Complementary Therapies in Medicine (2012) 20, 424430

Available online at www.sciencedirect.com

journal homepage: www.elsevierhealth.com/journals/ctim

Effect of integrated Yoga on neurogenic bladder

dysfunction in patients with multiple sclerosisA
prospective observational case series
Patil N.J. a,, Nagaratna R. a, Garner C. b, Raghuram N.V. a,
Crisan R. b
a

Division of Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhana Samsthana (SVYASA), Yoga University, Bengaluru, India
Neurological Rehabilitation Center, KWA Klinik Stift Rottal, Bad Griesbach, Germany
Available online 9 October 2012

KEYWORDS
Multiple sclerosis
(MS);
Yoga;
Neurogenic bladder
dysfunction (NBD);
Post void residual
urine

Summary
Background: Neurogenic bladder dysfunction (NBD) is a common distressful symptom in multiple
sclerosis (MS) affecting quality of life. Yoga has been widely used in treating various symptoms
of patients with MS.
Objectives: To evaluate the effect of integrated Yoga for NBD in patients with MS as an adjunct
to standard medical care.
Design: This open arm, pre-post study design assessed the outcome measures at base line and
after 21 days of integrated Yoga intervention. Setting: study was conducted at the center for
neurological rehabilitation at KWA-Klinik Stift Rottal in Bad Griesbach, Germany. Eleven MS
patients with NBD (mean age 46.7 11.24 years) with mean duration 17.2 years volunteered
to participate in the study. Interventions: integrated Yoga which includes preparatory yogic
loosening and breathing practices, Nadishuddi pranayama (alternate nostril breathing), moola
bandha (anal lock), kapalbhati (rapid nostril breathing) and deep relaxation technique was given
for 2 h per day for continuous 21 days. Outcome measures: ultrasound scanning for post void
residual urine volume (PVR), micturition check list (MCL), incontinence impact questionnaire-7
(IIQ-7) andurogenital distress inventory-6 (UDI-6) were used.
Results: Paired sample t-test showed signicant improvement in post void residual urine
(62.34%, p < 0.05), scores on micturition frequency checklist (25%, p < 0.05), incontinence
impact questionnaire-7 (32.77%, p < 0.05) and uro-genital distress inventory-6 (26.33%, p < 0.05).
Conclusion: This study points to the safety and effectiveness of integrated Yoga for bladder
symptoms as an adjunct to standard care in multiple sclerosis patients with neurogenic bladder
dysfunction in Germany. Further trails are necessary to conrm these ndings.
2012 Elsevier Ltd. All rights reserved.

Introduction
Corresponding author at: Division Yoga & Life Sciences, SVYASA,
Yoga University, Bangalore. Tel.: +91 9886211008;
fax: +9180 26608645.
E-mail address: ayushnitin@gmail.com (N.J. Patil).

Multiple sclerosis (MS) is an inammatory, demyelinating,

neurodegenerative disorder of the central nervous system
(CNS) with unknown aetiology.1 Europe has the highest

0965-2299/$ see front matter 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ctim.2012.08.003

Effect of integrated Yoga on neurogenic bladder dysfunction in multiple sclerosis

