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Yoga and Physiotherapy: A Speculative Review and Conceptual Synthesis

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• 66 • Chin J Integr Med 2009 Feb;15(1):66-72

REVIEW
Yoga and Physiotherapy: A Speculative Review and
Conceptual Synthesis
Paul Posadzki1 and Sheetal Parekh2

ABSTRACT This article presents the potential integration of yoga and physiotherapy when considering
the essence of their underlying concepts. Within the scope of this article the existence of several similarities
between these two 'concepts' has been suggested. Researchers, physiotherapists and their patients as
well as yoga practitioners can obtain valuable and additional arguments through the cross-fertilization of
ideas across presented studies united by shared, underlying concepts. The practice of yoga is based on
the following assumptions: complexity and multidimensionality, various positive influences on an individual's
wholeness through the mind, body, and the relationships between them. These assumptions may have the
potential to contribute towards the practice of physiotherapy and its underlying principles. The essence of
physiotherapy as a multifaceted process requires teamwork and efforts of various specialists like psychologists,
sociologists, occupational therapists and nurses if patients are to benefit. Ideally, the physiotherapist should
possess knowledge from these areas of science in order to professionally care about patients. Therefore, it
can be suggested that basic similarities exist between yoga and physiotherapy in terms of mutidisciplinarity
and complexity of holistic care. Such conceptual enrichment may be a useful source of inspiration for
physiotherapists concerned about their patients' overall health on a daily basis. The authors emphasize the
usefulness of yoga practice in clinical units and explain how the essence of Ayurvedic knowledge might be
extrapolated and incorporated into theoretical principles of physiotherapy process. The justification of the studies
included is also presented.
KEY WORDS yoga, physiotherapy, review, concept formation

Yoga, as adjunctive therapy and a way of
promoting and maintaining wellness, offers an
excellent example of the mind-body connection (1).
It has been suggested that yoga has diverse
clinical and non-clinical applications in the
physiotherapeutic process. This is mainly attributed
to the degree of complexity and multidimensionality
of influences that is apparent in both yoga exercises
and physiotherapy as continuous processes.
The similarities between yoga and physiotherapy
on the conceptual level include physiological,
psychological, spiritual, social and educational
dimensions of human health (2) . Yoga exercises
combined with physiotherapeutic processes, both
in clinical and non-clinical settings, can affect
various body structures and systems such as the
musculoskeletal, nervous, visceral, endocrine
and immune system. This would be beneficial for
patients with neurological, orthopedic, metabolic
and psychosomatic disorders. Nevertheless, the
main strength of this form of activity is that all the
body's dimensions (i.e. cells, tissues, organs) can
be influenced simultaneously within one entire
system.
In this review, the authors' aim is to present
the results from various researches on yoga and
combine them with the core, theoretical component
of physiotherapeutic processes. The rationale for
this combination is that yoga's philosophy and
physical exercises (asanas) share a number of
basic underlying principles of the physiotherapeutic
process. The principles of yoga resonate with the
principles of the physiotherapeutic process as in their
holistic approach towards health and well-being of
an individual. Therefore, the aim of this study is to
present yoga's potential role in terms of the whole
physiotherapeutic process. The theoretical cross-
fertilization of their mutual assumptions would lead
to various benefits in terms of the patient mind-body
relationship and general wellness. Consequently, this
would imply the possible integration of yoga with the
physiotherapeutic process at the conceptual level.
1. School of Medicine, Health Policy and Practice, University of
East Anglia, Norwich NR4 7TJ, UK; 2. School of Allied Health
Professions, University of East Anglia, Norwich NR4 7TJ, UK
Correspondence to: Dr. Paul Posadzki, Tel: 44-01603591223,
E-mail: P.Posadzki@uea.ac.uk
DOI: 10.1007/s11655-009-0066-0
Chin J Integr Med 2009 Feb;15(1):66-72
A further aim of this paper is to indicate potential
development prospects within the physiotherapeutic
process due to such "conceptual enrichment" and
how it would enhance the patient's sense of well
being and the physiotherapists' holistic approach.
