ArticlePDF Available

The Effect of Vinyasa Yoga Practice on the Well-Being of Breast-Cancer Patients during COVID-19 Pandemic

MDPI
International Journal of Environmental Research and Public Health (IJERPH)
Authors:

Abstract and Figures

Background: Vinyasa yoga practice improves body fitness and potentially positively affects practitioners' well-being and health. Due to the diverse intensity of practice and positions customized to the practitioner's needs, it can also support cancer patients. Undertaking physical activity that has a potentially positive effect on well-being and health was particularly important during the self-isolation that followed the COVID-19 pandemic. The purpose of this study was to evaluate the impact of three-month mild and moderate intensity vinyasa yoga practice on breast-cancer patients' stress perception, self-confidence, and sleep quality during COVID-19 induced self-isolation. Methods: Female breast-cancer patients participated in twelve-weeks of online vinyasa practice during the COVID-19 induced self-isolation period. Meetings were held once a week, where 60-min vinyasa yoga sequences were followed by 15 min of relaxation. Patients completed pre- and post-intervention surveys to evaluate changes in the following outcomes: stress perception, self-confidence, and sleep quality. Forty-one female patients enrolled in the Vinyasa course completed the pre-intervention survey, while 13 attended all the meetings and completed the post-intervention survey. Results: The effect of the twelve-week yoga and relaxation practice significantly reduced sleep problems and stress of oncological patients. The participants also declared an improvement in their general well-being and self-acceptance. Conclusion: Dynamic forms of yoga combined with mindfulness techniques can be applied to patients treated for oncological diseases. It contributes to improving their well-being. However, in-depth studies are needed to analyze the complexity of this effect.
Content may be subject to copyright.
Citation: Zok, A.; Matecka, M.;
Zapala, J.; Izycki, D.; Baum, E. The
Effect of Vinyasa Yoga Practice on the
Well-Being of Breast-Cancer Patients
during COVID-19 Pandemic. Int. J.
Environ. Res. Public Health 2023,20,
3770. https://doi.org/10.3390/
ijerph20043770
Academic Editor: Paul B. Tchounwou
Received: 15 January 2023
Revised: 11 February 2023
Accepted: 15 February 2023
Published: 20 February 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
International Journal of
Environmental Research
and Public Health
Article
The Effect of Vinyasa Yoga Practice on the Well-Being
of Breast-Cancer Patients during COVID-19 Pandemic
Agnieszka Zok 1, 2,* , Monika Matecka 3, Joanna Zapala 4, Dariusz Izycki 5and Ewa Baum 1,2
1
Department of Social Sciences and Humanities, Poznan University of Medical Sciences, 60-812 Poznan, Poland
2Division of Philosophy of Medicine and Bioethics, Poznan University of Medical Sciences,
60-812 Poznan, Poland
3Department of Occupational Therapy, Poznan University of Medical Sciences, 60-812 Poznan, Poland
4Department of Postgraduate Studies, SWPS University, 03-815 Warszawa, Poland
5Department of Cancer Immunology, Poznan University of Medical Sciences, 60-812 Poznan, Poland
*Correspondence: agzok@ump.edu.pl
Abstract:
Background: Vinyasa yoga practice improves body fitness and potentially positively affects
practitioners’ well-being and health. Due to the diverse intensity of practice and positions customized
to the practitioner’s needs, it can also support cancer patients. Undertaking physical activity that
has a potentially positive effect on well-being and health was particularly important during the self-
isolation that followed the COVID-19 pandemic. The purpose of this study was to evaluate the impact
of three-month mild and moderate intensity vinyasa yoga practice on breast-cancer patients’ stress
perception, self-confidence, and sleep quality during COVID-19 induced self-isolation. Methods:
Female breast-cancer patients participated in twelve-weeks of online vinyasa practice during the
COVID-19 induced self-isolation period. Meetings were held once a week, where 60-min vinyasa
yoga sequences were followed by 15 min of relaxation. Patients completed pre- and post-intervention
surveys to evaluate changes in the following outcomes: stress perception, self-confidence, and sleep
quality. Forty-one female patients enrolled in the Vinyasa course completed the pre-intervention
survey, while 13 attended all the meetings and completed the post-intervention survey. Results: The
effect of the twelve-week yoga and relaxation practice significantly reduced sleep problems and stress
of oncological patients. The participants also declared an improvement in their general well-being
and self-acceptance. Conclusion: Dynamic forms of yoga combined with mindfulness techniques can
be applied to patients treated for oncological diseases. It contributes to improving their well-being.
However, in-depth studies are needed to analyze the complexity of this effect.
Keywords: life quality; yoga; insomnia; well-being; physical activity
1. Introduction
Physical activity evokes growing interest in cancer patient rehabilitation [
1
]. An in-
creasing number of studies have shown that low to moderate-intensity exercises could
help cancer patients to recover, deal with treatment, and also have an impact on extend-
ing survival time [
2
5
]. It is worth mentioning that physical activity leads to improved
physiological and psychological functioning in oncological patients (a rehabilitation of
patients with advanced cancer). The importance of physical activity in the prevention [
6
]
and supportive treatment [
7
,
8
] of oncological diseases is increasingly emphasized. The
positive impact of physical activity in the period of recovery from the illness has also been
observed [
6
]. Despite this, patients avoid activity, and engaging patients in physical activity
is challenging for healthcare professionals [9].
Patients are also recommended various forms of psychotherapy [
10
12
], such as re-
laxation and guided imagery [
13
,
14
], mindfulness meditation (mindfulness-based stress
reduction) [
14
], music therapy [
15
,
16
], occupational therapy [
17
19
], and breathing exer-
cises [
20
22
]. Most of the mentioned therapies are a part of vinyasa yoga training, which
Int. J. Environ. Res. Public Health 2023,20, 3770. https://doi.org/10.3390/ijerph20043770 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2023,20, 3770 2 of 17
always includes breath work (Pranayama) and relaxation (Shavasana), enhanced by aro-
matherapy, music therapy, or/and visualization techniques or Nidra yoga. The sequence of
vinyasa yoga is created individually by the instructor (in contrast to, e.g., ashtanga yoga),
which enables adjusting the exercises to the patients’ individual needs. Therefore, it is
assumed that the practice of vinyasa yoga can be a form of support for patients with chronic
diseases, including oncology, in treatment and return to physical activity, thus affecting the
improvement of psychological well-being. It should also be remembered that the project
was carried out during the COVID-19 pandemic when many patients with chronic diseases
were deprived of access to rehabilitation and social contacts were significantly reduced.
