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Acta Psychiatr Scand 2007: 116: 226232 Copyright  2007 The Authors

All rights reserved Journal Compilation  2007 Blackwell Munksgaard


DOI: 10.1111/j.1600-0447.2007.01032.x ACTA PSYCHIATRICA
SCANDINAVICA

Yoga therapy as an add-on treatment in the


management of patients with schizophrenia
a randomized controlled trial
Duraiswamy G, Thirthalli J, Nagendra HR, Gangadhar BN. Yoga G. Duraiswamy1, J. Thirthalli1,
therapy as an add-on treatment in the management of patients with H. R. Nagendra2, B. N. Gangadhar1
schizophrenia a randomized controlled trial. 1
Department of Psychiatry, National Institute of Mental
Health and NeuroSciences (NIMHANS), Bangalore
Objective: Treatment of schizophrenia has remained unsatisfactory 560029, India and 2Swami Vivekananda Yoga
despite the availability of antipsychotics. This study examined the Anusandhana Samsthana (Deemed University),
ecacy of yoga therapy (YT) as an add-on treatment to the ongoing Banaglore 560019, India
antipsychotic treatment.
Method: Sixty-one moderately ill schizophrenia patients were
randomly assigned to YT (n 31) and physical exercise therapy (PT;
n 30) for 4 months. They were assessed at baseline and 4 months
after the start of intervention, by a rater who was blind to their group
status. Key words: yoga; physical exercise; schizophrenia
Results: Forty-one subjects (YT 21; PT 20) were available at the Jagadisha Thirthalli, Associate Professor, Department of
end of 4 months for assessment. Subjects in the YT group had Psychiatry, National Institute of Mental Health And
signicantly less psychopathology than those in the PT group at the Neuro Sciences (NIMHANS), PO Box No. 2900, Hosur
end of 4 months. They also had signicantly greater social and Road, Bangalore 560029, India.
occupational functioning and quality of life. E-mail: jagatth@yahoo.com
Conclusion: Both non-pharmacological interventions contribute to
reduction in symptoms, with YT having better ecacy. Accepted for publication April 11, 2007

Significant outcomes
Yoga therapy, as an add-on treatment along with antipsychotics is benecial in psychopathology and
other outcome measures in schizophrenia.

Limitations
Single-blind nature of the study: only the rater was blind to the group-status.
Intent-to-treat analysis could not be performed.
Extrapyramidal symptoms were the only side-effects systematically assessed.

course even while on medication (7). Furthermore,


Introduction
while the traditional antipsychotics have limita-
Schizophrenia is one of the leading causes of tions like extra pyramidal symptoms (EPS) and
disability among young adults (1). It creates a huge tardive dyskinesia, the newer antipsychotics result
economic burden for society (2). Current treatment in obesity, diabetes, and hyperlipidemia. Hence,
modalities have certain limitations: About 30% of there is search for alternative methods of treatment
patients with schizophrenia are refractory (3); in schizophrenia.
negative symptoms like anhedonia, apathy and Yoga has signicant eects in positive mental
amotivation can be worsened by medication and health (8, 9). It has been shown to be useful in
coexisting depression (4) and there are no eective treating psychiatric disorders including major
remedies for primary negative symptoms (5, 6); a depressive disorder (10), dysthymia and alcohol-
majority of the patients has relapsing and remitting dependence syndrome (11). Its ecacy has not

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Yoga therapy for the management of patients with schizophrenia

