Interventions to Improve CognitiveInterventions to Improve CognitiveInterventions to Improve CognitiveInterventions to Improve Cognitive FunctionFunctionFunctionFunction

AndAndAndAnd

Academic Performance of Medical StudentsAcademic Performance of Medical StudentsAcademic Performance of Medical StudentsAcademic Performance of Medical Students

Thesis submitted in partial fulfillment for the degree of

Doctor of Philosophy in Medical Physiology

By

DR.P.P.SHEELA JOICE

Under the guidance of

PROF. DR. R .GUNASEKARAN

Vinayaka Missions University

(Vinayaka Missions Research Foundation Deemed University)

Arriyanoor, Salem-636 308

Tamilnadu, India

September - 2016

Prof. Dr. R .Gunasekaran

Professor Place : Salem

Department of Physiology Date : 07/09/2016

Vinayaka MissionsKirubananda Variyar Medical College

Salem.

CERTIFICATE

I, Professor. Dr.R.Gunasekaran, certify that the thesis entitled

“Interventions to Improve Cognitive Function And Academic

Performance of Medical Students” submitted by Dr.P.P.Sheela Joice,

for the award of the degree of Doctor of Philosophy in Medical

Physiology is the record of research work carried out by her during

the period July 2011 to September 2016 under my guidance and

supervision and that this has not been formed the basis for the award

of any other degree, diploma, associateship, fellowship or any other

similar titles in this or any other institution of higher learning.

(Signature& Official seal of the guide)

DECLARATION

I, Dr.P.P.SheelaJoice, declare that the thesis entitle “Interventions to

Improve Cognitive Function And Academic Performance of Medical

Students”submitted by me for the award of Doctor of Philosophy in

Medical Physiology is the record of research work carried out by me

during the period of July 2011 to September 2016 under the guidance

of Prof. Dr.R.Gunasekaran, and that has not formed the basis for

the award of any other degree, diploma, associateship, fellowship or

any other similar titles in this or any other institution of higher

learning.

Place : Salem

(Signature of the candidate)

Date : 07/09/2016

ACKNOWLEDGEMENTS

Undertaking this PhD has been truly a challenging experience for

me and it would not have been possible to do without the support and

guidance that I received from many people.

I cannot find words to express my gratitude to my guide

Prof. Dr.R.Gunasekaran, Professor, Department of Physiology,

VMKV Medical College, Salem, without him this thesis would have

remained a dream. Thank you sir for picking me up as student at the

critical stage of my PhD. Thank you sir for everything you have

done in this work.

I am also extremely indebted to my mentor Prof. Dr. K.N. Maruthy,

Prof, Department of Physiology, Narayana Medical College,

Andhra Pradesh, for providing me all his support and

encouragement from the beginning to the last. Under his guidance I

successfully overcame many difficulties and learned a lot. Thank

you sir, for your valuable suggestions and corrections.

I wish to express my thanks to Dr.R.Kannappan, Associate

professor in Department of clinical Psychology, VMKV Medical

College, Salem, for his valuable guidance and support.

I immensely express my gratefulness to the former Dean

Prof. Dr.P.M.Subramaniam, and Prof. Dr.N.Mohan, Dean of

Annapoorana Medical College, Salem, for providing me with all the

necessary facilities and excellent infrastructure to carry out my

research work.

I wish to express my sincere thanks to the former Dean

Prof.Dr.K.Jayapal, of VMKV Medical College, for providing me

with all the necessary facilities. I gratefully acknowledge

Prof.Dr.P.S.Manoharan, Dean, VMKV Medical College, Salem,

for his understanding, encouragement and personal attention which

have provided good and smooth basis for my PhD tenure.

I would like to express my warm thanks to Prof.Dr.S.Anu, HOD

Department of Physiology, Annapoorana Medical College, Salem,

for her valuable suggestions and support. I warmly thank

Prof. Dr.Millind, Vice Principle & HOD, Department of

Physiology, VMKV Medical College, Salem, for his timely support.

I would like to thank all my department colleagues those who

supported me in my work. My sincere thanks to my statisticians,

who helped me to complete this work. I am grateful to all the students

who participated in this research for their valuable timely presence

and support.

A special word of thanks to my husband Dr.P.K.Sudhir, and my

daughter E.S.Dhieksha, who have cheerfully endured the hardships

in my life, with their moral support and constant encouragement.

I also place on record, my sense of gratitude to one and all who,

directly or indirectly have lent their helping hand in this venture.

Above all, I owe it all to The Almighty God for granting me the

wisdom, health and strength for establishing me to complete this

research thesis.

CONTENTS

Sl No

PARTICULARS PAGE

No

1. LIST OF FIGURES l-ll

2. LIST OF TABLES lll-lV

3. LIST OF ABBREVIATIONS V-Vll

4. CHAPTER-I INTRODUCTION 1-9

5. CHAPTER-II REVIEW OF LITERATURE 10-60

6. CHAPTER-III NEED FOR THE STUDY 61

7. CHAPTER-IV OBJECTIVES AND HYPOTHESIS 62

8. CHAPTER-V METHODOLOGY 63-73

9. CHAPTER-VI RESULTS AND DISCUSSION 74-114

10. CHAPTER-VII CONCLUSION 115-116

11. CHAPTER-VIII BIBLIOGRAPHY 117-154

12. ANNEXURE

a. Ethics Committee Clearance Certificate 155-156

b. Questionnaire 157-165

c. Student profile form 166

d. List of Original Paper Publications 167-181

LIST OF FIGURES

Sl.

No

FIGURES Page

No

1. STRESS RESPONSE SYSTEM 18

2.

SCIENTIFIC BASIS MECHANISMS OF YOGA ON

COGNITION 35

3. INFLUENCE OF MEDITATION ON COGNITIVE

FUNCTIONS

49

4.

COMPARISON OF LPS SCORE IN THREE GROUPS

BEFORE AND AFTER INTERVENTION 76

5.

COMPARISON OF HPS SCORE IN THREE GROUPS

BEFORE AND AFTER INTERVENTION 78

6.

COMPARISON OF GLOBAL MOTIVATION SCORE

FOR THE THREE GROUPS IN LPS STUDENTS

BEFORE AND AFTER INTERVENTION

81

7.

COMPARISON OF GLOBAL MOTIVATION SCORE

FOR THE THREE GROUPS IN HPS STUDENTS

BEFORE AND AFTER INTERVENTION

83

8.

COMPARISON OF MEMORY SCORE FOR THE

THREE GROUPS IN LPS STUDENTS BEFORE AND

AFTER INTERVENTION

86

9.

COMPARISON OF MEMORY SCORE FOR THE

THREE GROUPS IN HPS STUDENTS BEFORE AND

AFTER INTERVENTION

88

10. COMPARISON OF ART BEFORE AND AFTER

INTERVENTION IN THREE GROUPS 91

11. COMPARISON OF VRT BEFORE AND AFTER

INTERVENTION IN THREE GROUPS 93

12. COMPARISON OF CFF BEFORE AND AFTER

INTERVENTION IN THREE GROUPS 96

13.

COMPARISON OF ACADEMIC PERFORMANCE

BEFORE AND AFTER INTERVENTION IN THREE

GROUPS

99

14. YOGA AND MEDITATION IN ANS 103

LIST OF TABLES

Sl.

No TABLES

PAGE

No

1. Levels of stress in different stages of medical

students 15

2. Mean and Standard deviation of LPS in three

groups

74

3. Comparison of LPS score before and after

intervention in each groups 75

4. Mean and Standard deviation of HPS in three

groups

76

5. Comparison of HPS score before and after

intervention in each groups 77

6. Comparing GM of LPS in three groups. 79

7. Comparing GM of LPS before and after

intervention in three groups 80

8. Comparing GM of HPS in three groups. 81

9. Comparing GM of HPS before and after

intervention in three groups 82

10. Comparing memory of LPS in three groups 84

11. Comparing memory score of LPS before and

after intervention in three groups 85

12. Comparing memory of HPS in three groups 86

13. Comparing memory score of HPS before and

after intervention in three groups. 87

14. Comparison of ART in three groups 89

15. Comparison of ART before and after Intervention

in three groups. 90

16. Comparison of VRT in three groups 91

17. Comparison of VRT before and after Intervention

in three groups. 92

18. Comparison of CFF in three groups. 94

19. Comparison of CFF before and after Intervention

in three groups. 95

20. Comparison of Academic Performance Before

intervention in three groups. 97

21. Comparison of Academic Performance After

Intervention in three groups. 98

LIST OF ABBREVIATIONS

ABBREVIATION READ AS

ACTH ADRENOCORTICOTROPIC HORMONE

AD ANNO DOMINI

ADHD ATTENTION DEFICIT HYPERACTIVITY

DISORDER

ANS AUTONOMOUS NERVOUS SYSTEM

ANS AUTONOMIC NERVOUS SYSTEM

ART AUDITORY REACTION TIME

AVRT AUDIO VISUAL REACTION TIME

BMI BODY MASS INDEX

CBF CORONARY BLOOD FLOW

CFF CRITICAL FLICKER FUSION FREQUENCY

CNS CENTRAL NERVOUS SYSTEM

CRH CORTICOTROPHIN- RELEASING

HORMONE

CRT CUTANEOUS REACTION TIME

FA FOCUSED ATTENTION

FSH FOLLICLE-STIMULATING HORMONE

GABA GAMMA-AMINOBUTYRIC ACID

GHQ GENERAL HEALTH QUESTIONNAIRE

GMS GLOBAL MOTIVATION SCALE

HPS HIGH PERCEIVED STRESS

IBMT INTERGATIVE BODY MIND TRAINING

IQ INTELLIGENCE QUOTIENT

IYM INTEGRATED YOGA MODULE

LED LIGHT EMITTING DIODE

LH LUTEINIZING HORMONE

LPS LOW PERCEIVED STRESS

LSD LEAST SIGNIFICANT DIFFERENCE

MBSR MINDFULNESS-BASED STRESS

REDUCTION

MM MINDFULNESS MEDITATION

MRI MAGNETIC RESONANCE IMAGING

NPY NEUROPEPTIDE Y

OM OPEN MONITORING

PC PERSONAL COMPUTER

PGIMS POST GRADUATE INSTITUTE MEMORY

SCALE

PNS PARASYMPATHATHETIC NERVOUS

SYSTESM

PSS PERCEIVED STRESS SCALE

RT REACTION TIME

SA SUSTAINED ATTENTION

SD STANDARED DEVIATION

SNS SYMPATHETIC NERVOUS SYSTEM

SPECT SINGLE PHOTON EMISSION COMPUTED

TOMOGRAPHY

SPSS STATISTICAL PRODUCT AND SERVICE

SOLUTIONS

TM TRANSCENDENTAL MEDITATION

TV TELEVESION

US UNITED STATES

VRT VISUAL REACTION TIME

1

1. INTRODUCTION

Medical education in India is on the cross roads. It is a general

saying in the academic circles that the standard of education and

quality of students are deteriorating. These statements are quite

frequency repeated and naturally correlated with the academic

performance of the medical students. The students performances

are evaluated by the summative examinations and the results reflect

the performance. The major causes for the poor performance of

medical students are many. The standard and methodology of

premedical education is one of the mainly noted reason. At the time

of admission the socio economic background, the family support are

other factors influencing the academic standards of students. At the

time of entry to medical school Lack of motivation, absence of firm

goal and direction, multi dimensional distractions, and sudden drastic

change of living environment may have a direct effect on student’s

cognitive performances.

It is one of the major problem encountered by the teachers and

management of the medical collages in India. How to overcome the

problems and improve the standard of medical education is a major

concern for all the stake holders of education. Therefore steps can

be made to improve the quality of education only after the admission

2

of the students. One of the predominant factor adversely affecting the

performance of students at the early stages of their medical course is

stress. In modern times of medical education it has become utmost

necessity to probe various tools available to improve the cognitive

and intellectual performance of the students. When a boy or girl move

out of his or her house for the first time it creates a tremendous and

sudden change in the physical environment. Concurrently a great

change in mental environment. This sudden and drastic change in

mental and physical environment produce a profound impact on the

mental status of the child. In addition to this there will be a drastic

change in food habits which may have a direct impact on physical

health and an indirect adverse effect on mental health. Transitions

between earlier school setting and present day professional college

setting often create a noticeable difference. Student’s experiences the

feeling of moving to an environment that is less supportive compared

to earlier days. These age medical students feel that they are in a

situation with less support from teachers and fewer opportunities for

meaningful engagements [Eccles et al., 2003]. This adolescent age

is a critical period and some adolescents are likely to experience drop

in self competence and academic motivation. Different students react

differently to the same situation. One student may find challenging

what his friend finds stressful. Because it is the interaction between

3

the stressor and the individual and the individual’s response to the

situation that causes stress. Some are likely to undergo identity

crises. This is mostly because most of them are not physically and

mentally prepared to face so many changes in multiple domains in a

short span of time. There it is quite natural that these kinds of medical

students may be more likely to suffer from poor mental and physical

health. This may likely to engage in high risk behaviours and to

display low academic engagements. According to child psychologists

at this age the children are likely to start exploring new ways of

thinking about themselves and their interaction with surrounding

physical and biological environment [Eccles et al., 1993]. Conflicting

feelings are likely to develop, beginning to question their identity and

their feelings of self-worth. Some adolescents are likely to experience

significant fluctuations in mood. The adverse impact of this situation

may lead to more susceptible to depression and anxiety. But anxiety

is not bad in itself. Anxiety is good when it functions like a wake-up

call for you to switch to problem-solving mode. The various biological

changes associated with adolescence have been linked to changes in

arousal motivation and emotion [Steinberg., 2005] and risky behavior

[Ge et al., 1997]. These pubertal changes are in tandem with other

stressful events. At this age there will be a two dimensional impact on

the behaviour of the child. On one side the pubertal hormonal

4

changes and on the other side drastic change in physical and social

environment. These changes collectively influence on mood and

behaviour, the interplay of biological and environmental changes

likely to produce a range of negative psychological and behavioural

outcomes, including symptoms of depression and anxiety. The first

year medical students undergo all these turmoil’s in their life. At this

stage decline in their cognitive skills and academic performance are

expected. To prevent this degradation in the academic motivation and

intellectual performance, first up all one should understand the

precipitating factors. Once the multi factorial causes are understood

remedial measure can be taken.

