Effect of Early Yoga Practice on Post Stroke Cognitive Impairment

Abstract

Background: Post‑stroke cognitive impairment (PSCI) is a clinical entity that encompasses all types of cognitive impairment following
an index stroke. Yoga has been proven to have a beneficial effect not only on cardiovascular risk factors but also on cognition. Hence,
this study explored the PSCI spectrum and assessed the effect of yoga on PSCI. Methods: Forty stroke patients were enrolled in each
yoga and control arm in this study. After the baseline assessment, control arm was administered standard care (including physiotherapy)
while yoga arm received additional yoga intervention. Change in MoCA scores by 2 points in either direction, or FAB scale by 2
points at 6 months was taken as primary outcome, whereas improvement in MRS, CDPSS, CBS, and P300 values were considered
as secondary outcomes. Results: Significant improvements were observed in MoCA, FAB, MRS, CPDSS, and CBS scores in both
groups after 6 months. However, intergroup comparisons revealed better MoCA (25.5, IQR 22‑27) and FAB scores (15.5, IQR 14‑17)
in yoga group compared to controls (24, IQR20‑25.75) and (14, IQR12‑15.75). Equivalent improvement was observed in MRS and
CBS scores in both groups at 6 months; however, CDPSS score was better in yoga group (p = 0.0008). Both P300 amplitudes and
latencies improved in all patients and median P300 amplitudes were significantly better in control group; however, no difference could
be appreciated in P300 latencies improvement on intergroup comparisons at follow‑up. Conclusion: Study reveals that early yoga
intervention in stroke survivors leads to better improvement in cognitive abilities which would further facilitate in early reduction of
caregiver burden.

Full text

Annals of Indian Academy of Neurology ● Volume 26 ● Issue 1 ● January-February 2023 ● Pages ***-***
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EDITORIAL COMMENTARY
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Deepti Vibha, Mamta Bhushan Singh, MV Padma Srivastava,
Rohit Bhatia p-54
Effect of Early Yoga Practice on Post Stroke
Cognitive Impairment
Manshi Kashyap, Nirendra K. Rai, Ruchi Singh,
Ankur Joshi, Abhijit R. Rozatkar, Priyanka V. Kashyap,
Shweta Mishra, Sofia Mudda p-59
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© 2023 Annals of Indian Academy of Neurology | Published by Wolters Kluwer - Medknow 59
Abstract
IntRoductIon
Research and interventions in stroke survivors have primarily
been focused on physical disabilities, while research on
cognitive disabilities due to stroke remains limited.[1]
Post‑stroke cognitive impairment (PSCI) is a clinical entity
that encompasses all types of cognitive impairment following
an index stroke. It may affect up to one‑third of stroke
survivors.[2]
Important structures of brain are connected by various
association bers. Volume of these connections involved
in infarct is an important determinant of cognitive
decline. However, brain has an enormous capacity for
new synaptogenesis, neurogenesis, neuronal circuit
rewiring as well as new circuit formation (neuroplasticity).
Neuroplasticity is maximum during the initial phase of
recovery post‑stroke, and if intervened early, better outcomes
may be obtained.
Yoga has been reported to have benecial eect on traditional
risk factors of stroke as well as cognitive functions.[3‑5] Thus,
a regular practice of yoga and meditation among the patients
with stroke may help in improving the cognitive functions.
Considering these facts, present study was done to evaluate
the spectrum of PSCI, as well as to assess the eect of yoga
on PSCI in ischemic stroke with a recent, within one month
onset.
MateRIaLs and Methods
Design and ethics statement
It was a hospital‑based open‑label, randomized, control
study conducted at a tertiary care center in central India. As
it was a pilot study, a convenient sample size of 30 patients
in each arm (yoga arm and control arm) was planned to be
included. However, considering a drop‑out rate of 25%, nally
40 patients were included in each arm. In accordance with
the Declaration of Helsinki, all participants were recruited
after obtaining approval from the Institutional Human Ethics
Committee.
Background: Post‑stroke cognitive impairment (PSCI) is a clinical entity that encompasses all types of cognitive impairment following
an index stroke. Yoga has been proven to have a beneficial effect not only on cardiovascular risk factors but also on cognition. Hence,
this study explored the PSCI spectrum and assessed the effect of yoga on PSCI. Methods: Forty stroke patients were enrolled in each
yoga and control arm in this study. After the baseline assessment, control arm was administered standard care (including physiotherapy)
while yoga arm received additional yoga intervention. Change in MoCA scores by 2 points in either direction, or FAB scale by 2
points at 6 months was taken as primary outcome, whereas improvement in MRS, CDPSS, CBS, and P300 values were considered
as secondary outcomes. Results: Significant improvements were observed in MoCA, FAB, MRS, CPDSS, and CBS scores in both
groups after 6 months. However, intergroup comparisons revealed better MoCA (25.5, IQR 22‑27) and FAB scores (15.5, IQR 14‑17)
in yoga group compared to controls (24, IQR20‑25.75) and (14, IQR12‑15.75). Equivalent improvement was observed in MRS and
CBS scores in both groups at 6 months; however, CDPSS score was better in yoga group (p = 0.0008). Both P300 amplitudes and
latencies improved in all patients and median P300 amplitudes were significantly better in control group; however, no difference could
be appreciated in P300 latencies improvement on intergroup comparisons at follow‑up. Conclusion: Study reveals that early yoga
intervention in stroke survivors leads to better improvement in cognitive abilities which would further facilitate in early reduction of
caregiver burden.
