therapeutic effects of yoga for children: a systematic review of the literature€¦ · ·...

R E V I E W

Therapeutic Effects of Yoga forChildren: A Systematic Review ofthe LiteratureMary Lou Galantino, PT, PhD, MSCE, Robyn Galbavy, PT, MPT, and Lauren Quinn, DPT

Physical Therapy Program (M.L.G., R.G., L.Q.), The Richard Stockton College of New Jersey, Pomona, New Jersey, andUniversity of Pennsylvania (M.L.G.), Philadelphia, Pennsylvania

Purpose: We completed a systematic review of the literature on the effect of yoga on quality of life andphysical outcome measures in the pediatric population. We explored various databases and included case–control and pilot studies, cohort and randomized controlled trials that examined yoga as an exercise interven-tion for children. Summary of Key Points: Using the Sackett levels of evidence, this article reviews the literatureon yoga as a complementary mind–body movement therapy. We address the research through three practicepatterns according to the Guide to Physical Therapist Practice and provide considerations for the inclusion ofyoga into clinical practice. Statement of Conclusions and Recommendations for Clinical Practice: The evidenceshows physiological benefits of yoga for the pediatric population that may benefit children through therehabilitation process, but larger clinical trials, including specific measures of quality of life are necessary toprovide definitive evidence. (Pediatr Phys Ther 2008;20:66–80) Key words: adolescent, child, complementarytherapy, exercise movement techniques, human movement system, review article, yoga

INTRODUCTION

By the summer of 2006, “Kid Yoga” camps were ap-pearing on every corner,1 rivaling lemonade stands andsoccer camps in popularity. In April 2007, a search on theInternet with the terms “yoga and children” yielded closeto 6,120,000 hits.2 The Internet offers an abundance ofcertifications designed for teaching yoga to children.3 Fur-ther, almost every yoga studio in the country now offersclasses for young children.4 Indeed, yoga has now pene-trated popular culture for all age groups. As experts inmovement analysis and therapeutic exercise, physical thera-pists (PTs) hold the professional responsibility of determin-ing the value of yoga’s age-old art in modern day practice.

Today’s “typical child” is described as stressed out,5

under nourished,6 and sedentary.7 The complexity posedby these profiles demands treatment that taps into both the

physical and the psychosocial domain. A study by Parshad8

found the state of the mind and that of the body to beintimately related. If the mind is relaxed, the muscles in thebody will also be relaxed. Stress produces a state of physicaland mental tension. Yoga, developed thousands of yearsago, is recognized as a form of mind–body medicine. Thereare many forms of yoga with emphasis on various aspects ofbody mechanics, fitness, and spirituality (Table 1).

Parshad’s study demonstrates that yoga’s physicalpostures and breathing exercises improve muscle strength,flexibility, blood circulation and oxygen uptake, and hor-mone function. In addition, Parshad found that relaxationinduced by meditation helps to stabilize the autonomicnervous system with a tendency toward parasympatheticdominance. Physiological benefits that follow help individu-als who practice yoga to become more resilient to stressfulconditions and reduce a variety of important risk factors forvarious diseases, for example, cardiorespiratory diseases.8

Yoga shows promise as a new modality for the pediat-ric population. Despite its popularity in popular culture,careful examination of the research is necessary when in-tegrating this modality in traditional pediatric rehabilita-tion settings. The purpose of this systematic review is toexplore the evidence related to the effectiveness of yogawith respect to the practice patterns in the Guide to PhysicalTherapist Practice.9 We have classified the articles under

0898-5669/108/2001-0066Pediatric Physical TherapyCopyright © 2008 Section on Pediatrics of the American PhysicalTherapy Association.

Address correspondence to: Mary Lou Galantino, PT, PhD, MSCE, TheRichard Stockton College of NJ, PO Box 195, Pomona, NJ 08240. E-mail:[email protected]

DOI: 10.1097/PEP.0b013e31815f1208

66 Galantino et al Pediatric Physical Therapy

the following headings: neuromuscular, cardiopulmonary,and musculoskeletal according to their focus. As reviewers,we feel that the practice of yoga encompasses all three ofthese practice patterns. However, for the purpose of thisreview, we have assigned each article to the most pertinentpractice pattern according to the focus of each study.

METHODOLOGY

We searched the following electronic databasesthrough January 2007: Cochrane Central Register of Con-trolled Trials, MEDLINE, EMBASE, CINAHL, PsychINFO,and PEDro. The yoga register maintained by the Cochrane

Breast Cancer Group was also explored. We used searchterms related to yoga and pediatrics (children, develop-mental disabilities), exercise (eg, exercise, physical activ-ity, cardiorespiratory fitness), and publication type (eg, co-hort, case–control, clinical trial). This search strategy wasmodified as necessary for each database. Appropriate non-English language publications were not found. Of the studieswe found pertinent to review, four were published in the1980s, 10 in the 1990s, and 10 from 2000 to the present.

Studies were considered eligible for inclusion if theywere pilot in nature, cohort, case–control, or a randomizedclinical trial (RCT). An RCT is an experimental study in

TABLE 1Different Schools of Hatha Yoga Commonly Practiced in the United States

School Focus Description

Ananda Enlightenment Tool for spiritual growth while releasing unwanted tensions. Uses silent affirmations whileholding a pose as a technique for aligning body, energy, and mind. Series of gentle posesdesigned to move energy upward to the brain, preparing the body for meditation

Anusara The Heart Founded by John Friend in 1997, anusara yoga integrates the celebration of the heart,universal principles of alignment, and balanced energetic action in the performance ofasana. Anusara (pronounced ah-new-SAR-ah) means “following your heart.” In thisschool of yoga, each student’s abilities and limitations are deeply respected andhonored. Source: Lark, Liz. Yoga for Life. Carlton Books, London; 2001

Ashtanga/Power Yoga Fitness Athletic; Fast Paced and nonstop; not recommended for beginning students. At the core islinking the breath with each movement throughout the practice. Power Yoga is aderivative, using a more creative sequence of postures

Bikram/Hot Yoga Healing Athletic; Practiced in a room heated to 100! degrees, thus “Hot” Yoga. Sauna-like effecthelps move the toxins out of the body

Hatha Yoga/“Yoga” Holistic A major branch of yoga, developed by Goraksha and other adepts c. 1000 CE, andemphasizing the physical aspects of the transformative path, notably postures (asana)and cleansing techniques (shodhana), but also breath control (pranayama). SOURCE:“Hatha Yoga.” Accessed on September 14, 2007. Available at: http://www.yogajournal.com/newtoyoga/159.cfm

Integral Enlightenment Aimed at helping people integrate yoga’s teachings into their everyday work andrelationships. Incorporates guided relaxation, breathing practices, sound vibration(repetition of a mantra or chant), and silent meditation

Iyengar Detail Technical yoga, an intense focus on the subleties of each posture; great for beginningstudents. Strong focus on precise muscular and skeletal alignment; emphasizestherapeutic properties of the poses. Poses (especially standing postures) are typicallyheld much longer than in other schools of yoga to focus on alignment. Use of props(belts, chairs, blocks, and blankets) to accommodate special needs such as injuries orstructural imbalances

Kripalu Healing Therapeutic; gentle and spiritually focused; great for beginning students. Incorporatesinner focus and meditation within the yoga poses. Focus on alignment, breath, and thepresence of consciousness. Holding of the postures to the level of tolerance and beyond.Deepens concentration and focus of internal thoughts and emotions

Kundalini Enlightenment Dynamic; Esoteric; Energizing; Aimed at invoking dormant spiritual energy at the base ofthe spine. Incorporates breath-work, movement, postures, chanting, and meditating onmantras

Sivananda Enlightenment Traditional approach; can become very advanced. Rigid class structure of poses, breath-work, meditation, and relaxation. Emphasizes 12 basic postures to increase strength andflexibility of the spine. Focus on proper pose, breathing, relaxation, and diet (vegetarian), andpositive thinking and meditation

