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International Journal of Yoga

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Original Article www.ijoy.org.

in

Effect of yoga on quality of life of CLBP patients:


A randomized control study
Padmini Tekur, Singphow Chametcha, Ramarao Nagendra Hongasandra, Nagarathna Raghuram
Division of Yoga and Life Sciences, Swami Vivekananda Yoga Research Foundation (SVYASA), Bangalore, India

Address for correspondence: Ms. Padmini Tekur,


Division of Yoga and Life Sciences, Swami Vivekananda Yoga Research
Foundation (A Yoga University), # 19, Eknath Bhavan,
Gavipuram Circle, K.G. Nagar, Bangalore - 560 019, India.
E-mail: p_tekur@yahoo.co.in; rnagaratna@gmail.com

DOI: 10.4103/0973-6131.66773

ABSTRACT
Context: In two of the earlier Randomized Control Trials on yoga for chronic lower back pain (CLBP), 12 to 16 weeks of
intervention were found effective in reducing pain and disability.
Aim: To study the efficacy of a residential short term intensive yoga program on quality of life in CLBP.
Materials and Methods: About 80 patients with CLBP (females 37) registered for a week long treatment at SVYASA Holistic
Health Centre in Bengaluru, India. They were randomized into two groups (40 each). The yoga group practiced a specific
module for CLBP comprising of asanas (physical postures), pranayama (breathing practices), meditation and lectures on yoga
philosophy. The control group practiced physical therapy exercises for back pain.
Perceived stress scale (PSS) was used to measure baseline stress levels. Outcome measures were WHOQOL Bref for quality
of life and straight leg raising test (SLR) using a Goniometer.
Results: There were significant negative correlations (Pearson’s, P<0.005, r>0.30) between baseline PSS with all four domains
and the total score of WHOQOLBref. All the four domains’ WHOQOLBref improved in the yoga group (repeated measures
ANOVA P=0.001) with significant group*time interaction (P<0.05) and differences between groups (P<0.01). SLR increased
in both groups (P=0.001) with higher increase in yoga (31.1 % right, 28.4 % left) than control (18.7% right, 21.5 % left) group
with significant group*time interaction (SLR right leg P=0.044).
Conclusion: In CLBP, a negative correlation exists between stress and quality of life. Yoga increases quality of life and spinal
flexibility better than physical therapy exercises.
Key words: Chronic low back pain; flexibility; quality of life; stress; yoga.

INTRODUCTION episode, stress and depression that reduce the QOL.[4] CLBP
in women seems to be associated with the lowest quality of
In recent years, quality of life (QOL) has become a key life amongst many types of non-malignant chronic pains as
concept in the medical community where health care was observed in a survey carried out in a multidisciplinary
places dual emphasis on treatment and quality of care. pain clinic in Netherlands.[5]
The World Health Organization (WHO) defines QOL as
an ‘individual’s perception of his/her position in life in In CLBP, the reduction in quality of life could be
the context of culture and value system in which they attributed to sleep disturbances, fatigue, medication
live and in relation to their goals, expectations, standards abuse[6] functional disability[7] and stress. Amongst these,
and concerns’. [1] It depends on a patient’s physical, psychological factors such as depression, anxiety, fear
psychological and social responses to a disease and its and anger seem to have a greater impact than biomedical
treatment.[2] or biomechanical factors on CLBP related disability and
QOL.[8] Regression analysis in a group of 1208 chronic pain
One per cent of the US population is chronically disabled patients showed that pain catastrophizing had stronger
due to CLBP.[3] Studies on QOL in chronic diseases including association with quality of life than the intensity of
CLBP point to factors such as chronicity, seriousness of the pain.[5] Similarly, in patients with fibromyalgia [9] and

