Version May 2024
INTRODUCTION — Yoga is commonly used as a complementary or alternative practice for health promotion and amelioration of a variety of conditions. While scientific studies and integrative medicine programs at major medical centers and universities are bringing yoga into the mainstream of medical education, research, and clinical practice, they are also revealing its limitations [1-4].
This topic describes the practice and styles of yoga and their possible benefits and risks. The use of yoga for specific conditions is also discussed elsewhere:
●(See "Cancer-related fatigue: Treatment", section on 'Yoga'.)
●(See "Complementary and alternative therapies for rheumatic disorders".)
●(See "Complementary, alternative, and integrative therapies for asthma", section on 'Breathing exercises'.)
THE PRACTICE OF YOGA — Yoga is one of several mind and body practices (eg, massage, meditation, Pilates, qi gong, relaxation techniques, tai chi) that use interactions among the mind, body, and behavior to promote optimal health over the lifespan and improve different aspects of physical and mental health [1,5-8]. Among these, yoga, tai chi, and qi gong are sometimes called “meditative movement” practices because they include both meditative and physical movement elements. These practices differ in many ways in their historical foundations, features, and objectives, and exact definitions have proved challenging and controversial [9,10].
History and current practice
●History — Yoga has changed substantively since its origins in ancient India in approximately 300 BCE [11]. The earliest emergence as a philosophy focusing on expansion of consciousness, release from suffering, and omniscience dates from approximately 400 CE [12]. Physical movements were introduced with the development of hatha yoga in the 11th century. Hatha yoga remained in relative obscurity until the 18th century, when it reemerged in India as an amalgam of exercises including British military calisthenics, Indian gymnastics, and wrestling traditions of southwestern India [13].
In the late 19th century, Vivekanand, a particularly charismatic yogi, popularized Raja yoga, a Hindu philosophy and meditative practice without movements, in the United States [14]. During the first half of the 20th century, several yogis from India introduced Hatha yoga in the West, culminating in the 1950s when students of BKS Iyengar and his disciples began to open schools throughout the United States [14,15]. In 1970s, the first randomized controlled trials were published [16-18]. In the second half of the 20th and beginning of the 21st centuries, the interest in ancient Eastern philosophies, the fitness revolution, emigration of charismatic instructors, claims of a wide variety of benefits, and scientific studies suggesting efficacy led to an explosive uptake of yoga in the West.
●Current practice — Yoga is the most commonly used complementary health approach in the United States [19]. The proportion of practitioners has increased steadily since the first nationally representative studies in the 1990s [7,8,19-21]. In 2012, 8.9 percent of adults had participated in yoga in the prior 12 months; in the most recent survey, in 2017, it increased to 14.3 percent [22]. Compared with non-practitioners, those who practice are more likely to be female, young, non-Hispanic white, college-educated, insured, and in better general health [7,23,24]. However, between 2012 and 2017 in the United States, yoga practice increased among Hispanic persons (from 5.1 to 8.0 percent) and non-Hispanic Black persons (from 5.6 to 9.3 percent) [22,25].
Components of yoga — As it is most practiced in the West today, yoga has three main components: postures/poses (āsanas), breath control/regulated breathing (prānāyāma), and meditation/relaxation (dhyāna). Studies of yoga cited in this topic include all three components. Other definitions are more expansive and include dietary, social, mental, spiritual recommendations, and harmony with nature [26,27]. Several yoga styles are mentioned in the table (table 1).
●Postures/poses (āsanas) – Movement-based yoga postures now form the cornerstone of most yoga practices taught worldwide. Hundreds of different postures have been described [28]. Many are simple stretching exercises that are easy to perform, even for ill patients (picture 1) [29]. Others (picture 2 and picture 3) are more difficult, and supervision is recommended to assure safety (see 'Postures associated with adverse events' below). All postures, but especially more difficult ones, can be modified by students or teachers to make them less demanding. Some yoga postures (eg, tree [one-leg balance], bridge, chair, hamstring stretch) are nearly identical to physical therapy exercises.