Tantra Sensuality Perhaps the most misunderstood yoga style, tantra is not about sexual indulgence. Rather,it is about discovering and stimulating sensual spirituality. This yoga works with thehighly charged kundalini energy and, therefore, should always be guided and taught bya teacher. Tantra teaches practitioners how to use this energy for sexual pleasure, forbringing joy and wholeness to everyday life, and for aiding in spiritual evolution. Tantrayoga includes visualization, chanting, asana, and strong breathing practices. Source:Lark, Liz. Yoga for Life. Carlton Books, London; 2001

Viniyoga Healing Therapeutic; repetitious movements in and out of a posture. Individualistic; poses aresynchronized with the breath in sequences determined by the needs of the practitioner.Highly adaptable, thus good for students with physical injuries or limitations

Pediatric Physical Therapy Therapeutic Effects of Yoga for Children 67

which a clinical treatment is compared with a control con-dition, where subjects are randomly assigned to groups,10

and in our review, we compared exercise with a placebo,controlled comparison, or standard care. For the purposesof the review, yoga includes a combination of breathingexercises (pranayama), physical postures (asanas), andmeditation (spirituality).11–13

Yoga was defined as a form of leisure-time physicalactivity that was performed on a repeated basis during anextended period of time, with the intention of improvingfitness, performance, or health.14 Table 1 outlines the breadthof yoga styles, some of which were used in the reviewedstudies. Studies with an additional treatment arm or com-bined intervention (eg, yoga with traditional exercise)were included only if the effects of exercise could be iso-lated. A priori, we excluded reports that were available onlyin abstract form.

Trials were included only if they involved normallydeveloping children and children with various impair-ments of the muscular, cardiopulmonary, or neuromuscu-lar systems. Studies were required to have as a primaryoutcome quality of life (QOL), cardiorespiratory fitness orphysical functioning. Secondary outcomes of interest in-cluded cognition and attention. We also extracted data onadverse events resulting from the yoga intervention.

Three independent reviewers (R.G., L.Q., and M.L.G.)screened the titles and abstracts of identified studies foreligibility. When one of us deemed an article to be poten-tially relevant, we obtained the full text and all three re-viewers assessed it for inclusion. Information on patients,methods, interventions, outcomes, and adverse eventswere extracted from the original reports by the three inde-pendent reviewers onto paper forms that they had designedand pretested. Kappa coefficient of the reviewers was sub-stantial (r " 0.60–0.75) between the three raters. Dis-agreements were resolved by consensus (R.G., L.Q., andM.L.G.). The methodological quality of each study wasassessed using the following criteria15,16:

1. Was there adequate concealment of allocation?2. Was the method of randomization well described

and appropriate?3. Was the outcome assessment described as blinded

or unblinded?4. Was the method of blinding of the assessment of

outcomes well described and appropriate?5. Was there a description of withdrawals and

dropouts?6. Was there intention-to-treat analysis?7. Were withdrawals and dropouts less than 10%?8. Was adherence to the exercise intervention (atten-

dance or completion of exercise session) greaterthan 70%?

All items were scored using Sackett levels of evi-dence.17 Studies were defined as being of “high quality” ifthey fulfilled four or more of the eight quality criteria. Weincluded all the studies in this review, given the paucity ofyoga research in pediatrics. Of the 24 total studies identi-

fied, five were classified as level 4, four as level 3, 15 as level2, and none with level 1 grade of evidence. Based on ourcriteria for evaluation, using both methods, we found fewarticles that included our criteria for high quality. Al-though description of randomization was clear throughoutall studies, we have little data that describe outcome assess-ments with regard to the method of blinding, no informa-tion on intent-to-treat analysis, and what happened towithdrawals and dropouts. Therefore, studies were ofmoderate to low quality and require future investigationsthat incorporate all aspects of a rigorous clinical plan forrecruitment, retainment, blinding, and adherence.

NEUROMUSCULAR EFFECTS OF YOGA

Six of the 10 articles assigned to the neuromuscularpractice pattern were assessed as 2B grade for levels ofevidence, while four additional articles were grade 4. Muchvariability was noted in the duration of yoga interventionsand it is unclear how issues of bias were addressed. Al-though a trend is noted in improvements of motor plan-ning, performance, and mental and social acuity, furtherresearch is needed to incorporate yoga as a definitive mo-dality for the neurologically involved child.

Yoga seems to have a positive impact on motor per-formance in children and most studies have been con-ducted on children developing typically (Table 2). Fourstudies analyzed the effects of yoga on reaction time, plan-ning, execution time, and motor speed.18–21 Reaction timehas been used to quantify level of motor function, and thusspeaks to the overall functioning of the central nervoussystem (CNS).22 Pilot data by Bhavanani et al18 found thatmukh bhastrika yoga (bellows type breathing) produceddecreased visual reaction time and auditory reaction timein 22 healthy schoolboys. This indicates potentially im-proved sensory-motor performance and enhanced process-ing ability of the central nervous system.18 Another pilotstudy by Manjunath et al19 showed trends of improvedplanning and execution times in the yoga group in theTower of London test for both simple and complex tasks.The Tower of London test is standardized and addressesexecutive functions. The study revealed no change in thephysical training group.

Motor speed, like reaction time, is also a quantifica-tion of CNS processing. Dash et al20 analyzed the effects ofyoga training on a finger tapping task, to assess motorspeed in children and adults versus a control group of 38adults. Findings included significant increases in tappingspeed values after 10 days of yoga training in the children’sgroup and 30 days of yoga training in the adult group.Although not verified by diagnostic imaging, this and otherstudies point to the potential plasticity of the brain andCNS in response to yoga. Another study by Telles et al21

supports improved motor performance in children afteryoga training. This study of 90 children ages 9 to 13 yearsused a steadiness test that required the insertion of andholding of a metal stylus into holes of decreasing sizes. Theyoga group showed a significant decrease in errors,while the control group showed no change. Although an


TABL

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tim

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ith

spec

ific

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cbr

eath

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alth

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Tra

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part

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uite

dfo

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udy—

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erly

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ere

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tim

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me

note

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isin

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ted

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4

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ash

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152

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onth

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yrs)

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mas

sign

men

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oups

:one

grou

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1hr

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for

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phys

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plan

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and

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the

4-m

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task

s.T

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show

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ge.

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ning

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am

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ced

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and

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mpl

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sign

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gte

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age-

mat

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cont

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mila

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ssed

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hof

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tice

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brea

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(2)

left

nost

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thin

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tern

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nost

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or(4

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eath

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ess

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ipul

atio

nof

nost

rils

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hese

tech

niqu

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ere

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ada

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roun

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me.

Ver

bala

ndsp

atia

lm

emor

yw

asas

sess

edin

itia

llyan

daf

ter

10da

ys.

All

4tr

aine

dgr

oups

show

eda

sign

ifica

ntin

crea

sein

spat

ial

test

scor

esat

rete

st.A

vera

gein

crea

sein

spat

ialm

emor

ysc

ores

for

the

trai

ned

grou

psw

as84

%.

Itap

pear

sth

atyo

gabr

eath

ing

incr

ease

ssp

atia

lrat

her

than

verb

alsc

ores

,wit

hout

ala

tera

lized

effe

ct.

2B

8Pe

cket

al27

RG

/MLG

Inve

stig

ate

the

effe

ctiv

enes

sof

yoga

for

impr

ovin

gti

me

onta

skw

ith

10el

emen

tary

scho

olch

ildre

nw

hoev

iden

ced

atte

ntio

npr

oble

ms.

10el

emen

tary

scho

olst

uden

tsw

ith

atte

ntio

npr

oble

ms

(age

d6–

10yr

s)ac

ross

3gr

ade

leve

lsvo

lunt

eere

dto

part

icip

ate.

