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VOLUME 7, ISSUE 1 

 2024 
 

RESEARCH ARTICLE 

 

Mayo A.L, Cheung B, Li J, Jean S, Vijayakumar A, Hitzig S.L, et al. Feasibility of a yoga intervention in an inpatient limb loss rehabilitation program. Canadian 

Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 1, No.6. https://doi.org/10.33137/cpoj.v7i1.43896  

 

https://jps.library.utoronto.ca/index.php/cpoj/index
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https://doi.org/10.33137/cpoj.v7i1.43896


 

1 

Mayo A.L, Cheung B, Li J, Jean S, Vijayakumar A, Hitzig S.L, et al. Feasibility of a yoga intervention in an inpatient limb loss rehabilitation program. Canadian 
Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 1, No.6. https://doi.org/10.33137/cpoj.v7i1.43896  

 

 

RESEARCH ARTICLE 

 

FEASIBILITY OF A YOGA INTERVENTION IN AN INPATIENT LIMB LOSS REHABILITATION 

PROGRAM 

Mayo A.L1,2 *, Cheung B1, Li J1, Jean S3, Vijayakumar A1, Hitzig S.L1,4, Simpson R2,5 

1. St. John’s Rehab Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada. 
2. Temerty Faculty of Medicine, University of Toronto, Toronto, Canada. 
3. Department of Medicine, University of Montreal, Montreal, Canada. 
4. Department of Occupational Science and Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada. 
5. Toronto Rehabilitation Institute, University Health Network, Toronto, Canada. 
 
  
 

 

 

 

  

 

 

 

 

 

 

 

 

 

 

INTRODUCTION   

Lower extremity amputation (LEA) is associated with poor 

balance, decreased physical strength, and decreased 

mobility, as well as high rates of depression, and social 

isolation.1-6 Similar to global trends,7,8 the leading cause of 

LEA in Canada are dysvascular in nature due to 

complications of peripheral arterial disease (PAD) and/or 

diabetes mellitus (DM).9-11  

 

 

Other causes of LEA (non-dysvascular) include trauma, 

cancer or non-diabetes/PAD related infection and/or 

ischemia.12-15 Patients with dysvascular LEA often have a 

high number of co-morbidities,16 which requires them to 

adopt a chronic condition management approach while 

adapting to life with a new physical disability.17 In particular, 

residual limb pain and phantom limb pain (PLP) are 

commonly experienced post-amputation,18-20 for both 

dysvascular and non-dysvascular LEA (e.g., trauma, 

cancer, etc.), and can further reduce physical function and 

wellbeing.21-23 As a result of reduced mobility and health 

challenges, individuals with LEA have high rates of 

sedentary lifestyles,24 which can exacerbate their chronic 

health conditions, such as heart disease, PAD and DM; 

thereby elevating their risk for mortality.25 

 
OPEN  ACCESS 

ABSTRACT 

BACKGROUND: Limb loss is a life-changing event, which may be associated with limited mobility, pain, and 

low mood. Yoga interventions have been found to be beneficial for improving emotional wellness and pain in 

other patient populations. The benefits of including yoga in limb loss rehabilitation have not been well studied. 

OBJECTIVE: The purpose of this study was to determine if an adaptive yoga program would be suitable for 

individuals with newly acquired limb loss in a rehabilitation program.  

METHODOLOGY: A yoga video was co-designed by rehabilitation clinicians and a limb loss patient partner 

certified in yoga instruction. Surveys were used to collect patients’ socio-demographics and previous yoga 

experience. Participants completed a therapist guided group yoga video session, and then given online 

access to practice independently. Post-yoga participation surveys and qualitative interviews were conducted 

with patients to determine acceptance and feasibility of the yoga intervention. 

FINDINGS: Twenty-four participants with lower limb amputation(s) were approached to participate. The 

majority of participants (63%) had dysvascular-related amputations. Nineteen out of 24 recruited patients 

(79%) completed the yoga video session and the pre-yoga survey. Sixteen out of 19 participants completed 

the post-yoga survey, and eight also completed a qualitative interview. Five had previously undertaken yoga 

but rated themselves as novices. All participants felt that yoga was beneficial, easy to complete, and should 

be included in rehabilitation. Participants found yoga to be relaxing and some noted reduction in pain. Most 

preferred to do yoga in a group. Five out of eight patients (63%) interviewed continued to do the yoga video 

independently in hospital and post-discharge. Challenges with the yoga intervention included lack of a quiet 

yoga space, and dedicated time given other appointments/priorities.  

