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Iris Publishers - World Journal of Yoga, Physical Therapy and Rehabilitation (WJYPR)

Depression, Physical Decline and Existential Psychotherapy in Late Life

Authored by Luel Mae ZP Contreras*

Introduction

Late life brings with its wisdom, long experiences, contentment, and respect, love and care of many generations in the family. As an individual grows older, however, decline and changes are inevitable, too. So that, very common among the older persons are feelings of depression. How can this rapidly increasing population with growing demands for better quality of life, be helped? I conducted a research based on the Frankl’s Existential Theory and Logotherapy [1] and designed and implemented an intervention program for late life depression. The research had three phases. In Phase One, old participants (n=37) were administered tests and especially selected using the variables on age, cognitive functioning, depressive symptoms, gender, and perceived disability functioning. From those who qualified (n=28), 10 were randomly selected to participate in the Focused Group Discussion. From them, common themes and topics in old age were identified. These became the basis of the topics, tasks and activities of the intervention program. The program called the Existential Psychotherapy for Old Persons was designed and developed.

In Phase Two, the program was implemented in 18 sessions for eight weeks. 10 participants completed the 18 sessions. To measure effectiveness of the program, levels of depressive symptoms were monitored at the end of the sixth session, the 12th and the 18th session.

In Phase Three, four of the 10 participants to the Existential Psychotherapy for Old Persons were selected as subjects for the case study method. They narrated their stories to establish symptoms of depression. They were also asked factors which they considered to have contributed to the effectiveness of the program.

Findings of the Research

Phase One of the research, found a very high prevalence rate (94%) of depression among old people. Phase Two established three important points. First, old age depression can be described to be about emptiness, problems in memory, boredom, preference to stay at home, feeling that others are better, and helplessness. These were common symptoms of depression reported by the participants before the intervention was implemented. Secondly, after the implementation of the intervention, some symptoms reported before the start of the program were no longer present. Hence, the program can be described to effectively regulate feelings of energy, good spirits, and satisfaction in life, worth, happiness, hope, and going out and trying new things. Thirdly, statistically, therefore, a significant difference between levels of depressive symptoms reported before and after the intervention (Asymp. Sig. 2-tailed = 0.043) was found.

In Phase Three, factors were identified which were perceived to have contributed to the effectiveness of the Existential Psychotherapy for Old Persons. These made up the meaning triad [2] of the program or the creative, experiential and attitudinal meaning or values of the program. Meaning was experienced by the participants in the existential activities and tasks, in the relationships they recalled from the past, in the relationships they developed with the facilitators and other participants in the program, and the lessons they learned in spite their pain, suffering and negative experiences.

The Intervention Program

The Existential Psychotherapy for Old Persons was implemented in 18 sessions, in eight weeks or two months. The program generally aimed to recall and enumerate experiences which are sources of despair, sadness and joy and inspiration. The program facilitated the exploration of emotions and beliefs in attempts to assign options or new options for creating meaningful experiences.

Twelve sessions were conducted in group and six sessions were on one-on-one sessions with the participants. In group sessions, the participants were brought together in a specified venue for activities for about 90 minutes each session. Individual sessions were conducted in the homes of the participants for 45 minutes each session. Sessions were prepared according to themes about age in old age, developmental stages, physical body, family, salary and pension, services to others, calamity or disaster, farewell and goodbye, God, gatherings, personal values or wishes, and thanksgiving.

The program included strategies such as meditation, physical exercises, reminiscence, life review, individual work, group work, story-telling, song singing, coloring-task, drawing, individual disclosure, small- and big-group discourse or sharing, insight, integration, prayer, care of pechay plant, home visitations and interviews.

Each group session was composed of five parts. It had opening activities like meditation for the older participants, body exercise, singing or dancing, and prayer. The next was the working part with instructions and group or individual tasks to the old participants. The third part was sharing and processing. The fourth part was the transformation and integration part with insights or action plans. And the fifth part included closing prayer and songs.

Session Five

The fifth session of the intervention program was titled Ang Akong Lawas (My Body) and especially designed to explore and delve into issues of the physical body of the participants or to acknowledge physical capacities or decline. Printed drawings of body were distributed. The participants were asked to acknowledge hurting and painful parts of their bodies. Then, with the printed drawings, they color-shade those parts. They recalled experiences associated to the painful parts of the bodies. And more importantly, they were asked to recall experiences of gratefulness and joy and lessons learned despite pain.

Meaning was found in the courage to bear the suffering and pain, and in the support provided by family and relatives in helping them handle physical concerns, and also in actively providing care for the self and one’s own body. There was recall of times and gratitude in relationships when, for example, in spite hospitalization and physical pain, children came to take care of the participant:

They came back home. I thanked God for my children. I was so happy they came home, and they took good care of me.

Suffering was remembered with care and concern:

I thank God for the concern and worry of my husband.

The attitudinal meaning includes becoming more aware of the need to provide care for one’s body:

Sometimes, the reason of man’s body pain is about the food we eat. We must be conscious of healthy foods so that we help ourselves take good care of ourselves.

Conclusion

Session Five, as like the other sessions of tasks and activities of the designed and implemented intervention program, effectively facilitated the search for meaning in late life and finally, regulated depressive symptoms of the participants. Physical decline is an existential reality in old age and can contribute to feelings of depression. Existential Psychotherapy, the participation to the Existential Psychotherapy for Old Persons, and the search of meaning in the experiences of physical decline, however, can help regulate feelings of depression. The tasks of Session Five led to an exploration of suffering and pain, and the meaning of physical decline.

To read more about this article: https://irispublishers.com/wjypr/fulltext/depression-physical-decline-and-existential-psychotherapy-in-late-life.ID.000535.php

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[journal-of-yoga]

Iris Publishers - World Journal of Yoga, Physical Therapy and Rehabilitation (WJYPR)

Transpersonal Life: The Embodiment of Nonduality

Authored by Jan Kersschot

Opinion

Over the last decades, there has been a gradual shift from the patriarchal spiritual organizations of the last two thousand years into a more balanced approach which integrates both masculine and feminine qualities. We are less interested in leadership, dogma, hierarchy, idolatry and secrecy, and more open to friendship, equality, gentleness, compassion and availability to all. There is less duality between sacred and profane, between holy and evil, between philosophy and religion, between science and spirituality. Nonduality seems to be a bridge between all these apparently opposite views. Nonduality postulates that the ultimate reality cannot be cut in two-except by the mind. Everyone and everything is in fact an expression of a single timeless oneness. But how can we integrate the wisdom of nonduality in everyday life?

Transpersonal life is a term to describe a hybrid life which integrates the insights of nonduality with the apparent dualities in everyday life. It integrates so to speak the religious and mundane, the personal and the impersonal. Our ‘personal life’ is the story of our egoic personality. The ‘universal’ life, however, is egoless and timeless. The latter refers to the white paper on which our personal story is written. Those who practice Yoga or meditation may have had a taste of this ‘state’ which goes beyond (trans-) the personal realm. Although personal and impersonal seem to be incompatible, we should keep in mind that these two are not separate. Personal life is only a smaller part of impersonal life. A telling metaphor is the wave and the ocean. The wave is the human part of the human being, the ocean is the being part of that term. The wave stands for the story of the person, the Ocean refers to nondual Beingness. And we write Ocean and Beingness with a capital to describe their impersonal, timeless and borderless nature.

This so-called transpersonal adventure originates from the dance between the personal and the impersonal, between the wave and the Ocean. It usually starts with curiosity about the mystery of life, some deep spiritual experience of unconditional love and / or the sense that something fundamental is still missing in life. These are also the reasons why some people go to a temple, synagogue, ashram or church. But here, no dogma is accepted, no holy books are needed, no blind belief is required. We simply rely on direct experience. We start from a very basic idea, the childlike wonder of being. Just the sense ‘I am’. What do these two words really mean? Are we appreciative of our existence or do we take life for granted? Only a few people wake up in the morning with the thought, “I am grateful that I exist”.

Our conditioned mind doesn’t like such a statement. The egoic mind will reply, “Yes, I am alive, I exist, but I am suffering from back pain. And I might lose my job next year. I have other things on my mind than appreciating my aliveness. And I don’t see the benefits of that gratitude”. These are the typical reactions of the conditioned egoic mind. Most of us have such voices in our heads. The egoic mind is a master in ruminating and complaining - usually by creating all sorts of doom scenarios. And these narratives show up without any invitation. We describe these voices as the parrots in our heads. These parrots repeat the ideas, stories and dogmas we have learned from parents, grandparents, priests, friends, teachers at school and also from books, movies, newspapers, television programs, websites and social media. We are not referring here to practical knowledge like geography, mathematics and the weather broadcast because that information is neutral and practical. We are pointing to recurrent thought patterns which are always labelling everyone and everything. Usually, these voices are not bringing us inner peace and contentment but rather a sense of lack, separation and frustration. These voices are usually based on judging, expecting and comparing-not on observing with a clear unconditioned mind.

But what is this Beingness then? It is impossible to describe and yet it is everywhere. Nobody is excluded from being, no matter if one is a Buddhist, Christian, Muslim, Hindu, Jew or atheist. The ‘I am’ is universal. This being is so simple and so available without any effort, and yet it is usually overlooked because we are distracted by the voices in our head. A transpersonal life starts from the insight that the voices in our head are overshadowing ‘our’ Beingness. And this view can give us neutrality, stability and inner peace. This is also one of the major themes in nonduality.

But we may end up in a cold state of mind, which is sometimes found in certain nondual traditions where everything which is personal is neglected or suppressed. When we realize that our essence-Beingness-is the same in all human beings, something else may become clear. We describe it as the awakening of the universal center in the chest. Nonduality is not only understood but it is also ‘felt’ in the heart center as a deep sense of completeness. We first recognize the Heart in ourselves as a vibrant openness and then we realize that this same Heart is residing in the chest of every other human being we encounter. This Heart is like one universal Space. And we are not referring to the heart as an organ nor to the turmoil of personal emotions. It is a Space that doesn’t exclude anyone. This felt recognition is a good basis for a natural sense of unconditional love and compassion for everyone. Contemporary Buddhist teachers such as the Dalai Lama and Thich Nath Hanh are beautiful reminders of the full blossoming of the Heart center.

But the Heart is apparently covered up in most individuals by past experiences when the heart was injured when we were young. So, when our hearts start to blossom, we may in the beginning encounter several old injuries coming up, like feeling unloved or excluded. What has been suppressed for decades, may now suddenly come to the surface. When the heart area is more or less free from these, the flowering of the heart can be palpable.

Sometimes the nondual recognition can sink in even deeper. Then the embodiment is reaching the level of the belly. This may create a grounded sense of gratitude for the intrinsic power of life itself. When the belly is opening up, we may encounter old somatic contractions coming to the surface, such as feeling frightened, unsafe or unworthy. When the belly is more or less free from these, there is a natural sense of deep contentment and a joy for no reason [1].

When being witness of clarity in the head, compassion in the chest and a contentment in the belly, we should not take these personally. These are only descriptions of experiences which come and go. They are not personal experiences in the traditional sense but perfumes of the embodiment of nondual wisdom. They are transpersonal expressions of That which can never be felt, seen or described. The egoic mind has no access here. All these phenomena come and go, but the pure Beingness cannot come and go. And that impersonal Beingness is what we really are. It is fully present right now, even when we don’t sense its presence in the heart or belly. Nothing is ever lacking. And that is exactly what [1] nonduality is pointing to.

To read more about this article: https://irispublishers.com/wjypr/fulltext/transpersonal-life-the-embodiment-of-nonduality.ID.000534.php

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[journal-of-yoga]

Iris Publishers - Happy Easter

[journal-of-yoga]

Iris Publishers - World Journal of Yoga, Physical Therapy and Rehabilitation (WJYPR)

The Ground Baking Coffeermation and Its Aftermaths

Authored by Sir Pa Capona

Introduction

The pillars of motivation and well-being are founded on an ancient and venerated substance, coffee. You can toast us on this on. There are no theory to date that can Disbrow it. Not even if you change the grinding degree. In that regard, if anyone does it once more, I will certainly throw a temper tantrum. Even if it would be a mocha tempt. I will express it here once again, do not change the grinding degree. Another solo event and you would see doppio, sent to a drip to outer space. In this publication, we present a ground baking confirmation of a brand-new machinery for confit preparation (Figure 1).

No Further Words Needed

Software

The embedded software won’t ever give you up, won’t ever let you down, won’t ever run around and dessert you, for it is the uttermost stable software thy eyes will have ever grazed upon. Cofveve is its name and it shall be chanted across the ages. Its backup system via email is a feature even Steve J. would be jealous of.

The ancient writings on the walls of the CoffeestaSion are part of a native language that was spoken in the Republic of Valais (which was independent at that time, what a bless). É pëntchyè che mèton choïn à béire refers to the state of the coffee machine responsible after an unexpected change of the grinding degree; literally, it means Café owners start often to drink. Another inscription, Bâ lè làrme, refers to the user’s state after having used the machinery. A state of pure bliss. Literally, tears down under where flowing at a fast rate is omitted for better sounding. Finally, Bâle-me oûna tàssa de café is straightforward to decipher, it means Give me a cup of coffee, referring to the primary use of the whole setup [1-6].