10 International Journal of Yoga  Vol. 3  Jan-Jun-2010


Yoga in back pain

CLBP,[10] the degree of pain, perceived disability and QOL Study design
were influenced more by their mental health status than
the degree of physical impairment. In this randomized control study, 80 subjects who
satisfied the inclusion criteria were allotted to two
groups by a computer generated random number table
Multidisciplinary biopsychosocial rehabilitation has been
shown to be better than usual care in improving QOL with (www.randomizer.org). Numbered opaque envelopes were
reduction in pain and functional disability in patients with used to implement the random allocation to conceal the
chronic back pain.[11] Yoga, with its holistic approach to sequence until interventions were assigned. Magnetic
improve overall quality of life, offers several self regulatory resonance Imaging (MRI) scans of all patients were
practices that aim at correcting these psychological factors reviewed and X-ray pictures of lumbar spine (antero
that contribute to low QOL. An integrated approach to posterior and lateral view) were obtained. Demographic
yoga therapy (IAYT) that includes practices at physical, details vital clinical data, personal, family and stress
breathing, mental, intellectual and emotional levels has history were documented before starting the intervention.
been shown to be effective in improving the QOL in several Outcome variables were recorded on the first and seventh
chronic conditions such as fibromyalgia,[12] rheumatoid day. The experimental group trained under the yoga-based
arthritis[13] and cancer.[14] Our recent randomized control program whereas the control group received physical
study on patients with CLBP has shown that an intensive therapy exercise based program. The control group went
residential short term program of IAYT can reduce the on to the yoga group in the second week. Both groups had
intensity of pain and disability and improve spinal the same daily routine with matched intervention [Table 1].
flexibility.[15]
Blinding and masking
Objective The statistician, who randomized and analysed data, and the
This study was planned to: (i) compare the effect of researcher who carried out the assessments were blind to the
yoga with physical therapy exercises on QOL in patients subject’s group. The psychologist scored the coded answer
undergoing a short term intensive residential program for sheets of the questionnaires after completion of the study.
CLBP (ii) study the baseline correlations between QOL
and stress scores. Intervention
Yoga intervention
Hypothesis
The specific ‘integrated yoga therapy module for low back
QOL in yoga group would be better than control (physical pain’ was developed by a team of two yoga experts and a
exercise) as yoga is a multi-dimensional treatment modality physiatrist. The concepts of the modules were taken from
that caters to all the levels of existence.
traditional yoga scriptures (patanjali yoga sutra, and yoga
vasishtha) that highlight a holistic approach to health
MATERIALS AND METHODS management at physical, mental, emotional and intellectual
levels.[17] The practices consisted of asanas for back pain
Subjects
(yoga postures), pranayama, relaxation techniques,
A total of 160 patients with CLBP admitted to a holistic meditation, and lectures on yogic lifestyle, devotional
health home in Bengaluru (South India) from April 2005 sessions and stress management through yogic counseling.
to June 2006 were screened. Of these, 80 who satisfied the The physical practices (back pain special techniques
inclusion criteria were recruited. Statistical calculation [Table 2], included simple yogic movements and
using G power software yielded a sample size of 35 per maintenance in the final posture of asanas that provide
group for an effect size of 0.89 (calculated from our earlier stretch and relaxation. The safety of the practices
interventional pilot study) with an alpha at 0.05 powered was ensured by avoiding acute forward or backward
at 0.8. The inclusion criteria were (a) history of CLBP of movements of the spine and jerky movements while
more than three months (b) pain in lumbar spine with or designing the module.[18]
without radiation to legs and (c) age between 18 to 60 years.
Exclusion criteria were, (a) CLBP due to organic pathology Pranayama included yogic breathing practices to achieve
in the spine such as malignancy (primary or secondary), or a slow rhythmic pattern of breathing. The instructions for
chronic infections checked by X ray of lumbar spine.[16] The this included (a) slow down the breath rate, (b) exhalation
study was approved by the institutional review board and to be made longer than inhalation, and (c) develop an
the ethical committee of the university. A signed informed internal awareness. A prolonged easy, slow exhalation is
consent was obtained from all patients. the safest way to get mastery over the mind.[19]

International Journal of Yoga  Vol. 3  Jan-Jun-2010 11


Tekur, et al.

