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Effect of an Integrated Approach of Yoga Therapy on Quality of Life in Osteoarthritis of the Knee Joint: a Randomized Control Study

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Effect of an Integrated Approach of Yoga Therapy on Quality of Life in Osteoarthritis of the Knee Joint: a Randomized Control Study Original Article Effect of an integrated approach of yoga therapy on quality of life in osteoarthritis of the knee joint: A randomized control study John Ebnezar, Raghuram Nagarathna1, Yogitha Bali, Hongasandra Ramarao Nagendra1 Department of Orthopaedics, Dr. John’s Orthopaedic Centre, 1Division of Life Sciences, Swami Vivekananda Yoga Research Foundation (SVYASA), Karnataka, Bengaluru, India Address for correspondence: Dr. John Ebnezar, Department of Orthopaedics, Dr. John’s Orthopaedic Centre, Bilekahalli, Bannerghatta Road, Bengaluru, Karnataka, India. E-mail: [email protected] ABSTRACT Aim: This study was designed to evaluate the efficacy of addition of integrated yoga therapy to therapeutic exercises in osteoarthritis (OA) of knee joints. Materials and Methods: This was a prospective randomized active control trial. A total of t participants with OA of knee joints between 35 and 80 years (yoga, 59.56 ± 9.54 and control, 59.42 ± 10.66) from the outpatient department of Dr. John’s Orthopedic Center, Bengaluru, were randomly assigned to receive yoga or physiotherapy exercises after transcutaneous electrical stimulation and ultrasound treatment of the affected knee joints. Both groups practiced supervised intervention (40 min per day) for 2 weeks (6 days per week) with followup for 3 months. The module of integrated yoga consisted of shithilikaranavyayama (loosening and strengthening), asanas, relaxation techniques, pranayama, meditation and didactic lectures on yama, niyama, jnana yoga, bhakti yoga, and karma yoga for a healthy lifestyle change. The control group also had supervised physiotherapy exercises. A total of 118 (yoga) and 117 (control) were available for final analysis. Results: Significant differences were observed within (P < 0.001, Wilcoxon’s) and between groups (P < 0.001, Mann–Whitney U-test) on all domains of the Short Form-36 (P < 0.004), with better results in the yoga group than in the control group, both at 15th day and 90th day. Conclusion: Anintegrated approach of yoga therapy is better than therapeutic exercises as an adjunct to transcutaneous electrical stimulation and ultrasound treatment in improving knee disability and quality of life in patients with OA knees. Key words: Knee disability; osteoarthritis; SF-36; yoga. INTRODUCTION physical functions are the important goals of the present day therapy.[5,6] Osteoarthritis (OA) is the second most common rheumatological problem in India and has a prevalence The management of OA is still far from optimal, because rate of 22–39%.[1] It is characterized primarily by articular the medications currently available provide limited cartilage degeneration and a secondary periarticular bone symptomatic relief and are fraught with a number of response.[2,3] Worldwide prevalence rate of OA is 20% for [7] men, 41% for women, and it causes pain or dysfunction in side-effect. It is increasingly recognized that a key 20% of the elderly.[4] Relieving pain stiffness and improving outcome measure for any health-care intervention for OA is the change in health-related quality of life (QOL).[8,9] Access this article online Although OA itself is not a life-threatening disease, Quick Response Code QOL can significantly deteriorate with pain and loss of Website: mobility causing dependence and disability.[10] Health- www.ijoy.org.in related QOL may be measured by disease-specific and generic health status questionnaires. Western Ontario DOI: and McMaster Universities Osteoarthritis Index Score *** (WOMAC) is used to measure specific functional disability and SF-36 is used to measure general International Journal of Yoga Vol. 4 Jul-Dec-2011 55 Ebnezar, et al.: Yoga for osteoarthritis of knees health status that includes assessment of emotional Design functioning, energy level, and social functioning in addition to functional disability assessment. Aglamiş This was a prospective randomized parallel active control et al,[11] Foley et al,[12] and Diracoglu et al.[13] observed study on patients with OA knees in the age range of 35 80 greater increases in the SF-36 after the exercise program years. Patients attending the outpatient department of Dr of various durations for patients with OA knees. Kirkley John’s Orthopedic Center who satisfied the inclusion criteria et al.[14] showed that in patients assigned to arthroscopic were recruited for the study. After the initial screening for surgery, there was no improvement with health-related selection criteria, they were assigned to either the yoga QOL. In a study by Tekur et al.[15] the role of yoga in group or control group. A computer-generated random the improvement of QOL of patients with chronic low number table (www.randomization.com) was used for backache was discussed, and she showed that in the randomization. Numbered envelopes were used to conceal yoga group, there was significant improvement in the the sequence until the intervention was assigned. Both scores of WHOQOL (WHO’s Quality of life) brief on all groups were given the conventional physiotherapy using domains. In a study by Sudheer et al.