literature review of yoga

Key characteristics of effective yoga interventions for managing osteoarthritis: a systematic review and meta-analysis

• Systematic Review
• Open access
• Published: 27 June 2024

Cite this article

You have full access to this open access article

• Isha Biswas   ORCID: orcid.org/0000-0003-4930-8084 1 ,
• Gamze Nalbant   ORCID: orcid.org/0000-0002-5414-9383 1 ,
• Sarah Lewis   ORCID: orcid.org/0000-0001-5308-6619 1 &
• Kaushik Chattopadhyay   ORCID: orcid.org/0000-0002-3235-8168 1 , 2  

1 Altmetric

This systematic review aimed to synthesise the content, structure, and delivery characteristics of effective yoga interventions for managing osteoarthritis symptoms, including joint pain and joint function. JBI guidelines were followed. 17 databases were searched for randomised controlled trials (RCTs) assessing yoga’s effectiveness on osteoarthritis symptoms. Meta-analyses and a narrative synthesis were conducted to address the objective. The systematic review and meta-analysis included 18 and 16 articles (representing 16 and 14 RCTs), respectively. Overall, the included studies had low methodological quality scores. 10 of 14 yoga interventions effectively reduced pain (standardised mean difference (SMD) − 0.70; 95% confidence interval (CI) − 1.08, − 0.32) and/or improved function (− 0.40; − 0.75, − 0.04). Notably, 8 effective interventions had centre-based (supervised, group) sessions, and 6 included additional home-based (unsupervised, individual) sessions. Effective interventions included 34 yogic poses (12 sitting, 10 standing, 8 supine, 4 prone), 8 breathing practices, and 3 meditation and relaxation practices. 8 interventions included yogic poses, and 7 also incorporated breathing practices and/or meditation and relaxation practices. 4 interventions included yogic pose modifications for osteoarthritis. The median duration of centre-based sessions was 8 weeks and each session was around 53 min, mostly delivered once a week. The median duration of home-based sessions was 10 weeks and each session was 30 min, usually instructed to practice 4 times a week. Given previous studies’ limitations, a high-quality long-term RCT should be conducted using synthesised findings of previous effective yoga interventions.

Avoid common mistakes on your manuscript.

Introduction

Osteoarthritis is the most common type of arthritis among adults, affecting more than 500 million people, globally [ 1 , 2 ]. It is a long-term degenerative condition of the joints, characterised by main symptoms including pain, stiffness, and difficulty in movement [ 1 ]. It commonly affects the joints of the knees, hips, hands, and spine [ 1 ]. Osteoarthritis poses tremendous health (physical and psychological), social, and economic implications for the affected individual and society, severely affecting the individual’s self-efficacy and quality of life [ 3 , 4 , 5 , 6 ]. There is no cure for osteoarthritis, however, it can be managed [ 7 ]. The main aim of osteoarthritis management is to minimise joint pain and loss of function [ 7 ] . The traditional approaches to managing the symptoms rely mainly on pharmacological options (e.g., Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)) along with non-pharmacological approaches (e.g., moderate-to-high intensity exercises) [ 8 ]. However, side effects of long-term usage of pharmacological options (e.g., gastrointestinal toxicity), limited adherence to non-pharmacological approaches (due to exercise-related injuries), and costs associated with both approaches (e.g., treatment-related costs, equipment costs for exercise) are some of the reasons which potentially limit their use among individuals with osteoarthritis [ 1 , 9 ].

Yoga, a non-pharmacological treatment approach, has been recommended for osteoarthritis by an international osteoarthritis clinical guideline in 2019 [ 10 ] and some studies have also proposed yoga as a beneficial practice for people with arthritis [ 11 , 12 ]. The ancient practice of yoga originated in the Indian subcontinent and imparts a sense of well-being of the body and mind [ 13 ]. Yoga philosophy and practice were first described by Patanjali in the classic text Yoga Sutras [ 14 ] . The multi-factorial approach of yoga includes components such as yogic poses (asana), breathing practices (pranayama), and meditation (dhyana) and relaxation practices, along with a moderated lifestyle [ 14 ]. Yoga practice generally begins with slow movement sequences to increase blood flow and warm up muscles, followed by holding certain yogic poses (e.g., extension, rotation) that engage the muscles in contraction [ 15 , 16 ]. Movement of joints increases flexibility whereas standing poses improve balance and coordination by strengthening major muscle groups (e.g., hamstring muscles and quads), potentially reducing pain and improving function [ 17 , 18 , 19 ]. The worldwide popularity of yoga is rising, with nearly 300 million people across the world involved in its practice [ 20 ]. Generally, yoga is easy to learn with low risk involved, demands a low-to-moderate level of supervision, is inexpensive to maintain because of the minimal equipment requirement, and can be practised indoors and outdoors [ 21 , 22 , 23 ].

Existing systematic reviews and meta-analyses have reported the beneficial effects of yoga interventions on osteoarthritis symptoms, such as reduced pain and improved function [ 24 , 25 , 26 , 27 , 28 , 29 , 30 ]. These reviews have included randomised controlled trials (RCTs) [ 24 , 25 , 26 , 27 , 28 , 29 , 30 ], and in one review, also other study designs [ 29 ]. A systematic review and meta-analysis of 20 RCTs and 2 case series on knee and hip osteoarthritis showed that yoga significantly reduced pain scores (mean difference (MD) − 1.82, 95% confidence interval (CI) − 2.96 to − 0.67) and improved physical function scores (− 6.07, − 9.75 to − 2.39) compared to no intervention or usual care [ 29 ]. No adverse events related to yoga were reported [ 24 , 25 , 26 , 27 , 28 , 29 , 30 ]. However, all the above-mentioned systematic reviews have only described or reported but not synthesised the content, structure, and delivery characteristics of yoga interventions to manage osteoarthritis [ 24 , 25 , 26 , 27 , 28 , 29 , 30 ]. Therefore, this systematic review and meta-analysis aimed to fill this gap in the existing literature by narratively synthesising the content, structure, and delivery characteristics of effective yoga interventions for managing osteoarthritis symptoms. The intention was to facilitate the identification of the key features of effective yoga interventions for osteoarthritis, which could be combined for use in subsequent trials to test the effects of this yoga intervention on osteoarthritis patients.

This systematic review followed the JBI methodology for systematic reviews of effectiveness and the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines [ 31 , 32 ]. This review was conducted according to a priori published protocol [ 33 ] and registered with PROSPERO (CRD42022298155).

Inclusion criteria

We included studies conducted among adults (aged ≥ 18 years) diagnosed with osteoarthritis of one or more joints. No restrictions were applied regarding the diagnostic criteria of osteoarthritis; diagnoses based on physical examination, radiographic and MRI findings, and/or arthroscopy were included .

Intervention

Studies reporting at least one of the major components of yoga, namely, asana (yogic poses), pranayama (breathing practices), and dhyana (meditation) and relaxation practices were included. There were no restrictions on the type, frequency, duration, and delivery mode of the yoga intervention. Studies were excluded if they did not explicitly label the intervention as yoga.

Studies comparing yoga interventions with no intervention, sham intervention, non-pharmaceutical intervention (e.g., diet, physical activity, and educational intervention), or pharmaceutical intervention (e.g., NSAIDs) were included . Studies with only a head-to-head comparison of two or more yoga interventions (i.e., different in terms of content, structure, or delivery characteristics) were excluded.

We included studies that assessed the core outcomes of osteoarthritis, i.e., pain and/or function, as recommended in several guidelines [ 34 , 35 , 36 , 37 , 38 ]. Pain assessed using any scale (e.g., Visual Analogue Scale (VAS) and Numeric Rating Scale (NRS)) and function assessed using any scale (e.g., Arthritis Impact Measurement Scale (AIMS), including any joint-specific scale such as Foot and Ankle Ability Measure (FAAM), Knee Injury and Osteoarthritis Outcome Score (KOOS), and Hip Disability and Osteoarthritis Outcomes Survey (HOOS)) was eligible [ 34 , 35 ].

Study design

Only RCTs were included in the review, taking into account the feasibility and practical aspects of the research as well as the hierarchy of study designs.

Data sources and search strategies

The following 13 databases were searched to find published studies from their inception dates to 22 September 2023: (1) MEDLINE (Ovid), (2) EMBASE (Ovid), (3) PsycInfo (Ovid), (4) CINAHL (EBSCOHost), (5) Cochrane Central Register of Controlled Trials (CENTRAL), (6) Allied and Complementary Medicine (AMED) (Ovid), (7) SPORTDiscus (EBSCOhost), (8) Web of Science (Clarivate Analytics), (9) Turning Research Into Practice (TRIP), (10) AYUSH Research Portal ( http://ayushportal.nic.in/ , accessed 22 September 2023), (11) A Bibliography of Indian Medicine (ABIM) ( http://indianmedicine.eldoc.ub.rug.nl/ , accessed 22 September 2023), (12) CAM-QUEST ( https://www.cam-quest.org/en , accessed 22 September 2023), and (13) Physiotherapy Evidence Database (PeDro). Unpublished studies were searched using (1) OpenGrey (from 1997), (2) EthOS (from 1925), (3) ProQuest Dissertations and Theses (from 1980), and (4) DART-Europe-e-theses portal (from 1999). No language restrictions were applied. The search strategies were developed based on the following and in consultation with a Research Librarian at the University of Nottingham (UK): (1) the yoga component was based on a previous relevant systematic review [ 39 ], (2) the osteoarthritis component was based on the search strategies reported in the UK’s National Institute for Health and Care Excellence (NICE) guidelines for osteoarthritis management [ 40 ] and existing Cochrane systematic reviews on osteoarthritis [ 41 , 42 ], and (3) the pre-designed search filters for RCTs were used [ 43 , 44 , 45 ]. All the search strategies are detailed in the supplementary file (Appendix 1 ). The reference list of all the included studies and relevant previous systematic reviews was screened for additional studies.

Study screening and selection

Following the searches, all the identified citations were collated and uploaded to Endnote X9 (Clarivate Analytics, PA, USA) [ 46 ], and duplicate citations were removed. The remaining records were uploaded into Rayyan (Qatar Computing Research Institute [Data Analytics], Doha, Qatar) [ 47 ] and titles and abstracts were screened for eligibility by two independent reviewers (IB and GN). Studies identified as potentially eligible or those without an abstract had their full texts retrieved. The full texts of the studies were assessed for eligibility by two independent reviewers. Full-text studies that did not meet the inclusion criteria were excluded and the reasons for exclusion were reported (Appendix 2 ). Any disagreements that arose between the two reviewers were resolved through discussion. If a consensus was not reached, a third reviewer was consulted (SL/KC).

Assessment of methodological quality

The included studies were critically assessed using the standardised critical appraisal tool developed by JBI for RCTs, by two independent reviewers (IB and GN), assigning a score as met (Y), not met (N), unclear (U) or not applicable (n/a) [ 31 ]. The two reviewers independently assessed each criterion and commented on it. Any disagreements that arose between the two reviewers were resolved through discussion. If a consensus was not reached, then a third reviewer was involved (SL/KC). Regardless of methodological quality, all studies underwent data extraction and synthesis.

Data extraction

Data were extracted from the included studies using a pre-developed and pre-tested data extraction form, by two independent reviewers (IB and GN). If consensus was not reached through discussion, a third reviewer (SL/KC) was consulted. For both the symptoms (pain and function), the authors extracted the end-of-intervention data [ 34 , 48 ]. Where this time point was not reported, data from the time point closest to the end of the intervention were extracted. Intention-to-treat (ITT) data were preferred compared to per-protocol data [ 49 , 50 ]. Post-intervention data were extracted in preference to change from baseline data (i.e., post-intervention score − baseline score). Percentage change from baseline was not extracted, as it is highly sensitive to change in variance, and it also fails to protect from baseline imbalances, leading to non-normally distributed outcome data [ 51 ].

In the included studies, pain and function were reported as continuous data and so mean and standard deviation (SD) were extracted. Where no SDs were available, they were calculated from standard error (SE) or 95% CI using the formula from the Cochrane Handbook [ 52 ]. Where mean and SD for more than one intervention or control group were reported, the combined sample size, mean, and SD were calculated using the formulae in the Cochrane Handbook [ 52 ]. The corresponding authors of studies were contacted by e-mail (two times per author) to obtain missing or unclear data.

Data synthesis

Considering the errors in how authors analyse and report yoga interventions to be effective in studies (e.g., conducting pre-post analysis of outcomes within study arms but no comparative analysis between study arms), meta-analyses were conducted for yoga vs. any comparator to determine the true effectiveness of each included yoga intervention for both the outcomes—pain and function. The meta-analyses were conducted using Review Manager 5.4.1 (Copenhagen, The Nordic Cochrane Centre, The Cochrane Collaboration) [ 53 ]. Random-effects meta-analyses were conducted due to the heterogeneous nature of the yoga interventions. Since the included studies used difference scales to report pain and function measures, standardised mean differences (SMDs) with 95% CIs were calculated using forest plots.

A narrative synthesis of the identified effective yoga interventions from the meta-analyses for pain and function was conducted with the aid of tables and text, focusing on the content, structure, and delivery characteristics of the yoga interventions. Commonalities and differences of the yoga interventions effective for either or both the outcomes were synthesised. The Sanskrit and English names of all the yogic components used in the effective interventions and the number of RCTs using these practices were tabulated.

Study selection

6693 records were identified through the literature search. After removing duplicate records and title and abstract screening, 44 articles were retrieved for full-text screening. 18 articles were included in this systematic review representing 16 studies (RCTs) and 1402 participants [ 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 ]. 3 articles described the same RCT, providing data on different outcomes and therefore, were included as a single study in this review [ 55 , 56 , 57 ]. The study selection process is detailed in the PRISMA flowchart as shown in Fig.  1 . No additional articles were identified from citation searching. The list of articles ineligible following the full-text review and ongoing RCTs identified from trial registries are presented in the supplementary file (Appendix 2 ).

PRISMA flow diagram for included studies from searches of databases and registers only

Description of the included studies

9 studies were conducted in the USA [ 54 , 58 , 59 , 60 , 61 , 62 , 66 , 67 , 70 ], 4 studies in India [ 55 , 56 , 57 , 63 , 64 , 68 ], 1 study in Canada [ 65 ], 1 study in Iran [ 69 ], and 1 study in Australia [ 71 ]. The sample size of the studies ranged from 18 to 250. Studies recruited participants aged between 18 and 90 years and where reported, the mean age varied from 57 to 79 years. 13 studies included male and female participants and the remaining 3 recruited only female participants [ 58 , 64 , 65 ]. Where exact numbers were reported, female and male participants were 1049 and 333, respectively. 5 studies included participants with osteoarthritis of one or more lower extremity joints, including knee, hip, ankle or feet [ 59 , 61 , 62 , 66 , 67 ] and 9 studies included specifically knee osteoarthritis [ 55 , 56 , 57 , 58 , 60 , 63 , 64 , 65 , 68 , 69 , 71 ], 1 on hand osteoarthritis [ 54 ], and the affected joint was unclear in another study [ 70 ]. Where reported, the duration of osteoarthritis amongst participants ranged from more than a month [ 69 ] to more than 2 years [ 55 , 56 , 57 ]. Of 16 studies, 7 reported the use of pain medications among the participants [ 58 , 61 , 65 , 66 , 67 , 70 , 71 ]. In 4 of 7 studies, it was unclear if the participants used pain medications before and/or during the trial [ 58 , 61 , 66 , 67 ]. Where reported, 25–63% of participants used pain medications [ 61 , 66 ]. 3 of 7 studies explicitly reported the use of pain medications among participants before the trial [ 65 , 70 , 71 ], and where specified, this ranged from 61 to 73% [ 65 , 71 ]. In addition, 3 of 16 studies reported the use of non-pharmacological pain management (using physical therapy) before the trial, amongst 40%, 61%, and 78% of the participants, respectively [ 61 , 70 , 71 ]. Tables 1 and 2 report the characteristics of the studies and the details of the yoga interventions, respectively.

Methodological quality of included studies

Table 3 reports the methodological quality of the included studies. Overall, the methodology was not adequately reported in the included studies, resulting in low methodological quality scores (total “yes” percentage ranging from 15 to 54%). In real practice, yoga providers delivering the yoga intervention cannot be blinded. So, the response to question 5 of the checklist was marked as N/A (not applicable) in our methodological assessment. Some of the major issues in these studies included: (1) inadequate reporting of the randomisation process used to assign participants to study arms and thus, it was unclear if true randomisation was used or not; (2) inadequate reporting of the allocation concealment process and thus, it was unclear if the allocation to study arms was concealed or not; (3) imbalance between the treatment groups at baseline; (4) inadequate reporting of blinding of participants and outcome assessors (could have been achieved through sham therapies); (5) inadequate reporting of whether the study arms were treated identically other than the intervention of interest; (6) insufficient analysis of the differences between study groups about loss to follow up and reasons for loss to follow up in case of incomplete follow up for the entire trial duration; (7) inadequate reporting of ITT analysis and its details (i.e., whether participants were analysed in the groups to which they were initially randomised); (8) inadequate reporting of the measurement process of outcomes (including adverse events) and thus, it was unclear if the outcomes were measured in the same way for study arms or not; (9) no or inadequate description of the number of raters who assessed outcomes or their training, hence making it unclear if outcomes were assessed in a reliable manner; and (10) issues in the statistical power analysis, unclear minimum clinically important difference for the sample size calculation, no information on assumptions of statistical tests used, and errors in statistical analysis and reporting (e.g., pre-post analysis and not between groups).

Meta-analysis to determine effective studies

Of 16 studies included in this review, 2 could not be included in the meta-analysis because of insufficient data to calculate the mean and SDs for the yoga and control groups [ 61 , 70 ]. Therefore, a total of 14 studies (16 articles) were included in the meta-analysis to identify the individual effective interventions for each symptom—pain (13 studies) and function (13 studies). These studies compared yoga interventions with pharmacological and non-pharmacological interventions [ 54 , 55 , 56 , 57 , 58 , 59 , 60 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 71 ].

