. 2022 May 25;12(5):e059604. doi: 10.1136/bmjopen-2021-059604

Table 1.

Overview of the Upa Yoga programme

Programme component	Description	Rationale
Directional movement of the arms	This practice involves extending the arms in four directions (sideways, front, up and down) by rotating the wrists, while consciously focusing on the inhalation and exhalation of breath with each movement.	Studies show that fibromyalgia is common among patients living with IBS.³⁰ This could lead to pain of the muscles and joints, fatigue, and sleep concerns. The principle behind this practice is to lubricate the fluids in the joints, increase circulation and activate the energy nodes in these joints. Doing these practices everyday can relieve muscle and joint stiffness and reduce pain over time. This practice is recommended by the Isha Foundation to increase strengths and flexibility in preparation for Yoga Namaskar.
Neck practices	There are five sets of neck practices, each stretching the neck and final one working on the shoulder area.	The main cause of neck pain is usually muscle tension. Perceived stress can increase muscle tension. These neck exercises help relieve stress that can aggravate IBS symptoms. This practice is recommended by the Isha Foundation to increase strengths and flexibility in preparation for Yoga Namaskar.
Yoga Namaskar	This practice involves a series of seven consecutive steps of upper body stretching and squatting, aligned with breath.	This practice activates the lumbar region of the spine and strengthens the spinal muscles.³¹While Yoga Namaskar has not been specifically studied in patients with IBS, yoga squatting postures have been associated with significant decrease in depression among nine individuals with IBD²⁰ and anxiety in a randomised self as control study in 30 healthy subjects.³²
Alternate nostril breathing (Nadi Shuddhi)	The participant sits cross-legged with the spine comfortably erect and eyes closed. Closing the right nostril with the thumb, inhaling and exhaling through the left nostril. This is repeated on the right nostril by closing the left nostril with the ring finger.	Alternate nostril breathing is traditionally considered to alleviate mental unrest and promote physical and mental balance.^{33 34} It has been demonstrated to decrease perceived stress and improve autonomic function in a randomised control trial compared with control subjects in healthy male volunteers, and decreased state anxiety in a prospective study.^{35 36}
Mantra meditation (AUM chanting)	The participants sit cross-legged, and with eyes closed, uttering each of these 3 sounds 7 times. The important aspect to this utterance is the awareness of the reverberations each of the sounds produces in the corresponding parts of the body: a—below the navel, o—mid-point of the chest, m—pit of the throat.	This mantra is thought to facilitate energy flow, and through vibratory mechanisms, creates peace and harmony leading to increased mental alertness and may improve symptoms of depression.^{37 38}
Breath watching	The participants sit cross-legged with eyes closed and hold a hand gesture called the Yoga Mudra (the tips of the thumb and index finger come together forming a circle). They are instructed to maintain a gentle focus on the mid-point between both eyebrows (at the level of the pineal gland), while being conscious of the gentle movement of breath happening in their body.	Breathing in a focused manner can be used as a tool to promote positive changes to the mind, body and emotions.³⁹ Significant reduction in the level of state anxiety was found in a group of healthy male volunteers when they practised breath awareness.¹⁶

IBS, irritable bowel syndrome.