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R E V I E W
Therapeutic Effects of Yoga forChildren: A Systematic Review ofthe LiteratureMary Lou Galantino, PT, PhD, MSCE, Robyn Galbavy, PT, MPT, and Lauren Quinn, DPT
Physical Therapy Program (M.L.G., R.G., L.Q.), The Richard Stockton College of New Jersey, Pomona, New Jersey, andUniversity of Pennsylvania (M.L.G.), Philadelphia, Pennsylvania
Purpose: We completed a systematic review of the literature on the effect of yoga on quality of life andphysical outcome measures in the pediatric population. We explored various databases and included case–control and pilot studies, cohort and randomized controlled trials that examined yoga as an exercise interven-tion for children. Summary of Key Points: Using the Sackett levels of evidence, this article reviews the literatureon yoga as a complementary mind–body movement therapy. We address the research through three practicepatterns according to the Guide to Physical Therapist Practice and provide considerations for the inclusion ofyoga into clinical practice. Statement of Conclusions and Recommendations for Clinical Practice: The evidenceshows physiological benefits of yoga for the pediatric population that may benefit children through therehabilitation process, but larger clinical trials, including specific measures of quality of life are necessary toprovide definitive evidence. (Pediatr Phys Ther 2008;20:66–80) Key words: adolescent, child, complementarytherapy, exercise movement techniques, human movement system, review article, yoga
INTRODUCTION
By the summer of 2006, “Kid Yoga” camps were ap-pearing on every corner,1 rivaling lemonade stands andsoccer camps in popularity. In April 2007, a search on theInternet with the terms “yoga and children” yielded closeto 6,120,000 hits.2 The Internet offers an abundance ofcertifications designed for teaching yoga to children.3 Fur-ther, almost every yoga studio in the country now offersclasses for young children.4 Indeed, yoga has now pene-trated popular culture for all age groups. As experts inmovement analysis and therapeutic exercise, physical thera-pists (PTs) hold the professional responsibility of determin-ing the value of yoga’s age-old art in modern day practice.
Today’s “typical child” is described as stressed out,5
under nourished,6 and sedentary.7 The complexity posedby these profiles demands treatment that taps into both the
physical and the psychosocial domain. A study by Parshad8
found the state of the mind and that of the body to beintimately related. If the mind is relaxed, the muscles in thebody will also be relaxed. Stress produces a state of physicaland mental tension. Yoga, developed thousands of yearsago, is recognized as a form of mind–body medicine. Thereare many forms of yoga with emphasis on various aspects ofbody mechanics, fitness, and spirituality (Table 1).
Parshad’s study demonstrates that yoga’s physicalpostures and breathing exercises improve muscle strength,flexibility, blood circulation and oxygen uptake, and hor-mone function. In addition, Parshad found that relaxationinduced by meditation helps to stabilize the autonomicnervous system with a tendency toward parasympatheticdominance. Physiological benefits that follow help individu-als who practice yoga to become more resilient to stressfulconditions and reduce a variety of important risk factors forvarious diseases, for example, cardiorespiratory diseases.8
Yoga shows promise as a new modality for the pediat-ric population. Despite its popularity in popular culture,careful examination of the research is necessary when in-tegrating this modality in traditional pediatric rehabilita-tion settings. The purpose of this systematic review is toexplore the evidence related to the effectiveness of yogawith respect to the practice patterns in the Guide to PhysicalTherapist Practice.9 We have classified the articles under
0898-5669/108/2001-0066Pediatric Physical TherapyCopyright © 2008 Section on Pediatrics of the American PhysicalTherapy Association.
Address correspondence to: Mary Lou Galantino, PT, PhD, MSCE, TheRichard Stockton College of NJ, PO Box 195, Pomona, NJ 08240. E-mail:[email protected]
DOI: 10.1097/PEP.0b013e31815f1208
66 Galantino et al Pediatric Physical Therapy
the following headings: neuromuscular, cardiopulmonary,and musculoskeletal according to their focus. As reviewers,we feel that the practice of yoga encompasses all three ofthese practice patterns. However, for the purpose of thisreview, we have assigned each article to the most pertinentpractice pattern according to the focus of each study.
METHODOLOGY
We searched the following electronic databasesthrough January 2007: Cochrane Central Register of Con-trolled Trials, MEDLINE, EMBASE, CINAHL, PsychINFO,and PEDro. The yoga register maintained by the Cochrane
Breast Cancer Group was also explored. We used searchterms related to yoga and pediatrics (children, develop-mental disabilities), exercise (eg, exercise, physical activ-ity, cardiorespiratory fitness), and publication type (eg, co-hort, case–control, clinical trial). This search strategy wasmodified as necessary for each database. Appropriate non-English language publications were not found. Of the studieswe found pertinent to review, four were published in the1980s, 10 in the 1990s, and 10 from 2000 to the present.
Studies were considered eligible for inclusion if theywere pilot in nature, cohort, case–control, or a randomizedclinical trial (RCT). An RCT is an experimental study in
TABLE 1Different Schools of Hatha Yoga Commonly Practiced in the United States
School Focus Description
Ananda Enlightenment Tool for spiritual growth while releasing unwanted tensions. Uses silent affirmations whileholding a pose as a technique for aligning body, energy, and mind. Series of gentle posesdesigned to move energy upward to the brain, preparing the body for meditation
Anusara The Heart Founded by John Friend in 1997, anusara yoga integrates the celebration of the heart,universal principles of alignment, and balanced energetic action in the performance ofasana. Anusara (pronounced ah-new-SAR-ah) means “following your heart.” In thisschool of yoga, each student’s abilities and limitations are deeply respected andhonored. Source: Lark, Liz. Yoga for Life. Carlton Books, London; 2001
Ashtanga/Power Yoga Fitness Athletic; Fast Paced and nonstop; not recommended for beginning students. At the core islinking the breath with each movement throughout the practice. Power Yoga is aderivative, using a more creative sequence of postures
Bikram/Hot Yoga Healing Athletic; Practiced in a room heated to 100! degrees, thus “Hot” Yoga. Sauna-like effecthelps move the toxins out of the body
Hatha Yoga/“Yoga” Holistic A major branch of yoga, developed by Goraksha and other adepts c. 1000 CE, andemphasizing the physical aspects of the transformative path, notably postures (asana)and cleansing techniques (shodhana), but also breath control (pranayama). SOURCE:“Hatha Yoga.” Accessed on September 14, 2007. Available at: http://www.yogajournal.com/newtoyoga/159.cfm
Integral Enlightenment Aimed at helping people integrate yoga’s teachings into their everyday work andrelationships. Incorporates guided relaxation, breathing practices, sound vibration(repetition of a mantra or chant), and silent meditation
Iyengar Detail Technical yoga, an intense focus on the subleties of each posture; great for beginningstudents. Strong focus on precise muscular and skeletal alignment; emphasizestherapeutic properties of the poses. Poses (especially standing postures) are typicallyheld much longer than in other schools of yoga to focus on alignment. Use of props(belts, chairs, blocks, and blankets) to accommodate special needs such as injuries orstructural imbalances
Kripalu Healing Therapeutic; gentle and spiritually focused; great for beginning students. Incorporatesinner focus and meditation within the yoga poses. Focus on alignment, breath, and thepresence of consciousness. Holding of the postures to the level of tolerance and beyond.Deepens concentration and focus of internal thoughts and emotions
Kundalini Enlightenment Dynamic; Esoteric; Energizing; Aimed at invoking dormant spiritual energy at the base ofthe spine. Incorporates breath-work, movement, postures, chanting, and meditating onmantras
Sivananda Enlightenment Traditional approach; can become very advanced. Rigid class structure of poses, breath-work, meditation, and relaxation. Emphasizes 12 basic postures to increase strength andflexibility of the spine. Focus on proper pose, breathing, relaxation, and diet (vegetarian), andpositive thinking and meditation
Tantra Sensuality Perhaps the most misunderstood yoga style, tantra is not about sexual indulgence. Rather,it is about discovering and stimulating sensual spirituality. This yoga works with thehighly charged kundalini energy and, therefore, should always be guided and taught bya teacher. Tantra teaches practitioners how to use this energy for sexual pleasure, forbringing joy and wholeness to everyday life, and for aiding in spiritual evolution. Tantrayoga includes visualization, chanting, asana, and strong breathing practices. Source:Lark, Liz. Yoga for Life. Carlton Books, London; 2001
Viniyoga Healing Therapeutic; repetitious movements in and out of a posture. Individualistic; poses aresynchronized with the breath in sequences determined by the needs of the practitioner.Highly adaptable, thus good for students with physical injuries or limitations
Pediatric Physical Therapy Therapeutic Effects of Yoga for Children 67
which a clinical treatment is compared with a control con-dition, where subjects are randomly assigned to groups,10
and in our review, we compared exercise with a placebo,controlled comparison, or standard care. For the purposesof the review, yoga includes a combination of breathingexercises (pranayama), physical postures (asanas), andmeditation (spirituality).11–13
Yoga was defined as a form of leisure-time physicalactivity that was performed on a repeated basis during anextended period of time, with the intention of improvingfitness, performance, or health.14 Table 1 outlines the breadthof yoga styles, some of which were used in the reviewedstudies. Studies with an additional treatment arm or com-bined intervention (eg, yoga with traditional exercise)were included only if the effects of exercise could be iso-lated. A priori, we excluded reports that were available onlyin abstract form.
