Office of Public Health & Environmental Hazards

Complementary & Alternative Medicine (CAM) Yoga & Research WRIISC CA

Louise Mahoney, MS WRIISC, VA Palo Alto Health Care System

Gulf War Yoga Mat sold on GAIAM website IfIf youyou cancan breathebreathe…….... youyou cancan dodo yogayoga TheThe YogaYoga ExperienceExperience WhatWhat isis CAM?CAM?

Ginseng Root ƒ Complementary Medicine Use of non-western medical treatments in addition to…….. ƒ Alternative Medicine Yoga at EP-II Use of non-western medical Conference treatments instead of ……..

conventional western medicine NonNon--WesternWestern MedicineMedicine ƒ Natural Products (most commonly use form) – dietary supplements (fish oils, probiotics) ƒ Mind/Body - Yoga, Meditation, T’ai Chi, Hypnotherapy, Music Therapy ƒ Manipulative and Body-Based Practice - Chiropractic, Massage Therapy, Rolfing ƒ Movement Therapies - Feldenkrais method, Alexander technique, Pilates, Dance Therapy ƒ Energy Therapies – Reiki, QiGong NationalNational HealthHealth StatisticsStatistics ReportReport onon CAMCAM UsageUsage inin thethe UnitedUnited States,States, 20072007 ƒ Almost 40% of adults had used CAM in past 12 months ƒ Majority of those used CAM to treat back pain, neck pain, joint pain or stiffness – similar to 2002 report MostMost CommonCommon CAMCAM TherapiesTherapies CAMCAM UsageUsage inin VAVA Healthcare Analysis and Information Group (HAIG) Study on CAM Utilization in VHA 2002 ƒ 84% of VA facilities provide some form of CAM ƒ Most common activities include ƒ Acupuncture ƒ Biofeedback ƒ Guided imagery ƒ Hypnotherapy ƒ Meditation ƒ Music therapy ƒ Progressive relaxation ƒ Stress management WhatWhat isis Yoga?Yoga?

ƒ Developed from ancient Indian religious practice ƒ Word derived from Sanskrit root “yuj” meaning to bind ƒ Generally conceptualized as union of mind, body, and soul ƒ Based on the Yoga Sutras attributed to Patanjali in the 2nd century BCE ƒ Purpose of yoga is to end suffering of the mind 88 LimbsLimbs ofof YogaYoga 1. Yama – moral commandments 2. Niyama – discipline 3. Āsana – postures (what most call “Yoga” in the United States – also termed “Hatha” yoga) 4. Pranayama – control of breath 5. Pratyahara – freedom from domination of the senses and external objects 6. Dharana – concentration 7. Dhyana – meditation 8. Samadhi – super-consciousness PhysicalPhysical PracticePractice ofof YogaYoga (Asana)(Asana) ƒ Most yoga we practiced today in US based on teachings of Krishnamacharya (November 18, 1888 – November 3, 1989) ƒ Developed active form of yoga (Ashtanga) - ƒ Also practitioner of Ayurvedic medicine ƒ Father of T.K.V. Desikachar ƒ Teacher of Iyengar (Iyengar - introduced use of props – teach people at any level) ƒ T.K.V Desikachar ƒ Yoga practice is adapted to fit the individual and particular situation of each student – a therapeutic approach – called it Viniyoga initially ƒ Mentor of Richard Miller, developer of iRest AncientAncient vs.vs. ModernModern ƒ Most Yoga practiced today developed around the turn of the 20th century! ƒ Influenced by British Physical culture – gymnastics – brought to Indian palaces during colonization ƒ Pilates –developed in Britain during WWI, by Joseph Pilates was interned in a Veteran hospital in England. Developed prototype reformer with mattress springs to rehabilitate injured Veterans

YogaYoga CertificationCertification

ƒ Yoga Alliance ƒ Provides standards for yoga teacher training ƒ Recognizes appropriate training programs ƒ Provides Registration and continuing education requirements ƒ International Association of Yoga Therapists DoDo wewe needneed ResearchResearch onon YogaYoga andand Veterans?Veterans? ƒ PubMed search of “Yoga” ƒ >1500 published articles ƒ PubMed search of “Yoga” and “Veteran” ƒ 19 published articles – only 2 used Veterans as subjects ƒ The effectiveness of Yoga to help reduce chronic low back pain (Groessl, 2008) ƒ Yoga as physical fitness in a Veteran nursing home (Hamilton-Word V, 1982) EvidenceEvidence forfor YogaYoga asas TherapyTherapy Study Target Population Sample Results

Groessl et al, Low back Veterans 33 Significantly less: Pain, 2008 pain Depression, Fatigue Sherman et al, Chronic low Civilian 101 Both exercise and yoga 2005 back pain Adults reduced pain, yoga superior in medication use reduction Da Silva et al, Fibromyalgia Civilian 33 RY & RYT improve FIQ 2007 females scores & reduce VAS scores – RY continued to provide benefit after study Vera et al, Sleep and Healthy 26 Long term yoga practice 2009 HPA axis yoga improves SSQ, increase in practioners cortosol & controls ReviewsReviews

Literature Target Results Review

Yang, (review of Chronic diseases Weight loss, lower BP, lower 32 articles blood glucose, lower cholesterol Kirkwood et al, Anxiety Positive but inconclusive results (2005) review of 8 studies