●Breath control/regulated breathing/yogic breathing (prānāyāma) – Breath control is a longstanding component of many religious and meditative practices [30,31]. In yoga, breath control is referred to as prānāyāma, a portmanteau of the words "prānh" (vital air, life wind) and "āyāmh" (restraining, extending) [32]. It became a cornerstone of hatha yoga practice in the 10th century. Prānāyāma is defined as the deliberate modifications of the breathing process. Today it is practiced as slow, deep diaphragmatic breathing: about six breaths per minute with sequential mobilization of the diaphragm, lower chest, and upper chest. It has also been applied and studied in isolation from postures as rapid diaphragmatic breathing, alternate nostril breathing, and breath-holding [33].
●Meditation/relaxation – Meditation was the first component of yoga and an early part of Hinduism and Buddhism. The type of meditation practiced in yoga usually resembles mindfulness, which has been defined as the awareness that emerges through attending to the present moment from a nonjudgmental perspective [34] (see "Unipolar major depression: Treatment with mindfulness-based cognitive therapy", section on 'Theoretical foundation'). Yoga styles that primarily include meditation (Kundalini yoga, Sudarshan Kriya) [35] are not considered yoga for the purposes of this topic [9].
Styles of yoga — As practiced in the 21st century, yoga has many styles (table 1). Postures dominate almost all the styles but vary in intensity, difficulty, and whether they are briefly static (Ashtanga, Bikram) or flow continuously (Vinyasa). The amount and types of breath control and meditation also varies between styles [36].
Hatha and integrated yoga are generic terms for most of the styles practiced in Western societies. Commonly practiced Hatha styles include Iyengar, Vinyasa, and Kripalu. Many teachers describe their style as Hatha yoga without further specification because most styles originated from Hatha yoga. Some teachers mix styles and integrate philosophy and advice on best maintaining health and treating diseases [11]. Chanting, aspects of spirituality, music, and varied temperature may also be included in some styles (table 1).
Yoga teacher training and certification — Yoga has been in the process of professionalization in the United States. The Yoga Alliance registers schools and develops standards for teacher accreditation. The accreditation process is primarily based on hours of training (200, 500) with further specialization for teachers of children and prenatal yoga.
Yoga therapy — Yoga therapy is a specialized application of yogic principles, methods, and techniques to specific human ailments for diseases or injuries [37,38]. Yoga therapists often work one-on-one with individual patients. A more advanced set of educational standards and competencies have been established for the training of yoga therapists [39]. The minimum requirement for certification as a yoga therapist is 800 hours. A process for accrediting therapists, programs, and facilities that meet these standards has been developed by the International Association of Yoga Therapists.
RATIONALE FOR AND BARRIERS TO PRACTICE — Surveys report that the most common reasons for practicing yoga are increased flexibility and stress relief, followed by general fitness, improvement in overall health, and positive affect [7,19,21]. In addition, some practitioners use yoga to treat specific health problems, most commonly back and neck pain, stress, and arthritis [7,23,40-42]. In addition, many yoga participants cite spirituality as a reason for continuing to practice yoga [43]. The ability to practice yoga at home using online streamed or television-based services with minimal equipment is another reason for its popularity.
Barriers to yoga practice are similar to those identified for exercise in general (see "Exercise prescription and guidance for adults"). Clinicians' willingness to refer and patients' willingness to be referred are hindered by the absence of reimbursement for and follow-up reports by yoga teachers [44].
Other barriers may include skepticism regarding effectiveness, fear of injury, lack of ability/self-efficacy to perform the practices, preference for other physical activities, cultural bias, or logistical and scheduling difficulties [45-48].
CLINICAL APPLICATIONS — The benefits of yoga have been evaluated in more than 700 randomized controlled studies and more than 250 meta-analyses. Unfortunately, many of these trials have a high risk of bias [49]. Even studies with a low risk of bias may be compromised by lack of an appropriate active and inactive control groups. (See 'Challenges in yoga research' below.)
The best evidence suggests that yoga can be a helpful adjunct to recommended interventions for the following:
●Physical fitness
●Pregnancy
●Stress and anxiety
●Cardiac rehabilitation
●Cancer fatigue and insomnia
●Depression
●Fibromyalgia
●Low back pain
●Multiple sclerosis (balance)
●Parkinson disease
Health maintenance and quality of life
●Cardiovascular fitness – If performed at a moderate intensity for 150 minutes per week, American College of Cardiology/American Heart Association recommendations consider yoga sufficient for a healthy lifestyle [50]. However, yoga practices often do not achieve this intensity [51-55], so it may be especially applicable to adults with limited exercise capacity.
