Yoga is a scientific system of physical and mental practices that originated in India more than 3,000 years ago.^1,2 Translated, yoga means union — union of the mind, body, and spirit. Yoga is the art of fusing the body and mind for an overall sense of well-being.² With regular practice, one can learn to be at peace, relax the mind, and achieve health and happiness. Hatha yoga, in particular, is the yoga of physical discipline, integrating a system of physical postures and breathing techniques.¹ Hatha yoga benefits the entire body system. Physically, yoga improves flexibility, strength, coordination, balance, and circulation. Emotionally and mentally, yoga calms, builds self-esteem, clears the mind, and increases self-awareness and confidence.¹ Yoga has also been found to improve cardiorespiratory, thermoregulatory, and psychological functions, creating a sense of well-being.^3,4 Yoga is one of the most rapidly emerging disciplines aimed at integrating mind and body into harmony.⁵

Philosophy of Yoga

The meaning of yoga is science of the mind, and the essence of yoga is transformation.² In Yoga Sutras, the classical text of yoga (200 to 800 B.C.), Patanjali, “the Father of Yoga,” presented the basic philosophy of yoga and provided the guidelines for progressing along the path of yoga to achieve contentment and enlightenment.² Yoga is a systematic process of physical and mental training for the goal of self realization or truthfulness.⁶ For the child with special healthcare needs the ultimate goal of yoga is self awareness.⁷ Yoga provides a mechanism whereby children can discover a place of stillness and contentment within themselves that creates mental equilibrium, emotional stability, and physical health.⁸

The Practice of Yoga for the Child With Special Healthcare Needs

Yoga’s unique strength is its capacity to exercise the mind as well as the body, providing greater health both mentally and physically.^7,10 Children who practice yoga learn to develop and maintain health, which may set patterns for wellness later in life. To achieve the benefits of yoga, children need proper instruction and regular practice. In addition to a home exercise program, PTs may suggest that parents of children with special healthcare needs practice yoga themselves to understand and experience the benefits of yoga.

Five core components are the foundation of a yoga program designed for children with special healthcare needs: mantras, pranayama, kriyas, asanas, and savasana. Mantras, or chanting, are words or groups of words or sounds meant to focus the mind.⁶ The use of mantras improves attention and concentration. When sounds are combined with hand movements, mantras can be used to improve memory and motor coordination, and facilitate turn taking. Mantras help the development of speech skills by fostering social interaction, rhythm, intonation, and respiratory/breath support for speech.

Pranayama is the science of proper breathing. Yogic breathing is the practice of working with the breath to both improve respiratory efficiency and regulate the breathe to promote relaxation.^11,12 The act of respiration is for the most part involuntary, regulated by the autonomic nervous system.^4,11 However, voluntary control of respiration can be achieved. The depth, duration, and frequency of respiration can be modulated quite easily.¹¹ The science of pranayama is intimately connected with the autonomic nervous system. Pranayama brings the autonomic nervous system under conscious control through the functioning of the lungs.^4,11,12

Knowledge of the mechanics of respiration provides a clearer understanding of the physiology of pranayama. The dynamic of breathing is the process by which air moves into and out of the lungs. The mechanics of respiration are in part governed by the anatomical relationship of the organs in the thorax and the action of the autonomic nervous system.¹¹

The primary muscle of respiration is the diaphragm. The diaphragm is a musculofibrous sheet that separates the thoracic cavity from the abdomen, innervated by the phrenic nerve.^11,14 At its resting position, the diaphragm lies up in the chest cavity in a dome shape. During inhalation, the diaphragm contracts and moves down, flattening and thereby causing the ribs (along with the intercostal muscles of the chest) to expand.¹¹ The abdomen moves down and forward, pulling air into the lungs. Exhalation is primarily the result of passive recoil of the lungs.

