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+_____________________________________________________________________________________________________ 
+ 
+# Dean; 
+*Corresponding author: E-mail: drsujathadinesh2@gmail.com; 
+ 
+ 
+ 
+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: 
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+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: deepeshwar.singh@outlook.com
+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: WKHLRPMedknow_reprints@wolterskluwer.com
+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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+9.	 González-Valero G, Zurita-Ortega F, Ubago-Jiménez JL, Puertas-Molero P. 
+Use of meditation and cognitive behavioral therapies for the treatment 
+of stress, depression and anxiety in students. A systematic review and 
+meta-analysis. Int J Environ Res Public Health 2019;16:E4394.
+10.	 Kang YS, Choi SY, Ryu E. The effectiveness of a stress coping 
+program based on mindfulness meditation on the stress, anxiety, and 
+depression experienced by nursing students in Korea. Nurse Educ Today 
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+intervention on students’ stress and anxiety levels. Am J Pharm Educ 
+2019;83:7001.
+12.	 Krisanaprakornkit T, Krisanaprakornkit W, Piyavhatkul N, Laopaiboon 
+M. Meditation therapy for anxiety disorders. Cochrane Database Syst 
+Rev 2006;25:CD004998. [doi: 10.1002/14651858.CD004998.pub2].
+13.	 Vieten C, Wahbeh H, Cahn BR, MacLean K, Estrada M, Mills P, et al. 
+Table 4: Relation of mindfulness with anxiety, 
+impulsivity, depth of meditation, and quality of 
+life
+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
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+59
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+3
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+44
+45
+46
+47
+48
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+53
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+Krishna, et al.: Heartfulness meditation promotes mental health and well-being
+30 	
+Yoga Mīmāṃsā | Volume 54 | Issue 1 | January-June 2022
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+mhp.2018.08.003].
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+[Downloaded free from http://www.ym-kdham.in on Saturday, July 16, 2022, IP: 136.232.192.146]
diff --git a/subfolder_0/Add-on Yoga Therapy for Social Cognition in Schizophrenia_ A Pilot Study.txt b/subfolder_0/Add-on Yoga Therapy for Social Cognition in Schizophrenia_ A Pilot Study.txt
new file mode 100644
index 0000000000000000000000000000000000000000..026a29bb0aae50f8a3b388d7f115e35dbe13cc58
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+++ b/subfolder_0/Add-on Yoga Therapy for Social Cognition in Schizophrenia_ A Pilot Study.txt	
@@ -0,0 +1,207 @@
+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:
+ramji.zero@gmail.com
+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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diff --git a/subfolder_0/An Ayurvedic basis for using honey to treat herpes.txt b/subfolder_0/An Ayurvedic basis for using honey to treat herpes.txt
new file mode 100644
index 0000000000000000000000000000000000000000..bda554929a0ef3866c1c4ce5a0e57568dbbe8a60
--- /dev/null
+++ b/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: pyp.research@gmail.com
+2 JSS Institute of Naturopathy & Yogic Sciences,
+Ootacamund, Tamil Nadu, India
+e-mail: raghurajp@yahoo.com
+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
+LE17
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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: phsmph@nus.edu.sg
+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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+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: drsathyaprabha@gmail.com (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.
+r e f e r e n c e s
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+dystrophies. Semin Respir Crit Care Med 2002;23:231e8.
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+the European Society of Cardiology and the North American
+Society of Pacing and Electrophysiology. Circulation
+1996;93:1043e65.
+3. Liao D, Cai J, Rosamond WD, et al. Cardiac autonomic
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+based case-cohort study. The ARIC Study. Atherosclerosis
+Risk in Communities Study. Am J Epidemiol 1997;145:696e706.
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+Gangadhar BN. Modulation of cardiac autonomic functions in
+patients with major depression treated with repetitive
+transcranial magnetic stimulation. J Affect Disord
+2007;104:231e6.
+14. Pradhan C, Yashavantha BS, Pal PK, Sathyaprabha TN.
+Spinocerebellar ataxias type 1, 2 and 3: a study of heart rate
+variability. Acta Neurol Scand 2008;117:337e42.
+15. Sriranjini SJ, Ganesan M, Datta K, Pal PK, Sathyaprabha TN.
+Effect of a single dose of standard levodopa on cardiac
+autonomic function in Parkinson’s disease. Neurol India
+2011;59:659e63.
+16. Lanza GA, Dello Russo A, Giglio V, et al. Impairment of cardiac
+autonomic function in patients with Duchenne muscular
+dystrophy: relationship to myocardial and respiratory
+function. Am Heart J 2001;141:808e12.
+17. Inoue M, Mori K, Hayabuchi Y, Tatara K, Kagami S.
+Autonomic function in patients with Duchenne muscular
+dystrophy. Pediatr Int 2009;51:33e40.
+18. Yotsukura M, Fujii K, Katayama A, et al. Nine-year follow-up
+study of heart rate variability in patients with Duchenne-type
+progressive muscular dystrophy. Am Heart J 1998;136:289e96.
+19. Politano L, Palladino A, Nigro G, Scutifero M, Cozza V.
+Usefulness of heart rate variability as a predictor of sudden
+cardiac death in muscular dystrophies. Acta Myol
+2008;27:114e22.
+20. Hampton TG, Kale A, McCue S, Bhagavan HN, Vandongen C.
+Developmental changes in the ECG of a Hamster model of
+muscular dystrophy and heart failure. Front Pharmacol 2012;3:80.
+21. Jimenez J, Tardiff JC. Abnormal heart rate regulation in
+murine hearts with familial hypertrophic cardiomyopathy-
+related cardiac troponin T mutations. Am J Physiol Heart Circ
+Physiol 2011;300:H627e35.
+22. Wernicke D, Wessel N, Malberg H, Plehm R, Bauernschmitt R,
+Thierfelder L. Autonomic cardiac control in animal models of
+cardiovascular diseases II. Variability analysis in transgenic
+rats with alpha-tropomyosin mutations Asp175Asn and
+Glu180Gly. Biomed Tech Berl 2007;52:50e5.
+23. Wehling-Henricks M, Jordan MC, Roos KP, Deng B, Tidball JG.
+Cardiomyopathy in dystrophin-deficient hearts is prevented
+by expression of a neuronal nitric oxide synthase transgene
+in the myocardium. Hum Mol Genet 2005;14:1921e33.
+24. Herring N, Paterson DJ. Neuromodulators of peripheral
+cardiac sympatho-vagal balance. Exp Physiol 2009;94:46e53.
+25. Marko SB, Damon DH. VEGF promotes vascular sympathetic
+innervation. Am J Physiol Heart Circ Physiol 2008;294:H2646e52.
+26. Nico B, Corsi P, Vacca A, Roncali L, Ribatti D. Vascular
+endothelial growth factor and vascular endothelial growth
+factor receptor-2 expression in mdx mouse brain. Brain Res
+2002;953:12e6.
+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
diff --git "a/subfolder_0/Autonomic changes during \342\200\230OM\342\200\231 meditation..txt" "b/subfolder_0/Autonomic changes during \342\200\230OM\342\200\231 meditation..txt"
new file mode 100644
index 0000000000000000000000000000000000000000..b003a7e503a37b76f43b10c0bcf338ebf876413c
--- /dev/null
+++ "b/subfolder_0/Autonomic changes during \342\200\230OM\342\200\231 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.
diff --git a/subfolder_0/Barriers to yoga therapy as an add-on treatment for schizophrenia in India.txt b/subfolder_0/Barriers to yoga therapy as an add-on treatment for schizophrenia in India.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0c0383b3ceb5e0b2af0c6337b0e47d18057f971b
--- /dev/null
+++ b/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: jaganaarti@gmail.com
+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
diff --git a/subfolder_0/Changes in Bioenergy Field of Children with Autism following.txt b/subfolder_0/Changes in Bioenergy Field of Children with Autism following.txt
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+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: deepeshwar.singh@outlook.com
+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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diff --git a/subfolder_0/Combined Ayurveda and Yoga Practices for Newly Diagnosed Type 2 Diabetes Mellitus A Controlled Trial.txt b/subfolder_0/Combined Ayurveda and Yoga Practices for Newly Diagnosed Type 2 Diabetes Mellitus A Controlled Trial.txt
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@@ -0,0 +1,1020 @@
+Fax +49 761 4 52 07 14
+Information@Karger.com
+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
+alexhankey@gmail.com
+© 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: 
+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
+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: 
+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
+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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+Downloaded by: 
+King's College London                                  
+137.73.144.138 - 12/8/2017 12:49:12 PM
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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
diff --git a/subfolder_0/Cost of Management of Diabetes Mellitus A Pan India Study.txt b/subfolder_0/Cost of Management of Diabetes Mellitus A Pan India Study.txt
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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: rnagaratna@gmail.com
+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-
+cle/view/4202 (accessed 24 September 2020.  https://dx.doi.
+org/10.18203/2394-6040.ijcmph20190604
+11.	 Nagendra HR, Nagarathna R, Rajesh SK, et al. Niyantrita 
+Madhumeha Bharata 2017, Methodology for a Nationwide 
+Diabetes Prevalence Estimate: Part 1. International J Yoga 2019; 
+12(3): 179–192. https://doi.org/10.4103/ijoy.IJOY_40_18
+12.	 IBM Corp. Released 2012. IBM SPSS Statistics for Windows, 
+Version 21.0. Armonk, NY: IBM Corp.
+13.	 Lavado RF, Brooks BPC, Hanlon M, et al. Estimating health 
+expenditure shares from household surveys. Bull World Health 
+Organ 2013; 91: 519–524C. 10.2471/BLT.12.115535.
diff --git a/subfolder_0/Cumulative effect of shortterm and long-term.txt b/subfolder_0/Cumulative effect of shortterm and long-term.txt
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index 0000000000000000000000000000000000000000..27f6b203b372a45715958a117c23fa6f50ea8e58
--- /dev/null
+++ b/subfolder_0/Cumulative effect of shortterm and long-term.txt	
@@ -0,0 +1,1062 @@
+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: gurudeo.yoga@gmail.com
+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 | gurudeo.yoga@gmail.com 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 | gurudeo.yoga@gmail.com 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 | gurudeo.yoga@gmail.com 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 | gurudeo.yoga@gmail.com 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 | gurudeo.yoga@gmail.com 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 | gurudeo.yoga@gmail.com 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 | gurudeo.yoga@gmail.com 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
diff --git a/subfolder_0/Depression in Traditional Chinese Medicine high variances in.txt b/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 : 
+alexhankey@gmail.com 
+ 
+ 
+ 
+ 
+ 
+ 
+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  
+1. Voll R. Twenty years of electro acupuncture diagnosis in Germany: A progress report. Am 
+J Acupunct1975; 3:7-1. 
+2. Nakatani Y. Skin electric resistance and ryodoraku. J Autonomic Nerve 1956;6:52 
+3. Ahn AC, Martinsen OG. Electrical characterization of acupuncture points: Technical 
+issues and challenges. J Altern Complement Med 2007; 13:817–824. 
+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. 
+Reliability of AcuGraph system for measuring skin conductance at acupoints. 
+AcupunctMed2011; 29(3):221-6.  
+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.  
+7. Nagilla N, Hankey A, Nagendra HR. Effects of Yoga practice on Acumeridian Energies: 
+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 
+benefit health by improving organism regulation? Evidence from electrodermal measures 
+of acupuncture meridian properties. Int J Yoga, 2014; 7:1:32-40.  
+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.  
+21. Hankey A. The ontological status of western science and medicine. J Ayurveda Integr 
+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).    
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
diff --git a/subfolder_0/Design and validation of Integrated Yoga Therapy module for Antarctic.txt b/subfolder_0/Design and validation of Integrated Yoga Therapy module for Antarctic.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a26c0528c3585222706e7281e01d3e322a007d05
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+++ b/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: ramesh.mavathur@svyasa.org (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
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+J Ayurveda Integr Med (2018), https://doi.org/10.1016/j.jaim.2017.11.005
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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: ayushnitin@gmail.com
+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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+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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+[Downloaded from http://www.ijoy.org.in on Wednesday, July 27, 2016, IP: 14.139.155.82]
diff --git a/subfolder_0/Development of a Yoga programme for type-2 diabetes prevention (YOGA-DP) among high-risk people in India.txt b/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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@@ -0,0 +1,1691 @@
+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
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+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
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+Conflict of Interest: The authors declare that the research was conducted in the
+absence of any commercial or financial relationships that could be construed as a
+potential conflict of interest.
+Copyright © 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: reprints@medknow.com
+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.
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+2016;2016:1609317.
+27. Pecoits‑Filho R, Abensur H, Betônico CC, Machado AD, 
+Parente EB, Queiroz M, et  al. Interactions between kidney 
+disease and diabetes: Dangerous liaisons. Diabetol Metab Syndr 
+2016;8:50.
+28. Hirokawa K, Utsuyama M, Hayashi Y, Kitagawa M, Makinodan 
+T, Fulop T. Slower immune system aging in women versus men 
+in the Japanese population. Immun Ageing 2013;10:19.
+29. Caruso C, Accardi G, Virruso C, Candore G. Sex, gender and 
+immunosenescence: A key to understand the different lifespan 
+between men and women? Immun Ageing 2013;10:20.
+30. Klin SL, Flangan KL. Sex difference in immune responses. Nat 
+Rev Immunol 2016;16:626-38.
+Reproduced with permission of copyright owner.
+Further reproduction prohibited without permission.
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@@ -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: b_amaranath@yahoo.co.in   
+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 
diff --git a/subfolder_0/EFFECT OF YOGA BASED AND FORCED UNINOSTRIL BREATHING ON THE AUTONOMIC NERVOUS SYSTEM.txt b/subfolder_0/EFFECT OF YOGA BASED AND FORCED UNINOSTRIL BREATHING ON THE AUTONOMIC NERVOUS SYSTEM.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6be30bcbb91a507f0e9b4e319dccd4c360090c99
--- /dev/null
+++ b/subfolder_0/EFFECT OF YOGA BASED AND FORCED UNINOSTRIL BREATHING ON THE AUTONOMIC NERVOUS SYSTEM.txt	
@@ -0,0 +1,6 @@
+ 
+ 
+ 
+ 
+ 
+ 
diff --git a/subfolder_0/Effect Of Yoga On Cognitive Abilities In Schoolchildren From A Socioeconomically Disadvantaged Background.txt b/subfolder_0/Effect Of Yoga On Cognitive Abilities In Schoolchildren From A Socioeconomically Disadvantaged Background.txt
new file mode 100644
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--- /dev/null
+++ b/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 
+ 
diff --git a/subfolder_0/Effect of 6 months intense Yoga practice on lipid profile, thyroxine medication and serum TSH level in women suffering from hypothyroidism.txt b/subfolder_0/Effect of 6 months intense Yoga practice on lipid profile, thyroxine medication and serum TSH level in women suffering from hypothyroidism.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f56bb8ce6896f058c2e4f7f9ba61812b2736c8a0
--- /dev/null
+++ b/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: kgmhetre@gmail.com
+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 | kgmhetre@gmail.com 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 | kgmhetre@gmail.com 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 | kgmhetre@gmail.com 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.
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+Download Date | 4/8/16 12:34 PM
diff --git a/subfolder_0/Effect of Heartfulness Meditation Among Long-Term, Short-Term and Non-meditators on Prefrontal Cortex Activity of Brain.txt b/subfolder_0/Effect of Heartfulness Meditation Among Long-Term, Short-Term and Non-meditators on Prefrontal Cortex Activity of Brain.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c8466e9eadb1c394fdf0b6dc204bc739e4d9617a
--- /dev/null
+++ b/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, bsingh.bme@nitrr.ac.in
+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
+5 of 12
+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
+6 of 12
+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
+7 of 12
+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
+8 of 12
+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
+9 of 12
+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
+10 of 12
+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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+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: kuldeepkush86@gmail.com
+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.
diff --git a/subfolder_0/Effect of Pyramids and their Materials on Emergence and Growth of Fenugreek.txt b/subfolder_0/Effect of Pyramids and their Materials on Emergence and Growth of Fenugreek.txt
new file mode 100644
index 0000000000000000000000000000000000000000..086b826016356709cda0a08b0b41a88907a289ce
--- /dev/null
+++ b/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: ravi_itagi@yahoo.co.in 
+ 
+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 
+ 
diff --git a/subfolder_0/Effect of a yoga program on glucose metabolism and blood lipid levels in adolescent girls with polycystic ovary syndrome.txt b/subfolder_0/Effect of a yoga program on glucose metabolism and blood lipid levels in adolescent girls with polycystic ovary syndrome.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0dc82522c027a83b3ad0a1f0a3b3590c36d4a8db
--- /dev/null
+++ b/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.
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+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: nidhiyoga@gmail.com (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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+associated clinical and biochemical features in young women. Clin Endocrinol
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+syndrome: a systematic review. Hum Reprod Update 2011;17(2):171–83.
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+Insulin sensitivity and cardiac autonomic function in young male practitioners of
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+certain cardiovascular functions in type 2 diabetic patients. J Assoc Physicians
+India 2004;52:203–6.
+[14] Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Revised
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+polycystic ovary syndrome. Fertil Steril 2004;81(1):19–25.
+[15] Vigorito C, Giallauria F, Palomba S, Cascella T, Manguso F, Lucci R, et al. Beneficial
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+metformin for adolescents with polycystic ovary syndrome. Arch Pediatr Adolesc
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+cortisol during yoga exercise is correlated with alpha wave activation. Percept
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+R. Nidhi et al. / International Journal of Gynecology and Obstetrics 118 (2012) 37–41
diff --git a/subfolder_0/Effect of hot arm and foot bath on heart rate variability and blood pressure in healthy volunteers.txt b/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: samruddhi27vyas@gmail.com
+2 Department of Naturopathy, Government Yoga and Naturopathy Medical College, Arumbakkam, Chennai-600106, Tamil-
+nadu, India, E-mail: dr.mooventhan@gmail.com
+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: nkmsharma@gmail.com
+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
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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.
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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/
+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: b_amaranath@yahoo.co.in
+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: b_amaranath@yahoo.co.in
+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
+.R. Impact of Vedic worldview and gunas on transformational leadership. Vikalpa. 2004;29:1–31.
+4. Rangan R., Nagendra H., Bhat G.R. Effect of yogic education system and modern education system on memory. Int J Yoga. 2009;2:55–61. [PubMed]
+5. Kauts A., Sharma N. Effect of yoga on academic performance in relation to stress. Int J Yoga. 2009;2:39–43. [PubMed]
+6. Evans R.G. Patient centred medicine: reason, emotion, and human spirit? Some philosophical reflections on being with patients. Med Humanit.
+2003;29:8–14. [PubMed]
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+180. [PubMed]
+8. Sabina A.B., Williams A.L., Wall H.K., Bansal S., Chupp G., Katz D.L. Yoga intervention for adults with mild­to­moderate asthma: a pilot study.
+Ann Allergy Asthma Immunol. 2005;94:543–548. [PubMed]
+9. Bijlani R.L., Vempati R.P., Yadav R.K., Ray R.B., Gupta V
+., Sharma R. A brief but comprehensive lifestyle education program based on yoga
+reduces risk factors for cardiovascular disease and diabetes mellitus. J Altern Complement Med. 2005;11:267–274. [PubMed]
+10. Brown R.P., Gerbarg P.L. Sudarshan Kriya yogic breathing in the treatment of stress, anxiety, and depression: part I­neurophysiologic model. J Altern
+Complement Med. 2005;11:189–201. [PubMed]
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+2014;56:29–38. [PMC free article] [PubMed]
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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
+14. Wolf D.B. The vedic personality inventory: a study of the Gunas. J Indian Psychol. 1998;16:26–43.
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+16. Nagarathna R., Nagendra H.R. 5th ed. SVYP; Bangalore: 2003. Integrated approach of yoga therapy for positive health.
+17. Lokeswarananda S. The Ramakrishna Mission Institute of Culture; Calcutta: 1996. Taittiriya Upanisad; pp. 136–180.
+18. Nagarathna R., Nagendra H.R. 2nd ed. SVYP; Bangalore: 2003. Yoga.
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+volunteers. Int J Yoga. 2008;1:2–10. [PubMed]
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+22. Adhia H., Nagendra H., Mahadevan B. Impact of yoga way of life on organizational performance. Int J Yoga. 2010;3:55–66. [PubMed]
diff --git a/subfolder_0/Effect of integrated yoga therapy on pain morning stiffness and.txt b/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: rnagaratna@gmail.com
+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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+29. Bukowski EL, Conway A, Glentz LA. The effect of Iyengar yoga and 
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+31. Altman R, 
+Asch E, Bloch D, Bole G, Borenstein D, Brandt K, et al. Development 
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+39. Tait RC, Chibnall JT, Krause S. The pain disability index: Psychometric 
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+Assessment of Emotional States and Personality Traits: Measuring 
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+of the Spielberger State‑trait anxiety inventory (STAI) among urological 
+patients: A Malaysian study. 59:258‑67.
+42. Ranjitha R, Nagarathna R. Effect of yoga on pain , mobility, gait and balance 
+in patients with osteoarthritis of the knee. Bangalore: Dissertation submitted 
+to Swami Vivekananda Yoga Anusandhana Samastana (SVYASA); 2006.
+43. Bijlsma JW. Analgesia and the patient with osteoarthritis. Am J Ther 
+2002;9:189‑97.
+44. Raghuraj P, Ramakrishnan AG, Nagendra HR. Effect of two selected yogic 
+breathing techniques on heart rate variability. Indian J Physiol Pharmacol 
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+conditions of single thought and thoughtless states. Indian J Physiol Pharmacol 
+1992;36:293‑4.
+46. Perlman AI, Sabina A, Williams AL. Massage therapy for osteoarthritis of 
+the knee: A randomized controlled trial. Arch Intern Med 2006;166:2533‑8.
+47. 
+Baser HD, Jakie C, Kroner‑Herwig B. Incorporation of cognitive‑behavior treatment 
+into the medical care of chronic low back pain patients: A controlled randomized 
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+48. Lipchik GL, Milles K, Covington EC. The effects of multidisciplinary 
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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: rajesheskay@svyasa.org
+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]
diff --git a/subfolder_0/Effect of uninostril yoga breathing on brain hemodynamics_ A functional near-infrared spectroscopy study.txt b/subfolder_0/Effect of uninostril yoga breathing on brain hemodynamics_ A functional near-infrared spectroscopy study.txt
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@@ -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: hemant.bhargav1@gmail.com
+Copyright : © International Journal of Yoga
+This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix,
+tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
+Articles from International Journal of Yoga are provided here courtesy of Medknow Publications
+REFERENCES
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diff --git a/subfolder_0/Effect of yoga on quality of life of CLBP patients a randomizd control study.txt b/subfolder_0/Effect of yoga on quality of life of CLBP patients a randomizd control study.txt
new file mode 100644
index 0000000000000000000000000000000000000000..119fe9826c8a23c0819663f75d71be6843a3026b
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@@ -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: p_tekur@yahoo.co.in; rnagaratna@gmail.com
+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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+Hypotheses 2007;68:74-80.
+43.	 Telles S, Nagarathna R, Nagendra HR. Breathing through a particular nostril 
+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.
+Tekur, et al. 
+[Downloaded from http://www.ijoy.org.in on Thursday, March 03, 2011, IP: 117.211.90.10]
+17
+International Journal of Yoga  Vol. 3  Jan-Jun-2010
+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.
+48.	 Telles S, Nagarathna R, Nagendra HR. Autonomic changes during OM 
+meditation. Indian J Physiol Pharmacol 1995;39:418-20.
+49.	 Leonard BE. HPA and immune axes in stress: Involvement of the serotonergic 
+system. Neuroimmunomodulation 2006;13:268-76.
+50.	 Jevning R, Wilson AF, Davidson JM. Adrenocortical activity during 
+meditation. Horm Behav 1978;10:54-60.
+[Downloaded from http://www.ijoy.org.in on Thursday, March 03, 2011, IP: 117.211.90.10]
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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: hrnagendra@rediffmail.com
+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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+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:
+raghav.hcgrf@gmail.com
+Copyright : © 2017 Indian Journal of Palliative Care
+This is an open access article distributed under the terms of the Creative Commons Attribution-
+NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-
+commercially, as long as the author is credited and the new creations are licensed under the identical terms.
+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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diff --git a/subfolder_0/Effects of a Yoga Program on Health, Behavior and Learning Ability in School Children A Single Arm Observational Study.txt b/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
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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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+Single Arm Observational Study. Int J Complement Alt Med 5(1): 00138. DOI: 10.15406/ijcam.2017.05.00138
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diff --git a/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 b/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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index 0000000000000000000000000000000000000000..5293043db1ff8157387c91c386e806c3662c9c5e
--- /dev/null
+++ b/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	
@@ -0,0 +1,561 @@
+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: rnagaratna@gmail.com
+Copyright : © 2017 Indian Journal of Palliative Care
+This is an open access article distributed under the terms of the Creative Commons Attribution-
+NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-
+commercially, as long as the author is credited and the new creations are licensed under the identical terms.
+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.
+Rඍඎඍකඍඖඋඍඛ
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diff --git a/subfolder_0/Effects of two yoga based relaxation techniques on HRV.txt b/subfolder_0/Effects of two yoga based relaxation techniques on HRV.txt
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+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: anvesana@gmail.com
+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
6
+10/10/06
+14:45
+Art: 021606
+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
+tapraid1/str-str/str-str/str00406/str2003d06g
+enterlis
+S
6
+10/10/06
+14:45
+Art: 021606
+AQ: 2
+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
+enterlis
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+Art: 021606
+APA PROOFS
+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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+enterlis
+S
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+14:45
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+AQ: 3
+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
+S
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+10/10/06
+14:45
+Art: 021606
+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
6
+10/10/06
+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
+S
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+14:45
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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
+S
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+10/10/06
+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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+Art: 021606
+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
+Sarang and Telles
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+T1
+AQ: t1
+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
+Yoga Relaxation and HRV
+tapraid1/str-str/str-str/str00406/str2003d06g
+enterlis
+S
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+APA PROOFS
+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
+Sarang and Telles
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+APA PROOFS
+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
+Yoga Relaxation and HRV
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+APA PROOFS
+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.
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+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
+Sarang and Telles
+tapraid1/str-str/str-str/str00406/str2003d06g
+enterlis
+S
6
+10/10/06
+14:45
+Art: 021606
+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
diff --git a/subfolder_0/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.txt b/subfolder_0/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.txt
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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
+References
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+for the management of type II diabetes mellitus in adults:
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+YOGA AND SLEEP, CARDIAC HEALTH AND QoL IN ELDERLY
diff --git "a/subfolder_0/Effects of yoga on prakrti in children \342\200\223 a pilot study..txt" "b/subfolder_0/Effects of yoga on prakrti in children \342\200\223 a pilot study..txt"
new file mode 100644
index 0000000000000000000000000000000000000000..e826ebdd45d910187cbe64b4ad577f5edbfa9f35
--- /dev/null
+++ "b/subfolder_0/Effects of yoga on prakrti in children \342\200\223 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: ayursuch@rediffmail.com 
+(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: 
+ 
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+(2006). Randomized, controlled, six-month trial of yoga in healthy seniors: effects on cognition and quality of life: 
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+ 
+ 
+Received: July 2, 2012 
+Accepted: August 2, 2012 
+ 
+ 
+ 
+ 
+ 
diff --git a/subfolder_0/Effects of yogic breath regulation A narrative review of scientific evidence..txt b/subfolder_0/Effects of yogic breath regulation A narrative review of scientific evidence..txt
new file mode 100644
index 0000000000000000000000000000000000000000..f2e900eea22e22138794cbf6668990e83fd43a61
--- /dev/null
+++ b/subfolder_0/Effects of yogic breath regulation A narrative review of scientific evidence..txt	
@@ -0,0 +1,1325 @@
+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: aparsaoji@gmail.com (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.
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+cause of pneumothorax? A case report. Chest 2004;125:1951e2.
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+A.A. Saoji et al. / Journal of Ayurveda and Integrative Medicine xxx (2017) 1e9
+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
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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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+Self‑Supervision,” Proceedings of the IEEE/CVF Conference on 
+Computer Vision and Pattern Recognition; 2019. p. 5714-24.
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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]
diff --git a/subfolder_0/FACTORS INFLUENCING CHANGES IN TWEEZER DEXTERITY SCORES FOLLOWING YOGA TRAINING.txt b/subfolder_0/FACTORS INFLUENCING CHANGES IN TWEEZER DEXTERITY SCORES FOLLOWING YOGA TRAINING.txt
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index 0000000000000000000000000000000000000000..0e70f9eb88442d42936df5a1a91baa77e8de3222
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new file mode 100644
index 0000000000000000000000000000000000000000..91870ed19041db6c0840a803ff2fe64fe67242aa
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@@ -0,0 +1,48 @@
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
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diff --git a/subfolder_0/Guinness world record attempt as a method to pivot the role of Yoga in Diabetes management.txt b/subfolder_0/Guinness world record attempt as a method to pivot the role of Yoga in Diabetes management.txt
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index 0000000000000000000000000000000000000000..4552c721d9c827ffccb6487408a090a4399614b4
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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: akshay1anand@rediffmail.com
+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.
diff --git a/subfolder_0/HEART RATE VARIABILITY SPECTRUM DURING VIPASSANA MINDFULNESS MEDITATION.txt b/subfolder_0/HEART RATE VARIABILITY SPECTRUM DURING VIPASSANA MINDFULNESS MEDITATION.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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+1016/j.pscychresns.2010.09.011
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+449–456.
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+Mindfulness meditation improves cognition: evidence of brief mental training.
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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
diff --git a/subfolder_0/IMPROVEMENT IN VISUAL PERCEPTION FOLLOWING YOGA TRAINING.txt b/subfolder_0/IMPROVEMENT IN VISUAL PERCEPTION FOLLOWING YOGA TRAINING.txt
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diff --git a/subfolder_0/INFLUENCE OF EARLY RISING ON PERFORMANCE IN TASKS REQUIRING ATTENTION AND MEMORY.txt b/subfolder_0/INFLUENCE OF EARLY RISING ON PERFORMANCE IN TASKS REQUIRING ATTENTION AND MEMORY.txt
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+*Corresponding Author :
+Manjunath N.K., Ph.D. Associate Professor, Division of Yoga and Life Sciences,
+Swami Vivekananda Yoga Anusandhana Samsthana, # 19, Eknath Bhavan, Gavipuram
+Circle, K.G. Nagar, Bengaluru – 560019, India; Telephone : 080-22639983,
+Telefax: 080- 26608645, E-mail: nkmsharma@gmail.com
+INFLUENCE OF EARLY RISING ON PERFORMANCE IN TASKS
+REQUIRING ATTENTION AND MEMORY
+V. SHANKAR KUMARAN, BHAT RAMACHANDRA RAGHAVENDRA
+AND NANDI KRISHNAMURTHY MANJUNATH*
+Swami Vivekananda Yoga Anusandhana Samsthana,
+Bangalore, India
+(
+(
+(
+(
+( Received on November 5, 2011
+Received on November 5, 2011
+Received on November 5, 2011
+Received on November 5, 2011
+Received on November 5, 2011 )
+)
+)
+)
+)
+Abstract :
+Abstract :
+Abstract :
+Abstract :
+Abstract : Rising early in the morning has been a prescribed discipline of
+ancient Indian tradition. While there are no scientific studies comparing
+early rising volitionally versus circumstantially, selected studies on the
+latter (rising forcefully) have shown negative impact on an individual’s
+peroformance. Hence the present study was undertaken to assess the
+influence of early rising (during Brahma-muhurtha) on tasks requiring
+attention and the ability to recall. Fifty four normal healthy male volunteers,
+with ages ranging from 16-22 years from a residential school were selected.
+They were randomly allocated to two groups (Brahma-muhurtha and
+control). They were assessed on day 1, day 10 and day 20 of the intervention,
+using a digit letter substitution task and verbal and spatial memory task.
+The Brahma-muhurtha group were asked to rise before 4:30 am in the
+morning based on the traditional Indian astrological calculations, while the
+control group were allowed to wake up just before 7 am which was their
+regular timing for waking. Brahma-muhurtha group after 20 days showed
+a significant improvement in the net scores for digit letter substitution task
+as well as scores for verbal and spatial memory tasks. The control group
+also showed an improvement in the memory task but not in the task
+requiring attentional processes. The present study suggests that rising
+early in the morning as described in ancient Indian tradition influences the
+process of attention and can improve the ability to recall.
+Key words :
+Key words :
+Key words :
+Key words :
+Key words :
+Brahma-muhurtha
+early rising
+memory
+attention
+INTRODUCTION
+Circadian rhythm is a roughly 24-hour
+cycle in the biochemical, physiological or
+behavioral processes of living beings. The
+influence of the time of the day on daily
+activities has been attributed to the circadian
+rhythm (1). While no scientific basis can be
+found for specific time to wake up in the
+morning, the descriptions from ancient
+Indian literature, suggests Brahma-muhurtha
+(a fixed time early in the morning, based on
+the 
+traditional 
+Indian 
+astrological
+calculations) as the time for rising (2). Vishnu
+Indian J Physiol Pharmacol 2012; 56(4) : 337–344
+338
+Kumaran et al
+Indian J Physiol Pharmacol 2012; 56(4)
+smriti, an ancient Indian text describes
+Brahma-muhurtha as forty eight minutes
+before sun rise which is the sacred time to
+rise in the morning (3). 
+ 
+ 
+ 
+ Hence, 
+, 
+, 
+, 
+, rising at
+Brahma-muhurtha, individuals are prescribed
+to engage in doing all focused activities
+including meditation (4). Also, the time of
+rising in the morning has been believed to
+influence an individual’s performance across
+the day (5).
+Over generations, it has been a
+convention for people to get up early in the
+morning. However, the reasons behind rising
+early in the morning can be classified as
+(i) volitional (as a discipline/routine) and /
+or (ii) circumstantial (present day due
+to job requirements). While no rigorous
+documentation has been made to illustrate
+the influence of rising early in the morning
+volitionally, studies on the latter suggested
+adverse effects.
+An 
+earlier 
+study 
+reported 
+the
+relationship between Brazilian airline pilot
+errors and time of the day (6). It was shown
+that the risk of errors increased by almost
+50% in the early morning relative to the
+morning period (ratio of 1:1.46). For the
+period of the afternoon, the ratio was 1:1.04
+and for the night, a ratio of was 1:1.05.
+Hence, the authors speculated that the period
+of the early morning represented a greater
+risk of attention problems and fatigue.
+Another study on twenty-two airline cabin
+crew members, suggested that early morning
+work causes a reduction of sleep time and
+an increase in stress (7). A previous study
+which compared the early rising and delayed
+bedtime found that the early rising appeared
+to be more disturbing than the late bedtime
+(8).
+In contrast to the above mentioned
+adverse effects of early awakening, a recent
+study evaluated the cognitive performance
+of 2030 normal older adults across the day.
+Since, elderly people have been shown to
+have cognitive deficits; an attempt was made
+to evaluate the role of early morning
+awakening and the ability to remember. The
+best performance on a task requiring episodic
+memory was during early morning hours and
+late afternoon, worst performance occurred
+in mid-day (9).
+It is evident from the above mentioned
+reports the time of the day in general and
+early morning in particular has a definite
+influence on an individuals’ performance. But
+no attempts have been made to understand
+the impact of rising early in the morning
+volitionally on performance oriented tasks.
+Moreover, there are no scientific studies
+available on the influence of early morning
+awakening (Brahma-muhurtha) on focused
+attention & concentration as well as a
+memory task. Hence the present study was
+designed to evaluate the influence of rising
+at a particular time of early morning
+(Brahma-muhurtha) on the ability to
+remember and focus attention in healthy
+male volunteers.
+METHODS
+Participants
+Participants
+Participants
+Participants
+Participants
+Fifty 
+four 
+normal 
+healthy 
+male
+volunteers with ages ranging from 18 to 22
+years participated in the study. They were
+randomly allocated to two groups i.e.,
+Experimental (Brahma-muhurtha) and
+Control with 27 subjects in each group using
+a random number table (group mean age±SD,
+Indian J Physiol Pharmacol 2012; 56(4)
+Effect of Early Rising on Attention & Memory
+339
+19.07±2.09 years and 20.67±1.27 years
+respectively). All of them were students of a
+residential school for spiritual studies. A
+routine clinical examination showed that
+they all had normal health. Sleep disorders
+and allergic to the ambience of the morning
+weather were pre-set conditions for
+exclusion from the study. All participants
+expressed their willingness to participate in
+the experiment. The study protocol was
+explained to the subjects and their signed
+consent was obtained.
+Design
+Design
+Design
+Design
+Design
+Participants were assessed on day 1 (pre-
+assessment), day 10 (middle-assessment) and
+day 20 (post-assessment) of the intervention
+using digit letter substitution task and verbal
+and spatial memory test. The intervention
+was supervised by two senior faculty
+members of the school who also marked
+their daily attendance. The investigators
+were not aware of the groups which received
+the intervention and which was control till
+the data analysis was over as the data
+were coded. Hence, it was a single blind
+Randomized Control Trial.
+Assessments
+Assessments
+Assessments
+Assessments
+Assessments
+Digit-Letter Substitution Task (DLST)
+The digit-letter substitution task
+comprised of a worksheet on which digits (1
+to 9) were arranged randomly in 12 rows
+and 8 columns (10). An instruction key for
+“letter-for-digit” substitution was given at the
+top. Participants were required to make as
+many letter-for-digit substitutions as possible
+in 90 seconds. They were asked to choose
+any of the two possible strategies, i.e.,
+marking all nine digits in the random order
+they occurred, or selecting any one digit at
+a time. Also, they were free to follow a
+horizontal, vertical, or random path
+according to their choice. The total number
+of 
+substitutions 
+as 
+well 
+as 
+wrong
+substitutions was counted. The net scores
+were calculated by deducting wrong
+substitutions from the total substitutions
+attempted. Since the test was repeated thrice,
+(on day 1, day 10 and day 20), to prevent retest
+effect three separate sheets were prepared
+by changing the digit-letter pairs in the key
+and by randomly changing the sequence of
+digits in the working section (11).
+Verbal and Spatial Memory Test
+The verbal and spatial memory tests (12)
+were conducted by projecting the test
+material on a screen, allowing 10 sec. for
+each slide. After the 10 slides were shown,
+a mathematical problem (e.g., + 8 – 4 + 9 – 3
++ 6 – 5 – 7 + 2) was projected. Immediately
+after this, the subjects were asked to recall
+and write down (or in the case of spatial
+memory, to draw) within 60 sec. the 10 test
+items which were shown to them. For the
+verbal memory test standard nonsense
+syllables of three letters, e.g., XOL, were
+selected from a prepared list (13). Three
+different sets of 10 nonsense syllables were
+presented on Day 1, Day 10 and Day 20. The
+test for spatial memory consisted of 10 simple
+line drawings. Geometrical or other shapes
+which cannot be described verbally, e.g., a
+square or a circle, were not used. As
+described for verbal memory, there were
+three separate, similar sets of 10 line
+drawings used for Day 1, Day 10 and Day 20
+to overcome the learning effect due to
+repeated measurements.
+340
+Kumaran et al
+Indian J Physiol Pharmacol 2012; 56(4)
+Interventions
+Interventions
+Interventions
+Interventions
+Interventions
+The early rising (Brahma-muhurtha) group
+The participants were asked to rise at
+Brahma-muhurtha, i.e., before 4:30 am based
+on traditional Indian astrological calculations
+(Jyothishya) and sleep at 9:00 pm. As
+described else-where, Vishnu smriti, an
+ancient Indian text describes Brahma-
+muhurtha as forty eight minutes before sun
+rise which is the sacred time to rise in the
+morning (3).
+The late rising (control) group
+The participants were asked to wake up
+at 7:00 am and sleep at 11:30 pm. This was
+decided based on (i) astrological calculations
+(48 minutes after sunrise) as well as (ii)
+based on the subjective reports of the time
+of rising normally (7:00 am) at home before
+joining the residential school.
+Participants were acclimatized for a week
+to follow the timing of waking and sleeping
+based on the intervention. Both groups
+followed this routine for twenty days
+regularly. There were no differences in the
+routine activity except their waking and
+sleeping time. Their classes and other
+activities were adjusted according to waking
+time. The early rising group had time for
+self-study in the morning (i.e., 5:00 am – 7:00
+am) whereas late rising group had in the
+night (i.e., 9:30 pm – 11:30 pm). The total
+number of hours slept was same (7 hours 30
+minutes) for both the groups.
+Data analysis
+Data analysis
+Data analysis
+Data analysis
+Data analysis
+Statistical analysis was done using SPSS
+(Version 16.0). Repeated measures analysis
+of variance (RM ANOVA) were performed
+with one ‘within subject’s factor’ (assessments,
+i.e., Day 1, Day 10 and Day 20) and one
+between subjects factor (groups i.e. Brahma-
+muhurtha and control group). The interaction
+between assessments and groups was also
+analyzed. This was followed by a post hoc
+analysis with Bonferroni adjustment for
+multiple comparisons (day1, day 10, and day
+20). All comparisons were made with
+respective day 1 values.
+RESULTS
+For both digit letter substitution task and
+verbal and spatial memory tasks, the
+assessments were made on day 1 (pre-
+assessment), day 10 (middle-assessment) and
+day 20 (post-assessment) of the intervention.
+The group means and standard deviations
+for scores obtained in the digit-letter
+substitution task, and the verbal and spatial
+memory tasks taken on day 1, day 10 and
+day 20 in both groups (Brahma-muhurtha and
+control) are presented in Table I & Table II
+respectively.
+Digit Letter Substitution Task (DLST)
+The repeated measures analysis of
+variance (RM ANOVA) followed by post hoc
+tests for multiple comparisons were
+performed with Bonferroni adjustment and
+all comparisons were made with the
+respective day 1 values. The RM ANOVA
+for the net scores showed a significant
+difference in the within-subjects factor i.e.,
+assessments (day 1, day10 and day 20)
+[F=9.557, df=(1.812, 94.212), hence P<0.001],
+while the between-subjects factor i.e., groups
+(Brahma-muhurtha and Control) and the
+Indian J Physiol Pharmacol 2012; 56(4)
+Effect of Early Rising on Attention & Memory
+341
+interaction between the assessments and
+groups were not significantly different. The
+post hoc analysis with Bonferroni adjustment
+for Brahma-muhurtha group showed that
+there was a significant increase in net score
+(P<0.05) on day 20 as compared day 1 values.
+The other comparisons with in the group
+were not significant, while the control group
+showed no change.
+Verbal and Spatial Memory
+The repeated measures analysis of
+variance (RM ANOVA) followed by Post hoc
+tests for multiple comparisons were
+performed with Bonferroni adjustment and
+all comparison were made with the respective
+day 1values. The RM ANOVA showed a
+significant difference in the within-subjects
+factor i.e., assessments (day 1, day 10 and
+day 20) for both verbal [F=51.372, df = (1.908,
+99.206), hence P<0.001] as well as spatial
+memory scores [F=21.670, df = (1.812,
+94.230), hence P<0.001]. The between-
+subjects factor i.e., groups (Bramha-
+muhurtha and Control) and the interaction
+between the assessments and groups were
+not significantly different. The post hoc
+analysis with Bonferroni adjustment for
+Brahma-muhurtha group showed significant
+increase in verbal memory scores on day 10
+(P<0.01) and on day 20 (P<0.001) compared
+to day 1 values. Similarly, spatial memory
+scores showed an increase on day 10 (P<0.01)
+and on day 20 (P<0.01) compared to day 1
+values. In control group there was a
+significant increase in verbal memory scores
+on day 20 (P<0.001) compared to day 1
+TABLE I :
+Total score, net score and score for wrong substitution in a digital letter substitution
+task in Brahma-muhurtha (Early rising) group and control (Late rising) group recorded
+on day 1, Day 10 and Day 20. Values are group mean±SD.
+Brahma-muhurtha Group
+Control Group
+Variables
+(Early rising group)
+(Late rising group)
+Day 1
+Day 10
+Day 20
+Day 1
+Day 10
+Day 20
+Total Score
+56.78±11.76
+58.04±10.12
+61.52±9.80*
+56.70±8.36
+56.63±8.91
+59.15±7.09
+Score for wrong
+1.59±1.58
+2.19±1.76
+1.96±1.74
+1.48±1.48
+1.04±1.35
+1.15±1.32
+Substitution
+Net Score
+55.15±10.98
+55.96±9.89
+59.52±8.98*
+55.22±8.31
+55.59±8.88
+58±6.77
+*P<0.05, RMANOVA with Bonferroni adjustment comparing Day 10 and Day 20 values with respective
+Day1 values.
+TABLE II :
+Scores for verbal and spatial memory tasks in Bramha-muhurta group and control
+group recorded on Day 1, Day 10 and Day 20. Values are group mean±SD.
+Brahma-muhurtha Group
+Control Group
+Variables
+(Early rising group)
+(Late rising group)
+Day 1
+Day 10
+Day 20
+Day 1
+Day 10
+Day 20
+Verbal memory
+3.67±2.00
+4.96±1.89**
+6.48±1.60***
+3.41±1.62
+4.00±1.62
+5.52±1.60***
+Spatial memory
+4.44±1.63
+5.82±1.59**
+6.07±1.64**
+4.11±1.74
+5.11±1.25*
+5.78±1.39**
+*P<0.05, **P<0.01, ***P<0.001; RM ANOVA with Bonferroni adjustment comparing Day 10 and Day 20
+values with respective Day1 values.
+342
+Kumaran et al
+Indian J Physiol Pharmacol 2012; 56(4)
+values. Whereas, spatial memory scores
+increased on day 10 (P<0.05) and day 20
+(P<0.01) compared to day 1 values.
+DISCUSSION
+Rising early in the morning (during
+Brahma-muhurtha) for twenty days as a
+routine has improved the performance in a
+task requiring attention & concentration.
+Also, there was a significant improvement
+in the performance related to verbal and
+spatial memory task. The control group
+(which got up after sunrise) showed no
+change in the digit-letter substitution task,
+while the ability to recall has improved.
+It is evident from the earlier studies that
+circadian rhythm has a direct influence on
+the performance of an individual across the
+day (1). Rising early in the morning though
+has been a conventional practice over
+generations, earlier studies suggested diverse
+effects. While individuals who woke up early
+in the morning as an inevitable option (due
+to job requirements) demonstrated adverse
+effects in their performance (6), two separate
+studies mentioned below demonstrated
+enhanced performance in a memory task.
+A recent study in an elderly population
+showed better performance in a memory task
+in the morning hours (9). Similar results
+were observed in healthy adults in an earlier
+study (15). The results of the present study
+are in line with the observations made in
+the above mentioned studies, suggesting an
+improvement in both verbal and spatial
+memory task in both groups. Hence, it is
+evident from the present study that
+irrespective of the time of waking (before or
+after sunrise), early mornings have been
+shown to improve an individual’s ability to
+recall. The changes observed (improvement
+/better performance) in the morning can be
+attributed to (i) reduced distractibility, (ii)
+process of memory consolidation following
+overnight sleep and ready for registering new
+information and (iii) enhanced ability to
+recall. As the day progresses combination of
+factors have been shown to reduce an
+individual’s performance in tasks requiring
+memory (15).
+While the performance in memory
+improved in both groups, the performance
+in a task requiring attention improved only
+in the group which got up before sunrise.
+Since attentional processes involve different
+components such as phasic alertness,
+selective attention and vigilance (sustained
+attention, concentration), attempts were
+made to understand the influence of
+circadian rhythm on these processes. An
+earlier study in female undergraduate
+students reported a clear influence of time
+of the day (morning till night) on different
+performance oriented tasks requiring
+attention. The performance was best in the
+morning and the same deteriorated as the
+day progressed (14).
+The digit-letter substitution task used in
+the present study involved (i) focused
+attention (ability to respond discretely to
+specific stimuli), (ii) sustained attention
+(ability to maintain a consistent behavioral
+response during continuous and repetitive
+activity) and (iii) selective attention (ability
+to maintain a cognitive set in the face of a
+distracting or competing stimuli). Hence,
+changes seen in the net scores in the
+Brahma-muhurtha group can be attributed
+to complex interplay of physiological
+Indian J Physiol Pharmacol 2012; 56(4)
+Effect of Early Rising on Attention & Memory
+343
+mechanisms related to circadian rhythms.
+While a positive relationship between
+sympathetic tone and the attentional
+processes is well understood, (06) another
+study reported heightened sympathetic tone
+early in the morning (17). It can be
+speculated that along with a suitable external
+environment (of the early morning) for
+enhancing attentional activities, physiological
+mechanisms as well might have contributed
+favorably to produce the positive results seen
+in the present study.
+The group which got up during Brahma-
+muhurtha had done so volitionally as their
+routine was anyway going to change as the
+students had just joined a residential school,
+where they were expected to follow a routine
+including rising before sunrise. Whereas the
+group which got up after sunrise continued
+their regular timing of rising (7 am) which
+they were used to at their homes before
+joining the residential school. Hence, the
+results of the present study indicate the
+positive influence of early morning
+awakening as a routine, volitionally.
+The two major benefits demonstrated in
+the present study included an improved
+attention and aspects of memory. Since
+memory and attention span plays a major
+role in academic performance, it will be
+beneficial to apply the concept of early
+morning awakening in a student population.
+It is also speculated that slow learners and
+children with attention deficit hyperactive
+disorder can get benefited from such an
+intervention. In general, early morning
+awakening has shown to influence higher
+brain functions, hence it would be a good
+discipline and a lifestyle modification
+applicable to larger population including
+different age groups and gender. However,
+involving male subjects alone has been a
+limitation of the present study. It would be
+useful to conduct further research involving
+females and individuals belonging to different
+age groups. Perhaps, a cross sectional study
+in individuals who habitually get up early in
+the morning (long term) versus those who
+get up late would add additional value. Also,
+understanding the therapeutic benefits of
+such an intervention would be of great
+application.
+Further studies are required to
+understand the underlying mechanisms as
+well as its reproducibility not only in
+individuals who are early risers, but also in
+the late owls.
+REFERENCES
+1.
+Halberg F, Good R, Levine H. Some Aspects of
+the Cardiovascular and Renal Circadian Systems.
+Circulation 1966; 34: 715–717.
+2.
+Swami Sivananda. Yoga in daily life. Himalayas,
+India: A Divine Life Society Publication; 1999.
+3.
+Dutt MN. Vishnusmrti. Delhi: Parimala Publication;
+1997.
+4.
+Swami Sivananda. The Science of Pranayama.
+Himalayas, India: A Divine Life Society Publication;
+1997.
+5.
+Rama B. Astanga Sangraha of Vagbhata.
+Varanasi: Chaukhambha Visvabharathi; 2006.
+Chapter: 3, page: 34.
+6.
+De Mello MT, Esteves AM, Pires ML, et al.,
+Relationship between Brazilian airline pilot
+errors and time of day. Braz J Med Biol Res
+2008; 41: 1129–1131.
+7.
+Kecklund G, Akerstedt T, Lowden A. Morning
+work: effects of early rising on sleep and
+alertness. Sleep 1997; 20: 215–223.
+344
+Kumaran et al
+Indian J Physiol Pharmacol 2012; 56(4)
+8.
+Clodoré M, Benoit O, Foret J, et al., Early rising
+or delayed bedtime: which is better for a short
+night’s sleep ? Eur J Appl Physiol Occup Physiol
+1987; 56: 403–411.
+9.
+Martini B, Buffington AL, Welsh-Bohmer KA,
+Brandt J. Time of day affects episodic memory
+in older adults. Neuropsychol Dev Cogn B Aging
+Neuropsychol Cogn 2008; 15: 146–164.
+10. Natu MV, Agarwal AK. Digit letter substitution
+test (DLST) as an alternative to digit symbol
+substitution test (DSST). Hum Psycopharmacol
+Clin Exp 1995; 10: 339–343.
+11. Agarwal AK, Kalra R, Natu MV, Dadhich AP,
+Deswal RS. Psychomotor performance of
+psychiatric inpatients under therapy: assessment
+by paper and pencil tests. Hum Psychopharmacol
+2002; 17: 91–93.
+12. Manjunath NK, Telles S. Spatial and verbal
+memory test scores following yoga and fine arts
+camps for school children. Indian J Physiol
+Pharmacol 2004; 48: 353–356.
+13. Baddeley AD. Your memory – a user’s guide.
+New York: Avery; 1993.
+14. Valdez P, Ramírez C, García A, Talamantes J,
+Armijo P, Borrani J. Circadian rhythms in
+components of attention. Biol Rhythm Res 2005;
+36: 57–65.
+15. Mathur K, Bhattachara SK. Time-of-day dependent
+performance efficiency in student nurses. J Hum
+Ergol 1991; 20: 67–75.
+16. Cacioppo JT, Tassinary LG. Principles of
+Psychophysiology. Cambridge: Cambridge University
+Press; 1990.
+17. Kamath MV, Fallen EL. Diurnal variations of
+neurocardiac rhythms in acute myocardial
+infarction. Am J Cardiol 2001; 68: 155–160.
diff --git a/subfolder_0/Immediate Effect of Mind Sound Resonance Technique_unlocked.txt b/subfolder_0/Immediate Effect of Mind Sound Resonance Technique_unlocked.txt
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index 0000000000000000000000000000000000000000..7f295301dc22d3dda6915214c0cdb447e9c1227e
--- /dev/null
+++ b/subfolder_0/Immediate Effect of Mind Sound Resonance Technique_unlocked.txt	
@@ -0,0 +1,264 @@
+See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/301204063
+IMMEDIATE EFFECT OF MIND SOUND
+RESONANCE TECHNIQUE (MSRT- A YOGIC
+RELAXATION TECHNIQUE) ON COGNITIVE
+FUNCTIONs IN TYPE 2 DIABETES
+Article · June 2015
+READS
+7
+1 author:
+Kashinath Metri
+SVYASA Yoga University
+13 PUBLICATIONS   13 CITATIONS   
+SEE PROFILE
+Available from: Kashinath Metri
+Retrieved on: 27 July 2016
+44  |  Voice of Research, Vol. 4 Issue 1, June 2015, ISSN 2277-7733
+Diabetes is a metabolic disorder characterized by chronic elevated
+blood sugar levels. In the long run it it leads to multi-organ
+dysfunction like, heart, brain, kidneys, eyes, blood vessels,etc1.
+Many studies have demonstrated that diabetes poor cognitive
+functioning in terms of reduced, memory concentration,
+processing speed etc2. Diabetic patients are . Yoga is one of the
+ancient sciences. It was discovered and practiced by ancient Indian
+sages for the higher purposes of life like, self realization and
+achiement of super-natural powers called siddhi’s. Recent
+scientific studies on yoga revealed its healing secret in various
+health conditions such as diabetes3, hypertension4,
+cardiovascular disease5, parkinson’s disease6 etc. Yoga is also
+known to have a positive influence on psychological conditions
+like anxiety7, depression8, schizophrenia9 etc.
+MSRT: Mind sound resonance technique is one of  the
+mindfulness based relaxation techniques, in which resonance
+is generated by chanting the mantras. It leads to deep relaxation
+of the mind and body. Practice of MSRT enhances the
+relaxation, , wellbeing, will power etc10. It is known to reduce
+state anxiety, pain, tenderness and disability in patient with
+chronic low back pain11. In a another study MSRT reduced
+state anxiety and improved cognitive performance immediately
+after the practice in patient suffering from generalized anxiety
+disorder.12 This study was aimed to see the immediate effect of
+MSRT on cognitive functions in patients of type 2 diabetes.
+Method: Fourtythree subjects (18 male) with an age range
+between 30 to 65 (mean ± SD = 56.83 ± 12.54), suffering from
+diabetes type 2, since last minimum 5 years, were enrolled in
+this study [see table 1].
+Table 1: Demographic detail of the patients
+All the subjects were on anti-diabetic medication. Subjects had
+no previous expose to MSRT practice and were given one week
+of orientation to MSRT practice before the study. On7the day
+subjects were administered DLST before and immediately after
+the MSRT intervention.
+Measures: The digit letter substitution task (DLST): This test
+was developed from the Digit Symbol Substitution Test
+(DSST) as one of the subsets of the Wechsler intelligence scale.
+Substitution tests are essentially speed-dependent tasks that
+require the subject to match particular signs and symbols, digits
+or letters to other signs within a specified time period (90 s).13
+Substitution tasks involve visual scanning, mental flexibility,
+sustained attention, psychomotor speed and speed of
+information processing. DLST is a valid tool for assessing
+neuro-psychiatric illnesses and has been standardized for the
+Indian population14. Assessment: All assessments were
+performed on an empty stomach between 6:30 pm and 7:00
+pm. MSRT session was given in the supine position for 30
+min in a dark, quiet room. A pre-recorded audio-tape was used
+to give the MSRT instructions.
+Intervention: MSRT is one of the advanced yoga-based mindful
+relaxation techniques that involves experiencing with closed
+eyes the internal vibrations and resonance developed while
+counting the syllables A, U, M, Om and Mahamrityunjayamantra
+sounds. The details of MSRT practice, including the steps
+involved are described elsewhere.
+Data analysis: All statistical analysis was performed using
+the Statistical Package for Social Sciences (SPSS version 10.0).
+data was found normally distributed by the Shapiro-Wilcox
+test. The Paired sample t test was applied to find the pre-post
+changes.
+Result: There was significant improvement in total score (p =
+0.001; +24.99%) and net score (p = 0.001; +25.47%) of DLST
+[see table 2].
+IMMEDIATE EFFECT OF MIND SOUND RESONANCE TECHNIQUE (MSRT- A YOGIC
+RELAXATION TECHNIQUE) ON COGNITIVE FUNCTIONs IN TYPE 2 DIABETES
+Subarna Mohanty
+Yoga Therapist, S-VYASA University, Bangalore
+Kashinath Metri
+Assistant Professor, S-VYASA University, Bangalore
+Nagaratna R.
+Chief Medical Officer, Arigyadhama, S-VYASA University, Bangalore
+Nagendra H. R.
+Chancellor, S-VYASA University, Bangalore
+Abstract
+Diabetes is one of the chronic medical conditions with high prevalence rates. Long standing diabetes is associated with impaired cognitive functioning.
+Yoga is known to improve the cognitive functions in normal and many health conditions. Mind Sound Resonance Technique (MSRT) is one of  the
+mindfulness based yogic relaxation technique, know to enhance cognitive functions. The objective comprised to study the immediate effect of MSRT
+practice on cognitive functions in patient with type 2 diabetes. Forty three (18 male) type 2 diabetes patients with an age range between 30 to 65 (mean
+age ± SD = 56.83 ± 12.54) with minimum history of  diabetes since last 5 years, were enrolled in this study. All the subjects underwent training of
+15 sessions of  MSRT practice in 6 days. DLST test was used to assess psychomotor speed, which involves visual scanning, mental fl exibility,
+sustained attention, psychomotor speed and speed of information processing. On 7th day subjects were administered DLST before and immediately after
+the 30 minutes of MSRT intervention. Data was found normally distributed by Shapiro-Wilcox test. The paired sample t test was used to see the pre-
+post changes. There was significant improvement in total score (p = 0.001; +24.99%) and net score (p = 0.001; +25.47%) along with a
+nonsignificant decrease in wrong attempts (p- 0.855) of DLST. Present pilot study indicates that MSRT may have a potential role in enhancing
+psychomotor performance in patients suffering from diabetes, immediately after the practice. These findings need confirmation from studies with a
+larger sample size and randomized controlled design, which will be implicated in the future.
+Keywords: Mind sound resonance technique; psychomotor performance; diabetes, mindfulness, cognitive function.
+Voice of  Research
+Volume 4, Issue 1
+June 2015
+ISSN 2277-7733
+MIND SOUND RESONANCE TECHNIQUE
+Sr no 
+Gender 
+Number 
+Age (years) 
+1 
+Male 
+18 
+56.76 
+2 
+Female 
+25 
+57.00 
+3 
+Total 
+43 
+56.83 
+Voice of Research, Vol. 4 Issue 1, June 2015, ISSN 2277-7733 |  45
+Table 2: Details of Pre and Post test Scores
+TA=Total attempt, NA=Net attempt, WA=Wrong attempt, a
+paired sample t test, ** significance level at 0.001
+Graph 1: Graph showing changes mean score of DLST, before and
+immediately after the practice of MSRT
+Discussion: This study was aimed to see the immediate effect
+of MSRT on cognitive functions in patients with type 2 diabetes,
+at the end of  the study, we observed the significant
+improvement in total and net score of DLST. In one of the
+recent study on immediate effect of MSRT on state anxiety and
+psychomotor performance in patient with generalized anxiety
+disorder has shown to enhance psychomotor performance as
+compared to supine rest15. In another randomized controlled
+study, MSRT intervention, given daily for 10 days, was found
+useful in reducing the state anxiety in patients suffering from
+chronic neck pain.. In this study16.
+The results of this study are also in support of findings of
+previous studies. Possible mechanism behind these findings,
+after the practice of MSRT may be because, Yoga known to
+improve autonomic functions via triggering neurohormonal
+mechanisms that suppress sympathetic activity through down-
+regulation of thehypothalamic–pituitary–adrenal axis17 and
+mindfulness-based practices are predicted to enhance cognitive
+flexibility18.The strengths of the study are: (a) This
+multidisciplinary study encompasses the fields of yogic science,
+psychology and diabetology; (b) due to the short duration of
+yoga intervention, acceptability and adherence to therapy was
+good; and (c) as MSRT was delivered through a standard
+protocol, it could be reproduced in the exact way for all cases.
+Small sample size and lack of control group are the most
+important limitations of the study. This study was a pilot
+project to assess the response to MSRT in a small patient
+population to plan for a better study with a much higher sample
+size and better design in the future. There is a lack of objective
+variables to understand the mechanism of action of MSRT at
+the electro-physiological, neurological and biochemical levels.
+Future studies should include randomized controlled design
+with a larger sample size along with objective variables of
+autonomic functions such as heart rate variability nerve
+conduction velocity, biomarkers such as blood sugar level.
+Conclusion: The Present pilot study indicates that MSRT may
+have a potential role in enhancing cognitive functionings in
+patients suffering from type 2 diabetes, immediately after the
+practice. These findings need confirmation from studies with a
+larger sample size and randomized controlled design, which
+will be implicated in the future.
+References
+1Diagnosis and Classification of Diabetes Mellitus.American
+Diabetes Association.Diabetes Care January 2008 vol. 31
+no. Supplement 1 S55-S60
+2Journal of Clinical and Experimental Neuropsychology.The
+Relationship between Impaired Glucose Tolerance, Type 2
+Diabetes, and Cognitive Function.Volume 26, Issue 8,
+2004. Nesrine Awada, Michèle Gagnonb & Claude Messier.
+pages 1044-1080
+3Sharma R, Amin H, Prajapati PK. Yoga: As an adjunct therapy
+to trim down the Ayurvedic drug requirement in non
+insulin-dependent diabetes mellitus. Anc Sci Life. 2014 Apr-
+Jun;33(4):229-35
+4Tolbaños Roche L, Mas Hesse B.Application of an integrative
+yoga therapy programme in cases of essential arterial
+hypertension in public healthcare.Complement Ther Clin
+Pract. 2014 Nov;20(4):285-90.
+5Yadav A, Singh S, Singh K, Pai P. Effect of yoga regimen on
+lung functions including diffusion capacity in coronary artery
+disease patients: A randomized controlled study. Int J Yoga.
+2015 Jan;8(1):62-7.
+6Sharma NK, Robbins K, Wagner K, Colgrove YM. A randomized
+controlled pilot study of the therapeutic effects of yoga in
+people with Parkinson’s disease.Int J Yoga. 2015 Jan;8(1):74-9.
+7Dhansoia V, Bhargav H, Metri K. Immediate effect of mind
+sound resonance technique on state anxiety and cognitive
+functions in patients suffering from generalized anxiety
+disorder: A self-controlled pilot study.Int J Yoga. 2015
+Jan;8(1):70-3
+8Klainin-Yobas P1, Oo WN, Suzanne Yew PY, Lau Y.Effects
+of relaxation interventions on depression and anxiety
+among older adults: a systematic review. Aging Ment Health.
+2015;9:1-13
+9Ikai S, Suzuki T, Uchida H, Saruta J, Tsukinoki K, Fujii Y,
+Mimura M. Effects of weekly one-hour Hatha yoga therapy
+on resilience and stress levels in patients with schizophrenia-
+spectrum disorders: an eight-week randomized controlled
+trial.J Altern Complement Med. 2014 Nov;20(11):823-30.
+10Nagendra HR. Mind Sound Resonance Technique. Bangalore:
+Swami Vivekananda Yoga Prakashana; 2001. p. 51
+11Yogitha B, Nagarathna R, John E, Nagendra H. Complimentary
+effect of yogic sound resonance relaxation technique in
+patients with common neck pain. Int J Yoga 2010;3:18-25
+12Dhansoia, V., Bhargav, H., & Metri, K. (2015). Immediate
+effect of mind sound resonance technique on state anxiety
+and cognitive functions in patients suffering from generalized
+anxiety disorder: A self-controlled pilot study.International
+journal of yoga, 8(1), 70.
+13 Sheridan LK, Fitzgerald HE, Adams KM, Nigg JT, Martel
+MM, Puttler LI, et al. Normative symbol digit modalities
+test performance in a communitybased sample. Arch Clin
+Neuropsychol 2006;21:23-8
+14 Pradhan B, Nagendra H. Normative data for the digit-letter
+substitution task in school children. Int J Yoga 2009;2:69-72.
+15Dhansoia, V., Bhargav, H., & Metri, K. (2015) . Immediate
+effect of mind sound resonance technique on state anxiety
+and cognitive functions in patients suffering from
+generalized anxiety disorder: A self-controlled pilot
+study.International journal of yoga, 8(1), 70.
+16 Pradhan B, Nagendra H. Normative data for the digit-letter
+substitution task in school children. Int J Yoga 2009;2:69-72
+17Vempati RP, Telles S. Yoga-based guided relaxation reduces
+sympathetic activity judged from baseline levels. Psychol
+Rep 2002;90:487-94.
+18Lee JK, Orsillo SM. Investigating cognitive flexibility as a
+potential mechanism of mindfulness in generalized anxiety
+disorder. J Behav Ther Exp Psychiatry 2014;45:208-16
+Sr No 
+ PreMean 
+± 
+SD 
+PostMean 
+± 
+SD 
+% change 
+Pa- Value 
+TA 
+40.41 ± 15.27 
+50.51 ± 15.57 
++ 24.99 
+<0.001** 
+WA 
+0.60 ± 1.8 
+0.67 ± 1.8 
++ 11.67 
+0.88 
+NA 
+39.53 ± 15.66 
+49.60 ± 15.90 
++ 25.47 
+<0.001** 
+MIND SOUND RESONANCE TECHNIQUE
diff --git a/subfolder_0/Immediate Effects of Yoga Breathing with Intermittent Breath Holding on Response Inhibition among Healthy Volunteers.txt b/subfolder_0/Immediate Effects of Yoga Breathing with Intermittent Breath Holding on Response Inhibition among Healthy Volunteers.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a158ff63597e3b83d320c1a2b3d2b46a4e0ee9db
--- /dev/null
+++ b/subfolder_0/Immediate Effects of Yoga Breathing with Intermittent Breath Holding on Response Inhibition among Healthy Volunteers.txt	
@@ -0,0 +1,344 @@
+Int J Yoga. 2018 May-Aug; 11(2): 99–104.
+doi: 10.4103/ijoy.IJOY_65_16
+PMCID: PMC5934957
+PMID: 29755217
+Immediate Effects of Yoga Breathing with Intermittent Breath Holding on
+Response Inhibition among Healthy Volunteers
+Apar Avinash Saoji, BR Raghavendra, SK Rajesh, and NK Manjunath
+Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samthana, Bengaluru,
+Karnataka, India
+Address for correspondence: Dr. Apar Avinash Saoji, Swami Vivekananda Yoga Anusandhana Samsthana,
+19, Eknath Bhavan, Gavipuram Circle, KG Nagar, Bengaluru - 560 019, Karnataka, India. E-mail:
+aparsaoji@gmail.com
+Received 2016 Oct; Accepted 2017 Jun.
+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:
+There is very little evidence available on the effects of yoga-based breathing practices on response
+inhibition. The current study used stop-signal paradigm to assess the effects of yoga breathing with
+intermittent breath holding (YBH) on response inhibition among healthy volunteers.
+Materials and Methods:
+Thirty-six healthy volunteers (17 males + 19 females), with mean age of 20.31 ± 3.48 years from a
+university, were recruited in a within-subject repeated measures (RM) design. The recordings for stop
+signal task were performed on three different days for baseline, post-YBH, and post yogic breath
+awareness (YBA) sessions. Stop-signal reaction time (SSRT), mean reaction time to go stimuli (go
+RT), and the probability of responding on-stop signal trials (p [r/s]) were analyzed for 36 volunteers
+using RM analysis of variance.
+Results:
+SSRT reduced significantly in both YBH (218.33 ± 38.38) and YBA (213.15 ± 37.29) groups when
+compared to baseline (231.98 ± 29.54). No significant changes were observed in go RT and p (r/s).
+Further, the changes in SSRT were not significantly different among YBH and YBA groups.
+Conclusion:
+Both YBH and YBA groups were found to enhance response inhibition in the stop-signal paradigm.
+YBH could be further evaluated in clinical settings for conditions where response inhibition is altered.
+Keywords: Breath awareness, breath holding, cognition, pranayama, stop-signal task, yoga,
+Kumbhaka
+Introduction
+Yoga is an ancient traditional Indian practice that has become popular in the recent years, due to its
+plausible effects on health. The original form of yoga consists of a system of ethical, psychological,
+and physical practices. Though it has an ancient origin, it transcends cultures and languages.[1] In the
+recent years, there has been a growing interest in the scientific community about the effects of yoga in
+health and disease. One of the key physiological domains, which seems to be influenced by yoga
+practices, is human cognition. There is a growing interest in understanding the effects of yoga practices
+in neurocognitive, psychology, and psychiatric settings.[2] Several studies indicate the beneficial
+effects of yoga practices on the cognitive abilities.[3,4,5,6]
+Pranayama or the yoga breathing practices find a special emphasis in the yogic tradition. A verse in
+Hatha Yoga Pradipika, a traditional text on yoga, describes “When breath moves, the mind moves.
+When breath is without movement, the mind also settles down. Thus, a yogi attains steadiness by
+retaining the breath.”[7] The yogic texts describe four phases of breathing, namely, inhalation (puraka),
+internal retention of breath (antarkumbhaka), exhalation (recaka), and external retention of breath
+(bahyakumbhaka), which are practiced in varying proportions. Although the practice of breath holding
+and its benefits is emphasized in the ancient texts of yoga,[7,8,9] not much is known about the effects
+of yoga breathing with intermittent breath holding (YBH). The limited existing evidence suggests
+beneficial effects of YBH on autonomic activities,[10] baroreflex sensitivity,[11] and metabolic
+functions.[12]
+However, there are no studies evaluating the effects of YBH on cognition. The earlier studies on other
+yoga breathing techniques show positive influence on cognitive tasks involving visual and auditory
+reaction times (RTs),[13,14] attention,[15] spatial memory,[16] working memory,[17] and response
+inhibition.[18] Considering the importance in the traditional texts for the practice of breath retention
+and positive influence of yoga breathing techniques on the cognitive abilities, we hypothesized that
+YBH may positively influence human cognition.
+Response inhibition is one of the most important aspects of cognition. It is defined as the ability to
+inhibit unwanted responses according to change in the environment.[19] It is affected in various
+conditions such as schizophrenia[20] and attention-deficit hyperactivity disorder (ADHD).[21] The
+stop-signal task (SST) has proved to be a useful tool for the study of response inhibition in cognitive
+psychology, cognitive neuroscience, and psychopathology.[22] In SST, individuals act upon a go RT
+task. On a random selection of the trials (stop-signal trials), a stop signal is presented, instructing them
+to withhold their go responses.[19] The ability to stop the ongoing motor responses in a split second is
+a vital element of response control and flexibility that relies on frontal–subcortical network.[23]
+Further, stop-signal paradigm allows a sensitive estimate of inhibitory control known as the stop-signal
+RT (SSRT), which reflects the time taken to internally suppress a response.[22] Studies have
+demonstrated that the medications for the treatment of ADHD enhanced SSRT in healthy volunteers.
+[24,25] Recently, SST paradigm has also been used to demonstrate an enhanced response inhibition
+using a specific type of yoga breathing on response inhibition.[18] Hence, the present study was
+designed to evaluate whether the practice of YBH could enhance the ability of response inhibition
+through enhanced ability to inhibit unwanted responses as assessed using the stop-signal paradigm.
+Materials and Methods
+Participants
+A total of seventy volunteers, who were undergoing various long-term courses in yoga at a residential
+Yoga University, Bengaluru, India, were screened, out of which 42 volunteers were selected for the
+study. The experience of practicing yoga ranged from 6 months to 5 years. The screening for the
+recruitment, performed by a trained physician, ruled out the use of medication, smoking, alcohol
+consumption, stress-related as well as psychological or cardiorespiratory ailments. Six volunteers
+dropped out for various reasons during the 8-week training in yoga breathing. Finally, 36 volunteers
+(17 males + 19 females) were assessed for the current study. Participants' age ranged from 18 to 25
+years with a mean age of 20.31 years (standard deviation [SD] = 3.48). All participants reported to
+have a normal or corrected vision and normal hearing. The assessment was performed for female
+participants during the ovulatory phase to minimize the effect of menstrual cycles on the performance
+in SST.[26] The study was approved by the Institutional Ethics Committee of the University.
+Participants were recruited after obtaining written informed consent.
+Design
+We executed a within-subjects repeated measures (RM) design wherein each participant was assessed
+in three conditions on three different days (baseline, YBH, and yoga breathing with breath awareness
+[YBA]). Random allocation was used to minimize the learning effect. The time of day was kept
+constant for all sessions for an individual (between 4 pm and 6 pm) since time of the day may influence
+the physiology of breath holding.[27] Each session lasted for approximately 40 min, other than baseline
+session in which participants visited laboratory only for the assessment duration of about 15 min. The
+SST was recorded after both the trial conditions (YBH and YBA). All participants underwent 8-week
+orientation in the breathing practice prior to the actual assessment. This orientation was administered to
+avoid the individual variations in the practice. Due to the residential nature of the university, all 36
+volunteers who underwent the final assessment had more than 90% attendance for the training sessions.
+Intervention
+During both the experimental conditions, the participants were asked to sit erect, with closed eyes and
+focusing the awareness on breathing. The YBH session included the regulated yogic breathing for 20
+min incorporating phases of inhalation (puraka), internal retention of breath (antarkumbhaka),
+exhalation (recaka), and external retention of breath (bahyakumbhaka) in a ratio of 1:1:1:1 for 6 s each.
+The schematic representation of the breathing practice is depicted in Figure 1. We chose the presented
+intervention from a classical training methodology of pranayama suggested in the text of yoga.[8] The
+intervals of 6 s were decided based on an earlier study.[10] The duration of 6 s was ensured through
+verbal cues in a prerecorded audio track. During the YBA session, the participants were seated erect,
+performing normal breathing with breath awareness for the same duration of 20 min in the same test
+environment, including the audible cues.
+Figure 1
+Schematic representation of one cycle of the practice of yoga breathing with intermittent breath holding
+Assessment
+We assessed the participants at baseline and following YBH and YBA sessions. On all the days of
+assessment, the participants were asked to avoid consumption of caffeine, as it may alter the cognitive
+abilities. The SST paradigm developed by Verbruggen et al.[28] was presented using the INQUISIT
+Millisecond software package 4.0 (Millisecond Software, LLC, Seattle, USA) on an Dell desktop
+computer with a 21.5” color monitor. The configuration of the computers on which the task was
+presented was kept the same to maintain the uniform processing speed. All participants received a
+practice session prior to the experimental sessions to familiarize with the SST and procedures. The
+experiment was conducted individually in a room under normal fluorescent lighting in the research
+laboratory.
+Stop-signal paradigm
+The stop-signal paradigm is based on the horserace model where response execution races with the
+inhibitory process to determine whether a response is inhibited.[28,29] The primary task is to perform a
+two-choice task in which participants had to react as quickly and accurately as possible to discriminate
+between a left and a right arrow, presented at the center of the computer screen, in white, on a black
+background. The participant was supposed to respond with the alphabets “D” (for left arrow) and “K”
+(for right arrow) on a keyboard with the left and right index fingers, respectively. On no-signal trials
+(go task), only the primary task stimulus is presented. On stop-signal trials (stop task), an auditory
+“stop signal” beep is presented at a variable delay (stop-signal delay [SSD]) following the go stimulus.
+Participants were instructed to inhibit their responses on the trials with a stop-signal beep. Tasks were
+presented randomly: go task (75%) and stop task (25%). SSD is initially set at 250 ms and is adjusted
+continuously with dynamically tracking procedure, depending on the performance of the participant.
+Successful inhibitions resulted in an increase of the SSD by 50 ms, whereas failed inhibitions resulted
+in a reduction of the SSD by 50 ms. This procedure ensured that, on an average, each participant in
+each session had a probability of successful inhibition approaching 50%.[28] A schematic
+representation of the SST has been illustrated in Figure 2 based on the work of Logan et al.[19] A total
+of 392 trials were presented, divided over six blocks of 64 trials, lasting 3 min each. Participants waited
+for 10 s between blocks before they start the next block. The primary outcome measure was SSRT, an
+estimate of the participant's capacity for inhibiting the unwanted motor responses. SSRT was calculated
+by subtracting mean SSD from mean RT to go stimuli (go RT). Additional measures of interest are the
+probability of responding on stop-signal trials (p [r/s]) and go RT. Figure 3 illustrates the major
+outcomes of the stop-signal paradigm based on the computer program developed by Verbruggen et al.
+[28]
+Open in a separate window
+Figure 2
+Schematic representation of the stop-signal paradigm. The stop-signal task consists of go and stop-signal
+trials. A circle is presented for 500 ms, followed by a presentation of an arrow pointing either left or right.
+Participants are instructed to respond as fast as possible by pressing a left or right button, depending on the
+direction of the arrow. In the stop trials, an auditory stop signal occurs after the presentation of the arrow,
+and on these trials, participants must try to withhold their responses. The latency to the sound (the stop
+signal delay) varies dynamically throughout the study to produce the stop-signal delay 50, where
+participants can inhibit approximately 50% of their responses. The stop-signal reaction time is calculated
+as the median go reaction time minus the stop-signal delay 50, according to the race model.[19] Image
+courtesy: Madsen et al., 2009[41]
+Figure 3
+Illustration of the probabilities of responding on stop-signal trials based on the horserace model (Logan
+and Cowan, 1984), given the distribution of no-signal reaction times (primary task reaction time), the stop-
+signal delay, and the stop-signal reaction time. Probability of responding on stop-signal trials is
+represented by the area under the curve to the left of the dashed line. Image courtesy: Verbruggen et al.,
+2008
+Data analysis
+RM analysis of variance (RM-ANOVA) followed by post hoc Bonferroni adjustment was done to
+compare data recorded at baseline and following YBH and YBA sessions, using SPSS software Version
+16.0 (SPSS INC., Chicago, USA). The alpha level was set at 0.05 to determine the significance in
+performance in SST in three states. Paired samples t-test was applied to the data while comparing the
+performance at the baseline to post-YBH and post-YBA, respectively.
+Results
+The group means and SDs for the conditions at baseline and following the YBH and YBA sessions are
+presented in Table 1. RM-ANOVA results have been described in Table 2 which showed a significant
+effect for SSRT F (2, 34) = 4.74, P = 0.015, partial η2 = 0.22, however thep (r/s) and go RT showed
+nonsignificant changes. Within-sessions analyses revealed significant reductions in SSRT following
+YBH (t(35) ≤1.89, P < 0.05) and YBA (t(35) ≤0.2.71, P < 0.05) conditions when compared to the
+baseline. There was no significant difference between the two breathing practices (t(35) ≤0.0.23, P ≥
+0.816). Pair-wise comparison revealed no significant difference in bothp (r/s) and go RT among the
+conditions.
+Table 1
+Group mean±standard deviation values for the stop-signal task
+Table 2
+Results of the repeated measures analysis of variance
+Discussion
+The current study was designed to ascertain whether the practice of YBH affects the response
+inhibition indicated through the performance in the SST. The findings indicate a significant reduction
+in SSRT following both YBH and YBA, which was in contrast to our initial hypothesis that YBH and
+YBA may have differential effects on response inhibition. We also could not elicit significant changes
+in thep (r/s) and the go RT in both interventions, when compared to the baseline.
+There was a significant reduction in SSRT, suggesting that the practice of YBH and YBA resulted in
+enhanced response inhibition.[22] Further, although statistically insignificant, participants slowed down
+the go responses following both the conditions, which may be due to proactive response strategy to
+achieve a balance between competing goals, suggesting a flexible cognitive control.[30] Our results are
+concurrent to an earlier study on yoga breathing using SST paradigm.[18] The enhanced SSRT and
+slowing down of go RT represent better inhibitory control. A study performed on yoga in prison
+population showed enhanced response inhibition in a go/no-go task.[31] Studies have shown similar
+effects through the administration of medications for ADHD in healthy volunteers.[24,25]
+The observed results may be attributed to relaxation and the autonomic balance attained through the
+practice, which is indicated in earlier studies on yoga breathings.[10,11] There was enhanced response
+inhibition following both YBH and YBA conditions. A blood oxygen level-dependent functional MRI
+study performed to understand neural correlates of the voluntary breath holding demonstrated activity
+at the bilateral network of cortical and subcortical structures including the insula, basal ganglia, frontal
+cortex, parietal cortex and thalamus, and pons.[32] Response inhibition in SST paradigm is mediated
+through roles of the prefrontal-caudate and striato-thalamic activities.[33] In addition, vagus nerve
+stimulation was found to enhance response inhibition in patients with epilepsy.[34] Therefore, we
+speculate that YBH may enhance the response inhibition through activation of cortical and subcortical
+brain areas as well as enhanced vagal tone due to slow breathing.
+Breath awareness is the basis for several meditation techniques including Vipasana, mindfulness, and
+Sudarshan Kriya Yoga. It is understood from the existing literature that being aware of breath could
+help in enhancing the physiological and cognitive functions to optimal levels through promotion of
+relaxation and enhanced self-awareness.[35] Thus, the results following the YBA session could be
+attributed to focused attention of the volunteers on breathing and the relaxation attained through it.
+Further studies incorporating neuroimaging techniques could reveal the exact mechanisms involved
+with neurocognitive modulation through yoga breathing techniques.
+Assessing the long-term effects of yoga breathing on response inhibition was beyond the scope of the
+present study. Since our study included population of healthy young adults, the results may not be
+generalized to clinical populations at this stage. Further studies may be taken up to understand how
+different yoga breathing practices may alter response inhibition. A major limitation of the present study
+was the inability to ascertain the exact mechanism of action for the observations. It would be
+interesting to add neuroimaging techniques to further studies, to understand the underlying mechanisms
+of action. Altered response inhibition is observed in patients with ADHDs,[36] schizophrenia,[37]
+epilepsy,[38] obsessive-compulsive disorders,[39] as well as stressful situations.[40,41] It would
+therefore be interesting to observe whether yoga breathing could influence the response inhibition in
+such population.
+Conclusion
+The present study indicated a positive impact of YBH on the SST indicating enhanced response
+inhibition among healthy volunteers. Future studies in clinical setting with neuroimaging techniques
+are warranted.
+Financial support and sponsorship
+Nil.
+Conflicts of interest
+There are no conflicts of interest.
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diff --git a/subfolder_0/Immediate effect of mind sound resonance technique (MSRT - a yoga-based relaxation technique) on blood pressure, heart rate, and state anxiety in i.txt b/subfolder_0/Immediate effect of mind sound resonance technique (MSRT - a yoga-based relaxation technique) on blood pressure, heart rate, and state anxiety in i.txt
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@@ -0,0 +1,371 @@
+Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd
+DE GRUYTER
+Journal of Complementary and Integrative Medicine. 2018; 20170177
+Short communications
+YuniWang1 / Kashinath G Metri1 / Amit Singh1 / NagaratnaRaghuram2
+Immediateeffect ofmind sound resonance
+technique(MSRT – a yoga-based relaxation
+technique)on blood pressure, heart rate, and
+state anxiety in individuals with hypertension: a
+pilotstudy
+1 SVYASA University, Bengaluru, India, E-mail: kgmhetre@gmail.com
+2 Holistic Health Center, SVYASA University, Bengaluru, India
+Abstract:
+Background: Mind sound resonance technique (MSRT) is a yoga-based relaxation technique. Previous stud-
+ies on MSRT demonstrated its potential health-benefiting effects in both clinical and nonclinical population.
+Present study intended to assess the acute effect of MSRT intervention on blood pressure, heart rate (HR), and
+state anxiety in patients with essential hypertension (HTN).
+Methods: Thirty participants (13 females) with HTN, within the age range 30–60 years (with mean±SD:
+57.23±11.3 years), who visited SVYASA University campus to attend 1-week residential yoga program for HTN
+treatment, were considered for this study based on inclusion and exclusion criteria. All participants received a
+4-day MSRT orientation sessions prior to the study. Each participant underwent 30-min session of both MSRT
+and supine rest (SR) on 2 successive days. Systolic and diastolic blood pressures, pulse rate, and state anxi-
+ety were measured before and immediately after both MSRT and SR sessions. Data were analyzed using SPSS
+version 16. Repeated-measure analysis of variance was applied to assess within-subjects changes.
+Results: After MSRT session, significant decrease in systolic blood pressure (SBP), diastolic blood pressure
+(DBP), HR, and state anxiety was observed compared to baseline. Similarly, after SR session, significant changes
+were found in HR and state anxiety. No significant change was seen in SBP and DBP following SR compared
+to SR session; MSRT session showed significantly better improvement in SBP, DBP, HR, and state anxiety.
+Conclusion: Present study demonstrated the usefulness of single session of MSRT in reducing blood pressure,
+HR, and state anxiety among individuals with HTN as compared to SR. These findings encourage the further
+studies with larger sample size and long-term intervention with a robust research design.
+Keywords: anxiety, blood pressure, hypertension, mind sound resonance technique
+DOI: 10.1515/jcim-2017-0177
+Received: December 21, 2017; Accepted: April 16, 2018
+Introduction
+Hypertension (HTN) is a major public health problem and a leading cause of mortality all over the world,
+particularly in developed and developing countries [1]. Prevalence of HTN varies from 13% to 40% across
+the globe. Overall global prevalence of HTN is found to be 26.4% [2]. Uncontrolled blood pressure in HTN is
+directly responsible for increased risk of heart disease, cerebrovascular disease, and renal disease [3]. Thus,
+optimal blood pressure control is the primary objective of HTN treatment.
+Relaxation techniques have significant impact on human physiology and psychology [4]. Many relaxation
+methods have been developed and tested for their therapeutic effects in several health conditions including
+HTN.
+Further, relaxation methods, such as Yoga nidra, massage, transcendental meditation, biofeedback-assisted
+relaxation, etc., have produced beneficial effects on stress response, which was indicated by a decrease in anxi-
+ety, blood pressure, heart rate (HR), galvanic skin resistance, serum cortisol level, and basal muscle tone [5–9].
+Kashinath G Metri is the corresponding author.
+© 2018 Walter de Gruyter GmbH, Berlin/Boston.
+1
+Brought to you by | Université de Strasbourg
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+Wang et al.
+DE GRUYTER
+In a study, 8 weeks of relaxation therapy in addition to medication produced significant decrease in systolic
+and diastolic blood pressures among participants with HTN [10]. Another study reported a significant decrease
+in systolic and diastolic blood pressures following 2 weeks of transcendental meditation [11].
+Yoga is a form of alternative and complementary interventions [12]. Yoga consists of Asians, pranayama, med-
+itation, and relaxation techniques [13]. Previously, several randomized controlled studies have confirmed the
+beneficial effects of yoga intervention in HTN [14, 15].
+Table 1: Characteristics of participants.
+Variables
+n=30
+Age (average)
+57.23±11.3
+Gender distribution
+F=13, M=17
+Educational status (years)
+15±2.3
+Mean history of HTN (in years)
+8±3.8
+Type of antihypertensive medica-
+tion score and no. of participants
+• ACE inhibitors −16
+• CCB – 9
+• Alpha channel blockers – 3
+• Betablocker – 2
+Table indicates the number of males/females, average age, mean duration or HTN history, and number of participants on different kinds
+of antihypertensive medications. ACE – angiotensin-converting enzyme; CCB – calcium channel blockers.
+Table 2: Pre–post changes in mean and SD in all variables following MSRT and SR sessions.
+MSRT
+SR
+MSRT vs SR
+Variable
+Pre
+Post
+ES
+Pre
+Post
+ES
+p-Value
+ES
+HR
+(bpm)
+81.90±9.6
+75.93±8.2b
+0.67
+80.67±8.8
+78.21±9.3a
+0.27
+0.198
+0.27
+SBP
+(mmHg)
+139.37±14.7
+132.43±15.6b
+0.47
+138.43±12.4
+137.83±11.2
+0.04
+0.017a
+0.34
+DBP
+(mmHg)
+81.03±7.2
+76.83±7.1b
+0.58
+80.53±9.1
+79.03±8.3
+0.16
+0.047a
+0.31
+STAI-
+score
+40.83±8.6
+33.53±7.5b
+0.90
+40.43±8.4
+37.37±9.3b
+0.36
+0.003b
+0.51
+MSRT – mind sound resonance technique; SR – supine rest; HR – heart rate; SBP – systolic blood pressure; DBP – diastolic blood pressure;
+STAI – State Anxiety Inventory; b Statistical significance level at 0.001 level; a Statistical significance level at 0.001 level; ES – effect size.
+Mind sound resonance technique (MSRT) is a yoga-based relaxation technique. MSRT involves chanting of
+syllable A, U, M, AUM, OM, and Mahamrityunjaya Mantra loudly followed by mental chanting. Loud chanting
+of mantra produces a resonance in the body and individual experiences the deep relaxation state and a sense
+of calmness [16].
+Previous studies found that the practice of MSRT improves stress, anxiety, depression, self-esteem, and
+blood pressure and HR in clinical and nonclinical population [17, 18].
+The present study examined the acute effects of a single session of MSRT on blood pressure, HR, and state
+anxiety among hypertensive subjects by comparing with supine rest (SR) session.
+Materials and methods
+Study participants
+Participants were individuals with HTN within the age range between 30 and 60 years, who visited holistic
+health center of SVYASA University for the treatment of HTN during June–November 2017. Diagnosis criteria
+for HTN were participants taking antihypertensive medication after diagnosis by family physician.
+All the participants were on antihypertensive medication for the last 5 years (See Table 1).
+2
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+DE GRUYTER
+Wang et al.
+Inclusionand exclusioncriteria
+Individual with HTN within the age range 30–60 years, on regular antihypertensive medications, with history
+of HTN ≥5 years, both male and female subjects, and willing to participate in the study were considered for
+the study.
+Participants with resistance HTN (uncontrolled HTN, on more than two antihypertensive medications), car-
+diac arrhythmia, chronic respiratory problems (e.g. history of asthma, Chronic Obstructive Pulmonary Disease
+(COPD), etc.), acute musculoskeletal pain, and any kind of mental health ailments were excluded from the
+study.
+Thirty participants (13 females) recruited for the study. The mean age of the participants was 57.23±11.3
+years.
+Ethical clearance
+Study was approved by the institutional project evaluation committee of SVYASA University. All participants
+signed the consent form prior to the study commencement.
+Procedure
+Participants were recruited for the study using no-probability sampling method (snowball method).
+First, 15 participants received MSRT intervention on day 1 and SR intervention on day 2, and later, 15 par-
+ticipants received SR on day 1 and MSRT on day 2.
+Self-as-control design was followed. All subjects received both MSRT and SR intervention on 2 consecutive
+days.
+All the participants received a 4-day MSRT training sessions prior to the study.
+Assessments were done before and immediately after interventions using standard assessment instruments.
+Assessments
+Study was done in the morning session between 10 and 11 am after 2 h of breakfast. Participants were instructed
+to not have tea/coffee or any kind of food after breakfast till completion of the intervention. Both MSRT and SR
+sessions were given in supine position in a dark and quiet room. Around 50% of participants (15 participants)
+were administered MSRT intervention on day 1 and SR on day 2. Another 50% of participants were administered
+SR on day 1 and MSRT on day 2.
+Assessments were performed before and immediately after for both the interventions. Blood pressure and
+HR were recorded after 5 min of SR, and then, state anxiety inventory was administered.
+Cardiac variables
+Systolic blood pressure (SBP), diastolic blood pressure (BP), and HR were assessed using Omron HEM-7113
+digital BP-measuring device. Omron HEM-7113 is a valid and reliable instrument to measure blood pressure
+and HR [19].
+State anxiety
+State anxiety was assessed before and immediately after both the interventions using Spielberger’s State Anx-
+iety Inventory (STAI; From X-1). STAI is considered to be a valid, reliable, and sensitive inventory with high
+internal consistency, with Cronbach’s alfa of 0.86 for the total scores [20].
+Intervention
+MSRT is a yoga-based relaxation technique.
+MSRT involves chanting of syllables A, U, M, Om, and Mahamrityunjaya mantra loudly and mentally in
+supine position. The stepwise details of MSRT practice are mentioned elsewhere [21].
+3
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+DE GRUYTER
+Data analysis
+Data were analyzed using SPSS version 16 (IBM, Armonk, NY, USA). Data were presented as mean and SD.
+Repeated-measure analysis of variance (RM-ANOVA) with two within-subjects factors, i.e., session (MSRT and
+SR) and states (pre and post), was followed by post hoc tests for multiple comparisons with Bonferroni correction.
+Figure 1: Pre–post changes in heart rate following MSRT and SR.
+There is a decrease in heart rate in both MSRT and SR and higher decrease in heart rate after MSRT compared to SR.
+Figure 2: Pre–post changes in systolic BP following MSRT and SR.
+There is a decrease in heart rate in both MSRT and SR and higher decrease in heart rate after MSRT compared to SR.
+Figure 3: Pre–post changes in diastolic BP following MSRT and SR.
+There is a decrease in heart rate in both MSRT and SR and higher decrease in heart rate after MSRT compared to SR.
+4
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+Wang et al.
+Figure 4: Pre–post changes in diastolic BP following MSRT and SR.
+There is a decrease in heart rate in both MSRT and SR and higher decrease in heart rate after MSRT compared to SR.
+Results [Table 2]
+Repeated-measureanalysis of variance
+RM-ANOVA revealed a significant difference between the states (p<0.05; F=11.3, df=1,29).
+MSRT intervention
+There was a significant decrease in HR (p<0.001, effect size 0.67), SBP (p<0.001, effect size 0.47), DBP (p<0.001,
+effect size 0.58), and state anxiety (p<0.001, effect size 0.90) after MSRT intervention compared to baseline which
+is suggestive of improvement in blood pressure and state anxiety symptoms following 30 min of the MSRT.
+SR intervention
+After SR session, we observed a significant decrease in HR (p<0.001, effect size 0.27) and state anxiety (p<0.001,
+effect size 0.04) compared to baseline. No change was seen in SBP and DBP.
+Comparison of post-assessment across the sessions revealed a significant difference between the groups in
+SBP (p=0.01, effect size 0.34), DBP (p=0.047, effect size 0.31), and state anxiety (p=0.003, effect size 0.51) in MSRT
+session compared to SR session. No significant changes were observed in HR (p=0.19). These results indicate
+that MSRT session is superior to SR session in terms of reducing SBP, DBP, and state anxiety.
+Discussion
+In this study, 30-min MSRT interventions produced a significant decrease in systolic and diastolic blood pres-
+sures, HR, and state anxiety among individuals with HTN. Following SR session, a significant decrease in
+anxiety and HR was found, whereas no significant change in systolic and diastolic blood pressures was ob-
+served.
+These findings indicate the potential use of MSRT intervention on blood pressure, HR, and anxiety in indi-
+viduals with HTN.
+Previous studies also reported similar positive acute effects of MSRT in different health conditions.
+A study by Vipin et al., 2016, assessed single session of MSRT intervention on state anxiety and cognitive
+flexibility among generalized anxiety disorder subjects and compared with a single session of SR [22]. In this
+study, the significant improvement in state anxiety and cognitive function was observed in both MSRT and SR
+interventions. Further, compared to SR intervention, MSRT intervention was found to be significantly better.
+5
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+DE GRUYTER
+Various yogic techniques have been found to be useful in improving blood pressure. Previously, Shirley
+2013 reported a significant decrease in SBP and DBP following 10 min of alternate nostril breathing [23]. In
+another study by Tapas found significant decrease in systolic and diastolic blood pressures and HR following
+slow-paced breathing (6 breaths/min) for 5 min [24].
+Further, in a study, significant decrease in anxiety was observed following a sutra chanting, among sub-
+jects undergoing surgery [25]. In another study, 20 min of chanting produced significant decrease in sports
+competitive anxiety [26].
+Chanting of syllable A, U, M, OM, and Mahamrityunjaya mantra is the essence of the MSRT practice. While
+chanting, one requires to take a deep breath followed by slow exhalation. Thus, MSRT involves both slow-
+paced breathing and chanting of mantra which is recognized to have physiological and psychological effects,
+respectively.
+The changes in the blood pressure following MSRT intervention and SR may be attributed to decreased
+sympathetic activity as slow-paced breathing, which is associated with a decrease in the blood pressure and HR
+via downregulation of hypothalamo-puitary adrenal (HPA) axis activity [27]. Decreased HPA axis is associated
+with decreased amygdala activity in the brain, which is responsible for fear and anxiety response [28]. Further,
+MSRT involves the chanting of mantra and syllable OM; a previous study by Kalyani et al. 2011 showed that
+chanting of OM syllable is associated with deactivation of thalami and hippocampi which are involved with a
+fear response [29].
+The present study indicates the potential use of MSRT interventions in reducing blood pressure reduction
+in short span of time of 30 min. MSRT is a simple technique which can be done on bed in SR, requires less
+assistance, and has no side effects and at the same time is a cost-effective and non-pharmacological intervention.
+Further, this study presented the clinical importance of MSRT intervention in HTN. Present study suggests the
+potential clinical significance of MSRT in preoperative anxiety, HTN, resistance HTN, sinus tachycardia, anxiety,
+panic disorder, preoperative anxiety, etc.
+Small sample size, short-term intervention, and non-randomization are the major limitations of the study.
+This study encourages the further studies with long-term intervention with larger sample size and robust
+research design which will be done in the future. Future studies should also test the use of MSRT intervention
+in various clinical conditions mentioned above.
+Conclusion
+Present study provides preliminary findings on effects of single session of MSRT and supine on blood pressure,
+HR, and state anxiety, respectively, among individuals with HTN. Further, MSRT intervention was found to
+be an effective intervention to reduce blood pressure, HR, and state anxiety among individuals with HTN.
+These findings encourage the further studies with larger sample size and long-term intervention with a robust
+research design.
+Author contributions: All the authors have accepted responsibility for the entire content of this submitted
+manuscript and approved submission.
+Research funding: None declared.
+Employment or leadership: None declared.
+Honorarium: None declared.
+Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis,
+and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.
+References
+[1] Kearney PM, Whelton M, Reynolds K, Muntner P
+, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. The
+Lancet. 2005 Jan 15;365:217–23.
+[2] Gillespie CD, Hurvitz KA. Centers for Disease Control and Prevention (CDC). Prevalence of hypertension and controlled hypertension –
+United States, 2007–2010. MMWR Surveill Summ. 2013 Nov 22;62:144–48.
+[3] Verdecchia P
+, Angeli F, Gattobigio R, Rapicetta C, Reboldi G. Impact of blood pressure variability on cardiac and cerebrovascular complica-
+tions in hypertension. Am J Hypertens. 2007 Feb 1;20:154–61.
+6
+Brought to you by | Université de Strasbourg
+Authenticated
+Download Date | 10/25/18 3:29 AM
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+DE GRUYTER
+Wang et al.
+[4] Jacobs GD. The physiology of mind–body interactions: the stress response and the relaxation response. J Altern Complement Med. 2001
+Dec 2;7:83–92.
+[5] Najafian J, Gholestan Hashemi SMA. Study of the effect of relaxation and biofeedback assisted relaxation on patients with mild hyperten-
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+[6] Rainforth MV, Schneider RH, Nidich SI, Gaylord-King C, Salerno JW, Anderson JW. Stress reduction programs in patients with elevated
+blood pressure: a systematic review and meta-analysis. Curr Hypertens Rep. 2007 Dec 1;9:520.
+[7] Shapiro AP
+, Schwartz GE, Ferguson DC, Redmond DP
+, Weiss SM. Behavioral methods in the treatment of hypertension: a review of their
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+Psychiatry. 1970 Sep 1;1:195–200.
+[9] Metri KG, Pradhan B, Nagendra HR. Impact of short-term residential yoga-based lifestyle intervention on cognitive function in hyperten-
+sive patients. J Stem Cells. 2017;12:33.
+[10] Taylor CB, Farquhar JW, Nelson E, Agras S. Relaxation therapy and high blood pressure. Arch Gen Psychiatry. 1977 Mar 1;34:339–42.
+[11] Benson H, Rosner BA, Marzetta BR, Klemchuk HP
+. Decreased blood pressure in borderline hypertensive subjects who practiced medita-
+tion. J Chronic Dis. 1974 Mar 1;27:163–69.
+[12] Barnes PM, Powell-Griner E, McFann K, Nahin RL. Complementary and alternative medicine use among adults: United States, 2002.
+Seminars Integr Med. 2004 Jun 1;2:54–71. WB Saunders.
+[13] Harinath K, Malhotra AS, Pal K, Prasad R, Kumar R, Kain TC, et al. Effects of Hatha yoga and Omkar meditation on cardiorespiratory per-
+formance, psychologic profile, and melatonin secretion. J Altern Complement Med. 2004 Apr 1;10:261–68.
+[14] Hagins M, Selfe T, Innes K. Effectiveness of yoga for hypertension: systematic review and meta-analysis. Evidence-Based Complement
+Altern Med. 2013;2013.
+[15] Bijlani RL, Vempati RP
+, Yadav RK, Ray RB, Gupta V, Sharma R, et al. A brief but comprehensive lifestyle education program based on yoga
+reduces risk factors for cardiovascular disease and diabetes mellitus. J Altern Complement Med. 2005 Apr 1;11:267–74.
+[16] Nagendra HR. Mind sound resonance technique (MSRT). Bangalore: Swami Vivekananda Yoga Prakashana. 2001;51.
+[17] Rao M, Metri KG, Raghuram N, Hongasandra NR. Effects of mind sound resonance technique (yogic relaxation) on psychological states,
+sleep quality, and cognitive functions in female teachers: a randomized, controlled trial. Adv Mind Body Med. 2017;31:4–9.
+[18] Mohanty S, Metri K, Nagaratna R, Nagendra HR. Immediate effect of mind sound resonance technique (MSRT – a yogic relaxation tech-
+nique) on cognitive functions in type 2 diabetes. Voice Res. 2015 Jun;4:44–45.
+[19] El Assaad MA, Topouchian JA, Darne BM, Asmar RG. Validation of the Omron HEM-907 device for blood pressure measurement. Am J
+Hypertens. 2002 Apr 1;15:87A.
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+icana de Psicologia/Interamerican. J of Psychology. 2017 Jul 17;5.
+[21] Yogitha B, Nagarathna R, John E, Nagendra HR. Complimentary effect of yogic sound resonance relaxation technique in patients with
+common neck pain. Int J Yoga. 2010 Jan;3:18.
+[22] Dhansoia V, Bhargav H, Metri K. Immediate effect of mind sound resonance technique on state anxiety and cognitive functions in pa-
+tients suffering from generalized anxiety disorder: a self-controlled pilot study. Int J Yoga. 2015 Jan;8:70.
+[23] Telles S, Yadav A, Kumar N, Sharma S, Visweswaraiah NK, Balkrishna A. Blood pressure and Purdue pegboard scores in individuals with
+hypertension after alternate nostril breathing, breath awareness, and no intervention. Med Sci Monit. 2013;19:61.
+[24] Pramanik T, Sharma HO, Mishra S, Mishra A, Prajapati R, Singh S. The immediate effect of slow pace bhastrika pranayama on blood
+pressure and heart rate. J Altern Complement Med. 2009 Mar 1;15:293–95.
+[25] Pramanik T, Sharma HO, Mishra S, Mishra A, Prajapati R, Singh S. Immediate effect of slow pace bhastrika pranayama on blood pressure
+and heart rate. J Altern Complement Med. 2009 Mar 1;15:293–95.
+[26] Routhan T, Ruhela S. Chanting: a therapeutic treatment for sports competitive anxiety. Int J Scientific Res Publ. 2014;4.
+[27] Ross A, Thomas S. The health benefits of yoga and exercise: a review of comparison studies. J Altern Complement Med. 2010 Jan 1;16:3–
+12.
+[28] Dusek JA, Benson H. Mind-body medicine: a model of the comparative clinical impact of the acute stress and relaxation responses. Minn
+Med. 2009 May;92:47.
+[29] Kalyani BG, Venkatasubramanian G, Arasappa R, Rao NP
+, Kalmady SV, Behere RV, et al. Neurohemodynamic correlates of ‘OM’ chanting:
+a pilot functional magnetic resonance imaging study. Int J Yoga. 2011 Jan;4:3.
+7
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+International Journal of Yoga • Vol. 8 • Jan-Jun-2015
+70
+disabling mental disorder characterized by persistent 
+worrying, anxiety symptoms, tension and higher 
+sympathetic tone.[1] It is the most frequent anxiety disorder 
+in primary care, being present in 22% of primary care 
+patients who complain of anxiety problems.[1] GAD affects 
+women more frequently than men, and the prevalence 
+rates are high in midlife (prevalence in females over age 
+35 years: 10%) and older subjects. GAD is associated with 
+a significant economic burden owing to decreased work 
+productivity and increased use of health care services. 
+Patients with GAD demonstrate a considerable degree of 
+INTRODUCTION
+Generalized anxiety disorder (GAD) is a prevalent and 
+Short Communication
+Immediate effect of mind sound resonance technique on state 
+anxiety and cognitive functions in patients suffering from 
+generalized anxiety disorder: A self-controlled pilot study
+Vipin Dhansoia, Hemant Bhargav, Kashinath Metri
+Divison of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana (S-VYASA) University, Bengaluru, Karnataka, 
+India
+Address for correspondence:  Dr. Hemant Bhargav, 
+Swami Vivekananda Yoga Anusandhana Samsthana, Yoga University, 
+#19 Eknath Bhavan, No 19, Gavipuram Circle, Kempe Gowda Nagar, 
+Bengaluru - 560 019, Karnataka, India. 
+E-mail: hemant.bhargav1@gmail.com
+Objectives: To compare the immediate effect of mind sound resonance technique (MSRT) with supine rest (SR) on state 
+anxiety and psychomotor performance in 15 (eight male and seven female) right-handed generalized anxiety disorder patients 
+(GAD) with an age range of 34.8 ± 12.8 years.
+Materials and Methods: Self as control design was followed. Diagnosis of GAD was made by a psychiatrist using sections 
+of the Mini International Neuropsychiatric Interview (MINI). Participants practiced MSRT or SR (as control intervention) for 
+30 min at the same time for two consecutive days. The sequence of intervention was assigned randomly to the participants. 
+State anxiety was assessed using state trait anxiety inventory (STAI; Form X1). Digit letter substitution task (DLST) was used 
+to assess psychomotor performance, which involves visual scanning, mental flexibility, sustained attention, psychomotor speed 
+and speed of information processing. Intervention was given in a quiet dark room on an empty stomach. Subjects received 
+a training of MSRT and SR for 1 week before the data were taken. A pre-recorded audiotape was used to administer the 
+technique of MSRT. Difference in scores after baseline and intervention was used to check normality, and was found to be 
+normally distributed by the Kolmogrov–Smirnov test. The changes in STAI, DLST and difference in scores before and after 
+two interventions (MSRT and SR) were compared using the paired samples t test.
+Results: As compared with baseline, STAI scores reduced and DLST scores increased significantly (STAI; P < 0.01; DLST; 
+P < 0.01) after MSRT. After SR, there was a significant reduction in STAI scores from baseline (STAI; P < 0.05), but there was 
+no significant change in the DLST scores (P = 0.26). Comparison of the difference in scores for DLST and STAI before and 
+after the two interventions (MSRT and SR) showed a significantly higher score for DLST (P < 0.05) and a significantly lower 
+score for STAI (P < 0.01) for MSRT as compared with SR.
+Conclusion: This pilot study suggests that MSRT may have a potential role in reducing state anxiety and enhancing psychomotor 
+performance in patients suffering from GAD immediately after the practice. These findings need confirmation from studies with 
+a larger sample size and randomized controlled design, which are implicated in the future.
+Key words: Anxiety disorder; attention; mindfulness; mind sound resonance technique; psychomotor performance; state anxiety.
+Access this article online
+Website: 
+www.ijoy.org.in
+Quick Response Code
+DOI: 
+10.4103/0973-6131.146069
+ABSTRACT
+[Downloaded from http://www.ijoy.org.in on Wednesday, July 27, 2016, IP: 14.139.155.82]
+Dhansoia, et al.: Effect of mind sound resonance technique on patients with generalized anxiety disorder
+71
+International Journal of Yoga • Vol. 8 • Jan-Jun-2015
+impairment and disability.[1] It is reported that anxiety 
+disorders are associated with cognitive dysfunctions such 
+as reduced processing speed, attention and inhibition,[2] 
+which may be aggravated by anti-anxiety medications.[3]
+Yoga is an ancient traditional science of holistic living 
+that includes the practice of specific postures, regulated 
+breathing and meditation. Yoga has been found to be 
+an effective tool in managing stress levels.[4,5] Yoga, in 
+its essence, is a technique to achieve control over the 
+modifications of the mind and thereby balance the 
+lifestyle.[6] Yoga reduces sympathetic tone and brings about 
+a state of parasympathetic dominance.[4] There is mounting 
+evidence that yoga reduces anxiety symptoms.[7] A recent 
+randomized controlled study found encouraging results 
+of mindfulness-based interventions in GAD patients even 
+when the interventions are delivered remotely via the 
+Internet.[8] Recent researches also suggest that mindfulness-
+based practices may enhance the efficacy of cognitive 
+behavioral therapy in anxiety disorders by improving 
+cognitive flexibility.[9]
+Mind sound resonance technique (MSRT) is one of the 
+advanced mindful relaxation yoga techniques that uses 
+mantra to generate resonance, which mainly works through 
+the Manomaya Kosha to induce deeper relaxation for both 
+mind and body.[10] MSRT can be practiced in the supine 
+or sitting posture for improving well-being, concentration, 
+will power and relaxation.[10] One unpublished study 
+found that immediately after MSRT, there was a significant 
+increase in gamma brain wave coherence (indicative of 
+deep relaxation) than controls and significant reduction 
+in STAI scores in healthy volunteers in 32 subjects as 
+compared with controls.[11] MSRT intervention also led to 
+better reduction in pain, tenderness, disability and state 
+anxiety in patients suffering from chronic neck pain.[12]
+Hence, this study was planned with an aim to evaluate the 
+immediate effect of MSRT technique on state anxiety and 
+cognitive functions in GAD patients and compare it with 
+the supine rest (SR) test.
+MATERIALS AND METHODS
+Patients of GAD who had no general medical disease, 
+substance abuse and head injury, who could read and write 
+in English language and who had no previous exposure to 
+MSRT practice were included in the study. Patients were 
+recruited from inpatients and outpatients of the Holistic 
+Health Home  -  Arogyadhama, Bangalore, India. They 
+were diagnosed by a psychiatrist using sections of the 
+Mini International Neuropsychiatric Interview (MINI). 
+A total of 22 participants were screened within a 6-month 
+period from August 2013 to January 2014, of whom 
+18 satisfied the inclusion criteria. Of the 18 participants 
+who satisfied the inclusion criteria, three participants 
+dropped out because of inability to continue therapy at 
+the center, leaving a final sample size of 15. A total of 
+15 subjects (eight male and seven female) in the age range 
+of 34.8 ± 12.8 years, with duration of education ranging 
+from 13.5 ± 5.29 years, were enrolled in this study after 
+taking written informed consent. All the subjects were 
+right handed. They were suffering from GAD since the last 
+8.75 ± 6.23 years. A “self as control” design was followed. 
+All the participants were continuing their medications 
+as advised by their psychiatrist and achieved stable 
+state since the last 4 weeks. No changes were made in 
+medications during the course of the study. Subjects had 
+no previous exposure to the practice of MSRT and were 
+given a week-long orientation to the practice before the 
+study. All the procedures were reviewed and accepted by 
+the institutional review board.
+Measures
+State anxiety
+The primary outcome measure was assessment of the state 
+anxiety levels. It was assessed using a self-rated scale called 
+Spielberger’s State Anxiety Inventory (STAI; From X-1) at 
+the beginning and immediately after the end of the MSRT 
+and control (SR) sessions. STAI is a reliable, valid and 
+sensitive tool with a high degree of internal consistency 
+with Cronbach’s alfa of 0.86 for the total scores.[13]
+Psychomotor performance
+The digit letter substitution task (DLST) was developed 
+from the Digit Symbol Substitution Test (DSST) as one of the 
+subsets of the Wechsler intelligence scale.[14] Substitution 
+tests are essentially speed-dependent tasks that require 
+the subject to match particular signs and symbols, digits 
+or letters to other signs within a specified time period 
+(90 s).[14] Substitution tasks involve visual scanning, mental 
+flexibility, sustained attention, psychomotor speed and 
+speed of information processing.[15] DLST is a valid tool 
+for assessing neuro-psychiatric illnesses and has been 
+standardized for the Indian population.[15]
+Assessments
+All assessments were performed on an empty stomach 
+between 6:30 pm and 7:00 pm. Both MSRT and control 
+(SR) sessions were given in the supine position for 30 min 
+in a dark, quiet room. A pre-recorded audio-tape was used 
+to give the MSRT instructions. As a control session, simple 
+SR was performed by the same subjects on different days 
+under the same conditions. The sequence of control and 
+intervention sessions was decided randomly. Data were 
+taken immediately before and after MSRT and SR.
+[Downloaded from http://www.ijoy.org.in on Wednesday, July 27, 2016, IP: 14.139.155.82]
+Dhansoia, et al.: Effect of mind sound resonance technique on patients with generalized anxiety disorder
+International Journal of Yoga • Vol. 8 • Jan-Jun-2015
+72
+DISCUSSION
+To the best of our knowledge, this is the first study to 
+assess the immediate effect of a yogic intervention on 
+state anxiety in GAD patients. Previously, in a randomized 
+controlled study, MSRT intervention, given daily for 10 
+days, was found useful in reducing the state anxiety in 
+patients suffering from chronic neck pain as compared 
+with SR.[15] The state anxiety (as assessed by STAI) reduced 
+significantly by 19.3% whereas SR led to a non-significant 
+reduction of 8.1% at the end of 10 days.[14] Another study 
+used cyclic meditation (CM) in 57 healthy male volunteers 
+to show reduction in state anxiety immediately after 
+the practice (as assessed by STAI). There was a greater 
+magnitude of decrease in state anxiety after CM (22.4%) 
+compared with that after SR (5.6%).[16] In our study, we 
+found a significant reduction in state anxiety after both 
+MSRT as well as SR. A reduction of 45.78% and 7.69% 
+was observed after MSRT and SR, respectively. This greater 
+reduction in state anxiety after MSRT found in our study 
+can be explained on the following basis: first, we had 
+a comparatively small sample size and, thus, extreme 
+values may have contributed more toward the shift of the 
+means; secondly, our target population was already having 
+anxiety disorder, and such a population may show higher 
+sensitivity toward relaxation techniques such as MSRT and 
+SR as compared to a population without anxiety disorder. 
+The effect of MSRT on DLST has not been tested before, 
+and this study shows that apart from reducing anxiety, 
+MSRT technique can also lead to significant enhancement 
+of psychomotor performance in GAD patients. This is an 
+added benefit in this population as cognitive dysfunction 
+has been observed in patients with anxiety disorders, both 
+as a consequence of disease[2] and as a side-effect of anti-
+anxiety medications.[3]
+As for the mechanism, it has been shown that yoga reduces 
+stress and anxiety by improving autonomic functions 
+via triggering neurohormonal mechanisms that suppress 
+sympathetic activity through down-regulation of the 
+hypothalamic–pituitary–adrenal axis.[4] Mindfulness-based 
+practices may also enhance cognitive flexibility, which 
+further helps in controlling anxiety.[9]
+The strengths of the study are: (a) This multidisciplinary 
+study encompasses the fields of yogic science, psychology 
+and psychiatry; (b) no earlier study has reported an 
+immediate effect of a yogic relaxation technique on 
+state anxiety and cognitive functions in GAD patients; 
+(c) because the duration of yoga intervention was short, 
+acceptability and adherence to therapy was good; and (d) as 
+MSRT was delivered through a standard protocol, it could 
+be reproduced in the exact way for all cases.
+This study also has many limitations, which restrict its 
+generalizability. The most important limitation is the small 
+Intervention
+MSRT is one of the advanced yoga-based mindful relaxation 
+techniques that involves experiencing with closed eyes 
+the internal vibrations and resonance developed while 
+chanting the syllables A, U, M, Om and Mahamrityunjaya 
+mantra sounds. The details of MSRT practice including 
+the steps involved are described elsewhere.[12] As a control 
+intervention, non-guided SR was given for a period of 
+30 min.
+Data analysis
+All statistical analyses were performed using the Statistical 
+Package for Social Sciences (SPSS version 10.0). Difference 
+in scores after baseline and intervention was used to 
+check normality. This difference in scores was found to 
+be normally distributed for both MSRT and SR by the 
+Kolmogrov–Smirnov test. The changes in STAI, DLST and 
+difference in scores before and after the two interventions 
+(MSRT and SR) were compared using paired samples t test.
+RESULTS
+We observed that as compared with baseline, the STAI 
+scores reduced and the DLST scores increased significantly 
+after MSRT (STAI; P < 0.01; DLST; P < 0.01; Table 1), 
+whereas after SR, there was a significant reduction in the 
+STAI scores from baseline (STAI; P < 0.05; T
+able 1), but there 
+was no significant change in the DLST scores (P = 0.26).
+Comparison of the difference in scores for DLST and STAI 
+before and after the two interventions (MSRT and SR) 
+showed a significantly higher score for DLST (P < 0.05) 
+and a significantly lower score for STAI (P < 0.01) for 
+MSRT as compared with SR [Table 2].
+Table  1: Means and standard deviations of STAI and 
+DLST scores before and after MSRT and SR  (paired 
+samples t test)
+Group Intervention
+Mean±SD
+% 
+change
+Pa‑value
+Before
+After
+MSRT
+STAI
+52.42±17.00
+28.42±3.87
+−45.78
+0.00**
+DLST
+30.33±15.75 40.08±15.13 +32.14
+0.00**
+SR
+STAI
+49.92±21.85 46.08±22.29
+−7.69
+0.04*
+DLST
+28.08±15.00 30.85±16.80
++9.86
+0.26
+STAI = State and trait anxiety inventory; MSRT = Mind sound resonance 
+technique; SR = Supine rest; aPaired samples t test, **P<0.01, *P<0.05
+Table  2: Comparison of the difference in scores for 
+DLST and STAI before and after MSRT and SR
+Group
+Mean±SD (diff)
+% 
+change
+Pa‑value
+SR
+MSRT
+STAI
+−3.83±3.71
+−24.00±18.48
++526.63
+0.00**
+DLST
+2.67±7.80
+9.75±4.02
++265.16
+0.02*
+STAI = State and trait anxiety inventory; MSRT = Mind sound resonance 
+technique; SR = Supine rest; Diff = Difference in scores (post ‑ pre), aPaired 
+samples t test, **P<0.01, *P<0.05
+[Downloaded from http://www.ijoy.org.in on Wednesday, July 27, 2016, IP: 14.139.155.82]
+Dhansoia, et al.: Effect of mind sound resonance technique on patients with generalized anxiety disorder
+73
+International Journal of Yoga • Vol. 8 • Jan-Jun-2015
+sample size. This study was a pilot project to assess the 
+response to MSRT in a small patient population to plan 
+for a better study with a much higher sample size and 
+better design in the future. A self as control design was 
+used because of the lack of a sufficient number of subjects. 
+Secondly, this study did not follow-up as to how long the 
+response to MSRT continues. In the future, a dose-response 
+curve could be generated by performing repeated measures. 
+Third, no objective parameters were used to understand the 
+mechanism of action of MSRT at the electro-physiological, 
+neurological and biochemical levels. Lastly, we could have 
+used an active comparison such as music therapy delivered 
+via an audio tape for more rigorous evaluation of MSRT, 
+which we did not use this time.
+In the future, a randomized controlled design with a 
+larger sample size should be performed. Future studies 
+should use objective variables of autonomic functions 
+such as heart rate variability and galvanic skin resistance, 
+advanced neuroimaging devices such as EEG, fNIRS and 
+fMRI and biomarkers such as serum serotonin, oxytocin, 
+etc., to understand the mechanism of action. Effect of 
+MSRT should also be tested in other neuropsychiatric 
+disorders where psychomotor retardation is observed, for 
+example, brain-damaged individuals and patients suffering 
+from dementia and depression. Future studies should try to 
+use drug-naïve GAD subjects to rule out the effects of the 
+drugs and compare the effect of MSRT with other mind–
+body relaxation techniques, including music therapy.
+CONCLUSION
+This pilot study suggests that MSRT may have a potential 
+role in reducing state anxiety and enhancing psychomotor 
+performance in patients suffering from GAD immediately 
+after the practice. These findings need confirmation 
+from studies with a larger sample size and randomized 
+controlled design, which are implicated in the future.
+ACKNOWLEDGMENT
+The authors acknowledge all subjects in this study for 
+their participation.
+REFERENCES
+1. 
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+Nagendra HR, Narathna R. Promotion of Positive Health. Bangalore: Swami 
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+, Richardson J, Pilkington K. Yoga for anxiety: 
+A systematic review of the research evidence. Br J Sports Med 2005;39:884-91.
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+Boettcher J, Aström V, Påhlsson D, Schenström O, Andersson G, Carlbring 
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+Vivekananda Yoga Prakashana; 2001. p. 51.
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+Zala K. Immediate Effect of MSRT on Brain Wave Coherence in University 
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+16. Subramanya P, Telles S. Effect of two yoga-based relaxation techniques on 
+memory scores and state anxiety. Biopsychosoc Med 2009;3:8.
+How to cite this article: Dhansoia V, Bhargav H, Metri K. Immediate 
+effect of mind sound resonance technique on state anxiety and cognitive 
+functions in patients suffering from generalized anxiety disorder: A self-
+controlled pilot study. Int J Yoga 2015;8:70-3.
+Source of Support: Nil, Conflict of Interest: None declared
+[Downloaded from http://www.ijoy.org.in on Wednesday, July 27, 2016, IP: 14.139.155.82]
diff --git a/subfolder_0/Immediate effect of two yoga based relaxation techniques on cognitive functions in patients suffering from relapsing remitting multiple sclerosis.txt b/subfolder_0/Immediate effect of two yoga based relaxation techniques on cognitive functions in patients suffering from relapsing remitting multiple sclerosis.txt
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+Full Terms & Conditions of access and use can be found at
+http://www.tandfonline.com/action/journalInformation?journalCode=iirp20
+Download by: [14.139.155.82]
+Date: 28 February 2017, At: 22:16
+International Review of Psychiatry
+ISSN: 0954-0261 (Print) 1369-1627 (Online) Journal homepage: http://www.tandfonline.com/loi/iirp20
+Immediate effect of two yoga-based relaxation
+techniques on cognitive functions in patients
+suffering from relapsing remitting multiple
+sclerosis: A comparative study
+Praerna Bhargav, Hemant Bhargav, Nagarathna Raghuram & Christoph
+Garner
+To cite this article: Praerna Bhargav, Hemant Bhargav, Nagarathna Raghuram & Christoph
+Garner (2016) Immediate effect of two yoga-based relaxation techniques on cognitive functions
+in patients suffering from relapsing remitting multiple sclerosis: A comparative study, International
+Review of Psychiatry, 28:3, 299-308, DOI: 10.1080/09540261.2016.1191447
+To link to this article:  http://dx.doi.org/10.1080/09540261.2016.1191447
+Published online: 14 Jun 2016.
+Submit your article to this journal 
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+Citing articles: 2 View citing articles 
+ORIGINAL ARTICLE
+Immediate effect of two yoga-based relaxation techniques on cognitive
+functions in patients suffering from relapsing remitting multiple sclerosis:
+A comparative study
+Praerna Bhargava, Hemant Bhargava, Nagarathna Raghuramb and Christoph Garnerc
+aSchool of Yoga and Life Sciences, S-VYASA Yoga University, Bangalore, India; bArogyadhama Health Center, S-VYASA Yoga University,
+Bangalore, India; cKWA-Klinik f€
+ur Neurologische und Geriatrische Rehabilitation Stift Rottal, Bad Griesbach, Germany
+ABSTRACT
+Cognitive impairment (CI) is an important feature of relapsing remitting multiple sclerosis (RRMS).
+Yogic relaxation techniques have been found useful in improving various cognitive domains in
+health and disease. Eighteen subjects (13 females) in the age range of 51.5 ± 12.72 years with the
+diagnosis of RRMS by a neurologist (McDonald Criteria 2010) since last 18.16 ± 12.59 years were
+recruited into the study from a neuro-rehabilitation centre in Germany. Assessments were done
+before and immediately after two randomly allocated 30-min sessions of yogic relaxation: Cyclic
+Meditation (CM) and SR (supine rest or shavasana). Assessments were done for attention, psycho-
+motor performance, information processing speed, executive functions, and immediate and
+delayed recall using standard psychometric tools. RMANOVA was applied to analyse the data
+using SPSS version 10. Both CM and SR sessions improved scores on Digit Symbol Substitution
+Test (DSST) (p < 0.01) and Auditory Verbal Learning Test (AVLT) (p < 0.05). There was a signifi-
+cantly better performance in Trail Making Test (TMT)-A and forward digit span (FDS) after CM as
+compared to SR (p < 0.01). Yogic relaxation techniques may have an immediate enhancing effect
+on processing speed, psychomotor performance, and recall of RRMS patients. CM is better than
+SR in improving processing speed, short-term memory, and verbal working memory.
+ARTICLE HISTORY
+Received 19 October 2015
+Revised 9 April 2016
+Accepted 13 May 2016
+Published online 13 June
+2016
+KEYWORDS
+Cognition; cyclic meditation;
+relapsing remitting multiple
+sclerosis; shavasana;
+relaxation
+Introduction
+Multiple sclerosis is the most common chronic dis-
+abling disease of the central nervous system (CNS) in
+young adults (Compston & Coles, 2008; Currie, 2001).
+It is characterized by demyelination and axonal degen-
+eration. The demyelination of the nerve fibres inter-
+feres
+with
+the
+smooth
+and
+rapid
+conduction
+of
+electrical potentials along neuronal pathways in the
+CNS (Weiner, 2004). This interference has been associ-
+ated with motor, sensory, psychological, visual, blad-
+der, and sexual symptoms commonly experienced by
+people with MS (Chalk, 2007).
+Cognitive impairment (CI) has increasingly been
+recognized as an important feature of MS, with preva-
+lence
+ranging
+from
+43–70%
+(Amato,
+Zipoli,
+&
+Portaccio,
+2006).
+Three
+previous
+meta-analyses
+(Prakash,
+Snook,
+Lewis,
+Motl,
+&
+Kramer,
+2008;
+Wishart & Sharpe, 1997; Zakzanis, 2000) have quanti-
+tatively examined the nature of neurocognitive deficits
+in MS. Results from all three meta-analyses provided
+evidence for the presence of significant cognitive
+impairments in patients with MS. Importantly, one of
+the meta-analyses did not report differences in cogni-
+tive impairment as a function of disease sub-type
+(Wishart & Sharpe, 1997), whereas the other meta-
+analytic review reported that individuals with chronic-
+progressive MS had greater impairments on tasks of
+executive control, and those with relapsing-remitting
+multiple sclerosis (RRMS) have significantly higher
+memory-related dysfunction (Zakzanis, 2000). RRMS
+is the most common type of MS (Lublin & Reingold,
+1996). A meta-analysis was performed on 57 studies
+that quantified the overall magnitude of cognitive
+impairment in individuals with RRMS (Prakash et al.,
+2008). It was observed that individuals with RRMS
+had moderate decline in cognitive functioning as com-
+pared with healthy controls. Patients with RRMS
+showed the greatest cognitive impairment on measures
+of motor functioning, mood status, memory, and
+learning. Within each domain, processing speed, select-
+ive/focused attention, and tests of verbal-delayed recall
+showed significantly greater impairment than on any
+other measure. These impairments tend to start at an
+early stage of the disease and tend to worsen over
+time, resulting in significant functional impairment at
+CONTACT Praerna Bhargav
+praernabhargav@gmail.com
+School of Yoga and Life Sciences, S-VYASA Yoga University, Bangalore, India
+ 2016 Institute of Psychiatry
+INTERNATIONAL REVIEW OF PSYCHIATRY, 2016
+VOL. 28, NO. 3, 299–308
+http://dx.doi.org/10.1080/09540261.2016.1191447
+work and home (Patti, 2009) reducing patient’s life sat-
+isfaction and health-related quality-of-life, which are
+probably the most important determinants of employ-
+ment status and associated societal costs; they also
+adversely affect driving safety, household task comple-
+tion, social activity, physical independence, rehabilita-
+tion progress, coping skills, treatment adherence, and
+mental health (Langdon, 2011). Addressing cognitive
+dysfunction is recognized as a quality indicator in MS
+care (Cheng, Crandall, Bever, Giesser, Haselkorn, Hays,
+et al., 2010), and it could be as important to the patient
+as physical relapses or MRI lesions (Sicotte, 2011).
+Yoga, with its roots in ancient Indian philosophy, is
+used for physical, mental, and spiritual well-being.
+Yoga has been found to be effective for addressing
+problems with strength, flexibility, balance, gait, anx-
+iety, depression, and cognition enhancement (Salgado,
+Jones, Ilgun, McCord, Loper-Powers, & van Houten,
+2013). Various studies have shown that yoga helps in
+improving
+quality-of-life,
+disability
+limitation,
+and
+rehabilitation of the subjects with chronic diseases
+(Nesi, 2012). The results of researches done so far on
+the effects of Yoga in MS patients have shown positive
+outcomes at physical and psychological aspects such as
+decrease in pain, fatigue (Oken, Kishiyama, Zajdel,
+Bourdette, Carlsen, Haas, et al., 2004), bladder dys-
+function (Patil, Nagarathna, Garner, Raghuram, &
+Crisan, 2012), improvement in peak expiratory flow
+(Salgado et al., 2013), cognition (Oken, Flegal, Zajdel,
+Kishiyama, Lovera, Bagert, et al., 2006), anxiety and
+depression (Grossman, Kappos, Gensicke, D’Souza,
+Mohr, Penner, et al., 2010), attention (Rani & Rao,
+1996), performance, and quality-of-life (Doulatabad,
+Nooreyan, Doulatabad, & Noubandegani, 2012).
+Yoga as a therapy uses physical postures (
+asanas),
+breathing
+exercises
+(Pr
+a_
+n
+ay
+ama),
+meditation,
+and
+relaxation techniques. Independently and/or compre-
+hensively these have been shown to improve functions
+of various cognitive domains (Sridevi, Sitamma, &
+Rao, 1998) such as processing speed, attention, intelli-
+gence, executive functions, memory, and concentration
+in normal healthy volunteers (Manjunath & Telles,
+2001). Yoga has been found to improve selective atten-
+tion in MS patients as well (Velikonja, Curic
+´, Ozura, &
+Jazbec, 2010). Researchers have found that, after an
+acute bout of yoga, for tasks requiring greater amounts
+of executive control, the reaction times were shorter
+and the accuracy was significantly greater, indicating
+improvements in inhibition and working memory
+(Gothe, Pontifex, Hillman, & McAuley, 2013).
+Meditation practice reduces stress and increases
+calmness
+(Oman,
+Shapiro,
+Thoresen,
+Plante,
+&
+Flinders, 2008). Meditation is the key to reach the
+mastery over the modifications of mind, as defined by
+Patanjali Yoga Sutras (Taimini, 1986). Yoga postures
+are an important component of the yoga practices and
+are easier to practice in persons with poor attention
+span. Based on this a ‘moving meditation’ called ‘cyclic
+meditation’ (CM) was evolved which has cycles of
+yoga postures alternating with guided relaxation in
+supine rest (Subramanya & Telles, 2009a). CM has
+been found to enhance selective attention through
+increased P300 wave amplitude on auditory evoked
+potentials (Sarang & Telles, 2006a) and improve per-
+formance in letter cancellation tasks (Sarang & Telles,
+2007), immediately after the practice. Studies have
+found improvement in tasks assessing other cognitive
+domains such as memory, mental processing speed,
+attention and executive function, and state anxiety in
+healthy volunteers after CM (Sarang & Telles, 2007;
+Subramanya & Telles, 2009a, b).
+Thus, it was hypothesized that CM practice would
+improve important cognitive domains of psychomotor
+performance, selective attention, short-term memory,
+executive functions, and immediate and delayed recall
+in RRMS patients, immediately after the practice.
+Hence, the present study was planned.
+Materials and methods
+Subjects
+Sample size was calculated based on the mean and
+standard deviation obtained from our pilot study on
+five subjects. The effect size from this pilot study was
+0.65; thus, a sample size of 18 was derived by setting
+the alpha at 0.05, powered at 0.81 on G power
+software.
+Eighteen subjects (five males and 13 females) in the
+age range of 20–65 (51.5 ± 12.7) years, who were diag-
+nosed by a neurologist using McDonald Criteria 2010
+(Polman, Reingold, Banwell, Clanet, Cohen, Filippi,
+et al., 2011) to be suffering from RRMS were recruited
+for the study from a neuro-rehabilitation centre in Bad
+Griesbach, Germany. Subjects were suffering since last
+18.16 ± 12.59 years. The inclusion requirements were:
+(a) Subjects with relapsing-remitting or progressive
+MS, in the age range of 20–65 years, with EDSS 6.5
+(Kurtzke, 1983); (b) Patients who had not been
+exposed to regular (for at least a month in last 1 year)
+yoga therapy practices before; (c) Patients capable of
+following simple yoga-instructions mentally and phys-
+ically with or without chair support; and (d) those
+having knowledge of German and/or English language.
+The exclusion criteria were: (a) Those suffering from
+300
+B. PRAERNA ET AL.
+co-morbid communicable infections, advanced demen-
+tia, severe heart insufficiency (EF less than 35%), or
+on
+artificial
+cardiac
+pace
+maker
+and
+debilitating
+respiratory system disorders; (b) Those with difficulty
+in speaking or those with weakness of upper limb
+which may interfere with performance in the tests for
+assessment; and (c) Those with h/o substance abuse,
+any other organic brain illness, or major co-morbid
+psychiatric illness.
+Design
+Each patient was assessed before and immediately after
+two randomly allocated sessions: CM and supine rest
+(shavasana SR) on separate days in similar settings. To
+nullify any possible learning effect, the sequence of the
+two interventions was randomized for each subject.
+Both the interventions were administered for duration
+of 30 min. The study profile is shown in Figure 1.
+Assessments were done immediately before and after
+each intervention for attention, psychomotor perform-
+ance, information processing speed, executive func-
+tions, and short-term and delayed memory using
+standardized psychometric tools such as digit symbol
+substitution test (DSST), trail making test A and B
+(TMT- A and B), forward and backward digit span
+(FDS and BDS), and auditory verbal learning test
+(AVLT), respectively.
+Ethical considerations
+Signed informed consent was obtained from the sub-
+jects to participate in the study after explaining the
+protocol of the study. The approval of the research
+protocol was taken from the Institutional ethical com-
+mittee of S-VYASA University.
+Assessments
+Trained neuro-psychologist (from the neuro-rehabilita-
+tion centre where data collection was undertaken) per-
+formed all the assessments. The following assessments
+were done before and after CM and SR sessions:
+Trail Making Test A and B (TMT A and B)
+The
+Trail
+Making
+Test
+is
+a
+valid
+and
+reliable
+(Giovagnoli,
+Del
+Pesce,
+Mascheroni,
+Simoncelli,
+Laiacona, & Capitani, 1996) neuropsychological test of
+visual attention and task switching. The task requires a
+subject to ‘connect-the-dots’ of 25 consecutive targets
+on a sheet of paper. There are two parts to the test,
+(a) the targets are all numbers (1, 2, 3, etc.) and the
+test taker needs to connect them in sequential order;
+and (b) the subject alternates between numbers and
+letters (1, A, 2, B, etc.) (Arnett & Seth, 1995). If the
+subject makes an error, the test administrator is to cor-
+rect them before the subject moves on to the next dot.
+The goal of the test for the subject is to finish the test
+as quickly as possible. The time taken to complete the
+test is used as the primary performance metric. Part A
+examines cognitive processing speed, while part B
+examines the executive functioning.
+Digit Symbol Substitution Test (DSST)
+The digit symbol substitution test is a sub-set of the
+Wechsler Adult Intelligence Scale-Revised (WAISR)
+administered using paper and pencil (Wechsler, 1981).
+It measures sustained attention, information processing
+speed, and visuo-motor co-ordination. The participant
+is given a key grid of numbers and matching symbols
+and a test section with numbers and empty boxes. The
+test consists of filling in as many empty boxes as pos-
+sible, with a symbol matching each number. Ninety
+seconds were given to complete the task. The score
+was computed as the number of correctly substituted
+symbols within the 90-s time limit. This test has dem-
+onstrated high test–re-test reliability (Matarazzo &
+Herman 1984).
+Auditory Verbal Learning Test (AVLT)
+The
+Auditory
+Verbal
+Learning
+Test,
+including
+delayed recall, is a valid and reliable (M€
+uller, Hasse-
+Sander,
+Horn,
+Helmstaedter,
+&
+Elger,
+1997)
+tool
+which
+assesses
+short-term
+and
+delayed
+memory.
+Figure 1. Study profile.
+INTERNATIONAL REVIEW OF PSYCHIATRY
+301
+There are five presentations of the same list of 15
+words (List A) followed by presentation of a new
+distractor wordlist (List B) once. On each trial, sub-
+jects hear the full list of 15 words before being
+prompted to recall. After this, subjects are asked to
+perform free recall of the words again (without add-
+itional presentation) in two memory tests: IR A,
+immediate recall after the distractor list; and DR A,
+recall after a 20-min delay. In addition to this, one
+recognition list of 25 words which contains all the
+words from list A mixed with distracter words hav-
+ing semantic and phonemic foils are presented and
+the subject is asked to recognize the words of list A.
+The number of words correctly recalled by the par-
+ticipant on the fifth learning trial, after a 20-min
+delay and the number of correct hits, omitted ones,
+and any new words being committed in the recogni-
+tion list are all used in the analysis.
+Wechsler Memory Scale-Revised–Digit span forward
+and back ward
+The Wechsler Memory Scale–Digit-span task assesses
+verbal working memory’s number storage capacity. In
+this test, a list of random numbers is read out loud or
+presented at the rate of one per second. The test
+begins with two-to-three numbers, increasing until the
+person commits errors. Recognizable patterns (for
+example 2, 4, 6, 8) are avoided. At the end of a
+sequence, the person being tested is asked to recall the
+items in order in forward digit span. If they do this
+successfully, they are given a longer list (e.g. ‘9, 2, 4,
+1’). The length of the longest list a person can remem-
+ber is that person’s digit span. In the backward digit-
+span task the procedure is largely the same, except
+that subjects being tested are asked to recall the digits
+in reverse order. It has got good reliability and internal
+consistency (Wechsler, 1987).
+Intervention
+Experimental session
+The intervention was given by using a pre-recorded
+audiotape. The translation of the instructions for the
+practice, into German Language, was certified by using
+the
+back
+translation
+method.
+CM
+(Nagendra
+&
+Nagarathna, 1997) is a movement meditation that has
+a combination of ‘stimulating’ and ‘calming’ practices,
+described in an ancient yoga text Mandukya Karika
+(Chinmayananda, 1984), which suggests that such a
+combination is helpful in attaining mental equilibrium.
+The CM consists of three yoga postures (Table 2)
+interspersed with periods of three different types of
+relaxation. All postures were practiced slowly, with
+awareness on the part of body being moved. Total
+duration
+of
+practice
+was
+30 min.
+Subjects
+were
+instructed to keep their eyes closed throughout the
+period of practice (Nagendra & Nagarathna, 1997).
+Supine rest (Shavasana) session
+During the control session of supine rest (SR), the sub-
+ject lies down in supine posture (shavasana) with eyes
+closed, legs apart, and arms 12 inches away from the
+sides of the body. This practice was also given for
+30 min
+in
+similar
+settings
+on
+separate
+days.
+Table 1. Demographic details of subjects.
+Variable
+Number/range
+Mean ± SD
+Number of subjects
+18
+Gender
+Male
+5
+Female
+13
+Age (years)
+20–65
+51.5 ± 12.73
+Education (years)
+8–18
+13.166 67 ± 2.81
+Duration of MS (in years)
+13–43
+18.16 ± 12.59
+EDSS score
+6.5
+4.75 ± 1.9
+Handedness
+Right
+18
+Left
+0
+Ambulant
+4
+Chair bound
+9
+Used stick for walking
+5
+Co-morbid illness
+Hypertensive (1)
+Obesity (1)
+Hip arthrosis (1)
+Hypercholesterolemia (1)
+Medications
+Tizanidine (2)
+(number of subjects)
+Baclofen (3)
+Methotrexate (1)
+Cholecalciferol (2)
+Spasmik (2)
+Table 2. Steps involved in practice of cyclic meditation.
+Step no.
+Practice
+Duration
+1.
+Opening Prayer: Repetition of a verse from the
+Mandukya Karika
+1 min
+2.
+Instant Relaxation Technique (IRT): Isometric con-
+traction of muscles of the body ending with
+supine rest
+1 min
+3.
+Centring in Standing posture: Slowly coming up
+from the left side and standing at ease (tada-
+sana), ‘balancing’ the weight on both feet
+2 min
+4.
+Standing asanas/Sitting in chair (Modified form):
+Ardhakatichakrasana (Both sides)
+8 min
+5.
+Quick Relaxation Technique (QRT): Quickly relaxing
+the body by bringing awareness to abdominal
+movements and synchronizing it with breathing
+pattern
+3 min
+6.
+Sitting asanas/Sitting in chair (Modified form):
+Shashankasana and Ustrasana
+4 min
+7.
+Deep Relaxation Technique (DRT): Instructions to
+relax different parts of the body in sequence in
+supine posture (Shavasana)
+10 min
+8.
+Closing Prayer
+1 min
+302
+B. PRAERNA ET AL.
+The subjects were instructed to just relax and be aware
+of their bodily sensations and, if possible, to avoid
+sleep.
+In addition to this, patients were following their
+daily routine and other normal rehabilitation proce-
+dures prescribed by the neurologists.
+Data analysis
+All data were double-entered in Microsoft Excel and
+analysed
+using
+Statistical
+Package
+for
+the
+Social
+Sciences (SPSS) version 10.0. The Kolmogrov Smirnov
+test was used to assess the normality of all data. Data
+was analysed using repeated measures ANOVA with
+two ‘within and between sessions’ factors, i.e., Factor 1:
+between the sessions of CM and SR; and Factor 2: Pre
+and Post values of each session as ‘States’. This was
+followed
+by
+post-hoc
+analyses
+with
+Bonferroni
+adjustment comparing ‘Post’ with ‘Pre’ values within
+and between sessions.
+Results
+The demographic detail of the subjects is shown in
+Table 1. There was a significant reduction in TMT-A
+(RMANOVA with Bonferroni adjustment, p < 0.001)
+and TMT-B (p < 0.01) scores and increase in DSST
+total score (p < 0.01), forward digit span (p < 0.05),
+and AVLT trials 1–4, along with AVLT List B scores
+(p < 0.05) after CM (Table 3). The SR session showed
+a significant increase in DSST total score (p < 0.001),
+AVLT trials 1–5, immediate recall and delayed recall
+(p < 0.05), respectively, but there was also a significant
+decrease in forward digit span (p < 0.01).
+Between-groups comparison showed that TMT-A
+scores (p < 0.01) reduced and FDS scores (p < 0.01)
+Table 3. Within-group comparisons before and after cyclic meditation (CM) and supine rest (SR).
+SN
+Variable
+Session
+n
+Mean ± SD (Pre)
+Mean ± SD (Post)
+Df (Hypothesis,
+Error)
+F value
+pa value
+Effect size
+% change
+1
+TMT-a(sec)
+CM
+18
+51.25 ± 28.7
+38.3 ± 25.3
+(1,17)
+30.69
+0.001**
+0.47
+25.2
+SR
+47.13 ± 30.24
+45.5 ± 29.2
+(1,17)
+1.05
+0.59
+0.06
+3.4
+2
+TMT-b(sec)
+CM
+18
+103.70 ± 62.15
+91.92 ± 54.14
+(1,17)
+8.74
+0.009**
+0.21
+11.3
+SR
+97.46 ± 55.75
+89.3 ± 50.11
+(1,17)
+2.82
+0.11
+0.15
+8.3
+3
+DSST_T
+CM
+18
+35.69 ± 17.62
+39.31 ± 17.66
+(1,17)
+11.19
+0.004**
+0.20
+10.14
+SR
+33.56 ± 15.21
+38.38 ± 15.46
+(1,17)
+24.12
+0.001**
+0.31
+14.3
+4
+DSST_R
+CM
+18
+0.31 ± 0.60
+0.19 ± 0.40
+(1,17)
+0.65
+0.432
+0.22
+38.7
+SR
+0.31 ± .47
+0.31 ± 0.87
+(1,17)
+0.001
+1
+0
+0
+5
+FDS
+CM
+18
+6.0 ± 1.414
+6.56 ± 1.20
+(1,17)
+5.44
+0.03*
+0.42
+9.3
+SR
+6.31 ± 1.07
+5.63 ± 1.20
+(1,17)
+12.02
+0.003**
+0.59
+10.7
+6
+BDS
+CM
+18
+4.56 ± 1.031
+4.69 ± 0.793
+(1,17)
+0.48
+0.49
+0.13
+2.85
+SR
+4.69 ± 1.014
+4.69 ± 1.07
+(1,17)
+0.01
+1
+0
+0
+7
+AVLT Trial 1
+CM
+18
+9.27 ± 3.058
+12.00 ± 3.44
+(1,17)
+12.55
+0.003**
+0.83
+29.4
+SR
+7.73 ± 3.127
+11.40 ± 2.61
+(1,17)
+29.61
+0.001**
+1.26
+47.4
+8
+AVLT Trial 2
+CM
+18
+10.13 ± 2.97
+12.27 ± 3.17
+(1,17)
+10.65
+0.006**
+0.69
+30.5
+SR
+9.40 ± 2.53
+12.27 ± 1.98
+(1,17)
+39.46
+0.001**
+1.24
+30.5
+9
+AVLT Trial 3
+CM
+18
+11.33 ± 2.79
+12.87 ± 2.47
+(1,17)
+4.49
+0.05
+0.58
+13.5
+SR
+10.87 ± 2.10
+12.47 ± 2.06
+(1,17)
+7.11
+0.018*
+0.76
+15.2
+10
+AVLT Trial 4
+CM
+18
+11.87 ± 2.41
+12.87 ± 2.32
+(1,17)
+8.75
+0.01*
+0.42
+8.4
+SR
+11.13 ± 2.50
+13.27 ± 1.71
+(1,17)
+14.54
+0.002**
+0.96
+19.2
+11
+AVLT Trial 5
+CM
+18
+12.80 ± 2.73
+13.33 ± 1.98
+(1,17)
+2.51
+0.135
+0.21
+4.14
+SR
+11.87 ± 2.16
+13 ± 1.92
+(1,17)
+11.36
+0.005**
+0.55
+9.5
+12
+AVLT List B
+CM
+18
+6.87 ± 2.64
+8.33 ± 2.87
+(1,17)
+8.73
+0.01*
+0.52
+21.2
+SR
+6.13 ± 2.32
+7.53 ± 2.13
+(1,17)
+54.15
+0.001**
+0.62
+22.8
+13
+Instant Recall (IR)
+CM
+18
+11.47 ± 2.87
+12.27 ± 2.86
+(1,17)
+1.67
+0.21
+0.27
+6.9
+SR
+10.80 ± 2.88
+12.33 ± 2.92
+(1,17)
+8.85
+0.01*
+0.51
+14.1
+14
+Delayed Recall (DR)
+CM
+18
+11.60 ± 3.54
+12.60 ± 2.74
+(1,17)
+4.2
+0.06
+0.31
+8.6
+SR
+11.13 ± 2.87
+13.07 ± 2.60
+(1,17)
+29.14
+0.001**
+0.7
+17.4
+15
+Hits
+CM
+18
+14.27 ± 0.96
+14.73 ± 0.45
+(1,17)
+2.9
+0.11
+0.55
+3.2
+SR
+14.13 ± 1.40
+14.67 ± 0.48
+(1,17)
+3.02
+0.1
+0.43
+3.8
+16
+Omission Errors
+CM
+18
+0.73 ± 0.96
+0.27 ± 0.45
+(1,17)
+2.97
+0.11
+0.55
+63
+SR
+0.87 ± 1.40
+0.33 ± 0.48
+(1,17)
+3
+0.1
+0.43
+62
+17
+Commission Errors
+CM
+18
+1.20 ± 1.61
+1.07 ± 1.28
+(1,17)
+0.07
+0.67
+0.08
+10.8
+SR
+1.07 ± 1.66
+1.00 ± 1.13
+(1,17)
+0.18
+0.79
+0.04
+6.5
+aSignificance within sessions (pre vs post) using repeated measures ANOVA after adjustment for multiple comparisons: Bonferroni.
+*Significant at p < 0.05 level: mean difference within sessions.
+**Significant at p < 0.01 level: mean difference within sessions.
+TMT-a: Trail making test-a; TMT-b: Trail making test-b; DSST_T: Digit Symbol Substitution Test-Correct; DSST_R: Digit Symbol Substitution Test- Error; FDS:
+Forward Digit Span; BDS: Backward Digit Span; AVLT Trial 1–5 (Instant Recall of List A): Auditory Verbal Learning Test—Trial 1–5; List B: Distractor List; IR:
+Immediate Recall of List A; DR: Delayed Recall of List A; Hits: Number of Correct targets recognized in Recognition list; Omission: Number of targets missed
+in Recognition list; Commission: Number of wrong targets recognized in Recognition list.
+INTERNATIONAL REVIEW OF PSYCHIATRY
+303
+increased significantly after CM as compared to SR
+(Table 4).
+Discussion
+The present study has found CM to be useful in
+improving
+information
+processing
+speed
+(TMT-A;
+p < 0.001) and executive functions (TMT-B; p < 0.05)
+in patients suffering from RRMS. Although SR practice
+also leads to improvement in attention, psycho-motor
+performance, and memory, between-groups compari-
+son revealed CM to be significantly more effective
+than SR in improving verbal working memory, short-
+term memory (FDS; p ¼ 0.01), and information proc-
+essing speed (TMT-A; p < 0.01).
+Cognitive dysfunction is associated with reduced
+functional status, and is a major contributor to mor-
+bidity in RRMS. Although any area of cognition can
+be affected, information processing ability, attention,
+working memory, and executive functions are the most
+vulnerable ones (Chiaravalloti & DeLuca, 2008). Thus,
+the present study addressed an important symptom in
+RRMS population. A number of studies have shown
+that, as compared to healthy individuals, people with
+MS have significantly low functioning in cognitive
+domains of learning, memory, attention, processing
+speed, visuo-spatial abilities, language, and executive
+functions. In a recent study (Subramanya & Telles,
+2009b) that tested working memory on healthy volun-
+teers, the baseline scores for FDS and BDS were
+6.28 ± 1.4 and 5.07 ± 1.47, which is higher by 5.2% and
+10%, respectively, as compared to the scores of RRMS
+patients in our study. Another study (Raghavendra &
+Telles, 2012) assessed attention in healthy young vol-
+unteers; baseline scores for DSST were 55.13 ± 11.76,
+which is higher by 35.2% from the scores of our MS
+subjects. Similarly, baseline scores for TMT-a and
+TMT-b of healthy adults were found to be 33.07 ± 1.75
+and
+77.45 ± 4.17
+in
+another
+study
+(Mastroiacovo,
+Kwik-Uribe, Grassi, Necozione, Raffaele, Pistacchio,
+et al., 2015). These scores are lesser by 29.8% (TMT-a)
+and 20.5% (TMT-b) from those RRMS subjects who
+participated in our study. Although the above compar-
+isons are not age, gender, and race-matched, still they
+reinforce the fact that cognition is impaired in RRMS
+patients as compared to healthy individuals.
+There has been overwhelming evidence over the last
+few years that the most fundamental cognitive deficit
+experienced by MS individuals is information process-
+ing ability (Chiaravalloti & DeLuca, 2008), of which
+two components have been the focus of a recent study
+in MS: working memory (WM) and processing speed
+(PS) (Demaree, DeLuca, Gaudino, & Diamond, 1999).
+WM is the ability to maintain information, while sim-
+ultaneously processing and manipulating such infor-
+mation (Baddeley & Hitch, 1994) . Previously, a study
+used cyclic meditation (CM) in 57 healthy male volun-
+teers to show improvement in working memory (as
+assessed by forward and backward digit spans) imme-
+diately after the practice. There was a greater magni-
+tude of increase in scores for the digit span after CM
+(FDS: 27.7%; BDS: 33.5%) compared with that after
+Table 4. Between-group comparisons before and after cyclic meditation (CM) and supine rest (SR).
