Rajiv Gandhi University of Health Sciences s33

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA.

ANNEXURE II PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1 Name of the Candidate ADHIA NIKUNJ BHARATKUMAR And Address SRINIVAS COLLEGE OF PHYSIOTHERAPY AND REAEARCH CENTER,PANDESHWARA, MANGALORE-575001 2 Name of the Institute SRINIVAS COLLEGE OF PHYSIOTHERAPY AND RESEARCH CENTER, MANGALORE. 3 Course of Study and Master of Physiotherapy (MPT) Subject 2 years Degree Course. “Musculoskeletal Disorders & Sports”

4 Date of Admission 07/05/2009 To Course 5 Title of the Topic “ A Study to Find The Influence of Yogasana Practice on Balance and To Investigate The Prevalence of Musculoskeletal Injuries Among The Yoga Practitioners.”

1 6. Brief resume of the intended work: 6.1 Need for the study:

Balance or Postural Stability can be defined as the ability to control the center of gravity (COG) over the base of support (BOS), in a given sensory environment. Ability to maintain posture in standing or sitting is defined as static balance. Whereas the ability to maintain postural control during activities such as, reaching out for an object or walking is defined as dynamic balance1. Most reliable and valid method for measuring postural control involves using force plate to record an individual’s centre of pressure (COP) in standing position during a period of time2. It is estimated that one third to one half of the population over 65 years presents some problems with balance control, as shown in literature3. Since small balance impairment is a consequence of natural aging process, several studies showed that body sway increases with age. These studies show linear decline in balance ability as the age increases4,5. As the age advances, changes in the musculoskeletal, sensory and neural system (motor control) can begin to affect mobility. It is imperative that these systems work together to maintain a system of balance, especially as the body ages these system decline in function6. Thus the age related balance deficits may cause falls which are the commonest cause of injury related death7 or in one thirds of the cases8, fear of fall may develop which had an increased risk of falling, reduced activities of daily living, lower quality of life and increased institutionalisation9.

Hatha yoga is commonly practised yoga approach and is comprised of three aspects which are integrated with one another including (1) asanas or physical postures, (2) pranayama or breathing exercises and (3) meditation or relaxation10. On other hand Asthanga yoga consisted on eight-fold path includes: attitudes toward others/restraints (yamas), rituals/self observances

2 (niyamas), physical practice of postures (asana), breathing practice (pranayama), withdrawal of the senses (pratyahara), concentration (dharana), meditation (dhyana), state of enlightenment (Samadhi)11. The postures, practiced in yoga, are designed to increase flexibility and strengthen the body in a controlled fashion as well as improve balance. These poses are performed standing, sitting, reclining, or inverted and may involve forward bends, backward bends, twists, or balancing12. Breathing exercises link the postures together and help the mind focus. Any yoga session typically starts with the ‘Suryanamaskara’ (Sun Salutation) which is the kind of warm-up at the start of yoga session. The sequence consists of 10 postures set in a dynamic form, performed in a single, conscious and graceful flow performed with synchronized breathing. The postures ingeniously combine forward-bending poses countered with backward-bending ones13. Then different asanas are performed. It concludes with a short meditation session during which the participant lies supine with eyes closed while shifting attention inwardly to create a relaxed state of being. A yoga session typically last for 60–90 min12. A number of studies exist on the efficacy of yogasana. These include reduction of pain and improvement of dynamic muscular strength14 and flexibility in spectrum of musculoskeletal disorders,15-19 gait20, balance and co- ordination21, ankle flexibility and increased both isokinetic and isometric muscle strength and improved joint flexibility22. Numerous asanas or postures like vrikshasana, trikonasana, ardhachandrasana, konasana etc. are related with standing posture and derived position of standing which can have a substantial effect and can influence the balance or dynamic postural control of an individual. Further it is imperative to assess and document the type of asana (posture), duration of yoga practice per day, days per week and total year of practice and their association with balance. This may provide lucid information on relationship between types of asanas closely related to balance improvement. Hence a questionnaire will be

3 prepared to evaluate the above parameters on the yoga practitioner recruited in this study and correlated with the outcomes of balance. None of the study typically assessed the effect of yogasana on balance in normal healthy yoga practitioners. A good knowledge of the effect of yogasanas on the stability of stance allows to how yogasana practice helps in balance in healthy adults.Thus primarily this study attempts to find the influence of yogasanas on balance in experienced yoga practitioners, beginners and compared to healthy matched individuals those who are not exposed to yoga. There have been fewer studies surveying the musculoskeletal injuries like sprains, strains, aberration occurred by yoga23 but no comprehensive study has been reported in literatures reporting and comparing the incidence and rate (if any) of musculoskeletal injuries between experienced yoga practitioners, beginners with non yoga practitioners. This survey may provide information on long term effects of yoga on musculoskeletal injuries. Energetic and enthusiastic beginners and with non-certified yoga trainers may precipitate the chances of injury among yoga practitioners. Hence the second objective of the study is to survey and compare the rate, location, type and outcome of the injury among experienced yoga practitioners, beginner and compared with the non yoga practitioners through structured questionnaires.

