Effects of Yoga on Social Communication, Sensorimotor Skills, Physical Health, and Symptom Severity in Children with Autism Spectrum Disorder: A Systematic Review

Effects of Yoga on Social Communication, Sensorimotor Skills, Physical Health, and Symptom Severity in Children with Autism Spectrum Disorder: A Systematic Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Effects of Yoga on Social Communication, Sensorimotor Skills, Physical Health, and Symptom Severity in Children with Autism Spectrum Disorder: A Systematic Review Varvara Papasideri, Stylianos Sergios Chatziioannou This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7842859/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Autism Spectrum Disorder (ASD) is a neurodevelopmental condition characterized by persistent deficits in social communication, restricted and repetitive behaviors, and frequent comorbid challenges such as motor impairments, gastrointestinal dysfunction, and sleep disturbances. Yoga, a holistic mind–body intervention, has emerged as a promising complementary therapy, yet evidence of its effectiveness in children with ASD remains fragmented. Objective This systematic review aimed to synthesize current evidence on the effects of yoga interventions on social communication, sensorimotor abilities, physical health, and symptom severity in children and adolescents with ASD. Methods A systematic search of PubMed and CINAHL databases was conducted up to August 2025. Eligible studies included randomized controlled trials and clinical trials assessing yoga interventions in children ≤ 18 years with ASD. Data were extracted on study characteristics, intervention protocols, and measured outcomes. Risk of bias was assessed using the Joanna Briggs Institute (JBI) critical appraisal tool. Due to heterogeneity, a narrative synthesis was undertaken. Results Of 57 records screened, 7 studies met inclusion criteria (2 RCTs, 5 clinical trials) conducted in the United States, India, and Iran, involving children aged 3–16 years. Yoga interventions varied in duration and format (school-based, structured group programs, or remotely delivered). Findings demonstrated improvements in bilateral coordination, gross motor skills, balance, strength, and flexibility. Significant reductions were observed in autism symptom severity, irritability, social withdrawal, and behavioral dysregulation. Some studies reported improved sleep and gastrointestinal functioning. Social communication and imitation skills were also enhanced, with yoga supporting nonverbal communication, eye contact, and turn-taking. Conclusions Yoga appears to be an effective complementary intervention for children with ASD, with positive effects on motor, social, behavioral, and health outcomes. Despite encouraging results, evidence is limited by small sample sizes, diverse protocols, and heterogeneity of outcome measures. Standardized, large-scale randomized trials are needed to confirm these findings and guide integration of yoga into evidence-based ASD care. Autism Spectrum Disorder Yoga Children Social Communication Motor Skills Complementary Therapy Figures Figure 1 Introduction Autism Spectrum Disorder (ASD) is a neurodevelopmental condition characterized by persistent deficits in social communication and interaction, alongside restricted and repetitive patterns of behavior, interests, or activities. ASD typically manifests early in development and can significantly impact daily functioning. (Maenner et al., 2023 ). It belongs to a spectrum of disorders that also includes Asperger’s syndrome, Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS), Rett syndrome, and Childhood Disintegrative Disorder (Narasingharao et al., 2017 ). The prevalence of ASD has increased in recent years, with current estimates indicating that approximately 1 in 44 children are diagnosed (Maenner et al., 2023 ). The etiological factors associated with ASD are multifaceted and may include environmental influences, genetic predispositions, a family history of ASD, advanced maternal or paternal age, single-gene mutations, autoimmune conditions such as thyroid disorders or rheumatoid arthritis within the family, and complications during pregnancy (Narasingharao et al., 2017 ). ASD has a strong genetic component, with heritability estimates ranging from 64% to 91% (Tick et al., 2016 ). Specific genetic mutations and syndromes, including fragile X syndrome, have been linked to the disorder. Additionally, prenatal and perinatal factors—such as advanced parental age, low birth weight, and prenatal exposure to certain medications—have been implicated in increasing ASD risk (Sandin et al., 2014 ). Diagnosis is typically made based on behavioral observations and developmental history, often utilizing tools like the Autism Diagnostic Observation Schedule (ADOS) and the Autism Diagnostic Interview-Revised (ADI-R). Common symptoms include difficulty with reciprocal social interaction, delayed speech and communication skills, and sensory sensitivities (Okoye et al., 2023 ). ASD is a neurological condition characterized by difficulties in social communication skills and the presence of stereotyped and repetitive behaviors (Kaur & Bhat, 2019 ). Children with ASD often exhibit motor difficulties such as reduced balance and postural control, unsteady gait, poor coordination, as well as low proficiency in handwriting and fine motor skills (Bhat et al., 2011 ; Kaur et al., 2018 ). Specifically, the motor performance of children with ASD corresponds to that of typically developing children who are approximately half their chronological age (Staples & Reid, 2010 ). Additionally, motor delays are observed as early as the first year of life in infants later diagnosed with ASD, and the extent and severity of these delays appear to increase with development (Kaur et al., 2015 ; Lloyd et al., 2013 ). Additionally, children with ASD exhibit difficulties with imitation, which are often considered part of a broader praxis disorder (Dewey et al., 2007 ; Mostofsky et al., 2006 ). Specifically, they may show spatial errors (e.g., incorrect positioning of a limb in space), movement reversals (e.g., shaking the hand with the palm turned inward), and errors involving the substitution of body parts for tools (e.g., performing a “scissor” movement using the index and middle fingers) (Dewey et al., 2007 ; Williams et al., 2004 ). These errors may be observed during the imitation of movements, following instructions, or using tools (Kaur & Bhat, 2019 ). Motor difficulties and imitation impairments may have cascading effects on the social, communicative, and cognitive development of children with ASD (Dadgar et al., 2017 ; MacDonald et al., 2013 ). For example, children with limited motor skills might avoid playing with their peers, resulting in missed opportunities to develop social relationships (Radonovich et al., 2013 ). Similarly, challenges in praxis and imitation can restrict a child's ability to acquire new functional skills, such as dressing and feeding themselves, as well as social skills like gestures and joint social interaction (Ingersoll & Meyer, 2011 ). Therefore, it is clear that developing interventions that provide opportunities to improve motor skills and utilize them to enhance social-communicative abilities in children with ASD is especially important. Additionally, children with ASD often face physical challenges. Most of them experience sleep disturbances due to irregular sleep routines, such as inconsistent sleep times and frequent awakenings during the night, snoring, and mouth breathing while asleep. These issues can also contribute to various behavioral problems (Miano et al., 2007 ). Additionally, children with ASD often experience gastrointestinal issues such as bloating, food intolerances, intestinal inflammation, irritable bowel syndrome, diarrhea, gas, urinary and fecal incontinence, among others (Rao et al., 2008 ). Children with ASD who suffer from persistent gastrointestinal problems may not respond to any form of behavioral intervention unless these gastrointestinal issues are addressed first (Jyonouchi et al., 2014 ). Up to 80% of children with ASD experience sleep disturbances and gastrointestinal dysfunctions, which are often not adequately understood by their parents (Gorrindo et al., 2012 ; McElhanon et al., 2014 ). Over the past decades, yoga has become a popular complementary and alternative therapy used in a variety of cases (Kaur & Bhat, 2019 ). Yoga, which incorporates body postures and breathing techniques, helps balance the autonomic nervous system, promoting a sense of well-being and providing significant benefits for both mental and physical health (Shanker & Pradhan, 2022 ). Additionally, yoga affects various systems such as the motor system by improving flexibility, strength, and balance (Galantino et al., 2008 ); perceptual abilities through enhanced joint proprioception and kinesthesia (Mohanty et al., 2014 ); the cardiopulmonary system (Galantino et al., 2008 ); behavior by improving attention and alertness (Jensen & Kenny, 2004 ); as well as social-communication skills in children, including social interactions, speech, and emotional expression (Narasimhan et al., 2011 ). Yoga-based activities are easy to learn and can be adapted according to each child’s age and functional level (Kaur & Bhat, 2019 ). Η Yoga may contribute to the development of social skills such as imitation, communication abilities, eye contact, tolerance, and emotional regulation in children with ASD (Radhakrishna et al., 2010 ). Through various body movements and controlled breathing, yoga regulates elevated stress levels in children with ASD, affecting both their mind and body, and leading them to a state of calmness and relaxation (Shanker & Pradhan, 2022 ). This systematic review aims to comprehensively examine and synthesize existing evidence on the effects of yoga on social communication skills, sensorimotor abilities, physical health, and symptom severity in children with ASD. The review endeavors to provide rigorously evidence-based conclusions regarding the efficacy of yoga as a therapeutic intervention to enhance the quality of life and functional capabilities of children with ASD. Material and Methods Study Design This systematic review was conducted to evaluate the effectiveness of yoga as a therapeutic intervention for children and adolescents diagnosed with Autism Spectrum Disorder (ASD). The review was structured using the PICO framework. The population included individuals under 18 years of age with an ASD diagnosis. The intervention encompassed various forms of yoga employed as therapeutic approaches. Comparisons were made against either no intervention or alternative therapeutic methods. The primary outcomes assessed were social communication skills, sensorimotor abilities, physical health, and the severity of ASD symptoms. This systematic review adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines to ensure a transparent and reproducible methodology (Page et al., 2021), and employed the Joanna Briggs Institute’s (JBI) Critical appraisal checklist for systematic reviews and research syntheses to minimize bias (Hilton, 2024). This review was registered in PROSPERO with ID number CRD420251152980. Eligibility Criteria This review included studies that evaluated