1.1: Stress:

The Canadian physician [Hans Selye., 1936] who gave stress its

more popular modern day meaning, said that without stress, there is

no life. A moderate levels of stress may act as a stimulant for the

growth of the child. It was perhaps Selye who first suggested, in his

theory on the general adaptation syndrome, that all stressors have

almost the same effects. He divided the syndrome into three parts:

the alarm stage a kin to the fight or flight reaction, the resistance or

adaptation stage where the body tries to repair the damage and the

exhaustion stage where it becomes vulnerable to damage. The alarm

5

stage starts when a student confront danger, this is how student feel

in the beginning. He can almost hear his heart go lub-dub, lub-dub ,

he breathe faster, he can feel strange experiences like butterflies in

his stomach. In the resistance stage, there is a surge of hormones

like cortisol, adrenaline and noradrenaline, his arteries harden and his

blood suddenly has more clotting power to prevent blood loss in the

event of an injury. In fact, researchers at University of California and

Max Planck Institute of Psychiatry in Germany have evidence to show

that stress in infancy or early childhood can impair the development

of communication in the brain. Scientists found that increased

amounts of corticotrophin releasing hormone (CRH), a messenger in

the body’s response to stress, can inhibit the growth of dendrites

(branch-like extensions of a nerve cell that send and receive

messages from other nerve cells). At this juncture it can be

considered a positive step to introduce the adolescent medical

students to yoga and meditation. There are no drugs or surgeries

which can counter act the harmful effects of stress, we have within

ourselves an opposite reaction –the relaxation response. Though the

exact mechanism is yet to be researched, it is clear that with daily

practice of yoga and meditation, the body builds resistance to stress,

and related symptoms diminish.

6

1.2: Yoga:

Yoga can be meaningfully defined as a combination of posture

changing movements with a simultaneous control of respiration. It is

believed that yoga is a practice that emphasizes self-awareness and

self-acceptance. Because of this yoga offer protection against decline

in self-esteem. It is likely to generate a welcoming and supportive

environment, which will be a key in protecting adolescents from some

of the negative outcomes and depression. The psychological benefit

includes improvement in perceived quality of life and lower anxiety.

The adolescent behaviour and decisions made during this period are

likely to have a potential impact on later life outcomes. Therefore

implementing a positive intervention during this entire developmental

stage may have positive effect throughout future life. Yoga is an

important medicine for integrating an individual's physical, mental and

spiritual components to improve mind-body health particularly stress

related illnesses. Telles S et al., [1997] showed that yoga can reduced

fatigue and stress level. Durlak et al., [2011] identified that the

students those who were exposed to yoga practice had significantly

improved their attitudes, academic achievement and socio emotional

skills comparing to those students who did not participate in such

program. Six beneficial effects of yoga was listed they are cognitive

competence, attitudes toward self, accepting positive social

7

behaviour, improved emotional status, better academic performance

and reduction in emotional distress. It may be said that yoga

techniques can be beneficial for people as they navigate the critical

and crucial adolescent years.

1.3: Meditation:

Meditation is defined as self-controlled mental exercise by which the

practitioners focuses on their attention and awareness. It is like

keeping the attention on a particular item or a part of the body.

Though meditation is an inexpensive and effective way to counter

stress, it can be challenging to get started and stick with it. It is one

thing which is best learned from a teacher, rather than from self-help

books. Meditation can be used as a study booster to improve

academic performance [Hall., 1999]. Yoga and meditation modules

offers a great promise of positive transformation. Adolescent’s stage

is the time they face numerous biological, cognitive and emotional

changes; in such people yoga and meditation can do a positive

change in mental health, self-concept and cognition. Hence yoga and

meditation can support the young people as they pass the transition

through the potentially rocky adolescent years. Meditation has

become a popular tool for the management of stress in modern days.

A collective finding from all the researches undertaken by worlds

8

great universities like Harvard, Yale and MIT had suggested that long

lasting intellectual benefits like the capacity to think can be attained

by a regular practice of meditation along with improvement in

reasoning power and memory. “Simple Ways to Beat Stress,” [2008].

Reduction in psychological distress and enhancement in overall well-

being can be achieved by practising meditation. Several research

findings points that meditation may produce higher levels of attention.

Elevated attention may enhance grasping power. If this happens

storage of information as memory is likely to increase. Now it can be

concluded that once memory improves academic performance will

definitely improve. According to the hypothesis of Lutz et al., [2008]

meditation practice consists of three attention regulation subsystems.

There is a link between practice of meditation and improved mental

health, mood and affect, and cognition [Lazer et al., 2000]. Among

these non-invasive tools, the practice of yoga and meditation are very

significant. So in this study an attempt is made to explore the

beneficial effect of yoga and meditation for the improvement of

cognitive functions and academic performance of medical students.

Medical students confront enormous academic, psychosocial, and

existential stress throughout their course, leading to a cascade of

consequences both physically and psychologically. The declined

cognitive function of these students interferes in their academic

9

performance and excellence. Here there are various review articles

showing the importance of yoga and meditation on stress and

cognitive functions.

10

2. REVIEW OF LITERATURE

2.1: Stress:

The term stress is used both by common men and psychologists by

carrying a wide range of meanings. According to one group of

psychologists stress is a “stimulus” and but other group define it as a

“reaction”. However most widely accepted and used definition for

stress given by Hans Selye., [1936]. As a stimulus, stress may be

any external event or internal force that disturbs and upsets the

equilibrium of an organism. On the other hand, it is a response,

according to Selye stress is “a non-specific response of the body to

the demand”. Stress comes from within inside not from outside.

There’s no denying stress, or avoiding it, it is a survival mechanism.

Without stress we will not be motivated or driven towards common

goal.

Present day man’s lifestyle has changed without his awareness,

without knowing and giving a thought of what he goes through. He is

living amidst the network of pressures, tension and stress. It is

commonly said that everyone is facing the menace of stress in one

way or the other to some extent or to a great extent. The focus of our

present day education system is mainly on the production of

mechanical intellectuals, but not on the creation of human beings.

11

Here we lost the ultimate aim of education and life. We all face stress

at some point of time in our life irrespective of profession, strata of

society which we belong, or our position in which organizational

hierarchy. It is a common belief that stress affects everyone and

spares none. Philosophically it is said that, life is full of stress and

strain, to cope up with that is a continuous struggle. Each of us have

our own level of stress, a level of equilibrium within which stress could

be stimulating experience. When stress goes beyond this level only it

become distress and difficult to manage. Bob Montgomery and

Lynette Evans., [1989] in their book “You and Stress”, list five major

components of the stress process. It begins with stressors, which are

factors that cause stress. It can be fight with one of the family

member or a colleague, extra demands at workplace or home, or an

unexciting boring job. Research has found that even uncertainty and

lack of control over a situation can cause stress. Sometimes brooding

over the past and worrying about the future are stressful. The other

contributing components of the stress process can be one’s thoughts,

physiological processes, feelings and behaviour. It is common for an

ordinary man at this stage to feel everything appears to go wrong in

this situation; one can feel hopeless, helpless and resultantly his

action becomes dull. Once this stage comes it may results in reducing

the individual efficiency and effectiveness of playing his role in the

12

family, institution or organization, obviously this will further

compounds his misery. It was shown by [Segrin C., 1999] that stress

is very much prevalent among professional college students. The

stresses of higher education is been related to numerous physical

and mental health problems. This will adversely affect cognitive and

academic performance [Keogh et al., 2006]. According to [Daniel

Goleman., 2006] stress “handicaps our abilities for learning, for

holding information in working memory, for reacting flexibly and

creatively, for focusing attention at will, and for planning and

organizing effectively.” A small amount of stress may act as a

stimulant. But too much stress can interfere student's preparation,

concentration, and performance. At the same time positive stress

can be helpful to students by motivating them to peak performance

[Ratana Saipanish., 2003]. According to recent research at University

Medical centre, Chicago, people who worry a lot are more likely to

develop Alzheimer’s disease. High levels of stress hormones may

damage regions in the brain for memory. There is also evidence to

show that severe stress can derail the immune system. The stress is

often the cause of diseases or it can aggravate the diseases, delay

the recovery. The school and college going students experience

stress which can be easily appreciated that learning and memory can

be adversely affected by stress [Kaplan H.I et al., 2000]. Felsten &

13

Wilcox., [1992] showed the relationship between the academic

stresses pervading the life of students. He said stress produces

adverse impact on mental and physical health of the students, and

their ability to perform schoolwork effectively.

2.1.1: Stress level in medical students:

When the students reach to higher education they are likely to

experience a hostile and highly stressful environment [Ratana

Saipanish., 2003; Sherina et al., 2003]. When the students start

their medical education that will aggravate the state of stress. When

the students starts their medical training that will further aggravate

this state of stress. Aktekin et al., [2001] had showed the high

degrees of stress among the medical students about 21.6% to 56%

other studies by [Chandrashekar et al., 2007; Dahlin et al., 2005] and

others also showed a similar finding of occurrence of stress among

medical undergraduates. Sherina et al.,[2003]; yusoff et al.,[2010]

evaluated the level of stress among students of Malaysian

government colleges. Their findings suggested alarming level of

stress among the students to the extent of 29.1% to 41.9%. Zaid et

al.,[2007] showed that private medical college students has stress

level about of 46.2%. It is an alarming note that the stress level is

higher in medical students compared to other courses students. In the

14

neighbouring country Singapore almost same picture was observed

with a stress rate of 57% among medical students and a much lower

of 47% among law students [ko et al., 1999]. The study of [Aktekin et

al., 2001] in Turkey reported a similar world trend of 47.9% medical

students experiencing stress whereas only 29.2% of students

belonging to economic faculty experience stress. Indian students are

suffering from high level of stress, anxiety, depression and frustration,

which affect them and their families adversely. Deterioration of

healthy value system, due to which our adolescents are failed to

discriminate between “right and wrong”. Daily newspapers report

many of the abnormal tendencies of that can cause affecting

locomotors activity and altered behavioural changes (emotions and

anxiety) [Ambareesha Kondam., 2013].

Medical students experience a strong and continuous sense of

pressure. An attempt was made to evaluate the prevalence of

psychological distress among the different year of medical students

by compiling the works of several scientists. These facts showed that

psychological distress among the medical students were not uniform,

rather it varies depending on the stages of medical training. By

analysing the study report of several authors the following

generalization can be derived.

15

Levels of stress in different stages of medical students is given in

table:1

Year of study Level of stress Source

First year medical students

17.6 to 50% Aketin et al 2001 Guthrie et al 1995

Second year medical students

36.5 to 47.9%

Sherina et al 2003.

Yusoff et al 2011

Zaid et al 2007

Third year medical students

29.8 to 40.5% Sherina et al 2003

Yusoff et al 2010

Fourth year medical students

28.3 to 48.7% Guthrie et al 1995

Fifth year medical students

21.9 to 62.7% Guthirie et al 1995

It was a known and established fact since a long time that medical

students undergo a strong feeling of stress. Multiple attempts were

made to find out the underlying causes, consequences and possible

solutions. It is concluded that there are three major and prominent

reasons. First one is the question of how to study and understand

large quantum of information in a relatively short period and then face

the examinations.

16

So they may not get sufficient time to revise what they have studied

before the examinations. Second issue is the overloading of

tremendous amount of information in modern day medical curriculum

put the medical students under pressure. Thirdly they may not get

adequate time for understanding what they have studied as well as to

recall and memorise the information before the examinations. The

burden of understanding enormous quantum of information will

definitely put the students into stress. When they find that they cannot

do that will lead to a situation of disappointment and frustration.

Students will doubt their capacity to handle the burden of medical

curriculum [Yusoff.,2013]. Van Dulmen S et al.,[2007] had suggested

that the responses for stress are likely to differ based on the levels of

consciousness, and depending on whether stress in physiological or

psychological. Physiological and psychological stress can be

interrelated and one can have an impact on the other.

2.1.2: Physiological and Psychological effects of Stress:

The possible mechanism of action of stress on the body:

1. When a person faces a stressful or threatening situation, neurons

at the hypothalamus a part of brain may secrete a peptide known

as corticotrophin- releasing hormone, or CRH.

17

2. CRH reaches pituitary gland and stimulate to produce

adrenocorticotropic hormone, or ACTH.

3. Scientists suspect that CRH also affects behavior directly by acting

on certain brain regions.

ACTH, meanwhile, passes through the blood stream and causes

the adrenal glands- located just above the kidneys- to produce

cortisol, the best known of the stress hormones.

4. Cortisol increases the amount of glucose available to fuel the

body’s cells, prevents the immune system from over reacting to

injuries, and it also ensures that the brain doesn’t secrete too

much of CRH that keeps the stress response from spiraling out of

control. The schematic diagram given below shows how cortisol is

released in stress:

18

Figure: 1- STRESS RESPONSE SYSTEM:

Medical students may end up with a multifaceted problem and

complications as a result of prolonged stress. Khan et al., [2015]

made an attempt to list these problems as complications in

interpersonal relationships, loss of attention, inability to concentrate

and mental depression in addition to this loss of objectivity, tendency

to make mistakes are also likely to be observed. Over and above

this, stress in medical students can disturb the stability of the

student's health leading to illness. The common symptoms include

giddiness, heart problems, and disturbances in GIT functions,

absenteeism, and poor decision making ability. This even precipitate

as desire for the consumption of drugs and alcohol [O’Rourke et al.,

2010]. Douglas Mata A et al., [2015] cautioned that these risks are

19

likely to continue throughout training, it may even affect resident

physicians particularly with regard to depressive symptoms. German

medical students expressed a high degree of depression at a level of

2.4 times higher than average population. About 23.5% of German

medical students suffered from clinically significant depression

[Kamiar K et al., 2016]. It is natural to expect that the students are

likely to seek various coping skills to overcome the risk of stressful

situations.

According to [An H et al., 2012] the immediate impact of stress is that

it may produce two dimensional adjustments, one intellectual efforts

to overcome stress. If the students cannot manage their stress they

will become less capable to do their work effectively. O’Rourke et al.,

[2010] had suggested that stress levels and physical conditions are

interdependent and interrelated. Medical students are likely to

experience sleep disturbance, fatigue, and nausea because of

examination related stress. It even extends to disturb metabolism,

cause diarrhoea or constipation due to change in bowel patterns. Skin

disorders like acne, dermatitis, and psoriasis, may appear during the

examination time. According to [Rizvi A., 2010] these symptoms are

provoked by increased duration of study hours coupled with the

pressure of completing the courses with good marks. The behavioural

20

changes seen in medical students include their desire to consume

caffeinated beverages with an intention of preventing sleep at the

time of study. Obviously such students increase the quantity and

frequency of drinking coffee, tea, cola and energy drinks.

Physiologically it is seen high consumption of caffeine can cause an

elevation in the levels of adrenal hormones in the blood, both steroid

and catecholamine. Caffeine was proved to have double edged

disturbances in GIT- on one side it will block the absorption of certain

vital nutrients, on the other hand it cause hyper acidity. Disturbance of

mineral homoeostasis is another abnormality. Above all caffeine

decrease blood flow to brain, reduce insulin secretion. As a

consequences glucose homoeostasis get disturbed. On the other

hand stress can cause an elevation in the serum concentration of

several following hormones: norepinephrine, leptin, NPY, nitrite,

adreno cortico topic hormone (ACTH) and adrenaline. Further it can

be noted that high concentration of catecholamine and adrenal

steroids may lead to cardio vascular problems, induce tiredness,

weight gain and behavioural disturbances like depression. An H et

al.,[2012] showed the suppression of immunity and result in peptic

ulcers and heart burn. In females it is observed that there is an

alteration in the serum levels of the hormones of the menstrual cycle;

Because of the fluctuation in the levels of gonado tropic hormones

21

like FSH and LH during the examination periods it may disturb the

normal pattern of menstrual cycle. It is often felt that too much

exposure to stress is very bad at the same time a moderate level of

stress is beneficial as it induce the coping behaviour [Rizvi A., 2010].

