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REVIEW ARTICLE

Effects of Yoga on Stress Among Healthy Adults:

A Systematic Review
Feifei Wang, MSc; Attila Szabo, PhD, DSc

ABSTRACT
Background • Yoga was recommended in both clinical Results • Totally, 12 articles elaborating on the effects of
and nonclinical populations as therapy methods. The yoga or yoga-related interventions on stress management
diversity of yoga practice as a therapy method has rarely and remission were included in the review. This review
been discussed and it is essential to address the effects of included various types of yoga practice (e.g., Hatha yoga,
yoga on stress. Bikram yoga, Kundalini yoga, Sudarshan Kriya yoga,
Primary Study Objective • This article aims to investigate Kripalu yoga, Yin yoga). A time spectrum was conducted
the effect of different types of yoga on stress in healthy from 4 wks to 28 wks. This review revealed that most types
population. On the other hand, the authors intended to of yoga have positive effects on stress reduction in heathy
figure out yoga effects on stress systematically. populations.
Methods/Design • A systematic literature review was Conclusion • Further studies are recommended to
conducted to identify articles that assess the effect of yoga and examine the long-term effect of yoga and underlying
yoga-related interventions on stress reduction in nonclinical psychological mechanisms causing stress and mental
populations. Studies were classified according to the length restrain. In addition, it is suggested to consider age as a
of the intervention, yoga type, and measures of outcome. The risk factor affecting the effect of yoga on stress. (Altern
studies were selected throughout last 5 years (January 2014 to Ther Health Med. 2020;26(4):58-64).
November 2018) by using the key searching term yoga and
stress incorporation with tension and pressure. The selection
process followed the Prisma flow diagram.

Feifei Wang, MSc, is PhD student in Education at the poses (called asanas) with deep, rhythmed breathing and
Institute of Sports and Health Promotion, ELTE Eötvös meditation, with the goal of increasing physical flexibility
Loránd University, in Budapest, Hungary. Attila Szabo, and strength in skeletons.1 A treasury of 112 types of yoga
PhD, DSc, is Doctor of the Hungarian Academy of Sciences, written by Singh explicitly answered the context of yoga
Professor of Psychology, Institute of Psychology, and types, by which the highest reality was reached.2 Nevertheless,
Institute of Health Promotion and Sport Sciences, ELTE despite the wide variety of yoga, its implementation was
Eötvös Loránd University, in Budapest, Hungary. successful worldwide in scientific research.
The effects of yoga on health have been illustrated many
Corresponding author: Feifei Wang, MSc times. Studies have shown that yoga benefits health both in
E-mail address: [email protected] clinical patients and nonclinical populations. Yoga as a
treatment for insomnia among patiens with cancer and
survivors was systematically reviewed and suggested
promising evidence of yoga for its efficacy in improving
INTRODUCTION insomnia and sleep quality impairment.3 Evidence showed
Yoga has become popular as a therapeutic and relaxation psychophysiological effects of yoga, and it was suggested to
intervention among all age groups, including the older increase endogenous secretion of melatonin, which, in turn,
adults. Although there are many types and styles of yoga, might be responsible for improving the sense of well-being.4
typical yoga practices combine stretching and holding various In addition, meditation also showed physiological effect by

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Table 1. Inclusion and exclusion criteria used when selecting articles in the systematic review

Inclusion criteria Exclusion criteria

Population People above 18 years old People with clinical symptoms (physical or mental disorder, or undergoing regular
medical check) or in shift-work schedule
Intervention/exposure Yoga based study on stress Review (systematic review; meta-analysis)
Empirical or observational longitudinal study (follow-up study or retrospective study); Mixed study methods
Original studies
Comparison Contain intervention and controlled Case-control studies
groups
Outcome Outcome elaborated the effect of yoga on stress
Other Timeframe from January 2014 to Questionable analysis methods.
November 2018 Non-English study

