KARNATAKA SAMSKRIT UNIVERSITY ,

CHAMARAJAPETE, KARNATAKA

SRI TRINETRA INTERNATIONAL INSTIUTE

OF YOGIC SCIENCE, SRIRANGAPATTANNA

EFFECT OF PRONE ASANAS AND CYCLIC

MEDITATION ON PRIMARY DYSMENORRHEA

BY
DR NANDAN S
REG NO:PGDYF0121137
STIIYS

UNDER THE GUIDANCE OF

DR JAYAREANNA M.V ,
ASSISTANT PROFESSOR

KARNATAKA SAMSKRIT UNIVERSITY BENGALURU

 DECLARATION FORM

ON TOPIC OF “EFFECT OF PRONE ASANAS AND CYCLIC

MEDITATION ON PRIMARY DYSMENORRHEA” I HAVE DONE

DESSERTATION ON MY OWN WITH HELP OF BOOKS AND

DISCUSSING WITH GUIDE, I HERE BY DECLARE THAT THIS

DESSERTATION HAS NOT BEEN SUBMITTED TO ANY OF PG

DIPLOMA COURSES, OR ANY OF THE UNIVERSITIES.

DR NANDAN S

REG NO:PGDYF0121137
STIIYS

PLACE: DATE:
 KARNATAKA SAMSKRIT UNIVERSITY , KARNATAKA

CERTIFICATE

This is to certify that the dissertation entitled a “EFFECT OF PRONE

ASANAS AND CYCLIC MEDITATIONON PRIMARY

DYSMENORRHEA” is a clinical study done by DR NANDAN S , PGDYS

student

Seal and Sign of Guide

DR JAYAREANNA M.V ,
ASSISTANT PROFESSOR
KARNATAKA SAMSKRIT UNIVERSITY
BENGALURU

Date: :

Place:

ACKNOWLEDGMENT
I thank Dr.NAGESH N for his valuable support and encouragement.

I express my sincere gratitude to Dr.JAYAREVANNA M V for the continuous

support for my dissertition study, and for their patience, motivation, enthusiasm,

and immense knowledge. His guidance helped me in all the time of research and

completing my dissertition. I could not have imagined having a better advisor

and mentor for my study.

I acknowledge the support of all the subjects who participated in the study.

Finally I thank my Parents for supporting throughout my study period.

Date: Signature of the Candidate

 ABSTRACT

EFFECT OF PRONE ASANAS AND CYCLIC MEDITATION ON PRIMARY

DYSMENORRHEA

Background & Objectives:

Dysmenorrhoea is a common gynaecological medical condition characterised by severe

abdominal pain during menstruation. The incidence of primary dysmenorrhoea is rising these

days due to increased stress and life style errors. In the present scenario, its management

include pharmacological approaches which may attribute to possible adverse effects, thus

resulting in an increased demand for the use of Complementary & Alternative Medicine

(CAM) therapies. Yoga, a non-pharmacological intervention helps reduce pain without any

side effects. Hence, the present study aims at assessing the effect of asanas (yogic postures)

done in a prone position and Cyclic Meditation (CM) on primary dysmenorrhoea on severity

of pain, intensity of muscle cramps and systemic symptoms associated with menstruation in

adolescent girls.

Method:
In this Randomized Controlled Trial, 60 females aged 18-23 years who met the study criteria

and were residing at a hostel participating in an undergraduate program were selected.

Subjects were randomly allocated in to a Yoga group and a control group. Subjects were then

assessed by a pain analogue scale, menstrual cramp intensity level and associated systemic

symptom before and after 3 months (25 days in a month).

Result:

A pool of ninety subjects fulfilling the inclusion criteria was formed. From these, sixty

subjects of age range 18 to 23 years (Mean ±SD years) were randomly assigned to the

experimental group or the control group.

The experimental group was administered a standardised yoga module developed with an

objective to assess the combined role of selected yoga based mind-body practices. Within

group changes in the experimental group indicate a significant reduction in visual analogue

scale scores for pain (p<0.0001), menstrual cramps (p<0.0001) and overall symptom score

(p<0.0001). Also, a less significant reduction was observed in the visual analogue scores for

pain (p=0.0002) and overall symptom score (p=0.0003) in the control group. When compared

between both the groups, results showed a significant reduction in the yoga group in pain

(p<0.0001), menstrual cramps (p<0.0001) and symptom score (p=0.0003).

Interpretation & Conclusion:

The present study suggested that prone asanas and cyclic meditation for 3 months has a

significant effect on reducing symptoms and relieving pain associated with dysmenorrhoea.
Therefore yoga may be safely used as an alternative therapy for pain relief in primary

dysmenorrhoea

Key words: Primary dysmenorrhea, prone asanas, cyclic meditation, pain, discomfort

1. Introduction

Dysmenorrhoea literally means painful menstruation. But a more realistic and practical

definition includes cases of painful menstruation of sufficient magnitude so as to incapacitate

day to day activities (1) According to WHO adolescent means transformation period from

child hood to adult hood i.e. age group between 10-24 years. (2) In South East Asia, there are

about 350 million adolescents, which is nearly 22% of the population of the country.

Adolescence is the period in which dramatic changes in their physical, emotional,

psychological, sexual and social domains are seen. (3)

Adolescence is a progress period from youth to adulthood and is portrayed by a spurt in

physical, endocrinal, emotional and mental development with a change in complete reliance

towards freedom. The time of pre-adulthood for a young lady is a time of physical and mental

ground work for safe parenthood. As the direct reproducer of the future generation, the health

of pre-adult young ladies impacts their own wellbeing, yet additionally the soundness of

things to come populace. Almost a fourth of India’s populace contain young ladies

underneath 20 years. (4)

Dysmenorrhea is the most widely recognized gynaecologic complaint and the main source of

intermittent present moment school or work non-appearance among female adolescents and

young adults. (5) Dysmenorrhoea affects 50% of the reproductive age of girls (6), appears

first 2-3 years after onset of menarche (7), 10-25% of estimated range of women with

reproductive age of primary dysmenorrhea is severely affected. Prevalence of dysmenorrhea

is highly variable 45-90% of menstruating women. (8)

The incidence of primary dysmenorrhea falls with increase in age (9) and parity.(10)

Several studies show that prevalence of dysmenorrhea varies greatly depending on the data

collection and methods. A cross-sectional study done on dysmenorrhoea showed that

prevalence of dysmenorrhoea was found to be 72.7%,(9) whereas another study showed that

39% girls missed their classes, 53.5% daily activities got affected and those unable to

concentrate in the class had a prevalence range of 76.1% (11). 50% of menstrual women

reported with primary dysmenorrhea out of 90% adolescent’s girls in world wide. (12)

Studies on prevalence of dysmenorrhea shows many related factors like smoking, poor

hygiene, intake of caffeine, certain dietary habits, lack of exercise, obesity, low body mass

index, adolescence, psychological, genetic and even emotional and behavioural problem have

a negative impact on dysmenorrhea. (9) (13) Women who suffer from dysmenorrhea they are

unaware of alternative therapy how to apply in their life. (13)

Complementary and alternative medicines are adjuvant therapies that help to treat and

prevent various ailments. (14) CAM mainly encourages positive life style modifications,

advocate healthy dietary habits, and promote physiological, psychological and spiritual
health.(15) Complimentary therapy for dysmenorrhoea include Yoga, massage, reflexology,

nutrition, chiropractice, naturopathy and herbal medicine. (16)(17)

Yoga therapy is one of the CAM therapy responsible to obtain good health and emphasize on

disease prevention. (18) Yoga is an ancient Indian techniques. It is the science of right living

and as such is intended to be incorporated in daily life. It works on all aspects of human

existence- the physical, vital, mental, emotional, psychic and spiritual. (19)

Yoga consists of asanas (poses), mudras and pranayama (breath control), meditation and

bandhas. Practice of this brings lightness of the limbs, agility, balance, vitality, and

endurance. Regular practice of yoga improves flexibility, muscular activity, stress, and pain

and thereby improves the Quality of Life (QoL) of an individual (20) (21)