+SN
+Variable
+n
+Df (Hypothesis,
+Error)
+Mean ± SD
+(Pre CM)
+Mean ± SD
+(Pre SR)
+F value
+(Pre)
+pa value
+(Pre)
+Mean ± SD
+(Post CM)
+Mean ± SD
+(Post SR)
+F value
+(Post)
+pa value
+(Post)
+1
+TMT-a
+18
+(1,17)
+51.25 ± 28.7
+47.13 ± 30.24
+1.7
+0.21
+38.3 ± 25.3
+45.5 ± 29.2
+8.3
+0.01**
+2
+TMT-b
+18
+(1,17)
+103.70 ± 62.15
+97.46 ± 55.75
+0.9
+0.35
+91.92 ± 54.14
+89.3 ± 50.11
+0.12
+0.72
+3
+DSST_T
+18
+(1,17)
+35.69 ± 17.62
+33.56 ± 15.21
+0.67
+0.42
+39.31 ± 17.66
+38.38 ± 15.46
+0.18
+0.67
+4
+DSST_R
+18
+(1,17)
+0.31 ± 0.60
+0.31 ± 0.47
+0.001b
+1
+0.19 ± 0.40
+0.31 ± 0.87
+0.31
+0.58
+5
+FDS
+18
+(1,17)
+6.0 ± 1.414
+6.31 ± 1.07
+1.2
+0.28
+6.56 ± 1.20
+5.63 ± 1.20
+16.3
+0.01**
+6
+BDS
+18
+(1,17)
+4.56 ± 1.031
+4.69 ± 1.014
+0.23
+0.63
+4.69 ± 0.793
+4.69 ± 1.07
+0.01
+1
+7
+AVLT Trial 1
+18
+(1,17)
+9.27 ± 3.058
+7.73 ± 3.127
+1.88
+0.19
+12.00 ± 3.44
+11.40 ± 2.61
+0.46
+0.5
+8
+AVLT Trial 2
+18
+(1,17)
+10.13 ± 2.97
+9.40 ± 2.53
+0.48
+0.49
+12.27 ± 3.17
+12.27 ± 1.98
+0.01
+1
+9
+AVLT Trial 3
+18
+(1,17)
+11.33 ± 2.79
+10.87 ± 2.10
+0.3
+0.58
+12.87 ± 2.47
+12.47 ± 2.06
+0.42
+0.52
+10
+AVLT Trial 4
+18
+(1,17)
+11.87 ± 2.41
+11.13 ± 2.50
+0.9
+0.35
+12.87 ± 2.32
+13.27 ± 1.71
+0.8
+0.38
+11
+AVLT Trial 5
+18
+(1,17)
+12.80 ± 2.73
+11.87 ± 2.16
+2.65
+0.12
+13.33 ± 1.98
+13 ± 1.92
+0.51
+0.48
+12
+AVLT List B
+18
+(1,17)
+6.87 ± 2.64
+6.13 ± 2.32
+1.29
+0.27
+8.33 ± 2.87
+7.53 ± 2.13
+1.63
+0.22
+13
+Instant Recall (IR)
+18
+(1,17)
+11.47 ± 2.87
+10.80 ± 2.88
+1.04
+0.32
+12.27 ± 2.86
+12.33 ± 2.92
+0.01
+0.91
+14
+Delayed Recall (DR)
+18
+(1,17)
+11.60 ± 3.54
+11.13 ± 2.87
+0.33
+0.57
+12.60 ± 2.74
+13.07 ± 2.60
+0.45
+0.5
+15
+Hits
+18
+(1,17)
+14.27 ± 0.96
+14.13 ± 1.40
+0.18
+0.67
+14.73 ± 0.45
+14.67 ± 0.48
+0.31
+0.58
+16
+Omission Errors
+18
+(1,17)
+0.73 ± 0.96
+0.87 ± 1.40
+0.18
+0.67
+0.27 ± 0.45
+0.33 ± 0.48
+0.31
+0.58
+17
+Commission Errors
+18
+(1,17)
+1.20 ± 1.61
+1.07 ± 1.66
+0.13
+0.67
+1.07 ± 1.28
+1.00 ± 1.13
+0.38
+0.79
+aSignificance between sessions (CM vs SR) using repeated measures ANOVA after adjustment for multiple comparisons: Bonferroni.
+**Significant at p < 0.01 level: mean difference within sessions.
+TMT-a, Trail making test-a; TMT-b, Trail making test-b; DSST_T, Digit Symbol Substitution Test-Correct; DSST_R, Digit Symbol Substitution Test- Error; FDS,
+Forward Digit Span; BDS, Backward Digit Span; AVLT Trial 1–5 (Instant Recall of List A), Auditory Verbal Learning Test—Trial 1–5; List B, Distractor List; IR,
+Immediate Recall of List A; DR, Delayed Recall of List A; Hits, Number of Correct targets recognized in Recognition list; Omission, Number of targets missed
+in Recognition list; Commission, Number of wrong targets recognized in Recognition list.
+304
+B. PRAERNA ET AL.
+SR (FDS: 16.1%; BDS: 9.2%) (Subramanya & Telles,
+2009b). In our study, we found a significant increase
+in forward digit span (9.3%), whereas a non-significant
+increase in backward digit span (2.85%) after CM in
+MS patients. However, after SR we observed a signifi-
+cant reduction in FDS scores (10.7%) with not much
+difference in BDS scores. This shows that there is a
+difference in the way MS patients respond to yogic
+relaxation techniques as compared to healthy subjects
+on WM tasks. Healthy subjects show greater improve-
+ment in working memory after CM as compared to
+MS patients (27.7% vs 9.3%; FDS). This may be due to
+greater receptivity of healthy volunteers to these tech-
+niques as they have greater cognitive flexibility as com-
+pared to MS patients (Chiaravalloti & DeLuca, 2008).
+Similarly, the reason behind significant decline in FDS
+after SR in MS patients observed by us may be
+explained by the fact that practice of SR simply
+involves lying down for 30 min, which may cause
+induction
+of
+sleep
+and
+reduced
+alertness
+in
+MS
+patients who are more prone for fatigue (Krupp,
+Alvarez, LaRocca, & Scheinberg, 1988).
+The effect of CM or SR on DSST, TMT-A, TMT-B,
+and AVLT has not been tested before, and this study
+shows that, apart from increasing working memory,
+CM technique can also lead to significant enhance-
+ment of psychomotor performance, information proc-
+essing speed, executive function, and immediate and
+delayed recall in MS patients. This is an added benefit
+in this population, as cognitive dysfunction of these
+domains has been observed in patients with RRMS,
+both as a consequence of disease (Amato et al., 2006;
+Langdon, 2011) and as a side-effect of medications
+(Oken et al., 2006). Also, CM showed better improve-
+ment in information processing speed and working
+memory, as compared to SR, which are key cognitive
+deficits in MS. A recent study demonstrated that both
+WM and PS may contribute to performance on a com-
+plex information processing task, but PS is the key
+impairment and underlying cause of other cognitive
+impairments,
+such
+as
+WM
+(Lengenfelder,
+Bryant,
+Diamond, Kalmar, Moore, & DeLuca, 2006) and
+executive dysfunction (Drew, Starkey, & Isler, 2009).
+There has not been much research done so far to test
+the effectiveness of cognitive rehabilitation techniques
+aimed at improving PS in persons with MS (O’Brien,
+Chiaravalloti, Goverover, & DeLuca, 2008). The only
+study done on MS is computer-based training pro-
+grams, which showed improvement in information
+processing treatments, or treatments that address WM
+and PS combined. In our study we found a significant
+decrease
+(25.2%
+and
+11.3%)
+in
+time
+taken
+for
+information processing and executive performance,
+respectively.
+A number of studies have demonstrated efficacy of
+both CM and SR in enhancing cognitive functions in
+healthy individuals before (Sarang & Telles, 2006b,
+2007). Almost all previous studies found CM to be
+more effective than SR in improving cognitive func-
+tions. This improvement in cognitive ability can be
+explained by two mechanisms: decline in cognitive
+function has been found to be associated with low
+moods (depression) and Yoga techniques has been
+reported to produce improvements in mood (Berger &
+Owen, 1992); secondly, Yoga may improve more
+general attentional abilities as it emphasizes body
+awareness and involves focusing one’s attention on
+breathing or specific muscles or parts of the body. It
+produces similar effects as relaxation, as it tends to
+promote self-control, attention and concentration, self-
+efficacy, body awareness, and stress reduction (Nardo
+& Reynolds, 2002).
+Recent studies on CM suggested that sympathetic
+activation occurred during the yoga posture phase and
+the parasympathetic nervous system became dominant
+after the practice of CM (Sarang & Telles, 2006b). Its
+unique effect of improvement in attention while reduc-
+ing sympathetic tone may be related to increased pro-
+prioceptive input (during the practice of asanas) to the
+Reticular Activating System (RAS), which in turn
+keeps cortical areas receptive and active (Kandel,
+Schwartz, & Jessell, 2000). Mindfulness-based practices
+may also enhance cognitive flexibility, which further
+helps in better cognitive performance (Lee & Orsillo,
+2014). Another way through which CM may lead to
+better cognitive performance is by reduction in state
+anxiety immediately after the practice, as shown in a
+previous study (Subramanya & Telles, 2009b). Cyclic
+meditation is described as a moving meditation, as,
+during these practices, practitioners ideally assume a
+meditative state of mind which is characterized by
+interoception, awareness of body sensations, and relax-
+ation (Vishnu, 2001). A previous study on 60 young
+healthy individuals, assessing performance in atten-
+tional tasks following meditative focusing and focusing
+without meditation, showed better incidental learning
+and better accuracy (as assessed by digit symbol substi-
+tution test) after meditative focusing than just focusing
+without meditation (Raghavendra & Telles, 2012).
+Strengths
+The major strengths of the present study are: (a) This
+multidisciplinary study encompasses the fields of yogic
+science, psychology, and neurology; (b) the present
+INTERNATIONAL REVIEW OF PSYCHIATRY
+305
+study is the first attempt to assess the effect of yogic
+relaxation techniques on cognitive functions in a clin-
+ical condition like MS in a German population;
+(c) because the duration of yoga intervention was short,
+acceptability, and adherence to therapy was good; and
+(d) as CM was delivered through a standard protocol,
+it could be reproduced in the exact way for all cases.
+Limitations
+This study has several limitations as well. The most
+important limitation is small sample size. A self-as-
+control design was used because of the lack of a suffi-
+cient
+number
+of
+subjects.
+Second,
+although
+the
+sequence of two interventions was assigned randomly
+and the comparison between two interventions may
+nullify the practice effect of neuro-psychological tests
+to some extent, the possibility of changes in the post-
+assessment scores due to practice effect cannot be
+ruled out completely. Third, exploration of mood
+states was not performed in the present work. Thus, it
+is not clear whether the improvement in cognition was
+a direct effect of yogic relaxation techniques or it was
+due to improvement in the mood states. In the present
+study we did not follow-up as to how long the
+response to CM continues. In future, a dose–response
+curve could be generated by performing repeated
+measures.
+No-objective
+parameters
+were
+used
+to
+understand the mechanism of action of CM at the
+electro-physiological,
+neurological,
+and
+biochemical
+levels in MS patients. Lastly, it is difficult to determine
+any single pure measure to assess a particular cognitive
+domain, each task assesses many aspects of cognitive
+domains and it is, therefore, unclear whether utilizing
+a different measure would have altered the findings in
+any way. So, replication of these results with different
+measures is necessary to draw definitive conclusions
+about the constructs assessed. Overall, the present
+study is a preliminary attempt to assess the cognitive
+responses of RRMS patients to yoga relaxation techni-
+ques to get directions for future research in this area.
+The results should be generalized with caution.
+Future implications
+Future studies should find out the effect of yoga-based
+relaxation techniques on cognition of MS patients
+across different EDSS categories and find out whether
+the responses of the patients vary with extent of dis-
+ability. Future studies should also find out the prob-
+able mechanism of action of yoga-based relaxation
+techniques
+using
+objective
+variables
+of
+autonomic
+functions such as heart rate variability and galvanic
+skin resistance, advanced neuro-imaging devices such
+as EEG, fNIRS and fMRI, and biomarkers. Follow-up
+studies for assessment of long-term effect and required
+frequency
+of
+such
+interventions
+should
+also
+be
+planned. Future studies should use larger sample size
+with a randomized controlled design. Future studies
+should assess mood states along with cognition while
+assessing effects of yoga-based techniques in the MS
+population. The effect of CM should also be tested in
+other neuro-psychiatric disorders where psychomotor
+retardation is observed; for example, brain-damaged
+individuals and patients suffering from dementia and
+depression. Future studies should also use drug-naive
+MS subjects to rule out the effects of the drugs and
+compare the effect of CM with other mind–body relax-
+ation techniques.
+Conclusion
+Yogic relaxation techniques may have an immediate
+enhancing effect on processing speed, psychomotor
+performance, and recall of RRMS patients. CM is bet-
+ter than SR in improving processing speed, short-term
+memory, and verbal working memory.
+Acknowledgements
+We acknowledge the subjects who gave their consent and
+participated in this study. We are grateful for the co-
+operation by the staff and management of SVYASA Yoga
+University, Bangalore and KWA Klinik, Stift Rottal, Bad
+Griesbach, Germany.
+Disclosure statement
+The authors report no conflicts of interest. The authors
+alone are responsible for the content and writing of the
+paper.
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diff --git a/subfolder_0/Impact of yoga therapy in improving perceived stress, depression, and quality of life in elderly population A randomized controlled trial.txt b/subfolder_0/Impact of yoga therapy in improving perceived stress, depression, and quality of life in elderly population A randomized controlled trial.txt
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+62
+© 2022 Journal of Applied Consciousness Studies | Published by Wolters Kluwer - Medknow
+Introduction: Geriatric population is vulnerable to physical and emotional 
+discommodes that requires expert care from a holistic perspective. Depression, 
+stress, anxiety, etc., are the common problems faced by the elderly. Holistic 
+interventions such as yoga are reckoned to be a pillar in alleviating these issues; 
+however, most of the studies in this arena are conducted on elderly who resides in 
+shelter homes. Materials and Methods: Ninety‑six participants were randomized 
+to a yoga or waitlisted control group  (n  =  48 each). Yoga group received a set 
+of yogic practices for 12  weeks. Assessments were done using Perceived Stress 
+Scale  (PSS), Geriatric Depression Scale  (GDS), and older people quality of 
+life (OPQOL). Results: Yoga group has shown statistically significant reduction in 
+PSS (P < 0.001), GDS (P = 0.001), and improvement in the selected components 
+of OPQOL such as social relationship  (P  =  0.014), neighborhood  (P  =  0.001), 
+psychological well‑being  (P  =  0.001), financial circumstances  (P  =  0.001), and 
+OPQOL  –  total  (P  =  0.001). Discussion: The results indicate that yoga can 
+successfully be implemented in the elderly population on an outpatient basis and 
+can produce clinically beneficial effects. Nurses, physicians, and other therapists 
+should consider integrating yoga in the elderly. Conclusion: The results of 
+this study are encouraging to recommend yoga as a stand-alone mind-body 
+rehabilitation program for older adults. 
+Keywords: Depression, elderly population, perceived stress, quality of life, yoga
+Submission:  16-10-2021,	
+Revision:  31-01-2022, 
+Acceptance:  05-02-2022,	
+Publication:  26-04-2022
+Impact of Yoga Therapy in Improving Perceived Stress, Depression, and 
+Quality of Life in Elderly Population: A Randomized Controlled Trial
+H R Shree Ganesh, Pailoor Subramanya1, M Raghavendra Rao2, H S Vadhiraj2, Vivek Udupa3
+Access this article online
+Quick Response Code:
+Website: www.jacsonline.in
+DOI: 10.4103/ijoyppp.ijoyppp_26_21
+Address for correspondence: Dr. Pailoor Subramanya, 
+Department of Yoga Studies, School of Medicine and 
+Public Health, Central University of Kerala, Periya Post, 
+Kasaragod ‑ 671 320, Kerala, India. 
+E‑mail: pailoors@cukerala.ac.in
+Ivbijaro, 2013). Mental health disarrays are associated 
+with compromised quality of life, performance of 
+day‑to‑day activities, and increased dependency on 
+others  (Lima & Ivbijaro, 2013). The demographic 
+transition due to rapid urbanization/industrialization and 
+subsequent disintegration of joint family culture in India 
+has a huge role to play on diminished mental health of 
+Indian older adults. Reports suggest that susceptibility to 
+Original Article
+Introduction
+A
+ging is an inevitable phenomenon. With this 
+unprecedented rise in aging population, there is 
+a surge in health‑care needs and challenges associated 
+with this vulnerable group (Bhan et al., 2017). As per the 
+2013 data, India has 8% of its population above 60 years 
+of age or more. This number is expected to increase 
+by 18.3% in 2050  (Bhan et  al., 2017; GOI Office 
+of the Registrar General and Census Commissioner 
+India, 2011; United  Nations, 2013). Indian elderly 
+population are equally burdened by communicable 
+and noncommunicable diseases  (Ingle & Nath, 2008). 
+Among all the morbidities, elderly population are more 
+prone to mental health morbidities which is reckoned as 
+one of the greater challenge to be addressed (Lima & 
+Division of Life Science, 
+Swami Vivekananda Yoga 
+AnusandhanaSamsthana, 
+Bengaluru, 3Department 
+of Yoga and Naturopathy, 
+SarvaKshema Hospital and 
+Research Foundation, Udupi, 
+Karnataka, 1Department 
+of Yoga Studies, School 
+of Medicine and Public 
+Health, Central University of 
+Kerala, Kasaragod, Kerala, 
+2Department of Research, 
+Central Council for Research 
+in Yoga and Naturopathy, 
+New Delhi, India 
+Abstract
+This is an open access journal, and articles are distributed under the terms of the 
+Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows 
+others to remix, tweak, and build upon the work non‑commercially, as long as 
+appropriate credit is given and the new creations are licensed under the identical 
+terms.
+For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com
+How to cite this article: Shree Ganesh HR, Subramanya P, Rao MR, 
+Vadhiraj HS, Udupa V. Impact of yoga therapy in improving perceived 
+stress, depression, and quality of life in elderly population: A randomized 
+controlled trial. J Appl Conscious Stud 2022;10:62-8.
+[Downloaded free from http://www.jacsonline.in on Thursday, January 5, 2023, IP: 103.39.126.58]
+Ganesh et al.: Yoga in elderly
+63
+Journal of Applied Consciousness Studies  ¦  Volume 10  ¦  Issue 1  ¦  January‑June 2022
+depression, anxiety, dementia, and suicidal tendency is 
+directly proportional with the age (Parkar, 2015).
+The prevalence of depression among geriatric population, 
+as reported by a recent meta‑analysis is 34.4%, which 
+indicates that about 1/3rd  of India’s elderly population 
+is suffering from depression  (Pilania et  al., 2019). 
+Similarly, the prevalence of anxiety disorders among 
+the Indian geriatric population is estimated to be 10.8%. 
+Further to these, there are studies suggestive of a greater 
+proportion of elderly population in India, as like other 
+developing countries, who are living with compromised 
+health conditions which is associated with a higher 
+prevalence of morbidity  (Basu & King, 2013; Chatterji 
+et al.,  2008). All the aforementioned statistics suggests 
+that the Indian geriatric population are thriving through a 
+difficult situation where they have to deal with a greater 
+level of stress. Thus, depression, chronic morbidity 
+coupled with psychological stress can catalyze adverse 
+events in older adults like functional disability, frequent 
+hospitalization, and death (Carneiro et al., 2016).
+Yoga, a 3000‑year‑old Indian traditional wisdom 
+integrates the body, mind, and spiritual component of an 
+individual to invigorate health (Atkinson, 2009; Williams 
+et  al., 2003). Numerous studies have demonstrated 
+the mental health benefit of yoga in managing stress, 
+cultivating 
+positive 
+emotion, 
+and 
+balancing 
+the 
+mind  (Duan‑Porter et  al., 2016; Shohani et  al., 2018). 
+Yoga has also shown to ease psychological distress, 
+depression, mood, thereby offering improvement in 
+quality of life as well as physiological and functional 
+measures 
+in 
+elderly 
+population 
+(Mooventhan 
+& 
+Nivethitha, 2017). Although there are many studies 
+expressing the beneficial effects of yoga in the elderly, 
+most of the Indian studies in this arena are focused on 
+the special population among the elderly such as shelter 
+home elderly, homeless population, etc.,  (Grover & 
+Malhotra, 2015). Studies based on general community 
+or elders living in own homes are scarce in this 
+field (Bhandari & Paswan, 2021). Further, the feasibility 
+of delivering yoga therapy in diverse clinical settings 
+needs to be explored. This study focuses on assessing 
+the effects of yoga intervention on perceived stress, 
+self‑reported depression, and quality of life in the 
+elderly population not residing in any shelter homes 
+who underwent yoga therapy on an outpatient basis.
+Materials and Methods
+Design
+This study was conducted as a randomized controlled 
+trial and was approved by Institutional Ethical review 
+board. The trial was registered with Clinical Trail 
+Registry of India  (CTRI/2020/05/025268). This was a 
+prospective, two‑arm, randomized wait listed controlled 
+study comparing yoga‑based lifestyle intervention 
+program with usual care with randomization done 
+using computer‑generated random numbers and opaque 
+envelopes with group assignments by investigator who 
+was not involved in the field implementation of the study. 
+The participants were randomized to yoga (n = 48) and 
+waitlisted control group (n = 48) with allocation ratio of 
+1:1. Allocation concealment was done by individuals not 
+involved in the study.
+Participants
+The participants were elderly population residing at 
+Udupi, Karnataka who were referred by their primary 
+care physicians or voluntarily enrolled themselves in 
+response to our advertisements in local newspapers and 
+social media platforms. Consented participants were 
+randomized either into a yoga arm or a wait‑listed control 
+arm. Elderly population who are literate, aged between 
+60 and 75 years and had a Zubrod’s performance score 
+ranging between 0 and 2 were included in the study.
+Participants who had a history of yoga practice within 
+the past 12  months of recruitment were excluded from 
+the study. Other exclusion criteria for participation were 
+uncontrolled diabetes, uncontrolled hypertension, endocrine 
+disorders, known history of symptomatic heart disease, 
+lung disease, dementia, on bronchodilator prescription, 
+clinically requiring psychological support, poststroke 
+profile, neuromusculoskeletal illnesses, major orthopedic 
+disorders of the lower back, pelvis or lower extremities, 
+rheumatoid arthritis, osteoarthritis, history of recent 
+fractures/trauma affecting mobility, on a prescription drug 
+therapy for metabolic abnormalities, physical conditions 
+not suitable for exercise training, and tobacco users.
+Sample size
+Standardized effect size with cyclic meditation versus 
+supine rest on low frequency power on heart rate 
+variability was 0.25 and 0.75 for high frequency  (HF) 
+calculated using G power for paired differences. 
+Considering a conservative estimate of effect size as 
+0.75 for HF, the effect size was 0.75 and for an alpha 
+of 0.05, and 90% power the total sample size was 78 
+participants, i.e., 39 participants in each arm for a two 
+group allocation. Taking into consideration, a dropout 
+rate of 25%  (9 subjects) we will recruit, approximately 
+48 participants in each arm (Sarang & Telles, 2006).
+Those participants who were enrolled into yoga arm 
+started with yoga protocol for 3 months in an outpatient 
+yoga clinic immediately after the recruitment, whereas 
+participants in the control group did not receive any 
+interventions until the completion of the trial. We had 
+15 dropouts from the control arm owing to loss to 
+[Downloaded free from http://www.jacsonline.in on Thursday, January 5, 2023, IP: 103.39.126.58]
+Ganesh et al.: Yoga in elderly
+64
+Journal of Applied Consciousness Studies ¦  Volume 10  ¦  Issue 1  ¦  January‑June 2022
+follow‑up, re‑location from the study locality or the 
+participant enrolling in to other yoga sessions elsewhere 
+before the completion of the trial. We have included all 
+the participants originally enrolled for the study in the 
+final analysis based on intention to treat analysis. The 
+trial flow diagram is depicted in Figure 1.
+Intervention
+Yoga group received a customized yoga protocol that 
+includes Sukshma vyayama  (loosening exercises), 
+a set of asanas  (postures done with awareness), 
+breathing exercises, pranayama  (voluntarily regulated 
+nostril breathing), and yogic relaxation. The in‑person 
+sessions were scheduled thrice per week for 12  weeks 
+consecutively. All the participants were mandated to 
+attend three in‑person sessions per week and practice at 
+home on the remaining days of the week.
+Each of these sessions lasted for 1  h and was 
+administered by a trained yoga therapist. The control 
+groups remained as waitlist with routine daily activities 
+and were offered the same yoga intervention after the 
+completion of 12 weeks of waitlist control period.
+Assessments
+As discussed above, the main expected outcome 
+measures 
+were 
+melioration 
+of 
+perceived 
+stress, 
+depression, and quality of life. The assessments were 
+done using the following instruments.
+Perceived Stress Scale
+Perceived Stress Scale  (PSS) is one of the widely 
+used stress scale used to determine the magnitude 
+of situations that are perceived by individuals 
+as unpredictable, uncontrollable and detrimental 
+compared to previous month of their life. The 
+latest version of PSS is a 10‑item scale designed 
+as a self‑appraisal of the effects stressors on one’s 
+life (Cohen et al., 1983).
+Geriatric Depression Scale
+A 15‑item geriatric depression scale  (GDS) instrument 
+was used in this study to ascertain the status of 
+depression in our study participants. GDS can be 
+self‑administered or can be utilized as an interview tool 
+as the questions are of yes/no format which can be easily 
+comprehended by the elderly population  (Conradsson 
+et al., 2013; Montorio & Izal, 1996).
+Older people quality of life questionnaire
+The OPQOL is a 35‑item QoL measure which has a 
+5‑point Likert scales representing: Life overall, health, 
+social relationships and participation, independence, 
+control over life, freedom, home and neighborhood, 
+Enrollment
+Assessed for eligibility (n = 128)
+Randomized (n = 96)
+Allocation
+Follow-Up
+Allocated to intervention (n = 48)
+• Received allocated intervention (n = 48)
+Analysis
+Allocated to Waitlisted control (n = 48  )
+• Final Waitlisted control (n = 33  )
+• Did not receive allocated intervention
+  (Moved outside, joined other classes) (n = 8)
+Lost to follow-up (n = 0)
+Discontinued intervention (n = 0)
+Lost to follow-up (Moved outside,
+joined other classes) (n = 8)
+Analysed  (n = 48)
+• Excluded from analysis (n = 0)
+Analysed  (n = 48)
+• Intention to treat Analysis
+Excluded  (n = 32)
+•   Not meeting inclusion criteria (n = 25)
+•   Declined to participate (n = 5)
+•   Other reasons (n = 2)
+Figure 1: Trial profile
+[Downloaded free from http://www.jacsonline.in on Thursday, January 5, 2023, IP: 103.39.126.58]
+Ganesh et al.: Yoga in elderly
+65
+Journal of Applied Consciousness Studies  ¦  Volume 10  ¦  Issue 1  ¦  January‑June 2022
+psychological and emotional well‑being, financial 
+circumstances, and religion/culture (Bowling, 2009).
+Data analysis
+Data were analyzed using the Statistical Package for 
+the Social Sciences (SPSS) Software, Version 18, IBM, 
+New York, United States of America. The demographic 
+characteristics of the participants are presented using 
+descriptive statistics. While the two groups were 
+comparable at baseline, they were not normally 
+distributed. We therefore performed a nonparametric 
+Wilcoxon’s signed‑rank test and Mann − Whitney test to 
+assess the magnitude of the changes within and between 
+the groups. An alpha of 0.05 was considered significant. 
+Data were analyzed using an Intention to treat approach 
+where missing values of dropouts were substituted by 
+carrying forward their respective baseline values.
+Results
+We have recruited 96 participants who were randomized 
+into either of the group (n = 48 per group). At the end 
+of the trial, 81 participants  (yoga  =  48 and waitlisted 
+control  =  33) completed the study. The complete 
+demographic profiling is tabulated in Table  1. Gender 
+distribution was unequal across the groups.
+Comparison of perceived stress scale score
+There was a significant decrease in PSS scores within 
+yoga group  (P  =  0.0001) on Wilcoxon’s signed‑rank 
+test, whereas there was no significant change in the 
+control group. Compared to control group, yoga 
+group had statistically significant decrease in PSS 
+scores  (P  <  0.001) on Mann  −  Whitney U‑test. The 
+detailed results are tabulated in Table 2.
+Comparison of geriatric depression scale scores
+There was a significant decrease in self‑reported 
+depression 
+on 
+GDS 
+in 
+yoga 
+group 
+following 
+intervention  (P  =  0.001) on Wilcoxon’s signed‑rank 
+test, whereas there was no change within the control 
+group. There was a statistically significant decrease in 
+self‑reported depression score in yoga group as compared 
+to control group (P = 0.001) on Mann − Whitney U test, 
+as shown results in Table 2.
+Comparison of OPQOL scores
+Wilcoxon’s signed‑rank test to assess within group 
+showed a significant improvement in the various 
+components 
+of 
+OPQOL 
+such 
+as 
+psychological 
+well‑being, comfort in the neighborhood, financial 
+well‑being  (P  =  0.001) in both yoga and control 
+group, whereas the total scores were significant only 
+in the yoga group  (P  =  0.001). Mann  −  Whitney 
+test to assess between group difference showed 
+a significant improvement in social relationship 
+(z = −2.45, P  =  0.014), neighborhood  (z = −6.18, 
+P  =  0.001), psychological well‑being  (z = −6.18, 
+P  =  0.001), financial circumstances  (z = −7.06, 
+P  =  0.001), OPQOL  –  total (z = −9.09, P  =  0.001) 
+following intervention in yoga group as compared to 
+the control group as assessed by older people quality 
+of life questionnaire [Table 3].
+Table 1: Demographic profiling of the study groups
+Parameters
+Yoga group (n=48)
+Control group (n=48)
+Gender, n (%)
+Female
+34 (71)
+26 (54)
+Male
+14 (29)
+22 (46)
+Age (years), mean±SD
+62.6 (3.9)
+65.5 (3.4)
+Marital status (n)
+Single
+1
+0
+Married
+47
+48
+Body mass index, mean±SD
+25.32±3.27
+23.79±2.93
+Systolic blood pressure, mean±SD
+133.85±16.99
+145.71±24.19
+Diastolic blood Pressure, mean±SD
+74.13±7.89
+76.71±10.81
+Presence of comorbid illness/medical conditions (n)*
+Hypertension
+21
+19
+Diabetes mellitus
+23
+14
+Knee arthralgia
+25
+18
+Irregular bowels
+18
+18
+Chronic fatigue
+12
+15
+Lower back ache
+24
+24
+Skin allergy
+11
+11
+Asthma
+5
+11
+Disturbed sleep
+17
+9
+*Most of the participants had multiple medical conditions. SD: Standard deviation
+[Downloaded free from http://www.jacsonline.in on Thursday, January 5, 2023, IP: 103.39.126.58]
+Ganesh et al.: Yoga in elderly
+66
+Journal of Applied Consciousness Studies ¦  Volume 10  ¦  Issue 1  ¦  January‑June 2022
+Discussion
+Our result suggests that yoga therapy can successfully be 
+implemented in the elderly population on an outpatient 
+basis and can produce clinically beneficial effects for this 
+vulnerable population. Our study has shown significant 
+improvement in perceived stress, depression, and quality 
+of life following 3 months of intervention in yoga group 
+as compared to waitlisted control group.
+Yoga as an intervention for depression is widely 
+recommended by various studies  (Bridges & Sharma, 
+2017; Lee et  al., 2019; Mehta & Sharma, 2010; 
+Ramanathan et  al., 2017). Our results concur with 
+these earlier studies which are mostly conducted as an 
+in‑house yoga programs in assisted living facilities. 
+Systematic reviews on yoga and depression have 
+reported that most of the previous studies on yoga and 
+depression were short‑term studies averaging 6  weeks 
+of duration and a relatively small sample size  (Bridges 
+& Sharma, 2017). The present study took this fact in to 
+consideration and has evaluated the effects of yoga for 
+6 months with 96 participants.
+Yoga a scientific form of body mind therapy is hailed 
+for its influence on maintaining mental health, offering 
+happiness, and enhancing general well‑being. Earlier 
+studies have reckoned yoga to improve mobility, quality 
+of sleep, tolerability to pain, functional status, and 
+health related quality of life in older adults (Chen et al., 
+2010; Groessl et al., 2013; Kutz et al., 1985). Our study 
+reiterates these findings on a larger sample size with 
+a real‑time participants living in the family settings. 
+Considering the alarming numbers of depressive older 
+population in India  (Pilania et  al., 2019), the results 
+of this study are very important as heightened state 
+of mental well‑being and improvement in quality of 
+life can be attributed to marked improvement in daily 
+performance, reduction in age‑related falls and injuries.
+Our study also tried to demystify the general 
+thought that yoga practice cannot be consistently 
+delivered to older adults out‑side the assisted living 
+settings  (Bhandari & Paswan, 2021). Earlier studies 
+have reported various challenges such as concomitant 
+health problems, body aches, lack of prioritization as 
+challenges to run long‑term yoga program in older 
+population  (Cadmus‑Bertram et  al., 2013; Cheung 
+et  al., 2015). In the present study, despite some loss 
+to follow‑up in the wait‑listed control group, the entire 
+yoga group completed the 3  months yoga program, 
+which shows the acceptability and adherence of yoga as 
+a mind body program among geriatric population.
+Table 2: Comparison of self‑reported perceived stress 
+and depression among the study groups using the Mann–
+Whitney test
+Groups
+Mean±SD
+Between groups, P
+Mann–Whitney U test
+Pre
+Post
+PSS
+Yoga (n=48)
+18.23±4.93 3.65±2.96
+Z=−8.3, P<0.001
+Control (n=48) 17.02±5.14 17.38±5.58
+GDS
+Yoga, (n=48)
+5.42±2.99
+0.94±1.10
+Z=−7.49, P=0.001
+Control, (n=48) 4.17±2.92
+4.44±3.22
+PSS: Perceived stress score, GDS: Geriatric depression scale 
+scores, SD: Standard deviation
+Table 3: Comparison of scores on older peoples quality of life between yoga and control groups using the Mann–
+Whitney test
+Groups
+Mean±SD
+Between groups P
+Mann–Whitney U test
+Pre
+Post
+Social relationship
+Yoga
+20.81±1.73
+23.50±2.08
+Z=−2.45, P=0.014
+Control
+20.50±1.69
+19.75±3.04
+Neighborhood
+Yoga
+15.65±1.45
+18.75±2.16
+Z=−6.18, P=0.001
+Control
+15.60±1.12
+16.23±1.6
+Psychological wellbeing
+Yoga
+14.92±1.96
+19.5±1.11
+Z=−6.18, P=0.001
+Control
+14.5±1.54
+14±2.22
+Financial circumstances
+Yoga
+13.94±2.29
+16.40±2.41
+Z=−7.06, P=0.001
+Control
+13.71±2.25
+12.90±2.48
+OPQoL – total
+Yoga
+122.48±9.10
+147.92±8.50
+Z=−9.09, P=0.001
+Control
+121.67±7.56
+120.08±9.47
+OPQol: Older people quality of life
+[Downloaded free from http://www.jacsonline.in on Thursday, January 5, 2023, IP: 103.39.126.58]
+Ganesh et al.: Yoga in elderly
+67
+Journal of Applied Consciousness Studies  ¦  Volume 10  ¦  Issue 1  ¦  January‑June 2022
+Although we have included 96 participants in our study, 
+considering the pluralistic health issues prevailing in 
+geriatric population, future studies are warranted with 
+stratified samples based on economic strata, physical 
+ability, and medical conditions. The present study was 
+conducted to understand the feasibility and usefulness 
+of yoga in alleviating stress, depression and to improve 
+quality of life in the elderly in out‑patient settings. The 
+results are encouraging to integrate yoga into geriatric 
+care as it shares identical paradigms with elderly care 
+guidelines that warrants a whole‑person approach 
+that gives more value to quality of life and functional 
+independence than mere longevity  (Bell et  al., 2016). 
+Large scale systematic review also recommends yoga 
+to be used as an active form of practice in older adults 
+which has multi‑dimensional physical and mental health 
+impact on this vulnerable population. Health‑care 
+providers with knowledge of yoga therapy, especially 
+those nurses and/or therapists who are directly involved 
+in geriatric nursing can upscale the quality of care 
+amongst older adults to a greater extent.
+Further the benefits of yoga are not limited to the 
+recipients alone, robust studies have reported yoga to 
+benefit the nurses and health‑care providers by reducing 
+their stress levels, alleviate burn outs, and improve sleep 
+by providing serenity and mindfulness  (Hilcove et  al., 
+2021). Therefore, yoga functions as a synergetic tool 
+that complement the recipient as well as the provider. 
+A  conducive environment that benefits all the players 
+involved in healing is likely to induce holistic health 
+benefits that will be meaningful (Vinson, 2019).
+Conclusion
+To the knowledge of the authors, this is the first study to 
+evaluate the impact of yoga on self‑reported depression, 
+stress, and quality of life in the real‑life setting 
+outside institutional care. The results of this study 
+are encouraging to recommend yoga as a stand‑alone 
+mind‑body rehabilitation program for older adults.
+Financial support and sponsorship
+Nil.
+Conflicts of interest
+There are no conflicts of interest.
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+Importance of adherance to yoga in management of type
+2 diabetes
+Gaurav Kumar & Aarti Jagannathan & M. K. Sridhar
+Received: 30 December 2014 /Accepted: 27 February 2015
+# Research Society for Study of Diabetes in India 2015
+Dear Sir,
+In the study conducted by Nagarathna et al. [1], it was ob-
+served that yoga-based life style modification programme is
+similar to exercise-based life style modification in reducing
+blood glucose, HbA1c, triglycerides, total cholesterol and
+VLDL. An important feature in the interpretation of the results
+of the study, which the authors seemed to have missed, is the
+participant’s adherence to the yoga programme over the
+6-month period of the study. In yoga studies, adherence is
+usually objectively measured as the number of yoga classes
+the participant has attended over the given period of the inter-
+vention [2, 3]. Nagarathna et al. [1] have reported reasons for
+the number of drop-outs; however, depiction of the yoga ad-
+herence levels of the participants, who completed the study,
+could have helped better interpret the results of the study.
+Researchers have opined that Bdecreased adherence to
+yoga has the potential to decrease the effect of the in-
+tervention because subjects who might sustain the
+greatest benefit will receive a lower dose of the inter-
+vention and subjects with higher adherence rates may be
+functioning closer to maximum ability before the
+intervention^ [4]. To further research on this important
+concept of adherence in the field of yoga, we conducted
+a 4-year long-term follow-up to test the adherence to
+yoga and its resultant effects on blood glucose.
+Eighty-nine people with type 2 diabetes enrolled for
+yoga camps in the year 2010 in a community in
+Bangalore, but only 26 attended the camps in 2014
+(4th year follow-up). The average (SD) age, education,
+and duration of diabetes of these participants was 52.21
+(9.0) years, 14.15 (3.21) years, and 8.24 (6.84) years,
+respectively. The Integrated Approach to Yoga Therapy
+(IAYT) for Diabetes developed by Swami Vivekananda
+Yoga Anusandhana Samasthana (SVYASA) was taught
+for the first 8 months of the study after which they
+were advised home practice. Fasting blood sugar
+(FBS) was assessed at baseline, at the end of 3 months,
+8 months and 4 years, and a qualitative interview sched-
+ule (to understand reasons for adherence and non-
+adherence) and Holmes & Rahe Life event scale to
+measure stressful life events [5] was conducted at the
+end of 4 years.
+The results of the study showed that even though daily yoga
+classes were held for the first 8 months, only 39 participants
+out of 89 (43.8 %) attended the 8-month classes regularly,
+which further reduced to just 6 % in 2014. There was no sta-
+tistically significant reduction in FBS levels over the 4-year
+period (due to high attrition rates); however, during the time
+the yoga intervention was provided (first 8 months), the trend
+showed that FBS levels were lower as compared to the base-
+line. This could be attributed to the fact that qualitatively, par-
+ticipants experienced a feeling of well-being and positive
+changes which possibly motivated them to complete the
+8-month yoga programme. At the end of 4 years, most partic-
+ipants responded that they did not feel motivated to practice on
+their own at homes. Further there was a trend in their FBS
+G. Kumar
+Yoga and Education, S-VYASA, Bengaluru, India
+A. Jagannathan (*)
+Division of Yoga and Life Sciences, Swami Vivekananda Yoga
+Anusandhana Samasthana (S-VYASA), 19, Gavipuram,
+Kempegowda Nagar, Bengaluru 560019, India
+e-mail: jaganaarti@gmail.com
+M. K. Sridhar
+Division of Yoga and Spirituality, S-VYASA, Bengaluru, India
+Int J Diabetes Dev Ctries
+DOI 10.1007/s13410-015-0351-y
+levels being higher as compared to baseline (Table 1). The
+predictor analysis with FBS as a dependent variable showed
+a significant positive correlation between FBS and stress
+(r=0.42, p=0.04).
+Yoga practice thus qualitatively improves diabetes health
+status and makes participants feel happy, enthusiastic and
+active. However, stress and adherence to yoga are important
+factors in affecting blood glucose parameters in participants
+with diabetes. Future studies which test the efficacy of yoga
+interventions for diabetes need to pay attention to these two
+important parameters in analysing and interpreting the results
+between intervention effects and blood glucose parameters.
+Acknowledgments
+The authors would like to express their gratitude to
+Dr Sitaram, Head of Ayurveda Kuteeram, Kalyannagar, where this study
+was conducted, and Swami Vivekananda Yoga Anusandhana
+Samasthana (SVYASA) University for their financial and resource sup-
+port in conducting this study at Kalyan Nagar, Bengaluru,
+Compliance with ethical standards
+Conflict of interest
+Gaurav Kumar, Aarti Jagannathan and Shridhar
+MK declare that they have no conflict of interest.
+Ethical approval
+This article does not contain any studies with animals
+performed by any of the authors. All procedures performed in studies
+involving human participants were in accordance with the ethical stan-
+dards of the institutional and/or national research committee and with the
+1964 Helsinki declaration and its later amendments or comparable ethical
+standards.
+Informed consent
+Was obtained from all individual participants in-
+cluded in the study.
+References
+1. Nagarathna R, Usharani MR, Raghvendra Rao A, Chaku R, Kulkarni
+R, Nagendra HR. Efficacy of yoga based life style modification pro-
+gram on medication score and lipid profile in type 2 diabetes—a ran-
+domized control study; 1. Int J Diabetes Dev Countries. 2012;32(3):
+122–30.
+2. Speed-Andrews AE, Stevinson C, Belanger LJ, Mirus JJ, Courneya
+KS. Predictors of adherence to an Iyengar yoga program in breast
+cancer survivors. Int J Yoga. 2012;5(1):3–9.
+3. Skoro-Kondza L, Tai SS, Gadelrab R, Drincevic D, Greenhalgh T.
+Community based yoga classes for type 2 diabetes: an exploratory
+randomized controlled trial. BMC Health Serv Res. 2009;9:33.
+4. Flegal KE, Kishiyama S, Zajdel D, Haas M, Oken BS. Adherence to
+yoga and exercise interventions in a 6-month clinical trial. BMC
+Complement Altern Med. 2007;7(1):37.
+5. Holmes TH, Rahe RH. The social readjustment rating scale. J
+Psychosom Res. 1967;11(2):213–8.
+Table 1
+Paired sample t test/Wilcoxon sign rank test for fasting blood
+sugar over 4-year period
+Time selection
+Number
+FBS (pre)
+FBS (post)
+t/za
+p
+Baseline
+3rd month
+40
+134.55
+(34.35)
+129.52
+(50.36)
+0.819
+0.418
+Baseline
+8th month
+30
+142.60
+(32.43)
+139.06
+(50.48)
+0.391
+0.698
+Baseline
+4th year
+19
+130.16
+(32.44)
+139.74
+(44.71)
+−1.26a
+0.21
+a Wilcoxon sign rank test
+Int J Diabetes Dev Ctries
diff --git a/subfolder_0/Increased Prevalence of Type 2 Diabetes in South Asian Population - A Genetic Perspective.txt b/subfolder_0/Increased Prevalence of Type 2 Diabetes in South Asian Population - A Genetic Perspective.txt
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index 0000000000000000000000000000000000000000..161de8670f6b2af6cce7cc04dfa54ae6028afe3d
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+++ b/subfolder_0/Increased Prevalence of Type 2 Diabetes in South Asian Population - A Genetic Perspective.txt	
@@ -0,0 +1,143 @@
+Journal of Diabetes, Metabolic Disorders & Control
+Increased Prevalence of Type 2 Diabetes in South Asian 
+Population – A Genetic Perspective
+Submit Manuscript | http://medcraveonline.com
+ 
+Volume 3 Issue 3 - 2016
+Department of Molecular Bioscience, SVYASA University, India
+*Corresponding author: Venugopal V, Department of 
+Molecular Bioscience, SVYASA University, India, Tel: +91-80-
+226-399-61; Email: 
+Received: May 22, 2016 | Published: May 30, 2016
+Opinion
+J Diabetes Metab Disord Control 2016, 3(3): 00068
+Abstract
+Type 2 diabetes is complex disorder which results from interaction between the genes and 
+environment. The sudden increase in the incidence of diabetes across the world is attributed 
+to multiple factors like rapid urbanisation, diet and lack of physical activity. Nevertheless, 
+there are ample evidences that suggests diabetes to have a strong genetic basis. The incidence 
+of diabetes is disproportionately higher in certain ethnic population, type 2 diabetes in 
+special, is highly prevalent amongst South Asians and are six times more prone to type 2 
+diabetes when compared to the Caucasians. 
+Keywords: Diabetes; South Asians; Genetic factors
+Introduction
+Around 415 million individuals around the world have type 2 
+diabetes, of which 78 million are from South East Asia [1]. Many 
+theories have been put forth to explain the increased genetic 
+predisposition of type 2 diabetes in South Asian population. 
+The two most well renowned hypothesis are – the ‘Thrifty gene’ 
+hypothesis and ‘Genetic trash can’ hypothesis. The thrifty gene 
+hypothesis postulates that genes of our earlier ancestors are 
+genetically modified to cope up with the insecurities like lack of 
+continuous supply of food and natural disasters like fire, flood 
+and famine. People with metabolically efficient or ‘thrifty’ genes 
+managed to efficiently store energy as fat when food is available 
+and managed to survive later during periods of famine or non-
+availability of food. The hypothesis holds much more significance 
+in the context that nearly 90 famines being reported in the South 
+Asia over the past 2,500 years [2].
+‘Genetic trash can’ hypothesis states that multiple neutral gene 
+mutations increases risk of type 2 diabetes when accumulated 
+and concentrated in a population. This hypothesis is equally 
+consistent, considering that diabetogenes are generally recessive 
+and increased prevalence of type 2 diabetes in South Asians 
+might be attributed to the fact that they are less exogamous when 
+compared to other ethnic population [3]. Genetic susceptibility 
+is observed in various factors like Body Mass Index (BMI) or 
+waist circumference. For any given BMI or waist circumference, 
+South Asians have approximately 6% higher total body fat when 
+compared to Caucasians [4]. South Asians also present with 
+increased insulin resistance and early loss of beta cell function 
+than Caucasians for any given age. 
+Genetics
+Advancements in genetic technology over the past two 
+decades has facilitated in better understanding of the intricate 
+details regarding genes and genetic variations and also large 
+scale genetic studies. The Text-mined Hypertension, Obesity, 
+and Diabetes candidate Gene (T-HOD) database reports 563 
+identified genes which are associated with type 2 diabetes till 
+date. Though only very few Genome-wide Associated Studies 
+(GWAS) have been conducted so far on South Asian population, it 
+provides valuable information on the observed genetic variations. 
+One such GWAS conducted on south Asian population found six 
+novel signals by single nucleotide polymorphisms (SNPs) near 
+GRB14, ST6GAL1, VPS26A, HMG20A, AP3S2 and HNF4A [5]. In 
+a multistage meta-analysis, a novel locus at 13q12 in the SGCG 
+gene which is associated with type 2 diabetes susceptibility was 
+identified in the Punjabi Sikhs from India. An increased incidence 
+of the autosomal recessive LGMD2C was also reported in this 
+same population, which was attributed to the endogamy practised 
+within the community [6], which is in line with the ‘genetic trash 
+can’ hypothesis. 
+Epigenetics
+Epigenetics is an inheritable phenomenon that affects gene 
+expression without base pair changes and are characterised by 
+DNA methylation and histone modifications [7]. The epigenetic 
+changes observed in type 2 diabetes are often attributed to the 
+milieu interior of the foetus before birth (as in gestational diabetes) 
+or due to early exposure to nutritional stressors during early life 
+[8]. Few authors claim that epigenetic changes play a central role 
+in the pathogenesis of type 2 diabetes [8,9]. Folic acid intake has 
+been extensively studied for its effect on DNA methylation, as 
+folate carries a methyl group which acts as a methyl donor for 
+the DNA methylation. Apart from folate, dietary components like 
+methionine, choline, betaine and vitamin B12 also act as methyl 
+donors and influences the DNA methylation process. Similarly, 
+sulforafane in broccoli and diallyl sulfide in garlic plays a significant 
+role in histone modification [10] exhibiting the protective effects 
+of diet and nutrition in overcoming epigenetic changes.
+Conclusion
+In conclusion, type 2 diabetes is due to the complex interplay 
+of genetics, epigenetics and environmental factors. This mini 
+review considered the role of genetic and epigenetic factors in 
+the development of type 2 diabetes in south Asians and also the 
+possible role of environment in overcoming these modifications. 
+The review highlights that most of the risk factors attributed to 
+the Non-communicable diseases (NCDs) could be brought down 
+considerably through appropriate control over environment and 
+lifestyle.
+Increased Prevalence of Type 2 Diabetes in South Asian Population – A Genetic 
+Perspective
+2/2
+Copyright:
+©2016 Venugopal
+Citation: Venugopal V, Ragavendrasamy B (2016) Increased Prevalence of Type 2 Diabetes in South Asian Population – A Genetic Perspective. J 
+Diabetes Metab Disord Control 3(3): 00068. DOI: 10.15406/jdmdc.2016.03.00068
+References  
+1.	
+International Diabetes Federation (2015) IDF Diabetes Atlas, (7th 
+edn.), International Diabetes Federation, Brussels, Belgium. 
+2.	
+Murton B (2000) Famine. The Cambridge world history of food. 2: 
+1411-1427.
+3.	
+Lev-Ran A (1999) Thrifty genotype: how applicable is it to obesity 
+and type 2 diabetes? Diabetes Rev 7:1-22.
+4.	
+Chandalia M, Lin P, Seenivasan T, Livingston EH, Snell PG, et al. 
+(2007) Insulin resistance and body fat distribution in South Asian 
+men compared to Caucasian men. PloS one 2(8): e812.
+5.	
+Kooner JS, Saleheen D, Sim X, Sehmi J, Zhang W, et al. (2011) 
+Genome-wide association study in individuals of South Asian 
+ancestry identifies six new type 2 diabetes susceptibility loci. Nat 
+Genet 43(10): 984-989. 
+6.	
+Saxena R, Saleheen D, Been LF, Garavito ML, Braun T, et al. (2013) 
+Genome-wide association study identifies a novel locus contributing 
+to type 2 diabetes susceptibility in Sikhs of Punjabi origin from 
+India. Diabetes 62(5): 1746-1755.
+7.	
+Handel AE, Ebers GC, Ramagopalan SV (2010) Epigenetics: 
+molecular mechanisms and implications for disease. Trends Mol 
+Med 16(1): 7-16. 
+8.	
+Drong AW, Lindgren CM, McCarthy MI (2012) The genetic 
+and epigenetic basis of type 2 diabetes and obesity. Clinical 
+Pharmacology & Therapeutics 92(6): 707-715.
+9.	
+Wren JD, Garner HR (2005) Data-mining analysis suggests an 
+epigenetic pathogenesis for type 2 diabetes. J Biomed Biotechnol 
+2005(2): 104-112.	
+10.	 Sang-Woon Choi, Simonetta Friso (2010) Epigenetics: A New Bridge 
+between Nutrition and Health Adv Nutr 1: 8-16.
diff --git a/subfolder_0/Insights from vedic wisdom for future research in yoga..txt b/subfolder_0/Insights from vedic wisdom for future research in yoga..txt
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+59
+© 2018 International Journal of Yoga - Philosophy, Psychology and Parapsychology | Published by Wolters Kluwer - Medknow
+Insights from Vedic Wisdom for Future Research in Yoga
+Possible solution can be discovered by  (1) bringing 
+people, both Vedic scholars and modern scientists on a 
+common platform, and initiate a number of dialogues, to 
+discuss various aspects of the yoga research. (2) Develop 
+new breed of human resource with a refined skill to 
+understand ancient wisdom and to execute research 
+with modern methodology.  (3) Create an infrastructure 
+of conducting interdisciplinary research in yoga. These 
+efforts will lead to successful integration and enable the 
+development of new models, theories, and paradigms 
+to guide future research in yoga. The utility of such 
+models to understand mechanisms has been earlier 
+highlighted.[1] The development of such models is 
+necessary as it provides a framework for understanding 
+how yoga works and also providing direction to how it 
+can be applied for various real‑world problems.
+Example of model to field application
+One such model from Vedic literature is the concept of 
+five sheaths model of human existence or traditionally 
+known as pancha kosha model [Figure 1]. According to 
+this, our human existence is not only restricted to the 
+physical body, the annamaya kosha, but also other subtle 
+layers such as pranamaya kosha  (bioplasmic sheath), 
+monomaya kosha  (emotional sheath), vijnanamaya 
+kosha  (wisdom sheath), and anandamaya kosha 
+(bliss sheath).
+The Integrated Approach of Yoga Therapy  (IAYT),[2] 
+that is, used to address various psychosomatic ailments 
+is also based on this. According to this model, if there 
+are any imbalances at the level of physical body, then 
+making suitable corrections at subtler level, will lead 
+to a significant change in the physical level as well. 
+Originally, this model appears in Taittiriya Upanishad,[3] 
+to elucidate the nature of our existence. However, 
+this model can be utilized and applied to therapy. 
+Another model that comes from the famous text, 
+Yoga Vashistha,[4] also supports this view that making 
+a suitable correction at subtler levels corresponding 
+changes can be made at grosser level:
+आधिक्षये चाधिभवाः क्षीयन्ते व्याधयोऽप्यलम्।
+ādhikṣaye cādhibhavāḥ kṣīyante 
+vyādhayo’pyalam | 15.3.33
+(The Essence of Yogavaasishtha, p. 263)
+According to this, even the physical ailments emerging 
+out of mental affliction are removed, once those mental 
+afflictions are removed. Hence, the root cause of the 
+problem which is called aadhi has to be addressed, 
+and it is understood to be present in manomaykosha, 
+Editorial
+Modern science has been empirically discovering 
+the subtle laws of nature, both internal and external. 
+Although the journey has been long and paced, the 
+changes that it has brought in our world are remarkable. 
+Discovery of new laws of quantum mechanics in the 
+early 19th  century brings the reminiscences of the deep 
+human quest to understand the subtle nature. In this 
+journey toward understanding the subtle, can a support 
+from the well‑admired theories of the ancient wisdom 
+be of any use? Ancient Indian wisdom is one such 
+source that can give directions to numerous researches 
+in many modern disciplines. Yoga is one such branch 
+of knowledge from ancient Indian culture that is being 
+now perceived as a panacea for many modern‑day 
+crises. Even though utility of ancient wisdom is well 
+acknowledged by scientists, its implementation appears 
+to be weakly evident. How do we mend this gap 
+between ancient wisdom and modern science effectively, 
+especially in yoga?
+Science develops with observation, proposing theories 
+and experimentation. Theories in science are a gradual 
+development of ideas of eminent scientists over a period. 
+Unlike this, in yoga, already the core concepts are well 
+documented. To summarize the whole content of yoga 
+text, it can be said that yoga describes the process of 
+transformation to reach our highest potential. Having got 
+a sound theoretical basis of yoga, as elucidated in the 
+ancient yoga texts, should there not be profound growth 
+in yoga research on the empirical front? We, however, 
+observe that majority of the researches done in yoga is 
+of applied nature. Substantial work needs to be done 
+to understand the underlying science of yoga, applying 
+modern scientific methodology as much as possible and 
+if necessary innovate new methods to investigate some 
+of the challenging aspects of yoga. Easier said, the task 
+of integration of modern and the ancient knowledge 
+systems is challenging.
+Challenges and possible solutions to integration
+Some of the challenges in integration are as follows: 
+(1) Nonavailability of scholars who can expose us of 
+ancient wisdom, in a language that modern scientists 
+can understand. Most of the Vedic scholars are hidden 
+in their traditional courtyards.  (2) Lack of deeper 
+enthusiasm among modern researchers to understand 
+the depth of yogic philosophy and its practices. Number 
+of instances where yoga is poorly interpreted and 
+presented exemplifies this.  (3) Lack of interdisciplinary 
+fundamental research to scientifically validate some of 
+the proclaimed tenets of yoga.
+[Downloaded free from http://www.ijoyppp.org on Saturday, January 23, 2021, IP: 136.232.192.146]
+Nagendra: Vedic insights for yoga research
+60
+International Journal of Yoga ‑ Philosophy, Psychology and Parapsychology  ¦  Volume 6  ¦  Issue 2  ¦  July‑December 2018
+that sheath which lacks discriminatory ability. Once 
+that is addressed, the reverse action of healing starts 
+to percolate down to pranamayakosha, and ultimately 
+annamayakosha, the physical body. It is also known from 
+modern science that many of the psychosomatic diseases 
+that included many NCDs, the mind play an important 
+role in diseases progression. If we use this pancha kosha 
+model and start working at the subtler level which is 
+easier to manipulate, the results seen are rapid and 
+durable. This has also been our clinical experience for 
+the past five decades. Thus, models derived from ancient 
+texts were utilized to develop a robust therapy system 
+called IAYT. In order to further focus on the effect, some 
+advanced yogic practices were developed exclusively 
+for each of these koshas, such as cyclic meditation for 
+annamayakosha; Pranic Energization Technique for 
+pranamayakosha; Mind Sound Resonance Technique, 
+Mind Imagery Technique, Mind EMotion Technique 
+for manomayakosha; VIjnana SAdhana Koushala for 
+vijnanamayakosha, and ANanda AMrita Sinchana for 
+anandamayakosha. These techniques have been further 
+studied empirically, mostly trying to understand its 
+clinical utility, and now, it is time to understand the 
+integrated fundamental mechanism that holds the whole 
+model. Efforts are being taken to further the research in 
+this direction.
+Conclusion
+This journal strongly encourages contributions that bring 
+out the rich wisdom of ancient science by proposing good 
+models that can be subjected to further experimentation 
+and validation. Such models should become a part of 
+common parlance among yoga researchers so that we 
+grow in our understanding of our system in a complete 
+way.
+HR Nagendra
+Chancellor, Swami Vivekananda Yoga Anusandhana Samsthana, 
+ 
+19, Eknath Bhavan, Gavipuram Circle, K.G. Nagar, 
+Bengaluru ‑ 560 019, Karnataka, India. 
+ 
+E‑mail: chancellor@svyasa.edu.in
+References
+1.	
+Srinivasan  T. Models and mechanisms in yoga research. Int J 
+Yoga 2012;5:83‑4.
+2.	
+Nagarathna  R, Nagendra  HR. Integrated Approach of Yoga 
+Therapy for Positive Health. Bangalore: Swami Vivekananda 
+Yoga Prakashana; 2008.
+3.	
+Gambhirananda  S. Taittiriya Upanisad. Kolkata: Advaita 
+Ashrama; 1979.
+4.	
+Jnanananda B. The Essence of Yogavāsistha. 1st ed. Pondicherry: 
+Samata Books; 1982. p. 263.
+Figure 1: Pancha Kosha Model
+Access this article online
+Quick Response Code:
+Website: www.ijoyppp.org
+DOI: 10.4103/2347-5633.246335
+This is an open access journal, and articles are distributed under the terms of the 
+Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows 
+others to remix, tweak, and build upon the work non-commercially, as long as 
+appropriate credit is given and the new creations are licensed under the identical 
+terms.
+How to cite this article: Nagendra HR. Insights from vedic wisdom for future 
+research in yoga. Int J Yoga - Philosop Psychol Parapsychol 2018;6:59-60.
+[Downloaded free from http://www.ijoyppp.org on Saturday, January 23, 2021, IP: 136.232.192.146]
diff --git a/subfolder_0/Integrated Yoga Therapy for mental Illness.txt b/subfolder_0/Integrated Yoga Therapy for mental Illness.txt
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+8/11/2014
+Integrated Yoga Therapy for mental Illness
+http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3768208/
+1/4
+Indian J Psychiatry. Jul 2013; 55(Suppl 3): S337–S339.
+PMCID: PMC3768208
+Integrated Yoga Therapy for mental Illness
+H. R. Nagendra
+Sw ami Vivekananda Yoga Anusandhana Samsthana, Bangalore, Karnataka, India
+Address for correspondence: Dr. H. R. Nagendra, Sw ami Vivekananda Yoga Anusandhana Samsthana, Bangalore, Karnataka, India. E-mail:
+hrn@vyasa.org
+Copyright : © Indian Journal of Psychiatry
+This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, w hich
+permits unrestricted use, distribution, and reproduction in any medium, provided the original w ork is properly cited.
+See the article "Assessment of cognition in non-affected full biological siblings of patients w ith schizophrenia" on page S332.
+Mental disorders have been described as one of the most devastating disorders of mankind for two reasons. The first is
+its relatively widespread incidence, i.e., around 2% in India and a prevalence averaging to about 6% in a meta-analytical
+study (Math and Srinivasaraju, 2010). The other reason is the extent to which it renders a person incapable of taking
+care of him/herself. Majority of the papers submitted in this special issue, depict the effectiveness of yoga on varied
+parameters for mental disorders such as schizophrenia, depression, attention deficit hyper-activity disorder and patients
+with functional disorders. The few papers, which have looked at the effect of yoga on elderly or healthy caregivers also,
+have focused on mental health outcome variables. In this context, we need to understand the mechanisms that work in
+making yoga effective for mental disorders/mental health.
+Yoga practice may specifically help persons with mental illness in at least five ways:
+1. Calming effect: The more agitated a person is, the more difficult they find it to practice yoga and to relax.
+However, with more physical practices as Asanas, breathing practices and Kriyas (cleansing techniques as
+kapalabhati, Trataka, Neti, etc.) most patients with mental illness will be able to benefit by reducing the
+agitations they feel
+2. Increasing awareness: Yoga practice increases awareness of oneself and of ones’ surroundings. As a patient
+begins to be aware of the most basic physical sensations as heartbeat, pulse, etc., it becomes easier to suggest
+increasing the scope of awareness to include awareness of the surroundings and of other people
+3. Increasing the attention span: One of the reasons why it is very difficult for a mentally ill-patient to return to
+work even after the acute phase is because of the markedly reduced attention span and easy distractibility. A
+short attention span and the tendency to be easily distracted, make it very difficult for a schizophrenia patient to
+see any task through to completion, successfully. By practicing yoga, a patient may be able to maintain a state of
+focused attention with greater ease and for longer periods
+4. Acceptance and adaptability: One of the challenges for rehabilitation of persons with mental illness is that even if
+they are adequately rehabilitated in their homes, the environment there is often so unhealthy that they get a
+relapse. Certain ideas of acceptance and adaptability, which are part of yoga counseling, help the subjects to
+make a good transition from the therapy center to the world outside
+5. A sense of security: Bhakti yoga or indeed any form of devotion and surrender to a supreme entity or a role
+model of a person will be of great source of strength to a “recovered” patient (i.e., a person who, through
+medication, no longer has symptoms such as hallucinations, delusions, or bizarre behavior, in general). Very
+often, during the course of a long and difficult illness a patient may lose contact with his family. For a recovered
+8/11/2014
+Integrated Yoga Therapy for mental Illness
+http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3768208/
+2/4
+patient this lack of support may give rise to feelings of insecurity, reduce the chances of further improvement and
+even bring about a relapse. This is where a sense of bhakti or devotion and surrender to a supreme or ideal
+being may give the person an anchor with a feeling of reassurance and of security.
+The traditional texts believe that all these mental disorders arise out of imbalances in the Manomaya Kosa (mental and
+emotional levels). Knowing fully well that what I am doing is wrong, a person is drawn to do wrong things due to
+enslavement of the emotions. These imbalances amplify themselves resulting in mental illnesses called, “Adhis.” Prompted
+by the perceptual growth of desires, leading to anger, jealousy and such other powerful emotions, these mental diseases
+congeal within an individual and they begin to manifest themselves externally. Another explanation for psychosomatic
+illnesses is that when the mind is agitated during our interactions with the world at large, the uncontrolled speed of mind
+backed by powerful emotions lead to agitations and violent fluctuations in the flow of Prana (life force) in the Nadis
+(channels of Prana as blood vessels carrying blood) The Prana flows in wrong paths moving from one to another without
+rhythm and harmony. The Nadis can no more, in this condition, maintain stability and steadiness. These disturbances in
+the Prana and unsteadiness in the Nadis show up as breathing imbalances. Due to these imbalances, the food does not
+get properly digested. When this improperly digested food settles down in the body amidst such commotion, it results in
+ailments of psychosomatic type.
+To tackle these problems, we at Swami Vivekananda Yoga Anusandhana Samsthana advocate and have conclusively
+found benefits of the “Integrated approach of Yoga Therapy” (IAYT) [Figure 1]; which targets all five levels of existence
+(Pancha Kosas - i.e., physical, (Prana or) subtle energies, mental and intellectual levels), a holistic approach to treat
+patients with mental illnesses.[3]
+Figure 1
+Integrated Yoga Therapy Approach (IAYT)
+Excessive speed and demanding situation at the mental and physical levels (Annamaya Kosa and Pranamaya Kosa),
+upsurges caused by strong likes and dislikes at the emotional level (Manomaya Kosa) and conflicts, ego-centric
+behavior at the psychological level (Vijnanamaya Kosa) are responsible for imbalances found at gross levels [Figures 2
+and 3].
+Figure 2
+Pancha Kosa – Five sheaths of existence
+Figure 3
+Yogic definition of stress
+IAYT through “successive stimulation-relaxation helps break the loop of uncontrolled speed of thoughts (stress) [Figure 4
+and 5]”[1] as postulated in the commentary on Mandukya Upanishat mentioned below.
+Figure 4
+Panchakosaha model of IAYT – Slide 1
+Figure 5
+8/11/2014
+Integrated Yoga Therapy for mental Illness
+http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3768208/
+3/4
+Go to:
+Go to:
+Panchakosha model of IAYT – Slide 2
+Laye sambodhayet Cittam; Viksiptam samayet punah Sakasayam vijaniyat samapraptam na calayet.
+Awaken a drowsy or sleepy mind; calm down an agitated random mind; recognise the deep rooted stresses;
+releasing them all when balance and stability occurs, maintain it for long durations.
+As mentioned by Patanjali in his Sutras (Ibid, 2008;)
+Yogah cittavrtti nirodhah (Patanjali Yoga Sutra: 1.2)[4]
+Yoga is to “gain mastery over the mind or control over the mind”[2] (consisting of development of concentration on one
+hand and a capacity to calm down the mind or silence it effortlessly) and, harmonizes the disturbances at each of the five
+levels [Figure 6] Samatvam Yoga Ucyate (Bhagavad Gita).
+Figure 6
+Definition of Yoga
+Balance and equanimity is Yoga to tackle psychosomatic problems and psychiatric disorders.
+There are different yoga practices, which act at different levels. This is tered IAYT using the four streams of yoga: Jnana
+Yoga; Bhakti Yoga; Raja Yoga and Karma Yoga. It is recommended that one begins with the “physical” practices
+learning to relax the body and then to be ready for the more specific, mental state practices. In this manner through the
+practice of yoga one can gain mastery over the mind.
+It is often difficult to get persons with mental illness to feel motivated to do these yoga practices, but if they can be gently
+persuaded, they often begin to enjoy the practices and are eager to carry on.
+I sincerely appreciate the efforts of the National Institute of Mental Health and Neurosciences (NIMHANS) team in
+educating and motivating the patients with mental illnesses to practice yoga (a relatively new treatment methodology in
+psychiatry) as an alternative and complementary treatment method. This special issue in the Indian Journal of Psychiatry
+on “yoga for mental disorders” is another step forward in creating awareness about the yogic practices that could be
+therapeutic for patients with mental illnesses.
+Footnotes
+Source of Support: Nil
+Conflict of Interest: None declared.
+REFERENCES
+1. Math SB, Srinivasaraju R. Indian psychiatric epidemiological studies: Learning from the past. Indian J Psychiatry.
+2010;52:S95–103. [PMC free article] [PubMed]
+2. Nagendra HR, Nagarathna R. Bangalore: Vivekananda Yoga Research Foundation, Swami Vivekananda Yoga
+Prakashana; 2008R. New Perspectives in Stress Management.
+3. Nagarathna R, Nagendra HR. Bangalore: Swami Vivekananda Yoga Prakashana; 2004. Yoga for Promotion of
+Positive Health.
+8/11/2014
+Integrated Yoga Therapy for mental Illness
+http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3768208/
+4/4
+4. Krishnamoorthy . M.Sc (Yoga) – Dissertation. Bangalore: SYASA; 2007. Concept of anxiety according to ancient
+Indian scriptures.
+Articles from Indian Journal of Psychiatry are provided here courtesy of Medknow Publications
diff --git a/subfolder_0/Integrating Yoga in Oncology Is the wait over.txt b/subfolder_0/Integrating Yoga in Oncology Is the wait over.txt
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+++ b/subfolder_0/Integrating Yoga in Oncology Is the wait over.txt	
@@ -0,0 +1,168 @@
+LETTER TO THE EDITOR
+Integrating Yoga in Oncology: Is the wait over?
+Nagarathna Raghuram1 & Raghavendra M. Rao2,3 & H. R. Nagendra1
+Received: 18 August 2015 /Accepted: 7 January 2016 /Published online: 3 March 2016
+# Indian Association of Surgical Oncology 2016
+Diagnosis and treatment of cancer poses psychological threats
+and physical side effects to the patient over their extended hos-
+pital care that grossly affect the patient’s overall functional
+quality of life (QOL) [1]. Fear and anxiety coupled with
+cancer-related intrusive thoughts, age, socio demographic char-
+acteristics and financial concerns along with a tendency to-
+wards negativity (neuroticism) may conspire to heighten a
+women’s risk for psychologic distress which in turn can worsen
+the treatment related symptoms such as nausea and vomiting,
+pain and psychologic distress [2, 3].This can lead to helpless-
+ness/hopelessness, sleep disturbances, poor antitumor immune
+response, decrease in overall and disease free survival with
+early relapse/recurrence and heightened distress [4].
+Today we see a transition from cancer directed treatment
+that relies purely on tumour killing to treating the person who
+has cancer. Quality of life is given prime importance in treat-
+ment decision making. Quality of life is Bnot just relief from
+pain^ but implies getting back to normal life or even better life
+than they had before they were diagnosed and treated for
+cancer. In a holistic sense, it is moving towards better social,
+emotional, physical and spiritual wellbeing. However, the
+choice to accept the cancer diagnosis and live with it by
+making necessary changes in their lives is left to the decision
+of the patient.
+The use of complementary and alternative therapies
+(CAM) used by cancer patients significantly exceeds that of
+the general population. Patients primarily use these CAM ther-
+apies to enhance the body’s healing ability, to fight cancer
+more directly, to manage treatment-related side effects, or to
+improve their overall quality of life, including general symp-
+tom management and potential complications. Yoga as a
+Complementary mind body intervention has been used widely
+in cancer patients to promote a healthy lifestyle [5].
+Yoga as a complementary and mind body therapy is being
+practiced increasingly in both Indian and western populations.
+It is an ancient Indian science that has been used for therapeutic
+benefit in numerous health care concerns in which mental stress
+was believed to play a role. The effects of yoga cannot be just
+attributed primarily to stress reduction. It is also known to im-
+prove one’s perception and appraisal of the situations and help
+them cope effectively. Empirical evidence points to utility of
+yoga as a therapy and for prevention of non-communicable
+diseases and promotion of wellness. The practice of developing
+ones internal awareness and relaxation are said to be the main
+components of these practices that helps one to reach higher
+states of health which can be called Bpositive health^.
+A recent search on pubmed with key words Yoga and Can-
+cer showed up 263 publications. Among these fifty seven were
+clinical trials; forty were randomized control trials, thirty eight
+systematic reviews and five Meta analyses. Evidence from
+these studies and metanalysis show benefit finding for the effect
+of yoga interventions in managing cancer treatment related dis-
+tress, mood states, quality of life and symptoms [6, 7].
+Evidence from our own research studies have shown that
+integrated Yoga is beneficial in reducing the affective states
+such as anxiety [8], depression and perceived stress [9]. Yoga
+reduced treatment related distress and toxicity such as fatigue,
+* Raghavendra M. Rao
+raghav.hcgrf@gmail.com
+1
+Swami Vivekanada Yoga Anusandhana Samsthana,
+Jigani, Bengaluru, India
+2
+Healthcare Global Enterprises Ltd., Bangalore Institute of Oncology,
+Bengaluru, India
+3
+Division of Yoga and Life Sciences, SVYASA, No 19, Eknath
+Bhavan, Gavipuram Circle, Bangalore, KG Nagar 560019, India
+Indian J Surg Oncol (December 2015) 6(4):325–326
+DOI 10.1007/s13193-016-0492-6
+sleep disturbances, chemotherapy induced nausea and
+vomiting [10], constipation, sleep problems and pain [11].
+Our studies have also shown Yoga to modulate anti-tumour
+and anti-inflammatory immune responses (TNF alpha, NK
+cell counts) following surgery [12], reduce genotoxic stress
+(DNA damage following adjuvant radiotherapy) [13] and nor-
+malize stress hormones (salivary cortisol rhythm), thus mod-
+ulating the psychoneuroendocrinoimmune axes [9]. These
+studies have helped establish the stress reduction benefits of
+yoga through its influence on the hypothalamopituitary adre-
+nal axes. Yoga has been widely used by cancer patient’s world
+over in oncology practice to allay distress and reduce symp-
+tom burden in cancer patients.
+There are various forms of yoga that have been used includ-
+ing Hatha Yoga, Iyengar Yoga, Integrated Yoga, Sudarshan
+kriya Yoga, Pranayama, Mindfulness based stress reduction
+(Buddhist meditation),Viniyoga, Tibetian Yoga etc. The hetero-
+geneity in the type of yoga and the type of measures used has
+resulted in varied effects on the above outcomes. Whatever be
+the type of yoga, its goal is to attain relaxation and mindful
+awareness that helps in in reducing intrusive thoughts that can
+lead to increased anxiety and depression. Cancer patients find
+these interventions and beliefs congruent to their lifestyles and
+have adopted them positively in managing their daily hassles.
+The wait for evidence for the beneficial effects of yoga appears
+to be over. The time has come to integrate yoga into cancer care
+and survivorship programs just like the west did with psycho-
+logical and behavioural interventions.
+References
+1.
+Hughes J (1982) Emotional reactions to diagnosis and treatment of
+early breast cancer. J Psychosom Res 26(2):277
+2.
+Andrykowski MA, Jacobsen PB, Marks E, Gorfinkle K, Hakes TB,
+Kaufman RJ et al (1990) The role of anxiety in the development of
+anticipatory nausea in cancer chemotherapy: a review and synthe-
+sis. Psychosom Med Jul-Aug;52(4):458–475
+3.
+Jacobsen PB, Andrykowski MA, Redd WH, Die-Trill M, Hakes
+TB, Kaufman RJ et al (1988) Nonpharmacologic factors in the
+development of posttreatment nausea with adjuvant chemotherapy
+for breast cancer. Cancer Jan 15;61(2):379–385
+4.
+Andersen BL, Farrar WB, Golden-Kreutz D, Kutz LA, MacCallum R,
+Courtney ME, et al (1998) Stress and immune responses after surgical
+treatment for regional breast cancer. J Natl Cancer Inst 90:30–36
+5.
+Cassileth BR, Schraub S, Robinson E, Vickers A (2001) Alternative
+medicine use worldwide: the international union against cancer
+survey. Cancer 91(7):1390–1393
+6.
+Buffart LM, van Uffelen JG, Riphagen II, Brug J, van Mechelen W,
+Brown WJ, et al (2012) Physical and psychosocial benefits of yoga
+in cancer patients and survivors, a systematic review and meta-
+analysis of randomized controlled trials. BMC Cancer 12:559
+7.
+Cramer H, Lauche R, Dobos G (2014) Characteristics of random-
+ized controlled trials of yoga: a bibliometric analysis. BMC
+Complement Alternat Med 14:328
+8.
+Rao MR, Raghuram N, Nagendra HR, Gopinath KS, Srinath BS,
+Diwakar RB, et al (2009) Anxiolytic effects of a yoga program in
+early breast cancer patients undergoing conventional treatment: a
+randomized controlled trial. Complement Thermal Med 17(1):1–8
+9.
+Vadiraja HS, Raghavendra RM, Nagarathna R, Nagendra HR,
+Rekha M, Vanitha N, et al (2009) Effects of a yoga program on
+cortisol rhythm and mood states in early breast cancer patients
+undergoing adjuvant radiotherapy: a randomized controlled trial.
+Integr Cancer Ther 8(1):37–46
+10.
+Raghavendra RM, Nagarathna R, Nagendra HR, Gopinath KS,
+Srinath BS, Ravi BD, et al (2007) Effects of an integrated yoga
+programme on chemotherapy-induced nausea and emesis in breast
+cancer patients. Eur J Cancer Care Engl 16(6):462–474
+11.
+Rao RM, Nagendra HR, Raghuram N, Vinay C, Chandrashekara S,
+Gopinath KS, et al (2008) Influence of yoga on postoperative out-
+comes and wound healing in early operable breast cancer patients
+undergoing surgery. Int J Yoga 1(1):33–41
+12.
+Rao RM, Nagendra HR, Raghuram N, Vinay C, Chandrashekara S,
+Gopinath KS, et al (2008) Influence of yoga on mood states, dis-
+tress, quality of life and immune outcomes in early stage breast
+cancer patients undergoing surgery. Int J Yoga. 1(1):11–20
+13.
+Banerjee B, Vadiraj HS, Ram A, Rao R, Jayapal M, Gopinath KS,
+et al (2007) Effects of an integrated yoga program in modulating
+psychological stress and radiation-induced genotoxic stress in
+breast cancer patients undergoing radiotherapy. Integr Cancer
+Ther. 6(3):242–250
+326
+Indian J Surg Oncol (December 2015) 6(4):325–326
diff --git a/subfolder_0/Investigating paranormal phenomena Functional brain.txt b/subfolder_0/Investigating paranormal phenomena Functional brain.txt
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@@ -0,0 +1,506 @@
+International Journal of Yoga 
+ 
+! 
+ 
+Vol. 1:2 
+ 
+! 
+ 
+Jul-Dec-2008
+66
+Investigating paranormal phenomena: Functional brain 
+imaging of telepathy
+Ganesan Venkatasubramanian, Peruvumba N Jayakumar, Hongasandra R Nagendra1, Dindagur Nagaraja, Deeptha R1, 
+Bangalore N Gangadhar
+National Institute of Mental Health and Neurosciences, Bangalore, 1Swami Vivekananda Yoga Anusandhana Samsthana, Vivekananda Yoga 
+Research Foundation, Bangalore, India.
+Aim: “Telepathy” is defi
+ ned as “the communication of impressions of any kind from one mind to another, independently of the 
+recognized channels of sense”. Meta-analyses of “ganzfi
+ eld” studies as well as “card-guessing task” studies provide compelling 
+evidence for the existence of telepathic phenomena. The aim of this study was to elucidate the neural basis of telepathy by 
+examining an individual with this special ability. 
+Materials and Methods: Using functional MRI, we examined a famous “mentalist” while he was performing a telepathic task 
+in a 1.5 T scanner. A matched control subject without this special ability was also examined under similar conditions. 
+Results: The mentalist demonstrated signifi
+ cant activation of the right parahippocampal gyrus after successful performance 
+of a telepathic task. The comparison subject, who did not show any telepathic ability, demonstrated signifi
+ cant activation of 
+the left inferior frontal gyrus. 
+Conclusions: The fi
+ ndings of this study are suggestive of a limbic basis for telepathy and warrant further systematic 
+research. 
+Key Words: fMRI; parahippocampal gyrus; telepathy.
+Original Article
+Correspondence to: Dr. Ganesan Venkatasubramanian, 
+Department of Psychiatry,  National Institute of Mental Health and Neurosciences, 
+Bangalore - 560 029, India. 
+ 
+E-mail: gvs@nimhans.kar.nic.in 
+ABSTRACT
+INTRODUCTION 
+“Telepathy” is defined as “the communication of 
+impressions of any kind from one mind to another, 
+independently of the recognized channels of sense”.[1] 
+With the help of various rigorous paradigms over the 
+last 70 years, systematic research has lent support to 
+the reality of telepathy.[2] Meta-analyses of “ganzfield” 
+studies[3] as well as “card-guessing task”[4] studies provide 
+compelling evidence for the existence of telepathy. This 
+mysterious phenomenon has implications not only in the 
+cognitive sciences but also in the biological and healing 
+sciences.[2] It has long been assumed that conscious 
+intention has the capacity to affect living systems across 
+a distance. Intercessory prayers, healing energy, and 
+similar other methods have long been a part of medicine.
+[2] Hence, analyzing the underpinnings of telepathy might 
+potentially help in understanding the “distant-healing” 
+phenomena also. 
+Examining people with extraordinary capabilities 
+involving paranormal phenomena might help in a better 
+understanding of these puzzling entities.[5] Previous such 
+studies examining people with “special talents”[5,6] yielded 
+significant insights. Similarly, studies have been conducted 
+on people experiencing paranormal phenomena. A 
+functional MRI study on “distant intentionality” (defined 
+as sending thoughts at a distance) examined the brain 
+activation pattern in a recipient of thoughts from healers 
+who espoused some form for connecting or healing at a 
+distance. The recipient demonstrated significant brain 
+activations in the anterior and middle cingulate areas, 
+precuneus, and the frontal regions.[7] Previous studies[8,9] 
+examining subjects with telepathic ability suggested an 
+association of paranormal phenomena with the right 
+cerebral hemisphere. It has been reported that correlated 
+neural signals may be detected by fMRI in the brains of 
+subjects who are physically and sensorily isolated from 
+each other.[10] In light of these previous studies, we aimed 
+to examine the functional neuroanatomical correlates of 
+telepathy in Mr. Gerard Senehi, an “expert with telepathic 
+ability (mentalist)” using functional Magnetic Resonance 
+Imaging (fMRI). 
+[Downloaded free from http://www.ijoy.org.in on Tuesday, January 06, 2009]
+67
+International Journal of Yoga 
+ 
+! 
+ 
+Vol. 1:2 
+ 
+! 
+ 
+Jul-Dec-2008
+MATERIALS AND METHODS 
+Subjects 
+Mr. Gerard Senehi [Mr. GS] (aged 46 years) is well known 
+for his abilities to perform various paranormal tasks such 
+as telekinesis, mind reading, and telepathy (http://www.
+experimentalist.com). Mr. JS, the comparison subject, is a 
+43 –year-old male, who was aware of various paranormal 
+phenomena including telepathy, but did not have any 
+paranormal abilities to the best of his knowledge. Both 
+the subjects were right-handed[11] and possessed Master’s 
+Degrees. Both the subjects were screened using the 
+General Health Questionnaire[12] and a comprehensive 
+mental status examination was done to rule out any 
+psychiatric disorder. Neither of them had any history 
+suggestive of substance abuse or dependence, medical or 
+neurological disorders. Neither had any contraindication 
+for MRI. The study procedures were explained to the 
+subjects and written informed consent was obtained. 
+The study protocol was reviewed and approved by the 
+institute’s ethics committee. 
+Telepathy task 
+One of the investigators (PNJ) drew an image in the 
+presence of other investigators [HRN, BNG, and GVS]. 
+Figures 1A and 2A were the images drawn by PNJ for the 
+“mentalist” and the control subject while both were seated 
+in separate rooms. Neither the mentalist [GS] nor the 
+control subject [JS] knew what the image was. The subject 
+was then shifted to the MRI scanner and the investigator 
+(PNJ) was seated in the MRI console room (about 15 feet 
+away). Adequate precautions were taken to avoid sensory 
+leakages by following the guidelines of Hyman and 
+Honorton.[13] During the scan, the subject was instructed 
+to perform the act of telepathy to think about and identify 
+the probable image that would have been drawn by the 
+investigator during the designated epochs of “activation” 
+and not to engage in this task during the periods of “rest”. 
+The subjects were visually cued (using a mirror attached 
+to the head coil which reflected the cues projected on a 
+screen) by green and red stars to indicate the respective 
+onset of activation and rest epochs. The investigator 
+(PNJ) was also given the same cues and was engaged in 
+transmitting the image to the subject in the MRI scanner 
+during the “activation” periods, stopping during the 
+periods of rest. After the scanning, the subject was asked 
+to draw the image that he was able to obtain by performing 
+telepathy. Figure 1B was the image reproduced by the 
+“mentalist” and Figure 2B was the image reproduced by 
+the control. Both the subjects were scanned on the 3rd day 
+of the lunar cycle and at the same time of the day (1400 
+hours IST) separated by a three-month interval. 
+Imaging procedures 
+MRI was done with 1.5 Tesla Magnetom ‘vision’ scanner. 
+First, a T1-weighted three-dimensional Magnetization 
+Prepared Rapid Acquisition Gradient Echo sequence 
+was performed (TR = 9.7 msec; TE = 4 msec; nutation 
+angle = 12°; FOV = 250 mm; slice thickness 1 mm; 
+NEX = 1; matrix = 200 x 256; 160 sagittal slices). After 
+obtaining the anatomical MR images, echo-planar images 
+(EPI) were obtained. They consisted of 112 functional 
+acquisitions, with each acquisition consisting of 16 slices 
+(slice thickness = 8 mm without any interslice gap) in 
+the axial plane covering the entire brain. The parameters 
+for a multishot EPI sequence using Blood Oxygen Level 
+Dependent (BOLD) contrast were as follows: repetition 
+time = 4000 msec; echo time = 76 msec; flip angle = 
+90°; FOV = 250 mm; matrix 128 X 128. The acquisitions 
+were grouped in blocks of eight, yielding 14 blocks. 
+The condition for successive blocks alternated between 
+“rest” and the “telepathic” task, starting with “rest”. This 
+“rest-telepathy” paradigm yielded seven sets of “rest” and 
+“telepathy”. 
+Image analysis 
+The fMRI analysis was performed using Statistical 
+Parametric Mapping-2 (SPM2) (http://www.fil.ion.
+ucl.ac.uk/spm). The EPI images were realigned and 
+corrected for slice timing variations. The images were 
+then normalized[14] to the Montreal Neurological Institute 
+(MNI) space.[15] Finally, the images were smoothened with 
+a gaussian kernel of 6 mm full-width, half-maximum.
+SPM2 combines the General Linear Model and Gaussian 
+field theory to draw statistical inferences from BOLD 
+response data regarding deviations from the null 
+hypothesis in three-dimensional brain space.[16] The 
+images were analyzed using a block design paradigm with 
+a canonical hemodynamic response function. The epochs 
+of rest were subtracted from the epochs of the telepathic 
+task performance. The voxel-wise analysis produced a 
+statistical parametric map of brain activation associated 
+with the telepathic task in the MNI space. Significance 
+corrections for multiple comparisons were performed 
+using a False Discovery Rate (FDR) correction[17] (P < 0.05). 
+The coordinates of significant areas of activation were 
+transformed from MNI space[15] into the stereotactic space 
+of Talairach and Tournoux[18] using nonlinear transform.[19] 
+The brain regions were localized from the Talairach and 
+Tournoux co-ordinates using automated software.[20]
+RESULTS 
+The image [Figure 1B] reproduced by the “mentalist” 
+showed striking similarity to the original image drawn by 
+Telepathy: An fMRI study
+[Downloaded free from http://www.ijoy.org.in on Tuesday, January 06, 2009]
+International Journal of Yoga 
+ 
+! 
+ 
+Vol. 1:2 
+ 
+! 
+ 
+Jul-Dec-2008
+68
+the investigator (PNJ) whereas the one reproduced by the 
+control subject [Figure 2B] did not. The mentalist showed 
+significant activation involving the right parahippocampal 
+gyrus [Number of voxels = 160; Talairach and Tournoux 
+co-ordinates of peak activation: ‘x’ = 32, ‘y’ = -41, ‘z’ = 
+-6; T = 4.88; P (uncorrected) < 0.001; FDR-corrected P 
+= 0.018] [Figure 3] whereas the control subject showed 
+significant activation involving the left inferior frontal 
+gyrus [number of voxels = 363; Talairach and Tournoux 
+co-ordinates of peak activation: ‘x’ = -42, ‘y’ = 25, ‘z’ = 
+-8; T = 4.21; P (uncorrected) < 0.001; FDR-corrected P = 
+0.037] [Figure 4]. 
+DISCUSSION 
+To our knowledge, this is the first fMRI study to examine 
+the brain correlates of telepathy. Previous studies have 
+employed other functional brain mapping techniques 
+such as Single Photon Emission Computed Tomography 
+(SPECT)[8] and electroencephalography (EEG) and 
+MRI[9] to investigate paranormal phenomena in selected 
+individuals. In our study, telepathy was associated with 
+significant activation of the right parahippocampal gyrus; 
+whereas the control subject without telepathic ability, 
+activated the left inferior frontal gyrus under similar task 
+conditions. 
+A previous study[9] on Mr. Ingo Swann (who had the 
+special ability of remote-viewing) showed that the 
+proportions of unusual 7-Hz EEG spike and slow wave 
+activity over the occipital lobes per trial had a correlation 
+with the ratings of response accuracy. Neuropsychological 
+and MRI analyses suggested a differential structural and 
+functional organization within the parieto-occipital region 
+of Mr. Swann’s right hemisphere. 
+Another SPECT study[8] examined Mr. Sean Harribance, 
+who routinely experienced "flashes of images" of objects 
+that were hidden and of accurate personal information 
+concerning people with whom he was not familiar. The 
+"extrasensory" processes in Mr. Harribance correlated 
+quantitatively with morphological and functional changes 
+involving the right parietotemporal cortices (or its 
+thalamic inputs) and hippocampal formation. 
+Figure 1A: Image drawn by the investigator (PNJ) for the “mentalist” [Mr. GS]
+Figure 2A: Image drawn by the investigator (PNJ) for the control subject [Mr. JS]
+Figure 1B: Image reproduced by the mentalist [Mr. GS] after the telepathic 
+task
+Figure 2B: Image reproduced by the control subject [Mr. JS] after the telepathic 
+task
+Venkatasubramanian G, et al.
+[Downloaded free from http://www.ijoy.org.in on Tuesday, January 06, 2009]
+69
+International Journal of Yoga 
+ 
+! 
+ 
+Vol. 1:2 
+ 
+! 
+ 
+Jul-Dec-2008
+Together, these two studies suggest that paranormal 
+phenomena might have a relationship with the right 
+cerebral hemisphere, especially the right posterior cortical 
+and hippocampal regions. The parahippocampal region is 
+very closely linked to the hippocampus, both structurally 
+and functionally.[21] So, the current study findings also 
+support the association between the right hippocampal 
+system and paranormal phenomena. 
+In our study, the control subject activated his left inferior 
+frontal gyrus during his unsuccessful telepathic task 
+performance; this brain area is implicated in the “Theory 
+of Mind [ToM]”.[22] The attribution of mental states, such as 
+desires, intentions, and beliefs, to others has been referred 
+to as ToM.[23] Empathy, conceptually related to ToM, is 
+described as the ability to infer and share the emotional 
+experiences of another.[24] An earlier study reported that 
+psychic mind readers had greater cognitive empathy 
+than individuals without these abilities.[5] Importantly, 
+hippocampal brain regions are important for empathy.[25] 
+Thus, our observations derive indirect support from this 
+earlier study.[5]
+Superior empathizing abilities have been hypothesized 
+to be important for both telepathy[5] as well as for distant 
+intentionality.[7] Interestingly, the cuneus (a brain region 
+associated with empathy[26]) has been reported to be 
+linked with distant intentionality.[7] Also, in our study, 
+the hippocampal region (associated with empathy[25]) is 
+implicated in telepathy. These observations support the 
+hypothesized link between empathy and special abilities. 
+It is possible that people with telepathy or distant healing 
+abilities might possess the ability to activate differentially 
+specific brain regions (in localization, e.g., anterior vs 
+posterior brain regions or in lateralization, e.g, right vs 
+left brain) related to the empathy circuit in comparison 
+to individuals without these abilities. 
+On the contrary, empathy deficits[27] and cuneus[28] and 
+parahippocampal abnormalities[29] and anomalous right 
+hemisphere overactivation[30] have been reported in 
+schizophrenia. Most of these “left-hemisphere dominance 
+failure” findings have been conceptualized as being 
+“abnormal” in their tendency to increase a person’s 
+proclivity towards psychosis. Paradoxically, evolutionary 
+theories on psychosis propose an alternative possibility 
+that some of these traits might be of crucial utility.[31] 
+It has been proposed that this dominance failure (and 
+consequent right hemisphere overactivation) facilitates 
+the emergence of paranormal and delusion-like ideas 
+by way of right hemispheric associative processing 
+characteristics, i.e., coarse rather than focused semantic 
+activation. Interestingly, the ability to detect subtle 
+magnetic field energies might underlie paranormal 
+phenomena.[32] Moreover, magnetic field abnormalities 
+have been described to be the underlying basis for 
+psychotic symptoms.[33,34] However, it is yet to be examined 
+whether a conglomeration of these features (i.e., reduced 
+left hemispheric dominance, paranormal beliefs) are also 
+indicative of an inherent advantage towards acquiring 
+“special” abilities in some people (of course, with 
+enhancement towards psychosis in others) possibly due 
+to an enhanced tendency to perceive subtle geomagnetic 
+energy alterations. 
+Ours is probably the first fMRI study to examine the 
+neuroanatomical correlates of telepathy. fMRI offers 
+methodological advantages of nonradioactive and 
+noninvasive real-time imaging of the brain. We have 
+employed a well-researched and validated image analysis 
+paradigm with optimal correction for false positive results. 
+Our study methodology strictly adhered to the guidelines 
+for research on paranormal phenomena proposed 
+by Hyman and Honorton.[11] These include rigorous 
+precautions against sensory leakage, extensive security 
+Figure 3: Right Parahippocampal Gyrus Activation in the subject with telepathic 
+ability [Mr. GS], while performing a successful telepathic task. On the left hand 
+side, the activation is superimposed on a glass brain and on the right hand side, 
+the activation [yellow] is superimposed on a structural MR image
+Figure 4: Left Inferior Frontal Gyrus Activation in the control subject without any 
+telepathic ability [Mr. JS], while performing an unsuccessful telepathic task. On 
+the left hand side, the activation is superimposed on a glass brain and on the right 
+hand side, the activation [yellow] is superimposed on a structural MR image
+Telepathy: An fMRI study
+[Downloaded free from http://www.ijoy.org.in on Tuesday, January 06, 2009]
+International Journal of Yoga 
+ 
+! 
+ 
+Vol. 1:2 
+ 
+! 
+ 
+Jul-Dec-2008
+70
+procedures to prevent malpractices, full documentation of 
+all experimental procedures and equipment, and complete 
+specifications about statistical analyses. 
+Nonetheless, one has to be cautious while interpreting the 
+study findings due to the following limitations: i) ideally, 
+it would have been methodologically more rigorous if 
+Mr. Gerard had replicated the successful telepathic task 
+with similar brain activation during another session of 
+fMRI on a different occasion. As Mr. Gerard had reported 
+some inexplicable discomfort in the few days following 
+the fMRI, this could not be done; Ii) examination of just 
+one control subject is another limiting factor. 
+CONCLUSIONS 
+In summary, this study’s findings are suggestive 
+of an association between telepathy and the right 
+parahippocampal gyrus. The methodological rigor, 
+isolated and robust brain activation with telepathy, and 
+established theoretical relevance of this brain region with 
+reference to paranormal phenomena highlight the need for 
+further studies using advanced fusion imaging techniques 
+(simultaneous fMRI, EEG, and magnetoencephalography) 
+to examine telepathy. 
+ACKNOWLEDGMENTS 
+We sincerely thank Mr. Gerard Senehi and the comparison 
+subject [Mr. JS] for consenting to be subjects for this study. 
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+Venkatasubramanian G, et al.
+[Downloaded free from http://www.ijoy.org.in on Tuesday, January 06, 2009]
+71
+International Journal of Yoga 
+ 
+! 
+ 
+Vol. 1:2 
+ 
+! 
+ 
+Jul-Dec-2008
+33. Kasai K, Yamada H, Kamio S, Nakagome K, Iwanami A, Fukuda M, et al. 
+Neuromagnetic correlates of impaired automatic categorical perception of 
+speech sounds in schizophrenia. Schizophr Res 2003;59:159-72. 
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+Telepathy: An fMRI study
+[Downloaded free from http://www.ijoy.org.in on Tuesday, January 06, 2009]
diff --git a/subfolder_0/Investigation of Yoga Pranayama and Vedic Mathematics on Mindfulness, Aggression and Emotion Regulation.txt b/subfolder_0/Investigation of Yoga Pranayama and Vedic Mathematics on Mindfulness, Aggression and Emotion Regulation.txt
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+Int J Yoga. 2017 Sep-Dec; 10(3): 138–144.
+doi: 10.4103/0973-6131.213470
+PMCID: PMC5793008
+PMID: 29422744
+Investigation of Yoga Pranayama and Vedic Mathematics on
+Mindfulness, Aggression and Emotion Regulation
+Vasant Venkatraman Shastri, Alex Hankey, Bhawna Sharma,  and Sanjib Patra
+From the Division of Yoga and Physical Sciences, S-VYASA University, Bengaluru, Karnataka, India
+Department of Biology, Sri Sai Angels PU College, Chikmagalur, Karnataka, India
+Division of Yoga and Life Sciences, S-VYASA University, Bengaluru, Karnataka, India
+Address for correspondence: Mr. Vasant Venkatraman Shastri, S-VYASA, No. 19, Eknath Bhawan,
+Gavipuram Circle, K. G. Nagar, Bengaluru - 560 019, Karnataka, India. E-mail: vasanthvshastri@gmail.com
+Received 2016 Jul; Accepted 2016 Sep.
+Copyright : © 2017 International Journal of Yoga
+This is an open access article distributed under the terms of the Creative Commons Attribution-
+NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-
+commercially, as long as the author is credited and the new creations are licensed under the identical terms.
+Abstract
+Background:
+Competitive examinations, particularly in mathematics, have made emotional stress a major problem
+for preuniversity students, emotions like aggression toward fellow students and teachers increase.
+Mindfulness is a quality that reduces both emotional stress and aggression, so increasing mindfulness
+should be helpful.
+Aims:
+To study the effects of Yoga Pranayama (YP) and Vedic Mathematics (VM) on mindfulness,
+aggression, and emotion regulation.
+Methods:
+Participants were 12  graders attending a preuniversity college in Chikkamagaluru, India, of both
+genders. Exclusion criteria included major psychological problems. Three classes were arbitrarily
+assigned to one of three interventions, which consisted of 15 days each of 30 min daily instruction in
+YP, Group 1, VM, Group 2, or 30 min ordinary class work, Group 3, the control group. Assessments
+were made using the Mindfulness Attention Awareness Scale, the Nonphysical Aggression Scale from
+Pittsburgh Youth Study, and the Emotion Regulation Questionnaire.
+Statistical Analysis Used:
+SPSS 19.0.
+1
+2
+1
+2
+th
+Results:
+Mindfulness, aggression, and negative emotional regulation changed significantly for the YP group,
+while mindfulness alone improved significantly for the VM group. No group changed on positive
+emotion regulation. Controls apparently improved on aggression. An interesting post hoc correlation
+analysis is also reported, among other things directly linking increased mindfulness to decreased
+aggression.
+Conclusions:
+The study showed positive effects of traditional methods of decreasing emotional pressure on students
+facing preuniversity mathematics examinations. Increasing mindfulness is considered a way of
+increasing emotion regulation, so the failure of this study to provide evidence for that is of interest.
+Keywords: Aggression, emotion regulation, mindfulness, Pranayama, Yoga
+Introduction
+In recent years, stress has become a major factor affecting lives of children facing competitive
+professional examinations in the years before university.[1] This may be due to monotonous book-
+based teaching methods, which have created learning difficulties in education.[2] Mathematics is a
+subject that many students find very challenging and which can increase students’ reported levels of
+stress[3] more than other subjects. Most high paid private sector jobs like basic engineering or other
+professional degrees require mathematics as a major subject. These circumstances have made
+emotional stress a major problem for students attempting to enter the college or university course of
+their choice.[4] Frustration can lead to increase in aggression[5] toward teachers and fellow students,
+and other antisocial behavior patterns.[6] In schools, competitive professional examinations select
+those entering higher education for various professions. Today, they put new pressures and workloads
+on schoolchildren that some even argue to be unnecessary. Reducing the effects of such pressures is a
+matter of national urgency.
+The concept of mindfulness comes from the Pali concept of sati,[7] i.e., being aware of one's stream of
+consciousness, thinking patterns, and associated tendencies to action in the present moment.[8] Recent
+years have seen the publication of many studies on the quality of mind known as mindfulness[9]
+including studies of mindfulness training in schools.[10] Attempts have been made to design
+mindfulness-based education programs to improve the quality of teaching and learning.[11]
+Mindfulness is said to reduce aggression[12] and improve emotion regulation.[13,14] This study
+reports effects of two easily applied methods, Yoga Pranayama (YP) and Vedic Mathematics (VM),
+aiming to decrease emotional stress and aggression and increase mindfulness in preuniversity students
+facing competitive entrance examinations particularly in mathematics. An integrated Yoga intervention
+including Yoga postures, breathing exercises, and relaxation which have been reported to improve both
+mindfulness and emotional balance,[15] as well as cognitive performance,[16] but to our knowledge,
+the effect of teaching mathematics according to the methods of VM has not been studied in this context
+nor have the effects of YP alone been evaluated for effects on mindfulness.
+Yoga Pranayama
+Pranayama is the fourth of the eight limbs of Yoga[17] and has a deeply settling influence on the
+mind[18] helping the subject be in the present, i.e., “mindful.” It is, therefore, widely employed as a
+preparation for meditation.[8] It enlivens prana, or “subtle energy” in the tissues, now measured
+electrically at acupuncture points.[19] Its settling influence has been confirmed by such observations as
+test anxiety reduction, improved test performance,[20] and perceived stress reduction and improvement
+in cardiovascular parameters;[21,22] it also reduces aggression.[23] These results suggest that
+application of pranayama methods to decrease effects of stress in society might prove valuable.
+Teaching them in schools would make a highly beneficial life-long skill available[24] just as
+mindfulness-based interventions (MBI) are seen as achieving.[10]
+Hence, so many studies have been published on various pranayama programs that its effects may be
+considered quite well standardized. It can be used as a comparison for another method requiring
+assessment for comparative effects. In this context, YP represents a recognized way of managing mild
+levels of stress, and so improving emotion regulation and decreasing tendencies to aggression. In
+particular, pranayama practice usually involves focusing on the breathing process bringing the mind to
+the present moment. Improving that ability will clearly be of value when taking tests and exams.
+Vedic Mathematics
+VM[25] presents a new method of problem-solving in high school mathematics comprising 16 sutras
+and 16 upasutras, which have been much appreciated wherever they have been applied.[26] According
+to Charak (2002) (Quoted on back cover of Glover [2005]), “They make arduous mathematical
+situations look terribly simple to solve. I have taught … the principles … to my students in B. Ed.
+classes. They found the techniques extremely simple, less time consuming, and less likely to lead to
+mistakes.”[26] We have found that they offer students choice when performing calculations, thus
+introducing a “fun” element and increasing student enthusiasm. As a result, mathematics teachers in
+many different countries have extended their applications.[27]
+The system's ability to empower students to choose how to perform calculations means that students
+can select their preferred method in arithmetic, algebra, geometry, etc. Its use helps to develop
+students’ confidence and basic problem-solving abilities. Visualizing pictorial or algebraic patterns to
+solve problems increases students’ enjoyment of the process.[28] Problem-solving calculations become
+a game.
+This approach of VM allows teachers to give detailed reasons for the success of each method. In our
+estimate, a mature approach teaches VM not as a set of magical tricks but as teaching aids to
+communicate deeper aspects of a problem's structure and solution. In short, enabling students to
+visualize how and why each method works, resulting in added understanding, and increased confidence
+when faced with exam questions. A previously submitted paper has reported reductions in mathematics
+anxiety (Impact of Pranayama and VM on Math Anxiety and Cognitive Skills, submitted for
+publication). On this basis, we hypothesized that using VM would improve mindfulness and emotional
+regulation and reduce aggression in school students, particularly those in 11  and 12  grades.
+Methods
+Participants
+Three classes totaling 243 students studying in 12  Standard at Sri Sai Angels Preuniversity College,
+Chikkamagaluru, India, were arbitrarily assigned to YP group (YP – 73 students), VM group (VM – 80
+students), and control group (CG – 90 students).
+Design
+Three group, pre–post control design [Figure 1].
+th
+th
+th
+Figure 1
+Three classes of 12  grade preuniversity students were arbitrarily assigned to one of three interventions:
+Yoga Pranayama, Vedic Mathematics, and Controls. Baseline data were collected following which the
+respective intervention was given for 15 days to each group. Postdata were collected after the intervention
+Data extraction
+Pencil and paper tests on Mindfulness Attention Awareness Scale (MAAS), Nonphysical Aggression
+Scale from Pittsburgh Youth Study and Emotion Regulation Questionnaire (ERQ) as described below
+were given at baseline and after the 15-day intervention workshops.
+Interventions
+Students in the YP and VM groups participated in half hour workshops on their respective topics every
+day for 15 days [Table 1]. Controls had their usual conventional mathematics classwork routine,
+whereas the first two groups received respective workshops in addition to that. All three groups’
+workshops/classes were taken by the first author who is fully qualified to instruct in all these subjects.
+Comparison of conventional mathematics methods and VM methods is shown in the Appendix.
+th
+Table 1
+Intervention
+Open in a separate window
+The YP intervention workshops were conducted with students in a comfortable sitting position. The
+first two are technically Yoga purification exercises (Kriyas), while the third, Sectional Breathing, is
+closely related to certain Western approaches to improve the quality of breathing. The next three are
+classic YPs found in classic texts (Hatha YP, Nagendra, 2003) as is the more demanding final exercise,
+Bhramari Pranayama, in which eyes, ears, and mouth are covered by fingers.
+In the VM intervention workshops, standard topics in 11  and 12  grade mathematics syllabus were
+taught according to standard VM procedures. Table 1 displays representative examples, details of three
+are set out in the Appendix. The first employs “vertically and crosswise” to solve an example of
+simultaneous equations. The second simplifies integration of a reciprocal quadratic function
+(factorizable) using “transpose and apply.” The third example offers a multiple choice question on
+integrating reciprocal quadratic functions that cannot be factorized.
+th
+th
+Mindfulness attention awareness scale
+This represents the most difficult kind of problem in this level of mathematics in India since it requires
+understanding functions such as inverse hyperbolic functions that are less familiar to the student. Even
+good students incur conceptual problems, time loss, and errors when attempting these problems. In the
+workshops, VM sutras, “vertically and crosswise,” “transpose and apply,” and “addition and
+subtraction,” were all separately utilized in demonstrating alternative approaches to solving
+simultaneous equations, emphasizing the choice now being offered to students. Integration of
+reciprocal quadratic functions requires closer inspection and use of recommended VM time-saving
+patterns.
+Assessment instruments used
+The MAAS instrument[29] is a single-factor 15-item
+questionnaire. Total score on its six-point scale (1 = almost always to 6 = almost never) can vary from
+15 to 90, but normal scale score is taken as the average over the 15 items. Higher scores reflect higher
+levels of dispositional mindfulness. Researchers report MAAS reliability in university samples as 0.82.
+[29] The instrument has been validated in college, community adults, and cancer patient populations in
+different studies.[30,31] Mindfulness as measured by the MAAS is held to connect consciousness to
+emotional regulation, behavior regulation, and well-being.
+Nonphysical aggression scale from Pittsburgh youth study
+The Nonphysical Aggression Scale from Pittsburgh Youth Study[32,33] measures the nonphysical
+aggressive behavior of children, validated by a longitudinal study of 1517 inner-city boys in Pittsburgh,
+Pennsylvania, starting from 1987. The study regularly measured risk factors involved in disruptive,
+delinquent, drug-related, and antisocial behavior of adolescent and preadolescent boys in the beginning,
+and on half yearly assessment, and later extended assessments to include the female population.[34,35]
+Nonphysical Aggression Scale is 16 items of measuring nonphysical aggressive behaviors, such as
+arguing, bragging, seeking attention, disobeying parents or teachers, not getting along with others,
+swearing, and sulking. It has Internal Consistency 0.85 on a sample of 6-, 9-, and 12-year-old males
+followed into adulthood. Its 3-point scale ranges from 0 = not true to 2 = very true.
+Emotion regulation questionnaire
+The ERQ[36] consists of 10 items on a 7-point scale (1 = strongly disagree to 7 = strongly agree). It
+measures two important aspects of emotion such as emotional experience and emotional expression,
+both pointing to control and management of emotion. Questions concerning positive and negative
+emotions assess individual differences connected to cognitive reappraisal and expressive suppression.
+Average value of Cronbach's alpha is 0.79 for reappraisal and 0.73 for suppression. Test–retest
+reliability was 0.69 for both the scales. Reappraisal items are nos. 1, 3, 5, 7, 8, 10 and suppression
+items are numbers 2, 4, 6, 9. Scale scores are obtained by adding response values for each item on that
+scale.
+Statistical analysis
+IBM SPSS Statistics for Windows, Version 19.0, manufactured by IBM Corporation, Armonk, NY, was
+used to analyze data. The data were found to be normally distributed, so preliminary group
+comparisons were RM ANOVAs with post hoc Bonferroni correction for each of the four scales. Since
+this was found statistically significant, the predata for the three groups were compared and found not to
+be statistically significantly different on any of the tests. Next, paired sample t-tests were used to
+compare pre–post within group differences, and then group time interaction tests were used to compare
+differences between experimental and control groups.
+Results
+Demographic variables and age were not significantly different for the three groups. The RM ANOVAs
+were statistically significant for the tests of mindfulness, F (2, 240) = 19.88, P < 0.001, and aggression,
+F (2,240) = 14.49, P < 0.001, but not for either positive or negative ERQ scales. Experimental results
+are set out in Tables 2 and 3. Table 2 presents pre- and post-intervention values of the three groups on
+the four different scales, giving statistical significance of within-group pre–post differences. Table 3
+sets out between-group comparisons of Table 2's within-group differences, i.e., group-time interaction
+effects, giving their significances, as explained in Table 3 caption. Table 2 shows that mindfulness,
+aggression, and negative emotion regulation changed significantly for the YP group (P ≤ 0.001 for
+mindfulness and aggression; P ≤ 0.028 for negative emotion regulation), while for the VM group, only
+mindfulness improved significantly, P ≤ 0.001 [Table 2 and Figure 2], though changes in aggression
+may have showed a weak trend toward improvement (P = 0.15). No group changed significantly on
+positive emotion regulation. Controls seemed to improve on aggression, P ≤ 0.030 (paired sample t-
+test) [Table 2 and Figure 3]. Effect sizes (Cohen's d) were for the YP group, 0.93 (mindfulness), 0.78
+(aggression), and for the VM group, 0.29 (mindfulness).
+Table 2
+Pre- and post-values of the variables
+Table 3
+Within-group differences and significances of between-group comparisons
+Figure 2
+Shows Mindfulness Attention Awareness Scale pre–post mean scores with a significant increase in Yoga
+Pranayama and Vedic Mathematics (P ≤ 0.001) groups. All bars and attached error lines represent means ±
+standard deviations
+Figure 3
+Depicts pre- and post-mean scores of the three study groups on the Nonphysical Aggression Scale from
+Pittsburgh Youth Study. All bars and attached error lines represent means ± standard deviations. Decreases
+for Yoga Pranayama (−3.25, P ≤ 0.001) and Control (−0.79, P = 0.030) groups attained reportable
+significance, P ≤ 0.05
+Table 3 shows Group-Time interaction differences and significances. Mindfulness and aggression
+changed significantly more for the YP group than for VM and control groups, P ≤ 0.001 [Figure 4a and
+b], but within-group changes on positive and negative emotion regulation scores were not significantly
+different between the three groups.
+Figure 4
+(a) Group-time interaction effects on mindfulness scores. At time 1, i.e., pre, all the three groups are not
+significantly different from each other on mean mindfulness scores. At time 2, i.e., post, Yoga Pranayama
+group is significantly higher on mean mindfulness score from Vedic Mathematics (P = 0.001) and control
+(P = 0.005) groups. (b) Group-time interaction effects on Nonphysical Aggression scale. At time 1, i.e.,
+pre, all the three groups are not significantly different from each other on mean aggression scores. At time
+2, i.e., post, Yoga Pranayama groups mean aggression score is significantly lower from Vedic Mathematics
+(P = 0.001) and control (P = 0.011) groups
+Discussion
+Reported results are not entirely as hypothesized. The YP group performed best overall on the tests,
+possibly because the sequence of YP practices settles the mind and may bear some similarity to MBI.
+The VM group was observed to increase by a small amount in mindfulness with high significance but
+was not observed to decrease significantly in aggression as had been hypothesized. Increased
+confidence in a single subject, mathematics, may not necessarily translate into decreases in self-
+reported feelings of aggression, particularly as the learning environment did not change for teaching
+other subjects, and the learning environment has been found to be a significant factor in stress
+generation.[37]
+A possible reason for the observed increase in mindfulness in the VM group may be that giving
+students choice of how to perform calculations enhances their ability to reflect internally on their own
+preferences, thus increasing their capacity for a more internally directed orientation of awareness. It
+can also be argued that adding a fun element to the learning process involving pattern recognition, a
+right hemisphere activity,[38] may have improved participants’ capacity for being in the present
+moment.[39] Another possible reason is that reductions in mathematics anxiety may make mindfulness
+easier to maintain.
+The YP group improved far more in mindfulness than the other two groups (P = 0.0001 in both cases),
+and alone decreased highly significantly in aggression and significantly on negative emotion
+regulation. Several studies have reported increases in emotional regulation resulting from mindfulness
+training.[40] For one group to both increase in a measure of mindfulness and decrease in aggression
+and negative emotion is consistent with these results. In support of this, Yoga, including nadi-shodana
+pranayama as used in this study, has been found to be very effective in changing the levels of key
+endocrine molecules associated with stress such as epinephrine and norepinephrine.[41] This may
+explain its effectiveness in decreasing self-reported aggression on the Nonphysical Aggression Scale
+from Pittsburgh Youth Study.
+The observed effect of YP on mindfulness is important. Although the practice is not specifically
+designed to increase mindfulness, it is extremely calming and centering for participants’ awareness,
+and evidently increases mindfulness as a beneficial side effect.[8] Further studies of this could prove
+helpful.
+Yogic Kapalabhati Kriya washes away carbon dioxide and increases oxygen concentration, also
+revitalizes the functions of brain cells. Nāḍī Śuddhi brings sympathetic and parasympathetic balance in
+the nervous system and balance in anabolic and catabolic processes which would lead to clarity of
+mind and concentration.[17] Hence, this could be the reason to find the overall improvement in YP
+group.
+In contrast, controls’ observed decrease in aggression seems anomalous. When 12 group comparisons
+are made in a single study, one change reaching P < 0.05 by chance is not unusual.
+As regards possible connections between MAAS measured mindfulness and emotion and behavior
+regulation, we performed various correlations between premeasurements of our 243 participants in a
+post hoc analysis. Correlations between mindfulness and aggression reached significance, Pearson's r =
+−0.45, P < 0.0001, for prevalues, with similar values for postvalues, while those between prevalues of
+mindfulness and negative ERQ were r = −0.214, P = 0.001, while postvalues showed r = −0.236, P =
+0.001. While the first is clearly expected, the second result is interesting in that those with higher
+scores on mindfulness felt less need to hide negative feelings, possibly indicating that their general
+levels of negativity were less and equally that negative feelings may block mindful awareness.[42] The
+same might also be said about the first correlation, those with high levels of outward aggression,
+presumably originating in internal frustration, may be less capable of being in present moment states of
+mindfulness.[12]
+However, a similar analysis of correlations between the ERQ positive and ERQ negative scales yielded
+extraordinary results: Pearson's r = 0.24, P < 0.0002, prevalues, and r = 0.35, P < 0.0001 postvalues.
+Positive correlations between supposedly independent scales, even correlations of this magnitude, are
+not to be expected. The interpretation of this correlation is difficult but may mean that the test needs
+revalidation in India, where English may not be English speakers’ mother tongue.
+The strengths of the study include the number of participants for pre–post within group changes and
+intergroup comparisons. Moreover, it specifically supports the idea that YP can improve participants’
+quality of mindfulness[8] and help in students’ management of aggression issues.[23] The main
+weakness was the assignment of participants to groups by an arbitrary choice of which class took
+which intervention, rather than by a fully randomized assignment to different groups. Although the
+latter would have made the study technically superior, each class was naturally heterogeneous and had
+similar baseline sociodemographic characteristics; there is no reason to believe that it would have
+changed the overall findings and conclusions.
+Results of the study were sufficiently promising to encourage further research, particularly in light of
+the measurements on mathematics anxiety and other variables (submitted for publication). It is hoped
+that funds for larger, fully randomized studies will be forthcoming.
+Conclusions
+h
+While VM has been found highly effective in enhancing 12  grade exam results, it seems less effective
+on variables reported in this study. YP techniques, on the other hand, could be useful in schools and
+preuniversity colleges to produce more settled states of mind such as those associated with mindfulness
+and also to reduce symptoms of aggression that seem to result from examination pressures during the
+12  grade year of high school/preuniversity college when such stressors are at their peak.
+Financial support and sponsorship
+Nil.
+Conflicts of interest
+There are no conflicts of interest.
+Acknowledgment
+We would like to thank Sri Sai Angels School for providing subjects, place, and equipment to carry out
+the study. Authors would like to acknowledge Mr. Manjunath BS for technical support during data
+collection.
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diff --git a/subfolder_0/Management of Type II Diabetes by.txt b/subfolder_0/Management of Type II Diabetes by.txt
new file mode 100644
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@@ -0,0 +1,715 @@
+https://doi.org/10.1177/09727531211000041
+Annals of Neurosciences
+27(3-4) 266­
+–272, 2020
+© The Author(s) 2021
+Reprints and permissions:
+in.sagepub.com/journals-permissions-india
+DOI: 10.1177/09727531211000041
+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
+Management of Type II Diabetes by  
+Modulating the Modifiable Risk Factors:  
+A Future Roadmap for Prevention of 
+Cerebrovascular Complications
+Kanupriya Sharma1*, Priya Battu1*, Akshay Anand1,2,3
+, Raghuram Nagarathna4, 
+Navneet Kaur5, Neeru Malik6, Amit Singh7 and Hongasandhra R Nagendra8
+Abstract
+Background: Indian Diabetes Risk Score (IDRS) is a screening tool for quantifying the risk of diabetes mellitus (DM) 
+development in the Indian population. The present study has evaluated the level of risk of developing DM in Chandigarh and 
+Panchkula based on the IDRS score.
+Methods: As a part of a national diabetes control trial funded by the Ministry of Health and Family Welfare (MoHFW) and 
+the Ministry of AYUSH, Government of India, 1,916 participants from the Chandigarh and Panchkula regions were assessed 
+for the risk of developing DM. Risk assessment was done on the basis of the IDRS score which includes age, family history, 
+waist circumference, and physical activity as its contributing factors. Participants with an IDRS score <30 were in the low-risk 
+category, those with 30 to 50 were in the moderate-risk category, and those with >60 were in the high-risk category for DM.
+Results: Out of the 1,916 screened respondents (59.86% females and 40.14% males), 894 participants (46.65%) were at a 
+high risk for DM (IDRS >60), 764 (39.87%) were at a moderate risk (IDRS = 30–60), and 258 (13.46%) were at a low risk 
+(IDRS <30). Waist circumference contributed to 35.90% of the high-risk category followed by age (19.67%) and physical 
+activity (11.67%). Age and waist circumference also showed a strong correlation with the total IDRS score.
+Conclusion: The Chandigarh and Panchkula population showed a high tendency to develop DM based on the IDRS score. 
+Modifiable risk factors such as waist circumference and physical activity were the major contributing factors. Apart from the 
+modifiable risk factors, age was also another major contributing risk factor. Based on these outcomes, lifestyle modifications 
+like yoga and exercise can be proposed for this population as a preventive approach to reduce the risk of developing DM and 
+other associated cerebrovascular complications.
+Keywords
+Diabetes mellitus, Chandigarh, IDRS, waist circumference, physical activity 
+Received 03 November 2020; revised 16 January 2021; accepted 16 January 2021
+5 Department of Physical Education, Panjab University, Chandigarh, India
+6 Dev Samaj College of Education, Chandigarh, India
+4 VYASA Arogyadhama, Swami Vivekananda Yoga Anusandhana Samsthana, 
+Bengaluru, Karnataka, India
+2 Centre for Mind-Body Medicine, Post Graduate Institute of Medical 
+Education and Research (PGIMER), Chandigarh, India
+3 Centre for Cognitive Sciences  and Phenomenology, Panjab University, 
+Chandigarh, India
+1 Department of Neurology, Neuroscience Research Lab, Postgraduate 
+Institute of Medical Education and Research, Chandigarh, India
+Corresponding author:
+Raghuram Nagarathna, Swami Vivekananda Yoga Anusandhana Samsthana, 
+Bangalore, Karnataka 560019, India.
+E-mail: rnagaratna@gmail.com
+Co-corresponding author:
+Akshay Anand, Neuroscience Research lab Department of Neurology 
+PGIMER, Chandigarh, India.
+E-mail: akshay1anand@rediffmail.com
+Introduction
+Diabetes mellitus (DM) is a metabolic disorder that is 
+prevalent in the middle-aged and elderly population.1 The 
+population with DM has reached alarming proportions in 
+India with 2.4% in rural and 11.6% in urban areas.2 Lifestyle 
+and stress are some of the major causes of DM,3 and these 
+could also lead to the development of major neurological 
+*These contributed equally to this work.
+7 Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana 
+Samsthana, Bengaluru, India
+8 Swami Vivekananda Yoga Anusandhana Samsthana, Bengaluru, India 
+Sharma et al.	
+267
+disorders. DM is also associated with complications like 
+hypertension, dyslipidemia, and obesity, which can lead to 
+microvascular and macrovascular complications resulting in 
+strokes, coronary artery disease, renal failure, retinopathies, 
+and depression.4,5 DM is also strongly correlated with 
+dementia, vascular dementia, and Alzheimer’s disease,6,7 and 
+also diabetic retinopathy which most commonly leads to 
+blindness in adults.8 DM and complications related to it also 
+majorly impacts quality of life.9
+A lack of effective screening methods for DM risk 
+complicates the scenario. An early identification of the risk of 
+development of DM may help in reducing the prevalence of 
+DM by creating awareness. To ease this situation, Indian 
+Diabetes Risk Score (IDRS) has been developed as an 
+effective screening tool to detect the risk.10 IDRS was 
+developed as a screening tool by the Madras Diabetes 
+Research Foundation and validated in a Chennai Urban Rural 
+Epidemiology Study (CURES) study in 2005 by Mohan et 
+al.11 Based on the IDRS score, participants can be categorized 
+into low, moderate, and high risks of developing DM. 
+Numerous studies have shown high sensitivity and specificity 
+of IDRS to diagnose undetected DM.12–14. If physicians can 
+predict the risk of DM based on simple scales like IDRS with 
+high sensitivity and specificity, this will not only help in the 
+prevention of DM, but also in the prevention of above-stated 
+complications related to DM.
+The IDRS score is calculated based on two modifiable 
+(physical activity and waist circumference) and two 
+nonmodifiable risk factors (family history and age). 
+Modifiable risk factors such as waist circumference and 
+physical activity have been linked to DM occurrence time 
+and again.1 These can be moderated with lifestyle management 
+activities like yoga and exercise that can provide some 
+benefits by decreasing the contribution of the modifiable 
+Niyantrit Madhumeh 
+ 
+ 
+Screening for risk of DM across various 
+rural and urban regions of Chandigarh 
+and Panchkula (Haryana) was done
+ 
+N = 1,916 validated screening 
+forms with complete information
+ 
+Excluded screening data 
+with missing information 
+N = 894 
+IDRS >60 
+High DM risk 
+ 
+N = 764 
+IDRS 30–60 
+Moderate DM risk 
+N = 258 
+IDRS < 30 
+Low DM risk  
+ 
+Bharat study 2017
+Figure 1. Schematic Representing the Study Participant Distribution on the basis of IDRS Score. 
+contributing factors and may thus decrease the overall IDRS 
+score, which eventually decreases the risk of DM along with 
+other associated comorbidities.
+We have been previously working on biomarker discovery 
+and genetic screening for neurological diseases such as 
+amyotrophic 
+lateral 
+sclerosis,15–18 
+age-related 
+macular 
+degeneration,19–22 and Parkinson’s disease,23 developed various 
+animal models for retinal degeneration and memory loss,24–26 
+and studied the efficacy of umbilical cord blood-derived stem 
+cells in rescuing retinal degeneration and memory loss.26–28 Now 
+we have shifted toward the public health sector, and through this 
+study we wanted to identify the proportion of population of 
+Chandigarh and Panchkula under the risk of DM development 
+based on the IDRS scoring. We also wanted to identify the most 
+contributing IDRS factor in the high-risk category.
+Methodology
+Study Settings and Design
+As a part of a national study (Niyantrit Madhumeh Bharat 
+2017),11 a door-to-door screening across various regions of 
+Panchkula 
+(Haryana) 
+and 
+Chandigarh 
+was 
+done. 
+Information about the IDRS parameters was collected. 
+Along with IDRS parameters, information about habitat, 
+gender, and age was also collected.
+Sample Size and Sampling
+Various rural and urban areas of Chandigarh and Panchkula 
+were selected for this study. Based on inclusion and exclusion 
+criteria, participants were screened for DM risk using the 
+IDRS score.
+268	
+Annals of Neurosciences 27(3-4)
+Data Collection
+Data was collected in a questionnaire-based screening form, 
+and the details of the participants such as name, age, gender, 
+and habitat were collected and noted in the forms. Information 
+about IDRS parameters such as age, physical activity, and 
+family history of diabetes was obtained from the participants, 
+and waist circumference (another parameter of the IDRS 
+score) was measured using a measuring tape and was recorded 
+in centimeters.
+IDRS and Its Parameters
+IDRS was selected as a screening tool based on its high 
+sensitivity (95.12%) and specificity (28.95%). An IDRS 
+score is obtained based on the following parameters such as 
+age, family history, physical activity, and waist circumference. 
+Figure 1 shows the distribution of participants on the basis of 
+IDRS score. Based on the individual score of these parameters, 
+the total IDRS score was calculated and participants were 
+categorized into low risk with an IDRS score <30, moderate 
+risk with an IDRS score 30 to 60, and high risk with an IDRS 
+score ≥60. Table 1 shows individual IDRS parameters and 
+their scoring.
+Data Analysis
+Statistical analysis was done by using IBM SPSS 22. The 
+numbers of participants falling in different categories were 
+reported by using descriptive statistics. A chi-square test was 
+done to compare the risk factors within each IDRS risk 
+category. A one-sample Kolmogorov Smirnov (KS) test was 
+used to check the normality of the data. Correlation between 
+the IDRS factors was done using Spearman’s Rho correlation. 
+Values <0.05 were statistically significant.
+Results
+A total of 1,916 participants from the Chandigarh and 
+Panchkula regions were screened. Participants with missing 
+and undeterminable data were excluded from the study. Out 
+of the total population, 59.9% were females and 40.1% were 
+males. The average age of the participants was found to be 
+38.3 ± 13.6 years. Based on the IDRS score, 894 participants 
+were at a high risk for the development of DM (IDRS score 
+≥60), 764 were at a moderate risk (IDRS = 30–60), and 258 
+were at a low risk (IDRS <30).
+Distribution of Total Population Based on 
+Modifiable and Nonmodifiable Risk Factors of IDRS
+In the high-risk category, waist circumference contributed to 
+35.9%, whereas age contributed to 19.7%. No or low physical 
+activity contributed to 11.1% and 28.7% in the high-risk 
+category, respectively.
+Overall, modifiable risk factors such as waist circumference 
+and low physical activity contributed to 46.65% of high IDRS 
+score, and nonmodifiable risk factors contributed to 21.7% of 
+high IDRS score (Table 2).
+IDRS Distribution Based on Gender and Habitat
+Based on gender, females were more prone to DM with 34.2% 
+in the high-risk category as compared to 12.5% males. In the 
+moderate-risk category also, more females were there (21%) 
+in comparison to 18.9% males. In case of the low-risk 
+category, the numbers of both male (8.9%) and female (9%) 
+participants were almost similar.
+Based on habitat in the high-risk IDRS category, more 
+participants were from the rural areas (27.2%) in comparison 
+to urban areas (19.4%). The moderate-risk group also had 
+more participants from rural areas (23.6%) in comparison to 
+16.2% from urban areas. In the low-risk category, 8.5% were 
+from rural areas and 4.9% were from urban areas (Table 2).
+Correlation of Each IDRS Category With Total 
+IDRS Score
+Based on the number of participants in each IDRS category, a 
+correlation analysis of each factor with the total IDRS score 
+Table 1. IDRS Scoring Based on Modifiable and Nonmodifiable Risk Factors
+Parameters
+Scores
+Nonmodifiable risk 
+factors
+Age
+<35 
+Years = 10
+35–49 = 20
+≥50 = 30
+Family history
+Both nondiabetic parents 
+= 0
+One diabetic parent 
+= 10
+Both diabetic parents = 20
+Modifiable risk fac-
+tors
+Physical activity
+Vigorous = 0
+Moderate 
+= 10
+Mild = 20
+No exercise = 30
+Waist circumference: 
+Male 
+Female
+<90 cm = 0
+<80 cm = 0
+90–99 cm = 20
+80–89 cm = 20
+≥100 cm = 30
+≥90 cm = 30
+IDRS risk score
+<30 = Low risk
+30–60 = Moderate risk
+≥60 = High risk
+Abbreviation: IDRS: Indian Diabetes Risk Score.
+Notes: IDRS consists of two modifiable (i.e., waist circumference and physical activity) and two nonmodifiable (i.e., age and family history) risk factors. A 
+total IDRS risk score is calculated based on individual IDRS risk factors. Based on the total IDRS score, the DM risk categorization is done into <30, low 
+risk; 30 to 60, moderate risk; ≥60, high risk.
+Table 2. Number of Participants in Each IDRS Risk Factor Category
+IDRS Category
+Modifiable Risk Factors
+Nonmodifiable Risk Factors
+Physical Activity
+Waist Circumference
+Age
+Family History
+0
+10
+20
+30
+0
+20
+30
+0
+20
+30
+0
+10
+20
+High Risk
+IDRS ≥60
+16
+(0.8%)
+115
+(6.0%)
+550 
+(28.7%)
+214 
+(11.2%)
+15
+(0.8%)
+191
+(9.9%)
+688
+(35.9%)
+100
+(5.2%)
+417
+(21.7%)
+377
+(19.6%)
+678
+(35.4%)
+179
+(9.3%)
+38
+(1.9%)
+P-value
+(high risk vs. 
+moderate risk)
+<.001***
+<.001***
+<.001***
+<.001***
+<.001***
+<.001***
+<.001***
+<.001***
+<.001***
+<.001***
+<.001***
+<.001***
+<.001***
+High riskIDRS 
+≥60N = 894
+Males = 239, Females = 655; Urban = 372, Rural = 521
+Moderate riskI-
+DRS 30–60
+55
+(2.8%)
+150
+(7.8%)
+431
+(22.4%)
+126
+(6.5%)
+248
+(12.9%)
+314
+(16.3%)
+202
+(10.5%)
+573
+(29.9%)
+123
+\(6.4%)
+68
+(3.5%)
+641
+(33.4%)
+113
+(5.8%)
+8
+(0.4%)
+P-value
+(moderate risk vs. 
+low risk)
+<.001***
+<.001***
+<.001***
+<.001***
+<.001***
+<.001***
+<.001***
+<.001***
+<.001***
+<.001***
+<.001***
+<.001***
+<.001***
+Moderate risk
+IDRS 30–60
+N = 764
+Males = 361, Females = 403; Urban = 311, Rural = 452
+Low risk
+IDRS <30
+52
+(2.7%)
+60
+(3.1%)
+147
+(7.6%)
+0
+(0%)
+240
+(12.5%)
+18
+(0.9%)
+0
+(0%)
+257
+(13.4%)
+1
+(0.05%)
+0
+(0%)
+245
+(12.7%)
+14
+(0.7%)
+0
+(0%)
+P-value
+(low risk vs. high 
+risk)
+<.001***
+<.001***
+<.001***
+<.001***
+<.001***
+<.001***
+<.001***
+<.001***
+<.001***
+<.001***
+<.001***
+<.001***
+.080
+Low risk
+IDRS <30
+N = 258
+Males = 172, Females = 173; Urban = 95, Rural = 163
+Notes: The categorization of total participants into each IDRS risk category based on individuals’ IDRS risk scores. The number and percentage of participants in each category are depicted in the table along with the 
+comparative group difference in each IDRS risk category. Male and female participants and urban and rural residents of each IDRS risk category are also shown in the table. Data was analyzed using a chi-square test in 
+SPSS. ***depicts p<0.001.
+270	
+Annals of Neurosciences 27(3-4)
+A high proportion of the Chandigarh population in the 
+high waist circumference category have shown a higher 
+tendency of developing cardiometabolic disorders. We also 
+observed that the physical activity pattern was also a reason 
+for the high proportion of the population being at a high risk, 
+out of which 11.2% were performing no physical activity and 
+28.7% were mildly physically active. Low physical activity, 
+which is another parameter of sedentariness, has previously 
+been linked to the increase in the incidence of DM34 and also 
+neurodegenerative diseases18 as it increases the oxidative 
+stress. 
+As in our population we have found waist circumference 
+and physical activity as the major contributors in the high-
+risk population, this shows that a large proportion of this 
+population are prone to sedentariness, which puts them at a 
+high risk of developing DM and this could also further lead to 
+the 
+development 
+of 
+cardiometabolic 
+disease 
+and 
+neurodegenerative diseases.
+Our data is consistent with the previous studies which 
+have shown a high prevalence of T2DM and prediabetes in 
+the Chandigarh population.35,36 The Chandigarh population 
+has shown a higher acceptance about the role of yoga in the 
+DM management.37 Hence, this data not only highlights the 
+high risk of this population of developing DM, but also 
+highlights the need of lifestyle management through practices 
+such as yoga and exercise, which may act through alteration 
+in the molecular patterns and thus protect from development 
+of lifestyle disorders like DM.38 Yoga may also help in 
+improving lifestyle by reducing stress and anxiety, which are 
+a common part of today’s lifestyle and the cause of many 
+metabolic disorders such as DM, hypertension, etc.39 The 
+modifying risk factors (i.e., waist circumference and physical 
+activity) are strongly responsible for a high DM risk in this 
+population. Modifying these factors through lifestyle 
+management activities not only reduces the risk of DM, but 
+also can prevent various cardio vascular diseases (CVDs) and 
+neurological disorders.
+Conclusion
+This study shows that the population of Chandigarh and 
+Panchkula is at a high risk of developing DM. Apart from 
+age, low physical activity and waist circumference are the 
+major contributors. This indicates that screening programs 
+like this can be cost-effective doable measures at the 
+grassroots level before a referral for the mainstream health 
+care. This study also highlights the importance of incorporating 
+physical activities like yoga to reduce the risk of DM through 
+modulating the risk parameters of DM.
+Acknowledgments
+The authors acknowledge the support of the Indian Yoga Association 
+for manpower, Ministry of Health and Family Welfare, and Ministry 
+of AYUSH for bearing the overall cost of the project.
+Table 3. The Correlation of Individual IDRS Parameters With 
+Total IDRS Score
+IDRS Categories
+Correlation With 
+IDRS Score
+P-Value
+Family history
+0.189
+<.001
+Waist circumfer-
+ence
+0.702*
+<.001
+Physical activity
+0.336
+<.001
+Age
+0.764*
+<.001
+Notes. *Waist circumference and age have shown a stronger correlation 
+with the total IDRS score, with a correlation coefficient value >0.05. The 
+correlation of each IDRS category with the total IDRS score. Each IDRS 
+category has shown a significant correlation with the total IDRS score. 
+Data was analyzed by the Spearman correlation test using the SPSS.
+showed that all the parameters of IDRS had a significant 
+correlation with the total IDRS score. However, waist 
+circumference (0.702) and age (0.764) showed a relatively 
+stronger correlation with IDRS based on this data (Table 3).
+Discussion
+In the present study, IDRS was used as a screening tool to 
+assess the risk of type 2 diabetes mellitus (T2DM) 
+development in the population of Chandigarh and Panchkula. 
+A high proportion of the recruited population (46.6%) were 
+found to be at a high risk of DM. Major contributing factors 
+in the high-risk category were modifiable risk factors with 
+waist circumference contributing to 35.9%, and no or low 
+physical activity contributing to 11.2% and 28.7%.
+IDRS is a successfully used parameter to assess the 
+individual’s risk to T2DM in the Indian population. It has 
+been proved by various studies on the Indian population that 
+a high IDRS score is directly correlated to the development of 
+diabetes or prediabetes.29,2 A high proportion of the population 
+under the modifiable risk category would signify a higher 
+prevalence of sedentary lifestyle in the population. In our 
+population, a high contribution of modifiable risk factors in 
+the high-risk category shows the need of lifestyle management 
+practices for this group of population. It was found that 
+approximately half of the participants (46.6%) were at a high 
+risk of DM based on their IDRS score. Waist circumference 
+(measure of obesity) contributed highest to this high-risk 
+category, with 35.90% of the participants having a waist 
+circumference ≥100 cm in case of males and ≥90 cm in case 
+of females. Obesity is indeed associated with DM 
+development,30 and abdominal (visceral fat) obesity indicated 
+by a high waist circumference is a known indicative factor for 
+cardiometabolic diseases.31 Abdominal obesity also affects 
+the brain structure through neurodegenerative or vascular 
+processes and can thus lead to cognitive decline and 
+dementia.32,33
+Sharma et al.	
+271
+Authors Contribution
+KS: Writing, literature search and data compilation, PB: Writing, 
+editing and data analysis, AA: Conceptualization of the manuscript, 
+RN: Project PI, Corresponding author, NK: Data collection NM: 
+Data collection, AS: National project coordination, HN: Vision, 
+Project execution.
+Declaration of Conflicting Interests
+The authors declared no potential conflicts of interest with respect to 
+the research, authorship, and/or publication of this article.
+Ethical Statement
+Informed consent was obtained from all the volunteers who 
+participated in the study.
+Funding
+This research work was supported by the Ministry of AYUSH, 
+Government of India (grant number: 16-63/2016-17/ CCRYN/RES/
+Y&D/MCT/ dated 15.12.2016).
+ORCID iD
+Akshay Anand 
+ https://orcid.org/0000-0001-7947-5209
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diff --git a/subfolder_0/Methodology of Niyantrita Madhumeha Bharata Abhiyaan-2017, a Nationwide Multicentric Trial on the Effect of a Validated Culturally Acceptable Lifestyle Intervention for Primary Prevention of Diabetes_ Part 2.txt b/subfolder_0/Methodology of Niyantrita Madhumeha Bharata Abhiyaan-2017, a Nationwide Multicentric Trial on the Effect of a Validated Culturally Acceptable Lifestyle Intervention for Primary Prevention of Diabetes_ Part 2.txt
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+++ b/subfolder_0/Methodology of Niyantrita Madhumeha Bharata Abhiyaan-2017, a Nationwide Multicentric Trial on the Effect of a Validated Culturally Acceptable Lifestyle Intervention for Primary Prevention of Diabetes_ Part 2.txt	
@@ -0,0 +1,1247 @@
+Int J Yoga. 2019 Sep-Dec; 12(3): 193–205.
+doi: 10.4103/ijoy.IJOY_38_19
+PMCID: PMC6746053
+PMID: 31543628
+Methodology of Niyantrita Madhumeha Bharata Abhiyaan-2017, a
+Nationwide Multicentric Trial on the Effect of a Validated Culturally
+Acceptable Lifestyle Intervention for Primary Prevention of Diabetes:
+Part 2
+R Nagarathna, SK Rajesh,  S Amit,  S Patil,  A Anand,  and HR Nagendra
+Medical Director, VYASA, Bengaluru, Karnataka, India
+Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana, Bengaluru,
+Karnataka, India
+Post Graduate Institute of Medical Education and Research, Chandigarh, India
+Address for correspondence: Dr. Nagarathna R, SVYASA, No. 19 Eknath Bhavan, Gavipuram Circle, K. G.
+Nagar, Bengaluru - 560 019, Karnataka, India. E-mail: rnagaratna@gmail.com
+Received 2019 May; Accepted 2019 May.
+Copyright : © 2019 International Journal of Yoga
+This is an open access journal, and articles are distributed under the terms of the Creative Commons
+Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the
+work non-commercially, as long as appropriate credit is given and the new creations are licensed under the
+identical terms.
+Abstract
+Background:
+The rapidly increasing diabetes burden, reaching epidemic proportions despite decades of efforts,
+reflects our failure to translate the proven evidence for prevention of diabetes. Yoga, with its holistic
+approach, alters the habituated patterns of lifestyles and behaviour. Motivated by the accumulating
+evidence, the Government of India funded a large randomized controlled trial.
+Aims and Objectives:
+The twin objectives were: (a) estimate the prevalence of prediabetes and diabetes through a parallel
+multisite stratified cluster sampling method and (b) implement NMB 2017 (niyantrita madhumeha
+bharata abhiyaan), a randomized control trial using yoga based lifestyle program.
+Materials and Methods:
+Screening for Indian Diabetes Risk score(IDRS) was conducted in randomly selected clusters in all 7
+zones (65 districts from 29 states/union territories) of India. This was followed by detailed assessments
+in those with known diabetes and high risk (≥60) on IDRS. Those who satisfied the selection criteria
+and consented were recruited for the two armed waitlisted randomized control trial. A validated
+remedial diabetesspecific integrated yoga lifestyle module was taught to the experimental arm by
+certified volunteers of Indian Yoga Association. Followup assessments were done after 3 months in
+both groups. In this article, we report the methodology of the trial.
+Results:
+1
+1
+1
+2
+1
+1
+2
+Response to door to door visits (n-240,968 adults >20yrs) in randomly selected urban and rural
+households for screening was 162,330; detailed assessments (A1c, lipid profile, BMI, stress, tobacco
+etc) were performed on 50,199 individuals. Of these 12466 (6531 yoga 5935 control) consented and for
+the RCT; 52% females, 48% males; 38% rural, 62% urban; BMI 21.1 ± 3.8; waist circumference 91.7 ±
+11.9. A1c in diabetes subjects in yoga group was 7.63 ± 2.17 and 7.86 ± 2.13 in control group.
+Conclusion:
+This unique methodology provides the evidence to implement a validated yoga life style module using
+yoga volunteers in all parts of the country which is an urgent need to prevent India from becoming the
+global capital for diabetes.
+Keywords: Diabetes, India, methodology, traditional yoga lifestyle
+Introduction
+T2 diabetes mellitus (T2DM), a growing noncommunicable disease with major complications, poses
+great challenges for health-care industry across the globe, especially in the current millennium. The
+management of diabetes and its complications enforces a huge economic burden on nations and their
+health-care systems.[1] Many of the recent studies suggest that increasing prevalence will make India
+the world leader in diabetes by 2025.[2]
+Recent epidemiological studies have shown that lifestyle interventions are cost-effective in the
+prevention and management of T2DM. A systematic review of 53 studies brought to the fore that
+lifestyle interventions that include dietary modification and exercise reduce the incidence of T2DM.[3]
+China's Da Qing T2DM prevention study showed that dietary modification and regular physical
+activity reduce diabetes incidence by 51% in a 6-year period and 43% when followed up over 20 years.
+[4] The Diabetes Community Lifestyle Improvement Program (D-CLIP) demonstrated a 32% relative
+risk reduction in prediabetes.[5] The lifestyle modification program has effected in good reduction of
+incidence rate of diabetes in nondiabetic high-risk (body mass index [BMI] >34) people.[6]
+Yoga, when considered as a lifestyle intervention, presents a comprehensive and integrated solution to
+the T2DM problem by adopting an inclusive approach: integrating cleansing techniques, yogic postures
+(asanas), breathing practices (pranayama) and meditation, emotion culture, and a fiber-rich vegetarian
+diet. It comprises both the exercise required and stress reduction as a major component.[7,8] Findings
+on studies on yoga for T2DM offer evidence for multiple benefits, such as improved glycemic control,
+improvements in lipid profile, weight, cognition, nerve conduction velocity,[9] insulin sensitivity, and
+cardiovascular autonomic functions.[10] Select interventional studies on lifestyle and yoga are
+summarized in Table 1.
+Table 1
+Publication on studies on lifestyle and yoga in diabetes
+Open in a separate window
+BMI=Body mass index, HbA1c=Hemoglobin A1c, FBG=Fasting blood glucose, PPBG=Postprandial blood
+glucose
+Comparing exercise and yoga suggests that yoga is usually superior to physical exercise in health-
+related outcome measures such as blood glucose, blood lipids, and oxidative stress, with additional
+benefits such as improved insulin sensitivity, and subjective measures such as less fatigue, better sleep
+Sl.no
+Author Ref
+Title
+Result
+1
+Lifestyle
+intervention
+A
+Howells L
+et al.
+(2016)
+Clinical impact of
+lifestyle
+interventions for the
+prevention of
+diabetes: An
+overview of
+systematic reviews
+Concluded that relatively long-duration lifestyle interventions
+can limit or delay progression to diabetes when compared to
+time-limited interventions
+B
+Li G,
+Zhang P et
+al. (2008)
+The long-term effect
+of lifestyle
+interventions to
+prevent diabetes in
+the China Da Qing
+Diabetes Prevention
+Study: A 20-year
+follow-up study
+Compared with control, participants in combined lifestyle
+intervention group had 51% lower incidence of diabetes during
+the active intervention period and 43% lower incidence (0.57;
+0.41-0.81) over the 20-year period
+2
+Integrated
+yoga
+therapy
+A
+Monro R et
+al. (1992)
+Yoga therapy for
+NIDDM: A
+controlled trial
+FBG and HbAlc improved significantly better (P<0.05) in yoga
+than control group
+B
+Kumar V et
+al. (2016)
+Role of yoga for
+patients with type 2
+diabetes mellitus: A
+systematic review
+and meta-analysis
+Yoga as an add-on intervention in comparison to standard
+treatment; FBS - mean difference - 1.40, P<0.0001; PPBG –
+0.91, P<0.0001 HbA1c – 0.64, P<0.0002
+C
+Nagaraj C
+et al.
+(2013)
+Effect of integrated
+yoga therapy on
+nerve conduction
+velocity in type-2
+diabetics: A cross-
+sectional clinical
+study
+Significantly higher means of nerve conduction velocity in the
+right (P=0.004) and left wrists (P=0.017) in yoga group.
+Significant difference between groups in the right hand
+(P=0.004)
+D
+Chaya MS
+et al.
+(2008)
+Insulin sensitivity
+and cardiac
+autonomic function
+in young male
+Glucose clamp study in normal healthy yoga practitioners;
+fasting plasma insulin was significantly lower in the yoga than
+matched control volunteers. Insulin sensitivity was better
+(P<0.001) in yoga than controls (yoga 7.82 [2.29]; control 4.86
+and quality of life, and reduced medication requirement.[11,12] A few small studies of integrated yoga
+for prediabetes suggest reduction of risk of developing diabetes.[13,14]
+Further, our published controlled studies both in India and the UK between 1992 and 2014[9,11]
+pointed to the beneficial effect of the integrated yoga module. Based on this decade-long evidence, we
+undertook a feasibility study and implemented a community program all over India. This was on the
+occasion of the 2
+ International Day of Yoga (June 21, 2015) and was funded by the Ministry of
+Health and Family Welfare, Government of India. Planned as “yoga for diabetes week” between June
+21 and 27, 2015 and envisaged as 1-year follow-up activity, across 22 states and union territories of the
+country, 2099 week-long camps (131 in central, 63 in east, 3 in northeast, 16 in northwest, 366 in west,
+386 in north, and 1134 in south zones) were held; Indian Diabetes Risk Score (IDRS) and self-reported
+diabetes status were documented on 104,974 individuals; 56,352 participants with diabetes were taught
+the yoga module in camps by trained yoga volunteers from many nongovernmental organizations
+(mainly Arogyabharati) by using CDs and booklets, and blood tests (fasting blood glucose [FBG],
+postprandial blood glucose [PPBG], and lipid profile) were done on 23,260 participants. One-day
+follow-up review camp was conducted at the 4 , 7 , and 12  months. Results (report submitted to the
+Ministry of Health and Family Welfare, September 2016, and is available on request) showed
+statistically significant (P < 0.01) reduction in mean FBG from 135.6 ± 63.1 to 111.3 ± 57.4 (18%),
+hemoglobin A1c (HbA1c) from 7.14 ± 2 to 6.6 ± 1.7, and triglycerides from 166.9 ± 113.1 to 149.11 ±
+76. Interestingly, despite the huge numbers involved at different stages of the activity, there were no
+adverse effects which were reported.
+The present study was conceptualized as a multilevel cluster randomized controlled trial (RCT) to
+document the efficacy of a yoga-based lifestyle module, through a structured program at the
+community level. As a part of the trial, we also estimated the prevalence of prediabetes and diabetes in
+Phase 1 of the study. An earlier article published in this journal describes the methodology adopted for
+the rapid nationwide screening (phase 1) to arrive at prevalence estimates. Here, we report the
+methodology of the trial (phase 2) which assessed the efficacy of the structured intervention, to prevent
+the progression of prediabetes to diabetes including developing the validated standardized module of
+traditional yoga lifestyle.
+Methodology
+Sample size calculation
+The sample size was estimated based on the relative risk reduction in an earlier study, the D-CLIP, a
+randomized controlled translational trial of 578 overweight/obese Asian Indian adults and other
+references.[5,15,16] In brief, the annual incidence rate of diabetes was 11.1% in controls and 7.8% in
+intervention participants, and this provided a conversion rate at 3-month follow-up to be 3% in the
+control condition and 2% in intervention condition. Based on this, the required sample size for a two-
+group design, with α = 0.05 and 1 – β = 0.80, was estimated (http://www.sample-size.net) to be 5320 in
+each group (total 10,640 for two groups). Details of the sample size are presented in part 1 of this study
+in this journal.
+Study design
+In phase one of the study, a nationwide sampling strategy was adopted to identify the at-risk population
+which also provided an estimation of the prevalence of diabetes and prediabetes. This is already
+described in the previous article on methodology prevalence (part 1), and results of the prevalence are
+published separately. Phase two was to assess the efficacy of the structured intervention, to prevent the
+progression of prediabetes to diabetes (refer IJOY Part 1 methodology).
+In brief, a four-stage (zone – state – district – urban/rural) strategy was adopted for identifying study
+locations, which used random cluster sampling method and located households and individuals. Census
+enumeration blocks (CEBs) were randomly selected, and all eligible individuals (both genders between
+20 and 70 years) within the CEBs were contacted. Within the CEB, it was a two-step strategy. In step 1,
+the door-to-door survey enlisted eligible individuals and specifically inquired the status of diabetes and
+nd
+th
+th
+th
+Development of common yoga protocol for T2 diabetes mellitus
+scored them on the IDRS. In step 2, those reporting diabetes and those scoring high on the IDRS were
+invited for a detailed baseline assessment which included measuring HbA1c and other investigations.
+The trial chart is depicted in Figure 1.
+Figure 1
+Phase 2 of NMB - study protocol
+Randomization and blinding
+Cluster randomization was adopted and not individual-level random allocation.
+Two of the four villages and one or two out of two or four CEBs (depending on the population size of
+the CEB), in the selected ward, were randomly identified as the experimental group and the other was
+the waitlisted control.
+Being an interventional community-based cluster randomized trial, the study participants, staff, and
+investigators were not blinded to group allocation.
+Inclusion and exclusion criteria
+Adults of both genders in the identified village/CEB, capable of doing yoga and consenting to
+participate, were recruited and included:
+1. Self-reporting diabetes individuals – cross verified by prescription and/or medication use
+2. Newly diagnosed diabetes (with HbA1c >6.5%)
+3. Prediabetes (HbA1c levels between 5.3 and 6.49%)
+4. High score (>60) on IDRS, with or without hypertension and/or obesity.
+Those with severe obesity (BMI >40), history of uncontrolled hypertension, coronary artery disease,
+renal disease, diabetes retinopathy, previous head injury, tuberculosis, reported psychiatric problems
+(minor and major), history of major surgery in the past, pregnant women, and those planning to move
+out of the area within the next 3 months were excluded from the study.
+Quality assurance
+Quality control was implemented in all aspects of the trial: (a) development and standardization of
+common yoga protocol; (b) selection and training of research personnel (research associates [RAs] and
+senior research fellows [SRFs]) for documentation, monitoring, and training as trainers; (c) orientation
+of field-level certified yoga volunteers for uniformity in teaching the yoga module; and (d) follow-up.