Yoga vs comparator for pain

Overall, yoga interventions reduced pain compared to pharmacological and non-pharmacological interventions (SMD − 0.70; 95% CI − 1.08 to − 0.32) (Fig.  2 ).

Forest plot for yoga vs comparator (pain). N, sample size; SD, standard deviation; CI, confidence interval

Yoga vs comparator for function

Overall, yoga interventions were effective in improving function compared to pharmacological and non-pharmacological interventions (SMD − 0.40; − 0.75 to − 0.04) (Fig.  3 ).

Forest plot for yoga vs comparator (function). N, sample size; SD, standard deviation; CI, confidence interval

Yoga interventions in 9 (out of 13) studies were effective in reducing pain (6 in knees [ 55 , 56 , 57 , 58 , 60 , 64 , 68 , 71 ], 2 in lower extremities [ 59 , 62 ], and one in hand [ 54 ]. Yoga interventions in 6 (out of 13) studies were effective in improving function (5 in knees [ 55 , 56 , 57 , 60 , 63 , 68 , 71 ]) and one in the lower extremity [ 62 ]. Overall, 10 (out of 14) interventions were effective in reducing pain and/or improving function [ 54 , 55 , 56 , 57 , 58 , 60 , 62 , 63 , 64 , 68 , 71 ].

Content, structure, and delivery characteristics of effective yoga interventions for pain and/or function

Notably, 6 of 10 effective interventions had centre-based (supervised, group) sessions with additional home-based (unsupervised, individual) sessions [ 55 , 56 , 57 , 58 , 59 , 60 , 62 , 64 ], 2 interventions were completely centre-based [ 54 , 63 ] and one home-based [ 71 ]. Of the 2 completely centre-based interventions, one was supervised [ 54 ] and supervision detail was unclear in the other [ 63 ]. One study did not provide any details on intervention delivery [ 68 ] .

The content of effective yoga interventions was heterogeneous and included 34 different yogic poses (asana; 12 sitting, 10 standing, 8 supine, and 4 prone), 8 breathing practices (pranayama), and 3 meditation (dhyana) and relaxation practices. 8 of 10 effective interventions reported the major components of yoga used; all included asana, and 7 also incorporated pranayama and/or dhyana and relaxation practices. Three of the 10 interventions included all of these 3 major components of yoga [ 55 , 56 , 57 , 59 , 63 ], 3 consisted of asana and dhyana and relaxation practices [ 58 , 60 , 71 ], one included asana and pranayama [ 54 ], and one included only asana [ 68 ]. The majority of these studies were not specific about the exact yoga style, except for 3 which mentioned Hatha yoga [ 58 , 60 , 62 ].

Interventions that included all the 3 major components of yoga reported the time allocated to each component] [ 55 , 56 , 57 , 59 , 63 ]. The median time allocated to asana was around 19 min (IQR 10–25 min), pranayama was around 10 min (IQR 3–32 min), and dhyana and relaxation practice was around 12 min (IQR 10–82 min). Some of the common practices were Tadasana (palm tree pose) [ 55 , 56 , 57 , 59 , 60 , 68 ], Virabhadrasana 1&2 (warrior pose) [ 59 , 60 , 68 ], Nadishuddhi pranayama (alternate nostril breathing) [ 55 , 56 , 57 , 63 ], and Nadanusandhana (A-U-M Kara chanting) [ 55 , 56 , 57 , 63 ]. Table 4 details the various yoga practices (along with their Sanskrit and English names) effective for pain and/or function [ 72 , 73 ].

The median duration of centre-based sessions was 8 weeks (interquartile range (IQR) 8–12 weeks) and each session was around 53 min (IQR 45–60 min), and these sessions were mostly delivered once a week (reported in 4 of 8 interventions) [ 54 , 55 , 56 , 57 , 58 , 60 ]. Where reported (in 4 of 7 interventions) [ 55 , 56 , 57 , 58 , 60 , 71 ], the median duration of home-based sessions was 10 weeks (IQR 8–12 weeks) and each session was around 30 min (IQR 29–30 min), and these sessions were instructed to practice for 4 times a week [ 58 , 60 ]. One intervention which provided no details on whether it was centre- or home-based, reported session duration and frequency i.e., 30 min thrice a week for 4 weeks [ 68 ].

3 of 8 centre-based sessions specifically reported that lectures and counselling on yoga for osteoarthritis, educational materials with written instructions, peer support through group discussion and question-and-answer sessions were used to deliver the intervention [ 54 , 55 , 56 , 57 , 63 ]. To address participants’ needs (e.g., physical limitations), certain yogic poses were adapted in 4 of 10 interventions e.g., by using blocks, straps, blankets, and chairs [ 58 , 59 , 60 , 62 ]. Where reported (6 of 7 interventions), home-based sessions were delivered by providing written documents with pictures [ 58 , 59 , 60 , 62 , 64 ] and yoga videos (including demonstrations of modified yoga postures to meet individual needs) [ 71 ] to the participants.

Strategies were used to monitor and improve adherence to yoga practice at home in 6 of 7 interventions e.g., sharing self-recorded yoga diaries/log sheets, self-recorded yoga videos (documenting home practice details) with the trial team, and reminding and motivating participants e.g., through telephone calls and emails [ 55 , 56 , 57 , 58 , 59 , 60 , 62 , 71 ]. Participants were encouraged to practice yoga in the long term in 2 of 10 interventions [ 62 , 71 ] .

Our review found beneficial effects of yoga on two major symptoms of osteoarthritis i.e., pain and function, as also reported in previous reviews and meta-analyses [ 28 , 29 ]. However, this review is novel as it aims to identify and synthesise the key features (content, structure, and delivery characteristics) of effective yoga interventions. Although the components of effective yoga interventions were heterogeneous, some commonalities were identified. A majority of them involved participants attending yoga at a centre for supervised group sessions, once a week for a sustained period. Most also involved individual yoga practice at home, which was unsupervised, several times a week between centre-based sessions. These interventions generally incorporated yoga postures (asana), but a majority also included other major components including breathing practices (pranayama) and/or meditation (dhyana) and relaxation practices. Keeping in mind the participants’ needs (e.g., knee/hip pain), various modifications were provided to certain yogic poses using props (e.g., a chair as a support for standing poses). The review also indicated ways in which these interventions ensured maximum adherence to yoga among participants, especially to yoga practice at home, through regular contact with the participant or journaling of home practice.

Yoga has been recommended by an international osteoarthritis evidence-based clinical guideline developed by the American College of Rheumatology (ACR) and the Arthritis Foundation (AF) [ 10 ]. This guideline used the GRADE methodology to rate the quality of the available evidence and to develop the recommendations [ 10 ]. The guideline was developed by an expert panel representing the ACR, including rheumatologists, an internist, physical and occupational therapists, and osteoarthritis patients. The guideline “conditionally” recommends the use of yoga for managing symptoms of knee osteoarthritis. The conditional recommendation inferred that yoga could be used by the patients to manage knee osteoarthritis only after shared decision-making, including a detailed explanation of the benefits and harms of yoga to the patients, in a language and context they understand. However, due to a lack of evidence, no recommendations could be made for managing hand and hip osteoarthritis through yoga [ 10 ]. It is important to note that this guideline was based on a generic definition of yoga laid out by the National Center for Complementary and Integrative Health [NCCIH] as “a mind–body practice consisting of physical postures, breathing techniques, and meditation or relaxation”. Yoga includes a diverse range of components, so it is important to consider the aspects of yoga that are effective.

To the best of our knowledge, this is the first systematic review conducted by following a robust methodology to synthesise the content, structure, and delivery characteristics of effective yoga interventions for managing major osteoarthritis symptoms. Determination of the effectiveness of interventions was standardised across studies by using meta-analysis before finally the detailed characteristics of potentially effective yoga interventions were synthesised. Although we used a comprehensive search, only 16 studies met our inclusion criteria, 2 of which could not be included in the meta-analysis.

Our review highlighted some limitations in the included studies. Some studies had incomplete or unclear information on the time allocated to each component of the yoga intervention. Future RCTs should improve the reporting of this detail which would help in establishing the aspects of yoga practice that are most beneficial for improving osteoarthritis symptoms and therefore where the emphasis for future yoga-based interventions should lie. Most studies did not describe the qualifications of the yoga providers, instead only described the yoga providers as certified, experienced, or trained. Where yoga provider qualifications were reported in detail, there was no description of the yoga providers' training to deliver the specific intervention protocol. The expertise of yoga providers and their training in the intervention protocol are likely to be essential to the effectiveness of the intervention and in ensuring the fidelity and safety of the intervention [ 74 , 75 ]. Thus, future RCTs should ensure adequate reporting of the training details of the yoga providers. In terms of safety, a majority of the studies did not explicitly report adverse events related to yoga. This issue should be addressed and reporting should be improved in future RCTs, to indicate their safety. Most included studies were based in the US, predominantly included females, and reported on knee osteoarthritis. These factors potentially limit the generalisability of our findings. Existing evidence has shown a higher uptake of yoga among women as compared to men [ 11 ]. Although osteoarthritis is more common in women, it also affects men. So, it is important to explore the possible barriers to yoga practice among men (e.g., gender-based perceptions and their preference for other forms of physical activity) and take some initiatives (e.g., men-only yoga classes) to promote yoga among men for osteoarthritis, in future RCTs [ 76 ]. Lastly, most included studies involved relatively short-term follow-up, and only 2 of our included studies reported on encouraging participants to continue yoga practice. For a chronic condition like osteoarthritis, it will be important to explore whether yoga practice and its effects are sustained in the longer term.

Despite the low quality and heterogeneity of included studies, our findings suggest yoga interventions might be effective in managing osteoarthritis symptoms and highlight the key characteristics of effective yoga interventions for osteoarthritis. Supervised yoga practice in groups at a centre seemed to be one of the most consistent characteristics in the studies included in this review. This might reflect the importance of creating a community for yoga practice, given that most people with osteoarthritis are older, and may be socially isolated [ 77 ]. Older participants generally tend to be interested and adherent to yoga classes (at a centre) [ 78 ], which may also be why centre-based yoga sessions are an important feature of yoga practice. Adherence of participants to the yoga interventions is likely to play an important role in its effectiveness on osteoarthritis symptoms [ 79 ]. Most studies included in this review mentioned strategies such as self-reporting of home practice and ensuring regular contact with the participants to encourage them to adhere to yoga practice at home, though the level of adherence was generally not reported. To improve adherence to mind–body interventions such as yoga, some strategies including providing reminders, following up with the individual to ensure regular yoga practice, and catering to individual needs (e.g., modifying yogic poses), have been identified [ 80 ]. Further, it will be important to explore how yoga interventions might be implemented and integrated within the orthopaedic healthcare system [ 81 ]. Hence, future research should aim to develop a yoga program for managing osteoarthritis by using the synthesised findings from this review. This is likely to require the input of a variety of stakeholders, including osteoarthritis patients, yoga providers, and orthopaedic doctors to address the potential challenges and to consider the evidence base for its effective and safe incorporation, by using Delphi or similar methods.

Considering the methodological limitations of previous studies, including low quality of studies and heterogeneity between studies, a high-quality long-term RCT should be conducted to determine the effectiveness of yoga in managing osteoarthritis symptoms by using the synthesised key characteristics of previous effective yoga interventions, as identified by this review.

National Health Service (2023) Osteoarthritis. https://www.nhs.uk/conditions/osteoarthritis/ . Accessed 20 July 2023

GBD (2019) Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. https://vizhub.healthdata.org/gbd-results/ Accessed 20 July 2023

Sharma A, Kudesia P, Shi Q, Gandhi R (2016) Anxiety and depression in patients with osteoarthritis: impact and management challenges. Open Access Rheumatol Res Rev 8:103–113. https://doi.org/10.2147/OARRR.S93516

Article   Google Scholar  

Hunter DJ, Schofield D, Callander E (2014) The individual and socioeconomic impact of osteoarthritis. Nat Rev Rheumatol 10:437–441. https://doi.org/10.1038/nrrheum.2014.44

Article   PubMed   Google Scholar  

Leifer VP, Katz JN, Losina E (2022) The burden of OA-health services and economics. Osteoarthr Cartil 30:10–16. https://doi.org/10.1016/j.joca.2021.05.007

Article   CAS   Google Scholar  

Hunter DJ, March L, Chew M (2020) Osteoarthritis in 2020 and beyond: a Lancet commission. Lancet 36:10264. https://doi.org/10.1016/s0140-6736(20)32230-3

National Institute for Health and Care Excellence (NICE) (2020) Osteoarthritis: care and management. https://www.ncbi.nlm.nih.gov/books/NBK568417/ Accessed 25 November 2023

Buelt A, Narducci DM (2021) Osteoarthritis management: updated guidelines from the American College of Rheumatology and Arthritis Foundation. Am Fam Physician 103(2):120–121

PubMed   Google Scholar  

Marks R (2012) Knee osteoarthritis and exercise adherence: a review. Curr aging Sci 5(1):72–83

Kolasinski SL, Neogi T, Hochberg MC et al (2020) 2019 American College of Rheumatology/Arthritis Foundation Guideline for the management of osteoarthritis of the hand, hip, and knee. ArthritisRheumatol 72(2):220–233. https://doi.org/10.1002/art.41142

Cartwright T, Mason H, Porter A, Pilkington K (2020) Yoga practice in the UK: a cross-sectional survey of motivation, health benefits and behaviours. BMJ Open 10(1):e031848. https://doi.org/10.1136/bmjopen-2019-031848

Article   PubMed   PubMed Central   Google Scholar  

Cramer H, Ward L, Steel A, Lauche R, Dobos G, Zhang Y (2016) Prevalence, patterns, and predictors of yoga use: results of a U.S. nationally representative survey. Am J Prev Med 50:230–235. https://doi.org/10.1016/j.amepre.2015.07.037

Desikachar K, Bragdon L, Bossart C (2005) The yoga of healing: exploring yoga’s holistic model for health and well-being. Int J Yoga Therap 15:17–39. https://doi.org/10.17761/IJYT.15.1.P501L33535230737

Lasater J (1997) The heart of Patanjali. Yoga J 137:134–144

Google Scholar  

McCall T (2007) Yoga as medicine: the yogic prescription for health and healing.  New York, NY

Fishman L, Saltonstall E (2008)  Yoga for arthritis . New York, NY

Telles S, Singh N (2013) Science of the mind: ancient yoga texts and modern studies. Psychiatr Clin N Am 36(1):93–108. https://doi.org/10.1016/j.psc.2013.01.010

Goncalves LC, Vale RG, Barata NJ, Varejao RV, Dantas EHM (2011) Flexibility, functional autonomy and quality of life (QoL) in elderly yoga practitioners. Arch Gerontol Geriatr 53(2):158–162. https://doi.org/10.1016/j.archger.2010.10.028

Rathore M, Trivedi S, Abraham J, Sinha MB (2017) Anatomical correlation of core muscle activation in different yogic postures. Int J Yoga 10(2):59–66. https://doi.org/10.4103/0973-6131.205515

Zuckerman A (2020) Significant yoga statistics: 2020/2021 benefits, facts and trends. https://comparecamp.com/yoga-statistics/#TOC2 Accessed 20 November 2023

Anderson JG, Taylor AG (2011) The metabolic syndrome and mind-body therapies: a systematic review. J Nutr Metab. https://doi.org/10.1155/2011/276419

National Health Service (NHS) (2018) Exercise. https://www.nhs.uk/live-well/exercise/ Accessed 30 November 2023

Kocyigit BF, Sagtaganov Z, Yessirkepov M (2023) The effectiveness of yoga as a form of exercise in the management of rheumatic diseases. Rheumatol Int 43(5):795–801. https://doi.org/10.1007/s00296-023-05291-9

Sharma M (2014) Yoga as an alternative and complementary approach for arthritis: a systematic review. J Evid Based Complement Altern Med 19(1):51–58. https://doi.org/10.1177/2156587213499918

Ward L, Stebbings S, Cherkin D, Baxter GD (2014) Components and reporting of yoga interventions for musculoskeletal conditions: a systematic review of randomised controlled trials. Complement Ther Med 22(5):909–919. https://doi.org/10.1016/j.ctim.2014.08.007

Kan L, Zhang J, Yang Y, Wang P (2016) The effects of yoga on pain, mobility, and quality of life in patients with knee osteoarthritis: a systematic review. Evid Based Complement Altern Med. https://doi.org/10.1155/2016/6016532

Wang Y, Lu S, Wang R et al (2018) Integrative effect of yoga practice in patients with knee arthritis: a PRISMA-compliant meta-analysis. Medicine 97(31):e11742. https://doi.org/10.1097/md.0000000000011742

Lauche R, Hunter DJ, Adams J, Cramer H (2019) Yoga for osteoarthritis: a systematic review and meta-analysis. Curr Rheumatol Rep. https://doi.org/10.1007/s11926-019-0846-5

Zampogna B, Papalia R, Papalia GF et al (2020) The role of physical activity as a conservative treatment for hip and knee osteoarthritis in older people: a systematic review and meta-analysis. J Clin Med. https://doi.org/10.3390/jcm9041167

Denham-Jones L, Gaskell L, Spence N, Pigott T (2022) A systematic review of the effectiveness of yoga on pain, physical function, and quality of life in older adults with chronic musculoskeletal conditions. Musculoskeletal Care 20(1):47–73. https://doi.org/10.1002/msc.1576

Tufanaru C, Munn Z, Aromataris E, et al (2017) Chapter 3: Systematic reviews of effectiveness. The Joanna Briggs Institute: Adelaide, Australia. http://reviewersmanual.joannabriggs.org Accessed 20 November 2023

Page MJ, McKenzie JE, Bossuyt PM et al (2021) The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. PLoS Med 18(3):e1003583. https://doi.org/10.1371/journal.pmed.1003583

Biswas I, Lewis S, Chattopadhyay K (2022) Content, structure and delivery characteristics of yoga interventions for the management of osteoarthritis: a systematic review protocol. Int J Environ Res Public Health. https://doi.org/10.3390/ijerph19105806

Fernandes L, Hagen KB, Bijlsma JWJ et al (2013) EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis. Ann Rheum Dis 72(7):1125–1135. https://doi.org/10.1136/annrheumdis-2012-202745

National Institute for Health and Care Excellence (NICE) (2015) Osteoarthritis in over 16s. https://www.nice.org.uk/guidance/qs87 Accessed 26 November 2023

Rolfson O, Wissig S, van Maasakkers L et al (2016) Defining an international standard set of outcome measures for patients with hip or knee osteoarthritis: consensus of the international consortium for health outcomes measurement hip and knee osteoarthritis working group. Arthritis Care Res 68(11):1631–1639. https://doi.org/10.1002/acr.22868

American Academy of Orthopaedic Surgeons (2017) Osteoarthritis: Function and Pain Assessment Measure Methodology Report. https://osteoarthritis-function-and-pain-assessment-final-report-approved-by-b.pdf (aaos.org) Accessed 26 November 2023.

