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Yoga As Therapy: When Is It Helpful?

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Yoga As Therapy: When Is It Helpful? ONLINE EXCLUSIVE Genevieve Verrastro, MD Yoga as therapy: MAHEC Family Health Center at Biltmore, When is it helpful? Asheville, NC genevieve.verrastro@ Good evidence supports the use of specific types of yoga gmail.com The author reported no for low back pain, depression, and anxiety. Fair evidence potential conflict of interest is available for 4 other indications. relevant to this article. oga is practiced by 15.8 million Americans,1 and is often PRACTICE recommended as therapy for a variety of medical con- RECOMMENDATIONS ditions. However, the scientific literature on yoga is lim- › Y Consider recommending ited in scope and quality. This article presents good evidence for Iyengar yoga or Viniyoga yoga as treatment for chronic back pain, depression, and anxi- for the treatment of chronic ety, and fair evidence for treating asthma, symptoms of meno- low back pain in patients pause, hypertension, and mobility issues in the elderly. who express an interest in this modality. B › Consider recommending Yoga’s rising popularity as therapy yoga for the treatment of Yoga is a system of movement and breathing exercises meant depression and anxiety to foster mind-body connection. Its roots are in ancient Indian symptoms in patients who practices codified by the writer Patanjali in the first or second are interested in exploring century BCE.2 this approach. B The practice of yoga was introduced to the Western world Strength of recommendation (SOR) by a series of popular gurus from the 1930s to 1970s and con- A Good-quality patient-oriented sists primarily of asanas, or postures, and breathing exercises evidence known as pranayama. Since then, yoga has been further sub- B Inconsistent or limited-quality 1,2 patient-oriented evidence divided into different schools and brands TABLE( ), some of C Consensus, usual practice, which are extremely taxing and vigorous and should be per- opinion, disease-oriented evidence, case series formed only by fit and healthy individuals, while others are gentle and accessible to anyone. Yoga has steadily gained in popularity, and nearly half of those who practice it say they do so to improve their health.1 How useful is the research on yoga therapy? Yoga has been a subject of Western scientific inquiry for more than 100 years. It has been deemed effective for treating con- ditions from hypertension to epilepsy,3 but many claims are poorly substantiated. Most studies report on a single case or series. The few investigational studies are mainly very small, of short duration, and lacking in appropriate blinding. Moreover, yoga practices used in the interventions vary markedly, making comparison of results difficult. Interven- tions range from a single 1-hour session to weekly sessions JFPONLINE.COM VOL 63, NO 9 | SEPTEMBER 2014 | THE JOURNAL OF FAMILY PRACTICE E1 TABLE Common forms of yoga1,2 Hatha General term for yoga incorporating postures, as opposed to breathing or meditation exercises. Also used to describe a basic, beginner style with less challenging postures. Vinyasa Fluid, flowing style wherein students move continuously between postures with coordinated breathing. Most classes are geared towards fit, physically able students. Iyengar Style known for emphasis on props to maintain proper body alignment even in less flexible students. Accessible to anyone. Training for teachers is more formal and rigorous than with other disciplines. Ashtanga Vigorous school of yoga where students move rapidly and smoothly from one posture to the next. Recommended for more athletic students. Bikram Practiced in a room heated to over 100ºF to increase flexibility. The same sequence of postures and pranayama is used in every session. Best for physically able practitioners. (Also known as “hot” yoga.) Viniyoga Incorporates breathing and chanting exercises. Postures are gentle, and students flow from one to the next. Can be done by less fit students. Kundalini Flowing style of yoga with emphasis on breathing techniques. May have more spiritual aspects than other styles. Probably for more physically fit students. Kripalu Incorporates emotional and spiritual aspects similar to psychotherapy. Breathing and postures are combined in classes, which can be physically challenging. Anusara Emphasis on alignment similar to Iyengar. Also incorporates chanting and breathing exercises. Known for warm, lighthearted atmosphere in classes. Sudarshan A series of breathing techniques with differing rates and levels of airway resistance that practitioners claim Kriya can balance the autonomic nervous system. over several months to inpatient treatment gan its current credentialing project just that includes many lifestyle modifications. 