Init

ially

,the

yw

ere

recr

uite

dby

scho

olps

ycho

logi

st.T

hese

stud

ents

wer

eno

tdia

gnos

edw

ith

AD

HD

,but

docu

men

ted

tobe

“on

task

”$

80%

ofth

eti

me.

Ayo

gavi

deot

ape,

publ

ishe

dby

Gai

am,w

asus

edth

atre

quir

edth

ech

ildre

nto

follo

wan

adul

tins

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tor

and

thre

ech

ildre

nw

hoen

gage

din

deep

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thin

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ysic

alpo

stur

es,a

ndre

laxa

tion

exer

cise

sfo

r30

min

,tw

ice

aw

eek,

for

ape

riod

of3

wee

ks.

Stud

yw

asa

mul

tipl

eba

selin

ede

sign

.Tim

eon

task

was

defin

edas

the

perc

enta

geof

inte

rval

sob

serv

edth

atth

est

uden

tsw

ere

orie

ntat

ing

tow

ard

the

teac

her

orta

sk,

and

perf

orm

ing

the

requ

este

dcl

assr

oom

assi

gnm

ents

.The

resu

lts

indi

cate

def

fect

size

sth

atra

nged

from

1.5

to2.

7as

afu

ncti

onof

the

inte

rven

tion

.E

ffec

tsiz

esat

follo

w-u

pde

crea

sed,

butr

ange

dfr

om0.

77to

1.95

.Pee

rco

mpa

riso

nda

tain

dica

ted

that

clas

smat

es’

tim

eon

task

rem

aine

des

sent

ially

unch

ange

dth

roug

hout

the

thre

eph

ases

ofth

est

udy.

Peer

com

pari

son

data

indi

cate

dth

atcl

assm

ates

’tim

eon

task

rem

aine

des

sent

ially

unch

ange

dth

roug

hout

the

thre

eph

ases

ofth

est

udy.

4

(Con

tinu

ed)


improvement in the quality of research design, furtherinvestigation is needed for application in children withdisabilities.

Other studies suggest that yoga increases workingefficiency,23 and overall ability to concentrate and focus.24

Yoga fosters relaxation and breathing7 in a very active way,enabling children to channel their energy into goal-driventasks. These findings have implications for learning andclassroom behavior. Three studies specifically examinedthe use of yoga and meditation as a treatment for attentiondeficit hyperactivity disorder (ADHD) and would be con-sidered pilot in nature. One study by Jensen et al25 showedboth groups with improvements in several measurementscales with yoga participants improving significantly in thefive subscales of the Parents Rating Scales (CPRS). Thesecond study (Harrison et al)26 incorporated the entirefamily and measured treatment outcomes. A classroom-based study by Peck et al27 found yoga to improve time ontask in 10 elementary school children evidencing attentionproblems. Although these data do not provide strong sup-port for the use of yoga for ADHD, partly because the stud-ies are under-powered, they do suggest that yoga may havemerit as a complementary treatment for ADHD alreadystabilized on medication. Yoga remains an investigationaltreatment, but this study supports further research into itspossible uses to address behavioral challenges for this pop-ulation. These findings need to be replicated on largergroups with a more intensive supervised practice program.

Two studies suggest that academic learning of chil-dren developing typically may be further enhanced bymemory improvements afforded by yoga. In one of thesestudies, Manjunath et al28 compared performance of 90subjects in verbal and spatial memory tests. Thirty subjectswere in one of three groups: yoga camp, fine arts camp, orcontrol group. Members of the yoga group showed a 43%improvement in spatial memory test scores, while the finearts and control groups showed no change. Subjects in theyoga camp also engaged in game playing and story telling.However, we found it compelling that this group stillshowed improvement over the fine arts camp group, whomost likely also participated in similar social activities. Asecond study by Naveen et al strengthens the use of yogafor spatial memory scores. In this study, 108 school chil-dren aged 10 to 17 years were divided into four groups,each practicing in a different type of yoga breathing.29 Allfour groups evidenced improved spatial memory scores byan average of 84%. Verbal memory scores were also mea-sured in both these studies, and seem to remain unchangedafter the interventions.

Application of yoga for children with mental retarda-tion also shows promise. Uma et al30 demonstrated signif-icant improvements in IQ and social parameters comparedwith a control group through an intervention for 1 aca-demic year. Changes occurring at the neuromuscular levelenabled the more global effects of behavioral and cognitiveenhancements. Such benefits may be applied along thespectrum of children with neurological impairments butfurther RCT are needed to determine definitive use of yoga.

TABL

E2

Con

tinu

ed

No.

Stud

y1s

t/2n

dR

evie

wer

Feat

ures

Part

icip

ants

Inte

rven

tion

End

poin

tsSu

mm

ary

Evi

denc

eLe

vel

9T

elle

set

al21

RG

/MLG

Det

erm

ine

the

effe

ctof

yoga

onst

atic

mot

orpe

rfor

man

cein

child

ren.

Eac

hgr

oup

was

asse

ssed

ona

stea

dine

sste

stat

the

begi

nnin

gan

den

dof

the

stud

y.

Tw

ogr

oups

of45

child

ren

each

,(a

ged

9–13

yrs)

.Fo

r10

days

,one

grou

pre

ceiv

edtr

aini

ngin

yoga

(asa

nas,

pran

ayam

a,m

aint

enan

ceof

sile

nce,

visu

alfo

cusi

ngex

erci

ses,

and

gam

esto

impr

ove

atte

ntio

nsp

anan

dm

emor

y),w

hile

the

othe

rgr

oup

carr

ied

outt

heir

usua

lrou

tine

.

Aft

er10

days

,the

yoga

grou

psh

owed

asi

gnifi

cant

decr

ease

iner

rors

onth

est

eadi

ness

test

,whe

reas

the

“con

trol

grou

p”sh

owed

noch

ange

.

Chi

ldre

nen

gage

din

the

yoga

prog

ram

disp

laye

dim

prov

emen

tin

stat

icm

otor

perf

orm

ance

.

2B

10U

ma30

RG

/MLG

To

stud

yth

eef

fect

ofyo

gaon

child

ren

wit

hM

Rof

mild

,m

oder

ate,

and

seve

rede

gree

inw

ith

resp

ectt

oIQ

and

soci

alad

apta

tion

para

met

ers.

90ch

ildre

nse

lect

edfr

omfo

ursp

ecia

lsch

ools

(45

stud

ents

inyo

gatr

aini

nggr

oup

com

pare

dto

45st

uden

tsw

hoco

ntin

ued

thei

rus

uals

choo

lrou

tine

).

Exp

erim

enta

lgro

upun

derw

enty

ogic

trai

ning

for

1ac

adem

icye

ar(5

hin

ever

yw

eek)

wit

han

inte

grat

edse

tofy

ogic

prac

tice

s.

Hig

hly

sign

ifica

ntim

prov

emen

tin

the

IQan

dso

cial

adap

tati

onpa

ram

eter

sin

the

yoga

grou

pas

com

pare

dto

the

cont

rol(

pair

edtt

est)

.

Thi

sst

udy

show

sth

eef

ficac

yof

yoga

asan

effe

ctiv

eth

erap

euti

cto

olin

the

man

agem

ento

fchi

ldre

nw

ith

MR

.

2B


CARDIOPULMONARY EFFECTS OF YOGA

Ten articles were reviewed in the cardiopulmonarypractice pattern. Seven of the 10 reviewed articles wereclassified as level 2B, two as level 3B, and one as level 4(Table 3). Although the quality of evidence was varied, weconsidered all the articles enriching to our discussion.These studies reveal that yoga may be used with typicalchildren, and with physically or emotionally impaired chil-dren to improve cardiorespiratory parameters. Further,these studies also demonstrate that the processes initiatedby yoga practice can have an impact on the more globalissues of socialization and stress management. It is impor-tant to note that physical impairments are often heavilyinfluenced by psychosocial factors. Therefore, PTs mayconsider yoga as an adjunct for pediatric cardiopulmonaryrehabilitation.