Result

Be ready for an exhilarating experience like you have never had before. THE best coffee on campus awaits you at a fingertip. From solo to sharing a doppio, through having a doppio for yourself, the user interface reacts at any single touch in a smoother way than the cream of your coffee. You can even turn on and off the machine during weekends, what a revelation. The embedded box lets you slip in cash, for easy payment (you just need then to register it yourself via a simple menu).

To read more about this article: https://irispublishers.com/wjypr/fulltext/the-ground-baking-coffeermation-and-its-aftermaths.ID.000533.php

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[journal-of-yoga]

Iris Publishers - World Journal of Yoga, Physical Therapy and Rehabilitation (WJYPR)

SUNRISE - SUNSET - A Personal Reflection on Aging and Staying Healthy Through Daily Yoga and Qigong Practice

Authored by Warren B

Introduction

I began my study of Eastern Healing and Martial Arts in 1969. Since that time, I have immersed myself in a continual and progressive study of various forms of Eastern healing practice, internal and external Martial Arts, and the philosophical writings which underpin them. Nowadays, I am considered a Qigong ‘Master’ and an experienced Yoga practitioner / teacher.

I grew up in England but have now lived in Canada for nearly 40 years. By and large, I have adjusted to the rhythm of the seasons and the much harsher winters here. I have always tried to practice outdoors, as close to natural surroundings as possible, partially because of research on the benefits ascribed to practicing outdoors [1] and because I enjoy the tranquility.

In addition to my Eastern studies, I have studied and read widely on and utilized Western Healthcare Best Practices. In my own personal practice, I pay attention to the connections between the two approaches to health, as they often have much in common, and I emphasize these similarities and connections in my teaching.

Over the years my daily practice has had to change, to accommodate my general aging process and several physical injuries I have sustained. In this short article I examine some of the problems

I faced, and continue to face, and some of the changes I decided to make in my own daily practice, to adjust to these problems so that I may continue to remain healthy as I age.

Same-Same but Different - Some Connections between Yoga [2] and Qigong [3]

Several scholars have suggested that the origins of modern Qigong may be found in Buddhist and Yoga meditation techniques, practiced in India for thousands of years, that were brought to China and absorbed into the Chinese culture. Special mention is made of Bodhidarma (Da Mo), a Buddhist monk, who came from India around 500 A.D. to the Shaolin Temple in China. While this is probably an over-simplification, there are many connecting historical and practical threads between the two practices.

The modern practice of Qigong and Yoga have much in common [4-5]. They are:

• Ancient Eastern forms of exercise

• Involve whole body postures that also engage the mind

• Emphasise breathing techniques

• Teach awareness of body and mind

• Move energy and invoke a meditative state

• Promote overall health and spiritual awareness

Cross Training an Eastern Approach to Daily Practice

Over the years I have studied, practiced, and taught literally hundreds of Martial Arts, Qigong, and Yoga exercises. Around 10 years ago, after a period of focussing primarily on Qigong and Martial Arts, I began to reintroduce Yoga exercises into my weekly routines.

I build my weekly practices around rotating - Qigong/Martial Arts Sets and exercises, with standing, wall and counter-based Yoga stretches. All the sets I practice include mindfulness and meditation. Every day I use different sets and combinations of these Qigong and Yoga exercises in 2-3day rotations. This allows me to cross train my body, working different sets of muscles and strengthening different physiological and immunological facets of my body.

Cutting Your Coat According to Your Cloth Adapting Practice to Aging and Physical Changes

In 1982, I severely injured my spine from a fall. This injury exacerbated neck and knee injuries sustained from playing full contact sports when was younger and thought I was immortal!

Twenty-five years later, I injured my hip. The issue was in part age related but mainly it was aggravated by sitting and driving 50 kms each way to work every day. This created new problems with both knees. I went to see a physiotherapist, who was also my Qigong student at the time. After each session she sent me home with a set of Yoga exercises [6] which I often adapted based on my own knowledge. As mentioned above, these helped me reconnect to the Yoga I had studied several years before.

In 2016, at age 63, I retired early after 35+ years of working as a University professor. Almost overnight, I was no longer running up and down stairs several times a day, nor was I teaching 3-5 hours of movement classes weekly, nor simply walking to and from work. I was doing less daily unstructured physical activity, something that has long been linked to increased risks to health and mortality [7- 11].

Very soon, I found that aging and retirement had taken their toll. There were exercises that I used to do easily that I could no longer accomplish. My reduced level of activity, coupled with my love of cooking and eating, meant that my weight crept up.

Unfortunately, even five extra pounds made my back and knee injuries worse. Some days, simply getting up and down from the floor for yoga was a challenge. Then, after a vacation, where I drank and ate more than I probably should, the extra weight triggered a major irritation of my old spinal injury. This in turn caused problems in my hips and I lost feeling in my right leg.

This was the catalyst where I decided I had to take positive action and put my over 50 years of training and research to good use. I had to lose weight and keep it off.

In terms of cooking and eating, I started to measure ingredients more carefully, reduce alcohol consumption, and be especially conscious of food portion size. More importantly, I decided to redesign both the content and patterns of my daily exercise practice, as they were obviously no longer working.

Curly’s Rule Do the One Thing Well! Choosing Exercises that Meet Your Needs

I began to streamline my daily practice to better follow Curly’s rule: Do the one thing well! Enabled by the time afforded me in retirement, over the past four years I have worked to identify exercises from my vast repertoire that better suited the realities of aging and that took account of my various injuries. When I had several that did basically the same thing, I chose the best exercise for each intended outcome.

I also did extensive research on current best practice to treat my ailments, and on other people’s exercises and their purported health benefits. I selected several exercises to explore. If I was able to perform them adequately, and they fit my needs, I integrated them into my practice.

Through this process of research, contemplation, and practical exploration, I continue to cross train my body but from a vastly reduced Qigong and Yoga repertoire of exercises and sets [12]. More details about these exercises, and their benefits, may be found in previous publications [13-16].

Yoda’s Rule There Is No Try: Self-Discipline and Finding A Space to Practice

I am very disciplined. I try to perform my daily practice at least once a day. While not always successful in this goal, I have generally averaged 4-5 times a week throughout each year. Some days, when I am feeling “blue” or,” under the weather” - I have to force myself to practice. For I know these are the days I need the practice most!

No matter the weather or the location, I perform my daily practice. Whenever possible I try to find parks or green spaces in which to practice; or failing this, to look at.

On vacation, I will bring my yoga mat or use a blanket to do my floor-based Yoga practice. If available, I use the balcony of my hotel room to perform my Qigong and Martial Arts sets. If the room doesn’t have a balcony, I practice indoors clearing furniture to create space. I look out the window, which I open if possible. Ideally, I like to face trees or water, but I practice in whatever space is available, no matter how urban or obstructed the view, or how small the room (in Paris I once practiced in a room in which I could barely walk around the bed).

Sunrise-Sunset: Changing the Rhythm of Daily Practice as One Ages

In my late thirties, I began to realize that my exercises, sets, and sequences were no longer producing the same effects. I began to change my daily practice and have continued to revise and restructure my practice routines every few years. As I have continued to age, and to accommodate to physical restrictions created by weight change and injury, I continue to revise and change.

The location(s) for my practice

• I have stopped going outside during rainy or windy conditions, and Canadian winter.

• Several ancient texts advise against practising in these adverse conditions as it “leaches chi”.

• i.e. you expend almost as much energy to keep protected from the elements as you create from the exercises being performed.

• Also, some days I felt it took almost as long to put on enough layers of clothing to keep warm or protect against the wind as it did to practice.

The timing and frequency of my daily practice

• When I was working, I tried to do my morning practice ONCE a day for 50-80 minutes. VERY early every morning, before having breakfast and leaving for work.

• Currently, most days I practice Twice a day usually.

• 25-40 mins in morning.

• 25-40 mins in early evening.

• However, I do not stress about performing my daily practice.

• At a particular time.

• If I get up later, I do not stress about “getting my exercise in” but rather do my morning practice when I feel like it.

• Twice a day.

• If I only manage one session in a day-so be it.

My sets and exercises

• When I was working, I did more martial movements.

• I would practice Bagua/Taiji/Kung Fu twice as much as I did Yoga and Qigong.

• Since retiring I have reduced the emphasis on these martial forms and increased my Yoga and Qigong. Now I place.

• Less focus on locomotion / moving exercises.

• If I need to move, I go for a walk around the neighborhood [17].

• More emphasis on stationary, stretching, and core exercises.

• Even when I do practice moving, martial and physical exercises, I focus on my breathing patterns.

Start from Where You Are

Many people take up Yoga and Qigong as they grow older to try to stay healthy. Qigong and Yoga can be done almost anywhere. Both provide a thorough, non-stressful, and extremely low impact work out for the whole body which requires no special or expensive equipment. Often, people post the accomplishments of their daily practice online. These pictures, especially of beginners and older people, can inspire and encourage others.

However, there are also posts by very fit and healthy individuals of themselves performing extreme postures that focus on the intense physical nature of advanced asanas, or the martial aspects of Qigong. These emphasize physical prowess over ideals of health promotion, spiritual enlightenment, or union with the divine. Worse yet, they may persuade others to try feats beyond their capabilities, which could end in injury.

My Revels are Not Yet Ended

Over the years, and throughout my aging process, I have found that integrating Yoga And Qigong together has helped to strengthen my body, reduce my stress levels and enhance my sense of wellbeing. Currently, according to my doctors, I am an extremely healthy 66-year-old. I have never required an operation and am on no medications for any of the conditions often associated with aging. I have rarely been sick and on the few occasions I have been, I bounce back faster than normal.

While some of this may be good genes, I attribute my current health to a lifelong healthy lifestyle; a large part of which has been my daily Qigong and Yoga practice. I feel I am a living testament to the value of these exercises.

However, dealing with the inactivity of retirement, and all the extra financial, physical, and mental challenges this has created, has been difficult [18]. I have tried to adjust as best I can. Now, for health reasons, I watch what I eat and try to keep my weight within a manageable target range - because I have found that even five extra pounds aggravates my old injuries.

As I age, I have come to be more relaxed and smarter in my daily practice. I do not try to emulate individuals’ practice posted on social media. I continue to accept my aging process and simply adapt my practice to my changing situation, as best I know how. I can highly recommend this approach to others.

To read more about this article: https://irispublishers.com/wjypr/fulltext/sunrice-sunset-a-personal-reflection-on-aging-and-staying-healthy-through-daily-yoga.ID.000532.php

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[journal-of-yoga]

Iris Publishers - World Journal of Yoga, Physical Therapy and Rehabilitation (WJYPR)

Yoga and Its Effect on Glycemic Control and Oxidative Stress in People with Type 2 Diabetes in A Randomized Trial: Systematic Review and Meta-Analysis

Authored by Rashmi Shiju

Introduction

Diabetes mellitus is a progressive disease affecting large numbers of the people globally. According to the International Diabetes Federation (IDF) Atlas 9th edition, globally 463 million adults are affected with diabetes, and is estimated to rise to 700 million by 2045 without intervention [1]. Managing diabetes can be challenging and requires a multifaceted approach involving lifestyle changes and pharmacological intervention. People with diabetes do not infrequently use complementary and alternative medicine (CAM) with estimates ranging from 17% and 73% and involved lifestyle modification, yoga, qi gong, massage and herbs [2]. Yoga is the most common alternative holistic approach adopted by adults in many countries. According to national survey in the US, yoga use increased from 9.5% to 14.3% between 2012 and 2017 [3]. Yoga originated from India has been a traditional contemplative practice since time immemorial for the therapeutic intervention and health maintenance [4]. Yoga may be beneficial in almost all the ailments. [5-11]. It may have positive impact on endocrine system, nervous system, circulatory system, metabolism, psychology and cognition [12]. Yoga has also been shown to influence hormone regulation and studies suggest that regular practice of yoga can reduce cortisol and sympathetic activation while increasing serotonin, gaba aminobutyric acid (GABA) and oxytocin levels. [5,7,13,14]. This may in turn reduce anxiety, depression, perceived stress and improving sleep quality and male sexual functioning [15]. Yoga may have beneficial effect in people with T2DM, in terms of modifiable risk factors and metabolic syndrome [16-24]. The systematic review by Innes et al. [25] measured the influence of yoga-based programs on risk profiles in adults with type 2 diabetes. The review indicated that yoga may help in reducing the risk in adults with T2DM. The author also indicated that there are limited reviews to show the promising effect of yoga on psychological profiles in adults with diabetes. The systematic analysis by AlJasir et al. [26] showed that short-term benefit can be achieved by T2DM patient with the practice of yoga were however inconclusive and non-significant for the long-term outcomes of yoga practice. A systematic review and meta-analysis by Harpreet et al. [27] indicated that yoga participants successfully improved their glycated haemoglobin (HbA1c) as compared with the control people. Yoga also had significant improvements in lipid profiles, blood pressure, body mass index (BMI), waist/hip ratio and cortisol levels. A systematic review by Divya et al. [28] on effects of yoga on physical health and health related quality of life concluded that there were significant improvements in physical health and quality of life. In another systematic review and meta-analysis by Ramamoorthi et al. [29] reported significant improvements of yoga on glycaemic control, serum lipid profiles and other parameters in prediabetic populations. The present systematic review and meta-analysis will focus on patients with T2DM conducted through randomized controlled trials (RCTs) with yoga intervention such as Sudarshan kriya yoga, asanas, pranayamas and hatha yoga with duration at least four weeks. This review will give more focus to specific type of yoga intervention and its effect on glycaemic control, serum lipids and stress biomarkers. To our knowledge, this will be the first meta-analysis on oxidative stress markers.

