MEDICAL EDUCATION ONLINE

2024, VOL. 29, 2364486

https://doi.org/10.1080/10872981.2024.2364486

HUMANITIES IN MEDICAL EDUCATION

The psychosomatic impact of Yoga in medical education: a systematic review

and meta-analysis
Sabyasachi Maitya, Raman Abbaspourb, Stephan Bandelowa, Sehaj Pahwac, Taraneh Alahdadic, Sharan Shahc,
Praghosh Chhetrid, Ameet Kumar Jhae, Shreya Nauhriaf, Reetuparna Nathg, Narendra Nayakh
and Samal Nauhria i
a
Department of Physiology, Neuroscience, and Behavioral Sciences, St. George’s University School of Medicine, True Blue, Grenada;
b
Department of Electrical Engineering and Computer Science, York University, Toronto, Canada; cMedical Student Research Institute,
St. George’s University School of Medicine, True Blue, Grenada; dDepartment of Physiology, St. Matthew’s University School of Medicine,
Georgetown, Cayman Islands; eDepartment of Anatomical Sciences, St. Matthew’s University School of Medicine, Georgetown, Cayman
Islands; fDepartment of Child Protection, Cayman Islands Red Cross, Georgetown, Cayman Islands; gDepartment of Education Service,
St. George’s University School of Medicine, True Blue, Grenada; hDepartment of Microbiology, St. Matthew’s University School of
Medicine, Georgetown, Cayman Islands; iDepartment of Pathology, St. Matthew’s University School of Medicine, Georgetown, Cayman
Islands

ABSTRACT ARTICLE HISTORY

Non-clinical approaches such as meditation, yoga, and mindfulness are popular traditional Received 21 August 2023
therapeutical interventions adopted by many educational institutions to improve the physical Revised 31 May 2024
and mental well-being of learners. This study aimed to evaluate the effectiveness of yoga Accepted 31 May 2024
intervention in improving cardiopulmonary parameters such as blood pressure, heart rate, KEYWORDS
pulmonary function tests and psychosomatic symptoms such as depression, anxiety and Yoga; medical student;
stress in medical and dental students. Using the PRISMA protocol, a search from databases systematic review; medical
such as PubMed, Scopus, and Embase resulted in 304 relevant articles. After screening the education; meta-analysis;
title and abstracts, 47 papers were analyzed thoroughly and included in the qualitative physiology; Anxiety; stress;
analysis. 18 articles with homogenous statistical data on physiology and psychological para­ academic performance
meters were included for meta-analysis. In comparison to the control group, the study
showed a significant reduction of systolic blood pressure (SBP: 6.82 mmHg, z = -3.06,
p = 0.002), diastolic blood pressure (DBP: 2.92 mmHg, z = -2.22, p = 0.03), and heart rate
(HR: 2.55 beats/min, z = -2.77, p = 0.006). Additionally, data from 4 studies yielded
a significant overall effect of a stress reduction of 0.77 on standardized assessments due to
the yoga intervention (z = 5.29, p < 0.0001). Lastly, the results also showed a significant (z
= -2.52, p = 0.01) reduction of 1.2 in standardized anxiety tests in intervention group com­
pared to the control. The findings offer promising prospects for medical educators globally,
encouraging them to consider reformation and policymaking in medical curricula to enhance
academic success and improve the overall quality of life for medical students worldwide.

Introduction stress reduction, as they modulate sympathetic-vagal

balance [5]. Implementing mind-body physical activ­
Yoga, an ancient practice promoting holistic well-
ity, including yoga, in educational settings signifi­
being, has gained global popularity for its integration
cantly improves stress-related physiological health
of body, mind, and breath [1]. It offers health bene­
markers in students [6]. Self-care interventions, such
fits, stress reduction, and improved quality of life,
aligning tradition with modern needs [2]. Yoga’s sig­ as stress management courses and mind-body tech­
nificance in modern times stems from its compre­ niques like yoga and meditation, effectively reduce
hensive approach to health and wellness, positively perceived stress in graduate students, empowering
impacting physical fitness, mental clarity, stress them to manage stress in their future healthcare
reduction, emotional regulation, self-awareness, and roles [7]. Incorporating appropriate aerobic exercise,
overall well-being [2,3]. Activity- and occupation- including yoga, alleviates anxiety and enhances over­
based interventions like sports and yoga effectively all physical and mental health [8].
address mental health, behavior, and social participa­ Medical students face significant challenges and
tion concerns in children and youth [4]. Mind-body pressures in today’s demanding world, resulting in
exercises like yoga can be effective alternatives for high stress levels, burnout, and reduced well-being

CONTACT Samal Nauhria [email protected] Department of Pathology, St. Matthew’s University School of Medicine, Georgetown,
Cayman Islands

All authors contributed equally and share the first co- authorship.
© 2024 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The terms on which this article has been published allow the
posting of the Accepted Manuscript in a repository by the author(s) or with their consent.
2 S. MAITY ET AL.

