Introduction

Click here to watch yoga class participants doing the Downward Facing Dog pose.

Yoga is an ancient Indian practice which involves moving the body and training the mind to achieve balance and well-being. The purpose of traditional yoga is for each individual to be healthy, both physically and mentally, and able to reach his or her highest potential as a person.

Although there are different schools of traditional yoga (i.e. Bhakti Yoga, Karma Yoga, Patanjali's Ashtanga Yoga, Jnana Yoga, Kundalini Yoga, Swara Yoga, Raja Yoga, Kriya Yoga, and Mantra Yoga), Hatha Yoga is the most popular form practiced in the West. Hatha yoga's aim is to prepare the body for meditation through breathing and physical exercises. Hatha yoga emphasizes body-mind wellness through postures or asanas which tone and strengthen our muscles and increase our flexibility. The different asanas, particularly the twists and inversions, stimulate internal organs, as well as the nervous system, and promote circulation in all the body's major organs and glands. Research has shown that the practice of yoga as a lifestyle enhances overall health and prevents and reverses disease. (See References).

Yoga can be beneficial for individuals with disabilities or chronic health conditions through both the physical postures and breathwork. Each pose can be modified or adapted to meet the needs of the student. Yoga asanas can be performed while seated in a chair or wheelchair. Chair Yoga: the Sitting Mountain Series by Voelker-Binder was developed for individuals with arthritis, chronic obstructive pulmonary disease, multiple sclerosis, Parkinson's disease, osteoporosis, or stroke. Moreover, with time, the effects of the breathwork can affect a state of calm and renewal in one's life. Brown and Gerbarg (2005) concluded that Sudarshan Kriya yoga (SKY), a sequence of specific breathing techniques (ujjayi or loud breathing, Bhastrika or Bellows Breath, and Sudarshan Kriya, a powerful, rhythmic breathing technique) can alleviate anxiety, depression, everyday stress, post-traumatic stress, and stress-related medical illnesses.

Having mentioned the benefits of yoga practice, it should be noted that yoga is used to complement an individual's already established medical care, therapy program and exercise regime.

Components of Hatha Yoga

Pranayama or Breathwork - Pranayama is the science of proper breathing (Sumar, 1998). Breathing is a body process that is both autonomic and controllable. Most people find when they are anxious, their breath becomes quick and shallow. The simple process of slowing the breath down and breathing deeper has an immediate calming effect.

• Belly Breathing - Basic yoga breathing involves breathing in and out through the nose. Inhale, gently push the belly out, expanding the diaphragm first. Exhale, pulling the belly in at the end of the exhalation. This last movement pushes the air completely out of the lower portion of the lungs, removing all the toxins of the used air from the lungs. [From: http://www.hathayogalesson.com]

Asanas or Physical Postures - The physical movements in yoga, asanas are gentle and non-strenous stretches of the limbs and joints. These postures are coordinated with the breath and allow blood to circulate and vitalize every organ. Many asanas are modeled after movements that occur in nature such as tree, mountain, cat, dog, and cobra. Asanas focus on moving the joints through their full range of motion and lengthening muscles. The asanas are learned over time and with regular practice. They are meant to be held and are performed slowly and meditatively, combined with deep breathing.

Click here to watch yoga students with disabilities in Child's Pose, which is a relaxing asana/posture.

Dhyana or Meditation - Meditation usually refers to a state of extreme relaxation and concentration in which the body is generally at rest and the mind cleared of surface thoughts. The result is self-realization, and a clearer vision of life and the world.

Benefits of Yoga

Overall health benefits can be seen in:

• Digestive system. Bending and stretching poses help move and stimulate the digestive system
• Cardiovascular and cardiopulmonary systems. Specific types of yoga can be a good form of aerobic exercise that increases one's heart rate. The practice of pranayama helps expand lung capacity and heart strength.
• Lymphatic system. This is a primary component of an individual's immune system. Unlike blood, the lymphatic system has no pump. Instead it relies on muscle activity and body movement for circulation. Physical activity and stretching (yoga asanas) propels lymph, but it will also develop strong muscles that continually encourage lymph movement. Regular practice of pranayama stimulates the action of the lungs, diaphragm, and thorax which are a primary pump for the lymph fluid (Allbritton, 2003).
• Skeletal system and muscular systems. Asanas encourage the individual to keep his or her body in proper alignment. Regular yoga practice strengthens the muscles and increases overall flexibility.