Trials were included only if they involved normallydeveloping children and children with various impair-ments of the muscular, cardiopulmonary, or neuromuscu-lar systems. Studies were required to have as a primaryoutcome quality of life (QOL), cardiorespiratory fitness orphysical functioning. Secondary outcomes of interest in-cluded cognition and attention. We also extracted data onadverse events resulting from the yoga intervention.
Three independent reviewers (R.G., L.Q., and M.L.G.)screened the titles and abstracts of identified studies foreligibility. When one of us deemed an article to be poten-tially relevant, we obtained the full text and all three re-viewers assessed it for inclusion. Information on patients,methods, interventions, outcomes, and adverse eventswere extracted from the original reports by the three inde-pendent reviewers onto paper forms that they had designedand pretested. Kappa coefficient of the reviewers was sub-stantial (r " 0.60–0.75) between the three raters. Dis-agreements were resolved by consensus (R.G., L.Q., andM.L.G.). The methodological quality of each study wasassessed using the following criteria15,16:
1. Was there adequate concealment of allocation?2. Was the method of randomization well described
and appropriate?3. Was the outcome assessment described as blinded
or unblinded?4. Was the method of blinding of the assessment of
outcomes well described and appropriate?5. Was there a description of withdrawals and
dropouts?6. Was there intention-to-treat analysis?7. Were withdrawals and dropouts less than 10%?8. Was adherence to the exercise intervention (atten-
dance or completion of exercise session) greaterthan 70%?
All items were scored using Sackett levels of evi-dence.17 Studies were defined as being of “high quality” ifthey fulfilled four or more of the eight quality criteria. Weincluded all the studies in this review, given the paucity ofyoga research in pediatrics. Of the 24 total studies identi-
fied, five were classified as level 4, four as level 3, 15 as level2, and none with level 1 grade of evidence. Based on ourcriteria for evaluation, using both methods, we found fewarticles that included our criteria for high quality. Al-though description of randomization was clear throughoutall studies, we have little data that describe outcome assess-ments with regard to the method of blinding, no informa-tion on intent-to-treat analysis, and what happened towithdrawals and dropouts. Therefore, studies were ofmoderate to low quality and require future investigationsthat incorporate all aspects of a rigorous clinical plan forrecruitment, retainment, blinding, and adherence.
NEUROMUSCULAR EFFECTS OF YOGA
Six of the 10 articles assigned to the neuromuscularpractice pattern were assessed as 2B grade for levels ofevidence, while four additional articles were grade 4. Muchvariability was noted in the duration of yoga interventionsand it is unclear how issues of bias were addressed. Al-though a trend is noted in improvements of motor plan-ning, performance, and mental and social acuity, furtherresearch is needed to incorporate yoga as a definitive mo-dality for the neurologically involved child.
Yoga seems to have a positive impact on motor per-formance in children and most studies have been con-ducted on children developing typically (Table 2). Fourstudies analyzed the effects of yoga on reaction time, plan-ning, execution time, and motor speed.18–21 Reaction timehas been used to quantify level of motor function, and thusspeaks to the overall functioning of the central nervoussystem (CNS).22 Pilot data by Bhavanani et al18 found thatmukh bhastrika yoga (bellows type breathing) produceddecreased visual reaction time and auditory reaction timein 22 healthy schoolboys. This indicates potentially im-proved sensory-motor performance and enhanced process-ing ability of the central nervous system.18 Another pilotstudy by Manjunath et al19 showed trends of improvedplanning and execution times in the yoga group in theTower of London test for both simple and complex tasks.The Tower of London test is standardized and addressesexecutive functions. The study revealed no change in thephysical training group.
Motor speed, like reaction time, is also a quantifica-tion of CNS processing. Dash et al20 analyzed the effects ofyoga training on a finger tapping task, to assess motorspeed in children and adults versus a control group of 38adults. Findings included significant increases in tappingspeed values after 10 days of yoga training in the children’sgroup and 30 days of yoga training in the adult group.Although not verified by diagnostic imaging, this and otherstudies point to the potential plasticity of the brain andCNS in response to yoga. Another study by Telles et al21
supports improved motor performance in children afteryoga training. This study of 90 children ages 9 to 13 yearsused a steadiness test that required the insertion of andholding of a metal stylus into holes of decreasing sizes. Theyoga group showed a significant decrease in errors,while the control group showed no change. Although an
68 Galantino et al Pediatric Physical Therapy
TABL
E2
Neu
rom
uscu
lar
Evi
denc
e
No.
Stud
y1s
t/2n
dR
evie
wer
Feat
ures
Part
icip
ants
Inte
rven
tion
End
poin
tsSu
mm
ary
Evi
denc
eLe
vel
1Bh
avan
ani
etal
18
MLG
/LQ
To
dete
rmin
eau
dito
ryan
dvi
sual
reac
tion
tim
ew
ith
spec
ific
yogi
cbr
eath
ing.
22he
alth
ysc
hool
boys
(13–
16yr
s).
Tra
ined
yoga
part
icip
ants
recr
uite
dfo
rth
isst
udy—
able
tope
rfor
mm
ukh
bhas
tika
prop
erly
—w
ere
mea
sure
dbe
fore
and
afte
rni
nero
unds
ofbr
eath
ing.
Aud
itor
yan
dvi
sual
reac
tion
tim
evi
aco
mpu
ter.
Dec
reas
edre
acti
onti
me
note
d;th
isin
dica
ted
impr
oved
sens
ory-
mot
orpe
rfor
man
cean
den
hanc
edpr
oces
sing
ofC
NS.
4
2D
ash
and
Tel
les20
LQ/R
GA
sses
sth
eef
fect
sof
yoga
trai
ning
onfin
ger
tapp
ing
spee
d(a
sa
mea
sure
ofm
otor
spee
d).
53ad
ults
and
152
child
ren
(cat
egor
ized
acco
rdin
gto
age
and
gend
er)
befo
rean
daf
ter
yoga
trai
ning
and
38ad
ults
ofa
nony
oga
(con
trol
)gr
oup.
Yoga
grou
pre
ceiv
edyo
gatr
aini
ng(p
hysi
cal,
men
tal,
inte
llect
ual,
and
spir
itua
l)fo
r#
8hr
/day
for
10da
ysfo
rth
ech
ildre
nan
d30
days
for
the
adul
ts.
The
rew
asa
sign
ifica
ntin
crea
sein
base
line
tapp
ing
spee
dbe
twee
n0
and
10se
c,10
–20
sec,
and
20–3
0se
cin
both
adul
tsan
dch
ildre
naf
ter
30an
d10
days
ofyo
ga,
resp
ecti
vely
.How
ever
,for
both
grou
psat
base
line
and
final
asse
ssm
ents
,10–
20se
can
d20
–30
sec
wer
esi
gnifi
cant
lylo
wer
than
0–10
sec.
Incr
ease
inm
otor
spee
dfo
rre
peti
tive
finge
rm
ovem
ents
follo
win
gyo
gatr
aini
ng,b
utno
tin
stre
ngth
oren
dura
nce,
asth
ein
crea
sew
asno
tsu
stai
ned
over
30se
c.
2B
3H
arri
son
etal
26R
G/M
LGE
ffec
tsof
med
itat
ion
asa
fam
ilytr
eatm
entm
etho
dfo
rch
ildre
nw
ith
AD
HD
,us
ing
the
tech
niqu
esof
Saha
jaYo
gaM
edit
atio
n.
47C
hild
ren
(age
s4–
12yr
s)w
ith
the
diag
nosi
sof
AD
HD
mad
eby
ape
diat
rici
anor
ach
ildps
ychi
atri
st(m
ajor
ity
ofch
ildre
nw
ere
rece
ivin
gm
edic
atio
n).
6-w
eek
prog
ram
oftw
ice
wee
kly
clin
icse
ssio
ns(9
0m
in)
and
regu
lar
med
itat
ion
atho
me
(for
child
ren
and
pare
nts.
3so
urce
sof
data
colle
ctio
n:ch
ildse
lf-re
port
ques
tion
nair
es(B
urne
tt),
pare
ntra
ted
ques
tion
nair
es(C
onne
rsan
dC
PRS)
,and
exam
iner
test
ing/
inte
rvie
w(P
eabo
dypi
ctur
e/vo
cabu
lary
test
).
Saha
jayo
gam
edit
atio
nha
spo
tent
iala
sa
prom
isin
gth
erap
yfo
rch
ildre
nw
ith
AD
HD
whe
nof
fere
dvi
aa
fam
ilytr
eatm
enta
ppro
ach
and
used
inco
mbi
nati
onw
ith
exis
ting
med
ical
RX
.
2B
4Je
nsen
and
Ken
ny25
RG
/MLG
Eva
luat
eth
eus
eof
yogi
cex
erci
ses
asa
com
plem
enta
ryan
dal
tern
ativ
em
edic
ine
(CA
M)
toph
arm
acol
ogic
alth
erap
yin
redu
cing
the
beha
vior
alan
dat
tent
iona
lde
ficit
sym
ptom
sof
AD
HD
inbo
ys.