Keywords: Caregiver Burden Scale, Clinician‑Rated Dimensions of Psychosis Symptom Severity, Frontal Assessment Battery, Montreal
Cognitive Assessment, post‑stroke cognitive impairment, P300, yoga
Address for correspondence: Dr. Ruchi Singh,
Associate Professor, Department of Physiology, All India Institute of Medical
Sciences Bhopal, Madhya Pradesh, India.
E‑mail: ruchi.physiology@aiimsbhopal.edu.in
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licensed under the idencal terms.
For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com
DOI: 10.4103/aian.aian_808_22
Effect of Early Yoga Practice on Post Stroke Cognitive
Impairment
Manshi Kashyap, Nirendra K. Rai, Ruchi Singh1, Ankur Joshi2, Abhijit R. Rozatkar3, Priyanka V. Kashyap4, Shweta Mishra5, Sofia Mudda5
Departments of Neurology, 1Physiology, 2Community and Family Medicine, 3Psychiatry, 4Trauma and Emergency, 5AYUSH, AIIMS, Bhopal, Madhya Pradesh, India
Original Article
Submitted: 02‑Oct‑2022 Revised: 20‑Nov‑2022 Accepted: 25‑Nov‑2022
Published: 04‑Jan‑2023

Kashyap, et al.: Post stroke cognitive impairment and eect of yoga
Annals of Indian Academy of Neurology ¦ Volume 26 ¦ Issue 1 ¦ January‑February 2023
60
Participants
Both male and female patients of ages >18 years with
ischemic stroke onset within past 1 month, having a modied
Rankin scale (MRS) ≤3, who presented either to emergency
or outpatient department of neurology were included.
Participants having pre‑existing dementia or minimal cognitive
impairment (MCI), or those already practicing yoga were
excluded from the study. Patients having severe aphasia
and/or severe dysarthria, cardiopulmonary contraindication
for physical exercise as per the American College of Sports
Medicine or suering from any chronic disease with less
than 2 years of life expectancy, contraindications to undergo
magnitude resonance imaging (MRI) or for yoga/breathing
exercise (major artery stenosis/dissection etc), residing >50 km
from the research site or, pregnant or planning for pregnancy
during the study period or denied consent for the study were
excluded.
Randomization
Block random allocation of patients was done (with a block
size of 4) in two groups (yoga arm, N = 40; and control arm,
N = 40) using SPSS software. All the enrolled patients were
assessed and treated as per standard of care, which included
physiotherapy consultation.
Procedure
Standard tools like modied Rankin scale (MRS), Montreal
Cognitive Assessment (MoCA), Frontal Assessment
Battery (FAB), Clinician‑Rated Dimensions of Psychosis
Symptom Severity (CDPSS), and Caregiver Burden
Scale (CBS) were used to assess the baseline status of the
patients on dierent domains. All other investigations and
brain MRI were done as per standard of care.
P300
Event‑related potential (P300) was measured in neurology
laboratory, as an objective neurophysiological method to
assess cognition. P300 was recorded on neuropack‑4‑evoked
potential machine (Nihon Kohden). Each participant was
seated in a silent room, and electrodes were placed according
to the standard international 10‑20 system. Participants were
made to wear headphone and listen attentively to the auditory
stimuli being presented. Auditory odd‑ball paradigm with
pure tone stimuli was administered binaurally at an intensity
of 70 dB SPL at a rate of 0.5 Hz. The target tone (20%) of
2000 Hz; 80 dB and non‑target (80%) of 1000 Hz; 60 dB, were
presented at random order of occurrence. Patients were asked
to respond only to the infrequently presented target stimuli
by pressing the switch provided to him. After smoothening,
P300 latency values were recorded at the highest peak (i.e.,
maximum wave amplitude) of response curve.
Intervention‑ Hatha yoga
In the rst week of intervention, patients were expected to
attend yoga sessions for at least 5 days, to enable them to
learn the asanas/breathing techniques. Each yoga session was
of about 60 minutes, supervised by trained yoga teacher. This
consisted of 5 minutes of breathing exercises, 10 minutes of
strengthening exercises, 30 minutes of simple yoga asanas,
10 minutes of pranayama, and 5 minutes of meditation. On
rst session, a single 10‑minute lecture on yoga concepts
and possible benefits was described to all new enrolled
patients in yoga group. Standard rehabilitation as per stroke
disability was also oered to these patients along with yoga.
