Acta Psychiatr Scand 2011: 123: 147153  2010 John Wiley & Sons A/S

All rights reserved ACTA PSYCHIATRICA

DOI: 10.1111/j.1600-0447.2010.01605.x SCANDINAVICA

Eect of yoga therapy on facial emotion

recognition decits, symptoms and
functioning in patients with schizophrenia
Behere RV, Arasappa R, Jagannathan A, Varambally S, R. V. Behere1, R. Arasappa1,
Venkatasubramanian G, Thirthalli J, Subbakrishna DK, Nagendra HR, A. Jagannathan2, S. Varambally1,
Gangadhar BN. Eect of yoga therapy on facial emotion recognition G. Venkatasubramanian1, J.
decits, symptoms and functioning in patients with schizophrenia. Thirthalli1, D. K. Subbakrishna3,
H. R. Nagendra4, B. N. Gangadhar1
Objective: Facial emotion recognition decits have been consistently
Departments of 1Psychiatry, 2Psychiatric Social Work,
demonstrated in schizophrenia and can impair socio-occupational 3
Biostatistics, National Institute of Mental Health and
functioning in these patients. Treatments to improve these decits in Neurosciences, Bangalore and 4Swami Vivekananda
antipsychotic-stabilized patients have not been well studied. Yoga Yoga Anusandhana Samsthana (SVYASA) University,
therapy has been described to improve functioning in various domains Bangalore, India
in schizophrenia; however, its eect on FERD is not known.
Method: Antipsychotic-stabilized patients randomized to receive Yoga
(n = 27), Exercise (n = 17) or Waitlist group (n = 22) were assessed
at baseline, 2nd month, and 4th month of follow-up by raters blind to
group status. Assessments included Positive and Negative Syndrome
Scale (PANSS), Socio-Occupational Functioning Scale (SOFS), and
Tool for Recognition of Emotions in Neuropsychiatric DisorderS
(TRENDS).
Results: There was a signicant positive correlation between baseline
FERD and socio-occupational functioning (r = 0.3, P = 0.01).
Paired samples t test showed signicant improvement in positive and
negative symptoms, socio-occupational functioning and performance
on TRENDS (P < 0.05) in the Yoga group, but not in the other two Key words: schizophrenia; treatment; outcome
groups. Maximum improvement occurred at the end of 2 months, and B. N. Gangadhar, Professor, Department of Psychiatry,
improvement in positive and negative symptoms persisted at the end of National Institute of Mental Health and Neurosciences,
4 months. Bangalore-560029, India.
Conclusion: Yoga therapy can be a useful add-on treatment to improve E-mail: bng@nimhans.kar.nic.in
psychopathology, FERD, and socio-occupational functioning in
antipsychotic-stabilized patients with schizophrenia.
Accepted for publication August 20, 2010

Significant outcomes
Yoga as an add-on therapy improved psychopathology, emotion recognition decits, and socio-
occupational functioning in antipsychotic-stabilized patients with schizophrenia in comparison with
Physical Exercise and Waitlist groups.
The maximum change in variables occurred at the end of 2nd month of follow-up in the Yoga group
and the benets obtained persisted at the end of 4th month of follow-up.
Facial emotion recognition decits were associated with poorer socio-occupational functioning at
baseline.