Developmental benefits include:

• Developmental milestones are reached.
• Motor coordination is enhanced.
• Increased body awareness and orientation are achieved.
• Yoga practices develop focus and concentration.
• Yoga games encourage learning, creativity and imagination.

NOTE: RealPlayer is required to view each videoclip.
Click here to watch young students performing a spinal twist pose which enhances flexibility of the spine.	Click here to watch children with disabilities in a yoga class, performing balancing table pose which helps develop balance, body awareness and coordination, and strength.

Yoga Instruction for Children and Youth with Disabilities

Due to yoga's increasing popularity in the United States, numerous books, DVDs, audio tapes, and CDs are available that can aid in learning the philosophy and practice of the different types of yoga. However, for individuals with disabilities or chronic health conditions, it is best to learn yoga from a certified yoga therapist or yoga instructor who has the experience and background knowledge in teaching children and youth with disabilities.

The International Association of Yoga Therapists and Yoga for the Special Child websites are among the institutions that provide listings of yoga therapists.

In a yoga class for individuals with disabilities, yoga asanas are modified or adapted, and may be performed with the instructor's active assistance as needed. Although the instructor assists the child in getting into and out of a posture, keep in mind that the child is still doing the "work." Children should start with one-to-one yoga instruction, then progress to group classes when the child is ready - and if it is the least restrictive environment for the child, as determined by the yoga instructor and parent.

Click here to watch a yoga instructor assisting a student with a disability go deeper into a posterior stretch pose.

Teaching Guidelines for Yoga Instructors

Before the very first yoga session with a student, the yoga instructor needs to do an initial assessment of the student's current strength and endurance, physical challenges (i.e. spasticity, hypertonicity, hypotonicity, etc.) or barriers. An interview with the student's parent or guardian is helpful in getting information on any medications that the student is currently taking, or recently stopped taking. This may affect the student's physical, mental and emotional states. In addition, certain medications may make it unsafe to let the student do inversion asanas. The yoga instructor should then consult with the student's physician, explain the different asanas that may be used in the student's program, and ascertain which asanas are safe for the student to practice.

In addition, knowledge of other medical conditions, such as epilepsy prepares the instructor to handle an epileptic seizure if and when one does occur. Designing the yoga session to focus more on meditation and relaxation can aid in decreasing the frequency and duration of seizures (Yardi, 2001). Information about a student's diet at home and in school is also helpful. A student's behavior and attention span during the yoga session may be affected by the student's diet, specifically the lack of vital nutrients in the diet.

When designing an appropriate yoga session for the student, the personality, behavior, and attention span of the student should be taken into consideration. If a student is agitated, hyperactive or easily distracted, the instructor may have the student spend less time in each asana and more time doing music therapy and pranayama. Choose asanas that build focus and concentration, and are calming at the same time. Making a game or a storytelling activity incorporating the asanas keeps the student on task and involved in the yoga session. The instructor should be creative with each session, while adhering to the main structure of the class.

If an instructor is leading a group class (45-50 minutes), he or she is still expected to give equal time, attention, and/or assistance to each student as much as possible.

Yoga Equipment

An advantage of incorporating yoga practice as part of an individual's exercise program is that it does not require any fancy equipment. Yoga can be practiced anywhere - indoors, outdoors on the grass, or even on sand at the beach. Typically, a yoga mat or rug is used. Latex-free and eco-friendly mats are also available. Having some facial tissue within arms reach comes in handy during breathing exercises when the individual needs to clear his/ her nostrils. Yoga props such as blocks and straps aid in practicing an asana safely, as well as help the individual go deeper into a pose. An eye pillow and a light blanket can be used during deep relaxation.

A Typical Yoga Class for Children and Youth

A typical yoga class for infants is usually 30 minutes long. Group or one-to-one classes for children and youth last for 45 minutes. The components in a typical yoga session for children and youth with disabilities are discussed in the following sections.

To see another sample yoga session for an individual with a disability, view the NCPAD video clip series: Adapted Yoga for Children and Youth with Cerebral Palsy.

Start the class by having the student sit cross-legged (independently or with assistance) on the floor.