Thereafter, for the next 11 weeks, the intervention was
supervised via tele‑yoga sessions with the help of recorded
video telecast on Google Meet platform for at least 1–2 days
a week. All patients were encouraged to continue practicing
their respective rehabilitation activity for next 3 months with
a frequency of at least 4–5 days/week at home [Figure 1].
Once‑weekly reminders were provided to them with the help
of text messages. Patients replied with a missed call or text
message; and failure to do either of them was considered as
Figure 1: Workflow of the study

Kashyap, et al.: Post stroke cognitive impairment and eect of yoga
Annals of Indian Academy of Neurology ¦ Volume 26 ¦ Issue 1 ¦ January‑February 2023 61
non‑compliance. Patients in the control arm were advised to
continue with physical activity at home as per standard stroke
rehabilitation guideline.
Follow‑up data as per outcome criteria was collected at the
end of 6 months. Standard of care was given to all enrolled
patients as per international guidelines.
Outcome Measures: Primary outcome was dened as change
in MoCA by 2 points in either direction, or FAB scale by 2
points. While secondary outcomes were MRS; CDPSS, CBS,
and P300 values.
Statistical Analysis: Data analysis was done using Statistics
Package for Social Sciences (SPSS) version 16. Microsoft
Word and Excel were used to generate tables and gures. As
per our protocol, only those patients who completed at least
4 weeks of intervention will be nally included in analysis.
Tests of normality were done using Shapiro–Wilk test. Mean
and standard deviation were used for parametric data, whereas
median (interquartile range) was used for nonparametric
data. Unpaired t‑test, Mann–Whitney U‑test (intergroup
comparisons), and Wilcoxon signed rank test (intragroup
comparisons) were used to compare the baseline and follow‑up
variables between the cases and controls. A value of P < 0.05
was considered statistically signicant for all tests.
ResuLts
We included 88 individuals presenting with stroke between
March 2020 and April 2021. Of these, 8 patients left the
proposed intervention within 1 week, and nally 80 patients
were included in this study. Thirty patients out of 40 in yoga
arm (cases) were compliant and completed the intervention.
Two patients withdrew consent after the rst 2 weeks of
intervention as they complained of generalized body‑ache.
Six were non‑compliant and did not do the intervention in
prescribed manner and cited low motivation as the reason for
non‑compliance, while rest two patients were lost to follow‑up.
There was no death in the yoga arm. In the control arm, seven
patients were lost to follow‑up and one patient died during the
study period due to myocardial infarction. All other patients
were compliant to the standard of care. Demographic details
were as given in Table 1A and 1B. Hypertension, diabetes
mellitus, and advanced age (≥60 years) were the most common
risk factors in both the groups. More than 65% patients in
either group presented with motor impairment, 10 (25%)
patients in yoga group and 9 (22.5%) in control group had
aphasia, followed by ataxia in 8 (20%) patients in yoga group
and 9 (22.5%) in control group. There was no signicant
association between right vs. left hemisphere strokes in the two
groups at baseline (p = 0.067). Routine investigations done at
Table 1B: Baseline comparison of radiological
characteristics of the two groups
Radiological Findings Yoga group
(n=40)
Control group
(n=40)
Infarct location
Right hemisphere
Left hemisphere
Bilateral hemispheres
Brainstem
13 (32.5%)
20 (50%)
2 (5%)
5 (12.5%)
22 (55%)
14 (35%)
0 (0%)
4 (10%)
Vascular territory
ICA
ACA
MCA
PCA
VB
1 (2.5%)
2 (5%)
28 (70%)
4 (10%)
7 (17.5%)
1 (2.5%)
0 (0%)
30 (75%)
3 (7.5%)
7 (17.5%)
Watershed infarcts 1 (2.5%) 0 (0%)
Multi‑territorial infarcts 2 (5%) (both
PCA & VB)
1 (2.5%)
(MCA & PCA)
TOAST Classication
Large artery atherosclerosis (LAA)
Cardioembolic stroke (CES)
Small vessel disease (SVD)