increasing cardiac output, which inherently influence basal P (population): Regular healthy participants (not
metabolic rate.5 As to cognitive function, yoga practice hospitalized patients or with clinical diseases, not
showed no significant improvement in healthy population; pregnant ladies, not in day-night shifting works).
however, yoga practice disclosed inspiring results in quality I (intervention/exposure): Organizing yoga-based
of life and physical measures.6 Nevertheless, yoga-based intervention.
intervention program is feasible and efficacious in creating C (comparison): Studies comparing healthy adults
positive improvements of health and wellness.7 conducting yoga practice versus healthy adults not
The psychological effect of yoga has been examined in conduction yoga practice, where such comparison
previous study. Yoga appears to work on depression, anxiety, has been performed;
and self-efficacy. For instance, a systematic review carried out O (outcome): Effects of yoga practice on stress.
in 2004 investigated the effectiveness of yoga on the treatment
of anxiety and anxiety disorders. Evidence reported Inclusion and Exclusion Criteria
encouraging results with obsessive compulsive disorder The source of stress differs in adults regarding to the life
despite the diversity of intervention conditions and deficient management and social engagement. We accepted only
quality of the studies.8 Demonstrated by a recent review that studies conducted within adults (18 years and older in this
involved 27 studies, of which 19 studies reported significant study). Trials were excluded if any participants who were
reduction in state and/or trait anxiety.9 In women who suffer clinical patients with physical or mental symptoms, shift
from anxiety disorders, 2-month yoga class can lead to working personnel, or people with sleep disorder or perinatal
significant reduction in perceived levels of anxiety.10 women. The reason why we excluded shift-working personnel
The effect of yoga and stress has been examined in wide was that shift workers may suffer extra stress compared with
range of age groups and social status including prisoner and the heathy population with regular life routine. Pregnant
office set.11,12 The mechanism of yoga and stress has been women who have to go to hospital for regular medical check
underlined. Positive affect, self-compassion, inhibition of the was excluded due to their special body condition. People who
posterior hypothalamus and salivary cortisol from a current undergo sub-health condition (eg, people with sleep
systematic review were all shown to mediate the relationship disorders, insomnia) were also excluded because stress may
between yoga and stress.13 Due to the diversity of yoga interact with subhealth conditions.
practices and the vulnerable evidence existed in yoga types Studies which conducted with multiple or mixed
and stress in healthy populations, the present study sought to research methods were excluded. In addition, we also
better characterize the benefits of yoga on stress. This excluded publication of reviews articles and letter to editors
systematic review evaluates the current scientific evidence of in this study. If multiple published reports from the same
yoga practice on stress. We hypothesize that any types of yoga trial were available, only the report that contain the most
will have beneficial effects on stress. We examined this qualified information were taken into consideration.
question across a large age range. Nevertheless, we did not take the sample size as an exclusion
criterion. Meanwhile, reviews or longitudinal studies were
METHODS not included. The inclusion and exclusion criteria are
To examine our hypothesis, we conducted a systematic presented in Table 1.
review.
Quality Assessment
Databases and Search Terms We used the Critical Appraisal Skills Programme
The PICO standard15 was used as a supportive guideline (2018)16 checklist to assess the quality of the selected
in the study selection. Before assessing by PICO, all studies. These checklists were designed to be used as
manuscripts initially considered relevant by title and abstract educational pedagogic tools, as part of a workshop setting,
were eligible for inclusion. Details in PICO standard: therefore we do not suggest a scoring system. The core

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Figure 1. Checklist of Quality Assessment of Selected Studies

Hewett et al22 (2018)

Hylander et al31 (2017)
Marques et al26 (2017) % Yes
Maddux et al25 (2017) % No
Park et al24 (2017) % CT
Chandra et al23 (2017)
Garcia-Sesnich et al28 (2017)
Hunt et al32 (2017)
Peterson et al27 (2017)
Harkess et al29 (2016)
Lindahl et al1 (2016)
Bilderbeck et al11 (2015)
0% 20% 40% 60% 80% 100%
Note: %Y = percentage of “Yes”; %N = percentage of “No”; %CT = % of “Cannot tell.”

