The Therapeutic Application of : A Literature Review

By: Ashley Richiardi

Faculty Advisor: Rodger Tepe, PhD

A senior research project submitted in partial requirement for the degree Doctor of Chiropractic

March 28th, 2013

ABSTRACT

Objective This review provides an overview of the current literature discussing the health benefits and therapeutic applications of yoga in the treatment and management of a variety of mental and physical conditions. It seeks to qualify the research that exists to support or refute the use of yoga either as a stand-alone therapy or in conjunction with traditional treatments. Data Collection A computer search of PubMed, Google Scholar, and The Cochrane Collaboration literature databases was performed using the following terms: yoga, therapeutic, therapy, application, benefits, flexibility, strength, balance, low back pain, anxiety, depression, arthritis, , asthma. Articles included in this review met the following criteria: (1) peer-reviewed (2) published between 2000-2013 (3) discuss the use of yoga as an intervention.

Conclusion Sufficient research exists to substantiate claims that yoga increases flexibility, strengthens muscles, and improves balance and respiration. Current research demonstrates that yoga is a beneficial therapy for low back pain, osteoarthritis, asthma, anxiety, and depression. Additional research into the application of yoga in pregnancy and rheumatoid arthritis is warranted. Key Indexing Terms Yoga, Therapeutic, Application, Benefits

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INTRODUCTION

Yoga is an ancient mind-body therapy believed to have originated in India around 3000

BC. It was not until the end of the 19th century that yoga’s popularity reached the United States.

Yoga has quickly become a mainstream exercise and relaxation practice in Western society.

Around the 20th century the observed psychophysiological benefits spurred the advancement in the study of the therapeutic application of yoga. Yoga is now classified as a form of

Complementary and Alternative Medicine (CAM) by the National Institutes of Health and has a considerable body of evidence to support its use in a variety of conditions. A 2012 study conducted by The found that an estimated 20.4 million Americans practice yoga, spending $10.3 million a year on yoga services and merchandise.1 Additionally, 44% of currently non-practicing Americans report interest in beginning their own yoga practice.1 Due to the increased public interest in this health practice it is crucial to rigorously review the current research to determine the role yoga can serve in the management and treatment of specific conditions and populations.

While many forms of yoga exist, is the most widely practiced type of yoga in the world. In this form of yoga various postures () are incorporated with deep breathing techniques () and meditative practices (dhyanas). Yoga literally means “to join,” in reference to uniting the mind, body, and breath in one restorative practice.2 Originally Hatha yoga emphasized the mental and spiritual benefits of the practice, but since its adoption in

Western culture the physical benefits have become the focus.

The following yoga-related health claims will be evaluated in this review: increases flexibility, increases muscle strength, improves balance, and improves breathing patterns and

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lung function. Additionally, yoga has been suggested to be beneficial for a range of conditions, and the following will be included in this article: musculoskeletal disorders such as low back pain and osteoarthritis, pregnancy-related pain syndromes and disorders, asthma, and mental disorders including anxiety and depression. This research review explores both the physical and mental health benefits, therapeutic applications, and the proposed mechanisms of how yoga may improve health.

DISCUSSION

Health Benefits

It is important to first address the impact that a regular yoga practice can have on overall health prior to discussing its application to specific conditions and populations. The most common health claims tied to yoga include increased flexibility, stronger muscles, improved balance, and improved breathing patterns and lung function.

Increases Flexibility

Flexibility is commonly associated with advanced , and is also reported as the number one reason people begin a yoga practice.1 The component of yoga moves the body in and through poses which stretch specific muscles, tendons, fascia, and connective tissues.3 As soft tissue tension diminishes joints tend to exhibit an enhanced range of motion, as seen in advanced yoga poses.

A 2012 study of 250 subjects with osteoarthritis of the knee joint compared the range of knee flexion in patients performing 40 minutes daily of either hatha yoga (intervention) or therapeutic exercises (control) following transcutaneous electrical stimulation and ultrasound

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therapy.4 Measurements were taken on the 15th and 90th day of a 90 day intervention. This study found that the yoga group had significantly greater knee flexion (12.7% at 15 days, 26.5% at 90 days on the right; 13.5%, 28% left) than the control group (6.9%, 13.3% right; 5.6%, 11.5% left) at the time of both measurements.4 A randomized controlled trial conducted in 2013 evaluated the efficacy of a 9 week intervention compared to a home exercise control group in the treatment of chronic neck pain.5 Baseline and post-intervention measurements of cervical range of flexion, extension, bilateral rotation, and bilateral lateral flexion were obtained. The yoga group demonstrated greater gains in all cervical ranges of motion compared to the home exercise group.5 Chen et. al. found a significant increase in shoulder and hip ranges of motion in an elderly population following yoga therapy.6 An exploratory study (n=21) of the effect of an 8 week practice in healthy young adults found significant increases in lumbar spine, hamstring, and shoulder flexibility when compared to a control group.7

Increased flexibility is the most widely accepted health claim associated with a regular yoga practice. A considerable body of evidence exists to support this claim; however, further research in healthy populations with larger sample sizes is warranted.