+The common yoga protocol was
+considered the crux of the entire trial, and substantive efforts were spent to develop, refine, and finalize
+the protocol. This effort was led by a team of 16 experts [Table 2] including senior yoga masters from
+different yoga traditions (member institutions of Indian Yoga Association [IYA]), as well as
+experienced yoga researchers and diabetologists. Sixteen experts considered sufficient for Delphi[17]
+consultation undertook a series of brainstorming sessions to refine the yoga modules specific for the
+present study. The draft of the module had been validated[18] earlier and also during the nationwide
+week-long Madhumeha Mukta Bharat of International Day of Yoga 2015. This protocol was presented
+to the group, and written comments by all experts were compiled, discussed, and deliberated. The
+discussion was focused on how to avoid adverse effects in the target population (prediabetic and
+diabetic individuals with no complications) taking critical inputs from the diabetic experts as they
+watched a yoga teacher's demo of all the practices included in the module. The module was finalized
+after two Delphi rounds and two rounds of focus group discussion.
+Table 2
+Experts of yoga protocol committee
+Open in a separate window
+IYA=Indian Yoga Association
+Sl.no.
+Affiliation
+Role in expert committee
+1
+Chancellor
+Vice president - IYA Chairman of
+yoga protocol committee
+S-VYASA Yoga University
+Bengaluru
+2
+Assistant professor
+Researcher on yoga for diabetes
+Department of Endocrinology and Metabolic Disorder
+AIIMS, New Delhi
+3
+Senior scientist and project manager
+Researcher on yoga for diabetes
+MDRF, Chennai
+4
+Medical director
+Researcher on yoga for lifestyle
+diseases
+VYASA, Bengaluru
+5
+CEO. Kaivalyadhama Yoga Institute, Mumbai
+Yoga expert, IYA
+6
+Director
+Yoga expert, IYA
+Central Council for Research in Yoga and Naturopathy
+Government of India, New Delhi
+7
+Krishnamacharya Yoga Mandiram, Chennai
+Yoga expert, IYA
+8
+Advisor, AYUSH, New Delhi, Ramamani Iyengar Memorial
+Yoga Institute, Pune, Maharashtra
+Yoga expert, IYA
+9
+Experienced Iyengar yoga teacher
+Yoga expert, IYA
+Ramamani Iyengar Memorial Yoga Institute, Pune,
+Maharashtra
+10
+Director, Morarji Desai National Institute of Yoga, New
+Delhi
+Yoga expert, IYA
+11
+Director of CYTER, Puducherry
+Yoga expert, IYA
+Chairman, Research Wing of IYA
+12
+Mokshayatan International Yogashram, Saharanpur, Uttar
+Pradesh
+Yoga expert
+13
+International Sri Sri Yoga teacher with The Art of Living
+Yoga expert secretary general of IYA
+Bengaluru
+14
+Faculty
+Researcher on yoga for stress
+management
+S-VYASA University, Bengaluru
+15
+Director (Academic)
+Yoga expert
+Directorate of Vision of World
+Simplified KundaliniYoga
+The World Community Service Centre
+Aliyar, Tamil Nadu
+The specific yoga-based lifestyle yoga protocol [Table 3] consisted of practices for primary and
+secondary prevention of diabetes. These were selected from a large list of practices for lifestyle
+diseases, available in the tradition. The integrated module included yogic diet, physical practices (sun
+salutation and asanas), breathing (pranayama) and relaxation techniques, evidence-based meditation,
+[18,19] and group lectures/individual discussion on yoga concepts of stress management.
+Table 3
+Common yoga protocol for type 2 diabetes mellitus (to be practiced 7 days/week)
+Open in a separate window
+SN=Surya Namaskara
+Serial
+number
+Name of the practice
+Duration
+1
+Starting prayer: Asatoma Sat Gamaya
+2 min
+2
+Preparatory SukshmaVyayamas and Shithilikarana Practices
+6 min
+ 1. Urdhva-hasta Shvasana (hand stretch breathing 3 rounds at 90°, 135°, 180° each)
+ 2. Kati-Shakti Vikasaka (3 rounds each)
+  a. Forward and backward bending
+  b. Twisting
+ 3. Sarvanga Pushti (3 rounds clockwise, 3 rounds counterclockwise)
+3
+Surya Namaskara –sun salutation(SN)
+9 min
+ a. 10 step fast SN 6 rounds
+ b. 12 step slow SN 1 round (to be avoided by those with knee pain, cardiac
+problems, renal problem, low back pain, retinopathy and the elderly who are weak
+and not flexible; instead they can do Chair SN) modified version Chair SN: 7 rounds
+4
+Asanas (1 min per asana)
+15 min
+ Standing (1 min per asana)
+Trikonasana, Pravritta Trikonasana, Prasarita pada-hastasana
+ 2. Supine
+Jathara Parivartanasana, Pavanamuktasana, Viparitakarani
+ 3. Prone
+Bhujangasana, Dhanurasana followed by Pavanmuktasana
+ 
+ 4. Sitting
+Mandukasana, Vakrasana/Ardhamatsyendrasana, Paschimatanasana, ArdhaUshtrasana
+At the end, relaxation with abdominal breathing in supine position (vishranti), 10-15
+rounds (2 min)
+5
+Kriyas
+3 min
+ a. Agnisara: 1 min
+ b. Kapalabhati (at 60 breaths per minute for 1 min followed by rest for 1 min)
+6
+Pranayama
+9 min
+ a. Nadishuddhi (for 6 min, with antarkumbhaka and jalandharbandha for 2 s)
+ 
+ b. Bhramari (3 min)
+7
+Meditation (for stress management for deep relaxation and silencing the mind) cyclic
+meditation (those who are willing to practice techniques of relaxation evolved by their
+own institutes may do so)
+15 min
+8
+Resolve (I am completely healthy)
+1 min
+9
+Closing prayer: Sarvebhavantu Sukhinah
+1 min
+l
+60
+i
+Training of researchers
+The final yoga lifestyle protocol [Table 3] was developed as DVDs and booklets in different languages
+by the Central Council for Research in Yoga and Naturopathy (CCRYN), and was released on October
+2, 2016.[18,20] This new module was consistent to the American Diabetes Association
+recommendations for lifestyle change for the prevention of diabetes [Table 4].[19,20,21,22,23,24]
+Table 4
+Yoga lifestyle compared to American Diabetes Association recommendation of lifestyle
+programs
+ADA recommendation
+Yoga lifestyle
+Diet
+Plant source diet
+Satvic diet
+ Rich in whole grains, fruits, vegetables, legumes, and
+nuts
+Wholesome lacto-vegetarian diet
+ Low in refined grains, red or processed meats
+Makes mind calm and serene
+Mastery over agitated and stressed
+(rajas) mind, or dull and violent
+(tamas) mind
+ Nil - sugar-sweetened beverages
+Physical
+activity
+At least 2.5 h of moderate-to-vigorous intensity physical
+activity per week (i.e., brisk walking, water aerobics,
+swimming, or jogging)
+Daily 6 min - Loosening practices
+Daily 9 min - SN
+15 min/day×7 days=1.75 h/week
+Two to three sessions of resistance exercise per week
+(lifting five pound weights or doing pushups) 15×2 = 30
+min/week
+Incorporate flexibility exercises, such as stretching or yoga
+into your weekly routine 45 min/week
+Asanas and
+Kriyas - 18 min×7 days=126
+min=2.1 h/week
+Total=3.75 h/week
+3.85 h/week
+Stress
+management
+Diaphragmatic breathing
+Pranayama - 9 min
+Progressive muscular relaxation (40-50 min)
+Cyclic meditation 15-25 min
+Mindfulness all day
+Action in relaxation
+Karma yoga
+Abstinence
+from
+tobacco
+Cognitive behavior therapy
+Happiness analysis
+Jnana yoga
+Abstinence
+from
+alcohol
+Alcohol anonyms
+Faith and surrender yoga
+Bhakti yoga
+Open in a separate window
+ADA=American Diabetes Association, SN=Surya Namaskara
+Training of senior research fellows
+One-day zonal training programs were organized in five zones of India (Delhi, Bhopal, Bengaluru,
+Salem in Tamil Nadu, and Mumbai) to re-orient them as trainers of instructors and educate them in
+precise implementation of the trial.
+Training of yoga volunteers for diabetes movement
+The SRFs with the help of zonal coordinators organized 5 days’ intensive training for Yoga Volunteers
+for Diabetes Movement (YVDMs) who were certified yoga instructors of the member institutions of
+IYA with yoga teaching experience of more than 1 year. The 5-day residential camp [Table 5] covered
+all project-related topics including orientation to teach common yoga protocol and communication
+skills. They were trained to individualize the protocol based on participant's capacity such as age,
+gender, and flexibility to start with simple physical movements and slowly go on systematically over
+the 9 days as per the daily schedule to ensure that the participant had learned all the practices
+recommended in the protocol with the right understanding of the position and breathing pattern to go
+with each movement. Overall, a total of 32 camps were organized in different zones of India. The RA
+or principal investigator (PI) had prepared his/her schedule of visits to these camps to be present on the
+last day of the training conducted by the SRF. During these visits, the YVDMs were certified after they
+passed all three examinations namely the practical, theory, and oral.
+Table 5
+Schedule of 5-day training camps of Yoga-Certified Volunteers for Diabetes Movement in
+different zones
+Open in a separate window
+YVDM=Yoga-Certified Volunteers for Diabetes Movement, DM=Diabetes mellitus, FAQs=Frequently asked
+questions, CM=Cyclic meditation
+Time
+Day 1
+Day 2
+Day 3
+Day 4
+Day 5
+6-7.30
+am
+Arrival to
+training
+center
+Yoga
+Yoga practical class
+Yoga practical class
+Yoga
+practical
+examination
+Practical class
+7.30-9
+am
+Bath and break fast
+Bath and break fast
+Bath and break fast
+Bath and
+break fast
+9-10
+am
+Introduction to diabetes,
+medical perspectives
+and panchakosha level
+of yogic management of
+diabetes
+Pranayama theory
+and practice and
+practical
+Training for mobile
+apps
+Examination
+on use
+mobile apps
+10-11
+am
+Stress and diabetes
+concept and techniques
+of stress management
+through yoga
+Training for mobile
+apps use
+Individual and
+group Practical
+examination
+Examination
+on the use
+of mobile
+apps
+11.15-
+12 am
+Inauguration
+of program
+Yoga and modern
+concepts of diet for
+diabetes
+Training to use
+mobile apps
+Practical
+examination
+12-1
+pm
+Introduction
+to project
+Practical chair yoga
+practice - 1
+Chair Yoga Practice 2
+Practical yoga
+asana examination
+Valedictory
+program
+1-2
+pm
+Lunch
+Lunch
+Lunch
+Lunch
+Lunch
+2-3
+pm
+Details of
+project and
+duties of
+YVDM
+Theory and practice of
+cyclic mediation
+Organization and
+conducting yoga
+camps for diabetes
+Pranayama
+examination
+Departure
+3-4
+pm
+Introduction
+to cyclic
+meditation
+Data documentation
+Screening form
+Data documentation
+registration from
+Cm examination
+4-5.30
+pm
+Yoga
+practical
+and CM
+Screening form data
+taking
+Data documentation
+registration form
+6-7.30
+pm
+Theory and
+practical
+emotion
+culture and
+jnana yoga
+Theory and practical
+emotion culture
+Theory and practical
+jnana, karma and
+devotion culture yoga
+for yogic stress
+management
+Theory and
+practical jnana,
+karma, and
+devotion yoga for
+yogic stress
+management
+7.30
+Dinner
+Dinner
+Dinner
+Dinner
+During the camps, resources to conduct the intervention were provided to the YVDMs. These included
+ID cards and required study materials (a copy of the PowerPoint presentation, a pack of 2 DVDs,
+booklets on yoga for diabetes with common yoga protocol, hard copies of the forms to be filled up for
+the study, log book, banner templates, hand bills for conducting the camps, etc.) [Table 5].
+Intervention
+Yoga group: The intervention group [Table 3] received the specially prepared standardized yoga-based
+lifestyle change protocol along with standard diabetes management education for 3 months. Initially,
+yoga intervention was taught by the YVDMs as a 9-day camp (2 h daily) activity. This was followed by
+daily (individual or group) practice using DVDs and included 2-h weekly YVDM-supervised follow-up
+classes.
+In case of individuals with known diabetes, the prescribed antidiabetes medication dosage was noted. If
+the blood glucose was very high (FBG >200 mg/dl and PPBG >300 mg/dl), the local doctor made
+suitable changes in medication; if it was under moderate or good control, they were asked to continue
+the same medication; and if the blood glucose dropped below the normal values, the local doctor
+reduced the dosages with follow-up monitoring.
+For the newly diagnosed cases of diabetes, consultation with the local doctors was arranged who
+decided the management strategy, i.e., attending yoga lifestyle camps with or without oral
+hypoglycemic medication depending on the blood glucose levels.
+For those who were in prediabetes range, the SRF had a meeting to emphasize the role of adherence to
+yoga lifestyle to prevent diabetes.
+Attendance was maintained in each class and was checked by SRFs. House visits or phone calls were
+done to remind those who missed one or more classes. Daily attendance was maintained by the YVDM
+during the core session of 9 days. Duration and regularity of the self-reported yoga practice session
+using booklet or videos after the camp was documented based on the following questions: (a) “how
+many days per week did you do the yoga module” and (b) “on an average, how long did each yoga
+session last” (possible values: 0–15, 16–30, 31–45, 46–60, or >60 min). Dietary intake was monitored
+using a detailed food frequency questionnaire. Any other health problems encountered during the week
+were also documented during the weekly study visit.
+Intervention adherence
+Intervention adherence was assessed by evaluating (a) class attendance and (b) regularity of practice of
+yoga during the period of study. Participants attended an average of 5 (standard deviation 3.9) out of 9
+initial daily core intervention classes. Class attendance did not vary by sex; however, significantly
+fewer young participants (≤35 years) attended (48%) the study classes compared with of those aged
+36–60 years (62%) or those aged 60 or older (75%).
+There were no major adverse events or mortality during these 3 months of follow-up. There were a few
+cases of minor events such as spinal pain, knee pain, generalized body pains, or minor digestive
+disturbances. These were handled by offering corrective postures and relaxation techniques by
+consultation on WhatsApp with senior medical yoga professionals such as RA and PI, and/or by
+medication advice by the local family doctors. For example, there were 27 cases of mild lumbar pain –
+2 in Jammu and Kashmir, 4 in west zone, and 11 in south and east zones. For this, they were asked to
+cut down all forward-bending postures which were replaced by quick relaxation technique and
+pavanamuktasana lumbar stretch two times a day. Overall, knee pain was observed in five cases in
+central, three in north, and four in west zones. Digestive problems such as excessive belching or
+flatulence, constipation, or increased bowel frequency were reported in 12 cases in all zones which
+were corrected by remedial postures.
+The data were kept confidential by the data safety monitoring person in the IT team who would open
+the access to only the PI and RAs who reviewed them on a daily basis during pre-post data acquisition.
+Control group – The waitlist control group received standard diabetes management education. The
+YVDM who was allotted for monitoring the control group visited the places once a week for an
+interactive session of 1 h on Sundays to educate them about their lifestyle including diet, physical
+activity, and tobacco cessation as per the standard lifestyle education protocol. The YVDMs were in
+close touch with the participants through a WhatsApp group.
+The YVDMs were in touch with local doctors of the participants of both yoga and waitlist control
+groups to get medical supervision during the camps for any medical emergencies and also as chief
+guests for the inauguration and valedictory programs in the camps.
+Yoga camps
+The SRF and local YVDMs had already visited the selected places during phase one of the study to
+motivate the local leaders and philanthropic personnel of the site to organize 9-day yoga camps [
+Table 6].
+Table 6
+Daily schedule of training of participants in 9-day camps in 181 camps in all zones of India
+SL
+NO
+Practices
+Day 1
+Day 2
+Day 3
+Day 4-9
+1
+Starting prayer
+Yes
+Yes
+Yes
+Yes
+2
+Loosening exercises
+(normal, chair)
+Urdhva
+Hastasana
+Urdhva
+Hastasana
+Urdhva
+Hastasana
+Urdhva
+Hastasana
+KathiShakthi
+Vikasana
+KathiShakthi
+Vikasana
+KathiShakthi
+Vikasana
+KathiShakthi
+Vikasna
+Sarvangapusti
+Sarvangapusti
+Sarvangapusti
+3
+SN (normal, chair)
+10 step (4R’s)
+10 step (6R’s)
+10 step (6R’s)
+12 step (1R)
+12 step (4R’s)
+12 step (6R’s)
+4
+Asana (normal and/or
+chair)
+Standing
+Standing
+Standing
+Standing
+Supine
+Supine
+Supine
+Supine
+Prone
+Prone
+Prone
+Sitting
+Sitting
+5
+QRT
+Yes
+Yes
+Yes
+Yes
+6
+Kriya
+Kapalabhati
+Agnisara
+Agnisara
+Agnisara
+Kapalabhati
+Kapalabhati
+Kapalabhati
+7
+Pranayama
+Nadishuddhi
+Nadishuddhi
+Nadishuddhi
+Nadishuddhi
+Bhramari
+Bhramari
+Bhramari
+8
+Meditation
+Cyclic
+meditation (half)
+Cyclic
+meditation (full)
+Cyclic
+meditation
+Cyclic
+meditation
+9
+Resolve
+Not needed
+Yes
+Yes
+Yes
+10
+Closing prayer
+Yes
+Yes
+Yes
+Yes
+11
+Lecture DVD and
+interactive Q and A
+Yes
+Yes
+Yes
+Yes
+Open in a separate window
+SN=Surya Namaskara, QRT=Quick relaxation technique, DVD=Digital video disc
+In the districts selected for yoga intervention, each SRF (in charge of two districts) planned and
+conducted yoga camps (one camp in one or two villages in rural area and one camp for one or two
+CEBs in urban localities). The dates for the camp were planned to suit the local needs and to ensure
+availability of the SRF during all camps. The camps lasting for about 2 h every day were held in
+community or temple halls suitable for 15–30 persons to practice yoga. The 2-h sessions were held
+multiple times every day: for example, 6–8 am and 7–9 pm for working class of people and 10–30 am
+to 12–30 pm for homemakers and retired persons. The participants could register for any one of these
+sessions.
+All camp sites were provided with projection facilities in the halls. These sites had a consultation room
+for the therapist and/or the visiting doctor (when available) for documentation and personal discussions
+with the participants related to their lifestyle and stress. The YVDMs were in touch with local doctors
+of the participants for their medical support during the camps, handle any untoward adverse effects,
+and get advice on any change in medication and long-term monitoring.
+Attendance was maintained in each class and was checked by SRFs. House visits or phone calls were
+done to remind those who missed a class. Visits were made by zonal coordinator to the camps for
+random checking of the accuracy of the implementation of the trial protocol including the teaching
+methods, duration and timings of yoga classes, punctuality, and documentation of attendance. The RA
+based in the central office in Bengaluru was available on WhatsApp video call all 24 h for solving
+problems and give feedbacks. The common problems faced included arranging the halls, projectors,
+and speakers; toilet facilities in villages and CEBs; postal delay in the handout material reaching the
+venues during the planning phase; replacements for YVDMs during the camps if they had some
+personal or health problems; and queries by participants related to yoga for other health problems. The
+RAs, PI, and zonal coordinators made personal visits (a total of about 74) to one or more of these
+places during the planning and implementation phases. Photographs and videos were sent on a daily
+basis by the YVDMs to SRFs and hence made the quality assurance robust.
+Assessments
+All assessments done in phase 1 of the trial, available on mobile apps, were used as preintervention
+dataset, and the same measures were documented after 3 months on the recruited individuals of both
+yoga and control groups; measures related to yoga awareness and benefits and barriers to yoga practice
+were documented post assessment in the yoga group. The primary outcome was to look at the
+conversion from prediabetes to diabetes and normal zones on HbA1c after yoga lifestyle intervention.
+The secondary outcomes included effect of yoga on diabetes status, lipid profile, and stress measures
+apart from documenting the knowledge, awareness, and perception about the barriers and benefits of
+yoga in the population. The summary of the assessments is shown in Table 7.
+Table 7
+Assessments phase 2
+Open in a separate window
+SES=Socioeconomic status, NAS=Numerical Analog Scale, HbA1c=Hemoglobin A1c, PSS=Perceived stress
+scale, PHQ=Patient health questionnaire, PPBG=Postprandial blood glucose, FBG=Fasting blood glucose
+Follow-up
+Assessment
+variable
+Method
+Instrument used
+Validation
+Weight
+In kg
+Digital weighing scale
+KRUPS co. 2016
+Pre and post
+Retd. design no.
+161856
+Waist
+circumference
+In cm
+Measuring tape
+Pre and post
+Blood
+pressure
+MmHg
+Digital sphygmomanometer
+Omron co. 2016 Model
+HEM7120
+Questionnaires
+Details in app
+SES
+Int J Recent Trends Sci
+Technol 2014;11:1-2.
+Kuppuswamy’s SES scale revised for
+2014
+Income and
+expenditure
+Gururaj and Maheshwaran, 2014
+Monthly for, individual and family
+Sleep
+Quantity, quality, and sleep routine Pre-
+post
+Prepared for the
+purpose by our team
+Quality of life
+PHQ
+Stress
+PSS
+6 NAS for work, family, health, others,
+social, financial related stresses
+NAS
+Physical activity
+Typical daily work/home activity level,
+frequency and amount of mild, moderate,
+and vigorous activities
+Substance abuse
+Alcohol - quantity, frequency and
+duration, tobacco - smokeless and smoked
+Yoga related
+Yoga awareness
+(Nayak et al. 2014)
+Modified for the
+present Indian
+study[24]
+Yoga benefit scale
+(Nayak et al. 2014)
+Modified for the
+present Indian
+study[24]
+Yoga barrier scale
+(Nayak et al. 2014)
+Modified for the
+present Indian
+study[24]
+Blood tests
+FBG>8 h after last
+Glucose oxidase-peroxidase method
+“Mindray” autoanalyzer
+After the initial 9-day introductory camp, the participants were asked to continue the practices for 1 h
+daily and maintain a diary. In several rural areas (about 30% of villages), the participants decided to get
+together daily in the same venue instead of practicing individually in their houses. The YVDMs
+planned and conducted weekly 2-h Sunday morning group classes where yoga camps were conducted.
+The YVDMs created a WhatsApp group including all participants of the 9-day introductory camps.
+This facilitated in sending reminders for the weekly interactive review follow-up classes, monitoring
+their compliance of daily practices, and helping for any of their health-related issues. There were no
+major issues reported by the participants during the 3-month period.
+The dates of the camps had to be changed in nine places due to unavoidable circumstances such as
+local weather condition (heavy rains in south or snow fall in northwest zones), unexpected local
+political situation (roadblock in Manipur and election in Uttar Pradesh), illness of the SRF (Andhra and
+Kerala), and shifting of the SRF due to national cause (navy officer was the SRF in Goa who was
+transferred), resulting in delay in completion of the project by 2 months.
+Postintervention data [Table 7] were collected at the end of 3 months in both yoga and control locations
+by organizing the second round of assessments in the same venues by the same research team who
+were involved earlier.
+The YVDMs logged in the post data on the mobile app. The SRF was available for help in clearing any
+doubts of YVDMs. Post data were checked during the regular visit of the SRF and random visits of
+zonal coordinator and RA. Quality control was implemented for each blood sample at the National
+Accreditation Board for Testing and Calibration Laboratories (NABL) NABL-accredited laboratory.
+Statistical analysis
+Data were uploaded via mobile apps by the YVDMs under the supervision of SRFs. Pre- and post-data
+were checked and matched. SPSS software version 21 and R software version 3.5.2 (IBM Company,
+Armonk, New York 10504, United States of America;) for bio-statistical analyses were used for
+analysis. Cases with missing data were checked for uniformity and excluded from the analysis.
+Cases with missing data (at the time of entry or technical errors while downloading) were examined,
+and a protocol to manage such cases was drafted. For the latter, the data were downloaded again from
+the server to retrieve all possible data. If the missing data were less than 15%, after stratifying for area,
+gender, and age, the imputation (median/mean values) procedure was followed. Those that had more
+than 15% missing data were excluded from the analysis.
+The plan of analysis of data included (i) comparison of means of before and after the intervention
+between and within groups using paired samples t-test and/or repeated-measures ANOVA tests after
+checking for normality of data, (ii) Chi-square test for significance of the pre-post conversion, and (iii)
+binary logistic and multiple logistic regression analyses to estimate the degree of association between
+the variables.
+Ethical clearance
+Details of ethical clearance were presented in the other publication. In brief, the IYA's institutional
+ethical committee cleared the proposal after scrutinizing the complete project proposal including the
+headings in the budget to clarify that no payment in cash or kind was being offered to the participants
+and also checked the informed consent forms. The study was registered on the Clinical Trials Registry
+of India (registration number – trial REF/2018/02/017724).
+Results
+Table 7 shows the schedule and number of YVDM training camps conducted in different zones. We
+conducted a total of 145 yoga camps (81 in rural and 64 in urban areas). As against the planned 63
+camps in rural areas (one per 2 yoga villages/district), 18 more camps were conducted in villages which
+were placed far apart, primarily due to the sparsely populated forest and hilly villages which were
+randomly selected. Figure 2 shows the study profile of this RCT. A total of 1,62,330 were screened and
+69717 individuals were found eligible (Known diabetes and those at high score on IDRS) and hence
+invited to participate in the study. Of these 50199 subjects responded (72% response) and provided the
+pre intervention dataset for phase 2 of the trial. Out of these, 12466 (27.2%) consented to participate in
+the trial and Complete 3 month follow up data for analysis was available on 11254 (91.1%) who
+completed the 3 months follow up with 5932 under yoga arm and 5322 under control arm. Reasons for
+drop out (8%) are shown in the figure (mainly weather conditions). Although majority of them were
+interested they could not commit for 3 months of intervention [Figure 2] due to following key reasons:
+out of town for business or involved in social and political activities. About 9.8% expressed their
+unwillingness to participate as they were interested in other forms of exercise (they equated yoga to
+exercise) or due to religious reasons [Table 8].
+Open in a separate window
+Figure 2
+Trial profile
+Table 8
+Yoga camps in different zones
+Zones
+Rural
+Urban
+Conducted
+Planned
+Conducted
+Planned
+Northwest (J and K)
+8
+4
+3
+4
+North
+11
+12
+14
+12
+Northeast
+12
+10
+13
+10
+Central
+15
+10
+10
+10
+East
+9
+6
+5
+6
+West
+9
+10
+8
+10
+South
+19
+11
+11
+11
+Total
+83
+63
+64
+63
+Table 9 shows the characteristics of the participants of the two groups. The mean age was similar in
+both groups, higher in known diabetes group. There were more female participants in both groups.
+Participation in urban area was high in both groups. The mean BMI, waist circumference, and HbA1c
+were higher in the known diabetes group.
+Table 9
+Baseline characteristics of yoga and control groups
+Characteristics
+Overall
+Yoga group
+Control group
+Known
+DM
+Others with high risk
+on IDRS
+Known
+DM
+Others with high
+risk on IDRS
+Overall, n (%)
+12,364
+732 (5.9)
+5932 (48)
+378 (3.7)
+5322 (43.0)
+Age, mean±SD
+49.4±10.6
+52.3±10.8
+48.6±10.7
+52.9±10.2
+48.4±10.2
+Gender
+ Female, n (%)
+7093
+(58.2)
+381 (3.0)
+3440 (27.8)
+188 (1.5)
+3084 (24.9)
+ Male, n (%)
+5271
+(41.8)
+351 (2.8)
+2492 (20.1)
+190 (1.53)
+2238 (18.1)
+Location
+ Rural, n (%)
+4740
+(37.8)
+241 (1.9)
+1792 (14.5)
+167 (1.3)
+2540 (20.5)
+ Urban, n (%)
+7733
+(62.1)
+555 (4.5)
+4155 (33.6)
+245 (1.97)
+2778 (22.4)
+BMI, mean±SD
+21.1±3.80
+26.32±4.32
+20.7±3.70
+26.5±4.5
+20.5±3.67
+Waist circumference,
+mean±SD
+91.7±11.9
+91.76±12.0
+91.6±12.2
+92.85±11.9
+92.1±11.4
+HbA1c, mean±SD
+6.28±1.47
+7.63±2.17
+6.31±1.46
+7.86±2.13
+6.25±1.49
+Open in a separate window
+HbA1c=Hemoglobin A1c, BMI=Body mass index, SD=Standard deviation, DM=Diabetes mellitus, IDRS=Indian
+Diabetes Risk Score
+Discussion
+The present pan-India study (covering 95% of India's population) on yoga-based lifestyle intervention
+was an attempt to provide scientific evidence for the primary prevention of T2DM in both urban and
+rural sectors through community-based nationwide yoga-based lifestyle intervention aimed at turning
+the tide of India's increasing diabetes prevalence.
+This multicentric study adopted the principles of a RCT and targeted those at high risk for diabetes,
+those with prediabetes, and also patients with known or newly diagnosed diabetes. This article
+describes the methodology of the intervention study including developing the common yoga-based
+lifestyle module. Yoga-based lifestyle therapy was offered to the participants near their residence. The
+critical need for human resources in the management of chronic lifestyle and behavioral disorders is
+universally acknowledged. The design of the trial offers solution to the huge challenge of availability
+of lifestyle trainers in all parts of the country including remote places such as Jammu and Kashmir and
+Andaman, interior tribal areas such as Assam and Arunachal Pradesh, or the thinly populated interior
+forests such as Dakshina Kannada district of Karnataka. The IYA, the professional association of yoga
+teachers, provided the army of staff needed for implementation of the intervention: 1200 YVDMs, 35
+supervisors, and 2 overall coordinators. Leveraging on technology, it was possible to closely monitor
+the progress of the study.
+Deviation from the planned protocol was minimal. In 35 (29%) rural areas in south, north, and west
+zones, daily classes were conducted for 3 months (instead of once-a-week follow-up classes after the 9-
+day camps) on request by the enthusiastic participants and the local authorities.
+Strengths of the study
+This is the first large, nationwide, translational two-armed RCT that has looked at the effect of a
+standardized yoga lifestyle protocol in prediabetes in urban and rural population in India. The project,
+including the survey and intervention, was completed within 7 months. No major adverse effects were
+reported in any of the places and when reported, they included mild degree of spinal and knee pain, and
+generalized body aches which were handled by offering corrective postures and relaxation techniques
+on consultation on WhatsApp with senior medical yoga professionals such as RA and PI, and/or
+medication on advice of local family doctors.
+The numbers obtained at the end of the study period were found to be adequately powered to achieve
+the objectives set out at the beginning, namely, to document the efficacy of the structured intervention
+to prevent the progression of prediabetes to diabetes.
+Missing and wrong data entry (extreme values for blood pressure, weight, etc.) appears to be a key
+limitation; however, it is unlikely to influence the outcome of the intervention component of the study
+primarily as the outcomes measured are objective and hard outcomes.
+A major strength of this study was involvement by volunteers. Except for the RAs and SRFs, all others
+were paid a nominal honorarium just enough for boarding and lodging. We consider this to be a key
+issue as it makes the study and its methods more pragmatic and scalable.
+Suggestions for future work
+This recruited population may be followed up regularly to look at the long-term effects of yoga on
+lifestyle behavior. As yoga can be continued as culturally acceptable group practice, this may offer
+long-term answer to prevent India from becoming the global capital for diabetes.
+Financial support and sponsorship
+This study was financially supported by the Ministry of Health and Family Welfare, the Ministry of
+AYUSH, and Government of India, New Delhi, and Dr. Ishwar Acharya, the director of CCRYN,
+Government of India, New Delhi, sponsored the production of DVDs and preparation of booklets on
+yoga for diabetes.
+Conflicts of interest
+There are no conflicts of interest.
+Acknowledgments
+We acknowledge the Ministry of Health and Family Welfare, the Ministry of AYUSH, and Government
+of India, New Delhi, for funding this trial. We also thank Dr. Ishwar Acharya, the director of CCRYN,
+Government of India, for sponsoring the production of DVDs and preparation of booklets on yoga for
+diabetes. We are grateful to the members of the research advisory committee and yoga protocol
+committee for their inputs. We are indebted to the yoga masters of IYA including Sri Sri Ravishankar
+Guruji, Swami Ramdev, Swami Bharat Bhushan, and Sri Subodh Tiwari for their encouragement and
+contribution through their YVDMs as field officers for this trial. We thank the software team, RAs, all
+SRFs, yoga volunteers, and faculty and staff of VYASA and S-VYASA for their committed
+involvement during the implementation of the trial.
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diff --git a/subfolder_0/New Kind Of Biologically Active Orientation-Sensitive Field Coupling To Complexity Based Biological Regulatory Systems.txt b/subfolder_0/New Kind Of Biologically Active Orientation-Sensitive Field Coupling To Complexity Based Biological Regulatory Systems.txt
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@@ -0,0 +1,425 @@
+Editorial
+Forsch Komplementmed 2013;20:316–319
+Published online: October 21, 2013
+DOI: 10.1159/000356168
+Alex Hankey, Ph.D.
+Professor of Yoga and Physical Science
+Swami Vivekananda Yoga Anusandhana Samsthana
+Eknath Bhavan, 19 Gavipuram Circle
+Kempegowda Nagar, Bangalore 50019, India
+alexhankey@gmail.com
+© 2013 S. Karger GmbH, Freiburg
+1661-4119/13/0205-0316$38.00/0
+Accessible online at: 
+www.karger.com/fok
+Fax +49 761 4 52 07 14
+Information@Karger.com
+www.karger.com
+A New Kind of Biologically Active Orientation-Sensitive 
+Field – Coupling to Complexity-Based Biological  
+Regulatory Systems?
+Alex Hankeya    Ramesh Narayan Raob
+a	Swami Vivekananda Yoga Anusandhana Samsthana University, 
+b	Department of Animal Health, Karnataka Veterinary and Animal and Fisheries Sciences University, Bangalore, India
+Very occasionally one is privileged to read a scientific idea 
+of such breathtaking depth and originality that it has applica-
+tion to explain areas of experience not previously accessible to 
+science. Such is the idea presented in the first article in this is-
+sue, ‘The cavity structure effect in medicine: the physical as-
+pect’ by Liudmila B. Boldyreva [1], who briefly summarizes a 
+number of mathematical investigations into anomalous vacu-
+um states of superfluid quantum systems, and shows that they 
+have applications to understanding orientation and shape ef-
+fects observed by certain 19th and 20th century physicians 
+who placed patients in ‘cavities’ with particular shapes and ori-
+entations in order to cure specific diseases. 
+In today’s world, science has reached a certain measure of 
+richness and complexity, and many scientists are proud to 
+think that science is now essentially complete: all fundamental 
+scientific discoveries must have already been made, and little 
+or nothing remains to be done at fundamental levels. The only 
+valid scientific endeavors according to such scientists are to 
+dot the odd ‘i’ and cross the odd ‘t’ that has not already been 
+attended to. The problem for such scientists is that their views, 
+though shared by many, are purely doctrinal; there is no evi-
+dence that their beliefs are valid. The opposite rather holds: 
+there are large numbers of phenomena, which have been well 
+recorded by humans in many different cultures, and for which 
+there are not only no scientific explanations; there are no con-
+ceivable explanations at the current level of development of 
+scientific theory. Rupert Sheldrake is a towering example of a 
+scientist who has written extensively about such phenomena 
+in, e.g., ‘The Sense of Being Stared At’ [2], and has shown how 
+science that fails to acknowledge such phenomena suffers 
+from severe lacunae [3]. Another example of such a phenom-
+enon is homeopathy, discussed in the review article in this is-
+sue [4].
+Forschende Komplementärmedizin is fortunate that its 
+editorial board is not oriented in this direction, and its mem-
+bers are comfortable publishing papers about phenomena for 
+which there is, as yet, no scientific theory [5]. Human powers of 
+observation are thousands of years old, while modern science 
+as we know it only dates from Galileo Galilei, René Descartes, 
+Isaac Newton, and their discoveries of kinematics and me-
+chanics, coordinate algebra, and calculus, respectively, some 
+400 years ago. Compared to the body of recorded human expe-
+rience, modern science is in its infancy, and its much vaunted 
+successes need to be counterbalanced by acknowledging its 
+still severe limitations. Indeed, in the field of medicine, doctors 
+have relatively low life expectancy: is this not evidence that 
+they do not understand how to achieve health – and that doing 
+so may involve factors currently beyond science and the scien-
+tific imagination? Recent articles suggest that vitamin supple-
+ments, taken to promote health in the short term, increase the 
+occurrence of cancer and may even shorten life in the long 
+term. [6] 
+Cavity Structure Effect and Related Subtle Phenomena
+Phenomena like the ‘cavity structure effect’ [1] therefore 
+merit investigation, especially as they exist in different forms 
+in different cultures. In India, there is a tradition of architec-
+ture known as ‘Vastu Vidya’ – knowledge of ‘Vastu’, or the 
+placement and location of buildings such as domestic housing 
+and temples [7]. It is closely allied to the study of Indian astrol-
+ogy or ‘Jyotish’ [8], because the terms of reference used to de-
+scribe the two systems are the same. Like all ancient sci- 
+ences, Vastu Vidya and Jyotish work on the principle that the 
+manifest world of sensory experience is built in layers, and that 
+underlying the gross realm of sensory experience are levels of 
+subtle experience only available when awareness is refined 
+AG BASEL
+/2013 7:37:04 AM
+Forsch Komplementmed 2013;20:316–319
+A New Kind of Biologically Active Orientation- 
+Sensitive Field
+317
+ent times [12, 13]. Choosing starting times that traditionally 
+are considered maximally auspicious for living organisms was 
+found to significantly enhance bacterial growth and quality, 
+while inauspicious starting times decreased them. For virus 
+propagation in cellular hosts, the opposite was observed: times 
+considered auspicious for life decreased virus propagation, 
+while times inauspicious for life enhanced virus propagation. 
+Of the observed variance in microbial growth, Rao was able to 
+attribute between 70 and 80% to factors associated with start-
+ing time. 
+The implications of these experiments are truly revolution-
+ary: not only do they imply that many if not most microbial 
+growth processes are subject to influences identified by the 
+Vedic science of Jyotish, but also they clearly distinguish be-
+tween cells and viruses, identifying the latter as distinct from 
+living organisms. Current theory proposes that variations in 
+microbiological growth are due to purely random variations in 
+rates of chemical reactions involving ‘small numbers of big 
+molecules’ [14]. The experiments suggest this ‘stochasticity hy-
+pothesis’ is inadequate – stochasticity as the sole cause of vari-
+ation is denied by each and every experiment to date [8].
+A theory has been developed to explain these observations 
+[15]. It combines unusual aspects of astrophysics and biophys-
+ics. First the astrophysics: During solar system condensation, 
+collisions between dust particles, gas molecules, etc. generate 
+ultra-high order quantum correlations, which become organ-
+ized by system angular momentum and eventually become fo-
+cused in each planet. Second, the biophysics: In complexity 
+biology, preferred loci of regulatory control maximize sensitiv-
+ity of response, a condition implying that they are located at 
+feedback instabilities; physical instabilities, however, contain 
+high levels of internal quantum correlations and are therefore 
+susceptible to influences from any system with which they are 
+correlated. This means that biological regulatory systems can 
+be influenced by external sources of high-order quantum cor-
+relations, like those the astrophysics predicts to exist in the 
+planets. In conclusion, the ultra-high order quantum correla-
+tions found in the planets can provide subtle input into bio-
+logical regulatory systems and control the way they behave. 
+Relationship to Cavity Structure Effects
+But what are the mathematical properties of the physical 
+systems now believed to lie at the heart of biological regula-
+tion? Being unstable, they are associated with nonsimple har-
+monic potentials: the usual ‘quantizable’ structure of energy 
+levels is absent. Their effective potentials must obey power 
+laws greater than 2, so that their energy levels become infini-
+tesimally closely spaced close to the vacuum state. It is quite 
+possible that, for multicritical systems known to exist in higher 
+organisms [16], these new complexity-based models of organ-
+ism regulation effectively contain degenerate vacuum states 
+like superfluids, in which case, Boldyreva’s models may be-
+come applicable. 
+and sensitivity has developed on levels that are ‘sukshma’ or 
+subtle. Indeed, the ability to interact on subtle sensory levels is 
+one of the main purposes of traditional practices taught by the 
+ancient Vedic Rishis to their children, described in such stories 
+as those about Brighu and Svetaketu in the Taittiriya and 
+Chandogya Upanishads [9, 10]. 
+The central idea in all Indian sciences is that each subtle 
+level controls the level below it. Learning to operate on subtle 
+levels of nature is therefore the key to gaining control of dif-
+ferent aspects of life. This can even be seen in western life, 
+since the Vedic sciences regard the intellect as more subtle 
+than, and controlling the content of the mind. Those with more 
+highly functioning intellects therefore tend to find themselves 
+acknowledged as sources of inspiration, knowledge, and ex-
+pertise for those needing guidance in various fields. In the case 
+of human life itself, the Vedic sciences name various ‘subtle 
+bodies’ that control the ‘annamayokosha’, or gross physical 
+body acknowledged by modern bioscience: the ‘pranamayoko-
+sha’ (body of vital energy), the ‘manomayokosha’ (body of 
+mind including feelings and emotions), the ‘vijnanamayoko-
+sha’ (body of higher intellect with knowledge of the subtle 
+realms), and the ‘anandamayokosha’ (body of deep spiritual 
+experience and understanding) [9].
+The Vedic sciences thus extend themselves self-consistently 
+into fields that are currently beyond the limits of modern sci-
+ence, providing detailed accounts of how to access and under-
+stand them. If western science is to catch up with the Vedic 
+sciences, it must first gain the humility to acknowledge its 
+present limitations and learn to do experiments in fields for 
+which it presently has no theory [5, 11]. The observations quot-
+ed by Boldyreva [1], and the theory she develops are examples 
+of this kind of revolutionary science at work. What she states is 
+that, when the vacuum state of a system possesses superfluid 
+kind of properties, it gains measurable properties that differ 
+according to orientation with respect to other physical fields 
+such as gravitational or magnetic fields. Remarkably, this is ex-
+actly the kind of property that the Vedic sciences Jyotish and 
+Vastu ascribe to physical and biological structures. 
+Experimental Tests of Jyotish
+Recently, Jyotish has successfully stood up to a number of 
+tests of its predictions for microbiological processes [12]. It is 
+now time to develop new classes of theory that can help ac-
+commodate such new experimental phenomena into the over-
+all realm of science – a consistent underlying theoretical foun-
+dation. Boldyreva’s work contains just such possibilities and is 
+therefore of value in a far wider context. 
+The tests of Jyotish predictions are worth recounting, as the 
+theory developed to explain them may possibly be generalized 
+to a form akin to that proposed by Boldyreva. Rao and col-
+leagues at the Karnataka Veterinary and Animal and Fisheries 
+Sciences University have conducted a series of pilot experi-
+ments, consisting of observations of regular vaccination pro-
+duction runs for bacterial and viral vaccines started at differ-
+AG BASEL
+/2013 7:37:04 AM
+318
+Forsch Komplementmed 2013;20:316–319
+Hankey/Rao
+vacuum field of a number of possible kinds was in operation. If 
+readers remind themselves of the case of  molecular  orbital 
+fields surrounding an atom, they will see how they dominate 
+different directions differently: an ultra-simple example is the 
+tetragonal set of sp3 bonding orbitals in carbon. Vastu specifies 
+Jyotish fields surrounding a building that present suspicious 
+similarities to such kinds of directional wave functions – which 
+is precisely where Boldyreva is starting from with her super-
+fluid vacuum states. So in this proposed further level of detail 
+her theory seems to fit its proposed application. 
+Now, see how to apply this principle to one’s own life: If the 
+vibration of a planet is beneficial to a person as specified in 
+their birth chart – then being in the sector of a house where 
+that planet dominates will benefit them. Equally, if, according 
+to their birth chart, a planet is inimical to a person, then stay-
+ing/sleeping in a room in the corresponding position in a 
+house, as given in table 1, may cause harm of the kind specified 
+in their chart. Families with kitchens in the South West corner 
+may tend to eat leftovers and stale, toxic food. If the dining 
+room is there, they may get into arguments at the dinner 
+table. 
+In this regard the entrance to a house is also very important, 
+since the vibrations of the planet dominating the direction of 
+the entrance tend to pervade the whole house. In my own case, 
+the entrance to the building where I stay is in the middle of the 
+North side (Mercury); the room itself is in the North West cor-
+ner of the building (Moon); and the entrance to the room I use 
+is in its North East corner (Jupiter/Ketu). These 3 vibrational 
+influences are activated: Mercury from the building entrance, 
+the Moon from my room’s position in the building, and Jupi-
+ter/Ketu from the entrance I use. Should I want more effect 
+from the Moon, and less from Jupiter, I only have to stop using 
+the door in the North East corner, and start using the door that 
+I currently keep closed in the North West corner. In my case, 
+the Moon is both ‘Atma Karaka’ – indicator for the supreme 
+spirit within – and the planet guiding my career. She is highly 
+auspicious, while Jupiter is less so (for those whose natal charts 
+have my ascendant). In Vedic sciences, such principles are easy 
+to memorize and look simple to apply, but in real life when 
+many effects are present at once, judging which competing ef-
+fect wins requires experience. Problems are usually easily seen 
+and their remedies often are too. 
+Jyotish proposes that organisms themselves can take on dif-
+ferent ‘planetary’ qualities [8], while Vastu Vidya [7] suggests 
+that such ‘planetary vibrations’ surround organisms and physi-
+cal objects in specific patterns. These currently unexplainable 
+properties seem remarkably close to the new field effects pro-
+posed by Boldyreva [1]. Her results may have the potential to 
+explain far more than medical properties of cavity structures 
+– effects of housing, noted in Vastu Vidya and ‘Feng Shui’, and 
+how those incorporate planetary vibrations; houses are only 
+larger kinds of cavity structure after all. Might we not hypo­
+thesize that all involve the same complexity properties of or-
+ganism regulation used to explain influences of planetary posi-
+tions on biological processes? 
+Three Examples
+To illustrate how Indian traditional knowledge may provide 
+examples of Boldyreva’s statement that it is possible for fields 
+generated by a superfluid vacuum to generate different quali-
+ties along differently angled surfaces, consider [1] the way 
+Vastu Vidya arranges fields with different ‘planetary’ vibra-
+tions around a rectangular building, [2] how different plane-
+tary fields are said to surround the planet earth in Vedic astrol-
+ogy, Jyotish, and [3] certain kinds of specific predictions for 
+people. 
+First, consider table 1, which assigns one of the 9 ‘grahas’ to 
+each of the 8 main directional sectors of a rectangular building 
+– most precisely when its axes are aligned with the true North 
+and East. North East (top left) is said to be ‘governed by Jupi-
+ter and Ketu’; it is the only direction to have 2 grahas and is 
+considered the most spiritual and most auspicious for spiritual 
+liberation since Ketu is ‘Moksha Karaka’ – the indicator for 
+that goal. East is the Sun; South East is Venus; South is Mars; 
+South West is Rahu, the most inauspicious; West is Saturn, the 
+next most inauspicious; the North West is the Moon; North is 
+Mercury. This means that, in each direction given, the vibra-
+tional quality of the specified planet will be dominant. We may 
+imagine, that, in different directions relative to a house (a kind 
+of cavity), the superfluid vacuum field assumes different vibra-
+tory qualities, and that in each of the 8 directions, those corre-
+sponding most closely to the vibratory qualities of the planet 
+specified in table 1 are activated. This sequence of ideas is of 
+the kind for which a deductive theory could be established. 
+Hopefully one would only need to specify which superfluid 
+Table 1. Vastu Vidya: ‘grahas’ dominating the 8 
+principal directions in a building. Table 1 depicts 
+the 8 main directions, North, East, South, and 
+West, and those between them, indicating which 
+planet is activated in which direction according 
+to India’s ancient science of Sthapatya Veda / 
+Vastu Vidya, knowledge of Vastu: Jupiter to the 
+North East, Sun to the East, Moon to the North West, etc. We may understand that, analogously, Boldyreva’s superfluid vacuum fields may similarly 
+take on various ‘vibrational patterns’ in different directions, characteristic of particular kinds of superfluid field, and that, someday, it may be possible 
+to work out a deductive theory of Vastu. Similarly for all the examples given, once seen in complex field terms, many things seem less impossible
+North West 
+ 
+North
+ 
+North East
+ 
+Moon
+Mercury
+Jupiter / Ketu
+ 
+West
+Saturn
+ 
+Sun
+East
+ 
+Rahu
+Mars
+Venus
+ 
+South West
+ 
+South
+ 
+South East
+AG BASEL
+/2013 7:37:04 AM
+Forsch Komplementmed 2013;20:316–319
+A New Kind of Biologically Active Orientation- 
+Sensitive Field
+319
+other participants. In A. H.’s case, the vibrations of the snake 
+were correct and rightly placed for A. H. to ‘meet’ it at that 
+time. Similar vibrational matching happens between people: 
+the kind of person we meet for an appointment, our relative 
+directions, topics discussed and their utcome, can all be read 
+from positions of planets at the time, relative to those at our 
+birth. The level of detail can be astonishing – as in the case of 
+A. H.’s snake. 
+Conclusions
+In these ways, Boldyreva’s approach [1] may presage a 
+great expansion in scientific thought, since it may provide the 
+theory for phenomena recognized to exist for thousands of 
+years, but currently rejected by the scientific community on 
+the grounds that theoretically they are impossible. The human 
+organism contains several, empirically recognized, subtle lev-
+els of function detailed above. Each of these requires a possi-
+bly different kind of new physical theory to test by experiment. 
+The theory of feedback instabilities and criticality is quite well 
+developed and may describe one level of subtle phenomena 
+quite well [15, 16]. Boldyreva may well have identified another, 
+fitting the conceptual framework serendipitously well.
+Second, the case of the earth’s surface, the vibrational ef-
+fects of a planet are strongest when the planet is in the rising 
+sign, i.e. the direction towards which the surface of the earth is 
+moving at the time. Each planet also has different ‘aspects’ in 
+a chart, i.e. its own pattern of variation in strength round the 
+surface of the earth, as given in Jyotish. Directional variations 
+like these once again present the kind of behavior one sees in 
+atomic orbitals and might be derivable from quantum fields 
+corresponding to particular superfluid vacuum states. 
+Third, Jyotish and Vastu also combine to specify directional 
+properties when an event occurs in a person’s life. Properties 
+of particular events can be read through a combination of 
+­
+Jyotish charts at birth and at the time, and can specify the 
+­
+direction in which it occurred relative to the person – and oth-
+er details. When A. H. saw a small snake one evening in March 
+2014, R. N. R. correctly stated its direction (East), its size and 
+color (small and red), that there was water falling (it was be-
+ginning to drizzle), and the direction to a nearby temple 
+(North). All this is possible because there are ‘vibrational pat-
+terns’, i.e. of high order quantum correlations, continuously 
+acting on the fields of all participants in an event. As a result, 
+the ‘vibrations’ of one entity tend to match those surrounding 
+References
+  1	 Boldyreva LB: The cavity structure effect in medi-
+cine: the physical aspect. Forsch Komplementmed 
+2013;20:322–326.
+  2	 Sheldrake R: The Sense of Being Stared At. To­
+ronto, Park Street Press, 2009.
+  3	 Sheldrake R: The Science Delusion. London, Coro-
+net, 2012.
+  4. Hahn RG: Homeopathy: Meta-analyses of pooled 
+clinical data. Forsch Komplementmed 2013;20:376–
+381.
+  5	 Hankey A: Experimenting with phenomena that lack 
+theory. J Altern Complement Med 2008;15:203–204. 
+  6	 Vidal AC, Grant DJ, Williams CD, Masko E, Allott 
+EH, Shuler K, McPhail M, Gaines A, Calloway E, 
+Gerber L, Chi JT, Freedland SJ, Hoyo C: Associa-
+tions between intake of folate, methionine, and vi-
+tamins B-12, B-6 and prostate cancer risk in Ameri-
+can veterans. J Cancer Epidemiol 2012;2012:957467. 
+  7	 Svoba RE: Vastu: Breathing Life into Space. Dublin 
+(NH), Namarupa, 2013. 
+  8	 Maharishi Parashara: Brihat Parashara Hora Shas-
+tra. www.viswanadhajyothirnilayam.com/pdf/Brihat
+ParasaraHora.pdf (accessed 07.10.2013).
+  9	 Radhakrishnan S: Taittiriya Upanishad; in id.: The 
+Principal Upanishads. New Delhi, Harper Collins, 
+2001.
+10	 Krishnanda S: Chandogya Upanishad. Rishikesh, 
+Sivananda Ashrama, 1984. www.swami-krishnananda.
+org/chhand/Chhandogya_Upanishad.pdf (accessed 
+07.10.2013).
+11	 Sheldrake R: Seven Experiments That Could 
+Change the World. London, Fourth Estate, 1994. 
+12	 Rao NR, Renukaprasad C, Gajendragad M, Byre-
+gowda SM: Eight experiments on astromedicine: a 
+summary. Light on Ayurveda Journal 2013;11:42–47. 
+13	 Rao NR, Renukaprasad C, Sharma S: Starting time 
+dependence of yield in production of Ranikhet vi-
+rus vaccine: natural variations in rates of microbial 
+processes may have astrological explanations. Light 
+on Ayurveda Journal 2013;11:52–58.
+14	 Federoff N, Fontana W, Small Numbers of big mol-
+ecules. Science 2001;297:1129–1131.
+15	 Hankey A: Science meets astrology. Light on 
+ 
+Ayurveda Journal 2013;11:14–16.
+16	 Nytker M, Price ND, Aldana M, et al.: Gene expres-
+sion dynamics in the macrophage exhibit criticality. 
+Proc Natl Acad Sci USA 2008;105:1897–1900.
+AG BASEL
+/2013 7:37:04 AM
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+24
+© 2017 International Journal of Yoga ‑ Philosophy, Psychology and Parapsychology | Published by Wolters Kluwer ‑ Medknow
+Näsadiya Süktam: The Earliest Cosmology on Origins of Life
+RNA has been recognized as the “Last Universal Common 
+Ancestor (LUCA).” Modern‑day definition of life includes 
+a couple of features that is relevant for our discussion here. 
+One is that, for an organized entity to be called alive, it 
+should be able to replicate itself and the other is that it 
+should have the ability to query the processes or in other 
+words having the ability to change according to the needs 
+of the situation. RNA fulfills both the needs. Being most 
+versatile among all the biochemicals, having the ability 
+to store genetic information, acting as catalytic enzyme, 
+and using recombination and mutation to develop new 
+niches[6] were considered to hold the most appropriate 
+component of evolution. Recent experiments demonstrate 
+the ease with which RNA could have formed in the early 
+prebiotic broth; two prebiotic compounds, melamine and 
+barbituric acid, formed glycosidic linkages with ribose 
+and ribose‑5‑phosphate in water to produce nucleosides 
+and nucleotides in good yields.[7] A research group 
+demonstrated that structurally complex and highly active 
+RNA ligases were derived from random RNA sequences,[8] 
+suggesting randomness at some point might device key for 
+an orderliness.
+To the Indian mind, Vedas and Upanishads are believed 
+to provide solutions for simplest to the most complex 
+problems of the universe and from there on to the origin 
+of life. Material‑based scientists regard the deliberations 
+on the origin of life in various civilizations to be driven 
+by emotions, supernatural beliefs, and myths rather than 
+by rational reasoning. Instead of neglecting the beliefs of 
+the cultures, the changing meaning of articulation over 
+time should be incorporated to appreciate the underlying 
+wisdom. The contemporary scientists believe that, before 
+the Big Bang event, there was nothing at all, not even 
+time and space, and there was no day and night, light 
+and darkness – similar to void or “çünya” as claimed in 
+the Näsadiya Süktam.
+The Näsadiya Süktam, similar to the predictions of 
+RNA world theory, declares that, when Earth came 
+into existence, it was flooded everywhere with no 
+distinction between land and water and it was covered 
+with turbulent hot oceans. Further, it is described 
+that, from unmanifested, the seed for all life forms 
+manifested – which shall be interpreted as “the seed for 
+all life forms” developed from the abundant prebiotic 
+compounds that were available in the primitive earth.
+itrií+nae ivttae riZmre;amx> iSvdasI 3 Êpir iSvdais 3 t!,
+retaexa AasNmihman AasNTSvxa AvStaTàyit> prStat!. na 
+sU 5.
+Letter to Editor
+One of the most common and persistent quests for the 
+philosophers worldwide has been about the nature, 
+origin, and purpose of life. Origin of life forms has been 
+a serious question in the literature of most civilizations. 
+Various cultures have tried to answer this philosophical 
+question in several ways – based on their understanding. 
+Modern‑day scientists have also contributed their share 
+of theories to answer this question. Theology and science 
+have frequently wondered upon common questions, but 
+no other topic overlaps as much as the inquiry on the 
+origin of life. Detailed commentaries on Näsadiya Süktam 
+are beyond the scope of this article and can be found 
+elsewhere,[1‑3] and a compilation of interpretations made 
+by several authors can be found here.[4] Descriptions 
+made until date have been focused mostly on the 
+vedanta underlying the Näsadiya Süktam. In this letter, 
+we communicate our views interpreting specific slokas 
+of Näsadiya Süktam in the 10th  maëdala of Åg veda,[5] 
+limiting only to its mention of the concept of origin of 
+life forms to its relevance to the modern theories.
+Several theories have been proposed by the scientists 
+through experiments regarding the origin of life forms 
+on planet –“RNA World” – is one such widely accepted 
+theory. We have come across several similarities 
+between Näsadiya Süktam and RNA world theory, the 
+former dating back to several centuries and the latter is 
+from the 21st century.
+Looking back into the history, it appears that there were 
+conflicting beliefs among different cosmologies about 
+the origin of life. The Christian, Muslim, and Jewish 
+cosmologies combine the origin of universe and origin 
+of life on earth as happening at finite time period. 
+Whereas earlier, Greek philosophers like Aristotle 
+believed that the universe had existed forever and would 
+continue to exist forever and so were humans. In the 
+ancient Christian countries, the common belief until 
+the early 17th  century was that life forms originated 
+spontaneously. However, Francesco Redi in 1668 
+through experimentation disproved the spontaneous 
+generation theory by showing that maggots appearing on 
+the putrefying meat did not arise spontaneously but from 
+microorganism already present in the meat. Another 
+theory, called panspermia theory, explains that the first 
+life forms on Earth were carried on meteorites traveling 
+from different planets. However, due to lack of scientific 
+proof, this theory did not gain much attention.
+The RNA world theory proposes that RNA served as the first 
+structural, functional, and basic units of organization in the 
+most primitive life form. Also, because of its omnipresence, 
+[Downloaded free from http://www.ijoyppp.org on Wednesday, January 27, 2021, IP: 136.232.192.146]
+25
+International Journal of Yoga ‑ Philosophy, Psychology and Parapsychology  ¦  Volume 5  ¦  Issue 1  ¦  January‑June 2017
+Letter to Editor
+tiraçcrino 
+vitato 
+raçmireñämadhaù 
+svidäsé 
+dupari 
+svidäsit |
+retodhä äsanmahimäna äsantsvadhä avastätprayatiù 
+parastät || nä sü 5 ||
+#y< iviöiòyRt AabÉUv yid va dxe yid va n,
+yae ASyaXy]> prme VyaemNTsae A¼ ved yid va n ved. na sU 7.
+iyaà visriñöiryata äbabhüva yadi vä dadhe yadi vä na |
+yo asyädhyakñaù parame vyomantso aìga veda yadi vä 
+na veda || nä sü 7 ||
+Näsadiya Süktam further declares the quality of the 
+“seed of all life forms,” which resembles the qualities 
+of RNA. It is described that, that seed of all life forms 
+as a particle of query, stretched like a string, driven 
+by its inherent power and desire, “the seed of all life 
+forms,” was protected from all sides, which had the 
+property of increasing at will and keep itself identical. 
+RNA is known for evolving itself in a self‑replicating 
+fashion and contribute to new functions. The 
+replication process of RNA is very specific that it 
+replicates the same sequence of nucleotides from the 
+nucleotide pool  –  minimizing the chance of error 
+and preserving the function of RNA. The “querying” 
+and “capacity to replicate keeping itself identical” 
+might indicate the “seed of origin of life” mentioned 
+in Näsadiya Süktamto be the present‑day RNA. This 
+description in the Näsadiya Süktam might provide 
+a new dimension in perceiving implicit biological 
+phenomena.
+In summary, origin of life forms in Näsadiya Süktam can 
+be interpreted that the life form manifested itself from 
+the unmanifested by its own desire and the manifested 
+had its inherent nature to explore and replicate itself 
+to a similar entity. This description mentioned in the 
+Näsadiya Süktam matches precisely with the observation 
+proposed by the modern‑day scientists after scientific 
+experiments. It appears that Näsadiya Süktam should be 
+the earliest documented inquiry of such understanding, 
+holding more comprehension and relevance with the 
+present‑day cosmology.
+Financial support and sponsorship
+Nil.
+Conflicts of interest
+There are no conflicts of interest.
+Balakrishnan Ragavendrasamy, 
+ 
+Ramesh Mavathur Nanjundaiah, 
+ 
+Manjunath Nandi Krishnamurthy
+Anvesana Research Laboratories, Division of Yoga and Life 
+Sciences, S‑VYASA University, Bengaluru, Karnataka, India
+Address for correspondence: Dr. Ramesh Mavathur Nanjundaiah, 
+Anvesana Research Laboratories, Division of Yoga and Life 
+Sciences, S‑VYASA University, Bengaluru, Karnataka, India. 
+E‑mail: ramesh.mavathur@svyasa.org
+References
+1. 
+Maurer  WH. A  re‑examination of Rgveda  X.129, the Nasadiya 
+Hymn. JIES 1975;3:210‑37.
+2. 
+Brereton JP. Edifying puzzlement: Ṛgveda 10. 129 and the uses 
+of Enigma. J Am Orient Soc 1999;1:248‑260.
+3. 
+Bilimoria  P. Misconception about the Nature of Self in Hindu 
+Philosophy: A  Comparative Critique of Sankara’s Strategy and 
+Foundationalism. Sydney Studies in Religion 2008; Available 
+from: https://www.openjournals.library.sydney.edu.au/index.php/
+SSR/article/viewFile/667/647. [Last accessed on 2017 Aug 17].
+4. 
+Shankar  S. Rig Veda 10.129  –  Background Paper. Astitva; 
+2015. 
+Available 
+from: 
+https://www.archive.org/details/
+AstitvaDIN2072000010_201603. 
+[Last 
+accessed 
+on 
+2017 Aug 17].
+5. 
+Sontakke  NS, Kshikar  NS. Åg Veda Samhitä with the 
+Commentary of Saayanaachaarya. Mandala 9‑10. Vol.  4. Pune: 
+Vaidika Samshodhana Mandala; 1946.
+6. 
+Gilbert W. Origin of life: The RNA world. Nature 1986;319:6055.
+7. 
+Cafferty BJ, Fialho DM, Khanam J, Krishnamurthy R, Hud NV. 
+Spontaneous formation and base pairing of plausible prebiotic 
+nucleotides in water. Nat Commun 2016;7:11328.
+8. 
+Ekland  EH, Szostak  JW, Bartel  DP. Structurally complex and 
+highly active RNA ligases derived from random RNA sequences. 
+Science 1995;269:364‑70.
+Access this article online
+Quick Response Code:
+Website: www.ijoyppp.org
+DOI: 10.4103/ijny.ijoyppp_18_17
+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.
+How to cite this article: Ragavendrasamy B, Nanjundaiah RM, 
+Krishnamurthy MN. Nāsadiya Sūktam: The earliest cosmology on origins 
+of life. Int J Yoga - Philosop Psychol Parapsychol 2017;5:24-5.
+© 2017 International Journal of Yoga ‑ Philosophy, Psychology and Parapsychology | Published 
+by Wolters Kluwer ‑ Medknow
+[Downloaded free from http://www.ijoyppp.org on Wednesday, January 27, 2021, IP: 136.232.192.146]
diff --git a/subfolder_0/P300 and Heart Rate Variability Recorded Simultaneously in Meditation.txt b/subfolder_0/P300 and Heart Rate Variability Recorded Simultaneously in Meditation.txt
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+https://doi.org/10.1177/1550059418790717
+Clinical EEG and Neuroscience
+
+1­
+–11
+© EEG and Clinical Neuroscience 
+Society (ECNS) 2018
+Article reuse guidelines:
+sagepub.com/journals-permissions
+DOI: 10.1177/1550059418790717
+journals.sagepub.com/home/eeg
+Original Article
+Introduction
+Meditation is associated with attention. Meditation has been 
+described as a training in awareness which over a period of 
+time produces definite changes in perception, attention, and 
+cognition.1 This connection between meditation and attention 
+was mentioned in traditional yoga texts, particularly Patanjali’s 
+Yoga Sutras (the sage Patanjali, circa 900 bc). Two states of 
+meditation were described. These were meditation with focused 
+awareness (called dharana in Sanskrit; Patanjali’s Yoga Sutras, 
+Chapter III, Verse 1).2 This state is supposed to lead to the next 
+stage of effortless mental expansion in defocused meditation 
+(called dhyana in Sanskrit; Patanjali’s Yoga Sutras, Chapter III, 
+Verse 2). The practice of meditative focusing (dharana) has 
+been associated with better performance in a cancellation task 
+which requires focused and selective attention.3 In the present 
+study, meditative focusing was compared with another mental 
+state that involves focusing and is described in another ancient 
+Indian text. This mental state was nonmeditative focusing 
+(called ekagrata in Sanskrit; Bhagavad Gita, circa 400-600 bc; 
+Chapter VI, Verse 12). This mental state involves focusing the 
+attention while not in meditation, but previously did not result 
+in any changes in the cancellation task performance.3 A fourth 
+state for comparison was random thinking, which is also 
+described in the Bhagavad Gita (called Cancalata in Sanskrit; 
+Bhagavad Gita, circa 400-600 bc, Chapter VI, Verse 34).
+Apart from cancellation tasks attention is assessed in other 
+ways. The P300 component of auditory event related brain 
+potentials is generated when subjects attend to and discriminate 
+between stimuli which differ from one another in a specific 
+characteristic.4 The P300 is believed to reflect fundamental 
+cognitive events requiring attentional and immediate memory 
+processing.5 While attention is required for most activities, 
+focused attention and vigilance are associated with increased 
+sympathetic activity.6 In 30 practitioners in defocused medita-
+tion (dhyana), there was a reduction in sympathetic nervous 
+system (SNS) activity in different subdivisions such as changes 
+in heart rate variability (HRV) suggestive of a shift toward 
+790717 EEGXXX10.1177/1550059418790717Clinical EEG and NeuroscienceT
+elles et al
+research-article2018
+1Patanjali Research Foundation, Haridwar, Uttarakhand, India
+2ICMR Center for Advanced Research in Yoga and Neurophysiology, 
+S-VYASA University, Bengaluru, Karnataka, India
+Corresponding Author:
+Shirley Telles, Patanjali Research Foundation, Patanjali Yogpeeth, Haridwar, 
+Uttarakhand 249405, India. 
+Email: shirleytelles@gmail.com
+P300 and Heart Rate Variability Recorded 
+Simultaneously in Meditation
+Shirley Telles1,2, Deepeshwar Singh2
+, K. V. Naveen2, 
+Subramanya Pailoor2, Nilkamal Singh1, and Shivangi Pathak1
+Abstract
+Sympathetic activation is required for attention. Separate studies have shown that meditation (a) improves attention and (b) 
+reduces sympathetic activity. The present study assessed attention with the P300 and sympathetic activity with heart rate 
+variability (HRV). Forty-seven male subjects (group mean age ± SD, 21.6 ± 3.4 years) were assessed in 4 mental states: (a) 
+random thinking, (b) nonmeditative focusing, (c) meditative focusing, and (d) defocused meditation. These were recorded on 4 
+consecutive days. HRV, respiration, and P300 event-related potentials (ERPs) were recorded before and after the sessions. Data 
+were analyzed with repeated-measures analysis of variance followed by post hoc analysis. HRV showed a significant increase in 
+low-frequency (LF) power, decrease in high-frequency (HF) power and an increase in average heart rate based on the average 
+R-R interval after meditative focusing, compared with before. In contrast, the average heart rate decreased after defocused 
+meditation compared with before. There was a significant increase in the P300 peak amplitude after meditative focusing and 
+defocused meditation, with a reduction in peak latency after defocused meditation. These results suggest that after meditation 
+with focusing, there was sympathetic arousal whereas after defocused meditation, there was a decrease in the average heart 
+rate while participants carried out the P300 auditory oddball task sooner.
+Keywords
+meditation, defocusing, P300 event-related potentials, heart rate variability, attention, autonomic balance
+Received November 12, 2017; revised April 30, 2018; accepted June 19, 2018.
+2	
+Clinical EEG and Neuroscience 00(0)
+vagal dominance, increased sudomotor activity and reduced 
+sympathetic cutaneous vasomotor activity.7 This decrease in 
+sympathetic activity during defocused meditation is compati-
+ble with descriptions in the ancient texts of meditation as a state 
+in which focusing is effortless (Patanjali’s Yoga Sutras, Chapter 
+III, Verse 2). Hence it was considered interesting to determine 
+whether meditation would increase sympathetic activity when 
+meditators performed an attention task. In a single study, the 
+P300 and HRV were simultaneously recorded in 10 Vipassana 
+meditators.8 Attention and autonomic nervous system activity 
+were simultaneously assessed and reported. There was 
+increased attentional engagement (P3b peak amplitude; 
+Cohen’s d = 0.82) and autonomic regulation with a shift toward 
+reduced vagal tone after defocused meditation.8 Vipassana 
+meditation owes its origin to the teachings of Gautama the 
+Buddha (circa 528 bc). However, the Vippasana meditation 
+practiced in the study cited above was developed by S. N. 
+Goenka in the 1950s.9
+There has been no attempt to simultaneously record perfor-
+mance in an attention task along with sympathetic activity in 
+the meditation described in traditional yoga texts (Patanjali’s 
+Yoga Sutras, Chapter III, Verse 2). Hence, the objective of the 
+present study was, to simultaneously record the P300 and HRV 
+in participants practicing meditative focusing and defocused 
+meditation and compare these states with focusing and random 
+thinking.
+Materials and Methods
+Participants
+Sixty healthy male participants with ages between 20 and 32 
+years (group mean ± SD, 20.2 ± 3.1 years) participated in the 
+study. Participants were recruited through flyers distributed in 
+a yoga university in India. Thirteen participants were excluded 
+from the study because of motion artifact in the signals or 
+because of high electrode impedance during the recordings. 
+Despite attempts to correct this in repeat recordings it was not 
+possible as the artifacts persisted. Hence, the data from 47 par-
+ticipants (group mean age ± SD, 21.6 ± 3.4 years) were 
+included for the final analysis. Statistical calculation of the 
+sample size was not done prior to the experiment. However, 
+post hoc analyses showed for the present study, with the sample 
+size as 47 in each session, and with the Cohen’s d = 0.50, the 
+power was 0.80.10 The Cohen’s d was obtained from the P300 
+peak amplitude in the meditation session when the after value 
+was compared with before value. The inclusion criteria were 
+(a) the participants should have had at least 24 months experi-
+ence of meditation; (b) male participants alone were studied as 
+auditory evoked responses have been shown to fluctuate with 
+the phases of the menstrual cycle,11 and P300 evoked potentials 
+also varied with gender12; (c) no history of smoking; and (d) 
+normal health based on a routine clinical examination. The par-
+ticipants were examined by a person who had a professional 
+degree in conventional medicine (MBBS). This person obtained 
+a conventional case history and clinical examination of each 
+participant. The exclusion criteria were (a) person on any med-
+ication or herbal remedy; (b) presence of any illness, particu-
+larly psychiatric or neurological disorders; (c) any auditory 
+deficit; and (d) any attentional impairment. Psychiatric and 
+neurologic disorders were ruled out by a face-to-face interview 
+with the conventionally trained physician. This included ques-
+tions related to participants’ level of awareness and orientation. 
+None of the potential participants were involved in any other 
+ongoing research activity. The baseline characteristics of par-
+ticipants are given in Table 1.
+The study was approved by the ethics committee of the uni-
+versity. The variables to be recorded and the study design were 
+described to the participants and their signed consent to partici-
+pate in the study was obtained.
+Design of the Study
+Despite the fact that participants had prior experience of OM 
+meditation, all participants were given a 3-month orientation 
+program guided by an experienced meditation teacher. The 
+purpose of this orientation was to keep the practice of the 2 dif-
+ferent meditation states, namely, meditative focusing and defo-
+cused meditation, following a uniform method based on 
+specific instructions.
+Each participant was assessed in 4 sessions, to which they 
+were assigned randomly. The sessions were randomized using a 
+standard random number table. Two of them were nonmeditation 
+sessions: (a) nonmeditative focused thinking (ekagrata in 
+Sanskrit) and (b) random thinking (cancalata in Sanskrit). The 
+other 2 sessions were meditation sessions: (a) meditative 
+­
+focusing (dharana in Sanskrit) and (b) defocused meditation or 
+effortless meditation (dhyana in Sanskrit). Each session ­
+consisted 
+of 3 states: before (5 minutes), during (20 minutes), and after 
+(5 ­
+minutes). The study design has been presented schematically 
+Table 1.  Characteristics of the 47 Participants.
+Characteristics
+Mean ± SD or n (%)
+Age, years, mean ± SD
+21.6 ± 3.4
+Years of education
+  17 years and more
+18 (38.3)
+  Up to 15 years
+29 (61.7)
+Type of meditation
+Meditation on the 
+Sanskrit syllable OM
+Experience of meditation 
+practice, months
+47.9 ± 23.7
+  6-24
+27 (57.5)
+  24-48
+12 (25.5)
+  48-60
+8 (17.0)
+Socioeconomic statusa
+  High-income group
+3 (6.4)
+  Mid-income group
+37 (78.7)
+  Low-income group
+7 (14.9)
+aBased on Mukherjee A, Satija D. The Consumption Pattern of the Rising Middle 
+Class in India. New Delhi, India: Indian Council for Research on International 
+Economic Relations; 2012.
+Telles et al	
+3
+in Figure 1. The duration of the epochs as 5 minutes was decided 
+based on our earlier studies.7,13
+Assessment Procedure
+Recording Conditions.  Participants were assessed in 4 sessions, 
+that is, random thinking (cancalata), nonmeditative focused 
+thinking (ekagrata), meditative focusing (dharana), and defo-
+cused meditation (dhyana) while recording (a) HRV and respira-
+tory rate, and simultaneously (b) recording of P300 event-related 
+potentials (ERPs). The HRV, respiration, and P300 ERPs were 
+assessed in before and after the sessions. Participants were asked 
+to avoid substances which influence cognitive performance (par-
+ticularly tea and coffee for the caffeine content) on the day pre-
+ceding and on the day of the recording. Where this was 
+unavoidable the session was taken on another day.
+For assessments participants were seated in a sound atten-
+uated, dimly lit cabin with sound level 26 dB and monitored 
+on a closed-circuit television outside the cabin to detect if 
+they moved or fell asleep during a session. Instructions were 
+given through a 2-way intercom, so that participants could 
+remain undisturbed during a session. The temperature in the 
+recording room was maintained at 24.0°C ± 1.0°C. The aver-
+age humidity was 56% on the days the experiments were 
+conducted. The HRV, respiration, and P300 ERPs were 
+recorded with eyes closed.
+Autonomic variables.  The EKG (electrocardiogram) and 
+respiration were assessed throughout a session that lasted 
+for 30 minutes (though before and after epochs alone were 
+used for analysis) using a 16-channel polygraph system (MP 
+100 BIOPAC, Acknowledge Software, BIOPAC System Inc, 
+Goleta, CA). The EKG was recorded using Ag/AgCl pregelled 
+electrodes (Tyco Healthcare, Ratingen, Germany) and record-
+ing was made with Standard Limb Lead I configuration. Data 
+were acquired at the sampling rate of 1024 Hz and were ana-
+lyzed offline to obtain the HRV, which gives an indication of 
+the balance in the autonomic innervation to the heart.14 The 
+HRV can be modified by complex factors,15 including respira-
+tion. Noise-free data were included for analysis.
+Respiration rate.  Respiration was concurrently monitored in 
+an attempt to remove the contribution of respiration to the HRV, 
+especially lower frequencies (around 0.1 Hz) as the interaction 
+between the HRV and respiration is traditionally known.16 The 
+respiratory rate was recorded using a volumetric pressure trans-
+ducer fixed around the trunk about 8 cm below the lower costal 
+margin as the participants sat erect.
+Figure 1.  Schematic presentation of the study designs of the 4 sessions.
+Note: Sessions were modified for each participant. The heart rate variability (HRV), respiration, and P300 event-related potentials (ERPs) were recorded 
+before and after each intervention. Periods of recording are shown as stippled and periods of intervention are shown as hatched.
+4	
+Clinical EEG and Neuroscience 00(0)
+P300 event-related potentials.  The peak latency and peak 
+amplitude of P300 ERPs were recorded using Nicolet Bravo 
+System (Madison, WI). The P300 component was elicited with 
+a simple discrimination task known as the “oddball” paradigm, 
+in which 2 auditory stimuli were presented in a random series 
+so that one of them occurred infrequently, that is, considered 
+the oddball.17 In our experience, meditation practitioners found 
+auditory stimuli less distracting than visual or somatosensory 
+stimuli.
+(a)	 Electrode positions: The Ag/AgCl disk electrodes were 
+fixed with electrode gel (Ten 20 conductive EEG paste) 
+at the vertex (Cz), with reference electrodes on linked 
+earlobes (A1-A2) and with the ground electrode on the 
+forehead (FPz). Electrode placements were based on 
+the international 10-20 electrode placement system.18 
+The electrode impedance was kept at less than 5 kohm.
+(b)	 Amplifier settings: Standard settings for P300 ERPs 
+recordings were used.19 The EEG activity was ampli-
+fied with a sensitivity of 100 µV. The low-pass filter 
+was kept at 0.01 Hz and the high-pass filter was kept at 
+30 Hz. The P300 ERPs were computer averaged in 300 
+trial sweeps in the 0 to 750 ms range. The prestimulus 
+delay was kept at 75 ms and the level of artifact rejec-
+tion was set at 90%; if any trial had more than 10% of 
+artifacts, the entire trial was rejected.
+(c)	 Stimulus characteristics: Binaural tone stimuli of alter-
+nating polarity delivered at 0.9 Hz (stimulus repetition 
+rate) with a frequency of 1 kHz (50 cycles for the pla-
+teau, 10 cycles for the ramp) for the standard stimuli 
+and 2 kHz (10 cycles for the plateau, 20 cycles for the 
+ramp) for the target stimuli. The binaural tone stimuli 
+were used to trigger online averaging of the EEG.20 The 
+interstimulus interval was 1.1 seconds. The stimulus 
+intensity was set at 70 dB sound pressure level (SPL).
+(d)	 Task: The P300 component was elicited with a simple 
+discrimination task known as the “oddball” paradigm. 
+The oddball task consisted of discrimination between 2 
+tones: the standard tone, a 1000 Hz tone presented 240 
+times (80%), and the target tone, a 2000 Hz tone, pre-
+sented 60 times (20%), in random order.17 These “stan-
+dard” and “target” auditory stimuli were delivered 
+through close-fitting earphones (TDH-39, Amplivox, 
+Eynsham, UK). The participants were asked to distin-
+guish between the 2 tones and mentally count the “tar-
+get” stimuli. The equipment gives the number of target 
+stimuli delivered. Only those sessions in which the par-
+ticipants achieved 95% accuracy in counting target 
+stimuli were included. The participants were able to 
+maintain an accuracy >95% in counting the target 
+stimuli (ie, between 58.5 and 61.5 targets), though par-
+ticipants mentioned the number of counts as a rounded 
+off figure, either 58 or 61. None of the sessions had to 
+be excluded for this reason.
+Interventions
+Random thinking (Cancalata).  Participants were asked to 
+allow their thoughts to wander freely as they listened to a com-
+piled audio CD consisting of brief periods of conversation, 
+announcements, advertisements, and talks on diverse topics 
+recorded from a local radio station transmission. These con-
+versations were not connected and hence it was thought that 
+listening to them could induce a state of random thinking.
+Nonmeditative focused thinking (Ekagrata).  Participants lis-
+tened to a prerecorded lecture on the process of meditating and 
+the object of meditation, that is, the Sanskrit syllable OM. This 
+was intended to induce a state of nonmeditative focusing.
+Meditative focusing (Dharana).  Participants were asked 
+to open their eyes and gaze at the Sanskrit syllable OM as it 
+is written in Sanskrit. During this time, guided instructions 
+required them to direct their thoughts to physical attributes of 
+the syllable, that is, the shape, the size, and the color, and then 
+to close their eyes and continue to visualize the syllable men-
+tally. The main emphasis during meditative focusing was that 
+thoughts are consciously brought back (if they wander) to the 
+single thought of OM.
+Defocused meditation (Dhyana).  During this session partici-
+pants were instructed to keep their eyes closed and dwell on 
+thoughts of OM, without any effort, particularly on the subtle 
+(rather than physical) attributes and connotations of the sylla-
+ble. This would gradually allow the participants to experience 
+brief periods of silence, which they reported after the session.
+Data Extracted
+Heart rate variability and respiration.  Recordings of heart 
+rate variability and respiratory rate were taken for 30 min-
+utes for each participant. The before intervention (5 min-
+utes) and after intervention (5 minutes) data were analyzed 
+separately. Before and after sessions had 1 epoch of 5 min-
+utes. The recorded data were visually inspected off-line and 
+only noise-free data included for analysis. It was determined 
+that there were no abnormal beats such as extra systoles, 
+movement artifact, or any baseline drift, which could cause 
+a shift in the EKG trace and contribute to artifact. The HRV 
+power spectrum was obtained using fast Fourier transform 
+analysis.
+The energy in the HRV series in the following specific fre-
+quency bands was studied, namely, low-frequency (LF) band 
+(0.05-0.15 Hz) and high-frequency (HF) band (0.15-1.50 Hz) 
+and the LF/HF ratio. The LF and HF band values were 
+expressed as normalized units. The following components of 
+time domain HRV were analyzed: (a) average R-R interval (the 
+average of the intervals between adjacent QRS complexes or 
+the instantaneous heart rate), (b) RMSSD (root mean square of 
+the successive differences between R-R interval), (c) NN50 
+(the number of successive NN intervals with differences >50 
+Telles et al	
+5
+Table 2.  Peak Latencies and Peak Amplitudes of P300 Auditory-Evoked Potentials for the 4 Sessions in 2 States (Before and After) From 
+Cz-A1 Wave.a
+Latency (ms)
+Amplitude (µV)
+Waves
+Sessions
+Before
+After
+Cohen’s d
+Before
+After
+Cohen’s d
+P300 (Cz-A1)
+Random thinking
+331.53 ± 34.39
+339.38 ± 32.87
+0.23
+8.99 ± 3.91
+7.71 ± 3.97*
+0.33
+Nonmeditative focused thinking
+335.62 ± 35.18
+338.68 ± 38.11
+0.08
+8.97 ± 4.07
+9.01 ± 3.98
+0.07
+Meditative focusing
+338.55 ± 38.07
+335.23 ± 38.31
+0.09
+8.93 ± 4.24 10.23 ± 3.83*
+0.32
+ 
+Defocused meditation
+337.40 ± 37.27   327.47 ± 39.39*
+0.31
+7.47 ± 4.58
+8.56 ± 3.84*
+0.34
+aValues are given as group means ± SD.
+*P < .05 (repeated-measures analysis of variance with Bonferroni adjustment comparing after values with before values).
+Table 3.  Changes in frequency domain and time domain analysis of the heart rate variability (HRV) components. Values are group means ± SD.
+Sessions
+Variables
+Before
+After
+Cohen’s d
+Random thinking
+LF (n.u.)
+57.55±22.17
+63.16±20.76
+0.62
+HF (n.u.)
+42.45±22.17
+36.84±20.76
+0.62
+LF/HF ratio (ms2)
+4.48±15.88
+3.60±4.08
+0.34
+Average RR (msec)
+818.74±146.60
+802.37±121.74
+0.12
+Average HR (bpm)
+75.91±12.60
+77.27±11.00
+0.11
+RMSSD (ms)
+51.26±36.69
+51.19±34.90
+0.002
+pNN50
+25.34±22.28
+23.20±20.39
+0.10
+Non-meditative focused thinking
+LF (n.u.)
+58.67±21.54
+60.85±21.06
+0.10
+HF (n.u.)
+41.33±21.54
+39.15±21.06
+0.10
+LF/HF ratio (ms2)
+2.42±2.75
+2.18±2.80
+0.48
+Average RR (msec)
+805.82±133.26
+788.54±114.01
+0.14
+Average HR (bpm)
+76.94±12.60
+78.20±10.30
+0.11
+RMSSD (ms)
+49.61±33.67
+49.30±34.65
+0.01
+pNN50
+24.11±21.90
+22.31±19.47
+0.09
+Meditative focusing
+LF (n.u.)
+55.88±22.46
+64.63±20.90*
+0.66
+HF (n.u.)
+44.12±22.46
+35.37±20.90*
+0.56
+LF/HF ratio (ms2)
+2.37±2.64
+3.87±5.67
+0.44
+Average RR (msec)
+781.65±116.35
+814.48±114.72**
+0.28
+Average HR (bpm)
+78.91±11.72
+82.70±10.29**
+0.24
+RMSSD (ms)
+46.31±28.21
+51.52±39.01
+0.15
+pNN50
+21.79±20.72
+23.08±20.72
+0.06
+Defocused Meditation
+LF (n.u.)
+57.11±20.61
+51.91±17.66
+0.66
+HF(n.u.)
+42.89±20.61
+48.09±17.66
+0.57
+LF/HF ratio (ms2)
+2.07±1.80
+1.59±1.65
+0.66
+Average RR (msec)
+770.95±131.26
+796.56±121.98
+0.38
+Average HR (bpm)
+80.44±13.22
+77.50±11.39*
+0.37
+RMSSD (ms)
+46.23±34.68
+51.88±30.61
+0.42
+pNN50
+21.81±20.27
+25.82±21.41
+0.40
+Abbreviations: LF: low frequency band of the HRV; HF: high frequency band of the HRV; LF/HF: ratio of low frequency to high frequency; RR: the average of 
+time intervals between consecutive R-waves; HR: Heart Rate RMSSD: Root Mean Square of the Successive Differences; pNN50: the proportion derived by 
+dividing NN50 by the total number of NN intervals.
+*P < .05, **P < .01, ***P < .001 (repeated-measures analysis of variance, with post hoc analyses comparing and after).
+ms), and (d) pNN50 (proportion derived by dividing NN50 by 
+the total number of NN intervals; where NN50 is the number of 
+interval differences of successive NN intervals >50 ms). Mean 
+respiratory rate was calculated before and after sessions.
+P300 auditory oddball task.  The peak amplitude and the 
+peak latency of the P300 were measured at Cz. The peak 
+amplitude (in μV) was defined as the voltage ­
+difference 
+between baseline at stimulus delivery and the ­
+largest 
+­
+positive-going peak of the ERP waveform within 250 
+to 500 ms latency.17 The peak latency (ms) was defined 
+as the time from stimulus onset to the point of maximum 
+ 
+positive amplitude within the latency window (ie, 250- 
+500 ms).
+6	
+Clinical EEG and Neuroscience 00(0)
+Data Analysis
+Repeated-measures analyses of variance (ANOVA) followed 
+by pairwise post hoc analyses with Bonferroni adjustment were 
+carried out to compare data recorded after the 4 interventions 
+with data recorded before the 4 interventions using SPSS 
+(Version 16.0). There were 2 “within-subjects” factors, that is, 
+factor 1—sessions such as random thinking (cancalata), non-
+meditative focused thinking (ekagrata), meditative focusing 
+(dharana), and defocused meditation (dhyana) and factor 2—
+states, that is, before and after. There were separate repeated-
+measures ANOVAs for HRV components (frequency domain 
+and time domain), respiratory rate, and P300 ERPs (peak 
+latency and peak amplitude).
+For all variables (related to the HRV and P300 ERPs), the 
+post hoc analyses with Bonferroni adjustment for multiple 
+comparisons were carried out between mean values, for before-
+after comparisons.
+Results
+The group mean values ± SD for P300 ERPs (peak amplitude 
+and peak latency) and HRV components (from frequency 
+domain and time domain analyses) are given in Tables 2 and 3, 
+respectively. The summary of repeated-measures ANOVA for 
+HRV and respiration are given in Table 4. Similarly, the sum-
+mary of ANOVA results for peak latency and peak amplitude of 
+P300 ERPs are given in Table 5.
+Post hoc tests for multiple comparisons were performed 
+with Bonferroni adjustment and all comparisons were made 
+between “after” and “before” values for the 4 sessions, that is, 
+random thinking (cancalata), nonmeditative focused thinking 
+(ekagrata), meditative focusing (dharana), and defocused 
+meditation (dhyana). The Bonferroni correction was imple-
+mented by the SPSS software.
+There was a significant increase in LF power (P < .001) and 
+a decrease in HF power (P < .001) after meditative focusing 
+Table 4.  Summary of the Repeated-Measures Analysis of Variance (ANOVA) Showing Statistically Significant Results of Frequency Domain 
+and Time Domain Analysis of the Heart Rate Variability (HRV).
+Variables
+Factor
+F Value
+df
+Huynh-Feldt 
+Epsilon
+Level of 
+Significance
+ηp2
+Breath rate (cpm)
+States
+8.137
+(5, 230)
+0.728
+P < .001
+0.1
+Average heart rate (bpm)
+States
+6.643
+(5, 230)
+0.460
+P < .001
+0.07
+Sessions × States
+3.256
+(15, 690)
+0.568
+P < .001
+0.03
+Low-frequency (LF) power (Hz)
+Sessions
+27.076
+(3, 138)
+0.808
+P < .001
+0.37
+States
+6.980
+(5, 230)
+0.834
+P < .001
+0.13
+Sessions × States
+6.782
+(15, 690)
+0.783
+P < .001
+0.13
+High-frequency (HF) power (Hz)
+Sessions
+27.079
+(3, 138)
+0.808
+P < .001
+0.37
+States
+6.975
+(5, 230)
+0.835
+P < .001
+0.13
+Sessions × States
+6.787
+(15, 690)
+0.784
+P < .001
+0.13
+LF/HF ratio
+States
+4.100
+(5,230)
+0.520
+P < .001
+0.18
+Average RR (ms)
+State
+5.670
+(5, 230)
+0.482
+P < .001
+0.11
+Session × State
+3.827
+(15, 690)
+0.604
+P < .001
+0.08
+RMSSD (ms)
+States
+6.849
+(5, 230)
+0.624
+P < .001
+0.13
+Sessions × States
+1.928
+(15, 690)
+0.638
+P < .05
+0.04
+NN50 count
+States
+3.876
+(5,230)
+0.554
+P < .01
+0.02
+Sessions × States
+2.137
+(15, 690)
+0.564
+P < .01
+0.08
+pNN50 (%)
+States
+4.919
+(5, 230)
+0.527
+P < .001
+0.05
+Sessions × States
+2.782
+(15,690)
+0.561
+P < .01
+0.10
+Table 5.  Summary of the Repeated-Measures Analysis of Variance (ANOVA) Showing Statistically Significant Results of the Peak Latency 
+and Peak Amplitude of P300 Event-Related-Potential (ERP).
+P300 ERP
+Variables
+Factor
+F Value
+df
+Huynh-Feldt 
+Epsilon
+Level of 
+Significance
+ηp2
+Peak latency
+Sessions
+0.52
+3, 138
+0.94
+P > .05
+0.011
+States
+0.18
+1, 46
+1
+P > .05
+0.004
+Sessions × States
+3.10
+3, 138
+1
+P < .05
+0.063
+Peak amplitude
+Sessions
+2.55
+3, 138
+1
+P > .05
+0.053
+States
+1.51
+1, 46
+1
+P > .05
+0.032
+Sessions × States
+2.32
+3, 138
+0.96
+P < .01
+0.048
+Telles et al	
+7
+when compared with before. Similarly, in the time domain anal-
+ysis of the HRV spectrum, after meditative focusing, there was a 
+significant increase in average RR (P < .01) and average HR (P 
+< .01) compared with before. In contrast, after defocused medi-
+tation there was a significant decrease in average HR (P < .01).
+In P300 ERPs, post hoc analyses with Bonferroni adjust-
+ment for each session separately showed (a) a significant 
+increase in amplitude of P300 ERPs after meditative focusing 
+(before vs after; P < .05) and after meditation (before vs after; 
+P < .05), (b) a decrease in P300 peak latency after meditation 
+(P < .05), and (c) a decrease in the P300 peak amplitude after 
+random thinking (before vs after; P < .05). An averaged P300 
+waveform of the 47 subjects showing changes after defocused 
+meditation has been provided in Figure 2.
+Discussion
+Given the known associated between focused attention and 
+SNS activity, it was not surprising that meditative focusing was 
+associated with increased sympathetic activity based on the 
+HRV with changes in the P300 peak amplitude. In contrast, 
+after defocused meditation there was an increase in the P300 
+peak amplitude and a decrease in the P300 peak latency with no 
+increase in sympathetic activity.
+The P300 is an ERP elicited with a target classification that 
+indicates individual capacities for attentional control.17 The 
+P300 peak amplitude gives an approximate idea about the brain 
+activity related to processing incoming information and the 
+neural resources engaged in the task.4 The P300 latency peak 
+reflects the speed of stimulus classification and is generally not 
+related to the overt response and is independent of behavioral 
+reaction time. Since, the P300 peak latency is an index of infor-
+mation processing and stimulus classification, it is used to 
+assess cognitive functions. A shorter P300 peak latency is asso-
+ciated with superior cognitive performance in tasks.21,22
+Based on these interpretations the results of the present 
+study suggest that meditation with focusing and defocused 
+meditation increased attentional resources, while random 
+thinking appeared to reduce them (ie, the decrease in P300 
+peak amplitude after random thinking), whereas stimulus pro-
+cessing speed and efficiency improved with defocused medita-
+tion alone.
+These results resemble those of a study on transcendental 
+meditation (TM) where meditation decreased the P300 peak 
+latency unlike the control condition.20 More recently, the P300 
+peak amplitude increased with a decrease in latency at Cz and 
+Pz after a moving meditation called cyclic meditation (CM) 
+compared with an equal duration of supine rest.23 However, the 
+Figure 2.  Traces of averaged P300 event-related potentials (ERPs) of 47 participants: (a) before defocused meditation and (b) after 
+defocused meditation (with increase averaged P300 peak amplitude and decreased peak latency).
+8	
+Table 6.  A Summarized Comparison of P300 Event-Related Potential (ERP), Heart Rate Variability (HRV), and Combined P300 ERP and HRV Studies.a
+S. No.
+Author (s) and Year
+Participants
+Variables Studied
+Type of Meditation
+Design
+Results
+Conclusion
+P300 ERP in meditation
+1.
+Trautwein et al (2016)44 12 meditators 
+and 12 
+nonmeditators
+P300 event-
+related potential 
+(ERP)
+Loving-kindness 
+meditation (LKM)
+A cross-sectional 
+study
+Larger P300 amplitudes 
+for self-image vs other 
+image
+Prolonged meditation practice may 
+modulate self- vs other-related 
+processing
+2.
+Travis et al (2009)29
+n = 50 college 
+students
+P300 ERP latency
+Transcendental 
+meditation (TM) 
+practice
+Comparative 
+study
+No change in P300 ERP 
+latency
+No changes in habituation rates in 
+immediate-start students
+3.
+Cahn and Polich 
+(2009)45
+n = 15 
+experienced 
+Vipassana 
+meditators
+P300 ERP
+Meditation (Vipassana)
+Single session 
+study
+P3a amplitude from the 
+distracter was reduced 
+during meditation
+↓ Amplitude of neurophysiologic 
+processes that subserve 
+attentional engagement elicited by 
+unexpected and distracting stimuli
+4.
+Sarang and Telles 
+(2006)23
+n = 42 
+volunteers
+P300 ERP
+Yoga-based relaxation and 
+supine rest
+Self as control 
+design
+↑ P300 peak amplitudes 
+after CM at Fz, Cz, and 
+Pz sites
+“Cyclic” meditation enhances 
+cognitive processes underlying the 
+generation of the P300
+HRV in meditation
+1.
+Telles et al (2013)7
+n = 30 yoga 
+practitioners
+HRV
+Effortless meditation 
+(dhyana), meditative 
+focusing (dharana), 
+nonmeditative thinking 
+(ekagrata) and random 
+thinking (cancalata)
+Self as control 
+design (20 min 
+each)
+Frequency domain
+↓LF, ↑ HF, ↓LF/HF, 
+during dhyana
+Time domain
+↑ NN50, ↑pNN50 
+during dhyana
+Maximum changes were seen in 
+autonomic variables and breath 
+rate during the state of dhyana 
+suggest reduced sympathetic 
+activity and/or increased vagal 
+modulation
+2.
+Fiorentini et al 
+(2013)28
+n = 9 Zen 
+practitioners
+HRV
+Zazen meditation
+Single time 
+assessment
+Frequency domain
+↑ LF, ↓ HF, ↓LF/HF
+Repeated training to slow 
+down breathing reduces the 
+spontaneous breathing rate 
+with long term effects on the 
+cardiovascular control mechanisms
+3.
+Vempati and Telles 
+(2002)46
+n = 32 yoga 
+practitioners
+HRV
+Yoga-based relaxation and 
+supine rest
+Self as control 
+design (23 min 
+each)
+Frequency domain
+↓LF, ↑ HF, ↓LF/HF, after 
+yoga relaxation
+Sympathetic activity decreased after 
+guided relaxation based on yoga
+4.
+Travis (2001)47
+n = 30 regular 
+advanced 
+meditators
+HRV
+Transcendental 
+meditation (TM) vs 
+inner experience
+Self as control 
+design (20 min 
+each)
+Frequency domain
+↑ HF amplitude during 
+TM stage compared to 
+inner experience
+Monitoring patterns of physiological 
+variables may index dynamically 
+changing inner experiences during 
+meditation practice
+5.
+Travis and Wallace 
+(1999)48
+n = 20 regular 
+advanced 
+meditators
+HRV
+Transcendental 
+meditation (TM)
+Single session (10 
+min)
+Frequency domain
+↑ HF amplitude
+“Restfully alert” state during 
+meditation
+P300 and HRV simultaneously recorded in meditation
+1.
+Delgado-Pastor et al 
+(2013)8
+n = 10 males, 
+experienced 
+Vipassana 
+meditators
+P300 ERP and 
+HRV
+Vipassana meditation and 
+no meditation (random 
+thinking)
+Self as control 
+design
+↑ P3b amplitudes to 
+the target tone after 
+meditation; larger LF/
+HF ratio increase
+Increased attentional engagement 
+and autonomic regulation after 
+meditation
+aConclusions: (1) P300 ERPs alone showed larger amplitude during meditative practices and reduced amplitude for distractor while meditation. (2) HRV alone showed a significant decrease in low 
+frequency (LF) and LF/HF ratio and increase in high frequency (HF) during meditation suggesting that withdrawal of sympathetic activity and increase vagal modulation. (3) Simultaneous recordings of 
+P300 ERP and HRV showed a higher P3b amplitude during target tone detection and larger LF/HF ratio suggest increased attentional engagement and increase autonomic regulation after meditation.
+Telles et al	
+9
+above cited studies on the P300 in meditation (TM and CM) 
+did not simultaneously record the HRV.
+The HRV is interpreted based on frequency and time domain 
+analysis. In the frequency domain analysis of the HRV, the HF 
+component of the HRV is mainly contributed to by parasympa-
+thetic activity24 the LF component corresponds to both sympa-
+thetic and parasympathetic modulation, and the LF/HF ratio is 
+an indication of sympathovagal balance.25 In time domain mea-
+sures, the average R-R interval, NN50, and pNN50 are recog-
+nized to be dependent on vagal activity.26,27
+In the present study, after meditative focusing there was a sig-
+nificant increase in the LF power and decrease in the HF power 
+whereas after defocused meditation there was no change in LF or 
+HF power. In the time domain analysis, in meditative focusing 
+there was an increase in average R-R and average HR, whereas 
+in defocused meditation there was a decrease in average HR. 
+There were also changes during random thinking with an 
+increase in the LF power and decrease in the HF power of the 
+HRV. These results suggest that in meditative focusing both sym-
+pathetic and parasympathetic activity increase, in defocused 
+meditation parasympathetic activity increases while in random 
+thinking there was increased sympathetic activity.
+The HRV has been studied during different meditation tech-
+niques. Zazen meditation practitioners showed increased LF 
+power, decreased HF power, and decreased LF/HF ratio. This 
+suggests an increase in sympathetic activity and decrease in car-
+diac vagal activity with Zazen meditation.28 In contrast, 2 other 
+separates studies on TM showed higher HF amplitude, which 
+suggests an increase in vagal activity.20,29 Furthermore, a study 
+on defocused meditation (dhyana) reported reduced sympathetic 
+activity and increased vagal modulation during meditation.7
+Generally, attention is associated with increased sympa-
+thetic activity mediated through the locus coeruleus–noradren-
+ergic (LC-NA) system. The LC nucleus lies in the dorsal 
+pontine tegmentum and integrates functions related to arousal 
+and attention30 with noradrenergic-mediated behavior such as 
+stress and anxiety.31 The LC-NA system supplies noradrenalin 
+throughout the central nervous system, which modulates the 
+collection and processing of sensory information within corti-
+cal and subcortical sensory, attention, and memory circuits as 
+well as increases SNS activity.32
+In meditation, a single study recorded P300 with HRV 
+simultaneously, which showed better attention and increased 
+SNS, this resembles the focused meditation. However, in defo-
+cused meditation the attention increased but SNS activity 
+decreased.
+In order to understand this, the results of a previous func-
+tional magnetic resonance imaging (fMRI) report on similar 
+mental states as the present study (ie, defocused meditation, 
+focused meditation, random thinking and nonmeditative focus-
+ing), showed in defocused meditation there was activation in 
+(a) the right inferior frontal gyrus (RIFG), (ii) the right insular 
+cortex (RIC), and (iii) the left-orbital gyrus (LOG).33 Two of 
+them (the RIFG and the RIC) are involved in attention with 
+simultaneous sympathetic activation.34 The inferior frontal 
+gyrus (IFG) is normally associated with elevated cortical 
+activity with an increase in cognitive and attentional control35 
+and partly with psychological traits, which can influence the 
+stress response in rumination.36 This was assessed on a group 
+of 23 high and 22 low ruminators and showed reduced activity 
+in the RIFG. Hence, the increased RIFG activity in defocused 
+meditation suggests a mental state associated not only with 
+lower stress but also with lower attention control.36
+The IC is well recognized for interoception and emotion regu-
+lation, but it is now known to have a considerable role in atten-
+tion, decision making, and other executive functions.36,37,38 In 
+addition to this, the IC is also involved in autonomic regulation, 
+in particular, the RIC plays a critical role in parasympathetic auto-
+nomic modulation since resection of the RIC increased parasym-
+pathetic activity one may presume that IC activation has the 
+opposite effect, that is, decrease parasympathetic activity, which 
+would shift the ANS balance to sympathetic dominance.39 Hence, 
+this cortical area, like the RIFG also increases attention and pos-
+sibly increases SNS activity.
+The third area that showed activation in the fMRI study dur-
+ing defocused meditation compared to random thinking, was 
+the left orbital cortex.33 The left orbital cortex is associated 
+with a detached mental state.40 In defocused meditation, the 
+practitioners may attain such a state of detachment by defocus-
+ing in meditation.2 The orbital gyrus may activate attention 
+without activating the LC-NA system.36,41 Hence this or other 
+mechanisms may explain the findings of increased attention 
+and decreased sympathetic activity in defocused meditation 
+and in other yoga practices such as alternate nostril yoga 
+breathing.42 However, this remains a speculation that needs to 
+be explored further.
+Overall, the difference between the results of Vipassana 
+meditation, meditative focusing (dharana), and defoused med-
+itation (dhyana) is possibly related to the type of meditation. 
+While Vipassana meditation is associated with heightened 
+attention and awareness,8 defocused meditation is devoid of 
+any attempt to focus attention with effort. The summarized 
+table of previous studies on meditation related to P300 ERP 
+(alone), HRV (alone), and P300 ERP and HRV (recorded 
+simultaneously) are given in Table 6.
+Hence, the present study has helped to obtain answers for 
+the research question that was asked, that is, out of the 4 mental 
+states studied, in defocused meditation (dhyana) alone there 
+was a simultaneous improvement in attention along with 
+reduced sympathetic activation characteristic of the classical 
+definition of meditation as a state of alertful rest.43
+While the findings are reasonably straightforward, the study 
+has the following limitations: (a) the participants’ mental state 
+was based on their self-report, there was no way to verify this 
+objectively; (b) carrying out the attention task before and after 
+meditation could possibly reduce the quality of meditation; and 
+(c) all participants were assessed in 4 sessions, hence there may 
+have been an element of adaptation and boredom. Despite these 
+limitations, the present results suggest that defocused medita-
+tion practiced as described in the ancient yoga texts has decided 
+benefits in improving attention without causing physiological 
+arousal.
+10	
+Clinical EEG and Neuroscience 00(0)
+Author Contributions
+ST designed the study, interpreted the results and compiled the man-
+uscript. DS collected and analyzed the data and assisted in compiling 
+the manuscript. KVN assisted in designing the study, interpreting 
+the results and compiling the manuscript. S Pailoor assisted in col-
+lecting, analyzing, and interpreting the data. NS assisted in compil-
+ing the manuscript and proofreading the article. S Pathak assisted in 
+compiling the manuscript. All authors read and approved the final 
+manuscript.
+Declaration of Conflicting Interests
+The author(s) declared no potential conflicts of interest with 
+respect to the research, authorship, and/or publication of this 
+article.
+Funding
+The author(s) disclosed receipt of the following financial support for 
+the research, authorship, and/or publication of this article: The authors 
+gratefully acknowledge the funding from the Indian Council of 
+Medical Research (ICMR), Government of India, as part of a grant for 
+a Center for Advanced Research in Yoga and Neurophysiology (CAR-
+Y&N), (Project No. 2001-05010).
+ORCID iD
+Deepeshwar Singh 
+ https://orcid.org/0000-0002-9867-1405
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diff --git a/subfolder_0/PERFORMANCE ON PSYCHOMOTOR TASKS FOLLOWING TWO YOGA BASED RELAXATION TECHNIQUES.txt b/subfolder_0/PERFORMANCE ON PSYCHOMOTOR TASKS FOLLOWING TWO YOGA BASED RELAXATION TECHNIQUES.txt
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+    
+ 
+ 
+ 
+                          
+P
+PS
+SY
+YC
+CH
+HO
+OL
+LO
+OG
+GI
+IC
+CA
+AL
+L 
+ R
+RE
+EP
+PO
+OR
+RT
+TS
+S 
+  
+  
+  
+  
+  
+  
+  
+  
+  
+  
+  
+  
+  
+ P
+PE
+ER
+RC
+CE
+EP
+PT
+TU
+UA
+AL
+L 
+ A
+AN
+ND
+D 
+ M
+MO
+OT
+TO
+OR
+R 
+ S
+SK
+KI
+IL
+LL
+LS
+S 
+ 
+                                                                                                                                                          
+ 
+ 
+ 
+ 
+       
+ Box 9229    Missoula, Montana   59807 
+ 
+                            www.AmmonsScientific.com                  
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+ 
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+ 
+ 
+ 
+October 13, 2009 
+ 
+Dr. Shirley Telles 
+Patanjali Yogpeeth 
+Maharishi Dayananda Gram 
+New Delhi--Haridwar Highway 
+Bahadrabad, Haridwar 
+Uttarakhand 249402 
+INDIA 
+ 
+ 
+Dear Dr. Telles: 
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+This PDF contains the edited manuscript and a copy of the proof of your paper, “Performance in psychomotor 
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+Perceptual and Motor Skills, 2009, 109, 1-14.  © Perceptual and Motor Skills 2009
+DOI 10.2466/PMS.109.2.
+PERFORMANCE ON PSYCHOMOTOR TASKS FOLLOWING 
+TWO YOGA-BASED RELAXATION TECHNIQUES1, 2
+PAILOOR SUBRAMANYA
+Indian Council of Medical Research, 
+Centre for Advanced Research inYoga and 
+Neurophysiology, SVYASA, Bangalore, India
+SHIRLEY TELLES
+Patanjali Yogpeeth, Haridwar, India
+Summary.—Previously cyclic meditation and supine rest have been shown to 
+improve performance in a letter cancellation task requiring attention, visual scan­
+ning, and motor speed. The present study assessed the performance in 57 volun­
+teers (all male, M age = 26.5 yr., SD = 4.6) in three tasks, viz., a digit-letter substitu­
+tion task (DLST), a letter-copying task, and a circle-dotting task. The DLST assessed 
+attention and speed of information processing, while the other 2 tests assessed mo­
+tor speed. Each participant was assessed before and after three types of sessions: 
+Cyclic Meditation, Supine Rest, and Control (no intervention). DLST scores and 
+scores for letter-copying and circle-dotting tasks improved significantly after cyclic 
+meditation; the same scores also improved after supine rest. There was no change 
+after the no-intervention/Control session. From the results it was difficult to con­
+clude whether improved DLST scores after cyclic meditation were due to better 
+information processing speed or improved motor speed. 
+Meditation is recognized as a specific state of consciousness charac­
+terized by deep relaxation and increased internalized attention (Mura­
+ta, Takahashi, Hamada, Omori, Kosaka, Yoshida, et al., 2004). Meditators 
+with lower scores on trait anxiety were reported to more readily expe­
+rience meditation with a predominance of internalized attention, while 
+those with higher scores on trait anxiety more readily experienced medi­
+tation with a predominance of relaxation. In another study on Zen medi­
+tation, the frontal midline theta rhythm (Fm theta), electroencephalogram, 
+and heart rate variability were recorded simultaneously (Kubota, Sato, 
+Toichi, Murai, Okada, Hayashi, et al., 2001). The Fm theta reflects men­
+tal concentration as well as a meditative state or relief from anxiety. Both 
+sympathetic and parasympathetic indices were increased during the ap­
+pearance of Fm theta compared with control periods. Hence, meditation 
+appears to bring about a relaxed state with heightened internalized atten­
+tion and concentration. 
+1Address correspondence to Shirley Telles, Ph.D., Patanjali Yogpeeth, Maharishi Dayanand 
+Gram, Bahadrabad, Haridwar, 249402, Uttarakhand, India or e-mail (shirleytelles@gmail.
+com).
+2The authors gratefully acknowledge H. R. Nagendra, Ph.D., who derived the cyclic medi­
+tation technique from ancient yoga texts. The funding from the Indian Council of Medical 
+Research (ICMR), Government of India, as part of a grant (Project No. 2001-05010) toward 
+the Centre for Advanced Research in Yoga and Neurophysiology (CAR-Y&N) is also grate­
+fully acknowledged. 
+P. SUBRAMANYA & S. TELLES
+2
+Meditation has also been shown to modify the attention to external 
+stimuli and events. For example, the mismatch negativity (MMN), which 
+is an indicator of preattentive processing, was used to study the effects of 
+a concentrative meditation, Sahaj Samadhi meditation (Srinivasan & Baijal, 
+2007). Meditators had larger auditory MMN amplitudes than nonmedita­
+tors, suggesting that concentrative meditation enhances preattentive per­
+ceptual processes, with improved detection in auditory sensory memory. 
+Many studies on the effects of meditation on attention have focused 
+on concentration meditation, which is distinct from concentrative medita­
+tion, mentioned above. In this meditation, concentration is sustained on 
+a small object or the breath and the meditator is not diverted by distrac­
+tors (Mipham, 2000). Practice of concentration meditation was shown to 
+improve specific aspects of attention (Jha, Klein, Krompinger, & Baime, 
+2007). In this study, a group naïve to the meditation underwent 8 wk. of 
+intensive training and was compared to experienced meditators taking 
+part in a 1-mo. intensive retreat and to a meditation-naïve control group. 
+Three functionally and neuroanatomically distinct but overlapping atten­
+tional subsystems were studied. These were: alerting, orienting, and con­
+flict monitoring. At one assessment, the participants in the retreat showed 
+better conflict monitoring than the other groups. At another assessment 
+the meditators undergoing intensive training showed improved orient­
+ing relative to other groups, while participants in the retreat showed al­
+tered performance on the alerting component. This suggested that the 
+8-wk. intensive course improved the ability to endogenously orient at­
+tention, whereas those who took part in the retreat developed receptive 
+attentional skills associated with an improved exogenous alerting pro­
+cess. Concentration meditation also decreased attentional blink (Slagter, 
+Lutz, Greischar, Francis, Nieuwenhuis, Davis, et al., 2007), while changes 
+in the electroencephalogram and cortical thickness were found in long-
+term practitioners of compassion meditation (Lutz, Greischar, Rawlings, 
+Ricard, & Davidson, 2004) and of insight meditation (Lazar, Kerr, Was­
+serman, Gray, Greve, Treadway, et al., 2005). A functional magnetic reso­
+nance study showed that expert meditators (with an average of 19,000 hr. 
+of practice) had more activation than novices while focusing on a simple 
+visual stimulus, while expert meditators with over 44,000 hr. had less ac­
+tivation (Brefczynski-Lewis, Lutz, Schaefer, Levinson, & Davidson, 2007). 
+Also, in response to distractor sounds, expert meditators had less acti­
+vation in brain regions related to discursive thoughts and emotions, and 
+more activation in regions related to response inhibition and attention. 
+These findings suggested that the hours of practice influence mental pro­
+cesses related to attending to or ignoring specific stimuli. These findings 
+may also explain certain changes in advanced practitioners of Transcen­
+dental Meditation,™ described below.
+PSYCHOMOTOR TASKS AND YOGA
+3
+The effects of transcendent experiences described as occurring during 
+the practice of Transcendental Meditation™ were studied on the contin­
+gent negative variation amplitude, rebound, and distraction effects (Tra­
+vis, Tecce, Arenander, & Wallace, 2002). The contingent negative variation 
+is an event-related potential occurring between a warning stimulus and 
+an imperative stimulus requiring a response (Walter, Cooper, Aldridge, 
+McCallum, & Winter, 1964). Late contingent negative variation ampli­
+tudes were largest in meditators who had transcendent experiences every 
+day. Since late contingent negative variation reflects proactive preparatory 
+processes including mobilization of motor, perceptual, cognitive, and at­
+tentional resources, the results suggest that transcendent experiences are 
+related to cortical responses and executive functioning. 
+Another meditation technique called cyclic meditation was shown to 
+reduce the P300 peak latency and increase the P300 peak amplitude (Sa­
+rang & Telles, 2006a). The P300 component of event-related brain poten­
+tials (ERPs) is generated when persons attend to and discriminate stimuli 
+which differ in a single aspect. The P300 reflects fundamental cognitive 
+events requiring attentional and immediate memory processes (Polich, 
+1999). The results suggested that cyclic meditation enhanced these cogni­
+tive processes. Cyclic meditation practice also improved the performance 
+in a letter-cancellation task which requires selective attention, concentra­
+tion, visual scanning abilities, and a repetitive motor response (Sarang & 
+Telles, 2007). 
+The performance in a cancellation task hence requires certain mental 
+processes related to attention, as well as motor speed, during a repetitive 
+motor activity. Previously, a yoga program which included cyclic med­
+itation and supine rest increased motor speed in a standard finger-tap­
+ping task (Dash & Telles, 1999). This increase in tapping speed was seen 
+in children after a 10-day program and in adults after a 1-mo. program. 
+Hence, it was not possible to state whether the improved performance in 
+the cancellation task was due to improved attention or increased motor 
+speed. For this reason, the present study was designed to assess whether 
+cyclic meditation and supine rest would influence performance in: (i) a 
+task which requires attention and assesses speed of information process­
+ing, as well as motor speed, and (ii) tasks for motor speed alone. The task 
+which was used to assess attention, speed of information processing, and 
+motor speed was a digit-letter substitution task (DLST). Two tests were 
+used to assess motor speed. The first was a letter-copying task in which 
+the participants had to copy a specified letter in the space provided. The 
+number of spaces was the same as for the DLST. The other test for motor 
+speed required participants to make dots within the circumference of two 
+circles, as quickly as possible. 
+P. SUBRAMANYA & S. TELLES
+4
+The performance in these three tasks was assessed before and after 
+cyclic meditation, or supine rest, and this was compared to recordings be­
+fore and after an equal duration of no intervention (or control period). The 
+aim was to assess whether changes in motor speed (if any) influenced the 
+performance on the DLST. 
+Method
+Participants
+Fifty-seven male participants ages 18 to 40 years (M age = 26.5 yr., 
+SD = 4.6) participated in the study. All of them were in normal health 
+based on a routine clinical examination (Swash, 2001). Also, they were all 
+literate and could understand and undertake the tests. Participants were 
+staying at a residential yoga center located in southern India. Their expe­
+rience of the practice of cyclic meditation and relaxation while supine (su­
+pine rest) ranged between 6 and 54 mo. (M = 24.4, SD = 13.7). None of them 
+used tobacco, intoxicants, or consumed caffeinated beverages. They were 
+all right-hand dominant based on the Edinburgh Handedness Inventory 
+(Oldfield, 1971). The study had been explained to them. Their participa­
+tion in the study was voluntary. They were not specifically told about pre­
+vious studies on cyclic meditation and supine rest. However, they may 
+have known about them and this may have influenced the outcome of the 
+trial, which is a limiting factor of the study. They were not told the specific 
+hypothesis of the study or the purpose for each of the three tasks. The ap­
+proval of the Institutional Ethics Committee was obtained and the partici­
+pants’ signed informed consent was taken. 
+Measures
+Digit-letter substitution task.—The digit-letter substitution task consist­
+ed of a worksheet on which digits (1 to 9) were arranged randomly in 12 
+rows and eight columns (Natu & Agarwal, 1997). An instruction key for 
+“letter-for-digit” substitutions was shown at the top. Participants were re­
+quired to make as many letter-for-digit substitutions as possible in 90 sec. 
+They were told that there were two possible strategies, i.e., marking all 
+nine digits in the random order they occurred, or selecting any one digit 
+at a time. They were to choose whichever strategy suited them. They were 
+also told that they could follow a horizontal, vertical, or random path ac­
+cording to their choice. The total number of substitutions was counted 
+and each substitution scored as 1. Where the wrong letter was substituted, 
+these errors were counted (also as 1 each). The total numbers of substitu­
+tions and error substitutions were scored as described and the net scores 
+were calculated by deducting errors (wrong substitutions) from the total 
+substitutions attempted. 
+PSYCHOMOTOR TASKS AND YOGA
+5
+As this test was administered at the beginning and at the end of the 
+interventions, which required 22.5 min., to avoid any retest effect paral­
+lel worksheets were prepared by changing the digit-letter pairs in the key 
+and by randomly changing the sequence of digits in the working section 
+(Agarwal, Kalra, Natu, Dadhich, & Deswal, 2002). Hence, half the par­
+ticipants (n = 29) received worksheet A before a session, while the other 
+half (n = 28) received worksheet B before the session. Those who received 
+worksheet A before the session received worksheet B after the session. 
+This was reversed for the remaining participants. Similarly, there were dif­
+ferent worksheets for the remaining sessions. The digit-letter substitution 
+task has been used in a similar design in an Indian population, which in­
+dicated the validity of the task to study immediate effects (Natu & Agar­
+wal, 1997). 
+Letter-copying task.—The letter-copying task measured the psychomo­
+tor and motor speed components of the digit-letter substitution task as has 
+been described elsewhere (Morrens, Hulstijn, & Sabbe, 2008). Participants 
+were given the same worksheets as for the DLST; however, in this task, 
+participants did not have to attempt to substitute digits for letters based 
+on the key provided. Instead, they were asked to fill in all the boxes pro­
+vided with a single letter using their dominant hand. This was the first let­
+ter mentioned in the digit-letter substitution key. They were given 90 sec. 
+to do this. This task was completed by all 57 participants. The total num­
+ber of letters filled in was the score.
+Circle-dotting task.—In the circle-dotting task, the targets were two circles 
+drawn on paper, 6 cm in diameter with 24.5 cm between their centers. In 
+this paper-and-pencil task, participants were asked to make a dot within 
+the circumference of both circles alternately, using their dominant hand, 
+as rapidly as possible. This task is based on a standard “circle-dotting 
+task” for motor speed (Lezak, 1995). They were given 90 sec. to complete 
+the task. Only those dots which were actually within the circumference 
+of either circle were counted. Those which were on the circumference 
+were not counted. Separate scores (where one correctly placed dot was 
+scored as 1) were noted for the circle on the left and the circle on the 
+right. 
+For all tasks, the task sheets were scored by a person who was un­
+aware whether the participant was in a Cyclic Meditation or Supine Rest 
+session and whether the assessment was made at the beginning or at the 
+end of a session.
+Procedure 
+The fifty-seven participants were assessed in three types of sessions, 
+namely, (i) Cyclic Meditation, (ii) Supine Rest, and (iii) Control. The partic­
+P. SUBRAMANYA & S. TELLES
+6
+ipants were first assessed in Cyclic Meditation and Supine Rest sessions. 
+There were two schedules, (a) Cyclic Meditation on Day 1, and Supine 
+Rest on the next day (the CM/SR schedule), and (b) Supine Rest on Day 
+1 and Cyclic Meditation the next day (the SR/CM schedule). Participants 
+were randomly allocated to either schedule, to balance effects of order 
+of sessions. In addition, all participants were assessed before and after a 
+no-intervention Control session. Each session was 22:30 min. in duration. 
+Assessments were made immediately at the beginning and end of each 
+session. Separate sessions were conducted for each of the assessments. 
+Twenty-nine out of 57 participants were assigned to Schedule 1 (CM/SR) 
+and the remaining 28 participants were assigned to Schedule 2 (SR/CM). 
+Since there were three assessments, each participant was assessed in three 
+Cyclic Meditation sessions, in three Supine Rest sessions, and in three 
+Control sessions. There were no differences in results based on the order 
+of the sessions, when the “after” values were compared (p > .05, t test for 
+unpaired data). 
+Meditation Sessions
+Cyclic meditation.—During the Cyclic Meditation sessions, partici­
+pants kept their eyes closed and followed prerecorded instructions. The 
+instructions emphasized carrying out the practice slowly, with awareness 
+and relaxation. The practice began by repeating a verse (0:40 min.) from 
+the yoga text, the Mandukya Upanishad (Chinmayananda, 1984); followed 
+by isometric contraction of the muscles of the body ending with supine 
+rest (1:00 min.); slowly coming up from the supine position and standing 
+at ease (called tadasana) and “balancing” the weight on both feet, called 
+centering (2:00 min.); then the first actual posture, bending to the right (ar­
+dhakaticakrasana, 1:20 min.); 1:10 min. in tadasana for instructions about re­
+laxation and awareness; bending to the left (ardhakaticakrasana, 1:20 min.); 
+1:10 min. in tadasana as before; forward bending (padahastasana, 1:20 min.); 
+another 1:10 min. in tadasana; backward bending (ardhacakrasana, 1:20 
+min.); and slowly coming down in the supine posture with instructions 
+to relax different parts of the body in sequence (10:00 min.). The postures 
+were practiced slowly, with awareness of all the sensations felt. The total 
+duration of the practice was 22:30 min. (Telles, Reddy, & Nagendra, 2000). 
+Supine rest.—Supine rest was practiced as traditional shavasana (the 
+corpse posture), which meant lying flat on the ground with the legs apart, 
+arms away from the sides of the body, with the palms facing upwards, 
+while the eyes were closed (Muktibodhananda, 2004). This practice lasted 
+22:30 min., so that the duration was the same as for Cyclic Meditation ses­
+sions.
+Control.—During this session, the participants were seated and their 
+thoughts wandered at random. They were not given any other specific in­
+AUTHOR: Is this correct?
+PSYCHOMOTOR TASKS AND YOGA
+7
+structions, except for the fact that they were told that they were to avoid 
+meditating. This practice lasted for 22:30 min. The session was also at the 
+same time of the day as the Cyclic Meditation and Supine Rest sessions.
+Data Analysis
+Statistical analysis was done using SPSS (Version 10.0). Data of the to­
+tal substitutions, errors and net scores of DLST, total scores on the letter-
+copying task, and total scores on the circle-dotting task were analyzed us­
+ing the repeated-measures analyses of variance (ANOVAs). There were 
+two within-subjects factors, i.e., Time (pre-, postsession) and Session (Cy­
+clic Meditation, Supine Rest, Control). Post hoc tests with Bonferroni ad­
+justment were used to detect significant differences between mean values. 
+The percentage changes for each of the three tasks (i.e., digit-letter 
+substitution task, letter-copying task, and circle-dotting task) were cal­
+culated separately for Cyclic Meditation, Supine Rest, and Control ses­
+sions. The percentage change was calculated as [(after scores/before 
+scores × 100) – 100]. Pearson correlation coefficient test was used to assess 
+whether these percentage changes had any correlation with the length of 
+experience practicing yoga (expressed in months).
+Results
+The group means and standard deviations for scores obtained in the 
+digit-letter substitution task, letter-copying task, and circle-dotting task 
+taken before and after Cyclic Meditation, Supine Rest, and Control ses­
+sions are shown in Table 1.
+Digit-letter Substitution Task
+The repeated-measures analyses of variance (ANOVAs) showed 
+a significant difference between the three types of session for total 
+scores (F1.453,81.384 = 8.95, p < .001, Huynh-Feldt epsilon = 0.73; η2 = 0.33), er­
+rors or wrong substitutions (F1.534,85.905 = 0.70, p < .004, Huynh-Feldt epsi­
+lon = 0.77; η2 =0.07), and net scores (F1.391,77.895 = 10.26, p < .001, Huynh-Feldt 
+epsilon = 0.70; η2 = 0.36). There was a significant effect of Time for total 
+scores (F1,56 = 119.32, p < .001, Huynh-Feldt epsilon = 1.00; η2 =0.10) and net 
+scores (F1,56 = 115.83, p < .001, Huynh-Feldt epsilon = 1.00; η2 =0.11). There 
+was a significant interaction between Sessions and Time for total scores 
+(F1.822,102.042 = 66.67, p < .001, Huynh-Feldt epsilon = 0.88; η2 = 0.41 ) and net 
+scores (F1.828,102.356 = 73.84, p < .001, Huynh-Feldt epsilon = 0.91; η2 =0.43), sug­
+gesting the two factors were not independent.
+Post hoc tests for multiple comparisons were performed with Bon­
+ferroni adjustment and all comparisons were made with the respective 
+before states. After Cyclic Meditation sessions there was a significant in­
+crease in total scores (p < .001) and net scores (p < .001), compared to pre-
+session. Also, the scores after Cyclic Meditation sessions were significant­
+P. SUBRAMANYA & S. TELLES
+8
+ly different from scores after both Supine Rest and Control sessions for 
+total scores (p < .001), errors or wrong substitutions (Cyclic Meditation vs 
+Supine Rest, p < .021; Cyclic Meditation vs Control, p < .002; Supine Rest vs 
+Control, p < .001) and net scores (p < .001). 
+Letter-copying Task
+The repeated-measures ANOVAs showed a significant effect of Ses­
+sion for total scores (F1.185,66358 = 15.05, p < .001, Huynh-Feldt epsilon = 0.58; 
+η2 = 0.21). There was a significant effect of Time for total scores (F1,56 = 127.19, 
+p < .001, Huynh-Feldt epsilon = 1.00; η2 = 0.69). There was a significant in­
+teraction between Sessions and Time for total scores (F1.217,68.158 = 88.54, 
+p < .001, Huynh-Feldt epsilon = 0.60; η2 = 0.61), suggesting the two factors 
+were not independent.
+Post hoc tests for multiple comparisons were performed with Bonfer­
+roni adjustment and all comparisons were made with the respective be­
+fore states. There were significant increases in total scores of the letter-
+copying task following Cyclic Meditation sessions (p < .001), Supine Rest 
+sessions (p < .001), and Control sessions (p < .002) compared to the respec­
+TABLE 1
+Scores Obtained in Digit-letter Substitution Task, a Letter-copying 
+Task, and Circle-dotting Task Before and After Cyclic Meditation, 
+Supine Rest, and Control Sessions (N = 57)
+Task
+Variables and state
+Session
+Cyclic Meditation
+Supine Rest
+Control
+M
+SD
+M
+SD
+M
+SD
+Digit-letter 
+Substitution 
+Total Substitutions
+ Pre
+51.79
+9.21
+51.68
+11.16
+51.86
+9.42
+ Post 
+62.60*†
+9.88
+53.33
+10.34
+53.26
+8.59
+Errors
+ Pre
+0.18
+0.43
+0.35
+0.74
+0.30
+0.57
+ Post 
+0.11†
+0.36
+0.53
+1.14
+0.53
+0.89
+Net Substitutions
+ Pre
+51.61
+9.19
+51.33
+10.88
+51.56
+9.36
+ Post 
+62.49*†
+9.85
+52.81
+9.95
+52.74
+8.62
+Letter-
+copying 
+Total Attempted
+ Pre 
+86.93
+13.41
+86.42
+12.67
+85.32
+10.95
+ Post 
+98.44*†
+13.24
+90.16*
+10.94
+86.82
+9.36
+Circle-
+dotting 
+Left Circle
+ Pre
+71.75
+12.85
+69.86
+13.87
+70.98
+11.57
+ Post 
+86.07*†
+11.70
+72.68*
+12.90
+72.33
+9.62
+Right Circle
+ Pre
+72.53
+12.73
+69.23
+13.92
+71.65
+11.80
+ Post 
+86.61*†
+11.94
+72.12*
+13.00
+72.44
+9.48
+*p < .001, RM ANOVA, with Bonferroni adjustment, before compared with after respective 
+session. †p < .001, RM ANOVA, with Bonferroni adjustment, scores after Cyclic Meditation 
+compared with Supine Rest and Control sessions.
+PSYCHOMOTOR TASKS AND YOGA
+9
+tive pre-session values. Also, after Cyclic Meditation sessions, the scores 
+were significantly different from the scores after both Supine Rest and 
+Control sessions (p < .001 for both comparisons). 
+Circle-dotting Task
+The circle-dotting task showed a significant effect of Session for both 
+left-circle scores (F1.526,85.437 = 23.42, p < .001, Huynh-Feldt epsilon = 0.75; η2 = 
+0.30) and right-circle scores (F1.565,87.66 = 28.06, p < .001, Huynh-Feldt epsi­
+lon = 0.78; η2 = 0.33). Similarly, there was a significant effect of Time for left-
+circle scores (F1,56 = 106.69, p < .001, Huynh-Feldt epsilon = 1.00; η2 = 0.66) 
+and right-circle scores (F1,56 = 104.15, p < .001, Huynh-Feldt epsilon = 1.00; 
+η2 = 0.65). Also, there was a significant interaction between Sessions and 
+Time for left-circle scores (F1.808,101.248 = 66.63, p < .001, Huynh-Feldt epsilon 
+= 0.88; η2 = 0.54) and right-circle scores (F1.838,102.911 = 77.21, p < .001, Huynh-
+Feldt epsilon = 0.92; η2 = 0.58), suggesting the two factors were not inde­
+pendent.
+Post hoc tests for multiple comparisons were performed with Bonfer­
+roni adjustment and all comparisons were made with the respective be­
+fore states. After Cyclic Meditation and Supine Rest sessions, there were 
+significant increases in left-circle scores (p < .001) and right-circle scores 
+(p < .001). Also, scores after Cyclic Meditation sessions were significantly 
+different from scores after both Supine Rest and Control sessions for left-
+circle scores (p < .001) and right-circle scores (p < .001).
+Pearson Correlations Among Scores
+Pearson correlation coefficients were calculated between the percent­
+age changes in scores on the three tasks and months of yoga practice. There 
+was a significant positive correlation between the percentage change in 
+net scores on the digit-letter substitution task after Cyclic Meditation with 
+months of yoga practice (r = .30, p < .05, N = 57).
+Discussion
+Participants showed better performance in a digit-letter substitution 
+task, as well as in tasks for motor speed, following a session of cyclic med­
+itation. Following a period of supine rest for an equal duration there was 
+improved performance in tasks for motor speed, but not in the digit-letter 
+substitution task. There were no significant changes in the control group, 
+suggesting no retest effect.
+The digit-letter substitution task measures psychomotor performance 
+(Gerrard, Wheeldon, & McDevitt, 1995). This task is based on earlier de­
+veloped substitution tests (e.g., the Digit Symbol Substitution Test) but 
+uses overlearned signs (i.e., letters) instead of the symbols used in other 
+substitution tasks (van der Elst, van Boxtel, van Breukelen, & Jolles, 2006). 
+The task assesses attention, speed of perception and processing, as well 
+P. SUBRAMANYA & S. TELLES
+10
+as a repetitive motor response requiring motor speed (Orlowiejska-Gil­
+lert, Pajak, Szczudlik, Kawalec, & Pomykalska, 1998; de Groot, Hornstra, 
+Roozendaal, & Jolles, 2003). The results suggest that the Cyclic Meditation 
+sessions enhanced overall performance, i.e., the total scores, but also re­
+sulted in lower numbers of wrong attempts or errors (based on net scores) 
+compared to the Supine Rest sessions. However, before Cyclic Meditation 
+sessions, the mean score on wrong attempts was lower than before Supine 
+Rest or the Control sessions, though neither difference was statistically 
+significant. 
+The improved scores in the letter-copying task and the circle-dotting 
+task following Cyclic Meditation sessions show that speed for repetitive 
+motor activity was also better after Cyclic Meditation. This may have con­
+tributed to the better performance in the DLST after Cyclic Meditation 
+sessions, especially since the magnitude of change in the three tasks was 
+comparable. The percentage change in the mean score on the DLST after 
+Cyclic Meditation sessions was 21.0, while in the letter-copying and circle-
+dotting tasks percentage changes were 14.0 and 19.0, respectively. 
+Cyclic meditation is so named because it consists of alternating cy­
+cles of yoga postures interspersed with periods of supine relaxation (Na­
+gendra & Nagarathna, 1997). This “moving meditation” was devised by 
+Nagendra based on a description from ancient yoga texts (Chinmayanan­
+da, 1984). The practice has been shown to be followed by a period of re­
+duced physiological arousal based on a decrease in oxygen consumption 
+and minute ventilation (Telles, et al., 2000; Sarang & Telles, 2006c), changes 
+in the heart rate variability (Sarang & Telles, 2006b), and increased slow 
+wave sleep during the night following daytime practice of cyclic medi­
+tation (Patra & Telles, 2009). However, these changes occurred simulta­
+neously with a decreased latency and increased amplitude in the P300 
+(Sarang & Telles, 2006a) as well as improved performance in a letter-can­
+cellation task (Sarang & Telles, 2007). The P300 reflects the ability to sus­
+tain and shift attention while discriminating between stimuli which dif­
+fer in a single aspect, e.g., frequency of tones (Polich, 1999). The P300 also 
+indicates cognitive events requiring attentional and immediate memory 
+processes. Similarly, letter-cancellation tasks also require sustained atten­
+tion, as well as visual scanning and activation and inhibition of rapid re­
+sponses along with motor speed. These results taken together suggest that 
+cyclic meditation induces a state of reduced physiological arousal with 
+improved performance in tasks requiring attention. 
+Several meditation techniques have been shown to reduce anxiety 
+and feelings of tension (Kozasa, Santos, Rueda, Benedito-Silva, & De Or­
+nellas, 2008). In many cases, a reduction in anxiety is associated with bet­
+ter performance. For, example, persons with high trait anxiety took longer 
+PSYCHOMOTOR TASKS AND YOGA
+11
+to color name threatening words, compared to neutral words, when as­
+sessed on a modified Stroop color naming paradigm (Fox, 1993). Partici­
+pants with high trait anxiety were also distracted by separate color words 
+which produced no interference for those with low trait anxiety. The re­
+sults suggested that high trait anxiety is associated with a general inabili­
+ty to maintain attentional focus, not specific for threatening stimuli. While 
+anxiety was not measured in the present study, one may speculate that a 
+reduction of anxiety could have contributed to better performance.
+In a previous study, following both cyclic meditation and supine rest, 
+participants performed better in a letter-cancellation task (Sarang & Telles, 
+2007). In the present study, on a different group of cyclic meditation prac­
+titioners, performance in a digit-letter substitution task improved after cy­
+clic meditation but not after supine rest. This may be related to the fact that 
+the two psychomotor tasks (i.e., the letter-cancellation task and the digit-
+letter substitution task) assess comparable, yet different cognitive abilities. 
+The letter-cancellation task assesses the ability to sustain and shift atten­
+tion, immediate memory, visual scanning, and motor speed for repetitive 
+motor activity. The digit-letter substitution task also requires the ability to 
+sustain and shift attention, immediate memory (of the digit-letter combi­
+nation), and the task tests speed of information processing, as well as the 
+ability to process information and shift the attentional focus between dig­
+its and letters. It is difficult to say whether the improved performance in 
+the letter-cancellation task following both cyclic meditation and supine 
+rest in an earlier study (Sarang & Telles, 2007), and the improved perfor­
+mance in the digit-letter substitution task after cyclic meditation alone in 
+the present study, was due to differences in the abilities assessed by the 
+tasks or the fact that the yoga practitioners in the two studies were differ­
+ent. 
+In the present study, after both cyclic meditation and supine rest, the 
+performance in the tasks for motor speed in a repetitive motor task was 
+improved. The circle-dotting task studied also evaluates spatial intelli­
+gence and manual speed (de Andrés, Sánchez, Hidalgo, & Díaz, 2004). 
+The letter-copying task was used as a measure of motor speed, which al­
+lowed the repetitive motor activity component of the digit-letter substitu­
+tion task to be assessed separately as has been described elsewhere (Mor­
+rens, et al., 2008). The ability to carry out a repeated motor activity was 
+better after cyclic meditation and supine rest, with a greater magnitude of 
+improvement after cyclic meditation. This may be related to previous re­
+ports of better motor coordination and better performance in motor tasks 
+after yoga practice which included relaxation (Madan, Thombre, Bharathi, 
+Nambinarayan, Thakur, Krishnamurthy, et al., 1992; Telles, Hanuman­
+thaiah, Nagarathna, & Nagendra, 1993). 
+P. SUBRAMANYA & S. TELLES
+12
+Improved repetitive motor activity and motor speed may have con­
+tributed to the better performance in the digit-letter substitution task. The 
+improvement in the mean scores on the three tasks following Cyclic Med­
+itation sessions ranged from 14.0 to 21.0%. In contrast, there was no im­
+provement in mean DLST scores after Supine Rest, but the improvement 
+in the letter-copying task was 4.3% and the improvement in the circle-
+dotting task was 4.1%. Hence, an improvement in motor speed may have 
+contributed to the better performance on the DLST after Cyclic Medita­
+tion sessions. This is to some extent not supported by the improvement 
+in P300 after Cyclic Meditation sessions, as the P300 latency is an index of 
+stimulus processing rather than response generation and is used as a mo­
+tor-free measure of cognitive function. Improved motor speed in a repeti­
+tive motor activity task following yoga has been considered to be related 
+to better motor coordination (Telles, et al., 1993) either associated with, or 
+independent of, improved muscular efficiency following yoga (Madan, et 
+al., 1992). 
+Given the fact that yoga practice has effects on attention and mo­
+tor speed, the present findings show that it is difficult to assess the exact 
+contribution of improvement in either ability following yoga, if a task re­
+quires both abilities. Hence, in future research it would be best to use tasks 
+which selectively measure a specific function. 
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+digit substitution test: normative data for 1,858 healthy participants aged 24-81 
+from the Maastricht Aging Study (MAAS): influence of age, education, and sex. 
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+Accepted September 23, 2009.
+PERFORMANCE ON PSYCHOMOTOR TASKS FOLLOWING TWO 
+YOGA-BASED RELAXATION TECHNIQUES12 
+PAILOOR SUBRAMANYA1 AND SHIRLEY TELLES2* 
+1Indian Council of Medical Research, Center for Advanced Research in 
+Yoga and Neurophysiology, SVYASA, Bangalore, India 
+2
+Meditation is recognized as a specific state of consciousness characterized by deep 
+relaxation and increased internalized attention (Murata, Takahashi, Hamada, Omori, Kosaka, 
+Yoshida, et al., 2004). Meditators with lower scores on trait anxiety were reported to more 
+Patanjali Yogpeeth, Haridwar, India 
+Summary.—Previously cyclic meditation and supine rest have been shown to improve 
+performance in a letter cancellation task requiring attention, visual scanning, and motor 
+speed. The present study assessed the performance in 57 volunteers (all male, M age = 26.5 
+yr., SD = 4.6) in three tasks, viz., a digit-letter substitution task (DLST), a letter-copying task, 
+and a circle-dotting task. The DLST assessed attention and speed of information processing, 
+while the other 2 tests assessed motor speed. Each participant was assessed before and after 
+three types of sessions: cyclic meditation, supine rest, and no-intervention/control. DLST 
+scores and scores for letter-copying and circle-dotting tasks improved significantly after 
+cyclic meditation; the same scores also improved after supine rest. There was no change after 
+the no-intervention/control session. From the results it was difficult to conclude whether 
+improved DLST scores after cyclic meditation were due to better information processing 
+speed or improved motor speed.  
+                                        
+         
+1 Address correspondence to Shirley Telles, Ph.D., Patanjali Yogpeeth, Maharishi Dayanand Gram, Bahadrabad, 
+Haridwar, 249402, Uttarakhand, India, Telephone: +91-1334-240008, Fax: +91-1334-244805, or e-mail 
+(shirleytelles@gmail.com). 
+2The authors gratefully acknowledge H. R. Nagendra, Ph.D. who derived the cyclic meditation technique from 
+ancient yoga texts. The funding from the Indian Council of Medical Research (ICMR), Government of India, as 
+part of a grant (Project No. 2001-05010) towards the Centre for Advanced Research in Yoga and 
+Neurophysiology (CAR-Y&N) is also gratefully acknowledged.  
+ 
+ 
+1 
+readily experience meditation with a predominance of internalized attention, while those with 
+higher scores on trait anxiety more readily experienced meditation with a predominance of 
+relaxation. In another study on Zen meditation, the frontal midline theta rhythm (Fm theta), 
+electro-encephalogram and heart rate variability were recorded simultaneously (Kubota, Sato, 
+Toichi, Murai, Okada, Hayashi, et al., 2001). The Fm theta reflects mental concentration as 
+well as a meditative state or relief from anxiety. Both sympathetic and parasympathetic 
+indices were increased during the appearance of Fm theta compared with control periods. 
+Hence, meditation appears to bring about a relaxed state with heightened internalized 
+attention and concentration.  
+Meditation has also been shown to modify the attention to external stimuli and events. 
+For example, the mismatch negativity (MMN), which is an indicator of pre-attentive 
+processing, was used to study the effects of a concentrative meditation, Sahaj Samadhi 
+meditation (Srinivasan & Baijal, 2007). Meditators had larger auditory MMN amplitudes 
+than non-meditators, suggesting that concentrative meditation enhances pre-attentive 
+perceptual processes, with improved detection in auditory sensory memory.  
+Many studies on the effects of meditation on attention have focused on concentration 
+meditation which is distinct from concentrative meditation, mentioned above. In this 
+meditation, concentration is sustained on a small object or the breath and the meditator is not 
+diverted by distractors (Mipham, 2000). Practice of concentration meditation was shown to 
+improve specific aspects of attention (Jha, Klein, Krompinger, & Baime, 2007). In this study, 
+a group who were naïve to the meditation underwent eight weeks intensive training were 
+compared to experienced meditators taking part in an one-month intensive retreat, and to a 
+meditation-naïve control group. Three functionally and neuroanatomically distinct but 
+overlapping attentional subsystems were studied. These were: alerting, orienting, and conflict 
+monitoring. At one assessment the participants in the retreat showed better conflict 
+ 
+2 
+monitoring than the other groups. At another assessment the meditators undergoing intensive 
+training showed improved orienting relative to other groups, while participants in the retreat 
+showed altered performance on the alerting component. This suggested that the eight-week 
+intensive course improved the ability to endogenously orient attention, whereas those who 
+took part in the retreat developed receptive attentional skills associated with an improved 
+exogenous alerting process. Concentration meditation also decreased attentional blink 
+(Slagter, Lutz, Greischar, Francis, Nieuwenhuis, Davis, et al., 2007), while changes in the 
+electroencephalogram and cortical thickness were found in long term practitioners of 
+compassion meditation (Lutz, Greischar, Rawlings, Ricard, & Davidson, 2004) and of insight 
+meditation (Lazar, Kerr, Wasserman, Gray, Greve, Treadway, et al.. 2005). A functional 
+magnetic resonance study showed that expert meditators (with an average of 19,000 hours of 
+practice) had more activation than novices while focusing on a simple visual stimulus, while 
+expert meditators with over 44,000 hours had less activation (Brefczynski-Lewis, Lutz, 
+Schaefer, Levinson, & Davidson, 2007). Also, in response to distractor sounds, expert 
+meditators had less activation in brain regions related to discursive thoughts and emotions, 
+and more activation in regions related to response inhibition and attention. These findings 
+suggested that the hours of practice influence mental processes related to attending to or 
+ignoring specific stimuli. These findings may also explain certain changes in advanced 
+practitioners of Transcendental Meditation, described below. 
+The effects of transcendent experiences described as occurring during the practice of 
+Transcendental Meditation were studied on the contingent negative variation amplitude, 
+rebound, and distraction effects (Travis, Tecce, Arenander & Wallace, 2002). The contingent 
+negative variation is an event-related potential occurring between a warning stimulus and an 
+imperative stimulus requiring a response (Walter, Cooper, Aldridge, McCallum, & Winter, 
+1964). Late contingent negative variation amplitudes were largest in meditators who had 
+ 
+3 
+transcendent experiences every day. Since late contingent negative variation reflects 
+proactive preparatory processes including mobilization of motor, perceptual, cognitive, and 
+attentional resources, the results suggest that transcendent experiences are related to cortical 
+responses and executive functioning.  
+Another meditation technique called Cyclic Meditation was shown to reduce the P300 
+peak latency and increase the P300 peak amplitude (Sarang & Telles, 2006c). The P300 
+component of event-related brain potentials (ERPs) is generated when persons attend to and 
+discriminate stimuli which differ in a single aspect. The P300 reflects fundamental cognitive 
+events requiring attentional and immediate memory processes (Polich, 1999). The results 
+suggested that Cyclic Meditation enhanced these cognitive processes. Cyclic Meditation 
+practice also improved the performance in a letter-cancellation task which requires selective 
+attention, concentration, visual scanning abilities, and a repetitive motor response (Sarang & 
+Telles, 2007).  
+The performance in a cancellation task hence requires certain mental processes related 
+to attention, as well as motor speed during a repetitive motor activity. Previously, a yoga 
+program which included Cyclic Meditation and supine rest increased motor speed in a 
+standard finger-tapping task (Dash & Telles, 1999). This increase in tapping speed was seen 
+in children after a 10-day program and in adults after a 1-mo. program. Hence it was not 
+possible to state whether the improved performance in the cancellation task was due to 
+improved attention or increased motor speed. For this reason the present study was designed 
+to assess whether Cyclic Meditation and supine rest would influence performance in: (i) a 
+task which requires attention and assesses speed of information processing, as well as motor 
+speed and (ii) tasks for motor speed alone. The task which was used to assess attention, speed 
+of information processing, and motor speed was a digit-letter substitution task (DLST). Two 
+tests were used to assess motor speed. The first was a letter-copying task in which the 
+ 
+4 
+participants had to copy a specified letter in the space provided. The number of spaces was 
+the same as for the DLST. The other test for motor speed required participants to make dots 
+within the circumference of two circles, as quickly as possible.  
+The performance in these three tasks was assessed before and after Cyclic Meditation, 
+or supine rest, and this was compared to recordings before and after an equal duration of no 
+intervention or control period. The aim was to assess whether changes in motor speed (if any) 
+influenced the performance on the DLST.  
+Method 
+Participants  
+Fifty-seven male participants ages 18 to 40 years (M age = 26.5 yr., SD = 4.6) 
+participated in the study. All of them were in normal health based on a routine clinical 
+examination (Swash, 2001). Also, they were all literate and could understand and undertake 
+the tests. Participants were staying at a residential yoga center located in southern India. Their 
+experience of the practice of Cyclic Meditation and relaxation while supine (supine rest) 
+ranged between 6 and 54 mo. (M = 24.4, SD = 13.7). None of them used tobacco, intoxicants, 
+or consumed caffeinated beverages. They were all right-hand dominant based on the 
+Edinburgh Handedness Inventory (Oldfield, 1971). The study had been explained to them. 
+Their participation in the study was voluntary. They were not specifically told about previous 
+studies on cyclic meditation and supine rest. However, they may have known about them and 
+this may have influenced the outcome of the trial, which is a limiting factor of the study. 
+They were not told the specific hypothesis of the study or the purpose for each of the three 
+tasks. The approval of the Institutional Ethics Committee was obtained and the participants’ 
+signed informed consent was taken.  
+Measures 
+ 
+5 
+Digit-letter substitution task.—The digit-letter substitution task consisted of a 
+worksheet on which digits (1 to 9) were arranged randomly in 12 rows and 8 columns (Natu 
+& Agarwal, 1997). An instruction key for ‘letter-for-digit’ substitutions was shown at the top. 
+Participants were required to make as many letter-for-digit substitutions as possible in 90 sec. 
+They were told that there were two possible strategies, i.e., marking all nine digits in the 
+random order they occurred, or selecting any one digit at a time. They were to choose 
+whichever strategy suited them. They were also told that they could follow a horizontal, 
+vertical, or random path according to their choice. The total number of substitutions was 
+counted and each substitution scored as 1. Where the wrong letter was substituted, these 
+errors were counted (also as 1 each). The total number of substitutions and errors 
+substitutions were scored as described and the net scores were calculated by deducting errors 
+(wrong substitutions) from the total substitutions attempted.  
+As this test was administered at the beginning and at the end of the interventions which 
+required 22.5 min., to avoid any retest effect, parallel worksheets were prepared by changing 
+the digit-letter pairs in the key and by randomly changing the sequence of digits in the 
+working section (Agarwal, Kalra, Natu, Dadhich, & Deswal, 2002). Hence, half the 
+participants (n=29) received one set of worksheets (A) before a session, while the other half 
+(n=28) received worksheet B before the session. After the session, those who received 
+worksheet A before the session received worksheet B after the session. This was reversed for 
+the remaining participants. Similarly, there were different worksheets for the remaining 
+sessions. The digit-letter substitution task has been used in a similar design in an Indian 
+population, which indicated the validity of the task to study immediate effects (Natu & 
+Agarwal, 1997).  
+Letter-copying task.—The letter-copying task measured the psychomotor and motor 
+speed component of the digit-letter substitution task as has been described elsewhere 
+ 
+6 
+(Morrens, Hulstijn, & Sabbe, 2008). Participants were given the same worksheets as for the 
+DLST; however, in this task, participants did not have to attempt to substitute digits for 
+letters based on the key provided. Instead, they were asked to fill in all the boxes provided 
+with a single letter using their dominant hand. This was the first letter mentioned in the digit-
+letter substitution key. They were given 90 sec. to do this. This task was completed by all 57 
+participants. The total number of letters filled in was the score. 
+Circle-dotting Task 
+In the circle-dotting task, the targets were two circles drawn on paper, 6 cm in 
+diameter with 24.5 cm between their centers. In this paper-and-pencil task, participants were 
+asked to make a dot within the circumference of both circles alternately, using their dominant 
+hand, as rapidly as possible. This task is based on a standard ‘circle-dotting task’ for motor 
+speed (Lezak, 1995). They were given 90 sec. to complete the task. Only those dots which 
+were actually within the circumference of either circle were counted. Those which were on 
+the circumference were not counted. Separate scores (where one correctly placed dot was 
+scored as 1) were noted for the circle on the left and the circle on the right.  
+For all tasks, the task sheets were scored by a person who was unaware whether the 
+participant was in a Cyclic Meditation or supine rest session and whether the assessment was 
+made at the beginning or at the end of a session. 
+Procedure  
+The fifty-seven participants were assessed in three types of sessions, namely, (i) 
+Cyclic Meditation, (ii) Supine Rest, and (iii) Control. The participants were first assessed in 
+Cyclic Meditation and Supine Rest sessions. There were two schedules, (a) Cyclic Meditation 
+on day one, and Supine Rest on the next day (the CM/SR schedule), and (b) Supine Rest on 
+day one and Cyclic Meditation the next day (the SR/CM schedule). Participants were 
+ 
+7 
+randomly allocated to either schedule, to balance effects of order of sessions. In addition all 
+participants were assessed before and after a no intervention control session. Each session 
+was 22:30 minutes in duration. Assessments were made immediately at the beginning and 
+end of each session. Separate sessions were conducted for each of the assessments. Twenty-
+nine out of fifty-seven participants were assigned to schedule 1 (CM/SR) and the remaining 
+twenty-eight participants were assigned to schedule 2 (SR/CM). Since there were three 
+assessments each participant was assessed in three cyclic meditation sessions, in three supine 
+rest sessions, and in three control sessions. There were no differences in results based on the 
+order of the sessions, when the ‘after’ values were compared (p > .05, t test for unpaired 
+data).  
