Galantino _edited_IAYT_Integration of Yoga Into Rehabilitative Medicine

Yoga for Musculoskeletal Conditions: Integrating the

Evidence into Rehabilitation Medicine Practice

Mary Lou Galantino PT, PhD, MSCE

Richard Stockton College of NJUniversity of Pennsylvania

Session Goals

Lengthen the spine into the extremitiesWhat does the literature say about MS issues?Impact on general populations and chronic painPresent medically complex caseAddress integration of yoga in pedagogyFoster discussion regarding future research

Looking Through Our Yoga Lenses

Who are we as we view a diagnosis?

As the patient?

As the partner?

As a parent?

As the healthcare professional?

As a researcher?

As a policy maker?

As a community based organization?

Use of Yoga (Saper, 2004)

• 63% for maintenance of wellness and disease prevention

• 48% for specific health conditions• Back or neck pain, anxiety,

arthritis, depression, and fatigue

• 90% very or somewhat helpful for their health

“Yoga Therapy” (Hart, 2008)

• Yoga in medical therapy for specific ailments and disease processes

• Facilitated by a yoga teacher incorporating:• Physical postures (asanas), breathing techniques

(pranayama), chanting, meditation, relaxation

• Protocol is adapted to the individual’s capabilities and needs• Clinical decision making to assess, plan treatments,

create and apply interventions

Yoga for Musculoskeletal Issues

•General Population

•Boyle et al.

•Chen et al.

•Cowen et al.

•Telles et al.

•Carpal Tunnel Syndrome (CTS)

•Garfinkel et al.

•Sackett’s Levels of Evidence: 1, 2, 3, 4

•Rheumatoid Arthritis (RA)

•Bosch et al.

•Dash et al.

•Evans et al.

•Osteoarthritis

•Bukowski et al.

•Galantino et al.

•Garfinkel et al.

•Kolasinski et al.

Boyle, C., Sayers, S., Jensen, B., Headley, S., & Manos, T. (2004). The effects of yoga training and a single bout of yoga on delayed onset muscle

soreness in the lower extremity. Journal of Strength & Conditioning Research (Allen Press Publishing Services Inc.), 18(4), 723-729.

Level Of Evidence (LOE): 2c Objective: Determine effects of yoga training and

a single bout of yoga on the intensity of delayed onset muscle soreness (DOMS)

Participants: 24 yoga trained and non-trained female volunteers

Intervention: DOMS inducing bench step exercise. Results: Significant findings with VAS at 24 and

48 hours, appears to attenuate DOMS following eccentric exercise

Chen, K., & Tseng, W. (2008). Pilot-testing the effects of a newly-developed silver yoga exercise program for female seniors. Journal of Nursing

Research (Taiwan Nurses Association), 16(1), 37-46.

LOE: 2c Objective: Effects of a silver yoga program for female seniors Participants: 16 community-dwelling seniors Intervention: 70 minutes a week, 3 times a

week for 4 weeks Results: Percent body fat and systolic BP decreased,

ROM for shoulder flexion & extension increased, and sleep disturbance was minimized (all p<.05)

Telles, S., Dash, M., & Naveen, K. (2009). Effect of yoga on musculoskeletal discomfort and motor functions in professional computer

users. Work, 33(3), 297-306.

LOE: 1b Objective: Effect of yoga on MS

discomfort in computer workers Participants: 291 computer office

workers Intervention: Randomized to 5

days of 1 hour yoga sessions (146) or wait list control (145)

Results: Yoga group showed significant decrease in frequency, intensity, and degree of interference due to MS discomfort; increase in bilateral hand grip, right hand tapping speed, and sit and reach

Garfinkel, M., Singhal, A., Katz, W., Allan, D., Reshetar, R., & Schumacher, H. (1998). Yoga-based intervention for carpal tunnel syndrome: a

randomized trial. JAMA: Journal of the American Medical Association, 280(18), 1601-1603.

Studied effectiveness of yoga for CTS. LOE:2b Participants: 42 individuals with CTS Intervention: Randomized to yoga group with 11

postures biweekly for 8 weeks or a control group with a wrist splint

Results: Yoga group had significant improvement in grip strength (p=.009) and pain reduction), Phalen sign (p=0.008). No significant differences seen in sleep disturbance, Tinel sign, or median nerve conduction time.

