band (60–80 Hz) power in frontal, and
+medial prefrontal areas, and reduced beta band (13–25 Hz)
+power in ventral medial prefrontal, medial posterior and lateral
+parietal regions (Dor-Ziderman et al., 2013) and right inferior
+parietal lobules. These studies are consistent with fMRI and NIRS
+findings. Functional magnetic resonance imaging (fMRI) poses
+several challenges such as high sensitivity to participant’s motion,
+a loud, restrictive environment, low temporal resolution, and
+relatively high cost (Cui et al., 2011). Some of these challenges are
+overcome with new optical imaging technique: NIRS measure’s
+changes in oxy-hemoglobin and deoxy-hemoglobin (∆HbO
+and ∆HbR) concentration changes from the cortical surface
+and less invasive and expensive than fMRI (Bunce et al., 2006).
+Functional near infrared spectroscopy (fNIRS) is a compact
+and portable optical technique to monitor hemodynamics
+of the brain in real time (Son and Yazici, 2006; Lin et al.,
+2009).
+Brain
+hemodynamic
+responses
+during
+meditation,
+i.e.,
+∆HbO,
+∆HbR
+and
+total
+hemoglobin
+changes
+(∆THC)
+are in its infancy. In fact, there is only one study that
+assessed deoxyhemoglobin changes with a single wavelength
+probe placed over the left PFC during Qigong meditation
+(Cheng et al., 2010). Practitioners showed decrease in deoxy-
+hemoglobin and increase in oxy-hemoglobin concentration
+that suggest, meditation lead to left prefrontal activation during
+meditation.
+With this background, the present study was designed
+to assess the bilateral prefrontal hemodynamic responses in
+meditation and random thinking. Additionally, we investigated
+the hemodynamic changes and performance during a stroop
+color word task before and after meditation and random
+thinking. Since, stroop color word task is known to measure
+attention, interference, processing speed, and executive attention,
+we expected that this task to be the most sensitive to the effects of
+meditation.
+MATERIALS AND METHODS
+PARTICIPANTS
+A total of 25 right handed healthy male participants with ages
+ranging from 19 and 30 years (Mean, SD; 23.4 ± 3.7 years)
+were recruited from S-VYASA (a Yoga University), South India.
+All participants had a minimum of 12-month experience in
+meditation (group average experience ± S.D., 15.6 ± 14.2
+months) on the Sanskrit syllable “OM”
+. Three participants
+were excluded from the study because of large motion artifacts
+in the signals due to head movements or because of failure
+in probe placement due to obstruction by hair (Taga et al.,
+2003; Minagawa-Kawai et al., 2011). Thus, only data from 22
+participants (mean age 22.9 ± 4.6 years) were included in
+the final analysis. Participants fulfilling the following criteria
+were included in the study: (i) the participants with at least
+12 months of meditation experience; (ii) male participants
+alone were studied as cognitive abilities and cerebral blood
+flow (Brackley et al., 1999) have been shown to fluctuate
+which the phases of menstrual cycle (Yadav et al., 2002);
+and (iii) no history of smoking; and (iv) normal health
+on a routine clinical examination. Participants with following
+criteria were excluded from the study: (i) persons on any
+Frontiers in Systems Neuroscience
+www.frontiersin.org
+February 2015 | Volume 8 | Article 252 | 2
+Deepeshwar et al.
+Hemodynamic changes in meditation and attention
+T
+able 1 | Characteristics of 22 participants.
+Characteristics
+Age (in years) (group mean ± S.D.)
+22.9 ± 4.6 years
+Y
+ears of education
+17 years and more
+6 (27
+.3%)
+Upto 15 years
+10 (45.5%)
+Upto 12 years
+6 (27
+.3%)
+T
+ype of meditation
+Meditation on the
+Sanskrit syllable “OM”
+Experience of meditation
+practice (in months)
+6–12 months
+4 (18.2%)
+13–24 months
+3 (13.6%)
+25–36 months
+7 (31.8%)
+37–48 months
+6 (27
+.3%)
+48–60 months
+2 (9.1%)
+medication or herbal remedy; (ii) participants having clinical
+evidence of medical, neuropsychological, or drug abuse that
+would potentially alter cerebral blood flow (Liddle et al., 1992;
+Newberg et al., 2010a,b; Goldstein and Volkow, 2011); and (iii)
+any visual deficit; and (iv) any cognitive impairment. None of
+the potential participants were involved in any other ongoing
+research activity. The characteristics of participants are given in
+Table 1.
+The
+study
+was
+approved
+by
+the
+Institutional
+Ethics
+Committee of S-VYASA, a Yoga University (No.-RES/IEC-S-
+VYASA/11/2011). The study protocol, nature of the experiments
+and the operating mode of the instrument was explained to the
+subjects before obtaining signed informed consent.
+DESIGN
+The protocol utilized in the present study consisted of two sessions
+i.e., random thinking (cancalata) and meditation (dhyana), and
+eight States (Pre, Stroop_Pre, During (D1-D4 each of 5 min),
+Stroop_Post, and Post). Each participant was assessed for both
+the meditation and control session on two separate consecutive
+days. The sessions were randomized online with randomization
+software.1 During the acquisition and analysis of data, researcher
+was blinded to the session of the individual. The total duration of
+the each session was 60 min: Pre (5 min), Stroop_Pre (15 min),
+During (20 min), Stroop_Post (15 min), and Post (5 min).
+The schematic presentation of the design has been given in
+Figure 1.