•In a 2016 meta-analysis of 17 studies, the intensity of full yoga sessions ranged from light (less than 3 metabolic equivalents [METs]) to moderate (3 to 6 METs) aerobic intensity, with the majority classified as light intensity [51,56].
•Even at equivalent heart rates, energy expenditure with yoga was less than treadmill walking but was still sufficient to be classified as moderate exertion [57].
•In most studies comparing aerobic exercise and yoga, aerobic exercise groups showed significantly greater improvement in a variety of indicators (eg, peak VO2, anaerobic threshold) [58-60].
●Strength – Yoga may have benefits for strength and mobility as part of a comprehensive exercise program. (See "Exercise prescription and guidance for adults", section on 'Components of an exercise program'.)
Yoga may have benefits in improving strength and endurance in older adults; this is discussed separately. (See "Frailty", section on 'Exercise' and "Physical activity and exercise in older adults", section on 'Muscle strengthening' and "Physical activity and exercise in older adults", section on 'Flexibility'.)
●Flexibility – Randomized trials comparing yoga with untreated control groups report significant increases in flexibility in healthy subjects of various ages, comparable with those achieved with stretching. Two studies with active control groups (stretching/strengthening exercises in one [61] and aerobic exercise in the other [62]) found equivalent improvement in flexibility.
●Balance, mobility, and falls – While yoga improves measures of balance and mobility when compared with other exercises [63], studies have failed to find that yoga prevents falls [64-66].
●Risk factors for cardiovascular disease – When compared with inactive control groups, numerous systematic reviews and meta-analyses have found limited evidence that yoga may modestly reduce some risk factors for cardiovascular disease (eg, elevated blood pressure, glucose, lipids) [59,67-70]. In a randomized controlled trial with 68 participants with pre- and stage 1 hypertension, mean arterial pressure decreased by approximate 4 mmHg in the yoga group but not a metabolically matched exercise control [71].
●Health-related quality of life – A meta-analysis of healthy adults with a mean age of 60 concluded yoga improved quality of life measures compared with inactive controls [72]. Two of three high-quality randomized controlled trials in seniors with active control groups reported significant improvement in quality of life [61,73], while the third found equivalent increases [58]. When compared with active controls, yoga has shown greater improvement in quality of life in some conditions such as low back pain [74], osteoarthritis [75], and hypertension [76], equivalent improvements in other conditions such as breast cancer [77], burnout [78], and back pain [79], and less improvement in others such as multiple sclerosis [80].
●Cognition – Meta-analyses and randomized controlled trials examining the effects of yoga on cognitive function in adults without serious underlying diseases have conflicting results, with most combining active and inactive controls, other mind-body interventions, or both [81-85]. Perhaps the most interesting and comprehensive of these compared the effects of different types of exercise on executive function and concluded that, when practiced with vigorous intensity, yoga, as well as other forms of exercise, had positive effects on measures of executive function [83].
●Pregnancy – Although the average energy expenditure of prenatal yoga is less than that recommended, yoga during pregnancy may have significant maternal benefits:
•In the only randomized controlled trial comparing yoga with another form of exercise, yoga was more effective than walking in decreasing the risk of pregnancy-induced hypertension, preeclampsia, intrauterine growth restriction, small for gestational age, and low Apgar scores [86,87].
•A systematic review of five randomized controlled trials in which yoga was used as an add-on to prenatal care reported that yoga decreased stress, anxiety, depression, and pain and improved emotional wellbeing [88].
•Trials with inactive control groups have found have reported significant maternal benefits [86,89-97].
As with all forms of exercise during pregnancy, individuals considering yoga should be evaluated for contraindications before participation. Yoga in pregnancy is also reviewed elsewhere. (See "Exercise during pregnancy and the postpartum period".)
●Occupational stress reduction – Several studies have found yoga effective in easing several symptoms found in workplace and educational settings.