European Medicines Agency (2010) Guideline on clinical investigation of medicinal products used in the treatment of osteoarthritis. https://www.ema.europa.eu/en/clinical-investigation-medicinal-products-used-treatment-osteoarthritis-scientific-guideline Accessed 28 November 2023.

Nalbant G, Hassanein ZM, Lewis S, Chattopadhyay K (2022) Content, structure and delivery characteristics of yoga interventions for managing hypertension: a systematic review and meta-analysis of randomised controlled trials. Front Public Health. https://doi.org/10.3389/fpubh.2022.846231

National Institute for Health and Care Excellence (2022) Osteoarthritis: assessment and management NICE guideline: search strategies. https://www.nice.org.uk/guidance/ng226/documents/search-strategies Accessed 28 November 2023.

Cameron M, Chrubasik S (2014) Oral herbal therapies for treating osteoarthritis. Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.cd002947.pub2

Fransen M, McConnell S, Hernandez-Molina G, Reichenbach S (2014) Exercise for osteoarthritis of the hip. Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.cd007912.pub2

Higgins JPT, Thomas J, Chandler J, et al (2021) Cochrane handbook for systematic reviews of interventions Version 6.2. https://training.cochrane.org/handbook/current Accessed 03 December 2023.

Cochrane training (2023) RCT Filter used by Cochrane ENT. https://training.cochrane.org/handbook/current/chapter-04#section-4-4-7 Accessed 03 December 2023.

ISSG Search Filter Resource. https://sites.google.com/a/york.ac.uk/issg-search-filters-resource/home/rcts?authuser=0 Accessed 03 December 2023.

Endnote X9 Clarivate Analytics (2019) Endnote. http://endnote.com/ Accessed 05 December 2023.

Mourad O, Hossam H, Zbys F, Ahmed E (2016) Rayyan—a web and mobile app for systematic reviews. Syst Rev 5(1):210. https://doi.org/10.1186/s13643-016-0384-4

James KA, Heideken JV, Iversen MD (2021) Reporting of adverse events in randomized controlled trials of therapeutic exercise for hip osteoarthritis: a systematic review. Phys Ther. https://doi.org/10.1093/ptj/pzab195

Moher D, Hopewell S, Schulz KF et al (2010) CONSORT 2010 explanation and elaboration: updated guidelines for reporting parallel group randomised trials. Int J Surg 10(1):28–55. https://doi.org/10.1016/j.ijsu.2011.10.001

Beckett RD, Loeser KC, Bowman KR, Towne TG (2016) Intention-to-treat and transparency of related practices in randomized, controlled trials of anti-infectives. BMC Med Res Methodol. https://doi.org/10.1186/s12874-016-0215-2

Vickers AJ (2001) The use of percentage change from baseline as an outcome in a controlled trial is statistically inefficient: a simulation study. BMC Med Res Methodol. https://doi.org/10.1186/1471-2288-1-6

Higgins JPT, Li T, Deeks JJ (2019) Chapter 6: Choosing effect measures and computing estimates of effect. In Cochrane Handbook for Systematic Reviews of Interventions; Version 6.0; Higgins JPT, Thomas J, Chandler J, Cumpston M, Li, T, Page MJ. Eds.; Welch: Cochrane, VA, Canada.

Review Manager (RevMan) (2020) The Cochrane Collaboration.

Garfinkel MS, Schumacher HR Jr, Husain A, Levy M, Reshetar RA (1994) Evaluation of a yoga-based regimen for treatment of osteoarthritis of the hands. J Rheumatol 21(12):2341–2343

CAS   PubMed   Google Scholar  

Ebnezar J, Nagarathna R, Bali Y, Nagendra HR (2011) Effect of an integrated approach of yoga therapy on quality of life in osteoarthritis of the knee joint: a randomized control study. Int J Yoga 4(2):55–63. https://doi.org/10.4103/0973-6131.85486

Ebnezar J, Nagarathna R, Yogitha B, Nagendra HR (2012) Effect of integrated yoga therapy on pain, morning stiffness and anxiety in osteoarthritis of the knee joint: a randomized control study. Int J Yoga 5(1):28–36. https://doi.org/10.4103/0973-6131.91708

Ebnezar J, Nagarathna R, Bali Y, Nagendra HR (2012) Effects of an integrated approach of Hatha yoga therapy on functional disability, pain, and flexibility in osteoarthritis of the knee joint: a randomized controlled study. J Altern Complement Med 18(5):463–472. https://doi.org/10.1089/acm.2010.0320

Cheung C, Wyman JF, Resnick B, Savick K (2014) Yoga for managing knee osteoarthritis in older women: a pilot randomized controlled trial. BMC Complement Altern Med. https://doi.org/10.1186/1472-6882-14-160

Park J, Newman D, McCaffrey R, Garrido JJ, Riccio ML, Liehr P (2016) The effect of chair yoga on biopsychosocial changes in English- and Spanish-speaking community-dwelling older adults with lower-extremity osteoarthritis. J Gerontol Soc Work 59(7–8):604–626. https://doi.org/10.1080/01634372.2016.1239234

Cheung C, Wyman JF, Bronas U, McCarthy T, Rudser K, Mathiason MA (2017) Managing knee osteoarthritis with yoga or aerobic/strengthening exercise programs in older adults: a pilot randomized controlled trial. Rheumatol Int 37(3):389–398. https://doi.org/10.1007/s00296-016-3620-2

McCaffrey R, Park J, Newman D (2017) Chair Yoga: feasibility and sustainability study with older community-dwelling adults with osteoarthritis. Holist Nurs Pract 31(3):148–157. https://doi.org/10.1097/hnp.0000000000000184

Park J, McCaffrey R, Newman D, Liehr P, Ouslander JG (2017) A pilot randomized controlled trial of the effects of chair yoga on pain and physical function among community-dwelling older adults with lower extremity osteoarthritis. J Am Geriatr Soc 65(3):592–597. https://doi.org/10.1111/jgs.14717

Deepeshwar S, Tanwar M, Kavuri V, Budhi RB (2018) Effect of yoga-based lifestyle intervention on patients with knee osteoarthritis: a randomized controlled trial. Front Psychiatry. https://doi.org/10.3389/fpsyt.2018.00180

Kaur R (2018) Determinants of impact of two intervention packages on quality of life of 30–60-year-old women suffering from knee osteoarthritis in Gurdaspur Punjab a community-based trial. Dissertation, Panjab University

Kuntz A, Chopp Hurley JN, Brenneman EC et al (2018) Efficacy of a biomechanically based yoga exercise program in knee osteoarthritis: a randomized controlled trial. PLoS ONE. https://doi.org/10.1371/journal.pone.0195653

Zacharia S, Taylor EL, Branscum PW, Cheney M, Hofford CW, Crowson M (2018) Effects of a yoga intervention on adults with lower limb osteoarthritis: a randomized controlled trial. Am J Health Studies. https://doi.org/10.47779/ajhs.2018.60

McCaffrey R, Taylor D, Marker C, Park J (2019) A pilot study of the effects of chair yoga and chair-based exercise on biopsychosocial outcomes in older adults with lower extremity osteoarthritis. Holist Nurs Pract 33(6):321–326. https://doi.org/10.1097/hnp.0000000000000355

Vaghela N, Mishra D, Patel J, Dani V (2020) Promoting health and quality of life of patients with osteoarthritis of knee joint through non-pharmacological treatment strategies: a randomized controlled trial. J Educ Health Promot. https://doi.org/10.4103/jehp.jehp_39_20

Bokaeian HR, Esfandiarpour F, Zahednejad S, Mohammadi HK, Farahmand F (2021) Effects of an exercise therapy targeting knee kinetics on pain, function, and gait kinetics in patients with knee osteoarthritis: a randomized clinical trial. Adapt Phys Activ Q 38(3):377–395. https://doi.org/10.1123/apaq.2020-0144

Park J, Herron C (2021) Effects of a movement-based mind-body intervention in managing osteoarthritis symptoms in older adults. Innov Aging. https://doi.org/10.1093/geroni/igab046.1767

Article   PubMed Central   Google Scholar  

Bennell KL, Schwartz S, Teo PL et al (2022) Effectiveness of an unsupervised online yoga program on pain and function in people with knee osteoarthritis: a randomized clinical trial. Ann Intern Med 175(10):1345–1355. https://doi.org/10.7326/m22-1761

Chattopadhyay K, Mishra P, Manjunath NK et al (2020) Development of a yoga program for Type-2 Diabetes Prevention (YOGA-DP) among high-risk people in India. Front Public Health. https://doi.org/10.3389/fpubh.2020.548674

Yoga Journal (2023) A-Z directory of yoga poses. https://www.yogajournal.com/pose-finder/pose-finder/ Accessed 05 May 2023.

Hoffmann TC, Glasziou PP, Boutron I et al (2014) Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ. https://doi.org/10.1136/bmj.g1687

Ward L, Nault D, Cramer H, Moonaz S (2022) Development of the CLARIFY (CheckList stAndardising the Reporting of Interventions For Yoga) guidelines: a Delphi study. BMJ Open. https://doi.org/10.1136/bmjopen-2021-054585

Cagas JY, Biddle SJH, Vergeer I (2021) Yoga not a (physical) culture for men? Understanding the barriers for yoga participation among men. Complement Ther Clin Pract. https://doi.org/10.1016/j.ctcp.2020.101262

Siviero P, Veronese N, Smith T et al (2020) Association between osteoarthritis and social isolation: data from the EPOSA Study. J Am Geriatr Soc 68(1):87–95. https://doi.org/10.1111/jgs.16159

Flegal KE, Kishiyama S, Zajdel D, Haas M, Oken BS (2007) Adherence to yoga and exercise interventions in a 6-month clinical trial. BMC Complement Altern Med. https://doi.org/10.1186/1472-6882-7-37

Cheung C, Wyman JF, Savik K (2016) Adherence to a yoga program in older women with knee osteoarthritis. J Aging Phys Act 24(2):181–188. https://doi.org/10.1123/japa.2015-0048

Salmon PG, Santorelli SF, Kabat-Zinn J (1998) Intervention elements promoting adherence to mindfulness-based stress reduction programs in the clinical behavioral medicine setting. In: Shumaker SA, Schron EB, Ockene JK, McBee WL (ed) The Handbook of Health Behavior Change. New York: Springer Publishing Co, New York, pp 239–266

Mason H, Schnackenberg N, Monro R (2017) Yoga and healthcare in the United Kingdom. Int J Yoga Therap 27(1): 121–126. https://doi.org/10.17761/1531-2054-27.1.121

Download references

Acknowledgements

We would like to thank Sarah Beach, Research Librarian at the University of Nottingham, for her support in developing the search strategies.

This study was internally funded by the University of Nottingham, UK, including open access funding. The funding source had no involvement in designing the study or in writing the manuscript for publication.

Author information

Authors and affiliations.

Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, NG5 1PB, UK

Isha Biswas, Gamze Nalbant, Sarah Lewis & Kaushik Chattopadhyay

The Nottingham Centre for Evidence-Based Healthcare: A JBI Centre of Excellence, Nottingham, NG5 1PB, UK

Kaushik Chattopadhyay

You can also search for this author in PubMed   Google Scholar

Contributions

IB conceptualised and designed the systematic review with the help of SL and KC. IB and GN conducted the systematic review. IB wrote the first draft of the manuscript. All the authors contributed significantly to the revision of the manuscript. All authors read and approved the final manuscript. All authors take full responsibility for the integrity and accuracy of all aspects of the work.

Corresponding author

Correspondence to Isha Biswas .

Ethics declarations

Conflicts of interest.

All authors declare that the data supporting the findings of this review are available within the article and its supplementary information files.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 48 KB)

Rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ .

Reprints and permissions

About this article

Biswas, I., Nalbant, G., Lewis, S. et al. Key characteristics of effective yoga interventions for managing osteoarthritis: a systematic review and meta-analysis. Rheumatol Int (2024). https://doi.org/10.1007/s00296-024-05652-y

Download citation

Received : 25 March 2024

Accepted : 18 June 2024

Published : 27 June 2024

DOI : https://doi.org/10.1007/s00296-024-05652-y

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Meta-analysis
• Osteoarthritis
• Systematic review
• Find a journal
• Publish with us
• Track your research

• Posts (RSS)
• Comments (RSS)
• Mission Statement
• Board and Contact
• Weight, Glucose, Hypertension, Cholesterol
• Yoga as a self-care strategy
• Mindfulness-based stress reduction and health benefits.
• Meditation as psychotherapy
• Yoga for anxiety
• Yoga for depression
• Hatha Yoga for Depression
• Does Mindfulness Meditation Improve Anxiety and Mood Symptoms?
• An introduction to kundalini yoga meditation techniques that are specific for the treatment of psychiatric disorders.
• Yoga in cardiac health
• Psychophysiologic effects of hatha yoga on musculoskeletal and cardiopulmonary function
• The influence of yoga-based programs on risk profiles in adults with type 2 diabetes mellitus
• Risk indices associated with the insulin resistance syndrome, cardiovascular disease, and possible protection with yoga
• Meditation practices for health
• Yoga for menopausal symptoms
• Hatha yoga therapy management of urologic disorders
• An evidence-based review of yoga as a complementary intervention for patients with cancer
• Hemodynamic observations on a yogic breathing technique claimed to help eliminate and prevent heart attacks
• Therapeutic effects of yoga for children
• Clinical trials of meditation practices in health care
• Yoga in stroke rehabilitation
• Yoga as a therapeutic intervention
• Using yoga to treat disease
• Benchmarks used in researching yoga’s effect

Literature Review of Research on Yoga Benefits

• Yoga for Arthritis
• Yoga as Adjunctive Therapy for Migraines
• Hatha Yoga to treat Stress, Anxiety and Attentional Suppression
• Pranayama and Yoga Nidra for Cancer Treatment and Treatment-Related Anxiety and Depression
• The Benefits of Yoga and Meditation for Cellular Health and Aging
• Kundalini Yoga – cognitive benefits for older women at risk of Alzheimer’s disease
• Easing Fatigue and Anxiety Related to Multiple Sclerosis
• Iyengar Yoga and Rheumatoid Arthritis
• Effects of Yoga in People with Type 2 Diabetes
• Yoga for Trauma Survivors
• Short In-Class Survey to Measure Success!
• Teacher and Student Mid-Term and End-Term Surveys
• Want a Yoga Program at Your Organization?
• How Studios Can Help
• Become a Member
• Join Our Board
• Sponsor a Class
• Teaching Yoga in Service Settings
• What to Teach, Where, and How: Yoga Class Preferences of a Non-Studio-Based Outreach Yoga Community
• Motivations for Service
• 10 Commandments of Yoga Outreach
• Program Set Up Guide
• Site Visits
• Breathing Guide
• Responding to Abreactions
• Program Set Up Questionnaire
• Training Directory
• Yoga Activist Trainings
• Evaluate Trainings
• Request Scholarships
• What is a Yoga Outreach Teacher?
• What is a Yoga Outreach Understudy?
• Your First Yoga Class
• Student Practice Guides
• Grants & Features
• Fundraising
• Yoga Outreach Organization Directory
• Donate Mats
• Requesting Mats
• Program Reach
• Internships
• Donate Now!

At the request of Jasmine Chehrazi, Founder of  YogaActivist.org , a group of nine graduate students enrolled in the Master of Public Health (M.P.H.) program at The George Washington University conducted a literature review on the health benefits of yoga. The review provides  YogaActivist.org with information needed to further develop its network of studio-supported yoga outreach programs to diverse communities, both locally and nationally. Specifically, the review highlights the dynamic interplay between stress, weight, and other disease indicators—all of which can be addressed, if not mitigated, through routine participation in yoga.

The group of M.P.H. students searched for relevant articles in academic, peer-reviewed journals, including, but not limited to, the Journal of General Internal Medicine, Journal of Psychiatric Practice, Alternative Therapies in Health and Medicine, International Journal of Nursing Studies, Journal of Affective Disorders, Rehabilitation Oncology, and Topics in Clinical Nutrition. The search was by no means exhaustive, but the group found and summarized 19 different articles demonstrating the effectiveness of yoga in promoting physiological and mental health, as well as in controlling disease and disease indicators. While the 19 studies differ in study type, design, purpose, sample size, target population, yoga method(s) and technique(s), length of follow-up, and overall findings, they together demonstrate the widespread applicability of yoga to diverse populations, irrespective of gender, age, race/ethnicity, weight, or health status.

