Indian J Physiol Pharmacol 2004; 48 (3) : 269–285

SPECIAL INVITED ARTICLE

YOGA AS A THERAPEUTIC INTERVENTION : A BIBLIOMETRIC

ANALYSIS OF PUBLISHED RESEARCH STUDIES

SAT BIR S. KHALSA

Division of Sleep Medicine,

Department of Medicine,
Brigham and Women’s Hospital,
Harvard Medical School
( Received on May 8, 2004 )

Abstract : Although yoga is historically a spiritual discipline, it has also

been used clinically as a therapeutic intervention. A bibliometric analysis
on the biomedical journal literature involving research on the clinical
application of yoga has revealed an increase in publication frequency over
the past 3 decades with a substantial and growing use of randomized
controlled trials. Types of medical conditions have included psychopathological
(e.g. depression, anxiety), cardiovascular (e.g. hypertension, heart disease),
respiratory (e.g. asthma), diabetes and a variety of others. A majority of
this research has been conducted by Indian investigators and published in
Indian journals, particularly yoga specialty journals, although recent trends
indicate increasing contributions from investigators in the U.S. and
England. Yoga therapy is a relatively novel and emerging clinical discipline
within the broad category of mind-body medicine, whose growth is
consistent with the burgeoning popularity of yoga in the West and the
increasing worldwide use of alternative medicine.

Key words : yoga meditation pranayama asana

bibliometric mind-body medicine review

INTRODUCTION the human individual with the universal

and transcendent Existence” (1). These
Yoga is a practical discipline practices are believed to have originated in
incorporating a wide variety of practices early civilization on the Indian subcontinent
whose goal is the development of a state of and have been practiced historically in India
mental and physical health, well-being, and throughout East Asia. Yoga techniques
inner harmony and ultimately “a union of include the practice of meditation,

* Corresponding Address : Sat Bir S. Khalsa, Ph.D., Division of Sleep Medicine, Department of Medicine,
Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston,
MA 02115 (U.S.A).
Phone : (617) 732-7994, Fax : (240) 269-6205, Email : khalsa@hms.harvard.edu
Source of Support : Mentored Research Career Development Award (5K01AT000066)
from the National Centre for Complementary and Alternative Medicine of the
National Institutes of Health, U.S.A.
270 Khalsa Indian J Physiol Pharmacol 2004; 48(3)

regulation of respiration with a variety of the implementation of these techniques as

breathing exercises, and the practice of a a therapeutic intervention in a number of
number of physical exercises and postures, disorders which have psychosomatic
in which the focus is more on isometric c o m p o n e n t s . H i s t o r i c a l l y, t h i s l i m i t e d
exercise and stretching than on aerobic application of yoga techniques for specific
fitness. disorders is relatively recent compared
to the ancient Vedic origins of yoga (10).
A general feature of these practices is their Gharote (1987) has stated that “the
capability of inducing a coordinated therapeutic aspect of yoga does not feature
psychophysiological response, which is the in any of the traditional systems of self-
antithesis of the stress response. This help, except in the yoga sutras of Patanjali
“relaxation response” consists of a where we come across the word vyadhi
generalized reduction in both cognitive and meaning ‘disease’ in the list of disturbing
somatic arousal as observed in the modified factors of mind that are obstacles to
activity of the hypothalamic pituitary axis liberation. ... although yoga therapy was not
and the autonomic nervous system (2). a developed branch of yogic discipline as
Bagchi and Wenger (3), in their early classic such, we do get a glimpse of the therapeutic
yoga research study wrote, “...physiologically effects of the practices in some of the hatha
Yogic meditation represents deep relaxation yoga literature such as the Hatha Yoga
of the autonomic nervous system without Pradipika. However, advice is given here
drowsiness or sleep and a type of cerebral within the context of practice; that is, how
activity without highly accelerated to deal with the complaints that arise from
electrophysiological manifestation but faulty practice” (11). In fact, since the
probably with more or less insensibility to primary goal of yoga practice is spiritual
some outside stimuli for a short or long development, beneficial medical consequences
time.” A large number of subsequent of yoga practice can more precisely be
research studies examining the effects of described as positive “side effects” (12).
these techniques both in isolation and in
combination have further confirmed these The first systematic medical application
early results (4–9). Both short term and of yoga started in India in 1918 at the Yoga
long-term practice of yoga techniques are Institute at Versova near Mumbai, the
associated with reductions of basal cortisol precursor of the Yoga Institute at Santa
and catecholamine secretion, a decrease in Cruz (13). This was soon followed by the
sympathetic activity, with a corresponding clinical work at the Kaivalyadhama Yoga
i n c r e a s e i n p a r a s y m p a t h e t i c a c t i v i t y, Institute in Lonavala under Swami
reductions in metabolic rate and oxygen K u v a l y a n a n d a i n t h e 1 9 2 0 ’s ( 1 4 , 1 5 ) .
consumption and salutary effects on Subsequently, yoga therapy has proliferated
cognitive activity and cerebral in India with the establishment of yogic
neurophysiology. hospitals and clinics, notably the Swami
Vivekananda Yoga Research Institute near
Not surprisingly, the capability to affect Bangalore (sVYASA), and the widespread
psychophysiological functioning has led to application of yoga treatments by clinicians
Indian J Physiol Pharmacol 2004; 48(3) Bibliometric Analysis of Yoga Research 271