+Apart from their prior experience of meditation on “OM”
+, all
+participants were given a 3 month orientation, 5 days a week
+under the guidance of an experienced meditation teacher. The
+purpose of this orientation was for to ensure uniformity among
+all practitioners based on specific instructions.
+INTERVENTIONS
+Each
+participant
+sat
+cross-legged
+with
+eyes
+closed
+and
+followed
+pre-recorded
+instructions
+throughout
+meditation
+and random thinking sessions. An emphasis was placed on
+slowly, practice with awareness of physical and mental sensations,
+1http://www.randomizer.org
+and relaxation. The duration of each session was 20 min between
+06:00 to 06:30 h conducted 5 days a week. The theoretical
+aspects of the meditation were detailed by the meditation
+teacher on the first day. Following this, the practice of each
+session began with pre-recorded instructions. The practice of
+meditation was evaluated based on their self-reporting and by
+consultations with the meditation teacher. The two phases—
+random thinking (Rand) and meditative defocusing were as
+follows:
+1. Random thinking:
+Participants were asked to listen a compiled audio CD
+consisting
+of
+brief
+periods
+of
+random
+conversation,
+announcements, various advertisements and non-connected
+talks recorded from a local radio station transmission and
+allow their thoughts to wander freely. All these non-connected
+conversations could induce the state of random thinking.
+2. Meditative de-focusing or effortless meditation:
+In
+effortless
+meditation
+session,
+each
+participant
+was
+instructed to dwell effortlessly on thoughts of “OM”
+,
+particularly on the subtle (rather than physical) attributes and
+connotations of the syllable with closed eyes. This involved
+combined mental chanting with effortless defocusing on
+syllable “OM”
+. This gradually allowed the participants to
+experience brief periods of silence, which they reported after
+the session.
+ASSESSMENTS PROCEDURE
+Laboratory environment
+All Participants were assessed in a sound and light dampening
+Faraday cage. Participants’ were monitored using a closed circuit
+television outside the cabin to detect if they moved or fell asleep
+during a session. During the session, instructions were passed
+through a two-way intercom, so that participants could remain
+uninterrupted. The recording room temperature was maintained
+at 24.0 ± 1.0◦C with 56 percent average humidity during the
+conduct of experiments. The background noise level was 26 dB of
+the acoustically shielded chamber. For each participant, the data
+acquisition session lasted 60 min.
+Functional near infrared spectroscopy (fNIRS)
+A 16-channel continuous wave fNIRS imager system (FNIR1000-
+ACK-W, BIOPAC Systems, Inc., U.S.A) was employed to map
+changes in 1HbO, 1HbR and 1THC over bilateral PFC. The
+system consisted of a flexible probe to match contour of the
+human forehead (see Figure 2). The probe embedded with
+four LED diodes as light sources (at λ1 = 730 nm, λ2 = 830
+nm, λ3 = 850 nm) and ten photodiodes as detectors that were
+symmetrically arranged in an area of 3.5 × 14 cm2, conducing to
+16 nearest source—detector (i.e., channels) at 2.5 cm separation
+displayed in Figure 3. A source-detector distance provides a
+penetration depth of 1.25 cm (León-Carrion et al., 2008; Kim
+et al., 2010; Leon-Dominguez et al., 2014). The description of
+the probe setting is detailed in earlier studies (Krawczyk, 2002;
+Izzetoglu et al., 2005; Leon-Dominguez et al., 2014). During the
+experiment, the probe was firmly held with a velcro band on the
+forehead, and stretched from hairline to eyebrow in a sagittal
+Frontiers in Systems Neuroscience
+www.frontiersin.org
+February 2015 | Volume 8 | Article 252 | 3
+Deepeshwar et al.
+Hemodynamic changes in meditation and attention
+FIGURE 1 | Schematic representation of the study design. Note: Sessions were modified for each participant D1: During 1; D2: During 2; D3: During 3; D4:
+During 4.
+direction and from ear to ear in axial direction (Tian et al., 2009).
+The probes were positioned bilaterally on forehead, over the left
+and right frontal poles, a part of dorsolateral PFC, and a portion
+of the ventrolateral PFC. Regional cerebral blood flow (rCBF),
+∆HbO, ∆HbR, and ∆THC for each hemisphere were updated
+every 0.5 s. The four LEDs flashed in sequence; the reflected light
+from the brain as detected with the nearest photodiodes of each
+LED and converted into digital signals using an analog-digital
+converter (ADC) card in the control box. The digital data were
+sent to the laptop though a serial port. The sampling rate was 3 Hz
+across all 16 channels. The principles of measurement were based
+on the modified Beer-Lambert law for highly scattering media
+(Plichta et al., 2006) that agrees assessing changes in ∆HbO and
+∆HbR at a certain measured point (Hoshi and Tamura, 1993).
+Increases in ∆HbO and corresponding decrease in ∆HbR can be
+interpreted as a sign of functional brain activation.
+Stroop color word task
+Subjects were seated comfortably on a reclining chair in a Faraday
+cage, facing a 21 inch LCD monitor placed at a distance of
+70 cm from their eyes. Participants were required to focus on
+the center of the screen which was guided by a fixation object
+“+” followed by stimuli. Participants did a modified multiple-
+trial stroop task and were confronted with neutral, congruent,
+and incongruent stimuli on a black background using E-Prime
+2.0.8.90 (Psychological Software Tools, Inc., Pittsburgh, PA, USA).
+The stroop color word task consisted of red, green and blue
+colored boxes and the corresponding written words “RED”
+,
+“BLUE” and “GREEN”
+. The color was presented as color square
+(4.5 × 4.5 cm) boxes on a black background. The duration
+of the presented square boxes and words was 500 ms each.
