Research Articles

by Nikhil Ramburn and Sat Bir Singh Khalsa, Ph.D

Between 1960 and 1994, the population of those 85 years and older in the United States grew 274 percent and this fact, coupled with increased longevity, is significant since the elderly spend three times more on healthcare than their working counterparts. Therefore, it is important to understand better the pathophysiology of aging and possible therapies to slow its negative effects. The normal aging process results in several physiological changes. For example, there is alteration of pulmonary mechanics, respiratory muscle strength, gas exchange, and ventilatory control, which are the collective outcome of degradation to anatomical structures such as the bronchioles, alveoli, and intercostal muscles. The renal system is similarly affected by aging since the loss of the kidneys’ cortical tissue directly affects the filtration rate, which results in fluid and electrolyte abnormalities and eventual renal insufficiency. While specific pathological features have not been identified for gastrointestinal tract senescence, changes in neuromuscular function, changes in the structure of the gastrointestinal tract itself, and changes in the absorptive and secretory functions all alter normal gastrointestinal processes. Likewise, the size of the liver decreases after the age of 50, leading to decreases in protein synthesis, such as clotting factors. Common endocrine changes include menopause in women and a slow decline of testosterone in men. T-lymphocyte-mediated immunity is also impaired and the elderly are more susceptible to infections and communicable diseases. As far as neural changes, the elderly lose 6 percent to 11 percent of their brain cortex, which can lead to a decline in cognitive functioning and may also facilitate neurodegenerative processes such as Alzheimer’s, Parkinson’s, and Huntington’s diseases.

As to the underlying mechanisms and contributors, genetics are estimated to explain only 35 percent of lifespan and the physical and cognitive declines of old age. Aging is in fact a multifactorial process that which includes lifestyle factors such as diet and stress. It is interesting that the only kind of diet so far associated with longevity is a plant-based diet as seen in epidemiological studies in Okinawa, Japan and Loma Linda in California amongst other so-called “blue zones” of long-lived populations. Social, family, and community support has also been a significant factor in determining health and mortality. Managing stress, maintaining a healthy weight, and regular physical activity can all promote longevity. Yoga may provide many of the benefits of exercise such as maintaining cardiovascular and respiratory function but can also lengthen telomeres, which are the ends of the chromosomes important for genomic integrity that are known to deteriorate with chronic stress and aging that are, therefore, genetic markers of cellular health and aging. Both healthy behaviors and mind-body interventions positively influence telomere integrity.

Given that mind-body practices, such as yoga, have positive influences on stress, resilience, and health-related behaviors, there is good evidence that yoga has a positive influence on aging. For example, certain meditative forms of yoga, such as Kundalini Yoga (Kirtan Kriya meditation specifically), have been found to increase cerebral blood flow in areas of the prefrontal cortex associated with attention and has been shown to enhance memory through increased connectivity in the default mode network (DMN) of the brain, an area commonly involved in neurodegenerative disorders. Yoga breathing practices (pranayama) may also contribute to longevity by reducing stress through increasing activity of the parasympathetic nervous system (PNS) and down-regulating the hypothalamic–pituitary–adrenal (HPA) axis. Indeed, yogic breathing stimulates the afferent vagus nerves, which are the primary peripheral pathway of the PNS.

Yoga research has shown improvements in physical functioning in the elderly. In a recent meta-analysis, Australian and Swedish researchers reviewed six trials of relatively high methodological quality, totaling 307 participants, and found that yoga-based exercises resulted in small improvements in balance and medium improvements in physical mobility in people aged 60+ years old. Therefore, yoga may counteract immobility and fractures from falls which are both associated with senescence. A 2017 study at the Picardie Jules Verne University in France also found improvements in physical functioning, specifically proprioception. With aging, gait initiation is impacted due to functional degradation, but the researchers found that a group of elderly yoga practitioners had more lower leg muscle activation and a more stable gait initiation pattern when compared with a physically active group of elderly walkers. Lastly, a 32-week study from the University of Southern California (USC) compared twenty older adults averaging 70 years old who attended 60-minute Hatha yoga classes. The program incorporated physical postures as well as pranayama, and the results revealed significant improvements in physical function and lower-extremity strength, which correspond to the biomechanical improvements noted previously.

In addition, numerous cognitive benefits were found in the elderly who yoga practice. In a 2005 study conducted at the Psychiatric Neuroimaging Research Program of the Massachusetts General Hospital, researchers used magnetic resonance imaging to assess cortical thickness in 20 participants with extensive meditation experience. The participants were not monks, rather typical western meditation practitioners. While some were meditation teachers, others pursued traditional careers in fields such as law and healthcare. The researchers found that meditation may be associated with structural changes in areas of the brain that are important for sensory, cognitive, and emotional processing. These findings are significant, because they suggest that meditation may impact age-related declines in cortical structure. A subsequent study from the Israelita Albert Einstein Hospital in São Paulo, Brazil was the first study to examine the brain cortical thickness (CT) in elderly female yoga practitioners relative to controls. Twenty-one female elderly hatha yoga practitioners were recruited from the local yoga studios, and their brain CT was compared to 21 yoga-naive women of the same age, and physical activity. The study found significantly greater CT in the left prefrontal lobe in the women who had trained in yoga for a minimum of 8 years. These findings, once again, suggest that yoga practice may have a positive impact on mental health among the elderly through its neuroprotective effects.

Researchers have also investigated the impact of long-term yoga or meditation practice on fluid intelligence, a cognitive function involving the ability to solve new problems, use logic in new ways, and identify patterns. This capacity tends to peak early in life and decline as we enter old age. With the rapidly shifting technological landscape, the capacity to maintain fluid intelligence into old age will be critical in order to remain relevant and adaptive. In this study, fluid intelligence declined slower in long-term yoga practitioners and meditators relative to controls. The functional neural networks of yoga practitioners and meditators were also more resilient to damage compared to those of control subjects that did not practice. Furthermore, a study from the University of Illinois found that eight weeks of regular yoga practice resulted in improved working memory performance in sedentary older adults when compared to a stretching control group, thereby indicating that the mindfulness component of yoga is critical in its efficacy. These improvements were mediated by a decreased stress response as measured by salivary cortisol measurements (a biomarker of stress) and suggest that yoga may restore the balance in the stress-regulating systems in older adults, thereby preventing cognitive decline.

Studies in the field of molecular biology have shown that there are quantifiable changes with aging, specifically in genomic expression, in which changes in the activity of specific genes can be quantified as well as changes in the integrity of genes and telomeres. Since yoga can decrease oxidative damage to DNA and reduce cellular aging, researchers from the All India Institute of Medical Sciences (AIIMS), the premier medical research and clinical institution in India set out to determine whether yoga can impact telomere stability. Their 2018 review of the literature revealed that yoga may have a protective effect on telomere length and the telomerase enzyme responsible for maintaining the telomeres. Indeed, yoga may upregulate enzymes that degrade reactive oxygen species (ROS), thereby preventing oxidative damage to telomeric DNA sequences, which may explain these findings. In another study, AIIMS researchers set out to explore cellular aging through a prospective single-arm study. After just 12 weeks of a yoga and meditation-based lifestyle intervention, 96 healthy individuals had significant improvements in biomarkers of cellular aging compared to baseline values. ROS and cortisol were significantly lower and telomerase activity significantly increased, suggesting a reduced rate of cellular aging in yoga practitioners.

In summary, these encouraging findings suggest that yoga may be a viable strategy to slow down the aging process and maintain both physical and cognitive health into old age. Future trials with larger cohorts and long-term follow-ups will help us better understand the mechanisms underlying the beneficial biochemical changes induced by yoga practices.

Nikhil Rayburn grew up practicing yoga under mango trees in the tropics. He is a certified Kundalini Yoga teacher and has taught yoga to children and adults in Vermont, New Mexico, Connecticut, India, France, and Mauritius. He is a regular contributor to the Kundalini Research Institute newsletter and explores current yoga research.

Sat Bir Singh Khalsa, Ph.D. is the KRI Director of Research, Research Director for the Kripalu Center for Yoga & Health, and Assistant Professor of Medicine at Harvard Medical School. He has practiced a Kundalini Yoga lifestyle since 1973 and is a KRI certified Kundalini Yoga instructor. He has conducted research on yoga for insomnia, stress, anxiety disorders, and yoga in public schools. He is editor in chief of the International Journal of Yoga Therapy and The Principles and Practice of Yoga in Health Care and author of the Harvard Medical School ebook Your Brain on Yoga.

by Nikhil Ramburn and Sat Bir S. Khalsa, Ph.D.

Osteoporosis is the degeneration of bone tissue that occurs when new bone creation doesn’t keep up with the body’s natural process of old bone removal. Individuals may experience a decrease in height over time and localized pain, but many people have no symptoms until they experience a bone fracture. Women are more likely to develop osteoporosis, and a reduction in estrogen levels in women at menopause is one of the strongest risk factors for developing osteoporosis. Other risk factors include a diet low in calcium, obesity, comorbid inflammatory conditions such as Lupus and Rheumatoid Arthritis, and a sedentary lifestyle. Osteoporosis is considered a serious public health concern given that over 200 million people worldwide suffer from this disease, and approximately 30 percent of all postmenopausal women have osteoporosis in the United States.

Conventional pharmacotherapy includes bisphosphonates, a class of drugs for preventing bone density loss, although these have possible side effects including gastrointestinal toxicity, death of bone tissue in the jaw and other sites, and severe (and sometimes irreversible) leg cramps and bone pain. However, bone density is sensitive and responsive to physical activity. Numerous, controlled studies have demonstrated that people who exercise regularly have greater bone density than their sedentary counterparts. Resistance training and weight-bearing exercises can help slow down bone loss in part due to the dynamic loads delivered to the skeleton, which stimulates the deposition of more bone tissue. In addition, a diet containing green leafy vegetables along with nuts and legumes can provide the necessary calcium to reduce the risk of osteoporosis.

Complementary and integrative approaches such as yoga may offer many of the benefits of conventional exercise, while also enhancing balance, posture, flexibility, strength, and quality of life in the elderly. Indeed, yoga exercises may decrease fall risks and fractures because of their positive effects on balance. In addition, the ability to modify yoga exercises to accommodate individuals with a high risk of falls or fractures and who have limited strength makes this intervention particularly suitable to elderly osteoporotic patients. The combination of mild spinal flexion and extension, which are common within yoga practices, may decrease the risk for vertebral compression fractures whereas the moderate weight-bearing exercises in yoga can strengthen the core muscles that support the spine. A small 2009 feasibility pilot study found that markers of bone formation increased in osteogenic postmenopausal women after a 12-week yoga series, thereby indicating that yoga may have beneficial bone building effects in this group. Furthermore, a 2012 study at the University of Calgary investigated the reaction forces applied by Hatha yoga practitioners for the first time. The researchers found that a common 28-posture sequence applied a low impact Ground Reaction Force (GRF) to upper and lower extremities; however, further research is necessary to determine whether those forces are sufficient to maintain current bone health in yoga practitioners.

Preliminary biomedical research on the efficacy of yoga for osteoporosis is promising. In a single-group pilot study at the Columbia College of Physicians and Surgeons in New York in 2009, patients with osteoporosis or osteopenia (lower bone density than normal but not yet pathological) practiced a regimen of 10 yoga postures which were modified according to individual limitations. The poses included the triangle pose (Trikonasana), the upward and downward dog poses (Adho Mukha Svanasana and Urdhva Mukha Svanasana) amongst others. Each position was held for 20 to 30 seconds. Unfortunately, compliance was poor and only 11 patients out of 117 completed the 2-year protocol. Nevertheless, the results revealed statistically significant improvements in bone density scores in yoga practitioners, 5 patients with osteopenia were reclassified as normal, and 2 patients with osteoporosis were reclassified/downgraded to as osteopenia, thereby indicating that yoga exercises for as little as 8 to 10 minutes daily will increase bone density in older patients.

A subsequent study with a larger sample size was published in 2016 and documented a 10-year study of 741 internet-recruited volunteers. Participants used a 12-minute DVD of the yoga poses that would stimulate bone density (the same exercises from the pilot study described above). The poses were specifically selected to produce torque and bending of the proximal femur, compression of the pelvis, and twisting of the lumbar vertebral bodies as these are the most common sites of osteoporotic fractures. The researchers found that bone mineral density improved in hips, spine, and femur in the 227 moderately and fully compliant patients. In fact, monthly gain in bone density scores was significant in both the spine and femur while gains in hip bone density did not achieve statistical significance. Furthermore, no yoga-related injuries were imaged or reported. This current study therefore supports the efficacy and safety of yoga as a treatment for osteopenia and osteoporosis.

Another landmark study was a 5-year retrospective evaluation of Bikram Yoga in a select group of female Bikram Yoga instructors that had been practicing for at least three years and some for over 20 years. While high impact exercises can improve bone health, those same exercises are also well-documented to damage the hip and knee joints. The researchers therefore set out to ascertain whether the potential benefits of low impact weight-bearing Bikram Yoga exercises could offset those deleterious effects. The participants routinely did 4.5 hours of yoga a week but also actively taught yoga classes where they modeled the correct poses. These same participants, who remained active as instructors and practitioners, were scanned five years later. The researchers found that the premenopausal subjects showed an increase in bone density scores at the femoral neck, hip, and lumbar spine. In contrast, there was a decrease in bone mineral density in those same areas for post-menopausal subjects. Consequently, these results suggest that Bikram Yoga may be an effective countermeasure for preventing osteoporosis in pre-menopausal women but may not necessarily confer the same benefits to postmenopausal women.

More recently, researchers from the Bone Density Research Laboratory at the University of Oklahoma looked at the effects of an 8-month Ashtanga Yoga intervention on middle-aged premenopausal women using a randomized control design, the gold standard of scientific research. Thirty-four premenopausal women were randomly assigned to either a Yoga group (n = 16) or a control group (n = 18). The participants performed 60 minutes of an Ashtanga Yoga series including 15 minutes of warm- up exercises, 35 minutes of Yoga postures and 10 minutes of cool-down. After 8 months, the researchers found that serum markers of bone growth were maintained in the yoga group but significantly decreased in control subjects. On the other hand, no improvements in bone mineral density or tibia bone characteristics were noted. Therefore, these results suggest that regular, long-term Ashtanga Yoga had a small positive effect on bone formation.

In summary, the current body of evidence points towards increased bone mineral density with yoga practice, suggests improvements in serum markers of bone growth, and even demonstrates the potential for yoga to reverse bone loss that has reached the stages of osteopenia and osteoporosis. However, additional studies with larger randomized controlled trials and further investigation including a younger osteopenia-free population are necessary to support these findings and establish the benefits of yoga in relation to conventional exercises. Finally, some researchers warn that new pain and fractures can occur after participation in yoga flexion exercises given the extreme strain of some yoga positions. An assessment of fracture risk in older persons is critical in designing an effective and safe therapeutic yoga intervention.

by Nikhil Ramburn and Sat Bir Singh Khalsa, Ph.D

The prostate gland is part of the male reproductive system and is located just below the bladder and in front of the rectum. Cancer of the prostate manifests as an abnormal proliferation of cells. Although some men do not have any symptoms, prostate cancer is typically associated with painful or burning urination, blood in the urine or semen, difficulty emptying the bladder, and painful ejaculation. While researchers do not know the exact causes of prostate cancer, they have determined that certain genetic changes, whether inherited or acquired during a person’s lifetime, contribute to the disease. According to the American Cancer Society, a high consumption of red meat or high fat dairy products slightly increases the risk, while other risk factors include radiation or chemical exposure, older age (typically over 40), and a family history of prostate cancer. Prostate cancer is the second most common cancer in American men after skin cancer and is the second leading cause of cancer death with about 1 in 41 men predicted to die from this disease.

Although there are now a variety of conventional treatments for prostate cancer including surgeries, radiation, hormone therapy, and chemotherapy among others, reports suggest that 25-50 percent of prostate cancer patients use at least one complementary and integrative medicine modality. Acupuncture is popular and effective among patients who experience hot flashes as a side-effect of androgen-deprivation therapy for prostate cancer. A 2013 review of the literature on exercise and cancer found that populations who were more active had less side effects from anticancer therapy and greater chances of recovery. Yoga offers many of the benefits of exercise, but in addition, yoga is likely to also better improve stress, mood, pain perception, and self-efficacy in patients with cancer. Indeed, research has shown that yoga can improve quality of life and sleep-related outcomes in patients with lymphoma and breast cancer.

The 8-week Mindfulness Based Stress Reduction program, which incorporates meditation, body scan, and gentle yoga, in an early pilot study on 10 patients with early stage prostate cancer and 59 patients with breast cancer, showed significant improvements in overall quality of life scores, symptoms of stress, and sleep quality. The improvements in quality of life were associated with a decrease in activation of the stress hormone – cortisol. A follow-up study reported significant improvements at 6 and 12 months, showing that improvements in stress were maintained and that cortisol levels continued to decrease systematically over the course of the follow-up. The patients’ immune systems were likewise improved with a reduction in levels of pro-inflammatory cytokines.

In addition to stress, epidemiological data suggests that lifestyle choices such as diet may play an important role in cancer prevention. In 2003, in order to elucidate the effect of diet on prostate cancer, the lab of Dr. Dean Ornish (a pioneer of plant-based dietary intervention) conducted the Prostate Cancer Lifestyle Trial (PCLT), a randomized controlled trial (RCT), in which 93 men were assigned to either a control group or a vegan diet intervention group. The diet consisted of low-fat foods, legumes (including soy), whole grains, fruits and vegetables. In addition, the patients participated in stress management, psychosocial group support, and exercise programs including gentle yoga-based stretching, breathing, and meditation – this could therefore be considered a yoga lifestyle program. Adherence by intervention group participants was excellent at greater than 80 percent. They had a 4 percent decrease in prostate specific antigen (PSA, a measure of disease severity) whereas the non-intervention control patients had a 6 percent increase in PSA and 6 of those patients had to resort to conventional cancer treatment. Furthermore, no patients in the lifestyle intervention group needed radiation, surgery, or androgen deprivation therapy. Finally, when researchers exposed in vitro cancer cells to the serum of the lifestyle group patients, they observed 8 times more cancer growth inhibition than the control group serum, suggesting that this treatment approach had significant effects at the cellular and molecular level.

Cancer diagnosis and treatment is associated with significant psychosocial problems including stress, anxiety, denial, and exacerbated conflict with partners that needs to be addressed. Interviews with 44 of the participants in the PCLT group of the study after one year found that the lifestyle change intervention resulted in greater overall optimism and hope. In addition, patients experienced greater emotional availability and decreased conflict with their partners. Subsequent follow-up data also revealed significantly improved lifestyle behaviors compared with controls resulting in enhanced health-related quality of life (HR-QOL) scores and decreased stress. After 2 years, 27 percent of control group patients had reverted to conventional cancer treatment compared to less than 5 percent of the lifestyle group patients. These encouraging findings suggest that early-stage prostate cancer patients may be able to avoid or delay conventional treatment for at least 2 years by making changes in their diet and lifestyle.

Although the PCLT improvements in quality of life and mood and in the inhibition of cancer growth are important, molecular and biological outcomes, as strong objective outcome measures, are very worthy of analysis. Telomeres, which are protective DNA–protein complexes at the end chromosomes tend to shorten with disease and serve as a prognostic marker of risk, progression, and mortality in many types of cancer. In a pilot study funded by the US Department of Defense, Dr. Ornish and colleagues looked at the effects of a 3-month comprehensive lifestyle modification (with similar dietary and yoga-related practices to the PCLT) on 30 men with early stage prostate cancer. They found significantly increased levels of telomerase (the enzyme that counteracts telomere shortening). The researchers also identified significant modulation of biological processes that have critical roles in tumor growth and concluded that the intervention may change gene expression in the prostate. Remarkably, in the 5-year follow-up to this study, the relative telomere length in the experimental group continued increasing from baseline but decreased in the control group, therefore suggesting that long-term adherence to lifestyle changes can reverse damage to chromosomes.

The first study to examine the feasibility and benefit of a yoga program for prostate cancer survivors and their support persons was conducted by researchers at the University of Calgary in Canada. The yoga sessions ran weekly for 7 weeks and were 75 minutes in length. Participants were guided through gentle breathing, increasingly challenging yoga postures (as their flexibility improved over the 7 weeks) and 15 minutes of final relaxation in Shavasana pose. All the study participants, including their care-givers, reported significant improvements with regard to stress, fatigue, and mood after yoga. The researchers concluded that yoga therapy for prostate cancer survivors is a feasible intervention due to the high program adherence rate and the acute benefits for all participants.

In another landmark study, researchers from Neha Vapiwala’s lab at the University of Pennsylvania looked at the feasibility of an intensive yoga intervention for prostate cancer patients receiving outpatient radiotherapy. Although 18 of the 45 patients who started the program were unable to attend the requisite minimum number of yoga classes due to conflict with their radiation treatment times and the yoga class schedule, 12 of the remaining 27 participants attended over 50 percent of the classes. The results revealed reassuringly stable scores in erectile dysfunction, urinary incontinence, and quality of life. This prompted the researchers to conclude that a structured yoga intervention of twice-weekly classes was feasible for the cancer patients during a 6-9 week course of outpatient radiotherapy. They then conducted an RCT in which experimental group participants received twice-weekly yoga interventions over the 6- to 9-week courses of radiation therapy. Throughout the treatment, the yoga cohort reported significantly less fatigue than the controls. The sexual health scores and QOL emotional scores were also significantly higher in the yoga group.

In summary, these encouraging albeit preliminary findings suggest that yoga may be a viable complementary treatment for prostate cancer patients. The findings support the need for validation with larger cohorts and methods such as electronic activity tracking to better understand the underlying biochemical changes induced by the yoga practices. Future studies should address the previous limitations of attrition, unaccounted comorbid factors, bias, and small sample sizes. Future trials can also help us better understand the barriers to continued participation in yoga for prostate cancer survivors.

Nikhil Rayburn grew up practicing yoga under mango trees in the tropics. He is a certified Kundalini Yoga teacher and has taught yoga to children and adults in Vermont, New Mexico, Connecticut, India, France, and Mauritius. He is a regular contributor to the Kundalini Research Institute newsletter and explores current yoga research.

Sat Bir Singh Khalsa, Ph.D. is the KRI Director of Research, Research Director for the Kripalu Center for Yoga & Health, and Assistant Professor of Medicine at Harvard Medical School. He has practiced a Kundalini Yoga lifestyle since 1973 and is a KRI certified Kundalini Yoga instructor. He has conducted research on yoga for insomnia, stress, anxiety disorders, and yoga in public schools. He is editor in chief of the International Journal of Yoga Therapy and The Principles and Practice of Yoga in Health Care and author of the Harvard Medical School ebook Your Brain on Yoga.

By Sat Bir Singh Khalsa, Ph.D.

The ability to self-regulate internal states, either physical, mental, or emotional, is a fundamental construct underlying not only the field of mind-body medicine (which includes yoga), but also much of what is in the broader field of behavioral medicine. The practices in this realm include cognitive and meditation skills, relaxation techniques, and the contemplative mind-body practices of yoga, tai chi, and qi gong. Through these practices, one acquires the skills of regulating functions including physical movement, respiratory activity, cardiovascular functions, and cognitive and emotional activity and reactivity. Research studies have confirmed that yoga practice can lead to significant improvements in muscular tension, neuro-muscular activity and coordination, basal respiratory rate, blood pressure, heart rate, cognitive performance, meta-cognition, and management of mental stress and reactivity of emotion.

The control of some of these functions is mediated through the direct command of the central nervous system including the ability to consciously relax muscles and change respiration rate – this is somewhat self-evident. What has been of more interest scientifically, with respect to self-regulation, is the ability to exert control over processes believed to be automatically regulated, such as the autonomic nervous system, which can affect changes in the activity of internal organs and functions including heart activity, blood pressure, and metabolic rate. This is because historically, and even currently, in the field of medicine these activities have been believed to be out of the control of conscious will. One of the most well-known measures of this self-regulation of autonomic function is heart rate. Historically, what is of particular interest, are the early descriptions of instances/cases in the West that have suggested the feasibility of this kind of self-regulation.

William James was a very notable philosopher, psychologist, medical doctor, and Harvard faculty in the late 19th century. In fact, the Department of Psychology on the Harvard University campus now bears his name, William James Hall. He was a pioneer in the field of psychology who gained widespread recognition from his seminal 1890 textbook The Principles of Psychology, a tome of 1,200 pages taking 12 years to complete. He also had the opportunity to interact personally with yoga master and proponent Swami Vivekananda during his visits to Boston in the late 1800’s. This influenced his work in research on contemplative states and practices, and meditation specifically, culminating in his landmark 1902 book The Varieties of Religious Experience. He was one of the early academics to recognize and describe the mind-body interaction and the capacity for self-regulation. In his 1890 text he wrote a clear statement of the mind-body connection: “Mental states occasion also changes in the calibre of blood-vessels, or alteration in the heart-beats, or processes more subtle still, in glands and viscera. …it will be safe to lay down the general law that no mental modification ever occurs which is not accompanied or followed by a bodily change.” He then cites cases of “exceptional individuals” reporting direct effects on the heart rate at will –a famous medical anecdote of a Colonel Townsend who could stop his heart at will and a 1889 report on voluntary control of the heart by a Dr. S.A. Pease.

The case of Colonel Townsend can be traced back to its first description by George Cheyne M.D. in his 1733 book A Treatise of Diseases of all Kinds. He recounts being called to examine Townsend with two medical colleagues near the end of his life, as he was on his death bed suffering from a terminal disease. It was Townsend’s wish to convey to them an experience/phenomenon in which “…composing himself, he could die or expire when he pleased, and yet by an effort or somehow, he could come to life again.” Despite cautions by the doctors not to do a demonstration given his condition, the Colonel insisted, and Cheyne describes the event of that morning.

“We all three felt his pulse first: it was distinct, tho small and [weak]: and his heart had its usual beating. He composed himself on his back, and lay in a still posture some time: while I held his right hand, Dr. Baynard laid his hand on his heart, and Mr. Skrine held a clean [mirror] to his mouth. I found his pulse sink gradually, till at last I could not feel any, by the most exact and nice touch. Dr. Baynard could not feel the least motion in his heart nor Mr. Skrine the least soil of breath on the bright mirror he held to his mouth; then each of us by turns examined his arm, heart and breath but could not by the nicest scrutiny discover the least symptom of life in him.”

They then began to conclude that he had gone too far and had actually died. Surprisingly, after a half-hour he showed signs of life.

“As we were going away, we observed some motion about the body, and upon examination, found his pulse and the motion of his heart gradually returning: he began to breath gently and speak softly: we were all astonished to the last degree at this unexpected change, and after some further conversation with him, and among ourselves, went away fully satisfied as to all the particulars of this fact, but confounded and puzzled, and not able to form any rational scheme that might account for it.”.

Townsend died the next evening, leaving an intriguing anecdote about his possibility of controlling his heart.

The 1889 5-page report by Pease in the Boston Medical and Surgical Journal, the first U.S. medical journal and precursor to the New England Journal of Medicine, was entitled “Voluntary Control of the Heart”. In this paper he contended that “… we have now evidence that there are gifted individuals who have a certain amount of direct control over it” and noting that previously “physiologists have long been aware of the close relationship between the heart’s action and that of the brain; yet, for lack of sufficient evidence, have not granted that any direct control over the heart could be induced by a simple effort of the will”. He then recounts several anecdotes/cases of simple willful direct control of heart rate (including the Townsend report) distinguishing these from anecdotes describing an indirect effect on the heart rate due to physical/mechanical manipulation of the vagus nerve (such as physical pressure on the neck) or forced evocation of mental imagery or emotion (such as sadness). One of the cases he mentions describes the research by a Russian physician on an individual who was able to increase his heart rate, through direct willful control, by up to 35 beats per minute. Dr. Pease then presented a detailed analysis of heart, breath, and blood pressure recordings of an individual at Harvard Medical School who was also capable of increasing his heart rate, in this case by about 25 beats per minute. From his analysis, he concluded that this change was indeed through simple willful control or pure self-regulation of heart rate.

These articles and reports on control of heart rate occurring so early in the field of Western medicine indicate the early openness to the possibility and concept of the self-regulation of internal state. Once reports appeared in the West from India on advanced yogis who claimed the ability to self-regulate internal states, it was not so surprising that scientists began studies on these yogis. Ultimately, those studies provided a foundation for further research, the evolution of the field of biofeedback, and ultimately to our work in modern yoga research, which has expanded to studying the self-regulatory capabilities of yoga practices to change many internal psychophysiological functions. Most of these were believed to be out of the range of self-regulation, and most of modern medicine is still under that impression.

Sat Bir Singh Khalsa, Ph.D. is the KRI Director of Research, Research Director for the Kripalu Center for Yoga & Health, and Assistant Professor of Medicine at Harvard Medical School. He has practiced a Kundalini Yoga lifestyle since 1973 and is a KRI certified Kundalini Yoga instructor. He has conducted research on yoga for insomnia, stress, anxiety disorders, and yoga in public schools. He is editor in chief of the International Journal of Yoga Therapy and The Principles and Practice of Yoga in Health Care and author of the Harvard Medical School ebook Your Brain on Yoga.

by Ishpreet Singh, M.B.B.S. and Sat Bir Singh Khalsa, Ph.D.

Epilepsy is a disorder in which recurrent seizures are caused by abnormal electrical discharges in the brain. A person is diagnosed with epilepsy if they have two unprovoked seizures (or one unprovoked seizure with the likelihood of more) that were not caused by some known and reversible medical condition. There are different types of seizures. Generalized onset seizures affect both sides of the brain or groups of cells on both sides of the brain at the same time. On the other hand, focal onset seizures can start in one area or group of cells in one side of the brain. Epileptic seizures are the result of excessive and abnormal neuronal activity in the cortex of the brain and often brought on by factors such as stress, alcohol abuse, flickering light, or a lack of sleep, among others. An electroencephalogram (EEG) to look for abnormal patterns of brain waves and neuroimaging (CT scan or MRI) to look at the structure of the brain are also usually part of the diagnostic evaluation. In the United States, epilepsy affects an estimated 2.2 to 2.3 million people. The key driver of direct costs in epilepsy is medical service expenditures, which are substantial. However, the overwhelming majority of total costs are attributable to indirect costs such as job absenteeism. For general epilepsy populations, total annual direct healthcare costs per person ranged from $10,192 to $47,862 and epilepsy‐specific costs ranged from $1,022 to $19,749. These costs are a healthcare burden that needs to be addressed.

Epilepsy cannot usually be cured outright, but pharmaceutical medications can control seizures effectively in about 70 percent of the cases. The mainstay treatment of epilepsy is anticonvulsant medications, possibly for the person's entire lifespan. Trials of single medications are recommended initially. However, if this is not effective, two medications simultaneously may be prescribed. Medications available include older antiepileptic drugs such as phenytoin, carbamazepine, and valproate and newer ones which include lamotrigine, levetiracetam, zonisamide, etc. Adverse effects from medications are reported in 10 to 90 percent of people. Most adverse effects are dose-related and mild and can include mood changes, sleepiness, or unsteadiness in gait. Certain medications have side effects that are not related to dose such as rashes, liver toxicity, or suppression of the bone marrow. Importantly, up to a quarter of people stop treatment due to adverse effects and some medications are not appropriate during pregnancy. Therefore, there is a need for alternative, nonpharmacological interventions.

There is credible and mounting evidence that yoga and meditation practices can improve stress, psychophysiological hyperarousal, and psychological well-being, and may be helpful in treating clinical problems such as depression, anxiety, and chronic pain. The relationship between stress and epilepsy is well known. Stress leads to release of glucocorticoids, neuropeptides, and corticotrophin-releasing hormone (CRH), which can excite immature hippocampal neurons and cause seizures, resulting in a vicious cycle. A majority of adult patients with medically refractory epilepsies have mesial temporal lobe epilepsy. Yoga and meditation interventions may modulate the disturbed limbic system activity in such patients and may help to maintain normal homeostatic conditions. Stress reduction and subjective feelings of well-being may be important factors contributing to seizure reduction and EEG changes ascribed to some forms of meditation. Yoga is thought to achieve seizure control through experience-related plasticity or through a shift in autonomic output toward relative parasympathetic dominance. Other proposed mechanisms of yoga benefit include EEG desynchronization and activation of inhibitory circuits through vagal nerve stimulation. One study has suggested that yoga training stimulates the vagus nerve, which may be relevant because electrical stimulation of the vagus nerve has been shown to decrease seizure frequency by 28 to 38 percent. There is therefore a positive rationale for the therapeutic role of yoga and meditation practices.