estimated prevalence of MS in the world at 80 per 100,000
inhabitants.2 90% of MS patients suffer from some type of
neurogenic bladder dysfunction (NBD) during the course of
the disease.3 NBD is extremely disabling, as it profoundly
limits the social contact and the quality of life.4 Detrusor
hyperactivity with restricted storage capacity is the most
common type that leads to urgency, increased frequency
of micturition and incontinence. Some drugs are available
to treat these symptoms,5 the manifold side effects are
limiting their use and often the effect is not satisfactory.6
As a result of this many patients seek alternative therapies.7
Pelvic oor muscle training, electromyographic biofeedback
and neuromuscular electrical stimulation are the common techniques recommended for bladder dysfunction.8,9
Craniosacral therapy was also reported to be effective in
lower urinary tract symptoms.10 Use of complementary and
alternative medical therapies (CAM) for chronic illnesses
is growing in Western countries.11 A clinical overview of
mind-body interventions and their applications in neurology observed strong evidence for its efcacy in several
neurological conditions.12 These include interventions such
as cognitive behavior therapy, mindfulness meditation and
Yoga. An integrative review of eight intervention studies
in MS patients published from 2000 to 2005 revealed that
cognitive behavioral approaches are benecial in the treatment of depression and coping ability.13 A mindfulness-based
intervention was well accepted by adult MS patients with
relapsing-remitting or secondary progressive disease, as it
was very effective in improving the quality of life (HRQOL)
apart from reducing depression and fatigue.14
Yoga is an ancient science that is dened as an introspective method to gain mastery over the modications of the
mind.15 It includes various practices that include physical
postures, breathing exercises, guided relaxation, meditation and introspective enquiry into ones mind, intellect,
emotions, etc.16,17 Physiologically, Yoga practice is noted
to produce changes in heart rate, blood pressure, galvanic
skin response, respiratory rate, breath holding time, auditory reaction times, visual reaction times and intraocular
pressure.18 Efcacy of Yoga therapy in various ailments like
asthma,19 cardiovascular problems,20 diabetes21,22 and other
psychosomatic disorders is documented. A recent report by
Velikonja et al.23 recommends the use of Yoga as an aerobic physical activity in management of MS patients since it
incorporates a series of stretches that promote body control and planning of complex movements and thus help to
improve the quality of life by reducing spasticity, cognitive impairment, depression and fatigue. Meditation, which
is also another Yoga technique, was found to be useful
in reducing fatigue24 and was acknowledged to be a useful practice by MS patients in an anonymous, self-report,
Internet-based survey on 2529 respondents.25 In a 6-month
randomized control trail in 69 patients with MS, participants
in the Yoga group showed signicant improvement in measures of fatigue comparable to waiting-list control group.26
Thus there is emerging evidence for the complimentary role
of Yoga in the management of MS. There are no studies that
have looked at the efcacy of a specic set of yogic pelvic
oor practices combined with breathing techniques on bladder symptoms in MS. Hence the present study was designed
to evaluate the effect of integrated Yoga for NBD in patients
with MS as an adjunct to standard medical care.

425

Methods
Subjects
The study group of eleven MS patients (1 male, 10 female)
in age range of 1960 years consisted of patients who were
admitted for rehabilitation between April and June 2010 at
KWA Stift Rottal, Bad Griesbach.

Setting
This study was undertaken at KWA-Klinik Stift Rottal hospital in Bad Griesbach Germany. This hospital is specialized
in neurological rehabilitation, using state of the art rehabilitation methods including various complimentary and
alternate therapies like acupuncture, Yoga, ayurveda. Since
1995 there exists an intensive cooperation with S-VYASA
Yoga University in Bangalore, India which is known for
providing scientic basis for Yoga practices for different
ailments.19,27,28
Inclusion criteria were patients of both genders in age
range of 1860 years who
a. Satised Mc Donalds diagnostic criteria for multiple
sclerosis,29
b. Had score <7.5 on expanded disability status scale
(EDSS),30
c. Had score of >8 spontaneous micturitions in 24 h,
d. Could understand and follow the given Yoga techniques,
e. Capable of documenting the daily micturition frequency
according to a given form,
f. Willing to complete the necessary questionnaires and
undergo sonographic investigation of the bladder at
beginning and end of the study and
g. Consented to restrain from change of pharmacological
and non-pharmacological bladder related therapies during the study.
Exclusion criteria were
a. Patients with other known causes for increased frequency of micturition,
b. With cardiac decompensation,
c. Those subjects, who had changed their bladder inuencing drugs within the past four weeks,
d. Those subjects, who had practiced Yoga within last 3
months.
Signed informed consent was obtained from all patients
who participated in the study.
Ethical clearance for the proposal and the informed consent form in German language was obtained by the Ethical
committee (IEC) of S-VYASA University, which included two
members from Germany (one clinician and one administrator) who were present during the IEC meeting, to satisfy the
ethical requirements in their country.

Design
This was an open arm study with prepost design.

