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4. AIM AND OBJECTIVES

4.1 Aim of the research

1. To study and compile the available literature from traditional yogic scriptures on

Polycystic Ovarian Syndrome.

2. To find the prevalence of Polycystic Ovarian Syndrome among Indian adolescents.

3. To assess the effect of yoga based lifestyle program on adolescent Polycystic Ovarian

Syndrome, through a randomized control trial.

4.2 Objectives:

1. To explore the understanding of Polycystic Ovarian Syndrome according to traditional

yogic scriptures.

2. To estimate the prevalence of Polycystic Ovarian Syndrome among adolescent girls in

South India.

3. To investigate the effects of 12 weeks of integrated approach of yoga therapy (IAYT)

as a yoga based lifestyle program on clinical symptoms of adolescent polycystic

ovarian syndrome.

4. To study the changes in hormonal profile in PCOS adolescents after 12 weeks of

IAYT as a yoga based lifestyle program.

5. To assess the biochemical changes after 12 weeks of IAYT as a yoga based lifestyle

program on adolescent PCOS.

6. To study the effect of 12 weeks of IAYT as a yoga based lifestyle program on

psychological wellbeing of adolescent PCOS.

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4.3 Research Questions:

PART 1

Is the prevalence of PCOS in South Indian adolescents similar to the other countries?

PART 2

Is IAYT as/more effective than physical exercise therapy in improving clinical, hormonal,

biochemical and psychological functions in adolescent girls with PCOS?

4.4 Hypothesis:

4.4.1 PART 1: Prevalence of PCOS in Adolescent Girls

There was no hypothesis testing involved in the study as it was an effort to evaluate the

prevalence of the syndrome amongst the population that was being screened for the

interventional study.

4.4.2 PART 2: Effect of yoga on PCOS

The study hypothesized that in comparison to the matched control group practices, IAYT

practice would improve the clinical, hormonal, biochemical and psychological functions in

South Indian adolescent girls with PCOS.

4.4.3 Null hypothesis:

The yoga group will show changes similar to control group in clinical, hormonal,

biochemical and psychological functions.

64

5. METHODOLOGY OF EXPERIMENTAL RESEARCH

5.1 Subjects

The study was carried out on adolescent girls aged 15 to 18 years from a residential

college in Anantpur, Andhra Pradesh, India. Although they were students of one residential

college in Anantpur, they represented a larger geographical area as they were from semi-

urban and rural areas around the district.

5.1.1 Sample size

A sample size of 86 with 43 subjects in each arm of the study, was calculated keeping an

effect size of 0.61, with Type 1 error at 0.05 and power at 0.8. This effect size of 0.61 was

obtained by using mean and Standard Deviation values of testosterone after 6 months of

lifestyle modification and metformin compared to placebo in a study on obese PCOS women

(Tang T, Glanville J et al. 2006). For these calculations we used the noncommercial statistical

power analysis program G*Power (Faul F, Erdfelder E et al. 2009 Nov). The sample size that

was actually recruited was 90 subjects.

5.1.2 Source of subjects

Female students from Sri Sai residential college, Anantpur, Andhra Pradesh, South India

were screened and subsequently recruited into the study.

5.1.3 Selection Criteria

5.1.3.1 Inclusion Criteria

1. Adolescent girls aged 15-18 years

2. Girls with no prior experience of yoga.

3. Girls with BMI≥18.5.

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4. Those who satisfied the Rotterdam criterion for PCOS were included in the study.

The following were the definitions of the features:

a. Oligo/amenorrhea: absence of menstruation for 45 days or more and/or less

than eight menses per year (Kumarapeli V, Seneviratne RD et al. 2008).

b. Clinical hyperandrogenism: Modified Ferriman and Gallway (mFG) score

of 6 or higher (Chen X, Yang D et al. 2008). Using17 mF-G, some

researchers reported a value as low as 3, being abnormal. However, other

investigators have used the 95th 18 percentile of controls as the upper

normal limit, which 19 corresponds to an mF-G score of 6-8 in the

population studied. We used an mF-G score of 6 as the upper normal limit

in accordance with a study in South Asia by Chen et al (Chen X, Yang D et

al. 2008) since there are no studies defining the criteria for hirsutism in

Indian girls.

c. Biochemical hyperandrogenism: Serum testosterone level of > 82ng/dl in

the absence of other causes of Hyperandrogenism.

d. Polycystic ovaries: presence of >10 cysts, 2-8mm in diameter, usually

combined with increased ovarian volume of >10cm3, and an echo-dense

stroma in pelvic ultrasound scan (Franks S, Gharani N et al. 1997).