A primary emphasis in the practice of yoga is con-trolled-breathing techniques. This idea leads to new re-search on children with cardiopulmonary impairments.Our search yielded four studies that demonstrate yoga’smechanism of action on subjects with healthy cardiac func-tion. First, a study by Udupa et al31 analyzed the effects ofpranayama training (voluntary regulation of breathing) oncardiac function in normal young volunteers. Twenty-fourschool children were divided into a pranayama group and acontrol group. The pranayama group practiced breathingtechniques for 20 minutes daily for 3 months. A controlgroup maintained normal breathing. Researchers foundthat pranayama training effectively modulated ventricularperformance by decreasing sympathetic output and therebyincreasing parasympathetic output. This study providedbaseline evidence for the efficacy of yoga on cardiorespira-tory parameters in normal volunteers, and allowed for ex-panded research into populations with pathology.

Three additional studies examined the effects of yogaon volunteers with normal cardiac function who also hadanxiety. Such studies are important in that they implicatepsychosocial issues as contributors to autonomic impair-ments. This idea was supported by Telles et al32 in a studyon physically normal but socially or emotionally trauma-tized girls. In their study the researchers randomly selected40 girls between 12 and 16 years of age from a total of 120girls in a community home. All subjects had a history ofadjustment difficulties either at home or in society. Thestudy aimed to determine differences in autonomic andrespiratory parameters between these girls and those of thesame age living at home and attending a regular school.The community home group was found to have signifi-cantly higher breath rates, more irregular breathing pat-terns, and lower skin resistance values than their age-matched peers. These attributes are known to correlatewith fear and anxiety.33,34 Additionally, the study aimed tocompare the effects of two interventions—yoga andgames—on the same physiologic measurements. For anhour daily over a 6-month period, half of the communityhome girls engaged in relaxing yoga, while the other halfengaged in physical games such as relay races. Those par-

ticipating in the yoga arm of the study were found to havea significant decrease in breath rate, which seemed moreregular, but no significant increase in skin resistance. Bothgroups showed a significant decrease in resting heart rate.These findings suggest that yoga practice may reduce levelsof fear and anxiety more so than physical activity alone.This has implications for setting the background of emo-tional stability to execute physical demands of everydayactivity.

Platania-Solazzo et al35 conducted a study with similarimplications, in which the effects of relaxation therapywere assessed in a population of 40 hospitalized childrenand adolescents who had a diagnosis of adjustment disor-der and depression. This study assessed yoga’s effect, alongwith massage and relaxation, on decreases in self-reportedanxiety, anxious behavior, and fidgeting as well as in-creased positive affect. Decreases in cortisol levels werealso noted, which have an indirect effect on the cardiore-spiratory health of children.36 PT traditionally incorporatesseveral of the aspects mentioned in this intervention (mas-sage, relaxation, and biofeedback), suggesting that yoga asa modality may provide unique and creative ways to attaingoals in the cardiopulmonary practice pattern. Becausethis program incorporated massage, the specific effectsof the yoga component are difficult to determine. How-ever, we considered this evidence to be notable, espe-cially since the elements of relaxation and biofeedbackare intrinsic to the practice of yoga itself.

An additional study by Telles and Srinivas explored apopulation with normal cardiac function but increased lev-els of anxiety. This study analyzed the cardiopulmonaryeffects of yoga on volunteers who were visually impaired(VI).37 This sample displayed similar baseline measure-ments to the socially or emotionally traumatized popula-tion of community home girls32: higher breath rates, heartrates, and diastolic blood pressure. Previous studies foundthat young people with VI have significantly higher levelsof anxiety than their age-matched peers,38 to which in-creases in heart rate is often attributed. In the Telles andSrinivas study, 24 children with VI, ages 12 to 17 years,were age matched with normal-sighted peers. Half of thepairs participated in yoga for an hour each day, while theother half of the pairs performed “physical activity” work-ing in the garden and stretching. After 3 weeks, the rate ofrespiration was reduced in the children with VI who par-ticipated in yoga. There was no change in the children whoparticipated in the physical activity group. These resultsshow that although children with VI have higher physio-logic arousal than children who are normal-sighted, thisarousal may be reduced after participation in yoga. Thesestudies point out yoga’s utility in children with psychoso-cial impairments.

Four studies explored the effect of yoga on childrenwith specific respiratory impairments, namely, asthma.However, only one of these studies39 restricted participa-tion to the pediatric population. In the study by Jain et al39,46 children, with a mean age of 15.8 years and a childhoodhistory of asthma, were followed through 40 days of yoga


TABL

E3

Car

diop

ulm

onar

yE

vide

nce

No.

Stud

y1s

t/2n

dR

evie

wer

Feat

ures

Part

icip

ants

Inte

rven

tion

End

poin

tsSu

mm

ary

Evi

denc

eLe

vel

1C

lanc

eet

al43

RG

/MLG

To

eval

uate

the

effe

cts

ofa

grou

ppr

oces

sai

med

atin

crea

sing

the

body

sati

sfac

tion

ofch

ildre

nth

roug

hth

eus

eof

yoga

exer

cise

san

daw

aren

ess

trai

ning

.

12A

fric

anA

mer

ican

3rd

year

stud

ents

enro

lled

inan

elem

enta

rysc

hool

ina

larg

eso

uthe

rnci

ty.T

hese

subj

ects

wer

ese

lect

edfr

oma

pool

of17

stud

ents

iden

tifie

dby

thei

rPE

inst

ruct

oras

poor

lyco

ordi

nate

dan

dm

inim

ally

invo

lved

inPE

clas

ses,

rece

ivin

glo

wes

tsco

res

ona

subj

ecti

vete

stm

easu

ring

body

sati

sfac

tion

.Sub

ject

sw

ere

then

rand

omly

assi

gned

toei

ther

aco

ntro

l(n

"6)

orex

peri

men

tal

grou

p(n

"6)

.

Tre

atm

ents

essi

ons

cond

ucte

d3%

/wee

kfo

r4

wee

ksin

30m

inse

ssio

ns.E

xper

imen

tal

grou

pre

ceiv

edyo

gaex

erci

ses

deve

lope

dfo

rch

ildre

nan

daw

aren

ess

exer

cise

s,w

hile

the

cont

rol

grou

pco

ntin

ued

toat

tend

regu

lar

PEcl

asse

s.

Exp

erim

enta

lgro

upsh

owed

anin

crea

sein

dem

onst

rate

dbo

dysa

tisf

acti

onas

per

Chi

ldre

n’s

Body

Sati

sfac

tion

Tes

tand

Hum

anFi

gure

Dra

win

gte

sts,

whe

reas

nosu

chch

ange

was

foun

din

the

cont

rolg

roup

.

Yoga

appe

ars

tofa

cilit

ate

impr

ovem

enti

nbo

dysa

tisf

acti

on.F

urth

er,y

oga

may

pres

enta

mea

nsof

chan

ging

nega

tive

eval

uati

ons

ofth

ese

lfan

dth

ebo

dybe

fore

thes

ebe

com

ede

eply

engr

aine

din

the

self-

conc

epto

fthe

child

.

4

2Ja

inet

al39

RG

/MLG

To

exam

ine

the

effe

cts

ofyo

gaon

rest

ing

pulm

onar

yfu

ncti

ons,

exer

cise

capa

city

,and

exer

cise

-ind

uced

bron

chia

llab

ility

inde

xin

youn

gch

ildre

nw

ith

ahi

stor

yof

child

hood

asth

ma.