However, there has been controversy about the link between meditation practice and the neurological disorder of epilepsy. Some have suggested the concern that brain states induced by meditation could be conducive to triggering seizures in epileptics or could trigger epilepsy with patients with no known history or risk factors for epilepsy. The proposed epileptogenic influence of meditation is based on observed meditation-induced alterations in neurophysiology (hypersynchrony and increased coherence of brain activity) and neurochemistry (release of glutamate and serotonin). A study in 1993 found a significantly large incidence of complex partial epilepsy-like signs and experiences in meditators compared to controls. The study presented data of 221 meditators who displayed these signs compared to 860 non-meditators. However, several studies on patients with epilepsy practicing meditation have actually demonstrated improvement in seizure frequency and duration and EEG profile. A study published in 1995 has shown that experiences of unbounded awareness (transcendental consciousness) during meditation are correlated with specific physiological changes, e.g., global increase in EEG coherence, slowing of respiration and heart rate, and increased basal skin resistance. These changes are not epileptic-like and are not pathological but are positively correlated with intelligence, creativity, and mental health.

A number of studies have further attested to the safety and efficacy of yoga practices in epilepsy. Two unblinded randomized controlled trials (RCTs) in 1996 and 2008, recruited a total of 50 adults with refractory epilepsy and compared any type of classical Indian yoga to control conditions with no intervention or interventions such as yoga-mimicking exercises or Acceptance and Commitment Therapy. Results of the overall efficacy analysis showed that yoga treatment was better when compared with no intervention or interventions other than yoga. These data also suggested that yoga may have a role as an adjuvant therapy in the management of autonomic dysfunction in patients with refractory epilepsy.

A recent review paper on mindfulness-based interventions for epilepsy published in 2017 described three RCTs with a total of 231 participants in the USA (n = 171) and Hong Kong (n = 60). Significant improvements were reported in depression symptoms, quality of life, anxiety, and depression. Despite positive findings, the authors noted significant design limitations including unclear or high risk of bias, low statistical power, lack of measurement of longer-term effects, limited accounting for confounding factors, no measures of home practice, and poor reporting of randomization procedures, adverse events, and reasons for subject drop-outs. This systematic review concluded that there is limited evidence for the effectiveness of mindfulness-based interventions in epilepsy, however preliminary evidence suggests it may lead to some improvement in anxiety, depression, and quality of life.

In summary, yoga interventions may contribute positively to the treatment of epilepsy by enhancing quality of life and by decreasing seizure activity. Yoga interventions can be integrated into an outpatient clinic with good results, are noninvasive and low cost, and can be conducted even in the presence of language barriers and cultural differences. However, much more rigorous research needs to be conducted in this field and yoga can only be justified as an adjunctive treatment to antiepileptic drugs at the present time and should not generally be used as the sole treatment method.

Ishpreet Singh is a medical doctor and researcher from the Dayanand Medical College in India. He has worked extensively in India and USA with individuals with mental health and neurological disorders and is inclined towards integrating eastern yogic and meditation methods into mainstream medicine. He is an avid practitioner of Kundalini Yoga and meditation and brings this as a tool to help people heal, addressing deeper causes of illness and disease.

Sat Bir Singh Khalsa, Ph.D. is the KRI Director of Research, Research Director for the Kripalu Center for Yoga & Health, and Assistant Professor of Medicine at Harvard Medical School. He has practiced a Kundalini Yoga lifestyle since 1973 and is a KRI certified Kundalini Yoga instructor. He has conducted research on yoga for insomnia, stress, anxiety disorders, and yoga in public schools. He is editor in chief of the International Journal of Yoga Therapy and The Principles and Practice of Yoga in Health Care and author of the Harvard Medical School ebook Your Brain on Yoga.

By Nikhil Ramburn and Sat Bir Singh Khalsa, Ph.D.

The experience of anxiety, as clinically defined, is a feeling of dread and/or worry that may also be associated with continuing rumination and physical symptoms of the stress response such as rapid heartbeat, perspiration, and muscle tension. When this becomes persistent and heightened in intensity it may begin to meet the criterion of one of the anxiety disorders. Symptoms in anxiety disorders may manifest as panic attacks, feeling overwhelmed and uneasy in social situations, and a variety of possible phobias about specific places or future events. Anxiety is clinically significant if a patient suffers from anxiety symptoms for at least 6 months in any given year, as is the case for 6.8 million adults in the U.S. who suffer from one of the more common forms known as generalized anxiety disorder (GAD). Patients with GAD have persistent and excessive worry about a range of different things such as money, health, family, or anticipated disaster when there is no apparent reason for concern. Individuals find it difficult to control their worry. This may be related to past emotional traumas leading to an enlarged and overactive brain region called the amygdala, responsible for emotion and the stress response. When the over-sensitive amygdala is excessively activated, the basal ganglion region of the brain along with the frontal lobe, which are normally responsible for self-regulation, are unable to put the brakes on the amygdala. It is believed that a combination of biological and social factors, particularly stressful life events, play a role in the development of GAD.

Although pharmacotherapy is available for GAD patients, many patients remain untreated or are medicated but would prefer alternatives to pharmacotherapy. Prescription drugs that treat anxiety may only be effective at treating the physical symptoms and often carry a high risk for addiction and may severely impair mood, judgment, and cognition. Fortunately, for those patients with the knowledge and access to it, there is a credible behavioral alternative. Cognitive behavioral therapy (CBT) addresses negative thought patterns and cognitive distortions in the way we look at the world and ourselves. The efficacy of CBT for anxiety disorders has strong support from a good body of clinical research trial literature including meta analytic review studies.

A growing body of evidence suggests that contemplative practices such as yoga and meditation may also be effective at treating GAD. Indeed, yoga and meditation, through engaging the activity of the attention networks in the frontal lobe, is a form of self-regulation that can inhibit and regulate activity in brain areas, including the amygdala, that are associated with fear and stress-responses. This regulation thereby decreases emotional intensity and perceived stress levels and improves ability to manage everyday stressors and emotional reactions. During mindfulness meditation practices, such as Mindfulness Based Stress Reduction (MBSR), individuals become less reactive to unpleasant feelings and more reflective, which then leads to positive psychological outcomes. When researchers recently evaluated randomized controlled trials (RCTs) of MBSR interventions, they found that the practice is moderately to largely effective at reducing anxiety and depression symptom severity among individuals with a range of psychiatric conditions. The most comprehensive review to date examined the effects of 209 trials of mind body interventions (MBIs) which included 12,145 patients and found MBIs to be more effective in reducing psychological and medical symptom severity than a number of control conditions.

Yoga is one of the MBIs that may offer some advantages to the benefits conferred by meditation alone. Indeed, physical yoga exercises and breathing practices may induce the positive changes in brain neurochemistry that is linked to a more positive mood and affect. Specifically, yoga has been found to increase thalamic GABA levels (a brain neurotransmitter), in a similar fashion to pharmacologic agents acting on GABA levels to alleviate anxiety. Pranayama or yogic breathing may also contribute to the shift towards a dominance of the parasympathetic nervous system (associated with relaxation). Indeed, a recent meta-analysis of eight RCTs of yoga interventions with 319 participants revealed evidence for small, short-term benefits of yoga on anxiety compared to controls. However, in that review, there were no effects found for anxiety disorders that were formally diagnosed. The researchers concluded that “yoga might be an effective and safe intervention for individuals with elevated levels of anxiety” but that “there was inconclusive evidence for effects of yoga in anxiety disorders”.

A preliminary clinical evaluation of yoga for GAD was conducted at the outpatient center of Riverside Community Care in the Boston area, in collaboration with Boston University and Harvard Medical School researchers. The results were published in a 2015 paper in the journal Clinical Psychology and Psychotherapy. Thirty-two treatment-resistant GAD patients participated in an intervention (Y-CBT) consisting of CBT enriched with Kundalini Yoga as taught by Yogi Bhajan^®, a yoga style which is adaptable for therapeutic populations (the Guru Ram Das Center for Medicine and Humanology specializes in such applications). The classes in this study included 30 minutes of yoga, meditation, breathing practices (especially long, slow abdominal breathing), and deep relaxation practices. The participants’ post-intervention scores showed statistically significant improvements in anxiety, depression, panic, sleep, and quality of life. The study’s lead author, psychologist Manjit Kaur Khalsa and her colleague Dr. Greiner-Ferris, have recently published a book, The Yoga-CBT Workbook for Anxiety, detailing their strategy to reduce anxiety with a step-by-step six-week program of yoga, meditation, and CBT strategies. The results from this preliminary study suggest that Y-CBT may have potential as a promising treatment for those suffering from GAD.

Another more recent publication of a Kundalini Yoga-based study for GAD is currently in press in the International Journal of Yoga Therapy. In that study, forty-nine female participants meeting the DSM-IV criteria for GAD were recruited from the community near the Sundari Satnam Kundalini Yoga Center in Grafton, VT. Both Boston University and Harvard Medical School researchers were part of the study team. The subjects were randomized to either an 8-week Kundalini Yoga intervention or a group receiving treatment as usual. The experimental subjects met for 8 consecutive weeks for 1.25 hours in a group format and received intensive training in Kundalini Yoga kriyas incorporating yoga postures, breathing, mantra, meditation, and relaxation. Results revealed that the participants of the yoga group had lower levels of anxiety relative to control subjects and had a decrease in somatic symptoms. These new findings further support the potential role for the use of Kundalini Yoga as a therapy, in this case for patients with a formal diagnosis of GAD.

In summary, there is encouraging preliminary evidence suggesting efficacy of yoga for treating GAD patients, particularly for Kundalini Yoga as taught by Yogi Bhajan. However, much research remains to be done and so there is still insufficient evidence to make definitive recommendations about yoga therapy for this condition. More high-quality studies are warranted with larger sample sizes, and the mechanism of action for yoga’s therapeutic benefits in GAD patients needs further investigation. In fact, a ground-breaking NIH-funded, 5-year, multi-site trial that will be concluding soon, is evaluating the efficacy of Kundalini Yoga for GAD as compared to CBT and a psychological attention control condition (see the article: Yoga for Generalized Anxiety Disorder: Design of a Randomized Controlled Clinical Trial. The sample consists of 230 individuals with a primary DSM-5 diagnosis of GAD, 95 of which are receiving a manualized Kundalini Yoga group intervention delivered by local certified Kundalini Yoga instructors supervised by Dr. Sat Bir Khalsa, one of the co-investigators.

Stay tuned for future results of this work.

Nikhil Rayburn grew up practicing yoga under mango trees in the tropics. He is a certified Kundalini Yoga teacher and has taught yoga to children and adults in Vermont, New Mexico, Connecticut, India, France, and Mauritius. He is a regular contributor to the Kundalini Research Institute newsletter and explores current yoga research.

Sat Bir Singh Khalsa, Ph.D. is the KRI Director of Research, Research Director for the Kripalu Center for Yoga & Health, and Assistant Professor of Medicine at Harvard Medical School. He has practiced a Kundalini Yoga lifestyle since 1973 and is a KRI certified Kundalini Yoga instructor. He has conducted research on yoga for insomnia, stress, anxiety disorders, and yoga in public schools. He is editor in chief of the International Journal of Yoga Therapy and The Principles and Practice of Yoga in Health Care and author of the Harvard Medical School ebook Your Brain on Yoga.

By Ishpreet Singh, M.B.B.S. and Sat Bir Singh Khalsa, Ph.D.

Headache refers to any pain in the region of the head and/or neck. Headaches can be classified into two broad categories: primary, which include tension headache, migraine, and cluster headache, or secondary, which are symptoms due to the presence of another condition or disorder. According to the National Institutes of Health, the tension-type headache is the most common form of primary headache. Emotional stress at work or at school, physical tension, and neck or back strain due to poor posture are among some of the most common causes of tension-type headache. According to the published prevalence estimates of tension-type headache, the episodic form is affecting 38.3 percent of the U.S. population and the chronic form is affecting 2.2 to 3 percent of the U.S. population, while migraine affects 29.5 million Americans with higher prevalence among women (17 percent) compared to men (6 percent).

Migraine is characterized by severe pain intensity on one or both sides with a pulsating sensation and is often accompanied by nausea and sensitivity to light and/or sound. Migraines are classified as either "with aura" or "without aura.” It is strongly believed that changes in blood vessels, disruption in the endocrine system, and some aspects of metabolism can create a dysfunction in brain blood flow that is the cause of migraine or primary headaches. The most commonly used treatment for headaches continues to be pharmaceutical. The pharmaceuticals for tension-type headaches consist of analgesic, non-steroidal anti-inflammatory drugs (NSAIDs), and opiate medications. Medications for migraine sufferers are divided into two categories: drugs to treat acute attacks, and other daily drugs to reduce frequency and severity of attacks preventively in addition to botulinum toxin (Botox) type A injections which work as a potent inhibitor of muscle tone.

There is a good deal of existing knowledge regarding the causes of headache. For migraine, certain factors like depression/anxiety, medication overuse, poor sleep, and high stress are associated with worse outcomes. Stress is considered to be one of the most common triggers for migraine headache and a major factor in the progression of headaches from episodic to chronic. Chronic stress involves a hyperarousal of the autonomic nervous system and creates an imbalance between its two branches by increasing activity of the sympathetic nervous system, thus contributing to the interruption of the normal balanced state that is essential for health and well-being. As we know, stress and anxiety are modifiable risk factors and conventional psychological relaxation-related behavioral interventions targeting these factors in people living with chronic headache have been introduced.

As a well-known and efficacious strategy for stress management, yoga is obviously well-positioned as a promising candidate treatment. Yoga therapy for migraine generally focuses on the prevention of the episodes of occurrence, which includes not only addressing stress reduction but also avoidance of the various causes of the attacks. The physical movement with enhanced body awareness in yoga practice can reduce the habits of adopting problematic and maladaptive physical postures. Pain perception and regulation in general is also known to be modulated more effectively in yoga practitioners. There is also evidence of reduction in physiological markers of both inflammation and stress. Specifically relevant to benefits for addressing headache symptoms, yoga-based interventions have been associated with decreased blood pressure and heart rate. By decreasing both of these cardiovascular variables, yoga-based interventions potentially allow the heart to work more efficiently thus contributing to a more efficient blood supply to the brain and lowered sympathetic nervous system activity. Yoga may also contribute to some behavioral changes that positively affect headaches. These may include an increased social network or an increase in regular physical activity. Psychological changes, such as increased positive mental state, can also contribute to more effective coping mechanisms and increased pain acceptance/tolerance. Given the scientific rationale above, it is not too surprising that there have been a number of clinical trials reporting on the efficacy of yoga to treat headaches.

Perhaps the earliest yoga-related study in 1981 compared savasana (corpse pose) alone with a biofeedback intervention and found that the yoga posture was equivalent to the biofeedback intervention, consistent with prior research that found the similar practice of progressive relaxation to also be somewhat effective. This was followed a decade later by a Journal of Neurology India publication in 1991 of a well-conducted randomized controlled trial (RCT) in which 47 patients were assigned to yoga therapy and 38 to drug therapy for tension headache. The results of the study indicated that the yoga and drug treatment were both equally effective in significantly reducing the duration, intensity, and frequency of headaches. Depression and anxiety also showed a significant decline in both treatments. However, the magnitude of improvement was significantly more in the yoga group in comparison to the drug group. One year later, yoga researcher Dr. Latha in Chennai published a small RCT with 20 patients suffering from migraine and tension headache in which the yoga therapy group reported reductions in headache characteristics (e.g. intensity, duration, and frequency) and medication intake. In comparison, the control group reported an increase in symptoms. Both of these latter 2 studies were encouraging not only with respect to headache symptoms but also noted important factors related to mechanism and lifestyle relevant to yoga for headache.

Other notable and more recent studies include a large study of migraine sufferers published in 2007 in the journal Headache, in which 72 patients were randomly assigned to either yoga therapy, which included yoga postures, pranayama, and neti kriyas (nasal water cleansing) or a self-care group for three months. The yoga therapy group demonstrated lower headache frequency and lower pain rating compared to the self-care group. Furthermore, anxiety and depression scores were significantly lower in the yoga group. The journal Pain Management Nursing in 2014 published one of the very few U.S. yoga-for-headache studies. This was done in a pediatric population with 7 participants aged 11-18 using alignment-based yoga. It reported improved quality of life (parent-reported), daily functioning scores (self-/parent-reported), and decreased state anxiety scores (self-reported). In addition to providing positive support for the efficacy of yoga, a few studies have additionally evaluated potential mechanisms involved. For example, a 2007 controlled study at the prestigious All India Institute of Medical Sciences in Delhi conducted an efficacy trial demonstrating the involvement of muscle spasm in tension headache showing that the yoga intervention reduced both pain scores and muscle activity as measured by the electromyogram. Another Indian study demonstrated changes in both headache frequency and intensity with a yoga treatment, while also showing changes in vagal tone and sympathetic activity consistent with the downregulation of autonomic activation. A more recent study by an Iranian research team reported improvements in headache with yoga but did not observe hypothesized changes in nitric oxide levels. Overall these studies have all provided support and preliminary evidence for the potential use of yoga for headache and possible mechanisms involved in yoga’s benefit.

Limitations of the research literature in this field include the absence of control groups and provisions for reducing potential bias in the research design, relatively few RCTs, inadequate description of methods and yoga practice within the RCTs, and small sample sizes. The outcome measures were also mostly subjective patient evaluations. As with much of the preliminary research in yoga, there is also a lack of long-term follow-up data which would test the durability of the treatment effect. There is also a need for information about the duration of yoga participation, or ‘‘dose,’’ required for benefit. However, despite these limitations, the preliminary evidence that yoga therapy can be an effective treatment for migraine and tension type headache is encouraging.

Ishpreet Singh is a medical doctor and researcher from the Dayanand Medical College in India. He has worked extensively in India and USA with individuals with mental health and neurological disorders and is inclined towards integrating eastern yogic and meditation methods into mainstream medicine. He is an avid practitioner of Kundalini Yoga and meditation and brings this as a tool to help people heal, addressing deeper causes of illness and disease.

Sat Bir Singh Khalsa, Ph.D. is the KRI Director of Research, Research Director for the Kripalu Center for Yoga & Health, and Assistant Professor of Medicine at Harvard Medical School. He has practiced a Kundalini Yoga lifestyle since 1973 and is a KRI certified Kundalini Yoga instructor. He has conducted research on yoga for insomnia, stress, anxiety disorders, and yoga in public schools. He is editor in chief of the International Journal of Yoga Therapy and The Principles and Practice of Yoga in Health Care and author of the Harvard Medical School ebook Your Brain on Yoga.

By Nikhil Ramburn and Sat Bir Singh Khalsa, Ph.D.

Dysmenorrhea is defined as painful menstrual cramps originating from the uterus. The condition is commonly divided into two categories, namely primary dysmenorrhea, which is menstrual pain without an identifiable disease, and secondary dysmenorrhea, which has an identifiable cause such as endometriosis, fibroids, pelvic inflammatory disease, and the use of intrauterine contraceptive devices. The risk factors for dysmenorrhea include the duration of menstrual flow, younger age at onset of menstruation (menarche), smoking, obesity, and alcohol consumption. High levels of stress, depression, and anxiety can also greatly increase the incidence of dysmenorrhea. The disruption of social networks also appears to be a contributing factor to the condition. Although prevalence estimates vary from 45 percent to 95 percent, dysmenorrhea seems to be the most common women’s health condition regardless of age and nationality. Despite this high prevalence, conventional treatment most commonly includes birth control pills and painkillers such as non-steroidal anti-inflammatory drugs (NSAIDs; e.g. ibuprofen, naproxen, etc.). Many women also choose behavioral therapy for pain management such as relaxation and positive imagery although the evidence is limited as to their efficacy.

Yoga may prove to be a valuable complementary behavioral approach that does not carry the same health risks as conventional pharmacotherapy. Indeed, NSAIDs can induce stomach ulcers and birth control pills have been associated with an increased risk of thrombosis. Yoga may be an efficacious alternative since the practice can increase muscular strength and flexibility, thereby relieving congestion in organs, especially the uterus. Yoga can also reduce pain by helping the brain’s pain center regulate the pain mechanisms located in the spinal cord and moderate the secretion of natural painkillers in the body. Since yoga has been associated with enhanced self-regulation and a reduction in sympathetic activation and stress dominance, the practice may help an individual better cope with stress, anxiety, and depression which are risk factors for dysmenorrhea. Slow yogic breathing exercises may also reduce pain since focused exhalation reduces tension and stress. Finally, yoga may help reestablish a balance between the endocrine and reproductive systems.

There is growing research trial evidence supporting the practice of yoga to alleviate menstrual pain. A recent review of the literature included fifteen studies evaluating the impact of yoga on menstrual disorders. Of these, nine were randomized controlled trials (RCTs; the gold standard of scientific study design), and six were single group or single case intervention studies. The majority of the studies were conducted in India and the rest in other Asian countries and Iran (curiously, although researchers in the U.S. have been major contributors to research on yoga, to our knowledge, there is no U.S.-based research on this topic). The studies in this review focused on the impact of yoga on premenstrual symptoms and menstrual distress. Participants ranged between 13 and 45 years and were administered a range of yoga interventions including physical yoga, breathing, meditation, and two studies even measured the sole impact of progressive muscle relaxation techniques called Yoga Nidra. All the studies reported beneficial outcomes such as lower self-reported menstrual distress, lower serum homocysteine (which is an amino acid associated with vascular stress and blood clots), and reduced pain scores. It would be interesting to study the effects of yoga on menstruation in regular yoga practitioners, however, such a study has not yet been done.

A 2011 study conducted in the Department of Midwifery at the Islamic Azad University in Iran found that yoga reduced the severity and duration of primary dysmenorrhea. The trial participants consisted of 92 female students, 18-22 years old who were randomly assigned to the experimental yoga group or a control group. The experimental group practiced cobra, cat, and fish poses (common Hatha Yoga poses) during the luteal phase of the menstrual cycle and each group was evaluated for three menstrual cycles. The researchers found a significant improvement in pain intensity and duration in the yoga group when compared to both the baseline scores and the control group subjects. These preliminary findings suggest that yoga poses may be a safe and effective treatment for primary dysmenorrhea.

A study of 113 medical students from the Dr. Pinnamaneni Siddhartha Institute of Medical Sciences in India also measured the effect of yoga on primary dysmenorrhea. The 60 experimental group participants attended 40 minutes of yoga class every day for three months. In addition, they practiced 10 minutes of pranayama and meditation daily. The researchers observed that students who had the highest menstrual pain scores also scored higher on the stress scale. The results revealed that the yoga intervention group had pronounced and significant improvements in perceived stress and 82 percent of the subjects in this group reported complete stress relief. Furthermore, menstrual pain was significantly reduced after the yoga intervention when compared both to baseline and the control group.

Another recent study which investigated the effects of yoga on menstrual distress in undergraduate students was conducted at the nursing college of Konyang University in South Korea. Forty students were randomized to either the yoga intervention or the control group. The experimental group practiced yoga for 60 minutes weekly for 12 weeks and the program consisted of physical exercise, relaxation, and meditation. Once again, the researchers observed a significant decrease in menstrual pain intensity in yoga participants when compared to the control group.

Finally, a study from the School of Physical Therapy at Khon Kaen University in Thailand examined the effects of a specific set of yoga exercises on menstrual pain. 34 subjects, aged 18-22 years were randomized into either a yoga group or control group. The experimental group practiced yoga for 30 minutes twice a week over a 12-week period. The specific sequence started with a relaxation pose (Shavasana) followed by an active Sun Salutation series (Surya Namaskara) and ended with a series of poses targeting the lower legs and pelvis. The researchers noted significant improvements in menstrual pain, physical fitness, and quality of life in the yoga group when compared to baseline and to the control group.

Despite the growing body of evidence supporting the use of yoga to alleviate dysmenorrhea symptoms, the mechanisms underlying yoga’s efficacy are still not fully understood. One study focusing on Yoga Nidra found that the practice modulated the autonomic nervous system to decrease sympathetic dominance and this was correlated with a decrease in menstrual pain. Another possible mechanism is the reduction in serum homocysteine levels observed after an 8-week yoga intervention in one study. The reduction in this particular amino-acid may point to a restoration of the endothelial function of the uterus. Other research was able to rule out the role of the hormone progesterone in accounting for yoga’s therapeutic benefits. It is known that a progesterone decrease can lead to excessive uterine contraction during menses, however, after a 3-month yoga intervention, no difference was noted in the premenstrual progesterone levels of participants despite positive improvements in self-reported pain relief. However, ground-breaking evidence after yet another Yoga Nidra intervention suggests that yoga may modulate the neuroendocrine system and effectively change the hormonal profile of women with menstrual irregularities by reducing the thyroid-stimulating hormone, follicle-stimulating hormone, luteinizing hormone, and prolactin.

In summary, these encouraging albeit preliminary findings suggest that yoga therapy may be a viable complementary treatment for dysmenorrhea in reducing menstrual cramps and additionally lessening psychosocial stress levels that aggravate dysmenorrhea. Several studies to date have clearly presented their research methods and had replicable aims. However, the variability of yoga interventions across the studies conducted to date limits analysis of the results. Future studies should address the previous limitations of bias, high attrition rates, lack of randomization, lack of long-term follow-up, and self-reported methods to measure outcomes. In addition, by studying a broader segment of the population, the findings may be generalized. Finally, additional trials should further address the mechanisms behind yoga’s effectiveness for dysmenorrhea.

Nikhil Rayburn grew up practicing yoga under mango trees in the tropics. He is a certified Kundalini Yoga teacher and has taught yoga to children and adults in Vermont, New Mexico, Connecticut, India, France, and Mauritius. He is a regular contributor to the Kundalini Research Institute newsletter and explores current yoga research.

Sat Bir Singh Khalsa, Ph.D. is the KRI Director of Research, Research Director for the Kripalu Center for Yoga & Health, and Assistant Professor of Medicine at Harvard Medical School. He has practiced a Kundalini Yoga lifestyle since 1973 and is a KRI certified Kundalini Yoga instructor. He has conducted research on yoga for insomnia, stress, anxiety disorders, and yoga in public schools. He is editor in chief of the International Journal of Yoga Therapy and The Principles and Practice of Yoga in Health Care and author of the Harvard Medical School ebook Your Brain on Yoga.

By Nikhil Ramburn and Sat Bir Singh Khalsa, Ph.D.

Athletes get plenty of strength training and often do their stretching, so why would they need yoga? The postural, exercise, and breath-regulation aspects of yoga provide a unique opportunity for core strength training by engaging the entire midsection in order to support one’s body weight. Other physical benefits include improved coordination, proprioception, flexibility, relaxation, deeper respiration, and decreased recovery time from heavy workouts. In addition, the meditative/mindfulness aspects of yoga provide substantive psychological benefits that include improved stress and emotion regulation, improved mindful awareness, enhanced cognition and concentration, and the ability to achieve a flow state. “Flow” refers to an optimal psychological state involving a complete absorption in the task or activity at hand; a state generally coveted by athletes because it is associated with strong positive emotions, including a deep experience of peace, harmony, and unity. Self-regulation and performance enhancement being critical to athletic performance, it is not surprising that an increasing number of professional sports teams are implementing yoga as standard training practice.

Specific studies have been supportive of the benefits of yoga for athletes since the 1990s. An early study correlated the benefits of Transcendental Meditation with the improved pistol shooting performance of 30 undergraduate students. Similar improvements were observed in 25 elite shooters by a team of researchers at the Ullevål University Hospital in Oslo, Norway. The researchers observed a greater improvement in competition results among the group that received meditation training when compared to a control group. Another early study from the University of Nevada, observed significant improvements in the running performance of high school long-distance runners after yoga exercises when compared to a control group of a “motivational shouting” exercise intervention.

Some studies have focused in on specific physiological benefits that underlie the global improvements with yoga, such as a 2004 study, which was published in the Journal of Strength and Conditioning Research. The researchers observed the effects of a single yoga set on muscle soreness. 24 yoga-trained individuals were compared to a control group of 12 non-yoga-trained volunteers. All participants were female, and the researchers observed that both yoga training and the single yoga session appeared to attenuate peak muscle soreness after a session of eccentric exercise. These findings have significant implications for facilitating faster recovery from muscle soreness in athletes. A 2016 study published in the International Journal of Yoga examined the impact of 10 weeks of yoga on the flexibility and balance of college athletes. 14 soccer players took part in the bi-weekly yoga sessions, whereas the control group, which was comprised of baseball players, did not receive any additional yoga activity. The researchers observed significant gains in flexibility and balance in the yoga group whereas no significant changes were observed in the control group. Another landmark study evaluated the influence of yoga on the postural skills of the Italian short-track speed skating team. Eight men and seven women were given a total of 36 yoga sessions over eight weeks of high volume pre-season training. The researchers observed improvements in 11 of the 14 postural angles analyzed. In addition, no skaters suffered injury from the training volume, and coaches even reported improvements in the efficiency of skating technique.

Apart from the improvements in physical performance, yoga also confers the additional cognitive benefits of the meditative/mindfulness aspect of yoga. Applied sport psychology, in its efforts to enhance the competitive performance of athletes, has traditionally emphasized self-control and the elimination of negative thoughts and emotions. Recent evidence suggests, however, that this suppression may actually have the opposite effect of aggravating these thoughts and emotions. Rather, it is suggested that interventions that emphasize acceptance rather than direct change or suppression of cognitive and affective experiences may lead to enhanced athletic performance. A 2017 meta-analysis conducted by the Swiss Federal Institute of Sport and the University of Basel in Switzerland reviewed nine trials with 290 athletes of various disciplines including track athletes, cyclists, dart throwers, rugby players, and hockey players, to name a few. The athletes received a mindfulness intervention that varied from 4 weeks to over 2 years, and researchers found that mindfulness scores consistently improved across the various sport disciplines. In addition, researchers concluded that mindfulness practice can be considered a performance-enhancing training approach in precision sports such as shooting and dart throwing.

A recent study published in the Journal of Sport Rehabilitation in 2017 also found sufficient evidence to support the use of mindfulness with student-athletes to aid in managing negative emotions and perceived stress. There is also preliminary evidence that mindfulness-based interventions may reduce injury in the same student-athlete populations. One of the theoretical models that may explain these observed benefits is the effect of mindfulness on rumination and sport-specific coping skills. Researchers from the Center of Research on Welfare, Health, and Sports in Sweden, observed that athletes who are more mindful in daily life tend to regulate their negative emotions and not engage in excessive rumination, which may in turn, improve their coping skills in a variety of sport-related challenges.

A preliminary investigation into the effect of mindfulness and flow in elite youth swimmers included a 10-week yoga intervention. Although no statistically significant changes in mindfulness and flow were identified, participants did report perceived improvements in those aspects. Moreover, qualitative data suggested that the yoga intervention resulted in positive improvements on a range of cognitive and physiological aspects. It is possible that study weaknesses of small sample size and yoga practice compliance may have contributed to the nonsignificant quantitative findings. Other studies on higher level psychological benefits have been conducted, such as a pilot project conducted at George Mason University in Virginia, and found that five weeks of hatha yoga sessions resulted in an increase of self-reported mindfulness and greater goal-directed energy when compared to a nonrandomized control group.

In summary, studies to date have demonstrated the beneficial effects of yoga on specific components of athletic performance including both physical and cognitive characteristics. Future research should address the previous limitations of small sample sizes, lack of longer-term studies, and in some cases the absence of randomization. Dose response characteristics and the relative contribution to efficacy of the different components of yoga such as physical postures, breathing techniques, and meditation are worthy of additional study. These future trials would further improve our knowledge of the underlying mechanisms of how yoga practice enhances the specific components of athletic performance, which of course has relevance for human performance in the general population.

Nikhil Rayburn grew up practicing yoga under mango trees in the tropics. He is a certified Kundalini Yoga teacher and has taught yoga to children and adults in Vermont, New Mexico, Connecticut, India, France, and Mauritius. He is a regular contributor to the Kundalini Research Institute newsletter and explores current yoga research.

Sat Bir Singh Khalsa, Ph.D. is the KRI Director of Research, Research Director for the Kripalu Center for Yoga & Health, and Assistant Professor of Medicine at Harvard Medical School. He has practiced a Kundalini Yoga lifestyle since 1973 and is a KRI certified Kundalini Yoga instructor. He has conducted research on yoga for insomnia, stress, anxiety disorders, and yoga in public schools. He is editor in chief of the International Journal of Yoga Therapy and The Principles and Practice of Yoga in Health Care and author of the Harvard Medical School ebook Your Brain on Yoga.

By Nikhil Ramburn and Sat Bir Singh Khalsa, Ph.D.