Increases Muscle Strength

Muscle loss is a normal component of the aging process, but if uncontrolled it can lead to arthritis, back pain, and falls in the elderly.3 Several forms of weight-bearing exercise can promote increased muscle strength, but few activate the intrinsic musculature and lead to the overall muscle balance that yoga does.

The Bikram study referenced earlier measured dead-lift strength and hand-grip strength in 21 healthy young adults pre- and post-intervention. The results demonstrated a significant

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increase in dead-lift strength and no change in grip strength in the yoga group when compared with the control group.7 A larger study (n=143) looked at hand-grip strength in healthy adults, children, and patients with rheumatoid arthritis. This study found significant increases in hand- grip strength across all three populations receiving the yoga therapy compared to controls.8

The asanas used in Hatha yoga challenge various muscle groups and with continued practice can lead to measurable gains in muscle strength.7,8 Some types of yoga (i.e Vinyasa,

Ashtanga) are more rigorous than others and require the body to flow through poses seamlessly with breath, and are presumed to have a greater impact on muscle strength. Forms of therapeutic yoga that do not utilize weight-bearing postures and focus on relaxation of muscles may not offer this same benefit.

Improves Balance

Proprioception is another common age-related physiological functional loss. Diminished balance is associated with an increased risk of falls, a leading cause of hip fractures, loss of independence, and death in the elderly population.9 For this reason it is critical to evaluate the efficacy and safety of therapies that may help improve proprioceptive functioning to enable clinicians to make appropriate recommendations.

A Cochrane review of 94 randomized controlled studies (n=9,821) looked at the effect of various exercise programs on proprioception in an older population.9 Yoga was one intervention in a group referred to as “3-D exercise,” which also included tai chi, qi yong, and dance. This research review found a moderate improvement in balance immediately post-intervention for the

3-D exercise group.9 It is not possible to draw any conclusions on the relative efficacy of yoga versus similar therapies included in the 3D group based on the nature of this review. Several

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studies looking specifically at yoga have found it to be a useful intervention for improving balance in older adults. Brown et. al. found a 9.7 ± 9.4s improvement in one leg balancing following a 4 week yoga intervention.10 Oken et. al. conducted a 6 month long randomized controlled trial comparing a hatha yoga group to a walking exercise group and a wait-list control group.11 Yoga was found to be superior to both the exercise and control group in improving balance measures in the elderly.11

Improves breathing patterns and lung function

While many of the previous health benefits are likely a result of the asana component of yoga practice, improvements in respiratory function are largely attributed to the pranayamas, or breathing techniques of yoga. There are many aspects of that may contribute to enhanced lung function and improved breathing patterns. Nostril breathing is used for both inhalation and exhalation during yoga, allowing the nasal passages to act as a filter to warm and humidify the air while removing irritants before they reach the lungs.3 Slow, deep breaths are emphasized creating a calming effect on the nervous system.3 In Vinyasa (flow) yoga the goal is to seamlessly integrate the body movements with the breath, allowing a fluid transition from pose to pose. It is typical for a yoga class to begin and end with Savasana, focusing on the breath often while lying supine. Yoga therapists direct patients through breathing exercises, having them feel their belly soften and rise as they breathe in, and contract as they breathe out. This allows one to address abnormal breathing patterns he or she may have and consciously attempt to correct it. Postural awareness generally increases as a result of a regular yoga practice, and in combination with increases in flexibility and strength may lead to significant improvements in hyper-kyphotic postures. These slumped postures are common due to the demands of modern

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society and are problematic as they restrict the expansion of the lower rib-cage and inhibit the use of the abdominals for proper breathing.3

Therapeutic Applications of Yoga

Musculoskeletal disorders

Based on the numerous benefits yoga provides the musculoskeletal system, it is not surprising that its application to diseases of this system has been extensively studied. Research studies that look at yoga’s effect on two of the most common chronic musculoskeletal disorders, non-specific low back pain (LBP) and arthritis (OA/RA) will be included in this review.