5.1.3.2 Exclusion Criteria

1. Girls who fall under Rotterdam criteria of exclusion.

2. Girls with BMI<18.5.

3. Girls who were using oral contraceptives/hormone treatment/insulin-sensitizing

agents within previous 6 weeks.

4. Girls who were practicing yoga from a month or more.

66

5.2 Ethical clearance and consent

The study was approved by the Institutional Ethical Committee of Swāmi Vivekānanda

Yoga Anusandhāna Samsthāna (SVYASA) University. The college administration also gave

the ascent for the study. Signed Informed consent was obtained from the student and one of

the parents. The consent form had clearly stated about the randomized allotment to either of

the interventions. The utility of the control session as a conventionally accepted therapeutic

regime (not as a placebo waiting period) was clarified so that they could participate in both

the interventions with equal degree of motivation.

5.3 Screening

All female students of standard 11 and 12 attended an interactive introductory lecture

where the purpose and design of the study were elucidated. They were asked to report one

week later after obtaining the signed consent from their parents.

All girls who consented for the study were asked to fill up a short PCOS symptoms check

list that asked questions on the pattern of menstrual cycle, hirsutism, acne, alopecia,

acanthosis nigricans and information about past diagnosis or treatment of PCOS or any other

illnesses. After one week, individual interviews were conducted to confirm statements in the

check list. The research medical officer conducted a physical examination to look for external

features of PCOS and also to exclude other conditions that could mimic PCOS such as

Cushing’s syndrome, adrenal Hyperplasia or androgen producing neoplasm. Questions were

asked about the use of Oral Contraceptive Pills or any other hormones that could affect the

length of the menstrual cycle. Self–reported degree of hirsutism was assessed using modified

Ferriman-Gallwey (mF-G) scoring method. The girls were asked to compare the amount of

body hair they had with a chart of pictures displaying the degree of hair growth in nine

regions (i.e., upper lip, chin, chest, upper and lower abdomen, upper and lower back, upper

arms, and thighs). Hirsutism scores recorded by the girls were checked for accuracy during

67

clinical examination by the researcher and corrected with the consent of the participant when

deemed necessary.

Also girls were asked about the presence of acne or hair fall from the scalp although it was

not quantified. All girls with Oligomenorrhea and/or hirsutism (as per the above said

definitions) were asked to come for pelvic ultrasound and biochemical investigations.

5.4 Design of the study

This was a prospective, randomized, active interventional controlled trial in which 90

participants were randomly divided into two study arms: one arm practiced yoga based life

style modification and the other arm practiced physical exercise based lifestyle modification,

in the absence of any conventional treatment, for the same duration.

5.5 Randomization

PCOS girls were randomly assigned to two groups of 45 numbers each by using a

computer-generated random number table (www.randomizer.org ) by the pre labeled sealed

envelope method.

5.6 Blinding and Masking

Double blinding was not possible as this was an interventional study. The medical officer,

ultrasonologist and the laboratory staff were blind to the groups. Also the statistician who did

the randomization and the final analysis was blind to the source of the data. The

questionnaires’ coded answer sheets were analyzed only after completion of the study.

5.7 Variables

Variable of the study was specifically chosen to provide a comprehensive picture of the

changes that were brought about by the intervention. Since IAYT has effects at several levels,

it was deemed essential to select variables that could capture them. This battery of variables

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would help not just to highlight the clinical effects of the intervention but also lead us to

unearth the underlying mechanisms. Also these variables would help detect the differences

between yoga and exercise as an intervention for PCOS.

5.7.1 Symptom Check List

This was developed for the present study to obtain demographic details like clinical data,

personal and family history. (Table 4) Hirsutism was assessed using the scale provided along

with the check list:

Table 4: PCOS Symptom Check List

PERSONAL INFORMATION

1 Name

2 Age

3 Date of Birth

4 Class

5 Subjects

ANTHROPOMETRIC MESAURES

6 Height (meters)

7 Weight (kilogram)

8 BMI (kg/m2)

9 Waist (centimeters)

10 Hip (centimeters)

11 Waist : Hip Ratio

CLINICAL SYMPTOMS

12 Years since diagnosis

13 Cycle Characteristics Oligomenorrhea?

Longest Amenorrhea?