+Congruent trials comprised of square color boxes followed by
+words describing the color of the box written in the same color
+(e.g., the BLUE square box and the printed word “BLUE” in blue
+FIGURE 2 | The complete setup employed is herein presented. The
+fNIRS sensor is displayed with 4 light sources and 10 detectors (top) and 16
+optode (channel) measurement locations registered on the sensor.
+ink); incongruent trials comprised of words describing the color
+of the box written in a color other than that of the box (e.g., the
+RED square box and word RED written in blue ink); neutral trials
+comprised words written in white (e.g., the BLUE square box and
+word BLUE printed in white ink). Participants were instructed
+to reply as speedily and accurately as possible to the name of
+the color word (while ignoring the color itself) consistent to the
+color of the Box with a button press of the response key using
+the thumb of their right hand. To increase the potency of the
+conflict stimulus, 20% of trials were congruent (approximately 45
+trials), 20% were incongruent (approximately 45 trials) and 50%
+were neutral (90 trials). The duration of the stimulus was 500 ms,
+with a variable interstimulus interval (ISI) of 1000–2500 ms the
+experimental steps are illustrated in Figure 4.
+Frontiers in Systems Neuroscience
+www.frontiersin.org
+February 2015 | Volume 8 | Article 252 | 4
+Deepeshwar et al.
+Hemodynamic changes in meditation and attention
+FIGURE 3 | The 16 fNIRS optode (channel) measurement locations
+registered on the brain surface image are presented.
+FIGURE 4 | Experimental steps of Color word Stroop Task.
+Data acquisition
+The participants were assessed in two separate sessions i.e.,
+random thinking and meditation while recording hemodynamic
+activity on the PFC using 16-channel continuous wave fNIRS
+system. On the preceding day and on the day of the recording,
+participants were asked to avoid tea and coffee which are known
+to influence cognitive performance (Nehlig, 2010) and cerebral
+blood flow (Addicott et al., 2009). Where this was unavoidable
+the session was engaged on another day. The participants wore
+a flexible sensor pad over prefrontal region and covered with a
+black cloth. The probable artifacts such as heart rate pulsation,
+respiration and high frequency noise in raw data, which may
+possibly be induced by autonomic arousal caused during stroop
+task, was eliminated with pre designed finite impulse response
+(FIR) filters based on type, order, window function and cut-off
+frequency. For the present study, raw data were acquired from
+the probe, which is pre-filtered by two filters and processed in the
+data processing unit using COBI filter module. The first filter is
+a 10th order low-pass filter with cutoff frequency of 0.1 Hz with
+Blackman window. The second filter is a 20th order low-pass,
+with the normalized cut-off frequency of 0.1 Hz which uses a
+Hamming window. The filtered data were averaged according to
+the tasks and conditions for further statistical analysis.
+Data analysis
+The hemodynamic responses of bilateral PFC were recorded
+and data were averaged according to the task condition (pre,
+stroop_pre, during, stroop_post and post). Statistical analysis has
+been carried out on these differential values. Filtered data were
+tested with Kolmogorov-Smirnov test for normality. Repeated
+measures analysis of variance (RM-ANOVA) was used because
+the same individuals were assessed in repeated sessions on two
+separate days (i.e., random thinking and meditation). RM-
+ANOVA was performed with three “within subjects” factors, i.e.,
+Factor 1: Sessions (random thinking and meditation); Factor
+2: PFC (right and left). Factor 3: States (“Pre”
+, “Stroop_Pre”
+,
+“During” (D1 to D4), “Stroop_Post” and “Post”). The repeated
+measures ANOVAs were carried out for concentration changes of
+oxygenated and deoxygenated hemoglobin and total hemoglobin
+change (∆HbO, ∆HbR and ∆THbC) across the right and left
+PFC. This was followed by a post hoc analysis with Bonferroni
+adjustment for multiple comparisons between the mean values of
+different states (“During” and “Post”) and all comparisons were
+made with the respective “Pre” state.
+Moreover, for analysis of stroop task we compared the
+mean reaction time (ms) of neutral, congruent and incongruent
+conditions and hemodynamic responses of stroop color word task
+before and after the sessions (random thinking and meditation).
+The results were averaged for each side of PFC (right and left),
+parameter and subject separately to compare between different
+conditions and sessions. A repeated measures ANOVA was carried
+for multiple comparisons following Bonferroni adjustment.
+Statistical analyses were carried out using the Statistical software
+SPSS version 20.0 (SPSS Inc., Chicago, USA). The alpha level was
+set at p < 0.05. The effect size (d) defined by Cohen (1988), as the
+mean change score divided by the standard deviation of change,
+calculated for further statistical analysis.
+RESULTS
+BEHAVIORAL RESULTS
+Reaction
+times
+(RTs)
+were
+computed
+solely
+from
+the
+correctly answered trials. With respect to RT, a repeated—
+measures 3 way ANOVA with Sessions (random thinking
+and meditation) × States (“Stroop_Pre”
+, “Stroop_Post”) ×
+Conditions (neutral vs. congruent vs. incongruent). Repeated
+Frontiers in Systems Neuroscience
+www.frontiersin.org
+February 2015 | Volume 8 | Article 252 | 5
+Deepeshwar et al.
+Hemodynamic changes in meditation and attention
+measures ANOVA demonstrated a significant main effect for
+Sessions (F(1,21) = 4.862, p = 0.039, η2p = 0.188); Conditions
+(F(2,42) = 24.12, p < 0.001, η2p = 0.535); States (F(1,21) = 6.696,
+p < 0.023, η2p = 0.242), and the significant interaction between
+Sessions × States (F(1,21) = 45.36, p < 0.001, η2p = 0.684).