Garfinkel, M., Singhal, A., Katz, W., Allan, D., Reshetar, R., & Schumacher, H. (1998). Yoga-based intervention for carpal tunnel syndrome: a

randomized trial. JAMA: Journal of the American Medical Association, 280(18), 1601-1603.

Table 3. - Comparison Between Grip Strength, Pain, and Sensory and Motor Nerve Conduction Times

Variable n† Pre-test Post-test ImprovementGrip StrengthYoga 33 161.6 (70.4) 187.4 (68.8) 25.8 (41.4) 0.01Control 29 183.9 (69.5) 190.5 (68.2) 6.6 (41.1) 0.37

Pain, visual analog scale (1-10)Yoga 22 5.0 (2.8) 2.9 (2.2) 2.1 (3.1) 0.02Control 20 5.2 (2.1) 4.3 (2.2) 0.9 (2.8) 0.16

Median nerve sensory conduction, msYoga 35 4.4 (1.5) 3.97 (1.5) .42 (1.8) 0.18Control 32 4.66 (1.4) 4.36 (1.6) .29 (1.5) 0.28

Median nerve motor conduction, msYoga 33 4.79 (1.3) 4.27 (1.4) .52 (1.7) 0.08Control 29 4.78 (1.1) 4.52 (1.1) .26 (0.8) 0.09

P Value ‡

Bosch, P., Traustadóttir, T., Howard, P., & Matt, K. (2009). Functional and physiological effects of yoga in women with rheumatoid arthritis: a pilot

study. Alternative Therapies in Health & Medicine, 15(4), 24-31.

LOE: 2c Objective: The effect of Yoga on

neuroendocrine & physical function in women with rheumatoid arthritis

Participants: 16 postmenopausal women with RA I, II, or III

Intervention: 75 minute yoga classes 3 times a week for 10 weeks

Results: Significant decreases in HAQ disability index, decreased perception of pain and depression, improved balance, no changes in awakening or diurnal cortisol patterns

Dash, M., & Telles, S. (2001). Improvement in hand grip strength in normal volunteers and rheumatoid arthritis patients following yoga training.

Indian Journal of Physiology and Pharmacology, 45(3): 355-360.

LOE: 2b Objective: Study effects of yoga on normal

adults and children and patients with RA Participants: 37 normal adults, 86 normal

children, and 20 RA patients Intervention: Regular yoga exercises and control

group Results: Hand grip strength improved for all

participants, with adult females improving more than adult males

Evans, S., Moieni, M., Taub, R., Subramanian, S., Tsao, J., Sternlieb, B., et al. (2010). Iyengar yoga for young adults with rheumatoid arthritis: results

from a mixed-methods pilot study. Journal of Pain & Symptom Management, 39(5), 904-913

LOE: 2c Objective: Investigated the feasibility of using

Iyengar Yoga to treat RA in young adults Participants: 8 young adults with RA Intervention: 6 week biweekly Iyengar yoga

program Results: Significant improvement in pain, pain

disability, depression, mental health, vitality and self-efficacy were found. Interviews showed improvements with RA symptoms and functioning but uncertainty on its effect on pain

Garfinkel, M., Schumacher, H., Husain, A., Levy, M., & Reshetar, R. (1994). Evaluation of a yoga based regimen for treatment of osteoarthritis of the

hands. Journal of Rheumatology, 21(12), 2341-2343.

LOE: 2b Objective: Study effect of yoga on

hand osteoarthritis Participants: Adult patients Intervention: 8 week yoga program

(control group or no therapy) Results: Yoga group improved

significantly more in pain during activity, tenderness, and finger ROM than the control

Kolasinski, S., Garfinkel, M., Tsai, A., Matz, W., Van Dyke, A., & Schumacher, H. (2005). Iyengar yoga for treating symptoms of

osteoarthritis of the knees: a pilot study. Journal of Alternative & Complementary Medicine, 11(4), 689-693.

LOE: 2c Objective: Study feasibility and effectiveness of yoga on knee OA Participants: 11 obese subjects Intervention: 8 weeks of 90 minute Iyengar yoga

classes once weekly Results: Significant reductions in WOMAC pain,

and physical function, AIMS2 affect were observed. Trends of improvement were seen in WOMAC stiffness, AIMS2 stiffness, social and role, Physician GA and Patient GA

Kolasinski, S., Garfinkel, M., Tsai, A., Matz, W., Van Dyke, A., & Schumacher, H. (2005). Iyengar yoga for treating symptoms of

osteoarthritis of the knees: a pilot study. Journal of Alternative & Complementary Medicine, 11(4), 689-693.

