Non-communicable diseases (NCDs) remain a neglected health problem which requires utmost importance in recent times.[1] Chronic kidney disease (CKD) is one of the major contributors to increasing the morbidity and mortality of NCDs.[2] Despite advances in medicine, the disease burden remains unchanged. CKD affects 10% of the world’s adult population, with approximately 1.2 million deaths worldwide.[3] Globalisation of CKD is associated with other lifestyle diseases such as obesity, diabetes mellitus, cardiovascular disease and hypertension.[4] Specialised clinical protocol developed for effective management of CKD in patients with diabetes mellitus, hypertension, anaemia and coronary artery disease.[5-8] By the year 2040, CKD would be the fifth leading cause of death worldwide.[9] Hence, the effective management of CKD is the need of the hour. Complementary therapies such as yoga, meditation and acupuncture have gained momentum in recent years for the management of chronic illnesses.[10] A systematic review and meta-analysis on the efficacy of Alternative Medical Systems (Traditional Chinese Medicine, Ayurveda, Homeopathy and Naturopathy) in adult CKD showed improvement in biochemical markers and reduction in symptom severity scores.[11] In addition, research evidence on yoga states that it reduces oxidative stress, inflammation and sympathetic tone in CKD patients.[12,13] Yoga is a type of complementary and integrative therapy cognised worldwide. Yoga helps us to maintain physical, psychological and emotional balance with special attention on breathing, posture and meditation.[14] Yoga being the most cost effective, non-invasive and patient friendly treatment can be effectively used in patients with CKD. Therefore, the present study aims to develop a yoga module tailored for CKD patients with special attention to improving their general well-being.
MATERIALS AND METHODS Yoga protocol developmentThe present study was approved by the appropriate Research Ethics Committee (IEC/19/FEB/148/15). The yoga module was created with input from experts, including qualified professionals in yoga, naturopathy and nephrology, as well as through a review of previous literature on CKD.[13,14] Yoga practices were selected from classical yoga texts such as Hatha Yoga Pradipika, Yoga Darsana and light on yoga. [13,15-17] Available scientific evidence on yoga and CKD was significantly utilised to identify evidence-based practices that could be included in the module. The yoga module consisted of a pawnmuktasana series (loosening/anti-rheumatic group), 9 asanas, two pranayama, AUM chanting, yoga nidra and yogic counselling [Table 1].
Table 1: Proposed Protocol formulated for CKD patients.
S. No Yoga practices Duration/frequency 1. Pawanmuktasan series 1 5 rounds/5 min 2. Tadasana 3 rounds/3 min 3. Ardha chakrasana 3 rounds/3 min 4. Kati-chakrasana 3 rounds/3 min 5. Triyaka Tadasana 3 rounds/3 min 6. Dwikonasana 3 rounds/3 min 7. Supta swastikasana 3 rounds/3 min 8. Supta –udarakarsana 3 rounds/3 min 9. Sedubandasana 3 rounds/3 min 10. Uttanpadasana 3 rounds/3 min 11. Ardha pawnmuktasana 3 rounds/3 min 12. Vakrasana 3 rounds/3 min 13. Ardha matsyendrasana 3 rounds/3 min 14. Supta-badakonasana 3 rounds/3 min 15. Sarvangasana (wall support) 3 rounds/3 min 16. Bhujangasana 3 rounds/3 min 17. Dhanurasana 3 rounds/3 min 18. Ardha-shalabasana 3 rounds/3 min 19. Nadi-shodhana pranayama 15 rounds/5 min 20. Ujjai pranayama 10 rounds/5 min 21. Bhramari pranayama 10 rounds/5 min 22. AUM chanting 5 rounds/5 min 23. Yoga nidra 20 min 24. Deep relaxation technique 30 min 25. Yogic counselling 15 min Validation of protocolThe framework of the questionnaire was sent to 20 field experts (four yoga doctors, four yoga professors, four yoga research scholars, six yoga therapists and two nephrologists) through Gmail and Google documents to obtain their opinion on a three-point Likert scale ([1] = not necessary, [2] = useful but not essential and [3] = essential) for validation purpose. A panel of yoga experts, including yoga doctors, certified yoga instructors and nephrologists, were consulted to identify safe and beneficial practices. Experts who have more than 10 years of experience in treating various ailments with yoga therapy are included for validation purposes. The protocol was modulated in accordance with the comments from the expert. The content validity ratio (CVR) for each practice was calculated using Lawshe’s law, and those with CVR ≥0.6 are included in the final protocol.[18] The average of all CVRs was 0.76. A yoga module for CKD patients was formulated, validated and checked for practicability.