The usefulness of a medical intervention (either a pharmaceutical or a behavioral treatment) in either clinical practice or research should be evaluated not only by its efficacy but also by its cost-effectiveness, patient acceptability, and treatment adherence. Compliance or adherence describes the degree to which a patient correctly follows the prescribed treatment recommendations. Patient nonadherence can include not accurately carrying out the instructions, such as chanting the wrong mantra or breathing improperly in a yoga intervention, which can be due to misunderstanding the instructions. Nonadherence is also notoriously due to not carrying out the prescribed treatment such as not doing the yoga practice when scheduled, or not doing it for long enough, which is due to a number of factors such as time constraints, forgetting, or even completely ignoring treatment protocols. Apart from being a possible threat to the health of patients, nonadherence also carries a significant economic cost. The field of behavioral medicine views the reasons for nonadherence as ‘barriers’ to the accomplishment of a specified behavioral intervention. Those barriers may be subjectively reported by the patient or objectively measurable and include cultural issues, financial concerns, time constraints, space, and technological limitations.

Despite the promise and general popularity of yoga and yoga therapy, there are a number of barriers to yoga practice. One of these is the general public perception that yoga is primarily for women. Surveys in the general public consistently show that 75 to 80 percent of yoga practitioners are female. In fact, according to a 2015 University of Miami study, men are half as likely as women to engage in mindfulness practices. This same study found that those with a higher level of education were more likely to adopt a mindfulness practice and that non-Hispanic blacks and Hispanics were less likely to do so. A 2016 study by researchers from Simon Fraser University in Vancouver, Canada found that time constraint was the most common barrier for yoga practice. Other prevalent barriers include the belief that yoga requires great flexibility, is difficult to practice, and/or that it is unsuitable for special populations such as children, the elderly, or the obese. Those with larger bodies face high levels of stigma in relation to yoga (and physical activity in general) and this may serve as a strong barrier to their participation. Other significant barriers are beliefs that yoga is a religious practice or that it is inconsistent with one’s cultural heritage. On the other extreme, there is even a belief that yoga is nothing but physical postures. Finally, socioeconomic factors such as the cost impediment to yoga classes (such as transportation to classes and child care costs) can deter certain disadvantaged and low socioeconomic status populations from practicing yoga. These barriers are problematic because patients and research participants may entirely withdraw from the treatment before deriving any therapeutic benefits from their yoga practice.

Despite the benefits and growing acceptance of yoga and the importance of addressing barriers to practice, the literature has few studies on the factors contributing to the adherence to regular yoga practice. One such study was conducted by the SVYASA yoga university in Bengaluru, India and published in the International Journal of Yoga in 2014. The researchers evaluated students who had undergone a 1-month residential instructors’ course at the yoga university and found that irregularity in lifestyle, family, and occupational commitments were perceived as the strongest barriers to practice. Similarly, a 2009 focus group study of 50 participants from the University of Maryland School of Public Health also found the largest barrier to be lack of time, especially when taking yoga classes. The study included 36 yoga practitioners and one fourth of them found classes to be too costly. For the 14 people who had never previously practiced yoga, negative beliefs about the high level of flexibility required, that yoga is dominated by women or “new age” individuals with alternative lifestyles were significant barriers to participation.

A 2013 study by Mary Quilty, Sat Bir Singh Khalsa, and other colleagues highlighted this disparity in demographics for yoga participants. This study surveyed 604 adults who had registered for 4-week beginners' yoga programs within the Yoga Yoga network of studios in Austin, Texas and found the yoga demographics to be primarily female (87 percent), white (88 percent) and college educated (79 percent). Similar to other studies, they again found the primary barrier to practice was time constraints and availability. Interestingly, respondents perceived yoga to be primarily an exercise activity (92 percent), although there was also a strong perception of it being a spiritual activity (73 percent). The main reasons for their participation was for general wellness (81 percent), physical exercise (80 percent) and stress management (73 percent). In fact, 98 percent of participants believed that yoga would improve their health, making this internal motivator a significant facilitator to the practice of yoga.

Another notable study explored the perspectives of students and their classroom teachers on the implementation of a school-based yoga program. Too often, the opinion of these two key stakeholders have been ignored in favor of program implementers. This 2017 study by the University of Cincinnati and Johns Hopkins Bloomberg School of Public Health researchers focused on qualitative perspectives of 22 fifth and sixth-grade students and their teachers after a 16-week school-based mindfulness and yoga program in three public schools. Those schools serve low-income urban communities and therefore provide us with valuable insight into this underserved demographic. In this context, the most frequently mentioned instructor quality valued by youth was “respect,” which the youth associated with “fairness” and “not yelling a lot”. However, conflicts in scheduling was a major challenge to youth program participation since attending yoga required that they miss other activities they enjoyed, such as art class. Although teachers reported positive expectations from the program, factors that could enhance buy-in included training staff on the program goals and generalizing the yoga mindfulness skills into the classroom.

While the previous study focused on youth from low-income communities, a recently published 2017 study at Brigham and Women's Hospital and Harvard Medical School (including one of the authors, Sat Bir Singh Khalsa, as part of the research team) investigated the barriers and facilitators to yoga among low-income, racial/ethnic minority adults. Examinations of beliefs surrounding yoga participation among vulnerable populations are lacking in the literature and so this study bridges that gap. Twenty-four adults with and without prior yoga experience were recruited from an urban housing community to participate in an individual interview or focus group. The results highlighted barriers to engagement that included the perception that yoga lacks physicality and weight loss benefits. In addition, subjects talked about fear of injury, lack of perceived ability to perform the exercises, preference for other physical activities, and scheduling difficulties. On the other hand, the facilitators of yoga engagement included having a quality yoga instructor who provides individualized instruction, beginner level classes, and information highlighting the potential benefits of yoga such as stress reduction. It is interesting to note that participants were unsure about whether yoga provided sleep benefits and if the benefit was purely physical exhaustion. Therefore, much work remains in promoting yoga and educating on its benefits and underlying mechanisms.

Apart from adequate promotional messaging, in order to address the other significant barriers of cost and time, strategies are being developed to deliver yoga digitally, on demand, and in the comfort of participants’ homes. A 2017 commentary by the PrairieCare Medical Group in Minnesota explored the use of technology-assisted relaxation for pediatric patients that had been prescribed as Mind-Body techniques. Healthcare providers already know that delivering treatments through “play” experiences is an ideal way to provide therapeutic interaction and this is often termed “therapeutic play”. Given the prevalence of video games, children and teens may be particularly suited to therapeutic multimedia games that help them connect with the imagistic, emotional, and sensory elements of the right brain for symptom management and healing. There are currently several interactive mobile apps that promote yoga and other Mind-Body practices such as “Yoga by Teens”, “Take a Chill”, and “Breathing Bubbles”. A recent study published in the Journal of Alternative and Complementary Medicine in 2017 evaluated the feasibility of a home-based TeleYoga intervention on patients with both chronic obstructive pulmonary disease (COPD) and heart failure. Fourteen participants took part in either an 8-week TeleYoga intervention or an educational control group. The yoga classes were transmitted live via an internet connection to the participants’ televisions. The researchers found that the yoga intervention participants were adherent to classes despite technical issues. In addition, these frail patients were able to safely participate, enjoyed the program, and their dyspnea after exercise improved.

In conclusion, detailed evaluation of barriers to yoga practice is a new and growing area of research with promising insight into the adherence issues in yoga practice. The common barriers to yoga therapy appear to be time, cost, beliefs about yoga being a religion, impression that yoga is only for women, and fear that yoga requires great flexibility, as well as a lack of clarity as to the benefits of the practice. It is important for yoga therapists and researchers to address these barriers when delivering yoga interventions to ensure adherence and treatment success. Future studies should focus on minorities and men as well as medically underserved and vulnerable populations to better understand their specific barriers. Findings from future research could reveal what catalysts promote the initiation of yoga beyond benefits that most already know. For instance, is hearing about the health merits of yoga sufficient or is experiencing yoga necessary to address barriers to practice?

Nikhil Rayburn grew up practicing yoga under mango trees in the tropics. He is a certified Kundalini Yoga teacher and has taught yoga to children and adults in Vermont, New Mexico, Connecticut, India, France, and Mauritius. He is a regular contributor to the Kundalini Research Institute newsletter and explores current yoga research.

Sat Bir Singh Khalsa, Ph.D. is the KRI Director of Research, Research Director for the Kripalu Center for Yoga & Health, and Assistant Professor of Medicine at Harvard Medical School. He has practiced a Kundalini Yoga lifestyle since 1973 and is a KRI certified Kundalini Yoga instructor. He has conducted research on yoga for insomnia, stress, anxiety disorders, and yoga in public schools. He is editor in chief of the International Journal of Yoga Therapy and The Principles and Practice of Yoga in Health Care and author of the Harvard Medical School ebook Your Brain on Yoga.

By Nikhil Ramburn and Sat Bir Singh Khalsa, Ph.D.

The impact of employee wellbeing on overall productivity has attracted great attention in the last few years. Workers today are increasingly impacted by stress, musculoskeletal conditions (especially back and neck pain), low empowerment, sleep disturbance, low quality of life, low job satisfaction, and a sedentary lifestyle. Reasons for these modern challenges vary but it seems that the rising dependency on volatile global market forces create more pressure to make organizations more profitable, efficient, and accountable. Furthermore, the growth in technology at work, organizational restructuring, and the absence of clearly defined “work” hours have all negatively impacted employee wellbeing.

Chronic stress has been a key factor. Research has shown that stress can lead to depression, reduced job satisfaction and disruptions to personal relationships that can all increase the risk of injury to the workers themselves or to the people that their company serves. Stress also negatively impacts high-level cognitive functions, especially attention and memory, and this raises the already high stakes for those professionals who cope with situations that affect human lives on a daily basis.

Stress can lead to “burnout,” which has been defined as a syndrome of depersonalization, emotional exhaustion, and a sense of low personal accomplishment. An early theoretical model proposed two processes for the development of burnout. First, long-term job demands from which employees do not fully recover may lead to sustained arousal levels, eventually resulting in exhaustion, which is the energetic component of burnout. The second aspect is the motivational component of burnout, manifesting as reduced motivation, or withdrawal, and acts as a self-protective strategy to prevent further depletion. A revised model included a health impairment process, whereby burnout leads to depression, cardiovascular disease, or psychosomatic complaints.

The burnout syndrome is highly prevalent, with fewer than one in every five workers actively engaged in their work. Disengaged employees can be the cause of detrimental corporate outcomes such as poor job performance, low productivity, poor employee interactions, low creativity, absenteeism, presenteeism (on the job but not productive), and high employee turnover.

Average adults spend a quarter of their waking lives at work and job satisfaction accounts for a quarter of overall life satisfaction. Happiness at work should not be taken lightly since happiness provides positive benefits for not only the happy individuals themselves but also for their coworkers. In this light, happiness is almost a responsibility to one’s self and one’s coworkers. Indeed, research and site investigations have uncovered enormous financial and human costs associated with unhappy and unhealthy organizations. In one study of MBA students, those who scored high on wellbeing were shown to be superior decision makers, demonstrated better interpersonal behavior, and received higher overall performance ratings.

Fortunately, the notion of a healthy workplace has evolved throughout the past 60 years and human resource professionals have begun to prioritize healthy workplace programs as a competitive advantage to curtail rising health care costs, retain employees, and boost employee morale and interpersonal relationships. There is consistent evidence that a good social environment at work is associated with employee wellbeing and some companies are using team-building exercises, facilitated dialogue groups, and improved workspaces to increase the frequency of shared activities between workers. Other businesses are promoting physical activity as a strategic corporate priority to improve worker health and business performance. Employers are also turning to conventional cognitive behavioral interventions to improve worker wellbeing. In fact, a 2017 meta-analysis of digital mental health interventions delivered at work found statistically significant improvements on both psychological wellbeing and work effectiveness scores.

Yoga is yet another strategy that provides several of the psychological and physical health benefits mentioned above and, in addition, provides acquisition of a skill of self-regulation of stress and emotion. Its meditative component improves mindfulness that has been associated with improving quality of life and increasing self-compassion. On a deeper level, the philosophical and spiritual component of yoga can help employees increase life’s meaning and purpose. A 2014 review of yoga and exercise interventions in working populations evaluated five yoga studies, which reported improvements in stress and anxiety. They hypothesized that yoga may be superior to exercise interventions. Yoga programs can be delivered in multiple ways. Employees can be enrolled in a residential yoga program at a yoga retreat center allowing for an in-depth exposure to yoga practices and lifestyle in a highly supportive and nurturing environment. Alternatively, yoga can be delivered outside of the workplace at a nonresidential external venue or at home via DVD or an online program. Finally, yoga can be delivered onsite at the workplace. In this article, we focus on residential program research.

A study published in the Journal of Alternative and Complementary Medicine in 2016 compared 69 healthy individuals (58 women and 11 men) who were quasi-randomized to either a six-day Ayurvedic intervention of yoga, massage, diet, and journaling or a six-day residential vacation, both at the Chopra Center for Wellbeing at the La Costa Resort in Carlsbad, California. The participants in the program with yoga showed significant and sustained increases in ratings of spirituality and gratitude when compared to the vacation group, which showed no change. Interestingly, the yoga and Ayurveda group also showed increased ratings for self-compassion as well as a reduction in anxiety at the one-month follow-up. These findings suggest that a short-term intensive program in body-mind practices can lead to long term changes in perceived wellbeing. We should also note that the results show that a vacation alone is insufficient to yield sustained improvements in certain aspects of wellbeing.

A 2011 study from the Swami Vivekananda Yoga Anusandhana Samsthana University (S-VYASA) in Bengaluru, India further supports the benefits of a residential yoga intervention to enhance wellness. 72 corporate executives from the Oil and Natural Gas Corporation Limited went through 5 days of the Self-Management of Excessive Tension (SMET) program which combined “stimulating” yoga postures and “calming” supine rest practices in a comprehensive residential yoga lifestyle program. Brain wave recordings at baseline and post-intervention showed an increase in delta, theta, alpha, and gamma wave coherence but a decrease in beta waves. The authors concluded that these changes in brain wave coherence may point to heightened states of consciousness and increased wakefulness and vigilance, which are essential components of “executive efficiency.” Furthermore, they suggested that increases in frontal alpha coherence could reflect an enhancement of frontal lobe integration, which would result in greater cognitive flexibility, intelligence, and emotional stability. These findings, in combination with results from an Emotional Quotient (EQ) questionnaire test, indicate that the SMET program improves emotional stability and may have implications for “executive efficiency.”

A newly published study in the Journal of Occupational and Environmental Medicine by the coauthor (SBSK) and his colleagues examined the effects of a residential yoga-based program on the psychological health of frontline professionals who work with at-risk individuals in areas such as education, health care, and law enforcement/corrections. This is the first scientific investigation of the “Resilience – Integration - Self-awareness - Engagement” (RISE) program of the Kripalu Center for Yoga & Health that incorporates yoga-based practices with meditation, body scan, mindful communication, healthy nutrition, and sleep. 64 frontline professionals from education, healthcare, human services, and correctional institutions completed a baseline survey before participating in a five-day residential immersion program at the Kripalu Center in Stockbridge, MA. The program included five hours of daily structured sessions of yoga postures and exercises, meditation, breathing techniques, and education about mindful communication specifically targeted for these workers. The study found that participants’ self-reported stress, resilience, positive and negative affects (mood), mindfulness, empowerment, vitality, sleep quality, amount of exercise, and vegetable and fruit intake was significantly improved after participating in the RISE residential program. At the two-month follow-up, all measures remained improved except for duration of exercise. In fact, self-compassion only reached statistical significance at the two-month follow-up, suggesting long-term gains from a short residential yoga intervention.

These studies provide preliminary support for the benefits of residential yoga programs for stress reduction, improved behavior, and emotional and physical resilience in working adults. However, it is likely that corporate policymakers may prefer to invest in more economical worksite or home-based interventions, which have also been the focus of a larger number of published research studies. It remains to be seen whether intensive yoga retreat interventions may have better long-term outcomes than home or worksite-based yoga interventions, which would be best evaluated in a head-to-head comparison of a similar intervention in the same population within a single randomized controlled trial. In either case, the appearance of research on yoga in the workplace is a welcome addition to that of the parallel growth of research on yoga in schools and in healthcare.

Nikhil Rayburn grew up practicing yoga under mango trees in the tropics. He is a certified Kundalini Yoga teacher and has taught yoga to children and adults in Vermont, New Mexico, Connecticut, India, France, and Mauritius. He is a regular contributor to the Kundalini Research Institute newsletter and explores current yoga research.

Sat Bir Singh Khalsa, Ph.D. is the KRI Director of Research, Research Director for the Kripalu Center for Yoga & Health, and Assistant Professor of Medicine at Harvard Medical School. He has practiced a Kundalini Yoga lifestyle since 1973 and is a KRI certified Kundalini Yoga instructor. He has conducted research on yoga for insomnia, stress, anxiety disorders, and yoga in public schools. He is editor in chief of the International Journal of Yoga Therapy and The Principles and Practice of Yoga in Health Care and author of the Harvard Medical School ebook Your Brain on Yoga.

By Nikhil Ramburn and Sat Bir Singh Khalsa, Ph.D.

The most common breathing practice in yoga is long, slow, deep breathing. However, despite its simplicity and multiple benefits, it is also relatively misunderstood. The slow breathing practices in yoga are not simply slower, they are also deeper, with the diaphragm and lungs expanding more fully with each breath. Yogic breathing involves the noticeable movement of the abdomen, which extends outwards on each inhale, thereby earning it the name of abdominal or belly breathing. Apart from simple, slow, deep breathing, yogic breathing or pranayama, practices also include modified techniques such as Ujjayi, which involves a slight constriction of the glottis to create an audible breath. Other yogic breathing patterns may call for different breathing frequencies, different breath inhalation, retention, and exhalation ratios, segmented inhales and exhales, and breathing through specific nostrils. The deeper expansion of the lungs in simple, long, slow, yogic breathing effectively increases the lung surface available for gas exchange and so it is more efficient use of the lungs. In addition, dead space ventilation (movement of air during breathing in the trachea between the mouth and lungs that does not participate in gas exchange) is relatively reduced. The resulting increase in efficiency is equivalent to one possessing a larger lung.

Unfortunately, the understanding of the accurate benefits of yogic breathing is often compromised by certain claims and misconceptions. The most common of these is the notion that slow, yogic breathing increases oxygen in the blood and that most of the public, who are not privy to practicing this type of breathing, are walking around chronically oxygen deprived. In fact, unless one has a respiratory condition, such as chronic obstructive pulmonary disease or one is at high altitude, blood oxygen levels are normally well maintained at very high levels. It should be noted that respiratory physiology is a complicated issue whose details are outside of the scope of this article. However, the reality is that both slow and rapid yogic breathing practices, if done appropriately, do not yield significant changes in oxygen or carbon dioxide levels. The main reason for this is that the effect of the deeper breath in long slow deep breathing is counterbalanced by the slower respiration rate. Deeper breathing with a typical respiration rate would actually lead to clinical hyperventilation, a potentially harmful state, which should be taken into account when practicing yogic breathing.

Research on the long slow pranayama practice, when practiced appropriately, has been shown to slightly improve gas exchange under normal conditions. In early studies in 1964 at the Department of Psychiatry at Yale University, research fellow K.T. Behanan (trained in yoga at the Kaivalyadhama Yoga Institute in India) examined the effects of a series of pranayama practices on himself, with the results published in both a monograph and the Journal of Applied Physiology by his mentor. Three representative patterns of yogic breathing were tested, namely Ujjayi, Kapalabhati, and Bhastrika. While these techniques required a 12-35 percent increase in oxygen consumption above baseline, the relaxed breathing that immediately followed showed little indication that the subject had been exerting himself. A thorough study by Frostell et al. in 1983 using state of the art respiratory physiological research measures in advanced pranayama practitioners, made it clear that both slow and fast types of pranayama yielded minimal changes in both oxygen and carbon dioxide levels. A more recent pranayama research study published in the journal Evidence-Based Complementary and Alternative Medicine in 2013, had 17 yoga-naive participants tested to see if Ujjayi resulted in greater oxygen saturation when compared to regular slow yogic breathing. The results showed the greatest improvements in slow breathing without Ujjayi, likely due to the increased respiratory effort. However, Ujjayi did result in greater oxygen saturation. The researchers concluded that simple slow breathing with equal inspiration/expiration is the best technique for yoga naive subjects.

In addition to these studies performed under normal conditions, there is a growing body of evidence that yogic breathing improves gas exchange under altered, challenging conditions as well. In 1968, Shanker Rao from the Armed Forces Medical College in Pune, India looked at one subject who attempted yogic respiratory control at two different altitudes. The observations were carried out in the southwestern foothills of the Himalayas (12,500 ft.) and in Pune (1,800 ft.). He observed that the subject met increased demands for oxygen at high altitude by using long slow yogic breathing, which was effectively improving respiratory efficiency by increasing tidal volume (the total volume of air exchanged in each breath) instead of increasing the frequency of respiration.

Recent studies with a larger group of subjects support these early findings. In 2001, Luciano Bernardi et al. conducted a study in Albuquerque NM, comprising of 19 controls and 10 western yoga trainees to test breathing patterns and autonomic modulation at simulated high altitude. The researchers found that yoga trainees maintained better blood oxygenation without increasing ventilation (slow yogic breathing being a more efficient breathing method) and had reduced sympathetic activation when compared to controls. A subsequent study by Bernardi et al. looked at Caucasian yoga trainees, Nepalese Sherpas and Himalayan Buddhist monks. They found that yoga trainees were able to maintain oxygen exchange rates at high altitude that resembles the Himalayan natives. Therefore, respiratory adaptations induced by yoga practice may represent an efficient strategy to cope with altitude-induced hypoxia (inadequate oxygen supply). Another recent study lead by Colonel Himashree of the Indian Army and published in 2016, further confirmed these findings with a large sample size of two hundred Indian soldiers divided equally between an exercise control and yoga practice group. Indeed, the yoga group performed better at high altitude in a number of health indices such as respiratory rate, systolic and diastolic blood pressure, and anxiety rates.

In summary, slow yogic breathing is the most efficient way to ventilate and exchange oxygen and carbon dioxide. However, in addition to this benefit, long slow yogic breathing is also known to also offer numerous additional benefits including beneficial effects on heart rate variability, the chemoreflex response, autonomic function, and even on mood and mental health.

Nikhil Rayburn grew up practicing yoga under mango trees in the tropics. He is a certified Kundalini Yoga teacher and has taught yoga to children and adults in Vermont, New Mexico, Connecticut, India, France, and Mauritius. He is a regular contributor to the Kundalini Research Institute newsletter and explores current yoga research.

Sat Bir Singh Khalsa, Ph.D. is the KRI Director of Research, Research Director for the Kripalu Center for Yoga & Health, and Assistant Professor of Medicine at Harvard Medical School. He has practiced a Kundalini Yoga lifestyle since 1973 and is a KRI certified Kundalini Yoga instructor. He has conducted research on yoga for insomnia, stress, anxiety disorders, and yoga in public schools. He is editor in chief of the International Journal of Yoga Therapy and The Principles and Practice of Yoga in Health Care and author of the Harvard Medical School ebook Your Brain on Yoga.

By: Sandeep (Anu) Kaur, MS, RDN, RYT-500 and Sat Bir Singh Khalsa, PhD

Obesity, an important modifiable risk factor associated with chronic disease, is at epidemic levels in the U.S. with an expected 40 percent increase worldwide by 2030. The rise in obesity is associated with a sedentary lifestyle, dietary choices often high in calories, fat, and sugar, and stress-induced changes in psychophysiology and eating-related behavior. Traditional weight loss strategies focus on dietary changes and exercise which often result in only short-term weight loss that is ultimately regained. These weight loss approaches typically do not address the role of stress in obesity and do not appear to lead to long-term lifestyle behavior change that is necessary for weight maintenance. The rationale for yoga as an intervention for weight loss is that it is a multicomponent intervention targeting multiple physical, psychological, and behavioral factors. Although more intensive physical yoga exercises and postures result in higher energy expenditure, research studies suggest yoga goes beyond energetics. Yoga practice additionally provides positive changes in breath regulation, stress and emotion regulation, mind-body awareness, mindfulness, and even life purpose and meaning, all of which contribute to addressing the key factors in obesity. Hence, it is not surprising that a number of clinical research trials of yoga interventions have been conducted on obese patients.

One of the earliest research trials by Gharote and colleagues (1977) in India evaluated the effects of yoga on obesity via skinfold measurement and estimated body fat. They found a significant reduction in estimated body fat percentage in both men and women after two months of yoga treatment, paving the way for further studies of yoga and obesity as well as other lifestyle diseases such as diabetes. Divekar and colleagues (1978) reported decreased blood glucose and weight loss in individuals with chronic diabetes who practiced yoga outdoors for 45-minutes once a day and utilized slow and rhythmic contraction of muscles and deep slow breathing. Venkatareddy and colleagues (2003) also evaluated the impact of yoga asana and pranayama (breath techniques) on 30 obese Indian women who continued with their regular diet for three months. They too noted a significant reduction in weight and estimated body fat percentage at the end of 30 and 90-days. From the results of these early Indian randomized control trials (RCTs) it was hypothesized that yoga induces hypothalamic changes and conditioned the autonomic nervous system via the hypothalamus to influence other endocrine functions including insulin regulation. In another Indian yoga trial, Bera and colleagues (2003) randomly assigned 153 obese patients to either yoga training in a residential setting (consuming a pure vegetarian diet), a non-residential setting (subjects stayed at home on their usual diet) or a no-treatment control group. The researchers found a significant reduction in anthropometrics such as body weight, hip girth, body fat, and abdominal girth along with increased muscular strength and flexibility in the residential group compared to the other two groups. The authors concluded that yoga may be a more easily accessible form of exercise that can improve impaired musculoskeletal functioning in obese patients.

In the U.S., few residential multi-component yoga-based weight loss programs have been conducted. Braun and colleagues (2012) at the Kripalu Center for Yoga & Health evaluated a 5-day weight loss program that incorporated yoga, mindfulness, self-compassion, acceptance, non-dieting, and intuitive eating to promoted long-term weight loss. 37 participants, primarily Caucasian women, middle-aged, with high levels of education and income, and 84 percent classified as obese (Body Mass Index [BMI]  30), participated in the study. Although physical activity and mood disturbance improved significantly post-program, they did not reach significance at the 3-month follow-up, even though self-reported weight loss was statistically significant at the one-year follow-up. This study points to the potential of a yoga-based approach for obese individuals to foster well-being, stress management, mind-body awareness, improve nutrition choices, eating behavior, and to provide support for a deeper lifestyle change.

Other studies have been starting to look at the impact of in-house residential yoga weight loss programs that include yoga philosophy and Ayurvedic-inspired daily living strategies. Rioux and colleagues (2014) conducted a feasibility study with 12 women to evaluate a weight loss program based on principles of Ayurveda and yoga therapy with an emphasis on self-monitoring of lifestyle behaviors. Participants completed 75-minute supervised yoga classes three times a week and did the yoga practice an additional three times at home per week. There was a 7.1 kg difference between those who followed the program and those who did not. They also reported improved self-efficacy for exercise and diet change at long-term follow-up and improved energy, well-being, quality of life, and self-awareness. In another investigation, Braun and colleagues (2016) also evaluated the effectiveness of an Ayurveda-inspired weight management curricula with both yoga-experienced and yoga-naïve women. This novel pilot revealed improved self-reported psychosocial factors such as mindful eating and body image in both overweight/obese yoga-naïve and yoga-experienced women. These preliminary data suggest that group-based yoga weight management programs that include yoga and Ayurvedic lifestyle principles may help with weight maintenance.

More recently, Cramer and colleagues (2016) in Germany looked at the effect of yoga on abdominal circumference and other anthropometrics in 60 women with an abdominal circumference  35 inches and BMI  25 who were randomly assigned to either a 12-week yoga intervention or a no-treatment control. The researchers observed a significant reduction in waist circumference with the yoga intervention group compared to the untreated control group in addition to positive effects with the yoga intervention on anthropometric measures such as reduced waist-hip ratio, body weight, BMI, and percentage of body muscle. Yoga also improved participants self-reported mental and physical wellbeing, self-esteem, and perceived stress.

Overall, a review of the literature on yoga for weight loss in obese individuals postulate that enhanced awareness brought on by yoga leads to healthier food choices, slower and more mindful eating, and ultimately healthy body mass index. A major limitation of the RCTs were the small sample sizes and the limited methodology reporting on specific yoga techniques used. In a comprehensive meta-analysis on RCTs done for yoga and weight management, an analysis of 30 published research trials with a total of 2,173 participants indicated that yoga was considered a safe and effective intervention to reduce BMI in in otherwise healthy adults who were overweight or obese. Key factors that may play a role in yoga’s effectiveness in weight loss and maintenance are duration of practice, frequency, dietary elements, and the residential or home practice aspect.

In summary, the research published to date suggests that yoga can be an acceptable, safe, noninvasive, low-risk, and effective treatment option for obesity, reducing BMI and other anthropometric measures in obese or overweight adults. Importantly, yoga appears to affect key underlying risk factors including stress, emotion, mind-body awareness, and overall lifestyle behaviors. Additionally, the efficacy of yoga may possibly be supplemented and enhanced by interventions in residential treatment settings and by the additional incorporation of Ayurveda. Future yoga research with stronger research protocols will offer clarity and possibly confirm these preliminary findings that yoga can play an important role in the successful long-term treatment of obesity. An example of an ongoing trial in this direction is a comprehensive, country-wide study of yoga for obesity in India by the Patanjali Research Foundation led by yoga researcher Shirley Telles with a proposed sample size of 7,000 participants measuring anthropometric, biochemical, and psychological outcomes with a long-term, one-year follow-up.

By Nikhil Ramburn and Sat Bir Singh Khalsa, Ph.D.

Working memory is a component of our cognitive system that is responsible for holding and processing information over brief intervals. Researchers believe that working memory is central to cognitive functioning as it correlates with a number of outcomes such as intelligence and scholastic attainment and is linked to basic sensory processes. The expansion and decay of working memory over a lifetime is related to the normal development and degradation of the prefrontal cortex (PFC) in the brain, an area responsible for higher executive functioning.

Our behavioral state and circumstances, at any point in time including factors such as stress level, mood state, and physical activity, appear to play key roles in determining the quality and strength of working memory. For example, acute and chronic physiological stress impair working memory through decreases in PFC neuronal activity. In fact, chronic stress leads to even more profound deficits in working memory and eventual structural changes in the PFC such as an atrophy of neural pathways. In addition, mood states and the production of the neurotransmitter dopamine can impact the efficiency of working memory problem-solving capacity.

Working memory does deteriorate with age and disease. In fact, working memory is among the cognitive functions most sensitive to decline in old age since the PFC deteriorates more than other brain regions as we grow old. Not surprisingly, severe mental illnesses, such as schizophrenia and depression, can also decrease functioning of the PFC and thereby the efficacy of working memory. In childhood learning, working memory deficits correlate to attention, reading, and language challenges. Fortunately, behavioral interventions such as a wide range of physical activities such as yoga, tai chi, qi gong, cycling, running, resistance training, etc., as well as meditation, appear to confer an improvement/enhancement in working memory. One of the few meta-analytic reviews to investigate working memory exclusively found statistically significant evidence that chronic physical activity could improve working memory in healthy subjects whereas short-term physical activity did not confer significant gains.

Mindfulness meditation practices also appear to enhance working memory despite their focus on bringing the wandering mind back to the present moment instead of constantly updating it with new stimuli. In addition, meditation protects working memory against the deleterious effects of stress as reported in a 2010 study of military personnel by the laboratory of Dr. Amishi Jha at the University of Miami, Florida. A 2016 systematic review by researchers from Monash University in Melbourne, Australia, summarized and confirmed these findings. This review focused on outcomes following 8-week training programs such as Mindfulness Based Stress Reduction (MBSR) and examined whether working memory and other executive functions improved as a result of these interventions. Researchers found preliminary evidence for working memory capacity improvement, which could be attributed to the fact that monitoring present moment experience is a key skill of mindfulness practice.

Yoga may prove to be another effective complementary approach for improving working memory since it combines the benefits of exercise, meditation and pranayama (breathing exercises). Yoga has also been shown to improve attention, reduce stress and mood interference and can therefore protect against working memory deficits. Several studies from the prestigious laboratory of Dr. Edward McAuley at the University of Illinois focused on the relationship between yoga and cognition. In a 2014 study, 30 female college-aged participants completed both a yoga exercise session and an aerobic treadmill exercise session on separate days. The results showed significantly higher scores on working memory tasks after the yoga exercise as compared to the aerobic and baseline conditions. More recently, in 2016, the McAuley lab researchers looked at the effects of an 8-week yoga intervention on sedentary older adults (averaging 62 years old). The participants were randomized to a thrice weekly hatha yoga class which included yoga poses, meditation, breathing, and mantra or a stretching control group. The findings showed improved working memory performance in the yoga group, which appeared to be mediated by decreased stress as determined by outcome measures such as salivary cortisol levels. This encouraging evidence points towards yoga’s potential to decrease cognitive decline in older adults by protecting their PFC from the effects of stress.