Universities Index Score Before and after Yoga InterventionChange % Change % SD p

Pain 46.7 53.2 0.04aPhysical Function 39.1 44 0.04a

Stiffness 39 55.4 0.06bSD, standard deviation

Table 1 Change in Western Ontario and McMaster (WOMAC)

WOMAC subscale

aSigned rank testbStudent's t Test

Table 2 Change in Arthritis Impact Measurement Scales 2 (AIMS2)Scores Before and After Yoga Intervention

AIMS2 component Change % Change % SD pAffect 23.2 13.5 0.002a

Symptoms 36.5 65.9 0.1bSocial 2.2 38.9 0.6bRole 37.3 100.6 0.8b

SD, standard deviationaSigned rank testbt Test

Table 3 Change in Global Assessments (GA) Before and AfterYoga Intervention

GA Change % Change % SD pPatient 24.1 62.3 0.2aPhysician 29.5 79.3 0.2aSD, standard deviationaSigned rank test

Bukowski, E., Conway, A., Glentz, L., Kurland, K., & Galantino, ML. (2006). The effect of Iyengar yoga and strengthening exercises for people living with

osteoarthritis of the knee: a case series. International Quarterly of Community Health Education, 26(3), 287-305.

• LOE: 4 – Case series• Objective: Effectiveness of Iyengar yoga and exercise on

knee osteoarthritis• Participants: 15 men and women with knee osteoarthritis• Intervention: Randomization to either an Iyengar yoga

group, stretching/exercise group, or a control group with no structured program for 6 weeks

• Outcome Measures: Participants were rated before and after by right and left quadriceps strength, WOMAC scores, a globalized questionnaire, and sit and reach test

Bukowski, E., Conway, A., Glentz, L., Kurland, K., & Galantino, M. (2006). The effect of Iyengar yoga and strengthening exercises for people living with


• Participants 4, 5, 6, 11, 12, and 15 experienced decreases or no change in flexibility while the others all improved. 9 participants experienced improvement in pain and functional abilities according to their WOMAC scores.

Sit and Reach Test

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Bukowski, E., Conway, A., Glentz, L., Kurland, K., & Galantino, ML. (2006). The effect of Iyengar yoga and strengthening exercises for people living with


• Almost all participants improved in quadriceps strength. Those who did also rated better or the same on the sit and reach and WOMAC scores.

Right Quadriceps Strength

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Bukowski, E., Conway, A., Glentz, L., Kurland, K., & Galantino, M. (2006). The effect of Iyengar yoga and strengthening exercises for people living with


• 2 participants reported decreased function (non-exercise group); 3 reported no change (2 in non-exercise, 1 in exercise); 5 reported slight increase (2 yoga, 3 exercise); and 4 reported significant improvement (1 yoga, 3 exercise).

Global Assessments

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Health CareProvider

Galantino et al. (2010). Impact of Yoga on Functional Outcomes in Breast Cancer Survivors with Aromatase Inhibitor-Associated Arthralgias.

• LOE: 2b• Objective: Establish the feasibility of studying the impact of yoga on

objective functional outcomes for AI-associated arthralgia (AIAA).

• Participants: Postmenopausal women with stage I-III breast cancer who reported AIAA were enrolled in a single arm feasibility trial.

• Intervention: Iyengar yoga for twice a week (1.5 hours) for 8 weeks and participants were instructed to do a home-based yoga program.

• Results: Significant improvement in flexibility measured by SR and in balance measured by FR, both p<.01. Improvements were also seen in PSFS, QOL by FACT-B, both p<0.05. 80% adherence to HEP (15 mins, 3x/week), and no adverse effects.


Measure Baseline Mean (SD)

Week 5 Mean (SD)

p value*

Sit and Reach 22.90 (12.98) 30.10 (12.3) .009

Functional Reach 24.36 (16.37) 39.19 (14.62) .048

PSFS 4.40 (1.86) 7.21 (2.00) .004

BPI: Pain Severity 3.90 (1.63) 2.79 (1.84) .016

BPI: Pain Interference

2.75 (2.77) 1.45 (1.84) .070

FACT-B 89.33 (20.18) 106.05 (17.02) .015

Qualitative Analysis

Increased Energy “Feel sluggish before yoga, feel ready to go after! (JA)”“The yoga session left me feeling invigorated…(EP)”“My body felt really good after class, not tense, with more energy (NB)” “My muscles are sore, but I feel more energized (L)”