I. Chanting or Music Therapy

Begin the yoga session with Chanting or Music therapy. This activity brings the child's focus into the yoga session. The instructor leads the student into chanting 3 "Oms" (or substitute "Om" with "Peace", or "Love"). This is usually followed by singing the phrase "Hari Om" (or use any short song or nursery rhyme that the child is familiar with). This activity starts with slow singing, then progresses to faster singing of the phrase/song. Hand movements, such as clapping rhythmically to the song, can be incorporated into the activity. The chanting and the hand movements that go with it encourages concentration and attention; stimulates the diaphragm, lungs and vocal chords; and develops motor coordination.

Click here to watch children with disabilities in a yoga class performing chanting/ music therapy.

II. Pranayama or Breathing Exercises

Pranayama

• The Cleansing Breath is an ideal practice for children with asthma, sinus conditions, and bronchial congestion.
  1. Place one hand on the belly to feel the movement during this particular breathing exercise. With the other hand, hold a piece of facial tissue in front of the face. Take a slow, deep breath in, followed by a very quick, forced exhalation. The student should be able to see the tissue move with the exhalation.

• The Bellows Breath is a highly energizing, rapid-breathing exercise, providing many of the same benefits as the Cleansing Breath. These vigorous in-and-out movements of the abdomen strengthen the diaphragm; saturate the lungs and blood with freshly oxygenated air; and aid in digestion, thereby benefiting the entire body. Bhavanani, Madanmohan, & Udupa (2003) found that visual reaction time (VRT) and auditory reaction time (ART) significantly decreased in school-aged boys who practiced nine rounds of bellows breath or mukh bhastrika. Reaction time (RT) is an index of the processing ability of central nervous system and a simple means of determining sensory-motor performance. The authors recommended the practice of Bellows breath to individuals with prolonged RT, such as children with intellectual disabilities and older adults.
  1. Place one hand on the belly to feel the movement during this particular breathing exercise. Start with a rapid inhalation, immediately followed with a rapid exhalation. Start with doing one set of 10. Encourage the student to clear the nose after each set. For children, a helpful cue is to have their breathing imitate that of a "choo-choo" train.

• Alternate Nostril Breathing calms the mind; strengthens the entire nervous system and helps to balance the right and left hemispheres of the brain; strengthens the immune system; stimulates digestion; and develops concentration.
  
  NOTE: RealPlayer is required to view each videoclip.

  Click here to watch children with disabilities in a yoga class performing alternate nostril breathing.

  1. With the right hand, keep the thumb, ring and pinkie fingers up, while the index and middle fingers are down/ tucked. This hand gesture is known as Vishnu mudra. The thumb will cover the right nostril, while both the ring and pinkie fingers will cover the left nostril.
     
  2. Close the right nostril with the thumb, and take a deep inhale through the left nostril.
     
  3. Hold the breath in, closing both nostrils.
     
  4. Keeping the left nostril closed, exhale slowly through the right nostril.
     
  5. Take a deep inhale through the right nostril, hold the breath and exhale slowly through the left nostril.
     
  6. Repeat the exercise.

III. Eye Exercises

Eye exercises - These exercises strengthen and relax the eye muscles, as well as stimulate the optic nerve. The following exercise is good for beginners:

Click here to watch children with disabilities in a yoga class practicing eye exercises.

1. Sit cross-legged on the floor (or sit comfortably on a chair) with the body properly aligned, eyes are closed.
2. Slowly open the eyes and bring the right hand in front of the face (an arm's length distance). All the fingers are tucked in a fist except for the thumb, with the thumbnail facing toward the face.
3. Instruct the student to move the right hand up. With eyes wide open, track the thumb with the eyes only without blinking. Stop when the eyes cannot see the thumb anymore.
4. With the gaze relaxed and steady, follow as the right hand moves back to center.
5. Repeat this exercise, moving the hand down - back to center - right - back to center - left - back to center
6. After this set, rub the palms together until some warmth is generated
7. Gently cup the hands over the eyes ("palming") and relax.
8. Do another set of eye exercises. At the last set of exercises, end with palming and gently massage the eyelids with the fingertips, then massaging other areas of the face, neck and shoulders.

IV. Yoga Asanas

Yoga Asanas - The asanas practiced in each yoga session is determined by the instructor based on the student's needs and goals. When teaching a new asana, the instructor can start by breaking down the pose into its basic components, progressing on to the next component when the student is ready.

