Do We Need Yoga?
If you are a yoga enthusiast, it may be worthwhile asking the following questions
- With so many varieties of yoga being promoted today, each one claiming to be superior and pure, do they have any semblance to the yoga that was practiced in ancient India?
- Has the therapeutic or preventive efficacy of yoga in any of the states of human health and disease been conclusively proven?
- Is the practice of yoga totally safe?
Yoga, in its myriad forms, seems to be everywhere. It is being made out that yoga has a very wide presence and acceptance, from Health columns in newspapers to dedicated TV channels, from India to the US, from children to the elderly. The contributions of ancient Indian civilisation to science, mathematics and philosophy are passe; yoga is being branded as India’s greatest contribution ever to humanity. And yoga has opened up great business opportunities for many. While some have opened up exclusive, ‘patented’, yoga schools in corporate style, some others, savvier and adept in feeling the ‘pulse of the masses’, have metamorphosed into big time Poojya Jagadgurus (with the prefixes of Baba or Sri Sri or His Holiness by hijacking and renaming one or two methods of yoga practice. Not to be left behind, the Governments in India, in several states and even at the Centre, have decided to introduce yoga as a compulsory curriculum in physical training, right from the first standard. And the Hindutva Brigade, ever so eager to garner publicity from anything anciently Indian, has usurped yoga into its folds and posits itself at the vanguard of promoting yoga; any skepticism about yoga is branded by these forces as anti RSS, anti BJP, anti Hinduism, anti Indian and even anti national and unpatriotic.
But is the practice of yoga beneficial and necessary? Is it safe?
What is Yoga?
The practice of yoga was prevalent in ancient India, probably among the sages, who lived a very rigorous life, meditating for long lengths of time. It was sage Patanjali (2nd Century BC) who codified this into the Yoga Sutras, considered as the principal treatise on yoga. The practice of yoga has significantly evolved since then, particularly with the Hatha Yoga Pradipika written by Yogi Swatmarama, a sage of 15th century India and a disciple of Swami Gorakhnath. In this treatise, Swatmarama introduces Hatha Yoga as ‘a stairway to the heights of Raja Yoga‘ (of Patanjali), hence a preparatory stage of physical purification that renders the body fit for the practice of higher meditation. In the modern times, along with Patanjali’s Raja yoga, there are innumerable schools and styles of yoga and meditation, namely Agni yoga, Anahata yoga, Artistic yoga, Ashtanga Vinyasa yoga, Bhakti yoga, Bikram yoga or Hot yoga, Disco yoga, Divya yoga (of Baba Ramdev), Dream yoga, Hatha yoga, Hip-Hop yoga, Integral yoga, Iyengar yoga, Jnana yoga, Karma yoga, Kriya yoga, Kundalini yoga, Natya yoga, Power yoga, Restorative yoga, Siddha Samadhi yoga of Rishi Prabhakar, Six yogas of Naropa, Sahaja yoga, Silver yoga, Sivananda yoga, Sudarshana Kriya of Ravishankar, Surat Shabd Yoga, Tanscendental Meditation of Mahesh Yogi, Viniyoga, Yantra yoga, Yoga Nidra etc. Needless to say, each school claims its virtues and their individual popularity is commensurate with the marketing and networking abilities of the proponents. If Baba Ramdev Swamiji Maharaj is said to teach a set of seven pranayamas in a special sequence with some stress on Kapalbhati pranayam, His Holiness Sri Sri Ravi Shankar apparently had to ‘spend 10 days in deep contemplation and silence to gift to the world the Sudarshan Kriya’, branded as a ‘powerful revitalizing breathing technique’.[2-5]
Is there anything common between these several forms of ‘yoga’ and the yoga as practiced in its original form in ancient India? Are they yoga at all?
Is yoga beneficial to health?
Well, a practice that apparently started as a technique of helping the sages to concentrate in meditation has evolved into a all-curative ‘science’. If Baba Ramdev is to be believed, he (His Holiness Swami Ramdevji Maharaj) ‘is first in the world health history, to use freely available Pran (Oxygen) as a medicine and in turn remains successful in treating thousands of grief stricken persons suffering from lethal diseases like Diabetes, H.B.P., (high blood pressure) Angina, Blockages in Arteries, Obesity, Asthma, Bronchitis, Leucoderma, Depression, Parkinson, Insomnia, Migraine, Thyroid, Arthritis, Cervical Spondalities, (that should be spondylitis) Hepatitis, Chronic Renal Failure, Cancer, Cirrhosis of Liver, Gas, Constipation, Acidity etc. which are still a challenge in modern medical science. And his incessant endeavors to measure medicinal value of Pran (Oxygen) will soon give new turn to modern medical science.' And one can learn this heal-all technique by attending his camps (with different rates for front to last rows, usually in thousands) or even learn them free on his TV channel. Mass yoga for mass relief. And the marketing is so effective, even the so called educated and the elite seem to accept these claims without questions. Latest is the relatives of the Union minister Priyaranajan Das Munshi, now on a ventilatory support following a heart attack and stroke, seeking the services of Ramdev. The ministers at the central and several state governments in India are so much convinced about the benefits and safety of yoga that, very soon, training in yoga will be compulsory curriculum for students, right from the first standard.[8,9] But is there any unambiguous evidence that yoga is indeed beneficial for health?