The possible integration of yoga's essence, such as
beneficial effect on overall health, could be taught at
the academic level among physiotherapy students.
The practice of such conceptual congruence may
require some changes in the physiotherapy curriculum
which might be useful for the future therapists. The
authors hope that through this conceptual synthesis
physiotherapists will gain an understanding of the
philosophy and some practical knowledge of yoga.
BRIEF CHARACTERISTICS OF YOGA
Yoga offers a philosophical system for
approaching health holistically. Yoga originates from
Ayurveda – ancient knowledge that aims to discover
the true sense of human life and to find remedies
for diseases. It is estimated that yoga has been
developing for four to five thousand years, mainly
in Asia. Nowadays, yoga is being regarded within
Complementary and Alternative Medicine as a form
of mind-body medicine(3). An extensive renaissance of
yoga is being observed across the world.
Yoga creates inner, physical and emotional
balance through the use of postures (Hathayoga),
called asanas that are combined with breathing
techniques or pranayama, that are based mainly on
isometric muscle contractions (4). Yoga emphasizes
physical and spiritual self-control and can be
regarded as a way of harmonizing the balance
between catabolic and anabolic reactions within the
body(5,6). The yoga practice is related to high levels of
concentration and emotion control(7), and the main aim
of this kind of activity is self-realization, self-exploration
and bless-consciousness through consciousness
control(8). Yoga also offers guidance in relation to the
dietary habits and a self-regulated life-style, as well
as general, ethical and moral principles(9). Overall, the
main objective of yoga is the achievement of balanced
health and well-being, optimal fitness and increased
body resistance. From the therapeutic perspective it
is also important to emphasize that, when performed
correctly, yoga exercises have no adverse effects(10,11).
Nevertheless, competitiveness and specific indications
and contraindications of different yoga exercises must
be carefully respected(12).
• 67 •
CURRENT RESEARCH ON YOGA
Research related to overall health and well-being
is presented here. It is believed that this will provide
an insight into the broadness of yoga's effect on the
body's homeostasis and therefore, congruence with
physiotherapy process at the conceptual level. The
practice of yoga can lead to significant improvements
in physical, mental as well as spiritual health, as
discussed below.
Physiological Benefits of Yoga
Practicing yoga exercises leads to the autonomic
nerve plexuses and the endocrine system stimulation
by an increased pressure in the abdominal wall.
Thus, it is suggested that yoga asanas improve the
performance of the cardio-respiratory system (13) ,
enhance lung function together with increased strength
and endurance of respiratory muscles(14,15), leading to
increased vital capacity (VC)(16). It also normalizes blood
pressure and improves immunity(17), reduces heart rate
(HR), respiratory rate (RR) and increases red blood
cell volume(18). A significant reduction in the amount
of oxygen consumed with decreased breath rate and
increased breath volume has also been found(19,20).
Yoga may also significantly decrease fatigue(21). More
precisely, Yoga "intervention" increases regression
of coronary atherosclerosis and coronary lesions in
patients with severe coronary artery disease, whilst
simultaneously improving myocardial perfusion (22).
Yoga also improves symptomatic status, functional
class and risk factor profile(23). In this study, patients
performing yoga exercises required revascularisation
procedures (coronary angioplasty or bypass surgery)
less frequently.
From the physiotherapy point of view, Yoga may be
regarded as an appropriate way of using body postures
that offers enhanced cardio-pulmonary function, i.e.
improved breathing patterns or blood vessel contraction
as well as various physiological benefits.
Neuropsychological Benefits of Yoga
Yoga seems to stimulate the right brain hemisphere
and increase alpha wave frequencies (24). Patients
practicing yoga may also show a significant reduction in
the number of errors during static motor performance(25)
as well as improvement in sensory-motor performance
and enhanced processing ability of the central nervous
system(26) and eye-hand coordination(25).
• 68 •
It can be suggested that physiotherapists could
utilise yoga to facilitate the recovery processes among
stroke patients and improve their function.
