Yoga as an Adjunctive Intervention for Duchenne Muscular Dystrophy: A Scoping Review

Abstract

This scoping review aimed to explore and summarize the published evidence on yoga as an adjunctive intervention to standard rehabilitative care for individuals with Duchenne muscular dystrophy (DMD). A comprehensive literature search was conducted across five databases – PubMed/MEDLINE, SPORTDiscus, ProQuest Health and Medicine Collection, Web of Science Core Collection, and CINAHL – using the terms “Duchenne muscular dystrophy” (or DMD) and “yoga.” Studies were included if they (1) were published between January 2000 and December 2024; (2) involved participants with DMD; (3) examined yoga as an intervention; (4) were peer-reviewed; and (5) were published in English. We used a standardized data extraction form to capture study characteristics, including authorship, publication year, sample size, participant demographics, intervention details, outcome measures, and main results. We assessed study quality with the Modified Downs and Black Checklist (MDBC). Six studies met the inclusion criteria. Five were rated as having fair quality (MDBC score: 15–17/28), and one was rated as having poor quality (MDBC score: 3/28). Yoga interventions incorporated asanas (postures), dhyana (meditation), and pranayama (breathing practices). Outcome measures varied widely, encompassing mobility, self-care, comfort, heart rate variability, respiratory function, quality of life, and functional performance. Modest improvements were noted in pulmonary function and self-reported well-being; however, evidence remains limited and inconsistent. Current literature provides preliminary support for yoga as a complementary therapy in DMD rehabilitation. More rigorous, large-scale trials are needed to establish their efficacy and clinical relevance.

Introduction

Duchenne muscular dystrophy (DMD) is an X-chromosome-linked muscle disease that affects individuals assigned male at birth.[1] DMD arises from mutations in the dystrophin gene (gene ID: DMD), resulting in the absence of a functional dystrophin protein. Dystrophin is a critical component of the dystrophin-associated protein complex (DAPC).[1,2] The DAPC helps maintain calcium ion (Ca2+) homeostasis within skeletal and cardiac muscle fibers through mechanical and signaling roles.[1,3] Specifically, the DAPC is essential for enabling muscle fibers to withstand shear stress at the plasma membrane (i.e., shearing that occurs between the contractile apparatus, plasma membrane, and extracellular matrix) during muscular contractions (especially eccentric contractions) and tensile strain.[4,5,6] The absence of functional dystrophin results in increased permeability of muscle fiber plasma membranes to calcium ions (Ca2+), cellular stress in muscle fibers, and subsequent death, leading to the progressive degeneration of skeletal and cardiac muscle tissue. The tissue-level changes severely limit physical activity and functional independence in activities of daily living and ultimately lead to premature death around the age of 20 years.[1] An overview of pathophysiology and the current standard of care for DMD, and our study aim are presented in Figure 1.

Figure 1.

An overview of Duchenne muscular dystrophy (DMD) and our study aim. (a-d) Mutations in the dystrophin gene (DMD gene) on the X chromosome cause a loss of functional dystrophin protein. This affects the dystrophin-associated protein complex, leading to increased plasma membrane permeability, calcium ion dysregulation, chronic cellular stress, and the death of striated muscle fibers. (e-h) DMD causes progressive muscle fiber death and loss, along with replacement of muscle fibers with fibrous and fat tissue. Progressive weakness occurs in muscles of the limbs and trunk (affects mobility), the diaphragm (affects breathing), and the myocardium (affects heart function). (i) A summary of the clinical progression of DMD, from subtle early signs to loss of ambulation and eventual respiratory and/or cardiac failure. (j) Current standard care for DMD includes rehabilitation and steroidal anti-inflammatory medications. (k) We performed a scoping review on yoga as an adjunctive intervention to standard care in individuals with DMD. Image created in https://BioRender.com

DMD disease progression and associated impairments are only minimally controlled by medications, such as glucocorticoids (also known as steroidal anti-inflammatory drugs, corticosteroids, or steroids),[7] rehabilitative therapies,[8,9] and respiratory hygiene.[10] The limited options available in medical care may lead patients and caregivers to seek treatments classified as complementary and alternative medicine (CAM) therapies.[11,12] Surveys indicate that 70%–80% of individuals with DMD and their caregivers explore CAM therapies, such as yoga, to address the multifaceted challenges of the disease.[11,12] Yoga is a mind–body practice that integrates physical postures, breathing techniques, and meditation and has demonstrated potential benefits in enhancing mobility, cardiovascular function, and respiratory efficiency in both healthy individuals and those with various health conditions.[13,14,15,16] Given the promising outcomes observed when yoga interventions have been implemented for various health conditions, it is justified to ask whether a yoga intervention could offer similar benefits to individuals with DMD. However, to the best of our knowledge, there are no reviews of the published literature on yoga’s safety and efficacy for individuals with DMD. We therefore chose to address this knowledge gap by performing a scoping review of the existing evidence on the potential benefits of yoga for individuals with DMD, with the eventual goal of performing a systematic review and meta-analysis if sufficient evidence was found (https://doi.org/10.17605/OSF.IO/7U2XY).

In this paper, we present findings of the scoping review that we performed to explore the current literature on yoga as an adjunctive intervention to standard rehabilitative care for individuals with DMD. Specifically, this review aimed to assess whether yoga interventions improve functional outcomes, mobility, cardiovascular health, and respiratory function compared to preintervention levels and/or standard care. We framed our research question using the patient, intervention, comparison, and outcome format: “In individuals with DMD, does a yoga intervention improve functional outcomes compared to preintervention levels and/or provide an added benefit to standard care?”[17] Through our survey of the literature, we aimed to gain insights that could inform future studies and guide clinical practice in incorporating yoga into the management of DMD.