Table 1: Time table for two groups for week-long residential program daily schedule of practices for yoga and
control group
Time Yoga group Control group
05.00-05.30 am OM meditation – 30 minutes Walking - 30 minutes
05.30-06.30 am Yoga based special technique – 60 minutes Exercise based special technique - 60 minutes
06.30-07.30 am Bath and wash Bath and wash
07.30-08.15 am Chanting of yogic hymns – 45 minutes Video show (on nature) – 45 minutes
08.15-08.45 am Breakfast Breakfast
08.45-10.00 am Rest Rest
10.00-11.00 am Lecture (on yogic lifestyle) – 60 minutes Lecture (on healthy lifestyle) – 60 minutes
11.00-12.00 noon Pranayama (yogic breathing) – 60 minutes Non yogic breathing practice – 60 minutes
12.00-01.00 pm Yoga based special technique – 60 minutes Exercise based special technique – 60 minutes
01.00-02.00 pm Lunch(vegetarian diet) Lunch (vegetarian diet)
02.00-02.30 pm Deep relaxation technique – 30 minutes Rest at room – 30 minutes
02.30-04.00 pm Assessments and counseling Assessments and counseling
04.00-05.00 pm Cyclic meditation – 60 minutes Listening to music – 60 minutes
06.15-06.45 pm Divine hymns session (Bhajan) – 30 minutes Video show (on nature) – 30 minutes
06.45-07.45 pm Meditation with yogic chants (Mind sound resonance Walking – 45 minutes
technique) – 45 minutes
07.45-08.30 pm Dinner (vegetarian diet) Dinner (vegetarian diet)
08.30-10.00 pm Self study Self study
Hour to hour matching for the type of practices for the two groups was ensured

Table 2: Back pain special techniques for yoga group on in the blissful bed of inner silence achieved during
I. Supine postures all joyful moments of life. Thus the IAYT for back pain
1. Pavanamuktasana (wind releasing pose) series had a multidimensional approach to promote positive
• Supta pawanamuktasana (leg lock pose)
mood and well being through techniques for physical
• Jhulana lurkhanasana (rocking and rolling)
2. Ardha navasana (half boat pose) relaxation, breath manipulation to calm down the mind
3. Uttanapadasana (straight leg raise pose) and counseling sessions for cognitive change.
4. Sethubandhasana breathing (bridge pose lumbar stretch)
5. Supta udarakarshanasana (folded leg lumbar stretch)
6. Shavaudarakarshanasana (crossed leg lumbar stretch)
Control intervention
II. Prone postures
1. Bhujangasana (serpent pose)
The practices consisted of a set of physical movements
2. Shalabhasana breathing (locust pose) (certified by the senior physiatrist – Table 3), non-yogic
III. Quick relaxation technique in shavasana (corpse pose) safe breathing exercises, lectures on scientific information
IV. Sitting postures including (a) causes of back pain, (b) stress, QOL and CLBP
III. Quick relaxation technique in shavasana (corpse pose)
and (c) benefits of physical exercises. For the experimental
IV. Sitting postures
1. Vyaghra svasa (tiger breathing) group, video shows on animals, plants, nature etc. were
2. Shashankasana breathing (moon pose) used as placebo to engage them during the time when the
V. Standing postures yoga group had video shows on yoga or going through
1. Ardha chakrasana (half wheel pose) yogic counseling.
2. Prasarita pada hastasana (forward bend with legs apart)
3. Ardha kati chakrasana (lateral arc pose)
VI. Deep relaxation technique, in shavasana with folded legs Outcome variables
Quality of life
Meditation, considered to be a part of yoga, (antaranga
yoga) is a valuable tool to calm down uncontrollable surge WHOQOL-BREF is a standardized comprehensive
of negative emotions. Since most patients with CLBP have instrument for assessment of QOL comprising of 26 items
a component of psychological stress that may contribute to and was developed by the WHO. The scale provides a
poor quality of life, meditation and devotional sessions are measure of an individual’s perception of quality of life
relevant to correct the problem in a holistic way. Lectures for the four domains: (1) physical health (seven items) (2)
and individual yogic counseling for stress management psychological health (six items) (3) social relationships
to bring about a notional correction were focused on (three items) and (4) environmental health (eight items).
‘happiness analysis’.[20] In addition, it also includes two questions for ‘overall
quality of life’ and ‘general health’ facets. The domain
This analysis helps the patient (a) cognize the source scores are scaled in a positive direction (i.e., higher
and pattern of their emotional responses, (b) restore scores denote higher quality of life). The range of scores
freedom to change the emotional responses to chronic is 4-20 for each domain. The internal consistency of
pain and demanding life situations and (c) learn to stay WHOQOL-BREF ranged from 0.66-0.87 (Chronbach’s

12 International Journal of Yoga  Vol. 3  Jan-Jun-2010


Yoga in back pain

alpha co-efficient). The scale has been found to have good instructions in the manual. The sum of the scores on all
discriminant validity.[1] It has good test retest reliability and 10 items was the total PSS score.[21]
is recommended for use in health surveys and to assess the
efficacy of any intervention at suitable intervals according WHOQOLBref: After scoring, the mean values for total and
to the need of the study. individual domains were computed. These were multiplied
by four to obtain the final score comparable to WHOQOL
Perceived stress scale 100 as indicated in the manual.[1]