Through the literature review, the nine students found documentation of yoga’s effectiveness in treating musculoskeletal conditions, improving mental health, reducing stress and anxiety, increasing cortisol levels (associated with self-esteem and tenacity and lower levels of nervousness and depression), improving pulmonary function among asthmatic children, increasing exercise self-efficacy, reducing and/or controlling blood pressure, slowing weight gain, controlling diabetes mellitus, and improving overall mood. Such benefits extend to individuals across the life span. While yoga alone is insufficient to reverse disease or substantially improve health status, the literature suggests that yoga, when combined with other intervention measures, can reap significant physiological and mental health benefits for diverse populations. Yoga is a personal, non-competitive physical activity. When practiced correctly and routinely, yoga provides individuals of all ages with the motivation and self-efficacy needed to live and maintain healthier lifestyles.

Below is a summary of each of the 19 articles regarding the effectiveness of yoga interventions in promoting health. The summaries are categorized by the primary health or behavioral objective of each study.

Yoga and Mental Health

1) Lee SW, Mancuso CA, Charlson ME. Prospective study of new participants in a community-based mind-body training program. J Gen Intern Med. 2004;19(7):760-5.

FINDING: A 3-month yoga program improved mental health scores and other quality of life measures. Yoga Type: Dahn-hak. 1) stretching exercises for large muscle groups and shoulders, neck,hips, back, and knees, 2) postures are held for “energy accumulation 3) 5- to 10-minute meditation intended to facilitate “energy awareness”, 4) repetition of the large muscle group stretches. Yoga Frequency/Duration : 1-hour class offered 2-to-3 times per week for 3 months.

OBJECTIVE: To measure changes in health-related quality of life associated with 3 months of mind-body training as practiced in community-based settings.

METHODS: A prospective cohort study was done in eight centers for the practice of mind-body training in the metropolitan New York City area with 194 adults, and 171 completed the follow-up survey.  Participants typically attended a 1-hour class two to three times per week.  They were given a questionnaire before the classes began and 3 months later with questions about mental and physical health from validated survey instruments.

RESULTS: At baseline, new participants reported lower scores than U.S. norms for 7 of 8 domains of the Medical Outcomes Study SF-36 general health questionnaire.  After 3 months of training, within patient change scores improved in all domains (P< .0001), including a change of +15.5 in the mental health domain. In hierarchical regression analysis, younger age, baseline level of depressive symptoms and a history of hypertension were independent predictors of greater improvement in the SF-36 mental health score. Five participants (2.9%) reported a musculoskeletal injury.

2) Uebelacker LA, Epstein-Lubow G, Gaudiano, BA. Hatha. Yoga for depression: critical review of the evidence for efficacy, plausible mechanisms of action, and directions for future research. J Psychiatr Pract. 2010;16:22–33.

FINDING:  A review of eight clinical trials showed the yoga may help treat depression.  Note: Methodological concerns with most trials. Yoga Type : Some asana-focused, some meditation-focused Yoga Frequency/Duration : Varied in length from 3 days to 12 weeks and in intensity from daily to once per week.

OBJECTIVE: Review the literature of studies evaluating the efficacy of yoga for the treatment of depression and possible mechanisms .

METHODS: Studies were included in the review if they were clinical trials with one of the intervention arms involving a predominantly yoga intervention and a requirement for participants to have a diagnosed depressive disorder or elevated depression symptoms.

RESULTS: Eight trials were found. The number of participants ranged from 28 to 89.  Of the five studies that compared yoga to no/minimal treatment, four found some evidence that yoga was superior to the control group, and the final one did not directly compare the two groups. Studies varied in length of intervention from 3 days to 12 weeks and in intensity from daily to once per week, and different types of yoga were used (some asana-focused and some meditation-focused). Effect sizes of differences varied widely, and methodological differences and flaws threatening internal validity make it difficult to draw generalizable conclusions.

3) Birdee GS, Legedza, AT, Saper RB. Characteristics of yoga users: results of a national survey. J Gen Intern Med . 2008;23(10):1653-1658.

FINDING: A national survey of yoga users showed it to be helpful for overall health and well being, mental health, and musculoskeletal conditions. Yoga Type: N/A Yoga Frequency/Duration : Self-report that person had practiced yoga during past 12 months (and not tai chi or qi gong)

OBJECTIVE: To characterize yoga users, medical reasons for use, perceptions of helpfulness, and disclosure of use to medical professionals.

METHODS: A cross-sectional study was done using data from the National Health Interview Survey Alternative Medicine Supplement with 31,044 respondents. Survey participants were asked if they had practiced yoga during the past 12 months. If they had practiced yoga, but not tai chi or qi gong, they were asked whether they practiced yoga for medical conditions and if it helped their condition and also how important yoga was in maintaining their general health and well-being.

RESULTS: The prevalence of yoga use for health in the U.S. was 5.1percentwith a mean age of 39.5. Most yoga users (58%) felt that yoga was an important part of maintaining their health and well-being. A smaller percentage of yoga users reported using yoga to treat specific medical conditions (16%). Among medical conditions, 10.5percentand 3.3percentof yoga users reported using yoga to specifically treat musculoskeletal and mental health conditions, respectively. A majority of these yoga users reported yoga as helpful for their mental health (83%) and musculoskeletal condition (76%).

4) Woolery A, Myers H, Sternlieb B, Zeltzer L. A yoga intervention for young adults with elevated symptoms of depression. Alter Ther Health Med . 2004;10(2):60-63.

FINDING: A 5-week program of yoga showed reductions in depression and anxiety among young adults. Yoga Type : Iyengar Yoga Frequency/Duration : Two 1-hour classes per week for 5 weeks

OBJECTIVE: To determine the short-term effect of yoga on mood in mildly depressed young adults.

METHODS: Twenty-eight 18-29 year olds with mild depression were randomly assigned to an intervention group or a wait-list control group. The intervention group participated in a 5-week yoga program of two 1-hour classes per week. Measurements of depression and anxiety levels were made using the Beck Depression Inventory (BDI), State Trait Anxiety Inventory (STAI), and Profile of Mood States (POMS) survey instruments before classes began, midway through the program and at the program’s completion. Morning cortisol levels were also taken at the same time points.

RESULTS: The yoga group showed a significantly greater reduction in depression compared to the control group (p<.001). A similar pattern was seen for trait anxiety (p<.001) Significant pre- to post-class reductions were seen in depression-dejection, tension-anxiety, anger-hostility, fatigue-inertia, confusion-bewilderment, and total mood disturbance. Yoga participants also showed higher morning cortisol levels, which are associated with self-esteem, hardiness, and tenacity, and lower levels of nervousness and depression.

5) Chen KM, Chen MH, Chao HC, Hung HM Lin, HS, et al. Sleep quality, depression state, and health status of older adults after silver yoga exercises: cluster randomized trial. Inter J Nurs Stud. 2008;4:154-163.

FINDING: A 6-month yoga program improved sleep quality, depression, and perceived health status among older adults who reside in the community. Yoga Type : Warm up, hatha yoga gentle stretching, relaxation, and guided-imagery meditation. Yoga Frequency/Duration : 70 minutes three times per week for six months.

OBJECTIVE: To test the effects of six months of silver yoga exercises in promoting the mental health of older adults in senior activity centers, especially among the indicators of sleep quality, depression, and self-perception of health status.

METHODS: A cluster randomized trial was conducted in eight senior citizen activity centers in southern Taiwan. Participants were randomly assigned into either the experimental (n = 62) or the control (n = 66) group based on their attendance at selected senior activity centers. A 70-minute silver yoga exercise program was implemented three times per week for six months as the intervention for the participants in the experimental group.

RESULTS: The mental health indicators of the participants in the experimental group were significantly improved in comparison to the participants in the control group after the silver yoga interventions (all p < .05). Many of the indicators improved after three months of the intervention and were maintained throughout the six month study. These indicators included subjective sleep quality (as measured by the Pittsburgh Sleep Quality Index (PSQI) score), daytime dysfunction, physical and mental health perception, and depression state.Silver yoga exercise sessions were taught 3 times per week, for 70 minutes each session, over 6 months.  Each 70-minute session included a warm up, hatha yoga gentle stretching, relaxation, and guided-imagery meditation.  No additional details regarding postures or sequence are provided.  For consistency over the course of the intervention, yoga instructors followed a pre-recorded tape made by the principal investigator which verbally guided them through the sequence of postures for each session.

6 ) Gupta N, Khera S, Vempati RP, Sharma R, Bijlani RL. Effect of yoga based lifestyle intervention on state and trait anxiety. Indian J Physiol Pharmacol. 2006;50(1): 41-47.

FINDING: Short educational program for stress management and lifestyle modification based on yoga leads to reduction in anxiety. Yoga Type : Asanas and pranayama Yoga Frequency/Duration : 8-day outpatient course, 3-4 hours/day, over 10 days (with a 2-day weekend break)

OBJECTIVES: To study the short-term impact of a comprehensive, yet brief, lifestyle intervention based on yoga in diseased and normal individuals.

METHODS: The research subjects had a history of hypertension, coronary artery disease, diabetes mellitus, obesity, psychiatric disorders and thyroid disorders. The intervention consisted of asanas, pranayanama, relaxation techniques, group support, individualized advice, lectures and films on philosophy of yoga, and the place of yoga meditation in daily life, meditation, and stress management.

RESULTS: Outcome measures were anxiety scores taken on the first and last days of the course. Among diseased individuals, improvement was seen in anxiety levels.

7) Galantino ML, Cannon N, Hoelker T, Iannaco J, Quinn L. Potential benefits of walking and yoga on perceived levels of cognitive decline and persistent fatigue in women with breast cancer. Rehab Oncol. 2007;25(3):3-12.

FINDING: Exercise, specifically walking and yoga, have been proven effective in enhancing quality of life and decreasing fatigue in breast cancer populations. Yoga Type : variable Yoga Frequency/Duration : variable

OBJECTIVE: To investigate available evidence for the effect of walking and yoga on breast cancer survival following chemotherapy.

METHODS: Authors searched randomized clinical controlled trials, systematic reviews, cohort studies, and case series for information regarding the effect of walking and yoga on quality of life, persistent fatigue, and perceived levels of cognitive decline in breast cancer populations.

RESULTS: Yoga proved to be beneficial in breast cancer populations, leading to improvements in sleep quality, strength, flexibility, and quality of life. The three main components of yoga—asanas (yoga physical postures), pranayama (breathing exercises/patterns), and dhyana (meditation)—have been shown to decrease fatigue and improve perceptions of vitality.

8 ) Janakiramaiah N, Gangadhar BN, Naga Venkatesha Murthy PJ, Harish MG, Subbakrishna DK, et al. Antidepressant efficacy of Sudarshan Kriya yoga (SKY) in melancholia: a randomized comparison with electroconvulsive therapy (ECT) and imipramine. J Affect Disord. 2000;57(1-3):255-259.

FINDING: Once daily practice of Sudarshan Kriya yoga (SKY) was found to be equally effective to medication and nearly as effective as electro-shock therapy in the remission of depression among patients. Yoga Type : Sudarshan Kriya yoga was used with some changes.  To make it widely acceptable to patients and the medical profession, some of the adventitious components (e.g., briefing about positive attitudes to life ‘living in the present’, etc.) were dropped as were the meditative aspects. The physiological technique consisting of only specified rhythms of breathing. This adaptation for clinical purposes was designated Sudarshan Kriya Yoga. There were three sequential components interspersed with normal breating while sitting with eyes closed. The procedure closed with 10-15 minutes of Yoga Nidra (tranquil state) in supine position. Yoga Frequency/Duration : Six 45-minute sessions during mornings per week.  For patients with marked diurnal retardation, afternoon sessions were also recommended.  Mean number of sessions was 20.

OBJECTIVE: To investigate the efficacy of yoga practice as it compares to traditional treatments of clinical depression.

METHODS: Randomized, control study of 45 patients hospitalized with severe depression (as defined by the Beck Depression Inventory and Hamilton Rating Scale for Depression). The patients were divided into three groups with the first receiving electroconvulsive therapy three times weekly for four weeks. The second group was administered imiprimine, an antidepressant medication, at typical dosing. The last group was trained in SKY and encourages to practice it daily. Pre/Post test surveys focused on depressive effects.

RESULTS: Patients practicing SKY were noted to have a 67percentremission rate of their symptoms showed it to be as effective as imiprimine and nearly as effective as electroconvulsive therapy. Though compelling, the findings are subject to possible selection bias due to inadequate group sizes for statistical validity. However, they are highly suggestive that further investigation into the clinical efficacy of yoga practice is warranted and could present itself as a low-risk/high-reward alternative to traditional depression treatments.

9) Vedamurthachar A, Janakiramaiah N, Hegde JM, Shetty TK, Subbakrishna DK, et al. Antidepressant efficacy and hormonal effects of Sudarshan Kriya Yoga (SKY) in alcohol dependent individuals. J Affect Disord. 2006;94:249-253.

FINDING: Practice of yoga was found to demonstrate antidepressant effects in a randomized control trial among consenting patients participating in alcohol detoxification programs. Measures of cortisol, ACTH and prolactin revealed a possible biological mechanism for yoga’s effects. Yoga Type : The SKY consisted of three distinctive breathing periods (Pranayama):1. Ujjayi pranayama: Consists of slowdeep breathing. Each cycle includes breathing in, holding, breathing out and holding.2. Bhastrika pranayama consists of forced inhalation and exhalation 20 times. Ujjayi and Bhastrika pranayama requires about 12–15 min.3. Cyclical breathing consists of slow, medium, and fast cycles of breathing practiced for a total duration of 30min.These three procedures are done in sitting posture (Sukhasana) with eyes closed. This was followed by Yoga Nidra (lying in a tranquil state) for about 20 min. Yoga Frequency/Duration : One 65-minute session once per day for two weeks.

OBJECTIVE: To determine the effectiveness of yoga practice in the treatment of depression among individuals participating in alcohol dependence detoxification.

METHODS: After a week of detoxification management, subjects were recruited to participate in a randomized-control study. There were a total of 60 subjects who participated in a two-week study. The control group was provided standard detoxification, while the intervention group practiced daily sessions of breathing exercises and yoga practice. Effects were measured with the use of the Beck Depression Inventory (BDI) pre/post each session and morning plasma cortisol, ACTH and prolactin measures were taken prior to and following the two-week intervention.

RESULTS: Both the control and intervention groups displayed a reduction in self-reported depression symptoms according to the BDI. Additionally, there was a noted correlation between depression symptom reduction and reduction of morning plasma cortisol levels among the intervention group participants. Physical measures of cortisol suggest a biological pathway for the observed results among program participants. The small group size is a possible confounder of these results. Also, it was noted by those administering the study that depression symptoms declined in all patients over that same period. However, the level of reduction and the effects on cortisol measures suggest a biological pathway of depression reduction in those practicing yoga.

Yoga and Stress in Children

10) Mendelson T, Greenberg, MT, Dariotis, JK, Gould, LF, Rhoades, BL, et al. Feasibility and preliminary outcomes of a school-based mindfulness intervention for urban youth. J Abnorm Child Psychol. May 4, 2010; DOI:10.1007/s10802-010-9418-x.

FINDING: A 12-week intensive yoga program improved involuntary stress responses in 4 th and 5 th graders. Yoga Type : Yoga-inspired postures and movement series, including bending, stretching, and fluid movement. Poses were selected to enhance muscle tone and flexibility, and students were taught the health benefits of the poses. Students also practiced breathing, starting with beginner exercises and gradually moving to more advanced ones. These exercises trained the youths to use their breath to center and calm themselves. At the end of each class, youth lay on their backs with their eyes closed while the instructors guided them through a mindfulness practice, which involved attending to a specific focus for several minutes, such as paying attention to each breath or sending out positive energy to others. The brief period of discussion prior to the guided mindfulness practice in which instructors offered didactic information about topics such as identifying stressors, using mindfulness techniques to respond to stress, cultivating positive relationships with others, and keeping one’s mind and body healthy. This information was oftenwoven into the subsequent guided mindfulness practice (e.g., using the breath to create calm if something stressful has happened). Yoga Frequency/Duration : Four 45-minute session per week for 12 weeks.

OBJECTIVE: To assess the feasibility, acceptability, and preliminary outcomes of a school-based mindfulness and yoga intervention.

METHODS: Ninety-seven 4 th and 5 th graders in the inner city of Baltimore participated in a 4-day per week 12-week yoga and mindfulness program at school. Each yoga session lasted 45 minutes and occurred during a non-academic time period. Students were given a questionnaire to assess their stress response, depressive symptoms, and relations with peers and school, all of which used validated instruments.

RESULTS: Many students were eager to join the program, and a focus group showed that participants had a positive experience with the program.  The intervention group’s survey responses showed significant improvements in involuntary stress responses as compared to controls (p<.001). Significant different were also seen on three subscales, including rumination, intrusive thoughts, and emotional arousal (p<.01).

11) Stueck M, Gloeckner N. Yoga for children in the mirror of science: working spectrum and practice fields of the training of relaxation with elements of yoga for children. Early Child Dev Care. 2005;175:371-377.

FINDING: In a small study, a 15-week program of yoga and relaxation training improved stress responses in preteens. Yoga Type : 1) Relaxation. Used technique called ‘journey through the body’, which consists of different concentration tasks on single body parts. Other used first relaxation techniques are breathing techniques from yoga (ujjayi, nadhi shodana, alternating breathing). 2) Yoga exercises. a) 23 different yoga exercises (based on Shivananda-Yoga, Rishikesh/India) b) individual complex of yoga exercises c) participants can develop their own complex yoga and instruct others. 3) Series of activities such as massage techniques (partner massage, ball massage), meditation (candle meditation), sensory exercises (discovering of objects by touching and smelling), and interactive exercises (‘trust game’, ‘jumping lotus flower’) as well as six different imagery techniques. Yoga Frequency/Duration : One 1-hour session per week for 15 weeks.