Methods

Study design

We performed a scoping review of the published literature to explore the evidence on the effects of a yoga intervention in individuals with DMD. We performed our review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews (PRISMA-ScR) [Supplementary Figure 1 ^{(3.4MB, tif)} ], thus ensuring a rigorous and transparent methodology.[18,19,20,21] Since we planned to conduct a systematic review and meta-analysis in future based on the findings of our scoping review, we registered our review with the Open Science Framework (https://doi.org/10.17605/OSF.IO/7U2XY).

Literature search strategy

We developed a comprehensive search strategy to identify relevant studies. We conducted a literature search through the following electronic databases: PubMed/MEDLINE,[22] SPORTDiscus,[23] ProQuest Health and Medicine Collection,[24] Web of Science Core Collection,[25] and CINAHL.[26] The search strategies combined keyword variants and database-specific subject headings for the two primary search terms: “Duchenne muscular dystrophy” (or DMD) and “yoga.”

Inclusion and exclusion criteria

To be eligible for inclusion in our review, studies had to meet five specific criteria:

1. Recency: The studies had to be published between January 1, 2000, and December 31, 2024 – i.e., articles published in the new millennium

2. Population: The studies had to include individuals with a confirmed diagnosis of DMD

3. Intervention: The studies had to assess the effect of a yoga intervention on individuals with DMD

4. Publication type: The studies had to be published in peer-reviewed journals to ensure methodological rigor and credibility

5. Language: The original articles had to be published in English, aligning with the language of this review.

Studies that did not meet the inclusion criteria were excluded. These criteria were established to ensure the inclusion of recent, relevant, peer-reviewed, and accurately interpretable evidence in our review [Supplementary Figure 1 ^{(3.4MB, tif)} ].

Study selection and data extraction

Two independent reviewers screened studies for eligibility based on our inclusion criteria. Discrepancies between reviewers were resolved through discussion, and a third reviewer was consulted when consensus could not be reached.[20] Data were extracted using a standardized spreadsheet to capture key study characteristics, which included author details, year of publication, sample size, participant demographics, yoga intervention details, outcome measures, and results.

Quality assessment

The methodological quality of the included studies was assessed using the Modified Downs and Black Checklist (MDBC), which consists of 27 items evaluating study design, methodology, and reporting.[27,28] Two evaluators independently scored each study using the MDBC, with discrepancies resolved through discussion or consultation with a third evaluator. Total scores ranged from 0 (lowest quality) to 28 (highest quality). Based on established precedents, studies were categorized as “excellent” (26–28), “good” (20–25), “fair” (15–19), or “poor” (≤14) in quality.[28,29] Methodological appraisal is optional in scoping reviews under PRISMA-ScR guidelines;[21] however, we included MDBC scores to provide readers with a clearer understanding of the strength and translational relevance of the available evidence. This approach helps ascertain whether study outcomes arose from robust methodologies, thereby informing both clinical application and future studies.

Data synthesis

Since this is a scoping review, a narrative synthesis was performed to summarize the characteristics and findings of each study [Table 1 and Supplementary Table 1a-f].[30] The results were organized and presented according to study design, participant characteristics, yoga intervention details, outcome measures, and reported outcomes [Table 1 and Supplementary Table 1].

Table 1.

Characteristics of the study included in the scoping review

Study		Sample size (n)		Duration		Type of study		Intervention/Exposure		Outcome measures		Main Results		MDBC score
RCTs
Pradnya et al., 2019		Initially enrolled n=124. Completed n=88		12 months		RCT; 2 groups (home-based PT only versus home-based PT + yoga)		Physical therapy, postures (asanas), breathing exercises (pranayama), cleansing breathing patterns (kriya), Meditation		HRV - time domain and frequency domain		No group, time, or interaction effect		15/28
Dhargave et al., 2021		Initially enrolled n=124; Completed n=88		12 months		RCT; 2 groups (home-based PT only versus home-based PT + yoga)		Physical therapy, postures (Asanas), breathing exercises (Pranayama), cleansing breathing patterns (Kriya), Meditation		Spirometry FVC, PEFR, MVV, MVt		Significant time effect in both the groups. No group or interaction effect		15/28
Dhargave et al., 2022		n=124; Completed n=87		12 months		RCT; 2 groups (home-based PT only versus home-based PT + yoga)		Physical therapy, postures (asanas), breathing exercises (pranayama), cleansing breathing patterns (kriya), Meditation		PedsQL™		Significant time effect in subgroup scores. No group effect or interaction		15/28
Dhargave et al., 2022		Initially enrolled n=124; Completed n=88		12 months		RCT; 2 groups (home-based PT only versus home-based PT + yoga)		Physical therapy, postures (Asanas), breathing exercises (Pranayama), cleansing breathing patterns (Kriya), meditation		MDFRS and TFTs		Significant time effect in both the groups. No group or interaction effect		15/28
Other trials (non-RCTs)
Telles et al., 2011		Initially enrolled n=16. Completed n=10		18 months		Pre–post, longitudinal (one group)		Yoga and Ayurveda		Mobility, self-care, and level of comfort with no specific scales or data provided		Paper merely mentions that 4/10 patients improved		3/28
Rodrigues et al., 2014		Initially enrolled n=76. Completed n=26		10 months		Pre–post, longitudinal (one group)		Yoga breathing exercises (pranayama)		Spirometry FVC, FEV1 MEP, and MIP		Significant improvement in FVC and FEV1		17/28

The table presents a summary of six studies, including author information, subject characteristics, outcome measures, main results, and the quality of the evidence for each study. FEV₁: Forced expiratory volume in 1 s, FVC: Forced vital capacity, HRV: Heart rate variability, MDBC: Modified Downs and Black Checklist, MDFRS: Muscular Dystrophy Functional Rating Scale, MEP: Maximal expiratory pressure, MIP: Maximal inspiratory pressure, MVV: Maximal voluntary ventilation, MVt: Minute ventilation, PedsQL: Pediatric Quality of Life Inventory, PEFR: Peak expiratory flow rate, PT: Physical therapy, RCT: Randomized controlled trial, TFTs: Timed functional tests

Supplementary Table 1a.

