AN INTERVENTIONAL STUDY ON THE EFFECT OF YOGA AND PRANAYAMA ON

THE PHYSICAL AND MENTAL HEALTH OF MEDICAL STUDENTS

By

Dr. VIJAY RAJANA, M.B.B.S.,

Dissertation submitted to
Dr. N.T.R.UNIVERSITY OF HEALTH SCIENCES, VIJAYAWADA (A.P)
In partial fulfilment of the requirement for the degree of
DOCTOR OF MEDICINE
In
COMMUNITY MEDICINE

Under the guidance of

Dr. Y. PADMA SRI, M.D.
PROFESSOR
DEPARTMENT OF COMMUNITY MEDICINE
ANDHRA MEDICAL COLLEGE, VISAKHAPATNAM
ANDHRA PRADESH
2017-2020

i
ii
 ACKNOWLEDGEMENTS

First and foremost, I would like to express my deep sense of gratitude towards

my guide Dr.Y.PADMASRI M.D, Professor of Community Medicine for her invaluable

guidance; constant encouragement, expert suggestions, constructive criticism and

supervision which made this entire process an extremely enriching experience.

It is with a deep sense of gratitude that I acknowledge my professor and Head of

the Department Dr.B.DEVIMADHAVI, M.D, for her unrelenting support,

Encouragement, supervision and guidance.

I am extremely grateful to my co guide Dr.P.KRANTHI, M.D for his constant

encouragement and valuable guidance.

I am very thankful to my Associate Professors Dr.S.SUNITHA, M.D,

Dr.GANGABHAVANI, M.D., and Dr.P.J.SRINIVAS, M.D Community Medicine

department, AMC, for their valuable moral support.

I sincerely thank all my Assistant Professors specially Dr. K.K.LAKSHMI

PRASAD, Dr. K.V.PHANIMADHAVI, Dr. L.SIVAKUMAR, Dr. V.V.DURGA PRASAD,

Dr. ERRAYA, M.D for their kind help, valuable suggestions and moral support.

My heartfull thanks to all my seniors and my colleagues

Dr.K.AMALESWARI, Dr.B.DHANALAKSHMI, Dr.K.GAUTHAM, Dr.K.SUSHMA and

for their immense support, and heart full encouragement throughout my study.

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My heart full thanks to our YOGA TRAINERS

Dr. NAVSK RAVI KUMAR, M.D.(GEN MEDICINE), certified in YOGA.

Dr. P. LAXMAN RAO M.D.(ANATOMY),Diploma in YOGA(A.U) for their immense

support to carry out the entire training period smoothly.

My heart full thanks to Dr . J.V. PRAVEEN KUMAR, M.D (PUMONARY MEDICINE)

for his support to make this study possible.

Last but not least I would also like to express my gratitude to all participants

of this study (INCREDIBLES, 2017 BATCH OF AMC) for placing their trust in me and

I hope that this endeavour will have some positive impact on their lives too.

Date: 2-12-2019 Signature of candidate

Place: VISAKHAPATNAM Dr. VIJAY RAJANA

“Dedicated to all the YOGI’s who are working to make this earth
a better place for you and me and the entire universe.”

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 TABLE OF CONTENTS

S No CONTENT PAGE No

1 INTRODUCTION 1-4

2 AIM AND OBJECTIVES 5

3 REVIEW OF LITERATURE 6-20

4 MATERIALS AND METHODS 21-40

5 OBSERVATIONS AND RESULTS 41-56

6 DISCUSSION 57-67

7 CONCLUSIONS AND RECOMMENDATIONS 68-69

8 SUMMARY 70-71

9 REFERENCES 72-76

10 ANNEXURES ix

1) PARTICIPATE INFORMATION SHEET

2) GENERAL QUESTIONNAIRE x-xi

3)DSM 5 LEVEL 1 CROOS CUTTING SYMPTOM MEASURE
xii-xiii

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 4)GLOBAL PHYYSICAL ACTIVITY QUESTIONNAIRE. xiv-xvi

5)CONSENT FORM
xvii

6) Ethical clearance certificate xix

7) Plagiarism certificate xx-xxi

8)INTERVENTIONAL TRAINING PROGRAM
xxii-xxvi

LIST OF TABLES

TABL TITLE PAG

E No E No
1 Table 1: Various study tools used for measuring study variables 10

2 Table 2: Interventional training program 18

3 42
Table 3: BMI, HEIGHT, WEIGHT, AND AGE among the study
subjects

4 42
Table 4 : Distribution of students by Body Mass Index

5 44
Table 5: Distribution of Students Based On Their Total Physical
Activity

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6 45
Table 6: BMI and PHYSICAL ACTIVITY

7 46
Table 7: Means of percentage predicted forced vital capacity

before and after yoga in study subjects.

8 47
Table 8: Means of percentage predicted FEV1 before and after

yoga in study subjects.

9 48
Table 9: Means of percentage predicted PEFR before and after

yoga in study subjects

10 Table 10: Means of pulse rate before and after yoga in study 49
subjects
11 49
Table 11: Means of Systolic Blood Pressure (SBP) before and

after yoga in study and control group

12 50
Table 12: Means of Systolic Blood Pressure (SBP) before and
after yoga in the study and control group

13 51
Table 13: Comparison of highest domain scores before and after

yoga in study subjects.

14 55
Table 14: Comparision of Improvement in pulmonary functions in
both physical activity groups

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 LIST OF FIGURES

FIGURE No TITLE PAGE No

1 Fig 1: Flow-volume loop of Respiration 9

2 Fig 2: MIR INTERMEDICAL SPIROLAB 13

SPIROMETER AND data sheet obtained.

3 Fig 3: Students testing with spirometry under the 14

guidance of Pulmonologist.

4 Figure 4: Gender distribution among study 41

subjects
5
Fig 5: DISTRIBUTION OF BODY MASS INDEX IN
STUDY SUBJECTS
43

viii
 "Yoga is the journey of the self, through the self, to the self"

-the UNKNOWN.

INTRODUCTION

Since times immemorial, yoga is well known to humankind because of its various

positive outcomes like calmness in mind, resonance in the body, and increased

awareness about themselves.

Yoga is a way of life in ancient India, which includes changes in mental attitude,

diet, and the practice of specific techniques such as yoga asanas (postures),

breathing exercises (pranayamas), and meditation to attain the highest level of

consciousness. It brings balance and health to the physical, mental, emotional,

and spiritual dimensions of the individual.

Problem Statement

Physical inactivity is an important modifiable risk factor for premature morbidity. It has

been shown that sedentary behaviour and lack of physical activity independently

Increase the risk for metabolic syndromes, type 2 diabetes, cardiovascular disease, and

also depression, which is evidenced by the rise in the early onset of non-communicable

diseases and psychological problems in the younger population. Particularly medical

1
graduates are at greater risk of exposure to stressful events at a very early age during

their training, which is usually being neglected. According to recent studies, the

prevalence of perceived psychological stress among MBBS students was found to be

41.9(1). These submerged stresses and emotions among the medical graduates are

surfacing in different aspects like higher rates in hazardous substance abuse and co-

occurring mental restlessness among students, yet rarely seek treatment.(2)

Term Mental health is used to describe either a level of cognitive or emotional

wellbeing or an absence of mental disorders. It needs to be addressed as an

important component of improving the overall health and wellbeing of an individual.

Therefore, both reducing both sedentary time and increasing Physical activity levels

offer beneficial health effects caused by the different molecular and physiological

mechanisms.(3)

Motivation for Work

The major advantage of yoga over other physical fitness activities like running or

aerobics is it offers benefits not only in the physical domain but also in mental,

emotional and spiritual dimensions of health.

Medical students who are the torchbearers of the society should not fall back to mental

traumas, so this study aims to assess the burden of mental stress faced by the medical

students.

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With rising non-communicable diseases percentage in the Indian scenario, future

doctors are the ones who teach healthy lifestyles and diets to the public. If our students

themselves practice the health promotional measures, they are very more likely to guide

and motivate their patients and the community to do so.

.As an ancient holistic system of wellness, yoga is a scientifically validated, time

tested, and socially acceptable health promotional technique. But so far, very few

scientific studies have been done on the effect of yoga on health even though yoga

originated in India. Hence we aimed to know the effects of yoga on the physical and

mental health of medical students.

After its inception in the United Nations General Assembly in 2014 by approved by

several countries, The International Day of Yoga is celebrated in all parts of the globe

annually on 21st June since 2015. It has a special significance in many parts of the

world as it is the longest day of the year .(4)

Proposed Outcome of the Study

Yoga practice mainly consists of Asana (a particular position of the body which

contributes to the connectedness of body and mind), Pranayama (to control ones own

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breathing process), and meditation. It produces consistent physiological changes and

has a sound scientific basis.

Yogic Asana and Pranayama have been shown to reduce the resting respiratory rate.

Furthermore, they increase forced vital capacity, Timed vital capacity, and maximal

voluntary ventilation, breath-holding time, maximal inspiratory pressure and maximal

expiratory pressure.(5)

The effect of yoga on respiratory function has been an important area of research for

decades. Practicing Yoga, along with the improvement of pulmonary ventilation and gas

exchange, helps in the prevention, cure, and rehabilitation of many respiratory illnesses.

Urbanization and resultant environmental pollution also affect the respiratory system

along with a sedentary lifestyle. Pulmonary function tests permit an accurate and

reproducible assessment of the functional state of the respiratory system.

Vital capacity of the lung is a critical component of good health, and according to

studies, yoga helps in improving vital capacity (2.95 to 3.22 lit) which for those who

have diminished lung function and volume from a sedentary lifestyle serves as an

important benefit.

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 OBJECTIVES

1. To assess the effect of yoga and pranayama in improving Pulmonary

function tests, pulse rate and Blood pressure.

2. To assess the effect of yoga and pranayama on the mental health of

students.

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 METHODOLOGY

Study design: Interventional study.

Study setting: Andhra medical college (AMC).

Study subjects: Students from the 4th Semester of AMC.

Study period: November 2017 - November 2019.

Sample size: Based on the improvement in FEV1 in the previous study (6) from 2.82

to 3.12 lit, and standard deviation of post-intervention FEV1 value 0.30 was taken as

with absolute precision of 10 %, the sample size was calculated using formulae

2
Z1-α/2 SD
NN ≥≥
d

d=absolute precision

6
SD=standard deviation

The sample size obtained was 35.

Inclusion criteria: students who were willing and without any physical/health

complaints.