Methods

Study selection criteria and PICOS

Cochrane review guidance was followed in conducting the systematic review [30].

Population for this systematic review was defined as:b> Adult patients aged 18 years or greater having T2DM for more than one year confirmed by a physician based on the guidelines for diagnosis of T2DM. Exclusion criteria included ;studies on infants and children, gestational diabetes, pregnant women, non-diabetic patients, type 1 diabetic patients, complication of diabetes and studies with herbal drug intervention.

The intervention included:b> any type of yoga (hatha, bikram, iyengar, sudarshan kriya yoga, pranayama, astanga, asanas), and minimum four week of duration of yoga. Comparison was control groups receiving standard treatment of care.

Outcomes:b> The primary outcomes were changes in fasting plasma glucose (FPG) and HbA1c. Secondary outcomes included changes in serum high density lipoprotein (HDl), low density lipoprotein (LDL) and total cholesterol, BMI, stress biomarkers and quality of life.

Study design: Only randomized clinical trial was selected for inclusion.

Database search strategy

The search strategy was implemented in ; Pubmed, Embase, Scopus, Cochrane, Medline, CINAHL Plus were searched using the key words “Yoga OR asana* OR Bikram OR Iyengar OR pranayama OR hatha OR ashtanga OR Sudarshan Kriya Yoga AND diabetes OR diabet* OR non-insulin dependent OR diabetes mellitus OR T2 DM OR Type II diabetes mellitus”. Apart from the database, the bibliography of the articles selected were also searched. Limits applied were for age greater than 18, articles published from 1990 to 2015, English language. Moreover, an internet searching was done through Google Scholar and also clinical trial.gov website for randomized controlled trials. Literature on systematic reviews and metaanalysis of yoga and diabetes published until 2019 were included.

The results obtained from searching each electronic database using the above-mentioned key words were saved in the computer and online End Note in order to keep a track of all searches which included number of hits, database name, time period searched, limitations applied. The results of search from each database also exported to Excel to sort out duplication and based on the eligibility criteria of systematic review.

Data extraction and screening

All the six databases were searched with key words mentioned and then screened for duplicates. The title and the abstract were screened for relevance. Full text articles were then scanned according to the eligibility criteria. The details of the number of articles excluded with reason are depicted in the flow chart (Figure 1). The results obtained from the database were extracted using the extraction form (Appendix I).

Quality assessment

A short scale of seven criteria customized to yoga studies were used to assess the quality of the included studies established by the Cochrane collaboration [30].

Following questions were included in the quality checklist:

• Whether participants were randomized to groups randomly or through software or independantly.

• Were the baseline characteristics of the study groups properly assessed or there was any correction done to balance.

• Whether the study has calculated sample size through power analysis.

• Whether the study has considered loss of follow up, attrition.

• Whether the study had properly handled the missing data by using intention-to-treat analysis,

• Study integrity; was the study followed as planned.

• Whether the study was conducted with certified progessional yoga instructor or not. Each criterion was rated as 0(study does not meet criteria) or 1 (study met criteria).

When a criterion meets six or seven points then the study is assessed as high quality and when four or five criteria were mint then assessed as low and very low when zero or one criteria were met. Data collected were assessed for the quality of studies based on the quality criteria. If a trial meets first three criteria, then it is categorized as low risk of bias. (Table 1).

Data Analysis

Meta-analysis of the eligible studies was conducted using statistical RevMan software measuring the mean differences using the generic inverse variance method of analysis. Meta-analysis was performed for HbA1c reported as a percentage and FPG reported as mg/dl. When the units for reported values of FPG in the articles differed, the units were Mmol/L they were converted into mg/ dl by multiplying the mmol/L value by 18. The generic inversevariance method of analysis was used to pool all mean differences for continuous data and for combining intervention effect estimates reporting results from fixed-effect and random-effects models. Statistical heterogeneity was assessed using the I-squared statistic. Mean difference was calculated for the yoga group and the control group. Standard deviation was also extracted from the reviewed articles. Standard errors were converted to standard deviation were appropriate.

Results

Characteristics of the studies

1201 titles and abstract were identified and, nine trials met the eligibility criteria that included 788 participants. Characteristics of included trials depicted in Table 2. Four trials (44.4%) reported HbA1C as primary outcome. Seven trials reported FPG an outcome but only one trial (11.1%) reported serum cholesterol, LDL, HDL triglycerides as an outcome. Two trials (22.2%) reported quality of life as an outcome. Most trials (55.6%) practiced three months of yoga as an intervention whilst this ranged from eight weeks to nine months in the remaining trials. The duration of each yoga class also varied between the trials from one and two hours.

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[journal-of-yoga]

Iris Publishers - World Journal of Yoga, Physical Therapy and Rehabilitation (WJYPR)

Meditation for Health, Happiness, and Meaning-Making

Authored by Ani Kalayjian

“Meditation” in its modern sense refers to the yogic meditation that originated in India. In the late 19th century, theosophists adopted the word “meditation” to refer to various spiritual practices drawn from Eastern religions such as Hinduism, Buddhism, and Sikhism. Thus, the English word meditation does not exclusively translate into any single term or concept. Meditation has been helpful to reduce stress, reduce symptoms of Post-traumatic Stress Disorder (PTSD), as well as anxiety and depression. Meditation is an ancient practice that has been in existence for centuries, but only in the last two decades has scientific research supported its usefulness and effectiveness. This article will provide an overview of the benefits of meditation for those traumatized, as well as share its general benefits.

Through breath, meditation links our body with our heart and mind, providing emotional self-mastery and mindfulness. Mindfulness helps us practice self-love. Love is the center and the pendulum of duality swinging back and forth from positive/ negative, masculine/feminine, light/darkness, yin/yang… Remember, throughout the course of existence, we have swung farther and farther into the realm of polarities.

All disciplined religions incorporate some form of meditation. Meditative quiescence is said to have a quality of healing and of enhancing creativity. The Prophet Muhammad spent sustained periods in contemplation and meditation. It was during one such period that he began to receive the revelations of the Qur’an.

There is an abundance of research studies indicating the effectiveness and usefulness of meditation for relaxation, stress reduction, cognitive decline, reduction of anxiety, and PTSD related disorders. A recent research study conducted by [1] looked at how meditation impacted adults ages 55-90. Results showed that 8-week meditation significantly improved retrieving memories, decrease atrophy in the hippocampus, and decrease anxiety and stress.

Seventy years ago, the United Nations was founded on the principles of dignity, peace, justice and cooperation. UN’s Secretary- General Dag Hammarskjold stressed the relevance of these values stating: “Unless there is a spiritual renaissance, the world will know no peace.” There is a special designated room for meditation at the United Nations, and Mr. Hammarskjold, Delegates, Ambassadors and Non-Governmental Organization Representatives frequent the meditation room before important meetings.

Meditate for Peace by [2] indicated that 7000 people got together and meditated-- and global terrorism went down by 72 percent. Similarly, dramatic decreases were seen in war, fatalities and violent crime. Of course, there are always skeptics who want to argue about whether or not this is “real,” the fact is that those who meditate have reported improvements in their lives.

This positive impact of meditation has been documented in numerous peer-reviewed publications, including the Journal of Offender Rehabilitation. According to several research studies, mindfulness meditation -- a practice that encourages focusing attention on the present moment -- can ease emotional stress. And evidence is mounting that mindfulness also may have key benefits for physical health from lowering blood pressure to helping curb addiction. A new study conducted by researchers working in Wisconsin, Spain, and France shows that mindfulness can even affect our genes. Specifically, the study shows that mindfulness can limit the “expression” of genes associated with inflammation.

A recent National Institutes of Health (NIH) grant proved meditation’s effectiveness in generating alpha brain waves, which are relaxing and conducive to the sleep state. When our mind is tranquil and serene, our body then follows the mind’s lead and relaxes, thereby releasing fears and creating a metabolic state that is tranquil and pure consciousness. This state is not only free of fear and pessimism, it’s also a more optimistic state that heightens problem-solving skills and promotes an expanded view of the world in which we live and our role in it. A review of scientific studies identified relaxation, concentration, an altered state of awareness while suspending logical thought, and the maintenance of a selfobserving attitude as the behavioral components of meditation; this mode is accompanied by a host of biochemical and physical changes in the body that alter metabolism and decrease heart rate, respiration, blood pressure, and brain chemistry. Meditation has been used in clinical settings as a method of stress and pain reduction [3]. Meditation has also been used to reduce stress.

According to the 2012 National Health Interview Survey (NHIS), which included a comprehensive survey on the use of complementary health approaches by Americans, 17.7 percent of American adults had used a dietary supplement other than vitamins and minerals in the past year. These products were the most popular complementary health approach in the survey. Approximately 8% used meditation.

Meditation is used widely for traumatized individuals. ATOP Meaningfulworld Humanitarian Teams have used meditation in over 45 countries around the world with great success, meditators stating: “I came in with a headache and after the meditation my headache is gone,” “I had a pressure in my chest, feeling short of breath from my trauma, now after the meditation I feel the pressure is released,” exemplified some of the responses.

Research conducted with veterans’ to address the levels of PTSD. Interventions included yoga [4], meditation and mindfulness based cognitive therapy [5]. Results indicated a statistically significant reduction of stress and anxiety (Stoller et al. 2012), daytime dysfunction and Hyperarousal (Staples et al, 2013), decrease of depression [6].

Meditation has been integral in all deliberations in the Association for Trauma Outreach & Prevention (ATOP) at Meaningfulworld. Meditation is utilized at the beginning and end of all our monthly training and empowerment programs as well as at all of our humanitarian global outreach projects in more than 45 countries. Although most religions incorporate some form of meditation, at ATOP Meaningfulworld we focus on the healing and integrative aspects of meditation and its mind-body-eco-spirit effect, and therefore, it is not based on any religious foundation.

ATOP integrates meditation in the final stage of the sevenstep healing framework, in the 7-Step Integrative Healing Model (Biopsychosocial and Eco-Spiritual Model). At ATOP Meaningfulworld we use meditation to reduce stress in the central nervous system (CNS) and to strengthen the immune system. Our mind wanders and moves inward and outward like a pendulum: When we are able to relax the CNS, we are relaxing our mind. Of course, relaxation is challenging for many individuals, since we live in a culture that over-identifies with production and volume of doing, rather than being mindful and conscious.

Breath is the foundation and center of any meditation. This is very essential for traumatized people, when they experience shallow chest breathing, and shortness of breath. Based on the fight-freeze-flight protection system, our past traumatic history may have inhibited complete expression of our breath. When we start breathing deeply, diaphragmatically, or through our belly, we bring the breath below the chest and lungs, we are able to heal the remaining suffering of old trauma, we are empowered – we establish a healthy distance between the traumatic memory and its effect on our emotions and our physical body [7-9].

Meditation also helps us ignite the fire within, activating our passion and love for humanity and Mother Earth. In order to create fire, we need two things: oxygen and fuel. Oxygen intake and distribution improves with meditation. Oxygen helps us expand our thoughts, concentrate on the important, and relax the joints, muscles, and all of our internal organs. The fuel is our passion and commitment to serve ourselves, our families, and the human family at large.

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[journal-of-yoga]

Iris Publishers - World Journal of Yoga, Physical Therapy and Rehabilitation (WJYPR)

Mutation Induction, Detection and Breeding to Resist Viral and Fungal Diseases and Thermal Extremism for Vegetables

Authored by Yousif DP

Opinion

To artificially induce hereditary changes in plants, either physical or chemical agents are used. Ionizing radiation is a widely used physical agent to treat the seeds and other crops plant material to create heritable mutations. On other means, one of the most important breakthroughs in the history of genetics was the discovery that mutations can be induced by physical and chemical mutagens (agents that change the genetic base of an organism). Mutation induction, together with mutation detection a key element of mutation breeding, has been an important tool for plant breeders for more than 70 years to increase the genetic diversity of plants and derive new mutant lines with improved characteristics.

Generally, mutations are a result of large-scale deletions, inversions or translocations of chromosomes, or from point mutations (a type of mutation that causes a single change, insertion or deletion of the genetic material) in the DNA. Physical mutagens most often result in chromosome changes and larger DNA deletions while mutagenic chemicals typically cause point mutations. The degree of mutation also depends on the tissue and the time and dosage of exposure. DNA mutations are generally of the most interest to breeders.

Ionizing radiation, a Physical mutagen, mostly, can increase the natural mutation rate by 1,000 to 1 million-fold, and commonly used to induce heritable genetic changes. Since the 1960s, X-ray and gamma rays with a cobalt-60 source, have become the widely used mutagenic agents in plant mutation breeding.

The next step in mutation breeding is to detect which plants have indeed produced the desired new traits. The detection of novel induced mutants presents a major challenge because it occurs with low frequencies which requires the creation of very large mutant M1 population. It is very important how-to asses and select the useful mutants that have developed a new desirable trait mutated plant.

Collaboration between the FAO and IAEA in joint projects results to develop and adopt nuclear-based technologies that optimize mutation induction practices, with the goal to intensify crop production and preserve natural resources.

Screening protocols, such as for salt and drought tolerance screening methods or disease screening protocols, are efficient methods and practical tool for mutant phenotyping detection and breeding. Recent detection technologies have increased the efficiency of identifying the DNA changes that generate a new trait. TILLING (Targeting Induced Local Lesions in Genomes), allows directed identification of mutations in a specific gene. Detection of novel induced mutations has long been a bottleneck in plant mutation breeding. Screening for desired traits in plants and section practices increased and accelerate the development of mutant lines into commercial varieties.