When stress whether physical or mental enhance function and

performance it is known as eustress. O’Rourke et al., [2010]have

suggested anxiety disorders are common among large section of

medical students because stress and emotional disturbances are

interdependent. The students who have poor academic performance

are likely to display feelings of academic disappointment [Yussof et

al., 2013].

An attempt is made to list the important and noticeable mental

disturbances that can be produced by stress. The major mental

problems observed include a sense of unhappiness, sleep

disturbances and frustration. The list may further grow by including

the lack of concentration, inability to enjoy normal activities, losing

self-confidence, inability to face difficulties, inability to overcome

problems, inability to make decisions, inability to play a useful part in

things, and believing oneself to be worthless [Firth J., 1986]. Female

medical students may respond to the stress with stronger

manifestations of anxiety. Rizvi A., [2010] had postulated that

22

physiological, psychological and behavioural stressors may produce

marked metabolic disturbances in the body. Stress may also harm

professional effectiveness and usefulness by decreasing attention,

decrease judgement ability. This may hamper the capacity to create

an ideal interpersonal relationship between doctor and patient,

thereby resulting in overall negative impact on medical practice

[Barikana A., 2007].

Stress on one hand disturbs the quality of life in medical graduates on

the other hand it creates poor relationship between the doctor and

patient. Ultimately the quality of medical treatment and care may

suffer the high levels of stress may causes stress related anxiety,

frustration and mental depression. These psychological disturbances

may lead the medical students to drug abuse and create suicidal

tendency. Learning and memory of medical students are likely to be

disturbed and distracted due to chronic stress [Troyer D., 1990].

2.1.3: Stress and yoga:

Stress has been a known factor to affect attention, whereas yoga is

known to improve attention. So attempts have been made to establish

correlations between yoga and stress hoping that yoga may produce

some benefits. Cowan and Adams., [2005] have reported that a short

23

duration of yoga practice twice in a week was able to reduce the

perceived stress. Schure MB et al.,[2008] also suggested the similar

benefit of yoga in a group of students who participated in a 15 week

long yoga course along with other teaching schedule. The study

lasted for 4 years the findings were reported and emphasized the

beneficial effect of yoga. The positive benefits are seen in

physiological, psychological, sociological and in their spiritual

wellbeing. The beneficial effects produced by yoga was summarised

as, it produce a higher level of concentration, elevated degree of

mental clarity and increased availability of energy. Subjects identified

that participation in this mindfulness exercises, was useful to find the

causes of their stress, and to get rid of stress and other bad feelings.

The study relied on a self-report data that have been falsely positive

because it was required for a course, the study also strongly presents

some of the potential benefits of yoga that are recommend by other

researchers expand upon quantitatively.

The claims and hypothesis made by several other researchers

regarding the positive benefits of yoga and meditation has given us a

strong foundation for our present study. We presumed that if the

practice of yoga can lower the degree of stress and thereby improve

24

attention and concentration ultimately it will improve the academic

performance.

2.1.4: Stress and Meditation:

In recent years scientific community have developed very much

interest in the meditative practices in general and particularly with

regards to how meditation can affects brain function [Lutz et al., 2007;

Austin., 2009; Slagter et al., 2011]. It is nice to note that there is a

possibility of meditation training that leads to enduring changes in

brain function, even outside meditation sessions [Slagter et al.,

2011]. Relaxation need to be a primary objective of meditational

practice, mostly it is seen as the by-product of meditation. In the firm

opinion of [Kabat-Zinn., 1996] relaxation is taught as a stress

management technique to be used during stressful or anxiety

provoking situations. Meditation, in contrast, is not a technique whose

use is contingent upon stressful situations, but rather is conceived of

as a “way of being” that is to be cultivated regardless of day-to-day

circumstances. It is commonly believed that performance of the

student in an examination can be influence by the degree of stress. A

mild degree of stress may help to improve the scoring in examination,

but high levels of stress may likely to impair intellectual capabilities

25

needed for learning which will result in poor academic performance. It

can be concluded that presence of stress will disturb the mental

stability, enhance anxiety and produce depression. This state may

hinder concentration and focussing, this will in turn result in poor

grasping ability. A similar findings were reported by [Bremner and

Narayanan., 1988]. They showed a direct interrelationship between

high degree of stress and its negative manifestation as loss of

memory. This will intern definitely reduce the ability to learn. The

conclusion made by [Daniel Goleman., 2006] is very beautiful. He

summarized saying stress “handicaps our abilities for learning, for

holding information in working memory, for reacting flexibly and

creatively, for focusing attention at will, and for planning and

organizing effectively.” A long periods of continuous research by

people like [Baer., 2003; Brown et al., 2007; Murphy & Donovan.,

1997] with a community based study involving students general

public and practising doctors showed a convincing proof that

medication can prevent negative impact on mental state, reduce

stress and anxiety. At the same time it is likely to improve mental well-

being. [Shapiro et al., 2006] evaluated the benefits of MBSR practice

in refusing the stress level and overcoming negative mental health.

This finding provides support for the claim that mindfulness practice

can produce a positive benefit. Oman et al., [2008] in their recent

26

study have established that college students can be relieved of their

stress by subjecting themselves to a meditation based stress relief

program. Interestingly the researchers found a correlation between

participation in the meditation and forgiveness. A Chinese study by

[Tang et al., 2007] that indicated that even a short duration of

meditation training can produce a beneficial effect. In this study a

sizeable group of students have undergone short meditation training.

It was shown that the students who were exposed to this type of

course performed better on the attention network test, showed lower

levels of anger anxiety and fatigue. Even the biological indicator of

stress namely cortisol level in the blood showed a significant drop

with a simultaneous elevation in immunity. Benson H., [1975]

suggested hypertension can be managed by “relaxation response”

technique a type of meditation. He even suggested that control of

mind by meditation can avoid various stressful states and also the

disorders caused by them.

2.2: Yoga:

Yoga is an ancient discipline that brings balance and health to the

mental, physical, emotional, and spiritual dimensions of individuals.

Yoga is often depicted metaphorically as a tree and comprises eight

aspects, or ‘‘limbs:’’ yama (universal ethics), niyama (individual

27

ethics), asana (physical postures), pranayama (breath control),

pratyahara (control of the senses), dharana (concentration), dyana

(meditation), and Samadhi (bliss) [Iyengar BKS., 1976]. The word

yoga and English equivalent word “Yoke” are originated from ancient

Sanskrit word “YUJ” are derived from Sanskrit root “yuj” which refers

to union. Madanmohan., [2008] said that yoga is “a psycho-somatic,

spiritual discipline for achieving union and harmony between our

mind, body and soul and the ultimate union of our individual

consciousness with nature” the ancient Hindu text “yoga suthra”was

the basis for modern days yoga [William Broad J., 2012].

It was shown by earlier studies that physical activity and meditation

may improve attention. Therefore we can postulate that yoga being a

combination of coordinated physical exercise and meditation practice

it can be able to improve attention.

There are 8 limbs of yoga which can be treated as 8 steps. Each step

is aimed at one particular benefit. The ultimate achievement of yoga

is a perfect state of enlightenment which is called as “Samadi”. The

western world emphasises on the third step namely “aasana” or

physical postures. The fourth limb concentrate on breathing control

or “pranayama”. The seventh step is meditation or “dhyana”. In

28

western countries a combination of three limbs of yoga namely

“aasana” “pranayama” and “dhyana” are incorporated [Burgin T.,

2012]. Each form of yoga has a different purpose, but all of them

focus on “components of meditation, breathing, and activity or

postures”[Oken B S et al., 2006].

Hatha yoga mainly focuses on the union of mind-body-spirit through

practice of asanas (yoga postures), pranayama (yoga breathing),

mudra (body gestures), and skatkarma (internal cleansing). Hatha

yoga focuses on creating balance within our body. This is a balance

between the active and relaxing mind between strength and flexibility

in the body. Timothy McCall, author of “Yoga as Medicine,” says that

although vigorous practices like sun salutations and some breathing

exercises stimulate the SNS, research has demonstrated that such

vigorous practices followed by relaxation leads to deeper relaxation

than practicing relaxation alone. A well-rounded yoga practice often

begins with sun salutations and closes with shavasana or meditation.

Because yoga includes both sympathetic and parasympathetic

activation, your body and brain become even more relaxed into the

PNS baseline. Iyengar yoga is a branch of Hatha yoga, which

focuses on improving physical and mental well-being through

stretching of all muscle groups for strength, flexibility, and physical

29

balance. It consists of asanas performed in circuit that use isometric

contractions and relaxations of different muscle groups [Oken B S et

al., 2006]. Sahaj yoga is a simple technique that primarily focuses on

dhyana-meditation. A typical Sahaj yoga session consists of

questions and assertions by subjects followed by silent meditation.

The hands are placed in different positions throughout the session.

The goal is to mainly achieve a state of “thoughtless awareness”

[Sharma VK et al., 2006]. Another form of yoga is cyclic meditation. It

is mainly comprised of alternating cycles of asanas with periods of

supine relaxation. It alternates with awakening and calming of mind

and body [Sarang SP., 2007]. Sarang SP., [2006] has shown that

cyclic meditation cause “reductions in heart rate, respiratory rate, and

oxygen consumption”. Between 1996 and 2001, there was 50%

increase in American adults practicing yoga (Casden., 2005). Year

2015 is marked with world accepting yoga for human peace and

harmony, June 21st being declared as “International Yoga Day” by

United Nations Organization. Health scientists have carried out

extensive research projects in investigating the wide-ranging effects

of yoga on the body, mind, and psyche [Oken et al., 2006; Casden.,

2005]. Hatha yoga believes that by the combination of practice of

“aasanas” (yoga postures) “pranayama” (yoga breathing control)

30

“sathkarma” (internal cleaning) one can achieve a union of body mind

and spirit.

Hatha yoga aims at creating a perfect balance of body and mind,

equilibrium between active and passive relaxation of mind, and

balance between force and relaxation of muscles. Iyyangar yoga is

considered as a main branch of hatha yoga. This style of yoga

believes that a better physical and mental wellbeing can be achieved

by bringing a stretch on every group of muscles which will improve

the strength, flexibility and physical fitness. It is based on performing

different asanas in a regular pattern, producing an isometric

contraction and relaxation of various groups of muscles. On the

contrary sahaj yoga is a simple technique which aims at meditation-

“dhyana”. A regular force of sahaj yoga is composed of generating

questions and assertions by the person which is followed by silent

meditation. During this practice hands are kept at different positions.

Cyclic meditation is another common type of yoga. It is practiced by

alternating cycles of asanas or postures with durations of relaxation in

supine posture. It is likely to bring about cycles of “awakening” and

“calming” effect both to the body and mind. Casdon., [2005] has

noted that about 50% enhancement in the number of American

people practicing yoga was recorded during the period 1996 to 2001.

31

Medical scientist throughout the world carried out extensive research

studies to understand the impact of yoga on individual’s body, mind

and spirit.

Yoga philosophy thus helps one understand the world and become

aware about oneself. Yoga philosophy is a practical philosophy of

self- observation and inner inquiry. It is learnt by applying in daily life.

The analysis shows that majority of the students have a positive

attitude towards yoga and neither have objections if anyone practices.

They don‘t see yoga as a religion but as a form of physical and

mental exercise but believe that yoga can help them improve their

spirituality.

Even though many of them don‘t know the actual benefits or practices

of yoga they still believe that yoga is one of the best ways to maintain

good health of mind and body. Many of them meditate and do

breathing exercises to reduce stress, but they don‘t find yoga being

popular among college going students. Majority of them don‘t seem to

agree that the health sector in India has done enough to promote

yoga and are unhappy about it, they feel this because they have not

seen any promotion event on yoga or have not seen an

advertisement on TV.

32

It is observed that youth ignore yoga as they might have other better

options or they might not have any knowledge about it. They feel that

media should promote yoga through celebrities it can be effectively

promoted. The main reasons for people don‘t practice yoga could be

that they don‘t have enough knowledge about it, they are not trained,

they are lazy and feel its time consuming, they are busy and don‘t find

time to practice yoga, they are unaware of yoga‘s health benefits,

they might be attracted to other ways to maintain good health.

Thus the study tries to understand the beliefs and attitudes of college

students and tries to make use of the data in understanding where

yoga can be placed in the lives of students and how it can be a part of

the lifestyle of students.

2.2.1: Benefits of yoga:

2.2.2: Yoga on cognitive function and global motivation:

What is cognition? According to [Kendra Cherry., 2014] it means the

higher intellectual functions of the brain and includes thinking,

perception, logic, reasoning, memory, attention, planning, language,

and problem solving. It also include collection, processing and storing

of information by the brain that needs attention, memory and

executive functions (planning, problem solving, self-monitoring, self-

33

awareness). The language function comprises of comprehension and

formation of speech [Sohlberg et al., 1989]. The calculation ability

[Roux et al., 2003] visual perception and praxis skills are other forms

of higher functions of the brain [Donkervoort et al., 2000]. Cognitive

processes happens both in conscious or unconscious states and

often are divided into basic level skills (e.g., attention and memory

processes) and executive functions [Schutz et al., 2009].

According to modern psychology attention is a continuous process

of selecting out what is needed and discarding unwanted data from

the surrounding environment and of concentrating on any

particular point [Ashcraft., 2005; Goldstein., 2007]. Intellectual

functions are processes which have multiple dimensions like by which

one to note, understand and remember. This enables us to detect the

problem, recognize its seriousness reach at the logical judgement

and then perform the work. Several earlier studies had shown that

improvement in intellectual faculties like higher levels of perception,

critical thinking, logic, and greater memory can be achieved by

practicing yoga. The yogic practice of dhyan and shavasan are

useful to enhance attentiveness and thereby decreases reaction time

so that one can respond to situations much faster. Reaction time

refers to the speed and efficiency of processing of information at the

34

central nervous system and a simple tool for evaluating sensory-

motor performance. It was pointed out that a significant reduction in

visual and auditory reaction times by practising yoga

[Madanmohan et al., 1992 ; Malathi et al., 1989]. Bhavanani et al.,

[2003] showed that practice of mukhbhastrika pranayam (a yogic

technique in which deep inspiration is followed by forceful expiration)

can reduce reaction time. A decrease in reaction time indicates a

better sensory-motor integration and faster processing capacity. The

possible basis for this is due to greater arousal, faster rate of

information processing, improved concentration and / an ability to

ignore extraneous stimuli. Practice of yoga based relaxation

technique was definitely useful to improve scores on Letter

Cancellation task; a left-hemisphere dominant task with minimum

mistakes [Sarang and Telles., 2007]. These results suggest that yoga

practice brings about a greater improvement in this task which

requires selective attention, concentration, visual scanning abilities,

and a repetitive motor response. Findings from several research

studies clearly suggests the beneficial effects of yoga and meditation,

especially long-term practice, in improvement of the brain functions,

including the ability to concentrate and perform better in certain

tests. Long-term practitioners of yoga and meditation can achieve

35

better attention span, higher processing speed, ability to alternate

attention so naturally do better perform in interference tests.