Exclusion criteria: students with any pain/ condition restricting the body movements,

recent fractures, acute sinusitis.

SELECTION OF SUBJECTS

In this study, subjects were selected from the 4th semester of 2 nd year MBBS, Andhra

medical college, Visakhapatnam. Students who were willing to participate were included

in the study. They were explained about the purpose, nature, importance of the study,

and the procedure to be employed to collect the information. Further the role of the

subjects during the study and the testing procedure was also explained to them in

detail. An informed consent was obtained from all the members. The physical condition

of the subjects were assessed by a brief general and systemic examination by a

qualified medical practitioner and all the healthy subjects are requested to co-operate

and participate actively for the same.

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 EXPERIMENTAL DESIGN AND PROCEDURE

The subjects selected for the present study after baseline assessment were given six

weeks of yoga training by certified yoga trainers. which included yoga asana ,

pranayama and meditation. The subjects were asked not to change their lifestyle during

the study and were instructed not to perform any other physical exercises if they were

not doing the same regularly

STUDY VARIABLES

Data on characteristics such as age, gender, residence were collected using structured

questionnaire. Height was measured using a standardised measuring tape, weight was

measured using a standardised weighing machine. Body Mass Index (BMI) was

calculated by using the formulae weight in kg’s /square of height in meters. Their

physical activity was assessed by calculating metabolic equivalents from WHO Global

physical activity questionnaire.

I. PULSE RATE

II. BLOOD PRESSURE

a. Systolic blood pressure

b. Diastolic blood pressure

III. PULMONARY FUNCTION TESTS

a. Forced vital capacity (FVC)

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 b. Forced expiratory volume in first second (FEV1)

c. Peak expiratory flow rate

IV. Physical activity by global physical activity questionnaire

V. Mental health by DSM5 –LEVEL 1 Cross-Cutting Symptom Measure by

American psychiatric association.

OPERATIONAL DEFINITIONS

Fig 1: Flow-volume loop of Respiration(6)

Forced Vital Capacity (FVC)

Forced vital capacity is defined as the maximum volume of air a person can

expel from his lungs by a forcible expiration after the deepest possible

Inspiration.(7)

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Forced Expiratory Volume in first second (FEV1)

FEV1 is the volume of air that can forcibly be blown out in first 1 second, after full

inspiration

Peak Expiratory Flow Rate (PEFR)

The rate at which one litre of air is expelled over the fastest part of the expiratory curve

as Maximum forced expiratory flow rate or peak flow rate.

(Simply called person’s maximum speed of expiration)

It measures the airflow through the bronchi and thus the degree of obstruction in the

airways.(7)

Blood Pressure (BP)

The pressure measured in the circulatory system that is associated with cardiac

Contraction (systolic) and relaxation (diastolic).

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 STUDY TOOLS

Table 1: Various study tools used for measuring study variables

s.no STUDY VARIABLE STUDY TOOL

1. HEIGHT Measuring tape.

2. WEIGHT Weighing machine

3. PULSE RATE Pulse Ox meter

4. BLOOD PRESSURE Sphygmomanometer

5. PULMONARY Portable SPIROLAB

FUNCTION TESTS Spirometer

6. PHYSICAL ACTIVITY WHO Global physical

activity questionnaire

7. MENTAL HEALTH APA DSM5-LEVEL 1

Cross-Cutting Symptom

Measure-adult

ETHICAL CONSIDERATION

This study was approved by the AMC institutional ethics committee with

serial no: 50/IEC AMC-KGH/NOV/2018.

Informed consent was obtained from all the students who participated in the study

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 DATA COLLECTION

Measurements for the variables were taken from study group at the beginning (pre-

tests) and the end of the study , after six weeks (post-tests). All the data were collected

at a fixed time of the day between 4 pm to 7 pm to minimize any diurnal variation.

Purpose: To assess the Forced Vital Capacity (FVC), Forced Expiratory Volume in

First Second (FEV1), Peak Expiratory Flow Rate (PEFR) of the lung.

Equipment used: Spirolab spirometer, Disposable cardboard moth pieces, sprit and

cotton.

The subjects were instructed about procedure for recording Pulmonary function tests

and made acquainted with “ MIR intermedical Spirolab spirometer , an instrument for

recording pulmonary function tests with Pneumotach sensor” , a computerized

spirometer self-calibrating and fulfils the criteria for standardized lung function tests and

is designed as a low cost high performance instrument capable of giving highly accurate

repeatable test results. Three such readings were taken in sitting position under the

guidance of Pulmonologist in Andhra Medical College and then highest reading of

these was taken as final one.

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FIG 2: MIR INTERMEDICAL SPIROLAB SPIROMETER AND data sheet obtained.

Percentage of predicted values of FVC, FEV1, PEFR are the number of values each

student obtained in a spirometer out of their predicted FVC according to their height and

weight. So the actual values of FVC, FEV1, and PEFR which are expressed In Litres,

are expressed as percentages in the study for easy identification of improvement in all

pulmonary function tests.

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Fig 3: Students testing with spirometry under the guidance of Pulmonologist.

Procedure: The student was asked to sit comfortably on the chair and to take a

maximum inspiration away from the spirometer. Then he was asked to hold the

mouthpiece between the lips to create a good seal and expire as fast and as hard as

possible for as long as possible until no breath was left.

Once again he was asked to hold the mouth piece between the lips to create a

good seal and breath in and out for 2-3 tidal breaths. Then to inhale rapidly to

maximum capacity. Expire as hard as possible for as long as possible until

no breath was left. The subject had to be encouraged continuously to ensure the best

effort. For an acceptable test, the effort should be maximal smooth and cough free and

exhalation time at least 6 seconds. Each manoeuvre had to be performed thrice, and

the best value out of the three was noted. Before going to the next subject, the

disposable mouth piece was to be changed. When the subject was ready to blow out,

the unit had to be switched on and reset using the Reset switch.

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Scoring: Forced vital capacity, Forced expiratory volume first second and peak

expiratory flow rate values were to be immediately observed from a spirometer. Values

from the best of three similar readings were then taken as a percentage of predicted

values.

Blood Pressure

Purpose: To measure the systolic pressure (SP), diastolic pressure (DP), of the

subject.

Equipment used: A standardized sphygmomanometer and a stethoscope.

Procedure: the subject was asked to sit comfortably on the chair before the

measurement was taken. The cuff of the sphygmomanometer was wrapped around

the arm evenly with the lower edge approximately one inch above the antecubital

space. When the sound of the blood flow (Korotkoff sound) became audible the reading

in millimeters of mercury (mm of Hg) at that instant was recorded as the systolic

pressure.

The pressure was further released gradually as the sound of the pulse changed

in intensity and quality. The index of the diastolic pressure was noted in mm of Hg,

when the heart beat sound completely ceased.

Diastolic Pressure (DP): The process was continued to release the pressure and the

tone and volume of the sounds changed and finally disappeared in a faint murmur.

15
Blood pressure is measured in both arms for three times, and the average of the blood

pressure is taken a final blood pressure.

Administration of Questionnaire.

The questionnaire consists of 2 components

1. DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure—Adult

Questionnaire

2. WHO Global physical activity questionnaire.

In order to assess the impact on mental wellbeing DSM-5 Self-Rated Level 1 Cross-

Cutting Symptom Measure—Adult Questionnaire was used. It consists of 23 questions

that assess 13 psychiatric domains, like depression, anger, mania, anxiety, somatic

symptoms,psycosis, suicidal ideation, sleep problems, memory, repetitive thoughts and

behaviors, dissociation, personality functioning, and substance use. Each item inquires

about how oftenthe individual has been bothered by the specific symptom during the

past 2 weeks.

Each question on the measure is rated on a 5-point scale (0=none or not at all; 1= rare,

less than a day or two; 2= several days; 3=more than half the days; 4=nearly every

day. The score on each item within a domain should be considered. As additional

inquiry is based on the highest score obtained on any item within a domain, the doctor

16
is asked to indicate that score in the "Highest Domain Score" column. A rating of mild

or higher on any item within a domain may serve as a guide for additional inquiry and

follow up to determine whether a more detailed assessment for that domain is

necessary.(8)

The WHO developed a tool called Global Physical Activity Questionnaire

(GPAQ) for physical activity surveillance in countries. It collects information on physical

activity in three settings as well as sedentary behavior, which consists of 16 questions

(P1-P16). The domains are:

• Activity at work

• Travel to and from places

• Recreational activities

Metabolic Equivalents are used to express the intensity of physical activities.

MET is the ratio of a person's working metabolic rate relative to the resting

metabolic rate.

Overall, persons who spend more than 600 METS of energy per week are considered to

be physically active according to World health organization (GPAQ), and those who are

less than 600 METS are considered to be insufficiently active.(9)

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 INTERVENTIONAL TRAINING PROGRAM

All the subjects were received the same Yoga training under the guidance of a well-

trained Yoga instructor for 6 weeks for 1 hour daily, six days a week between 6:00 am

7:00 am. The yoga practice schedule consisted of Pranayama and Asanas, which was

concluded by prayer as follows;

SIX WEEKS ( Daily Morning from 6 AM to 7 AM)

PRAYER (5 min)

ASANAS (35 min)

s.no s.no

1 warm up(surya namaskar) 9 Bhujangasana

2 Tadasana, 10 viparitakarini

3 Padahastasana, 11 dhanurasana

4 trikonasana, 12 makarasana

5 vrukshasana, 13 ustrasana

6 ustrasana, 14 Paschimottasana

7 halasana 15 vajrasana

8 warm up (surya 16 navasana

namaskar)

17. savasana

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 PRANAYAAMA (15 min)

1. Anulom vilom (alternate breathing technique)

2. Kapalbhati (skull shining breath)

3. Brahmari pranayama (the humming bee breath)

4. Bhastrika pranayama ( the Bellows breath )

MEDITATION (5-10 MIN)

AUM CHANT

Table 2: Interventional training program

At the end of 6 weeks of above mentioned Yogic practice, once again, all the data of 35

subjects were assessed and recorded as done before the start of Yoga practice.

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 DATA ANALYSIS

The pre and post-intervention data (pulmonary function tests, Blood pressure, and

pulse rate,) obtained were entered into excel sheet and data was cleaned and analyzed

by using SPSS software. "paired t-test" was applied using SPSS SOFTWARE version

16 (trail version)to know the significance . p-value is taken as 0.05 .

Moreover, other qualitative data were expressed in percentages and quantitative data

were expressed in means with standard deviation.