Benefits of Yoga: Psychological and Spiritual
Wellness
Yoga asanas have shown significant reduction in
the symptoms of anxiety and depression(27-31). They can
also decrease oxidative stress(32) and relieve tensions
leading to better relaxation and concentration (33-35). This
may be partially explained by the work of Shannahoff-
Khalsa, who demonstrated that yoga asanas increase
dopamine and serotonin and decrease cortisol
secretion(3,36).
Studies on the effects of yoga on cognitive
functions have shown improvements in memory and
vigilance levels(37). Yoga techniques were found to be
effective in treating obsessive-compulsive disorder,
phobias, major depressive disorders, dyslexia, grief,
insomnia and other sleep disorders (3) and post-
traumatic stress disorder (PTSD)(38). Yoga can also
improve fear management through its soothing
effects in controlling anger and assisting effects in
coping mental challenges by helping patients to
turn negative thoughts into positive ones as well as
facilitating rehabilitation of patients prone to anti-social
behaviours (39). Yoga offers a new route to positive
mental health and helps to free individuals from
drug dependency (addictive and substance abuse
disorders) (12) and its associated problems (40). Yoga
techniques can enhance well-being, mood, mental
focus, and stress tolerance(39,41), promote personal
development by encouraging individual initiative and
self-belief and help to bring about improvements
in attitude and health behaviour. Yoga asanas are
observed by many as an open door to self-realization
and creation of the perfect union of the mind, body,
and spirit. The results indicate a statistically significant
improvement in various parameters such as better
sense of well being, self confidence, improved
effectiveness, better interpersonal relationship,
increased attentiveness, lowered irritability levels and
an optimistic outlook in life as some of the beneficial
effects enjoyed by the yoga practitioners indicated
by feedback score (28). Significant improvements in
perceived self-efficacy may also improve coping and
stress management among yoga practitioners (42).
Significant improvements in quality of life (QOL)
scores are also observed(43).
Chin J Integr Med 2009 Feb;15(1):66-72
The authors hypothesize that during yoga
exercises the same psychological and spiritual
resources are utilized by practitioners as used by
physiotherapists in order to improve the patients'
return to function. If verified, this hypothesis may be
a useful adjunct both to patients intended to develop
their psychological or spiritual features as well as
to physiotherapists who might consider expanding
their holistic approach as therapists using yoga's
essence. Furthermore, physiotherapist, osteopaths,
chiropractors or manual therapists could consider
yoga as a way of "mental mobilization" insofar as the
individual performs postures that comprise elements
of enhanced self-efficacy, self-development or positive
mind states such as optimism.
Benefits of Yoga: Musculoskeletal
Improvements and Posture Control
Some publications imply that yoga exercises can
influence the musculoskeletal and nervous systems
via mobilization or auto-mobilization of both joints
and nerves respectively (44,45). For example, one of
McKenzie's static procedures and the "Cobra" asana
are almost the equivalent and can directly lead to
alleviation of pain symptoms of low back and cervical
pain(46). This could suggest direct similarities between
these two approaches and the congruence of their
essence. From the physiotherapeutic perspective,
somatic dysfunction can be released and flexibility
and range of movement improved. With regards to
physiotherapeutic processes, yoga as a set of "static-
dynamic procedures" can be considered as a means
to "self-mobilisation" of the nervous system and the
joints, spine and limbs. Other research supports
this point of view, having demonstrated that patient
conditions improved considerably after six months
of yoga practice, with some markers of incorrect
posture completely disappearing such as head
protrusion, asymmetry of the shoulders, mamillas
and hips, shortening of the musculus pectoralis and
back extensors(16). Findings from another exploratory
study suggest that yoga practice may improve hip
extension, increase stride length and decrease
anterior pelvic tilt, and that yoga programs tailored
to individual needs may offer a cost-effective means
of preventing or reducing age-related changes in
these indices of gait function (47). Physiotherapists
specialized in orthopedic manual therapy might be
particularly interested in the beneficial effects of yoga
exercises on the musculoskeletal system(48), scoliosis
Chin J Integr Med 2009 Feb;15(1):66-72
prevention(49), passive correction of multidimensional
pelvic distortion(50), postural re-education, increased
range of motion in spinal column and improved
blood circulation in vertebral arteries(51) as well as the
prevention of soft tissue injury.