The diaphragm relaxes back into the dome shape, mildly compressing the lungs and heart, and along with the intercostal muscles, narrowing the rib cage. The natural breathing pattern in yoga practice is wavelike. As you breathe in, you expand your chest first and let the breath descend like a wave to your lower abdomen. Exhalation is a reverse wave from the bottom of the abdomen toward the chest. During yogic breath training, the diaphragm, abdominals (especially rectus abdominus), and the intercostals are strengthened and trained to more effectively move air in and out. This results in an increase in the quantity of circulating air within the lungs (tidal volume) and decreased number of breaths per minute (respiratory rate), resulting in more efficient respiration.^11,14

Within the practice of pranayama, there are variations to breathing technique. For example, an audible exhalation through the mouth deepens the discharge of stress. A glottal breath called ujjaye pranayama is often associated with mediation and alternate nostril breathing is calming and organizing. Physiologically, however, the most efficient breathing for every day functioning is diaphragmatic breathing.

For many children, this wavelike pattern of inhalation/exhalation is not the norm. Children with special healthcare needs often breathe in reverse, swelling the abdomen and expanding the chest during exhalation. This reverse breathing is often due to an exaggerated use of the chest muscles.¹¹ This atypical breathing pattern is readily apparent in many children with special healthcare needs, including those children diagnosed with asthma, cerebral palsy, Down syndrome, or autism.^6,15

Yogic Breathing

Most yogic breathing exercises are done by drawing air in through the nose. The mucous membranes, cilia, and turbinates serve to moisten the air and filter out toxic particles while warming the air as it enters the trachea.¹¹ In addition, breathing through the nose stimulates the olfactory nerves, providing a calming or grounding effect.^4,11 For a variety of reasons, many children with special healthcare needs breathe through their mouths rather than their noses.

Children may breathe through their mouths because of poor oral motor control, resulting in an inability to effectively close their lips or maintain efficient lip close; as a result of frequent blockage of the nasal cavity secondary to chronic rhinnorhea and/or sinusitis; or poor posture due to abnormal tonal patterns resulting in a forward head position, biomechanically making lip closure difficult and mouth breathing more efficient. Children who mouth breathe bypass the moisturizing and filtering of the nasal structures. Therefore the mucous membranes in the throat often dry out, placing these children at risk for throat irritation and infection.¹⁵

Breath and Emotions (The Limbic System)

The breath is intimately connected to the mind. When your mind is centered and quiet, so is your breath. When your mind is turbulent, your breathing becomes disorganized.¹⁴ In everyday life, patients experience many examples of how emotions affect breathing. When stressed, breathing is shallow and rapid; when depressed, breathing is heavy and labored.  Breathing patterns may vary during the day and change according to mood, previous activity, and current thoughts.^11,14

Medical science has shown a correspondence between emotion and breathing pattern. Yoga science recognizes a correspondence; but according to yoga, the relationship between breath and the mind is reciprocal. If a certain state of mind results in a certain mode of breathing, by consciously breathing we can evoke the corresponding state of mind.^11,14 In other words, by changing the breathing pattern, you can change the mind. By consciously making the breath deep, even, and regular, you can experience a noticeable release of tension, increased relaxation, and tranquility.^13,16

This relationship between breath and emotion is primarily a result of the action of the limbic system with influence from other cortical regions.^4,14 The limbic system (thalamus, hippocampus, and amygdala nucleus via neural connections to the hypothalamus) plays an important role in emotions.^4,14 It regulates the release of hypothalamic hormones and modulates the activity of the autonomic nervous system coordinating visceral responses with the emotional state.^4,14,16 Output of the autonomic nervous system is influenced by many regions of the brain.

Most of the regions produce their specific action by way of the hypothalamus. The hypothalamus in turn integrates the information it receives from these structures into a coherent pattern of autonomic response.¹⁴ The hypothalamus is the control center for the autonomic nervous system, and it directly regulates autonomic output and endocrine function and integrates motor and endocrine responses that produce emotional behavior.¹⁴ The autonomic nervous system controls temperature, heart rate, blood pressure, and respiration.^4,14 The parasympathetic nervous system of the autonomic nervous system has a role in regulating the body to a steady state or homeostasis. The hypothalamus regulates the autonomic nervous system in two ways:^4,14

• Through projections to the nuclei in the brainstem/spinal cord that act on preganglionic autonomic neurons to control temperature, blood pressure, heart rate, and respiration
• By acting on the endocrine system to release hormones that influence autonomic function