Mutation Breeding

Mutation breeding is the further step of mutation induction and mutation detection. It has many comparative advantages: it is cost effective, quick, proven and robust. It is also transferrable, ubiquitously applicable, non-hazardous and environmentally friendly. More than 3,200 mutant varieties – including numerous crops, ornamentals and trees – have officially been released for commercial use in more than 210 plant species from over 70 countries (FAO/IAEA Mutant Varieties Database).

Plant biotechnologies play an important role in mutation breeding. Plant tissue culture techniques are powerful tools in shortening the time needed to generate breeding mutant lines. This is a bottleneck for the exploitation of induced crop mutations that are recessive (in genetics, when one characteristic of a gene is not expressed because a more dominant one is displayed).

Project planning

Virus diseases became limited factor for vegetables production in Iraq. However, the virus host became available continuously and so causing high yield loss seasonally.

Tomato is an important crop which occupied an advanced degree in food demand all over the world and in Iraq is the first one of vegetables. There is many reasons consider a limited factor of this crop productivity. Virus infection especially Tomato Yellow Leaf Curl Virus (TYLCV) is in the present of the main problem and may lead to high or full losses of yield in some years. High temperature degree in summer which rise to about 45 -50o causes reduce flowering and fail of setting and so lead to high yield losses.

Potato also severe of many devastating virus diseases causing high productivity reduction annually, which indicates the urgent needs to reproduce of virus free tuber continuously to avoid their continuous concentration excess with successive generations. The shortage of thermal moderation period (20 -25°) which is suitable for potato growing, and tubers production beginning after one month of emergence in March to last of May in spring, and in October to half of December in Autumn cultivation.

Eggplant and pepper are important crops for food and health. Virus diseases such Eggplant and Pepper Mosaic became also a limited factor of production, in addition to the grey mold and white mold caused by the fungus Botrytis cinerae, and Sclerotinia sclerotiourum are important, especially in plastic houses. High temperature degree in summer causing to slow plant development, fruit growth, flower falling, and weak setting.

Searching for varieties or variants having resistance, or moderately resistance, or tolerance, or slow virus or fungus disease development became of high importance to avoid the negative impact of these diseases. Irradiation of seeds or tuber buds and plant tissue culture are of the important ways to induce genetic variation and developing short plant growth period or suitable for thermal extremism. This project including the following main subjects which presents the target project objectives:

• Determining of the mainly devastating virus and identification of their virulent strains.

• Testing of all available varieties of each crop to its important viruses’ strains and determines their different level of resistance, or tolerance, or slow symptoms development.

• Irradiation of seeds, or tubers, or tissue cultures of the selected varieties to induce new resistant traits and/ or new mutant cultivars.

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[journal-of-yoga]

Iris Publishers - World Journal of Yoga, Physical Therapy and Rehabilitation (WJYPR)

A Retrospective Study of the Correlation Between Hand Grip Strength and Functional Outcomes for Clients with Shoulder Pain

Authored by Andrew Ryan Lum

The upper extremity is comprised of the shoulder complex, arm, forearm, and hand [1,2]. For the upper extremity to function in all ranges and across all tasks, muscle and joint structures need to work well collectively. Deficits in one muscle or joint structure may therefore lead to changes in movement, strength or function in other joints or in overall functional status [3].

Upper extremity performance and functional mobility is better, when the shoulder is stable and pain free [4]. Shoulder pain is the third most common musculoskeletal condition with incidence ranges up to 2.5% [5]. These proximal aspects of the upper extremity can affect functional performance of the hand [6]. Hand grip strength has been found to correlate with strength of other muscle groups and thus can be utilized as a good predictor of overall upper body strength as well as identify people at higher risk of physical disability [7-11]. Grip strength tends to increase into the fourth decade of life while declining at an accelerated rate thereafter [12]. The right hand is characteristically stronger than the left and men typically have higher grip strength than women in the same age range [13].

Changes in shoulder position, health, and integrity have adverse effects on grip strength [2,4,6,7,10,14]. During grip strength testing, the muscles of the rotator cuff help stabilize the humerus4 as well as maintain scapular position in an ergonomically protracted state [6]. While the scapula is protracted, increased activation of muscles surrounding the scapula such as the serratus anterior, upper trapezius, as well as the flexor carpi ulnaris, flexor carpi radialis, and palmaris longus is observed and can further influence and improve grip strength measures [6]. When there is dysfunction in these muscles, through observation of decreased scapulohumeral rhythm and in combination with poor scapular position throughout movement, grip strength can reduce 13.14% in comparison to its norm for the individual [6]. Subsequently, fatigue in the upper extremity following a shoulder exhausting regime and recovery time, has led to a decrease in grip strength and was confirmed through electromyography (EMG) results as well as a reorganization of movement strategies [15]. This evidence illustrates a positive relation between shoulder function and grip strength force [10]. Application and utilization of this relationship could help with prediction of disability and functional limitations [9].

We sought to examine the correlational relationship between grip strength and self-reported functional outcomes in this study. In addition, we also sought to describe differences in strength and self-reported function after occupational therapy intervention in an outpatient setting. In our first aim, we examined the change in baseline and discharge scores between grip strength and selfreported function to assess for clinical and statistical significance. In the second aim, we examined correlations between baseline grip and self-reported function scores followed by discharge grip and self-reported function scores. We hypothesized that people with shoulder injury receiving a course of occupational therapy would not only demonstrate significant and meaningful change in these outcomes, but also that the outcomes would be moderately and significantly correlated.

Methods

A retrospective cohort design was used to examine a convenient sample of patient outcomes within an outpatient clinic in the University of Kansas Health System. Institutional Review Board reviews were conducted, and research was granted at both the University of Kansas Medical Center as well as the a Midwest hospital and The University of Kansas Medical Center to a Midwest university. Each recorded patient in this study had completed a full course of occupational therapy, including evaluation, treatment, and discharge within the dates of July 2014 to October 2018.

Inclusion criteria

1) males and females aged 18 to 85, with one of the following shoulder diagnoses per physician report: rotator cuff pathology, acute shoulder pain, and chronic shoulder pain. If the shoulder pain/diagnosis was accompanied by comorbidities not limited to the shoulder, or was secondary to another reason for treatment, the subject would be excluded. Additional exclusion criteria included: a history of neck/back pathology (including physician diagnosed and/or self-report), history of cognitive impairment, history of a neurological diagnosis, history of peripheral nerve injury, previous treatment for the affected shoulder on acute and/or acute rehab units, as well as individuals with balance impairments. Inclusion and exclusion were based upon the medical diagnosis provided by the physician referral, a chart review, as well as through the subjective interview information that was obtained from the patient during their treatment. A licensed occupational therapist (OT) with > 5 years of experience examined and treated all the patients in this cohort. The OT completed all outcome measures at baseline and post-intervention prior to discharge.

Hand strength

Measurement of grip strength was completed using a Jamar dynamometer following standardized procedures9 with the handle in the middle position across a three-trial test. The minimally important clinical difference (MCID) for grip strength from baseline to discharge is between 11.02lbs (5.0kg) and 14.5lbs (6.5kg) [16].

Shoulder Pain and Disability Index (SPADI)

The SPADI is a self-reported questionnaire developed to measure the pain and function associated with shoulder pathology for people with shoulder pain of musculoskeletal, neurogenic, or undetermined origin. It consists of 13 items in two domains: pain (pain symptoms, 5 items) and disability (physical function, 8 items). The items of both domains were scored on a visual analog scale ranging from 0 to 10, where 0 = no pain/no difficulty and 10 = worst pain imaginable/so difficult required help. Each domain score was equally weighted, then added for a total percentage score ranging from 0 to 100, where 0 = best (no pain and functioning normally) and 100= worst (extreme pain levels and complete functional impairment) [17]. The MCID for pre-intervention and post-intervention scores is 13 points [17].

Therapeutic Procedure

To better understand the outcomes, the procedures for assessment and intervention are outlined. An evaluation was completed in the first session of occupational therapy services.

The evaluation consisted of:

• Gathering of background information/occupational profile through a thorough chart review and subsequent interview.

• Measurements of active range of motion with goniometer (shoulder flexion, shoulder abduction, internal rotation, external rotation, and shoulder extension).

• Gross manual muscle testing of the shoulder on a 0 to 5 grading scale (shoulder flexion, shoulder abduction, internal, and external rotation).

• Manual orthopedic testing (e.g., Neer��s Impingement Test, Empty Can Test, Subscapularis Liftoff Test, Drop Arm Test, and Neural Tension Test) [18].

• Grip strength assessment.

• A self-reported rating of function using the SPADI.

Individualized goals were established based on the patient deficits, strengths and goals. Therapeutic interventions aligned with individual injury status and goals. Interventions consisted of therapeutic exercise; therapeutic activity (e.g., the Kinesio Tape Method, patient education); physical agent modalities (e.g., ultrasound, cold packs); Activity of Daily Living retraining (e.g., sleeping posture, bed mobility, overhead cleaning tasks); Instrumental Activity of Daily Living training; and work simulation. No specific grip exercises were provided or recommended.

Data Analysis

Due to the analysis of multiple factors and aims for this study, several statistical tests were run. Descriptive statistics were completed through a comparison of means within the sample (n=31). These statistics were utilized to determine means for age, diagnosis, and visits. Paired sample t-tests were utilized between baseline and post-intervention SPADI scores as well as between baseline and post-intervention affected UE grip strength measures (p<0.05). Spearman’s Rho’s correlation was utilized for examining the relationships between strength and function through baseline affected UE grip strength measures and SPADI scores as well as between the post-intervention affected UE grip strength measures and SPADI scores (p<0.05).

Result

An extensive chart review was conducted on complete patient charts dated from June 2014 to October 2018. Thirty-one patients met study criteria varying in range from 24 to 85 years with an average age of 59.1±13.2 years; 39% (12/31) were male and 61% (19/31) were female. Patients were seen for a minimum of 3 visits and a maximum of 30 visits but averaged 8.32±6.4 visits per treatment course (Table 1). By diagnosis, 55% (17/31) of patients presented with complaints of acute shoulder pain, 22.5% (7/31) chronic shoulder pain and 22.5% (7/31) with rotator cuff pathology, as diagnosed by the referring physician.

Across males and females, the baseline mean grip strength scores were (x ̅=74.9, SD: 32.1 lbs.; Range 10.3-151.7lbs. Mean discharge grip strength scores were (x ̅=82.5, SD: 31.2lbs; Range 33.4-155.3lbs). Pre- and post-intervention grip scores were significantly improved (p= 0.001). Because male and female scores are typically different, we also analyzed grip strength changes between males and females. Mean male baseline grip scores (x ̅=104.8; SD: 22.8lbs) were statistically different (p= 0.019) from mean discharge grip scores (x ̅=114.3; SD: 21.4lbs). Mean female baseline grip scores (x ̅=55.9; SD: 21.1lbs) were statistically different (p=0.029) from mean discharge grip scores (x ̅=62.1; SD: 15.2lbs).

In our second outcome, the mean baseline SPADI scores were (x ̅=37.7, SD: 21.6; Range 11-86). Following the completion of treatment, Table 1 highlights the mean discharge SPADI scores were (x ̅=11, SD: 11.4; range 0-53) which was significant (p=0.00).

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[journal-of-yoga]

Iris Publishers - World Journal of Yoga, Physical Therapy and Rehabilitation (WJYPR)

Sensory Diets

Authored by Vidya Pingale

Mini Review

Sensory diets, a sensory-based intervention, are used by occupational therapists to manage sensory processing disorder (SPD). SPD is prevalent in children with diagnoses, such as autism, attention deficit hyperactive disorder, learning disabilities, fragile X syndrome, and developmental delays [1,2]. Children with SPD show a decreased ability to respond and organize sensory stimuli. As a result, SPD affects their participation in daily activities of self-maintenance, learning, play, sleep, and social interaction [3]. Sensory diets consist of a group of multisensory activities, such as pushing a ball, jumping on a trampoline, pushups, stationary postures. These activities are customized for a child based on his/her sensory processing patterns to provide sensorimotor experiences to help stay alert and organized [4].

A review of the literature on sensory diets in the last 15 years found five studies that investigated the effectiveness of sensory diets or interventions with similar conceptualization. Fazlioğlu, et al. [5] investigated the effect of sensory activities similar to sensory diets on children (n = 30) between the ages of 7-11 years with a diagnosis of autism using a randomized control design. A twogroup analysis of variance after 12 weeks of intervention showed a significant main effect for groups on total scores of the sensory evaluation form (F1,28 = 5.84, p< .05), pretest-posttest test time (F1,28 = 98.38, p< .01), interaction of group and time (F1,28 = 119.38, p< .01), and posttest scores (F2,27 = 167.16, p< .01), suggesting sensory activities can be beneficial in reducing sensory processing related issues in children with autism.

A study by Lin, et al. [6] used a matched group pretest-posttest design to observe the effect of sensory strategies on children (n = 36) between the ages of 3-6 years with SPD. Improvements in activity level (t [17] = 2.09, p=0.03) and feet-swinging (t [17] = 2.26, p=0.02) were noted after 8 weeks of intervention, suggesting sensory strategies can be effective in managing activity level and sensory seeking behavior.

