research articles on yoga

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Why Yoga Is Good for Your Body and Brain, According to Science

When I (Dacher Keltner) was 18, I wandered into a yoga class in my first year of college, hosted on a basketball court in the school’s gym. At the time, some 40 years ago, yoga had mystical, somewhat cult-like connotations. While a handful of students waited on mats, the teacher arrived dressed in white clothes, looking like Jesus. After playing a song on a wooden flute, and reading a few Haiku poems, he led the class through a series of yoga postures. Yoga, just getting off the ground in the West, would prove to be a salve for my anxious tendencies.

Yoga may very well be one of our oldest happiness practices. Archeologists have discovered figurines in India that date from 5,000 years ago that represent what appear to be people in yoga postures. More certain is that yoga emerged some 2,500 years ago in Indus-Sarasvati civilization in Northern India as part of Hinduism.

Many in the West are familiar with one vein of yoga practices: the asanas, a Sanskrit that translates to “postures.” The full tradition is much broader, and encompasses pranayama (mindful breathing), meditations, chanting, sutras (yoga philosophy by the sage Patanjali), kriya (internal cleansing movements), and ethical principles related to kindness, selflessness, non-materialism, and nonviolence. Over its history, yoga has evolved into many forms, from Tai Chi and Qi Gong to hot yoga and core power yoga.

Today in the U.S., more than 36 million people practice yoga on a regular basis. They likely practice one of a couple kinds of yoga that derive from Vedic yoga and involve 12 basic postures, with names like plow, fish, cobra, locust, and bow pose. In addition to these metaphorical descriptions that add significance to the body’s movements, this kind of yoga also involves the teaching of deep breathing patterns and a focus on being present and mindful .

Does this practice work? Indeed, in the past decade, an emerging science of yoga has been uncovering the significant health and happiness benefits of this ancient practice. And it suggests that we should all think about hitting the mat more often.

The health benefits of yoga

Yoga is a practice of the mind and body, and it brings about health and happiness benefits through its direct influence on our nervous system.

Central to yoga is bringing awareness to our breath, also known as the “ujjayi pranayama,” the breath of fire. Deep breathing, like the kind cultivated in yoga, activates the vagus nerve, the large branch of nerves that begins at the top of the spinal cord and stimulates activation in the vocal apparatus, muscles that move the head and eyes, heart, respiration, digestive organs, and gut. Elevated vagal tone is good for a host of bodily functions, like digestion and immune function.

Some forms of slow yoga breathing involve contracting the glottis muscles in the throat, which improves the heart’s capacity to efficiently regulate blood pressure, and there’s some evidence that practicing yoga can reduce blood pressure .

In a recent study , 29 participants were randomly assigned to a four-month training program of either stretching or yoga respiratory exercises (ujjayi breath). During that time, the yoga group improved their inspiratory and expiratory pressures, the low/high-frequency ratio of heart rate variability, and heart rate variability itself—all markers of better cardiovascular and respiratory function . Simply stretching didn’t have the same effects.

Practice yoga

Jaylissa Zheng has created GGSC-tailored yoga videos, free of charge, that combine mindful body movements with science-backed meditations, available at JlissYoga.com.

In another recent study from a team at UC San Diego, 38 people who participated in a three-month yoga retreat showed a decrease in inflammatory processes , an immune response related to high blood pressure, diabetes, and autoimmune disease.

Given these shifts in the cardiovascular and nervous systems, it makes sense that yoga is good for our health. A regular practice can help loosen the muscles and connective tissues around the joints, which in turn can reduce aches and pains. In one recent study , 75 rheumatoid arthritis patients were randomly assigned to an eight-week yoga program or a waitlist. Rheumatoid arthritis, a painful condition that involves tender, swollen joints, is estimated to affect 54 million Americans each year and cost the health care system $19 billion . The patients who practiced yoga saw significant improvements in their experiences of physical pain, general health, vitality, and mental health, and these reductions in pain lasted nine months after the study ended.

According to other studies , practicing yoga can help reduce people’s stress, anxiety , and depression —perhaps better than traditional medication if you practice daily for over a month. Yoga has also been found to be an effective way to help people overcome addictions . In light of these findings, it’s not surprising that regular practitioners of yoga report being happier .

How yoga makes us happy

How does yoga make us happier? It might be related to its effects on heart rate variability and the vagus nerve, according to a review of 59 studies with a total of nearly 2,400 participants. People with higher heart rate variability and vagus nerve activity tend to be kinder and more compassionate, qualities that make for a happier life.

Yoga also shifts our brain chemistry . In one study, Chantal Villemure and colleagues from the National Institutes of Health used magnetic resonance imaging to examine gray matter in the brain, which naturally declines with age. They found that yoga practitioners had less grey matter decline in regions of the cortex involved in the experience of positive states such as joy and happiness.

Finally, yoga has been found to increase activity in the anterior cingulate cortex and the medial prefrontal cortex, brain areas that are associated with empathy, gratitude, and kindness. In other words, practicing yoga may help us experience more positive emotions and be more oriented toward others, both of which can create lasting happiness over time.

Eight years ago, I (Jaylissa Zheng) moved to New York. It was a move that left me suffering from many of the struggles that are rampant today: anxiety, sleeplessness, poor appetite, and a sense of despair. Medication did little, if anything, for my suffering. So I turned to yoga; I became a yoga teacher. And in performing and teaching this ancient happiness practice, I have found an embodied source of ever-richer resilience. Perhaps you, too, can find new meaning in one of the human race’s oldest happiness practices.

About the Authors

Jaylissa Zheng

Jaylissa Zheng is a student at UC Berkeley, a yoga teacher ( JlissYoga.com ), and (as of the Fall) a Ph.D. student, where she hopes to integrate yoga into her clinical practice.

Dacher Keltner

Uc berkeley.

Dacher Keltner, Ph.D. , is the founding director of the Greater Good Science Center and a professor of psychology at the University of California, Berkeley. He is the author of The Power Paradox: How We Gain and Lose Influence and Born to Be Good , and a co-editor of The Compassionate Instinct .

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The popularity of yoga has grown tremendously in the past decade. More than 10% of U.S. adults have practiced yoga at some point in their lives. Yoga practitioners spend on average US$90 a month, and the yoga industry is worth more than $80 billion worldwide .

Yoga is now a mainstream activity in the U.S. and is commonly portrayed as a healthy lifestyle choice. I am a behavioral scientist who researches how physical activity – and specifically yoga – can prevent and help manage chronic diseases.

Many people attribute improvements in their physical and mental health to their yoga practice. But until recently, research had been sparse on the health benefits of yoga. As the body of rigorous research on yoga grows, more and more work is showing the many health benefits of a yoga practice.

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What is yoga?

The name “yoga” is derived from the Sanskrit word “Yuj” meaning to unite, join or connect the mind, body and soul. The first text on yoga was written by the sage Patanjali over 2,000 years ago in India. Patanjali described yoga as “citta-vrtti-nirodhah,” or “stilling the mind.” This was achieved through a mix of breath work, meditation, physical movement and body purification practices, as well as ethical and moral codes for living a healthy and purposeful life.

Over the years, various yoga teachers have modified the original Patanjali yoga, resulting in different styles that vary in their intensity and focus. For example, some yoga styles such as Vinyasa focus more on intense movements similar to an aerobic workout. Restorative yoga includes more relaxation poses. Iyengar yoga uses props and emphasizes precision and proper alignment of body. These different styles provide options for individuals with different physical abilities.

Generally speaking, yoga instructors in the U.S. today teach styles that incorporate postures, breathing exercises and sometimes meditation.

What does the research show?

As yoga has grown in popularity in recent years, researchers have begun to study its effects and are finding that it has great benefit for mental and physical health.

Yoga involves physical movement, so it is no surprise that most types of yoga can help to improve a person’s strength and flexibility. In one study with healthy untrained volunteers, researchers found that eight weeks of yoga improved muscular strength at the elbow and knee by 10%-30% . Flexibility at the ankle, shoulder and hip joints also increased by 13%-188%.

There are a number of less obvious but meaningful benefits from yoga as well. Research has shown that yoga practice can reduce risk factors for heart disease such as high blood pressure, high cholesterol and abdominal obesity. Studies on older adults have shown significant improvements in balance, mobility , cognitive function and overall quality of life .

Yoga seems to be effective at managing pain, too. Research has found that yoga can improve symptoms of headaches , osteoarthritis , neck pain and low-back pain . In fact, the American College of Physicians recommends yoga as one of the options for initial nonpharmaceutical treatment for chronic low-back pain .

Yoga also provides many benefits for mental health. Researchers have found that a regular practice over eight to 12 weeks can lead to moderate reductions in anxiety and depressive symptoms as well as help with stress management .

A group of people sitting on yoga mats with their hands pressed together in front of their chests.

More than physical exercise

Yoga is a type of exercise in that it is a form of physical exertion that helps build fitness. A lot of the benefits researchers have found are due to the physical activity component and are similar to benefits from other forms of exercise like running, weightlifting or calisthenics.

But unlike these other activities, yoga practice incorporates mindfulness as a key aspect. With its focus on controlling breath, holding postures and meditation, yoga increases how much a person pays attention to the sensations of their body and the present moment. This mindfulness leads to many benefits not found from other forms of exercise.

Studies have shown that mindfulness training on its own can increase a person’s self-awareness, along with the ability to recognize and skillfully respond to emotional stress . It can even give a person greater control over long-term behavior. One study found that increased mindfulness from yoga can help people better recognize and respond to feelings of being full when eating, decrease binge eating and alleviate concerns over how their body looks .

My colleagues and I observed a similar effect in a pilot study on the benefits of yoga for individuals with Type 2 diabetes. After doing yoga twice a week for three months, several participants reported paying more attention to their diet, snacking less and eating healthier, even without any nutrition intervention . Our patients also reported less stress and an increased willingness to engage in other types of physical activities.

Yoga is clearly different from Western exercise in how it approaches mental health. With more research, it may be possible to understand the biological mechanisms as well.

Things to know if you want to start doing yoga

Yoga may not be helpful for all medical conditions or right for every person, but people of all age groups, body types and physical abilities can practice yoga. It can be a form of mental and physical exercise for people who do not enjoy sweating during strenuous forms of exercise or for individuals with medical or physical conditions who find working out in the gym challenging.

It is important to consider that although yoga is generally safe, just as with any other form of exercise, there is some risk of getting injured . Individuals with medical conditions who are new to yoga should practice it initially under the supervision of a trained instructor.

If you do decide to give yoga a try, talk to the yoga instructor first to assess whether the style they offer meets your preference and fitness levels. Remember, you may need to practice a couple of weeks to feel the benefits, physically and mentally.

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New Research Shows Yoga Reduces Stress and Improves Well-Being

Recent research found improvements in depression and anxiety through yoga..

Posted February 16, 2024 | Reviewed by Monica Vilhauer

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Studies published in 2024 demonstrate yoga’s positive effects on feelings of well-being.
The latest studies show reduced stress and improved well-being through yoga.
Recent research shows yoga reduced symptoms of depression and anxiety.

Recent world events (including the Covid-19 pandemic, as well as traumatic events worldwide) have undoubtedly increased stress levels in the US, Europe, and across the globe. In addition to traditional counseling, adjunctive and complementary therapies such as yoga may be especially helpful in reducing stress , as well as symptoms of depression and anxiety . Perhaps partially in response to the increased stress levels globally, there appears to be a plethora of recent academic research studies that examine the potential benefits of yoga.

2024 has revealed promising studies demonstrating that yoga may be just such a complementary therapy to assist in improving feelings of well-being, as well as potentially improving sleep quality and social connectedness, among other beneficial effects.

Different Yoga Types for Every Taste

Numerous forms of yoga exist, with a yoga practice for various tastes and preferences. In the West, Hatha Yoga refers to a number of yoga practices which tend to be slower paced and gentle. Restorative Yoga, an even slower-paced yoga, is meant to relax and restore. Then there are more vigorous and athletic types of yoga such as Vinyasa and hot yoga classes. Additionally, yoga varieties extend from yoga practices that hold the positions (called "postures") for longer periods of time (such as Yin Yoga) to the more traditional yogic practices such as Kundalini, which is both physical and spiritual . Fortunately, especially since the Covid-19 pandemic, one need not leave the comfort of one’s living room to practice yoga, as there are various online yoga classes to be found.

Latest Yoga Research: Yoga for Stress Reduction and Improved Mood

Three recent (2024) studies found that yoga significantly reduced feelings of stress and improved feelings of well-being. In a study newly published in the March 2024 issue of Acta Psychologica journal, individuals who practiced a particular yoga focused on yogic breathing called Sudarshan Kriya Yoga (SKY) demonstrated a significant reduction in stress scores following the yoga intervention. Additionally, the individuals practicing this yoga showed increases in social connectedness scores immediately following the yoga intervention and these scores continued to improve with regular yoga practice.

In February 2024, an online study reported in Frontiers in Public Health revealed that in another form of yoga called Isha yoga, participants reported significantly lower levels of stress and mental distress, as well as higher levels of well-being than individuals who were not practitioners of yoga. Furthermore, the well-being effects of yoga were also examined in the January 2024 issue of the Journal of Health Psychology , which reported on a 6-week randomized controlled trial (RCT), the gold standard of research. In this study, a Kundalini yoga intervention improved participants’ extrinsic affect (ability to express emotions) and their self-compassion, as well as their spiritual well-being.

Additional Recent Yoga Research Backs Up These Findings

Interestingly, the results of these three recent studies have been backed up by additional research published in the last year that examined a large number of yoga studies. The common thread found in a review of various studies was a reduction in symptoms of depression by those practicing yoga. In fact, one study examining older adults during the Covid-19 pandemic found a reduction in depression, anxiety, and stress for those in the experimental (yoga) group. Additionally, they discovered an improvement in their sleep while practicing Hatha yoga. The control group (who did not practice yoga) showed an opposite effect: they had an increase in their depression scores during the study. Additionally, a recent randomized controlled study examining effects of yoga as a complementary therapy for panic disorder also showed positive results in reduction of anxiety and improvement in quality of life.

Taken together, recent research findings indicate yoga may be a promising complementary or integrative therapy for assistance in the reduction of symptoms of depression and anxiety, as well as improvement in feelings of well-being. Additional benefits appear to include increased social connection, improved spiritual well-being and better sleep. As a complement to counseling, yoga holds a great deal of promise in improving well-being and we look forward to seeing further yoga research in the future.

Gamonal-Limcaoco, S., Montero-Mateos, E., Lozano-López, M. T., Maciá-Casas, A., Matías-Fernández, J., & Roncero, C. (2021). Perceived stress in different countries at the beginning of the coronavirus pandemic. The International Journal of Psychiatry in Medicine , 57 (4), 309–322. https://doi.org/10.1177/00912174211033710

Kanchibhotla, D., Harsora, P., & Subramanian, S. (2024). Influence of yogic breathing in increasing social connectedness among Indian adults. Acta Psychologica , 243 , 104164. https://doi.org/10.1016/j.actpsy.2024.104164

Malipeddi, S., Mehrotra, S., John, J. P., & Kutty, B. M. (2024). Practice and proficiency of Isha Yoga for Better Mental Health Outcomes: Insights from a COVID-19 survey. Frontiers in Public Health , 12 . https://doi.org/10.3389/fpubh.2024.1280859

Brandão T, Martins I, Torres A, Remondes-Costa S. Effect of online Kundalini Yoga mental health of university students during Covid-19 pandemic: A randomized controlled trial. Journal of Health Psychology. 2024;0(0). doi:10.1177/13591053231220710

Wu, Y., Yan, D., & Yang, J. (2023). Effectiveness of Yoga for major depressive disorder: A systematic review and meta-analysis. Frontiers in Psychiatry , 14 . https://doi.org/10.3389/fpsyt.2023.1138205

Baklouti, S., Fekih-Romdhane, F., Guelmami, N., Bonsaksen, T., Baklouti, H., Aloui, A., Masmoudi, L., Souissi, N., & Jarraya, M. (2023). The effect of web-based Hatha Yoga on psychological distress and sleep quality in older adults: A randomized controlled trial. Complementary Therapies in Clinical Practice , 50 , 101715. https://doi.org/10.1016/j.ctcp.2022.101715

Yadla, V. S., NJ, P., Kamarthy, P., & Matti, M. R. (2024). Effect of integrated yoga as an adjuvant to standard care for panic disorder: A randomized control trial study. Cureus . https://doi.org/10.7759/cureus.53286

Tamara Goldsby, Ph.D. , is a Clinical Research Psychologist affiliated with the University of California, San Diego (UCSD) and a sound healing researcher. Her goal is to bring healing to people on a large scale through her research and writing.

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The effects of yoga on anxiety and stress

Affiliation.

1 St. Elizabeth's Medical Center, Brighton, MA 02135, USA.
PMID: 22502620

Stress and anxiety have been implicated as contributors to many chronic diseases and to decreased quality of life, even with pharmacologic treatment. Efforts are underway to find non-pharmacologic therapies to relieve stress and anxiety, and yoga is one option for which results are promising. The focus of this review is on the results of human trials assessing the role of yoga in improving the signs and symptoms of stress and anxiety. Of 35 trials addressing the effects of yoga on anxiety and stress, 25 noted a significant decrease in stress and/or anxiety symptoms when a yoga regimen was implemented; however, many of the studies were also hindered by limitations, such as small study populations, lack of randomization, and lack of a control group. Fourteen of the 35 studies reported biochemical and physiological markers of stress and anxiety, but yielded inconsistent support of yoga for relief of stress and anxiety. Evaluation of the current primary literature is suggestive of benefits of yoga in relieving stress and anxiety, but further investigation into this relationship using large, well-defined populations, adequate controls, randomization and long duration should be explored before recommending yoga as a treatment option.