The schematic diagram present below explain the possible scientific

basis for this mechanisms [Balasubramaniam M., 2013].

Figure 2: SCIENTIFIC BASIS MECHANISMS OF YOGA ON

COGNITION

2.2.3: The Effects of Yoga on Memory:

The philosophy of yoga science believes that the body and mind are

in constant interaction. It cannot be separated, there is no such a

36

point where the body ends and mind begins. These both are

considered to be a single, integrated entity. Asanas brings benefits to

the brain by influencing the chemical balance. The physical impact of

yoga on the body is giving good strength and power to the body, and

also restoring stamina and increase the circulation of fresh blood

throughout the body. These changes can wake and fresh up the mind

and improve memory and also protects the body from diseases and

toxins generated by unhealthy lifestyles and habits [Iyengar BKS.,

2007].

Memory in modern science:

Memory is defined as the ability to recall and retain past events or

previously learnt information or skills. Memory is the term given to the

mechanisms and processes that is involved in the storage and

subsequent recall of information. The learning ability mostly depends

on the concentration and recalling power (memory). Research studies

have established that practices of yoga influence both these concepts

of improvement of memory thereby enhance learning ability [Kauts A

et al., 2012]. There is no doubt that memory is essential to all our

lives. Without the past memory we cannot operate in the present nor

think about the future.

37

Several studies have proved that practice of yogic exercises and

positive modification in life style can be beneficial to protect against

the negative impacts of stress on cognitive function, and also thereby

improving concentration and memory [Froeliger BE et al.,

2015;Longstreth H., 2014; Rocha KKF et al., 2012; Gothe N et al.,

2013;]. The same view point was earlier suggested by [Kocher.,

1976a] telling that regular practice of yoga increases both memory

and perception. He also claimed that yoga practice delays mental

fatigue.

Pasek and Daniel., [1984] showed that stress can be managed by

yoga practice. Memory and proper clear perception help for better

learning. Sometimes, learning is affected due to appearance of

mental fatigue, which is a state of disturbed perception and memory.

It is a fact that regular practice of yoga can improve both memory

[Kocher., 1976a] and perception on one hand and delay mental

fatigue [Kocher., 1976b] on the other hand. Thus yoga proves the

importance in improving learning ability and thereby enhancing

academic performance [Bera et al., 2004].

38

2.2.4: Yoga in anxiety:

Several studies have proved that the practice of yoga can lower the

basal anxiety scores significantly. Kozasa et al., [2008] reported that

practice of yoga program can significantly reduce scores on anxiety,

depression, and tension, reduces self-reported symptoms of

depression. Similarly, it was reported women suffering from mental

disturbances felt better by practising a short course on yoga probably

by bringing a significant betterment in the level of perceived stress,

reducing anxiety state and improving the feeling of subjective well-

being. This is evidenced by the decrease in salivary cortisol, degree

of fatigue and depression [Michalsen et al., 2005] .These studies

indicate that depressive and anxiety disorders can be controlled to a

great extent by practising yoga. [Malathi and Damodaran., 1999]

tried to establish a positive correlation between practice of yoga and

the degree of anxiety in first year MBBS students during regular

academic activities period and prior to examination. They found that

students exhibits a lower level of anxiety as measured by

Spillberger's anxiety scale. The benefit of yoga was reflected by

significant elevation in passing rate in the examination among yoga

practising students as compared to the control group. Multiple

beneficial effects are enjoyed by the people practising yoga. The most

noted overall benefits can be listed as feeling of relaxation, better

39

sense of well-being, enhanced ability to focus on improved work

efficiency. The other supplementary gains include improved

interpersonal relationship, better attentiveness, lowered distraction

levels, and an optimistic outlook in life. These findings suggests a

two dimensional benefit from yoga. On one hand it causes reduction

in basal anxiety level on other hand it also nullifies the elevated

anxiety state during stressful conditions like examinations. Obviously

when anxiety level decreases by practising yoga it is likely to create

a better coping up ability to both internal and external stress causing

agents. So it can be concluded that once they are relieved of the

burden of stress they are able to do their duties with calm disposition

which will definitely improve their performance. It was reported that

even a short duration of yoga practice can able to lower the level of

stress and anxiety status in practitioners with overreaching benefits.

2.2.5: Yoga in attention and concentration:

Attention is a required factor for intelligence. Attention has two

dimensions- one it can act as a resource, secondly it can play as a

skill for utilization of resource. The ability to attend to a particular work

in hand for a long duration of time is considered as required sustained

attention (SA). It is strongly interrelated with the mental effort

required to carry out the work in hand [Posner MI et al., 1978]. Among

40

the students the SA is reflected in their capacity to listen and

understand a class for a long duration of time at a stretch. It is shown

that several different brain areas participate in attention, there are

various types of attention and each of them are managed by different

areas of brain. SA is managed by the parietal area of brain. SA

reduces whenever there is a damage to the right prefrontal cortex

[Rueckert L et al.,1996]. Earlier studies on SA by [Saltz E., 1970]

suggested that improvement in performance on tasks requiring SA

can be achieved by decreasing anxiety by the practice of yoga

[Wallace RK et al., 1971; Rangan R et al., 2009]. A series of studies

by [Telles S et al., 1993; Sarang SP et al., 2007; Telles S et al., 2007;

Saltz E., 1970] have shown that improvement in attention span in

school children can be brought about by the combination of physical

forms of yoga like postures (Asana), voluntary controlling of breathing

(Pranayama), along with practising silence and visual focusing

exercises (Trataka). Yoga may enhance self-esteem in students,

there by improve the adjustment ability. Stress has an implication for

lowered self-esteem in students, and it was reported that regular

practice of yoga by medical students for a longer period may possibly

result in improved management of their daily stress [Posner MI.,

1978]. According to ancient yogic texts yoga has two components

“calming” and “stimulating”, the combination of both yogic practices

41

helps in increasing the span of attention [Telles S et al., 2000].

Sharma VK et al., [2006] demonstrated the effects of yoga on

cognitive functions as reflected by an improvement in memory and

attention. Stress show cognitive reactions resulting in an inability to

concentrate [Sailer HR et al., 1982]. It was reported that reduction in

stress can be produced by practicing transcendental meditation and

simultaneously decreased stress improves attention leading to an

enhanced academic performance [Wallace RK et al., 1983]. In the

opinion of [Naveen KV et al., 1997] yogic practices like asana,

pranayama, Vedic chanting, and meditation enhances attention, self-

esteem and improves visual and spatial memory [Telles S et al.,

1993]. Practicing super brain yoga by using the thumb and a finger to

apply pressure to each earlobe while doing knee bends and taking

breaths shows increased class participation, concentration, improved

quality of academic performance and social skills in a sample of US

school students [Chandrasekeran A., 2014].

2.2.6: Yoga in Academic performance:

Modern days, life is full of competitions and students are living in a

competitive world. Students are pressurized and compelled to do

well in their field. Thus there is a need to develop memory,

concentration among them. Many college students feel driven to

42

short cut methods to improve their memory and performances. They

are likely to try to improve their concentration and academic

performance by short cut methods of using drugs. So it is a must to

look for better and legal alternatives for improving attention and

concentration. De Santis et al., [2008] reported that college students

resorted to the use of illicit drugs as a stimulant was to enhance the

ability to concentrate on the academic work and to perform well.

Lee.,[1999] pointed to the yoga sutras’ “directions for understanding

life techniques fully , including the use of the body and the breath

and meditation, for attaining deeper wisdom;” such wisdom obtained

can surely be seen to incorporate with academic achievement.

2.3: Meditation:

Meditation is derived from meditatio, meaning to think, contemplate,

devise, and ponder, [Nathan Bailey., 1773].Meditation was introduced

as a translation for eastern spiritual practices. According to

[Goleman., 1988; Walsh., 1999] meditation is an essential element in

all religious and spiritual beliefs. Nowadays an attempt is made to

teach meditative practices in secular forms without binding to any

religious beliefs [Hart., 2007; Duerr., 2004]. Practice of meditation

enhances secretion of Dopamine, Acetylcholine, GABA, Serotonin,

Endorphin and Encephalin which cause an inner happiness,

43

concentration, memory, emotional maturity and overall fitness of the

body and mind [Joshi B.P ., 2016].

2.3.1: Types of meditation:

Based upon how the attentional processes are directed meditation is

broadly classified into two types: mindfulness and concentrative. But

practically most of meditation techniques lie somewhere in-between

the poles of these two general methods [J.Andresen., 2000; D. H.

Shapiro., 1984].

2.3.2: A type of meditation is mindfulness meditation:

Open Monitoring (OM) is another term used to denote mindfulness

meditation. In this type of mindfulness meditation the practitioner

maintain a specific attentional stance: and simultaneously allow

other feelings and thoughts, to arise. Examples include Zen,

Buddhist practice called Vipassana, and the modified version of

mindfulness meditation by the western people[J. Kabat-Zinn., 2003].

OM meditation aims to maintain a continuous state of monitoring (i.e.

clear reflexive awareness). While practicing OM meditation one can

meditate without explicitly focusing on any object, rather by being

attentive moment to moment, to everything.

44

2.3.3: What is concentrative meditation?

This type of concentrative meditation practice depends on

concentrating on specific mental or sensory activity: like repeating

same sound, focusing on a particular image, or focusing on breath.

So it can be called as Focused Attention (FA). Certain forms of yogic

meditation and the Buddhist sanatha meditation are the common

examples for FA and it mainly focus on the sensation of breath [B.

Rael Cahn et al., 2006]. In FA meditation one has to constantly

monitor the quality of attention. As attention will move away from

focusing point, and we have to notice that, and then restore attention

to the chosen object. While a person is focusing on any specific

image, suddenly he may get distracted by pain in his knee. At this

point of time person will try to overcome the distraction and has to

come back to attend original focusing point. Transcendental

Meditation (TM) is considered as a popular type of concentrative

meditation. While one group of researchers classify TM as a kind of

FA, other group maintains TM to be a separate class of meditation.

Transcendental meditation practice involves a mantra. This practice is

centred on repetition of mantras. However, unlike most mantra

mediations, any possible meaning of the mantra is not part of TM

practice. Rather, the individual is trained to appreciate the sound

45

value of the mantra at more refined ‘levels’ [Maharishi Mahesh Yogi.,

1969].

Some modified versions of meditative practices try to combine and

integrate the aspects of both concentrative and mindfulness types of

meditation. This can be achieved by clubbing focus on breathing (Zen

and Vipassana meditation) and uttering a mantra (eg: Transcendental

Meditation), but will permit have attention on other stimuli if they

become great, before returning to the object of attention.

According to [Kabat-Zinn., 1990], meditation is different from

relaxation training. Relaxation is characterized by progressive and

continuous muscle relaxation which is achieved by self-training.

Relaxation training need the maintenance of a particular

psychophysical state of decreased autonomic activity but meditation

require maintaining experiences as they present themselves in a

continuous basis; [Shapiro et al., 2006].

2.3.4: Benefits of meditation:

2.3.5: Cognitive enhancement:

Cahn & Polich., [2006] have reported that improvements on cognitive

performance can be seen in people who have undergone extensive

meditation training and Davidson et al.,[2003] showed the betterment

46

in mood by practising meditation. It was reported that enhancement

in attentional [Jha et al., 2007] and visuo-spatial processes can be

attained by long term meditation practice [Kozhevnikov et al., 2009].

Moore and Malinowski., [2009]showed that a short duration of

intensive meditation training improved the capacity of students to

retain attention during a dichotic listening task as evidenced by faster

reaction times in response to a deviant tone of teacher. It was

reported that experienced practitioners of Buddhist meditation can

have a strong positive correlation between mindfulness meditation

and sustained attention when compared to controls. Findings of

several studies establish that higher levels of intellectual processing

can be achieved by practising mindfulness meditation (MM).

Meditation is considered as a mental practice by keeping a relaxed

state of mind one can focus on the sensations of the breath/body.

During routine meditation, distractions are likely to happen but

meditator is taught to acknowledge discursive thoughts, and non-

judgmentally return his/her attention back to their breathing [Wallace.,

2006]. Mindfulness training cultivates moment-to-moment awareness

of the self and environment, Mindfulness meditation enhances meta-

cognitive processing [Austin., 1998]. Extensive and prolonged

practice of mindfulness meditation can enhance alertness and conflict

47

managing [Cahn & Polich., 2006; Jha et al., 2007], so it is believed

that enhancement in meta-awareness can be reached by practising

mindfulness meditation. This process helps the practitioner to avoid

irrelevant information so that longer duration of attention can be

maintained. So far, the studies have shown improvement in

intellectual functions only among regular meditators [Cahn & Polich.,

2006].

Recurrent mindfulness practice can be used to promote trait

mindfulness [Carmody et al., 2008] suggested that individuals

participating in an eight-week Mindfulness-Based Stress Reduction

course evidenced increases in trait mindfulness which mediate the

effects of training on clinical outcomes. Certain aspects of meta

cognition can be strengthened and improved by the practice of

meditation, especially the ability to be aware of one’s mental

processes through monitoring one’s mind [Segal et al., 2002].

Practice of meditation can help in learning process by increasing

awareness of one’s habitual thought patterns, enhancing information

retention. Practice of mindfulness based meditation can be used as a

cognitive therapy for a debilitating mood disorders (chronic

depression) that is driven by dysfunctional thought patterns that has

shown to be significantly useful [Ma & Teasdale., 2004; Teasdale et

48

al., 2000]. Shapiro et al., [2006] tried to explain how practice of

meditation may improve one’s cognitive functions. According to him

by practising meditation one can overcome internal conflicts, can

balance emotional state and can be more objective in dealing various

sensory inputs. This whole process is termed as ‘re-perceiving’.

Emotional intra personal and inter personal interactions can be

improved by the regular practice of yoga. This is brought about by

enhancing awareness of one’s internal states related to cognitive,

affective, and somatic aspects with the resulting ability to regulate

emotions more effectively. All these studies leads us to a conclusion

that students can acquire extra abilities and skills for managing the

stresses which they commonly face, due to competing demands of

academic worry by practising different types of mindfulness

meditation. Mindfulness-based meditative practice aims at emotion-

focused adjustments by accepting difficult cognitive and emotional

states in contrast to many cognitive-behavioural approaches aimed to

overcome stress. Lazar SW., [2005] reported the findings of a study

conducted by a group of Harvard neuroscientists. In their experiment

16 people were submitted to an eight-week mindfulness course, using

guided meditations and integration of mindfulness into everyday

activities. The results showed that MRI scans depicted that the grey

matter concentration increases in areas of the brain involved in

49

learning and memory, regulating emotions, sense of self. Other

studies also show a larger hippocampal and frontal volumes of grey

matter for long-term meditators. The figure given below represents

the influence of meditation on cognitive functions.

Figure:3 INFLUENCE OF MEDITATION ON COGNITIVE

FUNCTIONS

[l-V] shows both direct and indirect ways of effect of meditation on

cognition [l] shows that meditation have positive influence on

hypercholesterolemia and hypertension which represents as a risk

factors for Alzheimer’s disease .It also seen to increases cerebral

blood flow [II] and has a protective effect on the cortical thickness [III].