CONCLUSION: Yoga was widely accepted by the inpatient limb loss population. Yoga may complement 

traditional limb loss rehabilitation by providing patients a relaxing experience; however, further research is 

needed. 

 

 

ARTICLE INFO 

Received: August 26, 2024 

Accepted: October 7, 2024 

Published: October 24, 2024 
 

CITATION 

Mayo A.L, Cheung B, Li J, Jean S, 

Vijayakumar A, Hitzig S.L, et al. 

Feasibility of a yoga intervention 

in an inpatient limb loss 

rehabilitation program. Canadian 

Prosthetics & Orthotics Journal. 

2024; Volume 7, Issue 1, No.6. 

https://doi.org/10.33137/cpoj.v7i1

.43896 

KEYWORDS 

Yoga, Qualitative, Survey, Pain, 

Amputation, Rehabilitation, Lower 

Extremity Amputation 

 

* CORRESPONDING AUTHOR: 

Dr. Amanda L. Mayo,  

Affiliation: St. John’s Rehab Research Program, Sunnybrook Research 
Institute, Toronto, Canada. 

E-Mail: amanda.mayo@sunnybrook.ca 

ORCID ID: https://orcid.org/0000-0001-7061-2529 

 

Journal Homepage: https://jps.library.utoronto.ca/index.php/cpoj/index 

Volume 7, Issue 1, Article No.6. 2024 

 

 

https://doi.org/10.33137/cpoj.v7i1.43896
https://doi.org/10.33137/cpoj.v7i1.43896
https://doi.org/10.33137/cpoj.v7i1.43896
mailto:amanda.mayo@sunnybrook.ca
https://orcid.org/0000-0001-7061-2529
https://jps.library.utoronto.ca/index.php/cpoj/index


 

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Mayo A.L, Cheung B, Li J, Jean S, Vijayakumar A, Hitzig S.L, et al. Feasibility of a yoga intervention in an inpatient limb loss rehabilitation program. Canadian 
Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 1, No.6. https://doi.org/10.33137/cpoj.v7i1.43896  

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X FEASIBILITY OF A YOGA INTERVENTION IN AN INPATIENT LIMB LOSS REHABILITATION PROGRAM 

Mayo et al., 2024 

In Canada, limb loss rehabilitation programs traditionally 

include physiotherapy, occupational therapy, and/or 

prosthetic training.9 Inpatient rehabilitation programs are 

typically accessed by patients with newly acquired limb loss 

and/or for first time training with a prosthesis.9,17 It is known 

that patients with limb loss have high rates of adjustment 

disorder, depression and/or anxiety in the first months 

following amputation when they are accessing rehabilitation 

services,4 and that patients often feel that their mental 

health needs are not prioritized.26  Consequently, there is a 

need for wellness programs in Canadian limb loss 

rehabilitation programs, which are currently lacking.4,26 

Yoga has been found to be a promising intervention to 

improve health and wellness that can be adapted for people 

with physical disabilities. It has been found to improve mood 

and pain in a variety of patient populations, such as those 

with fibromyalgia, multiple sclerosis, and spinal cord 

injury.27-30 Yoga is an ancient practice with a focus on 

physical, mental, emotional, and spiritual health.31  

Developed in India, yoga has eight domains or “limbs,” 

which consist of yama (universal ethics), niyama (individual 

ethics), asana (physical postures), pranayama (breath 

control), pratyahara (control of the senses), dharana 

(concentration), dhyana (meditation), and samadhi (bliss).31 

Most healthcare yoga interventions have focussed on use 

of physical postures,31 breath control,32 and/or meditation.33 

Qualitative reports of different patient groups who have 

participated in yoga often share positive reactions to the 

intervention,34-36 and that it had some advantages to other 

forms of exercise (e.g., less fatiguing, less discomfort).33 

Adaptive yoga programs for individuals with limb loss exist37 

but its benefits have not been well studied, nor has yoga 

been incorporated regularly into limb loss rehabilitation 

programs. Given the high rates of sedentary lifestyles, pain, 

and psychological distress post-limb loss, yoga may be a 

promising intervention that can be introduced early in the 

rehabilitative process. As well, people with limb loss are 

known to have difficulty accessing community services, 

such as exercise programs due to lack of transportation, 

financial costs, and/or lack of suitable facilities.38,39 Hence, 

Adaptive yoga may offer patients with an exercise option 

they can pursue if other factors (i.e., income, transportation) 

create barriers to leisure-time physical activity. 