7 years ago, and it is far from ubiquitous in the Some studies required subjects to practice industry. Some types of yoga, such as Iyengar physically demanding asanas, while others and Bikram, have their own certification sys- focused on pranayama or practices similar to tems that teachers may preferentially use. guided relaxation. z Therapy credentialing. The Interna- tional Association of Yoga Therapists (IAYT) Helping patients navigate was founded in 1989 to define yoga therapy the yoga domain and to organize practitioners attempting to The variability in practices described as use yoga to treat health conditions. As of July “yoga” and the lack of a standardized creden- 2012, it had published suggested curricula for tialing for yoga teachers make it challenging yoga therapists requiring 800 hours of study.4 for patients to find a source suitable for their Clearly, it will take time for these standards to particular needs. Although choosing a style become disseminated through the industry. of yoga appropriate to one’s fitness level and At this point, IAYT membership does not re- finding an experienced instructor are not quire any certification or credentials.4 More- straightforward undertakings, physicians over, the broad and decentralized nature of familiar with the styles, risks, and benefits yoga practice means that any type of teacher of yoga can help direct patients seeking this and therapist credentialing or licensure will type of therapy. be controversial and not universally accepted The Yoga Alliance is the best-known cre- among practitioners. Because of the relative dentialing organization; it offers a 200-hour newness of teacher and therapist licens- and 500-hour curriculum covering anatomy, ing programs, many experienced and well- yoga philosophy, and hands-on practice, respected instructors may lack formal cre- and grants credit for years of experience in dentials or certifications. teaching.4 However, the Yoga Alliance be- Patients should do extensive research E2 THE JOURNAL OF FAMILY PRACTICE | SEPTEMBER 2014 | VOL 63, NO 9 YOGA THERAPY before choosing a type of yoga and an in- Most recently, Cramer et al10 found structor (see “Finding a yoga instructor” on 12 studies meeting inclusion criteria that re- page E4). They should choose a type of yoga ported on Viniyoga, Iyengar, and Hatha yoga suited to their fitness level and general health interventions. Ten of these studies were in- (TABLE1,2) to avoid serious injury, which can cluded in the meta-analysis, which strongly include fractures, neuralgia, and arterial favored yoga over control interventions for dissection.2 reducing pain and disability scores.10 Depression and anxiety The evidence for yoga’s benefits Yoga therapy for depression and anxiety has for specific conditions been commonly studied, given that aspects The promotion of yoga as medical treatment of mindfulness and relaxation are thought to is rife with dubious claims, but there is solid be important parts of treatment. Moreover, evidence for its benefits in some common patients uncomfortable with pharmacologic conditions. The evidence summaries that fol- therapy for their disorders may be amenable low reflect searches on Medline, via PubMed, to yoga treatment. In a recent Clinical Inquiry, and the Cochrane Database using the phrase Skowronek et al11 found evidence (strength of “yoga review.” recommendation [SOR] B) for yoga to treat depression and anxiety symptoms based on Back pain 3 recently published review articles that com- Iyengar yoga Often a stress-related musculoskeletal prob- mented on a total of 23 RCTs. and Viniyoga lem, back pain seems an appropriate indica- A handful of additional review papers on have been tion for treatment with yoga, and there is a this subject have selected slightly different shown large body of literature on the subject.5 In a groups of studies to include in their analy- effective in systematic review, Chou and Huffman6 found ses, but all have found generally positive re- reducing chronic only 3 studies meeting inclusion criteria on sults.12-14 Inclusion criteria varied: one review low back pain. yoga’s effectiveness for subacute or chronic omitted breathing-only modalities such as low back pain. One large study found 6 weeks Sudarshan Kriya yoga, while another includ- of Viniyoga was superior to conventional ex- ed them.12,14 One omitted Mindfulness-Based ercise programs and a self-care booklet in re- Stress Reduction (MBSR), which is a program ducing pain and “bothersomeness” scores, as developed in the United States based on well as reducing the need for analgesic medi- several Eastern and Western methodologies cation.7 Physician visits for back pain were including yoga.12 MBSR already has a large not reduced in the treatment group, how- body of literature supporting its use for anxi- ever.7 Also included in the systematic review ety and depression.12 were 2 smaller studies of Iyengar yoga on low One of these reviews,12 which involved back pain; results did not rise to statistical a meta-analysis of 9 studies regarding de- significance.6 pression, also included a meta-analysis of A review by Posadzki and Ernst8 included 5 studies on yoga for anxiety. Pooled results 4 randomized controlled trials (RCTs) not in- for depression showed significant benefit cluded in Chou and Huffman, although only for yoga over usual care, and smaller but one of these had >50 subjects. Yoga prac- still significant benefit for yoga over aero- tices for the treatment groups were mostly bic exercise or other relaxation techniques.
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