+Post hoc analysis revealed that there was a significant
+improvement in cognitive performance after meditation in all
+three conditions (neutral, congruent and incongruent) compared
+to random thinking session given in Table 1. The RTs differed
+in all the conditions (neutral vs. congruent vs. incongruent)
+in both the sessions. These findings verify that our attentional
+manipulation was indeed effective.
+The RTs were compared using two-tailed paired sample t-
+test, revealed significant differences among all three conditions
+(neutral, congruent and incongruent) in two different sessions
+(meditation and random thinking). In random thinking session,
+there were significant differences in neutral vs. congruent: t(21)
+= −3.86, p = 0.001; congruent vs. incongruent: t(21) = −2.31,
+p = 0.031; neutral vs. incongruent: t(21)= −5.92, p < 0.001
+whereas in meditation session, there was a significant difference
+in neutral—congruent: t(21) = −4.47, p < 0.001; congruent—
+incongruent: t(21) = −1.85, p > 0.05 (NS); neutral—incongruent:
+t(21) = −6.148, p < 0.001. The mean RTs were significantly shorter
+in the neutral (p = 0.002), congruent (p < 001) and incongruent
+(p < 0.003) conditions after meditation session whereas after
+the random thinking session, mean RTs were delayed in the
+neutral (p = 0.034) and incongruent (p = 0.008) conditions.
+The average RTs for neutral, congruent, and incongruent trials
+of the stroop color word task are given in Table 2. Subjects
+made negligible errors during the color word matching stroop
+task. For error rates, we did not make any statistical test, since
+their distributions are clearly not Gaussian. However, it can be
+supposed that interference effect also reveals itself in error rates.
+In summary, behavioral results of the stroop color word task
+are in accordance with the literature, as demonstrated by a clear
+interference effect in the participants for meditation and random
+thinking sessions.
+HEMODYNAMIC RESPONSES IN STROOP COLOR WORD TASK
+In the present study, the 16 channel fNIRS device provided a
+set of time series recorded over the PFC. The locations of the
+probed regions are shown in Figure 2. The order of the channels
+is from left to right, i.e., “1” is on the left and “16” is on the
+right as depicted in Figure 3. Analysis of hemoglobin signals
+i.e., ∆HbO or ∆HbR is still a controversial issue, specifically
+which hemoglobin signal is more reliably associated with brain
+activity still remain unclear (Schroeter et al., 2002). In this
+study, we have utilized three wavelengths (i.e.,750, 803 and 850
+nm). This combination is suitable only for detecting ∆HbO
+signal. Therefore we used ∆HbO, ∆HbR and ∆THC signals for
+statistical analysis. The groups mean values ± S.D. for the ∆HbO,
+∆HbR and ∆THC in stroop task and the two sessions (random
+thinking and meditation) in “Pre”
+, “During” and “Post” states are
+given in Table 3.
+For ∆HbO, the repeated—measures ANOVA for Sessions
+(Random thinking and Meditation) × PFC (Left and Right)
+× States (“Stroop_Pre”
+, “Stroop_Post”) revealed no significant
+main effect for Sessions, States and PFC. There was a significant
+interaction between PFC × States (F(1,175) = 9.87, p < 0.01,
+η2p = 0.053); Sessions × PFC × States (F(1,175) = 3.17, p < 0.01,
+η2p = 0.040).
+For ∆HbR, the repeated—measures ANOVA demonstrated
+significant main effect for Sessions (F(1,175) = 9.99, p < 0.01,
+η2p = 0.054); PFC (F(1,175) = 4.57, p < 0.05, η2p = 0.025).
+Also, there was a significant interaction between Sessions ×
+PFC (F = 5.11, p < 0.05, η2p = 0.028); Sessions × States
+(F(1,175) = 22.13, p < 0.001, η2p = 0.112); Sessions × PFC × States
+(F(1,175) = 9.81, p < 0.01, η2p = 0.053).
+For total hemoglobin (∆THC), the repeated—measures
+ANOVA revealed that there was a significant main effect for
+PFC (F(1,175) = 9.71, p < 0.01, η2p = 0.053), and the significant
+interaction between Sessions × PFC (F(1,175) = 5.33, p < 0.01,
+η2p = 0.03); Sessions × States (F(1,175) = 19.87, p < 0.001,
+η2p = 0.102); PFC × States (F(1,175) = 5.96, p < 0.05, η2p = 0.033);
+Sessions × PFC × States (F(1,175) = 14.20, p < 0.001, 0.075).
+The
+post
+hoc
+analysis
+with
+Bonferroni
+corrections
+demonstrated forehead hemodynamic responses during stroop
+task related to random thinking and meditation sessions are given
+in Table 3. The results demonstrated a significant decrease in the
+concentration of ∆HbO in left PFC (p = 0.016) and in the right
+PFC (p = 0.032) after random thinking session during stroop
+color word task, whereas, there was a significant improvement
+in ∆HbO in left PFC (p = 0.006) and right PFC (p = 0.046)
+following the meditation session.
+From the above observations, it can be concluded that
+meditation enhances bilaterally activation of the anterior PFC
+T
+able 2 | Group mean values ± S.D. of the reaction time scores (ms) of Stroop color word Task.