Several studies have been done on the effects of yoga on health and disease. Most of the studies have been done, naturally, in yogic institutions in India, and a few in prestigious institutes like the All India Institute of Medical Sciences (AIIMS), Delhi, National Institute of Mental Health, Neuro Sciences (NIMHANS), Bangalore and abroad. Most of these studies have been published in Indian journals and some in International journals too, particularly the journals of complimentary and alternative medical practice. Most of these studies have been small, short term, uncontrolled, non randomised, open with possible bias and without standard inclusion and exclusion criteria, without any standardised yoga modality and most have not provided any details of adverse outcomes.
Effect of yoga on breathing, heart rate, blood pressure, autonomic system, immunity etc. and on diseases like diabetes, high blood pressure, obesity, lipid disorders, cancers, asthma, chronic obstructive airway disease, epilepsy, mood, aggression, anxiety, depression, schizophrenia, obsessive compulsive disorder, attention deficit disorder, eating disorders, bowel diseases, pancreatitis, pregnancy, menopause, fibromyalgia, drug addiction, osteoarthritis, low back ache, thyroid disease, sleep, stroke, multiple sclerosis, carpal tunnel syndrome, kidney and urological disease, geriatrics, migraine, tuberculosis, filariasis etc., have been studied. And as mentioned, many different methods of yoga, like the Ashtanga yoga, Sahaja yoga, Hatha yoga, Kundalini yoga, Iyengar yoga, Silver yoga, Restorative yoga, Siddha Samadhi yoga, Sudarshana Kriya, Integrated yoga etc., and individual practices like Pranayama, various asanas (Shavasana, Sheershasana etc.), Kapalbhati, Kunjal kriya, Anuloma viloma, Mukh bastrika, as well as meditative methods of Mantra, Mindfulness, Transcendental meditation(TM) and Vipassana have been used in these studies.
As it is not possible to cite each and every paper, the conclusions of the various meta analysis and literature review of these studies is provided here.
Maria B. Ospina et al.,  have reported on the meta analysis of published literature on five broad categories of meditation practices, namely Mantra meditation, Mindfulness meditation, Yoga, Tai Chi, and Qi Gong. Eight hundred and thirteen studies on the therapeutic use of meditation practices, published between 1956 and 2005, were included of which 67% were intervention studies (286 RCTs, 114 NRCTs and 147 before-and-after studies), and 33% were observational analytical studies (149 cohort and 117 cross-sectional studies). Of these, sixty-five intervention studies examined the therapeutic effect of meditation practices for hypertension, other cardiovascular diseases, and substance abuse. Overall, the methodological quality of meditation research was found to be poor, with significant threats to validity in every major category of quality measured, regardless of study design. The majority of RCTs did not adequately report the methods of randomization, blinding, withdrawals, and concealment of treatment allocation. Observational studies were subject to bias arising from uncertain representativeness of the target population, inadequate methods for ascertaining exposure and outcome, insufficient follow-up period, and high or inadequately described losses to follow-up. The authors found that TM had no advantage over health education to improve measures of systolic blood pressure and diastolic blood pressure, body weight, heart rate, stress, anger, self-efficacy, cholesterol, dietary intake, and level of physical activity in hypertensive patients; Yoga did not produce clinical or statistically significant effects in blood pressure when compared to non-treatment and Yoga was no better than physical exercise to reduce body weight in patients with cardiovascular disorders. The authors also analysed 311 studies that evaluated the physiological and neuropsychological effects of meditation practices, the majority of which have been conducted in healthy participants. Although the meta-analysis revealed some consistent physiological effects of meditation practices in healthy populations on the reduction of heart rate, blood pressure, and cholesterol and neuropsychological effect in the increase of verbal creativity, the authors caution that the overall low methodological quality of the studies may result in overestimations of the treatment effects or compromise the generalizability of the study results and therefore, results from meta-analyses of the physiological and neuropsychological effects of meditation practices should be interpreted cautiously. The authors conclude that the field of research on meditation practices and their therapeutic applications is beset with uncertainty, the therapeutic effects of meditation practices cannot be established based on the current literature and firm conclusions on the effects of meditation practices in healthcare cannot be drawn based on the available evidence and it is imperative that future studies on meditation practices be rigorous in the design, execution, analysis, and reporting of the results.
Yoga and Diabetes Mellitus
A review by Innes KE et al.,  of the possible protection offered by yoga on the risk indices associated with insulin resistance syndrome (IRS) and cardiovascular disease (CVD), identified 70 eligible studies, including 1 observational study, 26 uncontrolled clinical trials, 21 nonrandomized controlled clinical trials and 22 RCTs. According to the authors, collectively, these studies suggested that yoga may reduce many IRS-related risk factors for CVD, may improve clinical outcomes, and may aid in the management of CVD and other IRS-related conditions. However, the methodologic and other limitations characterizing most of these studies preclude drawing firm conclusions and the authors suggest that additional high quality RCTs are needed to confirm and further elucidate the effects of standardized yoga programs on specific indices of CVD risk and related clinical endpoints.
Another review by Innes KE and Vincent HK included 15 uncontrolled trials, 6 non-randomized controlled trials and 4 randomized controlled trials (RCTs) (19702006) that evaluated the metabolic and clinical effects of yoga in adults with type 2 diabetes mellitus (DM) and clinical populations with cardiovascular disorders that included adults with comorbid DM. Although these studies suggest overall beneficial changes in several risk indices, the limitations characterizing most studies preclude drawing firm conclusions. The authors suggest additional high-quality RCTs to confirm and further elucidate the effects of standardized yoga programs in populations with type 2 DM.