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Peer-reviewed

Research Article

Yoga an effective strategy for self-management of stress-related problems and wellbeing during COVID19 lockdown: A cross-sectional study

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Software, Validation, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation National Resource Centre for Value Education in Engineering, Indian Institute of Technology Delhi, Noida, India

Contributed equally to this work with: Kamlesh Singh, Nitesh Sharma, Rahul Garg

Roles Conceptualization, Formal analysis, Project administration, Resources, Supervision, Writing – review & editing

Affiliations National Resource Centre for Value Education in Engineering, Indian Institute of Technology Delhi, Noida, India, Department of Humanities and Social Sciences, Indian Institute of Technology Delhi, New Delhi, India

Roles Conceptualization, Data curation, Formal analysis, Writing – review & editing

Roles Conceptualization, Supervision, Writing – review & editing

Affiliations National Resource Centre for Value Education in Engineering, Indian Institute of Technology Delhi, Noida, India, Department of Computer Science and Engineering, Indian Institute of Technology Delhi, New Delhi, India, Amar Nath and Shahsi Khosla School of Information Technology, Indian Institute of Technology Delhi, New Delhi, India

Pooja Swami Sahni,
Kamlesh Singh,
Nitesh Sharma,

Published: February 10, 2021
https://doi.org/10.1371/journal.pone.0245214
Peer Review
Reader Comments

This cross-sectional research aims to study the effect of yoga practice on the illness perception, and wellbeing of healthy adults during 4–10 weeks of lockdown due to COVID19 outbreak. A total of 668 adults (64.7% males, M = 28.12 years, SD = 9.09 years) participated in the online survey. The participants were grouped as; yoga practitioners, other spiritual practitioners, and non-practitioners based on their responses to daily practices that they follow. Yoga practitioners were further examined based on the duration of practice as; long-term, mid-term and beginners. Multivariate analysis indicates that yoga practitioners had significantly lower depression, anxiety, & stress (DASS), and higher general wellbeing (SWGB) as well as higher peace of mind (POMS) than the other two groups. The results further revealed that the yoga practitioners significantly differed in the perception of personal control, illness concern and emotional impact of COVID19. However, there was no significant difference found for the measure of resilience (BRS) in this study. Yoga practitioners also significantly differed in the cognitive reappraisal strategy for regulating their emotions than the other two groups. Interestingly, it was found that beginners -those who had started practicing yoga only during the lockdown period reported no significant difference for general wellbeing and peace of mind when compared to the mid- term practitioner. Evidence supports that yoga was found as an effective self- management strategy to cope with stress, anxiety and depression, and maintain wellbeing during COVID19 lockdown.

Citation: Sahni PS, Singh K, Sharma N, Garg R (2021) Yoga an effective strategy for self-management of stress-related problems and wellbeing during COVID19 lockdown: A cross-sectional study. PLoS ONE 16(2): e0245214. https://doi.org/10.1371/journal.pone.0245214

Editor: Gagan Deep, Wake Forest Baptist Medical Center, UNITED STATES

Received: October 10, 2020; Accepted: December 23, 2020; Published: February 10, 2021

Copyright: © 2021 Sahni et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The data underlying this study are available on OSF (DOI: osf.io/q7xy9 ).

Funding: The author(s) received no specific funding for this work.

Competing interests: No authors have competing interests.

Introduction

A report by the World Economic Forum estimates that about 2.6 billion people around the world have been in some kind of lockdown that may lead to second form of stress-related disorder epidemic in the second half of 2020 [ 1 ]. Similar to the World economic forum estimations, a survey by the Indian Psychiatric Society shows that two-fifth of the people are experiencing common mental disorders, due to lockdown and the prevailing COVID19 pandemic in India [ 2 ]. This indicates the need for an urgent action to reduce the adverse effects of the COVID19 lockdown on the general well-being of people.

Various factors have been suggested to be contributing to the worsening of mental health. One of the major factors reported causing stress, anxiety and depression is fear of getting infected with the virus/disease (COVID19) [ 3 ]. Previous studies examining illness perception in the context of other chronic diseases such as; diabetes, AIDS and myocardial infarction found that people create their representations of the illness related to its risk of contracting, cause, time the illness will last for, and the consequence of the illness [ 4 – 6 ]. Further, it is also suggested that beliefs plays an important role in the way people create notions for the controllability and cure of the illness [ 7 ]. These representations and notions are argued to determine the stress response, and the ways of coping, which is believed to affect the wellbeing [ 8 ]. On the other hand, some of the factors that influences the perceived effects of the illness are suggested to be the physical and mental health status of the individuals, with healthy people reporting less cognitive and emotional representations of illness [ 9 ]. Even the type of treatment and the preventive measures received are suggested to drive the illness coherence/ understanding and perception about personal control over the illness [ 10 ].

Even though there are some studies supporting that yoga can be used as complementary and alternate therapy for mental health, there is need for empirical research studies to provide evidence for yoga as effective strategy for self-management of stress-related problems during COVID19. Further, to the best of our knowledge the empirical investigation for the effects of yoga and other spiritual practices on illness perception and wellbeing related problems experienced by people during COVID19 has not been examined so far. The present research uses a cross-sectional study design to examine the effect of the practice of yoga and other spiritual practices on illness perception, and wellbeing of adults. In this study, wellbeing has been assessed through measures of depression, stress, anxiety, resilience, peace of mind and the strategies employed to regulate the emotional upheavals. This approach has been reported in earlier studies that have examined wellbeing in terms of anxiety, stress, and depression [ 11 – 13 ], emotion regulation [ 14 ]and as a measure of peace of mind [ 15 ]. Wellbeing has also been shown to positively correlate with resilience [ 16 ]

Previous research has suggested that yoga can be used as a non-pharmaceutical measure or as a complement to drug therapy for treatment or cure of modern epidemic diseases like mental stress, obesity, diabetes, hypertension, coronary heart disease, and chronic obstructive pulmonary disease [ 17 ]. Some recent studies also propose that yoga can assume a ground-breaking complementary and alternative therapy in the battle against the novel coronavirus while improving the physical and mental wellbeing of people in this pandemic circumstance [ 18 , 19 ]. However, for long researchers have debated the role of yoga and other spiritual practices in the mental health of people [ 20 ]. The practice of yoga is most commonly perceived as physical exercise that helps in gaining flexibility, physical strength and helps to relax. In Indian philosophical texts, yoga is treated as a spiritual practice that is related to training of the mind. Patanjali yoga sutra describes yoga as a practice of ‘Chitta vritti nirodha’ literally translating as controlling or calming of the mind. Most commonly, a typical yoga schedule follows a combination of asanas (postures), pranayama (breath control), pratyahara (withdrawal of senses), Dharana (concentration), dhyana (meditation) and Samadhi (absorption). While asanas are reported to help in improving the physical strength and flexibility, it is argued to also help in building concentration [ 21 ]. Preliminary research suggests that pranayama calms the nervous system and helps in regulating the blood pressure [ 22 ]which is further argued to improve the stress response. Pratyahara , Dharana , Dhyana includes techniques such as; mantra chanting, yoga nidra , and antar mouna that are said to help in developing an ability to internally witness the sensory inputs [ 23 ]. This witnessing capacity is speculated to help one in the reappraisal of the problem in hand, control the fluctuations of the mind and reduce the unconscious negative mental perceptions. Apart from yoga, there are some other spiritual practices such as listening to satsang [ 24 ], swadhyaya (reading Holy Scriptures) [ 25 ] and rendering seva (selfless service to the community) that have been reported to help maintain wellbeing, reduce stress, anxiety and depression [ 26 , 27 ].

Materials and methods

In this research three groups; yoga practitioners, other spiritual practices and non-practitioners were examined for the differences in the measures of illness perception and wellbeing. Additionally, differences based on the duration of practice were also examined in three categories; long-term, mid- term and beginner group. A cross-sectional study was designed using standardized scales for wellbeing related measures and illness perception, questions about daily practices and demographics. An online questionnaire booklet was prepared using google forms and data was collected via social networking groups and email mailing lists. The responses were analyzed using SPSS ver. 26.0.

Participants

The sample consisted of a total of 668 adults, out of which 96.26% (n = 643) chose to participate and 3.74% (n = 25) declined. Out of the 643 participants, there were 64.7% males (n = 416), 34.7%, females (n = 223), and four preferred not to say about their gender. The age range was 18–72 years (M = 28.12 years, SD = 9.09 years). In the sample, a total of 59% (n = 380) were students and 41% (n = 263) were from non- student groups. The non-student group had 34.4% (n = 221) working adults and the remaining 6.5% (n = 42) were from other categories (retired, homemaker). Concerning qualification, 53.2% (n = 342) participants were from postgraduate and higher qualification, 20.8% (n = 134) from graduate, 23.3% (n = 150) from intermediate or pursuing graduate, and the remaining 2.6% (n = 17) were from high school or below education level. Majority (73.2%) of the participants were from urban (n = 471), whereas 16.5% (n = 106) were from semi-urban, and 10.26% (n = 66) reported being from rural areas of residence.

Within the study sample, 59.6% (n = 384) reported that they practice yoga (includes asana, pranayama, meditation, mantra chanting or any other form of yogic practice) and were categorized as yoga practitioners and 40.4% (259) responded not following any yogic practice. Out of the participants that reported not following any yogic practice, 17.6% (n = 113) reported following one or more of the other forms of spiritual practices for example; watching online spiritual programs (50%), online satsang (14.37%), reading holy scriptures(23.25%), performing seva (12.5%), and were categorized as other spiritual practitioner group. The remaining 22.7% (n = 146) participants reported that they do not follow yogic or any other spiritual practices and they were termed as a non-practitioner group. Further, among the yoga practitioners, 35% (n = 134) were beginners (those who had started yoga practice during COVID19 lockdown period), 39.7% (n = 152) were mid- term (1≤year of practice≤4), and 25.32% (n = 97) were Long term (≥ 5 years of practice) practitioners. Within the beginners, 39.9% reported practicing yoga for all days in the week, 23.9% for 5–6 days, 23.2% for 3–4 days and 13% for 1–2 days in a week. For mid-term practitioners 32.4% reported practicing yoga for all days in the week, 30.4% for 5–6 days, 29.7% for 3–4 days and 7.4% for 1–2 days in a week. For long term practitioners, 58.8% reported practicing yoga for all days in the week, 19.6% for 5–6 days, 11.3% for 3–4 days and 10.3% for 1–2 days in a week. The data for frequency in terms of hours of practice per day was asked as an open choice question,’ How many minutes in a day do you practice yoga? Beginners reported on an average spending 31.24 mins, mid-term practitioner average of 39.10mins, and long term practitioners reported spending average of 51.25 mins, for their daily yoga practice.

Brief Illness Perception.

(BIPQ) [ 3 ] was used to measure the individual’s perception of COVID19 by adapting the Brief Illness Perception Questionnaire. The adapted version of BIPQ had 12 items designed to rapidly assess the cognitive and emotional representations of COVID19 illness. The five dimensions of cognitive representation of COVID19 illness was assessed through 9 items; identity—the label the person uses to describe the illness and the symptoms they view as being part of the disease (sample item: How much do you think the infected person experiences symptoms from this illness?); consequences—the expected effects and outcome of the illness (sample item: How much does this illness affect the person who suffers from it?); understanding—personal understanding about the cause of the illness (sample item: How well do you feel you understand this illness?); timeline—how long the patient believes the illness will last (sample item: How long do you think the illness last for those who have it?); and cure or control—the extent to which the patient believes that they can recover from or control the illness (sample item: How much control do you feel you have over this illness?). The emotional representation of COVID19 was assessed by 2 items incorporating negative reactions such as fear, anger, and distress (sample item: How much does thinking about this illness affect you emotionally? e.g. does it make you angry, scared, upset or depressed?). Assessment of the causal representation is by an open-ended response item adapted from the IPQ-R, which asks patients to list the three most important causal factors in rank order. All of the items except the causal question are rated using a 0-to10 response scale. The higher the score is, the greater the perception of the illness for that particular item. The total scale alpha coefficient in this study sample was 0.64.

Depression, Anxiety and Stress Scale.

(DASS-9) [ 28 ] was used to measure the depression, anxiety and stress experienced by the participants during the COVID19 lockdown period using DASS-9. It is the shorter version of DASS-42 [ 29 ] and consists of three sub-factors with 3 items each viz., depression (sample item: I found it difficult to work up the initiative to do things), anxiety (sample item: I experienced trembling eg. in the hands), and stress (sample item: I tended to overreact to). The instructions were modified to suit the current research and participants were asked to rate how much each statement applied to them during the lockdown period. Cronbach’s alpha for the total DASS-9 was reported by Yusoff (2013) equal to .72 whereas for Depression, Anxiety and Stress factors, alphas were .52, .57, and .55, respectively [ 29 ]. In this study sample the Cronbach alpha for total DASS-9, depression, anxiety and stress was found to be 0.73, 0.63, 0.64, and 0.53 respectively.

Scale of General Wellbeing.

(SGWB) [ 30 ] was used to measure the general wellbeing through fourteen common constructs as indicators of well-being viz., happiness, vitality, calmness, optimism, involvement, self-awareness, self-acceptance, self-worth, competence, development, purpose, significance, self-congruence and connection (sample item: I accept most aspects of myself). All items were phrased positively and rated on a Likert scale from 1 (Not at all) to 5 (very true), indicating experiences in life overall. Previous studies have reported a Cronbach alpha for SGWB ranging from 0.82 to 0.92 [ 30 ]. In this study sample, the Cronbach alpha for the total scale was found to be 0.93.

Brief Resilience Scale.

(BRS) [ 31 ] was used to measure resilience. The scale contains 6 items measuring the ability to bounce back from stress and difficulties (e.g., “I usually come through difficult times with little trouble”). The items are rated on a 5-point Likert scale from 1 (Strongly Disagree) to 5 (Strongly Agree). The possible score ranges from 1 (minimum resilience) to 6 (maximum resilience). Three items are negatively worded and are reversed scored. Adequate reliability, with Cronbach’s alpha ranging from .80 to .91 in 4 different samples was reported in an earlier study [ 31 ]. In this study sample, the Cronbach alpha was found to be 0.73.

Peace of Mind Scale.

(POMS) [ 15 ] was used to measure peace of mind through a single factor model presented by POMS. The scale consists of a 5 item scale that measures affective wellbeing. The items reflect the experiences of internal peace and harmony in general terms (e.g., I have peace and harmony in my mind) as well as in everyday circumstances (e.g., I feel content and comfortable with myself in daily life). Participants indicated how often they experience the internal states described in each of the items on a scale of 1 (not at all) to 5 (all the time). The five-item POMS (Cronbach alpha = 0.78) was used in this study which had previously been confirmed for the Indian population [ 32 ]. In this study sample, the Cronbach alpha was found to be 0.91.

Emotion Regulation Questionnaire.

(ERQ) [ 33 ] was used to assess the commonly used strategies to alter emotion through ERQ viz., 6 items on cognitive reappraisal (sample items: “When I’m faced with a stressful situation, I make myself think about it in a way that helps me stay calm”), and 4 items on expressive suppression (sample items: “When I am feeling negative emotions, I make sure not to express them”). Participants responded to each item using a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). The average of all the scores in each subscale of cognitive reappraisal and expressive suppression are used for analysis. The higher the score represents greater the use of that particular emotion regulation strategy, conversely lower scores means less frequent use. In a four study sample reported the Cronbach alpha ranging for reappraisal facet 0.75 to 0.82 and suppression factor 0.68–0.76 [ 34 ]. In this study sample, the Cronbach alpha for cognitive reappraisal and expressive suppression was found to be 0.83 and 0.75 respectively.

Apart from the standardized scales as described above, the data collection booklet included consent form, yoga schedule, and demographic information schedule. The categorization of the yoga practitioners, and non-practitioners was based on the dichotomous question; ‘Do you practice yoga (includes asana, pranayama, meditation, mantra chanting or any other form of yogic practice) in your daily routine?” The non-yoga practitioner group was further classified based on multiple response question; ‘Any other form of spiritual practice do you follow?’ for example; online Satsang (listening to devotional songs), watching spiritual programs, reading Holy Scriptures, selfless service or any other. This formed a group of other spiritual practitioners and the rest of non-yoga practitioners formed a third group classified as non-practitioners. The yoga practitioners were also asked about the duration of their practice. The demographic profile consisted of information about age, gender, qualification, working status and place of residence. An additional item on the three most important causal factors (in rank order) of stress during lockdown was also asked through a question ‘Please list in rank-order the THREE most important factors that you believe are reasons for stress due to lockdown’.

Preparation for the study.

The study was designed for both Hindi and English speaking population keeping in mind the diversity in the preference for language in the population. At the outset, the original English scales for which the Hindi version was not available (ERQ and BRS), were translated into Hindi by a bilingual expert working in the area of psychological assessment. The Hindi translations of all the scales were then evaluated by the first and second author to check for adequacy of translation. Modifications were made wherever the Hindi translations were not found to adequately capture the intended meaning. Further, a bilingual expert independently back-translated these scales from Hindi to English. The back translations were again reviewed by the first and second author and matched to the original scales. At this stage, most items were found to aptly represent the content of the original English scales. The finalized Hindi and English scales were used to prepare the data collection booklet.

Data collection and analysis

The cross-sectional study was conducted using an online survey. The sample for the study was recruited through the distribution of an online message consisting a brief introduction to the study and a link to the google form of data collection booklet using social networks, mailing lists and snowballing techniques. The online message with the link was especially circulated among the yoga practitioner groups. An electronic consent was obtained from each of the participants before beginning the survey. The data collected was anonymous and no personal details that could identify the participants were asked in the google form. Participants were assured that the data will be kept confidential and only be used for research purposes. The google form was available for responses from 26 th April -8 th June 2020 (beginning of Unlock 1.0), corresponding to four to ten weeks of the lockdown in India.