BENEFICIAL ASPECTS OF YOGA IN
CLINICAL PRACTICE
There are several clinical implications to the
consideration of yoga asanas as a useful adjunct to the
physiotherapy process. Frequently, physiotherapists
have to manage serious clinical conditions, including
cardiologic, metabolic, musculoskeletal, orthopaedic
as well as psychosomatic disorders. Research
results that can be considered as directly related
to physiotherapists' practice and some of the most
relevant beneficial aspects of yoga in the clinical
setting are presented below.
Effects of Yoga on Compromised Groups
Several evaluations suggest that yoga is an
appropriate physical activity for various compromised
groups, such as individuals with rheumatoid arthritis
(Dash & Telles 2001), carpal tunnel syndrome(52) and
irritable bowel syndrome(53). Other evidence shows that
yoga is a safe and effective clinical treatment modality
in patients with end-stage renal disease(54). Yoga may
lead to an improvement in aphasia as well as fine motor
coordination in stroke patients(55). Yoga appears to
bring about changes in some of the electrophysiological
responses studied in epileptic patients(56). Beneficial
effects of yoga on social and psycho-emotional
functioning were observed as well as significant
increase in invigoration, acceptance and relaxation
among cancer survivors(29,43,56-58). Statistically significant
improvements were observed in sleep efficiency in
insomnia patients (18,59). Not only has yoga training
been shown to reduce pain symptoms significantly,
but also to benefit patient's functionality and muscular
strength(60). It can be claimed that with a physician's
consultation, physiotherapists might consider yoga as a
useful adjunct to cancer patients and adjust this form of
activity to their individual needs.
Yoga and Metabolic Disorders
It has been demonstrated that yoga can
positively influence diabetes patients. Statistically
significant changes were found in serum total
cholesterol and triglyceride levels, fasting plasma
glucose, low-density lipoprotein cholesterol, the
• 69 •
ratio of total cholesterol to high-density lipoprotein
cholesterol among yoga practitioners (22). It is also
worth emphasizing that these changes were more
marked in subjects with hyperglycaemia or hype-
rcholesterolemia(61).
Significant improvements in the exercise
capacity and decrease in body weight have also been
observed, which may bring benefits to the body's
metabolism. Another study has demonstrated a
significant reduction in basal metabolic rate among
yoga practitioners(62).
　
CONCLUSIONS
Generally, yoga exercises are performed slowly
and carefully in closed kinematic chains (isolated
positions or static postures) that may include active
stretching, isometric muscle contractions, mindful
concentration and appropriate breathing patterns.
Analogically, physiotherapeutic processes are
"designed" to improve range of motion, flexibility,
strengthen weakened muscles, alleviate pain
symptoms or enhance patient's function in general.
At the conceptual level, the basic congruence
with physiotherapy may exist as both yoga and
physiotherapeutic processes can improve muscle
strength, increase joint range of motion and soft
tissues flexibility, mobilise nerve tracks, correct the
body's misalignments, enhance proprioception and
consequently, facilitate body's awareness, deactivate
trigger points activity and alleviate pain symptoms.
This allows the patient to find a position of ease,
develop self-actualisation, self confidence and
self-efficacy, promote effectiveness and personal
development, enhance well-being and QOL and help
to cope with stress.