14 Acne (refer scale1) Sites:

Grade: Mild / Moderate / Severe

15 Alopecia (refer scale2) Grade: Mild / Moderate / Severe

16 Hirsutism (refer scale3)

Lip ________

Chin ________

Chest ________

Upper Abdomen ________

Lower Abdomen ________

Arms ________

Thighs ________

Upper Back ________

Lower Back ________

TOTAL ________ out of 36

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17 Acanthosis Nigricans Sites:

18 History DM ______ CVS ______

Cancer ______ Other ______

19 Family History DM _______ Sisters? ____ CVS _______

Cancer _______ Other _____

20 Genetics?

21 Treatments if any

22 Any Other Information

HIRSUTISM GRADING SYSTEM - The Ferriman- Gallwey Model

This scale quantifies the extent of hair growth in nine key anatomic sites. Hair growth is

graded using a scale from 0 to 4 for each site. The maximum score is 36 and a score more

than 8 indicates the presence of androgen excess.

SCORE SITE 1 2 3 4

Upper Lip

Chin

Chest

Upper Abdomen

Lower Abdomen

Arms

Thighs

Upper Back

Lower Back

70

5.7.2 Laboratory assessment:

After obtaining the information for symptom check list, all girls with oligomenorrhea

and/or hirsutism (as per the above said definitions) were asked to come for laboratory

assessment.

Table 5: Techniques for objective measures

S.No. Parameter Via

1. Abdominal Ultrasound Philips HD 11XE ultrasound system.

Hormonal assessment

2. Luteinizing Hormone

Fasting sample of venous blood.

3. Follicle Stimulating Hormone

4. Serum Testosterone

5. Prolactin

6. Thyroid Stimulating Hormone

7. Anti Mullerian Hormone

8. Fasting Insulin

Insulin Resistance

HOMA-IR: Glucoe X Insulin/22.5 (when

glucose is in molar units mmol/L.)

BSIN: Blood sugar/ Insulin.

Biochemical assessment

9. Fasting Blood Sugar Fasting sample of venous blood.

Lipid Profile

10.1 Triglycerides

Fasting sample of venous blood.

10.2 Total cholesterol

10.3 High Density Lipoprotein

10.4 Low Density Lipoprotein

10.5 Very Low Density Lipoprotein

10.6 Tchl/HDL Total cholesterol/High Density Lipoprotein.

5.7.3 Psychological Assessment:

Stress, anxiety, emotion and quality of life were measured using following scales.

Table 6: Techniques for Psychological Variables

S.No. Variable Via

1. Measure of Anxiety State & Trait Anxiety X1

State & Trait Anxiety X2

2. Measure of Stress Perceived Stress Scale

3. Measures of Affect or

Measures of Emotion Positive Affect Negative Affect Scale

4. Measure of quality of life Polycystic Ovarian Syndrome Quality of Life

questionnaire

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According to the World Health Organization (2006) (WHO 2006), “Normally, emotions

such as anxiety, anger, pain or joy interact to motivate a person to a goal-directed action.

However, when certain emotions predominate and persist beyond their usefulness in

motivating people for their goal-directed behavior, they become morbid or pathological.” It is

therefore essential to evaluate and monitor emotional states in diagnosis and treatment just as

physicians in medical examinations routinely measure pulse rate, blood pressure, and

temperature, the vital signs that provide essential information about physical health.

When a physician detects an abnormal pulse or elevated blood pressure during a medical

examination, these symptoms may indicate a potentially significant problem in the

functioning of the cardiovascular system. Intense anxiety and anger may be considered as

analogous to elevations in pulse rate and blood pressure.

Similarly, as high fever may indicate that the immune system is not protecting the person

from harmful viruses; symptoms of depression and anxiety often reflect the presence of

pervasive unresolved conflicts that contribute to an emotional fever.

Manifestations of anxiety, anger, and depression are critical psychological vital signs that

are strongly related to an individual's well-being. Therefore, it is essential to evaluate the

emotional health by using appropriate psychological parameters.