6.2 Review of Literature:

1. Telles S et al. (2009) studied the effect of yoga on musculoskeletal discomfort and motor functions in professional computer users and reported that 1 hour daily 5 days a week can improve bilateral hand grip strength, the right hand tapping speed, and low back and hamstring flexibility compared to the wait list group24.

4 2. Hart CE et al. (2008) explored the effect of yoga on strength steadiness and balance in young adults who performed yoga for 24 yoga sessions in 8 weeks and concluded that for young adults, a short- term yoga program of this type can improve balance substantially, produce modest improvements in leg strength, and improve leg muscle control for less-steady subjects25.

3. Tekur P et al. (2008) assessed a 7 days intensive experimental yoga therapy in a group of chronic low back pain subject and compared it with other group attending physical exercises and reported that the 7 days intensive yoga therapy is more effective in reducing pain related disability and improving spinal mobility as compared to the other group19.

4. Jani Mikkonen et al. (2008) in a survey of musculoskeletal injuries in Ashtang Vinyasa Yoga practitioners found that prevalence of injuries lasted more than 1 month was 62% and most common sites were hamstring, knee, and low back23.

5. Verginia S. et al. (2005) studied the effect of 6 weeks of either ashtang yoga or hatha therapy in 26 healthy adults and found that both the groups showed improved dynamic muscular strength, endurance and flexibility for trunk muscles14.

6. DiBenedetto M et al. (2005) in an exploratory study of 8 weeks duration studied the effect of Iyengar Hatha Yoga program on 19 elderly subject. Their findings suggested that yoga program tailored to elderly adults improved hip extension, increased stride length and decreased anterior pelvic tilt thus improving these indices of gait function20.

5 7. Bastille JV et al. (2004) applied a yoga based rehabilitation protocol including postural and gait training with yoga poses for 8 weeks on 4 post stroke hemi paresis patients and measured the balance with berg balance scale. They reported that there was improvement in the berg balance score at the end of the study21.

8. Greendale GA et al. (2002) experimented effects of yoga on 21 hyperkyphotic women. Though there were no apparent reduction in the hyperkyphosis, majority of the subjects reported increased postural awareness, physical well being and improved physical functioning26.

9. James A. Raub et al. (2002) did a literature review of researches present in the field from 1985 till present and concluded that hatha yoga has an impact of muscular strength and flexibility of an individual27.

10.Tran et at. (2001) in a study of 10 healthy untrained volunteers measured the effects of hatha yoga on various health related aspects of physical fitness. After 8 week of intervention the results reflected improvements in isokinetic muscular strength and trunk flexibility22.

11.Colledge NR et al. (1994) measured postural sway in 4 different age groups by posturography and concluded that postural sway increased linearly with age4.

6.3 Objectives of the study:

6 1. To measure the influence of Yogasanas on the balance among yoga practitioners.

2. To survey and compare the rate, location, type and outcome of the injury among yogasana practitioners compared with the normal healthy individuals.

6.4 Hypothesis:

Experimental hypothesis: There will be influence of Yogasana on the balance among yoga practitioners.

Null hypothesis: There will be no influence of Yogasana on the balance among yoga practitioners.

MATERIALS AND METHODS:

7.1 Source of data: Male and female subjects between the age range of 40-60 years who match the inclusion criteria will be selected in this study. Subjects will be taken from different yoga institutes from mangalore and neighboring towns.

Sampling: Purposive sampling.

Sample size: 40 for balance assessment protocol.

7.2 Method of collection of data:

7 Measurement procedure : Subjects will be recruited from different yoga institutions in mangalore/neighboring towns. In department a written consent (approved by the institution) will be obtained stating voluntary acceptance. All consented subjects will be divided into three groups according to the time duration of their yoga practice. All subjects will be measured for height, weight and general assessment (demographic data). First questionnaire will be given to fill up the subject’s yoga history. The second questionnaire will be obtained regarding musculoskeletal injuries during the time period of yogasana practice. For assessing the balance the Bertec force plate will be used. Subjects will be explained and demonstrated about all the positions on the floor before taking the force plate reading. 7.