[9,10]. Recognizing the importance of addressing search terms included ‘yoga,’ ‘medical students’ and ‘den­
these issues, integrating yoga practices into medical tal student’ including all subheadings.
education has emerged as a potential solution to
promote students’ health and well-being [11].
Selection of studies
Horiuchi et al. found that yoga benefits medical
students and recommend its integration into aca­ Three reviewers (SS, SP and TA) independently eval­
demic health centers, fostering student wellness and uated the papers retrieved based on their titles and
empowering future physicians [11]. Yoga offers var­ abstracts. To be included for a detailed examination,
ious benefits to medical students, improving physical the relevant papers had to meet the following criteria.
well-being, preventing musculoskeletal issues, redu­ They reported data on the prevalence, impact of yoga
cing stress, and enhancing focus and emotional resi­ intervention or practice in medical or dental students
lience [12]. Yoga interventions present cost-effective at the undergraduate level and conducted in any
options for stress reduction and musculoskeletal geographic location. All types of studies, both quali­
pain relief [13]. Yoga techniques and mind-body tative and quantitative study designs, including cross-
medicine consistently reduce stress and burnout in sectional and cohort-based designs, were considered.
healthcare workers exposed to heavy workloads and Non-peer-reviewed materials such as editorials, let­
high stress levels [14]. ters, commentaries, incomplete data, reviews, confer­
While supported by various studies and anecdotal ence posters, preprints, and dissertations were
evidence, conducting a comprehensive meta-analysis excluded from the analysis. Any uncertainties or dis­
will provide a rigorous evaluation of the impact of yoga agreements regarding study selection were resolved
on medical students’ well-being and academic perfor­ through consensus among the reviewers.
mance. This meta-analysis aims to systematically review
the literature on the impact of yoga practices on medical
Data extraction
students’ physical and psychological well-being. This
paper reviews the evidence that the yoga leads to The data extraction process involved reviewer (RA,
improvement of blood pressure (BP), heart rate (HR), SM) gathering relevant information, which was then
stress and anxiety levels, academic performance, and crosschecked by other researchers (AJ, SB). An Excel
overall quality of life. Thus, contributing to sheet was used to record details such as author
a comprehensive understanding of the potential benefits names, publication year, geographical location, study
and implications of integrating yoga into medical educa­ duration, age range of participants, sample size, Yoga
tion [11]. Ultimately, this study aims to guide educators, intervention type, and reported benefits of yoga for
administrators, and policymakers in implementing effec­ each eligible study. In case of incomplete data or
tive interventions for the well-being of medical students unclear aspects, attempts were made to contact the
in the contemporary educational landscape. original study authors for clarification. Any discre­
pancies or disagreements among the reviewers was
resolved through consensus and discussion with
another reviewer (SN).
Methods
Search strategy Within-group mean difference variance estimates
Preferred Reporting Items for Systematic Reviews and The effect estimates for all outcomes are based on the
Meta-Analyses (PRISMA) and Meta-Analysis of difference between change over time in the interven­
Observational Studies in Epidemiology (MOOSE) proto­ tion group compared to the same change in the con­
cols were followed by the researchers [15,16]. The proto­ trol group. Accordingly, only studies that include
col used in this study was registered in International control groups are included in the quantitative meta-
prospective register of systematic reviews (PROSPERO), analysis. We also list intervention effects found in
the Center for Reviews and Dissemination, University of studies that did not include control groups in the
York (CRD42023429107) prior to the commencement of forest plots, since the consistency and direction of
the project. intervention effects is relevant to the conclusions,
Published studies were searched in electronic data­ but these studies are not included in the overall effect
bases namely, PubMed (US National Library of estimates of the meta-analysis.
Medicine, National Institutes of Health), Scopus, Change over time within each treatment group was
Embase, and google scholar for potentially relevant stu­ presented in virtually all included studies as the out­
dies from inception up to December 2022. Articles pub­ come measure means and standard deviations in each
lished in English from selected databases were included group, before and after intervention. However, the
only. The authors agreed among themselves on the final meta-analysis requires the mean difference per group
search strategy. The medical subject headings (MeSH) over time, and its standard deviation between the two
 MEDICAL EDUCATION ONLINE 3

time points. The mean difference is easily calculated by Statistical analyses

subtracting the group means at time 1 from time 2, but
All analyses were carried out in R version 4.3.0, using
the standard deviation (SD) of this difference score is
package ‘meta’ for the meta-analyses, forest and fun­
more difficult to estimate. In the case of unrelated
nel plots. For the physiological outcomes (cardio-
samples, the SDs could simply be pooled via one of
vascular and lung function) we report the raw mean
the standard pooling methods. However, repeated
differences, because they are inherently meaningful
scores from the same group are related samples,
and easier to interpret than a standardized mean
where one would expect individual scores to correlate
difference. All included studies also used the same
over time, reducing the expected variance compared to
outcome scale for the physiological parameters,
unrelated samples. This within-subject correlation is
e.g., mm Hg for blood pressure or litres for forced
equivalent to the test-retest reliability of each outcome
expiratory volume. However, the psychological out­
measure, which we used to estimate the within-group
come scores rely mostly on questionnaires, which can
variances of the mean difference scores according to
have different scales according to the number of
the well-known formula for the variance of the differ­
included items per domain, and different ranges of
ence between related samples:
the Likert scale for each item. The varying scales
make a 1-point change difficult to interpret, and
impossible to combine without standardization.
Accordingly, effects for the psychological outcomes
are reported as standardized mean differences
Within-subject test-retest correlations for cardio-
(SMD), essentially dividing the raw effect size by the
vascular function parameters were assumed to be
standard deviation, akin to Cohen’s d effect sizes. We
0.95 for heart rate, 0.86 for systolic blood pressure
used Hedges’ g method for SMD estimates through­
(SBP), and 0.85 for diastolic blood pressure (DBP),
out, which includes an additional correction for small
as reported by [17]. Test-retest correlations for lung
sample sizes compared to Cohen’s d.
function parameters were taken from [18], averaged
across the pediatric and adult cohorts.
A correlation of 0.97 was assumed for all lung
Results
function outcomes, except functional vital capacity
(FVC), for which 0.94 was reported. Test-retest Search results and study characteristics
correlations for the 10 item perceived stress scale
In total, our initial search yielded 304 results. This
(PSS) were averaged from all available studies with
includes both database searching and hand search.
1–4 week testing intervals listed in [19], arriving at
After reading the abstracts, 236 were excluded from
an estimate of 0.77. The stress subscale of the 42-
this list. A further 21 were excluded once the entire
items DASS was used to assess perceived stress in
article was thoroughly read. Overall, 47 articles were
one of the included studies, for which [20] report
used for systematic review, a further 18 were included
a test-retest reliability of 0.82. Test-retest correla­
in the meta-analysis. One article with duplicate data
tions for the STAI state anxiety measure [21] range
was removed (Solanki, 2020). Figure 1 shows the
more widely across various populations and re-test
PRISMA chart.
intervals. We averaged estimates from studies with
The exclusion criteria included articles not rele­
retest intervals close to 2 weeks, arriving at an
vant to the objectives of this study, not conducted on
approximate and conservatively estimated test-
medical students, full text not available even after
retest correlation of 0.75 [22]. One study assessed
contacting the authors, study design not an original
anxiety via the DASS anxiety subscale, for which
research and articles where appropriate information
we assumed a retest correlation of 0.86 according
and statistical data was not available. A detailed
to [20].
synthesis of the studies included is provided in
To determine the sensitivity of the reported results
Table 1.
to the test-retest correlation estimates described
The results of this study were categorized into four
above, we repeated all analyses with lower assumed
themes: Knowledge and awareness of yoga, effect of
test-retest correlations, by subtracting 0.2 from the
yoga on physiology, psychology and academia.
r values listed above (i.e., reduction by an absolute
Figure 2 represents the number of articles found in
20%). The resulting r values ranged from 0.55–0.77,
each of these four categories and their subcategory.
at the low end of what would be considered a valid
and reliable test. There was no change in the pattern
of results, all effects that were previously significant
Knowledge and perception of yoga
remained so. Accordingly, the reported results appear
robust even if test-retest correlations were signifi­ How students perceive the effectiveness of yoga could
cantly weaker than those reported in the literature. affect their commitment to this activity. Seven articles
4 S. MAITY ET AL.