A landmark study in 2017 by researchers at the Department of Psychology, Texas State University aimed to assess the impact of yoga on specific working memory subconstructs such as ‘maintenance’ and ‘manipulation’ tasks. Working memory subtests can differentiate and evaluate between short-term storage (maintenance) and manipulation of task-relevant information from both short-term and long-term storage (manipulation). Forty-three healthy subjects (8 males, 35 females) participated in 6-sessions of 60-minute yoga classes. The hatha yoga program consisted of asana (yoga exercises) connected with pranayama (breath exercises) and concluded with mindfulness meditation in supine rest. This yoga intervention was associated with improvement on both ‘manipulation’ and ‘maintenance’ working memory measures as well as enhanced mindfulness scores. This study ads valuable insight into the potential of yoga training for cognitive enhancement.

Another notable study investigated the effects of combining yoga and working memory training among healthy middle aged adults. Researchers from Manipal University in Mangalore, India, randomly assigned a total of 45 participants into 3 groups. Group 1 received both yoga and working memory training whereas group 2 received only working memory training, and group 3 was the no-training control. Both working memory training and yoga interventions lasted 45 minutes, once a day for 10 sessions. The yoga classes consisted only of pranayama, mudras (hand positions) and mantra (chanting OM) for their known beneficial effects on cognitive abilities. Asana were not included, which may in fact increase compliance in middle-aged adults and requires less space for performance. While working memory training resulted in positive outcomes on cognitive abilities as expected, the combined yoga and working memory group (group 1) showed even greater benefits on the same measures. This may be due to the additional benefits provided by yoga practice such as increased alertness and decreased stress.

In summary, studies to date have provided preliminary evidence that yoga practice may result in improved working memory in healthy adults, even when compared to conventional working memory training tasks. Future research should address the limitations of previous studies, which include small sample sizes and lack of longer-term follow-up evaluations. It would also be important to evaluate the response of other populations such as children and individuals with known working memory deficits. Ultimately, future working memory research trials will also shed light on the relative contribution to efficacy of the different components of yoga such as physical postures, breathing techniques and meditation. Such future studies would further improve our knowledge of the underlying mechanisms of yoga in cognitive function and ideally consist of larger randomized controlled trials and more comprehensive neuropsychological batteries.

by Nikhil Ramburn and Sat Bir Singh Khalsa, Ph.D.

The understanding of pain proposed by the International Association for the Study of Pain has remained unchanged since its first publication in 1979. It is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” Unfortunately, the neurobiological complexity of pain is not fully conveyed by this definition. Unpleasant stimuli are picked up by peripheral sensors, called nociceptors, which innervate the skin, deep tissues, and internal organs. Nerve cell conduits (axons), which can be myelinated (covered in a white insulating sheath) for rapid signal conduction or unmyelinated (which carry signals for slow, burning pain), transmit the stimuli through the dorsal horn of the spinal cord to the brain. While the brain’s somatosensory cortex is important for pain localization, a large network comprising the insula, anterior cingulate cortex, prefrontal cortex, and the thalamus is activated during acute pain experience. This was traditionally called the “pain matrix.”

However, contemporary scientific models acknowledge that pain is not a direct result of nociceptive input and the simple pain pathway highlighted above. Scientists know that our perception is critically determined by behavioral and psychological expectations and can be modified through learning. The most impressive and extensively studied example of this phenomenon is in placebo analgesics. In placebo studies, patients with agonizing pain report complete pain relief after the administration of a sugar pill that they are led to believe is a powerful painkiller. Since pain is an actively constructed experience, that can be modified through learning, some scientists propose an educational approach to treatment. The objective in this strategy is to shift the patient’s conceptualization of pain from a marker of tissue damage to that of a perceived need to protect the body tissue. This process is termed “functional pain literacy” and includes teaching the patient that pain and nociception (unpleasant signals) are not the same thing.

Despite advances in the field of educational psychology to modify our perception of pain, chronic pain is one of the most common conditions worldwide affecting 20 percent of the world’s population. It is estimated that it costs the United States between $560 to $635 billion annually to care for those with chronic pain, exceeding the healthcare costs associated with cardiovascular disease, diabetes, and cancer combined. These facts highlight the need for effective pain regulation strategies in modern medicine. Unfortunately, conventional pharmacological treatment, especially opioid painkillers, have a high potential for addiction. In 2015, 12.5 million people misused prescription opioids resulting in over 15,000 deaths and totaling $78.5 billion in economic costs. It is in the context of this current healthcare crisis that the Kripalu Center for Yoga & Health is hosting a chronic pain management conference in October 2017. This conference aims at bringing together healthcare innovators and practitioners to explore a new treatment paradigm for pain. Some of the speakers include Lorimer Moseley, PhD, a clinical and research physiotherapist who has advanced the concept of functional pain literacy; Lonnie Zeltzer, MD, an expert in the field of yoga for pediatric pain; Fadel Zeidan, PhD, a leader of mindfulness-based pain relief treatment; and Sat Bir S. Khalsa, PhD, who will address the psychophysiological mechanisms underlying the benefits of yoga for chronic pain management.

Indeed, there is strong scientific rationale for the use of yoga, meditation, and other complementary approaches in the treatment of pain. National surveys consistently find that 30-40 percent of the US population use complementary approaches such as acupuncture, massage therapy, yoga, and meditation to alleviate their painful conditions. Mindfulness meditation may be effective at reducing chronic pain symptoms by modulating a host of endogenous neurochemical systems. The result is a significant reduction in pain-related brain activity and activation in higher-order brain areas such as the insula. One of the first mindfulness meditation trials in pain studies found that long-term Zen meditation practitioners required significantly higher levels of noxious thermal stimulation to report similar levels of pain as age-matched controls. Although the Zen practitioners showed significant activation of “sensory processing” brain regions, they showed a reduced activation in areas of the brain that evaluate pain.

Similar results were observed in North American long-term yoga practitioners, in a recent study conducted at the National Institutes of Health, who tolerated pain more than twice as long as control subjects not practicing yoga. The yogis also had more gray matter in the brain insular region, which correlated with pain tolerance. In an examination of the ways in which pain was tolerated by each group, the yogis were found to use yoga-based cognitive strategies, such as acceptance and increased interoceptive awareness, and behavioral strategies, such as relaxation and slow breathing, whereas controls tried to actively distract themselves or ignore the pain, which are less effective ways to manage pain. These findings suggest that yoga practice can teach us new ways to deal with sensory inputs and modulate our reaction to them.

The research of Lonnie Zeltzer (one of the speakers at the Kripalu conference), provides more evidence supporting the use of yoga for pain regulation. For example, a small randomized controlled trial using Iyengar Yoga included 26 female participants (mean age = 28 years) with rheumatoid arthritis. The intervention consisted of 6 weeks of classes held twice per week at the UCLA Pediatric Pain Program yoga studio where numerous yoga props such as blocks, blankets, and bolsters were available to support subjects with a limited range of motion. The women attended 96 percent of the yoga classes, suggesting a high degree of feasibility of yoga therapy for this population. Furthermore, the yoga intervention group showed significantly greater improvement on measures of pain disability and general health and vitality scores when compared to control subjects not practicing yoga, but assigned to a delayed yoga treatment condition. Follow-up data after the end of the yoga intervention showed that those improvements were maintained after 2 months, suggesting the long-term gains of a yoga intervention.

Another study by Zeltzer et al. assessed the impact of a 6-week Iyengar Yoga intervention on irritable bowel syndrome (IBS) symptoms in adolescents and young adults. Although the attrition rate was greater with this population, subjects still attended 75 percent of classes and results showed improvements in pain, psychological distress, fatigue, sleep, and quality-of-life scores. The young adult subjects (aged 18–26 years) reported significantly improved IBS symptoms when compared to untreated control subjects, whereas the teenagers (aged 14-17 years) saw more benefits in physical functioning. Both studies by Zeltzer et al. suggest the suitability of yoga for managing chronic pain in adolescents and young adults.

These encouraging findings are emerging in the context of new developments in the field of pain psychology which suggest that pain is an actively constructed experience and can be modified through learning and mind-body behavioral strategies. We have seen how yoga can develop the skill in practitioners to modulate their pain response through cognitive strategies such as breathing, relaxation, acceptance, and increased interoceptive awareness.

The potential benefits of complementary therapies such as yoga are all the more important due to the current opioid epidemic. In fact, the guidelines released in May 2017 by the Food and Drug Administration (FDA) recommends that doctors look at nonpharmacological approaches, such as complementary therapies, in managing acute and chronic pain and, in 2010, the Office of The Army Surgeon General Pain Management Task Force Report listed yoga as a Tier 1 treatment modality for pain management.

Nikhil Rayburn grew up practicing yoga under mango trees in the tropics. He is a certified Kundalini Yoga teacher and has taught yoga to children and adults in Vermont, New Mexico, Connecticut, India, France, and Mauritius. He is a regular contributor to the Kundalini Research Institute newsletter and explores current yoga research.

Sat Bir Singh Khalsa, Ph.D. is the KRI Director of Research, Research Director for the Kripalu Center for Yoga & Health, and Assistant Professor of Medicine at Harvard Medical School. He has practiced a Kundalini Yoga lifestyle since 1973 and is a KRI certified Kundalini Yoga instructor. He has conducted research on yoga for insomnia, stress, anxiety disorders, and yoga in public schools, he is editor in chief of the International Journal of Yoga Therapy and The Principles and Practice of Yoga in Health Care and author of the Harvard Medical School ebook Your Brain on Yoga.

by Sandeep (Anu) Kaur, MS, RDN, RYT-500 and Sat Bir Khalsa, Ph.D

Obesity, defined as a Body Mass Index (BMI) of 30 or greater, is an epidemic in the US and a pivotal link between increased risk of cardiovascular disease, cancer, and other chronic diseases. Yoga, a mind-body approach, has been increasingly practiced for improving overall health. Most yoga practitioners indicate that the top reason for starting a yoga practice is to improve their health and manage weight. Yoga’s goal of “union of mind-body-spirit” along with the utilization of physical postures, breathing techniques, deep relaxation, and meditative/mindfulness practices offers an internal self-contemplative state that differentiates yoga from conventional exercise such as strength/weight training or aerobic exercise.

Previous studies have established that despite initial psychological and physiological benefits from traditional diet and exercise programs, these weight loss strategies and other conventional medical treatments are relatively poor with respect to long-term adherence to healthy lifestyle changes. This remains a major barrier and weakness in these conventional health approaches. A number of different healthy behaviors are known to influence weight control such as increased exercise, decreased meal portions, and decreased fat and sugar intake. As a form of fat-burning exercise, preliminary clinical trials suggest that yoga practice may or may not contribute strongly to cardiovascular fitness, depending upon the specific yoga style and physical exercises practiced. More recently, research has been conducted on the role of increased mind-body awareness which is connected to both mindful eating behavior and body image awareness.

Most lineages/styles of yoga engender greater body awareness that is associated with a healthier relationship with food and greater body satisfaction. There is also a relationship between chronic stress and weight regulation. Evidence indicates that activation of the stress system is associated with increased consumption of high fat, high sugar foods, and abdominal weight gain. This may be due to increased hypothalamic-pituitary adrenal axis stimulation that elevates levels of the stress hormone cortisol and the activation of the autonomic nervous system (enhanced sympathetic activity and release of adrenaline and reduction of parasympathetic vagal activity). It is well known that yoga is highly effective for regulation of these stress systems, and therefore may mitigate stress-induced binge eating and poor dietary choices (such as so-called comfort foods) that are high in carbohydrates, sugar, and fat. These beneficial psychophysiological characteristics with respect to weight regulation likely account for the observation that regular practitioners of integrative, complementary, and mind-body techniques, including yoga, report healthier weight regulation.

With respect to broader populations, a 2014 study at Columbia University looked at associations between lifestyle behaviors such as dietary changes, conventional supplement use, exercise, and complementary modalities such as yoga. They found those that those using complementary and alternative medicine (CAM) were 4.7 times more likely to engage in healthy lifestyle behaviors than individuals not using CAM. More recently in 2016, in a large sample of internet-using adult volunteers in France, a study examined if practice of any mind-body technique was associated with weight. This study found that 13.8% of the general population were practicing a mind-body modality and the most common practices were meditation (7.6%) and yoga (4.8%) with 7.9% regular users and 5.8% occasional users. Consistent mind-body technique users were the least likely to be obese or overweight. These associations suggest that CAM users (who include a large proportion of mind-body and yoga practitioners) may be a population committed to overall wellness. More specific to yoga, there are now a number of studies examining subpopulations of yoga practitioners with respect to weight regulation.

In a large observational study, Dr. Emily White, Dr. Alan R. Kristal, and colleagues at the University of Washington were one of the first to retrospectively examine the relationship between weight and yoga practice in healthy men and women between the ages of 53 to 57 from the national Vitamins and Lifestyle study (VITAL) with 15,550 participants in 2000-2002. A relatively small number of individuals reported having a yoga practice 7.5% (n=1,039), a statistic similar to that from the national yoga prevalence reported in the national cross-sectional 2002 National Health Interview Survey (NHIS). They found yoga practice during the previous 10 years, since age 45, was associated with attenuated weight gain as compared with non-practitioners for those who were overweight or obese. There were also significant trends for healthier diet patterns and more physical activity in yoga practitioners than in non-yoga practitioners.

Yoga researcher Gurjeet Birdee, MD and colleagues examined the NHIS survey data from 2002 to evaluate yoga’s use for health. They found yoga practitioners were more likely to be healthy and fewer were obese, with most yoga users reporting yoga as significant in maintaining their overall health. Similarly, a more recent study of the prevalence, trends, and correlates of yoga practice in England between 1997 and 2008, using the Health Survey for England data, found that those practicing yoga (as defined by any yoga practice in the last 4 weeks) had a lower BMI, better self-rated general health, and reported a higher frequency of moderate-to-vigorous level of physical activity. Other studies have directly and specifically approached and examined yoga practitioners.

Yoga researcher Nina Moliver and colleagues using an internet survey assessed whether long term yoga practice was associated with BMI in middle-aged women. They interviewed 211 female yoga practitioners (ages 45 to 80) to evaluate if BMI varied based on the length and frequency of their yoga practice. They found a significant inverse relationship such that an increase in yoga experience predicted a lower BMI. Additionally, 49 individuals who had 25 or more years of yoga practice had no obesity. Furthermore, a comparison of the yoga practitioners with general population values of those with similar age and gender revealed a lower BMI in the yoga practitioners.

Perhaps the best research of this kind has been conducted recently by Alyson Ross and colleagues at the National Institutes of Health. They conducted a national survey of American yoga practitioners and observed that higher frequency of practice was associated with decreased BMI. Rather than years of yoga practice or class participation, it was frequency of yoga practice outside of class that was repeatedly a predictor of facets of health including BMI, fruit and vegetable consumption, mindfulness, and subjective well-being.

Although the Human Immunodeficiency Virus (HIV) is no longer the potential global killer epidemic that it was a few decades ago and has faded from the media attention it once had, it is still a prevalent and deadly disease that demands attention and resources. HIV weakens a person’s immune system by destroying CD4 T-cells, which fight disease and infection. If left untreated, HIV progresses to Acquired Immune Deficiency Syndrome (AIDS) in about 10 to 12 years. Scientists believe that HIV may have jumped from apes to humans as far back as the late 1800’s, although 1981 marks the first official reporting of what has become known as the AIDS epidemic. The virus is transmitted through contact with infected blood, semen, or vaginal fluids. Therefore, individuals who engage in risky behaviors such as unprotected sex with multiple partners or drug users who share syringes are at a higher risk for acquiring HIV. These reasons also make prisons high-risk environments for HIV transmission. In addition, stress, which compromises the immune-neuroendocrine pathways can lead to greater replication of the HIV virus and faster disease progression.

Currently about 36.7 million people worldwide are living with HIV and in 2014 it was the 8th leading cause of death for those aged 25-34. Pharmacological treatments such as Antiretroviral Therapy (ART) slow the progression of the disease, increasing both life expectancy and quality of life. However, there are significant side effects from HIV medications that range from rashes, anemia, nausea and diarrhea to severe liver or kidney failure. Psychotherapy is also recommended to help with the impairment in quality of life, as feelings of hopelessness, depression and stress are common amongst HIV patients.

Up to 74% of individuals with HIV also commonly seek out complementary therapies to manage HIV symptoms or medication side effects. One such therapy is Yoga, which has been associated with reducing psychological distress, increasing T-cell count and buffering the decline of CD4 T-cells. Yoga is well-known for its capability of decreasing stress activation in both the autonomic system via reduction in sympathetic activity, and also in the hypothalamic-pituitary-adrenal axis via a reduction in cortisol levels. Evidence suggests that elevated cortisol levels may enhance viral replication and lead to faster HIV disease progression. The increased viral load can also inhibit the formation of new undifferentiated blood cells (hematopoietic stem cells) and yoga appears to play a role in restoring normal levels of hematopoiesis through potential regulation of gene expression and other unknown mechanisms. Yoga also enhances quality of life and increases self-efficacy by enabling patients to take a more active role in their treatment. The spiritual component of yoga is an additional benefit that can enhance psychological well-being amongst individuals with chronic illness.

These mechanisms may help to explain the recent encouraging findings of yoga for HIV research. In 2016 researchers from the School of Yoga and Life Sciences at the S-VYASA University in Bengaluru, a leading yoga research institute in India, studied 44 HIV patients who were randomized to either a Yoga intervention or a control group. The hour-long Yoga intervention included physical postures, breathing, relaxation and meditation, practiced 6-days a week for a month. The control group continued with their daily routine at the HIV rehabilitation center. At the end of the study, control subjects had an increase in anxiety and depression scores as well as a reduction in CD4 cell counts, although these changes were not statistically significant. On the other hand, the yoga participants showed a significant reduction in depression scores and a significant increase in CD4 cell counts when compared to the control group. Therefore, it appears that only one month of yoga practice is sufficient to reduce depression and improve immunity in HIV adult patients.

Another recent pilot study was published in the Journal of Complementary and Alternative Medicine in 2015. Researchers at the Miami Center for AIDS research, at the University of Miami, FL looked at 24 HIV patients who also use crack cocaine. The subjects were assigned to either a Yoga Meditation (YM) intervention or a non-contact control group. The YM group participated in two 60-minute sessions weekly that included yogic movements, breathing, meditation and Yoga Nidra relaxation. The intervention lasted 2 months and researchers concluded that the program was acceptable and feasible with 89% overall attendance and 83% participation in the yoga sessions. Although the YM participants showed modest improvements on their Quality of Life (QOL) scores, their salivary cortisol levels did not change. Researchers attribute this anomaly to the nature of the subpopulation (cocaine users with HIV), the small sample size and short intervention time. However, significant improvements on the Perceived Stress Scale and Impact of Events Scale (QOL variables) were noteworthy. Since both these scales measure stress and response to stressful/traumatic events, these positive findings suggest that a longer intervention might further improve QOL in this population.

Despite the encouraging results of these early studies, they are limited in strength due research design limitations of small sample sizes, short intervention times and the lack of active control groups. Larger randomized control trials (RCTs) are required to add statistical power and better understand the mechanisms underlying the efficacy of yoga interventions for HIV patients. An exciting new study in Halifax, Canada will be assessing the effects of a 12-week, community-based yoga intervention on cognition, balance, mental health, and quality of life in 30 HIV patients. Continued research and new studies will further our understanding of the therapeutic potential of yoga for HIV patients and highlight the mechanisms underlying the observed benefits.

by Nikhil Ramburn and Sat Bir Singh Khalsa, Ph.D.

For centuries, muscle pains have been known as rheumatism but the term Fibromyalgia (FM) was not coined until 1976. It was even more recently, in 1981 that the first clinical study validated the symptoms associated with FM, and there was some historical period of controversy as to the underpinnings of this disorder and whether this was in fact a credible and distinct disease condition. Fibromyalgia is a syndrome that affects muscles and soft connective tissue and the symptoms include chronic pain, fatigue, disturbed sleep, and mood issues. Somewhat unique to FM is the existence of painful tender points or trigger points across the body. Researchers believe that FM amplifies pain by affecting the way that the brain processes pain signals. Onset of this disorder can sometimes be attributed to physical trauma, surgery, infection, or psychological stress. FM is one of the most common chronic pain conditions with an estimated 10 million people affected in the U.S. While close to 90% of FM patients are women, the disorder also occurs in men and children of all ethnic groups. Conventional treatment includes pain medication, antidepressants, and sleeping pills aimed at managing symptoms. However, the common drug side effects include dizziness, nausea, fatigue, and the serotonin-norepinephrine reuptake inhibitor class of antidepressants may raise blood pressure and cause heart palpitations. Other conventional recommendations include physical therapy, relaxation training, and cognitive behavioral therapy, the latter treatment attesting to the role that thought processes and psychological factors play in pain syndromes.

Complementary and integrative treatment approaches such as yoga and meditation are also widely used by patients with FM in search of relief. Yoga provides many of the benefits associated with the treatments mentioned above and may be useful as complementary treatment for FM. Patients with FM tend towards inactivity and yoga provides light physical activity that can slowly improve physical conditioning. The increased flexibility is important for patients who present stiffness and muscular shortenings that can worsen fatigue and pain. In addition, the strength and cardiovascular gains from yoga may provide a basis for further aerobic exercises, which are indicated as beneficial for FM patients. Yoga, consistent with evidence in its positive role in pain regulation, can also contribute to the management of chronic pain by inhibiting brain activity in pain-related regions, such as the somatosensory cortex. Finally, the self-awareness and mindfulness developed by yoga may help to reduce levels of anxiety and depression, thereby also impacting the emotional components of pain. These gains in relaxation and pain reduction would also have positive effects on stress and sleep patterns.

In 2007 researchers from the University of Sao Paulo in Brazil, conducted the first clinical trial on the efficacy of yoga for FM treatment. Gerson Da Silva et al. studied 40 women who were randomized into a ‘yoga only’ group or a ‘yoga and massage’ group. For eight weeks, the subjects participated in stretching, breathing, and relaxing yoga techniques. In addition, the ’yoga and massage’ group also received Tui Na, which is a traditional form of Chinese bodywork. Researchers observed significant decreases in pain intensity and improvements on the Fibromyalgia Impact Questionnaire (a commonly used tool to evaluate the impact and symptoms of FM) in both groups. However, over time, contrary to the typical belief that more is better, the patients in the ‘yoga only’ group reported less pain intensity than the group that had added massage and bodywork, suggesting that a passive therapy could decrease control over FM symptoms and therapies which enhance self-efficacy may be preferable.

Another landmark study investigated the effects of yoga on cortisol levels in FM patients. Cortisol is a steroid hormone that is produced in response to stress and may have secondary effects on pain, fatigue, immune function, and sleep. Researchers from York University in Toronto, Canada investigated 22 female subjects who participated in 75-minute gentle Hatha yoga classes consisting of postures, breathing, and meditation, twice weekly for 8 weeks. The results suggested that a yoga intervention can reduce pain and catastrophizing (dysfunctional negative thoughts), increase acceptance, and alter total cortisol levels in women with FM. While the yoga intervention did not result in improvements in anxiety and depression scores, other yoga studies of women with FM have shown this additional benefit. Nonetheless, the observed changes in cortisol levels provide preliminary objective evidence for the mechanisms underlying the efficacy of yoga for FM patients.
A more recent study, published in the International Journal of Yoga Therapy in 2016 was led by yoga researcher James Carson of the Oregon Health & Science University in Portland, OR. His research team’s previous pilot studies showed significant improvement in FM patients after a yoga intervention. Long-term follow-up evaluations showed that patients sustained most of their treatment gains. The study collected pilot data on 7 female patients who participated in an 8-week yoga intervention, with 120-minute classes weekly. The classes included gentle stretching, meditation, breathing techniques, and didactic presentations on the application of yogic principles to optimal coping. They recorded significant changes in heat pain tolerance, pressure pain threshold, and heat pain after-sensations. These improvements suggest mitigation of several abnormalities associated with FM such as increased sensitivity to heat and lower pain tolerance. This small study sheds light on how yoga may affect pain pathways in FM patients and reveals some of the underlying mechanisms by which positive outcomes are achieved.
Not surprisingly, these early studies, while encouraging, are limited by small sample sizes and in some cases, the absence of a control group. Larger randomized control trials (RCTs) are required to add statistical power and better understand the mechanisms underlying the efficacy of yoga interventions. Furthermore, these studies have focused on females with the condition, and it would be useful to include male participants in future trials to increase the generalizability of the findings. An ongoing study sponsored by the U.S. Department of Veteran Affairs is, in fact, recruiting both male and female veterans with FM to participate in an RCT comparing the effectiveness of a yoga-based intervention with a structured exercise program

By: Sandeep (Anu) Kaur, MS, RDN, RYT-500 and Sat Bir Khalsa, Ph.D

Obesity has been on the rise for decades in the United States and is a critical risk factor associated with chronic diseases such as heart disease, hyperlipidemia, type II diabetes, hypertension, stroke, and certain types of cancer. Factors contributing to the obesity epidemic include a sedentary lifestyle with low levels of physical activity, a diet high in calories and low in nutrients, poor social norms around food choices, mindless and/or stress-induced overeating, and increased stress itself. In the United States, 36% of adults and 17% of youth are officially obese. Based on the Centers for Disease Control and Prevention guidelines, obesity is defined as a body mass index (BMI) of 30 or greater. Obesity prevalence is highest among middle-aged adults (40.2%) and older adults over the age of 60 (37.0%) compared to younger adults (32.3%). Despite recent studies showing a plateau in the growth in prevalence of obesity in certain geographic areas in the United States, the rates are likely slowing down rather than reversing. Adult and childhood obesity national percentages continue to remain above the government’s Healthy People 2020 program goal of 30.5% for adults and 14.5% for children.

Traditionally, weight loss strategies have focused mainly on diet and exercise as a method to decrease caloric intake and increase energy expenditure, which generally is effective with initial weight loss. However, most people regain weight over time due to regression in eating habits and decreased exercise adherence, underscoring the need for alternative forms of dietary and physical activity approaches that are effective over the long term. Other conventional treatments have included pharmacotherapy and bariatric surgery, which have potentially serious complications and do not directly address the underlying health behaviors or complex psychological issues associated with initial weight gain. Conventional psychotherapy and behavioral therapy have been used to manage disordered eating such as binge or stress eating and encourage positive behavioral changes and healthier food choices through cognitive restructuring and the adoption of more functional thought patterns. Mindfulness based therapies, such as yoga and meditation, promote self-regulation of attention on the present moment experience with an attitude of openness, acceptance and curiosity, and increase stress coping and resilience, which are both important characteristics for supporting change in health behaviors. Furthermore, movement based mindfulness strategies further add the physical dimension, improving fitness, respiratory function, and management of stress and physical tension.

To better understand how yoga affects weight loss, Ross and colleagues conducted semi-structured interviews with individuals who fit the national demographics, majority being white, educated females who were either overweight and had struggled to lose weight or who were of normal weight and had lost weight unintentionally through the practice of yoga. Of the practitioners, 95% reported positive psychological changes with a mindset focus on general health rather than exclusively weight loss, improved mood, emotional stability, reduced stress, increased self-esteem and self-acceptance. Mindfulness was a key component of the feedback received from the interviews. Participants reported increased mindfulness around the food they consumed and the connection to the emotions they felt. Yoga reduced unconscious and emotional eating, and participants also reported that the stress reduction associated with yoga shifted their attitude and allowed them to choose healthier foods. Another unique theme that emerged was emotional support. Sixty percent of participants indicated that the yoga community and culture at yoga studios played a role in feeling supported and yoga teachers served as role models, which was different from yoga in a gym setting. Additionally, 90% noted physical changes from increased muscle tone to improved sleep and decreased pain. Nearly half the participants reported losing weight specifically in their abdomen, which has special significance with respect to obesity and weight regulation.

Abdominal adiposity often noted with obesity has been shown to have a strong relationship with stress and cortisol release. Excessive visceral fat behaves as an endocrine organ, affecting levels of adipocytokines, such as leptin and adiponectin. Leptin is associated with increased inflammation and adiponectin which is protective, is low in the presence of obesity. Inflammatory cytokines, such as Interleukin-6 and tumor necrosis factor–alpha have also been shown to be released from adipose tissue leading to a state of low grade inflammation with the potential of becoming disease-related inflammation. The underlying mechanism for yoga’s effectiveness on stress-related eating has been hypothesized to involve the down-regulation of both the hypothalamic-pituitary adrenal (HPA) axis and the sympathetic–adrenal medullary response of the autonomic nervous system to stress. It is speculated that abdominal weight loss may also be an indication of decreased HPA axis activation. Evidence supports the finding that stress and the release of cortisol are associated with increased consumption of high fat, high sugar foods.

Physical activity is a critical component to keep obesity and chronic disease at bay, yet low exercise adherence is a common cause of weight gain. Bryan and colleagues assessed yoga’s impact on exercise adherence in inactive adult participants in a 10-week randomized controlled pilot study that had subjects meet twice-weekly for hatha yoga classes. Individuals in the yoga group went from an inconsistent exercise routine to consistently participating in the yoga class and doing additional exercise. Qualitative data from interviews with participants showed that they experienced increased self-awareness and improved perception towards their desire and their ability to exercise, which in turn increased overall exercise adherence. One participant shared, “yoga makes me feel better, and therefore I want more of it,” underscoring participants’ improved perceptions and mind-body awareness. Increase in general well-being, exercise adherence, and exercise self-efficacy (the belief in one’s ability to do the exercise) were all positively correlated.

In summary, yoga as a multi-dimensional mind-body activity offers more than just a form of energy expenditure through the physical postures and exercises. It likely plays a vital and stronger role in weight management through behavioral, physical and psychosocial effects which lead to improved healthy eating habits. More needs to be understood about yoga’s relationship with nutrition and biomarkers indicating dietary changes such as antioxidant intake. Current yoga studies are starting to look at the effectiveness of yoga programs on increasing dietary compliance, overall well-being and health behaviors in both normal weight and obese individuals. Yoga philosophy has always acknowledged the connection between mind and diet as one way to create harmony. Continued yoga research may offer insight and a better understanding of yoga’s role as a potential long-term, holistic approach to weight loss alone or in combination with conventional weight loss strategies.

by Nikhil Ramburn and Sat Bir Singh Khalsa, Ph.D.

Cardiac arrhythmias are a group of conditions characterized by an irregular heartbeat. One such condition is atrial fibrillation (AF), which affects the upper chambers of the heart (the atria). Rapid and irregular heartbeats are the primary cause of symptoms associated with AF. These symptoms include palpitations, dizziness, anxiety, and reduced exercise capacity, which eventually result in severely impaired quality of life. AF tends to progress from short episodes to longer, more frequent attacks although asymptomatic episodes are common even in patients who routinely exhibit symptoms. Common medical complications include large variations in blood pressure and an increased risk of stroke. A few lifestyle risk factors have been identified for AF, the most important one being hypertension along with obesity, alcohol, and caffeine consumption.

Despite recent advances in pharmacotherapy, ventricular arrhythmia and AF mortality rates are still high and by the age of 80 years, the lifetime risk of developing AF is approximately 22%. There is increasing epidemiological significance of AF given reports predicting a doubling of AF prevalence by 2050. The current lack of effective treatment for AF exacerbates this grim forecast. Conventional treatment is based on pharmacotherapy and ablative/surgical strategies, both of which have limitations. Antiarrhythmic drug therapy is associated with a relatively high recurrence rate and can paradoxically precipitate more ventricular arrhythmia. On the other hand, catheter ablation can effectively suppress the early stages of AF (paroxysmal AF) but is difficult to achieve with persistent AF or concomitant cardiac disease. Therefore, there is a need for integrative and complementary therapies that go beyond symptom alleviation to treat the underlying lifestyle risk factors and improve the quality of life of individuals with AF.

Yoga therapy may prove to be one such complementary treatment for AF. Yoga is especially known for its ability to affect the autonomic nervous system, including both sympathetic and parasympathetic activity, which results in a positive impact on heart rate and blood pressure. Furthermore, yoga practice has been shown to reduce stress and anxiety thereby improving quality of life for AF patients. Finally, yoga has potential efficacy in addressing underlying lifestyle risk factors, such as obesity, by improving behaviors including eating and physical activity. Yoga practice may also lead to a reduction in excessive alcohol and caffeine consumption by enhancing awareness of the physical body and providing alternative coping tools. In light of these benefits, the efficacy of yoga therapy for AF has been an attractive alternative treatment, especially since there are significantly few, if any, negative side effects and yoga is less expensive than medications or surgery.