the effectiveness of yoga as a therapeutic intervention to improve social communication skills, sensorimotor abilities, physical health, and symptom severity in children with ASD. The assessment of the outcomes studied was based on the use of valid and standardized self-report tools or objective questionnaires. Eligible studies were limited to randomized and non-randomized controlled trials published in English up to August 2025. Non-interventional studies, reviews, case reports, opinion pieces, non-English publications, and studies lacking complete outcome data were excluded. Search Strategy A comprehensive literature search was conducted in PubMed and CINAHL, utilizing a combination of MeSH terms and keywords such as "yoga," "autism spectrum disorder,", "effect", "children," and "adolescents." Additional searches were performed in other databases and reference lists to ensure the inclusion of all relevant studies”. Boolean operators were employed to refine and optimize the search results. The search was limited to English-language studies involving human participants, published up to August 2025. Additionally, citation tracking and manual screening of reference lists from included articles were performed to ensure thorough coverage. Study Selection Two reviewers independently screened the titles and abstracts of all identified studies. The full texts of studies deemed potentially relevant were reviewed to determine their eligibility according to predefined inclusion criteria. Any disagreements were resolved through discussion with a third reviewer. The study selection process was documented using the PRISMA flow diagram. Data Extraction A uniform data extraction tool was employed to gather detailed information on the studies’ features, participant numbers, varieties of yoga practices used, assessed outcomes, and results concerning the therapeutic impact of yoga on ASD. Data Synthesis Due to the considerable heterogeneity among study designs, intervention protocols, and outcome measures, conducting a meta-analysis was not feasible. Therefore, a narrative synthesis was undertaken with the aim of elucidating the effects of yoga on improving social communication skills, sensorimotor abilities, physical health, and symptom severity in children with ASD. Ethics As this review analyzed previously published data, no primary data collection was involved. It was assumed that all included studies had obtained prior ethical approval. Results The database searches yielded a total of 57 records, comprising 27 records from CINAHL and 30 records from PubMed. The abstracts were uploaded to Rayyan software, which identified 26 duplicates that were subsequently removed. Screening was conducted on 31 abstracts, leading to the manual exclusion of 17 abstracts. Of the 14 full-text articles sought, 10 were retrieved, as one could not be accessed. Following eligibility assessment, 6 articles were excluded due to irrelevance, leaving 7 studies that met the inclusion criteria. The included studies comprised 2 randomized controlled trials (RCTs) and 5 clinical trials. A detailed illustration of the study selection process is provided in the accompanying PRISMA flow diagram (Fig. 1 ). The studies included in this review were conducted in the United States (Kaur & Bhat, 2018; Hensel et al., 2023; Rosenblatt et al., 2011 ), India (Narasingharao et al., 2017 ; Shanker & Pradhan, 2022 ), and Iran (Sotoodeh et al., 2017 ). They involved children and adolescents aged 3 to 16 years with a diagnosis of Autism Spectrum Disorder (ASD). To assess outcomes, these studies utilized a range of standardized and validated measurement tools. Motor skills were evaluated using the Bruininks-Oseretsky Test of Motor Proficiency – 2nd Edition (BOT-2) (Kaur & Bhat, 2018). ASD symptom severity was measured through the Autism Treatment Evaluation Checklist (ATEC) (Sotoodeh et al., 2017 ; Shanker & Pradhan, 2022 ). Behavioral characteristics were assessed using the Behavioral Assessment System for Children – 2nd Edition (BASC-2) and the Aberrant Behavior Checklist (ABC) (Rosenblatt et al., 2011 ). Social communication skills were examined with the Social Responsiveness Scale-2 (SRS-2) (Shanker & Pradhan, 2022 ), while additional physical health indicators such as anthropometric data, balance, muscle strength, and flexibility were included in assessments by Hensel et al. (2023). Rosenblatt et al. ( 2011 ) conducted a pilot study aimed at evaluating the therapeutic effects of yoga in children with ASD. The sample consisted of 24 children aged 3 to 16 years diagnosed with ASD, who participated in an eight-week multidimensional program combining yoga, dance, and music therapy based on the relaxation response (RR). The study outcomes were measured using the Behavioral Assessment System for Children, Second Edition (BASC-2) and the Aberrant Behavioral Checklist (ABC) (Rosenblatt et al., 2011 ). Regarding the study results, significant improvements were recorded in the BASC-2 scores, mainly in children aged 5 to 12 years. Particularly noteworthy was the statistically significant change (p = 0.003) in the “Atypicality” subscale, which evaluates core characteristics of the autism spectrum. As for the assessment with the ABC scale, none of the individual subscales showed statistically significant changes. However, a trend toward improvement was observed in the “Irritability” subscale of the ABC in school-aged children (p = 0.06) (Rosenblatt et al., 2011 ). Narasingharao et al. ( 2017 ) evaluated the effectiveness of a structured yoga intervention in addressing sleep problems, gastrointestinal disorders, and behavioral issues in children with ASD. The sample consisted of 61 children aged 5 to 16 years with ASD, along with their parents, who were divided into two groups: the intervention group (n = 32) and the control group (n = 29). The researchers developed a 61-item questionnaire, with 15 items assessing sleep disturbances (SQ1–SQ15), 16 items evaluating gastrointestinal issues (nutrition and digestion) (FQ1–FQ16), and 30 items focusing on behavioral problems (BQ1–BQ30). The 75-minute yoga sessions took place between 9:30 a.m. and 10:45 a.m., shortly before school started. The yoga exercises were selected from the programs of the Integrated Application of Yoga Therapy (IAYT) of S-VYASA. After three months of regular yoga practice, significant improvements were observed in physiological issues such as sleep disturbances and gastrointestinal dysfunctions. In contrast, the control group showed no improvement. Furthermore, significant improvement was noted in all the behavioral questionnaire items (BQ1–BQ30) in the yoga group, except for item BQ-26, which pertains to the children’s savant abilities — that is, exceptional intelligence in specific areas — which may require a longer intervention period with yoga for changes to become evident (Narasingharao et al., 2017 ). Sotoodeh et al. ( 2017 ) examined the effect of a Yoga Training Program (YTP) on the severity of autism in children with High Functioning Autism (HFA). The sample consisted of 29 children aged 7 to 15 years, who were randomized into either the yoga group or the control group. Participants in the yoga group attended an 8-week yoga program (24 sessions). Parents or caregivers of the children completed the Autism Treatment Evaluation Checklist (ATEC) at the beginning and at the end of the intervention. The analysis results showed statistically significant differences between the two groups in all ATEC subscales, except for subscale I (speech/language/communication) (Sotoodeh et al., 2017 ). Kaur and Bhat ( 2019 ) evaluated the effect of a physiotherapy intervention based on creative yoga on motor skills and imitation abilities in children with ASD. The study sample consisted of 24 children with ASD, aged 5 to 13 years, who received either physiotherapy with yoga intervention (n = 12) or an academic intervention (n = 12) for 8 weeks. The Bruininks-Oseretsky Test of Motor Performance – Second Edition (BOT-2) was used to assess motor skills, while imitation abilities were evaluated through known, educationally specialized actions: yoga poses for the yoga group and construction activities for the academic group. After the intervention, children in the yoga group showed improvement in gross motor skills (p < 0.006) and bilateral coordination (p < 0.006), according to BOT-2 results. Conversely, children in the academic group showed significant improvement in fine motor skills (p = 0.03). Regarding imitation skills, both the yoga group (p < 0.02) and the academic group (p < 0.02) showed a reduction in imitation/performance errors during the execution of the specialized actions (yoga poses and construction activities, respectively). Additionally, children’s intelligence quotient (IQ) was positively correlated with improvements in fine motor skills in the academic group (p = 0.02), but not in the yoga group (p = 0.29), indicating that children with higher IQ in the academic group showed greater improvement in fine motor skills post-intervention compared to children with lower IQ. Furthermore, IQ was negatively correlated with improvements in imitation for the yoga group (p = 0.02), but not for the academic group (p = 0.1), suggesting that children with lower IQ showed greater improvement in imitation of poses following training (Kaur & Bhat, 2019 ). In the randomized controlled trial by Shanker & Pradhan ( 2022 ), the effect of integrating a yoga program into special schools on autism severity in children with ASD was examined. The sample consisted of 43 children aged 5 to 15 years with ASD, coming from four special schools, who were randomized into two groups: the yoga group (n = 23), where children participated in daily 45-minute yoga sessions for 12 weeks, and the control group (n = 20), where children did not participate in yoga and continued with other school activities. The intervention included a variety of relaxation exercises and dynamic practices, breathing exercises, asanas (body postures), pranayama (controlled breathing techniques), relaxation, and chants/mantras. The effectiveness of the intervention on autism severity was evaluated using the Autism Treatment Evaluation Checklist (ATEC), which was completed by parents before and after the intervention. The key characteristics of the participants did not differ significantly between groups: autism severity (p = 0.96) and age (p = 0.82). The yoga group showed a significant reduction in the total ATEC score over time (p < 0.001). This reduction was attributed to significant improvements in the subscales of speech/language/communication (p = 0.011) and health/physical condition/behavior (p = 0.049) (Shanker & Pradhan, 2022 ). Additionally, in another study by Shanker & Pradhan ( 2023 ), the effect of school-based yoga on social responsiveness and problematic behavioral characteristics was examined in 43 children with ASD. The children’s teachers assessed social responsiveness and behavioral problems using the Social Responsiveness Scale-2 (SRS-2) and the Aberrant Behavior Checklist-2 (ABC-2) before and after the yoga intervention. Following the intervention, significant improvements were observed in the mean scores in the areas of social communication on the social responsiveness scale (p = 0.021), irritability (p = 