Detailed characteristics and outcomes of included studies

STUDY → DETAILS ↓		Pradnya Dhargave et al. (2019)
DOI and QR code		doi: 10.4103/ijoy.IJOY_12_18
Journal		International Journal of Yoga
MDBC score		15/28. Based on established precedents: “excellent” (26–28), “good” (20–25), “fair” (15–19), or “poor” (≤14)
Type of article		RCT
Participants (sex, age, number enrolled, location, etc.)		Males, 5–10 years, 124 genetically confirmed to have DMD enrolled, NIMHANS (Bengaluru, Karnataka, India). Individuals who were nonambulant were excluded
Groups, interventions, final sample size after dropouts		Group 1. PT only. n=45. Group 2. PT plus yoga. n=43
Intervention(s)		PT: Active and passive ROM exercises to all the joints (10 min); active and active-assisted breathing exercises (5 min); task-oriented exercises, such as rolling, lying to sitting, sitting to standing, standing, walking, and climbing one flight of stairs (10 min); activity-based breathing exercises, such as blowing pieces of paper, blowing candles placed at varying distances, and blowing balloons of different sizes (10 min); stretching exercises for trunk, chest wall, and commonly affected joints (10 min) Yoga: Yoga movements, postures, and stretches in standing (10 min); yoga breathing exercise (10 min); attaining, maintaining, and exiting asanas (yoga postures, 10 min); yoga cleansing breathing (7 min); yoga meditation (8 min) Other treatments: Steroidal anti-inflammatory medication for all participants. Body weight-controlled dose. Oral prednisolone at 0.75 mg/kg/day from diagnosis and continued throughout study Log maintained by participants and caregivers to record participation in interventions
Intervention frequency and duration		Group 1. PT at home in the morning and evening (PT only). Daily for 1 year. Five follow-up visits Group 2. Yoga in the morning and PT in the evening at home (PT + yoga). Daily for 1 year. Five follow-up visits
Main outcome measure(s) and change		HRV measures to calculate SVB (a lower number indicates improvement) and HFNu (a higher number indicates improvement) SVB. Group 1 went from 1.3±0.8 to 1.0±0.7 over 1 year. Group 2 went from 1.3±1.1 to 1.1±0.8 over 1 year. Authors say that there was a significant time effect for both the groups, i.e., 12 months different from baseline, but P=0.141. No significant difference between Group 1 and 2, implying that PT + yoga was not better than PT alone (P=0.537) HFNu. Group 1 went from 36.3±12.3 to 40.4±16.0 over 1 year. Group 2 went from 2. 38.3±16.1 to 45.6±28.9 over 1 year. Authors say that there was a significant time effect for both the groups, i.e., 12 months different from baseline, but P=0.054. No significant difference between Group 1 and 2, implying that PT + yoga was not better than PT alone (P=0.420)
Clinical relevance		Yoga does not appear to have an added benefit compared to standard PT alone in relation to heart rate variability, which is relevant to sympathetic-parasympathetic control of the heart, which in turn is linked to cardiac function and cardiovascular health

PT: Physical therapy, HRV: Heart rate variability, MDBC: Modified Downs and Black Checklist, SVB: Sympathovagal balance, HFNu: high-frequency Nu, NIMHANS: National Institute of Mental Health and Neurosciences, DOI: Digital Object Identifier, DMD: Duchenne muscular dystrophy, RCT: Randomized controlled trial

Supplementary Table 1f.

Detailed characteristics and outcomes of included studies

STUDY → DETAILS ↓		Marcos Rojo Rodrigues et al. (2014)
DOI and QR Code		DOI: 10.1590/s1806-37132014000200005
Journal		Brazilian Journal of Pulmonology (Jornal Brasileiro de Pneumologia)
MDBC score		17/28. Based on established precedents: “excellent” (26–28), “good” (20–25), “fair” (15–19), or “poor” (≤14)
Type of article		Exploratory, pre–post, longitudinal study. Authors disclose that the main goal was to assess safety and feasibility
Participants (sex, age, number enrolled, location, etc.)		Males, 6–14 years (mean age 9.5±2.2), 76 enrolled after confirmation of DMD through molecular assessment of skeletal muscle, University of São Paulo School of Medicine (São Paulo, Brazil)
Groups, interventions, final sample size after dropouts		Single yoga intervention group. No control group. n=26
Intervention(s)		Yoga: Hatha yoga breathing exercises taught individually to each participant. Yogic breathing exercises were performed three times per day – i.e., three sessions per day Kapalabhati. First exercise that was learned. Exclusively performed for the first 3 months and continued with other techniques until the end of study. Involves nasal exhalations produced by fast, vigorous contraction of abdominal and pelvic muscles, followed by passive inhalations. Three sets of 120 repetitions at each session Uddiyana. Learned at 3 months after starting study and continued until the end. Involves holding breathing (apnea) after full forced expiration, followed by thoracic expansion without inhalation, and maintaining closed glottis. Three repetitions of holding breath for 10 s Agnisara. Learned at 6 months after study entry and continued until the end. Involves maximal forced exhalation, maintaining an apneic state, and moving the abdominal wall in and out. Five repetitions of moving the abdomen in and out in apneic state Other interventions: Patients were on a standardized regimen of steroidal anti-inflammatory medication for at least 3 months prior to start of study and during study PT: No mention of physical or other rehabilitative therapies being received by participants during the study Log maintained to record completion of each yogic breathing exercise session
Intervention frequency and duration		Ten-month study. Participants maintained yoga breathing exercise log with help of caregivers, and only those who recorded 75% compliance were included in final analysis (n=26). Yogic breathing exercises performed three times per day for 10-month study period
Main outcome measure(s) and change		Pulmonary function assessed by spirometry, consistent with American Thoracic Society/European Respiratory Society Task Force standards for lung function testing FVC, % predicted. Increased from 82.3±18.6% at baseline to 90.3±22.5% at 10 months. P=0.02 FEV1, % predicted. Increased from 83.8±16.6% at baseline to 90.1±17.4% at 10 months. P=0.04 MEP. No significant change. 63.9±27.6% at baseline and 66.8±27.6% at 10 months. P>0.05 MIP. No significant difference. 41.4±13.7% at baseline and 43.7±12.8% at 10 months. P>0.05
Clinical relevance		Authors conclude that the yoga breathing exercise protocol that they followed was both feasible and safe for individuals with DMD. The data suggest that the yogic breathing exercise regimen followed in this study improved both FVC and FEV1 over the 10-month duration of the study