Typically, the student warms up with a set series of specific asanas, called the Sun Salutations. Komitor and Adamson's (2000) text provides a kid-friendly reference card showing the sun salutations for children. Budilovsky & Adamson (2003) provide instruction on the Seated Sun Salutations.

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Click here to watch children with disabilities in a yoga class practicing the shoulderstand pose.	Click here to watch children with disabilities in a yoga class practicing the fish pose, which is a counter-pose to the shoulderstand.

The instructor then leads the student into individual asana practice after the warm-up. The asanas practiced should be a balanced set which include postures that work on balance, strength and flexibility; twists and inversions; forward and backward bends; postures done in the following positions: seated, standing, prone, and supine.

NOTE: RealPlayer is required to view each videoclip.
Click here to watch yoga students practice forward and backward rolling.	Click here to watch yoga students practice a prone body stretch, alternating the arms and legs.

V. Deep Relaxation

Deep Relaxation - This is an important part of the yoga session in that it helps the student learn how to relax his or her body. Deep relaxation provides an opportunity for the body to slow down and absorb all the energy from the yoga practice. It is also a practice in stillness.

With the lights dimmed, relaxing music playing, and distractions in the room removed, the student is asked to go into shavasana or the Corpse Pose. Shavasana consists of comfortably lying supine on the floor, with the arms to the side, palms facing up. The feet are about shoulders-width apart. A blanket may be placed over the body for warmth. An eye pillow may be placed over the eyes to let them relax in darkness.

Click here to watch a yoga instructor facilitate students in final relaxation.

To facilitate relaxation, the student is verbally cued to bring awareness to his or her breath. If the student is responsive to massage, the instructor can perform gentle massages starting from the feet and up, giving attention to areas of the body that are tense.

Another technique that can help the student relax is by facilitating progressive relaxation. Here, the instructor verbally cues the student to consciously contract or tense the muscle and then consciously relax the muscle. The exercise starts with contracting and relaxing the muscles of the feet and legs, and then progresses up the body toward the head.

Then, slowly let the student out of deep relaxation. Cue the student to deepen the breath. With eyes still closed, let the student become aware of his or her surroundings. Have the student start to move their fingers and toes, and then gently stretch their body as if they were about to get up from a brief nap. Have the student slowly roll over to the right side, in a fetal position. When the student is ready, come up to a seated position.

VI. End of the Yoga Session

End of session - End the session by chanting "Om" three times. Then have the child place the palms together in front of the body and say "Namaste", which means "I recognize and honor the divine light in you!" (Komitor & Adamson, 2000).

Resources for Teaching and Learning Yoga

Books

1. Heriza, N. (2004). Dr. Yoga: A complete program for discovering the head-to-toe benefits of yoga. Tarcher/Penguin: New York, NY.
2. Sumar, S. (1998). Yoga for the special child: A therapeutic approach for infants and children with Down syndrome, cerebral palsy, learning disabilities. Special Yoga Publications: Evanston, IL.

Web Sites

1. Yoga for the Special Child - A schedule for Yoga for the Special Child Teacher Training Programs is posted on their website
2. Chair Yoga: The Sitting Mountain Series (CD) by Lakshmi Voelker - http://yogawithlakshmi.com/
3. YogaKids - http://www.yogakids.com
4. Hatha Yoga Lesson web site: http://www.hathayogalesson.com

Instructional Video

1. Yoga with a Master (Hatha Yoga video recommended by Cedars-Sinai Preventive and Rehabilitative Cardiac Center). http://iymagazine.org/shop.html

Organizations

1. Yoga for the Special Child :
   Sarasota , Florida
2. Rehabilitation Institute of Chicago :
   Chicago , Illinois

Books

1. Heriza, N. (2004). Dr. Yoga: A complete program for discovering the head-to-toe benefits of yoga. New York, NY: Tarcher/Penguin.
2. Sumar S. (1998). Yoga for the Special Child: A Therapeutic Approach for Infants and Children with Down Syndrome, Cerebral Palsy, and Learning Disabilities. Buckingham, Vermont: Special Yoga Publications; Route 1.