A review of yoga programs for four leading risk factors of chronic diseases by Kyeongra Yang  included 32 articles published between 1980 and April 2007. Although the studies found that yoga interventions were generally effective in reducing body weight, blood pressure, glucose level and high cholesterol, only a few studies examined long-term adherence and not enough studies included diverse populations at high risk for diabetes and its related common health problems.
Another review of yoga in Type 2 diabetes mellitus by Aljasir et al., included five trials with 363 participants that met the inclusion criteria with medium to high risk of bias and different intervention characteristics. Pooling of the studies was not possible due to the wide clinical variation between the studies. The studies showed improvement in outcomes among patients with type 2 diabetes, but these were mainly among short term or immediate diabetes outcomes and not all were statistically significant. The results were inconclusive and not significant for the long-term outcomes. No adverse effects were reported in any of the included studies. The authors conclude that short-term benefits for patients with diabetes may be achieved from practicing yoga, but further research is needed in this area and a definitive recommendation for physicians to encourage their patients to practice yoga cannot be reached at present. They further suggest that factors like quality of the trials and other methodological issues should be improved by large randomized control trials with allocation concealment to assess the effectiveness of yoga on type 2 diabetes.
Yet another review by Alexander GK et al., concluded that although yoga has a positive short-term effect on multiple diabetes-related outcomes, long-term effects of yoga therapy on diabetes management remain unclear.
Yoga and Cancer
An evidence-based review of yoga as a complementary intervention for patients with cancer by Smith KB and Pukall CF  included ten studies of which six were RCTs. Across studies, the majority of participants were women, and breast cancer was the most common diagnosis. Methodological quality ranged greatly across studies, with the average rating indicating adequate quality. Studies also varied in terms of cancer populations and yoga interventions sampled. The authors concluded that although some positive results were noted, variability across studies and methodological drawbacks limit the extent to which yoga can be deemed effective for managing cancer-related symptoms and suggested that further research in this area is certainly warranted.
Yoga and Hypertension (High Blood Pressure)
According to Dosh SA, the limited studies evaluating yoga and meditation in the treatment of hypertension have focused on reduction in blood pressure rather than patient-oriented outcomes, such as a reduction in morbidity and mortality. Although Transcendental meditation and yoga may have been shown to reduce blood pressure, the studies of these modalities are small and the experimental designs have a limited capacity to detect an independent treatment effect or a placebo effect. Therefore, physicians who include any of these modalities in their hypertension treatment plan should carefully monitor each patient for adequacy of blood pressure control, development of risk factors, and evidence of end-organ damage. At this time, alternative therapies should be considered experimental adjuncts to lifestyle modification and medical therapy that have not been shown to improve patient-oriented outcomes.
Yoga and epilepsy
A review of yoga for control of epilepsy by Nandan Yardi  concluded that there is a dearth of randomized, blinded, controlled studies related to yoga and seizure control and that a multi-centre, cross-cultural, preferably blinded (difficult for yoga), well-randomized controlled trial, especially using a single yogic technique in a homogeneous population such as Juvenile myoclonic epilepsy is justified to find out how yoga affects seizure control and quality of life (QOL) of the person with epilepsy.
A Cochrane Review of yoga for epilepsy could not draw any reliable conclusions.
Yoga for anxiety and depression
A review of the studies on yoga in the treatment of depression by Karen Pilkington et al., included five randomised controlled trials, each of which utilised different forms of yoga interventions and in which the severity of the condition ranged from mild to severe. All trials reported positive findings but methodological details such as method of randomisation, compliance and attrition rates were missing. No adverse effects were reported with the exception of fatigue and breathlessness in participants in one study. Although the initial indications are of potentially beneficial effects of yoga interventions on depressive disorders, variation in interventions, severity and reporting of trial methodology suggests that the findings must be interpreted with caution and further investigation of yoga as a therapeutic intervention is warranted. The authors also opine that several of the interventions may not be feasible in those with reduced or impaired mobility.
A review of complimentary therapies for depression by Jorm et al., identified thirty-seven treatments and found some limited evidence to support the effectiveness of yoga breathing exercises. None of the treatments reviewed was well supported by evidence as for standard treatments such as antidepressants and cognitive behaviour therapy, and many warrant further research.
A review of eight studies on the effectiveness of yoga for the treatment of anxiety and anxiety disorders by Kirkwood et al., found that although some positive results were reported, there were many methodological inadequacies. Owing to the diversity of conditions treated and poor quality of most of the studies, the authors of the review concluded that it was not possible to say that yoga was effective in treating anxiety or anxiety disorders in general and recommended further research.
A Cochrane Review on meditation therapy in anxiety disorders  could not draw any conclusion in view of the availability of only two RCTs of moderate quality that ranged from 12-18 weeks. The overall dropout rate in both studies was high (33-44%) and neither study reported on adverse effects of meditation.
Yoga for asthma
Use of complementary and alternative medical (CAM) practices by the patients of asthma is quite common, with some reports suggesting that as many as 30-40% of asthmatics have tried CAM. Breathing exercises and yoga have been widely used to treat asthma in Eastern and Western societies for many years, and generally centre on manipulating the respiratory pattern to reduce respiratory frequency and hyperventilation. It is still, however, far from clear whether or not breathing exercises can improve asthma outcomes, in which groups they may be effective, or what the mechanism of effect may be.