0.041), and social withdrawal (p = 0.047) in behavioral problems (Shanker & Pradhan, 2023 ). Simultaneously, the study by Helsel et al. ( 2023 ) evaluated the feasibility of remotely delivered yoga to improve four physical activity-related skills — motor skills, strength, balance, and flexibility — in adolescents with ASD. Of the 20 participants (mean age 13.2 ± 2.2 years, 60% boys), 19 completed the 12-week intervention and attended 83% of the scheduled yoga sessions. Overall, physical activity-related skills showed significant improvement before and after the intervention (p = 0.005). Specifically, significant increases were observed in leg strength (12.5%, p = 0.039), flexibility (40.3%, p = 0.008), and dynamic balance on the right (11.1%, p = 0.001) and left leg (8.1%, p = 0.003) over the 12-week period (Helsel et al., 2023 ). Table 1 Characteristics of the included studies Authors (year publication) Country Study design Sample Intervention group Control group Outcomes - Measures Results Kaur & Bhat (2018) USA Non-randomized clinical trial 24 children with ASD, aged 5–13 years N = 24 Yoga sessions included breathing exercises, imitative poses, partner poses, and relaxation techniques, alongside context-appropriate social activities designed to encourage greeting and farewell songs, touch/contact games, and visual engagement games. The yoga poses were organized around meaningful themes such as songs, stories, and games. N = 24 Academic activities: reading, arts and crafts, and building supplies such as Play-Doh, LEGO, and ZOOB BOT-2, Training-specific imitation test Baseline and 8th week Following the intervention, children in the yoga group demonstrated significant improvements in gross motor performance on the BOT-2 and exhibited fewer imitation/praxis errors when replicating training-specific yoga poses. Conversely, children in the academic group showed enhancements in fine motor performance on the BOT-2 and made fewer imitation errors during the completion of training-specific building tasks. Frequency: 4 sessions/ week (2 expert sessions and 2 parent sessions) Intensity: 40 to 45 min for expert; 20 to 25 min for parent sessions Duration: 8 weeks Hensel et al (2023) USA Non-randomized clinical trial 19 adolescents with ASD. N = 19 The yoga intervention was delivered to groups of adolescents with ASD (4–6 per group) in their home remotely using Zoom Thirty-minute yoga sessions were delivered 3 times per week across the 12-week intervention. - Feasibility, Anthropometrics (Height, Weight, and Waist Circumference), Motor Skills, Muscular Strength, Static and Dynamic Balance, Flexibility, Physical Activity and Sedentary Time Assessed before and after the intervention. Significant improvements were observed over the 12-week period in leg strength (increased by 12.5%, p = 0.039), flexibility (increased by 40.3%, p = 0.008), and dynamic balance in both the right leg (improved by 11.1%, p = 0.001) and left leg (improved by 8.1%, p = 0.003). Narasingharao et al. ( 2017 ) Ινδία Non-randomized clinical trial 61 children, aged 5–16 years, with ASD. N = 31 The 75-minute yoga program took place between 9:30 a.m. and 10:45 a.m., just before school started. The yoga exercises were selected from the Integrated Application of Yoga Therapy (IAYT) programs of S-VYASA. N = 29 No intervention 61-item questionnaire developed by the researchers Completed by the parents before and after the intervention. Significant changes were observed after the yoga intervention in three areas of concern: sleep problems, gastrointestinal problems, and behavioral problems. Rosenblatt et al ( 2011 )ΗΠΑ Πιλοτική κλινική µελέτη 24 children, aged 3–16 years, with ASD. Ν = 24 8-week multimodal yoga, dance, and music therapy program based on the relaxation response (RR) - BASC-2 και ABC Completed by the parents before and after the intervention. Robust changes were found on the BASC-2, primarily for 5–12-year-old children. Sotoodeh et al ( 2017 )Ιραν RCT 29 children with ASD, aged 7–15 years Ν = 15 24 sessions yoga (30- min) for 8 weeks which include Warm up, Calming poses and Strengthening poses. Ν = 14 ATEC Completed by the parents before and after the intervention. There were significant differences between the two groups with regards to all ATEC sub-scores except ATEC I (speech/language/communication). Shanker & Pradhan ( 2022 ) Ινδία RCT 43 children with ASD, aged 5–15 years N = 23 Daily 45-minute yoga session for 12 weeks. The intervention consisted of various loosening and dynamic practices, breathing exercises, asanas (postures), pranayama (breathing techniques), relaxation, and chanting. N = 20 None intervention ATEC Completed by the parents before and after the intervention. There was a significant reduction in the total ATEC scores overtime in the yoga group (p < 0.001). Shanker & Pradhan ( 2022 ) Ινδία SRS-2 and ABC-2 Completed by the teachers before and after the intervention. Significant changes were observed post-intervention in the mean scores of the social communication aspect in social responsiveness (p = .021), irritability (p = .041), and social withdrawal (p = .047) aspects of problem behaviors. BOT-2: Bruininks-Oseretsky Test of Motor Proficiency–2nd Edition; RCT: randomized clinical trial; ATEC: Autism Treatment Evaluation Checklist; BASC-2: Behavioral Assessment System for Children, Second Edition; ABC: Aberrant Behavioral Checklist; SRS-2: Social Responsiveness Scale-2; ABC-2: Aberrant Behavior Checklist − 2 Discussion One of the findings of our systematic review was that yoga improves bilateral coordination and gross motor skills (Kaur & Bhat, 2019 ). The existing data on yoga interventions in children and adolescents with ASD remain limited. However, studies conducted with typically developing children suggest that yoga positively influences various motor domains, including strength, endurance, speed, flexibility, and coordination (Birdee et al., 2009 ; D’Souza & Avadhany, 2014 ; Tran et al., 2001 ). Specifically, yoga appears to enhance motor function through several mechanisms, such as increased angiogenesis in muscle tissue, alternating activation of motor neurons to delay muscle fatigue, elongation of elastic connective and muscular tissues, and improved sensorimotor perception during movement execution (Galantino et al., 2008 ). dditionally, yoga contributes to the enhancement of joint proprioception—that is, the ability to perceive the position and movement of limbs—resulting in more efficient coordination among the moving parts of the body (Galantino et al., 2008 ). Additionally, yoga has been found to improve motor skills, strength, balance, and flexibility in adolescents with ASD (Helsel et al., 2023 ). It is worth noting that Kaur and Bhat ( 2019 ) did not observe improvements in balance among children participating in the yoga intervention, a discrepancy that may be attributed to differences between the training activities and the assessment tasks. Specifically, the balance subtest of the BOT-2 includes a combination of static activities (e.g., one-leg stance) and dynamic activities (e.g., heel-to-toe walking), whereas the yoga intervention focused almost exclusively on static balance exercises (e.g., maintaining the tree pose). Furthermore, the subtest requires children to maintain poses both with and without visual guidance; however, during the yoga training, children practiced balance exclusively with visual feedback (Kaur et al., 2018 ). Another important finding of this review concerns the improvement of imitation skills in children participating in yoga programs (Kaur et al., 2018 ). ocial tracking skills — that is, the ability to visually attend to and process the actions of social partners — play a crucial role in effective imitation (Dziuk et al., 2007 ). Children with ASD often exhibit reduced eye contact and limited capacity to track others’ actions, which negatively impacts their ability to observe and imitate social behavior patterns (Dawson et al., 2004 ). During yoga sessions, children were encouraged to observe and imitate the movements of the instructor or behavioral model (Kaur et al., 2018 ). Consequently, these training activities contributed to enhancing social tracking skills and turn-taking, leading to improved ability to imitate both familiar and novel actions following the intervention (Mostofsky et al., 2006 ). Another finding was that yoga improves the severity of symptoms in children with ASD (Shanker & Pradhan, 2022 ; Sotoodeh et al., 2017 ). Specifically, in the study by Sotoodeh et al. ( 2017 ), significant improvements were observed in all ATEC subscales except for subscale I (speech/language/communication) (Sotoodeh et al., 2017 ). n the other hand, in the study by Shanker & Pradhan ( 2022 ), the integration of yoga into the school curriculum reduced the severity of symptoms in children with ASD, as a significant improvement was noted in subscale I of the ATEC (Shanker & Pradhan, 2022 ), This improvement in subscale I could be attributed to the unique method of sound repetition (chanting) during the yoga sessions. Children with ASD can imitate sounds such as “OM” and recite a few words when they receive daily stimulation through chanting. Additionally, the rhythmic buzzing of the “bee’s breath” humming enhances oral-motor and motor functions (Radhakrishna et al., 2010 ). Porter argues that yoga provides effective opportunities to improve both verbal and nonverbal communication through various forms of verbal and motor imitation of speech (Porter, 2013 ). It is worth noting that subscale II of the ATEC assesses social skills. In the study by Sotoodeh et al. ( 2017 ), particular emphasis was placed on the child’s communication with the instructor through eye contact, aiming to improve one of the core communication skills (Sotoodeh et al., 2017 ). Through this process, the children imitated the instructor and enjoyed the training sessions. Previous studies have shown that physical exercise interventions directly reduce social dysfunction. Participation in physical activities and sports plays a significant role in the psychosocial development of both typically developing children and children with developmental disorders (Movahedi et al., 2013 ; Smith, 2003 ). Furthermore, the study by Shanker & Pradhan ( 2023 ) found that yoga can improve certain aspects of social responsiveness (Shanker & Pradhan, 2023 ). Yoga may support critical motor components of social reciprocity by encouraging imitation skills, which are fundamental for effective social communication. Yoga sessions subtly cultivate nonverbal communication skills, such as eye contact and facial expressiveness, through interactions with yoga instructors and peers (Radhakrishna et al., 2010 ; Shanker & Pradhan, 2023 ). Also, subscale III of the ATEC assesses cognitive and sensory awareness. A yoga program can enhance self-awareness by focusing attention on bodily sensations. For example, when the instructor asks the child to perform the corpse pose, the child is encouraged to concentrate on another sense, such as hearing. Meditation techniques like yoga represent an art of efficient and adaptive management of neurobehavioral energy; yoga has the potential to activate or disengage conscious mental processes and sensory awareness(Khanna & Greeson, 2013 ). On the other hand, subscale IV