In the mental health questionnaire, the highest domains were used to assess the

improvement in the domains of mental health. Percentage change in the domains

scores were taken as an effect due to intervention.

Physical activity was assessed by using metabolic equivalents per minute (METS) using

the global physical activity questionnaire. And their association with BMI is tested.

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 REVIEW OF LITERATURE

Review of literature is done under following headings

1. Yoga and Pranayama

2. Studies on the effect of Yoga on Pulmonary function tests.

3. Studies on the effects of Yoga on Mental health.

4. Studies on physical activity and sedentary lifestyle.

Throughout our life, we are breathing continuously and involuntarily, day in and day out,

during waking and sleeping states. The very first instruction in the teaching of

Pranayama is to observe this breathing process as it is going on naturally, without

trying to modify it. Even such a simple act has a physiological implication. Involuntary

respiration is controlled by the respiratory center, situated in the midbrain. But once

we become aware of the process of respiration, its control shifts to the cerebral

cortex. This involvement of the cerebral cortex causes the cortex to develop. Further

development of the cerebral cortex leads to a higher stage of the evolutionary cycle.(10)

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 Yoga: the historical outlook

In Indian history, Yoga originated from the Sanskrit word meaning "yoking" or "joining" is

"the means for transforming consciousness and attaining liberation (moksha) from

karma and rebirth (samsara).” It is a practice through which a student strives,

(1) to control nature to make the soul fit for union with the Oversoul, and

(2) to attain union with universal soul and thus the liberation of the soul from the rounds

of rebirth and death.(11)

"Yoga is popularly known as a program of physical exercises (asana) and breathing

exercises (Pranayama).

Yoga began in India as early as 5000 B.C., It emerged in the hymns of the ancient

Hindu text like Upanishads (600–500 B.C.)and also mentioned in the classic Indian

poem Mahabharata (400 B.C. - 400 A.D.) and discussed in the most famous part of that

poem, the Bhagavad Gita.

Yoga was systemized by Patanjali in the Yoga Sutras (300–200 B.C.). Patanjali coded

the purpose of Yoga as knowledge of the true "Self" (God) and outlined eight steps for

direct experience of "Self.” (12)

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 Asthanga yoga

Yoga (ashtanga) is generally depicted metaphorically as a tree and comprises eight

aspects, or "limbs." Around 900 BC, The ancient sage Patanjali codified the ancient

Yoga as ashtanga, which is one of the six schools of Indian philosophy called Yoga

Darshan.(13)

The eight limbs are:

1. Yama (Universal Ethics),

2. Niyama (Individual Ethics),

3. Asana (Physical Postures),

4. Pranayama (Breath Control),

5. Pratyahara (Control Of The Senses),

6. Dharana (Concentration),

7. Dhyana (Meditation),

8. Samadhi (Bliss).

Each limb is connected to the whole tree, in the same way that all bodily limbs are all

connected to each other. If someone pulls the body by the leg, the rest of the body will

23
automatically follow. In the same way, when one pulls one of the eight limbs of Yoga,

the others will naturally come. They are not stages to be achieved in succession.(13)

Hatha yoga includes the practice of asana, pranayama’s, and kriyas (purification

techniques including breathing cleansing techniques and shatkarmas–six groups of

purification practices).(14)

Physiology of Pranayama

Patanjali, the first sage who described the eight limbs of Yoga, described Pranayama as

the gradual unforced cessation of breathing and Asanas as different physical

postures that makes muscles more strong and flexible. Yoga practice causes the

betterment of pulmonary functions.

The process of respiration has three components.(10)

1. Inspiration for air,

2. Retention ( kumbhaka ),

3. Expiration.

It can be said that Retention of Breath is Pranayama, not inspiration and expiration,

which are natural processes. (10)

Retention is again of three types.

1. Bahir kumbhaka : Retention of Breath at the end of expiration.

24
2. Antar kumbhaka: holding the Breath after the inspiration of air, and

3. Sahaja kumbhaka: holding the Breath with no particular state of respiration into

consideration.

Respiratory Mechanism in Breath Retention

The process of gaseous diffusion is dependent mostly

1. the extent of alveoli surface area available,

2. the condition of the membrane in between,

3. the pressure of gases on either side of the membrane. (15)

The heart rate is decreased in inspiration. As a result, the resting period of the heart-

the diastole- is prolonged. Not only does the heart muscle relaxes, but also the

compartments of the heart are also better filled with blood. During the next systole,

more blood is pushed into circulation with a better force. Thus general circulation is

improved.(16)

During Retention, no new air is entering the lungs, so oxygenation of blood won't occur.

The resulting decrease in oxygen tension up to a certain level has an advantage as the

brain is most sensitive to this decreased oxygen tension, If the Quality of the blood is

less in oxygenation, the brain tries to get more blood in quantity. (17)

25
Anywhere in the body and even in the brain, all the capillaries won't be in a functioning

state at all times. Some of them will be lying in a dormant or collapsed state. These

capillaries are opened up in order to receive a greater amount of blood. The effect is

more particularly in the brain. Hence cerebral anoxia leads to cerebral vasodilation,

which improves circulation by opening up more blood vessels. (27)

It must be stressed that this effect is beneficial only up to a certain level. It is

distinctly harmful Beyond this level. Hence, it is always emphasized that the practice of

Retention of Breath must be learned under the guidance of an experienced teacher.

Slow expiration

The third phase of respiration is expiration.it is a passive act. It should take more time

than for inspiration.

Firstly there is a mechanical advantage by slow expiration. The sudden release of the

elastic tissue in the lungs will comeback violently, but on slow-release, it will maintain its

elasticity. The major advantage of slow expiration, however, is in the brain and psyche.

i.e., the conscious effort required for slow release needs the help of the cerebral cortex

in the brain. The cerebral cortex then sends inhibitory impulses to the respiratory

centre situated in the midbrain. These inhibitory impulses from the cerebral cortex

overflow into the adjoining area of the hypothalamus, which is concerned with

emotions. Hence, there is a soothing effect on slow expiration.

26
Different types of Pranayama practiced in our study are

1. Anulom -vilom (alternate breathing technique)

2. Kapalbhati (skull shining breath)

3. Brahmari pranayama (the humming bee breath)

4. Bhastrika pranayama ( the Bellows breath )

Bhastrika pranayama

Bhastrika ( bellow type of Pranayama) forcefully expels the gases from the stomach.

This is entirely a mechanical effect.

The rectus abdominus and the other anterior abdominal wall muscles are well exercised

during bhastrika pranayama. On properly developing these muscles

through Pranayama, the intestinal organs in the abdominal cavity get proper support

from the front. The organs which are attached to the spinal column are loosely

hanging in the abdominal cavity. If they lack support in front, they are likely to cause a

stretch on the lumbar spine, which leads to low back pain. But by toning up abdominal

muscles, and making support to intestines in the front, the strain on the spine is

reduced, and back pain is relieved.

The stagnant blood which is collected in the splanchnic venous pool of the intestines is

pumped out, which increases the amount of blood in total circulation.

27
Bhastrika pranayama exercises the diaphragm and renews the residual air in the

lungs. It is a process of hyperventilation, leading to respiratory alkalosis, which has a

soothing effect on the respiratory centre. Hence we can retain air better after this

Pranayama.(18)

Mechanism of Pranayama

While Pranayama practicing the cascade begins with stretch receptors in the lungs,

aortic arch, and carotid arteries. Inside the lungs, a mild increase in the tidal volume will

activate the Hering-Breuer reflex .this reflex translates the increased activity of stretch

receptors to increased activity of Vagus nerve producing inhibitory signals from the

action of slowly adapting receptors and hyperpolarising currents.

These inhibitory signals coming from cardiorespiratory regions involving vagi are

believed to synchronize neural elements in the brain leading to changes in the

autonomic nervous system, and a resultant condition characterized by reduced

metabolism and parasympathetic dominance.

The net result is increased in the "relaxing hormones” i.e. (such as GABA), and

decrease in the release of “excitatory hormones”. A similar reflex also happens with

baroreceptors in the aorta and carotid bodies in the carotid arteries, when the body is

flooded with relaxation hormones the heart rate slows down, blood vessels relax

28
(resulting in decreased blood pressure), anxiety decreases and digestion improves.

(19)

The most obvious secondary benefit of this type of breathing is strengthening the

accessory breathing muscles, such as internal and external intercostal muscles(

between the ribs). As we are actively concentrating on inhaling for longer than normal,

we utilize more of our lung capacity in normal uncontrolled breathing. The average

person only utilizes about one –third of the total lung capacity, but when we

actively manipulate our inhales and exhales, we strengthen the muscles and prepare

ourselves for situations when Breath needs to be increased like while doing

exercise.(19)

ASANAS

Yoga postures (asana) involve isometric contraction, which is known to increase

skeletal muscle strength. Yoga training improves the strength of expiratory as well as

inspiratory muscles.[18] Yoga strengthens the respiratory muscles due to which chest

and lungs inflate and deflate to the fullest possible extent and muscles used to the

maximal extent.

As asana are performed in synchronization with the breathing, it further increases the

oxygen-carrying capacity to the muscles, which are stretched in various poses.

However, in Yoga as our consciousness is focussed voluntarily with the help of the

cerebral cortex on the muscles of stretching, increased oxygen concentration in the

muscles leads to greater flexibility, and new capillaries are formed to balance the

increased demand.(20)

29
 Studies on Physical Parameters

Pulmonary function tests (FVC, FEV1, PEFR)

1. In a study conducted by A James et al., Pondicherry university (2009)

“On the effects of twelve weeks of yoga asana, Pranayama, and meditation on

biochemical, physiological, and psychological variables” among 20 male subjects in

comparison with a control group. They found that There was an significant improvement

in forced vital capacity*(FVC) from 2.95 lit preintervention mean to 3.22 lit post

interventional mean (p-value 0.004)and FEV1 FROM 2.88 preintervention mean to 3.16

post-intervention mean(p-value 0.005).PEFR from 413.15 to 474.6 in 12 weeks of yoga

training.(p value 0.03)(6)

2. A study by M.S. Nayer et al. (2007) on the effects of Yogic exercises on human

physical efficiency Which was conducted on 53 cadets of National Defence Academy

reported that parameters like ventilation, minute volume, rate of

respiration, pulse rate and blood pressure, Vital Capacity (V.C.), Maximum Breathing

Capacity (MBC), Forced Expiratory Volume (FFV 10 Sec) and Breath Holding Time in

the study subjects recorded a highly significant results. They reported an increase in

Breath-holding time (from 54 to 106 Sec and FVC from 1.98 to 2.89 L/m2 body

surface area). And FEV1increased from 2.6 to 2.91 lit/sec.(5)

30
3. In a study conducted by Keshur A.et.al., to know the effects of Yoga on

pulmonary function tests. (2015) In a government medical college Gujarat.There was

a significant increase in Breath Holding Time in all from 27.5 to 34.70 seconds mean

after a yoga period of 10 weeks. Improvement in Breath holding time may be due to

practice of Yoga, which makes stretch receptors to withstand more stretching. Also, the

sensitivity of the respiratory centre to carbon dioxide is reduced. Hence

respiratory centre can withstand higher carbon dioxide concentrations in the alveoli and

the blood. With training, a subject can exercise voluntary control on the respiratory

muscles overriding the excitatory stimuli to respiratory centres. In addition, there is

gradual acclimatization of receptors to the increased concentrations of carbon dioxide.