OBJECTIVE: To determine whether yoga can assist in reducing stress responses in preteens.

METHODS: Forty-eight 11-12-year olds with abnormal exam anxiety participated in the study with 21 students assigned to the experimental group to participate in a 15-session program of relaxation, yoga, and other meditation and social interaction exercises. Each session lasted one hour. A questionnaire with stress-related items was given to students before the sessions began, immediately after the 15-week program, and three months after the program ended.

RESULTS: Students involved in the program showed improvement in several stress measures. Significant effects were seen in a comparison immediately after the training: decreased aggression, decreased helplessness in school, decreased physical complaints, improved stress coping abilities. In a comparison 3-months later, the following effects were seen: improvements in emotional balance, decreased anxiety, decreased shyness in social contacts, and decreased impulsiveness. In the first post-test measurement, parents also reported their students as being calmer and more balanced (71.4%), less impulsive, aggressive and hot-tempered (38.1%), more concentrated (38.1%), and having fewer complaints (38.1%).  Comparisons to the control group were not statistically measured.

Yoga and Attention Problems in Children

12) P eck HL, Kehle TJ, Bray MA, Theodore LA. Yoga as an intervention for children with attention problems. School Psych Rev. 2005;34z:415-424.FINDING: A small study showed an improvement in “time on task” for elementary school students with attention problems. Yoga Type : “Yoga Fitness for Kids” DVD by Gaiam (2003). Deep breathing, postures, and relaxation exercises.  Poses included frog, downward dog and bridge. Movement in a gamelike manner interspersed between poses. Ended with guided imagery while lying on their backs. Yoga Frequency/Duration : Two 30-minute sessions per week for 3 weeks.

OBJECTIVE: To investigate the effectiveness of yoga for improving time on task in children with attention problems.

METHODS: Ten students ages 6-10 with attention problems (but not diagnosed with Attention Deficit Hyperactivity Disorder (ADHD)) participated in a 30-minute yoga videotape program twice per week for 3 weeks. Measurements were made of children’s “time on task”, defined as the percentage of intervals observed where the students had eye contact with the teacher or assigned task and performed the requested classroom assignments in 10-minute observations. Measurements occurred twice per week as follows: baseline for 3-7 weeks (varying by grade level), intervention for 3 weeks, and follow-up for 3 weeks.  Measurements occurred at the same time each day, and a child of the same gender (for each child in the program) in each classroom was chosen as a comparison.

RESULTS: An improvement in the mean “time on task” was seen both immediately following the intervention (effect size 1.5 to 2.7) and in the follow-up period (effect size 0.77 to 1.95). No change was seen in the comparison group.

Yoga and Asthma in Children

13) Jain SC, Rai L, Valecha A, Jha, UK,  Bhatnagar SO ,  Ram K . Effect of yoga training on exercise tolerance in adolescents with childhood asthma. J Asthma . 1991;28(6):437-442.

FINDING: Yoga training improved pulmonary function and exercise capacity in children and teens with asthma. Yoga Type : Yogic cleansing procedures, postures, and breathing. Yoga Frequency/Duration : Daily for 90 minutes in morning and 1 hour in evening for 40 days.

OBJECTIVE: To determine if yoga can improve pulmonary function and exercise capacity in children with asthma.

METHODS: A study of 46 children with a mean age of 15.8 years and a history of asthma was performed. Children participated in 40 days of yoga training, and measurements were made of forced expiratory volume, distance walked in a 12-minute time period and overall physical fitness as assessed by a modified Harvard Step Test. Twenty-six patients were followed for up to two years and asthma symptoms and medication requirements were measured.

RESULTS: Improvements were seen in expiratory volume, distance walked in a 12-minute time period and overall physical fitness.  Of patients followed for up to two years, children showed a continued reduction in asthma symptoms and less need for medication.  Fourteen of the children with mild asthma who continued yoga every day for 15-30 minutes remained asymptomatic.NOTE: This article was not available through GWU. The data were obtained from the abstract and from a review article: Galantino ML, Galbavy R, Quinn L. Therapeutic effects of yoga for children: a systematic review of the literature.  Pediatr Phys Ther . 2008;20(1):66-80.

Yoga and Obesity, Diabetes, and Cardiovascular Disease

14) Kristal AR, Littman AJ, Benitez D, White E. Yoga practice is associated with attenuated weight gain in healthy, middle-ages men and women. Altern Ther Health Med. 2005;11(4):28-33.

FINDING: Practicing yoga for four or more years slowed weight gain in middle-ages adults. Yoga Type : N/A Yoga Frequency/Duration : Self-report of number of days per week and minutes per day they practiced yoga and the number of years. Yoga practice was grouped into three categories of increasing intensity.

OBJECTIVE: To examine whether yoga practice is associated with a lower mean 10-year weight gain after age 45.

METHODS: 15,550 adults ages 53 to 57 were recruited into the Vitamin and Lifestyle cohort study between 2000 and 2002.  A validated physical activity questionnaire was given to the participants, which asked about a variety of activities including yoga.  Participants reported the number of years in the last 10 years that they did each activity and the number of days per week and minutes per day.  Yoga practice was grouped into three categories of increasing intensity. Self-reported weight and height were used to calculate participants’ current BMI, and the weight change was calculated from the difference between their current weight and their weight at age 45 (also by self-report).

RESULTS: Individuals with a BMI less than 25 who practiced yoga for four or more years had a 3.1 lb. lower weight gain than those who had not practiced yoga. Individuals who were overweight and practiced yoga for four or more years showed an 18.5 lb. lower weight gain. All models were adjusted for other physical activity, dietary factors, and other obesity-related variables.

15) Sahay BK. Role of yoga in diabetes. J Assoc of Physicians India . 2007; 55 :121-126.

FINDING: Yoga has a role in diabetes control and prevention. Yoga Type : Pranayama Yoga Frequency/Duration : N/A

OBJECTIVE: To assess the role of yoga on glycemic control, insulin kinetics, body composition, exercise tolerance, and co-morbidities including hypertension and dyslipidemia.

METHODS: Individuals with diabetes and without diabetes were randomized to different groups and performed yogic practices for 45 minutes each day, which was followed by relaxation practices.

RESULTS: The studies confirmed that yoga has a useful role in the control of diabetes mellitus. Fasting and postprandial blood glucose levels decreased significantly. There were significant changes in insulin kinetics and those of counter-regulatory hormones such as cortisol. There was a decrease in fatty acids. There was an increase in lean body mass and a decrease in body fat percentage. The number of insulin receptors was increased, and there was an improvement in insulin sensitivity and a decline in insulin resistance.

16) Yang K, Bernardo LM, Sereika SM, Conroy MB, Balk J, et al. Utilization of a 3-month yoga program for adults at high risk for type 2 diabetes: a pilot study. Evid Based Complement Alternat Med . Published on-line: August  18, 2009 doi:10.1093/ecam/nep117. 1-7.

FINDING: Yoga may help to lower adult risk for type 2 diabetes, reduce cardio-metabolic risk factors, and increase exercise self-efficacy. Yoga Type : Vinyasa Yoga Frequency/Duration : 1-hour sessions, 2 times per week, for 3 months. Each session began with a 5-7 min warm-up and ended with a 10 min relaxation period.

OBJECTIVE: To conduct a pilot study to assess the feasibility of implementing a 12-week yoga program among adults at high risk for type 2 diabetes.

METHODS: Twenty-three adults were randomly assigned to either a yoga intervention group, which participated in a 3-month yoga intervention with 1-hour Vinyasa style yoga sessions twice per week, or an educational group, which received general health educational materials every 2 weeks. Participants had to: (1) be between 45 and 65 years of age; (2) be non-exercisers (no more than 30 minutes twice per week) for the previous year; (3) have a family history of type 2 diabetes, and; (4) have at least one cardio-metabolic risk factor. All participants completed questionnaires and had blood tests at baseline and at the end of the 3-month program to measure blood pressure, blood glucose, insulin, lipid levels, and body weight, as well as to assess exercise self-efficacy.

RESULTS: Compared with the education group, the yoga group experienced improvements in weight, blood pressure, insulin, triglycerides, and exercise self-efficacy. Findings suggest that a yoga program would possibly help to lower adults’ risk for type 2 diabetes, as well as reduce cardio-metabolic risk factors for adults at high risk for type 2 diabetes.

17) Guarracino JL, Savino S, Edelstein S. Yoga participation is beneficial to obesity prevention, hypertension control, and positive quality of life. Top Clin Nutr . 2006;21(2):108-113.

FINDING: Yoga may be beneficial in controlling weight, blood pressure, and mood. Yoga Type : Hatha and relaxation yoga. Yoga Frequency/Duration : The majority of study participants (55.7%) had practiced yoga for less than 1 year, followed next by those who had practiced yoga for more than 5 years (31.4%). The majority of participants (57.1%) practiced yoga for 1-2 hours per week, followed by those who spent less than 1 hour per week practicing yoga (24.3%).

OBJECTIVE: To evaluate the effects of hatha and relaxation yoga on obesity, blood pressure, and quality of life.

METHODS: Seventy healthy women and men ages 18 years or older were recruited from 3 fitness centers in Massachusetts after completing a 1-hour yoga class and were asked to complete a survey. The survey was used to measure how the participants felt after the yoga class, and questions included those related to yoga frequency and duration, other physical activity and duration, past and present medication use, food consumption behavior, demographic information, and data related to height, weight, blood pressure, tricep skinfold, and waist and mid-arm circumference.

RESULTS: According to survey results of the 70 participants, hatha and relaxation yoga had a statistically significant role in controlling weight, hypertension, and mood. Of the participants, those who had practiced yoga for less than 1 year had a significantly higher systolic blood pressure (mean 117.13) than those who had practiced yoga for 1-4 years (mean 107.56). However, the survey participants’ mean BMI (24.41) was significantly different from the BMI used as a cutoff for determining obesity (30.0), thus suggesting that individuals who practice hatha and relaxation yoga may not generally be obese.

18) Yang K. A review of yoga programs for four leading risk factors of chronic diseases. Evid Based Complement Alternat Med . 2007;4(4):487-491.

FINDING: Yoga programs may be effective in reducing body weight, blood pressure, blood glucose, and cholesterol. Yoga Type : Other than duration and frequency, most articles did not describe the yoga sessions in detail. Of the few articles that did identify the type of yoga studied, the most common was Hatha yoga. Yoga Frequency/Duration : The most common duration and frequency of yoga sessions in the studies were 30-60 min per session, with sessions meeting daily for 4-10 weeks. Many studies also used sessions meeting 2-3 times per week for 8-12 weeks.

OBJECTIVE: To review published studies of yoga programs and to determine the effect of yoga interventions on chronic disease risk factors, such as overweight, hypertension, high glucose level, and high cholesterol.

METHODS: A systemic search was conducted, yielding 32 articles from electronic databases published between 1980 and 2007. Of the 32 articles reviewed, 12 described experimental studies, 18 described quasi-experimental studies, and 2 described observational studies. Only 7 of the studies were conducted in the United States, and only 16 of the studies focused on subjects with diabetes, hypertension, or cardiovascular disease.

RESULTS: In analyzing the 32 articles, the authors found that yoga interventions are generally effective in reducing body weight, blood pressure, blood glucose level, and cholesterol level. However, only a few studies examined long-term effects.

Yoga and other Health Issues

19) Pullen PR, Thompson WR, Benardot D, Brandon LJ, Mehta PK, et al. The Benefits of yoga for African American heart failure patients. Med Sci Sports and Exerc. 2010:42(4): 651-657.

FINDING: Yoga improves cardiovascular endurance for African Americans who have suffered from heart failure. Yoga Type : Pranayama and Asanas. Yoga Frequency/Duration : 5 minute warm-up, including breathing exercises a 40 minute period of postures, ending with a 15 minute relaxation phase. Patients attended a total of 16 supervised sessions over an 8-10 week period.

OBJECTIVE: To see if yoga can improve physical and psychological parameters (cardiovascular endurance (VO2peak), flexibility, quality of life (QoL) and inflammatory markers) among patients with heart failure (HF), particularly among African Americans.

METHODS: Forty patients (38 AA, 1 Asian, 1 Caucasian) with systolic or diastolic HF were randomized to the yoga group (YG, N=21) or the control group (CG, N=19). All patients were asked to follow a home walking program. Pre- and post-measurements included a treadmill stress test to peak exertion, flexibility, interleukin-6 (IL-6), C- reactive protein (CRP), and extra cellular-super oxide dismutase (EC-SOD). QoL was assessed by the Minnesota Living with Heart Failure Questionnaire (MLwHFQ).

RESULTS: Yoga therapy offered additional benefits to the standard medical care of predominantly AA HF patients by improving cardiovascular endurance, QoL, inflammatory markers and flexibility.

Teacher Feature: Carlos Gomes

Carlos shares his joy for yoga with arguably one of the toughest constituencies out there: teenage boys currently held in juvenile detention. Through a program with Yoga Behind Bars, a Seattle-based nonprofit providing prisoners access to yoga classes, Carlos uses his talents to empower these very unique individuals.   YAO: Why did you choose to […]

Teacher Feature: Zabie Yamasaki of Transcending Sexual Trauma Through Yoga

Zabie Yamasaki specializes in teaching trauma-informed yoga to survivors of sexual assault. She says, “This is a community that continues to astound me by their resilience, courage, and undeniable strength. It’s a true gift to hold space for what is often times a lifelong process of healing.” What drew you to this work? As a survivor […]

[email protected]     © 2022 Yoga Activist | Design donated by David Onate

• Open access
• Published: 15 May 2023

Perceived benefit of yoga among adults who have practiced yoga for a long time: a qualitative study

• Şengül Akdeniz 1 &
• Özlem Kaştan 2  

BioPsychoSocial Medicine volume  17 , Article number:  19 ( 2023 ) Cite this article

5477 Accesses

2 Citations

13 Altmetric

Metrics details

Previous quantitative studies have shown many of the perceived benefits of yoga practice on the mind and body. Although there are many quantitative studies in the international literature on yoga, the number of qualitative studies showing the experience of yoga practice is insufficient. An accurate demonstration of yoga participents experiences, opinions, and judgments on this subject requires a qualitative, rather than a quantitative approach.

This study was to explore the benefit perceived by adults who have practiced yoga for a long time.

Design and method

This qualitative study is based on a hermeneutic–phenomenological approach. The research sample consisted of 18 adults who volunteered to participate in the research and regularly joined yoga practice. The study data were collected through individual and focus group interviews with the participants who practise yoga and analyzed by content analysis method.

We created five themes. Themes coded by researchers: meaning of the concept of yoga (theme 1), physical, mental, and social state before starting yoga (theme 2), reasons for practising yoga (theme 3), the participants' experiences related to their physical and mental health and social relationships (theme 4), and difficulties of doing yoga (theme 5). In addition, individuals in the study reported their perceptions of the concept of "yoga" through the creation of metaphors that completed the following sentence “yoga is like ……”. These metaphors were used to give insight into the participants deep feelings about yoga.

Conclusions

Both in their individual and focus group interviews, almost all of the participants described that doing yoga has positive benefits on the mind and body. The positive experiences of the participants in the study included decrease in pain and flexibility, increase in sleep quality, development of positive personality traits, increase in self-esteem, and coping with anxiety and stress more effectively. Because the study was qualitative and long-term, it was able to evaluate the beliefs, attitudes and behaviors of individuals in a realistic, systematic, and detailed manner.

While low stress levels create a positive impact, higher ones adversely affect the functioning of all organs and systems in the organism and may lead to various diseases. It is therefore important to manage to control stress and cope with it [ 1 ]. Various techniques are used to control or reduce stress and change stress-coping strategies and behaviors. Yoga is a technique for relaxing the mental health and controlling stress via internal and external resources [ 2 ]. Studies on yoga suggest that yoga is an effective method of coping with stress, leading to growing self-awareness and a positive increase in quality of life [ 3 , 4 , 5 , 6 , 7 ]. Studies have found that yoga has positive effects on coping with stress, increasing sleep quality, growing self-confidence, relaxation, and strengthening memory and concentration [ 8 , 9 ]. A randomized controlled study on yoga puts forward that yoga is effective in coping with neuronal and endocrine changes and stress, and also decreases the prevalence of mental illnesses by reducing depression and anxiety [ 9 ]. The study conducted by Tulloch et al. (2018) shows that yoga has a significant role in improving balance, movement, and mental health [ 6 ].

Studies suggest that yoga has positive effects on physical health as well as on mental health. It is reported that the use of yoga-based exercises as an alternative complementary treatment has a positive effect on various chronic diseases, such as paralysis [ 10 ], arthritis [ 11 ], obesity [ 9 ], type 2 diabetes [ 12 ], cardiovascular disease [ 13 ], metabolic syndrome [ 14 ], and cancer [ 15 ]. There are many studies showing the positive physical, mental, and social effects of yoga. As yoga has spread all over the world and has been nourished by the cultures in the areas where it has spread, many types of yoga have emerged. The most important effects of all types of yoga are that they teach the power to reveal the positive qualities of human beings and to reduce their deficiencies [ 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 ].

Tulloch et al. suggest that yoga allows a person to focus, enter a peaceful state, and then incorporate the benefits of this relaxing experience into their lifestyle [ 6 ]. Yoga reveals the integrity of mind, body, muscle, bone, and spiritual in a holistic manner. When practicing yoga, people know which muscle is moving in each stretching movement, and a physical integrity is achieved by concentrating on it. Yoga is a great form of exercise focused on human anatomy for physical health. When it comes to yoga movements, many people may think of some acrobatic movements and difficult postures. Because each individual's anatomical structure, joints and bones are different, the limits of being able to do these postures are also different. As the movements are performed, the body opens and stretches. Yoga poses, which have hundreds of variations today, have been diversified over time by yoga experts according to their knowledge of anatomy and the areas they focus on. The perception of yoga as a part of physical culture has been attributed to its stress-reducing and relaxing properties based on anatomical and physiological assumptions [ 2 , 4 , 5 , 6 ]. Yoga is also used as an alternative treatment for some diseases. According to the literature, there are no studies showing negative physical, mental, or social effects of yoga. However, more studies are needed on exactly which health problems yoga has a positive effect on.