This is important because it is rooted in a social network and the resulting ability to receive
informal support that significantly impacts a person’s well-being [
23
]. Physical activity
was also strongly associated with a reduced risk of severe COVID-19 complications among
infected adults [2426].
During the COVID-19 pandemic, in the period covered in presented study, self-
isolation was the recommended way to prevent SARS-CoV-2 infection. Self-isolation
was extremely important, especially for cancer patients, as they are a group at higher risk
of death or complications due to their systemic immunosuppressive state caused by the
disease and its drug treatment [27]. In addition, cancer patients tend to be older and have
other comorbidities (e.g., hypertension, diabetes, and cardiovascular disease) associated
with a worse prognosis in COVID-19, reinforcing the importance of self-isolation efforts
in these patients [
28
]. A negative consequence of self-isolation was physical inactivity
and prolonged sitting, as well as increased anxiety, depressive symptoms, and increased
fatigue [28].
The study aimed to analyze the effect of yoga intervention complemented by relaxation
exercises on the well-being of patients treated for oncological diseases during the COVID-19
pandemic. Special attention was paid to the aspects of insomnia and lowered mood, which
may have been exacerbated by the need for isolation. Patients’ expectations of starting
exercise, and the recognized effects of exercise, were also examined.
2. Materials and Methods
The study was approved by the Bioethics Committee at the PUMS No. 181/21.
2.1. Patients Recruitment
Breast-cancer patients were recruited through the “Otulina” and “PsycheSomaPolis”
NGO foundations providing wide and comprehensive care for oncology patients (https:
//fundacjaotulina.pl (accessed on 4 January 2022), https://www.psychesomapolis.org
(accessed on 4 January 2022)). A total of 41 breast-cancer patients were recruited from
January to April 2021. Inclusion in the study occurred through an interactive online
registration form. During registration, patients were asked to complete pre-intervention
surveys (The survey form and row data answers are attached as Supplementary Materials).
After completing the series of yoga sections, the patients were asked to respond to post-
intervention surveys. Participation was entirely voluntary. Participants were instructed
that they could withdraw from the study at any time without giving a reason in accordance
with the applicable ethical rules.
2.2. Questionary Form
The survey was prepared using Google Forms. Each patient received a link to the
survey and filled it out on their computer. The survey questionnaire contained three
sections. In the first, respondents answered questions related to their current problems with
the disease and their experiences with yoga practice. The second section of the questionnaire
dealt with issues related to the patient’s quality of life with particular attention to self-
perception and level of independence. Questions in this section addressed issues related to
the daily activities of cancer patients and their levels of happiness/sadness. The last part
consisted of sociodemographic questions, where we asked about age, place of residence,
Int. J. Environ. Res. Public Health 2023,20, 3770 3 of 17
or education. Respondents completed the questionnaire before and after the project. The
final questionnaire included additional questions about the results of the classes. The
post-intervention questionnaire was performed directly after the last meeting with the BC
patients that had participated in all meetings.
2.3. Intervention and Yoga Exercise Protocol
Vinyasa yoga sessions were conducted from April to the end of June 2021 every
Wednesday at 4 p.m. Due to the COVID-19 self-isolation periods, the practices were carried
out online via the Zoom application. Each participant had their own computer with camera,
internet access, their own exercise mat and a home-prepared space for performing exer-
cises. During the meetings, the instructor explained the various positions and performed
them with the participants. The 60-min vinyasa practice was followed by fifteen-minute
relaxation (Shavasana).
The vinyasa postures (asanas) were carefully selected considering the individual needs
and abilities of the patients and adapted to their health condition. At the beginning, a
personal health report was collected regarding the patients’ condition, complications and
possible contraindications to the exercises. Appropriate exercise sequences were created to
increase the accuracy of the selection of exercises and prevent possible complications. Yoga
activities were also adapted to the patients after lymphadenectomy. Therefore, transitions in
yoga postures were limited to 4-point kneeling with appropriate cues and “cat” and “cow”
poses (viniasa positions). The practice began in a comfortable sitting position (on a mat or
chair), calming the breath and performing simple exercises to mobilize the available body
part. The second part featured more vigorous exercises involving different parts of the body.
Positions that required lifting the arms and opening the chest (such as gomukmhasana) were
performed. Attention was focused on equivalent positions, such as tree pose (vrikasana)
or warrior 3 in the flowing sequence of vinyasa Yoga. The third part was dominated by
lying down positions, using aids such as bolsters, blocks, and straps (the aids could be used
at any time during the class). The last position was shavasana. Relaxation was performed
lying on the back with arms spread wide and eyes closed. During relaxation, the instructor
involved the following techniques: bibliotherapy, music therapy, mindfulness rotation
training, and visualization.
2.4. Statistic
Pre- and post-intervention survey results were downloaded and saved in “xlsx” format.
Statistical analysis and visualization of the obtained results were performed in the statistical
software environment “R” (version 3.5.1) with several additional libraries. Xlsx files were
imported into R using the “openxslx” library [
29
]. The number of response options given to
the respective questions and the corresponding percentages were calculated. The obtained
values were shown as a table or were visualized using the ggplot2 library [30].
In the next step, we analysed the responses submitted before and after the intervention.
Using the personal ID included in both surveys, data were extracted for only patients who
fulfilled pre- and post-intervention surveys. The Shapiro-Wilk normality test was used to
verify the data’s conformance to a normal distribution. Since most of the data did not meet
the assumptions of a normal distribution, a non-parametric test was used for statistical
analyses. The Wilcoxon signed-ranks test was used for group comparisons. The values of
p< 0.05
were considered statistically significant. The median, interquartile range, mean,
and standard deviation were calculated and presented on the graphs.
2.5. Analysis of Multiple Answer Questions
The total number of responses, the percentage per response, and the percentage per
patient population were calculated and presented as a table using the “multiResponse”
function from the “userfriendlyscience” package [
31
]. Correlations between the given
answer variants were visualized using the “arcdiagram” package [
32
]. The obtained arc
plot showed the level of correlation representing the exponent of the answer variants most
Int. J. Environ. Res. Public Health 2023,20, 3770 4 of 17
frequently marked together. Individual answers in multiple-choice questions were also
presented by means of heatmap where the answer to a given variant was marked in black
colour. For this purpose, the “Complexheatmap” package was used [33].