In the first step of data analysis, the responses for the Hindi (n = 96) and English (n = 547) scale were analyzed using an independent t-test that showed no significant difference in illness perception or wellbeing related measures in any of the practitioner groups due to difference in language (all ps>0.05). Therefore, the remaining analysis was conducted on the combined English and Hindi data. In the next step, the descriptive analysis was conducted and the internal reliability scores (Cronbach alpha) for each scale was computed. To confirm the factor structure of the scales used for this study sample, the data were subjected to confirmatory factor analysis. Multivariate analysis (MANOVA) was conducted to examine the differences in the mean scores of illness perception and wellbeing related measures among the yoga practitioners, other spiritual practitioners, and non- practitioner groups. The open-ended question was analyzed using percentage analysis. Lastly, MANOVA was also performed within the yoga practitioner group based on the duration of practice.

Descriptive analysis

The descriptive statistics of all the dependent variables were analyzed. Three outliers identified based on extreme values more than three IQR’s (interquartile range) [ 35 ] computed from Tukey’s hinges in SPSS, were deleted. Confirmatory factor analysis (CFA) showed that most of the fit statistics for all the scales were in the acceptable range. Statistics presented in Table 1 .

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Demographic variables

The relationship between demographic variables (age, gender, qualification, working status, and place of residence) was examined on illness perception (BIPQ), wellbeing related measures (DASS, SGWB, POMS, BRS) and Emotion regulation strategies (ERQ). MANOVA results indicated no statistically significant main effect of working status and qualification on the COVID19 perception, wellbeing measures (DASS, SGWB, POMS, and BRS) or emotion regulation strategies (ERQ). However, there was a significant effect of gender on the mean scores of illness concern F (1,634) = 11.14, p<0.001, partial eta squared = .02, and emotional representation of COVID19 F (1,634) = 10.50, p<0.001, partial eta squared = .02, partial eta squared = .02, with females reporting higher illness concern (M = 8.18, SD = 2.20),and higher emotional impact of COVID19 (M = 5.73, SD = 3.03) than males illness concern (M = 7.50, SD = 2.83), and emotional impact of COVID19 (M = 5.00, SD = 3.03), respectively. There was a significant effect place of residence on illness consequence of COVID19 F (1,634) = 5.61, p<0.05, partial eta squared = -.01, with urban participants reporting higher concern for consequences of COVID19 (M = 7.76, SD = 5.34) than semi-urban (M = 6.95, SD = 2.55) or rural (M = 7.22, SD = 2.88).

Age had a significant effect on depression (DASS-D) F (1,634) = 9.34, p<0.005, partial eta squared = -.01 and Peace of Mind (POMS) F (1,634) = 13.02, p<0.001, partial eta squared = -.02, with participants from age group 18–25 years reporting higher depression (DASS-D)(M = 0.97, SD = 0.70) than age group 26–35 years (M = 0.81, SD = .60), age group 36–45 years (M = 0.64, SD = 0.62) and age group 46 and above (M = 0.61, SD = 0.57). Lower mean scores for Peace of Mind (POMS) were reported by the participants of age group 18–25 years (M = 3.09, SD = 0.94) than age group 26–35 years (M = 3.42, SD = 1.07), age group 36–45 years (M = 3.55, SD = 1.07) and age group 46 and above (M = 3.80, SD = 1.00).

Effect of yoga and other spiritual practice on illness perception, and wellbeing measures

Before conducting the MANOVA, Pearson correlation was performed between all dependent variables to test the multivariate assumption that the dependent variables would be correlated with each other in the moderate range [ 40 ]. A meaningful pattern of correlations was observed amongst most of the dependent variables (r = - 0.460 to r = 0.448), suggesting the appropriateness of MANOVA. Correlations are presented in S1 Table . Additionally, the BOX’s M value of 575.82 was associated with less than a p-value of 0.001, which was interpreted as non-significant based on Huberty and Petoskey’s (2000) guidelines (i.e p < .005) [ 41 ]. Thus, the covariance matrices between the groups were assumed to be equal for the MANOVA.

The MANOVA was conducted to test the hypothesis that there would be one or more mean differences between the spiritual practitioner levels (yoga practitioners, other spiritual practitioners, and non-practitioners) and COVID19 perception, wellbeing related measures, as well as in their emotion regulation strategies. After controlling for the confounding effect of demographic variables a statistically significant MANOVA effect was obtained, Pillai’s’ Trace = .19, F (38, 1220) = 3.13, p<0.001. The multivariate effect size was estimated at .156.

A series of Levene’s F tests, to examine the homogeneity of variance assumption was conducted and the statistics are presented in Table 2 . In the third stage, a series of post hoc analyses (Tukey’s HSD) were performed to examine the individual mean difference comparisons across all three groups. The summary of post hoc comparisons is presented in Table 3 .

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COVID19 perception-BIPQ.

There was a statistically significant difference in group means for the personal control (IP3) F (2,639) = 14.81, p < .001, Coherence/ understanding (IP7) F (2,639) = 4.95, p < .01 Emotional representation (IP8) F (2,639) = 5.17, p < .0.01, Risk perception (IP10 and IP11) F (2,639) = 4.01, p < .01, Personal preventive Control (IP12) F (2,639) = 6.30, p < .01. However, there were no significant differences found in the COVID19 representation of illness perception with respect to consequence (IP1), timeline (IP2), treatment control (IP4), identity (IP5) and illness concern (IP6).

A post hoc analysis (Tukey HSD) revealed significant differences in mean scores of yoga practitioner group for personal control (IP3)(M = 6.22, SD = 2.72), coherence/understanding (IP7) (M = 7.58, SD = 2.22), and Emotional representation (IP8) (M = 4.95, SD = 3.20) when compared to the mean scores of other spiritual practitioner group for personal control (M = 5.06, SD = 2.62), coherence/understanding (IP7)(M = 7.29, SD = 2.44), emotional representation (IP8)(M = 5.74, SD = 2.87), and also for mean scores of non-practitioner for personal control (M = 4.88, SD = 2.6), Coherence/understanding (IP7) (M = 6.83, SD = 2.28), emotional representation (IP8)(M = 5.66, SD = 2.97), all ps<0.05 with higher mean interpreted as a higher perception of personal control over the illness /COVID19, higher coherence/understanding and higher emotional representation of COVID19. However, there was no significant difference between the other spiritual practices and the non-practitioner group, all ps >0.05.

There was also a statistically significant difference in the mean scores of yoga practitioner for risk perception (IP10 and IP11) (M = 5.88, SD = 2.75), when compared with the mean scores of non-practitioner risk perception (M = 6.59, SD = 2.58), p<0.05, with lower mean scores interpreted as a lower perception of risk to contract COVID19. However, there was no significant difference in the mean scores of other spiritual practitioner group when compared with the yoga practitioner group, and the non-practitioner group, both ps>0.05.

There was also a statistically significant difference in the mean scores for the perception of preventive control (IP12) of yoga practitioner (M = 7.10, SD = 2.44), when compared with other spiritual practitioner group (M = 6.75, SD = 2.23), and non-practitioner (M = 6.17, SD = 2.62), p<0.001, with higher mean scores interpreted as a higher perception of personal preventive control over COVID19. However, there was no significant difference in the mean scores of the other spiritual practitioner group, when compared with the yoga practitioner group and the non-practitioner group, both ps>0.05. Means plot is shown in Fig 1 .

Means Plot for COVID19 perception of (i) consequence; (ii) timeline; (iii) personal control; (iv) treatment control; (v) identity; (vi) illness concern; (vii) coherence/ understanding; (viii) emotional representation; (x) risk perception; (xi) peer risk perception; (xii) preventive control for three practitioner groups. Note: Error bars at 95% Cl.

https://doi.org/10.1371/journal.pone.0245214.g001

Percentage analysis of the causal representation of COVID19 on the responses received to the open-ended question (IP9) which asks patients to list the three most important causal factors in the rank order revealed that 48.25% ranked lack of adequate and timely information as the foremost reason for the spread of COVID19, followed by consumption of animal flesh (17.06%) and international movement of tourists and immigrants (16.74%). Other causal factors listed by participants included; lack of immunity, lack of medical facilities/treatment, improper/late action on lockdown measures etc.

Wellbeing related measure (DASS, SGWB, POMS, BRS).

There was a statistically significant difference in group means for depression (DASS-D) ( F (2,639) = 12.48, p < .001, partial eta square = .058, and stress (DASS-S) ( F (2,639) = 3.80, p < .05, partial eta square = .015. However, there was no statistically significant difference in group means for anxiety (DASS-A), p >.05.

Further, a post hoc analysis (Tukey HSD) revealed significant differences in mean scores for depression (DASS-D) among yoga practitioner group (M = 0.74, SD = .63), when compared with other spiritual practitioner group (M = .93, SD = .58), and non-practitioner group (M = 1.13, SD = .73), both ps< 0.001, with higher mean scores signifying higher depression. There was also a significant difference in mean scores for stress (DASS-S) for yoga practitioner group (M = .79, SD = .61) when compared with other spiritual practitioner group (M = .94, SD = .60), and non-practitioner group (M = .95, SD = .61), both ps< 0.001, with higher mean scores signifying higher stress. There was also a significant difference in the mean scores for stress (DASS-S) between other spiritual practitioners and the non- practitioner, p<0.05. Whereas, there was no statistically significant difference for anxiety or depression between the other spiritual practitioner group and non-practitioner group p>0.05.

Percentage analysis of the additional item on the three most important causal factors (in rank order) of stress during lockdown revealed that majority of the participants reported isolation due to lockdown (23.17%), fear of loss of job/business (financial insecurity) (18.57%), and fear of contracting virus (10.32%) as three main causes of stress during COVID19 lockdown. Other reasons of stress included; media reports and inadequate information (7.93%), the uncertainty of future (7.40%), routine disturbances (6.66%), educational loss (5.87%), and family issues (3.65%). Interestingly, 8.89% of the participants reported having no stress at all. A gender wise analysis of the causal factors of stress shows that females higher percentage of females (25.89%) reported stress due to isolation due to lockdown than males (22.11%). Whereas, financial insecurity was ranked as major cause of stress by more males (19.59%) than females (17.41%).

There was also a statistically significant difference in group means for wellbeing (SGWB) F (2,639) = 31.20, p < .001, partial eta squared = .112, and peace of mind (POMS) F (2,639) = 30.99, p < .001, partial eta square = .114. However, there was no statistically significant difference in group means for resilience (BRS), p < .05. Further, a post hoc analysis (Tukey HSD) revealed that mean scores of yoga practitioner group for wellbeing (SGWB) (M = 3.74, SD = .78), and peace of mind (POMS) (M = 3.565, SD = .96) differed significantly when compared with the other spiritual practitioner group mean scores for wellbeing (SGWB) (M = 3.28, SD = .67), peace of mind (POMS) (M = 3.13, SD = .96), and non-practitioner group mean scores for wellbeing (SWGB) (M = 3.11, SD = .85), peace of mind (POMS) (M = 2.73, SD = .99), all ps< 0.001. There was no significant difference between the mean scores for wellbeing (SWGB) between other spiritual practitioner groups and non-practitioner groups p>0.05. However, for peace of mind (POMS) there was a statistically significant difference between the other spiritual practitioner group and non-practitioner group p<0.001, with higher mean scores signifying higher wellbeing and higher peace of mind. Means plot is shown in Fig 2 .

Means plot for Wellbeing measures (i) Depression; (ii) Anxiety; (iii) Stress; (iv) Wellbeing; (v) Peace of Mind and (vi) Resilience for three practitioner groups. Note: Error bars at 95% Cl.

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Emotion regulation strategies (ERQ).

There was a statistically significant difference in group means for cognitive reappraisal strategies (ERQ-C) F (2,639) = 14.85, p < .001, partial eta square = .059. However, there was no significant difference in the group mean scores for Expressive suppression (ERQ-E), p>0.05). Further, a post hoc analysis (Tukey HSD) revealed significant differences in mean scores for yoga practitioner group (M = 5.24, SD = 1.07), other spiritual practitioner group (M = 4.85, SD = 1.17), and non-practitioner group (M = 4.57, SD = 1.19), both ps< 0.001. There was also a statistically significant difference between the other spiritual practitioner group and non-practitioner group p<0.001, with higher mean scores signifying higher emotion regulation through cognitive reappraisal strategies. Means plot is shown in Fig 3 .

Means Plot for Emotion regulation i) Cognitive appraisal ii) Expressive suppression for three practitioner groups. Note: Error bars at 95% Cl.

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Effect of duration of yoga practice on illness perception and wellbeing measures

The MANOVA was conducted to test the hypothesis that there would be one or more mean differences in the wellbeing for different groups of yoga practitioners differentiated based on the number of practice years. After controlling for the confounding effect of demographic variables a statistically significant MANOVA effect was obtained, Pillai’s’ Trace = .229, F (38, 716) = 2.43, p<0.001. The multivariate effect size was estimated at .114.

Before conducting a series of follow up ANOVAs, the homogeneity of variance assumption was tested for all the dependent variables. A series of Levene’s F tests, to examine the homogeneity of variance assumption was conducted and is presented in Table 4 . A series of one-way ANOVA was conducted followed by a series of post hoc analyses (Tukey's HSD) were performed to examine the individual mean difference comparisons across all three groups of spiritual practitioners and all the dependent variables. The results revealed statistically significant comparisons as listed in Table 5 .

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COVID19 perception (BIPQ).

There was a statistically significant difference in group means for the Personal control (IP3) F (2,367) = 3.571, p < .05, partial eta squared = 0.02, Illness concern(IP6) F (2,367) = 6.70, p < .001, Emotional representation (IP8) F (2,367) = 3.31, p < .0.05, Risk perception(IP11) F (2,367) = 5.64, p < .005. However, there was no significant difference found in the mean scores of COVID19 representation of illness perception for the consequence (IP1), timeline (IP2), treatment control (IP4), identity (IP5) and Coherence/Understanding (IP7)

A post hoc analysis (Tukey’s HSD) revealed significant differences in mean scores of long term practitioner for personal control (IP3) (M = 6.68, SD = 2.79), illness concern(IP6) (M = 6.93, SD = 3.3), emotional representation (IP8) (M = 4.27, SD = 2.80), risk perception (IP10 and IP11) (M = 5.40, SD = 3.04) when compared with beginners mean scores of personal control (IP3) (M = 5.75, SD = 2.68),illness concern (M = 8.23, SD = 2.11), emotional representation (M = 5.44, SD = 2.89), risk perception(IP10 and IP11) ((M = 6.14, SD = 2.40), all ps<0.005, with higher mean interpreted as a higher perception of personal control, illness concern, emotional impact and higher risk perception of contracting COVID19. There was also a statistically significant difference in mean scores between beginners' illness concern (M = 8.23, SD = 2.11), and mid-term (M = 7.53, SD = 2.67) p<0.005. However, there was no significant difference between the long term and mid-term practitioners group for illness concern p>0.05. Means Plot shown in Fig 4 .

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Wellbeing related measures (DASS, SGWB, POMS, BRS).

There was a statistically significant difference in group means for depression (DASS-D) ( F (2,367) = 4.15, p < .05, partial eta square = .022, anxiety (DASS-A) F (2,367) = 5.19, p < .01, partial eta square = .03 and a trend in group means for stress (DASS-S), F (2,367) = 2.71, p = .068. Further, a post hoc analysis (Tukey HSD) revealed significant differences in mean scores between long term practitioner group depression (DASS-D)(M = 0.55, SD = .55), Anxiety (DASS)(M = .26, SD = .38), and mid-term practitioner group depression (DASS-D) (M = .81, SD = .67), anxiety (DASS-A) (M = .48, SD = .56), and beginners group depression (DASS-D) (M = .80, SD = .60), all ps< 0.005, with higher mean scores signifying higher depression, and anxiety. There was no statistically significant difference between the mid-term and beginner practitioner group.

There was a statistically significant difference in group means for SGWB ( F (2,367) = 22.60, p < .001, partial eta square = .110, and POMS ( F (2,375) = 15.10, p < .001, partial eta square = .076. However, there was no statistically significant difference found in group means for BRS, p < .05. Post hoc analysis (Tukey HSD) revealed significant differences in mean scores of Wellbeing (SGWB) of long term practitioner group (M = 4.10, SD = .64) when compared with mid- term practitioner group (M = 3.79, SD = .65) and beginners group (M = 3.42, SD = .84), both ps< 0.001. Mean scores of POMS for long-term practitioner group (M = 4.03, SD = .91) also differed significantly with the mean scores of mid-term practitioner group (M = 3.50, SD = .87), and beginner practitioner group (M = 3.27, SD = .94), both ps< 0.001. There was also a statistically significant difference in the wellbeing (SGWB) mean scores and peace of mind (POMS) mean scores between the mid-term practitioner group and beginner group p>0.05, with higher mean scores signifying higher peace of mind. Means plot is shown in Fig 5 .

Means plot for Wellbeing measures (i) Depression; (ii) Anxiety; (iii) Stress; (iv) Wellbeing; (v) Peace of Mind and (vi) Resilience for three yoga practitioner groups based on duration of the yoga practice. Note: Error bars at 95% Cl.

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Emotion regulation measure (ERQ).

There was a statistically significant difference in group means for ERQ (cognitive reappraisal) ( F (2,375) = 5.30, p < .005, partial eta square = .028. However, there was no significant difference in the group mean scores for ERQ (Expressive suppression), p>0.05), indicating that the duration of yoga practice affects cognitive reappraisal strategies for emotion regulation. Further, a post hoc analysis (Tukey HSD) revealed significant differences in mean scores between long-term practitioner group (M = 5.51, SD = .97), and beginner group (M = 5.0, SD = 1.02) with higher mean scores signifying higher emotion regulation through cognitive reappraisal strategies. There was no statistically significant difference between the mid-term practitioner group and beginner group p>0.05. Means plot is shown in Fig 6 .

