Therapeutic Effects of Yoga for Children: A Systematic Review of the Literature

Abstract

Purpose: 

We completed a systematic review of the literature on the effect of yoga on quality of life and physical outcome measures in the pediatric population. We explored various databases and included case–control and pilot studies, cohort and randomized controlled trials that examined yoga as an exercise intervention for children.

Summary of Key Points: 

Using the Sackett levels of evidence, this article reviews the literature on yoga as a complementary mind–body movement therapy. We address the research through three practice patterns according to the Guide to Physical Therapist Practice and provide considerations for the inclusion of yoga into clinical practice.

Statement of Conclusions and Recommendations for Clinical Practice: 

The evidence shows physiological benefits of yoga for the pediatric population that may benefit children through the rehabilitation process, but larger clinical trials, including specific measures of quality of life are necessary to provide definitive evidence.

In Brief

This systematic review reports the physiological effects of yoga that may benefit children during the rehabilitation process, but larger clinical trials including specific measures of QOL are necessary to provide definitive evidence.

INTRODUCTION

By the summer of 2006, “Kid Yoga” camps were appearing on every corner,¹ rivaling lemonade stands and soccer camps in popularity. In April 2007, a search on the Internet with the terms “yoga and children” yielded close to 6,120,000 hits.² The Internet offers an abundance of certifications designed for teaching yoga to children.³ Further, almost every yoga studio in the country now offers classes for young children.⁴ Indeed, yoga has now penetrated popular culture for all age groups. As experts in movement analysis and therapeutic exercise, physical therapists (PTs) hold the professional responsibility of determining the value of yoga's age-old art in modern day practice.

Today's “typical child” is described as stressed out,⁵ under nourished,⁶ and sedentary.⁷ The complexity posed by these profiles demands treatment that taps into both the physical and the psychosocial domain. A study by Parshad⁸ found the state of the mind and that of the body to be intimately related. If the mind is relaxed, the muscles in the body will also be relaxed. Stress produces a state of physical and mental tension. Yoga, developed thousands of years ago, is recognized as a form of mind–body medicine. There are many forms of yoga with emphasis on various aspects of body mechanics, fitness, and spirituality (Table 1).

TABLE 1: Different Schools of Hatha Yoga Commonly Practiced in the United States

Parshad's study demonstrates that yoga's physical postures and breathing exercises improve muscle strength, flexibility, blood circulation and oxygen uptake, and hormone function. In addition, Parshad found that relaxation induced by meditation helps to stabilize the autonomic nervous system with a tendency toward parasympathetic dominance. Physiological benefits that follow help individuals who practice yoga to become more resilient to stressful conditions and reduce a variety of important risk factors for various diseases, for example, cardiorespiratory diseases.⁸

Yoga shows promise as a new modality for the pediatric population. Despite its popularity in popular culture, careful examination of the research is necessary when integrating this modality in traditional pediatric rehabilitation settings. The purpose of this systematic review is to explore the evidence related to the effectiveness of yoga with respect to the practice patterns in the Guide to Physical Therapist Practice.⁹ We have classified the articles under the following headings: neuromuscular, cardiopulmonary, and musculoskeletal according to their focus. As reviewers, we feel that the practice of yoga encompasses all three of these practice patterns. However, for the purpose of this review, we have assigned each article to the most pertinent practice pattern according to the focus of each study.

METHODOLOGY

We searched the following electronic databases through January 2007: Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, PsychINFO, and PEDro. The yoga register maintained by the Cochrane Breast Cancer Group was also explored. We used search terms related to yoga and pediatrics (children, developmental disabilities), exercise (eg, exercise, physical activity, cardiorespiratory fitness), and publication type (eg, cohort, case–control, clinical trial). This search strategy was modified as necessary for each database. Appropriate non-English language publications were not found. Of the studies we found pertinent to review, four were published in the 1980s, 10 in the 1990s, and 10 from 2000 to the present.