Although yoga is known to be especially effective in protective and improving the health of healthy adults, scientific studies in this field are both few in number and are usually short-term studies. Among the studies that have been conducted on yoga, qualitative studies in which the subjective experiences of individuals practising yoga are questioned are limited. In the literature review, there was no qualitative study on yoga conducted in Turkey that take into account long-term lifestyle and for which positive effects are revealed. Yoga is less well known and practiced in Turkey compared to other countries. One of the first reasons for this is that yoga is not well known in Turkey. In addition, the income and education level compared to other countries constitute other factors affecting the promotion and demand of yoga education and philosophy. Yoga as an academic research subject in Turkey started to intensify after 2015. The exact number of yoga practitioners in Turkey is not known. Compared to abroad, there are very few yoga instructors and yoga centers in Turkey compared to other countries. It is thought that this study will contribute to the recognition of yoga in Turkey.

This study was done for a long period, two years, to investigate how the emotions, thoughts, and experiences of adults related to the effect of yoga-based exercises on their physical, mental, emotional, belief, and social health states.

Study design and sampling

In order to explore the benefit perceived on the physical, spiritual, emotional and social situations by adults who have practiced yoga for a long time, we used a qualitative research method that investigates the event(s) related to a situation in depth within a person’s own boundaries (environment, time, etc.) to do a holistic analysis [ 16 ]. The study used a holistic, multiple design; a case study design in which more than one situation perceived as holistic is handled and compared. The population of the study consisted of the individuals practising yoga.

In a qualitative study, data collection is terminated when the data reaches a saturation point, when there is no new information, and/or data starts to repeat itself [ 16 ]. Therefore, our research participants consisted of 18 individuals who volunteered to participate in the research and regularly joined yoga practice. Individual interviews were done in January 2020, and focus group interviews were held in February 2020. The participants were given information about the place and time of the meeting, and a meeting room was made available and arranged in a way that was suitable fort he study.

Data collection

Data was collected through individual and focus group interviews with the participants and through participant observation. The participants practiced yoga two days a week. For this reason, focus group participants were divided into two groups of nine, with the groups meeting on different days, and the group participants were interviewed before and after doing yoga. The group discussions lasted approximately one hour. Focus group interviews allowed us to see social interactions before and after yoga.

The interviews were conducted via a semi-structured interview form. A Personal Information Form and a Semi-Structured Interview Form were used during the interviews. It took an average of 45–50 min. to conduct these interviews. The researcher acting as a participant observer went to a yoga studio selected for participant observation two days a week from April 5, 2018 to March 11, 2020. During this time, social communication was observed in different areas of the studio such as classrooms, changing rooms, and kitchen. Yoga classes are voluntarily offered at the yoga studio and there may be changes in the profile of the students who join these classes. The researcher attended yoga classes between 12.00–13.00 h, twice a week, for 2 years. During the first year, the participant observer researcher attended yoga classes almost without missing any of them, and recognized changes in his body and thinking about what yoga is and its effects. The researcher acting as a participant observer observed all participants individually from the beginning of his participation in the yoga classes. Participants did their physical activity of yoga on a mat that was suitable for the person's height, that was heat-insulated, and that was not too high and did not allow slipping. It was done under the guidance of a trainer in a yoga hall appropriate for yoga. The participants were observed to have experienced difficulties in performing some physical movements due to their age and flexibility characteristics, particularly in the initial phase. It was observed that as time passed and yoga activity became a habit among the participants, these difficulties decreased in parallel with the duration of yoga. Moreover, both the atmosphere of the yoga hall and the group interaction of all participants were observed.

Personal information form

The personal information form contains questions about seven items: gender, age, education, occupation, chronic disease, chronic pain, and duration of yoga practice.

Semi-structured interview guide

The semi-structured interview form contains six questions including the meaning of the concept of yoga, the physical, mental and social state before starting yoga, the reasons for practising yoga, the effects of yoga on the physical, mental and social state, the difficulties of doing yoga, and a metaphor to explain what yoga is like. In addition, the researcher asked probing questions in order to deepen and clarify the issue during the individual interview.

Data analysis

The data obtained as a result of individual interviews was analyzed through the descriptive analysis method. This analysis method addresses the statements and results of the participants regarding the research question. Data is summarized and interpreted according to the pre-determined themes in this type of analysis [ 16 ]. Data analysis was done with the Nvivo 10 package program. Firstly, the data collected as a result of individual interviews and participant observations was documented, and upon completion of all individual interviews, themes were created. Researchers initially worked independently while creating themes, and then the themes were compared and common themes were formed. In the data analysis, the researchers obtained mostly consistent results. When the researchers did not agree with each other, the interview text was read in detail in order to obtain a common impression by making an in-depth naive reading. For the reliability of the research, two experts who did not know about the study were asked to code according to the themes. Apart from descriptive data, numerical analyzes of data collected as a result of individual interviews were also presented and interpreted in the study. Moreover, in order to increase the validity and reliability of the study, direct quotations were made from participant statements.

Ethical aspect of research

Ethical approval from ……University Clinical Research Ethics Committee (approval number: 70904504/299, date of approval 05/07/2019) and permission from the yoga trainer who contributed to the research were obtained for carrying out the study. This study was conducted in accordance with the principles of the Helsinki Declaration. The yoga practitioners who participated in the study were informed that the research was a scientific study, that an individual interview would be held, and that their real names would not be used in data analysis, each participant was given a code number (P1–P18) and their informed voluntary consent was obtained.

Analysis of the Personal Information Form found that the age range of the 18 participants was between 23 and 68 years, 6 were between 40–50 years old and 16 were women. Considering the occupations, 4 were lecturers, 3 were civil servants, 6 were students, teachers, or retired teachers (2 each), and 1 each was a nurse, painter, administrative assistant, massage therapist, or housewife. With respect to the disease state of the participants, it was revealed that 15 of them had a history of chronic disease, 11 had chronic pain, and 3 had anxiety disorder. The duration of yoga practice varied from 2 to 5 years (Table 1 ).

We created five themes. Themes coded by the researchers: meaning of the concept of yoga (theme 1), physical, mental and social state before starting yoga (theme 2), reasons for practising yoga (theme 3), the participants' experiences related to their physical and mental health, and social relationships (theme 4), and difficulties of doing yoga (theme 5). In addition, individuals in the study reported their perceptions of the concept of "yoga" through the creation of metaphors that completed the following sentence “yoga is like ……”. These metaphors were used to give insight into the participants deep feelings about yoga.

Theme 1: Meaning of the concept of yoga

Of the participants, 11expressed the meaning of the concept of yoga with the theme “exercise”, while 5 replied “healthy life” and “calmness”, 3 ‘harmony’, and 2 "awareness" and “balance” (Table 2 ). Some of the participants' statements regarding the meaning of the concept of yoga are as follows:

For me, the concept of yoga means standing against the speed culture created by our current age, and the calmness that occurs as a result this stance (P3) (Theme-calmness) .

Yoga means ensuring harmony between the inner world and the outer world for me (P12) (Theme-harmony-balance).

It is a form of physical exercise that focuses on breathing and protects our physical and mental health through stretching movements (P4) (Theme-exercise-healthy life).

It's the best time I spare to myself. I become aware of my whole body (P13) (Theme-awareness).

It is the movements and rest that calm your mind and make you feel mentally fit while stretching and resting the body through relevant body movements (P9) (Theme-exercise).

Theme 2: Physical, mental, and social state before starting yoga

After the participants were asked about their physical, mental and social state before starting yoga, they gave the following responses: 6 were "doing sports other than yoga"; 4 were "fatigued" and had "coping difficulty"; 3 had " physical ailments', 'sedentary life' and felt 'negative emotions', and 1 had 'social isolation' (Table 2 ).

Some of the participants' statements about their physical, spiritual and social state before starting yoga are as follows:

I couldn't find time to rest, I often had neck pain, and I had lung disease in the winters (P10) (Theme—physical ailments).

I had fatigue, leg pain and oedema, as well as varicose pain that did not go away (P17) (Theme—physical ailments).

I had a monotonous life, I was a fairy godmother, I always said yes to everyone, and I did not have time to spare to myself and to be on my own (P18) (Theme-sedentary life).

I was interested in sports that required more speed. I didn't know the importance of slowing down and awareness of body (P11) (Theme-sports other than yoga).

I was in a stressful state with difficult-to-cope emotions (P1) (Theme-feeling negative emotions- coping difficulty).

Before starting yoga, I was less tolerant of events and feeling more lonely, and thanks to yoga, I believe that I have overcome these negative emotions, and my presence in the universe is so pleasant and I am grateful for being a part of the universe (P5) (Theme-feeling negative emotions).

Before I started doing Yoga, especially my mind was like a machine running full-time (P3) (Theme-fatigue).

I had a very intense pace of work. Since my husband worked out of the city, it was really exhausting and wearing to assume the responsibility of two children, to be both a mother and father, to run a large hospital and to attend classes at school (P15) (Theme-Coping difficulty).

I've been trying to do yoga with you for two years. During this period, I had angio ablation because of rhythm disturbance, but it was not successful and drug treatment was started. Meanwhile, I had anxiety and a fear that I didn't know about, I started yoga at this very moment, my fears decreased every day, I felt my soul healed, and after five months, I stopped taking antidepressants. I felt relief in my heart (P16) (Theme-anxiety).

Theme 3: Reasons for practising yoga

Participants stated that they practised yoga for a healthy life (8), to raise awareness (6), to reduce pain (9), to be calm (3), to cope with stress (1), and to increase positive thinking (1) (Table 2 ).

Some of the participants' statements regarding their reasons for practising yoga are as follows:

Yoga strengthens the immune system, allows you to have a healthy skeletal system, and even strong and flexible muscles, and it regulates the circulatory system, positively affects the digestive system, reduces stress, improves sleep quality, and improves communication skills and self-confidence (P6) (Theme—healthy life).

When I do yoga, I feel that I think in a healthier way and my body is healthier. I also feel mentally and spiritually purified (P9) (Theme—healthy life).

Severe cricks started in my back. I had crick in my back for five times in a year, I stayed in bed for months and had injections. The quality of my life decreased so much that I was afraid to even go for a walk. I went to a doctor and the doctor said I was having a heavy muscle spasm, and he recommended yoga. My brother had been practising yoga for about a year and he was so happy, I started it thanks to him. I was in a lot of pain on the first day when I started yoga. And when I got out of the yoga hall, a miracle happened. I felt so good, I can't describe it. I got healthy again (P8) (Theme—Reducing pains).

I started yoga because I thought it would relax my mind. I thought it would help me relax and get me out of the stressful situation. And it helped as I thought (P15) (Theme—coping with stress).

Being able to be on my own and integrating with myself mentally and physically, I feel my calm and peaceful mood in my daily life increased, and I feel my muscles relax and my body relax (P16) (Theme- raising awareness).

Events that used to worry me for days and make me nervous now make me laugh. I can focus better now. And most importantly, my energy has gone up. Now I can easily get rid of the usual negativities around me (P10) (Theme—increasing positive thinking).

Theme 4: Experiences of the participants' physical, mental and social state

Participants stated the effects of yoga on their physical, mental and social states as follows: increasing positive emotions (12), relieving (11), reducing pain (9), increasing positive personality traits and raising awareness (5), increasing sleep quality and self-esteem (4).

Some of the participants' statements about the effects of yoga on their physical, mental and social states are as follows:

I had back and neck pain due to working at a desk and stress. I had less pain for 2 years (P10) (Theme-reducing pain).

Physically, my muscle structure has been strengthened, and I can see it clearly. My spinal posture has improved. I feel it is good for my herniated disc. It relieved my back pain (P12) (Theme- reducing pain).

My back pain has decreased, I have become more flexible and I feel more peaceful. (P4) (Theme- reducing pain).

My back pain with which I had struggled before yoga is over… I have not taken a single muscle relaxant for 7 months, I have not had an injection… I had headaches like migraine and they decreased greatly (P8) (Theme- reducing pain).

Thanks to the breathing exercises, the quality of my sleeping pattern got better (P13) (Theme- increasing sleep quality).

My sleeping pattern has become regular by proper breathing since I started practicing yoga, (P17) (Theme- increasing sleep quality).

Psychologically, yoga has transformed me into a more balanced and calm person (P1) (Theme-increasing positive personality traits).

On the days when I practice yoga, my brain works harder, and I'm more humorous and tolerant, smiling and less forgetful (P2) (Theme-increasing positive personality traits).

Yoga allowed me to become stronger psychologically, and it increased my quality of life, and since it motivated me positively, based on the belief that I could do whatever I wanted, positive thoughts in my soul were reflected on my body and created an integrity (P10) (Theme- increasing self-esteem-increasing positive emotions).

Being aware of my body and emotions has been good for my physical and mental health (P11) (Theme—increasing awareness).

For me, yoga takes you on a journey into your inner world. It raises awareness of your body, your inner world, and your essence. It teaches to be unified with the body, to listen to it and to perceive the messages coming from it (P12) (Theme- raising awareness).

I feel much more energetic, I do not get sick, I do not feel pain in my body, I do not get tired, I do not get angry, I am calmer when communicating with people and I can understand them. Since I feel stronger, I have no difficulty in performing my work and I can work with pleasure (P6) (Theme- increasing positive emotions).

I feel energetic thanks to the deep breath I take in yoga. The feeling of fatigue is over (P16) (Theme—relieving).

I feel a relief in my joints, and I do not feel fatigue (P2) (Theme- relieving).

But I think yoga decreases the stress level and increases the happiness hormone, and ensures spiritual, mental and physical balance (P16) (Theme—coping with stress).

I can say that it allows me to control my anxiety because it calms my mind psychologically (P9) (Theme—coping with stress) (Table 2 ).

Theme 5: Difficulties of doing yoga

Participants described, their difficulties in practising yoga, with the themes of physical difficulty (10) and mental difficulty (1).

Some of the participants' statements about the difficulties of practicing yoga are as follows:

While practising yoga, you have to throw away the thoughts in our head for 1–1.5 h, and if you push yourself away for a moment, you will break from the group in yoga because the movements are coordinated with commands. This is of course difficult after a certain age (P2) (Theme- mental difficulty). This participant (P2) is the oldest participant of the study group.

Some of the movements we do physically are difficult for me, which is because I didn't do yoga or any sports when I was a child, so it can sometimes be difficult for me to manage my muscles (P10) (Theme—physical difficulty) (Table 2 ).

Metaphors about doing yoga

When participants were asked to compare their experience of doing yoga to something thirteen metaphors emerged (Fig.  1 ). The responses to the question about the metaphor for practicing yoga were generally collected within the framework of supporting and guiding (teacher, sports, lighthouse, energy source), relaxing and peaceful (worshipping, lightning rod, nature, sea, sun), flexibility and elegance (swan, flamingo, butterfly, child) themes.

Participants’ metaphors for practising yoga

Worshipping: I can compare yoga to worshipping because I think it is a spiritual and meditative action. I feel that I am getting closer to God. (P1) .

Sports: The human body is an excellent machine. Yoga is a sport that makes this machine work most perfectly for many years. All organs support each other physically and chemically. The brain governs it (P2).

Lightning rod: I would compare it to a lightning rod. Because I think that yoga grounds the tense energy accumulated on the body, just as the lightning rod provides grounding without damaging the building where the lightning strikes (P9).

Nature: The only thing which I can compare yoga to is nature's own cycle. Because while we are practising yoga as a part of nature, we begin to stretch at first, and move slowly with breathing exercises. Then we get caught up in the flow of yoga, just like the flow of nature. Finally, we finish the action of yoga as nothing in nature is infinite. However, since there is no end in nature, yoga is also completely unfinished, and we turn into another type, mood and energy frequency (P3).

Sun: I compare yoga to the sun because it warms me inside (P4).

Sea: I think of yoga practice as the peace/infinite happiness that the still/calm blue sea gives me (P5). I compare yoga to the deep blue sea with its visible bottom, creating waves towards the golden sand, containing cleanliness, clarity and peace in it (P10).

Lighthouse: Yoga prevents you from getting lost by allowing you to find your direction like a lighthouse (P6).

Energy source: I would say yoga is an energy source of life because I would change my whole life according to yoga. This has been my belief. (P8).

Flamingo: I compare practising yoga to a flamingo standing on one leg. Flamingos regulate their body temperature by being able to stand on one leg for a long time (P11).

Child: I compare yoga to a child. Because they can make every move with their flexible body (P13).

Butterfly: I would compare yoga to flying like a butterfly over the fragrant coloured flowers in a lush environment on the river bank. Because that's how I feel when I practise yoga (P15).

Teacher: I compare yoga to a teacher. It teaches us our spiritual and physical body. It teaches the spiritual depths of the body to turn back to the essence (P16).

Swan: I feel like a swan while practising yoga, the climax of emotions, elegant movements, movements as if you are evolving into nature (P18).

With this study, the experiences of individuals who have been practicing yoga for a long time were revealed. The benefit perceived by adults who practiced yoga for a long time was demonstrated in terms of physical, mental, and social aspects by qualitative analysis method. The findings obtained from the study showed that at the end of the yoga practice, which was applied two sessions per week for two years, the individuals had reductions in pain and flexibility, relaxation in the spiritual field, higher sleep quality, positive personality traits, self-esteem, and positive emotion, and they were effectively able to cope with anxiety and stress.