of the ATEC evaluates health, physical condition, and behavioral issues, such as diarrhea, constipation, hyperactivity, eating disorders, sleep problems, and stereotypical behaviors in children. In the study by Sotoodeh et al. ( 2017 ), the yoga program had a significant positive impact on these issues. Yoga exercises have a beneficial effect on functional abdominal pain, reducing both the intensity and frequency of pain episodes. Regular yoga practice for children with ASD can alleviate gastrointestinal discomfort and sleep disturbances (Narasingharao et al., 2017 ), while also decreasing hyperactivity and aggression (Rosenblatt et al., 2011 ). Teaching yoga to children with ASD promotes learning inclusion by incorporating multisensory methods that encourage better responses. Children become more receptive to the rhythmic patterns and movements of yoga, regulating their anxiety levels toward a parasympathetic state. Regular yoga practice can lead children with ASD to experience calmness, resilience, and self-regulation. Thus, yoga can positively influence children with ASD by inducing a relaxation response that enhances their sense of health and well-being (Shanker & Pradhan, 2022 ). Another important finding was that yoga contributes to the improvement of behavioral problems in children with ASD. Specifically, in the study by Shanker & Pradhan ( 2023 ), children who participated in the yoga program showed a significant reduction in irritability and social withdrawal compared to the control group (Shanker & Pradhan, 2023 ). The guided rhythmic and repetitive movements of yoga serve as an effective regulatory strategy for children with ASD, helping them manage stress responses by promoting relaxation and reducing the need for problematic behaviors (Artchoudane et al., 2019 ). During the intervention, the children gradually improved their participation and active engagement in the yoga sessions, responding to instructors’ directions. Furthermore, group yoga enhances social opportunities and may mitigate the inherent tendencies toward social withdrawal often observed in children with ASD(Litchke et al., 2018 ). Yoga provides multiple reinforcements for social interaction, both with peers and yoga instructors. Social communication and interaction with peers can have a positive impact on the learning of children with ASD. In the study by Shanker & Pradhan ( 2023 ), the intervention began with a partner exercise and gradually increased to four, with children showing greater comfort performing yoga in a group setting. This facilitated a gradual transition from hyperarousal to relaxation, reducing social anxiety and fostering comfort and cooperation in group activities (Shanker & Pradhan, 2023 ). This review also has some limitations. First, sample sizes were often small, limiting the generalizability of the findings. Furthermore, the duration and frequency of interventions varied significantly across studies, making it difficult to compare results. The use of different assessment tools and the lack of standardized yoga protocols in some cases also limit the reliability of the conclusions. Conclusion The effects of yoga on children with ASD generally show positive outcomes, indicating that yoga can improve various aspects of functionality and behavior in these children. Specifically, improvements have been observed in areas such as atypical behaviors, irritability, motor skills, social communication, sleep disturbances, and gastrointestinal dysfunctions. Additionally, yoga appears to contribute to reducing the severity of autistic traits and enhancing physical fitness, including strength, balance, and flexibility. These findings highlight the effectiveness of yoga as a complementary intervention for children with ASD, which can be implemented both in school settings and specialized therapeutic programs. As a holistic mind-body intervention, yoga can exert beneficial therapeutic effects on the central and autonomic nervous systems, facilitating the regulation of stress responses and integrating multiple functions such as cognitive ability, coordination, attention, emotions, and sensory processing. 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Prev Cardiol 4(4):165–170. https://doi.org/10.1111/J.1520-037X.2001.00542.X Williams JHG, Whiten A, Singh T (2004) A systematic review of action imitation in autistic spectrum disorder. J Autism Dev Disord 34(3):285–299. https://doi.org/10.1023/B:JADD.0000029551.56735.3A Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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09:03:34","extension":"html","order_by":24,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":134637,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7842859/v1/b74b56efdab2c8e84b24bf70.html"},{"id":93571268,"identity":"18d304eb-440a-4d91-9a29-3a16da937be7","added_by":"auto","created_at":"2025-10-15 09:03:33","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":34187,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA flowchart\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7842859/v1/4d0f9a276513bf65645a899b.png"},{"id":93576106,"identity":"4680e9e9-7169-44e0-a489-e0bc185c792a","added_by":"auto","created_at":"2025-10-15 09:27:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":638062,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7842859/v1/851c2721-7be7-4d40-8099-e2cf61d023e2.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eEffects of Yoga on Social Communication, Sensorimotor Skills, Physical Health, and Symptom Severity in Children with Autism Spectrum Disorder: A Systematic Review\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAutism Spectrum Disorder (ASD) is a neurodevelopmental condition characterized by persistent deficits in social communication and interaction, alongside restricted and repetitive patterns of behavior, interests, or activities. ASD typically manifests early in development and can significantly impact daily functioning. (Maenner et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). It belongs to a spectrum of disorders that also includes Asperger\u0026rsquo;s syndrome, Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS), Rett syndrome, and Childhood Disintegrative Disorder (Narasingharao et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). The prevalence of ASD has increased in recent years, with current estimates indicating that approximately 1 in 44 children are diagnosed (Maenner et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe etiological factors associated with ASD are multifaceted and may include environmental influences, genetic predispositions, a family history of ASD, advanced maternal or paternal age, single-gene mutations, autoimmune conditions such as thyroid disorders or rheumatoid arthritis within the family, and complications during pregnancy (Narasingharao et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). ASD has a strong genetic component, with heritability estimates ranging from 64% to 91% (Tick et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Specific genetic mutations and syndromes, including fragile X syndrome, have been linked to the disorder. Additionally, prenatal and perinatal factors\u0026mdash;such as advanced parental age, low birth weight, and prenatal exposure to certain medications\u0026mdash;have been implicated in increasing ASD risk (Sandin et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Diagnosis is typically made based on behavioral observations and developmental history, often utilizing tools like the Autism Diagnostic Observation Schedule (ADOS) and the Autism Diagnostic Interview-Revised (ADI-R). Common symptoms include difficulty with reciprocal social interaction, delayed speech and communication skills, and sensory sensitivities (Okoye et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eASD is a neurological condition characterized by difficulties in social communication skills and the presence of stereotyped and repetitive behaviors (Kaur \u0026amp; Bhat, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Children with ASD often exhibit motor difficulties such as reduced balance and postural control, unsteady gait, poor coordination, as well as low proficiency in handwriting and fine motor skills (Bhat et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Kaur et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Specifically, the motor performance of children with ASD corresponds to that of typically developing children who are approximately half their chronological age (Staples \u0026amp; Reid, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). Additionally, motor delays are observed as early as the first year of life in infants later diagnosed with ASD, and the extent and severity of these delays appear to increase with development (Kaur et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Lloyd et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2013\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAdditionally, children with ASD exhibit difficulties with imitation, which are often considered part of a broader praxis disorder (Dewey et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2007\u003c/span\u003e; Mostofsky et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). Specifically, they may show spatial errors (e.g., incorrect positioning of a limb in space), movement reversals (e.g., shaking the hand with the palm turned inward), and errors involving the substitution of body parts for tools (e.g., performing a \u0026ldquo;scissor\u0026rdquo; movement using the index and middle fingers) (Dewey et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2007\u003c/span\u003e; Williams et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2004\u003c/span\u003e). These errors may be observed during the imitation of movements, following instructions, or using tools (Kaur \u0026amp; Bhat, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMotor difficulties and imitation impairments may have cascading effects on the social, communicative, and cognitive development of children with ASD (Dadgar et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; MacDonald et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). For example, children with limited motor skills might avoid playing with their peers, resulting in missed opportunities to develop social relationships (Radonovich et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Similarly, challenges in praxis and imitation can restrict a child's ability to acquire new functional skills, such as dressing and feeding themselves, as well as social skills like gestures and joint social interaction (Ingersoll \u0026amp; Meyer, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Therefore, it is clear that developing interventions that provide opportunities to improve motor skills and utilize them to enhance social-communicative abilities in children with ASD is especially important.