Chou & Huffman, Chronic low back Small advantage of yoga over (2007) pain exercise in some but benefits of yoga last longer than benefits of yoga SummarySummary ofof BenefitsBenefits ƒ Reduced back pain ƒ Lowered stress ƒ Increased functional ability ƒ Improved sleep ƒ Increased cardiovascular health ƒ Lower cholesterol ƒ Decrease general pain such as experienced in fibromyalgia PossiblePossible MechanismsMechanisms ofof ActionAction ƒ ? ƒ Improve structural/postural alignment ƒ Improve muscle tone and flexibility ƒ Enhance function and regulation of autonomic nervous system and re- setting of chronic pain response ƒ Modulation of hormones

WRIISCWRIISC--CACA YogaYoga ƒ January, 2010 – Program start ƒ 2 Mat classes – 1/week each ƒ Mixed gender mat class ƒ Women only mat class ƒ July 2010, Chair yoga class added ƒ ~59 referrals to WRIISC yoga through CPRS consult WRIISCWRIISC--CACA YogaYoga (cont(cont’’d)d) ƒ Mixed gender mat class ƒ 20 referrals, 14 have attended at least once, 4 have completed baseline & post 12-week report ƒ Women only mat class ƒ 24 referrals, 10 have attended at least once, 3 have completed baseline & post 12-week ƒ Chair yoga ƒ 15 referral, 10 have attended at least one session, 6 have completed baseline & post 12- week GulfGulf WarWar II VeteransVeterans && YogaYoga ƒ 36 GWI Veterans visited WRIISC-CA since January 2008 ƒ 5 of 12 (42%) of Veterans who visited when Yoga was offered participated in class ƒ 18 (50%) expressed an interest in yoga and indicated they would like information about home practice BarriersBarriers toto Attendance?Attendance? ƒ Location not convenient ƒ No transportation ƒ No childcare ƒ Conflicts with work schedule ƒ Class held during high traffic commute time ƒ Not psychiatrically or medically stable PilotPilot Data:Data: n=12n=12 ƒ Feasibility – Will Veterans participate in yoga? ƒ Yes, with caveats not related to yoga ƒ SF-12 – Health and Well-Being ƒ Increase in energy – most significant ƒ Trend toward improvement in most others areas except depression ƒ McGill Pain Short Form ƒ Decrease in pain intensity SFSF--1212 EnergyEnergy LevelLevel McGillMcGill PainPain ShortShort FormForm PilotPilot DataData (cont(cont’’d)d)

ƒ PTSD Checklist (PCL-M) ƒ Small trend downward ƒ Flanders Fatigue Scale ƒ Small trend upward ƒ Yoga Satisfaction Questionnaire YogaYoga SatisfactionSatisfaction –– n=12n=12 ƒ Yoga class quality: 5 item scale from poor to excellent: ƒ All answered either “Excellent” or “Very Good” ƒ Do you feel better after class than you did before? ƒ All answered “Yes” ƒ Would you participate in WRIISC yoga again? ƒ All answered “Yes” ƒ Would you recommend WRIISC yoga to a friend? ƒ All answered “Yes” ƒ Have your symptoms improved? ƒ 3 answered “Yes, completely” ƒ 6 answered “Yes, somewhat” VeteranVeteran CommentsComments ƒ “It is one thing I look forward to because for that short amount of time I have hope” – Female Operation Iraqi Freedom Veteran ƒ “Best thing in years” – Male Korean War Veteran ƒ “Wonderful for body and soul” –Female Gulf War I Veteran ƒ “Great class, should meet 2x per week” – Male Vietnam War Veteran” OtherOther BenefitsBenefits

ƒ Provides opportunity for Veterans to bond with other Veterans in a positive space ƒ Relief from social isolation cause by the illness ƒ Sense of belonging to a group ƒ Lets Veterans know that the VA cares about them GulfGulf WarWar VeteransVeterans

ƒ Common Symptoms ƒ Chronic Pain ƒ Chronic Fatigue ƒ Disrupted Sleep ƒ Gastrointestinal Disorders ƒ Anxiety ƒ Depression 1212 weekweek RandomizedRandomized ControlledControlled TrialTrial ƒ Enroll ~ 100 GWI/OEF/OIF Veterans ƒ Assess for: ƒ Pain ƒ Functional disability ƒ Sleep ƒ Depression ƒ Anxiety ƒ Memory ƒ Genetic factors WRIISC Washington, DC [email protected] 1-800-722-8340 WRIISC East Orange, NJ [email protected] 1-800-248-8005 WRIISC Palo Alto, CA WRIISC Referrals [email protected] 1-888-482-4376

Contact your local WRIISC for referral information.

MoreMore informationinformation @@ www.warrelatedillness.va.govwww.warrelatedillness.va.gov ReferencesReferences 1. Groessl EJ, Weingart KR, Aschbacher K, Pada L, Baxi S.(2008). Yoga for veterans with chronic low-back pain, J Altern Complement Med., Nov;14(9),1123-9. 2. Hamilton-Word V, Smith FW, Jessup E. (1982). Physical fitness on a VA nursing home unit, Geriatr Nurs. 3(4), 260-2. 3. Pal, G.K., Velkumary, S., Madanmohan, (2004). Effect of short- term practice of breathing exercises on autonomic functions in normal human volunteers, Indian J Med Res, 120, 115-121. ƒ Yank, K. (2007). A Review of Yoga Programs for Four Leading Risk Factors of Chronic Diseases, eCAM, 4(4), 487–491. NamasteNamaste