Static balance measures: While standing on the force plate Centre Of Pressure (COP) will be measured using following 3 conditions: a) Normal standing with eyes open and eyes closed. b) Tandem standing with eyes open and eyes closed. c) One leg standing only with eyes open. Subject will stand bare foot on the force plate for ten seconds performing each task and the reading will be taken.

Dynamic balance measures: And then Limits Of Stability (LOS) will be measured using Functional Reach Test (FRT). Method for FRT: Subjects will be asked to stand on the force platform with eyes open to put

8 through the following tasks to measure balance: Functional Reach Test for Limits Of Stability: Each subject will be positioned on the force plate, the yard stick will be placed along the subject’s shoulder at the level of acromion. Anatomical Landmark: Head Of the Third Meta-carpal Initial reach distance (D1): Reference line will be drawn on the force plate and subject will be asked to stand erect, keeping his great toe on the reference line. Then subject will be asked to raise the upper extremity parallel to the floor and initial distance (D1) will be measured. Final reach distance (D2): It will be measured after the subject has performed maximal forward reach. 2 practice trials will be allowed followed by 3 measurement trials, the maximum reach distance will be considered for recording.

Materials to be used:  Bertec Force platform  Yoga questionnaires  Pen  Paper  Yard stick

Inclusion Criteria 1. Healthy individuals practicing yogasana less than two years for beginners group. 2. Healthy individuals practicing yogasana more than 5 years for experience group. 3. Healthy individuals those who have not undergone any yoga 9 training non-practitioner group.

Exclusion Criteria 1. Any congenital or acquired musculoskeletal deformity.

2. Any neurological disorders.

3. Any systemic diseases.

4. Pregnancy.

Statistical analysis

Study design: Exploratory/Co-relational study

TEST: chi-square test, ANOVA, correlation coefficients tests

7.3 Does the study require any investigations or interventions to be conducted on patients or other humans or animals? If so please describe briefly. YES. This study intends to Find The Influence of Yogasana Practice on Balance.

7.4 Has ethical clearance been obtained from your institution in case of 7.3? YES. Consent has been taken from institute’s ethical clearance committee.

List of references:

1. Darcy A. Uphrend: Neurological rehabilitation. 4th edition, United

10 States of America. Mosby. Pp. 618-619. 2. Satu P., Pertti E., Markku K., Jaakko K. Timo T., Tiana R.: Force platform balance measures as predictors of indoor and outdoor falls in community-dwelling women aged 63-76 years. The Journals of gerontology series A: Biological Sciences and Medical Sciences 63: 171- 178. 3. Hausdorff JM, Nelson ME, Kaliton D, Layne JE, Bernstein MJ, Nuernberger A, Singh MA: Etiology and modification of gait instability in older adults: a randomized controlled trial of exercise. J Appl Physiol 82:262-269, 2001. 4. Colledge NR, Cantley P, Peaston I, Brash H, Lewis S, Wilson JA: Ageing and balance: the measurement of spontaneous sway by posturography. Gerontology 1994; 40(5):273-278 5. Takuo Fujita, Shoji Nakamura, Mutsumi Ohue, Yoshio Fujii, Akimitsu Miyauchi, Yasuyuki Takagi, Hirofumi Tsugeno: Effect of age on body

sway assessed by computerized posturography: J Bone Miner Metab (2005) 23:152–156. 6. Sarah Clary, Cathleen Barnes, Debra Bemben, Allen Knehans and Michael Bemben: Effects of Ballates, Step aerobics and walking on Balance in women aged 50-75 years. Journal of Sports Science and Medicine (2006) 5, 390-399. 7. Baker SP, Harvey AH: Fall injuries in the elderly, Clin Geriatr Med. 1985 Aug;1(3):501-12. 8. Vellas BJ, Wayne SJ, Romero LJ, Baumgartner RN, Garry PJ: Fear of falling and restriction of mobility in elderly fallers. Age Ageing. 1997 May;26(3):189-93. 9. Cumming RG, Salkeld G, Thomas M, Szonyi G: Prospective study of the impact of fear of falling on activities of daily living, SF-36 scores, and nursing home admission: J Gerontol A Biol Sci Med Sci. 2000 May;55(5):M299-305.