A significant increase in MVV is seen from 110 /min to 120 /min mean after Yoga

practice in subjects which might be due to increased strength and endurance of

respiratory muscles. They reported that improvement is due to integrated interaction of

respiratory muscles, chest wall, alveoli and airways - mediated by increased lung

compliance; which in turn, could be a result of the enhanced release of lung

surfactants and prostaglandins. This study also showed a significant decrease in

R.R. from 17.83 to 16.18 per minute respiratory rate mean after Yoga practice. (21)

4. In a study conducted by Keshur karmur A. et al., on Effect of ten weeks yoga

practice on pulmonary function tests(2015) there was an improvement in forced vital

capacity from 2.25 lit to 3.03, FEV1 from 1.99 TO 2.53, PEFR from 6.50 TO 8.02 and all

31
the results were significant. In their yoga training schedule, they included Pranayama

like Kapalbhati and Nadi-sadhana, which involves powerful strokes of exhalation, which

trains the subject to make full use of the diaphragm and abdominal muscles. Slow,

deep, and full inhalation and exhalation, as in Anulom-vilom and Bhastrika Pranayama,

also improves respiratory muscle strength. (22)

5. In a study done by Yadav et al., on the effect Of Yoga on pulmonary function tests

(2009) in 30 male individuals reported that parameters like FVC from 2.7 to 3.12 lit,

FEV1 from 2.74 to 3.04, AND PEFR showed significant improvement after 12 weeks of

yoga practice. (p-value 0.04)

6. In a study conducted by SAVITA SINGH et.al. On the "effect of yoga practices on

pulmonary function tests Including transfer factor of the lung for carbon monoxide (telco)

in asthma patients.” They assessed the pulmonary function tests and also the Quality of

life change before and after Yoga.

After Yoga the patients showed significant improvement in TLCO from 21.25±4.75

ml/mmHg/min to 23.35±4.47 ml /mm Hg/min FVC from 3.23±0.93 1 to 3.43±0.93 1,

FEV1 from 2.80±0.71 1 to 3.11, FEVI/FVC from 81.35±7.08% to 82.19±5.24%, PEFR

from 5.53±1.46 l/sec to 6.41±1.03 l/sec MVV from 74.31±20.11 l/min to 85.33±24.42

l/min, SVC from 2.84±0.80 1 to 3.20±0.83 1, thus showing significant improvement in

Pulmonary parameters as compared to baseline, P<0.001.(23)

32
7. In a study conducted by Makwana et al., to find out the effect of short term yoga

practice on ventilatory function tests, they used 35 healthy normal male subjects, their

age ranging from 20 to 35 years. They reported that the experimental group of 25

subjects underwent ten weeks of yogic practices for 90 minutes daily .They found out

that 1. the rate of respiration decreased significantly (P.L. .05) in the study group

more than the control group. 2. Vital capacity has been found to increase significantly

from 2.75 to 3.18 liters in Yoga than the control group (p value< 0.04). 3. Tidal volume

did not show any significant change in the yoga and control groups. (24)

8. In a study conducted by Hari Krishna et.al., at All India Institute of Medical Sciences,

Delhi, India(2008), reported that adding a comprehensive yoga-based mind-body

intervention to the conventional treatment improved several measures of pulmonary

function in subjects .. Yoga improved the Quality of life and reduced medication use in

bronchial asthma, and achieved the reduction earlier than conventional treatment alone

(24). Yoga training produced a statistically significant increase in p-value (<0.05 ) in

FVC from 2.63 to 2.95. Lit, FEV1from 2.60 to 2.84lit/sec, peak expiratory flow rate

(PEFR) also increased significantly (P < 0.01) after the yoga training. But, the increase

in these parameters in the control group was statistically not significant and

demonstrated that yoga training for six months improved lung function, the strength of

inspiratory and expiratory muscles among school children aged 12–15 years. It is

suggested that Yoga must be introduced at the school level to improve physiological

functions, overall health, and performance of students.(25)

33
9. In a study conducted by Abhinav et.al,(2011) , on the Evaluation of Global Physical

Activity Questionnaire (GPAQ) among Healthy and Obese Health professionals in

Central India Total physical activity measured in mean MET minutes per week was

625.6, 786.3,296.5, and 296.5 for third-year students, final-year students, interns, and

faculty respectively (p ≤ 0.05). Overweight problems were seen in 19.7%, 24.7%,

24.7%, and 30.8% of third-year students, final-year students, interns, and faculty

members, respectively (p ≤ 0.001). A significant correlation was seen between physical

activity categorical indicator and BMI.(26)

Blood pressure and pulse rate

10. In a study done by Vaidya et al.,on the effect of Yoga on pulse and blood

pressure among medical students(2001) – in 40 boys and girls of 16-18 years. They

reported that on six weeks of training There was a decrease in pulse rate after the

yoga training in boys and girls. (p-value <0.002)(27)

11. In a study done by Prasad et.al.(2006), on the effect of Yoga on overall wellbeing,

among 44 subjects, 38 were males, and 6 were females in the age of 20-69 years. Their

pre yoga systolic pressure and diastolic pressure was 140 mm hg

34
and 90 mm of Hg. They reported that practicing savasana twice a day for 30 minutes for

a period of 3 months. After the practice, the patients had a definite feeling of well being

as they reported a marked improvement in headache, narrowness, irritability, and also

their average mean blood pressure significantly reduced from 140 to 107 mm Hg after

the treatment and diastolic from 90 mm of hg to 82 mm of Hg (p-value <0.04) (28)

12. In a study conducted by A.James,(2009) on the effect of yogasanas and Pranayama

on physiological aspects of health reported that after 12 weeks of yoga intervention

Systolic Blood pressure decreased from 115 to 105 mm of Hg .diastolic blood pressure

decreased from 74 to 67 mm oh Hg(p-value 0.01). pulse rate decreased from 75.5 to

69.9 / min.(p-value (0.03) Breath-holding time increased from 52.5 to 100.5 sec..(p

value 0.048)(6)

13.In a study conducted by M.S.Nayer et.al.on effect of Yoga on human physical

efficiency, in national defense academy. They reported that all the groups showed a

significant decrease in pulse rate during exercise from 79.6 to 75.1beats /min

(p-value 0.04)(5).

14. In a study conducted by Kerstin Khattab(2011), the effect of Iyengar Yoga on

cardiovascular system they reported that an increased Cardiac Parasympathetic

Nervous Modulation Among Healthy Yoga Practitioners. They reported that on training

11 yoga professionals for 90 min once a week with Iyengar yoga, the mean R.R.

interval was significantly higher during the time of yoga intervention, compared to the

35
placebo program conducted among 11 control ( p<0.004). The increase in Heart Rate

Variability was significantly higher during Yoga than during placebo program. They

reported that relaxation by yoga training is associated with a significant increase in

cardiac vagal modulation.(29)

Studies on Mental Health

15. In a study conducted by Suprabha Srivastava1*et.al(2017) on Interventional

Effect of Bhramari Pranayama on Mental Health among College Students, A

Mental Health Scale (Kamlesh Sharma 1996) was used before and after Yoga.They

reported that results show the increased mental health score from 74.26 pre mean to

94.46 posts mean mental score after Bhramari Pranayama intervention for a period of 6

weeks.(30)

16. In a study conducted by Bravo, Adrian J et al. (2018) on “College student mental

health: An evaluation of the DSM-5 self-rated Level 1 cross-cutting symptom

measure.” They reported that Preliminary evidence supports its utility with clinical

samples. , however, the comprehensive structure of the DSM-5 Level 1 measure may

be used for a high-risk population that is less likely to seek treatment. They stated that

College students have high rates of hazardous substance use and co-occurring

mental health symptoms, yet rarely seek treatment. They also reported that the

psychometric properties of the DSM-5 Level 1 measure the large, diverse sample of

36
non-treatment-seeking college students. Data recruited from ten universities in ten

different states across the U.S. evidenced psychometric validation of the DSM-5 Level 1

and they stated that , the prevalence of potential symptom presentation for the domains

are as follows: anxiety (27.89%), depression (27.87%), anger (27.54%), sleep

disturbance (25.47%), mania (21.91%), personality functioning (20.07%), somatic

distress (17.11%), memory (12.09%), dissociation (11.70%), repetitive thoughts

and behaviors (10.95%), suicidal ideation (7.46%), and psychosis (4.00%). For

substance use, we present the rates by specific substances: alcohol use (32.06%),

tobacco (15.53%), and other drug marijuana use (14.68%).(31)

17.In a study conducted by Hailey Meaklim et al. to assess the “feasibility of

implementing the DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure into a

sleep psychology clinic to identify coexistent psychiatric symptomatology”. They stated

that it was simple and quick to administer and score and reported high levels of

psychiatric symptomatology in sleep psychology patients. Sleep problems(86%) were

the most common domain of psychiatric symptomatology reported. Anxiety (66%),

depression (65%), anger (64%), and somatic symptoms (50%) were also very common,

and Suicidal ideation was acknowledged by 26% of patients. In fact, 82% of

patients had at least one diagnosed comorbidity upon referral (e.g., psychiatric, physical

health, or other sleep disorder.(32)

37
18. In a study by A.JAMES, the mental health of the participants was also assessed by

using a mental health questionnaire(self-concept scale and type of personality). there

was a significant improvement in the mental health score from 60.6 pre-tests mean to

68.5 post-test mean in the study (p value< 0.03)(6)

19. In a study by Johns and pate(2017) to investigate the relationship between

change in physical fitness level and changes in locus of control and self-concept.