Focused Exercise

Kriyas are cleansing processes designed to improve digestion, elimination, and visual coordination.^6,7 Specific pranayama exercises whereby air is expelled by forceful upward movement of the diaphragm is used to eliminate excess phlegm and mucous in the sinus cavity and respiratory tract. Specific abdominal toning and strengthening exercises improve digestion and elimination. Eye exercises focusing and following visual stimuli facilitate dissociation of eye/head movements and improve visual coordination.^6,15

Asanas or postures increase muscle strength and flexibility, improve balance and coordination, and increase endurance.^6,7,13 The practice of asanas with pranayama is central to the process of yoga. Asanas form the basis of the mind-body integration work. Ujjaye, or glottal breathing, during asanas helps with focus and concentration. Asanas are practiced in two ways:

• Using rhythmic breath to come into and out of pose practiced in a continuous flowing sequence (vinyasa) (e.g., sun salutation)
• Practicing poses separately in a logical sequence statically held in a comfortable, stable manner

A balanced routine works the entire body. Asanas are performed in supine, prone, sitting, standing, and inverted, which incorporates forward, back, and lateral bending; rotation; and balance poses. Yoga asanas involve paying very close attention to the body. The greatest benefit comes from relaxing in a given pose. When relaxed in an asana, the child can concentrate on the inhale/exhale breath, rhythm of movement, and sensory experiences.

The intent is to maintain inward focus throughout the asana. By paying attention to what his or her body is doing during asanas, the child increases body awareness (proprioceptive/kinesthetic awareness), coordination, balance, and motor planning.

Asanas create flexibility and strength and when performed in repetitive sets can be an aerobic exercise increasing endurance and energy. Yoga makes children feel good about themselves. The mastery of challenging asanas (balance poses/postures requiring increased strength) along with the use of positive affirmations during asanas helps children develop increased self-confidence and increased self-esteem.¹⁰

Although no known contraindications are associated with yoga per se, there are contraindications to inversions (positions whereby the head is lower than the heart) and headstands that must be established. If a child with special healthcare needs has seizures, the PT should consult with the child’s doctor for specific recommendations regarding exercise precautions involving inversions. Inversions are contraindicated in children with severe heart conditions and/or high blood pressure. Headstands are contraindicated and to be avoided if there is any concern with the safety or stability of the child’s neck.

Particularly in children diagnosed with Down syndrome or other chromosomal abnormalities, headstands are contraindicated if atlantoaxial instability is a suspected or known risk. For all children, particularly those with cardiorespiratory conditions, caution should be used during inversions and headstands. PTs should frequently check response to the activity, including oxygenation, color, respiratory rate, and sweating.

Savasana, or deep relaxation, is the conclusion and culmination of every yoga session. Savasana includes progressive relaxation and visualization meditation.^6,7,15 Children should practice l0 to 20 minutes of silence and stillness. Savasana allows the body to absorb the benefits of mantra, asana, pranayama, and kriyas while permitting the mind to slow down and rest. Learning to relax is an important skill for children to master. The ability to release stress and tension helps children develop stillness and tranquility. Teaching children to be aware of the positive changes in their minds and bodies after practicing yoga increases self-esteem and self-awareness.

Yoga fosters a lifetime of healthy habits, including proper exercise, conscious eating, environmental awareness, and positive coping skills/stress management. The goal of self-awareness and self-realization, may well come from a path of peace, confidence, and calmness developed through yoga.

“Yoga for the Special Child”

Several yoga certification programs are available to train PTs in the practice of yoga with children. “Yoga for the Special Child,” however, was designed specifically for children with special needs.⁶ The program’s philosophy and method provide the foundation for a systematic approach to therapeutic yoga for children with special healthcare needs. “Yoga for the Special Child” was founded by Sonia Sumar⁶ and is based on the principles and practices of hatha yoga.