[16] about the role of transcutaneous electrical stimulation and ultrasound for yoga about QOL in normal volunteers, 28% in physical, 15 days. 16% in psychological, 10.17% in social, and 8.8% in the environmental domain changed significantly after Both groups had supervised practices at the center for 40 shifting to the control intervention in the second week. min daily (6 days/week) after physiotherapy (20 min) for 2 weeks. The yoga classes were conducted in the basement There are no studies that have looked at disability and of the hospital where one hall is exclusively dedicated QOL measures in patients with OA knees after integrated for yoga therapy. The study group was taught integrated yoga therapy involving loosening, strengthening, asanas, yoga and the control group was taught the non-yogic physiotherapy exercises by certified therapists. After this, etc. Hence, this study was planned with an aim to assess they were asked to practice daily at home for the next 3 the effects of the integrated approach of yoga therapy on months. Compliance was supervised by telephone calls QOL using a generic health-status tool involving SF-36 in once in 3 days and a weekly review was conducted once patients with OA knee. a week for 3 months. The daily review cards were checked for the regularity and doubts if any were clarified. The MATERIALS AND METHODS evaluation was conducted by the senior research fellow. All patients were asked to tick the practices daily after the A total of t patients with OA knees from the outpatient home practice in the diary provided for the purpose; at department of Dr John’s Orthopedic Center, Bengaluru, every visit their clinical progress and therapy received on were recruited for the study. A sample size of 250 was the day were documented. All assessments were carried obtained on G power software by fixing the alpha at 0.05 out on 1st, 15th, and 90th days. powered at 0.8 and an effect size of 0.379 considering the mean and SD of an earlier study.[17] A total of t of both genders in the age group of 35–80 years (59.56 ± 8.18) in Blinding and masking the yoga group and (59.42 ± 10.66) control group with OA As this was an interventional study, double blinding was knees (one or both joints) satisfying theAmerican College not possible. The answer sheets of the questionnaires were of Rheumatology (ACR) Guidelines[18] for diagnosis were coded and analyzed only after the study was completed. included. The inclusion criteria were (i) persistent pain Here, the statistician who did the randomization, for 3 months prior to recruitment, (ii) moderate-to-severe data analysts, and the researcher who carried out the [19] pain on walking, (iii) Kellegren and Lawrence radiologic assessments were blinded to the treatment status of the grading of II–IV in X-rays taken within 6 months prior subjects. to entry, and (iv) those fully ambulant, literate, and willing to participate in the study. Those with (i) grade Intervention for the yoga group I changes in -ray, (ii) acute knee pain, (iii) secondary osteoarthritis due to rheumatoid arthritis, gout, septic The daily routine practiced at the center in the yoga arthritis, tuberculosis, tumor, trauma, or hemophilia, group included 40 min of integrated yoga therapy practice and (iv)those with major medical or psychiatric disorders after 20 min of physiotherapy with transcutaneous were excluded. electrical stimulation and ultrasound for 2 weeks [Table 1]. The integrated yoga therapy practice The study was approved by the institutional review board included shithilikaranavyayamas (loosening practices), (IRB) and ethical committee of SVYASA (Swami Vivekananda saktivikasaka (strengthening practices) followed by Yoga Anusandhana Samsthana) University. Signed informed yogasanas and relaxation techniques with devotional consent was obtained from all the participants. songs. Later patients were advised to continue the 56 International Journal of Yoga Vol. 4 Jul-Dec-2011 Ebnezar, et al.: Yoga for osteoarthritis of knees Table 1: Yoga module for osteoarthritis knees Table 1: contd/- Conventional physiotherapy was carried 20.0 min B. Standing asanas out only at the center for 15 days which • Bhujangasana included • Shalabasana • TENS: 10 min • ViparitaKarani • Ultrasound: 10 min 10. Deep relaxation technique (DRT) is a three- 5.0 min Integrated yoga practice: This was made 40.0 min phase guided relaxation technique with to practice by the patient at the center for relaxation from toes to the head, feeling 40 min for 15 days after the conventional of letting go, chanting OM and feeling of physiotherapy and later advised to continue limitless expansion through visualization. at home for the next 3 months. This 11. Nadishuddhi pranayama - Nadishuddhi 3.0 min included the following practices: Pranayama is a slow rhythmic technique Shithilikaranavyayama loosening exercises: 10.0 min of alternate nostril breathing involving the 1. Foot and ankle loosening practices phases of inhalation and exhalation using • Passive rotation of each toe 10 rounds 1.0 min nasika mudra.
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