Studies were considered eligible for inclusion if they were pilot in nature, cohort, case–control, or a randomized clinical trial (RCT). An RCT is an experimental study in which a clinical treatment is compared with a control condition, where subjects are randomly assigned to groups,¹⁰ and in our review, we compared exercise with a placebo, controlled comparison, or standard care. For the purposes of the review, yoga includes a combination of breathing exercises (pranayama), physical postures (asanas), and meditation (spirituality).^11–13

Yoga was defined as a form of leisure-time physical activity that was performed on a repeated basis during an extended period of time, with the intention of improving fitness, performance, or health.¹⁴Table 1 outlines the breadth of yoga styles, some of which were used in the reviewed studies. Studies with an additional treatment arm or combined intervention (eg, yoga with traditional exercise) were included only if the effects of exercise could be isolated. A priori, we excluded reports that were available only in abstract form.

Trials were included only if they involved normally developing children and children with various impairments of the muscular, cardiopulmonary, or neuromuscular systems. Studies were required to have as a primary outcome quality of life (QOL), cardiorespiratory fitness or physical functioning. Secondary outcomes of interest included cognition and attention. We also extracted data on adverse events resulting from the yoga intervention.

Three independent reviewers (R.G., L.Q., and M.L.G.) screened the titles and abstracts of identified studies for eligibility. When one of us deemed an article to be potentially relevant, we obtained the full text and all three reviewers assessed it for inclusion. Information on patients, methods, interventions, outcomes, and adverse events were extracted from the original reports by the three independent reviewers onto paper forms that they had designed and pretested. Kappa coefficient of the reviewers was substantial (r = 0.60–0.75) between the three raters. Disagreements were resolved by consensus (R.G., L.Q., and M.L.G.). The methodological quality of each study was assessed using the following criteria^15,16:

1. Was there adequate concealment of allocation?
2. Was the method of randomization well described and appropriate?
3. Was the outcome assessment described as blinded or unblinded?
4. Was the method of blinding of the assessment of outcomes well described and appropriate?
5. Was there a description of withdrawals and dropouts?
6. Was there intention-to-treat analysis?
7. Were withdrawals and dropouts less than 10%?
8. Was adherence to the exercise intervention (attendance or completion of exercise session) greater than 70%?

All items were scored using Sackett levels of evidence.¹⁷ Studies were defined as being of “high quality” if they fulfilled four or more of the eight quality criteria. We included all the studies in this review, given the paucity of yoga research in pediatrics. Of the 24 total studies identified, five were classified as level 4, four as level 3, 15 as level 2, and none with level 1 grade of evidence. Based on our criteria for evaluation, using both methods, we found few articles that included our criteria for high quality. Although description of randomization was clear throughout all studies, we have little data that describe outcome assessments with regard to the method of blinding, no information on intent-to-treat analysis, and what happened to withdrawals and dropouts. Therefore, studies were of moderate to low quality and require future investigations that incorporate all aspects of a rigorous clinical plan for recruitment, retainment, blinding, and adherence.

NEUROMUSCULAR EFFECTS OF YOGA

Six of the 10 articles assigned to the neuromuscular practice pattern were assessed as 2B grade for levels of evidence, while four additional articles were grade 4. Much variability was noted in the duration of yoga interventions and it is unclear how issues of bias were addressed. Although a trend is noted in improvements of motor planning, performance, and mental and social acuity, further research is needed to incorporate yoga as a definitive modality for the neurologically involved child.

Yoga seems to have a positive impact on motor performance in children and most studies have been conducted on children developing typically (Table 2). Four studies analyzed the effects of yoga on reaction time, planning, execution time, and motor speed.^18–21 Reaction time has been used to quantify level of motor function, and thus speaks to the overall functioning of the central nervous system (CNS).²² Pilot data by Bhavanani et al¹⁸ found that mukh bhastrika yoga (bellows type breathing) produced decreased visual reaction time and auditory reaction time in 22 healthy schoolboys. This indicates potentially improved sensory-motor performance and enhanced processing ability of the central nervous system.¹⁸ Another pilot study by Manjunath et al¹⁹ showed trends of improved planning and execution times in the yoga group in the Tower of London test for both simple and complex tasks. The Tower of London test is standardized and addresses executive functions. The study revealed no change in the physical training group.