\u003c/p\u003e\u003cp\u003eAdditionally, children with ASD often face physical challenges. Most of them experience sleep disturbances due to irregular sleep routines, such as inconsistent sleep times and frequent awakenings during the night, snoring, and mouth breathing while asleep. These issues can also contribute to various behavioral problems (Miano et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). Additionally, children with ASD often experience gastrointestinal issues such as bloating, food intolerances, intestinal inflammation, irritable bowel syndrome, diarrhea, gas, urinary and fecal incontinence, among others (Rao et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). Children with ASD who suffer from persistent gastrointestinal problems may not respond to any form of behavioral intervention unless these gastrointestinal issues are addressed first (Jyonouchi et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Up to 80% of children with ASD experience sleep disturbances and gastrointestinal dysfunctions, which are often not adequately understood by their parents (Gorrindo et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; McElhanon et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOver the past decades, yoga has become a popular complementary and alternative therapy used in a variety of cases (Kaur \u0026amp; Bhat, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Yoga, which incorporates body postures and breathing techniques, helps balance the autonomic nervous system, promoting a sense of well-being and providing significant benefits for both mental and physical health (Shanker \u0026amp; Pradhan, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Additionally, yoga affects various systems such as the motor system by improving flexibility, strength, and balance (Galantino et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2008\u003c/span\u003e); perceptual abilities through enhanced joint proprioception and kinesthesia (Mohanty et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2014\u003c/span\u003e); the cardiopulmonary system (Galantino et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2008\u003c/span\u003e); behavior by improving attention and alertness (Jensen \u0026amp; Kenny, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2004\u003c/span\u003e); as well as social-communication skills in children, including social interactions, speech, and emotional expression (Narasimhan et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Yoga-based activities are easy to learn and can be adapted according to each child\u0026rsquo;s age and functional level (Kaur \u0026amp; Bhat, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Η Yoga may contribute to the development of social skills such as imitation, communication abilities, eye contact, tolerance, and emotional regulation in children with ASD (Radhakrishna et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). Through various body movements and controlled breathing, yoga regulates elevated stress levels in children with ASD, affecting both their mind and body, and leading them to a state of calmness and relaxation (Shanker \u0026amp; Pradhan, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis systematic review aims to comprehensively examine and synthesize existing evidence on the effects of yoga on social communication skills, sensorimotor abilities, physical health, and symptom severity in children with ASD. The review endeavors to provide rigorously evidence-based conclusions regarding the efficacy of yoga as a therapeutic intervention to enhance the quality of life and functional capabilities of children with ASD.\u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eThis systematic review was conducted to evaluate the effectiveness of yoga as a therapeutic intervention for children and adolescents diagnosed with Autism Spectrum Disorder (ASD). The review was structured using the PICO framework. The population included individuals under 18 years of age with an ASD diagnosis. The intervention encompassed various forms of yoga employed as therapeutic approaches. Comparisons were made against either no intervention or alternative therapeutic methods. The primary outcomes assessed were social communication skills, sensorimotor abilities, physical health, and the severity of ASD symptoms.\u003c/p\u003e\u003cp\u003e This systematic review adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines to ensure a transparent and reproducible methodology (Page et al., 2021), and employed the Joanna Briggs Institute\u0026rsquo;s (JBI) Critical appraisal checklist for systematic reviews and research syntheses to minimize bias (Hilton, 2024). This review was registered in PROSPERO with ID number CRD420251152980.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEligibility Criteria\u003c/h3\u003e\n\u003cp\u003eThis review included studies that evaluated the effectiveness of yoga as a therapeutic intervention to improve social communication skills, sensorimotor abilities, physical health, and symptom severity in children with ASD. The assessment of the outcomes studied was based on the use of valid and standardized self-report tools or objective questionnaires. Eligible studies were limited to randomized and non-randomized controlled trials published in English up to August 2025. Non-interventional studies, reviews, case reports, opinion pieces, non-English publications, and studies lacking complete outcome data were excluded.\u003c/p\u003e\n\u003ch3\u003eSearch Strategy\u003c/h3\u003e\n\u003cp\u003eA comprehensive literature search was conducted in PubMed and CINAHL, utilizing a combination of MeSH terms and keywords such as \"yoga,\" \"autism spectrum disorder,\", \"effect\", \"children,\" and \"adolescents.\" Additional searches were performed in other databases and reference lists to ensure the inclusion of all relevant studies\u0026rdquo;. Boolean operators were employed to refine and optimize the search results. The search was limited to English-language studies involving human participants, published up to August 2025. Additionally, citation tracking and manual screening of reference lists from included articles were performed to ensure thorough coverage.\u003c/p\u003e\n\u003ch3\u003eStudy Selection\u003c/h3\u003e\n\u003cp\u003eTwo reviewers independently screened the titles and abstracts of all identified studies. The full texts of studies deemed potentially relevant were reviewed to determine their eligibility according to predefined inclusion criteria. Any disagreements were resolved through discussion with a third reviewer. The study selection process was documented using the PRISMA flow diagram.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eData Extraction\u003c/h3\u003e\n\u003cp\u003eA uniform data extraction tool was employed to gather detailed information on the studies\u0026rsquo; features, participant numbers, varieties of yoga practices used, assessed outcomes, and results concerning the therapeutic impact of yoga on ASD.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eData Synthesis\u003c/h2\u003e\u003cp\u003eDue to the considerable heterogeneity among study designs, intervention protocols, and outcome measures, conducting a meta-analysis was not feasible. Therefore, a narrative synthesis was undertaken with the aim of elucidating the effects of yoga on improving social communication skills, sensorimotor abilities, physical health, and symptom severity in children with ASD.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEthics\u003c/h3\u003e\n\u003cp\u003eAs this review analyzed previously published data, no primary data collection was involved. It was assumed that all included studies had obtained prior ethical approval.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe database searches yielded a total of 57 records, comprising 27 records from CINAHL and 30 records from PubMed. The abstracts were uploaded to Rayyan software, which identified 26 duplicates that were subsequently removed. Screening was conducted on 31 abstracts, leading to the manual exclusion of 17 abstracts. Of the 14 full-text articles sought, 10 were retrieved, as one could not be accessed. Following eligibility assessment, 6 articles were excluded due to irrelevance, leaving 7 studies that met the inclusion criteria. The included studies comprised 2 randomized controlled trials (RCTs) and 5 clinical trials. A detailed illustration of the study selection process is provided in the accompanying PRISMA flow diagram (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe studies included in this review were conducted in the United States (Kaur \u0026amp; Bhat, 2018; Hensel et al., 2023; Rosenblatt et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2011\u003c/span\u003e), India (Narasingharao et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Shanker \u0026amp; Pradhan, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), and Iran (Sotoodeh et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). They involved children and adolescents aged 3 to 16 years with a diagnosis of Autism Spectrum Disorder (ASD). To assess outcomes, these studies utilized a range of standardized and validated measurement tools. Motor skills were evaluated using the Bruininks-Oseretsky Test of Motor Proficiency \u0026ndash; 2nd Edition (BOT-2) (Kaur \u0026amp; Bhat, 2018). ASD symptom severity was measured through the Autism Treatment Evaluation Checklist (ATEC) (Sotoodeh et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Shanker \u0026amp; Pradhan, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Behavioral characteristics were assessed using the Behavioral Assessment System for Children \u0026ndash; 2nd Edition (BASC-2) and the Aberrant Behavior Checklist (ABC) (Rosenblatt et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Social communication skills were examined with the Social Responsiveness Scale-2 (SRS-2) (Shanker \u0026amp; Pradhan, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), while additional physical health indicators such as anthropometric data, balance, muscle strength, and flexibility were included in assessments by Hensel et al. (2023).