19bo
ys(8
–13
yrs)
wit
hA
DH
D(d
iagn
osis
mad
eby
spec
ialis
tpe
diat
rici
ans)
and
stab
ilize
don
med
s(1
1in
expe
rim
enta
lgr
oup,
8in
cont
rolg
roup
).
20w
eekl
y1
hryo
gagr
oup
sess
ions
20or
cont
rol
(“co
oper
ativ
eac
tivi
ties
”).
Sign
ifica
ntim
prov
emen
tsfo
und
for
yoga
on5
ofth
eC
onne
rs’
Scal
es.S
igni
fican
tim
prov
emen
tsw
ere
foun
din
cont
rolg
roup
for
3or
the
Con
ners
’sca
les.
Dat
am
easu
red
wit
hA
NO
VA
.
Thi
sda
tado
esno
tpro
vide
stro
ngsu
ppor
tfor
use
ofyo
gafo
rA
DH
D,p
arti
cula
rly
beca
use
stud
yw
asun
derp
ower
ed,b
utsu
gges
tsyo
gaha
sm
erit
asa
CA
Mfo
rth
ispo
pula
tion
.
4
5M
anju
nath
and
Tel
les28
RG
/MLG
Stud
yco
nduc
ted
tode
term
ine
ifyo
gatr
aini
ngan
dcr
eati
veac
tivi
ties
that
acti
vate
the
Rhe
mis
pher
e(f
ine
arts
)m
ayaf
fect
mem
ory
posi
tive
ly.
60el
emen
tary
scho
olst
uden
ts(a
ged
11–1
6yr
s)w
ith
atte
ntio
npr
oble
ms
volu
ntee
red
topa
rtic
ipat
ein
this
inve
stig
atio
n.30
child
ren
atte
nded
ayo
gaca
mp
and
the
othe
r30
afin
ear
tsca
mp.
Yoga
cam
p:8
hra
day
for
10da
ys.(
cam
pal
soin
clud
edga
mes
and
stor
yte
lling
).
The
grou
ptr
aine
din
yoga
show
eda
sign
ifica
ntin
crea
sein
spat
ialm
emor
yte
stsc
ores
(43%
incr
ease
),w
hile
verb
alm
emor
yte
stsc
ores
rem
aine
dth
esa
me
inal
loft
hech
ildre
n.(m
ulti
vari
ate
and
Tuk
eyte
st).
Thi
sde
mon
stra
tes
that
yoga
prac
tice
impr
oves
dela
yed
reca
llof
spat
iali
nfo.
2B
(Con
tinu
ed)
Pediatric Physical Therapy Therapeutic Effects of Yoga for Children 69
TABL
E2
Con
tinu
ed
No.
Stud
y1s
t/2n
dR
evie
wer
Feat
ures
Part
icip
ants
Inte
rven
tion
End
poin
tsSu
mm
ary
Evi
denc
eLe
vel
6M
anju
nath
and
Tel
les19
LQ/R
GA
sses
sth
epe
rfor
man
cein
the
Tow
erof
Lond
onte
stat
the
begi
nnin
gan
den
dof
am
onth
ofyo
gatr
aini
ng.
20gi
rls
(age
s10
–13
yrs)
stud
ying
ata
resi
dent
ials
choo
l.R
ando
mas
sign
men
tto
2gr
oups
:one
grou
ppr
acti
ced
yoga
for
1hr
15m
in/d
ay,7
days
/wk
for
am
onth
,whi
leth
eot
her
grou
pw
asgi
ven
phys
ical
trai
ning
for
the
sam
eti
me.
The
yoga
grou
psh
owed
asi
gnifi
cant
redu
ctio
nin
plan
ning
tim
efo
rbo
th2-
mov
esan
d4-
mov
esta
sks,
exec
utio
nti
me
inbo
th4-
mov
esan
d5-
mov
esta
sks,
and
inth
enu
mbe
rof
mov
esin
the
4-m
oves
task
s.T
heph
ysic
altr
aini
nggr
oup
show
edno
chan
ge.
Yoga
trai
ning
for
am
onth
redu
ced
the
plan
ning
and
exec
utio
nti
me
insi
mpl
eas
wel
las
com
plex
task
san
dfa
cilit
ated
reac
hing
the
targ
etw
ith
asm
alle
rnu
mbe
rof
mov
esin
aco
mpl
exta
sk.
4
7N
avee
net
al29
RG
/MLG
Sinc
ehe
mis
pher
icm
emor
yfu
ncti
ons
are
also
know
nto
bela
tera
lized
,the
stud
yas
sess
edth
eef
fect
sof
unin
ostr
ilbr
eath
ing
onpe
rfor
man
cein
verb
alan
dsp
atia
lmem
ory
test
s.
Scho
olch
ildre
n(N
"10
8)w
hose
ages
rang
edfr
om10
–17
yrs
wer
era
ndom
lyas
sign
edto
4gr
oups
.Eac
hgr
oup
prac
tice
da
spec
ific
yoga
brea
thin
gte
chni
que.
An
age-
mat
ched
cont
rolg
roup
of27
wer
esi
mila
rly
asse
ssed
.
Eac
hof
4gr
oups
prac
tice
da
spec
ific
yoga
brea
thin
gte
chni
que:
(1)
righ
t-no
stri
lbr
eath
ing,
(2)
left
nost
ril
brea
thin
g,(3
)al
tern
ate
nost
rilb
reat
hing
or(4
)br
eath
eaw
aren
ess
wit
hout
man
ipul
atio
nof
nost
rils
.T
hese
tech
niqu
esw
ere
prac
tice
dfo
r10
days
,4ti
mes
ada
y,27
roun
dsea
chti
me.
Ver
bala
ndsp
atia
lm
emor
yw
asas
sess
edin
itia
llyan
daf
ter
10da
ys.
All
4tr
aine
dgr
oups
show
eda
sign
ifica
ntin
crea
sein
spat
ial
test
scor
esat
rete
st.A
vera
gein
crea
sein
spat
ialm
emor
ysc
ores
for
the
trai
ned
grou
psw
as84
%.
Itap
pear
sth
atyo
gabr
eath
ing
incr
ease
ssp
atia
lrat
her
than
verb
alsc
ores
,wit
hout
ala
tera
lized
effe
ct.
2B
8Pe
cket
al27
RG
/MLG
Inve
stig
ate
the
effe
ctiv
enes
sof
yoga
for
impr
ovin
gti
me
onta
skw
ith
10el
emen
tary
scho
olch
ildre
nw
hoev
iden
ced
atte
ntio
npr
oble
ms.
10el
emen
tary
scho
olst
uden
tsw
ith
atte
ntio
npr
oble
ms
(age
d6–
10yr
s)ac
ross
3gr
ade
leve
lsvo
lunt
eere
dto
part
icip
ate.
Init
ially
,the
yw
ere
recr
uite
dby
scho
olps
ycho
logi
st.T
hese
stud
ents
wer
eno
tdia
gnos
edw
ith
AD
HD
,but
docu
men
ted
tobe
“on
task
”$
80%
ofth
eti
me.
Ayo
gavi
deot
ape,
publ
ishe
dby
Gai
am,w
asus
edth
atre
quir
edth
ech
ildre
nto
follo
wan
adul
tins
truc
tor
and
thre
ech
ildre
nw
hoen
gage
din
deep
brea
thin
g,ph
ysic
alpo
stur
es,a
ndre
laxa
tion
exer
cise
sfo
r30
min
,tw
ice
aw
eek,
for
ape
riod
of3
wee
ks.
Stud
yw
asa
mul
tipl
eba
selin
ede
sign
.Tim
eon
task
was
defin
edas
the
perc
enta
geof
inte
rval
sob
serv
edth
atth
est
uden
tsw
ere
orie
ntat
ing
tow
ard
the
teac
her
orta
sk,
and
perf
orm
ing
the
requ
este
dcl
assr
oom
assi
gnm
ents
.The
resu
lts
indi
cate
def
fect
size
sth
atra
nged
from
1.5
to2.
7as
afu
ncti
onof
the
inte
rven
tion
.E
ffec
tsiz
esat
follo
w-u
pde
crea
sed,
butr
ange
dfr
om0.
77to
1.95
.Pee
rco
mpa
riso
nda
tain
dica
ted
that
clas
smat
es’
tim
eon
task
rem
aine
des
sent
ially
unch
ange
dth
roug
hout
the
thre
eph
ases
ofth
est
udy.
Peer
com
pari
son
data
indi
cate
dth
atcl
assm
ates
’tim
eon
task
rem
aine
des
sent
ially
unch
ange
dth
roug
hout
the
thre
eph
ases
ofth
est
udy.
4
(Con
tinu
ed)
70 Galantino et al Pediatric Physical Therapy
improvement in the quality of research design, furtherinvestigation is needed for application in children withdisabilities.