TABLE 2: Neuromuscular Evidence

TABLE 2: Continued

TABLE 2: Continued

Motor speed, like reaction time, is also a quantification of CNS processing. Dash et al²⁰ analyzed the effects of yoga training on a finger tapping task, to assess motor speed in children and adults versus a control group of 38 adults. Findings included significant increases in tapping speed values after 10 days of yoga training in the children's group and 30 days of yoga training in the adult group. Although not verified by diagnostic imaging, this and other studies point to the potential plasticity of the brain and CNS in response to yoga. Another study by Telles et al²¹ supports improved motor performance in children after yoga training. This study of 90 children ages 9 to 13 years used a steadiness test that required the insertion of and holding of a metal stylus into holes of decreasing sizes. The yoga group showed a significant decrease in errors, while the control group showed no change. Although an improvement in the quality of research design, further investigation is needed for application in children with disabilities.

Other studies suggest that yoga increases working efficiency,²³ and overall ability to concentrate and focus.²⁴ Yoga fosters relaxation and breathing⁷ in a very active way, enabling children to channel their energy into goal-driven tasks. These findings have implications for learning and classroom behavior. Three studies specifically examined the use of yoga and meditation as a treatment for attention deficit hyperactivity disorder (ADHD) and would be considered pilot in nature. One study by Jensen et al²⁵ showed both groups with improvements in several measurement scales with yoga participants improving significantly in the five subscales of the Parents Rating Scales (CPRS). The second study (Harrison et al)²⁶ incorporated the entire family and measured treatment outcomes. A classroom-based study by Peck et al²⁷ found yoga to improve time on task in 10 elementary school children evidencing attention problems. Although these data do not provide strong support for the use of yoga for ADHD, partly because the studies are under-powered, they do suggest that yoga may have merit as a complementary treatment for ADHD already stabilized on medication. Yoga remains an investigational treatment, but this study supports further research into its possible uses to address behavioral challenges for this population. These findings need to be replicated on larger groups with a more intensive supervised practice program.

Two studies suggest that academic learning of children developing typically may be further enhanced by memory improvements afforded by yoga. In one of these studies, Manjunath et al²⁸ compared performance of 90 subjects in verbal and spatial memory tests. Thirty subjects were in one of three groups: yoga camp, fine arts camp, or control group. Members of the yoga group showed a 43% improvement in spatial memory test scores, while the fine arts and control groups showed no change. Subjects in the yoga camp also engaged in game playing and story telling. However, we found it compelling that this group still showed improvement over the fine arts camp group, who most likely also participated in similar social activities. A second study by Naveen et al strengthens the use of yoga for spatial memory scores. In this study, 108 school children aged 10 to 17 years were divided into four groups, each practicing in a different type of yoga breathing.²⁹ All four groups evidenced improved spatial memory scores by an average of 84%. Verbal memory scores were also measured in both these studies, and seem to remain unchanged after the interventions.

Application of yoga for children with mental retardation also shows promise. Uma et al³⁰ demonstrated significant improvements in IQ and social parameters compared with a control group through an intervention for 1 academic year. Changes occurring at the neuromuscular level enabled the more global effects of behavioral and cognitive enhancements. Such benefits may be applied along the spectrum of children with neurological impairments but further RCT are needed to determine definitive use of yoga.

CARDIOPULMONARY EFFECTS OF YOGA

Ten articles were reviewed in the cardiopulmonary practice pattern. Seven of the 10 reviewed articles were classified as level 2B, two as level 3B, and one as level 4 (Table 3). Although the quality of evidence was varied, we considered all the articles enriching to our discussion. These studies reveal that yoga may be used with typical children, and with physically or emotionally impaired children to improve cardiorespiratory parameters. Further, these studies also demonstrate that the processes initiated by yoga practice can have an impact on the more global issues of socialization and stress management. It is important to note that physical impairments are often heavily influenced by psychosocial factors. Therefore, PTs may consider yoga as an adjunct for pediatric cardiopulmonary rehabilitation.