+Meditation Sessions 
+Cyclic Meditation.—During the Cyclic Meditation sessions, participants kept their 
+eyes closed and followed prerecorded instructions. The instructions emphasized carrying out 
+the practice slowly, with awareness and relaxation. The practice began by repeating a verse 
+(0:40 min) from the yoga text, the Mandukya Upanishad (Chinmayananda, 1984); followed 
+by isometric contraction of the muscles of the body ending with supine rest (1:00 min.); 
+slowly coming up from the supine position and standing at ease (called tadasana) and 
+‘balancing’ the weight on both feet, called centering (2:00 min.); then the first actual posture, 
+bending to the right (ardhakaticakrasana, 1:20 min.); with 1:10 min. in tadasana for 
+instructions about relaxation and awareness; bending to the left (ardhakaticakrasana, 1:20 
+min.); 1:10 min. as before; forward bending (padahastasana, 1:20 min.); another 1:10 min.; 
+backward bending (ardhacakrasana, 1:20 min.); and slowly coming down in the supine 
+posture with instructions to relax different parts of the body in sequence (10:00 min.). The 
+postures were practiced slowly, with awareness of all the sensations felt. The total duration of 
+the practice was 22:30 min. (Telles, Reddy, & Nagendra, 2000).  
+ 
+8 
+Supine rest.—Supine rest was practiced as traditional shavasana (the corpse posture), 
+which meant lying flat on the ground with the legs apart, arms away from the sides of the 
+body, with the palms facing upwards, while the eyes were closed (Muktibodhananda, 2004). 
+This practice lasted 22:30 min., so that the duration was the same as for Cyclic Meditation 
+sessions. 
+Control.—During this session, the participants were seated and their thoughts 
+wandered at random. They were not given any other specific instructions, except for the fact 
+that they were told that they were to avoid meditating. This practice lasted for 22:30 min., the 
+session was also at the same time of the day as the Cyclic Meditation and SR sessions. 
+Data Analysis 
+Statistical analysis was done using SPSS (Version 10.0). Data of the total substitutions, errors 
+and net scores of DLST, total scores on the letter-copying task and total scores on the circle-
+dotting task were analyzed using the repeated measures analyses of variance (ANOVAs). 
+There were two within-subjects factors, i.e., Time (pre-, post-session) and Session (Cyclic 
+Meditation, Supine Rest, Control). Post hoc tests with Bonferroni adjustment were used to 
+detect significant differences between mean values.  
+The percentage change(s) for each of the three tasks (i.e., digit-letter substitution task, letter-
+copying task, and circle-dotting task) were calculated separately for Cyclic Meditation, 
+Supine Rest and Control sessions. The percentage change was calculated as [(after 
+scores/before scores X 100)-100]. Pearson correlation coefficient test was used to assess 
+whether these percentage changes had any correlation with the length of experience 
+practicing yoga (expressed in months). 
+Results 
+ 
+9 
+The group means and standard deviations for scores obtained in the digit-letter substitution 
+task, letter-copying task, and circle-dotting task taken before and after Cyclic Meditation, 
+Supine Rest and Control sessions are shown in Table 1. 
+Digit-letter substitution task 
+The repeated-measures analyses of variance (ANOVA) showed a significant 
+difference between the three types of session for total scores (F1.453,81.384 = 8.95, p < .001, 
+Huynh-Feldt epsilon = 0.73; η2 = 0.33), errors or wrong substitutions (F1.534,85.905 = 0.70, p < 
+.004, Huynh-Feldt epsilon = 0.77; η2 =0.07), and net scores (F1.391,77.895 = 10.26, p < .001, 
+Huynh-Feldt epsilon = 0.70; η2 = 0.36 ). There was a significant effect of Time for total 
+scores (F1,56 = 119.32, p < .001, Huynh-Feldt epsilon = 1.00; η2 =0.10) and net scores (F1,56 = 
+115.83, p < .001, Huynh-Feldt epsilon = 1.00; η2 =0.11). There was a significant interaction 
+between Sessions and Time for total scores (F1.822,102.042 = 66.67, p < .001, Huynh-Feldt 
+epsilon = 0.88; η2 = 0.41 ) and net scores (F1.828,102.356 = 73.84, p < .001, Huynh-Feldt epsilon 
+= 0.91; η2 
+The repeated-measures ANOVAs showed a significant effect of Session for total 
+scores (F
+=0.43), suggesting the two factors were not independent. 
+Post hoc tests for multiple comparisons were performed with Bonferroni adjustment 
+and all comparisons were made with the respective before states. After Cyclic Meditation 
+sessions there was a significant increase in total scores (p < .001) and net scores (p < .001), 
+compared to pre-session. Also, the scores after Cyclic Meditation sessions were significantly 
+different from scores after both Supine Rest and Control sessions for total scores (p < .001), 
+errors or wrong substitutions (Cyclic Meditation vs Supine Rest, p < .021; Cyclic Meditation 
+vs Control, p<.002; Supine Rest vs Control, p < .001) and net scores (p < .001).  
+Letter-copying Task 
+1.185,66358 = 15.05, p < .001, Huynh-Feldt epsilon = 0.58; η2 = 0.21). There was a 
+significant effect of Time for total scores (F1,56 
+Comment [SAI1]:  
+= 127.19, p < .001, Huynh-Feldt epsilon = 
+Table 1 
+ 
+10 
+1.00; η2 = 0.69 ). There was a significant interaction between Sessions and Time for total 
+scores (F1.217,68.158 = 88.54, p < .001, Huynh-Feldt epsilon = 0.60; η2 =0.61), suggesting the 
+two factors were not independent. 
+Post hoc tests for multiple comparisons were performed with Bonferroni adjustment 
+and all comparisons were made with the respective before states. There were significant 
+increases in total scores of the letter-copying task following Cyclic Meditation sessions (p < 
+.001), Supine Rest sessions (p < .001), and Control sessions (p < .002) compared to the 
+respective pre-session values. Also, after Cyclic Meditation sessions, the scores were 
+significantly different from the scores after both Supine Rest and Control sessions (p < .001 
+for both comparisons).  
+Circle-dotting task 
+The circle-dotting task showed a significant effect of Session for both left circle 
+scores (F1.526,85.437 = 23.42, p < .001, Huynh-Feldt epsilon = 0.75; η2 = 0.30 ) and right circle 
+scores (F1.565,87.66 = 28.06, p < .001, Huynh-Feldt epsilon = 0.78; η2 = 0.33 ). Similarly, there 
+was a significant effect of Time for left circle scores (F1,56 = 106.69, p < .001, Huynh-Feldt 
+epsilon = 1.00; η2 = 0.66), and right circle scores (F1,56 = 104.15, p < .001, Huynh-Feldt 
+epsilon = 1.00; η2 = 0.65). Also, there was a significant interaction between Sessions and 
+Time for left circle scores (F1.808,101.248 = 66.63, p < .001, Huynh-Feldt epsilon = 0.88; η2 = 
+0.54) and right circle scores (F1.838,102.911 = 77.21, p < .001, Huynh-Feldt epsilon = 0.92; η2 
+Post hoc tests for multiple comparisons were performed with Bonferroni adjustment 
+and all comparisons were made with the respective before states. After Cyclic Meditation and 
+Supine Rest sessions there were significant increases in left circle scores (p < .001) and right 
+circle scores (p < .001). Also, scores after Cyclic Meditation sessions were significantly 
+= 
+0.58), suggesting the two factors were not independent. 
+ 
+11 
+different from scores after both Supine Rest and Control sessions for left circle scores (p < 
+.001) and right circle scores (p < .001). 
+Pearson Correlations Among Scores 
+Pearson correlation coefficients were calculated between the percentage changes in 
+scores on the three tasks and months of yoga practice. There was a significant positive 
+correlation between the percentage change in net scores on the digit-letter substitution task 
+after Cyclic Meditation with months of yoga practice (r = .30, p < .05, n = 57). 
+Discussion 
+Participants showed better performance in a digit-letter substitution task, as well as in 
+tasks for motor speed following a session of cyclic meditation. Following a period of supine 
+rest for an equal duration there was improved performance in tasks for motor speed, but not 
+in the digit-letter substitution task. There were no significant changes in the control group, 
+suggesting no retest effect. 
+The digit-letter substitution task measures psychomotor performance (Gerrard, 
+Wheeldon, & McDevitt, 1995). This task is based on earlier developed substitution tests (e.g., 
+the Digit Symbol Substitution Test) but uses over-learned signs (i.e., letters) instead of the 
+symbols used in other substitution tasks (van der Elst, van Boxtel, van Breukelen, & Jolles, 
+2006). The task assesses attention, speed of perception and processing, as well as a repetitive 
+motor response requiring motor speed (Orlowiejska-Gillert, Pajak, Szczudlik, Kawalec, & 
+Pomykalska, 1998; de Groot, Hornstra, Roozendaal, & Jolles, 2003). The results suggest that 
+the Cyclic Meditation sessions enhanced overall performance, i.e., the total scores, but also 
+resulted in lower numbers of wrong attempts or errors (based on net scores) compared to the 
+supine rest sessions. However, before Cyclic Meditation sessions, the mean score on wrong 
+attempts was lower than before Supine Rest or the Control sessions, though neither difference 
+was statistically significant.  
+ 
+12 
+The improved scores in the letter copying-task and the circle-dotting task following 
+Cyclic Meditation sessions show that speed for repetitive motor activity was also better after 
+Cyclic Meditation. This may have contributed to the better performance in the DLST after 
+Cyclic Meditation sessions, especially since the magnitude of change in the three tasks was 
+comparable. The percent change in the mean score on the DLST after Cyclic Meditation 
+sessions was 21.0, while in the letter-copying and circle-dotting task percent changes were 
+14.0 and 19.0, respectively.  
+Cyclic meditation is so named because it consists of alternating cycles of yoga 
+postures interspersed with periods of supine relaxation (Nagendra & Nagarathna, 1997). This 
+“moving meditation” was devised by Nagendra based on a description from ancient yoga 
+texts (Chinmayananda, 1984). The practice has been shown to be followed by a period of 
+reduced physiological arousal based on a decrease in oxygen consumption and minute 
+ventilation (Telles, et al., 2000; Sarang & Telles, 2006a), changes in the heart rate variability 
+(Sarang & Telles, 2006b) and increased slow wave sleep during the night following daytime 
+practice of cyclic meditation (Patra & Telles, 2009). However, these changes occurred 
+simultaneously with a decreased latency and increased amplitude in the P300 (Sarang & 
+Telles, 2006c) as well as improved performance in a letter-cancellation task (Sarang & 
+Telles, 2007). The P300 reflects the ability to sustain and shift attention while discriminating 
+between stimuli which differ in a single aspect, e.g., frequency of tones (Polich, 1999). The 
+P300 also indicates cognitive events requiring attentional and immediate memory processes. 
+Similarly, letter-cancellation tasks also require sustained attention, as well as visual scanning 
+and activation and inhibition of rapid responses along with motor speed. These results taken 
+together suggest that cyclic meditation induces a state of reduced physiological arousal with 
+improved performance in tasks requiring attention.  
+ 
+13 
+Several meditation techniques have been shown to reduce anxiety and feelings of tension 
+(Kozasa, Santos, Rueda, Benedito-Silva, & De Ornellas, 2008). In many cases a reduction in 
+anxiety is associated with better performance. For, example, persons with high trait anxiety 
+took longer to color name threatening words, compared to neutral words, when assessed on a 
+modified Stroop color naming paradigm (Fox, 1993). Participants with high trait anxiety were 
+also distracted by separate color words which produced no interference for those with low 
+trait anxiety. The results suggested that high trait anxiety is associated with a general inability 
+to maintain attentional focus, not specific for threatening stimuli. While anxiety was not 
+measured in the present study, one may speculate that a reduction of anxiety could have 
+contributed to better performance. 
+In a previous study, following both cyclic meditation and supine rest, participants 
+performed better in a letter-cancellation task (Sarang & Telles, 2007). In the present study, on 
+a different group of cyclic meditation practitioners, performance in a digit-letter substitution 
+task improved after cyclic meditation but not after supine rest. This may be related to the fact 
+that the two psychomotor tasks (i.e., the letter-cancellation task and the digit-letter 
+substitution task) assess comparable, yet different cognitive abilities. The letter-cancellation 
+task assesses the ability to sustain and shift attention, immediate memory, visual scanning, 
+and motor speed for repetitive motor activity. The digit-letter substitution task also requires 
+the ability to sustain and shift attention, immediate memory (of the digit-letter combination), 
+and the task tests speed of information processing, as well as the ability to process 
+information and shift the attentional focus between digits and letters. It is difficult to say 
+whether the improved performance in the letter-cancellation task following both cyclic 
+meditation and supine rest in an earlier study (Sarang & Telles, 2007) and the improved 
+performance in the digit-letter substitution task after cyclic meditation alone in the present 
+ 
+14 
+study, was due to differences in the abilities assessed by the tasks or the fact that the yoga 
+practitioners in the two studies were different.  
+In the present study, after both cyclic meditation and supine rest, the performance in 
+the tasks for motor speed in a repetitive motor task was improved. The circle-dotting task 
+studied also evaluates spatial intelligence and manual speed (de Andrés, Sánchez, Hidalgo, & 
+Díaz, 2004). The letter-copying task was used as a measure of motor speed, which allowed 
+the repetitive motor activity component of the digit-letter substitution task to be assessed 
+separately as has been described else where (Morrens, Hulstijn, & Sabbe, 2008) . The ability 
+to carry out a repeated motor activity was better after cyclic meditation and supine rest, with 
+a greater magnitude of improvement after cyclic meditation. This may be related to previous 
+reports of better motor coordination and better performance in motor tasks after yoga practice 
+which 
+included 
+relaxation 
+(Madan, 
+Thombre, 
+Bharathi, 
+Nambinarayan, 
+Thakur, 
+Krishnamurthy, et al., 1992; Telles, Hanumanthaiah, Nagarathna, & Nagendra, 1993).  
+Improved repetitive motor activity and motor speed may have contributed to the better 
+performance in the digit-letter substitution task. The improvement in the mean scores on the 
+three tasks following Cyclic Meditation sessions ranged from 14.0 to 21.0%. In contrast, 
+there was no improvement in mean DLST scores after Supine Rest, but the improvement in 
+the letter-copying task was 4.3% and the improvement in the circle-dotting task was 4.1%. 
+Hence, an improvement in motor speed may have contributed to the better performance on 
+the DLST after Cyclic Meditation sessions. This is to some extent not supported by the 
+improvement in P300 after Cyclic Meditation sessions, as the P300 latency is an index of 
+stimulus processing rather than response generation and is used as a motor-free measure of 
+cognitive function. Improved motor speed in a repetitive motor activity task following yoga 
+has been considered to be related to better motor coordination (Telles, et al., 1993) either 
+ 
+15 
+associated with, or independent of, improved muscular efficiency following yoga (Madan, et 
+al., 1992).  
+Given the fact that yoga practice has effects on attention, and motor speed, the present 
+findings show that it is difficult to assess the exact contribution of improvement in either 
+ability following yoga, if a task requires both abilities. Hence, in future research it would be 
+best to use tasks which selectively measure a specific function.  
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+19 
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+Accepted September 23, 2009. 
+TABLE 1 
+Scores Obtained in Digit-letter Substitution Task, a Letter-copying Task, and Circle-dotting 
+Task Before and After Cyclic Meditation, Supine Rest, and Control Sessions (N = 
+57) 
+Task 
+Variables and 
+state 
+Session 
+Cyclic Meditation 
+Supine Rest 
+Control 
+M 
+SD 
+M 
+SD 
+M 
+SD 
+Digit-letter 
+substitution  
+Total 
+Substitutions 
+ 
+ 
+ 
+ 
+ 
+ 
+ Pre 
+51.79 
+9.21 
+51.68 
+11.16 
+51.86 
+9.42 
+ Post  
+62.60†
+9.88 
+‡ 
+53.33 
+10.34 
+53.26 
+8.59 
+Errors 
+ 
+ 
+ 
+ 
+ 
+ 
+ Pre 
+0.18 
+0.43 
+0.35 
+0.74 
+0.30 
+0.57 
+ Post  
+0.11
+0.36 
+‡ 
+0.53 
+1.14 
+0.53 
+0.89 
+Net 
+Substitutions 
+ 
+ 
+ 
+ 
+ 
+ 
+ Pre 
+51.61 
+9.19 
+51.33 
+10.88 
+51.56 
+9.36 
+ Post  
+62.49†
+9.85 
+‡ 
+52.81 
+9.95 
+52.74 
+8.62 
+Letter-
+copying  
+Total 
+attempted 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+20 
+ 
+ Pre  
+86.93 
+13.41 
+86.42 
+12.67 
+85.32 
+10.95 
+ Post  
+98.44†
+13.24 
+‡ 
+90.16† 
+10.94 
+86.82 
+9.36 
+Circle-
+dotting  
+ 
+Left circle 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ Pre 
+71.75 
+12.85 
+69.86 
+13.87 
+70.98 
+11.57 
+ Post  
+86.07†
+11.70 
+‡ 
+72.68† 
+12.90 
+72.33 
+9.62 
+Right circle 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ Pre 
+72.53 
+12.73 
+69.23 
+13.92 
+71.65 
+11.80 
+ Post  
+86.61†
+11.94 
+‡ 
+72.12† 
+13.00 
+72.44 
+9.48 
+†p < .001, RM ANOVA, with Bonferroni adjustment, before compared with after of 
+respective session. 
+‡p < .001, RM ANOVA, with Bonferroni adjustment, scores after Cyclic Meditation 
+compared with Supine Rest and Control sessions. 
+ 
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diff --git a/subfolder_0/Performance in attentional tasks following meditative focusing and focusing without meditation_unlocked.txt b/subfolder_0/Performance in attentional tasks following meditative focusing and focusing without meditation_unlocked.txt
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+Original Article
+	
+Ancient Science of Life / Jul-Sep 2012 / Vol 32 / Issue 1
+49
+Performance in attentional tasks following 
+meditative focusing and focusing without 
+meditation
+B. R. Raghavendra, Shirley Telles1
+Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana, Bengaluru, 1Director, Patañjali Research 
+Foundation, Haridwar, India
+INTRODUCTION
+M
+editation has been defined as a training in awareness, 
+which when practiced over a period of time produces 
+definite changes in perception, attention, and cognition.[1] 
+Meditation is also recognized as a specific consciousness 
+state in which deep relaxation and increased internalized 
+attention exist at the same time.[2]
+All meditation practices have been classified into two 
+main categories, based on how attention is directed.[3] 
+ABSTRACT
+Background/Aims: Ancient Indian yoga texts have described 
+four mental states. These are caïcalatä  (random thinking), 
+ekāgratā (focusing without meditation), dhāraṇā (meditative 
+focusing), and dhyāna (defocused meditative expansiveness). 
+A previous study compared the performance in a cancellation task 
+at the beginning and end of each of the four mental states (practiced 
+for 20 minutes each, on four separate days) showed an increase in 
+the scores after dhāraṇā. Hence, the present study was designed 
+to assess the effects of dhāraṇā (meditative focusing) and 
+ekāgratā (focusing without meditation) on two attention tasks (i) d2 
+test of attention and (ii) digit symbol substitution test. Materials and 
+Methods: Sixty normal healthy male volunteers with ages ranging 
+from 17 to 38 years (group mean age ± S.D., 24.87 ± 4.95) were 
+studied. Assessments were made before and after the practice of 
+ekāgratā and dhāraṇā on two separate days. Results: After both 
+types of focusing, there was a significant improvement in all measures 
+of the d2 test of attention (TN, E, TN‑E, E%, and CP). However, the 
+performance in the digit symbol substitution test was better after 
+dhāraṇā but did not change after ekāgratā. Conclusions: Hence, 
+in summary, dhāraṇā (meditative focusing) and ekāgratā (focusing 
+without meditation) produce nearly comparable results though 
+dhāraṇā (meditative focusing) results in better incidental learning 
+and better accuracy (as assessed by the substitution task).
+KEY WORDS: Attention, concentration, dhāraṇā, ekāgratā, 
+incidental learning
+One category is called focused attention meditation (FA), 
+during which attention is sustained and focused on a given 
+object. The second category is called open monitoring 
+meditation (OM), where meditators are required not to 
+react, while monitoring the content of ongoing experience. 
+This style is a method by which the practitioner is aware of 
+all mental content from one moment to the next.
+More recently, the description has been expanded to 
+include a third category, automatic self‑transcending. 
+A study described the three broad categories of meditation 
+techniques and their EEG patterns.[4] The three categories 
+were as follows: (i) Focused attention meditation, (ii) open 
+monitoring meditation, and (iii) automatic self‑transcending 
+which includes techniques intended to transcend their own 
+activity. The changes in EEG were higher gamma power and 
+coherence during focused attention meditation, decreased 
+frontal delta and increased frontal midline theta during 
+open monitoring meditation, and higher frontal alpha 1 
+coherence during automatic self‑transcending meditation. 
+These changes were consistent with the idea that focused 
+attention meditation would be associated with EEG changes 
+seen during directed attention, whereas open monitoring 
+meditation and self‑transcending were associated with 
+lower frequency EEG bands, usually associated with 
+relaxation.[4]
+These classifications are compatible with the concept of 
+meditation in an ancient Indian yoga text (Patañjali’s Yoga 
+Sūtras; circa 900 B.C.). Meditation was considered as the final 
+practice before the individual reaches the state of ultimate 
+Access this article online
+Quick Response Code:
+Website:
+www.ancientscienceoflife.org
+DOI:
+10.4103/0257-7941.113799
+>'RZQORDGHG IUHH IURP KWWSZZZDQFLHQWVFLHQFHRIOLIHRUJ RQ 0RQGD\ $XJXVW   ,3 @  __  &OLFN KHUH WR GRZQORDG IUHH $QGURLG DSSOLFDWLRQ IRU WKLV
+MRXUQDO
+Raghavendra and Telles: Performance in attentional tasks and meditation
+50 	
+Ancient Science of Life / Jul-Sep 2012 / Vol 32 / Issue 1
+transcendence called samādhi. There were eight stages 
+systematically described by the Sage Patañjali in the Yoga 
+Sūtras (aphorisms). These eight stages are (i) and (ii) yamas 
+and niyamas (rules for good conduct), (iii) āsanas (physical 
+postures), (iv) prāṇāyāmas (voluntarily regulated breathing), 
+(v) pratyāhāra  (withdrawal, particularly from external 
+sensations), (vi) dhāraṇā (meditative focusing), (vii) dhyāna 
+(a defocused state of mental expansiveness), and (viii) 
+samādhi  (an experience of transcendence or ultimate 
+realization). The sixth and seventh stages pertain to 
+meditation. The sixth stage is known as dhāraṇā (meditative 
+focusing) which is defined as confining the mind within 
+a limited mental area  (“deśa‑bandhaścittasya dhāraṇā”; 
+Patañjali’s Yoga Sūtras, Chapter III, Verse 1).[5] The seventh 
+stage, dhyāna is supposed to inevitably follow the stage of 
+dhāraṇā (meditative focusing). The eighth stage is one of 
+ultimate spiritual realization (samādhi).
+Apart from dhāraṇā and dhyāna there are two other 
+mental states, i.e.  caïcalatä and ekāgratā, described in 
+another ancient text (the Bhagavadgītā, compiled circa 500 
+B.C.). caïcalatä is a state of random thinking (Bhagavadgītā, 
+Chapter VI, Verse 34).[6] The second state is ekāgratā, during 
+which the attention is directed to a series of associated 
+thoughts (Bhagavadgītā, Chapter VI, Verse 12).[6] Hence, 
+ekāgratā is a state of focusing without meditation.
+A study compared the performance in a cancellation task 
+in 70 normal healthy male volunteers at the beginning 
+and end of the four types of sessions (20 minutes each on 
+four separate days, in a random order), namely caïcalatä, 
+ekāgratā, dhāraṇā and dhyāna.[7] The results showed that 
+scores in the cancellation task improved after dhāraṇā. 
+The letter cancellation task assesses selective attention and 
+concentration.[8] It was interesting to note that meditative 
+focusing improved selective attention whereas focusing 
+without meditation did not show such an effect.
+The present study was designed to determine the 
+effects of ekāgratā  (focusing without meditation) and 
+dhāraṇā (meditative focusing) practiced on two separate 
+days using two different tests used to assess attention, i.e., 
+(i) d2 test of attention and (ii) digit symbol substitution test.
+MATERIALS AND METHODS
+Participants
+Sixty male volunteers with ages ranging from 17 to 
+38 years (group mean age ± S.D., 24.87 ± 4.95 months) 
+were recruited for the study. They were all students of a 
+yoga university in Southern India. Their health status was 
+evaluated by a routine case history and clinical examination. 
+They had normal health and were not on any medication. 
+The conditions to exclude participants from the study were 
+chronic illnesses, particularly psychiatric or neurological 
+disorders, cognitive disorders, and visual deformities. 
+Male volunteers alone were selected as the mental state 
+of female volunteers is known to vary with the phases of 
+the menstrual cycle.[9] All participants had been practicing 
+meditation on the Sanskrit syllable, Om for 30 minutes 
+each day, 5 days in a week (group average experience ± SD; 
+14.83 ± 8.63 months). Apart from their prior experience of 
+meditation on Om, they were given a 3 month orientation 
+program to practice dhāraṇā under the guidance of an 
+experienced meditation teacher. The project was approved 
+by the institution’s ethics committee. The study protocol 
+was explained to the subjects and their signed consent was 
+obtained.
+Design
+Each participant was assessed in two sessions on separate 
+days. These two sessions were dhāraṇā and ekāgratā. Half of 
+the total participants were randomly allocated to dhāraṇā 
+session first and ekāgratā session later and the other half 
+had the order reversed. Assessments were done before and 
+after the practice of dhāraṇā and ekāgratā sessions. After 
+1 week (as a wash‑out period), the order of the sessions 
+was reversed and assessments were done before and after 
+the sessions. Participants who did dhāraṇā first, practiced 
+ekāgratā subsequently and vice versa. This 1 week gap was 
+given to wash out any possible learning effect. The time of 
+the day for assessment was kept constant for both sessions. 
+Both sessions were of 20 minutes in duration.
+Assessments
+d2 test of attention
+The d2 test is a timed test of selective attention and 
+concentration.[10] The one page test form provides sections 
+for recording data about the subject, test scores, and has a 
+practice sample. On the reverse side is the standardized 
+test, consisting of 14 lines, each comprised of 47 characters 
+for a total of 658 items. The test items are composed of the 
+characters “d” and “p” with one to four dashes, arranged 
+either individually or in pairs above and below the letter. 
+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 seconds per line. The d2 test of attention has 
+shown a high level of reliability and of validity.[10] The 
+reliability was tested on different scoring indices and with a 
+variety of methods. The internal stability of test indices, TN, 
+TN‑E, and CP proved to be very high (r > 0.90). Reliability 
+coefficients of E% are expected to be somewhat lower. The 
+>'RZQORDGHG IUHH IURP KWWSZZZDQFLHQWVFLHQFHRIOLIHRUJ RQ 0RQGD\ $XJXVW   ,3 @  __  &OLFN KHUH WR GRZQORDG IUHH $QGURLG DSSOLFDWLRQ IRU WKL
+MRXUQDO
+Raghavendra and Telles: Performance in attentional tasks and meditation
+	
+Ancient Science of Life / Jul-Sep 2012 / Vol 32 / Issue 1
+51
+stability of E% is less affected in test–retest experiments, 
+and thus can be improved with re‑testing. In a series of 
+test–retests, and intervals of up to 40 months, d2 test indices 
+TN, TN‑E, and CP demonstrated satisfactory to good 
+reliability (r > 0.70). The validity of the test is documented 
+by a large volume of research.[10]
+Digit symbol substitution test
+The digit symbol substitution test is a subset of the Wechsler 
+Adult Intelligence Scale‑Revised (WAISR) administered 
+using paper and pencil.[11] It measures sustained attention, 
+response speed, and visuo‑motor coordination. The 
+participant is given a key grid of numbers and matching 
+symbols and a test section with numbers and empty 
+boxes. The test consists of filling in as many empty boxes 
+as possible with a symbol matching each number. Ninety 
+seconds were given to complete the task. The score was 
+computed as the number of correctly substituted symbols 
+within the 90‑s time limit. To avoid re‑test effect parallel 
+worksheets were prepared by changing the digit‑symbol 
+pairs in the key and by randomly changing the sequence 
+of digits in the working section. This test has demonstrated 
+high test–retest reliability.[12] Test–retest reliability tends 
+to run high, with correlation coefficients in 0.82 to 0.88 
+range.[12]
+Interventions
+Participants were given a three month training to practice 
+dhāraṇā based on specific instructions under the guidance 
+of an experienced meditation teacher who had no other 
+part in the trial. The evaluation of the participants’ 
+practice of dhāraṇā was based on their self‑report as well 
+as consultations with the meditation teacher. Participants 
+were not given special training to practice ekāgratā. This was 
+because ekāgratā is a non‑meditative focusing which is easy 
+to practice and hence does not require any special training.
+Brief descriptions of both sessions are given below:
+(i) Ekāgratā (Focusing without meditation)
+Participants listened to a pre‑recorded lecture on meditation. 
+This was not about meditation on the Sanskrit syllable Om, 
+but about meditation in general. It was speculated that 
+listening to a lecture on a particular topic might induce the 
+state of non‑meditative focusing.
+(ii) Dhāraṇā (Meditative focusing)
+Participants were asked to open their eyes and gaze at the 
+syllable “Om” as it is written in Sanskrit for 30 seconds. 
+Followed by this, participants were asked to close their 
+eyes and audio instructions for dhāraṇā were played. The 
+meditative focusing on the Sanskrit syllable Om consisted 
+of mental visualization of the symbol Om. Dhāraṇā involves 
+conscious effort to keep the focus on the syllable “Om”.
+Data analysis
+Statistical analysis was done using SPSS (Version 19.0). Since 
+the same individuals were assessed in repeat sessions on 
+separate days (i.e. ekāgratā and dhāraṇā), repeated measures 
+analysis of variance was used  (ANOVA). Repeated 
+measures analysis of variance (ANOVA) were performed 
+with two “within subjects” factors, i.e. Factor 1: Sessions; 
+ekāgratā and dhāraṇā and Factor 2: States; “Pre”, and “Post”. 
+This was followed by a post‑hoc analysis with Bonferroni 
+adjustment comparing “pre” with “post” values.
+RESULTS
+The group mean and standard deviation for scores obtained 
+in the d2 test of attention and digit symbol substitution test 
+are presented in Table 1.
+Repeated measures analysis of variance
+Two‑way repeated measures ANOVA were conducted where 
+subjects were measured before and after dhāraṇā as well as 
+ekāgratā. There was a significant difference between States 
+for all measures of the d2 test of attention (i) Total Number 
+processed (TN) F (1, 59) = 79.13, P < 0.001; (ii) Errors (E) 
+F (1, 59) = 26.69, P < 0.001; (iii) TN‑E F (1, 59) = 161.88, 
+P < 0.001; (iv) E% F (1, 59) = 59.14, P < 0.001; (v) Concentration 
+Performance (CP) F (1, 59) = 201.43, P < 0.001. Scores on the 
+digit symbol substitution test showed a significant difference 
+between the Sessions F (1, 59) = 14.86, P < 0.001 and States 
+F (1, 59) = 40.43, P < 0.001. There was also a significant 
+interaction between Sessions and States F (1, 59) = 11.13, 
+P < 0.01.
+Post hoc analyses with Bonferroni adjustment
+There was a significant increase in the total number 
+processed (TN), TN – E, and concentration performance (CP) 
+after ekāgratā as well as dhāraṇā (P < 0.001, post hoc analyses 
+following ANOVA). There was a significant decrease in 
+errors (E) after ekāgratā ((P < 0.01) and dhāraṇā (P < 0.001). 
+And also, there was a significant decrease in E% after 
+ekāgratā (P < 0.001) and dhāraṇā (P < 0.001). Digit symbol 
+substitution test scores showed a significant increase after 
+dhāraṇā (P < 0.001) while ekāgratā showed no change.
+DISCUSSION
+In the present study, 60 male volunteers with experience in 
+meditation were assessed in the d2 test of attention and digit 
+>'RZQORDGHG IUHH IURP KWWSZZZDQFLHQWVFLHQFHRIOLIHRUJ RQ 0RQGD\ $XJXVW   ,3 @  __  &OLFN KHUH WR GRZQORDG IUHH $QGURLG DSSOLFDWLRQ IRU WKLV
+MRXUQDO
+Raghavendra and Telles: Performance in attentional tasks and meditation
+52 	
+Ancient Science of Life / Jul-Sep 2012 / Vol 32 / Issue 1
+symbol substitution test after dhāraṇā (meditative focusing) 
+and ekāgratā (focusing without meditation).
+The digit symbol substitution test is used to assess 
+perceptual‑motor speed during copying, visual scanning, 
+and incidental learning.[13,14] The d2 test of attention is 
+essentially a cancellation task, which measures selective 
+attention and concentration.[10,15] After both types of focusing 
+there was a significant improvement in all measures of the 
+d2 test of attention (TN, E, TN‑E, E%, and CP). However, 
+the performance in the digit symbol substitution test was 
+better after dhāraṇā but did not change after ekāgratā.
+The main difference between two tests is that the digit 
+symbol substitution test has a component of incidental 
+learning. It is possible that incidental learning improves 
+after dhāraṇā due to greater relaxation which may not occur 
+after ekāgratā. Learning and memory are closely related to 
+relaxation.[16] A previous study showed that 23 minutes 
+of a “moving meditation” called cyclic meditation (CM) 
+improved primary working memory.[17] The improvement 
+was attributed to better relaxation following cyclic 
+meditation. The same reason may be the basis for the results 
+in the present study though this is just a speculation as it 
+was not actually studied by objective variables.
+With respect to the d2 test of attention, following both 
+ekāgratā and dhāraṇā, there was a comparable improvement, 
+particularly in the (i) total number processed (TN), (ii) TN‑E, 
+and (iii) concentration performance (CP).
+The total number processed is a reliable measure of 
+attention allocation, processing speed, amount of work 
+completed, and motivation.[10] When the errors are 
+subtracted from total number (TN‑E), the value is a measure 
+of attentional and inhibitory control, and the relationship 
+of speed and accuracy of performance.[10] Concentration 
+performance (CP) is derived from the number of correctly 
+crossed out relevant items minus the errors of commission or 
+over‑inclusion when irrelevant letters are crossed out. This 
+is good indicator of the coordination of speed and accuracy 
+of performance.[10] Despite the fact that concentration 
+performance (CP) appeared comparably improved after 
+ekāgratā and dhāraṇā, the reduction in errors was more after 
+dhāraṇā (26.48%) compared to ekāgratā (15.44%).
+Errors  (E) include both errors of omission  (E1) or 
+under‑inclusion and errors of commission  (E2) or 
+over‑inclusion. The number of errors is sensitive to 
+attentional control, rule compliance, accuracy of visual 
+scanning, carefulness, and cognitive flexibility. Perhaps the 
+only difference between the two states (dhāraṇā and ekāgratā) 
+with respect to the d2 test could be related to the accuracy 
+of visual scanning and cognitive flexibility. Though even 
+this is difficult to conclude, the given comparable scores 
+in concentration performance (CP) after dhāraṇā (21.14%) 
+and ekāgratā (18.06%).
+The findings did not reveal noticeable difference between 
+dhāraṇā and ekāgratā except in the digit symbol substitution 
+test performance. This suggests that dhāraṇā and ekāgratā 
+did not bring about marked differences in attention 
+task performance. It would have been ideal to have a 
+simultaneous assessment of the physiological measures to 
+assess the level autonomic arousal during the two states. 
+This is particularly of interest as attention is known to 
+Table 1: Scores in the d2 test of attention and the digit symbol substitution test, before and after ekāgratā (focusing without 
+meditation) and dhāraṇā (meditative focusing). Values are group mean±S.D. and arrows show the direction of change
+Task
+Variable
+Ekāgratā (focusing without meditation)
+Dhāraṇā (meditative focusing)
+Pre
+Post
+Pre
+Post
+D2 test of attention
+TN
+528.67±84.27
+572.13±70.83***↑
+531.37±77.98
+580.50±62.75***↑
+% change
+‑
+8.22
+‑
+9.25
+E
+53.63±39.82
+45.35±32.12**↓
+50.22±33.70
+36.92±26.14***↓
+% change
+‑
+15.44
+‑
+26.48
+TN-E
+475.03±82.42
+526.78±73.40***↑
+481.15±80.09
+543.58±64.09***↑
+% change
+‑
+10.89
+‑
+12.98
+E %
+10.08±6.85
+7.96±5.41***↓
+9.52±5.92
+6.36±4.24***↓
+% change
+‑
+21.03
+‑
+33.19
+CP
+176.10±49.45
+207.90±45.79***↑
+181.35±47.95
+219.68±39.86***↑
+% change
+‑
+18.06
+‑
+21.14
+DSST
+Scores on DSST
+55.53±11.76
+57.82±10.80
+57.13±11.43
+64.67±10.54***↑
+% change
+‑
+4.12
+‑
+13.20
+***P<0.001; RM ANOVA with Bonferroni adjustment comparing post values with pre values, TN: Total number processed, E: Error, CP: Concentration performance, 
+DSST: Digit symbol substitution test
+>'RZQORDGHG IUHH IURP KWWSZZZDQFLHQWVFLHQFHRIOLIHRUJ RQ 0RQGD\ $XJXVW   ,3 @  __  &OLFN KHUH WR GRZQORDG IUHH $QGURLG DSSOLFDWLRQ IRU WKL
+MRXUQDO
+Raghavendra and Telles: Performance in attentional tasks and meditation
+	
+Ancient Science of Life / Jul-Sep 2012 / Vol 32 / Issue 1
+53
+modulate sympathetic activation.[18] The other limitation 
+of the study is that there was no assessment on third day 
+when a participant was given no intervention.
+In summary, dhāraṇā  (meditative focusing) and 
+ekāgratā (focusing without meditation) produce nearly 
+comparable results though dhāraṇā results in better 
+incidental learning and better accuracy (based on the digit 
+symbol substitution test performance).
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+stability and VIQ‑PIQ differences. J Clin Neuropsychol 1984;6:351‑66.
+13.	 Joy S, Fein D, Kaplan E. Decoding digit symbol: Speed, memory, and 
+visual scanning. Assessment 2003;10:56‑65.
+14.	 Joy  S, Kaplan  E, Fein  D. Speed and memory in the WAIS‑III 
+Digit Symbol‑Coding subtest across the adult lifespan. Arch Clin 
+Neuropsychol 2004;19:759‑67.
+15.	 Rose JE, Behm FM, Salley AN, Bates JE, Coleman RE, Hawk TC, 
+et  al. Regional brain activity correlates of nicotine dependence. 
+Neuropsychopharmacology 2007;32:2441‑52.
+16.	 Nava E, Landau D, Brody S, Linder L, Schächinger H. Mental relaxation 
+improves long‑term incidental visual memory. Neurobiol Learn Mem 
+2004;81:167‑71.
+17.	 Subramanya P, Telles S. Effect of two yoga‑based relaxation techniques 
+on memory scores and state anxiety. Biopsychosoc Med 2009;3:8‑12.
+18.	 Moses ZB, Luecken LJ, Eason JC. Measuring task‑related changes in 
+heart rate variability. Conf Proc IEEE Eng Med Biol Soc 2007;2007:644‑7.
+Address for correspondence:
+Dr. Shirley Telles, 
+Patañjali Research Foundation, Patañjali Yogpeeth, 
+Haridwar, Uttarakhand ‑ 249 408, India. 
+E‑mail: shirleytelles@gmail.com
+How to cite this article: Raghavendra BR, Telles S. Performance in 
+attentional tasks following meditative focusing and focusing without 
+meditation. Ancient Sci Life 2012;32:49-53.
+Source of Support: The study was funded by the Indian Council of 
+Medical Research (ICMR), Government of India, as part of a grant (Project 
+No. 2001-05010) toward the Center for Advanced Research in Yoga 
+and Neurophysiology (CARY& N) at S-VYASA, Bengaluru. Conflict of 
+Interest: None declared.
+Staying in touch with the journal
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diff --git a/subfolder_0/Prana and electrons in health and beyond.txt b/subfolder_0/Prana and electrons in health and beyond.txt
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+++ b/subfolder_0/Prana and electrons in health and beyond.txt	
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+8/11/2014
+Prana and electrons in health and beyond
+http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4097910/
+1/4
+Go to:
+Int J Yoga. 2014 Jan-Jun; 7(1): 1–3.
+doi:  10.4103/0973-6131.123469
+PMCID: PMC4097910
+Prana and electrons in health and beyond
+TM Srinivasan
+Dean of Yoga and Physical Sciences, Sw ami Vivekananda Yoga Anusandhana Samsthana (S VYASA Yoga University), #19, Eknath Bhavan,
+Gavipuram, KG Nagar, Bengaluru - 560 019, India. E-mail: editor@ijoy.org.in
+Copyright : © International Journal of Yoga
+This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, w hich
+permits unrestricted use, distribution, and reproduction in any medium, provided the original w ork is properly cited.
+Prana and electrons have overlapping properties in the subtle and gross domains respectively. Prana cannot be measured
+at this time; however, its interaction with the biosystem has been the subject of study in Ayurveda and Yoga. Even
+definition of death is based on loss of prana. Chi, the equivalent of prana in Traditional Chinese Medicine (TCM) is
+claimed to be measured through instruments and its loss has been observed at the time of death. Electrons have also
+come under study recently in health of individuals. Here, we have a complex and yet unexplored area of subtle energies
+that impacts health and may be useful in defining death.
+PRANA
+In the perspective of Yoga, prana is the primordial energy of the universe. Prana is dispersed through the entire material
+world. “Prana is both macrocosmic and microcosmic and is the substratum of all life. Mahaprana (the great prana) is the
+cosmic, universal, all-encompassing energy out of which we draw substance through the breathing process” (p. 1).[1]
+Further, the author says, “The moment prana leaves the body consciousness departs because prana and consciousness
+are the two poles of one source – the self” (p. 2).[1] Here, then is a definition of death-prana leaving the body. Thus in
+most languages of India, death is referred to as prana leaving the physical body. Further, it is said that inadequate amount
+of prana in parts of the body could result in ill-health. Prana could be controlled in the tradition of Yoga not only for good
+heath, but for managing the energy in the environment also.
+Prana has some similarities to chi in TCM. While measurement of prana has not been accomplished, chi seems to have
+come under quantification. Many of the instruments related to acupuncture activity measurements either tacitly assume or
+claim to measure chi. Similar to prana, availability and circulation of chi in the body is related to health. Hypo- or
+hyperactivities of meridian functions are related to chi availability; with meridian connecting to organs, the organ integrity
+could also be measured, says the theory.
+While both prana and chi seems to be related to cellular and organ function, a clear equivalence to physical or
+biochemical variables is not possible at this time. It should be noted that all biochemical processes are ultimately driven by
+electron transport. However, we are only able to track the functions of macroscopic events such a molecular function in a
+cell or an organ. It is not likely that this lacuna will be overcome any time soon; following electron transport is very subtle
+and seems to exceed the competency of present day technology. Perhaps electrons should be tagged with radio-active or
+other macroscopic elements but then, such tagging will change the transport of electrons themselves! Let us leave the
+question to electro-biochemists! Meanwhile, let us see how electrons are involved in evolution and in the human body
+maintaining health.
+8/11/2014
+Prana and electrons in health and beyond
+http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4097910/
+2/4
+Go to:
+ROLE OF ELECTRONS IN HEALTH
+Electron is one of the fundamental particles in material evolution. It is postulated that electrons came into existence at an
+early stage of cosmogenesis when the universe went through a big bang and started cooling. In an extremely short time
+sequence after the big bang, perhaps in a matter of first 3 s, electrons emerged from the hot, primordial soup.[2] The
+universe is said to be about 13 billion years old, hence the first 3 s occurred a long time ago. However, electrons are
+stable and traceable fundamental particles and give rise to many other fundamental particles and molecules. Lack of
+adequate electron density in the body is purported to give rise to ill-health, leading from sleeplessness to perhaps even
+incidence of cancer. Thus electrons take part in all manner of physical, physiologic and perhaps also psychological
+stability and homeostasis.
+Let us look at the role of electrons in health and in the process we call life.
+Desaturation in cells maintains an electrical balance through electron mobility and electron-ion balance. When the chance
+for desaturation is lost, the cell seems to go out of control and disorder sets in. Protein molecules are the basic building
+blocks of the body and their activity is controlled by nucleic acids (deoxyribonucleic acid, ribonucleic acid) to act within
+specific boundaries. Removing electrons from its immediate environment could increase reactivity of a biological
+molecule. When an electron is removed, the molecule becomes a free radical and this we know now to be highly
+reactive.
+The famous scientist and Noble Laureate, Dr. Albert Szent-Gyorgyi states, “The living state is the electronically
+desaturated state of protein … Nature is simple but subtle” (p. 17).[3] He leads us into a fascinating discussion of how
+life could have evolved on earth based on oxygen as a strong electron acceptor; this leads to a high degree of
+desaturation of protein and corresponding high degree of differentiation and development. The complexity we see in life
+forms around us could be due to the subtle property of oxygen to accept electrons!
+All living tissues seem to give signals in electron spin resonance (ESR) experiments. When a varying magnetic field at a
+particular microwave frequency is applied to a biological specimen the cell absorbs the energy imposed at specific
+resonance conditions. The ESR signal is obtained as a result of formation of free radicals during normal metabolism or in
+some abnormal conditions. In normal individuals, the body usually flushes out these free radicals. In cancer, however, the
+involved proteins have a low degree of desaturation. It is stated, “any factor that inhibits charge transfer and the
+desaturation of protein has to be oncogenic and any factor that promotes these must be carcinogenic” (p. 69).[3] As
+proteins are desaturated, the electrons attach themselves to oxygen molecules; chronic inadequate supply of oxygen
+could also lead to cancer. Unfortunately, cancer cells are not sick cells; they have high vitality and reproduce themselves
+very fast.
+In summary, it may be said that lack of electrons in the protein mix of the body could lead to many disorders. Lack of
+oxygen as an acceptor of the excess electrons could also lead to the proliferation of cells leading to cancer. Thus, it is
+said, “Taking out electrons irreversibly means killing” (p. 18).[3]
+There has been recent interest in the role of electrons in health. An interesting paper reviews the role of electrons as
+possible antioxidant in promoting health in people.[4] In a large number of studies, it has been documented that circadian
+cortisol rhythm is an important contributing factor for maintaining health. Disruption of this rhythm could lead to a number
+of health problems related to cardiovascular, autoimmune, mood related and even sleep disorders. A common factor in
+all this seems to be non-availability of adequate supply of electrons to the body. When electrons are made available
+through a simple method like earthing the bed or earthing the site of injury establishing a free flow of electrons from
+ground to the body, there seems to be dramatic improvements in the conditions.
+Chronic inflammation is thought to be a precursor to many diseases including cancer. As a response to inflammation and
+invading organisms, immune cells of the body release oxidizing agents or free radicals. To restore electrical neutrality,
+these radicals tear away electrons from the invading cells and in the process kill the cells. If the free radicals drift away
+from the site of work to new areas within the body, this could cause damage to normal cells.[4,5] Earthing a patient and
+8/11/2014
+Prana and electrons in health and beyond
+http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4097910/
+3/4
+Go to:
+facilitating the flow of electrons into the body reduces inflammation and lessens pain as seen through infrared
+photographic studies (p. 958).[5] The author says “The most reasonable hypothesis to explain the beneficial effects of
+earthing is that a direct earth connection enables both diurnal electrical rhythms and free electrons to flow from the earth
+to the body” (p. 955).[5]
+Thus, it is clear from the above narration that invading cells could be destroyed through electron transfer from the
+invaders to immune cells. Availability of electrons from other sources like the earth could reduce free radical activity in the
+body. Szent-Gyorgyi has mentioned with considerable foresight that permanent loss of electrons in a biological system is
+equivalent to killing it. Hence, measuring the electron availability may be a method for determining health and even death
+of an organism .
+NEAR DEATH EXPERIENCES
+There are many studies regarding near death experiences (NDE) and a complete journal is devoted to this enigmatic
+subject since 1980's. A recent survey from ten Dutch hospitals summarize a prospective study, wherein a total of 344
+cardiac patients were resuscitated after a cardiac arrest. Based on EKG records, all the patients were declared clinically
+dead. Of this, 62 people (18%) who were resuscitated reported NDE.[6] There are also some dramatic single cases
+reported in NDE literature.[7,8] This enigma raises the following question: If a person is declared dead and then, after a
+while, he/she wakes up, is it not an indication that our definition of death is inadequate? We need to look at more
+fundamental causes for death or for life processes. Herein, the role of electrons in life processes and assessment of
+availability of electrons in a biosystem becomes important.
+An instrument known as gas discharge visualization (GDV) seems to draw out electrons from finger tips and correlate
+them to the health status of organs connecting the finger segments as per acupuncture theory.[9,10] A high voltage pulse
+is applied at high frequency to the finger and the electrons that are drawn out impact the surrounding air molecules and
+create a gas discharge seen as a glow around the finger. These are termed GDV-grams. This is similar to Kirlian
+photography that was popular in the 1970s and 1980s. However, since the finger tips are related to acupuncture system
+and connected organs, it is normal to look at data represented to tease out health status of an individual. Further, there is
+a study by the same author, which shows the changes in the electron emissions and hence the light output from the fingers
+as a person goes through the death process (p. 75).[9] Here, it is first useful to remember that all objects (including
+inanimate) gives rise to GDV-gram. So, even a dead tissue would give a light discharge, though the quantity of discharge
+is very low and sometimes goes down to zero (when all free electrons are drawn out).
+There are three dramatic cases reported as persons goes through the process of death. One is natural death, the second
+is death due to accident and the third is a case of suicide studied by the authors. In normal death, the intensity of glow
+(number of electrons drawn out) slowly reduces to low levels (as in an inanimate matter) within 24 h. In both accident
+and suicide deaths, there are wild fluctuations in the intensity of glow, taking around 74 h in these cases to subside to
+inanimate levels. This is an unusual and dramatic observation; life processes in traumatic death takes at least three days to
+come to an end. There are many ways of interpreting the results, from slowing of death processes in traumatic cases to
+departure of a “vital element” that seems to struggle to leave the body that has become uninhabitable. We shall not tarry
+here since these thoughts are controversial, to say the least.
+The result of these observations unfortunately only one of each case presented so far is that depletion of electrons could
+be a fundamental indicator of death. Thus, trying to study the electron availability could be fundamental not only for health
+reasons, but for understanding death process itself.
+We might have a simplified interaction diagram between the subtle domain and the gross as shown here:
+PRANA ⇔ CHI ⇔ ELECTRONS ⇔ HEALTH
+The arrows indicate the interaction between the elements. These elements are distinct in conception and activity level.
+Prana is considered most subtle and non-physical, next is chi which is grosser and is observable and lastly, electrons
+8/11/2014
+Prana and electrons in health and beyond
+http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4097910/
+4/4
+Go to:
+Go to:
+which interact with physical systems. This model needs to be tested through experimentation; suffice it to say at this time
+that a more fundamental model for life processes are required if we need to understand health in an organism and the
+death process.
+Footnotes
+Source of Support: Nil
+Conflict of Interest: None declared
+REFERENCES
+1. Saraswati SN. Prana, Pranayama, Prana Vidya. Bihar, India: Bihar School of Yoga; 1994.
+2. Allday J. Quarks, Leptons and the Big Bang. 2nd ed. Bristol and Philadelphia: Institute of Physics Publishing; 2002.
+pp. 5–8.
+3. Szent-Gyorgyi A. The Living State. New York, USA: Marcel Dekker Inc.; 1978.
+4. Oschman JL. Chronic disease: Are we missing something? J Altern Complement Med. 2011;17:283–5.
+[PMC free article] [PubMed]
+5. Oschman JL. Can electrons act as antioxidants. A review and commentary? J Altern Complement Med.
+2007;13:955–67. [PubMed]
+6. van Lommel P, van Wees R, Meyers V, Elfferich I. Near-death experience in survivors of cardiac arrest: A
+prospective study in the Netherlands. Lancet. 2001;358:2039–45. [PubMed]
+7. Alexander E. Proof of Heaven; A Neurosurgeon's Journey into the Afterlife. New York: Simon and Schuster; 2012.
+8. van Lommel P. Consciousness Beyond Life. New York: Harper Collins; 2010. pp. 169–76.
+9. Korotkov K. Human Energy Field; Study with GDV Bioelectrography. New Jersey, USA: Backbone Publishing;
+2002.
+10. Korotkov K, Williams B, Wisneski LA. Assessing biophysical energy transfer mechanisms in living systems: The
+basis of life processes. J Altern Complement Med. 2004;10:49–57. [PubMed]
+Articles from International Journal of Yoga are provided here courtesy of Medknow Publications
diff --git a/subfolder_0/Prevalence of Diabetes and Its Determinants in the Young Adults Indian Population-Call for Yoga Intervention.txt b/subfolder_0/Prevalence of Diabetes and Its Determinants in the Young Adults Indian Population-Call for Yoga Intervention.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d183cb569376f165526d059320174fe572b961e6
--- /dev/null
+++ b/subfolder_0/Prevalence of Diabetes and Its Determinants in the Young Adults Indian Population-Call for Yoga Intervention.txt	
@@ -0,0 +1,1241 @@
+Prevalence of Diabetes and Its
+Determinants in the Young Adults
+Indian Population-Call for Yoga
+Intervention
+Raghuram Nagarathna 1*†, Parul Bali 2†, Akshay Anand 3*, Vinod Srivastava 4,
+Suchitra Patil 5, Guruprasad Sharma 5, Krishna Manasa 5, Viraaj Pannu 6, Amit Singh 5
+and Hongasandra R. Nagendra 5
+1 Vivekananda Yoga Anusandhana Samsthana, Bengaluru, India, 2 Department of Biophysics, Postgraduate Institute of Medical
+Education and Research, Chandigarh, India, 3 Neuroscience Research Lab, Department of Neurology, Postgraduate Institute of
+Medical Education and Research, Chandigarh, India, 4 College of Social Work, University of Kentucky, Lexington, KY, United States,
+5 Department of Yoga and Life Science, Swami Vivekananda Yoga Anusandhana Samsthana, Bengaluru, India, 6 Government
+Medical College and Hospital Sector 32, Chandigarh, India
+Background: The young Indian population, which constitutes 65% of the country, is fast
+adapting to a new lifestyle, which was not known earlier. They are at a high risk of the
+increasing burden of diabetes and associated complications. The new evolving lifestyle is
+not only affecting people’s health but also mounting the monetary burden on a developing
+country such as India.
+Aim: We aimed to collect information regarding the prevalence of risk of diabetes in young
+adults (<35 years) in the 29 most populous states and union territories (7 zones) of India,
+using a validated questionnaire.
+Methods: A user-friendly questionnaire-based survey using a mobile application was
+conducted on all adults in the 29 most populous states/union territories of India, after
+obtaining ethical clearance for the study. Here, we report the estimation of the prevalence of
+the risk of diabetes and self-reported diabetes on 58,821 young individuals below the age of 35
+years.Risk fordiabeteswasassessedusinga standardizedinstrument,theIndiandiabetesrisk
+score (IDRS), that has 4 factors (age, family history of diabetes, waist circumference, and
+physical activity). Spearman’s correlation coefficient was used to check the correlations.
+Results: The prevalence of high (IDRS score > 60), moderate (IDRS score 30–50), and
+low (IDRS < 30) diabetes risk in young adults (<35 years) was 10.2%, 33.1%, and 56.7%,
+respectively. Those with high-risk scores were highest (14.4%) in the Jammu zone and
+lowest (4.1%) in the central zone. The prevalence of self-reported diabetes was 1.8% with
+a small difference between men (1.7%) and women (1.9%), and the highest (8.4%) in
+those with a parental history of diabetes. The south zone had the highest (2.5%), and the
+north west zone had the lowest (4.4%) prevalence.
+Frontiers in Endocrinology | www.frontiersin.org
+December 2020 | Volume 11 | Article 507064
+1
+Edited by:
+Hans Ulrich Häring,
+Tübingen University Hospital,
+Germany
+Reviewed by:
+Jan Broz
+ˇ,
+Charles University, Czechia
+Peter Mikael Nilsson,
+Lund University, Sweden
+*Correspondence:
+Raghuram Nagarathna
+rnagaratna@gmail.com
+Akshay Anand
+akshay1anand@rediffmail.com
+†These authors have contributed
+equally to this work and share first
+authorship
+Specialty section:
+This article was submitted to
+Clinical Diabetes,
+a section of the journal
+Frontiers in Endocrinology
+Received: 24 October 2019
+Accepted: 07 October 2020
+Published: 11 December 2020
+Citation:
+Nagarathna R, Bali P, Anand A,
+Srivastava V, Patil S, Sharma G,
+Manasa K, Pannu V, Singh A and
+Nagendra HR (2020) Prevalence of
+Diabetes and Its Determinants in the
+Young Adults Indian Population-Call
+for Yoga Intervention.
+Front. Endocrinol. 11:507064.
+doi: 10.3389/fendo.2020.507064
+ORIGINAL RESEARCH
+published: 11 December 2020
+doi: 10.3389/fendo.2020.507064
+Conclusions: Indian youth are at high risk for diabetes, which calls for an urgent action
+plan through intensive efforts to promote lifestyle behavior modifications during the
+pandemics of both communicable and noncommunicable diseases.
+Keywords: prevalence, diabetes, young adult Indian population, IDRs, lifestyle - related disease
+INTRODUCTION
+India is a fast developing economy with a considerable number
+of diabetes patients. Its health care cost is rising with a deterioration
+in health standards among the economic productive young
+population (1–4). It is the country with the second highest
+numbers after China with 65.1 million diabetes cases that
+estimated in 2013. This is expected to increase up to 109.0
+million in 2035 (5). The highest prevalence of diabetes was noted
+in low-income countries (LIC) and lowest in high-income
+countries (HIC) (6). The diabetes primarily affects individuals
+over 50 years of age in HIC, whereas in middle-income countries
+(MIC), the prevalence is higher in young individuals, which is the
+most productive age group. The prevalence in older age again rises
+as these young individuals age with increased life expectancies
+(5, 7).
+Diabetes has become a global pandemic and threat for world
+health due to demographic variations and cultural differences of
+societies supplemented by aging phenomena. It is a costly disease
+that has been identified as the prime causative factor for
+blindness, lipoprotein abnormalities, or mitochondrial dysfunction
+causing cardiovascular diseases, renal failure, and amputation in
+several countries (8–10). The World Health Organization (WHO)
+has reported 24 million cases of diabetic neuropathy, 5 million
+cases of retinopathy, and 6 million cases of amputation due to
+diabetes. The mortality in individuals with diabetes is chiefly due to
+cardiac complications. Therefore, diabetes can cause undesirable
+consequences and, hence, needs urgent consideration in the young
+population in order to timely strategize effective prevention
+therapies (8, 11).
+Genetic and environmental factors, such as heredity, change
+in lifestyle, age, smoking habits, increased alcohol consumption,
+screen time, parental conflicts, improper sleep, education, and
+stress, predispose young adults to diabetes, which is exacerbated
+with diabetic comorbid conditions (12). Obesity is the main risk
+factor that accounts for 80%–85% of the risks of developing type-
+2 diabetes (13).
+The lack of physical activity among the younger population
+is a matter of concern as 84% of girls and 78% of males in
+Australia did not meet the criteria for minimum physical activity
+corresponding to their age. As a consequence, females were
+found to be more overweight than males (14). The risk of
+diabetes in young adults can be managed by routine physical
+activity and adopting a healthy and balanced diet, which focuses
+on the increased intake of dietary fiber (15–17). The WHO
+strongly recommends reducing the intake of free sugars
+throughout one’s lifetime by avoiding foods or beverages
+containing added monosaccharides and disaccharides (18). A
+study was conducted in an urban slum in a large metropolitan
+city in northern India, which noted a high prevalence of
+metabolic disorders, such as obesity, dyslipidemia, and diabetes
+mellitus in middle age, particularly in females in such an
+economically deprived population (19). Hence, such prevalence
+studies are required even at a national level to examine the
+important risk factors in this economic productive young
+population in order to have effective prevention strategies.
+Our study was aimed to estimate the prevalence of low,
+moderate, and high risk of diabetes in young adults. We
+conducted a nationwide study by collecting information
+regarding prevalence of risk of diabetes in young adults using a
+validated questionnaire. Moreover, the contribution of other
+sociodemographic factors, such as age, physical activities, yoga,
+family history, vitals, diet, gender, marriage, education, occupation,
+and socioeconomic status, were further collected to examine
+diabetic progression.
+METHODS
+Sampling and Study Population
+The study was conducted after ethical clearance from the ethical
+committee of the Indian yoga association with reference number
+RES/IEC-IYA/001. The data used in this analysis has been
+collected during phase 1 of the NMB 2017 trial, a large
+translational, multicenter, cluster-sampled research trial aimed
+to assess the efficacy of yoga-based lifestyle modification as a
+primary prevention strategy for diabetes in a community setting.
+The methodological details of the study have been reported
+previously (20, 21). In brief, the data collection aimed at
+screening 4000 adults per district in 60 randomly selected
+districts representative of the Indian adult population. There
+were two research associates (who designed the study and
+monitored work of senior research fellows), 30 senior research
+fellows (who worked in each district and monitored the work of
+yoga volunteers for diabetes movement [YVDMS]). The 1200
+YVDMs were involved in data collection and yoga training in the
+next part of the study. These YVDMs were trained for data
+collection as per their schedule (Supplementary Table 3).
+Sample Size Estimation
+Keeping in mind the twin objectives of the study, the sample size
+estimation was based on the relative risk reduction (30%) in
+prediabetes individuals reported in the Community Lifestyle
+Improvement Program study (22). We used annual incidence rates
+of diabetes as 18.3% in the control conditions as per IDPP-1 study
+(23). This provided a conversion rate at 3-month follow-up of 4.57%
+and3.0%,respectively,forcontrolandinterventionconditions.Using
+the sample size calculator (http://www.sample-size.net), the required
+Nagarathna et al.
+Prevalence and Determinants of Self-Reported Diabetes
+Frontiers in Endocrinology | www.frontiersin.org
+December 2020 | Volume 11 | Article 507064
+2
+sample size for a two-group design with a = 0.05 and (1−a) = 0.80
+was estimated to be 1949 for each group (a total of 3898 individuals).
+Factoring an attrition of 20%, the final sample size was estimated to
+be 4678 individuals with prediabetes. To obtain 4678 individuals
+with prediabetes, it was calculated that there was a need to screen
+77,967 adults above the age of 20 years (4678 × 100/6; the least
+reported prevalence of prediabetes in India has been 6.0% (24).
+Thus, the study plan included screening of approximately 155,933
+individuals across 60 Indian districts (10% of all districts as per
+the 2011 Census of India), assuming a nonresponse rate of 50%.
+Consequently, the study targeted approximately 4000 adults
+per district with equal involvement of the urban and rural areas.
+Assessments
+We acquired information on diabetes and risk scores by a door-
+to-door survey using a mobile application with detailed person-
+level information about age, gender, income details, educational
+qualifications, and marital status.
+The Indian Diabetes Risk Score (IDRS) developed by Mohan
+et al. in 2005 was used for risk analysis (25). IDRS is a validated
+instrument with optimum sensitivity (72.5%) and specificity
+(60.1%) used widely in India in several studies (26). It is a
+convenient, simple, and economical tool for the detection of a
+high-risk population that uses age, waist circumference, parental
+diabetes history, and physical activity (27) (Supplementary Table
+4). The combined scores of the 4 factors contribute to the
+prediction of risk level of an individual. The individuals with
+scores > 60, 30–50, and <30 are considered to be high, moderate,
+and low risk, respectively (Supplementary Table 1). We measured
+waist circumference in centimeters using a measuring tape. Self-
+reported diabetes was confirmed by checking the medication that
+they were taking and/or medical reports during the door-to-door
+visits. The questionnaire was tested for interrater reliability in a
+preliminary study between two YVDMs using the Kappa
+coefficient value, which was found to be 0.83.
+Sampling Strategy
+Niyantarit Maduhmeha Bharat (NMB) 2017 was a pan-India
+randomized multicluster translational trial with dual objectives,
+namely, a survey for prevalence and lifestyle intervention for the
+population at high risk and known diabetes (Figure 1). Details of
+the methods have been published (20, 21) earlier. In brief, a four-
+stage (zone–state–district-urban/rural) strategy was adopted for
+identifying study locations, using a random cluster sampling
+method and located households and individuals. Clustering was
+performed by dividing each state into districts and each district
+into rural and urban localities. Census enumeration blocks
+(CEB) were randomly selected from the randomly selected
+wards, and all eligible individuals (both genders between 20
+and 70 years) within the CEB were contacted. The door-to-door
+survey enlisted eligible individuals and specifically enquired
+about the status of diabetes and scored them on the IDRS.
+Field personnel [1200 volunteers (20/district), supervised by
+35 senior research officers and 5 zonal coordinators] were trained
+in a 5-day residential program to ask appropriate questions in
+local languages that included practical tests by visiting nearby
+villages and urban wards.
+Statistical Analysis
+Data were analyzed using SPSS (21.0) version. The estimation of
+prevalence was calculated using the distribution of frequency and
+percentage using cross tabs descriptive. Chi-square and Fisher
+exact tests were used for mean differences. Binary logistic
+regression analysis was done to find the association between
+independent predictors of diabetes. Self-reported diabetes was
+considered as a dependent variable. Gender, area, marital status,
+parental history, IDRS, physical activity, and waist circumference
+were covariates by keeping the reference factors rural for area,
+female for gender, vegetarian for diet (Supplementary Table 2)
+etc. as mentioned in Table 5.
+RESULTS
+Prevalence of Self-Reported Diabetes
+and Its Risks Based on Gender,
+Marital Status, and Parental History
+According to the national survey (NMB-2017), the young
+diabetes population was screened across the nation on the
+basis of IDRS and self-reported diabetes, using validated IDRS;
+60,194 individuals were selected on the basis of IDRS score, and
+58,821 were selected on the basis of self-reported diabetes as
+young adults (<35 years). Gender-related risk of diabetes was
+found to be similar in men and women. The prevalence of self-
+reported diabetes in young females was 1.9% and in men 1.7%.
+On the basis of IDRS risk, no significant difference was found in
+the female and male diabetes population (Table 1). The marital
+FIGURE 1 | Population sampling strategy of nationwide NMB study.
+Nagarathna et al.
+Prevalence and Determinants of Self-Reported Diabetes
+Frontiers in Endocrinology | www.frontiersin.org
+December 2020 | Volume 11 | Article 507064
+3
+status analysis revealed that 1.5% of unmarried, 2.0% of married,
+and 1.5% of separated individuals were found to have self-
+reported diabetes. Among these, married (11.6%) and
+separated (11.0%) individuals were under higher risk of
+diabetes than unmarried ones (p < 0.001) (Table 1). Similarly,
+the frequency distribution of unmarried, married, and separated
+people based in IDRS was also found to be significantly different
+among these groups.
+Interestingly, it has been found that 1.3%, 5%, and 8.4% of
+diabetic subjects were self-reported with no parental history of
+diabetes, one diabetes parent, and both diabetes parents with
+diabetic history, respectively (P < 0.001). Frequency distribution
+based on the parental history of diabetes has also reflected
+significantly higher numbers in high IDRS scores as compared
+to low-risk IDRS. Results suggest the inheritance pattern of
+diabetic condition, which may be triggered with familial
+lifestyle or genetic susceptibility of parents and trait transmission
+in siblings.
+Prevalence of Self-Reported Diabetes and
+Its Risk Based on BMI, Physical Activity,
+and Waist Circumference
+Participants were categorized into normal, underweight, and
+overweight/obese. It was found that the overweight (2.4%) and
+obese (>30) (3.3%) young population was at significantly higher
+risk of diabetes than the normal (1.3%) and underweight (1.1%)
+young population (Table 1). The percentage of self-reported
+diabetes individuals with normal, high, and moderate health
+risks based on waist circumference is as follows: 1.3%, 3.2%, 2.0%
+(p< 0.001). The IDRS scores (based on waist circumference) were
+also significantly higher in high-risk participants based on waist
+circumference of individuals, i.e., almost 33.6% more than
+moderate (11.7%) and normal (0.4%) individuals (Table 1).
+The frequency distribution based on physical activities was
+also in concordance with the BMI and waist circumference of the
+participants. It was found that the proportion of individuals who
+performed no, mild, moderate, or vigorous physical exercise
+were comparable.
+Differential Frequency of Self-Reported
+Diabetes and Its Risk Factors Based on
+Different Indian Geographical Location
+The zone-wise prevalence of diabetes (self-reported) was
+significantly different (<0.001) and reported as follows in
+descending order: south, north, east, northeast, central, west,
+and Jammu. However, no gender-wise significant differences
+were found (Table 2). Zone-wise distribution of high and
+moderate IDRS risk of diabetes was also reported as south,
+north, west, Jammu, northeast, east, and central (Table 3), and
+the data showed significant differences among these groups.
+TABLE 1 | Frequency distribution of diabetes participants (self-reported) with context to gender, anthropometric parameters, and different geographical locations in India.
+Variables
+Total (%)
+Diabetes(Self-reported)
+IDRS
+Total
+Low Risk
+Moderate Risk
+High Risk
+p-value
+N
+%
+p-value
+N
+%
+N
+%
+N
+%
+58821
+1078
+1.8%
+60194
+34145
+56.7%
+19933
+33.1%
+6116
+10.2%
+<0.001
+Gender
+Male
+27720
+479
+1.7%
+0.059
+28287
+16137
+57.0%
+9324
+33.0%
+2826
+10.0%
+0.157
+Female
+30708
+585
+1.9%
+31552
+17836
+56.5%
+10473
+33.2%
+3243
+10.3%
+Area
+Rural
+27045
+486
+1.8%
+0.221
+27998
+16230
+58.0%
+9028
+32.2%
+2740
+9.8%
+<0.001
+Urban
+30418
+574
+1.9%
+30766
+17029
+55.4%
+10502
+34.1%
+3235
+10.5%
+Parental history of DM
+Non- parents
+46521
+618
+1.3%
+<0.001
+51009
+31269
+61.3%
+16579
+32.5%
+3161
+6.2%
+<0.001
+One parents
+6653
+333
+5%
+7317
+2189
+29.9%
+2844
+38.9%
+2284
+31.2%
+Both parents
+1061
+89
+8.4%
+1136
+96
+8.5%
+381
+33.5%
+659
+58.0%
+Marital status
+Married
+40525
+805
+2.0%
+<0.001
+42166
+22225
+52.7%
+15049
+35.7%
+4892
+11.6%
+<0.001
+Un-married
+15383
+236
+1.5%
+16097
+10686
+66.4%
+4320
+26.8%
+1091
+6.8%
+Separated
+65
+1
+1.5%
+73
+42
+57.5%
+23
+31.5%
+8
+11.0%
+BMI
+Under weight
+(<18.5)
+3665
+41
+1.1%
+<0.001
+3884
+3103
+79.9%
+677
+17.4%
+104
+2.7%
+<0.001
+Normal weight
+(18.5-25)
+21797
+293
+1.3%
+23078
+15061
+65.3%
+6463
+28.0%
+1554
+6.7%
+Over- weight
+(25-30)
+8548
+201
+2.4%
+9031
+3858
+42.7%
+3607
+39.9%
+1566
+17.3%
+Obese
+(>30)
+3291
+110
+3.3%
+3448
+1277
+37.0%
+1309
+38.0%
+862
+25.0%
+Waist circumference
+High Risk
+10556
+338
+3.2%
+<0.001
+11230
+566
+5.0%
+6887
+61.3%
+3777
+33.6%
+<0.001
+Moderate risk
+17025
+346
+2%
+18706
+5776
+30.9%
+10733
+57.4%
+2197
+11.7%
+Normal
+26617
+355
+1.3%
+29526
+27212
+92.2%
+2184
+7.4%
+130
+0.4%
+IDRS
+Low- risk
+30775
+335
+1.1%
+<0.001
+–
+–
+Moderate risk
+18442
+338
+1.8%
+High- risk
+5638
+366
+6.5%
+Physical activity
+No
+7274
+148
+2.0%
+0.084
+12191
+4828
+39.6%
+4087
+33.5%
+3276
+26.9%
+<0.001
+Mild
+12249
+265
+2.2%
+23215
+8582
+37.0%
+12434
+53.6%
+2199
+9.5%
+Moderate
+21921
+395
+1.8%
+16581
+12979
+78.3%
+2983
+18.0%
+619
+3.7%
+Vigorous
+15028
+246
+1.6%
+8207
+7756
+94.5%
+429
+5.2%
+22
+0.3%
+Nagarathna et al.
+Prevalence and Determinants of Self-Reported Diabetes
+Frontiers in Endocrinology | www.frontiersin.org
+December 2020 | Volume 11 | Article 507064
+4
+However, frequency distribution of self-reported diabetes was
+comparable in urban areas (1.9%) and rural localities (1.8%) that
+showed statistically insignificant differences between the two (p =
+0.221, Table 1). The proportion of individuals taking treatment
+to control diabetes was estimated. Results demonstrated that
+only 54.5% of the young diabetes adults were taking treatment to
+control diabetes, and there were no medications being taken by
+45.5% of the diabetes subjects (Table 4).
+Relative Risk of Diabetes
+By using logistic regression, high- and moderate-risk young
+adults (based on IDRS) were found to have higher odds of
+developing diabetes as compared to low-risk young adults.
+Unmarried young adults had 1.290 higher odds (p < 0.001) of
+diabetes as compared to married individuals. The comparison
+was made for relative risk of diabetes (28) within each parameter
+using a binary multinomial logistic regression analysis. Both
+higher and lower odds of diabetes as compared to the reference
+variable have been reproduced in Table 5. Logistic regression
+analysis to see the impact of BMI and food habits on IDRS
+scoring has revealed the imperative impact of both on diabetes.
+Obese participants can significantly stimulate the diabetic
+condition (Table 6).
+DISCUSSION
+India is the second-largest populated country in the world. It is
+estimated that India has more of a young population compared
+to other countries in the world. According to the 2011 census,
+out of the total population, about 65% of the population of India
+are under the age of 35 (29). India has more than 40 million
+diabetes cases with a good majority across the nation not aware
+of the disease and comorbid factors. As diabetes risk varies with
+increasing age, early detection and intervention may prevent
+serious health complications and healthcare-related cost. The
+diabetes population in young adults has a tendency to become
+readily or more vulnerable to comorbid diabetes illnesses (30).
+Complications related to diabetes are becoming a major cause of
+morbidity and mortality in the young population (31). Rapidly
+increasing burden of Diabetes in the young might reder
+population to early predisposition to age related disorders
+which have no treatment (32–35). Primarily, the risk of
+diabetes is associated with age, obesity, parental diabetes
+history, smoking, type of diet, and physical inactivity (36).
+The studies have shown that diabetes might be linked to
+genetic and environmental factors (37). Parental history is
+generally believed to play a major role in the prediction of
+TABLE 3 | Zone-wise risk of diabetes based on IDRS score.
+Zone
+p-value
+North
+(n = 6844)
+South
+(n = 12317)
+East
+(n = 9650)
+West
+(n = 9507)
+Central
+(n = 10294)
+Jammu
+(n = 5370)
+North East
+(n = 6212)
+IDRS
+High risk
+848 (12.4%)
+1699 (13.8%)
+727 (7.5%)
+1126 (11.8%)
+425 (4.1%)
+774 (14.4%)
+517 (8.3%)
+<0.001
+Moderate risk
+2312 (33.8%)
+5978 (48.5%)
+2919 (30.2%)
+3174 (33.4%)
+1607 (15.6%)
+2114 (39.4%)
+1829 (29.4%)
+Low risk
+3684 (53.8%)
+4640 (37.7%)
+6004 (62.2%)
+5207 (54.8%)
+8262 (80.3%)
+2482 (46.2%)
+3866 (62.2%)
+The proportion of high, moderate, and low risks based on IDRS was calculated zone-wise that includes north, south, east, west, central, Jammu, and north-east India.
+TABLE 2 | Zone-wise frequency distribution of self-reported diabetes participants.
+Zone
+Total (N)
+Diabetes (%)
+p-value
+Gender
+Total (N)
+Diabetes
+p-value
+n
+%
+North
+6565
+117 (1.8%)
+<0.001
+Male
+2857
+45
+1.6%
+=0.242
+Female
+3615
+71
+2.0%
+South
+15734
+389 (2.5%)
+Male
+7465
+182
+2.4%
+=0.971
+Female
+8050
+197
+2.4%
+East
+8611
+152 (1.8%)
+Male
+3901
+60
+1.5%
+=0.168
+Female
+4663
+90
+1.9%
+West
+8812
+135 (1.5%)
+Male
+4564
+64
+1.4%
+=0.296
+Female
+4235
+71
+1.7%
+Central
+8889
+151 (1.7%)
+Male
+4148
+67
+1.6%
+=0.555
+Female
+4725
+84
+1.8%
+North-West
+4857
+44 (0.9%)
+Male
+2095
+15
+0.7%
+=0.224
+Female
+2762
+29
+1.0%
+North-East
+5353
+90 (1.7%)
+Male
+2690
+46
+1.7%
+=0.792
+Female
+2658
+43
+1.6%
+TABLE 4 | Proportion of self-reported diabetes individual prescribed for treatment.
+Treatment
+No treatment
+Diabetes Subjects
+54.5%
+45.5%
+Nagarathna et al.
+Prevalence and Determinants of Self-Reported Diabetes
+Frontiers in Endocrinology | www.frontiersin.org
+December 2020 | Volume 11 | Article 507064
+5
+diabetes. Therefore, we analyzed the percentage prevalence of
+self-reported diabetes in both parents with diabetes, no parents
+with diabetes, and one parent diabetes. This survey revealed that,
+overall, 1.3% of the diabetes cases had no parental history, which
+is possibly explained by the change in lifestyle or some epigenetic
+factors that can contribute to the development of such diabetes
+cases. Our study demonstrates that young adults with both
+diabetes and one diabetes parent are at a high risk of
+developing diabetes as compared to both nondiabetes parents.
+Comparison of the relative risk of diabetes within each variable
+showed significant results except gender. We observe that marital
+status (separated vs. married) was also found to be associated
+with diabetes risk. The current study suggests that unmarried
+individuals are also at increased risk of diabetes but less than
+married and separated people. This could be possibly because of
+more stress or hormonal changes in unmarried as compared to
+married people, which may be the contributing factors for
+developing diabetes risk; however, further studies are required
+to conclude these possibilities. Although, it is difficult to
+speculate why unmarried individuals as compared to separate
+and married were more affected by diabetes, it is possible that the
+former group ignored health and wellness as compared to
+the latter.
+It was also found that the risk of diabetes varies according to
+areas and zones. Based on the IDRS score, the study found that
+the urban young population is under higher risk of diabetes than
+the rural counterparts. The southern region was found to have
+more young diabetes population i.e., 2.5%. The study conducted
+in India shows a similar prevalence of diabetes in the urban
+population (24). Nevertheless, the distribution characters in all
+cities were found to be comparable except socioeconomic status.
+Dietary habits played a vital role in enhancing the diabetes
+risk and awareness, and more attention is required regarding this
+aspect. Diet, with high glycemic load, results in diabetes
+complications (38). Interestingly, the study outcomes reveal
+that the young vegetarian population was under a higher risk
+of diabetes than the nonvegetarian self-reported diabetes
+population. This reflects the predominant consumption of
+vegetarian diets rich in carbohydrates, such as rice, wheat, oil,
+and fatty foods. Additionally, it is worth noting that consumption
+of sweets is also an integral part and parcel of the Indian culture,
+which could be responsible for the development of diabetes
+among the young adult population (39). However, other studies
+suggest that the typical vegetarian diet helps in reducing the
+diabetes risk (40). This controversial fact needs further
+investigation, including the amount and types of diet with an
+appropriate control group. India is the habitat of different
+religions and many cultures having different eating behaviors
+and unique lifestyles. Hence, these variations, cultural diversity,
+customs, and heterogeneity across the nation are great challenges
+TABLE 6 | Logistic regression to see the association of BMI and food habit with IDRS scores.
+Variables in the Equation
+B
+S.E.
+Wald
+df
+P-value
+OR
+95% C.I.
+Lower
+Upper
+Step 1a
+BMI
+24.097
+2
+0.000
+BMI (<23.5, Normal)
+0.486
+0.206
+5.541
+1
+0.019
+1.626
+1.085
+2.436
+BMI (23.6-27.5, obese)
+0.823
+0.168
+24.089
+1
+<0.0001
+2.277
+1.639
+3.163
+Non-veg
+0.849
+0.508
+2.792
+1
+0.095
+2.338
+.863
+6.330
+Constant
+-5.305
+0.518
+104.737
+1
+0.000
+0.005
+TABLE 5 | Multinomial logistic regression analysis showing the odds of diabetes within each variable.
+Variable
+Reference Variable
+Dependent variable with
+self reported diabetes
+Odds Ratio (95% CI)
+p-value
+Area
+Rural
+Urban
+1.364(1.206-1.542)
+0.000
+Gender
+Male
+Female
+1.197(1.061-1.351)
+0.003
+Parental DM history
+Both non Diabetes
+One parent diabetic
+3.893(3.399-4.459)
+<0.001
+Two parent diabetic
+6.633(5.266-8.355)
+<0.001
+Marital status
+Unmarried
+Married
+1.290(1.116-1.491)
+0.000
+Diet
+Vegetarian
+Non-vegetarian
+2.208(0.757-5.488)
+0.159
+Yoga practice
+No
+Yes
+1.613(1.332-1.954)
+<0.001
+IDRS
+Low risk
+High risk
+6.211(5.340-7.223)
+<0.001
+Moderate risk
+1.674(1.438-1.950)
+<0.001
+Physical activity
+Vigorous
+Moderate
+0.801(0.852-0.984)
+0.035
+Mild
+0.894(0.738-1.088)
+0.203
+No
+1.065(0.869-1.305)
+0.548
+Waist circumference
+Normal risk
+Moderate risk
+1.535(1.322-1.782)
+<0.001
+High risk
+2.447(2.105-2.845)
+<0.001
+BMI
+Underweight
+Overweight
+2.128(1.518-2.985)
+0.000
+Obese
+3.057(2.129-4.389)
+0.000
+The odds ratio was calculated for geographical location, gender, marital status, parental DM history, diet, yoga practice, IDRS, physical activity, waist circumference, and BMI.
+Nagarathna et al.
+Prevalence and Determinants of Self-Reported Diabetes
+Frontiers in Endocrinology | www.frontiersin.org
+December 2020 | Volume 11 | Article 507064
+6
+to associate it with diabetes even though it has been shown that
+changes in the dietary pattern may reduce the chance of
+diabetes (41).
+The individuals who showed high IDRS but did not develop
+diabetes need to be followed up for any late development of
+diabetes, especially if it had not manifested in early life (< 35
+years). There is a need to develop a cost-effective and preventive
+management program to reduce or prevent diabetes
+complications in young adults. As yoga is emerging as a cost-
+effective lifestyle intervention and alternative, its efficacy in the
+prevention of diabetes can be examined in Indian population
+studies where its acceptability is high. The level of physical
+activity index among young adults with diabetes shows that
+26.9% of the young adults with high-risk diabetes did not
+perform any physical activity, and 9.5% and 3.7% of these
+individuals were engaged in mild and moderate physical
+activity, respectively, indicating that a sedentary lifestyle is one
+of the major risk factors in the development of diabetes among
+younger adults. Results demonstrated that only 54.5% of the
+young diabetes adults were taking treatment to control diabetes,
+and there were no medications being taken by 45.5% of the diabetes
+subjects (Table 4). The possible reason can be that patients might be
+asymptomatic as we analyzed in young population.
+Studies show that yoga helps in the activation of the
+hypothalamic pituitary axis and sympatho-adrenal component
+known to inhibit glucose uptake by inhibiting insulin release,
+inducing insulin resistance and increasing hepatic glucose
+production (42). Vigorous exercises have shown to increase
+HDL level, and moderate intensity exercises are effective in
+reducing VLDL (43). Young adults with higher risk for
+diabetes may benefit from practicing yoga as well as managing
+their obesity by engaging in vigorous and moderate intensity
+exercises to manage their lipid profile (Figure 2).
+Interestingly, young diabetes patients are amenable to reversal
+by intensive lifestyle intervention as seen in this young diabetes
+study (44). The diabetes young population has greater chances of
+reversal because of reduced risk factors as compared to the aged
+group. Diabetes, if it remains untreated/undetected in the early
+stage of life, may become more complicated in the later stage of
+life (30). Young diabetes often remains undetected as aged people
+continue to be tested for multiple health problems and
+identification and corresponding intervention programs are
+essential for this population. This study suggests that about
+one fourth of the young adult population in India is at a high
+risk of developing diabetes and in need of the public provision of
+lifestyle modification programs.
+Limitations
+The study used cluster sampling, which might have contributed
+to the sample selection bias. As a result, some subjects with
+diabetes might have refused to admit to having diabetes. It is also
+possible that a few subjects are wrongly believed to have diabetes,
+and there is no validation of such self-reported diabetes.
+Furthermore, undiagnosed diabetes could be another
+confounder. Subjects frequently ignore the subtle signs and
+symptoms of asymptomatic diabetes. The possibility of
+underestimation of the prevalence of diabetes in the proposed
+population may be the main limitation.
+FIGURE 2 | Yoga benefit in decreasing diabetic risks: The studies show that yoga causes vagal stimulation and, therefore, decreases inflammatory cytokines and
+heart rate as well as blood pressure. The yoga activates parasympthatic system that possibly leads to decreased perception of stress, activation, or reactivity of the
+sympathoadrenal system and HPA axis. Further, it may enhance metabolic and psychological responses, insulin sensitivity, glucose tolerance, improved lipid profile,
+mood, and decreased visceral adiposity.
+Nagarathna et al.
+Prevalence and Determinants of Self-Reported Diabetes
+Frontiers in Endocrinology | www.frontiersin.org
+December 2020 | Volume 11 | Article 507064
+7
+DATA AVAILABILITY STATEMENT
+All datasets generated for this study are included in the article/
+Supplementary Material. Data is available with the principal investigator.
+ETHICS STATEMENT
+Ethical permission obtained from Institutional Ethics Committee
+(IEC) meeting held at Indian Yoga Association, Morarji Desai
+National Institute of Yoga with reference no. RES/IEC-IYA/001
+dated 16th Dec 2016.
+AUTHOR CONTRIBUTIONS
+RN is a grant PI involved in conceptualization, editing of
+manuscript. PB was involved in original writing and data
+analysis. VS edited the manuscript. AA was involved in
+conceptualization of manuscript. VS edited the manuscript. SP
+was involved in data curation and analysis. GS and AS were
+involved in the acquisition of data. VP was involved in writing,
+editing and collection of data on site as physician. HRN was
+involved in conceptualization of manuscript, obtained resources
+and mentoring of work. All authors contributed to the article and
+approved the submitted version.
+ACKNOWLEDGMENTS
+We acknowledge AYUSH for funding and Department of
+Biotechnology, India for DBT-RAship program.
+SUPPLEMENTARY MATERIAL
+The Supplementary Material for this article can be found online
+at: https://www.frontiersin.org/articles/10.3389/fendo.2020.
+507064/full#supplementary-material.
+SUPPLEMENTARY TABLE 1 | Assessments phase.
+SUPPLEMENTARY TABLE 2 | Diet information.
+SUPPLEMENTARY TABLE 3 | Schedule of 5-day training camps of Yoga-
+Certified Volunteers for Diabetes Movement in different zones.
+SUPPLEMENTARY TABLE 4 | for Physical activity measurement.
+REFERENCES
+1. Owen N, Sparling PB, Healy GN, Dunstan DW, Matthews CE. Sedentary
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+Conflict of Interest: The authors declare that the research was conducted in the
+absence of any commercial or financial relationships that could be construed as a
+potential conflict of interest.
+Copyright © 2020 Nagarathna, Bali, Anand, Srivastava, Patil, Sharma, Manasa,
+Pannu, Singh and Nagendra. This is an open-access article distributed under the
+terms of the Creative Commons Attribution License (CC BY). The use, distribution or
+reproduction in other forums is permitted, provided the original author(s) and the
+copyright owner(s) are credited and that the original publication in this journal is
+cited, in accordance with accepted academic practice. No use, distribution or
+reproduction is permitted which does not comply with these terms.
+Nagarathna et al.
+Prevalence and Determinants of Self-Reported Diabetes
+Frontiers in Endocrinology | www.frontiersin.org
+December 2020 | Volume 11 | Article 507064
+9
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+© 2020 Acta Medica International | Published by Wolters Kluwer - Medknow
+108
+Abstract
+Original Article
+Introduction
+The increase in the incidence of type  2 diabetes 
+mellitus (T2DM) is attributable to various factors such as 
+genetic predisposition, rapid urbanization, smoking, and 
+intake of diet rich in refined carbohydrates, sugar‑sweetened 
+beverages  (SSBs), sedentary lifestyle, and obesity.[1] 
+The World Health Organization  (WHO) urges the health 
+decision makers to develop effective strategies to pause the 
+steady rise in noncommunicable diseases (NCDs) through 
+proper control of risk factors.[2] There are several lifestyle 
+interventions that are being interrogated for their efficacy 
+to prevent the incidence and effective management of 
+complications of T2DM. Studies in the past have suggested 
+that simple lifestyle modifications delay the onset of diabetes 
+mellitus by 11 years when compared to metformin, which 
+was able to delay it only by a span of 3 years.[3] However, 
+risk factors for any given condition might vary in different 
+ethnic populations.[4,5] Indians especially have multiple risk 
+factors making them more prone to T2DM when compared to 
+Caucasian counterparts.[6] Rapid physical and psychological 
+changes are quite common in adolescents and young adults 
+due to increasing demand from peers, family, and society, and 
+it is well documented that the behaviors developed during 
+this period have a bigger impact on health in adulthood.[7] The 
+lifestyle of adolescents and young adults is complex, which 
+increases the significance of the current study conducted on 
+the Indian population aged between 16 and 25 years.
+Materials and Methods
+The study design
+A cross‑sectional study design was adopted for this study. 
+All the participants were asked to provide their response to 
+Introduction: This was a cross sectional study to understand the prevalence of modifiable risk factors of diabetes among adolescents and 
+young adults in India. Materials and Methods: The pilot study was carried out using a questionnaire based survey. A literature review was 
+performed to explore the common risk factors associated with type 2 diabetes mellitus and a self administered questionnaire was developed 
+and validated. The snowball sampling method was applied and the questionnaire was sent through E mails, social networking sites, and 
+applications. Results: A total of 317 young adults and adolescents, aged between 16 and 25 years, across eight different states of India 
+completed the survey. Among the various risk factors, 64.04% had normal healthy sleeping hours of 6–8 h, and 71.61% happy with the sleep 
+quality. Only 23.08% skipped breakfast more than three times a week and 40.69% reported to consume whole grains every day. About 68.46% 
+had little or no stress. The major concern was the low of physical activity (>150 min/week) and inadequate fruit intake (>1 serving a day) 
+among 75.1% and 81.07% of respondents, respectively. Conclusion: Low physical activity and inadequate fruit intake are the important risk 
+factors prevalent in the given age group. 
+Keywords: Lifestyle, physical activity, risk factors, type 2 diabetes mellitus, young adults
+Address for correspondence: Dr. A. Mooventhan, 
+Department of Research and Development, Government Yoga and 
+Naturopathy Medical College, Chennai, Tamil Nadu, India. 
+ 
+E‑mail: dr.mooventhan@gmail.com
+Access this article online
+Quick Response Code:
+Website:  
+www.actamedicainternational.com
+DOI:  
+10.4103/ami.ami_124_20
+This is an open access journal, and articles are distributed under the terms of the Creative 
+Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to 
+remix, tweak, and build upon the work non‑commercially, as long as appropriate credit 
+is given and the new creations are licensed under the identical terms.
+For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com
+How to cite this article: Venugopal V, Ilavarasu JV, Mooventhan A. 
+Prevalence of modifiable risk factors associated with diabetes in indian 
+adolescents and young adults: A pilot study. Acta Med Int 2020;7:108-12.
+Prevalence of Modifiable Risk Factors Associated with Diabetes 
+in Indian Adolescents and Young Adults: A Pilot Study
+V. Venugopal, Judu V. Ilavarasu1, A. Mooventhan2
+Departments of Yoga and 2Research and Development, Government Yoga and Naturopathy Medical College, Chennai, Tamil Nadu, 1Division of Yoga and Physical 
+Sciences, SVYASA (Deemed to be University), Bengaluru, Karnataka, India
+Submitted: 27‑Jul‑2020    Accepted: 16-Oct-2020.    Published: 21-Dec-2020
+[Downloaded free from http://www.actamedicainternational.com on Wednesday, January 27, 2021, IP: 10.232.74.27]
+Venugopal, et al.: Modifiable diabetes risk factors in India
+Acta Medica International  ¦  Volume 7  ¦  Issue 2  ¦  July-December 2020
+109
+a questionnaire‑based survey at only one point in time. The 
+analysis was performed after completion of the study.
+Study settings
+The study was carried out at Anvesana laboratories, 
+SVYASA (Deemed to be University), Bengaluru, India.
+Participants
+A total of 317 participants aged between 16 and 25 years 
+from eight different states of India were recruited through the 
+snowball sampling method based on the following inclusion 
+and exclusion criteria. Male and female adolescents and young 
+adults of Indian citizen who are willing to provide their response 
+to the specified questionnaire through social media and willing 
+to participate in the study were included. Nonresident Indians, 
+participants with a history of diabetes and other systemic 
+illness, and mental illness were excluded from the study. 
+The study protocol was approved by the Institutional Ethics 
+Committee (IEC) of SVYASA (Deemed to be University) (IEC 
+approval Number: RES/IEC‑SVYASA/74/2015) and informed 
+consent was obtained from the participants.
+Assessments
+The assessment was taken using a questionnaire related to 
+various modifiable risk factors associated with T2DM. An 
+initial literature search was performed to identify the various 
+risk factors associated with T2DM, in PubMed, Medline, and 
+Google Scholar. Questions were framed under four major 
+domains, namely diet, physical activity, sleep, and stress. 
+After framing the questions, it was sent to 25 subject matter 
+experts (SMEs) for construct validity. SMEs were selected 
+based on the criteria of being endocrinologists, with a minimum 
+of five research publications in peer‑reviewed journals. The 
+response was obtained from 16, out of the 25 SMEs to whom 
+the questions were sent (64%). After framing the final set of 
+questionnaires, it was digitalized and sent to respondents across 
+the country, through the snowball sampling method.
+A total of 12 close‑ended questions were asked along with 
+demography details. Social networking sites and mobile 
+applications were used for the same. Every question was 
+carrying a brief description of one or two lines explaining the 
+question further. For example, an explanation of what “one 
+serving size of fruit” means, what are “whole and refined 
+grains,” etc.
+Data analysis
+Responses received from the assessment were pooled together 
+in Microsoft Excel. Descriptive statistics were performed and 
+the sample data (demographic details and the response to the 
+questionnaire) were presented in frequency and percentage 
+using Statistical Package for the Social Sciences (SPSS) for 
+Windows, Version 16.0. Chicago, SPSS Inc.
+Results
+A total of 317 participants from eight different states of India 
+responded to the questions. The demographic details of the 
+respondents are provided in Table 1. On skipping breakfast, 
+38.43% of respondents said that they never skip breakfast 
+and another 38.49% skip only once or twice per week. About 
+81.07% take <1 serving, whereas 16.72% take 2–3 servings, 
+and only 2.21% take >5 servings of fruit in a day. Consumption 
+of carbonated drinks was less, as 34.7% said that they hardly 
+consume carbonated drinks and 41.32% said that they drink 
+only once or twice per week. Whole‑grain consumption was 
+a part of everyday diet in 40.69% and 17.67% mentioned that 
+whole grains are rarely part of their diet. On taking refined flour 
+products, 61.20% responded that they take 1–3 days/week, 
+whereas 26.50% take rarely, 6.31% take 4–6 days/week, and 
+5.99% take almost every day. No structured physical activity or 
+outdoor sports activity was reported in 33.4% of respondents. 
+Another 41.64% did 30–90 min of physical activity in a week, 
+whereas only 9.78% and 15.14% did 90–150 min and >150 min 
+of physical activity in a week. Around 63.1% of respondents 
+mentioned that their usual mode of transport was either 
+two‑wheeler or a four‑wheeler and only 36.9% of individuals 
+in this particular age group preferred using public transport 
+or commuting by walk. Six to 8 h of sleep was reported by 
+64.04% of respondents. About 71.61% are happy with their 
+Table 1: Demographic details of the study participants
+Parameters
+n (%)
+Age group
+Adolescence (16-18)
+89 (28.10)
+Early adulthood (19-25)
+228 (71.90)
+Education
+School going
+65 (20.50)
+College going
+222 (70.03)
+Postgraduate
+26 (8.20)
+Working
+4 (1.26)
+City/town
+Rural
+141 (44.48)
+Urban
+176 (55.52)
+Gender
+Male
+136 (42.90)
+Female
+181 (57.10)
+State
+Andhra Pradesh
+36 (11.36)
+Bihar
+21 (6.62)
+Gujarat
+28 (8.83)
+Karnataka
+68 (21.45)
+Kerala
+37 (11.67)
+Maharashtra
+22 (6.94)
+Tamil Nadu
+68 (21.45)
+Uttar Pradesh
+37 (11.67)
+Family history
+None
+116 (36.59)
+Either or
+126 (39.75)
+Both
+75 (23.66)
+Socioeconomic status - Total family income
+Low (<Rs. 2 lakhs/annum)
+185 (58.36)
+Medium (Rs. 2-5 lakhs/annum)
+87 (27.44)
+High income (>Rs. 5 lakhs/annum)
+45 (14.20)
+[Downloaded free from http://www.actamedicainternational.com on Wednesday, January 27, 2021, IP: 10.232.74.27]
+Venugopal, et al.: Modifiable diabetes risk factors in India
+Acta Medica International  ¦  Volume 7  ¦  Issue 2  ¦  July-December 2020
+110
+quality of sleep. Mild or no stress was perceived by 68.46% 
+of respondents [Table 2].
+Discussion
+Lifestyle plays a significant role in the development of 
+Type 2 diabetes. There are numerous modifiable risk factors 
+that are attributed to the increased prevalence of T2DM. It is 
+well documented that Indians are more prone to T2DM than 
+Caucasians, and the increased risk is not merely due to the 
+nonmodifiable genetic risk factors.[6] Modifiable risk factors 
+such as diet and physical activity also play an important role 
+in the increased prevalence of T2DM.[8] Early intervention 
+might probably help prevent T2DM and metabolic syndrome 
+better. The current study was conducted on Indian adolescents 
+and young adults to understand the degree of exposure to 
+various risk factors of T2DM. Skipping breakfast more than 
+three times a week increases the risk of obesity and T2DM.[9] 
+About 38.43% of respondents in our study mentioned that 
+they never skip breakfast and another 38.49% reported that 
+they skip once or twice a week. Whole‑grain consumption 
+reduces the risk of diabetes.[10,11] Around 40.69% mentioned 
+that whole grains are a part of their everyday meal. Carbonated 
+and SSBs are the other dietary risk factors that increase the 
+risk of T2DM.[12,13] Consumption of one serving of carbonated 
+drink per day increases the risk of T2DM by 26%,[14] but 34.7% 
+of the respondents had reported that they hardly consume 
+carbonated drinks and another 41.32% said that they drink 
+only once or twice per week.
+Sleep duration and quality of sleep are gaining increasing 
+significance as an important risk factor in the pathogenesis of 
+T2DM.[15] Sleep duration has a “U‑shaped” relation with the 
+risk of diabetes. Sleeping <6 h or >8 h increases the risk of 
+diabetes.[16] In our study, 64.04% of respondents reported to 
+have the optimum sleep of 6–8 h every day and 71.61% were 
+happy with the quality of sleep.
+The major concern in the given sample which constituted mostly 
+young adults (71.9%) and school‑going adolescents (28.1%) is 
+the lack of physical activity. No structured physical activity or 
+outdoor sports activity was observed in 33.4% of respondents. 
+Another 41.64% did 30–90 min of physical activity in a 
+week which is below the American Diabetes Association 
+recommendation of 150 min physical exercise per week.
+[17] The findings are in line with the findings of a previous 
+large‑scale study in India, in which 54.4% were found to be 
+not physically active.[8] Reduced physical activity had been 
+reported in adolescents of other ethnic groups as well.[18,19] 
+Another interesting observation in the study was the preferred 
+mode of transport in particular adolescence and young adults’ 
+age group. Around 63.1% of respondents mentioned that they 
+use either a two‑wheeler or a four‑wheeler for commuting and 
+only 36.9% preferred using public transport or commuting by 
+walk. Thus, reduced physical activity seems to be the strongest 
+risk factor observed in the given adolescent and young adult 
+population.
+An increase in fruit consumption is associated with the 
+reduction in body weight, waist circumference,[20] and T2DM 
+risk.[21,22] Higher fruit intake was associated with significantly 
+lower fasting blood insulin, homeostatic model assessment 
+of insulin resistance, and risk of developing diabetes by 12% 
+Table 2: Participants’ responses to the questionnaire 
+assessed in the study
+Parameters
+Participant responded, n (%)
+Skipping breakfast/week
+Never
+125 (39.43)
+1-2 days
+122 (38.49)
+3-5 days
+35 (11.04)
+Almost everyday
+35 (11.04)
+Fruit intake/day
+0-1 serving
+257 (81.07)
+2-3 servings
+53 (16.72)
+5 or more servings
+7 (2.21)
+Carbonated drinks/week
+Never
+110 (34.70)
+Up to 400 mL
+131 (41.32)
+Up to 1000 mL
+68 (21.45)
+>1000 ml
+8 (2.52)
+Whole grains intake/week
+Rarely
+56 (17.67)
+1-3 days
+106 (33.44)
+4‑6 days
+26 (8.20)
+Almost everyday
+129 (40.69)
+Refined flour products intake/week
+Rarely
+84 (26.50)
+1-3 days
+194 (61.20)
+4-6 days
+20 (6.31)
+Almost everyday
+19 (5.99)
+Exercise/outdoor sports activity/week
+<30 min
+106 (33.44)
+30-90 min
+132 (41.64)
+90-150 min
+31 (9.78)
+>150 min
+48 (15.14)
+Mode of transport
+By walk
+60 (18.93)
+Public transport
+57 (17.98)
+Two‑wheeler
+162 (51.10)
+Four‑wheeler
+38 (11.99)
+Stress
+No stress
+58 (18.30)
+Mild stress
+159 (50.16)
+Moderate stress
+92 (29.02)
+Severe stress
+8 (2.52)
+Sleeping h/day (h)
+>6
+82 (25.87)
+6-8
+203 (64.04)
+8-9
+30 (9.46)
+>9
+1 (0.32)
+Overall sleep quality (subjective)
+Happy
+227 (71.61)
+Unhappy
+90 (28.39)
+[Downloaded free from http://www.actamedicainternational.com on Wednesday, January 27, 2021, IP: 10.232.74.27]
+Venugopal, et al.: Modifiable diabetes risk factors in India
+Acta Medica International  ¦  Volume 7  ¦  Issue 2  ¦  July-December 2020
+111
+compared to nonconsumers. Likewise, consuming fresh fruit 
+more than 3 days/week was associated with a 13%–28% 
+lower risk of developing diabetes‑related complications 
+affecting large blood vessels (e.g., ischemic heart disease 
+and stroke) and small blood vessels (i.e., kidney diseases, 
+eye diseases, and neuropathy) compared to consuming fresh 
+fruit <1 day/week.[20] In addition, the dose‑response relations 
+also indicate that relatively high fruit may still decrease the 
+risk of T2DM. To minimize the risk of dietary factors and 
+reduce the incidence of T2DM; The WHO has recommended 
+the public for consuming more than 400 g or five servings of 
+fruit and vegetable per day.[22] In the present study, 81.07% 
+of respondents reported that they take <1 serving, whereas 
+16.72% take 2–3 servings, and only 2.21% take >5 servings 
+of fruit in a day. This suggests that inadequate fruit intake 
+is also an important risk factor contributing to the increased 
+incidence of T2DM in India. In summary, the current study 
+was conducted on respondents from eight different states across 
+India. Reduced physical activity and inadequate fruit intake 
+seem to be the most common risk factors observed in the given 
+adolescent and young adult population.
+With the increasing prevalence of diabetes in India, there is 
+a growing need for a public health strategy to address the 
+problem of physical inactivity in this age group and prevent 
+T2DM. The promotion of physical activity is an essential 
+public health and health promotion strategy to improve the 
+health of individuals.[2] Likewise, school‑based programs on 
+healthy lifestyle and improved physical activity would be 
+beneficial. A large systematic review conducted on 36,593 
+children and adolescents suggested that school‑based physical 
+activity promotion programs are effective in increasing 
+the duration of physical activity and reduce time spent 
+watching television.[23] A combination of school‑based and 
+community‑based health promotion programs might have a 
+synergistic effect in improving the health status and would 
+prevent childhood obesity and T2DM.
+Strengths and limitations
+The main strength of the study is focusing exclusively 
+on the adolescent and young adult population. Several 
+health‑compromising behaviors and health‑enhancing 
+behaviors adopted in adolescence often persist into adulthood.[7] 
+Early dietary modifications and improved physical activity 
+would be beneficial not only in overcoming childhood 
+obesity but also help in preventing metabolic syndrome and 
+T2DM.[24‑26] Targeting this particular age group and improving 
+their lifestyle would be of greater significance, especially while 
+designing and implementing lifestyle modification strategies 
+in nationwide diabetes prevention programs. In this study, we 
+had also piloted on the usage of social media as an effective 
+health tool to recruit using the snowball sampling method. 
+Our initial concern was whether the questionnaires would 
+reach low‑socioeconomic and rural parts of the country. To 
+our surprise, 44.5% of the respondents were from rural parts 
+of the country and 58.4% of the respondents were from low 
+socioeconomic status. One of the limitations of the study is 
+responses given by the respondents were “subjective” and 
+thus might be less reliable than objective ways of measuring. 
+Second is the unavailability of data from the remaining states 
+of the country. The data used in the current pilot study are only 
+from eight of the 29 states in India. Representative samples 
+from all the states of the country would possibly be obtained 
+in our main study.
+Conclusion
+Among the various risk factors of diabetes, lack of physical 
+activity and inadequate fruit intake seem to be the major risk 
+factors of this particular adolescent and young adult group. 
+Promoting physical activity in the form of sports or other 
+community activity and adequate fruit intake is essential to 
+prevent the increase in the prevalence of NCDs in developing 
+countries like India. Large‑scale studies across the country are 
+required to consolidate our findings.
+Financial support and sponsorship
+Nil.
+Conflicts of interest
+There are no conflicts of interest.
+References
+1.	 Hu FB. Globalization of diabetes: The role of diet, lifestyle, and genes. 
+Diabetes Care 2011;34:1249‑57.
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+Organization; 2014. Available from: https://apps.who.int/gb/archive/
+pdf_files/WHA59/A59_23-en.pdf?ua=1.” [Accessed on 25 October 
+2020].
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+Prevalence of diabetes and prediabetes in 15 states of India: Results 
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+grain consumption and the risk of type 2 diabetes: A systematic review 
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+Venugopal, et al.: Modifiable diabetes risk factors in India
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+Woodhead  C, et  al. Association between sugar‑sweetened and 
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+and dose‑response meta‑analysis of prospective studies. Br J Nutr 
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+Sugar‑sweetened beverages and risk of metabolic syndrome and type 2 
+diabetes. Diabetes Care 2010;33:2477‑83.
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+risk of type 2 diabetes: A meta‑analysis of prospective studies. Diabetes 
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+16.	 Kowall B, Lehnich AT, Strucksberg KH, Führer D, Erbel R, Jankovic N, 
+et al. Associations among sleep disturbances, nocturnal sleep duration, 
+daytime napping, and incident prediabetes and type  2 diabetes: The 
+Heinz Nixdorf Recall Study. Sleep Med 2016;21:35‑41.
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+adolescents. J Youth Adolesc 1998;27:245‑53.
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+Prev Med 2004;27:277‑83.
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+Schwedhelm C, et al. Food groups and risk of type 2 diabetes mellitus: 
+A  systematic review and meta‑analysis of prospective studies. Eur J 
+Epidemiol 2017;32:363‑75.
+22.	 Li M, Fan Y, Zhang X, Hou W, Tang Z. Fruit and vegetable intake and 
+risk of type  2 diabetes mellitus: Meta‑analysis of prospective cohort 
+studies. BMJ Open 2014;4:e005497.
+23.	 Dobbins  M, Husson  H, DeCorby  K, LaRocca  RL. School‐based 
+physical activity programs for promoting physical activity and fitness 
+in children and adolescents aged 6 to 18. Cochrane Database Syst Rev 
+2013;2:CD007651.
+24.	 Telama  R, Yang  X, Leskinen  E, Kankaanpää A, Hirvensalo  M, 
+Tammelin T, et al. Tracking of physical activity from early childhood 
+through youth into adulthood. Med Sci Sports Exerc 2014;46:955‑62.
+25.	 Kemper HC, Post GB, Twisk JW, van Mechelen W. Lifestyle and obesity 
+in adolescence and young adulthood: Results from the Amsterdam 
+Growth and Health Longitudinal Study (AGAHLS). Int J Obes Relat 
+Metab Disord 1999;23 Suppl 3:S34‑40.
+26.	 Nupponen M, Pahkala K, Juonala M, Magnussen CG, Niinikoski H, 
+Rönnemaa T, et  al. Metabolic syndrome from adolescence to 
+early adulthood: Effect of infancy‑onset dietary counseling of 
+low‑saturated‑fat: The Special Turku Coronary Risk Factor Intervention 
+Project (STRIP). Circulation 2015;131:605‑13.
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diff --git a/subfolder_0/Prevalence of polycystic ovarian syndrome in Indian adolescents.txt b/subfolder_0/Prevalence of polycystic ovarian syndrome in Indian adolescents.txt
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+Original Study
+Prevalence of Polycystic Ovarian Syndrome in Indian Adolescents
+Ram Nidhi MSc Yoga,
+EQ1
+Venkatram Padmalatha MBBS, MRCPI, Raghuram Nagarathna MBBS, MD *,
+Ram Amritanshu MSc Yoga
+Division of Yoga and Life Sciences, SVYASA University, Bangalore, India
+Q1
+a b s t r a c t
+Background: PCOS is a common female endocrine disorder with prevalence ranging from 2.2% to 26%. Most reports have studied adult
+women with age ranged from 18 to 45 years. The aim of this study was to find the prevalence of PCOS in Indian adolescents.
+Method: We prospectively studied 460 girls aged 15 to 18 years from a residential college in Andhra Pradesh, South India, who underwent
+clinical examination. Out of which 72 girls with oligomenorrhea and/or hirsutism were invited for biochemical, hormonal, and ultraso-
+nographic evaluation for diagnosis of PCOS by Rotterdam criteria.
+PCOS was defined as the presence of any two of the three features: (1) Oligo/amenorrhea: absence of menstruation for 45 days or more
+and/or #8 menses per year. (2) Clinical hyperandrogenism: Modified Ferriman and Gallway (mFG) score of 6 or higher. (3) Polycystic
+ovaries: presence of O10 cysts, 2e8 mm in diameter, usually combined with increased ovarian volume of O10 cm3, and an echo-dense
+stroma in pelvic ultrasound scan.
+Results: Out of 460 girls, one (0.22%) had oligo/amenorrhea with clinical hyperandrogenism, 29 (6.30%) had oligomenorrhea with polycystic
+ovaries, one (0.22%) had polycystic ovaries with clinical hyperandrogenism and 11 (2.39%) had oligomenorrhea with polycystic ovaries in
+the presence of clinical hyperandrogenism. Thus 42 (9.13%) girls satisfied Rotterdam’s criteria for PCOS, which increased to 50.46 (10.97%)
+when imputed data were included.
+Conclusion: Prevalence of PCOS in Indian adolescents is 9.13%.This draws attention to the issue of early diagnosis in adolescent girls.
+Key Words: PCOS, Adolescents, India
+Introduction
+Polycystic ovarian syndrome (PCOS) is the most common
+female endocrine disorder with a highly variable prevalence
+estimates, ranging from 2.2% to 26%1e6 which is attributed
+to lack of a universal definition.7
+In the year 2004, the most accepted Rotterdam criterion
+was formulated by the PCOS Consensus Workshop Group,
+(Rotterdam
+ESHRE/ASRM-Sponsored
+PCOS
+Consensus
+Workshop Group). According to this, PCOS is diagnosed if at
+least two of the following three features namely (1) oligo/
+amenorrhea, (3) clinical or biochemical hyperandrogenism,
+and (3) PCO on ultrasonography are present and other
+conditions that could mimic PCOS such as Cushing’s
+syndrome, late onset adrenal hyperplasia, or androgen
+producing neoplasm are excluded.8 Because there are no
+established criteria for the diagnosis of PCOS in adolescents,
+the adult criteria are applied to adolescents as well.
+The manifestations of PCOS may develop in adolescence
+but may not be diagnosed until well into adulthood. It is
+believed that both genetic predisposition and life style
+factors contribute to the etiology of PCOS. Gestational
+factors such as disturbed fetal programming in utero and
+birth weight (small and/or large-for-gestational-age) have
+been postulated to be the earliest precursors of PCOS.9
+Premature adrenarche has been found to carry a 15e20%
+risk of developing PCOS.10 Though a female may be genet-
+ically predisposed to developing PCOS,11,12 it is yet to be
+understood as to how genetic predisposition results in the
+final expression of PCOS. Altered life style that includes high
+calorie diet and lack of exercise resulting in obesity and
+insulin resistance which has been well recognized as
+a exacerbating factor for PCOS.13 Association between stress
+and PCOS has been documented14,15 but there are no studies
+that directly point to stress as an etiological factor.
+The prevalence rates of PCOS depend to a great extent on
+the criteria used to define this disorder. In 1980s the use of
+ultrasound imaging revealed that that polycystic ovaries
+were commonly associated with hirsutism and hyper-
+androgenemia in women with regular ovulatory cycles.16,17
+Studies showed that women with regular cycles and poly-
+cystic ovaries share many of the biochemical features of
+PCOS.18
+Also to study the genetic basis of this syndrome,
+studies done on familial PCOS suggested that subjects
+with classic features of PCOS, anovulation and hyper-
+androgenism, may have an affected sister who is equally
+hyperandrogenemic,
+but
+has
+regular
+cycles19,20
+and
+polycystic
+ovaries.21
+Thus
+it
+would
+seem
+unwise
+to
+consider the anovulatory hirsute female to have a funda-
+mentally
+different
+disorder
+from
+the
+female
+with
+hirsutism and regular cycles or the nonhirsute woman
+with anovulatory infertility.
+Conflict of Interest: It is declared that none of the authors involved in this study
+have any conflict of interest and we have independently declared the same in the
+form provided by the journal.
+* Address correspondence to: Raghuram Nagarathna, MBBS, MD, #19, Eknath
+Bhavan, Gavipuram Circle Kempegowdanagar, Bangalore - 560 019
+E-mail address: rnagaratna@gmail.com (R. Nagarathna).
+1083-3188/$ - see front matter 
 2011 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc.
+doi:10.1016/j.jpag.2011.03.002
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+Therefore certainly Rotterdam criterion looks more
+inclusive than the NIH criterion.
+Also in the literature we find differences in prevalence
+percentages for NIH and Rotterdam criterion. Michelmore
+et al reported a prevalence of 26% according to Rotterdam
+criteria and 8% according to NIH criteria.2 Similar reports
+were observed in a recent survey on 728 women wherein
+the prevalence was 8.7% according to NIH criteria and 17.8%
+according to Rotterdam criteria.22
+The prevalence seems to vary widely in different coun-
+tries. In the U.S., two studies that used NIH criteria have
+documented prevalence rates of 4% in a population of 400
+women4 and 6.6% in women from a southeastern univer-
+sity.6 Prevalence among women from other races appears to
+be similar. A study on 154 Caucasian women in Madrid,
+Spain, also found similar prevalence rates of 6.5%.3 Thus, it
+appears that the prevalence of clinically evident PCOS in
+women of reproductive age in Europe and America ranges
+from 6.5 to 8.0% using the 1990 NIH criteria and it rises two-
+to three-fold if the Rotterdam criteria are applied.
+The prevalence in Asian countries appears to be lower,
+with a reported prevalence of 2.4% in China1 and 6.3% in Sri
+Lanka23 (Rotterdam criteria).
+To our knowledge, there are no studies that have repor-
+ted the prevalence of PCOS in India although there are
+studies on metabolic and other abnormalities in patients
+with PCOS in India.24 One study on Indian women living in
+England has shown a high prevalence of 52% which cannot
+reflect the prevalence of PCOS.25 There are reports that
+Indian patients with PCOS have higher fasting insulin levels
+and greater IR compared to British and Australian white
+women with PCOS.26,27 There appears to be significant
+ethnic and racial variations in the clinical presentation of
+PCOS, including the frequency of obesity and insulin resis-
+tance and it is possible that the prevalence of PCOS might
+differ among different sections of the society and different
+age groups in India.26
+Identifying and treating adolescents with PCOS is of
+prime importance, as adult womenwith PCOS have a 10-fold
+increased risk of developing type 2 diabetes, and a 2-fold
+increased risk of the metabolic syndrome. Hence the current
+study was undertaken to estimate the prevalence of PCOS
+among adolescent girls in South India using Rotterdam’s
+criteria.
+Materials and Methods
+This study was carried out on adolescent girls between
+15 to 18 years from a College in Anantapur, Andhra Pradesh,
+India. Although they were students of one residential
+college in Anantapur, they represented a larger geograph-
+ical area because they were from semi-urban and rural
+areas around the district. All participants were clinically
+healthy and none were suffering from chronic or acute
+diseases.
+Definitions
+The definition of PCOS, in 1990, when it was first
+described by National Institute of Health (NIH) included
+hyperandrogenism and ovulatory dysfunction but did not
+include polycystic ovarian morphology on ultrasonography
+as a necessary criterion for diagnosis. Much later, in the year
+2004, the Rotterdam criterion was formulated by the PCOS
+Consensus Workshop Group, (Rotterdam ESHRE/ASRM-
+Sponsored PCOS Consensus Workshop Group) according
+to which PCOS was defined as presence of any two of the
+three features: oligo/amenorrhea, clinical and/or biochem-
+ical hyperandrogenism, and polycystic ovaries.
+Oligo/amenorrhea: absence of menstruation for 45 days
+or more and/or #8 menses per year.23
+Clinical
+hyperandrogenism:
+Modified
+Ferriman
+and
+Gallway (mFG) score of 6 or higher.1 Using mF-G, some
+researchers reported a value as low as 3, which was
+abnormal. However, other investigators have used the 95th
+percentile of controls as the upper normal limit, which
+corresponds to an mF-G score of 6e8 in the population
+studied. We used an mF-G score of 6 as the upper normal
+limit in accordance with a study in South Asia by Chen
+et al22 because there are no studies defining the criteria for
+hirsutism in Indian girls.
+Biochemical
+hyperandrogenism:
+Serum
+testosterone
+level of O82 ng/dl in the absence of other causes of
+hyperandrogenism.
+Polycystic ovaries: presence of O10 cysts, 2e8 mm in
+diameter, usually combined with increased ovarian volume
+of O10 cm3, and an echo-dense stroma16 in pelvic ultra-
+sound scan.
+Data Collection
+The study was approved by the Institutional Ethical
+Committee of Swami Vivekananda Yoga Anusandhana
+Samsthana (SVYASA) University. The college administration
+also gave the assent for the study. Participants (students of
+the college) initially attended an interactive introductory
+lecture by the senior research staff where the study design
+and purpose was elucidated. They were asked to report one
+week later after obtaining the signed consent from their
+parents.
+All girls who consented for the study were asked to fill up
+a short PCOS symptoms check list that asked questions on
+the pattern of menstrual cycle, hirsutism, acne, alopecia,
+and acanthosis nigricans, and information about past
+diagnosis or treatment of PCOS or any other illnesses. After
+one week, individual interviews were conducted to confirm
+statements in the check list. The research medical officer
+conducted a physical examination to look for external
+features of PCOS and also to exclude other conditions that
+could mimic PCOS such as Cushing syndrome, adrenal
+hyperplasia or androgen producing neoplasm. Questions
+were asked about the use of oral contraceptive pills or any
+other hormones that could affect the length of
+the
+menstrual cycle.
+Selfereported degree of hirsutism was assessed using
+modified Ferriman-Gallwey (mF-G) scoring method. The
+girls were asked to compare the amount of body hair they
+had with a chart of pictures displaying the degree of hair
+growth in nine regions (i.e., upper lip, chin, chest, upper and
+lower abdomen, upper and lower back, upper arms, and
+R. Nidhi et al. / J Pediatr Adolesc Gynecol xxx (2011) 1e5
+2
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+thighs). Hirsutism scores recorded by the girls were
+checked for accuracy during clinical examination by the
+researcher and corrected with the consent of the participant
+when deemed necessary.
+Also girls were asked about the presence of acne or hair
+fall from the scalp although it was not quantified.
+All girls with oligomenorrhea and/or hirsutism (as per
+the above said definitions) were asked to come for pelvic
+ultrasound and
+biochemical
+investigations.
+Ultrasound
+scanning of the abdomen and pelvis with special attention
+on ovaries was carried out by a certified postgraduate
+medical ultrasonologist using Philips HD 11XE ultrasound
+system.
+Fasting sample of venous blood (10 ml) was drawn in the
+morning (6:00e8:00
+AM) at the hostel premises. The
+samples were packed in ice (3e4
C) and transported to the
+laboratory within 4e6 hours for separation. Serum was
+separated by centrifugation and stored at 20
C until it was
+analyzed at certified laboratories.
+Hormone estimates including total testosterone (TT),
+luteinizing hormone (LH), follicle- stimulating hormone
+(FSH) and Prolactin (PRL), were done by Fully Automated
+Bidirectionally Interfaced Chemi Luminescent Immuno
+Assay with Intra assay coefficients of variation of 2.6%, Inter
+assay coefficients of variation of 4.3% and Sensitivity of 10
+ng/dl. TSH was measured by Ultra Sensitive Sandwich
+Chemi Luminescent Immuno Assay.
+Results
+Five-hundred twenty girls attended the introductory
+lecture. Of these 460 girls (88.46 %) responded and agreed
+to participate. Their age ranged between 15 and 18 years
+with a mean age of 15.7 years. Figure 1 outlines the data
+collection procedure and outcomes. A “probable diagnosis”
+of PCOS was found among 72 girls (15.65%) identified to
+have oligo/amenorrhea and/or clinical hyperandrogenism.
+Of these, 59 (81.94%) had oligo/amenorrhea in the presence
+or absence of clinical hyperandrogenism and 13 (18.05%)
+had
+regular
+menstrual
+cycles
+with
+clinical
+hyper-
+androgenism. All the 72 girls were asked to come for
+ultrasound scanning and blood test. 17 did not consent for
+undergoing ultrasound scanning due to personal reasons.
+Out of the 55 girls who underwent ultrasound scanning,
+44 had polycystic ovaries on ultrasonography. All of the 72
+girls gave blood sample for biochemical and hormonal
+evaluations. Two girls were excluded as they had hypo-
+thyroidism
+while
+one
+girl
+was
+excluded
+due
+to
+hyperthyroidism.
+In summary, out of the 460 girls screened, 42 girls
+satisfied Rotterdam criteria of PCOS. Thus, the prevalence of
+PCOS was 9.13% in this population. Among 42 PCOS girls,
+one girl (2.38%) had oligo/amenorrhea with clinical hyper-
+androgenism, 29 (69.05%) had oligomenorrhea with poly-
+cystic ovaries, one girl (2.38%) had polycystic ovaries with
+clinical hyperandrogenism and 11(26.19%) girls had oligo-
+menorrhea with polycystic ovaries in the presence of clin-
+ical hyperandrogenism. Out of 42 girls who had PCOS, 12
+(2.61%) satisfied the NIH criteria.
+However, by assuming that the girls who did not have an
+ultrasound had a similar prevalence of polycystic ovaries
+and including the imputed data, the total prevalence esti-
+mates increased to 10.97%. Table 1 shows the estimated
+prevalence of PCOS for each phenotype under Rotterdam
+criteria.
+Table 2 shows the mean values for demographic,
+anthropometric, and biochemical characteristics. Of the 42
+PCOS girls, 97.62% had oligo/amenorrhea in the presence or
+absence of hyperandrogenism and 30.95% had an mFG score
+of 6 or higher, although only 4.76% had a testosterone level
+greater than 82 ng/dl. Polycystic ovaries were seen among
+97.62%. Thus majority of the girls with PCOS had oligo/
+amenorrhea and polycystic ovaries.
+14.29% had a BMI greater than 23 although only 7.14%
+were overweight with a BMI greater than 25. Android
+obesity, with a waist hip ratio greater than 0.85 was seen in
+26.19%. The ratio of LH to FSH greater than 1:1 was seen in
+50%.
+Fig. 1. Trial profile.Ă
+Table 1.
+Estimated Prevalence Including Imputed Values for All Phenotypes under Rotterdam
+Criteria
+Phenotypes according to Rotterdam
+Total known
+PCOS n (%)
+Total þ imputed
+polycystic ovaries n
+(%)*
+a. Oligomenorrhea þ clinical and/or
+biochemical hyperandrogenism þ
+polycystic ovaries
+11 (2.39)
+11.92 (2.59)
+b. Oligomenorrhea þ clinical and/or
+biochemical hyperandrogenism only
+1 (0.22)
+1.08 (0.23)
+c. Clinical and/or biochemical
+hyperandrogenism þ polycystic ovaries
+1 (0.22)
+3.25 (0.71)
+d. Oligomenorrhea þ polycystic ovaries
+29 (6.30)
+34.21 (7.44)
+Total
+42 (9.13)
+50.46 (10.97)
+* Includes imputed values of the number of girls with polycystic ovaries in the
+group that did not have an ultrasound. This was calculated within each phenotype
+by multiplying the proportion with polycystic ovaries in the group completing an
+ultrasound, by the number not undertaking an ultrasound. [E.g., for phenotype c. (1/
+4)  9 5 2.25; where n 5 9 did not have an ultrasound in this phenotype; where 2.25
+þ 1 5 3.25 (the imputed value)].
+R. Nidhi et al. / J Pediatr Adolesc Gynecol xxx (2011) 1e5
+3
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+FLA 5.1.0 DTD 
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+Discussion
+To the best of our knowledge, this is the first study on the
+prevalence of PCOS ever carried out in India. This study has
+shown 9.13% prevalence of PCOS according to Rotterdam
+criteria in girls between 15 to 18 years of age, which
+increased to 10.97% when imputed data were included.
+Other studies on Asian population have reported lower
+prevalence rates: 6.3% in Sri Lankan population23 and 2.4%
+in Chinese population.1 This higher prevalence in India as
+compared to other Asian countries could be expected
+because we know the strong etiological link between PCOS
+and diabetes, and India has the higher prevalence of
+diabetes.
+Comparison of our results with those of other authors is
+difficult since there are limited data in the literature about
+PCOS in adolescence.
+The prevalence of 10.97% reported in our study is close to
+that reported by March et al in an Australian population
+which showed a prevalence of 11.9%,22 although there are
+small differences in the diagnostic criteria used in the two
+studies. Their inclusion for clinical examination was based
+on menstrual irregularity and/or self reported hirsutism of
+mF-G score $8. They defined menstrual irregularity as
+a cycle length of #21 days or $35 days, or $ a 4-day vari-
+ation. Only those satisfying these criteria were invited for
+ultrasound of the ovaries and blood tests and the remaining
+women were considered to not have PCOS. In our study the
+inclusion was based on menstrual irregularity of $45 days
+and/or presence of hirsutism with an mFG score greater
+than 6. All of these girls were invited for pelvic ultrasound.
+Inclusion in the study based on the mF-G score is still
+debatable because determination of hirsutism using mF-G
+scale is subjective, with significant inter-observer varia-
+tion and also it depends on the ethnicity of the population.
+Only 5.65% of girls out of 460 girls screened in our study had
+clinical hyperandrogenism with an mF-G score $6.
+In comparison with other studies that have used
+Rotterdam criteria, among 42 confirmed PCOS in our study,
+the prevalence of oligo/amenorrhea observed (97.62%) was
+similar to that found in the Sri Lankan population (95.1%)
+but much higher compared to that found in South
+Australian population (23.8%). This points to a higher
+prevalence of oligo/amenorrhea in the Asian scenario.
+The age groups studied in Chinese (20e45 years), South
+Australian (27e34 years), and Sri Lankan (15e39 years)
+populations had a wide age range whereas our study was
+restricted to adolescents with a narrow age range of 15e18
+years. The lowest age limit for inclusion has been recog-
+nized as 15 years, since the mean age of menarche reported
+among Indian girls is 13.34 years (standard deviation 1.26)28
+and 1.5 years after menarche is required to exclude the
+period
+of
+menstrual
+irregularity
+that
+usually
+follows
+menarche.29 We also tried to minimize the selection bias of
+the participant in the study by recruiting the girls from one
+educational institution who had not sought medical help for
+any of these symptoms pointing to PCOS.
+India being the epicenter of diabetes, it is important to
+diagnose young females for possible metabolic disorders.
+Studies show that Indian patients with PCOS have higher
+fasting insulin levels and greater IR compared to British and
+Australian white women with PCOS.26,27 We now know that
+glucose intolerance and diabetes is common in young and
+asymptomatic PCOS females and especially in Asian pop-
+ulations.30 Early recognition and treatment can avoid the
+long-term health risks.
+This is the first report on prevalence of PCOS in south
+Indian adolescents, which is 9.13% in the age group of 15e18
+years. 97.62% of girls had oligomenorrhea and 30.95% had
+clinical hyperandrogenism, out of which 97.56% and 92.31%,
+respectively, had polycystic ovaries on ultrasonography.
+Hence it is important that the girls with this symptom
+should be referred for ultrasound and blood tests to facili-
+tate early identification.
+The sampling frame does restrict generalizations since
+our sample was girls from one educational institution.
+Restricting the inclusion age range to 15e18 years which
+reflects the prevalence in adolescents is the strength of our
+study.
+Acknowledgments
+We are thankful to the Central Council for Research in
+Yoga and Naturopathy, Ministry of Health, for funding this
+Table 2.
+Demographic, Anthropometric and Biochemical Parameters (mean  SD)
+Variable
+Total (n 5 42)
+Phenotype I (n 5 11)
+Phenotype II (n 5 1)
+Phenotype III (n 5 1)
+Phenotype IV (n 5 29)
+Age (years)
+15.67  0.78
+16  0.7
+16
+15
+16  1
+Height (m)
+1.53  0.06
+2  0.07
+1.52
+1.49
+2  0.05
+Weight (kg)
+47.47  6.36
+50  7.4
+43
+44
+47  5.9
+BMI (kg/m2)
+20.24  2.55
+21  2.6
+18.6
+19.8
+20  2.6
+Waist Circumference (cm)
+69.25  6.66
+71  7.39
+67
+64
+69  6.68
+Hip Circumference (cm)
+84.68  7.38
+86  7.92
+81
+85
+85  7.58
+Waist Hip Ratio
+0.82  0.04
+1  0.05
+0.8
+0.75
+1  0.04
+Luteinizing Hormone (mIU/ml)
+9.11  6.51
+14  5.84
+11.91
+10.1
+7  5.99
+Follicle Stimulating Hormone (mIU/ml)
+6  1.52
+6  1.3
+7.2
+6.5
+6  1.6
+LH to FSH RATIO
+1.54  1.02
+2  0.91
+1.65
+1.55
+1  0.86
+Serum Testosterone (ng/dl)
+33.37  20.47
+52  25.63
+39.8
+48.1
+26  13.08
+Prolactin (ng/ml)
+9.73  4.18
+10  3.82
+10.1
+9.81
+10  4.37
+Thyroid Stimulating Hormone (mIU/ml)
+2.24  0.99
+2  0.8
+3.1
+2.14
+2  1
+Phenotype I. Oligomenorrhea þ Clinical and/or Biochemical Hyperandrogenism þPolycystic Ovaries (n 5 11).
+Phenotype II. Oligomenorrhea þ Clinical and/or Biochemical Hyperandrogenism (n 5 1).
+Phenotype III. Clinical and/or Biochemical Hyperandrogenism þPolycystic Ovaries (n 5 1).
+Phenotype IV. Oligomenorrhea þ Polycystic Ovaries (n 5 29).
+R. Nidhi et al. / J Pediatr Adolesc Gynecol xxx (2011) 1e5
+4
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+FLA 5.1.0 DTD 
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+project. We would like to place on record our gratitude for
+the support provided by the Vice Chancellor, SVYASA
+University. We gratefully acknowledge the cooperation of
+the staff and administration of Sri Sai College in recruiting
+the students and carrying out the study. We are also grateful
+to Satyam Diagnostic Labs for its assistance with ultrasound
+and Suhruda Laboratory for its assistance with blood assays.
+We thank many others involved in the interviews, data base
+construction, and data entry.
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+https://doi.org/10.1177/09727531211016271
+Annals of Neurosciences
+28(1-2) 21­
+–28, 2021
+© The Author(s) 2021
+Reprints and permissions:
+in.sagepub.com/journals-permissions-india
+DOI: 10.1177/09727531211016271
+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
+A Prospective Study on Type-2 Diabetic 
+Complications and Efficacy of Integrated  
+Yoga: A Pan India 2017
+Suchitra S. Patil1, Nagarathna Raghuram1, Amit Singh1, Rajesh S. K.2, 
+Sabzar Ahmed1 and Nagendra Hongasandra1
+Abstract
+Background: Type 2 diabetes (T2DM) contributes to high mortality and morbidity because of its major complications 
+related to kidney, heart, brain, and eyes. It also poses a high risk for mortality because of COVID-19. Studies suggest the 
+possible implications of Yoga in delaying or attenuating such complications.
+Methodology: This was a pan-India multi centered cluster-randomized (4 level) two-armed trial in the rural and urban 
+population of all populous states of India. Data were obtained using mobile app in all adults in the household of the selected 
+clusters.
+Results: We report the diabetes related complications in 16623 adults (48% males, 52% females) from 65 districts (1 in 10 
+districts, 2011 census) of 29 (out of 35) states and Union Territories of India; mean age was 48.2 ± 12.46 years. Out of this 
+40% lived in rural and 62% in urban locations. In high risk diabetes individuals (scored ≥ 60 points on Indian diabetes risk 
+score key), 18.0% had self-reported history of (peripheral neuropathy, 6.1% had h/o major strokes, 5.5% had minor strokes 
+(transient ischemic episodes), 18.1% had lower limb claudication, 20.5% leg ulcers, 4.4% had h/o cardiac surgery, 4.8% 
+angioplasty, and 15.1% had diabetes retinopathy. Complications were higher in rural than in urban areas, higher in people 
+with extended duration of diabetes. Integrated yoga module for three months (one hour daily) showed significantly better 
+reduction in symptoms related to complications as compared to control group (P < .001)
+Conclusion: The alarming high prevalence of complications in diabetes population calls for urgent action, where yoga may 
+show the benefits in reduction of symptoms of complications.
+Keywords
+High-risk diabetes, Complications, Yoga, Prevalence of known and newly diagnosed diabetes
+Received 23 September 2020; revised 15 February 2021; accepted 30 March 2021
+1 Department of Yoga and Life Science, Swami Vivekananda Yoga 
+Anusandhana Samsthana, Bengaluru, Karnataka, India.
+2 Department of Yoga and Physical Science, Swami Vivekananda Yoga 
+Anusandhana Samsthana, Bengaluru, Karnataka, India
+Corresponding Author:
+Suchitra S. Patil, Swami Vivekananda Yoga Anusandhana Samsthana 
+(SVYASA), 19, Eknath bhavan, Gavipuram Circle, Kempegowda Nagar, 
+Bengaluru, Karnataka 560019, India.
+E-mail: suchitra@svyasa.edu.in
+Introduction
+In the recently estimated worldwide prevalence of diabetes, it 
+has been appraised that 20% of world diabetes population 
+belongs to South Asia. Many studies on the prevalence of 
+diabetes have demonstrated that India will become the 
+diabetes capital of the world by 2030, with a global increase 
+of type 2 diabetes by 48% (186 million).1,2,3,4
+Type 2 Diabetes is known for its complications culminating 
+in mortality and morbidity because of micro-vascular and 
+macro-vascular changes. The association between socio-
+economic status and the prevalence of diabetes with 
+propensity of for macro-vascular disease has been reported. 
+Mortality in diabetes is chiefly because of the effect of 
+metabolic imbalances affecting the vital organs of the body 
+(including heart, brain, and kidney).5
+Neuropathy in DM
+Approximately 50% of adults with diabetes will be affected 
+by peripheral neuropathy in their lifetime.6 A study in UK 
+on 6487 diabetes patients reported an overall prevalence of 
+neuropathy of 28.5% . When it was compared between type 
+1 and type 2 diabetes, neuropathy was observed in 22.7% in 
+type 1 and 32 % in type 2 diabetes. An association between 
+22	
+Annals of Neurosciences 28(1-2)
+peripheral neuropathy and increasing age (5% in 20–29 
+year age group and 44% in 70–79 year age group) has also 
+been observed.7
+Retinopathy in DM
+A pooled analysis of data from eight population-based eye 
+surveys in the United States has shown that the estimated 
+crude prevalence rates for retinopathy and vision-threatening 
+retinopathy were 40.3% and 8.2%, respectively, in patients 
+with diabetes, whereas the prevalence rates in the US general 
+population were only 3.4% and 0.75%, respectively.8
+Looking at the Indian scenario, Chennai urban rural 
+epidemiology study established the overall prevalence of 
+diabetes Retinopathy as17.6% which included 21% in patients 
+with known diabetes and 5% in newly detected diabetes 
+cases.9 Another Chennai study showed similar results with a 
+diabetes retinopathy prevalence of 18%. Retinopathy was 
+significantly associated with higher risk in men, in those with 
+longer than 15 years duration of diabetes and use of insulin.10
+Heart Disease in DM
+The age and sex-adjusted cardiovascular disease incidence 
+rate was 286 per 10000 person-years in the patients who 
+attended examination during 1955–1966, whereas it had 
+increased to 147 per 10000 in the patients who attended 
+examination during 1997–1995.11
+Two systemic reviews and meta analyses have shown that 
+integrated yoga lifestyle that included yogic diet, physical 
+postures, pranayama, relaxation techniques, meditation, and 
+yogic concepts for stress management is a safe and effective 
+intervention that improves not only the glycemic outcomes 
+but reduces the associated risk factors for complications in 
+adults with type 2 diabetes.12,13,14 Yoga resulted in significant 
+reduction of BMI, improved glycemic control, and melon 
+aldehyde besides increase in glutathione and vitamin C when 
+compared to standard care groups with micro vascular and 
+macro vascular complications.15 Other yoga studies have 
+shown improvement in balance and improvement in nerve 
+function in cases with sub-clinical neuropathy.16 Yoga asana 
+resulted in increase of median nerve conduction velocity.17
+Sahay et al reported lowering of drug requirement and the 
+incidence of acute complications like infection and ketosis, 
+decrease in free fatty acids, increase in lean body mass and 
+decrease in body fat percentage and decline in insulin 
+resistance.18 Thus, yoga appears to be a vital adjuvant in the 
+management of risk factors, disease progression, and 
+complications of type 2 diabetes.19
+In this study, we plan to report the prevalence of 
+complications of diabetes in a high-diabetes risk (score more 
+than 60 on Indian diabetes risk score [IDRS] key) in the 
+Indian population in 2017 and the effect of a short-term yoga 
+lifestyle intervention on the complications of type 2 diabetes.
+Methodology
+The study methodology relating to the formation of research 
+advisory committee, ethical clearance, registration of the trial, 
+sample size calculation, four-level randomization in rural and 
+urban locations for selection of the survey clusters, training of 
+personnel, are reported in detail in our earlier publications.20,21 
+In brief Niyantrita Madhumeha Bharata (Control of Diabetes 
+in India) 2017, or NMB 2017, was a two-phased nationwide 
+study with the twin objectives of estimating the prevalence of 
+diabetes and prediabetes and its complications in a high-risk 
+population followed by an randomized control trial (RCT) 
+using a validated yoga lifestyle protocol.
+Phase 1 was a cross-sectional door-to-door survey using a 
+multilevel stratified cluster sampling technique in randomly 
+selected clusters of urban and rural populations, covering 65 
+(10%) districts of the most populous states/union territories 
+(29/35) of India. This captured the data on IDRS and self-
+reported diabetes individuals. This was followed by detailed 
+assessments of the presence of complications, the status of 
+diabetes control, laboratory, and other investigations only in 
+the high diabetes risk (≥ 60 on IDRS) individuals (17852).
+Phase 2 was a two-armed RCT for three months on a 
+subsample of 4822 (Yoga: 3,130, control –1692) to test the 
+efficacy of a validated common yoga-based lifestyle protocol.
+Intervention
+In the current study, the intervention of a validated integrated 
+yoga lifestyle protocol was taught by trained certified yoga 
+therapists at all locations daily for 9 days (2 hours/day) in 
+camps followed by weekly supervised group classes and daily 
+one hour home practice using the help of a video and/or 
+booklet. The yoga module included specific practices that 
+would help in lifestyle change through stress management and 
+long-term behavioral change. This included practices that 
+would correct deep-seated imbalances at (a) physical level: 
+Yogic, simple wholesome nutritionally balanced diet, cleansing 
+techniques (yogic nasal wash—neti, stomach wash—dhoti, 
+and neuro-respiratory detox kriya—kapalabhati), and asanas 
+designed for offering deep rest to the sick tissues; (b) pranayama 
+designed to slow down the rate of breathing to improve 
+parasympathetic tone; (c) meditation and relaxation techniques 
+for autonomic stability; and (d) notional correction and 
+devotional sessions for stress management.
+Ethical Clearance
+Ethical clearance was obtained by the Institutional Ethical 
+Committee of the Indian Yoga Association. Registration was 
+obtained at the central trial registry of India. Funding was 
+given by the Ministry of Health and Family Welfare and the 
+Ministry of AYUSH Government of India, New Delhi.
+Patil et al.	
+23
+Data Acquisition
+Details of the methodology of the four-level randomization 
+(clustered 29 populous states into seven zones; randomly 
+selected 1:10 districts in each state; one census enumeration 
+block in one randomly selected ward in one randomly 
+selected urban town, and four villages with 250–300 
+households in rural areas, covering 4,000 population per 
+district) using randomizer.com, of the urban and rural clusters 
+to collect representative samples from all seven zones of 
+India, is published in earlier.22 Briefly, in the first phase, the 
+data was collected at two levels, using a screening 
+questionnaire to estimate the frequency of self-reported 
+diabetes and comorbidities, select the population at risk for 
+diabetes on IDRS. In the second level, only those in high risk 
+(> 60 on IDRS) and self-reported diabetes were invited for 
+detailed assessments.
+Collection of Data of Complications
+Table 1 shows the questions pertaining to complications.
+The mobile app that was used for detailed data collection 
+included the questions with binary answers (Table 1) to 
+document the complications and associated conditions related 
+to the nervous system, cardiovascular, musculoskeletal, renal, 
+and ophthalmic complications with 3–4 items under each 
+heading.
+Table 1. Complications - Questions Used for Factor Analysis.
+Code
+Medical History Stroke
+Answer
+MHS
+Have you ever been told by a health care provider 
+that you have had any of the following problems?
+MHS1
+Stroke
+No 0
+Yes 1
+MHS2
+Transient ischemic attacks 
+(TIA or "mini-strokes")
+No 0
+Yes 1
+Heart
+Answer
+HEA
+Have you ever had any of the following operations or 
+procedures related to your heart? (circle one answer 
+on each line)
+HEA1
+Coronary artery bypass sur-
+gery (open heart surgery)
+No 0
+Yes 1
+HEA2
+Coronary angioplasty ("bal-
+loon" heart procedure)
+No 0
+Yes 1
+HEA3
+Heart catheterization (an-
+giogram)
+Code
+Pain/lesions in body or feet 
+or legs
+BFL
+Have you ever been told by a health care provider 
+that you have any of the following problems with 
+your shoulder, feet or legs?
+Code
+Medical History Stroke
+Answer
+BFL1
+Peripheral vascular disease 
+(poor circulation in the legs) 
+Any infected wound or ulcer 
+which is not healing
+No 0
+Yes 1
+BFL2
+Do you have stiffness and 
+pain in your shoulder since 
+last three month or more
+No 0
+Yes 1
+BFL3
+Intermittent claudication 
+(cramping in the calves after 
+exercise)
+No 0 
+Yes 1
+BFL4
+Peripheral neuropathy (nerve 
+problems causing numbness, 
+tingling, or burning)
+No 0
+Yes 1
+KD
+Kidney disease
+KD1
+Have you ever been told by a 
+health care provider that you 
+have kidney disease?
+No 0
+(skip to next section) 
+Yes 1
+KD2
+Do you now take medication 
+for your kidney disease?
+No 0
+(skip to next section) 
+Yes 1
+KD3
+How many tabs/doses and 
+how many times a day do 
+you have to take your medi-
+cation for kidney disease?
+1. Once a day
+2. Twice a day
+3. Three times a day 99 
+Don 't know/Not sure
+Code
+High blood pressure
+HBP1
+Have you ever been told by a 
+health care provider that you 
+have High blood pressure?
+No 0 
+(skip to next section) 
+Yes 1
+HBP2
+Do you now take medication 
+for your high blood pres-
+sure?
+No 0 
+(skip to next section) 
+Yes 1
+HBP3
+How many tablets a day do 
+you have to consume for 
+high blood pressure?
+1. Once a day
+2. Twice a day
+3. Three times a day 
+don't know/Not sure
+Code
+High cholesterol
+HC1
+Have you ever been told by a 
+health care provider that you 
+have high cholesterol?
+No 0 
+(skip to next section) 
+Yes 1
+HC2
+Do you now take medication 
+for your high cholesterol?
+No 0 
+(skip to next section) 
+Yes 1
+HC3
+How many tablets a day do 
+you have to consume for 
+high cholesterol?
+1. One tablet at each 
+intake
+2. Two tablets at each 
+intake
+3. Three tablets at 
+each intake
+4. More than four 
+tablets at each intake 
+Don't know/Not sure
+(Table 1 continued)
+(Table 1 continued)
+(Table 1 continued)
+24	
+Annals of Neurosciences 28(1-2)
+Code
+Medical History Stroke
+Answer
+Code
+Any other disease or complications
+CO1
+Have you ever been told by a 
+health care provider that you 
+have any other disease or 
+complications at present?
+No 0 
+(skip to next section) 
+Yes 1
+EYE1
+Have you ever been diag-
+nosed with any of the fol-
+lowing ocular conditions: e.g.: 
+glaucoma, cataracts, macular 
+degeneration, eye injury, 
+retinal disease, blindness, dry 
+eyes
+No 0
+Yes 1
+C02
+Other complications
+C03
+Do you now take medication 
+for your other disease or 
+complications?
+No 0 
+(skip to question xx) 
+Yes 1
+CO4
+How many tabs/dose and 
+how many times a day do 
+you have to take your medi-
+cation for any other disease 
+or complications?
+1. Once a day
+2. Twice a day
+3. Three times a day 
+Don’t know/Not Sure
+Reliability and validity of the factors checked by 
+Cronbach’s α for subscales. Results: 0.762 with a  
+factor loading of 0.7 in different factors
+Statistical Analysis
+Data were uploaded via mobile apps by trained field personnel 
+under the supervision of senior research fellows. Uploaded 
+data from screening forms (about 4 < 0.001/district), 
+registration forms, and laboratory data (about 50, < 0.001) 
+were checked for perfect matching of coding. The data set was 
+analyzed using Statistical Package for Social Sciences (SPSS) 
+(23.0) and R software for bio-statistical analyses. Chi-square 
+test was adopted for checking the significance of distribution.
+Results
+Figure 1 shows the consort diagram. Of the 17852 adults 
+screened, data of 16,623 at high risk for diabetes (> 60 on 
+IDRS) were available for analysis after removing missing 
+values. The mean age was 48.2 ± 12.46 years, 48% were 
+males; 39% rural, and 41% urban clusters. The mean duration 
+of diabetes was 7.6 ± 8.3 years. Of these, data on 4,822 
+respondents (yoga group 3130, control group 1692) for the 
+intervention were available for analysis.
+Table 2 shows the percentage of individuals in different 
+categories who reported a history of different complications.
+Neurological Complications
+Major stroke was reported in 6.1% of patients with diabetes 
+with higher percentages in self-reported known diabetes 
+patients which increased from 4.7% to 8%, as the duration of 
+diabetes increased from 1st to 20th year. Similar trends were 
+found in minor strokes (transient ischemic attacks [TIA]) 
+with an overall prevalence of 5.5%, higher in self-reported 
+(8.1%) known diabetes individuals. Two percent of those who 
+were not aware of their diabetes (newly diagnosed, A1c > 
+6.5%) already had experienced these minor episodes of TIA.
+Peripheral neuropathy was reported in 18.0% of patients 
+with diabetes, higher (22.7%) in the self-reported known 
+diabetes group than newly diagnosed (12.6%) or the 
+prediabetes group (14.4%). In the newly detected and 
+prediabetes adults, leg-related complications (claudication 
+and foot ulcer) were higher when compared to other 
+neurological or cardiac complications. (Table 2)
+Cardiovascular Complications
+Reports of history of coronary artery bypass graft surgery and 
+angioplasty were higher in self-reported diabetes (5%, 7%) 
+than the newly diagnosed diabetes (3.7%, 2.2%) and 
+prediabetes (2.2%, 1.8%). Peripheral vascular problems with 
+intermittent claudication of lower limbs (18.1%) and leg 
+ulcers (20.5%) showed high prevalence. Retinopathy was 
+found in 15.1% of diabetes adults.
+Subgroup Analyses
+Looking at the gender differences, most of the major 
+complications such as strokes, claudication, neuropathies, 
+retinopathy, and foot ulcers were higher in females than 
+males. (Table 3), whereas the history of cardiac bypass 
+surgery and angioplasties was higher in males.
+(Table 1 continued)
+Rural
+6,578
+(36.8%)
+Data collected for 
+complication prevalence
+17,852
+Urban
+11,297
+(63.2%)
+Not included for 
+analysis 1,229
+reason –
+extreme values 
+and
+incomplete data 
+Rural
+6,466
+(38.9%)
+Analyzed 16,623
+Known DM 3423
+New diabetes 3098
+Pre diabetes 3,641
+Others with high risk 6,461
+For pre-post analysis
+Yoga group 3,130
+Control group 1,692
+Urban
+10,157
+(61.1%)
+Figure 1. Study Profile
+Patil et al.	
+25
+Table 2. Prevalence of Complications in Diabetes Group
+Groups
+Neuro
+Cardiac
+Kidney 
+Disease
+Limb
+Eyes
+Major 
+stroke 
+(in %)
+Minor 
+stroke 
+(in %)
+Peripheral 
+neuropathy 
+(in %)
+Bypass 
+(in %)
+Balloon 
+angioplasty 
+(in %)
+Claudica-
+tion (in %)
+Foot 
+ulcer 
+(in %)
+Patients with diabetes-re-
+lated eye problems (in %)
+Total DM
+6.1
+5.5
+18.0
+4.4
+4.8
+3.2
+18.1
+20.5
+19.9
+Self -re-
+ported DM
+8.5
+8.1
+22.7
+5.0
+7.0
+4.4
+22.9
+25.8
+25.1
+New DM
+3.4
+2.4
+12.6
+3.7
+2.2
+1.5
+12.4
+14.1
+13.8
+Pre DM
+3.0
+2.2
+14.4
+2.2
+1.8
+1.3
+14.0
+14.8
+14.6
+Table 3. Prevalence of Complications in The Study Population
+Groups
+Neuro
+Cardiac
+Kidney 
+Disease
+Limb
+Eyes
+Major 
+stroke 
+(in %)
+Minor 
+stroke 
+(in %)
+Peripheral 
+neuropathy 
+(in %)
+Bypass 
+(in %)
+Balloon 
+angioplasty 
+(in %)
+Claudication 
+(in %)
+Foot 
+ulcer 
+(in %)
+Patients with 
+diabetes eye 
+(in %)
+Gender
+M
+8.1
+6.7
+23.0
+4.4
+3.2
+5.3
+19.7
+23.1
+25.2
+F
+8.9
+9.4
+33.1
+2.0
+2.7
+3.7
+26.1
+28.9
+25.1
+Area
+Urban
+7.9
+7.4
+25.8
+5.3
+2.8
+5.0
+23.1
+25.5
+26.2
+Rural
+9.0
+8.7
+35.2
+4.6
+3.1
+4.0
+22.6
+26.2
+23.5
+Age
+20-35
+7.0
+6.5
+25.8
+2.8
+2.2
+7.5
+17.2
+24.3
+11.2
+35-50
+7.6
+6.7
+27.4
+4.0
+2.5
+4.5
+22.2
+26.2
+21.8
+50-70
+7.6
+6.9
+28.1
+5.7
+3.5
+4.3
+22.5
+27.4
+28.7
+Zones
+NW
+2.6
+1.3
+25.8
+2.6
+1.2
+0.9
+23.1
+14.4
+31.0
+N
+3.6
+2.7
+31.8
+2.2
+0.9
+1.3
+26.0
+19.7
+32.1
+NE
+3.3
+8.1
+22.5
+0.5
+0.4
+4.3
+21.4
+19.0
+30.0
+W
+5.3
+3.5
+24.6
+5.3
+1.9
+2.5
+24.1
+27.0
+24.3
+C
+10.1
+7.6
+33.2
+6.1
+2.1
+6.9
+38.6
+32.5
+26.0
+E
+11.2
+6.0
+35.4
+5.8
+10.1
+7.2
+21.2
+42.9
+23.4
+S
+5.9
+3.6
+24.7
+5.8
+2.4
+4.9
+16.3
+20.3
+23.3
+Age and Complications
+Foot ulcer, shoulder pain, neuropathies, and eye problems 
+were higher in older age (50–60 years) than younger ones; 
+history of intermittent limb claudication was high in the 
+younger (20–35 group) diabetes population.