There is now a small but growing body of clinical trial research evidence documenting the beneficial effects of yoga on patients with heart arrhythmia. A 2012 study from the Sant Gadge Baba Amravati University in India, was the first to present data on the effects of pranayama (yogic breathing) on markers of myocardial (heart tissue) electrical instability. Researchers evaluated 27 patients after a 12-week program of 36 pranayama sessions. The intensity of the exercises was modified and all participants were successful in completing the pranayama intervention. The results showed numerous promising improvements in cardiovascular health. For example, exercise capacity increased by 25% and the indices of ventricular electrical repolarization dispersion (a marker of heart tissue malfunction) was markedly reduced. This last finding indicates a significant decrease in the patients’ risk of having ventricular dysrhythmia and sudden cardiac-induced death. These marked improvements suggest that more traditional forms of yoga that include pranayama should be considered in clinical yoga therapy applications.

The first study to examine the impact of yoga in patients with AF was published in 2013 in the prestigious Journal of the American College of Cardiology. Researchers from the University of Kansas Hospital and Medical Center evaluated at 53 patients with paroxysmal AF who were between 18 and 80 years old. All patients received Iyengar yoga training for 60 minutes at least twice weekly and sessions consisted of pranayama, physical yoga exercises and relaxation. The results showed that the yoga intervention significantly reduced the number of symptomatic episodes and improved resting heart-rate and blood pressure. In addition, depression, anxiety, and quality of life scores improved significantly, thereby highlighting the efficacy of yoga in addressing the secondary impacts of AF on mental and physical health. These early findings underscore the therapeutic value of a low-cost, non-invasive behavioral treatment like yoga. Future research is needed to elucidate whether the findings are applicable to more chronic forms of AF.

A more recent study by investigators in the Divisioin of Cardiovascular Medicine at the Danderyd Hospital in Stockholm, Sweden was published in 2017. In this clinical trial, 80 patients with paroxysmal AF were randomly assigned to either a standard care control group or received standard treatment in combination with yoga for 12 weeks. The Kundalini Yoga-based intervention (Mediyoga http://en.mediyoga.com/) was adapted for individuals with cardiac diseases and included deep breathing followed by light movements, Sat Kriya, and meditation. The results showed that yoga significantly improved quality of life scores, an important outcome for this patient population. In addition, heart rate and blood pressure scores were significantly lower in the yoga group when compared to those of the control group. Since hypertension is an important risk factor for AF and most patients have poorly regulated blood pressure, these results suggest that yoga may prove to be an important complementary treatment for this condition.

Despite these encouraging preliminary findings demonstrating the efficacy and absence of significant side effects for yoga interventions in AF patients, they are based on very few trials and more studies with larger sample sizes are required to substantiate these results. Future research is also needed to elucidate some of the mechanisms underlying the markers of electrical instability in heart tissue and how yogic breathing and exercises can positively impact the abnormal electrical activity of heart cells.

By Nikhil Ramburn and Sat Bir Singh Khalsa, Ph.D.

The Kirtan Kriya meditation is one of the unique signature practices of Kundalini Yoga as taught by Yogi Bhajan. There are multiple benefits ascribed to this kriya and, most importantly, recent research has shown that this practice can reduce stress levels and increase brain activity in areas associated with memory.

A leading voice in the integrative medical approach to the prevention of Alzheimer’s disease, Dr. Dharma Singh Khalsa and the Alzheimer’s Research & Prevention Foundation (ARPF), features Kirtan Kriya on their website home page. The ARPF was founded in 1993 by Dharma Singh Khalsa, M.D. and has funded and conducted years of research with eminent university research centers across the U.S. and in Europe. The ARPF is dedicated to pursuing longitudinal studies on the therapeutic benefits of Kundalini Yoga therapy and especially Kirtan Kriya on cognitive decline, mild cognitive impairment, and Alzheimer’s prevention, including functional imaging studies, genomics, biomarkers and neurocognitive testing. Prominent researchers who have collaborated with Dr. Dharma Khalsa on recently published Kirtan Kriya research funded in part by ARPF include Dr. Kim Innes of West Virginia University and Dr. Helen Lavretsky of the Department of Psychiatry at UCLA.

Dr. Lavretsky is a geriatric psychiatrist who jokingly says that she left Russia for America to find Kundalini Yoga as taught by Yogi Bhajan. In fact, his teachings profoundly impacted her personal and professional life and she now teaches and conducts research in the neuroscience of integrative mental health and the neuroscience of consciousness and enlightenment. In January of 2017, Dr. Lavretsky and colleagues published their findings from a randomized controlled trial (RCT) involving 81 participants aged 55 and above with mild cognitive impairment (with symptoms such as significantly forgetting names and misplacing items). The subjects were assigned to either 12 weeks of standardized memory enhancement training (MET, which is a known conventional therapy) or yoga and then followed over a six-month period. The yoga group participated in weekly 60-minute Kundalini Yoga classes, which included warm-ups, breath training (pranayama), 12 minutes of Kirtan Kriya, meditation, and Shavasana (deep rest). The yoga training group also practiced Kirtan Kriya for 12-minutes daily at home. After the 12-week intervention, there was no difference in dropout rates suggesting the suitability of Kundalini Yoga and Kirtan Kriya for this population. While both groups showed significant memory improvement at 12 weeks post-intervention and the 24-week follow up, only the yoga group showed significant improvements in measures of executive functioning, depression, anxiety, and psychological resilience.

In addition to these results, a subsample of 25 participants from this study were examined using functional magnetic resonance imaging (fMRI) to document brain connectivity, structure, and chemical changes associated with the 12 weeks of yoga or MET. Dr. Lavretsky and her colleagues found that yoga was just as effective as memory training in improving connections between brain regions involved with verbal memory performance. These preliminary findings are encouraging and suggest that yoga can produce functional changes in the brain associated with improved memory in seniors.

Dr. Kim Innes is a well-known yoga researcher who has investigated the efficacy of yoga for a number of medical conditions including type 2 diabetes, sleep disorders, and cardiovascular disease as well as in the elderly and women’s health. In a Yoga Journal profile of her yoga research, she was quoted, “It was my personal experience with yoga and the benefits I felt, like reduced stress and better sleep, that sparked my interest in studying yoga as a disease intervention.” Her Kirtan Kriya study, also published in January 2017, reported similar improvements in cognition and memory in older adults with subjective cognitive decline. This was the first RCT designed to examine the effects of mind-body practices on memory and cognitive functioning in this population. The study evaluated 60 older adults assigned to either a Kirtan Kriya meditation group or a music listening program. The subjects practiced at home for 12 minutes every day for 12 weeks. Participants in both groups showed marked and significant improvements in subjective memory functioning and objective cognitive performance after 12 weeks. Furthermore, the post-intervention follow-up revealed that the substantial gains in memory and cognition were maintained or further increased suggesting that Kirtan Kriya meditation is an effective protocol to sustain memory improvements in older adults with preclinical stages of Alzheimer’s disease. As an additional benefit, Kirtan Kriya showed greater improvement in sleep, mood, stress, and quality of life scores when compared to the music group.

The research by ARPF and Drs. Lavretsky and Innes has drawn significant attention to the potential of Kirtan Kriya through a number of news reports and articles. The research suggests that Kirtan Kriya seems to be an effective intervention to increase brain activity in areas associated with memory and has long lasting effects. However, these preliminary trials are limited by relatively small sample sizes and further longitudinal studies with larger and more diverse samples are required to generalize and confirm these findings. Furthermore, it would be advantageous if different additional objective biomarkers of cognition and memory loss could be measured in Kirtan Kriya research order to deepen our understanding of the mechanisms of action for this meditation. The potential of a simple behavioral intervention that could prevent symptoms of cognitive decline, and Alzheimer’s itself, would be a major contribution to this common and growing medical concern.

By Nikhil Ramburn and Sat Bir Singh Khalsa, Ph.D.

 

The most common breathing practice in yoga is long, slow, deep breathing.  However, despite its simplicity and multiple benefits, it is also relatively misunderstood.  The slow breathing practices in yoga are not simply slower, they are also deeper, with the diaphragm and lungs expanding more fully with each breath. Yogic breathing involves the noticeable movement of the abdomen, which extends outwards on each inhale, thereby earning it the name of abdominal or belly breathing. Apart from simple slow, deep breathing, yogic breathing or pranayama practices also included modified techniques such as Ujjayi, which involves a slight constriction of the glottis to create an audible breath. Other yogic breathing patterns may call for different breathing frequencies, different breath inhalation, retention, and exhalation ratios, segmented inhales and exhales, and breathing through specific nostrils. The deeper expansion of the lungs in simple long slow yogic breathing effectively increases the lung surface available for gas exchange and so it is more efficient use of the lungs. In addition, dead space ventilation (movement of air during breathing in the trachea between the mouth and lungs that does not participate in gas exchange) is relatively reduced. The resulting increase in efficiency is equivalent to one possessing a larger lung.

 

Unfortunately, the understanding of the accurate benefits of yogic breathing is often compromised by certain claims and misconceptions. The most common of these is the notion that slow yogic breathing increases oxygen in the blood and that most the public not privy to practicing this type of breathing are walking around chronically oxygen deprived.  In fact, unless one has a respiratory condition, such as chronic obstructive pulmonary disease or one is at high altitude, blood oxygen levels are normally well maintained at very high levels. It should be noted that respiratory physiology is a complicated issue whose details are outside of the scope of this article, however, the reality is that both slow and rapid yogic breathing practices, if done appropriately, do not yield significant changes in oxygen or carbon dioxide levels. The main reason for this is that the effect of the deeper breath in long slow deep breathing is counterbalanced by the slower respiration rate. Deeper breathing with a typical respiration rate would actually lead to clinical hyperventilation, a potentially harmful state, which should be taken into account when practicing yogic breathing.

 

Research on the long slow pranayama practice, when practiced appropriately, has been shown to slightly improve gas exchange under normal conditions. In early studies in 1964, at the Department of Psychiatry at Yale University, research fellow K.T. Behanan (trained in yoga at the Kaivalyadhama Yoga Institute in India) examined the effects of a series of pranayama practices on himself, with the results published in both a monograph and the Journal of Applied Physiology by his mentor. Three representative patterns of yogic breathing were tested, namely Ujjayi, Kapalabhati and Bhastrika. While these techniques required a 12-35% increase in oxygen consumption above baseline, the relaxed breathing that immediately followed, showed little indication that the subject had been exerting himself. A very thoroughly done study by Frostell et al. in 1983 using state of the art respiratory physiological research measures in advanced pranayama practitioners, made it clear that both slow and fast types of pranayama yield minimal changes in both oxygen and carbon dioxide levels.  A more recent pranayama research study published in the journal Evidence-Based Complementary and Alternative Medicine in 2013, had 17 yoga-naive participants tested to see if Ujjayi resulted in greater oxygen saturation when compared to regular slow yogic breathing. The results showed the greatest improvements in slow breathing without Ujjayi, likely due to the increased respiratory effort. However, Ujjayi did result in greater oxygen saturation. The researchers concluded that simple slow breathing with equal inspiration/expiration is the best technique for yoga naive subjects.

 

In addition to these studies performed under normal conditions, there is a growing body of evidence that yogic breathing improves gas exchange under altered, challenging conditions as well. In 1968, Shanker Rao from the Armed Forces Medical College in Pune, India looked at one subject who attempted yogic respiratory control at two different altitudes. The observations were carried out in the South-Western foothills of the Himalayas (12,500 ft.) and in Pune (1,800 ft.). He observed that the subject met increased demands for oxygen at high altitude by using long slow yogic breathing, which was effectively improving respiratory efficiency by increasing tidal volume (the total volume of air exchanged in each breath) instead of increasing the frequency of respiration.

 

Recent studies with a larger group of subjects support these early findings. In 2001, Luciano Bernardi et al. conducted a study in Albuquerque NM, comprising of 19 controls and 10 western yoga trainees to test breathing patterns and autonomic modulation at simulated high altitude. The researchers found that yoga trainees maintained better blood oxygenation without increasing ventilation (slow yogic breathing being a more efficient breathing method) and had reduced sympathetic activation when compared to controls. A subsequent study by Bernardi et al. looked at Caucasian yoga trainees, Nepalese Sherpas and Himalayan Buddhist monks. They found that yoga trainees were able to maintain oxygen exchange rates at high altitude that resembles the Himalayan natives. Therefore, respiratory adaptations induced by yoga practice may represent an efficient strategy to cope with altitude-induced hypoxia (inadequate oxygen supply). Another recent study lead by Colonel Himashree of the Indian army and published in 2016, further confirmed these findings with a large sample size of two-hundred Indian soldiers divided equally between an exercise control and yoga practice group. Indeed, the yoga group performed better at high altitude in a number of health indices such as respiratory rate, systolic and diastolic blood pressure and anxiety rates.

 

In summary, slow yogic breathing is the most efficient way to ventilate and exchange oxygen and carbon dioxide.  However, in addition to this benefit, long slow yogic breathing is also known to also offer numerous additional benefits including beneficial effects on heart rate variability, the chemoreflex response, autonomic function, and even on mood and mental health.

by Nikhil Ramburn and Sat Bir S. Khalsa, Ph.D.

 

Osteoarthritis (OA) is the most common form of arthritis and is characterized by degenerative joint changes that cause pain and decreased function over time. In addition to loss of joint function and muscle strength, OA symptoms include pain, sleep disturbance which can lead to depression, anxiety and social isolation. Since the most commonly affected joints in OA are the hip and knee joints, which are essential to mobility, arthritis is the most common cause of disability. In fact, approximately 50 million US adults have doctor-diagnosed arthritis with older adults being the most affected. It is noteworthy that non-hispanic blacks and hispanics have worse arthritis impact despite having the same or lower prevalence of arthritis compared to non-hispanic whites. Given the high prevalence and chronic nature of OA, it imposes upwards of $60 billion in healthcare costs and lost productivity in the U.S. The joint degeneration caused by OA is currently irreversible and conventional treatment focuses primarily on symptom alleviation and maximizing joint function.

 

The common therapies for OA include gentle exercise, heat and cold application, stress reduction, weight management, and pharmacotherapy. Unfortunately, chronic use of pain-relief medication such as acetominophen may have significant side effects on the liver and nonsteroidal anti-inflammatory drugs can impact the stomach and cardiovascular system. On the other hand, appropriate exercise has few negative side effects and is effective at reducing pain, increasing day-to-day function and improving sleep. However, arthritis itself is one of the most common reasons for limiting physical activity. Therefore, in order to improve quality of life, many patients need to find ways to take more responsibility and initiative for their own care, which is why attention is increasingly focused on non-pharmacological interventions that enhance self-care and self-efficacy.

 

Complementary and integrative approaches include yoga which is known to improve self-efficacy in patients with chronic diseases.  A key practice underlying this is the increase in mindfulness and mind-body awareness that is a hallmark of the meditative component of yoga practice, making patients more awareness of the effects of their behaviors on their condition, allowing them to gravitate towards beneficial behaviors and away from negative ones.  Furthermore, yoga practices are well known to reduce chronic stress, which not only impact the disorder itself, but can also lead to a cascade of positive outcomes on other comorbid factors of OA such as improved sleep, decreased anxiety and a better ability to detach from the psychological experience of pain.  In addition, yoga comes with the benefits of physical exercise exercises including stretching, strengthening and balance and the associated safety component in the ability to adjust pace and intensity.

 

Existing biomedical research on the efficacy of yoga for OA is promising, and shows some evidence of reduced pain, sleep disturbance, and disability. A recent systematic review published by researchers at the University of Minnesota and Florida Atlantic University in the American Journal of Physical Medicine & Rehabilitation in 2016, examined 12 reports, four of which were randomized controlled trials (RCTs) involving a total of 589 participants with OA-related symptoms. This study found that yoga interventions resulted in reductions in pain, stiffness and swelling but the results on physical function and psychosocial well-being were inconclusive because of the variety of outcome measures used. Of all OA symptoms, yoga seems to have the most positive effect on pain. Not surprisingly, there also seems to be a strong positive relationship between the number of yoga sessions per week and the efficacy of yoga in physical function and emotional well-being in the reviewed studies. This is encouraging since it suggests that the repetition of yoga exercises does not have negative effects on the joints of OA patients and therapeutic yoga programs for OA patients could focus on sustained daily practice as opposed to weekly interventions. In fact, no adverse events were reported. Unfortunately, the majority of the trials were of medium methodological quality and only one trial was of high quality, which prevents us from drawing definitive conclusions at this point.

 

The first RCT to assess the effect of a yoga intervention on patients with OA of the hands and fingers was published in the Journal of Rheumatology in 1994. Results revealed that the 8-week long, weekly yoga practice yielded significantly greater improvements than the controls’ measures for pain, tenderness and finger range of motion. Another early study, also from 1994, looked at a different type of arthritis, rheumatoid arthritis (RA). This first-ever RCT examining the effects of yoga on RA included 20 participants, in which the intervention group practiced gentle physical postures and breathing techniques whereas the control group received their usual medical treatment. After 3 months, grip strength increased significantly in the yoga group but not in the controls. Both of these early studies were relatively short in duration and underpowered, but they did provide us with the first demonstration of the potential of yoga as an effective therapy for arthritis.

 

More recently in 2015, the first published study to attempt the design of a yoga strengthening program with functional relevance was conducted by Brenan et al. in Ontario, Canada. This single-group trial included 45 women with knee OA undergoing a yoga program focused on lower extremity strengthening and hip mobility using a variety of squats and lunges. Improvements were observed in all subscales of the Knee injury and Osteoarthritis Outcome Score, such as decreased pain and improved quality of life, with the greatest improvement occurring in the sports and recreation subscale.

 

Another landmark study published in the Journal of Rheumatology in 2015 is the largest-ever RCT of yoga for OA and RA. Seventy five sedentary adults with RA or knee OA were randomly assigned to 8 weeks of yoga (two 60-min classes and 1 home practice per week) or to a delayed treatment control (waitlist). Moonaz et al. found that yoga was associated with substantial improvements in physical and general health perceptions, pain, energy and mood when compared to the control group. In addition, yoga was not associated with any adverse effects. It is worth noting that this is only the second study in arthritis (of 20 published to date) to include safety data. This preliminary evidence is encouraging and suggests that yoga may help sedentary individuals with arthritis safely increase physical activity and improve physical and psychological health as well as quality of life.

 

In summary, the current body of evidence points towards decreased pain in yoga program participants and suggests improvements in several risk indices mentioned previously such as mood and quality of life. However, additional studies with active comparison groups in diverse settings and other forms of arthritis are necessary to support these findings and establish the benefits of yoga in relation to traditional exercise. Currently, an ongoing pilot study at the National Institutes of Health Clinical Center, in Maryland is the first to evaluate the feasibility and acceptability of a yoga intervention for arthritis in minority communities. Future studies in diverse settings are vitally important because of the high impact of arthritis in minority populations.

by Nikhil Ramburn and Sat Bir S. Khalsa, Ph.D.

Multiple Sclerosis (MS) is a chronic disease with an unpredictable course characterized by inflammation and neurodegeneration of the central nervous system, specifically demyelination (nerve cells in the brain are wrapped in myelin, which insulates and protects the cells and helps speed nerve transmission). These processes cause symptoms such as pain, muscle cramps, stiffness, spasms, and fatigue. Stress is an aggravating factor that exacerbates demyelination. This disorder is an autoimmune condition (in which the body’s immune system actually works against its own cells and tissues) and the trigger responsible for it is unknown. Like most autoimmune illnesses, female patients are affected 2 to 3 times more frequently than males. MS is the third most common cause of disability in the United States in individuals 15 to 50 years old. The premature morbidity and productivity lost to this disability results in major financial burdens on the patient, family, and healthcare system. An individual’s quality of life is likewise affected due to restricted mobility, chronic pain, and impaired social cognition that in turn often leads to decreased self-worth, anxiety, and depression. Unfortunately, pharmacological treatment is only modestly effective and is associated with serious side effects such as psychosis, seizures, and brain damage. On the other hand, conventional psychotherapy is a valuable part of MS management as it can help patients reduce chronic distress while improving psychosocial function.

To manage chronic stress, some patients have practiced complementary therapies such as Mindfulness Based Interventions (MBIs), which have provided improvements in quality of life, depression, and fatigue. The well-known Mindfulness-Based Stress Reduction program (MBSR) and other MBIs have become increasingly popular at managing different aspects of chronic illness in the last 30 years. Although published research studies of MBIs in MS are scarce, a 2014 review based on 3 studies of good methodological quality with a total of 183 patients indicated improvements in mental health and physical parameters such as fatigue. The beneficial effects of a mindfulness practice may be related to a decrease in emotional dysregulation and stress management as observed in lower levels of the stress hormone cortisol. There is strong evidence of improved activity and high adherence as well as a reduction in patient fatigue due to physical therapy. However, there is currently no definitive evidence for the effects of exercise on cognition in patients with MS.

Yoga may also prove to be a viable complementary therapy for MS since it provides the benefits of both physical activity and meditation and also includes breath regulation, which is known to be a useful strategy for pain management. Furthermore, traditional forms of yoga foster the cultivation of awareness, insight and spirituality which may further help patients cope with chronic pain. In fact, yoga has been shown to be as beneficial as aerobic exercise therapy and may be more practical for some MS patients as it is a low-impact form of exercise. Yoga as a therapeutic intervention is now well known to improve outcomes such as self-efficacy, mental health, and quality of life in a variety of conditions and is therefore a viable intervention candidate for MS patients and has been evaluated as such.

The first literature review and meta-analysis of studies of yoga for MS examined seven Randomized Control Trials (RCTs) with a total of 670 patients. This 2014 review was conducted by German researchers and a researcher from the Mashad University of Medical Sciences in Iran and revealed short-term benefits of yoga on fatigue and mood outcomes. In addition, yoga group participants reported fewer exacerbations of multiple sclerosis as compared to usual care or exercise treatment subjects. However, the current research has yet to highlight the impact of yoga on more objective physician-rated outcomes such as mobility and cognitive function in patients with MS and there is a potential methodological bias in studies to date. Despite such limitations, there is encouraging evidence that yoga is equally effective as conventional exercise interventions in improving both patient-reported and physician-rated outcomes.

The first randomized control trial of yoga in MS was published in 2014 and looked at a 6-month yoga intervention on 69 subjects who were randomized to one of three groups: yoga, exercise, or a control group. Weekly 90-minute modified Iyengar Yoga classes incorporated postures including support from walls and chairs to account for patient fatigue, spasticity, and cerebellar dysfunction. Classes emphasized breathing, relaxation, and meditation during the session and participants were also strongly encouraged to adhere to a daily home practice. The results demonstrated that the yoga program improved fatigue to the same degree as traditional exercise and had the same level of adherence as exercise.

A more recent pilot study conducted at a neuro-rehabilitation center in Germany evaluated the impact of a 3-week program of Integrated Yoga and Physical Therapy (IYP) on 11 patients. Participants received an intervention consisting of yogic physical postures, pranayama and meditations along with physical therapy (PT) techniques 5 days a week, for 5 hours each day. Researchers noted a significant improvement in visual reaction time as well as mental health outcomes such as depression and anxiety. Unfortunately, this study did not assess the effects of yoga and physical therapy separately and was limited by a small sample size and the lack of long-term follow-up data. Another study published in 2016 reported on the effects of a six-month yoga program developed at the College of Physical Education in Campinas, Brazil. A total of 12 women who had no prior experience with yoga were assigned to either a control or a yoga training group where they received weekly 60-min yoga classes. The researchers reported significant improvement in measures of postural balance only in the yoga group. Importantly, improvements with the yoga intervention were especially apparent in patients with a higher score on the disability status scale highlighting its feasibility for this population.

In summary, studies to date have demonstrated strong short-term and moderate long-term efficacy of yoga in alleviating symptoms in MS patients without significant adverse side-effects. Future research should evaluate changes in immune parameters and investigate which components of yoga practice might be providing the greatest efficacy for improving patient outcome. In addition, cost-effectiveness analyses are needed to assist in justifying the practical clinical implementation of yoga for MS and future research should also address the limitations of small sample size and risk of bias. Such future research efforts would improve our knowledge of the underlying mechanisms of yoga in MS treatment and allow yoga therapists to devise more effective interventions.

By Nikhil Ramburn and Sat Bir Singh Khalsa, Ph.D.

The term autism has gone from a relatively obscure medical diagnosis to a household word. The autism spectrum disorder (ASD) now includes disorders that were previously considered separate such as Asperger’s syndrome and childhood disintegrative disorder. ASD is a neurodevelopmental disorder that impairs a child's ability to communicate and interact with others. Symptoms vary widely between patients and include restricted repetitive behaviors, interests, and activities. In addition, speech delays are common in children with ASD. Although, the specific causes of ASD have yet to be identified, several risk factors have been identified in the literature research, such as genetics, prenatal and perinatal factors, neuroanatomical abnormalities, and environmental factors. In recent years, the number of children identified with ASD has increased and doctors are better trained to identify ASD even in adulthood. The prevalence of this disorder is global, with approximately 1-3% of all children diagnosed with ASD. Its social impact is devastating.

Treatment options for ASD have increased but most interventions are outcome-driven and remain heavily dependent upon meeting insurance standards, often at the detriment of meeting the patient’s multiple overlapping needs. In addition, conventional pharmacological treatments only address the external symptoms such as irritability, depression, and hyperactivity. Pharmacological interventions show no clear benefit in treating core symptoms and have known adverse effects. The non-medical treatment options for comorbid depression and anxiety in ASD primarily includes cognitive behavioral therapy (CBT) and while studies have described positive effects of this intervention, researchers have also highlighted several limitations. Notably, the gains from CBT may be relatively short-lasting and generalization of CBT to real-life situations appears to be limited. Therefore, holistic therapies that address the varying needs of patients, and facilitate the learning of long-lasting skills such as self-management and social awareness are required.

Yoga and meditation may prove to be one such holistic intervention. Indeed, meditation positively affects core executive functions such as self-control and cognitive flexibility and this can help patients better handle situations of high executive demand. Meditation has been shown to strengthen inter-hemispheric brain connectivity by increasing activation of the Corpus Callosum, a white matter structure which connects the left and right brain hemisphere. Since ASD patients often suffer from sensory integration dysfunction, they could benefit from more efficient interhemispheric information transfer and the resulting increase in integration of complementary experiences. Furthermore, meditation improves breathing patterns and studies showing changes in hormone levels demonstrate the potential of meditation to change physiological parameters and rhythms. Other traditional forms of yogic meditation employ the use of mantras that act as psychophysical modulators of health. Since language, music, and singing share the same functional networks, singing mantra with music may compensate for deficiencies in language acquisition. In addition, chanting of mantra accompanied by mudras or hand gestures facilitates interhemispheric synchronicity, which is set into motion by rhythmic vocal sounds and breathing patterns. These traditional forms of meditation, which have become known in the west through disciplines such as Kundalini Yoga, are easier to adhere to and to monitor.

Apart from the benefits of the breath, mantra, and mudra, yoga also includes body movement and awareness. Physical activity allows children with ASD to learn concepts related to impulse control, the ability to calm the body after activity, and overall self-regulation. In fact, children with ASD often lack coordination and body awareness and yoga movement has been shown to increase vestibular and proprioceptive awareness that can support sustained attention, behavioral regulation, and general body awareness. The repetition and routine of movement sequences such as sun salutations may increase a child’s capacity to carry out motor plans and has the benefit of capitalizing on the patient’s inherent need for structure and repetition. Furthermore, parents who practice alongside their children may also benefit from reduced parenting stress, keeping them from rejecting and becoming over-reactive to their children.

A 2015 review of the research on the efficacy of yoga for patients with ASD by Gwynette et al. reveals that so far only two studies published in peer-reviewed journals have implemented a standardized protocol, assessed clinical outcomes, and utilized either a control group or the subjects as their own control. Nevertheless, these studies together with other published trials suggest that yoga interventions may indeed improve core symptoms of ASD and several case studies support this finding despite inherent weaknesses in statistical power, risk of bias in the experimental design, and inconsistent outcome measures.

One of the studies in the Gwynette et al. review is a 2011 pilot study from the Saint Francis Hospital and Medical Center in Hartford, Connecticut. The researchers looked at the efficacy of an 8-week yoga, dance, and music therapy program using a group of 24 ASD-diagnosed children aged 3-16 years. While the study reported statistically significant improvements for all subjects in psychological and behavioral characteristics, the multimodal nature of the treatment prevents us from knowing how much the yoga component contributed to efficacy.

Another small study in Bengaluru India, applied vigorous warm-ups and loosening practices followed by traditional yoga postures (asana), yogic breathing, and mantra in 12 children with ASD over a period of two academic years. The results confirmed previous reports of qualitative behavior changes including increased tolerance of sitting and adult proximity, and subsequent socialization. Quantitative results showed regularization of aberrant immune activity.

In another study, Koenig et al. compared students undergoing a daily 16-week yoga intervention with students who engaged in their standard morning routine. They found that the intervention group showed a reduction of maladaptive behaviors, including irritability, lethargy, social withdrawal, hyperactivity, and noncompliance. Since this was a manualized yoga curriculum, it may serve as a viable behavioral intervention for school-based therapists. Although the study demonstrates the significant impact of yoga interventions on key classroom behaviors among children with ASD, the lack of randomization and absence of blind raters may have contributed to bias in the study.

As ASD awareness increases and is more commonly diagnosed, application and testing of holistic therapeutic interventions are important, such as yoga, that address the various needs of the patient. Despite the significant limitations in the research in this new field, the potential efficacy of yoga appears promising. It is a potentially cost-effective therapeutic approach that seems to be well received by ASD patients and their parents and so future research of increasing quantity and quality is warranted.

By Nikhil Ramburn and Sat Bir Singh Khalsa, Ph.D.
Attention Deficit Hyperactivity Disorder (ADHD), as outlined in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), is a relatively newly defined mental health condition that has achieved wide notoriety in modern society. However, excessive hyperactive, inattentive and impulsive children have been described in the medical literature for the last 200 years. While the clinical nomenclature has changed over time, many of the historical descriptions are consistent with the modern diagnostic criteria for ADHD. The three clusters of ADHD symptoms are inattention (easily distracted, wandering off task, difficulty sustaining focus, disorganized), hyperactivity (restlessness, moving constantly when it is not appropriate, excessive fidgeting, tapping or talking), and impulsivity (hasty actions without forethought that may have high potential for harm or negative consequences, desire for immediate rewards or gratification, socially intrusive behavior). Given the similarity between these symptoms, and those resulting from the chronic sleep deprivation that is universally common in children, adolescents, and adults, it is important that a careful diagnosis be made by qualified clinicians. ADHD affects children and teens and can continue into adulthood. In fact, ADHD is one of the most prevalent psychiatric disorders of childhood with an estimated prevalence of 5%.
This condition may have a negative impact on a child’s lifestyle by negatively affecting academic achievement, social relationships, and quality of life. Other common associated clinical features include disturbed sleep, which may impact cognitive functioning, and obesity, which seems especially prevalent in children with ADHD. In addition, individuals are at a high risk for comorbid disorders from the presence of depression in approximately 30% of patients and anxiety in more than 25% of patients. The presence of these exacerbating and comorbid risk factors warrants special treatment considerations. While conventional psychotherapy may address the comorbid risk factors, it usually does not provide training in self-regulation which may help children with ADHD to choose and adopt socially appropriate behaviors. In addition, current pharmacotherapy treatments including stimulants, while relatively effective in the short term, may carry serious side effects such as low appetite, cardiovascular irregularities, suicidal thoughts, and sleep disturbance. For these reasons, the safety and effectiveness of behavioral, complementary, and integrative therapies need to be further evaluated.
Yoga may prove to be one of those therapeutic approaches since the ability to calm the incessant fluctuations of the mind is a fundamental component of yogic philosophy and practice. In fact, advanced practitioners report less mind wandering and distractibility. This suggests that more traditional forms of yoga, which include meditation, could be useful to promote the control of attention. Indeed, mindfulness meditation can improve neuropsychological deficits present in ADHD patients such as attention control, emotion regulation, and executive functioning by strengthening the brain regions believed relevant to these deficits. A further benefit of mindfulness meditation in ADHD is that patients learn to observe and become aware of emotional states as temporary passing events, thereby enhancing emotional regulation, which helps to prevent impulsive reactions to emotions. Recent studies indicate that mindfulness meditation training has ameliorating effects on ADHD symptoms, which makes traditional forms of yoga, which include meditation, a viable alternative to conventional psychopharmacological treatments. In addition, yoga incorporates the benefits of physical exercise, which has shown moderate to large positive effects on inattention, hyperactivity, impulsivity, anxiety, executive function, and social disorders in children with ADHD.
There are fewer than a dozen research studies of yoga on ADHD patients, although this number is likely to increase with the growing prevalence of yoga and meditation in the treatment of neuropsychiatric disorders. Most of the studies do not have a control group and contain a high risk of bias due to design limitations. The general findings, without being conclusive, do suggest that yoga could improve several of the risk factors associated with ADHD. For example, a 2004 randomized controlled trial (RCT) assessed 19 boys who were stabilized on medication and then randomly assigned to a yoga or a control group where they carried out cooperative activities. The yoga group received postural training which included stretching and load bearing in combination with rhythmical respiratory exercises. The yoga group also received relaxation training where participants progressively relaxed different body parts. Finally, a concentration technique called Trataka was imparted where participants focused on a word or shape followed by seeing the image with eyes closed while staying concentrated. The results showed several significant improvements in the yoga group but not in the control group on five subscales of the Conners’ Parents Rating Scales (CPRS), a standardized ADHD questionnaire, which measures opposition, emotional liability, restlessness, and the ADHD index. Although the small sample size and limited data set did not provide strong support for the use of yoga for ADHD, the findings did suggest that yoga may have merit as a complementary treatment for boys already stabilized on medication.
Another much more recent study was conducted by the prestigious National Institute of Mental Health and Neurosciences in Bengaluru, India in 2013 and evaluated 9 children diagnosed with ADHD. After 8 yoga sessions, researchers noted a significant improvement in the ADHD symptoms as assessed via several tools including the ADHD rating scale and disease severity. However, non-adherence among children to the yoga practice post-discharge from the child psychiatry unit in this study highlights one of the limitations of long-term yoga therapy for children. Despite the small sample size and lack of a control group, this study showed that children can learn yoga and that in-patients with ADHD do receive benefits from a yoga practice. A separate Indian study of a peer-mediated multimodal behavioral program, conducted in a poor urban setting in India showed similar improvements in students with ADHD. Local high school student volunteers facilitated the implementation of the Climb-Up program consisting of yoga, meditation and play therapy for 69 younger students aged 6 to 11, which resulted in remarkable improvements in the students’ school performances that were sustained throughout the year. By using local volunteers who also acted as mentors for the younger children, the study demonstrated that yoga could be a cost-effective solution that can be easily implemented in schools.
In summary, the published single-arm studies and pilot RCTs are statistically underpowered but provide preliminary support for the use of yoga with meditation in the treatment of individuals with ADHD. However, given the fact that this is a new field of clinical investigation, findings need to be replicated on larger groups and contain follow-up data to evaluate the long-term outcomes of yoga for ADHD. Ongoing research at the University of California, Davis is in fact using a RCT design for a 6-week yoga intervention in pre-school age children with, or ‘at risk’ for, ADHD. Investigators will examine behavioral symptoms, attention control and heart rate variability (HRV), which is an indicator of self-regulatory capacity. Another new study, at New York University, is focusing on children with increased levels of emotion dysregulation and inattention at the Girls Preparatory Charter School of the Bronx. Researchers are looking at the capacity of Little Flower Yoga for Kids, a yoga and mindfulness program for children to improve a child’s ability to sustain attention and regulate emotion. It is likely that new publications will appear regularly from recently completed clinical trials in this growing field of research.