A Cochrane review of breathing retraining in asthma included seven randomised or quasi-randomised controlled trials in patients of all ages, two of which were on yoga. The techniques of teaching breathing retraining as well as the length and frequency of the treatment interventions varied considerably; 45 minute sessions of yoga breathing training three times a week for 16 weeks in the one and for 2.5 hours for two weeks in another. As the outcome measurements also varied considerably, the authors concluded that at present no reliable conclusions could be drawn concerning the use of breathing exercises for asthma in clinical practice.
Another review by Thomas Ritz of Stanford University  included six controlled and three uncontrolled studies done between 1980 and 2000 that employed a variety of methods, such as progressive relaxation, functional relaxation, autogenic training, or yoga. Most studies had low sample sizes and suffered from one or more methodological deficiencies, such as suboptimal data analysis, high dropout rates, problematic measurement procedures, or insufficient descriptions of methodology and results. Overall effects on parameters of lung function, symptoms, medication consumption, and health care use were generally negligible.
Another review by Lane DJ and Lane TV  concluded that there is no place for any alternative approach in the management of the vast majority of cases of acute, severe asthma. However, some patients of persistent asthma could benefit from such approach and techniques such as yoga deserve further evaluation. The authors suggest that as all asthmatic patients cannot respond, it is important to find ways of identifying those who will. They also suggest that some form of regulation should be exercised over non-medicinal alternative medicines to ensure that they are marketed only when they too have statutory standards of efficacy and safety.
Claudia Steurer-Stey et al., also opine that except for four controlled trials, most of the studies showing beneficial effects of yoga in asthma were short term, uncontrolled and qualitative trials, and even though breathing techniques and muscular relaxation may have some potential, it is not possible to make a firm judgment.
Yoga for chronic pain
A review of eight mind-body interventions for chronic pain in older adults  concluded that there is not yet sufficient evidence to conclude that these interventions reduce chronic nonmalignant pain in older adults and that further research should focus on larger, clinical trials of mind-body interventions.
Yoga and children
A systematic review of the literature on the effect of yoga on quality of life and physical outcome measures in the pediatric population by Galantino ML et al., included 24 studies of which none could be considered as of high quality. Although description of randomization was clear throughout all studies, there was little data that described outcome assessments with regard to the method of blinding, no information on intent-to-treat analysis, and what happened to withdrawals and dropouts. None of the reviewed studies provided adequate data to assess improvements in QOL over a significant part of childhood and adolescence, as most were of short duration. Also there was a wide variability in study interventions with many different types of yoga regimens prescribed. A further limitation was the non-specificity with respect to the timing of the yoga intervention. Clinical heterogeneity was evident, particularly, in trials carried out during treatment for asthma raising concern about confounding issues. The reviewers also felt that the poor adverse event reporting in most of the studies limited any conclusions about the relative safety of yoga as an exercise, and the small samples provided insufficient power to detect meaningful differences in rates of rare adverse events. Even though all the studies showed an effect, this may be due to researcher or selection bias and the promising preliminary results are based on a relatively small number of trials with significant methodological weaknesses. Therefore, the authors recommend that research is needed to determine the best forms of yoga for children with specific impairments and to establish a doseresponse relationship for children of different ages.
Yoga and memory
The most appealing benefit ascribed to yoga and meditation is that the practice enhances memory and concentration. Interestingly, there are no studies that prove any such benefit! While some very small and short studies on limited functions have shown some benefit [33-36], other studies have shown no benefit at all.[37,38]
Research of Ramdev
‘Baba’ Ramdev claims that his research has “proven yog results”. And this is the research he has quoted on his website: Ten patients of diabetes, results of blood sugar done 8 days apart; eight patients and cholesterol, studied after 8 days; cold and flu, “coming soon”; arthritis, “coming soon”; Osteoporesis (?), “coming soon”; depression, “coming soon”; kidney disorders – studied in 6 cases, most are near normal and improvements not significant; and of the ‘research’ on ECG and pulmonary function tests – no details available, except the mention that results were abnormal and some improved.
Two papers from Ramdev’s Patanjali Yog Peeth have been published, not as full papers, but only as Letters to the editor. The study by Manjunath Krishnamurthy and Shirley Telles  had drop out of 22% and 47% cases from yoga and ayurveda groups respectively and yet claimed significant improvement compared to wait-list controls, who had 13% drop outs. And one wonders how the pilot study on the impact of yoga and pranayam on obesity, hypertension, blood sugar, and cholesterol  ever got published as the authors themselves have admitted that there were ‘several drawbacks, short comings’, that it was not controlled, that the ‘glucometer was malfunctioning'(!?), that the ‘measurements were done at 6-7 days’ (and yet showed significant weight loss and other benefits (?!), that ‘it was not known whether they were sustained’ and that the ‘weight loss could also be due to dietary modification’ etc. Other samples of ‘research’ by Ramdev and his ‘disciples’ are also of similar quality [41,42] and if these can be called as ‘research’, anything else shall pass.
