The Road to Incorporating Yoga Therapy Into Healthcare: the Role of Science and Research

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Brigham & Women’s Hospital Harvard Medical School The Road to Incorporating Yoga Therapy Into Healthcare: The Role of Science and Research

IAYT Symposium on Yoga Therapy and Research June 16, 2017

Sat Bir S. Khalsa, Ph.D. Assistant Professor of Medicine, Harvard Medical School Director of Research, Kundalini Research Institute Research Director, Kripalu Center for Yoga and Health Editor in Chief, International Journal of Yoga Therapy Research Associate, Benson Henry Institute for Mind Body Medicine Research Affiliate, Osher Center for Integrative Medicine Yoga and Yoga Therapy Yoga Alliance/Yoga Journal Survey 2016

From: http://www.yogajournal.com/yogainamericastudy/ Yoga Alliance/Yoga Journal Survey 2016

From: http://www.yogajournal.com/yogainamericastudy/ The Professional Transformation of Yoga into Mainstream Society

Public Schools, Workplaces, Healthcare

Ashrams, Studios, Yoga Centers, Gyms, Spas The Professional Transformation of Yoga into Mainstream Society

Public Schools, Workplaces, Healthcare

Research

Ashrams, Studios, Yoga Centers, Gyms, Spas Rationale for Yoga in Modern Healthcare Non-communicable Diseases (NCDs)

…NCDs are the leading cause of death in the world…

In most middle- and high-income countries NCDs were responsible for more deaths than all other causes of death combined...

Noncommunicable Diseases, Country Proﬁles, World Health Organization, 2011

…NCD deaths are projected to increase by 15% globally between 2010 and 2020 (to 44 million deaths).

Global status report on noncommunicable diseases 2010 World Health Organization Stress Awareness Worldview The Acute Care Model

• Focused on treatment and/or intentional suppression of symptoms at the expense of underlying causes and contributing factors • Dominated by a disease-focused approach rather than a patient-centered holistic approach • Highly invested in pharmaceutical, surgical and other highly technological diagnostic and treatment strategies • Incentivized to emphasize speed, high volume, and immediate symptom relief • Responsibility for healthcare is primarily on the provider • Prevention and health maintenance is not emphasized

From: http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-healthcare-from-a-global-perspective

From: Developmental origins of noncommunicable disease: population and public health implications, Hanson M, Gluckman P, American Journal of Clinical Nutrition, 94:1754S–8S, 2011. Research on Yoga for Stress, Awareness, Worldview Reasons for Practice in a Beginners Program

From: Yoga in the real world: Perceptions, motivators, barriers, and patterns of use, Quilty MT, Saper RB, Goldstein R, Khalsa SBS, Global Advances in Health and Medicine, 2:44-49, 2013. Stress in Beginner Yoga Students

Perceived Stress 18

17 p < 0.0001 16

13 Average Score PSS Score Average

12 BaselineEnd Program

From: Yoga as a stress reduction technique for women, Quilty M, Khalsa SBS, Saper R, Abstract submitted to 137th APHA Annual Meeting & Exposition, 2009. Stress in Occupational Setting

From: Yoga for reducing perceived stress and back pain at work, Hartfiel N, Burton C, Rycroft-Malone J, Clarke G, Havenhand J, Khalsa SB, Edwards RT, Occupational Medicine 62:606–612, 2012. Perceived Stress Stress in 20 Frontline 15 Professionals

N=71 from fields of 5 education, healthcare, and Baseline Post Follow-up corrections in a residential Resilience 5-day Kripalu program 92

84 From: Trent N, Dusek J, 82 Miraglia M, Pasalis E, Khalsa SBS, in preparation. 80 Baseline Post Follow-up

Mindfulness in Yoga Practitioners Freiburg Mindfulness Inventory 95

75 Average Change Score Change Average Controls Marginal Moderate High Intensity of Yoga Practice

Total Mindfulness Observing Awareness 10 1 Controls 3 8 0 2 6 1 4 -1 Controls 2 Controls Yoga 0 0 -2 -1 Yoga -2 Yoga -3 -4 -2 FFMQ Average Score -6 -4 -3 Observing Average Score Awareness Average Score

From: Yoga Enhances Positive Psychological States in Young Adult Musicians, Butzer B, Ahmed K, Khalsa SB, Applied Psychophysiology and Biofeedback, 41, 191-2020, 2016. Total Mindfulness Kripalu Rise Score 150 Program in p = .065 the 140 Workplace 130