Relieved Stress/Anxiety “As usual I feel so relaxed and ready to face my day with a more mellow

approach…after yoga class…yoga helps me breathe and be more patient (EP)”“I left class relaxed and thrilled to see the sunlight as I walked out the door (EP)”“…it calms my mind and gives me positive energy, especially on a day like today

which could turn bad at any moment (NG)”“I went out side to meditate. The sun was warm, so I focused on it. Lots of

chatter in my head, but it went away and I tried to relax. I also did alternate nostril breathing. It was nice. (L)”

Frequency of Responses

Empowering “I am feeling good about myself (JA)”“I do not have the words to express how much I have gained from this

experience. I know that yoga will continue to be part of my life (LF)”“It makes me feel like I can do something about the aches instead of

groaning and complaining (NB)”Relief from Aches & Pains

“my body was aching, so I finally did a good 20 minute yoga practice …I love yoga! It cures all that ails ya! I feel much better already. (EP)”

“The wrist exercises were great for all the problems in my hands and wrists (EP)”

“The lunges against the wall are helping to relieve my knee pain…my knees feel better…lower back pain is definitely better! (LF)”

Qualitative Findings from Journals

Weight loss/increased physical fitness “It makes me feel stronger when I can find the time to do

30 minutes a day (EP)”“My whole body feels less bulky (NB)”

Increased flexibility/functioning “my body will function better throughout the day…and I

feel so good all over…nice and loose with mental calmness too. (EP)”

“I am glad we are practicing balancing, I am awful at it and have found that [Andee’s] instructions really help (NB)”

“When Naida used the wall it was challenging, and I am sure I will be sore, but I really got a great stretch. I feel my inner thighs (NG)”

“…my still achy body feels almost like new again (EP)”

Sustainability

Importance of Breathing “The breathing through the poses really helps, especially when she [Andee]

suggested I visualized my breath passing right along and through the problem areas…it worked! (EP)”

Deep breathing helps to alleviates stress, calm my nerves (EP)Importance of Camaraderie, Community & Sharing

“I wish more people would come and see the benefits of participating in this trial (EP)”

We spent some time going over how we felt that day and then addressed our aches and pains in class. It felt good to share with other who have the same experience (JA)”

Can be done anywhere/transferability “had to get a mammogram and while waiting there did pranayama. Just the

thing to tune your mind off (NB)”I did some breathing and wrist stretches at the eye doctor. It took the stress out

of the possibility of surgery (JA)”

Research Summary

• While some of these studies were randomized controlled trials (RCT), most were: • small sample size• pilot studies• cohort studies • requiring future investigation on

• Various Patient populations• Medically Complex Populations

Case Study

A Simple Orthopedic Case Leading to Other Medically Complex Issues

Referral to PT for TKR Rehab

Initial Referral and Treatment

54 yr old female with R – TKR 1/24/09

Edema and pain

Antalgic Gait

Amb w/ walker – progressed to cane

Pt motivated to return to full function

MLD to RLE

MFR to scar

Corrected ant ileum

Instructed in ADL and optimal body mechanics

HEP (including self MLD, exercises and breathing techniques)

6 weeks post IE

Good results in amb skills use of cane onlyPatient eager to return to ice skatingc/o systemic MS painHx of IBSPrimary relationship concernsReferral for psychosocial support

12 weeks after PT initiation

Noted 12/18 points + for FMS, BP increased

Pt c/o TMJ dysfunction and c-spine pain

Continued psychosocial support

Rx: MLD, MFR, intraoral techniques, CST, MET’s, breathing and mind-body techniques

HEP – emphasis on stress management

Complexity of Evolving Diagnoses Warrants Addition of Comprehensive and

Holistic Care

WB on RLE with Cat/Cow

Attention to the spine

Patient c/o LBP secondary to pelvic obliquity

MET

MFR

Core stability exercises

BP concerns

Breathing Focus in Cat/Cow

Developmental Process in Yoga

Warrior Pose to Increase WB RLE

Continued Manual Therapy Before Movement Dynamics

Provided safe environment for expression of emotionsFocused on the connection between stress and physical manifestationsNutritional consult to address IBS and weight loss (BP)Emphasis on self-corrections & mind-body in HEP

Triangle

Pain Management and Yoga

Effects of chemical dependence on affective disorders in pain management is well documented

Yoga has been shown to decrease somatic complaints in normal women

Shavasana or corpse pose (supine) is an effective technique for alleviating depression and increase positive change significantly

Wahbeh H, Elsas M, Oken BS. (2008). Mind–body interventions: Applications in neurology. Neurology, 70:

2321–2328.