Journals

1. Bastille, J. V., & Gill-Body, K. M. (2004). A yoga-based exercise program for people with chronic poststroke hemiparesis. Physical Therapy, 84(1), 33-48.
2. Bhavanani, A. B., Madanmohan, & Udupa, K. (2003). Acute effect of Mukh bhastrika (a yogic bellows type breathing) on reaction time. Indian Journal of Physiology and Pharmacology, 47(3), 297-300.
3. Bijlani, R. L., Vempati, R. P., Yadav, R. K., Ray, R. B., Gupta, V., Sharma, R., et al. (2005). A brief but comprehensive lifestyle education program based on yoga reduces risk factors for cardiovascular disease and diabetes mellitus. Journal of Alternative and Complementary Medicine, 11(2), 267-274.
4. Shannahoff-Khalsa, D. S., Sramek, B. B., Kennel, M. B., & Jamieson, S. W. (2004). Hemodynamic observations on a yogic breathing technique claimed to help eliminate and prevent heart attacks: a pilot study. Journal of Alternative and Complementary Medicine, 10(5), 757-766.
5. Harinath, K., Malhotra, A. S., Pal, K., Prasad, R., Kumar, R., Kain, T. C., et al. (2004). Effects of Hatha yoga and Omkar meditation on cardiorespiratory performance, psychologic profile, and melatonin secretion. Journal of Alternative and Complementary Medicine, 10(2), 261-268.
6. Brown, R. P., & Gerbarg, P. L. (2005). Sudarshan Kriya yogic breathing in the treatment of stress, anxiety, and depression: part I-neurophysiologic model. Journal of Alternative and Complementary Medicine, 11(1), 189-201.
7. Birkel, D. A., & Edgren, L. (2000). Hatha yoga: improved vital capacity of college students. Alternative Therapies in Health and Medicine, 6(6), 55-63.
8. DeMayo, W., Singh, B., Duryea, B., & Riley, D. (2004). Hatha yoga and meditation in patients with post-polio syndrome. Alternative Therapies in Health and Medicine, 10(2), 24-25.
9. Galantino, M. L., Bzdewka, T. M., Eissler-Russo, J. L., Holbrook, M. L., Mogck, E. P., Geigle, P., et al. (2004). The impact of modified Hatha yoga on chronic low back pain: a pilot study. Alternative Therapies in Health and Medicine, 10(2), 56-59.
10. McIver, S., O'Halloran, P., & McGartland, M. (2004). The impact of Hatha yoga on smoking behavior. Alternative Therapies in Health and Medicine, 10(2), 22-23.
11. Jacobs, B. P., Mehling, W., Avins, A. L., Goldberg, H. A., Acree, M., Lasater, J. H., et al. (2004). Feasibility of conducting a clinical trial on Hatha yoga for chronic low back pain: methodological lessons. Alternative Therapies in Health and Medicine, 10(2), 80-83.
12. Riley, D. (2004). Hatha yoga and the treatment of illness. Alternative Therapies in Health and Medicine, 10(2), 20-21.
13. Garfinkel, M., & Schumacher, H. R., Jr. (2000). Yoga. Rheumatic Diseases Clinics of North America, 26(1), 125-132.
14. Jayasinghe, S. R. (2004). Yoga in cardiac health (a review). European Journal of Cardiovascular Prevention and Rehabilitation, 11(5), 369-375.
15. Kreitzer, M. J., Gross, C. R., Ye, X., Russas, V., & Treesak, C. (2005). Longitudinal impact of mindfulness meditation on illness burden in solid-organ transplant recipients. Progress in Transplantation, 15(2), 166-172.
16. Oken, B. S., Kishiyama, S., Zajdel, D., Bourdette, D., Carlsen, J., Haas, M., et al. (2004). Randomized controlled trial of yoga and exercise in multiple sclerosis. Neurology, 62(11), 2058-2064.
17. Ott, M. J. (2002). Yoga as a clinical intervention. Advance for Nurse Practitioners, 10(1), 81-83, 90.
18. Ripoll, E., & Mahowald, D. (2002). Hatha Yoga therapy management of urologic disorders. World Journal of Urology, 20(5), 306-309.
19. Tran, M. D., Holly, R. G., Lashbrook, J., & Amsterdam, E. A. (2001). Effects of Hatha Yoga Practice on the Health-Related Aspects of Physical Fitness. Preventive Cardiology, 4(4), 165-170.
20. Yardi, N. (2001). Yoga for control of epilepsy. Seizure, 10(1), 7-12.

This fact sheet was last updated on 03-02-2007.

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