and yoga institutes (15–17). This trend has well-being : psychophysical and spiritual.
a l s o s p r e a d i n t e r n a t i o n a l l y, w i t h t h e Further, Yoga is a paradigmatic system of
appearance of yoga therapy centers, the religious therapeutics – a path of healing
inclusion of yoga programs in hospital that serves the purpose of religious
cancer programs and affiliated alternative liberation. Among world traditions, classical
medicine centers and the establishment of Yoga is a useful starting point for inquiry
a new breed of clinicians called yoga into the relationship of medical and
therapists, for which there are yoga therapy religious health because it connects the
t r a i n i n g p r o g r a m s a n d a s o c i e t y, t h e cultivation of physical and psychological
International Association of Yoga Therapists health with spiritual well-being and
(IAYT), based in the United States. There exemplifies the idea of religious liberation
are now also several dozen books available as healing” (22). Anand (1991) has stated
specifically on the topic of yoga therapy in this more simply: “The ultimate aim of
general, and even on yoga therapy for medical sciences is the attainment of
specific disorders (18, 19). optimum physical and mental health for the
individual. The ultimate aim of yogic
The application of yoga in such a limited practices is also the same, viz. physical and
and strictly therapeutic manner has drawn mental well-being” (23).
some criticism from proponents of yoga (14),
given that yoga techniques are in fact part Research on the psychophysiological
of an ancient and sacred spiritual tradition effects of yoga practice began with
historically applied as a holistic lifestyle Kuvalyananda’s work in the 1920’s, and
discipline (20). This concern has been there are a number of published reviews of
further aggravated by the rapidly growing this basic research literature (4, 5, 7, 14,
popularity of yoga in the west and its 24). Research on therapeutic applications of
subsequent commercialization and yoga and meditation began more recently
application as a trendy body slimming and (14), and although there are reviews of this
fitness tool. “Postures are taught as ends in literature, many of these are restricted to
themselves merely to heal an illness, reduce specific disorders (20, 25–27). Furthermore,
stress, or look better. The fact that these a good deal of research has been published
postures are a foundation for self-realization in yoga specialty journals such as Yoga
is generally ignored. Yoga is often thought Mimamsa , which are not easily accessible
of as calisthenics, epitomized by the and therefore not consistently reviewed or
headstand, the lotus posture, or another cited. A previous bibliometric analysis has
pretzel-like pose.” (21). However, from a examined publications up to 1986 on both
broader perspective, both the healing of basic and clinical research on meditation,
disease and spiritual endeavors share a yoga and related topics, and incorporated a
common ground historically, in that many variety of article types including theoretical
religious traditions incorporate a healing essays, case reports, reviews and abstracts
component. This is perhaps especially true (28). The purpose of this bibliometric
of yoga: “Classical yoga is a source of many analysis is to identify the current full extent
specific concepts and practices that promote of the yoga therapy studies published in
272 Khalsa Indian J Physiol Pharmacol 2004; 48(3)