Other studies suggest that yoga increases workingefficiency,23 and overall ability to concentrate and focus.24
Yoga fosters relaxation and breathing7 in a very active way,enabling children to channel their energy into goal-driventasks. These findings have implications for learning andclassroom behavior. Three studies specifically examinedthe use of yoga and meditation as a treatment for attentiondeficit hyperactivity disorder (ADHD) and would be con-sidered pilot in nature. One study by Jensen et al25 showedboth groups with improvements in several measurementscales with yoga participants improving significantly in thefive subscales of the Parents Rating Scales (CPRS). Thesecond study (Harrison et al)26 incorporated the entirefamily and measured treatment outcomes. A classroom-based study by Peck et al27 found yoga to improve time ontask in 10 elementary school children evidencing attentionproblems. Although these data do not provide strong sup-port for the use of yoga for ADHD, partly because the stud-ies are under-powered, they do suggest that yoga may havemerit as a complementary treatment for ADHD alreadystabilized on medication. Yoga remains an investigationaltreatment, but this study supports further research into itspossible uses to address behavioral challenges for this pop-ulation. These findings need to be replicated on largergroups with a more intensive supervised practice program.
Two studies suggest that academic learning of chil-dren developing typically may be further enhanced bymemory improvements afforded by yoga. In one of thesestudies, Manjunath et al28 compared performance of 90subjects in verbal and spatial memory tests. Thirty subjectswere in one of three groups: yoga camp, fine arts camp, orcontrol group. Members of the yoga group showed a 43%improvement in spatial memory test scores, while the finearts and control groups showed no change. Subjects in theyoga camp also engaged in game playing and story telling.However, we found it compelling that this group stillshowed improvement over the fine arts camp group, whomost likely also participated in similar social activities. Asecond study by Naveen et al strengthens the use of yogafor spatial memory scores. In this study, 108 school chil-dren aged 10 to 17 years were divided into four groups,each practicing in a different type of yoga breathing.29 Allfour groups evidenced improved spatial memory scores byan average of 84%. Verbal memory scores were also mea-sured in both these studies, and seem to remain unchangedafter the interventions.
Application of yoga for children with mental retarda-tion also shows promise. Uma et al30 demonstrated signif-icant improvements in IQ and social parameters comparedwith a control group through an intervention for 1 aca-demic year. Changes occurring at the neuromuscular levelenabled the more global effects of behavioral and cognitiveenhancements. Such benefits may be applied along thespectrum of children with neurological impairments butfurther RCT are needed to determine definitive use of yoga.
TABL
E2
Con
tinu
ed
No.
Stud
y1s
t/2n
dR
evie
wer
Feat
ures
Part
icip
ants
Inte
rven
tion
End
poin
tsSu
mm
ary
Evi
denc
eLe
vel
9T
elle
set
al21
RG
/MLG
Det
erm
ine
the
effe
ctof
yoga
onst
atic
mot
orpe
rfor
man
cein
child
ren.
Eac
hgr
oup
was
asse
ssed
ona
stea
dine
sste
stat
the
begi
nnin
gan
den
dof
the
stud
y.
Tw
ogr
oups
of45
child
ren
each
,(a
ged
9–13
yrs)
.Fo
r10
days
,one
grou
pre
ceiv
edtr
aini
ngin
yoga
(asa
nas,
pran
ayam
a,m
aint
enan
ceof
sile
nce,
visu
alfo
cusi
ngex
erci
ses,
and
gam
esto
impr
ove
atte
ntio
nsp
anan
dm
emor
y),w
hile
the
othe
rgr
oup
carr
ied
outt
heir
usua
lrou
tine
.
Aft
er10
days
,the
yoga
grou
psh
owed
asi
gnifi
cant
decr
ease
iner
rors
onth
est
eadi
ness
test
,whe
reas
the
“con
trol
grou
p”sh
owed
noch
ange
.
Chi
ldre
nen
gage
din
the
yoga
prog
ram
disp
laye
dim
prov
emen
tin
stat
icm
otor
perf
orm
ance
.
2B
10U
ma30
RG
/MLG
To
stud
yth
eef
fect
ofyo
gaon
child
ren
wit
hM
Rof
mild
,m
oder
ate,
and
seve
rede
gree
inw
ith
resp
ectt
oIQ
and
soci
alad
apta
tion
para
met
ers.
90ch
ildre
nse
lect
edfr
omfo
ursp
ecia
lsch
ools
(45
stud
ents
inyo
gatr
aini
nggr
oup
com
pare
dto
45st
uden
tsw
hoco
ntin
ued
thei
rus
uals
choo
lrou
tine
).
Exp
erim
enta
lgro
upun
derw
enty
ogic
trai
ning
for
1ac
adem
icye
ar(5
hin
ever
yw
eek)
wit
han
inte
grat
edse
tofy
ogic
prac
tice
s.
Hig
hly
sign
ifica
ntim
prov
emen
tin
the
IQan
dso
cial
adap
tati
onpa
ram
eter
sin
the
yoga
grou
pas
com
pare
dto
the
cont
rol(
pair
edtt
est)
.
Thi
sst
udy
show
sth
eef
ficac
yof
yoga
asan
effe
ctiv
eth
erap
euti
cto
olin
the
man
agem
ento
fchi
ldre
nw
ith
MR
.
2B
Pediatric Physical Therapy Therapeutic Effects of Yoga for Children 71
CARDIOPULMONARY EFFECTS OF YOGA
Ten articles were reviewed in the cardiopulmonarypractice pattern. Seven of the 10 reviewed articles wereclassified as level 2B, two as level 3B, and one as level 4(Table 3). Although the quality of evidence was varied, weconsidered all the articles enriching to our discussion.These studies reveal that yoga may be used with typicalchildren, and with physically or emotionally impaired chil-dren to improve cardiorespiratory parameters. Further,these studies also demonstrate that the processes initiatedby yoga practice can have an impact on the more globalissues of socialization and stress management. It is impor-tant to note that physical impairments are often heavilyinfluenced by psychosocial factors. Therefore, PTs mayconsider yoga as an adjunct for pediatric cardiopulmonaryrehabilitation.
A primary emphasis in the practice of yoga is con-trolled-breathing techniques. This idea leads to new re-search on children with cardiopulmonary impairments.Our search yielded four studies that demonstrate yoga’smechanism of action on subjects with healthy cardiac func-tion. First, a study by Udupa et al31 analyzed the effects ofpranayama training (voluntary regulation of breathing) oncardiac function in normal young volunteers. Twenty-fourschool children were divided into a pranayama group and acontrol group. The pranayama group practiced breathingtechniques for 20 minutes daily for 3 months. A controlgroup maintained normal breathing. Researchers foundthat pranayama training effectively modulated ventricularperformance by decreasing sympathetic output and therebyincreasing parasympathetic output. This study providedbaseline evidence for the efficacy of yoga on cardiorespira-tory parameters in normal volunteers, and allowed for ex-panded research into populations with pathology.
Three additional studies examined the effects of yogaon volunteers with normal cardiac function who also hadanxiety. Such studies are important in that they implicatepsychosocial issues as contributors to autonomic impair-ments. This idea was supported by Telles et al32 in a studyon physically normal but socially or emotionally trauma-tized girls. In their study the researchers randomly selected40 girls between 12 and 16 years of age from a total of 120girls in a community home. All subjects had a history ofadjustment difficulties either at home or in society. Thestudy aimed to determine differences in autonomic andrespiratory parameters between these girls and those of thesame age living at home and attending a regular school.The community home group was found to have signifi-cantly higher breath rates, more irregular breathing pat-terns, and lower skin resistance values than their age-matched peers. These attributes are known to correlatewith fear and anxiety.33,34 Additionally, the study aimed tocompare the effects of two interventions—yoga andgames—on the same physiologic measurements. For anhour daily over a 6-month period, half of the communityhome girls engaged in relaxing yoga, while the other halfengaged in physical games such as relay races. Those par-
ticipating in the yoga arm of the study were found to havea significant decrease in breath rate, which seemed moreregular, but no significant increase in skin resistance. Bothgroups showed a significant decrease in resting heart rate.These findings suggest that yoga practice may reduce levelsof fear and anxiety more so than physical activity alone.This has implications for setting the background of emo-tional stability to execute physical demands of everydayactivity.
Platania-Solazzo et al35 conducted a study with similarimplications, in which the effects of relaxation therapywere assessed in a population of 40 hospitalized childrenand adolescents who had a diagnosis of adjustment disor-der and depression. This study assessed yoga’s effect, alongwith massage and relaxation, on decreases in self-reportedanxiety, anxious behavior, and fidgeting as well as in-creased positive affect. Decreases in cortisol levels werealso noted, which have an indirect effect on the cardiore-spiratory health of children.36 PT traditionally incorporatesseveral of the aspects mentioned in this intervention (mas-sage, relaxation, and biofeedback), suggesting that yoga asa modality may provide unique and creative ways to attaingoals in the cardiopulmonary practice pattern. Becausethis program incorporated massage, the specific effectsof the yoga component are difficult to determine. How-ever, we considered this evidence to be notable, espe-cially since the elements of relaxation and biofeedbackare intrinsic to the practice of yoga itself.