11 10. Garfinkel, M., Schumacher Jr., H.R., 2000. Yoga. Rheumatic Disease Clinics of North America 26 (1), 125–132. 8. 11. Iyengar, B.K.S., 1979. Light on yoga, revised edition. Shocken books, New York. 12. Susan S, Sonja S, Venu A: Yoga and pilates in the management

of low back pain; Curr Rev Musculoskelet Med (2008) 1:39–47. 13. Omkar S.N., Meenakshi M, Debarun D A mathematical model of effects on specific joints during practice of the Sun Salutation e A sequence of yoga postures Journal of Bodywork & Movement Therapies (2009) 1-8. 14. Virginia S. Cowen, Troy B. Adams: Physical and perceptual benefits of yoga asana practice: results of a pilot study; Journal of Bodywork and Movement Therapies (2005) 9, 211–219. 15. Karen J. Sherman, Daniel C. Cherkin, Janet Erro, Diana L. Miglioretti and Richard A. Deyo: Comparing Yoga, Exercise, and a Self-Care Book for Chronic Low Back Pain: A Randomized, Controlled Trial; Annals of Internal Medicine: Volume 143 Number 12; pp:849-856. 16. Kimberly Anne Williamsa, John Petronis, David Smith, David Goodrich, Juan Wu, Neelima Ravi, Edward J. Doyle Jr, R. Gregory Juckett, Maria Munoz Kolar, Richard Gross, Lois Steinberg; Effect of Iyengar yoga therapy for chronic low back pain; Pain 115 (2005) 107– 117. 17. Williams K, Abildso C, Steinberg L, Doyle E, Epstein B, Smith D, Hobbs G, Gross R, Kelley G, Cooper L; Evaluation of the effectiveness and efficacy of Iyengar yoga therapy on chronic low back pain; Spine (Phila Pa 1976). 2009 Sep 1;34(19):2066-76. 18. Saper RB, Sherman KJ, Cullum-Dugan D, Davis RB, Phillips RS, Culpepper L.: Yoga for chronic low back pain in a predominantly minority population: a pilot randomized controlled trial.; Altern Ther Health Med. 2009 Nov-Dec;15(6):18-27. 12 19. Tekur P, Singphow C, Nagendra HR, Raghuram N: Effect of short-term intensive yoga program on pain, functional disability and spinal flexibility in chronic low back pain: a randomized control study; J Altern Complement Med. 2008 Jul;14(6):637-44. 20. Margarete DiBenedetto, Kim E. Innes, Ann G. Taylor, Pamela F. Rodeheaver, Jennifer A. Boxer, H. Jeffrey Wright, D. Casey Kerrigan; Effect of a Gentle Iyengar Yoga Program on Gait in the Elderly: An Exploratory Study; Arch Phys Med Rehabil Vol 86, September 2005. Pp- 1830-1837. 21. Bastille JV, Gill-Body KM: A yoga-based exercise program for people with chronic poststroke hemiparesis; Phys Ther. 2004 Jan;84(1):33-48. 22. Tran MD, Holly RG, Lashbrook J, Amsterdam EA.: Effects of Hatha Yoga Practice on the Health-Related Aspects of Physical Fitness; Prev Cardiol. 2001 Autumn;4(4):165-170. 23. Jani Mikkonen, Palle Pedersen, Peter William McCarthy: A Survey of Musculoskeletal Injury among Ashtanga Vinyasa yoga Practitioners; INTERNATIONAL JOURNAL OF YOGA THERAPY – No. 18 (2008); pp-59-64. 24. Telles S, Dash M, Naveen KV: Effect of yoga on musculoskeletal discomfort and motor functions in professional computer users.; Work. 2009;33(3):297-306. 25. Hart CE, Tracy BL: Yoga as steadiness training: effects on motor variability in young adults.; J Strength Cond Res. 2008 Sep;22(5):1659- 69. 26. Gail A. Greendale, Anna McDivit, Annie Carpenter, Leanne Seeger and Mei-Hua Huang: Yoga for Women With Hyperkyphosis: Results of a Pilot Study; American Journal of Public Health Vol 92, No. 10, October 2002; 1611-1614. 27. James A. Raub: Psychophysiologic Effects of Hatha Yoga on Musculoskeletal and Cardiopulmonary Function: A Literature Review The

13 Journal of Alternative and Complementary Medicine. December 2002, 8(6): 797-812

14 9 Signature of the Candidate

10 Remarks of the Guide

11 Name & Designation of:

11.1 Guide DR. RAMPRASAD M. Associate professor in physiotherapy and Principal

11.2 Signature

11.3 Co-Guide (If Any) DR. PURUSOTHAM CHIPPALA Assistant professor in physiotherapy

11.4 Signature

DR. T.JOSELEY SUNDERRAJ 11.5 Head of the Department PANDIAN Associate Professor in Physiotherapy and P.G. Coordinator 11.6 Signature

12 12.1 Remarks of Chairman and DR. RAMPRASAD M. Principal Associate professor in physiotherapy and Principal

12.2 Signature