+Complications in Rural and Urban Population
+The number of diabetes patients who reported a history of 
+foot ulcer, shoulder pain, strokes, and or eye-related 
+complaints was higher in the rural regions than urban areas; 
+the prevalence of claudication and nerve problems was high 
+in urban than rural localities.
+Complications in Different Zones of India
+Number of individuals with foot ulcer, shoulder pain, 
+claudication, and history of stroke was highest in the East 
+zone; nerve problem was highest in the central zone and eye 
+problems were highest in the North zone (Table 3).
+The proportion of all complications increased with the 
+increasing duration of diabetes. The percentage of individuals 
+with foot ulcers, shoulder pain, nerve problems, claudication, 
+and eye problems was highest in those with a duration of 
+diabetes of 15–20 years (Table 4).
+The following changes were noticed in prepost changes 
+in complications: after yoga, 10% reported reduction in 
+foot ulcers, whereas in the control group it increased by 
+2%. About 5.1% reported a reduction in symptoms related 
+to the eyes. There was 5.1% reduction in diabetes 
+retinopathy in yoga and 7% increase in Control group. 
+Shoulder pain reduced by 9.5%, while in control it 
+increased by 4%; peripheral neuropathy related symptoms 
+reduced by 10.6%, while it increased in the control group 
+by 1%. (Table 5)
+26	
+Annals of Neurosciences 28(1-2)
+Discussion
+The current pan India community-based cluster-randomized 
+trial of 2017 describes the prevalence ofself-reported 
+complications in 16623 adults with high diabetes risk (score 
+> 60 on IDRS) and also the effect of yoga intervention of 
+three months duration.
+Comparisons
+Overall, the neurological complications were reported in 
+29.6%, cardiac (bypass surgery + angioplasty) in 9.2% of 
+diabetes individuals. An earlier study in Goa23 in 2010 had 
+reported the prevalence of diabetes complications as follows: 
+neuropathy 60%, coronary heart disease -32.3%, cataract 
+20%, retinopathy 15.4%, peripheral vascular disease 11.5%, 
+and cerebrovascular accidents (CVAs) 6.9% . They also had 
+reported the rising trend in the prevalence of diabetes 
+complications with advancing duration of diabetes which is 
+also seen in our study.
+In the present study, we found the prevalence of self-
+reported known diabetes was higher in females than males, 
+and the prevalence of complications corresponded to the 
+overall prevalence of diabetes in females. This observation of 
+higher prevalence of self-reported diabetes in high-risk 
+females could be because of obesity which is a major risk 
+factor in Indians and is known to be higher in women.24,25
+The prevalence of diabetes complications was higher in 
+rural than urban regions. The awareness about health was 
+found to be much lower in rural areas when compared to 
+urban areas. Studies have discussed that knowledge about 
+diabetes and health awareness is negligible in rural areas26. 
+This may be the explanation for the high prevalence of 
+complications in rural areas. As expected, the prevalence was 
+higher among people with a longer duration of diabetes.
+A study on the prevalence of neuropathy in 6487 diabetes 
+individuals in the UK in the year 1993 was 32.1% in type 2 
+diabetes patients.7 The researchers observed that the 
+prevalence of diabetic peripheral neuropathy increased with 
+age, from 5% in the 20–29 year age group to 44.2% in the 
+70–79 year age group. But in our study, it was 25.8% in the 
+age group 20–35, in the age group 50–70 it was 28.1%.
+Prevalence of neuropathy increases with the duration of 
+diabetes, and earlier studies have reported neuropathy in 20.8 
+% in patients with diabetes duration of fewer than five years 
+and 36.8 % in those with greater than ten years duration.7  
+Table 4. Duration of Diabetes and Complications.
+Complications
+1–5 years (in %)
+5–10 years(in %)
+10–15 years(in %)
+15–20 years(in %)
+SignificanceP (Independent 
+Samples t-test)
+Stroke
+4.7
+5.7
+8.2
+8.0
+.029
+Minor stroke
+3.2
+3.5
+7.2
+6.2
+.022
+neuropathy
+22.7
+22.3
+27.8
+31.5
+.052
+Claudication
+19.9
+19.2
+22.7
+25.3
+.266
+Foot ulcer
+22.6
+23.1
+29.9
+25.3
+.122
+Kidney disease
+3.2
+3.3
+5.2
+3.2
+.002
+Bypass surgery
+3.4
+3.4
+9.3
+9.2
+.002
+Balloon surgery
+2.5
+3.4
+5.0
+6.8
+.002
+Patients with dia-
+betes retinopathy
+23.4
+27.7
+32.1
+35.8
+.000
+Shoulder pain
+24.0
+25.2
+31.4
+32.7
+.011
+Table 5. Symptoms Related to Complications Before and After Intervention
+Complications
+Yoga Pre(in %)
+Yoga Post (in %)
+Control Pre(in %)
+Control Post(in %)
+Significance
+Foot ulcer
+17.3
+7.2
+17.9
+19.5
+P < .001
+Shoulder pain
+18.5
+9.0
+20.1
+24.1
+P < .001
+Claudication
+15.9
+6.8
+15.7
+17.3
+P < .001
+Neuropathy
+16.4
+5.8
+16.0
+17.0
+P < .001
+Diabetic eye
+15.6
+10.5
+16.8
+23.8
+P < .001
+Patients with diabe-
+tes retinopathy
+15.6
+10.5
+16.8
+23.8
+P < .001
+Patil et al.	
+27
+The prevalence in our study seems to be similar; it increased 
+from 22.7% in those with 1–5 years duration of diabetes to 
+31.5% in those who had diabetes for 15–20 years.6,7
+We observed a prevalence (25.1%) of retinopathy in our 
+sample. Ghodasra et al observed an 18.0% prevalence of 
+diabetic retinopathy in patients with diabetes in 2006. In their 
+study, the variables that were significantly associated with 
+increased risk of patients with diabetic retinopathy included 
+gender (men at greater risk), use of insulin, and longer 
+duration of diabetes.10 Similar was our observations in our 
+subjects with known diabetes as we noted an association of 
+retinopathy with increased age, female gender, and duration 
+of diabetes.
+Studies 
+have 
+shown 
+strong 
+association 
+between 
+hypertension and hyperlipidemia with diabetic nephropathy.27 
+Patients with diabetes complications and/or coronary artery 
+disease had higher prevalence of stroke.31
+In the current study, three months of intervention of a 
+validated integrated yoga lifestyle protocol has shown 
+significant (P < .001) reduction in all self-reported 
+complications. We hypothesize that the observed results of 
+reduction of self–reported complications in the present study 
+could be because of stress reduction. It is evident by the 
+earlier studies that patients with diabetes complications have 
+increased oxidative stress levels.28 It is also known that 
+chronic stress leads to poor control of diabetes with increased 
+risk of micro and macro-vascular complications through 
+activation of the hypothalamic-pituitary-adrenal axis, 
+resulting in increased levels of cortisol, epinephrine, 
+norepinephrine, 
+glucagon, 
+prolactin, 
+leptin, 
+and 
+neuropeptides.22 Chronic activation of the HPA axis is also 
+associated with increased level of inflammatory cytokines 
+that contribute to insulin resistance in type 2 diabetes. Chronic 
+psychological stress can result in insulin resistance, 
+hypertension, and an increased risk of cardiovascular events.29 
+A systematic review on yoga practices on oxidative stress in 
+different populations reported that diabetes patients showed 
+increased glutathione, vitamin C content, and superoxide 
+dismutase activity and decreased malondialdehyde content 
+following yogic practices; prediabetes and hypertensive 
+patients showed reduced malondialdehyde content following 
+yogic practices, and renal disease patients showed decreased 
+protein oxidation and increased superoxide dismutase activity 
+following yogic practices. The review concluded that regular 
+yogic practices can improve antioxidants and reduce oxidative 
+stress in healthy, diabetes, prediabetes, hypertensive, and 
+renal disease patients.30
+Strengths of the Study
+It is the first parallel survey covering 29 states/union territories 
+of India on the prevalence of complications and the effect of 
+yoga on all self-reported complications. The self-administered 
+questionnaire used is found to be reliable and valid. This is 
+also the first report that offers evidence to the beneficial effect 
+of yoga in reducing the symptoms (self–reported) related to 
+complications of diabetes.
+Limitations of the Study
+The limitation of the study was that there were no objective 
+measures of the status of the complications as it was self-
+reported data.
+Conclusions
+The prevalence of complications is high in known diabetes 
+individuals. Integrated yoga module can play a significant 
+role in reduction in symptoms related to diabetes complications 
+as self-reported symptoms are reduced. But this should be 
+studied further with bio markers. This study offers important 
+evidence to implement urgent action by policy makers to 
+prevent complications and also offer protection to diabetes 
+community during the present COVID-19 pandemic.
+Acknowledgements
+We are thankful to the Ministry of health and family welfare and 
+Ministry of AYUSH (routed through Central Council for Research 
+in Yoga and Naturopathy), Government of India for funding this 
+project. We would like to thank the executive committee of Indian 
+yoga Association for their continued support. We also thank Art of 
+Living Institute, Vethathiri Maharishi College of Yoga, Patanjali 
+Yoga-peeth, PGI Chandigarh and SVYASA for providing more than 
+1200 yoga volunteers. We acknowledge the members of the research 
+advisory board of NMB for their inputs at all stages of the study.
+Ethical Statement
+Ethical clearance was obtained by the Ethics Committee of the 
+Indian Yoga Association. The study was registered on central trial 
+registry of India (Registration Number – Trial REF/2018/02/017724).
+This article complies with the International Committee of Medical 
+Journal editor’s (ICMJE) uniform requirements for the manuscript.
+Declaration of Conflicting Interests
+The authors declared no potential conflicts of interest with respect to 
+the research, authorship, and/or publication of this article.
+Funding
+Funding for the study was provided by the Ministry of health and 
+family welfare and the Ministry of AYUSH routed through 
+Central Council for Research in Yoga and Naturopathy, 
+Government of India.
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+tions among the states of India: The Global Burden of Disease 
+Study1990–2016, Lancet Glob Health 2018 September 11; 6: 
+e1352–e1362 https://www.thelancet.com/pdfs/journals/langlo/
+PIIS2214-109X(18)30387-5.pdf
+26.	 Kasliwal RR, Kulshreshtha A, Agrawal S , et al. Prevalence of 
+cardiovascular risk factors in Indian patients undergoing coro-
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+371–375.
+27.	 Buren PNV, and Toto R. Hypertension in patients with diabe-
+tes nephropathy: Epidemiology, mechanisms, and management. 
+Adv Chronic Kidney Dis 2011; 18: 28–41.
+28.	 Kumawat M, Singh N, and Singh S. Status of antioxidant 
+enzymes and lipid peroxidation in type 2 diabetes mellitus with 
+neuropathy. Ann Neurosci 2005; 12: 49–52.
+29.	 Innes KE, Bourguignon C, and Taylor AG. Risk indices associ-
+ated with insulin resistance syndrome, cardiovascular disease, 
+and possible protection with yoga: A systematic review. J Am 
+Board Fam Pract 2005; 18: 491-519.
+30.	 Pal R and Gupta N. Yogic practices on oxidative stress and 
+of antioxidant level: A systematic review of randomized con-
+trolled trials. J Complement Integr Med 2017 October 25; 16(4): 
+/j/jcim.2019.16.issue-4/jcim-2017-0079/jcim-2017-0079.xml. 
+DOI: 10.1515/jcim-2017-0079. PMID: 29068790.
diff --git a/subfolder_0/Randomizedcontrolled trial of yoga in women with breast cancer undergoing radiotherapy.txt b/subfolder_0/Randomizedcontrolled trial of yoga in women with breast cancer undergoing radiotherapy.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a2dcccc29741dc68baabbdf57ae392c6ebcc4ff6
--- /dev/null
+++ b/subfolder_0/Randomizedcontrolled trial of yoga in women with breast cancer undergoing radiotherapy.txt	
@@ -0,0 +1,1287 @@
+Randomized, Controlled Trial of Yoga in Women With
+Breast Cancer Undergoing Radiotherapy
+Kavita D. Chandwani, George Perkins, Hongasandra Ramarao Nagendra, Nelamangala V. Raghuram,
+Amy Spelman, Raghuram Nagarathna, Kayla Johnson, Adoneca Fortier, Banu Arun, Qi Wei,
+Clemens Kirschbaum, Robin Haddad, G. Stephen Morris, Janet Scheetz, Alejandro Chaoul, and Lorenzo Cohen
+See accompanying article on page 1040
+Kavita D. Chandwani, University of Roches-
+ter Medical Center, Rochester, NY; Kavita
+D. Chandwani, George Perkins, Amy
+Spelman, Kayla Johnson, Adoneca Fortier,
+Banu Arun, Qi Wei, Robin Haddad, Janet
+Scheetz, Alejandro Chaoul, and Lorenzo
+Cohen, The University of Texas MD Ander-
+son Cancer Center, Houston, TX; G.
+Stephen Morris, St. Jude Children’s
+Research Hospital, Memphis, TN;
+Hongasandra Ramarao Nagendra, Nela-
+mangala V. Raghuram, Raghuram Nagara-
+thna, Swami Vivekananda Yoga
+Anusandhana Samsthana, Bengaluru, India;
+and Clemens Kirschbaum, Technical
+University of Dresden, Dresden, Germany.
+Published online ahead of print at
+www.jco.org on March 3, 2014.
+Supported in part by Grants No.
+R21CA102385 and R01CA138800 from
+the National Cancer Institute; the
+National Cancer Institute Cancer Center
+Support Grant No. CA016672; National
+Cancer Institute Grant No. R25CA10618;
+and philanthropic support for the Integra-
+tive Medicine Program, The University of
+Texas MD Anderson Cancer Center.
+Presented in part at the American
+Psychosomatic Society Annual Meet-
+ing, San Antonio, TX, March 2011; the
+American Society of Clinical Oncology
+Annual Meeting, Chicago, IL, June
+2011; and the International Congress of
+North American Consortium of Comple-
+mentary Medicine and Health, Portland,
+OR, May 2012.
+Authors’ disclosures of potential conflicts
+of interest and author contributions are
+found at the end of this article.
+Clinical Trials repository link available on
+JCO.org.
+Corresponding author: Lorenzo Cohen,
+PhD, Integrative Medicine Program,
+The University of Texas MD Anderson
+Cancer Center, Department of Integra-
+tive Medicine, 1515 Holcombe Blvd,
+Unit 460, Houston, TX 77030; e-mail:
+lcohen@mdanderson.org.
+© 2014 by American Society of Clinical
+Oncology
+0732-183X/14/3210w-1058w/$20.00
+DOI: 10.1200/JCO.2012.48.2752
+A
+B
+S
+T
+R
+A
+C
+T
+Purpose
+Previous research incorporating yoga (YG) into radiotherapy (XRT) for women with breast cancer finds
+improved quality of life (QOL). However, shortcomings in this research limit the findings.
+Patients and Methods
+Patients with stages 0 to III breast cancer were recruited before starting XRT and were randomly
+assigned to YG (n  53) or stretching (ST; n  56) three times a week for 6 weeks during XRT or
+waitlist (WL; n  54) control. Self-report measures of QOL (Medical Outcomes Study 36-item
+short-form survey; primary outcomes), fatigue, depression, and sleep quality, and five saliva
+samples per day for 3 consecutive days were collected at baseline, end of treatment, and 1, 3, and
+6 months later.
+Results
+The YG group had significantly greater increases in physical component scale scores compared
+with the WL group at 1 and 3 months after XRT (P  .01 and P  .01). At 1, 3, and 6 months, the
+YG group had greater increases in physical functioning compared with both ST and WL groups
+(P  .05), with ST and WL differences at only 3 months (P  .02). The group differences were
+similar for general health reports. By the end of XRT, the YG and ST groups also had a reduction
+in fatigue (P  .05). There were no group differences for mental health and sleep quality. Cortisol
+slope was steepest for the YG group compared with the ST and WL groups at the end (P  .023
+and P  .008) and 1 month after XRT (P  .05 and P  .04).
+Conclusion
+YG improved QOL and physiological changes associated with XRT beyond the benefits of simple
+ST exercises, and these benefits appear to have long-term durability.
+J Clin Oncol 32:1058-1065. © 2014 by American Society of Clinical Oncology
+INTRODUCTION
+Radiotherapy (XRT) is often the final step in the
+multimodal treatment regimen for women with
+breast cancer. Patients often experience treatment-
+related adverse effects (fatigue, pain, lymphedema,
+neuropathy, cardiotoxicity, sleep disturbances,
+and cognitive problems) that negatively affect
+physical, psychological, social, and spiritual as-
+pects of quality of life (QOL)1,2 and may create
+negative health consequences.3
+Research on yoga (YG) in patients with cancer
+has increased considerably in the last decade, and a
+variety of YG programs studied in cancer have re-
+ported improvements in stress and QOL,4 fatigue
+and emotional health,5,6 pain, vitality, and QOL,7
+positive affect,5 joint pain, fatigue, and sleep distur-
+bance,8,9 and fatigue in women with metastatic
+breast cancer10 and obese breast cancer survivors.11
+Studies of a Patanjali-based integrated YG program
+for patients with breast cancer developed by the Vive-
+kananda Yoga Anusandhana Samsthana (VYASA)
+have consistently reported improvement in anxiety,
+symptom severity, and distress,12-14 nausea and
+vomiting,15 and affect and global QOL14 as well as
+beneficial effects on natural-killer cell counts16 and
+radiation-induced DNA damage.13
+Previous YG research has a number of limita-
+tions, including small sample size (ranging from 18
+to168);absenceofobjectiveoutcomemeasures;lack
+of active control groups; and lack of long-term
+follow-up after the end of the YG program. One
+objective measure of interest is cortisol rhythm.
+Studies have revealed that both elevated levels of
+JOURNAL OF CLINICAL ONCOLOGY
+O R I G I N A L
+R E P O R T
+VOLUME
+32
+
+NUMBER
+10
+
+APRIL
+1
+2014
+1058
+© 2014 by American Society of Clinical Oncology
+2014 from 141.30.141.33
+Information downloaded from jco.ascopubs.org and provided by at Staats-und Universitatsbibliothek Dresden on April 24,
+Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
+cortisol and a blunted, less steep, diurnal cortisol slope are associated
+with worse survival in women with breast cancer.17,18 Vadiraja et al14
+alsoreportedsignificantlyreducedmorningandoverallmeancortisol
+levels in patients with breast cancer participating in a YG program.
+We previously reported that participation in the VYASA YG
+program two times a week for patients with breast cancer undergoing
+XRT resulted in significantly better general health perception (GH)
+and physical functioning (PF) scores at the end of XRT and greater
+benefit finding 3 months after XRT than in women in a waitlist (WL)
+control group.19 This study tested the hypotheses that participation in
+YG three times a week during XRT would have long-term effects on
+physical and mental health (MH) aspects of QOL (primary out-
+comes), fatigue, depression, and sleep disturbances and result in
+steeper cortisol slope (secondary outcomes) relative to an active
+stretching (ST) or WL control groups.
+PATIENTS AND METHODS
+Patients
+Women with stages 0 to III breast cancer were recruited before XRT.
+Inclusion criteria were  18 years old; ability to read, write, and speak English;
+and scheduled to undergo daily adjuvant XRT for 6 weeks at MD Anderson
+Cancer Center. Patients with lymphedema; metastatic bone disease; deep vein
+thrombosis; documented diagnosis of a formal thought disorder (eg, schizo-
+phrenia); extreme mobility problems; or who had practiced YG in the year
+before diagnosis were excluded. The protocol was approved by the institu-
+tional review board.
+Randomization and Schedule
+Eligible patients were identified through an institutional database or by
+referring physicians and were approached at their simulation appointment.
+After giving written informed consent, participants completed a baseline as-
+sessment including self-report measures and provided saliva samples to assess
+diurnal cortisol rhythm. Blood samples for future assays, an actigraphy watch
+(worn 24 hours a day for 7 days to assess sleep quality), and questionnaires
+assessing plausible mediators were also collected and will be reported in a
+subsequent article. Participants were then randomly assigned to one of three
+groups: 1) YG; 2) ST; or WL control by using a form of adaptive randomiza-
+tion,20 according to age, stage of disease, time since diagnosis, type of surgery,
+and chemotherapy (neoadjuvant or adjuvant). Follow-up assessments were
+conducted during the last week of treatment and 1, 3, and 6 months later.
+Participants were given a gift certificate ($20 value) after each assessment
+completion. Participants in the WL group received usual care, completed all
+assessments on the same timeline as the active groups, and were offered YG or
+ST classes at the end of their study participation. All participants were asked to
+refrain from participating in any other YG classes while on study.
+Intervention Programs
+Participants in the YG and ST groups attended up to three 60-minute
+classes per week during their 6 weeks of XRT. Classes were held near the
+radiationtreatmentcenterinlargeconference-styleroomsdedicatedtobehav-
+ioral research. Classes were offered to accommodate participants’ schedules,
+most often being given in a one-on-one just before or after XRT. Each partic-
+ipantreceivedanaudioCDandawrittenmanualoftheprogramtoencourage
+at-homepractice.CompliancewasdeterminedweeklyduringXRTandateach
+follow-up with an evaluation and practice log that asked about length and
+frequency of practice at home.
+TheintegratedYGprogram,describedpreviously,19includedthefollow-
+ing: (1) preparatory warm-up synchronized with breathing; (2) selected pos-
+tures, or asana (forward-, backward-, and side-bending asanas in sitting and
+standing position, cobra posture, crocodile, and half-shoulder-stand with
+support); (3) deep relaxation (supine posture); (4) alternate-nostril breathing,
+or pranayama; and (5) meditation. The program was taught by VYASA-
+trained teachers.
+The ST program included exercises recommended specifically for
+women undergoing or recovering from breast cancer treatment.21,22 The
+exercises included standing, lying down, and sitting positions and approxi-
+mated the gross movements of the YG exercises (eg, horizontal arm stretch,
+breaststroke,neckstretch,quarterbackthrowingafootball).Participantswere
+introduced the stretches in a stepped approach and learned all of the material
+overthecourseofthefirstfourclasses.Classesweretaughtbyphysiotherapists
+from Rehabilitative and Physical Therapy at MD Anderson.
+Measures
+General QOL was assessed by the Medical Outcomes Study 36-item
+short-form survey (SF-36). The SF-36 assesses PF, physical impediments to
+role functioning, bodily pain, GH, vitality, social functioning, emotional im-
+pediments to role functioning, MH, and includes an overall physical compo-
+nent scale (PCS) and mental component scale (MCS).23,24 The PCS and MCS
+were the primary outcomes. If the component scale was significant, then the
+subscales were analyzed as secondary outcomes. Higher scores reflect better
+QOL, with increases from baseline indicating improved QOL. Normed-based
+scoring is presented with a population mean  50 and standard deviation 
+10. A change of five points or more is considered clinically significant.25,26
+Fatigue was assessed by using the Brief Fatigue Inventory,27 a question-
+naire used in clinical settings to assess fatigue severity and its impact on QOL.
+Lower scores reflect less fatigue.
+Sleep disturbances were assessed by using the Pittsburgh Sleep Quality
+Index (PSQI),28 a questionnaire that assesses sleep disturbances over a
+1-month period. We report on the total score. Lower scores reflect fewer
+sleep disturbances.
+Depression was assessed by using the Centers for Epidemiological
+Studies-Depression (CES-D) measures,29 a well-validated measure focusing
+on affective components of depression. Lower scores reflect fewer depres-
+sive symptoms.
+Cortisol
+Five saliva samples (waking, 45 minutes later, approximately 8 and 12
+hours after waking, and at bedtime) were obtained for 3 consecutive days at
+each assessment. Participants chewed on a cotton swab (Salivette; Sarstedt,
+Newton, NC), placed it in a plastic tube (Sarstedt), and then it was frozen at
+80°C for later time-resolved immunoassay with fluorescence detection per-
+formed at the University of Dresden. Values  0.0001 and  70 nmol/L were
+classified as missing. If patients missed a collection point, they were told to
+leave the tube empty. Of the data received, 2.8% of the saliva samples were
+classifiedasmissing(eitheremptyornotwithinrange).Approximately30%of
+thepatients(21%to34%,dependingonthetimepoint)didnotprovidesaliva
+samples. There were no differences between patients providing samples and
+thosewhodidnotonthebasisofgroupassignment,medical,demographic,or
+outcome measures. Slopes were calculated without the waking sample, using
+the other four samples throughout the day. A steeper, more negative cortisol
+slope indicates better cortisol regulation. Medical information was obtained
+from medical records.
+Data Analyses
+For analysis of the self-report measures, we examined change from
+baseline to follow-up. To test group differences, PROC MIXED procedures in
+SAS version 9.2 were used. Changes from baseline were regressed on group,
+time (treated as categorical), and group  time interaction; the intercept was
+treated as random effect; the covariance structure was unstructured. There
+werenosignificantgrouptimeinteractions,andgroupcomparisonsateach
+assessment are presented from the mixed models. Because of non-normality,
+cortisol levels were log-transformed, and slopes were calculated and regressed
+on saliva collection time (hours after waking up in the morning); the slopes
+were then used as the dependent variable in the general linear model analyses
+as described above, examining slopes covarying for baseline levels. All analyses
+were controlled for randomization factors. We also controlled for baseline
+SF-36 GH scores in the SF-36 GH analyses due to imbalances across groups.
+The primary and secondary outcomes remained the same, and we present the
+results without covariates.
+The primary outcomes were the PCS and MCS subscales of the SF-36 at
+1 month post-XRT. Although our pilot work only found group differences in
+Yoga, QOL, and Cortisol in Women With Breast Cancer
+www.jco.org
+© 2014 by American Society of Clinical Oncology
+1059
+2014 from 141.30.141.33
+Information downloaded from jco.ascopubs.org and provided by at Staats-und Universitatsbibliothek Dresden on April 24,
+Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
+PCS measures at the end of XRT,19 we hypothesized that increasing the
+amount of YG from two to three times a week would result in more lasting
+effects (ie, at least 1 month post-XRT). The end of XRT time point and the
+longer term follow-up at 3 and 6 months were designated as secondary time
+points. We adjusted the  level for significance to P  .029 by conducting a
+Bonferroni correction taking into account the correlation between the two
+variables.30 Assuming a two-tailed significance level of P  .029, with 50
+patients per group and 80% power, we would detect differences between any
+pairofgroupmeansof0.63standarddeviationunits,asimilareffectsizetothat
+found in our previous study (range, 0.44 to 0.47).19 The secondary outcomes
+of the subscales from the component scores of the SF-36, Brief Fatigue Inven-
+tory, PSQI, CES-D, and cortisol slope at each time point were regarded as
+exploratory analyses.
+RESULTS
+Two hundred ninety-four eligible women were approached and 191
+consented to participate. Thirteen dropped out before, and 15 after,
+they were randomly assigned, for a final sample size of 163 (YG  53,
+ST  56, WL  54; Fig 1). Retention was high, with no group differ-
+encesinlosstofollow-upornumberofclassesattendedonthebasisof
+whether patients provided follow-up data or not. In addition, there
+were no differences between patients with and without missing data
+on the basis of medical, demographic, or baseline outcome measures.
+All groups were similar in baseline demographic, medical, self-
+report measures (except for SF-36 GH), and cortisol slopes (Tables 1
+and 2). Eighty-seven percent of YG and 85% of ST participants at-
+tended12classes(mean,YG13.8;ST14.7).Onlythreepatients
+in each group attended fewer than half the classes. Practice outside of
+class was high ( twice per week) for the YG group 1 month post-
+treatment and then declined at 3 and 6 months (71%, 55%, and 45%,
+respectively). Practice outside of class ( twice per week) for the ST
+group was lower at 1 month and then increased somewhat at 3 and 6
+months (53%, 69%, and 60%, respectively). Baseline and follow-up
+means of self-report measures are presented in Table 2.
+SF-36
+Significantly greater increases from baseline were observed in
+PCS scores for the YG group compared with the WL group at 1 and 3
+months (P  .01 and P  .01, respectively; Fig 2). No other compar-
+isons reached significance. There were no significant effects for
+the MCS.
+Eligible patients approached
+(N = 294)
+Consented and enrolled in study
+(n = 191)
+Dropped or taken off study
+(n = 13)
+Random assignment
+(n = 178)
+Dropped or taken off study prior to radiotherapy
+(n = 15)
+Yoga
+(n = 53)
+Stretch
+(n = 56)
+Waitlist
+(n = 54)
+End of treatment
+(n = 49)
+End of treatment
+(n = 52)
+End of treatment
+(n = 48)
+1 month after radiotherapy
+(n = 39)
+1 month after radiotherapy
+(n = 44)
+1 month after radiotherapy
+(n = 43)
+3 months after radiotherapy
+(n = 41)
+3 months after radiotherapy
+(n = 41)
+3 months after radiotherapy
+(n = 42)
+6 months after radiotherapy
+(n = 43)
+6 months after radiotherapy
+(n = 43)
+6 months after radiotherapy
+(n = 46)
+)
+3
+0
+1
+ 
+=
+ 
+n
+(
+ 
+d
+e
+s
+u
+f
+e
+R
+)
+5
+6
+ 
+=
+ 
+n
+(
+ 
+e
+m
+i
+t
+ 
+o
+N
+ 
+ 
+  Not interested 
+(n = 34)
+  Wanted intervention group 
+(n = 4)
+Fig 1. Flow of study participants over study period.
+Chandwani et al
+1060
+© 2014 by American Society of Clinical Oncology
+JOURNAL OF CLINICAL ONCOLOGY
+2014 from 141.30.141.33
+Information downloaded from jco.ascopubs.org and provided by at Staats-und Universitatsbibliothek Dresden on April 24,
+Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
+Analyses of the PCS subscales revealed significant effects for the
+PF and GH. Group differences in PF scores revealed significantly
+greater increases for the YG group compared with the WL group at 1,
+3, and 6 months (P  .002; P  .0001; P  .001, respectively), with
+marginal group differences at the end of treatment (P  .08); greater
+increases for the YG group compared with the ST group at 1 and 3
+months (P  .01; P  .05, respectively), with marginal group differ-
+ences at 6 months (P  .08); and greater increases in the ST group
+compared with the WL group at 3 months (P  .02; Fig 2). GH
+outcomes followed a similar pattern, with significantly greater in-
+creases in GH scores for the YG group compared with the WL and ST
+groups at 1 and 3 months (all P  .01; Fig 2). No significant group
+effects were found for other SF-36 subscales.
+Fatigue
+Significantly greater decreases in fatigue were observed for the
+YG and ST groups compared with the WL group by the end of
+treatment (P  .04; P  .02, respectively), with marginally significant
+differencesobservedfortheYGgroupcomparedwiththeWLgroupat
+1month(P.09)andfortheSTgroupcomparedwiththeWLgroup
+at 3 months (P  .07; Fig 3). There were no significant group differ-
+ences at any time point for CES-D or PSQI scores.
+Salivary Cortisol
+GLManalysisofcortisolslopes,covaryingforbaseline,revealeda
+group main effect at the end of treatment (adjusted means: YG
+0.104, SE 0.011; ST 0.072, SE 0.009; WL 0.064, SE 0.010; P 
+.02),withtheYGgrouphavingasignificantlysteeperslopethantheST
+and WL groups (P  .023 and P  .008, respectively). There was also
+a marginally significant group main effect at the 1-month follow-up
+(adjusted means: YG 0.104, SE 0.011; ST 0.073, SE 0.010; WL
+0.073, SE 0.010; P  .07), with the YG group having a significantly
+steeper slope than the ST and WL groups (P  .05 and P  .04,
+respectively;Fig4).Therewerenodifferencesinslopeattheothertime
+Table 1. Baseline Characteristics of Study Participants by Group
+Patient Demographics
+and Clinical Characteristics
+Yoga
+(n  53; 33%)
+Stretch
+(n  56; 34%)
+Waitlist
+(n  54; 33%)
+No.
+%
+No.
+%
+No.
+%
+P
+Age
+.79
+Mean  SE
+52.38  1.35
+51.14  1.32
+52.11  1.34
+Range, years
+26-77
+25-79
+30-69
+Disease stage
+.99
+0
+5
+10
+6
+11
+7
+13
+I
+16
+30
+18
+32
+17
+31
+II
+15
+28
+14
+25
+15
+28
+III
+17
+32
+18
+32
+15
+28
+Surgery
+.71
+Mastectomy (without reconstruction)
+12
+23
+17
+31
+12
+22
+Mastectomy (with reconstruction)
+6
+11
+3
+5
+5
+9
+Breast conserving
+35
+66
+36
+64
+37
+69
+Chemotherapy
+.73
+Yes
+36
+68
+34
+61
+34
+63
+No
+17
+32
+22
+39
+20
+37
+Marital status (n  151)
+Married and living together
+31
+67
+37
+71
+34
+64
+.75
+Not cohabitating
+15
+33
+15
+29
+19
+36
+Ethnicity (n  150)
+.56
+Black/African American
+9
+19
+9
+17
+7
+13
+White
+32
+68
+28
+55
+37
+71
+Latino/Hispanic/Mexican
+4
+9
+8
+16
+5
+10
+Asian/Pacific Islander
+2
+4
+4
+8
+1
+2
+Other
+0
+0
+2
+4
+2
+4
+Employment status (n  140)
+.1
+Employed full-time
+14
+31
+17
+35
+10
+22
+Employed part-time
+1
+2
+4
+8
+8
+17
+Employed, taken time off
+11
+25
+10
+20
+5
+11
+Not employed
+19
+42
+18
+37
+23
+50
+Education (n  152)
+.59
+High school or technical school
+10
+21
+12
+23
+17
+32
+Some college
+17
+36
+14
+27
+15
+28
+Higher education
+20
+43
+26
+50
+21
+40
+Income (n  149)
+.17
+ $75,000
+31
+67
+26
+51
+26
+50
+ $75,000
+15
+33
+25
+49
+26
+50
+Minority representation reflects that of women diagnosed with breast cancer in Harris County.
+Yoga, QOL, and Cortisol in Women With Breast Cancer
+www.jco.org
+© 2014 by American Society of Clinical Oncology
+1061
+2014 from 141.30.141.33
+Information downloaded from jco.ascopubs.org and provided by at Staats-und Universitatsbibliothek Dresden on April 24,
+Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
+Table 2. Raw Means and Standard Deviations of Self-Report Measures at Baseline and Follow-Up Time Points
+Baseline
+Last Week of Treatment
+1 Month Post-Treatment
+3 Months Post-Treatment
+6 Months Post-Treatment
+YG
+ST
+WL
+YG
+ST
+WL
+YG
+ST
+WL
+YG
+ST
+WL
+YG
+ST
+WL
+No.
+%
+No.
+%
+No.
+%
+P
+No.
+%
+No.
+%
+No.
+%
+P
+No.
+%
+No.
+%
+No.
+%
+P
+No.
+%
+No.
+%
+No.
+%
+P
+No.
+%
+No.
+%
+No.
+%
+P
+PCS
+41.8 1.3 43.0 1.1 44.9 1.4
+.20 42.3
+1.3 44.5
+1.1 44.1 1.2 .47 47.0
+1.3 46.8 1.4 45.5 1.2 .04
+48.2
+1.2 47.4
+1.4 46.1 1.2 .05
+46.9
+1.4 47.5 1.4 46.6 1.1
+.18
+PF
+41.9 1.3 44.7 1.2 45.9 1.2
+.06 43.7
+1.4 46.0
+1.1 45.7 1.3 .18 47.3† 1.3 46.6 1.3 47.0 1.1 .005 48.7† 1.1 47.2‡ 1.2 46.3 1.4 .0001 47.8 1.4 47.4 1.4 46.5 1.2
+.005
+GH
+44.8 1.5 50.4 1.2 47.7 1.2
+.01 47.1
+1.4 50.6
+1.1 48.0 1.3 .28 47.9† 1.5 49.2 1.4 46.9 1.5 .003 49.2† 1.4 50.5
+1.3 46.3 1.5 .005
+47.7
+1.6 51.7 1.3 49.8 1.1
+.35
+RF
+36.8 1.5 37.1 1.3 38.3 1.6
+.70 39.1
+1.4 41.1
+1.4 40.8 1.5 .54 44.2
+1.5 43.8 1.7 43.5 1.5 .50
+45.0
+1.6 45.5
+1.7 44.3 1.4 .66
+44.3
+1.6 46.4 1.5 44.1 1.3
+.28
+BP
+44.2 1.4 44.8 1.2 44.6 1.5 1.00 44.3
+1.3 46.4
+1.3 45.1 1.4 .67 47.5
+1.5 48.3 1.6 48.4 1.4 .98
+49.0
+1.4 48.9
+1.5 47.5 1.5 .84
+46.8
+1.5 48.3 1.4 48.3 1.3
+.81
+MCS
+42.2 1.7 45.8 1.4 42.0 1.8
+.20 47.2
+1.9 49.5
+1.2 47.1 1.7 .88 46.2
+2.1 47.0 1.7 49.1 1.5 .07
+46.5
+2.0 50.1
+1.6 46.6 1.9 .80
+46.8
+1.9 50.8 1.5 48.8 1.4
+.75
+CES-D 15.4 1.5 11.7 0.8 15.1 1.4
+.07 17.3
+1.4 17.8
+1.1 15.8 1.4 .53 13.1
+1.7 11.6 1.4 12.3 1.3 .19
+13.9
+1.7
+9.6
+1.4 12.9 1.6 .68
+13.9
+1.8 10.4 1.4 11.5 1.3
+.23
+PSQI
+8.3 0.6
+8.5 0.5
+8.2 0.5
+.90
+6.7
+0.5
+8.3
+0.6
+7.3 0.5 .60
+7.0
+0.6
+7.7 0.7
+5.8 0.6 .40
+6.5
+0.5
+7.3
+0.5
+6.4 0.6 .5
+7.1
+0.5
+7.2 0.6
+6.4 0.6 1.00
+BFI
+3.2 0.3
+3.0 0.3
+2.6 0.3
+.30
+2.9 0.3
+2.5‡ 0.3
+3.2 0.4 .03
+2.7
+0.4
+2.7 0.3
+2.7 0.3 .22
+2.6
+0.3
+2.3
+0.4
+3.0 0.4 .15
+2.8
+0.4
+2.5 0.3
+2.6 0.3
+.56
+NOTE. The baseline P values are from analysis of variance of raw scores. The follow-up P values represent the group main effects from the MIXED models analyses of change scores and the noted group
+differences are from the same MIXED models. Significant group differences are labeled below.
+Abbreviations: BFI, Brief Fatigue Inventory; BP, Medical Outcomes Study 36-Item Short-Form Survey (SF-36) Bodily Pain; CES-D, Center for Epidemiologic Studies-Depression; GH, SF-36 General Health; MCS,
+SF-36 Mental Component Score; PCS, SF-36 Physical Component Score; PF, SF-36 Physical Functioning; PSQI, Pittsburg Sleep Quality Index; RP, SF-36 Role-physical; ST, stretching; WL, waitlist; YG, yoga.
+YG versus WL, P  .05.
+†YG versus ST, P  .05.
+‡ST versus WL, P  .05.
+Chandwani et al
+1062
+© 2014 by American Society of Clinical Oncology
+JOURNAL OF CLINICAL ONCOLOGY
+2014 from 141.30.141.33
+Information downloaded from jco.ascopubs.org and provided by at Staats-und Universitatsbibliothek Dresden on April 24,
+Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
+points (data not shown) or waking cortisol levels at any time point
+(data not shown).
+Although there were no group differences between patients with
+and without missing data on demographic, medical, or the outcome
+variables at baseline, we imputed the missing data by using multiple
+imputations (SAS version 9.2 MI procedure) with Markov Chain
+Monte Carlo method and then used the MIANALYZE procedure to
+generate statistical inferences. All the analyses remained the same or
+resulted in smaller P values except for cortisol slopes, but the pattern
+remained the same (end of treatment: YG v ST, P  .083; YG v WL,
+P  .015; 1-month follow-up: YG v ST, P  .21; YG v WL, P  .14).
+DISCUSSION
+To our knowledge, this is the first study to compare the effects of YG
+against active ST and WL control groups in a cancer population.
+Compared with the WL group, the YG group had higher PCS scores 1
+and 3 months after XRT (primary outcome), better PF at 1, 3, and 6
+months, better GH at 1 and 3 months, less fatigue by the end of XRT,
+and steeper cortisol slopes at the end of XRT and 1 month later.
+Compared with the ST group, the YG group reported better PF 1 and
+3 months after XRT, GH at 1 and 3 months, and had steeper cortisol
+slopes by the end of treatment. The improvement in PF in the YG
+group is also considered clinically significant because there was 
+five-point increase, which was not the case for the other two
+groups.25,26 Although the ST group reported less fatigue by the end of
+XRT and improved PF 3 months after treatment relative to the WL
+group, no other differences emerged between the ST and WL groups.
+There were no significant group differences for MH outcomes or
+sleep disturbances.
+The present findings of improvements in PF and GH are consis-
+tent with the results of the pilot study using the same YG interven-
+tion.19Therewas,however,amorelastingeffectofdeliveringYGthree
+times a week in the current study versus two times a week in the pilot
+study, with group differences in PF lasting through the 6-month
+follow-up versus just 1 week after the end of XRT. Although the
+minimumfrequencyofYGpracticetoachievepositivebenefitshasyet
+to be determined, it is generally believed that daily practice is ideal.
+Class attendance was extremely high, as was observed in the pilot
+study,19 and higher than that reported by other studies.31,32
+ThelackofbenefitformeasuresofMH,fatigue,andsleepdistur-
+bances is also consistent with the pilot trial.19 Even though the YG
+Mean Change From Baseline
+Time Point
+8
+6
+4
+7
+5
+2
+3
+0
+1
+−1
+−3
+−2
+End of
+radiotherapy
+1 month
+3 month
+6 month
+Yoga
+Stretch
+Waitlist
+Mean Change From Baseline
+Time Point
+8
+6
+4
+7
+5
+2
+3
+0
+1
+−1
+−3
+−2
+End of
+radiotherapy
+1 month
+3 month
+6 month
+Yoga
+Stretch
+Waitlist
+Mean Change From Baseline
+Time Point
+6
+4
+5
+2
+3
+0
+1
+−1
+−3
+−2
+End of
+radiotherapy
+1 month
+3 month
+6 month
+Yoga
+Stretch
+Waitlist
+A
+B
+C
+*
+*
+*†
+*†‡
+*
+*†
+*†
+Fig 2. Change from baseline in Medical Outcomes Study 36-item short-form
+survey (SF-36) subscale scores. (A) SF-36 PCS change from baseline; (B) SF-36
+physical function change from baseline; (C) SF-36 general health change from
+baseline. Significance values are from the MIXED models of change scores at
+each follow-up time point. (*) Yoga versus waitlist, P  .05. (†) Yoga versus
+stretch, P  .05. (‡) Stretch versus waitlist, P  .05.
+Mean Change From Baseline
+Time Point
+1.0
+0.6
+0.2
+0.8
+0.4
+0
+−0.4
+−0.2
+−0.6
+−1.0
+−0.8
+End of
+radiotherapy
+1 month
+3 month
+6 month
+Yoga
+Stretch
+Waitlist
+*†
+Fig 3. Change from baseline for fatigue. Significance values are from the MIXED
+models of change scores at each follow-up time point. (*) Yoga versus waitlist,
+P  .05. (†) Stretch versus waitlist, P  .05.
+Yoga, QOL, and Cortisol in Women With Breast Cancer
+www.jco.org
+© 2014 by American Society of Clinical Oncology
+1063
+2014 from 141.30.141.33
+Information downloaded from jco.ascopubs.org and provided by at Staats-und Universitatsbibliothek Dresden on April 24,
+Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
+program included components to address aspects of MH through
+relaxationandmeditation,thiswasaminorcomponentrelativetothe
+physicalmovementsthewomenpracticed.Inaddition,MCSscoresof
+thewomenbytheendofXRTwerenotclinicallysignificantlydifferent
+than the general population, and they improved across the course of 6
+months, suggesting a possible ceiling effect for MH. The same pattern
+was seen for fatigue and sleep disturbances. Although some studies
+show that YG improves these outcomes, most research has been con-
+ducted in cancer survivors after treatment has ended, used YG pro-
+grams that were perhaps less physical with more of a focus on
+relaxation,5,6 or targeted specific symptoms.9,33,34 In addition, im-
+provements in PF may become more apparent over time with other
+outcomes being more stable.35 Yet, it may be beneficial to examine if
+programs placing a greater emphasis on relaxation and meditation
+may have resulted in improved MH and sleep quality outcomes.
+The current study also examined an objective measure of stress
+arousal by assessing the diurnal changes in circulating cortisol levels
+during waking hours. Although there was a blunting of the cortisol
+slope by the end of XRT, participants in the YG group had a signifi-
+cantly steeper cortisol slope than the other groups. Although the
+clinical significance of this finding is unclear, it does suggest the
+positive effects of YG on the stress hormone cortisol. There is
+evidence that a blunted cortisol slope is associated with tumor
+progression18 and decreased survival17 in patients with breast can-
+cer, so maintaining a sustained steep cortisol slope may therefore
+have prognostic implications.
+Although this study controlled for the ST and attention com-
+ponents associated with the YG program, the ST group did not
+learn any aspects of relaxation. However, the YG group resulted in
+greater improvement in PF, likely resulting from the physical as-
+pects of YG. Study groups were not blinded, and treatment expecta-
+tions were not assessed. In addition, because of the number of
+secondaryoutcomesandmultiplecomparisons,significantgroupdif-
+ferencesforsecondaryoutcomes(fatigueandcortisolslope)shouldbe
+interpreted cautiously.
+The current study found that, for some outcomes, YG yielded
+better subjective and objective results than either ST or usual care.
+There were fewer differences between ST and WL groups. Although
+physical therapy is a reimbursable expense in the United States and
+will likely help patients recover faster, expanding to include services
+such as YG should be considered. Future studies should examine
+methods to increase practice frequency outside of class, examine the
+benefits of different YG components by using appropriate controls,
+conduct such trials in a blinded manner, assess expectations, and
+conduct multilevel cost-benefit analyses.
+AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS
+OF INTEREST
+The author(s) indicated no potential conflicts of interest.
+AUTHOR CONTRIBUTIONS
+Conception and design: Kavita D. Chandwani, George Perkins,
+Hongasandra Ramarao Nagendra, Nelamangala V. Raghuram,
+Raghuram Nagarathna, Banu Arun, G. Stephen Morris, Janet Scheetz,
+Alejandro Chaoul, Lorenzo Cohen
+Financial support: Lorenzo Cohen
+Provision of study materials or patients: George Perkins, Banu Arun,
+Clemens Kirschbaum, G. Stephen Morris, Janet Scheetz, Lorenzo Cohen
+Collection and assembly of data: Kavita Chandwani, Amy Spelman,
+Kayla Johnson, Adoneca Fortier, Qi Wei, Clemens Kirschbaum
+Data analysis and interpretation: Kavita Chandwani, Qi Wei, Robin
+Haddad, Lorenzo Cohen
+Manuscript writing: All authors
+Final approval of manuscript: All authors
+log(cortisol [nmol/L])
+Time
+3.0
+2.5
+1.5
+2.0
+1.0
+0
+0.5
+45 minutes
+8 hours
+12 hours
+Bedtime
+Yoga
+Stretch
+Waitlist
+A
+log(cortisol [nmol/L])
+Time
+3.0
+2.5
+1.5
+2.0
+1.0
+0
+0.5
+45 minutes
+8 hours
+12 hours
+Bedtime
+Yoga
+Stretch
+Waitlist
+B
+log(cortisol [nmol/L])
+Time
+3.0
+2.5
+1.5
+2.0
+1.0
+0
+0.5
+45 minutes
+8 hours
+12 hours
+Bedtime
+Yoga
+Stretch
+Waitlist
+C
+Fig 4. Log-transformed cortisol level daily curves. (A) Daily log-cortisol mean at
+baseline. No group differences. (B) Daily log-cortisol mean at end of radiotherapy.
+Yoga has steeper slope than stretch and waitlist groups (P  .027 and P  .008,
+respectively). (C) Daily log-cortisol mean at 1 month. Yoga has steeper slope than
+waitlist (P  .05 and P  .04, respectively). Significance values are from the GLM
+analysis of cortisol slopes at each time point, covarying for baseline.
+Chandwani et al
+1064
+© 2014 by American Society of Clinical Oncology
+JOURNAL OF CLINICAL ONCOLOGY
+2014 from 141.30.141.33
+Information downloaded from jco.ascopubs.org and provided by at Staats-und Universitatsbibliothek Dresden on April 24,
+Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
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+32. Moadel AB, Shah C, Wylie-Rosett J, et al:
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+quality of life. J Clin Oncol 25:4387-4395, 2007
+33. Bower JE, Garet D, Sternlieb B: Yoga for
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+■■■
+Yoga, QOL, and Cortisol in Women With Breast Cancer
+www.jco.org
+© 2014 by American Society of Clinical Oncology
+1065
+2014 from 141.30.141.33
+Information downloaded from jco.ascopubs.org and provided by at Staats-und Universitatsbibliothek Dresden on April 24,
+Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
+Acknowledgment
+We thank Mira Rao and Daksha Shah for their wonderful work teaching the yoga program to the participants, and we thank the Department
+of Scientific Publications, The University of Texas MD Anderson Cancer Center for their helpful editorial comments on the article.
+Chandwani et al
+© 2014 by American Society of Clinical Oncology
+JOURNAL OF CLINICAL ONCOLOGY
+2014 from 141.30.141.33
+Information downloaded from jco.ascopubs.org and provided by at Staats-und Universitatsbibliothek Dresden on April 24,
+Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
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+                                               
+1
+TANG / www.j-tang.org
+2020 / Volume 10 / Issue 1 / e3
+Original article
+Relationship between Spiritual Health, Mindfulness and Emotion Regulation 
+among French Emerging Adults
+Pascal Papillon1, Sasidharan K. Rajesh2
+1Ph.D. Scholar, Division of Yoga and Management Studies, Swami Vivekananda Yoga Anusandhana Samsthana,19, Eknath 
+Bhavan, Gavipuram Circle, K.G.Nagar, Bangalore, India. 2Associate Professor, Division of Yoga and Physical Sciences, 
+Swami Vivekananda Yoga Anusandhana Samsthana,19, Eknath Bhavan, Gavipuram Circle, K.G.Nagar, Bangalore, India.
+ABSTRACT
+Spirituality is the dynamic and inherent dimension of humanity. This study aims to evaluate the relationship 
+between Spiritual Health, Mindfulness and Emotion Regulation among French Emerging Adults.  An 
+online cross-sectional survey design consisted of four hundred and twenty-one samples were recruited from 
+different universities at Strasbourg, France. Participant’s age ranged from 18 to 28 years with a mean age 
+of 20.77 years (SD=2.22). The results, highlights that Spiritual Health Measure was significant and positive 
+association with Mindfulness (r=.45, p < .01) and Reappraisal (r=.22, p < .01). Further, the significant 
+negative correlation observed with Spiritual Dissonance (r=.44, p < .01) and Suppression (r=.24, p < .01).  
+These findings support emerging literature on Spiritual Health. Future studies should evolve an intervention 
+model to promote Spiritual Health and Positive Health.
+Keywords: France, spiritual health, mindfulness, emotion regulation, university students
+INTRODUCTION
+Spirituality is the dynamic and inherent dimension of humanity 
+(Puchalski, 2014). It relates to the way person’s search for 
+meaning in life; it includes connectedness to others, self, nature, 
+and transcendence (Fisher, 2011; Weathers, Mccarthy, & Coffey, 
+2016). Spiritual Health represents the principles that guide 
+human life (Fisher, 2013). Spirituality Health is recognized as a 
+central element of holistic development and plays a key role in 
+mental health. Result’s highlight spiritual inclination protects 
+youth from negative outcomes (e.g., risk behaviors and mental 
+illness), and promotes positive and flourishing development 
+(Hardy, Nelson, Moore, & King, 2019). Further, spiritual based 
+coping strategies can help in demanding situations to enhance 
+their psychological and physical health (Hill & Pargament, 
+2003). Furthermore, systematic review and meta-analysis of the 
+efficacy of spiritual-based interventions for substance use have 
+shown the evidence of efficacy in helping people with substance 
+use problems (Hai, Franklin, Park, DiNitto, & Aurelio, 2019).
+The concept of spirituality is multidimensional. Based on 
+extensive literature review, Fisher and Gomez conceptualized a 
+comprehensive hierarchical multidimensional definition and 
+measure of Spiritual Health (Gomez & Fisher, 2003). The model 
+encompasses four complex domains (Gomez & Fisher, 2005), 
+namely personal, communal, environmental and transcendental. 
+The personal factor expresses how oneself related to meaning, 
+purpose, and values in life. While the communal domain is stated 
+as interpersonal relationships, between self and others. Further, 
+the environmental construct refers how a person relates to nature 
+and environment. Finally, transcendental domain deals with the 
+connection of self with something beyond the human level or 
+God. The collective results of the four domains encompass the 
+global dimension of Spiritual Health (Fisher, 2011). Hence, 
+Spiritual health is operationalized as an active state of being, 
+echoed in the quality of relationships that people have in up to 
+four domains of spiritual well-being: Personal domain; 
+Communal domain; Environmental domain, and Transcendental 
+domain. Based on the multidimensional model of Spiritual 
+Health, the Spiritual Health and Life-Orientation Measure 
+(SHALOM) was developed (Fisher, 2010). The 20-items 
+SHALOM questionnaire comprises five items reflecting the four 
+domains of spiritual health. The SHALOM consists of two 
+responses per item. The Spiritual Health Measure (SHM) which 
+assesses lived experience, and Life Orientation Measure (LOM) 
+reflected on ideals for Spiritual Health. Spiritual Dissonance is 
+an additional facet of Fisher’s Spiritual Health model (Fisher & 
+Brumley, 2008). The non-congruence between the ideals and 
+lived experience scores is considered as Spiritual Dissonance.
+Studies on the association between Spirituality and 
+Psychological Well-Being have augmented in recent decades 
+(Gonçalves, Lucchetti, Menezes, & Vallada, 2017). Spirituality 
+embraces religious practices and cultural beliefs (Sadat hoseini, 
+Razaghi, Khosro Panah, & Dehghan Nayeri, 2019); in other 
+words, Spiritual Health is mingled into the faith and ethos of the 
+populace. Further, Spiritual Health is interwoven into the culture 
+of the community. Hence, present study evaluates the 
+relationship between Spiritual Health and Psychological Well-
+Being (Mindfulness and Emotional Regulation) among a sample 
+of French emerging adults, additionally explores the importance 
+of religion and spirituality among the sample.
+MATERIALS AND METHODS
+An online cross-sectional survey design was used to observe the 
+relationship between Spiritual Health and Psychological Well-
+Being. Four hundred and twenty-one non-probabilistic, 
+*Correspondence: Sasidharan K. Rajesh
+E-mail: rajesheskay@svyasa.edu.in
+Received Sep 28, 2019; Accepted Jan 03, 2020; Published Feb 28, 2020
+doi: http://dx.doi.org/10.5667/tang.2020.0003
+©2020 by CellMed Orthocellular Medicine Pharmaceutical Association
+This is an open access article under the CC BY-NC license.
+(http://creativecommons.org/licenses/by-nc/3.0/)
+Relationship between Spiritual Health, Mindfulness and Emotion Regulation among French Emerging Adults
+2
+TANG / www.j-tang.org
+2020 / Volume 10 / Issue 1 / e3
+intentional sample were recruited from different universities at 
+Strasbourg, France. A snowball sampling technique was adopted 
+to recruit participants, with persons who have initially joined the 
+research referred others. The cover letter containing information 
+about the aim of the study and paper version of the questionnaire 
+was shared to subject population via electronic format, built on 
+the Google Form. Data were automatically and anonymously 
+collected and stored into Excel file by the Google Form. 
+Participant’s age ranged from 18 to 28 years with a mean age of 
+20.77 years (SD=2.22). Most of the respondents (77.4%) 
+identified as women while 22.6% identified as men. The areas of 
+education were various but health areas represented 65.1% of the 
+population. Participants were not provided with any incentives 
+for their participation.
+ASSESSMENTS
+Spiritual Health and Life-Orientation Measure (Gomez & 
+Fisher, 2005) 
+SHALOM, Spiritual Well-Being questionnaire has scales for 
+personal, communal, environmental, and transcendental spiritual 
+well-being. In all, there are 20 items, with five items for each of 
+the four scales to allow for self-ratings of these items using a 
+five-point Likert scale, ranging from very low (rated 1) to very 
+high (rated 5). This scale is asking respondents to evaluate how 
+each item reflects their experience most of the time: personal (e.g. 
+meaning in life), communal (e.g. love for other people), 
+environmental (e.g. oneness with nature) and transcendental (e.g. 
+oneness with God). Each item requires the respondents to 
+consider: (a) How important the item is for optimal spiritual 
+health, in their opinion? and (b) how this item reflects their daily 
+personal experience. SHALOM is a valid and reliable instrument 
+for assessing spiritual health.
+Freiburg Mindfulness Inventory (Trousselard et al., 2010)
+Mindfulness was measured on unidimensional model using the 
+Freiberg Mindfulness Inventory (FMI). The 14-item self-
+reported questionnaire uses a 4-point Likert scale rating from 1 
+(Rarely) to 4 (Almost always). Scores range from 14 to 56, with 
+higher scores indicating higher levels of mindfulness.  This 
+scale has robust psychometric properties; the internal reliability 
+score (Cronbach's alpha) was .86.
+Emotion Regulation Questionnaire (Christophe, Antoine, 
+Leroy, & Delelis, 2009)
+The Emotion Regulation Questionnaire (ERQ) comprises 10 
+items assessing the emotion regulation strategies. ERQ assesses 
+the typical use of Emotion Suppression (four items, e.g., “I keep 
+my emotions to myself”) versus Reappraisal (six items, e.g., 
+“When I want to feel less negative emotion, I change the way 
+I’m thinking about the situation”). Each item is rated on a scale 
+from 1 (strongly disagree) to 7 (strongly agree).  The reported 
+Cronbach’s alpha was 0.76 for the cognitive Reappraisal and 
+0.72 for the Suppression.
+RESULTS
+All statistical analyses were performed using the statistical 
+package (Love et al., 2019) JASP (Version 0.10.2). Descriptive 
+statistics of SHALOM and its four domains, Spiritual Health, 
+Life-Orientation, Spiritual Dissonance, Mindfulness, and 
+Emotion Regulation are summarized in Table 1. Notably, 
+emerging adults lived experience on each domain is less than the 
+ideal scores on SHALOM questionnaire.
+Table 1. Descriptive statistics of SHALOM and its four domains, 
+Spiritual Health, Life-Orientation, Spiritual Dissonance, Mindfulness, 
+and Emotion Regulation
+Variables
+Mean
+Std. Deviation
+Personal (ideal)
+4.48
+0.52
+Personal (lived experience)
+3.21
+0.73
+Communal (ideal)
+4.52
+0.49
+Communal (lived experience)
+3.56
+0.64
+Environmental (ideal)
+3.90
+0.79
+Environmental (lived experience)
+3.06
+0.77
+Transcendental (ideal)
+2.63
+1.24
+Transcendental (lived experience)
+1.99
+0.95
+Spiritual Health Measure
+11.82
+2.09
+Life Orientation Measure
+15.54
+2.13
+Spiritual Dissonance
+3.72
+1.95
+Mindfulness
+37.04
+6.09
+Reappraisal
+27.88
+6.67
+Suppression
+14.48
+5.26
+Descriptive statistics of participants’ religious and spiritual 
+characteristics, are summarized in Table 2. The results, 
+highlights that sample of French emerging adults reported the 
+importance of spirituality (totalized high and very high- 57.2%) 
+is higher compared to the importance of religion (totalized high 
+and very high- 17.8%).
+Table 2. Descriptive statistics of participants’ Religious and Spiritual 
+characteristics
+Variable
+Frequency
+Percent
+Importance 
+of 
+religion
+Very Low
+62
+14.7
+Low
+62
+14.7
+Moderate
+55
+13.1
+High
+42
+10.0
+Very High
+33
+7.8
+Importance 
+of 
+spirituality
+Very Low
+48
+11.4
+Low
+51
+12.1
+Moderate
+81
+19.2
+High
+131
+31.1
+Very High
+110
+26.1
+Pearson correlations were used to examine the association 
+between Spiritual Health, Life-Orientation, Spiritual Dissonance, 
+Mindfulness, and Emotion Regulation. Zero-order correlation 
+between variables summarized in Table 3. Spiritual Health 
+Measure was significant and positive association observed with 
+Life Orientation Measure (r=.57, p < .01), Mindfulness (r=.45, p 
+< .01) and Reappraisal (r=.22, p < .01). Further, the significant 
+negative correlation observed with Spiritual Dissonance (r=.44, 
+p < .01) and Suppression (r=.24, p < .01). Life Orientation 
+Measure was significant and positive association observed with 
+Spiritual Dissonance (r=.47, p < .01), Mindfulness (r=.16, p 
+< .01) and Reappraisal (r=.14, p < .01).  Furthermore, the 
+significant negative correlation observed with Suppression 
+Relationship between Spiritual Health, Mindfulness and Emotion Regulation among French Emerging Adults
+3
+TANG / www.j-tang.org
+2020 / Volume 10 / Issue 1 / e3
+Table 3. Correlation between Spiritual Health, Life-Orientation, Spiritual Dissonance, Mindfulness, and Emotion Regulation
+Spiritual Health 
+Measure
+Life Orientation 
+Measure
+Spiritual 
+Dissonance
+Mindfulness
+Reappraisal
+Life Orientation Measure
+.575**
+Spiritual Dissonance
+-.447**
+.475**
+Mindfulness
+.453**
+.160**
+-.312**
+Reappraisal
+.229**
+.141**
+-.092
+.337**
+Suppression
+-.243**
+-.127**
+.123*
+-.092
+.108*
+**. Correlation is significant at the 0.01 level (2-tailed).
+*. Correlation is significant at the 0.05 level (2-tailed).
+(r=.12, p < .01). The Spiritual Dissonance was significant and 
+negative relation observed with Mindfulness (r=.31, p < .01) and 
+no statistically significant correlation with Reappraisal. As well, 
+a significant positive correlation was observed with Suppression 
+(r=.12, p < .05). Mindfulness was significant and positive 
+association observed with Reappraisal (r=.33, p < .01). Further, 
+there was no statistically significant correlation between 
+Mindfulness and Suppression. Reappraisal was significant and 
+positive association observed with Suppression (r=.10, p < .05).
+A multiple regressions was run to predict Spiritual Health 
+from Spiritual Dissonance, Mindfulness, Reappraisal and 
+Suppression. The multiple regression model statistically 
+significantly predicted Spiritual Health, F (4, 416) = 56.228, p 
+< .0005, adj. R2 = .345. Regression coefficients and standard 
+errors can be found in Table 4.
+Table 4. Summary of multiple regression analysis
+Variable
+B
+SEB
+β
+p
+Intercept
+9.379
+0.672
+< .001
+Dissonance
+-0.345
+0.045
+-0.321
+< .001
+Mindfulness
+0.101
+0.015
+0.295
+< .001
+Reappraisal
+0.038
+0.013
+0.121
+0.005
+Suppression
+-0.075
+0.016
+-0.189
+< .001
+B = Unstandardized regression coefficient; SEB = Standard error of 
+coefficient; β= Standard coefficient
+DISCUSSION
+The purpose of this study was to examine the relationship 
+between Spiritual Health, Mindfulness and Emotion Regulation 
+as well as to understand the role of Spiritual Dissonance in a 
+sample of French emerging adults. The present study result 
+highlights the significant positive relationship between self-
+reported Spiritual Health and Mindfulness. Further, results shed 
+light on the significant association of Spiritual Health with the 
+aspects of emotional processes. Furthermore, Spiritual 
+Dissonance has shown a negative relation with Spiritual Health 
+and Mindfulness. The strong associations between various areas 
+of Psychological Well-Being and Spiritual Health are in line with 
+what has been found in different studies (Gonçalves et al., 2017; 
+Hai et al., 2019). Further, the Spiritual Dissonance results are 
+consistent with the previous results (Fisher & Brumley, 2008; 
+Gomez & Fisher, 2003).
+The emerging adults meet a lot of stress and pressures in 
+order to do well in the personal and to accomplish later 
+professional success in life. The earlier result has reported the 
+highly spiritual individuals to have the ability to adapt and cope 
+with adverse times (Rosmarin, Alper, & Pargament, 2015). 
+Further, prior findings suggest that taking care of the spiritual 
+may help in risky behaviors (Beckwith, 2006). This study 
+reflects that students who have better Spiritual Health may be 
+able to cope with the demanding situation, and the Mindfulness 
+will help to reframe or reinterpret adverse experiences. Further, 
+Spiritual Well-Being will be shielding against negative outcomes 
+because of the sense of belonging in nurtured in individuals. 
+There is mounting empirical direction to support the association 
+between spirituality and stress management (Kim & Seidlitz, 
+2002). Efforts to the upsurge the awareness of spirituality and 
+endorse spiritual growth, and well-being has been prevailing on 
+implications for stress reduction. It agreed the importance of 
+Spiritual Health and Well-Being outcomes; family and school 
+education should focus on enhancing Spiritual Well-Being may 
+be beneficial for dealing with risky behaviors and positive health.
+The limitations of this research must also be considered. First, 
+this data originated from an online cross-sectional survey, so the 
+analyses precluded causal relationships. Longitudinal (Kim & 
+Seidlitz, 2002) detect the potential cause-and-effect relationships 
+between Spiritual Health and Well-Being. Participants 
+completed a self-report anonymous survey, so they could have 
+altered their responses due to social desirability. Then, the 
+sample included was emerging adults attending university, 
+excluding people who did not attend. Further, participants’ 
+history of risky behaviors was not assessed. Furthermore, the 
+assessment of Spiritual Well-Being through a single tool may not 
+apprehend all the facets of spirituality.
+In conclusion, the results of this study shown a significant 
+relationship between Spiritual Health and Well-Being. The 
+different dimensions of spirituality may have a beneficial and an 
+effective role in the students’ health.  Repetition of our models 
+utilizing prospective assessments and interventions to promote 
+Spiritual Health among the diverse demographics, community, 
+and clinical samples will offer useful directions for positive 
+health.
+ACKNOWLEDGEMENTS
+We thank Damien Corubolo for his help in developing the 
+Relationship between Spiritual Health, Mindfulness and Emotion Regulation among French Emerging Adults
+4
+TANG / www.j-tang.org
+2020 / Volume 10 / Issue 1 / e3
+Google Form. Further, we thank all the participants of the study. 
+Thanks to Professor John Fisher who has granted permission to 
+translate the SHALOM questionnaire to French language.
+CONFLICT OF INTEREST
+None
+SOURCE(S) OF SUPPORT
+This research received no specific grant from any funding 
+agency in the public, commercial, or not-for-profit sectors
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+efficacy of spiritual/religious interventions for substance use 
+problems: A systematic review and meta-analysis of randomized 
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+Religious and Spiritual Influence in Adolescence: A Systematic 
+Review of 30 Years of Research. Vol. 29, Journal of Research 
+on Adolescence. 2019. p. 254–75. 
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+Measurement of Religion and Spirituality: Implications for 
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+Love J, Selker R, Marsman M, Jamil T, Dropmann D, Verhagen 
+J, et al. JASP: Graphical statistical software for common 
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diff --git a/subfolder_0/Resting state functional near infrared spectroscopy..txt b/subfolder_0/Resting state functional near infrared spectroscopy..txt
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index 0000000000000000000000000000000000000000..b33efde1d6d6b88452007dfd8bea59f6aeff33b7
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+++ b/subfolder_0/Resting state functional near infrared spectroscopy..txt	
@@ -0,0 +1,59 @@
+Resting state functional near infrared spectroscopy
+Carlos V. Rizzo-Sierra1-3, Singh Deepeshwar4, Sanjay Kumar4, Hemant Bhargav4, Manjunath 
+Krishnamurthy4, Nagendra R. Hongasandra4
+1NeuroniKaS Laboratory, Unicolciencias, Colombia
+2ICMR Center for Advanced Research in Yoga & Neurophysiology, SVYASA Yoga University, India
+3School of Industrial Engineering, St. Thomas University, Colombia
+4Division of Yoga and Life Sciences, Swami Vivekananda Yoga University (S-VYASA), Bangalore, Karnataka, India
+The present study investigated the spatial-temporal variation of oxygenated hemoglobin (HbO), deoxygenated hemoglobin 
+(Hb), blood volume (BV) and blood oxygenation (BO) concentration changes in the prefrontal cortex, measured with 
+functional near-infrared spectroscopy (fNIRS) during resting state. We examined 36 healthy right handed subjects seating 
+with their minds and body quiet and still, as well as their eyes closed for 5 minutes. The spatial mean concentration change of 
+the four estimated parameters across subjects was found near zero; Moreover, the mean concentration changes across 
+subjects for HbO and Hb were found to be more reduced than those of BV and BO. In addition, there were no statistically 
+voxelwise significant differences for the mean concentration changes related to HbO, Hb, BV, neither BO; This finding 
+strongly suggests for a spatial stability in the mean concentration changes during resting state.
+Keywords – Brain oxygenation, Continuous wave, Functional near-infrared spectroscopy, NIRS, Optical imaging
+Introduction:  fNIRS has been in development as a useful tool for neuroimaging studies [1-3]. Among these, the 
+instruments for continuous wave (CW) measurements based on the modified Lambert–Beer law (MLB) [4,5] are the 
+most readily available commercially. Instruments of this type allow observation of dynamic changes in regional cerebral 
+blood flow (rCBFs) in real time by monitoring the concentration changes in cerebral HbO and Hb. However, it is 
+difficult to quantitatively measure HbO and Hb concentrations in the cerebral tissue separately from those in the 
+extracerebral tissue. These problems have limited the use of fNIRS. Indeed, proper resting state calibration studies are 
+missing within the fNIRS literature. As a matter of fact, this has not been well understood by many fNIRS users. Here, a 
+common fNIRS-CW system is employed to determine the variation in the spatial-temporal resting state activity in 
+cerebral tissue across healthy subjects. Methods: Thirty six right-handed healthy subjects (27 males and 9 females, with 
+a mean age (± SD) of 27.92 (± 4.78) years and 24.11 (± 2.71) years respectively) volunteered for the study. They seated 
+with their minds quiet as much as possible and their eyes closed; the prefrontal cortex was monitored for 5 minutes 
+employing a fNIRS-CW system first described by Chance et al  (1998) [6]. The sensor has a temporal resolution of 500 
+milliseconds per scan with 2.5 cm source-detector separation allowing for approximately 1.25 cm of penetration depth. 
+The employed fNIRS system is composed of three modules: a flexible headpiece (sensor pad), which holds 4 light 
+sources and 10 detectors to enable a fast placement of all 16 optodes/voxels. Home built-in algorithms in MATLAB 
+were employed for the data analysis. Further, balanced one-way ANOVA was performed voxelwise, for each of the 
+independent four estimated parameters directly related to prefrontal activity: 1. HbO, 2. Hb, 3. BV: HbO + Hb,  4. BO: 
+HbO – Hb. Results: Voxelwise, the spatial mean concentration change of the four estimated parameters across subjects 
+is near zero; although, the variation across them is remarkable, specifically, the voxelwise standard deviation is higher 
+for voxels 8, 9 and 10. These voxels spatially correspond to the center of the frontal lobe. Moreover, the mean of 
+changes across subjects for HbO and Hb concentration are more reduced, with smaller standard deviation than those of 
+BV and BO. Furthermore, there are no statistically voxelwise significant differences for the mean concentration changes 
+related to HbO, Hb, BV, or BO. The highest Std values voxelwise for HbO, Hb, BV and BO are 2 (min: -2.96, max:  
+7.37), 1.6 (min: -6.26, max: 4.59), 2.8 (min: -3.08, max: 13.08), and 2.0 (min: -3.34, max: 8.09) micromol, relating 
+voxels 9, 8, 9 and 9 respectively. These results show that none of the 16 voxels have means significantly different from 
+each other, across 36 subjects, for none of the four estimated parameters.  Conclusion: We investigated the spatial-
+temporal variation of HbO and Hb concentration changes over the prefrontal cortex during resting state. The present 
+study strongly suggests a spatial stability in the concentration recorded during 5 minutes; the human frontal lobe resting 
+activity follows a spatially homogeneous trend. However, it is evident that the high variation found across subjects, 
+specially at the center of the frontal lobe deserves special attention and detailed research study.
+REFERENCES
+[1] Y. Hoshi, M. Tamura, “Detection of dynamic changes in cerebral oxygenation coupled to neuronal function during mental work in man”, Neurosci 
+Lett, 1993; 150: 5–8.
+[2]  K. Kato, A. Kamei, S. Takashima et al, “Human visual cortical function during photic stimulation monitoring by means of near-infrared 
+spectroscopy”, J. Cereb. Blood Flow Metab, 1993; 13: 516–520.
+[3] A. Villringer, J. Plank, C. Hock et al, “Near-infrared spectroscopy (NIRS): a new tool to study hemodynamic changes during activation of brain 
+function in human adults”, Neurosci Lett, 1993; 154: 101–104.
+[4] B. Chance, Z. Zhuang, C. Unah et al, “Cognition-activated low frequency modulation of light absorption in human brain”, Proc Natl Acad Sci 
+USA, 1993; 90: 3770–3774. 
+[5] D. T. Delpy, M. Cope, P. van der Zee et al, “Estimation of optical pathlength through tissue from direct time of flight measurement”, Phys Med 
+Biol, 1998; 33:1433–1442.
+[6]  B. Chance, E. Anday, S. Nioka et al, “A novel method for fast imaging of brain function, non-invasively, with light”, Optics Express, 1998; 
+2:411– 423. 
diff --git a/subfolder_0/Right uninostril yoga breathing influences ipsilateral components.txt b/subfolder_0/Right uninostril yoga breathing influences ipsilateral components.txt
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+Abstract A previous report described selective electrical
+activity of the cerebral hemispheres with uninostril breath-
+ing. In the present study, middle latency auditory evoked
+potentials (MLAEPs) were recorded from symmetrical
+scalp sites during the practice of uninostril yoga breathing.
+There were two sessions (40 min each) of right nostril
+yoga breathing (RNB) and of breath awareness (BAW),
+with (i) ‘before’, (ii) test (either RNB or BAW) and (iii)
+‘after’ periods. The participants were 14 male volunteers
+aged between 18 and 33 years, and the setting was a yoga
+centre. MLAEPs were recorded from symmetrical scalp
+sites (C4 and C3). During RNB, the peak amplitudes of
+two negative components (viz. Na wave and Nb wave)
+were significantly increased on the right side. Increased
+peak amplitudes of Na and Nb waves suggested that RNB
+increased the number of neurons recruited on the right
+side, suggesting a possible application of RNB in certain
+psychiatric disorders with cerebral hemispheric imbalance.
+Key words Right nostril yoga breathing • Breath aware-
+ness • Middle latency auditory evoked potentials
+Introduction
+The nasal cycle is an ultradian rhythm with alternating paten-
+cy of the left and right nostrils, occurring every one to eight
+hours [1]. In awake humans, these spontaneous shifts in nos-
+tril dominance have been correlated with changes in the
+activity of the two cerebral hemispheres, based on electroen-
+cephalographic (EEG) studies [2], performance in hemi-
+sphere-specific tasks [3] and studies of cerebral blood flow
+[4]. In addition to spontaneous shifts the EEG changes with
+forced uninostril breathing were also studied, and a higher
+amplitude was reported over the hemisphere contralateral to
+the nostril kept patent [5]. Previous experiments studying the
+effect of hyperventilation through the nose on EEG activity
+in the cortex suggest that the activity is produced by a neur-
+al reflex mechanism in the superior nasal meatus [6].
+There are specific yoga breathing practices (pranayamas)
+that involve breathing selectively through a particular nostril.
+These techniques can be practiced effortlessly for prolonged
+periods and allow the effects of unilateral nostril breathing to
+be evaluated. Uninostril yoga breathing may be exclusively
+through the right or left nostril. For the present study, the
+effects of right uninostril yoga breathing were evaluated.
+Left uninostril yoga breathing was not studied as traditional
+yoga texts mention that this practice can make a person
+“lethargic and lead to an introverted state of mind” and hence
+should not be practiced unless specifically advised by a
+teacher (guru) [7]. However, unpublished data comparing
+left nostril yoga breathing and breath awareness (BAW) are
+detailed in the Discussion, in which no specific effect was
+observed when breathing through the left nostril.
+With this background this study was designed to com-
+pare the middle latency auditory evoked potentials
+(MLAEPs), recorded from symmetrical scalp sites over
+left and right cerebral hemispheres, during a right nostril
+yoga breathing (RNB) practice as compared to BAW.
+MLAEPs were chosen to be studied, as the MLAEP com-
+ponents are known to have similar latency and amplitude
+Neurol Sci (2004) 25:274–280
+DOI 10.1007/s10072-004-0354-9
+P. Raghuraj • S. Telles
+Right uninostril yoga breathing influences ipsilateral components
+of middle latency auditory evoked potentials
+O R I G I N A L
+Received: 14 April 2004 / Accepted in revised form: 19 November 2004
+P. Raghuraj • S. Telles ()
+Vivekananda Yoga Research Foundation
+No. 19, Eknath Bhavan, Gavipuram Circle
+K.G. Nagar, Bangalore 560 019, India
+e-mail: anvesana@vsnl.com
+P. Raghuraj, S. Telles: Uninostril yoga breathing influences MLAEPs
+275
+characteristics on the right and left side, in normal persons
+[8]. This evaluation of the effects of uninostril yoga
+breathing on MLAEPs was expected to add to the under-
+standing of possible lateralised changes in MLAEPs and
+therapeutic implications in certain psychiatric disorders
+known to be lateralised, such as schizophrenia [9].
+In summary, the present study aimed at testing the sci-
+entific hypothesis that uninostril yoga breathing influenced
+the electrical activity of the two cerebral hemispheres,
+selectively producing detectable alterations in MLAEPs.
+Materials and methods
+Subjects
+Fourteen healthy male volunteers with ages ranging from 18 to 33
+years (group average age±SD, 26.3±3.5 years) were studied. These
+individuals had experience of the practice of uninostril yoga breath-
+ing as well as of BAW, ranging from 6 to 36 months prior to the study
+(group average±SD, 27.3±10.9 months). The signed informed con-
+sent of all subjects was obtained. None of the subjects had: (i) upper
+respiratory tract infection which could have resulted in nasal block-
+age or (ii) nasal septal deviation, or any other nasal abnormality.
+Design
+Subjects were assessed in two separate sessions (i.e., RNB and
+BAW) at the same time of the day on different days. Each session
+consisted of 40 min of recording for each subject, with 30 min of
+a test period preceded and followed by two periods of 5 min each.
+During the test periods of the two sessions, two recordings each
+were obtained for RNB and for BAW, which were averaged for
+analysis. Baseline nostril patency was confirmed using a mirror
+to measure the right and left nostril vapour condensation patterns
+upon exhalation. With this method the condensation of vapour of
+the dominant nostril was larger and visible longer [10].
+Recording of evoked potentials
+MLAEPs were recorded in the 100-ms, poststimulus time period
+without delay (Nicolet Bravo, USA), from both left and right
+symmetrical scalp sites referenced to the ipsilateral ear lobes
+(i.e., C3-A1 and C4-A2 respectively), with the ground electrode on
+the ventral surface of the left forearm. The preamplifier band-
+width was set at 10-1500 Hz and 1500 responses were averaged
+for each assessment. The rejection level was expressed as a per-
+centage of the full-scale range of the analog-to-digital converter.
+This level was set at 90%. Binaural click stimuli of 50 ms dura-
+tion and alternating polarity at the rate of 5 Hz were delivered
+through acoustically shielded earphones (Amplivox, UK). The
+threshold of hearing was noted for each subject and the intensity
+was kept at 60 dB above the normal hearing level (nHL) [average
+dB (nHL)±SD, 27.9±4.5 dB (nHL)].
+MLAEP components
+Peak amplitudes of short latency wave V, and middle latency Na,
+Pa and Nb waves were measured from a zero DC baseline. Peak
+latency was measured from the time of click delivery.
+The auditory evoked potential components were described as
+follows: wave V was the maximum positive peak between 5 and 8
+ms, and the Na wave was the maximum negative peak preceding
+the Pa wave, which is a positive component occurring between 25
+and 32 ms. The Nb wave was taken as the first maximum negative
+component immediately following the Pa wave [11].
+Right nostril yoga breathing and breath awareness
+RNB is voluntary breathing through the right nostril, while the left nos-
+tril is kept occluded with gentle pressure from the ring and little fingers
+of the right hand (nasika mudra in Sanskrit) [12, 13]. Breathing is vol-
+untarily regulated to be slow and deep with awareness of breathing.
+During BAW there was no voluntary manipulation of the
+nostrils, instead subjects breathed slowly and deeply, being
+aware of their breath, as for RNB.
+Data analysis
+Two factor analyses of variance [14] were performed to compare
+peak amplitudes of the MLAEP components recorded in the two
+sessions (Factor A, i.e., RNB sessions and BAW sessions). The
+test conditions (i.e., pre, during, post) constituted Factor B.
+Separate analyses were performed for MLAEPs recorded from
+symmetrical scalp sites on the left and right side. The Tukey test
+for multiple comparisons was used to detect significant differ-
+ences between group mean values.
+Similar analyses as mentioned in 1 above, were done for the
+peak latencies of the MLAEP components.
+Results
+Two factor ANOVA and Tukey test
+The peak amplitudes of the Na and the Nb waves recorded
+during RNB were significantly higher over the right hemi-
+sphere than those of the corresponding waves collected dur-
+ing the BAW session and during the preceding and follow-
+ing periods of RNB.
+Na wave peak amplitudes recorded on the right side for
+RNB sessions were significantly different from BAW sessions
+[F=4.47 (Factor A=RNB vs. BAW), since F (2,78)=3.09, at
+p=0.05, hence p<0.05]. The multiple comparison Tukey test
+for the highest significant difference showed that the Na wave
+peak amplitude on the right side was significantly greater dur-
+ing RNB compared to the values during BAW (q=3.04, as q
+(2,78) at p=0.05 is equal to 2.82, hence p<0.05).
+276
+P. Raghuraj, S. Telles: Uninostril yoga breathing influences MLAEPs
+The Nb wave peak amplitude recorded on the right side for
+the RNB session was significantly different from the BAW
+session [F=3.15 (Factor A=RNB vs. BAW), as F (2,78)=3.11
+at p=0.05, hence p<0.05]. The multiple comparison Tukey test
+for the highest significant difference showed that the Nb wave
+peak amplitude on the right side was significantly greater dur-
+ing RNB compared to the values during BAW, q=3.45, as q
+(2,78) at p=0.025 is equal to 3.25, hence p<0.025. Similarly,
+the Nb wave peak amplitude on the right side was significant-
+ly greater during RNB compared to the preceding value,
+q=3.23, as q (2,78) at p=0.05 is equal to 2.82, hence p<0.05.
+There were no significant differences between base-
+line values for RNB and BAW sessions.
+The Tukey test did not show any significant differ-
+ences between the Na and Nb waves recorded on the left
+side during the two sessions. Also, waves V and Pa were
+not significantly different on either side.
+Figure 1 shows recordings of MLAEPs pre-, during and
+post-RNB session, recorded on the left (C3-A1) and right
+side (C4-A2) for all subjects, with each tracing representing
+the averaged MLAEP from a single subject. Similarly,
+Figure 2 shows the recordings made pre-, during and post-
+BAW session on left and right sides.
+The group average values of peak amplitudes and
+latencies of the MLAEPs for RNB and BAW sessions are
+given in Tables 1 and 2 respectively.
+Fig. 1 Recordings of MLAEPs pre-, during and post-
+RNB recorded on the left (C3-A1) and right (C4-A2)
+side for all subjects, with each tracing representing
+the averaged MLAEP from a single subject
+Fig. 2 Recordings of MLAEPs pre-, during and post-
+BAW recorded on the left (C3-A1) and right (C4-A2)
+side for all subjects, with each tracing representing the
+averaged MLAEP from a single subject
+Discussion
+During RNB, compared to a period of BAW, there was a
+significantly higher peak amplitude of the Na wave on the
+right side. This is the negative peak preceding the positive
+Pa wave (25–32 ms). Similarly, the peak amplitude of the
+Nb wave (the first maximum negative peak following the
+Pa wave) was significantly higher on the right side during
+RNB compared to the preceding period as well the period
+of BAW. There were no changes found on either side dur-
+ing BAW. There was no correlation between changes dur-
+ing the session and pre-session nostril patency.
+Regarding the origins of the MLAEPs, there are two
+schools of thought which claimed the neural and the mus-
+cular origin of MLAEPs, and have been equivocal. Ruhm
+and colleagues [15] termed the smaller potentials as
+cochleoneurogenic and the bigger ones as vestibulomyo-
+genic. Davis [16] also differentiated these responses
+according to their myogenic and neurogenic origin. The
+myogenic part which originated from posterior auricular
+and neck muscles was called the sonomotor reflex with an
+onset at 12 ms. In the present study it is also important to
+note that the auricular reference electrodes may have
+picked up myogenic activity. However, ear lobe recording
+has been shown to have less muscle artefacts compared to
+recording from the mastoid [17], which was the reason for
+selecting auricular reference recording.
+The neurogenic part according to Davis [16] originated
+at the medial geniculate body (thalamus), primary cortical
+areas and the immediate adjoining secondary areas. Ruhm
+and colleagues [15] were among the first to establish the
+neurogenic origin of auditory middle latency responses by
+recordings from the brain surface during craniectomies .
+Currently the neural generators of the different compo-
+nents are as follows: the Na wave has been postulated to be
+due to activity at the mesencephalic or diencephalic level
+[18], the Pa wave corresponds to the activity at the superi-
+Table 1 Peak amplitudes of MLAEPs in RNB and BAW sessions
+V wave
+Na wave
+Pa wave
+Nb wave
+RNB
+BAW
+RNB
+BAW
+RNB
+BAW
+RNB
+BAW
+Pre
+L
+0.71±0.23
+0.87±0.28
+1.68±1.57
+0.79±0.76
+0.95±0.89
+0.96±0.34
+0.95±0.89
+0.92±0.54
+R
+0.67±0.21
+0.88±0.35
+1.21±1.04
+0.75±0.50
+0.88±0.56
+1.00±0.56
+0.88±0.56
+0.81±0.60
+During
+L
+0.60±0.30
+0.82±0.26
+1.67±1.23
+1.00±0.62
+1.36±1.20
+0.95±0.44
+1.36±1.20
+1.01±0.44
+R
+0.64±0.21
+0.76±0.20
+1.86±2.04*
+1.01±0.70
+1.59±1.55
+1.00±0.45
+1.59±1.55**†
+0.83±0.38
+Post
+L
+0.68±0.28
+0.84±0.27
+1.20±0.68
+0.97±0.70
+1.13±0.77
+1.19±0.85
+1.13±0.77
+1.46±1.53
+R
+0.75±0.21
+0.74±0.23
+1.10±0.80
+0.91±0.65
+1.01±0.91
+0.92±0.36
+1.01±0.91
+0.87±0.43
+L, left side; R, right side. Values are group mean±SDs
+*p<0.05, **p<0.025, multiple comparison Tukey test, during RNB vs. BAW; †p<0.05, multiple comparison Tukey test, ‘during’vs. ‘pre’, RNB
+Table 2 Peak latencies of MLAEPs in RNB and BAW sessions
+V wave
+Na wave
+Pa wave
+Nb wave
+RNB
+BAW
+RNB
+BAW
+RNB
+BAW
+RNB
+BAW
+Pre
+L
+5.5±0.30
+5.5±0.30
+13.9±1.50
+13.6±2.20
+30.3±3.50
+30.7±3.60
+49.0±6.80
+51.9±8.80
+R
+5.6±0.30
+5.5±0.20
+13.7±1.30
+13.9±1.40
+30.8±2.90
+30.8±2.50
+48.2±4.20
+50.2±7.90
+During
+L
+5.8±0.90
+5.3±0.40
+14.5±1.90
+14.6±1.90
+29.6±3.60
+30.6±3.90
+50.9±6.50
+50.8±7.10
+R
+5.4±0.40
+5.4±0.40
+13.7±1.60
+14.8±1.90
+29.9±3.70
+30.3±3.90
+49.6±6.50
+48.0±7.00
+Post
+L
+5.3±0.40
+5.6±0.20
+14.0±1.70
+13.8±1.10
+30.7±3.70
+30.7±3.30
+48.6±5.40
+52.3±8.10
+R
+5.2±0.20
+5.2±0.20
+13.7±1.30
+15.0±2.10
+31.2±2.40
+31.2±2.80
+49.6±7.70
+50.7±6.80
+L, left side; R, right side. Values are group means±SDs
+P. Raghuraj, S. Telles: Uninostril yoga breathing influences MLAEPs
+277
+278
+P. Raghuraj, S. Telles: Uninostril yoga breathing influences MLAEPs
+or temporal gyrus [19] and the generator of the Nb wave is
+relatively localised in the dorso-posterior-medial part of
+the Heschl’s gyrus, i.e., the primary auditory cortex [8].
+In summary, the MLAEPs have a myogenic component
+that can be minimised by fully relaxing the subject [20]. In
+the present study the amplitudes of the Na wave and the
+Nb wave increased during yoga breathing. While the earli-
+er component (i.e., the Na wave) may have been modified
+by myogenic activity, the chance of muscle artefacts con-
+tributing to the Nb wave amplitude is unlikely. Also, in
+pranayamas involving nostril manipulation, voluntary
+occlusion of the nostrils is traditionally done with the right
+hand [13]. Hence the tonic muscular contraction of the
+right arm could have influenced (if at all) the activity over
+the left hemisphere in the form of movement-related activ-
+ity. This was not seen in the present study.
+Apart from the myogenic contribution to MLAEPs, a
+report on the variation of the middle latency evoked poten-
+tials with the physical characteristics of the stimuli,
+showed the Na and Pa waves are the most consistent and
+reliable waves evoked [21–23]. P0 and Nb are the next
+most reliable.
+An increase in the amplitude of an evoked potential
+component has been interpreted as being indicative of
+effective activation of the underlying neural generator
+[24]. The Na wave has been postulated to be due to activi-
+ty at the mesencephalic or diencephalic level [18].
+Intracerebral recording in man has shown that the neural
+generator of the Nb wave is relatively localised in the
+dorso-posterior-medial part of the Heschl’s gyrus, i.e., the
+primary auditory cortex [8]. As described above, the Na
+wave is believed to correspond to the mesencephalic-dien-
+cephalic (thalamic) level, possibly the medial geniculate
+body, while the Nb wave is relatively localised in the
+Heschl’s gyrus. Changes at the cortical level during the
+yoga breathing practice studied here could be expected to
+be lateralised, as was described in other studies on uninos-
+tril breathing [2, 5]. In attempting to understand why sub-
+cortical changes were also lateralised (i.e., the Na wave), a
+possible explanation is that the descending corticofugal
+control mechanisms could be expected to exert significant
+influences on the processing of information at the brain-
+stem and thalamic levels [25]. As it has been recognised
+that the corticofugal descending inputs to the medial
+geniculate body are stronger ipsilaterally than contralater-
+ally, these descending pathways may explain the later-
+alised effect at these subcortical levels [26].
+The Pa component has been shown to be correlated
+with activity at the level of the superior temporal gyrus
+[19]. If the uninostril yoga breathing were to produce a lat-
+eralised effect, it would be likely to have had a lateralised
+effect at this level. In the present study the Pa wave ampli-
+tude showed a higher value on the right side during RNB
+as compared to the changes on the left side, but this differ-
+ence was not significant. A possible explanation is as fol-
+lows. When measuring the peak amplitudes of individual
+components of evoked potentials, an inherent difficulty is
+that an increase in a positive component would influence
+the amplitude of a subsequent negative component and
+vice versa [27]. In the present case, the Pa wave is a posi-
+tive component occurring between two negative waves i.e.,
+the Na and the Nb waves, both of which showed an
+increase in amplitude. Hence the increase in the ampli-
+tudes of the preceding Na and succeeding Nb negative
+waves may have influenced the amplitude of the Pa wave,
+which is in between them. A usual way of overcoming this
+problem is to measure the peak-to-peak amplitude.
+However, in the present study this method was not chosen
+as the changes in neural generators corresponding to spe-
+cific waves individually were intended to be studied.
+A previous report on cytoarchitechtonic data suggests
+that the primary auditory cortices of right and left hemi-
+spheres are similarly organised [28]. This may explain why
+under baseline conditions auditory evoked potentials with
+neural generators in the right and left primary auditory
+cortices have similar latency and amplitude characteristics
+[8]. Hence the asymmetric increase in amplitudes of
+MLAEP components during RNB appears to be related to
+the breathing practice, rather than asymmetry in the under-
+lying neural generators.
+Previous studies on EEG activity of right and left hemi-
+spheres related to spontaneous shifts in nostril dominance
+have suggested that there was an increase in the EEG
+amplitude over the contralateral hemisphere [2]. Similarly,
+contralateral hemispheric activation based on EEG activi-
+ty was also demonstrated during forced uninostril breath-
+ing [5]. In these studies increased EEG amplitudes were
+considered indicators of increased mental activity in that
+hemisphere.
+Performance in hemisphere-specific tasks immediately
+after forced uninostril breathing showed that after forced
+left nostril breathing there was improved performance in
+spatial tasks, considered as right hemisphere functions. As
+verbal tasks were performed better after forced RNB, it
+was stated that contralateral hemisphere activation
+occurred with forced uninostril breathing [29].
+Previous studies described a contralateral hemisphere
+function enhancing effect based on the EEG, whereas in
+the present study changes in MLAEPs suggested that
+enhancement occurred ipsilaterally. Other studies on the
+performance in hemisphere-specific tasks related to both
+spontaneous shifts in nostril dominance and forced uni-
+nostril breathing reported improved performance in tasks
+specific to the contralateral hemisphere [3, 29]. In contrast,
+yoga breathing through right, left and alternate nostrils as
+well as BAW with no nostril manipulation, improved per-
+formance in a right hemisphere task (spatial memory) with
+no lateralised effect following yoga [30]. In order to deter-
+mine whether the trend of an increase in amplitudes of
+evoked potential components ipsilateral to the nostril
+through which breathing is practiced occurred irrespective
+of the nostril, it is necessary to refer to unpublished data of
+a study also on 14 male volunteers (group average
+age±SD, 26.86±5.04 years) who were evaluated in ‘left
+nostril yoga breathing (LNB)’ and in ‘BAW sessions’.
+There were no significant changes during the left nostril
+yoga breathing and the peak amplitudes of the Na and Nb
+waves are mentioned here. For the Na wave on the left side
+in the LNB session: 1.12±1.45 µV (pre), 1.45±1.72 µV
+(during), 1.19±1.67 µV (post); and in the BAW session:
+0.67±0.87 µV (pre), 0.62±0.45 µV (during), 0.74±0.68 µV
+(post). For the Na wave on the right side in the LNB ses-
+sion: 1.22±2.21 µV (pre), 1.03±0.78 µV (during),
+1.08±1.45 µV (post); and in the BAW session: 1.37±1.11
+µV (pre), 1.14±1.42 µV (during), 1.14±0.79 µV (post). For
+the Nb wave on the left side in the LNB session: 0.64±0.68
+µV (pre), 0.65±0.45 µV (during), 0.52±0.56 µV (post); and
+in the BAW session: 0.51±0.54 µV (pre), 0.45±0.38 µV
+(during), 0.38±0.17 µV (post). For the Nb wave on the
+right side in the LNB session: 0.76±0.81 µV (pre),
+0.60±0.51 µV (during), 0.64±0.66 (post); and in the BAW
+session 0.84±0.53 µV (pre), 0.53±0.47 µV (during),
+0.30±0.25 µV (post).
+Spontaneous shifts in nostril patency and forced uni-
+nostril breathing have similar effects (i.e., contralateral
+enhancement of hemispheric activity). In the present study,
+the higher peak amplitudes of two MLAEP components on
+the right side suggested that RNB brought about effective
+activation of underlying diencephalic and primary audito-
+ry cortical generators on the right side.
+Certain psychiatric disorders are known to be associat-
+ed with selective disruption of the function of a specific
+hemisphere. Uninostril breathing practices have potential
+use in conditions like this. For example, left forced uni-
+nostril breathing was tried with success in obsessive com-
+pulsive disorder, which was described by Shannahoff-
+Khalsa and Beckett (1996) as a disorder of the right hemi-
+sphere [31]. This makes it desirable for the effects of these
+practices to be understood in normal volunteers.
+Acknowledgements The study was supported by funds from the
+“DST-FIST” programme, Government of India, and the Temple
+of the Universe, Alachua, FL, USA.
+References
+1. Keuning J (1968) On the nasal cycle. J Int Rhinol 6:99–136
+2. Werntz DA, Bickford RG, Bloom FE, Shannahoff-Khalsa D
+(1983) Alternating cerebral hemispheric activity and the lat-
+eralization of autonomic nervous function. Hum Neurobiol
+2:39–43
+3. Klein R, Pilon D, Prosser S, Shannahoff-Khalsa D (1986)
+Nasal airflow asymmetries and human performance. Biol
+Psychol 23:127–137
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+Pranavidya. Bihar School of Yoga, Bihar, India
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+eral forced nostril breathing on cognitive performance. Int J
+Neurosci 73:61–68
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+Yoga breathing through a particular nostril increases spatial
+memory scores without lateralized effects. Psychol Rep
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diff --git a/subfolder_0/SU105. Mechanisms of Yoga in Schizophrenia Focus on Mirror Neuron Activity.txt b/subfolder_0/SU105. Mechanisms of Yoga in Schizophrenia Focus on Mirror Neuron Activity.txt
new file mode 100644
index 0000000000000000000000000000000000000000..19aafdd987f7ead6a7f2a84bdc5494cbfd53a6e8
--- /dev/null
+++ b/subfolder_0/SU105. Mechanisms of Yoga in Schizophrenia Focus on Mirror Neuron Activity.txt	
@@ -0,0 +1,123 @@
+International Congress on Schizophrenia Research
+Posters (Sunday)	
+S199
+Background: Individuals who have a psychotic disorder often find it dif­
+ficult to recognize emotions, read others’ mental states, and assess social 
+situations. These social cognitive deficits are highly predictive of problems 
+in daily life functioning. Meta-analyses show that social cognition can be 
+improved by social cognition training (SCT) approaches; however, long-
+term effects appear to be limited. Given that training of cognitive func­
+tions is best executed in a manner that resembles and is integrated with 
+participants’ daily lives as much as possible, a plausible explanation is that 
+the stimuli and techniques that are typically used in SCT do not sufficiently 
+resemble real-life social interactions. Several key characteristics of real-
+world interactions are absent from these stimuli, most notably interaction 
+with the material.
+Methods: To improve transference of SCT to daily life functioning and 
+interaction, we have therefore developed a SCT which utilizes Virtual 
+Reality (VR). VR is highly realistic, eliciting genuine psychological reac­
+tions, and highly interactive: the environment and the virtual people (“ava­
+tars”) in it react to the actions of the participant. At the same time, VR is 
+customizable and controllable, allowing for training that is tailored to the 
+individual.
+Results: A new form of SCT, utilizing VR (called “DiSCoVR”), has been 
+developed. DiSCoVR consists of 16 sessions, provided over the course 
+of 8 weeks, in which the following social cognitive domains are trained: 
+(1) Emotion perception; (2) Social perception and Theory of Mind (ie, 
+understanding the context and interdependence of emotions, thoughts and 
+behavior); and (3) Social interaction training (ie, understanding the other 
+person and choosing an adequate response). These domains are trained in 
+VR, supplemented by coaching from a therapist, and homework assign­
+ments. DiSCoVR is currently being piloted amongst 25 mental health ser­
+vice clients and 25 healthy controls in the northern Netherlands. In this 
+pilot, we primarily test the acceptability and feasibility of the intervention. 
+Furthermore, effects of the intervention on several domains of social cog­
+nition are investigated. Moreover, social behavior in VR is studied using 
+heart rate and eye tracking data, comparing healthy controls and clients.
+Conclusion: We will present a theoretical framework for DiSCoVR. 
+Moreover, we will demonstrate the intervention and provide preliminary 
+results of the ongoing pilot study.
+SU105. MECHANISMS OF YOGA IN 
+SCHIZOPHRENIA: FOCUS ON MIRROR 
+NEURON ACTIVITY
+Sneha Karmani*, Ramajayam Govindaraj, Harleen Chhabra, 
+Shalini Anji, Pooja More, Urvakhsh Mehta, 
+Shivarama Varambally, and Ganesan Venkatasubramanian
+National Institute of Mental Health and Neuro Sciences
+Background: Schizophrenia is associated with positive symptoms, nega­
+tive symptoms, and deficits in neurocognition as well as social cognition. 
+Deficits in social cognition are more closely linked to functional outcome 
+than general/nonsocial cognitive deficits. The “mirror-neuron system” is 
+the substrate for social cognition and is shown to have diminished acti­
+vation in schizophrenia. Of late, yoga been identified as a therapy across 
+many psychiatric disorders, including schizophrenia. Recent understanding 
+of mechanism of yoga in improving negative symptoms of schizophrenia 
+could be due to enhancement of mirror neuron activation (MNA).
+Methods: Schizophrenia patients were offered add-on yoga therapy with 
+ongoing medication. Subjects in yoga group underwent supervised yoga 
+therapy for 1 month (20 sessions, 1-h duration). The control group included 
+schizophrenia patients who received treatment as usual. Both groups were 
+assessed on PANSS and socio-occupational functioning scale (SOFS) at 
+the beginning and end of 1 month. Mirror neuron activity was assessed 
+using functional Near Infra-Red Spectroscopy (fNIRS) with experimental 
+task (action observation and action execution) before and after 1 month. 
+Statistical analysis was done using R software.
+Results: There was a significantly greater increase in left ventral premotor 
+cortex MNA in yoga therapy group (n = 7) when compared with control 
+group (n = 7) (Mann-Whitney U = 5.0; P = .013).
+Conclusion: The current study provides preliminary evidence for response 
+to yoga therapy in schizophrenia patients. Observation and imitation of 
+yoga practices may cause changes in the activation of mirror neurons. 
+Future studies need to systematically evaluate the same.
+SU106. INVESTIGATING THE SHORT- AND 
+LONG-TERM BENEFITS OF EXERCISE IN 
+EARLY PSYCHOSIS
+Joseph Firth*,, Rebekah Carney1, Paul French2, Rebecca Elliott1, 
+and Alison Yung1
+1University of Manchester; 2University of Liverpool
+Background: Exercise has previously been shown to reduce symptoms of 
+schizophrenia in long-term patients, along with improving their physical 
+health and cognitive functioning. However, the effects of exercise in first-
+episode psychosis (FEP) have not been widely investigated.
+Methods: Twenty-eight people with FEP participated in 10 weeks of super­
+vised exercise twice weekly, using activities tailored to their own choice. 
+Participant engagement was measured, and various aspects of physical 
+health, mental health, and cognitive functioning were assessed. Participants 
+were assessed at baseline, 10 weeks, and then 6 months after the supervised 
+intervention, and compared to a group of patients with FEP who did not 
+receive an exercise intervention.
+Results: Over the 10-week intervention, participants achieved 107 minutes 
+(mean average) of moderate-to-vigorous exercise per week. Furthermore, 
+at 10 weeks (ie, immediately postintervention), there were improvements in 
+total symptoms, negative symptoms, waist circumference, verbal memory, 
+social cognition, and social functioning (all P < .05). After 6 months, 55% 
+of participants had continued to exercise. Psychiatric assessments at the 
+6-month follow-up showed that positive and negative symptoms were still 
+significantly lower than preintervention scores. However, post hoc analy­
+ses revealed that only those who had maintained regular exercise over the 
+6 months had continued to show significantly reduced symptoms, whereas 
+those who had ceased exercising had regressed to baseline scores. Previously 
+observed benefits of exercise for social functioning were also maintained at 
+the follow-up, although improvements in waist circumference and cogni­
+tion were lost.
+Conclusion: Future research should aim to establish sustainable methods for 
+maintaining regular exercise and explore the effectiveness of “step-down” 
+support following supervised interventions in order to improve physical 
+health outcomes and facilitate psychosocial recovery in FEP.
+SU107. DISRUPTED CONTINUITY OF 
+SUBJECTIVE TIME IN THE MILLISECONDS 
+RANGE IN THE SELF-DISTURBANCES 
+OF SCHIZOPHRENIA: CONVERGENCE OF 
+EXPERIMENTAL, PHENOMENOLOGICAL, 
+AND PREDICTIVE CODING ACCOUNTS
+Aaron Mishara*, and Anne Giersch2
+1The Chicago School of Professional Psychology; 2INSERM
+Background: The impression of time continuity is a pervasive and given prop­
+erty of our subjective life. However, it appears to be compromised in schizo­
+phrenia patients who experience what has been labeled “self-disturbances” 
+(Ichstörungen). Both experimental and phenomenological approaches sug­
+gest that gaps in continuity of self-experience in schizophrenia patients reflect 
+a disruption of temporal processing on different time scales. We hypothesized 
+Downloaded from https://academic.oup.com/schizophreniabulletin/article-abstract/43/suppl_1/S199/3076046
+by guest
+on 05 March 2018
diff --git a/subfolder_0/Sleep Disorders in Individuals With High Risk for Diabetes in Indian Population..txt b/subfolder_0/Sleep Disorders in Individuals With High Risk for Diabetes in Indian Population..txt
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--- /dev/null
+++ b/subfolder_0/Sleep Disorders in Individuals With High Risk for Diabetes in Indian Population..txt	
@@ -0,0 +1,848 @@
+https://doi.org/
+Annals of Neurosciences
+27(3-4) 183­
+–189, 2020 
+© The Author(s) 2021
+Reprints and permissions:
+in.sagepub.com/journals-permissions-india
+DOI: 10.1177/0972753121998470
+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
+Sleep Disorders in Individuals With High  
+Risk for Diabetes in Indian Population
+Kalyan Maity1,2, Raghuram Nagarathna3, Akshay Anand4,5, Suchitra S. Patil1, 
+Amit Singh1, SK Rajesh1, Latha Ramesh3, P Sridhar3, Uttam Kumar Thakur6, and 
+Hongasandra R Nagendra1
+Abstract
+Background: Sleep restores physiology and neurochemical components of our body and is essential for physical and mental 
+health. Sleep disorders (SDs) are associated with insulin resistance and metabolic disorders. The association between SDs 
+and diabetes needs to be understood in the Indian population.
+Purpose: The purpose was to investigate the association between SD and diabetes in the Indian population.
+Methods: As a part of nationwide Niyantrita Madhumeha Bharata Abhiyaan-2017 (NMB-2017), a cross-sectional study was 
+conducted and data was collected from seven zones of India, after screening through the Indian Diabetes Risk Score (IDRS). 
+The sleep quality was assessed on a scale of 1 to 4 (very good = 1, very bad = 4). The time taken to fall asleep (sleep latency) 
+was assessed on a scale of 0 to 5 (“0” = nil and “5” = >1.5 h). Stress was assessed by the perceived stress scale.
+Results: Bad sleep quality was positively (odds ratio 1.055, CI [1.001, 1.113], and P < .01) associated with self-reported 
+known diabetes. Increased sleep time (sleep latency) was associated significantly with IDRS high risk (odds ratio 1.085, CI 
+[1.008, 1.168], and P = .01), with an average sleep latency (maximum range 5 [>1.5 h], mode 2 [10 to 30 min]) minutes. 
+Moderate stress was significantly associated with bad sleep quality (odds ratio 1.659).
+Conclusion: A positive association of bad sleep quality and stress with diabetes, and an increased sleep latency in the IDRS 
+high-risk population point to the role of modifiable risk factors. Behavioral modification and stress reduction by using yoga 
+may be beneficial in the better management of diabetes.
+Keywords
+Sleep quality, diabetes, Indian diabetes risk score, stress
+Received 03 October 2020; revised 07 October 2020; accepted 07 October 2020
+1 Swami Vivekananda Yoga Anusandhana Samsthana (S-VYASA), Bengaluru, 
+Karnataka, India
+2 Department of Neurology, Neuroscience Research Lab, Postgraduate 
+Institute of Medical Education and Research (PGIMER), Chandigarh, India
+3 Vivekananda Yoga Anusandhana Samsthana (VYASA), Bengaluru, 
+Karnataka, India
+4 Centre for Mind Body Medicine, PGIMER, Chandigarh, India
+5 Centre for Mind Body Medicine, PGIMER, Chandigarh, India
+6 Department of General Surgery, Postgraduate Institute of Medical 
+Education and Research (PGIMER), Chandigarh, India
+Corresponding author:
+Raghuram Nagarathna, Vivekananda Yoga Anusandhana Samsthana 
+(VYASA), Bengaluru, Karnataka 560019, India.
+E-mail: rnagaratna@gmail.com
+Introduction
+Sleep is a biological process involving both physiological and 
+neurochemical aspects of life.1,2 Circadian rhythm and sleep 
+homeostasis influence each other and regulate the sleep–wake 
+cycle.3 Sleep can be considered as a health indicator.4 The 
+quality of sleep decides the physical and mental wellbeing of an 
+individual,3 especially slow-wave sleep or deep sleep has been 
+demonstrated to be practically identified with optimal recovery 
+and neuroplasticity.5–6 Seven to eight hours of night sleep is 
+medically considered to be good enough to refresh the body.
+Sleep promotes and performs important restorative 
+functions for body homeostasis.2 Sleep deprivation or 
+inadequate sleep is directly associated with sleep disorders 
+(SDs) and other health issues, such as mood disturbance,7 
+impaired memory,8 metabolic disorders like diabetes, 
+obesity,9 and hypertension.10 It is estimated that approximately 
+184	
+Annals of Neurosciences 27(3-4)
+20% to 30% of the general population has one or the other 
+type of SD.11
+It has been seen that common health conditions such as 
+diabetes, cardiovascular, neurological, urinary, or respiratory 
+disorders 
+are 
+some 
+of 
+the 
+major 
+SD-associated 
+comorbidities.12 Low quality of sleep has been reported in 
+38.4% of diabetes patients. Homeostasis model assessment 
+of insulin resistance showed a strong association of 
+obstructive sleep apnea (OSA) with high insulin resistance, 
+excessive body weight or obesity, and hypertension.13 
+Another study showed a lack of sleep or fragmented sleep 
+leads to insulin resistance, gain in body weight, type 2 
+diabetes,14,15 and hypertension.16,17 The duration of sleep also 
+plays a major role as a diabetes risk factor. Tan et al.18 in their 
+review on the effect of sleep duration on diabetes individuals 
+showed that both short-duration sleep (≤5 and 6 h/night) and 
+long-duration sleep (>8 h/night) are detrimental to diabetes 
+individuals.19,20
+India, the second-most populous country, reports around 
+seven million new diabetes patients every year, and SDs are 
+common amongst these patients.21 Previous studies show that 
+type 2 diabetes mellitus (DM) patients have a higher 
+prevalence of insomnia, increased daytime sleep, and 
+increased rapid eye movement sleep timing. OSA and DM are 
+common amongst the aged and obese individuals. Both OSA 
+and DM are associated with a higher risk of developing 
+cardiovascular 
+complications, 
+resulting 
+in 
+increased 
+morbidity and mortality.22 Earlier studies on short sleep or 
+disturbed sleep suggest impaired glucose tolerance in healthy 
+individuals.22 However, an association between SDs and 
+diabetes is poorly understood in the Indian population. Hence, 
+our study explored the prevalence of SDs in individuals with 
+a high risk for diabetes, based on Indian Diabetes Risk Score 
+(IDRS) which is a validated simple screening tool used to 
+detect undiagnosed individuals with DM or those at a higher 
+risk of developing DM.23
+Figure 1. Trial Profile
+ 
+Level 1 
+Screening forms with IDRS and Known DM 
+1,62,330 
+IDRS high risk 
+ 
+IDRS moderate risk 
+ 
+IDRS low risk 
+ 
+Rural-77,870 (48%) 
+Urban- 84,360 (52%) 
+Phase 1 
+3 months 
+ 
+Rural 
+24,096 (48%)  
+Level 2 assessment (blood test)  
+50,199 
+Urban 
+26,103 (52%) 
+ 
+ 
+Self-reported DM                 
+         7,461                
+  
+Invited for 
+intervenƟon 
+ 
+High Risk                                        
+42,738 
+ 
+ 
+Reasons for no response 
+a. Time constraints: out of town for business 
+b. Weather: Snowfall J&K, Hot(>450C) -Odisha 
+c. Heavy rains: Karnataka, Maharashtra 
+d. PoliƟcal: State elecƟon-UP 
+e. AgitaƟon: Road blockages Manipur 
+f.  Not interested in yoga 
+ 
+Phase 2 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+Analyzed for sleep factor 
+16,383 
+ 
+Rural-6,571 (40.1%) 
+ Detailed data 
+in high risk 
+group    
+16,383 
+Urban- 9,812 (59.8%) 
+ 
+ 
+ 
+ 
+Maity et al.	
+185
+Methods
+Study Design
+As a part of nationwide trial, the data was collected from 
+seven zones of India (east, west, central, north, northeast, 
+northwest, and south) in 2017 (the details have been published 
+in methodology of our part 1 paper).24 In short, the sampling 
+process was divided into seven levels. With the help of 1,200 
+volunteers for diabetes movements, 35 senior research 
+fellows, 2 research associates, and 7 zonal coordinators, this 
+cross-sectional survey was completed. IDRS was used to 
+identify high-risk individuals.
+Participants
+A total of 1,62,330 subjects [rural, 77,870 (48%); urban, 
+84,360 (52%)] were screened. Of these, 50,199 subjects 
+[rural, 24,096 (48%); urban, 26,103 (52%); IDRS high risk, 
+42,738; self-reported DM, 7,461] with IDRS high risk and 
+self-reported DM were selected for detailed investigations. 
+Data for a sleep factor analysis was acquired from 16,383 
+subjects [rural, 6,571 (40.1%); urban, 9,812 (59.8%)].
+Outcome Measures
+An initial survey was done to screen the participants by the 
+IDRS to identify high-risk individuals. IDRS consists of four 
+parameters: age, family history, physical activity, and waist 
+circumference. A score of 0 to 30 is considered as low risk, 30 
+to 50 moderate risk, and ≥60 as high risk.
+Sleep Assessments: To measure sleep habits, there was a 
+sleep questionnaire comprising six questions.
+Of these, the two most important questions were taken for 
+the present sleep analysis.
+(a) Sleep quality: During the past month, how would you 
+rate your sleep quality overall? (Score 1, very good; 2, fairly 
+good; 3, fairly bad; and 4, very bad.)
+(b) How long has it taken you to fall asleep each night? 
+(None 0; at least 10 min, 1; 10 to 30 min, 2; 30 min to 1 h, 3; 
+1 to 1.5 h, 4; and >1.5 h, 5.)
+Stress: Stress was measured by using an analog scale 
+questionnaire which contained six questions related to work, 
+family, health, financial, social, and other stress. It measured 
+levels of stress from 0 (none) to 10 (severe).
+Perceived Stress Scale: Perceived stress was measured 
+by using the perceived stress scale which contains 10 
+questions related to feelings and thoughts in the last month. It 
+was associated with internal consistency (Cronbach’s α) of 
+0.82 and convergent validity of 0.64–0.71.25
+Statistical Analysis
+Data was uploaded via Mobile Apps by trained field 
+personnel under the supervision of senior research fellows. 
+The data set was analyzed using the SPSS software for 
+biostatistical analyses.
+To calculate the odds ratio, ordinal regression was 
+implemented; reference was set to sequential contrast for all 
+ordinal variables. For known diabetes and known 
+hypertension, unknown diabetes and unknown hypertension 
+were the references, respectively. For IDRS high risk, IDRS 
+low risk was the reference category. For obesity, normal was 
+the reference. Regression was done to analyze the association 
+of overall stress with overall sleep quality and that of overall 
+depression with sleep quality.
+Ethical clearance was obtained from the ethical committee 
+of Indian Yoga Association.
+Results
+Table 1 represents the demographic details of 16,383 
+participants; the mean age of the participants was 48 years. 
+The distribution of participants with respect to their location 
+was as follows: urban cluster constituted 60%, and rural 40%, 
+females constituted 53% of the study population, while males 
+constituted 47%. The average body mass index (BMI) of the 
+participants was 25.90, which suggest that the participants 
+fall under the overweight category based on BMI estimates. 
+Overall fasting blood glucose (FBG) was 117.1 mg/dL and 
+glycated hemoglobin (HbA1c) was 6.33%.
+Table 2 represents the sleep quality and sleep latency in 
+different groups; 1.055 (1.001–1.113) is significantly 
+associated with the status of known diabetes. Increased sleep 
+time/sleep latency is associated significantly with IDRS high 
+risk, with an odds ratio of 1.085 (CI [1.008, 1.168]). Bad 
+sleep quality and increased sleep time are associated 
+nonsignificantly with obesity and the status of known 
+hypertension.
+In Table 3, we can see that the moderate stress was 
+significantly associated with bad sleep quality, but was not 
+significantly associated with sleep latency/sleep time. 
+Although moderate depression and medium perceived stress 
+were associated positively with sleep quality, they were not 
+significant.
+Table 1. Demographic Characteristics of Participants
+T
+otal 
+N
+16,383
+Age
+Mean (SD)
+47.7 (12.5)
+Area
+Rural
+6,571 (40.1%)
+Urban
+9,812 (59.9%)
+Gender
+Male
+7,700 (47.0%)
+Female
+8,683 (53.0%)
+T
+otal
+16,383
+BMI
+Overall
+25.90 (13.80)
+FBG
+117.1 (54.50)
+HbA1c
+6.33 (1.74)
+186	
+Annals of Neurosciences 27(3-4)
+Table 2. Sleep Quality and Sleep Latency in Different Groups
+Variables
+Sleep Quality
+Significance
+Sleep Time/Sleep Latency
+Significance
+Known diabetes
+1.055(1.001–1.113)*
+0.04
+.962(.919–1.006)
+0.09
+Known hypertension
+1.019(.968–1.072)
+0.46
+1.015(.972–1.060)
+0.49
+IDRS high risk
+1.072(.982–1.170)
+0.12
+1.085(1.008–1.168)*
+0.03
+Obesity
+1.005(.939–1.076)
+0.88
+1.009(.953–1.068)
+0.76
+*How long has it taken you to fall asleep each night?
+*During the past month, how would you rate your sleep quality overall?
+Note: 1 = very good; 2 = fairly good; 3 = fairly bad; 4 = very bad.
+Comment: There was significant predictive association between diabetes, high diabetes.
+Table 3. Association Between Sleep Quality, Stress, and Depression
+Sleep Factor
+Parameter
+Significance
+Exp(B)
+95% Wald Confidence Interval for 
+Exp(B)
+Lower
+Upper
+Sleep time 
+Minimum stress
+.368
+1.342
+.708
+2.544
+Moderate stress
+.120
+1.659
+.877
+3.142
+Minimal depression
+.909
+.953
+.417
+2.180
+Mild depression
+.913
+.955
+.422
+2.161
+Moderate depression
+.710
+1.171
+.509
+2.693
+Moderately severe depression
+.875
+.934
+.400
+2.185
+Perceived stress low
+.895
+.920
+.265
+3.193
+Perceived stress medium 
+.858
+.893
+.260
+3.072
+Sleep quality
+Minimum stress
+.296
+1.417
+.737
+2.727
+Moderate stress
+.043
+1.965
+1.023
+3.776
+Minimal depression
+.935
+1.036
+.449
+2.386
+Mild depression
+.716
+1.165
+.511
+2.659
+Moderate depression
+.644
+1.219
+.526
+2.826
+Moderately severe depression
+.944
+1.031
+.437
+2.431
+Perceived stress low
+.834
+1.134
+.349
+3.688
+Perceived stress medium 
+.681
+1.278
+.397
+4.110
+Discussion
+This pan-India data that used two general questions to assess 
+the previous month’s sleep quality and sleep latency of the 
+participants revealed a significant positive association of 
+sleep quality and sleep latency with known diabetes and 
+IDRS 
+high 
+diabetes 
+risk, 
+respectively. 
+It 
+was 
+a 
+noninterventional study. So, there is no control group. We 
+have taken nondiabetics to compare diabetic subjects. We 
+have done the regression analysis, and the results showed that 
+moderate stress was significantly associated with poor sleep 
+quality, but not associated with sleep latency.
+Earlier studies showed that stress is significantly associated 
+with the bad quality of sleep.26,27 Our study showed a 
+significant association between moderate stress and poor 
+sleep quality.
+A previous study showed complications and durations of 
+diabetes can influence the quality of sleep and depression in a 
+diabetes population.28 In our study, we checked the association 
+of sleep quality with depression and perceived stress. Even 
+though it shows a positive association, it was not significant.
+A cross-sectional study on 332 Gujarati subjects (between 
+13 and 20 years of age) showed that inadequate sleep does not 
+affect the blood glucose levels in adolescents.29 That study 
+was on adolescents, but our study was on adults; this seems to 
+point out that although insufficient sleep does not affect the 
+blood glucose level of adolescents, it may affect the blood 
+glucose level of adults. Another cross-sectional study on 1,258 
+subjects (Indian = 855, Malay = 403) between 40 and 80 years 
+of age showed that the abnormal sleep duration is associated 
+with the diabetic kidney disease.30 Another review showed 
+that poor sleep quality and short sleep duration were associated 
+with cardiometabolic risk and adverse effects on diabetes, 
+hypertension, obesity, and in turn some epigenetic changes.32–34 
+Our study showed similar results with a significant association 
+between poor sleep quality and known diabetes. Our study did 
+Maity et al.	
+187
+not show any significant association between sleep quality 
+and obesity or sleep quality and hypertension.
+This is the first study from the Indian population consisting 
+of a large sample size where an association between sleep 
+factors and diabetes risk has been demonstrated.
+In our earlier studies, we have examined various markers 
+for different neurodegenerative disorders such as age-related 
+macular degeneration,35–40 amyotrophic lateral sclerosis,41,42 
+and Parkinson’s disease,43 and described various treatment 
+strategies for the brain and nervous system,44 and retinal 
+degeneration.45 However, in the recent study, we did not 
+include any biomarker to examine the sleep factor. As sleep is 
+associated with our brain function, therefore further studies 
+can be undertaken to examine the correlation between the 
+neurodegenerative diseases and sleep factor in this diabetic 
+population. Alzheimer’s disease and Brahmi (Bacopa 
+monniera) as one of the treatment modalities for it have also 
+been discussed in our previous review paper.46,47 An 
+association between memory loss, sleep deficits, and the 
+corresponding interventions such as yoga and Brahmi can 
+add a new dimension to the research in the diabetic population. 
+Our earlier literature has also provided evidence for the 
+correlation between oxidative stress and neurodegenerative 
+disorders48 and stem cell transplantation for neural disorders.49 
+Stress biomarkers and a sleep factor analysis for a larger 
+diabetic population are thus warranted in future. We have 
+developed different animal models for various diseases such 
+as Alzheimer’s disease,50 and amnesia,51,52 and also discussed 
+various animal models of neural metabolism for developing 
+the treatment modalities.53 For mechanistic studies, the 
+animal model resources can be used.
+Limitation of the Study
+The limitation of the study is that a standardized validated 
+questionnaire was not used to assess the sleep factor. So, we 
+were unable to do the domain analysis of different variables 
+of sleep.
+Conclusion
+Poor sleep quality is associated with known diabetes, and 
+increased sleep latency is associated with a high diabetes risk. 
+Bad sleep quality or SD can be an indicator of diabetes, and 
+increased sleep latency can be an indicator of IDRS high risk. 
+However, further study is required by using a comprehensive 
+sleep questionnaire to confirm the results in the Indian 
+diabetes population.
+Acknowledgment
+We would like to thankfully acknowledge the Ministry of Health 
+and Family Welfare, and the Ministry of AYUSH, Government of 
+India, New Delhi, India, for funding this project. We would like to 
+thank Dr Ishwar Acharya for his great contribution. He helped in 
+accomplishing this project by monitoring the project and preparing 
+the necessary DVDs (by Mr. Advait, Mrs. Akanksha, and the team) 
+and books for the project. We are appreciative to all individuals of 
+the scientific advisory committee of Niyantrita Madhumeha Bharata 
+(NMB). We would also like to thank the members of advisory 
+committee, members of executive board, each and every individual 
+involved in developing the common yoga protocol for NMBA, and 
+Dr Anand Balayogi Bhavanani, Director, Standing Research 
+Committee of the Indian Yoga Association (IYA), for their 
+simultaneousness and dynamic investment at various periods of the 
+venture. We would like to thank all directors and masters of all the 
+major yoga institutions around the nation for providing trained and 
+responsible yoga volunteers. We thank the software development 
+team for their extraordinary support throughout the project. We are 
+appreciative to all yoga volunteer for diabetes movements, junior 
+research fellows, senior research fellows, and research associates 
+who worked with incredible energy to finish the venture inside the 
+booked timetables under troublesome climate conditions and 
+political and other issues. We express gratitude toward Mr. Jain and 
+the office staff of NMBA. We would like to thank all the staff and 
+students of S-VYASA for their support and service.
+Author Contribution
+Kalyan Maity1, Raghuram Nagarathna2, Akshay Anand3, Suchitra S. 
+Patil4, Amit Singh5, Rajesh SK6, Latha Ramesh7, Sridhar P8, Uttam 
+Kumar Thakur9, and Hongasandra R Nagendra10
+KM 
+2.
+RN
+3.
+AA
+4.
+SSP
+5.
+AS
+6.
+RSK
+7.
+LR
+ 
+8.
+SP
+9.
+UKT
+10.
+HRN
+Concept of 
+manuscript
+ 
+✓
+✓
+ 
+✓
+✓ 
+ 
+✓
+Design
+ 
+✓
+✓
+✓
+✓
+✓
+✓
+✓
+Defini-
+tion of 
+intel-
+lectual 
+content
+✓
+✓
+ 
+✓
+✓
+ 
+✓
+Lit-
+erature 
+search
+✓ 
+ 
+✓
+✓
+✓
+✓
+Data 
+acquisi-
+tion
+ 
+✓
+✓
+✓ ✓
+✓
+ 
+Data 
+analysis
+ 
+✓
+✓
+✓
+Statis-
+tical 
+analysis
+ 
+ 
+✓
+✓
+✓
+Manu-
+script 
+prepara-
+tion
+✓
+✓
+✓
+Manu-
+script 
+editing
+✓
+✓
+✓ 
+ 
+ 
+ 
+ 
+✓
+ 
+ 
+✓
+✓
+188	
+Annals of Neurosciences 27(3-4)
+KM 
+2.
+RN
+3.
+AA
+4.
+SSP
+5.
+AS
+6.
+RSK
+7.
+LR
+ 
+8.
+SP
+9.
+UKT
+10.
+HRN
+Manu-
+script 
+review
+✓
+✓
+✓
+✓
+ 
+✓
+✓
+✓
+Guaran-
+tor
+✓
+✓
+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
+The study was conducted after obtaining the ethical clearance from 
+the Institutional Ethics Committee (IEC) of Indian Yoga Association 
+(IYA). Written informed consent in their native language was taken 
+from every individual before physical/biochemical assessment. IEC 
+reference no: RES/IEC-IYA/001 (dated. 16/12/2016). CTRI 
+registration no: CTRI/2018/03/01280.
+Funding
+The Ministry of Health and Family Welfare and the Ministry of AYUSH, 
+Government of India, New Delhi was the funding source for this project.
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+128
+© 2017 International Journal of Yoga | Published by Wolters Kluwer ‑ Medknow
+Introduction
+Obesity is a serious health problem, and it 
+is increasing all over the world.[1,2] Obesity 
+is increasing among urban populations in 
+India and other South Asian parts. As per 
+the World Health Organization  (WHO), 
+19% of the Indian male population and 
+23% of female population are overweight. 
+In addition, 3.1% male and 6.5% female 
+population are obese in India.[2] As per the 
+National Family Health Survey 2007 in 
+Maharashtra, 15.9% male and 18.1% female 
+are overweight or obese, respectively.[3]
+Lifestyle 
+changes, 
+urbanization, 
+and 
+socioeconomic status are risk factors for 
+noncommunicable 
+diseases 
+including 
+obesity.[1,4,5] The alternative therapies for 
+obesity are effective and desirable for its 
+prevention and control.[6]
+Obesity is considered as imbalance of 
+energy intake and energy expenditure. The 
+excessive intake of sugar and junk food 
+causes deposition of fat.[7] The development 
+Address for correspondence: 
+Dr. Pailoor Subramanya, 
+Division of Yoga and Life 
+Sciences, Swami Vivekananda 
+Yoga Anusandhana Samsthana, 
+#19 Eknath Bhavan, Gavipuram 
+Circle, Bengaluru, Karnataka, 
+India. 
+E‑mail: pailoors@gmail.com
+Access this article online
+Website: www.ijoy.org.in
+DOI: 10.4103/ijoy.IJOY_53_16
+Quick Response Code:
+Abstract
+Background: Obesity is a big challenge all over the world. It is associated with many 
+noncommunicable diseases. Yoga known to be add‑on treatment may be effective for obesity control. 
+Aim: To assess the effect of integrated approach of yoga therapy  (IAYT) for body composition 
+and quality of sleep in adult obese male. Subjects and Methods: A  randomized controlled trial 
+was conducted for 14  weeks on obese male of urban setting. Eighty individuals were randomly 
+divided into two groups, i.e., yoga group (n = 40; age; 40.03 ± 8.74 years, body mass index [BMI] 
+28.7  ±  2.35 kg/m2) and control group  (age; 42.20  ±  12.06  years, BMI 27.70  ±  2.05 kg/m2). The 
+IAYT was imparted to yoga group for 1½ hour for 5  days in a week for 14  weeks. The control 
+group continued their regular activities. The body composition by InBody R20 and sleep quality 
+by Pittsburgh Sleep Quality Index  (PSQI) were assessed. Statistical analysis was done for within 
+and between groups using SPSS version  21. The correlation analysis was done on the difference 
+in pre‑post values. Results: The results showed that weight  (P  =  0.004), BMI  (P  =  0.008), bone 
+mass (P = 0.017), obesity degree (P = 0.005), and mineral mass (P = 0.046) were improved in yoga 
+group and no change in control group (P > 0.05). The global score of PSQI improved (P = 0.017) 
+in yoga group alone. Conclusion: The results indicate the beneficial effects of IAYT on body 
+composition and sleep quality in obese males. The yoga practice may reduce obesity with the 
+improvement in quality of life.
+Keywords: Body composition, body mass index, integrated approach of yoga therapy, male obese, 
+sleep
+Sleep Quality and Body Composition Variations in Obese Male Adults 
+after 14 Weeks of Yoga Intervention: A Randomized Controlled Trial
+Original Article
+PB Rshikesan, 
+Pailoor Subramanya1, 
+Deepeshwar Singh1
+Research Scholar, Swami 
+Vivekananda Yoga Anusandhana 
+Samsthana, 1Division of Yoga 
+and life Sciences, Swami 
+Vivekananda Yoga Anusandhana 
+Samsthana, Bengaluru, 
+Karnataka, India
+How to cite this article: Rshikesan PB, 
+Subramanya  P, Singh D. Sleep quality and body 
+composition variations in obese male adults after 14 
+weeks of yoga intervention: A randomized controlled 
+trial. Int J Yoga 2017;10:128-37.
+Received: August, 2016. Accepted: January, 2017
+of obesity is still not fully known, but 
+it is a multifactorial disease involving 
+many factors such as stress, environment, 
+behavioral, lifestyle, social network, and 
+genetic factors.[8‑10] The body composition 
+parameters 
+are 
+better 
+indications 
+to 
+understand the intricacies of obesity.
+The stress is one of the causes of obesity 
+and the poor quality of sleep. A  recent 
+study reported that the association between 
+sleep duration and obesity is not clearly 
+established.[11] 
+Another 
+recent 
+study 
+concluded that body composition and diet 
+are linked to sleep physiology and suggested 
+for dietary interventions for treating the 
+sleep disorders and for improving sleep 
+quality.[12] Furthermore, it is reported that 
+sleep duration is a crucial factor influencing 
+the bodyweight and eating behavior and 
+the recent study concluded that reduced 
+sleep duration is negatively associated with 
+body composition.[13] In addition, there 
+was association between higher fat mass 
+This is an open access article distributed under the terms of the 
+Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0 
+License, which allows others to remix, tweak, and build upon the 
+work non‑commercially, as long as the author is credited and the 
+new creations are licensed under the identical terms.
+For reprints contact: reprints@medknow.com
+Rshikesan, et al.: Yoga intervention and obesity
+129
+International Journal of Yoga | Volume 10 | Issue 3 | September‑December 2017
+and poor sleep efficiency in two separate studies, one on 
+college students[14] and the other on preschool children.[15]
+Further, a recent study reported that disturbance in sleep and 
+circadian rhythm are also risk factors for the development 
+of obesity.[16] The endocannabinoid system, a regulator in 
+hedonic feeding, may be the link between sleep, circadian 
+rhythm, and feeding behavior.[16] Also, the variation in gut 
+microbe composition, circadian misalignment, and sleep 
+are linked, in the development of obesity.[16] Further, as per 
+the critical review of published studies on the role of sleep 
+quality on metabolic syndrome, it is concluded that the 
+sleep and metabolic interactions exist and are operational 
+in specific settings.[17] Thus, it is noted that the relation 
+between sleep diet and body composition parameters are 
+complex, and specific study of these causative factors, 
+applicable to the urban male adults, will be rewarding.
+The obesity standard is different for different ethnic groups. 
+The WHO definition is that body mass index  (BMI) 
+≥25 kg/m2 is overweight and BMI  ≥30 kg/m2 is obesity. 
+However, for Asian population, BMI cutoff points are lesser 
+and BMI above 23 kg/m2 is considered as overweight and 
+above 25 kg/m2 is considered as obese.[18,19] In the current 
+study, we have considered aforementioned standard for the 
+obese adults.
+The present methods for controlling the obesity are bit 
+expensive with many limitations and it will be useful if 
+alternative methods are validated.[6] Yoga is one of the 
+ancient mind–body therapies from India, consisting of 
+specific yoga postures, breathing practices, and meditation 
+techniques for the treatment of obesity. According to sage 
+Patanjali, the essence of yoga is to control over the turbulent 
+mind (circa. 400 BC, P.Y.S. Chapter I, Verse II).[20] Previous 
+studies have shown that the psychosomatic diseases are 
+effectively prevented and controlled by yogic practices.[21]
+A very recent systematic review study from 30 trials 
+compared from the 441 records, on effects of yoga 
+on weight‑related outcome, reported that yoga can be 
+preliminarily considered as safe and effective intervention 
+for weight reduction.[22] However, it was reported that, 
+though obese or overweight individuals had effect on 
+the BMI reduction, these effects were not robust against 
+selection bias.[22] Yoga and body composition studies 
+along with sleep parameters are very limited. Further, the 
+earlier studies were lacking the assessments of specific 
+urban working male subjects which is done in the current 
+randomized controlled study.
+In addition, the yoga practice requires minimum space and 
+investments compared to many other physical activities. 
+Thus, it is prudent to explore the yoga therapy for long‑term 
+weight reduction in urban adults. Therefore, the present 
+study is intended to investigate the effect of 14 weeks yoga 
+training on body composition and sleep quality in obese 
+adults.
+Subjects and Methods
+Total of 80 obese male participants were enrolled in the 
+present study. The sample size was calculated based on 
+the prior study of Dhananjai et  al. using an open source 
+software G*Power.[23,24] In the earlier study on obesity, hip 
+circumference had the lesser effect size and considering this 
+parameter the minimum sample size was 29. The power of 
+sample size used was 0.9.
+In the current study, of 80 participants enrolled, 8 were 
+dropout and 72 completed the intervention. The integrated 
+approach of yoga therapy  (IAYT) was imparted to yoga 
+group for 1½ h for 5  days in a week, for 14  weeks. The 
+yoga intervention details are given in Table 1. No specific 
+physical exercise was administered to the control group, 
+but they were asked to continue their regular normal 
+routine. All participants were recruited by advertisement 
+and telephone messages in Anushakti Nagar, Mumbai, 
+India. The trial profile of the study is given in Figure 1.
+Inclusion criteria
+(i) BMI between 23 kg/m2 and 35 kg/m2,  (ii) only male 
+adult ages from 18 to 60 years, and (iii) normal health for 
+doing simple yoga practices. No participants were trained 
+to yoga practices before were included.
+Exclusion criteria
+(i) Individuals who had surgery in the past 6  months, 
+(ii) any other neurological or psychiatric problems, and 
+(iii) other health conditions (such as pain and injury) were 
+unsuitable for doing yoga were excluded from the study. 
+All participants were randomized into two groups with 
+Table 1: Yoga intervention details
+The 5 part daily (5 days a week) yoga
+Yoga intervention
+Duration (minutes)
+Lecture and Counselling
+10
+Warm Up
+10
+Suryanamaskara
+10
+Asana
+30
+Pranayama
+Surya Anuloma Viloma
+Nadishudhi
+Ujjayi
+Bhramari
+Bhastrika
+Vibhagiya Pranayama
+Cooling Pranayamas
+15
+Meditation
+OM Meditation
+Mind Sound Resonance Technique
+Cyclic Meditation
+Shavasana
+15
+Total duration
+90
+Rshikesan, et al.: Yoga intervention and obesity
+130
+International Journal of Yoga | Volume 10 | Issue 3 | September‑December 2017
+minimization of cofactors by an open source software 
+program MinimPy.[25,26] The study was approved by the 
+Institutional Ethical Committee, and informed consent was 
+obtained from each participant. Both groups received their 
+respective measurement values food log format and basic 
+sample meal plan prepared for sedentary male adults based 
+on standard guidelines.[27]
+Assessments
+Sleep quality
+The Pittsburgh Sleep Quality Index  (PSQI) is one of 
+the validated scales for assessing the quality of sleep 
+applicable for various groups.[28] PSQI questionnaire was 
+used for the assessment of quality of sleep.[29] This contains 
+19 items and gives 7 component scores of subjective 
+sleep quality (slpq), sleep latency, duration, habitual sleep 
+efficiency  (hsle), sleep disturbance, sleep medication, and 
+daytime dysfunction. In addition, there is a global score on 
+quality of sleep. The maximum global score is 21. PSQI 
+score more than 5 is considered as poor quality.[29] This 
+scale is validated in different populations (with Cronbach’s 
+alpha 0.8) and is an effective screening tool.[30,31] In 
+earlier studies, the global PSQI score  >5 got diagnostic 
+sensitivity of 89.6% and specificity of 86.5%  (κ = 0.75, 
+P  <  0.001) for differentiating poor and good sleepers.[31] 
+The questionnaire was filled by individuals in hard copy 
+in single sitting in a comfortable position, before body 
+composition assessments.
+Body composition
+There are different methods for the body composition 
+assessment. 
+Bioelectrical 
+impedance 
+(BIA) 
+principle 
+was used in the current study for body composition 
+assessments. The InBody, Maltron, Tanita, etc., are some 
+of the validated instruments. In the current study, we have 
+used InBody R20 instrument to assess the different indices 
+of body composition in obese adults.[32]
+BIA principle was used to estimate body composition and is 
+a non invasive method.[33‑37] The InBody R20 is a validated 
+scale for BIA which is used for scientific studies on obesity.[32] 
+The major outcomes are weight, body fat mass, percentage 
+body fat, skeletal muscle mass, BMI, basal metabolic 
+rate  (BMR), waist‑hip ratio, total body water, fat‑free 
+mass (FFM), segmental muscle mass and segmental fat mass, 
+and mineral mass (Mm). The readings were taken with empty 
+stomach in the morning for both pre‑post readings.
+The body composition was assessed in the morning with 
+overnight fasting. The instrument used was InBody R20 (Sr. 
+No PA 904F1D1 of M/s Bio space Co. Ltd.,) from the UK, 
+and the same instrument was used for measurements of both 
+before and after the intervention. All accessories metallic 
+items were removed from pockets and the participants 
+were asked to stand straight and still on the foot pad with 
+light clothing. The foot was placed in the foot pad as per 
+the shape of the electrode guide. First, the body weight 
+was registered and then they were asked to hold the hand 
+grips properly without moving the body. The readings were 
+directly transferred to the connected computer. The height 
+was measured using anthropometric inelastic tape.
+Data extraction/procedure
+PSQI contains 19 self‑rated questions for scoring. The 
+19 questions are combined to form seven component score, 
+each of which has a range of 0–3 points. Zero indicates 
+no difficulty and 3 indicates severe difficulty. The seven 
+components are added together to get global score with a 
+range of 0–21 points, 21 indicating severe difficulty in all the 
+areas. After scoring 7 components and the global score, as 
+per the scoring procedure,[29] the data were coded, tabulated, 
+screened, and carried out the data entry for processing.
+The InBody R20 instrument was connected by universal serial 
+bus to computer while taking the individual assessments and 
+the raw data of the individual body composition parameters 
+were recorded in computer during assessment. The coded 
+and tabulated data were screened and transferred to single 
+excel sheet in the requisite format for analysis.
+Data analysis
+This  statistical package for the social sciences(SPSS) 
+owned by IBM  version was used for the data analysis. 
+The data were analyzed for normality using Shapiro‑Wilk 
+test. Further, for all the pre‑post values of both yoga and 
+control groups, the paired sample t‑test was carried out, on 
+Assessed for
+eligibility = 89
+Excluded = 9
+Randomized
+n = 80
+(yoga group = 40 and control group = 40)
+Yoga group
+(n = 37)
+Control group
+(n = 35)
+Dropouts 
+Yoga = 3
+Control = 5
+Pre- assessments
+Pre- assessments
+Body composition
+& PSQI
+Body composition
+& PSQI
+Post - assessments
+(after 14 weeks)
+Post - assessments
+(after 14 weeks)
+Body composition
+& PSQI
+Body composition
+& PSQI
+Analysis
+Figure 1: Trial profile
+Rshikesan, et al.: Yoga intervention and obesity
+131
+International Journal of Yoga | Volume 10 | Issue 3 | September‑December 2017
+all the variables which were found normally distributed. 
+The body composition parameters and PSQI global score 
+distribution were found normal, but the seven components 
+of PSQI were not normal. For these seven components of 
+PSQI, nonparametric test was carried out using Wilcoxon 
+signed‑rank test. The 
+between‑groups analysis was 
+performed using the independent sample t‑test for the pre 
+and post values of yoga and control groups. To find the 
+relative improvement among the variables, the change in 
+each variable was correlated each other. In the analysis, 
+P < 0.05 was considered statistically significant.
+Results
+The baseline demographic educational and anthropometric 
+data were found similar. In yoga group, the age of 
+individuals ranged from 26 to 60 and in control group 
+from 21 to 58  years. The baseline data of age and height 
+are given in Table  2. The yoga group  BMI ranged from 
+25.33 kg/m2 to 34.84 kg/m2 (mean ± standard deviation [SD]; 
+28.7  ±  2.35 kg/m2) and for the control group it was from 
+25.01 kg/m2 to 33.64 kg/m2 (mean ± SD; 27.70 ± 2.05 kg/m2). 
+For all participants, BMI was found above 25 kg/m2. The 
+50% of individuals in each group was with age between 18 
+and 40  years and 50% were in age group of 40–60  years. 
+Similarly, education of half of each group was up to degree 
+and balance half was post graduate or above.
+The within‑group analysis results are given in Table  3. In 
+both the groups, the PSQI global score was improved but the 
+improvement was significant (P < 0.02) in yoga group alone.
+The PSQI global score of 5 and above is considered as 
+poor quality.[38] Before the intervention, PSQI global score 
+was more than 5, in the yoga group and there was 18% 
+improvement in the score. The score improved to good 
+quality (4.16 ± 2.03) after the intervention.
+The body weight in the yoga and control groups decreased 
+after intervention. However, the weight reduction was 
+significant in yoga group  (P  =  0.004) alone. Similarly, 
+improvement in the BMI was significant in yoga group 
+(P  <  0.01) alone. In addition, reduction in bone mass 
+(Bm) and mineral mass (Mm) (P  <  0.02) and obesity 
+degree  (current weight divided by ideal weight multiplied 
+by 100)  (P  <  0.01) were significant in yoga group and 
+no change in control group. In both groups, both the arm 
+lean masses increased whereas in control group trunk lean 
+mass also increased. In both the groups, all other body 
+composition parameters were reduced.
+The seven component PSQI scores of yoga and control 
+groups are given in Tables  4 and 5, respectively. In the 
+yoga group, out of 7 PSQI components, 5 showed the 
+improvement in trends from pre to post and the balance two 
+components, (hsle; P < 0.02) and (slpq; P < 0.03), reported 
+significant improvement. The global score of PSQI showed 
+significant improvement in yoga group alone. In the control 
+group, though the component of slpq improved (P < 0.04), 
+the use of sleep medication and daytime dysfunction 
+showed increasing (worsened) trend.
+In the between‑group analysis, the changes were not 
+significant in pre as well as in post readings. The 
+postintervention between‑group analysis results are given 
+in Table 6.
+To find out the relative improvements  (from pre to post) 
+among the variables, each variable was correlated with 
+each other. The outcome is summarized in Table  7. There 
+was a significant positive correlation of BMI with protein 
+mass  (r  =  0.308, P  <  0.01), Mm  (r  =  0.227, P  <  0.05), 
+bone mass (r = 0.233, P < 0.05), BMR (0.237, P < 0.01), 
+fat mass  (0.511, P  <  0.01), FFM  (0.0.324, P  <  0.01), 
+total body water  (r  =  0.324, P  <  0.01), skeletal muscle 
+mass  (r  =  0.326, P  <  0.01), and PSQI score  (r  =  0.201, 
+P  <  0.05). It was also found that FFM is strongly and 
+positively correlated to BMR.
+None of the participants reported any adverse effect of 
+yoga intervention.
+Discussions
+The aim of the current study was to find out the effects 
+of 14  weeks IAYT intervention on body composition 
+and sleep parameters. As an outcome of intervention, the 
+PSQI global score as well as the slpq and sleep efficiency 
+components were improved with significance, which was 
+consistent with the improvements in body composition 
+parameters. The body weight, obesity degree, BMI, bone 
+mass, and Mm were reduced with significance in yoga 
+group alone. Further, there was a trend of improvement in 
+all the body composition parameters in yoga group. In the 
+current study of 1st time yoga doers, the slpq and efficiency 
+scores improved 34.6% and 54%, respectively. This shows 
+the possibility of the yoga intervention in combating the 
+obesity difficulties in urban setting. Further, as reported 
+earlier, sleep parameters play a key role in energy 
+metabolism[39,40] and the current study shows improvement 
+in both sleep quality and body composition parameters.
+Table 2: Baseline data of age and height
+Variable
+Yoga group (n=37)
+Control group (n=35)
+Pre
+95% CI
+Pre
+95% CI
+Age (years)
+40.03±8.74
+37.12-42.94
+42.20±12.06
+38.76-46.89
+Height (m)
+169.45±7.35
+167.00-171.90
+169.29±6.37
+167.17-171.65
+CI = Confidence interval
+Rshikesan, et al.: Yoga intervention and obesity
+132
+International Journal of Yoga | Volume 10 | Issue 3 | September‑December 2017
+A recent previous study[41] assessing the circadian measures 
+(i.e., melatonin and cortisol) in middle‑aged men showed 
+evidence of association of altered circadian rhythms with 
+reduced melatonin response and cognitive impairment. This 
+previous study[41] showed a link between circadian rhythms 
+sleep and cognition. Further, recent previous cross‑sectional 
+study[42] showed that the yoga practice reduces the cortisol 
+levels anxiety and depression. In addition, relaxation 
+induced by diaphragmatic breathing decreases the oxidative 
+stress and cortisol levels.[43] The hatha yoga practices reduce 
+psychological stress and affective eating as per previous 
+studies.[44] In the current study, yoga practice might have 
+reduced the cortisol levels and oxidative stress, effecting 
+improvement in the sleep quality.
+Table 3: Within‑group analysis
+Variable
+Yoga group (n=37)
+Control group (n=35)
+Pre
+Post
+Pre
+Post
+Wt (kg)
+82.63±10.05
+81.51±10.00**
+79.45±8.85
+79.22±8.93
+BMI (kg/m2)
+28.7±2.35
+28.33±2.42**
+27.70±2.05
+27.61±2.01
+BMR (kcal)
+1582.81±151.60
+1574.35±145.84
+1566.83±128.98
+1564.37±130.06
+Bm (kg)
+3.16±0.44
+3.08±0.42
+3.11±0.39
+3.09±0.39
+Obdr
+130.52±10.65
+128.77±10.98**
+126.11±9.41
+125.56±9.27
+Smm (kg)
+31.61±4.18
+31.37±4.04
+31.14±3.59
+31.04±3.60
+Fm
+26.48±5.42
+25.75±6.03
+24.04±5.65
+23.91±5.63
+Pfin
+31.94±4.36
+31.43±4.84
+30.05±5.14
+29.98±5.14
+Aobd
+0.94±0.03
+0.94±0.03
+0.94±0.03
+0.93±0.03
+Ralm (kg)
+3.33±0.49
+3.35±0.53
+3.23±0.44
+3.27±0.46
+Lalm (kg)
+3.28±0.47
+3.29±0.52
+3.21±0.42
+3.25±0.45
+Tlmr (kg)
+26.15±2.89
+26.12±3.08
+25.59±2.58
+25.77±2.71
+Rllm (kg)
+8.49±1.27
+8.47±1.25
+8.33±1.10
+8.27±1.08
+Lllm (kg)
+8.54±1.26
+8.49±1.18
+8.27±1.06
+8.24±1.07
+Wmra (kg)
+1.86±0.61
+1.81±0.70
+1.64±0.61
+1.62±0.62
+Wmla (kg)
+1.88±0.61
+1.84±0.71
+1.65±0.60
+1.62±0.62
+Wmt (kg)
+14.35±2.83
+13.97±3.24
+13.06±3.09
+13.05±3.10
+Wmrl (kg)
+3.54±0.74
+3.42±0.75
+3.23±0.71
+3.17±0.66
+Wmll (kg)
+3.53±0.73
+3.41±0.74
+3.22±0.71
+3.16±0.65
+Pfra
+34.00±6.95
+33.10±7.28
+31.73±8.26
+31.25±8.75
+Pfla
+34.59±6.99
+33.82±7.53
+31.94±8.04
+31.36±8.89
+Pft
+33.96±4.04
+33.34±4037
+32.22±5.03
+32.09±5.19
+Pfrl
+28.21±3.89
+27.59±4.11
+26.75±4.43
+26.53±4.28
+Pfll
+28.04±3.87
+27.49±4.12
+26.80±4.46
+26.56±4.27
+Pm (kg)
+11.09±1.38
+11.02±1.35
+10.94±1.18
+10.90±1.19
+Mm
+3.77±0.52
+3.70±0.50*
+3.74±0.45
+3.71±0.46
+Tbwm (kg)
+41.14±5.14
+40.90±4.95
+40.59±4.35
+40.54±4.40
+Sklm (kg)
+53.00±6.60
+52.68±6.37
+52.29±5.62
+52.20±5.66
+Ffm (kg)
+56.09±7.03
+55.71±6.74
+55.36±5.97
+55.25±6.03
+PSQI
+5.08±2.75
+4.16±2.03*
+4.86±2.5
+4.23±2.45
+slpq
+0.84±0.69
+0.57±0.55*
+0.83±0.41
+0.63±0.55*
+Slpl
+0.81±0.70
+0.68±0.67
+0.77±0.91
+0.69±0.83
+Slpd
+0.68±0.75
+0.76±0.55
+0.83±0.75
+0.69±0.76
+Hsle
+0.59±0.93
+0.27±0.51*
+0.46±0.74
+0.23±0.49
+Sldd
+1.30±0.70
+1.14±0.54
+1.29±0.57
+1.26±0.61
+Uslm
+0.14±0.35
+0.08±0.28
+0.03±0.17
+0.09±0.28
+Dtd
+0.73±0.69
+0.68±0.53
+0.66±0.54
+0.66±0.68
+The significance levels ‑ (*P<0.05, **P<0.01 and P<0.001). Wt = Weight, BMI = Body mass index, BMR = Basal metabolic rate, Bm = 
+Bone mineral mass, Obdr = Obesity degree, Smm = Skeletal muscle mass, Fm = Body fat mass, Pfin = Percentage body fat from InBody, 
+Aobd = Abdominal obesity degree, Ralm = Right arm lean mass, Lalm = Left arm lean mass, Tlmr = Trunk lean mass, Rllm = Right leg 
+lean mass, Lllm = Left leg lean mass, Wmra = Water mass of right arm, Wmla = Water mass of left arm, Wmt = Water mass of trunk, 
+Wmrl = Water mass of right leg, Wmll = Water mass of left leg , Pfra = Percentage body fat of right arm, Pfla = Percentage body fat of left 
+arm, Pft = Percentage body fat of trunk, Pfrl = Percentage body fat of right leg, Pfll = Percentage body fat of left leg, Pm = Protein mass, 
+Mm = Mineral mass, Tbwm = Total body water mass, Sklm = Skeletal lean mass, Ffm = Fat free mass, PSQI = Pittsburgh Sleep Quality 
+Index‑global score, slpq = Subjective sleep quality score, Slpl = Sleep latency score, Slpd = Sleep duration score, hsle = Habitual sleep 
+efficiency score, Sldd = Sleep disturbance score, Uslm = Use of sleep medication score, Dtd = Daytime dysfunction score
+Rshikesan, et al.: Yoga intervention and obesity
+133
+International Journal of Yoga | Volume 10 | Issue 3 | September‑December 2017
+Stress is cause for many diseases in urban life as reported 
+in many previous studies. The stress causes the immediate 
+and long‑term disturbance in the psychoneuroendocrine 
+and 
+immunological 
+pathways. 