3. Results
Forty-one female cancer patients (N = 41) joined the project and solved the initial
survey form. Thirteen patients completed the full cycle of yoga practice and fulfilled the
final survey (N = 13). The socio-demographic characteristics of the group regarding the
answers given before starting the practice are shown in Table 1.
Table 1.
Socio-demographic characteristics of the cancer patients who participated in yoga classes.
The number of declared responses (N) as well as the percentage distribution (%) were determined
based on the results of a survey conducted before the yoga course.
Parameter N %
Age ranges
25–30 2 4.88
31–36 1 2.44
37–45 13 31.71
46–51 12 29.27
52–60 6 14.63
61–69 7 17.07
Sex
Women 41 100
I live with
with the family 24 58.54
with soul mate 11 26.83
alone 6 14.63
Residence
city with a population of over 100,000 20 48.78
city of 26,000–100,000 residents 5 12.2
city of 10,000–25,000 residents 7 17.07
city of less than 10,000 inhabitants 4 9.76
village 5 12.2
Education
higher education 34 82.93
high school education 7 17.07
Do you practice yoga?
Yes, regularly 1 2.44
Yes, sometimes 27 65.85
I never practiced yoga 13 31.71
Are you receiving treatment with chemo/radiotherapy?
Finished treatment 22 53.66
I am in the process of treatment 16 39.02
I do not qualify for treatment 3 7.32
More than 65% of female participants (N = 27, 65.85%) admitted that they practiced
yoga occasionally. Only one person declared regular practice (N = 1, 2.44%). A total of 31%
had never practice yoga in any way before (N = 13, 31.71%).
More than half of the participants (N = 22, 53.6%) completed treatment with chemother-
apy and radiotherapy. During the project, 16 patients (39%) underwent treatment, and
three declared themselves ineligible for systemic therapy.
Int. J. Environ. Res. Public Health 2023,20, 3770 5 of 17
The largest group of patients were women between 37–45 (N = 13, 31.7%) and 46–51
(N = 12, 29.3%) years of age. Most of the women said they live with their families (
N = 24
,
58.4%). Residents of large cities (N = 20, 48.8%) with higher education (N = 34, 83%)
predominated among the subjects.
In the first part of the study, we analyzed the health problems and ailments of breast
cancer patients who participated in yoga classes. Figure 1shows the results for the pre-
intervention survey. A comparison of the answers given before the beginning of the course
with those answered after the final meeting of vinyasa yoga course was also carried out
and is presented as Figure S1. The analyzed question set included only answers from a
numerical scale, where 1 means never, and 4 means very often. In order to identify the most
common health problems and ailments, the questions set were ranked from those with the
highest number of responses answering 4. Consistent with this approach, patients very
often felt irritable, worried, and depressed in the past week (respectively 26.83%, 26.83%,
21.95% very often and 34.15%, 21.95%, 19.51% often). The patients also declared sleep
difficulties in the past week (21.95% very often, 21.95 often). On the other hand, a short
walk outside the home never caused problems for most patients (68.29%).
Int.J.Environ.Res.PublicHealth2023,20,xFORPEERREVIEW5of18
Iamintheprocessoftreatment1639.02
Idonotqualifyfortreatment37.32
Morethan65%offemaleparticipants(N=27,65.85%)admittedthattheypracticed
yogaoccasionally.Onlyonepersondeclaredregularpractice(N=1,2.44%).Atotalof31%
hadneverpracticeyogainanywaybefore(N=13,31.71%).
Morethanhalfoftheparticipants(N=22,53.6%)completedtreatmentwith
chemotherapyandradiotherapy.Duringtheproject,16patients(39%)underwent
treatment,andthreedeclaredthemselvesineligibleforsystemictherapy.
Thelargestgroupofpatientswerewomenbetween37–45(N=13,31.7%)and46–51
(N=12,29.3%)yearsofage.Mostofthewomensaidtheylivewiththeirfamilies(N=24,
58.4%).Residentsoflargecities(N=20,48.8%)withhighereducation(N=34,83%)
predominatedamongthesubjects.
Inthefirstpartofthestudy,weanalyzedthehealthproblemsandailmentsofbreast
cancerpatientswhoparticipatedinyogaclasses.Figure1showstheresultsforthepre
interventionsurvey.Acomparisonoftheanswersgivenbeforethebeginningofthe
coursewiththoseansweredafterthefinalmeetingofvinyasayogacoursewasalsocarried
outandispresentedasFigureS1.Theanalyzedquestionsetincludedonlyanswersfrom
anumericalscale,where1meansnever,and4meansveryoften.Inordertoidentifythe
mostcommonhealthproblemsandailments,thequestionssetwererankedfromthose
withthehighestnumberofresponsesanswering4.Consistentwiththisapproach,
patientsveryoftenfeltirritable,worried,anddepressedinthepastweek(respectively
26.83%,26.83%,21.95%veryoftenand34.15%,21.95%,19.51%often).Thepatientsalso
declaredsleepdifficultiesinthepastweek(21.95%veryoften,21.95often).Ontheother
hand,ashortwalkoutsidethehomenevercausedproblemsformostpatients(68.29%).
Figure1.Healthproblemsandailmentsofthecancerpatientswhoparticipatedinyogaclasses.The
numberofdeclaredresponses(n—showninbrackets)andthepercentagedistribution(%)were
determinedbasedontheresultsofasurveyconductedbeforetheyogacoursebegan.Thesurvey
questionswereansweredwithreferencetoanumericalscalewhere1meansnever,2—sometimes,
3—often,and4—veryoften.Thequestionswereorderedaccordingtotheanswersinwhichmost
respondentsmarked4—asveryoften.
Wealsoexaminedpatients’motivationstopracticevinyasayoga.Oneofthesurvey
questionscompletedbeforethecourse—“Whatareyourmotivationstopracticeyoga?
wasamultiplechoicequestioncontainingthemostcommonreasonsforstartingthe
practice.TheresultsareshowninFigure2.Mostoften,patientsindicatedthatthereason
forjoiningthecoursewasthedesiretostretchthebody(N=32),theneedtoincrease
vitality(N=29),andbetterstressmanagement(N=26).Accordingtothecorrelation
analysisoftheprovidedanswers,presentedonthearcdiagram(Figure2B),thepatients
mostlymarkedtogether“theneedtoincreasevitality”,“thedesiretostretchthebody”,
and“betterstressmanagement”.Percentageofresponses(inrelationtototalfrequency=
Figure 1.
Health problems and ailments of the cancer patients who participated in yoga classes.