Meditation also reduces stress [IV] anxiety and depression [V].

50

All these given mechanisms together lead to better cognitive

functions [Rafał Marciniak et al .,2014].

2.3.6: Memory:

The memory is one of the higher function of the brain to store and

recollect information of both verbal and nonverbal nature at a later

time and date. According to Patanjali yoga sutras, ‘memory is an

experienced object not being lost from the mind’. Explicit or

declarative memory is that, which can be brought to conscious

awareness. Visual and spatial memory is an important part of explicit

memory [Rao SL et al., 2004]. Anterior areas of the temporal cortex

are involved in representation of verbal conceptual knowledge

organized categorically [Thompson-Schill SL et al., 2003].

Earlier studies by [Alexander CN et al., 1979; Wallace RK et al., 1980]

have shown that there is improvement in academic performance in

subjects performing transcendental meditation. Sarina Grosswald J

et al., [2008] studied to understand the mechanism how to decrease

stress and anxiety by the practice of transcendental meditation. A

group of students of age ranging 11-14 years were made to practice

TM twice daily in school. The observation of this study revealed that

practice of TM produced a significant reductions in stress and

51

anxiety levels and improvements in ADHD symptoms. It is an

accepted fact that stress reduces working memory. Therefore it can

be concluded that since stress can be reduced by meditation,

betterment of working memory is the natural consequence of

practising meditation. Hölzel et al., [2011 ] examined differences in

brain structure between participants received an 8-week mindfulness

training program and a waiting list control group. Whole brain

analyses identified increases in the posterior cingulate cortex, the

temporo-parietal junction, and the cerebellum in the mindfulness

training group compared with the controls.

2.3.7: Attention and concentration:

Practice of meditation improves cognitive functions and performance

in attentional tasks by improved ability of attention, increased

maintenance of attention skills. This view point was supported by

several authors like [Valentine and Sweet., 1999; Carter et al.,2005;

Cahn and Polich., 2006; Slagter et al.,2007; Hodgins & Adair., 2010].

These positive benefits are strongly correlated with anatomical and

physiological alterations seen in brain of meditators compared to

controls. A strong theoretical framework and background for the

study of meditation were given collectively by several scientists like

[Hoelzel et al., 2011; Luders et al., 2011; Kang et al., 2013; Lutz et

52

al., 2008]. There are three subsystems in meditation practice.

Meditation comprises of three things – ability to have selective

attention, which relates to the selection of information from the flow of

sensory inputs. Secondly meditation also requires continued attention

for longer monitoring of the object of meditation. Finally while

meditating; one often has to have the ability to detect distraction and

able to quickly redirect attention from a source of distraction toward

the intended object of meditation.

2.3.8: Academic Performance:

Several scientific studies have revealed that regular practice of

meditation improves overall performance of a person who practices it.

Miskiman., [1972] suggests in his studies superior learning ability

and improved ability to focus on attention, effectively can be made

possible by practicing the TM. The people practising TM program

shows a better ability to organize thoughts, a quality important to

memory and abstract thinking. Tjoa., [1972] found subjects who were

regularly practicing the TM technique increased intelligence and

decreased neuroticism. Collier.,[1973] studied highly significant

improvement in students grades in the very first month after learning

TM. This emphasizes us this technique is of great value and

important to improve the academic performance and achievement of

53

students. Hjelle., [1974] clearly states that subjects practicing T.M.

were more self-actualizing, more internally controlled and less

anxious. Howard., [1975] states positive changes in high school

students practicing the TM technique in creativity and intellectual

performance. Wegnar and Bagchi., [1961] in their study found that

through meditation practice one can have control over the activities of

Autonomous Nervous System (ANS). Wenger et al., [1961] studied

meditation processes can control certain “involuntary” physiological

functions for the benefit of the subject. Vanselow., [1968] said that TM

can be used as a therapeutic tool for relieving mental and physical

tension. Wallace., [1969] found that practice of Transcendental

meditation can make significant reduction in metabolic rate, changes

in blood biochemistry, increase in skin resistance and a consistent

pattern of changes in electrical activity of the brain. Wallace., [1971]

distinguished the state produced by TM from commonly encountered

states of consciousness and suggested that it may have practical

applications. Tjoa., [1972] proved that subjects regularly practicing the

T.M. technique showed improved intelligence and decreased

neuroticism. Dennis., [1974] observed an increase in grade point

average in student who were practicing T.M., and also he further

suggested TM can improve the achievements of students at all levels

of education.

54

2.3.9:Meditation in general health:

Udupa., [1978] observed the importance of meditation on biochemical

parameters and found that it lowered plasma cortisol, urinary nitrogen

and this suggest a less stressful state. Lovell-Smith., [1982] have

proved that regular practice of transcendental meditation could

improve general, physical, mental health, and simultaneously an

improvement in overall wellbeing as reflected by a relief from

insomnia, decreased need for tranquilizers, and in some headaches.

Vanden Berg and Mulder., [1976] found in Transcendental Meditation

(T.M.) practitioners greater self-esteem, better self-image, greater

ego-strength, satisfaction and self-actualization while less

neuroticism, depression and less sensitivity to criticism.

2.3.10: Yoga and Meditation in Auditory Visual Reaction Time

and Critical Flicker Fusion Frequency:

The reaction time can be defined as the time interval between

application of a stimulus and presentation of an appropriate voluntary

response in the subject. Determination of reaction time is a non –

invasive simple tool by which the evaluation of PNS and CNS can be

done. So the reaction time has got physiological as well as clinical

significance. The determination of simple reaction time can also

55

determine the processing speed at CNS and the efficiency of

co-ordination between the sensory and motor systems.

RT is a frequently used tests in the experimental physiology to

evaluate the sensory-motor performance and their interaction. It is

defined as the time interval between the onset of a signal (stimulus)

and the appearance of a movement response by Senel O et al.,

[2006]. Auditory Reaction Time (ART), the Visual Reaction Time

(VRT) and the Cutaneous Reaction Time (CRT) are frequently used

reaction time tests. The reaction time is considered as an index for

the processing ability of the central nervous system. So it is being

used in mental chronometry, psychometric psychology and also in

training mentally challenged children [Linden DE et al., 2007;Parrot

AC., 1991] Shorter reaction time represents a better performance,

which is a prerequisite for sports and other professions. Therefore

reaction time test has a great physiological as well as clinical

significance. [Tandon OP., 1998].

2.3.11: Basis of reaction time:

The determination of simple reaction time is an attention task that

evaluates basically the speed of processing of information. While

performing simple reaction time experiments, single stimulus is taken

56

and single response is produced. The time gap between application

of stimulus and appearance of response is considered as simple

reaction time for example ‘reaction to sound’. “Reaction Time”

indicates how fast a person can respond to a stimulus. The stimulus

may be in the form of something the subject hears, sees and feels,

the response is in the form of his/ her immediate reaction. The

reaction time can be subdivided into different components.

Mental processing time: It is a combination of perception, situational

awareness, sensation, selection of appropriate response and

programming the response. So it is considered as the time taken to

perceive and understand the stimulus that has occurred and to decide

upon a proper response by the responder.

Movement time: After a suitable response is selected, the

responder must carry out the needed muscle movement. The

movement time is the time required for the motor preparation (e.g.

tensing muscles) and execute motor response. Usually the time

taken for carrying out motor response is almost equal in every one.

Therefore the variations in reaction time is due to differences in

central processing time. Each of these elements of act need time and

57

this time can be easily quantified. We can also measure time required

for doing certain simple work as the speed of work. Such simple tasks

can be easily and rapidly performed whereas the more complex tasks

need longer time to be completed. Therefore marking the timing of

responses is critical in physiological experimentation. The few cells in

motor cortex changed their firing level well before the response. Thus

it is an evidence that both visual and motor cortex were taking part in

normal reaction time performance and the time needed for their

integration is measured [Glickstein M., 1972]. The information may

pass from sensory cortex to motor cortex through several anatomical

pathways. The visual cortex is connected to motor cortex by three

different pathways. These connections are established by means of

series of cortico-cortical synapses. One of such neural loop is from

cortex to basal ganglia from basal ganglia to ventral thalamus and

back to motor cortex. Second neural loop is connection from cortex

to pons from pons to cerebellum and then to ventral thalamus and

finally back to motor cortex. The final motor response is decided at

cortical association areas. The motor activities are planned in frontal

in collaboration with cortex as well as in basal ganglia and the lateral

sensory portions of cerebellar cortex. Both basal ganglia and

cerebellum send inputs to pre-motor and motor cortex, via thalamus.

Motor impulses generated at the motor cortex are mostly transmitted

58

to the skeletal muscles via the cortico-spinal tracts and some of the

motor impulses are conveyed through the corresponding cortico-

bulbar tracts to motor neurons of cranial nerves in brain stem. There

are some additional motor pathways in the form of some collaterals

from these pathways and a few direct pathways from motor cortex to

terminate on brain stem nuclei as well as motor neurons of spinal

cord and these pathways can also coordinate voluntary movements

[Ganong WF., 2012].

Yoga is generally considered as a mind-body therapy. It is claimed

that yoga can decrease the stress, thereby enhance one’s ability to

focus the attention, improve the cognitive abilities, and also increase

and improve the strength of organ systems and ultimately the

suppleness of the nervous system. It has been reported that yoga

training improves the CNS processing and so brings about better

human performance [Hayes M et al., 2010]. This fact gave this study

an impetus to investigate whether a short course of the yoga practice

could be used as a therapy for improving the reaction time. Malathi

and Parulkar., [1989] have reported that yoga training course of six

weeks duration produces a significant decrease in visual and auditory

reaction times. A decrease in RT indicates an improved sensory

motor performance and could be due to an enhanced processing

59

ability of the central nervous system. The effect of yoga training on

the central nervous mechanisms could be due to i) greater arousal

and faster rate of information processing ii) improved concentration

power and ability to ignore and/or inhibit extraneous stimuli. Yoga

practitioners experience a better attention and less distractibility. It

has been reported that yoga practice results in a decreased mental

fatigability and an increase in performance quotient [Udupa KN et

al.,1972]. The study confirms that yoga training leads to a significant

reduction in visual and auditory reaction times. Hence, RT can be

used as a simple, quantitative and objective method for monitoring

the beneficial effects of yoga practice. A desirable and significant

changes in perception, attention and cognition can be produced by

the practice of meditation [Brown., 1977]. Several experimental

evidences were shown to prove that yoga practice can increases the

visual perceptual sense. It was shown that perceptual sensitivity is

not restricted to subtle aspects of the stimulus alone, as detection of a

high frequency flickering stimulus was found to improve following

yoga training [Ramana et al., 1997; Telles et al., 1995]. It is

presumed that yoga is effective in reducing physiological signs of

stress, such as lowering of heart and respiratory rate and oxygen

consumption. This beneficial effect can be contributed to increase

CFF after yoga [Joseph et al., 1981]. CFF was found to be lower

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during specific states of stress like hunger and thirst [Ali & Amir.,

1989]. The decrease in the degree of illusion perceived in a short

period would be due to cognitive judgemental factors, but not retinal

or cortical factors as generally understood [ Coren & Girgus., 1973].

The way in which the subject interprets incoming visual information

based on experience do influence, the cognitive judgmental

hypothesis and strategies of judgment. So the training through yoga

to focus and defocus have influenced the cognitive judgmental factors

of the subjects, to significantly reduce the degree of illusion

perceived.

The findings of several research studies points that practice of

yoga and meditation can produce a healthy persons, reflected with

improved cognitive functions- attention, concentration, memory and

better academic achievements.

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3. NEED FOR THE STUDY

In the current scenario of medical education it is a challenge for the

teaching faculty to improve the standard of medical education and

performance of medical students. How to do this is a great question. We

considered ancient techniques of practicing yoga and meditation can be

effectively utilized to improve the cognitive skills of students. Therefore

we considered it is important to study how the practice of yoga and

meditation will help the intellectual performance of students. Yoga has

many physiological and psychological benefits. It is broadly accepted

that practice of yoga leads to several physiological and mental benefits.

But the cognitive benefits of yoga is not yet clearly understood. Under

this background we decided to explore the effect of yoga and meditation

to improve the academic standards and cognitive functions of students.

Cognition and intelligence have multiple aspects, most common among

them are attention, memory, concentration, motivation, perception, and

problem solving. All these given aspects collectively contribute while

quantifying intelligence quotient (IQ). The ultimate aim of our study is to

know the benefits of practicing yoga and meditation for the improvement

of intellectual functions.

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4. OBJECTIVES AND HYPOTHESIS

4.1: Objectives:

1) To find out the effect of yoga and meditation in high and low

perceived stress groups of medical students.

2) To evaluate the benefits of yoga and meditation in global

motivation of the medical students.

3) To find out the effect of yoga and meditation in memory of the

medical students.

4) To find out the influence of yoga and meditation on auditory and

Visual reaction time of medical students.

5) To find out the impact of yoga and meditation on critical flicker

fusion frequency of medical students.

6) To find out the beneficial effect of yoga and meditation for the

Overall improvement of academic performance of medical

students.

4.2: Hypothesis:

Practice of yoga and meditation may improve the cognitive function

and academic performance of medical students.

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5. METHODOLOGY

5.1: Materials and methods:

5.1.1: Tools Used:

Audio visual reaction time -measuring device( PC 1000 Hertz’s

Reaction Timer), Audacity software 2.1.1, Head phone (1000 hertz’s

tone), Critical flicker fusion frequency measuring device controlled by

sweep Gen software V3.5.4.29, personal computer, Cohen perceived

stress scale, PGI memory scale, Global motivation scale, SPSS 20.0

software for statistical analysis.

5.1.2: Participants

We considered 180 medical students in age group of (17-23) years,

who were in self-reported good health, undergoing first year MBBS in

Annapoorana medical college, Salem. The study protocol was

explained to the participants and their written informed consent was

obtained.

The project was approved by the institutional ethical committee of

Annapoorana medical college Salem, India [AMC/Ethics/Proc. No:10,

dated- 03/09/12].

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5.1.3: Inclusion Criteria:

Healthy medical students age from 17-23yrs with BMI of 18 to 25. BMI

was calculated by the formula Weight in kilograms/Height in meter2.

5.1.4: Exclusion Criteria:

Alcoholics, smokers and Students who practiced yoga or meditation in

the past one year. Students on medication for (epilepsy), cardiovascular

and respiratory illness. Students with hearing and visual impairment.

5.2: Study Design

The study was designed in such a way that the participants were

divided into three groups,

1. Yoga group (n-60).

2. Meditation group (n-60).

3. Control group (n-60).

The subjects of Experimental Group was given yoga and meditation

training in a quiet room which was maintained at a comfortable

temperature (25 ± 2ºC) for six days a week. The training was done

under the supervision of a yoga expert for 30 minutes in the morning

from 6.30 to 7 am in Annapoorana medical college for a total duration

of 4 months. The control group did not undergo yoga or meditation

65

practice during this period. The participants involved in the study were

blind to the experimental conditions. We familiarized the participants

with the different test scale and experimental produce to obtain

results that were more consistent. On the day of assessment

participants reported to the Department of Physiology, Annapoorana

Medical College between 9 and 10 AM, at least two hours after taking

a light breakfast.