Another study investigated the effect of sensory diets on sensory processing, psychosocial skills, and classroom engagement of children (n = 3) between the ages of 5-8 years with SPD using customized sensory diets. The binomial test results indicate that with sensory diets, all participants showed a significant decline in sensory seeking behaviors during individual (p<.05) and group activities (p<.10). Changes in interruptive or disruptive behaviors were significant for one participant for group activities, and all participants for individual activities (p < .05). Similarly, changes in classroom engagement were significant for all participants for group activities and one participant for individual activities (p < .05). These results favor the use of sensory diets for managing SPD [7].

A study that investigated the effect of a group proprioceptive program on nine-year-old children with SPD (n = 3) using a singlesubject ABA design and found a decline in the duration of aggressive behaviors of two participants and frequency of aggressive behaviors in one participant with nine days of intervention. Binomial test results suggest that the decline was (p< .05) statistically significant [8]. On the contrary, a single-subject alternating treatments design study that researched the effectiveness of sensory diets on children (n = 4) of ages 6-11 years with a diagnosis of autism did not find any improvements in self-injurious behaviors with 10 days of intervention [9]. Results of these studies cast doubt on the effect of sensory diets or similar interventions.

This review suggests that continued research is needed to investigate the effectiveness of sensory diets. Three studies in this review show promising results. However, intervention strategies, protocols, dosages, and dependent variables used in these studies show significant variations. These variations may have led to differences seen in the results of the studies. As it appears now, sensory diets can have a role in managing SPD; however, they should be used judiciously and in alignment with therapeutic goals.

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[journal-of-yoga]

Iris Publishers - World Journal of Yoga, Physical Therapy and Rehabilitation (WJYPR)

YOGA as a Potential Mind-Body Medicine for Circadian Rhythm Restoration for Cancer Patients

Authored by Yu Huei Liu

Short Communication

Cancer patients receiving chemotherapy suffer from a variety of side effects, including insomnia [1], However, the underling mechanisms behind insomnia during and/or after chemotherapy are not yet fully understood. Both cancer and anticancer therapeutics alter the production of proinflammatory cytokines such as sleep inducers TNF-α, IL-1 β and IL-6, to change the immune responses depending on immune cells repertories, which subsequence function on the central nervous system and the sleep– wake rhythms, by which to alter sleep behavior [2,3].

Currently no specific treatment for chemotherapy-related insomnia, nonprescriptive and prescriptive sleep medicines are the only way to choose even though those medications have not been evaluated in cancer patients. On the other hand, although dysfunction in circadian rhythms is a common occurrence in older adults and is a symptom of neurodegeneration [4], studies also suggest that circadian rhythm disruptions might potentially risk for developing neurodegenerative diseases such as Alzheimer’s disease [5-7] and Parkinson’s disease [7,8]. Although the causalrelationship requires to be evaluated in larger and longitudinal studies [9,10], it points the importance to address chemotherapyrelated insomnia to improve patients’ potentials to complete treatment for cancer, the recovery rate, and their quality of life.

 Yoga is the original mind-body medicine that keeps physical homeostasis as well as mental and spiritual harmony in human. Several evidence-based mind-body medicine, including yoga, have been successfully used for the management of insomnia and have demonstrated efficacy in cancer patients receiving chemotherapy [11,12]. Indeed, yoga has been shown to improve sleep quality of chemotherapy-related insomnia especially for breast cancer patients [13-17], however, the underlying mechanism require to be identified. In addition, whether it is potent enough to manage chemotherapy-related insomnia for other cancer patients require further investigation. More high-quality randomized control trials to support the scientific evidence are warranted. This is what we eager to work on

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Literature Review: Trauma-Informed Yoga in Couples & Family Therapy

Authored by Mindy Tran

Couples and family therapists are trained to view the world from a systemic lens, meaning that they practice closely examining our clients’ interpersonal relationships in addition to the clients’ intrapersonal and intrapsychic view of themselves. Understanding our clients systemically means that the therapist pays attention to different aspects of their identities, such as their social location, their past experiences, their support systems, and their identities. Therapists notice how these multiple dominant systems are working simultaneously in order to provide the clients’ internal world with meaning. A primary source that helps therapists better understand the client is by taking in the information that the clients tell us using their own words. As a result, much of mainstream therapy is conducted in the form of a conversation. Unfortunately for many therapy clients who have experienced trauma in their lifetime, talking with a therapist may not be enough to help the client as a whole. In addition to a client maybe having a memory of the past traumatic experience(s) that they experienced, their bodies also went through that same traumatic experience as well. Our clients’ brains are organized in a way that helps us survive in stressful situations, but the outcome of survival may result in our brains prioritizing our past traumatic memories, and our bodies reacting as if those events are occurring again in the present moment Van der Kolk [1] Trauma-informed yoga, or yoga that is taught from a trauma-informed lens, is one solution to incorporating the body into the therapy process since it offers a way for the clients to explore their experiences within their bodies while giving them permission to move at their own pace. By integrating trauma-informed yoga into a client’s treatment plan, therapists are able to begin addressing the client as a whole, offering them the experience of embodied awareness which, over time, can help our clients minimize their post-traumatic symptoms and feel more comfortable with living fully in the present moment.

Theoretical Perspectives on Trauma-Informed Yoga

In a survey that was conducted by Yoga Alliance in 2016 gathered information on individuals across the country who have practiced any form of yoga within the past year, and found that about thirty six million Americans, or roughly ten percent of the country’s population, have practiced yoga at some point in their lives Macy D [2]. Although not everyone has practiced yoga at some point in their lives, yoga is still a household name and yoga resources are widely available to many individuals through local gyms, studios, community organizations, or on the internet. The physical yoga practice is a bottom-up approach that utilizes breathing and movement cues to invite practitioners to tune into the sensations that they are experiencing in their bodies, increasing their sense of interoception Danylchuk [3]. During yoga, the student is led by an instructor that provides various cues that invite the client to observe the ebb and flow of their own emotions while also observing the physical sensations and mental states that accompany them Forbes [4]. By introducing ways that the client can practice feeling into their bodies, they can start to develop embodied awareness where they begin to feel into their experiences in the present moment while also recognizing their own needs [5].

A trauma-informed yoga practice can be used as an intervention when working with clients who are experiencing post-traumatic symptoms because it can help address some of the somatic symptoms in the body the same way that talk therapy can address some of the cognitive issues Emerson and Hopper [6]. The principles of trauma-informed yoga are rooted in traumainformed care principles that were developed by the Center for Disease Control in partnership with the Substance Abuse and Mental Health Service Administration that was intended to help those who are in the service field, under the assumption that individuals more likely than not have experienced some kind of traumatic event throughout their lifetime, to be able to provide the most appropriate and responsive care possible to their clients [7]. Trauma-informed care includes five core concepts: safety, choice, collaboration, trustworthiness, and empowerment. Incorporating these principles into a yoga practice would include ensuring that the class is both physically and emotionally a safe space, utilizing invitational language that allows the client to explore different modifications and postures, working with the students to adapt the class or cues based on the student’s needs, building rapport with the students, and empowering the students to take effective action to meet their needs.

In order to understand how trauma-informed yoga an effective tool can be to use in conjunction with talk therapy, it is important to understand how trauma affects the body. When a person experiences something that is traumatic, meaning that we have experienced something that was unbearable and intolerable that has also taken away our power and control, our brains and bodies will organize itself in a way that will increase their likelihood of survival [1]. During trauma, the body’s natural ability to cope has been overwhelmed and as a result, the body’s sympathetic nervous system, or “fight-flight-or-freeze,” will kick in to prepare the body to react. Over time, if the trauma has not been properly processed by the brain’s prefrontal cortex, the past trauma may begin reappearing during times when the person is otherwise safe and out of harm’s way. The cluster of symptoms that are most common amongst those who have experienced trauma in the past have been categorized as Post-Traumatic Stress Disorder (PTSD) in the Diagnostic and Statistical Manual of Mental Disorders. PTSD symptoms include intrusive symptoms including nightmares or flashbacks; avoidance to people, places, or things that are associated with the trauma; cognitions and moods that are negatively altered due to the traumatic event; and changes in a person’s behaviors that begin after the traumatic event [8]. In addition to a traumatic event being a one-time occurrence, other forms of trauma include complex trauma that could happen over the course of a long period of time and perpetrated by someone who has a close interpersonal relationship to the person Pleines [9], or intergenerational trauma that can pass along some specific reactions or maladaptive behaviors attributed to past traumas [10]. Regardless of the means that the trauma happened, the aftermath of symptoms is often times felt in the body just as much, if not more, than it is felt in the mind.

From a therapeutic standpoint, it is also helpful to take into account attachment theory when discussing trauma and embodiment because attachment patterns can be reflective of the individual’s internal working model. An internal working model is developed through the interactions that the person has with their primary caretakers during infancy that becomes internalized. As the child grows up, they use their internal working model to help them navigate the world [11]. Having a secure attachment figure allows the child to explore their world more freely because they are aware that they have a place among their caretaker where they feel a sense of belonging [12]. This sense of belonging within securely attached children influences the child’s internal working model and communicates to the child that the world is a safe place to exist. If the child had grown up in an environment where their caretaker was inconsistent or was not available, the child’s internal working model may begin to expect that the world will be just as inconsistent or unavailable to them. The internal working model is also how the child learns how to react to the world, including how safe they feel to advocate for their needs, how they handle receiving from or giving to others, and also how they are able to feel their emotions. If a child did not have a sense of safety for them to feel into their emotions, then they may grow up unable to access those emotions anymore [12].

Clinical Implications of Trauma-Informed Yoga for Couples & Family Therapists Couples & Family Therapists

Trauma is an extremely complex topic that has many manifestations that vary from person to person, which means that the treatment for trauma must be equally complex. Unfortunately for therapists, the use of mindfulness tools such as yoga have not been as common in the therapy room Briere & Scott [13], but as more and more research is being done on the efficacy of these ancient practices, the more it may become integrated into treatment. When treating trauma, the therapist must view this from a systemic standpoint and consider different factors such as the person’s environment, their family, their support systems, and any other strengths or weaknesses that may impact their capacity to heal. As couples and family therapists, we are able to apply this systemic lens to the intrapersonal dynamic of the client and consider the ways that the client’s different parts are not working in harmony with one another. Trauma-informed yoga can be a very effective addition to the treatment plan for our clients who are working towards healing trauma because of yoga’s inherent focus on the embodied experience. Even if the clients are hesitant or unwilling at first to try any kind of yoga or embodiment practice, being able to have this as an opportunity available to them and to support them in the choice that they make can be a really healing experience in itself.

Reflection

As someone who has been practicing yoga for over a decade, I can attest to the fact that yoga provides a path for its students that can create a shift in the way that they relate to their bodies. Traumainformed yoga can be a powerful tool in trauma healing and can be a refreshing change of pace from the traditional talk therapy setting. Yoga by no means can replace the importance of talk therapy, but instead it can help to extend the therapeutic process from the mind into the body and from the therapy room into the real world. For some of the clients who I work with, it is difficult for them to discuss their past traumatic experiences in fear that they will be flooded with emotions when they “go there,” or some of my other clients may feel no connection to most of the physical sensations in their bodies due to their past traumatic experiences. When working with clients who have difficulty with speaking to their experience, I have found that being able to incorporate some movement that is influenced by trauma-informed yoga can be helpful in providing a sense of grounding and comfort for the client. I have also found it to be helpful to be aware of the trauma-informed yoga classes that are nearby, so that I can offer that resource to my clients.

Conclusion

Trauma often times will take a person away from the present moment and will intrude their lives in a way that makes them feel unsafe. Trauma survivors may have difficulties with their interpersonal relationships, self-esteem, working or going to school, and many other aspects of their lives because they are unable to overcome their post-traumatic symptoms. Trauma-informed yoga, in addition to traditional therapy, can facilitate the client’s journey towards feeling embodied awareness in the present moment. As this practice begins to gain traction and show up in many more communities, it is important that couples and family therapists, and other mental health professionals, be aware of this resource. One of my reasons for going into this work of trauma-informed yoga and couples and family therapy is so that I would be able to help my clients heal from their past so that they can begin to live their lives in the present moment, and trauma-informed yoga is a tool that can bring them closer to that goal

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Wishing You A Happy Thanksgiving Day!!!

It’s time to wish on the occasion of Thanksgiving Day for everyone on behalf of  World Journal of Yoga, Physical Therapy and Rehabilitation (WJYPR). We Wish you Happy Thanksgiving Day to you and your family!!!

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Iris Publishers - World Journal of Yoga, Physical Therapy and Rehabilitation (WJYPR)

Ch’i Perspective of Illness and Healing

Authored by Liou Chin Ping

Ch’I self-psychology

Lee CT [1], the proponent of ch’i-self psychology, posited that illness in body, mind, and spirit is caused by the imbalance of ch’i. On the physical dimension, he believed that the imbalance of ch’i can have a negative impact on the cardiovascular, bones and skeletal, muscular, and endocrine system. The imbalance refers to the quantity of ch’i one has, the balance between yin-ch’i and yang-ch’i, and the flow of ch’i. On the psychological dimension, Lee proposed that the imbalance of ch’i may reduce one’s mental and emotional ability and produce symptoms such as decreased attention span, productivity, reduced productivity and creativity, and emotional imbalance. On the spiritual dimension, Lee believes that when the ch’i the individuals have is too low in its density, they may be able to commune with other spiritual beings composed of different kind of ch’i or energy. These individuals might experience themselves as being with extraordinary human ability or mysterious power. This may lead them further to a reduced stability, lack of self-control, and even to a possessed state.