Participants of adult fitness program who had volunteered to participate in the study. On

testing the subjects for cardiovascular fitness and assessing with the Rotten Interval -

External scale and self-concept for a locus of control. They reported that exercising

three times a week for 12 weeks with Aerobic exercise resulted in

Decrease in body fat percentage(b) significant increase in self concept(p-value

<0.05).the locus of control didn't show any significant change. (6)

20. In a study done by Rahul Bansal, Monika Gupta (2106), on effect on ten weeks of

yoga training on the mental health of medical students in Govt.medical college, Gujarat.

Reported significant improvement in mean mental health scores (18.02 premean score

to 10.8 posts mean score)(p-value <0.04) in the 4 tested areas by using validated

GENERAL HEALTH QUESTIONNAIRE-28,consisting of somatic symptoms

,anxiety/insomnia, social dysfunction, depression and also reported 30 % better

sleep,25 % better control of anger, 80 % increase in energy levels and active

throughout the day.(33)

38
21. In a study conducted by SAVITA SINGH et.al, on the effect of Yoga on Quality of life

reported that the improvement in mean score of Quality of life- Symptom domain from

4.56±0.43 to 6.21±0.63, activity domain from 4.38±0.91 to 6.03±0.73, emotion domain

from 4.16±0.73 to 5.58±0.82, environment domain from 3.80±1.13 to 4.80±1.07 thus,

showing significant improvement in Quality of life.(p-value <0.05).(23)

After reviewing all the available literature on various benefits of yoga and including both

physical and mental and changing trends in students who are more prone to stress and

sedentary behaviour among younger students, we thought yoga would be a best

therapy for energizing the medical students .

But so far only few studies are there in the India which explains the mental domain

along with physical benefits of yoga. Hence we want to fill the Gap by adding the

scientific evidence through our study to the already existing nectar of knowledge on

yoga.

39
 RESULTS

The study was conducted among 35 students of the 4th semester of Andhra medical

college.

Thirty of them are residing in the medical college hostel, and five students are day

scholars, .and all of them attended the yoga sessions five days a week for six weeks in

the month of June-July, 2019.

General characteristics of the study subjects

Figure 4: Gender distribution among study subjects

Gender distribution
F M

31%

69%

Among the 35 subjects, 69 % were female, and 31 % were male students.

40
All the study participants ranged from 19 to 21 years; the mean age of the subjects in

the present study was 19.65± 0.764years. The mean height (cm) was 160.6 ± 6.66, the

mean weight (kg) was 65.6± 8.765, and the mean BMI (kg/m2) was 24.05 at the start of

the study in the group.

Table 3: BMI, HEIGHT, WEIGHT, AND AGE among the study subjects

PARAMETERS Mean

AGE 19.6 years

HEIGHT 160.6 centimeters

WEIGHT 65.6 kilograms

Body mass index(BMI) 24.05

Table 4 : Distribution of students by Body Mass Index

BODY MASS INDEX

NUMBER PERCENTAGE
(BMI) CATEGORIES
Normal(18.5 to 22.9) 11 31.4
Overweight(23 to 24.9) 14 40.0
Obese 1(25 to 29.9) 10 28.6
Total 35 100.0

41
In the study population, no one was underweight, and 31 % were in the normal BMI
category 40% were in the overweight category, and 28.6 % of students were in obese
category. The mean body mass index (BMI) of the study population is 24.05.

Fig 5: DISTRIBUTION OF STUDY SUBJECTS by BODY MASS INDEX

40
40
35 31.4
28.6
30
25
Series1
20
Series2
15
10
5
0
(18.5 to (23 to (25 to 29.9)obese
22.9)normal 24.9)overweight 1

1. PHYSICAL ACTIVITY

1.1.1. GLOBAL PHYSICAL ACTIVITY QUESTIONNAIRE(GPAQ)

2. PHYSICAL PARAMETERS

2.1. pulmonary function tests

2.1.1.1. Forced vital capacity(FVC)

2.1.1.2. Forced expiratory volume in 1st sec(FEV1)

2.1.1.3. PEAK EXPIRATORY FLOW RATE (PEFR)

2.2. Blood pressure(SYSTOLIC AND DIASTOLIC)

42
 2.3. Pulse rate
3. MENTAL HEALTH

3.1.1. DSM 5- LEVEL 1 CROSS-CUTTING SYMPTOM MEASURE

Global physical activity questionnaire (GPAQ)

Table 5: Distribution of Students Based On Their Total Physical Activity

No .of
Physical activity percentage
students

Physically active(>600 MET) 23 65.7%

Insufficiently active (<600 MET) 12 34.3%

Total 35 100

Overall, 23(65.7%) of the study subjects had a physical activity of >600 METS per

week as required by the WHO standards.

12 (34.3 %) of the study group are “insufficiently active” <600 MET according to

WHO standards.

43
Table 6: BMI and PHYSICAL ACTIVITY

Chi-
New cat BMI Total square
METcat value
18.6 to 22..9 23 to 24.9 >25

>600 MET 7(30.4%) 9(39.1%) 7(30.4%)) 23

<600 MET 3(25%) 6(50%) 3(25%) 12

0.895
Total 10 14 10 35

Among students who are physically active(>600 Mets) 30.4% of the students were

normal,39.1% were overweight and 30.4% were obese according to their BMI.

Among the students who are insufficiently active (<600 METS) 25% of the students

were normal, 50% of them were overweight and 25% of them were obese according to

their BMI. But there is no significant association between physical activity and BMI..(P-

VALUE >.0.05)

44
 Results of Physiological Parameters

The values of all pulmonary function parameters like FVC, FEV1, PEFR are expressed

as a percentage of predicted value by a spirometer for maintaining uniformity among all

the participants.

Forced vital capacity

Table 7: Means of percentage predicted forced vital capacity before and after

yoga in study subjects.

MEAN of
Standard
parameter %predicted P VALUE
deviation
FVC

FVCbefore 79.800 7.0786

Study 0.00

FVCafter 87.114 7.6649

Significance at 0.05 level

The mean of percent predicted forced vital capacity increased from 79.800 to 87.114 in

the study group after six weeks of yoga intervention (p-value 0.00) which was

statistically significant (p-value 0.00)

45
 Forced expiratory volume in 1st sec

Table 8: Means of percentage predicted FEV1 before and after yoga in study

subjects.

MEAN of

parameter %predicted Standard

FEV1 Deviation p-value

FEV1Before
84.029 9.9424

0.0400

FEV1after 91.486 9.3820

The mean of percent predicted forced expiratory volume in 1 st sec increased from 84.02

pre-intervention to 91.42 post-intervention, and the results are statistically significant(p-

value 0.04) p-value is less than 0.05.

46
 Peak Expiratory Flow Rate

Table 9: Means of percentage predicted PEFR before and after yoga in study

subjects

MEAN of

%predicted

parameter FEV1 Std. Deviation p-value

PEFR before
69.714 13.3649

0.0000

PEFR after 82.800 9.6247

significance value < 0.05

The means of percent predicted peak expiratory flow rate has increased from 69.7%

pre-test mean to 82.8 % post-test mean( p-value 0.00). The results are statistically

significant (p < 0.05).

47
 Pulse Rate

Table 10: Means of pulse rate before and after yoga in study subjects

Std.
parameter n Mean p value
Deviation

Pulse rate
35 79.485 5.548
before
0.001
4.021
Pulse rate after 35 76.057

The pulse rate decreased in the study group after the study period from 79.48 to 76.05,

and the difference is statistically significant.(p vale 0.001)

Systolic Blood Pressure

Table 11: Means of Systolic Blood Pressure (SBP) before and after yoga in study

and control group

parameter n Mean Std. Deviation p-value

SBP before 35
110.286 9.23
0.0670
SBP after 35 112.000 7.97

48
The systolic blood pressure increased from 110 to 112 mm of Hg in the study group

after the six weeks study period, which is not statistically significant (p-value >0.05).

Diastolic Blood Pressure

Table 12: Means of Systolic Blood Pressure (SBP) before and after yoga in the
study and control group

Std.

parameter n Mean Deviation p-value

DBP before 35
76.286 6.4561
0.3320

DBP after 35 76.800 5.1894

The diastolic blood pressure changed from 76.2 to 76.8 mm of Hg in the study group

after the study period, and it is not statistically valued =0.332(p-value >0.05)

49
 DSM 5 -Level 1 Cross-Cutting Symptom Measure

The highest domain score are divided into 2 categories.

 One : Highest domain score of 1 (options 0 ( not at all) and 1 (less than a day or

two) on Likert scale)

 Two and above: A rating of mild, i.e., 2(several days ) or greater(3-more than

half the days 4-almost every day) on any item within a domain may serve as a

guide for additional inquiry and follow up to determine if a more detailed

assessment for that domain is necessary.

Table 13: Comparison of highest domain scores before and after yoga in study

subjects.

Highest STUDY GROUP

s.no DOMAIN domain

PREYOGA POSTYOGA
score P-value
n(%) n(%)

1 11(32) 12(34) 1.000

1 Depression
≥2 24(68) 23(66)

1 30(86) 23(66)

2 Anger 0.09
≥2 12(34)) 5(14)

50
 1 20(57 18(52)
0.8
Mania ≥2 15(43) 17(48)
3

1 10(29) 32(91)
4 Anxiety 0.00*
≥2 25(71) 3(9)

1 12(34) 16(45)
5 Somatic symptoms 0.4
≥2 23(66) 19(55)

1 28(80) 35(100)
6 Suicidal ideation 0.01*
≥2 7(20) 0

1 35(100) 35(100)
7 NA
Psychosis ≥2 0 0

1 29(83) 35(100)
8 Sleep problems 0.02*
≥2 6(17) 0

1 29(83) 34(97)
9 Memory 0.1

≥2 6(17) 1(3)

Repetitive thoughts 1 24(68) 35(100)

10 0.000*
and behaviours ≥2 11(32) 0

1 29(83) 35(100)
11 Dissociation 0.02*
≥2 6(17) 0

Personality 1 17(49) 34(97)

12 0.000*
functioning ≥2 18(51) 1(3)

51
 1 35(100) 35(100)
13 Substance use NA
≥2 0 0

*statistically significant

In the depression domain, 68% of students were in the highest domain percentage

before the intervention, which was decreased to 66% post yoga. But these results are

not statistically significant. p-value (1.000)

In the anger domain, 34% of students were in the highest domain percentage before the

intervention, which was decreased to 14% post-yoga. Which was not statistically

significant. p-value (0.09)

In the mania domain, 43% of students were in the highest domain percentage before

the intervention, which was increased to 48% post-yoga, but these results are not

statistically significant. p-value (0.80)

In the somatic symptoms domain, 23% of students were in the highest domain

percentage before the intervention, which was decreased to 19% post-yoga. But these

results are not statistically significant. p-value (1.000)

In the psychosis domain, none of the students were in the highest domain percentage

before the intervention.