Yoga exercises may be incorporated into
physiotherapy practice leading to positive health
influences in terms of cardio-pulmonary, orthopaedic
and neurological functions. Within the scope of
this article, the authors have tried to emphasize
that the extrapolation of yoga's quintessence into
physiotherapeutic practice would potentially combine
all the benefits discussed (for example, in terms of
muscle relaxation, breathing and heart rate, level of
concentration, overall functionality and life satisfaction
via normalized cardio-respiratory, endocrine,
musculoskeletal and central nervous system) above
within one "physiotherapeutic modality". To be more
• 70 •
precise, for example, pranic breathing patterns
might be useful for various groups of compromised
patients, specifically those with cardio-pulmonary
disturbances. Yoga's philosophical background is
rooted in knowledge that has been accumulating
over several millennia and offers a route to spiritual
development for patients after serious injury-for
example, with tetraplegia. Improved muscle strength
may also be beneficial in orthopaedic patients who
have immobilised limb(s). It can also be suggested
that yoga's "popularity" may bring positive effects on
patient's willingness to exercise, especially among the
elderly.
The underlying principles of both yoga and
physiotherapy suggest that these are complex and
continuous, covering spiritual, mental, physiological and
social dimensions of health, well being and quality of an
individual's life. Therefore, the essential value of yoga
exercises, with their multidimensional influence and
"interdisciplinary" approach to human unity and integrity
should be particularly useful in physiotherapy practice
on a routine basis. Subsequently, physiotherapists
may understand that yoga's philosophy or underlying
principles can be a useful adjunct to their normal
therapeutic management. It may lead to their patients'
overall health and well-being as their physical, mental,
spiritual and social well-being may be affected
simultaneously, i.e. holistically. Yoga exercises can
be also regarded as an effective "psychological
rehabilitation" by improving patients' emotional well-
being, cognitive functions, motivational patterns and
engagement in the recovery process.
Implications for Practice
If these similarities exist between yoga and
physiotherapy, then there are several key issues that
need to be addressed. Firstly, from a pragmatic point
of view, the incorporation of yoga may be applicable
to clinical practice and the home, where patients
are instructed to perform special kinds of physical
activity to sustain the health effects obtained with their
physiotherapist. Secondly, from the psychological
perspective yoga may also make the physiotherapeutic
processes more attractive to patients, especially those
with low motivation, by enhancing their willingness
to participate more actively in the recovery process.
Thirdly, from the therapist's point of view, yoga may
be an effective modality in terms of work ergonomics
and prevention of overloading their bodies.
Chin J Integr Med 2009 Feb;15(1):66-72
Physiotherapists may therefore consider that
asanas enfold the core of their normal therapeutic
management affecting patients' physiological,
psychological and spiritual well-being by the use of
tranquilizing effects on joint mobilization and pain
reduction, increased sense of serenity and heightened
awareness, respectively. As a result of this conceptual
synthesis, physiotherapists may also achieve an
awareness of yoga's complex and multidimensional
benefits on patient's overall health, leading to the
incorporation of some asanas into their regular
practice. Specifically, instead of separately performing
relaxation exercises, facilitating breathing patterns
and practicing meditation in order to mobilize joints
and normalize blood pressure and central nervous
system functions. Yoga offers a way of combining
these modalities.
Changes in the academic curriculum of
physiotherapy might be implemented and yoga
courses should also be made available to students.
Physiotherapy students may consider personal and
professional development by combining their current
knowledge with yoga's application in their ways of
approaching patients.
Yoga exercises can also be a useful method for
therapists who are potentially vulnerable to overload
their musculoskeletal system after continuous hours
of workouts with their patients. Yoga asanas may
be regarded as a form of preventive medicine within
healthcare environments and society.
All the same, a physiotherapist must be aware
that yoga exercises bring benefits to overall health
only when performed correctly and should therefore,
approach each patient individually with respect to
his or her learning abilities and resources. Potential
and specific indications and contraindications of yoga
applications must be also taken into account.
FUTURES RESEARCH
Future research should include potential patient
benefits, physiotherapists' satisfaction as well as
cost-effectiveness of extrapolating the principles of
yoga into clinical practice. Since yoga exercises have
multidimensional effects in terms of recovery from
traumatic injuries, future research could also cover
the complexity of yoga influences on general health
and the uniqueness of yoga's approach to each
Chin J Integr Med 2009 Feb;15(1):66-72
patient as a unified psycho-spiritual and physiological
wholeness.
　　
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(Received September 1, 2008)
Edited by TAO Bo