Advances in Human Biology

REVIEW ARTICLE
Year
: 2021  |  Volume : 11  |  Issue : 4  |  Page : 3--12

Psychophysiological effects of yoga on stress management among medical and allied health professional students during COVID-19 pandemic: A narrative review


Sankalan Sarkar1, Bidyadhar Sa2, Keerti Singh1, Uma Gaur1, Ambadasu Bharatha1, Virginia Victor2, Sayeeda Rahman3, Md Anwarul Azim Majumder1,  
1 Faculty of Medical Sciences, The University of the West Indies-Cave Hill Campus, Barbados
2 Faculty of Medical Sciences, The University of the West Indies-St. Augustine Campus, Trinidad and Tobago
3 School of Medicine, American University of Integrative Sciences, Bridgetown, Barbados

Correspondence Address:
Bidyadhar Sa
Centre for Medical Sciences Education, Faculty of Medical Sciences, The University of the West Indies, St. Augustine Campus
Trinidad and Tobago

Abstract

The impact of coronavirus disease 2019 (COVID-19) pandemic has raised health concerns worldwide. Medical and allied health professional schools are seeking ways to alleviate stress and improve the quality of life among students. The effects of yoga have proven to be successful against stress. The review aimed to examine the psychophysiological effects of yoga on stress management among medical and allied health professional students during COVID-19 pandemic. The authors reviewed existing literature and official documents, which mostly focussed on the effect of yoga among medical and health professional students. Mental stress among these students is known to be higher than that of the general population. Sudden changes due to the pandemic are likely to have a significant impact on these students. Uncertainties concerning teaching, learning and assessment generate stress and anxiety, and social distancing further contributes to loneliness. Yoga has gained recognition not only in improving mental health and quality of life, but it also helps in improving respiratory and immune health. Although many published studies examined the psychophysiological effects of yoga among health professional students; only a few medical and allied health professional schools have incorporated yoga into an integrated curriculum for a holistic approach. In response to the COVID-19 crisis, the use of yoga for stress reduction and immune modulation should be considered as a complement to other treatments. There is a need to integrate yoga into medical and health science curricula to prepare physically fit and mentally sound prospective healthcare professionals.



How to cite this article:
Sarkar S, Sa B, Singh K, Gaur U, Bharatha A, Victor V, Rahman S, Azim Majumder MA. Psychophysiological effects of yoga on stress management among medical and allied health professional students during COVID-19 pandemic: A narrative review.Adv Hum Biol 2021;11:3-12


How to cite this URL:
Sarkar S, Sa B, Singh K, Gaur U, Bharatha A, Victor V, Rahman S, Azim Majumder MA. Psychophysiological effects of yoga on stress management among medical and allied health professional students during COVID-19 pandemic: A narrative review. Adv Hum Biol [serial online] 2021 [cited 2021 Dec 5 ];11:3-12
Available from: https://www.aihbonline.com/text.asp?2021/11/4/3/328394


Full Text



 Introduction



The pandemic of coronavirus disease 2019 (COVID-19) is posing a threat to health, affecting all aspects of life, in general, and psychological well-being, in particular.[1] Large-scale observational studies published to date indicate that symptoms of anxiety, depression and self-reported stress are common psychological reactions to the COVID-19 pandemic among the general community and vulnerable populations such as frontline health-care workers.[2],[3],[4],[5],[6] Another vulnerable population who has been significantly impacted is medical and allied health professional students. As a result of the pandemic, an educational emergency was declared resulting in interrupted learning, shifts in delivery of learning to online mode, cancelled examinations and deprived hands-on practical and clinical training. More importantly, students' professional trajectory was put at stake.[5],[6],[7],[8],[9],[10]