The program outlines four levels of practice (preparatory, inductive, interactive, and imitative), and instruction and assistance is based on children’s ages and developmental levels.⁶ Preparatory stage exercises are passive and designed to prepare the children for asanas. As the children develop more motor control, they begin to participate in the asanas with guidance from the PT. Next they practice a variety of movements and poses with the instructor providing a decreased amount of support. As the children become more independent, asanas and breathing exercises become more advanced, and the teacher’s assistance is minimal. Children are first instructed individually; later they join an integrated children’s group class.

Yoga and Physical Therapy

The basic methods of assessment used by pediatric PTs to evaluate a child are the same for implementing a yoga program for a child with special healthcare needs.¹⁷ Clinical and diagnostic observations are used to assess skills, and interpretations of findings are used to design an appropriate therapeutic plan.¹⁸ As in any evaluation a detailed medical and developmental history is obtained from the parent or primary caregiver.

Specific tests of functioning (e.g., goniometry, muscle strength testing, muscle tone, musculoskeletal structural evaluation, and assessment of activities of daily living) are employed as indicated. A functional assessment of gross motor skills, including balance, coordination, sensory/perceptual skills and integration, and motor control/motor planning is performed. Specific standardized tests are used as indicated. Cardiopulmonary functioning, endurance, response to treatment, as well as cognitive functioning are evaluated.

A summary of clinical findings, strengths and limitations, as well as the family’s needs and desires establish functional goals for the child and guide the development of a therapeutic yoga program.^17,18 As in all therapy treatments, PTs must monitor the child’s response to treatment and establish measurable outcomes for evaluation.¹⁹

Yoga as a Therapeutic Activity

Yoga can be modified for children of all abilities and therefore is appropriate for use as a therapeutic treatment for children with a variety of diagnoses: Down syndrome, cerebral palsy, neuromuscular disorders, pediatric oncological disorders, chronic pain syndrome, asthma, ADHD, and autism spectrum disorder for example.^{6,13,16,17,20-24} Children with special healthcare needs are stressed physically, physiologically, and psychologically. Therefore, yoga programs for them are designed to meet their physical, behavioral, and learning needs. To begin, the PT must prepare the yoga environment prior to treatment.¹⁵ This includes not only the physical environment (yoga mat, low lighting, appropriate music, comfortable temperature) but the psychological environment (therapist relaxed and focused, establishing a cooperative and trusting relationship between the therapist and child, ensuring the child feels safe and comfortable). Each yoga program is individually tailored to meet the unique needs of each child based on his or her specific limitations and the defined benefits/goals of yoga for that child.¹⁵

Examples of Therapeutic Application to Specific Diagnoses

For a child diagnosed with chronic pain, gentle holding asanas could be introduced at a slower pace. Modifications that allow choices and control over movement provide opportunities for relaxation, improved mobility, and reduced anxiety. Children diagnosed with dyspraxia, developmental motor discoordination, or other movement disorders may benefit from a yoga program that provides increased proprioceptive and kinesthetic input to improve body awareness.

Simpler and fewer asanas done repetitively increases motor planning and motor control. Providing visual cues such as printed cards of postures helps children to improve organization, attention, and learning. For the child diagnosed with ADHD, it is important to match the yoga program to the child’s energy and attention level. The use of clear, brief instructions helps the child to focus and attend to verbal directions. Yoga sessions may begin with a few fast-paced repetitions and then progressively move the child to asanas on the mat.

For the child diagnosed with ADHD, mantras encouraging exhalation may be calming, and pranayama can work to progressively slow down breathing by gradually lengthening exhalations. For the child diagnosed with Down syndrome, a yoga program that incorporates a variety of asanas can improve muscle strength and coordination while providing overall greater physical control of movement. The importance of savasana for all children cannot be overstated.

The American Academy of Pediatrics recognizes the increasing use of complementary and alternative medicine in children,^13,20,25 and studies show its use is considerably higher in children with special healthcare needs.^19,20,25 However, there is little research on the effectiveness of yoga as a complimentary and alternative approach to treatment in children.^19,25,26 To validate yoga for children diagnosed with special healthcare needs, PTs require appropriate training in the use of yoga as a therapeutic approach to treatment. Additionally, research regarding the effectiveness of yoga in the treatment of children diagnosed with special healthcare needs is essential.