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Discussion and conclusions

The aim of present research was to study the effect of practice of yoga and other spiritual practices on the illness perception, wellbeing measures and emotion regulation strategies for adults during COVID19 lockdown. Additionally, the effect of demographic variables such as age, gender, qualification, working status and place of residence was also analyzed. The confirmatory factor analysis confirmed the factor structure for the study sample, which strengthens the findings of this research.

The results examining the demographic variables demonstrate that females reported higher illness concern and were emotionally more impacted than males by the COVID19 lockdown. This finding is in line with an earlier review of literature that reported females to be twice more vulnerable to stress than males in conditions or events of adversity [ 16 , 17 , 19 ]. A recent study investigating depression, anxiety and stress due to COVID19 also found higher stress among females than males [ 42 ]. The reason for higher stress in females can be argued to be partially due to increase in the household chores in the absence of any house helps during lockdown, specially for those also managing their professional work. Further, it was also found that younger participants from age group 18–25 years reported feeling more depressed, and had lower peace of mind than older participants. A stressful situation such as fear of losing a job, uncertainty about the future can trigger anxiety, depression and is believed to affect the peace of mind. The rationale for the association of stress and age is given by a study investigating differences in coping strategies across lifespan. The study suggests that older adults use coping strategies that are indicative of greater impulse control and they tend to evaluate conflict situations more positively than younger adults [ 16 – 18 ]. In another study it was found that older adults had lower levels of psychological distress and better dispositional coping compared to younger adults [ 43 ]. Perhaps the fear arising from uncertainties was dealt more efficiently by the older population, such that it affected their wellbeing positively. Interestingly, in this study the urban population reported higher perception of the COVID19 consequences than reported by the participants from rural or semi-urban areas. Perhaps, the urban population felt that COVID19 lockdown is going to affect them more adversely than the rural or semi-urban. One of the reasons for this difference could be the job insecurity. Another plausible explanation for the difference in perception of the COVID 19 consequence can be derived from research that states that urban populations are reported more prone to psychological distress than their rural counterparts [ 44 ]. Since urban population consists of the majority of service class which is dependent on their jobs for livelihood, they are more likely to perceive graver consequences of COVID19 lockdown than their rural counterparts which comprise mostly of self- employed people.

The results examining the effect of yoga practice demonstrate that yoga practitioners perceived having higher personal control, higher coherence/understanding, lower emotional impact, lower risk and higher preventive control for contracting COVID19 than other spiritual practitioners and non-practitioners. A number of studies have reported physical and mental health benefits of yoga practice [ 45 – 47 ]. A healthy individual is found to perceive lower cognitive and emotional effects of the illness and a higher preventive control over the illness [ 9 ]. On the other hand, the participants who negatively perceived the COVID19 effects experienced greater levels of stress, anxiety or depression and lower wellbeing, also reported in a study on cancer patients [ 48 ]. Additionally, in light of the findings of the previous study, the notion that an individual is following a treatment or preventative control therapy positively affects the perception about how well the illness is understood and a sense of personal control over the illness [ 10 ]. In this study also yoga practitioners reported to have a better understanding and higher personal control over COVID19. Perhaps yoga practitioners felt that yoga is an effective therapy to cope with COVID19 both for physical as well as mental health.

In this study, it was also found that yoga practitioners had lower depression, lower stress, lower anxiety, higher wellbeing, and higher peace of mind than the other spiritual practitioners and non-practitioner group. Interestingly, the other spiritual practitioners were also found to have a significantly higher peace of mind than the non-practitioners. The other spiritual practitioner group also reported lower depression, anxiety, stress and higher wellbeing than the non-practitioner group, however the difference was not found to be statistically significant in this study. Possibly the other spiritual practices; reading Holy Scriptures and rendering seva (selfless service) to the needy and destitute provided solace and peace of mind. A previous study has also reported a positive association between reading scriptures and positive affect and sukha (happiness) and a negative association with negative affect and dukkha (unhappiness) [ 32 ]. As for the non-practitioner group, participants that reportedly followed none of the yoga or spiritual practices, also reported the highest mean score of depression, anxiety and stress and lowest wellbeing and peace of mind.

Results showed that there was no significant difference in resilience among the yoga practitioners, other spiritual practitioners and non-practitioner group. Resilience has for long been debated by researchers to be a trait construct. In this study also resilience was found to be perhaps a more trait-like construct that unfolds over time in response to internal strengths and external supports across lifespan that foster positive outcomes in the face of adversity.

In this study, a significant effect of duration of practice was found on illness perception, and wellbeing related measures. Long term practitioners reported higher personal control and lower illness concern in contracting COVID19 than the mid-term or beginner group. The long- term and mid-term practitioners also reported perceiving lower emotional impact of COVID19 and lower risk in contracting COVID19 than the beginners. The general wellbeing was reported higher by the long term and mid- term practitioners than the beginners group. Further, the long term practitioners were found to have highest peace of mind, lowest depression and anxiety with no significant difference in the mid-term and the beginner group. In an earlier study, sustained practice of yoga is reported to enhance physical strength, promote and improve respiratory and cardiovascular function. The improved physiological functions are believed to reduce stress, anxiety, depression, and enhance overall well-being. In line with the outcomes from this study, the regular practice has also been argued to lead changes in life perspective, self-awareness, a sense of balance between body and mind and generally a positive outlook to life that maintains general wellbeing even in difficulties [ 49 , 50 ]. Interestingly, in this study the beginner group, which had started practicing yoga during COVID19 lockdown, reported comparable mean scores of wellbeing and peace of mind with the mid-term practitioner groups. When compared with the non-practitioner group, the beginner group also had lower depression, anxiety, stress and higher wellbeing, peace of mind. Perhaps the routine practice of yoga helped the beginner practitioners to calm the mind and maintain a positive disposition during difficult times of COVID19 lockdown. The outcomes reveal that yoga practice helps in illness perception about COVID19 such that the long- term practitioners feel a better sense of preventive control with a notion of being less prone to contracting COVID19. This perception of lesser vulnerability and a better sense of control over COVID19 is argued to generate lesser stress problems and promote higher wellbeing. The emotion regulation strategy of cognitive reappraisal is further argued to breed a balanced and coherent understanding about the COVID19. The balanced representation of the unknown is argued to tone down the fear factor due to uncertainties caused by COVID19 lockdown thus decreasing the stress, anxiety and depression. Such a state of mind allows one to view an adverse situation with a more pragmatic approach and helps in maintaining a peaceful disposition.

Altogether, the findings from this study shows that yoga is found to be an effective way to manage the stress, anxiety and depression due to and during COVID19 lockdown. The evidence further supports that yoga could be used as a complementary and alternative therapy for the stress related problems due to COVID19. It may also help health practitioners in further promoting yoga-based interventions to facilitate the self-management of the mental health issues due to COVID19.

Supporting information

S1 table. correlations..

https://doi.org/10.1371/journal.pone.0245214.s001

Acknowledgments

The authors appreciates all those who participated in the study and helped to facilitate the research process.

1. Website. [cited 25 Sep 2020]. Available: Van Hoof, E. (2020, April). Lockdown is the world’s biggest psychological experiment-and we will pay the price. In World Economic Forum (Vol. 9). https://www.weforum.org/agenda/2020/04/this-is-the-psychological-side-of-the-COVID19-pandemic-that-were-ignoring
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Scientific Research on Yoga

Main research categories.

Substantial research has been done on many of the populations and parts of the body that COVID-19 preys on most. Use this section of Yoga Alliance's website to learn more about scientific research on the effects of yoga on the elderly , respiratory function , anxiety , and depression , to name a few.

Perhaps more than ever, yoga is being widely studied and evaluated for its positive effects and benefits. At Yoga Alliance, we curate the latest and most relevant research on yoga’s applications in health, wellness, and disease. We have filtered it in a digestible manner for our Registered Yoga Schools and Registered Yoga Teachers as well as for the broader yoga community.

This evidence-based research not only reveals the science of yoga, it also explains its therapeutic efficacy when used in conjunction with conventional medicine. Our goal is that this impactful content will be utilized in a way that highlights even more of yoga’s ancient, multi-faceted ability to improve lives.

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Our Director of Yoga Research Dr. Sat Bir Singh Khalsa is a renowned yoga research expert and yoga teacher who has committed his professional life to clinical research surrounding yoga’s full spectrum of healing efficacy.

View a collection of brief videos briefly summarizing yoga research on a variety of specific topics, conditions and populations. These are easy to understand for non-scientists and convey many of the scientific principles and rationale in key studies showing yoga’s benefits.

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Yoga for Depression – What Does the Research Say?

A New Meta-Analysis Offers Convincing Evidence for the Effectiveness of Yoga for Major Depressive Disorder

Depression is a debilitating mental health condition that affects millions of people worldwide. It is a leading cause of disability and places a tremendous burden on individuals during the prevention and treatment process. While antidepressant medications are commonly prescribed, they often come with unwanted side effects. As a result, there is growing interest in mind-body practices like yoga to help alleviate depressive symptoms.

Promising Results from 34 Randomized Controlled Trials

A new systematic review and meta-analysis published in Frontiers in Psychiatry examines the evidence on the effectiveness of yoga for treating major depressive disorder (MDD). The researchers evaluated data from 34 randomized controlled trials with a total of over 2,300 participants.

The results are promising – overall, the analysis found that yoga had a moderate effect on reducing the severity of depressive symptoms compared to control groups, as assessed by common depression rating scales. This positive effect was seen in diverse groups from North America, Europe, India and China, although the majority of study participants were female with an average age of 32.

Various Yoga Styles Prove Beneficial

In terms of yoga styles, a variety were used in the included studies. The most common were Hatha yoga (a general category that includes physical postures), Iyengar yoga (a style focused on alignment), and Sudarshan Kriya yoga (which incorporates specific breathing practices). Yoga interventions that also included a meditation component appeared to be especially beneficial. The typical duration of the yoga programs was 8-12 weeks.

Yoga Shows High Safety Profile

Importantly, yoga was found to be well-tolerated with a high safety profile. The main side effect reported was mild muscle soreness that resolved over the course of the intervention. No serious adverse events occurred. This suggests yoga may provide an appealing alternative or adjunct to standard depression treatments, which often have more problematic side effects.

The meta-analysis also looked at the effects of yoga on anxiety symptoms, which frequently co-occur with depression. Four studies using a common anxiety scale found that yoga had a small positive impact on reducing anxiety levels. However, more research is needed in this area.

Limitations and Future Directions

While the results are encouraging, the study authors note some limitations. The overall quality of evidence from the included trials was low to moderate. More high-quality randomized controlled trials with larger sample sizes are needed to increase confidence in the findings. The optimal “dosage” of yoga in terms of frequency and duration of practice to achieve anti-depressant effects also remains unclear.

The exact mechanisms by which yoga may help alleviate depression are not yet fully understood. However, it’s thought that yoga may impact both physiological and psychological pathways involved in depression. On a biological level, yoga has been shown to reduce inflammation, regulate stress hormones, and promote neuroplasticity in brain regions implicated in depression. Psychologically, yoga encourages mindfulness, relaxation, and self-compassion which may help counter depressive thought patterns.

Yoga as a Complementary Treatment for Depression

In conclusion, this comprehensive meta-analysis provides promising evidence that yoga can be an effective complementary treatment for depression, with minimal risk of adverse effects.

It may be especially appealing for those who cannot tolerate or do not respond to standard depression treatments.

While more robust research is still needed, these findings support the incorporation of yoga into treatment plans for major depressive disorder. If you are struggling with depression, consult your healthcare provider to discuss whether a yoga program may be right for you as part of a holistic treatment approach.

Also, read...

Yoga’s energy centers: what science says about the chakras, yoga research: is yoga helpful for fertility, related courses, yoga, fascia and healthy aging: keys to keeping the fascia youthful and supple, yoga and fascia sensing: cultivating interoception for enhanced well-being and embodiment, pelvic floor health from the ground up: an 8-week journey through the deep core line, the yoga of money: moving beyond myths and stepping into abundance, awaken the possible: a journey of self-discovery and transformation through gentle somatic yoga.

Original Published here: Effectiveness of yoga for major depressive disorder: A systematic review and meta-analysis, Front. Psychiatry, 22 March 2023

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Yoga for Health: What the Science Says

Clinical Guidelines, Scientific Literature, Info for Patients: Yoga for Health

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The American Academy of Pediatrics (AAP) recommends yoga as a safe and potentially effective therapy for children and adolescents coping with emotional, mental, physical, and behavioral health conditions. Yoga can help children learn to self-regulate, focus on the task at hand, and handle problems peacefully. Yoga may also improve balance, relieve tension, and increase strength when practiced regularly. Because some yoga poses are harder than others, the AAP cautions that even children who are flexible and in good shape should start slowly.

What Does the Research Show?

In a 2019 study , 5-year-old kindergartners doing yoga twice a week in school in place of standard physical education showed less inattention and hyperactivity and completed a task faster than 5-year-olds doing physical education or no exercise.
A 2016 review found that school-based yoga programs seem to help improve adolescents’ health.
A 2015 systematic review of 16 studies (including 6 randomized controlled trials, 2 nonrandomized preintervention-postintervention control-group designs, 7 uncontrolled preintervention-postintervention studies, and 1 case study) for yoga interventions addressing anxiety among children and adolescents concluded that nearly all studies included in the review indicated reduced anxiety following a yoga intervention. However, the reviewers noted that because of the wide variety of study populations, limitations in some study designs, and variable outcome measures, further research is needed to enhance the ability to generalize and apply yoga to reduce anxiety.

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Yoga’s popularity among older Americans is growing. National survey data show that 6.7 percent of U.S. adults age 65 and over practiced yoga in 2017, as compared to 3.3 percent in 2012, 2.0 percent in 2007, and 1.3 percent in 2002.

Older adults who practice yoga should put safety first. It’s a good idea to start with an appropriate yoga class—such as one called gentle yoga or seniors yoga—to get individualized advice and learn correct form. Chair yoga is an even gentler option for seniors with limited mobility. And it’s important for older people with medical issues to talk to both their health care providers and the yoga teacher before starting yoga.

A 2015 study funded by NCCIH compared 14 experienced yoga practitioners to 14 physically active control participants of similar ages. In the control group, the amount of gray matter was lower in older participants than younger ones. In the yoga practitioners, there was no relationship between gray matter and age. Among the yoga practitioners, the volume of certain brain regions increased with the number of years of yoga experience and weekly amount of yoga practice.

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Only a small amount of research has investigated yoga for general well-being, such as improving sleep and reducing stress, and the findings have not been completely consistent. Nevertheless, some preliminary research results suggest that yoga may have several different types of benefits for general well-being.

Stress Management . Some research indicates that practicing yoga can lead to improvements in physical or psychological aspects of stress.
Balance . Several studies that looked at the effect of yoga on balance in healthy people found evidence of improvements.
Positive Mental Health . Some but not all studies that looked at the effects of yoga on positive aspects of mental health found evidence of benefits, such as better resilience or general mental well-being.
Health Habits . A survey of young adults showed that practicing yoga regularly was associated with better eating and physical activity habits, such as more servings of fruits and vegetables, fewer servings of sugar-sweetened beverages, and more hours of moderate-to-vigorous activity. But it wasn’t clear from this study whether yoga motivates people to practice better health habits or whether people with healthier habits are more likely to do yoga. In another study, however, in which previously inactive people were randomly assigned to participate or not participate in 10 weeks of yoga classes, those who participated in yoga increased their total physical activity.
Quitting Smoking . Programs that include yoga have been evaluated to see whether they help people quit smoking. In most studies of this type, yoga reduced cigarette cravings and the number of cigarettes smoked. Findings suggest that yoga may be a helpful addition to smoking cessation programs.
Weight Control . In studies of yoga in people who were overweight or obese, practicing yoga has been associated with a reduction in body mass index. An NCCIH-supported comparison of different yoga-based programs for weight control showed that the most helpful programs had longer and more frequent yoga sessions, a longer duration of the overall program, a yoga-based dietary component, a residential component (such as a full weekend to start the program), inclusion of a larger number of elements of yoga, and home practice.

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Yoga may help relieve low-back pain and neck pain, but it has not been shown to be helpful for some other painful conditions such as headache, arthritis, fibromyalgia, or carpal tunnel syndrome.

In 2017, the European League Against Rheumatism (EULAR) evaluated non-pharmacologic therapies, including complementary health approaches, and issued revised recommendations for the management of fibromyalgia. The strength of these recommendation is “based on the balance between desirable and undesirable effects (considering values and preferences), confidence in the magnitude of effects, and resource use. A strong recommendation implies that, if presented with the evidence, all or almost all informed persons would make the recommendation for or against the therapy, while a weak recommendation would imply that most people would, although a substantial minority would not.” Based on the evaluation of acupuncture, meditative movement practices (e.g., tai chi, qi gong, and yoga), and mindfulness-based stress reduction, the recommendation for each was weak for use of the therapy.
A 2015 Cochrane review of 61 trials involving 4,234 predominantly female participants with fibromyalgia concluded that the effectiveness of biofeedback, mindfulness, movement therapies (e.g., yoga), and relaxation techniques remains unclear as the quality of evidence was low or very low.
A 2018 report by the Agency for Healthcare Research and Quality evaluated 8 trials of yoga for low-back pain (involving 1,466 total participants) and found that yoga improved pain and function both in the short term (1 to 6 months) and intermediate term (6 to 12 months). The effects of yoga were similar to those of exercise.
A 2017 Cochrane review of 12 trials involving 1,080 participants found low- to moderate-certainty evidence that yoga compared to non-exercise controls results in small to moderate improvements in back-related function at 3 and 6 months. Yoga may also be slightly more effective for pain at 3 and 6 months, however the effect size did not meet predefined levels of minimum clinical importance.
A 2017 review of 3 studies (involving 188 total participants) found that yoga had short-term benefits for both the intensity of neck pain and disability related to neck pain.
A 2015 attempt to review the research on this topic found only one study with 72 participants that could be evaluated. That study had favorable results, with decreases in headache intensity and frequency.
A 2018 meta-analysis of 13 clinical trials involving 1557 patients with knee osteoarthritis and rheumatoid arthritis found that regular yoga training may be useful in reducing knee arthritic symptoms, promoting physical function, and general wellbeing in arthritic patients.
A 2017 review of two studies found some beneficial effect on pain, but due to the high risk of bias in both studies, the reviewers gave a weak recommendation for yoga in rheumatoid arthritis. Yoga incorporates several elements of exercise that may be beneficial for arthritis, including activities that may help improve strength and flexibility.