been examined in schizophrenia. Several features study period. Sixty-one patients were recruited into
of yoga make it an attractive option in schizo- the study between March 2003 and August 2004.
phrenia: It has been shown to improve cognitive
functions in normal individuals (1215); it is also
Assessments
useful in reducing stress (9). Since schizophrenia is
associated with cognitive decits, and relapse of Psychopathology was assessed using Positive And
schizophrenia is associated with stress (16, 17), Negative Syndrome Scale for Schizophrenia,
yoga may be particularly helpful in this condition. PANSS (23). An MD trainee (GD) with a 2-year
Furthermore, yoga has positive eects on the experience in clinical psychiatry administered the
blood glucose, cholesterol and total lipids (18, PANSS. He was trained in administering PANSS
19). This aspect makes it an interesting add-on using eight training videos. The subjects were also
treatment, as a majority of schizophrenia patients rated on the following: (a) social and occupational
treated with antipsychotic medication suer from functioning was assessed using Social and Occu-
dyslipidemia and obesity (20). pational Functioning Scale [SOFS (24)]; (b) side-
eects were assessed using the Simpson Angus
Scale for Extrapyramidal Symptoms (25) and
Aims of the study
Abnormal Involuntary Movement Scale [AIMS
The primary objective of this study was to examine (26)]; (c) quality of life was assessed using WHO
the eect of 4 months of yoga therapy (YT) as an Quality of Life BREF Version, WHOQOL-BREF
add-on treatment on the psychopathology of (27). All assessments were done twice before
schizophrenia patients. The secondary objectives randomization and after 4 months. After the
were to examine its eects on the quality of life and baseline assessments were done, subjects were
social functioning. To control for changes due to randomly assigned, using a computer-generated
non-specic factors, the eect of yoga was com- random number table, to receive either YT (n
pared to that of physical training (PT). Subjects 31) or PT (n 30) for the next 4 months. The two
with schizophrenia were randomized to receive YT groups were similar in demographic and illness
or PT as add-on treatments to their antipsychotic characteristics and in the psychopathology ratings
drugs, and their clinical outcome was evaluated at baseline (Table 1).
after 4 months.
Training
Material and methods A therapist trained to teach both YT and PT
taught the subjects in their allocated treatment
Subjects
groups. He taught yoga and exercise in separate
The subjects for this study were schizophrenia
Table 1. Demographic profile, illness parameters and psychopathology scores of
patients attending the out-patient and in-patient
subjects in Y.T. and P.T. groups
services of National Institute of Mental Health and
Neuro Sciences, Bangalore, India. They belonged Variables YT group PT group t-value P-value
to the age group of 1855 years. Patients with
Age, years 32.53 7.9 31.30 7.9 0.38 0.70
severe physical ailments like recent and decompen- Sex ratio*, M : F 19:12 23:7 1.68 0.27
sated myocardial infarction, fracture, seizure dis- Unmarried : married* 24:7 19:11 1.45 0.27
orders, mental retardation or comorbid substance Duration of illness (months) 99.1 96.1 81.1 81.4 0.82 0.41
CGI illness severity score 4.8 0.8 5.2 0.9 )1.55 0.12
dependence (except nicotine dependence) were Antipsychotic dosage 469.7 195.7 476 205 )0.12 0.90
excluded. Only patients with Clinical Global PANSS scores
Impression Severity Scale (21) score of 4 or more Positive score 17.03 6.5 20.17 6.8 )1.8 0.07
and who were cooperative for YT were included. Negative score 21.31 5.7 22.83 6.3 )0.78 0.43
Depression subscore 10.54 3.3 10.33 3.9 0.23 0.82
Written informed consent was obtained from all Anergia subscore 9.61 2.6 10.33 3.3 0.93 0.36
the participants. At least one family member SOFS score 13.1 10.5 14.5 6.6 0.51 0.68
accompanied each subject; the family members Total AIMS score 4.2 7.9 2.2 3.2 1.2 0.22
helped the subjects to understand and consent Total Simpson Angus score 2.0 1.8 1.7 2.3 0.50 0.61
Quality of life
for the study. The diagnosis was conrmed by Psychological QOL 49.3 19.8 48.4 19.1 )0.71 0.47
using Structured Clinical Interview for DSM-IV Physical QOL 52.9 21.5 56.5 14.8 0.86 0.93
[SCID-IV (22)]. All patients were on antipsychotic Social QOL 49.7 22.1 56.6 22.1 )1.2 0.21
medication for several months, and there was no Environmental QOL 52.0 19.9 55.7 15.9 0.73 0.47

change in their medication dose for at least 4 weeks All values except * are mean standard deviation; v2-value; Chlorpromazine
before their entry into the study and through the equivalents in mg/day.