research journals, including the specialty databases with the term “yoga” as a
yoga publications, so as to provide an keyword. Also excluded are applied studies
accurate survey of the best research of mindfulness meditation (Vipassana) or the
published and examine the trends within mindfulness-based stress reduction program
this research discipline. (MBSR), despite the fact that MBSR utilizes
yogic stretching postures as part of the
METHODS intervention, although this is generally
incorporated in the context of providing a
The scope of this review will be focus for mindfulness. Finally, reports of
restricted to clinical trial studies appearing applied research using other simplified
in research journals, which report on forms of meditation practice such as the
interventions incorporating yoga or yoga- Relaxation Response technique, have also
based techniques for the treatment been excluded.
of medical or psychiatric conditions or
their associated symptoms. Abstracts, Published reports of yoga therapy
dissertations, reports or proceedings of research studies were first identified
meetings, and book chapters have been through searches of electronic databases,
excluded. In a few circumstances, depending primarily Medline (Pubmed), Psychinfo and
upon the extent of the information provided, the Indian Medlars Centre database.
brief reports or research letters in journals Additional citations were also acquired from
have also been included. Publications of the reference sections of research
case reports, case series, descriptions publications and reviews of the literature.
of treatment programs with minimal A concerted effort was also made to identify
qualitative reported outcome measures, and research studies published in yoga specialty
population survey studies reporting on the journals, especially Yoga Mimamsa .
prevalence of use of yoga as a therapeutic
intervention have not been included. Only publications for which reprints
could be acquired were subjected to analysis.
Although meditation is an integral part Each study was evaluated as to the presence
of yoga practice, studies examining of a control group and whether subjects
meditation alone without simultaneous were randomized to different study arms,
incorporation of yogic breathing and/or to yield 3 possible study categories:
specific yoga postures have not been uncontrolled trials, controlled trials, and
included. This was done to restrict the scope randomized controlled trials (RCT’s). To
of the review, since the meditation research avoid any influence on the analysis from
literature is extensive and has been any potential bias in the quality or
reviewed previously (9, 29–32). Notably, this objectivity in publications in yoga specialty
criterion has excluded published research journals as compared with non-yoga
on the therapeutic application of research journals, the analysis has been
Transcendental Meditation (TM), despite the done separately for each category. Each
fact that TM is in fact a yogic style of publication was also categorized as to the
meditation and is often cited in research disease or disorder in the subject/patient
Indian J Physiol Pharmacol 2004; 48(3) Bibliometric Analysis of Yoga Research 273

population, the country in which the study

was performed, the year of publication and
the group sample sizes in the RCT’s.

RESULTS

A total of 181 publications in 81 different

journals published in 15 different countries
were identified that met the criteria for the
analysis and full reprints were acquired for
all of these. A bibliography of these
publications is in the Appendix. The journals
with the most publications included Yoga
Mimamsa (31), Indian Journal of Physiology
and Pharmacology (10), Journal of the
Association of Physicians of India ( 1 0 ) ,
Alternative Therapies in Health and
Medicine (7), Indian Journal of Psychiatry
(6), British Medical Journal (5) and Lancet
(5). In addition to these, there were 5
journals each with 4 publications, 5 with 3
publications, 8 with 2 publications, and 56
journals each with 1 publication. A total of
96 publications appeared in 27 journals Fig. 1 : The 2 pie charts above show the proportions of
all publications (top) and non-yoga specialty
published in India, 43 publications in 24 journal publications (bottom) that have reported
U.S. journals, 21 publications in 11 British on studies using RCT's, a non-randomized control
group, and no control group.
journals and 21 publications in 19 journals
from 12 other countries. A total of 34
publications were in yoga specialty journals uncontrolled studies, 45.6% for randomized
with 31 in Yoga Mimamsa, 2 in the Journal controlled studies, and 14.3% for studies
of the International Association of Yoga with a non-randomized control group.
Therapists and 1 in the Journal of the Yoga
Institute . Sample sizes for the separate study arms
prior to the intervention and any subject
An analysis of the type of studies withdrawal or disimpanelment were
reported (Fig. 1) revealed that 48.1% of the averaged for each RCT publication. From
181 publications were on uncontrolled the total of 67 average sample size values,
studies, 39.8% were on RCT’s, and 12.2% the frequency distribution for the 62 values
were on studies incorporating a control less than 65 is shown in Fig. 2 plotted in
group that did not use randomized subject bins of 5. Of the 5 sample size values not
assignment. In the 147 non-yoga journal shown in this figure, 4 ranged from 91 to
publications, the percentages were 40.1% for 102 and the highest was 311. The vast
274 Khalsa Indian J Physiol Pharmacol 2004; 48(3)