426

Procedures
The details of the intervention were explained explicitly in
German language and all queries answered before taking
the signature on the consent form. All MS patients admitted
to hospital, who fullled the inclusion and exclusion criteria were included in the study during a period of 4 months
(AprilJuly 2010). Yoga practices were taught by a certied
Yoga therapy doctor of S-VYASA University, invited by KWA
Stift Rottal, Bad Griesbach Germany.
Participants were sitting on a chair, practicing Yoga in
a calm and well ventilated room with a background soothing music. The practice was performed twice a day, i.e.
one hour in group and another hour individually for 21 days
(all days of week). In addition to Yoga therapy, all subjects underwent standard medical and rehabilitative care
which included medication (none for bladder symptoms)
prescribed by a neurologist specialised in multiple sclerosis. They all had a planned schedule of daily routine
that included (a) physiotherapy (PT) that focussed on balance and gait training, (b) occupational therapy (OT) for
training in activities of daily living, and (c) speech and
swallowing therapy if required. Care was taken to avoid
teaching any bladder related exercises or therapies in the
PT or OT department. The standard care was maintained
and unaltered for all the patients throughout the study
period.

Measurements
All outcome measurements were taken before and after 21
days of intervention.
Micturition check list (MCL)
All patients were given a MCL sheet to note the number of
visits to toilet. Total number of visits per day (8 a.m. on previous day till 8 a.m. the next day) was considered as the MCL
score. The average of the MCL scores of 3 days before Yoga
intervention started and that of 3 days after 3 weeks of intervention were used as pre and post-MCL scores respectively,
for analysis.
Post void residual urine volume (PVR)
Ultrasonographic measure was used for assessment of residual urine volume. Bladder volume measurements were
performed at the same time of the day immediately after
emptying the bladder. The measurements were done at
baseline and after 21 days of intervention.
Incontinence impact questionnaire-7 (IIQ-7)31
IIQ-7 consists of 7 questions related to the psychological
impact of their incontinence. Each question offers 4 choices:
not at all (0), slightly (1), moderately (2), greatly (3). Total
score on IIQ-7 ranges from 0 to 100. The average score is
multiplied by 33.3 to get a scale ranging from 0 to 100.

N.J. Patil et al.

multiplied by 33 1/3, to get a scale ranging from 0 to 100.
UDI-6 had a Cronbachs alpha of 0.93.

Yoga intervention
The integrated Yoga module for multiple sclerosis with
hyperactive bladder was designed by Yoga professionals of
S-VYASA in discussion with the attending neurologist based
on concepts taken from the traditional Yoga scriptures
(Patanjali Yoga Sutras, Yoga vasishtha and Upanishads) that
highlight a holistic life style for positive health at physical,
mental, emotional and intellectual levels.32 The integrated
Yoga module included the following practices: Yogic sukshma
vyayama (loosening and strengthening practices): these are
safe rhythmic repetitive stretching movements synchronized
with breathing that mobilize the joints and strengthen the
muscles.
Relaxation techniques: two types of guided relaxation
techniques were interspersed in the module. (1) Each physical practice was followed by a guided relaxation for the
stretched part. Guided relaxation done with awareness after
each movement is an important component of Yoga that promotes self healing by providing deep conscious rest to the
tissues.
(2) Deep relaxation technique (DRT): this is a 15 min
guided relaxation has four fragments. After guiding the
relaxation from toe to waist the person chants aaa sound
and sends the vibrations to these relaxed parts. Then the
instructions to relax the waist up to the neck are followed
by uuuu chanting. This is followed by relaxation of head
region and mmm chanting.
Then the entire body is scanned internally from toes to
head followed aaa uuu mmm chanting which is repeated 3
times to feel the resonance in the whole body.
Kapalbhati kriya: this is a breath cleansing technique
that promotes alert state of mind. This involves active quick
exhalations simulating the sound of a bellow interspersed
with passive inhalations at a frequency of 30 strokes/min
and 1 min rest. Repeat for 2 more rounds.
Bandhas: Moola bandha (anal lock) refers to strong contraction of the pelvic oor muscles with cessation of breath,
and Uddiyana bandha (abdominal muscle lock) that is done
by sucking in the abdominal wall while holding the breath
after complete exhalation.
Pranayama: the practice of voluntary regulated breathing while the mind is directed to the ow of breath is called
pranayama. These practices promote autonomic balance
through mastery over the mind Nadishuddi pranayama refers
to alternate nostril breathing.33
Counselling: these sessions were aimed at understanding
the need for life style change and preventing the relapses by
yogic self management of psychosocial stresses. Yogic concepts of health and disease, role of mind in the course of
MS. They also explained how mind can heal the body through
Yoga.