In a high-quality trial, insurance company employees interested in participating in a study to reduce stress in their workplace were randomized to yoga, mindfulness, or no treatment. Stress, sleep quality, and heart rhythm coherence improved equally in both treatment groups compared with untreated controls [98].
•Workers in health care facilities for older adults randomized to yoga or mindfulness had decreased emotional exhaustion and depersonalization compared with untreated controls [99].
•In tertiary education students, a meta-analysis found a moderately significant effect size for yoga or meditation for anxiety and stress compared with inactive controls and smaller and nonsignificant effect sizes compared with active controls [100].
Treatment of specific health problems
Neuropsychiatric disorders
●Depression – Several meta-analyses and more recent randomized controlled trials have suggested yoga may be effective alone or as an add-on therapy for patients with unipolar major depression [101-105].
•A 2013 meta-analysis (seven studies, 240 participants) that separated active and inactive controls reported yoga was comparable to aerobic exercise and antidepressants and was more effective than inactive controls [101]. However, sample sizes and biases of randomized controlled trials were cited as preventing definitive conclusions [106]. A meta-analysis in patients with cancer reached similar conclusions [103].
•A 2022 trial with 500 participants comparing yoga with cognitive behavioral therapy reported that depressive symptoms, generalized anxiety, and fatigue improved in both groups [104].
●Insomnia
•A randomized trial comparing yoga with a sleep hygiene control group found that yoga was associated with a greater self-reported improvement in sleep quality sustained at six-month follow-up [107]. However, two meta-analyses concluded that, while yoga may improve sleep quality, other forms of exercise (walking) and meditation may be superior [108,109].
●Multiple sclerosis
•A 2020 meta-analysis of 10 randomized controlled trials with a total of 693 patients concluded that yoga and other exercise had similar positive effects on fatigue compared with inactive controls [110].
•A 2022 meta-analysis (31 randomized controlled trials with 904 patients) showed that while all forms of exercise were beneficial, yoga as well as virtual reality training and aerobic training are more effective in improving the balance function, while other forms of exercise were more effective at improving functional walking ability [111].
•A trial comparing yoga and exercise for multiple sclerosis found no improvement in cognitive function in either group [112].
●Parkinson disease
•A 2021 meta-analysis (10 studies, 359 participants) that combined active and inactive controls reported yoga improved motor function, balance, and functional mobility; reduced anxiety and depression; and increased quality of life [113]. Another meta-analysis reached similar conclusions [114].
•A meta-analysis comparing 10 different exercise interventions suggested that yoga as well as dance virtual reality training and resistance training offers better advantages than other exercise interventions for motor function [115].
•A well-designed trial with 187 participants (included in the above meta-analyses) compared yoga with stretching and resistance training and found the two interventions equally effective in improving motor dysfunction and mobility; yoga participants significantly reduced anxiety and depressive symptoms [116].
●Posttraumatic stress disorder
•A 2018 meta-analyses reported that there was insufficient evidence to conclude small sample sizes and low quality of randomized controlled trials [117].
•Trauma-sensitive yoga was developed for treatment of posttraumatic stress disorder due to a variety of causes [118,119]. A meta-analysis found only marginally significant to no effects [120], a subsequent the study in 152 women, predominantly African American veterans, comparing trauma-sensitive yoga with cognitive processing therapy found that trauma-sensitive yoga improved symptoms and had a higher retention rate and a more sustained effect than cognitive processing therapy [121].
●Cognitive impairment
•Meta-analyses have reported that evidence is insufficient to recommend yoga for cognitive impairment in cancer patients [122].
•A trial comparing yoga and exercise in substance abusers admitted to an inpatient treatment program found yoga and exercise equivalent in increasing a variety of cognitive functions [123].
●Burnout
•In a randomized controlled trial of employees on sick leave due to burnout, yoga, cognitive-behavioral therapy and mindfulness-based cognitive-behavioral therapy had equivalent significant improvements in health-related quality of life and the main domains of burnout [78].
•In a randomized controlled trial of health care workers who assisted older adults, yoga or mindfulness once per week for six weeks had an equivalent significant decrease in the Japanese Burnout Scale and salivary amylase [99].