The perceived stress scale (PSS) measures a global


perception of stress response on a continuum from mild Data analysis
to severe.[21] It has 10 items asking the subject to rate how Data was analyzed using SPSS version 10.0. Statistical tests
often they have perceived an event in their life over the used included Kolmogorov–Smirnov’s test for normality
last month. The measure has good reliability, validity and
of baseline data, independent samples ‘t’ for baseline
internal consistency with a Cronbach’s alpha of 88. It has
matching of the two groups, repeated measures ANOVA
been widely used, is general in nature, and brief. We have
for group*time interaction followed by post hoc analysis
used it only for baseline correlations with QOL and not
for within and between group differences and Pearson’s
after the intervention as it cannot be administered before
correlation test for correlations.
one month for retest.

Straight leg raising test[22] RESULTS

A goniometer (Anand Agencies, Pune) that has two scales Figure 1 shows the study profile. There were no drop outs as
fixed at one end to a compass (calibrated in degrees), was this was a residential short term program. The two groups,
used to measure straight leg raising (SLR). It was placed yoga and control (40 each), were similar with respect to
with the stationary arm parallel to the edge of the table, the socio-demographic and medical characteristics [Table 4]. The
moving arm along the lateral midline of the thigh and the baseline data for all variables were normally distributed and
axis over the superior half of the greater trochanter. Then did not differ significantly between groups (P>0.05). Table 5
the leg was raised passively until the patient reported pain. shows the results of all variables. There were no adverse events.
The angle between the two scales is read on the compass.
The procedure is repeated on both sides Perceived stress scale
PSS was used only for baseline assessments and correlations
Other measurements taken in this group of patients to assess
with QOL. The mean scores of PSS for the whole group
disability, spinal flexibility, severity of pain,[15] anxiety and
(n=80) was higher (18.80 plus/minus 6.22) than the
depression have been reported (under revision) as different
normative mean value (14.1) for normal adult Indians.[21]
publications
There were 60 patients (31 in yoga and 29 in control) who had
scores greater than 14. Correlations between scores of PSS
Data extraction
and total WHOQOL Bref in the whole group (n=80) showed
PSS was assessed using a five-point scale (0=never;
4=very often). The scores on four items that were worded 120 Self Referred
in the opposite direction were reverse-scored as per the 40 Referred by physicians

Table 3: Control group practices


126 interested in participation
1) Standing hamstring stretch
2) Cat and Camel
3) Pelvic tilt
4) Partial curl 80 Satisfied selection criteria
5) Piriformis stretch Randomly Assigned
6) Extension exercise
7) Quadriceps leg raising
8) Trunk rotation
9) Double knee to chest
Experimental Group 40 Control Group 40
10) Bridging
11) Hook lying march
12) Single knee to chest stretch
13) Lumbar rotation Final Analysis on 40 Final Analysis on 40
Experimental group Control group
14) Press up
15) Curl ups
Figure 1: Trial profile

International Journal of Yoga  Vol. 3  Jan-Jun-2010 13


Tekur, et al.

significant negative correlations at r=0.59, (P=0.01). The Straight leg raising


correlations between PSS and the four domains were as
follows. physical r=0.31, (P=0.005); psychological r=0.48 There was significant increase in SLR in both groups at
P<0.001 with significant group*time interaction for SLR
(P<0.001); social r=0.46 (P<0.001) and environmental
right side at P=0.04.
r=0.39, (P<0.001).