An additional study by Telles and Srinivas explored apopulation with normal cardiac function but increased lev-els of anxiety. This study analyzed the cardiopulmonaryeffects of yoga on volunteers who were visually impaired(VI).37 This sample displayed similar baseline measure-ments to the socially or emotionally traumatized popula-tion of community home girls32: higher breath rates, heartrates, and diastolic blood pressure. Previous studies foundthat young people with VI have significantly higher levelsof anxiety than their age-matched peers,38 to which in-creases in heart rate is often attributed. In the Telles andSrinivas study, 24 children with VI, ages 12 to 17 years,were age matched with normal-sighted peers. Half of thepairs participated in yoga for an hour each day, while theother half of the pairs performed “physical activity” work-ing in the garden and stretching. After 3 weeks, the rate ofrespiration was reduced in the children with VI who par-ticipated in yoga. There was no change in the children whoparticipated in the physical activity group. These resultsshow that although children with VI have higher physio-logic arousal than children who are normal-sighted, thisarousal may be reduced after participation in yoga. Thesestudies point out yoga’s utility in children with psychoso-cial impairments.
Four studies explored the effect of yoga on childrenwith specific respiratory impairments, namely, asthma.However, only one of these studies39 restricted participa-tion to the pediatric population. In the study by Jain et al39,46 children, with a mean age of 15.8 years and a childhoodhistory of asthma, were followed through 40 days of yoga
72 Galantino et al Pediatric Physical Therapy
TABL
E3
Car
diop
ulm
onar
yE
vide
nce
No.
Stud
y1s
t/2n
dR
evie
wer
Feat
ures
Part
icip
ants
Inte
rven
tion
End
poin
tsSu
mm
ary
Evi
denc
eLe
vel
1C
lanc
eet
al43
RG
/MLG
To
eval
uate
the
effe
cts
ofa
grou
ppr
oces
sai
med
atin
crea
sing
the
body
sati
sfac
tion
ofch
ildre
nth
roug
hth
eus
eof
yoga
exer
cise
san
daw
aren
ess
trai
ning
.
12A
fric
anA
mer
ican
3rd
year
stud
ents
enro
lled
inan
elem
enta
rysc
hool
ina
larg
eso
uthe
rnci
ty.T
hese
subj
ects
wer
ese
lect
edfr
oma
pool
of17
stud
ents
iden
tifie
dby
thei
rPE
inst
ruct
oras
poor
lyco
ordi
nate
dan
dm
inim
ally
invo
lved
inPE
clas
ses,
rece
ivin
glo
wes
tsco
res
ona
subj
ecti
vete
stm
easu
ring
body
sati
sfac
tion
.Sub
ject
sw
ere
then
rand
omly
assi
gned
toei
ther
aco
ntro
l(n
"6)
orex
peri
men
tal
grou
p(n
"6)
.
Tre
atm
ents
essi
ons
cond
ucte
d3%
/wee
kfo
r4
wee
ksin
30m
inse
ssio
ns.E
xper
imen
tal
grou
pre
ceiv
edyo
gaex
erci
ses
deve
lope
dfo
rch
ildre
nan
daw
aren
ess
exer
cise
s,w
hile
the
cont
rol
grou
pco
ntin
ued
toat
tend
regu
lar
PEcl
asse
s.
Exp
erim
enta
lgro
upsh
owed
anin
crea
sein
dem
onst
rate
dbo
dysa
tisf
acti
onas
per
Chi
ldre
n’s
Body
Sati
sfac
tion
Tes
tand
Hum
anFi
gure
Dra
win
gte
sts,
whe
reas
nosu
chch
ange
was
foun
din
the
cont
rolg
roup
.
Yoga
appe
ars
tofa
cilit
ate
impr
ovem
enti
nbo
dysa
tisf
acti
on.F
urth
er,y
oga
may
pres
enta
mea
nsof
chan
ging
nega
tive
eval
uati
ons
ofth
ese
lfan
dth
ebo
dybe
fore
thes
ebe
com
ede
eply
engr
aine
din
the
self-
conc
epto
fthe
child
.
4
2Ja
inet
al39
RG
/MLG
To
exam
ine
the
effe
cts
ofyo
gaon
rest
ing
pulm
onar
yfu
ncti
ons,
exer
cise
capa
city
,and
exer
cise
-ind
uced
bron
chia
llab
ility
inde
xin
youn
gch
ildre
nw
ith
ahi
stor
yof
child
hood
asth
ma.
46yo
ung
child
ren
wit
ha
hist
ory
ofch
ildho
odas
thm
a(m
ean
age
"15
.8yr
s).A
llsu
bjec
tsha
da
clin
ical
hist
ory
and
evid
ence
ofre
curr
ent
epis
odes
ofas
thm
adu
ring
the
last
year
.All
part
icip
ants
had
mild
tom
oder
ate
asth
ma
and
exer
cise
-in
duce
dbr
onch
ocon
stri
ctio
n.
Subj
ects
adm
itte
dfo
r40
days
inth
eho
spit
alof
the
Cen
tral
Res
earc
hIn
stit
ute
for
Yoga
.Dai
lyyo
gafo
r90
min
inth
em
orni
ngan
d1
hrin
the
even
ing
was
taug
htby
ate
amof
yoga
inst
ruct
ors
(yog
iccl
eans
ing
proc
edur
es,
post
ures
,and
brea
thin
g).
Yoga
trai
ning
resu
lted
ina
sign
ifica
ntin
crea
sein
pulm
onar
yfu
ncti
onan
dex
erci
seca
paci
ty.A
follo
w-u
pst
udy
span
ning
2yr
ssh
owed
ago
odre
spon
sew
ith
redu
ced
sym
ptom
scor
ean
ddr
ugre
quir
emen
tsin
thes
esu
bjec
ts.
Itis
conc
lude
dth
atyo
gatr
aini
ngis
bene
ficia
land
may
impr
ove
FVC
,FE
V,
and
MM
FR.T
hefin
ding
ssh
owth
atyo
gatr
aini
ngde
crea
sed
exer
cise
indu
ced
bron
choc
onst
rict
ion.
2B
3K
hana
met
al42
MLG
/LQ
Exa
min
edw
heth
erau
tono
mic
and
pulm
onar
yfu
ncti
ons
are
impr
oved
afte
ra
shor
t-te
rmyo
gatr
aini
ng.
Six
mal
esan
dth
ree
fem
ales
wit
hag
era
nges
12–6
0yr
s(w
ith
aver
age
dura
tion
ofdi
seas
e13
.55
yrs)
.
Yoga
asan
as,p
rana
yam
atw
ice/
day
for
1hr
each
sess
ion
(14
sess
ions
)fo
r7
days
ata
cam
pin
New
Del
hi.P
atie
nts
wer
eke
ptun
der
the
sam
ere
laxe
den
viro
nmen
tal
cond
itio
ns.
RH
Rsi
gnifi
cant
lyde
crea
sed;
sym
path
etic
reac
tivi
tyre
duce
d;Pu
lmon
ary
func
tion
test
ssh
owed
impr
ovem
ent.
Ver
ysm
alls
ampl
esi
ze,b
utin
itia
lsug
gest
ion
that
pers
ons
wit
has
thm
aca
nbe
nefit
from
ash
ort-
term
yoga
prog
ram
.
3B
4N
agen
dra
and
Nag
arat
hna41
MLG
/LQ
Pros
pect
ive
coho
rtfo
llow
ed57
0su
bjec
tsw
ith
asth
ma
for
3–54
mos
and
mea
sure
dcl
inic
alca
rdio
pulm
onar
ypa
ram
eter
sov
erti
me
(par
amet
ers
are
exte
nsiv
e,ra
ngin
gfr
omno
.ofa
ttac
kspe
rw
eek
tosp
utum
prod
ucti
on).
Age
rang
e7–
78yr
s;m
ajor
ity
ofpa
rtic
ipan
tsw
ere
mal
es;c
linic
alst
udy
over
ape
riod
of3
yrs.
Yoga
trai
ning
for
2w
eeks
(2.5
hrda
ily)
or4
wee
ks(1
.25
hr)
incl
uded
asan
as,
pran
ayam
a,m
edit
atio
n,de
voti
onal
sess
ion
and
lect
ure.
Coh
ortw
asfo
llow
edfo
r3–
54m
os.P
arti
cipa
nts
cate
gori
zed
into
1of
3gr
oups
:tho
sew
hopr
acti
ced
irre
gula
rly,
regu
larl
y,an
dth
ose
that
disc
onti
nued
;Sub
ject
ive
and
obje
ctiv
eda
taco
llect
edon
30pa
ram
eter
s(1
8sp
ecifi
can
d12
gene
ral)
.
Reg
ular
grou
ppr
acti
cesh
owed
mos
tim
prov
emen
tw
hile
the
irre
gula
rgr
oup
the
leas
t;pe
akex
pira
tory
flow
rate
show
edsi
gnifi
cant
impr
ovem
ent
tow
ard
norm
alcy
;ap
prox
imat
ely
69%
ofth
eto
talg
roup
redu
ced
orst
oppe
dm
edic
atio
n;m
ost
ofth
esp
ecifi
cpa
ram
eter
sim
prov
ed.