The number of declared responses (n—shown in brackets) and the percentage distribution (%) were
determined based on the results of a survey conducted before the yoga course began. The survey
questions were answered with reference to a numerical scale where 1 means never, 2—sometimes,
3—often, and 4—very often. The questions were ordered according to the answers in which most
respondents marked 4—as very often.
We also examined patients’ motivations to practice vinyasa yoga. One of the survey
questions completed before the course—“What are your motivations to practice yoga?” was
a multiple-choice question containing the most common reasons for starting the practice.
The results are shown in Figure 2. Most often, patients indicated that the reason for
joining the course was the desire to stretch the body (N = 32), the need to increase vitality
(
N = 29
), and better stress management (N = 26). According to the correlation analysis
of the provided answers, presented on the arc diagram (Figure 2B), the patients mostly
marked together “the need to increase vitality”, “the desire to stretch the body”, and “better
stress management”. Percentage of responses (in relation to total frequency = 157) and
percentage of (41) cases (percentage of response frequency in relation to 41 patients) are
presented on Figure 2C.
Int. J. Environ. Res. Public Health 2023,20, 3770 6 of 17
Int.J.Environ.Res.PublicHealth2023,20,xFORPEERREVIEW6of18
157)andpercentageof(41)cases(percentageofresponsefrequencyinrelationto41
patients)arepresentedonFigure2C.
Figure2.Cancerpatients’motivationstopracticeyoga.Patientsweregiventheopportunityto
indicatemultipleornoreasonsforparticipatinginyogapractice(multipleanswerquestion).(A)a
heatmaprepresentingindividualresponsestothequestion“Whatareyourmotivationstopractice
yoga?.Theanswersofeachpatientarepresentedinseparaterows(N=41).Theblackcolorofthe
heatmapcellsindicatesthatthepatient’sselectionofaparticularanswervariant.(B)Correlationof
answervariantsaimedatidentifyingthemostfrequentlyselectedanswerstogether.Thelevelof
correlationwasindicatedbytheintensityandthicknessofthelineconnectingthegivenanswer
variants.(C)Summarytableshowingthepercentageofresponses(inrelationtototalfrequency=
157)andpercentageof(41)cases(percentageofresponsefrequencyinrelationto41patients).
Inthenextstep,weanalyzedchangesinpatients’responsesbeforeandafterthe
intervention.Forthispurpose,weselectedsetsofresponsesassignedtoindividual
patientsfromtwoquestionnaires.Figure3showsthechangesinresponsesregarding
irritability,depression,difficultysleeping,andlossofselfconfidence.Thequestionswere
answeredonapointscalewhere1meansneverwhile4—veryoften.Thequestionswere
formattedinsuchawaythatalowerscoreindicatesareductionintheanalyzedproblem.
Thus,thepotentialbenefitoftheinterventionforpatientswasexpressedbyloweringthe
meanscorevalues.Itwasobservedthatfemalepatientsdeclaredastatistically
significantlylowerscorevalueinthe“Haveyouexperienceddifficultysleepinginthe
pastweek?questionaftercompletingthevinyasayogacourse(meanbeforeintervention
=2.46,meanpostintervention=1.77),indicatingthattheirproblemsrelatedtodifficulty
sleepingdecreased.Thepatients’feelingsofdepressionwerestatisticallylowerafterthe
intervention(meanpreintervention=2.46,meanpostintervention=2.08).Patientssense
ofirritabilitywassignificantlyloweraftertheintervention(meanpreintervention=2.69,
meanpostintervention=2.15).Wealsoshowedthatselfconfidenceincreased
significantlyinbreastcancerpatientsafterthevinyasayogacourse.Themeanofthe
responsestothequestion“Haveyourecentlylostselfconfidence?”wassignificantly
lowerintheresponsesgivenafterthecourse(meanpreintervention=2.08,meanpost
intervention=1.69).
Figure 2.
Cancer patients’ motivations to practice yoga. Patients were given the opportunity to
indicate multiple or no reasons for participating in yoga practice (multiple answer question). (
A
) a
heatmap representing individual responses to the question “What are your motivations to practice
yoga?”. The answers of each patient are presented in separate rows (N = 41). The black color of the
heatmap cells indicates that the patient’s selection of a particular answer variant. (
B
) Correlation
of answer variants aimed at identifying the most frequently selected answers together. The level of
correlation was indicated by the intensity and thickness of the line connecting the given answer vari-
ants. (
C
) Summary table showing the percentage of responses (
in relation to total frequency = 157
)
and percentage of (41) cases (percentage of response frequency in relation to 41 patients).
In the next step, we analyzed changes in patients’ responses before and after the
intervention. For this purpose, we selected sets of responses assigned to individual patients
from two questionnaires. Figure 3shows the changes in responses regarding irritability, de-
pression, difficulty sleeping, and loss of self-confidence. The questions were answered on a
point scale where 1 means never while 4—very often. The questions were formatted in such
a way that a lower score indicates a reduction in the analyzed problem. Thus, the potential
benefit of the intervention for patients was expressed by lowering the mean score values. It
was observed that female patients declared a statistically significantly lower score value in
the “Have you experienced difficulty sleeping in the past week?” question after completing
the vinyasa yoga course (
mean before intervention = 2.46
,
mean post intervention = 1.77
),
indicating that their problems related to difficulty sleeping decreased. The patients’ feelings
of depression were statistically lower after the intervention (
mean pre-intervention = 2.46
,
mean post-intervention = 2.08). Patients’ sense of irritability was significantly lower af-
ter the intervention (mean pre-intervention = 2.69, mean post-intervention = 2.15). We
also showed that self-confidence increased significantly in breast cancer patients after the
vinyasa yoga course. The mean of the responses to the question “Have you recently
lost self-confidence?” was significantly lower in the responses given after the course
(mean pre-intervention = 2.08, mean post-intervention = 1.69).
After three months of exercise, the participants’ satisfaction levels improved signifi-
cantly.
Int. J. Environ. Res. Public Health 2023,20, 3770 7 of 17
Int.J.Environ.Res.PublicHealth2023,20,xFORPEERREVIEW7of18
Figure3.Irritability,depression,difficultysleeping,andlossofselfconfidencelevelinoncological
patientsbeforeandaftera3monthyogapractice.Thesurveyquestionswereansweredregarding
anumericalscalewhere1meansneverand4—veryoften.Eachdotrepresentsanindividualpatient
response.Greydottedconnectinglineindicatessamepatientbeforeandafteryogaintervention.