Research on Sudarshan Kriya
Some pilot studies have been reported on the benefits of Sudarshan Kriya of Ravishankar and almost all authors have recommended larger, randomised, controlled studies with robust design to confirm the findings.  However, the Art of Living Foundation proclaims that independent medical research has demonstrated significant benefits of these programmes and this explains why the workshops taught by the Art of Living are such a rage the world over!
Marian Garfinkel, Director at BKS Iyengar Yoga Studio of Philadelphia, PA, USA feels that most alternative therapies have not been evaluated using clinically controlled trials and that as a result, a National Institutes of Health expert panel concluded that current evidence is inadequate for the development of high quality trials. Quoting Fontanarosa and Lundberg  that ‘some advocates of alternative medicine argue that many alternative therapies cannot be subjected to the standard scientific method and thus, instead must rely on anecdotes, beliefs, theories, testimonials, and opinions to support effectiveness and justify continued use,’ he asserts that the lack of complete studies and the lack of evidence on safety and outcomes are unacceptable and additional research should be completed. He feels that as yoga and other alternative therapies are difficult to evaluate, these investigations should not simply assess symptomatic relief but must take advantage of modern research techniques and look at objective effects on cells and organs.
Why do we then have to believe the claims that yoga is a tonic for each and every problem of mankind?
Is Yoga Safe?
On the one hand, most of the published studies on yoga do not provide much information on the adverse outcomes and some of them have had high drop outs for unexplained reasons. On the other, there are several reports to show that the practice of yoga can result in complications, from simple headache to severe, irreversible neurological damage. The Consumer Product Safety Commission of the US reported over 13,000 cases treated for yoga-related injuries in an emergency room or a doctor’s office in three years.[47,48] Cases of musculoskeletal injuries and fractures[49-52] (even among yoga teachers), stroke [53-55], cervical spinal cord injury, foot drop, pneumothorax, subcutaneous and mediastinal emphysema, rectus sheath hematoma, dental erosion, increased intraocular pressure and glaucoma[62-66], fatal air embolism etc., have been reported.
It is an accepted fact that injuries do occur while practicing yoga. These have been blamed on the too ambitious participants who try to force their bodies into positions they are not ready for or who are inattentive to the ‘messages of their bodies or instructors’ or on failure of the instructors to give proper modifications. Muscular injuries like pulled hamstrings are said to be commonly seen in yoga classes, strains of the hip flexors, the neck and the low back are also said to be common. Certain yoga postures can place a lot of stress on bursae in the shoulders, elbows and wrists and overuse can lead to bursitis or tendinitis around the shoulder or elbow, exacerbate carpal tunnel syndrome or produce wrist strain. Hyperextension of the knees or elbows may cause tear or pinch of the menisci, ligaments or the joint cartilage. Herniation, fractures and degeneration of intervertebral discs are some of the more serious yoga injuries.
In a survey of musculoskeletal injury among 110 Ashtanga Vinyasa yoga practitioners, a total of 107 musculoskeletal injuries were reported and 68 practitioners (62%) reported having had at least one injury lasting longer than one month, and some practitioners reported more than one injury. The rate of new practice-related injuries was 1.18 injuries per 1,000 hours of practice. If recurrence of pre-existing injury and non-specific low back pain of unknown origin were included, the injury rate became 1.45 injuries per 1,000 hours of practice. The three most common injury locations were hamstring, knee, and low back.
A case of a fracture separation of the epiphyseal plate of the distal tibia in a 15-year-old girl during the execution of a yoga posture has been reported, raising concerns about the safety of yoga in growing children.
When a 14 year old boy died at a yoga camp organised by Baba Ramdev, the self-styled yoga guru initially refuted it to be due to yoga, only to turn around the very next day to caution his followers to be careful with the practice of yoga!
The fact that yoga may not be safe is acknowledged by many who have expertise in yoga. According to Vijai P. Sharma, PhD, of the Behavioral Medicine Center, Cleveland, TN, slow-breathing pranayama, including techniques such as bhramari, shitali, sitkari, or nadi shodhana, pose relatively low health risks as long as the practitioner employs steady attention, patience, discipline, and, above all, does not exceed his or her comfortable capacity. But kapalabhati and bhastrika, both rapid breathing techniques, (extensively mass propagated by Ramdev and Ravishankar respectively) pose greater risk. He cautions that some practitioners seem to throw all caution to the wind in their enthusiasm for pumping their breath faster and faster, thereby increasing the risk of hyperventilation. Furthermore, he says, indiscriminant practice of kapalabhati and bhastrika may reinforce or worsen preexisting structural or functional problems and excessively strain the cardiopulmonary system. Cautioning that rapid breathing pranayama techniques may aggravate a pre-existing structural or medical condition, or cause significant pain and discomfort, he suggests to avoid practicing kapalabhati and bhastrika in conditions such as lung disease, pregnancy, recent unhealed surgeries, especially of head, neck, and trunk, significant degree of scoliosis, low or high blood pressure, diabetes, kidney disease, seizures/epilepsy, ear, nose, or eye diseases, chronic head pain, migraine, or cluster headaches etc., (what is left?!). Unless practitioners exercise out-of-the-ordinary patience and self-control, he says, rapid breathing techniques such as kapalabhati and bhastrika are likely to be performed incorrectly and prove harmful in the long run.