2B
(Con
tinu
ed)
Pediatric Physical Therapy Therapeutic Effects of Yoga for Children 73
TABL
E3
Con
tinu
ed
No.
Stud
y1s
t/2n
dR
evie
wer
Feat
ures
Part
icip
ants
Inte
rven
tion
End
poin
tsSu
mm
ary
Evi
denc
eLe
vel
5N
agar
athn
aan
dN
agen
dra40
MLG
/LQ
Cas
eco
ntro
lled
clin
ical
tria
lto
dete
rmin
eth
ebe
nefit
sof
yoga
onas
thm
a.
106
pati
ents
wit
hes
tabl
ishe
dbr
onch
ial
asth
ma.
Fift
y-th
ree
rand
omly
allo
cate
dpa
tien
tsw
illin
gly
serv
edas
cont
rols
,con
tinu
ing
taki
ngth
eir
usua
ldru
gsdu
ring
the
stud
y.A
gera
nge
9–47
yrs;
38m
ales
and
15fe
mal
es.5
3pa
irs
mat
ched
for
age
and
sex,
type
and
seve
rity
ofas
thm
a.
Tw
ow
eek
trai
ning
inan
inte
grat
edse
tofy
oga
exer
cise
s(b
reat
hing
,m
edit
atio
nan
dde
voti
onal
sess
ion)
for
65m
inda
ily.
Cas
e-co
ntro
lgro
ups
wer
efo
llow
edfo
rup
to30
mos
.All
wer
eev
alua
ted
at6
mo
inte
rval
son
num
bers
ofat
tack
s,se
veri
tysc
ore,
drug
trea
tmen
tsco
rean
dpe
akflo
wra
te.
Dro
p-ou
trat
ehi
gh(2
5su
bjec
ts).
How
ever
,the
rew
asa
sign
ifica
ntly
grea
ter
impr
ovem
enti
nth
eyo
gagr
oup
inth
ew
eekl
ynu
mbe
rof
asth
ma
atta
cks,
scor
esfo
rdr
ugtr
eatm
ent,
and
peak
flow
rate
.
3B
6Pl
atan
ia-S
olaz
zoet
al35
RG
/MLG
The
imm
edia
teef
fect
sof
rela
xati
onth
erap
yw
ere
asse
ssed
in40
hosp
ital
ized
child
ren
and
adol
esce
nts
(age
s8–
19,m
ean
"13
.4w
ith
1/2
the
sam
ple
bein
gad
oles
cent
)w
ith
diag
nose
sof
adju
stm
ent
diso
rder
and
depr
essi
on.
Rel
axat
ion
ther
apy
(RT
)ef
fect
sw
ere
asse
ssed
usin
ga
wit
hin
subj
ects
pret
est/
post
test
desi
gnan
dby
com
pari
son
wit
ha
cont
rolg
roup
of20
depr
esse
dan
dad
just
men
tdi
sord
erpa
tien
tsw
how
atch
eda
1hr
rela
vide
otap
e.(4
0in
expe
rim
enta
lgro
up,2
0in
cont
rol)
.
The
1hr
RT
clas
sco
nsis
ted
ofyo
gaex
erci
se,a
brie
fm
assa
ge,a
ndpr
ogre
ssiv
em
uscl
ere
laxa
tion
.Thi
scl
ass
was
offe
red
two
tim
esa
wee
k.
Dec
reas
esw
ere
note
dIn
both
self-
repo
rted
anxi
ety
and
inan
xiou
sbe
havi
oran
dfid
geti
ngas
wel
las
incr
ease
sin
posi
tive
affe
ctin
the
RT
grou
p,bu
tnot
the
vide
ogr
oup.
Inad
diti
on,
adju
stm
entd
isor
der
pts
and
a1/
3of
depr
esse
dpt
ssh
owed
decr
ease
sin
cort
isol
leve
lsfo
llow
ing
RT
,whi
leno
chan
ges
wer
eno
ted
inth
evi
deo
grou
p.
Both
diag
nost
icgr
oups
(adj
ustm
entd
isor
der
and
depr
essi
on)
appe
ared
tobe
nefit
from
the
RT
clas
s.
2B
7St
ueck
and
Glo
eckn
er5
RG
/MLG
Tra
inin
gof
rela
xati
onw
ith
elem
ents
ofyo
gafo
rch
ildre
nte
chni
que
(Str
ess
hand
ling
prog
ram
).
48fif
thgr
ade-
pupi
lsw
hosh
owed
abno
rmal
exam
inat
ion
anxi
ety.
21w
ere
plac
edin
expe
rim
enta
lgro
up,
and
27in
toco
ntro
lgro
up.
15se
ssio
nsof
60m
in(r
elax
atio
n,yo
ga,a
ndgr
oup
acti
vity
).
Pre/
post
com
pari
son
ofps
ycho
logi
can
dph
ysio
logi
cva
riab
les
wit
hth
ree
mea
suri
ngin
terv
als
(rat
ing
scal
esof
subj
ecti
vefe
elin
gsan
del
ectr
oder
mal
acti
vity
).
Tra
inin
gca
nin
crea
seem
otio
nalb
alan
cein
the
long
-ter
man
dre
duce
fear
s.Fe
elin
gof
help
less
ness
was
clea
rly
redu
ced.
2B
8T
elle
set
al32
MLG
/LQ
Det
erm
ine
diff
eren
ces
inH
R,b
reat
hing
rate
and
skin
resi
stan
cebe
twee
na
yoga
prog
ram
ora
grou
pth
atpa
rtic
ipat
edin
gam
es.
28gi
rls
(age
d12
–16
yrs)
from
com
mun
ity
hom
esw
ith
ahi
stor
yof
diff
icul
tyin
adju
stin
gat
hom
eor
inso
ciet
y.14
pair
sw
ere
mat
ched
for
age
and
dura
tion
ofst
ayin
the
hom
ean
dra
ndom
assi
gnm
entt
oei
ther
grou
p(y
oga
orga
mes
).
Inte
rven
tion
last
edfo
r6
mos
:1
hrev
ery
day
ofyo
ga(p
ostu
res
for
50m
inan
dre
laxa
tion
for
10m
in)
or1
hrga
mes
(40
min
)an
dre
lay
race
s(2
0m
in).
Mea
sure
men
tsta
ken:
EK
Gan
dvo
lum
etri
cpr
essu
retr
ansd
ucer
(for
resp
irat
ion
and
skin
resi
stan
ce).
Yoga
and
gam
esde
crea
ses
HR
;yog
aal
sosi
gnifi
cant
lyde
crea
sed
brea
thra
te;n
osi
gnifi
cant
chan
gein
skin
resi
stan
cein
eith
ergr
oup.
Res
ults
sugg
estt
hata
yoga
prog
ram
whi
chin
clud
esre
laxa
tion
,aw
aren
ess,
and
grad
edph
ysic
alac
tivi
tyis
aus
eful
addi
tion
toth
ero
utin
eof
child
ren
inth
eco
mm
unit
yho
me.
2B
(Con
tinu
ed)
74 Galantino et al Pediatric Physical Therapy
training. Increased capacity was found in the subjects’forced expiratory volume, distance walked in a 12-minutetime period, and overall physical fitness as assessed by amodified Harvard Step Test. Although only 26 patientscould be followed for up to 2 years, these patients showedcontinued reduction in symptoms, along with decreaseddrug requirements. Additionally, 14 of these patients (allinitially diagnosed with mild asthma) who continued yogapractices everyday for 15 to 30 minutes remained asymp-tomatic, suggesting the utility of regular practice.
Three additional studies strengthen the evidence foryoga in the asthmatic population. However, these studiesinclude, but are not necessarily restricted to the pediatric pop-ulation. Two of these studies were conducted by Nagendra etal.40,41 In 1985, a case controlled study by Nagendra et al40
reported significant improvements in the weekly numberof asthma attacks, scores for drug treatment, and peak flowrate in yoga participants versus nonparticipants. Subjectswere matched for age, sex, type, severity and duration ofasthma. The rigor of this study was weakened by a highdropout rate. In 1986, Nagendra et al41 strengthened theirfindings with a prospective cohort study of 570 asthmatics,which explored the use of yoga over an extended timeperiod (ranging from 3 months to 4.5 years). Results re-vealed regularity of practice to be the strongest predictor ofimproved peak expiratory flow and decreased use of med-ication. An additional study by Khanam et al42 found apositive correlation between yoga and cardiopulmonaryimprovements. This study was underpowered with a mark-edly shorter time frame of intervention (7 days), suggestingthat asthmatics can benefit from even a short-term yogaprogram.
Two additional studies suggest that yoga may improvecardiorespiratory parameters in children as a secondaryeffect of decreased anxiety. Clance et al43 analyzed the ef-fects of yoga on body satisfaction in a study involving 12third grade students. Six students in the experimentalgroup receiving yoga demonstrated improvements in self-image, while the six students in the control group did not.These results suggest that yoga may reduce stress and anx-iety related to low body satisfaction or poor self-image inchildren. Further, the breathing techniques used in yogafoster decreased anxiety.32 Although underpowered andconsidered pilot in nature, this study has important impli-cations for the physical aspects of development that areindirectly impacted by psychosocial parameters.