Addiction
●Smoking cessation – A meta-analysis and a subsequent randomized controlled trial found that yoga may be a helpful add-on to cognitive-behavioral therapy for smoking cessation. However, none of the studies included an active comparator [124,125].
●Methadone maintenance – A randomized controlled trial comparing weekly Hatha yoga with traditional group psychotherapy found that clients experienced similar changes in various psychological, sociological, and biological measures [126].
Cancer — Yoga for cancer patients is discussed separately. (See "Cancer-related fatigue: Treatment", section on 'Yoga' and "Overview of complementary, alternative, and integrative medicine practices in oncology care, and potential risks and harm", section on 'Yoga'.)
Cardiovascular disease and rehabilitation — A meta-analysis of seven randomized controlled trials comparing yoga and rehabilitation versus usual rehabilitation alone concluded there was no effect on all-cause mortality but that quality of life, triglycerides, and high-density lipoprotein cholesterol, blood pressure, and body mass index were significantly improved [127]. The best of these studies did not detect any effects of yoga on patients after an acute coronary event, although follow-up stopped at three months [128]. The two randomized controlled trials conducted in India resulted in improvements in quality of life and reduction in stress levels at the end of five years after coronary artery bypass graft [129]. Still, yoga did not decrease major adverse cardiovascular events after ST-elevation myocardial infarction [130].
Vasovagal syncope — A randomized controlled trial comparing yoga as an adjunct with guideline-based therapy found yoga superior to guideline-based therapy alone in reducing the symptomatic burden and improving quality of life [76].
Musculoskeletal system — Increases in flexibility have been reported in controlled trials of yoga in patients with a variety of common musculoskeletal problems [131].
●Low back pain — Yoga for low back pain is discussed elsewhere. (See "Exercise-based therapy for low back pain", section on 'Choice of exercise: All programs are beneficial'.)
●Osteoarthritis — A three-arm, yoga-based exercise program with minimal knee adduction moment for knee osteoarthritis produced clinically but not statistically meaningful improvements in pain, self-reported physical function, and mobility in women with osteoarthritis compared with no exercise, and equivalent improvement compared with exercise [132]. (See "Complementary and alternative therapies for rheumatic disorders".)
●Osteoporosis — The effect of a one-leg balance (tree pose) added onto exercise (30 minutes/day for 12 weeks) found a statistically significant improvement in measures of balance compared with exercise alone [133].
●Carpal tunnel syndrome — A randomized trial in 42 patients with carpal tunnel syndrome found that an eight-week yoga program focusing on the upper body improved grip strength, but wrist splinting did not [61]. (See "Carpal tunnel syndrome: Treatment and prognosis", section on 'Other nonsurgical options'.)
●Fibromyalgia — Yoga for patients with fibromyalgia is discussed separately.
Pain control — In a 2012 meta-analysis of 16 trials including 1000 participants, yoga slightly improved pain-associated disability in several different pain conditions, including migraine, rheumatoid arthritis, and low back pain [134]. Yoga is recommended as one of several nonpharmacologic therapy options for the treatment of chronic low back pain [135,136] and may be effective in labor pain. (See "Exercise-based therapy for low back pain" and "Nonpharmacologic approaches to management of labor pain".)
Asthma — Breathing exercises and the effect on asthma are discussed separately. (See "Complementary, alternative, and integrative therapies for asthma", section on 'Breathing exercises'.)
Risks associated with yoga
Injury — Like other forms of exercise, yoga may be associated with adverse events such as injury. Unfortunately, isolated reports of severe injuries have raised unnecessary concerns about yoga's safety.
Subsequently, well-designed studies found no evidence that yoga is associated with higher rates of injury than exercises of similar levels of impact and exertion [137]. In a meta-analysis including 94 randomized trials, there were no differences in the frequency of adverse events between yoga and active control groups [138]. When compared with inactive interventions that did not involve exercise (eg, counseling, health education), more intervention-related adverse events were found with yoga [138].