+Sessions
+States
+Pre
+Post
+t-value
+P value
+% Change
+Rand
+Neutral
+643.18 ± 130.654
+660.00 ± 113.641
+−2.274
+0.034*
+2.62
+Congruent
+783.64 ± 117
+.333
+790.91 ± 119.440
+−0.876
+0.391
+0.93
+Incongruent
+871.41 ± 136.070
+892.73 ± 136.004
+−2.920
+0.008**
+2.45
+Med
+Neutral
+638.64 ± 118.615
+617
+.73 ± 121.653
+3.533
+0.002**
+−3.27
+Congruent
+794.55 ± 118.029
+764.55 ± 112.238
+6.205
+<0.001***
+−3.78
+Incongruent
+865.00 ± 137
+.797
+819.09 ± 133.627
+3.302
+0.003**
+−5.31
+*p < 0.05; p < **0.01; ***p < 0.001; repeated measures of ANOVA with Bonferroni adjustment comparing Post values with Pre values. Values are group means ±
+S.D. Rand—Random Thinking; Med—Meditation.
+Frontiers in Systems Neuroscience
+www.frontiersin.org
+February 2015 | Volume 8 | Article 252 | 6
+Deepeshwar et al.
+Hemodynamic changes in meditation and attention
+Table 3 | Group mean values ± S.D. of the oxyhemoglobin (∆HbO), deoxyhemoglobin (∆HbR) and total hemoglobin change (∆THC) of Stroop color word task before, during and after random
+thinking (rand) and meditation (Med).
+Sessions
+Voxels
+Pre
+Stroop_Pre
+During
+Stroop_Post
+Post
+D1
+D2
+D3
+D4
+Oxyhemoglobin (∆HbO)
+Rand
+Left PFC
+−0.71 ± 3.71
+−0.64 ± 7
+.39
+0.51 ± 7
+.58
+0.15 ± 6.69
+0.25 ± 7
+.16
+0.21 ± 7
+.61
+0.83 ± 7
+.41
+0.80 ± 7
+.22
+Right PFC
+−2.65 ± 5.56
+0.81 ± 4.59
+−2.21 ± 12.47
+−1.30 ± 12.45
+−1.69 ± 12.67
+−1.65 ± 12.49
+−1.56 ± 11.90
+−1.00 ± 10.02
+Med
+Left PFC
+−0.43 ± 6.53
+−0.93 ± 2.55
+−1.13 ± 3.17
+−0.79 ± 3.22
+−0.64 ± 3.54
+−0.77 ± 3.98
+−0.09 ± 5.15
+0.44 ± 5.25
+Right PFC
+−2.45 ± 7
+.18
+−1.30 ± 2.64
+−0.71 ± 4.07*
+−0.44 ± 3.84*
+−0.19 ± 3.86**
+−0.89 ± 3.70
+−0.79 ± 3.89
+0.35 ± 4.41***
+Deoxyhemoglobin (∆HbR)
+Rand
+Left PFC
+−0.20 ± 15.36
+−1.70 ± 4.23
+−2.03 ± 5.27
+−0.98 ± 5.94
+−0.73 ± 6.45
+−0.73 ± 6.57
+−0.32 ± 8.80
+−0.91 ± 8.10
+Right PFC
+−5.18 ± 10.80
+−2.86 ± 3.65
+−3.22 ± 6.89
+−1.78 ± 5.75***
+−0.48 ± 8.08***
+0.01 ± 8.05***
+1.22 ± 8.18***
+0.19 ± 10.25***
+Med
+Left PFC
+−1.57 ± 6.61
+−1.27 ± 8.85
+−2.82 ± 18.20
+−2.25 ± 18.82
+−2.38 ± 19.15
+−2.29 ± 18.82
+−2.28 ± 19.80
+−2.23 ± 17
+.63
+Right PFC
+−3.90 ± 8.22
+−3.00 ± 7
+.93
+−7
+.19 ± 23.46
+−8.16 ± 23.09
+−8.14 ± 23.43
+−8.15 ± 22.72*
+−7
+.28 ± 23.56
+−7
+.04 ± 19.93
+T
+otal hemoglobin change (∆THC)
+Rand
+Left PFC
+−1.70 ± 5.39
+−1.83 ± 9.87
+−1.58 ± 20.98
+−1.39 ± 21.02
+−1.73 ± 21.40
+−1.66 ± 21.16
+−1.71 ± 21.56
+−1.02 ± 19.70
+Right PFC
+−4.29 ± 6.67
+−3.28 ± 9.05
+−8.85 ± 28.49
+−9.07 ± 27
+.55*
+−10.41 ± 26.99***
+−10.28 ± 26.52***
+−10.26 ± 26.89**
+−8.41 ± 21.55**
+Med
+Left PFC
+−0.78 ± 17
+.63
+−2.98 ± 7
+.98
+−3.50 ± 9.7
+−2.18 ± 10.23
+−1.82 ± 10.74
+−1.98 ± 11.34
+−1.21 ± 14.27
+−1.15 ± 13.88
+Right PFC
+−5.11 ± 11.97
+−4.36 ± 5.29
+−4.37 ± 7
+.48
+−2.83 ± 7
+.18**
+−1.94 ± 8.48***
+−2.16 ± 9.14**
+−1.45 ± 10.11**
+−0.57 ± 11.07***
+**p < 0.01; repeated measures of ANOVA with Bonferroni adjustment comparing During and Post values with Pre values. Values are group means ± S.D.
+Frontiers in Systems Neuroscience
+www.frontiersin.org
+February 2015 | Volume 8 | Article 252 | 7
+Deepeshwar et al.
+Hemodynamic changes in meditation and attention
+and consequently, a stronger increase of oxygenation and cerebral
+blood flow during stroop task at the right PFC due to interference
+reduction.