Yoga is a mind-body practice that helps strengthen the muscles, reduce stress and alleviate

physical symptoms. (22)

According to yoga, the human body consists of 5 sheaths. The seed of stress is situated in the

manomaya Kosha, (23) and has a negative impact on the human body. If is not managed it

may be prone to chronic pain. Untreated stress may weaken the immune system and its

functions. (24) When there’s stress there is an arousal of the sympathetic nervous system and

by the practice of yoga based mind-body practices it helps to balance the autonomic nervous

system. (25) In physiological stressors such as pain, practice of yoga helps reduce pain by
releasing endorphins which is primarily secreted from the pituitary gland and thus by

reducing inflammation, it improves the functioning of the immune system. (26) (27)

Aim of yoga helps to deal with the physical level and relive the mental tension. (19)

Asanas are useful, not only to revive the body but also to regenerate the glands and

strengthen the nervous system, eventually curing mental and physical illness. They bring the

human body under complete control of the mind. (28) Practice of yoga combines with mind-

body practices posture sequence along with the breath regulation enhance the effect on

cognitive, emotional and autonomic regulation. (29)

Hence this study aims at understanding the effect of prone asanas and cyclic meditation on

primary dysmenorrhea subjects by establishing strong evidences against the extent of efficacy

of this treatment modality in the management primary dysmenorrhea

 2. OBJECTIVES

Aim: The aim of the study is to assess the effect of prone asanas and cyclic meditation on

primary dysmenorrhea.

Objectives: To assess effect of prone asanas and cyclic meditation on

• Intensity of Pain

• Menstrual cramps

• Assessment of systemic symptoms including headache, dizziness, diarrhea, faint,

mood change, tiredness, nausea and vomiting

 3. Review of Literature

3.1 Introduction:

Most of the adolescents face dysmenorrhea in their reproductive age. (30)

Dysmenorrhea affects their performance, academic, furthermore, were answerable for school

truancy. (31) Numerous studies have showed that the pervasiveness of primary dysmenorrhea

differed from roughly 50% to 90%. (32)

3.2 Anatomy and physiology of uterus:

The uterus is an empty pyriform strong organ arranged in the pelvis between the bladder in

front and the rectum behind.

3.2.1 POSITION:
Its typical position is that of anteversion and anteflexion. The uterus generally grades to the

right (dextrorotation) so the cervix is coordinated to one side (levorotation) and comes in

close connection with the left ureter.

3.2.2 MEASUREMENTS AND PARTS:

The uterus measures about 8cm long, 5 cm wide at the fundus and its wall are about 1.25cm

thick. Its weight from 50gm to 80gm.

3.2.3 It has got the following parts:

1. Body or corpus

2. Isthmus

3. Cervix (1)

1. Body or corpus: the body has

a) A fundus

b) 2surfaces, anterior or vesical and posterior or intestinal

c) Two lateral borders

a)A fundus: It lies above opening of the uterine cylinders. It is raised like a vault. It is shaped

by the free upper finish of the uterus. It is secured with peritoneum and it is directly forward

when the bladder is empty.

b) 2 surfaces, front or vesical and back or intestinal:

- Anterior surface is level and it is identified with the urinary bladder. The body of the uterus

covered with the peritoneum and forms the posterior or superior wall of the uterovesical

pouch.

- Posterior surface is convex and is related to coils of the terminal ileum and to the sigmoid

colon.
c) Two lateral borders: is round and convex. The uterine tube opens in to the uterus at the

upper end of this border. (33)

2. Isthumus: it is present between the body and the cervix. It is limited above by the

anatomical internal os and below by the histological internal os (aschoff). (34)

3. Cervix: It is round and hollow fit as a fiddle and measures about 2.5cm. Some of the lower

portion of the cervix extends in to the foremost mass of the vagina which separates in to

supravaginal and vaginal parts.

-The supravaginal part of the cervix is related:

a) Anteriorly to the bladder

b) Posteriorly to the rectouterine pouch, containing coils of intestine and to the rectum.

c) On each side, to the ureter and to the uterine conduit, implanted in parametrium. The fibro

fatty tissue between the two layers of the expansive tendon and underneath it, is known as the

parametrium. It is generally inexhaustible close to the cervix and vagina.

-Vaginal parts of the cervix projects in to the anterior wall of the vagina. The space between

it and the vaginal wall are called the vaginal fornices. The cervical canal opens in to the

vagina by an opening called the external os. (33)

Coronal section showing different parts of the uterus

3.2.4 Cavity:

The cavity of the uterine body is triangular on coronal segment with the base above and the

summit underneath. It quantifies about 3.5cm. The typical length of the uterine depression is

6.5-7 cm. there is no cavity in the fundus.

RELATIONS

-Anteriorly: Above the internal OS, the body forms the posterior wall of the uterovesical

pouch. Below the internal os, it is separated from the base of the bladder by loose areolar

tissue.
-Posteriorly: It is covered with peritoneum of the broad ligament are attached between which

the uterine artery ascends up. Attachment of the Mackenrodt’s ligament extend from the

internal os down to the supravaginal cervix and lateral vaginal wall.

3.2.5 STRUCTURES:

Body-The divider comprises of three layers from outside inwards.

a) Parametrium: It is the serous coat which contributes the whole organ with the exception

of the lateral borders. The peritoneum is intimately adherent to the underlying muscles.

b) Myometrium: it comprises of thick bundles of smooth muscles strands held by connective

tissue and are arranged in various direction. During pregnancy, in any case, three distinct

layers can be recognized external longitudinal, center interlacing and inner circular.

c) Endometrium: the mucous coating of the cavity is called endometrium. As there is no

submucous layers, the endometrium is straightforwardly oppose to the muscles coat. It

comprises of lamina propria and surface epithelium. The surface epithelium is a solitary layer

of ciliated columnar epithelium. The lamina propria contains stromal cells, endometrial

organs, vessels and nerves. The glands are simple tubular and lined by mucus secreting non-

ciliated columnar epithelium which penetrate the stroma and sometimes even enter the

muscle coat.

3.2.6 Cervix:
The cervix is made basically composed of fibrous connective tissue. The smooth muscle

filaments normal 10-15%. Just the posterior surface has peritoneal coat. Mucous coat lining

and the endocervix is simple columnar with basal nuclei and the lining of the gland is non-

ciliated secretory columnar cells.

3.2.7 Secretion:

The endometrial secretion is scanty and watery. Secretion of the cervical gland is alkaline and

thick, rich in mucoprotein, fructose and sodium chloride.

3.2.8 Peritoneum in relation to the uterus:

- Traced anteriorly: the peritoneum covering the superior surface of the bladder reflects over

the anterior surface of the uterus at the degree of the inner os. The pouch, so formed, is called

uterovesical pouch. The peritoneum thereafter, is firmly attached to the anterior and posterior

walls of the uterus and upper one-third of the posterior vaginal wall where from where it is

reflected over the rectum. The pouch, so formed is called Pouch of Douglas (PoD).

- Traced laterally: the adherent peritoneum of the anterior and posterior wall of the uterus is

continuous laterally forming the broad ligament. Laterally, it extends to the lateral pelvic

walls where the layers reflect to cover the anterior and posterior aspect of the pelvic cavity.

On its superior free border, lies the fallopian tube and on the posterior layer, the ovary is

attached by mesovarium.

3.2.8 Blood supply:

Arterial supply: The blood supply is from the uterine arteries one on each side. The arteries

emerges directly from the anterior division of the internal iliac. Different sources are ovarian

and vaginal conduits with which the uterine supply routes anastomose.

Veins: The venous channels compare to the arterial course and drain in to the internal iliac

veins.

3.2.9Lymphatics:
-Body: From the fundus and upper part of the body of the uterus, the lymphatics drain into

preaortic and lateral aortic groups of glands. Cornu drains to superficial inguinal glands along

the round ligament. Lower part of the body drains in to external iliac groups.