The original purpose of this study was to determine if a yoga 

for limb loss in-person program could be incorporated into a 

LEA inpatient rehabilitation program. However, due to the 

COVID-19 pandemic and episodes of restricted group 

exercise, the focus of the study was shifted to determine the 

feasibility and acceptability of using an online adaptive yoga 

video intervention among patients with LEA. We 

hypothesised that individuals with LEA would be interested 

in participating in an online yoga video program, and that it 

would be an acceptable addition to traditional limb loss 

rehabilitation programs. 

METHODOLOGY 

A mixed methods study design was used to test the 

feasibility and acceptability of an adaptive online yoga 

intervention for inpatient rehabilitation patients with newly 

acquired limb loss. The main research question was to 

determine if an adaptive virtually-delivered yoga program 

for limb loss is feasible to implement in a rehabilitation 

inpatient setting, and to determine if the program would be 

well-received by participants. Post-yoga Likert scale 

intervention surveys were used to determine participant 

acceptance of, and experiences with the adapted yoga 

program. Semi-structured interviews were conducted to 

explore participant thoughts on perceived benefits, what is 

needed to improve the program, and to gather other 

suggestions for making the yoga intervention more 

accessible to the wider limb loss community. 

Participants 

The inclusion criteria for the study were English-speaking 

adult patients with LEA of any etiology (dysvascular, 

trauma, cancer, etc.) admitted to the Inpatient Amputee 

Rehabilitation Unit at Sunnybrook St. John’s Rehab 

Hospital in Toronto, ON, Canada. To take part, participants 

were required to be medically cleared physically and 

cognitively to be able to participate in the adaptive online 

yoga intervention by the unit’s physical medicine and 

rehabilitation physician (Physiatrist). In addition, 

participants needed to have internet access in their homes, 

a device that would enable them to access the adapted 

online yoga intervention, and were able to undergo the 

study assessments. This study received ethics approval by 

the Research Ethics Board of the Sunnybrook Health 

Sciences Centre (REB #5227). 

Adaptive Yoga Intervention 

The yoga intervention was designed by our team of 

physiatrists with expertise and training in yoga and LEA 

(Mayo A.L, Simpson R), as well as by a physiotherapist 

(Cheung B) and an occupational therapist (Li J) with LEA 

expertise. The basis for the program was established by 

reviewing Marsha Danzig’s Yoga4Amputee 

(https://www.yogaforamputees.com) instructor training 

materials,37 and by consulting with a study partner, who is a 

person with LEA (Hauer, L) and a certified yoga instructor. 

To accommodate individuals with new LEA who may not yet 

have a prosthesis, a chair-based yoga program was 

created. The created video was 45 minutes, and the 

instructor for the video yoga session was our patient partner 

with LEA. The yoga video was made available online on a 

YouTube channel, which was only accessible to those who 

were provided a link for viewing. The physiotherapist 

(Cheung B) and occupational therapist (Li J) on our study 

team completed online training provided by Yoga for 

Amputees (https://www.yogaforamputees.com/classes-

training) to learn the yoga exercises. These therapists 

https://doi.org/10.33137/cpoj.v7i1.43896
https://www.yogaforamputees.com/
https://www.yogaforamputees.com/classes-training
https://www.yogaforamputees.com/classes-training


 

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Mayo A.L, Cheung B, Li J, Jean S, Vijayakumar A, Hitzig S.L, et al. Feasibility of a yoga intervention in an inpatient limb loss rehabilitation program. Canadian 
Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 1, No.6. https://doi.org/10.33137/cpoj.v7i1.43896  

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X FEASIBILITY OF A YOGA INTERVENTION IN AN INPATIENT LIMB LOSS REHABILITATION PROGRAM 

Mayo et al., 2024 

provided orientation to study participants, and supervised 

participants who took part in a group video session.  

Participants completed the yoga video session in groups of 

2-4 during their inpatient amputee rehabilitation admission.  

Once the group video session was completed participants 

were given the YouTube link so they could continue to 

participate in yoga independently.  

Procedure 

Admitted patients with LEA to St. John’s Rehab Hospital 

who met the inclusion criteria were informed about the study 

by a member of their rehab care team (therapist or 

physician). If the participants wanted to learn more, the 

study coordinator followed-up and obtained informed 

consent for those participants who agreed to participate. 

Twenty-four participants were recruited into this study 

between August 2022 and June 2023. A study flow-chart is 

illustrated in Figure1. 