+HEMODYNAMICS RESPONSES IN MEDITATION AND RANDOM
+THINKING
+For ∆HbO, the repeated—measures ANOVA for Sessions
+(Random thinking and Meditation) × PFC (Left and Right) ×
+States (Pre Stroop_Pre, D1-D4, Stroop_Post, Post) demonstrated
+a significant main effects for States (F(7,1225) = 5.23, p < 0.001,
+η2p = 0.029). There was a significant interaction between the PFC
+× States (F(7,1225) = 2.42, p < 0.001, η2p = 0.014); Sessions ×
+Hemispheres × States (F(7,1225) = 7.32, p < 0.05, η2p = 0.040).
+For ∆HbO, the repeated—measures ANOVA showed there
+was a significant main effect for Sessions (F(1,175) = 12.20,
+p < 0.001, η2p = 0.065); PFC (F(1,175) = 7.89, p < 0.01,
+η2p = 0.043) and States (F(7,1225) = 3.55, p < 0.001, η2p = 0.019).
+There was a significant interaction between the Sessions × PFC
+(F(1,175) = 4.13, p < 0.001, η2p = 0.023); Sessions × States
+(F(7,1225) = 9.99, p < 0.001, η2p = 0.054); Sessions × PFC × States
+(F(7,1225) = 10.37, p < 0.001, η2p = 0.056).
+For total hemoglobin change (∆THC), there was a significant
+main effect for Sessions (F(1,175) = 5.07, p < 0.05, η2p = 0.028);
+PFC (F(1,175) = 12.20, p < 0.001, η2p = 0.065); and States
+(F(1,175) = 2.79, p < 0.01, η2p = 0.016) and a significant
+interaction between the Sessions × PFC (F(1,175) = 6.45, p < 0.05,
+η2p = 0.036); Sessions × States (F(7,1225) = 9.06, p < 0.001,
+η2p = 0.049); PFC × States (F(7,1225) = 2.34, p < 0.05,
+η2p = 0.036]; Session × PFC × State (F(7,1225) = 14.51, p < 0.001).
+Post hoc analyses with Bonferroni corrections were performed
+on ∆HbO, ∆HbR and ∆THC and all comparisons were made
+with respective “Pre” state. These have been summarized in
+Table 3. There was a significant increase in ∆HbR at the right
+PFC (p = 0.005) after random thinking session whereas there was
+a significant increase in the left PFC (p = 0.02) and in right PFC
+(p < 0.001) after meditation session. Similarly, in ∆THC, there
+was a significant decrease in blood flow change in the right PFC
+(p < 0.001) after the random thinking session whereas there was
+a significant increase in blood flow change in the left (p = 0.03)
+and in right PFC (p < 0.001) after meditation session.
+In summary, as described in Table 3 and in Line diagrams
+(Figures 5–7), there was a positive trend to show a significant
+increase in the concentration of oxyhemoglobin change (∆HbO)
+during meditation session at right PFC (as shown in Figure 5).
+There was a significant decrease in deoxyhemoglobin change
+(∆HbR) (as shown in Figure 6) during meditation session
+whereas there was a significant increase in the concentration of
+deoxyhemoglobin change during random thinking session at the
+right PFC. Additionally, there was also a significant increase in the
+total hemoglobin change (∆THC) during and after meditation
+sessions (Figure 7) and decrease in the total hemoglobin change
+(∆THC) during and after random thinking session.
+DISCUSSION
+The primary goal of the present study was to ascertain whether
+meditation increases rCBF at bilateral PFC, measured with
+fNIRS, compared to random thinking. Our secondary goal was
+to observe the RT scores and relative changes in cerebral blood
+flow, and to determine if there are persistent effects following
+meditation session compared to random thinking session.
+Results as confirmed with recent studies on meditation with
+spectroscopy (Cheng et al., 2010), SPECT imaging (Newberg
+et al., 2001, 2010a,b; Cohen et al., 2009) and fMRI (Short et al.,
+2010; Guleria et al., 2013; Zeidan et al., 2014) have revealed that
+meditation program resulted in significant increases in baseline
+CBF ratios in the prefrontal, superior, inferior and orbital frontal
+cortex, dorsolateral prefrontal cortex (DLPFC), right dorsal
+medial frontal lobe, cingulate gyrus and right sensorimotor
+cortex. In present study, we found that brain activation, measured
+by changes in ∆HbO and ∆THC concentration in the right
+prefrontal area was followed by a strong decrease in ∆HbR
+concentration
+during
+meditation.
+Additionally,
+the
+rCBF
+significantly increased in the right frontal lobe during stroop
+task after meditation, which suggest the improvement in the
+participant’s performance (reaction time) during the task. The
+total blood oxygenation (∆THC) level in the PFC could rise
+with increasing task load from neutral to congruent, and then
+incongruent; this would demonstrate a positive correlation with
+performance measures. The changes in regional blood flow is
+mediated by changes in neural activity in a single region or in
+several selective regions of the brain (Lauritzen, 2001).
+Earlier studies have demonstrated that the PFC is activated
+particularly on the right PFC and anterior cingulate cortex (ACC)
+in willful act and tasks that require intense focused and sustained
+attention (Frith et al., 1991; Pardo et al., 1991; Vogt et al., 1992;
+Petersen and Posner, 2012). A study on eight Tibetan Buddhist
+meditators demonstrated improved activity in the PFC bilaterally
+(though greater on the right hemisphere) and the cingulate gyrus
+during meditation (Newberg and Iversen, 2003). This suggests
+that meditation begins with activation of the PFC and anterior
+cingulate gyrus associated with the will or intent to clear the mind
+of thoughts or to focus on an object (Edwards et al., 2012).