Further, a study by Stueck et al5 found that yoga andrelaxation techniques may increase emotional balance inthe long term, reduce fears and feelings of helplessness, aswell as aggression and negative feelings, and improve over-all well-being. This study used a stress-handling programwith elements of yoga in 48 fifth grade students withexamination anxiety. Postintervention, the participantstransferred the learned breathing techniques and self-instructions to situations beyond school to promotehealthy stress management and stress prevention, bothof which are a means of primary prevention of cardio-pulmonary complications.44
TABL
E3
Con
tinu
ed
No.
Stud
y1s
t/2n
dR
evie
wer
Feat
ures
Part
icip
ants
Inte
rven
tion
End
poin
tsSu
mm
ary
Evi
denc
eLe
vel
9T
elle
san
dSr
iniv
as37
MLG
/LQ
Asc
erta
indi
ffer
ence
sbe
twee
nra
tes
ofbr
eath
ing,
HR
and
dias
tolic
BPbe
twee
nch
ildre
nw
hoar
evi
sual
lyim
pair
edan
dth
ose
who
are
norm
alsi
ghte
dan
dth
eef
fect
sof
yoga
vsph
ysic
alac
tivi
tyon
thes
epa
ram
eter
s.
28ch
ildre
n(a
ged
12–1
7yr
s)m
atch
edfo
rag
ean
dde
gree
ofbl
indn
ess
rand
omiz
edto
yoga
orph
ysic
alac
tivi
ty.
Inte
rven
tion
last
edfo
r3
wee
ks:1
hrev
ery
day
ofyo
ga(p
ostu
res
for
50m
inan
dre
laxa
tion
for
10m
in)
or1
hrof
phys
ical
acti
vity
(gar
deni
ngan
dst
retc
hing
).
Mea
sure
men
tsta
ken:
BP,
EK
G,v
olum
etri
cpr
essu
retr
ansd
ucer
(for
resp
irat
ion
and
skin
resi
stan
ce).
Aft
er3
wee
ks,y
oga
grou
psh
owed
sign
ifica
ntre
duct
ion
inbr
eath
rate
(no
chan
gein
phys
ical
acti
vity
).R
esul
tssu
gges
tth
atch
ildre
nw
ith
visu
alim
pair
men
thav
ehi
gher
phys
iolo
gica
laro
usal
than
child
ren
wit
hno
rmal
sigh
t,w
ith
am
argi
nalr
educ
tion
inar
ousa
lfol
low
ing
yoga
.
2B
10U
dupa
etal
31M
LG/L
QD
eter
min
ew
heth
erpr
anay
amtr
aini
ngha
san
effe
cton
vent
ricu
lar
perf
orm
ance
,in
effe
ctim
prov
ing
card
iore
spir
ator
yfu
ncti
ons.
24sc
hool
child
ren
(hea
lthy
boys
aged
13–1
5yr
s)ra
ndom
lyas
sign
edto
pran
ayam
brea
thin
gor
cont
rolf
or3
mos
.
Pran
ayam
brea
thin
gor
norm
albr
eath
ing,
20m
inda
ilyfo
ra
dura
tion
of3
mos
.
Syst
olic
tim
ein
terv
als
and
card
iac
auto
nom
icfu
ncti
onte
sts,
both
noni
nvas
ive
test
sfo
rm
easu
ring
vent
ricu
lar
perf
orm
ance
.
Pran
ayam
mod
ulat
esve
ntri
cula
rpe
rfor
man
ceby
incr
easi
ngpa
rasy
mpa
thet
icac
tivi
tyan
dde
crea
sing
sym
path
etic
acti
vity
.
2B
Pediatric Physical Therapy Therapeutic Effects of Yoga for Children 75
MUSCULOSKELETAL EFFECTS OF YOGA
We reviewed four studies pertaining to the musculo-skeletal practice pattern. Two of the four studies were clas-sified as 2B level of evidence, while the other two wereassigned level 3B (Table 4). These studies reveal that yogamay be used with children developing typically, or chil-dren who are not meeting national norms for fitness andbody composition, or children with elevated stress levels toimprove musculoskeletal parameters.
Orthopedic injuries in children are often caused bylack of strength and flexibility,45 which are addressed in themusculoskeletal practice pattern. The four studies re-viewed showed significant effects of yoga and its breathingtechniques on the musculoskeletal system in children.Three of these four studies were from the Indian Journal ofPhysiology and Pharmacology.46–48 Although these studieswere not very recent, they lay down the foundational workin this body of evidence, and provide a starting point uponwhich to build future studies. The results and conclusionsof these studies suggest that yoga can be introduced duringschool to improve physiological function, overall health,and performance of students. Further RCTs are needed todetermine definitive effects of yoga.
A study by Mandanmohan et al46 found that 6 monthsof yoga training in 20 school children aged 12 to15 yearsproduced significant gains in handgrip strength and endur-ance as well as inspiratory and expiratory muscle strength.This research design involved yoga training that took placeover more than 6 months, which allowed the study to ex-amine the long-term effects of yoga training. Perhaps fu-ture studies could involve a larger number of subjects, andexamine the effects of yoga after the 6 months of training.
Similar gains in grip strength were found in a study byRaghuraj et al,47 in which school children 11 to 18 years oldtook part in pranayama breathing for 10 days. Increasedgrip strength in both hands was found in the pranayamagroup, while no change was found in the control group.This study used random assignment to one of five groupsthat spanned a large range of children’s ages (11–18 yearsold). An additional study by Raghuraj and Telles replicatedthese findings of increased grip strength after 6 months ofyoga in 12- to 16-year-old girls.48 These gains have impli-cations for using yoga for total body strengthening.
Obesity, another growing concern in our pediatricpopulation, may also be reduced through the implementa-tion of yoga programs. A pilot study by Slawta et al49 enti-tled “Be a Fit Kid” included a 12-week program of yogadesigned to improve physical fitness and nutritional habitsin children. The program also included a physical activitycomponent (running, jumping, and strengthening) alongwith a nutrition program. After the intervention, signifi-cant improvements were found in body composition andfitness in those who participated 75% of the time. Becausethe “Be a Fit Kid” program used a holistic approach, thespecific effects of the yoga component are difficult to de-termine. However, we felt that the study was important toinclude, given that it portrays yoga as an important con-
tributor to an overall healthy lifestyle. Considering the re-cent trend of child participation in yoga classes, it is likelythat more studies investigating children who are obeseshould be conducted with more rigorous methodology.This pilot study established the framework for replicationin a larger, randomized sample.
Thus, in addressing the musculoskeletal issues of flex-ibility and strength, these studies demonstrate that yogacan have an impact on stress management and obesity.Both of these issues having a major impact on the social-ization of developing children, so it can be seen that yoganot only impacts physically, but also emotionally and psy-chosocially. Therefore, PTs can consider yoga as a toolfor not only musculoskeletal, neuromuscular, and car-diopulmonary problems, but also as a holistic approachto the entire mind– body of these children, thus address-ing many issues that arise in children developing typi-cally and atypically.
INTERPRETATION
This review summarizes available evidence regardingthe effects of yoga as an intervention for QOL and physicaloutcomes in children. None of the reviewed studies pro-vided adequate data to assess improvements in QOL over asignificant part of childhood and adolescence, as most wereof short duration. The 24 studies included in this reviewwere of variable quality, and none were considered to be ofhigh quality. Our conclusions are tempered by this fact.Clearly, further progress must be made to improve re-search quality and include measures of QOL. Future trialsshould focus on adequate randomization, concealment ofallocation, and blinding of outcome assessors throughoutthe study.
A noteworthy feature of trials included in this reviewwas the wide variability in study interventions. Many dif-ferent types of yoga regimens were prescribed. The diver-sity in yoga prescription is not surprising, given the culturefrom which yoga emanates. Westernization of this modal-ity may compromise the full intent of yoga practice inthe United States when compared with India. Con-versely, the wide variety in study outcomes and mea-surement methods is surprising. The short duration orcomplete lack of follow-up data examining the effect ofyoga on QOL and rehabilitative outcomes in the longterm are also noted. Moreover, data are lacking to sup-port the use of yoga in preventing further disability inthese three practice patterns.
A further limitation is the nonspecificity with re-spect to the timing of the yoga intervention. Clinicalheterogeneity was evident, particularly, in trials carriedout during treatment for asthma. This resulted from tri-als in which the participants were undergoing one of avariety of additional drug treatments; therefore, con-founding issues are of concern.
Finally, poor adverse event reporting in most of thestudies limits any conclusions about the relative safety ofyoga as an exercise, and the small samples provide insuffi-cient power to detect meaningful differences in rates of rare
76 Galantino et al Pediatric Physical Therapy
TABL
E4
Mus
culo
skel
etal
Evi
denc
e
No.
Stud
y1s
t/2n
dR
evie
wer
Feat
ures
Part
icip
ants
Inte
rven
tion
End
poin
tsSu
mm
ary
Evi
denc
eLe
vel
1M
anda
nmoh
anet
al46
LQ/R
G/
MLG
Eff
ecto
fyog
atr
aini
ngon
resp
irat
ory
pres
sure
san
dha
ndgr
ipen
dura
nce.