147
Behere et al.
Limitations
Baseline matching of Waitlist and Yoga groups on parameters such as negative symptoms and Tool
for Recognition of Emotions in Neuropsychiatric DisorderS Accuracy Score may have improved the
methodology of the study.
A longer duration of supervised yoga therapy by the trained yoga therapist may have produced more
robust results.
The ndings need to be replicated in a larger sample of patients.
Introduction
Schizophrenia is a clinical syndrome characterized
by abnormalities in cognition, perception and
behaviour. Recently, decits in the sphere of
social cognition are being increasingly recognized
in schizophrenia (1). Facial emotion recognition
decits (FERD) are an important component of
impairment in social cognition (2). FERD have
been consistently demonstrated in patients with
schizophrenia (3, 4). These decits have been
demonstrated for negative emotions of fear and
anger (5, 6).
Facial emotion recognition decits can lead to
impairment in interpersonal communication and
may underlie diculties in social adjustment (7).
These decits are also associated with poor work
and global functioning, suggesting that aect
recognition is an important aspect of psychosocial
and occupational functioning in stable out-patients
(8). Hence, interventions to improve FERD can
enhance the socio-occupational functioning in
schizophrenia.
Studies have shown that FERD could be
improved by behavioural interventions like cogni-
tive enhancement training (9). Recently, we
reported that risperidone treatment can improve
FERD in drug-nave subjects (10). However,
FERD have been described as a residual decit in
schizophrenia and have been documented in anti-
psychotic-stabilized patients (11). The scope of the
current conventional treatments for residual de-
cits is limited. Yoga is a traditional Indian system
used in alternative and complementary medicine.
In a randomized controlled trial, it has been found
to improve negative symptoms and functioning in
antipsychotic-stabilized patients with schizophre-
nia (12).
To date, there have been no studies on the eect
of yoga as an add-on treatment for FERD.
Aims of the study
To study the eect of yoga as an add-on treatment
on emotion recognition decits, psychopathology,
and socio-occupational functioning in antipsy-
chotic-stabilized patients with schizophrenia.
148
Material and methods
Sample
Patients with a diagnosis of schizophrenia (DSM
IV), who were on regular follow-up and willing to
give consent for the study, were recruited from the
Outpatient services of the Department of Psychi-
atry, NIMHANS. A qualied psychiatrist con-
rmed the diagnosis independently based on
clinical interview, information obtained from care-
givers, and supportive information from case
records. A total of 91 patients were included in
the study with their age ranging from 18 to
60 years and Clinical Global Impression (CGI)
score 3 (as assessed by the treating psychiatrist).
These patients were on stabilized antipsychotic
medications for 6 weeks or longer, as decided by
the treating psychiatrist, before being recruited
into the study and continued the same medication
until the completion of the study. Patients with
comorbid psychiatric disorders, medical or neuro-
logical illness were excluded. The study was
approved by the ethics committee of the institute.
Procedure
Using computer-generated random numbers, 91
patients were allocated to three treatment groups:
Yoga (n = 34), Exercise (n = 31), and Waitlist
(n = 26). The numbers were not necessarily equal.
The variations in these numbers were not signi-
cantly dierent from chance. The randomization
was performed by one of the authors in the study
(Dr JT). The raters were blind to the status, and
the raters were not involved in imparting yoga
therapy or exercise.
Yoga and Exercise groups received the yoga and
exercise training respectively from a trained yoga
instructor for a period of a month. For the next
2 months, they practiced yoga or exercise at home.
The patients caregivers were instructed to monitor
the yoga therapy at home and keep a log of the
yoga sessions practiced. Patients in the Waitlist
group did not receive any add-on intervention.
Patients in all the three groups continued to receive
stable dose of antipsychotic medications until the
end of the study. As per study protocol, only those