46yo

ung

child

ren

wit

ha

hist

ory

ofch

ildho

odas

thm

a(m

ean

age

"15

.8yr

s).A

llsu

bjec

tsha

da

clin

ical

hist

ory

and

evid

ence

ofre

curr

ent

epis

odes

ofas

thm

adu

ring

the

last

year

.All

part

icip

ants

had

mild

tom

oder

ate

asth

ma

and

exer

cise

-in

duce

dbr

onch

ocon

stri

ctio

n.

Subj

ects

adm

itte

dfo

r40

days

inth

eho

spit

alof

the

Cen

tral

Res

earc

hIn

stit

ute

for

Yoga

.Dai

lyyo

gafo

r90

min

inth

em

orni

ngan

d1

hrin

the

even

ing

was

taug

htby

ate

amof

yoga

inst

ruct

ors

(yog

iccl

eans

ing

proc

edur

es,

post

ures

,and

brea

thin

g).

Yoga

trai

ning

resu

lted

ina

sign

ifica

ntin

crea

sein

pulm

onar

yfu

ncti

onan

dex

erci

seca

paci

ty.A

follo

w-u

pst

udy

span

ning

2yr

ssh

owed

ago

odre

spon

sew

ith

redu

ced

sym

ptom

scor

ean

ddr

ugre

quir

emen

tsin

thes

esu

bjec

ts.

Itis

conc

lude

dth

atyo

gatr

aini

ngis

bene

ficia

land

may

impr

ove

FVC

,FE

V,

and

MM

FR.T

hefin

ding

ssh

owth

atyo

gatr

aini

ngde

crea

sed

exer

cise

indu

ced

bron

choc

onst

rict

ion.

2B

3K

hana

met

al42

MLG

/LQ

Exa

min

edw

heth

erau

tono

mic

and

pulm

onar

yfu

ncti

ons

are

impr

oved

afte

ra

shor

t-te

rmyo

gatr

aini

ng.

Six

mal

esan

dth

ree

fem

ales

wit

hag

era

nges

12–6

0yr

s(w

ith

aver

age

dura

tion

ofdi

seas

e13

.55

yrs)

.

Yoga

asan

as,p

rana

yam

atw

ice/

day

for

1hr

each

sess

ion

(14

sess

ions

)fo

r7

days

ata

cam

pin

New

Del

hi.P

atie

nts

wer

eke

ptun

der

the

sam

ere

laxe

den

viro

nmen

tal

cond

itio

ns.

RH

Rsi

gnifi

cant

lyde

crea

sed;

sym

path

etic

reac

tivi

tyre

duce

d;Pu

lmon

ary

func

tion

test

ssh

owed

impr

ovem

ent.

Ver

ysm

alls

ampl

esi

ze,b

utin

itia

lsug

gest

ion

that

pers

ons

wit

has

thm

aca

nbe

nefit

from

ash

ort-

term

yoga

prog

ram

.

3B

4N

agen

dra

and

Nag

arat

hna41

MLG

/LQ

Pros

pect

ive

coho

rtfo

llow

ed57

0su

bjec

tsw

ith

asth

ma

for

3–54

mos

and

mea

sure

dcl

inic

alca

rdio

pulm

onar

ypa

ram

eter

sov

erti

me

(par

amet

ers

are

exte

nsiv

e,ra

ngin

gfr

omno

.ofa

ttac

kspe

rw

eek

tosp

utum

prod

ucti

on).

Age

rang

e7–

78yr

s;m

ajor

ity

ofpa

rtic

ipan

tsw

ere

mal

es;c

linic

alst

udy

over

ape

riod

of3

yrs.

Yoga

trai

ning

for

2w

eeks

(2.5

hrda

ily)

or4

wee

ks(1

.25

hr)

incl

uded

asan

as,

pran

ayam

a,m

edit

atio

n,de

voti

onal

sess

ion

and

lect

ure.

Coh

ortw

asfo

llow

edfo

r3–

54m

os.P

arti

cipa

nts

cate

gori

zed

into

1of

3gr

oups

:tho

sew

hopr

acti

ced

irre

gula

rly,

regu

larl

y,an

dth

ose

that

disc

onti

nued

;Sub

ject

ive

and

obje

ctiv

eda

taco

llect

edon

30pa

ram

eter

s(1

8sp

ecifi

can

d12

gene

ral)

.

Reg

ular

grou

ppr

acti

cesh

owed

mos

tim

prov

emen

tw

hile

the

irre

gula

rgr

oup

the

leas

t;pe

akex

pira

tory

flow

rate

show

edsi

gnifi

cant

impr

ovem

ent

tow

ard

norm

alcy

;ap

prox

imat

ely

69%

ofth

eto

talg

roup

redu

ced

orst

oppe

dm

edic

atio

n;m

ost

ofth

esp

ecifi

cpa

ram

eter

sim

prov

ed.

2B

(Con

tinu

ed)


TABL

E3

Con

tinu

ed

No.

Stud

y1s

t/2n

dR

evie

wer

Feat

ures

Part

icip

ants

Inte

rven

tion

End

poin

tsSu

mm

ary

Evi

denc

eLe

vel

5N

agar

athn

aan

dN

agen

dra40

MLG

/LQ

Cas

eco

ntro

lled

clin

ical

tria

lto

dete

rmin

eth

ebe

nefit

sof

yoga

onas

thm

a.

106

pati

ents

wit

hes

tabl

ishe

dbr

onch

ial

asth

ma.

Fift

y-th

ree

rand

omly

allo

cate

dpa

tien

tsw

illin

gly

serv

edas

cont

rols

,con

tinu

ing

taki

ngth

eir

usua

ldru

gsdu

ring

the

stud

y.A

gera

nge

9–47

yrs;

38m

ales

and

15fe

mal

es.5

3pa

irs

mat

ched

for

age

and

sex,

type

and

seve

rity

ofas

thm

a.

Tw

ow

eek

trai

ning

inan

inte

grat

edse

tofy

oga

exer

cise

s(b

reat

hing

,m

edit

atio

nan

dde

voti

onal

sess

ion)

for

65m

inda

ily.

Cas

e-co

ntro

lgro

ups

wer

efo

llow

edfo

rup

to30

mos

.All

wer

eev

alua

ted

at6

mo

inte

rval

son

num

bers

ofat

tack

s,se

veri

tysc

ore,

drug

trea

tmen

tsco

rean

dpe

akflo

wra

te.

Dro

p-ou

trat

ehi

gh(2

5su

bjec

ts).

How

ever

,the

rew

asa

sign

ifica

ntly

grea

ter

impr

ovem

enti

nth

eyo

gagr

oup

inth

ew

eekl

ynu

mbe

rof

asth

ma

atta

cks,

scor

esfo

rdr

ugtr

eatm

ent,

and

peak

flow

rate

.

3B

6Pl

atan

ia-S

olaz

zoet

al35

RG

/MLG

The

imm

edia

teef

fect

sof

rela

xati

onth

erap

yw

ere

asse

ssed

in40

hosp

ital

ized

child

ren

and

adol

esce

nts

(age

s8–

19,m

ean

"13

.4w

ith

1/2

the

sam

ple

bein

gad

oles

cent

)w

ith

diag

nose

sof

adju

stm

ent

diso

rder

and

depr

essi

on.

Rel

axat

ion

ther

apy

(RT

)ef

fect

sw

ere

asse

ssed

usin

ga

wit

hin

subj

ects

pret

est/

post

test

desi

gnan

dby

com

pari

son

wit

ha

cont

rolg

roup

of20

depr

esse

dan

dad

just

men

tdi

sord

erpa

tien

tsw

how

atch

eda

1hr

rela

xing

vide

otap

e.(4

0in

expe

rim

enta

lgro

up,2

0in

cont

rol)

.