TABLE 3: Cardiopulmonary Evidence

TABLE 3: Continued

TABLE 3: Continued

A primary emphasis in the practice of yoga is controlled-breathing techniques. This idea leads to new research on children with cardiopulmonary impairments. Our search yielded four studies that demonstrate yoga's mechanism of action on subjects with healthy cardiac function. First, a study by Udupa et al³¹ analyzed the effects of pranayama training (voluntary regulation of breathing) on cardiac function in normal young volunteers. Twenty-four school children were divided into a pranayama group and a control group. The pranayama group practiced breathing techniques for 20 minutes daily for 3 months. A control group maintained normal breathing. Researchers found that pranayama training effectively modulated ventricular performance by decreasing sympathetic output and thereby increasing parasympathetic output. This study provided baseline evidence for the efficacy of yoga on cardiorespiratory parameters in normal volunteers, and allowed for expanded research into populations with pathology.

Three additional studies examined the effects of yoga on volunteers with normal cardiac function who also had anxiety. Such studies are important in that they implicate psychosocial issues as contributors to autonomic impairments. This idea was supported by Telles et al³² in a study on physically normal but socially or emotionally traumatized girls. In their study the researchers randomly selected 40 girls between 12 and 16 years of age from a total of 120 girls in a community home. All subjects had a history of adjustment difficulties either at home or in society. The study aimed to determine differences in autonomic and respiratory parameters between these girls and those of the same age living at home and attending a regular school. The community home group was found to have significantly higher breath rates, more irregular breathing patterns, and lower skin resistance values than their age-matched peers. These attributes are known to correlate with fear and anxiety.^33,34 Additionally, the study aimed to compare the effects of two interventions—yoga and games—on the same physiologic measurements. For an hour daily over a 6-month period, half of the community home girls engaged in relaxing yoga, while the other half engaged in physical games such as relay races. Those participating in the yoga arm of the study were found to have a significant decrease in breath rate, which seemed more regular, but no significant increase in skin resistance. Both groups showed a significant decrease in resting heart rate. These findings suggest that yoga practice may reduce levels of fear and anxiety more so than physical activity alone. This has implications for setting the background of emotional stability to execute physical demands of everyday activity.

Platania-Solazzo et al³⁵ conducted a study with similar implications, in which the effects of relaxation therapy were assessed in a population of 40 hospitalized children and adolescents who had a diagnosis of adjustment disorder and depression. This study assessed yoga's effect, along with massage and relaxation, on decreases in self-reported anxiety, anxious behavior, and fidgeting as well as increased positive affect. Decreases in cortisol levels were also noted, which have an indirect effect on the cardiorespiratory health of children.³⁶ PT traditionally incorporates several of the aspects mentioned in this intervention (massage, relaxation, and biofeedback), suggesting that yoga as a modality may provide unique and creative ways to attain goals in the cardiopulmonary practice pattern. Because this program incorporated massage, the specific effects of the yoga component are difficult to determine. However, we considered this evidence to be notable, especially since the elements of relaxation and biofeedback are intrinsic to the practice of yoga itself.

An additional study by Telles and Srinivas explored a population with normal cardiac function but increased levels of anxiety. This study analyzed the cardiopulmonary effects of yoga on volunteers who were visually impaired (VI).³⁷ This sample displayed similar baseline measurements to the socially or emotionally traumatized population of community home girls³²: higher breath rates, heart rates, and diastolic blood pressure. Previous studies found that young people with VI have significantly higher levels of anxiety than their age-matched peers,³⁸ to which increases in heart rate is often attributed. In the Telles and Srinivas study, 24 children with VI, ages 12 to 17 years, were age matched with normal-sighted peers. Half of the pairs participated in yoga for an hour each day, while the other half of the pairs performed “physical activity” working in the garden and stretching. After 3 weeks, the rate of respiration was reduced in the children with VI who participated in yoga. There was no change in the children who participated in the physical activity group. These results show that although children with VI have higher physiologic arousal than children who are normal-sighted, this arousal may be reduced after participation in yoga. These studies point out yoga's utility in children with psychosocial impairments.