The pandemic presents a number of stressors for students. Uncertainties concerning teaching, learning and assessment generate stress and anxiety, and social distancing further contributes to loneliness.[11],[12] Medical and allied health professional schools are seeking ways to reduce stress and improve the quality of life among students, not only during the current pandemic but also in the post-COVID-19 period. Numerous studies suggest that yoga has gained prominence in improving mental health and quality of life and in the treatment of many psychiatric and psychosomatic disorders.[1],[13],[14],[15] Yoga has been practiced for several 1000 years as an immortal cultural outcome of Indus Sarasvati Valley civilisation in South Asia's north-western regions dating back to 2700 B.C.[16] It has gained popularity in western countries over the past few decades.[17] Techniques in yoga strengthen the body while healing mental and emotional issues. The eight branches of yoga can be broadly narrowed into four types: karma yoga, where we use the body; bhakti yoga, whereby the emotions are used; gyana yoga, in which the mind and intellects are used; and kriya yoga, in which the energy is used.[16] Hatha yoga, a popular practice of yoga, especially in the western world, integrates all three practices, which includes asanas (gentle stretching postures), pranayama (exercises of breath control) and kriyas (purification techniques).[17] Similarly, mindfulness yoga is a combination of Buddhist mindfulness practices and hatha yoga.[18] Various clinical researches on yoga propose and recommend neurophysiological, psychological and immunological mechanisms for effective stress reduction.[19]

Further, scientific research has established that the physiological, psychological and biochemical effects of yoga are anti-stress in nature.[20],[21] The practice of yoga and meditations can be very effective to not only reduce stress among medical and health professional students during the current pandemic and post-COVID-19 period but to also improve respiratory and immune health. This makes for a better quality of life.[2],[22],[23] Through the techniques of meditation, asanas and pranayama, yoga yields a positive effect in managing stress and enhancing academic performance.[24],[25] Prominent medical institutes such as Harvard Medical School have already recommended yoga, meditation and controlled breathing for its students to address anxiety issues related to the novel coronavirus.[26] The United Nations published yoga and meditation as wellness tips to combat COVID-19 on their website.[21] Integrating yoga with medical and health professional curriculums has yielded positive results.[27],[28] To ensure students' physical and mental well-being, it is now imperative to adopt the antiquity of yoga's holistic approach with the multi-dimensional benefits in medical and health professional schools around the world during and after the COVID-19 pandemic. The review aimed to examine the psychophysiological effects of yoga on stress management among medical and allied health professional students during the COVID-19 pandemic.

 Methods



We searched and reviewed literature that focussed on stress among medical and allied health professional students due to the COVID-19 pandemic and the role of yoga intervention to alleviate mental stress and anxiety. PubMed, Scopus and Google Scholar were searched using specific keywords, e.g., COVID-19 pandemic, yoga, mental stress, anxiety, medical and allied health students. Original studies, reviews, editorials, commentaries, perspectives and short communications on the COVID-19 pandemic were reviewed. Information from websites of national and international professional associations and organisations was extracted. Reference lists from retrieved articles and reports were examined manually for relevant information.

 Psychophysiological Effects of Yoga on Stress Management



Stress can be defined as a state of threatened homoeostasis or disharmony caused by intrinsic or extrinsic stressors, which is counteracted by a series of physiological and behavioural responses to support the optimal homoeostasis.[29],[30] The essential components of the stress system are the autonomic nervous system (ANS) and hypothalamic–pituitary–adrenal (HPA) axis, which are involved in mobilising a successful adaptive response against a stressful status [Figure 1]. Hyper- or hypo-activation of the stress system in relation to chronic and potent stress can significantly disturb the body's equilibrium, leading to allostasis, with a range of clinical conditions, including anxiety, depression, cognitive impairment and heart diseases.[30]{Figure 1}

Reviews also reported that yoga intervention reduced stress significantly.[1],[13],[14],[15],[31] Yoga intervention reduces stress by altering neurophysiological (reducing sympathetic activation and enhancing vagal activity, leading to decreased cortisol and HPA axis activation)[32] and neuroendocrinological activity,[33] positive psychological self-awareness, compassion and mindfulness adjustment[34] and improved immunological mechanisms (reduced interleukin 6, proinflammatory nuclear factor kappa light chain enhancer of activated B cells and increased activity of antiviral interferon regulatory factor) [Figure 1].[35] However, only a few studies have reported on the plasma catecholamine levels.[32],[33] Since majority of these effects are mostly observed as a brief and temporary phenomenon, more meticulous efforts and observations are needed in the future.