Low back pain

Low back pain is one of the most common and costly pain syndromes affecting society today. More than 80% of Americans will suffer from low back pain during their lives with direct medical costs and in-direct costs related to lost productivity totaling $100-200 billion annually.12

Traditional treatments for this non-specific pain syndrome have not been proven to be highly successful or cost-effective, making research in to alternative treatments essential.13 All of the studies reviewed found yoga to be an effective therapy in the management of chronic low back pain.13,14,15,16,17 One of the largest RCTs conducted to date compares the effects of yoga, a self- care book, and a stretching class on low back pain. The results indicate that yoga is significantly more effective than the self-care book, but not more effective than the stretching group.13 It is consistent with logic that this group demonstrated a similar outcome since yoga itself is a series of stretches. These results indicate that asana is the critical component of yoga that serves to alleviate back pain. Additional research on the effect of yoga in acute low back pain is warranted.

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Arthritis

There are several types of arthritis that differ in cause and presentation, but most share a common symptom of joint pain. Arthritis pains often cause patients to decrease or discontinue physical activities which may lead to muscle and ligament weakening, loss of flexibility, and ultimately progression of the disease.18 The American College of Rheumatology (ACR),

Osteoarthritis Research Society International (OARSI), and the Ottawa Panel recommend stretching, strengthening, and conditioning exercises to preserve physical function, increase strength and improve endurance for people with arthritis.18 The isometric strengthening performed in yoga asana is uniquely beneficial to arthritis patients as it provides the joint stability while challenging intrinsic musculature and minimizing potential joint strain.18 As the patient flows through yoga asanas the joints are put through a greater range of motion balancing flexibility with strength.3 Several research studies have demonstrated yoga significantly decreases pain and disability in patients with osteoarthritis.4,18,19 No conclusive statements can be made in regard to rheumatoid arthritis due to poor design and small sample sizes, however pilot studies demonstrate that yoga may play a beneficial role in the management of RA that deserves further investigation.20,21

Pregnancy

Pregnancy is a period when biomechanical and physiological changes occur rapidly as the body adapts to support the growing fetus. This is especially true in the 3rd trimester, when the weight of the baby nearly doubles putting additional strain on the low back, pelvic floor, and diaphragm. Common complaints during this period include low back pain, lower extremity swelling, urinary incontinence, and heartburn. In addition to physical stressors, pregnancy is

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often accompanied by psychological stressors and in some cases severe anxiety which can exacerbate symptoms. Pregnant women are demonstrating an increased interest in natural, alternative solutions for these symptoms due to the inherent risks of pharmaceutical use during pregnancy. Sun et. al. looked at the effect of yoga on pregnancy-related symptoms. This study found that women who participated in a 12-14 week yoga intervention during their pregnancy reported fewer discomforts.22 Similarly, rates of natural births and home-births have recently increased, indicating the need for natural labor pain coping methods. A Cochrane review found that yoga significantly reduced labor pain and the length of labor while increasing satisfaction with pain relief and the overall childbirth experience.23 These conclusions are consistent with

Chuntharapat’s findings that the yoga group had greater maternal comfort during labor and 2 hours post-labor, less labor pain, and shorter labor times than the control group.24 Additionally, yoga may help prevent common pregnancy complications such as pre-term labor, low birth weight, maternal hypertension, and isolated intrauterine growth retardation.25

Research has demonstrated yoga is a beneficial therapy for the pregnant patient, however not all types of yoga are suitable for this population. Pre-natal yoga is typically a gentle variation of Hatha yoga where sequences and poses are specifically tailored to meet the needs of the pregnant patient. Heated yoga (Bikram) and certain yoga poses, such as those with extreme extension (Boat) or that require the woman to lay on her stomach (Cobra) may be contraindicated during pregnancy making it imperative that this therapy be performed with a qualified yoga therapist that specializes in the needs of this population.

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Asthma

Pranayama has been suggested to be useful in the management of respiratory conditions such as asthma. Yoga uses deep, nasal breathing which strengthens the diaphragm and enables the lungs to fill completely to provide oxygen to the lower lobes. Nostril breathing helps warm the air and filter out irritants making asthmatic attacks less likely.3 In pranayama focus is turned to the breath, and inhalation is balanced with exhalation in slow, deep breaths.

Asthma is a condition in which the bronchials constrict causing symptoms such as wheezing, shortness of breath, and chest tightness.3 Bidwell et. al. found that a 10 week yoga intervention improved respiratory function and quality of life in a small population of asthmatic women.26 In a larger randomized controlled trial the yoga group demonstrated improved pulmonary measures, including peak expiratory flow rate and initial forced expiratory volume as well as decreased occurrence of exercise induced bronchoconstriction.27 Manocha et. al. found that airway hyperresponsiveness to methacholine improved significantly in the yoga group compared to controls.28 Current research demonstrates that yoga is an effective adjunctive treatment in the management of asthma.