Table 2. Assessment of Risk of Bias

Adequate Blinding Incomplete Selective Overall

sequence Allocation (of outcome outcome data outcome assessment of
Studies generation? concealment? assessors) addressed? reporting? risk of bias
Hewett et al22 (2018) yes yes yes yes yes Low
Hylander et al31 (2017) yes unclear yes yes yes Uncertain
Marques et al26 (2017) yes yes yes yes yes Low
Maddux et al25 (2017) yes yes yes yes yes Low
Park et al24 (2017) yes yes yes yes yes Low
Chandra et al23 (2017) yes yes yes unclear no Uncertain
Garcia-Sesnich et al28 (2017) unclear yes no unclear yes Uncertain
Hunt et al32 (2017) yes no no yes yes High
Peterson et al27 (2017) yes yes no yes unclear High
Harkess et al29 (2016) yes yes unclear yes yes Uncertain
Lindahl et al1 (2016) yes yes no unclear no High
Bilderbeck et al11 (2015) unclear no yes yes unclear High

Note: “Low” indicates low risk of bias; “High” indicates high risk of bias; “Uncertain” indicates the risk of bias is uncertain.

CASP checklists were based on JAMA ‘Users’ guides to the of risk of bias examined all of the included studies from
medical literature adapted from Guyatt et al,17 which piloted 5 domains:
with health care practitioners. The checklist was adopted
when rating the selected studies, we did not make comments 1. Was the allocation sequence adequately generated?
on the studies. All items are rated as “yes,” “no,” or “can’t 2. Was allocation adequately concealed?
tell,” and Figure 1 summarizes the items by the checklist. 3. Was knowledge of the allocated intervention
adequately prevented during the study?
Bias Assessment 4. Were incomplete outcome data adequately addressed?
Publication bias always need to be taken into 5. Are reports of the study free of suggestion of selective
consideration in systematic review. However, up to now, outcome reporting, and each of questions was given
there is no exact tool to assess the publication bias. With the 3 answers: yes, no or unclear. Higgins suggested that if
comprehensive search strategy, we relied on the tool for risk a trial address all the 5 domains with “yes,” the trial
of bias assessment produced by Cochrane to explore the will be considered to have “low overall risk of bias”;
potential effects of publication bias on our results. There are however, in cases in which even one of those
2 dimensions concerning the validity of the study to assess 5vdomains get an “unclear” or “no“ assignment, the
whether the study is asking appropriate research question trial will be considered to have an “ unclear or high
(external validity), and whether it answers its research overall risk of bias.”18 The details risk of bias assessment
question “correctly” (internal validity).18 The Cochrane tool is listed in Table 2.

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Figure 2. Study Selection Process

Records identified through database searching Additional records identified through other sources
(n = 1469) (n = 1)
Identification

Records after duplicates removed

(n = 1266)

Records screened Records excluded by title and

(n = 1266) abstract (n = 1191)
Screening

Full-text articles assessed for Full-text articles excluded (n = 47) with reasons:
eligibility (n = 75) • Clinical patients
• Shifted workers
• People with pyschological problems
Eligibility

• Participants are perinatal women

• Mix-methods studies
• Review
• Stree as mediator for Yoga
• Letter to editor

Studies included in qualitative

synthesis (n = 28)
Included

Studies included in quantitative

synthesis (systematic analysis)
(n = 12)

RESULTS Characteristics of Included Studies

Study Selection Flow The 12 studies involved 672 participants. The details of
Database searching using the method described led to involved articles are presented in Table 3. Based on the
the retrieval of 1469 studies (PubMed: 732, Scopus: 737). An eligibility criteria, studies with both case and control group
additional source (International Journal of Yoga) online Web comparison were included. Different intervention methods
site was checked. All of the studies were filtered step by step. were performed in various ages groups in adults. Various
From tittle and abstract, it is feasible to spotted out the types of yoga practice (eg, Hatha yoga, Bikram yoga,
ineligible participants (eg, clinical patients, people under Kundalini yoga, Sudarshan Kriya yoga, Kripalu yoga, Yin
regular medical check) and research methods (eg, reviews, yoga) with 3 spectrum from 4 weeks to 28 weeks were
protocols). After screening tittles and abstract, 75 articles conducted. Single studies were published in 2015 and 2018,
went through full-text examination. The articles were 2 studies were published in 2016, and the rest of the included
examined by the aforementioned exclusion criteria. Finally, studies were published in 2017. All of the studies organized
12 studies were included in the system review. The flow chart case group and control group and measured the participants
of study selection process was showed in Figure 2. pre-post intervention. Participants were distributed

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Table 3. The details of selected studies