The

1hr

RT

clas

sco

nsis

ted

ofyo

gaex

erci

se,a

brie

fm

assa

ge,a

ndpr

ogre

ssiv

em

uscl

ere

laxa

tion

.Thi

scl

ass

was

offe

red

two

tim

esa

wee

k.

Dec

reas

esw

ere

note

dIn

both

self-

repo

rted

anxi

ety

and

inan

xiou

sbe

havi

oran

dfid

geti

ngas

wel

las

incr

ease

sin

posi

tive

affe

ctin

the

RT

grou

p,bu

tnot

the

vide

ogr

oup.

Inad

diti

on,

adju

stm

entd

isor

der

pts

and

a1/

3of

depr

esse

dpt

ssh

owed

decr

ease

sin

cort

isol

leve

lsfo

llow

ing

RT

,whi

leno

chan

ges

wer

eno

ted

inth

evi

deo

grou

p.

Both

diag

nost

icgr

oups

(adj

ustm

entd

isor

der

and

depr

essi

on)

appe

ared

tobe

nefit

from

the

RT

clas

s.

2B

7St

ueck

and

Glo

eckn

er5

RG

/MLG

Tra

inin

gof

rela

xati

onw

ith

elem

ents

ofyo

gafo

rch

ildre

nte

chni

que

(Str

ess

hand

ling

prog

ram

).

48fif

thgr

ade-

pupi

lsw

hosh

owed

abno

rmal

exam

inat

ion

anxi

ety.

21w

ere

plac

edin

expe

rim

enta

lgro

up,

and

27in

toco

ntro

lgro

up.

15se

ssio

nsof

60m

in(r

elax

atio

n,yo

ga,a

ndgr

oup

acti

vity

).

Pre/

post

com

pari

son

ofps

ycho

logi

can

dph

ysio

logi

cva

riab

les

wit

hth

ree

mea

suri

ngin

terv

als

(rat

ing

scal

esof

subj

ecti

vefe

elin

gsan

del

ectr

oder

mal

acti

vity

).

Tra

inin

gca

nin

crea

seem

otio

nalb

alan

cein

the

long

-ter

man

dre

duce

fear

s.Fe

elin

gof

help

less

ness

was

clea

rly

redu

ced.

2B

8T

elle

set

al32

MLG

/LQ

Det

erm

ine

diff

eren

ces

inH

R,b

reat

hing

rate

and

skin

resi

stan

cebe

twee

na

yoga

prog

ram

ora

grou

pth

atpa

rtic

ipat

edin

gam

es.

28gi

rls

(age

d12

–16

yrs)

from

com

mun

ity

hom

esw

ith

ahi

stor

yof

diff

icul

tyin

adju

stin

gat

hom

eor

inso

ciet

y.14

pair

sw

ere

mat

ched

for

age

and

dura

tion

ofst

ayin

the

hom

ean

dra

ndom

assi

gnm

entt

oei

ther

grou

p(y

oga

orga

mes

).

Inte

rven

tion

last

edfo

r6

mos

:1

hrev

ery

day

ofyo

ga(p

ostu

res

for

50m

inan

dre

laxa

tion

for

10m

in)

or1

hrga

mes

(40

min

)an

dre

lay

race

s(2

0m

in).

Mea

sure

men

tsta

ken:

EK

Gan

dvo

lum

etri

cpr

essu

retr

ansd

ucer

(for

resp

irat

ion

and

skin

resi

stan

ce).

Yoga

and

gam

esde

crea

ses

HR

;yog

aal

sosi

gnifi

cant

lyde

crea

sed

brea

thra

te;n

osi

gnifi

cant

chan

gein

skin

resi

stan

cein

eith

ergr

oup.

Res

ults

sugg

estt

hata

yoga

prog

ram

whi

chin

clud

esre

laxa

tion

,aw

aren

ess,

and

grad

edph

ysic

alac

tivi

tyis

aus

eful

addi

tion

toth

ero

utin

eof

child

ren

inth

eco

mm

unit

yho

me.

2B

(Con

tinu

ed)


training. Increased capacity was found in the subjects’forced expiratory volume, distance walked in a 12-minutetime period, and overall physical fitness as assessed by amodified Harvard Step Test. Although only 26 patientscould be followed for up to 2 years, these patients showedcontinued reduction in symptoms, along with decreaseddrug requirements. Additionally, 14 of these patients (allinitially diagnosed with mild asthma) who continued yogapractices everyday for 15 to 30 minutes remained asymp-tomatic, suggesting the utility of regular practice.

Three additional studies strengthen the evidence foryoga in the asthmatic population. However, these studiesinclude, but are not necessarily restricted to the pediatric pop-ulation. Two of these studies were conducted by Nagendra etal.40,41 In 1985, a case controlled study by Nagendra et al40

reported significant improvements in the weekly numberof asthma attacks, scores for drug treatment, and peak flowrate in yoga participants versus nonparticipants. Subjectswere matched for age, sex, type, severity and duration ofasthma. The rigor of this study was weakened by a highdropout rate. In 1986, Nagendra et al41 strengthened theirfindings with a prospective cohort study of 570 asthmatics,which explored the use of yoga over an extended timeperiod (ranging from 3 months to 4.5 years). Results re-vealed regularity of practice to be the strongest predictor ofimproved peak expiratory flow and decreased use of med-ication. An additional study by Khanam et al42 found apositive correlation between yoga and cardiopulmonaryimprovements. This study was underpowered with a mark-edly shorter time frame of intervention (7 days), suggestingthat asthmatics can benefit from even a short-term yogaprogram.

Two additional studies suggest that yoga may improvecardiorespiratory parameters in children as a secondaryeffect of decreased anxiety. Clance et al43 analyzed the ef-fects of yoga on body satisfaction in a study involving 12third grade students. Six students in the experimentalgroup receiving yoga demonstrated improvements in self-image, while the six students in the control group did not.These results suggest that yoga may reduce stress and anx-iety related to low body satisfaction or poor self-image inchildren. Further, the breathing techniques used in yogafoster decreased anxiety.32 Although underpowered andconsidered pilot in nature, this study has important impli-cations for the physical aspects of development that areindirectly impacted by psychosocial parameters.

Further, a study by Stueck et al5 found that yoga andrelaxation techniques may increase emotional balance inthe long term, reduce fears and feelings of helplessness, aswell as aggression and negative feelings, and improve over-all well-being. This study used a stress-handling programwith elements of yoga in 48 fifth grade students withexamination anxiety. Postintervention, the participantstransferred the learned breathing techniques and self-instructions to situations beyond school to promotehealthy stress management and stress prevention, bothof which are a means of primary prevention of cardio-pulmonary complications.44

TABL

E3

Con

tinu

ed

No.

Stud

y1s

t/2n

dR

evie

wer

Feat

ures

Part

icip

ants

Inte

rven

tion

End

poin

tsSu

mm

ary

Evi

denc

eLe

vel

9T

elle

san

dSr

iniv

as37

MLG

/LQ

Asc

erta

indi

ffer

ence

sbe

twee

nra

tes

ofbr

eath

ing,

HR

and

dias

tolic

BPbe

twee

nch

ildre

nw

hoar

evi

sual

lyim

pair

edan

dth

ose

who

are

norm

alsi

ghte

dan

dth

eef

fect

sof

yoga

vsph

ysic

alac

tivi

tyon

thes

epa

ram

eter

s.

28ch

ildre

n(a

ged

12–1

7yr

s)m

atch

edfo

rag

ean

dde

gree

ofbl

indn

ess

rand

omiz

edto

yoga

orph

ysic

alac

tivi

ty.

Inte

rven

tion

last

edfo

r3

wee

ks:1

hrev

ery

day

ofyo

ga(p

ostu

res

for

50m

inan

dre

laxa

tion

for

10m

in)

or1

hrof

phys

ical

acti

vity

(gar

deni

ngan

dst

retc

hing

).