By Nikhil Ramburn and Sat Bir Singh Khalsa, Ph.D.

Schizophrenia is a severe mental disorder that impacts a person’s cognitive and social abilities. The symptoms may include delusions, hallucinations, lack of motivation, reduction in spontaneous speech, and social withdrawal. The clinical symptoms of schizophrenia often represent typical examples of self-disturbance as patients struggle to recognize themselves as the source of their own thought and actions and are confused about self/non self-boundaries. Individuals suffering from schizophrenia may experience multiple acute episodes throughout their lifetimes and medical morbidity and mortality rates remain elevated in these patients. Naturally, this psychopathological condition greatly decreases an individual’s quality of life and social and occupational functioning, which in turn creates a considerable socioeconomic burden.

While there is no specific known cause of schizophrenia, most psychiatrists agree that it is multi-factorial. Individuals may likely have a genetic predisposition toward the condition, which may be activated by environmental stressors such as perinatal viruses, obstetric complications, and childhood trauma. There may be a neurodevelopmental aspect to schizophrenia, where excessive amounts of dopamine in brain regions such as the hippocampus are believed to play a role in the development of the illness. In addition, patients with schizophrenia frequently have a high baseline level of physiological arousal where the body is chronically agitated and alert. This is often compounded by a suppressed parasympathetic nervous system, which regulates the body’s capacity to calm down. This hyper-responsivity to stress may in turn lead to chronic activation of the body’s stress-response system including the autonomic system (sympathetic and parasympathetic) and the hypothalamic-pituitary-adrenal (HPA) axis and contribute to prolonged mental and physical distress. Unfortunately, stress is both a trigger and by-product of schizophrenic episodes. Other lifestyle risk factors include the lack of physical activity and a fast and shallow breathing pattern, which can exacerbate the stress reactivity.

Conventional treatment for schizophrenia primarily includes pharmacotherapy and psychotherapy. While antipsychotic medication has greatly reduced morbidity and mortality, it comes at the cost of severe side effects, as most patients need long-term treatment. Therefore, complementary and integrative medicine (CIM) are extensively sought after with 63% of psychiatric patients using CIM therapies including yoga especially in depression and anxiety disorders. Indeed, several of the disease factors can be addressed by a therapeutic yoga intervention. Influential models of schizophrenia suggest that a disturbed sense of self (the inability to distinguish self from non-self) is a core component of the illness. Studies in healthy individuals indicate yoga practices may improve self-reflection through highly focused attention, sustained posture, breath regulation, and meditation techniques. Indeed, to distinguish the conscious self who is the agent (purusha) from that which can be objectified and is the content of experience (prakrti) determines the integration of the self in yogic philosophy.

In addition, biomedical models provide further rationale for therapeutic yoga interventions. Yoga could enhance quality-of-life in schizophrenia patients by improving social cognition and empathy through the reinforcement of the premotor and parietal mirror neuron system. This neuron system is activated both by acting or observing the same action by another person. Yoga classes facilitate this process by teaching coordinated physical postures through imitation. Oxytocin, a hormone involved in social bonding is also produced in the experience of enhanced social connectivity of yoga classes, leading to better social cognition and improved social outcomes. Exercise has likewise proven beneficial for patients with schizophrenia, yielding improvements in clinical symptoms, quality of life, and global functioning. In addition to the benefits of conventional exercise, yoga may also have a positive effect on cognition, which particularly highlights the therapeutic potential of yoga in conditions like schizophrenia. This is particularly relevant for traditional styles of yoga that incorporate meditation, which may help in strengthening the lateral and medial pre-frontal brain networks. Finally, the stress reduction benefits of yoga and meditation in normalizing the function of the HPA axis and increasing parasympathetic activation are well-known.

While prior systematic reviews have suggested the efficacy of yoga in relieving schizophrenia symptoms, the first meta-analysis was published by Cramer et al. in 2013 and included five randomized controlled trials RCTs from India, China, the USA, and Belgium with a total of 337 patients. Yoga interventions in these studies included postures/exercises, pranayama, and meditation/mindfulness and were compared either to usual care, exercise, or both. Intervention lengths and intensities varied between a single 30-minute session to 25 45-minute sessions over a period of 1 month followed by 3 months of home-based yoga. This systematic review found moderate evidence for short-term effects of yoga on quality of life scores and effects were present only in studies with high risk of bias, with no evidence for short-term effects. Despite study limitations such as possible bias and small sample size initial results are encouraging and suggest that yoga may be useful in treating clinical symptoms while improving socio-occupational functioning in schizophrenia patients.

The first study to examine the effect of yoga therapy on oxytocin levels in schizophrenia was also published in 2013. This RCT was conducted by Jayaram et al. in the laboratory of Dr. B.N. Gangadhar at the Integrated Centre for Yoga within the prestigious National Institute of Mental Health and Neurosciences in Bengaluru, India. The study included a total of 43 patients that were maintained on antipsychotic medication and randomly assigned to receive either the yoga intervention or to continue on medication alone. The yoga therapy group showed a significant improvement in socio-occupational functioning, which is consistent with previous findings, but also showed an increase in plasma oxytocin levels. Apart from the increased social interaction of yoga classes, yoga may modulate oxytocin synthesis by increasing the activity of the vagal nerve, highlighting its potential efficacy as an adjunct treatment for schizophrenia.

In summary, studies to date have demonstrated the moderate short-term efficacy of yoga to improve clinical symptoms of schizophrenia while providing socio-cognitive benefits. This is a cost-effective and empowering practice that allows a patient to recognize that behavioral skills such as deep breathing and meditation can alleviate emotional and psychological distress. However, given the fact that this is a new field of clinical investigation, the results must be considered as preliminary in nature, and further evidence is required before recommending yoga as a routine intervention for schizophrenia patients. Current ongoing research at a large academic center in New Delhi, India is using a 3-armed RCT to examine the effectiveness of yoga supplementation as compared to physical exercise and conventional treatment to evaluate cognitive state, overall function, and symptom severity. It is likely that new publications will appear regularly from recently completed clinical trials in this growing field of research.

By Nikhil Ramburn and Sat Bir Singh Khalsa, Ph.D.

Chronic obstructive pulmonary disease (COPD) is an inflammatory lung disease characterized by obstruction of lung airflow. Emphysema and chronic bronchitis are the two most common conditions that contribute to COPD. COPD symptoms include difficulty breathing, cough, wheezing, and shortness of breath. Individuals suffering from COPD are at risk for more frequent respiratory infections, cardiovascular conditions, lung cancer, and pulmonary hypertension. An individual’s quality of life is likewise affected because of their inability to partake in daily activities due to difficulty breathing and this can lead to psychological distress and depression. A primary cause of COPD is long-term exposure to lung irritants that damage the lungs and the most common irritant is cigarette smoke. Other lifestyle risk factors include lack of physical activity, a shallow and rapid breathing pattern, and psychological stress. In fact, stress is a common cause of flare-ups in COPD patients since stress itself can cause shallowness of breath and faster breathing.

COPD is the third leading cause of death in the U.S. behind cancer and heart disease and more than 3 million Americans are diagnosed with the condition each year. Current estimates suggest that COPD costs the nation about $50 billion annually in direct and indirect healthcare expenditures. In addition to the large burden on the healthcare system, the economic costs of COPD are compounded by lost productivity to premature morbidity and mortality making this condition a major public health concern. Unfortunately, the conventional methods of treatments are only of limited efficacy for this condition since existing medications do not modify the long-term deterioration of lung function. The increasing prevalence of COPD requires that we develop effective behavioral interventions that go beyond symptomatic treatment and focus on rehabilitation. While aerobic exercise and strength training are moderately effective behavioral interventions, yoga and especially controlled yogic breathing (pranayama) have been shown to improve respiratory rate, oxygen levels in the blood, and overall quality of life in patients with COPD.

Several of the disease factors can be addressed by a therapeutic yoga intervention. Yoga may be a beneficial therapy for COPD because it involves physical activity along with breath regulation and has well documented stress-reduction benefits. Indeed, yoga training reduces respiratory rate and increases the strength of respiratory muscles. Slow, abdominal, yogic breathing is known to be more efficient in gas exchange of oxygen and carbon dioxide through deeper opening and expansion of the lungs. In addition, yoga decreases autonomic arousal and heart rate while reducing depression, anxiety, and panic attacks. Yoga also promotes healthy behavior habits, which can contribute to reducing lifestyle risk factors such as smoking. Finally, yoga may help COPD patients gain confidence that they can control their breathing, which along with the increase in physical performance could significantly improve their quality of life.

It is therefore not surprising that pranayama techniques have been shown to have therapeutic potential in treating COPD. In a case control study, conducted at a tertiary care institution in India, 50 individuals with moderate to severe COPD were divided into an intervention arm and control group. Half the individuals were trained in pranayama for 30 minutes twice a day while receiving their usual medication while the control group only received their usual medical treatment. Outcomes were assessed after 3 months and the intervention arm revealed significant improvement in the COPD assessment test and a 6-minute walk test, whereas the control group showed no such improvement. Researchers have suggested that pranayama results in various mechanisms of lung efficiency such as the rehabilitation of nonfunctional or closed airways. In addition, since pranayama promotes abdominal respiration it relieves the breathing diaphragm, improves oxygenation, and increases overall circulation. Pranayama also clears the airways and improves ciliary action, which helps to combat mucous secretions. Consequently, systemic inflammation is reduced and so are its manifestations. Therefore, more traditional yoga styles/practices that include pranayama as a key component are likely to be a better treatment strategy than the use of physical yoga exercises alone.

In the first meta-analysis and review of research on the efficacy of yoga for COPD, Liu et al. looked at five randomized controlled trials (RCTs) from 1978 to 2012 which encompassed 233 participants. The sample size per RCT ranged from 30 to 100 subjects per study and the duration of studies ranged from 12 weeks to 9 months. The reviewed trials all included pranayama alone or with yoga postures and the results reveal improvements in a variety of measures demonstrating improved lung capacity, ventilation and breath holding capacity after short-term yoga practice. In addition, studies suggested that yoga training may improve exercise capacity, prevent lung function decline, improve quality of life, and reduce dyspnea (a feeling of insufficient breathing or air hunger) in patients with COPD. However, these studies have a number of research design limitations including the small sample size of some studies. Despite these limitations, these preliminary results are encouraging and indicate that yoga training may be effective in improving lung function and functional exercise capacity in COPD patients compared with conventional therapy.

The first study to specifically measure the effects of yoga breathing on respiratory pattern and oxygen saturation in patients with COPD was published in 2009. This pilot study was conducted in Nepal by the team of Italian yoga researcher Luciano Bernardi and involved 11 patients, aged 59 to 80 years, with moderate to very severe COPD. Three of the patients were smokers, 2 nonsmokers, and 6 were former smokers. The patients practiced a complete, deep, slow yogic breathing pattern where they were asked to mobilize in sequence the diaphragm, lower chest, and then the upper chest during both inspiration and expiration. The main finding is that participants showed significant improvement in oxygen saturation (blood levels). To its credit, the yogic technique was not difficult to achieve and maintain, requiring at most 12 minutes to learn and patients reported feeling comfortable during the session. Despite the small sample size and lack of randomization, this pilot study provides encouraging preliminary evidence and encourages more extensive randomized trials to assess the long-term effects of yoga training for patients with COPD.

A more recent study evaluating yoga for COPD was a RCT involving 60 patients from the Guru Teg Bahadur Hospital in New Delhi, India. The 30 subjects from the experimental group practiced yoga for 2 months for 45 minutes in the morning and were monitored weekly for compliance at the cardiopulmonary laboratory. The transfer factor of the lung for carbon monoxide (TLCO), a measure of the ability of gas to transfer from the alveoli to the red blood cells, was recorded in both the control and experimental groups at baseline and after 2 months. This is significant because diffusion capacity is impaired in chronic lung disease and this was the first time that the effect of yogic exercises on lung transfer factor was evaluated. The results showed a statistically significant improvement after two months of yoga training whereas the control group which underwent conventional drug treatment had no change in TLCO.

In summary, studies to date have demonstrated the short-term efficacy of yoga to improve lung function and functional exercise capacity in patients with COPD compared with conventional therapy. This suggests that yoga could be a useful an adjunct pulmonary rehabilitation program for COPD patients. This is a cost-effective, easy to learn solution that addresses the underlying causes of COPD rather than just the symptoms. In addition, yoga provides the benefits of alleviating anxiety, improving quality of life and preventing deterioration of the lungs and musculature due to inactivity. Future research should ideally address the previous limitations of small sample sizes, lack of longer-term studies and inadequate data reporting and also provide information on the underlying mechanisms of yoga in COPD treatment. Innovative solutions such as Tele-Yoga interventions where classes are delivered via multipoint videoconferencing promise to make yoga therapy even more accessible and affordable to patients with COPD.

By Nikhil Ramburn and Sat Bir Singh Khalsa, Ph.D.

Hypertension is a condition of abnormally high blood pressure which may eventually damage artery walls and lead to cardiovascular complications. Patients rarely show any symptoms such as headaches and shortness of breath but hypertension remains a major risk factor for heart attack, stroke, chronic heart failure, and chronic kidney disease. Worldwide, hypertension is one of the most important causes of premature morbidity and mortality and is responsible for 7.6 million deaths per year. Hypertension is a major public health concern with estimated direct and indirect annual costs of $76.6 billion in the USA. A diet high in salt along with our modern sedentary and stress-laden lifestyle have in part contributed to the rise in the prevalence of hypertension. Therefore, lifestyle modification, mainly dietary changes and physical activity, are frequently recommended for patients with hypertension along with conventional pharmacological treatments. Unfortunately, poor adherence and the inability of these standard interventions to address underlying causes such as lifestyle stress render these conventional methods of treatment only modestly effective. This is especially the case with this disorder in which patients are not directly experiencing uncomfortable symptoms of the disease and are therefore less motivated to make lifestyle changes.

Since expert panels on hypertension continuously stress the importance of non-pharmacological approaches and lifestyle modifications, it is imperative that we identify alternative strategies that effectively lower blood pressure while addressing the underlying risk factors. Yoga is likely to prove to be one such alternative treatment option since it addresses several of the factors contributing to the development of hypertension, especially lifestyle stress. Indeed, several key mechanisms make yoga a potentially beneficial therapy for hypertension. Yoga practices directly stimulate the vagus nerve, increasing parasympathetic activity and reducing activation of the sympathetic nervous system; they also positively impact neuroendocrine function and inflammatory pathways. These mechanisms are critically beneficial for hypertension because of the stress-induced sympathetic dominance in the autonomic nervous system.

Pranayama, specifically slow breathing practices, are known to have direct and immediate impact on the autonomic nervous system and blood pressure by enhancing baroreflex sensitivity. This significant finding has been particularly well-characterized by the elegant and rigorous studies of pranayama researcher Luciano Bernardi in Italy, which clearly demonstrated the pronounced effects of slow yogic breathing on both the respiratory chemoreflex response as well as the baroreceptor reflex response in both normal and hypertensive subjects. As early as 2001, he concluded that “Enhanced baroreflex sensitivity might be one factor inhibiting the chemoreflex during slow breathing. A slowing breathing rate may be of benefit in conditions such as chronic heart failure that are associated with inappropriate chemoreflex activation.”

More recently, slow pranayama was shown to be effective in reducing blood pressure in an Indian study by yoga researchers Bhavanani, Madanmohan, et al. involving 29 patients with hypertension or prehypertensive conditions. Within only five minutes of practice of Pranava Pranayama, which involves a slow and deep inhale followed by a prolonged chant of AUM (OM), subjects revealed a statistically significant reduction in systolic pressure and supine heart rate, both indicators of cardiovascular function and sympathetic activation. In addition, the immediacy of the results (within 5 minutes) indicates that yogic breathing may also be used in acute clinical interventions when blood pressure needs to be lowered as quickly as possible. These findings also suggest that pranayama should be considered as a key component in yoga interventions.
The first systematic review of the literature on the efficacy of yoga for hypertension was published in 2014 and included 39 cohort studies, 30 nonrandomized controlled trials (NRCTs), 48 randomized controlled trials (RCTs) and 3 case reports. The yoga interventions ranged from 1 week to 4 years and involved a total of 6,693 subjects. Most studies reported favorable outcomes with yoga effectively reducing blood pressure in both normotensive and hypertensive populations. The investigation of yoga as a treatment for hypertension has a long-standing history, and in fact, the very first RCT ever published on yoga was on hypertension. In that early United Kingdom study from 1975, 37 hypertensive patients were randomly allocated to yogic relaxation, breathing, and meditation or to simple relaxation, twice weekly for 60 minutes over the course of 6 weeks. At the end of the trial, the yoga group had a significantly greater reduction in systolic and diastolic blood pressure compared to the control group. Although this early study had a number of methodological short-comings, it was overall of acceptable quality. Since that first research trial, the number of RCTs that have been published on this topic have made hypertension one of the most researched areas of yoga therapy.

More recent studies have since provided similar findings, including a landmark paper published in the Journal of Clinical Hypertension in 2014. This is the first RCT to show the significant effects of yoga when compared with an exercise control group. The participants in both groups were asked to attend two 55-minute classes per week for 12 weeks and to perform 3 sessions of home practice for 20 minutes each week. The study included 84 individuals with prehypertension and stage 1 hypertension between 21 and 70 years of age, with over 90% female and predominantly African American. The results in this high minority population indicated that yoga decreased blood pressure while the active control intervention (nonaerobic exercise) did not. The mean systolic and diastolic blood pressure decreased by approximately 5 mm Hg and 4mm Hg respectively, consistent with values found in other controlled studies of yoga for hypertension and comparable to those obtained from other non-pharmacological strategies such as diet, physical exercise and salt reduction.

Another more recent rigorous study conducted at the University of Pennsylvania by Dr. Debbie Cohen and colleagues was just published in 2016. This 3-armed RCT allocated 137 patients with prehypertension and stage 1 hypertension into one of 3 groups: a dietary intervention with a walking program, a regular, twice-weekly yoga practice, or a combination of these two. This was the first study to directly examine how yoga compared to a dietary intervention. All three interventions had a favorable effect on blood pressure reduction with a significantly greater reduction in systolic blood pressure at 12 weeks in the yoga and combination groups as compared with the control group of diet and walking alone. Although the blood pressure reductions were small, they are still noteworthy since even a 2 mm Hg fall in mean systolic blood pressure results in 7% and 10% decreased risk of death from heart disease and stroke respectively, which is a clinically significant reduction in morbidity and mortality rate.

In summary, studies to date have demonstrated the efficacy of yoga, and especially of pranayama, for lowering blood pressure in hypertension without significant adverse side-effects. Future research should provide more data on safety and address the problem of adherence to long-term practice. Despite the encouraging results from existing studies, the American Heart Association has not yet recommended yoga as a non-pharmacologic intervention because of the lack of high-quality, RCTs. Given the potential efficacy of yoga for hypertension (and its added value in addressing the underlying causes rather than just symptoms) and the likely cost-effectiveness of such interventions, the need for larger, high-quality RCTs with long-term follow-ups is critically important. Future research will further improve our knowledge of the underlying mechanisms of yoga action in hypertension and will facilitate the development of even more effective yoga interventions.

Yoga for Back Pain: The Science and Research Evidence

By Nikhil Ramburn and Sat Bir Singh Khalsa, Ph.D.

Back pain is characterized by muscular pain, which may also include shooting pain that radiates down the legs and limited flexibility or range of motion of the back and neck. Because of the wide spectrum of symptoms, back pain may receive a variety of diagnoses such as sciatica or herniated disks. The nondescript form that lacks a precise diagnosis is called Low Back Pain (LBP). LBP is one of the leading causes of absence from work and is a major public health concern in industrialized societies. The condition is widely prevalent with up to 85% of individuals experiencing at least some degree of back pain in their lifetime. Although 90% of all patients with acute LBP recover rapidly without any specific treatment, the remaining 10% are at risk of developing chronic pain and disability. Chronic low back pain is a large burden on the healthcare system with high economic costs compounded by a substantial number of days of lost productivity annually.

An individual’s quality of life is likewise affected due to restricted mobility and the inability to partake in daily tasks. This often leads to decreased self-worth and depression. Unfortunately, the conventional methods of treatment are only modestly effective. Exercise is one of the few proven treatments for chronic low back pain, however its benefits are often very small. Other treatment options apart from medication, include spinal manipulation, acupuncture, massage, and yoga.

LBP is the most common condition for which complementary therapies are used with more than half of LBP patients in the United States utilizing complementary treatment options. Out of the 15 million of American adults who have practiced yoga at least once, 20% of those use yoga explicitly for back pain relief. In fact, even the American Pain Society’s guidelines recommend that clinicians consider offering yoga to patients with chronic LBP. Several of the factors contributing to the development of back pain can be addressed by a therapeutic yoga intervention. Our modern sedentary and stress-laden lifestyle has in part contributed to the rise in prevalence of back pain. The absence of physical activity weakens muscles, making them unable to support normal structural weight, and chronic stress produces short, tense muscles that limit range of motion, which can lead to back pain. In addition, the upsurge of obesity and occupations that require heavy lifting are all risk factors that can trigger back pain. Yoga may be a beneficial therapy for back pain because it involves physical movement along with added benefits of mental focus and stress-reduction.

Indeed, yoga exercises reduce physical impairment by increasing muscular strength and flexibility. Yoga also increases conscious body awareness and self-efficacy which can contribute to reducing the risk factors of poor posture and inappropriate movement and muscular activity. Yoga is particularly well-recognized as an effective method of reducing psychological stress. Specifically, yoga improves neuroendocrine function by normalizing the actions of the stress systems, including cortisol from the hypothalamic pituitary adrenal (HPA) axis and adrenaline and sympathetic activation from the autonomic nervous system. Although back pain is likely to be thought of as a purely muscular and mechanical disorder, the role of stress, mood, and pain perception contribute substantially to the experience of back pain. In fact, somewhat surprisingly, mindfulness and meditation have been shown to have therapeutic potential in treating back pain. Back pain patients in a recent MBSR (Mindfulness-Based Stress Reduction) intervention in 2015, published in the prestigious Journal of the American Medical Association, showed significant decrease of pain intensity along with improved physical and mental quality of life scores. Therefore, more traditional yoga styles/practices that include meditation as a key component are likely to be a better treatment strategy than the use of physical yoga exercises alone.

In the first meta-analysis and review of research on the efficacy of yoga for LBP, Cramer et al. included an analysis of 10 randomized controlled trials (RCTs) through January 2012 which encompassed 967 chronic low back pain patients. The majority of the studies had a low risk of bias, which gives us more confidence in the validity of the results. Six of the RCTs originated from the United States, 2 from the UK and 2 from India. Although the majority of patients were adult female Caucasians, the Indian studies included Asians, and some US studies looked at ethnic minorities, thereby making the results of the review applicable for the majority of LBP patients. The reviewed trials varied in the yoga styles used, but all compared yoga to control interventions and revealed strong evidence for short-term efficacy and moderate evidence of long-term impact of yoga on patients with chronic back pain. Surprisingly, there was no statistically-significant evidence for either short-term or long-term effects on health-related quality of life. On the other hand, yoga was not associated with serious adverse events which makes it a viable alternative to conventional drug treatment that often carries negative side-effects.

One of the studies reviewed was a landmark paper published in the Annals of Internal Medicine in 2005. In this 3-armed randomized control trial (RCT), 101 adults with chronic low back pain were treated with either 12-weekly sessions of yoga, therapeutic conventional exercise, or a self-care book, to determine relative efficacy. Interviewers who were blind to the treatment conducted telephone interviews at baseline and at 6, 12, and 26 weeks after the start of the study. The results of the study suggested that yoga is an effective treatment method for chronic LBP that had long-term benefits. Furthermore, medication use, which was similar among groups at baseline, decreased most sharply in the yoga group. Only 21% of participants in the yoga group reported medication use during the week before the 26-week interview compared with 50% in the exercise group and 59% in the book group. A common limitation to these behavioral intervention studies is observation bias but since in this case the interviewers were blind to the treatment assignments, this bias was minimized. Additionally, the large sample size allows for conclusive albeit preliminary assertions regarding the effectiveness and safety of yoga as an intervention in this population.

More recent research evaluating yoga for chronic back pain has investigated whether similar results are seen in more diverse populations. In 2009, Robert Saper’s research team at the Boston University School of Medicine, along with Karen Sherman and their colleagues, conducted a novel trial focusing on minority populations. This is significant because despite the increase in the popularity of yoga in the US, it is far less common among minorities and individuals with lower incomes or education. In this pilot RCT, 30 adults with a mean age of 44 years, 83% of them female and of racial or ethnic minorities, were randomly assigned to a standardized 12-week protocol of Hatha yoga classes or a usual care waitlist control group. The yoga participants had statistically significant reduction in pain intensity and medication after 12 weeks compared to the control group. Beyond the 12-week intervention period however, participant retention was poor and participants sought out treatments other than yoga, so it may be necessary to provide continuing yoga treatment support in this population.
Most of the studies to date have focused almost exclusively on chronic, nonspecific LBP, and therefore little is known about the efficacy of yoga in treating musculoskeletal conditions and pain in other areas of the back. In a study published in 2011 in the Yoga & Physical Therapy Journal, Lynn Schultz along with Sat Bir S. Khalsa and colleagues investigated the potential of yoga to ameliorate a broad range of back pain disorders. The study consisted of 24 adults with a complaint of chronic back pain who attended a 12-week program of weekly group yoga classes based on the system of the Krishnamacharya Healing Yoga Foundation (KHYF), a school well-known for its specialization in yoga therapy that includes asana, pranayama, core strengthening, meditation, bhavana (visualization), and mantra. Participants also practiced regularly at home and maintained a journal. The results demonstrated that the yoga classes significantly improved quality of life, decreased disability and pain, and improved physical functioning and mood. Subjects reported less depressive feelings, anger, fatigue, and confusion, indicating that yoga may not only improve back pain itself, but also the co-occurring symptoms.
In summary, studies to date have demonstrated the strong short-term and moderate long-term efficacy of yoga in treating a wide variety of back pain conditions without significant adverse side-effects. Future research should address the previous limitations of small sample sizes, moderate adherence, and lack of longer-term studies. They should also perhaps evaluate the dose response characteristics and the relative contribution to efficacy of the different components of yoga such as physical postures, breathing techniques, and meditation. These future trials would further improve our knowledge of the underlying mechanisms of yoga in back pain treatment and allow yoga therapists to devise more effective interventions.

(The consideration of yoga as a cost-effective and non-invasive adjunct therapy for treating Type 2 Diabetes.)

By Nikhil Ramburn and Sat Bir Singh Khalsa, Ph.D.

Type 2 Diabetes Mellitus (DM2), also called adult-onset diabetes, is a metabolic disease that was formerly only diagnosed in midlife but is now impacting younger adults and even children. This disorder is characterized by defects in insulin production and action, resulting in elevated blood glucose levels, which can lead to serious medical consequences. Long-term complications from diabetes account for more adult cases of vision loss, end-stage kidney disease, and amputations than any other disease. In addition, diabetes significantly increases the risk of cardiovascular disease and may be linked to cancer. DM2 is largely a lifestyle disease caused by inadequate physical activity, diets rich in highly-processed foods and refined sugars, and elevated levels of life-stress. Twenty-eight million people in the United States have DM2, and more than 80 million are considered to be at high risk of developing it, a state called prediabetes or metabolic syndrome. Worldwide, more than 350 million people are estimated to have DM2, a disease affecting many developing countries with limited resources.

The high cost and relatively low effectiveness of conventional treatment has resulted in an economic burden estimated to total $322 billion annually in the United States. Conventional treatment aims at controlling glucose levels through medications, education, and behavior change schemes. However, behavior change is notoriously hard to enact because the same environmental and social conditions that gave rise to the disease-causing behavior are still in place. Pharmaceutical treatment drawbacks include dependency, resistance, and adverse long-term effects. Consequently, there has been a concentrated search for non-pharmaceutical treatment and preventative measures. Behavioral treatments such as lifestyle interventions addressing the risk factors of obesity and sedentary activity reduce the development of diabetes by as much as 58% and decrease the need for medications. However, current conventional behavioral lifestyle interventions have limited effectiveness; this is a factor that may likely be improved with yoga.

Yoga interventions address several DM2 risk factors and bring a much-needed holistic approach to DM2 treatment. In yoga, physical exercises are linked to lifestyle and behavioral changes that include diet, relaxation, and stress management. A lesser-known aspect of yoga is the social support that a yoga class or community provides and social support is strongly linked to improved diabetes self-care and clinical outcomes. Yoga is better known for increasing fitness and physical function, thereby improving both glucose metabolism, and psychological health. At the same time, yoga promotes and supports weight loss and thereby addresses obesity which is a major cause of DM2 onset and complications. Finally, the two most beneficial and consistent outcomes of yoga are an increase in mind body awareness and stress-coping ability. This leads to a host of positive downstream effects including improvements in healthy behaviors, avoidance of unhealthy behaviors, better sleep cycles, balanced neuroendocrine status, improved metabolic function, and reduced inflammatory responses. There is convincing research that shows that yoga improves mindfulness and mind body awareness, and this may well encourage individuals to gravitate to healthy behaviors such as exercise and healthy food choices, and away from unhealthy habits such as consuming junk food. This is all due to their enhanced experience of the positive effects of these behaviors. Evidence suggests that stress may play a major role in the development of diabetes, which is why relaxation techniques, such as are found in yoga, could serve as a very effective complement to other lifestyle modifications. Therefore, there is every reason to believe that yoga should be efficacious in preventing and treating DM2.