MDBC: Modified Downs and Black Checklist, DOI: Digital Object Identifier, DMD: Duchenne muscular dystrophy, FEV₁: Forced expiratory volume in 1 s, FVC: Forced vital capacity, MEP: Maximal expiratory pressure, MIP: Maximal inspiratory pressure, PT: Physical therapy

Supplementary Table 1b.

Detailed characteristics and outcomes of included studies

STUDY → DETAILS ↓		Pradnya Dhargave et al. (2021)
DOI and QR Code		doi: 10.4103/ijoy.IJOY_49_20
Journal		International Journal of Yoga
MDBC score		15/28. Based on established precedents: “excellent” (26–28), “good” (20–25), “fair” (15–19), or “poor” (≤14)
Type of article		RCT
Participants (sex, age, number enrolled, location, etc.)		Males, 5–10 years, 124 genetically confirmed to have DMD enrolled, NIMHANS (Bengaluru, Karnataka, India). Individuals who were on steroidal anti-inflammatory medication for>3 months at time of enrollment, those with cardiopulmonary concerns, and those who were nonambulant, were excluded
Groups, interventions, final sample size after dropouts		Group 1. PT only. n=45. Group 2. PT plus yoga. n=43
Intervention(s)		PT: Active and passive ROM exercises to all the joints (5 min); active and active-assisted breathing exercises (5 min); task-oriented exercises, such as rolling, lying to sitting, sitting to standing, standing, walking, and climbing one flight of stairs (15 min); Activity-based breathing exercises, such as blowing pieces of paper, blowing candles placed at varying distances, and blowing balloons of different sizes (10 min); stretching exercises for trunk, chest wall, and commonly affected joints (10 min) Yoga: Yoga movements, postures, and stretches in standing (10 min); yoga breathing exercise (10 min); attaining, maintaining, exiting asanas (yoga postures, 10 min); yoga cleansing breathing (7 min); yoga meditation (8 min) Other treatments: Steroidal anti-inflammatory medication for all participants. Body weight-controlled dose Log maintained by participants and caregivers to record participation in interventions
Intervention frequency and duration		Group 1. PT at home in the morning and evening (PT only). Daily for 1 year. Five follow-up visits Group 2. Yoga in the morning and PT in the evening at home (PT+yoga). Daily for 1 year. Five follow-up visits
Main outcome measure(s) and change		Pulmonary function tests. FVC (L). Group 1 increased from 0.9±0.2 to 1.0±0.3 over 1 year. Group 2 increased from 0.8±0.3 to 1.0±0.3 over 1 year. Time effect for both the groups was significant, implying significant improvement over 1 year of treatment (P=0.001). No group effect, implying that PT + yoga was not better than PT alone (P=0.777) PEFr (L/min). Group 1 increased from 100.6±41.7 to 126 8±44.2. Group 2 increased from 103.4±41.2 to 116.6±48.4. Time effect for both the groups was significant, implying significant improvement over 1 year of treatment (P=0.001). No group effect, implying that PT + yoga was not better than PT alone (P=0.347) Tidal volume (L). Group 1 went from 0.4±0.2 to 0.4±0.1 over 1 year. Group 2 went from 0.3±0.2 to 0.3±0.1 over 1 year. No time effect, implying no significant improvement over 1 year (P=0.154). No group effect, implying that PT + yoga was not better than PT alone (P=0.166) MVV (L/min). Group 1 increased from 28.1±9.7 to 34.6±11.0 over 1 year. Group 2 increased from 28.7±9.4 to 32.6±10.7 over 1 year. Time effect for both the groups was significant, implying significant improvement over 1 year of treatment (P<0.001). No group effect, implying that PT + yoga was not better than PT alone (P=0.817) Tidal volume during MVt (L). Group 1 went from 0.3±0.1 to 0.5±0.2. Group 2 went from 0.4±0.1 to 0.5±0.2. Time effect for both the groups was significant, implying significant improvement over 1 year of treatment (P<0.001). No group effect, implying that PT + yoga was not better than PT alone (P=0.753)
Clinical Relevance		Yoga does not appear to have an added benefit compared to standard PT alone in relation to pulmonary function

PT: Physical therapy, MDBC: Modified Downs and Black Checklist, DOI: Digital Object Identifier, FVC: Forced vital capacity, PEFR: Peak expiratory flow rate, MVV: Maximum voluntary ventilation, MVT: Maximum voluntary ventilation, DMD: Duchenne muscular dystrophy, RCT: Randomized controlled trial, NIMHANS: National Institute of Mental Health and Neurosciences

Supplementary Table 1c.