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Cancer . Quite a few studies have been done on yoga for people with cancer, especially on women with breast cancer. These studies have produced some evidence that yoga can help improve quality of life and reduce fatigue and sleep disturbances. Other forms of exercise may have similar benefits.
Multiple Sclerosis . A small amount of research in people with multiple sclerosis found that yoga has short-term benefits on fatigue and mood, but it doesn’t affect muscle function, reasoning ability, or quality of life. The effects of yoga on fatigue are similar to those of other kinds of exercise.
Chronic Obstructive Pulmonary Disease (COPD) . Studies in people with COPD have shown that yoga may improve physical ability (such as the capacity to walk a certain distance in a specific length of time), lung function, and quality of life.
Asthma . Studies of yoga in people with asthma have shown that it probably leads to small improvements in symptoms and quality of life.

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Anxiety or Depression . Yoga may be helpful for anxiety or depressive symptoms associated with difficult life situations. However, the research on yoga for anxiety disorders, clinical depression, or posttraumatic stress disorder (PTSD), although mildly positive, is still very preliminary.
Cardiovascular Risk Factors . Stress and a sedentary lifestyle increase people’s risk of cardiovascular disease. Because yoga involves physical activity and may help reduce stress, it might help reduce the risk of cardiovascular disease. However, not much research has been done on this topic. Some studies have suggested that yoga may improve some risk factors, such as blood pressure and cholesterol levels, but the findings aren’t definitive.
Diabetes . Some research has suggested that participating in yoga programs is associated with better blood sugar control in people with type 2 diabetes, at least on a short-term basis.
Irritable Bowel Syndrome (IBS) . Some research has suggested that yoga may help to decrease IBS symptoms and severity, but the findings aren’t strong enough for definite conclusions to be reached.
Menopause Symptoms . Growing research indicates that yoga may help to reduce some menopause symptoms, and it’s at least as effective for menopause symptoms as other types of exercise.
Sleep Problems . Some research has indicated that practicing yoga may improve sleep in a variety of groups of people, including people with cancer, older adults, people with arthritis, pregnant women, and women with menopause symptoms.

.header_greentext{color:green!important;font-size:24px!important;font-weight:500!important;}.header_bluetext{color:blue!important;font-size:18px!important;font-weight:500!important;}.header_redtext{color:red!important;font-size:28px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;font-size:28px!important;font-weight:500!important;}.header_purpletext{color:purple!important;font-size:31px!important;font-weight:500!important;}.header_yellowtext{color:yellow!important;font-size:20px!important;font-weight:500!important;}.header_blacktext{color:black!important;font-size:22px!important;font-weight:500!important;}.header_whitetext{color:white!important;font-size:22px!important;font-weight:500!important;}.header_darkred{color:#803d2f!important;}.Green_Header{color:green!important;font-size:24px!important;font-weight:500!important;}.Blue_Header{color:blue!important;font-size:18px!important;font-weight:500!important;}.Red_Header{color:red!important;font-size:28px!important;font-weight:500!important;}.Purple_Header{color:purple!important;font-size:31px!important;font-weight:500!important;}.Yellow_Header{color:yellow!important;font-size:20px!important;font-weight:500!important;}.Black_Header{color:black!important;font-size:22px!important;font-weight:500!important;}.White_Header{color:white!important;font-size:22px!important;font-weight:500!important;} Safety

Yoga is generally considered a safe form of physical activity for healthy people when it’s done properly, under the guidance of a qualified instructor. But it’s possible to get hurt practicing yoga—just as when participating in other physical activities.

The most common injuries associated with yoga are sprains and strains. Serious injuries are rare. The risk of injury associated with yoga is lower than that for higher impact sports activities.

Older adults, women who are pregnant, and those who have health conditions should discuss their needs with their health care providers and yoga instructor. They may need to modify or avoid some yoga poses and practices.

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BMC Psychiatry

The effect of yoga on sleep quality and insomnia in women with sleep problems: a systematic review and meta-analysis

Wei-li wang.

1 Department of Psychiatry, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan

Kuang-Huei Chen

Ying-chieh pan, szu-nian yang.

2 Department of Psychiatry, Beitou Branch, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan

Yuan-Yu Chan

3 Department of Psychology, Chung Yuan Christian University, Taoyuan, Taiwan

Associated Data

All data analyzed during this study are included in this published article and the original studies’ publications.

To examine the effectiveness and safety of yoga of women with sleep problems by performing a systematic review and meta-analysis.

Medline/PubMed, ClinicalKey, ScienceDirect, Embase, PsycINFO, and the Cochrane Library were searched throughout the month of June, 2019. Randomized controlled trials comparing yoga groups with control groups in women with sleep problems were included. Two reviewers independently evaluated risk of bias by using the risk of bias tool suggested by the Cochrane Collaboration for programming and conducting systematic reviews and meta-analyses. The main outcome measure was sleep quality or the severity of insomnia, which was measured using subjective instruments, such as the Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), or objective instruments such as polysomnography, actigraphy, and safety of the intervention. For each outcome, a standardized mean difference (SMD) and confidence intervals (CIs) of 95% were determined.

Nineteen studies in this systematic review included 1832 participants. The meta-analysis of the combined data conducted according to Comprehensive Meta-Analysis showed a significant improvement in sleep (SMD = − 0.327, 95% CI = − 0.506 to − 0.148, P < 0.001). Meta-analyses revealed positive effects of yoga using PSQI scores in 16 randomized control trials (RCTs), compared with the control group in improving sleep quality among women using PSQI (SMD = − 0.54; 95% CI = − 0.89 to − 0.19; P = 0.003). However, three RCTs revealed no effects of yoga compared to the control group in reducing insomnia among women using ISI (SMD = − 0.13; 95% CI = − 0.74 to 0.48; P = 0.69). Seven RCTs revealed no evidence for effects of yoga compared with the control group in improving sleep quality for women with breast cancer using PSQI (SMD = − 0.15; 95% CI = − 0.31 to 0.01; P = 0.5). Four RCTs revealed no evidence for the effects of yoga compared with the control group in improving the sleep quality for peri/postmenopausal women using PSQI (SMD = − 0.31; 95% CI = − 0.95 to 0.33; P = 0.34). Yoga was not associated with any serious adverse events.

This systematic review and meta-analysis demonstrated that yoga intervention in women can be beneficial when compared to non-active control conditions in term of managing sleep problems. The moderator analyses suggest that participants in the non-breast cancer subgroup and participants in the non-peri/postmenopausal subgroup were associated with greater benefits, with a direct correlation of total class time with quality of sleep among other related benefits.

Sleep problems are one of the most common medical complaints. Lack of sleep is associated with significantly decreased work performance, impaired daytime function, and increased health care costs [ 1 ]. Sex-based differences in sleep problems have been widely published and discussed across sleep articles. Insomnia is approximately 1.41 times more common in women than in men [ 2 ]. Female populations at certain stages in their life span may be more vulnerable to insomnia. In these stages, hormonal changes associated with hormones, such as follicle-stimulating hormones (FSHs), luteinizing hormones (LHs), and progesterone, may play an important role in influencing women’s sleep construction [ 3 ] during adolescence [ 4 ], pregnancy and postpartum [ 5 ] or menopause [ 6 ]. Several behavioral, psychological and pharmacological treatments are available for insomnia, however, their efficacy varies considerably. The evidence of efficacy for cognitive behavior therapy is now well established in many reviews [ 7 , 8 ], but availability remains poor. Pharmacotherapy remains the most common treatment [ 9 ], although hypnotics have been associated with many side effects, such as drowsiness, cognitive impairment, dependence, tolerance and poor long term efficacy [ 10 ].

Yoga has been widely adapted in the modern Eastern and Western hemispheres in a variety of ways. Yoga is an ancient form of exercise that focuses on strength, flexibility, and breathing to boost physical, mental and spiritual health [ 11 ]. There are many different styles of yoga, such as Tibetan, Iyengar, and Hatha Yoga. Some styles are more vigorous than others, whereas some may have different areas of emphasis, such as posture or breathing. The main components of yoga in Europe or America are mostly associated with physical posture ( Asana ) and breathing control ( Pranayama ) and meditation ( Dhyana ) [ 11 ]. A trial in yoga for persistent fatigue breast cancer survivors showed yoga is safe and effective at improving fatigue severity, depressive moods, and sleep quality [ 12 ]. Yoga is also characterized as a mindful mode of physical activity. Mindfulness, as an important component of yoga, improves sleep disturbance by increasing melatonin levels, reducing hyperarousal, and addressing stress related cardiac and respiratory abnormalities [ 13 ].

The term “sleep quality” is commonly used in sleep medicine. In 1989, Buysse et al. referred to sleep quality as a “complex phenomenon that is difficult to define and measure objectively” [ 14 ]. Good sleep quality is associated with better health, less daytime sleepiness, greater well-being and better psychological functioning [ 15 ]. Recently, sleep quality is defined as one’s satisfaction of the sleep experience, integrating aspects of sleep initiation, sleep maintenance, sleep quantity, and refreshment upon awakening [ 16 ]. The National Sleep Foundation (NSF) released the key indicators of good sleep quality, as established by a panel of experts. They include increase in sleeping time while in bed (at least 85% of the total time), falling asleep in 30 min or less, waking up no more than once per night and being awake for 20 min or less after initially falling asleep. However, there was less or no consensus regarding sleep architecture or nap-related variables as elements of good sleep quality [ 17 ]. Poor sleep quality is one of the defining features of chronic insomnia [ 18 ]. Although recent systematic reviews and meta-analyses have assessed the efficacy and safety of yoga in specific groups of women, such as those with prenatal depression [ 19 ] and primary dysmenorrhea [ 20 ] in different stages, evidence for the efficacy of yoga in improving sleep quality and insomnia of women has not yet been systematically assessed. Thus, the aim of this review was to systematically evaluate and perform a meta-analysis of the available data on the efficacy and safety of yoga in terms of improving sleep quality and insomnia in women.

Before beginning the review, we followed the checklist for systematic reviews in concurrence with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines [ 21 ] and suggestions by the Cochrane Collaboration for programming and conducting systematic reviews and meta-analyses [ 22 ].

Eligibility criteria

Types of studies.

Randomized controlled trials (RCTs), randomized crossover studies, and cluster randomized trials were all eligible for this meta-analysis. No restrictions in terms of language and countries were applied.

Types of participants

Studies that included women (aged ≥18 years) with sleep problems were eligible. No restrictions on the ethnicity and comorbidity of participants were applied.

Types of interventions

No restrictions regarding yoga type, form, structure, frequency, duration or length of intervention programs were applied. Studies on cointerventions that included yoga as a part of multicomponent interventions were excluded because it would be difficult to distinguish the effects of yoga from additional modalities. Studies in control interventions that compared yoga treatments with nontreatment, usual care, wait-lists, and education without active physical exercise programs were all eligible.

Types of outcome measures

The primary outcome of this study was sleep quality. To be included in this review, studies had to assess at least one of the sleep quality measures by using standardized instruments and provide outcomes both at the baseline and follow-up for primary outcomes. In particular, instruments in question include subjective measurements, such as the Pittsburgh Sleep Quality Index (PSQI) and Insomnia Severity Index (ISI), or objective measurements, such as polysomnography (PSG) and actigraphy. The PSQI score have been recommended as a reliable, valid and standardized instrument to measure and to identify quality of sleep. The widely employed Pittsburgh Sleep Quality Index (PSQI), provides a measure of global sleep quality, including sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction [ 14 ]. The seven components of the PSQI are standardized of areas routinely assessed sleep complaints with possible range of 0–21 points. A global PSQI score of 5 or higher provided a sensitive and specific measure for poor sleep quality [ 14 ]. The ISI score is a reliable and valid instrument to quantify perceived insomnia severity. A global ISI score of 8 or higher is indicative of some degree of insomnia, while moderate insomnia has a score of 15–21 and severe insomnia with a score of 22–28 [ 23 ]. PSG or actigraphy reports the most complete and precise information on the construction and distribution of sleep periods, such as total sleep time (TST), sleep efficiency (SE), and wake time after sleep onset (WASO) [ 24 ]. Sleep quality is also sometimes measured from PSG and actigraphy. Among these objective indices are measures such as sleep onset latency, total sleep time, wake time after sleep onset, sleep efficiency, and number of awakenings [ 25 ].

Secondary outcomes : The secondary outcome included in this study was the safety of the intervention, which was assessed as number of patients with adverse events (AEs), including serious adverse events or nonserious events. Serious adverse events referred to those events that caused death, life-threatening situations, hospitalization, disability or permanent damage, congenital anomaly/birth defect, or the need for medical or surgical intervention to prevent any of the aforementioned outcomes [ 26 ]. All other adverse events were regarded as nonserious.

Search methods

The search strategy comprised four electronic databases from their inception through June 01, 2019: Medline/PubMed, ClinicalKey, ScienceDirect, Embase, PsycINFO, and the Cochrane Library. The literature search was constructed around search terms for “yoga,” “women,” and “sleep” and was adapted for each database as necessary. The complete search strategy for PubMed was as follows: (“yoga” OR “asana” OR “pranayama” OR “dhyana”) AND (“women” OR “female”) AND (“sleep” OR “sleep quality” OR “sleep disturbance” OR “insomnia”). Additional reference lists of identified original articles or reviews, the table of the contents of the Journal of Yoga and Physical Therapy , and Journal of National Taiwan Sports University were searched manually.

Retrieved articles were scanned independently to verify their eligibility, and the entire text was assessed by two reviewers. A conflict of reviewers’ opinions on inclusion or exclusion of any article was discussed with a third reviewer to reach a consensus.

Data extraction and management

Two reviewers independently extracted data on design (e.g., article setting, author/year, country of studies, and sampling strategy), participants (e.g., age, body max index, clinical characteristics, comorbid condition, and overall sample size), interventions (e.g., yoga type, frequency of sessions per week, duration of yoga intervention, and total length of intervention time), control interventions (e.g., type, frequency, length, and duration), and outcomes (e.g., outcome measures with sleep quality and safety-related events). A conflict of reviewers’ opinions was discussed with a third reviewer until consensus was reached.

Risk of bias in individual studies

Two reviewers independently assessed the risk of bias in each study. There were seven domains of assessment for the risk of bias include in the following: (1) random sequence generation, (2) allocation concealment, (3) blinding of participants and personnel, (4) blinding of outcome assessment, (5) incomplete outcome data, (6) selective reporting, and (7) other biases using the Cochrane Systematic Review Manual risk of bias assessment tool [ 22 ]. All domains were scored as low risk, high risk, or unclear risk of bias and assessed individually. A risk of bias table was completed for each included study. A conflict of reviewers’ opinions was discussed with a third reviewer until consensus was reached.

Data assessment of overall effect size

A meta-analysis was conducted with Review Manager 5 software (Version 5.3, The Nordic Cochrane Centre, Copenhagen) and Comprehensive Meta-Analysis Software using a random effects model if at least two studies assessing this specific outcome were obtainable. For continuous outcomes, standardized mean differences (SMDs) with 95% confidence intervals (CIs) were calculated as the difference in means between groups divided by the pooled standard deviation. For studies that did not report data with standard deviations, we calculated these values from standard errors, confidence intervals, or t -values. If adequate information was available, we would plan to perform subgroup analysis. The p value of the summary effect < 0.05 were regarded as indicating statistical significance.

A negative SMD was provided a definition to display the beneficial effects of yoga intervention compared with the control intervention for sleep quality outcomes. Cohen’s categories were used to assess the significance of the overall effect size, with SMD = 0.2–0.5: small effect size; SMD = 0.5–0.8: medium effect size; and SMD > 0.8: large effect size [ 27 ].

Assessment of heterogeneity

Statistical heterogeneity between studies was analyzed using the I 2 statistics and the Cochrane chi-square. The variance between studies was measured using the tau-square (Tau 2 ). The level of heterogeneity was classified as I 2 = 0–24%: low heterogeneity; I 2 = 25–49%: moderate heterogeneity; I 2 = 50–74%: substantial heterogeneity; and I 2 = 75–100%: considerable heterogeneity. Given the low power of this test when only few studies or studies with a low sample size are included in a meta-analysis, a P value of ≤0.1 for the chi-square test was regarded as indicating significant heterogeneity [ 22 ].

Moderator analyses

Moderator and meta-regression analyses were further performed to identify possible reasons for interstudy heterogeneity. The subgroup analysis produced prespecified covariates, including outcome measurement tools, participant type, study quality, study region, participant age, intervention duration and study sample size.

Risk of publication bias

Risk of publication bias was evaluated for each meta-analysis that included at least 10 studies. Funnel plots generated using Review Manager 5 software was estimated from individual studies against each study’s standard error. Publication bias was evaluated through visual analysis, in which roughly the symmetrical funnel plot signifies no evidence of high risk of publication bias [ 28 ]. Potential publication bias was evaluated using the Egger’s Intercept Test, with p values < 0.05 signifying significant bias.