3.2.10 Cervix: on each side, the lymphatics drain in to external iliac, obturator lymph nodes

either directly or through paracervical lymph nodes, internal iliac groups and sacral groups.

3.2.11 Nerves: The nerve supply of the uterus is derived principally from the sympathetic

system and partly from the parasympathetic system. Sympathetic components are from T5

and T6 (motor) and T10-L1 spinal segments (sensory). The somatic distribution of uterine

pain is that area of abdomen supplied by T10-L8. The parasympathetic system is represented

on either side by the pelvic nerve which consists of both motor and sensory fibers from S2,

S3, S4 and ends in the ganglia of Frankenhauser. (34)

3.2.12 Ovary:

Each ovary weight about 15gms. Each ovary superficially covered by a single layer of

epithelium called germinal epithelium. (35)

A pair of ovaries is located (one on each side) behind and below the fallopian tubes. Each

ovaries length is 3-5cm and it attached to the uterus by the broad ligament and round

ligament of ovary.

Structure: histologically each ovary consists of following parts:

1. Germinal epithelium: The term germinal epithelium is a misnomer, it does not produce

any germ cells.

2. Cortex:

• Tunica albuginea: it is present just below the germinal epithelium

• Stroma: it is present deep to the tunica albuginea, is made up of reticular fibres and

numerous fusiform cells that resemble mesenchymal cells.

• Ovarian follicle: each follicle contains a developing ovum.

3. Medulla: It consists of connective tissue in which numerous blood vessels (mostly veins),

smooth muscles and elastic fibres are present.

4. Hilum: it is refers to the area where ovary attaches to mesentery. It is site for entry of

lymphatics and blood vessels. (36)

3.2.13 Normal menstruation:

Menstrual blood is predominantly arterial, with only 25% of the blood being of venous

origin. It contains tissue debris, prostaglandins, and relatively large amount of fibrinolysin

from endometrial tissue. (37)

Duration of menstrual cycle is usually 28 days. But, under physiological conditions, it may

vary between 20 and 40 days (38)

3.2.14 Hormonal control of reproductive growth in females

Hormonal influence of menstrual cycle:

There are four hormone directly involved in menstrual cycle they are:

1. FSH

2. LH

3. Oestrogen

4. Progesterone (39)
 • FSH: It is produced by the anterior pituitary gland and it is a glycoprotein hormone.

(40) FSH is essential for ovarian function because it promotes the maturation of the

ovarian follicle. (41) It is also responsible for the rupture of the matured follicle

leading to release of the ovum. Before the ovulation there is an elevation in the FSH

level. (39)

• LH: It is secreted in the anterior pituitary (42)and stimulate the corpus luteum to

secrete progesterone. (43) Concentration of LH shows a sharp elevation just before the

day of ovulation. This is known as LH surge (39)

3. Oestrogen: It is largely secreted by theca interna cells of the ovarian follicle and in a

small quantity by corpus luteum. Oestrogen promotes the growth of the ovarian follicle. (44)

The concentration of oestrogen level in the blood shows two peaks:

a) 1st peak is before the day of ovulation

b) 2nd peak is in the middle of luteal phase (39)

4. Progesteron: Small quantity of progesterone is secreted by the theca interna cells 1 st

half of menstrual cycle.

Large quantity of progesterone was secreted by the corpus luteum latter half of

menstrual cycle. Small amount of progesterone was secreted by the adrenal cortex also. (44)

The concentration of the progesterone shows a peak around the middle of luteal phase and

withdrawal of progesterone is responsible for the uterine bleeding. (39)

3.2.15 Ovarian cycle:

It is divided in to 2 phase

1. Follicular Phase
2. Luteal phase

1. Follicular phase:

Pre ovulatory phase duration 14 days. Maturation of the ovarian follicle is completed around

14th day of the menstrual cycle. Maturation of the ovarian follicle is brought by the action of

FSH. Ovarian follicle or graafian follicle start growing from one of the ovary. Combined

action of FSH and LH mature follicle ruptures and releases the ovum. This process is known

as ovulation.

Test for ovulation or test for time of ovulation:

a) Recording basal body temperature: Body temperature recorded from the rectum or vagina

every day. During the ovulation period there is slight elevation in body temperature 0.5

Celsius. It is due to thermogenic effect of the progesterone.

b) Examination of the cervix: During ovulation secretion from cervix is very thin, afterwards

it becomes thick.

c) Endometrial biopsy: Shows the presence of functioning corpus luteum indicating ovulation

is over.

d) Examination of vagina: It reveals that after ovulation vaginal cornification disappear.

e) Estimation of plasma concentration of LH: Before ovulation there is an elevation in LH

concentration and progesterone shows gradual rise after ovulation.

f) Urine examination: After ovulation Pregnanediol, metabolic of progesterone appears.

g) Estimation of FSH and LH: Concentration of FSH and LH rise before ovulation. (39)

2. Luteal phase:

Luteal phase extends between 15th and 25th day of menstrual cycle. During this phase corpus

luteum developed hence this phase is called luteal phase. (44)

During this period cell of the ruptured follicles, are retained as corpus luteum. LH also

stimulate the corpus luteum to secrete, progesterone. (39)

title
(44)

3.3 Applied aspect of uterus

Dysmenorrhea: dysmenorrhea means cramping pain accompanying menstruation (45)

3. Classification of dysmenorrhea

3.3.1 Primary dysmenorrhea:

Primary dysmenorrhea is the recurrent cramps during menses without identifiable pelvic

pathology. Primary dysmenorrhea starts shortly within 6 months after menarche. It is due to

the hyperactivity of the myometrium causing hypoxia (46) (47)

3.3.2Secondary dysmenorrhea:
Menstrual pain associated with underlying pelvic pathology. Pain maybe related to pelvic

pathology such as endometriosis, pelvic inflammatory disease, fibroids, adenomyosis and

uterine polyps. (48) (49) 10% of the young adults suffer from secondary dysmenorrhea with

the most common cause being endometriosis. (50) Dull type of pain situated in the front and

back without radiation. Pain appears 2-3 days prior to the period and relives with the start of

bleeding. (1)

3.3.3 Incidence:

The incidence in which most common gynaecological complaint is primary dysmenorrhea.

(51)The incidence of primary dysmenorrhea of sufficient magnitude with incapacitation is

about 15-20 % with the advent of oral contraceptives and non- steroidal anti-inflammatory

drugs. (1)

3.3.4 Risk factors:

Nutritional deficiency also may be one of the risk factor for dysmenorrhea. Lack of nutrition

leads to Low Body Mass Index. (52) Adolescents are more prone to primary dysmenorrhea.

(53)A prospective study shows that dysmenorrhea also associated with Exposure to

Environmental Tobacco Smoke, life style changes and psychological disorders trigger

dysmenorrhea. Increased prevalence of dysmenorrhea in low socioeconomic status.

(54) (55) (56) (57) Age <20 more prone Primary dysmenorrhea like smoking, nulli parity,

heavy menstrual flow, high socioeconomic status, anxiety and depression. (58)

3.3.5 Aetiolopathology of primary dysmenorrhea:

The mechanism of initiation of uterine pain in primary dysmenorrhea is difficult to establish.

But the following are too often related:

 • Mostly confined to adolescents

• Almost always confined to ovulatory cycle

• The pain is usually cured following pregnancy and vaginal delivery

• The pain is related to dysrhythmic uterine contraction and uterine hypoxia

3.3.6 Psychosomatic factors:

Tension and anxiety during adolescence; lower the pain threshold.

3.3.7 Abnormal anatomical and functional aspect of myometrium:

Uterine myometrial hyperactivity has been observed in case of primary dysmenorrhea. The

outer myometrium and the subendometrial myometrium are found to be different structurally

and functionally. The subendometrial layer of myometrium known as junctional Zone (JZ).

This is marked hyperperistalsis of the JZ in women with endometriosis and adenomyosis.