Stroke of some other determined
etiology
6 (15%)
0 (0%)
24 (60%)
1 (2.5%)
3 (7.5%)
1 (2.5%)
19 (47.5%)
1 (2.5%)
Data presented as n (%); ICA‑ internal carotid artery; ACA‑ anterior
cerebral artery; MCA‑ middle cerebral artery; PCA‑ posterior cerebral
artery, VB‑ vertebrobasilar
Table 1A: Comparison of baseline characters of the two
groups
Patient Particulars Yoga group
(n=40)
Control group
(n=40)
Mean age 52.85±13.70 55.18±13.24
Male 28 (70%) 31 (66%)
Female 12 (30%) 13 (32.5%)
Educated 30 (75%) 26 (65%)
Uneducated 10 (25%) 14 (35%)
Clinical ndings:
Motor impairment
Aphasia
Sensory impairment
Forced gaze deviation
Hemianopia
Ataxia
Apraxia
Others (dysphagia/dysarthria/
vertigo/dizziness/headache)
31 (77.5%)
10 (25%)
2 (5%)
0 (0%)
0 (0%)
8 (20%)
0 (0%)
19 (47.5%)
27 (67.5%)
9 (22.5%)
6 (15%)
0 (0%)
1 (2.5%)
9 (22.5%)
1 (2.5%)
26 (65%)
Risk factors
Hypertension
Diabetes mellitus
Advanced age (≥60 years)
Smoker
Chronic kidney disease (CKD)
Hereditary/Acquired thrombophilia
Coronary artery disease (CAD)
Family history
Past TIA/stroke
32 (80%)
15 (37.5%)
15 (37.5%)
11 (27.5%)
4 (10%)
0 (0%)
1 (2.5%)
6 (15%)
5 (12.5%)
35 (87.5%)
16 (40%)
15 (37.5%)
10 (25%)
2 (5%)
0 (0%)
2 (5%)
3 (7.5%)
7 (17.5%)
Body mass index
Underweight (BMI <18.5)
Normal BMI 18.5‑24.9)
Overweight (BMI 25‑29.9)
Obese (BMI ≥30)
1 (2.5%)
16 (40%)
22 (55%)
1 (2.5%)
0 (0%)
22 (55%)
15 (37.5%)
3 (7.5%)
Data presented as n (%) and mean±SD; P<0.05 is signicant “*”. P value
for mean age ‑0.563 (Unpaired t‑test)

Kashyap, et al.: Post stroke cognitive impairment and eect of yoga
Annals of Indian Academy of Neurology ¦ Volume 26 ¦ Issue 1 ¦ January‑February 2023
62
baseline yielded comparable results in both the groups. Small
vessel disease was the most common mechanism of stroke in
both groups [Table 1B].
Baseline median total MoCA and total FAB scores were
comparable in both groups (p = 0.075 and P = 0.066,
respectively). However, individual domain scores of naming
and visuospatial domains in MoCA, and mental exibility
and programming domain scores of FAB were signicantly
dierent at baseline [Table 1C]. Baseline CDPSS, MRS, P300
latency, and amplitude were comparable in both groups.
Patients in yoga arm showed significant improvement
in total MoCA scores, total FAB scores, MRS, CDPSS,
and CBS scores (p = 0.0001) from their baseline
scores [Figure 2] [Table 2]. Regarding individual domains
of MoCA, signicant improvements were seen in visuospatial,
attention, abstraction, recall, and orientation. While in
FAB subdomains, all, except environmental autonomy,
showed signicant improvement. Median P300 latencies
also improved at Fz, Cz, and Pz at follow‑up. However,
the changes in P300 amplitudes could not reach a level of
signicance [Table 2].
In control group, also significant improvements were
observed in all the measured scores, i.e., MoCA, FAB, MRS,
CDPSS, and CBS (p < 0.0001) [Figure 2]. Improvement
was observed in all the domains of MoCA except naming
and language. FAB scores improved in all domains. P300
latencies improved at Fz, Cz as well as Pz while amplitude
improvement was seen at Fz and Cz amplitude (p < 0.05)
[Table 3].
Comparison of cases and controls after 6 months of designated
intervention revealed better MoCA scores (25.5, IQR 22‑27)
and FAB scores (15.5, IQR 14‑17) in yoga group compared
to that of control group (24, IQR 20‑25.75) and (14, IQR
12‑15.75) [Figure 2]. The CDPSS score was better in yoga
group after intervention (p = 0.0008). However, dierence in
improvement in the MRS and CBS scores was not statistically
signicant. P300 latencies improved in both yoga and control
group; however, no dierence was seen in follow‑up P300
latencies values when compared between the two groups.
However, the dierence in the median amplitudes at Fz, Cz,
and Pz was signicantly better in control group having higher
amplitude [Table 4].
dIscussIon
Stroke is one of the leading causes of disability, with a
sexual dimorphic presentation having male preponderance.