Four studies explored the effect of yoga on children with specific respiratory impairments, namely, asthma. However, only one of these studies³⁹ restricted participation to the pediatric population. In the study by Jain et al³⁹, 46 children, with a mean age of 15.8 years and a childhood history of asthma, were followed through 40 days of yoga training. Increased capacity was found in the subjects' forced expiratory volume, distance walked in a 12-minute time period, and overall physical fitness as assessed by a modified Harvard Step Test. Although only 26 patients could be followed for up to 2 years, these patients showed continued reduction in symptoms, along with decreased drug requirements. Additionally, 14 of these patients (all initially diagnosed with mild asthma) who continued yoga practices everyday for 15 to 30 minutes remained asymptomatic, suggesting the utility of regular practice.

Three additional studies strengthen the evidence for yoga in the asthmatic population. However, these studies include, but are not necessarily restricted to the pediatric population. Two of these studies were conducted by Nagendra et al.^40,41 In 1985, a case controlled study by Nagendra et al⁴⁰ reported significant improvements in the weekly number of asthma attacks, scores for drug treatment, and peak flow rate in yoga participants versus nonparticipants. Subjects were matched for age, sex, type, severity and duration of asthma. The rigor of this study was weakened by a high dropout rate. In 1986, Nagendra et al⁴¹ strengthened their findings with a prospective cohort study of 570 asthmatics, which explored the use of yoga over an extended time period (ranging from 3 months to 4.5 years). Results revealed regularity of practice to be the strongest predictor of improved peak expiratory flow and decreased use of medication. An additional study by Khanam et al⁴² found a positive correlation between yoga and cardiopulmonary improvements. This study was underpowered with a markedly shorter time frame of intervention (7 days), suggesting that asthmatics can benefit from even a short-term yoga program.

Two additional studies suggest that yoga may improve cardiorespiratory parameters in children as a secondary effect of decreased anxiety. Clance et al⁴³ analyzed the effects of yoga on body satisfaction in a study involving 12 third grade students. Six students in the experimental group receiving yoga demonstrated improvements in self-image, while the six students in the control group did not. These results suggest that yoga may reduce stress and anxiety related to low body satisfaction or poor self-image in children. Further, the breathing techniques used in yoga foster decreased anxiety.³² Although underpowered and considered pilot in nature, this study has important implications for the physical aspects of development that are indirectly impacted by psychosocial parameters.

Further, a study by Stueck et al⁵ found that yoga and relaxation techniques may increase emotional balance in the long term, reduce fears and feelings of helplessness, as well as aggression and negative feelings, and improve overall well-being. This study used a stress-handling program with elements of yoga in 48 fifth grade students with examination anxiety. Postintervention, the participants transferred the learned breathing techniques and self-instructions to situations beyond school to promote healthy stress management and stress prevention, both of which are a means of primary prevention of cardiopulmonary complications.⁴⁴

MUSCULOSKELETAL EFFECTS OF YOGA

We reviewed four studies pertaining to the musculoskeletal practice pattern. Two of the four studies were classified as 2B level of evidence, while the other two were assigned level 3B (Table 4). These studies reveal that yoga may be used with children developing typically, or children who are not meeting national norms for fitness and body composition, or children with elevated stress levels to improve musculoskeletal parameters.

TABLE 4: Musculoskeletal Evidence

Orthopedic injuries in children are often caused by lack of strength and flexibility,⁴⁵ which are addressed in the musculoskeletal practice pattern. The four studies reviewed showed significant effects of yoga and its breathing techniques on the musculoskeletal system in children. Three of these four studies were from the Indian Journal of Physiology and Pharmacology.^46–48 Although these studies were not very recent, they lay down the foundational work in this body of evidence, and provide a starting point upon which to build future studies. The results and conclusions of these studies suggest that yoga can be introduced during school to improve physiological function, overall health, and performance of students. Further RCTs are needed to determine definitive effects of yoga.

A study by Mandanmohan et al⁴⁶ found that 6 months of yoga training in 20 school children aged 12 to15 years produced significant gains in handgrip strength and endurance as well as inspiratory and expiratory muscle strength. This research design involved yoga training that took place over more than 6 months, which allowed the study to examine the long-term effects of yoga training. Perhaps future studies could involve a larger number of subjects, and examine the effects of yoga after the 6 months of training.