Literature search

The results of the literature search and screening process are summarized in Fig. 1 . The literature search totaled 1338 records; one additional record was retrieved from the Journal of National Taiwan Sports University in the Chinese language database [ 29 ]. In all, 1295 records were excluded because they did not meet all predefined inclusion criteria or were duplicated. Forty-four full-text articles were assessed for eligibility. Twenty-five were excluded because they were not randomized [ 29 , 30 ], did not include relevant outcomes [ 31 – 37 ], did not include only female participants [ 38 – 46 ], included yoga as a part of a multimodal intervention (or combined with other intervention) [ 47 – 50 ], lacked adequate control [ 51 ], and did not include a form of yoga intervention [ 52 , 53 ]. Nineteen full-text articles with 1832 participants were included in the qualitative synthesis and were included in the meta-analysis. All articles were published in English.

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Flowchart of the results of the literature search

Study characteristics

A total of 19 studies were considered eligible for systematic reviews. Information regarding the characteristics of the sample, yoga or control group interventions, outcome measures, and results are listed in Tables 1 and and2 2 .

Characteristics of included studies

Authors, year country	Main characteristics of the studied population	Sample characteristics (sample size, age)	Intervention group comparison group	Sleep outcome measures	Outcomes
Danhauer SC et al. 2009 [ ] America	Women (≥18 y) with breast cancer (any stage), 2–24 months post-primary treatment (surgery) following initial diagnosis and/or had a recurrence of breast cancer within the past 24 months	44, G1 = 22, G2 = 22 Mean age: G1 = 54.3 y/o (SD = 9.6), G2 = 57.2 y/o (SD = 10.2)	G1 = Restorative Yoga G2 = Control group (wait list control)	PSQI	The total score of PSQI improved: No statistically significant finding G1 vs. G2 ( = 0.97)
Chandwani KD et al. 2010 [ ] America	Women (≥18 y) with breast cancer (stage 0-stage III) who were scheduled to undergo radiotherapy at The University of Texas M.D. Anderson Cancer Center	61, G1 = 30, G2 = 31 Mean age: G1 = 51.39 y/o (SD = 7.97), G2 = 54.02 y/o (SD = 9.96)	G1 = Yoga G2 = Control group (wait list control)	PSQI	The total score of PSQI improved: No statistically significant finding G1 vs. G2 ( > 0.05)
Bower JE et al. 2012 [ ] America	Post-menopausal women (aged 40–60 y) diagnosed with Stage 0 – II breast cancer; completed local and/or adjuvant cancer therapy (with the exception of hormonal therapy) at least 6 months and experiencing persistent cancer-related fatigue	31, G1 = 16, G2 = 15 Mean age: G1 = 54.4 y/o (SD = 5.7), G2 = 53.3 y/o (SD = 4.9)	G1 = Iyengar Yoga G2 = Control group (health education)	PSQI	The total score of PSQI improved: No statistically significant finding G1 vs. G2 ( > 0.05)
Kiecolt-Glaser JK et al. 2014 [ ] America	Women (stage 0-IIIa breast cancer survivors in age from 27 to 76 y) had completed cancer treatment within the past 3 years (except for tamoxifen / aromatase inhibitors) and were at least 2 months post surgery or adjuvant therapy or radiation	200, G1 = 100, G2 = 100 Mean age: G1 = 51.8 y/o (SD = 9.8), G2 = 51.3y/o (SD = 8.7)	G1 = Hatha Yoga G2 = Control group (wait list control)	PSQI	The total score of PSQI improved: G1 vs. G2 ( = 0.03)
Ratcliff CG et al. 2016 [ ] America	Women (aged ≥18 y) with breast cancer (diagnosed with stage 0 to III) scheduled to undergo daily adjuvant XRT (radiotherapy treatment) for 6 weeks at MD Anderson Cancer Center	163, G1 = 53, G2 = 56, G3 = 54 Mean age: G1 = 52.38 y/o (SD = 1.35), G2 = 51.14 y/o (SD = 1.32), G3 = 52.11 y/o (SD = 1.34)	G1 = Yoga G2 = Stretching G3 = Control group (wait list control)	PSQI	The total score of PSQI improved: No statistically significant finding G1 vs. G3 ( > 0.05)
Taylor T R et al. 2018 [ ] America	Women (aged 18–65 y), no pregnant, breast cancer survivor of at least 12 months post-surgery and treatment (excluding hormone therapy), free of medical contraindications reported by their physician	33, G1 = 18, G2 = 15 Mean age: G1 = 54.9 y/o (SD = 8.8), G2 = 52.6 y/o (SD = 8.2)	G1 = Restorative yoga G2 = Control group (wait list control)	ISI	The total score of ISI improved: No statistically significant finding G1 vs. G2 ( = 0.89)
Chaoul A et al. 2018 [ ] America	Women (aged ≥18 y) with breast cancer stage (American Joint Committee on Cancer (AJCC) TNM) I to III who were undergoing chemotherapy, were able to read, write and speak English; and were scheduled to undergo neoadjuvant or adjuvant therapy (weekly or every 21 days) at The University of Texas MD Anderson Cancer Center	227, G1 = 74, G2 = 68, G3 = 85 Mean age: G1 = 49.5 y/o (SD = 9.80), G2 = 50.4 y/o (SD = 10.3), G3 = 49.0 y/o (SD = 10.1)	G1 = Tibetan Yoga G2 = Stretching group G3 = Control group (Usual care)	PSQI Actigraphy	The total score of PSQI improved: No statistically significant finding G1 vs. G3 ( = 0.32) Actigraphy: Statistically significant finding in sleep efficiency (SE) G1 vs. G3 ( = 0.02), wake after sleep onset (WASO) G1 vs. G3 ( = 0.0003), but no statistically signify finding on sleep onset latency (OL) G1 vs. G3 ( = 0.89), total sleep time (TST) G1 vs. G3 ( = 0.19)
Porter LS et al. 2019 [ ] America	Women (aged ≥18y) receiving treatment for metastatic breast cancer had a life expectancy ≥9 months as estimated by their treating oncologist; could speak and read English	63, G1 = 43, G2 = 20 Mean age: G1 = 56.3 y/o (SD = 11.6) G2 = 59.4 y/o (SD = 11.3)	G1 = Yoga G2 = Control group (social support group)	PSQI	The total score of PSQI improved: No statistically significant finding G1 vs. G2 ( > 0.05)
Elavsky S et al. 2007 [ ] America	Sedentary or low-active middle-aged women (aged 42–58 y) during the menopausal transition who had no history of surgical menopause and had not used hormone therapy or at least 6 months. Baseline analyses revealed that overall sleep quality was poor in the sample (Mean PSQI = 6.21, SD = 3.46) with 88% of sample scoring	163, G1 = 61, G2 = 63, G3 = 39 Age range:42–58 y/oMean age:49.9 y/o (SD:3.6)	G1 = Yoga G2 = walking G3 = Control group	PSQI	The total score of PSQI improved: No statistically significant finding G1 vs. G3 ( > 0.05)
Afonso RF et al. 2012 [ ] Brazil	Postmenopausal women (aged 50–65 y) with insomnia diagnosed by specialist based on DSM4, amenorrhea for 1 year or longer, had follicle-stimulating hormone (FSH) ≥ 30 mIU/ml, and had a BMI (Body mass index) < 30 kg/m	61, G1 = 16, G2 = 21, G3 = 24 Age range:50–65 y/o	G1 = Yoga G2 = Passive stretching G3 = Control group	ISI Polysomnography	The total score of ISI improved: G1 vs. G3 ( < 0.05) Polysomnography: No statistically significant finding G1 vs. G3 ( > 0.05)
Newton KM et al. 2014 [ ] America	Previous sedentary women (aged 40–62 y) in menopausal transition or postmenopausal or had hysterectomy with FSH ≥ 20 m IU/mL and estradiol ≤50 pg/mL, with ≥14 vasomotor symptoms /week in each of three consecutive weeks and had not used hormone therapy for past 1 month.	249, G1 = 107, G2 = 142 Age range:40–62 y/o	G1 = Yoga G2 = Control group (usual activity)	PSQI ISI	The total score of PSQI improved: G1 vs. G2 ( = 0.049) The total score of ISI improved: G1 vs. G2 ( = 0.007)
Buchanan, D.T. et al. 2017 [ ] America	Women (aged 40–62 y) in menopausal transition or postmenopausal or had hysterectomy with FSH ≥ 20 mIU/mL and estradiol ≤50 pg/mL, generally in good health; experiencing 14 or more hot flashes/night sweats per week (on 2-w screening diaries); and hot flashes rated as bothersome or severe on four or more occasions/week	186, G1 = 52, G2 = 54, G3 = 80 Mean age: G1 = 55.3 y/o (SD = 3.9), G2 = 55.6 y/o (SD = 3.5), G3 = 54.2 y/o (SD = 3.7)	G1 = Yoga G2 = Exercise G3 = Control group (usual activity)	Actigraphy	Statistically no significant finding in sleep efficiency (SE) G1 vs. G3 ( > 0.05), wake after sleep onset (WASO) G1 vs. G3 ( > 0.05), sleep onset latency G1 vs. G3 ( > 0.05), total sleep time (TST) G1 vs. G3 ( > 0.05)
Ide MR et al. 2008 [ ] Brazil	Women with fibromyalgia syndrome (1990 American College of Rheumatology criteria) with time availability	40, G1 = 20, G2 = 20 Mean age: G1 = 46.61 y/o (SD = 9.80), G2 = 45.47 y/o (SD = 8.65)	G1 = Yoga breathing exercises in warm water G2 = Control group	PSQI	The total score of PSQI improved: G1 vs. G2 ( = 0.004)
Innes KE et al. 2012 [ ] America	Nonsmoking women (aged 45–79 y), post-menopausal (≥12 months amenorrheic) physical inactive (exercising less than 20 min, 3 times per week) and overweight (BMI ≥ 25 kg/m and/or waist circumference ≥ 88 cm) with restless legs syndrome	20, G1 = 10, G2 = 10 Mean age: G1 = 58.4 y/o (SD = 6.32), G2 = 58.9 y/o (SD = 9.10)	G1 = Iyengar Yoga G2 = Control group (education film group)	PSQI	The total score of PSQI improved: G1 vs. G2 ( = 0.01)
Cheung C et al. 2014 [ ] America	Community-dwelling women (aged 65–90 y) had symptomatic osteoarthritis (OA) of knee diagnosis for at least 6 months without previous training in any form of yoga	36, G1 = 18, G2 = 18 Mean age: G1 = 71.9 y/o, G2 = 71.9 y/o	G1 = Yoga G2 = Control group (wait list control)	PSQI	The total score of PSQI improved: No statistically significant finding G1 vs. G2 ( = 0.15)
Fang R et al. 2015 [ ] China	Female nurses (aged of 25–51 y) with normal communication abilities and willingness to participate study	120, G1 = 61, G2 = 59 Mean age: G1 = 35.13 y/o (SD =10.98), G2 = 36.05 y/o (SD = 9.91)	G1 = Yoga G2 = Control group	PSQI	The total score of PSQI improved: G1 vs. G2 ( < 0.001)
Ebrahimi M et al. 2017 [ ] Iran	Women (aged 38–53 y) with Type 2 Diabetes mellitus lack of any diabetic complications, no participation in any kind of regular aerobic exercise and resistance training over the last 6 months, BMI < 40 kg/m , not being under insulin treatment	45, G1 = 15, G2 = 15, G3 = 15 Mean age: G1 = 48.18 y/o, G2 = 44.69 y/o, G3 = 47.93 y/o	G1 = Yoga G2 = Aerobic exercise G3 = Control group	PSQI	The total score of PSQI improved: G1 vs. G3 ( < 0.05)
Rao M et al. 2017 [ ] India	Female teachers, aged between 30 and 55 years were willing to participate in the study and had no previous exposure to any form of yoga practice.	60, G1 = 30, G2 = 30 Mean age: G1 = 43.0 y/o (SD = 9.77) G2 = 40.0 y/o (SD = 7.32)	G1 = Yoga-based, mindfulness relaxation G2 = Control group (wait list control)	PSQI	The total score of PSQI improved: G1 vs. G2 ( < 0.01)
Nalgirkar SP et al. 2018 [ ] India	Women (aged 20–50 y) and diagnosed for primary dysfunctional uterine bleeding (DUB) with no underlying systemic pathology	30, G1 = 15, G2 = 15 Mean age: G1 = 29.85 y/o (SD =4.45) G2 = 30.85 y/o (SD =4.42)	G1 = Yoga G2 = Control group (wait list control)	PSQI	The total score of PSQI improved: No statistically significant finding G1 vs. G2 ( > 0.05)

Authors, year
country

Main characteristics of the studied population

Sample characteristics
(sample size, age)

Intervention group
comparison group

Sleep outcome measures

Outcomes

Danhauer SC et al. 2009 [ ]

America

Women (≥18 y) with breast cancer (any stage), 2–24 months post-primary treatment (surgery) following initial diagnosis and/or had a recurrence of breast cancer within the past 24 months

44, G1 = 22, G2 = 22

Mean age:

G1 = 54.3 y/o (SD = 9.6), G2 = 57.2 y/o (SD = 10.2)

G1 = Restorative Yoga

G2 = Control group

(wait list control)

PSQI

The total score of PSQI improved:

No statistically significant finding

G1 vs. G2 ( = 0.97)

Chandwani KD et al. 2010 [ ]

America

Women (≥18 y) with breast cancer (stage 0-stage III) who were scheduled to undergo radiotherapy at The University of Texas M.D. Anderson Cancer Center

61, G1 = 30, G2 = 31

Mean age:

G1 = 51.39 y/o (SD = 7.97), G2 = 54.02 y/o (SD = 9.96)

G1 = Yoga

G2 = Control group

(wait list control)

PSQI

The total score of PSQI improved:

No statistically significant finding

G1 vs. G2 ( > 0.05)

Bower JE et al. 2012 [ ]

America

Post-menopausal women (aged 40–60 y) diagnosed with Stage 0 – II breast cancer; completed local and/or adjuvant cancer therapy (with the exception of hormonal therapy) at least 6 months and experiencing persistent cancer-related fatigue

31, G1 = 16, G2 = 15

Mean age:

G1 = 54.4 y/o (SD = 5.7), G2 = 53.3 y/o (SD = 4.9)

G1 = Iyengar Yoga

G2 = Control group

(health education)

PSQI

The total score of PSQI improved:

No statistically significant finding

G1 vs. G2 ( > 0.05)

Kiecolt-Glaser JK et al. 2014 [ ]

America

Women (stage 0-IIIa breast cancer survivors in age from 27 to 76 y) had completed cancer treatment within the past 3 years (except for tamoxifen / aromatase inhibitors) and were at least 2 months post surgery or adjuvant therapy or radiation

200, G1 = 100, G2 = 100

Mean age:

G1 = 51.8 y/o (SD = 9.8), G2 = 51.3y/o (SD = 8.7)

G1 = Hatha Yoga

G2 = Control group

(wait list control)

PSQI

The total score of PSQI improved:

G1 vs. G2 ( = 0.03)

Ratcliff CG et al. 2016 [ ]

America

Women (aged ≥18 y) with breast cancer (diagnosed with stage 0 to III) scheduled to undergo daily adjuvant XRT (radiotherapy treatment) for 6 weeks at MD Anderson Cancer Center

163, G1 = 53, G2 = 56, G3 = 54

Mean age:

G1 = 52.38 y/o (SD = 1.35), G2 = 51.14 y/o (SD = 1.32), G3 = 52.11 y/o (SD = 1.34)

G1 = Yoga

G2 = Stretching

G3 = Control group (wait list control)

PSQI

The total score of PSQI improved:

No statistically significant finding

G1 vs. G3 ( > 0.05)

Taylor T R et al. 2018 [ ]

America

Women (aged 18–65 y), no pregnant, breast cancer survivor of at least 12 months post-surgery and treatment (excluding hormone therapy), free of medical contraindications reported by their physician

33, G1 = 18, G2 = 15

Mean age:

G1 = 54.9 y/o (SD = 8.8), G2 = 52.6 y/o (SD = 8.2)

G1 = Restorative yoga

G2 = Control group

(wait list control)

ISI

The total score of ISI improved:

No statistically significant finding

G1 vs. G2 ( = 0.89)

Chaoul A et al. 2018 [ ]

America

Women (aged ≥18 y) with breast cancer stage (American Joint Committee on Cancer (AJCC) TNM) I to III who were undergoing chemotherapy, were able to read, write and speak English; and were scheduled to undergo neoadjuvant or adjuvant therapy (weekly or every 21 days) at The University of Texas MD Anderson Cancer Center

227, G1 = 74, G2 = 68, G3 = 85

Mean age:

G1 = 49.5 y/o (SD = 9.80), G2 = 50.4 y/o (SD = 10.3),

G3 = 49.0 y/o (SD = 10.1)

G1 = Tibetan Yoga

G2 = Stretching group

G3 = Control group

(Usual care)

PSQI

Actigraphy

The total score of PSQI improved:

No statistically significant finding G1 vs. G3 ( = 0.32)

Actigraphy:

Statistically significant finding in sleep efficiency (SE) G1 vs. G3 ( = 0.02), wake after sleep onset (WASO) G1 vs. G3 ( = 0.0003), but no statistically signify finding on sleep onset latency (OL) G1 vs. G3 ( = 0.89), total sleep time (TST) G1 vs. G3 ( = 0.19)

Porter LS et al. 2019 [ ]

America

Women (aged ≥18y) receiving treatment for metastatic breast cancer had a life expectancy ≥9 months as estimated by their treating oncologist; could speak and read English

63, G1 = 43, G2 = 20

Mean age:

G1 = 56.3 y/o (SD = 11.6)

G2 = 59.4 y/o (SD = 11.3)

G1 = Yoga

G2 = Control group

(social support group)

PSQI

The total score of PSQI improved:

No statistically significant finding

G1 vs. G2 ( > 0.05)

Elavsky S et al. 2007 [ ]

America

Sedentary or low-active middle-aged women (aged 42–58 y) during the menopausal transition who had no history of surgical menopause and had not used hormone therapy or at least 6 months. Baseline analyses revealed that overall sleep quality was poor in the sample (Mean PSQI = 6.21, SD = 3.46) with 88% of sample scoring

163, G1 = 61, G2 = 63, G3 = 39

Age range:42–58 y/oMean age:49.9 y/o (SD:3.6)

G1 = Yoga

G2 = walking

G3 = Control group

PSQI

The total score of PSQI improved:

No statistically significant finding

G1 vs. G3 ( > 0.05)

Afonso RF et al. 2012 [ ]

Brazil

Postmenopausal women (aged 50–65 y) with insomnia diagnosed by specialist based on DSM4, amenorrhea for 1 year or longer, had follicle-stimulating hormone (FSH) ≥ 30 mIU/ml, and had a BMI (Body mass index) < 30 kg/m

61, G1 = 16, G2 = 21, G3 = 24

Age range:50–65 y/o

G1 = Yoga

G2 = Passive stretching

G3 = Control group

ISI

Polysomnography

The total score of ISI improved:

G1 vs. G3 ( < 0.05)

Polysomnography:

No statistically significant finding

G1 vs. G3 ( > 0.05)

Newton KM et al. 2014 [ ]

America

Previous sedentary women (aged 40–62 y) in menopausal transition or postmenopausal or had hysterectomy with FSH ≥ 20 m IU/mL and estradiol ≤50 pg/mL, with ≥14 vasomotor symptoms /week in each of three consecutive weeks and had not used hormone therapy for past 1 month.