18

Number of Publications
80
16 Sam ple Sizes in N on -yoga Journal R C Ts Non -y og a journ als
N um ber of Publications

14 Non -y og a J ou rn al R CTs
60
12

10 40
8
20
6

4 0
2 India US Eng land Europ e Australia Other
0
C ountry in w hich Study was Perform ed
5 10 15 20 25 30 35 40 45 50 55 60 65

Average Study Sam ple Size Fig. 4 : This histogram shows the distribution of the
publications relative to the country in which the
Fig. 2 : This histogram shows a distribution of the
study was conducted for all publications, and for
average group sample sizes for publications
non-yoga journal RCT publications.
reporting on RCT's plotted with a bin size of 5.

majority of sample sizes (53/67 = 70%) were Results of an analysis of the countries
30 or less. in which the studies were conducted are
shown in the bar graph distribution in
The chronological distribution of Fig. 4 for the non-yoga journal studies and
publication date is presented in Fig. 3 and the non-yoga journal RCT studies. For both
is shown for all publications, non-yoga non-yoga journal publications and non-yoga
journal publications and for non-yoga journal RCT’s, a majority of the studies have
journal randomized control trial publications been conducted in Indian institutions (58%
in 5-year bins. Twelve publications in 2004 of all non-yoga journal publications,
(5 of them RCT’s) have not been included in and 48% of all non-yoga journal RCT
this analysis. A gradual increase in publications). This is followed by U.S.
publications is apparent up until 1989, after researchers, with fewer than half as many
which the numbers appear maintained at publications and then by investigators in
the same level. England (with 9 of 14 studies published by
Patel and colleagues). The 17 publications
All
in all journals by European research groups
35
No n -yog a Jou rn als were distributed amongst the Czech
N um ber of P ublications

Republic and Spain (3 each), Germany,

30 No n -yog a Jou rn al RC Ts

Russia, Italy and Poland (2 each) and

25

20
Sweden, Yugoslavia, and the Netherlands
15
(1 each). Countries contributing one
10
publication each to the Other category are
5
Canada and Singapore. The number of RCT
0
publications in India is also greater than
1963- 1969- 1974- 1979- 1984- 1989- 1994- 1999-
1968 1973 1978 1 983 1988 199 3 1998 2003 that of the U.S. and England. However,
Year of Publication
the proportion of all non-yoga journal
Fig. 3 : The histogram shows the chronological trend in
5-year intervals for all publications, non-yoga publications in India that are RCT’s (32/85
publications and non-yoga randomized trial
publications. In all histograms, the non-yoga = 38%) is less than that of the U.S. (18/31
publications are a subset of all publications, and = 58%) and England (12/14 = 86%). Of the
the non-yoga journal RCT publications are a
subset of the non-yoga publications. 34 yoga journal publications (not shown
Indian J Physiol Pharmacol 2004; 48(3) Bibliometric Analysis of Yoga Research 275

in Fig. 3), 29 were from investigators in populations for all 181 publications (12
India, followed by Italy (2), Spain (2) and studies had 2 or more disorders), 162 clinical
Russia (1). study populations for the 147 non-yoga
journal publications (9 studies had 2 or more
The type of disorders studied were disorders). Within the 147 non-yoga journal
assigned to broad categories as shown in publications, the discrete disorders that
Fig. 5. About one third of the psychiatric were studied the most were asthma (23),
conditions consisted of depressive disorders hypertension (21), heart disease (18),
diabetes (16), depression or dysthymia (14),
and anxiety (6). There were 76 clinical
Psychiatric populations for the 67 non-yoga journal RCT
Cardiovascular
publications (4 studies had 2 or more
disorders).
Respiratory