In the memory domain, 17 % of students were in the highest domain percentage before

the intervention, which was decreased to 3% post-yoga. But these results are not

statistically significant. p-value (0.1000)

52
In the dissociation domain, 17% of students were in the highest domain percentage

before the intervention, which was decreased to 0% post-yoga. But these results are not

statistically significant. p-value (1.000)

In the substance abuse domain, none of the students were in the highest domain

percentage before the intervention.

Out of the 13 domains, a significant difference was observed in domains of anxiety,

suicidal ideation, sleep problems, repetitive thoughts and behaviors, and

personality functioning.

In the anxiety domain, 71% of students were in the highest domain percentage before

the intervention, which was decreased to 9% post-yoga. These results are statistically

significant. p-value (0.001)

In the suicidal ideation domain, the yoga highest domain percentage was 20% which

was decreased to 0% post-yoga, and it is statistically significant p-value(0.01)

In the sleep problems domain, the preyoga highest domain percentage was 17 %

which was decreased to 0% post yoga, and these results are statistically significant(p-

value: 0.000)

In the repetitive thoughts and behaviours domain, 32 % of os students were in the

highest domain percentage which was decreased to 0% post-yoga, and these results

are statistically significant .p value (0.000)

53
In the personality functioning domain, the preyoga highest domain percentage was

51%, which was decreased to 3% post-yoga. p-value (0.000)

Table 14: Comparison of Improvement in pulmonary functions in both

physical activity groups
Std.
Mean P-value
METcat Deviation

FVC before - after 7.7826 4.2422 .000*

FEV1 Before - after 6.3478 4.3652 .000*

PEFR before - after 11.8696 8.2313 .000*

SBP mm hg before -
1.7391 4.9103 .103
after

>600 MET DBP before - after .7826 3.8133 .336

Pulse rate before –

2.0435 5.6527 .097
pulse rate after

FVC before - after 6.4167 6.2879 .005*

FEV1Before -
3.9167 3.5792 .003*
FEV1after
<600 MET
PEFR before - after 14.3333 11.2034 .001*

SBP mm hg before -
1.6667 5.7735 .339
after

54
 Pulse rate before –
6.0833 4.5017 .001*
pulse rate after

*statistically significant

Among the study population who are having a good physical activity before intervention

i.e.,>600 METS of physical activity showed significant results after the intervention, just

like them the study population who are not having good physical activity i.e., <600

METS also showed significant improvement(p-value <0.05).

But the mean improvement of FVC (7.78) AND FEV1 (6.34) was more in physically

active group when compared to improvement in FVC (6.41)and FEV1(3.9)) in

physically inactive group.

55
 DISCUSSION

In the present study it was hypothesized that there would be a significant effect on

physiological and psychological variables as a result of six weeks of yogasana,

pranayama, and meditation practice.

The results are discussed in the following order:

1. General characteristics

2. Physiological characteristics

3. Mental characteristics

General characteristics

1.Age and Gender

The mean age of students in the present study is 19.65 ± 0.764, and all of them are

students of the 4th semester in Andhra medical college, unlike in other studies like

keshur A karmur who conducted the study in age population of 19-45 in people

attending the yoga centre.

In the present study, subjects include 23 females and 12 males and all are in fourth

semester unlike in a study by A.James et.al, which included only 20 male as a study

group and considered it as their limitation in their study.

All the study subjects in the present study are relatively young in age and medical

students who have knowledge regarding human Physiology and Anatomy so they have

more scope for understanding the mechanisms of pranayama breathing and conscious

56
exercises while practising yoga when compared to the subjects in other studies like

keshur karmur et.al which included General population .(21)

2.Physical activity

In the present study On assessing the physical activity of students using GPAQ

students who are physically active and insufficiently active both showed significant

improvement in pulmonary function tests.

But the mean improvement of FVC (7.78) AND FEV1 (6.34) was more in physically active group

when compared to improvement in FVC (6.41)and FEV1(3.9)) in physically inactive group.

Which are consistent with the study of Madanmohan et al. [21], Chen and Kuo [22] who have

reported that respiratory muscle endurance is more in physically active than sedentary men.

(34)

Among the study subjects of fourth semester over all 40% are overweight and 28% are

obese1 similar to a study conducted by Abhinav Singh, Bharathi Purohit, which used

Global Physical Activity Questionnaire (GPAQ) to assess the physical activity of 324

dental health care professionals (third-year students, final-year students, interns, and

faculty). Overweight problems were observed in 19.7%, 24.7%, 24.7% and 30.8% of

third-year students, final-year students, interns, and faculty members, respectively (p ≤

0.001)..(26)

57
In the present study, among the physically insufficient (<600 METS) subjects, 50 % o

are in overweight and 25% are in obese and only 25% of them are in normal weight

category. But this not showed any statistical significance between BMI and physical

activity unlike in a study by Abhinav Singh et.al., in which a significant correlation was

seen between physical activity categorical indicator and BMI .The mean BMI

obtained in our study was 24.05.

Physiological characteristics

3 .Pulmonary function tests

1.FVC and FEV1

On analysing the results of present study before and after 6 weeks of regular yoga

practice, it was found that there is highly significant improvement in all the pulmonary

function parameters like FVC from 79.8±7.07% to 87.1 % ±7.7%(8.2%) of the predicted

value based on their BMI(p value 0.00) , FEV1 from 84.01 to 91.4(7.4%) (p-value 0.04),

PEFR from 69.7 to 82.8(p value 0.00) , similar to other studies like keshur Kumar et al.

which showed increase in FVC from 2.25 TO 3.03 lit (30.3%) , FEV1 from 1.99 TO 2.53

lit/sec(27.8%),(22) and also in study A. James(6) which showed improvement in

pulmonary function tests FVC from 2.95 to 3.22(9%) FEV1 from 2.88 to 3.12(8.3%)

58
and others studies like L.N. Joshi et al. [15], Rajkumar Yadav et al. [16], Madanmohan

et al. [17]

The improvement in FVC and FEV1 in our study was similar to study by A james which

practiced yoga for 12 weeks by consistently performing a variety of Asana but

improvement in percentage is lesser when compared to study by keshur karmur .which

may be due to the various factors difference in age, health of the subjects before

interventipon and duration of intervention i.e., for 10 weeks and 12 weeks.

The reason for improvement may be due to fact that muscles of the thoracic cavity are

constantly being recruited during their active and conscious usage during the active

breathing techniques in yoga according to Charles Darwin, Use and Disuse theory.

This recruitment may lead to greater musculature effort and thereby result in

improved FVC.

Pranayama, like Kapalbhati and bhastrika included in our present yoga training

schedule involves powerful strokes of exhalation, which trains the subject to make full

use of diaphragm and abdominal muscles.

Slow, deep, and full inhalation and exhalation as in Anulom-vilom pranayama also

improves the strength of respiratory muscles. Hence evaluation of respiratory muscle

strength is important from physiological and also clinically.(35)

59
 3. PEFR

In our study the peak expiratory flow rate increased from PEFR from 69.7 % to 82.8 %

(13.1%) (p-value 0.00) similar to other studies like A.JAMES which showed

improvement from 413.2 TO 474.4(14.7%) and keshur kumar etal which showed an

increase of PEFR from 7.14 TO 8.77 (22%)(p vale 0.001) (22) and in studies of K

Upadhyay Dhungel et al. [18], Vinayak P. Doijad et al. [19], and Ankad Roopa B et al.

[20]] showed the significant increase in PEFR i.e from 6.50 ± 2.33 to 8.02±2.20(23%).

(36)

Stimulation of pulmonary stretch receptors by the expansion of the lung relaxes smooth

muscles of the larynx and tracheobronchial tree; probably this modulates the caliber of

the airways and reduces airway resistance. The increase in PEFR among the

volunteers might be due to rise in thoracic -pulmonary compliances and bronchial

dilatation.

The increase in PEFR by yogic exercise was due to the following changes in respiratory

dynamics:

1. increased respiratory muscle strength by the exercises of these muscles,

2. Cleansing of airways secretions and

3. Efficient use of diaphragmatic and abdominal muscles by various types of in a

Pranayama like bhastrika pranayama, thereby emptying and filling the respiratory

apparatus more efficiently and completely. (36)

60
 4. Pulse rate

In the present study pulse rate decreased from 79 beats/min to 76 beats/min even

though that is not statistically significant reduction in pulse rate after regular practice of

yoga, but the change is attributed to increased vagal tone( parasympathetic

dominance) and decreased sympathetic activity as reported in the study of

A.JAMES(2) which reported that there is a change in pulse rate before and intervention

from 75.5 to 69.9 , and Joshi et al from 79.8 to 72.2 beats /min(15) . Decreased

sympathetic activity reduces catecholamine secretion which also leads to vasodilation

followed by improvement in the peripheral circulation. It is also reported that regular

practice of yoga reduces Basal metabolic rate and Resting oxygen consumption. All

these may be responsible for the reduction in resting pulse rate. (27)

5. Blood pressure

In our present study, the mean systolic pressure before the intervention was 110±9.23

mm of Hg and after the intervention was 112±7.97mm of Hg of systolic blood

pressure(p-value >0.05)and it is statistically not significant.

The diastolic blood pressure changed from 76.2 to 76.8 mm of Hg in the study group

after the study period, and it is not statistically valued =0.332(p-value >0.05)

But in contrast, other studies like. S.M. Vaidya and M.S. Pansare(14), Keshur A.

Karmur et al. (10),a.james and Karmur KA(9) they showed a significant decrease in

61
systolic blood pressure from 115 mm of Hg to 105 mm of Hg and diastolic blood

pressure from 74 mm of hg to 68 mm of Hg. May be due to the lesser duration of yoga

training the present study did not derive significant changes in blood pressure.

As Yoga asanas, involve isometric contraction it is known to increase skeletal muscle

strength. Breathing along with asanas improves the strength of expiratory as well as

inspiratory muscles. therefore the respiratory muscles are made to work to a maximal

extent.

As Pranayama involves deep inhalation and prolonged exhalation the focus is on

more prolonged expiration and efficient use of abdominal and diaphragmatic muscles.

This simple act trains the lungs to get emptied and filled more completely and efficiently.