+The 
+hypothalamus 
+pituitary adrenal  (HPA) axis and sympathetic nervous 
+system gets adversely affected and hyperactivated by 
+influx of emotions from limbic system under the mental 
+stress.[45] This increases the release of hormones of cortisol 
+and catecholamine. The repeated state of “fight or flight” 
+mode makes the HPA axis firing continuously and disrupting 
+the homeostasis leading to metabolic disorders. Most of the 
+yogic practices promote parasympathetic activation and 
+regulation and normalization of HPA axis.[45] In addition, 
+the yoga practices give vagal stimulation reducing heart 
+rate and blood pressure. The metabolic and psychological 
+parameters were improved by balance in the HPA axis, 
+insulin resistance, and lipid metabolism.
+Further previous studies showed that insufficient sleep is 
+linked to increase in obesity,[46,47] especially the visceral 
+adipose tissue.[48,49] In the current study, the sleep duration 
+of yoga group increased along with significant reduction 
+in abdominal obesity degree. The relation between sleep 
+duration and obesity is not linear, and the poor sleep and 
+emotional stress are mediating factors in obesity.[11] Thus, 
+in the real life setting, the extending of sleep is found to 
+promote reducing the desire for high energy foods.[50] This 
+might have affected the weight reduction.
+Also, as reported previously,[11] the emotional stress 
+and poor sleep are mediating factors in the relationship 
+between 
+obesity 
+(expressed 
+in 
+body 
+composition 
+parameters) and sleep duration. The sleep duration 
+affects the body composition[51] and may be more time 
+period of intervention needed to get more significant 
+results. In addition, studies reported the role of certain 
+type of diet pattern,[52] affecting the quality of sleep. 
+In the current study, there was no restriction on food 
+though the sample meal plan was provided to both the 
+groups and the inputs on diet information were equal to 
+both the groups.
+There are studies on the effect of the leptin and adiponectin 
+hormones which effects out the satiety center in 
+hypothalamus. The leptin and adiponectin helps regulate the 
+energy balance by inhibiting the hunger. A  recent study[53] 
+of 12  weeks yoga‑based lifestyle intervention program 
+showed significant reduction in serum leptin levels with 
+improvements in anthropometric parameters. The frequency 
+of self‑reported yoga practice showed a significant negative 
+relationship with leptin and also with adiponectin to leptin 
+ratio.[54] Further previous studies[54] showed that intensive 
+yoga practice has beneficial health consequences in body 
+weight due to changes in leptin and or adiponectin. The 
+metabolic improvements obtained in the current study 
+may be due to energy homeostasis effected by leptin and 
+adiponectin.
+Further, the circadian misalignment in urban lifestyle is 
+a predominant factor and this leads to adverse effect in 
+energy balance. The endocannabinoid system is signaling 
+the pathways to modulate the metabolic functions.[55,56] 
+Table 4: Within‑group analysis of Pittsburgh Sleep Quality Index components of yoga group
+Variable
+Pre‑mean±SD
+Means 95% CI
+Post‑mean±SD
+Means 95% CI
+Significant (two‑tailed)
+Z‑score
+slpq
+0.84±0.69
+0.61-1.07
+0.57±0.55
+0.38-0.75
+0.03
+−2.24b
+Slpl
+0.81±0.70
+0.58-1.04
+0.68±0.67
+0.45-0.90
+0.23
+−1.21b
+Slpd
+0.68±0.75
+0.43-0.92
+0.76±0.55
+0.57-0.94
+0.47
+−0.728c
+hsle
+0.59±0.93
+0.29-0.90
+0.27±0.51
+0.10-0.44
+0.02
+−2.52b
+Sldd
+1.30±0.70
+1.06-1.53
+1.14±0.54
+0.96-1.31
+0.11
+−1.60b
+Uslm
+0.14±0.35
+0.02-0.25
+0.08±0.28
+−0.01.-0.17
+0.41
+−8.16b
+Dtd
+0.73±0.69
+0.50-0.96
+0.68±0.53
+0.50-0.85
+0.67
+−0.43b
+Wilcoxon signed‑rank test ‑ bBased on positive ranks, cBased on negative ranks, The sum of negative ranks equals the sum of positive ranks. 
+Slpq = Subjective sleep quality, Slpl = Sleep latency, Slpd = Sleep duration, hsle = Habitual sleep efficiency, Sldd = Sleep disturbance, Uslm 
+= Use of sleep medication, Dtd = Daytime dysfunction, SD = Standard deviation, CI = Confidence interval
+Table 5: Within‑group analysis of Pittsburgh Sleep Quality Index components of control group
+Variable
+Pre‑mean±SD
+Means 95% CI
+Post‑mean±SD
+Means 95% CI
+Significant (two‑tailed)
+Z‑score
+slpq
+0.83±0.41
+0.67-0.98
+0.63±0.55
+0.44-0.82
+0.04
+−2.11b
+Slpl
+0.77±0.91
+0.46-1.08
+0.69±0.83
+0.40-0.97
+0.37
+−0.91b
+Slpd
+0.83±0.75
+0.57-1.09
+0.69±0.76
+0.43-0.95
+0.24
+−1.17b
+hsle
+0.46±0.74
+0.20-0.71
+0.23±0.49
+0.06-0.40
+0.10
+−1.66b
+Sldd
+1.29±0.57
+1.09-1.48
+1.26±0.61
+1.05-1.47
+0.74
+−0.33b
+Uslm
+0.03±0.17
+−0.03-0.09
+0.09±0.28
+−0.01-0.18
+0.32
+−1.00c
+Dtd
+0.66±0.54
+0.47-0.84
+0.66±0.68
+0.42-0.89
+1.00
+−0.00d
+Wilcoxon signed‑rank test ‑ bBased on positive ranks, cBased on negative ranks, dThe sum of negative ranks equals the sum of positive ranks. 
+slpq = Subjective sleep quality, Slpl = Sleep latency, Slpd = Sleep duration, hsle = Habitual sleep efficiency, Sldd = Sleep disturbance, Uslm 
+= Use of sleep medication, Dtd = Daytime dysfunction, CI = Confidence interval, SD = Standard deviation
+Rshikesan, et al.: Yoga intervention and obesity
+134
+International Journal of Yoga | Volume 10 | Issue 3 | September‑December 2017
+The uncontrolled binge eating behavior inherent with 
+easy availability of junk food in the urban lifestyle further 
+promotes the unbalance in energy intake and expenditure. 
+The endocannabinoid signaling is reported as neurochemical 
+mechanism in response to stress[56] and endocannabinoid 
+system is chronically unregulated due to stress, promoting 
+the drive to eat merely out of pleasure, in the absence of 
+any energy deficit. A  recent study[57] on effect of exercise 
+on endocannabinoid on male rats with high‑fat diet induced 
+obesity indicated a reversal of metabolic syndrome.[58] The 
+current study of yoga intervention also includes loosening 
+exercises and süryanamaskära along with other yoga 
+techniques. The overactivation of the endocannabinoid 
+system is reduced by the yoga practices as evident from the 
+metabolic improvements.
+The 
+two 
+parameters 
+of 
+body 
+composition, 
+bone 
+mineral  (Bm) content and Mm, may increase after 
+sufficiently long period. Previous study showed that 
+compared to sedentary people, the marathoners  (both 
+male and female) had higher bone stiffness and density.
+[59] Furthermore, a systematic review on Bm accrual by 
+exercise reported increase in Bm with weight‑bearing 
+exercise, in children and adolescents, after 6  months.
+[60] Unlike the physical exercise, the yoga practice was 
+reported to decrease the Bm and Mm values in the 
+beginning. After sufficiently longer period, the Bm and 
+Mm showed increasing trend.[61] In the recent study of 
+yoga intervention on weight reduction, the Bm started 
+increasing in the beginning, and after 22  months of yoga 
+practice, Bm started decreasing.[61] It was noted that there 
+Table 6: Between‑group analysis results
+Variable
+Mean±SD
+t
+Significant (t‑tailed)
+Difference in mean 95% CI lower/upper
+Yoga post
+Control post
+Wt
+81.51±10.00
+79.22±8.93
+1.02
+0.310
+2.29 (−2.17-6.76)
+BMI
+28.33±2.42
+27.61±2.01
+1.37
+0.175
+0.72 (−0.33-1.77)
+PSQI
+4.16±2.03
+4.23±2.45
+−0.13
+0.901
+−0.07 (−1.12-0.99)
+BMR
+1574.35±145.84
+1564.37±130.06
+0.31
+0.761
+9.98 (−55.11-75.07)
+Bm
+3.08±0.42
+3.09±0.39
+−0.20
+0.846
+−0.02 (−0.21-0.17)
+Obd
+128.77±10.98
+125.56±9.27
+1.34
+0.186
+3.21 (−1.58-8.0)
+Smm
+31.36±4.04
+31.04±3.60
+0.36
+0.718
+0.33 (−1.47-2.13)
+Fm
+25.75±6.03
+23.91±5.63
+1.34
+0.186
+1.84 (−0.91-4.59)
+Pfin
+31.43±4.84
+29.98±5.14
+1.23
+0.222
+1.45 (−0.90-3.80)
+Aobd
+0.94±0.03
+0.93±0.03
+0.72
+0.476
+0.01 (−0.01-0.02)
+Ralm
+3.35±0.53
+3.27±0.46
+0.73
+0.466
+0.09 (−0.15-0.32)
+Lalm
+3.29±0.52
+3.25±0.45
+0.38
+0.707
+0.04 (−0.19-0.27)
+Rllm
+8.47±1.25
+8.27±1.08
+0.70
+0.487
+0.19 (−0.36-0.74)
+Tlm
+26.12±3.08
+25.77±2.71
+0.51
+0.608
+0.35 (−1.02−1.72)
+Lllm
+8.49±1.18
+9.24±1.07
+0.96
+0.34
+0.25 (−0.27-0.78)
+Wmra
+1.81±0.70
+1.62±0.62
+1.21
+0.231
+0.19 (−0.12-0.50)
+Wmla
+1.84±0.71
+1.62±0.62
+1.35
+0.182
+0.21 (−0.10-0.53)
+Wmt
+13.97±3.24
+13.05±3.10
+1.23
+0.225
+0.92 (−0.57-2.41)
+Wmrl
+3.42±0.75
+3.17±0.66
+1.49
+0.141
+0.25 (−0.08-0.58)
+Wmll
+3.41±0.74
+3.16±0.65
+1.54
+0.128
+0.25 (−0.07-0.58)
+Pfra
+33.10±7.28
+31.25±8.75
+0.98
+0.331
+1.85 (−1.92-5.63)
+Pfla
+33.82±7.53
+31.36±8.89
+1.28
+0.208
+2.46 (−1.40-6.32)
+Pft
+33.34±4.37
+32.09±5.19
+1.10
+0.273
+1.25 (−1.0-3.50)
+Pfrl
+27.59±4.11
+26.53±4.28
+1.07
+0.287
+1.06 (−0.91-3.03)
+Pfll
+27.49±4.13
+26.56±4.27
+0.94
+0.351
+0.93 (−1.04-2.90)
+Pm
+11.02±1.35
+10.90±1.19
+0.38
+0.707
+0.11 (−0.49-0.71)
+Mm
+3.7±0.50
+3.71±0.46
+−0.10
+0.921
+−0.1 (−0.24-0.21)
+Tbwm
+40.90±4.95
+40.54±4.40
+0.33
+0.746
+0.36 (−1.85-2.57)
+Sklm
+52.68±6.37
+52.20±5.66
+0.34
+0.736
+0.48 (−2.36-3.32)
+Ffm
+55.71±6.75
+55.25±6.03
+0.31
+0.760
+0.46 (−2.55-3.48)
+Wt = Weight, BMI = Body mass index, PSQI = Pittsburgh Sleep Quality Index, BMR = Basal metabolic rate, Bm = Bone mineral 
+mass, Obd = Obesity degree (current wt/ideal wt)×100, Smm = Skeletal muscle mass, Fm = Body fat mass, Pfin = Percentage body fat, 
+Aobd = Abdominal obesity degree (waist‑hip ratio), Ralm = Right arm lean mass, Lalm = Left arm lean mass, Rllm = Right leg lean mass, 
+Tlm = Trunk lean mass, Lllm = Left leg lean mass, Wmra = Water mass of right arm, Wmla = Water mass of left arm, Wmt = Water mass of 
+trunk, Wmrl = Water mass of right leg, Wmll = Water mass of left leg, Pfra = Percentage body fat of right arm, Pfla = Percentage body fat 
+of left arm, Pft = Percentage body fat of trunk, Pfrl = Percentage body fat of right leg, Pfll = Percentage body fat of left leg, Pm = Protein 
+mass, Mm = Mineral mass, Tbwm = Total body water mass, Sklm = Skeletal lean mass, Ffm = Fat free mass, CI = Confidence interval, 
+SD = Standard deviation
+Rshikesan, et al.: Yoga intervention and obesity
+135
+International Journal of Yoga | Volume 10 | Issue 3 | September‑December 2017
+is a complex relationship between adiposity and bone 
+tissue. The physiopathological participation of adiposity 
+in homeostasis of bone involves adipokines remodeling.
+[62] These molecules released from fat cells interfere 
+in the bone metabolism and the different degrees of 
+body weight will differently interfere with Bm.[62] The 
+serum leptin is inversely associated with Bm density 
+and strongly associated with fat mass.[63] The yoga 
+training involved asana pranayama meditation and other 
+awareness components which might have made the mind 
+peaceful and influenced the homeostasis positively. The 
+psychoneuroendocrine and immune mechanism systems 
+are improved by yoga practice reducing the stress and 
+improving the balance of the systems.[64]
+Further, in the body composition, the fat mass is 
+negatively correlated and FFM is positively correlated 
+to Bm and Mm in the current study, as reported in 
+previous studies.[65] Thus, the weight reduction achieved 
+by intervention is also by reduction in the FFM. Ideally, 
+the fat is to be reduced and lean body mass is to be 
+increased after doing yoga.[66] In yoga group, the left arm 
+lean mass and right arm lean mass showed increasing 
+trend and more duration of yoga practice may be required 
+for improvement with significance. In the control group, 
+in addition to improvements in arm lean mass, trunk lean 
+mass also showed increasing trend. This may be due to 
+the physical activities of the control group.
+It was also found that the BMI was strongly correlated 
+to FFM and the BMR as reported earlier.[67] The eating 
+behavior and sleep act together and affect weight 
+reduction.[38] The current study showed that BMI was 
+positively correlated to global score of PSQI and the 
+slpq influenced the weight reduction. Thus, the weight 
+reduction in yoga group is due to the improvement in 
+the stress sleep and eating patterns caused by yoga 
+training.
+The current study was one of the early studies with sleep 
+and body composition exclusively for obese male adults 
+in an urban setting. The study showed that IAYT reduces 
+the obesity and improves sleep quality. In the current study, 
+the same instruments including InBody R20 were used for 
+both the pre and post assessments since the measurement 
+by different analyzers will be misleading.[68]
+In the current study, the control group was not given 
+chance to gather together, which is a form of social 
+cohesion. In the yoga group, the social cohesion also 
+might have affected stress reduction and sleep quality. 
+Although the food log format and sample food plan were 
+given for information to the individuals, diet pattern of 
+the participants was not assessed. Above are considered 
+as limitations of the study.
+Although the minimization of cofactors was done to have 
+balance between the two groups, the age range was noted 
+large in the current study. For future studies, narrow range 
+of age and trials at different urban cities, having different 
+food habits can be considered.
+Conclusion
+Yoga intervention will be effective for controlling the 
+obesity in male and improving their quality of life. The 
+body composition parameters sleep quality were improved 
+due to yoga intervention.
+Acknowledgments
+The authors acknowledge with thanks the yoga circle, 
+Anushakti Nagar, Mumbai, for the help in conducting the 
+specified IAYT yoga class.
+Table 7: Correlations
+Wt
+BMI
+PSQI
+BMR
+Bm
+Smm
+Fm
+Pfin
+Pm
+Mm
+Ffm
+Tbwm
+Sklm
+Wt
+1
+BMI
+0.993**
+1
+PSQI
+0.196*
+0.201*
+1
+BMR
+0.322** 0.327**
+0.149
+1
+Bm
+0.243*
+0.233*
+0.041
+0.809**
+1
+Smm
+0.317** 0.323**
+0.160
+0.995**
+0.776**
+1
+Fm
+0.522** 0.511**
+0.022
+−0.639** −0.528** −0.640**
+1
+Pfin
+0.367** 0.356** −0.009 −0.752** −0.593** −0.755**
+0.975**
+1
+Pm
+0.308** 0.317**
+0.147
+0.988**
+0.773**
+0.994**
+−0.640** −0.754**
+1
+Mm
+0.227*
+0.218*
+0.073
+0.852**
+0.943**
+0.820**
+−0.580** −0.658** 0.814**
+1
+Ffm
+0.319** 0.324**
+0.146
+1.000**
+0.810**
+0.994**
+−0.641** −0.753** 0.988** 0.854**
+1
+Tbwm
+0.324** 0.330**
+0.157
+0.998**
+0.781**
+0.994**
+−0.637** −0.750** 0.988** 0.827** 0.998**
+1
+Sklm
+0.319** 0.326**
+0.161
+0.998**
+0.782**
+0.996**
+−0.641** −0.754** 0.990** 0.828** 0.998** 0.999**
+1
+**Correlation is significant at the 0.01 level (one‑tailed), *Correlation is significant at the 0.05 level (one‑tailed). Wt = Weight difference between 
+post and pre, Bm = Bone mass, Smm = Skeletal muscle mass, Fm = Body fat mass, Pfin = Percentage body fat from in body, Pm = Protein mass, 
+Mm = Mineral mass, Ffm = Fat free mass, Tbwm = Total body water, Sklm = Skeletal muscle mass, BMI = Body mass index, PSQI = Pittsburgh 
+Sleep Quality Index, BMR = Basal metabolic rate
+Rshikesan, et al.: Yoga intervention and obesity
+136
+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.
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+Saudi Journal of Sports Medicine | January - April 2015 | Volume 15 | Issue 1
+37
+Surya namaskara training for enhancing 
+selective attention in orphan boys: 
+A randomized control study
+Original Article
+ Thounaojam Memtonbi Devi, 
+ 
+Tikhe Sham Ganpat, 
+ 
+Sanjay Kumar1, 
+ 
+Nagendra Hongasandra Ramarao
+ Department of Yoga and 
+Management, Swami Vivekananda 
+Yoga Anusandhana Samsthana 
+University, Bengaluru, Karnataka, 
+India
+Address for correspondence: 
+Dr. Tikhe Sham Ganpat, 
+Swami Vivekananda Yoga 
+Anusandhana Samsthana 
+University, (Prashanti Kutiram), 
+19, Eknath Bhavan, Gavipuram 
+Circle, Kempegowda Nagar, 
+Bengaluru ‑ 560 019, Karnataka, India. 
+E‑mail: rudranath29@gmail.com
+Background: Surya namaskara (SN) training is a part of yoga; it consists of a sequence of postures done 
+with breath regulation, relaxation and awareness of energy centers. The selective attention (SA) is a vital 
+function mediated by the right frontal‑parietal cortex. The cancellation tests require visual selectivity 
+and a repetitive motor response. The six letter cancellation task (SLCT) is useful to assess functions 
+such as SA, focused attention, visual scanning, and the activation and inhibition of rapid responses. 
+Assessing SA in orphan boys (OB) is a part of the neuropsychological evaluation to know their academic 
+performance (AP). Objective: To assess the effect of SN training on SA in OB using SLCT. Subjects and 
+Methods: Sixty OB with 11.3 ± 2 years of mean age were divided randomly, using computerized random 
+number table into two groups (n = 30 in SN training group and n = 30 in control group). The SLCT data 
+were collected before (pre) and after (post) the SN training and control of 1 month duration. Results: 
+The Shapiro‑Wilk Test and Paired Samples Test using Statistical Package for the Social Sciences 16 (IBM 
+Corporation, USA) showed that there was 50.75% increase (P < 0.001) in total attempted (TA) and 
+52.99% increase (P < 0.001) in net score (NS) after SN training, whereas there was decrease in TA and 
+NS in control group. Furthermore, there was no significant change observed in the wrong cancellation 
+scores in both SN training and control group. Thus, it was revealed that SN training can increase TA 
+and NS, and decrease wrongly attempted scores that is associated with an increase in SA. Conclusion: 
+The present study suggests that SN training may enhance SA among OB, thus, may prove useful for 
+their AP
+. Additional well‑designed studies are needed before a strong recommendation can be made 
+on the efficacy of SN training for enhancing SA, and thereby improving AP
+.
+Key words: Orphan boys, selective attention, six letter cancellation task, Suryanamaskara
+ABSTRACT
+.) تدريب دراسة مراقبة عشوائيةSurya namaskara(   لتعزيز االنتباه االنتقائي لدى الفتيان األيتام
+ خلفية: تدريب سوريا ناماسكرا جزءا من رياضة اليوغا الشهيرة؛ و يتألف من سلسلة من المواقف التي
+ تمارس مع تنظيم التنفس و االسترخاء و الوعي بمراكز الطاقة. ومن المغروف ان االنتباه االنتقائي
+ وظيفة جيوية تتوسط القشرة الجدارية األمامية للدماغ، باالضافة الى ان اختبارات اإللغاء  تتطلب قدرة
+ بصرية على االنتقاء. أما مهمة إلغاء الحروف الستة فهي مفيدة في تقييم الوظائف مثل االنتباه االنتقائي
+ ، االهتمام المركّز و المسح الضوئي المرئي، و تنشيط و تثبيط الردود السريعة . تعد عملية االنتباه
+.االنتقائي عندالفتيان األيتام جزءا من التقويم العصبي النفسي لمعرفة أداءهم األكاديمي
+.أهداف الدراسة: كان هدف هذه الدراسة  تقويم أثر التدريب في الفتيان األيتام ا باستخدام طريقة إلغاء الحروف الستة
+ و تم تقسيمهم13 - 11  من الفتيان األيتام ترواحت أعمارهم بين60 عينة الدراسة و منهجها: تم اختبار
+ كعينة 30  منهم خضعوا للتدريب و03 ،عشوائيا إلى مجموعتين باستخدامرقم عشوائي محوسب
+. ضابطة. وقد اختيرت بيانات إلغاء الحروف الستة قبل التدريب و بعده بشهر واحد
+ النتائح : باستخدام اختبار شا بيرو ــ ويلك و اختبار العينة المقترنة با ستخدام حزمة العلوم االجتماعية
+  زيادة بعد التدريب%52.99  و%50.75  أظهرت النتائج أن هناك زيادة في المجموع بنسبة16
+ في صافي النتيجة بعد أداء التدريب و أظهرت النتائج انخفاضاً في مجموعة التدريب و المجموعة
+ الضابطة. و قد أظهرت النتائح أن التدريب قد يزيد مجموع المحاوالت ونتائج التدريب، و يخفض من
+. المحاوالت الخاطئة المصحوبة باالهتمام المركز
+ الخالصة: تشير الدراسة إلى أن التدريب قد يؤدي إلى تعزيزاالنتباه االنتقائي بين الفتيان األيتام مما
+ يحسن أداءهم األكاديمي. و هناك حاجة لدراسات مصممة تصميما جيدا ، قبل التوصية باستخدام
+.التدريب لتعزيز االنتباه االنتقائي لتحسين األداء األكاديمي
+Access this article online
+Website: www.sjosm.org
+DOI: 10.4103/1319-6308.149534 
+Quick Response Code:
+[Downloaded free from http://www.sjosm.org on Thursday, February 4, 2021, IP: 136.232.192.146]
+Devi, et al.: Role of Surya namaskara training in orphan boys
+Saudi Journal of Sports Medicine | January - April 2015 | Volume 15 | Issue 1
+38
+INTRODUCTION
+Attention is an essential element of cognition and has 
+been characterized in two ways, that is, either as a 
+resource or capacity or as a skill of resource deployment. 
+The selective attention (SA) is the capacity to attend 
+to a task in hand for the required period. It is almost 
+related with sustained attention, and associated with 
+task difficulty or complexity.[1] The SA is easier for 
+simple tasks than that of complex tasks. It is almost 
+associated with the mental effort required by the 
+task in hand.[2] The capacities to study and listen to a 
+lecture for an extended length of time are examples of 
+SA. Various brain areas mediate attention, different 
+ones being responsible for different types of attention. 
+The right front parietal area mediates sustained 
+attention. Damage to the right prefrontal cortex is 
+associated with poor SA.[3] Imaging studies have shown 
+that vigilance tasks requiring SA to activate a network 
+of neurons in the right frontal and parietal cortices.[4] 
+Previous studies on SA suggests that reduced anxiety 
+can improve the performance on tasks requiring SA[5] 
+and yoga’s anxiety reducing effects[6] could also have 
+facilitated this. Similarly, modern education system 
+and Gurukula education system improve SA in 
+school boys, but Gurukula education system is more 
+effective.[1] Several studies have been published to 
+analyze the effect of different aspects of yoga including 
+physical postures, and meditation on SA. Special 
+physical postures (Asana), voluntary regulation of 
+breathing  (Pranayama), maintaining silence, and 
+visual focusing exercises (Trataka) improve attention 
+span in school children.[7‑9] However, the changes in SA 
+that characterize the efficacy of Surya namaskara (SN) 
+training in orphan boys (OB) have not been reported 
+earlier adequately.
+Objective
+The present study was designed to assess the effect of 
+SN training on SA in OB using six letter cancellation 
+task (SLCT).
+SUBJECTS AND METHODS
+Subjects
+Sixty OB with 11.3 ± 2 years of mean age were divided 
+randomly into two groups using computerized random 
+number table (n = 30 in SN training and n = 30 in the 
+control group).
+Inclusion criteria
+Orphan boys with age ranging from 8 to 14 years.
+Exclusion criteria
+(i) Physically handicapped, (ii) taking medication (iii) 
+using any other wellness strategy.
+Design
+Randomized control study.
+Source
+The OB home, Manipur.
+Informed consent
+An informed consent form was obtained from all the 
+participants.
+The institutional review board approval
+The study was approved by the institutional review 
+board of Swami Vivekananda Yoga Anusandhana 
+Samsthana University, Bangalore and authorities of 
+OB home, Manipur.
+Intervention
+All the subjects participated in the SN training[10,11] of 
+1 month duration, which was conducted in OB home, 
+Manipur.
+Assessment
+The SLCT[8,10] data was collected before (pre) and after 
+(post) the 1 month SN training. The SLCT consisted of 
+a test worksheet that specified the six target letters to 
+be cancelled and had a “working section” that consisted 
+of letters of the alphabet arranged randomly in 14 
+rows and 22 columns. The participants were asked to 
+cancel as many six target letters as possible, which 
+were printed at the top of working section of the test 
+sheets, in the specified time, that is, 90 s. They were 
+told that there were two possible strategies, that 
+is, (i) doing all six letters at a time, or (ii) selecting 
+any one target letter out of the six. They were asked 
+to choose whichever strategy suited them. They were 
+also told that they could follow a horizontal, vertical 
+or a random path according to their choice.
+Data collection
+The total number of cancellations and wrong 
+cancellations (WCs) were scored, and the net scores 
+(NSs) were calculated by deducting the WCs from 
+the total cancellations attempted. As this test was 
+administered before and after the 1 month intervention 
+of SN training, parallel work sheets were prepared by 
+changing the sequence of the letters randomly in the 
+working section. Both the groups, that is, SN training 
+and control received one set of worksheets before a 
+session and paralleled worksheets after the session. 
+The SLCT was used in a similar design in an Indian 
+population, indicating the validity of the task.[8,10]
+Data scoring
+The scoring was done by a person, who was unaware, 
+when the assessment was made whether the 
+participant was engaging in SN training or control, 
+[Downloaded free from http://www.sjosm.org on Thursday, February 4, 2021, IP: 136.232.192.146]
+Devi, et al.: Role of Surya namaskara training in orphan boys
+Saudi Journal of Sports Medicine | January - April 2015 | Volume 15 | Issue 1
+39
+and whether the assessment was of “before (pre)” or 
+“after (post)” session.[12]
+Statistical analysis
+The Statistical Package for the Social Sciences‑16 
+(IBM Corporation, USA) was used for the statistical 
+analysis of the SLCT data. The Shapiro‑Wilk test 
+showed that the data were normally distributed. 
+Further, the Paired Samples test was used to test the 
+level of significance.
+RESULTS
+Cancellation tasks require visual selectivity and 
+a repetitive motor responses.[13] They are not only 
+require SA, but also visual scanning and activation and 
+inhibition of rapid responses. The present study found a 
+significant increase in SA scores after the SN training. 
+The data analysis of SLCT scores showed 50.75% 
+increase (P < 0.001) in total attempted (TA) scores of 
+SN training group, whereas in control it was decreased 
+by 0.83% (P < 0.05). The NS analysis showed 52.99% 
+increase (P < 0.001) in SN training group whereas it 
+was 1.94% decrease (P < 0.05) in control group. The 
+wrongly attempted (WA) score analysis showed no 
+significant change in either of the groups [Table 1].
+DISCUSSION
+The mechanism of how yoga may reduce total time 
+taken and errors made in SLCT, and how it may 
+increase SA may be understood by three cardinal 
+principles of yoga: Relax the body, slow down the 
+breath and calm down the mind.[14] Recent research 
+has shown a positive relationship between the 
+personality trait and academic performance (AP). 
+Previous study on yoga reported enhanced SA as a 
+result of the practice of yoga way of life. The result 
+indicates the paramount importance of yoga to 
+improve AP.[8,9] A study on performance in an SLCT 
+in 35 male experienced meditators with experience 
+ranging from 6 to 12 months reported enhanced SA 
+with Dharana or focusing on the symbol “OM”.[15] 
+Similarly, a recent study on SN training reported 
+that the practice of 108 SN increases TA and NS 
+and decreases WA scores in SLCT that is associated 
+with an increase in sustained attention.[10] Thus, the 
+SN training holds a great promise in enhancing SA 
+in healthy individuals. The sharp memory and SA 
+are important skills for academic and professional 
+performance. The techniques to improve these skills 
+are not taught either in education or company training 
+courses. Any system that can systematically, improve 
+these skills will be of value in schools, universities, and 
+workplaces.[16] The present study is consistent with 
+these research findings, indicating that the practice of 
+SN training can result in better AP through improving 
+SA as assessed through SLCT in OB.
+CONCLUSION
+The present study suggests that SN training can result 
+in improvement of SA among OB, thus paving the way 
+for their AP. Although this preliminary research is 
+promising, well designed studies are needed before a 
+strong recommendation can be made.
+ACKNOWLEDGMENT
+Authors acknowledge Swami Vivekananda Yoga 
+Anusandhana Samsthana University, Bangalore for 
+granting permission to carry out this work.
+REFERENCES
+1.	
+Rangan R, Nagendra HR, Bhatt R. Effect of yogic education system and 
+modern education system on sustained attention. Int J Yoga 2009;2:35‑8.
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+Posner MI. Chronometric Explorations of Mind. In: Hillsdale NJ, editor.
+Erlbaum: Lawrence Erlbaum Associates; 1978. p. 269.
+3.	
+Rueckert L, Grafman J. Sustained attention deficits in patients with right 
+frontal lesions. Neuropsychologia 1996;34:953‑63.
+4.	
+Pardo JV
+, Fox PT, Raichle ME. Localization of a human system for sustained 
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+7.	
+Telles S, Hanumanthaiah B, Nagarathna R, Nagendra HR. Improvement 
+in static motor performance following yogic training of school children. 
+Percept Mot Skills 1993;76:1264‑6.
+8.	
+Sarang SP, Telles S. Immediate effect of two yoga‑based relaxation 
+techniques on performance in a letter‑cancellation task. Percept Mot 
+Skills 2007;105:379‑85.
+9.	
+Telles S, Raghuraj P, Maharana S, Nagendra HR. Immediate effect of three 
+yoga breathing techniques on performance on a letter‑cancellation task. 
+Percept Mot Skills 2007;104:1289‑96.
+10.	
+Arun K, Prithvi A, Ganpat TS, Deshpande S, Pailoor S, Ramarao NH. 
+Suryanamaskara exercise enhances sustained attention. Saudi J Sports 
+Med 2014;14:31‑4.
+Table 1: Data analysis
+SLCT
+SN group (mean±SD)
+Percentage increase=↑
+Percentage decrease=↓
+P
+Control group (mean±SD)
+Percentage increase=↑
+Percentage decrease=↓
+P
+Before (pre)
+After (post)
+Before (pre)
+After (post)
+TA
+24.43±14.63
+36.83±18.68
+50.75↑
+<0.001***
+32.13±8.13
+31.87±8.02
+0.83↓
+0.030*
+WA
+0.47±1.85
+0.17±0.53
+64.29↓
+0.411
+0.27±0.64
+0.73±1.62
+175.00↑
+0.143
+NS
+23.97±14.61
+36.67±18.59
+52.99↑
+<0.001***
+37.73±11.67
+37.00±11.68
+1.94↓
+0.019*
+***Significant at 0.001 level, *Significant at 0.05 level (paired samples test). SN=Surya namaskara, SD=Standard deviation, SLCT=Six letter cancellation task, 
+TA=Total attempted, WA=Wrongly attempted, NS=Net score
+[Downloaded free from http://www.sjosm.org on Thursday, February 4, 2021, IP: 136.232.192.146]
+Devi, et al.: Role of Surya namaskara training in orphan boys
+Saudi Journal of Sports Medicine | January - April 2015 | Volume 15 | Issue 1
+40
+11.	
+Nagarathana R, Nagendra HR. Integrated Approach of Yoga Therapy for 
+Positive Health. Bangalore, India: Swami Vivekananda Yoga Prakashan; 
+2011. p. 65.
+12.	
+Kelland  DZ, Lewis  RF. The digit vigilance test: Reliability, 
+validity, and sensitivity to diazepam. Arch Clin Neuropsychol 
+1996;11:339‑44.
+13.	
+Lezak MD. Neuropsychological Assessment. 3rd ed. New York, USA: 
+Oxford University Press; 1995.
+14.	
+Murthy RS. From local to global‑Contributions of Indian psychiatry to 
+international psychiatry. Indian J Psychiatry 2010;52:S30‑7.
+15.	
+Kumar S, Telles S. Meditative states based on yoga texts and their 
+effects on performance of a letter‑cancellation task. Percept Mot Skills 
+2009;109:679‑89.
+16.	
+Pradhan B, Nagendra HR. Effect of yoga relaxation techniques on 
+performance of digit‑letter substitution task by teenagers. Int J Yoga 
+2009;2:30‑4.
+Cite this article as: Devi TM, Ganpat TS, Kumar S, Ramarao NH. Surya 
+namaskara training for enhancing selective attention in orphan boys: A 
+randomized control study. Saudi J Sports Med 2015;15:37-40.
+Source of Support: Nil, Conflict of Interest: None declared.
+[Downloaded free from http://www.sjosm.org on Thursday, February 4, 2021, IP: 136.232.192.146]
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--- /dev/null
+++ b/subfolder_0/Suryanamaskara exercise enhances sustained attention.txt	
@@ -0,0 +1,229 @@
+8/11/2014
+<i>Suryanamaskara</i> exercise enhances sustained attention :Kavitha Arun, Asharaj Prithvi, Tikhe Sham Ganpat, Sudheer Deshpande, Subrmanyam Pail…
+http://www.sjosm.org/printarticle.asp?issn=1319-6308;year=2014;volume=14;issue=1;spage=31;epage=34;aulast=Arun
+1/5
+ORIGINAL ARTICLE
+Year : 2014  |  Volume : 14  |  Issue : 1  |  Page : 31--34
+Suryanamaskara exercise enhances sustained attention
+Kavitha Arun1, Asharaj Prithvi1, Tikhe Sham Ganpat2, Sudheer Deshpande3, Subrmanyam Pailoor1, Nagendra
+Hongasanra Ramarao4,  
+1 Directorate of Distance Education, Sw ami Vivekananda Yoga Anusandhana Samsthana University, Bangalore, Karnataka, India
+2 Departments of Yoga and Management, Sw ami Vivekananda Yoga Anusandhana Samsthana University, Bangalore, Karnataka, India
+3 Registrar, Sw ami Vivekananda Yoga Anusandhana Samsthana University, Bangalore, Karnataka, India
+4 Chancellor, Sw ami Vivekananda Yoga Anusandhana Samsthana University, Bangalore, Karnataka, India
+Correspondence Address:
+Tikhe Sham Ganpat
+Assistant Professor, Department of Yoga and Management, Sw ami Vivekananda Yoga Anusandhana Samsthana University,
+(Prashanti Kutiram), 19, Eknath Bhavan, Gavipuram Circle, Kempegow da Nagar, Bangalore - 560 019, Karnataka 
+India
+Abstract
+Background: The Suryanamaskara (SN) exercise is a comprehensive yoga technique which incorporates physical
+activity, breath regulation, relaxation and awareness. Apart from improving physical stamina and endurance, SN has
+been shown to influence an individual«SQ»s perception and performance. But its immediate effect on sustained
+attention was not reported adequately. Objective: The study was designed to assess the immediate effect of 108 SN
+on sustained attention, efficiency and speed of visual scanning in subjects participated in Rathasapthami day (the
+seventh day following the Sun«SQ»s northerly movement). Materials and Methods: In this single and mixed group pre-
+post study, 96 subjects with mean age 33.15 ± 13.61 years participated. The Six Letter Cancellation Test (SLCT) and
+Digit Letter Substitution Test (DLST) data were collected immediately before and after 108 SN. Statistical Analysis:
+Means, Standard Deviations, Kolmogorov-Smirnov test and Wilcoxon Signed Ranks Test were used for analyzing the
+data with the help of SPSS-16. Results: When compare with predata analysis, the SLCT showed 30.61% increase (P <
+0.001) in Total Attempted (TA), 81.58% decrease (P < 0.01) in Wrongly Attempted (WA) and 31.87% increase (P <
+0.001) in Net Score (NS). Similarly, the DLST showed 38.71% increase (P < 0.001) in TA, 13.64% decrease (P = 0.001)
+in WA and 35.44% increase (P < 0.001) in NA. Thus, the analysis of SLCT and DLST scores shows that SN was
+associated with increase in TA and NS and decrease in WA scores. Conclusion: When compared with pre data
+analysis, the post analysis of SLCT and DLST scores showed that the SN was associated with increase in TA and NS
+and decrease in WA scores. Thus, the SN holds great promise in enhancing sustained attention in healthy individuals.
+Well-designed studies are needed before a strong recommendation can be made.
+How to cite this article:
+Arun K, Prithvi A, Ganpat TS, Deshpande S, Pailoor S, Ramarao NH. Suryanamaskara exercise enhances sustained
+attention.Saudi J Sports Med 2014;14:31-34
+How to cite this URL:
+Arun K, Prithvi A, Ganpat TS, Deshpande S, Pailoor S, Ramarao NH. Suryanamaskara exercise enhances sustained
+8/11/2014
+<i>Suryanamaskara</i> exercise enhances sustained attention :Kavitha Arun, Asharaj Prithvi, Tikhe Sham Ganpat, Sudheer Deshpande, Subrmanyam Pail…
+http://www.sjosm.org/printarticle.asp?issn=1319-6308;year=2014;volume=14;issue=1;spage=31;epage=34;aulast=Arun
+2/5
+attention. Saudi J Sports Med [serial online] 2014 [cited 2014 Aug 11 ];14:31-34 
+Available from: http://www.sjosm.org/text.asp?2014/14/1/31/131610
+Full Text
+ Introduction
+In Indian culture, yoga has traditionally been a part of daily routine which is meant for attaining healthy life. [1] The
+Suryanamaskar (SN) also called as Sun salutation, sun adoration for health, efficiency and longevity is a part of Indian
+traditional yogic practices. [2] SN is a part of yoga; it consists of a sequence of postures done with synchronized
+breathing. The practice of few cycles of SN is known to help in maintaining good health and vigor. The practice of SN
+does not need any extra gadgets. Also, it is very much aerobic and invigorates the body and the mind. [3]
+Attention is an important skill for academic and professional performance. Techniques to improve these skills are not
+taught either in education or training courses. Attention is an essential element of cognition. Sustained attention is the
+capacity to attend to a task in hand for a required period of time. [4] The capacities to study and listen to a lecture for an
+extended length of time are examples of sustained attention. With so much of distractions in this technology-driven
+world it is becoming difficult for people to concentrate. The sustained attention (SA) is a vital function mediated by the
+right front parietal cortex. The SA is the capacity to attend to a task in hand for a required period of time. It is closely
+associated with task difficulty or complexity. [4] It is closely associated with the mental effort required by the task in
+hand. [5] The capacities to study and listen to a lecture for an extended length of time are examples of SA.
+Thus, SN becomes a kind of activity which involves almost every part of the body and is considered as a complete
+exercise. Many of SN practitioners also believe that regular practice of few cycles, when performed properly leads to
+development and strengthening of almost every part of the body. [6] The SN when practiced as a part of integrated
+approach of yoga therapy can improve hot flushes and night sweats. It also can improve cognitive functions such as
+remote memory, mental balance, attention and concentration, delayed and immediate recall, verbal retention and
+recognition tests. [7] It is known that Six Letter Cancellation Test (SLCT) and Digit Letter Substitution Test (DLST)
+measure SA [8] and there was no study available evaluating the immediate effect of 108 rounds of SN on SA.
+Objectives
+To study immediate effect of 108 SN on SA in subjects using SLCT and DLST.
+ Materials and Methods
+Subjects
+The 96 participants (45 males and 49 females) with 33.15 ± 13.61 years of mean age participated in this study.
+Inclusion criteria
+(i) Healthy individuals. (ii) Willing to participate.
+Exclusion criteria
+Pregnant ladies.
+Design
+Single group pre-post study.
+8/11/2014
+<i>Suryanamaskara</i> exercise enhances sustained attention :Kavitha Arun, Asharaj Prithvi, Tikhe Sham Ganpat, Sudheer Deshpande, Subrmanyam Pail…
+http://www.sjosm.org/printarticle.asp?issn=1319-6308;year=2014;volume=14;issue=1;spage=31;epage=34;aulast=Arun
+3/5
+Source of subjects
+The subjects for the present study were selected from the program who participated on Rathasaptami Day (the seventh
+day following the Sun's northerly movement).
+Informed consent
+An informed consent was obtained from all the participants.
+The institutional review board approval
+The study was approved by the institutional review board (IRB) of S-VYASA University.
+Intervention
+In the present study, all subjects of the Rathasapthami day participated in 108 rounds of SN. Each cycle consists of 12
+steps performed consecutively one after the other. The cycle begins with Stithi or Pranamasana; the prayer posture. It is
+then followed by the following positions in a sequence. Position 1-Hasta Utthanasana, the raised arms pose, Position
+2-Padahastasana, the hand to foot pose, Position 3-Ashwasanchalana, the equestrian pose, Position 4-Santolasana,
+the balancing pose, Position 5-Shashakasana, the hare pose, Position 6-Ashtang Namasakarasan, the salutations
+with eight parts or points pose, Position 7-Bhujangasana, the cobra pose, Position 8-Parvatasana, the mountain pose,
+Position 9-Shashakasana, the hare pose, Position 10-Ashwasanchalana, the equestrian pose, Position 11-
+Padahastasana, the hand to foot pose and Position 12-Hasta Utthanasana, the raised arms pose and then coming
+back to the Stithi. [9]
+Assessments: SLCT and DLST
+SLCT
+The SLCT consisted of a test worksheet that specified the six target letters to be cancelled and had a 'working section'
+that consisted of letters of the alphabet arranged randomly in 14 rows and 22 columns. The participants were asked to
+cancel as many six target letters as possible, which were printed at the top of working section of the test sheets, in the
+specified time, that is, 90 seconds. They were told that there were two possible strategies, that is, (i) doing all six letters
+at a time, or (ii) selecting any one target letter out of the six. They were asked to choose whichever strategy suited them.
+They were also told that they could follow a horizontal, vertical or a random path according to their choice. The scoring
+was done by a person who was unaware when the assessment was made. The total number of cancellations and
+wrong cancellations were scored and the net scores were calculated by deducting the wrong cancellations from the
+total cancellations attempted. The SLCT is a valid tool for measuring the SA, concentration and VS. [8]
+DLST 
+The DLST worksheet consists of an 8 rows × 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. The 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. The scoring was done by a person who was unaware when the assessment was made. The
+DLST is a valid tool for measuring the SA, concentration and VS. [8]
+Data collection
+The SLCT and DLST data were collected before (pre) and after (post) the practice of 108 SN.
+8/11/2014
+<i>Suryanamaskara</i> exercise enhances sustained attention :Kavitha Arun, Asharaj Prithvi, Tikhe Sham Ganpat, Sudheer Deshpande, Subrmanyam Pail…
+http://www.sjosm.org/printarticle.asp?issn=1319-6308;year=2014;volume=14;issue=1;spage=31;epage=34;aulast=Arun
+4/5
+Statistical analysis
+The SPSS-16 was used for statistical analysis. The SLCT and DLST data were checked for normal distribution by
+using the Kolmogorov-Smirnov test. The data analysis showed that the data was not normally distributed. The Wilcoxon
+Signed Rank Test was used to test the significance of the change between pre and post measurements of SN.
+ Results
+When compared with pre data analysis, the SLCT showed 30.61% increase (P < 0.001) in Total Attempted (TA),
+81.58% decrease (P < 0.01) in Wrongly Attempted (WA) and 31.87% increase (P < 0.001) in Net Score (NS) [Table 1].
+Similarly, the DLST showed 38.71% increase (P < 0.001) in TA, 13.64% decrease (P = 0.001) in WA and 35.44%
+increase (P < 0.001) in NA [Table 2]. Thus, the analysis of SLCT and DLST scores shows that SN was associated with
+increase in TA and NS and decrease in WA scores.{Table 1}{Table 2}
+ Discussion
+In the present study it was observed that the SLCT and DLST scores of TA and NS were increased significantly and WA
+scores decreased in participants in 108 SN as compared to pre measurement. The cancellation tasks involve SA,
+concentration, visual scanning, and activation and inhibition of rapid responses. [10] A previous study by Patil and
+Telles [11] assessed performance on the related SLCT immediately before and after cyclic meditation (CM) and supine
+rest. This study reported that 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. [12] The DLST was developed from the Digit Symbol Substitution Test, one of the subsets of
+the Wechsler intelligence scale. [13] The 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. [14] The
+substitution tasks involve visual scanning, mental flexibility, SA and psychomotor speed, speed of information
+processing and rapid response activation and inhibition process. [15] A previous study on the SLCT showed that long-
+term yoga practitioners have superior cognitive abilities than non-meditators in the old age group. [16] Using the SLCT
+tool, it was reported that both modern education system and Gurukula education system (GES) improve SA in school
+boys and reveal that GES is more effective. [17] Similarly, previous study on SLCT showed that SN as a part of
+integrated approach of yoga therapy can improve hot flushes and night sweats. It can also improve cognitive functions
+such as remote memory, mental balance, attention and concentration, delayed and immediate recall, verbal retention
+and recognition tests. [7] The results of the present study are consistent with these findings and suggest that SN may
+enhance SA.
+ Conclusion
+The present study suggest that the practice of 108 SN increases TA and NS and decreases WA scores in SLCT and
+DLST which is associated with increase in SA. Thus, the SN holds a great promise in enhancing SA in healthy
+individuals. Although this preliminary research is promising, well-designed studies are needed before a strong
+recommendation can be made.
+ Acknowledgement
+8/11/2014
+<i>Suryanamaskara</i> exercise enhances sustained attention :Kavitha Arun, Asharaj Prithvi, Tikhe Sham Ganpat, Sudheer Deshpande, Subrmanyam Pail…
+http://www.sjosm.org/printarticle.asp?issn=1319-6308;year=2014;volume=14;issue=1;spage=31;epage=34;aulast=Arun
+5/5
+Authors acknowledge Swami Vivekananda Yoga Anusandhana Samsthana (S-VYASA) University for granting
+permission to carry out this work.
+References
+1
+Posner MI. Chronometric Explorations of Mind. In: Hillsdale, NJ, editor. Erlbaum: Lawrence Erlbaum Associates;
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+Bhutkar MV, Bhutkar PM, Taware GB, Surdi AD. How eff ective is sun salutation in improving muscle strength,
+general body endurance and body composition? Asian J Sports Med 2011;2:259-66.
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+Mandlik V. History of yoga. In: Yog Shikshan Mala, Yog Parichay. 6 th ed. Nashik, India: Yogchaitanya Publication;
+2001. p. 36-45.
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+Omkar S, Mour M, Das D. Motion analysis of sun salutation using magnetometer and accelerometer. Int J Yoga
+2009;2:62-8.
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+Unkule N. Advantages of Suryanamaskars. In: Nisargopchar Varta. National Institute of Naturopathy. Pune, India:
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+Chattha R, Nagarathna R, Padmalatha V, Nagendra HR. Effect of yoga on cognitive functions in climacteric
+syndrome: A randomised control study. BJOG 2008;115:991-1000.
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+Natu MV, Agarwal AK. Testing of stimulant effects of coffee on the psychomotor performance: An exercise in
+clinical pharmacology. Indian J Pharmacol 1997;29:11-4.
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+Nagarathana R, Nagendra HR. Integrated Approach of Yoga Therapy for Positive Health. Bangalore, India:
+Swami Vivekananda Yoga Prakashan; 2011. p. 65.
+10
+Lezak MD, Howieson DB, Loring DW. Neuropsychological Assessment. New York: Oxford University Press;
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+Sarang SP, Telles S. Immediate effect of two yoga-based relaxation techniques on performance in a letter-
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+Agarwal AK, Kalra R, Natu MV, Dadhich AP, Deswal RS. Psychomotor performance of psychiatric inpatients
+under therapy: Assessment by paper and pencil test. Hum Psychopharmacol 2002;17:91-3.
+13
+Wechsler D. WAIS-R Manual. New York: The Psychological Corporation; 1981. p. 12.
+14
+van der Elst W, van Boxtel MP, van Breukelen GJ, Jolles J. The letter digit substitution test: Normative data for
+1,858 healthy participants aged 24-81 from the Maastricht Aging Study (MAAS): Influence of age, education, and
+sex. J Clin Exp Neuropsychol 2006;28:998-1009.
+15
+van Hoof JJ, Lezak MD. Neuropsychological Assessment. 3 rd ed. New York: Oxford University Press; 1995. p. 3-
+7.
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+Prakash R, Rastogi P, Dubey I, Abhishek P, Chaudhury S, Small BJ. Long-term concentrative meditation and
+cognitive performance among older adults. Neuropsychol Dev Cogn B Aging Neuropsychol Cogn 2012;19:479-
+94.
+17
+Rangan R, Nagendra HR, Bhatt R. Effect of yogic education system and modern education system on sustained
+attention. Int J Yoga 2009;2:35-8.
+ 
+ 
+Monday, August 11, 2014
+ Site Map | Home | Contact Us | Feedback | Copyright and Disclaimer
diff --git a/subfolder_0/Th Biosc NB.txt b/subfolder_0/Th Biosc NB.txt
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+Vol.:(0123456789)
+1 3
+Theory in Biosciences 
+https://doi.org/10.1007/s12064-023-00391-3
+ORIGINAL ARTICLE
+A computational investigation of cis‑gene regulation in evolution
+Mohammed Mahmud1 · Mulugeta Bekele1 · Narayan Behera2,3 
+Received: 13 January 2022 / Accepted: 27 March 2023 
+© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2023
+Abstract
+In biological processes involving gene networks, genes regulate other genes that determine the phenotypic traits. Gene regula-
+tion plays an important role in evolutionary dynamics. In a genetic algorithm, a trans-gene regulatory mechanism was shown 
+to speed up adaptation and evolution. Here, we examine the effect of cis-gene regulation on an adaptive system. The model 
+is haploid. A chromosome is partitioned into regulatory loci and structural loci. The regulatory genes regulate the expres-
+sion and functioning of structural genes via the cis-elements in a probabilistic manner. In the simulation, the change in the 
+allele frequency, the mean population fitness and the efficiency of phenotypic selection are monitored. Cis-gene regulation 
+increases adaption and accelerates the evolutionary process in comparison with the case involving absence of gene regula-
+tion. Some special features of the simulation results are as follows. A low ratio of regulatory loci and structural loci gives 
+higher adaptation for fixed total number of loci. Plasticity is advantageous beyond a threshold value. Adaptation is better for 
+large number of total loci when the ratio of regulatory loci to structural loci is one. However, it reaches a saturation beyond 
+which the increase in the total loci is not advantageous. Efficiency of the phenotypic selection is higher for larger value of 
+the initial plasticity.
+Keywords  Evolution · Cis-gene regulation · Waddington experiment · Genetic algorithm · Phenotypic plasticity
+Introduction
+Understanding of the evolutionary processes is a challenging 
+area in evolutionary biology. Phenotypic plasticity can pro-
+vide better adaptation to an environment and accelerates the 
+course of evolution (Behera and Nanjundiah 1995). Pheno-
+typic plasticity can facilitate the evolution of beneficial gene 
+activity patterns in gene regulatory circuits (Espinosa-Soto 
+et al 2011). In a new environment, the rate of adaptation 
+increased due to a history of phenotypic plasticity (Fierst 
+2011). Plasticity plays an important role in an organism’s 
+development that leads to the expression of robust pheno-
+types owing to environmental variation (Hollander et al 
+2015). The populations with phenotypic plasticity can easily 
+retain novel adaptive traits than their non-plastic counter-
+parts (Lalejini et al. 2021). It can facilitate gene expression. 
+Gene regulation is a cellular process that controls the rate 
+and manner of gene expression—a process by which infor-
+mation from a gene is used in the synthesis of a functional 
+gene product. Thus, it allows a cell to be a more efficient in 
+responding to changing conditions by adjusting its physi-
+ology. Gene regulation is a means by which cells control 
+over both structural and functional processes taking place 
+in an organism. It is the basis for cellular differentiation, 
+morphogenesis and phenotypic plasticity (Agrawal 2001). 
+In the process of gene expression, genes and gene products 
+interact and form networks on several levels (Albert 2004). 
+In doing this, a complex set of instructions between genes, 
+ribonucleic acid (RNA) molecules, proteins and other com-
+ponents of the gene expression system determine when and 
+where specific genes are activated. Transcription factors are 
+proteins which can activate or inhibit copying of DNA to 
+messenger RNA (mRNA). Since transcription factors are 
+themselves products of genes. Hence, genes regulate each 
+other’s expression by forming the gene regulatory networks 
+(Nachman 2004).
+ 
+*	 Narayan Behera 
+	
+narayan.behera@astu.edu.et
+1	
+Department of Physics, Addis Ababa University, 
+P.O.Box 1176, Addis Ababa, Ethiopia
+2	
+Department of Applied Physics, Adama Science 
+and Technology University, P. O. Box 1888, Adama, Ethiopia
+3	
+Division of Physical Science, SVYASA University, Eknath 
+Bhavan, Kempegowda Nagar, Bengaluru 560019, India
+	
+Theory in Biosciences
+1 3
+The two key processes of gene expression are: transcrip-
+tion process due to which a mRNA copy is made from a 
+DNA and translation process by which this transcribed 
+mRNA is translated into protein (Aluru 2005). The tran-
+scription process occurs when the enzyme called RNA 
+polymerase binds to DNA molecule (Alberts et al. 2004). 
+This binding process controls gene expression. Proteins are 
+the major controller of the binding process. But, a protein 
+molecule which undertakes the controlling of binding pro-
+cess itself could be regulated. This can occur when some 
+other molecules bind to a protein and cause it to undergo 
+structural changes. The amount of mRNA produced during 
+transcription process is a measure of the level of activity of a 
+functional gene (Aluru 2005). After a mRNA is copied from 
+a DNA, the transcribed mRNA is translated into a protein. In 
+general, gene regulation is viewed as a number of sequential 
+processes, the most important being transcription and trans-
+lation. They control the level of a gene’s expression.
+The regulation in gene expression at the genomic level 
+may take place in two different manners. The regulation of 
+a gene by another gene can happen on the same chromo-
+some. Thus, the structural and regulatory genes reside on 
+the same chromosome which is known as cis-gene regula-
+tion. Trans-gene regulation happens when the regulation of 
+a structural gene on one chromosome is caused by regulatory 
+genes present on another chromosome (Nestler and Hyman 
+2002). These two types of gene regulations are mainly used 
+to understand the effect of inter-specific variation and evolu-
+tion in gene expression. The evolution of gene expression 
+and regulation within and between species is believed to 
+have played key roles in adaptation.
+A gene regulation system consists of structural genes and 
+gene regulators. The regulators are generally the transcrip-
+tion factors, but small molecules, like RNAs and metabo-
+lites. Gene expression is mediated by cis-regulatory ele-
+ments and trans-regulatory elements. Therefore, evolution 
+of gene expression can be caused by a change in cis- or 
+trans-regulatory elements or both. The cis-regions affect a 
+very specific gene expression signal. The structural genes, 
+regulatory genes and the regulatory connections between 
+them form gene networks. The development is buffered 
+against unpredictable environmental and genetic effects. 
+A molecular genetic analysis of the establishment of tho-
+racic segmental identity under the control of the ultrabitho-
+rax (UBX) gene in Drosophila melanogaster is presented 
+(Gibson and Hogness 1996). The experiments have demon-
+strated that increased sensitivity to ether is correlated with 
+a loss of expression of UBX in the third thoracic disks. A 
+great proportion of the genetic variation for transcriptional 
+stability can be accounted by polymorphism in the UBX 
+gene. Trans-gene regulation can speed up the evolutionary 
+process. The model is successfully applied to Waddington’s 
+experiment of genetic assimilation (Behera and Nanjundiah 
+1997, 2004). Positive selection may have significantly con-
+tributed to cis-regulatory divergence (Schaefke et al. 2013). 
+In the recent years, study of cis-acting gene regulation has 
+gained momentum for understanding the possibility of rapid 
+evolutionary change.
+The inter-specific gene expression differences are caused 
+by cis-elements spread throughout the genome (Wittkopp 
+2004). Trans-effects are seen more important as the inter-
+acting loci are separated from the chromosome regions 
+(Savarese and Grosschedl 2006). In the bacterial strains, 
+the functional dependence of cis-antisense RNA has been 
+investigated (Georg and Hess 2011). Genetic mechanisms 
+of phenotypic evolution can be understood by cis-regulatory 
+divergence (Wittkopp and Kalay 2012). When phenotypes 
+are governed by regulatory interactions, hybrid incompat-
+ibility can evolve as a consequence of parallel adaptation 
+in parental populations. This happens due to the interacting 
+genes creating the same phenotype through incompatible 
+allelic combinations. Tulchinsky et al. (2014) studied the 
+evolutionary conditions that promote and constrain hybrid 
+incompatibility in regulatory networks. They used a bio-
+energetic model involving thermodynamics and kinetics of 
+transcriptional regulation. Massively parallel reporter assays 
+with well-defined sequences provide the statistical power to 
+understand about the cis-regulatory function (White 2015). 
+A computational model of reproductive isolation utilizes a 
+map from genotype to phenotype based on the biophysics 
+of protein–DNA binding. The biophysical model provides a 
+robust mechanism of rapid reproductive isolation for small 
+populations and large sequences that does not require posi-
+tive selection (Khatri and Goldstein 2015).
+Allele specific variations from a natural population have 
+shown the relationships between the trans- and cis-regu-
+latory effects (Osada et al. 2017). The evolution of gene 
+expression occurring in cis- and in trans-regulations and 
+their response to the environment is reviewed (Signor and 
+Nuzhtin 2018). Brain function with psychological disorder 
+has been considered to find the relative contribution of cis- 
+and trans-regulation for gene transcription (Reuveni et al 
+2018). A stronger constraint to evolution and speciation 
+is provided by the biophysics and population size (Khatri 
+and Goldstein 2019). The long non-coding RNAs as tran-
+scriptional units contribute to gene regulatory networks and 
+hence to spatial and temporal gene expression study (Gil 
+and Ulitsky 2020). Cis-gene regulation plays important role 
+involving artificial selection of domesticated chickens (Wang 
+et al. 2019). The evolution of gene regulatory elements 
+contributes to complex disorders of human vision (Cherry 
+et al. 2020). The gene expression dynamics is relevant to the 
+evolution of cis-regulatory sequences (Shih and Fay 2021). 
+Evolution of genetic variants is governed by the regulatory 
+complexity where the transcription factors are most robust 
+to cis-acting variation (Flohlay et al. 2021).
+Theory in Biosciences	
+1 3
+A few reviews involving gene regulation, evolution and 
+speciation are given below. Gene regulation and speciation 
+is analyzed (Mack and Nachman 2017). Speciation and the 
+developmental alarm clock is investigated (Cutter and Bun-
+dus 2020). Molecular and evolutionary dynamics creating 
+variation in gene expression is considered (Hill et al. 2021).
+Model
+The model used here is a modified version of the work of 
+Behera and Nanjundiah (1995, 1996, 1997, 2004) on adap-
+tive evolution using genetic algorithm approach. In their 
+work, they have considered a population of haploid genotype 
+having distinct structural loci and regulatory loci idealized 
+as one-dimensional strings. Here, we have considered the 
+haploid chromosome where both regulatory genes and struc-
+tural genes reside. We intended to see the regulation pattern 
+and plasticity of the phenotype. The a priori probabilities p 
+for each allele on chromosomal locus, total number of indi-
+viduals in a population It and the total number of loci on a 
+chromosome Nt are specified. Using these predefined param-
+eters, at first step we create initial population of specified 
+number of individuals and proceed by regulating plasticity. 
+After calculating the fitness of each phenotype, we select the 
+better phenotypes for further reproduction. To have the next 
+generation, we implement crossover method for generating 
+offsprings (Pachuau et al. 2021). A genetic algorithm model 
+is used to study the evolution of a population.
+Simulations are conducted with 1056 number of individu-
+als where each individual has 30 genetic loci. This num-
+ber is chosen such that the population size is kept constant 
+after random mating of 33 individuals with two offsprings 
+per mating pair. These parameters have been considered to 
+compare the outcomes of our simulation containing cis-gene 
+regulation to the evolutionary dynamics of trans-gene regu-
+lation considered by Behera and Nanjundiah (1997). Due to 
+the stochastic nature of the computer model, each simulation 
+is repeated ten times, and the mean value is calculated.
+Creating initial population
+Individual genes have allelic states as 0 and 1. The plastic 
+allele is X on structural loci. A 0 state represents the state of 
+a gene that is not active (off-state) and a 1 state represents 
+the state of a gene which is active (on-state). The plastic 
+allele X can be changed to 1 with some probabilities after 
+gene regulation takes effect. The population consists of indi-
+viduals of haploid genotype. Each genotype is represented 
+by one chromosome idealized as one-dimensional string of 
+length Nt which is further divided into two parts: regulatory 
+gene with string length of Nr and structural gene with string 
+length of Ns. Each locus on the regulatory gene has two 
+possible allelic states, 0 and 1. Similarly, a structural gene 
+has three allelic states: 0, 1 and X.
+Alleles on a regulatory locus or a structural gene locus 
+are specified probabilistically. A random number generator 
+is used to generate a uniformly distributed pseudo-random 
+numbers in the interval (0, 1). The probabilities of alleles 0 
+and 1 on regulatory loci are p0r and p1r, respectively. Simi-
+larly, the probabilities of alleles 0, 1 and X on structural loci 
+are p0s, p1s and pXs, respectively. The p's are equivalent to 
+allele frequencies. Each p is nonnegative and the sum of 
+p's on regulatory loci (p0r + p1r) is equal to 1. Similarly, p0s, 
+p1s and pxs on structural loci add up to 1. Since we are deal-
+ing with a single chromosome having both regulatory and 
+structural loci, the allele values on each locus are assigned 
+differently for both regulatory loci and structural loci.
+The phenotype is determined by the action of entire set 
+of alleles in the structural genes. But, structural genes are 
+regulated by the regulatory genes. Therefore, the regulatory 
+genes influence the phenotype indirectly. A sample of four 
+chromosomes is given here for illustration.
+Regulation of genes via plastic genes
+After the initial population is created by assigning allele 
+values on each chromosomal locus, we need to specify 
+the unspecified plastic allele ‘X’ on the structural loci. On 
+average a genotype has n alleles type X in its structural loci 
+where n is equal to Ns multiplied by pxs(0). Here, pxs(0) 
+stands for the frequency of X alleles in structural locus at 
+zero generation. For each genotype in each generation, a sys-
+tematic process updates the plastic allele X to 1. This can be 
+done by going through the procedures we call coin-tossing 
+trial. A maximum of ­
+2n coin-tossing trials are carried out in 
+each genotype to attain the intended target point (Behera and 
+Nanjundiah 1997). The best phenotype has a target where 
+all allelic states are of 1-types. If the frequency of allele 1 
+over regulatory loci (p1r) is less than the random number 
+generated, the allele X on structural loci will be updated 
+to 1-like allele and if not it is left as it is. In each trial, all 
+the X’s are updated independently following generation of 
+fresh random numbers. The maximum allowed number of 
+coin-tossing trials continue until all X's are updated to 1. 
+The actual number of trial is noted for each genotype when 
+all the X’s get updated to 1 states. If all the X’s cannot get 
+updated to 1 state according to the above rules even after the 
+maximum allowed trials, then the original genotype is kept 
+as it is with all its X, 0 and 1 states.
+Fitness calculation
+Once the allele values on each structural locus of a chro-
+mosome are specified (when all X's on structural gene are 
+updated to 1-like allele) for all individuals in a generation, 
+	
+Theory in Biosciences
+1 3
+the fitness for each genotype in a generation is calculated. 
+Only the structural genes participate in the fitness calcula-
+tion. Depending on whether it depends on the plastic allele 
+X or not, we calculate two components of fitness.
+The first component of fitness WD (adaptive fitness) 
+depends solely on the final phenotype as all X's in the struc-
+tural loci are updated to 1-like allele within the allowed 
+number of trials. It reflects the degree of matching between 
+the attained phenotype and the initial phenotype. All the 
+allele values over all loci of a chromosome (after all X's 
+updated to 1) are added. The sum is divided by the total 
+number of structural loci. This is done for all individual 
+chromosomes in a population. Mathematically adaptive fit-
+ness can be defined as:
+where ‘i’ represents locus number on each genotype, and di 
+is the allele value on locus ‘i.’ The di may be specified as 0 if 
+allele on locus ‘i’ is 0 and 1 when the allele on locus ‘i’ is 1.
+The second component of fitness is a plastic fitness which 
+reflects the dynamic aspect of phenotype. Plastic fitness is 
+represented by Wp which is the final phenotype attained after 
+coin-tossing trial is finished. Mathematically, plastic fitness 
+is defined as (Behera and Nanjundiah; 1997):
+Here, ­
+2n represents the maximum number of allowed trial 
+to reach the intended target point, and the actual trial is the 
+trial undertaken to change all X’s to 1-like.
+The maximum number of allowed trial is the same for 
+every genotypes and is independent of the number of X's 
+it carried. But, the number of allowed trial depends on a 
+priori probability of X, in the starting generation pXs(0) and 
+the number of structural loci (Ns). For each genotype hav-
+ing large number of X's at initial population, the less likely 
+it is that all of them will become 1-like allele within the 
+allowed trial. If any of structural loci does not contain X's, 
+but contain at least one 0-like allele, Wp = 0. On the other 
+hand, if coin-tossing is stopped before the full quota of trials 
+is exhausted, Wp takes a value between 0 and 1.
+In order to find the overall effect of the fitness function 
+for each individual of a population, it is necessary to find 
+the average fitness. This can be done by using the fractional 
+weight–age function ‘f’ which implies the degree of match-
+ing between the two components of the fitness. Mathemati-
+cally total fitness can be written as:
+(1)
+WD = 1
+Ns
+Nt
+∑
+i=Nr+1
+di
+(2)
+WP = 2n−actual number of trial
+2n
+(3)
+WT = f.WD + (1 −f)WP
+where f is a positive number lying between 0 and 1 which 
+we call fractional weight–age. Varying the value of ‘f’ would 
+vary the fitness or rate of plasticity. In all of our simulation, 
+we used f = 0.5 for simplicity. The total fitness WT is calcu-
+lated for all individuals and then sorted in decreasing order 
+to select the fittest individuals.
+After the fitness of each individual in the generation is 
+determined, it is necessary to calculate population mean fit-
+ness for each successive generation to examine which gener-
+ation is more adaptable to the environment. This can be done 
+by calculating the mean fitness of the population as follows:
+Here, MF and WT(i) represent the mean fitness and total fit-
+ness of the ith individual, respectively.
+The top 33 individuals with higher fitness are selected 
+out of 1056 individuals. Here, each pair of parents creates 
+two different individuals with changed genotypes due to 
+crossover effect. These 33 selected individuals further are 
+allowed to mate and reproduce randomly so that the total 
+population is kept constant in each generation. The effec-
+tiveness of phenotypic selection can be measured by the 
+function H called as the efficacy of phenotypic selection. It 
+represents the fraction of population which consists of indi-
+viduals having allelic states 1 and X on their structural loci 
+and following coin-tossing process acquires the phenotype 
+corresponding to that of the genotype consisting of allele 1 
+only. In addition, H shows the proportion of individuals that 
+have the maximum possible fitness in any generation even if 
+they have not attained the target genotype.
+Selection of more fit phenotype
+Once the fitness of each individual has been calculated and 
+arranged in a decreasing order of their relative fitness, trun-
+cation selection is performed. Individuals with better fitness 
+are selected for further reproduction. If we select n num-
+ber of individuals from the total individuals, It, and if these 
+selected individuals are allowed to recombine we will have 
+the new individuals as a result of recombination.
+Mating and recombination
+Once we selected the individuals fit enough for further 
+reproduction, the next step is to determine how they recom-
+bine with each other to produce offspring. Here, typically 
+we select two individuals and allow them to produce two 
+offspring. This can be done by randomly choosing a crosso-
+ver point and allowing the two individuals to exchange their 
+allele values over chromosomal loci. The process proceeds 
+until all individuals recombine with each other (without 
+(4)
+MF = 1
+It
+It
+∑
+i=1
+WT(i)
+Theory in Biosciences	
+1 3
+repetition) and produce total offspring which are equal in 
+number to the total number of initial population. More spe-
+cifically, we have used one-point crossover recombination 
+process where a single point is chosen at random on the 
+first individual and the same point is chosen on the second 
+individual. This splits individuals into a left hand side (LHS) 
+and right hand side (RHS). Then, two offspring individuals 
+can be produced by:
+a.	 Taking the right hand side (RHS) of the second indi-
+vidual, and adding it to the left hand side (LHS) of the 
+first individual.
+b.	 Taking the LHS of the first individual and adding it to 
+the RHS of the second individual.
+The process of recombination takes place between every 
+individual. During the recombination process, the alleles in 
+the chromosomes of the two individuals are exchanged so 
+that the offspring genotypes differ from the parents.
+It is important to note that in the above crossover opera-
+tion, offspring which are better in fitness than their parents 
+are created in successive generations. This is because of the 
+fact that the fitter individuals in a population are allowed to 
+recombine. It is by recombination process the next genera-
+tion is created. The population size is kept constant. How-
+ever, every crossover may not bring us better offspring indi-
+viduals. But, we do not worry about bad phenotypes since 
+they will get eliminated in the next reproduction operation 
+(selection of the fittest). We are dealing with better offspring 
+since it is likely to get more copies of it in the next recom-
+bination process. Thus, after some run we might have indi-
+viduals that are better in their fitness than their parents. The 
+simulation code will be provided at the journal website.
+Results
+In this section, we present our results in three parts. First, we 
+investigate the effect of change of allele frequency through 
+generation by comparing the frequency of different alleles 
+on both regulatory loci and structural loci for a given chro-
+mosome in population. Second, we look at how population 
+mean fitness which is directly related to the problem in 
+study (phenotypic plasticity) changes through generation, 
+and finally, we finish by studying the effectiveness of phe-
+notypic selection.
+Change of allele frequency
+The genes on regulatory loci control the action of genes 
+on the structural loci in this model of cis-regulation. Thus 
+for 0 and 1 alleles over regulatory loci, the allele frequen-
+cies are p0r and p1r, respectively, and for 0, 1 and X alleles 
+over structural loci the allele frequencies are p0s, p1s and 
+pXs, respectively. From the simulation outcome, we have 
+recorded the frequency of 0 and 1 alleles over regulatory 
+loci, and of 0, 1 and X alleles over structural loci. More 
+specifically, we have observed the change in frequencies of 
+alleles in regulatory and structural loci from generation to 
+generation. (Figs. 1, 2, 3).
+The frequency of allele 1 averaged over regulatory loci 
+increases from one generation to the next generation while 
+that of allele 0 decreases with generation number (Fig. 4). In 
+other words, this can be interpreted as the probability of an 
+organism to adapt to the environment increases from genera-
+tion to generation as a result of natural selection. The natural 
+selection favors individuals of higher fitness. This can hap-
+pen if the probability of a plastic allele to become 1 allele 
+increases. Furthermore, this can happen if the frequency of 
+1 allele in the regulatory loci increases. Therefore, the incre-
+ment in the frequency of allele 1 on regulatory loci directly 
+helps to successfully regulate the action of plastic genes in 
+structural loci in such a way that the fitness increases. The 
+frequency of allele 1 on regulatory loci’s incremental pro-
+cess is somewhat different as the number of regulatory loci 
+Nr varies as shown in Fig. 5. For small values of Nr, the fre-
+quency of allele 1 in the regulatory loci increases rapidly and 
+attains its maximum value. But for large values of Nr, the 
+Fig. 1   A sample of population
+Fig. 2   Illustration of recombination process between two mating indi-
+viduals by means of single-point crossover
+	
+Theory in Biosciences
+1 3
+frequency increases steadily. The natural selection is more 
+efficient when the ratio of structural loci to the regulatory 
+loci is large.
+On the other hand, the frequency of allele 1 averaged 
+over structural loci always increases from generation to 
+generation, while that of allele 0 always decreases (Fig. 6). 
+This result is expected as allele 1 confers higher fitness to 
+the individual. But, the frequency of plastic allele X aver-
+aged over structural loci either increases or decreases in the 
+course of time depending on the initial strength of plasticity 
+Fig. 3   Flowchart of the genetic 
+algorithm
+Fig. 4   Change in allele fre-
+quency on regulatory loci as a 
+function of generation number 
+(a single simulation) with initial 
+conditions: p1r = 0.1, p1s = 0.5, 
+pXs = 0.3, Nr = 12, Nt = 30 and 
+It = 1056. These are stochastic 
+simulations. The output with 
+respect to generation num-
+ber will change for different 
+simulation when the seed value 
+is changed. So we have given 
+one representative simulation 
+only. But for the calculation of 
+mean value, say average fitness, 
+at equilibrium, the mean value 
+at equilibrium is taken over the 
+results of 10 simulations
+Theory in Biosciences	
+1 3
+pxs (0) (Fig. 7). The plastic alleles can survive in the popula-
+tion if their initial frequency crosses a threshold value. Oth-
+erwise the plastic alleles can go extinct from the population 
+in the course of evolution.
+Mean population fitness
+The mean population fitness MF increases over the succes-
+sive generation as it is expected for the population under 
+natural selection (Fig. 8). But, the incremental process in 
+mean population fitness is not similar for different initial 
+parameters. This shows that the external parameters have 
+their own impact on the mean population fitness and hence 
+adaptation. For example, the mean population fitness at 
+fixation increases with increase in initial probability of 
+allele 1 in the regulatory loci and increasing number 
+of chromosomal length Nt. Figure 9 shows that as p1r 
+increases, the mean fitness at fixation linearly increases. 
+The adaptation to an environment increases as the fre-
+quency of allele 1 is more in the starting generation. The 
+adaptation will be poor if the frequency of allele 1 is less 
+in the initial generation. As chromosomal length increases, 
+the mean fitness at fixation increases as shown in Fig. 10. 
+This is shown for equal number of structural and regula-
+tory loci. This happens due to the presence of allele 1 in 
+regulatory loci which are strongly selected in successive 
+generations in favor of better adaptation.
+Fig. 5   Plot of change in allele 
+frequency on regulatory loci as 
+a function of generation number 
+(a single simulation) for differ-
+ent values of number of regula-
+tory loci (Nr = 4, 8 and 12) with 
+initial conditions: p1r = 0.1, 
+p1s = 0.5, pXs = 0.3, Nt = 30, and 
+It = 1056
+Fig. 6   Change in allele fre-
+quencies at structural loci as a 
+function of generation number 
+(a single simulation). The 
+initial conditions are: p1r = 0.1, 
+p1s = 0.35, pXs = 0.25, Nt = 30, 
+Nr = 12 and ­
+It = 1056
+	
+Theory in Biosciences
+1 3
+Effectiveness of phenotypic selection
+The effectiveness of the phenotypic selection is monitored 
+by a parameter H which is defined as follows. H is the per-
+centage of the population for which all the alleles in each 
+loci of an individual reached the state of 1’s within the 
+allowed number of trials. As it is expected from population 
+under natural selection, H increases in the course of time as 
+shown in Fig. 11. The figure shows that for first four or five 
+generation H stays zero and began to increase slowly for one 
+or two generation, and then increases sharply over a course 
+of one or two generations. Then, the H attains rapidly its 
+maximum value. The effectiveness of phenotypic selection 
+can be affected by external parameters. In our simulation, 
+we have seen the effect of initial strength of regulation, p1r, 
+initial strength of plasticity, pXs, chromosomal length, Nt, 
+and initial number of population, It, on H. Both the increase 
+in initial strength of regulation p1r(0) and the increase in 
+initial strength of plasticity pXs(0) favor the increase in the 
+efficacy of H as shown in Fig. 12 and Fig. 13, respectively. 
+Fig. 7   Change in frequency of 
+plastic allele X over structural 
+loci as a function of genera-
+tion number (a single simula-
+tion) for different values of 
+initial strength of plasticity 
+(pXs(0) = 0.45 and pXs(0) = 0.25). 
+The initial conditions are: 
+p1r = 0.1, p1s = 0.5, pXs = 0.3, 
+Nt = 30 and It = 1056
+Fig. 8   Mean fitness as a func-
+tion of generation number 
+(a single simulation). The 
+initial conditions are: p1r = 0.1, 
+p1s = 0.5, pXs = 0.3, Nt = 30 and 
+It = 1056
+Theory in Biosciences	
+1 3
+On the other hand, H at fixation decreases with the increase 
+in value of chromosomal length Nt (Fig. 14) which implies 
+that phenotypic selection would be effective with small num-
+ber of loci (chromosomal length).
+Again the effectiveness of phenotypic selection can be 
+affected by the initial number of individuals in a population. 
+This implies that the phenotypic selection is effective for large 
+number of individuals in a given population (Fig. 15). The 
+figure shows that the efficacy function H began to increase in 
+a short time (after small number of generation) for large initial 
+number of population.
+Fig. 9   Population mean fitness 
+at fixation as a function of 
+the initial strength of regula-
+tion p1r(0). The simulation is 
+conducted for 10 experiments. 
+The variations are within one- 
+and two-standard deviations 
+of the mean. Initial conditions 
+are: f = 0.5, ­
+pXs(0) = 0.39, 
+p1s(0) = 0.3, Nt = 30 and Nr = 12
+Fig. 10   Population mean fit-
+ness at fixation as a function of 
+chromosomal length (Nt). The 
+simulation is conducted for 10 
+experiments. The variations are 
+within one- and two-standard 
+deviations of the mean. Each 
+simulation is run over 1000 gen-
+erations. Initial conditions are: 
+f = 0.5, p1s = 0.3, pXs(0) = 0.39 
+and Nr = Nt/2
+	
+Theory in Biosciences
+1 3
+Discussion
+Behera and Nanjundiah (1997) considered the case where 
+the gene on one chromosome regulates the gene action on 
+the other chromosome. The central idea of their work is 
+the structural loci have plasticity and genetic variation. 
+In their work, the main existence of regulatory chromo-
+some is to help manifest the plasticity in favor of beneficial 
+allele and hence increase adaptation in a given environ-
+ment. In our case, both regulatory genes and structural 
+genes are present in the same chromosome. The recombi-
+nation scheme provides different dynamics for the geno-
+types in the next generation in comparison with the case 
+when they are present in different chromosomes. Here, the 
+fitness is calculated not only by the structural genes but it 
+is also indirectly affected by the regulatory genes.
+Gene regulation and adaptation
+One of the ways we evaluated the adaptation phenomenon 
+is by calculating the frequency of an operating allele (allele 
+Fig. 11   The effectiveness 
+of phenotypic selection (as 
+measured by the value of H) 
+as a function of generation num-
+ber (a single simulation). The 
+initial conditions are: p1r = 0.1, 
+p1s = 0.2, pXs = 0.3, Nr = 12, 
+Nt = 30 and It = 1056
+Fig. 12   The effectiveness 
+of phenotypic selection (as 
+measured by the value of H) at 
+fixation as a function of initial 
+strength of regulation p1r. The 
+simulation is conducted for 10 
+experiments. The variations are 
+within one- and two-standard 
+deviations of the mean. Each 
+simulation is done for 1000 time 
+steps. The initial conditions are: 
+p1s = 0.3, pXs = 0.39, Nr = 12, 
+Nt = 30 and It = 1056
+Theory in Biosciences	
+1 3
+1) over a chromosome. This happens when the operat-
+ing allele (allele 1) frequently occurs over a chromosome 
+(within a genotype). In the case of trans-gene regulation, 
+the frequency of allele 1 over regulatory loci and that of the 
+allele X over structural loci increase while that of allele 1 
+over structural loci (p1s) decreases sometimes depending on 
+initial conditions (Behera and Nanjindiah 1997). But in the 
+case of cis-gene regulation as we can see from Fig. 4 and 
+Fig. 6, the frequency of allele 1 in both over regulatory loci 
+and structural loci increases from generation to generation. 
+This happens for two reasons: first, the regulation of plas-
+tic allele X over structural loci by a cis-gene on regulatory 
+Fig. 13   The effectiveness of 
+phenotypic selection (as meas-
+ured by the value of H) at fixa-
+tion as a function of priori prob-
+ability of allele X at structural 
+loci pXs(0). The simulation is 
+conducted for 10 experiments. 
+The variations are within one- 
+and two-standard deviations of 
+the mean. There are 1000 time 
+steps for each simulation. The 
+initial conditions are: p1r = 0.39, 
+p1s = 0.3, Nr = 12, Nt = 30 and 
+It = 90
+Fig. 14   The effectiveness 
+of phenotypic selection (as 
+measured by the value of H) 
+at fixation as a function of 
+chromosomal length (Nt). The 
+simulation is conducted for 10 
+experiments. The variations are 
+within one- and two-standard 
+deviations of the mean. Each 
+simulation has 1000 time steps. 
+The initial conditions are: 
+p1r = 0.4, p1s = 0.1, pXs = 0.5, 
+­
+Nr = ­
+Nt/2, Nt = 30 and It = 1056
+	
+Theory in Biosciences
+1 3
+loci enables the frequency of allele 1 on structural loci to 
+increase. Second, the frequency of allele 1 in both regulatory 
+loci and structural loci increases due to the phenotypic selec-
+tion taking place between individuals of the population. This 
+is strong in successive generations due to the recombination 
+effect as both structural and regulatory loci exist in the same 
+chromosome.
+Gene regulation and rate of evolution
+Cis-gene regulation in genetic materials of an organism 
+speeds up the evolutionary process because of the plastic 
+allele X over structural loci changes to the beneficial 1 allele 
+with a higher probability in successive generations. Thus, a 
+genetic capability for modifying the expression of gene over 
+a chromosome can itself act as a selective force in favor of 
+alleles with potentially variable phenotypic effects. We can 
+express the rate of evolution in terms of generation num-
+ber. This means when fixation point is reached in short time 
+(less number of generations), there is an accelerated rate of 
+evolution. The rate of evolution is faster in cis-regulation in 
+comparison with the case of no gene regulation. In an earlier 
+paper, the case of no gene regulation was explored (Behera 
+and Nanjundiah 1995).
+Survival of the fittest
+To get the appropriate reproductive population, we have 
+selected the fitter individuals in the current population and 
+recombine them with each other. Hence, an individual with a 
+high fitness value in a population has a great chance of being 
+selected to generate a progeny for the next generation. The 
+selection operator in genetic algorithm model enables us to 
+select the phenotypes with better fitness value for the next 
+generation. In addition to selection, regulation of structural 
+gene by alleles on regulatory loci helps to have the best fit 
+individuals. These can be expressed in terms of allele 1 fre-
+quency on structural loci. By starting with some minimum 
+value of p1r and regulating the plastic allele X over structural 
+loci, we have obtained the increasing values of p1s as shown 
+in Fig. 6.
+Role of the ratio of the regulatory genes 
+to the structural genes
+In our simulation, we have observed that for an increase in 
+the number of regulatory loci and correspondingly decrease 
+in number of structural loci, the incremental process of allele 
+1 frequency varies. For example, for small ratio of the num-
+ber of regulatory loci to the number of structural loci, the 
+frequency of allele 1 on regulatory loci increases rapidly 
+and reaches its fixation point with small number of genera-
+tion. But as the ratio of the number of regulatory loci to that 
+of structural loci increases, the increase in the frequency 
+of allele 1 over regulatory loci as a function of generation 
+begins to slow its incremental process and reaches its fix-
+ation point with large number of generation as shown in 
+Fig. 5. Physically this implies that we have more chance to 
+regulate the genes on the structural loci with a small num-
+ber of regulatory loci. Hence, the population may have the 
+chance to adapt to the environment in a short time. The total 
+chromosome length is kept constant.
+Effectiveness of phenotypic selection
+As natural selection leaves behind individuals having bet-
+ter fitness in a given population, it is known as a dominant 
+factor in bringing adaptive evolution (Swanson 2003). To 
+realize this fact, in our case we calculated the efficacy func-
+tion H to measure the effectiveness of the selection operator. 
+Fig. 15   The effectiveness 
+of phenotypic selection (as 
+measured by the value of H) 
+as a function of generation 
+number for different number of 
+total individuals in a population 
+(It). It is the result of a single 
+simulation. The initial condi-
+tions are: p1s = 0.2, pXs = 0.2, 
+p1r = 0.39, Nt = 30 and Nr = 12
+Theory in Biosciences	
+1 3
+As we can see from Fig. 11, the function H increases from 
+generation to generation. This implies that the selection 
+becomes more and more effective from generation to gen-
+eration. Therefore, as time increases the population becomes 
+better and better adaptive to the environment. Since the indi-
+viduals having greater fitness relative to the other individuals 
+in a population are selected for further reproduction, they 
+may have the chance to produce offspring better than their 
+parents. Thus, as time keeps changing, population becomes 
+better and better for further reproduction. In other words, 
+phenotypic selection becomes more effective from one gen-
+eration to the next. This is similar to the case of trans-gene 
+regulation studied by Behera and Nanjundiah (1997) where 
+phenotypic selection favors the adaptive evolution.
+From our simulation results, we have observed the effect 
+of external parameters on H. For example, with increase in 
+the initial strength of regulation, p1r(0), the efficacy function 
+H at fixation begins to increase (Fig. 12) which implies that 
+as p1r(0) is allowed to increase, the unspecified allele X over 
+structural loci might have the chance to be updated to allele 
+1 more easily in a short time. H increases with the increase 
+in value of a priori probability of allele X on structural loci 
+pXs(0) (Fig. 13). This means the greater value of pXs(0), the 
+less we have allele 0 on structural loci and the more we get 
+the chance to obtain phenotypes with higher mean fitness 
+which helps us to have better fit phenotypes after selec-
+tion operation. Contrary to the cases we saw above, Fig. 14 
+shows that the increase in the number of total loci on a single 
+chromosome results in the less effective of phenotypic selec-
+tion. Physically this implies that within the same other initial 
+parameters, phenotypic selection can be more effective with 
+a small number of loci over a chromosome.
+Summary and conclusions
+In this work, we have computationally developed a model 
+of cis-gene regulation in adaptive evolution by using the 
+technique of genetic algorithm. The ability of these models 
+to mimic the phenomenon of natural adaptation in evolution-
+ary biology enables us to study the way by which cellular 
+genes regulate their expression over a chromosome. As a 
+first step, we have randomly created a population of specified 
+number of individuals with each individual having chromo-
+somal length ­
+Nt. The process by which a plastic allele X 
+over structural loci is updated to 1-like allele due to a gene 
+on regulatory loci brought us with phenotypic variation. If 
+this regulation of gene changes all plastic alleles over struc-
+tural loci to 1-like allele in a short time, we can say that a 
+rapid evolutionary adaptation occurs among individuals of 
+a population. To know the degree of individual’s adaptation, 
+we have evaluated the fitness for each individual of a popula-
+tion. This means an individual with higher fitness value in 
+relative to the other individuals of a population obtain higher 
+degree of adaptation.
+The frequency of allele 1 over structural loci always 
+increases as a function of time, where the frequency of allele 
+0 over structural loci decreases from generation to genera-
+tion. But, the frequency of plastic allele X over structural 
+loci either increases or decreases depending on the initial 
+strength of plasticity (pXs(0)). This means approximately 
+for pXs(0) above 0.4, pXs increases with generation but for 
+pXs(0) less than 0.4, pXs is a decreasing function of time. This 
+threshold level of plasticity is a peculiar feature of adap-
+tive evolution. In general, the increment in mean fitness of a 
+population is due to the combined effect of gene regulation 
+and selection of the better fit individuals in a population. 
+But, the way we choose the initial parameters slightly affects 
+the incremental process of population mean fitness.
+We have observed that efficacy of phenotypic selection 
+increases from generation to generation which implies that 
+selection is effective to bring a rapid evolutionary adapta-
+tion. This selection becomes favorable with increase in value 
+of priori probability of allele 1 over regulatory loci and allele 
+X over structural loci but selection becomes less effective 
+for long length of chromosome. Phenotypic selection is 
+one of the effective operations in evolutionary process that 
+brings individuals more adaptive to the changing condition. 
+We conclude that the cis-regulation in a gene expression 
+favors the adaptation process and also speeds up the rate of 
+evolution.
+Rapid evolution was observed in experiments on genetic 
+assimilation (Waddington 1956, 1961; Gibson and Hogness 
+1996). Waddington did experiment on fruit fly (Drosophila 
+melanogaster species) on the bithorax trait. The bithorax 
+trait was developed as a result of ether shock due to environ-
+mental influence. Then, he found that the threshold level of 
+ether shock required decreased in successive generations for 
+the offspring of fruit fly to give rise to bithorax traits. Finally 
+in the ­
+14th generations, no ether shock was required and the 
+fruit fly off spring developed bithorax trait in almost 100% 
+individuals. That means the trait was a result of environ-
+mental effect has gone into the genes over a few generations 
+of selection and evolution. This looks like a Lamarckian 
+result in evolutionary biology. But, it can be explained in 
+Darwinian terms by postulating regulating genes and struc-
+tural genes. The structural genes determine the fitness of 
+the organism, but the regulatory genes regulate the mani-
+festation of the structural genes. The cis-regulation in our 
+model through the genetic algorithm is a promising theo-
+retical framework to explain the Waddington experiment on 
+genetic assimilation and rapid evolution. This model will be 
+explored in a future work. Furthermore, a detailed compara-
+tive analysis will be carried out between the cis- and trans-
+gene regulations in future research.
+	
+Theory in Biosciences
+1 3
+Author contributions  The research problem was conceived by NB and 
+MB. The programming was done, data were obtained, and the paper 
+was written by MM. All authors have read and revised the manuscript.
+Funding  No funding was received for conducting this study.
+Declarations 
+Competing interest  The authors have no competing interests to declare 
+that are relevant to the content of this article.
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+Review Article
+Traditional practices and recent advances in Nadi Pariksha:
+A comprehensive review
+P. Venkata Giri Kumar a, *, Sudheer Deshpande b, H.R. Nagendra c
+a Division of Yoga and Physical Sciences, S-VYASA Yoga University, Bengaluru, Karnataka, India
+b VYASA, Eknath Bhavan, Bengaluru, Karnataka, India
+c S-VYASA Yoga University, Bengaluru, Karnataka, India
+a r t i c l e
+i n f o
+Article history:
+Received 4 May 2017
+Received in revised form
+12 October 2017
+Accepted 16 October 2017
+Available online 10 August 2018
+Keywords:
+Gati
+Kathinya
+Pulse wave velocity
+a b s t r a c t
+The significance of Nadi Pariksha is well understood and effectively used by Ayurveda practioners for
+assessing Tridoshas and various physiological and psychological states of the patient. The traditional texts
+Sarangadhara Samhita, Yoga Ratnakara, Basavarajeeyam and Bhavaprakasha have discussed the details of
+Nadi Pariksha in succinct set of slokas. Ayurveda has thousands of years of rich experience in Nadi Par-
+iksha with strong literature support but is subjective in nature and the need for studying nadi with a
+scientific approach is well understood. Recently, pulse wave velocity has gained significant research
+interest as it is considered to be a strong indicator of cardiovascular disease; however, the relevance of
+pulse wave analysis to Nadi Pariksha has not been studied. In this review, traditional methods of Nadi
+Pariksha as defined in Ayurveda classics and the recent advances in pulse wave analysis are discussed. As
+per classical texts, qualities or properties of pulse such as pulse movement (gati), speed of the pulse
+(vega), stability of the pulse (sthiratva) and hardness of the artery (kathinya) play major role in Nadi
+Pariksha and in the current review these properties were analyzed and compared with the modern pulse
+parameters namely pulse wave velocity, pulse rate variability and arterial stiffness. The significance of
+pulse wave velocity in cardiovascular studies is discussed and the need for extending these studies to
+Ayurveda is highlighted.
+© 2017 Transdisciplinary University, Bangalore and World Ayurveda Foundation. Publishing Services by
+Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
+licenses/by-nc-nd/4.0/).
+1. Introduction
+Ayurveda is well known for Nadi Pariksha and classical texts
+have emphasized its significance in assessment of Tridoshas which
+are the basis of disease diagnosis and prognosis [1e4]. There is a
+precise description of dosha predominance in the texts which can
+be sensed from specific locations on radial artery and accordingly
+vata dosha is felt at the root of the thumb which can be sensed with
+index finger, next to it is pitta dosha which can be sensed with
+middle finger followed by kapha dosha sensed by ring finger. As per
+ayurveda balanced Tridoshas represent the sound health and viti-
+ated doshas lead to diseases. According to Yoga Ratnakara all the
+diseases can be diagnosed from Nadi and it was compared with
+strings of veena playing all the ragas which signifies the importance
+of Nadi Pariksha [3]. The speed, stability and gati of the pulse vary
+with the aggravated doshas and assessing such variations with Nadi
+Pariksha is an art and science of its own. The traditional ayurvedic
+practitioners were adept in pulse based diagnosis and used to di-
+agnose the diseases effectively by just placing fingers on the radial
+artery.
+Ayurveda has rich experience in pulse based diagnosis but it is
+subjective in nature and is highly dependent on skill of the physi-
+cian. In recent past there is a growing research interest in acquiring
+the pulse from Tridosha locations and analyzing the pulse wave
+forms scientifically in the context of ayurveda. The pulse patterns of
+vata, pitta and kapha doshas were studied in detail by Upadhyaya as
+part of the clinical and experimental studies on Nadi Pariksha using
+Dudgeon Sphygmograph [5]. It was a detailed study covering the
+systematic review of ayurvedic literature, hemodynamics and sta-
+tistical analysis of pulse patterns representing vata, pitta and kapha
+doshas of normal and diseased persons. The mean pulse rate and
+mean pulse pressure were studied across vata, pitta and kapha
+doshas and the significance of pulse parameters rate, rhythm,
+* Corresponding author.
+E-mail address: girikumar.pv@gmail.com (P.V.G. Kumar).
+Peer review under responsibility of Transdisciplinary University, Bangalore.
+Contents lists available at ScienceDirect
+Journal of Ayurveda and Integrative Medicine
+journal homepage: http://elsevier.com/locate/jaim
+https://doi.org/10.1016/j.jaim.2017.10.007
+0975-9476/© 2017 Transdisciplinary University, Bangalore and World Ayurveda Foundation. Publishing Services by Elsevier B.V. This is an open access article under the CC
+BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
+Journal of Ayurveda and Integrative Medicine 10 (2019) 308e315
+volume, force, tension, character and hardness of the artery were
+analyzed in the context of ayurveda. In similar lines Vasant has
+analyzed the physiological significance of pulse parameters gati
+(movement), vega (rate), tala (rhythm), bala (force), tapamana
+(temperature), akruti (volume and tension) and kathinya (consis-
+tency of the vessel wall) across vata, pitta and kapha doshas [6].
+These initial studies accentuated the importance of the pulse
+parameters in analyzing Tridoshas in more scientific way compared
+to qualitative analysis. In this review the pulse measuring locations
+used in Tridosha analysis were highlighted and qualities or prop-
+erties of Nadi as explained in ayurveda classics were discussed. The
+physiological significance of qualities of Nadi was analyzed and
+compared them with the modern pulse parameters which includes
+pulse wave velocity, arterial stiffness and pulse rate variability.
+Recent advances in pulse wave analysis were highlighted and the
+relevance of pulse wave analysis techniques to Nadi Pariksha was
+underscored. As part of the review various pulse measuring in-
+struments used in current research and its application to Tridosha
+analysis were discussed. Traditional practices in Nadi Pariksha were
+manual and there were no instruments available for measuring the
+pulse whereas modern pulse wave analysis makes use of in-
+struments both in clinical and research applications. In this review
+the role of modern instruments in studying the traditional pulse
+parameters was discussed.
+The ancient texts of ayurveda were included in the study of Nadi
+Pariksha. The ayurveda texts included were Sarangadhara Samhita,
+Yoga Ratnakara, Basavarajeeyam and Bhavaprakasha. Nadi Vijnana
+by Upadhyaya and Secrets of the Pulse by Vasant were also included
+in the study of traditional practices of Nadi Pariksha. A detailed
+search was undertaken using key words Nadi, Nadi Pariksha in
+pubmed, google scholar, science direct and google. The search
+yielded only six papers which discussed Nadi Pariksha [7e13] as per
+classical texts and there were no papers discussing the relevance of
+recent advances in pulse wave analysis to Nadi Pariksha which
+underlines the need for a comprehensive review of Nadi Pariksha.
+2. Pulse parameters
+Traditionally Nadi Pariksha was done by sensing the pulse at
+three locations on radial artery and assessing doshas from palpation
+of the pulse. The qualities or properties of the Nadi are vital in
+assessing doshas as part of Nadi Pariksha. The classical texts have
+emphasized the significance of gati, a unique quality of the pulse, as
+part of Nadi Pariksha and as per texts gati plays a key role in disease
+diagnosis [1e4]. There is no equivalent term for gati in modern
+medicine and pulse movement is the closely matching term in
+modern medicine which can be associated to gati. There are many
+other qualities of pulse apart from gati (pulse movement) which
+texts have highlighted and in this review the gati and other quali-
+ties of pulse were discussed in detail.
+As per Ashtanga Hridayam guru (heavy), manda (slow), hima
+(cold), snigdha (unctuous), slakshna (smooth), sandra (solid), mridu
+(soft), sthira (stable), sukshma (subtle), visada (non slimy) and their
+opposites laghu (light), tikshna (quick, fast), usna (hot), ruksha (dry),
+khara (roughness) drava (liquid), kathina (hard), cala (moving),
+sthula (big), picchila (slimy) are twenty qualities or gunas which
+play key role in disease diagnosis and specifically in assessing
+doshas [14]. The qualities of pulse also need to be understood from
+these properties and the review of classical texts revealed that the
+texts have used the terms manda (slow), vega (fast), sthira (stable),
+capala (unstable), kathina (hard), sukshma (subtle) and picchila
+(slimy) while explaining the qualities of pulse [1e4]. The texts have
+explained the significance of the pulse properties, but in qualitative
+manner which is subjective in nature and the need for quantitative
+description of these properties is well understood in the light of
+evidence based research. This necessitates the review of pulse
+properties defined in classical texts with a view to understand the
+physiological significance of the pulse and identify the modern
+pulse parameters which can be associated to the traditional pulse
+properties.
+The qualities manda (slow), vega (fast), sthira (stable), capala
+(unstable) and kathina (hard) are of research significance as these
+qualities or properties are measurable and can be associated to
+modern pulse parameters. The terms manda (slow) and vega (fast)
+correspond to the speed or velocity of the pulse and in Sar-
+angadhara Samitha while explaining Nadi Pariksha vidhi the term
+vega is used for increased pulse rate and ksheena and manda are the
+terms used for decreased pulse rate [4]. The term vega can be
+closely associated to speed of velocity of the pulse and can be
+associated to modern pulse parameters such as pulse rate and pulse
+wave velocity.
+The stability of the pulse has been dealt with in detail in the
+texts while explaining Nadi Pariksha and the texts have used terms
+sthir (stable) and capal (unstable) while explaining the stability of
+the pulse [3,4]. The stability is referred as sthiratva in doshadi vij-
+naniya
+adhyaha
+(sutrasthana)
+of
+Ashtanga
+Hridayam
+while
+explaining prakruta dosha karma [14]. The texts have not used the
+term sthiratva while explaining Nadi Pariksha but this term can be
+used to represent the stability of the pulse and can be closely
+associated to modern parameter pulse rate variability. As stable
+pulse is more rhythmic in nature the term tala which corresponds
+to rhythm can also be used to represent stability of the pulse and
+Vasant has used the term tala in Secrets of the Pulse [6]. In this re-
+view the term sthiratva has been used to represent the stability of
+the pulse as it is used in most of the classical texts.
+The texts have used the term kathinya to explain the hardness of
+the artery and reference to kathinya is available only in Basavar-
+ajeeyam. In dviteeya prakarana of Basavarajeeyam while explaining
+the signs of mrityu nadi the term kathinya has been used and in
+triteeya prakarana of Basavarajeeyam the term kathinya is used to
+explain the nature of kapha [1]. The term kathin (hard) represented
+as kathinya corresponds to hardness of the artery and can be closely
+associated to modern pulse parameter arterial stiffness. Vasant [6]
+has used the term consistency of the vessel wall to explain kathi-
+nya whereas Upadhyaya [5] has used the term condition of the
+vessel wall for the same. In this review the term hardness of the
+artery is used to represent kathinya and is associated to arterial
+stiffness which is measurable and has research significance.
+In summary gati (pulse movement), vega (speed of the pulse),
+sthiratva (stability of the pulse) and kathinya (hardness of the ar-
+tery) are identified as measurable qualities of Nadi which can be
+closely associated to modern pulse parameters pulse movement,
+pulse wave velocity, pulse rate variability and arterial stiffness
+respectively. In this review the qualities of Nadi have been dis-
+cussed in line with the modern pulse parameters with a view to
+bring out the physiological significance behind Nadi Pariksha.
+2.1. Gati (pulse movement)
+The dosha predominance can be well assessed with gati which is
+a very unique way of diagnosis in ayurveda wherein the movement
+of the pulse has been compared with the movement of animals,
+birds and reptiles. According to the texts the movement of vata
+pulse, well known as sarpa gati, will be curved resembling move-
+ment of snake (sarpa) and leech (jaluka). The curved and zigzag
+nature of movement is the significance of vata pulse and in Basa-
+varajeeyam the vata pulse has been explained to be of vakra and
+kutil in nature which signifies the curved movement [1]. Bhavap-
+rakasha has not compared the gati with the movement of animals
+or birds but similar to Basavarajeeyam explained it to be of vakra in
+P.V.G. Kumar et al. / Journal of Ayurveda and Integrative Medicine 10 (2019) 308e315
+309
+nature [2]. The movement of pitta pulse, well known as manduka
+gati, was compared with the movement of frog which will be
+hopping and jumping in nature and was explained with the words
+capal and utplutya which signifies the jumping nature. The slow
+movement (manda gati) is the significance of kapha pulse, well
+known as hamsa gati, which has been compared with the move-
+ment of swan. The ayurveda texts have explained the gati of the
+pulse when more than one dosha is present and according to the
+texts gati will be of sarpa and manduka in nature if both vata and
+pitta doshas are in aggravation, similarly it will be of sarpa and
+hamsa in nature if vata and kapha doshas are in aggravation and will
+be of manduka and hamsa in nature if pitta and kapha doshas are in
+aggravation. It is quite evident from the texts that gati plays a sig-
+nificant role in assessing the dosha predominance and traditional
+ayurveda doctors were adept in assessing gati from nadi.
+2.1.1. Pulse movement
+The traditional practice of assessing gati has been in practice for
+thousands of years but it is very subjective in nature and in the
+current context of evidence based research it is important to assess
+the nature of gati in scientific manner with a clear understanding of
+its physiological significance. Upadhyaya as part of his clinical and
+experimental studies on Nadi Pariksha discussed the physiological
+significance of gati from rate, volume and character of the pulse and
+according to him vata pulse signifies the rate of the pulse to be fast,
+volume to be small and character to be curvilinear resembling sarpa
+gati, if the rate is slow, volume to be high and character is of
+jumping in nature it resembles pitta pulse and slow rate with vol-
+ume in between vata and pitta resembles kapha pulse [5]. In
+another study by Joshi, nadi patterns of healthy and diseased per-
+sons were analyzed using computational models with promising
+results [12]. These initial studies highlight the physiological sig-
+nificance of gati but needs thorough validation to establish the
+physiological significance of gati and its nature across Tridoshas in
+various states of the health. As it is quite evident from the texts that
+gati plays an important role in assessing dosha, it is utmost
+important that current research in ayurveda should focus on the
+ways of validating gati in a measurable way.
+2.2. Vega (speed of the pulse)
+The speed of the pulse is another aspect which ayurveda has laid
+much importance in understanding various physiological, psycho-
+logical and pathological states of the person. According to Sar-
+angadhara and Bhavaprakasha [2,4], the increase in lust and anger
+result into fast nadi and on the other hand nadi will be slow due to
+the increase in sorrow and fear. Sarangadhara has related the speed
+of the nadi to digestive fire and said nadi will be fast when the
+digestive fire is active and will be slow when the digestive fire is
+weak. Traditionally ayurveda doctors used to assess speed of the
+pulse from nadi but now with the advent of bio medical in-
+struments measuring the speed of pulse has become simple and
+sophisticated. The pulse rate is well known measure of the speed of
+pulse and has been widely used in clinical practice which gives
+initial assessment of state of the health but warrants the need for
+further investigations to diagnose the disease. Pulse wave velocity
+is another parameter with significant research interest and can be
+associated to vega and there is a need to study this parameter in the
+context of ayurveda.
+2.2.1. Pulse wave velocity
+The blood flows faster in aorta compared to peripheral network
+and the speed varies from meters per second in aorta to mm per
+second in peripheral network. The velocity of the pulse wave is
+termed as pulse wave velocity (PWV) and normally ranges from 5
+to 15 m/s. In the recent past pulse wave velocity (PWV) is consid-
+ered as an indicator of cardiovascular risk and has gained signifi-
+cant research interest [15]. The longitudinal studies have shown
+that aortic PWV is a strong predictor of future cardiovascular events
+and all cause mortality [16]. The longitudinal studies on aortic and
+carotid stiffness in predicting the cardio-vascular disease are listed
+in Table 1 [17]. The European Society of Hypertension and European
+Society of Cardiology has suggested a threshold exceeding 12 m/s as
+a conservative estimate of significant alterations in aortic function
+of hypertensive patients and later the threshold has been adjusted
+to 10 m/s considering the true anatomical distance traveled by
+pulse wave [18]. The studies on the subjects with hypertension, end
+stage renal disease and geriatrics have confirmed the predictive
+value of aortic PWV especially in assessing the cardiovascular
+events [19e21].
+The studies have shown significant results with pulse wave
+velocity in modern medicine and in the context of ayurveda the role
+of PWV in Tridosha analysis need to be explored. The pulse wave
+velocity may not be directly related to vega defined in traditional
+text but can be closely associated to it and the variations in doshas
+can be studied by measuring the pulse wave velocity. The dosha
+predominance has been discussed in classical texts of ayurveda and
+according to the texts kapha dominance can be seen in childhood,
+pitta dominance in middle age and vata dominance in old age.
+Secondly as per ayurveda nature of vata corresponds to fastness,
+pitta corresponds to medium speed and kapha corresponds to
+slowness. The studies have shown that the pulse wave velocity
+measured using carotid femoral technique increases with age and
+hence pulse wave velocity can be considered as an important pulse
+parameter in studying dosha dominance and classifying doshas.
+Carotid femoral technique is gold standard and as a first step it can
+be used to study the pulse wave velocity in the context of Tridosha
+analysis.
+2.3. Sthiratva (stability of the pulse)
+The ayurveda classics have discussed the stability of the pulse in
+detail with a mention of intermittent nadi which will be sometimes
+slow, sometimes fast and sometimes stops in between. Basavar-
+ajeeyam has used the term sthitva sthitva to explain the intermittent
+pulse while explaining the qualities of sannipatha nadi [1]. As per
+the texts nadi which is intermittent in nature and is sensed in the
+locations other than the specified place indicates to be fatal which
+may lead to early death of the patient. Basavarajeeyam [1] and Yoga
+Ratnakara [3] have termed it as asadhya nadi and as per Basavar-
+ajeeyam it is the nature of mrityu nadi also. The stability of the pulse
+Table 1
+Longitudinal studies on aortic and carotid stiffness.
+Measurement site
+Type of patient (Reference)
+Follow
+up (years)
+Mean
+age
+Aortic PWV (Regional
+arterial stiffness)
+End Stage Renal Disease [19]
+6
+51
+Hypertension [21]
+9.3
+50
+Elderly (>70) [20]
+2.5
+87
+End Stage Renal Disease [48]
+5.2
+55
+Hypertension [29]
+5.7
+51
+Impaired Glucose Tolerance [49]
+10.7
+51
+Hypertension [50]
+7.9
+51
+Elderly [51]
+4.6
+74
+General Population [15]
+10
+64
+General Population [52]
+9.4
+55
+Elderly [53]
+4.1
+72
+Ascending aorta
+(invasive)
+Recurrent acute Coronary Heart
+Disease [54]
+3
+55
+Carotid stiffness
+(local stiffness)
+End Stage Renal Disease [55]
+2.1
+58
+End Stage Renal Disease [56]
+7.9
+43
+P.V.G. Kumar et al. / Journal of Ayurveda and Integrative Medicine 10 (2019) 308e315
+310
+also depends on various physiological and psychological states of
+the person. According to Sarangadhara Samhita nadi will be strong
+and steady in healthy persons and the nadi of a hungry person will
+be irregular when compared to that of a person who has just taken
+the food [4].
+2.3.1. Pulse rate variability
+Traditionally rhythm of the pulse is felt from the palpation of the
+pulse which is more qualitative in nature but with instruments it is
+possible now to acquire the pulse as time series enabling the
+rhythm of the pulse to be analyzed in quantitative manner. In the
+recent past there is a growing research interest in studying pulse
+rate variability (PRV) as surrogate marker of heart rate variability
+(HRV) [22e24]. There are no equivalent terms in traditional texts
+which can be compared with PRV but intermittent nadi can be
+closely associated to PRV as the nature of intermittent nadi can be
+well understood by looking into pulse rate variability and missing
+peaks, beat to beat alterations in pulse interval are some of the
+important parameters which can explain the intermittent nadi. The
+beat to beat alterations of the pulse wave acquired using Nadi
+Tarangini showed significant variations across different age groups
+and disorders [25]. The arterial pulse intervals (API), analyzed
+across time domain, frequency domain and non linear measures
+showed significant variations across age and disorders [26]. The
+stability or rhythm of the pulse has a significant role in Nadi Par-
+iksha but there was no detailed description in the texts about its
+association with Tridoshas. As the pulse acquisition has become
+much more sophisticated there is a need to study the association of
+pulse rate variability with Tridoshas. An indepth study of inter-
+mittent nadi is the need of the day as it is considered to be serious
+as per the texts and extending PRV analysis to Tridoshas can be a
+significant step in Nadi Pariksha.
+2.4. Kathinya (hardness of artery)
+The hardness of the artery is closely associated to kathinya and
+only Basavarajeeyam has discussed the nature of kathin nadi in
+detail [1]. As per Basavarajeeyam vata nadi will be hard and the
+hardness of the artery has been explained with the words kathor
+and kathin whereas the hardness of the artery due to pitta and
+kapha doshas was not mentioned. The hardness (kathin) and
+roughness (khara) of the artery corresponds to vata dosha as per
+ayurveda and Basavarajeeyam compared vata nadi with string of
+veena which signifies the hardness of the vata nadi. The blood flow
+in hardened arteries will be fast compared to normal arteries which
+implies that vata pulse will be fast which is in agreement with
+ayurveda. According to Basavarajeeyam if nadi is kathin, very slow
+moving in a curved manner, if it is displaced from its original po-
+sition then it is considered as mrityu nadi and is an indicator for
+early death of the patient.
+2.4.1. Arterial stiffness
+The arteries stiffen due to age and atherosclerosis and recently
+the arterial stiffness measured from pulse wave velocity (PWV) has
+gained significant research importance as it is considered to be
+strong predictor of cardio-vascular events [16,27] and Alberto et al.
+have discussed in detail the role of arterial pulse wave analysis in
+cardiovascular risk assessment [28]. A longitudinal study by Bou-
+touyrie provides the first direct evidence that the aortic stiffness is
+an independent predictor of primary coronary events in hyper-
+tensive patients [29] and in another independent study by Laurent,
+the aortic stiffness is confirmed to be in an independent predictor
+of all cause and cardiovascular mortality in hypertensive patients
+[21]. The pulse wave velocity, a surrogate measure of arterial
+stiffness, closely corresponds to the description of mrityu nadi.
+The stiffness index (SI) is a measure of arterial stiffness and is
+measured from radial artery which closely corresponds to the
+volume pulse measured using photoplethysmograph (PPG). The SI
+measured from digital volume pulse (DVP) of PPG is strongly
+associated to cardiovascular risk score emphasizing the significance
+of its utility in cardiovascular risk stratification [30]. In our previous
+study we have seen that the SI measured from radial artery using
+Nadi Tarangini, a pulse acquisition system, has shown significantly
+high values at vata location for diabetes compared to non-diabetes
+and SI was negatively correlated to fasting plasma glucose in non
+diabetes subjects [31]. The study has shown SI at pitta location was
+significantly high compared to vata and kapha locations which
+might be due to the fact that the average age of the subjects both in
+diabetes and non-diabetes groups is around 50 years a pitta
+dominant age. Nadi Tarangini has three linearly placed pressure
+transducers which can be placed on the Tridosha locations of radial
+artery and the pulse will be acquired from vata, pitta and kapha
+locations. The advantage of such a system is that the arterial stiff-
+ness measured from three locations can be analyzed simulta-
+neously and initial studies with Nadi Tarangini have shown that the
+arterial stiffness varies significantly across vata, pitta and kapha
+locations. The pressure wave as it propagates from central to pe-
+ripheral arteries gets amplified at peripheral artery due to multiple
+reflections from various reflection sites and the reflection sites are
+closer to peripheral arteries when compared to central arteries. As a
+result due to the pulse amplification, peripheral arteries do not give
+accurate results in cardiovascular studies and hence the arterial
+stiffness measured from peripheral arteries was not used as a sur-
+rogate for aortic and carotid stiffness [17] and there are very limited
+cardiovascular studies with radial artery. As radial artery plays a
+major role in ayurveda, SI measured from radial artery can be
+considered as significant parameter in Tridosha analysis. As the
+significance of arterial stiffness is well understood from the texts of
+ayurveda and also from the recent studies, there is a need to study
+the arterial stiffness in the context of Tridosha analysis.
+3. Pulse locations
+Ayurveda has laid much emphasis on sensing the pulse at radial
+artery primarily to assess doshas but it has not limited the pulse
+location to just radial artery but has clearly defined that the pulse
+can be sensed from eight locations. The classical text Basavar-
+ajeeyam has mentioned about eight locations to sense nadi and
+accordingly there are two at radial artery, two at ankle, two at neck
+region and two at nasal region [1]. It is also mentioned that the
+knowledge of vata, pitta and kapha doshas can be obtained from
+radial artery and Nadi Pariksha based on radial artery has been
+widely practiced as it is important to assess Tridoshas for any dis-
+ease diagnosis and treatment. Though radial artery plays a major
+role in disease diagnosis and treatment, nadi at neck and nasal
+regions was also considered as important nadi in diagnosis and
+prognosis of disease. The fear, sorrow, anger, lust and fever are
+some of the symptoms which can be sensed from the nadi at neck
+and similarly the diseases pertaining to head, eyes and ears can be
+diagnosed from the nadi at nose. The status of life and health, fever
+and its relief are sensed from nadi at ankle. It is evident from the
+literature of Ayurveda that nadi pariksha has a major role in disease
+diagnosis and is not limited to radial artery but extended to other
+arteries.
+As per modern physiology pulse is palpated at radial, carotid,
+femoral, brachial and ankle arteries and this is in line with the
+description in ayurveda except that there was no mention of
+femoral artery in ayurveda and arteries at nasal region in modern
+physiology are not highlighted. The significance of radial artery
+based pulse diagnosis is well understood in ayurveda and has been
+P.V.G. Kumar et al. / Journal of Ayurveda and Integrative Medicine 10 (2019) 308e315
+311
+widely practiced but the nadi at other locations are not explored
+much. On the other hand the radial artery has a very limited role in
+modern medicine and is limited to just measuring the pulse rate
+whereas they have given much emphasis on carotid, femoral,
+brachial and ankle arteries which were widely used in measuring
+the pulse wave velocity.
+4. Pulse measurement techniques and instruments
+The pulse parameters and their analysis play key role in disease
+diagnosis in both ayurveda and modern medicine. In the evidence
+based research, pulse measurement techniques and the in-
+struments used for such measurements are very critical. There are
+multiple pulse measurement techniques for assessing arterial
+stiffness from central and peripheral arteries. The pulse wave ve-
+locity and stiffness index are measures of arterial stiffness and
+techniques are developed to assess arterial stiffness from pulse
+wave velocity and stiffness index. The standard pulse wave velocity
+measurement techniques are carotid femoral pulse wave velocity
+(cfPWV) and brachial ankle pulse wave velocity (baPWV). The ca-
+rotid and femoral arteries are used for pulse wave velocity mea-
+surement in carotid femoral pulse wave velocity (cfPWV) technique
+whereas brachial and ankle arteries are used for pulse wave ve-
+locity measurement in brachial ankle pulse wave velocity (baPWV)
+technique. Stiffness Index (SI) is measured from the radial artery. In
+this section pulse measurement techniques and instruments used
+for measurement were discussed.
+4.1. Carotid femoral pulse wave velocity (cfPWV) technique
+The measurement of pulse wave velocity using carotid femoral
+pulse wave velocity is the standard technique and is considered to
+be non invasive, robust and reproducible method for assessing the
+arterial stiffness [32]. The carotid femoral pulse wave velocity
+(cfPWV) has gained significant research interest in the recent past
+and the pulse wave velocity measured with cfPWV technique is
+considered as gold standard [18]. In cfPWV technique pulse wave
+will be obtained at carotid and femoral arteries and the distance
+between these two arteries will be recorded. The pulse wave ve-
+locity, a surrogate measure of arterial stiffness, is considered as the
+ratio of distance between carotid and femoral arteries to the time
+taken for the pulse to travel from carotid to femoral arteries [32].
+Pulse Wave Velocity ¼ Distance/pulse transit time from carotid to
+femoral
+The advantage with the cfPWV is that it is a gold standard but
+the process of measuring the arterial stiffness requires good
+amount of skill in acquiring the pulse [33]. The cfPWV technique is
+a non invasive, robust and reproducible method and is widely used
+in epidemiological studies [32].
+The pulse transit time and measurement of distance between
+carotid and femoral arteries need to be understood while assessing
+pulse wave velocity using cfPWV. The pulse transit time is
+measured using foot to foot method wherein foot is considered to
+be the end of the diastole. The distance between carotid and
+femoral arteries is measured physically and is considered as an
+estimate of the true distance traveled by the pulse wave but the
+inaccuracies in the distance measured may lead to errors in the
+absolute value of PWV. As the true distance traveled by the pulse is
+critical for PWV it is recommended that the distance from carotid
+artery to sternal notch is subtracted either from the total distance
+between carotid and femoral arteries or from the distance between
+sterna notch to femoral artery [32].
+4.2. Carotid femoral pulse wave velocity (cfPWV) measuring
+instruments
+There are number of devices available today to measure the pulse
+wave velocity using cfPWV technique. Complior from Alam Medical,
+SphygmoCor from Atcor Medical, PulsePen from Dia Tecne, Vasera
+from Fucuda Denshi Co Ltd, Vicorder from Skidmore Medical Ltd are
+some of the instruments used for measuring the pulse wave velocity
+[34]. Complior and SphygmoCor are widely used in PWV based
+studies [35] and the way pulse transit time and distance between
+arteries are computed varies between these two devices.
+The Complior (Alam-Medical, France) is based on pressure
+transducers and the pulse at carotid and femoral arteries is ac-
+quired simultaneously. The correlation algorithm is applied be-
+tween the two simultaneous pulse recordings to determine the
+pulse transit time. The distance traveled by pulse is obtained by
+directly measuring the distance between carotid and femoral ar-
+teries [32,35].
+In the SphygmoCor system (Artcor, Sydney, Australia) high fi-
+delity applanation tonometers are used for pulse acquisition and
+the pulse is acquired at carotid artery along with the ECG recording
+followed by femoral pulse acquisition with simultaneous ECG
+recording. The pulse transit time is computed by subtracting the
+time difference between ECG and carotid pulse peak from the time
+difference between ECG and femoral pulse peak. The distance
+traveled by the pulse is computed by subtracting the distance be-
+tween sternal notch to carotid artery from the distance between
+sternal notch to femoral artery [32,35].
+The PulsePen [34] is another device which uses two methods in
+assessing the pulse wave velocity. In the first method two tonom-
+eters are used and the pulse is acquired simultaneously at both
+carotid and femoral arteries. This is similar to the method used in
+Complior. In the second method only one tonometer is used
+wherein pulse is acquired from carotid and femoral arteries sepa-
+rately and synchronized with ECG. This method is similar to
+SphygmoCor.
+The Vasera [34] uses cardio-ankle vascular index (CAVI) as an
+index for arterial stiffness measurement but this device needs
+further validation. The Vicorder [34] is similar to Complior but the
+algorithms used are not clear and this device also needs further
+validation.
+There are many other devices and methods used in assessing
+arterial stiffness and the abridged version of expert consensus
+document on arterial stiffness has summarized them [32]. Apart
+from the standard non imaging techniques the ultrasound and
+Magnetic Resonance Imaging (MRI) are the imaging methods used
+in assessing pulse wave velocity using which the path length can be
+directly measured which is the biggest advantage but is very
+expensive solution [36]. Recently many devices have come to the
+market but it is important to verify the scientific validity of such
+instruments before using them in research [34].
+4.3. Brachial ankle pulse wave velocity (baPWV) technique
+The brachial ankle pulse wave velocity (baPWV) is another
+technique introduced in Japan in 2000 to measure the pulse wave
+velocity from brachial and ankle arteries [37] The complexities
+involved in arterial stiffness measurement with cfPWV technique
+have been addressed in baPWV. The pulse wave velocity is
+measured in baPWV by connecting volume plethysmographic
+sensors to the cuffs connected to brachial and ankle locations. The
+pulse wave velocity is computed as the ratio of virtual arterial
+length between these two arteries to the pulse transit time from
+brachial to ankle arteries [37]. The virtual arterial length is
+P.V.G. Kumar et al. / Journal of Ayurveda and Integrative Medicine 10 (2019) 308e315
+312
+estimated from the height of the subject which eliminates the need
+for physically measuring the distance between arteries [38].
+The virtual arterial length is computed as shown below.
+Path length from heart to brachium (Lb) ¼ 0.2195*height of the person
+(cm)  0.20734
+Path length from heart to ankle (La) ¼ 0.8129*height of the person
+(cm) þ 12.238
+Virtual arterial path length ¼ La  Lb
+The pulse acquisition and physical distance measurement have
+been extremely simplified in baPWV due to which it has gained
+significant clinical interest but there are number of questions and
+concerns on the measurement of arterial stiffness using baPWV
+which Sugawara has addressed thoroughly in his review [37]. The
+height based arterial path length computation grossly over-
+estimates the actual path length resulting in overestimation of
+PWV values when compared with the arterial path length
+measured using MRI [39] but height based path length can be
+converted to actual length with an adjustment factor as PWV
+measured from height based path length is linearly correlated to
+PWV measured from actual path length [37]. As the baPWV tech-
+nique is simple to use and pulse wave velocity is strongly correlated
+to pulse wave velocity measured using cfPWV, it has gained much
+of clinical and research interest and number of studies have been
+done using this technique [37,40e42].
+4.4. Brachial ankle pulse wave velocity (baPWV) measuring
+instruments
+There are not many devices available for measuring pulse wave
+velocity using baPWV technique and AT-form PWV/ABI (Colin,
+Kamaki, Japan) and VP-2000 (Colin, Kamaki, Japan) are the devices
+widely used by researchers for measuring pulse wave velocity. The
+baPWV measuring devices consist of volume plethysmographic and
+oscillometric sensors, electrocardiogram and phonocardiogram. The
+volume pulse is measured using volume plethysmographic sensors,
+blood pressure is measured using oscillometric sensors, electrocar-
+diogram is used to synchronize pulse at brachial and ankle arteries
+and phonocardiogram is used to detect the heart sound. In baPWV
+pulse wave velocity is measured by connecting volume plethysmo-
+graphic sensors to the cuffs connected to brachial and ankle [40].
+4.5. Stiffness index from radial artery
+The arterial stiffness can be measured from radial artery also but
+the mechanism to measure
+the stiffness
+is different when
+compared to cfPWV and baPWV techniques. The pulse wave ac-
+quired from radial artery is composed of forward and reflected
+waves as shown in Fig. 1 wherein a peak appears in the forward
+wave during systolic phase of the pulse and a peak corresponding
+to reflected wave appears in diastolic phase of the pulse. The time
+taken for diastolic peak from the systolic peak depends on the
+stiffness of the arteries and height of the person. Hence stiffness
+index (SI) is measured as the ratio of height of the person to the
+time difference between systolic and diastolic peaks [43]. The pulse
+wave measured from radial artery is closely associated to the digital
+volume pulse measured from PPG and is related to it by a transfer
+function [44]. Hsein-Tsai have demonstrated the significant corre-
+lation between the stiffness index measured using PPG and radial
+artery [43]. Initial studies have shown promising results with radial
+artery but the significance of arterial stiffness measured from radial
+artery yet to be established. As per ayurveda kathinya is closely
+associated to arterial stiffness and there is a need to extend the
+studies on arterial stiffness to Tridosha analysis.
+4.6. Stiffness index from radial artery
+The sensor and semiconductor technologies have advanced
+further and precise pulse acquisition systems are available to
+measure the pulse at radial artery which resulted in resurgence of
+traditional Tridosha analysis in a more scientific manner. Nadi Tar-
+angini [45], Nadi Yantra [46] and Nadi Pariksha Yantra [47] are some
+of the instruments available to acquire the pulse at Tridosha loca-
+tions simultaneously. Nadi Tarangini is a pulse based acquisition
+system based on linearly spaced pressure transducers which con-
+verts the pulse pressure to electrical signal and provides the pulse
+wave in the form of time series [45]. The pulse wave acquired using
+Nadi Tarangini is similar to digital volume pulse from PPG with clear
+systolic and diastolic peaks in place.
+As pulse measurement is well established and studies have
+shown significant results there is a need to extend these techniques
+and devices to the studies of ayurveda with a view to bring the
+physiological significance of Nadi Pariksha to limelight. The pulse
+wave velocity, pulse rate variability and arterial stiffness are some
+of the parameters which can be studied in the context of ayurveda
+and the scope can be increased further to analyze various other
+parameters which can add value to Nadi Pariksha.
+5. Conclusion
+Ayurveda has thousands of years of experience in Nadi Pariksha
+and classical texts have emphasized the significance of Nadi in
+disease diagnosis and prognosis. The texts have explained the na-
+ture of nadi and its variations in a very qualitative manner using the
+traditional parameters gati, vega, sthira, capala and kathinya. The
+traditional parameters are closely associated to the modern pa-
+rameters such as pulse wave velocity, pulse rate variability and
+hardness of the artery which was discussed in this review thor-
+oughly. It is important to study these modern parameters in the
+context of ayurveda to bring the hidden secrets of Nadi Pariksha to
+limelight. There is a dire need for extending the recent advance-
+ments in pulse measurement techniques and instruments to
+develop the framework for Nadi Pariksha and bring the scientific
+approach to pulse based diagnosis which is the need of the day.
+Fig. 1. Pulse wave acquired using Nadi Tarangini, representing various peaks and time
+periods of the radial pulse. P1 ¼ pulse amplitude at systolic peak; P2 ¼ pulse ampli-
+tude at inflection point; P3 ¼ pulse amplitude at dicrotic notch; P4 ¼ pulse amplitude
+at Diastolic Peak; Time periods T1, T2, T3, T4 are measured from start of the systolic
+phase. T1 ¼ time period at systolic peak; T2 ¼ time period at inflection point;
+T3 ¼ time period at dicrotic notch; T4 ¼ time period at diastolic peak. SI ¼ height of the
+person (cm)/(T4  T1].
+P.V.G. Kumar et al. / Journal of Ayurveda and Integrative Medicine 10 (2019) 308e315
+313
+Sources of funding
+None.
+Conflict of interest
+None
+Acknowledgments
+We express our sincere thanks to S-VYASA in supporting this
+study.
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@@ -0,0 +1,1320 @@
+Copyright @ 2008 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
+ARTICLE COVER SHEET
+LWW
+Journal of The North American Menopause Society
+FLA, EDI
+Article : GME20548
+Creator : fn02
+Date : Thursday March 27th 2008
+Time : 04:55:11
+Article Title : Treating the climacteric symptoms in Indian women with an
+integrated approach to yoga therapy
+Number of Pages (including this page) : 11
+Template Version : 2.6
+11/15/07
+Scripts:
+1. sc_Extract_Xml
+2. AssymFrame
+3. sc_Multifig_Marker
+4. Autopagination compliant
+5. sc_TwoColAff–for 2-column affiliation
+Copyright @ 2008 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
+Menopause: The Journal of The North American Menopause Society
+Vol. 15, No. 5, pp. 000/000
+DOI: 10.1097/gme.0b013e318167b902
+* 2008 by The North American Menopause Society
+Treating the climacteric symptoms in Indian women with an integrated
+approach to yoga therapy: a randomized control study
+Ritu Chattha, MSc,1 Nagarathna Raghuram, MD, FRCP,2
+Padmalatha Venkatram, FRCOG (Lond), MRCP (Ire),3 and Nagendra R. Hongasandra, ME, PhD4
+Abstract
+Objective: To study the effect of yoga on the climacteric symptoms, perceived stress, and personality in
+perimenopausal women.
+Method: One hundred twenty participants (ages 40/55 y) were randomly divided into two study arms, ie, yoga
+and control. The yoga group practiced an integrated approach to yoga therapy comprising surya namaskara (sun
+salutation) with 12 postures, pranayama (breathing practices), and avartan dhyan (cyclic meditation), whereas the
+control group practiced a set of simple physical exercises under supervision of trained teachers for 8 weeks (1 h
+daily, 5 days per week). The assessments were made by Greene Climacteric Scale, Perceived Stress Scale, and
+Eysenck’s Personality Inventory before and after the intervention.
+Results: Of the three factors of the Greene Climacteric Scale, the Mann-Whitney test showed a significant
+difference between groups (P G 0.05) in the vasomotor symptoms, a marginally significant difference (P = 0.06) in
+psychological factors but not in the somatic component. Effect sizes were higher in the yoga group for all factors.
+There was a significantly greater degree of decrease in Perceived Stress Scale scores (P G 0.001, independent
+samples t test) in the yoga group compared with controls (between-group analysis) with a higher effect size in the
+yoga group (1.10) than the control (0.27). On the Eysenck’s Personality Inventory, the decrease in neuroticism was
+greater (P G 0.05) in the yoga group (effect size = 0.43) than the control group (effect size = 0.21) with no change
+in extroversion in either the yoga or control group.
+Conclusions: Eight weeks of an integrated approach to yoga therapy decreases climacteric symptoms, perceived
+stress, and neuroticism in perimenopausal women better than physical exercise.
+Key Words: Climacteric Y Yoga Y Cognitive abilities.
+B
+ecause the average life span of women in India has
+approached 62 years, the problems of menopause
+have attained a greater significance,1 and the study of
+menopause is emerging as an issue.2 The Indian subcontinent
+is a mix of many ethnic groups and cultures where the
+perception of menopause varies and symptoms are different
+from region to region. Although the most striking feature of
+menopause is the cessation of menstruation, other biological
+and psychosocial events occur and can be classified as
+stressors or facilitators.3 A study in seven Southeast Asian
+countries (Hong Kong, Indonesia, Korea, Malaysia, the
+Philippines, Singapore, and Taiwan), in which approximately
+400 women in each country were questioned about a number
+of climacteric complaints; the prevalence of hot flashes and
+sweating was lower than in Western countries, but was
+nevertheless not negligible.4
+At menopause, some women present a clinical picture of
+not only the specificity of estrogen deficiency, such as hot
+flashes, but also a nonspecific psychological syndrome
+characterized largely by anxiety and depression.5 A cohort
+of 16,065 women ages 40 to 55 years examined the
+association between psychological distress and natural
+menopause in a community sample of African American,
+white, Chinese, Hispanic, and Japanese women participating
+in a national women’s health study. Rates of psychological
+distress were highest in early perimenopause (28.9%) and
+lowest in premenopause (20.9%) and postmenopause (22%).
+In a US sample of 170 menopausal women between the ages
+of 45 and 54, menopausal symptoms, seeking social support,
+and neuroticism accounted for 21% of the variance in rating
+menopause as stressful.6 Perimenopausal depressed women
+are more likely to report both negative life events and
+diminished self-esteem.7
+Hormone therapy (HT) holds a risk of breast cancer and a
+threefold risk of venous thromboembolism, inducing feelings
+of fear.8 A randomized, controlled study of healthy post-
+menopausal women who were taking oral HT observed that
+Received August 2, 2007; revised and accepted January 8, 2008.
+From
+1Swami Vivekananda Yoga Research Foundation,
+AQ1
+Bangalore,
+India; 2Division of Yoga and Life Sciences, Swami Vivekananda Yoga
+Research Foundation, Bangalore, India; 3Maiya Multispecialty Hospital,
+Bangalore, India; and 4Swami Vivekananda Yoga Research Foundation,
+Bangalore, India.
+Financial disclosure: None reported.
+Address correspondence to: Ritu Chattha, MSc, Division of Life
+Sciences, Swami Vivekananda Yoga Research Foundation, #19, Eknath
+Bhavan, Gavipuram Circle, Kempegowda Nagar, Bangalore, 560019,
+India. E-mail: chattha.ritu@yahoo.com; rn44@rediffmail.com
+Menopause, Vol. 15, No. 5, 2008
+1
+Copyright @ 2008 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
+stress coping did not change after estrogen therapy. The
+women in the target group were successfully treated for
+vasomotor symptoms but had significantly higher neuroti-
+cism score compared with the comparison group.9 The stress
+coping is an individual propensity and not dependent on
+specific hormonal status during menopause. Because of the
+serious adverse effects of HT, there has been a gap in the
+management of menopausal symptoms, emphasizing the need
+to develop and explore the efficacy of alternative therapeutic
+avenues that have recently demonstrated promise in alleviat-
+ing menopausal symptoms.10
+Among nonpharmacological alternative therapies that have
+been studied, one study used relaxation response in 33 meno-
+pausal women who demonstrated significant decreases in hot
+flash intensity, tension/anxiety, and depression.11 Yoga,
+developed thousands of years ago, is emerging as a form of
+mind-body medicine. An Indian study observed a remarkable
+decrease (P G 0.001) in the anxiety scores within 10 days of
+an educational yoga program for lifestyle modification and
+stress management.12 Women with emotional distress who
+participated in yoga training demonstrated pronounced and
+significant improvements in perceived stress, state and trait
+anxiety, well-being, vigor, fatigue, and depression.13 A pilot
+trial that chose eight restorative yoga poses for 8 weekly
+90-minute sessions found that the mean number of hot
+flashes per week decreased by 30.8% and mean hot flash
+score decreased by 34.2% and demonstrated the feasibility
+of teaching yoga to middle-aged women without previous
+yoga experience. The high rates of participant retention
+and satisfaction suggest that yoga is an acceptable
+intervention in the American population.14 After a 10-week
+yoga program comprising breathing techniques, postures,
+and relaxation poses designed specifically for menopausal
+symptoms, significant pre-/posttreatment improvements
+were found for severity of questionnaire-rated total meno-
+pausal symptoms, hot-flash daily interference, and sleep
+efficiency, disturbances, and quality.15 An earlier three-arm
+randomized, controlled study also showed yoga to be as
+effective as walking in reducing the vasomotor symptoms of
+menopause.16
+There are no randomized, controlled studies on yoga or
+meditation in perimenopause in Indian women. The present
+study was designed to examine the efficacy of an integrated
+approach to yoga therapy (IAYT), a nonpharmacological
+therapy that offers techniques to promote positive health at
+the physical, mental, social, and spiritual levels in alleviating
+perimenopausal symptoms.
+METHODS
+Participants
+A sample size of 108 was derived for an effect size of 0.52
+(calculated from the pre/post mean and SD values of the
+vasomotor outcome variable from an earlier study),17 with >
+at 0.05 and power at 0.8. Because the power would be lower
+for between-group analysis, a larger sample size of 120 was
+planned for the study.
+Of 201 women experiencing menopausal symptoms
+screened, 120 women (married or single) who satisfied the
+inclusion criteria of (1) age between 45 and 55 years
+irrespective of whether they were menstruating regularly
+(symptomatic women who had stopped menstruating more
+than 3 years ago were also included) and (2) a serum follicle-
+stimulating hormone (FSH) level of 15 mIU/mL or more on
+the sixth day of the menstrual cycle if the woman was
+menstruating regularly or at the time of recruitment, if the
+woman had stopped menstruating or had irregular cycles
+were selected for the study. Women who had undergone
+hysterectomy with retained ovaries were also included.
+Exclusion criteria were (1) having practiced yoga for 1
+month or more; (2) no knowledge of English; (3) less than
+high school education; (4) taking HT; (5) any surgery in past
+3 months; (6) gynecological problems such as endometriosis,
+fibroids, ovarian cysts, and prolapsed uterus; (7) hypertension
+(A-blockers or centrally acting antihypertensive drugs may
+affect vasomotor symptoms); (8) diabetes mellitus (vascul-
+opathy or autonomic neuropathy may affect vasomotor
+symptoms); (9) hypo-/hyperthyroidism, which may affect
+the sympathetic responses of climacteric; and (10) taking
+psychiatric medication.
+Source of participants
+The study was conducted at Swami Vivekananda Yoga
+Research Foundation (SVYASA), a yoga university, in
+Bangalore city. Participants were recruited from gynecolog-
+ical outpatient clinics in 14 different areas of Bangalore
+through posters, newspaper advertisements, and circulation of
+pamphlets as well as through word of mouth. Classes were
+conducted at 14 nodal centers
+AQ2
+of SVYASA in different parts
+of the city.
+Formal approval was obtained by the institutional review
+board and ethics committee of SYVASA. Signed informed
+consent was provided by each participant before recruitment
+after addressing any questions about the design of the study.
+Design
+This was a prospective, randomized, controlled trial in which
+120 participants were randomly divided into two study arms:
+one arm practiced an IAYT and the other arm practiced a set of
+physical exercises. The women who satisfied the inclusion
+criteria were registered in different nodal centers, and
+AQ3
+roll
+numbers were assigned that were randomly divided into two
+groups using a computer-generated random number table
+(www.randomizer.org) prepared for the specific number of
+participants available in the center. Participants were assessed
+for the menopausal and psychological symptoms before and
+after the eighth week of intervention. Both yoga and control
+groups were given their respective set of exercises, which
+were done for 1 hour per day, 5 days per week for 8 weeks,
+by trained instructors for both yoga and nonyoga groups.
+Blinding
+Because this was an interventional study, it could not be a
+double-blind study, but attempts were made to blind and
+2
+Menopause, Vol. 15, No. 5, 2008
+* 2008 The North American Menopause Society
+CHATTHA ET AL
+Copyright @ 2008 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
+mask wherever feasible to reduce the bias. The statistician
+who did the randomization of the serial numbers of
+participants and the final analysis was blind to the source of
+the data. The response sheets for the Greene Climacteric
+Scale (GCS), Eysenck_s Personality Inventory (EPI), and
+Perceived Stress Scale (PSS) were coded and kept away for
+final analysis and were decoded only after complete analysis.
+The questionnaires were administered by a psychologist (who
+was not involved in interacting with the participants) to the
+whole group before randomization. Care was taken to arrange
+the timing and venue of the classes for the two groups
+suitably to avoid interaction and exchange of information and
+techniques between participants of the two groups.
+Assessments
+Biochemical
+Serum FSH was used for initial screening of the women to
+satisfy one of the inclusion criteria. Blood samples for serum
+FSH levels were collected in Anand Diagnostic Laboratory,
+Bangalore. Estimation of FSH was carried out by the
+electrochemiluminescence method using Roche Elecsys
+2010 FSH kit. Per the standardization, the normal range for
+the FSH values during the follicular phase for regularly
+menstruating Indian women is 3.5 to 12.5 mIU/mL (Anand
+Laboratory FSH reference value). For the present study, a
+value greater than 15 mIU/mL was considered for the in-
+clusion criterion.18
+GCS
+The GCS is a menopause rating scale consisting of 21
+items pertaining to the psychological, somatic, and vaso-
+motor symptoms of menopause with a severity scale from 0
+to 3 (0 = not at all, 1 = a little bit, 2 = quite a bit, 3 =
+extremely). The participants were instructed to indicate the
+most appropriate severity rating according to the present state
+of their health.19 A study was conducted with Indian
+menopausal women (N = 518) in which the GCS was
+administered. The scores for psychological, somatic, and
+vasomotor symptoms were calculated using the factor
+analysis done on a larger Indian perimenopausal popula-
+tion.20 That analysis showed a slight difference from the
+factor structure derived by Greene in 1976 for a European
+population.21 The test-retest reliability of 50 menopausal
+women over a 2-week period had yielded the following
+reliability coefficients: psychological scale = 0.87, somatic
+(physical) scale = 0.84, and vasomotor scale = 0.83, which
+were statistically highly significant.22 For content validity,
+only symptoms confirmed by other factorial studies as having
+a statistically significant factor loading were included in the
+final scale.23
+PSS
+The PSS is a widely used psychological instrument for
+perception of stress. Items were designed to determine how
+unpredictable, uncontrollable, and overloaded respondents
+find their lives. The scale also includes a number of direct
+queries about current levels of experienced stress. It has 10
+questions about the feelings and thoughts during the past
+month.24 Validity and reliability of the test has been
+documented in many studies.25
+EPI
+The EPI measures two major dimensions of personality:
+extroversion and neuroticism. It is a 57-item dichotomous
+questionnaire rating the two psychological states: neuroticism
+(24 items) and extroversion (24 items) with nine questions
+for lying scores. The scoring is accomplished by aligning the
+scoring keys furnished, with the manual counting one for
+each underlined answer uncovered by the holes in the keys.
+A lying score of 5 is set as the cutoff point where inventory
+answers cease to be accepted. The test-retest reliability of the
+EPI runs between 0.84 and 0.94.26
+Intervention
+Yoga intervention
+The yoga module used for the IAYT experimental
+intervention for perimenopausal women was developed
+specifically for the purpose culled from original scriptures
+(Patanjali yoga sutras and Mandukaya karika) that highlight
+the concepts of a holistic approach to health management at
+physical, mental, emotional, and intellectual levels with
+techniques to improve mental equilibrium. All these practices
+are aimed at one common goal, ie, to Bdevelop mastery over
+modifications of the mind[ (chitta vritti nirodhahVSage
+Patanjali) through Bslowing down the rate of flow of
+thoughts in the mind[ (manah prashamana upayah
+yogahVSage Vasishta).
+T1
+Table 1 gives the list of practices:
+1.
+Sun salutation includes a flow of 12 postures combined
+with breathing and chanting.27
+2.
+Yogic breathing practices combined with simple body
+movements to achieve a slow, rhythmic breathing
+pattern, is the safest way to get mastery over the mind.28
+The principles involved in the technique of breathing
+were slow down the rate of breathing while synchroniz-
+ing the body movements with breathing, ensure that
+exhalation was longer than inhalation, and practice with
+TABLE 1.
+Practices used for the two intervention groups
+No.
+Experimental group
+Control group
+1
+Lectures on IAYT, diet, emotion
+culture, concepts and
+management of stress
+according to yogic (15 min)
+Lectures on importance of
+exercise, role of diet in
+menopause, stress, stress
+physiology (15 min)
+2
+Breathing exercises (10 min)
+Loosening practices (10 min):
+Hasta a
+ˆya
+ˆma vvasanam
+(hands in and out breathing)
+Twisting
+Hasta vista
+ˆra vvasanam
+(hands stretch breathing)
+Forward and backward bending
+Gulpha vista
+ˆra vvasanam
+(ankle stretch breathing)
+Side bending
+Vya
+ˆghra vvasanam
+(tiger breathing)
+Spinal twist
+Setu bandha vvasanam
+(bridge posture breathing)
+Toe walking
+3
+Suryanamaskara (sun salutation)
+(10 min)
+Brisk walk (10 min)
+4
+Avartan dhyanam (cyclic
+meditation) (25 min)
+Supine rest (25 min)
+IAYT, integrated approach to yoga therapy.
+AQ4
+Menopause, Vol. 15, No. 5, 2008
+3
+YOGA IN CLIMACTERIC SYNDROME
+Copyright @ 2008 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
+full awareness of the touch of the flow of air through the
+nostrils down the air passages.
+3.
+Cyclic meditation is considered to be a part of yoga that
+works directly at the mind level (Antaranga yoga), which
+is a valuable tool to reach a state of alertful rest (calming
+down or silencing the internal dialogue). Cyclic medi-
+tation is a 35-minute practice that includes a combination
+of activating and pacifying practices to reach deeper
+quietitude and equilibrium than meditating in a single
+posture.29
+4.
+The women were given lectures on the physiology of
+menopause and a healthy lifestyle including diet,
+exercise, and yogic stress management techniques. They
+were also given yogic concepts to achieve a notional
+correction to help each woman (1) recognize her ability
+to tap her inner energy, which is made of immense bliss
+that could keep up her youthful feeling and allay fears,
+(2) restore her built-in freedom to change her responses
+to situations, and (3) learn to touch the bed of silence,
+which is the source of all creativity that is essential for
+promotion of any psychological function.30
+Control intervention
+The control group practiced a set of exercises comprising
+easy (nonsweating) body movements supervised by physical
+trainers for 1 hour daily 5 days per week for 8 weeks. They
+also had lectures and individual counseling on conventional
+modern medical concepts about a healthy lifestyle including
+diet, exercise, and physiology of menopause and stress
+management techniques.
+Data analysis
+The answer sheets of the questionnaires were scored per
+the instructions in the manual by a psychologist and were
+analyzed by the statistician using SPSS version 10.0. The
+Kolmogorov-Smirnov test of normality was used. To
+compare the pre/post values, nonparametric tests (Mann-
+Whitney for between yoga and control groups and Wilcoxon
+for within-group analysis) were used for GCS as the data
+were not normally distributed and parametric tests (inde-
+pendent samples t test and paired samples t) were used for
+EPI and PSS, which were normally distributed. In view of
+the small number of dropouts, intent-to-treat analysis was
+not planned.
+The baseline values for all the variables in both groups
+were compared using an independent samples t test. Effect
+sizes were calculated to measure the magnitude of change
+after 8 weeks within and between the two groups.31 Based on
+the results of factor analysis of the GCS in the south Indian
+population,20 the first question of the GCS (BIs the heart
+beating quickly or strongly?[) was not taken into account as
+it did not contribute to any of the three factors (with nil factor
+loading). Correlations between the three factors with PSS and
+EPI were done by using Spearman_s Q test.
+RESULTS
+F1
+Figure 1 describes the trial profile. Of 120 participants,
+there were total 12 dropouts, 5 in the yoga group and 7 in the
+control group due to inability to come to the venue regularly
+(attendance 975% considered regular) because of (1)
+husband_s ill health, (2) transfer to another city, and (3)
+unexpected events in the family. The analysis was done for a
+total of 108 participants (54 in each group). The trial profile
+shows that there were only 12 dropouts from the initial group
+of 120 participants.
+FIG. 1.
+AQ5
+TABLE 2.
+Demographic data
+S no.
+AQ6
+Variables
+Yoga group
+Control group
+1
+Age, y (mean T SD)
+49 T 3.60
+48 T 4.00
+No. of women aged 40/45 y
+13
+14
+No. of women aged 46/50 y
+22
+23
+No. of women aged 51/55 y
+19
+17
+2
+W/H
+14/40
+9/45
+3
+BMI (mean T SD)
+28 T 3.4
+29 T 4
+4
+V/NV
+43/11
+45/9
+5
+Premenopausal
+No.
+FSH, mIU/mL (mean T SD)
+No.
+FSH, mIU/mL (mean T SD)
+14
+43.88 T 21.64
+16
+37.94 T 17.52
+Irregular menstrual cycles
+17
+47.16 T 23.45
+20
+38.72 T 14.94
+Menopause
+9
+83.65 T 43.59
+7
+56.90 T 20.77
+Postmenopausal
+14
+59.50 T 18.67
+11
+66.81 T 21.14
+FSH, mIU/mL (mean T SD)
+56 T 29.90
+47 T 21.5
+There is no significant difference between groups in all the variables at baseline. W/H, working/housewives; BMI, body mass index; V/NV, vegetarian/
+nonvegetarian; FSH, follicle-stimulating hormone; Premenopausal, having regular menstruation; Menopause, menopause reached between 1 and 3 years ago;
+Postmenopausal, menopause reached more than 3 years ago.
+4
+Menopause, Vol. 15, No. 5, 2008
+* 2008 The North American Menopause Society
+CHATTHA ET AL
+Copyright @ 2008 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
+T2
+Table 2 shows the demographic data. Maximum partic-
+ipation was from age group 46 to 50 years. Of the total
+participants, 87.76% were housewives, and those who
+worked were either high school teachers or bank officials.
+Baseline matching
+The baseline values were not significantly different
+between the yoga and control groups (P 9 0.01) for all the
+variables including age, serum FSH, body mass index,
+psychological, somatic, vasomotor, perceived stress, and
+extroversion except neuroticism (higher scores in the yoga
+group).
+Comparisons with normative data
+The scores in this study for psychological (6.18 T 3.48),
+somatic (6.16 T 4.25), and vasomotor (4.41 T 1.79) were
+much lower compared with those for the Scottish women
+(N = 50) with 12.33 T 6.15, 3.45 T 2.44, and 2.31 T 2.04 for
+the three factors, respectively.22 The values for extroversion
+and neuroticism in our population were also found to be
+much lower (10.77 T 3.40 and 10.51 T 4.59, respectively)
+than the normal scores (26.08 T 8.55 and 17.37 T 10.10,
+respectively) in American women. The score for PSS24 is
+higher in the present study group (17.52 T 6.38) than the
+normative values (12.60 T 6.10) for American housewives.
+GCS
+There was a significant difference (P G 0.05) between
+groups in the vasomotor factor, a marginally significant
+difference (P = 0.06) in psychological factor, and no change
+in the somatic component (
+T3
+Table 3). Within-group analysis
+showed significant improvement in all three factors in the
+yoga group (P G 0.001) and for only the psychological factor
+(P G 0.05) in the control group. Effect sizes were higher in
+the yoga group for all factors.
+PSS
+There was a significantly greater decrease in the yoga
+group compared with controls (between-group analysis) in
+PSS scores (P G 0.001) (
+T4
+Table 4). The magnitude of stress
+reduction was greater in the yoga group (effect size = 1.10)
+than in the control group (effect size = 0.27).
+EPI
+There was a greater magnitude of change in neuroticism in
+the yoga group (effect size = 0.43) than in the control group
+(effect size = 0.21), with significant differences between
+groups (P G 0.05) (
+T5
+Table 5). Within-group analysis showed a
+highly significant decrease (P G 0.001) in the yoga group and
+no change in the control group. There was no significant
+change in extroversion in either group.
+Correlations
+There was a positive correlation between FSH and age and
+a negative correlation between FSH and extroversion on the
+EPI; anxiety and depression on the GCS were positively
+correlated with PSS and neuroticism on the EPI; somatic
+symptoms on the GCS positively correlated with PSS scores,
+neuroticism, FSH, and age; and vasomotor symptoms signifi-
+cantly correlated with PSS scores and neuroticism (
+T6
+Table 6).
+DISCUSSION
+In this single-blind, prospective, randomized, two-armed
+study on 108 perimenopausal women, climacteric symptoms,
+perceived stress, and personality were assessed before and
+after 8 weeks of intervention. On the GCS, there was a
+significant difference between groups in the vasomotor
+factor, a marginally significant difference in the psycholog-
+ical factor, and no change in the somatic component. There
+was a significantly greater decrease in stress levels in the
+yoga group compared with the control group on the PSS. On
+the EPI, there was a greater change in neuroticism in the yoga
+group than in the control group. There were positive corre-
+lations between age and FSH and also between GCS, PSS,
+and neuroticism scores.