Detailed characteristics and outcomes of included studies

STUDY → DETAILS ↓		Pradnya Dhargave et al. (2022)
DOI and QR Code		DOI: 10.26463/rjpt. 2_2_4
Journal		RGUHS Journal of Physiotherapy
MDBC score		15/28. Based on established precedents: “excellent” (26–28), “good” (20–25), “fair” (15–19), or “poor” (≤14)
Type of Article		RCT
Participants (Sex, age, number enrolled, location, etc.)		Males, 5–10 year, 87 genetically confirmed to have DMD enrolled, NIMHANS (Bengaluru, Karnataka, India). Mean age 96.95±16.08 months for Group 1. Mean age 99.02±18.41 months for Group 2. Individuals with cardiopulmonary concerns and those on steroidal anti-inflammatory drugs were excluded
Groups, interventions, final sample size after dropouts		Group 1. PT only. n=44. Group 2. PT plus yoga. n=43
Intervention(s)		PT: Active and passive ROM exercises to all the joints (5 min); active and activeassisted breathing exercises; taskoriented exercises, such as rolling, lying to sitting, sitting to standing, standing, walking, climbing one flight of stairs, etc.; Activitybased breathing exercises, such as blowing pieces of paper, blowing candles placed at varying distances, blowing balloons of different sizes, etc.; Stretching exercises for trunk, chest wall, and commonly affected joints. Times for each aspect not given. 45 min total Yoga: Yoga movements, postures, and stretches in standing (10 min); yoga breathing exercise; attaining, maintaining, exiting Asanas (yoga postures); yoga cleansing breathing; yoga meditation. Times for each aspect not given. 45 min total Log maintained by participants and caregivers to record participation in interventions
Intervention frequency and duration		Group 1. PT at home in the morning and evening. Daily for 1 year. Five follow-up visits Group 2. Yoga in the morning and PT in the evening at home. Daily for 1 year. Five follow-up visits
Main outcome measure(s) and change		PedsQL neuromuscular module version 3.0 (completed by caregiver). My neuromuscular disease component. Only this component is directly relevant to physical function – the other two assessed communication and family support. Group 1 increased significantly from 1394.32±169.55 to 1461.93±187.12 over 1 year (P=0.004), implying that PT alone did have a beneficial effect. Group 2 did not show a statistically significant change and went from 1427.33±165.82 to 1447.67±194.78 over 1 year (P=0.05), implying that adding PT to yoga might negatively affect this outcome measure. No significant difference between Group 1 and 2 at 1 year (P=0.729), implying that PT + yoga was not actually better or worse than PT alone (P=0.753), thus rejecting the notion that yoga has a negative effect when added to PT (authors report no significant difference at baseline for both the groups, P=0.361) Total PedsQL Score. Includes all three components. Group 1 increased from 2111.79±32.12 to 2193.18±37.79 over 1 year (P=0.003). Group 2 went from 2150.58±198.09 to 2139.53±267.61 (P=0.179). No significant difference between Group 1 and Group 2 at 1 year (P=0.337)
Clinical relevance		Yoga does not appear to have an added benefit compared to standard PT alone in relation to PedsQL™ neuromuscular module version 3.0 (completed by caregiver). Rather, there seems to be a numerical trend suggesting that yoga might diminish the benefits of PT, although this was not validated by statistical analyses

RGUHS: Rajiv Gandhi University of Health Sciences, PT: Physical therapy, MDBC: Modified Downs and Black Checklist, DOI: Digital Object Identifier, RCT: Randomized controlled trial, NIMHANS: National Institute of Mental Health and Neurosciences, PedsQL - Pediatric Quality of Life Inventory, DMD: Duchenne muscular dystrophy

Supplementary Table 1d.