Figure 1. PRISMA protocol of literature search process.

focused on the perception, knowledge, and attitude of chosen for the overall effect analysis. The results
students toward yoga. It was determined that more showed significant (z = −2.22, p = 0.03) reduction of
than 90% of students are aware of the benefits of yoga −2.92 mmHg in DBP following in intervention group
[65,65,67,68]. Despite this, on average, less than 20% compared to control. Lastly Figure 3C illustrates the
of students practice yoga regularly [46,47,65,66,68]. effect of Yoga on HR. The six included studies
The main barriers in practicing yoga were time man­ involved 345 and 308 participants in the intervention
agement, lack of motivation, and laziness [66,67]. and control group respectively. The random effects
Overall, one study found that 95% of participants model was chosen for the overall effect analysis
wish to practice yoga following the study [43]. because of a high variance (I2 = 96.0%, p < 0.0001).
Another study found that more than 90% of students The analysis showed a that HR significantly decreased
believe yoga should be part of medical school’s curri­ by 2.55 beats/min (z = −2.77, p = 0.006).
culum to help them maintain physical and mental Practice of Yoga has also shown to have
health [65]. a significant effect on the respiration. The top themes
highlighting the effect of Yoga were on tidal volume
(TV), vital capacity (VC), Forced vital capacity
Physiological impact of yoga
(FVC), Forced expiratory volume (FEV1), and peak
Cardiopulmonary Improvement expiratory flow rate (PEFR). While these parameters
Figure 3A summarizes the effects of yoga interven­ do not show a significant change in control group,
tion on SBP. Data from five studies with more than they all show a significant increase after yoga
300 participants in treatment and control groups was [23,25,26,35]. Only Akhani et al., 2019 [25] did not
included, yielding a significant overall effect of a SBP find a significant increase in TV.
reduction of 6.82 mmHg due to the yoga intervention
(z = −3.06, p = 0.002). The random effects model was Other physiological effects
chosen for the overall effect analysis due to the pre­ Besides cardiovascular and respiratory parameters,
sence of significant variance between the included yoga effects other physiological parameters as well. It
studies (I2 = 98.4%, p < 0.0001). Similarly, Figure 3B was found that yoga decreases serum IFN-γ levels [30].
represents the effect of Yoga on DBP. Four studies While serum cortisol levels increase after yoga [30],
with 310 and 275 participants in the intervention and salivary cortisol is shown to decrease [39]. Moreover,
control groups were included. Due to high variance yoga not only significantly reduces PMS symptoms, but
(I2 = 95%, p < 0.0001), the random effects model was it also works better than calcium carbonate [32].
Table 1. Summary of the 47 articles included in this study.
Author Location Population Period of intervention Conclusion
Jahan et al., 2020a [23] Bangladesh 100 medical students (18–20 10 min/day, 4 weeks Yoga significantly improved respiratory parameters
years)
Jahan et al., 2020b [24] Bangladesh 100 medical students (18–20 10 min/day, 4 weeks Yoga led to a decrease in SBP, DBP and HR
years)
Akhani et al., 2019 [25] India 300 medical students > 18 years 6 days/weekly, 4 weeks Yoga improves cardiorespiratory efficiency
Karthik et al., 2014 [26] India 50 medical students (17–19 years) 30 min/day, 2 months Yoga improves pulmonary functions
Pal et al., 2014 [27] India 85 med students 1 h/day, 6 weeks Right nostril breathing increases sympathetic activity.
Left nostril breathing increases parasympathetic activity and promotes cardiovascular health.
Hm et al., 2012 [28] India 60 med students (average 17.2 N/A Better sleep in Yoga groups.
years)
Parshad et al., 2011 [29] N/A 64 med student (21.3 ± 2.6 years) 6 weeks Improves cardiovascular function.
Proposes improvement in stress management (not supported by results)
Gopal et al., 2011 [30] India 60 female medical students (17– 35 mins/day, 12 weeks Yoga decreases physiological, autonomic, endocrine and psychological effects of examination stress.
20 years)
K et al., 2017 [31] India 100 med students (18.16 ± 0.38 90 Days Yoga reduces HR, SBP and DBP
years)
Bharati, 2016 [32] India 58 female med student 1 h/day, 5 day/week, 3 months Yoga reduces PMS symptoms better compared to calcium carbonate
Lakshmi and Vaithianathan, India 30 (18–25 years) 12 weeks Yoga significantly decreases HR and improved aggression
2022 [33]
Chhetri et al., 2020 [34] India 52 male med student (20 Yoga; 20 20 mins No significant change in cardiovascular parameters between Yoga and Meditation groups.
meditation)
Thirupathi and K, 2016 [35] India 60 male med students 45 min daily for 10 weeks Yoga improves lung function
Mehta et al., 2018 [36] India 36 med students 1h daily for 4 weeks Yoga significantly lowers SBP and DBP
Monson et al., 2017 [37] USA 77 Dental students 60 min biweekly for 13 weeks Yoga reduces pain
Hc et al., 2015 [38] India 60 med students Yoga group has been practicing Yoga for 1 year could reduce physiological arousal
yoga for 1 year
Pandey et al., 2016 [39] India 40 med students 1h daily, 3 months Yoga decreases salivary cortisol, which could be used to manage stress
Lee et al., 2022 [40] USA 64 med students 8 yoga sessions Yoga reduced stress while not impacting exam score
Ahlers et al., 2021 [41] USA 53 med students 20 hours of yoga in total Virtual Wellness and Learning Communities program promotes medical student wellness
Nakashima et al., 2020 [42] USA 108 med students 2, 30 min sessions Yoga improves wellbeing, reduces burnout
Waechter et al., 2021 [43] Grenada/USA 44 med students 12 weeks No significant difference between Yoga or control group on stress, anxiety, psychological distress or
academic performance
Nithiya and Palve, 2018 [44] India 250 med students 1 month significant decrease in anxiety, but not stress following yoga
Bansal et al., 2013 [45] India 90 med students 45 min/day, 1 month significant improvement in somatic symptoms, anxiety, social dysfunction, and depression following
yoga.
Prasad et al., 2016 [46] USA 27 med students 6 weeks Yoga reduces stress and increases feelings of peace, focus and endurance
Simard and Henry, 2009 [47] Canada 16 med students 16 weeks Yoga decreases stress and improves general well-being
Shankarapillai et al., 2012 [48] India 100 dental students 1 week Yoga reduces stress
Sunita et al., 2022 [49] India 105 female med students 40 min, 12 weeks Yoga decreases anxiety, depression, and anger while increasing sense of wellbeing
Bond et al., 2013 [50] USA 27 med students Once/week, 11 weeks Yoga increasing self-regulation and self-compassion. While not significant, it decreases perceived stress
while increasing empathy
Erogul et al., 2014 [51] USA 57 med students 20 min/day, 8 week Yoga decreased perceived stress and increased self-compassion
Mehta and Taneja, 2013 [52] India 36 med students 1h/day, 4 weeks Yoga increases general well-being
Kukade and K, 2022 [53] India 64 med students 1 h/day, 3 months Yoga significantly improves happiness, psychological wellbeing, mindfulness, spiritual well-being, and
sleep.
MEDICAL EDUCATION ONLINE