There is significant changes seen in JZ line in women with dysmenorrhea. So there is

irregular thickening and hyperplasia of smooth muscles and less vascularity. This is known as

JZ hyperplasia. (1)

3.3.8 Imbalance in the autonomic nervous system:

In women with chronic pelvic pain there is autonomic dysregulation. It is due to repeated

exposure to stress, leading to high levels of sympathetic activity and reduction in the

parasympathetic activity. (59)

Sympathetic nervous system activates due to stress there is a release of epinephrine and nor

epinephrine which increases the contraction of the smooth muscles. (60)

There is an overactivity of the sympathetic nerves hypertonicity of the circular fibers

of the isthmus and internal os (1)

3.3.9 Role of Prostaglandin (PG):
Compared with eumenorrheic women, prostaglandins are elevated in menstrual extracts of

women with primary dysmenorrhea. (46) In follicular phase and early luteal phase the PG

secretion is very low but it suddenly rises shortly after the onset of menstruation. (61) PG are

derived from the polyunsaturated fatty acids and synthesized from arachidonic acid by the

action of enzyme prostaglandin synthetase. Prostaglandin biosynthesis occurs everywhere in

the body. Mainly prostaglandin E2 and F2 α are produced in small quantities in the

endometrium throughout the menstrual cycle. There is a fourfold PGF 2 α in endometrium

increases, a significant PGF2 α rise in plasma in those with dysmenorrhea compared to the

normal subject. (62)

title
In addition there is significant rise PGF2 α which leads to a sudden myometrial hyperactivity

accompanied by uterine hypoxia (63) PGF2α concentration occurred 15--45 sec after the peak

in intensity of uterine contraction. (64) Increase level of prostaglandin released in to the

systemic circulation leads to nausea, vomiting, headache, faintness. (62)In menstrual period

PGE2 and PGF2 α is high in dysmenorrhea compared to the women with painless period.

(65)The prostanoid and prostaglandin are elevated in small quantities in the endometrium.

The role of prostanoids such as thromboxane A2, prostacyclin, and leukotrienes have been

mentioned. Role of prostacyclin is a potent vasodilator and uterine relaxant hence it reduces

primary dysmenorrhea. Prostanoids and Prostaglandins are biosynthesized from arachidonic

acid via the COX pathway. After production of arachidonic acid from hydrolysis of

phospholipids by phospholipase. Progesterone level decline during luteal phase. This causes

the release of phospholipase enzyme by labilization of lysosome. (46) (66)

Progesterone and oestrogen also play a role in primary dysmenorrhea. Probably due to intake

of oral contraceptives it inhibits the cyclic endometrial development and ovulation hence

there is a scanty blood flow and maximum pain present during primary dysmenorrhea.(62)

When Progesterone is synthesized and released there is disruption of the endometrium cells

causing vasoconstriction, and there is a cellular dissolution due to release of lysosomal

enzymes and a breakdown of membrane phospholipids which cause release of PG synthesis.

(61) In ovulatory cycle under the action of progesterone; prostaglandins (PGF2 α, PGE2 ) are

secreted from the secretory endometrium. PGF2 α is a strong vasoconstrictor which causes

ischemia (angina) of the myometrium. When there is increased production of prostaglandin

there is increased myometrial contraction with or without dysrhythmia.

title

.(1)
3.3.10 Role of vasopressin:

Vasopressin is secreted from the posterior pituitary. There is increase plasma level of both

prostaglandin and arginine vasopressin during dysmenorrhea. Vasopressin increases

prostaglandin synthesis. When there is a high level of vasopressin, it decreases the blood flow

and leads to hypoxia thereby increasing the uterine contractility. (67) (68) (69)

title
()

3.3.11Endothelin:
It is structurally similar to 21- amino acid peptide consists of Enothelian-1, Endothelin-2, and

Enothelin-3 out of which Endothelin-1 is a most powerful vasoconstrictor. ET-1 is produced

in the smooth muscles. Endothelin causes’ myomterial smooth muscles contraction,

especially in the endomyometrial JZ. Local myometrial ischemia caused by endothelins and

PGF2 α aggravate uterine dysperistalsis and hyperactivity. (70) (71) (72) (1)

3.3.12 Platelet activing factor (PAF):

PAF and leukotriene is increased in menstruating women, (73)(74) and hence stimulates the

myometrial contraction.(1) 5 lipoxygenase stimulates the byosynthesis of leukotrine and

leads to contraction of the uterine muscles. Elevation of leukotrine C4 and D4 in women with

primary dysmenorrhea compared to the women without menstrual pain. Leukotriene C4 are

specifically bound to the myometrial cells, and is likely to contribute to the uterine

hypercontractility seen in primary dysmenorrhea. (46) (75)

title

3.4 Clinical features:

Primary dysmenorrhea is widely prevalent; more than 50% of teenagers and 30-50% of

menstruating women suffer from varying degree of discomfort. (45) Pain begins just few

hours or just with the onset of menstruation, severity of the pain typically last for 8 to 24

hours characterised by crampy, spasmodic pain confined to lower abdomen, thigh; may

radiate to back or legs. Symptoms like nausea, vomiting, fatigue, diarrhoea, headache and
tachycardia may be associated and also may be accompanied by vasomotor changes causing

pallor, cold sweats and occasional fainting (1) (76)

3.5 Conventional management for primary dysmenorrhea:

3.5.1 Pharmacological management:

3.5.1.1 Non steroid anti-Inflammatory drugs (NSAIDs):

NSAIDs and combination of oral contraceptive (OC) drugs are the most common treatment

modalities for the treatment for dysmenorrhea. (77) Pharmacological intervention with

common used drugs like Diclofenac, ibuprofen, aspirin, mefenamic cid, ketoprofen are the

best initial management for primary dysmenorrhea. (78)

These drugs helps to inhibit the synthesis of prostaglandin synthetase enzymes, which are

necessary for regulation of prostaglandin biosynthesis and no reduction in the menstrual

fluid. (79) Oral contraceptives maybe contra indicated to life; like hypertension, venous

thrombosis, stroke, heart attack are advised not to take combination of oral contraceptive

pills. (80) (81)

3.5.1.2Glyceryl Trinitrate:

Nitric oxide relaxes the smooth muscles and so may have implications on dysmenorrhea. 0.1-

0.2 mg of nitro-glycerine taken just for hourly just few days of the menstrual cycle, there was

significant reduction in pain. Some 20% reported that headache was present. (82) (83)

3.5.1.3 Levonorgestrel:

Levonorgestrel-releasing intra uterine system (LNG-IUS) are not only used as contraception

but also used for dysmenorrhea, adenomyosis, menorrhagia. It can potentially be used as

contraceptive for 5 years. The study shows that during the period of 12 months there was
reduction in menstrual blood volume and uterine volume. A study also reported that there

was a significant improvement in the haemoglobin level. (84)

3.5.1.4 Calcium channel blockers:

Preventing entry of calcium in to the smooth muscles, reduces the uterine contraction and

promote vasodilatation. (46)

3.5.2 Surgery:

3.5.2.1 Laparoscopic uterosacral nerve ablation (LUNA):

LUNA for primary dysmenorrhea has not been found beneficial. (1) There is no effect LUNA

has necessary component and its self-having no benefit on dysmenorrhea associated with

endometriosis. (85)

3.5.2.2 Pre-sacral neurectomy (PNS):

Total removal of the pre-sacral nerves which is present within the boundaries of the interiliac

triangle. This surgery is done to cut down the sensory pathways (viaT11-T12) from the

uterus. (86) (1)

3.5.2.3 Dilatation of the cervical canal:

It is done under anaesthesia for slow dilatation of the cervix to relive pain by damaging the

sensory nerve ending. (1)

3.6 Non pharmacological treatment

3.6.1 TENS
It is a self-administered, non-invasive technique to relive pain. (87) TENS rises the pain

threshold signal and thus by blocking the nerve root results in reduction of hyper contractility

of the uterus. TENS also stimulate the release of endorphin from the peripheral nerves and

spinal cord thus reducing the pain. (46) (88)

3.6.2 CAM

Yoga therapy is one of the CAM therapies for preventing the disease and promoting health.