Theboxplotshowsthemedianandinterquartilerange.Ontherightsideofeachgraph,the
diamondsymbolshowsthemeanvaluewithstandarddeviation.Adecreaseinthemeanvalue
indicatesareductionintheanalyzedproblem.
Afterthreemonthsofexercise,theparticipantssatisfactionlevelsimproved
significantly.
Toanalyzeoverallefficiencyandsatisfaction,wecomparedparticipantsresponses
totwoquestions.Figure4showsthechangesinresponsesregardingabilitytoperform
dailyactivitiesandsubjectiveassessmentofone’sownhealth.Thesurveyquestionswere
answeredregardinganumericalscalewhere,forFigure4A:1meansmorethanusualand
4—lessthanusual.Itwasobservedthatthepatientsdeclaredastatisticallysignificantly
lowerscoreonthequestion“Haveyoubeenabletoenjoyyourusualdailyactivities
lately?”aftercompletingthevinyasayogacourse(meanbeforetheintervention=2.15,
meanaftertheintervention=1.69),indicatingthattheirproblemswithperformingdaily
activitieshaddecreased.
Figure4B:presentschangesinpatientsperceptionsoftheirownhealth,where1
meansverybadand7—perfect.Weobservedthatfemaleparticipantsdeclareda
statisticallysignificanthigherscoreonthequestion“Howdoyouassessyouroverall
healthduringthepastweek?aftercompletingtheproject(meanbeforetheintervention
=4.85,meanaftertheintervention=5.62),indicatingthattheyassesstheirhealthstatusas
better.
Figure 3.
Irritability, depression, difficulty sleeping, and loss of self-confidence level in oncological
patients before and after a 3-month yoga practice. The survey questions were answered regarding a
numerical scale where 1 means never and 4—very often. Each dot represents an individual patient
response. Grey dotted connecting line indicates same patient before and after yoga intervention. The
box-plot shows the median and interquartile range. On the right side of each graph, the diamond
symbol shows the mean value with standard deviation. A decrease in the mean value indicates a
reduction in the analyzed problem.
To analyze overall efficiency and satisfaction, we compared participants’ responses to two
questions. Figure 4shows the changes in responses regarding ability to perform daily activities
and subjective assessment of one’s own health. The survey questions were answered regarding
a numerical scale where, for Figure 4A: 1 means more than usual and 4—less than usual. It
was observed that the patients declared a statistically significantly lower score on the question
“Have you been able to enjoy your usual daily activities lately?” after completing the vinyasa
yoga course (mean before the intervention = 2.15, mean after the intervention = 1.69), indicating
that their problems with performing daily activities had decreased.
Int.J.Environ.Res.PublicHealth2023,20,xFORPEERREVIEW8of18
Figure4.Thedegreeofenjoymentofdailyactivities(A)andpatients’selfassessmentoftheiroverall
healthstatus(B)inoncologicalpatientsbeforeandaftera3monthyogapractice.Thesurvey
questionswereansweredregardinganumericalscalewhere,forFigure4A:1meansmorethan
usualand4—lessthanusual,andforFigure4B:1meansverybadand7—perfect.Eachdot
representsanindividualpatientresponse.Greydottedconnectinglineindicatessamepatientbefore
andafteryogaintervention.Theboxplotshowsthemedianandinterquartilerange.Ontheright
sideofeachgraph,thediamondsymbolshowsthemeanvaluewithstandarddeviation.
Anothersetofquestionswasanalyzedtoassessthesatisfactionanddepressive
tendenciesoffemalepatients.Cancerpatientschoseoneoftheindividualstatementsthat
mostcharacterizedtheirphysicalandemotionalstate,determinedbeforeandaftera3
monthyogapractice.Theanalysisshowedthatexercisepositivelyaffectedthepatients’
mentalstate.Beforethestartoftheproject,46.15%ofparticipantsansweredaffirmatively
tothequestion“I’mnotsadordepressedaftercompletion,61.54%gavesuchananswer.
Participantslooktothefuturemorepositively.Tothequestion“Ioftenworryaboutthe
futurebeforethestartoftheclass,53.85%answeredaffirmatively,aftertheaffirmative
answerswere38.46%.Accordingtotheparticipants’declarationsbeforetheproject,
30.77%answeredthequestion“I’mnottooworriedaboutthefuture”affirmatively,while
after,53.85%declarednoworries.Selfsatisfaction,ontheotherhand,wasdeclaredby
53.85%ofparticipantsstartingtheprojectand61.54%uponcompletion.However,the
patientstendencytocrydecreased.Thequestion“Idon’tcrymorethanusual”was
answeredintheaffirmativeby53.85%ofpeople.Aftertheproject,theresponseswere
92.31%.Participantsdeclaredalessertendencytowardnervousnessaftertakingthe
course.Thequestion“I’mmorenervousandunpleasantthanbefore”wasanswered
affirmativelyby38.46%ofparticipantsbeforetheexercise,andafterbyonly7.69%.In
addition,participantsindicatedthattheprojectsignificantlyimprovedthequalityoftheir
sleep,with61.54%sayingthattheysleptbetteraftertheprojectthanbefore;beforethe
project,goodsleepwasreportedby15.38%.Atotalof84.62%ofthosestartingtheproject
answeredintheaffirmativetothequestion,“I’mtiringmuchfasterthanbefore”,while
aftertheexercise,46.15%declaredtiringquickly.
Attheendoftheproject,weaskedtheparticipantstodeclaretheeffectsofthe
exercisestheynoted.Inresponsetothequestion,wegavethetraineesmultiplechoices.
Themostfrequentlychosenanswerwas“Improvebodyflexibility,declaredbyten
patients;ninechose“stressrelief.”Theanswer“Improvingmentalhealthwasselected
byeightparticipants.
4.Discussion
Thecoronavirusdisease(COVID19)pandemichasradicallychangedourdaily
activities.Toreducethepaceofthepandemic,theWorldHealthOrganizationhas
recommendedsocialisolationmeasures,especiallyingroupsatriskofsevereinfection,
suchastheelderlyandpeoplewithchronicillnesses,includingcancerpatients[34].Since
Figure 4.
The degree of enjoyment of daily activities (
A
) and patients’ self-assessment of their
overall health status (
B
) in oncological patients before and after a 3-month yoga practice. The survey
questions were answered regarding a numerical scale where, for Figure 4A: 1 means more than usual
and 4—less than usual, and for Figure 4B: 1 means very bad and 7—perfect. Each dot represents an
individual patient response. Grey dotted connecting line indicates same patient before and after yoga
intervention. The box-plot shows the median and interquartile range. On the right side of each graph,
the diamond symbol shows the mean value with standard deviation.