+Meditation increases CBF and decreases cerebrovascular
+resistance (CVR) suggesting a contributing vascular mechanism
+(Jevning et al., 1996) which reflect cerebral activation. The
+CVR reduction being associated with cognitive improvement
+which suggests a vascular contribution to cognitive enhancement
+(Nation et al., 2013). During meditation, the activation of right
+PFC is theoretically associated with the activity in the reticular
+nucleus of the thalamus. This activation may be accomplished
+by the PFC’s production and distribution of glutamate, a known
+excitatory neurotransmission (Cheramy et al., 1987; Finkbeiner,
+1987), which communicate with other brain structures such as
+lateral geniculate and lateral posterior nuclei of the thalamus
+(Portas et al., 1998). An early study on meditation with single
+photon emission computed tomography (SPECT) demonstrated
+a general increase in thalamic activity that was proportional to
+the activity levels in the PFC (Newberg et al., 2001; Edwards et al.,
+2012). The activation on the right PFC causes increased activity
+in the reticular nucleus during meditation, the results may be
+decreased sensory input entering into the posterior superior
+parietal lobule which is involved in the analysis and integration
+of higher order visual, auditory, and somesthetic information
+(Adair et al., 1995).
+Frontiers in Systems Neuroscience
+www.frontiersin.org
+February 2015 | Volume 8 | Article 252 | 8
+Deepeshwar et al.
+Hemodynamic changes in meditation and attention
+FIGURE 5 | Line graph represents averaged Oxy-hemoglobin
+change at right prefrontal cortex (rPFC) in two sessions i.e.,
+random thinking and meditation and Stroop task. Note: Line
+graph represents comparisons between baseline, stroop_pre, during
+sessions (random thinking and meditation), stroop_post, and post.
+Stroop Pre showed higher Oxy-hemoglobin change compared to
+baseline. During and after meditation, the cerebral oxygenation was
+higher in rPFC compared to random thinking.
+FIGURE 6 | Line graph represents averaged Deoxy-hemoglobin change at
+right PFC in two sessions i.e., random thinking and meditation and
+Stroop task. Note: Line graph represents de-oxyhemoglobin changes was
+higher in right PFC during random thinking (D2, D3, and D4), stroop task and
+after random thinking. In other hand, during meditation, there was a decrease
+in de-oxyhemoglobin in D3 level in rPFC.
+A major strength of the present study was to examine the
+states of meditation and random thinking related hemodynamic
+responses in cerebral oxygenation during performance of the
+stroop color word task. It is a well established phenomenon that
+executive processes are facilitated by the frontal lobe and due to
+stroop interference brain activity may depend on increased ability
+to recruit frontal neural resources (Schroeter et al., 2004b). This
+allowed us to examine whether there is an increase in oxygenation
+with meditation corresponding to an ability to recruit appropriate
+resources for task performance or a decrease in activation
+corresponding to better optimization and possible reduction in
+task difficulty with meditation. In a study, fNIRS showed stroop
+interference is consistently associated with the ACC and the
+lateral prefrontal cortex (LPFC), especially the DLPFC, where
+the ACC is considered to be susceptible to conflict, and the
+DLPFC is purported to implement cognitive control (Carter
+et al., 2000; Leung et al., 2000). DLPFC may involve attentional
+maintenance while ACC monitors performance (MacDonald
+et al., 2000). Another similar study suggested meditation may
+enhance specific subcomponents of attention such as conflict
+monitoring or performance (Jha et al., 2007). Although fNIRS
+cannot monitor the cortical activation in the ACC because
+its measurement is limited to lateral cortical surfaces, it has
+successfully monitored the activation of the LPFC associated with
+stroop interference (Schroeter et al., 2002, 2003, 2004a,b; Ehlis
+et al., 2005).
+There have been several neuroimaging studies evaluating the
+cerebral blood flow and performance of different meditation
+practices using behavioral, EEG and (Carter et al., 2005) fMRI
+imaging. Previous studies on meditation and EEG reported,
+greater midline theta power and slow alpha power in the
+frontal area during meditation (Takahashi et al., 2005; Chan
+Frontiers in Systems Neuroscience
+www.frontiersin.org
+February 2015 | Volume 8 | Article 252 | 9
+Deepeshwar et al.
+Hemodynamic changes in meditation and attention
+FIGURE 7 | Line graph represents averaged total hemoglobin change at
+rPFC in two sessions i.e., random thinking and meditation and Stroop
+task. Note: Line graph represents total hemoglobin change was higher in
+rPFC during meditation (D2, D3, and D4), in stroop task, and in post session.
+In other hand, there was a decrease in rPFC during random thinking (D2, D3,
+and D4), in stroop task and in post session.