Mental disorders

Yoga is a unique form of exercise that integrates the body, breath, and mind into one restorative practice. In this system of healing four basic principles are defined which underlie the theory and practice of yoga.29 The first principle defines the human body as a holistic unit made up of interrelated components that are inseparable from one another. The second principle states that each person’s needs are unique, and that treatments must be tailored to each individual. The third principle in yoga proposes that healing comes from within rather than from an external

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source. Yoga requires that the patient play an active role in their healing, which is self- empowering and can lead to a greater sense of autonomy. The fourth principle identifies the importance of mental health in the healing process, suggesting that individuals with a positive mind-state heal more quickly than those with a negative mind-state.

Stress/Anxiety

Anxiety is a healthy sympathetic response to physical and emotional stressors. In cases of uncontrolled anxiety people report debilitating symptoms such as obsessive thoughts, insomnia, migraines, digestive problems, dizziness, shortness of breath, and heart palpitations.3 People are reporting higher levels of stress today than ever before, likely due in part to the non-stop demands of the digital world. In pranayama, diaphragmatic breathing triggers the vagal response to produce a calming effect on the nervous system and relieve sympathetic dominance.30 Tekur et. al. found that patients with chronic low back pain who participated in a one week yoga intervention demonstrated decreased state and trait anxiety while the exercise control group had no significant changes in anxiety.16 Smith et. al. compared yoga’s effect on anxiety to progressive muscle relaxation using the State Trait Personality Index, General Health

Questionnaire, and Short Form-36. Both interventions demonstrated a favorable effect on anxiety measures, but yoga was found to have a greater impact on mental health.31 In a study of pregnant women who had undergone in-vitro fertilization (IVF) yoga was found to reduce pregnancy- related stress and anxiety.32 Yoga has been found useful in the management of stress and anxiety in a wide range of populations and diseases.

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Depression

Patients that suffer from chronic pain syndromes or life-threatening diseases are at a

higher risk for developing depressive disorders. Offering these patients a therapy where they play

an active role in managing their pain provides a sense of control over the condition that can help

relieve some of the mental stress that contributes to depression. Buffart et. al. performed a meta-

analysis of randomized controlled trials discussing the physical and psychosocial benefits of

yoga in cancer patients and survivors. This review found that yoga had a significant, large effect

on depression in this population.33 Additional psychosocial outcomes following yoga therapy

include reduced distress and anxiety, as well as improvements in quality of life, emotional

function, and social function.33 Tekur et. al. found that yoga was more effective than

physiotherapy exercises in reducing depression in patients with chronic low back pain (CLBP).16

Similarly, Williams et. al. found that yoga therapy had a greater effect on depression than

conventional treatment for CLBP.34 Groessl et. al. also looked at the effect of yoga in a CLBP

population. They found that yoga did reduce measures of depression, but this effect was greater

in women than in men.35

Conditi First Author Popula Length of Type Findings on (year) tion Interventio of Size n Study LBP Sherman(2011) n=228 12 weeks RCT Yoga was more effective than the self-care book group and similar in effect to the traditional stretching group. LBP Saper (2009) n=30 12 weeks RCT Yoga group demonstrated decreased pain, decreased analgesic and opiate use, and greater overall improvement than the traditional care control group. LBP Tilbrook (2011) n=313 12 weeks RCT Yoga group showed greater improvements in function than the traditional care group at 3, 6, and