Lee called his healing modality ‘ch’i-tsai healing.’ The term ‘tsai’ refers to both ‘presence’ and ‘stabilizing.’ Lee explained that his healing method works toward recovery of ch’i. The ch’i-tsai therapist should know how to diagnose the quantity and balance of ch’i in the patient; how to recover their patient’s ch’i, and how to teach their patient ch’i-related practices.

The ch’i-tsai healing includes diagnosis of the state of ch’i and ch’i therapy two procedures. Lee assumed that the state of ch’i in the human body can be detected by the hands of a trained ch’itsai therapist. The imbalanced states of ch’i are such as uneven distribution, leakage, scattered, solidified, sick, collapsed energy, and so on Lee CT [1]. Ch’i-therapy includes external ch’i emission and ch’i-related practices instruction. It aims at helping patients recover their balance of ch’i in the body.

Yi shu: The Art of Living

Yi shu is a healing modality proposed by [2]. Yi means change; and shu, the way or the art. Hence, taking these two characters together, yi shu means the art of living with change. This healing modality mainly developed from the yin-yang–wu- hsing theory in the traditional Chinese medicine (TCM). It emphasizes the interconnectedness among human beings, social systems, and the natural environment. It assumes that essence, ch’i, and spirit are the three major components of the human person.

In yi shu, being healthy means an individual is in a state of harmony and balance. By contrast, when people are ill; their intrapersonal components such as internal organs, essence, ch’i, and spirit, and relationships with self, others and the environment will be in a disharmonious and imbalanced state. It is assumed that emotion is the cause of all diseases. Emotion can be induced by inner mental image or by outer stimuli such as interpersonal relationships, social phenomena, or natural environment; and may have an impact on the function of internal organs, hormone secretion, and ch’i-flow. It is believed that the five evolving phases each has its corresponding emotion. For example, lung corresponds to anxiety and sadness; liver, anger; spleen, worry, heart, joy and surprise; and kidney, fear. The emotions can also affect the flow of ch’i. For example, joy eases; anger increases; sadness scatters, fear reduces, worry and inflexibility stagnates the flow of ch’i.

The goal of healing is to help individuals break ch’i blockages, reach a state of harmony and balance, and achieve authenticity in their relationships with self, others, and the environment. Yi shu emphasizes healing the whole person through dealing with emotions. The therapeutic procedure includes diagnosis a creative process of healing. The diagnosis is conducted through interrogation enquiry, feeling the pulse, or observation of the complexion; and healing, through CRE, creative art, psychodrama, and herbal medicine. It is assumed that this procedure may help clients release their negative emotions, promote flow of ch’i and blood, and regain harmony and balance among the various systems in the physical body.

The Integrative Body-Mind-Spirit (I-BMS)

I-BMS is another ch’i-related healing modality which was proposed by Lee Ng, Leung and Chan [3] for the social work profession. I-BMS was developed based on the yin-yang perspective, Traditional Chinese Medicine (TCM), Taoism, and Buddhism philosophies. The following review will focus on how ch’i is understood in their study. Lee CT [1], yi-shu: the art of living, developed by Gong [2], and the integrative body-mind-spirit (I-BMS) developed by Lee Ng, Leung and Chan [3].

The characteristics of yin ch’i and yang ch’i as understood by Lee Ng, Leung and Chan [3] include connectedness; relativism; mutuality and interdependence; constant change; dynamic equilibrium; the centrality of balance and harmony; and the attainment of balance in movement. Lee Ng, Leung and Chan [3] believed that a problem occurs because something has disrupted the dynamic balance of the system. A system that is out of balance will inevitably become stagnant and disconnected. It will overemphasize one single-dimensional aspect of any phenomenon, character, behavior, perception, thought pattern, sensation, or mood, etc. without recognizing the complementary existence of other aspects. As a result, there will be a disconnection in that particular aspect of human experience and this disconnection will then manifest itself as one or many different problems.

Lee Ng, Leung and Chan [3] contended that all things are interconnected and that the relationship between yin and yang is mutually dependent. They suggest that therapists should not only focus on how to get rid of the symptoms; on the contrary, they should also look at the strengths, potentials, and capabilities in the client and the system. All aspects of a person or an experience should be treated as parts of the dynamic balance within the whole. They argue that change only occurs when one notices that the dynamic balance within the self and between the self and the world is broken. Change is a process of moving toward a new balance.

They conceptualize client change based on the abovementioned philosophical orientations, including such elements as change is the rule, mindfulness, acceptance and go with the flow, healing from within and compassion. They emphasize that healing abilities are inherent and need to be recognized and developed. They suggest the use of the mindfulness practice, ch’i-kung exercise, massage, body-scan meditation, and small-group discussion to cultivate attitudes of acceptance and compassion. They believe that this may enhance body-mind-spirit connection, restore the equilibrium and the systems’ self-healing capacity.

Moreover, this is the only healing modality among the three, which emphasizes the importance of the therapists’ self-care. Lee Ng, Leung and Chan [3] argued that ‘the ‘self’ of the therapist is inseparable with how she or he relates to clients and families, how she or he understands a client’s situation and makes clinical judgement in assessment and treatment, what she or he views as effective treatment, and what she or he does in a session’ [3]. Therefore, they suggested that to become authentic and effective healthcare providers, therapists should find ways to nurture their own body-mind-spirit well-being.

Summary

The three healing modalities as examined above show the efforts the health care professionals made to incorporate the concept of ch’i into their practice. They all claim their understandings of ch’i to be based on the Chinese philosophies such as Taoism, Confucianism, Buddhism, TCM or the theory of ying-yang-wu-hsing. They believe that human person as a whole involving body, mind, and spirit; and these three dimensions are interconnected and unified by ch’i.

However, the concept of ch’i emphasized by each of them is slightly different. In ch’i-self psychology, ch’i is conceptualized as something biological, quantifiable, measurable, connected to the supernatural beings [1]. It is believed that ch’i can be replenished, made it flow harmoniously or distributed evenly by the therapist through external ch’i therapy. By contrast, yi shu underlines relations between ch’i and emotions and the connection of this with the internal organs. It emphasizes healing the whole person through dealing with negative emotions and ch’i and takes into account both the equilibrium within the human body and harmonious and balanced relationships with self, others, social systems, and natural environment [2]. On the other hand, the I-BMS tends to regard ch’i as a metaphysical idea and underline the importance of the equilibrium and interconnectedness with the self, others, and the environment

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Digest Review of Yoga as an Effective Treatment for those with Low Back Pain

Authored by Johnston Green A

Clinical Question

Is yoga a more effective treatment than standardized care for those over 18 years of age with low back pain?

Data Sources

Studies were identified by searching Medline, the Cochrane Library, Embase, Cambase, and Psycinfo databases through January 2012. The search included key terms yoga and low back pain with specific adaptations as needed on a database by database basis. References in each of the articles were also screened.

Study Selection

Articles included in this systematic review were randomized controlled trials that compared yoga with any other intervention for participants older than 18 y who had low back pain regardless of etiology. Each article also employed at least 1 patient-centered outcome measure.

Quality Assessment and Data Extraction

Independently, two reviewers appraised the caliber and composition of each article while employing a third review if needed to reach an agreement in case of disparity in evaluation results. The 12 criteria suggested by the Cochrane Back Review Group in the 2009 Updated Method Guidelines for Systematic Reviews were employed by the reviewers. Each item was rated as yes, no, or unclear. To be designated as having low risk of bias, a study had to achieve at least 6 of 12 criteria without possessing a serious flaw. Outcome assessment was determined to be shortterm if performed close to 12 weeks post-intervention. Long-term assessment was deemed to be follow-up close to 12 months after the treatment. This systematic review had the reviewers extract data which included participant characteristics, control conditions, interventions, co-interventions, outcome measures, and results.

Main Results

Originally 160 records were identified from the search of the databases. After removing duplicate articles and excluding those that did not meet criteria, 12 full-text articles were assessed for quality with 10 selected for the qualitative systematic review and 8 of those being included in the quantitative meta-analysis. As assessed using the 12 criteria in the 2009 Updated Method Guidelines for Systematic Reviews as established by the Cochrane Back Review Group, eight studies showed a low risk of bias with two studies having a high risk of bias.

The results of the studies were split into the short-term and long-term categories. These two categories were assessed for the each of the following three effects as applicable:

• Pain.

• Back-specific disability.

• Health-related quality of life.

The recommendations of the Cochrane Back Review Group provided for the valuation of the levels of evidence for each study. Strong evidence was found for the short-term effectiveness on pain (standardized mean differences (SMD) = -0.48; 95% CI, -0.65 to -0.31; P<0.01) and back –specific disability (SMD= -0.59; 95% CI, -0.87 to -0.30; P <0.01). Long term benefits were supported by moderate evidence in terms of pain (SMD = -0.33; 95% CI, -0.59 to -0.07; P =0.01) and back-specific disability (SMD = -0.35; 95%CI, -0.55 to -0.15; P<0.01). Effectiveness was assessed by patientcentered outcomes for pain and back-specific disability. Quality of life was also evaluated with no evidence reported at either the short or the long term.

Conclusion

There is currently limited data available which makes it challenging to designate yoga as either superior or inferior to the standard level of treatment for LBP. However, the data presented in this systematic review suggests that yoga does not provide for detrimental effects and lends itself to be more effective than education alone. A prior qualitative systematic review from Posadzki P and Ernst E [1] along with Büssing A, et al. [2] metaanalysis on yoga for chronic pain2have reached similar conclusions with encouraging evidence that yoga is an applicable treatment for LBP. Additionally, there is promise of two new large-scale RCTs providing supporting data.

Commentary

Low back pain (LBP) is a frequent and often high cost reason for health care provider visits in the United States. [3] As such, it is crucial to find effective and low-cost treatment options for those that suffer from this condition. LBP may be diagnosed and treated based on symptom presentation including radiculopathy, musculoskeletal tissue abnormalities, and the cause for the dysfunction [3]. Exercise has been determined to be an effective treatment for LBP with yoga being included in this intervention [4]. However, the level of effect that yoga included exercise has on LBP are small.

Studies have been performed which compared the benefits of yoga, exercise, and education as therapeutic interventions for those with LBP. While not always noted, various approaches to yoga therapy studied included integrative techniques, Viniyoga, Hatha, and Iyengar. A study in this systematic review contrasted the use of Viniyoga to an exercise class targeted toward those with LBP as well as the use of a back-pain care book for education [4]. The Viniyoga and exercise class were each performed for 75 minutes on a weekly basis [4]. The mainly middle-aged population (30-40 years of age) of this study reported that the Viniyoga produced positive results lasting 14 weeks after the intervention’s conclusion in regard to pain and back-specific disability as assessed by a modified Roland Disability Scale and the Short-Form 36 Health Survey [4]. These outcomes were in comparison to the exercise group which had some improvement while the book group reporting very minimal decreases in disability [4]. While there has yet to be published evidence of the mechanisms by which yoga is able to ease pain, the concept of yoga is that it teaches one to unite their body, mind, and soul through a psycho-somatic-spiritual connection during its practice [5]. Additional support of the benefits of this practice were discovered when comparing Iyengar yoga with education for the treatment of chronic low back pain (CLBP) almost a decade later. [6] This randomized control trial performed by Williams, et al. [6] assessed Iyengar and educational interventions in patients with LBP symptomology lasting longer than 3 months by splitting them into a group per each treatment. Iyengar yoga places an emphasis on structural alignment using props in conjunction with a specific sequence of poses and breath control [6]. Much like the other studies, the yoga group showed significant improvement in pain level and management as well as standard of disability not only at the end of the intervention but at a 3- month follow-up when compared to the education only group [6].

While multiple studies have shown the advantages to using yoga for LBP when compared to standardized treatment, it is important to note that not each practice discipline will produce the same results. Kundalini yoga which can be performed seated, lying, or standing and lends itself to be more gentle than traditional forms of yoga was compared to strength training as well as education in regard to efficacy as a treatment for back pain [7]. Based on the results of those that practiced Kundalini once a week, there were no statistically significant difference when compared with attending a weekly strength training class in regard to missing work due to pain and disability [7-8].

This particular systematic review revealed yoga to be an appropriate treatment approach when addressing those with LBP following a minimum of 75 minute session once a week with additional practice homework of 30 minutes 3-4 times a week Further support for the use of specific disciplines of yoga in those with LBP compared with exercise and/or education is evident when studies are assessed on an individual basis. The concept that yoga does not lend itself to many unfavorable effects when practiced by those with LBP makes it attractive as a treatment avenue especially for active patients. Continued research is needed at this time to ascertain the connection between yoga and its ability to improve pain levels and function in those with LBP

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Progress of Research on the Mechanisms by Which Yoga Contributes to the Rehabilitation of Chronic Low Back Pain

Authored by Xinyan Zheng

Introduction

Back pain is the most common human spinal disorder. It can be caused by lesions in the skin, subcutaneous tissue, muscles, ligaments, spine, ribs, spinal cord, and meninges. Low back pain typically manifests in the lower lumbar spine and lumbosacral and sacroiliac regions. It is usually dull and tingling, with local tenderness and/or radiation along the lower extremities. It is often accompanied by inadequate movement capability, pitching inconvenience, lack of weight-bearing ability, walking difficulty, and/or limb fatigue. More severe symptoms are forward lumbar bending, back extension, scoliosis, and spinal deformity. The 3-month prevalence rate of low back pain is estimated to be 25%, and the lifetime prevalence rate is estimated to be as high as 84% [1-3]. Low back pain poses a great societal and economic burden, as it is related to a decline in work efficiency, poor quality of life, and high medical costs [4]. Its treatment forms the largest category of medical claims (20–25%) [5], with direct medical costs exceeding $34 billion annually [6].