+et al., 2008). Zazen meditation showed increased alpha-1 and
+alpha-2 frequency activity of EEG in right prefrontal areas
+including insula, parts of the somatosensory, motor cortices
+and temporal areas (Faber et al., 2014). A subsequent study,
+on Satyananda Yoga meditation practice, showed greater source
+activity in low frequencies (particularly theta and alpha 1) during
+mental calculation, body-steadiness and mantra meditation
+(Thomas et al., 2014). Additionally, body-steadiness and mantra
+meditation showed greatest activity in right side of superior
+frontal and precentral gyri, parietal and occipital lobes. Similarly,
+neuroimaging studies on meditation practice, when compared
+to the control session showed significantly increased oxy-
+hemoglobin and CBF in the medial PFC which was associated
+with the intense focus-based component of the practice (Wang
+et al., 2011). Meditation involves attentional regulation and leads
+to increased activity in brain regions associated with attention
+such as DLPFC and ACC. The long-term practitioners had
+significantly more consistent and sustained activation in the
+DLPFC and the ACC during meditation vs. control in comparison
+to short-term practitioners (Baron Short et al., 2010). These
+studies suggest that willful acts and tasks that require sustained
+attention are initiated via activity in the PFC, particularly in the
+right hemisphere (Posner and Petersen, 1990; Frith et al., 1991;
+Pardo et al., 1991; Ingvar, 1994). Meditation requires focus of
+attention on objects which thereby activates PFC, particularly in
+the right hemisphere (Cohen et al., 2009), as well as the cingulate
+gyrus (Herzog et al., 1990; Lazar et al., 2000; Newberg et al.,
+2001). This demonstrated that during meditation there was an
+increased activity in the PFC bilaterally (greater on the right)
+and the cingulate gyrus (Newberg and Iversen, 2003). Therefore,
+the process of meditation seems to happen by activation of the
+prefrontal and cingulate cortex which are associated with the
+will or intent to clear one’s mind of thoughts or to focus on an
+object.
+In other imaging studies on meditation, there have been
+inconsistent results regarding the frontal cortex. A recent study
+showed decreased frontal activity during externally guided word
+generation compared to internal or volitional word generation
+(Cross et al., 2012). Thus, prefrontal and cingulate activation
+may be associated with the volitional aspects of meditation.
+Meditation with fluorodeoxyglucose (FDG) PET in eight subjects
+undergoing Yoga meditative relaxation (Herzog et al., 1990)
+reported increased rCBF in the frontal: occipital ratio of cerebral
+metabolism. Specifically, there was a mild increase in the frontal
+lobe, but marked decreases in metabolism in the occipital and
+superior parietal lobes. In addition to these studies, the PFC
+is reported to have a crucial role in social cognitive skills
+and along with the cingulate gyrus governs social behavior
+tasks related to Theory of Mind, empathy, moral reasoning,
+and evaluation of emotional states (Declerck et al., 2006). The
+PFC is essential for flexible behavior because it inhibits the
+habitual responses that have become inappropriate (Mesulam,
+1998). But, an increase in the activity of PFC (determined by
+fNIRS) is not necessarily beneficial always. For example, animal
+experimentation has shown that the electrical activation of the
+medial PFC prevent the proper sequence of pressing the lever
+and collecting the reward (a pellet of food) in an operant
+condition task (Cross et al., 2012; Jurado-Parras et al., 2012)
+and also prevent the expression of an already acquired classically
+conditioned eyelid response (Leal-Campanario et al., 2007, 2013).
+However, in our study we infer that activation of prefrontal
+cortices after meditation had beneficial effects on cognition
+as manifested by improved performance in stroop color word
+task.
+The
+present
+study
+reported
+increased
+oxy-hemoglobin
+concentration because of enhanced neural activity and cerebral
+blood flow in the prefrontal area during meditation compared
+to random thinking. In such studies, it is very important to
+understand the influences of systemic artifacts such as those
+from the heart, breathing, superficial perfusion, etc., which may
+be induced by the cognitive tasks related stress and autonomic
+responses. For example, a recent study performed on peripheral
+physiological measurements with temporal correlations of
+fNIRS and fMRI signals concluded that the physiological
+Frontiers in Systems Neuroscience
+www.frontiersin.org
+February 2015 | Volume 8 | Article 252 | 10
+Deepeshwar et al.
+Hemodynamic changes in meditation and attention
+basis of the systemic artifact is a task-evoked sympathetic
+arterial vasoconstriction monitored by a decrease in venous
+volume and these artifacts are fairly common (Kirilina et al.,
+2012). They also suggested that the separation of fNIRS signals
+originating from activated brain and from scalp is a necessary
+precondition for unbiased fNIRS brain activation maps and
+pre-processing of the raw data using high definition filters is
+necessary.
+In summary, the results of the present study provided first
+evidence that the oxygenation levels are increased in the PFC
+during meditation compared with random thinking in the same
+practitioners. Further event-related NIRS studies may apply well-
+tested fMRI paradigms in studies with children and patients,
+utilizing the advantages of the method.
+ACKNOWLEDGMENTS
+This research work was supported by the Center for Advanced
+Research in Yoga and Neurophysiology, Swami Vivekananda Yoga
+Research Foundation, Bangalore, India. We are gateful to Dr.
+Shirley Telles, Dr. Manjunath N.K. and Dr. Hemant Bhargav for
+their support and guidelines with regards to data acquisition and
+analysis.
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+Conflict of Interest Statement: 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.
+Received: 01 November 2014; accepted: 22 December 2014; published online: 17
+February 2015.
+Citation: Deepeshwar S, Vinchurkar SA, Visweswaraiah NK and Nagendra HR (2015)
+Hemodynamic responses on prefrontal cortex related to meditation and attentional
+task. Front. Syst. Neurosci. 8:252. doi: 10.3389/fnsys.2014.00252
+This article was submitted to the journal Frontiers in Systems Neuroscience.
+Copyright © 2015 Deepeshwar, Vinchurkar, Visweswaraiah and Nagendra. This
+is an open-access article distributed under the terms of the Creative Commons
+Attribution License (CC BY). The use, distribution and reproduction in other forums
+is permitted, provided the original author(s) or licensor 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 Systems Neuroscience
+www.frontiersin.org
+February 2015 | Volume 8 | Article 252 | 13

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