(18) GIVE PROPER INTRO FOR CAM

3.7 Role of yoga in maintaining health and disease:

According to the World Health Organisation (WHO), the state of Health is defined as a state

of complete physical, mental and social wellbeing and not merely an absence of disease or

infirmity. WHO also suggests a fourth dimension i.e. "spiritual wellbeing" (89)

3.7.1 Concept of health and yoga

title
In the diagram, 3rd quadrant the region of ill health; represents what normally we designate

as Sickness. Underneath this level, man acts intuitively and is also, similar to a creature. The

first quadrant, the region marked as 'normal man', indicates the state of normal health. As he

moves along the line further up, he gets more beneficial, highlighted by numerous torpid

resources communicating all the more distinctively. This is appeared as the locale of

‘superman'. In this stage, the limitations of normal man, namely, the strong urges of thirst,

hunger, fear and sex are reduced greatly and are fully under control. (90)

As per the idea of Sri Aurobindo, the new resources of more profound impression of the

world past the five faculties develop right now superhuman presence. Further, development

drives man to unfurl the more profound layers of awareness and extend the range of his

insight to move towards heavenly nature or flawlessness. Yoga is an orderly cognizant

process for quickening the development of an individual from his creature level towards a

definitive condition of heavenly nature. (89)

3.7.2 In the tradition of yoga and Upanishad there are 5 sheaths of existence:
Annamaya kosha: The outermost layer, representation of the gross physical body,

Pranamaya Kosha: The second covering of the Self is the pranamaya kosha or essential

sheath comprising of the five pranas or essential energies and the five karma indriyas or

organs of activity. This degree of being is related with the breath, the prana, and the crucial

life force.

Manomaya kosha: the psychical body is responsible for the functions of mind, namely

perception, analysis, memory and also the emotions.

Vijnanamaya Kosha: Vijnanamaya kosha, represents not only ‘cognition’ but also ‘intellect’

and ‘wisdom.

Anandamaya kosha: Anandamaya kosha, the blissful sheath, is the most interior of the

kosha, the first of the koshas surrounding the Atman (91)

3.7.3Yogic concept of illness:

Anandamaya kosha is the healthiest with a perfect harmony and balance of all his faculties. In

manomaya kosha level imbalance start. Likes and abhorrence shave come to play at this

level. These lopsided characteristics intensify themselves coming about dysfunctional

behaviour called Aadhis. The Aadhis (primary disease) are of two fold Saara (the essential)

and Saamanya (ordinary). The secondary disease called Vyadhi. (90)

Title
3.7.4The psychosomatic illness: title

Yoga is not only preventive, but curative too. It aims to develop symmetry, coordination, and

endurance of the body. (92)

Yoga originates from ancient India and has many branches characterised by the integration of

Asana, pranayama and meditation. (93) Yoga is the simplest method of relaxation of body

and mind which helps to improve the physical and psychological status. By the practice of

pranayama and asana regularly it is very beneficial for all women who are suffer from

menstrual disorders. Asana represent a physical posture or position of the body and helps

enhance body functions. So it is useful method by creating strength and endurance,

improving circulation and energy flow, cleansing organ and other system and expanding

muscles and joints. (94)

3.8Asana:
Hathasya prathama angatvat asanam poorvam uchyathe, kuryat asanam stairyam Aarogyam

cha Angalaghavam (H.Y.P – 1:17)

Among the practices of hatha yoga asana to be practiced first and it gives Steadiness body

and mind, freedom from diseases and Flexibility (95)

3.8.1Classification of asanas:

Asanas can be classified in to

• Cultural asana: It mainly helps in reconditioning of the body and mind. By

practicing cultural asanas, a sense of wellbeing, peace and stability is brought about.

The postural defect, disturbed function of various system, improper muscle tone must

be corrected in order to cultivate correct mental attitude.

• Sub group A: asana working on the spinal column: bhujangasana, shalabhasana,

Dhanurasana, Ardha-matsendryasana, Chakrasana, Vakrasana, Ushtrasana

• Sub group B: Asana working on the interoceptors:

 • Asanas working on and through proprioceptors: predominantly work on various

proprioceptors mechanism of the skeletal body. Asanas like Baddhapadmasana,

Gomukhasana, Matsyasana, Vajrasana, Trikonasana, Bhadrasana,

Padahastasana, Supta-vajrasana

• Asanas working on and through visceroreceptors:

Yoga mudra, Paschimottanasana, Mayurasana, Ardha-matyendriyasana, Supta

vajrasana, Halasana, Pavana-muktasana.

• Sub group C: Asanas working on vestibular organ: Asanas predominantly work on

and through the sense organs of balance including vestibular organs. Asanas like

Sirshasana, viparitakarni, garudasana, vrischikasana, vrikshasana, kukkutasana,

bakasana, padahastasana,

2. Relaxative asanas: Relaxative asanas mainly helps to eliminate the physical as well as

mental tension. Shavasana, makarasna are the important asanas which bring about relaxation

of the body and mind.

3. Meditative asanas: It provides stable and comfortable position of the body to make the

mind more steady for the process of meditation, dharana, dhyana and Samadhi. Asana like

Padmasana, Siddhasana. (96)

3.9Meditation:
Meditation” refers to a group of techniques, most of which originated in Eastern religious or

spiritual traditions and are practiced today for stress reduction and other health-related

purposes. (97)

Meditation is a mind-body practice. It has many methods and variations, all of which are

grounded in the silence and stillness of compassionate, non-judgmental present-moment

awareness. (98) Meditation has additionally gotten broadly utilized in mental and medical

practices for pressure the executives just as an assortment of physical and mental issue (99)

3.9 Previous studies of yoga and cyclic meditation in relation to dysmenorrhea

An experimental study was directed on 3 stances of yoga in pre-adult young ladies with

essential dysmenorrhoea, Findings recommended yoga presents are protected and safe

treatment for primary dysmenorrhea. (22)

An imminent controlled preliminary was directed in 35 ladies with essential dysmenorrhoea

and 35 sound controls in a network based investigation. Yoga intercession, two times every

week for 30 minutes/meeting, continuously for about two months. Yoga mediation was seen

as related with decreases in seriousness of dysmenorrhea. (100)

A study was conducted on Positive impact of cyclic meditation on subsequent sleep. The

study concluded that practicing cyclic meditation twice a day appeared to improve the

objective and subjective quality of sleep on the following night. (101)

A review of the scientific studies on the cyclic meditation shows that the practice of CM

during day time has been shown to increase in the subsequent night. This suggest that CM

practice reduce the anatomical arousal, improve attention, and improve quality of sleep.

(102)

By practice of CM increases association and strengthens the connectivity between frontal and

parietal lobes, the major nodes of default mode network and executive attention network,

enhancing the important stages of creativity such as preparation, incubation, and illumination.

(103)

Study was conducted on Effect of cyclic meditation on quality of life and perceived stress in

female adolescence. The findings suggest that practice 1-month of CM showed that there is a

significant impact on QOL and perceived stress in an adolescent girl. (104)

Study was conducted on immediate effect of cyclic meditation on state mindfulness in normal

healthy volunteers: A controlled study. The study conclude that practice of single session of

cyclic meditation calms the mind and helps to develop a better level of mindfulness. This

signifies the individual heightened attention on body, breath and mind, which is known to

further enhances the higher mental functions. (105)

A study was conducted on effect of CM on job related stress in it professionals. By practice

of CM it helped IT professionals for enhancing their physical and psychological wellbeing

including ability to manage work related tasks effectively. (106)

A study was conducted on influence of cyclic meditation on selected physiological

parameters. The study concluded that by practice of CM there was a significant improvement

in cardio respiratory endurance. (107)

35 days of practice of cyclic meditation leads to significant immediate effect of CM in

reduction of stress level in high school athletes who practice sports 4hrs/day. The result

encourage those who are in to sports to adopt CM as a part of their daily schedule to reduce

the stress level. (108)

A study was conducted on the neurophysiological effects of meditation based on evoked and

event related potential recording. The study shows that EPs are useful in localizing changes

that occur in the thalamus, thalamo-cortical connection and primary relays and enhancement

in attention and increased efficiency of brain resource allocation as suggested by ERP studies

are indeed correct. (109)

A study was conducted on heart rate variability in women following a meditation technique.