More than 65% of our patients were male, of middle age
with mean age of 54.01 ± 13.43 years. In present study, we
evaluated a spectrum of post‑stroke cognitive impairment
Table 1C: Baseline comparison of cognitive functions (using MoCA, FAB), CDPSS, and caregiver burden among yoga and
control group
TOOL/SCALE Yoga group (n=40) Control group (n=40) Mann‑Whitney U P
Baseline MOCA
Visuospatial
Naming
Attention
Language
Abstraction
Recall
Orientation
20 (17‑22.25)
2.5 (1‑3)
2 (2‑3)
4 (2‑5)
2 (2‑3)
1 (0‑1)
3 (2‑4)
5 (4‑6)
19 (15.75‑21)
1 (1‑3)
2 (2‑2)
3.5 (2‑4)
2 (2‑2)
1 (0‑1)
3 (2.75‑4)
4.5 (4‑6)
615.5
577.5
608.5
720.50
672
763
793.5
702.5
0.075
0.024*
0.024*
0.431
0.120
0.691
0.946
0.318
Baseline FAB
Conceptualization
Mental exibility
Programming
Sensitivity to interference
Inhibitory control
Environmental autonomy
12 (10‑14)
1 (1‑2)
2 (1‑2)
2 (2‑3)
2 (1‑2.25)
2 (1‑2)
3 (3‑3)
11 (8.75‑11)
1.5 (1‑2)
1 (1‑1.25)
2 (1‑2)
2 (1‑2)
2 (1‑2)
3 (3‑3)
611
752.5
528
564
753.5
751
800
0.066
0.619
0.003*
0.014*
0.632
0.613
1.0
Baseline CDPSS 1.5 (1‑2.25) 2 (1‑3) 663 0.172
Baseline CBS 14.5 (8‑22.25) 18 (12.75‑20) 674.5 0.227
MRS 2 (1‑2) 2 (1‑3) 655 0.134
P300 values Cases (n=37) Controls (n=35) Mann‑Whitney U P
Fz Latency (ms)
Cz Latency (ms)
Pz Latency (ms)
Fz Amplitude (µv)
Cz Amplitude (µv)
Pz Amplitude (µv)
414 (323.25‑504.75)
418 (342.25‑522)
429 (348‑514)
2.13 (0.71‑4.26)
2.09 (0.61‑4.19)
1.76 (0.72‑4.80)
410 (370‑481.5)
413 (368.75‑471.5)
415 (369‑476)
1.83 (0.84‑2.51)
1.98 (0.97‑3.68)
2.05 (1.19‑4.04)
792
789
796
705.5
795.5
766
0.939
0.916
0.969
0.363
0.965
0.743
Data presented as median (IQR); P<0.05 is signicant “*”. Mann‑Whitney U‑test. MoCA‑ Montreal Cognitive Assessment, FAB‑ Frontal Assessment
Battery, CDPSS‑ Clinician‑Rated Dimensions of Psychosis Symptom Severity, and CBS‑Caregiver Burden Scale

Kashyap, et al.: Post stroke cognitive impairment and eect of yoga
Annals of Indian Academy of Neurology ¦ Volume 26 ¦ Issue 1 ¦ January‑February 2023 63
decits in multiple domains, namely visuospatial, language,
naming, programming, conceptualization, mental exibility,
sensitivity to interference, and inhibitory control. Patients
of both yoga arm and the control arm showed signicant
improvements in MOCA and FAB scores after 6 months of
follow‑up [Figure 2], but these scores were better in yoga
Table 2: Intragroup comparison of cognitive functions (using MoCA, FAB), CDPSS, and caregiver burden among the yoga
group
Tool/Scale At baseline (n=30) At follow‑up (n=30) Wilcoxon signed rank z score P
MOCA
Visuospatial
Naming
Attention
Language
Abstraction
Recall
Orientation
20.5 (18‑22.25)
3 (1‑3)
2 (2‑3)
4 (2‑5)
2 (2‑3)
1 (0‑1)
3 (3‑4)
5.5 (4‑6)
25.5 (22‑27)
3 (3‑4)
3 (2‑3)
5 (3.75‑6)
2 (2‑3)
1 (1‑2)
4 (4‑5)
6 (6‑6)
‑4.8
‑3.002
‑1.342
‑3.89
‑1.6
‑3.08
‑4.191
‑3.391
0.0001*
0.003*
0.180
0.0001*
0.102
0.002*
0.0001*
0.001*
FAB
Conceptualization
Mental exibility
Programming
Interference
Inhibitory control
Environmental autonomy
12 (10.75‑14)
1 (1‑2)
2 (1‑2)
2 (2‑3)
2 (1‑2.25)
2 (1‑3)
3 (3‑3)
15.5 (14‑17)
2 (2‑3)
2 (2‑2)
3 (2.75‑3)
3 (2‑3)
3 (2‑3)
3 (3‑3)
‑4.81
‑3.94
‑2.95
‑3.62
‑3.54
‑3.72
0.0
0.0001*
0.0001*
0.003*
0.0001*
0.0001*
0.0001*
1.000
CDPSS 1 (1‑2) 0 (0‑0) ‑4.66 0.0001*
CBS 14 (7.75‑21.25) 3 (1‑6) ‑4.70 0.0001*
MRS 1 (1‑2) 0 (0‑1) ‑4.86 0.0001*
P300 values At baseline (n=28) At follow‑up (n=28) Wilcoxon Signed rank z score P
Fz LATENCY 419.5 (329.5‑548.25) 314.5 (299.25‑345.5) ‑4.55 0.0001*
Cz LATENCY 416.5 (328‑554) 312 (299.5‑354.25) ‑4.361 0.0001*
Pz LATENCY 415.5 (348‑515.5) 312 (299.5‑356.75) ‑4.493 0.0001*
Fz AMPLITUDE 2.06 (0.68‑4.18) 2.30 (1.34‑4.12) ‑0.091 0.927
Cz AMPLITUDE 2.16 (0.60‑5.33) 2.53 (2.03‑3.46) ‑0.182 0.855
Pz AMPLITUDE 1.70 (0.67‑5.26) 1.76 (0.97‑4.07) ‑0.205 0.838
Data presented as median (IQR); P<0.05 is signicant “*”. Wilcoxon signed rank test. MoCA‑ Montreal Cognitive Assessment, FAB‑ Frontal Assessment
Battery, CDPSS‑ Clinician‑Rated Dimensions of Psychosis Symptom Severity, and CBS‑Caregiver Burden Scale
Figure 2: Rain Cloud diagram for cases and controls showing changes in MoCA and FAB scores. Individual points show individual patients, the
bifurcating line between the box plot shows median, the maximum distribution of cloud (grey) is showing the maximum clustering of patients at that level

Kashyap, et al.: Post stroke cognitive impairment and eect of yoga
Annals of Indian Academy of Neurology ¦ Volume 26 ¦ Issue 1 ¦ January‑February 2023
64
arm compared to controls (p = 0.034; P = 0.003) [Table 4].