Diabetes
DISCUSSION
Neurological

M usculoskeletal
All
It is unlikely that all of the yoga therapy
N on -yoga Journals
N on -yoga Journal RCTs
research publications meeting criteria have
been acquired. In particular, a number of
O ther

0 10 20 30 40 50
Indian journals have not been indexed as
N um ber of Publications
well and are difficult to acquire, particularly
Fig. 5 : This histogram shows the distribution of the
publications relative to the disorder in the study
the yoga specialty journals. Furthermore,
population as classified into the categories the inclusion and exclusion criteria have
indicated on the vertical axis. Numbers of
publications are shown for all publications, non- been rather arbitrary, especially regarding
yoga journal publications and non-yoga journal the inclusion of techniques which are very
RCT publications.
similar to classical yoga practices.
Nevertheless, it is likely that the vast
and this was followed in order of prevalence majority of publications have been examined
by anxiety, addictive disorders and then and that the general trends reported in this
a variety of other psychopathological study are sufficiently representative.
conditions. Cardiovascular conditions were
almost evenly split between either There are a number of cautions that
hypertension or heart disease. Respiratory should be noted in interpreting this
conditions were predominantly asthma, with literature. There is no single standardized
a smaller contribution of chronic obstructive yoga practice format, nor is this likely or
pulmonary disease and a few other necessarily desirable in the future. There
respiratory conditions. Neurological is a very wide range of the types of yoga
conditions included mostly headache and interventions used in this literature,
epilepsy, whereas musculoskeletal disorders ranging from individual breathing or
included a wide array of unrelated postural techniques to complete yoga
conditions. Analysis of all the publications lifestyle interventions involving dietary and
was based on a total of 202 clinical study psycho-spiritual techniques. Application of
276 Khalsa Indian J Physiol Pharmacol 2004; 48(3)

the interventions is equally varied, from an Indian and a U.S. psychiatry journal
individual practice to group sessions, from (see Appendix). Both studies were conducted
daily practice sessions to weekly sessions, in India and compared active yoga
and from short duration to long duration treatments with inactive placebo control or
sessions. Also, the quality of publications pharmacological treatments in patients with
included in this review varies dramatically, anxiety and depression. The first yoga
with some publications presenting less therapy publications by researchers outside
material than is apparent in many abstracts. of India were published by Chandra Patel
Finally, a number of publications have and colleagues in England, who conducted
been reports of separate results of a series of both uncontrolled and RCT’s of
different outcome variables from the yoga and biofeedback treatment for
same study; nevertheless, these have hypertension between 1973 and 1976 (see
been treated as distinct publications in this Appendix). The first publication of a yoga
study. study (an RCT) from a U.S. research group
(Hopkins & Hopkins, see Appendix) did not
From the proportion of publications appear until 1979. A consistent increase in
reporting RCT’s, it is clear that the yoga frequency of publications is apparent up to
specialty journal publications, while 1989, after which the frequency has been
providing valuable preliminary data, have stable, suggesting the possibility of
not been as rigorous as those published in saturation or ceiling effect of productivity
non-yoga journal publications. The fact that in this field. However, the fact that there
almost half of the non-yoga journal are already 12 publications in 2004, with 5
p u b l i c a t i o n s h a v e r e p o r t e d R C T ’s i s of them RCT’s, suggests that there may
encouraging, as these trials provide the most again be a sharp increase in the near future.
valuable information. The sample size This may be due in part to the recent
analysis, however, suggests that the vast increased interest in yoga as an alternative
majority of these studies have been small medical intervention, particularly in the
RCT’s. We s t ( 3 3 ) , a n d i n c r e a s e d f u n d i n g b y
government agencies such as the National
It is clear that published research Center for Complementary and Alternative
in yoga therapy has lagged significantly Medicine in the U.S.
behind that of basic research in yoga which
b e g a n i n t h e 1 9 2 0 ’s ( 2 8 ) . T h e e a r l i e s t Clearly, the overwhelming amount of
publication meeting the criteria in research published has come from Indian
this study was published in 1967 in the investigators. The percentages found in this
journal Yoga Mimamsa by Bhole, which analysis are similar to an estimate made in
was an uncontrolled study evaluating a 1991 of the percentages in the entire field
multicomponent yoga treatment for asthma of yoga research (both basic and applied),
conducted at the Kaivalyadhama yoga which suggested that 50% of the research
institute (see Appendix). The first RCT was performed in India (14). The
publications meeting the criteria in this predominance of Indian investigators is in
study were published by Vahia et al. in contrast to the usual trend in scientific
Indian J Physiol Pharmacol 2004; 48(3) Bibliometric Analysis of Yoga Research 277