patients who completed all assessments at the end
of the study duration were included in the nal
data analysis. Those patients who dropped out or
those who required a change in dosage of antipsy-
chotics during the study duration were not
included. During follow-up assessments, number
of drop-outs was 7 in Yoga group, 14 in Exercise
group, and 4 in Waitlist group. Hence, the number
of patients who completed the study and included
in the nal analysis was 27 in Yoga group, 17 in
Exercise group, and 22 in Waitlist group. The
drop-outs were not signicantly dierent from the
nal study sample in their baseline clinical and
demographic characteristics. The patients who
dropped out either had not practiced yoga at
home or did not come for follow-up assessments
because of logistical reasons. It is interesting to
note that none of the patients were excluded from
the initial sample for reason of change in dosage of
antipsychotic medication.
The yoga module developed by Swami Viveka-
nanda Yoga Anusandhana Samsthana (SVYASA)
was used. The techniques have been reported in an
earlier study (12); briey, it consisted of loosening
exercises, breathing practices, suryanamaskara,
sitting, supine, and prone posture asanas along
with pranayama and relaxation techniques. Med-
itation was not included in the module. The
exercises were adapted from the National Fitness
Corps Handbook for Middle High and Higher
Secondary Schools. It consisted of brisk walking,
jogging, and exercises in standing and sitting
postures and relaxation. For further details regard-
ing the yoga and exercise techniques, please see
Appendix 1.
Patients socio-demographic data were collected
using semistructured data sheet. Their psychopa-
thology was assessed by Positive and Negative
Syndrome Scale (PANSS) (13). Socio-occupational
functioning was assessed by Socio-Occupational
Functioning Scale (SOFS) (14). Their emotion
recognition abilities were assessed using Tool for
Recognition of Emotions in Neuropsychiatric
DisorderS (TRENDS) (15). This is a culturally
sensitive, ecologically valid tool, consisting of 52
static (still) and 28 dynamic (video clip) images (i.e.
totally 80 images) of six basic emotions happy,
Table 1. One-way anova chi-square analysis of baseline clinical and demographic variables in patient groups
Variable Yoga (Mean SD)
Age (years) 31.3 9.3
Duration of illness (months) 126.2 101.6
Sex (M : F) 18 : 9
Mean dosage of antipsychotic and 335.0 205.3 [400]
[range] (CPZ equivalents in mg day)
Eect of yoga therapy on patients with schizophrenia
sad, fear, anger, surprise, disgust, and a neutral
expression emoted by four experienced actors (one
young man, one young woman, one older man,
and one older woman). The performance on
TRENDS was assessed by calculating the total
number of images that were correctly indentied
out of a maximum of 80 and termed the TRENDS
Accuracy Score (TRACS). Patients were assessed
at the baseline, 2nd and 4th month of follow-up.
All assessments were made by raters who were
blind to the group status.
Statistical analysis
One-way anova was used to assess dierences in
baseline clinical and demographic variables among
the three groups. The paired-samples t test was
used to assess the change in variables after the
study period in the individual groups. Pearsons
correlation analysis was performed to look at the
association between the clinical variables.
Results
On one-way anova, the subjects in all three groups
were comparable on age, sex, and duration of
illness. The three groups diered signicantly on
baseline negative symptoms (F = 4.8, P = 0.01)
and baseline TRACS (F = 3.2, P = 0.05) with the
Yoga group having greater negative symptom
score and lower TRACS (Table 1).
Change in variables between baseline and 2nd
month follow-up and baseline and 4th month
follow-up in the individual groups was examined
using paired-samples t test (Table 2). In the Yoga
group, there was signicant change in positive and
negative symptoms and TRACS. The improvement
continued to remain signicant even after the 4th
month assessments. The improvement in positive
and negative symptoms and SOFS score remained
signicant after applying Bonferroni correction for
multiple comparisons. There were no signicant
changes in variables in either the Exercise or the
Waitlist groups. The maximum change in variables
occurred at the 2nd month of follow-up. On
correlation analysis, it was observed that lower
baseline scores on TRACS correlated with poorer
Exercise (Mean SD) Waitlist (Mean SD) F (v2) P
30.2 8.0 33.6 9.9 0.74 0.5
86.6 93.1 121.6 108.6 0.82 0.4
14 : 3 15 : 7 1.4 0.5
297.9 150.9 [300] 340.0 172.4 [675] 0.21 0.8
149
Behere et al.

Table 2. Pairedsamples t test comparing change in variables from baseline to 2nd month$ and 4th month# of follow-up in individual patient groups

Group Variables Baseline 2nd month 4th month t$ value P$ value t# value P# value

Yoga Positive symptoms 15.1 11.7 11.9 4.7 12.1 5.4 3.5 0.002* 2.8 0.008*
Negative symptoms 17.8 4.9 14.7 3.9 14.7 3.8 5.1 <0.001* 3.5 0.002*
TRACS 49.4 11.4 54.1 11.7 54.6 14.4 2.3 0.03* 1.8 0.09
SOFS score 30.8 7.4 25.1 6.4 25.7 7.9 4.4 <0.001* 0.38 0.7
Exercise group Positive symptoms 14.9 4.3 13.5 4.7 14.1 5.4 1.5 0.2 0.6 0.6
Negative symptoms 14.8 3.9 13.9 3.3 13.5 4.4 0.94 0.4 1.5 0.2
TRACS 51.3 10.7 51.2 10.7 52.8 10.4 0.03 0.9 0.65 0.5
SOFS score 26.2 5.1 23.9 4.7 22.0 6.8 1.9 0.07 1.3 0.2
Waitlist group Positive symptoms 14.7 6.3 12.9 5.2 11.8 5.6 1.7 0.1 2.02 0.06
Negative symptoms 14.3 3.7 13.7 3.7 13.7 3.6 0.61 0.6 0.65 0.52
TRACS 56.9 9.4 58.4 8.9 53.4 16.4 0.74 0.5 0.99 0.3
SOFS score 27.1 6.6 24.9 6.1 25.2 5.4 2.1 0.05* 0.27 0.8