Study Participants Intervention Duration Study design Outcome Measurements of assessing

method stress
Hewett et al22 (2018) 63 Adults (37.2 ± 10.8 y) Bikram yoga 16 weeks A randomized P.E. 10-item Perceived Stress
controlled trial Scale (PSS)
Hylander et al31 (2017) 49 middle-aged Yin yoga 5 weeks A case-control study P.E. 4-iterm Perceived Stress
participants Scale (PSS-4)
Marques et al26 (2017) 34 women (83.16 ± 7.4 y) Chair-based Yoga 28 weeks Case-control study P.E. Perceived Stress Scale (PSS)
Maddux et al25 (2017) 80 students (mean age Power yoga 16 weeks Pre-post intervention P.E. 10-item Perceived Stress
46 y) Scale (PSS)
Park et al24 (2017) 51 first-year Kripalu yoga 8 weeks A randomized P.E. 21-item Depression, Anxiety
undergraduates controlled trial and Stress Scale (DASS-21)
Chandra et al23 (2017) 20 humans aged 21- to Sudarshan Kriya 30 days Case-control study P.E. Stress Determination Test
30-y- old yoga (SDT)
Garcia-Sesnich et al28 26 people aged 18- to Kundalini Yoga 3 months Case-control study P.E. Perceived Stress Scale (PSS)
(2017) 45-y-old (Spanish version)
Hunt et al32 (2017) 60 undergraduate Mindfulness 4 weeks Case-control study P.E. Beck Depression Inventory
students training; Pre-post intervention (BDI)
Yoga alone Spielberger State/Trait
Anxiety Inventory
Peterson et al27 (2017) 142 individuals Multicomponent 6 weeks Pre-post intervention P.E. 10-item Perceived Stress
(43 ± 13.90 y) Breath-Based Yoga Scale (PSS)
Harkess et al29 (2016) 84 middle-aged women Yoga class 2 months A case-control trial P.E. Kessler Psychological
Distress Scale (K10);
Perceived Stress Scale (PSS)
Lindahl et al1 (2016) 8 participants 60-min Hatha yoga 7 weeks Pre-post intervention P.E. Perceived Stress Scale (PSS)
(66.5 ± 0.3 y) sessions
Bilderbeck et al11 (2015) 55 participants Yoga course 10 weeks Pre-post intervention P.E. Perceived Stress Scale (PSS)
(prisoners)

Note: P.E.= Positive Effect; N.E.= Negative Effect; N/L= No effect or Lack of evidence

randomized or nonrandomized. Stress was measured by The association between age and yoga effect was under
perceived stress scale (PSS) in all of the studies. Studies either investigation. Stress management interventions were highly
use 4-item or 10-item of PSS. Additional scales such as Beck regarded by first-year college students and demonstrated
Depression Inventory (BDI),19 Depression, Anxiety and dominant effects by Park et al.24 The yoga-based intervention
Stress Scale (DASS-21),20 and Kessler Psychological Distress consisted of Kripalu yoga (a form of hatha yoga) was reported
Scale (K10)21 were used in these studies. as being helpful in school and at home.24 Power yoga was
organized in males (n = 43, age: 45.5 years [10.0]) and females
Effects of Yoga on Stress (n = 43, age: 47.1 [10.4]), and after 16 weeks’ intervention, the
Greater improvement (or decrease) in perceived stress PSS scores dropped significantly.25 Nevertheless, the included
showed significant relation to greater yoga class attendance.11 articles showed clues of the interaction between age and the
Despite the duration, length, frequency, and types of yoga function of yoga practice. A group of older women (age:
practice conducted in difference trials, positive results of 83.16 ± 7.4 years) participated chair-based yoga, consisted of
yoga were found. Baseline and postintervention characteristics an exercise class intervention which based on the essential
were measured of the 8 participants who completed Hatha philosophy of Hatha yoga and its asanas, presented differences
yoga intervention, and perceived stress levels assessed by the with a large effect size (P = .052, d = .85) in the exercise group
PSS significantly decreased after the intervention (age: 83.73 ± 6.86 years) and control group
(preintervention, 13.6 ± 1.2 versus postintervention, 8.9 ± 1.2), (age: 82.73 ± 8.46 years).26 In addition, the examination of
with a large effect size of 1.38.1 A 16-week Bikram yoga Kundalini Yoga (KY) after 3 months of regular practice
program conducted randomized control study also revealed presented statistical significance of perceived stress score
a significant decrease in perceived stress (P = .001, compared with control group in the basal measurement.27
η2p = 0.173, 4.7 [95% CI: 2.1, 7.4)] at end of intervention in the The 3-day retreat program, named Shambhavi
experimental versus the control group.22 Sudarshan Kriya Yoga Mahamudra kriya, is a yogic practice that includes both deep
(SKY) including Sudarshan kriya, Bhastrika pranayama, and breathing and meditation techniques suggested that may
Yoga nidra, is believed to be a powerful rhythmic breathing represent a natural treatment for stress reduction.28 However,
technique, and proved to be a more positive alternative of it is suggested to take long-term effect of yoga intervention
“medication” for stress management in previous study.23 into consideration. Harkess29 yielded that short-term yoga