Mental health

Most of the students often experience significant stress during their training in medical

colleges and universities but are not evaluated and they don’t even seek for help. But

the fact the prevalence is increasing now a days as evidenced in the present study that

out of 35 students these symptoms are present as

Depression(68%),anger(34%),anxiety(71%),sleep,isturbance(17%),mania(43%),per

sonality functioning(51%),somatic symptoms

(66%),memory(17%),dissociation(17%),repetitive thoughts and

62
behaviours(32%),suicidal ideation(20%). just like the study conducted by Bravo,

Adrian J et al. (2018) with Data recruited from ten universities in ten different states

across the U.S which showed the prevalence of potential symptom presentation for the

domains like anxiety (27.89%), depression (27.87%), anger (27.54%), sleep

disturbance (25.47%), mania (21.91%), personality functioning (20.07%), somatic

distress (17.11%), memory (12.09%), dissociation (11.70%), repetitive thoughts

and behaviours (10.95%), suicidal ideation (7.46%), and psychosis (4.00%).(31)

In the present study, there is a significant change in the mental health domains of the

students by decrease in percentages like Anxiety by 60% (p-value 0.01), sleep

problems by 17%(p value 0.02), repetitive thoughts and behaviours by 32 % (p-

value 0.00), personality functioning by 48% (p-value 0.00), and suicidal ideation

by 20%(p-value 0.01).

The results are also similar to others like In a study done by Rahul Bansal et.a., on

medical students of a government medical college in Gujarat reported significant

improvement in mean mental health scores (18.02 premean score to 10.8 posts mean

score)(p-value <0.04) in the 4 tested areas consisting of somatic symptoms

,anxiety/insomnia, social dysfunction, depression and also reported 30 % better

sleep,25 % better control of anger, 80 % increase in energy levels and active

throughout the day.(3)

63
So there is an improvement in the mental health by increasing in the quality of sleep

and mental health among the study group who practiced yoga ,pranayama and

meditation regularly due to various reasons just like in a study by A.James which has

significant improvement in the mental health score from 60.6 pre-tests mean to 68.5

post-test mean in the study (p value< 0.03)(6)

These changes can be explained by some facts like

As students are engaged in the yoga practices as a self-care behavioural treatment,

yoga interventions might well increase self-confidence and self-efficacy.

And also evidences show that Pranayama helps one to discover the great life force

(Prana) that exists both within and around us. It is breath (prana) that gives one energy

and life. By learning to control one's breath, one can gain control over their emotions

and other mental states as well as gradually becoming more sensitive to one's

mind. Breathing pattern also affects the mind and nervous system, with the direct

correlation between the breath and Anxiety, the breath is shorter, more frequent,

and quite shallow in anxiety. The breathing pattern maintains a level of arousal.

The Pranayama, like Bhramari Pranayama, stimulates the reflex of the Autonomic

Nervous System, in turn, the level of noradrenaline, a compound that functions as a

hormone and neurotransmitter in the nervous system, actually increase with a deeper

breathe and resonates while exhaling. This secreted noradrenalin, in turn, helps one

64
to decrease the level of neuro-hormones responsible for various stresses, Anxiety,

and aroused mental state in deeper form through the bio-feedback mechanism. (37)

May be these mental benefits of meditation and Pranayama transformed some students

who are on the verge of suicidal ideation according to our study.

Even though our study didn't show significant changes in domains like depression and

anger other studies like Rahul Bansal, Monika Gupta et al. on medical students also

showed significant improvement in 4 domains like somatic symptoms, somatic

symptoms, Anxiety, and insomnia, social dysfunction and severe depression

by using general health questionnaire-28.

By gaining control over the mind through breath like in Pranayama, repetitive,

unwanted thoughts and behaviours which enter our mind can be curtailed by yoga and

Pranayama, as evidenced by the significant decrease in repetitive thoughts and

behaviours category by 32% of students in our study.

Although a significant increase in pulmonary function parameters after the yoga practice

in the present study is similar with the findings of other studies like on effects of yoga

practice in healthy individuals, the present study had some added benefit because in

the present study, there involved a regular combined practice of Pranayama, Asana,

AUMkar citation, and Prayer( integral yoga )for six weeks continuously, whereas many

other studies reported the effects of Pranayama, Asana or meditation practice for

different duration individually.

65
 Conclusions

Present study was done to investigate the interventional effect of yoga and pranayama

on the physical and mental health of medical students.

1. There is a significant improvement in pulmonary function tests (FVC, FEV1,

PEFR) among the study subjects after 6 weeks yoga .This improvement in

pulmonary function tests was independent of their routine physical activity.

2. There is a significant decrease in pulse rate among the study group.

3. The change in the Blood pressure after intervention was not significant.

4. Practice of yoga had a significant improvement in mental health domains like

anxiety, sleep problems, suicidal ideation, repetitive thoughts and

behaviours and personality functioning.

5. Though Yoga is an individual health promoting practice when done as a group

would be more sustained.

6. . The control group would have helped to find out the whether the effect was only

due to yoga practice.

7. . As this study is done by a convenient sampling method, the confounding factors

could not be completely excluded.

66
 Recommendations

1. Practice of yoga is helpful in improving certain physiological conditions and

improvement in mental health.

2. As Practice of yoga is more sustained as a group activity it may be promoted in

medical colleges as it is acceptable, accessible, and cost-effective and

encourages self-reliance.

67
 Summary

The study was conducted among 35 students of 4th semester of Andhra medical

college.30 of them are residing in medical college hostel and 5 students are day

scholars and all of them attended the yoga classes 5 days a week for 6 weeks in the

month of June - July, 2019.

The mean age of the subjects in the present study was 19.65± 0.7 years. The mean

height (cm) was 160.6 ± 6., the mean weight (kg) was 65.6± 8.7 and the mean BMI

(kg/m2) was 24.05 at the beginning of study .Among these 40 % were in overweight

category and 28.6 % of students were in obese 1 category.

After 6 weeks yoga study period, there was a

1. Significant improvement in the mean of percent predicted forced vital capacity from

79.80 to 87.11(0.00)

2. Significant improvement in the mean of percent predicted forced expiratory volume

in 1st sec from 84.02 to to 91.42 .p-value (0.04)

3. Significant improvement in the means of percent predicted peak expiratory flow rate

has from 69.7% to 82.8 % ( p value 0.00)

4. Significant decrease in the pulse rate from 79.48 to 76.05 beats /min p value

0.001).

5. The systolic blood pressure changed from 110 to 112 mm of hg which is not

statistically significant (p value >0.05)

68
6. The diastolic blood pressure changed from 76.2 to 76.8 mm of Hg which is not

statistically significant (p-value =0.332)

7.Out of the 13 domains of DSM 5 Level 1 cross cutting symptom measure , a

significant difference was observed in domains of anxiety(p value 0.001), suicidal

ideation(p value 0.01), sleep problems( p value 0.00), repetitive thoughts and

behaviours,(p value 0.00) and personality functioning(p value 0.00).

69
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 Annexure 1

PARTICIPANT INFORMATION SHEET

NAMASTE YUVA, my greetings to you all

As a part of my dissertation We are doing a study entitled " An interventional study

on Effects of physical yoga and pranayama on physical and mental health of
medical students "

2.The participants in this study are 18_25 years old students of 4th semester Andhra
medical college, Visakhapatnam .

Before participating in this study , you should know the following details :

1. You will be given an informed consent form .Your written consent is mandatory to
participate in this study.

2. Your general details i.e. Name, age, gender, education, contact number for
communication , awareness regarding yoga, and experiences will be collected for
information purpose .

3. Questions regarding physical and mental aspects are included in the questionnaire.

4. Your Height ,Weight, Blood pressure ,Pulse rate ,and Lung function tests (using
spirometer ) Will be assessed before and after intervention.

5. The intervention totally include Asana, Pranayama and Meditation which will be
carried out for 1 hour a day for 4 days in a week for 6 weeks.

6. You are not being forced to participate in this study. It's purely voluntary whether to
participate or not.

7. The information provided by you will be kept confidential and the data is used only
for statistical analysis.

8. Thank you for your valuable time.

Dr Vijay Rajana

ix
 Annexure 2
Questionnaire

NAME: HOSTELLER/DAY SCHOLAR :

PHONE NO:

GENDER:

1.What kind of physical activity (exercise) you do regularly for at least 10 min continuously?

a. none b. walking c. Jogging d. going to gym e. yoga f. others(specify) ________

2.In what type of activities do you indulge in when you feel stressed?

a. listen to music b. talk to friends c. watch a movie d. read a book e.do physical activity f.any
other (specify)____________

3.Do you think yoga would be more holistic for maintenance of physical activity ?

a. strongly disagree b. disagree c. neither disagree nor agree d. agree e. strongly agree

4.Do you suffer from any of the following medical illnesses?

a. Obesity b. Hypertension c. Diabetes d. Bronchial asthma e. any allergies

f.any other specify_______________

x
 BEFORE STUDY AFTER STUDY
HEIGHT
WEIGHT
SYSTOLIC BLOOD PRESSURE
DIASTOLIC BLOOD PRESSURE
PULSE RATE
FORCED VITAL CAPACITY(FVC)
FORCED EXPIRATORY
VOLUME(FEV1)
PEAK EXPIRATORY FLOW
RATE(PEFR)

xi
 Annexure 3
DSM-5 Self-Rated Level 1 Cross-Cutting
Symptom Measure—Adult

Instructions: The questions below ask about things that might have bothered you. For each
question, circle the number that best describes how much (or how often) you have been
bothered by each problem during the past TWO (2) WEEKS.