Marian Garfinkel  feels that if performed incorrectly, asanas can be injurious and exacerbate the problem being treated. According to him, it is critical to know how to begin yoga for treatment. As all yoga is not the same, the wide variation among teachers and practitioners who offer yoga-based approaches to treatment can confuse both physician and patient and picking a yoga teacher may be more difficult than picking a physician. He also cautions that many Western-oriented presentations about yoga that exaggerate and make extravagant, inappropriate claims should be viewed with caution.
Is Yoga Necessary?
Considering the above, the following are clear:
- The practice of yoga was developed by the sages and yogis in ancient India who meditated rigorously and led a punishing life. The need and applicability of these practices in the day-today life of commoners of the present day is unclear.
- Today, there are several schools of ‘yoga’ that claim to offer the benefits of the Ancient Indian Yoga. Many of them have modified, simplified, renamed or repackaged the original practices mentioned in the Yoga Sutras of Patanjali or the Hatha yoga Pradipika. The basis of such modifications remain unclear and it is also not clear whether these modern versions have whatever utility that the ancient yoga practices had. David Shapiro, PhD of Geffen School of Medicine, University of California, Los Angeles, a long time academic researcher and teacher, and an Iyengar Yoga practitioner for more than ten years, feels that the diversity of Yoga schools, methods, and theories is a serious complication.
- The many studies that have been published have used different yogic practices in different settings in different patient groups, selected on differing criteria. All the meta analysis and reviews of the published research have concluded that most of these studies are of poor quality and not standardised. Therefore, it is not possible to arrive at any sweeping conclusions about the utility or adverse effects of yoga based on these studies.
- Many studies on yoga have had very high drop out rates, as high as 50%, with no mention made about adverse outcomes or reasons for drop outs and many studies are silent on complications and adverse outcomes. On the other, there are many case reports of serious complications from yoga and some practitioners and experts of yoga advise caution in the practice of yoga.
- All studies of yoga in children are small, short and open without any details on adverse outcomes and no studies are available in very young children. Absence of data on the safety of yoga in children and reports such as a case of epiphyseal fracture separation in a 15 year old girl should alert us to be cautious. In addition, there are several restrictions regarding food, dress and time of practicing yoga, making it almost impossible for kids to perform yoga at school. Also, several yoga practices are restricted during menstruation and hence complusory yoga tarining in schools may be awkward and embarrassing for girls and their parents.
It is therefore reasonable to suggest the following:
- Yoga may have limited use on individual basis, and the type of yoga or its asanas etc., should be carefully chosen on the basis of the individual’s health status and needs, in due consultation with the treating doctor and well trained yoga therapist, choosing whom may be a daunting task..
- Sweeping statements that yoga is effective for all, in all ages, for all diseases and that it is totally safe are not supported by evidence and the practice of yoga on the basis of such belief may not be advisable.
- There is no data on safety of yoga in young children. Diseases like congenital heart disease, childhood asthma, deformities of the joints and especially the spine, may pose risk among kids.
- Therefore, practice of yoga in mass sessions or in front of the TV or in school premises, without proper evaluation of the subject and proper interaction with the trained yoga therapist may not be useful and may be even risky.
- Therefore, compulsory yoga education for students by physical education teachers from class 1, as is being planned by many states and even the Central government of India, is not desirable under any circumstances.
- Breath of Life Available at http://www.artofliving.org/Programmes/
- Sudarshan Kriya : How The Magic Unfolds. Available at http://www.tehelka.com/story_main16.asp
- Pranayama. Available at http://knowyoga.org/tiki-index.php?page=Pranayama
- Art of Living Practice of Sudarshan Kriya. Available at http://www.pranajournal.com/kriya.htm
- Baba Ramdev bats for minister on ventilator. Available at
- Yoga to be mandatory in schools. Available at
- Off to a good start. Available at
- Khalsa SB. Yoga as a therapeutic intervention: a bibliometric analysis of published research studies. Indian J Physiol Pharmacol. 2004 Jul;48(3):269-85. Abstract at http://www.ncbi.nlm.nih.gov/pubmed/15648399
- Ospina MB, Bond K, Karkhaneh M et al. Meditation Practices for Health: State of the Research. AHRQ Publication No. 07-E010. June 2007. Available at http://www.ahrq.gov/downloads/pub/evidence
- Innes KE, Bourguignon C, Taylor AG. Risk Indices Associated with the Insulin Resistance Syndrome, Cardiovascular Disease, and Possible Protection with Yoga: A Systematic Review. The Journal of the American Board of Family Practice. 2005;18:491-519 Available at http://www.jabfm.org/cgi/reprint/18/6/491
- Innes KE, Vincent HK. The Influence of Yoga-Based Programs on Risk Profiles in Adults with Type 2 Diabetes Mellitus: A Systematic Review. eCAM 2007 4(4):469-486; doi:10.1093/ecam/nel103 Available at http://ecam.oxfordjournals.org/cgi/reprint/4/4/469