249, G1 = 107, G2 = 142

Age range:40–62 y/o

G1 = Yoga

G2 = Control group

(usual activity)

PSQI

ISI

The total score of PSQI improved:

G1 vs. G2 ( = 0.049)

The total score of ISI improved:

G1 vs. G2 ( = 0.007)

Buchanan, D.T. et al. 2017 [ ]

America

Women (aged 40–62 y) in menopausal transition or postmenopausal or had hysterectomy with FSH ≥ 20 mIU/mL and estradiol ≤50 pg/mL, generally in good health; experiencing 14 or more hot flashes/night sweats per week (on 2-w screening diaries); and hot flashes rated as bothersome or severe on four or more occasions/week

186, G1 = 52, G2 = 54, G3 = 80

Mean age:

G1 = 55.3 y/o (SD = 3.9),

G2 = 55.6 y/o (SD = 3.5),

G3 = 54.2 y/o (SD = 3.7)

G1 = Yoga

G2 = Exercise

G3 = Control group

(usual activity)

Actigraphy

Statistically no significant finding in sleep efficiency (SE) G1 vs. G3 ( > 0.05), wake after sleep onset (WASO) G1 vs. G3 ( > 0.05), sleep onset latency G1 vs. G3 ( > 0.05), total sleep time (TST) G1 vs. G3 ( > 0.05)

Ide MR et al. 2008 [ ]

Brazil

Women with fibromyalgia syndrome (1990 American College of Rheumatology criteria) with time availability

40, G1 = 20, G2 = 20

Mean age:

G1 = 46.61 y/o (SD = 9.80), G2 = 45.47 y/o (SD = 8.65)

G1 = Yoga breathing exercises in warm water

G2 = Control group

PSQI

The total score of PSQI improved:

G1 vs. G2 ( = 0.004)

Innes KE et al. 2012 [ ]

America

Nonsmoking women (aged 45–79 y), post-menopausal (≥12 months amenorrheic) physical inactive (exercising less than 20 min, 3 times per week) and overweight (BMI ≥ 25 kg/m and/or waist circumference ≥ 88 cm) with restless legs syndrome

20, G1 = 10, G2 = 10

Mean age:

G1 = 58.4 y/o (SD = 6.32), G2 = 58.9 y/o (SD = 9.10)

G1 = Iyengar Yoga

G2 = Control group (education film group)

PSQI

The total score of PSQI improved:

G1 vs. G2 ( = 0.01)

Cheung C et al. 2014 [ ]

America

Community-dwelling women (aged 65–90 y) had symptomatic osteoarthritis (OA) of knee diagnosis for at least 6 months without previous training in any form of yoga

36, G1 = 18, G2 = 18

Mean age:

G1 = 71.9 y/o,

G2 = 71.9 y/o

G1 = Yoga

G2 = Control group

(wait list control)

PSQI

The total score of PSQI improved:

No statistically significant finding

G1 vs. G2 ( = 0.15)

Fang R et al. 2015 [ ]

China

Female nurses (aged of 25–51 y) with normal communication abilities and willingness to participate study

120, G1 = 61, G2 = 59

Mean age:

G1 = 35.13 y/o

(SD =10.98),

G2 = 36.05 y/o

(SD = 9.91)

G1 = Yoga

G2 = Control group

PSQI

The total score of PSQI improved:

G1 vs. G2 ( < 0.001)

Ebrahimi M et al. 2017 [ ]

Iran

Women (aged 38–53 y) with Type 2 Diabetes mellitus lack of any diabetic complications, no participation in any kind of regular aerobic exercise and resistance training over the last 6 months, BMI < 40 kg/m , not being under insulin treatment

45, G1 = 15, G2 = 15, G3 = 15

Mean age:

G1 = 48.18 y/o,

G2 = 44.69 y/o,

G3 = 47.93 y/o

G1 = Yoga

G2 = Aerobic exercise

G3 = Control group

PSQI

The total score of PSQI improved:

G1 vs. G3 ( < 0.05)

Rao M et al. 2017 [ ]

India

Female teachers, aged between 30 and 55 years were willing to participate in the study and had no previous exposure to any form of yoga practice.

60, G1 = 30, G2 = 30

Mean age:

G1 = 43.0 y/o (SD = 9.77)

G2 = 40.0 y/o (SD = 7.32)

G1 = Yoga-based, mindfulness relaxation

G2 = Control group

(wait list control)

PSQI

The total score of PSQI improved:

G1 vs. G2 ( < 0.01)

Nalgirkar SP et al. 2018 [ ]

India

Women (aged 20–50 y) and diagnosed for primary dysfunctional uterine bleeding (DUB) with no underlying systemic pathology

30, G1 = 15, G2 = 15

Mean age:

G1 = 29.85 y/o (SD =4.45)

G2 = 30.85 y/o (SD =4.42)

G1 = Yoga

G2 = Control group

(wait list control)

PSQI

The total score of PSQI improved:

No statistically significant finding

G1 vs. G2 ( > 0.05)

BMI Body max index, DSM4 Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria, DUB Dysfunctional uterine dysfunction, ECOG-PS Eastern Cooperative Oncology Group Performance Status, FSH Follicle-stimulating hormone, G1 Group 1, G2 Group 2, G3 Group 3, ISI Insomnia Severity Index, OA Osteoarthritis, OL Onset latency, PSQI Pittsburgh Sleep Quality Index, SE Sleep efficiency, TST Total sleep time, WASO Wake time after sleep onset, XRT Radiotherapy treatment

Characteristics of yoga programs and outcome assessment of studies included in the systematic review

Authors, year country	Specific type of yoga	Yoga frequency (sessions/week)	Session length (mins/week)	Study duration (weeks/ study)	Number of sessions/study Total lengths (h)/study	Safety (adverse events)	Basal score of PSQI (SD) and follow-up	Basal score of ISI (SD) and follow-up
Elavsky s et al. 2007 [ ] America	Iyengar Yoga (Hatha Yoga)	2	90	16	32 (24 h)	Not reported	G1 = 6.9 0(3.94) G1 = 6.48 (4.22) G3 = 5.46 (2.96) G3 = 5.44 (3.63)	–
Afonso RF et al. 2012 [ ] Brazil	Asanas Yoga	2	120	16	32 (32 h)	Not reported	–	G1 = 14.1 (5.87) G1 = 9.7 (4.64) G3 = 15.2 (4.8) G3 = 13.7 (4.64)
Newton KM et al. 2014 [ ] America	Yoga program	2	90	12	24 (18 h)	Reported	G1 = 7.7 (3.34) G1 = 5.6 (3.30) G2 = 8.4 (3.30) G2 = 5.8 (2.91)	G1 = 11.8 (5.25) G1 = 7.4 (5.07) G2 = 12.2 (5.13) G2 = 6.8 (4.35)
Buchanan, D.T. et al. 2017 [ ] America	Viniyoga	1	90	12	12 (18 h)	Not reported	–	–
Danhauer SC et al. 2009 [ ] America	Restorative Yoga	1	75	10	10 (12.5 h)	Not reported	G1 = 8.3 (4.7) G1 = 6.1 (4.3) G2 = 8.6 (5.3) G2 = 7.0 (4.2)	–
Chandwani KD et al. 2010 [ ] America	Yoga	2	120	6	12 (12 h)	Not reported	G1 = 7.3 (3.83) G1 = 7.3 (4.67) G2 = 7.1 (3.89) G2 = 7.1 (5.38)	–
Bower JE et al. 2012 [ ] America	Iyengar Yoga	2	90	12	24 (36 h)	Not reported	G1 = 9.2 (3.3) G1 = 8.1 (2.5) G2 = 9.1 (3.5) G2 = 7.7 (2.6)	–
Kiecolt-Glaser KJ et al. 2014 [ ] America	Hatha Yoga	2	180	12	24 (36 h)	Reported	G1 = − G1 = 7.0 (2.15) G2 = − G2 = 6.3 (2.18)	–
Cheung C et al. 2014 [ ] America	Hatha Yoga	1	60	8	8 (8 h)	Not reported	G1 = 6.5 (4.2) G1 = 5.0 (2.2) G2 = 5.4 (2.8) G2 = 6.1 (2.2)	–
Ratcliff CG et al. 2016 [ ] America	Yoga program	3	180	6	18 (18 h)	Not reported	G1 = 8.3 (3.9) G1 = 6.7 (3.1) G3 = 8.2 (3.7) G3 = 7.3 (3.7)	–
Taylor TR et al. 2018 [ ] America	Restorative Yoga	1	75	8	8 (10 h)	Not reported	–	G1 = 10.18 (8.74) G1 = 7.89 (7.17) G2 = 7.56 (6.82) G2 = 6.20 (7.11)
Chaoul A et al. 2018 [ ] America	Tibetan Yoga	4	300–360	1	4 (5–6 h)	Not reported	G1 = 7.8 (3.7) G1 = 7.3 (3.6) G3 = 8.1 (4.2) G3 = 8.1 (4.4)	–
Porter LS et al. 2019 [ ] America	Mindful Yoga	1	120	8	8 (16 h)	Not reported	G1 = 8.6 (3.34) G1 = 8.6 (3.01) G2 = 7.6 (2.73) G2 = 7.6 (3.42)	–
Ide MR et al. 2008 [ ] Brazil	Yoga breathing exercises in warm water	4	240	4	16 (16 h)	Not reported	G1 = 13.17 (4.00) G1 = 9.95 (1.15) G2 = 11.82 (5.05) G2 = 13.88 (1.28)	–
Innes K E et al. 2012 [ ] America	Iyengar yoga	2	180	8	16 (24 h)	Not reported	G1 = 8.71 (3.63) G1 = 3.57 (1.49) G2 = 9.25 (3.32) G2 = 8.00 (2.94)	–
Fang R et al. 2015 [ ] China	Yoga	> 2	> 100–120	24	> 48 (40–48 h)	Not reported	G1 = 9.98 (1.89) G1 = 7.61 (1.25) G2 = 10.24 (2.35) G2 = 10.31 (2.42)	–
Ebrahimi M et al. 2017 [ ] Iran	Yoga program	3	270	12	36 (54 h)	Not reported	G1 = 14.40 (5.92) G1 = 3.73 (3.49) G3 = 13.91 (5.52) G3 = 13.27 (5.58)	–
Rao, M et al. 2017 [ ] India	Yoga-based, mindfulness relaxation	5	150	4	20 (10 h)	Not reported	G1 = 5.63 (3.31) G1 = 3.10 (1.26) G2 = 4.86 (2.52) G2 = 5.9 (1.93)	–
Nalgirkar SP et al. 2018 [ ] India	Yoga program	3	180	12	36 (h)	Not reported	G1 = 15.16 (8.29) G1 = 12.75 (4.73) G2 = 9.91 (4.69) G2 = 10.08 (3.75)	–

Study and participant characteristics

Of the 19 RCTs that were included in Table 1 , six RCTs included healthy participants [ 60 – 63 , 67 , 69 ], including nurses [ 67 ], teachers [ 69 ], and women in the menopausal transition period or postmenopausal period [ 60 – 63 ]. The other 13 RCTs included breast cancer patients undergoing treatment [ 55 , 57 – 59 ], breast cancer patients who had completed treatment [ 12 , 54 , 56 , 71 ], type 2 diabetes mellitus patients [ 68 ], fibromyalgia patients [ 64 ], knee osteoarthritis patients [ 66 ], restless leg syndrome patients [ 65 ], and patients experiencing dysfunctional uterine bleeding [ 70 ].

Overall, the 19 RCTs included were conducted in the United States [ 12 , 54 – 60 , 62 , 63 , 65 , 66 , 71 ], Brazil [ 61 , 64 ], India [ 69 , 70 ], Iran [ 68 ], and China [ 67 ]. Study participants were recruited from hospitals [ 54 , 55 , 57 , 58 , 67 , 68 , 70 , 71 ], outpatient clinics [ 59 , 61 ] and schools [ 69 ]. The process of recruitment also included using purchased lists and health-plan enrollment files [ 62 , 63 ] and multiple other mechanisms, including flyers, newspaper advertisements, web-based announcements, brochures, public health departments, tumor registry systems, and doctor referrals [ 12 , 56 , 60 , 65 , 66 ]. One study did not reveal the source from which participants were recruited [ 64 ]. Nineteen studies included in the systematic review displayed a baseline of PSQI higher than 5 or ISI higher than 8, indicating poor sleep quality or insomnia. The only exceptions were two studies, with individual control groups in each study displaying a baseline of PSQI lower than 5 [ 69 ] or ISI lower than 8 [ 71 ]. The sample size ranged from 20 to 249 with a median of 96. Participant’s mean age ranged from 29.8 to 71.9 years, with a median of 50.1 years. All participants were women.

Intervention characteristics

Of the 19 included studies in Table Table1, 1 , three reported using Iyengar Yoga [ 12 , 60 , 65 ]; two reported using Hatha Yoga [ 56 , 66 ]; two reported using Tibetan Yoga [ 58 , 61 ]; two reported using Restorative Yoga [ 54 , 71 ]; one reported using Vini Yoga [ 63 ]; one reported using Yoga Relaxation with MindSound Resonance Technique [ 69 ]; one reported using yoga breathing exercise in warm water [ 64 ]; and only seven RCTs revealed yoga programs with postures, breathing, relaxation or mediation, without defining a specific style of yoga [ 55 , 57 , 59 , 62 , 67 , 68 , 70 ]. All RCTs included yoga postures in their yoga intervention; 16 RCTs included yoga breathing; 15 RCTs included yoga relaxation; 12 RCTs included meditation; and 7 RCTs included all contents with postures, breathing, relaxation, and meditation for the yoga intervention group [ 55 , 57 , 62 , 67 , 68 , 70 , 71 ]. The duration of yoga interventions ranged from 1 week to 24 weeks, with a median of 10 weeks; the frequency of yoga interventions ranged from one to five weekly sessions of 45 to 120 min. Sixteen studies compared the yoga group with waitlist control groups with no specific treatment; three studies compared the yoga group with the control group, including two studies for education groups [ 12 , 65 ] and one study for social support groups [ 59 ].

Outcome measures

All studies evaluated outcomes directly at the end of interventions. All studies assessed the subjective or objective measurements of sleep quality: 16 RCTs used the PSQI; three RCTs used the ISI [ 61 , 62 , 71 ]; one RCT used PSG [ 61 ]; and two RCTs used actigraphy [ 58 , 63 ]. Safety-related events were reported in only two RCTs [ 56 , 62 ].

Risk of bias

Risk of bias in individual assessments.

Graphical representation of the risk-of-bias assessment is represented in Fig. 2 . All studies had a high or unclear risk of bias in at least one domain. All studies claimed to be randomized; however, three studies did not reveal their content and method of random sequence [ 54 , 61 , 68 ]. Twelve studies did not report methods applied to perform adequate allocation [ 54 , 55 , 57 – 61 , 63 , 67 – 70 ]. Most studies offered no data material on blinding. Three studies clearly reported that participants and personnel were blinded [ 12 , 59 , 66 ]. Four studies clearly reported that researchers and outcome assessments were blinded [ 12 , 56 , 59 , 66 ]. Six studies had insufficient data on attrition rates [ 60 – 62 , 64 , 65 , 68 ]. Twelve studies had a low risk of selection reporting; only two studies had a high risk of selective reporting due to several reported outcome parameters not being revealed in study protocol or duplicate publications reporting different results of the same trial [ 61 , 62 ]. Six studies had a high risk of other potential sources of bias due to poor participant compliance, intervention length, sample size or baseline differences [ 60 , 64 – 66 , 70 , 71 ].