Chronic low back pain (CLBP), Defined as low back pain persistence for >3 months [7], can be caused by

• Traumatic, degenerative (spinal stenosis), and inflammatory conditions.

• Paravertebral soft-tissue diseases and lumbar muscle degeneration.

• Stimulation of the spinal cord and spinal nerve root, spinal cord compression, or acute myelitis.

• Visceral diseases (e.g., pleurisy, pyelonephritis).

• Mental factors or chronic fatigue syndrome.

• Occupational factors (e.g., excessive bending/twisting, restrictive work position, vibration, heavy physical labor, monotonous repetitive work) and insufficient leisure activities.

Patients with CLBP can develop functional disability [8], sleep disorders, fatigue, and drug abuse [9]. CLBP is the most common cause of large workday losses and disability claims [10]. About 1% of the American population (men and women) has chronic disability due to low back pain [11].

The pathogenesis of CLBP involves mechanical instability and inflammatory factors that stimulate nerve endings. Spinal instability means that under a normal physiological load, the spine cannot maintain the normal interbody anatomical relationship without secondary injury to the spinal cord or nerve root, and without pain or dysfunction caused by structural changes (deformities). Many studies have confirmed the relationship between proprioceptive disorder and CLBP

The rehabilitation of chronic pain, considered as a chronic disease, should rely greatly on patients’ self-management, with family and social support [12]. Most patients depend on their doctors and lack relevant guidance after leaving the hospital, especially with regard to back rehabilitation exercises. Current treatments for CLBP include bed rest, medication, traction, local closure, physiotherapy, and exercise therapy [13]. Poor self-management behavior is the main factor affecting CLBP rehabilitation outcomes, leading to recurrence. Exercise and the maintenance of a certain lower-back activity range are considered to effectively reduce pain intensity and to improve the functional status of patients with CLBP, and exercise is commonly advocated as a first-choice treatment [14-16]. Indeed, a recent clinical practice guideline from the American College of Physicians strongly recommends exercise therapy interventions for CLBP [17]. The best form and duration of such exercise, however, remain open questions.

Yoga originated in India thousands of years ago and has become popular throughout the world; about 14.9 million people in the United States practice yoga [18]. Yoga provides a self-correcting, holistic approach to health and has been shown to be effective for several chronic lifestyle-related diseases, such as osteoarthritis [19], rheumatoid arthritis [20], essential hypertension [21], bronchial asthma [22,23], irritable bowel syndrome [24], diabetes [25], arterial disease [26], and depression [27]. It is an increasingly common and effective treatment for pain and related disabilities [28,29], including chronic muscle pain–related diseases [30] such as CLBP. In recent years, the use of complementary alternative medicines (CAMs) has increased by nearly 10%; back pain is the most common cause of use [31], and yoga is among the most common CAM activities [32,33]. In the 2002 National Health Interview Survey on supplemental and alternative medicines, more than 10 million American adults reported the use of yoga for health reasons; 10.5% of yoga practitioners reported that they used yoga for musculoskeletal diseases, and 76% reported that yoga was helpful [34]. Thus, an understanding of the effect of yoga on CLBP rehabilitation could use the design of yoga-based interventions to reduce or treat CLBP.

Characteristics and Effects of Yoga

Yoga is composed mainly of breathing, postures, and meditation, leading to smoothing of the whole-body meridian Qi, improvement of blood circulation, gland stimulation to balance secretion, function-activating visceral massage, nerve relaxation, muscle extension, flexibility development, enhanced immune system function [35],increased antioxidant defense enzymes and promotion of the delay of cell aging [36]. Yoga can improve the electrical activity of brain cells, which is conducive to brain control, and adjust the functions of various viscera, especially those of the endocrine system [37]. Yoga practice can thus benefit a wide range of people. The difficulty and amount of yoga exercise are easy to control, and yoga has low facilities and equipment requirements. Consistent yoga practice can improve fitness, temperament, and mood [22]. With the acceleration of the speed and complexity of life, yoga is regarded as a part of the new “green” lifestyle, adopted by increasing numbers of people as a light inner- and outer-body fitness technique.

Controlled yogic breathing balances the autonomic (sympathetic) nervous system and reduces habitual muscle and skeletal tension, thereby reducing fatigue and stress [38,39]. Yogic breathing differs from usual superficial breathing in that it is deep, slow, uniform, and rhythmic, involving the larynx, thorax, and abdomen, and thus diaphragmatic movement. The alveolar ventilation volume reaches 5100 ml/min, much higher than that of normal breathing. Breath-adjustment exercises accompanied by appropriate music can help the practitioner to enter a stable and quiet state, improve consciousness and muscle perception, and enhance nerve control ability for the respiratory and muscular systems, thereby preparing him or her for physical and mental exercises. Yoga posture practice is a delicate and slow process involving twisting, squeezing, stretching, and pulling. It starts with simple postures that gradually develop practitioners’ physical perception and motor ability. Yogic movement enriches the blood supply and flow to deep tissue, improving microcirculation [37]. Meditation is a key part of yoga practice; it helps the practitioner concentrate, so that the brain can understand the world more clearly and feel subtle changes in the body.

Lemay et al. [40] found that the performance of mindfulness exercises at least once a week alleviated college students’ stress and anxiety. Indian medical experts have found that yoga postures have positive effects on blood glucose control and nerve conduction and can reduce the clinical neuropathy of H-deficiency diabetes [41]. In a study conducted in Thailand, yoga reduced blood pressure in hypertensive patients [42]. Yoga also has a positive effect on the treatment of stubborn obstructive diseases, it has been reported that women who often take part in yoga have a 30–40% reduction in the incidence of breast cancer [43].

Research on yoga for CLBP rehabilitation

Many studies have demonstrated that yoga plays an important role in CLBP rehabilitation. In a systematic analysis, Posadzki P et. al [44] showed that yoga reduced CLBP significantly more effectively than did conventional exercise. Michael et al. [45] compared the effects of yoga and Qigong as rehabilitation training for patients with CLBP. The results showed that participating in a 3-month yoga or qigong program did not improve chronic back pain, back function and quality of life during a 3- or 6-month period. Keosaian, et al. [46] explored the experiences of low-income minority adults taking part in a yoga dosing trial for chronic low back pain that has the potential to favorably impact health in a predominantly lowincome minority population. It confirmed that yoga is an effective multidimensional treatment for CLBP. Patricia, et al. [47] showed that yoga significantly reduced pregnancy-related low back pain. Goode, et al. [48] drew an evidence map for the efficacy of yoga for CLBP, evidence suggests benefit of yoga in midlife adults with non-specific CLBP for short- and long-term pain and back-specific disability, but the effects of yoga for health-related quality of life, wellbeing and acute LBP are uncertain. Without additional studies, further systematic reviews are unlikely to be informative. Williams, et al. [49] compared the effects of Iyengar yoga and standard medical care as rehabilitation training for adults with CLBP; after 6 months of treatment, yoga had improved functional disorders, pain intensity, and depression, and reduced analgesic use, compared with the control group. Sherman, et al. [50] found that when compared to a self-care book, 12 weekly 75-minute Viniyoga classes resulted in both statistically and clinically significant improvements in functional status but when compared to conventional therapeutic exercises, were statistically significant but not clinically important. Padmini Tekur and others [51] found that short-term intensive comprehensive yoga training reduced pain and dysfunction, and increased spinal flexibility, in patients with CLBP.

Mechanism of yoga’s contribution to CLBP rehabilitation

Through progressive stretching and twisting posture exercises, yoga can alleviate lumbar muscle spasm, release adhesion, enhance lumbar spine stability, and increase the joint range of motion [52]. It has been found to increase hip flexion and spinal and hamstring flexibility in patients with low back pain [53,54]. The coordination of breathing and posture exercises enables the inhaled energy to reach the deepest tissues, resulting in musculoskeletal stretching, increased capillary opening, improved blood supply, and promotion of oxygen and metabolite transportation; further strengthening exercise can provide more abundant oxygen to all tissues of the body, increasing the oxygen content of blood and purifying it [52], thereby improving the blood supply and metabolism of the waist soft tissue.

The mechanism by which yoga relieves pain, however, is not completely clear. It may be related to decreased nerve or physiological sensitivity of painful tissue or to a change in the adaptability of compressed tissue. Harte [55] found increased endorphins and enkephalin in yoga practitioners, with the release of these analgesic substances effectively alleviating pain.

From the perspectives of biomechanics and anatomy, yoga can strengthen the lumbar extensor muscles (including the polyfidus and sacrospinal muscles) and abdominal muscles, providing support for the spine; spinal twisting stimulates the intervertebral discs and articular capsules, stretch in the direction of rotation promotes spinal rotation and vertebral mobility, and polyfidus muscle contraction–reduction–relaxation cycles comprise effective training. These effects conform to the principles of strength training and muscle stretch [56]. Yoga exercises effectively maintain overall spinal stability and flexibility, reduce the pressure between vertebral bodies, and correct slight displacements of the lumbar intervertebral discs and foramina. It can also ease nerve root compression, and alleviate or avoid common conditions related to CLBP, such as lumbar disc herniation. In addition, psychological effects of yoga can contribute to CLBP rehabilitation. Yoga can relieve depression, and fear [49]. Studies have shown that meditation can alleviate fear [57], enhance self-belief and improve the pain-coping ability of patients with chronic pain [7].

Matters Needing Attention in Yoga Practice

Reasonable yoga practice has a certain effect on CLBP rehabilitation, but unsuitable practice can be a source of injury. Attention must be paid to the following points in yoga practice. First, the dorsal (including lumbar) and abdominal muscles should be exercised at the same time to enhance the balancing of their strength, with consideration of the lumbar curvature and the size of sacral tilt.

Second, yoga posture practice should fully consider the practitioner’s flexibility, balance, and strength. Stretching should be performed gently and slowly, within the body’s limits and without excessive drag, to prevent muscle strain. The practitioner should explore and gradually understand the state of his or her body, pay attention to the anatomical characteristics of the correct positions, and protect the joints; exercise intensity should be increased gradually.

Third, the practitioner should focus on the feeling of the physical exercise, perceiving the effects of each action. Only by actively guiding the practice can physical and mental relaxation be achieved. Fourth, rehabilitation training plans to improve the physical fitness of corresponding muscle groups should be formulated scientifically according to the degree of CLBP, to establish the correct exercise mode. In addition, the practice should include full preparatory activities and post-exercise meditation to take full advantage of the adjustments and recovery of function achieved.

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[journal-of-yoga]

Iris Publishers - World Journal of Yoga, Physical Therapy and Rehabilitation (WJYPR)

Anxiety Reduction and Emotional Responding After a Session of Yoga

Authored by Rodney K Dishman

Introduction

Randomized trials show that regular exercise is accompanied by clinically relevant reductions in symptoms of anxiety [1,2], and experimental studies of a single session of exercise show a small reduction in state anxiety that varies according to the type and intensity of the exercise and the comparator used. Reductions in state anxiety have been most consistent after treadmill exercise at high intensities when compared to quiet rest [3]. However, with the exception of one study of yoga practice, the types of exercise in those published reports were limited to a prescribed exposure to traditional forms including walking or running on a treadmill, leg cycling, stair climbing, or resistance exercise rather than a mode of exercise routinely practiced by participants prior to their acute exposure in a laboratory or clinic.

Yoga, an alternative mindful exercise that is commonly performed at light-to-moderate intensities [4,5], is practiced by an estimated 10% of U.S. adults [6]. It has shown some promise as an adjuvant for treating anxiety and its comorbidities of depression, sleep disorders, and schizophrenia [7-10]. However, we could find only three experimental studies of state anxiety after a session of yoga practice [11-13]. Just one of those studies compared yoga to traditional exercise. In a sample of 40 psychiatric inpatients diagnosed with schizophrenia, anxiety was reduced after 30 minutes of Hatha Yoga or 20 minutes of leg cycling exercise at self-selected intensity when each condition was compared to 20 minutes of quiet rest or reading [13].

Here, we studied a sample of yoga practitioners who did not have a known psychiatric disorder. Although they did not have elevated anxiety, we expanded on past research [3] by eliciting an emotional response in these participants prior to, and again after, exercise to test whether a change in emotional processing after yoga practice might help explain its expected anxiolytic effect. We also examined whether yoga might further protect against elevated anxiety in response to subsequent emotional provocation, as reported in a recent study of cycling exercise [14]. Emotional processing was assessed by affective ratings of emotional pictures and objectively by valence-modification of the acoustic startle eye blink response during picture viewing, which was not affected by leg cycling in a prior report [15].