Prior to completing the yoga session, participants 

completed a Likert-scale survey comprised of 10 questions 

that collected data on socio-demographics, previous yoga 

experiences, and digital literacy (Figure 2). To understand 

more in-depth the individual experiences of participants with 

the yoga intervention, participants were requested to take 

part in a post-yoga survey, and in a semi-structured 

interview. The interview incorporated the following five 

questions:   

1: Why were they interested in participating in the program? 

2: What concerns, if any, did they have about participating 

in an online yoga intervention? 

3: What aspects they enjoyed or did not like? 

4: Suggestions for improvement? 

5: Any other insights about promoting yoga to the limb loss 

community? 

 

These interviews were conducted over phone or by Zoom 

and ranged from 10-30 minutes. Interviews were then 

transcribed verbatim for narrative analysis. 

Analysis 

Descriptive statistics and frequencies were used to analyze 

the data. To understand acceptability and feasibility of the 

adaptive online yoga intervention, the rate of yoga 

participation was calculated, which included the ability of 

participants to complete the video in the group session at 

the inpatient rehabilitation setting, and independent use of 

the yoga video post group session was calculated. For the 

interview data, a narrative research approach40-42 was taken 

to highlight participant experience and feedback regarding 

their attitudes about yoga, its’ perceived benefits, and 

recommendations for improvement. Study team members 

(Vijayakumar A, Mayo A.L) coded responses and identified 

themes from the interviews.  Given that the interviews were 

relatively short (10 – 30 minutes), a descriptive narrative 

summative approach was determined to be sufficient to 

obtain critical insights about the yoga intervention. To help 

illustrate the main findings of the interview data, illustrative 

quotes with key participant descriptors are provided.  

 

 

Figure1: Study protocol flow chart. 

RESULTS 

Of the twenty-four participants who were deemed eligible 

and approached to participate in the study, 19 agreed to 

participate in the yoga intervention (79% enrollment rate). 

All of the participants were those with a newly acquired LEA 

within the past three months, with one patient who was 

admitted for a second amputation with history of a 

contralateral amputation the year prior.  Seven (37%) had a 

traumatic etiology, and the rest (63%) had a dysvascular 

etiology. Four participants were female (21%) and 15 (79%) 

were male. Participants’ ages ranged from 25 to 85 years 

old, with an average age was 58.9 years (SD=18.9). Only 

four of the participants (21%) had participated in yoga 

before the study, and all these participants rated 

themselves as novice level yoga participants.  In terms of 

digital literacy, the majority self-rated themselves as having 

good levels of literacy (68%), with only two rating 

themselves as being very good or excellent (11%), and the 

rest stating it was fair or poor (21%). The complete 

demographics of the participants, self-rated technology 

skills and yoga experience are outlined in Table 1. 

Of the 19 participants that participated in the adaptive yoga 

intervention, 16 (84%) completed the post-yoga survey 

(Appendix  A), while 3 were unable to complete it due to 

being discharged from inpatient rehabilitation or declined to 

complete. Post-yoga survey results are illustrated in  

Figure 2. The results of the post-yoga survey report that the 

majority participants found yoga to be a positive calming 

experience. All but one yoga participant (95%) were 

comfortable doing yoga and only 2 of the 16 (13%) 

respondents stated they did not wish to do yoga again. All 

participants found the video easy to complete. 

Participants 

recruited into the 

study 

Group yoga 

video session 

Post-yoga survey 

+/- interview 

Pre-yoga survey 

(if consent 

obtained) 

https://doi.org/10.33137/cpoj.v7i1.43896


 

4 

Mayo A.L, Cheung B, Li J, Jean S, Vijayakumar A, Hitzig S.L, et al. Feasibility of a yoga intervention in an inpatient limb loss rehabilitation program. Canadian 
Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 1, No.6. https://doi.org/10.33137/cpoj.v7i1.43896  

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X FEASIBILITY OF A YOGA INTERVENTION IN AN INPATIENT LIMB LOSS REHABILITATION PROGRAM 

Mayo et al., 2024 

Eight (42%) yoga participants completed post-yoga semi-

structured interviews in addition to the post-yoga survey via 

phone or Zoom. Key themes that were identified from the 

transcripts were openness to yoga, calming/relaxing 

benefits, peer support, and need for a dedicated yoga space 

and time in rehabilitation. 

 Expectations and Openness to Yoga 

Most of the participants did not have any pre-set 

expectations of taking part in yoga, and indicated they 

joined to just learn more about it and how it may help them 

to stay more active. For instance, one person stated: “I 

didn’t have any expectations or hopes, to be honest, I was 

just trying it out.” (Male, 25 years, Left BKA), with others 

commenting:  

“I just want to experience what yoga is.” (Male, 57 years, 

Right AKA) 

“So, I was actually very open to it. I feel it helped that I had 

a good relationship with the roommate at the time I had, so 

it was easier to get involved, so it made it even more 

enjoyable and comfortable to go to, because you had a 

familiar companion and a friend.” (Male, 39 years, Left 

BKA). 