None Slight Mild Moderate Severe Highest

Not at Rare, less Several More than Nearly Domain
During the past TWO (2) WEEKS, how much (or how often) have you been
all than a day days half the every Score
bothered by the following problems? or two days day (clinician)
I. 1. Little interest or pleasure in doing things? 0 1 2 3 4
2. Feeling down, depressed, or hopeless? 0 1 2 3 4
II. 3. Feeling more irritated, grouchy, or angry than usual? 0 1 2 3 4
III. 4. Sleeping less than usual, but still have a lot of energy? 0 1 2 3 4
5. Starting lots more projects than usual or doing more risky things than 0 1 2 3 4
usual?
IV. 6. Feeling nervous, anxious, frightened, worried, or on edge? 0 1 2 3 4
7. Feeling panic or being frightened? 0 1 2 3 4
8. Avoiding situations that make you anxious? 0 1 2 3 4
V. 9. Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)? 0 1 2 3 4
10. Feeling that your illnesses are not being taken seriously enough? 0 1 2 3 4
VI. 11. Thoughts of actually hurting yourself? 0 1 2 3 4
VII. 12. Hearing things other people couldn’t hear, such as voices even when no 0 1 2 3 4
one was around?
13. Feeling that someone could hear your thoughts, or that you could hear 0 1 2 3 4
what another person was thinking?
VIII. 14. Problems with sleep that affected your sleep quality over all? 0 1 2 3 4
IX. 15. Problems with memory (e.g., learning new information) or with location 0 1 2 3 4
(e.g., finding your way home)?
X. 16. Unpleasant thoughts, urges, or images that repeatedly enter your mind? 0 1 2 3 4
17. Feeling driven to perform certain behaviors or mental acts over and over 0 1 2 3 4
again?
XI. 18. Feeling detached or distant from yourself, your body, your physical 0 1 2 3 4
surroundings, or your memories?
XII. 19. Not knowing who you really are or what you want out of life? 0 1 2 3 4
20. Not feeling close to other people or enjoying your relationships with them? 0 1 2 3 4
XIII. 21. Drinking at least 4 drinks of any kind of alcohol in a single day? 0 1 2 3 4
22. Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco? 0 1 2 3 4

xii
23. Using any of the following medicines ON YOUR OWN, that is, without a 0 1 2 3 4
doctor’s prescription, in greater amounts or longer than prescribed [e.g.,
painkillers (like Vicodin), stimulants (like Ritalin or Adderall), sedatives or
tranquilizers (like sleeping pills or Valium), or drugs like marijuana, cocaine
or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin,
inhalants or solvents (like glue), or methamphetamine (like speed)]?

Instructions to Clinicians
The DSM-5 Level 1 Cross-Cutting Symptom Measure is a self- or informant-
rated measure that assesses mental health domains that are important
across psychiatric diagnoses. It is intended to help clinicians identify
additional areas of inquiry that may have significant impact on the
individual’s treatment and prognosis. In addition, the measure may be used
to track changes in the individual’s symptom presentation over time.

This adult version of the measure consists of 23 questions that assess 13

psychiatric domains, including depression, anger, mania, anxiety, somatic
symptoms, suicidal ideation, psychosis, sleep problems, memory, repetitive
thoughts and behaviors, dissociation, personality functioning, and substance
use. Each item inquires about how much (or how often) the individual has
been bothered by the specific symptom during the past 2 weeks. If the
individual is of impaired capacity and unable to complete the form (e.g., an
individual with dementia), a knowledgeable adult informant may complete the
measure. The measure was found to be clinically useful and to have good
test-retest reliability in the DSM-5 Field Trials that were conducted in adult
clinical samples across the United States and in Canada.

Scoring and Interpretation

Each item on the measure is rated on a 5-point scale (0=none or not at all;
1=slight or rare, less than a day or two; 2=mild or several days; 3=moderate
or more than half the days; and 4=severe or nearly every day). The score on
each item within a domain should be reviewed. Because additional inquiry is
based on the highest score on any item within a domain, the clinician is asked

xiii
to indicate that score in the “Highest Domain Score” column. A rating of mild
(i.e., 2) or greater on any item within a domain (except for substance use,
suicidal ideation, and psychosis) may serve as a guide for additional inquiry
and follow up to determine if a more detailed assessment for that domain is
necessary. For substance use, suicidal ideation, and psychosis, a rating of
slight (i.e., 1) or greater on any item within the domain may serve as a guide
for additional inquiry and follow-up to determine if a more detailed
assessment is needed. The DSM-5 Level 2 Cross-Cutting Symptom
Measures may be used to provide more detailed information on the symptoms
associated with some of the Level 1 domains (see Table 1 below).

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 Annexure 3

Global Physical Activity Questionnaire (GPAQ)

Physical Activity
Next I am going to ask you about the time you spend doing different types of physical activity in a typical week. Please answer
these questions even if you do not consider yourself to be a physically active person.

Think first about the time you spend doing work. Think of work as the things that you have to do, study/training in hospital wards
and field areas. In answering the following questions 'vigorous-intensity activities' are activities that require hard physical effort
and cause large increases in breathing or heart rate, 'moderate-intensity activities' are activities that require moderate physical
effort and cause small increases in breathing or heart rate.(like carrying bags and doing medical procedures)

Questions Response Code

Activity at work

1 Does your work involve vigorous-intensity activity that Yes 1

causes large increases in breathing or heart rate like
[carrying or lifting heavy loads, digging or construction
P1
work] for at least 10 minutes continuously?
No 2 If No, go to P 4

2 In a typical week, on how many days do you do

Number of days P2
vigorous-intensity activities as part of your work? └─┘

3 How much time do you spend doing vigorous-intensity P3

activities at work on a typical day? └─┴─┘: └─┴─┘
Hours : minutes
(a-b)
hrs mins

4 Does your work involve moderate-intensity activity that Yes 1

causes small increases in breathing or heart rate such
as brisk walking [or carrying light loads] for at least 10
P4
minutes continuously?
No 2 If No, go to P 7

5 In a typical week, on how many days do you do

Number of days P5
moderate-intensity activities as part of your work? └─┘

6 How much time do you spend doing moderate-intensity P6

activities at work on a typical day? └─┴─┘: └─┴─┘
Hours : minutes
(a-b)
hrs mins

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Travel to and from places

The next questions exclude the physical activities at work that you have already mentioned.

Now I would like to ask you about the usual way you travel to and from places. For example to work, for shopping, to market, to
place of worship.

7 Do you walk or use a bicycle (pedal cycle) for at least 10 Yes 1 P7

minutes continuously to get to and from places?
No 2 If No, go to P 10

8 In a typical week, on how many days do you walk or

bicycle for at least 10 minutes continuously to get to and Number of days P8
from places? └─┘

9 How much time do you spend walking or bicycling for P9

travel on a typical day? └─┴─┘: └─┴─┘
Hours : minutes
(a-b)
hrs mins

Recreational activities

The next questions exclude the work and transport activities that you have already mentioned.

Now I would like to ask you about sports, fitness and recreational activities (leisure),

10 Do you do any vigorous-intensity sports, fitness or Yes 1

recreational (leisure) activities that cause large increases
in breathing or heart rate like [running or football,] for at
P10
least 10 minutes continuously?
No 2 If No, go to P 13

11 In a typical week, on how many days do you do

vigorous-intensity sports, fitness or recreational (leisure) Number of days P11
activities? └─┘

12 How much time do you spend doing vigorous-intensity P12

sports, fitness or recreational activities on a typical day? └─┴─┘: └─┴─┘
Hours : minutes
(a-b)
hrs mins

xvi
Physical Activity (recreational activities) contd.
Que
Co
stio Response
de
ns

13 Do you do any moderate-intensity sports, Yes 1

fitness or recreational (leisure) activities that
causes a small increase in breathing or heart
rate such as brisk walking,(cycling, swimming, P13
volleyball)for at least 10 minutes continuously? No 2 If No, go to P16

[INSERT EXAMPLES] (USE SHOWCARD)

14 In a typical week, on how many days do you do

moderate-intensity sports, fitness or Number of days P14
recreational (leisure) activities? └─┘

15 How much time do you spend doing moderate-

└─┴─┘: └─┴─┘ P15
intensity sports, fitness or recreational (leisure)
Hours : minutes
activities on a typical day? (a-b)
hrs mins

Sedentary behaviour

The following question is about sitting or reclining at work, at home, getting to and from places, or with friends
including time spent [sitting at a desk, sitting with friends, travelling in car, bus, train, reading, playing cards or
watching television], but do not include time spent sleeping.

[INSERT EXAMPLES] (USE SHOWCARD)

16 How much time do you usually spend sitting or

reclining on a typical day? └─┴─┘: P16
Hours : minutes └─┴─┘
(a-b)
hrs min s

xvii
 Annexure 5

CONSENT FORM FROM THE SUBJECTS FOR THEIR

VOLUNTAR PARTICIPATION IN THE PRESENT INVESTIGATION.
ND
INVESTIGATOR: DR. R VIJAY, 2 YR POST GRADUATE.
THESIS GUIDE: DR.Y.PADMASRI, PROFESSOR.
TITLE OF STUDY: “AN INTERVENTIONL STUDY ON THE EFFECTS OF YOGA AND
PRANAYAMA ON PHYSICAL AND MENTAL HEALTH OF MEDICAL STUDENTS”.
I_____________________of _______semester , Roll no_____________certify
that investigator has explained me in detail, the nature, purpose and
significance of the proposed intervention and investigations. I am aware of
experimentation effect of yoga and pranayama on physiological variables and
mental health. I am voluntarily willing to participate as one of the subjects in
the study.
Place:
Date:
Signature of the subject.

xviii
 అంగీకారం తెలుపు పత్రము
------------------- అనే నేను --------------------- సెమిసట ర్, ఆంధ్ర
మెడికల్ క఺లేజీ లో చదువుతుననాను. ఈ అధ్యయనం చేయువ఺రు , ఈ
అధ్యయనం ఎందుకు , అందులో జరిపే ప్రకయ
రి లో గల లాభములు నషట ములు
మరియు ప఺లగొను వ఺రి హకుులు సేకరించిన సమాచనరం గోప్యంగ఺ ఉంచుటకు
ననకు అరథమెైన భాషలో తెలియజేస఺రు.
నేను ఇచేే సమాచనరము విశ్లేష఻ంచి నివేదిక తయారు చేయుటకు ఉప్యోగ
ప్డుతుందని అరథం చేసుకుననాను.
నన ఇషట ప్ూరవకంగ఺ ఈ యోగ మరియు ప఺రణనయామా ప్రిశ్ోధ్న లో
ప఺లగొనుటకు అంగీక఺రం తెలియజేసు ుననాను.
పెైన చెప్పబడిన స఺ర఺ంశం అంతన నేను ఎవవరి పర ర తనాహం లేకుండన
ఇషట ప్ూరవకం గ఺నే ఇచనేను.
తేదీ:
సంతకం/ ఎడమ
చేతిబొ టనువేలి
ర ముదర :

xix
 Annexures 6
INSTITUTIONAL ETHICS CLEARANCE CERTIFICATE

xx
 Annexure 7
PLAGIARISM CERTIFICATE

xxi
xxii
 Annexure 8

Interventional training program

Fig: students practising vajrasana

s Fig : Mental aspect of yoga and meditation class by international yoga gold medalist

J.D.CHAKRAVARTHY.

xxiii
xxiv