120 Pre-RISE Post-RISE Mindfulness Factors

20 From: Trent N, Dusek J, 15 Miraglia M, Pasalis E, Khalsa Observe Describe Awareness Non-Judge Non-React SBS, unpublished data. Pre-RISE Post-RISE Survey Studies in Practitioners

Non-Ashram Respondents Subjective Effects Ashram Respondents Became aware of a new reality

Felt a personality change

Experience resulted in change in life

Experience of oneness

In touch with divine or spiritual

0 20 40 60 80 100 Percent with Positive Response

From: Intense personal experiences: Subjective effects, interpretations, and after- effects, Wilson SR, Spencer RC, Journal of Clinical Psychology 46:565-573, 1990. Psychology of Yoga Practitioners

From: Yoga experience as a predictor of psychological wellness in women over 45 years, Moliver N, Mika E, Chartrand M, Haussmann R, Khalsa S, International Journal of Yoga, 6:11-9, 2013. Self-transcendence in Yoga Practitioners

Transpersonal Identification vs. Self-Differentiation 7 AY 6 Practitioners

5 p=0.000003

4 Score 3 Controls 2

From: Processing of proprioceptive and vestibular body signals and self-transcendence in Ashtanga yoga practitioners, Fiori F, David N, Aglioti SM, Frontiers in Human Neuroscience, 8:734, 2014. Spirituality in Yoga Practitioners Multidimensional Inventory for Religious/Spiritual Well-Being (RSWB)

RSWB Total Hope Immanent 240

40 220

38 200

180

Average Change Score Change Average Average Change Score Change Average Controls Marginal Moderate High Controls Marginal Moderate High Experiences Connectedness of Sense and Meaning 40

41 35 40 30 39

Average Change Score Change Average Average Change Score Change Average Controls Marginal Moderate High Controls Marginal Moderate High

From: The relationship between yoga involvement, mindfulness & psychological well-being, Gaiswinkler L, Unterrainer HF, Complementary Therapies in Medicine, 26:123-7, 2016. 2016. B, SB, K, Khalsa Ahmed and 41:191 Biofeedback, Psychophysiology Applied From: Average Difference Scores -4 -2 0 2 4 6 8 Yoga States in Positive Psychological Enhances Young Butzer Musicians, Adult Positive Psychological Changes in Musicians with Kripalu Yoga Dispositional Flow - Total - Flow Dispositional Yoga Control -0.5 0.0 0.5 1.0 Autotelic Experience Autotelic Yoga Control - 202, Yoga Practices Postures, Breathing, Relaxation, Meditation

Fitness Self-Regulation Awareness Spirituality ↑Flexibility ↑Emotion Regulation ↑Attention ↑Transcendence ↑Strength ↑Stress Regulation ↑Mindfulness ↑Unitive State ↑Coordination/Balance ↑Resilience ↑Concentration ↑Flow ↑Respiratory Function ↑Equanimity ↑Cognition ↑Transformation ↑Self-Efficacy ↑Self-Efficacy ↑Meta-cognition ↑Life Meaning/Purpose

Global Human Functionality ↑Physical & Mental Health, ↑Physical, Mental, Emotional Performance, ↑Positive Behavior Change, ↑Social Responsibility, Values, Relationships, ↑Quality of Life, ↑Life Purpose & Meaning, ↑Spirituality Yoga Therapy Research Chronology of Yoga Therapy Research

250 Yoga Therapy 200 Research Publications

150 All RCT

100

# of Peer-Reviewed # Publicationsof Peer-Reviewed 0 67-73 74-78 79-83 84-88 89-93 94-98 99-03 04-08 09-13 5-Year Windows From: Yoga as a therapeutic intervention: A bibliometric analysis of published research studies from 1967-2013, Jeter PE, Slutsky J, Singh N, Khalsa SBS, Journal of Alternative and Complementary Medicine, 21:586-92, 2015. Yoga Research Journals

 Yoga Mimamsa (1924)  International Journal of Yoga Therapy (1990)  International Journal of Yoga (2008)  Indian Journal of Ancient Medicine and Yoga (2008)  Journal of Yoga and Physical Therapy (2011)  International Scientific Yoga Journal SENSE (2011)  International Journal of Yoga and Allied Sciences (2012)  International Journal of AYUSH: Ayurveda, Yoga, Unani ,Siddha and Homeopathy (2012)  Journal of Advanced Research in Ayurveda, Yoga, Unani, Siddha and Homeopathy (2014)  Journal of Yoga and Physiotherapy (2016)  International Journal of Advanced Ayurveda, Yoga, Unani, Siddha and Homeopathy (2016)  International Journal of Yoga, Physiotherapy and Physical Education (2016)  MOJ Yoga & Physical Therapy (2016)  International Journal of Yoga Natural Therapy (newly founded) Yoga Therapy Research by Disorders

Mental Health Cardiovascular Respiratory Musculoskeletal Cancer Diabetes Neurological Women's Health Obesity Other

102030405060708090 Number of Publications From: Yoga as a therapeutic intervention: A bibliometric analysis of published research studies from 1967-2013, Jeter PE, Slutsky J, Singh N, Khalsa SBS, Journal of Alternative and Complementary Medicine, 21:586-92, 2015.