SOFS, Socio-Occupational Functioning Scale; TRACS, TRENDS Accuracy Score; TRENDS, Tool for Recognition of Emotions in Neuropsychiatric Disorders.
*Significance at P < 0.05.

socio-occupational functioning as measured by
SOFS (r = 0.3, P = 0.01). There was no signi-
cant correlation between TRACS and positive or
negative symptoms. There was no signicant cor-
relation between change in negative symptoms and
change in TRACS.
Discussion
This is the rst study to explore the eect of yoga
therapy on FERD. The results of this study show
that yoga therapy as an add-on to antipsychotic
treatment can be benecial in improving positive
symptoms, negative symptoms, FERD, and socio-
occupational functioning. The results of this study
support the ndings of an earlier study that
demonstrated yoga as an add-on therapy to benet
several dimensions of outcome in schizophrenia (12).
Although there was a signicant dierence in
negative symptoms and TRACS between groups at
baseline, there was no signicant correlation
between change in negative symptoms and
change in TRACS, suggesting that change in
negative symptoms alone might not have resulted
in improvement in emotion recognition scores. In
the Exercise and Waitlist groups, the negative
symptoms and FERD did not improve, supporting
the current understanding that these are residual
decits in schizophrenia. The possibility of anti-
psychotic medication confounding the results was
minimized by ensuring stable antipsychotic dos-
ages for 68 weeks prior to study and throughout
the study duration. Hence, the nding of signi-
cant improvement in these parameters in antipsy-
chotic-stabilized patients is of important clinical
relevance.
The correlation between FERD and socio-occu-
pational functioning supports ndings of earlier
studies (7). Impairment in facial emotion recogni-
tion abilities can impair the ability to interact in
social situations and hence can aect socio-
occupational functioning (16). However, interven-
tions to improve these decits are limited. We
recently reported risperidone to improve FERD in
antipsychotic-nave schizophrenia (10). Structured
interventions such as cognitive enhancement ther-
apy have also been described to improve these
decits (9). However, these interventions can be
time-intensive, requiring trained mental health
professionals. Yoga therapy is a popular alterna-
tive system of medicine, and resources to obtain
this training are widely available in a developing
country like India, where mental health resources
are sparse. After an initial training period, patients
can continue practice at home, which can reduce
dependence on mental health resources. Interest-
ingly, benets of yoga therapy that occurred at the
2nd month of follow-up continued to persist even
at the 4th month. One genuine concern is the
monitoring of yoga practice at home. Although
patients and caregivers were instructed to maintain
a logbook of yoga practice, many of the patients
did not maintain the logbook as per our expecta-
tion. A longer duration of supervised yoga therapy
by the trained yoga therapist may have produced
more robust results.
Integration of conventional psychiatric treat-
ments with mind body practices is an emerging
eld. An example of this is the recent study that
integrated yoga breath intervention with exposure
therapy in post-traumatic stress disorder and
depression in survivors of Tsunami (17). Hence, it
is important that yoga therapists should receive
training in mental health disorders to sensitize
them to the needs of the psychiatric population.
The mental health professionals should work in
close association with the yoga therapists, so that
they are readily available to handle the needs of the
patients, if they may arise. In this context, it is
interesting to note that in our study, none of the