Int. J. Environ. Res. Public Health 2023,20, 3770 8 of 17
Figure 4B: presents changes in patients’ perceptions of their own health, where 1
means very bad and 7—perfect. We observed that female participants declared a statis-
tically significant higher score on the question “How do you assess your overall health
during the past week?” after completing the project (mean before the intervention = 4.85,
mean after the intervention = 5.62
), indicating that they assess their health status as better.
Another set of questions was analyzed to assess the satisfaction and depressive ten-
dencies of female patients. Cancer patients chose one of the individual statements that most
characterized their physical and emotional state, determined before and after a
3-month
yoga practice. The analysis showed that exercise positively affected the patients’ mental
state. Before the start of the project, 46.15% of participants answered affirmatively to
the question “I’m not sad or depressed” after completion, 61.54% gave such an answer.
Participants look to the future more positively. To the question “I often worry about the
future” before the start of the class, 53.85% answered affirmatively, after the affirmative
answers were 38.46%. According to the participants’ declarations before the project, 30.77%
answered the question “I’m not too worried about the future” affirmatively, while after,
53.85% declared no worries. Self-satisfaction, on the other hand, was declared by 53.85%
of participants starting the project and 61.54% upon completion. However, the patient’s
tendency to cry decreased. The question “I don’t cry more than usual” was answered in
the affirmative by 53.85% of people. After the project, the responses were 92.31%. Partici-
pants declared a lesser tendency toward nervousness after taking the course. The question
“I’m more nervous and unpleasant than before” was answered affirmatively by 38.46% of
participants before the exercise, and after by only 7.69%. In addition, participants indicated
that the project significantly improved the quality of their sleep, with 61.54% saying that
they slept better after the project than before; before the project, good sleep was reported
by 15.38%. A total of 84.62% of those starting the project answered in the affirmative to the
question, “I’m tiring much faster than before”, while after the exercise, 46.15% declared
tiring quickly.
At the end of the project, we asked the participants to declare the effects of the
exercises they noted. In response to the question, we gave the trainees multiple choices.
The most frequently chosen answer was “Improve body flexibility,” declared by ten patients;
nine chose “stress relief.” The answer “Improving mental health” was selected by eight
participants.
4. Discussion
The coronavirus disease (COVID-19) pandemic has radically changed our daily activi-
ties. To reduce the pace of the pandemic, the World Health Organization has recommended
social isolation measures, especially in groups at risk of severe infection, such as the elderly
and people with chronic illnesses, including cancer patients [
34
]. Since isolation precautions
also apply to sports activities, home workouts remained the only option for playing sports
and staying active during the pandemic due to the introduced restrictions, and the patients’
physical activity decreased significantly [
35
]. However, a growing number of studies
indicate a significant influence of appropriately selected physical activity on the healing
process [
9
,
36
]. The effectiveness of the online exercise protocol was confirmed by a study by
Grazioli et al. indicating that training conducted remotely can also help improve patients’
quality of life [
37
]. In comparison, the effectiveness of combined training in a non-cancer
population is indicated by a meta-analysis by Jamka et al., who showed a more favorable
effect of such an intervention on glucose and insulin homeostasis and lipid profile [
38
].
The effectiveness of home-based intervention during a pandemic was also confirmed by
Natalucci et al., who indicated that a 3-month home-based lifestyle intervention focused
on a Mediterranean diet and aerobic exercise significantly reduced echocardiographic
signs of diastolic dysfunction and improved autonomic function. In addition, there were
significant improvements in BMI, cardiorespiratory fitness, metabolic and inflammatory
parameters [
39
]. Our study also confirmed that online classes could both improve patients’
fitness and positively affect their psychological well-being (Figure 5). Scientific evidence
Int. J. Environ. Res. Public Health 2023,20, 3770 9 of 17
supports the safety and effectiveness of physical activity, indicating—for people with can-
cer experience—health benefits such as reduced anxiety, reduced depressive symptoms,
reduced fatigue, improved quality of life, and improved physical function [
40
43
]. The
importance of sleep and relaxation for both mental and physical health is also emphasized.
This is particularly relevant during the pandemic period, as isolation also induced feelings
of loneliness among patients, which can further compound negative health effects not
only in terms of mental health, but also with physical illnesses such as cardiovascular dis-
ease [
44
,
45
] and elevated blood pressure [
46
,
47
]. In addition, a systematic review noted that
loneliness and social isolation were risk factors for early mortality [
48
50
]. Hawkley et al.
suggest that loneliness among middle-aged and older adults is an independent risk factor
for physical inactivity and increases the likelihood of physical inactivity cessation over
time [
51
]. Researchers point to the key role of social support in initiating physical activity
and regularity [
52
,
53
]. Their findings provide an important argument for encouraging
exercise among people at risk of loneliness due to isolation. Although online classes do
not solve the problem of loneliness, they provide motivation to exercise and reinforce the
regularity of the effort taken.
Int.J.Environ.Res.PublicHealth2023,20,xFORPEERREVIEW10of18
Figure5.Selfevaluationofyogapracticeeffects.Patientsweregiventheopportunitytoindicate
multipleornobenefitsafterfinishingthewholeyogacourse(multipleanswerquestion).(A)a
heatmaprepresentingindividualresponsestothequestion“Didyounoticetheeffectsofyoga
practice?”.Theanswersofeachpatientarepresentedinseparaterows(N=13).Theblackcolorof
theheatmapcellsindicatesthatthepatient’sselectionofaparticularanswervariant.(B)Correlation
ofanswervariantsaimedatidentifyingthemostfrequentlyselectedanswerstogether.Thelevelof
correlationwasindicatedbytheintensityandthicknessofthelineconnectingthegivenanswer
variants.(C)Summarytableshowingthepercentageofresponses(inrelationtototalfrequency=
44)andpercentageof(13)cases(percentageofresponsefrequencyinrelationto13patients).
Althoughthepositiveeffectsofyogaonpatientspsychologicalwellbeinghavelong
beenknown[55–59]thestudyconductedinthisprojectshowedthatcancerpatientscould
successfullypracticevinyasayoga.Modernyoga’sdistinctiveblendofmovementand
breathmaximizesthebenefitsofphysicalactivity.Duringpractice,patientsnotonly
strengthenandstretchtheirbodybutalsoimprovetheirbreathingcapacity[60].Related
tothepractice,learningcalm,prolongedbreathingtemporarilyimprovespatientswell
being[61],andteachesthemtocopewiththestresstheymayexperienceinthefuture.