Once tried, however, participants stated they would like 

more yoga sessions to participate in during rehabilitation.   

Therapeutic Benefits 

In terms of the perceived therapeutic benefits, all eight 

participants found the yoga session calming. One patient 

who had experienced recent trauma found the session to be 

relaxing where he stated: “Honestly, I liked the way it went. 

Just in a room, quiet, I was at peace.” (Male, 25 years, Left 

BKA). As well, participants felt it complimented their formal 

rehabilitation by offering gentler exercises, stretching, and 

teaching breathing techniques. One person commented 

that compared to their physiotherapy sessions, yoga was 

not painful at all. Other specific aspects that participant 

enjoyed were the stretching:  

“Physically, I love the stretches. I love the way I feel limber, 

but comfortable. Because when you’re going through this 

process, you’re using other muscles to compensate for your 

balance, just your motion, how you do day-to-day stuff. 

You’re using different parts of your back muscles that you 

don’t use daily, so you get tight and crampy. So, the 

stretching from the yoga was great for that.” (Male, 74 years, 

AKA and BKA) 

Overall, all the participants enjoyed the yoga video, felt safe 

completing the video, and were happy they participated in 

the program. 

Group in Setting with Peers 

Participants appreciated having a peer limb loss instructor 

for the video since they felt it modeled ways on how they 

could move with their amputation. In general, the ability to 

connect with peers was highly valued, with six of the eight 

(75%) participants rating they would benefit the most from 

yoga doing it in a group setting. One person shared: 

“Socially. Yes, I knew the guys in there. Maybe I met a 

couple guys in there that weren't there before. So, yes, there 

are benefits of that” (Female, 74 years, Left BKA). Overall, 

it provided a number of social opportunities to patients, and 

Table 1: Demographics of the study population. 

Age Sex Level of education Etiology 
Level of 

amputation 
Technology 

Skills 
Yoga 

experience 
Yoga level 

59 Male College Trauma BKA* Good No N/A 

25 Male Some college Trauma BKA Good No N/A 

46 Female High school Trauma AKA** Good No N/A 

68 Male College Dysvascular BKA Very Good No N/A 

39 Male Some college Trauma BKA Good Yes Novice 

57 Female High school Trauma AKA Fair Yes Novice 

68 Female Some high school Dysvascular AKA Poor No N/A 

31 Male High school Dysvascular BKA Good No N/A 

81 Male Some high school Dysvascular AKA Fair No N/A 

85 Male High school Dysvascular AKA Good No N/A 

69 Male College Dysvascular BKA Fair No N/A 

28 Male High school Trauma AKA Good Yes Novice 

58 Male Some high school Dysvascular BKA Good No N/A 

74 Male University Trauma AKA Good Yes Novice 

50 Male High school Dysvascular AKA Good No N/A 

74 Male High school Dysvascular BKA Good No N/A 

83 Male High school Dysvascular BKA Good No N/A 

48 Male College Dysvascular BKA Excellent Yes Novice 

76 Female University Dysvascular AKA/BKA Good No N/A 
 

*Below-the-knee amputation (BKA)     ** Above-the-knee amputation (AKA) 

 

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Mayo A.L, Cheung B, Li J, Jean S, Vijayakumar A, Hitzig S.L, et al. Feasibility of a yoga intervention in an inpatient limb loss rehabilitation program. Canadian 
Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 1, No.6. https://doi.org/10.33137/cpoj.v7i1.43896  

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X FEASIBILITY OF A YOGA INTERVENTION IN AN INPATIENT LIMB LOSS REHABILITATION PROGRAM 

Mayo et al., 2024 

highly beneficial for receiving peer support. Importantly, one 

participant (Male, 25 years, BKA) commented that his post-

traumatic stress disorder (PTSD) made him unable to focus 

on yoga if he was alone.  

Yoga Post-Discharge 

Five out of the eight (63%) interviewed participants 

continued to do the yoga video after the group session while 

still in inpatient rehabilitation and at home. Participants 

completing the video independently were able to access the 

video without issues. Two of the home participants felt yoga 

was better while admitted to rehabilitation because there 

were more distractions at home, and no one to supervise 

them or do yoga with at home.  