5.2.1: Intervention

Yoga and meditation module were prepared by yoga expert and the

participants were given training on it for two days before the session

started. The experimental group practiced yoga asanas (Physical

Training) and meditation (mental training) in empty stomach. The asana

pose and duration are as follows-

a) Suryanamaskar-4 minutes; Tones up the nervous system and

improves memory [Paresh D., 2013].

b) Padmasana (lotus pose) -4 minute;Increases awareness and

attentiveness [Telles S et al., 2000].

c) Paschimottanasana (posterior stretching pose) -4 minutes; It acts

as a stress reliever [Schure MB et al., 2008].

66

d) Padahastasana (boat pose) -4minutes; Blood flow to head

improved [Sarang SP., 2006].

e) Super brain yoga- 1 minutes; Improves memory [Chandrasekeran

A., 2014].

f) Vrikshasana (Tree stand pose)-1 minutes; Builds self-confidence

and esteem [Kozasa et al., 2008].

g) Vajrasana (pelvic pose) -2 minutes; Helps you in relaxing [Sarang

SP., 2007].

h) Sarvangasana (Shoulder stand pose)-4 minutes; Blood flow to

head improved [Sarang SP., 2006].

i) Shavasana (Corpse pose) -6 minutes; Improves concentration

[Longstreth H., 2014].

Meditation sessions started with Om chanting, the different modules are

as follows.

a) Om chanting for 8 minutes,

b) Follow own breathing 4 minutes,

c) Concentrate on simple visual object-(Buddha) 4 minute,

d) Practice visualization-create a new space 6 minutes,

e) Do a body scan 8 minutes.

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5.3: Parameters Measured and Procedure:

5.3.1: Audio Visual Reaction Test (AVRT):

Auditory and Visual reaction time was recorded by using an

instrument called PC 1000 controlled by Audacity software 2.1.1

built by Dr Maruthy KN by a joint venture between Vivek Electronics

Bangalore [Parekh N et al., 2004;Muhil M et al., 2014]. The

participants reported to the Department of Physiology, Annapoorana

Medical College between 9 and 10 AM, at least two hours after taking

a light breakfast. VRT was measured in all 180 students, In

experimental group before giving intervention recording was done first

and then after 12 weeks of intervention again VRT was recorded. In

control group similarly on first day VRT was measured and again after

12weeks without any intervention VRT was measured. Similar

method of recording was followed for all parameters.

Auditory and Visual reaction time was recorded with PC1000 which is

a 1000 hertz square wave oscillator which has a soft key for start and

stop function. PC 1000 Reaction timer instrument has two

components (A &B) connected to each other. First component (A) has

a start button and it is handled by the examiner only. Second

component (B) has a stop button which will be handled by the subject

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alone and also it has a small red LED which receives the visual

stimulus and head phone (1000 hertz’s tone) to receive auditory

stimulus. The colour of the light is selected as red because red colour

lasts for longer duration at sensory receptors. The audacity software

was installed in the personal computer. To this computer both

component A and component B are connected. The reaction time in

0.001sec accuracy in wave format is recorded and documented by

the audacity software. When the recording begins the ‘start’ button in

the component (A) is pressed by the examiner which was away the

view of the subject and the subject was told to press the ‘Stop’ button

in component (B) with the right index finger first as soon as the

subject sees the red light in the instrument. The visual Reaction time

was recorded in audacity software. Similarly auditory reaction time

was recorded with the head phone connected to it. The examiner

pressed the ‘start’ button which was out of the view of the subject and

the subject was told to press the stop button with the right index finger

first when the subject hears the sound through the head phone.

Audacity software records the auditory reaction time.

All subjects were right handed and used their right hand to press the

switch to stop the quartz clock of the apparatus. Before measuring

VRT, each subject was asked to identify the flashing of red light. Each

69

Subject was told to press the switch when she/he saw the light.

Minimum three trials are taken for both VRT and ART measurement.

The average of three recording was calculated as final VRT and ART.

5.3.2: Critical Flicker Fusion Frequency Test (CFF):

CFF was measured employing in house built LED based instrument

built by a joint venture between Dr Maruthy KN and Vivek Electronics

Bangalore. This instrument has two components. One component has

a flickering light source placed in a board of white background (to

provide central field stimulation). Light source is presented separately

to the individual eye by covering the other eye. A monochromatic

light, red light (light emitting diode) with wave length 630 nm is used

as it is perceived for longer time in the retina [Hema Shankar et al.,

2007].There is no delay period for switching on, as the light source is

a solid state LED. Flickering of the light source is designed so that the

on period and off period are kept equal. Second component is a

variable frequency square wave oscillator which can give oscillations

in the range of 10- 80 hertz with an accuracy of 0.5 hertz.

To measure CFF, examination room is partially illuminated, subject is

made to sit comfortably and presented with a red light source at a

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distance of 25-30 centimetres. Frequency of oscillations are

gradually increased. Subject is instructed to respond when the

flickering light source appears as a single fused light and that

particular frequency is critical flicker fusion frequency (CFF). The

frequency was measured from the recorded data using sweep Gen

software V3.5.4.29. CFF was measured in right and left eye

separately and average of three frequencies was considered as final

CFF value for that subject.

5.3.3: Academic Achievement Test.

Academic performance was assessed by the test marks in physiology

which was conducted before intervention and after intervention,

[Kauts et al., 2009] in yoga, meditation and control groups. The

scores collected were statistically analysed.

5.3.4: Cohen Perceived Stress Scale (PSS).

The Perceived Stress Scale (PSS) was used to identify the levels of

perceived stress in medical students. Yoga and meditation module

was used as an intervention treatment for the experimental group for

30 minutes daily in morning for three months. The original version of

the scale had 10 items asking the participants to rate their stress over

a period of past month in 15 minutes [Cohen.S et al., 1983] with

71

seven items negatively stated and seven items positively stated. For

the study we do refer to the subscale representing the negatively

stated items as “Stress” and to the subscale representing the

positively stated items as “Coping.” Two short forms were also

developed [S. Cohen et al.,1988). The first short form has 10 items,

six negatively stated and four positively stated. The second short form

has four items, two negatively stated and two positively stated. The

response set ranges from 0 (never) to 4 (very often) and positively

stated items are reverse coded before items are summed with higher

scores indicating more perceived stress. Scores for the 10-item form

range from 0 to 40 [Wolf TM .1994]. The sample items of PSS are

presented in the annexure. The collected scores were statistically

analysed.

5.3.5: Global Motivation Scale

To assess the motivation level of students the French version of the

global motivation scale (GMS) was used in our studies in both

experiment and control group [ Guay et al., 1999]. GMS assesses

three type of intrinsic motivation [ vallerand., 1997, valleand et al.,

1992, 1993] three type of extrinsic motivation ( Identified, introjected

and external regulation) and motivation. There are four items per

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subscale and thus a total of 28 items. Each item represents a

possible reason for doing things in general. Items are scored on a 7

point Likert-type scale. All items are measured on a 7-point Likert

scale ranging from 1 (does not correspond at all) to 7 (corresponds

exactly). Results from past studies confirmed the factor structure of

the scale and revealed an adequate level of internal consistency as

well as satisfactory test–retest reliability [Guay et al., 2003]. The

sample items of GMS are presented in the annexure. The 28 item

was asked to answer in 10 minutes and it was statistically analysed.

5.3.6: Post Graduate Institute- Memory Scale (PGIMS)

The PGI memory scale (PGIMS) [Pershad D et al., 1976 and 1979]

was used to evaluate memory function of subjects. PGI memory

scale is made up of ten sub-tests. Different aspects of memory can be

measured by these tests. These ten sub groups of tests are –

Remote memory: This is a simple test in which six simple questions

relating to the past events of personal life were asked.

Recent memory: It is made up of a set of five questions to evaluate

the subjects ’s capacity to recall information and events in the recent

past.

73

Immediate recall: This test comprises of sequential reproduction of

the sentences in verbatim.

Mental balance: This test aims at getting an idea of balance over

ones mental functioning.

Attention and concentration: This aspect of memory function was

assessed by the test of digit span forward and backward repetition.

Verbal retention for similar pairs: It evaluates subject’s capacity to

associate with similar words.

Verbal retention for dissimilar pairs: In this test the capacity of

subject to associate with dissimilar words were evaluated.

Visual retention: In this test subjects were given a geometrical

figure, after a gap of thirty seconds they are directed to draw the

same.

Recognition: Some common pictures were shown to the subjects

later they are asked to recognize the pictures.

Delayed recall: In this test the subjects were asked to recall the three

sentences of earlier immediate recall test. So it is the continuation of

immediate recall test.

This scale contains 10 questions and the participants were asked to

answer this in 20 minutes before and after intervention. The sample

items of PGIMS are presented in the annexure. The scores are

statistically analysed.

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6. RESULT AND DISCUSSION

6.1: To find out the effect of yoga and meditation in high perceived

stress groups (HPS) and low perceived stress groups (LPS) of

medical students.

We divided the participants into HPS and LPS with the help of PSS

questionnaire. The participants who scored above 30 was considered

as HPS and score less than 20 was considered as LPS.

Table 2: Mean and Standard deviation of LPS in three groups

Group

Mean ± SD

Before intervention After intervention

Control 17.38 ± 1.675 17.38 ± 1.645

Yoga 17.67 ± 1.796 14.26 ± 1.741

Meditation 17.46 ± 1.766 14.10 ± 1.795

F-value 0.464 69.716

P-value > 0.05 < 0.001**

** significant at p< 0.001 level

Results given in Table 2 shows that F-value (0.464) of ANOVA was

found to be not significant as P-value is >0.05 before intervention.

Comparison of LPS value after intervention among three groups was

done by using one way ANOVA and the F-value (69.716) was found

75

to be significant indicating that there exists significant difference in

LPS after intervention among the three groups. As the P-value was

found to be <0.001. This shows that the stress level significantly

reduced after intervention. Interventions yoga and meditation are

useful to reduce the perceived stress. Both yoga and meditation

shows almost similar beneficial effects.

Table 3: Comparison of LPS score before and after intervention

in each groups.

Group Mean ± SD

P-value Before After

Control 17.38 ± 1.675 17.38 ± 1.645 1.000

Yoga 17.67 ± 1.796 14.26 ± 1.741 < 0.001**

Meditation 17.46 ± 1.766 14.10 ± 1.795 < 0.001**

** 0.01 level of significance

In table-3 Paired t-test was done to compare LPS before and after

intervention in each groups. In control group, P-value was not

significant showing no significant difference before and after

intervention. In yoga and meditation group P-value was significant <

0.001. This indicates that the level of stress has reduced in

experimental group when compared with control group. It is found

that there is no difference in the beneficial effects of yoga and

76

meditation as both of them reduce the level of stress to almost to a

same extent.

Figure 4: Comparison of LPS score in three groups before and

after intervention.

Table 4: Mean and Standard deviation of HPS in three groups.

Group Mean ± SD

Before intervention After intervention

Control 35.26 ± 1.741 35.28 ± 1.752

Yoga 35.31 ± 1.840 31.18 ± 1.668

Meditation 35.25 ± 1.823 31.23 ± 1.606

F-value 0.022 120.037

P-value > 0.05 < 0.001**

** significant at p< 0.001 level

17.38 17.67 17.4617.38

14.26 14.1

Control Yoga Meditation

Before Intervention After Intervention

LPS

77

Results given in Table 4 shows that F-value of the ANOVA was not

significant as P-value is >0.05 before intervention. Comparison of

HPS value after intervention among three groups was done by using

one way ANOVA and the F-value was found to be significant

indicating that there exists a marked difference in HPS after

intervention among the three groups. As the P-value was found to be

<0.001. This shows that the stress level significantly reduced after

intervention. Both yoga and meditation have almost same beneficial

effects.

Table 5: Comparison of HPS score before and after intervention

in each groups.

Group Mean ± SD

P-value

Before After

Control 35.26 ± 1.741 35.28 ± 1.752 0.321

Yoga 35.31 ± 1.840 31.18 ± 1.668 < 0.001**

Meditation 35.25 ± 1.823 31.23 ± 1.606 < 0.001**

** significant at 0.01 level

In table-5 Paired t-test was done to compare HPS before and after

intervention in each groups. In control group, P-value was found to be

not significant indicating that there exists no significant difference

78

before and after intervention. Where as in yoga and meditation group

P-value was found to be significant < 0.001. This shows that the

stress level have reduced in experimental group when compared to

control group.

Figure 5: Comparison of HPS score in three groups before and

after intervention.

35.26 35.31 35.2535.28

31.18 31.23

Control Yoga Meditation

Before Intervention After Intervention

HP

S

79

The figure well represent the decrease in stress level in meditation

and yoga group when compared to control group before and after

intervention.

6.2: To evaluate the impact of yoga and meditation in global

motivation (GM) of LPS and HPS of the medical students.

Table 6: Comparing GM of LPS in three groups.

Group

Mean ± SD

Before intervention After intervention

Control 86.87 ± 1.698 86.85 ± 1.682

Yoga 87.23 ± 1.419 91.57 ± 1.648

Meditation 86.75 ±1.813 91.02 ± 1.954

F-value 1.376 130.152

P-value > 0.05 < 0.001**

** significant at P< 0.01 level

The data given in Table 6 shows that F-value of GM in LPS before

intervention was not significant as P-value is >0.05. Comparison of

GM value after intervention among three groups was done by using

one way ANOVA and the F-value was significant indicating that there

exists marked difference in GM after intervention among the three

groups. As the P-value was found to be <0.001. This shows that the

GM level in LPS significantly increased after intervention.

80

Table 7: Comparing Global motivation score of LPS before and

after intervention in three groups.

Group Mean ± SD

P-value

Before After

Control 86.87 ± 1.698

86.85 ± 1.682 0.321

Yoga 87.23 ± 1.419

91.57 ± 1.648 < 0.001**

Meditation 86.75 ±1.813

91.02 ± 1.954 < 0.001**

** significant at 0.01 level

In table-7 Paired t-test was done to compare GM before and after

intervention in each one of the group. In the control group, P-value

was found to be not significant indicating no significant difference

before and after intervention. Where as in yoga and meditation

group P-value was found to be significant < 0.001. This indicates

GM in LPS has improved in intervention group when compared to

control group. This agrees to the hypothesis that practice of yoga

and meditation are useful to improve global motivation among the

medical students.

81

Figure 6: Comparison of Global motivation score for the three

groups in LPS students before and after intervention.

Table 8: Comparing GM of HPS in three groups.