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Duraiswamy et al.

groups. The yogasanas were from the integrated Table 2. Comparison of demographic profile, illness parameters and psychopa-
thology scores between completed and dropped out patients
yoga treatment developed by Swami Vivekananda
Yoga Anusandhana Samsthana (SVYASA) (28). It Completed Dropout
was a 1-h programme consisting of (a) Sithilikar- Variables (n 41) (n 20) t/v2-value P-value
ana Vyayama; (b) asanas including surya namaskar;
Yoga : exercise 21:20 10:10 0.01 0.93
(c) breathing practice; and (d) relaxation tech- Age, years 30.41 7.9 34.3 6.6 )1.8 0.06
niques. The ratio of Vyayama:asana:breathing Sex ratio*, M : F 28:13 14:6 0.01 1.00
practice was 1:1:1. Meditation was not a part of Unmarried : married* 31:10 12:8 1.5 0.24
Duration of illness (months) 77.7 82.1 119.6 99.1 )1.7 0.08
the yoga module. The exercises were adapted from Antipsychotic dosage 479.0 183.4 460 231 0.34 0.72
the National Fitness Corps Handbook for CGI illness severity score 5.02 0.8 5.05 0.6 )0.11 0.91
Middle High and Higher Secondary Schools (29). Positive score 18.9 7.2 18.0 5.2 0.48 0.62
This 1-h module of PT consisted of brisk walking, Negative score 22.5 6.5 20.8 4.9 1.1 0.27
Anergia score 9.95 3.1 10.0 3.0 )0.05 0.95
jogging and exercises in standing and sitting Depression score 10.7 3.7 9.95 3.4 0.74 0.46
postures and relaxation (see Appendix). The sub- SOFS scores 14.6 10.7 12.5 8.5 0.83 0.41
jects in both groups underwent training for 15 days Total AIMS score 2.7 3.8 2.3 2.2 0.28 0.77
(1 h a day; 5 days a week for 3 weeks). Both Total Simpson Angus Scale score 14.6 10.7 12.5 5.8 0.83 0.41

training sessions were held in the same therapy hall The difference was not significant (P < 0.05) All values except * are mean SD;
at dierent time points of the day. Of the 61 v2-value; Chlorpromazine equivalents in mg/day.
recruited, 16 (26%) did not complete the training.
The reasons for non-completion included disinter-
est and long distance from the hospital for out-
Results
patients. The subjects who completed the training
period continued to practice their respective ther- The PANSS total and subscores signicantly
apies for the next 3 months in the same sequence dropped from pre- to post-assessment in both the
and for the same duration as in the training groups. Likewise, signicant reduction in SOFS
sessions. The therapist reviewed the adherence and total score occurred in both the groups. On the
the correctness of yoga or physical exercises once a other hand, QOL scores changed signicantly only
month; the subjects were also reminded through in the YT group (Table 3 and Fig. 1). ancova
telephone and letters about practicing the exercises. results indicated that the scores diered signi-
cantly between groups at the end of 4 months after
controlling for the corresponding baseline scores,
Follow up
age, sex, marital status, duration of illness, dose of
All but four subjects who completed 3 weeks of antipsychotics and the type of antipsychotic. The
training were available for follow-up assessment subjects in the YT group scored signicantly lower
after 4 months. The nal sample of 41 patients (21 in dierent symptom dimensions (except positive
in YT and 20 in PT) and the remaining 20 from the syndrome score) and PANSS total score. They also
original sample were comparable on demographic scored signicantly better on SOFS and QOL
and clinical variables. Comparable proportions scores. There were no serious adverse events such
(33% each) of patients allocated initially to each as delirium, confusion, suicidality or any serious
of the two groups were available for the nal physical complications in either group during the
sample (Table 2). four-month period.