Alire et al., 2020 [54] USA 77 dental students 90 min, for 10 weeks Yoga significantly decreased stress-related symptoms
Singh et al., 2020 [55] N/A 120 female dental students 40 min/day for 4 weeks Yoga reduces stress. But yoga combined with motivational videos has a more substantial effect
(Continued )
5
6 S. MAITY ET AL.

Psychological impact of yoga

Short term yoga practice did not significantly affect the perception of students toward the benefits of this
yoga group reported less depression, state anxiety, trait anxiety, GSI, and increases in empathy as well as

Yoga improved memory but had no significant effect on attention, processing speed, executive function
No significant result was found. However, it was suggested that peer-led yoga could improve wellbeing

Practicing yoga could help students to management their stress, increase their attention, and maintain
The effect of yoga on the psychology of medical and
dental students has also been observed. Figure 4A
summarizes the effects of yoga intervention on stress.

Yoga improved attention and mental focus. It also could enhanced academic performance

Wile 92% of students were aware of the benefits of yoga, only 35% practiced it regularly
Data from 4 studies was with more than 100 partici­
pants in treatment and control groups was included,
yielding a significant overall effect of a stress reduc­

Yoga significantly improves memory, language fluency and visuospatial skills

tion of 0.77 on standardized assessments due to the
yoga intervention (z = 5.29, p < 0.0001). Both the ran­
Yoga increases state mindfulness for students with high level of stress dom effects model and common effect model yielded

Students have a positive outlook toward yoga but lack motivation.

similar results (I2 = 0.0%, p = 0.98). Similarly,
Figure 4B represents the effect of Yoga on anxiety. 4
Conclusion

Yoga improves attentional control and working memory.

studies with 114 and 160 participants in the interven­

Yoga improves attention, concentration, and memory

tion and control groups were included. The results

showed significant (z = −2.52, p = 0.01) reduction of
1.2 in standardized anxiety tests in intervention
group compared to the control. Due to a high var­
Yoga promotes academic performance

iance (I2 = 92.9%, p < 0.0001), random effects model

was chosen for the overall effect analysis. Besides
physical and mental health.

anxiety and stress, depression was also observed to

or cognitive function.

significantly decrease in yoga group [43,47,49,55,57].

spirituality

Other psychological parameters:

activity

Yoga has also been shown to improve other cognitive

aspects of medical and dental students. For instance,
practice of yoga has been shown to enhance memory
30 min, 5 days/week, 12 weeks
8, 1–1.5 hour weekly sessions

and attention [53,58,60,61,63]. However, Kumar

Period of intervention

et al., 2020 [43] found no significant change in atten­

N/A (Questionnaire only)

N/A (Questionnaire only)

N/A (Questionnaire only)

6 days/week, 3 months

tion or memory. Yoga also enhances self-regulation

2.5 h/week, 7 weeks

and state-mindfulness [33,50,62]. Other advantages of

30h of practice

2h/day, 5 days

yoga include better sleep quality [11], reduced

6 months
1 month

depression [45,49,53,55,56], and reduced pain [37].

15 min

Overall, yoga enhances the mental wellbeing of med­

1h

ical and dental students [45].

physiotherapy and 89 nursing
132 dental and dental hygiene

Yoga practice and academic improvement

116 med, 42 dental, 21
40 male med students
Population

206 dental students

The impact of yoga on medical and dental students’

73 dental students
100 med students

176 med students

150 med students

73 med students

30 med students
60 med students
20 med students

80 med students

academic performance were investigated. Only 6 arti­

cles focused on this aspect. Most studies found an
students

students

increase in academic performance following yoga prac­

tice [28,30,58,64] which could be due to a better sleep
quality [28], improved attention and mental focus [58],
or reduction in stress associated with examination [30].
Location

On the other hand, Lee et al.. (2022) [40] and Waechter

Canada

et al.. (2021) [43] found no evidence of academic

Nepal
India
India

India
India

India
India

India
India

India
USA

USA

improvement following yoga.

Santhanam Kumar et al., 2020

Ankamreddy et al., 2019 [66]

Premalatha et al., 2021 [64]

Deshpande and Chari, 2016

Danilewitz et al., 2016 [57]

Nadig and Shah, 2020 [68]

Sreenivas et al., 2022 [58]

Thomas and D, 2017 [60]

Discussion
Shrestha et al., 2022 [65]
Kondam et al., 2017 [61]
Shapiro et al., 1998 [56]
Table 1. (Continued).

Braun et al., 2019 [62]

Yoga, an ancient Hindu spiritual practice in India has

P et al., 2018 [63]

been evolving over thousands of years. It includes

physical exercise such as asanas, pranayama and
Author

kriyas, breath control, meditation, with a primary

[59]

[67]

focus on an all-inclusive role where the person

 MEDICAL EDUCATION ONLINE 7

Figure 2. Distribution of Articles Across Investigation Categories. A total of 47 articles were included in our analysis.