+Comparison of baseline with normative values
+The baseline values in this study on all variables were
+lower than the normative values provided in the man-
+ual,20,24,26 except on the PSS. The most prominent difference
+was in the psychological and somatic symptoms on the GCS
+and the extroversion score on the EPI.22,26 The differences in
+the scores could be explained by sociocultural differences
+between the two countries (United States and India). The
+evidence from different surveys to date indicates that
+TABLE 3.
+Greene Climacteric Scale results
+Factor
+Yoga group
+Control group
+Pa
+Effect size
+pre/post
+Pb
+Mean T SD pre
+Mean T SD post
+Mean T SD pre
+Mean T SD post
+Y
+C
+Y
+C
+Y-C
+PSY
+6.18 T 3.48
+3.65 T 2.76
+5.42 T 3.26
+4.74 T 3.04
+G0.001
+0.01
+0.83
+0.26
+0.06
+SOM
+3.45 T 2.44
+2.16 T1.74
+3.01 T 1.90
+2.16 T 2.04
+G0.001
+0.22
+0.74
+0.19
+0.19
+VAS
+2.31 T 2.04
+1.47 T 1.30
+2.16 T 1.50
+1.95 T 1.30
+G0.001
+0.24
+0.66
+0.18
+0.03
+PSY, psychological; SOM, somatic; VAS, vasomotor symptoms; Y, yoga group; C, control group.
+aWilcoxon test.
+bMann-Whitney test (only post results presented) calculated using SPSS version 10.0.
+TABLE 4.
+Perceived Stress Scale results
+Group
+Mean T SD pre
+Mean T SD post
+Pa
+Effect
+size
+pre/post
+Pb
+Effect
+size
+Y-C
+Y
+17.74 T 6.15
+11.74 T 6.15
+G0.001
+1.10
+G0.001 0.66
+C
+17.3 T 6.61
+15.63 T 5.61
+0.003
+0.27
+Y, yoga; C, control.
+aPaired samples t test.
+bIndependent samples t test.
+AQ7
+Menopause, Vol. 15, No. 5, 2008
+5
+YOGA IN CLIMACTERIC SYNDROME
+Copyright @ 2008 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
+cultural differences in vasomotor symptom perception and
+reporting reflect both the underlying biological differences
+and an important sociocultural factor of the attitude toward
+menopause.32
+Comparison with other studies on physical exercise
+and perimenopausal symptoms
+AQ8
+The control group in the present study who practiced
+physical exercises for 8 weeks demonstrated decreased
+perception of stress and the psychological symptoms.
+Physical activities of different types have been found to be
+beneficial in climacteric women. In a 4-month randomized,
+controlled exercise trial with three arms, ie, walking, yoga,
+and control, it was observed that both walking and yoga were
+equally effective in enhancing a positive affect and meno-
+pause-related quality of life and decreasing a negative
+affect.16 In another study of 50 pre- and postmenopausal
+women, the results of a 12-week exercise program provided
+only partial support for the role of aerobic exercise in
+reducing stress responses,33 although both groups achieved
+comparable improvements in aerobic fitness.
+Comparison with other studies on yoga
+There are three published studies on yoga and perimeno-
+pausal symptoms. Of these, two were pilot studies that
+showed the beneficial effect and the other was the three-
+armed study that showed no significant difference between
+walking and yoga. The present study has clearly demon-
+strated through a randomized, controlled trial the superiority
+of yoga over physical activity in managing all three
+climacteric symptoms, stress, and neuroticism. The difference
+could be in the duration and frequency of administration and
+the type of the practices in different studies. This was also
+observed by Waelde et al,34 who concluded that the duration
+and frequency of the practice of yoga seems to be important
+because the average number of minutes of weekly yoga/
+meditation practice had a positive association with improve-
+ment in depression in their study of a six-session yoga/
+meditation program designed to help caregivers of dementia
+patients cope with stress. To date, we have many studies that
+provide evidence of the role of yoga in reducing anxiety and
+depression in the normal adult and geriatric populations as
+well. In a waitlist control design, the practice of Iyengar yoga
+showed significant decreases in self-reported symptoms of
+depression and trait anxiety in 28 young adults.35 Another
+three-armed study in which IAYT was introduced to 69
+elderly institutionalized individuals showed a significant
+decrease in their scores for depression in the yoga group at
+both 3 and 6 months.36
+Mechanism of action
+Sympathetic arousal resulting in increased catecholamines
+and cortisol levels mediated through the hypothalamic-
+pituitary-adrenal axis has been recognized to be the mecha-
+nism of increased stress and anxiety and the vasomotor and
+perimenopausal syndrome. Hence, the documented evidence
+of a decrease in these neurohumors and electrophysiological
+changes of sympathetic arousal after yoga practice had been
+proposed as its mode of action.37,38
+Mechanism, stress, yoga, biochemistry (cortisol
+and F-aminobutyric acid [GABA])
+In a study that compared 20 stressed and 20 nonstressed,
+nonsmoking premenopausal women between the ages of 42
+and 52 years, the stressed women had elevated evening
+salivary cortisol levels, indicating sympathetic arousal.39
+There are randomized, controlled studies that have shown
+a significant decrease in stress levels after practicing yoga in
+participants with mild to moderate levels of stress40 and also
+a trend for higher morning cortisol levels after 5 weeks of 1-
+hour weekly Iyengar yoga classes.35 Robert McComb et al41
+in their study on resting levels of stress hormones, physical
+functioning, and submaximal exercise responses in women
+with heart disease undergoing an 8-week mindfulness-based
+stress-reduction program brought out the fact that just a once-
+weekly program of stress reduction is quite ineffective and
+fails to change stress hormone levels. An interesting study by
+Streeter et al42 suggests that the practice of yoga may reduce
+the depressive symptoms of perimenopause by increasing
+TABLE 5.
+Eysenck_s Personality Inventory results
+Variable
+Mean T SD pre
+Mean T SD post
+Pa
+Effect size pre/post
+P b
+Effect size Y-C
+Extroversion
+11.30 T 3.88
+11.31 T 2.94
+0.965
+0.00
+0.006
+0.54
+Y
+C
+10.24 T 2.92
+9.83 T 2.49
+0.315
+0.15
+Neuroticism
+9.78 T 4.36
+7.91 T 4.28
+G0.001
+0.43
+0.009
+0.51
+Y
+C
+11.24 T 4.82
+10.24 T 4.83
+0.085
+0.21
+Y, yoga group; C, control group.
+aPaired samples t test.
+bIndependent samples t test.
+TABLE 6.
+Correlation matrix
+Variable
+PSYCH
+SOM
+VAS
+PSS
+EXT
+NEU
+FSH
+Age
+PSYCH
+1.00b
+0.56b
+0.40b
+0.56b
+NS
+0.61b
+NS
+NS
+SOM
+1.00b
+0.44b
+0.41b
+NS
+0.43b
+NS
+0.21a
+VAS
+1.00b
+0.27a
+NS
+0.44b
+0.25a
+0.34b
+PSS
+1.00b
+NS
+0.48b
+0.18a
+NS
+EXT
+1.00b
+NS
+0.22
+NS
+NEU
+1.00b
+0.20a
+NS
+FSH
+1.00
+0.19a
+Age
+1.00b
+PSYCH, psychological; SOM, somatic; VAS, vasomotor symptoms; PSS,
+Perceived Stress Scale; EXT, extroversion; NEU, neuroticism; FSH, follicle-
+stimulating hormone; NS, not significant correlation.
+aP G 0.05.
+AQ9
+6
+Menopause, Vol. 15, No. 5, 2008
+* 2008 The North American Menopause Society
+CHATTHA ET AL
+Copyright @ 2008 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
+GABA levels in the brain. This study examined the GABA
+levels by measuring the GABA-to-creatinine ratio in the
+brain using magnetic resonance spectroscopy in normal adult
+yoga and nonyoga practitioners and showed a 27% increase
+in GABA levels in the yoga group after a 60-minute yoga
+session with no change after a reading session in comparison
+with a nonyoga practitioner group.
+Yoga and electrophysiology for sympathetic tone
+Reduced sympathetic tone through yogic relaxation techni-
+ques has also been documented. In a control study on guided
+yogic relaxation, significant decreases in heart rate, skin
+conductance levels, and finger plethysmogram have been
+reported. In addition, the spectral analysis of heart rate
+variability showed a decrease in low-frequency (sympathetic
+tone indicator) and an increase in high-frequency (parasympa-
+thetic tone indicator) bands, indicating decreased physiological
+arousal.43 Another study of seven experienced meditators
+studied in two types of sessions, ie, meditation (with a period
+of mental chanting of BOM[) and control (with a period of
+nontargeted thinking), there was a significant decrease in heart
+rate and an increase in the cutaneous peripheral vascular
+resistance during meditation, which is a sign of increased
+mental alertness, even while being physiologically relaxed.44
+CM and rest
+A specific type of meditation called avartan dhyanam
+(CM) was incorporated as the main practice in the present
+study based on our earlier studies in which it is shown that
+CM brings about a deep state of physiological rest. Two days
+of a stress reduction program using CM in 26 executives with
+occupational stress showed a significant decrease in the
+power of the low-frequency component of the heart rate
+variability spectrum and low frequency-to-high frequency
+ratio and breath rate.45 The oxygen consumption is consid-
+ered a general index of the metabolic rate during physio-
+logical activities.46 A significantly greater resting metabolic
+rate was found in a high trait anxious group than in a low trait
+anxious group,47 suggesting that a higher rate of oxygen
+consumption may be associated with higher anxiety.48 A
+reduction in oxygen consumption has been reported after
+meditation practices and relaxation response.43 A rarely
+quoted traditional yoga scripture (Mandukya karika) points
+to an interesting intrinsic mental phenomenon that, in a
+meditative technique that involves a series of alternating
+activity (physical movements or mental chanting) and non-
+activity (relaxation or stoppage of internal dialogue) with
+awareness, the degree of rest that follows will be deeper than
+the physiological rest achieved during only restful meditation
+in one posture and hence can facilitate stress release at deeper
+levels. During CM, the extremely slow, conscious move-
+ments of the body provide a high sense of sensitivity to grasp
+the subtle changes happening inside the body, which may go
+unnoticed in a simple meditative state.28 The practice of CM
+decreased oxygen consumption to 32% compared with the
+preceding period as well as with a reduction of 10.1% with a
+period of supine rest of equal duration.48
+Despite the emergence of a range of nonhormonal treat-
+ments for menopausal symptoms, a need still exists for safe
+and effective therapeutic options that directly target the
+underlying thermoregulatory mechanisms for women who
+want treatment but prefer to avoid hormone therapy or for
+whom hormone therapy is contraindicated.49 Thus, this study
+has shown the efficacy of integrated yoga in helping
+perimenopausal women improve their inner mastery, which
+could lead to better coping capacities, gracefully accept the
+change in their reproductive state, overcome stressors of
+aging, combat anxiety and depression, and thereby improve
+their personality to enjoy the freedom from monthly
+menstruation and divert their energies toward spiritual
+growth.
+Strength of this study
+This is the first randomized, controlled trial on yoga
+practice in Indian women of climacteric age. An objective
+measure, serum FSH level, was used as the inclusion
+criterion rather than only the subjective symptoms of
+menopausal rating scales. The types of practices for the yoga
+and control interventions were matched, and the practices
+were supervised by trained instructors for the entire period of
+the study.
+Limitations
+This randomized, controlled trial included a highly
+selective group of women, excluding those with associated
+illnesses such as diabetes and hypertension, which are
+common diseases of this age, because this would interfere
+with the uniformity of the intervention and the resultant
+conclusions. This may raise the question of generalizability
+of the application of the conclusions of this study to practice.
+Although earlier independent studies have shown the benefits
+of yoga in diabetes and hypertension,50 it will be interesting
+to design studies that would recruit perimenopausal women
+with these common problems in future studies.
+It would have been interesting to see the effect of the
+practice of IAYT if we had assessed FSH and estradiol levels
+before and after the intervention.
+Because the significant benefits found in the control group
+on the psychological factor of the GCS and PSS would lead
+to bias toward the null hypothesis in conclusions on the
+effects of yoga, inclusion of a third group who do not do any
+practice in the design of the study would shed light on the
+true treatment effects.
+Suggestions for future work
+Inclusion of vasomotor symptom diaries as another
+variable could provide more detailed information about the
+efficacy of the intervention. Functional studies to look at the
+neurohormonal changes in the brain and autonomic functions
+during mental stress challenge before and after IAYT in
+perimenopausal women would shed light on the mechanism.
+This study has shown the benefits in Indian women. It will be
+useful to conduct similar studies in other countries where
+yoga may not be available as a traditional practice.
+Menopause, Vol. 15, No. 5, 2008
+7
+YOGA IN CLIMACTERIC SYNDROME
+Copyright @ 2008 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
+Applications of the study
+Because yoga is popular as a complementary and
+alternative therapy with more than 15 million persons (more
+women) practicing yoga in the United States51 and awareness
+among general practitioners,52 this study can add to the
+scientific evidence so that gynecologists can recommend it to
+their patients instead of prescribing hormone therapy. Yoga,
+which is a self-corrective technique when popularized as a
+treatment modality, not only can prevent and treat the
+perimenopausal syndrome but also can help in preventing
+many of the stress-related problems of the modern lifestyle
+that these women are prone to after menopause. The
+philosophy and practices of yoga provide a good field of
+study for internal experimentation during the empty nest,
+postretirement phase of a woman’s life and help her to grow
+in her personality to lead a healthy and happy life.
+CONCLUSIONS
+This single-blind, prospective, randomized, controlled trial
+hasshownthatyogadecreasesclimactericsymptoms,perceived
+stress, and neuroticism in perimenopausal women better
+than physical exercise in 8 weeks. Thus, an IAYT could be
+one of the preferred nonhormonal, lifestyle-modifying regi-
+mens for perimenopausal women.
+Acknowledgments: We extend our gratitude to Dr. Ravi Kulkarni
+for his help in the statistical analysis. We thank Dr. Ramprasad of
+Anand Diagnostic Laboratory for his assistance in biochemical
+assessments. We are thankful to all the yoga teachers, especially
+Shri Dattatreya, Pankaja Sheshadri, Pushp
+AQ10
+a, and Ambika and the
+physical trainers who conducted the classes for this project and the
+women for their cooperation during the study. We are also grateful
+to the heads of the organizations that promoted the study and
+provided the facilities in which to conduct the classes in different
+locations in Bangalore.
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+Menopause, Vol. 15, No. 5, 2008
+* 2008 The North American Menopause Society
+CHATTHA ET AL
+Copyright @ 2008 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
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+chronic stress in premenopausal, middle-aged women. Psychosom Med
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+physiological responses to a two day stress management program.
+J Indian Psychol 2000;18:33/37.
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+metabolic rate influenced by anxiety in college men. J Appl Physiol
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+Gynecol 2007;196:97/106.
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+practitioner. A survey of Perth GPs. Physician 2000;29:602/606.
+Menopause, Vol. 15, No. 5, 2008
+9
+YOGA IN CLIMACTERIC SYNDROME
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diff --git a/subfolder_0/YOGA TRAINING AND MOTOR SPEED BASED ON A FINGER TAPPING TASK.txt b/subfolder_0/YOGA TRAINING AND MOTOR SPEED BASED ON A FINGER TAPPING TASK.txt
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@@ -0,0 +1,7 @@
+ 
+ 
+ 
+ 
+ 
+ 
+ 
diff --git a/subfolder_0/Yoga Improves Quality of Life and Benefi t Finding in Women Undergoing Radiotherapy for Breast Cancer.txt b/subfolder_0/Yoga Improves Quality of Life and Benefi t Finding in Women Undergoing Radiotherapy for Breast Cancer.txt
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--- /dev/null
+++ b/subfolder_0/Yoga Improves Quality of Life and Benefi t Finding in Women Undergoing Radiotherapy for Breast Cancer.txt	
@@ -0,0 +1,2610 @@
+ARTICLE
+ 
+Journal of the Society for Integrative Oncology, Vol 8, No 2 (Spring), 2010: pp 43–55 
+43
+© 2010 BC Decker Inc
+DOI 10.2310/7200.2010.0002
+Kavita D. Chandwani:  
+Department of Behavioral Science; Bob Thornton: 
+ 
+Integrative Medicine Program; George H. Perkins:  
+Department of Radiation 
+Oncology; and Banu Arun:  
+Department of Breast Medical Oncology, The Uni-
+versity of Texas M. D. Anderson Cancer Center, Houston, TX; H.R. Nagendra: 
+ 
+Swami Vivekananda Yoga Anusandhana Samsthana, Bangalore, India; and Qi 
+Wei  
+and Lorenzo Cohen:  
+Department of Behavioral Science and Integrative 
+Medicine Program, The University of Texas M. D. Anderson Cancer Center, 
+Houston, TX. 
+ 
+Presented in part at the 64th Annual Meeting of the American Psychoso-
+matic Society, March 1–4, 2006, Denver, CO; the 42nd Annual Meeting of the 
+ 
+American Society of Clinical Oncology, June 2–6, 2006, Atlanta, GA; and the 
+48th Annual Meeting of the American Society for Therapeutic Radiology and 
+Oncology, November 5–9, 2006, Philadelphia, PA. 
+ 
+Reprint requests: Lorenzo Cohen, PhD, Department of Behavioral Science, 
+Unit 1330, The University of Texas M. D. Anderson Cancer Center, 1515 
+ 
+Holcombe Blvd, Houston, TX 77030; e-mail: lcohen@mdanderson.org. 
+include fatigue, skin changes, and pulmonary symptoms. 
+Patients also report anxiety and depression before, during, 
+and after radiotherapy. 
+6 Research has also shown that can-
+cer patients who have a higher tendency to ruminate have 
+worse long-term adjustment. 
+7 
+ Importantly, physical symp-
+toms, psychological maladjustment, and distress can remain 
+signifi
+ cant problems during the fi
+ rst year after diagnosis and 
+treatment 
+8,9 
+ and may continue for 2 or more years after treat-
+ment. 
+10–13 Therefore, developing and testing behavioral pro-
+grams that can buffer some of these treatment-related side 
+effects is important for improving patient outcomes. 
+ 
+Yoga is an ancient Indian science and way of life formally 
+described by Patanjali in the treatise  
+Yoga Sutras more than 
+2,000 years ago. 
+14–16 Yoga helps in the attainment of balance, 
+ultimately leading to a healthy mind and body. 
+17 Yoga has 
+been used in India to treat disease for millennia, 
+17 and recent 
+research has shown yoga to be benefi
+ cial as a preventive and 
+therapeutic tool 
+18–20 in both healthy 
+21–24 and chronically ill 
+25–29 
+populations. 
+ 
+The fi
+ rst study of yoga in a cancer setting reported 
+improvement in QOL during and for some time immedi-
+ately after the completion of radiotherapy. 
+30 The fi
+ rst ran-
+domized trial of yoga in cancer patients found lower levels 
+of sleep disturbances in Tibetan yoga practitioners during 
+a 3-month follow-up period compared to a wait-list (WL) 
+ 
+A 
+cancer diagnosis is associated with physiologic changes; 
+the fear of death, progression or recurrence of disease, 
+changes in quality of life (QOL) and social relationships, and 
+an overall loss of sense of control 
+1–3 can lead to a high degree 
+of distress that may cause harm to recovery. Patients with 
+breast cancer usually receive multimodal treatment, includ-
+ing surgery, chemotherapy, and/or radiotherapy, over an 
+extended period of time, 
+4,5 leading to an accumulation of 
+related morbidity over time. The side effects of radiotherapy 
+ 
+Yoga Improves Quality of Life and Benefi
+ t Finding in Women 
+Undergoing Radiotherapy for Breast Cancer 
+ 
+Kavita  
+D. Chandwani, MPH, MD,  
+Bob  
+Thornton, MPH,  
+George  
+H. Perkins, MD,  
+Banu  
+Arun, MD, 
+ 
+N.V.  
+Raghuram, PhD,  
+H.R.  
+Nagendra, PhD,  
+Qi  
+Wei, MPH, and  
+Lorenzo  
+Cohen, PhD 
+ 
+This study examined the effects of yoga on quality of life (QOL) and psychosocial outcomes in women with breast cancer undergo-
+ing radiotherapy. Sixty-one women were randomly assigned to either a yoga or a wait-list group. Yoga classes were taught biweekly 
+during the 6 weeks of radiotherapy. Participants completed measures of QOL, fatigue, benefi
+ t fi
+ nding (fi
+ nding meaning in the cancer 
+experience), intrusive thoughts, sleep disturbances, depressive symptoms, and anxiety before radiotherapy and then again 1 week, 
+1 month, and 3 months after the end of radiotherapy. General linear model analyses revealed that compared to the control group, the 
+yoga group reported signifi
+ cantly better general health perception ( 
+p = .005) and physical functioning scores ( 
+p = .04) 1 week postra-
+diotherapy; higher levels of intrusive thoughts 1 month postradiotherapy ( 
+p = .01); and greater benefi
+ t fi
+ nding 3 months postradio-
+therapy ( 
+p = .01). There were no other group differences in other QOL subscales for fatigue, depression, or sleep scores. Exploratory 
+analyses indicated that intrusive thoughts 1 month after radiotherapy were signifi
+ cantly positively correlated with benefi
+ t fi
+ nding 
+3 months after radiotherapy ( 
+r = .36,  
+p = .011). Our results indicated that the yoga program was associated with statistically and clini-
+cally signifi
+ cant improvements in aspects of QOL. 
+ 
+benefi
+ t fi
+ nding, breast cancer, 
+ quality of life, yoga 
+ 
+Key words: 
+44 
+Journal of the Society for Integrative Oncology, Spring 2010, Volume 8, Number 2
+control group. 
+31 A recent randomized controlled trial in 
+women with breast cancer after chemotherapy found less of a 
+decrease in social well-being among women in the yoga group 
+(YG) than among a WL control group 
+32 
+ and more favorable 
+outcomes in overall QOL, social and emotional well-being, 
+and spirituality for a subgroup of participants not undergo-
+ing chemotherapy during the study period. A trial conducted 
+in India examined the effects of yoga versus a supportive 
+therapy/coping-preparation intervention for women with 
+breast cancer undergoing conventional treatment. Women in 
+the YG reported lower frequency and intensity of nausea and 
+anticipatory nausea following four cycles of chemotherapy 
+and better QOL and mood (depression and anxiety) by the 
+end of chemotherapy than women in the control group. 
+33 In 
+a separate series of analyses from the same study, the investi-
+gators reported a smaller decrease in natural killer (NK) cell 
+percentages from pre- to postsurgery and postchemotherapy 
+in the YG than in the control group, and NK cell percentages 
+were signifi
+ cantly higher in the YG than in the control group 
+postchemotherapy. 
+34 
+ A similar study from the same inves-
+tigators examined the effects of yoga in women with breast 
+cancer undergoing radiotherapy and found signifi
+ cantly less 
+anxiety, depression, perceived stress, and DNA damage by 
+the end of radiotherapy in the YG compared to a control 
+group receiving supportive counseling. 
+35 
+ 
+Research examining mindfulness-based stress  
+reduction 
+(MBSR), a multicomponent meditation program that includes 
+asana (yoga postures), found that MBSR was associated with 
+lower levels of total mood disturbance and distress 
+36 and that 
+the effects persisted for 6 months in a mixed cancer popula-
+tion. 
+37 
+ Another study of MBSR found signifi
+ cant improve-
+ments in mood, sleep quality, and fatigue in a mixed cancer 
+population. 
+38 All prior research was conducted once patients 
+had completed their primary cancer treatment. We were inter-
+ested in determining whether it is feasible to have patients par-
+ticipate in a yoga program during radiotherapy and to assess 
+the initial effects of the program. In addition to determining 
+yoga’s effects on general measures of QOL, including physical 
+and mental health, we were interested in determining whether 
+participating in a yoga program increases patients’ ability to 
+fi
+ nd meaning in their illness experience. Previous research 
+had found that a 10-week cognitive behavioral stress man-
+agement intervention for women with breast cancer resulted 
+in increased benefi
+ t fi
+ nding, fewer intrusive thoughts, and 
+reduced depressive symptoms. 
+39,40 
+ 
+ 
+Based on the previous research, we hypothesized that 
+participating in a yoga program during radiation treat-
+ment would improve aspects of QOL and adjustment dur-
+ing and after treatment. Specifi
+ cally, we hypothesized that 
+YG participants would report higher physical and mental 
+measures of QOL, lower levels of fatigue, better sleep qual-
+ity, fewer intrusive thoughts and avoidance behaviors, and 
+increased benefi
+ t fi
+ nding than WL participants. 
+ 
+Patients and Methods 
+ 
+Study Population 
+ 
+Women with stage 0–III breast cancer who were at least 
+18 years old; who were able to read, write, and speak English; 
+and who were scheduled to undergo radiotherapy at The 
+University of Texas M. D. Anderson Cancer Center were eli-
+gible to participate in the study. Patients who had any major 
+psychiatric diagnosis (eg, a mood or thought disorder, to 
+have a more homogeneous sample) or physical limitations 
+that would prohibit participation in the yoga program (eg, 
+lymphedema or unresolved surgical issues) were excluded. 
+M. D. Anderson’s Institutional Review Board approved the 
+protocol, and each participant provided written informed 
+consent. 
+ 
+Procedures 
+ 
+Before the start of radiotherapy, each patient underwent an 
+initial baseline (T1) assessment. Participants were then ran-
+domly assigned to either the YG or the WL control group 
+by use of minimization, a form of adaptive randomization 
+described previously, 
+41 
+ so that the groups were evenly bal-
+anced according to age, disease stage, time since diagnosis, 
+type of surgery, prior chemotherapy, and baseline scores of 
+anxiety and sleep disturbance. The T1 assessment included a 
+series of questionnaires to collect demographic information 
+and information about prior use of stress management tech-
+niques. (Four patients in the YG and two in the WL group 
+reported practicing yoga “currently” and seven in the YG and 
+nine in the WL group practiced in the past. There were no 
+statistically signifi
+ cant group differences.) Other physiologic 
+measures, including saliva and blood samples, were also col-
+lected, but those data are not presented in this article. 
+ 
+Women in the YG attended up to two 60-minute yoga 
+classes each week during their 6 weeks of radiotherapy (for 
+a maximum of 12 classes). The classes were attended by 
+only the research participants. Owing to scheduling issues, 
+the majority of women had classes in a one-on-one setting 
+with the instructor. A few women had classes in groups of 
+two. If a patient missed her scheduled class, a makeup class 
+was scheduled. Each class was taught at M. D. Anderson by a 
+trained yoga instructor who followed a manual for the yoga 
+program. Postradiotherapy assessments of the participants 
+ 
+Chandwani et al, Yoga Improves Quality of Life and Benefi
+ t Finding 
+45
+in both groups were done 1 week (T2), 1 month (T3), and 
+3 months (T4) after their last radiotherapy session. 
+ 
+Women who were assigned to the WL group were given 
+the option of attending the same yoga program as the YG 
+after the completion of the last assessment. All women 
+received a $25 gift certifi
+ cate for completing each of the four 
+main assessments. 
+ 
+Yoga Program 
+ 
+Patanjali’s  
+Yoga Sutras 
+ is accepted as the most authentic and 
+traditional text of yoga. 
+14–16 In the  
+Yoga Sutras 
+, yoga is defi
+ ned 
+as “mastery over the modifi
+ cations of the mind” (chitta vrtti 
+nirodhah). The text provides eight major techniques to 
+achieve this mastery. The goal of all of these techniques is to 
+overcome confl
+ icts of life and live in harmony with nature 
+(tato dwandwa anabhighatah). Detailed descriptions of eight 
+specifi
+ c techniques (Ashtanga) are highlighted to achieve this 
+ultimate goal. These include moral injunctions for a healthy 
+lifestyle (yama and niyama), maintaining the body in differ-
+ent postures (asanas), techniques for slowing down the rate 
+of breathing (pranayama), and four different steps of medi-
+tation (pratyahara, dharana, dhyana, and samadhi). All yoga 
+schools around the world adopt one or more of these eight 
+techniques in their yoga programs. 
+ 
+The yoga program used for this study comes from Patanjali’s 
+yoga tradition. The program was developed in collabora-
+tion with faculty from the Vivekananda Yoga Anusandhana 
+Samsthana (VYASA), a yoga research  
+foundation and university 
+in Bengaluru, India. The VYASA faculty have developed specifi
+ c 
+modules for different diseases and conditions that are used 
+in yoga therapy camps (residential and nonresidential) in 20 
+ 
+different countries. The effi
+ cacy of these modules in chronic dis-
+eases and conditions such as asthma, 
+42 arthritis, 
+43 low back pain, 
+44 
+cancer, 
+33,35,45 and others has been previously published. The 
+multidimensional module of yoga used in this study included 
+(a) preparatory warm-up movements synchronized with 
+breathing (10 minutes); (b) maintenance in selected  
+postures 
+(forward-, backward-, and side-bending asanas in sitting and 
+standing positions, cobra posture, crocodile, and half-shoulder-
+stand with support) (25 minutes); (c) deep relaxation technique 
+(in corpse posture, 10 minutes); (d) alternate-nostril breathing 
+(pranayama) (5 minutes); and (e) meditation (10 minutes) (all 
+times are approximate). The program was taught by VYASA-
+trained teachers. The movement portions of the program are 
+gentle yet allow participants to be active. 
+ 
+Participants received a 60-minute audio CD of the yoga 
+program and a manual with photographs and instructions 
+for home practice. Patients were encouraged to practice the 
+full yoga once per day outside the classes at the hospital and 
+after the end of radiotherapy. If they could not practice the 
+whole program daily, they were encouraged to practice as 
+much as possible. 
+ 
+Measures 
+ 
+General QOL was assessed using the Medical Outcomes 
+Study 36-item short-form survey (SF-36), 
+46 which assesses 
+several distinct domains over the past 4 weeks: physical 
+functioning, physical impediments to role functioning, pain, 
+general health perceptions, vitality, social functioning, emo-
+tional impediments to role functioning, and mental health 
+(alpha values ranged from 0.77 to 0.90; all internal reliability 
+estimates are for the current sample at baseline). The SF-36 
+generates two main standardized component scores: the 
+physical component score (PCS; physical aspects of QOL) 
+and the mental component score (MCS; mental health 
+aspects of QOL) 
+46 
+ with reliability estimates in the current 
+sample of greater than 0.90. Higher scores indicate a better 
+QOL, and for the PCS and MCS, the general population has a 
+mean of 50 with a standard deviation of 10. A change or dif-
+ference of 5 points or more on the PCS and MCS is consid-
+ered clinically signifi
+ cant. For the subscale scores, the range 
+is 0 to 100, and a change or difference of 10 points or more is 
+considered clinically signifi
+ cant. 
+47,48 The PCS and MCS were 
+the primary outcome measures. A general measure of QOL 
+was chosen over a disease-specifi
+ c measure as women at this 
+stage of treatment are generally doing relatively well in terms 
+of their QOL, and we did not want to have a ceiling effect. 
+ 
+Fatigue was assessed using the Brief Fatigue Inventory 
+(BFI), 
+49 a nine-item questionnaire in which participants rate 
+the severity of their fatigue at that moment and how much it 
+interfered with their lives during the previous 24 hours. An 
+average score is calculated, with higher scores representing 
+worse fatigue; the range is 0 to 10 (alpha = 0.94). 
+ 
+Sleep disturbances were assessed using the Pittsburgh 
+Sleep Quality Index (PSQI), an 18-item self-rated question-
+naire that assesses sleep disturbances over the past month. 
+50 
+A total score and seven subscales were derived; they included 
+subjective sleep quality, sleep latency, sleep duration, habitual 
+sleep effi
+ ciency, sleep disturbances, use of sleep  
+medications, 
+and daytime dysfunction. Higher scores  
+represent worse 
+sleep quality, and scores greater than 5 are often reported by 
+patients attending a sleep disorders clinic. 
+ 
+Symptoms of depression were assessed using the Center 
+for Epidemiologic Studies Depression Scale (CES-D), 
+51 
+a 20-item self-report measure of depression that focuses 
+on depressive feelings and behaviors over the past week 
+(alpha = 0.87). Scores range from 0 to 60, with higher scores 
+representing worse symptoms. Scores of 16 and above are 
+46 
+Journal of the Society for Integrative Oncology, Spring 2010, Volume 8, Number 2
+cancer, time since diagnosis, type of surgery, prior chemo-
+therapy, and the respective baseline variable for the outcome 
+measure. The inclusion of the factors used for randomization 
+as covariates increases power. 
+41 The feasibility of conducting 
+the trial was determined by the number of eligible partici-
+pants who declined, yoga class attendance, and evaluation of 
+the classes. An intent-to-treat approach was used to analyze 
+the data. Data analyses were performed using  
+SA 
+S software 
+( 
+SAS version [r] 9.1.3, SAS Institute Inc., Cary, NC). 
+ 
+Results 
+ 
+Of the 137 eligible breast cancer patients asked to take part 
+in the study, 81 agreed to participate; however, 10 of the 81 
+withdrew after providing consent because they did not have 
+enough time to participate, there was a change in treatment 
+plan, there was a death in the family, refusal of extra time 
+off from work, and other family or personal issues or prob-
+lems. The 71 remaining participants were randomly assigned 
+to the YG or WL group, but 10 dropped out of the study 
+before the start of radiotherapy; reasons cited included lack 
+of transport, change of treatment location, and lack of time. 
+Of the remaining 61 participants, 30 were in the YG and 31 
+were in the WL group. Twenty-seven (90%) of the YG par-
+ticipants and 31 (100%) of the WL participants completed 
+the T2 assessment; 26 (87%) of the YG participants and 27 
+(87%) of the WL participants completed the T3 assessment; 
+and 27 (90%) of the YG participants and 29 (93%) of the WL 
+participants completed the T4 assessment ( 
+Figure 1 
+). The 
+demographic and medical characteristics of the participants 
+are shown in  
+Table 1 
+. There were no signifi
+ cant group differ-
+ences for the demographic, medical, and baseline scores for 
+the outcome measures (all  
+p values > .2). 
+ 
+ 
+Yoga Class Attendance 
+ 
+Fifteen YG participants (50%) attended all 12 classes (pri-
+mary or make-up classes); eight (28%) attended 11 classes; 
+and one (3%) attended 10 classes. One participant was able 
+to attend only two classes because of a family emergency. 
+Each of the remaining fi
+ ve participants attended three, four, 
+fi
+ ve, seven, or eight classes; reasons cited for missing classes 
+included being out of town, lack of time or transportation, 
+other health problem, or being busy at work. During the 
+course of radiotherapy, 8 participants (28%) reported prac-
+ticing yoga outside of class every day, 12 (40%) reported 
+practicing more than twice a week, 8 (28%) reported practic-
+ing twice a week, and 1 (3%) reported not practicing outside 
+the classes at the hospital owing to a lack of time. Frequency 
+of postradiotherapy yoga practice decreased somewhat over 
+time (twice a week or more: T2, 86%; T3, 80%; T4, 50%). 
+often regarded as criteria for further evaluation for clinical 
+depression. 
+ 
+Changes in anxiety levels were assessed using the 20-item 
+STATE portion of the Speilberger State/Trait Anxiety Inven-
+tory. 
+52 Respondents rated how they felt during the past week 
+based on situational factors that can infl
+ uence anxiety lev-
+els. Scores range from 20 to 80, with higher scores indicating 
+greater anxiety (alpha = 0.94). This scale is widely used for 
+research of diseased and healthy populations. 
+53 
+ 
+Intrusive thoughts or the tendency to ruminate on or to 
+avoid thoughts about cancer-related stressors was measured 
+using the Impact of Events Scale (IES), a 15-item self-report 
+scale that assesses intrusion (intrusively experienced ideas, 
+images, feelings, or bad dreams) (range 0–35; alpha = 0.82) 
+and avoidance (consciously recognized avoidance of certain 
+ideas, feelings, or situations) (range 0–40; alpha = 0.65) dur-
+ing the past week. 
+54 Higher scores represent greater intrusion 
+and avoidance. 
+ 
+Finding meaning in cancer was measured using the 
+Benefi
+ t Finding Scale (BFS). 
+55 This 17-item scale assesses 
+benefi
+ ts in different domains, including accepting life’s 
+imperfections, changing priorities, and developing a sense 
+of purpose in life. Higher scores represent higher benefi
+ t 
+fi
+ nding (alpha = 0.96). The scale is scored as a single fac-
+tor and has shown moderate association with psychological 
+ 
+well-being. 
+39,40,56 
+ 
+Tracking data were kept regarding patient interest dur-
+ing the recruitment period, study attrition, yoga class atten-
+dance, frequency of yoga practice at home, and completion 
+of questionnaires. Participants in the YG completed a brief 
+evaluation of the class and of their home practice each week 
+when they attended the yoga classes and at T2, T3, and T4. 
+ 
+Data Analyses 
+ 
+Descriptive analyses in terms of means and standard devia-
+tions/errors of the demographic, medical, and psychosocial 
+variables were calculated. To ensure that the groups were effec-
+tively matched in terms of medical and demographic factors, 
+differences between the groups were assessed using two-sample
+ 
+t 
+-tests for comparing continuous variables and chi-square 
+tests for categorical variables. Feasibility was  
+determined 
+by the number of eligible participants who declined to par-
+ticipate, class attendance, and attrition after randomization. 
+Our criterion for successful enrolment was that at least 50% 
+of eligible women approached enrol in the study and that 
+fewer than 35% of participants drop out after randomiza-
+tion. General linear model (GLM) analysis was  
+conducted to 
+examine group differences at each of the  
+assessment points. 
+Covariates in each of the analyses included age, stage of 
+ 
+Chandwani et al, Yoga Improves Quality of Life and Benefi
+ t Finding 
+47
+thoughts scores (YG, 7.1 [1.1]; WL, 4.1 [1.2];  
+p 
+ = .01; d = 0.48; 
+change from baseline: YG, −0.3; WL, −1.8) at T3, with the 
+YG reporting more intrusive thoughts than the WL, with less 
+of a decrease from baseline; no signifi
+ cant group differences 
+were seen at other time points or for the avoidant behaviors 
+subscale ( 
+Figure 3 
+).
+ 
+GLM analyses revealed signifi
+ cant group differences in 
+BFS at T4 (YG, 52.8 [1.91]; WL, 47.3 [2.06];  
+p = .01; d = 0.51; 
+change from baseline: YG, 8.6; WL, 2.3), with higher scores 
+in the YG, but no signifi
+ cant group differences were seen at 
+T2 ( 
+p = .18) or T3 ( 
+p = .26) (see  
+Figure 3 
+). 
+ 
+There were no signifi
+ cant group differences for the PSQI, 
+CES-D, BFI, and STATE scales; all outcomes remained stable 
+over time in both groups (see  
+Table 2 
+). 
+ 
+All analyses were conducted using two methods to 
+impute the missing data, allowing complete case analyses at 
+each time point: (1) simple mean imputation—we replaced 
+the missing data with the group means at the correspond-
+ing time point and (2) multiple imputations—we used the 
+ 
+SAS 
+ V9.2 MI procedure with Markov Chain Monte Carlo 
+method to impute 10 times and then used the MIANALYZE 
+procedure to generate statistical inferences. All analyses 
+remained the same except for a decrease in the  
+p 
+ value for 
+PCS at T2 ( 
+p = .1). 
+ 
+Table 2 shows baseline and follow-up adjusted least-
+square means (with standard errors [SEs] and effect size 
+using the Cohen d 
+57,58 
+) by group for the SF-36. A GLM analy-
+sis revealed signifi
+ cant group differences for the PCS at T2 
+(YG, 43.1 [1.8]; WL, 39.0 [1.7];  
+p 
+ = .04; d = 0.44; change 
+from baseline: YG, 1.7; WL, −2.8); no signifi
+ cant group dif-
+ferences were observed at T3 and T4. Further GLM analyses 
+using the four component subscales that make up the PCS 
+ 
+(general health perceptions, physical function, role-physical, 
+and bodily pain) revealed signifi
+ cant group differences for 
+ 
+general health perceptions (YG, 78.8 [4.7]; WL, 66.6 [4.9]; 
+ 
+p 
+ = .005; d = 0.47; change from baseline: YG, 10.7; WL, −4.4) 
+and physical function scores (YG, 76.8 [3.8]; WL, 67.6 [3.7]; 
+ 
+p 
+ = .04; d = 0.46; change from baseline: YG, 5.2; WL, −7.3), 
+with the YG reporting better QOL ( 
+Figure 2 
+). A marginally 
+signifi
+ cant group difference was observed in general health 
+scores at T3 (YG, 71.6 [3.6]; WL, 64.36 [4.7];  
+p = .08). There 
+were no signifi
+ cant group differences for the other two sub-
+scales at T2 or for other subscales at T3 and T4. As can be seen 
+in  
+Table 2 
+, the MCS levels remained stable throughout the 
+entire study and showed no signifi
+ cant group differences. 
+ 
+Table 3 shows baseline and follow-up adjusted least-
+square means (with SEs) by group for the other outcomes. 
+Signifi
+ cant group differences were observed in intrusive 
+ 
+1. 
+Figure  Participant recruitment and attrition. 
+Eligible patients approached
+N = 137
+Consented and enrolled in study
+N = 81
+Withdrew from study N = 10
+Randomized N = 71
+Yoga N = 30
+Control N = 31
+1 week after
+radiotherapy N = 27 
+Withdrew from study prior to radiotherapy N = 10
+1 week after
+radiotherapy N = 31
+1 month after
+radiotherapy N = 26
+1 month after
+radiotherapy N = 27
+3 months after
+radiotherapy N = 29
+3 months after
+radiotherapy N = 27
+T1
+T2
+T3
+T4
+48 
+Journal of the Society for Integrative Oncology, Spring 2010, Volume 8, Number 2
+ 1.
+Table
+  Characteristics of Study Participants
+Characteristic
+Yoga Group (n = 30)
+Wait-List Control 
+Group (n = 31)
+p Value
+Age (yr), mean ± SD
+51.39 ± 7.97
+4.02 ± 9.96
+.26 
+ Range (yr)
+37.1–67.6
+31.8–67.9
+Disease stage
+.23 
+ 0
+2 (7)
+ 1
+6 (20)
+10 (32)
+ 2
+12 (40)
+15 (48)
+ 3
+10 (33)
+6 (19)
+Surgery
+.92
+ Mastectomy
+12 (40)
+12 (39)
+ Breast-conserving surgery
+18 (60)
+19 (61)
+Chemotherapy
+.94
+ Yes 
+23 (77)
+24 (77)
+Marital status (n = 60)
+.70
+ Married and living together
+24 (83)
+21 (68)
+ Not cohabiting
+5 (17)
+10 (32)
+Ethnicity (n = 59)
+.76
+ Black/African American 
+1 (3)
+2 (7)
+ White/Caucasian 
+24 (80)
+23 (79)
+ Latino/Hispanic/Mexican 
+3 (10)
+2 (7)
+ Asian/Pacifi
+ c Islander 
+1 (3)
+ Other (Caucasian/Pacifi
+ c Islander)
+1 (3)
+2 (7)
+ 
+Employment status (n = 60)
+.39
+ Employed full-time
+5 (17)
+8 (27)
+ Employed part-time
+4 (13)
+2 (7)
+ Not employed
+21 (70)
+20 (67)
+Education (n = 60)
+.64
+ High school or technical school
+6 (20)
+4 (13)
+ Some college
+6 (20)
+5 (17)
+ Higher education
+18 (60)
+21 (70)
+Data are number (%) among participants in each group, unless otherwise indicated.
+ 
+Exploratory Analyses 
+ 
+Owing to the unexpected group differences in intrusive 
+thoughts at T3, with the YG reporting signifi
+ cantly greater 
+scores, we explored the association between the outcome 
+measures at T3 and benefi
+ t fi
+ nding at T4. There was a sig-
+nifi
+ cant positive correlation between intrusive thoughts at 
+T3 and the BFS at T4 ( 
+r 
+ = .36,  
+p 
+ = .011), suggesting that 
+the higher the level of intrusive thoughts at T3, the greater 
+the benefi
+ t fi
+ nding at T4. However, the greater the symp-
+toms of depression (CES-D) at T3, the lower the levels of 
+the BFS at T4 ( 
+r = −.31,  
+p = .027). No other factors at T3 
+were associated with the BFS at T4. Examination of the asso-
+ciation between intrusive thoughts at T3 with the outcome 
+variables at T3 revealed only a modest positive correlation 
+between intrusive thoughts and the CES-D ( 
+r = .30,  
+p 
+ = .04); 
+negative correlations between intrusive thoughts and general 
+health ( 
+r 
+ = −.30,  
+p 
+ = .04), bodily pain ( 
+r 
+ = −.30,  
+p = .04) and 
+mental health subscale of the SF-36 ( 
+r = −.31,  
+p = .03); posi-
+tive correlation between intrusive thoughts and sleep distur-
+bances ( 
+r = .39,  
+p = .006) and anxiety ( 
+r = .40,  
+p 
+ = .004); and 
+a nonsignifi
+ cant positive correlation with benefi
+ t fi
+ nding
+( 
+r = .30,  
+p = .15). 
+ 2.
+Table
+  Baseline, Adjusted Follow-Up Means, and Effect Sizes for SF-36 Subscales
+Follow-Up
+Baseline (T1)
+1 wk (T2)
+1 mo (T3)
+3 mo (T4)
+SF-36 Measure
+YG 
+(n = 30)
+WL 
+(n = 31)
+p 
+Value
+YG 
+(n = 27)
+WL 
+(n = 31)
+p 
+Value
+d
+YG 
+(n = 26)
+WL 
+(n = 27)
+p 
+Value
+d
+YG 
+(n = 27)
+WL 
+(n = 29)
+p 
+Value
+d
+PCS 
+41.5 (1.5)
+41.8 (1.9)
+.42
+43.1 (1.8)
+39.0 (1.7)
+.04
+0.44
+44.9 (2.9)
+44.4 (3.1)
+.87
+0.03
+46.9 (2.9)
+44.8 (3.0)
+.42
+0.13
+MCS 
+47.8 (2.2)
+48.0 (2.0)
+.87
+49.7 (1.7)
+49.9 (1.7)
+.92
+−0.02
+52.8 (1.7)
+50.6 (1.7)
+.38
+0.24
+50.9 (2.7)
+50.4 (2.9)
+.87
+0.03
+General health
+68.2 (3.1)
+71.0 (2.9)
+.5
+78.8 (4.7)
+66.6 (5.0)
+.005
+0.47
+71.6 (3.6)
+64.3 (4.1)
+.08
+0.35
+69.1 (4.0)
+64.5 (4.4)
+.31
+0.20
+Physical function
+71.6 (3.4)
+74.9 (4.4)
+.56
+76.8 (3.8)
+67.6 (3.7)
+.04
+0.46
+81.7 (5.2)
+78.9 (5.6)
+.55
+0.10
+86.2 (5.1)
+80.0 (5.4)
+.18
+0.22
+Body pain
+62.3 (4.3)
+61.5 (4.4)
+.9
+63.5 (6.8)
+58.5 (7.0)
+.4
+0.13
+75.3 (5.5)
+80.2 (6.1)
+.44
+−0.16
+69.9 (6.3)
+73.2 (6.8)
+.63
+−0.09
+Role-physical
+33.9 (7.5)
+29.8 (6.5)
+.68
+46.0 (8.7)
+48.1 (8.2)
+.83
+−0.05
+50.8 (11.1)
+48.0 (11.9)
+.79
+0.05
+76.8 (12.6) 66.5 (13.1)
+.37
+0.15
+Mental health
+75.2 (2.8)
+75.9 (3.0)
+.87
+80.4 (3.1)
+79.1 (3.2)
+.61
+0.08
+82.1 (2.9)
+83.0 (3.3)
+.8
+−0.05
+82.7 (4.4)
+81.8 (4.8)
+.85
+0.04
+Role-emotional
+64.4 (7.8)
+60.2 (7.5)
+.7
+76.4 (11.6)
+76.2 (12.0)
+.98
+0.00
+91.3 (8.8)
+74.8 (9.8)
+.1
+0.33
+88.8 (9.5)
+83.0 (10.2)
+.58
+0.11
+Social function
+67.1 (4.8)
+71.0 (4.3)
+.55
+84.6 (7.1)
+80.0 (7.5)
+.47
+0.12
+85.2 (4.8)
+84.8 (5.4)
+.94
+0.01
+85.2 (6.1)
+86.2 (6.6)
+.88
+−0.03
+Vitality
+51.3 (3.7)
+51.9 (3.3)
+.91
+62.5 (5.5)
+56.5 (5.8)
+.22
+0.20
+65.1 (4.2)
+59.5 (4.7)
+.24
+0.23
+61.8 (5.4)
+57.2 (5.8)
+.43
+0.15
+d = effect size; MCS = standardized mental component scale; PCS = standardized physical component scale; SF-36 = Medical Outcomes Study 36-item short-form survey; 
+WL = wait-list control group; YG = yoga group. 
+Data are mean (standard error). T2–T4 scores are adjusted means after controlling for the covariates (age, stage of cancer, time since diagnosis, type of surgery, prior chemotherapy [yes/no], and the 
+respective baseline variable for the outcome measure). Signifi
+ cance levels are from general linear model analyses, YG vs WL.
+ 
+Chandwani et al, Yoga Improves Quality of Life and Benefi
+ t Finding 
+49
+50 
+Journal of the Society for Integrative Oncology, Spring 2010, Volume 8, Number 2
+2.
+Figure  Mean general health (A) and physical function (B) scores. T2–T4 scores are the adjusted means after controlling for the covariates 
+age, stage of cancer, time since diagnosis, type of surgery, prior chemotherapy (yes/no), and the respective baseline variable for the outcome 
+measure. T1 = baseline; T2 = 1 week after the end of radiotherapy; T3 = 1 month after the end of radiotherapy; T4 = 3 months after the end 
+of radiotherapy. There were statistically signifi
+ cant group differences for general health and physical function at T2.
+B
+A
+90
+Difference = 12.2
+ = .005
+Difference = 9.2
+ = .04
+85
+80
+General health
+Physical function
+75
+70
+65
+60
+90
+85
+80
+75
+70
+65
+60
+T1
+T2
+T3
+T4
+T1
+T2
+T3
+T4
+Yoga
+Waitlist
+Yoga
+Waitlist
+ 
+Discussion 
+ 
+To our knowledge, this is one of only two studies that have 
+incorporated yoga into the treatment plan for women under-
+going radiotherapy and one of just a few randomized studies 
+of yoga in a cancer population. Attendance at yoga sessions 
+was extremely high and was much higher than that in other 
+studies in which cancer survivors participated in a yoga pro-
+gram after treatment. 
+31,32 Perfect attendance was achieved 
+by only 32% of participants in one study 
+31 and in another 
+by less than 10% 
+31,32 
+; in the current study, 50% had perfect 
+attendance and 81% overall attended more than 80% of the 
+classes. From baseline to 1 week after the end of treatment, 
+women in the YG had an increase in some aspects of QOL, 
+and women in the control group had a decrease in the same 
+aspects. Group differences in general health perceptions were 
+also clinically signifi
+ cant, and the differences in physical func-
+tion scores were within 1 point of clinical signifi
+ cance (76.8 
+vs 67.6), with clinically signifi
+ cant differences for change 
+scores (a 10-point or greater difference on a 100-point scale 
+is regarded as clinically signifi
+ cant in QOL). 
+47 However, the 
+differences between groups became insignifi
+ cant over time. 
+ 
+That the YG participants maintained better QOL 
+throughout treatment and into the recovery period suggests 
+the potential benefi
+ ts that yoga can have when incorporated 
+into the treatment plan for women with breast cancer who 
+are undergoing radiotherapy. Recent research has also sug-
+gested that staying physically active during and after treat-
+ment for breast cancer is benefi
+ cial for maintaining QOL. 
+59 
+The benefi
+ ts of staying active during treatment become espe-
+cially important given that patients typically reduce their 
+physical activity during breast cancer treatment. 
+60 However, 
+the benefi
+ ts derived from yoga may not be simply a result of 
+the physical aspects of yoga (asanas) as yoga also involves a 
+relaxation component brought on by breath awareness and 
+suggestions of increasing one’s own internal awareness. 
+ 
+Our fi
+ ndings are consistent with some of the previous 
+research examining yoga and other mind-body programs for 
+participants with cancer. Banerjee and colleagues reported 
+that YG participants had reduced anxiety, depression, 
+and perceived stress by the end of radiotherapy, whereas 
+increases in these aspects were seen in the control group. 
+35 
+However, physical functioning and other aspects of QOL 
+were not assessed. A study of tai chi chuan (a mind-body 
+program from the Chinese tradition similar to yoga) in a 
+sample of breast cancer survivors found increased functional 
+capacity, better QOL, and increased self-esteem compared to 
+increased fl
+ exibility but declines in self-esteem and QOL in a 
+psychosocial support therapy group. 
+61,62 
+ 
+At the start of our study, the women’s MCSs were simi-
+lar to those of a general healthy population and improved 
+slightly by the end of treatment and into recovery. This may 
+be because the women had already come a long way in their 
+cancer journey and, in fact, were near the end of the treat-
+ment trajectory. This type of “fl
+ oor effect” is not uncommon 
+in psychosocial research, and it is therefore not surprising 
+that yoga could not improve a woman’s mental health scores 
+above normal levels of functioning. Similarly, fatigue levels 
+ 3.
+Table
+  Baseline, Adjusted Follow-Up Means, and Effect Sizes for Fatigue, Sleep Disturbances, Measures of Mental Health, and Benefi
+ t Finding
+Follow-Up
+Baseline (T1)
+1 wk (T2)
+1 mo (T3)
+3 mo (T4)
+Measure
+YG 
+(n = 30)
+WL 
+(n = 31)
+p 
+Value
+YG 
+(n = 27)
+WL 
+(n = 31)
+p 
+Value
+d
+YG 
+(n = 26)
+WL 
+(n = 27)
+p 
+Value
+d
+YG 
+(n = 27)
+WL 
+(n = 29)
+p 
+Value
+d
+Fatigue
+2.3 (0.3)
+2.3 (0.4)
+.97
+1.9 (0.7)
+2.5 (0.8)
+.32
+−0.15
+1.5 (0.5)
+1.4 (0.4)
+.93
+0.04
+1.6 (0.6)
+2.0 (0.6)
+.55
+−0.12
+Sleep
+7.3 (0.7)
+7.1 (0.7)
+.74
+6.6 (1.0)
+6.7 (1.0)
+.94
+−0.02
+8.1 (0.8)
+7.6 (0.9)
+.56
+0.11
+7.3 (0.9)
+7.1 (1.0)
+.83
+0.04
+Depression
+11.6 (1.7)
+10.5 (1.2)
+.61
+6.6 (2.1)
+7.0 (2.2)
+.83
+−0.03
+7.7 (1.3)
+8.2 (1.5)
+.73
+−0.06
+7.7 (2.3)
+9.0 (2.5)
+.63
+−0.10
+Anxiety
+36.3 (2.5)
+32.7 (1.8)
+.24
+28.0 (2.2)
+30.2 (2.4)
+.3
+−0.18
+32.1 (2.3)
+33.1 (2.5)
+.7
+−0.08
+30.2 (2.6)
+32.1 (2.8)
+.52
+−0.13
+Impact of events
+Intrusive
+7.7 (1.3)
+5.9 (0.9)
+.26
+5.9 (1.6)
+5.4 (1.7)
+.73
+0.06
+7.1 (1.1)
+4.1 (1.2)
+.01
+0.48
+4.9 (1.5)
+4.5 (1.5)
+.79
+0.05
+Avoidant
+9.8 (0.9)
+8.7 (1.4)
+.5
+7.3 (1.9)
+9.1 (2.0)
+.27
+−0.17
+7.5 (1.5)
+9.8 (1.7)
+.19
+−0.27
+7.0 (2.1)
+10.65 (2.3)
+.12
+−0.31
+Benefi
+ t fi
+ nding
+44.2 (2.7)
+45.0 (3.2)
+.86
+50.5 (2.45)
+47.6 (2.6)
+.18
+0.21
+54.7 (2.6)
+51.4 (2.8)
+.26
+0.23
+52.8 (1.9)
+47.3 (2.1)
+.01
+0.51
+d = effect size; WL = wait-list control group; YG = yoga group. 
+Data are mean (standard error). T2–T4 scores are adjusted means after controlling for the covariates (age, stage of cancer, time since diagnosis, type of surgery, prior chemotherapy [yes/no], and 
+the  
+respective baseline variable for the outcome measure). Signifi
+ cance levels are from general linear model analyses, YG vs WL. 
+ 
+Chandwani et al, Yoga Improves Quality of Life and Benefi
+ t Finding 
+51
+52 
+Journal of the Society for Integrative Oncology, Spring 2010, Volume 8, Number 2
+were quite low throughout the study. Importantly, because of 
+the timing of assessments, the worst levels of fatigue among 
+the participants may have been missed as previous research 
+indicates that fatigue is highest in the middle of radiothera-
+py. 
+63 
+ Future research should consider targeting patients who 
+are experiencing specifi
+ c symptoms prior to or during radio-
+therapy. In the current trial, the sample size was too small to 
+conduct exploratory analyses of subsets of patients experi-
+encing treatment-related symptoms. 
+ 
+The increase in participants’ reported benefi
+ t fi
+ nding in 
+their cancer experience is similar to that found in a study of 
+a 10-week cognitive behavioral stress management interven-
+tion, in which women with breast cancer reported increased 
+benefi
+ t fi
+ nding, fewer intrusive thoughts, and reduced depres-
+sive symptoms. 
+39,40 What is remarkable is that in the current 
+study, intrusive thoughts remained elevated 1 month after the 
+end of treatment for those in the YG and were signifi
+ cantly 
+higher than those in the WL group and were associated with 
+increased levels of benefi
+ t fi
+ nding by 3 months after the end 
+of treatment. Interestingly, symptoms of depression as mea-
+sured by the CES-D 1 month after the end of treatment were 
+negatively associated with benefi
+ t fi
+ nding at 3 months, and 
+there was little association between intrusive thoughts and 
+depression scores. This suggests that there is something spe-
+cifi
+ c about intrusive thoughts that may lead to greater benefi
+ t 
+fi
+ nding. Research examining emotional adjustment to post-
+traumatic experiences suggests that information surrounding 
+a traumatic experience needs to be processed appropriately 
+for the individual to effectively adapt to the stressor 
+64–66 
+; thus, 
+the increase in intrusive thoughts may represent the patients 
+trying to process the information surrounding their experi-
+ence. Heightened levels of intrusive thoughts experienced 
+during the aftermath of a traumatic event may help indi-
+viduals more effectively adjust to the stressor and ultimately 
+to fi
+ nd benefi
+ t in the traumatic experience. In the yoga pro-
+gram, it was suggested that the participants focus on their 
+breathing without making an attempt to stop the fl
+ ow of 
+thoughts; whether this directly infl
+ uenced intrusive thoughts 
+and benefi
+ t fi
+ nding observed in the YG needs to be corrobo-
+rated by further research. 
+ 
+An association between increased benefi
+ t fi
+ nding and 
+lower distress has been reported in patients with early-stage 
+breast cancer 
+39 
+; however, other research has also reported 
+the opposite association. 
+67 Furthermore, a curvilinear rela-
+tionship between benefi
+ t fi
+ nding and intrusive thoughts 
+has also been observed. 
+68 
+ Such inconsistent fi
+ ndings could 
+be because of differences in study populations, the timing 
+of assessments, or some other factor, suggesting that further 
+research to understand mediators of improved outcomes is 
+warranted. 
+ 
+One important limitation of this study was the lack of 
+an active comparison group. Research that attempts to rep-
+licate the current fi
+ ndings and that examines the effects of 
+yoga in a larger sample of more diverse patients, over longer 
+3.
+Figure  (A) Mean benefi
+ t fi
+ nding scores and (B) mean impact of event scores (intrusive subscale in solid lines and avoidant subscale in 
+dashed lines). T2–T4 scores are adjusted means after controlling for the covariates age, stage of cancer, time since diagnosis, type of surgery, 
+prior chemotherapy (yes/no), and the respective baseline variable for the outcome measure. T1 = baseline; T2 = 1 week after the end of 
+radiotherapy; T3 = 1 month after the end of radiotherapy; T4 = 3 months after the end of radiotherapy. There were statistically signifi
+ cant 
+group differences for benefi
+ t fi
+ nding at T4 and for intrusive thoughts at T3.
+B
+A
+60
+12
+10
+8
+6
+4
+2
+55
+50
+Benefit finding
+Impact of event
+45
+40
+T1
+T2
+T3
+T4
+T1
+T2
+T3
+T4
+Yoga
+Waitlist
+Yoga
+Waitlist
+Yoga
+Waitlist
+Difference = 5.5
+ = .01
+Difference = 3.0
+ = .01
+ 
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+Acknowledgment 
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+Financial disclosure of authors: Support was provided in part 
+by The National Cancer Institute R21CA102385 and phil-
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+The University of Texas M. D. Anderson Cancer Center. 
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+Financial disclosure of reviewers: None reported. 
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+Full Terms & Conditions of access and use can be found at
+http://www.tandfonline.com/action/journalInformation?journalCode=iirp20
+Download by: [14.139.155.82]
+Date: 28 February 2017, At: 23:33
+International Review of Psychiatry
+ISSN: 0954-0261 (Print) 1369-1627 (Online) Journal homepage: http://www.tandfonline.com/loi/iirp20
+Yoga and physical exercise – a review and
+comparison
+Ramajayam Govindaraj, Sneha Karmani, Shivarama Varambally & B.N.
+Gangadhar
+To cite this article: Ramajayam Govindaraj, Sneha Karmani, Shivarama Varambally & B.N.
+Gangadhar (2016) Yoga and physical exercise – a review and comparison, International Review of
+Psychiatry, 28:3, 242-253, DOI: 10.3109/09540261.2016.1160878
+To link to this article:  http://dx.doi.org/10.3109/09540261.2016.1160878
+Published online: 04 Apr 2016.
+Submit your article to this journal 
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+Citing articles: 2 View citing articles 
+REVIEW ARTICLE
+Yoga and physical exercise – a review and comparison
+Ramajayam Govindaraj, Sneha Karmani, Shivarama Varambally and B.N. Gangadhar
+NIMHANS Integrated Centre for Yoga, Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore,
+India
+ABSTRACT:
+Yoga is a multifaceted spiritual tool with enhanced health and well-being as one of its positive
+effects. The components of yoga which are very commonly applied for health benefits are asanas
+(physical postures), pranayama (regulated breathing) and meditation. In the context of asanas,
+yoga resembles more of a physical exercise, which may lead to the perception that yoga is
+another kind of physical exercise. This article aims at exploring the commonalities and differences
+between yoga and physical exercise in terms of concepts, possible mechanisms and effectiveness
+for health benefits. A narrative review is undertaken based on traditional and contemporary litera-
+ture for yoga, along with scientific articles available on yoga and exercise including head-to-head
+comparative trials with healthy volunteers and patients with various disease conditions. Physical
+exercises and the physical components of yoga practices have several similarities, but also
+important differences. Evidence suggests that yoga interventions appear to be equal and/or
+superior to exercise in most outcome measures. Emphasis on breath regulation, mindfulness dur-
+ing practice, and importance given to maintenance of postures are some of the elements which
+differentiate yoga practices from physical exercises.
+ARTICLE HISTORY
+Received 3 December 2015
+Revised 28 February 2016
+Accepted 29 February 2016
+Published online 31 March
+2016
+KEYWORDS
+Yoga; asana; pranayama;
+physical exercise;
+mindfulness
+Introduction
+Yoga, as it gains popularity from people of all walks of
+life, is also compared with many movement based
+practices,
+especially
+physical
+fitness
+exercises.
+The
+apparent similarity of external movements makes one
+sometimes to equate yoga with exercises. This article
+aims at comparing and contrasting yoga with physical
+exercises from the physiological, psychological, and
+spiritual perspectives
+Origin and intention
+Yoga
+The very meaning of the word yoga (controlling the
+mental modifications; communion with the universal)
+(Iyengar, 2007) signifies the importance it attaches to
+mental and spiritual well-being, stretching beyond just
+physical well-being. Though the practice of yoga was
+in existence from the pre-vedic period, it was around
+2500-3000 years ago that it got a structured format
+when Sage Patanjali consolidated the theory and prac-
+tical concepts of yoga, assimilating ideas mainly from
+samkhya and vedic philosophy (Radhakrishnan, 2008).
+During the times of Patanjali, though asanas (physical
+postures) were in practice, they were not given much
+significance, as the focus was more on meditation and
+hence some postures conducive to the practice of
+meditation alone were incorporated in their spiritual
+practices. This is very much evident, as one does not
+find even a single named asana in the whole of the
+Patanjali yoga sutras.
+Sages who followed Patanjali tried to modify the
+practices of yoga by incorporating more physical com-
+ponents, as it is little easier to focus on movements
+than just directly on the mind. In spite of adding
+more physical components in the name of asanas, the
+aim remained the same – ‘controlling the mental mod-
+ifications’ with physical postures as one of the scaf-
+folds. This is apparent from the way the asanas are
+practiced
+(slow
+with
+synchronized
+breathing
+and
+mindful awareness of the movements), unlike other
+physical exercises.
+From a conceptual point of view, the eight limbs of
+Patanjali yoga clearly signify a hierarchical (although it
+need not be sequential) pattern of developing con-
+sciousness from gross to a subtle level in a systematic
+manner (Iyengar, 2012).
+CONTACT Dr. Shivarama Varambally, Additional Professor
+ssv.nimhans@gmail.com
+Department of Psychiatry, National Institute of Mental Health and
+Neurosciences, Hosur Road, Bangalore, India
+ 2016 Institute of Psychiatry
+INTERNATIONAL REVIEW OF PSYCHIATRY, 2016
+VOL. 28, NO. 3, 242–253
+http://dx.doi.org/10.3109/09540261.2016.1160878
+Yama, Niyama- Behavioural level
+Asana, Pranayama-Physical level
+Prathyahara, Dharana- Mental level
+Dhyana, Samadhi - Spiritual level
+So, the concept of yoga has been fabricated with the
+idea of achieving peace rather than health alone unlike
+exercise.
+Exercise
+The Oxford English dictionary defines exercise as
+‘activity requiring physical effort, carried out to sustain
+or improve health and fitness’. However, if we consider
+exercise to be any form of physical activity, then exer-
+cise surely dates back to the origin of the species,
+when humans exercised regularly, even if they may not
+have understood the concept of exercise at the time.
+Hunting,
+ritualistic
+dancing,
+and
+building
+shelter
+were – and still are - various forms of exercise.
+However, exercise including sports, athletics and gym-
+nastics as a profession started developing only in the
+18th century (Berryman, 2010). Until the development
+of exercise as a profession, it was mainly used for
+training warriors; as a recreation in the form of dem-
+onstration in public gatherings as sports or gymnastics,
+and by few like Confucius, Hippocrates and Galen as a
+therapeutic or preventive tool (Tipton, 2014).
+Therefore, from the historical point of view, exercise
+and related activities were mainly a form of recreation
+in earlier civilizations and slowly emerged as a form of
+therapy (preventive/curative) in recent times.
+Classification
+Yoga
+At a fundamental level, yoga can be classified in one
+of the two categories:
+i.
+Patanjali Ashtanga yoga
+Focused on direct contemplative practices like
+meditation with or without movement based con-
+templative practices like asana and pranayama
+(Iyengar, 2007).
+ii.
+Hatha yoga
+Includes kriyas as an important purification practi-
+ces of the vital energy body, before starting other com-
+ponents of yoga including Yama, Niyama, asana etc.
+(Muktibodhananda, 1998). In this school of thought,
+movement based contemplative practices like asana,
+pranayama are given equal importance to that of dir-
+ect contemplative practices like meditation.
+Apart from this classification, with the background
+of
+‘‘yoga
+as
+a
+process
+of
+communion
+with
+the
+supreme’’ spiritual masters like Swami Vivekananda
+classified (Feuerstein, 1990)yoga as a way of attaining
+the aim of communion with supreme, through various
+means as follows,
+Jnana yoga- through intellect
+Bhakti yoga- through culturing emotions
+Karma yoga- through elevated actions
+Raja yoga- through conscious control of the will
+In recent times, many classifications and styles have
+sprouted, with their own modifications based on their
+experiences and the needs of the people. However,
+essentially all of them are centered on one or more of
+the above mentioned schools of thought.
+Movement based practices like asana, pranayama
+are only a small component of the entire spectrum of
+yoga practices. Since the vast majority of people prac-
+tice the physical components only, most people equate
+yoga with physical exercise. Even considering asana
+alone, there are significant differences in the way phys-
+ical movements are done in yoga and physical exercise.
+This makes it compelling to call yogasana as a move-
+ment-based contemplative practice or a psycho-spiritual
+practice rather than just a set of physical movements.
+Exercise
+Exercises basically are of three types
+i.
+isotonic/dynamic/locomotor
+type-e.g.
+stretching
+exercise
+ii.
+isometric/static type-e.g. handgrip
+iii.
+Resistive type (combination of isotonic and iso-
+metric)-e.g. free weight lifting
+Depending on the type of energy used, it can also
+be classified as aerobic, anaerobic or a combination of
+the two.
+A mere look at the classification gives the idea that
+exercise regimens are meant for neuromuscular or car-
+dio-respiratory training, unlike yoga which focuses more
+on the mind. Nevertheless, even exercise, if done mind-
+fully, can also become a spiritual practice comparable to
+the asana component of yoga, and yogasana if done
+mechanically can be a mere physical activity as well.
+Process of doing
+Yoga
+Classically yoga practices follow the below sequence.
+a.
+Starting prayer- salutation to sage Patanjali/other
+invocation of interest.
+INTERNATIONAL REVIEW OF PSYCHIATRY
+243
+b.
+Slow movements with breathing awareness and
+loosening exercise - to prepare the lungs and
+muscles
+for
+asanas
+and
+pranayama
+practices,
+and also to avoid muscle soreness.
+c.
+Asanas/Bodily postures-different sets of asanas
+depending on the need of the subject.
+d.
+Pranayama/Regulated
+breathing-
+Different
+sets
+depending on the need of the subject
+e.
+Direct contemplative practices/Meditation-Dharana
+and Dhyana
+f.
+Post
+meditative
+relaxation
+with
+positive
+suggestion.
+g.
+Ending prayer-Giving good wishes and pure feel-
+ings for all beings of the universe.
+The whole sequence is built in a way that trains an
+individual to slowly transcend from the gross material-
+istic physical level to a deeper divine level of existence.
+This falls in line with the different levels of conscious-
+ness mentioned in Taittriya Upanishad (Mahadevan,
+2010) as depicted below in Figure 1.
+We can see practices for different layers of con-
+sciousness from gross physical level to the most subtle
+level built in a very systematic manner, where asana is
+one of the components meant for the grossest layer of
+consciousness at the physical level.
+Not mentioned in the sequence are the Yama and
+Niyama which are basically personal and social con-
+duct related spiritual values like non-violence, truthful-
+ness etc. which are not one time practices, but a way
+of living. In this light, yoga is not mere bending the
+body or holding the breath for an hour or so, but it’s
+a way of living-an effort to bring peace in life of the
+self and also of others through value inculcation and
+some
+mind,
+body
+and
+breath-based
+systematic
+training.
+Practically, most yoga teachers focus mainly on
+asana and pranayama part alone, at least in the
+beginning, as it is more objective and also easy to start
+with for amateurs. So it is worthwhile to explain only
+the yogasana part and how it stands distinct from
+physical exercise.
+According to Patanjali, ‘‘steady and comfortable
+posture is asana’’- sthiram sukham asanam (Iyengar,
+2007).
+Performing
+an
+asana
+involves
+three
+levels
+as
+follows,
+a.
+Attaining the posture with movements
+b.
+Maintaining the posture comfortably with no
+movements
+c.
+Releasing the posture with movements.
+As per Patanjali’s definition of asana, step b men-
+tioned above only is asana, not the movements used
+to
+reach
+the
+state
+or
+to
+release
+the
+state.
+Misunderstanding the movements as asana makes one
+compare yogasana to physical exercise. The real con-
+cept of yoga in its comprehensive meaning (controlling
+the
+mental
+modifications)
+has
+a
+strong
+relation
+with the posture (holding the pose comfortably) not
+with the movements, as described below.
+In
+terms
+of
+neuro-muscular
+physiology,
+phasic
+responses are related with movements, whereas tonic
+responses are related with mental attitude and a sus-
+tained mental attitude gives rise to particular posture
+(not the asana, but the way a person stands, sits etc.).
+If mental attitude can give rise to posture, then a par-
+ticular posture can also be used to correct the mental
+attitude. This is the key concept upon which asana is
+defined as a posture, which will have an effect on
+one’s mental attitude, not the movements associated
+with
+the
+postures
+(Kuvalayananda
+&
+Vinekar,
+1963).When one holds a posture for a certain period
+of time within their limit, initially at a subconscious
+level, reflexes to avoid the posture surfaces effectively,
+but with slowness and steadiness, synchronized breath-
+ing and mindful awareness, postures open the door for
+wilful control of subconscious activities, including pro-
+tective reflexes. This also explains the definition of
+yoga as wilful control of mental modifications.
+If holding the posture is asana, then can it be equa-
+ted to just isometric exercise? The answer is an
+emphatic no, because asana is not just holding a pos-
+ture, but holding comfortably with the mind in an
+expansive state, focusing on infinity in a relaxed state
+(of course perfection comes with only long term
+practice).
+An experiment in one of the oldest yoga institutes -
+Kaivalyadhama
+in
+Maharashtra,
+India
+supports
+Figure 1. Layers of Consciousness.
+244
+R. GOVINDARAJ ET AL.
+the
+above
+mentioned
+view
+(Gore,
+2007).
+Paschimottanasana when performed as isometric exer-
+cise led to increase in the heart rate increase by 32%
+from initial resting state and Electromyography (EMG)
+showed increased contraction of muscles, whereas when
+performed as asana (with effortlessness &relaxation), it
+led to only around 6% increase in heart rate and main-
+tenance phase duration increased by 10–50%.
+Exercise
+Exercise typically involves the following sequence
+a.
+Warm up
+b.
+Exercise
+c.
+Relaxation
+Some of the warm up exercises are used as a pre-
+paratory work out for yogasana to avoid muscle sore-
+ness, as yogasana for the beginners is physiologically a
+combination of isotonic and isometric exercise (includ-
+ing both the movements and the posture holding).
+Energy and metabolic system
+The basic metabolic systems in the muscle are (Vaz
+et al., 2014)
+a.
+Phosphocreatine-creatine system
+b.
+Glycogen-lactic acid system
+c.
+Aerobic system
+The phosphagen system is used for power surges of
+few seconds (eg.-weight lifting), the aerobic system is
+used for prolonged athletic activity (eg.- jogging, mara-
+thon run), and the glycogen-lactic acid system for
+intermediate activity.
+Yoga
+The type of the energy system used in yogasana prac-
+tice depends on the speed of the practice, intensity of
+the practice, and the expertise of the practitioner. In
+general, beginners most often utilize the anaerobic
+energy system due to speed and jerky movements,
+unconscious holding of the breath, and their increased
+effort to hold the pose which leads to fatigue and
+exhaustion with sympathetic overactivity. However,
+with long term practice, the effort and fatigue become
+less unlike in most exercises, where lactic acid accumu-
+lation and oxygen debt leads to post-exercise exhaus-
+tion and fatigue. Oxygen consumption and metabolic
+demand is lower during yoga practice, including asana,
+pranayama and meditation (Subramanya & Telles,
+2009). Recent studies have also shown that the sympa-
+thetic activation in trained yoga professionals is lesser
+compared
+to
+novice
+practitioners
+(Gopal
+&
+Lakshmanan, 1972).
+Exercise
+The energy system used again depends on the duration
+of exercise and the intensity. However, as mentioned
+earlier, the striking difference is lactic acid accumula-
+tion and post exercise fatigue and exhaustion, which is
+usually not found in yoga practitioners.
+Effect on mind and body
+Yoga
+The effect of yoga on the mind is manifold, and it
+depends not only on the yoga practice, but also the
+yoga teacher, as both teaching competence and value
+inculcation are important. Effects on mind from the
+different components of yoga can be listed as follows,
+(Iyengar, 1979; Iyengar, 2012)
+a.
+Starting and ending prayer is a powerful positive
+suggestion, especially when done in groups.
+b.
+Yama and Niyama being universal values, have
+profound impact on one’s inner peace.
+c.
+Asanas, if done systematically and mindfully, not
+only impact the body, but become a form of
+meditation for advanced practitioners.
+d.
+Pranayama is a powerful technique to still the
+mind, making it ready for the advanced practices
+of contemplation.
+e.
+Prathyahara, Dharana and Dhyana reduce the
+speed of thought and help in streamlining the
+mind with more concentration.
+f.
+Samadhi is a state of transcendence and union
+with the universal consciousness.
+Hypothetically, mindful awareness of all the compo-
+nents of yoga gradually shifts the autonomic nervous
+system more towards the parasympathetic side or a bal-
+anced sympathetic-parasympathetic tone, finally leading
+to overall positive health in a cascading manner.
+Effects of yogic practices on individual organ
+systems
+Neuromuscular and endocrine system
+Yogasanas are largely isometric positions, and encour-
+age
+red-slow
+twitch
+fibres
+(Type-I),
+retuning
+the
+INTERNATIONAL REVIEW OF PSYCHIATRY
+245
+muscles to slower, more energy-efficient mode, appro-
+priate for reaching meditative states. In other words,
+the nervous system moves from sympathetic to para-
+sympathetic
+dominance
+as
+the
+yogasana
+practice
+retunes the muscle fibres away from type-II and
+towards type-I fibres. An experimental study also sup-
+ports this supposition regarding yogasana and muscle
+fibres (Balasubramanian & Pansare, 1991). In another
+study it was also found that with yogasana practice the
+aerobic
+power
+VO2
+max
+increased
+significantly,
+whereas anaerobic power decreased significantly (Ray
+et al., 2001).
+Adrenal hormone cortisol is also of great interest
+for yogasana practitioners and researchers. In a prelim-
+inary experimental study by Brainard et al., the cortisol
+drop between 11am and 12noon after one hour yoga-
+sana practice showed a slight drop as is normal for
+circadian rhythm in controls, whereas the beginner
+yoga practitioners showed more substantial cortisol
+level drop and experienced students, even much more
+substantial drop in cortisol level, suggesting yogasana
+practice could be an antidote for stress, which other-
+wise increases the cortisol levels (Brainard et al., 1997).
+Differences
+between
+yoga
+and
+aerobic
+exercise
+may be a result of their differential effects upon the
+HPA axis (Ross & Thomas, 2010). Low-intensity
+exercises tend to lower cortisol levels, while high
+intensity exercise leads to proportional increases in
+cortisol (Howlett, 1987). Thus yoga, involving slow
+and often non-strenuous activity positively affects the
+HPA axis response to stress by lowering sympathetic
+stimulation, therefore lowering levels of nor-epineph-
+rine
+and
+epinephrine
+(Selvamurthy
+et
+al.,
+1998).
+Aerobic exercise, on the other hand, appears to
+stimulate the sympathetic nervous system, therefore
+raising
+plasma
+epinephrine
+and
+nor-epinephrine
+(Bloom et al., 1976)
+Mind and Yoga
+In a recent study, yogasana practice was also found to
+increase brain derived neurotrophic factor (BDNF)
+and
+oxytocin,
+which
+are
+relevant
+for
+cognition
+(Jayaram et al., 2013; Naveen et al., 2013).
+BDNF and serotonin (5-hydroxytryptamine, 5-HT)
+are known to regulate synaptic plasticity, neurogenesis
+and neuronal survival in the adult brain. Serotonin has
+been proposed as one of neuromodulators mediating
+the effect of yoga (Kinser et al., 2012), which is sup-
+ported by higher levels of serotonin in meditators
+than non-meditators (Walton et al., 1995). Serotonin
+levels were also found to increase following laughter
+therapy
+in
+middle
+aged
+women
+with
+depression
+(Cha & Hong, 2015). BDNF has been found to
+increase following yoga and serotonin levels main-
+tained in patients with low back pain (Lee et al., 2014)
+with reduction in pain symptoms, thus suggesting the
+neuromodulatory effect of yoga in pain syndromes.
+Recent studies also found that yogasana practice
+increases the level of the neurotransmitter Gamma
+Amino Butyric Acid (GABA), which can induce a
+relaxed
+state
+conducive
+for
+meditative
+practices
+(Streeter et al., 2010). Yoga practices including OM
+chanting have been shown to reduce activity in limbic
+system, suggesting a role in regulation of emotions
+(Kalyani et al., 2011). In an interesting study, Cole
+observed
+that
+placing
+a
+student
+in
+supported
+Sethubandhasana or Padmasana position lead to an
+immediate shift from beta to alpha or theta type of
+EEG waves, suggesting a shift from aroused state to a
+deeper meditative state or sleep itself (Cole, 1989).
+Immune system
+Effect
+of
+Yogasana
+on
+immune
+system
+can
+be
+explained in the following ways:
+a.
+The general shift towards parasympathetic tone
+with yoga practice bolsters the immune system.
+b.
+Yogasana practice promotes the formation of red
+blood cells (Chohan et al., 1984) and white blood
+cells.
+c.
+Since a large part of the immune response is the
+transport
+of
+infectious
+agents
+to
+the
+site
+of
+lymphocyte action, yogasana practice improves the
+immune function by improving the circulation.
+Many of the inverted yoga poses facilitate the ven-
+ous and lymphatic drainage, and hence the circu-
+lation. B cells and T cells are found to readily
+increase
+in
+numbers
+with
+positive
+thinking,
+whereas negative thinking can reduce their num-
+bers (Rossi, 1993). Yogasana practice being a
+mindful awareness gives an experience of positive
+feeling and a sense of well-being, which increases
+the number of immune cells. Studies also support
+these statements in diseases like cancer which has
+a
+strong
+connection
+with
+psycho-immunology
+(Kochupillai et al., 2005; Rao et al., 2008).
+d.
+Yoga also appears to reduce markers of inflamma-
+tion like C-reactive protein and interleukin- 6 and
+influence
+virus-specific
+immune
+responses
+(Morgan et al., 2014).
+e.
+Recent systematic review suggest that yoga could
+mediate the positive effects on immune system
+through
+various
+inflammatory
+markers
+including
+cytokines
+(Interleukin-6,
+Tumor
+246
+R. GOVINDARAJ ET AL.
+Necrosis Factor-alpha, Interlukin-1beta, Interferon
+gamma) and cortisol levels (Pascoe & Bauer,
+2015).
+Cardio-respiratory system
+With
+regard
+to
+the
+cardiorespiratory
+system,
+the
+inverted
+yogasana
+postures
+and
+pranayama
+are
+unique among the yoga practices in terms of their
+effect on cardiorespiratory system. Inverted asanas
+like Sarvangasana, Halasana and Sirsasana create a
+volume overload on the heart at the initial stage of
+practice, but in the long run, they act in a paradox-
+ical way through sensitizing the baroreceptors, reduc-
+ing the heart rate and blood pressure (Robin, 2002)
+and
+hence
+are
+recommended
+for
+conditions
+like
+hypertension, although they need to be done with
+precautions under a competent teacher at the begin-
+ning
+stage
+(Iyengar,
+1979).
+Practices
+like
+Sethubandhasarvangasana,
+Vipritadandasana
+and
+Suptavirasana which have backward-bending compo-
+nents are good relievers of angina in Ischemic heart
+disease (Krishna, 2008).
+Pranayama is often mistaken for deep breathing or
+hyperventilation. Pranayama acts in a unique way by
+acting on the chemoreceptor area in the brain, which
+are sensitive to carbon di oxide (CO2). In pranayama,
+the important component is the holding of the breath
+(kumbhaka), which causes rise in CO2 level (central
+chemoreceptor area) and decrease in oxygen level (per-
+ipheral chemoreceptor area). However, in terms of
+haemoglobin oxygen saturation, kumbhaka enhances
+delivery of oxygen to tissues. The deep and slow
+breathing components of pranayama improve the
+inspiratory and expiratory volume, the vital capacity,
+and also reduce the dead space, as all parts of respira-
+tory tract are used.
+Psychologically, the phase of kumbhaka with opti-
+mal increase in CO2 level creates a state of alert
+calmness
+which
+is
+essential
+for
+the
+practice
+of
+meditation.
+Abdominal systems (Digestive, Renal and
+Reproductive)
+Most of the abdominal organs which are held in pos-
+ition by mesentery get enough rest during yogasanas,
+especially in the inverted poses like sarvangasana,
+which
+relieves
+the
+gravitational
+strain
+on
+them.
+Problems like prolapse of rectum, uterus can be
+avoided with regular practices of poses like sarvanga-
+sana. Forward bending poses like Paschimottanasana
+which stretch the retroperitoneal organs, including
+kidney,
+are
+useful
+in
+renal
+disorders.
+Poses
+like
+Ardhamatsyendrasana which has abdominal twist, cre-
+ates unique geometrical shape in their final position,
+which
+gives
+massage
+to
+organs
+like
+liver
+and
+spleen(Iyengar, 1979).
+Kriyas (cleansing practices) like Vamanadhouthi
+(regurgitative cleansing), Shankhaprakshalana (cleans-
+ing of entire digestive tract) are indicated for acidity
+and flatulence. Vamanadhouthi is highly recommended
+even in respiratory ailments like bronchial asthma, as
+it improves the mucociliary clearance (Nagarathna &
+Nagendra, 1985). Nauli and Uddiyana create a nega-
+tive suction pressure in the abdominal cavity which
+temporarily clamps the blood vessels and on releasing
+it, gives a new fresh supply of blood to the abdominal
+organs (Gore, 2007).
+Exercise
+Exercise is mainly targeted towards muscular and
+cardiorespiratory training. It also has many positive
+effects on most of the systems mentioned above if
+done moderately. Regular (particularly aerobic) exer-
+cise also appears to benefit the immune system and
+helps to offset diminished adaptive responses and
+chronic
+inflammation.
+There
+is
+a
+possibility
+that
+strenuous
+exercise
+may
+cause
+acute
+immunologic
+changes (such as diminished NK cell activity), which
+may predispose to infection in certain individuals
+(Haaland et al., 2008). Regular moderate exercise
+reduces the risk of infection compared with a seden-
+tary lifestyle, but very prolonged bouts of exercise
+and periods of intensified training are associated
+with
+an
+increased
+risk
+of
+infection
+(Gleeson
+&
+Walsh, 2012).
+BDNF levels have also been found to increase with
+moderate exercise (Coelho et al., 2013). Similarly acute
+physical exercise with mild and low stress can effi-
+ciently induce optimal neuronal activation that is
+involved
+in
+the
+antidepressant/anxiolytic
+effects
+through regulation of serotonin system, while high
+intensity exercise may have the opposite effect (Otsuka
+et al., 2016).
+However, yoga practices have many components
+with different levels of gravitational effect (standing,
+sitting, inverted, lateral bending poses, etc.) which
+have organ-specific effects, and also a holistic effect by
+shifting the whole functioning of the body from a fast,
+stressful sympathetic mode to a slow, steady and
+relaxed but alert parasympathetic mode. Also, yoga
+practices such as uni-nostril breathing involve volun-
+tary
+control
+of
+cerebral
+laterality
+which
+is
+quite
+unique.
+INTERNATIONAL REVIEW OF PSYCHIATRY
+247
+Adverse effects and Precautions
+Yoga
+Adverse effects of yoga, if practiced under supervision,
+are rare. However, some injuries or other effects have
+been reported, most commonly with the asana and
+pranayama components. Some meditative practices
+have been reported to worsen or provoke psychotic
+symptoms in vulnerable subjects, although the litera-
+ture is minimal (Walsh & Roche, 1979). In view of
+this, meditative practices may be avoided in subjects
+with a history of psychosis.
+The most common injuries with asanas are muscular
+sprains, which usually occurs as a result of inadequate
+warm up. Other rare but reported injuries due to
+improper
+asana
+practice
+without
+proper
+guidance
+include neurological injuries, vascular injury, and liga-
+ment injuries (Robin, 2002). Neurological damage and
+vascular damage are more likely to happen with inverted
+poses like Sirsasana, sarvangasana, Halasana, etc. which
+have either hyper flexion or extension of neck, which
+can affect the more delicate blood vessels (vertebral/
+basilar) or nerve plexus (brachial plexus) running across
+the cervical region. Overstretching beyond one’s cap-
+acity or time limit may lead to serious ligament injuries,
+especially in the knees, ankles and shoulders.
+Pranayama, if practiced improperly for a longer
+time, can lead to agitation, anxiety, and tremors,
+(Iyengar, 1979).
+Exercise
+Exercise, considering its wide range of practices includ-
+ing sports, gymnastics, athletics, weight lifting, etc. has
+a higher chance of causing injuries by the nature of
+the work out itself compared to yogasana practices. It
+may range from a simple sprain to a serious fracture,
+depending on the nature of the exercise.
+Yoga and Exercise-Evidence from comparative
+trials
+Choosing a proper control for yoga is a challenge for
+many
+reasons
+(Gangadhar
+&
+Varambally,
+2011).
+Nevertheless, attempts have been made to use exercise as
+a control for yoga in some of the studies with many of
+them favouring yoga as not only an effective alternate
+but also with additional benefits compared to exercise.
+Mental health
+Studies in patients with schizophrenia show significant
+improvement in psychopathology, socio-occupational
+functioning and facial emotion recognition compared
+to exercise at the end of two and four months (Behere
+et al., 2011; Duraiswamy et al., 2007). In patients with
+epilepsy, sahaja yoga meditation practice reduced the
+stress level as measured by Galvanic Skin Resistance
+(GSR), blood lactate and urinary vinyl mandelic acid
+(U-VMA), and also improved the visual contrast sensi-
+tivity significantly compared to their exercise counter-
+parts (Panjwani et al., 1995; Panjwani et al., 2000).
+In a recent trial comparing sports climbing (SC) to
+yoga in multiple sclerosis (MS), yoga was found to
+improve selective attention, whereas SC reduced the
+fatigue;
+both
+did
+not
+significantly
+alter
+mood
+(Velikonja et al., 2010). In an another study with MS
+patients, physical exercise and yoga were found to be
+equally effective in reducing fatigue, with no significant
+effect on mood at the end of six months (Oken et al.,
+2004). However, a small study by Sandroff et al.
+reported that treadmill walking was better than yoga
+for improving the mood in patients with MS patients
+(Sandroff et al., 2015).
+In middle aged and elderly healthy volunteers, yoga
+helped in significantly improving the mood, quality of
+life and reducing anxiety scores compared to exercise
+(Oken et al., 2006; Streeter et al., 2010). In an eight
+week intervention trial with healthy adolescents, yoga
+intervention led to a significant decrease in verbal
+aggressiveness,
+as
+compared
+to
+physical
+exercise
+(Deshpande et al., 2008).
+Cardio-respiratory health
+In healthy men aged 20-35 years, yoga and omkar
+meditation practices led to better cardiac parameters in
+terms of orthostatic tolerance, heart rate, and blood
+pressure compared to exercise (Harinath et al., 2004).
+In elderly healthy volunteers, yoga modulated the
+baroreceptor sensitivity favourably, and improved sym-
+patho-vagal
+balance
+as
+measured
+by
+Heart
+Rate
+Variability (HRV) (Santaella et al., 2011), whereas
+exercise had no effect on baroreceptor sensitivity
+(Bowman et al., 1997).
+In an interesting study, Khattab et al. compared
+HRV
+during
+a
+60-minute
+yoga
+practice
+versus
+60 minutes of park walking in long-term Iyengar yoga
+practitioners (n ¼ 11) as well as in healthy, age- and
+sex-matched control subjects who had no prior experi-
+ence with yoga or meditation. The long-term yoga
+practitioners exhibited significantly greater HRV, par-
+ticularly in those measures associated with parasympa-
+thetic tone, during the yoga intervention than during
+walking. They also had greater HRV than the control
+248
+R. GOVINDARAJ ET AL.
+group subjects during both yoga and walking (Khattab
+et al., 2007).
+In a trial conducted by Ray et al, absolute value of
+VO2Max increased significantly, and physical exertion
+score after maximal exercise decreased significantly, in
+the yoga group after 6 months, with no change in the
+physical exercise group (Ray et al., 2001). A recent
+meta-analytic review reported that yoga and physical
+exercises like walking or cycling were equally effica-
+cious in reducing the risk factors of cardiovascular dis-
+orders (Mayor, 2014).
+A RCT comparing the effects of yoga to non-aer-
+obic exercise on ambulatory blood pressure (BP) in
+individuals
+with
+Pre-
+and
+Stage
+1
+Hypertension
+(Hagins et al., 2014) demonstrated that a yoga inter-
+vention can lower BP in patients with mild hyperten-
+sion, while the active control intervention (non-aerobic
+exercise) used in this study did not reduce BP.
+Yoga-based
+respiratory
+training
+significantly
+improves the dynamic lung function (such as forced
+vital capacity, forced expiratory volume in 1 second,
+forced expiratory volume percentage, peak expiratory
+flow rate, and maximum voluntary ventilation) com-
+pared
+to
+exercise
+in
+middle
+aged
+healthy
+men
+(Harinath et al., 2004). Similar reports have been
+reported in elderly healthy volunteers as well (Santaella
+et al., 2011).
+Women’s health
+A recent study in high-risk pregnancy subjects suggest
+that guided yogic practices and visualization improves
+intrauterine fetal growth and the utero-fetal placental
+circulation better than the conventional antenatal exer-
+cise (Rakhshani et al., 2015).In another study by the
+same group, yoga was found to be significantly better
+in improving most of the domains of quality of life
+compared to the usual antenatal exercise (Rakhshani
+et al., 2010). Recent reviews on yoga for perinatal
+women also suggest yoga is a more effective tool than
+the usual perinatal exercise and that it also helps in
+reducing perinatal depression (Gong et al. 2015, Jiang
+et al. 2014).
+In peri-menopausal women, yoga helps in improv-
+ing the attention and concentration more than exer-
+cise, along with reduced hot flushes and night sweats
+(Chattha et al., 2008). In an another large study con-
+ducted by Nayak et al, yoga was more effective in
+improving quality of life than physical exercise (Nayak
+et al., 2014).
+Yoga practices were demonstrated to produce better
+improvement in quality of life and fatigue perception
+than
+exercise
+in
+patients
+with
+carcinoma
+breast,
+although both interventions showed positive results
+(Ya
+glı et al. 2015; Yagli & Ulger 2015). Yoga has also
+been shown to reduce the perceived stress in carcin-
+oma breast patients requiring surgery, during pre- and
+post-operative period (Kovac
+ˇic
+ˇ & Kovac
+ˇic
+ˇ, 2011).
+Musculoskeletal health
+In a large study among osteoarthritis patients, yoga
+was significantly better in improving the knee disabil-
+ity and quality of life than the usual physiotherapy
+exercises (Ebnezar et al., 2011).It was also as effective
+as
+exercise
+in
+improving
+back-related
+functions
+(Sherman et al., 2005) in patients with chronic low
+back pain.
+Yoga has been used extensively as a treatment for
+low back pain, with evidence for significant pain
+reduction in short-term as well as long-term studies
+(Cramer et al., 2013). A study comparing yoga with
+stretching exercise and a self-care book on back-pain
+(Sherman et al., 2011) found that yoga classes were
+more effective than a self-care book, but not more
+effective than stretching classes, in improving function
+and reducing symptoms due to chronic low back pain,
+with benefits lasting at least several months.
+In a RCT comparing yoga and home-based exercise
+program for chronic nonspecific neck pain (Cramer
+et al., 2013), yoga was more effective in relieving the
+pain. Yoga reduced neck pain intensity and disability
+and improved health-related quality of life. Yoga also
+seemed to positively influence the functional status of
+neck muscles in terms of range of motion and pro-
+prioceptive acuity.
+Endocrine and Metabolic health
+In patients with Type-2 Diabetes mellitus, hatha yoga
+is as effective as conventional physical exercise in
+improving the lipid profile, fasting blood glucose and
+antioxidant status (Gordon et al., 2008).
+In a study by Harinath et al, three months of yoga
+practice, but not physical exercise, increased plasma
+melatonin level, possibly substantiating the sense of
+well-being
+which
+most
+yoga
+practitioners
+report
+(Harinath et al., 2004).
+In an RCT (Telles et al., 2014) including 68 partici-
+pants, of which 63 were obese (5 overweight), both
+yoga and walking improved anthropometric variables
+(body weight, BMI, waist circumference, hip circum-
+ference), body composition (lean mass and body
+water) and serum lipid profile in overweight and obese
+persons. However, yoga increased serum leptin levels
+and
+walking
+re
+duced
+serum
+adiponectin
+levels.
+INTERNATIONAL REVIEW OF PSYCHIATRY
+249
+Reduction of adiponectin has been associated with
+insulin resistance, dyslipidemia, and atherosclerosis in
+humans, while action of leptin is to inhibit appetite,
+stimulate thermogenesis, enhance fatty acid oxidation,
+decrease glucose, and reduce body weight and fat
+(Yadav et al., 2013).
+A study examining stress-related outcomes in col-
+lege students compared the effects of a single class of
+yoga to African dance and a college lecture. While
+both the dance and yoga reduced perceived stress and
+negative affect, salivary cortisol increased in African
+dance
+and
+decreased
+in
+Hatha
+yoga
+participants
+(West et al., 2004).
+Conclusion
+Physical exercises and the physical components of
+yoga
+practices
+have
+several
+similarities,
+but
+also
+important differences. Evidence suggests that yoga
+interventions appear to be equal and/or superior to
+exercise in nearly every outcome measured (Ross &
+Thomas, 2010). Emphasis on breath regulation, mind-
+fulness during practice, and importance given to main-
+tenance of postures differentiates yoga practices from
+physical exercises. They also have differential effects
+on the body and the brain, both in healthy subjects
+and in persons suffering from various physical and
+mental disorders. In addition, yoga offers significant
+advantages in terms of enhancing positive mental
+health in the healthy population, and providing thera-
+peutic benefit as a sole or adjunct therapy in a range
+of physical and neuropsychiatric disorders. It is pos-
+sible that yoga might not only be an acceptable add-
+ition to care, but an effective, feasible, and accepted
+alternative to exercise (Ross & Thomas, 2010).
+Like exercise, yoga has advantages in that it is cost-
+effective, non-invasive, has minimal risk of adverse
+effects or drug interactions, does not require medical
+supervision for practice, and has the added benefit of
+improving physical fitness. These aspects are likely to
+increase patient preference and compliance, and may
+appeal to patients intolerant of or reluctant to use
+medication (da Silva et al., 2009). Like yoga, low-inten-
+sity exercise seems to have beneficial effects on the
+mind and body. The biological mechanisms underlying
+the effects of each need to be further teased out in
+research studies.
+Disclosure statement
+The authors report no conflict of interest. The authors
+alone are responsible for the content and writing of
+the paper.
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diff --git a/subfolder_0/Yoga as a Therapeutic Intervention in the Management of Dysfunctional Uterine Bleeding_ A Controlled Pilot Study.txt b/subfolder_0/Yoga as a Therapeutic Intervention in the Management of Dysfunctional Uterine Bleeding_ A Controlled Pilot Study.txt
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+++ b/subfolder_0/Yoga as a Therapeutic Intervention in the Management of Dysfunctional Uterine Bleeding_ A Controlled Pilot Study.txt	
@@ -0,0 +1,318 @@
+J Midlife Health. 2018 Jan-Mar; 9(1): 8–13.
+doi: 10.4103/jmh.JMH_76_17
+PMCID: PMC5879852
+PMID: 29628722
+Yoga as a Therapeutic Intervention in the Management of Dysfunctional
+Uterine Bleeding: A Controlled Pilot Study
+Snehal Pankaj Nalgirkar, Suhas Ashok Vinchurkar, Apar Avinash Saoji, and Sriloy Mohanty
+Division of Yoga and Life Sciences, S-VYASA, Bengaluru, Karnataka, India
+Center for Integrative Medicine and Research, AIIMS, New Delhi, India
+Address for correspondence: Dr. Suhas Ashok Vinchurkar, Swami Vivekananda Yoga Anusandhana
+Samsthana (S-VYASA Yoga University), 19, Eknath Bhavan, Gavipuram Circle, KG Nagar, Bengaluru - 560
+019, Karnataka, India. E-mail: suhasvinchurkar@gmail.com
+Copyright : © 2018 Journal of Mid-life Health
+This is an open access article distributed under the terms of the Creative Commons Attribution-
+NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-
+commercially, as long as the author is credited and the new creations are licensed under the identical terms.
+Abstract
+Background:
+Dysfunctional uterine bleeding (DUB) is one of the most common gynecological disorders encountered
+in women during the reproductive age. Yoga therapy has shown promising benefits in several
+gynecological disorders.
+Methods:
+Thirty women between the ages of 20 and 40 years with primary DUB were randomly assigned to a
+yoga (n = 15) and a waitlist control group (n = 15). Participants in the yoga group received a 3-month
+yoga module and were assessed for hemoglobin values, endometrial thickness (ET), pictorial blood loss
+assessment chart (PBAC), State-Trait Anxiety Inventory, perceived stress scale, and Pittsburgh Sleep
+Quality Index (PSQI) before and after a 3-month follow-up period.
+Results:
+At the end of 3 months of intervention, the yoga group, unlike the control group, reported a significant
+reduction in the anxiety scores (P < 0.05) and perceived stress (P < 0.05). The PSQI scores indicated a
+reduction in sleep disturbances (P < 0.001) and the need for sleep medications (P < 0.01) and higher
+global scores (P < 0.001). However, there were no changes in PBAC and ET in both the groups.
+Conclusion:
+The results indicate that yoga therapy positively impacts the outcome of DUB by reducing the
+perceived stress and state anxiety and improving the quality of sleep. This warrants larger clinical trials
+to validate the findings of this pilot study.
+Kൾඒඐඈඋൽඌ: Dysfunctional uterine bleeding, menstrual disorders, yoga, yoga therapy
+Iඖගක඗ඌඝඋගඑ඗ඖ
+1
+1
+Menstrual cycle is a complex entity involving many interactions of the central nervous, endocrine, and
+reproductive systems, i.e., hypothalamus, pituitary gland, and ovaries. It has been observed that many
+pathophysiological states associated with menstrual dysfunction have an increased incidence in the
+recent past. Over the years, it has been established that stress and drugs could have a potential to affect
+the menstrual cycle in various ways.[1]
+Dysfunctional uterine bleeding (DUB) is defined as a state of abnormal uterine bleeding without any
+clinically detectable organic, systemic, or iatrogenic cause.[2] Data from the WHO's multicenter survey
+report the prevalence of excessive menstrual bleeding ranging from 8% to 27%.[3,4] DUB is most
+common in extremes of the reproductive age. Among women aged 30–49 years, one in twenty consults
+the general practitioner each year with menorrhagia, making DUB one of the most commonly
+encountered gynecological problems. About 30% of all women report having had menorrhagia, and it
+accounts for two-thirds of all hysterectomies.[5] The prevalence of the occurrence of DUB is found to
+be ovular (10%) and anovular or oligo-ovular (90%), the latter being the most common cause of
+abnormal uterine bleeding.[5]
+Among psychological factors, stress is the most imperative factor affecting the menstrual cycle. Stress
+influences all the body systems through other neurohormonal connections, the hypothalamo–pituitary–
+adrenal (H-P-A axis) as well as hypothalamo–pituitary–ovarian axis (H-P-O axis). Studies demonstrate
+that the glucocorticoids released due to the stress put forth an inhibitory action on the gonadotropin-
+releasing hormone (GnRH), thereby distressing the ovarian function. Elevated levels of corticotrophin-
+releasing hormone (CRH) and cortisol also suppress the GnRH secretion and consequently decline
+ovulation. Thus, stress could significantly diminish reproductive functions in an effort to maintain
+homeostasis.[6] Previous studies have found that the stress influences the incarcerated women leading
+to high rates of amenorrhea and menstrual irregularity.[7] Evidence also suggests an association of
+sleep disturbances and disturbed circadian rhythm with menstrual disorders.[8,9] Abnormal uterine
+bleeding is also associated with loss of health-related quality of life when compared to healthy women
+with the same age. DUB leads to significant direct and indirect costs as well as loss of productivity.[10]
+The most common conventional management of DUB involves progestin therapy in varied doses based
+on the age. Low-dose combination hormonal contraceptive therapy (20–35 μg ethinylestradiol) is the
+mainstay of treatment for adolescents up to the age of 18 years. For women aged 40 years or older,
+before menopause, the treatment consists of cyclic progestin therapy, low-dose oral contraceptive pills,
+levonorgestrel intrauterine device, or cyclic hormone therapy. Although these treatments are found to
+be effective, they do have adverse effects on the overall health of the women. The drawback to medical
+therapy, in addition to side effects, is that the benefit lasts only while the patient takes the medication.
+Surgical options have concentrated mainly on endometrial ablation and hysterectomy, and it is unclear
+whether one is superior to the other in terms of long-term outcome and patient satisfaction.[11]
+With the advent of adversities with conventional management, patients have started exploring
+complementary and alternative medicine (CAM) therapies for managing DUB.[12] According to a
+survey, CAM therapies are commonly used by women for menstrual disorders to reduce pain and
+discomfort and yoga is among the top 5. The CAM therapies are found to be safe and known to
+enhance the quality of life in women.[13]
+It has been demonstrated that regular practice of yoga has beneficial effects on both phases of the
+menstrual cycle by bringing physical and psychological well-being and by balancing neuro-endocrinal
+axis.[14,15] In India, yoga therapy is commonly recommended for treating various noncommunicable
+diseases and for overall well-being.[16,17,18] Yogic therapy helps in improving hormonal and
+biochemical changes related to H-P-O and H-P-A axes in polycystic ovarian syndrome (PCOS).[19]
+Yoga Nidra is reported to be beneficial in managing the psychological impact of menstrual disorders.
+[20,21] Overall, yoga is known to be beneficial in the general well-being of individuals in health and
+disease.
+To the best of our knowledge, there are no studies reporting the effects of yoga practices on the health
+status of patients suffering from DUB. Given the vital role of yoga in the management of several
+disorders relating to women, the current study was executed to ascertain the role of an integrated yoga
+module in the management of DUB.
+Mඍගඐ඗ඌඛ
+Design
+The present study was a parallel-arm controlled pilot trial to compare the outcome of participants
+assigned to experimental (yoga and conventional care) group with that of a wait-listed control
+(conventional care alone) group. Participants were randomly assigned to either yoga or control groups
+using a computer-generated program (www.randomizer.org) with a 1:1 allocation ratio.
+Ethical considerations
+The ethics committee of the university approved the study. The variables to be recorded and the study
+design were described to the participants and a signed informed consent to participate in the study was
+obtained.
+Participants
+Thirty participants out of 52 were found eligible for the trial. They were randomly allocated into two
+groups, namely yoga (n = 15, group mean age ± standard deviation (SD), 29.85 ± 4.45 years) and a
+wait-listed control group (n = 15, group mean age ± SD, 30.85 ± 4.42 years). One participant from each
+group dropped up during the follow-up period and therefore finally 14 participants in each group were
+assessed and interpreted. Participants were recruited from the gynecology departments of three leading
+hospitals in Central India. Participants satisfying the age range of 20–50 years and diagnosed for
+primary DUB with no underlying systemic pathology were included in the study. Females with benign
+and malignant pelvic lesions, coagulation disorders, hypothyroidism, liver diseases, and pregnancy
+were excluded from the study. Figure 1 represents the schematic of the Trial Profile.
+Figure 1
+The flow of participants through the trial (trial profile)
+Intervention
+Yoga group
+For the assessment of blood loss
+The yoga group was trained in an Integrated Approach of Yoga Therapy (IAYT) specially
+designed for menstrual disorders [Table 1]. Yoga group practiced this protocol for 3 consecutive
+months for 60 min a day for 3 days a week. This IAYT protocol included special yoga physical
+postures (asanas), breathing techniques (pranayama), and meditation (dhyana) for menstrual disorders
+aiming reduction in bleeding and pain, reduction in stress levels that women undergo during that
+period, and overall well-being.
+Table 1
+Integrated Approach of Yoga Therapy module for dysfunctional uterine bleeding
+The wait-listed control group received standard care under the supervision of the consulting
+gynecologist for the same duration of 3 months. They were offered general counseling and were asked
+to avoid any yoga-based practices during the experimental duration. After the intervention period, they
+were offered training in yoga for the same duration as the experimental group.
+Assessments
+Variables were obtained at baseline and at the end of interventional period. The variables included
+assessments for blood loss–comprising hemoglobin, pictorial blood loss assessment chart (PBAC),
+endometrial thickness (ET), and psychological assessments including Spielberger's State-Trait Anxiety
+Inventory (STAI), Perceived Stress Scale (PSS), and Pittsburgh Sleep Quality Index (PSQI). The
+assessments were as follows
+1. Hemoglobin: Hemoglobin was assessed as a fundamental indicator of blood loss as well as the
+general health as it signifies the nutritional support for all the systems in the body. Increased
+amount of blood loss is debilitating and may lead to anemia. Hence, to assess the severity of
+blood loss, hemoglobin was measured by taking a blood sample. The hemoglobin concentration
+was measured using the Coulter method
+For the psychological assessment
+2. PBAC: The PBAC was used as an alternative for measuring blood loss. A pictorial chart score of
+100 or more, when used as a diagnostic test for menorrhagia, was found to have a specificity and
+sensitivity of >80%[22]
+3. ET: ET was assessed using routine gynecological ultrasound. In the current study, ET was
+measured at the 11  or 12  day of menstrual cycle.[23]
+1. Spielberger's STAI: Spielberger's STAI was used as a self-report measure with a subset of items
+for state and trait anxiety. Participants were asked to answer twenty questions in each subtest on
+a Likert scale from 1 (not at all) to 4 (very much so)[24]
+2. PSS: The Perceived Stress Scale (PSS) is a classic stress assessment instrument. The tool, while
+originally developed in 1983, remains a popular choice for helping us understand how different
+situations affect our feelings and our perceived stress. The questions in this scale asked about the
+subjects feelings and thoughts during the previous month. In each case, subjects were asked to
+indicate how often they felt or thought a certain way.[25]
+3. PSQI: PSQI is a self-rated questionnaire that assesses sleep quality and disturbances over a 1-
+month time interval and probes clinically important and patient-relevant symptoms in the areas
+of sleep quality and quantity. PSQI is a 19-item self-rated questionnaire to assess the quality of
+sleep. It also includes a 5-bed partner or roommate questions, which are not included in the
+scoring.[26]
+Data analysis
+Statistical analysis was performed using IBM SPSS 21.0 (IBM Corp, Armonk, NY). Data were tested
+for normality and appropriate statistical tests were applied for respective variables.
+Paired sample t-test was applied to ascertain the within-group (pre-post) differences for both yoga and
+control groups. Independent samples t-test was applied to understand the between-group changes in the
+postscores of hemoglobin, PBAC, ET, STAI, and PSS.
+PSQI data were analyzed using repeated measures (RM) ANOVA. There were eight “within-subjects”
+factors, i.e., subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep
+disturbances, use of sleeping medication, daytime dysfunction, and global PSQI score. Post hoc
+analyses with a least significant difference were performed using Bonferroni correction and all
+comparisons were made with the respective “pre” states.
+For all the analyses, 95% confidence intervals are presented and P < 0.05 was considered statistically
+significant.
+Rඍඛඝඔගඛ
+Paired sample t-test and independent samples t-test were run within and between participants,
+respectively. There were no significant changes between the groups in hemoglobin levels, PBAC, and
+ET. However, the control group showed significant improvement (paired sample t-test, t = 2.381, P <
+0.05) in the pre-post comparison of the hemoglobin levels. Yoga group demonstrated a significant
+reduction in the perceived stress (paired sample t-test, t = 2.622, P < 0.05) and STAI scores (paired
+sample t-test, t = 2.159, P < 0.05), whereas the control group had no significant changes. Yoga group
+also showed significant improvement in the PSQI global scores following the intervention duration
+(RM ANOVA, mean difference = 5.250, −5.250, P < 0.001) See Tables 2 and 3.
+th
+th
+Table 2
+Outcome variables following 12 weeks of Integrated Approach of Yoga Therapy and control
+Table 3
+The changes in Pittsburgh Sleep Quality Index following 12 weeks' Integrated Approach of
+Yoga Therapy and control
+Dඑඛඋඝඛඛඑ඗ඖ
+The present study demonstrated significant reductions in perceived stress and anxiety among women
+suffering from DUB following the yoga intervention for 12 weeks in comparison to the baseline data.
+There were no significant changes observed between groups in the hemoglobin, ET, or the PBAC.
+Although there was a significant increase in hemoglobin in the control group when compared to
+baseline, the mean postvalue of hemoglobin in the control group remained lower than that of the yoga
+group. In addition, a mean change of 0.4 g% may not be considered clinically significant. There was no
+deterioration of hemoglobin levels in the yoga group when compared to baseline. The global scores of
+PSQI were significantly improved following the practice of yoga and were primarily associated with
+reduced sleep disturbances and the need for sleep medications.
+The role of yoga in reducing stress is well documented,[27,28] and our study concurs with the findings
+of earlier studies on yoga practices in menstrual disorders. An earlier study comparing the autonomic
+functions and psychological well-being of females suffering from premenstrual syndrome
+demonstrated enhanced autonomic functions and psychological well-being following the practice of
+yoga.[14] There was evidence of significant reduction of the anxiety score in women suffering from
+PCOS.[15] Nidhi et al. also demonstrated enhanced hormonal profile in women suffering from PCOS
+following a 12-week integrated yoga intervention.[19] Another study compared the practice of Yoga
+Nidra, a relaxation technique in yoga, practiced for 6 months by the patients suffering from menstrual
+irregularities with nonpractitioners. The results of this study reported a significant improvement in
+psychological well-being and general health following the practice of Yoga Nidra.[21] The current
+study indicated beneficial effects of yoga practice on sleep in patients with DUB. Earlier studies on
+yoga show improved sleep quality in different populations.[29] Improvement in the sleep quality may
+also play a potential role in the regulation of menstruation, by restoring the overall hormonal balance.
+[30]
+The role of perceived stress and anxiety in modulating the hormonal status is well documented.[31] We
+postulate that yoga may influence the CRH and corticosteroid levels through reduction of perceived
+stress and anxiety. These hormones are known to inhibit the GnRH secretion and thereby responsible
+for the ovarian dysfunction in patients suffering from DUB.[5] Therefore, IAYT might be useful in
+reducing the stress and anxiety and thereby balancing the H-P-O and H-P-A axes. The endocrinal
+profile could be used as a variable in future studies to understand the underlying mechanisms of
+beneficial effects of yoga in DUB.
+The observations from the current study suggest that there could be an improvement in the hormonal
+status of the individuals with menstrual disorders due to reduced anxiety, stress, and an improved sleep
+quality following the practice of yoga.
+We speculate that the trend of improvement observed in the variables of the current study could reach
+statistical significance with a larger sample size. These results therefore warrant further large-scale
+trials to establish the efficacy of yoga as a treatment modality for patients with DUB. Yoga, being a
+cost-effective and easy-to-adapt lifestyle intervention, could be a beneficial tool to complement the
+conventional therapies involved in managing DUB.
+C඗ඖඋඔඝඛඑ඗ඖ
+Although the current study failed to substantiate the benefits of yoga in the objective variables in
+patients with DUB, the changes in subjective measures were significant to ascertain the beneficial
+changes. Overall, the results of this pilot study demonstrate that yoga practices can diminish perceived
+stress and anxiety and improve sleep quality in patients suffering from DUB and thereby improve their
+quality of life.
+Financial support and sponsorship
+Nil.
+Conflicts of interest
+There are no conflicts of interest.
+Rඍඎඍකඍඖඋඍඛ
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+Publications
diff --git a/subfolder_0/Yoga as an adjunct modality for promotion of healthy use of information technology.txt b/subfolder_0/Yoga as an adjunct modality for promotion of healthy use of information technology.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c1acd935403d3fbda58167d96f3cddc3603032c0
--- /dev/null
+++ b/subfolder_0/Yoga as an adjunct modality for promotion of healthy use of information technology.txt	
@@ -0,0 +1,178 @@
+© 2016 International Journal of Yoga | Published by Wolters Kluwer - Medknow
+176
+support programs for the promotion of healthy use of 
+technology on out-patient basis.
+Research examined the risk factors associated with 
+internet addiction in high school teenagers and identified 
+male gender, drinking behavior, family dissatisfaction, 
+and experience of recent stressful events as the major 
+ones.[8] The study also shows that IA has a direct impact 
+on depression, anxiety, and stress.[9]
+Yoga, a holistic mind-body therapy that utilizes physical 
+postures, breathing practices, meditation, and relaxation 
+techniques have recently become popular as an important 
+adjunct to conventional modalities of treatment for the 
+management of various psychiatric disorders[10] including 
+addictions.[11] Therefore, we incorporated yoga therapy as 
+an add-on in SHUT Clinics. As a part of this approach, users 
+(70 users who reported physical distress due to excessive 
+use [10–12 h a day] of desktop/smart phone) were counseled 
+to perform brief integrated yoga program, whenever the 
+usages exceed more than 1 h/day. The integrated yoga 
+program involved: Joint loosening practices with breath 
+synchronization for 10 min (moving head forward and 
+backward as well as clockwise and anticlockwise ten 
+times each), blinking of eyes (twenty times), stretching 
+of hand/legs and moving the wrist/legs clockwise and 
+anticlockwise (ten times each) followed by Kapalabhati 
+Kriya (skull shining breath) at 100 strokes/min for 2 min, 
+Nadi-shuddhi pranayama (alternate nostril breathing) for 
+5 min, and Bhramari (humming breath) pranayama for 
+5 min. Subjects were also offered yogic counseling based 
+on the principles of mind management from Bhagavad 
+Gita.[12] These practices were demonstrated to them and 
+supervised during sessions. The clinical interview revealed 
+them to be at the action stage of motivation for these yoga 
+practices. They were also motivated for lifestyle changes. 
+The follow-up for assessing the efficacy of this program 
+was carried out at 3 months interval for 45 IA subjects who 
+continued the treatment. All of them reported reduction in 
+the body pain and neck strain. Yoga practices also brought 
+positive lifestyle changes in the form of regulated sleep, 
+improved appetite, enhanced communication with others, 
+and increased recreational activities outside the home. Due 
+to these positive lifestyle changes and reduced physical 
+symptoms such as neck strain and body pain, they reported 
+30–40% reduction in their technology use at the end of 3rd 
+month. Moreover, those under yoga program showed better 
+compliance with conventional modes of management may 
+it be drugs or psychotherapeutic techniques.
+Dear Sir,
+The Internet is a new technology that has impacted the 
+world and provided many benefits. At the same time, 
+it has had negative ramifications. Reports indicate that 
+some online users were becoming addicted to the Internet 
+in much the same way that others became addicted to 
+drugs or alcohol, which resulted in poor psychological 
+well-being, reduced work performance, social withdrawal, 
+poor self-confidence, family problems, marital breakdown, 
+poor diet, sleep deprivation, and cardio-pulmonological 
+complications.[1,2] Other adverse consequences associated 
+with Internet addiction (IA) include negative academic 
+consequences. A study used pathological gambling as a 
+model and defined addictive internet use as an impulse-
+control disorder that does not involve an intoxicant.[3]
+In a survey among 350 (200 females and150 males), 
+24% had problematic usage of internet.[4] Another 
+epidemiological survey on 2755 subjects from Bengaluru 
+in the age group of 18–65 years (50.5% males and 49.5% 
+females) found that addictive use was present among 1.3% 
+(2% males and 0.6% females) for internet, 4.1% (5% males 
+and 3.1% females) for mobile phones, and 3.5% for social 
+networking sites.[5] It was observed that the hours spent 
+on internet by dependent users were greater than those 
+of the non-dependent users. Those dependent on internet 
+scored higher than the non-dependent on the loneliness 
+measures.[6] Similarly, screening of 621 students from class 
+11th and 12th in higher secondary schools of Ahmedabad 
+city of India revealed that 12% were dependent on 
+internet.[7]
+In response to this fast emerging problem of Internet 
+addiction, National Institute of Mental Health and 
+Neurosciences, Bengaluru has started India’s first technology 
+de-addiction center called as the “SHUT Clinic” (Service for 
+Healthy Use of Technology). SHUT Clinic has been getting 
+2–3 patients of IA/week with complaints of excessive 
+use of internet that hampers their socio occupational 
+functioning. Patients are chiefly belonging to male gender, 
+in the age group of 14–19 years and from middle to upper 
+socioeconomic status. Most common reported usages of 
+internet are video gaming, mobile texting, social networking 
+sites, and pornography using smart phones, computers at 
+home, or cyber cafe. The average usage of internet varied 
+from 10 to 12 h/day. Physical distress (body pain, dryness 
+of eyes, and neck strain) is commonly reported dysfunction 
+among the users. SHUT Clinic provides psychology-based 
+Letter to Editor
+Yoga as an adjunct modality for promotion of healthy use of 
+information technology
+[Downloaded from http://www.ijoy.org.in on Wednesday, July 27, 2016, IP: 14.139.155.82]
+177
+International Journal of Yoga • Vol. 9 • Jul-Dec-2016
+Letter to Editor
+Since high-stress levels, physical distress, and unregulated 
+lifestyle are important contributors toward internet 
+addiction, integrated yoga program with its comprehensive 
+holistic approach may serve as a useful adjunct to enhance 
+the efficacy of conventional modes of treatment.
+Financial support and sponsorship 
+Nil.
+Conflicts of interest
+There are no conflicts of interest.
+Manoj Kumar Sharma, Hemant Bhargav1
+Department of Clinical Psychology, NIMHANS Centre for Well Being, 
+Service for Healthy Use of Technology Clinic, NIMHANS, 
+ 
+1Division of Yoga and Life Sciences, SVYASA University, Bengaluru, 
+Karnataka, India
+Address for correspondence: 
+Dr. Manoj Kumar Sharma, 
+ 
+Department of Clinical Psychology, NIMHANS Centre for Well 
+Being, Service for Healthy Use of Technology Clinic, NIMHANS, 
+Govindaswamy Block, Bengaluru - 560 029, Karnataka, India. 
+E-mail: shutclinic@gmail.com
+REFERENCES
+1.	
+Christakis DA. Internet addiction: A 21st century epidemic? BMC Med 
+2010;8:61.
+2.	
+Flisher C. Getting plugged in: An overview of internet addiction. J Paediatr 
+Child Health 2010;46:557-9.
+3.	
+Barthakur M, Sharma MK. Problematic internet use and mental health 
+problems. Asian J Psychiatr 2012;5:279-80.
+4.	
+Young KS. Internet addiction: The emergence of a new clinical disorder. 
+Cyberpsychol Behav 1998;1:237-44.
+5.	
+Sharma MK, Benegal V, Rao G, Thennarasu K. Behavioral addiction in the 
+community: An exploration. Indian Council Med Res 2013:1-89. [Funded 
+unpublished work].
+6.	
+Nalwa K, Anand AP. Internet addiction in students: A cause of concern. 
+Cyberpsychol Behav 2003;6:653-6.
+7.	
+Yadav P, Banwari G, Parmar C, Maniar R. Internet addiction and its correlates 
+among high school students: A preliminary study from Ahmedabad, India. 
+Asian J Psychiatr 2013;6:500-5.
+8.	
+Lam LT, Peng ZW, Mai JC, Jing J. Factors associated with Internet addiction 
+among adolescents. Cyberpsychol Behav 2009;12:551-5.
+9.	
+Akin A, Iskender M. Internet addiction and depression, anxiety and stress. 
+Int Online J Educ Sci 2011;3:138-48.
+10.	 Balasubramaniam M, Telles S, Doraiswamy PM. Yoga on our minds: A 
+systematic review of yoga for neuropsychiatric disorders. Front Psychiatry 
+2013;3:117.
+11.	
+Khanna S, Greeson JM. A narrative review of yoga and mindfulness 
+as complementary therapies for addiction. Complement Ther Med 
+2013;21:244-52.
+12.	 Nagarathna R, Nagendra HR. Yoga module for anxiety. In: Nagendra HR, 
+editor. Yoga for Anxiety and Depression. 1st ed. Bangalore: Swami Vivekananda 
+Yoga Prakashan; 2001. p. 33-86.
+Access this article online
+Website: 
+www.ijoy.org.in
+Quick Response Code
+DOI: 
+10.4103/0973-6131.183706 
+How to cite this article: Sharma MK, Bhargav H. Yoga as an adjunct 
+modality for promotion of healthy use of information technology. Int J 
+Yoga 2016;9:176-7.
+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.
+[Downloaded from http://www.ijoy.org.in on Wednesday, July 27, 2016, IP: 14.139.155.82]
diff --git a/subfolder_0/Yoga based cardiac rehabilitation after coronary artery bypass surgery.txt b/subfolder_0/Yoga based cardiac rehabilitation after coronary artery bypass surgery.txt
new file mode 100644
index 0000000000000000000000000000000000000000..415d032c34bae9c7e26e9e0fe34a7b3586f49b2d
--- /dev/null
+++ b/subfolder_0/Yoga based cardiac rehabilitation after coronary artery bypass surgery.txt	
@@ -0,0 +1,1887 @@
+Original Article
+Yoga based cardiac rehabilitation after coronary
+artery bypass surgery: One-year results on LVEF,
+lipid profile and psychological states e A
+randomized controlled study
+Nagarathna Raghuram a,*, Venkateshwara Rao Parachuri c,
+M.V. Swarnagowri b, Suresh Babu b,c, Ritu Chaku b, Ravi Kulkarni d,
+Bhagavan Bhuyan c, Hemant Bhargav b,
+Hongasandra Ramarao Nagendra b
+a Dean, Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana University,
+19 Eknath Bhavan, Gavipuram Circle, Kempegowda Nagar, Bangalore, Karnataka, India
+b Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana University,
+19 Eknath Bhavan, Gavipuram Circle, Kempegowda Nagar, Bangalore, Karnataka, India
+c Department of Cardiology, Narayana Hrudayalaya Institute of Cardiac Sciences, No. 258/A,
+Bommasandra Industrial Area, Hosur Road, Anekal Taluk, Karnataka, India
+d Symbiosis International University, Pune, India
+a r t i c l e i n f o
+Article history:
+Received 26 September 2013
+Accepted 11 August 2014
+Available online 28 August 2014
+Keywords:
+Yoga
+Physiotherapy
+Cardiac rehabilitation
+LVEF
+Risk factors
+a b s t r a c t
+Objective: To compare the long term effects of yoga based cardiac rehabilitation program
+with only physiotherapy based program as an add-on to conventional rehabilitation after
+coronary artery bypass grafting (CABG) on risk factors.
+Methods: In this single blind prospective randomized parallel two armed active control
+study, 1026 patients posted for CABG at Narayana Hrudayalaya Institute of Cardiac Sci-
+ences, Bengaluru (India) were screened. Of these, 250 male participants (35e65 years) who
+satisfied the selection criteria and consented were randomized into two groups.
+Within and between group comparisons were done at three points of follow up (i.e. 6th
+week, 6th month, and 12th month) by using Wilcoxon's signed ranks test and Mann
+Whitney U test respectively.
+Results: Yoga group had significantly (p ¼ 0.001, Mann Whitney) better improvement in
+LVEF than control group in those with abnormal baseline EF (<53%) after 1 year. There was
+a better reduction in BMI in the yoga group (p ¼ 0.038, between groups) in those with high
+baseline BMI (23) after 12 months. Yoga group showed significant (p ¼ 0.008, Wilcoxon's)
+reduction in blood glucose at one year in those with high baseline FBS 110 mg/dl. There
+was significantly better improvement in yoga than the control group in HDL (p ¼ 0.003), LDL
+(p ¼ 0.01) and VLDL (p ¼ 0.03) in those with abnormal baseline values. There was signifi-
+cantly better improvement (p ¼ 0.02, between groups) in positive affect in yoga group.
+Within Yoga group, there was significant decrease in perceived stress (p ¼ 0.001), anxiety
+* Corresponding author. Tel.: þ91 9845088086.
+E-mail address: rnagaratna@gmail.com (N. Raghuram).
+Available online at www.sciencedirect.com
+ScienceDirect
+journal homepage: www.elsevier.com/locate/ihj
+i n d i a n h e a r t j o u r n a l 6 6 ( 2 0 1 4 ) 4 9 0 e5 0 2
+http://dx.doi.org/10.1016/j.ihj.2014.08.007
+0019-4832/Copyright © 2014, Cardiological Society of India. All rights reserved.
+(p ¼ 0.001), depression (p ¼ 0.001), and negative affect (p ¼ 0.03) while in the control group
+there was reduction (p ¼ 0.003) only in scores on anxiety.
+Conclusion: Addition of yoga based relaxation to conventional post-CABG cardiac rehabili-
+tation helps in better management of risk factors in those with abnormal baseline values
+and may help in preventing recurrence.
+Copyright © 2014, Cardiological Society of India. All rights reserved.
+1.
+Introduction
+World Health Organization (WHO) has been sounding an
+alarm on the rapidly rising burden of cardio-vascular disor-
+ders for the past 15 years.1 The reported prevalence of coro-
+nary artery disease (CAD) in adult surveys has risen 4-fold
+over the last 40 years (to a present level of around 10%) ac-
+counting for 29% of all deaths in 2005.2 It strikes Indians early
+and kills many in their productive mid-life years.3
+Coronary artery bypass grafting (CABG) is by far the most
+common among the surgical methods of management in
+CAD4 even in India. The cardiac functional status and the level
+of psychosocial stress before surgery can influence the quality
+of life and prognosis after CABG.5,6 LVEF as seen in 2D-echo-
+cardiogram has favorable correspondence to invasive data7
+and has been found to be of predictive value for both, the
+immediate post-operatives prognosis (the duration of hospital
+stay) and late mortality after CABG.8,9 Depression has been
+found to be another independent prognostic factor for mor-
+tality, readmission, cardiac events and lack of functional
+benefits 6 months10 to 5 years11 after CABG. These observa-
+tions point to the need for integrating psychosocial in-
+terventions
+during critical
+care to
+provide holistic and
+effective management after CABG.12
+Several studies have documented the benefits of relaxation
+techniques in pre and post-operative period. In a two armed
+randomized
+controlled
+study,
+Engblom
+et
+al13
+showed
+increased hobby activities and reduction in scores on Beck's
+Depression Index during the first post-operative year after
+CABG in the group who had a comprehensive post-op reha-
+bilitation (physical exercise, relaxation training, group dis-
+cussion sessions and dietary advice) as compared to the group
+who
+had
+hospital
+based
+rehabilitation.
+Another
+study
+observed significant reductions in both state and trait anxiety
+after 6 weeks of progressive muscular relaxation in anxious
+patients after CABG.14 Patients who listened to audiotape in-
+formation containing information to improve post-operative
+outcomes had significantly increased physical activity with
+fewer symptoms of shoulder pain or back pain or anorexia,
+than the control group.15
+It is noteworthy that a few similar interventional stud-
+ies,13e15 observed no changes in the quality of life after 6
+weeks to one year of interventions which points to the need
+for carefully designed type, frequency and duration of in-
+terventions. Yoga including meditation has been incorporated
+in life style interventions in CAD since nineteen seventies.
+Yoga is emerging as a useful rehabilitation tool for various
+chronic
+lifestyle
+related
+ailments.16
+Transcendental
+Meditation (TM) program has been found to decrease CAD risk
+factors,
+cardiovascular
+morbidity,17,18
+carotid
+atheroscle-
+rosis,19 and mortality.20,21 Intensive yoga based life style
+modification program have been shown to retard coronary
+atherosclerosis.22e24 There are no published studies reporting
+the effect of add-on yogic relaxation techniques in post-CABG
+rehabilitation. Hence the present study was planned to assess
+the complimentary effects of yogic relaxation with the hy-
+pothesis that this would offer additional benefits to conven-
+tional post-CABG rehabilitation.
+2.
+Methods
+2.1.
+Participants
+One thousand twenty six patients with CAD (established by
+coronary angiogram) who were posted for elective CABG sur-
+gery at Narayana Hrudayalaya Institute of Cardiac Sciences
+(NHICSc), Bengaluru (India) were screened. Two hundred and
+fifty male participants in the age range of 35e65 years, who
+fulfilled the selection criteria were randomized into two
+groups.
+Inclusion criteria were: (a) those with established double or
+triple vessel disease posted for elective CABG, (b) males be-
+tween 35 and 65 years of age, and (c) those with their resi-
+dential address within 200 km from NHICSc hospital to ensure
+compliance for follow up. Female patients posted for CABG
+were excluded as the post-CABG prognosis is different in fe-
+males25 and the number of females available for final sub-
+group analysis would be insufficient. Other exclusion criteria
+were: emergency CABG, CABG with valve surgeries, acute and
+chronic renal failure with or without dialysis, physical dis-
+abilities that would prevent them from doing yoga practices,
+neuro-psychiatric illness, and patients already exposed to
+yoga. Those with left ventricular ejection fraction (LVEF) <30%
+were also excluded as the ethical committee was not
+convinced about the safety of the procedure and this was the
+first study with no published evidence for the safety of the
+yoga techniques used.
+The study was funded by the Department of AYUSH,
+Ministry of Health and Family Welfare, New Delhi, India under
+the ‘Extra Mural Research’ scheme. The research protocol
+including the informed consent forms in English and Kannada
+languages, were approved by the institutional ethics com-
+mittee of both SVYASA University and NHICSc. Signed
+informed consent was obtained from all participants before
+recruitment.
+i n d i a n h e a r t j o u r n a l 6 6 ( 2 0 1 4 ) 4 9 0 e5 0 2
+491
+2.2.
+Design
+This was a single blind longitudinal prospective randomized
+parallel two armed control study, conducted by the division of
+yoga and life sciences of the SVYASA University, Bengaluru,
+India between 2003 and 2007 at NHICSc., Bengaluru.
+2.3.
+Procedure
+Participants were allocated to two groups using a computer-
+generated random number table (www.randomizer.org). The
+table was generated by the statistician at the university cen-
+ter, that allocated them to the yoga based life style modifica-
+tion
+program
+(YLSP)
+or
+physiotherapy
+based
+life
+style
+modification program (PTLSP) groups. After recruitment all
+baseline data were documented by the research team. The
+Yoga therapist personally visited the ward and taught yogic
+relaxation twice a day for 1e3 days after admission during the
+pre-operative preparation. After ensuring the correctness of
+practice with right understanding, the patient was asked to
+continue the practice using a pre-recorded audio tape. After
+the surgery, the nurses in the ICU ensured the practice
+through the audio player. Two to three days before discharge,
+when the patient was out of the ICU, the yoga therapist sat
+with the patient and revised the practice under supervision.
+After discharge they were asked to continue the practices
+twice daily. They were taught more yoga techniques (Table 1)
+during their 6th week and 6th month follow up visits. Home
+practice (one hour/day) was monitored by providing a life style
+diary and regular weekly phone calls by the therapist. All
+relevant data were taken on the day before surgery and during
+their follow up visits after 6 weeks, 6 months and 1 year after
+surgery.
+2.4.
+Blinding
+As this was an interventional study, the participants and
+trainers could not be blinded; the team who did the laboratory
+assessments and the statistician were blind to the source of
+the data.
+2.5.
+Intervention
+Pharmacotherapy as advised by the clinician and the con-
+ventional post-operative rehabilitation practices, were com-
+mon to both groups. The medication dosages during the
+baseline and intervention periods were kept stable by partic-
+ipant and physician consent. There was no significant differ-
+ence in the percentage of subjects taking medications in the
+two groups (Table 3). Under conventional post-CABG rehabil-
+itation, common daily practices (30 min) were administered
+by a team of trained physiotherapists to both groups which
+included: (a) gradually increasing distance and speed of
+walking with intermittent relaxation covering a total of about
+2 km/day, (b) breathing exercises and (c) breathing through
+Table 1 e List of practices for the experimental group (yoga based life style modification program).
+Module
+Duration
+Yoga based life style modification program
+1
+Pre-op day to 6 weeks
+Deep Relaxation Technique (DRT)
+Mind sound resonance technique (MSRT)
+Nadisuddhi Pranayama
+2
+6 weeks to 6 months
+Sukshma vyayamas for
+Wrist e Manibandha shakti vikasaka
+Back of hand e Karaprasta shakti vikasaka
+Elbows e Kaphoni shakti vikasaka
+Neck e Griva shakti vikasaka I & II
+Back e Kati shakti vikasaka I & II
+Eyes e Netra shakti vikasaka
+Legs e Padasanchala
+Quick relaxation technique (QRT), DRT and MSRT
+3
+6 months to 12 months
+Yogic Breathing practices
+Prasarita hasta swasah (Hands in & out breathing)
+Utkashita hasta swasah (Hands stretch breathing)
+Vyaghra swasah (Tiger breathing)
+Ekapadauttana swasah (Straight leg raise breathing)
+Asanas e 20 min
+Standing position
+Ardha kati chakrasana (Lateral half wheel posture)
+Trikonasana (Triangle posture)
+Vrikshasana (Tree posture)
+Garudasana (Eagle posture)
+Prone posture
+Bhujangasana (Serpent posture)
+Sitting posture
+Vakrasana (Spinal twist with leg straight)
+Ardhamatsyendrasana (Half spinal twist)
+Vajrasana (Diamond posture)
+Supine posture, QRT, DRT and MSRT
+i n d i a n h e a r t j o u r n a l 6 6 ( 2 0 1 4 ) 4 9 0 e5 0 2
+492
+lung exerciser. Different sets of reading material were pro-
+vided for the two groups.
+2.6.
+Yoga intervention (Table 1)
+The integrated yoga intervention included simple and safe
+practices at physical, mental, emotional, intellectual levels to
+reach a state of mastery over the modifications of the mind
+(Chitta Vritti Nirodhah e definition of yoga by sage Patanjali)
+through effortless blissful inner awareness during all prac-
+tices. Three yoga modules (of 30 min each) were prepared to
+suit the three periods of rehabilitation. The first module (upto
+6th week) included MSRT (Mind Sound Resonance Technique),
+breath awareness and DRT (deep relaxation technique), all
+done in supine posture. MSRT is a systematic training con-
+sisting of 8 steps of sound meditation (based on M

+andukya
+Upanishad26 and Gheranda Samhit

+a.27 It involves gentle chant-
+ing of the syllables A, U, M, and OM to feel the resonance in-
+side the body cavities i.e. abdomen, chest, skull and entire
+trunk respectively. This is done repeatedly while alternating
+between audible chanting (Ahata N

+adanusandh

+ana) and mental
+chanting (An

+ahata N

+adanusandh

+ana). This phase is followed by
+a resolve and closing prayer. Physical postures and pranayama
+practices were added in the second (6th week to 6th month)
+and third (6th month to 12th month) yoga modules (Table 1).
+These three modules of integrated approach of yoga therapy
+for life style disorders were developed by experts on the basis
+of ancient yogic scriptures. These modules have been found to
+be safe and beneficial in our clinical practice at 250 bedded
+holistic health home, Arogyadhama, Bangalore, since last 20
+years.28
+Counseling for the YLSP group on yogic life style modifi-
+cation included the concepts of right living from Indian yoga
+psychology while the PTLSP group were counseled using sci-
+entific information on life style modification recommended in
+conventional cardiac rehabilitation programs.29 This concept
+of right living according to yogic tradition was introduced
+gradually in these modules as the person would return to
+work and normal life style. These included concepts of do's
+(niyamas) and don'ts (yamas) from Asht

+anga yoga of Patanjali,30
+Karma yoga from Bhagavadgita that helps in working without
+stress31; Bhakti yoga, the path of pure love that opens up av-
+enues for healthy relationships32; and J
+nana yoga that trans-
+forms the basic notions about life through introspective
+correction of the meaning and purpose of life.33 All these
+concepts were meant to help the individual to move towards
+blissfully contented joyful living with the right understanding
+in tune with the laws of nature that govern one's existence.
+2.7.
+Control group intervention
+The
+non-yogic
+intervention
+for
+the
+control
+group
+was
+designed to match the duration (30 min), and the level of
+physical activity suitable to different stages in the post-
+operative period (Table 2). This module of physical activity
+was an add-on and different from the conventional physio-
+therapy based rehabilitation which was common to both
+groups.
+The practices included mild stretches followed by breath-
+ing exercises and supine rest. Care was taken by the therapists
+to avoid the yoga concepts while counseling or teaching the
+control group intervention.
+2.8.
+Measurements
+All demographic details and base line data were documented
+on
+pre-op
+day.
+The
+routine
+pre-operative
+assessments
+included coronary angiogram performed one to four weeks
+before posting for surgery, Echocardiogram, ECG, lipid pro-
+files, renal function tests, clinical assessments etc as per the
+conventional hospital protocol.
+2.8.1.
+Left ventricular ejection fraction (LVEF)
+2D Doppler Echo-cardiogram was recorded using Vivid-4
+model, GE Company's ultrasound sound equipment, USA
+(Pmax e 1.2 KVA, Frequency e 50 Hz) by a certified technician
+using a 3 MV (lesser resolution) transducer. This was docu-
+mented in the pre-operative week, and also during each follow
+Table 2 e List of practices for the control group (physiotherapy based life style modification program).
+Module
+Duration
+Physiotherapy based life style modification program
+1
+Pre-op day to 6 weeks
+Breathing practices
+Physiotherapy exercises for wrist, back of hand, elbows, neck, back and
+legs
+2
+6 weeks to 6 months
+Breathing exercises e Inhale through the nose and exhale forcibly through
+the mouth
+Breathing through lung exerciser
+Additional Physiotherapy exercises for wrist, back of hand, elbows, neck,
+Back, legs, Shoulder rotation, slow side bending, knee cap tightening
+Supine rest
+3
+6 months to 12 months
+Additional Physiotherapy exercises
+Standing position practices
+Sit-ups, Hip rotation, Knee rotation, Forward drill,
+Backward drill, Sideward drill, Full arm rotation,
+Free walking,
+Sitting in a chair e
+Chakki chalana, Ankle bending, Toe Bending,
+Leg spread exercises with support - sideways, front and back
+Supine rest
+i n d i a n h e a r t j o u r n a l 6 6 ( 2 0 1 4 ) 4 9 0 e5 0 2
+493
+up visit in 6th week, 6th month and 12th month after the
+surgery.
+BMI and other clinical variables were also documented at
+each of the follow up visits.
+2.9.
+Biochemical measures
+Fasting blood glucose (intra-assay CV ¼ 0.9%, inter-assay
+CV ¼ 1.8%), Total cholesterol (intra-assay CV ¼ 0.8%, inter-
+assay CV ¼ 1.7%) and triglycerides (intra-assay CV ¼ 1.5%,
+inter-assay CV ¼ 1.8%) were measured using the enzymatic
+calorimetric method. HDL cholesterol (intra-assay CV ¼ 2.9%,
+inter-assay CV ¼ 3.6%) was measured using a homogenous
+calorimetric assay, whereas LDL cholesterol (intra-assay
+CV ¼ 0.9%, inter-assay CV ¼ 2.0%) was measured using a ho-
+mogenous turbidimetric assay.
+2.10.
+Psychological measures
+Perceived stress scale (PSS): This is a popularly used self-rated
+measure of ‘stress in daily life’ that is perceived by the subject
+as uncontrollable and overwhelming. It is a validated tool34
+that has 14 items scored on a 5-point scale and with a reli-
+ability score of 0.85.35
+Hospital anxiety and depression (HADS) is a widely used
+validated36,37 self-reported instrument designed to assess
+anxiety and depression in non-psychiatric population. This
+14-item questionnaire consists of two sub-scales of seven
+items for self-reported anxiety and depression. Patients are
+asked to answer what they experienced during the last two
+weeks, on a scale of 4 ranging from 0 (“not at all”) to 3 (“very
+much”). The reliability of HADS, and the two sub-scales
+(HADS-anxiety and HADS-depression) are 0.85, 0.79 and 0.87
+respectively.38
+Positive and Negative Affect Scale (PANAS): PANAS has two
+sub-scales i.e. positive affect (PA) and negative affect (NA)
+consisting of 10 items each. PA reflects the extent to which a
+person feels enthusiastic, active, and alert. A high PA score
+reflects a state of high energy, full concentration and plea-
+surable engagement. NA is a general dimension of subjective
+distress subsuming a variety of aversive mood states. A high
+NA score indicates more distress. This descriptive scale has
+proven validity39 and its reliability ranges from 0.86 to 0.90 for
+PA and 0.84 to 0.87 for NA.39
+2.11.
+Data extraction and analysis
+Data were analyzed using SPSS version 10.0. The baseline
+comparisons between the two groups were done by using in-
+dependent samples t test. The baseline mean values of the
+drop out group were also compared with that of the study
+group by independent samples t test. As the data were not
+normally distributed, Wilcoxon's signed rank test and Man-
+neWhitney U test were used to compare the means within
+and between groups respectively.
+3.
+Results
+Fig. 1 shows the trial profile. Of the 1026 screened, 250 fulfilled
+the selection criteria and were recruited after obtaining the
+informed consent. Forty in yoga group and forty five in control
+group dropped out. The main reason for drop out was the
+constraint on time to come for follow up to NHICSc, as most of
+the patients were from different towns in Karnataka and they
+opted to get their routine follows up done from local medical
+practitioners.
+The baseline characteristics are shown in Table 3. The
+groups were matched with no significant (p > 0.01, indepen-
+dent samples t test) difference between the groups at baseline
+except that the number of subjects consuming alcohol were
+higher in the yoga group. Comparison of baseline mean values
+of the drop out group with those who continued with the
+study also showed no significant difference. Three patients in
+yoga group and four in control group had very low (25e35%)
+baseline
+LVEF.
+Table
+4
+shows
+the
+results
+after
+the
+intervention.
+Table 3 e Demographic data.
+Particulars
+YLSP
+PTLSP
+Sex (only male)
+n ¼ 129
+n ¼ 121
+Age range (years)
+35e65
+35e65
+Age (years) Mean (SD)
+53.34 (6.42)
+52.6 (6.85)
+Education
+School
+25
+26
+Undergraduates
+37
+39
+Graduates
+26
+40*
+Post-Graduates
+32
+25
+Socio-economic
+Status
+Upper class
+10
+08
+Middle class
+65
+79
+Lower class
+35
+42
+Duration of CAD
+<1 year
+71
+80
+1e5
+42
+42
+5e10
+7
+08
+Nature of CAD
+SVD
+20
+15
+DVD
+31
+39
+TVD
+69
+76
+Associated
+conditions
+HTN
+38
+31
+DM
+20
+15
+HTN þ DM
+53
+63
+Ejection fraction
+35
+3
+4
+36e40
+8
+6
+41e45
+11
+18
+46e50
+19
+27
+51e55
+33
+36
+56e60
+46
+38
+Medications
+Antiplatelet
+agents
+117
+111
+Statins
+89
+86
+Beta-blockers
+67
+69
+ACEI/ARB's
+76
+65
+CCB/Nitrates
+29
+24
+Hypoglycemic
+agents
+73
+78
+Family history of CAD
+28
+22
+Cigarette smoking
+23
+22
+Tobacco chewing
+18
+16
+Alcohol consumption
+25
+15*
+*p < 0.05, Independent Samples t test.
+Abbreviations: YLSP: yoga life style program; PTLSP: physiotherapy
+life style program; SVD: single vessel disease; DVD: double vessel
+disease; TVD: triple vessel disease; HTN: hypertension; DM: dia-
+betes mellitus; CAD: coronary artery disease; SD: standard devia-
+tion;
+ACEI:
+Angiotensin
+Converting
+Enzyme
+Inhibitors;
+ARB:
+Angiotensin Receptor Blocker; CCB: Calcium Channel Blocker.
+i n d i a n h e a r t j o u r n a l 6 6 ( 2 0 1 4 ) 4 9 0 e5 0 2
+494
+3.1.
+LVEF
+The recent guidelines from the American Society of Echocar-
+diography have defined an abnormal ejection fraction (EF) of
+the left ventricle on echocardiographic measurement as one
+that is less than 55%.40 Similarly, a few other studies defined
+LVEF less than 0.55 as systolic dysfunction in heart failure
+patients.41,42 Based on data from a number of more recent
+studies, a value less than 54% has been suggested as the cut-
+off value that is associated with moderate adverse out-
+comes.43 Another study on a large cohort (2300 subjects) of
+European white and Indian Asian subjects that looked at
+ethnicity-specific reference values of LVEF reported a cut off
+value of 52%.44 Based on these studies, as our target popula-
+tion belonged to Indian Asian community, we set our cut off
+LVEF value as 53%, which was our median value between the
+reported cut off values. Thus, we considered values 53% as
+normal and <53% as abnormal for the analysis of our data.
+There was significant improvement in LVEF in both groups
+with no significant difference between groups at each point of
+follow up. In the subgroup with abnormal baseline EF (<53,
+median) there was progressive increase in both yoga and
+control groups. Yoga group improved better than control
+group all along and the Mann Whitney showed significant p
+values (p ¼ 0.02) at one year.
+In the subgroup with normal baseline EF (53, median), the
+yoga group showed continuing increase in EF, while there was
+a decrease in EF at all points in the control group. The Mann
+Whitney did not show significant difference between groups
+at any of these points of follow up.
+3.2.
+Secondary outcome measures
+3.2.1.
+BMI
+We used a value of 23 as the value to define overweight,45,46 as
+it has been found that Indians have higher risk at lower values
+of BMI and the recommended cut off value is 23 (25 in Cau-
+casians). Thus, in the subgroup with high baseline BMI (23),
+there was a significant difference between groups (p ¼ 0.038)
+with better reduction in yoga group after one year. Also, this
+subgroup (BMI  23) showed that the weight and BMI
+decreased significantly within both groups at 6 weeks and 6
+months, whereas only the yoga group showed significant
+reduction at the end of the year (p < 0.001). In those with BMI
+<23, there was no significant change in both the groups at any
+of the three time points (Table 4).
+3.3.
+Biochemical variables
+There were total 93 patients with baseline FBS 110 mg/dl (55
+in yoga the group and 38 in the control). There was better
+glycemic control in yoga group, as seen by significant decrease
+within the group in those with FBS 110 mg/dl (p ¼ 0.008) at
+the end of 1 year, whereas in the control group the reduction
+was not statistically significant (p ¼ 0.8). There was no be-
+tween group difference (p ¼ 0.41) (Table 5). There were 11
+Fig. 1 e Trial profile.
+i n d i a n h e a r t j o u r n a l 6 6 ( 2 0 1 4 ) 4 9 0 e5 0 2
+495
+patients who had baseline FBS 200 mg/dl (5 in yoga group
+and 6 in the control); analysis showed that there was a sig-
+nificant reduction in FBS in those with FBS 200 mg/dl in the
+yoga group at 6 months (p ¼ 0.003) and at one year (p ¼ 0.03),
+whereas in the control group there was a significant reduction
+after 6 months (p ¼ 0.008) with non-significant change at the
+end of the year (p ¼ 0.06) (Table 5) with no significant differ-
+ence between the groups at the end of 6 months (p ¼ 0.213) as
+well as one year (p ¼ 0.32) (Table 5).
+3.3.1.
+Lipid profile
+There was significant decrease in triglycerides within both
+groups (p ¼ 0.001) in those who had high baseline values
+(150 mg/dl) with no significant difference between the
+groups (p ¼ 0.37). There was significantly better increase in
+HDL in yoga than control group (p ¼ 0.003 between groups).
+Also the increase in those with low HDL values (<35 mg/dl)
+was better in yoga (p ¼ 0.001) group than the control (p ¼ 0.03)
+group. LDL levels also reduced significantly in both the groups,
+with non-significant difference between groups.
+Looking at sub-group analysis, the yoga group showed
+significant reduction in LDL (p ¼ 0.01) levels with significant
+difference between the groups (p ¼ 0.01) in those who had
+values >100 mg/dl. VLDL reduced in both the groups signifi-
+cantly with a better reduction (p ¼ 0.03) in Yoga than the
+control. Thus, yoga group had better changes in lipid profile
+than control group in those with abnormal baseline values.
+3.4.
+Psychological variables
+3.4.1.
+PSS, HADS and PANAS (Table 5)
+Within Yoga group, there was significant decrease in PSS
+(p ¼ 0.001), HADS-Anxiety (p ¼ 0.001), HADS-Depression
+(p ¼ 0.001), and PANAS-Negative (p ¼ 0.03). In Control group,
+there
+was
+significant
+decrease
+only
+in
+HADS-Anxiety,
+(p ¼ 0.003). Also, there was significant difference between
+Yoga and Control groups in positive component of PANAS
+(p ¼ 0.02).
+This improvement in positive affect points to better well-
+ness and quality of life. Although no specific validated ques-
+tionnaire has been included here, the clinicians who checked
+all patients during follow up reported that those who had
+practiced yoga returned to normalcy much faster and earlier
+than the control group.
+4.
+Discussion
+This single blind prospective randomized two armed active
+control study has shown that YLSP was significantly better
+than PTLSP in increasing LVEF (p ¼ 0.02, Mann Whitney test)
+one year after CABG surgery in those with abnormal (<me-
+dian) baseline LVEF values. YLSP was also more beneficial in
+normalizing many risk factors including BMI, blood glucose,
+triglycerides, VLDL, LDL and HDL in those with abnormal
+baseline values. Although anxiety and depression reduced in
+both cases, positive affect increased only in the yoga group
+pointing to the role of yoga in promoting psychological well-
+ness in addition to the physical benefits.
+Table 4 e Changes in ejection fraction in yoga and control groups after post-CABG rehabilitation.