Detailed characteristics and outcomes of included studies

STUDY → DETAILS ↓		Pradnya Dhargave et al. (2022)
DOI and QR Code		DOI: 10.4103/ijptr.ijptr_8_22
Journal		Indian Journal of Physical Therapy and Research
MDBC score		15/28. Based on established precedents: “excellent” (26–28), “good” (20–25), “fair” (15–19), or “poor” (≤14)
Type of article		RCT
Participants (sex, age, number enrolled, location, etc.)		Males, 5–10 years (mean age 7.9±1.5 years), 124 genetically confirmed to have DMD enrolled, NIMHANS (Bengaluru, Karnataka, India)
Groups, interventions, final sample size after dropouts		Group 1. PT only. n=45. Group 2. PT plus yoga. n=43
Intervention(s)		PT: Active/passive ROM exercises, active/assisted breathing, task-oriented exercises, activity-based breathing exercises, stretching exercises. 10 repetitions on each side. Times for each aspect not given. 45 min total Yoga: Sukshma and Sthula vyayama; breathing exercises. Meditation. Asanas: Pavanamukthasana, Markatasana and Sethubandasana in supine lying, Bhujangasana in prone lying, Vakrasana and Marjalasana in sitting, Tadasana and Vrikshasana in standing. Pranayama and kriya: Yogic breathing, Bhastrika and Bhramari, Nadishuddi, Kapalabhati. Times for each aspect not given. 45 min total Other treatments: Standing and walking for 1 h daily for all participants. Steroidal anti-inflammatory medication for all participants (had to have been on medication for<3 months) Log maintained by participants and caregivers to record participation in interventions
Intervention frequency and duration		Group 1. PT at home in the morning and evening. Daily for 1 year. Five follow-up visits Group 2. Yoga in the morning and PT in the afternoon at home. Daily for 1 year. Five follow-up visits
Main outcome measure(s) and change		MDFRS and TFT MDFRS: Group 1. PT only. 120.3±6.1 to 118.4±11.3 over 1 year. Group 2. PT and yoga. 118.3±7.9 to 113.7±15.7 over 1 year. No significant difference between Group 1 and 2. P=0.322 at 1 year TFTs     Standing from supine: Group 1-16.5±10.4 to 12.3±13.1 over 1 year. Group 2-12.2±6.9 to 10.6±5.9 over 1 year. P=0.192 between the groups at 1 year     Standing from sitting: Group 1-4.7±4.1 to 2.5±2.3 over 1 year. Group 2-3.7±2.4 to 4.2±5.9 over 1 year. P=0.878 between the groups at 1 year     Donning a T-shirt: Group 1-21.7±18.0 to 18.9±15.6 over 1 year. Group 2-23.5±6.6 to 19.3±10.2 over 1 year. P=0.367 between the groups at 1 year     Cutting paper with scissors: Group 1-27.0±27.1 to 20.6±13.9 over 1 year. Group 2-26.0±12.3 to 19.4±9.9 over 1 year. P=0.961 between the groups at 1 year     Walking 30 ft as fast as possible: Group 1-10.0±4.5 to 10.7±10.8 over 1 year. Group 2-11.5±6.3 to 11.5±11.6 over 1 year. P=0.314 between the groups at 1 year     Climbing four stairs: Group 1-15.9±9.9 to 8.8±8.9 over 1 year. Group 2-15.9±11.9 to 8.4±6.4 over 1 year. P=0.624 between the groups at 1 year
Clinical relevance		Yoga does not appear to have an added benefit compared to standard PT alone in relation to MDFRS and TFTs

PT: Physical therapy, MDBC: Modified Downs and Black Checklist, DOI: Digital Object Identifier, RCT: Randomized controlled trial, NIMHANS: National Institute of Mental Health and Neurosciences, MDFRS: Muscular Dystrophy Functional Rating Scale, TFT: Timed functional tests, DMD: Duchenne muscular dystrophy

Supplementary Table 1e.

Detailed characteristics and outcomes of included studies

STUDY → DETAILS ↓		Shirley Telles et al. (2011)
DOI and QR Code		DOI: 10.4103/0973-1075.84544
Journal		Indian Journal of Palliative Care
MDBC score		3/28. Based on established precedents: “excellent” (26–28), “good” (20–25), “fair” (15–19), or “poor” (≤14)
Type of article		Letter to the Editor based on an exploratory, pre–post, longitudinal study
Participants (sex, age, number enrolled, location, etc.)		Males, 4–23 years (mean age 11.2±5.3 years), 16 confirmed to have DMD based on muscle biopsy enrolled, Patanjali Research Foundation (Haridwar, India)
Groups, interventions, final sample size after dropouts		Single yoga intervention group. No control group. n=10
Intervention(s)		Yoga: Paper mentions that yoga interventions were based on the traditional text, Patanjali’s Yoga Sutras, compiled Circa 900 BC. No specific details regarding yoga postures, movements, or breathing techniques are provided Other interventions: Patients who completed the study were on Ayurvedic medications prescribed by the research center. Paper mentions that Ayurvedic medications were in the form of polyherbal tablets and liquid decoctions. No specific details regarding the ingredients of the medications are provided. No specific details are provided on whether or not the same medications and dosages were used for all patients
Intervention frequency and duration		Patients learned yoga for a week and were then followed up at home by telephone for 18 months. No information provided on how often patients performed yoga or took their Ayurvedic medications
Main outcome measure(s) and change		No clear information on outcome measures. The paper generally says that mobility, self-care, and level of comfort were assessed based on responses to relevant questions. No quantitative data are provided. The paper just says that at the end of 18 months, positive outcomes in mobility, self-care, and respiratory ease were noted in the 3 (out of 10) patients who were regular with yoga and Ayurveda
Clinical relevance		Based on the individuals that stringently followed the yoga and Ayurveda program, the authors suggest that yoga and Ayurveda might have a beneficial effect with good adherence to the prescribed treatment. The authors also suggest that further investigation with larger sample sizes would be needed for definitive conclusions

MDBC: Modified Downs and Black Checklist, DOI: Digital Object Identifier, DMD: Duchenne muscular dystrophy

Results

We identified six research studies based on our inclusion criteria [Table 1 and Supplementary Table 1]. Four of these were randomized controlled trials (RCTs),[31,32,33,34] and two were exploratory pre–poststudies with convenience samples.[35,36] The initial search yielded a total of 708 items, and only seven items were identified as having met the inclusion criteria. Of the seven articles from which data extraction was performed, one was excluded since it assessed the effect of yoga on inflammatory myopathies and not DMD.[37] All four RCTs received a score of 15/28 on the MDBC, which met our preset criteria for being adjudged as “fair” in quality [Table 1 and Supplementary Table 1].