 Stress among Medical/Allied Health Professional Students: Role of Yoga



Students enrolled in medical and allied health professional programmes have high levels of mental stress and a poor quality of life.[13],[36],[37],[38],[39],[40],[41],[42] Heavy workload and pressure to perform better leads to stress, depression and burnout.[43] A higher level of stress leads to 'sympathetic overdrive'. Mental, physical and spiritual health are consequently compromised, deteriorating the overall quality of life as a result of a pandemic.[7] Stress and depression can have multiple adverse effects if left untreated. These can lead to chronic conditions such as increased risk of respiratory infection and adverse effects on the immune and cardiovascular system. As a consequence, poor quality of life together with poor academic performance can lead to suicidal tendencies, ultimately negatively affecting overall physical health.[14],[36]

The effect of yoga on stress, depression and anxiety has been widely studied among medical, nursing and other health professional students. It was concluded that yoga has been effective in reducing stress and improving the psychological well-being of healthcare professionals (HCPs) and students. Scientific evidence strongly indicates that yoga has promotive, preventive as well as curative potential and has become widely accepted as a non-pharmacotherapeutic and safe modality for stress management and improving health.[7],[40],[44],[45],[46] Regular yoga practice improves various physiological and psychological functions of the body.[44] Therefore, it can positively influence mental health and improve overall well-being.[45],[46],[47] It reduces perceived stress and anxiety, lowers levels of stress markers as well as cultivates positive emotions, empathy, compassion and self-regulation. Further, it lowers levels of work-related stress, enhances functionality and improves self-care behaviour in medical students and HCPs.[48],[49] Further, McConville et al.,[50] in their meta-analysis, reported that mindfulness-based interventions reduce stress, anxiety and depression and enhance mindfulness, mood, self-efficacy and empathy in health professional students. They also felt that these inventions can easily be adapted and integrated into the curricula.[50] Another systematic review reported that mindfulness-based interventions were helpful/useful to reduce stress and mentally prepare medical and allied health professionals for their future careers.[43] Although some indirect evidence is showing an increase in mindfulness capacity, functional neuroimaging studies show no direct evidence, indicating an association between brain and behavioural improvement following mindfulness training.[51] Review reports suggest that yoga practices were effective in the management of stress among healthcare workers and that yogic intervention has helped combat the various occupational hazards associated with the dental profession and has a positive effect on reducing psychological stress.[40],[52] To evaluate the effect of yoga on the psychological function of students, many studies recommended that yoga could be implemented in the early part of related academic medical curricula.[41],[42],[45],[46] Strategies for stress prevention and management should be implemented to improve students' professional performance, ensure proper patient care and prevent drop-out. There is a need for more evidence-based research with the highest methodological quality, including larger samples and adequate control interventions in the field of yoga and its psychophysiological effects on students' health and academic performance. [Table 1] shows the positive effect of yoga on stress management of medical and other health professional students.[45],[46],[47],[53],[54],[55],[56],[57],[58],[59],[60]{Table 1}

 Yoga and Stress Management: Integration in Medical and Health Professional Curricula