Data analysis
Urogenital distress inventory-6 (UDI-6)31
This consists of 6 questions related to urogenital distress.
Each question offers 4 choices: not at all (0), slightly
(1), moderately (2) and greatly (3). The average score is

SPSS version 16 was used for statistical analysis. Data were

normally distributed. Paired samples t-test was used to compare the pre post values.

Effect of integrated Yoga on neurogenic bladder dysfunction in multiple sclerosis

Table 1

Yoga module.

Sl. no. Name of practice

1
2
3

4
5
6
7
8

427

Duration in
minutes

Hands in and out breathing

3
Hand stretch breathing
6
Yogic sukshma vyayama Loosening 15
exercises 3 repetitions each
i. Neck movements
ii. Forward and backward bending
iii. Ankle exion and extension
iv. Spinal twist
v. Shoulder rotation
vi. Movements of all small joints.
Moola bandha
5
Moola bandha + Uddiyana bandha
5
Kapalbhati forced nostril breathing 6
Nadishuddi pranayama
5
Deep relaxation technique (DRT).
15
Total duration

Figure 1 MCL (micturition check list) 24 h, MCL daytime and

night before and after intervention.

Micturition Check List (MCL)

MCL (24 h) reduced signicantly (p = 0.001) from 15.27 2.9
to 11.46 1.57 with 25% improvement. Table 1 shows number of micturitions, split in day, night and 24 h, before and
after intervention. Night time micturitions were reduced
more than the day time micturitions (44% vs 16%), leading to
mean reduction of 25% (Fig. 1). The mean frequency reduced
both during the day and night.

60

Results
Eleven patients (10 females, 1 male) with MS participated in
the study. The mean age was 46.7 11.24 years. The mean
duration of the disease was 17.18 9.51. Table 2 shows the
results of 21 days of Yoga intervention.
There was signicant (p < 0.01) improvement in all variables after Yoga intervention.

Table 2

Post void residual urine (PVR)

The post void residual urine volume reduced from
88.73 45.8 to 33.36 29.4 with 62.34% change (p = 0.004).
The PVR reduced to nil in three patients (Fig. 2).

Changes in all variables after integrated Yoga.

Serial number
of patients

1
2
3
4
5
6
7
8
9
10
11

IIQ-7

PVR

UDI-6

MCL (24 h)

MCL (Day)

MCL (Night)

Pre

Post

Pre

Post

Pre

Post

Post

Post

Pre

Post

30
52
160
50
99
80
130
35
70
125
145

40
15
92
35
0
35
65
55
0
30
0

56.43
61.38
84.81
47.19
56.43
70.62
84.81
37.62
51.81
84.81
99

37.62
23.43
56.43
18.81
37.62
56.43
75.24
56.43
23.43
66
42.57

49.5
33
33
38.28
60.39
27.39
43.89
49.5
27.39
71.28
87.78

43.89
10.89
27.39
27.39
49.5
16.5
16.5
60.39
16.5
60.39
54.78

14
13
18
16
20
14
12
11
18
14
18

10
10
12
10
13
11
9
14
12
12
13

9
12
14
10
15
10
10
10
12
11
14

7
9
12
8
12
8
7
11
10
10
12

11.5

Mean

88.8

33.5

66.8

44.9

47.4

34.92

15.27

11.46

SD

45.8

29.4

19.3

18.6

19.2

19.22

2.9

1.57

2.02

Pre

Post

5
1
4
6
5
4
2
1
6
3
4

3
1
3
2
1
3
2
3
2
2
1

9.6

3.7

2.1

1.96

1.8

0.8

% Change

62.34

32.77

26.33

25

16.53

43.24

Effect size
Cohens d
p value

1.13

1.17

1.06

1.37

0.83

1.37

0.004

0.003

0.006

0.001

0.020

0.001

Abbreviations: MCL: micturation check list = no. of visit to the toilet in a day, PVR: ultrasonographic measure of post void residual urine
volume (ml), IIQ-7: incontinence impact questionnaire-7, UDI-6: urogenital distress inventory-6. SD: standard deviation.