CVR = (Ne−N/2)/N/2
where,
Ne = Total number of panellists indicating ‘essential’ for each practice.
N = Total number of panellists.
Sequence of practiceThe sequence of practice is from standing asana, supine lying, sitting, and prone lying, followed by breathing techniques, meditation and yogic counselling.
RESULTSAll experts (n = 20) provided opinions on the selected yoga practices to be followed for CKD. Table 2 shows the validation of yoga practices for CKD. In the final interpretation of the module, 15 out of 25 items in the formulated protocol were retained, according to changes suggested by the experts.
Table 2: Protocol approved by expert.
S. No Yoga practices Duration/frequency CVR Lashle’s law 1. Pawanmuktasan series 1 5 rounds/5 min 0.7 2. Ardha chakrasana 3 rounds/3 min 0.8 3. Kati-chakrasana 3 rounds/3 min 0.9 4. Triyaka Tadasana 3 rounds/3 min 0.7 5. Supta –udarakarsana 3 rounds/3 min 0.8 6. Sedubandasana 3 rounds/3 min 0.7 7. Vakrasana 3 rounds/3 min 0.8 8. Supta-badakonasana 3 rounds/3 min 0.7 9. Bhujangasana 3 rounds/3 min 0.9 10. Ardha-Shalabasana 3 rounds/3 min 0.7 11. Nadi-shodhana pranayama 15 rounds/5 min 0.8 12. Bhramari pranayama 10 rounds/5 min 0.7 13. AUM chanting 5 rounds/5 min 0.7 14. Yoga nidra 20 min 0.8 15. Yogic counselling 15 min 0.7 DISCUSSIONThe practices in the yoga protocol were framed from the knowledge of the pre-existing literature and the scientific evidence available to date. The experts also agreed on the clinical importance of the developed module for improving the physical and mental well-being of patients with CKD. Similar to other protocols, the present protocol also contains asanas (posture), pranayama (breathing technique), AUM chanting and yoga nidra (relaxation). The present protocol was revised and validated only using two aspects: [1] CVR and[2] suggestions and comments from the experts. Recommended duration of practice was 1 h session at least weekly twice for the period of 12 weeks. In addition, experts also suggested giving utmost importance to slow and rhythmic breathing patterns along with the practice. Experts were also asked to add any missed-out practices from the literature which will be potentially beneficial for CKD patients. Most of the experts (n = 16) agreed and did not add up any practices. Few experts (n = 4) asked to emphasise the importance of a plant-based yogic diet. Yoga practices included in the final protocol were easy to practice, and they can be modified based on individual needs. In recent times, yoga protocol was formulated for specific conditions such as depression, mental health, somatoform disorder and diabetes.[19-22] However, there is no specific module developed for CKD; hence, we aimed to formulate a yoga protocol for patients with CKD. There are a few limitations in the present module; we have sent the module to 35 yoga experts out of them, only 20 responded. Obtaining information from more experts would be very beneficial. All the experts are of Indian origin; hence, it limits the generalisation of the protocol with respect to the Western context. We have not asked for the sequence of the asanas in which they could be practised.
CONCLUSIONThe yoga practices developed based on experts’ opinion is the first step toward the development of a validated protocol for CKD. However, randomised control trials are needed to check the efficiency of the protocol. If the current module is beneficial, then it can be used as therapeutic tool in patients with CKD.
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