This study shows that the state of relaxation after CM result in parasympathetic dominance in

women, as evidenced by the increased HF component of the RR interval series. (110)

4. METHODOLOGY
4.1 Study design:

A total of 90 Subjects were screened and after fulfilling inclusion criteria and diagnostic

criteria 60 subjects were selected and randomly divide into 2 groups, Group 1 n=30 Prone

asanas(9 minutes ) and cyclic meditation(28 minutes ) , Group 2 n= 30 Control group ,

baseline data will be recorded before the intervention for both the groups. Subject belong to

Group 1 taught prone asanas9 minutes for 3 months 25 days in a month and cyclic meditation

for 28 minutes for 3 months 25 days in a month and Group 2 will not have any treatment. All

the subjects were asked to follow the same diet for the period of 3 months. Post data will be

recorded after the completion of 3 months. All the details of the study will be explained to the

subjects and an informed consent (Appendix 1) will be obtained from all the subjects before

the study. The data collected was tabulated & analysed using appropriate statistical methods.

4.2.1Ethical consideration:

Ethical clearance was obtained from the institutional ethical committee has approved the

thesis and ethical clearance registration certificate number EC-022 date 19.02.2018

4.2.2 Criteria for Diagnosis

 Typically, primary dysmenorrhea is characterized by a crampy suprapubic pain that begins

somewhere between several hours before and a few hours after the onset of the menstrual

bleeding. Symptoms peak with maximum blood flow and usually last less than one day, but

the pain may persist up to 2 to 3 days. Symptoms are more or less reproducible from one

menstrual period to the other. The pain is characteristically colicky and located in the midline

of the lower abdomen but may also be described as dull and may extend to lower quadrants,

the lumbar area, and the thighs. Frequently associated symptoms include diarrhea, Nausea

and vomiting, fatigue, light-headedness, headache, dizziness and, rarely, syncope and fever.

(111)

4.2.3Inclusion criteria: RE-WRITE THIS SECTION

• Adolescent girls who are having dysmenorrhea between the age group of 18-

23years.

• Adolescent girls who can understand English or Kannada

4.2.4 Exclusion criteria: RE-WRITE THIS SECTION

• Adolescent girls with gynecological problems and undergoing treatment. BE

SPECIFIC

• Adolescent girls who are not willing to participate in the study

• Women without primary dysmenorrhea (26)

4.2.5 Study period: 3 months 25 days/month

4.2.6Study sample size: n=60

4.2.7Grouping: 2 groups
 Group 1: Yoga and cyclic meditation (n=30)

Group 2: Control group (n=30)

4.2.8Illustration of study plan: Trial profile

4.3Primary outcome variables

4.3.1Pain analogue scale:

The Visual analogue scale developed by Cline. (112) The Visual analogue scale (VAS)

provides a continuous scale for subjective magnitude estimation and consists of a straight

line, the limits of which carry a verbal description of each extreme of the symptom to

be evaluated. The line is usually 10cm long and horizontal, (113) though different lengths

and orientations have been employed and proven satisfactory. The subjects are made to assess

the severity of pain related to dysmenorrhea by visual assessment technique with a scale of 0-

10cm. The severity of pain was assessed before and after intervention by a visual analogue

scale. The visual analogue scale (VAS) is a tool widely used to measure pain. Subjects were

asked to indicate a perception of pain intensity along a 10 cm horizontal line. (113) (114)

4.3.2Menstrual cramps (RE-WRITE)

Assessment of the muscle cramping was done at 4 stages of intensity of cramps (0-3) such as

none, mild, moderate, severe (115) (116)

 None Mild Moderate Severe

4.3.3Assessment of systemic symptoms:

Assessment of systemic symptoms including headache, dizziness, diarrhea, faint, mood

change, tiredness, nausea and vomiting was carried out using the verbal multidimensional

scoring system for evaluation of systemic symptoms is graded from 0 to 3, (0 =no

symptoms), (1=symptoms exist only mildly and do not interfere with routine activities),(2=

symptoms exist moderately and interfere with routine activities but are not debilitating) and

(3=symptoms exist severely and are completely debilitating). (117)

• Headache None Mild Moderate severe

• Dizziness None Mild Moderate severe

• Diarrhea None Mild Moderate severe

• Faint None Mild Moderate severe

• Mood changes None Mild Moderate severe

• Tiredness None Mild Moderate severe

• Nausea None Mild Moderate severe

• vomiting None Mild Moderate severe

4.4Intervention:

4.4.1Bhujangasana (cobra pose) (3 times of 1 minute maintenance = 3 minutes) (19)

Lie flat on the stomach with the legs straight, feet together and the soles of the feet

uppermost. Place the palms of the hands flat on the floor, below and slightly to the side of the

shoulders. The fingers should be together and pointing forward. The arms should be

positioned so that the elbows point backward and are close to the sides of the body. Rest the

forehead on the floor and close the eyes. Relax the whole body, especially the lower back.

Slowly raise the head, neck and shoulders. Straightening the elbows, raise the trunk as high as

possible. Use the back muscles more than the arm muscles. Be aware of using the back

muscles first while starting to raise the trunk. Then use the arm muscles to raise the trunk

further and arch the back. Gently tilt the head backward, so that the chin points forward and
the back of the neck is compressed. In the final position, the pubic bone remains in contact

with the floor and the navel is raised a maximum of 3 cm. If the navel is raised too high, the

bend tends to be in the knees and not in the back. The arms may or may not be straight; this

will depend on the flexibility of the back. Hold the final position. To return to the starting

position, slowly bring the head forward, release the upper back by bending the arms, lower

the navel, chest, shoulders and finally the forehead to the floor. Relax the lower back

muscles.

4.4.2Dhanurasana (bow pose) (3 times of 1 minute maintenance = 3 minutes) (19)

Lie flat on the stomach with the legs and feet together, and the arms and hands beside the

body. Bend the knees and bring the heels close to the buttocks. Clasp the hands around the

ankles. Place the chin on the floor. This is the starting position. Tense the leg muscles and

push the feet away from the body. Arch the back, lifting the thighs, chest and head together.

Keep the arms straight. In the final position the head is tilted back and the abdomen supports

the entire body on the floor. The only muscular contraction is in the legs; the back and arms

remain relaxed. Hold the final position for as long as is comfortable and then, slowly relaxing

the leg muscles lower the legs, chest and head to the starting position. Release the pose and

relax in the prone position until the respiration returns to normal.

4.4.3Shalabhasana (locust pose) (3 times of 1 minute maintenance = 3 minutes) (19)

Lie flat on the stomach with the legs and feet together and the soles of the feet uppermost.

The arms may be placed either under the body or by the sides, with the palms downward or

the hands clenched. Stretch the chin slightly forward and rest it on the floor throughout the

practice. Close the eyes and relax the body. This is the starting position. Slowly raise the legs

as high as possible, keeping them straight and together. The elevation of the legs is produced

by applying pressure with the arms against the floor and contracting the lower back muscles.

Hold the final position for as long as is comfortable without strain. Slowly lower the legs to

the floor. This is one round. Return to the starting position and relax the body with the head

turned to one side.

4.4.5 CYCLIC MEDITATION

Step 1

Starting prayer (1 minute)

Laye Sambodhaye cittam viksiptam samayet punah

Sa kasayam vijaniyat samapraptam na calayet

Meaning: In a state of mental inactivity awaken the mind; when agitated, calm it; between

these two states realize the possible abilities of the mind. If the mind has reached the state of

perfect equilibrium then do not disturb again. (118)

Lie on your back. Relax the whole body on the ground. legs apart, hands apart, palms facing

the roof, smiling face, let go all parts of the body. As you repeat the prayer feel the resonance

throughout the body.