“That's the difficult part because now you've changed 

environments. Unless people really find it beneficial to them 

and necessary, they're not going to follow. Perfect example, 

right here. And that's the way it will go unless they have had 

enough sessions that they see how the real long-term 

benefit of this. One, two or three sessions.” (Female, 74 

years, Right AKA). 

Hence, there were mixed findings regarding participants’ 

willingness to continue with yoga once discharged home, 

and that some participants reported they may be more 

inclined to participate in yoga more independently if they 

were reminded or coached to do so.  

Feedback and Recommendations  

Many participants stated the chosen yoga room (unit patient 

education room) was not ideal for the intervention. One 

person commented: “Like I said, probably a proper room, to 

put the people on a mindset, like rest. Like for the people 

feel more rest and focus on the class.” (Male, 28 years, 

Right AKA). As well, all eight interviewed participants’ 

desired yoga to be a scheduled session in regular 

rehabilitation programming. Many participants wanted to do 

scheduled yoga at least once a week.  

“Two times a week was pretty cool. It wasn’t a big group, so 

I think it worked for that. I think as a group gets bigger, you 

can have an A group or B group, like a morning group, 

afternoon group. I don’t know, something like that.” (Male, 

39 years, Left BKA). 

Other suggestions by participants were to have pamphlets 

or information packages to give to patients before they 

enroll, and that a mix of in-person and online sessions would 

be preferred, with one person commenting: “Well, I'm still 

old school, but I still like the in person and it's more personal. 

Even if you got six or eight people that are with you, it's more 

personal if you got an instructor there.” (Female, 74 years, 

Right AKA). As well, issues of digital literacy and access 

were raised as potential barriers.   

DISCUSSION 

The purpose of the present study was to explore the 

feasibility and acceptability of an adapted online yoga video 

program. Based on our findings, it appears there was a high 

degree of interest in exploring yoga given that 79% of 

approached participants wanted to learn more. As well, 

despite our participants having little or no experience with 

yoga, they were enthusiastic about participating in the 

intervention based on our survey and qualitative data; with 

many of them reporting to find it beneficial for their 

wellbeing. This finding is similar to other studies exploring 

yoga in other patient populations. For instance, one study 

that piloted an adapted yoga program for spinal cord injury 

patients had qualitative reports by patients stating they had 

high satisfaction with the program, that it helped them with 

 

Figure 2: Post-yoga survey results (n =16 participants). 

I felt calm & 

peaceful while 

doing yoga 

The yoga 

practice 

was easy to 

complete 

I felt pain 

during the 

yoga 

practice 

Yoga 

improved 

the way I 

feel  

I felt anxious 

during the 

yoga 

practice 

I would 

recommend 

yoga to other 

patients 

I would 

like to do 

yoga 

again 

I felt safe 

while doing 

yoga 

I felt 

overwhelmed 

by including 

yoga practice 

on top of my 

regular 

therapy 

I felt 

comfortable 

while doing 

yoga 

Strongly Disagree / Disagree Neutral Agree / Strongly Agree 

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6 

Mayo A.L, Cheung B, Li J, Jean S, Vijayakumar A, Hitzig S.L, et al. Feasibility of a yoga intervention in an inpatient limb loss rehabilitation program. Canadian 
Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 1, No.6. https://doi.org/10.33137/cpoj.v7i1.43896  

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X FEASIBILITY OF A YOGA INTERVENTION IN AN INPATIENT LIMB LOSS REHABILITATION PROGRAM 

Mayo et al., 2024 

experiences of the self and relaxation, and helped with pain 

relief.28 Similar to other studies on other populations where 

patients noting yoga had advantages over other forms of 

exercise,33 our participants’ commented that participating in 

yoga was less strenuous than other activities typical of 

inpatient rehabilitation (e.g., physiotherapy) and it may be 

that relaxation is a modality underutilized in current rehab 

programming for LEAs.  

Of the patients interviewed, 5/8 (63%) continued the yoga 

intervention practice beyond the study intervention session. 

Frequent practice of yoga has been associated with 

physical, emotional, and mental health benefits.43 Studies 

exploring the impact of yoga often do so over a series of 

sessions. For instance, a recent randomized controlled trial 

that tested the benefits of yoga in a traumatic LEA 

population found that those (n=24) who took part in the 18 

week yoga intervention (daily 30 minute yoga session; 

including unsupervised sessions) yielded significant 

improvements in overall quality of life, as well as in physical, 

psychological and environmental domains of wellbeing 

compared to a group receiving usual prosthetic and 

rehabilitation treatments without yoga (n=23). These effects 

were detected as early as six weeks.44 Our yoga intervention 

showed promise in being a suitable adjunct activity to 

inpatient rehabilitation, but our participants indicated they 

would like more frequent yoga sessions.  Similar findings for 

more frequent sessions have been noted in other yoga 

studies.36,43 Integration of yoga practice into regular 

rehabilitation programming would appear to benefit 

participants but a suitable quiet space, yoga content, and 

scheduling of yoga around other rehab activities would be 

needed.    