In observational and randomized trials, minor injuries associated with yoga are relatively common, but serious injuries are rare [137]. In a national survey in the United States, 0.6 percent of yoga practitioners reported an injury that led to discontinuation of practice, 0.2 percent required medical attention, and 0.01 percent required an emergency department visit [139]. A survey of Ashtanga yoga practitioners in Finland estimated a rate of 1.2 musculoskeletal injuries per 1000 hours of practice [140]. In a subsequent one-year prospective study of 354 recreational yoga participants, 5 percent developed pain that lasted more than three months and limited their yoga practice time [141].
Increased age may be associated with greater risk of injury from yoga. While a prospective study found no risk factors associated with yoga-related injuries [141], in other studies injuries were more likely to occur in older people and those with preexisting health problems [139].
Types of injury — Musculoskeletal injuries are the most common adverse events associated with yoga, particularly soreness, strains, and sprains [137,142]. Observational studies indicate that the most common site of injuries is the trunk, lower extremities (especially the hamstrings or knees), and head/neck [139,140,143].
More serious adverse events associated with yoga have been reported in case reports and case series. These include cerebrovascular dissection or occlusion [144-147], femoral fracture [148], vertebral compression fracture [149], and injuries of the sciatic, median, ulnar, and common peroneal nerves [150-154]. Two cases of late dislocation of total hip arthroplasties have been reported [155], although a retrospective study of 797 arthroplasty patients suggested that the overall risk is low [156].
Bikram (hot) yoga (table 1) has been associated with case reports of a myocardial infarction [157] and a prolonged seizure from hyponatremia [158].
Postures associated with adverse events — The risks due to specific postures have not been evaluated in controlled studies. However, in observational studies, poses that involve extreme flexion or extension may be associated with an increased risk of a compression fracture in patients with osteoporosis or osteopenia [149]. In addition, several other postures may be associated with increased risk of injury, including inverted poses (such as headstands, handstands, shoulder stands), variations of the lotus position (picture 2), and forward and backward bends [41,142,149].
COUNSELING PATIENTS
Referral of patients — Yoga studios are found in most cities in the United States and other Western countries. Patients in need of basic fitness can be referred to studios with teachers who have completed basic 200- or 500-hour accreditation. Patients with specific health problems (see 'Treatment of specific health problems' above) can also be referred to accredited yoga therapists. However, variation in levels of training of yoga teachers and the different styles of yoga that they teach means that outcomes achieved in randomized controlled cannot be assured. Further, patients should be made aware that health insurers do not provide reimbursement.
Benefits, risks, and precautions — Yoga appears to be similar in benefits and safety to other low- or moderate-exertion exercises [138]. (See 'Clinical applications' above.)
An approach to counseling patients regarding the appropriate and inappropriate use of complementary and alternative therapies is discussed elsewhere. (See "Complementary and integrative health in pediatrics", section on 'Discussing complementary therapies with patients and families'.)
Preventing injury — As with any new physical activity, increasing the intensity over time will reduce the risk of injury. General guidelines for injury prevention include [159,160]:
●Avoiding painful yoga poses. While poses may be challenging, they should not be painful.
●Avoiding difficult postures (picture 2) until they can be done safely. Teachers should suggest modifications or variations to most poses so they can be done gradually, comfortably, and safely.
●Avoid prolonged or extreme ranges of motion for large joints (eg, hip rotation, knee flexion, shoulder rotation).
●Maintaining proper hydration when practicing, especially when practicing in elevated temperatures.
●Using caution with or avoiding inversion postures (eg, headstands and shoulder stands (picture 2), especially in patients with cervical disc disease or glaucoma).
●Ceasing practice and seeking medical care if there is worsening pain, paresthesia, or other neurologic or musculoskeletal dysfunction symptoms.
Considerations for specific patient populations — For patients with underlying health problems, the clinician and patient should together determine how yoga will fit into an overall plan to maintain or improve the patient's health. General health status and specific comorbidities must be considered in choosing a particular style of yoga. The clinician and patient should discuss avoiding postures or yoga styles that may exacerbate health problems or increase the risk of serious adverse events. For example:
●Patients with glaucoma and cervical disc disease should avoid inverted postures (eg, headstand, handstand, shoulder stand) [142].
●Patients with osteoporosis or osteopenia should be counseled about avoiding poses involving extreme spinal flexion and extension, which may increase the risk of vertebral compression fracture [149].