5.7.3.1 State –Trait Anxiety Inventory (STAI)

STAI developed by Spielberger et al (1970) consists of 2 forms (Y1 and Y2) each

comprising of 20 items rated on a 4 point scale (Spielberger CD, Gorsuch RL et al. 1970).

Form Y1 assesses state anxiety, defined as ‘a transitory emotional state that varies in

intensity, fluctuates over time and is characterized by feelings of tension and apprehension

and by heightened activity of the autonomic nervous system’. It evaluates how the

respondents feel right now at this moment.

72

Form Y2 evaluates trait anxiety, which is ‘a relatively stable individual predisposition to

respond to situations perceived as threatening’.

The overall median alpha co-efficient is 0.92 and the tool has adequate concurrent,

convergent, divergent and construct validity (Spielberger CD, Gorsuch RL et al. 1970). It has

been extensively used in the Indian context and found to be useful.

5.7.3.2 Perceived Stress Scale

The Perceived Stress Scale is the only empirically established index of general stress

appraisal. The PSS is not a diagnostic instrument, so there are no cut-offs.

PSS-10 (Cohen S and Williamson G 1988) scores are obtained by reversing the scores on

the four positive items, e.g., 0=4, 1=3, 2=2, etc. and then summing across all 10 items. Items

4,5, 7, and 8 are the positively stated items. Scores can range from 0 to 40, with higher scores

indicating greater stress.

The Perceived Stress Scale (PSS) has adequate internal test and retest reliability is

correlated in the expected manner with a range of self-report and behavioral criteria. Cohen

and Williamson, proved internal reliability with a coefficient alpha of 0.78.

Earlier studies show that the relationships between PSS and the validity criteria were

unaffected by age and sex (Cohen S, Kamarck T et al. 1983). It was used for assessing

baseline stress scores.

5.7.3.3 The Positive and Negative Affect Schedule (PANAS):

Used as a psychometric scale, the PANAS shows relations between positive and negative

affect with personality stats and traits. Ten descriptors are used for each PA scale and NA to

define their meanings.

Participants in the PANAS are required to respond to a 20-item test using 5-point scale

that ranges from very slightly (1) to extremely (5)

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Reliability and Validity reported by Watson (Watson D, Clark LA et al. 1988) was

moderately good. For the Positive Affect Scale, the Cronbach alpha coefficient was 0.86 to

0.90; for the Negative Affect Scale, 0.84 to 0.87. Over an 8-week time period, the test-retest

correlations were 0.47-0.68 for the PA and 0.39-0.71 for the NA. The PANAS has strong

reported validity with such measures as general distress and dysfunction, depression, and state

anxiety.

5.7.3.4 Polycystic Ovary Syndrome Health-Related Quality of Life Questionnaire

(PCOSQ):

Polycystic Ovary Syndrome Questionnaire (PCOSQ), a questionnaire developed to

measure the health-related quality of life (HRQoL) of women with polycystic ovary syndrome

consists of a total of 26 items grouped into 5 domains: emotions (8 items), body hair (5

items), weight (5 items), infertility (4 items), and menstrual problems (4 items). Each question

is associated with a 7-point scale in which 7 represents optimal function and 1 represents the

poorest function. Scoring is done by dividing each domain total score by the number of items

in the domain. A score of less than 5 for any domain indicates significant adverse impact.

In year 2004, Jones et al (Jones GL, Benes K et al. 2004) showed that all PCOSQ

dimensions were internally reliable with Cronbach's a scores ranging from 0.70 to 0.97. Intra-

class correlation coefficients to evaluate test & retest reliability were high (range 0.89±0.95, P

< 0.001). Construct validity was demonstrated by high correlations for all comparisons of

similar scales of the SF-36 and PCOSQ (0.49 and 0.54).

5.7.4 Anthropometry:

Weight was measured using the research grade electronic weighing scale for pre and post

readings. Height was measured using a simple measuring tape. Body Mass Index (BMI) was

calculated using metric formula:

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Metric BMI Formula

BMI = Weight in kilograms (kg)

Height in Meters 2 (m2)

Following are the cut off points of BMI for Asian population, as per the WHO criteria (WHO

expert consultation January 10, 2004). Therefore, all the girls with BMI ≥ 18.5 were included

in the study.