150

patients had worsening of positive symptoms
during the duration of yoga therapy. Further,
none of the patients required increase in dose of
antipsychotics. This probably suggests that yogas-
anas and breathing techniques can be practiced by
patients with schizophrenia without worsening of
psychotic experiences.
In conclusion, yoga as an add-on treatment
improves positive and negative symptoms, and
emotion recognition abilities in antipsychotic-
stabilized patients with schizophrenia, which in
turn might improve their socio-occupational func-
tioning. Further systematic studies are needed to
study the benecial eects of yoga in patients with
schizophrenia and their potential neurobiological
mechanisms.
Acknowledgement
This study was supported by AYUSH grant awarded to Dr BN
Gangadhar vide letter no. Z.31018/1/2006-Y&N/R&P(Ay)/
EMR. The authors thank the anonymous reviewers for the
thorough review of the manuscript that has helped immensely
in improving the quality of the manuscript.
Declaration of interest
There is no conict of interest to declare by any of the authors
in relation to this manuscript. None of the authors are
associated with any pharmaceutical companies by way of
being on speakers list of pharmaceutical companies, receiving
grants from industry or being members of pharmaceutical
advisory boards.
References
1. Brune M. Emotion recognition, theory of mind, and social
behavior in schizophrenia. Psychiatry Res 2005;133:135
147.
2. Grady CL, Keightley ML. Studies of altered social cogni-
tion in neuropsychiatric disorders using functional neu-
roimaging. Can J Psychiatry 2002;47:327336.
3. Mandal MK, Pandey R, Prasad AB. Facial expressions of
emotions and schizophrenia: a review. Schizophr Bull
1998;24:399412.
4. Bediou B, Krolak-Salmon P, Saoud M et al. Facial expres-
sion and sex recognition in schizophrenia and depression.
Can J Psychiatry 2005;50:525533.
5. Kohler CG, Turner TH, Bilker WB et al. Facial emotion
recognition in schizophrenia: intensity eects and error
pattern. Am J Psychiatry 2003;160:17681774.
6. Mandal MK, Jain A, Haque-Nizamie S, Weiss U, Schneider F.
Generality and specicity of emotion-recognition decit in
schizophrenic patients with positive and negative symp-
toms. Psychiatry Res 1999;87:3946.
7. Kee KS, Green MF, Mintz J, Brekke JS. Is emotion pro-
cessing a predictor of functional outcome in schizophrenia?
Schizophr Bull 2003;29:487497.
8. Hofer A, Benecke C, Edlinger M et al. Facial emotion
recognition and its relationship to symptomatic, subjective,
and functional outcomes in outpatients with chronic
schizophrenia. Eur Psychiatry 2009;24:2732.
Eect of yoga therapy on patients with schizophrenia
9. Hogarty GE, Flesher S. Practice principles of cognitive
enhancement therapy for schizophrenia. Schizophr Bull
1999;25:693708.
10. Behere RV, Venkatasubramanian G, Arasappa R, Reddy N,
Gangadhar BN. Eect of risperidone on emotion recog-
nition decits in antipsychotic-naive schizophrenia: a
short-term follow-up study. Schizophr Res 2009;113:72
76.
11. Kucharska-Pietura K, David AS, Masiak M, Phillips ML.
Perception of facial and vocal aect by people with
schizophrenia in early and late stages of illness. Br J Psy-
chiatry 2005;187:523528.
12. Duraiswamy G, Thirthalli J, Nagendra HR, Gangadhar BN.
Yoga therapy as an add-on treatment in the management
of patients with schizophreniaa randomized controlled
trial. Acta Psychiatr Scand 2007;116:226232.
13. Kay SR, Opler LA, Lindenmayer JP. The Positive and
Negative Syndrome Scale (PANSS): rationale and stan-
dardisation. Br J Psychiatry Suppl 1989;7:5967.
14. Saraswat N, Rao K, Subbakrishna DK, Gangadhar BN. The
Social Occupational Functioning Scale (SOFS): a brief
measure of functional status in persons with schizophrenia.
Schizophr Res 2006;81:301309.
15. Behere RV, Raghunandan VN, Venkatasubramanian G,
Subbakrishna DK, Jayakumar PN, Gangadhar BN.
TRENDS: a Tool for Recogniton of Emotions in Neuro-
psychiatric DisorderS. Indian J Psychol Med 2008;30:
3238.
16. Hooker C, Park S. Emotion processing and its relationship
to social functioning in schizophrenia patients. Psychiatry
Res 2002;112:4150.
17. Descilo T, Vedamurtachar A, Gerbarg PL et al. Eects of a
yoga breath intervention alone and in combination with an
exposure therapy for post-traumatic stress disorder and
depression in survivors of the 2004 South-East Asia tsu-
nami. Acta Psychiatr Scand 2010;121:289300.
Appendix: Yoga therapy and physical exercise modules
Appendix A: The integrated yoga therapy module; duration: 1 h
I. Shithileekarana vyayama (loosening exercises)
(1) Jogging-2 min
(2) Mukha dhouti (cleansing through a single blast breath)
30 s
(3) Twisting 1 min
(4) Hand stretch breathing 2 min
(5) Forward and backward bending 1 min
(6) Tiger Breathing: nine rounds 1 min
(7) Cycling 1 min
(8) Sashankasana (moon posture) breathing 1 min
(9) Dandasana (sta posture) 30 s
II Asanas:
II A. Suryanamaskar (sun salutation) (12 rounds) 6 min
151
Behere et al.
II B. Instant relaxation technique (IRT) 1 min
Shavasana (corpse posture) this involves progressively
tensing all the muscles of the body in 15 s, relaxing all of
them instantaneously and staying relaxed for 45 s
II C. Sitting posture asanas:
II C.1. Vakrasana (twist posture) 30 s
II C.2. Prasarita pada paschimatanasana (stretching of back
with stretched legs) 1 min
II C.3. Ustrasana (camel posture) 1 min
II D. Prone posture asanas:
II D.1. Bhujangasana (cobra posture) 1 min
II D.2. Shalabhasana (locust posture) 1 min
II D.3. Dhanurasana (bow posture) 1 min
II E. Supine posture asanas:
II E.1. Sarvangasana (shoulder stand) 3 min
II E.2. Matsyasana (sh posture) 1 min
III Breathing exercises:
III A. Kapalabhati (cleansing breath exercise): 6080 rounds
2 min
III B. Sectional (abdominal, thoracic, clavicular, and full
yogic) breathing: each ve rounds 4 min
III C. Nadi-shuddi pranayama (balancing breath): nine
rounds 2 min
III D. Nadanusandhana (feeling of inner sound while chanting
A, U, M) each nine rounds 10 min
IV Quick relaxation technique (QRT) 3 min. This involves
adopting Shavasana and three phases of observing
abdominal movements, synchronizing them with deep
breathing, and feeling of energy and collapsing all the
muscles
Appendix B: Physical exercises: adopted from the National
Fitness Corps Handbook for Middle High and Higher Secondary
Schools (29); duration: 1 h*
I Brisk walking 10 min
II Jogging 5 min
III Exercise in standing posture 20 min
III A. Position: attention
(1) Raising the arms forward to the shoulder level palms facing
each other, ngers together
152
(2) Bending arms, bringing sts in the armpits with elbows
pushed backward
(3) Returning to position one
(4) Returning to position of attention
Yoga therapy for the management of patients with schizo-
phrenia
III B. Position: attention
(1) Raising the arms forward to the shoulder level, ngers
together
(2) Flinging arms sideward to the shoulder level, palms facing
the ground heel raise
(3) Returning to position one
(4) Returning to position of attention
III C. Position: attention
(1) Stepping the left leg forward and raising the arms forward,
palms are kept facing each other and ngers are kept
together
(2) Flinging arms sideward at the shoulder level, palms facing
the ground and lounging left leg forward
(3) Returning to position one
(4) Returning to position of attention
III D. Position: attention
(1) Raising arms forward to the shoulder level palms facing
each other with the ngers together
(2) Raising the arms upward, palms facing each other and with
ngers together heels are raised
(3) Returning to position one
(4) Returning to position of attention
III E. Position: attention
(1) Raising arms sideward, shoulder level, palms facing the
ground, ngers together
(2) Squatting on toes, inging arms upwards, palms facing
each other
(3) Returning to position one
(4) Returning to position of attention
III F. Position: attention
(1) Jumping feet astride, raising arms sideward, palms facing
the ground
(2) Flinging arms upward above head with a clap and jumping
feet together
 Eect of yoga therapy on patients with schizophrenia