●Patients with hip arthroplasties should be cautioned that a number of yoga positions may put the hip outside of a safe range [155,161].
●Patients who choose Bikram or hot yoga should be warned about the potential increased risk of exertion at the high temperature and humidity at which this form of yoga is practiced. (See "Exertional heat illness in adolescents and adults: Epidemiology, thermoregulation, risk factors, and diagnosis".)
●Although most styles of yoga are generally considered safe in pregnancy, pregnant women should practice yoga in classes intended explicitly for prenatal patients or consult their provider to discuss other styles of yoga.
Choice of style — As the few randomized comparisons of yoga styles have not found important differences, the choice of style is usually not clear cut and is likely to be patient driven. However, the clinician may be helpful in guiding the patient to consider the following:
●The patient’s goals (see "Exercise prescription and guidance for adults")
●The availability of research matching a style to a particular need
●Safety of the yoga style given the state of the practitioner's health
●Speed of practice, level of difficulty, and exertion (table 1)
●Length of classes
●Patient preferences for class structure (in person, indoors/outdoors, private or group)
●Teacher training, experience, and certification (see 'Yoga teacher training and certification' above)
CHALLENGES IN YOGA RESEARCH — Scientific studies of yoga are improving in their adherence to standards for randomized controlled trials (see "Evidence-based medicine"), systematic reviews, and meta-analyses. (See "Systematic review and meta-analysis".)
However, there are numerous methodologic challenges to evaluating the effectiveness of yoga. Among the most common problems are lack of a clearly defined yoga intervention, lack of an appropriate active control (eg, a similar level of physical activity or other mind-body practice); lack of a predefined primary outcome, especially one that is clinically important; and inability to distinguish between yoga's specific and nonspecific effects (eg, benefits from expectation, social interaction during class, therapeutic and interpersonal skills of the yoga teacher). Meta-analyses that evaluate the effect of yoga often combine people who are healthy and those with diseases. These challenges have necessitated the development of guidelines specific to evidence-based studies of yoga [36,162-164].
RESOURCES — Many major universities have training programs and information for both patients and health care professionals in yoga and other mind and body practices.
●The International Association of Yoga Therapists provides a searchable database of individual members and training programs, accreditation standards, and links to relevant research.
●The National Institutes of Health's National Center for Complementary and Integrative Health provides sections on yoga for health professionals and consumers, including a yoga fact sheet for patients.
●Mayo Clinic has information written by health care professionals on yoga.
●University of Minnesota's Center for Spirituality & Healing provides information for the general public about enhancing wellbeing and exploring complementary and integrative healing practices including yoga.
SUMMARY AND RECOMMENDATIONS
●Definition and components – Yoga is a form of light to moderate exercise, shown to improve strength, flexibility, balance, and quality of life. The principal components are postures, breath control, and meditation. (See 'Health maintenance and quality of life' above and 'Components of yoga' above.)
●Clinical applications – While yoga is recommended in popular media for many indications, evidence of its effectiveness is limited for most. The best evidence suggests that yoga is a helpful adjunct to recommended interventions for the following health conditions (see 'Clinical applications' above):
•Physical fitness, especially in adults with limited exercise capacity
•Pregnancy
•Stress and anxiety
•Cardiac rehabilitation
•Cancer fatigue and insomnia
•Depression
•Fibromyalgia
•Low back pain
•Multiple sclerosis (balance)
•Parkinson’s disease
●Yoga therapy – Yoga therapy is a specialized application of yogic principles, methods, and techniques to specific human ailments for diseases or injuries. (See 'Yoga therapy' above.)
●Choice of style – The choice of a style of yoga should take into account the patient’s underlying state of health, the patient’s reasons for practicing yoga, and the yoga style’s safety, speed, level of difficulty, and exertion (table 1); patient preferences for class structure; and teacher training and certification. (See 'Choice of style' above.)
●Counseling patients – Caution is especially important in patients with cervical disc disease, glaucoma, and osteoporosis. Such patients should be advised to avoid inversion postures (eg, head, hand or shoulder stands) and extreme spinal flexion or hyperextension (picture 2). (See 'Counseling patients' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Robert Saper, MD, MPH, who contributed to an earlier version of this topic review.
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