Yoga is now valued and recognised as an integrated science in global health sectors, especially in medical education. In 2014, the General Assembly of the United Nations proclaimed June 21 the 'International Day of Yoga' to raise awareness of global mental health.[61] Yoga deserves a prominent place in the curriculum of all health professional education.[62] Incorporating yoga in health sciences education will help future professionals to take a positive healthcare approach and disperse this positivity to their patients and communities.[63] In India, the land where yoga originated, the Ministry of AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy) integrated yoga in health professional education as an ancient healing wisdom with modern scientific medicine. To implement this, various universities in India developed integrated curricula with all the medical and health professional sciences to build a holistic integration with positive outcomes.[27],[49],[62] Yoga has been successfully integrated into nursing, MBBS and BDS curriculum in different forms such as extra/co-curricular activities, lecture series and practical sessions. It impacted positively on students' overall well-being.[27],[49],[62]

Other medical schools around the world also took similar initiatives. There are recommendations to integrate mindfulness curriculum into formal undergraduate medical education.[28],[47] The University of Pennsylvania's Perelman School of Medicine, USA, has introduced yoganatomy in an effort to integrate student wellness into the curriculum which taught stress management.[63] Ankamreddy et al., 2019 reported on students' positive opinion regarding yoga intervention and recommended the practice be included in the curriculum.[64] A study in New York on the effect of 6 weeks of yoga and meditation on medical students showed a significant reduction in perceived stress and an improvement in the sense of well-being.[65]

Now, the use of complementary and alternative medicine approaches, commonly referred to as integrative medicine (I.M.), include topics such as meditation, mindfulness, yoga, aromatherapy and animal-assisted therapy.[66] The Academic Consortium for I.M. and Health in the USA acknowledged the need for education and training of medical students in various I.M. modalities and whole-health approaches. Mayo Clinic in Rochester, Minnesota, USA, a member of the Academic Consortium for I.M. and Health, developed a mandatory 4-year medical school curriculum in I.M. which is taught by I.M. professionals and physicians.[67]

A mandatory short IM curriculum, developed and implemented in Mayo Clinic School of Medicine, USA, was found to improve students' knowledge of I.M. and personal health practices.[68] In India, yoga was introduced in the MBBS (Mahatma Gandhi Medical College), Nursing (Kasturba Gandhi Nursing College) and BDS (Indira Gandhi Institute of Dental Sciences) curricula with the support of the Centre for Yoga Therapy, Education and Research, Pondicherry. The majority of the students (>80%) rated the yoga lectures as excellent and reported that 'yoga sessions had helped them to adjust better to college life and also that the stress management techniques enhanced their ability to do well in curricular and extracurricular activities'.[27] Based on the evidence mentioned above, it is the time to integrate yoga education in the health sciences curricula to reap maximum benefits, especially during and post-COVID-19 pandemic period.

 Yoga Practices for Medical/Health Professional Students during and Post-Coronavirus Disease 2019



The COVID-19 pandemic disproportionately affected the mental health of a wide range of communities.[69] A June 2020 survey from the Centers for Disease Control and Prevention of 5412 US adults found that 40.9% of the respondents reported 'at least one adverse mental or behavioural health condition', including depression, anxiety, post-traumatic stress and substance abuse, with rates that were 3–4 times higher than the rates 1 year earlier.[70] Remarkably, 10.7% of the respondents reported to have seriously considered suicide in the last 30 days.[70] Moreover, sudden interpersonal loss associated with COVID-19, along with severe social disruption, can easily overwhelm the ways individuals and families cope with bereavement.

Undoubtedly, the COVID-19 pandemic lockdown and academic cessation in the academic process added an extra burden on the prevailing mental health issues. A survey on the COVID-19 pandemic conducted among the 30,725 undergraduate students and 15,346 graduate and professional students at nine USA public research universities revealed that the majority (67%) of students screened positive for major depressive disorder; half of them (32%) screened positive for generalised anxiety disorder. Disorder rates were more pronounced among students of low-income status.[71]