Step 2

Instant relaxation technique (IRT) (1 minute)

Bring your legs together, join the heels, toes together, palms by the side of the body. Keep

your face smiling till the end. Gently bring your awareness to the tip of the toes stretch the

toes, tighten the ankle joint, and tighten the calf muscle. Pull up the knee caps. Tighten the

thigh muscles. Compress and squeeze the buttocks. Exhale and suck in the abdomen. Make

the fist of the palms and tighten the arms. Inhale and expand the chest. Tighten the shoulder,

neck muscles and compress the face. Tighten the whole body from toes to the head Tighten

…..Tighten……tighten Release and relax

Linear awareness (2 minute)

Now slowly bring the left hand over head along the ground. Slowly turn over the left side.

Place the head on the left arm. The right leg on the left leg, right palm on the right thigh. Let

the whole body relax.

The entire weight of the body coming down to the ground through the left side. Fine linear

awareness. Slowly start coming up to the Tadasana. Let all the movements slow down. Let

the breathing be deep, slow and continuous. Keep your eyes closed. Carefully feel the

changes in your body as you reach the vertical position. Feel the flow of the blood down the

heart. Feel the heartbeat and the pulse. Chant Mmmm…….. (Bhramari) to generate 3D

awareness and feel the whole body resonating.

Step 3

Centering (2 minute)

Slowly lean forward. Feel the weight of the entire body on the toes. Pointed awareness.

Slowly lean backwards. Feel the weight on the heels. Surface awareness. Come to the centre.

Lean to the right. The weight of the entire body is on the right edge of the right foot. Linear
awareness. Lean to the left. Come to the centre. Fine surface awareness. Now the whole body

is centred, the weight of the whole body is equally distributed throughout the soles of the feet.

Relax the shoulders, arms hanging freely down. Smiling face. Feel all the changes taking

place in the body

Step 4

Standing Asana
ArdhaKatiChakrasana(7minutes)(boththeside)
Slowly start raising the right arm sideways upwards, 45°raise the arm further slowly and

continuously to horizontal position, enjoy the movement. As the right arm reaches

90°position twist the palms at the wrist. Pointed awareness and glide the right arm up to

135°position.beautiful pointed awareness on the deltoid muscles on the right arm. As the

right arm reaches up the vertical position feel the nice stimulation in the shoulder muscles.

The right biceps touching the right ear, feel the beautiful surface awareness. Feel the blood

gushing down the arm. Smiling face. Stretch the right arm from the tip of the fingers of the

right palm. The entire right portion of the body gets stretched, but not the face. Face always

smiling and relaxed. Slowly start bending down to the left. Left palm sliding down along the

left thigh. Fine movement of surface awareness. Enjoy the fine stretch of the waist muscles

on the right side and compression on the left side. Observe all the changes taking place in

your body. Slowly start coming back to vertical position. Feel the blood flowing down, the

nerve impulses throughout the body. Again stretch and pull up the right arm and the entire

right portion of the body stretched from the toes to the tip of the fingers. Slowly start bringing

the right arm down 135° gliding down smoothly. Feel the pointed awareness at the shoulder

as you reach horizontal position and at the wrist as you slowly turn the palm downwards.

Further bring down the right arm to 45. Feel the tingling sensation at the tips of the fingers.

Continuously glide down the hand by the side of the thigh and hang it freely. Have a glance

of the body again from the toes to the head. Entire right portion of the body is beautifully

charged with nerve impulse, light and energized.

Like that only have to perform on the left side.

Step 5

Quick relaxation technique (3minute)

Phase 1- Observing the abdominal movements

Bring your awareness to the movements of the abdominal muscles moving up and down as

you breathe in and out. Recognize the haphazardness and jerky movement of the abdominal

muscles. Do not manipulate the breathing, let it be natural, simply observe he abdominal

movement. Count yourself 5 rounds mentally, one inhalation and one exhalation forming one

round.

Phase 2-Associate with breathing

Synchronize the abdominal movements with the breathing. While inhaling the abdomen

bulging up and while exhaling the abdomen –sinking down. Inhale….deeply and

exhale…..completely. Continue up to 5 rounds.

Phase 3-Breathing with feeling

.As you inhale, the abdominal muscles are coming up feel the whole body getting energized

and feel the lightness. As you exhale, feel the whole body collapses and sinks down nicely,

releasing all the stresses and tension completely. Inhale….deeply and exhale ….completely.

Continue up to 5rounds. Chant an A-kara in low voice (30second) feel the vibration in lower

parts of the body.

Bring your legs together and hands by the side of the body. Come up straight with the support

of the elbows to the sitting legs stretched relaxation position Sithili Dandasana.
Step 6

Sitting Asana
Vajrasana(2minute)

Kneel on the floor. Bring the big toes together and separate the heels. Lower the buttocks

onto the inside surface of the feet with the heels touching the sides of the hips. Place the

hands on the knees, palms down. The back and head should be straight but not tense. Avoid
excessive backward arching of the spine. Close the eyes, relax the arms and the whole body.

Breathe normally and fix the attention on the flow of air passing in and out of the nostrils.
Shashankasana(2minute)
Sit in vajrasana, placing the palms on the thighs just above the knees. Close the eyes and

relax, keeping the spine and head straight. While inhaling, raise the arms above the head,

keeping them straight and shoulder width apart. Exhale while bending the trunk forward from

the hips, keeping the arms and head straight and in line with the trunk. At the end of the

movement, the hands and forehead should rest on the floor in front of the knees.

If possible, the arms and forehead should touch the floor at the same time. Bend the arms

slightly so that they are fully relaxed and let the elbows rest on the floor.

Ushtrasana(2minute)

Sit in vajrasana. Stand on the knees with the arms at the sides. The knees and feet should be

together but may be separated if this is more comfortable. Lean backward, slowly reaching

for the right heel with the right hand and then the left heel with the left hand. Do not strain.

Push the abdomen forward, trying to keep the thighs vertical, and bend the head and spine

backward as far as possible. Try to relax the whole body, especially the back muscles, into

the stretch. The weight of the body should be evenly supported by the legs and arms. The

arms should anchor the shoulders to maintain the arch of the back. Remain in the final

position for as long as is comfortable. Return to the starting position by slowly releasing the

hands from the heels one at a time

Step 7
Deep relaxation technique (6 minute)

Phase 1- Bring your awareness to the tip of the toes, gently move your toes and relax.

Sensitize the soles and relax, relax your feet, loosen the ankle joints, relax the calf muscles,

pull up the knee caps, release and relax, relax your thigh muscles, buttock muscles, loosen the

hip joints, relax the pelvic region and waist region. Totally relax your lower part of the body

R..e…l…a…x…. Chant A-kara..(30 seconds) feel the vibration in lower parts of the body.

Phase 2- Gently bring your awareness to the abdominal region and observe the abdominal

movements for a while, relax your abdominal muscles, relax the chest muscles. Gently bring
your awareness on your lower back, relax your lower back and loosen all the vertebral joints

one by one. Relax the muscles and nerves around the backbones. Relax your middle back,

shoulder blades and upper back muscles, totally relax. Shift your awareness to the tip of the

fingers, gently move them a little and sensitize. Relax your fingers one by one. Relax your

palms, loosen the wrist joints, relax the forearms, loosen the elbow joints, relax the hind

arms-triceps, biceps and relax your shoulders. Shift your awareness to your neck, slowly turn

your head to the right and left, again bring back to the centre. Relax the muscles and nerves

of the neck. Relax the muscles and nerves of the neck. Relax your middle part of the body,

totally relax R…e..l…a….x… Chant U- kara(30 seconds) feel the vibration in the middle

part of your body.

Phase 3- Gently bring your awareness to your head region. Relax your chin, loosen your

lower jaw and upper jaw, relax your lower and upper gums, lower and upper teeth and relax

your tongue. Relax your palates-hard and soft, relax your throat and vocal chords. Gently

shift your awareness to your lips, relax your lower and upper lips. Shift your awareness to

your nose, observe your nostrils, and feel the warm air touching the walls of the nostrils as

you exhale and feel the cool air touching the walls of the nostrils as you inhale. Observe for a

few seconds and relax your nostrils. Relax your cheek muscles, feel the heaviness of the

cheeks and have a beautiful smile on your cheeks. Relax your eye balls muscles, feel the

heaviness of the eye balls, relax your eye lids, eye brows and the space between the eye

brows. Relax your forehead, temple muscles, ears, the sides of the head, back of the head and

crown of the head. Relax your head region totally R…e…l…a…x….and chant M- kara (30

secods) Feel the vibration in your head region.