Group Mean ± SD

Before intervention After intervention

Control 136.74 ± 1.672 136.72 ± 1.675

Yoga 136.98 ± 1.628 140.34 ± 2.016

Meditation 136.44 ± 1.858 140.16 ± 1.899

F-value 1.509 72.834

P-value > 0.05 < 0.001**

** significant at P< 0.01 level

86.87

87.23

86.7586.85

91.57

91.02

Control Yoga Meditation

GM

(LP

S)

Before Intervention After Intervention

82

The data given in Table 8 shows that F-value of GM in HPS before

intervention was not significant as P-value is >0.05. Comparison of

GM value after intervention among three groups was done by using

one way ANOVA and the F-value was significant indicating that

there exists marked difference in GM because of intervention

among the three groups. As the P-value was found to be <0.001.

This shows that the GM level in HPS significantly increased after

intervention. The level of improvement in global motivation among

LPS and HPS are almost to a same degree. Interestingly yoga and

meditation have similar beneficial effect in enhancing global

motivation.

Table 9: Comparing Global motivation score of HPS before and

after intervention in three groups.

Group Mean ± SD

P-value Before After

Control 136.74 ± 1.672 136.72 ± 1.675 0.321

Yoga 136.98 ± 1.628 140.34 ± 2.016 < 0.001**

Meditation 136.44 ± 1.858 140.16 ± 1.899 < 0.001**

** significant at 0.01 level

83

In table-9 Paired t-test was done to compare GM before and after

intervention in each group. In the control group, P-value was not

significant indicating that there exists no significant difference

before and after intervention. Where as in yoga and meditation

group P-value was found to be significant < 0.001.

This shows GM in HPS has improved in experimental group when

compared with control group.

Figure 7: Comparison of Global motivation score for the three

groups in HPS students before and after intervention.

136.74136.98

136.44136.72

140.34140.16

Control Yoga Meditation

GM

(HP

S)

Before Intervention After Intervention

84

The figure represent Improved global motivation in experiment

group when compared to the control group before and after

intervention.

6.3: To evaluate the impact of yoga and meditation in the

memory of LPS and HPS of the medical students.

Table 10: Comparing memory of LPS in three groups.

Group Mean ± SD

Before intervention After intervention

Control 54.41 ± 2.716 54.41 ± 2.716

Yoga 54.41 ± 2.848 60.89 ± 1.898

Meditation 54.97 ± 2.683 60.85 ± 1.682

F-value 0.835 184.275

P-value > 0.05 < 0.001**

** significant at P<0.001 level

Results given in Table 10 shows that F-value of Memory in LPS

before intervention was not significant as P-value is >0.05.

Comparison of Memory after intervention among three groups was

done by using one way ANOVA and the F-value was significant

indicating that there exist marked difference in memory because of

intervention among the three groups. As the P-value was found to

85

be <0.001. This shows that memory level in LPS significantly

increased after intervention. Findings of this study suggests that

practice of yoga and meditation may improve the memory storage

ability of the students which has a far reaching influence in cognitive

functioning of students.

Table 11: Comparing memory score of LPS before and after

intervention in three groups.

Group Mean ± SD

P-value

Before After

Control 54.41 ± 2.716

54.41 ± 2.716 1.000

Yoga 54.41 ± 2.848

60.89 ± 1.898 < 0.001**

Meditation 54.97 ± 2.683

60.85 ± 1.682 < 0.001**

** significant at 0.001 level

In table-11 Paired t-test was done to compare memory before and

after intervention in all the groups. In the control group, P-value was

not significant indicating that there exists no significant difference

before and after intervention. Where as in yoga and meditation

group P-value was significant < 0.001. This indicates memory in

LPS has improved in experimental group when compared with

control group.

86

Figure 8: Comparison of memory score for the three groups in

LPS students before and after intervention.

Table 12: Comparing memory of HPS in three groups.

Group Mean ± SD

Before intervention After intervention

Control 64.51 ± 2.447 64.52 ± 2.426

Yoga 64.67 ± 2.399 69.41 ± 2.283

Meditation 65.16 ± 2.368 69.52 ± 2.188

F-value 1.228 93.842

P-value > 0.05 < 0.001**

** significant at P<0.001 level

54.41 54.41

54.97

54.41

60.89 60.85

Control Yoga Meditation

ME

MO

RY

(LP

S)

Before Intervention After Intervention

87

Results given in Table 12 shows that F-value of Memory in HPS

before intervention was not significant as P-value is >0.05.

Comparison of Memory after intervention among three groups was

done by using one way ANOVA and the F-value was significant

indicating that there exists marked difference in memory because of

intervention among the three groups. As the P-value was <0.001.

This shows that memory level in HPS significantly increased after

intervention. It can be noted that the beneficial effects of

intervention by yoga and meditation was more for LPS group than

HPS group.

Table 13: Comparing memory score of HPS before and after

intervention in three groups.

Group Mean ± SD

P-value

Before After

Control 64.51 ± 2.447 64.52 ± 2.426 1.000

Yoga 64.67 ± 2.399 69.41 ± 2.283 < 0.001**

Meditation 65.16 ± 2.368 69.52 ± 2.188 < 0.001**

** significant at 0.01 level

88

In table-13 Paired t-test was done to compare memory before and

after intervention in each group. In the control group, P-value was not

significant indicating that there exists no significant difference in

before and after intervention. Where as in yoga and meditation group

P-value was found to be significant < 0.001. This shows memory in

HPS has improved in experimental group when compared with

control group.

Figure 9: Comparison of memory score for the three groups in

HPS students before and after intervention.

The figure well indicates the changes occurred in memory of control

and experimental group before and after intervention. This also shows

that yoga and meditation group almost have similar effect.

64.5164.67

65.16

64.52

69.41 69.52

Control Yoga Meditation

ME

MO

RY

(HP

S)

Before Intervention After Intervention

89

6.4: To find out the influence of yoga and meditation on auditory

and visual reaction time of medical students.

Table 14: Comparison of ART in three groups.

Group

Mean ± SD

Before intervention After intervention

Control 280.25 ± 5.565 279.78 ± 7.105

Yoga 281.08 ± 5.391 276.47 ± 5.344

Meditation 279.98 ± 4.560 276.48 ± 5.144

F-value 0.733 6.225

P-value > 0.05 < 0.01**

** significant at P< 0.001 level

Comparison of ART value after intervention among three groups was

done by using one way ANOVA and the results are given in Table14.

F-value was significant indicating that there exists marked difference

in ART because of intervention among three groups. As the F-value

was found to be significant, Least Significant Difference (LSD) test

was carried out to find out which of the groups are significantly

different. Results shows that there exists no marked difference in the

ART value after intervention among meditation group (276.48) and

Yoga group (276.47). However, in these two group ART after

intervention was significantly lower than that of control group.

90

Table 15: Comparison of ART before and after Intervention in

three groups.

Group Mean ± SD

P-value

Before After

Control 280.25± 5.565 279.78±7.105 1.000

Yoga 281.08± 5.391 276.47±5.344 < 0.001**

Meditation 279.98± 4.560 276.48±5.144 < 0.001**

** significant at 0.01 level

In table-15 Paired t-test was done to compare ART before and after

intervention in each group. In the control group, P-value was not

significant indicating that there exists no significant difference before

and after intervention. Where as in yoga and meditation group P-

value was found to be significant < 0.001. This shows that ART has

decreased in experimental group when compared with control group.

Figure 10: Comparison of ART before and after Intervention in

three groups.

Table 16: Comparison of VRT in

Group

Control

Yoga

Meditation

F-value

P-value

** significant at P< 0.001 level.

91

: Comparison of ART before and after Intervention in

: Comparison of VRT in three groups.

Mean ± SD

Before intervention After intervention

331.33 ± 2.370 331.22 ± 2.888

331.50 ±2.879 327.57 ±2.788

330.40 ±3.237 328.02 ± 3.116

2.594 27.603

> 0.05 < 0.001**

< 0.001 level.

: Comparison of ART before and after Intervention in

After intervention

331.22 ± 2.888

327.57 ±2.788

328.02 ± 3.116

27.603

< 0.001**

92

Comparison of VRT value after intervention among three groups was

done by using one way ANOVA and the results are given in Table 16.

F-value (27.603) was found to be significant indicating that there

exists significant difference in VRT after intervention among the three

groups. As the F-value was significant, Least Significant Difference

(LSD) test was carried out to find out which of the groups are

significantly different. Results shows that there exists no marked

difference in the VRT because of intervention among meditation

group (328.02) and yoga group (327.57). However, in these two

groups VRT after intervention was significantly lower than that of

control group.

Table 17: Comparison of VRT before and after Intervention in

three groups.

Group

Mean ± SD P-value

Before After

Control 331.33±2.370 331.22±2.888 1.000

Yoga 331.50± 2.879 327.57±2.788 < 0.001**

Meditation 330.40± 3.237 328.02±3.116 < 0.001**

** significant at 0.01 level

In table-17 Paired t-test was done to compare VRT before and after

intervention in each group. In the case of control group, P

found to be not significant indicating that there exists no significant

difference before and a

meditation group P-value was found to be significant at < 0.001

indicating that VRT have

compared with control group.

Figure 11: Comparison of VRT before and afte

three groups.

93

test was done to compare VRT before and after

intervention in each group. In the case of control group, P-

found to be not significant indicating that there exists no significant

difference before and after intervention. Where as in

value was found to be significant at < 0.001

VRT have decreased in experimental group when

compared with control group.

: Comparison of VRT before and after Intervention in

test was done to compare VRT before and after

-value was

found to be not significant indicating that there exists no significant

fter intervention. Where as in yoga and

value was found to be significant at < 0.001

decreased in experimental group when

r Intervention in

94

The figure represent the change in VRT before and after intervention

in control and experimental group. There is a slight better result in

yoga group when compared to meditation group.

6.5: To find out the Impact of Yoga and Meditation on Critical

Flicker Fusion Frequency (CFF).

Table 18: Comparison of CFF in three groups.

Group

Mean ± SD

Before intervention After intervention

Control 39.73 ± 1.219 39.73 ± 1.191

Yoga 40.08 ± 1.381 42.85±1.571

Meditation 41.52 ± 1.444 43.27 ± 1.625

F-value 29.330** 102.820

P-value < 0.001 < 0.001**

**significant at p< 0.001 level

Results given in Table 18 shows that F-value of CFF before

intervention was not significant as P-value is >0.05. Comparison of

CFF after intervention among three groups was done by using one

way ANOVA and the F-value was significant indicating that there

exists marked difference in CFF because of intervention among the

three groups. As the P-value was found to be <0.001. This shows

that CFF significantly increased after intervention. The increase in

95

CFF is advantageous in central processing of information which in

turn essential for improving cognitive functions.

Table 19: Comparison of CFF before and after Intervention in

three groups.

Group Mean ± SD

P-value

Before After

Control 39.73±1.219 39.73±1.191 1.000

Yoga 40.02± 1.381 42.85±1.571 < 0.001**

Meditation 41.52± 1.444 43.27±1.625 < 0.001**

** significant at 0.01 level

In table-19 Paired t-test was done to compare CFF before and after

intervention in each group. In control group, P-value was not

significant indicating that there exists no significant difference before

and after intervention. Where as in yoga and meditation group P-

value was found to be significant < 0.001. This shows that CFF have

improved in experimental group when compared with control group.

Figure 12: Comparison of CFF before and after Intervention in

three groups.

The figure well indicate the improvement in CFF in experimental

group when compared to the control group. When comparing the

yoga and meditation group there is a slight betterment in the

meditation group then yoga group.

96

Figure 12: Comparison of CFF before and after Intervention in

The figure well indicate the improvement in CFF in experimental

group when compared to the control group. When comparing the

yoga and meditation group there is a slight betterment in the

then yoga group.

Figure 12: Comparison of CFF before and after Intervention in

The figure well indicate the improvement in CFF in experimental

group when compared to the control group. When comparing the

yoga and meditation group there is a slight betterment in the

97

6.6: To compare the effect of practice of yoga and meditation for

overall improvement of academic performance of medical

students.

Table 20: Comparison of Academic Performance Before

intervention in three groups.

Group Theory Practical Overall

Mean Std.

Deviation Mean

Std. Deviation

Mean Std.

Deviation

Control 51.22 14.241 33.57 7.041 84.78 16.931

Yoga 52.90 12.718 33.48 5.809 86.38 15.729

Meditation 52.58 12.710 33.77 6.247 86.35 15.608

F-value 0.274 0.031 0.193

P-value >0.05

>0.05

>0.05

Results in Table20 shows that F-values corresponding to theory

(0.274, p=0.761), practical (0.031, p=0.969) and overall total (0.193,

p=0.824) was found to be not significant at 0.05 levels as the p-values

are >0.05. This shows that there exists no significant difference in the

academic performance in terms of theory, practical and overall total of

the three groups before intervention.

98

Table 21: Comparison of Academic Performance after

Intervention in three groups.

Group Theory Practical Overall

Mean Std.

Deviation Mean

Std. Deviation

Mean Std.

Deviation

Control 49.95 13.639 32.78 6.143 82.73 16.198

Yoga 61.20 8.967 35.73 4.602 96.93 11.385

Meditation 58.47 10.644 35.05 5.302 93.52 13.641

F-value 16.320 4.932 17.105

P-value < 0.001** <0.01** < 0.001**

**significant at p < 0.01 level

Comparison of academic performance after intervention among

three groups was done by using one way ANOVA followed by Least

Significant Difference (LSD) test and the results are given. This was

done for theory, practical and overall academic performance

separately. All the three F-values were significant showing a marked

difference among the three groups. LSD shows that there exists no

significant difference in the academic performance among meditation

group and yoga group. However, academic performance in control

group was less when compared to that of meditation and yoga

group. This reveals that academic performance of the medical

students can be improved by the practice of yoga and meditation.

Both yoga and meditation provide almost identical benefits.

Figure 13: Comparison of Academic performance before and

after intervention in three groups.

The figure well indicate the difference in academic performance

before and after intervention in experiment and control group. This

study has well proved yoga and meditation can improve the cognitive

functions and academic performance of medical students.

99

: Comparison of Academic performance before and

after intervention in three groups.

indicate the difference in academic performance

before and after intervention in experiment and control group. This

study has well proved yoga and meditation can improve the cognitive

functions and academic performance of medical students.

: Comparison of Academic performance before and

indicate the difference in academic performance

before and after intervention in experiment and control group. This

study has well proved yoga and meditation can improve the cognitive

100

Discussion

The present study have evaluated the effects of yoga and meditation

in the cognitive functions and academic performance of medical

students. It was expected that students in yoga and meditation would

report improved affect, although there was no significant change

between yoga and meditation group, there was a significant change in

control and yoga, also control and meditation group in all the recorded

parameters.

The first objective of our study was to evaluate the impact of yoga

and meditation among high and low perceived stress groups. Many

researchers have already found that the level of stress in medical

students is high when compared to the general population and that of

students in other courses [Aktekin M et al., 2001, Firth J., 1986,Ko

SM et al., 1999]. Higher levels of stress among medical students

has been observed and documented since a long past. Different

attempts were made to find out the underlying causes, consequences

and possible solutions. It was concluded that there are three

predominant issues, related to the development of stress among

medical students. First one is that the students are compelled to

acquire large amount of new information in a short period and then to

face the examinations and evaluations. So the students may not get

101

adequate time to review what they have studied. Second issue is the

overloading of tremendous amount of information in modern day

medical curriculum put the medical students under pressure. Thirdly

they have a very short time for understanding and recollecting all the

information learnt. Obviously the over burdening of students with

excess load of information is likely to push them to a feeling of

disappointment because they may find it difficult to handle all the

information at once and feel difficult to pass the examination. It was

noted that several medical students are struggling with their own

limited capacity to meet the challenges of medical curriculum [Yussof

et al., 2013].