- Yang K. A Review of Yoga Programs for Four Leading Risk Factors of Chronic Diseases. eCAM, doi:10.1093/ecam/nem154. Available at http://ecam.oxfordjournals.org/cgi/reprint/nem154v1
- Aljasir B, Bryson M, Al-shehri B. Yoga Practice for the Management of Type II Diabetes Mellitus in Adults: A systematic review. eCAM, doi:10.1093/ecam/nen027 Available at http://ecam.oxfordjournals.org/cgi/reprint/nen027v1
- Alexander GK, Taylor AG, Innes KE, Pamela K, Selfe TK. Contextualizing the Effects of Yoga Therapy on Diabetes Management: A Review of the Social Determinants of Physical Activity. Family & Community Health. July/September 2008;31(3):228-239. Abstract at http://www.familyandcommunityhealth.com/
- Smith KB, Pukall CF. An evidence-based review of yoga as a complementary intervention for patients with cancer. Psycho-Oncology. 2008 Sep 26 http://www3.interscience.wiley.com/journal/121410881/abstract
- Dosh SA. The Treatment of Adults with Essential Hypertension.The Journal of Family Practice January 2002;51(1):74-79 Available at http://www.jfponline.com
- Yardi N. Yoga for control of epilepsy. Seizure. 2001;10(1):7-12. http://linkinghub.elsevier.com/
- Ramaratnam S, Sridharan K. Yoga for epilepsy. Cochrane Database of Systematic Reviews. 2002,
Issue 1. Art. No.: CD001524. DOI: 10.1002/14651858.CD001524. Available at http://mrw.interscience.wiley.com/cochrane/
- Pilkington K, Kirkwood G, Rampes H, Richardson J. Yoga for depression: The research evidence. Journal of Affective Disorders. December 2005;89(1-3):13-24 Abstract at http://www.sciencedirect.com/
- Jorm AF, Christensen H, Griffiths KM, Rodgers B. Effectiveness of complementary and self-help treatments for depression. MJA 2002;176:S84–S96. Available at http://www.mja.com.au/
- Kirkwood G, Rampes H, Tuffrey V, Richardson J, Pilkington K. Yoga for anxiety: a systematic review of the research evidence. British Journal Of Sports Medicine. December 2005;39(12):884-891. Available at
- Krisanaprakornkit T, Krisanaprakornkit W, Piyavhatkul N, Laopaiboon M. Meditation therapy for anxiety disorders. Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD004998. DOI: 10.1002/14651858.CD004998.pub2. Available at http://mrw.interscience.wiley.com/cochrane/
- Ernst E. Complementary/Alternative Medicine for Asthma: We Do Not Know What We Need To Know. CHEST. January 1999;115(1):1-3 Available at http://www.chestjournal.org/content/115/1/1.full
- Thomas, M. Breathing exercises and asthma. THORAX. August 2003;58(8):649-650 Available at http://pt.wkhealth.com/
- Holloway EA, Lasserson TJ. Breathing exercises for asthma. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD001277. DOI: 10.1002/14651858.CD001277.pub2. http://mrw.interscience.wiley.com/cochrane/
- Ritz T. Relaxation Therapy in Adult Asthma: Is There New Evidence for Its Effectiveness? Behavior Modification 2001;25(4):640-666. Available at http://bmo.sagepub.com/cgi/content/abstract/25/4/640
- DJ Lane, TV Lane. Alternative and complementary medicine for asthma. Thorax 1991;46:787-797. Available at http://www.pubmedcentral.nih.gov/
- Steurer-Stey C, Russi EW, Steurer J. Complementary and alternative medicine in asthma – do they work? A summary and appraisal of published evidence Swiss Med Wkly 2002;132:338–344 Available at http://www.smw.ch/docs/
- Morone NE, Greco CM. Mind-body interventions for chronic pain in older adults: a structured review. Pain Med. 2007 May-Jun;8(4):359-75 http://www.ncbi.nlm.nih.gov/pubmed/
- Galantino, ML, Galbavy R, Quinn L. Therapeutic Effects of Yoga for Children: A Systematic Review of the Literature. Pediatric Physical Therapy. 2008;20(1):66-80. Available at
- Srinivasan N, Baijal S. Concentrative meditation enhances preattentive processing: a mismatch negativity study. Neuroreport. 2007 Oct 29;18(16):1709-12.
- Joshi M, Telles S. Immediate effects of right and left nostril breathing on verbal and spatial scores. Indian J Physiol Pharmacol. 2008 Apr-Jun;52(2):197-200.
- Manjunath NK, Telles S. Spatial and verbal memory test scores following yoga and fine arts camps for school children. Indian J Physiol Pharmacol. 2004 Jul;48(3):353-6.
- Naveen KV, Nagarathna R, Nagendra HR, Telles S. Yoga breathing through a particular nostril increases spatial memory scores without lateralized effects. Psychol Rep. 1997 Oct;81(2):555-61.
- Madden DJ, Blumenthal JA, Allen PA, Emery CF. Improving aerobic capacity in healthy older adults does not necessarily lead to improved cognitive performance. Psychol Aging. 1989 Sep;4(3):307-20.
- Kimbrough S, Balkin R, Rancich A. The Effect of Inverted Yoga Positions on Short-term Memory. The Online Journal of Sport Psychology. 2007;9(2):34-42 Available at http://www.athleticinsight.com/Vol9Iss2/YogaPDF.pdf
- Krishnamurthy M, Telles S. Effects of Yoga and an Ayurveda preparation on gait, balance and mobility in older persons. Med Sci Monit 2007;13(12). Available at
- Gokal R, Shillito L, Swami Ramdevji Maharaj. Pilot study on the impact of yoga and pranayam on obesity, hypertension, blood sugar, and cholesterol. The Journal of Alternative and Complementary Medicine. December 1, 2007, 13(10): 1056-1058. Available at http://www.liebertonline.com/doi/abs/10.1089/acm.2007.0679
- Deshpande PB. Improve health and reduce healthcare costs from Pranayam with six sigma. Available at http://www.sixsigmaquality.com
- Past Research (2003-2007) at http://www.divyayoga.com/RandD.htm
- Published research. Available at http://www.aolresearch.org/pubresearch.html
- Garfinkel M. Yoga as a Complementary Therapy. Geriatrics Aging. 2006;9(3):190-194.