In other words, greater number of individuals achieved
better scores for both MOCA and FAB in yoga arm, as
depicted in the rain cloud diagram [Figure 2]. Almost all
the domains of MOCA (except naming and language) and
FAB had improvement after 6 months but on intergroup
analysis; this dierence was signicant for the visuospatial,
naming, and recall domains of MOCA and for motor
programming, sensitivity to interference, and inhibitory
control domain of FAB scores (p < 0.05) with yoga arm
[Tables 2, 3, 4]. Yoga is a simple, economical, and easily
acceptable community‑based technique which has shown
promising results as a neurorehabilitation technique in several
diseases including stroke.[6] Schmid et al.[7] have shown the
benecial eects of yoga on the multiple aspects of physical
functioning. Being eective for psychological wellbeing in
addition to the known physical benets makes yoga t as an
additional neuro‑rehabilitative technique among patients of
stroke. Huber et al.[8] in their meta‑analysis tried to explore
the eects of motor‑cognitive interventions on stroke patients
and concluded that benecial eects of such interventions
on the cognitive functions in these patients remain under
explored. As post‑stroke cognitive and gait impairments have
been suggested to share structural and functional roots, stroke
has been linked to Motoric Cognitive Risk syndrome, where
cognitive and gait impairments remain intertwined.[9] Yoga
has shown to improve multiple variables in various population
of neurological disabilities including stroke. Hence, in the
present study we tried to explore benecial eects of yoga
on cognition in stroke patients, and we found improvement
in almost all domains; however, as the median scores in
visuospatial and naming of MOCA and motor programming
of FAB domain were not comparable at baseline, probably
due to dierential hemisphere (right vs. left) involvement
in the two groups, eect of yoga on these domains remains
uncertain. Also, it is noteworthy that for MOCA, we had
already added correction factor (1 point) for subjects with
total duration of formal education 12 years or less, as per the
recommendation.[10] Hence, education is not a confounding
factor in our study.
Secondary outcomes were also achieved in both groups
showing signicant improvement in caregiver’s burden score,
CDPSS score, and MRS scores The improvement in CDPSS
score was signicantly better in the yoga arm compared
to control arm (p = 0.0008). There was no dierence in
improvement in MRS score between the two groups. This is
probably because MRS score is based on functional status,
and there is plenty of existing evidence that any kind of
physical activity, be it yoga or physical therapy, reduces
post‑stroke physical disability and improves function.