WHOQOL BREF DISCUSSION


This randomized control study on 80 patients with CLBP,
Table 5 shows the results after the intervention in the two
who underwent a residential intensive training program
groups. There was significant group*time interaction and
for one week, showed that there was significant negative
difference between groups on all domains at P<0.01. Within
correlation in the baseline values of PSS with all domains
group analysis showed significant improvement in yoga group of WHOQOL. There was significantly better (P<0.01)
and non-significant change in control group on all domains. improvement in quality of life on all domains of WHO
QOL and SLR (right) in yoga than control group.
Table 4: Demographic data
Variables Yoga Control About 75% (60/80) of this group of patients with CLBP
Number of participants 40 40 had stress levels above 14.1 (limiting value for Indians).[21]
Males (M) 19 25 The negative correlation observed in this study supports
Females (F) 21 15
earlier observations of ‘higher the stress levels lower the
Age (mean ± SD) 49 ± 3.6 48 ± 4
Education QOL’ (1). Subjective experience of one’s own life in the
a) High school M-3, F-11 M-5, F-3. light of altered external stressors such as financial strain
b) College M-10, F-8 M-13, F-10 or family responsibilities[23] can lead to fear of uncertainty
c) Post graduate M-6, F-2 M-7, F-2 of the future[24] resulting in a viscous loop contributing to
Males
poor quality of life.[25]
Working-sedentary 14 16
Working-non sedentary 5 8
Females A study on the relationship between chronic pain and
Working 6 7 health related quality of life (HRQOL) showed that 58% of
Housewives 15 8
CLBP
patients had depression and anxiety with severe reduction
< 1 year 10 11 in physical, psychological and social well-being. [26]
1-5 years 9 11 A predictable relationship between HRQOL with functional
5-10 years 11 10 status and psychological factors has also been documented.[27,28]
> 10 years 10 8
Cause
Lumbar spondylosis (LS) 6 5 Several non-pharmacological interventions including
Prolapsed intervertebral 6 7 ‘back school program’,[29] mindfulness based meditation,[30]
LS with PID 19 15 cognitive behavior modification[7] and multidisciplinary
Muscle spasm 9 13
programs[31] have been shown to be effective in reducing

Table 5: Results of all variables post intervention (Repeated measures ANOVA)


Within groups Between
Yoga Control groups
Variable Mean ± SD 95% CI ES % P Mean ± SD 95% CI ES% P ES P
change values change values value
PHY Pre 11.87 ± 2.5 11.07 to 12.67 1.19 27.55 <0.001 12.49 ± 2.26 11.76 to 13.21 0.25 4.96 0.113 0.253 0.001
Post 15.14 ± 1.56 14.64 to 15.64 13.11 ± 2.17 12.42 to 13.81
PSYCH Pre 13.15 ± 2.34 12.40 to 13.9 0.85 15.82 <0.001 13.12 ± 2.42 12.34 to 13.89 0.08 1.75 0.588 0.085 0.001
Post 15.23 ± 1.34 14.81 to 15.66 13.35 ± 2.71 12.48 to 14.22
SOC Pre 13.43 ± 3.32 12.38 to 14.49 0.43 10.17 0.001 13.50 ± 3.30 12.44 to 14.56 0.47 3.45 0.291 0.60 0.004
Post 14.80 ± 2.71 13.93 to 15.67 13.03 ± 3.16 12.02 to 14.04
ENV Pre 13.45 ± 2.2 12.75 to 14.15 0.54 8.77 0.001 13.44 ± 2.32 12.70 to 14.18 0.03 0.45 0.811 0.036 0.017
Post 14.63 ± 1.6 14.11 to 15.14 13.50 ± 2.16 12.81 to 14.19
SLRR Pre 57.95 ± 20.23 51.48 to 64.42 1.14 31.14 0.001 57.68 ± 24.65 49.79 to 65.56 0.99 18.67 0.001 0.407 0.04
Post 76.00 ± 16.38 70.76 to 81.24 68.45 ± 20.48 61.90 to 75.00
SLR L Pre 59.00 ±18.54 53.07 to 64.93 1.19 28.38 0.001 56.30 ± 23.71 48.72 to 63.88 0.70 21.45 0.001 0.430 0.16
Post 75.75 ± 15.04 70.94 to 80.56 68.38 ± 19.03 62.29 to 74.46
PHY = Physical health, PSYCH = Psychological health, SOC = Social health, ENV = Environment, area domains of WHOQOL Bref. SLRR = Straight leg raising
right side, SLRL = Straight leg raising left side, CI = Confidence interval, ES = Effect size