Inevitably, the medical professional students and HCPs are the first responders to render the COVID-19 pandemic control and preventive strategies. In general, they undergo behavioural, affective and cognitive changes that demand adaptation during the disruptive environmental outbreak and its progression.[72] Therefore, restoring healthy psychology and mind set and keeping high levels of motivation in HCPs for optimum functioning are the important health imperatives.[72] During these challenging times, extreme physical and mental fatigue due to insufficient resources and the handling of death can cause moral injury and post-traumatic stress disorder in health workers. The role of yoga and meditation becomes indispensable at this point.[73],[74],[75]

During the COVID-19 pandemic, various studies were conducted worldwide to assess the psychological stress among medical and health professional students. Many institutes conducted online cross-sectional surveys among students, nurses and allied HCPs [Table 2].{Table 2}

They all concluded that COVID-19 had significant impact on medical students academic, health and mental well-being.[5],[6],[76],[77],[78],[79] A very high level of anxiety and depression was reported among nursing and allied HCP students and workers.[5],[6],[76],[77],[78],[79],[80],[81],[82],[83],[84],[85]

Several studies demonstrated that yoga reduces sympathetic response due to stress,[86],[87] while also improving mental well-being, mindfulness, positivity, self-awareness, coping mechanisms and decreasing secondary traumatic stress.[88],[89],[90] The United Nations published yoga and meditation on wellness tips to combat against COVID-19 on their website.[21] Other prominent health institutions have developed free online yoga classes with movement and mindfulness breaks for frontline healthcare workers amid chaos at work, which include 'Inner Engineering Online', 'Down dog App', 'Yoga 2.0 studio', 'I love Namaste', 'Meditation in Medicine', 'Headspace' and 'Sweat yoga'.[91],[92],[93],[94],[95],[96],[97]

A combined study by the Massachusetts Institute of Technology, the University of California-San Diego the Chopra Library for Integrative Studies and Harvard University, concluded that 'certain practices of meditation, yoga asana (postures) and pranayama (breathing) might be effective adjunctive means of treating and preventing SARS-CoV-2 infection'.[22] Yoga tools developed for well-being, mental clarity and emotional stability, along with physical flexibility during COVID-19, are being incorporated and tested by the National Study of Undergraduate Students at Rutgers University.[98] The Practice of Inner Engineering Online offered by the Isha Research Centre, USA, during COVID-19 resulted in an over 50% reduction in stress for compliant participants at the Harvard Medical School.[99] It led to a significant increase in energy, joy, mindfulness and work engagement at Rutgers University, USA.[100] Now is therefore the appropriate time to incorporate both theoretical and practical components of yoga into the medical and allied health curricula to improve the quality life of the students.[101] Now, more than ever HCPs also need yoga and meditation practices to relieve stress.

 Conclusion and Recommendations



The global COVID-19 pandemic impacted every sphere of human life, including medical and allied health professional students. It has been documented that, if left untreated, exposure to stressors is associated with multiple serious adverse effects and poor academic performance. Empirical evidence supports yoga as a complementary strategy for stress management and improved well-being. Medical and HCP students have experienced reduced stress, anxiety, depression, immune modulation, improved well-being, self-esteem, compassion and self-awareness after practicing yoga.

In response to the COVID-19 crisis, the use of yoga for stress reduction and immune modulation should be considered as the basis for its complementary role in treatments. There is also a need to integrate yoga into the medical and health science curricula to prepare physically fit and mentally sound prospective Health Care Professionals (HCPs). Several medical and health professional universities that integrated yoga into their curricula observed an overall positive impact. More empirical studies are required to analyse the effectiveness of yoga-based curricula on the health and well-being of medical and health professional students.

Acknowledgement

We extend our gratitude to Mrs. Stella Williams, Former Lecturer in Health Communication, Centre for Medical Sciences Education, Faculty of Medical Sciences, The University of the West Indies, St Augustine Campus, Trinidad and Tobago, for her assistance in reviewing this manuscript for English language and grammar.

Financial support and sponsorship

Nil.

Conflicts of interest

Dr. MAAM and Prof. BS are in the Editorial Board of Advances in Human Biology. The other authors report no conflicts of interest in this work.

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