Figure 3. The Meta-analysis on the Effect of Yoga on systolic SBP (A), DBP (B), and HR (C) Among Medical and Dental Students.
8 S. MAITY ET AL.

Figure 4. The Meta-analysis on the Effect of Yoga on Stress (4A) and Anxiety (4B) Among Medical and Dental Students.

achieves balance and harmony in the body and mind Our data from the 3826 medical and dental stu­
in totality [69] which may enhances physical, mental, dents found that yoga intervention improves physiol­
intellectual, and spiritual well-being [70]. ogy outcomes such as cardiovascular system (CVS)
There has been a growing interest in the potential and respiratory system. In addition, there is also
benefits of yoga on both physiological and mental a significant improvement in relieving stress, anxiety
well-being considering its easy access and the non- and depression which may enhance the academic and
invasive way to prevent and manage the disease bur­ social life of the medical and dental students. This
den. Practicing yoga is affordable and accessible to study is the first meta-analysis to investigate the effi­
many people because of the plausible positive impact cacy of yogic intervention on cardiopulmonary func­
on health and cognitive outcomes. Therefore, grow­ tions and psychological wellbeing in medical and
ing interest in the use of yoga to manage or treat dental students.
disease burden has been a topic of research among
academicians. Several ongoing randomized clinical
Impact of yoga on physiology
trials have provided preliminary evidence of positive
psychosomatic impact of yoga in preventing and A fundamental aspect of yoga is the practice of var­
managing diseases. ious asanas (postures), which involve stretching and
Healthcare trainees often face high levels of stress, strengthening different muscle groups. Recent studies
anxiety, and burnout due to the rigorous demands of have shown that regular yoga practice may increase
their studies and training. Consequently, exploring the flexibility and balance in male college athletes and
the impact of yoga on medical and dental students therefore, a way to improve athletic performance
has become a subject of interest in recent years. This [71]. Increased flexibility can also reduce the risk of
review aims to assess the existing literature and shed injuries and promote better body posture and align­
light on the potential positive effects of incorporating ment among healthy individuals. Specific yoga prac­
yoga into the lives of medical and dental students to tices often incorporate mindful breathing techniques,
improve their physical and psychological well-being such as pranayama, which involve controlled breath
as well as overall academic performance. regulation. A retrospective case-control study showed
 MEDICAL EDUCATION ONLINE 9

the antihypertensive effect of yoga and overall high-density lipoproteins [81]. The specific impact of
improvement of cardiovascular function amongst yoga on CVS might also vary according to the type of
general patient population [72]. practice. For instance, the ‘Brahmari Pranayama’
Our findings revealed that yoga has a positive role technique is particularly effective in lowering blood
in reducing inflammatory markers such as serum pressure and HR, promoting a state of rest and
interferon-gamma (IFN-γ) levels [30] amongst med­ improved digestion by fostering parasympathetic
ical and dental students. A recent review also high­ dominance within the body [82,83]. Overall, the find­
lights the potential for yoga to be used as adjuvant ings of this study offer compelling evidence for the
therapy in conditions with an inflammatory compo­ potential advantages of yoga in maintaining cardio­
nent, such as cardiovascular and chronic respiratory vascular health for medical and dental students.
disease, by reducing levels of C-reactive protein,
interleukin-1, interleukin-6, tumor necrosis factor-
alpha (TNF-α) and IFN-γ [73].
Yoga and SBP/DBP
Our systematic-review also showed that serum
cortisol levels increase after yoga amongst medical Our findings indicate that yoga leads to a significant
trainee [30]. In contrast, we also found evidence reduction in SBP and DBP among medical and dental
that salivary cortisol levels decrease following yoga students. This observation could be attributed to var­
[39]. This discrepancy may be attributed to various ious factors, including a decrease in heart rate (HR),
factors, with a reduction in stress levels being a likely reduction in stress levels, and overall improvement in
significant influence, leading to decreased cortisol fitness. Our results are consistent with prior research,
levels. The interplay between reduced stress and demonstrating that yoga practice can significantly
other variables, such as inflammation, might cause enhance various health metrics, including SBP, DBP,
either an increase or decrease in serum and salivary HR, respiratory rate, waist circumference, waist-to-
cortisol levels. These contradictory effects underscore hip ratio, lipid profile, HbA1c, and insulin resis­
the complexity of the relationship and highlight the tance [81].
need for further targeted research to elucidate the This discovery may hold significant value for med­
underlying mechanisms. ical and dental students, as it points to a potential
decrease in the risks of coronary heart disease and
stroke. Research has suggested that lowering SBP by
Yoga and CVS
just 3 mmHg could reduce stroke mortality by 8%
Cardiovascular diseases are the leading cause of mor­ and cut the incidence of coronary heart disease by
tality worldwide [60,74]. Based on WHO data from 5% [84,85]. Moreover, a recent meta-analysis has
2019, an estimated 17.9 million people died from emphasized the impact of yoga, revealing
cardiovascular diseases, representing 32% of all global a substantial reduction in both SBP and DBP by
deaths. Of these deaths, 85% were due to heart attack approximately 4.7 and 3.2 mm Hg, respectively, con­
and stroke [75]. Furthermore, cardiovascular diseases tributing significantly to the prevention of cardiovas­
are more prevalent in developing countries like India cular diseases [86].
as compared to their western counterparts [76,77].
Hence, it is important to understand that simple
therapeutic strategies such as practicing yoga are
Yoga and HR
cost-effective and yield promising results in reducing
the disease burden and mortality rate. Several studies Our findings, which show a notable reduction in HR
have examined the positive effect of yoga on physio­ and blood pressure after weeks of Common Yoga
logical, biochemical, and neuro-cognitive parameters Protocol practice, align with prior studies suggesting
[78–80]. that yoga effectively lowers blood pressure [87,88].
Our study, through a meta-analysis, substantiates Yoga interventions induce para-sympathomimetic
that engaging in several weeks of yoga practice can effects, leading to reductions in SBP, DBP, as well as
enhance the CVS among medical and dental students. HR [89,90]. This study did not find any significant
This is highlighted by reductions in heart rate (HR), difference in systolic-diastolic BP in the comorbid
systolic blood pressure (SBP), and diastolic blood group as compared to the naïve groups. Although
pressure (DBP). The mechanisms behind yoga’s the cause could not be ascertained, a potential reason
improvement of CVS health are multifaceted and could be the diminished vasodilatory effects resulting
may include activation of the parasympathetic sys­ from reduced nitric oxide in compromised endothe­
tem, mitigation of stress levels, or enhancements in lium. Earlier studies by Chauhan et al. [91] among
overall fitness. A randomized controlled trial further others had reported similar effects of 1-month yoga
supports yoga’s role in cardiovascular health by nor­ and meditation practice in the reduction of SBP, DBP
malizing body mass index, SBP, and both low and and body mass index (BMI).
10 S. MAITY ET AL.