(3) Returning to position one (2) Elbows bend, palms touching head

(4) Returning to position of attention (3) Same as 1

III G. Position: attention (4) Back to position

(1) Hands forward upward rise to shoulder level, palms facing IV B. Position: cross-legged sitting, hands slanting
each other, heels raise
(1) Hands sideward, upward, elbows bend, palms touch the
(2) Half squat, chest rm (hands bent at elbows) palm head
downward, middle ngers1 2 distance from each other
(2) Trunk bend, head downward
(3) Hands sideward raise, knees straight
(3) Same as 1
III H. Position: attention
(4) Back to position
(1) Hands forward raised, half-knee bent (no gap between
knees) IV C. Position: cross-legged sitting, hands slanting

(2) Back to position Chest rm (i.e. elbow bent palms downward and in front of
the chest)
(3) Hands sideward raised, half-knee bent
(1) Elbows backward press (chest expanding action)
(4) Back to position.
(2) Hands forward sideward backward press
IV. Sitting posture exercises 20 min
IV D. Position: cross-legged sitting, hands sideward slanting.
IV A. Position: cross-legged sitting, hands slanting 13: hands upward, downward swing, clap over head

(1) Hands rise over had slowly without bending at elbows, *The therapist would give 2 min time in between the dierent
palms touching each other, ngers extended upward exercises with a non-specic instruction, just relax now.

153