Because the study was qualitative the situations experienced by the individuals, their reactions to events and their beliefs, attitudes and behaviours were evaluated in a more realistic, systematic and detailed way. The original aspect of this study is that it is both a qualitative study and that the participants became aware of the positive effects of yoga in daily life and adopted the habit of regularly practicing yoga. One of the conclusions that can be obtained from this study is that starting yoga early and continuing it for a long time will relieve physical difficulties. Thus, individuals can be encouraged to participate in daily life and their quality of life can be improved by increasing their yoga physical fitness and physical activity levels.

For the participants participating in this study, yoga has different meanings, such as exercise, healthy life, worshipping, calmness, harmony, awareness, and balance. The origin of the word "yoga" in the literature is etymologically based on the Sanskrit words "joug" and "yuj (g)" which mean "connection" and "unity". As a thought, yoga means that all different aspects that make up the human being are combined with it in a balanced way. In this context, yoga is also expressed as a “life system’ that explains the basic principles of life and the “truth” in its entirety without breaking it down [ 17 ]. In a study on yoga, the meaning of yoga was expressed as body awareness, energy and physical, mental and emotional integrity caused by physical posture, breathing work and relaxation [ 18 ]. In another study, participants interpreted yoga as regeneration, moral force and, awareness of the body, a finding similar to our study [ 19 ].

A study by Kuru, Alici and colleagues [ 20 ], similarly stated that for participants, yoga meant personal transformation. It is known in the literature that yoga has positive contributions to both healthy people and those with health problems in the physical, social, and spiritual aspects. Similar to the results of the study, other studies have shown that yoga improves mood [ 21 ], reduces stress [ 22 ], increases well-being [ 23 ] and improves the quality of life [ 3 , 24 ].

In this study, metaphor terms related to practicing yoga were usually collected within the framework of the supporting, guiding, relaxing, peaceful, flexibility and elegance themes. The study showed that the metaphors for practising yoga were in harmony with the literature. It is generally accepted in the literature that yoga creates physical and psychological benefits, and it is generally reported that it can be used for strengthening muscles, reducing stress, and maintaining the physical and psychological well-being of the person, and relieving the ailments such as fatigue, pain, difficulty in concentration and loss of balance [ 25 ]. Yoga is also a lifestyle activity, and lifestyle contributes to the continuity of the ontological sense of security. We, as human beings, need ontological security due to our concern about the continuation of our existence. We manage this anxiety through daily routine, social interactions, and lifestyle choices [ 26 ]. Yoga practice aims to improve or maintain physical fitness and health [ 8 ]. The perception of yoga as a part of physical culture has been attributed to its stress-reducing and relaxing properties depending on anatomical and physiological assumptions [ 27 ]. Physical activity stimulates several brain chemicals that make you feel happier, much more relaxed, and less anxious. Scientific studies show that physical activity performed through yoga can decrease depression. The results of this study revealed positive improvements with yoga from the aspects of feeling good and positive emotions, more positive perception of one's body image, physical self-esteem, and self-pride. Moreover, as in similar studies, it was seen in this study that yoga decreased stress, improved stress-coping power, and positively affected the quality and duration of sleep among those having sleep disorders [ 9 , 10 , 11 , 27 , 28 ].

In this study, female participants were in the majority as in other studies [ 28 , 29 ]. In this study, only two of the eighteen participants were male. When yoga studies are examined, it is seen that yoga is a field where women are predominant. The reasons for this situation are the effects of certain gender roles and stereotypes about women and men. It is accepted that women are more open to innovation, spiritual practices, and accepting their shortcomings. These differences that are accepted as existing between men and women are based on gender roles. According to the results of the research, it was revealed that not practicing yoga is a result of prejudice in men and that they are worried that they will experience social prejudice. The data obtained from studies showing the socio-demographic characteristics of yoga practitioners in Turkey are similar to the results of this study [ 7 , 29 , 30 ].

Limitations of study

The results of this study were limited to people who practice yoga in a particular institution. In addition, due to the nature of the qualitative study, it only covers the answers of eighteen participants.

The study has enabled us to deeply understand what yoga is and how it affects people. It has been found that problems such as pain and anxiety that individuals face in their daily life can be more easily solved with regular yoga practice. Yoga is a slow and elegant activity suitable for all participants that can improve the life energy of the participants. Practicing yoga has brought about positive developments in the subjects, such as feeling good and positive, experiencing inner comfort and peace, feeling stronger in their world of belief, perceiving their own body images more positively, valuing themselves physically and being proud of themselves. It is recommended that the effects of yoga be revealed by qualitative research in different populations. It is recommended that yoga be started at an early age and done regularly as it provides easy resolution of significant problems such as pain, anxiety, sleeping, stress, that negative affect our daily life.

Availability of data and materials

The data and materials of the current study are available from the corresponding author on reasonable request.

Marinov T, Gencheva N, Angelcheva M, Ignatov I, Dimitrov V. Influence of yoga practices on stress coping strategies. J Med Physiol Biophys. 2017;39:57–63.

Google Scholar  

Kaviya L, Priya AJ, Devi RG. Comparative study of health and physical status of sedentary workers performing yoga and aerobic exercise. Drug Invent Today. 2019;12(9):1849–51.

Hendriks T, Jong J, Cramer H. The effects of yoga on positive mental health among healthy adults: A Systematic Review and Meta-Analysis. J Altern Complement Med. 2017;23(7):505–17.

Article   PubMed   Google Scholar  

Cheung C, Wyman JF, Bronas U, McCarthy T, Rudser K, Mathiason MA. Managing knee osteoarthritis with yoga or aerobic/strengthening exercise programs in older adults: a pilot randomized controlled trial. Rheumatol Int. 2017;37:389–98. https://doi.org/10.1007/s00296-016-3620-2 .

Noradechanunt C, Worsley A, Groeller H. Thai Yoga improves physical function and well-being in older adults: a randomised controlled trial. J Sci Med Sport. 2017;20:494–501. https://doi.org/10.1016/j.jsams.2016.10.007 .

Tulloch A, Bombell H, Dean C, Tıedemann A. Yoga-based exercise improves health-related quality of life and mental well-being in older people: a systematic review of randomised controlled trials. Age Ageing. 2018;47(4):537–44. https://doi.org/10.1093/ageing/afy044 .

Yoshihara K, Hiramoto T, Oka T, Kubo C, Sudo N. Effect of 12 weeks of yoga training on the somatization, psychological symptoms, and stress-related biomarkers of healthy women. Biopsychosoc Med. 2014;8(1):1–9. https://doi.org/10.1186/1751-0759-8-1 .

Article   PubMed   PubMed Central   Google Scholar  

Francis T, Devi RG, Jyothipriya A. Comparative study on the effect of intense exercise and yoga on memory. Drug Invent Today. 2019;12(4):735–7.

Rshikesan PB, Subramanya P. Effect of integrated approach of yoga therapy on male obesity and psychological parameters- A randomised controlled trial. J Clin Diagnostic Res. 2016;10(10):1–6. https://doi.org/10.7860/JCDR/2016/21494.8727 .

Article   Google Scholar  

Portz JD, Waddington E, Atler KE, Van Puymbroeck M, Schmid AA. Self-management and yoga for older adults with chronic stroke: a mixed-methods study of physical fitness and physical activity. Clin Gerontol. 2018;41(4):374–81. https://doi.org/10.1080/07317115.2016.1252453 .

Kuntz AB, Chopp-Hurley JN, Brenneman EC, Karampatos S, Wiebenga EG, Adachi JD, Noseworthy MD, Maly MR. Efficacy of a biomechanically-based yoga exercise program in knee osteoarthritis: a randomized controlled trial. PLoS ONE. 2018;13(4):1–18. https://doi.org/10.1371/journal.pone.0195653 .

Article   CAS   Google Scholar  

Kumar PN, Balakrishnan R, Kana V. A pilot cross-sectional survey on awareness and practice regarding Type 2 Diabetes mellitus and its management with Yoga. J Ayurveda Integr Med. 2020;11(2):106–9.

Prabhakaran D, Chandrasekaran AM. Yoga for the prevention of cardiovascular disease. Nat Rev Cardiol. 2020;17(9):536–7.

Khoshnaw DM, Ghadge AA. Yoga as a complementary therapy for metabolic syndrome: a narrative review. J Integr Med. 2021;19(1):6–12.

Lin PJ, Peppone LJ, Janelsins MC, Mohile SG, Kamen CS, Kleckner IR, Mustian KM. Yoga for the management of cancer treatment-related toxicities. Curr Oncol Rep. 2018;20(1):1–9.

Yıldırım A, Şimşek H. Sosyal Bilimlerde Nitel Araştırma Yöntemleri, Nitel Araştırma Desenleri ve Süreci. Ankara: Seçkin Yayıncılık; 2016. p. 21–34.

M, McClanahan M, McArthur Warren S, Rogers R, Ballmann C. A comparison of the acute effects of different forms of yoga on physiological and psychological stress: a Pilot Study. Int J Environ Res Public Health. 2020;17(17):6090.

Regan EW, Wende M, Blake C, Fritz S. Yoga for everyone: a qualitative study of a community yoga class for people with disability. Physiother Theory Pract. 2020:1–11. https://doi.org/10.1080/09593985.2020.1765438 .

Schmid AA, Van Puymbroeck M, Fruhauf CA, Bair MJ, Portz JD. Yoga improves occupational performance, depression, and daily activities for people with chronic pain. Work. 2019;63(2):181–9.

Kuru- Alici N, Arikan-Dönmez A. A systematic review of the effect of laughter yoga on physical function and psychosocial outcomes in older adults. Complement Ther Clin Pract. 2020;41: 101252.

Saeed SA, Cunningham K, Bloch RM. Depression and anxiety disorders: benefits of exercise, yoga, and meditation. Am Fam Physician. 2019;99(10):620–7.

PubMed   Google Scholar  

Albracht-Schulte K, Robert-McComb J. The effects of yoga and quiet rest on subjective levels of anxiety and physiological correlates: a 2-way crossover randomized trial. BMC Complement Altern Med. 2018;18(1):280.

Yang K, James KA. Yoga, as a transitional platform to more active lifestyle: a 6-month pilot study in the USA. Health Promot Int. 2016;31(2):423–9.

Cocchiara RA, Peruzzo M, Mannocci A, Ottolenghi L, Villari P, Polimeni A, Guerra F, La Torre G. The use of yoga to manage stress and burnout in healthcare workers: a systematic review. J Clin Med . 2019;8(3):284.

T, Tanahashi T, Sudo N, Lkhagvasuren B, Yamada Y: Changes in fatigue, autonomic functions, and blood biomarkers due to sitting isometric yoga in patients with chronic fatigue syndrome. Biopsychosoc Med. 2018;12:3. https://doi.org/10.1186/s13030-018-0123-2 . PMID: 29643935; PMCID: PMC5891891.

Rezaei S, Mahfeli M, Mousavi SV, Poorabolghasem HS. The effect of laughter yoga on the quality of life of elderly nursing home residents. Caspian J Neurol Sci. 2019;5(1):7–15.

Lee EC, Adams W, Sandoval-Skeet N, Hoyt A, Lee K. Yoga as an adjunct activity for medical students learning anatomy. BMC Med Educ. 2022;22(1):188.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Wang WL, Chen KH, Pan YC, Yang SN, Chan YY. The effect of yoga on sleep quality and insomnia in women with sleep problems: a systematic review and meta-analysis. BMC Psychiatry. 2020;20(1):195.

Öznalbant E, Alvarez MD. A socio-cultural perspective on yoga tourism. Tour Plan Dev. 2020;17(3):260–74. https://doi.org/10.1080/21568316.2019.1606854 .

Atkinson NL, Permuth-Levine R. Benefits, barriers, and cues to action of yoga practice: a focus group approach. Am J Health Behav. 2009;33(1):3–14. https://doi.org/10.5993/ajhb.33.1.1 . (PMID: 18844516).

Download references

Acknowledgements

The authors would like to thank all the yoga participants in this study for sharing their feelings, opinions, and experiences.

The authors declare that this study has received no financial support.

Author information

Authors and affiliations.

Department of Healthcare Services, Vocational School of Healthcare Services, Akdeniz University, 07070, Antalya, Turkey

Şengül Akdeniz

Department of Medical Services and Techniques, Vocational School of Health Services, University, 07070, Antalya, Turkey

Özlem Kaştan

You can also search for this author in PubMed   Google Scholar

Contributions

ŞA and ÖK performed the research; ŞA collected and analyzed the data; ŞA and ÖK designed the research study and wrote the paper. All authors approved the final version of the article, including the authorship list.

Corresponding author

Correspondence to Şengül Akdeniz .

Ethics declarations

Ethics approval and consent to participate.

Ethics committee approval was received for this study from the ethics committee of Akdeniz University Faculty of Medicine (Date: 05.07.2019, No. 299).

Verbal and written informed consent was obtained from participants who participated in this study.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Akdeniz, Ş., Kaştan, Ö. Perceived benefit of yoga among adults who have practiced yoga for a long time: a qualitative study. BioPsychoSocial Med 17 , 19 (2023). https://doi.org/10.1186/s13030-023-00276-3

Download citation

Received : 18 April 2022

Accepted : 05 May 2023

Published : 15 May 2023

DOI : https://doi.org/10.1186/s13030-023-00276-3

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Perceived benefit
• Mental health
• Physical health
• Qualitative study

BioPsychoSocial Medicine

ISSN: 1751-0759

• Submission enquiries: Access here and click Contact Us
• General enquiries: [email protected]

• DOI: 10.1016/j.jogc.2024.102579
• Corpus ID: 270455457

The Effect of Yoga Therapy in Premenstrual Syndrome: A Systematic Review and Meta- Analysis of Randomized Controlled Trials.

• Monika Ranga , Kalindi Dev
• Published in Journal of Obstetrics and… 1 June 2024

22 References

Evaluation of the effectiveness of yoga in management of premenstrual syndrome: a systematic review and meta-analysis, effect of 16 weeks yogic intervention in premenstrual syndrome., effect of yogic intervention on premenstrual syndrome among adolescence, effect of yoga exercise on premenstrual symptoms among female employees in taiwan, to compare the effects of aerobic exercise and yoga on premenstrual syndrome, impact of yoga training intervention on menstrual disorders, yoga positively affected depression and blood pressure in women with premenstrual syndrome in a randomized controlled clinical trial., the effects of acupressure and yoga for coping with premenstrual syndromes on premenstrual symptoms and quality of life., yoga improves anxiety and vital signs of women with premenstrual syndrome, effects of yoga on quality of sleep of women with premenstrual syndrome., related papers.

Showing 1 through 3 of 0 Related Papers

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List

The Use of Yoga to Manage Stress and Burnout in Healthcare Workers: A Systematic Review

Rosario andrea cocchiara.

1 Department of Public Health and Infectious Diseases, Sapienza University, 00185 Rome, Italy; [email protected] (R.A.C.); [email protected] (A.M.); [email protected] (P.V.)

Margherita Peruzzo

2 Department of Oral and Maxillofacial Sciences, Sapienza University, 00161 Rome, Italy; [email protected] (M.P.); [email protected] (L.O.); [email protected] (A.P.); [email protected] (F.G.)

Alice Mannocci

Livia ottolenghi, paolo villari, antonella polimeni, fabrizio guerra, giuseppe la torre.

The purpose of this systematic review is to analyze and summarize the current knowledge regarding the use of yoga to manage and prevent stress and burnout in healthcare workers. In February 2017, a literature search was conducted using the databases Medline (PubMed) and Scopus. Studies that addressed this topic were included. Eleven articles met the inclusion criteria. Seven studies were clinical trials that analyzed yoga interventions and evaluated effectiveness by gauging stress levels, sleep quality and quality of life. A study on Chinese nurses showed statistical improvement in stress levels following a six-month yoga program (χ2 = 16.449; p < 0.001). A population of medical students showed improvement in self-regulation values after an 11-week yoga program (from 3.49 to 3.58; p = 0.04) and in self-compassion values (from 2.88 to 3.25; p = 0.04). Four of the included articles were observational studies: They described the factors that cause stress in the work environment and highlighted that healthcare workers believe it is possible to benefit from improved physical, emotional and mental health related to yoga activity. According to the literature, yoga appears to be effective in the management of stress in healthcare workers, but it is necessary to implement methodologically relevant studies to attribute significance to such evidence.

1. Introduction

Healthcare professionals daily face heavy stress loads. Even during training, medical students and healthcare professionals must cope with heavy workloads and high stress levels in a competitive environment that facilitates the onset of burnout [ 1 , 2 ].

This pattern continues to be equally complex in the working environment where professionals must cope with a demanding job, the stress of shiftwork and various responsibilities derived from their chosen medical field [ 3 ].

The term “burnout” is usually referred to helping professions. It indicates a prolonged exposure to physical and psychological stress that results in deterioration of the emotional functioning of the individual and in a difficulty of adaptation to their professional commitments [ 4 ].

Most of the published literature regarding this topic focuses on the nursing category as it represents the most prominent group of healthcare providers and effectively combines the main health problems: Both psychological and physical stress [ 5 , 6 , 7 ]. Other professionals, such as surgeons and dentists have exhibited similar issues: These must be added to the numerous working hours they spend in stationary and incorrect posture from which musculoskeletal conditions such as back pain, neck or shoulder strain, headache and carpal tunnel syndrome derivate [ 8 ].

This pattern has captured the attention of healthcare managers who are now seeking solutions to these problems [ 9 ]. Burnout and stress impact the physical and mental health of the individual and compromise the quality of care as they generate dissatisfaction, anxiety and an increased risk for patients [ 10 , 11 , 12 ].