Data on the benefits of yoga for dysvascular LEA patients, 

however, is needed, and the nuances and appropriateness 

of yoga for trauma populations requires further attention.  

For instance, one of our participants with a traumatic 

etiology noted that doing yoga on his own triggered his 

PTSD. PTSD is a common issue following major trauma, 

and is associated with a variety of symptoms, including 

intrusions (e.g., unwanted flashbacks), engaging in 

avoidant behaviors to avoid trauma reminders, negative 

alterations in mood and cognition, and hypervigilance.45  

There is evidence that mindfulness-based approaches 

(encouraging of fostering nonjudgment and acceptance of 

one’s thoughts and emotions as they occur in the present 

moment),46 which yoga interventions sometimes integrate 

through the meditation component, are not well-suited for 

trauma populations if not properly introduced or monitored.  

For some persons with PTSD, mindfulness-based 

approaches may lead to increased distress, especially 

individuals who are prone to flashbacks, rumination, or are 

easily triggered by their trauma memories.47 Thus, although 

adapted yoga holds promise for people with LEA, like 

Mindfulness-based approaches, it too may need further 

adaptation to ensure it is ‘trauma sensitive’. 

Not surprisingly, participants were interested in undertaking 

yoga in a group and appreciated having the online video 

being led by someone with limb loss. In one qualitative study 

exploring facilitators and barriers to physical activity, 

participants (N=33) commented about the importance of 

social support and being surrounded by peers with a shared 

mutual experience of the impact of limb loss.38 Hence, 

participating in a group of peers that was led, albeit 

asynchronously, by a peer was likely a motivating factor for 

wanting to take part in the intervention.  

Limitations 

There are several limitations to the present study.  First, the 

original purpose was to do an in-person yoga program at 

our inpatient setting. Unfortunately, our study was set to 

commence just as the COVID-19 pandemic occurred, which 

required us to delay the start of the program, and then to 

modify it to minimize the spread of potential infection. This 

re-adjustment led to the creation of an online video whereby 

our team was able to introduce the yoga intervention by a 

yoga trained physiotherapist and occupational therapist, 

which was then pursued by participants on their own accord.  

Unfortunately, we were only able to create a 45-minute 

session video, and did not collect data on efficacy of the 

program. This was not pursued due to our initial desire to 

create a suitable adapted yoga program that had basis for 

the limb loss population.37 As well, our emphasis was on 

feasibility and acceptability, and therefore we focused on 

those metrics as the starting point for the development of 

the intervention. Our data indicates that an adapted online 

yoga video was feasible to implement in our inpatient 

setting, but its’ broader feasibility cannot be determined 

based on our available data. Despite the limitations of the 

study, it does appear that yoga was deemed acceptable by 

our participants through the ratings on the survey and by 

their qualitative reports.  

Future work 

Future work should explore clinical efficacy via a more 

robust controlled trial for LEA populations as well as hybrid 

or tele-rehabilitation models of delivery. As noted, people 

with LEA fail to participate in sufficient levels of physical 

activity, which increases their risk for the development of 

cardiovascular disease, and mortality.24,48,49 There is 

evidence that tele-rehabilitation approaches can serve to 

improve yoga adherence and is clinically effective in a 

variety of rehabilitation patients, which may help to maintain 

long-term benefits and engagement in physical activity.50-52 

Studies evaluating Yoga-based interventions should 

consider how to facilitate their uptake while in clinic to 

ensure safe practices are taught to patients while a tele-

rehabilitation or app-based component may enable patients 

to continue with yoga once home, which may provide a 

source of activity to those who face numerous barriers to 

accessing exercise in their communities. As well, a more 

https://doi.org/10.33137/cpoj.v7i1.43896


 

7 

Mayo A.L, Cheung B, Li J, Jean S, Vijayakumar A, Hitzig S.L, et al. Feasibility of a yoga intervention in an inpatient limb loss rehabilitation program. Canadian 
Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 1, No.6. https://doi.org/10.33137/cpoj.v7i1.43896  

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X FEASIBILITY OF A YOGA INTERVENTION IN AN INPATIENT LIMB LOSS REHABILITATION PROGRAM 

Mayo et al., 2024 

robust study should be undertaken to further explore the 

nuances of the benefits of yoga post-limb loss. 