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Risk of bias in individual studies. +, low risk of bias;?, unclear risk of bias; −, high risk of bias (a). Risk of bias for each criterion presented as percentages across all included studies (b)

Publication bias

The meta-analysis of the effect of yoga on the sleep quality of women that involved yoga groups compared with control groups included 16 studies. The asymmetrical shape of the funnel plot indicated that subjective publication bias was detected (Fig. 3 ). Objective publication bias was analyzed using Egger’s Regression Test. Egger’s Test consists of the regression between the accuracy of the studies and standardized effects, which are weighted by the inverse of variance. Borderline findings ( P = 0.05) show objective evidence on publication bias between precision and standardized effects of studies in the present study, specifically suggesting need for future studies to expound on the issue.

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Funnel plot of estimate of publication bias in meta-analysis of the effects of yoga on women’s sleep quality compared to control groups (PSQI). SE: standard error; SMD: standardized mean difference

Analysis of overall effects

Primary outcomes.

The random effects model was applied to analyze the 19 RCTs outcomes by different sleep outcome measurement tools. The meta-analysis of combined data conducted with Comprehensive Meta-Analysis, showed a significant improvement in sleep problems (SMD = -0.327, 95% CI = − 0.506 to − 0.148, P < 0.001). However, significant heterogeneity existed among all the studies (Q = 43.152, I 2 = 58.287%, P = 0.001). Therefore, moderator and meta-regression analyses were conducted to further explore the determinants of the heterogeneity.

The meta-analysis revealed the effects of yoga compared with the control group on the sleep quality and insomnia of women using the PSQI or ISI, as displayed in Fig. 4 . Sixteen RCTs revealed evidence for effects of yoga compared with the control group in improving sleep quality in women using the PSQI (SMD = − 0.54; 95% CI = − 0.89 to − 0.19; P = 0.003). However, three RCTs revealed no effects of yoga compared with the control group in reducing the severity of insomnia in women using ISI (SMD = − 0.13; 95% CI = − 0.74 to 0.48; P = 0.69). Two RCTs revealed no effects of yoga compared with control group in improving sleep efficiency (SMD = 0.85; 95% CI = − 0.56 to 2.26; P = 0.26) or total sleep time (SMD = − 0.06; 95% CI = − 0.26 to 0.13; P = − 0.59) in women using actigraphy.

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Forest plots for the effects of yoga on sleep quality in women versus control groups. a the global score of the Pittsburgh Sleep Quality Index (PSQI) b the global score of the Insomnia Severity Index (ISI). CI, confidence interval; IV, inverse variance; SD, standard deviation

Secondary outcomes (safety)

Only two studies reported safety-related events. Two events revealed in one study could potentially be attributed to yoga intervention: two women reported the recurrence of chronic back and/or shoulder problems [ 56 ]. In another study, adverse events reported did not differ between the yoga intervention group and the control group ( P = 0.41). These adverse events included muscle aches and strains (6.7%, yoga group; 10.3%, control group), low back pain (4.2%, yoga group; 3.1%, control group), or changes in strength or sensation in arms and legs (5.5% yoga group; 8.9% control group). Dropouts were not regarded as being adverse events because they did not explicitly show a possible reason or explanation for dropout in the original study. No serious adverse effects were reported in the included studies.

Subgroup analyses

Participants were divided into two separate subgroups. Meta-analyses revealed the effects of yoga compared with the control group for women with breast cancer in Fig. 5 . Seven RCTs revealed no evidence for the effect of yoga compared with the control group in improving sleep quality for women with breast cancer using the PSQI (SMD = − 0.15; 95% CI = − 0.31 to 0.01; P = 0.5). Four RCTs revealed no evidence for effects of yoga compared with the control group in improving sleep quality for women undergoing treatment for breast cancer (SMD = − 0.08; 95% CI = − 0.29 to 0.13; P = 0.45). Three RCTs revealed no evidence for positive effects of yoga in terms of improving sleep quality for women with breast cancer who had completed treatment compared with the control group (SMD = − 0.25; 95% CI = − 0.50 to 0.00; P = 0.05).

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c Forest plots of the effects of yoga on the sleep quality of women with breast cancer (including women under treatment and women who had completed treatment) versus a control group using the global score of the Pittsburgh Sleep Quality Index (PSQI). CI, confidence interval; IV, inverse variance; SD, standard deviation

The meta-analysis showed evidence of the positive effects of yoga on sleep quality compared with control groups for peri/postmenopausal women as displayed in Fig. 6 . Four RCTs revealed no evidence for effects of yoga compared with control groups in improving sleep quality in peri/postmenopausal women using the PSQI (SMD = − 0.31; 95% CI = − 0.95 to 0.33; P = 0.34). Two RCTs revealed no evidence for effects of yoga compared with the control group in reducing severity of insomnia in peri/postmenopausal using ISI (SMD = − 0.29; 95% CI = − 1.23 to 0.65; P = 0.55).

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Forest plots displaying the effects of yoga versus control groups on sleep quality in peri/postmenopausal women in ( d ) the global score of the Pittsburgh Sleep Quality Index (PSQI) ( e ) the global score of Insomnia Severity Index (ISI). CI, confidence interval; IV, inverse variance; SD, standard deviation

Moderator analyses, meta-regression

Moderator analyses and meta-regression are presented in Table 3 . Significant factors in observed heterogeneity were identified in yoga on sleep quality and insomnia in women with sleep problems. Studies that used PSQI as outcome measurement tool showed a greater reduction in sleep problems than other studies that used other instruments as outcome measurement tools ( Hedges ’ g = − 0.369 vs. 0.031, P = 0.002). Participants without breast cancer showed more improvement in sleep problems than participants with breast cancer ( Hedges ’ g = − 0.522 vs. -0.148, P = 0.001). Studies without peri/postmenopausal women showed more improvement in sleep problems than studies with peri/postmenopausal women ( Hedges ’ g = − 0.419 vs. -0.084, P = 0.003). Regression analyses revealed a positive correlation with total length of class hours ( p = 0.003), indicating that more total class hours, increased the chance to have significant results. Regression analyses revealed a negative correlation with mean age ( p = 0.003) and sample size ( p = 0.032) of study, indicating that the younger, and smaller sample sizes were more likely to have significant results.

Mean effect sizes and moderator analyses of yoga in women with sleep problems

Parameter	Results	Effect Size (Hedges’g)	95%CI


PSQI	16	- 0.369	−0.559, − 0.178	0.002
Others	3	0.031	− 0.265, 0.328

Breast cancer group	8	−0.148	−0.304, 0.009	0.001
Non-breast cancer group	11	−0.522	−0.821,-0.224

Peri/postmenopausal	6	−0.084	−0.269, 0.102	0.003
Others	13	−0.419	−0.647,-0.191

American	13	−0.123	−0.240,-0.006	< 0.001
Others	6	−0.844	−1.114,-0.573

High/ unclear risk	3	−0.578	−1.272, 0.116	0.001
Low risk	16	−0.292	−0.473,-0.111

	19		0.000,0.003	0.032
	19		−0.021,-0.004	0.003
	19		−0.03,0.087	0.20
	17		0.008,0.035	0.003

* P value <0.05 indicated a significant difference

Sensitivity analyses

In the included studies with low risk of selection bias, reporting bias, and other bias, the effect of yoga group compared to control group on women sleep PSQI did not change substantially, including random sequence generation bias (SMD = − 0.45; 95% CI = − 0.84 to − 0.11; P = 0.01; heterogeneity: I 2 = 88%; χ 2 = 107.43, P < 0.00001), allocation concealment bias (SMD = − 0.77; 95% CI = − 1.37 to − 0.16; P = 0.01; heterogeneity: I 2 = 88%; χ 2 = 40.95, P < 0.00001), selective reporting bias (standard mean difference = − 0.59; 95% CI = − 1.10 to − 0.08; P = 0.02; heterogeneity: I 2 = 88%; χ 2 = 93.11, P < 0.00001) and other bias (standard mean difference = − 0.53; 95% CI = − 1.03 to − 0.04; P = 0.03; heterogeneity: I 2 = 86%; χ 2 = 44.03, P < 0.00001). The effect compared with the control group remained significant in terms of sensitivity analyses of performance bias, detection bias, or attrition bias after eliminating high risk bias or uncertain risk bias of the studies.

Summary of evidence

In this systematic review of 19 studies for yoga’s effect on improving women’s sleep quality and severity of insomnia, 19 RCTs revealed evidence for yoga improving sleep problems in women (SMD = − 0.327, 95% CI = − 0.506 to − 0.148, P < 0.001). As shown in Fig. 4 , 16 RCTs meta-analysis suggests yoga can bring 1.2 points improvement in PSQI score (SMD = − 0.54; 95% CI = − 0.89 to − 0.19; P = 0.003). However, seven RCTs revealed no evidence for yoga improving sleep quality in women with breast cancer (Fig. (Fig.5, 5 , SMD = − 0.15; 95% CI = − 0.31 to 0.01; P = 0.5). Four RCTs revealed no evidence for improving PSQI in peri/postmenopausal women (Fig. (Fig.6, 6 , SMD = − 0.31; 95% CI = − 0.95 to 0.33; P = 0.34). Two RCTs revealed no evidence for improving ISI in peri/postmenopausal women (Fig. (Fig.6, 6 , SMD = − 0.29; 95% CI = − 1.23 to 0.65; P = 0.55).

However, heterogeneity of effects were high across all studies. In Table 3 , our moderator analyses yielded statistically significant differences, the effect of yoga for improving sleep problems in non-breast cancer subgroup, non peri/postmenopausal subgroup are superior to breast cancer subgroup, peri/postmenopausal subgroup.

Overall, the application of yoga was not associated with worsening of sleep problems or increased adverse effects. Only two studies explicitly assessed safety-related nonserious adverse events. Yoga is most likely a comparatively safe intervention in this population. However, future RCTs should take more measures to ensure stricter reporting of adverse events and reasons for dropouts.

Comparison with prior reviews

There was no systematic review available that explicitly focused on yoga for improving sleep quality and insomnia in a specific gender. Ours is the first systematic review and meta-analysis with 19 RCTs that to focus on the effects of yoga on women with sleep problems. A previous review published until February 2019 included subgroup analysis of yoga on mind-body therapies on insomnia [ 72 ]. This recent review illustrated that yoga had beneficial effects on subjective sleep quality in participants in all gender groups. Our meta-analysis with 16 RCTs uncovered evidence for the effects of yoga on the sleep quality in women. Only six RCTs were found to have overlapped with this previous review [ 58 , 61 , 62 , 65 – 67 ]. Our meta-analysis also examined the potential effect on specific subgroups, such as breast cancer and peri/postmenopausal subgroups, with these subgroups serving as potential factors in sleep quality effects (although the result did not show any clear difference). Significant subgroup differences were identified for the following participants types: (peri/postmenopausal vs. non peri/postmenopausal, breast cancer vs. non-breast cancer). Results from the peri/postmenopausal subgroup of women in our systematic review also agreed with previous published reports that suggested that yoga had no significant effect on the severity of insomnia in middle-aged women [ 73 ]. There were baseline differences between participants based on intervention assignment in PSQI scores [ 62 , 65 ]. This may have contributed to results displaying no significant effect in sleep quality in the peri/postmenopausal subgroup of women. Yoga seems to be effective for reducing total menopausal symptoms including psychological, somatic, vasomotor and in previous systematic review and meta-analysis [ 74 ], but there is no direct answer in the study focusing on reducing sleep problems. Future research should ensure more rigorous methodology and adequate sample size concerning the effects of yoga on quality of sleep improvement among the subgroup of peri/postmenopausal women.

Compared to yoga intervention, previous systematic reviews also indicate that programmed exercise improved sleep quality in middle-aged women [ 73 ]. However, these reviews are also limited to high heterogeneity of clinical evidence and failed to provide any specific suggestions for exercise dosages or formats. Additionally, other reviews included an overly wide range of nonpharmacological interventions ranging from walking [ 75 ], tai chi [ 76 ], qigong exercise [ 72 ] showing evidence of beneficial effect in improving self-rated sleep quality. However, despite this, heterogeneity remained high due to difference of interventions and target populations. Our meta-analysis conducted to further explore the determinants of the heterogeneity with subgroup analysis for categorical moderators and continuous moderators to find significant factors for observed heterogeneity.

External and internal validity

Major threats to external validity included the specificity of variables of sampled participants and multiple yoga types or styles. The majority of RCTs included participants from North America, South America, and Asia; lacking studies from Europe and Africa. It might not be as universally transferable to other areas.

There were several other limitations in this review: the wide variety of diagnoses included; the inclusion of only certain types of people or professions, such as nurses, teachers, and peri/postmenopausal women; and patients with breast cancer, type 2 diabetes mellitus, fibromyalgia syndrome, osteoarthritis of the knee, restless leg syndrome, and primary dysfunctional uterine bleeding. The heterogeneity of interventions with different types or styles of yoga (postures, breathing, relaxation, or mediation), and potential bias were included in this systematic review.

Other threat to internal validity was study bias. Only few effects were robust against all potential bias. All of our studies claimed to have applied randomization methods; however, three RCTs failed to provide the design protocol of randomization. Some of the included studies may not have been truly randomized. Erroneous allocation concealment has been empirically revealed to be a significant source of bias in RCTs [ 77 ]. Our included studies only had a low risk or an unclear risk of detection bias without high risk detection bias. The results of meta-analysis did no changed when studies excluded high risk or unclear risk reviews on selection bias or reporting bias. The internal validity of the review appeared to be limited but acceptable.

Strengths and weaknesses

This is the first and latest systematic review and meta-analysis available on yoga for sleep quality and insomnia in women. A large number of RCTs on female population-related physiological and physiological comorbidities and risk factors in insomnia were included. There were five primary limitations of this review. First, subjective publication bias revealed in this review may have been due to selective reporting bias, which means that articles with negative findings may have not been published or poor methodological quality of including articles. We have applied Egger’s Test for objective publication bias in our review. Second, the participant characteristics included in the review were heterogeneous; subgroups were included to analyze the effectiveness of different participant groups; and the small number of RCTs limited data presentation. Third, the severity of the sleep complaints and health status of participants was not considered or individually listed in each study. Baseline differences in PSQI scores were found between intervention and control groups in three studies [ 56 , 62 , 65 ]. This may have led to heterogeneity. The fourth limitation was the intensity, frequency, and duration of yoga interventions were heterogeneous; short term applications of less than 1 month yoga intervention were found in some studies [ 58 , 64 , 69 ]. Only four reviews reported long-term follow up effects, ranging from 3 months to 12 months [ 55 – 58 ]. Lastly, lack of safety issue evaluation including serious adverse events or nonserious events in each study.

Implications for further research

This systematic review and meta-analysis was limited by the low methodological quality of included studies. Further RCTs should ensure rigorous methodology and reporting, which would mean adequate sample size, adequate randomization, allocation concealment, intention-to-treat analysis, and blinding of at least outcome assessors [ 78 ]. Researchers for study interventions may need to apply a standard protocol. Adequate reporting of safety issues with yoga intervention should be discussed in future randomized controlled trials. Evidence was limited because few studies report safety-related adverse effects. Most of the included studies failed to report this aspect.

This systematic review and meta-analysis demonstrated that yoga intervention in women has benefits compared to non-active control conditions in term of managing sleep problems. The moderator analyses suggested that participants in the non-breast cancer subgroup or participants in the non-peri/postmenopausal subgroup were associated with greater benefits, with the longer total length of class time, the more beneficial these practices were.

Acknowledgements

Not applicable.

Abbreviations

AEs	Adverse events
BMI	Body max index
CI	Confidence interval
DSM4	Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria
DUB	Dysfunctional uterine dysfunction
ECOG-PS	Eastern Cooperative Oncology Group Performance Status
FSH	Follicle-stimulating hormone
G1	Group 1
G2	Group 2
G3	Group 3
ISI	Insomnia Severity Index
IV	Inverse variance
LH	Luteinizing hormones
MD	Mean differences
OA	Osteoarthritis
OL	Onset latency
PRISMA	Preferred reporting items for systematic reviews and meta- analyses
PSQI	Pittsburgh Sleep Quality Index
RCT	Randomized controlled trial
SD	Standard deviation
SE	Sleep efficiency
SE	Standard error
SMD	Standardized mean differences
SWS	Slow- wave sleep
TST	Total sleep time
WASO	Wake time after sleep onset
XRT	Radiotherapy treatment

Authors’ contributions

WLW, KHC, YCP, SNY and YYC designed the study. WLW conducted the literature searches. Selection of studies and data extraction: KHC and YCP. Disagreements were resolved by discussion or arbitration by YCP and SNY. Statistical analysis: WLW, KHC, YCP, SNY and YYC. FC drafted the manuscript. WLW, KHC, YCP, SNY and YYC critically revised the manuscript and approved the final version.

The authors thank to the editor’s valuable suggestion. This work was supported by the Taoyuan Armed Forces General Hospital (AFTYGH-10831 and TYAFGH-D-109026). The funder had no involvement in the design of this study and will not have any role during its execution, analyses or interpretation of data, writing the manuscript, and decision to submit the manuscript for publication.

Availability of data and materials

Ethics approval and consent to participate, consent for publication, competing interests.

The authors declare that they have no competing interests.

Publisher’s Note

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

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Introduction

Materials and methods

Participants

Brief Illness Perception.

Depression, Anxiety and Stress Scale.

Scale of General Wellbeing.

Brief Resilience Scale.

Peace of Mind Scale.

Emotion Regulation Questionnaire.

Preparation for the study.

Data collection and analysis

Descriptive analysis

Demographic variables

Effect of yoga and other spiritual practice on illness perception, and wellbeing measures

COVID19 perception-BIPQ.

Wellbeing related measure (DASS, SGWB, POMS, BRS).

Emotion regulation strategies (ERQ).

Effect of duration of yoga practice on illness perception and wellbeing measures

COVID19 perception (BIPQ).

Wellbeing related measures (DASS, SGWB, POMS, BRS).

Emotion regulation measure (ERQ).

Discussion and conclusions

Supporting information

Acknowledgments

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