Statistical analysis Discussion


Statistical Package for Social Sciences version At the end of 4 months schizophrenia patients in
10.0.1 (SPSS Inc., 1999) was used for the analysis. the YT group showed better ratings than those in
The group-dierences were analysed using inde- PT on dierent symptom dimensions of schizo-
pendent sample t-test. Paired t-test was used to phrenia. They were also better in their social and
analyse the prepost changes. The ratings at the occupational functions and quality of life. These
end of 4 months were compared between the were statistically signicant after controlling for
groups by using analysis of covariance (ancova). the eects of baseline ratings, age, sex, marital
Age, sex, marital status, duration of illness, dose of status, as also duration of psychosis besides the
antipsychotics (in CPZ-equivalents), the type of type and the dosage of antipsychotics. Not only
antipsychotic (typical or atypical) and the corres- were the dierences statistically signicant, they
ponding baseline scores were used as covariates. were substantial too. For instance, the eect-size
a was xed at 5% (P < 0.05). for the dierence in mean total PANSS score at the

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Yoga therapy for the management of patients with schizophrenia

Table 3. Analysis of covariance of scores at the end


of 4 months YT group* PT group*

Variable Baseline 4 month Baseline 4 month F-value P-value

PANSS
Positive 18.19 7.1 12.19 5.9 19.10 7.2 14.60 5.9 1.40 0.24
Negative 21.90 6.2 14.19 5.1 24.05 6.9 19.75 7.3 10.1 <0.01
Depression score 10.54 3.3 5.71 2.3 10.93 3.3 8.60 4.04 8.5 <0.01
Anergia score 9.6 2.6 6.9 2.6 10.33 3.3 9.30 3.6 4.7 0.03
Total 76.14 16.9 51.05 16.4 83.85 20.2 66.00 23.2 5.0 0.03
SOFS score 14.62 11.4 7.05 8.0 14.85 10.2 11.40 9.9 7.98 <0.01
QOL
Physical 53.57 24.0 65.82 12.8 54.10 14.4 56.60 18.1 4.4 0.04
Psychological 51.79 20.2 66.87 17.5 44.79 17.4 49.17 19.0 11.4 <0.01
Social 53.17 24.1 68.45 20.4 55.83 21.5 47.70 23.0 7.8 <0.01
Environmental 55.65 20.7 66.22 15.2 53.13 14.8 48.13 18.6 12.8 <0.01
AIMS 3.2 4.3 1.3 2.1 2.3 3.3 1.5 2.4 0.54 0.46
Simpson Angus Scale 2.0 1.9 1.1 1.2 1.7 2.4 1.6 1.8 3.02 0.09

*Mean SD; d.f., 1,32.

Positive Syndrome Negative Syndrome PANSS-Depression Anergia PANSS-Total


26 26 12 12 100
22 22 10 10 85
18 18 8 8 70
14 14 6 6 55
10 10 4 4 40
BL 4M BL 4M BL 4M BL 4M BL 4M
PANSS Scores

SOFS Physical QOL Psychological QOL Social QOL Environmental QOL


16 72 72 72 72
13 65 65 65 65
10 58 58 58 58
7 51 51 51 51
4 44 44 44 44
BL 4M BL 4M BL 4M BL 4M BL 4M
SOFS and QOL Scores

YT PT

Fig. 1. Charts showing the changes in psychopathology, social and occupational functioning and quality of life in both groups over
time. BL, baseline; 4M, 4 months.

end of 4 months was 0.74 and that for SOFS score expectation-bias. In 74% of the subjects medica-
was 0.48, suggesting that the dierences were tions and their dosages were unchanged for at least
moderate-to-large. 8 weeks before entering the study, and in all
It appears that the addition of YT oers benets subjects there was no change for at least 4 weeks.
across several dimensions in schizophrenia. How- Medication was changed during the study period in
ever, no signicant dierence was seen between the only two patients (one from each group) as they
groups in the positive syndrome score on PANSS. had exacerbation of symptoms. Thus the results
This could be because the positive symptoms were are not attributable to changes in antipsychotic
already very low (mean total positive syndrome medications. The trainer was qualied to train
score 18.6) achieved perhaps by the use of both forms of treatments. Furthermore, the exer-
antipsychotics. At this low level of positive symp- cises taught in the PT group were very simple.
toms, further improvement from YT could not be Having a separate physical therapist for the PT
demonstrated. group would not have inuenced the quality of
This is the rst study to nd the clinical eects training, but would have introduced a confounding
specically of addition of YT in schizophrenia in a factor in the form of therapist variable. Use of the
randomized controlled design. The rater was blind same trainer to train both the groups for an equal
to the group status of the patients at both stages of duration of time and for equal number of days
the assessment. The rating on the second occasion avoided this confound.
was done without referring to the previous scores. Some other methodological issues should be
These steps minimized the scope for any rater- or considered while interpreting the results. It was a