CONCLUSION 

An adaptive yoga video for people with LEA was widely 

accepted by the inpatient population in this study. Yoga may 

complement traditional limb loss rehabilitation, which can 

enable patients to better adjust early post-amputation while 

providing a physical activity that is relaxing, and that holds 

a number of benefits to their wellbeing. The introduction of 

an adapted yoga intervention while in-hospital that is paired 

with an online video they can use once discharged from 

hospital may contribute to patients’ wanting to continue in 

the engagement in this beneficial mind-body intervention. 

However, more research is needed to explore 

implementation considerations and suitability of this 

intervention for different sub-types of patients, as well as to 

determine clinical efficacy.   

ACKNOWLEDGEMENTS 

We would like to dedicate this manuscript to Marsha Danzig, who 

met with the study team and provided guidance in the design of the 

yoga video for this study. Ms. Danzig passed away in 2022 and was 

a person with lived experience who taught adaptive yoga for 20 

years. We would also like to thank our patient partner Leonard 

Hauer who helped create our yoga intervention. As well, we would 

like to thank our participants for taking part in the study. 

DECLARATION OF CONFLICTING INTERESTS 

The authors have no declared conflicts of interest. 

AUTHORS CONTRIBUTION 

• Amanda Mayo: conceived the study design, obtained the 

funding for the project, worked to design the yoga intervention 

with a patient partner with expertise in yoga, oversaw the 

intervention, analyzed the data, wrote and revised the 

manuscript. 

• Betty Cheung: obtained the funding for the project, worked to 

design the yoga intervention with a patient partner with 

expertise in yoga, oversaw the intervention, and analyzed the 

data.  

• June Li: obtained the funding for the project, worked to design 

the yoga intervention with a patient partner with expertise in 

yoga, oversaw the intervention, and analyzed the data.  

• Stephanie Jean: worked to design the yoga intervention with 

a patient partner with expertise in yoga and edited the 

manuscript. 

• Abirami Vijayakumar: coordinated the study, recruited 

participants, collected data, and analyzed the data. 

• Sander Hitzig: conceived the study design, obtained the 

funding for the project, wrote and revised the manuscript. 

• Robert Simpson: conceived the study design, obtained the 

funding for the project, and worked to design the yoga 

intervention with a patient partner with expertise in yoga.   

All authors reviewed the manuscript and approved the final version. 

SOURCES OF SUPPORT 

This research study was funded by the Sunnybrook Health 

Sciences Centre Practice Based Research and Innovation Seed 

Grant. 

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CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

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Appendix A: Likert Survey Post-Yoga Session 

 

1) I felt calm and peaceful while doing yoga  

1-Strongly disagree; 2- Disagree; 3- Neither agree nor 

disagree; 4-Agree; 5-Strongly Agree 

2) The yoga practice was easy to complete 

1-Strongly disagree; 2- Disagree; 3- Neither agree nor 

disagree; 4-Agree; 5-Strongly Agree 

3) I felt pain during the yoga practice 

1-Strongly disagree; 2- Disagree; 3- Neither agree nor 

disagree; 4-Agree; 5-Strongly Agree 

4) Yoga improved the way I feel 

1-Strongly disagree; 2- Disagree; 3- Neither agree nor 

disagree; 4-Agree; 5-Strongly Agree 

5) I felt anxious during the yoga practice 

1-Strongly disagree; 2- Disagree; 3- Neither agree nor 

disagree; 4-Agree; 5-Strongly Agree 

6) I would recommend yoga to other patients 

1-Strongly disagree; 2- Disagree; 3- Neither agree nor 

disagree; 4-Agree; 5-Strongly Agree 

7) I would like to do yoga again 

1-Strongly disagree; 2- Disagree; 3- Neither agree nor 

disagree; 4-Agree; 5-Strongly Agree 

8) I felt safe while doing yoga 

1-Strongly disagree; 2- Disagree; 3- Neither agree nor 

disagree; 4-Agree; 5-Strongly Agree 

9) I felt comfortable while doing yoga 

1-Strongly disagree; 2- Disagree; 3- Neither agree nor 

disagree; 4-Agree; 5-Strongly Agree 

10) I feel overwhelmed by including yoga practice on 

top of my regular therapy 

1-Strongly disagree; 2- Disagree; 3- Neither agree nor 

disagree; 4-Agree; 5-Strongly Agree 

 

 

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