Similar gains in grip strength were found in a study by Raghuraj et al,⁴⁷ in which school children 11 to 18 years old took part in pranayama breathing for 10 days. Increased grip strength in both hands was found in the pranayama group, while no change was found in the control group. This study used random assignment to one of five groups that spanned a large range of children's ages (11–18 years old). An additional study by Raghuraj and Telles replicated these findings of increased grip strength after 6 months of yoga in 12- to 16-year-old girls.⁴⁸ These gains have implications for using yoga for total body strengthening.

Obesity, another growing concern in our pediatric population, may also be reduced through the implementation of yoga programs. A pilot study by Slawta et al⁴⁹ entitled “Be a Fit Kid” included a 12-week program of yoga designed to improve physical fitness and nutritional habits in children. The program also included a physical activity component (running, jumping, and strengthening) along with a nutrition program. After the intervention, significant improvements were found in body composition and fitness in those who participated 75% of the time. Because the “Be a Fit Kid” program used a holistic approach, the specific effects of the yoga component are difficult to determine. However, we felt that the study was important to include, given that it portrays yoga as an important contributor to an overall healthy lifestyle. Considering the recent trend of child participation in yoga classes, it is likely that more studies investigating children who are obese should be conducted with more rigorous methodology. This pilot study established the framework for replication in a larger, randomized sample.

Thus, in addressing the musculoskeletal issues of flexibility and strength, these studies demonstrate that yoga can have an impact on stress management and obesity. Both of these issues having a major impact on the socialization of developing children, so it can be seen that yoga not only impacts physically, but also emotionally and psychosocially. Therefore, PTs can consider yoga as a tool for not only musculoskeletal, neuromuscular, and cardiopulmonary problems, but also as a holistic approach to the entire mind–body of these children, thus addressing many issues that arise in children developing typically and atypically.

INTERPRETATION

This review summarizes available evidence regarding the effects of yoga as an intervention for QOL and physical outcomes in children. None of the reviewed studies provided adequate data to assess improvements in QOL over a significant part of childhood and adolescence, as most were of short duration. The 24 studies included in this review were of variable quality, and none were considered to be of high quality. Our conclusions are tempered by this fact. Clearly, further progress must be made to improve research quality and include measures of QOL. Future trials should focus on adequate randomization, concealment of allocation, and blinding of outcome assessors throughout the study.

A noteworthy feature of trials included in this review was the wide variability in study interventions. Many different types of yoga regimens were prescribed. The diversity in yoga prescription is not surprising, given the culture from which yoga emanates. Westernization of this modality may compromise the full intent of yoga practice in the United States when compared with India. Conversely, the wide variety in study outcomes and measurement methods is surprising. The short duration or complete lack of follow-up data examining the effect of yoga on QOL and rehabilitative outcomes in the long term are also noted. Moreover, data are lacking to support the use of yoga in preventing further disability in these three practice patterns.

A further limitation is the nonspecificity with respect to the timing of the yoga intervention. Clinical heterogeneity was evident, particularly, in trials carried out during treatment for asthma. This resulted from trials in which the participants were undergoing one of a variety of additional drug treatments; therefore, confounding issues are of concern.

Finally, poor adverse event reporting in most of the studies limits any conclusions about the relative safety of yoga as an exercise, and the small samples provide insufficient power to detect meaningful differences in rates of rare adverse events. For example, inverted postures can impact blood pressure^50,51 and represents a barrier to exercise for some patients, yet none of the included studies formally explained or monitored for the effect of specific postures.

The evidence suggests that yoga is an effective intervention to improve cardiorespiratory fitness, physical functioning, and behavior in children and adolescents. All the studies showed an effect and this may due to researcher or selection bias. Although these preliminary results are promising, the findings are based on a relatively small number of trials with significant methodological weaknesses. On the basis of our findings, we make the following research recommendations. Methodologically rigorous studies designed to examine different yoga regimens (see Table 1) are needed to better understand the role of yoga as it impacts the developing child and QOL. The yoga prescription should be reported in detail (frequency, intensity, time, and type of exercise) to allow for determination of exercise dose–response. To this end, adherence to exercise should be reported for both completion of exercise sessions (attendance) and yoga intervention (intensity and duration). Furthermore, monitoring of activity in the comparison group(s) is necessary to assess potential contamination. Consensus is required on standardized methods of assessing physical fitness and body composition to allow for pooling of data and for comparisons across studies. Future trials should formally monitor for, and report the incidence of, potential adverse events such as change in blood pressure.