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single-blind study. In the YT group, the knowledge 5. Siris SG. Diagnosis of secondary depression in schizo-
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1991;17:7598.
had a positive eect. This eect can only be 6. Stahl SM, Buckley PF. Negative symptoms of schizo-
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not practical, as subjects in India are quite aware of Scand 2007;115:411.
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have been in order. However, this could not be 8. Becker I. Uses of yoga in psychiatry and medicine. In:
done because the subjects who dropped out of the Muskin PR, ed. Complementary and alternative medicine in
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(30)] was not made. PANSS scores formed the Antidepressant ecacy of sudarshan kriya yoga (SKY) in
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reliability with a senior psychiatrist would have 11. Nespor K. Treatment needs of alcohol dependent women.
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the respective treatments, it is possible that the akshmi R. The integrated approach of yoga; a therapeutic
level of adherence could have varied in the subjects. tool for mentally retarded children: a one year controlled
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A quantitative assessment of this by way of a 13. Vani PR, Nagarathna R, Nagendra HR. Progressive increase
written log could have thrown useful light on this. in critical icker fusion frequency following yoga training.
At this stage, it is dicult to comment on the Indian J Physiol Pharmacol 1997;41:7174.
possible mechanism by which YT helps in schizo- 14. Naveen KV, Telles S. Yoga and psychosis: risks and
phrenia. There is evidence that yoga helps in therapeutic potential. J Indian Psychol 2003;21:1.
15. Manjunath NK, Telles S. Improved performance in the
positive mental health (9). Yoga also reduces Tower of London tests following yoga. Indian J Physiol
stress (10). Stress is associated with the worsening Pharmacol 2001;45:351354.
of schizophrenia symptoms (31, 32) and, reduction 16. Ayuso-Gutierrez JL, Del rio vega JM. Factors inuencing
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17. Norman RM, Malla AK, Mclean TS et al. An evaluation of
include measures of stress also to examine this issue. a stress management program for individuals with schi-
This is particularly important, as there is a good zophrenia. Schizophr Res 2002;58:293303.
body of literature that suggests that regular phys- 18. Bijlani RL, Vempati RP, Yadav RK et al. A brief but
ical exercise also mitigates the eects of stress (33). comprehensive lifestyle education program based on
In conclusion, this study showed YT is benecial yoga reduces risk factors for cardiovascular disease and
diabetes mellitus. J Altern Complement Med 2005;11:267
in schizophrenia as an add-on treatment. This 274.
benet is seen across several dimensions of the 19. Innes KE, Bourguignon C, Taylor AG. Risk indices associ-
schizophrenia outcome. It remains to be estab- ated with the insulin resistance syndrome, cardiovascular
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20. Paton C, Esop R, Young C, Taylor D. Obesity, dyslipidae-
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Appendix
Yoga therapy and physical exercise modules
Appendix A The integrated yoga therapy module (28); duration: 1 h