Measurestoreducestressappeartobeextremelyimportant,asmanystudieshaveshown
thatstresspromotesthedevelopmentofcancer[62–66].FurthermoreChalayeetal.,
observesthatSlowDeepBreathingisasimpleandeasytousemethodofrelievingacute
painthatcaneasilybeusedduringpainfulmedicalprocedurestoalleviateanacutepain
crisisorasacomplementarypaintherapyforchronicpain[67].Buschremarksthat
prolongedcalmbreathinginducesadecreaseinsympatheticactivityandattenuationof
painperception,suggestingthatbreathinterventioniseasytolearn[68].Researchersnote
thatelementsofphysical,mental,andspiritualdisciplinessuchasmoststylesofyoga,Qi
Gong,andTaiChicanbeusedtotreatchronicbulbarconditions[68–71].However,
previousresearchersrarelyindicatedthestyleofyogatraining.Themostcommon
practicewasthemethodofIyengar[72–75],accordingtowhichtheposturesareworked
staticallywiththeuseofmanyaids(chairs,rollers,blocks,straps);aftertakingone
position,thepractitionermaintainsitandrefinesitwithmicromovements.Thepractice
Figure 5.
Self-evaluation of yoga practice effects. Patients were given the opportunity to indicate
multiple or no benefits after finishing the whole yoga course (multiple answer question). (
A
) a
heatmap representing individual responses to the question “Did you notice the effects of yoga
practice?”. The answers of each patient are presented in separate rows (N = 13). The black color of
the heatmap cells indicates that the patient’s selection of a particular answer variant. (
B
) Correlation
of answer variants aimed at identifying the most frequently selected answers together. The level
of correlation was indicated by the intensity and thickness of the line connecting the given answer
variants. (
C
) Summary table showing the percentage of responses (in relation to total frequency = 44)
and percentage of (13) cases (percentage of response frequency in relation to 13 patients).
The analysis by Zapala et al. identified several needs of oncology patients during the
pandemic. The authors indicated that the desire for recovery is not the only need of patients.
Peace of mind significantly influences their well-being, which can be achieved through
Int. J. Environ. Res. Public Health 2023,20, 3770 10 of 17
physical activity and breathing exercises. The pandemic has significantly complicated
and hindered the process of identifying and adequately responding to the needs of cancer
patients. Consequently, it has exacerbated the suffering of patients and their relatives [
54
].
Therefore, the activities we conducted responded to the needs of patients and resulted in
improved satisfaction with daily life activities and assessment of overall health (Figure 4).
Although the positive effects of yoga on patients’ psychological well-being have
long been known [
55
59
] the study conducted in this project showed that cancer patients
could successfully practice vinyasa yoga. Modern yoga’s distinctive blend of movement
and breath maximizes the benefits of physical activity. During practice, patients not
only strengthen and stretch their body but also improve their breathing capacity [
60
].
Related to the practice, learning calm, prolonged breathing temporarily improves patients’
well-being [
61
], and teaches them to cope with the stress they may experience in the
future. Measures to reduce stress appear to be extremely important, as many studies
have shown that stress promotes the development of cancer [
62
66
]. Furthermore Chalaye
et al., observes that Slow Deep Breathing is a simple and easy-to-use method of relieving
acute pain that can easily be used during painful medical procedures to alleviate an acute
pain crisis or as a complementary pain therapy for chronic pain [
67
]. Busch remarks that
prolonged calm breathing induces a decrease in sympathetic activity and attenuation of
pain perception, suggesting that breath intervention is easy to learn [
68
]. Researchers note
that elements of physical, mental, and spiritual disciplines such as most styles of yoga,
Qi-Gong, and Tai Chi can be used to treat chronic bulbar conditions [
68
71
]. However,
previous researchers rarely indicated the style of yoga training. The most common practice
was the method of Iyengar [
72
75
], according to which the postures are worked statically
with the use of many aids (chairs, rollers, blocks, straps); after taking one position, the
practitioner maintains it and refines it with micro-movements. The practice is devoid of
dynamic transitions between positions. It is definitely a mild form of physical activity.
Vinyasa yoga is characterized by much greater equanimity. It can take the form of mild or
moderate activity. In addition to the effects of yoga associated with mindfulness practice,
systematic participation in Vinyasa yoga can effectively improve cardio-respiratory fitness
and strengthen the body and can be used as an alternative method to traditional aerobic
exercise [
76
]. Vinyasa is a dynamic style that emphasizes the seamless connection between
movement and breath. The dynamic nature of vinyasa yoga helps strengthen the body
further and improve the student’s condition [
77
,
78
]. The freedom to create sequences and
the lack of need for aids allow for a customized practice that can be done almost anywhere,
making it easier for patients to engage in this activity. Patients participating in our project
were able to perform elements of the practice even during hospitalization. A piece of floor,
a carpet/mat, or socks to prevent slipping were sufficient. In addition, the combination of
mild to moderate vinyasa yoga training and breathing practice benefits health holistically,
increasing physical fitness and facilitating a sense of relaxation and inner peace [
79
]. The
awareness of breathing, which is the basis of yoga, and the dynamics characteristic of
vinyasa influence the psychological well-being of the patients and improve their physical
efficiency, which results in a reduction in fatigue during longer distances (walking). Pina
et al. note that even a single session of vinyasa yoga can have a positive effect on the
mood of exercisers. Researchers highlight the efficacy of a single bout of vinyasa yoga in
improving AIx, an index of wave reflection influenced by vascular resistance and systemic
arterial stiffness [
77
,
80
]. In addition, note the effectiveness of vinyasa yoga in enhancing
mood and non-HDL cholesterol levels [
77
]. The results of our research confirm the positive
effects of vinyasa on well-being. It has been confirmed both in the aspect of reduction in
fatigue and better rating of current well-being (Figures 3and 4).
Insomnia is a common problem among cancer patients, potentially devastatingly
impacting their quality of life [
81
84
]. Despite its prevalence, oncology literature rarely
considers it [81,8588], and patients can rarely count on ongoing systemic assistance.
Patients at the beginning of the project complained of severe sleep problems (Figure 2).