In consideration of these premises, the published literature indicates that yoga and other mind-body meditation programs provide some innovative solutions, scientifically recognized as effective methods to enhance empathy, reduce stress and improve physical work-related issues in healthcare professionals [ 13 , 14 ].

In some cases, yoga programs have been readapted to meet the needs of the work environment as being structured in less time-invasive sessions to be held in the workplace, in association with daily meditation to be carried out individually at home [ 15 ]. The clinical trials have highlighted significant efficacy in stress management, the reduction of burnout and in overall improvement of quality of life (QoL).

The aim of this study is to analyze and summarize all the current knowledge concerning yoga as an effective technique for the prevention and management of stress and burnout among healthcare workers.

2. Materials and Methods

2.1. identification of relevant studies.

This systematic review was performed following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria [ 16 ]. Two electronic databases were examined: Medline (PubMed) and Scopus. The following search algorithm was applied: “yoga AND stress management AND health professional”. In February 2017, eligible studies were selected through a multi-step approach (title reading, abstract and full-text assessment) by two independent researchers.

2.2. Study Selection and Eligibility Criteria

Search results found in both databases (PubMed and Scopus) were uploaded for screening into JabRef 3.8.1. A first selection was performed by filtering duplicates and subsequently, a title and abstract screening was conducted. All potentially relevant articles were then independently reviewed for full text and assessed for eligibility. Studies were included if they addressed the question of yoga used to manage stress and reduce physical pathologies in healthcare professionals. No restriction of year of publication or language was applied during the study selection. Any disagreement between the reviewers was resolved through a consensus session with a third reviewer. Figure 1 shows the flowchart of the selection of articles.

Research flowchart displaying selection and analysis of the items included in the systematic review.

2.3. Data Extraction

The same selection strategy was used for data extraction: two different reviewers collected the data and any disagreement was resolved by a consensus session. The following information were gathered: Author; study design (observational study or clinical trial); year of publication; country; outcomes; quality score. After analyzing the full-text, the main identified target populations were medical specialists, mental healthcare providers, nurses and dentists.

2.4. Quality Assessment

The Jadad scale [ 17 ] was used for the quality assessment of the clinical trials included in the systematic review. The Newcastle-Ottawa Scale (NOS) [ 18 ] was used to evaluate observational studies.

After duplicates were eliminated, 26 potentially relevant studies were identified. Following the screening of titles and abstracts, 15 studies were excluded as they did not meet the inclusion criteria. Ultimately, eleven articles were included in the review. Among these, seven were clinical trials and four were observational studies. Table 1 and Table 2 summarize the characteristics of the included studies. Three articles focused on the nurse population, six articles on medical specialists and two articles on dentists. Ten studies were conducted in the USA and just one was conducted in China.

Clinical trials included in the systematic review.

Observational studies included in the systematic review.

The quality assessment of clinical trials presented scores between a minimum of 1/5 and a maximum of 5/5. The average score was 1/5, which indicates an overall low quality of the studies. These data might be related to the difficulty in applying the parameters of this evaluation scale to these type of interventions (for instance, the difficulty of administering a yoga session to a blind population). The quality assessment for observational studies gave a minimum score of 5/9 and a maximum score of 8/9; the recorded average score of 6.5/9 indicates an overall good quality of the included observational studies.

Lastly, it can be stated that the studies included in our literature review addressed the same conclusions and were of average quality.

3.1. Physical Problems in Healthcare Professionals

Operating within a difficult setting, healthcare workers run into many stressful events that can compromise their state of health [ 22 ]. Often, as a consequence of the demand to maximize performance and productivity at work, health professionals’ needs to release emotional and physical tensions are ignored [ 23 ]. This inevitably results in serious issues affecting their health [ 24 ].

Work-related issues can be physical or affect the subject’s emotional network [ 22 ]. In the first situation the musculoskeletal apparatus is put under pressure. In the workplace there are situations that create a bio-mechanical overload, muscle tension and fatigue [ 25 ]. A stationary and inappropriate posture, the effects of repetitive tasks that require an accurate “execution” and that limit normal movement can be the cause of a physical injury [ 26 ]. Consequently, chronic degenerative diseases of the spine, neck and upper limbs affecting doctors, surgeons, dentists and nurses are frequent in the healthcare sector [ 27 , 28 , 29 ].

Dental hygienists represent a relevant example of this issue as they often experience neck and back pain, eye problems, muscle tension, headaches or carpal tunnel syndrome. These medical conditions are caused by poor posture, demanding schedules and long working hours, which can have a substantial negative impact on the physical well-being of the person and afflict the quality of professional life and job satisfaction [ 8 ].

Likewise, nurses are often exposed to physical stress resulting from lifting and moving heavy weights, which can lead to physical injury as backpain or herniated disc and that can interfere with their professional life [ 20 ].

3.2. Psycho-Emotional Problems in Healthcare Professionals

Due to their exposure to high stress levels, healthcare professionals often experience severe anxiety conditions that may lead to psycho-emotional disruption and ultimately result in burnout [ 30 ]. The psychologist Freudenberger coined the term “burnout” to describe the symptoms of professional exhaustion [ 31 ]. This word indicates the psycho-physical depletion of healthcare providers who gradually lose the ability to adapt to daily stress within the workplace [ 32 ]. The subject presents a combination of anxiety and distress, and consequently becomes unstable and neurotic [ 33 ].

Maslach, Professor of psychology at the University of California, Berkeley is considered one of the most important scientists regarding the burnout phenomenon, which he defines as “an emotional depletion syndrome, a depersonalization, and a reduction in personal abilities” that may arise in subjects whose professions “are concerned with the people” [ 34 ].

The consequences of this condition of psycho-physical distress hinder the well-being of the workforce and affect patients’ health, with both financial and organizational implications for healthcare systems.

3.3. The Use of Yoga as a Tool for the Welfare of the Healthcare Worker

Starting from their university training, medical and nursing students are exposed to heavy workloads, excessive stress and a competitive atmosphere [ 35 , 36 ]. These factors can negatively affect their future professional lives [ 1 , 2 ]. For this reason, it is necessary to identify an effective approach offering targeted solutions for stress management and contributing to achieving a healthy condition for these professional categories [ 37 ].

The discipline of yoga was originally defined as confined within a predominantly spiritual and meditative field. It evolved over time and assumed a more multifaceted nature of mixed techniques that combine mental with physical well-being [ 38 ]. This integrated approach guarantees holistic benefits for the individual. Firstly, aerobic and anaerobic exercises improve the musculoskeletal structure, the insulin circuit, the hormone system, and the metabolism [ 39 , 40 , 41 ]. Furthermore, the benefits achieved from sports or gymnastic exercise are enhanced by the association with meditation activities and psychoanalytic techniques that help to induce relaxation and self-awareness; this technique helps to improve cognitive flexibility and increase attention, acceptance and control of emotional reactions [ 42 , 43 ].

It is recognized that the daily practice of simple exercises strengthens the body and helps individuals to manage the burdens of life, work and interpersonal relationships [ 44 ]. Until a couple of decades ago, the term “meditation” was absent from medical textbooks and scientific articles. However, this approach is now becoming widely acknowledged. The examined scientific literature dealt mainly with the possibility of using meditation techniques—yoga in particular—to manage physical and mental stress, and their use has recently been hypothesized as a possible answer to work-related issues of healthcare workers [ 38 ].

From the scientific literature review it was seen that health professionals are receptive to this matter and perceive demanding workloads, intense care provision, conflicting expectations, patient management and family expectations as stressful factors that inevitably negatively affect their own health [ 3 ]. These elements are especially highlighted by some professional categories such as palliative care clinicians who are exposed to severe stress in their particularly challenging area of work. As an alternative to conventional cognitive training, healthcare workers recognize mind–body skills as important tools that can help them in managing their work activities [ 3 ]. Nurses for example, the largest group of healthcare professionals, are exposed to both physical and psychological stressors. In an anonymous survey conducted by Kemper et al., 50% of respondents were shown to have great expectations in mind–body training aimed at reducing anxiety, gaining serenity and a greater psychic well-being. About 99% of respondents reported having tried a mind–body practice in the 12 months prior to the study and among these 34% declared participation in meditation activities such as yoga, chi or qigong [ 20 ]. Conversely, in the category of dental hygienists references to yoga were more focused on solving problems related to low backpain and neck pain [ 8 ].

Moreover, clinical trials are useful in establishing the evidence of a greater effectiveness of this innovative approach and can highlight the potential of such disciplines by comparing them to normal cognitive trainings.

Fang and Li’s clinical trial examines a population of 120 nurses randomized into two groups: one group followed a yoga program, while the other group followed no program. A six-month follow-up analysis shows that the yoga group reports reductions in stress levels (χ2 = 16.449; p = 0.001) Change using “χ2” [ 6 ]. The study of Alexander et al., conducted on a nurse population involved in an eight-week yoga program, also shows higher levels of self-care compared to a population who did not participate [ 5 ]. Riley’s work, in addition to giving an estimate of how yoga can improve the physical and psychological health status of staff, estimates how yoga programs are more effective than cognitive training programs in determining a better mental well-being and a reduction of stress-related consequences [ 19 ]. Finally, Bond et al. carried out a trial focused on medical students that were involved in an 11-week mind–body course: Statistically significant improvements were recorded in self-regulation values, which rose from 3.49 to 3.58 ( p = 0.003), and in self-compassion values, which arose from 2.88 to 3.25 ( p = 0.04). The perceived stress scores decreased from 1.55 to 1.48, and empathy levels increased from 5.64 to 5.80, however these values were not statistically significant ( p = 0.70 and p = 0.30, respectively) [ 1 ].

4. Discussion

Increasing the use of yoga and meditation can provide a valid help to the healthcare workers in achieving a stable psycho-physical well-being that enhances their value within their work environment. This is mainly through simple meditation exercises which do not require a specific environment and can even be performed in any workplace setting [ 45 ]. The yoga program discussed in the study of Klatt et al. emphasizes the advantages of an activity that prove to be feasible and adaptable to the working environment [ 15 ]. Furthermore, the implementation of an individualized approach could guarantee an effective impact on the specific health needs of the employees. Programs such as Mindfulness in Motion (MIM) are delivered within the workplace and structured in short sessions that do not impact professional routine [ 15 ]. Alternatively, these yoga sessions could be organized alongside other activities such as art, music and writing. Along these lines, the Arts-in-Medicine program (AIM) described by Repar and Patton was devised. In addition, in this case, improvements were seen in the perceived levels of stress and overall well-being of individuals [ 7 ].

Within the scope of occupational medicine there are many interventions that can improve the psychological and physical well-being of healthcare workers, such as rescheduling working shifts or frequency and duration of breaks [ 46 ]. Nevertheless, the studies in this systematic review have shown an evident effectiveness of the yoga approach and suggest that a synergistic positive effect could be achieved when combining it with the other above-mentioned interventions [ 47 ].

The weaknesses of this analysis are undeniably related to the low numerical consistency of studies present in the literature and at the same time to the heterogeneity of the interventions that results in a difficulty to make any comparison. The studies included in this review are relatively recent: 2007 is the earliest year of publication and this highlights even more the innovation and the broad potential of this insight.

Alternatively, the strengths of this study are represented by the revolution that this type of approach brings for the management of healthcare workers as the costs for implementing them are low in comparison to the considerable projected costs of financial and welfare benefits. Healthcare administrators, who are called upon to offer efficient solutions to workers’ health issues, must acknowledge the importance of this simple and effective approach.

5. Conclusions

According to the published literature, yoga is effective in the prevention and management of musculoskeletal and psychological issues. In addition to an improvement in physical problems and in quality of sleep, both stress levels and burnout are consistently reduced in subjects who practice yoga techniques and mind–body meditation. Although the data published highlight the full potential and possible benefits derived from these techniques, in order to warrant a widespread diffusion as a daily practice, it would be necessary to broaden the subject further and acquire more robust scientific evidence by designing and implementing research studies equipped with a solid methodological structure on bigger sample groups.

Author Contributions

R.A.C. and M.P. conducted the literature search, the selection of articles, data extraction and write-up of the manuscript. A.M., L.O., P.V., A.P., G.L.T. and F.G. were involved in the design of the study and revision of the paper.

Conflicts of Interest

The authors declare no conflict of interest.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• My Bibliography
• Collections
• Citation manager

Save citation to file

Email citation, add to collections.

• Create a new collection
• Add to an existing collection

Add to My Bibliography

Your saved search, create a file for external citation management software, your rss feed.

• Search in PubMed
• Search in NLM Catalog
• Add to Search

Yoga in the schools: a systematic review of the literature

Affiliation.

• 1 University at Buffalo, State University of New York, NY, USA. [email protected]
• PMID: 23070680

Objective: The objective of this research was to examine the evidence for delivering yoga-based interventions in schools.

Methods: An electronic literature search was conducted to identify peer-reviewed, published studies in which yoga and a meditative component (breathing practices or meditation) were taught to youths in a school setting. Pilot studies, single cohort, quasi-experimental, and randomized clinical trials were considered.

Research: quality was evaluated and summarized.

Results: Twelve published studies were identified. Samples for which yoga was implemented as an intervention included youths with autism, intellectual disability, learning disability, and emotional disturbance, as well as typically developing youths.

Conclusion: Although effects of participating in school-based yoga programs appeared to be beneficial for the most part, methodological limitations, including lack of randomization, small samples, limited detail regarding the intervention, and statistical ambiguities curtailed the ability to provide definitive conclusions or recommendations. Findings speak to the need for greater methodological rigor and an increased understanding of the mechanisms of success for school-based yoga interventions.

PubMed Disclaimer

Publication types

• Search in MeSH
• Citation Manager

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.

Are white noise machines bad? Here’s what the latest science says.

We conducted a review of the medical literature on white noise machines for young children. All the devices generated alarmingly loud sounds.

I’ve been using a white noise machine since my son was born. It helps him sleep. Is that bad? Could it affect his hearing?

Many American households turn to white noise machines to help their children get to and stay asleep. White noise is made up of different frequencies, creating a background sound that can muffle potential disturbances. The devices are easy to use, often in the form of a stand-alone machine or a smartphone app. The positives of this seemingly low-risk intervention are obvious: better sleep.

But just how low risk is it? To find out, we conducted a review of the available literature on white noise machines for young children. The results, recently published in the journal Sleep Medicine, showed that all tested devices generated alarmingly loud sounds.

There is no uniform standard for noise exposure from consumer products like white noise machines. For occupational noise, however, the National Institute for Occupational Safety and Health (NIOSH) recommends limiting exposure to less than 85 decibels over eight hours and 82 decibels over 16 hours. That’s roughly equivalent to noise from a lawn mower over eight hours or standing near busy traffic for 16 hours.

Get Well+Being tips straight to your inbox

A toddler might sleep for 10 to 12 hours a night, but infants may sleep up to 16 hours over the whole day . In our review, we found that across 24 white noise machines and six phone apps, all could produce sound that violated the NIOSH guideline for an eight-hour work shift. Some white noise machines can reach volumes of 91 decibels — around the same level as a Metrorail train roaring through a station at top speed.

Most parents probably aren’t setting the machines at the loudest setting. But this finding means that during a typical night’s sleep, a white noise machine at maximum volume exposes children to noise that can cause permanent hearing loss.

Changing the type of sound to music, static, rumble or tones does not make the sound safer, but lowering the volume does. In general, you should keep your white noise machine at the lowest volume that helps your child sleep. Our recommendation is to keep the volume at 60 decibels or less.

Can white noise machines damage hearing?

White noise exposure near its maximum volume is harmful in multiple ways. Loud, extended noise exposure causes mechanical stress to inner ear sensory hair cells, inflammatory damage to their supporting structures and damage to the nerve ending to the hair cells. This causes breakage of the tiny hairlike receptor proteins on their surface, cell death and loss of supporting cells.

Our research builds on this to show that white noise exposure in young children is even more of a concern due to its potential impact on physiological and social development. Animal models with noise exposure between 60 and 80 decibels have shown stunted vocal development and delayed development of neurons in the auditory processing centers of the brain.

Similarly, studies of children near high ambient noise like high traffic, train or plane noise have been linked to negative effects on sleep duration , sleep disturbances, cognitive development, behavioral issues, reading proficiency and even changes on brain imaging of regions related to language development.

What is a safe level for a white noise machine?

White noise within reasonable limits may help children — and parents — sleep without causing harm. We found studies showing that white noise applied at 60 decibels or less — about the volume of a quiet conversation — showed a decrease in nighttime arousals, increased sleep time and increase sleep efficiency (time spent asleep while in bed).

To check whether your white noise machine is at a safe volume, you can purchase a decibel meter online or download an app on your smartphone. NIOSH created a free app calibrated specifically for iPhones, called the NIOSH Sound Level Meter (SLM) app.

Place the white noise machine at the volume you usually use it and place your decibel meter where your child sleeps. The sound intensity should be well below 82 decibels.

Lt. Col. Isaac Erbele is the associate program director for otolaryngology-head and neck surgery at Brooke Army Medical Center in San Antonio. Capt. Russell De Jong is a resident surgeon in otolaryngology-head and neck surgery at Brooke Army Medical Center in San Antonio. The views expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, Wilford Hall Ambulatory Surgical Center, the Defense Department or any agencies under the U.S. government.

A prescription for better living

• Taking care of your skin doesn’t have to be expensive. Here’s a simple, science-backed routine for day and night.
• Our nails are a unique window into our overall health. Here’s what to know about the diseases associated with distinctive nail changes.
• Do you get sleepy in the afternoon after eating lunch? The most likely culprit is your circadian rhythm, but what you eat may also play a role.
• Does acupuncture work for chronic pain? The evidence for using it to treat headaches and back pain is convincing.
• Next time you get a leg cramp, try taking a sip of pickle juice. Athletes have long used it to ward off cramps, and studies show it may actually work.
• Are salads actually good for you ? It depends on what you add to it, especially your choice of dressing.