Mea

sure

men

tsta

ken:

BP,

EK

G,v

olum

etri

cpr

essu

retr

ansd

ucer

(for

resp

irat

ion

and

skin

resi

stan

ce).

Aft

er3

wee

ks,y

oga

grou

psh

owed

sign

ifica

ntre

duct

ion

inbr

eath

rate

(no

chan

gein

phys

ical

acti

vity

).R

esul

tssu

gges

tth

atch

ildre

nw

ith

visu

alim

pair

men

thav

ehi

gher

phys

iolo

gica

laro

usal

than

child

ren

wit

hno

rmal

sigh

t,w

ith

am

argi

nalr

educ

tion

inar

ousa

lfol

low

ing

yoga

.

2B

10U

dupa

etal

31M

LG/L

QD

eter

min

ew

heth

erpr

anay

amtr

aini

ngha

san

effe

cton

vent

ricu

lar

perf

orm

ance

,in

effe

ctim

prov

ing

card

iore

spir

ator

yfu

ncti

ons.

24sc

hool

child

ren

(hea

lthy

boys

aged

13–1

5yr

s)ra

ndom

lyas

sign

edto

pran

ayam

brea

thin

gor

cont

rolf

or3

mos

.

Pran

ayam

brea

thin

gor

norm

albr

eath

ing,

20m

inda

ilyfo

ra

dura

tion

of3

mos

.

Syst

olic

tim

ein

terv

als

and

card

iac

auto

nom

icfu

ncti

onte

sts,

both

noni

nvas

ive

test

sfo

rm

easu

ring

vent

ricu

lar

perf

orm

ance

.

Pran

ayam

mod

ulat

esve

ntri

cula

rpe

rfor

man

ceby

incr

easi

ngpa

rasy

mpa

thet

icac

tivi

tyan

dde

crea

sing

sym

path

etic

acti

vity

.

2B


MUSCULOSKELETAL EFFECTS OF YOGA

We reviewed four studies pertaining to the musculo-skeletal practice pattern. Two of the four studies were clas-sified as 2B level of evidence, while the other two wereassigned level 3B (Table 4). These studies reveal that yogamay be used with children developing typically, or chil-dren who are not meeting national norms for fitness andbody composition, or children with elevated stress levels toimprove musculoskeletal parameters.

Orthopedic injuries in children are often caused bylack of strength and flexibility,45 which are addressed in themusculoskeletal practice pattern. The four studies re-viewed showed significant effects of yoga and its breathingtechniques on the musculoskeletal system in children.Three of these four studies were from the Indian Journal ofPhysiology and Pharmacology.46–48 Although these studieswere not very recent, they lay down the foundational workin this body of evidence, and provide a starting point uponwhich to build future studies. The results and conclusionsof these studies suggest that yoga can be introduced duringschool to improve physiological function, overall health,and performance of students. Further RCTs are needed todetermine definitive effects of yoga.

A study by Mandanmohan et al46 found that 6 monthsof yoga training in 20 school children aged 12 to15 yearsproduced significant gains in handgrip strength and endur-ance as well as inspiratory and expiratory muscle strength.This research design involved yoga training that took placeover more than 6 months, which allowed the study to ex-amine the long-term effects of yoga training. Perhaps fu-ture studies could involve a larger number of subjects, andexamine the effects of yoga after the 6 months of training.

Similar gains in grip strength were found in a study byRaghuraj et al,47 in which school children 11 to 18 years oldtook part in pranayama breathing for 10 days. Increasedgrip strength in both hands was found in the pranayamagroup, while no change was found in the control group.This study used random assignment to one of five groupsthat spanned a large range of children’s ages (11–18 yearsold). An additional study by Raghuraj and Telles replicatedthese findings of increased grip strength after 6 months ofyoga in 12- to 16-year-old girls.48 These gains have impli-cations for using yoga for total body strengthening.

Obesity, another growing concern in our pediatricpopulation, may also be reduced through the implementa-tion of yoga programs. A pilot study by Slawta et al49 enti-tled “Be a Fit Kid” included a 12-week program of yogadesigned to improve physical fitness and nutritional habitsin children. The program also included a physical activitycomponent (running, jumping, and strengthening) alongwith a nutrition program. After the intervention, signifi-cant improvements were found in body composition andfitness in those who participated 75% of the time. Becausethe “Be a Fit Kid” program used a holistic approach, thespecific effects of the yoga component are difficult to de-termine. However, we felt that the study was important toinclude, given that it portrays yoga as an important con-

tributor to an overall healthy lifestyle. Considering the re-cent trend of child participation in yoga classes, it is likelythat more studies investigating children who are obeseshould be conducted with more rigorous methodology.This pilot study established the framework for replicationin a larger, randomized sample.

Thus, in addressing the musculoskeletal issues of flex-ibility and strength, these studies demonstrate that yogacan have an impact on stress management and obesity.Both of these issues having a major impact on the social-ization of developing children, so it can be seen that yoganot only impacts physically, but also emotionally and psy-chosocially. Therefore, PTs can consider yoga as a toolfor not only musculoskeletal, neuromuscular, and car-diopulmonary problems, but also as a holistic approachto the entire mind– body of these children, thus address-ing many issues that arise in children developing typi-cally and atypically.

INTERPRETATION

This review summarizes available evidence regardingthe effects of yoga as an intervention for QOL and physicaloutcomes in children. None of the reviewed studies pro-vided adequate data to assess improvements in QOL over asignificant part of childhood and adolescence, as most wereof short duration. The 24 studies included in this reviewwere of variable quality, and none were considered to be ofhigh quality. Our conclusions are tempered by this fact.Clearly, further progress must be made to improve re-search quality and include measures of QOL. Future trialsshould focus on adequate randomization, concealment ofallocation, and blinding of outcome assessors throughoutthe study.

A noteworthy feature of trials included in this reviewwas the wide variability in study interventions. Many dif-ferent types of yoga regimens were prescribed. The diver-sity in yoga prescription is not surprising, given the culturefrom which yoga emanates. Westernization of this modal-ity may compromise the full intent of yoga practice inthe United States when compared with India. Con-versely, the wide variety in study outcomes and mea-surement methods is surprising. The short duration orcomplete lack of follow-up data examining the effect ofyoga on QOL and rehabilitative outcomes in the longterm are also noted. Moreover, data are lacking to sup-port the use of yoga in preventing further disability inthese three practice patterns.

A further limitation is the nonspecificity with re-spect to the timing of the yoga intervention. Clinicalheterogeneity was evident, particularly, in trials carriedout during treatment for asthma. This resulted from tri-als in which the participants were undergoing one of avariety of additional drug treatments; therefore, con-founding issues are of concern.

Finally, poor adverse event reporting in most of thestudies limits any conclusions about the relative safety ofyoga as an exercise, and the small samples provide insuffi-cient power to detect meaningful differences in rates of rare


TABL

E4

Mus

culo

skel

etal

Evi

denc

e

No.

Stud

y1s

t/2n

dR

evie

wer

Feat

ures

Part

icip

ants

Inte

rven

tion

End

poin

tsSu

mm

ary

Evi

denc

eLe

vel

1M

anda

nmoh

anet

al46

LQ/R

G/

MLG

Eff

ecto

fyog

atr

aini

ngon

resp

irat

ory

pres

sure

san

dha

ndgr

ipen

dura

nce.

40st

uden

tvol

unte

ers,

ages

12to

15yr

s.Yo

gatr

aini

ng(a

sana

san

dpr

anay

amas

)fo

r6

mos

and

cont

rolg

roup

.

Yoga

trai

ning

prod

uced

stat

isti

cally

sign

ifica

nt(p

$0.

05)

incr

ease

inha

ndgr

ipst

reng

than

dha

ndgr

ipen

dura

nce.

Yoga

trai

ning

prod

uced

stat

isti

cally

sign

ifica

nt(p

$0.