428

Figure 2 PVR (post void residual) urine volume before and

after Yoga intervention.

N.J. Patil et al.

reduction in the PVR (62.3%), the number of visits to the
toilet in a day (26.33%), and scores on IIQ-7 (32.77%) and
UDI-6 (26.33%) after 3 weeks of bladder specic Yoga intervention (as adjunct to PT and OT) in a German neuro-rehab
hospital. One patient showed aggravation of all measures
which was due to a relapse of the disease leading to generalized worsening of her physical condition. This deterioration
did not appear to be related to the practice of Yoga as per
observations of the patient and the neurologist.
Strength of the study: this is the rst pilot study that has
tested the acceptability and usefulness of a specic module of integrated Yoga for bladder symptoms in German
patients with MS.
Weaknesses of the study: the small sample size and
absence of a control group were the major weaknesses of
this study. As Yoga was used as adjunct, the effects of
other general rehabilitation procedures that with established benets in MS patients cannot be excluded without
comparing with a control group. The results suggest that
the specic Yoga-therapy module may have contributed to
this improvement as special care was taken to avoid the use
of any medication specic to NBD. Another limitation was
the duration of the intervention. As, MS is a disease with
exacerbations and remissions, although these cases were in
remission and stable, long term follow up studies are necessary to prove the efcacy. The program being supervised
by a visiting faculty from India might also have had a positive psychological impact. This may be taken note of while
designing future studies.

Figure 3 IIQ-7 (incontinence impact questionnaire-7) before

and after Yoga intervention.

Comparisons

Figure 4 UDI-6 (urogenital distress inventory-6) before and

after Yoga intervention.

Incontinence impact questionnaire-7 (IIQ-7)

The IIQ-7 score reduced (p = 0.004) from 66.81 19.31 to
44.91 18.65 with 32.77% change, (p = 0.003) (Fig. 3).

Urogenital distress inventory-6 (UDI-6)

UDI-6 reduced from 47.4 19.21 to 34.92 19.22 with
26.33% change (p = 0.006) (Fig. 4).

Discussion
This open arm pilot study on eleven MS patients with neurogenic bladder dysfunction has shown signicant (p < 0.05)

There are two earlier studies on Yoga in patients with MS.

Velikonja et al.23 randomized 20 MS patients in Slovenia
into two groups [sports climbing (SC) and Yoga]. 10 weeks
of intervention showed signicant (p = 0.015) reduction in
fatigue (32.5%) after SC, and Yoga helped in increasing selective attention performance (17%, p = 0.005). There were
no signicant improvements in spasticity, executive function or mood in both groups. Oken et al.26 randomized 69
patients with MS to three groups viz. Yoga, stationary bicycling exercise and wait list control. 6 months of weekly
intervention showed reduction in fatigue (increased vitality)
with no changes in cognitive functions or mood. A study on
integrated Yoga in neurorehabilitation (epilepsy, depression,
and post-traumatic stress disorder) has shown signicant
improvement in quality of life and sleep.34
To the best of our knowledge, the present case series
is the rst one to document the effect of Yoga for bladder
symptoms in patients with MS. There are studies that have
documented the results of conventional PT protocols for NBD
in MS. In a well designed RCT McClurg et al.8 randomized
30 female MS patients with bladder dysfunction into three
groups [Group 1: Pelvic Floor Training and Advice (PFTA);
Group 2: PFTA and EMG Biofeedback; and Group 3: PFTA,
EMG Biofeedback and NMES (Neuromuscular Electrical Stimulation)]. Assessments at 9th week showed that the group
that had all three interventions had signicantly superior
benet as measured by the number of leaks and pad test
than the other two groups. Although there was a similar pattern of improvement in Incontinence Impact Questionnaire