All four RCTs had the same first author and were from the same center [Table 1 and Supplementary Table 1].[31,32,33,34] The subjects were 5-10 years old at enrollment and had received genetic confirmation of DMD. In each RCT, about 88 subjects successfully completed a 1-year longitudinal study with five follow-up visits. Roughly half of the 88 subjects in each study were assigned to a physical therapy (PT) only group, while the rest were assigned to a PT and yoga group. All subjects performed their prescribed PT and PT + yoga at home. The PT-only group performed PT-specific exercises in the morning and evening. The PT + yoga group performed yoga in the morning and PT-specific exercises in the evening. Both the groups followed this routine daily for 1 year. Each PT session was about 45 min and included active and passive ranging exercises to all the joints; active and active-assisted breathing exercises; task-oriented exercises, such as rolling, lying to sitting, sitting to standing, standing, walking, and climbing one flight of stairs; activity-based breathing exercises, such as blowing pieces of paper, blowing a candle placed at varying distances, and blowing balloons of different sizes; stretching exercises for the trunk, chest wall, and commonly affected joints. Each yoga intervention session was about 45 min and included yoga movements, postures, and stretches in standing; yoga breathing exercises (pranayama); attaining, maintaining, and exiting yoga postures (asanas); yoga cleansing breathing (kriyas); and yoga meditation. The earliest of these publications examined heart rate variability (HRV),[31] followed by studies on pulmonary function,[32] Pediatric Quality of Life (PedsQL^™),[33] and, most recently, the Muscular Dystrophy Functional Rating Scale (MDFRS) and timed functional tests (TFTs).[34] All four RCTs showed no significant group or interaction effects, suggesting that yoga, in addition to PT, did not yield better results [Table 1 and Supplementary Table 1].

Among the non-RCTs, one was in the form of a letter to the editor, which did not contain a description of outcome measures and had no quantitative data.[36] This paper merely stated that of the 10 individuals who completed the 18-month study, the 3–4 individuals who were regular in their yoga practice showed positive outcomes in “mobility, self-care, and respiratory ease.” The inclusion of unspecified Ayurvedic medications also confounded this study. This study received an MDBC score of 3/28 (“poor” rating).

The other non-RCT among our list of six articles received the highest MDBC score, overall (17/28, “fair”).[35] The investigators enrolled 76 subjects, out of which 26 completed the study (6–14 years, mean age = 9.5 ± 2.2 years; all subjects were on standard glucocorticoid pharmacotherapy). The main intervention was yogic breathing techniques (three times per day, 10 months), and the main outcome measure was pulmonary function. The study found that when 10-month postintervention data were compared to baseline data, forced vital capacity increased from 82.3% ±18.6% of predicted to 90.3% ± 22.5% of predicted (P = 0.02), and forced expiratory volume in 1-s increased from 83.8 ± 16.6 of predicted to 90.1 ± 17.4 of predicted (P = 0.04) [Table 1 and Supplementary Table 1]. Unfortunately, since this study did not have a standard treatment control group, it was not possible to ascertain if yoga had an added benefit compared to standard treatment alone (e.g., steroids plus PT).

None of the six reviewed studies indicated that yoga had a detrimental effect, suggesting that adding yoga to standard care is safe. However, these studies did not indicate that yoga yielded better outcomes than standard care.

Discussion

The purpose of this scoping review was to evaluate whether or not yoga has a beneficial effect on individuals with DMD, given its reported positive effects in healthy individuals and those with various health conditions.[13,14,15,16] Physical activity, including exercise, is widely recognized as beneficial for overall health – even for individuals with DMD.[9] However, skeletal muscle fragility in DMD could make exercise a double-edged sword, especially when forceful eccentric or lengthening muscle contractions are encountered.[1] While eccentric contractions are known to facilitate muscle growth, greater force production, and protection against injury in healthy individuals,[38] they can cause significant cellular stress and death in dystrophin-deficient muscle fibers.[3,6,39] Certain low-impact exercises have shown promise in DMD – for example, low-impact cardiorespiratory exercises (e.g., stationary cycling), body weight-supported walking, aquatic therapy, passive range of motion exercises, isometric contractions, and breathing exercises have been shown to mitigate immobility-related complications, slow muscle degeneration, and improve quality of life in individuals with DMD.[40,41,42,43,44]

In the past, the life expectancy of individuals with DMD was around 20 years, with medical care being mainly focused on preserving ambulation for as long as possible.[45] However, advancements in glucocorticoid dosing, assisted ventilation, treatments for comorbidities (e.g., respiratory and urinary infections), powered mobility devices, and inclusive architectural designs have extended life expectancy by approximately 10 years.[46,47,48] Furthermore, emerging genetic therapies can potentially restore functional dystrophin in skeletal and cardiac muscle fibers, thus raising hopes of converting DMD into a nonlethal condition and preserving functional independence throughout a normal lifespan.[1,49] These developments underscore the need for therapeutic exercise programs that preserve ambulation, cardiorespiratory function, and muscle mass, thus ensuring that a clinically meaningful amount of muscle fibers remain viable for future genetic interventions.

The term “yoga” originates from the Sanskrit word meaning “union” or “to yoke,” reflecting its holistic approach to unifying the body, mind, and spirit.[50] While modern interpretations often emphasize physical postures (asanas) and breathing techniques (pranayama), traditional yoga encompasses a broader spectrum of practices, including ethical living, meditation, and spiritual growth.[51] The diversity of yoga practices, with ancient texts referencing over 8 million asanas,[51] creates challenges for standardization in research. Clear descriptions of yoga interventions are essential to ensure reproducibility and validity in scientific studies.[52,53] Among the studies included in this review, the four RCTs, which we identified, provided detailed descriptions of yoga interventions, albeit using technical terminology, which nonexperts might find difficult to understand.[31,32,33,34] The non-RCT by Rodrigues et al., clearly outlined the yoga protocol with simple descriptive terms that even nonexperts may understand.[35] However, the study by Telles et al. did not provide a detailed description of the yoga intervention.[36]