Available at http://www.medscape.com/viewarticle/525187_1
- Fontanarosa P, Lundberg G. Alternative medicine meets science. JAMA 1998;280:1618-9.
- Paul P. When Yoga Hurts. Time. Oct. 04, 2007. Available at http://www.time.com/time/magazine/article/0,9171,1668470,00.html
- Perrine JW. Bad karma: When yoga harms instead of heals: Inexperienced teachers and overeager students behind rise in injuries. Available at
- Mikkonen J, Pedersen P, McCarthy PW. A Survey of Musculoskeletal Injury among Ashtanga Vinyasa Yoga Practitioners. International Journal of Yoga Therapy 2008;18(1):59-64 Available at
- Platts-Mills TF, Burg MD, Pollack ZT. Calcaneal avulsion fracture. Emergency Medicine Journal 2007;24:231
- Bianchi G, Cavenago C, Marchese M. Can the practice of yoga be dangerous? Considerations over a case of epiphyseal separation of the distal tibia in a teenager. Journal of Orthopaedics and Traumatology. 2004;5(3):188-190. Available at
- Goodall EY. Preventing & Healing Injury in Asana: Acetabular Labral Tears. Yoga Therapy in Practice August 2006;2(3):16-17 Available at http://www.iayt.org/publications_Vx2/ytip/aug06/Goodall0806.pdf
- Nagler W. Vertebral artery obstruction by hyperextension of the neck. Arch Phys Med Rehabil 1973;54:237-240
- Hanus SH, Homer TD, Harter DH. Vertebral artery occlusion complicating yoga exercises. Arch Neurol 1977;4:574-575
- Russell WR. Yoga and the vertebral arteries. Br Med J [Clin Res] 1972;1:685
- Sethi PK, Batra A, Sethi NK, Torgovnick J, Tortolani E. Compressive Cervical Myelopathy Due To Sirsasana, A Yoga Posture: A Case Report: The Internet Journal of Neurology 2007; 6(1): http://www.ispub.com/ostia/index.php
- Chusid J. Yoga foot drop. JAMA. 1971;217:827-828.
- Johnson DB, Tierney MJ, Sadighi PJ. Kapalabhati Pranayama: Breath of Fire or Cause of Pneumothorax? A Case Report. CHEST May 2004;125(5):1951-1952 Available at
- Kashyap AS, Anand KP, Kashyap S. Complications of yoga. Emergency Medicine Journal 2007;24:231; doi:10.1136/emj.2006.036459
- Sharma H, Shekhawat NS, Bhandari S, Memon B, Memon MA. Rectus sheath haematoma: a rare presentation of non-contact strenuous exercises. British Journal Of Sports Medicine. October 2007;41(10):688-690 Available at http://pt.wkhealth.com/pt/
- Meshramkar R, Patil SB, Patil NP. A case report of patient practising yoga leading to dental erosion. International Dental Journal 2007;57(3s1):184-186
- Baskaran M, Raman K, Ramani K, Roy J, Vijaya L, Badrinath S. Intraocular Pressure Changes and Ocular Biometry during Sirsasana (Headstand Posture) in Yoga Practitioners. Ophthalmology 113(8):1327-1332. Available at
- Fahmy JA, Fledelius H. Yoga-induced attacks of acute glaucoma. A case report. Acta Ophthalmol (Copenh). 1973;51(1):80-4.
- Gallardo MJ, Aggarwal N, Cavanagh HD, Whitson JT. Progression of glaucoma associated with the Sirsasana (headstand) yoga posture Advances in Therapy. 2006;23(6):921-925 Available at http://www.springerlink.com/content/7028026506g54887/
- Monteiro de Barros DS, Bazzaz S, Gheith ME, Siam GA, Moster MR. Progressive Optic Neuropathy in Congenital Glaucoma Associated With the Sirsasana Yoga Posture Ophthalmic Surg Lasers Imaging 2008;39:339-340 Available at http://osli.com/showAbst.asp?thing=17763
- Bertschinger DR, Mendrinos E, Dosso A. Yoga can be dangerous-glaucomatous visual field defect worsening due to postural yoga. British Journal of Ophthalmology. 2007;91(10):1413-1414
- Corrigan GE. Fatal air embolism after Yoga breathing exercises. JAMA. 1969 Dec 8;210(10):1923
- Crews L. Injury prevention: Yoga IDEA Fitness Journal Feb 2006 p56
- Mishra A. Boy, 14, dies at Ramdev’s yoga camp 4 Jan 2007. Available at
- Mishra A. Don’t overdo yoga, warns Ramdev 5 Jan 2007. Available at
- Sharma VP. Yoga Therapy in Practice: Pranayama Can Be Practiced Safely International Journal of Yoga Therapy 2007;17:75-79
- David Shapiro. Is the Yoga World Ready? An Academic Perspective. International Journal of Yoga Therapy 2006;16:7-8