• 23 chapters with theory, rationale, research & practice • ~60 chapter contributors, ~30 yoga therapist contributors “…decrease use of medications, resulting in substantial cost savings for hospitals in the care of oncology patients.” “Mind body interventions … have the potential to substantially reduce healthcare utilization at relatively low cost and thus can serve as key components in any population health and health care delivery system.”

“…if all 3 interventions are constrained by resources, medical yoga treatment is the optimal choice.” Yoga for Health and Prevention Yoga Practice Associations

From: National survey of yoga practitioners: mental and physical health benefits, Ross A, Friedmann E, Bevans M, Thomas S, Complementary Therapies Medicine, 21:313-23, 2013. Perceptions of Yoga on Health

Belief about Yoga and Health

Yoga has helped me to attain or maintain a healthier weight

My energy level is better because of yoga

My sleep is better because of yoga

I am happier because of yoga

My health has improved because of yoga

0 20 40 60 80 100 Percent of Respondents Agreeing or Strongly Agreeing with the Belief

From: Increased Hatha yoga experience predicts lower body mass index and reduced medication use in women over 45 years, Moliver N, Mika E, Chartrand M, Burrus S, Haussmann R, Khalsa S, International Journal of Yoga, 4:77-86, 2011. Yoga for Exercise Adherence

“The acute-feeling responses to the yoga classes were favorable and may have been a key con- tributor to participants' improved perceptions of ability, which may have further fostered adherence.”

“The participants reported an increased self-awareness as a result of their experience.”

From: The effects of yoga on psychosocial variables and exercise adherence: a randomized, controlled pilot study, Bryan S, Pinto Zipp G, Parasher R, Alternative Therapies in Health and Medicine, 18:50-9, 2012. . Yoga in Medicine United States

NCCIH Interactions

Yoga in Medicine Veterans Administration Yoga as a Tier 1 Intervention for Pain The topic was therapies such as meditation, massage, and yoga to help Veterans with [PTSD]. The goal …was to explore the existing evidence on complementary and alternative medicine (CAM) for PTSD and forge a future research agenda.

Meditation, imagery, acupuncture, and yoga are the most frequently offered mind and body practices in the Department of Veterans Affairs.

Future research should include yoga as it is currently understudied among veterans and military personnel. [6 of 89 studies reviewed] “Participants rated massage, meditation, acupuncture, and yoga as priorities for promotion across the VHA.” …specific complementary therapies can help to alleviate symptoms such as pain and fatigue as well as help with psychological issues like post traumatic stress disorder (PTSD) and depression. Recognizing this, Veterans Administration (VA) hospitals and the War Related Illness and Injury Study Center (WRIISC) have made Integrative Medicine a high priority.

[CAM] strategies such as yoga are widely available in the private sector, and some Veterans have requested that the VHA make them available in the VA system. Determining the state of evidence on the benefits and harms of yoga and other CAM modalities is a priority for the VHA.

Yoga in Medicine United Kingdom An open letter to the NHS by Dr. Matt Joslin: “I want to see whether there is a way to marry the amazing healing sustaining practice that is Yoga with the services offered by the NHS.” Programs and Activities • Started October, 2016: in association with All Party Parliamentary Group on Indian Traditional Sciences • Support of Lord Andrew Stone of Blackheath, increasing awareness in Parliament of the value of yoga • Motion read in the House of Commons • A 10-week social prescribing course for patients as early intervention • An NHS staff well-being program Heather Mason • Brochures for all GPs and GP associations • Yoga program for junior doctors • All Party Parliamentary Group on Yoga Research Activities • Governmental funding for research on the prescribing program on patients (N>200) • Research on the prescribing program on NHS staff • A completed consumer survey (N = 2,000) on perceptions of therapeutic benefits of yoga (50% indicated that if yoga was available on the NHS they would gladly try it) • Yoga survey to social prescribing network (N~4,000) NHS staff, researchers, patients

Research Funding Kripalu | center for yoga & health