001)

incr

ease

inm

axim

umex

pira

tory

pres

sure

,m

axim

umin

spir

ator

ypr

essu

re,

forc

edex

pira

tory

volu

me,

and

peak

expi

rato

ryflo

wra

te.

Yoga

trai

ning

for

6m

osim

prov

eslu

ngfu

ncti

on,s

tren

gth

ofin

spir

ator

yan

dex

pira

tory

mus

cles

asw

ella

ssk

elet

alm

uscl

est

reng

than

den

dura

nce.

Itis

sugg

este

dth

atyo

gabe

intr

oduc

edat

scho

olto

impr

ove

phys

iolo

gica

lfun

ctio

n,ov

eral

lhea

lth,

and

perf

orm

ance

ofst

uden

ts.

3B

2R

aghu

raja

ndT

elle

s48

LQ/R

G/

MLG

Com

pare

mot

oran

dse

nsor

y(v

isua

l)pe

rfor

man

cein

thre

egr

oups

ofsu

bjec

ts:g

irls

ina

com

mun

ity

hom

ew

hoha

dle

arne

dyo

ga,

girl

sin

aco

mm

unit

yho

me

trai

ned

inph

ysic

alac

tivi

ty,a

ndgi

rls

who

wer

eat

tend

ing

are

gula

rsc

hool

.

80gi

rls

(age

s12

–16

yrs)

from

ast

ate-

com

mun

ity

hom

ebe

caus

eof

diff

icul

tyin

adju

stin

gat

hom

e,at

scho

ol,o

rin

soci

ety.

6m

osof

yoga

,6m

osof

phys

ical

trai

ning

,or

neit

her

(con

trol

grou

p).

Phys

ical

trai

ning

grou

pha

dsi

gnifi

cant

lylo

wer

crit

ical

flick

erfu

sion

freq

uenc

y,hi

gher

degr

eeof

opti

cali

llusi

on,a

ndlo

wer

righ

than

dgr

ipst

reng

thth

anco

ntro

lgro

up.Y

oga

grou

pha

dhi

gher

crit

ical

flick

erfu

sion

freq

uenc

y,lo

wer

degr

eeof

opti

cali

llusi

on,a

ndm

argi

nally

grea

ter

hand

grip

stre

ngth

than

the

phys

ical

trai

ning

grou

p,bu

tw

asno

tsig

nific

antl

ydi

ffer

ent

from

the

cont

rolg

roup

.

The

repo

rted

high

erst

ress

leve

lsin

com

mun

ity

hom

esu

bjec

tsre

duce

dse

nsor

ype

rcep

tion

byca

usin

gch

ange

atpe

riph

eral

and

cent

rall

evel

s.T

oso

me

exte

nt,y

oga

mod

ifies

this

effe

ct.A

ddit

iona

lly,y

oga

appe

ared

toim

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adverse events. For example, inverted postures can impactblood pressure50,51 and represents a barrier to exercise forsome patients, yet none of the included studies formallyexplained or monitored for the effect of specific postures.

The evidence suggests that yoga is an effective inter-vention to improve cardiorespiratory fitness, physicalfunctioning, and behavior in children and adolescents. Allthe studies showed an effect and this may due to researcheror selection bias. Although these preliminary results arepromising, the findings are based on a relatively smallnumber of trials with significant methodological weak-nesses. On the basis of our findings, we make the followingresearch recommendations. Methodologically rigorous stud-ies designed to examine different yoga regimens (see Table1) are needed to better understand the role of yoga as itimpacts the developing child and QOL. The yoga prescrip-tion should be reported in detail (frequency, intensity,time, and type of exercise) to allow for determination ofexercise dose–response. To this end, adherence to exerciseshould be reported for both completion of exercise sessions(attendance) and yoga intervention (intensity and dura-tion). Furthermore, monitoring of activity in the compar-ison group(s) is necessary to assess potential contamina-tion. Consensus is required on standardized methods ofassessing physical fitness and body composition to allowfor pooling of data and for comparisons across studies.Future trials should formally monitor for, and report theincidence of, potential adverse events such as change inblood pressure.

SUMMARY OF LITERATURE REVIEW

Complementary and alternative medicine (CAM)encompasses five areas of modalities according to theNational Institutes of Health—National Center for CAM: bi-ologically based interventions, manipulative and body-based methods, mind–body therapies, energy-based ap-proaches, and alternative medical systems. Yoga is onemind–body therapy that has emerged as an educational-based intervention and to improve various medical condi-tions for children.

Patient expectations regarding CAM interventionshave important implications for treatment adherence, at-trition, and clinical outcome.52 Little is known, however,about parent and child treatment expectations regardingCAM approaches, especially yoga for problems presentedby children and adolescents. One study revealed that par-ents often have higher expectations of CAM therapiesthan do their children.52 Additionally, enhanced expec-tations often resulted in better outcomes. Thus, the useof alternative modalities must take into considerationthese influential factors. Therefore, it is important thatPTs are increasingly aware of the potential complemen-tary and beneficial effects of various CAM modalities inchildren’s rehabilitation.

The use of yoga for rehabilitation may have diverseapplications. Yoga practice may benefit children with men-tal challenges by improving their mental ability, along withmotor coordination and social skills. Children with physi-

cal disabilities may also experience restoration of somedegree of functional ability after practicing yoga. Childrenwho are VI can decrease their abnormal anxiety levels, andchildren in a group home can improve their sleep, appetite,and general well being, as well as a decrease in physiolog-ical arousal.53

Evidence from the previous studies of yoga as a CAMintervention have implications for PTs in the neuromuscu-lar areas of learning, motor control, and coordination. PTsmight apply these findings to their patients with asthma orsimply as a form of biofeedback in stress management.Further, outcomes may be enhanced by applying findingsfrom these studies to young athletes or children who areoverweight. Regardless of the goal, yoga seems to be a mul-titasking modality that simultaneously treats physical im-pairments and psychosocial issues such as stress, anxiety,or hyperactivity. Many of these studies set out to measurepurely physical parameters, but encompass psychosocialissues. Moreover, many of the studies in this reviewoverlap or address multiple practice patterns, making itdifficult to distinguish the effects of yoga on one specificimpairment.

The available studies according to Sackett classifica-tion system17 are predominantly level 2B grade evidenceand below. It is well known that the inclusion of nonran-domized or uncontrolled trials leads to an overestimationof the effect of an intervention. Therefore, as noted in thestudies presented in this article, yoga has a consistent trendin improvement. However, it is recommended that moreRCTs be planned for future examination of the evidence foryoga to be consistently included into the PT plan of care.Specific measures of QOL should be added to physiologicdata collection. In addition, future meta-analyses should berestricted to RCTs whenever possible.54

Much of the literature reviewed has been conducted inIndia and comprises all the elements of yoga includingpostures (asanas), breathing (pranayama), and spirituality(meditation). As Eastern philosophies and practices aretaken to other countries, it may be compartmentalizedwithout the lack holism of the philosophy and practicewhen examined in research. Therefore, appropriate useand full description of the practice of yoga is required forfuture design of clinical trials. Further research is neededto explore the integration of yoga into clinical practice. PTstreating children have an opportunity to add to existingexercise protocols and incorporate the benefits of yoga.However, research is needed to determine the best forms ofyoga for children with specific impairments and to establish adose–response relationship for children of different ages.

This review of the literature supports evidence foryoga that guide us in determining issues that will be im-portant in the design of larger pediatric rehabilitation clin-ical trials. Future studies should examine the effect of yoga,as well as the magnitude and the variability of the responsethroughout childhood and adolescence. Compelling evi-dence exists that demonstrates the effect within the neuro-muscular, cardiopulmonary, and musculoskeletal practicepatterns. The breadth of these studies has implications in


all areas of PT practice, particularly in complementing ex-isting wellness programs and clinical interventions forchildren.

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