Effect of integrated Yoga on neurogenic bladder dysfunction in multiple sclerosis

(IIQ) the result was not statistically signicant. In comparison, our present study has shown signicant improvement
in IIQ-7 within 3 weeks of Yoga intervention which is a more
cost effective program.
In another publication in 74 MS patients with urinary tract
dysfunction, McClurg et al.9 reported 48.6% reduction of
PVR at 9th week and 53.8% at 24th week following combined treatment of PFT, EMG biofeedback and NMES. Our
present study has shown 62.3% reduction in PVR within 3
weeks. In addition to this reduction in PVR, the present study
has also shown signicant reduction in other urogenital variables, i.e. reduction in the number of visits to toilet in 24 h
(from 15.27 to 11.46) and scores on UDI-6 that resulted in
improved quality of sleep. However, as the present study
lacks a control group, a randomized control study using the
same module of Yoga may add scientically acceptable evidence for the superiority of Yoga over the techniques of
physiotherapy for bladder symptoms in MS patients.

Mechanism
The mechanism of the improvement observed after Yoga
needs further exploration. The urge incontinence in MS is
attributed to an imbalance of the autonomic nervous system
and/or spastic over activity of the detrusor and sphincter
muscles.35 Although we do not have data from our study,
the study by Velikonja et al.23 did not nd any change in
spasticity after 10 weeks of Yoga intervention in patients
with MS. In a survey on 2529 MS patients, high levels of
psychosocial stress was reported to be one of the adverse
factors that contribute to the severity and progression of the
disease.25 In addition, it has also been shown that stress is
an important precipitating factor for the specic symptom
of incontinence in MS patients.36 Hence we may postulate
that the improvement in incontinence after Yoga may be
due to its inuence on ANS. There are several studies that
have shown that integrated Yoga program can reduce psychological stress levels and improve ANS balance.34,37,38 A
few studies have demonstrated that, integrated Yoga that
included yogic guided relaxation and Nadishuddi pranayama
(incorporated in the present Yoga module for NBD) can
improve sympathovagal balance.33,34,38 Moola bandha (anal
lock) was another important component of this specic
Yoga module for NBD. This is similar to the commonly used
pelvic oor exercises (PFE) which is known to have positive
impact on bladder dysfunction in MS patients.39 In comparison to PFE, the Yogic Moola bandha has the components of
breathing and mindfulness relaxation that helps in better
neuromuscular co ordination. Thus the effect of Yoga seems
to be traceable to three factors, i.e. balancing the ANS,
stress reduction and better neuromuscular co-ordination of
the pelvic oor muscles.

Implications of the study

All patients expressed their interest in continuing Yoga at
home because of the psychological and physical benets
they experienced within 3 weeks. Yogas holistic approach
focuses on mindbody intervention strategies that promote
self healing12 ; it is feasible, cost effective and has negligible
side effects compared to other treatments.4042 Thus it has

429

the potential to be incorporated as a useful module into the

conventional protocol for NBD in MS around the globe.

Suggestions for future research

RCT with adequate sample size and long term follow up is
recommended. Inclusion of subjective and objective measures to assess stress levels while designing future RCTs may
throw light on the proposed mechanisms.

Conclusion
This pilot study in a neuro-rehab hospital points to the safety
and effectiveness of using a specic module of integrated
Yoga for bladder symptoms as an adjunct to standard care
in German patients with neurogenic bladder dysfunction
in multiple sclerosis. However, randomized controlled trials with adequate sample size and long term follow up are
necessary to conrm these ndings.

Conict of interest
None of the authors have conict of interest.

Acknowledgements
We acknowledge all the participants. We thank Dr. Nagendra HR the Vice chancellor, Dr. Naveen KV the Joint director
research, Dr. Kulkarni R and Dr. Pradhan B the biostatisticians of S-VYASA University, Bengaluru for their guidance at
all stages. We thank Dr. Ganesan M for his help in revising
the manual. We thank the staff and management of SVYASA
Yoga University, Bengaluru and KWA, Klinik Stift Rottal, Bad
Griesbach, Germany for their co-operation.

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