BMI Weight Status Categories

BMI Weight Status

Below 18.5 Underweight

18.5 – 23 Normal

>23 Overweight/obese

Waist circumference was measured at the midway between the lowest rib margin and iliac

crest, and hip circumference was measured at the widest trochanters using ongoing quality

control. Waist to hip ratio (WHR) was calculated:

Waist to Hip Ratio

WHR = Waist Circumference in meters (m)

Hip Circumference in meters (m)

5.7.5 Abdominal Ultrasound:

Abdominal ultrasound scanning of the pelvis with special attention on ovaries was carried

out by a certified postgraduate medical ultrasonologist using Philips HD 11XE ultrasound

system. Vaginal ultrasound scanning was not acceptable to the girls or the parents.

5.7.6 Hormonal assessment:

Fasting sample of venous blood (10ml) was drawn in the morning (6:00-8:00am) at the

hostel premises. The samples were packed in ice (3-4o C) and transported to the laboratory

within 6 hours. Serum was separated by centrifugation and stored at -20 C until it was

analyzed at certified laboratories. Post intervention blood sample was drawn after staying 5

days off the practice to find the effect of 3 months of training and not the residual effect of the

last session.

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Hormone estimates including total testosterone (TT), luteinizing hormone (LH), follicle-

stimulating hormone (FSH) and Prolactin (PRL), were done by Fully Automated

Bidirectionally Interfaced Chemi Luminescent Immuno Assay. Thyroid Stimulating Hormone

(TSH) was measured by Ultra Sensitive Sandwich Chemi Luminescent Immuno Assay.

Serum AMH levels was assessed by using a second generation enzyme immunoassay (AMH-

EIA kit; Immunotech A Beckman Coulter Company, Marseilles, France). The intra- and inter-

assay coefficients of variation were 5.1 & 6.6% respectively for AMH, 3.8 &4.3% for FSH,

4.9 & 6.5% for LH and 4.0 & 5.6% for testosterone. Serum insulin was estimated by Solid

Phase Radio Immuno Assay with an intra and inter assay coefficient of variation of 2.2% &

6.1% and specificity of 4ng/ml.

5.7.7 Biochemical assessment:

Total cholesterol (intra-assay coefficient of variation CV 0.8%, interassay CV 1.7%),

triglycerides (intra-assay CV 1.5%, interassay CV 1.8%), and glucose (intra-assay CV 0.9%,

interassay CV 1.8%) were measured using the enzymatic calorimetric method. HDL

cholesterol (intra-assay CV 2.9%, interassay CV 3.6%) was measured using a homogenous

calorimetric assay, whereas LDL cholesterol (intra-assay CV 0.9%, interassay CV 2.0%) was

measured using a homogenous turbidimetric assay.

5.7.8 Insulin Resistance:

Insulin resistance was measured through Homeostasis Model Assessment (HOMA).

HOMA was derived by calculating the product of fasting serum insulin- fasting serum

glucose, divided by a constant (Katz A, Nambi SS et al. 2000) which have been shown to be

reliable derived indices of insulin resistance.

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5.8 Intervention

The specific modules of intervention were developed by a team of experts that included a

physiatrist, a gynecologist and yoga therapy physician. Care was taken to match the lectures,

practical classes and the type of relaxation technique used in the two modules.

5.8.1 Yoga intervention

The concepts for the intervention were taken from traditional yoga scriptures (Patanjali

yoga sutras, Upaniśads and Yoga Vasishtha) that highlight a holistic approach to health

management at physical, mental, emotional and intellectual levels (Nagarathana R and

Nagendra HR 2001). The practices consisted of āsanas (yoga postures), prāņayama,

relaxation techniques, meditation, and lectures on yogic lifestyle and stress management

through yogic counseling. The physical practices progressed from Suryanamaskāra to final

yoga postures āsanas of four categories (prone, standing, supine and sitting) to provide

activation followed by deep rest to mind body complex based on scriptural reference

(Nagendra 2007). Prāņayama included yogic breathing practices to bring about a slow

rhythmic breathing pattern with exhalation longer than inhalation. (Nagendra HR and

Nagarathna R 2004).

Table 7: General benefits of IAYT (Nagarathana R and Nagendra HR 2001)

KOŚA TECHNIQUES EFFECTS

Annamaya Kośa

(AMK)

Kriya

Activating and revitalizing the organs

Toning up their functions

Desensitization

Development of deep internal awareness.