We recorded the PSS score in assessing role of yoga and meditation

in stress reduction of medical students and observed significant

reduction in there score before and after intervention. This change

may be due to various physiological and psychological changes

caused by yoga and meditation. The employment of yoga practice to

overcome stress was further supported by many researchers like

[Schure M.B et al., 2008]. Cowen and Adams., [2005] have reported

that a short training of yoga can lower perceived stress on the

General Well-Being Schedule. When a person faces a stressful or

threatening situation, neurons at the hypothalamus a part of brain

102

may secrete a peptide known as corticotrophin- releasing hormone,

or CRH. The cortisol level increases in blood when stressed, it is the

stress hormone. Scientists suspect that CRH also affects behaviour

directly by acting on certain brain regions [Van DulmenS et al., 2007].

Many studies have showed that yoga and meditation acts as a best

medicine to bring down cortisol level which in turn can bring down

stress [West J et al., 2004, Kamei T et al., 2000].

Stress on one hand disturbs the quality of life in medical students and

on the other hand it will adversely affect the quality of patient care and

produce a negative impact on the complex psychodynamics of the

doctor- patient relationship. Because of increased stress, medical

students likely to develop a dangerous level of stress-related anxiety,

frustration, depression, drug abuse, and it may even lead to suicide.

Even chronic stress disturb memory, learning and solving abilities

which require flexible thinking [Troyer D., 1990].

In our study after yoga and meditation it was reported that students

felt several benefits in all the aspects like physical, emotional,

mental, spiritual, and in addition in their interpersonal relationships.

Timothy McCall, author of “Yoga as Medicine,” says yoga and

meditation together can keep a balance between both SNS and PNS.

Figure:14YOGA AND MEDITATION IN ANS

Yoga was supposed to produce a higher awareness of the body,

higher energy availability, and better

Subjects participated in

overcome the causes of

STRESSSYMPATHETIC

PUPILS EXPAND

FAST & SLOW

BREATHING

HEART PUMPS FASTER

GUT

INACTIVE

103

YOGA AND MEDITATION IN ANS.

supposed to produce a higher awareness of the body,

higher energy availability, and better mental clarity and concentration.

Subjects participated in these mindfulness meditation , were able to

overcome the causes of their stress, and were able to get relief from

STRESS CALAM SYMPATHETIC PARASYMPATHETIC

PUPILS SHRINK

SLOW & DEEP

BREATHING

HEART SLOWS

GUT ACTIVE

PUPILS EXPAND

FAST & SLOW

BREATHING

HEART PUMPS FASTER

supposed to produce a higher awareness of the body,

mental clarity and concentration.

these mindfulness meditation , were able to

to get relief from

104

stress and other negative emotions, while the control group did not

have this positive feeling and well-being.

The second objective was effect of yoga and meditation in global

motivation. Global motivation is important to know ones global self-

determined motivation, it deals with interpersonal relationships,

education, work and other activities which predict how one would

regulate his or her own behaviour [Vallerand and Ratelle., 2002]. It

has an important role in cognitive functions and academic

performance. Cognitive functions are intellectual processes which

have multiple dimensions like ability to perceive or understand ideas.

This enables one to concentrate on the problem, integrate the needed

information, proceed towards the logical conclusion, which finally

helps to make decision and then execute the work. Improvement in all

aspects of perception, thinking, reasoning, and remembering can be

achieved by the regular practice of yoga. Yoga and meditation can

improve the motivation in a person, to fully concentrate and actively

participate in their activities. Here in our studies, the difference was

observed in the experimental group, the level of global motivation

improved in students who participated in yoga and meditation

whereas, there was no change observed in control group. Yoga may

enhance self-esteem in students, there by improve the adjustment

105

ability. Stress has an implication for lowered self-esteem in students,

and it was reported that regular practice of yoga by medical students

for a longer period may possibly result in improved management of

their daily stress [Posner MI., 1978].Concentration on body posture

and movement are must during yoga exercises. This obviously

produce an improvement in the mental abilities [Galantino M et al.,

2008]. These results provide important clues regarding the neural

mechanisms by which motivation exerts both global and local

influences on cognitive control. It is desirable to note that yoga and

meditation not only makes our brain more efficient, but also improves

our executive function—the brain activity related to decision-making

and cognitive performance. When regular meditation is done global

motivation is improved which in turn improve cognitive functions and

also which improves academic performance[Cahn & Polich., 2006].

The results of the present study also proves that yoga and meditation

can improves memory. This results remain in tuned with the other

earlier studies, which reported that practice of yoga and meditation

improves memory. It is a proven fact that regular practice of yoga can

increases both memory Kocher.,1976a] and perception on one hand

and delay mental fatigue on the other hand [Kocher., 1976b].

Theimmediate change in memory with three months practice of

meditation and yoga may be due to personality development, higher

106

concentration and reduction of distraction of thoughts (mind

wandering) due to meditation training. A study have shown that

people who meditate exhibit higher levels of gyrification- the folding”

of the cerebral cortex as a result of growth, which in turn may allow

the brain to process information faster. Though the research did not

prove this directly, scientists suspect that gyrification is responsible

for making the brain better at processing information, making

decisions, forming memories, and improving attention, [Luders E et

al., 2012]. The investigations done by various researches proved that

yogic practice improves memory of the school children, [Kochar.,

1974, Kochar and Partap., 1972]. However our study have shown that

12 weeks of yoga and meditation practice can improve memory of

medical students which in turn can improves the cognitive functions in

them.

Recent research study suggests that stress can lead to hippocampal

volume reduction which in turn leads to hippocampal-dependent

memory impairment and points on negative effects of stress in the

structure and function of the hippocampus [Kuhlmann S et al., 2005;

McEwen BS., 2002; Van Petten C., 2004; Lupien SJ et al., 2005].

Practice of yoga emphasizes body awareness and involves focusing

one’s attention on breathing or specific muscles or parts of body;

107

therefore it may be possible that yoga can improve more general

attention abilities. Attention focus is one of the major aspect of yoga

practice. It produces relaxation like similar effects in that it tends to

promote self-control, attention and concentration, self-efficacy, body

awareness and stress reduction [Palsane and Kochar, 1973]. The

effects of practicing yoga and meditation on the psycho physiological

parameters related to stress and general emotional health could have

an indirect effect on cognition. Indeed, it has been shown that stress

levels interfere with memory performance, the mechanisms

underlying improvement in cognitive tasks induced by yoga practice

are not completely understood. It has been suggested that this effect

arises from the improvement in mental concentration [Rocha,

2012].This may be true because mind is the main key which controls

all other activity. It has been already shown that stress levels interfere

with memory performance. A combination of Mindfulness Based

Stress Reduction (MBSR) programs and practice of yoga, improved

mood and affective functions [Nyklícek and Kuijpers, 2008]. In

general, mind and body control techniques may have potential

beneficial effects on cognition because they are involved in active

attention exercises. For example, it has been shown that yoga

practice enhances subject’s attention on breathing and specific body

muscles, referring to a general improvement in attention capacity

108

[Oken and Zajdel., 2006]. On the other hand, cognition improvement

may be indirectly achieved by the attenuation of emotional intensity

and stress reduction produced by the regular practice of yoga. The

mindfulness training program is in relation with changes in grey

matter concentration in brain regions involved in learning and memory

processes, emotion regulation and self-referential processing. These

earlier studies showed that mindfulness meditation is related with

brain structures in distributed regions of the brain: the right anterior

insula, amygdala, temporo-parietal junction, orbitofrontal cortex,

hippocampus, posterior cingulate cortex and cerebellum. Breathing

through a particular nostril increased spatial memory scores [Naveen

KV et al. 1997]. When meditation is practiced over a period of time it

can improves perception, attention, and cognition [Brown DP., 1977].

Many of the research studies have shown improvement in attentional

task performance following meditation.

In the fourth objective, the influence of yoga and meditation on

auditory reaction time and visual reaction time was studied. Yoga is

commonly called as a mind-body therapy and it has often been

claimed that it can enhance one’s ability to focus the attention,

improve the cognitive abilities, decrease the stress and improve the

organ system’s strength and the suppleness of the nervous system. It

109

has been reported that yoga training improves the human

performance, which includes the CNS processing [Hayes M et al.,

2010]. This fact gave us interest to investigate whether a short

course of the yoga and meditation practice could be used as a

therapy for improving the reaction time.

The results here revels that, there is significant reduction in auditory

and visual reaction time in yoga and meditation group when

compared to control group. This may be due to increase in processing

capability of CNS. To evaluate the processing speed of central

nervous system and the speed of co-ordination between the sensory

and motor systems are estimated by measuring simple reaction time.

Simple reaction time is an indirect marker of processing capability of

CNS. Reaction time measures of how fast one individual can react

to a specific stimulus. Sensory neurons act as a transducer, convert a

stimulus into an electrical signal, which is transmitted along the

sensory neuron(s), after words through one or more than one

neurons of CNS and then later transmitted along the length of the

motor neuron(s). While evaluating ‘simple reaction time’ we consider

only one stimulus and one response. Reaction time is “defined as

interval of time between presentation of stimulus and appearance of

appropriate voluntary response in subject” [Mohan M et al., 1984].

110

Yoga practice leads to overall improvement in joint flexibility and

physical fitness. The significant improvement - in coordinates the

hand movements and steadiness which is also noted in other

research studies [Madanmohan et al., 1992 and 2008, Gopal et al.,

1974]. This improvement in flexibility of joints and co-ordination of

hand movement’s steadiness is responsible for faster reaction time.

Yoga brings a link between psychic and somatic aspect of body

functions and improved motor performance, nerve conductions,

speed motor action, increased level of consciousness and calmness.

It lowers neuro-humoral activity, lowers rate of mental fatigability,

increase performance quotient and improves memory [Modanmohan

et al., 2008, Jansi RN et al., 2006, Saeed SA et al., 2010]. Yoga

quickens the neuronal transmissions, calm the mind, increase the

concentration and improve the performance. Calm mind and

increased concentration can fasten the reaction time [Madanmohan

et al., 1992, Malathi et al., 1989]. Yoga is involved in restoring the

under activities of the Parasympathetic Nervous System (PNS) and

the Gamma Amino-Butyric Acid (GABA) systems. This restoration

may be partly through the stimulation of the vagal nerves [Streeter

CC et al., 2007]. A Single-Photon Emission Computed Tomography

(SPECT) study demonstrated that the yoga training program

increased the Cerebral Blood Flow (CBF) and that the changes in

111

particular, appeared to have a greater impact on the right hemispheric

function, particularly in the frontal lobes [Cohen DL et al., 2009]. Now,

it can be emphasized that the improvement in the reaction time may

be related to the above facts. Effect of yoga and meditation on

reaction time could be due to greater cortical arousal, faster rate of

information processing, improved concentration power, improved

memory and ability to ignore external stimuli, with less distractibility

[Malathi A et al., 1989]. Thus regular practice of yoga and meditation

in medical students leads to reduced audio-visual reaction time by

improving concentration power, memory and reducing perceived

stress. These positive results can be applied to improve their

academic performance and to boost up their confidence levels.

The next objective of our study reveals the effect of yoga and

meditation on critical flicker fusion frequency. The results shows

increase in CFF value in experiment group which reveals that yoga

and meditation can make a great change by improving the neural

performance and reducing fatigue and stress level. The CFF can be

defined as “the frequency at which a flickering light is perceived to be

steady”. The phenomenon of "fusion" can be explained by two

physiological explanations. This involves the peripheral visual

pathway. (i) “the frequency at which the optic tract discharges may

112

limit the ability to perceive high frequency light stimuli” and (ii)

“ganglion cells of the "onoff' variety, which discharge when

illumination comes on and goes off produce a response which is

indistinguishable from their discharge under steady illumination, at a

frequency of about 35 flashes per second” [Deutsch JA et al ., 1973].

There is a somewhat different explanations suggesting that the eye

itself may respond at higher frequencies than the value of the CFF

obtained by behavioural or psychophysical techniques, and is hence

not the limiting factor in determining the CFF. This lead to the

conclusion that the brain plays a major role in temporal resolution of

the flickering stimulus rather than the eye [Riggs LA 1984]. Yoga

practices for a month not only led to a reduced level of optical

illusion created by Muller-lyer lines and raised the critical fusion

frequency but also improved neural performance, higher critical fusion

frequency indicating reduced fatigue and stress level [Tells S et al.,

1997]. When the stress level reduced by yoga and meditation the

attention concentration and memory is improved. So here in our

study, increase in CFF level in yoga and meditation group is an

indirect indication for reduced stress, improved attention,

concentration and memory.

113

The final goal of our study was the effect of yoga and meditation in

academic performance of medical students. The study results we

obtained shows significant improvement in academic performance of

students who participated in yoga and meditation training. But the

control group remained same without any improvement. These results

remain in coordinated with the earlier studies such as [Janowiak et

al., 1994; Kauts et al., 2009; Wheeler et al., 2007; Brewer et al.‚

2010; Krishna., 2006; Benson et al., 2000; Lee., 1999; Linden.,

1973; Takhar etal., 2012; Angus., 1989; Hopkins., 1979] which

found that meditation, practiced over long periods, can produces

definite changes in perception, attention, and cognition. Other study

have showed that yoga techniques are helpful in management of

anxiety, stress and improvement in concentration. It is very clear that

when anxiety and stress is reduced, concentration, alertness,

attentiveness and memory will improve. All these physiological and

psychological changes by yoga and meditation have made the

difference in the academic performance of the study group. The only

limited studies done on yoga and meditation in cognitive functions

and academic achievements in college students.

114

It is clearly relevant from our study that yoga and meditation has a

significant role in enhancing the cognitive function as well as

academic performance of medical students by reducing anxiety,

stress, and improving attention, concentration, memory, motivation &

visual perception.

115

7. CONCLUSION

The goal of this research was to evaluate the effect of yoga and

meditation in cognitive functions and academic performance of

medical students. Research done here points out that practice of

yoga and meditation have a better impact on cognitive functions, by

improving the global motivation, attention, concentration and memory.

The present study also revealed that medical students exhibit a

significant level of perceived stress which can be reduced by yoga

modules.

This study also shows yoga and meditation decrease auditory and

visual reaction time and increase critical flicker fusion frequency

which indicates increase in processing capability of central nervous

system and reduce in fatigue and stress. The study has obviously

proved that the above changes gained by yoga and meditation

positively improves the academic performance of the medical

students.

Based on the findings of the present study it may be concluded that

interventions of yoga and meditation can improve the cognitive

functions and academic performance of medical students.

116

There is an ever growing volume of research studies to support these

findings. It is postulated that in future yoga and meditation can

become a part of medical curriculum to benefit the student’s

academic performance.

117

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