Yoga and respiratory system expansion and stretching, enhances chest mobility,
allowing for deeper inhalation and exhalation. The act
To assess the physiological impact of yoga on respira­
of maintaining poses also engages the respiratory mus­
tory functions, various lung function tests are
cles, providing a mild form of resistance training for
employed. Spirometry is a common test that mea­
these muscles [97].
sures lung volumes and capacities, including forced
Chemoreceptors play a crucial role in regulating the
vital capacity (FVC) and forced expiratory volume
respiratory center, which is responsible for controlling
(FEV1). These metrics indicate the amount of air
the rate and depth of breathing. Located primarily in
a person can exhale forcibly and rapidly after a deep
the carotid bodies in the carotid arteries and the aortic
inhalation. Improvement in these values signifies
bodies in the aorta, these specialized sensory cells are
enhanced lung function and efficiency. Peak expira­
sensitive to changes in the levels of certain gases, parti­
tory flow rate (PEFR) is another measure used to
cularly oxygen (O2) and carbon dioxide (CO2), as well
assess the maximum speed at which air can be
as the pH of the blood. When oxygen levels in the blood
exhaled forcefully, reflecting airway patency.
decrease (hypoxia) or carbon dioxide levels rise (hyper­
In our present study focusing on respiratory para­
capnia), the chemoreceptors detect these changes and
meters, the majority of the articles we included empha­
send signals to the respiratory center in the brainstem.
sized the impact of yoga on several aspects, including
These signals trigger adjustments in the rate and depth
tidal volume (TV), vital capacity (VC), FVC, FEV1, and
of breathing to restore proper gas exchange. In response
PEFR. Our analysis revealed that these parameters gen­
to low oxygen levels, chemoreceptors stimulate an
erally saw a significant increase following yoga practice
increase in respiratory rate and depth, helping to
in the majority of the studies [23,25,26,35]. However,
improve oxygen intake. Similarly, in the presence of
one particular study, Akhani et al., 2019 [25], did not
excess CO2, chemoreceptors prompt the respiratory
identify a substantial increase in TV.
center to initiate faster and deeper breathing to expel
Our findings are in alignment with previous
CO2 and maintain proper acid-base balance. The inter­
research, adding to the growing body of evidence
action between chemoreceptors and the respiratory
supporting the positive effects of yoga on pulmonary
center is a vital feedback loop that ensures the body’s
functions. A recent meta-analysis explored the impact
respiratory rate matches its metabolic demands and
of yogic interventions on respiratory functions in
maintains blood gas levels within a narrow range. This
healthy individuals and found substantial enhance­
regulatory mechanism helps ensure sufficient oxygen
ments in FVC, FEV1, the FEV1/FVC ratio, PEFR
supply and efficient removal of CO2, contributing to
and respiratory muscle strength metrics such as
overall respiratory homeostasis [98].
Maximal inspiratory and expiratory pressures [92].
Various yoga practices are based on specific
Similarly, a study targeting healthy inactive middle-
breathing techniques that contribute to the process
aged individuals showed marked improvements in
both physical and respiratory functions following an of eliminating CO2 from the body through its unique
8-week yoga intervention [93]. In another compelling pattern of forceful exhalations and passive inhala­
investigation, participants demonstrated long-term tions. This technique can help enhance respiratory
changes in their resting breathing pattern, character­ efficiency and facilitate the removal of CO2 from
ized by increased TV and reduced ventilatory the body. Kapalbhati involves rapid, forceful exhala­
response to both chemoreceptor and mechanical sti­ tions achieved by contracting the abdominal muscles.
muli [94]. These findings underscore the idea that This active exhalation expels a significant amount of
consistent engagement in yoga’s breathing exercises air from the lungs, leading to a more efficient
can influence innate respiratory regulation, further removal of CO2. Exhaling vigorously leads to
supporting the therapeutic potential of yoga in a larger volume of CO2-rich air pushed out of the
respiratory health. lungs, creating space for fresh, oxygen-rich air to be
Yoga’s positive impact on respiratory functions can inhaled during the subsequent passive inhalation. The
be attributed to a combination of physiological forceful exhalations also require the engagement of
mechanisms. Engaging in yoga practices involves con­ the diaphragm, abdominal muscles, and intercostal
scious regulation of breath, known as pranayama, muscles. Regular practice strengthens these respira­
which enhances the efficiency of the respiratory system. tory muscles, improving their efficiency in moving air
Deep and controlled breathing techniques, such as in and out of the lungs. Adequate oxygen levels are
Anulom Vilom and Kapalbhati Pranayama, help to essential for cellular metabolisms, which in turn pro­
strengthen the respiratory muscles, increase lung capa­ duce CO2 as a waste product that needs to be elimi­
city, and improve the exchange of oxygen and carbon nated. Additionally, Kapalbhati, like other pranayama
dioxide [95,96]. These practices stimulate the parasym­ techniques, helps reduce stress and anxiety. Stress can
pathetic nervous system, leading to relaxation and contribute to shallow breathing, where not enough
decreased respiratory rate. Furthermore, chest air is exchanged, leading to an accumulation of CO2
 MEDICAL EDUCATION ONLINE 11