Phase 4-Observe your whole body from toes to head and relax, chant AUM in a single breath

A….U….M….(30 second) Feel the resonance throughout the body.

Phase 5- Slowly come out the body consciousness and visualize your body lying on the

ground completely collapsed.

Phase 6- Imagine the vast beautiful blue sky. The limitless blue sky. Expand your awareness

as vast as the blue sky. Merge yourself in to the blue sky. You are becoming the blue sky.

You are the blue sky. Enjoy the infinite bliss. E….N….J….O….Y….the blissful state of

silence and all pervasive awareness.

Phase 7-slowly come back to body consciousness. Inhale deeply. Chant an Om- kara.(30

second) Feel the resonance throughout the body. The soothing and massaging effect from

toes to head.
Phase 8-Gently move your whole body a little. Feel the lightness, alertness and energy

throughout the body. Slowly bring your legs together and the hands by the side of the body.

Turn over to the left or the right side and come up when you’re ready (119) (120)

4.4.6 Data analysis: All the data were tabulated in a spreadsheet and were manually checked

for errors. Kurtosis and Skewness of all the baseline variables were between ±2 and

Kolmogorov-Smirnov test for normality indicated normal distribution of data (p>0.05).

Parametric tests: paired t test and independent t tests were performed to assess the within and

between group changes respectively

5 Result:

A pool of ninety subjects fulfilling the inclusion criteria was formed. From the volunteers,

sixty subjects of age range 18 to 23 years (Mean ±SD years) were randomly assigned to the

experimental group or the control group.

The experimental group was administered a standardised yoga module developed with an

objective to assess the combined role selected yoga based mind-body practices. Within group

changes in the experimental group indicate a significant reduction in visual analogue scale

scores for pain (p<0.0001), menstrual cramps (p<0.0001) and overall symptom score

(p<0.0001). Also, a less significant reduction was observed in the visual analogue scores for

pain (p=0.0002) and overall symptom score (p=0.0003). Between group comparison showed
a significant reduction in the yoga group in pain (p<0.0001), menstrual cramps (p<0.0001)

and symptom score (p=0.0003).

Table: Table representing the pre and post changes (Mean ± SD) of all the variables before

and after the intervention from experimental and control groups. Levels of significance

following Paired samples and Independent samples t test for within group and between group

changes are mentioned

6 Discussion:
The present study was aimed to investigate the effectiveness of Prone Asanas and Cyclic

Meditation on primary dysmenorrhea. The total 90 subjects where screened with diagnostic

criteria, inclusion and exclusion criteria was done. After screening total number of 60

subjects were recruited for the study. Initially pre-assessment VAS, menstrual cramps,
assessment of menstrual symptom were done and then were randomly divided into 2 groups.

Group A (n=30) practised asana (9 minutes) and cyclic meditation (28 minutes/day 25 days

for a period of 3 months) and Group B (n=30; control group). Both the groups were not on

any medication, their diet was being controlled (being in a hostel mainly junk food and soft

drinks were avoided). After the study period of 3months 25days/month post assessment of

both the group were recorded and sent for statistical analysis. There was no adverse effect

reported during and after the intervention. In current study following prone asanas and cyclic

meditation there was a significant reduction in the VAS scale for pain, menstrual cramps and

overall symptom score, where as in the control group there was less significant reduction was

observed in VAS for pain and overall symptom score.

According to Yang NY, practice of yoga helps to reduce the menstrual pain intensity level

and muscle cramps, 60 minutes yoga for once a week for 12 weeks. The program combined

with physical exercise, relaxation and meditation. The result shows that pain intensity level

and muscle cramp significantly reduced. (121)

Rakhshaee Z. suggested that yogic posture helps to strengthen the spinal flexibility and

supple the spine, decrease stress to promote relaxation and increasing in blood circulation to

reduce the intensity of pain by gate control mechanism. (22) Gate controlling mechanism

present in the spinal cord which is regulated by the brain, practice of yoga secrete the beta-

endorphin which is a Natural pain killer helps to reduce the pain. (122)

According to Quillen MA, anxiety and distress is the most common which will trigger

menstrual pain, practice of yoga and relaxation technique alleviate the symptom and pain,

(123) Other study suggested that practice of yoga and meditation are mind-body therapies
helps to reduce the stress level, control the negative emotion, and managing the pain and also

promote the health by reducing the inflammation and improve the immune system function.

(124) (26)

Physiological stressor such as pain (26) may impact on mental level lead to anxiety,

depression. (125) This leads to arousal of sympathetic nervous system (25) by the stimulation

of the HPA axis and there is a release of catecholamines. (126) it played a very important role

in emotional reaction to various stressor leads disturb the quality of life. Catecholamine secret

in the different menstrual phase leads to changes in the mood and behaviour. Adrenalin and

noradrenalin secretion altered the psychologic function and promote anxiety and stress (127)

(128)

Stress, anxiety, depression activate the production of pro-inflammatory cytokines and

affect the immune system. Stress, anxiety, depression activate the production of pro-

inflammatory cytokines and affect the immune system.(129) high stress level enhances

the sympathetic activity which turn in to vigorous contraction of the uterus and over

production of prostaglandin and leukotriene, result in muscle cramp and systemic

symptom like nausea, vomiting and bloating. (130)

In this study mind body practice helps to reduce the stress level, stabilizlise the emotional

control and negative thinking. When we correlate with the other study suggested that practice

of yoga posture with guided relaxation technique balance the autonomic nervous system, also

helps deeper state of awareness, promote the awareness, according to Shetkar RM they

observed that delta wave is shifted to the gamma wave. Delta wave indicate that mental
activity dullness or because of stress, whereas gamma wave indicate that positive feeling,

alertness, and increase the awareness. (131) (132)

According to William P emotional distress affects the perceived severity of menstrual pain

and disability, regular practice of aerobic exercise helps to reduce the fat, reduce stress,

improve the behavioural changes. (133) It is due intense stretching over pelvic area helps to

relax the uterine muscles result in increase blood flow and metabolism of the uterus thus by

help to reduce the muscle cramp and reduce the dysmenorrhoeal symptom. (134)

Hence practice of yoga based on mind body practice helps to balance the autonomic nervous

system to reduce the pain control, pain tolerance, regulate the cytokine level and improve the

immune system function. (126)

6.1.1Limitation of the study:

• Small sample size

6.2 Direction for future research:

• Conducting study with a large sample size

• A comparative study can be done between prone asana and cyclic meditation to

evaluate which is having more benefit.

 7. Conclusion:

The present study suggested that prone asanas and cyclic meditation

for 3 months has astonishing effect on reducing the symptom and

relive the pain. So yoga can be safely used as an alternative therapy

for pain relief in primary dysmenorrhoea

 8. Summary
Prone asanas are commonly used by the yoga consultant in the treatment modalities for

primary dysmenorrhea but for the cyclic meditation significantly not proved. Hence this

study was done to assess effect of prone asanas and cyclic meditation in the management of

primary dysmenorrhea. After fulfilling the diagnostic criteria out of 90 subjects, 60 subjects

were recruited for the study. Pre assessment VAS for pain, menstrual cramps, assessment

symptom were taken then 60 subjects were randomly allocated in to experimental group and
control group. After 3 months 25 days in a month post assessment were done. Both the group

were followed same diet.

The result of the present study showed that, significant decrease in VAS for pain, menstrual

cramps and overall symptom score, where as in the control group there was less significant

reduction was observed in VAS for pain and overall symptom score which indicate that mind

body practice helps to release of endorphin which are produced by the brain to enhance the

pain threshold and also balance the sympathetic as well as parasympathetic nervous system.

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