Table 3: Intragroup comparison of cognitive functions (using MoCA, FAB), CDPSS, and caregiver burden among the
control group
Tool/scale At baseline (n=32) At follow‑up (n=32) Wilcoxon signed rank z score P
MOCA
Visuospatial
Naming
Attention
Language
Abstraction
Recall
Orientation
19 (15‑21)
1 (1‑3)
2 (2‑2)
4 (2‑4)
2 (2‑2)
1 (0‑1)
3 (2‑4)
4.5 (4‑6)
24 (20‑25.75)
2 (2‑3)
2 (2‑3)
5 (4‑6)
2 (2‑2)
1 (1‑2)
4 (3‑4)
6 (6‑6)
‑4.96
‑3.37
‑1.73
‑4.32
‑1.0
‑4.11
‑3.55
‑4.04
0.0001*
0.001*
0.083
0.0001*
0.317
0.0001*
0.0001*
0.0001*
FAB
Conceptualization
Mental exibility
Programming
Interference
Inhibitory control
Environmental autonomy
11 (8‑13)
1 (1‑2)
1 (1‑1.75)
2 (1‑2)
2 (1‑2)
2 (1‑2)
3 (3‑3)
14 (12‑15.75)
2 (2‑3)
2 (2‑2)
2 (2‑3)
2 (2‑2)
2 (2‑3)
3 (3‑3)
‑4.89
‑4.38
‑4.37
‑3.50
‑2.13
‑2.82
0.0
0.0001*
0.0001*
0.0001*
0.0001*
0.033*
0.005*
1.000
CDPSS 2 (1‑3) 0 (0‑1) ‑4.72 0.0001*
CBS 17 (12‑20) 6 (2‑9.75) ‑4.78 0.0001*
MRS 2 (1‑2.75) 1 (0‑1) ‑4.99 0.0001*
P300 values At baseline (n=29) At follow‑up (n=29) Wilcoxon signed rank z score P
Fz LATENCY 410 (373‑477) 334 (307‑362.5) ‑4.60 0.0001*
Cz LATENCY 414 (370‑471) 326 (310‑364) ‑4.59 0.0001*
Pz LATENCY 416 (370‑474) 326 (310‑359.5) ‑4.53 0.0001*
Fz AMPLITUDE 1.94 (0.87‑2.83) 3.15 (2.17‑4.42) ‑3.27 0.001*
Cz AMPLITUDE 1.98 (0.97‑3.80) 4.11 (2.37‑4.72) ‑2.49 0.013*
Pz AMPLITUDE 2.12 (1.19‑4.00) 3.59 (2.32‑4.16) ‑1.91 0.056
Data presented as median (IQR); P<0.05 is signicant “*”. Wilcoxon signed rank test. MoCA‑ Montreal Cognitive Assessment, FAB‑ Frontal Assessment
Battery, CDPSS‑ Clinician‑Rated Dimensions of Psychosis Symptom Severity, and CBS‑Caregiver Burden Scale

Kashyap, et al.: Post stroke cognitive impairment and eect of yoga
Annals of Indian Academy of Neurology ¦ Volume 26 ¦ Issue 1 ¦ January‑February 2023 65
Also, reduction in caregiver burden in yoga arm was not
signicantly greater than that in the control group. This could
be because the caregivers mostly focused on the burden due
to physical impairment which showed improvement with
early intervention of yoga or physical exercise in either of
the groups. Additionally, the patients enrolled in our study
only had mild‑to‑moderate disability. Hence, the burden was
probably not as signicant as it would have been with severe
physical disability.
Dejanović et al.[11] demonstrated that P300 latencies in stroke
patients were signicantly longer and the P300 amplitudes
were signicantly smaller than those of the control group.
Both these changes are indicators of cognitive slowing and
have been observed in various diseases and brain injury.[11]
In their study, the latency of P300, but not the amplitude,
showed a highly signicant average improvement 12 months
after the stroke compared to that at baseline without any
intervention. Similar improvement was also seen in our study
in the P300 latencies in both the groups after 6 months of
follow‑up; however, no dierences were observed in the P300
latencies between cases and controls neither at baseline nor at
follow‑up. Interestingly, there was signicant improvement in
the amplitude of P300 in control arm at Fz, Cz, and Pz but no
improvement in yoga arm. Although P300 is used as a correlate
in cognitive processing, there is still ambiguity regarding the
neural generators of P300. P300 amplitude increases with an
increase in mental eort, but a decline in P300 amplitude with
increasing task diculty has also been reported.[12,13] Probably,
recruitment of few compensatory additional neural networks
aects the P300 amplitudes.[14] Intracranial studies, lesion
studies, and fMRI‑EEG studies point toward multiple neural
generators of P300. Hence, P300, recorded at dierent places,
may have dierent source resulting from dierent mixture of
cognitive mixtures. In another words, the P300 measured at
Fz consists of another source mix (i.e., reecting a dierent
mixture of cognitive processes) than the P300 at Pz, and if
this source mix changes, dierences in trajectories are to be
expected.[15] Hence, it may be possible that compensatory
recruitment of neural circuits with the help of yoga diers
from those recruited after spontaneous recovery and may be
responsible for the dierence in the amplitude.