Metabolic Regulation
Studies evaluating yoga interventions in patients with DM2 found that yoga normalized metabolic functions which resulted in increased insulin sensitivity, glucose tolerance, and improved lipid profiles. These beneficial effects of yoga on glycemic control are well documented. A recent review in the International Journal of Yoga Therapy looked at the evidence for the benefits of yoga in adults with DM2. Peer-reviewed studies published between 1970 and 2006 looked at the effects of yoga on diabetes and diabetes risk factors in a broad range of outcomes, such as insulin resistance, glucose intolerance, elevated blood pressure, and excess body weight. Each of these factors is strongly implicated in the development and progression of DM2. Despite considerable variability in design, clinical measures, and target populations, most trials reported positive changes in at least one of the outcomes related to DM2 and in clinical outcomes as well. The most recent review of research on yoga therapy for DM2 was published this year by Kim Innes of West Virginia University in the Journal of Diabetes Research. Researchers found 33 papers reporting findings from 25 controlled trials (12 of them RCTs) representing 2170 participating research subjects, and concluded that “collectively, the findings suggest that yogic practices may promote significant improvements in several indices of importance in DM2 management, including glycemic control, lipid levels, and body composition. More limited data suggest that yoga may also lower oxidative stress and blood pressure; enhance pulmonary and autonomic function, mood, sleep, and quality of life; and reduce medication use in adults with DM2.”

Improved Sense of Well-Being
In a pilot study conducted by Shanti Shanti Kaur Khalsa and Guru Parkash Kaur of the Guru Ram Das Center for Medicine and Humanology (founded by Yogi Bhajan in Espanola, New Mexico to apply the practices of Kundalini Yoga for therapeutic populations), they applied 3 questionnaires to evaluate the effectiveness of an 8-week Kundalini Yoga and lifestyle intervention program in diabetic patients. One of these was the Audit of Diabetes Dependent Quality of Life, which measures individuals’ perception of the impact of diabetes on their quality of life. Improvement in quality of life was measured in 9 of 11 participants. The second scale was the Profile of Mood States which consists of subscales measuring the following moods: anger, confusion, depression, fatigue, anxiety, and vigor. There was statistically significant improvement in all of the above mood states following participation in the diabetes program. The third measure was the Functional Assessment of Chronic Illness Therapy - Spiritual Well-Being, which measures a faith factor as well as a meaning-and-peace factor. There was a statistically significant improvement in spiritual well-being following participation in the diabetes program as measured by this scale. The evaluation showed that most participants found the components of the program extremely helpful especially in the areas of mood, stress management, quality of life, and ability to relax. Although such findings support the efficacy of yoga as a therapeutic intervention to improve quality of life and stress management, larger randomized control trials are required to substantiate the results.

Assist Controlling Glucose Levels
There is now a growing number of studies with larger sample sizes showing that yoga can have positive impact on diabetes. For example, a recent Indian study from 2015 highlights the efficacy of yoga in controlling blood glucose levels in patients with DM2. The study was conducted at the Department of Physiology and Diabetic clinic of a teaching hospital over a period of two years. The subjects were 30 middle-age male diabetic patients and an equal number of non-diabetic volunteers made up the control group. The significant decrease in blood glucose levels after yoga in both the experimental and control groups indicates the potential role of yoga as preventive and treatment strategies for DM2. In addition, there is some reason to believe that yoga may rejuvenate or regenerate beta cells of the pancreas which can normalize insulin production.

Given its positive effects on metabolic regulation, physical well-being, and mental health, yoga can be considered as a cost-effective and non-invasive adjunct therapy for treating DM2. With few exceptions, the studies document beneficial changes in yoga program participants and suggest improvements in several risk indices mentioned previously such as glucose tolerance, insulin sensitivity, lipid profiles, blood pressure, oxidative stress, and pulmonary function. However, several of the current studies have small sample sizes which prevent the generalization of findings. The therapeutic potential of yoga in the face of a worldwide epidemic of diabetes warrants additional research, which will require more funding from our public health institutions. This would likely prove to be a valuable investment given that conventional pharmaceutical treatment comes with a number of side effects and limited efficacy. Yoga is potentially a highly cost-effective protocol to treat and prevent DM2 since it addresses the underlying causes along with symptoms.

Neuroimaging Research on Yoga and Meditation: EEG Studies
Nikhil Ramburn and Sat Bir Singh Khalsa, Ph.D.

Meditation is a cognitive activity that requires us to focus our attention and awareness. Chronic distraction, via technology and information, is so widespread in the Aquarian Age that Yogi Bhajan called the phenomenon “info-dementia”. One of the antidotes is the regular practice of meditation, which gives us the cognitive tools to control our attention. This leads to improved mind-body awareness, which is in turn associated with numerous benefits including improved emotional regulation, stress-coping, and resilience. When we engage in the act of meditation, we activate the attention networks of the brain in the prefrontal cortex that inhibit the limbic system responsible for emotion, which is one of the ways that we self-regulate. Meditation, like any other behavioral activity, improves through repetition and practice as our brains become more skillful at performing the task. We now have the technology to observe and objectively measure how the brain activity of meditators changes over time. Neuroscientists use modern tools such as functional magnetic resonance imaging (fMRI) and single-photon emission computed tomography (SPECT) to record changes in cerebral blood flow (CBF), which is an indirect marker of brain activity.

With the advent of this new technology, research studies are showing that there are brain function changes in long-term meditation practitioners. SPECT and fMRI meditation studies have highlighted brain regions showing changes related to mind-body awareness, attention control and emotional regulation. While specific changes in CBF and brain activation have been recorded in meditators during actual practice, other neuroimaging studies have evaluated the long-term effects of meditation.

Such long-term changes were measured in an early 2007 study from the University of Wisconsin on Tibetan Buddhist meditators with varying levels of experience. The evidence suggested that a sustained meditation practice can have lasting changes in brain activity. Researchers observed a subtle and interesting difference in the caudate region, which is located deep within the brain near the thalamus and plays a key role in sustained awareness. During the first few minutes of the meditation session, novice and experienced meditators alike had increased caudate activation. However, as the meditation session progressed, caudate activity decreased in expert meditators. On the other hand, novice meditators did not display the same activity decrease in the caudate region. Increased caudate activity is common in novice meditators during mindful breath or mantra awareness. It appears that as meditators get more advanced, the caudate region only gets activated in the beginning of the practice. This suggests that experienced practitioners may begin by focusing their mind but subsequently access a less focused and more transcendental state as they transition into a deeper state of meditation. However, caution is indicated in generalizing this finding to all meditation practices, since this difference may be a unique characteristic amongst Tibetan Buddhist meditators.

In later research in 2010 comparing brain function in meditators and non-meditators, Andrew Newberg M.D., director of research at the Jefferson-Myrna Brind Center of Integrative Medicine, and colleagues evaluated the cerebral blood flow (CBF) of long-term and non-meditators using SPECT imaging. The twelve long-term meditators who participated had more than fifteen years of practice and meditated for 30-60 minutes daily. In experiments where participants meditated in the scanner itself, researchers found that experienced meditators had significantly higher CBF levels in the prefrontal cortex, parietal cortex and caudate. The frontal lobe in particular is associated with the ability to self-regulate and underlies attention and sustained concentration. These differences in brain function are congruent with the well-documented phenomenon that long-term meditators can better self-regulate, focus and sustain their awareness.

Another finding from the same study revealed that long-term meditators had higher CBF in the parietal lobe regions even while they were in a resting or non-meditative state. The higher ongoing normal brain activity in long-term meditators is in contrast to previous evidence of a decrease in parietal lobe activity during meditation. Researchers explain this discrepancy by speculating that long-term practitioners start out with a higher activity level and thereby experience a larger decrease in parietal lobe activity during meditation. The parietal lobe is associated with personal space and has been implicated with out-of-body experiences. This is consistent with advanced meditators reporting feelings of transcendence and non-localized awareness, where their experience seems untethered to the physical body. Furthermore, long-term meditators had significantly higher CBF levels in the midbrain, which is related to the autonomic nervous system. This alteration of mid-brain function is indicative of profound effects on the autonomic nervous system, which regulates much of the body’s involuntary vital processes like the control of respiration and cardiovascular function. Significant research shows that long-term meditators have the ability to control autonomic functions previously believed to be beyond conscious control, which is a hallmark of self-regulation.

Another interesting question in this field pertains to the time required for the changes in brain function to take place. It appears that changes in brain function can begin to occur in as little as 8 weeks of regular meditation. A later study by Newberg along with Dharma Singh Khalsa, M.D., the president and medical director of the Alzheimer’s Research and Prevention Foundation, and his colleagues looked at the cerebral blood flow (CBF) levels in the frontal lobe regions of 15 subjects with memory impairment. Within only 8-weeks of practicing Kirtan Kriya (KK), a well-known meditation practice within Kundalini Yoga as taught by Yogi Bhajan, these inexperienced meditators had significantly higher CBF levels in their frontal lobe and right superior parietal lobe than control subjects. This was associated with improvements in several memory tests as well as significant improvement in fatigue and anxiety measures. The fact that Kirtan Kriya was able change brain neurophysiology within only 8 weeks, shows that meditation can quickly change brain function.

The observation that brain activity of long-term meditators is different from non-meditators has important implications for understanding the relationship between the brain and meditation. However, this field is still in its infancy and the current studies are limited by small sample sizes, which reduces the statistical strength of the findings and hinders our ability to make generalizations across meditation styles. Another challenge, as with any research on behavioral activity, is to determine whether the subject is actually meditating and succeeding or not meditating when asked to do so. Another confound is that expert meditators consider meditation to permeate their everyday states of awareness thereby blurring the lines between strictly meditative and non-meditative states. Finally, the noisy environment created by these scanners during the experiments is also a challenge for the act of meditation. However, despite these experimental weaknesses and limitations, there is now a growing body of research showing that we can indeed image and objectively measure the changes in brain activity that occur over time in meditators. The brain function changes in long-term meditators is reflected in the improvements in behavior and mental-emotional states.

Yoga as a Therapy to Treat Depression
By Sat Bir Singh Khalsa, Ph.D.

Depression is a prevalent and debilitating mental health condition that can affect anyone at anytime. Researchers have found that the majority of individuals with major depressive disorder (MDD) report only a 50% decrease in symptoms with the use of antidepressant medication, the standard treatment for depression. MDD significantly affects daily functioning, with 60% of depressed individuals reporting that the condition has a severe or very severe impairment on their daily lives. The chronic nature of depression is that there is most likely a cyclical relationship in the brain mechanisms involved in the regulation of mood and stress responsivity, such that depression may occur because of life stress and life stress may be a result of depression. This suggests that managing stress may break this cycle.
As a common complementary therapy in the United States, yoga may be particularly helpful for depression because it can be adapted to daily mood through integrating practices to enhance physical, emotional, and spiritual health. Most notably, yoga is easily available and can be self-administered. The slow rhythmic breathing practices and meditative/ relaxation practices of yoga are designed to induce a sense of calm, well being, stress tolerance, and mental focus, all of which can be of help for depressed individuals. Stress is one of the major known risk factors for the development of depression. Increased risk of depression can result from life events like divorce, death, or loss of employment, in addition to chronic stresses like illness, lack of social support, and numerous daily stressors. Given yoga’s ability to improve stress coping, yoga has some potential for both preventing and coping with depression and its symptoms.

In understanding how depression works, it is important to examine the brain, in particular the ventromedial (or subgenual) prefrontal cortex (VMPFC). The VMPFC integrates limbic, emotion-related information and translates this into modulation of autonomic and behavior outflow. Also, the VMPFC appears to function as a nodal brain region whereby social and emotional conditions interact with information from the body related to stress and relaxation, and is likely to contribute to mechanisms by which mind-body therapies like yoga can influence mood, social function, as well as autonomic output. Major input to the VMPFC includes projections carrying feedback from the body related to stress and viscerosensory signals. Because yoga encourages mindfulness, positive self-talk, and self-acceptance, which may help increase self-confidence and sense of self, these aspects may engage the VMPFC by encouraging a focus on body movements and the breath. In fact, researchers have shown that the application of mindfulness and meditation over the long-term enhances emotion regulation by reducing emotionally reactivity and this is reflected in actual structural changes in the brain; the amygdala in the limbic system responsible for emotion is actually reduced in size. This, in turn, reduces concentrations of stress-signaling molecules and increases dopamine levels. These effects improve the potential for better control over emotions, mood, and anxiety and for increased relaxation. Further, it is important to point out that practicing yoga does not typically involve ignoring depressive or anxious thoughts, but rather focuses more on non-judgmental acceptance of these thoughts, resulting in positive effects for depressed individuals.

The use of yoga as both an alternative and an adjunct to standard treatment for depression is reflected by the increasing number of studies assessing yoga as a treatment for depression. The quantity of this research has reached the point where there are now well over a dozen published systematic reviews and meta-analyses of the research on mind-body medicine approaches for depression including 4 review papers specific to yoga for depression published since 2005. An early 2005 review identified and described 5 clinical randomized controlled trials suggesting some benefit of yoga. In 2010, a review paper by researchers at Brown University School of Medicine reported on 8 clinical trials, and in addition to supporting yoga’s potential efficacy, also described the potential mechanisms involved. More recently in 2013, a more rigorous review, a so-called meta-analysis that applies statistical analytic techniques to published research results, was published by a group led by German yoga researcher Holger Cramer. This study found 27 clinical trials and examined the 12 of these that were randomized controlled trials that involved a total of 619 patients/research participants. They concluded that yoga is efficacious as compared with usual/standard clinical care, and somewhat better than relaxation or aerobic exercise, and benefits were shown for both patients with depressive disorders and in individuals with elevated levels of depression.

Interestingly, they also noted that the more meditation-based forms of yoga appeared to be more beneficial than the more exercise-focused yoga styles. However, a more recent informal review paper in 2014 reported on six studies employing yoga styles that had physical practices/asanas as a core component, and concluded that there were positive benefits. Not surprisingly, as with any novel field of research, there are limitations on the quality of the yoga for depression clinical research literature and therefore of what can be claimed. For example, there are few studies that solely investigate the effects of yoga for depression, the study sample sizes are small in many studies and the generalizability of benefits noted in participants who demonstrate the motivation to participate and comply in studies of yoga may be questionable, the severity of depression is not known across studies, and although adverse effects have not been reported in these studies, details of how the assessments have been completed are lacking. Nevertheless, the research literature is encouraging enough to support publication of a brief 2014 Journal of Family Practice paper (that reaches more practicing clinicians) that summarized these published reviews concluding that “Yes, yoga can reduce symptoms of anxiety and depression…”.

An advantageous factor in the application of yoga as a treatment for depression may be that yoga is safe, cost-effective, and can be used as an adjunct to medication. Increasingly, health care providers are encouraging their clients and patients to use self-management approaches for the treatment and management of chronic diseases such as depression. The fact that yoga is versatile, allows for personalization, and can be practiced in studios, gyms, outdoors, and at home is ideal for this form of self-care. Mind-body therapies, like yoga, can support pharmacological and psychological therapies by improving stress and emotion regulation and reactivity. Social support, which is an additional benefit of group yoga practice, has proven to have a positive impact on some individual’s mood and coping skills. Thus, the practice of yoga warrants serious consideration as a potentially efficacious strategy that would allow depressed individuals to cope with their depressive symptoms and their consequences. Further rigorous research is warranted to clarify specific mechanisms of yoga’s efficacy for depression and to determine the best practices and application of yoga that yield optimum benefit.

Neuroimaging Research on Yoga and Meditation: EEG Studies
Nikhil Ramburn and Sat Bir Singh Khalsa, Ph.D.

Historical anecdotal evidence abounds for the benefits of yoga and meditation and even for the underlying psychophysiological and psychological mechanisms of its action. Since the history of the practice goes back thousands of years, the writings of the yoga and meditation masters over the millennia have given us valuable insight into how meditation works. However, anecdotal evidence can be very subjective and may not apply to the general population. Therefore, more objective studies have tried to quantify the effects of meditation and the neurophysiological processes involved. One of the early scientific tools used to study the contemplative practices has been electroencephalography (EEG). The EEG records the electrical activity of the brain with electrodes on the surface of the scalp and registers the distinctly different brain wave patterns that occur over different regions of the scalp and that change their characteristics over time and with different meditation practices.

EEG research has revealed that yoga has positive and unique effects on brain activity by stimulating alpha, beta, and theta brainwaves. These changes in brain activity have been associated with improvements in cognition, mood, and anxiety. Alpha brainwave activity has been correlated with increased cognitive performance such as faster recall of information from memory. Likewise, beta waves have been linked to increased cognitive skills, which are associated with improved academic performance and mood. Those beneficial brain wave activities were observed in the various EEG studies on yoga practitioners.

The first EEG studies from the early sixties and seventies revealed increases in alpha and theta wave amplitude in yoga practitioners. Later studies were consistent with these findings, such as in a 1992 Indian EEG study, in which a breathing and relaxation yoga practice was equated with gradual and significant increases in alpha activity over 30 consecutive days of training. Those increases in alpha activity were registered in the occipital and prefrontal cortices of the brain. Scientists have found an integral link between the prefrontal cortex and the personality. This finding is consistent with Yogi Bhajan’s description of the frontal lobe of the brain as the control center for the personality and several meditations in the Kundalini Yoga tradition target this brain area.

In another more recent study from 2013, a group of Indian police trainees performed asana-based yoga and pranayama. Just as in the previous study, these subjects also displayed increase in alpha wave activity along with amplification of beta brainwaves. Several more EEG studies have demonstrated that a natural practice like yoga can induce brain wave activity associated with a vast array of cognitive and mood benefits. Therefore, the EEG studies have been instrumental in initiating our understanding of the yogi’s meditative mind.
The recent advent of the popularity of Buddhist inspired mindfulness meditation has yielded an additional body of research literature on its EEG characteristics. In a recent review of EEG studies on mindfulness meditation published in a 2015 issue of the journal Neuroscience and Biobehavioral Reviews by a team of U.K. researchers, the authors examined 56 publications. They concluded “that mindfulness was most commonly associated with enhanced alpha and theta power as compared to an eyes closed resting state, although such outcomes were not uniformly reported. No consistent patterns were observed with respect to beta, delta and gamma bandwidths.” This conclusion is in essence not much different from previous meditation studies, in which a single point, or closed focus, form of meditation has been used. The fact that the EEG is not able to show substantial differences between meditation forms may suggest that it has significant limitations.

Despite its benefits, the capability of EEG recordings may not do full justice as a tool to evaluate the subtlety of meditative practices and experience. This technology has the limitation of representing the activity of millions of neurons through interpreting brain wave activity alone. Another major limitation to the EEG is its poor spatial resolution since it is most sensitive to the neural activity in the superficial layers of the brain, because the scalp electrodes are a significant distance away from the neurons through the barriers of the skull and scalp. Deeper structures in the brain that are further from the scalp electrodes such as the cingulate gyrus or hippocampus have less contribution to the EEG signal. While the early neuroimaging studies have yielded valuable information about the effects of yoga on brain activity, the limitations of the EEG technology have restricted what we can learn from these studies. There is now new neuroimaging technology that offers measurements that are free of the many artifacts and limitations of the EEG.

The Emerging Neuroscience of the Wandering Mind and Meditation
By Hsin-ya Chow, M.F.A. and Sat Bir Singh Khalsa, Ph.D.

Like an imaginary friend, mind wandering might keep us company when we're waiting for a bus or waiting in the doctor's office. However, it also pays us less welcome visits when we're trying to concentrate on reading or completing a time-sensitive task. This ubiquitous characteristic of the human mind has been well-known for centuries and was described in the ancient Upanishad scriptures: "…this mind of mine is extremely restless" and "It wanders from a cloth to a pot and thence to a big cart. The mind wanders among objects as a monkey does from tree to tree." (Annapurna Upanishad III-5 and Annapurna Upanishad III-6).

Human beings have a natural propensity for mind wandering. Mind wandering is what occurs when we are contemplating scenarios of our past or future such as last week's argument with the spouse or the outcome of an upcoming business meeting. There are some recent and ongoing studies that show the evolutionary advantages of mind wandering. Creative problem solving, future planning, and as a refresher or relief from tedium are some of the possible benefits. However, it is when we dwell, as we most often do, on more challenging or stressful topics, such as the past argument with the spouse or the upcoming business meeting, that a less friendly form of mind wandering occurs. This may progress further into a more pernicious activity known as rumination, in which there is a persisting continual loop, the chewing of thoughts over and over, and this comes with a price. Emotionally, it comes at the cost of one's happiness and sense of well-being. The study of mind wandering has now actually become a focus of scientific research to understand its consequences and underlying mechanisms. Most notably, a Harvard study on mind wandering in everyday activities, published in the prestigious journal Science, showed that people were less happy when their minds were wandering than when they were not and that, “The ability to think about what is not happening is a cognitive achievement that comes at an emotional cost.”

In the brain, mind wandering is primarily associated with a network of interacting brain regions called the default mode network (DMN), although recent research is suggesting that other brain regions are also involved. Some forms of activity in the DMN have been shown to have a direct link to mood disturbance and psychiatric conditions. The more one ruminates, the more the default mode network is strengthened. This phenomenon is known as brain plasticity and works very much like the way building a muscle might happen. The more time spent exercising the muscle, the more it grows, and the stronger it becomes. The more time spent in mind wandering and rumination, the more the brain is dominated by performing that activity, and the unhappier you become. Over time, too much DMN activation in rumination is associated with risk factors for mental health conditions such as depression, addictive behaviors, attention deficit disorders, and anxiety disorders.

On the flip side, there is a brain activity that is very different than mind wandering or rumination which is associated with task-oriented functions that require focus and control of attention. One of these activities is meditation, the relaxed focus of attention. Instead of the past or future thinking in mind wandering, this activity involves focus on the here-and-now and involves activation of the attention networks in the brain in the frontal lobe. Meditation is a proven mechanism for training the mind and there are two primary meditation forms. One is closed focus or concentrative meditation, in which one focuses attention on a single point or target such as the breath, an image, or a mantra. The other form is referred to as open focus, open monitoring, or mindfulness meditation in which one observes the flow of thought or sensation in consciousness. What is common to both forms of meditation is that mind wandering inevitably intervenes repeatedly, and the task is to redirect the mind to the object of attention in a relaxed manner.
This alternation between focus of attention and mind wandering is a hallmark of the practice of meditation. An elegant neuroimaging research study of meditation in the fMRI brain scanner (functional magnetic resonance imaging) distinguished this pattern of activity during meditation, revealing four distinct phases in a repetitive sequence: mind wandering, awareness of mind wandering, shifting of attention back to the intended focus, and sustained attention or focus. It was the DMN that was observed to become active during the mind-wandering phase, whereas the prefrontal cortex was activated during the focus phase. In longer term meditators, it was noted that these individuals were able to more quickly return to the focus phase of meditation, suggesting that there are lasting changes in brain regions associated with long-term practice of the task-focused attention in meditation. Other research is indicating that activation of the attention networks in the prefrontal cortex has inhibitory effects on the limbic system where emotions are regulated. This is significant, because it means that the minds of meditators, on the whole, are benefiting in a sustainable way.

Research is suggesting that individuals more prone to mind wandering and rumination are potentially more at risk for the development of mood disturbance and even psychiatric conditions. In long-term meditators, regions of the limbic system are actually structurally reduced in size compared with non-meditators and the risk for mood disorders is reduced. There is lowered emotional reactivity and an increased ease in decision-making. Increases in relaxation, improvements in focusing, and higher performance emerges. The more one meditates, the more one spends time activating the attention networks, and the less time one spends in DMN activity, and it is likely that structural changes follow the degree of activity in each network. Ultimately, with long-term meditation, the first known published description of the active control of attention in the act of meditation in the Upanishad scriptures is realized: "… the man who has a discriminating intellect as his driver, and a controlled-mind as the reins, reaches the end of the path--that supreme state of Vishnu." (Katha Upanishad 1-III-9).

Research on Yoga in the School Setting
Nikhil Ramburn, B.A. and Sat Bir Singh Khalsa, Ph.D.

Children and teenagers today face mounting pressure to perform academically along with numerous stressors in their social and family lives. The consequence has been an alarming increase in the prevalence of physical, mental health, and behavioral problems. Despite the long-held role of schools to provide an academic education leading to success in the job market, parents, educators, and students are increasingly demanding more than academic success from schools. As a result, numerous programs to promote health and prevent problem behavior in the school system have sprung up. Unfortunately, many programs are fragmented and not well-integrated into school structures. To address this problem, the education system is in need of programs that support mental and physical health and that can be easily integrated into the school curriculum.

Studies on the therapeutic effects of yoga for youth indicate that it is efficacious in improving both physical and mental health, making yoga a prime contender to meet the school system’s need for an effective and holistic health and wellness program that can promote social and emotional learning (SEL) goals such as self-awareness and stress regulation.

Research into school-based yoga programs is a nascent and growing field. The first study of this kind, published in the journal Academic Therapy in 1976, reported that elementary school children exhibited calmer behavior and improvement in psychomotor skills following a yoga program. The authors also suggested that yoga may be more beneficial than other gross-motor physical activities because of its calming aspect. A follow-up study in the same journal in 1979 by the same researchers surveyed 34 children in Delaware who exhibited educational problems. The children were six to eleven years old and given fifteen minutes of yoga instruction before being assessed for their concentration levels. The study showed that students worked with greater efficacy following periods of yoga. However, like many studies in a new field of investigation, sample sizes were small, there was no control group and there was actually no statistically significant differences in improvements between changes in a yoga period as opposed to a general psychomotor program. However, statistically significant results were found in a 1989 randomized control trial of 80 students attending a private, religiously affiliated middle school in northern New Jersey. This study published as a doctoral dissertation at Seton Hall University showed that yoga meditation showed efficacy as a self-regulation strategy, thereby demonstrating the value of yoga to meet SEL goals.

Over the past ten to fifteen years, evaluations of school-based yoga and meditation approaches targeting children have increased significantly in both quantity and quality of studies. The recent surge in the popularity of mindfulness practices by the general public and has also been reflected in educational settings. In a small, randomized control trial of urban youth in 2014, application of the well-known Mindfulness-Based Stress Reduction was associated with qualitative outcomes of increased calm, conflict avoidance, self-awareness, and self-regulation. These are all essential characteristics that make a productive learning environment and healthy school community. Mindfulness practices were also associated with a significant reduction in depression and stress in a nonrandomized parallel group study in 2012 showing the benefit of mindfulness programs in addressing the mental health epidemic facing today’s youth. More recently, a larger randomized control trial with fourth and fifth-grade students showed that students receiving a school-based mindfulness program showed greater decreases in depression, aggression and were rated by peers as more trustworthy, kind and helpful. Those same students had a more normalized diurnal profile of the stress hormone cortisol as determined by salivary assays.

With respect to yoga studies in school settings, a recent review paper published in the International Journal of Yoga Therapy identified twelve peer-reviewed studies of school-based yoga programs. Seven of the studies reviewed were conducted in the United States in public elementary schools both within the curriculum and in after-school programs. In India, studies were conducted on yoga programs in both residential schools and special education schools and studies of English and German public school yoga programs were also identified. Research designs involved in this research included pilot studies, single group trials, quasi-experimental and randomized clinical trials. Although most of the students were normally healthy youth, some of the yoga studies included students with autism, and with intellectual and learning disabilities.

In terms of characteristics that were observed to improve, students receiving the yoga intervention reported fewer negative behaviors, showed less body dissatisfaction and lower levels of stress. In addition, students were able to plan and execute tasks more quickly, were more self-confident, and communicated better with their teachers and peers. A study of Indian students, showed that students made fewer errors in depth perception after a yoga intervention. In a German public school, there was a decrease in group aggression and increase in stress-coping ability. Finally, significant improvements on IQ and social adaptation were noted in a special education school in India. Although the effects of participating in school-based yoga programs appeared generally beneficial, methodological limitations including the lack of randomization, small samples, limited details regarding the intervention and statistical ambiguities have limited the drawing of definitive conclusions at this point.

Despite these weaknesses, these findings do suggest that yoga provides a skillset to facilitate SEL such as stress management and self-regulation, thereby providing a cost-effective, evidence-based program to schools. As a holistic system of mind-body practices, yoga has been found to be an effective complementary therapy to promote health and reduce many factors related to physiological diseases in the adult research literature. Given that strong evidence exists between the promotion of SEL and beneficial student outcomes, more rigorous trials and funding are needed to support the research into school-based yoga programs. Further high quality research will be useful towards justifying the inclusion of yoga into the school curriculum, which may then become a universal practice and spread across the globe, completely reshaping education in the Aquarian Age.

The Early History and its Significance
Sat Bir Singh Khalsa, Ph.D.
The contrast between East and West provides a fascinating study in the difference in perception and understanding of the nature of the world. The origin and development of the contemplative practices of yoga and meditation date back to the most early of Eastern civilizations, and the East is deeply imbued with a reverence for the value of the most profound internal experiences. Western culture, on the other hand, has been more influenced by the development and influence of the scientific method in understanding the physical world, systematically and precisely uncovering the underlying physical laws of the Universe. The earliest research on yoga and meditation is one that is characterized by this East/West contrast, historically mirrored by the Western British rule of India for centuries, and by the marked difference between the technological, reductionistic nature of scientific research and the holistic, integrative and unitive nature of yoga.

The first biomedical scientific research on yoga was conducted by Indian investigators in Indian institutes. In the 1920’s, Swami Kuvalyananda founded the Kaivalydhama Yoga Institute in Mumbai and the yoga research journal Yoga Mimamsa (which are both still very active today) and began research on specific yoga practices. In the frontispiece of the first issue of Yoga Mimamsa dated October, 1924, he prophetically wrote:

The Yogins, right from Patanjali, the greatest exponent of Yogic science, knew how to induce the highest spiritual stages. As the objective sciences had not developed till late, it was not possible for these stages to be experimented upon; and though lately there has been a startling advance in modern sciences, their exclusive material tendency and the equally exclusive spiritual tendency of the Yogins have led to a complete but an unlucky divorce of the two schools of thought. The Kaivalyadhama is anxious to wed these together and produce results which will lead to the realization of the ideal indicated above.

THE Yoga-Mimansa Quarterly will publish researches of the Asrama Kaivalyadhama. The workers of this Asrama are tackling, according to the modern scientific methods, the great Yogic culture of India in its different aspects. Nothing that has not been tested either clinically or in the laboratory will appear in the pages of this periodical. What truths will be revealed by these researches nobody can predict. But it looks very probable that the research-work of the Asrama will enrich the field of physiology, psycho-physiology, therapeutics, spiritual and physical culture, etc. Years of labour in psycho-physiology may help the scholars to solve some of the toughest problems of philosophical thought.

Given what is only a very recent exponential growth in integrative medicine and yoga research over the past decade, it is clear that Kuvalyananda was a visionary far ahead of his time. His early research at Kaivalyadhama involved x-ray and pressure measurements of the yogic abdominal exercises nauli and uddiyana and the blood pressure effects of yogic postures. Later studies in the 1950’s examined at gas exchange and air pressure changes occurring during pranayama practices. One of Kuvalyananda’s students, K.T. Behanan, pursued studies on pranayama as a research fellow at Yale University in the 1930’s, which yielded publications in American biomedical journals and his book Yoga: It’s Scientific Basis in 1937.

Aside from research out of Kaivalyadhama, over the course of the 3 decades from the 1930’s through the 1950’s, there were only a handful of other yoga research initiatives that led to publications. In one of the earliest instances of research on yoga for therapeutic purposes was a brief German report published in 1933 evaluating yoga treatments on 42 subjects with constipation showing complete recovery or marked improvement in 28 of them. In the U.S., a Minneapolis physician stumbled across the benefits of long deep breathing for the treatment of angina pectoris in his patients, coming to the realization that this was a yoga-based practice after correspondence with yogi Paramahansa Yogananda, and called the practice “attentive breathing” in a case series report published in 1948.

Early reports over the past 3 centuries by Western travelers and writers described the feats of expert master yogis and “fakirs” to dramatically alter their bodily and psychological functioning. These yogis could purportedly survive prolonged underground burial, withstand pain, stop their heart activity and achieve profound altered states of consciousness. These reports suggested special skills or abilities unknown to medical science, which peaked the interest of a number of Western scientists. In 1851, a regimental surgeon in Benares named N.C. Paul who had studied and practiced yoga for 35 years, published the book Treatise on the Philosophy of Yoga in which he analyzed the biology of gas exchange and metabolism apparently involved in the yogic feat of surviving prolonged underground burial and he also tried to address the relationship between frequency of breathing and yogic states of consciousness. However, this work did not involve any real experimentation or measurements, and so was therefore more of a hypothesis paper than a research report.