Despite the challenges associated with standardizing and describing various aspects of yoga interventions, yoga remains an appealing intervention for DMD due to its potential to modulate the endocrine and autonomic nervous systems, thus promoting cardiorespiratory health.[51,52,53,54] For example, a meta-analysis in patients with coronary artery disease (not in DMD) found that yoga improved VO2 max, reduced systolic and diastolic blood pressure, and enhanced cardiovascular outcomes, albeit with low-certainty evidence.[55] In the context of DMD, yoga may offer cardiovascular benefits without the risks associated with eccentric contractions inherent to traditional cardiorespiratory exercises like walking.[56] HRV, an autonomic nervous system balance marker,[57] was assessed in one study included in this review; however, no significant differences were observed between the standard PT group and the PT + yoga group, except for minor age-stratified changes, which also did not indicate improved autonomic balance.[31] In addition, while yoga has shown potential to improve pulmonary function across various disease conditions, the evidence remains limited for DMD.[58] For instance, one of the studies that we reviewed reported significant improvements in pulmonary function following yogic breathing techniques, but the lack of a control group limits the strength of these findings.[35] It is worth conducting additional studies to assess if yoga provides pulmonary benefits while minimizing the risk of eccentric contraction-induced limb muscle damage, which can occur with traditional cardiorespiratory exercises such as walking.

Earlier in the Discussion, we highlighted the importance of preserving muscle mass and strength in DMD to maximize the potential benefits of emerging gene therapies – unfortunately, none of the studies included in this review directly assessed muscle mass (e.g., through magnetic resonance imaging) or strength (e.g., through dynamometry). One study came close to indirectly assessing muscle strength using the MDFRS and TFTs to evaluate arm function and mobility; however, both the standard PT and PT + yoga groups showed similar improvements over 1 year.[34]

Overall, our scoping review suggests that yoga does not provide a significant added benefit over standard care alone (e.g., steroids and/or PT), in relation to cardiovascular outcomes, pulmonary function, mobility, functional tests, or quality of life in individuals with DMD. However, the evidence is limited in quantity and low to fair in quality. Notably, all RCTs included in this review were conducted at a single center, potentially involving overlapping participant cohorts, thus limiting generalizability to the global DMD population. In addition, the lack of detailed descriptions on how challenging yoga postures were adapted for participants with varying functional abilities (e.g., older individuals exhibiting Gowers’s sign) is a notable limitation.[59] Compliance with the arduous intervention protocols in the RCTs, such as requiring twice-daily sessions (yoga in the morning and PT in the evening for the experimental group or PT in the morning and evening for the control group), poses a significant challenge, particularly in pediatric populations. Future studies should consider more feasible and adaptable intervention designs for adherence and practicality.

While this review focused on physical outcomes, it is important to acknowledge the neuropsychiatric aspects of DMD.[60] Approximately 24% of individuals with DMD experience anxiety, and 11% report depression.[60] Given yoga’s documented benefits in reducing depression and anxiety in the general population, future research should explore its potential to improve mental health and overall quality of life in individuals with DMD.[61]

As highlighted in several places, our review was primarily limited by the small number of published studies (six) that met our inclusion criteria. Expanding the inclusion criteria to include other neuromuscular diseases and myopathies was not justified, as it would have detracted from our goal of evaluating the effects of yoga on DMD.[37] The second major limitation was that among the six articles that met the inclusion criteria, only four were RCTs.[31,32,33,34] Furthermore, all RCTs were from the same first author and research center and had highly varied outcome measures (HRV, pulmonary function, quality of life, and functional ratings scale with timed function tests. The diverse set of outcome measures made it difficult to assess whether yoga truly made a difference in altering the primary pathophysiological concerns of DMD, specifically muscle weakness and wasting. Among the non-RCTs, one was in the form of a brief letter to the editor, providing no information on the intervention, outcome measures, or objective data; it merely stated that patients who followed their yoga and Ayurvedic medicine intervention showed improvements in mobility, self-care, and level of comfort.[36] The other non-RCT received the highest MDBC score (17/28) among the six articles, but unfortunately lacked a control group, and therefore could not help ascertain if a program of yoga breathing exercises plus steroids is better than steroids alone or steroids plus PT. None of the reviewed studies included long-term follow-up beyond 1 year.

In terms of future directions, rigorous studies with large sample sizes, suitable control groups, and objective outcomes that focus on the primary pathophysiological aspects of DMD (muscle weakness and wasting and reduced functional movement) are likely to inform clinicians whether incorporating yoga into DMD care would have an added benefit. Another useful pursuit might be to assess whether yoga can serve as an alternative to cardiorespiratory exercise, helping to maintain cardiorespiratory fitness in the context of reduced exercise tolerance and reducing the risk of exercise-induced muscle damage from repeated muscle contractions.

Conclusion

Based on our scoping review, we conclude that a yoga intervention does not appear to have a harmful effect or provide a significant added benefit in maintaining mobility, improving quality of life, or reducing cardiopulmonary symptoms in individuals with DMD. However, drawing on additional non-DMD literature, we predict that the unique value of yoga, particularly yogic breathing techniques, may lie in its potential to confer cardiovascular and respiratory benefits like those achieved through traditional cardiorespiratory exercises (e.g., walking), but without the risk of damaging eccentric muscle contractions that are often inevitable during such activities.

Conflicts of interest

There are no conflicts of interest.

Supplementary Figure 1

Sources of evidence. Flow diagram prepared based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews (PRISMA) Extension for Scoping Reviews. A total of 708 records were identified through database searches, with 55 duplicates removed prior to screening. After screening 653 records, 7 full-text reports were assessed for eligibility. One report was excluded (studied inflammatory myopathy and not DMD), resulting in 6 studies included in our final scoping review. PRISMA-ScR: Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews

Funding Statement

Nil.