In a study of moderate stroke patients, 58 patients were
divided into yoga and conventional treatment groups.[16]
After 12 weeks of yoga training, the cerebral blood oxygen
content of stroke patients had signicantly increased, and
blood oxygen contents gradually approached that of normal
people. On weekly monitoring, it was found that signicant
increase in blood oxygen content in brain of patients started in
the third week of experiment. Furthermore, in this study, the
recovery of cognitive function was inspected by monitoring
Table 4: Comparison of cognitive functions (using MoCA, FAB), CDPSS, and caregiver burden among cases and control
at 6‑month follow‑up
Tools/Scales CASES (n=30) Median (IQR) CONTROLS (n=32) Median (IQR) Mann‑Whitney U P#
MOCA
Visuospatial
Naming
Attention
Language
Abstraction
Recall
Orientation
25.5 (22‑27)
3 (3‑4)
3 (2‑3)
5 (3.75‑6)
2 (2‑3)
1 (1‑2)
4 (4‑5)
6 (6‑6)
24 (20‑25.75)
3 (1.25‑3)
2 (2‑3)
5 (4‑6)
2 (2‑2)
1 (1‑2)
4 (3‑4)
6 (6‑6)
331.0
337.5
352.0
444.0
400.0
473.5
335.0
476.0
0.034*
0.031*
0.036*
0.598
0.146
0.917
0.026*
0.923
FAB
Conceptualization
Mental exibility
Programming
Interference
Inhibitory control
Environmental autonomy
15.5 (14‑17)
2 (2‑3)
2 (2‑2)
3 (3‑3)
3 (2‑3)
3 (2‑3)
3 (3‑3)
14 (12‑15.75)
2 (2‑3)
2 (2‑2)
2 (2‑3)
2 (2‑2)
2 (2‑3)
3 (3‑3)
275.0
479.0
379.0
311.5
284.0
301.5
480.0
0.003*
0.987
0.056
0.006*
0.002*
0.005*
1.000
CDPSS 0 (0‑0) 0 (0‑1) 326.0 0.008*
CBS 3 (1‑6) 6 (2‑9.75) 405.5 0.289
MRS 0 (0‑1) 1 (0‑1) 379.0 0.120
P300 values Cases(n=28) Controls (n=29) Mann‑Whitney U P
Fz Latency 314.5 (299.25‑345.5) 334 (307‑362.5) 328.0 0.213
Cz Latency 312 (299.5‑354.25) 326 (310‑364) 308.5 0.119
Pz Latency 312 (299.5‑356.75) 326 (310‑359.5) 316.5 0.153
Fz Amplitude 2.3 (1.34‑4.12) 3.15 (2.17‑4.42) 279.5 0.043*
Cz Amplitude 2.53 (2.03‑3.46) 4.11 (2.37‑4.72) 268.0 0.028*
Pz Amplitude 1.76 (0.97‑4.07) 3.59 (2.32‑4.16) 252 0.014*
Data presented as n (%) and mean±SD; #Mann‑Whitney U‑test, “*” P value <0.05. MoCA‑ Montreal Cognitive Assessment, FAB‑ Frontal Assessment
Battery, CDPSS‑ Clinician‑Rated Dimensions of Psychosis Symptom Severity, and CBS‑Caregiver Burden Scale

Kashyap, et al.: Post stroke cognitive impairment and eect of yoga
Annals of Indian Academy of Neurology ¦ Volume 26 ¦ Issue 1 ¦ January‑February 2023
66
the brain wave of patients when faced with a problem.[16] The
authors reported that, with the same problem, yoga‑trained
patients showed greater brain activity compared to those who
underwent conventional rehabilitation therapy. Moreover,
the significant difference in the brain waves between
experimental and control group basically appeared in the
fourth and fth week of experiment. This study showed
that the yoga increases blood oxygen content and probably
enhances the brain activity and improves cognitive ability.[16]
In another systematic review, it has been suggested that
healthy yoga practitioners have higher GM volume in a
number of regions involved in cognitive function including
frontal lobe (i.e., bilateral orbital frontal, right middle frontal,
and left precentral gyri), limbic (i.e., left parahippocampal
gyrus, hippocampus, and insula), temporal (i.e., left superior
temporal gyrus), occipital (i.e., right lingual gyrus), and
cerebellar regions.[17] Another important aspect of cognition
specially for memory is the default mode network (DMN) of
the brain. It is usually activated during rest and deactivated
with an external task. Usually, connectivity of DMN decreases
with age and in dementia. This review also reported a better
DMN activity with yoga practice. Hence, we can hypothesize
that yoga might have changed the various connectivity and
gray matter densities in patients with PSCI, resulting better
outcome.
Although studies have explored the effects of yoga on
improvement in post‑stroke motor function and balance, data
on its eects on post‑stroke cognitive impairment is scarce. Our
study is probably rst randomized controlled study which has
explored this aspect. The yoga exercises prescribed in our study
were suitable for rehabilitation of stroke patients with moderate
disability (MRS 3 or below). Our study is also unique as it
focuses on early yoga intervention. Hence, our study shows
that early yoga intervention in stroke survivors will improve
their cognitive abilities. Our study used tele‑yoga, which had
many advantages. It provided easy access to patients, especially
during the pandemic when movement was restricted across
the country. It also saved transport costs for patients and
increased compliance. In our study, the compliance was 75%.
Most common reason for non‑adherence was feeling of fatigue
and generalized weakness and low motivation. There were no
deaths in the yoga arm during the period of study, while 1 death
was reported in the control arm due to myocardial infarction.
The limitation of our study was its small sample size. This
study can serve as the stepping stone to future large‑scale,
well‑designed trials in this regard.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conicts of interest.
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