Traumatic brain injury affects an estimated 69 million individuals worldwide every year. The long-term effects of traumatic brain injury can lead to significant chronic medical problems such as decreased motor function, cognitive decline, decreased respiratory function, and sleep disturbances. Traumatic brain injuries also contribute to annual excess healthcare expenditures. New holistic approaches to the rehabilitation of traumatic brain injury patients have shown some promise in improving patient health and decreasing health care costs. Yoga is an intervention that may be beneficial when integrated into a rehabilitation program for this patient population. This review will examine the benefits of yoga in the rehabilitation process and its potential benefits in traumatic brain injury patients. A review of literature was conducted through the Samford University library database and found positive results in the use of yoga as part of the rehabilitation process of traumatic brain injury patients.
Keywords: Traumatic brain injury; yoga; Rehabilitation; Non-pharmacologic treatment; Holistic care
Traumatic brain injury (TBI) affects an estimated 69 million individuals worldwide each year . The highest overall incidence of TBI is in North America and is responsible for 30% of injury deaths in the United States1. Long-term effects of TBI are broad and can lead to chronic changes in cognition, motor and sensation function, behavioral changes, respiratory function, chronic headaches, sleep disturbance and decreased emotional well-being [2,3]. The economic burden of TBI is an estimated $76.5 billion yearly . Over the past two decades the United States has also seen a rise in traumatic brain injuries among its military personnel fighting in the War on Terror. According to recent data, 33% of all combat-injured patients and 60% of blast-injured patients at Walter Reed Army National Military Medical Center had suffered a TBI . Approximately 15% of all troops in active combat in the War on Terror possibly suffered a TBI . Rehabilitation for patients suffering from chronic TBI can impact both patient outcomes and the economic burden of TBI. Research has shown that implementation of a TBI rehabilitation program can increase patient levels of function and can greatly reduce the long-term cost to patients and the healthcare system . Recently, the practice of yoga has been incorporated into rehabilitation programs of both military and civilian patients suffering from TBI. In an effort to better validate the usefulness of yoga in the rehabilitation of TBI patients, a review of literature was conducted to determine the effectiveness of these programs.
A literature search was conducted to identify studies focusing on the use of yoga in the rehabilitation of patients suffering from TBI. The Samford University library database was utilized, and the following search terms were used: Yoga and Traumatic Brain Injury, Yoga and Rehabilitation and Traumatic Brain Injury, Yoga and Brain Injury.
iii. Studies did not focus specifically on the use of yoga for brain injuries
iv. There were no measurable outcomes reported in the
A total of 99 articles were found through the database search.
84 articles were excluded after review of the title and abstract.
The 15 remaining articles were then examined closely using the
selection criteria and a final 6 articles were included in the final
All six studies measured the varying effects of yoga during
the rehabilitation of patients with traumatic brain injuries (Table
1). All studies showed significant improvements in patients who
used yoga as a part of their rehabilitation program. Silverthorne
et al.  found that compared to a control group, a 40-week yoga
program showed significant improvement in patients breath
holding (p=<.05), heart rate (p=<.01), physical function (p=<.01),
and self-reported emotional well-being (p=<.01). Montgomery et
al.6 evaluated the effects of an 8-week yoga program on patients
with TBI. The Difficulty in Emotional Regulation Scale (DERS)
and the Quality of Life After Brain Injury (QOLIBRI) scores were
used for quantitative analysis.
At the end of the study, participants had a 16% improvement
for the DERS and a 6% improvement for the QOLIBRI .
Qualitative analysis of the program was also found to be beneficial
in terms of self-reported concentration, self-control, confidence,
and self-development . Combs et al.  found during their
pilot study of 19 military personnel with TBI in a Veterans
Affairs Polytrauma Transitional Rehabilitation Program (PTRP)
positive effects on the belief of participant overall health, sleep,
and anxiety. Qualitative analysis during the study found selfreported
improvements in the categories of stress management,
relaxation, pain management, and overall general benefit .
Donnely et al.  also measured the significance of
incorporating an 8-week yoga program into the rehabilitation
of TBI patients. Thirty-one patients completed pre- and postprogram
QOLIBRI questionnaires and the overall QOLIBRI scores
had statistical improvement from 1.93 (SD = 0.27) to 2.15 (SD =
0.34, p=0.01)8. There was also an increase in the Emotions and
Feeling subscales of the QOLIBRI measurement from 1.69 (SD
= 0.40) to 2.01 (SD = 0.52, p=0.01) and 2.1 (SD = 0.34) to 2.42
(SD = 0.39, p=0.01) respectively . Similar to Silverthorne et
al. , Wen et al.  chose to examine how the addition of yoga
into rehabilitative programs could possibly be beneficial for
both the physical and mental ailments of patients with TBI. Two
participants were entered into the study and the quantitative
measurement tools were used for the study were the Pittsburgh
Sleep Quality Index, Neuropathy Pain Scale, and the Behavior
Rating Inventory of Executive Function (BRIEF) with evaluation
taking place pre-, during, and post-intervention . One patient
had a 25% reduction in depression symptoms post-intervention
and a 12.5-25% improvement in the Inhibition and Emotional
Control scales of the BRIEF measurement tool . Qualitative
measurements were also promising with reported reduction in
pain and decreased difficulty with sleep .
Schmid et al.  used quantitative and qualitative data
to evaluate the clinical significance of adding an 8-week
1:1 yoga program to the rehabilitation program of patients
suffering from TBI. There were measurable improvements
among all participants with group balance increasing by 36%,lower extremity strength increasing by 100%, and endurance
increasing by 105% . Qualitative data was positive from all
participants and supported the utilization of yoga to improve
physical functioning among TBI patients .
The studies used for this mini review show positive results
with the integration of yoga into the rehabilitation programs of
patients suffering from chronic traumatic brain injuries. There
are difficulties when discerning the true impact of using yoga in
these programs due to the diversity of the studies. Only two of the
studies included in this review had both experiment and control
groups used for intervention comparison [3,8]. There were also
multiple measurement tools used for the studies with only two
studies utilizing the same measurement tool for comparison
(QOLIBRI) [6,8]. All studies had relatively low sample sizes
with the largest sample size being n=318. In all studies, both
quantitative and qualitative data supported the hypothesis that
yoga integration into a TBI rehab program would be beneficial.
In both studies with control groups, the experimental group had
statistically significant positive results when compared with
the control group [3,8]. All studies had qualitative data which
was found to be positive and showed that participants both
enjoyed and felt that they benefited from the yoga intervention.
It is likely that given the cost benefits and the current positive
research regarding yoga intervention more research will be
done to incorporate this type of program into the rehabilitation
of patients suffering from traumatic brain injuries.
The findings suggest that utilizing yoga in the rehabilitation
programs of TBI patients is beneficial. The results are
encouraging, and hopefully future research will be conducted in
an effort to improve the overall health and outcomes of patients
suffering from TBI. Larger sample sizes and multi-facility
research would be beneficial to decrease the current study