Āsana and

Suryanamaskāra

Physical revitalization,

Deep relaxation and

Mental calmness

Prāņamaya Kośa

(PMK)

Kriya Development of deep internal awareness

Titiksha – stamina building

Prāņayama

Regulation of breath

Remove the random agitations

in prāņa flows

Manomaya Kośa

(MMK) Dharāna

Culturing of mind accomplished by focusing

of the mind

77

Dhyāna

Relaxed dwelling of the mind in a single

thought for longer and longer durations leads

to deep rest of the organs

Vijnānamaya

Kośa

(VMK)

Lecture & Yogic

Counseling

Knowledge burns the strong attachments,

obsessions, likes and dislikes which are the

basic reasons for the agitations of mind.

Anandamaya Kośa

(ANMK)

Working in

blissful awareness

Self-awareness and learn to maintain

equipoise (samatva) in all actions.

A module specific to PCOS was developed, keeping in mind the general benefits that

IAYT had to offer. This resulted in a fresh module, which would focus on the requirements of

PCOS girls. Table below shows the IAYT practices for PCOS and their respective benefits.

An attempt was made to elicit suggestions regarding the feasibility and applicability of

each of the practices selected as the yoga intervention for PCOS. A structured questionnaire

was prepared for this purpose and sent to 10 yoga researchers around the globe. This

questionnaire consisted of the list of practices that were included in the intervention and

responses were sought under five different factors (duration, stress reduction, androgen level

reduction, amenorrhea, weight). Of the 10 experts contacted 3 responded with opinions and

comments which is provided under (APPENDIX XIII). The resultant module has tried to

incorporate most of the feedback provided by the respondents. This effort fell short in its

purpose of obtaining adequate data to support a substantially valid intervention and if taken

forward could aide in validating a set of practices designed for an intervention. The results of

this study however, indirectly confirm the validity of the intervention.

Table 8: Benefits of IAYT practices in PCOS

PRACTICE TECHNIQUE ACTIVITY

Lecture/

counselling

To educate the mind about

ādhija vyādhi. “Awareness is half the solution”

Suryanamaskāra Exercise of all body parts.

AMK -Teasing out of fat from sub-

cutaneous tissue by repeated muscle work

outs

PMK-Harmonizing effect at prāņa level

Āsanas Sthira sukham āsanam AMK-Bring balance at prāņa level

Prone Maintain in final posture

effortlessness and expansion

AMK-Reduction of fat at shoulder and

buttock level

PMK- Balancing the prāņa

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Standing

AMK- Reduction of fat at limbs, buttocks

and abdominal regions

PMK- Opening of apāna

Supine

AMK- Reduction of fat at abdominal

region

PMK- Dislodges apāna

Sitting AMK- Reduction of fat at abdominal level

PMK- Opening of apāna

Relaxation Deep progressive relaxation

of the body/ mind

AMK, MMK- Stress reduction through

alertful rest (reduced sympathetic activity)

(Vempati RP and Telles S 2002)

Prāņayama Slowing down, improve

rhythm of breathing, AMK- Stress reduction

Vibhagiya

Prāņayama

Preparation for full yogic

breathing PMK- Balance prāņa

Kriya

(Kapalabhati)

Activate and cleanse lungs,

and brain

AMK- Vitalizes and releases locks in the

prāņic body

Suryanuloma

viloma

(evidence for weight

reduction)

AMK- Right nostril breathing increases

oxygen consumption by 28%. (Telles S,

Nagarathna R et al. 1994)

Nāḍi shuddhi

Balance surya and Chandra

nāḍis

Cleanses and balances

prāņa

PMK- Evidence for parasympathetic

dominance, useful for hypertension

(Srivastava RD, Jain N et al. 2005)

Meditation Stress reduction through

alertful rest

MMK- Increased mental alertness, even

while being physiologically relaxed shown

by the reduced heart rate (Telles S,

Nagarathna R et al. 1995)

The module of integrated approach of yoga therapy practice is prepared with following basic

structure:

1. First 8 minutes of the sessions was lectures focusing on various topics described below.

2. 12 minutes – Sunsalutation and QRT

3. 12 minutes – Yoga Āsana (prone, standing, inverted and sitting)