in the body. By promoting relaxation and deep, con­ The mechanisms underlying the positive impact of
trolled breathing, Kapalbhati helps counteract yoga on mental health are complex and multifaceted.
shallow breathing patterns and ensures the efficient The proposed mechanisms by which yoga might have
elimination of CO2 [99]. an impact on mental health include cognitive/affec­
These findings are promising, revealing that yogic tive and biologic mechanisms [110].
interventions significantly enhance pulmonary func­ The cognitive mechanism of yoga includes direct­
tions and respiratory muscle strength parameters in ing attention to the present moment, encompassing
physically healthy individuals. Yoga’s influence on thoughts, feelings, and body sensations without judg­
respiratory functions is a multi-faceted process invol­ ment. Yoga fosters mindfulness and self-awareness,
ving controlled breathing techniques and specific asa­ allowing individuals to observe their thoughts and
nas. The combined effect of these practices enhances emotions without judgment. Our analysis revealed
lung capacity, strengthens respiratory muscles, and that medical and dental students who engage in
promotes relaxation, ultimately leading to improved yoga practice demonstrate improved mindfulness
respiratory efficiency. This can potentially benefit and self-awareness [53,56,57,62]. Therefore, this prac­
individuals with respiratory conditions such as tice can lead to enhanced emotional regulation and
asthma, and other respiratory diseases [100,101]. reduced reactivity to stressful situations.
By integrating this daily practice of mindfulness,
students foster the ability to concentrate on current
experiences rather than dwelling about the past or
Impact of yoga on psychological well being
future. Moreover, the non-judgmental approach
Numerous independent studies and reviews have col­ helps alleviate self-criticism. By learning to attend to
lectively demonstrated that yoga serves as an effica­ their immediate experiences, including thoughts and
cious remedy for managing stress and anxiety emotions, individuals realize calmer and more cen­
[70,102,103]. College students often have low levels tered state of mind thereby decreasing stress and
of physical activity and thus ample research has been anxiety while promoting mental health.
conducted to analyze the effect of yoga on students’ Biologic mechanisms of yoga also affect the under­
mental health. The data from these studies indicate lying pathophysiology of depression and anxiety.
that yoga has beneficial effects at the psychophysio­ Yoga practices have been associated with positive
logical level, leading to reduced stress levels in stu­ effect on the structure and/or function of the brain
dents and an overall enhancement in well-being areas such as hippocampus, amygdala, prefrontal cor­
[104–107]. Not all students will have the requisite tex, cingulate cortex, and brain networks [111]. Yoga-
skills to manage stress and employ effective coping based practices also regulate the autonomic nervous
strategies. Among these strategies, physical activity is system (ANS), which is linked to depression and
one that might be underutilized by a considerable anxiety [112,113]. Yoga improves the ANS balance
number of students. by promoting the activation of the parasympathetic
Our meta-analysis, which included over 100 med­ nervous systems (PNS), responsible for the body’s
ical and dental students in both treatment and con­ rest-and-digest response, while inhibiting the sympa­
trol groups, showed a significant overall effect of thetic nervous systems (SNS) responsible for the
stress reduction as a result of the yoga intervention, fight-or-flight response. This balance may explain
as measured by standardized assessments yoga’s stress-reducing effects.
[43,46,47,51,54,57]. Similarly, studies focusing on Beside activating PNS, yoga also increases
the effect of yoga on anxiety, with sample sizes of GABA levels by stimulating the vagus nerve, lead­
114 and 160 participants in the intervention and ing to mood enhancement. It has also been shown
control groups respectively, demonstrated that yoga can modify neurotransmitters such as
a significant reduction in anxiety as measured by serotonin, norepinephrine, dopamine, and melato­
standardized tests [30,43,44,48,55,57]. In addition to nin. As neurotransmitter levels offer reliable indi­
the positive impacts on stress and anxiety, our sys­ cators for assessing psychological conditions, these
tematic-review found a notable decrease in depres­ findings provide a profound understanding of the
sion among those participating in the yoga group beneficial impacts that complementary therapies
[45,49,53,55,56]. like yoga and meditation can have on the human
Our analysis also revealed that yoga appears to body. These effects may be linked to enhanced
have a positive effect on overall intelligence, visuos­ neuroplasticity and reduced stress, both of which
patial working memory, and attention among medi­ can influence cognitive performance positively.
cal students [58–60,63]. Additionally, research has Additionally, yoga might reduce hypothalamic-
demonstrated that the practice of yoga can enhance pituitary-adrenal axis activation and inflammation,
fluid intelligence, general mental abilities, and execu­ potentially impacting the underlying causes of
tive functions [108,109]. depression and anxiety [114–116]. Regular yoga
12 S. MAITY ET AL.

practice may thus help regulate the stress response note that these protective effects might not persist if
and reduce cortisol levels, contributing to yoga practice is halted.
improved mental well-being. The physical postures and relaxation techniques
The scientific evidence supporting the positive incorporated in yoga also contribute to overall phy­
impact of yoga on both physiology and mental health sical health such as better sleep quality, indirectly
is continually growing. Regular practice has been supporting mental acuity and attentiveness in the
associated with improved flexibility, cardiovascular classroom [28]. As the evidence accumulates, educa­
health, and respiratory function in both the general tional institutions are increasingly recognizing yoga’s
public as well as medical and dental students. potential to positively impact students’ academic
Moreover, yoga’s stress-reducing effects and its ability achievements and are incorporating it into their well­
to enhance mindfulness and emotional regulation ness programs to provide students with holistic sup­
make it a valuable tool for promoting mental well- port for their academic endeavors.
being and managing various mental health conditions
amongst healthcare trainees. While yoga can comple­
Knowledge and awareness of yoga
ment traditional medical treatments, it is essential to
acknowledge that it may not be a standalone solution Incorporation of beneficial evidence-based comple­
for severe mental health disorders. As research in this mentary practices like yoga into a student’s daily life
field progresses, further insights into the specific depends on the effective delivery of such healthy
mechanisms of action and the optimal implementa­ practices. Achieving this goal involves scrutinizing
tion of yoga as a therapeutic intervention will likely the health-seeking behavior of the population, parti­
emerge, solidifying its role in enhancing overall cularly focusing on the knowledge – practice gap.
health and well-being. This gap refers to the discrepancy between knowing
about beneficial health practices and actually adopt­
ing them. The students across the many streams are
Academic life and yoga curriculum
generally stressed during the academic curriculum,
The impact of yoga on the academic performance of more specifically during the exams, seminars, and
students is gaining recognition as an influential factor training. The knowledge and awareness about yoga
in their overall scholastic journey. Engaging in reg­ play a significant role and benefit the students’ aca­
ular yoga practice has been linked to improvements demics and quality of life. Yoga’s acceptability varies
in various cognitive and emotional aspects that among individuals and therefore, conducting
directly contribute to academic success amongst a university-wide survey and collecting feedback
medical and dental students [28,30,58,64]. The posi­ becomes imperative to comprehensively comprehend
tive effect of yoga on medical and dental students’ the knowledge – practice gap [118].
academic performance could be attributed to The perception of yoga’s effectiveness among med­
enhanced mental ability, reduced stress, and better ical and dental students may influence their commit­
sleep quality. ment to engaging in this practice. Seven studies
Yoga’s emphasis on mindfulness and focused examined students’ awareness, attitudes, and under­
breathing techniques cultivates heightened concen­ standing of yoga, revealing that over 90% recognize
tration and cognitive clarity, enabling students to its benefits [65,65,67,68]. In contrast, fewer than 20%
absorb and process information more effectively. of students regularly practice yoga [46,47,65,66,68],
Yoga enhances overall intelligence, visuospatial work­ citing time management issues, lack of motivation,
ing memory, and attention, in medical students [58– and laziness as primary barriers [66,67].
60,63]. It has also been shown that yoga enhances Encouragingly, one study found that 95% of partici­
fluid intelligence, general mental ability, and execu­ pants expressed a desire to practice yoga after parti­
tive function [108,109]. The observed enhancements cipating in the study [43], while another revealed that
in general intelligence, visuospatial working memory, more than 90% believe yoga should be integrated into
and attention are anticipated to have a positive medical school curricula to support physical and
impact on students’ academic accomplishments. mental well-being [65].
Additionally, the stress-reduction benefits of yoga The high awareness of yoga’s benefits among medi­
play a significant role in enhancing mental resilience, cal and dental students, coupled with a strong desire to
minimizing performance anxiety, and promoting practice it, underscores its potential value in their edu­
a positive mindset [30,45]. One study conducted to cation. Despite barriers such as time management and
analyze the impact of yoga on academic stress in motivation, most students believe yoga should be part
adolescents (ages 14 to 16) during their career- of the curriculum. Integrating yoga into medical and
deciding exams showed that yoga effectively reduced dental school programs could not only support stu­
psychosocial stress in students and could be useful in dents’ physical and mental well-being but also align
school curricula [117]. Nonetheless, it’s important to with their expressed preferences and beliefs.
 MEDICAL EDUCATION ONLINE 13