\u003c/p\u003e\u003cp\u003eRosenblatt et al. (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) conducted a pilot study aimed at evaluating the therapeutic effects of yoga in children with ASD. The sample consisted of 24 children aged 3 to 16 years diagnosed with ASD, who participated in an eight-week multidimensional program combining yoga, dance, and music therapy based on the relaxation response (RR). The study outcomes were measured using the Behavioral Assessment System for Children, Second Edition (BASC-2) and the Aberrant Behavioral Checklist (ABC) (Rosenblatt et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Regarding the study results, significant improvements were recorded in the BASC-2 scores, mainly in children aged 5 to 12 years. Particularly noteworthy was the statistically significant change (p\u0026thinsp;=\u0026thinsp;0.003) in the \u0026ldquo;Atypicality\u0026rdquo; subscale, which evaluates core characteristics of the autism spectrum. As for the assessment with the ABC scale, none of the individual subscales showed statistically significant changes. However, a trend toward improvement was observed in the \u0026ldquo;Irritability\u0026rdquo; subscale of the ABC in school-aged children (p\u0026thinsp;=\u0026thinsp;0.06) (Rosenblatt et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2011\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eNarasingharao et al. (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) evaluated the effectiveness of a structured yoga intervention in addressing sleep problems, gastrointestinal disorders, and behavioral issues in children with ASD. The sample consisted of 61 children aged 5 to 16 years with ASD, along with their parents, who were divided into two groups: the intervention group (n\u0026thinsp;=\u0026thinsp;32) and the control group (n\u0026thinsp;=\u0026thinsp;29). The researchers developed a 61-item questionnaire, with 15 items assessing sleep disturbances (SQ1\u0026ndash;SQ15), 16 items evaluating gastrointestinal issues (nutrition and digestion) (FQ1\u0026ndash;FQ16), and 30 items focusing on behavioral problems (BQ1\u0026ndash;BQ30). The 75-minute yoga sessions took place between 9:30 a.m. and 10:45 a.m., shortly before school started. The yoga exercises were selected from the programs of the Integrated Application of Yoga Therapy (IAYT) of S-VYASA. After three months of regular yoga practice, significant improvements were observed in physiological issues such as sleep disturbances and gastrointestinal dysfunctions. In contrast, the control group showed no improvement. Furthermore, significant improvement was noted in all the behavioral questionnaire items (BQ1\u0026ndash;BQ30) in the yoga group, except for item BQ-26, which pertains to the children\u0026rsquo;s savant abilities \u0026mdash; that is, exceptional intelligence in specific areas \u0026mdash; which may require a longer intervention period with yoga for changes to become evident (Narasingharao et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSotoodeh et al. (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) examined the effect of a Yoga Training Program (YTP) on the severity of autism in children with High Functioning Autism (HFA). The sample consisted of 29 children aged 7 to 15 years, who were randomized into either the yoga group or the control group. Participants in the yoga group attended an 8-week yoga program (24 sessions). Parents or caregivers of the children completed the Autism Treatment Evaluation Checklist (ATEC) at the beginning and at the end of the intervention. The analysis results showed statistically significant differences between the two groups in all ATEC subscales, except for subscale I (speech/language/communication) (Sotoodeh et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eKaur and Bhat (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) evaluated the effect of a physiotherapy intervention based on creative yoga on motor skills and imitation abilities in children with ASD. The study sample consisted of 24 children with ASD, aged 5 to 13 years, who received either physiotherapy with yoga intervention (n\u0026thinsp;=\u0026thinsp;12) or an academic intervention (n\u0026thinsp;=\u0026thinsp;12) for 8 weeks. The Bruininks-Oseretsky Test of Motor Performance \u0026ndash; Second Edition (BOT-2) was used to assess motor skills, while imitation abilities were evaluated through known, educationally specialized actions: yoga poses for the yoga group and construction activities for the academic group. After the intervention, children in the yoga group showed improvement in gross motor skills (p\u0026thinsp;\u0026lt;\u0026thinsp;0.006) and bilateral coordination (p\u0026thinsp;\u0026lt;\u0026thinsp;0.006), according to BOT-2 results. Conversely, children in the academic group showed significant improvement in fine motor skills (p\u0026thinsp;=\u0026thinsp;0.03). Regarding imitation skills, both the yoga group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.02) and the academic group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.02) showed a reduction in imitation/performance errors during the execution of the specialized actions (yoga poses and construction activities, respectively). Additionally, children\u0026rsquo;s intelligence quotient (IQ) was positively correlated with improvements in fine motor skills in the academic group (p\u0026thinsp;=\u0026thinsp;0.02), but not in the yoga group (p\u0026thinsp;=\u0026thinsp;0.29), indicating that children with higher IQ in the academic group showed greater improvement in fine motor skills post-intervention compared to children with lower IQ. Furthermore, IQ was negatively correlated with improvements in imitation for the yoga group (p\u0026thinsp;=\u0026thinsp;0.02), but not for the academic group (p\u0026thinsp;=\u0026thinsp;0.1), suggesting that children with lower IQ showed greater improvement in imitation of poses following training (Kaur \u0026amp; Bhat, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn the randomized controlled trial by Shanker \u0026amp; Pradhan (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), the effect of integrating a yoga program into special schools on autism severity in children with ASD was examined. The sample consisted of 43 children aged 5 to 15 years with ASD, coming from four special schools, who were randomized into two groups: the yoga group (n\u0026thinsp;=\u0026thinsp;23), where children participated in daily 45-minute yoga sessions for 12 weeks, and the control group (n\u0026thinsp;=\u0026thinsp;20), where children did not participate in yoga and continued with other school activities. The intervention included a variety of relaxation exercises and dynamic practices, breathing exercises, asanas (body postures), pranayama (controlled breathing techniques), relaxation, and chants/mantras. The effectiveness of the intervention on autism severity was evaluated using the Autism Treatment Evaluation Checklist (ATEC), which was completed by parents before and after the intervention. The key characteristics of the participants did not differ significantly between groups: autism severity (p\u0026thinsp;=\u0026thinsp;0.96) and age (p\u0026thinsp;=\u0026thinsp;0.82). The yoga group showed a significant reduction in the total ATEC score over time (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This reduction was attributed to significant improvements in the subscales of speech/language/communication (p\u0026thinsp;=\u0026thinsp;0.011) and health/physical condition/behavior (p\u0026thinsp;=\u0026thinsp;0.049) (Shanker \u0026amp; Pradhan, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAdditionally, in another study by Shanker \u0026amp; Pradhan (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), the effect of school-based yoga on social responsiveness and problematic behavioral characteristics was examined in 43 children with ASD. The children\u0026rsquo;s teachers assessed social responsiveness and behavioral problems using the Social Responsiveness Scale-2 (SRS-2) and the Aberrant Behavior Checklist-2 (ABC-2) before and after the yoga intervention. Following the intervention, significant improvements were observed in the mean scores in the areas of social communication on the social responsiveness scale (p\u0026thinsp;=\u0026thinsp;0.021), irritability (p\u0026thinsp;=\u0026thinsp;0.041), and social withdrawal (p\u0026thinsp;=\u0026thinsp;0.047) in behavioral problems (Shanker \u0026amp; Pradhan, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSimultaneously, the study by Helsel et al. (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) evaluated the feasibility of remotely delivered yoga to improve four physical activity-related skills \u0026mdash; motor skills, strength, balance, and flexibility \u0026mdash; in adolescents with ASD. Of the 20 participants (mean age 13.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2 years, 60% boys), 19 completed the 12-week intervention and attended 83% of the scheduled yoga sessions. Overall, physical activity-related skills showed significant improvement before and after the intervention (p\u0026thinsp;=\u0026thinsp;0.005). Specifically, significant increases were observed in leg strength (12.5%, p\u0026thinsp;=\u0026thinsp;0.039), flexibility (40.3%, p\u0026thinsp;=\u0026thinsp;0.008), and dynamic balance on the right (11.1%, p\u0026thinsp;=\u0026thinsp;0.001) and left leg (8.1%, p\u0026thinsp;=\u0026thinsp;0.003) over the 12-week period (Helsel et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristics of the included studies\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAuthors (year publication)\u003c/p\u003e\u003cp\u003eCountry\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStudy design\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSample\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIntervention group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eControl group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOutcomes - Measures\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eResults\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eKaur \u0026amp; Bhat (2018)\u003c/p\u003e\u003cp\u003eUSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eNon-randomized clinical trial\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e24 children with ASD, aged 5\u0026ndash;13 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;24\u003c/p\u003e\u003cp\u003eYoga sessions included breathing exercises, imitative poses, partner poses, and relaxation techniques, alongside context-appropriate social activities designed to encourage greeting and farewell songs, touch/contact games, and visual engagement games. The yoga poses were organized around meaningful themes such as songs, stories, and games.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;24\u003c/p\u003e\u003cp\u003eAcademic activities: reading, arts and crafts, and building supplies such as Play-Doh, LEGO, and ZOOB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eBOT-2, Training-specific imitation test\u003c/p\u003e\u003cp\u003eBaseline and 8th week\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eFollowing the intervention, children in the yoga group demonstrated significant improvements in gross motor performance on the BOT-2 and exhibited fewer imitation/praxis errors when replicating training-specific yoga poses. Conversely, children in the academic group showed enhancements in fine motor performance on the BOT-2 and made fewer imitation errors during the completion of training-specific building tasks.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eFrequency: 4 sessions/ week (2 expert sessions and 2 parent sessions)\u003c/p\u003e\u003cp\u003eIntensity: 40 to 45 min for expert; 20 to 25 min for parent sessions\u003c/p\u003e\u003cp\u003eDuration: 8 weeks\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHensel et al (2023)\u003c/p\u003e\u003cp\u003eUSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNon-randomized clinical trial\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19 adolescents with ASD.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;19\u003c/p\u003e\u003cp\u003eThe yoga intervention was delivered to groups of adolescents with ASD (4\u0026ndash;6 per group) in their home remotely using Zoom\u003c/p\u003e\u003cp\u003eThirty-minute yoga sessions were delivered 3 times per week across the 12-week intervention.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFeasibility, Anthropometrics (Height, Weight, and Waist Circumference), Motor Skills, Muscular Strength, Static and Dynamic Balance, Flexibility, Physical Activity and Sedentary Time\u003c/p\u003e\u003cp\u003eAssessed before and after the intervention.