Although the evidence is still limited, the American College of Physicians and American Pain Society recently recommended the addition of yoga or progressive relaxation for patients with acute low back pain who do not improve with self-care options.

Iyengar Yoga vs. Enhanced Usual Care on Blood Pressure in Patients with Prehypertension to Stage I Hypertension: A Randomized Controlled Trial

Cohen D, Bloedon LT, Rothman R, Farrar JT, Galantino ML, Volger S, MayorC, Szapary P, Townsend RR

PURPOSE: Iyengar Yoga (IY) has been purported to reduce blood pressure though evidence from randomized trials is lacking.

METHODS: RCT to assess the effects of 12 weeks of IY vs. Enhanced Usual Care (EUC) on 24 hour ambulatory BP in yoga-naïve adults with untreated pre-hypertension or stage I HTN.

RESULTS: 26 and 31 subjects in the IY and EUC arms, respectively, completed the study. There were no differences in BP between the groups at 6 or 12 weeks.

Results

In the EUC group, 24 hr systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) significantly decreased by 5, 3, and 3 mm Hg, respectively from baseline at 6 weeks (p<0.05), but were no longer significant at 12 weeks.

In the IY group, 24 hr SBP was reduced by 6 mm Hg at 12 weeks compared to baseline (p=0.05). 24 h DBP (p<0.01) and MAP (p<0.05) decreased significantly each by 5 mm Hg. No differences were observed in catecholamine or cortisol metabolism to explain the decrease in blood pressure in the IY group at 12 weeks.

IY for HTN – Funded by NCCAM

12 weeks of IY produces clinically meaningful improvements in 24 hr SBP and DBP. Larger studies are needed to establish the long term efficacy, acceptability, utility, and potential mechanisms of IY to control blood pressure.

One year later with Holistic Rehabilitation

Spiritual aspects addressedLiving with chronic diseaseFocus on self-careHone positive attributesHEP with emphasis on mind-body-spirit techniques

What does this case teach us?

Be aware of underlying systemic issuesAttend to psychospiritual concerns Intervene with what resonates with the clientBe fully present to emerging concerns throughout various episodes of careKeep current on the latest evidence to add to our repertoire of interventions

How do we increase health care professional’s knowledge of yoga?

• Need for continuing education on yoga and other CAM

• Issues limiting integration into PT school curriculum:• Time, evidence, speakers available

• Other disciplines offering CAM content in curriculum• Nursing, occupational therapy (OT), medicine, physician

assistant, pharmacy, public health

Geigle P, Galantino ML. (2009) Complementary and Alternative Medicine in Physical Therapist Curriculum in the U.S.

Physiother Inter Res.

Purpose: Determine the current prevalence, and at what level, CAM content is included in PT education

All 196 US-accredited programs were surveyed.

Results: 47% PT programs responded. Most commonly included CAM areas were: manipulative and body-based methods, alternative medical systems and biologically based therapies. Most frequent responses to limitations to including CAM in PT curriculum were: limited curriculum time, lack of evidence supporting CAM practices and trouble locating qualified CAM presenters.

Integrating Wellness Coaching and Yoga

Implemented an 8 week group WC program for first year DPT students (2 cohorts)

Weekly practice of yoga as part of the WCMeasures: Perceived Stress Scale, Student

Stress Scale, Qualitative dataOutcome: PSS significant – trends noted over the

course of 2 years

Integrate CAM into Health Professional Programs (Gaylord & Mann, 2007)

1. Prevalence and growth of CAM in the United States

2. Response to governmental, legislative, and other mandates

3. Need for enhanced communication between conventional providers and patients using CAM

4. Need to enhance safety of CAM use and interactions with conventional care

5. CAM education's positive impact on broadening core competencies for conventional health care professionals

6. Positive impact on enhancing cultural competency

7. Need for better communication between conventional and CAM providers

8. Potential for improving health care coordination

9. Potential impact on increasing CAM research quality and capacity

10. Potential for enhancing quality of care through informed CAM use

Themes of CAM Education (Sierpina, Schneeweiss, Frenkel, et al, 2007)