Potential barriers and prospects homogenous included studies. A summary synthesis

of all included literature showing the effects of yoga
Implementing yoga programs in medical education faces
intervention on physiology, mental health, and aca­
several challenges and barriers that warrant careful exam­
demic life is given. Meta-analysis of various psycho­
ination. One prominent obstacle is the need for
somatic outcomes provides significant association in
a paradigm shift in the traditional medical curriculum,
the yoga intervention group as compared to control.
which may be resistant to integrating complementary
Our summary table has provided the duration of
and alternative practices like yoga. Skepticism among
yoga intervention that is likely to give significant
faculty members and administrators regarding the scien­
results wherever possible. A continuous yoga practice
tific basis and efficacy of yoga in medical training may
is likely to produce significant improvements in car­
pose a significant hurdle. Awareness among faculty and
diovascular, respiratory, mental health parameters
designing an appropriate faculty development program
along with improvement in academic performance
by certified yoga expert can overcome the challenges and
of medical students.
barriers in implementing yoga in medical education.
There are several limitations that are identified in
Additionally, time constraints within the medical school
our study. Firstly, although the included articles mea­
curriculum could be a limiting factor, as educators may
sured many outcomes, the articles significantly vary in
perceive the incorporation of yoga as an additional
terms of methodological approaches, population selec­
demand on an already tight schedule. Infrastructure
tion, duration of the yoga intervention, weekly fre­
and resource limitations, such as the availability of qua­
quency of yoga, practice, and studied population, etc.
lified yoga instructors and suitable spaces for practice,
These variations limit the conclusive effectiveness of
may also impede successful implementation.
yoga outcomes amongst the medical students. For each
Furthermore, addressing diverse student preferences,
outcome included in the meta-analysis, there were less
cultural sensitivities, and potential misconceptions
than 10 studies and hence potential publication bias
about the spiritual aspects of yoga presents a nuanced
was not assessed. Additionally, several different types of
challenge. Overcoming these barriers necessitates colla­
scales were used in different studies to measure the
borative efforts among medical educators, administra­
same outcomes such as anxiety, stress, and depression.
tors, and the broader medical community to foster
This reduced the homogeneity of the data and reduced
a more inclusive and holistic approach to medical
the number of articles in physiology and mental health
training.
functions. The articles that did not use the control
To address the challenges in implementing yoga pro­
group were not included in the meta-analysis, further
grams within medical education, there is a pressing need
reducing the number of the articles. The absence of
for extensive, forward-looking, and diverse pilot initia­
specific metrics related to academic performance, the
tives that span multiple centers and employ various
lack of a direct comparison between the yoga interven­
methodologies [119]. These projects should aim to dis­
tion group and a control group, and the insufficient
cern the effectiveness of incorporating a yoga curriculum,
exploration of academic stressors is a current limitation
encompassing both practical sessions and theoretical
due to insufficient homogenous data availability. It will
components, as a countermeasure to the adverse effects
be interesting to explore this avenue further in future
of the undergraduate medical school environment. This
studies with more standardised study designs.
environment has been identified as a contributing factor
Encouraging the incorporation of these elements in
to the development of depression, anxiety, and ineffective
future revisions would enhance the overall quality
coping strategies among medical students. The proposed
and applicability of the yoga intervention studies.
pilot projects should systematically explore how yoga
Finally, several unpublished literatures, thesis, or
interventions can be seamlessly integrated into the curri­
any grey literature were not included in the current
culum. By conducting large-scale studies across multiple
study, thus may limit any important information
centers, researchers can not only evaluate the impact of
regarding our results too.
yoga on mental well-being but also identify practical
solutions to overcome logistical barriers, engage faculty
support, and tailor the program to diverse student pre­ Conclusion
ferences. These initiatives are essential for paving the way
Yoga presents a compelling avenue to enhance the
toward a more comprehensive and resilient medical edu­
physical and mental well-being of medical and den­
cation system.
tal students. By improving effectiveness, fostering
collaboration, enhancing focus, and contributing to
a more positive outlook on life, yoga offers multi­
Strength and limitations
faceted benefits. In an era where anxiety and depres­
The strengths of our research include comprehensive sion are often addressed through psychological
search strategy from the various databases, indepen­ interventions and medications, the mind-body
dent screening, and meta-analysis of all relevant approach embodied by yoga offers a refreshing
14 S. MAITY ET AL.

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