SUMMARY OF LITERATURE REVIEW

Complementary and alternative medicine (CAM) encompasses five areas of modalities according to the National Institutes of Health—National Center for CAM: biologically based interventions, manipulative and body-based methods, mind–body therapies, energy-based approaches, and alternative medical systems. Yoga is one mind–body therapy that has emerged as an educational-based intervention and to improve various medical conditions for children.

Patient expectations regarding CAM interventions have important implications for treatment adherence, attrition, and clinical outcome.⁵² Little is known, however, about parent and child treatment expectations regarding CAM approaches, especially yoga for problems presented by children and adolescents. One study revealed that parents often have higher expectations of CAM therapies than do their children.⁵² Additionally, enhanced expectations often resulted in better outcomes. Thus, the use of alternative modalities must take into consideration these influential factors. Therefore, it is important that PTs are increasingly aware of the potential complementary and beneficial effects of various CAM modalities in children's rehabilitation.

The use of yoga for rehabilitation may have diverse applications. Yoga practice may benefit children with mental challenges by improving their mental ability, along with motor coordination and social skills. Children with physical disabilities may also experience restoration of some degree of functional ability after practicing yoga. Children who are VI can decrease their abnormal anxiety levels, and children in a group home can improve their sleep, appetite, and general well being, as well as a decrease in physiological arousal.⁵³

Evidence from the previous studies of yoga as a CAM intervention have implications for PTs in the neuromuscular areas of learning, motor control, and coordination. PTs might apply these findings to their patients with asthma or simply as a form of biofeedback in stress management. Further, outcomes may be enhanced by applying findings from these studies to young athletes or children who are overweight. Regardless of the goal, yoga seems to be a multitasking modality that simultaneously treats physical impairments and psychosocial issues such as stress, anxiety, or hyperactivity. Many of these studies set out to measure purely physical parameters, but encompass psychosocial issues. Moreover, many of the studies in this review overlap or address multiple practice patterns, making it difficult to distinguish the effects of yoga on one specific impairment.

The available studies according to Sackett classification system¹⁷ are predominantly level 2B grade evidence and below. It is well known that the inclusion of nonrandomized or uncontrolled trials leads to an overestimation of the effect of an intervention. Therefore, as noted in the studies presented in this article, yoga has a consistent trend in improvement. However, it is recommended that more RCTs be planned for future examination of the evidence for yoga to be consistently included into the PT plan of care. Specific measures of QOL should be added to physiologic data collection. In addition, future meta-analyses should be restricted to RCTs whenever possible.⁵⁴

Much of the literature reviewed has been conducted in India and comprises all the elements of yoga including postures (asanas), breathing (pranayama), and spirituality (meditation). As Eastern philosophies and practices are taken to other countries, it may be compartmentalized without the lack holism of the philosophy and practice when examined in research. Therefore, appropriate use and full description of the practice of yoga is required for future design of clinical trials. Further research is needed to explore the integration of yoga into clinical practice. PTs treating children have an opportunity to add to existing exercise protocols and incorporate the benefits of yoga. However, research is needed to determine the best forms of yoga for children with specific impairments and to establish a dose–response relationship for children of different ages.

This review of the literature supports evidence for yoga that guide us in determining issues that will be important in the design of larger pediatric rehabilitation clinical trials. Future studies should examine the effect of yoga, as well as the magnitude and the variability of the response throughout childhood and adolescence. Compelling evidence exists that demonstrates the effect within the neuromuscular, cardiopulmonary, and musculoskeletal practice patterns. The breadth of these studies has implications in all areas of PT practice, particularly in complementing existing wellness programs and clinical interventions for children.