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practice may yield some benefits to stressed individuals, but on baroreflex in elder population.37 Thus, yoga practice with
the long-term evaluation is required to determine the optimal physical movement and gestures should be taken into
dose for improvements and maintenance.29 In the study, consideration before conducting among older adults.
women (n = 116) between the ages of 35 and 65 years were
allocated to a twice-weekly, hour-long yoga class for a period Limitations
of 2 months, or into a waitlist control. Following the statistical Limitations exist in this review. Methodological problems
methods of mixed-model analyses of variances and quadratic appeared in most of the selected studies including sample
time (Time 2) included for PSS examination, the study size limitation, short intervention period, and other factors.
showed that stress level did not improve significantly.29 As mentioned previously, we did not take small sample size
The effectiveness of yoga and mindfulness practice on as an exclusion criterion, but a small sample may bias the
stress need to be clarified. There are differences and validity of the study. In addition, the effect size of the
interactions between yoga and mindfulness. Both meditation included studies was not considered in the statistical analysis.
and yoga are implementations of mindfulness therapy.30 The
YOMI program, a psychoeducational training program that CONCLUSION
bridges psychological theory and knowledge with the practice Though the association of exercise and age by previous
of mindfulness and yin yoga, contributed significantly to study showing that many critical questions remain regarding
decreased levels of perceived stress increased levels of the relationship of aging and exercise, the positive effects of
mindfulness to participants.31 Hunt et al32 conducted a yoga were highly regarded. Both cognitive behavior therapy
multigroup study with 4 groups (“Mindfulness Training and yoga are promising stress management techniques.38
Alone”; “Yoga Alone”; “Multicomponent Mindfulness Given that yoga and cognitive behavior therapy (CBT) have
Training groups”; “Study Break with a Therapy Dog”) not been indicated any difference in coping with stress, it is
dismantled yoga and explicated mindfulness training in a suggested to explore the deeper function of yoga and CBT in
brief stress reduction intervention in college students.32 It is neurology level. Due the various subcategories of yoga, a
suggested that the “mindfulness training alone group” comprehensive knowledge of yoga is recommended.
experienced the least stress challenge compared with Moreover, physical activity has many well‐established
combined group and yoga alone group. health benefits, and physiological benefits of yoga help
people become more resilient to stressful conditions, but
DISCUSSION strenuous exercise increases muscle oxygen flux and elicits
The evidence of positive effect of yoga on stress intracellular events that can lead to increased oxidative
management becomes apparent. All types of yoga and yoga- injury.39 Nevertheless, more studies should be conducted to
based interventions (eg, mindfulness-based yoga, meditation- underlay biological mechanisms leading to its stress reduction
based yoga) illustrated significant benefit to stress release. effect in healthy populations.
The influences of yoga on stress have been studied from a
wide spectrum. The diversity of yoga practice and in AUTHOR DISCLOSURE STATEMENT
The authors declare that there is no conflict of interests regarding the publication of this
conjunction with mindfulness intervention are suggested to paper. Feifei Wang conceived, designed and wrote the paper; Attila Szabo improved the
help stress reduction and management. Yoga has a long approach of the systematic review and revised the final version of the paper. Both
history and recognized as a form of mind-body medicine. authors read and approved the final version of the manuscript. There is no interest
conflict to disclose.
The physical postures and breathing exercises improve the
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64 ALTERNATIVE THERAPIES, JUL/AUG 2020 VOL. 26 NO. 4 Wang—Yoga and Stress Among Healthy Adults