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eSignificant improvements were observed over the 12-week period in leg strength (increased by 12.5%, p\u0026thinsp;=\u0026thinsp;0.039), flexibility (increased by 40.3%, p\u0026thinsp;=\u0026thinsp;0.008), and dynamic balance in both the right leg (improved by 11.1%, p\u0026thinsp;=\u0026thinsp;0.001) and left leg (improved by 8.1%, p\u0026thinsp;=\u0026thinsp;0.003).\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNarasingharao et al. (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2017\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eΙνδία\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNon-randomized clinical trial\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e61 children, aged 5\u0026ndash;16 years, with ASD.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;31\u003c/p\u003e\u003cp\u003eThe 75-minute yoga program took place between 9:30 a.m. and 10:45 a.m., just before school started. The yoga exercises were selected from the Integrated Application of Yoga Therapy (IAYT) programs of S-VYASA.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;29\u003c/p\u003e\u003cp\u003eNo intervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e61-item questionnaire developed by the researchers\u003c/p\u003e\u003cp\u003eCompleted by the parents before and after the intervention.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eSignificant changes were observed after the yoga intervention in three areas of concern: sleep problems, gastrointestinal problems, and behavioral problems.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRosenblatt et al (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2011\u003c/span\u003e)ΗΠΑ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eΠιλοτική κλινική \u0026micro;ελέτη\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24 children, aged 3\u0026ndash;16 years, with ASD.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eΝ\u0026thinsp;=\u0026thinsp;24\u003c/p\u003e\u003cp\u003e8-week multimodal yoga, dance, and music therapy program based on the relaxation response (RR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eBASC-2 και ABC\u003c/p\u003e\u003cp\u003eCompleted by the parents before and after the intervention.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eRobust changes were found on the BASC-2, primarily for 5\u0026ndash;12-year-old children.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSotoodeh et al (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2017\u003c/span\u003e)Ιραν\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRCT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29 children with ASD, aged 7\u0026ndash;15 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eΝ\u0026thinsp;=\u0026thinsp;15\u003c/p\u003e\u003cp\u003e24 sessions yoga (30-\u003c/p\u003e\u003cp\u003emin) for 8 weeks which include Warm up, Calming poses and Strengthening poses.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eΝ\u0026thinsp;=\u0026thinsp;14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eATEC\u003c/p\u003e\u003cp\u003eCompleted by the parents before and after the intervention.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eThere were significant differences between the two groups with regards to all ATEC sub-scores except ATEC I (speech/language/communication).\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eShanker \u0026amp; Pradhan (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eΙνδία\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eRCT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e43 children with ASD, aged 5\u0026ndash;15 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;23\u003c/p\u003e\u003cp\u003eDaily 45-minute yoga session for 12 weeks.\u003c/p\u003e\u003cp\u003eThe intervention consisted of various loosening and dynamic practices, breathing exercises, asanas (postures), pranayama (breathing techniques), relaxation, and chanting.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;20\u003c/p\u003e\u003cp\u003eNone intervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eATEC\u003c/p\u003e\u003cp\u003eCompleted by the parents before and after the intervention.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eThere was a significant reduction in the total ATEC scores overtime in the yoga group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eShanker \u0026amp; Pradhan (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eΙνδία\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSRS-2 and ABC-2\u003c/p\u003e\u003cp\u003eCompleted by the teachers before and after the intervention.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eSignificant changes were observed post-intervention in the mean scores of the social communication aspect in social responsiveness (p\u0026thinsp;=\u0026thinsp;.021), irritability (p\u0026thinsp;=\u0026thinsp;.041), and social withdrawal (p\u0026thinsp;=\u0026thinsp;.047) aspects of problem behaviors.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e\u003cp\u003eBOT-2: Bruininks-Oseretsky Test of Motor Proficiency\u0026ndash;2nd Edition; RCT: randomized clinical trial; ATEC: Autism Treatment Evaluation Checklist; BASC-2: Behavioral Assessment System for Children, Second Edition; ABC: Aberrant Behavioral Checklist; SRS-2: Social Responsiveness Scale-2; ABC-2: Aberrant Behavior Checklist \u0026minus;\u0026thinsp;2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOne of the findings of our systematic review was that yoga improves bilateral coordination and gross motor skills (Kaur \u0026amp; Bhat, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). The existing data on yoga interventions in children and adolescents with ASD remain limited. However, studies conducted with typically developing children suggest that yoga positively influences various motor domains, including strength, endurance, speed, flexibility, and coordination (Birdee et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; D\u0026rsquo;Souza \u0026amp; Avadhany, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Tran et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2001\u003c/span\u003e). Specifically, yoga appears to enhance motor function through several mechanisms, such as increased angiogenesis in muscle tissue, alternating activation of motor neurons to delay muscle fatigue, elongation of elastic connective and muscular tissues, and improved sensorimotor perception during movement execution (Galantino et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). dditionally, yoga contributes to the enhancement of joint proprioception\u0026mdash;that is, the ability to perceive the position and movement of limbs\u0026mdash;resulting in more efficient coordination among the moving parts of the body (Galantino et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2008\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAdditionally, yoga has been found to improve motor skills, strength, balance, and flexibility in adolescents with ASD (Helsel et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). It is worth noting that Kaur and Bhat (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) did not observe improvements in balance among children participating in the yoga intervention, a discrepancy that may be attributed to differences between the training activities and the assessment tasks. Specifically, the balance subtest of the BOT-2 includes a combination of static activities (e.g., one-leg stance) and dynamic activities (e.g., heel-to-toe walking), whereas the yoga intervention focused almost exclusively on static balance exercises (e.g., maintaining the tree pose). Furthermore, the subtest requires children to maintain poses both with and without visual guidance; however, during the yoga training, children practiced balance exclusively with visual feedback (Kaur et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAnother important finding of this review concerns the improvement of imitation skills in children participating in yoga programs (Kaur et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). ocial tracking skills \u0026mdash; that is, the ability to visually attend to and process the actions of social partners \u0026mdash; play a crucial role in effective imitation (Dziuk et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). Children with ASD often exhibit reduced eye contact and limited capacity to track others\u0026rsquo; actions, which negatively impacts their ability to observe and imitate social behavior patterns (Dawson et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2004\u003c/span\u003e). During yoga sessions, children were encouraged to observe and imitate the movements of the instructor or behavioral model (Kaur et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Consequently, these training activities contributed to enhancing social tracking skills and turn-taking, leading to improved ability to imitate both familiar and novel actions following the intervention (Mostofsky et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2006\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAnother finding was that yoga improves the severity of symptoms in children with ASD (Shanker \u0026amp; Pradhan, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Sotoodeh et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Specifically, in the study by Sotoodeh et al. (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2017\u003c/span\u003e), significant improvements were observed in all ATEC subscales except for subscale I (speech/language/communication) (Sotoodeh et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). n the other hand, in the study by Shanker \u0026amp; Pradhan (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), the integration of yoga into the school curriculum reduced the severity of symptoms in children with ASD, as a significant improvement was noted in subscale I of the ATEC (Shanker \u0026amp; Pradhan, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), This improvement in subscale I could be attributed to the unique method of sound repetition (chanting) during the yoga sessions. Children with ASD can imitate sounds such as \u0026ldquo;OM\u0026rdquo; and recite a few words when they receive daily stimulation through chanting. Additionally, the rhythmic buzzing of the \u0026ldquo;bee\u0026rsquo;s breath\u0026rdquo; humming enhances oral-motor and motor functions (Radhakrishna et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). Porter argues that yoga provides effective opportunities to improve both verbal and nonverbal communication through various forms of verbal and motor imitation of speech (Porter, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2013\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIt is worth noting that subscale II of the ATEC assesses social skills. In the study by Sotoodeh et al. (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2017\u003c/span\u003e), particular emphasis was placed on the child\u0026rsquo;s communication with the instructor through eye contact, aiming to improve one of the core communication skills (Sotoodeh et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Through this process, the children imitated the instructor and enjoyed the training