40st
uden
tvol
unte
ers,
ages
12to
15yr
s.Yo
gatr
aini
ng(a
sana
san
dpr
anay
amas
)fo
r6
mos
and
cont
rolg
roup
.
Yoga
trai
ning
prod
uced
stat
isti
cally
sign
ifica
nt(p
$0.
05)
incr
ease
inha
ndgr
ipst
reng
than
dha
ndgr
ipen
dura
nce.
Yoga
trai
ning
prod
uced
stat
isti
cally
sign
ifica
nt(p
$0.
001)
incr
ease
inm
axim
umex
pira
tory
pres
sure
,m
axim
umin
spir
ator
ypr
essu
re,
forc
edex
pira
tory
volu
me,
and
peak
expi
rato
ryflo
wra
te.
Yoga
trai
ning
for
6m
osim
prov
eslu
ngfu
ncti
on,s
tren
gth
ofin
spir
ator
yan
dex
pira
tory
mus
cles
asw
ella
ssk
elet
alm
uscl
est
reng
than
den
dura
nce.
Itis
sugg
este
dth
atyo
gabe
intr
oduc
edat
scho
olto
impr
ove
phys
iolo
gica
lfun
ctio
n,ov
eral
lhea
lth,
and
perf
orm
ance
ofst
uden
ts.
3B
2R
aghu
raja
ndT
elle
s48
LQ/R
G/
MLG
Com
pare
mot
oran
dse
nsor
y(v
isua
l)pe
rfor
man
cein
thre
egr
oups
ofsu
bjec
ts:g
irls
ina
com
mun
ity
hom
ew
hoha
dle
arne
dyo
ga,
girl
sin
aco
mm
unit
yho
me
trai
ned
inph
ysic
alac
tivi
ty,a
ndgi
rls
who
wer
eat
tend
ing
are
gula
rsc
hool
.
80gi
rls
(age
s12
–16
yrs)
from
ast
ate-
com
mun
ity
hom
ebe
caus
eof
diff
icul
tyin
adju
stin
gat
hom
e,at
scho
ol,o
rin
soci
ety.
6m
osof
yoga
,6m
osof
phys
ical
trai
ning
,or
neit
her
(con
trol
grou
p).
Phys
ical
trai
ning
grou
pha
dsi
gnifi
cant
lylo
wer
crit
ical
flick
erfu
sion
freq
uenc
y,hi
gher
degr
eeof
opti
cali
llusi
on,a
ndlo
wer
righ
than
dgr
ipst
reng
thth
anco
ntro
lgro
up.Y
oga
grou
pha
dhi
gher
crit
ical
flick
erfu
sion
freq
uenc
y,lo
wer
degr
eeof
opti
cali
llusi
on,a
ndm
argi
nally
grea
ter
hand
grip
stre
ngth
than
the
phys
ical
trai
ning
grou
p,bu
tw
asno
tsig
nific
antl
ydi
ffer
ent
from
the
cont
rolg
roup
.
The
repo
rted
high
erst
ress
leve
lsin
com
mun
ity
hom
esu
bjec
tsre
duce
dse
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l,or
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ugh
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lsin
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wit
hout
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raliz
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awta
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ea
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ram
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ysic
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ges
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yrs)
.12
wee
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ogra
m(B
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id)
(3%
/wk
for
2hr
)of
phys
ical
acti
vity
(run
ning
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ping
,yo
ga,a
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reng
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ses)
and
nutr
itio
n(d
ietr
ich
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geta
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,fru
its,
unsa
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ted
fats
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who
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ains
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ndsu
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ifica
ntim
prov
emen
tsw
ere
obse
rved
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utri
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alkn
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ts,a
ndin
thos
eth
atpa
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ipat
ed75
%of
the
tim
e,si
gnifi
cant
redu
ctio
nsin
tota
lch
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tero
land
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lyce
ride
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lth
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otio
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ms
can
bew
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ecei
ved
bych
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nan
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ayfa
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the
deve
lopm
ento
fadu
ltlif
esty
le-
rela
ted
dise
ases
.
3B
Pediatric Physical Therapy Therapeutic Effects of Yoga for Children 77
adverse events. For example, inverted postures can impactblood pressure50,51 and represents a barrier to exercise forsome patients, yet none of the included studies formallyexplained or monitored for the effect of specific postures.
The evidence suggests that yoga is an effective inter-vention to improve cardiorespiratory fitness, physicalfunctioning, and behavior in children and adolescents. Allthe studies showed an effect and this may due to researcheror selection bias. Although these preliminary results arepromising, the findings are based on a relatively smallnumber of trials with significant methodological weak-nesses. On the basis of our findings, we make the followingresearch recommendations. Methodologically rigorous stud-ies designed to examine different yoga regimens (see Table1) are needed to better understand the role of yoga as itimpacts the developing child and QOL. The yoga prescrip-tion should be reported in detail (frequency, intensity,time, and type of exercise) to allow for determination ofexercise dose–response. To this end, adherence to exerciseshould be reported for both completion of exercise sessions(attendance) and yoga intervention (intensity and dura-tion). Furthermore, monitoring of activity in the compar-ison group(s) is necessary to assess potential contamina-tion. Consensus is required on standardized methods ofassessing physical fitness and body composition to allowfor pooling of data and for comparisons across studies.Future trials should formally monitor for, and report theincidence of, potential adverse events such as change inblood pressure.
SUMMARY OF LITERATURE REVIEW
Complementary and alternative medicine (CAM)encompasses five areas of modalities according to theNational Institutes of Health—National Center for CAM: bi-ologically based interventions, manipulative and body-based methods, mind–body therapies, energy-based ap-proaches, and alternative medical systems. Yoga is onemind–body therapy that has emerged as an educational-based intervention and to improve various medical condi-tions for children.
Patient expectations regarding CAM interventionshave important implications for treatment adherence, at-trition, and clinical outcome.52 Little is known, however,about parent and child treatment expectations regardingCAM approaches, especially yoga for problems presentedby children and adolescents. One study revealed that par-ents often have higher expectations of CAM therapiesthan do their children.52 Additionally, enhanced expec-tations often resulted in better outcomes. Thus, the useof alternative modalities must take into considerationthese influential factors. Therefore, it is important thatPTs are increasingly aware of the potential complemen-tary and beneficial effects of various CAM modalities inchildren’s rehabilitation.
The use of yoga for rehabilitation may have diverseapplications. Yoga practice may benefit children with men-tal challenges by improving their mental ability, along withmotor coordination and social skills. Children with physi-
cal disabilities may also experience restoration of somedegree of functional ability after practicing yoga. Childrenwho are VI can decrease their abnormal anxiety levels, andchildren in a group home can improve their sleep, appetite,and general well being, as well as a decrease in physiolog-ical arousal.53
Evidence from the previous studies of yoga as a CAMintervention have implications for PTs in the neuromuscu-lar areas of learning, motor control, and coordination. PTsmight apply these findings to their patients with asthma orsimply as a form of biofeedback in stress management.Further, outcomes may be enhanced by applying findingsfrom these studies to young athletes or children who areoverweight. Regardless of the goal, yoga seems to be a mul-titasking modality that simultaneously treats physical im-pairments and psychosocial issues such as stress, anxiety,or hyperactivity. Many of these studies set out to measurepurely physical parameters, but encompass psychosocialissues. Moreover, many of the studies in this reviewoverlap or address multiple practice patterns, making itdifficult to distinguish the effects of yoga on one specificimpairment.
The available studies according to Sackett classifica-tion system17 are predominantly level 2B grade evidenceand below. It is well known that the inclusion of nonran-domized or uncontrolled trials leads to an overestimationof the effect of an intervention. Therefore, as noted in thestudies presented in this article, yoga has a consistent trendin improvement. However, it is recommended that moreRCTs be planned for future examination of the evidence foryoga to be consistently included into the PT plan of care.Specific measures of QOL should be added to physiologicdata collection. In addition, future meta-analyses should berestricted to RCTs whenever possible.54
Much of the literature reviewed has been conducted inIndia and comprises all the elements of yoga includingpostures (asanas), breathing (pranayama), and spirituality(meditation). As Eastern philosophies and practices aretaken to other countries, it may be compartmentalizedwithout the lack holism of the philosophy and practicewhen examined in research. Therefore, appropriate useand full description of the practice of yoga is required forfuture design of clinical trials. Further research is neededto explore the integration of yoga into clinical practice. PTstreating children have an opportunity to add to existingexercise protocols and incorporate the benefits of yoga.However, research is needed to determine the best forms ofyoga for children with specific impairments and to establish adose–response relationship for children of different ages.
This review of the literature supports evidence foryoga that guide us in determining issues that will be im-portant in the design of larger pediatric rehabilitation clin-ical trials. Future studies should examine the effect of yoga,as well as the magnitude and the variability of the responsethroughout childhood and adolescence. Compelling evi-dence exists that demonstrates the effect within the neuro-muscular, cardiopulmonary, and musculoskeletal practicepatterns. The breadth of these studies has implications in
78 Galantino et al Pediatric Physical Therapy
all areas of PT practice, particularly in complementing ex-isting wellness programs and clinical interventions forchildren.
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