14 International Journal of Yoga  Vol. 3  Jan-Jun-2010


Yoga in back pain

pain, disability and improving QOL in CLBP. There are no Environmental health
studies on effect of yoga on QOL in CLBP.
The mean value in this domain which was lower (12.8) than
Deshpande et al. have shown the beneficial effect of a non- normal (14.5) improved significantly to reach normalcy
residential integrated yoga program that assessed the QOL (14.6) after yoga and not after physical exercises. This
using WHO QOL100 on 184 normal volunteers in south domain has questions that deal with problems relating to
India.[32] We have used these scores for comparison with financial resources, physical safety, physical environment
our scores on WHOQOL Bref in CLBP patients. such as pollution, noise, climate etc. One of the definitions
of yoga (Bhagavad-Gita) says that yoga results in equanimity
and balance (samatavam) that can help in better tolerance
Physical health
to environmental changes (sheeta ushna samah-tolerence
The baseline scores for this domain (mean 11.9) in CLBP to heat or cold). Studies have shown that yoga changes
(present study) patients were lower than the scores (mean the physiological responses to stressors by improving
13.8) in normal volunteers.[32] After yoga it increased to autonomic stability with better parasympathetic tone in
14.5 in normal volunteers and 15.14 in patients with CLBP normal adults[43] and reducing sympathetic arousal with
pointing to the normalizing effect of yoga on physical QOL. improved performance in congenitally blind children[44]
This domain of WHOQOLBref deals with features such and community home girls.[45]
as mobility, fatigue, pain, sleep, work capacity etc The
observed improvement can be attributed to reduction in Yoga texts explain how integrated yoga techniques help
pain and disability with improvement in spinal flexibility.[15] in improving the quality of life. Voluntary reduction
Other studies on integrated yoga in healthy children and in violence and aggressiveness [46] during emotional
adults have shown better physical stamina[33] dexterity and reactions of anxiety[47] or depression[37] is achieved through
eye hand coordination.[34] Better quality and duration of restful awareness during all the practices in general and
sleep after yoga has been reported in the elderly.[35] meditation in particular.[48] This mastery over emotional
surges leads to controlled and need based physiological
Psychological health responses to stressfully demanding situations instead of
uncontrolled overtones of HPA axis[49,50] during chronic
There was a significant (20%) improvement in yoga pain.
group with non- significant change in control group. The
baseline values were much lower (mean 13.0) than normal
volunteers (14.7) and increased (15.2 in CLBP) similar to
CONCLUSION
normal volunteers (15.5) after yoga. The improvement This randomized control study has shown that patients
seen in this domain that deals with questions relating with CLBP had high stress levels with a negative
to feelings, self esteem, spirituality, thinking, learning, correlation with QOL. A week long residential intensive
memory etc. may be attributed to reduction in anxiety yoga program increased the QOL and spinal flexibility
and depression. Several studies have shown the effect better than physical therapy exercises for CLBP.
of yoga in reducing anxiety[36] depression[37] and stress[38]
with enhanced mental health as observed by improved
Limitations of the study include
perceptual sharpness,[39] memory[40] and better information
(i) Since both groups were in the same campus, the
processing at the thalamic level.[41]
possibility of some interaction and exchange of
ideas could not be ruled out, although special
Social health care was taken to keep the groups engaged
The mean scores changed from 13.0 to 14.8 in CLBP independently
patients and 14.8 to 15.2 in normal volunteers. This (ii) Short term intervention of one week may be
domain has questions relating to problems in interpersonal considered a major limitation. A follow-up of
relationships, social support etc which could be the patients who were asked to continue the practices
main source of stress contributing to spinal pain. They daily (one hour) with the help of video and audio
were addressed during lectures and at a personal level in instructions is planned
yoga counseling sessions. They were aimed at achieving
an introspective cognitive change by recognizing the Suggestions for future work
psychological freedom ‘to react, not to react or change (i) Generalization of this program for different cultures
the usual pattern of reaction to situations’ highlighted needs to be assessed
in yoga texts.[17] This would have resulted in reversal of (ii) Objective measures such as EMG may be included
the biochemical processes and opened up the connective (iii) Three arm studies that combine yoga during
tissue plasticity.[42] physiotherapy may show synergistic effects

International Journal of Yoga  Vol. 3  Jan-Jun-2010 15


Tekur, et al.

ACKNOWLEDGMENTS 21. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress.


J Health Soc Behav 1983;24:385-96.
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with the statistical analysis of data. Our thanks are due to instruments. Phys Ther 1983;63:1429-33.
Dr. Usha Rani, for her help in scoring the questionnaires. We thank 23. Nicholas M, Sharp TJ. Cognitive-behavioral programs: Theory and
all the staff of SVYASA for their cooperation in conducting the application. Int Anesthesiol Clin 1997;35:155-70.
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