+Group
+Baseline
+6th week
+6th month
+1 year
+n
+Mean ± SD
+n
+Mean ± SD
+Wilcoxon p value
+n
+Mean ± SD
+Wilcoxon p value
+n
+Mean ± SD
+Wilcoxon p value
+EF Total
+Y
+129
+52.22 ± 6.69
+111
+54.58 ± 5.80
+0.001
+106
+54.96 ± 5.38
+0.001
+89
+55.91 ± 5.21
+0.001
+C
+121
+53.39 ± 7.14
+96
+53.85 ± 6.33
+0.001
+102
+53.94 ± 6.68
+0.001
+76
+54.12 ± 6.84
+0.001
+Mann Whitney
+p value
+0.16
+0.38
+0.9
+0.5
+EF 53
+Median
+Y
+69
+47.36 ± 5.23
+61
+51.61 ± 6.15
+0.001
+55
+52.42 ± 5.89
+0.001
+49
+53.28 ± 5.69
+0.001
+C
+60
+47.07 ± 5.68
+50
+49.0 ± 5.55
+0.001
+48
+48.72 ± 6.29
+0.001
+33
+48.89 ± 6.76
+0.001
+Mann Whitney
+p Value
+0.63
+0.24
+0.43
+0.02*
+EF 53
+Median
+Y
+60
+57.87 ± 2.31
+50
+58.03 ± 2.66
+0.001
+51
+58.34 ± 2.55
+0.001
+40
+58.53 ± 2.27
+0.001
+C
+61
+58.72 ± 2.05
+46
+57.94 ± 3.37
+0.001
+54
+57.96 ± 5.38
+0.001
+43
+55.91 ± 5.21
+0.001
+Mann Whitney
+p Value
+0.04*
+0.55
+0.98
+0.38
+*p < 0.05, **p < 0.001.
+Legend: Yoga group showed significantly better increase in EF than control group in those with abnormal baseline EF (EF  53, median). There was significant improvement in both groups with no
+significant difference between groups at each point of follow up. In subgroup with abnormal baseline EF (53, median) there was progressive increase in EF in both yoga and control groups. Yoga group
+improved better than control group all along and the Mann Whitney showed significant p values (p ¼ 0.02) at one year. In the subgroup with normal baseline EF (53, median), the yoga group showed
+continuing increase in EF, while there was a decrease in EF at all points in the control group. The Mann Whitney did not show significant difference between groups at any of these points of follow up.
+Abbreviations: Y: yoga group (yoga life style program); C: control (physiotherapy life style program); SD: standard deviation; EF: Ejection Fraction.
+i n d i a n h e a r t j o u r n a l 6 6 ( 2 0 1 4 ) 4 9 0 e5 0 2
+496
+Table 5 e Changes in BMI and psychological measures after one year of intervention.
+Variable
+Group
+Base line
+Mean (SD)
+95% CI
+1 Year
+Mean (SD)
+95% CI
+p e value
+(within group)
+% Change
+p e value
+(between the groups)
+STRESS
+PSS
+Y
+18.76 (4.73)
+9.48e28.03
+15.54 (4.5)
+6.72e24.36
+0.001**
+14.94
+0.12
+C
+16.28 (4.46)
+7.53e25.021
+16.75 (4.30)
+8.32e25.178
+0.49
+6.71
+PANAS
+Positive
+Y
+39.18 (8.16)
+23.18e55.17
+40.54 (7.97)
+24.91e56.16
+0.08
+3.47
+0.02*
+C
+34.67 (8.72)
+17.57e51.76
+35.83 (8.72)
+18.73e52.92
+0.36
+3.34
+Negative
+Y
+28.57 (8.71)
+11.49e45.64
+26.82 (8.08)
+10.98e42.65
+0.03*
+6.12
+0.97
+C
+27.0 (9.46)
+8.45e45.54
+26.3 (7.62)
+11.36e41.23
+0.76
+2.59
+HADS
+Anxiety
+Y
+7.42 (3.40)
+0.75e14.08
+5.75 (3.46)
+1.03 to 12.53
+0.001**
+27.03
+0.42
+C
+7.84 (3.05)
+1.86e13.81
+6.15 (2.98)
+0.30e11.99
+0.003*
+13.02
+Depression
+Y
+6.59 (3.44)
+0.15 to 13.33
+4.65 (3.51)
+2.22 to 11.52
+0.001**
+30.77
+0.07
+C
+6.85 (3.56)
+0.12 to 13.82
+5.61 (3.30)
+0.85 to 12.07
+0.05*
+14.66
+BMI (kg/m2)
+23
+Y
+26.60 (2.30)
+26.16e27.03
+24.47 (1.85)
+20.84e28.09
+0.001**
+8.00
+0.038*
+C
+26.15 (2.10)
+25.76e26.53
+25.82 (2.25)
+21.41e30.23
+0.161
+1.26
+<23
+Y
+21.47 (1.32)
+18.88e24.05
+21.70 (1.35)
+20.72e22.67
+0.55
+1.07
+0.39
+C
+21.07 (1.50)
+19.13e24.01
+20.94 (2.49)
+18.32e23.56
+0.50
+0.61
+Total
+Y
+26.76 (3.24)
+20.40e33.11
+23.93 (2.56)
+18.91e28.94
+0.001**
+6.72
+0.001**
+C
+25.22 (3.15)
+19.04e31.39
+24.93 (3.46)
+18.14e31.71
+0.09
+1.15
+Body weight (kgs)
+65
+Y
+73.71 (7.88)
+58.26e89.15
+67.13 (7.59)
+52.25e82.00
+0.001
+8.93
+0.001**
+C
+75.73 (7.97)
+60.10e91.35
+73.88 (8.08)
+58.04e89.71
+0.0015
+2.45
+<65
+Y
+63.13 (4.98)
+53.36e72.89
+60.42 (4.47)
+51.65e69.18
+0.001**
+4.29
+0.64
+C
+61.33 (6.57)
+48.45e74.20
+61.10 (7.85)
+45.71e76.48
+0.67
+0.37
+Total
+Y
+69.01 (8.85)
+51.66e86.35
+64.12 (7.42)
+49.57e78.66
+0.001**
+7.32
+0.01*
+C
+68.17 (10.34)
+47.90e88.43
+67.34 (10.41)
+46.93e87.74
+0.035
+1.22
+FBS (mg%)
+110
+Y
+147.22 (35.46)
+77.71e216.72
+135.52 (52.03)
+33.54e237.49
+0.008*
+7.65
+0.41
+C
+153.77 (41.07)
+73.27e234.26
+142.48 (50.66)
+43.18e241.77
+0.08
+7.34
+125
+Y
+156.17 (21.34)
+115.15e197.99
+149.3 (61.9)
+27.98e270.62
+0.59
+4.20
+0.47
+C
+154.41 (18.07)
+119.00e189.82
+139.00 (46.50)
+47.86e230.14
+0.17
+9.97
+200
+Y
+233.00 (29.46)
+159.81e306.19
+164.00 (14.17)
+136.23e191.77
+0.03*
+29.60
+0.32
+C
+228.40 (27.42)
+190.85e270.15
+159.80 (44.63)
+72.33e247.27
+0.06
+30.03
+<125
+Y
+117.20 (36.71)
+45.25e181.15
+121.28 (47.06)
+29.05e213.15
+0.46
+3.48
+0.95
+C
+111.35 (38.34)
+36.21e186.49
+120.76 (45.65)
+31.29e210.13
+0.21
+8.45
+Total
+Y
+122.3 (44.13)
+35.80e208.79
+119.50 (45.64)
+30.04e208.95
+0.04*
+2.79
+0.75
+C
+121 (49.61)
+23.76e218.23
+124.02 (46.49)
+32.89e215.14
+0.27
+2.41
+*p < 0.05, **p < 0.001.
+Legend: Table 5 shows significant differences between the groups where yoga-based lifestyle modification (Y) group showed better improvement in positive affect, BMI and bodyweight as compared to
+physiotherapy-based lifestyle modification (C).
+Abbreviations: PSS: Perceived Stress Scale; PANAS: Positive and Negative Affect Scale; HADS: Hospitals Anxiety and Depression Scale; BMI: Body Mass Index; FBS: Fasting Blood Sugar; Y: yoga group
+(yoga life style program); C: control (physiotherapy life style program); SD: standard deviation.
+i n d i a n h e a r t j o u r n a l 6 6 ( 2 0 1 4 ) 4 9 0 e5 0 2
+497
+To our knowledge, this is the first randomized controlled
+yoga based life style study with a yearlong follow up in pa-
+tients after CABG. A systematic review47 of cardiac rehabili-
+tation studies on 7683 patients with coronary heart disease
+from earlier meta-analyses concluded that both comprehen-
+sive cardiac rehabilitation and rehabilitation program based
+on exercise only are effective in reducing cardiac mortality.
+Cardiac mortality reduced by 31%, with exercise based cardiac
+rehabilitation and 26% with comprehensive cardiac rehabili-
+tation program. Although such life style modification studies
+had established the role of intensive life style modification
+programs in risk-factor modification and prolonging survival
+among post-myocardial infarction (MI) patients before 2000,
+the efficacy of these programs in reducing risk factors in pa-
+tients after CABG were not well-established48 until more
+recent randomized prospective studies. A well designed ran-
+domized control study on behavioral and educational cardiac
+rehabilitation program as early as 1995 by Oldenburg et al48
+had shown few differences in risk factors between the study
+groups one year after CABG. Detry et al49 studied the effects of
+early and short-term (2e3 months) intensive multidisciplinary
+ambulatory cardiac rehabilitation program after coronary ar-
+tery bypass surgery (CABG) or acute myocardial infarction
+which showed better compliance to aspirin intake, a low rate
+of smoking (14% of the patients), a 15% increase in physical
+capacity and decrease in resting heart rate. They also
+observed a 4 mg/dl increase in the HDL-cholesterol while our
+study has shown an increase in HDL by 8 mg/dl after yoga
+(6.45 mg% in control group) in those who had low HDL values
+(Table 6).
+4.1.
+LVEF
+In patients with CAD, reduced left ventricular function is a
+good predictor of unfavorable long term prognosis8 and is an
+important indicator for in-hospital and late mortality after
+CABG for CAD.50,7,8 An intensive information, education and
+counseling program in CAD patients with more than 70%
+stenosis and left ventricular ejection fraction of more than
+30%, showed significant improvement in LVEF in those with
+adherence to the new life style regimen by 80% or more.51
+Goodman
+et
+al52
+studied
+the
+effects
+of
+12
+weeks
+of
+Table 6 e Changes in lipid profile after one year of intervention.
+Lipids
+Group
+Base line
+Mean (SD)
+95% CI
+1 Year
+Mean (SD)
+95% CI
+p e value
+(within group)
+% Change
+p e value
+(between the
+groups)
+Total
+Chol.
+>200
+Y
+221.33 (23.86)
+162.06e280.61
+183.33 (65.73)
+20.03e346.63
+0.19
+17.16
+0.22
+C
+219.33 (12.20)
+206.52e232.15
+217.67 (29.31)
+186.90e248.43
+0.76
+14.78
+<200
+Y
+146.09 (25.13)
+140.05e152.13
+159.59 (36.53)
+150.82e168.37
+0.002*
+8.45
+0.95
+C
+146.12 (21.73)
+140.35e151.89
+160.51 (33.97)
+151.49e169.52
+0.001**
+9.85
+Total
+Y
+151.24 (30.35)
+91.75e210.72
+163.04 (38.01)
+88.54e237.53
+0.007*
+7.80
+0.61
+C
+154.21 (29.92)
+95.56e212.85
+167.43 (38.90)
+91.18e243.67
+0.003*
+8.57
+TGLYD
+150
+Y
+228.00 (80.99)
+202.10e253.90
+158.45 (60.17)
+139.20e177.70
+0.001**
+30.50
+0.37
+C
+237.46 (70.17)
+214.06e260.86
+175.30 (60.00)
+155.29e195.30
+0.001**
+26.30
+<150
+Y
+115.03 (20.73)
+107.56e122.51
+114.88 (47.15)
+97.88e131.87
+0.99
+0.13
+0.41
+C
+116.93 (20.31)
+108.89e124.96
+125.48 (45.85)
+107.34e143.62
+0.23
+8.20
+Total
+Y
+180.19 (83.54)
+16.45e343.92
+142.57 (62.9)
+19.28e265.85
+0.001**
+20.87
+0.03*
+C
+187.13 (78.74)
+32.79e341.46
+155.28 (57.98)
+41.63e268.92
+0.001**
+17.02
+HDL
+<35
+Y
+30.17 (3.15)
+28.16e32.17
+37.92 (6.99)
+33.47e42.36
+0.001**
+25.68
+0.57
+C
+29.75 (3.91)
+27.92e31.58
+36.20 (11.80)
+30.68e41.72
+0.03*
+21.68
+35
+Y
+40.45 (4.81)
+39.33e41.58
+40.21 (9.55)
+37.98e42.43
+0.82
+0.59
+0.19
+C
+40.77 (5.85)
+39.05e42.49
+37.98 (8.66)
+35.43e40.52
+0.01*
+6.84
+Total
+Y
+38.67 (6.29)
+26.34e50.99
+40.23 (9.30)
+22.00e58.45
+0.19
+4.034
+0.003*
+C
+37.23 (7.39)
+22.74e51.71
+37.17 (9.68)
+18.19e56.14
+0.34
+6.0
+LDL
+100
+Y
+122.52 (22.60)
+112.23e132.81
+91.38 (43.04)
+71.79e110.98
+0.01*
+25.41
+0.01*
+C
+114.67 (13.76)
+107.05e122.29
+125.20 (33.87)
+106.44e143.96
+0.27
+9.18
+<100
+Y
+66.54 (19.75)
+61.72e71.36
+92.19 (28.58)
+85.22e99.17
+0.001**
+27.82
+0.84
+C
+69.27 (17.21)
+64.62e73.93
+91.15 (29.57)
+83.15e99.14
+0.001**
+31.58
+Total
+Y
+75.97 (27.65)
+21.77e130.16
+96.61 (29.51)
+38.77e154.44
+0.001**
+27.16
+0.75
+C
+78.17 (24.15)
+30.83e125.50
+98.77 (33.53)
+33.05e164.48
+0.001**
+26.35
+VLDL
+40
+55.42 (15.81)
+49.62e61.22
+55.16 (36.89)
+41.63e68.70
+0.91
+0.46
+0.37
+55.75 (13.67)
+51.12e60.38
+48.50 (24.04)
+40.37e56.63
+0.065
+13.00
+<40
+26.52 (6.49)
+24.94e28.11
+27.52 (14.27)
+24.04e31.00
+0.57
+3.77
+0.70
+26.99 (7.72)
+24.64e29.33
+28.55 (12.60)
+24.71e32.38
+0.46
+5.46
+Total
+Y
+34.92 (16.28)
+3.01e66.82
+28.51 (12.59)
+3.83e53.18
+0.001**
+18.35
+0.03*
+C
+36.21 (15.28)
+6.26e66.15
+31.58 (13.22)
+5.66e57.49
+0.03*
+11.95
+*p < 0.05, **p < 0.001.
+Legend: Table 6 shows significant differences between the groups where yoga-based lifestyle modification (Y) group showed better improvement
+in total triglycerides, total HDL, LDL in those with baseline more than or equal to 100 mg% and total VLDL as compared to physiotherapy-based
+lifestyle modification (C).
+Abbreviations: Chol: Cholesterol; TLGYD: Triglycerides; LDL: Low Density Lipoproteins; HDL: High Density Lipoproteins; VLDL: Very Low Density
+Lipoproteins; Y: yoga group (yoga life style program); C: control (physiotherapy life style program); SD: standard deviation.
+i n d i a n h e a r t j o u r n a l 6 6 ( 2 0 1 4 ) 4 9 0 e5 0 2
+498
+endurance exercise training on exercise performance and left
+ventricular ejection fraction (EF) in a group of uncomplicated
+CABG (n ¼ 31) cases. A significant improvement in VO2max
+was observed after training, accompanied by an increase in
+the EF during submaximal exercise (60 ± 3% versus 63 ± 2% at
+40% VO2max; 61 ± 3% versus 64 ± 3% at 70% VO2max).
+Although our patients had lower baseline EF values (53%) than
+Goodman's study group (60%) who were given endurance ex-
+ercise training, the degree of change after the intervention
+was similar (around 3%) in both studies. Thus, the effects of
+both endurance exercise training and yoga appear to offer
+comparable effects on EF in post-CABG patients. In our study,
+we observed that LVEF reduced significantly in the control
+group in those with normal LVEF values (53, median) over a
+span of one year. Though, there was no significant difference
+between the groups for above mentioned results, this reduc-
+tion within the control sub-group is surprising, as both the
+groups
+underwent
+successful
+CABG
+surgery.
+Here,
+one
+possible explanation could be the absence of relaxation ses-
+sions in the control group which were a primary focus in the
+yoga intervention. In a randomized controlled prospective
+study,53 90 post MI patients were randomly assigned to either
+exercise training plus individual relaxation group or exercise
+training only. Results showed that the occurrence of cardiac
+events, consisting of cardiac death and of readmission to
+hospital for unstable angina pectoris, coronary artery bypass
+grafting (CABG) or recurrent infarction, were significantly
+higher in the exercise training only group than the group with
+add-on relaxation in the 2e3 years follow up period after
+infarction.53 Also, another study showed that for post-CABG
+patients with normal LVEF (55%), the same inpatient exer-
+cise protocol triggered a more attenuated cardiac autonomic
+response compared with patients with reduced LVEF (<55%).54
+This finding suggested that post-CABG patients with normal
+and abnormal LVEF may respond differently to the same ex-
+ercise protocol in terms of their cardiac autonomic responses
+and those with abnormal LVEF responding more favorably
+than those with normal LVEF, and the volume of the inpatient
+exercises should be prescribed according to the left ventricu-
+lar function following recovery from CABG.54 This may
+possibly explain the reduction in LVEF in those with normal
+values (53, median) in the control group in our study.
+4.2.
+Mechanism
+We propose that yoga may have operated by reducing stress
+arousal.55,56 It is known that, chronic stress has an important
+role in the pathogenesis of atherosclerosis57,58; psychological
+distress, depression and state anxiety are extremely frequent,
+often clustered, in patients after CABG60; and these are
+important determinants of health care utilization within 6
+months post discharge in CABG patients.61
+Several studies have shown that intensive cardiac rehab
+techniques do reduce many psychological abnormalities. A
+year-long prospective study on post-CABG cardiac rehabilita-
+tion program showed significant decrease in state anxiety and
+depression.62
+In
+another
+study,63
+there
+was
+significant
+reduction in anxiety and depression in the anxious and
+depressed groups at 12 weeks and 6 months but there was no
+significant reduction at 12 months after an exercise and
+education-based rehabilitation program after CABG in our
+study, the yoga group has shown sustained reduction in
+anxiety, depression, perceived stress and negative affect even
+after one year. Reduction in
+sympathetic activity after
+yoga55,59 has been documented which explains the improve-
+ment in these variables observed in the present study. It is
+interesting to note that positive affect was significantly better
+in those who practiced yoga instead of PT exercises after CABG
+pointing to yoga's ability to promote positive wellbeing; this
+could be an important factor that contributed to the compli-
+mentary benefits.
+Stress reducing effects of yoga that offer correction in the
+mind set by regular introspective practices at physical,
+mental, emotional, and intellectual levels, have been investi-
+gated in both healthy volunteers and patients with many non-
+communicable diseases. This may be mediated through better
+autonomic regulation as shown by many studies.64e66 Yoga
+may produce favorable effects through modulation of neuro-
+endocrino-immunologic pathways. Cortisol levels are posi-
+tively associated with stress and anxiety67 and Yoga has been
+shown to reduce cortisol levels both in health68 and disease69
+pointing to its effect on Hypothalamo-pituitary-adrenal (HPA)
+axis.
+In addition, the roles of yoga on stress mediators that in-
+fluence metabolic abnormalities related to lipids (adipose
+tissue that influences atherosclerosis) have been documented.
+Kiecolt-Glaser et al70 compared adiponectin and leptin levels
+in well-matched novice (n ¼ 25) and expert yoga practitioners
+(n ¼ 25) on three different visits. They found that leptin, which
+plays a pro-inflammatory role, was 36% higher among novices
+compared to experts and experts' average adiponectin (anti-
+inflammatory in effect) levels were 28% higher than novices
+across all three visits. In addition, experts' average adipo-
+nectin to leptin ratio was nearly twice that of novices.70 In our
+study, we observed better reduction in BMI, lipids and diabetic
+state in the yoga group than those who practiced physical
+exercise regularly. Thus, we hypothesize that yoga's effects
+may be mediated through both central and peripheral adap-
+tation
+mechanisms
+i.e.
+stress-reduction
+and
+adipokine
+mechanisms.
+4.3.
+Limitations of the study
+(i) Recruitment took longer than expected. (ii) There were
+about 40% drop outs at the end of one year and hence we could
+not carry out intention to treat analysis. (iii) As the surgeons
+were not confident to allow any new intervention for their
+high risk cases we could not plan to include patients with very
+low LVEF undergoing CABG. (iv) Only male patients were
+included in the study as the numbers of female patients were
+very few. (v) 2D Doppler Echo-cardiogram findings are sub-
+jective and may vary from technician to technician. (vi) It
+would have been valuable to include waist circumference as
+an index of central obesity along with the weight and BMI
+which may be considered in future studies.
+4.4.
+Strengths of this study
+(i) This is the first randomized control study that incorporated
+integrated yoga program starting from the day before CABG
+i n d i a n h e a r t j o u r n a l 6 6 ( 2 0 1 4 ) 4 9 0 e5 0 2
+499
+surgery and had regular follow up of a comprehensive battery
+of measurements for one year; (ii) The sample size was good
+and the hospital follows an internationally accepted protocol
+for surgery and cardiac rehabilitation; (iii) Well matched
+active intervention with equal attention to both groups during
+the entire period of follow up; (iv) Results pointing to better
+efficacy of YLSP than PTLSP; (v) 12.5% increase in LVEF after
+one year in those with high risk (low EF) and other risk factors.
+5.
+Conclusion
+Integrated yoga based cardiac rehabilitation for one year after
+uncomplicated CABG normalizes risk factors including LVEF,
+BMI, Blood glucose and Lipids which may be attributed to
+improvement in positive affect, decrease in stress, anxiety,
+depression and negative affect. Continued follow up of these
+cases is planned.
+5.1.
+Recommendations
+We recommend that these yoga modules be incorporated in
+all post-CABG cardiac rehabilitation programs for better in-
+hospital outcome and long term prognosis.
+5.2.
+Suggestions for future work
+(i) We recommend similar studies to be designed in other
+parts of India and the World to establish the generalizability of
+this intervention of this three tier module of YLSP. (ii)
+Continuous follow up of these patients for longer period. (iii)
+More studies using subtle instruments to measure myocardial
+perfusion are necessary to understand the mechanisms.
+Conflicts of interest
+All authors have none to declare.
+Acknowledgments
+We are grateful to AYUSH, Ministry of Department of Health
+and Family Welfare, New Delhi, India, for funding this project.
+We acknowledge all the cardiologists, cardiac surgeons and
+echo technicians of NHICSc, Bengaluru for their co-operation.
+We thank all the therapists, biostatistician and staff of
+SVYASA for their contribution in conducting the project and
+writing this manuscript.
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+Original Research Article (Clinical)
+Yoga-based pulmonary rehabilitation for the management of dyspnea
+in coal miners with chronic obstructive pulmonary disease: A
+randomized controlled trial
+Rajashree Ranjita*, Alex Hankey, H.R. Nagendra, Soubhagylaxmi Mohanty
+Division of Yoga and Life Science, Swami Vivekananda Yoga University, SVYASA, Bengaluru, Karnataka, India
+a r t i c l e
+i n f o
+Article history:
+Received 26 August 2015
+Received in revised form
+25 October 2015
+Accepted 11 December 2015
+Available online 18 August 2016
+Keywords:
+Chronic obstructive pulmonary disease
+Dyspnea
+Exercise capacity
+Fatigue
+Yoga
+a b s t r a c t
+Background: Coal mine dust exposure causes chronic airflow limitation in coal miners resulting in
+dyspnea, fatigue, and eventually chronic obstructive pulmonary disease (COPD). Yoga can alleviate
+dyspnea in COPD by improving ventilatory mechanics, reducing central neural drive, and partially
+restoring neuromechanical coupling of the respiratory system.
+Objectives: To evaluate the effectiveness of Integrated Approach of Yoga Therapy (IAYT) in the man-
+agement of dyspnea and fatigue in coal miners with COPD.
+Materials and methods: Randomized, waitlist controlled, single-blind clinical trial. Eighty-one coal
+miners (36e60 years) with stable Stages II and III COPD were recruited. The yoga group received an IAYT
+module for COPD that included asanas, loosening exercises, breathing practices, pranayama, cyclic
+meditation, yogic counseling and lectures 90 min/day, 6 days/week for 12 weeks. Measurements of
+dyspnea and fatigue on the Borg scale, exercise capacity by the 6 min walk test, peripheral capillary
+oxygen saturation (SpO2%), and pulse rate (PR) using pulse oximetry were made before and after the
+intervention.
+Results: Statistically significant within group reductions in dyspnea (P < 0.001), fatigue (P < 0.001)
+scores, PR (P < 0.001), and significant improvements in SpO2% (P < 0.001) and 6 min walk distance
+(P < 0.001) were observed in the yoga group; all except the last were significant compared to controls
+(P < 0.001).
+Conclusions: Findings indicate that IAYT benefits coal miners with COPD, reducing dyspnea; fatigue and
+PR, and improving functional performance and peripheral capillary SpO2%. Yoga can now be included as
+an adjunct to conventional therapy for pulmonary rehabilitation programs for COPD patients.
+© 2016 Transdisciplinary University, Bangalore and World Ayurveda Foundation. Publishing Services by
+Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
+licenses/by-nc-nd/4.0/).
+1. Introduction
+Chronic obstructive pulmonary disease (COPD) is character-
+ized by progressive airflow obstruction, which is mainly irre-
+versible [1]. Evidence shows that coal miners suffer increased
+risk of coal mine dust lung disease including COPD as a respi-
+ratory hazard of coal mining [2]. Cumulative exposure to coal
+dust is associated with increased risk of airway limitation [3]
+resulting in dyspnea and fatigue on exertion limiting physical
+activity [4], adversely affecting daily living [5] and quality of life
+[6].
+Although
+dyspnea,
+“subjective
+experience
+breathing
+discomfort”
+[7]
+is
+considered
+the
+primary
+activity-limiting
+symptom in coal miners [8], other symptoms like fatigue the
+“subjective perception of mental or physical exhaustion due to
+exertion” [9] is a common feature in coal miners with COPD. It is
+one of the most frequently reported, distressing side effects
+reported by COPD patients, often having significant long-term
+consequences.
+Pulmonary rehabilitation is a comprehensive intervention that
+includes exercise training, education, and behavior modification,
+designed to improve the physical and psychological condition of
+people with COPD [10]. The evidence is increasing for the efficacy
+of several kinds of exercise training as part of pulmonary reha-
+bilitation aimed at reducing dyspnea and fatigue, as well as
+* Corresponding author. SVYASA, No. 19, Eknath Bhavan, Gavipuram Circle,
+Kempegowda Nagar, Bengaluru 560 019, Karnataka, India.
+E-mail address: drrajashreeyoga@gmail.com (R. Ranjita).
+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.2015.12.001
+0975-9476/© 2016 Transdisciplinary University, Bangalore and World Ayurveda Foundation. Publishing Services by Elsevier B.V. This is an open access article under the CC
+BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
+Journal of Ayurveda and Integrative Medicine 7 (2016) 158e166
+improving health-related quality of life and exercise capacity
+in individuals with COPD [11]. Yoga has been included as a
+component of exercises prescribed for many pulmonary reha-
+bilitation programs [12]. It has also been included as an adjunct
+to physical therapy treatment in industrial rehabilitation pro-
+grams and proven to enhance mind-body coordination [13].
+Studies of short-term yoga practices have reported improved lung
+function
+parameters
+[14],
+increased
+diffusion
+capacity
+[15],
+decreased dyspnea-related distress [16], and improved health-
+related quality of life [17]. Yoga would show efficacy for coal
+miners with COPD, a topic on which no previous study appears to
+have been done.
+The IAYT is a program which was first applied to asthma
+some 30 years ago [18]. Other than respiratory problems, ben-
+efits have been demonstrated for various disorders such as
+cancer [19,20], coronary artery bypass graft [21], hypertension
+[22], asthma [23], diabetes mellitus [24], osteoarthritis of knee
+[25], low back pain [26], anxiety and depression [27], autism
+spectrum disorder [28], and schizophrenia [29]. It includes
+asanas; pranayama; relaxation techniques; meditation; yogic
+counseling for stress management; chanting; and lectures on
+yogic lifestyle and philosophy [30].
+Limited studies on COPD using other yoga systems have
+assessed its efficacy in an adjunctive role [14e17]. Here we report a
+randomized controlled study of coal miners with COPD, evaluating
+the effects of IAYT on dyspnea, fatigue, exercise tolerance, periph-
+eral capillary oxygen saturation (SpO2%), and pulse rate (PR). We
+hypothesized that these parameters would improve in yoga group
+as compared to a control group, at least partly for reasons similar to
+its efficacy to asthma [18,23,31].
+2. Materials and methods
+2.1. Participants
+The coal miners of Rampur Colliery, Odisha, India were recruited
+as study participants. The study sample consisted of 81 non-
+smoking male coal miners in the age range 36e60 years. Of 279
+coal miners screened, 162 failed at least one exclusion criterion;
+another 36 refused informed consent for the investigation; 81
+signed up for the trial, but after nine further dropouts, final data
+were only available for 72 participants (Fig. 1).
+2.2. Inclusion criteria
+Non-smoker male coal miners, aged 36e60 years, with moder-
+ate to severe stable physician-confirmed COPD satisfying Global
+Initiative for Obstructive Lung Disease (GOLD) criteria, those with
+forced expiratory volume 1 (FEV1)/forced vital capacity ratio < 0.7
+and postbronchodilator FEV1 < 80% predicted, clinically stable for
+at least 3 months prior to enrollment, able to walk without aid,
+willing to complete all study assessments and provide informed
+consent were included in the study.
+2.3. Exclusion criteria
+Patients with recent COPD exacerbation, unstable angina, res-
+piratory tract infection within 1 month of the start of the study,
+myocardial infarction, angioplasty, heart surgery in the previous 3
+months, basal blood pressure > 180/100 mmHg, resting PR > 120
+bpm, body mass index (BMI) > 35 kg/m2, injury-free, no history of
+Yoga group
+(n = 41)
+Control group
+(n = 40)
+Did not meet the inclusion criteria 
+(n = 162)
+Random assignment (n = 81)
+Intervention 12 
+weeks
+Drop outs
+(n = 4)
+Drop outs
+(n = 5)
+Final analysis
+Yoga (n = 36)
+Final analysis
+Control (n = 36)
+Attendance <60% (n = 2),
+Illness (n = 1)
+Out of station (n = 2)
+Unable to return for post 
+data (n = 1)
+Illness (n = 2)
+Out of station (n = 1)
+Reasons for drop 
+out
+Total patients screened
+(n = 279)
+Declined informed consent
+(n = 36)
+Underwent clinical examination
+(n = 243)
+Fig. 1. Participant's flow chart
+R. Ranjita et al. / Journal of Ayurveda and Integrative Medicine 7 (2016) 158e166
+159
+hospitalization, previous involvement in yoga rehabilitation pro-
+grams, neuromuscular conditions interfering with exercise tests,
+present and ex-smokers (smoking is a confounding variable) were
+excluded.
+2.4. Ethical clearance and informed consent
+The study protocol was passed by S-VYASA's Institutional Ethical
+Committee. All procedures were performed according to the
+Declaration of Helsinki research ethics. Each participant received
+detailed information about the study and provided written
+informed consent before the trial commenced.
+2.5. Study design
+A randomized controlled trial (RCT) on coal miners with COPD
+comparing add-on effect of IAYT to usual conventional care. Par-
+ticipants were randomized to yoga or waitlist control groups. The
+yoga group received IAYT for 90 min 6 days a week for 12 weeks.
+2.6. Blinding and masking
+Participants in yoga intervention group could not be blinded to
+treatment allocation arm due to the nature of the intervention. The
+team involved in assessments and the statistician who performed
+the randomization and final analysis were not involved in admin-
+istering the intervention.
+2.7. Intervention
+Included a combination of asanas, loosening exercises, breathing
+exercises, pranayama, cyclic meditation, and yogic counseling and
+lectures (Table 1). IAYT aims to give a holistic treatment correcting
+imbalances at physical, mental, emotional, and intellectual levels
+using various components like those listed above [30]. For COPD
+special techniques were selected aiming for:
+1. Deeply relax various different muscle groups
+2. Slow the breath through breathing practices
+3. Strengthen respiratory muscles
+4. Calm the mind
+5. Balance emotions - equipoise
+6. Develop internal awareness and bliss in action.
+Participants in the yoga group were given yoga training sessions
+for 90 min, 6 days a week for 12 weeks by trained yoga instructors.
+They were instructed to perform asanas in a relaxed state of mind,
+without superfluous power, in a smooth, harmonized, steadily
+controlled manner, being fully cognizant of the physical move-
+ments
+with
+well-coordinated
+breathing
+pattern.
+Pranayamas
+included both slow and fast breathing practices. Waitlist controls
+were offered the 12 weeks yoga program after the intervention
+period and post-testing were complete.
+2.8. Assessments
+Six minute walk distance (6MWD), dyspnea, and fatigue were
+measured in both groups pre- and post-intervention. Participants
+were first administered the 6 minute walk test (6MWT), noting
+their distance walked in meters. Dyspnea and fatigue symptoms
+(on the Borg scale) and physiological data (SpO2, PR) were then
+recorded.
+2.9. Six minute walk test
+This was performed according to the American Thoracic Society
+guidelines [53]. As an objective measurement of true functional
+capacity, the 6MWT is usually better than self-reports or ques-
+tionnaires to overcome over- or under-estimation. For patients
+with COPD it is a good indicator of exercise capacity and also re-
+flects an individual's submaximal level of functional capacity to
+perform activities of daily living. In clinical practice, it is commonly
+used after a therapeutic intervention to evaluate improvement of
+responses, both symptomatic (dyspnea and fatigue) and physio-
+logical (distance walked, peripheral capillary SpO2%, and PR).
+Participants were asked to walk back and forth at their own pace
+in a flat, straight, hard surfaced 35 m corridor, and to try and cover
+as much distance as possible in the time allotted. Rest stops were
+permitted during the test, but they were instructed to resume
+walking as soon as possible. Standardized phrases were used at
+each minute (e.g., “You are doing fine. Five minutes to go,” “Keep up
+the rhythm. Four minutes to go,” “You are doing fine. You are
+halfway to the end,” “Keep up the rhythm. Only 2 min to go,” “You
+are doing fine. Only 1 min to go”). Total distance covered was
+recorded.
+2.10. Dyspnea
+Participants were asked to rate their subjective scores of
+“shortness of breath” on cessation of the 6MWT using the modified
+Borg scale on a score of 0e10. This consists of a vertical number
+scale ranging from 0 (none) to 10 (maximal), with corresponding
+verbal expressions of the magnitude of breathing difficulty. Higher
+scores indicate worse dyspnea.
+2.11. Fatigue
+Participants were asked to rate their degree of fatigue on a
+vertical modified Borg's scale labeled 0e10, with 0 at the top
+indicating “nil” fatigue and “10” at the bottom representing “worst
+possible experience of fatigue.” The scores were noted before and
+after the intervention.
+2.12. Pulse oximetry
+Pulse oximetry is a non-invasive method affording a rapid
+measurement of oxygenation of hemoglobin in the peripheral
+capillary [54]. Post-exercise peripheral capillary SpO2% and PR were
+assessed for every participant using a portable pulse-oximetry
+device (Nonin 9570 light emitting diode pulse oximeter, USA).
+Percentage of peripheral capillary SpO2% was measured after con-
+necting the optical diodes on the patients' fingers by trans-
+cutaneous pulse oximetry. Each experiment was performed thrice,
+and mean values were recorded. None had a baseline SpO2 < 88% or
+received domiciliary oxygen therapy.
+2.13. Data collection
+Demographic and vital clinical data (Table 2) including personal,
+job, family, and stress history were obtained by semistructured
+interviews at the time of enrollment. Participants underwent
+physical
+examinations,
+anthropometric
+measurements,
+and
+assessment of lung function. BMI was calculated as body weight in
+kilograms divided by height in meters squared. Dyspnea and fa-
+tigue were assessed by modified Borg scale. Peripheral capillary
+SpO2% and PR were measured by pulse oximetry as described
+above.
+R. Ranjita et al. / Journal of Ayurveda and Integrative Medicine 7 (2016) 158e166
+160
+Table 1
+Integrated approach of yoga therapy for chronic obstructive pulmonary disease used in this study.
+Name of the practices
+Duration
+(min)
+Methodology
+Benefits
+Layer/Kosa
+Breathing practices
+10
+Standing
+The movement of hands, legs, abdominal,
+or thoracic muscles as needed in each
+exercise is synchronized with the
+breathing
+For inhalation and exhalation, “in” and
+“out” instructions of the mind (or that of
+teacher) is used
+Effort should be made to slow down the
+breathing gradually
+Eyes will remain closed retaining the
+awareness throughout the practice [32]
+Strengthen the respiratory muscles,
+develop the awareness of expansion and
+contraction of the airways, make
+breathing uniform, continuous and
+rhythmic, oxygenate all parts of the lung,
+opens out blocked air passages, stabilize
+effect on bronchial reactivity, and
+improve respiratory function [18,32e34]
+Pranamaya Kosa
+(sheath of vital
+energy) [30,35,36]
+Hands in and out breathing
+1
+Hands stretch breathing
+1
+Ankle stretch breathing
+1
+Sitting
+Dog breathing
+1
+Rabbit breathing
+1
+Tiger breathing
+1
+Shashankasana breathing
+(moon pose)
+1
+Prone
+Bhujangasana breathing
+1
+Shalabhasana breathing
+1
+Supine
+1
+Straight leg raising breathing
+Loosening practices
+10
+These are performed stepwise with speed
+and repetitions which involve loosening
+of the joints, flexing of the spine.
+Attention during the practice is
+emphasized. The speed and number of
+repetitions should be increased
+depending on individual's capacity [32]
+Improve stamina in all muscles, flexibility,
+and tolerance to exercise, clears CO2,
+improve pulmonary function, respiratory
+pressures, and overall cardiorespiratory
+fitness [32,37,38]
+Annamaya Kosa
+(sheath of physical
+awareness) [30,35,36]
+Forward and backward bending
+Side bending
+Twisting
+Pavanamuktasana kriya (alternate leg)
+Rocking and rolling
+Surya Namaskara 
 3 rounds
+1
+1
+1
+1 
 2
+1 
 2
+1 
 3
+Yogasanas (physical postures)
+20
+Sthiram sukham asanam//P.Y.S.2/46
+Yogasanas are firm and comfortable
+postures. The key aspects are relaxation of
+the body, slowness of mind and of
+awareness of breathing [30]
+Yogah chitta vritti nirodhah//P.Y.S.1/2
+Mastery over the modifications of the
+mind, release mental tensions by dealing
+with physical level, revitalize and relax
+the body, calm down the mind [32,39,40]
+Annamaya Kosa
+(sheath of physical
+awareness) [30,35,36]
+Standing
+Ardhakati chakrasana
+(lateral arc pose)
+Padahastasana (forward bend pose)
+Ardha chakrasana (half wheel pose)
+Starting posture: Tadasana
+Relaxation: Shithila Tadasana
+Open up chest, improves stamina,
+increase confidence [32,39,40]
+2
+2
+2
+Sitting
+Vakrasana (twisting posture)
+Ardhamatsyendrasana (half spinal
+twist posture)
+Paschimottanasana (sleeping
+thunderbolt posture)
+Starting posture: Dandasana
+Relaxation: Shithila Dandasana
+Improve flexibility of spine and
+strengthens thoracic, abdominal, and
+limb muscles [32,39,40]
+2
+2
+2
+Prone
+Bhujangasana (serpent pose)
+Shalabhasana (locust pose)
+Starting posture: Makarasana
+Relaxation: Makarasana
+Improve shoulder flexibility, stamina in
+thigh muscles, release stiffness, increase
+lung capacity, and promote expansion of
+rib cage [32,39,40]
+2
+2
+Supine
+Sarvangasana (shoulder stand pose)
+Matsyasana (fish pose)
+2
+2
+Starting posture: Savasana
+Relaxation: Savasana
+Invigorate all parts of the body, improve
+metabolic rate [32,39,40]
+Yoga chair breathing
+10
+This is a special eight stepped breathing
+technique developed by SVYASA found on
+the knowledge base to help in breaking
+the vicious cycles of anxiety and
+bronchospasm during acute attacks by
+deconditioning autonomic arousal
+[32,33,41]. The participants were asked to
+resort to this technique using a chair as a
+props
+Deep relaxation of respiratory muscles,
+opens up airway obstruction, overcomes
+the bronchospasm effectively, minimizes
+the acute episodes, improves confidence,
+and reduces panic anxiety [32,33,41]
+Pranamaya Kosa
+(sheath of vital
+energy) [30,35,36]
+Instant relaxation technique
+Neck muscle relaxation with chair
+support
+Neck movements in Vajrasana
+Shashankasana movement
+Relaxation in Tadasana
+Neck movements in Tadasana
+Ardha chakrasana - Padahastasana
+Quick relaxation technique
+1
+1
+1
+1
+1
+1
+1
+1
+Pranayama
+10
+Tasmin sati svasa prasvasayor gati
+vicchedah pranayamahjP.Y.S. 2/49
+After perfection of posture is attained, the
+movements of inhalation and exhalation
+are regulated by consciously breathing
+long, subtly and with counts while having
+attention on different parts of the body
+[42]
+Pranayamenayuktena sarvarogakshayo
+bhavet| jH.Y.P. 2/16
+Improves balance of body-mind complex,
+brings emotional stability through
+slowing down the mental and physical
+processes, decreases metabolic activity,
+activates parasympathetic state, and
+improves lung function parameters
+[30,39,43,44]
+Pranamaya Kosa
+(sheath of vital
+energy) [30,35,36]
+Kapalabhati (frontal brain cleansing)
+(high-frequency yoga breathing
+technique)
+2
+Kapalabhati consists of a series of fast
+successive bursts of exhalations followed
+by automatic passive inhalations [39,45]
+It is performed rapidly like the bellows of
+a blacksmith [40]
+Kapalabhatirvikhyata
+kaphadosavisosanijH.Y.P 2/35
+Strengthens diaphragm, cleanses lungs
+and entire respiratory tract, improves
+lung capacity, and increases tolerance of
+brain cells to acidebase imbalances in
+blood stream [39,40,45]
+(continued on next page)
+R. Ranjita et al. / Journal of Ayurveda and Integrative Medicine 7 (2016) 158e166
+161
+Table 1 (continued )
+Name of the practices
+Duration
+(min)
+Methodology
+Benefits
+Layer/Kosa
+Vibhagiya pranayama (sectional
+breathing)
+2
+Preparatory practice having three
+sections:
+Abdominal
+Thoracic
+Clavicular breathing [39,45]
+Increases vital capacity of the lungs, slows
+down the breath, strengthens of all three
+groups of muscles of respiration [39,45]
+Nadishodhana pranayama (alternate
+nostril breathing)
+2
+Sitting in padmasana, air should be
+inhaled through the left nostril after
+having retained the breath as long as
+possible, it should be exhaled through the
+right nostril, and again inhaled through
+right after performing kumbhaka and
+exhaled through the left nostril [39,40,45]
+Opens up nostrils, clears the nasal
+passages, calms down the mind, helps in
+bronchial asthma, nasal allergy,
+bronchitis, brings reduction in stress and
+autonomic balance, increases PEFR, PP,
+decreases PR, RR, BP, increases
+parasympathetic activity [39,40,45,46]
+Ujjayi pranayama (diaphragmatic
+breathing)
+2
+With closed mouth, air should be inhaled
+deeply until the breath fills all the space
+between the throat down to the lungs
+with a hissing sound, after kumbhaka, the
+air should be exhaled through the left
+nostril [39,40,45]
+This removes phlegm in the throat and
+helps in diseases due to kapha like
+tonsillitis, sore throat, chronic cold, cough
+and bronchial asthma, lowers the oxygen
+consumption and metabolic rate
+[39,40,45,47]
+Bhramari pranayama (bee breathing)
+2
+After quick inhalation air is exhaled
+slowly producing a soft humming sound
+[39,40,45]
+Relieves stress and cerebral tension,
+harmonize the mind, deals problems of a
+sore throat, tonsils, etc. [39,40,45]
+Meditation
+10
+Meditation should be done in any
+comfortable meditative posture with
+spine erect and eyes closed. Consciously
+breath is slowed down allowing the mind
+to calm down [30,42]
+Improves information processing in brain,
+reduces stress, decreases metabolic and
+RR, calms down the mind [30,42,48]
+Manomaya Kosa
+(sheath of mental
+activities) [30,35,36]
+Nadaanusandhana (alternate day)
+10
+Different sounds like A,U,M and AUM are
+chanted loudly so that they generate fine
+resonance all over the body [30,40]
+Improves emotional equipoise, higher
+creativity, freshness, lightness, awareness
+and expansion [30,40]
+Om meditation (alternate day)
+10
+Sitting in any meditative posture “Om” is
+chanted mentally, not giving chance for
+distractions [30]
+Achieves calmness, peace, serene, bliss,
+silence state of mind, improves
+concentration, memory, attention span
+[30,49,50]
+DRT in Savasana (corpse pose)
+10
+DRT is an eight step method developed by
+SVYASA DRT is an eight step method
+developed by SVYASA, practiced
+preferably lying down in savasana with
+eyes closed. This is done by taking a trip to
+different parts of the body from toes to
+head gradually with visualization,
+awareness and deeper feeling of
+relaxation [30]
+Invigorates deep rest, decreases
+metabolic rate, reduces demand and
+stress, PR, RR, BP, muscle tension, oxygen
+consumption [30,51,52]
+Annamaya Kosa
+(sheath of physical
+awareness) [30,35,36]
+Yogic counseling/lectures
+10
+Yoga counseling, lectures, and
+interactions through questions and
+answers were essential for awareness of
+one's problems. It was conducted in a
+group and later one to one basis [30]
+Helps to diagnose and remove the
+psychological conflicts of the individuals,
+enhances positive thinking and facilitates
+stress management [30]
+Vijnanamaya Kosa
+(sheath of self-
+knowledge) [30,35,36]
+Yoga philosophy and health, basis and
+applications of yoga, Panchakosa viveka
+(five layers of existence), Lifestyle
+modification, emotion and coping, diet
+and exercise, COPD causes,
+complications and lifestyle factors,
+Stress reaction and its management
+Kriya (once a week)
+90
+To cleanse the inner tracts, thereby
+developing involuntary control over
+voluntary reflexes [32]
+Develops inner awareness; desensitizes
+hypersensitive reactions in the pathways
+[32,33]
+Annamaya Kosa (sheath
+of physical awareness)
+[30,35,36]
+Theory on kriya
+10
+The procedure is explained with the help
+of diagrams prior to the practice
+Provides knowledge on procedure,
+benefits, and limitations of each kriya
+Jala Neti
+20
+Lukewarm saline water is inserted
+through one nostril with a special neti pot
+and allowed to flow through the other
+nostril [32]
+Kaphadosa vinashyantijG.S 1/51
+Destroys the disorders of phlegm. Clears
+nasal passages, hypersensitivity, sinusitis
+and bronchitis [32]
+Sutra Neti
+20
+Blunt soft rubber catheter is gently
+pushed through nose and pulled out
+through mouth massaging the nasal
+passage [32]
+Clears nose and pharynx, mastery over
+involuntary reflexes of sneezing and
+cough, desensitize to dust and pollution,
+relieves in nasal allergy [32]
+Vamana Dhouti
+25
+Stomach is filled with warm saline water
+until one feels like vomiting. By pressing
+middle three fingers of the right hand on
+the root of the tongue vomiting sensation
+is stimulated until all water comes out
+[32]
+Kasasvasaplihakustham
+kapharogaschavimsatih
+Dhautikarmaprabhavena prayantyeva na
+samshayah H.Y.P.2/25
+Clears the air passages through reflex
+stimulation, useful for asthma and
+bronchitis [32]
+DRT
+15
+DRT was given by eight-step method of
+SVYASA [30]
+Invigorates deep rest, decreases HR, RR,
+BP, muscle tension, oxygen consumption
+[30,52]
+COPD ¼ Chronic obstructive pulmonary disease, DRT ¼ Deep relaxation technique, HR ¼ Heart rate, BP ¼ Blood pressure, RR ¼ Respiration rate, PR ¼ Pulse rate.
+R. Ranjita et al. / Journal of Ayurveda and Integrative Medicine 7 (2016) 158e166
+162
+2.14. Statistical analysis
+Statistical analysis was performed using SPSS 18 (IBM Corpo-
+ration, USA). After ascertaining normality of data, paired t-tests
+were used to determine the significance of variable differences
+before and after the intervention. Means of the both groups were
+compared for all variables using Student's t-test. Categorical vari-
+ables were analyzed using the Chi-square test. The level of statis-
+tical significance was set at P < 0.05 for all tests.
+3. Results
+3.1. Demographic data
+Of the 81 coal miners who were recruited, 72 (36 in each group)
+completed all assessments. Fig. 1 shows the study profile. There
+were five dropouts from the yoga and four from the control group.
+Table 2 compares the demographic details, clinical and functional
+characteristics, and stress history of the study population. No
+significant differences were found in this comparison. The mean
+age of the yoga group was 53.69 ± 5.66 years (range: 36e60 years)
+and in the control group, 54.36 ± 5.40 years (range: 37e60 years).
+The number of participants with GOLD Stage II and GOLD Stage III
+was 19 and 17 in yoga; and 21 and 15 in the control group. The
+mean duration of disease was 9.92 ± 3.25 years in yoga group and
+10.69 ± 2.54 years in the control group. Differences between mean
+ages, severity, and duration of disease in the two groups were not
+significant.
+3.2. Changes in the variables after yoga intervention
+For the majority of patients, the intensity of dyspnea and fatigue
+decreased after the yoga intervention; they were also able to walk
+further in the stipulated 6 min time. Similar improvements were
+also observed between pre- and post-intervention testing in their
+physiological responses (SpO2 and PR) after the 6MWT (Table 3).
+3.3. Dyspnea and fatigue
+Paired sample t-test showed a small but insignificant decrease
+in dyspnea score of 6.09% (P ¼ 0.127) and in fatigue score of 5.65%
+(P ¼ 0.226) in the control group. In contrast, the observed re-
+ductions in mean dyspnea score of 24.41% and in mean fatigue
+score of 25.86% in the yoga group after the intervention were both
+highly significant (P < 0.001). These suggest definite improvements
+in cardiorespiratory fitness levels. Statistically, there was a signifi-
+cant difference between the postvalues of
+the two
+groups
+(P ¼ 0.018, independent sample t-test).
+3.4. Six minute walk test
+The post intervention changes in the 6MWD in both the groups
+were statistically significant (P < 0.001). But the magnitude of
+change was higher (19.93%) for the yoga group than the control
+group (5.39%). In addition, significant group mean differences were
+observed between yoga and control group's post intervention
+scores (P ¼ 0.047, independent sample t-test).
+3.5. Peripheral capillary oxygen saturation and pulse rate
+Paired sample t-test showed a significant change in peripheral
+capillary SpO2% and PR after yoga training sessions in the yoga
+group, but no change in controls. Peripheral capillary SpO2%
+increased by 1.32% (P < 0.001) in yoga group but remained almost
+Table 2
+Homogeneity test for age, life stress, duration of disease, and anthropometric
+measures between the yoga and control group.
+Variable
+Yoga
+Control
+Number of participants
+36
+36
+Age (mean ± SD)
+53.69 ± 5.66
+54.41 ± 5.40
+Diagnosis
+Asthmatic bronchitis
+9
+7
+Chronic bronchitis
+12
+18
+Emphysema
+15
+11
+Duration of employment in coal mines
+(mean ± SD)
+28.36 ± 4.62
+27.72 ± 4.23
+Duration of disease since diagnosis
+(mean ± SD)
+9.92 ± 3.25
+10.69 ± 2.54
+Stress history n (%)
+Family
+8 (22.2)
+6 (16.7)
+Financial
+7 (19.4)
+9 (25.0)
+Health
+12 (33.3)
+14 (38.9)
+Job
+6 (16.7)
+5 (13.9)
+Nil
+3 (8.3)
+2 (5.6)
+GOLD COPD severity, n (%)
+GOLD II e moderate
+19 (52.8)
+21 (58.3)
+GOLD III e severe
+17 (47.2)
+15 (41.7)
+Height (cm)
+161.17
+158.75
+Weight (kg)
+62.73
+59.38
+BMI (kg/m2)
+24.15
+23.57
+GOLD ¼ Global Initiative for Obstructive Lung Disease, BMI ¼ Body mass index,
+SD ¼ Standard deviation, COPD ¼ Chronic obstructive pulmonary disease.
+Table 3
+Clinical outcomes of participants before intervention (baseline), at end of therapy.
+Variables
+Yoga (n ¼ 36)
+Control (n ¼ 36)
+Between groups
+Pre
+Post
+Pre
+Post
+Mean ± SD
+CI (LB
+to UB)
+Mean ± SD
+CI (LB
+to UB)
+Mean ± SD
+CI (LB
+to UB)
+Mean ± SD
+CI (LB
+to UB)
+Pre
+versus
+pre
+Post
+versus
+post
+Group*time
+interaction
+Borg -
+dyspnea
+5.08 ± 1.40
+4.61e5.56
+3.84 ± 1.75***
+3.25e4.44
+5.25 ± 1.61
+4.71e5.79
+4.93 ± 2.02
+4.24e5.62
+0.641
+0.018
+<0.001
+Borg -
+fatigue
+4.91 ± 1.34
+4.46e5.37
+3.64 ± 1.64***
+3.08e4.19
+4.78 ± 1.69
+4.21e5.35
+4.51 ± 1.68
+3.95e5.08
+0.701
+0.028
+<0.001
+6MWD (m)
+298.36 ± 65.20
+276.30e
+320.42
+357.81 ± 73.45***
+332.95e
+382.66
+304.67 ± 67.59
+281.80e
+327.53
+321.08 ± 80.17***
+293.96e
+348.21
+0.688
+0.047
+<0.001
+SpO2%
+92.47 ± 1.87
+91.84e
+93.11
+93.69 ± 2.47***
+92.86e
+94.53
+92.36 ± 1.58
+91.82e
+92.90
+92.58 ± 1.71
+92.00e
+93.16
+0.787
+0.030
+<0.001
+PR
+104.27 ± 8.37
+101.45e
+107.11
+99.80 ± 7.41***
+97.30e
+102.31
+103.08 ± 8.38
+100.25e
+105.92
+104.17 ± 8.38
+101.33e
+107.00
+0.547
+0.022
+<0.001
+***P < 0.001. 6MWT ¼ 6 min walk test, SpO2 ¼ Peripheral capillary oxygen saturation, PR ¼ Pulse rate, SD ¼ Standard deviation, CI ¼ Confidence interval, LB ¼ Lower bound,
+UB ¼ Upper bound, 6MWD ¼ 6 min walk distance.
+R. Ranjita et al. / Journal of Ayurveda and Integrative Medicine 7 (2016) 158e166
+163
+unchanged (0.24%, P ¼ 0.173) in control group with a significant
+difference between the groups (P ¼ 0.030). In the yoga group PR
+decreased by 4.28% (P < 0.001), whereas it increased by 1.05%
+(P ¼ 0.054) in controls. There was a significant difference between
+the postvalues of groups (independent samples t-test, P ¼ 0.022).
+4. Discussion
+The study evaluated add-on effects of 12 weeks integrated yoga
+therapy on dyspnea, fatigue, functional exercise capacity, SpO2, and
+PR in coal miners with COPD as an adjunct to conventional care. No
+adverse effects were observed. Patients in yoga and control groups
+were
+statistically
+similar
+across
+all
+parameters
+at
+baseline
+(P > 0.05). The two groups were comparable. Results showed sta-
+tistically significant declines in dyspnea and fatigue and increase in
+functional performance in coal miners with COPD after the yoga
+intervention, leading to some plausibly concrete conclusions. Sig-
+nificant, firm, and progressive improvement in the key objective
+variables; functional exercise capacity, SpO2 and PR in the yoga
+group but not controls indicate yoga's effectiveness.
+The encouraging effect of yoga on COPD is consistent with
+conclusions of previous studies [14e17]. In this study, 6MWD
+increased by 59.45 m in the yoga group and 16.41 m in controls; a
+clinically significant difference in participants' exercise perfor-
+mance,
+similar
+to
+Donesky's
+2009
+pilot
+study
+(improved
+21.5 ± 7.0 m for yoga, 8.3 ± 10.9 m for usual care) after yoga training.
+A meta-analysis of five RCTs involving 233 patients [55] concluding
+that yoga training has a positive effect on functional exercise ca-
+pacity in patients with COPD also supports these findings. Another
+study on severe COPD, 54 m (95% confidence interval, 37e71 m)
+was identified as the minimum difference in a COPD patient to
+perceive improvements between one test and another as clinically
+significant [56]. Another study observed a mean increase of 50 m
+(20%) in 6MWD for COPD patients after exercise and diaphragmatic
+strength training [57]. Mahler et al. [58] showed a comparable
+small decrease in dyspnea intensity, regardless of improved exer-
+cise capacity after six weeks exercise training in COPD patients. An
+earlier study has reported yoga breathing exercise induced greater
+resting SpO2 in patients with COPD [59].
+Differences in the sampling, study design, characteristics of
+participants, type of yoga training and duration of yoga may ac-
+count for differences in findings to some extent. Our population
+comprised mild to severe COPD sufferers attending an outpatient
+clinic. Our findings may differ from those of hospital-based studies.
+To meet exacting demands of methodology, some recent studies
+may have overlooked basic features of yoga, which is much more
+than breathing exercises. Including all components of yoga
+together as in IAYT used in this study has more beneficial effects.
+However, none of the previous trials have gone into the possible
+mechanisms by which yoga might help COPD and did not provide
+adequate data or sufficient clinical evidence to support the bene-
+ficial effects of yoga training on these relevant findings.
+Mechanisms to account for the favorable effects of yoga training
+are complex and yet to be elucidated. Several factors may
+contribute to the beneficial effects observed in this study. Yoga
+represents a form of mind-body fitness. IAYT includes a combina-
+tion of asanas, pranayama, meditation and relaxation, and inter-
+nally directed mental focus on awareness of self, breathing, and
+energy. Regular practice tones up general body systems, calms the
+mind, improves blood circulation, enhances energy levels, expands
+the lungs, relaxes chest muscles, and increases the strength of
+respiratory muscles [30]. It has been found that slow comfortable
+breaths help patients breathe more deeply by efficiency of the
+shoulder, thoracic, and abdominal muscles; lead to an increase in
+parasympathetic
+modulation
+and
+regulating
+chemoreceptive
+sensitivity [60].
+Observed improvements in perception of dyspnea may result
+from a decrease in sympathetic reactivity achieved by yogic
+training, promoting broncho-dilatation by correcting abnormal
+breathing patterns and reducing muscle tension in inspiratory and
+expiratory muscles [32]. Improved breathing patterns may widen
+bronchioles so that larger numbers of alveoli can be efficiently
+perfused [15]. Pranayama practices stretch lung tissue, alleviating
+dyspnea by decreasing dynamic hyperinflation of the rib cage and
+recuperating
+gas
+exchange,
+enhancing
+respiratory
+muscles'
+strength and endurance, and optimizing thoracoabdominal pat-
+terns of motion [61]. Modifications in efferent vagal activity affect
+the caliber of airways reducing dyspnea.
+Observed improvements in fatigue scores can be explained by
+various interrelated factors. First, in asanas, muscles are toned,
+energy conserved and sympathetic activity balanced, while mental
+relaxation and greater parasympathetic function affect cardiore-
+spiratory activity, relax the vasomotor center, and reduce PR, ulti-
+mately leading to reduced feelings of fatigue. Pranayama helps in
+the full utilization of the lungs, enhancing ventilatory function,
+reducing oxygen debt, improving gas exchange, and thus prevent-
+ing exhaustion.
+Observed improvements in 6MWD are due to yoga's beneficial
+effects
+on
+musculoskeletal
+and
+cardiorespiratory
+systems,
+improving cardiovascular efficiency and homeostatic control of the
+body. Muscle conditioning during yoga's intense stretching pos-
+tures helps by improving oxidative capacity and strength of skeletal
+muscles, flexibility, endurance, coordination, power, static and
+dynamic
+stability,
+decreasing
+glycogen
+utilization,
+in
+turn
+improving physical performance and increasing walking pace and
+stride length [62].Yoga relaxation techniques have shown to
+improve cardiopulmonary endurance through body-and-breath
+control, which manifest clinically as improved lung capacity,
+increased oxygen delivery and decreased PR, resulting in overall
+improved exercise capacity. Improvements in 6MWD in the control
+group were statistically but not clinically significant (< 54 m).
+Changes in score may also be due to ordinary performance (no
+intervention),
+improved
+coordination,
+finding
+optimal
+stride
+length, or overcoming anxiety [53].
+Improvements in blood SpO2% may be associated with the
+practice of pranayama, which engage normally unventilated lungs
+and help circulation, ventilation, and perfusion better, increasing
+oxygen delivery to muscles. Pranayama increases strength of res-
+piratory muscles, reduces sympathetic reactivity, probably through
+improved oxygen delivery to tissues, possibly supplemented by
+acquired “tolerance” to hypoxia produced by changes in chemo-
+reflex threshold and decreased dyspnea.
+Deep relaxation technique, an important component of IAYT
+showed significant reductions in the yoga group's PR, possibly due
+to modulation of cardiac autonomic function and cardiorespiratory
+efficiency. It may also synchronize neural elements in the brain,
+leading to ANS changes, resulting parasympathetic dominance and
+blunted sympathetic activity leading to reduced PR [3]. Pranayama
+modifies various inflatory and deflatory lung reflexes and interacts
+with central neural elements to improve homeostatic control [63].
+In this study, yoga may have reduced ventilator requirements at the
+end of 6MWT, thereby decreasing PR.
+4.1. Scope and limitations of the study
+This is the first randomized controlled study of yoga for coal
+miners with moderate to severe COPD. It used IAYT, and its
+reasonable sample size offers good evidence for the benefits of
+yoga-based rehabilitation. Having additional subgroups stratified
+R. Ranjita et al. / Journal of Ayurveda and Integrative Medicine 7 (2016) 158e166
+164
+as mild, moderate, severe, and very severe would have made the
+study more vigorous. In addition, we did not measure arterial blood
+gas components, such as PaO2, which would have produced more
+detailed results, providing a fuller picture of subject's physiology. If
+the measures of PR monitoring and heart rate variability had been
+used during the exercise test, effects would have been assessed
+more objectively. Similarly, assessments of biochemical variables
+involved would throw light on mechanisms. We would recommend
+a multicenter RCT to confirm results of the study, with a longer
+follow-up of 12 months or more to evaluate long-term efficacy.
+5. Conclusions
+The study's promising results, reducing dyspnea and fatigue,
+and improving functional exercise capacity in COPD patients,
+indicate the value of using yoga in programs of pulmonary reha-
+bilitation as an adjunct to conventional care. More rigorously
+designed, larger scale research with longer follow-up should be
+conducted, particularly as that would also expand yoga's evidence
+base.
+Source of support
+Nil.
+Conflicts of interest
+None declared.
+Acknowledgment
+The authors would like to acknowledge Mr Rajeev Lochan for
+technical assistance; the teachers of the yoga classes, Mrs. Sumati
+Badhai, and Mr. Kunja Bihari Badhai for providing individualized
+and continual support for the participants; Mr. Arjun Biswal for
+coordinating the program and Dr. Balaram Pradhan, Ph.D. for sta-
+tistical analysis.
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+breast cancer undergoing radiotherapy. J Clin Oncol 2014;32:1058e65.
+[20] Vadiraja R, Raghavendra HS, Nagarathna R, Nagendra HR, Rekha M, Vanitha N,
+et al. Effects of a yoga program on cortisol rhythm and mood states in early
+breast cancer patients undergoing adjuvant radiotherapy: a randomized
+controlled trial. Integr Cancer Ther 2009;8:37e46.
+[21] Raghuram N, Parachuri VR, Swarnagowri MV, Babu S, Chaku R, Kulkarni R,
+et al. Yoga based cardiac rehabilitation after coronary artery bypass surgery:
+one-year results on LVEF, lipid profile and psychological states e a random-
+ized controlled study. Indian Heart J 2014;66:490e502.
+[22] Mashyal P, Bhargav H, Raghuram N. Safety and usefulness of laghu shankha
+prakshalana in patients with essential hypertension: a self controlled clinical
+study. J Ayurveda Integr Med 2014;5:227e35.
+[23] Rao YC, Kadam A, Jagannathan A, Babina N, Rao R, Nagendra HR. Efficacy of
+naturopathy and yoga in bronchial asthma. Indian J Physiol Pharmacol
+2014;58:233e9.
+[24] McDermott KA, Rao MR, Nagarathna R, Murphy EJ, Burke A, Nagendra RH,
+et al. A yoga intervention for type 2 diabetes risk reduction: a pilot ran-
+domized controlled trial. BMC Complement Altern Med 2014;14:212.
+[25] 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;5:28e36.
+[26] Tekur
+P,
+Nagarathna
+R,
+Chametcha
+S,
+Hankey
+A,
+Nagendra
+HR.
+A comprehensive yoga programs improves pain, anxiety and depression in
+chronic low back pain patients more than exercise: an RCT. Complement Ther
+Med 2012;20:107e18.
+[27] Satyapriya M, Nagarathna R, Padmalatha V, Nagendra HR. Effect of integrated
+yoga on anxiety, depression & well-being in normal pregnancy. Complement
+Ther Clin Pract 2013;19:230e6.
+[28] Radhakrishna S, Nagarathna R, Nagendra HR. Integrated approach to yoga
+therapy and autism spectrum disorders. J Ayurveda Integr Med 2010;1:
+120e4.
+[29] Duraiswamy G, Thirthalli J, Nagendra HR, Gangadhar BN. Yoga therapy as an
+add-on treatment in the management of patients with schizophrenia e a
+randomized controlled trial. Acta Psychiatr Scand 2007;116:226e32.
+[30] Nagarathna R, Nagendra HR. Integrated approach of yoga therapy for positive
+health. 2nd ed. Bangalore: Swami Vivekananda Yoga Prakashan; 2013.
+[31] Nagendra HR, Nagarathna R. An integrated approach of yoga therapy for
+bronchial asthma: a 3-54-month prospective study. J Asthma 1986;23:
+123e37.
+[32] Nagarathna R, Nagendra HR. Yoga for bronchial asthma. 1st ed. Bangalore:
+Swami Vivekananda Yoga Prakashan; 2012.
+[33] Nagarathna R, Nagendra HR. Yoga for common ailments. 2nd ed. Bangalore:
+Swami Vivekananda Yoga Prakashan; 2003. p. 64e71.
+[34] Santaella DF, Devesa CR, Rojo MR, Amato MB, Drager LF, Casali KR, et al. Yoga
+respiratory training improves respiratory function and cardiac sympathovagal
+balance in elderly subjects: a randomised controlled trial. BMJ Open 2011;1:
+e000085.
+[35] Lokeswarananda S. Taittiriya upanisad. 1st ed. Kolkata: The Ramakrishna
+Mission Institute of Culture; 2005. p. 142e52.
+[36] Nagendra HR. The basis for an integrated approach in yoga therapy. Kanya-
+kumari: Vivekananda Kendra Prakashan Trust; 1980.
+[37] Mody BS. Acute effects of Surya Namaskar on the cardiovascular & metabolic
+system. J Bodyw Mov Ther 2011;15:343e7.
+[38] Bhavanani AB, Udupa K, Madanmohan, Ravindra PN. A comparative study of
+slow and fast suryanamaskar on physiological function. Int J Yoga 2011;4:
+71e6.
+[39] Saraswati SS. Asana, pranayama, mudra bandha. 4th ed. Munger: Yoga Pub-
+lications Trust; 2012.
+R. Ranjita et al. / Journal of Ayurveda and Integrative Medicine 7 (2016) 158e166
+165
+[40] Muktibodhananda S. Hatha yoga pradipika. 2nd ed. Munger: Yoga Publica-
+tions Trust; 2004.
+[41] Nagarathna R, Nagendra HR, Seethalakshmi R. Yoga e chair breathing for
+acute episodes of bronchial asthma. Lung India 1991;9:141e4.
+[42] Saraswati SS. Four chapters on freedom. 1st ed. Munger: Yoga Publications
+Trust; 2008.
+[43] Jerath R, Edry JW, Barnes VA, Jerath V. Physiology of long pranayamic
+breathing: neural respiratory elements may provide a mechanism that ex-
+plains how slow deep breathing shifts the autonomic nervous system. Med
+Hypotheses 2006;67:566e71.
+[44] Dinesh T, Gaur G, Sharma V, Madanmohan T, Harichandra Kumar K,
+Bhavanani A. Comparative effect of 12 weeks of slow and fast pranayama
+training on pulmonary function in young, healthy volunteers: a randomized
+controlled trial. Int J Yoga 2015;8:22e6.
+[45] Nagendra HR. Pranayama the art and science. 3rd ed. Bangalore: Swami
+Vivekananda Yoga Prakashan; 2007.
+[46] Upadhyay Dhungel K, Malhotra V, Sarkar D, Prajapati R. Effect of alternate
+nostril breathing exercise on cardiorespiratory functions. Nepal Med Coll J
+2008;10:25e7.
+[47] Telles S, Desiraju T. Oxygen consumption during pranayamic type of very
+slow-rate breathing. Indian J Med Res 1991;94:357e63.
+[48] Telles S, Raghavendra BR, Naveen KV, Manjunath NK, Kumar S, Subramanya P.
+Changes in autonomic variables following two meditative states described in
+yoga texts. J Altern Complement Med 2013;19:35e42.
+[49] Telles S, Nagarathna R, Nagendra HR. Autonomic changes while mentally
+repeating two syllables e one meaningful and the other neutral. Indian J
+Physiol Pharmacol 1998;42:57e63.
+[50] Telles S, Nagarathna R, Nagendra HR. Autonomic changes during “OM”
+meditation. Indian J Physiol Pharmacol 1995;39:418e20.
+[51] Vempati RP, Telles S. Yoga-based guided relaxation reduces sympathetic ac-
+tivity judged from baseline levels. Psychol Rep 2002;90:487e94.
+[52] Telles S, Reddy SK, Nagendra HR. Oxygen consumption and respiration
+following two yoga relaxation techniques. Appl Psychophysiol Biofeedback
+2000;25:221e7.
+[53] Crapo RO, Casaburi R, Coates AL, Enright PL, MacIntyre NR, McKay RT, et al.
+ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care
+Med 2002;166:111e7.
+[54] Schermer T, Leenders J, in 't Veen H, van den Bosch W, Wissink A, Smeele I,
+et al. Pulse oximetry in family practice: indications and clinical observations
+in patients with COPD. Fam Pract 2009;26:524e31.
+[55] Liu XC, Pan L, Hu Q, Dong WP, Yan JH, Dong L. Effects of yoga training in
+patients with chronic obstructive pulmonary disease: a systematic review and
+meta-analysis. J Thorac Dis 2014;6:795e802.
+[56] Redelmeier DA, Bayoumi AM, Goldstein RS, Guyatt GH. Interpreting small
+differences in functional status: the six minute walk test in chronic lung
+disease patients. Am J Respir Crit Care Med 1997;155:1278e82.
+[57] Weiner P, Magadle R, Berar-Yanay N, Davidovich A, Weiner M. The cumulative
+effect of long-acting
+bronchodilators,
+exercise, and inspiratory muscle
+training on the perception of dyspnea in patients with advanced COPD. Chest
+2000;118:672e8.
+[58] Mahler DA, Fierro-Carrion G, Mejia-Alfaro R, Ward J, Baird JC. Responsiveness
+of continuous ratings of dyspnea during exercise in patients with COPD. Med
+Sci Sports Exerc 2005;37:529e35.
+[59] Pomidori L, Campigotto F, Amatya TM, Bernardi L, Cogo A. Efficacy and
+tolerability of yoga breathing in patients with chronic obstructive pulmonary
+disease: a pilot study. J Cardiopulm Rehabil Prev 2009;29:133e7.
+[60] Bernardi L, Sleight P, Bandinelli G, Cencetti S, Fattorini L, Wdowczyc-Szulc J,
+et al. Effect of rosary prayer and yoga mantras on autonomic cardiovascular
+rhythms: comparative study. BMJ 2001;323:1446e9.
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+obstructive pulmonary disease (COPD). J Rehabil Res Dev 2003;40(5 Suppl. 2):
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+randomized controlled study. Indian J Allergy Asthma Immunol 2006;20:
+98e104.
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+Wilkins Publishers; 2012.
+R. Ranjita et al. / Journal of Ayurveda and Integrative Medicine 7 (2016) 158e166
+166
diff --git a/subfolder_0/Yoga-based lifestyle treatment and composite treatment goals in Type 2 Diabetes in a rural South Indian setup- a retrospective study.txt b/subfolder_0/Yoga-based lifestyle treatment and composite treatment goals in Type 2 Diabetes in a rural South Indian setup- a retrospective study.txt
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+1
+Scientific Reports |         (2020) 10:6402  | https://doi.org/10.1038/s41598-020-63133-1
+www.nature.com/scientificreports
+Yoga-based lifestyle treatment and 
+composite treatment goals in Type 
+2 Diabetes in a rural South Indian 
+setup- a retrospective study
+Geetharani Arumugam1, Raghuram Nagarathna1, Vijaya Majumdar1*, Mandeep Singh2, 
+Rambabu Srinivasalu2, Rajagopal Sanjival2, Venkat S. Ram3 &  
+Hongasandra Ramarao Nagendra1
+This multicentre retrospective study examined the effects of adjunct yoga-treatment in achieving 
+composite cardiovascular goals for type 2 diabetes (T2D), set forth by the American Diabetes 
+Association (ADA) in rural Indian settings. Records were extracted for 146 T2D patients, aged ≥20–70 
+years, and treated under the “Apollo Total Health Programme” for rural diabetes management, 
+for the period April 2016 to November 2016. The study cohort comprised of two treatment groups 
+(n = 73 each); non-yoga group (standard of care) and yoga group (adjunct yoga-treatment). 
+Propensity score matching was applied between the study groups to define the cohort. Composite 
+cardiovascular scores were based on the combination of individual ADA goals; A1c < 7%, blood 
+pressure (BP) < 140/90 mmHg, stringent BP (<130/80 mmHg) and lipid, LDL-C < 100 mg/dl [risk 
+factor for atherosclerotic cardiovascular disease]. Logistic regression was used to compare between 
+the two treatment groups. Compared to standard of care, adjunct yoga-treatment was found to 
+significantly facilitate the attainment of ADA composite score by 8-fold; A1c, ~2-fold; LDL-C, ~2-fold; 
+BP < 140/90 mmHg and <130/80 mmHg by ~8-and ~6-fold respectively. This study provides the first 
+evidence for significant efficacy of adjunct yoga-treatment for the attainment of favourable treatment 
+goals for T2D in rural Indian settings. Clinical Trial Registration Number: CTRI/2020/02/0232790
+Type 2 Diabetes (T2D) is a chronic progressive metabolic disease, pathophysiologically hallmarked by insulin 
+resistance and hyperglycemia, and clinically underlined by associated severe macrovascular and microvascular 
+ramifications1. According to the current estimates of the 8th edition of the atlas, International Diabetes Federation 
+(IDF), 425 million people are afflicted by T2D across the globe2. As well-reflected in the current IDF estimates 
+of 2018, with 72.95 million resident T2D populations, India is one of the most severely afflicted countries with 
+the epidemic. Urbanization and change of lifestyle are attributed as the major underlying causes of this rising 
+epidemic1,3,4.
+Efficient diabetes care is a crucial aspect of the disease owing to its progressive nature5–7. Intensive glycemic 
+control delays development and aids in prevention of late T2D complications5,8. However, glycemic control is 
+not a stand-alone measure for efficient T2D care6,7. The compound pathophysiology of T2D is associated with 
+many other deranged metabolic indices contributing to the development of cardiovascular comorbidities1,9. The 
+most effective approach towards reduced mortality and morbidity in T2D appears to be comprehensive risk fac-
+tor reduction targeting glycemic control, management of blood pressure and dyslipidemia9,10. These factors also 
+underlie the guidelines for Standards of Medical Care issued towards efficient cardiovascular control in T2D 
+by American Diabetes Association (ADA) which are updated annually in the month of January7. ADA guide-
+lines recommend a combined target for [A1c < 7% and blood pressure (BP) < 140/90 mmHg (older cut off for 
+BP < 130/80 mmHg) for diabetes care. Though the recent guidelines of lipid management do not specify LDL-C 
+targets, the guidelines recommended LDL-C cut-off as <100 mg/dl for effective cardiovascular control against 
+1Division of Life sciences, Swami Vivekananda Yoga Anusandhana Samsathana, Bengaluru, 560106, Karnataka, 
+India. 2Health Programme-Apollo Hospitals Ardhagiri road, Aragonda village, Tavanampalle mandal, Chittoor 
+district, 517129, Andhrapradesh, India. 3Apollo Hospitals, Hyderabad, Telengana, India. *email: majumdar.vijaya@
+gmail.com
+OPEN
+2
+Scientific Reports |         (2020) 10:6402  | https://doi.org/10.1038/s41598-020-63133-1
+www.nature.com/scientificreports
+www.nature.com/scientificreports/
+atherosclerotic cardiovascular disease7. Despite of these guidelines, at least one-third of patients with T2DM fail 
+to achieve their ADA goals11–13. The ultimate success of treatment algorithms of T2D is strongly associated with 
+concomitant synergistic lifestyle changes along with pharmacotherapy14. According to current ADA guidelines, 
+lifestyle management, with medical nutrition therapy and physical activity, is a fundamental component of dia-
+betes care6. These guidelines also recommend incorporation of yoga, the ancient skillset of Indian origin, into the 
+regimen of physical activity based on individual preferences5. Yoga is an ancient Indian practice that emphasizes 
+balancing of various aspects (like physical, mental, emotional, and spiritual) of an individual.
+South Asian ethnicity including Indians has been characterized as one of the most challenging population for 
+diabetes care with suboptimal status3,14. Though initially considered a “disease of opulence”
+, the recent trends sug-
+gest that diabetes has significantly impacted rural India, characterized by inadequate health care, and poverty15,16. 
+The recent visibility of T2D epidemic in rural India notifies an increasing trend in the prevalence estimates; esca-
+lated from 1% to 4–10% in the year and reaching as high as 13.2% in an earlier report16. India is an agricultural 
+nation, with 72.2% of the population residing in its rural sector, hence the trending high prevalence of the rural 
+diabetes epidemic are highly alarming16. Several distinct cultural and socioeconomic factors define the epidemic 
+of T2D in rural India17. Response and efficacy of lifestyle interventions are governed by cultural practices as well 
+as genetic/ethnic makeup18. India is a vast country and an amalgamation of various social, cultural and sub-ethnic 
+groups. In view of the reported high receptivity of yoga on diabetes management in Asians Indians3, we aimed 
+to evaluate the effectiveness of this cost-effective lifestyle treatment in the marginalized rural clinical settings of 
+Southern India.
+Results
+Baseline Characteristics. 
+Records of a total of 146 T2D patients were retrieved. The mean age of the study 
+cohort was 55.61 ± 10.90 years, the majority were female 64.40% (n = 94) , and 76.03% (n = 111) belonged to 
+low socioeconomic status. The recruited study cohort had an average duration of diabetes of ~6 years. According 
+to the ADA criteria, 54.79% (n = 80) of the total study cohort was found to be above recommended A1c targets 
+(≥7.0%, 53 mmol/ml), 81.51% (n = 119) above BP1 targets (≥130/80 mmHg), 47.26% (n = 69), above BP2 tar-
+gets (≥140/90 mmHg) and 47.94% (n = 70) above lipid targets (LDL ≥ 100 mg/dl)19. Overall, at baseline, 93.83% 
+(n = 137) and 85.62% (n = 125) of the study cohort was found to be above combined ADA composite scores 1 and 
+2, respectively. The cohort was also observed to have generalized obesity with a mean BMI of 26.69 ± 4.58 Kg/
+m2. Importantly, 85.62% (n = 125) of the study cohort was found to be overweight/obese according to the Asian 
+cut off for BMI (≥23 kg/m2)20. At baseline, subjects in the yoga group had significantly lower DBP levels than the 
+non-yoga group (yoga, 80.66 ± 9.30 mmHg vs. 84.52 ± 10.12 mmHg; P = 0.032) but were similar to the control 
+group with respect to other parameters (Table 1).
+Effect of Yoga treatment on the attainment of ADA-laid goals. 
+Yoga treatment was found to have a 
+significant beneficial effect on attainment of the composite ADA goal, reflected by an increase of 2.74% [baseline, 
+6.85% (n = 5) to follow-up, 9.59% (n = 7)] in the number of subjects meeting the composite score 1, whereas 
+the control group exhibited a pronounced deterioration by 4.11% [baseline (5.48%), n = 4) to follow-up (1.37%, 
+n = 1) (Table 2)]. Similarly, there was an increase of 12.33% [baseline, 15.07% (n = 11) to follow-up, 27.40% 
+(n = 20)] in the number of subjects meeting the composite score 2, whereas the control group exhibited a pro-
+nounced deterioration by 8.22% [baseline 13.70%, (n = 10) to follow-up 5.48%, (n = 4) (Table 2)]. When analysed 
+by multiple regression, yoga treatment was found to be 10-fold (OR = 10.20, 95% CI = 0.69–174.19) borderline 
+significant (P = 0.060) and ~8-fold (OR = 8.22, 95% CI = 2.02–33.49), statistically significant (P = 0.003), effective 
+towards attaining the favourable composite ADA score 1 and 2, respectively (Table 2).
+With respect to the status of A1C goals of ADA (<7%), 46.58% (n = 34) subjects were found to meet criteria 
+for in the yoga group at baseline, however, the percentage increased to 54.79% (n = 40) at follow-up (Table 2). 
+In the non-yoga group, the percentage of subjects with A1c criteria decreased from 43.84% (n = 32) to 36.99% 
+(n = 27) (Table 2). The difference in the distribution between the patients meeting ADA criteria for A1c was 
+statistically significant between yoga and non-yoga treatment groups at the follow-up (P = 0.046). When ana-
+lysed by multiple logistic regression, modelled by covariates, age, sex, duration of diabetes, socioeconomic status, 
+baseline A1c values, yoga treatment was found to be significantly associated with the ~2-fold (OR = 2.44, 95% 
+CI = 1.19–5.00, P = 0.015) higher chances of attainment of favourable A1c cut off (<7%) as compared to standard 
+of care (Table 2).
+The percentage of subjects who met the ADA-criteria with respect to favourable LDL-C, < 100 mg/dl, 
+increased from 52.05% (n = 38) to 54.79% (n = 40) in the yoga group (Table 2). However, in the non-yoga group, 
+there was a decrease from 52.05% (n = 38) to 38.36% (n = 28) in the number of subjects who met the LDL-C cri-
+teria (Table 2). The distribution of patients with favourable LDL-C values was not significant between yoga and 
+non-yoga groups at the follow-up (Table 2). However, when analysed by logistic regression, adjusted for covariates 
+and, baseline lipid status, yoga treatment was found to be significantly associated with the ~2-fold (OR = 2.22, 
+95% CI = 1.06–4.68, P = 0.035) increased chances for the attainment of favourable LDL-C outcome (<100 mg/dl) 
+as compared to standard of care alone (Table 2).
+We assessed the BP outcomes with old and revised favourable cut-offs recommended by ADA (Table 3). When 
+analysed with old cut-off (<130/80 mm Hg), we could observe a pronounced increase in the percentage of sub-
+jects meeting the favourable BP outcome from 21.92% (n = 16) to 34.25% (n = 25) in the yoga group (Table 2). 
+On the contrary, in the non-yoga group, the number of T2D patients who met BP criteria of <130/80 mm 
+Hg decreased from 15.07% (n = 11) to 8.22% (n = 6) (Table 2). When analysed by logistic regression, yoga treat-
+ment was found to be associated with ~6.4-fold (OR = 6.37, 95% CI = 2.24–18.08, P = 0.001) increase the chances 
+of favourable BP cut-offs (<130/80) at follow-up. When analysed with revised new BP cut-off (<140/90 mm Hg), 
+we could observe a pronounced increase in the percentage of subjects meeting the favourable BP outcome from 
+3
+Scientific Reports |         (2020) 10:6402  | https://doi.org/10.1038/s41598-020-63133-1
+www.nature.com/scientificreports
+www.nature.com/scientificreports/
+60.27% (n = 44) to 84.93% (n = 62) in the yoga group (Table 2), yoga treatment was also found to be associated 
+with 8.28-fold (95% CI, 3.52–19.48, P < 0.0001) increased chances for the revised favourable BP cut-offs,. In the 
+non-yoga group, the number of T2D patients who met BP criteria decreased from 45.21% (n = 33) to 39.73% 
+(n = 29) (Table 2).
+We also analysed the status of cardiovascular control for the subgroup of study cohort with uncontrolled dia-
+betes (A1c ≥ 8.0%), n = 44. We could observe 63.16% success towards attainment of lipid goal (LDL < 100 mg/dl) 
+and 26.32% for BP targets (130/80 mmHg) 89.47% for BP target (140/90) by 6-months of yoga treatment (data not 
+shown). However, the controls exhibited deterioration with respect to these goals (data not shown).
+Effect of yoga treatment as compared to standard of care was demonstrated with respect to the attainment of 
+favourable BMI cut-off (<23 Kg/m2) for Asians (Table 2). When analysed by logistic regression, yoga treatment 
+Variable
+Groups
+P value
+Yoga (n = 73) 
+Non-yoga (n = 73)
+Age, Years
+≤ 45
+14 (19.18)
+19 (26.03)
+0.429
+> 45
+59 (80.82)
+54 (73.97)
+Sex, n (%)
+Men
+28 (38.36)
+24 (32.88)
+0.604
+Women
+45 (61.64)
+49 (67.12)
+Socio-economic status, n (%)
+High
+4 (5.48)
+3 (4.11)
+0.109
+Medium
+9 (12.33)
+19 (26.03)
+Low
+60 (82.19)
+51 (69.86)
+Hypertension, n (%)
+Yes
+25 (34.25)
+29 (39.73)
+0.607
+No
+48 (65.75)
+44 (60.27)
+Obesity
+BMI ≤ 25Kg/m2
+32 (43.84)
+38 (52.05)
+0.740
+BMI > 25 Kg/m2
+41 (56.16)
+35 (47.95)
+Known diabetes, n (%)
+Yes
+44 (60.27)
+41 (56.16)
+0.737
+No
+29 (39.73)
+32 (43.84)
+Duration of diabetes, n (%)
+≤5 years
+28 (38.36)
+27 (36.99)
+1.000
+>5 years, n (%)
+45 (61.64)
+46 (63.01)
+Body mass index, BMI (kg/m2)
+27.18 ± 4.07
+26.16 ± 5.06
+0.139
+Medication for T2DM, n (%)
+Yes
+34 (46.58)
+38 (52.05)
+0.508
+No
+39 (53.42)
+35 (47.95)
+Anti-hypertensive drugs, n (%)
+0.604
+Yes
+24 (32.88)
+28 (38.36)
+No
+49 (67.12)
+45 (61.64)
+Lipid-lowering drugs
+0.001
+Yes
+3 (4.11)
+17 (23.29)
+No
+70 (95.89)
+56 (76.71)
+Biochemical variables
+A1c (%)
+7.4 ± 2.3
+7.7 ± 2.3
+0.605
+FBS, mg/Dl
+100.27 ± 24.72
+114.66 ± 45.042
+0.189
+PPBS, mg/dL
+175.21 ± 46.87
+197.26 ± 67.76
+0.088
+SBP, mm Hg
+126.07 ± 13.78
+130.44 ± 16.05
+0.060
+DBP, mm Hg
+80.66 ± 9.30
+84.52 ± 10.12
+0.032
+Total Cholesterol, mg/dl
+177.71 ± 27.94
+176.36 ± 34.11
+0.437
+Triglyceride, mg/dl
+144.59 ± 28.68
+143.69 ± 44.27
+0.120
+LDL-c, mg/dL
+103.55 ± 26.53
+102.16 ± 32.90
+0.557
+HDL-c. mg/dL
+45.24 ± 1.72
+45.30 ± 2.66
+0.120
+Table 1.  Baseline characteristics of theT2DM cohort with and without yoga treatment. Test statistics, Pearson’s 
+chi-square for categorical variables & Mann-Whitney U tests for continuous variables; FBS, fasting blood 
+glucose; PPBS, postprandial blood glucose; SBP, systolic blood pressure; DBP, diastolic blood pressure; LDL-c 
+low density lipoprotein cholesterol, continuous values are presented as meand ± SD.
+4
+Scientific Reports |         (2020) 10:6402  | https://doi.org/10.1038/s41598-020-63133-1
+www.nature.com/scientificreports
+www.nature.com/scientificreports/
+was found to be associated with 62-fold (OR = 61.73, 95% CI = 3.19–1193) increased chances of attainment of the 
+favourable BMI cut-off over a period of 6 months (Table 2).
+Outcomes in continuous measures. 
+Over the study period of around 6-months, the yoga-group exhib-
+ited significant within-group beneficial mean changes and percent changes in A1c, −0.50%, (−5.03%); FBS, 
+−11.27 mg/dL (−8.00%); PPBS, −25.51 (−−11.44%); Wt., −2.91 (-4.18%); BMI, −1.14 Kg/m2 (−4.04%); SBP, 
+−5.30 (−3.02%); DBP, −4.57 (−4.60%); TC, −2.94 mg/dl (−1.49%), HDL-c, −0.70 mg/dl (−1.49%) (Table 3). 
+With respect to triglyceride (TG), we could observe an unexpected increase in the mean TG levels in the yoga 
+group, 11.74 ± 3.72 mg/dl (31.94%) (Table 3). We observed pronounced worsening of the metabolic variables in 
+the non-yoga group (Table 3). We could observe a deteriorating trend in the mean difference of these variables 
+from baseline in the non-yoga group (Table 3). Significant within-group differences were also observed in the 
+non-yoga group for FBS, 11.14 mg/dl (18.31%); BMI, 0.76 Kg/m2 (4.06%); HDL-c, −2.51 mg/dl (−4.72%), and 
+TG, 67.70 mg/dl (59.01%). Between-study group differences between yoga group and non-yoga group very sig-
+nificant with respect to all the studied parameters (Table 3).
+Discussion
+Type 2 diabetes is associated with vascular complications and enhanced risk of cardiovascular events. Therefore, 
+ADA has suggested a multifactorial targeted approach towards efficient management of T2D [glycemic, lipid, 
+and blood pressure]5,7. Use of such composite endpoints in clinical studies also help in the better understanding 
+of the net effect of an intervention or a therapy rather than individual endpoints21,22. Further, studies targeting 
+composite endpoints have been reported to have higher statistical efficiency as compared to those with individual 
+endpoints22. We hereby highlight the grim status of diabetes management with respect to the attainment of the 
+ADA laid primary treatment goals, in rural Indian settings. At baseline of the study, 54.79% was found to be above 
+ADA laid A1c targets (≥7.0%), 47.26% was found to be above lipid targets (LDL-C > 100 mg/dl) and 81.51% were 
+found to be above BP cut-offs of>130/80 mmHg, and 47.26% were found to be above the revised BP cut-offs 
+(<140/90 mmHg)5. Overall, only 6.16% (n = 9) of the total study cohort was found to be meeting the composite 
+Outcome
+Baseline
+Follow up
+Logistic Regression analysis
+Yoga, n (%)
+Non-Yoga, n (%)
+P Value
+Yoga, n (%)
+Non-Yoga, n (%)
+P Value
+Adjusted OR
+Adjusted CI
+P Value
+A1c target
+<7%
+34(46.58)
+32(43.84)
+0.868
+40(54.79)
+27(36.99)
+0.046
+2.44
+1.19–5.00
+0.015
+≥7%
+39(53.42)
+41(56.16)
+33(45.21)
+46(63.01)
+1(ref)
+BP1
+<130/80 mm Hg
+16(21.92)
+11(15.07)
+0.286
+25(34.25)
+6 (8.22)
+<0.0001
+6.37
+2.24–18.08
+0.001
+≥ 130/80 mm Hg
+57(78.08)
+62(84.93)
+48(65.75)
+67(91.78)
+1(ref)
+BP2
+<140/90 mmHg
+44 (60.27)
+33(45.21)
+0.097
+62(84.93)
+29(39.73)
+<0.0001
+8.28
+3.52–19.48
+<0.0001
+≥140/90 mm Hg
+29 (39.73)
+40(54.79)
+11(15.07)
+44(60.27)
+1(ref)
+LDL-c target
+<100 mg/dl
+38(52.05)
+38(52.05)
+1.000
+40(54.79)
+28(38.36)
+0.068
+2.22
+1.06–4.68
+0.035
+≥ 100 mg/dl)
+35(47.95)
+35(47.95)
+33(45.21)
+45(61.64)
+1(ref)
+Composite Score 1
+Favourable
+5(6.85)
+4(5.48)
+0.712
+7(9.59)
+1(1.37)
+0.013
+10.20
+0.69–174.19
+0.060
+Unfavourable
+68(93.15)
+69(94.52)
+66(90.41)
+72(98.63)
+1(ref)
+Composite Score 2
+Favourable
+11(15.07)
+10(13.70)
+1.000
+20(27.40)
+4(5.48)
+0.001
+8.22
+2.02–33.49
+0.003
+Unfavourable
+62(84.93)
+63(86.30)
+53(72.60)
+69(94.52)
+1(ref)
+BMI
+<23 Kg/m2
+6(8.22)
+15(20.55)
+0.057
+11(15.07)
+5(6.85)
+0.184
+61.73
+3.19–1193
+0.006
+≥23 Kg/m2
+67(91.78)
+58(79.45)
+62(84.93)
+68(93.15)
+1(ref)
+Table 2.  Association of yoga-treatment versus non-yoga treatment with ADA cut-offs and Logistic regression 
+at follow-up. OR, Odds ratio; OR (A1c target) for yoga vs. non-yoga groups, adjusted for age, sex, occupation, 
+BMI at baseline, duration of diabetes, glycaemic indices, (FBS, PPBS and A1c) at baseline and intake of oral 
+hypoglycaemic drug, BP, Blood pressure OR(BP targets) for yoga vs. non-yoga groups adjusted for age, sex, 
+duration of diabetes, socioeconomic status, SBP and DBP at baseline; and medication for blood pressure. 
+OR(LDL-c target) for yoga vs. non-yoga groups adjusted for age, sex, occupation, duration of diabetes, 
+BMI, LDL-c, TG, TC and HDL-c at baseline, * additionally adjusted for lipid lowering drugs. OR(BMI) for 
+yoga vs. non-yoga groups adjusted for age, sex, duration of diabetes, education, smoking status and alcohol 
+consumption, and BMI Values at baseline Ref: Reference group, non-yoga treatment group Composite score 
+1(favourable): A1c < 7.0%, BP1 < 130/80 mm Hg, LDL-c < 100 mg/dl, additionally adjusted for baseline glucose, 
+lipid values and BMI values, and medications. Composite Score 2 (favourable): A1c < 7.0%, BP2 < 140/90 mm 
+Hg, LDL-c < 100 mg/dl.
+5
+Scientific Reports |         (2020) 10:6402  | https://doi.org/10.1038/s41598-020-63133-1
+www.nature.com/scientificreports
+www.nature.com/scientificreports/
+score of all the three treatment targets at the baseline. However, a prior report by Menon et al.15, indicated only 
+1–3% of Indian T2D population achieving the combined treatment goals of ADA in an urban clinical setup. The 
+pathophysiological link between obesity and T2D was also evident in the study cohort, wherein, 62.33% (n = 91) 
+of the cohort sample was found to be obese. As majority of the cohort sample (~80%), belonged to low socio-
+economic status23, this poor status of cardiovascular risk control could be attributed to lack of pharmacologic 
+management, governed by poor awareness and socioeconomic status in the rural Indian settings.
+Lifestyle management plays an essential role in the efficient control of diabetes status6,24. Yoga, as a lifestyle 
+intervention has been reported to lead to beneficial health outcomes related to cardiovascular and metabolic 
+disorders including T2D25,26. Based on its high reported receptivity and cost-effectiveness, yoga holds a strong 
+potential as a lifestyle management skill in Indian scenario3. This is the first report wherein the efficacy of yoga 
+treatment was assessed in aiding the cardiovascular fitness with respect to achievement of ADA laid primary 
+treatment goals of T2D in rural Indian settings. Our findings reflect a magnitude of success of 10.96% attained by 
+6-months of yoga treatment on overweight/obese T2D Indian rural cohort. However, Ikramuddin et al. reported 
+Variables
+Group
+Baseline values, 
+mean ± SE (95% 
+CI)
+Follow up values. 
+mean ± SE (95% 
+CI)
+Mean change 
+from baseline 
+mean ± SE (95% 
+CI)
+Within 
+study 
+groups
+Between study groups
+Percentage change 
+from baseline (95% 
+CI)
+Test 
+statistics
+Test statistics
+Partial 
+eta 
+squared
+P value
+F
+P value
+A1c (%)
+Yoga-group
+7.40 ± 1.30 
+(7.03–7.77)
+6.90 ± 1.29 
+(6.53–7.27)
+−0.50 ± 1.49 
+(−0.15 to −0.85)
+−5.03 (−9.64 to 
+−0.42)
+0.002
+19.18
+≤0.001
+0.120
+Non-yoga group
+7.75 ± 1.88
+8.05 ± 1.94
+0.30 ± 2.99
+10.66 (1.26 to 20.1)
+0.396
+Fasting plasma glucose, 
+mg/dl
+Yoga-group
+100.27 ± 24.72 
+(93.02–107.52)
+89.00 ± 10.14 
+(81.75–96.25)
+−11.27 ± 22.91 
+(−16.62 to −5.93)
+−8.00 (−11.7 to 
+−4.29)
+<0.0001
+48.69
+≤0.001
+0.259
+Non-yoga group
+114.66 ± 45.04 
+(107.41–121.91)
+126.33 ± 41.03 
+(115.66–130.91)
+11.15 ± 56.53 
+(−3.62 to 25.89)
+18.31(5.91 to 30.7)
+0.019
+Postprandial plasma 
+glucose, mg/dl
+Yoga-group
+175.20 ± 46.87 
+(162.25–188.16)
+149.70 ± 30.46 
+(136.74–162.66)
+−25.51 ± 40.01 
+(−34.84 to −16.17)
+−11.44 (−15.7 to 
+−7.2)
+<0.0001
+49.25
+≤0.001
+0.262
+Non-yoga group
+197.26 ± 67.76
+212.53 ± 73.44
+14.63 ± 117.23
+19.82 (4.02 to 35.6)
+0.249
+Weight, Kg
+Yoga-group
+68.82 ± 27.18 
+(66.33–71.29)
+65.90 ± 10.28 
+(63.50–68.30)
+−2.90 ± 2.37 
+(−3.46 to −2.36)
+−4.18 (−4.96 to 
+−3.39)
+<0.0001
+29.96
+≤0.001
+0.176
+Non-yoga group
+65.82 ± 12.36
+67.33 ± 11.82
+1.51 ± 6.07
+2.30 (−0.23 to 4.83)
+<0.0001
+BMI, Kg/m2
+Yoga-group
+27.18 ± 4.07 
+(26.25–28.27)
+26.02 ± 0.51 
+(25.02–27.02)
+−1.14 ± 1.20 
+(−1.44 to −0.92)
+−4.04 (−5.01 to 
+−3.05)
+<0.0001
+29.01
+≤0.001
+0.172
+Non-yoga group
+26.16 ± 5.06 
+(25.12–27.13)
+26.92 ± 4.33 
+(25.79–27.88)
+0.76 ± 2.67 (0.04 
+to 1.39)
+4.06 (1.15 to 6.97)
+0.002
+Systolic blood pressure, 
+mmHg
+Yoga-group
+126.07 ± 13.78 
+(119.65–125.12)
+120.77 ± 10.55 
+(118.03 − 123.50)
+−5.30 ± 17.97 
+(−9.50 to −1.11)
+−−3.02 (−6.22 to 
+0.18)
+0.026
+57.94
+≤0.001
+0.293
+Non-yoga group
+130.44 ± 16.05 
+(128.39 − 133.86)
+135.11 ± 11.88 
+(132.34-138.05)
+4.67 ± 18.86
+5.19 (1.38 to 9)
+0.083
+Diastolic blood 
+pressure, mmHg
+Yoga-group
+80.66 ± 9.30 
+(78.54-82.77)
+76.08 ± 7.28 
+(73.97-78.20)
+4.57 ± 10.51
+−4.60 (−7.59 to 
+−1.61)
+0.001
+40.76
+≤0.001
+0.225
+Non-yoga group
+84.52 ± 10.11 
+(82.40 −86.64)
+86.23 ± 9.86 
+(83.72-88.13)
+1.71 ± 13.33 (−2.17 
+to 4.46)
+2.94 (−0.93 to 6.81)
+Total Cholesterol, 
+mg/dl
+Yoga-group
+177.71 ± 27.94 
+(170.60-184.82)
+174.77 ± 26.87 
+(167.66-181.88)
+−2.94 ± 33.88 
+(−10.85 to 4.96)
+−1.49 (−2.27 to 
+−0.708)
+0.439
+6.40
+0.012
+0.044
+Non-yoga group
+176.36 ± 34.11 
+(169.25-183.47)
+185.26 ± 28.88 
+(181.31-196.26)
+8.90 ± 43.30 (−0.63 
+to 25.69)
+5.05 (2.76 to 7.34)
+0.055
+LDL Cholesterol, mg/dl
+Yoga-group
+103.55 ± 26.53 
+(96.74-110.36)
+98.96 ± 25.42 
+(92.15-105.77)
+−4.59 ± 33.22 
+(−12.34 to 3.16)
+−1.03 (7.42 to 9.48)
+0.312
+4.56
+0.035
+0.032
+Non-yoga group
+102.15 ± 32.69 
+(95.30-109.01)
+108.54 ± 32.09 
+(102.01-116.22)
+6.22 ± 48.55 (−4.44 
+to 20.24)
+18.81 (5.71 to 31.9)
+0.141
+HDL Cholesterol, 
+mg/dl
+Yoga-group
+45.24 ± 1.72 
+(44.62-45.86)
+44.54 ± 1.92 
+(43.92-45.16)
+−0.70 ± 1.91 
+(−1.15 to −0.26)
+−1.49 (−2.44 to 
+−0.536)
+0.013
+11.11
+0.001
+0.074
+Non-yoga group
+45.30 ± 0.32
+42.79 ± 3.96
+−2.51 ± 5.11
+−4.72 (−7.33 to 
+−2.11)
+<0.0001
+Triglycerides, mg/dl
+Yoga-group
+144.59 ± 28.68 
+(134.25-154.93)
+156.33 ± 32.05 
+(145.99 −166.66)
+11.74 ± 31.79 (4.32 
+to 19.16)
+31.94 (23.1 to 40.8)
+0.010
+27.08
+≤0.001
+0.016
+Non-yoga group
+143.69 ± 43.96 
+(133.29-154.10)
+211.39 ± 83.81 
+(174.36-195.94)
+67.70 ± 93.95 
+(20.38 to 
+62.86)
+59.01 
+(41 to 
+77)
+<0.0001
+Table 3.  Distribution of continuous variables between yoga and non-yoga treatment groups at baseline and 
+follow up. Data are represented as mean ± SE (95% confidence interval) P-value of < 0.05 was set as significant 
+between baseline and follow-up on within group and between group comparisons; CI, confidence interval, A1c; 
+P value- Within study groups, Test statistics t-test; P value-Between study groups test statistic- ANCOVA.
+6
+Scientific Reports |         (2020) 10:6402  | https://doi.org/10.1038/s41598-020-63133-1
+www.nature.com/scientificreports
+www.nature.com/scientificreports/
+a success rate of 19% with respect to ADA composite endpoint over a period of 12 months on patients with 
+uncontrolled T2D27. Further, compared to usual care, 6-months of yoga treatment was also found to be associated 
+with 8-fold higher (OR = 8.22, 95% CI = 2.02–33.49) success towards the attainment of ADA composite scores 
+(with revised BP cut-off of 140/90 mmHg) in rural Indian settings. With respect to individual composite goals, 6 
+months of yoga treatment was found to have a higher likelihood of attainment of A1c goal by ~2-fold (OR = 2.44, 
+95% CI = 1.19–5.00); LDL-C by ~2-fold (OR = 2.22, 95% CI = 1.06–4.68); blood pressure<140/90 mmHg by 
+~8-fold [OR = 8.28, 95% CI, 3.52–19.48)] in rural T2D population compared to standard of care. The observed 
+2-fold higher potential of yoga-treatment as compared to standard of care towards attainment of LDL-c tar-
+gets in the rural Indian T2DM cohort deserves clinical attention. Control of dyslipidemia in Indian T2DM 
+patients has been reported to be very poor; with almost half of them not reaching their LDL-C goal28. These 
+findings are important as Coronary Artery Disease (CAD) mortality remains high in the Indian patients with 
+T2DM. Similarly, the observed 8-fold increased impact of yoga on BP control as compared to standard of care 
+is an important clinical outcome. Hypertension is a prevalent co-morbidity in T2D patients associated with an 
+increased risk of cardiovascular events and mortality29,30. This coexistence has been reported to enhance the risks 
+of nephropathy and retinopathy31,32.
+As previously reported by Ikramuddin et al., intense lifestyle intervention could aid in 31% success towards 
+attainment of glycemic, 70% for lipid and 70% for BP targets (130/80 mmHg) over a period of 12 months in a 
+mixed ethnic population of uncontrolled T2D (HbA1c ≥ 8.0%)27. Interestingly, in the present subgroup of patients 
+with uncontrolled T2D, HbA1c ≥ 8.0% yoga treatment of 6 months duration was found to be effective with 
+26.32% success in attainment of glycaemic control, 63.16% for lipid, and 26.32% for BP goals (130/80 mmHg). 
+These findings indicate that if assessed for long-term effects, yoga treatment could match the magnitude of the 
+potential of intense lifestyle-interventions as described for overweight/obese uncontrolled T2D patients27.
+Glycemic control is the primary target of diabetes management strategies towards prevention of the devas-
+tating complications such as blindness, kidney failure and amputations7,9. We could observe significant absolute 
+decrease in mean A1c% by 0.5 in the yoga group over a period of 6 months. The magnitude of reduction by 0.5% 
+in A1c holds strong clinical significance, based on the reported epidemiological association between 1% reduction 
+in the A1c value with 14% reduction in myocardial infarction (MI), 21% reduction in diabetes-related mortality 
+and 37% reduction in microvascular complications33. Further significant and beneficial yoga treatment-induced 
+mean percentage reductions in SBP (4.33%); DBP (5.66%); and TC (1.65%) could also be observed in the present 
+study. These findings support earlier reported beneficial cardiovascular effects of yoga25,26.
+Weight loss remains a major challenge in diabetes due to the complex interplay between metabolic, neu-
+roendocrine and psychological factors34. In a prior study intensive lifestyle intervention of 1 year was reported 
+to achieve an average 8.6% weight loss along with significant reduction of A1C, and CVD risk factors, with sus-
+tained effects up to 4 years24. In the present study, we could observe a 4.18% reduction in weight over a period 
+of 6 months under yoga-treatment. Our results highlight the equivalent potential of yoga to intense weight-loss 
+intended lifestyle interventions in overweight/obese T2D patients. A favourable and differential effect of 61-fold 
+(OR = 61.73, 95% CI = 3.19–1193) was also observed for BMI outcome of <23 kg/m2 in the yoga group against 
+standard of care. The observed significant impact of yoga-treatment on BMI outcome in diabetes bears strong 
+clinical relevance as weight management is an important component of efficient diabetes care7. Further, weight 
+loss through lifestyle changes remains the first-line therapy for T2DM34. Available observational evidence suggest 
+various clinical benefits of weight loss in diabetes including improvement in glycemic control, reduced risk of 
+cardiovascular events alongwith improvements in quality of life, mobility, and physical function35,36. However, 
+we could not assess the sustenance of weight-related effects of yoga in this short-duration study. Based on the 
+proposed self-regulation modality of yoga, wherein yoga could lead to repatterning of hedonic neurocircuitries, 
+we speculate sustained weight-loss effects with long-term yoga-treatment37.
+The study is limited by its observational nature. The difference-in-means method used to establish the equiv-
+alence between the study groups could be limited in its capacity to control the confounding by baseline variables. 
+To this end, we conducted propensity score matching with “nearest neighbour” method for matching of the treat-
+ment groups for key covariates. Further, logistic regression was also done to adjust for the effect of the covariates 
+to assess the study outcomes. The observed poor outcome in the standard of care group deserves attention of phy-
+sicians and clinicians working in the rural sector of India. The poor outcome could possibly be attributed to poor 
+adherence to medication and prescribed physical activity in the rural T2D population suggesting that there is a 
+need to explore strategies to facilitate adherence with the patients/caregivers17. Since Indian patients were found 
+to be receptive to yoga, yoga-based treatment could be a pragmatic solution for effective diabetes management. 
+Based on the epidemic proportions of T2DM in India, there is an urgent need to conduct a large, prospective, 
+long-term study of the efficacy of yoga on attaining all of the ADA goals in the rapidly increasing T2DM popula-
+tion. Early initiation of yoga treatment to target adequate diabetes care has the potential to prevent the devastating 
+complications including not just the microvascular but also loss of time from work and quality of life.
+Methods
+Cohort identification. 
+The study was part of an ongoing service activity defined as the “Total Health 
+Programme” (THP) India’s first integrated rural healthcare service delivery network, initiated by the Apollo 
+Group (https://www.apollohospitals.com/corporate/initiatives/csr-at-apollo/total-health-programme). THP 
+aimed at patients for various diseases across the adopted villages for effective disease management in collab-
+oration with Swami Vivekananda Yoga Anusandhana Samsathana (S-VYASA) (http://svyasa.edu.in/). During 
+the month of April/May 2016, 324 adults diagnosed with T2D, aged ≥20 years to 70 years, from 12 nearby vil-
+lages of the Chittoor district, Andhra Pradesh, India, were originally referred to the Apollo health scheme for 
+diabetes management. T2D was defined as per the American Diabetes Association criteria19. When the records 
+were screened, out of 277 initially referred patients, only 150 were found to complete regular supervised yoga 
+7
+Scientific Reports |         (2020) 10:6402  | https://doi.org/10.1038/s41598-020-63133-1
+www.nature.com/scientificreports
+www.nature.com/scientificreports/
+treatment, and amongst them 73 only had sufficient laboratory data until November 2016. Figure 1 details the 
+steps involved in cohort selection. Medical records of these 73 patients were retrieved for the study. Patients 
+undergoing insulin treatment, pregnant or breastfeeding, or who had severe vascular, hepatic, renal diseases or 
+cancer were excluded from the study. Patients with atherosclerotic cardiovascular disease (ASCVD)7 were also 
+excluded. Records of an equal number of T2D patients were retrieved as a non-yoga group who opted for only 
+standard of care treatment at the rural Apollo clinics during the same period of time. Difference-in-means of the 
+age, the proportion of sex and blood A1c levels were matched between yoga and non-yoga groups before finaliz-
+ing the selection of the cohort sub-groups (n = 73 each). This was followed by matching the sub-groups through 
+propensity score matching. Thus, we defined a cohort of 146 T2D patients, diagnosed with T2D as per ADA cri-
+teria19. Both yoga and non-yoga groups were followed from the (index date; date of first check up with prescribed 
+treatment) until the end of 6 months. Parameters of interest were included at the time of admission/index date 
+(baseline) and at an average of 6 months of follow-up. Written consent was obtained from the study subjects 
+and the study was approved by the Institutional Ethics Committee of Swami Vivekananda Yoga Anusandhana 
+Samsathana, Bengaluru, India. Informed consent was obtained from all the study subjects. All methods were per-
+formed in accordance with the relevant guidelines and regulations. The study was registered with ClinicalTrials.
+gov (NCT01212133); registration number: (CTRI/2020/02/0232790).
+Measures. 
+The duration of yoga- treatment was approximately six months. Primary parameters of inter-
+est were the follow-up status of revised ADA laid treatment goals of diabetes;A1C < 7.0% (<53 mmol/mol), 
+and BP cut- offs (<140/90 mmHg). Additionally based on ADA definition of risk factors of Atherosclerotic 
+Cardiovascular Disease (ASCVD)7, the treatment goals also included <100 mg/dl of LDL-C, and stringent BP 
+goals (<130/80 mmHg). Composite score was defined based on the meeting of all the target goals. Secondary 
+outcomes were continuous measures of A1c, FBS (fasting blood glucose), PPBS (postprandial blood glucose), 
+LDL-Cholesterol (LDL-C), SBP, DBP, weight, total cholesterol (TC), triglyceride (TG) diastolic blood pressure 
+(DBP), and body mass index (BMI). Patient demographic and anthropometric information including age, sex, 
+Figure 1.  Flowchart of the study design.
+8
+Scientific Reports |         (2020) 10:6402  | https://doi.org/10.1038/s41598-020-63133-1
+www.nature.com/scientificreports
+www.nature.com/scientificreports/
+socioeconomic status, duration of diabetes, medication, weight, blood pressure, height was also extracted. BMI 
+was calculated as weight in kilograms divided by the square of height in meters. Asian cut-off for BMI (≥25 kg/m2) 
+was used to define obesity20.
+Intervention. 
+The administration of yoga was carried out at Apollo rural and satellite clinics (https://www.
+apollohospitals.com/corporate/initiatives/csr-at-apollo/total-health-programme) for T2D patients from nearby 
+villages. Non-yoga group, the T2D patients received the standard of care for diabetes as per ADA guidelines 
+from a physician-coordinated team5. The patients were also referred for diabetes self-management education 
+and support for strengthening and empowering their diabetes knowledge and self-care behaviors as per ADA 
+guidelines. The yoga treatment given to the patients was derived from a validated integrated yoga module devel-
+oped by Angadi et al.38. The treatment protocol included daily supervised administration of yoga sessions for 
+one hour. The yoga module was comprised of loosening practices, asanas, pranayama, relaxation techniques, and 
+meditation; (detailed protocol has been appended as a supplement table no. 1). Only certified yoga therapists 
+were involved in the administration of the yoga-treatment. Both the yoga and non-yoga treatment groups were 
+followed from the date of admission into the clinics, till November 2016.
+Statistical analyses. 
+Missing data were minimal. Continuous variables were tested for normality with the 
+Shapiro-Wilk test. We used descriptive statistics with mean and 95% confidence intervals [CIs]), and standard, 
+or percentages (numbers) for representation of T2D patient’s baseline characteristics. Categorical variables were 
+described using frequencies. Socioeconomic status was determined by using Kuppuswamy’s scale22. Outcome 
+measures were compared using Analysis of covariance (ANCOVA) to adjust for baseline measures and to provide 
+an unbiased estimate of the mean group differences. A General linear model (GLM) for multivariate analysis 
+was developed with covariates of baseline values of the outcome variables, age, medication and duration of dia-
+betes. P-value of < 0.05 was set as significant and < 0.0001 was set as highly significant. Statistical analysis was 
+performed using SPSS version 21.0, Microsoft Excel-2013 and R studio version 1.1.423. For comparisons within 
+treatment groups from baseline to follow-up, a Wilcoxon signed rank test was performed. Propensity scores were 
+calculated for each subject based on primary baseline covariates known to be associated with diabetes treatment 
+and/or the study outcomes, including age, sex, socioeconomic status, disease duration, medication, and biochem-
+ical parameters using the “nearest neighbour” method (Appendix, supplementary material). Logistic regression 
+was then used to identify predictors of successful achievement of the favourable ADA and BMI outcomes. Models 
+of the relationships were created with independent variable including age, sex, duration of diabetes, yoga treat-
+ment vs. non-yoga treatment, baseline values of variables of biological relevance.
+Data availability
+The datasets generated during and/or analysed during the current study are available from the corresponding 
+author on reasonable request.
+Received: 4 July 2019; Accepted: 20 March 2020;
+Published: xx xx xxxx
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+Acknowledgements
+We are thankful to the “Apollo Total Health Group’ for the financial support provided to conduct the study. We 
+acknowledge the support and continued involvement of the chairman, doctors, researchers and field workers 
+of ‘Apollo Total Health Group’ and yoga therapists of S-VYASA University in the study. The funding sponsor 
+contributed in design of the study, data collection and data analysis. A special thanks to Sai Lakshmi Prasanna 
+M, senior yoga therapist. We have not paid to write this article to any pharmaceutical company or other agency. 
+We also thank the USV (PVT) Ltd for the generous donation of digital BP measurement machines which were 
+utilized in this study.
+Author contributions
+G.A. contributed to the study design, planned the cohort, data collection and analysis. N.R. revised the 
+experiment design, and reviewed the manuscript. V.M. analysed the data and wrote the manuscript. S.M. is the 
+chief advisor of Total Health-A CSR initiative of Apollo Hospitals enterprise limited. R.S. and R.S. are the project 
+and deputy medical directors of Total Health, respectively. S. M., R.S., and R.S. planned the cohort, designed the 
+study and contributed to the data collection. V.S. R reviewed the manuscript. N.H.R. contributed to the discussion 
+section and reviewed the manuscript. We also declare Dr. Nagarathana R as the guarantor of the entire study. The 
+corresponding author had full access to all the data in the study and had final responsibility for the decision to 
+submit for publication.
+Competing interests
+The authors declare no competing interests.
+Additional information
+Supplementary information is available for this paper at https://doi.org/10.1038/s41598-020-63133-1.
+Correspondence and requests for materials should be addressed to V.M.
+Reprints and permissions information is available at www.nature.com/reprints.
+Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and 
+institutional affiliations.
+10
+Scientific Reports |         (2020) 10:6402  | https://doi.org/10.1038/s41598-020-63133-1
+www.nature.com/scientificreports
+www.nature.com/scientificreports/
+Open Access This article is licensed under a Creative Commons Attribution 4.0 International 
+License, which permits use, sharing, adaptation, distribution and reproduction in any medium or 
+format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Cre-
+ative Commons license, and indicate if changes were made. The images or other third party material in this 
+article are included in the article’s Creative Commons license, unless indicated otherwise in a credit line to the 
+material. If material is not included in the article’s Creative Commons license and your intended use is not per-
+mitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the 
+copyright holder. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/.
+ 
+© The Author(s) 2020
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+© 2018 International Journal of Yoga | Published by Wolters Kluwer ‑ Medknow
+44
+Introduction
+Quality of life  (QOL) and stress levels 
+after coronary artery bypass graft (CABG) 
+surgery 
+are 
+important 
+assessments 
+to improvise health strategies in the 
+management of coronary artery disease 
+(CAD).[1] 
+There 
+could 
+be 
+definitive 
+complications of surgery such as the risk of 
+failure,[2,3] resulting in higher mortality rate 
+at 5  years than 1  year after CABG,[4] with 
+6.3% requirement of revascularization.[5] 
+QOL scores correlate with survival rates 
+and both are affected adversely by the 
+stress levels. The QOL improves at 5 years 
+without any association with preoperative 
+ejection fraction (EF),[6] but this association 
+was not found at 12 years of CABG.[7,8]
+Lifestyle behavior follow‑up is poor in 
+low‑income 
+countries,[9] 
+especially 
+in 
+Address for correspondence: 
+Dr. Eraballi Amaravathi, 
+Division of Yoga and Life 
+Sciences, Swami Vivekananda 
+Yoga Anusandhana Samsthana 
+University, 19 Eknath Bhavan, 
+Gavipuram Circle, Kempegowda 
+Nagar, Bengaluru, Karnataka, 
+India. 
+E‑mail: om.amaravathi@gmail.
+com
+Access this article online
+Website: www.ijoy.org.in
+DOI: 10.4103/ijoy.IJOY_57_16
+Quick Response Code:
+Abstract
+Objectives: This study was aimed to assess the efficacy of yoga‑based lifestyle program  (YLSP) 
+in improving quality of life  (QOL) and stress levels in patients after 5  years of coronary artery 
+bypass graft (CABG). Methodology: Three hundred patients posted for elective CABG in Narayana 
+Hrudayalaya Super Speciality Hospital, Bengaluru, were randomized into two groups: YLSP and 
+conventional lifestyle program  (CLSP), and follow‑up was done for 5  years. Intervention: In 
+YLSP group, all practices of integrative approach of yoga therapy such as yama, niyama, asana, 
+pranayama, and meditation were used as an add‑on to conventional cardiac rehabilitation. The control 
+group (CLSP) continued conventional cardiac rehabilitation only. Outcome Measures: World Health 
+Organization (WHO)‑QOL BREF Questionnaire, Perceived Stress Scale, Positive and Negative 
+Affect Scale (PANAS), and Hospital Anxiety and Depression Scale  (HADS) were assessed before 
+surgery and at the end of the 5th  year after CABG. As data were not normally distributed, Mann–
+Whitney U‑test was used for between‑group comparisons and Wilcoxon’s signed‑rank test was used 
+for within‑group comparisons. Results: At the end of 5 years, mental health (P = 0.05), perceived 
+stress (P  =  0.01), and negative affect  (NA)  (P  =  0.05) have shown significant improvements. 
+WHO‑QOL BREF score has shown improvements in physical health  (P  =  0.046), environmental 
+health (P  =  0.04), perceived stress  (P  =  0.001), and NA  (P  =  0.02) in YLSP than CLSP. Positive 
+affect has significantly improved in CLSP than YLSP. Other domains of WHO‑QOL‑BREF, PANAS, 
+and HADS did not reveal any significant between‑group differences. Conclusion: Addition of 
+long‑term YLSP to conventional cardiac rehabilitation brings better improvements in QOL and 
+reduction in stress levels at the end of 5 years after CABG.
+Keywords: Cardiac rehabilitation, coronary artery bypass graft, coronary heart disease, 
+meditation, yoga‑based lifestyle program
+Yoga‑Based Postoperative Cardiac Rehabilitation Program for Improving 
+Quality of Life and Stress Levels: Fifth‑Year Follow‑up through a 
+Randomized Controlled Trial
+Original Article
+Eraballi Amaravathi, 
+Nagendra 
+Hongasandra 
+Ramarao, 
+Nagarathna 
+Raghuram, 
+Balaram Pradhan
+Division of Yoga and Life 
+Sciences, Swami Vivekananda 
+Yoga Anusandhana Samsthana 
+University, Bengaluru, 
+Karnataka, India
+How to cite this article: Amaravathi E, Ramarao NH, 
+Raghuram N, Pradhan B. Yoga‑based postoperative 
+cardiac rehabilitation program for improving quality of 
+life and stress levels: Fifth‑year follow‑up through a 
+randomized controlled trial. Int J Yoga 2018;11:44-52.
+Received: September, 2016. Accepted: March, 2017.
+This is an open access article distributed under the terms of the 
+Creative Commons Attribution-NonCommercial-ShareAlike 3.0 
+License, which allows others to remix, tweak, and build upon the 
+work non-commercially, as long as the author is credited and the 
+new creations are licensed under the identical terms. 
+For reprints contact: reprints@medknow.com
+young CABG patients,[10] and after the first 
+diagnosis of CAD, hence, it is important to 
+develop a simple, effective, and low‑cost 
+strategies for the secondary prevention of 
+further morbidity and mortality.[9]
+Worldwide, 
+approximately 
+20% 
+of 
+people who receive primary health care 
+have depression or anxiety disorders in 
+general.[11] Anxiety is associated with 
+high risk of coronary heart disease  (CHD) 
+mortality in particular of prior depression 
+status.[12] The presence of anxiety and/or 
+depression before surgery has the effect 
+on cardiac rehabilitation outcomes after 
+surgery, and both the factors are triggered 
+and contributed using stress levels; hence, 
+there is a need for early diagnosis and 
+supportive therapeutics that involve mind–
+body interventions.[13] There is need for 
+International Journal of Yoga | Volume 11 | Issue 1 | January‑April 2018
+Amaravathi, et al.: A randomized controlled trial
+45
+interventions which target stress management[14] and 
+improve QOL, in particular after CABG.[8]
+Cognitive behavioral therapies and other mindfulness‑based 
+stress management programs can bring significant change 
+in depression scores than usual care after CABG[15] and also 
+improve the physical and mental health.[16,17] However, these 
+programs require one‑to‑one sessions with a specialist and 
+are time‑consuming and costly. Yoga therapy is simple and 
+cost‑effective, it can be offered in groups, and people can 
+be trained to practice regularly on their own with regular 
+monitoring and follow‑ups. Studies on yoga after CAD[18] 
+and CABG[11,15] are available. Long‑term follow‑ups of 
+relaxation‑based lifestyle change studies in CAD with or 
+without myocardial infarction (MI) have been reported.[17,19,20]
+In a previous randomized controlled study, we have reported 
+the beneficial effects of yoga‑based lifestyle program (YLSP) 
+program as an add‑on to conventional cardiac rehabilitation 
+in improving left ventricular EF, psychological states, and 
+various other risk factors at the end of 1st the year as compared 
+to ELSP through randomized controlled trial  (RCT).[21] The 
+present study aims at looking at the effect of YLSP in QOL 
+and stress levels after 5 years of CABG surgery.
+Methodology
+The results of a year‑long follow‑up of the EF and other 
+measures have been reported in our earlier publication.[21] At 
+that time (2005–2007), all patients were advised to continue 
+their home practices that were taught to them in person 
+before discharge after CABG in the hospital.
+Subjects
+In the initial funded (Ministry of Health and Family Welfare, 
+Central Ministry, New  Delhi, India) project on the effect 
+of YLSP, conducted between 2005 and 2007 at Narayana 
+Hrudayalaya Institute of Cardiac Sciences  (NHICSc), 
+Bengaluru, we had recruited 300 participants who satisfied 
+the selection criteria from a pool of 1026 screened patients 
+who were posted for CABG (trial profile).
+Selection criteria
+The inclusion criteria for the study were  (a) males posted 
+for CABG with double or triple vessel disease,  (b) EF 
+above 30%, and (c) those residing within 200 km distance 
+from the hospital. Those with other system diseases, those 
+with EF  <30%, those who were posted for valve repair 
+in addition to CABG, and emergency CABG cases were 
+excluded from the study [Table 1]. For the present study, we 
+included all those cases who could give us the feedback; in 
+the case of death, we had obtained the information from the 
+relatives who received the follow‑up phone calls or letter.
+Ethical clearance and informed consent
+The present follow‑up study protocol was approved by the 
+Ethical Committee of NHICSc and Swami Vivekananda 
+Yoga Anusandhana Samasthana (SVYASA) University.
+Written informed consent was obtained at the time of 
+recruitment for the RCT which had mentioned about the 
+long‑term follow‑up.
+Procedure
+The present study reports the results of the 5th‑year 
+follow‑up of those who were recruited for the initial 
+RCT between 2005 and 2007. For this follow‑up study, 
+the research team was in continuous contact with all the 
+participants through phone calls and reminder letters. One 
+of the research team members met the participant at these 
+follow‑up visits. All those who came for the follow‑up 
+went through a review session of yoga  (experimental 
+group) or exercise  (control group) practice session for 
+1 h and gave their feedback on the current health status 
+and completed the psychological questionnaires. The 
+results of the follow‑up investigations were reviewed by 
+the cardiology team with suitable advice on changes in 
+medication and lifestyle.
+Measurements
+•	
+Perceived Stress Scale  (PSS): It a self‑reporting 
+validated tool[19,22] for assessing the perception of stress 
+over the past 1 month,[20,23] with the reliability of 0.85, 
+and this can be used after CABG[21]
+•	
+Positive and negative affect scale (PANAS): PANAS has 
+four subscales, i.e., positive affect (PA), negative affect 
+(NA), other positive, and other negative consisting of 
+10, 10, 4, and 6 items each with validity and reliability 
+of 0.86–0.9 for PA and 0.84–0.87 for NA[22,24]
+•	
+Hospital Anxiety and Depression Scale  (HADS): 
+A  self‑reported valid[23,25] instrument designed to 
+assess the anxiety and depression in nonpsychiatric 
+population. This questionnaire consists of two subscales 
+of seven items for anxiety and depression. The report 
+will be based on the past 2 weeks on the scale of four 
+ranging from 0  (“not at all”) to 3  (“very much”). The 
+reliability was 0.85 for HADS and 0.79 and 0.87 for 
+the two subscales  (HADS‑anxiety  [HADS‑A] and 
+HADS‑depression [HADS‑D])[24,26]
+•	
+QOL: World Health Organization  (WHO) QOL‑BREF 
+has 26 questions developed by WHO. It is a scale that 
+measures four domains such as physical (7 items), 
+mental (6 items), social  (3 items), and environmental 
+health (8 items), which is perceived by the person. 
+First and second questions related to “overall QOL” 
+and “general health” facets are not included for 
+scoring as per the user manual. The range of scores 
+is 4–20 for each domain and scales in a positive 
+direction  (i.e.,  higher scores denotes higher QOL). 
+The internal consistency is ranged from 0.66 to 
+0.87  (Cronbach’s alpha coefficient). This has good 
+validity and test–retest reliability and is recommended 
+for the use in health surveys and to assess the efficacy 
+of any intervention at suitable intervals according to 
+the study.[25,27]
+International Journal of Yoga | Volume 11 | Issue 1 | January‑April 2018
+Amaravathi, et al.: A randomized controlled trial
+46
+Intervention
+Practices common to both groups
+The present study interventions include different practices; 
+pharmacotherapy, 
+study 
+material, 
+and 
+the 
+cardiac 
+rehabilitation program for 30  min by a physiotherapy 
+expert were common to both the groups.
+Experimental group (yoga‑based lifestyle program)
+Yoga starting with simple and safe practices suited to the 
+stamina of participant is used. Integrative approach of yoga 
+therapy‑based yoga modules which are described in detail 
+in our previous work[21] was used [Table 2]. Counseling on 
+lifestyle modification includes concepts of Ashtanga yoga 
+(Yama, Niyama) with the scientific background.
+Control group  (physiotherapy‑based lifestyle program: 
+Conventional lifestyle program)
+Warm‑up exercises including breathing exercises and some 
+more physiotherapy‑based exercises in different positions 
+as per the stamina and those comparable with yoga asanas 
+were administered  [Table  2]. Counseling was given by the 
+physician about the lifestyle modification.
+Data analysis
+SPSS version-20, Armonk NY: IBM Corp  was used 
+to analyze the data. Since the data were not normally 
+distributed 
+on 
+Kolmogorov–Smirnov 
+test, 
+thus, 
+nonparametric tests such as Wilcoxon’s signed‑rank test 
+and Mann–Whitney U‑test  (MWT) were used to compare 
+the means within and between groups, respectively.
+Results
+Trial profile
+The trial profile [Figure 1] represents the procedure of study 
+from recruitment to 5th  year after CABG. Three hundred 
+individuals (150 in each group) who satisfied the selection 
+criteria were recruited. Because of memories of trauma from 
+CABG, mortality (two in conventional lifestyle program 
+[CLSP], one in YLSP), long distance to travel to reach the 
+hospital, and heavy traffic, we lost the follow‑up of nearly 
+100 people in each group. Later, the imputation method was 
+conducted to add the two missing items of each questionnaire. 
+This happened both at baseline and 5th‑year data. More than 
+two items were excluded totally from other questionnaires 
+also. This gave the less sample size for further analysis. Total 
+of 36 in control group and 37 in yoga group is the sample 
+size in all questionnaires and at both times of data collection.
+Table  1 shows the demographic details. There was no 
+significant difference of sample size between the groups, 
+age, gender, education, or socioeconomic status. All of 
+them were married, were graduates/postgraduates, and 
+were in middle/low socioeconomic status. Most of them 
+had hypertension, diabetes, and/or obesity. There was no 
+difference between the groups for other risk factors as well.
+World Health Organization quality of life‑BREF
+Table  3 shows the results of QOL and perceived stress 
+levels at 5th year of CABG participants.
+Total scores
+Total 
+WHO‑QOL‑BREF 
+scores 
+were 
+nonsignificant 
+change between groups after 5  years  (P  =  0.105). There 
+were significant improvement within YLSP group  (4.36%, 
+P  =  0.097) and nonsignificant change in CLSP group 
+(−1.11%, P = 0.819) after 5 years.
+Domain 1 (D1): Physical health
+Physical health scores showed nonsignificant change 
+between groups after 5  years  (P  =  0.167). There were 
+significant improvement within YLSP group  (7.27%, 
+Table 1: Demographic data
+Categories
+Groups
+Chi‑square 
+test (P)
+CLSP
+YLSP
+Sample size
+150
+150
+‑
+Gender
+Male
+Male
+‑
+Age range (years)
+35-65
+35-65
+‑
+Educational level (%)
+School
+25 (47.2)
+28 (52.8)
+2.04 (0.56)
+Under graduation
+47 (53.4)
+41 (46.6)
+Graduation
+36 (44.4)
+45 (55.6)
+Postgraduation
+42 (53.8)
+36 (46.2)
+Religion (%)
+Hindu
+138 (49.3)
+142 (50.7)
+0.85 (0.355)
+Others
+12 (60)
+8 (40)
+Economic status (%)
+Upper class
+12 (44.4)
+15 (55.6)
+0.51 (0.77)
+Middle class
+91 (51.4)
+86 (48.6)
+Lower class
+47 (49)
+49 (51)
+Angiogram report (%)
+Single vessel disease
+26 (61.9)
+16 (38.1)
+13.99 (0.003)
+Double vessel disease
+27 (37.5)
+45 (62.5)
+Triple vessel disease
+95 (51.9)
+88 (48.1)
+Myocardial infarction
+50 (66.7)
+25 (33.3)
+Associated problems (%)
+Diabetes mellitus
+74 (47.1)
+83 (52.9)
+2.12 (0.54)
+Hyper tension
+91 (51.7)
+85 (48.3)
+Obesity
+41 (42.7)
+55 (57.3)
+Others
+5 (45.5)
+6 (54.5)
+Risk factors (%)
+Alcohol
+18 (42.9)
+24 (57.1)
+1.19 (0.75)
+Family history
+26 (43.3)
+34 (56.7)
+Smoking
+19 (42.2)
+26 (57.8)
+Tobacco
+21 (52.5)
+19 (47.5)
+Duration of coronary 
+artery disease (year) (%)
+<1
+83 (47.4)
+92 (52.6)
+0.55 (0.75)
+1-5
+59 (50.4)
+58 (49.6)
+5-10
+8 (42.1)
+11 (57.9)
+CLSP = Conventional lifestyle program, YLSP = Yoga‑based life 
+style program
+International Journal of Yoga | Volume 11 | Issue 1 | January‑April 2018
+Amaravathi, et al.: A randomized controlled trial
+47
+P 
+= 
+0.046) 
+and 
+nonsignificant 
+change 
+in 
+CLSP 
+group (0.25%, P = 0.628) after 5 years.
+Domain 2 (D2): Psychological
+Mental health scores showed significant improvement 
+between groups after 5  years  (P  =  0.058) with YLSP 
+group showing better results than CLSP group. There 
+was nonsignificant change in YLSP group  (3.20%, 
+P = 0.203) and in CLSP group (−2.09%, P = 0.640) after 
+5 years.
+Domain 3 (D3): Social relationships
+There was a nonsignificant improvement between 
+the groups for the social interaction scores after 
+5  years  (P  =  0.141). There were nonsignificant 
+improvement in YLSP group (−2.12%, P  =  0.601) 
+and significant improvement in CLSP group (−7.4%, 
+P = 0.098) after 5 years.
+Domain 4 (D4): Environment
+Environmental health scores showed the nonsignificant 
+change between groups after 5  years  (P  =  0.240). There 
+were significant improvement within YLSP group  (5.07%, 
+P  =  0.044) and nonsignificant change in CLSP group 
+(0.73%, P = 0.907) after 5 years.
+Perceived stress scale
+Perceived stress scores were significantly reduced in the 
+YLSP group as compared to CLSP group at the end of 
+5  years (P  =  0.011). There was significant improvement 
+1026 assessed for eligibility
+726 did not meet inclusion criteria
+Randomization 300
+150: Conventional Lifestyle
+Program (CLSP)
+- 150 Received intervention
+150: Yoga-based Lifestyle
+Program (YLSP)
+- 150 Received intervention
+At the end of 5th Year
+61 Lost to follow-up
+- Long distance to
+ 
+travel= 7
+- Death= 2
+52 Lost to follow-up
+- Long distance to
+ 
+travel= 6
+- Death=1
+Missing data analysis
+Missing data analysis
+- 36 Included in Analysis
+- 0 Excluded in analysis
+- 37 Included in Analysis
+- 0 Excluded in analysis
+Figure 1: Trial profile
+Table 2: Intervention
+Duration
+Conventional session details
+Yoga session details
+Baseline
+Breathing practices
+Physiotherapy exercises for; wrist, back of hand, elbows, 
+neck, back and legs
+DRT
+MSRT
+Nadi Shodhana Pranayama ‑ alternate nostril yoga breathing
+Until 
+5th year
+Additional physiotherapy exercises in standing position
+Sit‑ups, hip rotation, knee rotation, forward drill, backward 
+drill, sideward drill, full arm rotation, free walking
+Sitting in a chair
+Ankle bending and toe bending
+Leg spread exercises with support‑side ways, front and back
+Supine rest
+Yogic breathing practices
+Prasarita Hasta Swasah ‑ hands in and out breathing
+Utkasita Hasta Swasah ‑ hands stretch breathing
+Vyaghra Swasah ‑ tiger breathing
+Ekapada uttanasana Swasah ‑ straight leg raise breathing
+Standing asanas ‑ 20 min
+Ardha Kati Chakrasana ‑ lateral half wheel posture
+Trikonasana ‑ triangle posture
+Vrikshasana ‑ tree posture
+Garudasana ‑ eagle posture
+Prone lying asanas
+Bhujangasana ‑ serpent posture
+Sitting asanas
+Vakrasana ‑ spinal twist with leg straight posture
+Ardha Matsyendrasana ‑ half spinal twist posture
+Vajrasana ‑ diamond posture
+Supine lying: QRT, DRT, and MSRT
+DRT = Deep relaxation technique, MSRT = Mind sound resonance techniques, QRT = Quick relaxation technique
+International Journal of Yoga | Volume 11 | Issue 1 | January‑April 2018
+Amaravathi, et al.: A randomized controlled trial
+48
+within YLSP group (17.96%, P = 0.001) with nonsignificant 
+change in CLSP group (12.13%, P = 0.063).
+Table 4 shows the alternate assessment of stress like 
+PANAS and HADS.
+Positive and negative affect scale
+PA scores did not show significant difference between the 
+groups after 5 years (P = 0.323). There were nonsignificant 
+increase in PA in the YLSP group  (5.95%, P  =  0.364) 
+and significant improvement in the CLSP group  (11.82%, 
+P = 0.02) after 5 years.
+NA 
+scores 
+reveal 
+significant 
+improvement 
+in 
+the 
+between‑group differences after 5  years  (P  =  0.05). There 
+were nonsignificant reduction of NA scores in YLSP group 
+(−7.3%, P  =  0.204) and significant increase within CLSP 
+group (30.7%, P = 0.003) after 5 years.
+Hospital anxiety and depression scale
+No significant between‑group differences were observed 
+for either HADS‑A or HADS‑D score at the end of 5 years. 
+Although the results were not significant in within‑group 
+comparisons, there was higher tendency for YLSP group to 
+show the reduction in depression scores (−2.14% in YLSP 
+group vs. 1.78% in CLSP group).
+Discussion
+We observe that continuous practice of YLSP program as 
+an add‑on to conventional cardiac rehabilitation program 
+leads to better improvement in the QOL and reduction 
+of perceived stress as compared to physiotherapy‑based 
+lifestyle program in patients, 5  years after CABG. There 
+was no significant difference between groups at the 
+baseline.
+To the best of our knowledge, there are no studies 
+reporting 5‑year follow‑up on QOL after CABG. Studies 
+show that surgical impacts are better for physical health 
+and functional capacity of QOL after CABG, but the 
+psychological domain of QOL remains unaffected.[26,28]
+Perceived stress scale
+The present study showed significant improvement in PSS 
+scores after 5  years in YLSP group. Lifestyle counseling 
+can reduce the over weight, lipid levels, blood pressure 
+and glucose imbalances in cardiac risk population.[29] It 
+has been observed that lateralization of cerebral activity 
+during stress may stimulate the heart asymmetrically, 
+and this may lead to cardiac arrhythmias.[30,31] Previously, 
+mindfulness‑based practice was used in experienced 
+meditators wherein better cortisol recovery was observed 
+after social stress test. Recovery of stress after mindfulness 
+meditation has been demonstrated to be due to regulation of 
+histone deacetylases and associated inflammatory pathways. 
+This reflects the probable therapeutic mechanism of action 
+of mind–body therapies such as yoga, in stress‑related 
+disorders.[27,29] Previously, it was observed that intensive 
+lifestyle counseling helped patients with cardiovascular risk 
+factors, by reducing their body weight, blood pressure, lipid, 
+and glucose levels.[21,28,30] In another study, aerobic exercises 
+for 35  min and 35  min of walking were compared with 
+Table 3: Comparison of quality of life and perceived 
+stress scale variables from baseline to 5th year
+Sub‑ 
+scale
+Group
+n
+Mean±SD
+WSRT Percentage 
+change
+Baseline
+5th year
+D1
+C
+36
+23.50±3.0
+23.56±3.2
+0.628
+0.25
+Y
+37
+23.08±3.9
+24.89±3.7
+0.046*
+7.27
+MWT
+0.690
+0.167
+D2
+C
+36
+19.61±2.9
+19.22±2.9
+0.640
+−2.09
+Y
+37
+20.22±3.4
+20.89±3.4
+0.203
+3.20
+MWT
+0.375
+0.058*
+D3
+C
+36
+10.44±1.7
+9.72±2.1
+0.098
+−7.4
+Y
+37
+10.57±2.1
+10.35±1.9
+0.601
+−2.12
+MWT
+0.927
+0.141
+D4
+C
+36
+25.50±4.4
+25.69±4.2
+0.907
+0.73
+Y
+37
+25.81±4.3
+27.19±3.3
+0.044*
+5.07
+MWT
+0.971
+0.240
+Total
+C
+36
+79.06±9.6
+78.19±10.6
+0.819
+−1.11
+Y
+37 79.68±12.1 83.32±10.8
+0.097
+4.36
+MWT
+0.786
+0.105
+PSS
+C
+36
+16.72±5.3
+19.03±4.4
+0.063
+12.13
+Y
+37
+19.57±5.0
+16.59±3.9
+0.001**
+−17.96
+MWT
+0.307
+0.011*
+*P≤0.05, **P≤0.005. D1 = Physical health, D2 = Psychological, 
+D3 = Social Relationships, D4 = Environment, PSS = Perceived 
+stress scale, n = Sample size, C = Conventional lifestyle program, 
+Y = Yoga‑based lifestyle program, SD = Standard deviation, 
+MWT = Mann-Whitney U‑test, WSRT = Wilcoxon’s signed‑ranks test
+Table 4: Comparison of positive and negative affect scale 
+and hospital anxiety and depression scale variables from 
+baseline to 5th year
+Subscale
+Group n
+Mean±SD
+WSRT Percentage 
+change
+Baseline
+5th year
+PANAS‑PA C
+36 15.58±6.3 17.67±5.2 0.022*
+11.82
+Y
+37 17.84±5.9 18.97±5.8 0.364
+5.95
+MWT
+0.189
+0.323
+PANAS‑NA C
+36 7.47±4.3 10.78±4.8 0.003*
+30.70
+Y
+37 9.11±5.6
+8.49±5.5
+0.204
+−7.30
+MWT
+0.179
+0.05*
+HADS‑A
+C
+36 18.28±2.9 18.17±2.5 0.825
+−0.60
+Y
+37 18.08±2.5 18.16±2.9 0.940
+0.44
+MWT
+0.713
+0.802
+HADS‑D
+C
+36 15.39±3.5 15.67±2.5 0.621
+1.78
+Y
+37 15.68±2.5 15.35±2.4 0.545
+−2.14
+MWT
+0.542
+0.573
+*P≤0.05, PANAS = Positive and negative affect scale, 
+PA = Positive affect, NA = Negative affect, HADS = Hospital Anxiety 
+and Depression Scale, A = Anxiety, D = Depression, n = Sample 
+size, C = Conventional lifestyle program, Y = Yoga‑based lifestyle 
+program, SD = Standard deviation, MWT = Mann-Whitney U‑test, 
+WSRT = Wilcoxon’s signed‑ranks test
+International Journal of Yoga | Volume 11 | Issue 1 | January‑April 2018
+Amaravathi, et al.: A randomized controlled trial
+49
+stress management training for 16  weeks. It was observed 
+that with its emphasis on emotion and behavior of person, 
+stress management program lead to greater reduction in 
+the general distress.[30,32] Worse physical health in terms 
+of depression, osteoporosis, arthritis, cancer, prephysical 
+problems, and poor mental health in terms of anxiety,[33] 
+depression, and worse emotional score is more in elder 
+patients after aortic valve replacement  (AVR) with or 
+without CABG.[34,35] The basic knowledge about the disease 
+process and the steps to be taken after diagnosis also makes 
+much difference in adherence to lifestyle program.[35,36] This 
+may be the reason for nonsignificant improvements of the 
+control group.
+Positive and negative affect scale ‑ Positive affect
+It showed better nonsignificant improvement in CLSP 
+group [Table 4]. This result is supported by a study 
+showing association of self‑care and PA scores after 1 year 
+in chronic heart failure patients.[36,37] Circadian hyper 
+amplitude tension and abnormal low diastolic BP have been 
+associated with NAs.[38] PA scores correlated negatively 
+with the tumor necrosis factors and interleukins in 79% 
+men of 67 ± 9 years of age.[38,39]
+Positive and negative affect scale ‑ Negative affect
+It showed significant increase in CLSP compared to YLSP 
+[Table 4]. In contrast, previously, another study observed 
+similar results at 9th  year of follow‑up of CHD patients 
+after conventional rehabilitation which may be the reason 
+for less QOL in CLSP.[1,18,40] Non-significant increase 
+of PANAS‑PA in YLSP supported by the reduction of 
+PANAS‑NA might increase the QOL after CABG.[39] 
+CLSP group showed increased negative emotions may be 
+because of the trigger of acute coronary syndrome with 
+negative emotions such as events in workplace.[40] In a 
+population‑based study, cardiovascular disease did not 
+affect the emotional well‑being of the subjects but shown 
+association of negative emotions with cardiogenic drugs at 
+old age of about 84 years.[41] May the risk aversion[42] from 
+surgery, future life expectations[43] at the time of assessment 
+show the personality change over a period of 5 years after 
+CABG. Anxiety and depression are common for CABG 
+before and after the surgery.[44] Better QOL after CABG 
+reduce the chance of depression.[45] Anxiety has much 
+influence on cardiac adverse events than distress after 
+5 years of CABG.[2]
+Hospital anxiety and depression scale
+Nonsignificant changes of HADS‑A and HADS‑D scores 
+happened after 5 years in both groups [Table 4]. Depression 
+reduced with lifestyle program after 1 year in CHD patients 
+with or without diabetes mellitus.[45] Depression but not 
+anxiety is associated with the number of hospitalizations, 
+hospital stay, and all‑cause mortality in ischemic heart 
+disease.[46] In CHD, the chance of HADS-D score is more 
+and it will be much with the presence of risk factors like 
+systolic blood pressure and body mass index.[47] High 
+cholinergic neurotransmission associated with anxiety‑like 
+traits.[48] Anxiety may be associated with irregular growth 
+hormone and melatonin rhythms which can be altered by 
+basic lifestyle habits.[49] Minor events of daily life associates 
+with adrenocortocal activity.[50] Baseline psychological 
+deviations between groups are because of the surgical 
+trauma, and it can influence the outcomes of phase-2 
+rehabilitation.[12,13,51] One‑quarter of cardiac arrest patients 
+suffer from cognitive impairment that is dysfunction of 
+medial temporal lobe and impaired short‑term memory 
+after 4 years of cardiac arrest.[52] Minor events of daily life 
+associates with adrenocortical activity.[50]
+BREF‑quality of life
+Domain 1: Physical health (D1)
+There is significant improvement of physical health part 
+of QOL in YLSP as in a study of add‑on yoga in aerobic 
+training.[3] The exercise capacity improved with home‑based 
+rehabilitation as in center based rehabilitation after MI[53] as 
+the improvements of the CLSP group of the present study. 
+Cardiac resynchronization therapy improves physical health 
+after 4 years of CABG or AVR.[3]
+Domain 2: Psychological (D2)
+The present study showed nonsignificant improvement of 
+mental health in YLSP as the supportive atmosphere, caring 
+relationship, diet, and lifestyle change led to physiological 
+changes such as reduction of anxiety, depression, and 
+arrhythmia as in atrial fibrillation patients.[54] Both the 
+functional capacity and the overall well-being improved 
+paralelly after 2 years of heart transplantation with the 
+possibility of comparing themselves with healthy individual 
+than patients.[55]
+Domain 3: Social relationships (D3)
+Non-significant improvement in CLSP resembles the 
+conventional rehabilitation program which reduced the 
+resting heart rate and increases duration of exercises and 
+peak oxygen consumption and overall QOL after CABG.[56,57] 
+Conventional rehabilitation phase-3 along with relaxation 
+technique has shown better QOL than individual techniques 
+in cardiac syndrome.[58] Generalization of treatment after 
+longterm follow up will improves the social functioning.[59]
+Domain 4: Environment (D4)
+Significant improvement in YLSP after 5 years has 
+similarities with previous study where improvements 
+are because of better coping ability if they are married, 
+living with family and the children were employed[60] 
+Previous regular leisure time activities prevent the 
+suffering after CABG.[61] Therapeutic life style may need 
+to be a central focus of mental, medical, and public 
+health.[62]
+International Journal of Yoga | Volume 11 | Issue 1 | January‑April 2018
+Amaravathi, et al.: A randomized controlled trial
+50
+Total scores
+Non-significant improvement of total QOL was observed in 
+YLSP after 5 years. Low‑intensity exercises can improve 
+heart rate and functional capacity of CABG patients 
+who has low‑  and moderate‑risk factors.[63] Aerobic 
+training and yoga improve the muscle strength, 6‑min 
+walk test distance,[64] which could be the base for overall 
+improvement of health‑related QOL.[60]
+Psycho‑biological mechanisms
+The present study showed that perceived stress, PA, NA, 
+anxiety, and depression in day‑to‑day life are the initial step 
+of physiological disturbance of the body. There is significant 
+correlation found between general knowledge about the 
+CHD risk factors and ability to follow lifestyle changes 
+and medication.[65] Lateralization of cerebral activity during 
+emotional stress may stimulate the heart asymmetrically 
+and develop cardiac arrhythmias showing the need for 
+meditation techniques.[29,31] Yoga is not a few postures but a 
+holistic lifestyle which promotes health at physical, mental, 
+emotional, and spiritual levels,[66,67] with a component of 
+stretching, physical postures, breath control, concentration 
+techniques which improve organ and immune function.[68] 
+The scientific backgrounds of physiological changes have 
+well documented in conventional rehabilitation research 
+and can be indicative to yoga programs as well.[68,69]
+Autonomic 
+nervous 
+system 
+dysregulation 
+leads 
+to 
+depression after CABG.[70,71]
+Limitations and future plans
+Follow‑up was poor even with 200  km of distance. Lack 
+of interest from the subjects for follow‑up after getting 
+better in health was a major reason for high attrition rate. 
+Risk factor analysis, complications, and hospitalization 
+would have helped know the lifestyle better. We could not 
+include the patients who wanted to change to experimental 
+group to reach the health than the completion of work. All 
+psychological parameters measured to ensure the role of 
+mind in health maintenance but could not bring the cardiac 
+measures to prove in a quantitative way.
+As our treatment is home-based and self paced program, 
+which proves that the solution is at door step. This works for 
+high‑risk population (after 5 years of CABG surgery). With 
+all boundaries, we could get some samples from both groups 
+for further study which ensures the interest of participants 
+in continuation of program. Response to the phone calls 
+and visiting at review times make sure about the interest 
+and comfort toward the intervention. Hence, integration of 
+physical exercises well known as conventional rehabilitation 
+and the traditional lifestyle well known as yoga benefited 
+the CABG patients. Patients use to demonstrate the asked 
+practice and were replying yes for regularity. However, 
+this was not documented. All psychological parameters 
+measured to ensure the role of mind in health maintenance.
+Conclusion
+Addition of long‑term YLSP to conventional cardiac 
+rehabilitation brings better improvement in QOL and 
+reduction in stress levels at the end of 5 years after CABG. 
+However, there are a large number of patients which have 
+been lost to follow‑up in the present study; hence, larger 
+studies with better follow‑up and cardiac end points are 
+needed.
+Acknowledgements
+We acknowledge all the cardiologists, cardiac surgeons 
+and echo technicians of NIHSc, Bangaluru, for their 
+cooperation. We thank all the therapists, Biostatistician, and 
+staff of SVYASA for their contribution in conducting the 
+study.
+Financial support and sponsorship
+We are grateful to AYUSH, Ministry of Department of 
+Health and Family Welfare, New Delhi, India, for funding 
+this study.
+Conflicts of interest
+There are no conflicts of interest.
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+© 2018. This work is published under
+https://creativecommons.org/licenses/by-nc-sa/4.0/ (the “License”).
+Notwithstanding the ProQuest Terms and Conditions, you may use this content
+in accordance with the terms of the License.
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