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12 months. LBP Tekur (2012) n=80 1 week RCT Yoga group had significant decreases in pain levels (49%) versus physiotherapy controls (17.5%). LBP Williams (2005) n=60 16 weeks RCT Yoga group demonstrated significant reductions in pain intensity (64%), functional disability (77%) and pain medication usage (88%). OA Ebnezar (2012) n=250 12 weeks RCT Yoga group showed significantly greater improvements in walking time and pain, knee disability, range of knee flexion, joint tenderness, swelling, and crepitus than in the therapeutic exercise group following E-stim and US. OA Kolasinski (2005) n=11 8 weeks PS This pilot study demonstrated significant reductions in pain and improvements in function following an 8 week yoga intervention in patients with OA of the knees. RA Evans (2001) n=8 6 weeks PS This pilot study found significant improvements in pain and disability in young adults with RA. RA Bosch (2009) n=16 10 weeks PS This pilot study showed decreased disability, pain, and depression as well as increased balance in a small sample of RA+ post-menopausal women. Pregnan Sun (2010) n=88 12-14 weeks CCT Yoga group reported fewer pregnancy discomforts cy and great self-efficacy ratings compared to controls. Pregnan Chuntharapat n=74 6 sessions CCT Yoga group had greater maternal comfort during cy (2008) labor and 2 hours post-labor, less labor pain, and shorter labor times than the control group. Pregnan Narendran (2005) n=335 18-20 weeks CMCT Yoga group demonstrated improved birth weight, cy decreased risk of pre-term labor and complications such as pregnancy induced hypertension and isolated intrauterine growth retardation. Asthma Bidwell (2012) n=19 10 weeks RCT Asthmatic women reported significantly improved respiratory function and quality of life following a 10 week yoga intervention. Asthma Vempati (2009) n=57 8 weeks RCT Yoga group demonstrated improved pulmonary measures and Asthma Quality of Life scores as well as reduced occurrence of exercise induced bronchoconstriction. Asthma Manocha (2002) n=59 16 weeks RCT Yoga group demonstrated improved levels of airway hyperresponsiveness to methacholine (1.5 doubling doses) when compared to controls. Anxiety Smith (2007) n=131 10 weeks RCT Yoga was found to be as effective as progressive muscular relaxation in reducing anxiety and more effective at improving mental health measures. Anxiety Shim (2012) n=46 12 weeks PS In a study of women pregnant via IVF the yoga group reported less pregnancy-related stress and

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anxiety than controls. Anxiety Tekur (2012) n=80 1 week RCT Yoga group had significantly reduced state anxiety (20.4%) and trait anxiety (16%) scores while the exercise control group had no significant change in anxiety. Depressi Tekur (2012) n=80 1 week RCT Yoga was found to have a greater effect on on depression than physiotherapy exercises (47%, 19.9% respectively) CLBP Depressi Groessl (2012) n=53 10 weeks PS This study found that women veterans with CLBP on had significantly greater improvements in depression and other mental health measures than men performing the same yoga therapy. Depressi Williams (2009) n=90 24 weeks RCT CLBP patients receiving yoga therapy on demonstrated significantly greater improvements in depression using Beck’s Depression Inventory than those receiving traditional treatment.

CONCLUSION

Eighteen independent clinical trials evaluating the efficacy of yoga as a therapy are

reviewed in this paper, and those findings are summarized in the previous table on page 13.

Additionally, conclusions from several comprehensive yoga meta-analyses are included in the

discussion. In short, current research has found that yoga is a beneficial therapy for low back

pain, osteoarthritis, asthma, anxiety, and depression. Yoga as a treatment for low back pain has

the strongest level of research support, with the greatest number recent of clinical trials with the

highest quality research designs. There is a solid body of evidence, including randomized

controlled trials, to support the use of yoga in the treatment of asthma, anxiety and depression.

One strong, well designed study with a high population size (n=250) supports the use of yoga to

manage osteoarthritis related pain. Additional research into the application of yoga in pregnancy

and arthritis is warranted to make any definitive statements on its effect due to the small sample

sizes and lack of proper randomization and controls in existing research. However, preliminary

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research studies have demonstrated a positive effect on both rheumatoid arthritis and pregnancy outcomes with the use of yoga therapy. Common to all of the yoga studies reviewed was the absence of serious adverse events, which implies the inherent safety of yoga as a treatment for a variety of conditions.

Yoga research trials are often critiqued for design flaws; therefore it is essential to identify the inherent limitations in designing an appropriate control group and randomization in this type of therapy. It seems infeasible to design a control group that simulates all the mind- body-breath components of yoga where both the participants and instructors are blind to which treatment the group is receiving. For this reason yoga is typically compared to conventional treatment controls, wait-list controls, or physical therapy controls. Future yoga studies could be improved by increasing the sample size and utilizing both a wait-list control as well as an intervention control group to study the magnitude of the placebo effect. Furthermore, yoga research could be improved by the development of yoga sequences specifically tailored to the condition. Low back conditions could be studied separately to determine which poses are more beneficial for specific conditions, i.e flexion based asanas for spinal stenosis versus extension based asanas for discogenic pain syndromes.

The research into the therapeutic application of yoga is a relatively new area of study, but the direct and indirect observation of its benefits dates back thousands of years. While older yoga studies fail to meet modern research criteria, there is now a rapidly growing body of scientifically supported evidence that attests that yoga is useful in the management of a variety of mental and physical conditions. It is crucial for the physician, yoga therapist, and patient to all have a clear understanding of the role yoga can serve as well as the limitations of this therapy to maximize the benefits of this dynamic therapy.36

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