I. Shithileekarana vyayama (loosening exercises)


(1) Jogging-2 min
(2) Mukha dhouti (Cleansing Through A Single Blast Breath) 30 sec
(3) Twisting 1 min
(4) Hand stretch breathing 2 min
(5) Forward & backward bending 1 min
(6) Tiger Breathing: nine rounds 1 min
(7) Cycling 1 min
(8) Sashankasana (moon posture) breathing 1 min
(9) Dandasana (staff posture)- 30 sec
II Asanas:
II A. Suryanamaskar (sun salutation) (12 rounds) 6 min
II B. Instant relaxation technique (IRT) 1 min
Shavasana (corpse posture) this involves progressively tensing all the muscles of the body in 15 s, relaxing all of them instantaneously and staying relaxed for 45 s
II C. Sitting posture asanas:
II C.1. Vakrasana (twist posture) 30 s
II C.2. Prasarita pada paschimatanasana (stretching of back with stretched legs) 1 min
II C.3. Ustrasana (camel posture) 1 min
II D. Prone posture asanas:
II D.1. Bhujangasana (cobra posture) - 1 min
II D.2. Shalabhasana (locust posture) - 1 min
II D.3. Dhanurasana (bow posture) - 1 min
II E. Supine posture asanas:
II E.1. Sarvangasana (shoulder stand) 3 min
II E.2. Matsyasana (fish posture) 1 min
III Breathing exercises:
III A. Kapalabhati (cleansing breath exercise): 6080 rounds 2 min
III B. Sectional (abdominal, thoracic, clavicular and full yogic) breathing: each 5 rounds 4 min
III C. Nadi-shuddi pranayama (balancing breath): nine rounds 2 min
III D. Nadanusandhana (feeling of inner sound while chanting A, U, M) each 9 rounds 10 min
IV Quick relaxation technique (QRT) 3 min. This involves adopting Shavasana and three phases of observing abdominal movements, synchronizing them with deep
breathing and feeling of energy and collapsing all the muscles

Appendix B Physical exercises: adopted from the national fitness corps. Handbook for middle high and higher secondary schools (29); duration: 1 h*

I Brisk walking 10 min


II Jogging 5 min
III Exercise in standing posture 20 min
III A. Position: attention
(1) Raising the arms forward to the shoulder level palms facing each other, fingers together
(2) Bending arms, bringing fists in the armpits with elbows pushed backward
(3) Returning to position one
(4) Returning to position of attention

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Duraiswamy et al.

III B. Position: attention


(1) Raising the arms forward to the shoulder level fingers together
(2) Flinging arms sideward to the shoulder level, palms facing the ground heel raise
(3) Returning to position one
(4) Returning to position of attention
III C. Position: attention
(1) Stepping the left leg forward and raising the arms forward, palms are kept facing each other and fingers are kept together
(2) Flinging arms sideward at the shoulder level, palms facing the ground and lounging left leg forward
(3) Returning to position one
(4) Returning to position of attention
III D. Position: attention
(1) Raising arms forward to the shoulder level palms facing each other with the fingers together
(2) Raising the arms upward, palms facing each other and with fingers together heels are raised
(3) Returning to position one
(4) Returning to position of attention
III E. Position: attention
(1) Raising arms sideward, shoulder level, palms facing the ground, fingers together
(2) Squatting on toes, flinging arms upwards, palms facing each other
(3) Returning to position one
(4) Returning to position of attention
III F. Position: attention
(1) Jumping feet astride, raising arms sideward, palms facing the ground
(2) Flinging arms upward above head with a clap and jumping feet together
(3) Returning to position one
(4) Returning to position of attention
III G. Position: attention
(1) Hands forward upward rise to shoulder level, palms facing each other, heels raise
(2) Half squat, chest firm (hands bent at elbows) palm downward, middle fingers1/2 distance from each other
(3) Hands sideward raise, knees straight
III H. Position: attention
(1) Hands forward raised, half-knee bent (no gap between knees)
(2) Back to position
(3) Hands sideward raised, half-knee bent
(4) Back to position.
IV. Sitting posture exercises 20 min
IV A. Position: cross-legged sitting, hands slanting
(1) Hands rise over had slowly without bending at elbows, palms touching each other, fingers extended upward
(2) Elbows bend, palms touching head
(3) Same as 1
(4) Back to position
IV B. Position: cross-legged sitting, hands slanting
(1) Hands sideward, upward, elbows bend, palms touch the head
(2) Trunk bend, head downward
(3) Same as 1
(4) Back to position
IV C. Position: cross-legged sitting, hands slanting
Chest firm (i.e. elbow bent palms downward and in front of the chest)
(1) Elbows backward press (chest expanding action)
(2) Hands forward sideward back-ward press
IV D. Position: cross-legged sitting, hands sideward slanting. 13: hands upward, downward swing, clap over head

*The therapist would give 2 min time in between the different exercises with a non-specific instruction, just relax now.

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