Multiple factors contribute to insomnia among patients with breast cancer, including
Int. J. Environ. Res. Public Health 2023,20, 3770 11 of 17
endocrine therapy and hot flashes, pain and discomfort from local therapy, and fear
of recurrence [
81
,
87
]. The SRAS-CoV-2 pandemic further compounded the problem of
insomnia during our research. The pandemic has contributed to health problems such
as stress, anxiety, depressive symptoms, insomnia, denial, anger, and fear on a global
scale [8991]. The age of our female patients can also be considered a factor that increases
the risk of insomnia [
92
]. Therefore, improving sleep quality in female patients appears to
be a meaningful result. Those participating in the supervised project reported a significant
reduction in sleep problems after a series of yoga practices (Figure 3).
The effectiveness of non-pharmacological support for insomnia is also suggested
by Zeichner et al., noting that such intervention can reduce comorbidities and reduce
healthcare resource utilization. Cognitive-behavioral therapy for insomnia, mindfulness,
and yoga are three behavioral health interventions they recommend for treating sleep
disorders in cancer patients [
93
]. A meta-analysis conducted by researchers in Taiwan on
the effects of yoga on sleep quality indicated—surprisingly enough—an improvement in
sleep quality in female patients who followed the practice [
94
]. However, it should be
noted that previous studies did not take into account such important aspects as the style of
yoga practiced by the participants of the classes and the time of day when the classes were
held. Meanwhile, when analyzing the relationship between yoga practice and sleep quality,
it is essential to consider a mediating factor—the type of asanas (postures) performed at
a particular time of day. Intense evening practice, combined with ujjayi breathing [
95
] is
very energizing, which may adversely affect sleep parameters. Taking this into account,
the patients participating in the self-project were offered classes in the morning. Calming
breathing such as box breathing, Nadi shodan [
96
], or bhramari [
97
,
98
] were also used at the
end of the class. Since the yoga sessions were recorded and additional breathing exercises
were prepared for the patients, they could apply them at any time.
As declared by project participants, a reduction in stress, feelings of depression, and
nervousness testify to an improvement in the subjects’ quality of life. Researchers from
Shiraz University, who conducted an eight-week yoga course for women with breast
cancer-related lymphedema, came to similar conclusions. They noted that Yoga exercises
could influence most of the functional and symptom-related aspects of QoL in women
with breast cancer. A significant increase in physical, cognitive, and emotional functioning
and a significant reduction in pain, fatigue, insomnia, and financial difficulties should be
noted as the positive result of yoga exercise [
99
]. Zhi et al. note that yoga may reduce
feeling in patients with chemotherapy-induced peripheral neuropathy [
100
]. Although
the researchers point to the need for additional studies, our patients’ feelings of anxiety
decreased significantly.
The improvement in subjective feelings of tension, stress, and health anxiety that
we have observed in patients, may also be related to the fatigue reduction observed
by J.E. Bower et al. The analyses showed that yoga intervention targeted at improving
fatigue might be a feasible and effective treatment for breast cancer survivors with per-
sistent cancer-related fatigue [
57
]. A meta-analysis by Essen and London researchers led
to similar conclusions, suggesting the need to bolster the evidence [
61
,
101
]. P. S. Sahni
et al. showed that yoga practitioners perceived greater personal control, greater consis-
tency/understanding, less emotional impact, less risk, and greater preventive control over
COVID-19 infection than other individuals. They also showed that physical and mental
health patients of yoga practitioners felt that their practice was an effective therapy in
coping with COVID-19 [
102
]. Similar observation was also confirmed in our study (Table 2,
Figures 35).
Int. J. Environ. Res. Public Health 2023,20, 3770 12 of 17
Table 2.
Question sets in which oncology patients chose one of individual statements that most
characterize their physical and emotional state determined before and after a 3-month yoga practice.
The table presents individual statements with the total number of answers (N) and the percentage
distribution. The analysis was performed for patients who completed the entire yoga practice
program (N = 13).
Answer Before (N) After (N) Before % After %
I am constantly so sad and unhappy that it is unbearable 1 0 7.69 0
I am experiencing constant sadness, depression and I cannot free myself from these experiences 1 1 7.69 7.69
I often feel sad and depressed 5 4 38.46 30.77
I’m not sad or depressed 6 8 46.15 61.54
I often worry about the future 7 5 53.85 38.46
I’m afraid that nothing good awaits me in the future 2 1 15.38 7.69
I’m not too worried about the future 4 7 30.77 53.85
I feel self-loathing 1 0 7.69 0
I’m not satisfied with myself 5 5 38.46 38.46
I’m satisfied with myself 7 8 53.85 61.54
I cry more often than I used to 6 1 46.15 7.69
I don’t cry more than usual 7 12 53.85 92.31
Everything that used to irritate me has become indifferent 1 0 7.69 0
I am constantly nervous and irritable 1 1 7.69 7.69
I’m more nervous and unpleasant than before 5 1 38.46 7.69
I’m no more nervous than I used to be 6 11 46.15 84.62
I sleep well, as usual 2 8 15.38 61.54
I sleep worse than I used to 7 5 53.85 38.46
I wake up a few hours too early and can’t get to sleep 1 0 7.69 0
In the morning, I wake up 1–2 h too early and find it difficult to get back to sleep again 3 0 23.08 0
I’m tiring much faster than before 11 6 84.62 46.15
I get tired of everything I do 0 1 0 7.69
Well, I’m getting more tired than before 2 6 15.38 46.15
Although researchers have considered various styles of yoga, vinyasa, due to its fluid,
dance-like quality, can deepen feelings of satisfaction with the practice. Vinyasa yoga is
called meditation in motion because it focuses on the fluidity of movement, body, and
breath. Calming the breath in a comfortable seated position, activating the deep muscles,
and protecting the spine—the three elements with which the practice begins—facilitate the
focus during class. The fluidity and dynamics of the sequence allows participants to focus
on the exercises. The relaxation at the end of the course provides a rest after the exercises,
making it easier to return to daily activities. The protocol according to which the classes
were conducted took into account all aspects of vinyasa yoga training. Embracing yoga
as a whole-physical activity combined with mindfulness techniques can have a tangible
impact on the perceived quality of life. This does not involve the spiritual aspect of the
practice, which may or may not necessarily accompany the practice of vinyasa, but the
purely physical benefits of movement, conscious breathing, and guided relaxation, as we
have shown in our research.
Limitations of the Study
Despite the fact that both our results and the observations of other researchers demon-
strate a positive aspect of yoga practice that does not carry the risk of