It was almost a century later, that Western physiologists outside of India traveled to India with portable recording equipment to investigate these claims. Therese Brosse, a French cardiologist who was a fellow at Harvard Medical School came to India in 1935 to investigate the claim that accomplished yogis could stop their heart beats. Although her published study was not fully convincing with respect to the ability to completely stop the heart rhythm, it did show that these practitioners had the ability to slow their heart rates substantially, suggesting that they could control the autonomic innervation of the heart. A 1950 report in the prestigious British medical journal Lancet described a witnessed account of the survival of a yogi in a sealed underground chamber for over 3 days. Also in the 1950’s, French researchers Das and Gastaut reported results of electroencephalographic recordings that showed discrete and profound changes in brain waves during the deep meditative state of Samadhi, that were also associated with marked changes in heart rate. Perhaps the best study of this kind was the classic report “Electro-physiological correlates of some Yogi exercises” published in 1957 by Basu Kumar Bagchi, a University of Michigan professor and close boyhood friend of Paramahansa Yogananda, and Marion A. Wenger, a UCLA psychologist. They spent 5 months traveling across India seeking out yoga masters and holy men and described their challenges in that paper: “Dozens of informants and Yogic subjects were personally contacted in 17 places in different parts of India, in addition to carrying on a fairly large volume of correspondence from America and in India. A large number of leads on Yogis proved unproductive. Many Yogis were not interested, some would not cooperate. Many could not be reached. It would appear that more time, effort, travel, and expense were involved than would be considered warranted in an adventure like this.” Recordings with their portable electrophysiological recording equipment showed that these yogis had a marked slowing of breath rate, an ability to slow heart rate, and a deep relaxation of the autonomic nervous system.

The key value of the very early research in yoga was in first bringing to light the possibility for self-regulation of internal physiological functions through yogic practices, a construct that was novel to conventional modern psychophysiology and medicine. These early findings on self-regulatory abilities inspired accelerated research in the 1960’s and later, and have stood the test of time having been echoed and confirmed by the results of many subsequent modern research studies on yoga, meditation and other contemplative and mind-body practices. Physiological and psychological self-regulation, particularly stress coping and resilience (and control of the autonomic system and the hypothalamic pituitary adrenal axis) and emotion regulation, now represents one of the most important outcomes of yoga practice and has enormous implications for improving both human functioning and disease symptomatology.

Yoga in Public Schools: A Nationwide Grass Roots Movement

Nikhil Ramburn and Sat Bir Singh Khalsa, Ph.D.

According to recent national surveys, there is currently a large and growing burden of psychological disorders such as depression, anxiety and substance abuse in our youth that is almost universal. In addition to this, a significant percentage of youth are obese and at risk for lifestyle diseases such as type 2 diabetes. Furthermore, behavioral problems such as physical inactivity, bullying, and school dropouts are becoming commonplace. Key factors contributing to these problems are the inability of youth to cope with the chronic stress of modern society and a lack of mind body awareness. Unfortunately, the focus of our school system has been exclusively on academic performance and preparing children to succeed in the adult job market, and it has essentially ignored the teaching of life skills such as stress and emotion regulation that would represent an education of the whole child.

Yoga includes practices designed to calm the nervous system and is ideally suited to alleviate the stressors faced by students. It represents a lifelong skill that can be learned and applied over a short period of time. Furthermore, yoga promotes mind-body awareness that can lead to sustainable and long-term positive changes in behavior. It is therefore logical and likely that school-based yoga interventions may have a preventive impact, targeting early risk factors for physical and psychological disorders and negative behaviors.

Remarkably, the implementation of grassroots yoga programs in public schools by both individuals and by formal yoga in school organizations offering school-specific yoga curriculums has actually become a movement. In a paper recently accepted for publication in the journal Advances in Mind-Body Medicine (School-Based Yoga Programs in the United States: A Survey by Butzer B, Ebert M, Telles S, and Khalsa SBS), a survey of these yoga in schools programs across the U.S. was conducted. The study identified and characterized 36 programs, which have been offering yoga in over 940 schools and have formally trained over 5,000 instructors in their curricula. To be included in the analysis in this study, yoga in school programs had to include yoga physical postures and exercises and/or yogic breathing practices, but virtually all also included relaxation techniques and meditation/mindfulness practices. The study analyzed each program’s scope of work, curriculum characteristics, teacher certification and training requirements, implementation model, mode of operation, and primary geographical region.

All programs were designed to be secular and teach universal values or life skills, which makes them suitable for public school settings. Most programs also included aspects beyond the physical by incorporating ethics or philosophy in their lessons. Several additional activities were also included in a number of these programs. Games, songs, journaling, crafts and team building exercises that would not typically be considered yoga per se are common auxiliary learning tools that have been seamlessly woven into the yoga lessons. The inclusion of those non-traditional components allows the yoga programming to be integrated with school values and social and the few social and emotional learning programs already in existence. In recognizing the need for this social and emotional component, the Collaborative for Academic, Social and Emotional Learning (CASEL) has been promoting the inclusion of social and emotional learning in schools. Although the majority of the yoga programs have no formal relationship to the CASEL, many of the program goals are aligned with the core CASEL competencies of enhancing students' self-awareness, self-management, social awareness, relationship skills, and responsible decision-making.

While some programs focus exclusively on school programming, others also run their yoga programs at mental health organizations, community youth programs, or at-risk community youth organizations. The Kundalini Yoga-based Y.O.G.A. for Youth program based out of Los Angeles offers yoga classes to urban youth, giving them tools for self-discovery, discipline, self-respect and community engagement (see: http://www.yogaforyouth.org). Since its inception in 1993, Y.O.G.A. for Youth has served over 16,000 young people in Los Angeles county alone. Y.O.G.A. for Youth offers opportunities for youth to practice yoga and relaxation in schools, community facilities, hospitals and detention centers. Its unique programs have been designed to combat a myriad of issues that plague our youth today including stress, anger, depression, anxiety, low self-esteem, poor concentration and obesity. A recent research study was conducted on Y.O.G.A. for Youth programs in L.A. charter schools, in which notable improvements in stress, resilience and mood were noted. An ongoing research study is evaluating the benefits of an after school Y.O.G.A. for Youth program in North Carolina.

Traditional bureaucratic structures and misunderstanding amongst parents about the secular nature of yoga has led to some reluctance in the implementation of yoga in schools. Future research should examine the most effective and feasible avenues for delivering school-based yoga programming given these unique challenges. The yoga in schools movement is an appropriate countermeasure for the current challenges in our youth’s health and behavior and should lead to improved social and emotional skills, classroom behavior, and academic performance. There is also a critical need for research studies to quantify and document these benefits in order to provide policy makers with the justification to support the widespread implementation of yoga in our school curricula.

Have you been teaching yoga in schools or wanting to pitch a yoga program to your local school? We hope Dr. Sat Bir’s article this month provides you some general insight and direction for how to approach teaching yoga in a school near you!

The Rationale for Yoga in Schools

By Sat Bir Singh Khalsa, Ph.D.

Children and adolescents living the United States today are faced with many stressors, including problems with family and peers, the pressure to perform well and succeed academically, and the many physical and emotional changes that come with puberty. If unmanaged, chronic stress can lead to significant mood disturbance and is well-known as a risk factor for psychiatric conditions. In fact, a comprehensive research survey has revealed that the cumulative prevalence of psychiatric problems by age 21 exceeds 80% in the United States suggesting that these conditions are nearly universal in our youth. Furthermore, another survey study indicates that the majority of psychiatric conditions in adults have child-adolescent onsets. Therefore, there is a great need to address this high mental health burden in children and adolescents and to also prevent the occurrence of psychiatric disorders in adulthood. A growing number of educators, parents and students believe that schools need to provide more than academic instruction in order to ensure that children are not only successful in school, but also in life. However, the modern education system is faced with the pressure to enhance the academic performance of students, resulting in a lack of time and resources for developing students’ life-coping skills.

An important recent construct relevant for the behavioral competence of youth is so-called social and emotional learning (SEL), which refers to the processes through which children and adults acquire and effectively apply the knowledge, attitudes, and skills necessary to understand and manage emotions, set and achieve positive goals, feel and show empathy for others, establish and maintain positive relationships, and make responsible decisions. The Collaborative for Academic, Social, and Emotional Learning (CASEL) strives to advance SEL science, evidence-based practice, and policy, and provides a published guide to existing programs that are believed to be effective for SEL. In an ideal world, CASEL would see every school in the nation providing evidence-based SEL programming to all students in preschool through high school.

The practice of yoga is effectively a form of SEL, with potentially additional advantages. With yoga practice, students start developing the ability to regulate their stress and emotions, to develop full awareness of their mind and body, and improve their physical health and functioning through the physical movements and postures, breathing exercises, meditation practices, and relaxation techniques. These are skills which lead to improved functioning and coping overall, thereby preventing the risk factors for impaired mood, behavior and health. Encouragingly, the Kripalu Yoga in Schools program has just recently been included in the CASEL guide, and it is likely that other contemplative practice-based curricula will be added in future. Traditional SEL programs are often challenging to integrate into the standard academic curriculum, mostly due to limited time and resources. School-based yoga programs, on the other hand, have the advantage of possibly being integrated relatively seamlessly into existing standard physical education class settings.

There is a growing number yoga programs being implemented in public schools across North America. Research on these programs indicates that offering yoga programs within the school curriculum is an effective way to help students develop self-regulation, mind-body awareness, and physical fitness, resulting in the promotion of SEL skills and positive student outcomes. School-based yoga research is in its infancy, however it is important to note that it is a growing field. Most existing studies are preliminary and have focused on elementary school students with limited studies on the long-term effects of yoga in schools. School-based yoga programs have been shown to improve behavior, mental state, health and performance, while at the same time preventing much of the stress experienced by students. Specifically, studies have revealed that yoga interventions produce positive effects on several factors such as emotional balance, the ability to concentrate, cognitive efficiency, anxiety, negative thought patterns, emotional and physical impairments, emotional and stress reactivity, and negative behaviors. Several studies have also found the beneficial effects of school-based yoga programs on teacher-perceived factors such as classroom behavior and SEL skills, concentration, mood, ability to function under pressure, hyperactivity, attention, adaptive skills, behavioral symptoms, and internalizing symptoms.

Additionally, a small number of studies have examined the effects of school-based yoga physiological outcomes and found that yoga participation was associated with decreased cortisol concentrations, more stable breathing patterns, and improvements in heart rate variability. A credible hypothesis regarding the meditative/mindfulness component of yoga practice, is that they increase mind-body awareness, which in turn leads to positive behaviors; specifically, an increased awareness of the rewarding feelings and experiences that occur when one engages in positive behavior, encourage more of that behavior. For example, after yoga training, students may find that they are no longer attracted to junk food, because they become acutely aware of the negative bodily response and sensations after consuming it. Recent neurobiological hypotheses suggest that yoga may exert its beneficial psychological effects through physiological mechanisms that calm the nervous system, possibly through the stimulation of the vagus nerve, as a result improving stress management and self-regulation. Other recent studies suggest that yoga may enhance several aspects of physical fitness, such as improved respiratory function, increased exercise adherence, and reduced obesity risk factors. There are also studies suggesting that yoga is as effective as, and in some cases better than, standard physical exercise in the improvement of positive health-related outcomes.

The movement of yoga in schools shows promise for improving a variety of student outcomes, however, the need for more studies and future research is critical. Because school attendance is mandatory, yoga in schools may play a vital role in helping children establish healthy lifestyle behaviors from an early age. Therefore, the implementation of yoga in schools could have far-reaching implications for school health, and also for society as a whole. In summary, there is a need for SEL skills for our youth, existing research suggests that yoga provides SEL skills that improve mental and physical heath in childhood, and, therefore, school-based yoga programs may as a result have long-term implications for health in adulthood. Currently, grassroots efforts for yoga programs in schools across North America have been increasing, but more studies showing the benefits of these programs will be instrumental to expanding the presence of yoga in schools. The scientific rationale for yoga in the public schools described in this article has been more fully articulated in a peer reviewed manuscript that is currently in press in the Journal of Children’s Services (Yoga within the School Curriculum: A Scientific Rationale for Improving Social-Emotional Learning and Positive Student Outcomes; Butzer B, Bury D, Telles S, Khalsa SBS), which we hope will be of use as a supportive document for yoga-in-school program administrators in justifying the application of their programs in school settings. We are hopeful that yoga could become a well-accepted and universal part of school curricula.

Yoga for Substance Abuse: Scientific Rationale and Research Evidence
By Nikhil Ramburn, B.A. and Sat Bir Singh Khalsa, Ph.D.

Substance use disorder is marked by a dependency on alcohol or drugs to function, and may include impaired control and inability to moderate one’s substance use. It becomes clinically significant when the behavior pattern and day to day activities are impaired or the patient is under distress. The user may experience recurrent social or interpersonal problems and may find himself in physically hazardous situations. Another symptom is the increased tolerance for the substance along with substance-specific withdrawal syndromes. Substance use disorder and addictive behavior are complex conditions with numerous underlying psychological, behavioral and physical components. The pathological pursuit of relief through substance use or other addictive behaviors affects neurotransmission within reward structures of the brain, thereby altering motivational impulses and supplanting healthy self-care behavior. This leads the patient to adopt maladaptive behavior in seeking rewards such as food, sex, alcohol and other drugs. Another psychophysiological underpinning to this disorder is stress. Stress is correlated with negative health behaviors and physiological impairment, contributing to substance use and/or abuse and chronic disease development. Given the chronic nature of substance abuse, the likelihood of relapse is high. Therefore, treatment that is truly successful over the long term often involves a radical shift in perspective and a change of deeply rooted behaviors.

In 2011, the Centers for Disease Control and Prevention reported that there were more than 40,000 unintentional drug overdose deaths in the United States. The abuse of tobacco, alcohol, and illicit drugs costs more than $700 billion annually in expenses related to crime, lost work productivity and health care. It has been plausibly ascertained that 47% of the U.S. adult population suffers from maladaptive signs of an addictive disorder.

Yoga is widely recognized as an effective treatment for stress but the benefits of yoga in treatment of substance abuse may extend beyond stress relief alone. Yoga and meditation have been proposed as effective treatment for this condition because of their positive impact on several psychophysiological processes. Yoga has been demonstrated to reduce both the overt behavioral and underlying neuroendocrine components of stress. Those suffering from substance use disorder will often seek relief from daily stressors by using drugs or alcohol, and yoga may prevent relapse by offering a healthy way of managing stress. Yoga has also been shown to improve conditions of depression and anxiety and induce a higher state of consciousness that effectively replaces the attraction of substance-induced high. This is particularly important given the chronic nature of addiction and the pathological search for pleasure through substance use. Furthermore, yoga has been shown to improve self-awareness of one's mental and physical state, thereby allowing for improved self-regulation and preventing destructive behavior before its onset. Moreover yoga can improve self-esteem and promote a better understanding between an individual and his/her social world.

There are a few notable studies of yoga for addictions, some of which have shown that it is successful in addressing some of the psychophysiological underpinnings of the disease. An older Indian study evaluating yoga for alcohol abusers, revealed that subjects receiving yoga treatment showed normalization of the stress hormones cortisol and catecholamines. At Ankang hospital in Tianjin, China, yoga was found to significantly improve mood and quality of life in women undergoing detoxification for heroin dependence. A Harvard researcher in Boston found that outpatient methadone clients undergoing weekly yoga classes showed equivalent improvements in psychological, sociological and biological measures to subjects undergoing psychotherapy over a six-month period. Finally, in another small Indian study, yoga was shown to offer statistically greater improvements in withdrawal symptoms for drug addicts.

One of Yogi Bhajan’s efforts on his arrival in the West was to provide Kundalini Yoga as a way out of drug use. 3HO SuperHealth® is a therapeutic yogic lifestyle developed by Yogi Bhajan that combines Kundalini Yoga, meditation, therapeutic dietary and juice formulas, and counseling and Humanology (applied psychology from the Kundalini Yoga perspective). 3HO SuperHealth® has been used to address dependency on alcohol, drugs, smoking, food issues, co-dependency, gambling, work, and computers. It also includes tools to manage stress, depression, fatigue and anxiety. SuperHealth® has been accredited by the Joint Commission on Accreditation of Healthcare Organizations and received its highest commendation, being rated in the top 10% of residential programs in the United States.

In 1991, a report on the 3HO SuperHealth® program running successfully for many years in Tucson, Arizona concluded that Kundalini Yoga and Kundalini Yoga meditations play a major role in treatment success for drugs, alcohol and anxiety, especially in maintaining recovery. After the SuperHealth® program, participants reported significant improvement in their spiritual life, peace of mind and ability to handle stress. Currently, 3HO SuperHealth®, spearheaded by Mukta Kaur Khalsa (author of Healing Addictive Behavior:Yogic Science for Transformation as taught by Yogi Bhajan) offers trainings around the world in this yogic approach to breaking addictive behavior.

More recently, a 90-day residential SuperHealth® program for substance abuse was conducted at a psychiatric hospital in Amritsar, India. This region in northern India is particularly prone to substance abuse due to its proximity to strong opium production and trafficking in Pakistan. The primary therapeutic modality was 45 days of thrice daily Kundalini Yoga as taught by Yogi Bhajan® supplemented by a variety of additional SuperHealth® and integrative medical therapies delivered by a number of Kundalini Yoga instructors and therapists. Study participants showed improvements on a number of psychological self-report questionnaires including the Behavior and Symptom Identification Scale and the Quality of Recovery Index. Qualitatively, participants reported greater emotional wellbeing, less pain, less reactivity and the ability to sleep better. These results were published in the peer-reviewed Journal of Ethnicity in Substance Abuse in 2008.

The results of these initial studies point out the effectiveness of yoga and yogic lifestyle as therapy in their own right and as complementary treatment to more conventional clinical practices. Yoga has been shown to effectively target the psychological, biological and behavioral functions implicated in the pathophysiology of addiction. However, more research is needed with larger sample sizes, over a longer timeframe and with replicable methodology to see if similar results are achievable across different programs.

The Prevalence and Characteristics of Yoga Practice in the General Public
By Srilatha Vuthoori, M.S. and Sat Bir Singh Khalsa, Ph.D.

Yoga has become very trendy in modern society and is rapidly increasing in popularity. Yoga is so well known for its reputation as a healthful practice that it is also used in numerous media advertisements to market products from pharmaceutical drugs to insurance. There is now also an official International Day of Yoga, on June 21st, recently designated by the UN General Assembly in response to a proposal by the prime minister of India. This increase in the prevalence and popularity of yoga in mainstream society is unprecedented.

Swami Vivekananda was the first influential figure to bring yoga to the West. Addressing the 1893 World Parliament of Religions in Chicago he described the universality of religions and the philosophy of aspiring to infinite consciousness. Other notable yoga figures in the 1920’s and 1930’s were Paramahansa Yogananda who lectured to Boston academics, and political and religious leaders, Indra Devi who opened a yoga studio in Hollywood, and Krishnamurti, famous for his eloquent lectures on Eastern philosophy and yoga. In 1966 B.K.S. Iyengar’s Light on Yoga was published in the US, a book that is still considered a classic for yoga practice. The 60’s and 70’s saw the arrival of many yoga masters who came to teach yoga to North Americans including Swami Satchidananda, Amrit Desai, Swami Rama, Swami Vishnu-Devananda and Yogi Bhajan. Despite yoga’s popularity in the West not much was known regarding the prevalence and demographics of yoga users.

We now have available a number of statistical studies describing the use and the characteristics of yoga practice in different populations. A Yoga Journal survey found that 8.7% of U.S. adults (20.4 million adults) practiced yoga in 2012. The National Health Interview Survey (NHIS) conducted by the U.S. Centers for Disease Control (CDC) tracks the public’s practice of complementary and integrative medicine and revealed that yoga practice almost doubled between 2002 and 2012, increasing from 5.1% (10.4 million adults) to 9.5% of the population, respectively. In Australia, 12% of the adult population was found to practice yoga.

Studies conducted in the U.S., the U.K. and Australia also found that yoga users are likely to be young, female, white, college educated and employed (82% with disposable incomes). Adults aged 18-44 were the majority of those practicing yoga in 2012 (11.2% of U.S. adults aged 18-44). According to Yoga Journal’s survey, the individuals practicing yoga are 4 times more likely to be female (82.2% woman vs. 17.8% men). Another study examining the sociodemographic barriers in U.S. adults for mindfulness practices found that men were three times less likely to practice yoga. Reasons that may account for this gender imbalance include the possibility that men are not attracted to yoga because they are less flexible than women, or may feel out of place in venues dominated by women. However, the introduction of Power yoga, Bikram yoga and other yoga focused on strengthening may be slowly increasing the number of men practicing yoga. The NHIS survey also found that white adults were the majority of yoga users (11.2% of white adults in 2012). In contrast, the use of yoga among Hispanic adults and blacks was approximately 5% of these minorities in 2012. A survey tracking income in yoga practitioners revealed a strong disparity in this characteristic showing that over 30% of yoga users have an annual household income of $75,000 or more, with 15% earning over $100,000. A similar disparity exists with regards to education with nearly 50% of yoga practitioners having completed a college-level education or higher.

Flexibility, general conditioning, stress relief, improvement in overall health and physical fitness were the top reasons for starting yoga. In Australia, while 58% of respondents gave ‘reduce stress or anxiety’ as a reason for starting yoga, 79.4% of participants continued for this reason. A study of participants in the beginner’s yoga programs provided by the Yoga studios in Austin, Texas entitled Yoga in the Real World: Perceptions, Motivators, Barriers and Patterns of Use was recently published in the journal Global Advances in Health and Medicine. This study showed that the major reasons for practice included general wellness (81%), physical exercise (80%) and stress management (73%). Other reasons for practice included seeking a spiritual experience (37%) and therapeutic intentions including alleviating a health condition (28%), illness prevention (23%), and doctor recommendation (5%).

There are more than 400,000 photos tagged #yogi on Instagram, enough to warrant a New York Times trend piece. The popularity of yoga is also reflected in the use of yoga in surprising places. There is an annual closing of New York City’s iconic Times Square for thousands of people to practice yoga on June 21st, The International Day of Yoga. Last year over 11,000 people participated, which is truly remarkable. This year delegates from the U.N. and India will be present to recognize the International Day of Yoga. Several airports now have dedicated yoga rooms for air travelers (e.g. San Francisco International and Helsinki Airports). There are also numerous fashionable yoga retreat spots now available in destinations including Mexico, Costa Rica, Bahamas, Hawaii and Bali.

Despite yoga’s popularity overall, yoga is most prevalent among white, female, educated, and higher income segments of the population. A recent CDC report on health disparities in the U.S. showed that education levels and race are predictors of poor health outcomes. For example, minorities and low education individuals were more likely to report fair or poor self-rated health and more physically and mentally unhealthy days than others. Meanwhile, studies show that yoga practice can help reduce stress and anxiety, improve fitness, and enhance mood and overall sense of wellbeing. However, the minority populations that need yoga the most (in terms of stress relief and increased well-being), are least likely to practice yoga. Although there are programs to promote yoga for underprivileged populations, the effort is small and penetration to the broader public is slow. Therefore, conducting well-designed clinical research studies could provide the evidence base required to justify implementation of yoga programs in the public schools, healthcare system, and workplace, extending the benefits of yoga to a larger number of people, including disadvantaged populations.

Yoga Research on Neurodegenerative Diseases
By Elizabeth Morris, M.Div. and Sat Bir Singh Khalsa, Ph.D.
Although life expectancy and the percentage of the population that is elderly has risen dramatically since 1970, so too has the rise in the number of people suffering from neurodegenerative diseases such as dementia, Alzheimer’s disease, and Parkinson’s disease. Some of the greatest risk factors for neurodegenerative diseases include chronic stress, stroke, depression, sleep deficits, and mood disturbance. Statistics suggest that as many as 36 million people currently suffer from neurodegenerative diseases such as dementia. By 2030, this statistic may almost double in magnitude with scientists predicting that as many as 66 million people could be affected.

Despite this alarming trend, substantial growth is occurring in research specifically focused on reducing behavioral risk factors of neurodegenerative diseases and/or preventing the degenerative changes that come with aging through mind-body therapies such as yoga and meditation. A notable example of interest is a set of studies conducted by the laboratory of Harvard Medical School researcher Sara Lazar in which changes were measured in brain activity, cortical thickness and gray matter with meditation. Gray matter is involved in muscle control, sensory perception, memory, emotions, speech, decision-making and self-control. The findings suggest an increase in cortical thickness in areas associated with emotional integration and attention among experienced meditation practitioners as compared to individuals with no history of meditation. In addition, the results suggest that meditation is brain protective and associated with reduced tissue decline with age. A study assessing fluid intelligence and aging in long-term yoga and meditation practitioners found that fluid intelligence declined more slowly in yoga practitioners and meditators. Fluid intelligence governs an individual’s capacity to think logically and solve problems in new situations and often declines steadily with aging. In general, meditation was positively correlated with an increase in resilience and showed a slower rate of decline in brain functional architecture and a preservation of brain network integration. It is likely that we are at the beginning of an era that will see a substantial increase in research devoted to mind-body medicine on aging.

Despite this growth in research on aging and risk factors, very few mind-body studies have been conducted on cognitive impairment relative to existing neurodegenerative diseases. A recent review study published in the journal Frontiers in Behavioral Neuroscience in 2014 assessed seven studies focusing on a range of meditation techniques classified as both open monitoring and focused attention on elderly suffering from neurodegenerative diseases. This review concluded that meditation practices have a positive effect on memory, verbal fluency and cognitive flexibility. A study on Kirtan Kriya, a well-known practice within Kundalini yoga as taught by Yogi Bhajan™, showed particularly significant improvements in stress, quality of sleep, mood, sympathetic activation and memory in adults suffering from cognitive decline. Kirtan Kriya was incorporated into an 8-week trial and participants who practiced Kirtan Kriya on a regular basis showed significant increase in blood flow to the prefrontal, parietal and auditory areas of the brain. Participants also showed significant improvement in verbal fluency, logical memory and retrospective memory, or the ability to remember people, words, and events encountered in the past. This mantra-based meditation apparently leads to positive biochemical transformation in the brain and activates areas of the brain associated with attention and exclusive functions (frontal area, cingulate cortex), while diminishing the negative impact of aging on the brain.

One organization that is at the forefront of promoting cutting edge research in this area is the Alzheimer’s Research and Prevention Foundation (ARPF; see: www.alzheimersprevention.org), a nonprofit dedicated to preventing neurodegenerative diseases such as Alzheimer’s by funding research and providing educational initiatives and memory screenings. Dr. Dharma Singh Khalsa, M.D. founded the ARPF in 1993 and the influence of his organization and its efforts inspired an invitation to testify before the U.S. Congress in 2003 to articulate the importance of lifestyle influences on Alzheimer’s disease. The ARPF continues to fund studies on the therapeutic benefits of Kundalini Yoga on subjective cognitive decline, mild cognitive impairment and Alzheimer’s prevention. The ARPF has research initiatives in California, West Virginia, Pennsylvania and Sweden, and educates the public on ways to maximize brain function and reduce memory loss through diet and brain-specific nutrients, stress management, physical and mental exercise and spiritual/psychological wellbeing. By focusing on Kirtan Kriya, the ARPF suggests that cognitive decline can be significantly reduced based on studies that show Kirtan Kriya’s effects including reducing memory loss, improving sleep, increasing cerebral blood flow during chanting meditation, down regulating inflammatory genes, increasing frontal lobe activity to significantly improve attention and concentration, and improved immunity.

Of particular significance, the ARPF is currently supporting the Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) in partnership with the Ministry of Health in Finland. The FINGER study is a groundbreaking research project and the largest study in history to date on the prevention of Alzheimer’s disease. It will include over 1,200 subjects undergoing nutritional guidance, exercise, cognitive training and social activity. Research being conducted at UCLA and the University of West Virginia, aims to show that Kirtan Kriya is a viable mind-body prevention for the millions who suffer from cognitive decline. Mind-body practices such as yoga and Kirtan Kriya may be highly effective in reducing the incidence and influence of the common risk factors associated with the escalation of neurodegenerative diseases.

Yoga for Psychotic Disorders
By JanSev Singh and Sat Bir Singh Khalsa, Ph.D.

Research on the therapeutic value of yoga has been growing rapidly, including research studies that are becoming more rigorous in research design, and studies that are evaluating diseases never before evaluated. Had you asked just a decade ago whether yoga might have been useful for more serious psychiatric conditions such as autism, psychosis or schizophrenia, the answer would likely have been an outright negative or at least an expression of strong skepticism. However the efficacy of yoga as therapy seems to know no bounds, and there is now credible evidence emerging in favor of yoga for treating such disorders, especially for the psychotic disorder schizophrenia.

A psychotic disorder refers to an abnormal or deranged function of an individual’s mental state with delusional and paranoid tendencies as well as depression, social dysfunction, endocrine irregularities and lack of motivation. Schizophrenia and psychosis stand out among psychotic disorders listed in the DSM-V (the widely accepted clinical reference text for psychiatric diagnoses) for their highly debilitating symptoms and the ongoing struggle to effectively provide treatment. The prevalence of schizophrenia is roughly 5 people affected in 1,000 and more than 60% of the patients diagnosed with schizophrenia have recurring symptoms for life. A lack of understanding of schizophrenia makes the disorder a burden to diagnose, let alone treat. Risk factors include an individual’s genetic predisposition, exposure to chemicals, pharmaceuticals and recreational drugs and low socioeconomic status.

Because the underlying causal factors for schizophrenia are not yet fully known, the best course of action for clinicians is to aim at symptom control. Drug therapy treatments have made significant advances, especially with so-called “positive” symptoms such as delusions and hallucinations, while the “negative” symptoms (amotivation and depression) as well as cognitive symptoms tend to linger. Also, pharmacotherapy for schizophrenia has been known to cause other complications both clinical and psychological, leading to a desire for possible effective behavioral treatments that would eliminate both side effects and compliance issues with medications. Given that yoga therapy has been shown to improve emotion regulation, cognition, endocrine function and metabolism as well as menstrual dysfunction, it is not surprising that it has been considered for psychotic disorders. As it turns out, yoga appears to have potential benefit for schizophrenia. Over a dozen research trials evaluating yoga as a primary or adjunct treatment for this disorder have been published over the past six years, many of which were conducted by the research team of Dr. B.N. Gangadhar at the Advanced Center for Yoga, Mental Health and Neurosciences within the prestigious National Institute of Mental Health and Neurosciences in Bengaluru, India, which is India’s premier psychiatric treatment and research institution. In fact, the quantity of this research has led to publication of at least three review papers summarizing this evidence, although given the small number of trials, most of which are preliminary in nature, only modest conclusions of efficacy are possible at this point in time.

In a study by Gangadhar’s group published in 2012, schizophrenic patients were tested using a Positive and Negative Symptom Scale at the start of a four-month trial. During the four months one group practiced 45 minutes of yoga nearly every day while another group did not. The group that practiced yoga showed improvements, based on a negative symptom scale report, of 35 percent of the patients the while less than 10 percent of the patients who did not practice yoga showed improvement. Other studies that focused on yoga as an add-on therapy showed improvements in both negative and positive symptom scales and even quality of life scales. While the biological mechanisms of how yoga works are not entirely known, researchers have identified some possible explanations through experimental findings.

Schizophrenic patients tend to display social cognitive deficits. It is understood that one particular hormone, oxytocin, modulates social cognition by enhancing the processing of positive social emotional cues. Individuals with low levels of oxytocin demonstrate impaired social functioning, as seen in individuals diagnosed with autism. One study which focused on oxytocin levels and social cognition indicated that yoga improved oxytocin levels in schizophrenic patients who were also undergoing pharmacological therapy. One explanation of how yoga affects oxytocin levels is through stimulation of the vagus nerve, which in animals has been correlated with increased oxytocin levels. Although the impact of yoga treatment has been reported in “negative” symptom scales, there are also studies that report improving trends in positive symptom scales as well.

Supported by just a few studies, yoga may also be proving a useful treatment for patients suffering from psychosis as an add-on or adjunctive treatment in patients concurrently treated with antipsychotics. Clinically, yoga seems to be most beneficial in promoting quality of life and alleviating negative symptoms such as social dysfunction and depression. In one study, psychotic patients in a yoga practice group displayed comparable improvements in negative symptom measures to those that exercised, but the yoga group’s depression ratings improved more sharply than those in the exercise group. Future research studies might aim at employing longer term practices in comparing yoga with exercise in order to reveal more differences between these two forms of add-on therapy, as other studies have already done in non-psychosis research.

Yoga offers an approach to healthcare that many allopathic researchers and practitioners have yet to fully understand, exerting its therapeutic benefit at the connection and interface between the mind and body. Fortunately there are inspired pioneer clinicians and biomedical researchers dedicated to the advancement of yoga therapy as an accepted clinical treatment. However, like research on other behavioral and psychological interventions, research on yoga comes with significant scientific and technical challenges including reliance on “subjective” measures and the possible influence of multiple confounding variables in the intervention. For example, a strength of the study in which oxytocin was reported to be elevated from yoga practice is the use of an “objective” biochemical measure. However, another possible mechanism by which patients could have improved in this study is the social exposure that came with attending a yoga class. Addressing this issue requires refinements/improvements in the experimental design to control for this variable. Once the volume of clinical research evidence becomes convincing, and the underlying psychophysiological mechanisms are more clearly understood, yoga treatment may ultimately become a routine prescription for various conditions by healthcare providers, and, at least in some cases, not just as an adjunctive treatment.