sessions. Previous studies have shown that physical exercise interventions directly reduce social dysfunction. Participation in physical activities and sports plays a significant role in the psychosocial development of both typically developing children and children with developmental disorders (Movahedi et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Smith, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2003\u003c/span\u003e). Furthermore, the study by Shanker \u0026amp; Pradhan (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) found that yoga can improve certain aspects of social responsiveness (Shanker \u0026amp; Pradhan, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Yoga may support critical motor components of social reciprocity by encouraging imitation skills, which are fundamental for effective social communication. Yoga sessions subtly cultivate nonverbal communication skills, such as eye contact and facial expressiveness, through interactions with yoga instructors and peers (Radhakrishna et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Shanker \u0026amp; Pradhan, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAlso, subscale III of the ATEC assesses cognitive and sensory awareness. A yoga program can enhance self-awareness by focusing attention on bodily sensations. For example, when the instructor asks the child to perform the corpse pose, the child is encouraged to concentrate on another sense, such as hearing. Meditation techniques like yoga represent an art of efficient and adaptive management of neurobehavioral energy; yoga has the potential to activate or disengage conscious mental processes and sensory awareness(Khanna \u0026amp; Greeson, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2013\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOn the other hand, subscale IV of the ATEC evaluates health, physical condition, and behavioral issues, such as diarrhea, constipation, hyperactivity, eating disorders, sleep problems, and stereotypical behaviors in children. In the study by Sotoodeh et al. (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2017\u003c/span\u003e), the yoga program had a significant positive impact on these issues. Yoga exercises have a beneficial effect on functional abdominal pain, reducing both the intensity and frequency of pain episodes. Regular yoga practice for children with ASD can alleviate gastrointestinal discomfort and sleep disturbances (Narasingharao et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2017\u003c/span\u003e), while also decreasing hyperactivity and aggression (Rosenblatt et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Teaching yoga to children with ASD promotes learning inclusion by incorporating multisensory methods that encourage better responses. Children become more receptive to the rhythmic patterns and movements of yoga, regulating their anxiety levels toward a parasympathetic state. Regular yoga practice can lead children with ASD to experience calmness, resilience, and self-regulation. Thus, yoga can positively influence children with ASD by inducing a relaxation response that enhances their sense of health and well-being (Shanker \u0026amp; Pradhan, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAnother important finding was that yoga contributes to the improvement of behavioral problems in children with ASD. Specifically, in the study by Shanker \u0026amp; Pradhan (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), children who participated in the yoga program showed a significant reduction in irritability and social withdrawal compared to the control group (Shanker \u0026amp; Pradhan, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The guided rhythmic and repetitive movements of yoga serve as an effective regulatory strategy for children with ASD, helping them manage stress responses by promoting relaxation and reducing the need for problematic behaviors (Artchoudane et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). During the intervention, the children gradually improved their participation and active engagement in the yoga sessions, responding to instructors\u0026rsquo; directions. Furthermore, group yoga enhances social opportunities and may mitigate the inherent tendencies toward social withdrawal often observed in children with ASD(Litchke et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eYoga provides multiple reinforcements for social interaction, both with peers and yoga instructors. Social communication and interaction with peers can have a positive impact on the learning of children with ASD. In the study by Shanker \u0026amp; Pradhan (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), the intervention began with a partner exercise and gradually increased to four, with children showing greater comfort performing yoga in a group setting. This facilitated a gradual transition from hyperarousal to relaxation, reducing social anxiety and fostering comfort and cooperation in group activities (Shanker \u0026amp; Pradhan, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis review also has some limitations. First, sample sizes were often small, limiting the generalizability of the findings. Furthermore, the duration and frequency of interventions varied significantly across studies, making it difficult to compare results. The use of different assessment tools and the lack of standardized yoga protocols in some cases also limit the reliability of the conclusions.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe effects of yoga on children with ASD generally show positive outcomes, indicating that yoga can improve various aspects of functionality and behavior in these children. Specifically, improvements have been observed in areas such as atypical behaviors, irritability, motor skills, social communication, sleep disturbances, and gastrointestinal dysfunctions. Additionally, yoga appears to contribute to reducing the severity of autistic traits and enhancing physical fitness, including strength, balance, and flexibility. These findings highlight the effectiveness of yoga as a complementary intervention for children with ASD, which can be implemented both in school settings and specialized therapeutic programs.\u003c/p\u003e\u003cp\u003eAs a holistic mind-body intervention, yoga can exert beneficial therapeutic effects on the central and autonomic nervous systems, facilitating the regulation of stress responses and integrating multiple functions such as cognitive ability, coordination, attention, emotions, and sensory processing. Within a school environment, yoga can enhance the brain\u0026rsquo;s capacity to manage stress, improve cognitive functioning and concentration, and promote the acceptance of new information and skills by the children. The skills acquired through yoga can facilitate improvements in social responsiveness and reductions in problematic behaviors in children with ASD.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eArtchoudane S, Bhavanani A, Ramanathan M, Mariangela A (2019) Yoga as a therapeutic tool in autism: A detailed review. Yoga Mimamsa 51(1):3. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4103/YM.YM_3_19\u003c/span\u003e\u003cspan address=\"10.4103/YM.YM_3_19\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBhat AN, Landa RJ, Galloway JC (2011) Current perspectives on motor functioning in infants, children, and adults with autism spectrum disorders. 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J Autism Dev Disord 34(3):285\u0026ndash;299. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1023/B:JADD.0000029551.56735.3A\u003c/span\u003e\u003cspan address=\"10.1023/B:JADD.0000029551.56735.3A\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Autism Spectrum Disorder, Yoga, Children, Social Communication, Motor Skills, Complementary Therapy","lastPublishedDoi":"10.21203/rs.3.rs-7842859/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7842859/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eAutism Spectrum Disorder (ASD) is a neurodevelopmental condition characterized by persistent deficits in social communication, restricted and repetitive behaviors, and frequent comorbid challenges such as motor impairments, gastrointestinal dysfunction, and sleep disturbances. Yoga, a holistic mind\u0026ndash;body intervention, has emerged as a promising complementary therapy, yet evidence of its effectiveness in children with ASD remains fragmented.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e\u003cp\u003eThis systematic review aimed to synthesize current evidence on the effects of yoga interventions on social communication, sensorimotor abilities, physical health, and symptom severity in children and adolescents with ASD.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA systematic search of PubMed and CINAHL databases was conducted up to August 2025. Eligible studies included randomized controlled trials and clinical trials assessing yoga interventions in children\u0026thinsp;\u0026le;\u0026thinsp;18 years with ASD. Data were extracted on study characteristics, intervention protocols, and measured outcomes. Risk of bias was assessed using the Joanna Briggs Institute (JBI) critical appraisal tool. Due to heterogeneity, a narrative synthesis was undertaken.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eOf 57 records screened, 7 studies met inclusion criteria (2 RCTs, 5 clinical trials) conducted in the United States, India, and Iran, involving children aged 3\u0026ndash;16 years. Yoga interventions varied in duration and format (school-based, structured group programs, or remotely delivered). Findings demonstrated improvements in bilateral coordination, gross motor skills, balance, strength, and flexibility. Significant reductions were observed in autism symptom severity, irritability, social withdrawal, and behavioral dysregulation. Some studies reported improved sleep and gastrointestinal functioning. Social communication and imitation skills were also enhanced, with yoga supporting nonverbal communication, eye contact, and turn-taking.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eYoga appears to be an effective complementary intervention for children with ASD, with positive effects on motor, social, behavioral, and health outcomes. Despite encouraging results, evidence is limited by small sample sizes, diverse protocols, and heterogeneity of outcome measures. Standardized, large-scale randomized trials are needed to confirm these findings and guide integration of yoga into evidence-based ASD care.\u003c/p\u003e","manuscriptTitle":"Effects of Yoga on Social Communication, Sensorimotor Skills, Physical Health, and Symptom Severity in Children with Autism Spectrum Disorder: A Systematic Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-15 09:03:29","doi":"10.21203/rs.3.rs-7842859/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b0c96bec-3612-43d3-9e20-b901ad1deb0e","owner":[],"postedDate":"October 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-15T09:03:29+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-15 09:03:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7842859","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7842859","identity":"rs-7842859","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}