research in which the U.S., England, Europe factor is likely the socio-political drive to
and Japan dominate productivity, but is address disorders that have the highest
perhaps not surprising given the Indian mortality rates. In this regard, heart
origin of yoga practice. However, many of disease, asthma, diabetes and hypertension
the studies performed in India have been are amongst disorders with the highest
published in Indian journals, and peer- mortality rates. It is therefore unlikely
review procedures of some of these journals that the analysis of the types of disorders
may not be as rigorous as those of Western studied with yoga interventions will provide
journals. Furthermore, Indian investigators reliable information about which disorders
have generated proportionately fewer RCT’s yoga is most useful for. The appropriate
than their Western counterparts. This would study for that determination would be a
suggest a greater effort is necessary for meta-analysis that would evaluate relative
Indian scientists to continue moving towards effect sizes for yoga treatments across
improving their experimental design disorders.
approaches. With the dramatic increase in
popularity of yoga in the West, it is possible It is hoped that the analysis and
t h a t We s t e r n l a b o r a t o r i e s m a y b e g i n bibliography presented in this study has
increasing the frequency of research in this elucidated the existing research literature
area faster than that in India. For example, in this area and will support research efforts
for the time period 1973 to 1989, the number evaluating the psychophysiological effects of
of Indian and U.S. published RCT’s was yoga practice, and the use of yoga as an
11 and 2, respectively. From 1990 to 2004 effective primary or adjunct therapeutic
the number of Indian-based studies was intervention.
21, a two-fold increase, whereas the number
of U.S. studies was 16, an eight-fold ACKNOWLEDGEMENTS
increase.
The author is deeply indebted to his
The three types of disorders most spiritual teacher Yogi Bhajan, a master of
evaluated in yoga studies have been Kundalini Yoga, for his inspiration and
psychiatric conditions, cardiovascular guidance, and for bringing the ancient
disorders, and respiratory disorders. The technology of yoga to North America. The
discrete disorders receiving the most author is also grateful to Ian Nagus, Hari
attention were asthma, hypertension, Mandir Kaur Khalsa, Kristen Crowley,
diabetes, depression or dysthymia, heart K e r s t e n D r y d e n , J o h n P a s s a n e s e , D r.
disease and anxiety. It is likely that the Ramesh Bijlani and Dr. Julie Staples for
choice of disorder chosen for evaluation of assistance in acquisition of the publication
y o g a ’s e f f e c t i v e n e s s h a s a n u m b e r o f reprints. The author is supported by a
contributing factors. One of these is the Mentored Research Career Development
s u i t a b i l i t y o f y o g a ’s e f f e c t i v e n e s s i n Award (5K01AT000066) from the National
counteracting stress and reducing Center for Complementary and Alternative
autonomic arousal, factors which are known Medicine of the National Institutes of
to contribute to these disorders. Another Health, U.S.A.
278 Khalsa Indian J Physiol Pharmacol 2004; 48(3)

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APPENDIX
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