1. Integration into the existing required curriculum2. Visibility/Identifiable 3. Faculty development4. Leadership5. Accessible and reliable reference resources6. Long-term sustainability

Creative Strategies

• Group setting with rehabilitation specialists also trained in yoga therapyWelcome trained yoga teachers into clinical settings for collaborative work

• Offer special classes for specific conditions• Integrate individual poses into standard

therapeutic exercise to familiarize patients

Acknowledgements

Patients participating in our yoga research

Graduate DPT students

FUNDING SOURCES:

RSC

NJ Cancer Consortium for Research

NIH-NCCAM

Translational Research– Wellness Community

With Gratitude…

FamilyFriendsDedicated mentorsEach one of YOU!

Works CitedBosch, P., Traustadóttir, T., Howard, P., & Matt, K. (2009). Functional and physiological effects of yoga in women with rheumatoid arthritis: a pilot study. Alternative

Therapies in Health & Medicine, 15(4), 24-31.

Boyle, C., Sayers, S., Jensen, B., Headley, S., & Manos, T. (2004). The effects of yoga training and a single bout of yoga on delayed onset muscle soreness in the lower extremity. Journal of Strength & Conditioning Research (Allen Press Publishing Services Inc.), 18(4), 723-729.

Bukowski, E., Conway, A., Glentz, L., Kurland, K., & Galantino, M. (2006). The effect of Iyengar yoga and strengthening exercises for people living with osteoarthritis of the knee: a case series. International Quarterly of Community Health Education, 26(3), 287-305.

Chen, K., & Tseng, W. (2008). Pilot-testing the effects of a newly-developed silver yoga exercise program for female seniors. Journal of Nursing Research (Taiwan Nurses Association), 16(1), 37-46.

Cowen, V., & Adams, T. (2005). Physical and perceptual benefits of yoga asana practice: results of a pilot study. Journal of Bodywork & Movement Therapies, 9(3), 211-219.

Dash, M., & Telles, S. (2001). Improvement in hand grip strength in normal volunteers and rheumatoid arthritis patients following yoga training. Indian Journal of Physiology and Pharmacology, 45(3): 355-360.

DiStasio, S. A. (2008). Integrating yoga into cancer care. Clinical Journal of Oncology Nursing, 12(1): 125-130.

Evans, S., Moieni, M., Taub, R., Subramanian, S., Tsao, J., Sternlieb, B., et al. (2010). Iyengar yoga for young adults with rheumatoid arthritis: results from a mixed-methods pilot study. Journal of Pain & Symptom Management, 39(5), 904-913.


Garfinkel, M., Schumacher, H., Husain, A., Levy, M., & Reshetar, R. (1994). Evaluation of a yoga based regimen for treatment of osteoarthritis of the hands. Journal of Rheumatology, 21(12), 2341-2343.

Garfinkel, M., Singhal, A., Katz, W., Allan, D., Reshetar, R., & Schumacher, H. (1998). Yoga-based intervention for carpal tunnel syndrome: a randomized trial. JAMA: Journal of the American Medical Association, 280(18), 1601-1603.

Works Cited

Gaylord, S. A., & Mann, J. D. (2007). Rationales for CAM Education in Health Professions Training Programs. Academic Medicine, 82(10), 927 - 933.

Hart, J. (2008). An overview of clinical applications of therapeutic yoga. Alternative and Complementary Therapies, 14(1): 29-32.

Kolasinski, S., Garfinkel, M., Tsai, A., Matz, W., Van Dyke, A., & Schumacher, H. (2005). Iyengar yoga for treating symptoms of osteoarthritis of the knees: a pilot study. Journal of Alternative & Complementary Medicine, 11(4), 689-693.

Saper, R.B., Eisenberg, D., Davis, R.B., et al. (2004). Prevalence and patterns of adult yoga use in the United States: Results of a national survey. Altern Ther Health Med, 10: 44-49.

Sierpina, V. S., Schneeweiss, R., Frenkel, M. A., Bulik, R., & Maypole, J. (2007). Barriers, strategies, and lessons learned from complementary and alternative medicine curricular initiatives. Academic Medicine, 82(10), 946 - 950.

Telles, S., Dash, M., & Naveen, K. (2009). Effect of yoga on musculoskeletal discomfort and motor functions in professional computer users. Work, 33(3), 297-306.

Documents

Galantino _edited_IAYT_Integration of Yoga Into Rehabilitative Medicine