4. 10 minutes – Guided relaxation

5. 8 minutes – Prāņayama

6. 10 minutes - Meditation

The daily talk at the beginning of each class included topics that ensured the right

understanding of yoga as a tool for mind management and notional correction. These sessions

included specific topics as listed below

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a) Educational lectures on life style and

PCOS

b) Āsanas for mind mastery

c) Concept of yoga and health d) Prāņayama for mind mastery

e) Scriptural basis of yoga therapy f) Meditation for mind mastery

g) Definition of yoga as mind mastery h) Yogic diet for mind mastery

i) Techniques of yoga for therapy j) Yogic counselling using yama, niyama,

karma yoga and bhakti yoga for mind

mastery

All girls received at least one session (about one hour each) of individualized counseling

that was aimed at cognitive restructuring based on yoga philosophy. These interactive

sessions enhanced their ability to cope with their stresses such as interpersonal relationship

issues, peer pressure, examination tension, etc. using yogic concepts and answered their

medical queries about the prognosis of their disease, interpretation of the results of the

hormonal assays.

5.8.2 Control intervention

Table 9 shows the hour long module of practices for the control group that consisted of a

set of physical movements, non-yogic safe breathing exercises followed by supine rest

(without instructions) that were matched with the yoga module. The daily five minutes

lectures included the scientific information including causes of PCOS, life style and PCOS,

and the benefits of physical exercises. One session of counseling was ensured for the students

in the control group also. Care was taken by the counselors not to introduce any of the yogic

concepts during these sessions while addressing their concerns and educating them on healthy

life style including diet and exercise for weight and stress management.

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Table 9: Matched practices between yoga and exercise groups

YOGA GROUP Time EXERCISE GROUP Time

Group Lectures

Lectures, in the form of

cognitive restructuring based on

the spiritual philosophy

underlying yogic concepts.

8 min

Group Lectures

Lectures on conventional

modern medical concepts about

a healthy lifestyle including diet,

exercise.

15 min

Suryanamaskāra (Sun

Salutation) 12 min Brisk Walk 15 min

Prone Asanas

Cobra Pose (Bhujangasana)

Locust Pose (Salabhasana)

Bow Pose (Dhanurasana)

Prone Exercises

Prone Head Lift

Prone Leg Rising

Tiger Leg Stretch

1 min 1 min

1 min 1 min

1 min 1 min

Standing Asanas

Triangle Pose (Trikonasana)

Twisted Angle Pose (Parsva

konasana)

Spread Leg Intense Stretch

(Prasarita padottanasana)

Standing Exercises

Spread Leg Side Bending

Spread Leg Twisted Bending

Spread Leg Forward Bend

1 min 1 min

1 min 1min

1min 1 min

Supine Asanas

Inverted Pose (Viparita Karni)

Shoulder Stand (Sarvangasana)

Plough Pose (Halasana)

Supine Exercises

Straight leg raising

Straight Leg Supine Twist

Cycling (Clockwise – Counter

Clockwise)Bended knee

Crunches

1 min 1 min

1 min 1 min

1 min 1 min

Sitting Asanas

Sitting Forward Stretch

(Paschimottanasana)

Fixed angle Pose (Baddha

konasana)

Garland Pose (Malasana)

Sitting Exercises

Spread Leg Forward Bend

Spread Leg Alternate Toe

Touching

Squat pose

1 min 1 min

1 min 1 min

1 min 1 min

Guided relaxation (Savasana) 10 min Supine Rest 18 min

Breathing Techniques

(Prāņayama)

Sectional Breathing (Vibhagiya

Prāņayama) 2 min

Forceful Exhalation (Kapala

Bhati) 2 min

Right Nostril Breathing

(Suryanuloma Viloma) 2 min

Alternate Nostril Breathing

(Nāḍi Shuddhi) 2 min

Om Meditation 10 min

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6. DATA COLLECTION AND ANALYSIS

All statistical analyses were performed using SPSS version 17.0. The assumption that the

two groups have the same variances was tested by using the F-test. Kolmogorov–Smirnov test

was used to check for normal distribution which showed that the dataset was skewed and not

normally distributed.

As our hypothesis was to compare the changes after yoga with that of exercise. But the

data was not normally distributed, hence non-parametric analysis was done. Difference scores

(delta change) between the two groups was calculated by subtracting pre from post values for

each variable. Mann-Whitney U test was used to compare change score between the two

groups.