Contemporary theorists characterize emotions as being organized along orthogonal dimensions of affective valence (i.e., pleasantness) and affective arousal. The two primary motivational systems along the valence dimension are the appetitive system, governing approach toward pleasant stimuli, and the defensive system, governing withdrawal from unpleasant, averse stimuli [16,17]. Emotional priming of these systems can be evidenced by the magnitude of the acoustic startle eye blink response (electromyographic measurement of the obligatory eye blink reflex after an acoustic startle probe), which is potentiated when processing unpleasant foreground stimuli (e.g., faces or scenes) but inhibited when processing pleasant stimuli [17]. An augmented startle response is seen in several anxiety disorders [18] and when anxiety is experimentally induced in people without an anxiety disorder [19]. Administration of anxiety-reducing drugs (e.g., benzodiazepines) to healthy people results in decreased startle response magnitude to unpleasant or threatening stimuli [20-22].

The aim of the study we report here was to examine whether yoga practice elicits a reduction in anxiety after emotional priming by exposure to scenes that elicit defensive or appetitive emotional systems. We compared responses after yoga practice, leg cycling exercise at self-selected intensity, and quiet rest. We hypothesized that state anxiety and the magnitude of the acoustic startle eye blink response during affective picture viewing would be attenuated after yoga practice but not after leg cycling exercise or quiet rest. We also hypothesized that decreased state anxiety would be positively associated with decreased startle magnitude.

Acknowledgment

Recruitment

Protocols complied with the Declaration of Helsinki and were approved by the Institutional Review Board. Students were contacted via their university e-mail address and were invited to complete an online screening questionnaire (www.qualtrics.com). Individuals 18-35 years old who reported at least 150 minutes of moderate-to-vigorous physical activity in the week prior to screening, experience with yoga (at least once a month for 6 months or more), and the ability to perform 20 minutes of selfdirected yoga were invited to participate in the study. Individuals with more than one risk factor for cardiovascular disease, a history of cold sensitivity (e.g. Reynaud’s syndrome), who were seeking clinical treatment for psychological disorders, or currently taking psychoactive drugs were ineligible for the study.

Participants

A total of 229 undergraduates attending the University of Georgia responded and were screened. Of those, 45 were eligible and 23 were enrolled (i.e. gave informed consent to participate in the experiment and participated in at least one of the three visits). Six participants dropped out of the study for various reasons, and two participants completed the three visits but did not have useable eye blink data at one or more sessions. Here we report on 11 females and 4 males who had regularly practiced Hatha Yoga for six months to 12 years and completed the experimental protocol. They were aged 20 to 35 years (26.1±5.2), moderately active, reporting 26 to 377 minutes per day of moderate, hard, or very hard physical activity the past week (133 ± 96), and most had normal weight with a body mass index (kg weight/m2 height) of 19.5 to 37 (23.8 ± 4.3).

Procedures

The seven-day physical activity recall validated for college students [23] was used to measure moderate-to-vigorous leisure time physical activity level the week prior to the study. Participants complete a medical questionnaire to confirm they were healthy enough to complete 20 minutes of moderate-intensity cycling exercise. Participants also reported their experience with yoga and their medication use. Participants completed 3 laboratory visits scheduled at least 2 days apart. On their first visit to the laboratory, participants provided informed consent and screening for contraindications to exercise was accomplished with the Physical Activity Readiness Questionnaire [24]. Participants completed each of three randomly assigned conditions: a self-directed yoga session, a leg cycling session on a stationary cycle at self-selected intensity, and a quiet rest condition when the participant sat quietly in a chair in the cycling exercise room. Cycling was done on a Lode electronicallybraked cycle ergometer.

Warm-up (3 minutes, 25 Watts) was followed by 20 minutes of cycling at a self-selected intensity. Participants cycled at 40 Watts and were given the choice to maintain, increase, or reduce resistance by “a lot” (15 watts) or “a little” (5 watts) every five minutes until the end of the 20-minute bout (3 times total). Participants cooled down for 2 minutes at 25 Watts. There was a linear increase (p<.001) in power output from (mean ± SD) 52.3 ± 4.2 watts to 68.3 ± 11.8 watts. Average HR during the 20-minute session was 60 ± 7.7 watts. Heart rate was measured continuously during cycling exercise using a Polar® Vantage XL heart rate monitor (Polar Electro, Inc., Woodbury, NY, model 145900). There was a linear increase (p<.001) in HR from (mean ± SD) 103 ± 19 bpm to 121 ± 26 bpm. Average HR during the 20-minute session was 113 ± 23 bpm, 55% ± 12% of age-estimated maximum HR, which is light-tomoderate intensity [25]. Yoga was completed in a secluded room. Participants were instructed to conduct a familiar warm-up for 3 minutes prior to, and 2 minutes of a familiar cool-down routine (savasana) after, 20 minutes of self-directed yoga poses (asanas). There was no change (p=.672) in HR from (mean ± SD) 100 ± 22 bpm to 98 ± 19 bpm. Average HR during the 20-minute session was 100 ± 20 bpm, 50% ± 10% of age-estimated maximum HR. Heart rate during Hatha Yoga in practitioners typically ranges between 80 to 115 bpm, or about 50-55% of maximum HR [4,5]. Heart rate did not change during quiet rest (p= .414) and averaged 74 ± 17 bpm.

State anxiety

Anxiety was assessed by the state version (X1) of the State-Trait Anxiety Inventory [26] administered at baseline after participant preparation, and again prior to and at the end of each affective picture show presentation.

Affective pictures

Three randomly assigned presentations of affective pictures were used to manipulate emotional state during each of the three conditions. Participants viewed each presentation on a screen approximately 21inches from their face while seated in a semirecumbent position. Each affective presentation included 18 scenes; 6 unpleasant, 6 pleasant, and 6 neutral photos chosen from the International Affective Picture System (IAPS) image pool [27]. All pleasant and pleasant photos were rated as arousing [28], and each photo was only viewed once throughout the experiment [29]. Each IAPS photo appeared for 6 seconds. During the 10 seconds after each slide was presented, the participants provided affective ratings of valence and arousal using the Self-Assessment Manikin (SAM) rating scale. Ratings were followed by a random intercluster interval ranging between 3-5 seconds. Presentations lasted between 8 minutes and 55 seconds and 17 minutes and 35 seconds, depending on how long each participant took to respond to the SAM scales.

Affective ratings

The SAM rating scales [30] are analog scales used to measure subjective reports of affective valence and arousal. The SAM is a pictogram that exhibits levels of affective experience on independent continua of valence (from pleasant to unpleasant) and arousal (high arousal to low arousal). This is a 9-point scale that is marked with a pen or pencil. Participants were asked to rate their emotions felt during the presentation of each picture during the slide shows. Scores at averaged across each picture content (pleasant, neutral, unpleasant) at baseline before each condition were compared to published norms [27] for the slides employed to confirm that the slide content was perceived as intended.

Acoustic startle probe

The acoustic startle probe was administered once per picture during each affective presentation. The second and third pictures in each cluster (12 of 18 pictures in presentation) were accompanied by a startle probe administered randomly between 2.5 and 5.5 seconds following picture onset. The startle probe was a 50 ms burst of 95 dB (A) broadband white noise produced by a Coulbourn Instruments audio source module (model V85-05) and amplified by a RadioShack 40-watt amplifier. It was delivered binaurally through Sony model MDR-V200 dynamic stereo headphones, with an instantaneous rise/fall time [31]. The intensity of the acoustic stimulus was calibrated at the surface of the headphone using a sound level meter (General Radio Company, Concord Massachusetts).

Electromyography (EMG)

EMG recordings of the obicularis oculi provided recordings during each presentation of emotional scenes according to standard procedures [32]. The surface of the skin was lightly abraded, and two miniature biopotential skin electrodes filled with Mansfield R & DTD-40 electrode gel were attached 5 mm lateral from the exocanthion and 10 mm medial and 5 mm inferior to that location. Electrode impedance was verified as less than 10 kohm using a Grass electrode impedance meter (model EZM 4). EMG signals were amplified 100 times using a Grass P5 series AC amplifier, digitized at 1000 Hz, and displayed using Spike2 version 6.08 software. Recorded data incl the mean amplitude and its standard deviation of the amplitude for the 1 second prior to probe onset, amplitude at probe onset, and peak amplitude within a response window of 20-100 milliseconds after probe onset. All amplitude measures were integrated, rectified, and expressed in millivolts. Response amplitude was designated as the difference between amplitude at probe onset and peak amplitude. Trials with excessive background noise and trials during which the subject was blinking at the time of probe onset were excluded.

Excessive background noise was defined as trials for which the standard deviation of the amplitude during the 1 second prior to probe onset was greater than or equal to 3 SD from the mean standard deviation within each subject per visit. Spontaneous eye blinks at probe onset were identified as ≥ 3 SD from the mean amplitude of the 1 second prior to probe onset for each trial. Finally, response amplitudes < 2 SD from the amplitude at probe onset were considered non-responses. A total of 51 startle responses were excluded because of excessive noise or blinking and 118 trials were excluded as non-responses, leaving a total of 1451 valid startle responses out of 1620 probes (90%). Response magnitude was calculated as the product of mean response amplitude in millivolts and the response probability (mM=mA*P), where response probability represents the proportion of valid responses out of total possible responses for each valence [32]. Response magnitudes were transformed and expressed as z-scores within each participant for each day of testing to control for differences in basal EMG activity between subjects and within subjects across visits.

Statistical analyses

Statistical analyses were conducted using IBM SPSS version 22. A3 condition (yoga, cycling, rest) x3 valence (positive, neutral, negative) x time repeated measures ANOVA tested the hypothesis of condition x time effects on state anxiety and condition x time x valence effects on emotional modulation of ASER magnitude. Interactions were decomposed using orthogonal polynomial contrasts for time and condition and Helmert contrasts of yoga with the cycling and rest conditions. Follow-up simple main effects of time within condition were also conducted by RM-ANOVAs within condition and valence. When assumptions of sphericity were violated, we reported epsilon and Huynh-Feldt corrected estimates. Effect sizes associated with the F statistics are expressed as η2. Statistical power to detect a moderate effect (η2 ≥ .10) exceeded .80 at an alpha of .05 [33].

To determine whether startle eye blink magnitude was directly related to state anxiety, 3-Condition (yoga, cycling, quiet rest x 4-Time x Sex mixed model ANCOVAs with time-varying covariates were also conducted. Reduction in the F statistic and partial η2 in the adjusted (i.e., conditional) model, compared to the unconditional model, was interpreted as the startle eye blink magnitude accounting for a significant percentage of the change in state anxiety, i.e., 1 – (adjusted η2/ unconditional η2) [34].

Discussion

The primary novel findings of the study are that a session of yoga practice mitigated the increase in state anxiety elicited by affective picture viewing and attenuated the magnitude of the acoustic startle response to both pleasant and unpleasant picture content, when compared to leg cycling exercise and quiet rest. The concurrent reductions in self-reported anxiety and the startle eye blink probe provide convergent subjective and objective evidence that yoga practice was anxiolytic. Yoga practice also protected against elevated state anxiety during a second exposure to the emotional scenes.

However, state anxiety after yoga was unrelated to startle eye blink response, and neither pleasantness nor emotional arousal in response to picture content was altered by yoga practice. Although yoga reduced anxiety after emotional priming by scenes that elicited either defensive- or appetitive-emotional systems, the hypothesis that anxiety reduction after yoga would be explainable by altered emotional processing was not supported. Neither yoga nor leg cycling altered the appraisal of picture content as pleasant, unpleasant or arousing. Thus, the results extend past findings by showing that yoga practice reduces anxiety elicited by emotionally arousing pictures and may provide anxiolytic prophylaxis against subsequent emotional provocation. However, like leg cycling exercise, yoga did not alter emotional processing measured here as valence-modification of the acoustic startle eye blink response during emotional picture viewing. Hence, we interpret the attenuated startle response after yoga as a general neural deactivation or relaxation effect [15].

The results agree with earlier reports from our laboratory that low- or moderate-intensity leg cycling exercise does not alter state anxiety or emotional responding measured by ratings of affective picture content and the acoustic startle eye blink response, when compared to quiet rest [15,35]. Here, participants chose to cycle at about 55% of maximum HR, similar to the average intensity of Hatha Yoga practice, which approximates an intensity that is less than 40% VO2peak, when given opportunities to change the intensity as they preferred. We did not assess whether participants viewed yoga practice or leg cycling as pleasant or unpleasant during each session, which might influence state anxiety after high intensity, but likely not the light intensity exercise used here [36]. We previously reported that moderate intensity leg cycling is evaluated as an emotionally neutral experience [37].

We are aware of only two other reports of randomized studies of anxiety after a single session of yoga practice. In a study of 86 men and women aged 18 to 64 years who had completed a onemonth yoga course, state anxiety was reduced in participants assigned to 20 min of shavasana (corpse pose) but not after 20 minutes of supine rest [11]. In a study of young male residents at a yoga center, anxiety was lowered more after about 10 minutes of cyclic meditation yoga postures followed by 10 minutes of corpse pose, when compared with an equal period of corpse pose only [12]. Explanations for the anxiety reductions were not tested in those studies.

Conclusion

The results extend past findings by showing that Hatha Yoga practice reduced anxiety elicited by emotionally arousing pictures and provided prophylaxis against subsequent emotional provocation. The effects of Yoga were large enough (about one-half standard deviation) that they could be clinically meaningful. The reduction in the objective startle response concurrent with lowered self-reported anxiety supports that yoga practice is anxiolytic, but anxiety responses did not depend on the startle response, and like leg cycling exercise, yoga did not alter emotional processing of affective scenes.

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