Effects of a Yoga Intervention as a Supportive Therapy in Arthritis

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Objectives: The ancient system of Yoga has been suggested as a supportive self-management therapy for arthritis. The purpose of this study was to examine the effects of a Social Cognitive Theory-based Kundalinî-Yoga intervention on arthritis patients. Design: The study utilized a pre-test, post-test design. Setting: The study was implemented through a wellness committee at the worksite of a Midwestern state health and human services department. Subjects: A total of 24 participants enrolled in the study from which 15 completed the course. Intervention: A basic intervention of 6 weeks with six 75-minute Friday lunch hour classes teaching âsanas, prânâyâma, relaxation, and meditation was implemented. Outcome measures: A psychometric scale was developed that measured self-reported pain, joint swelling, joint stiffness, functional independence, self-efficacy for performing âsanas, prânâyâma, relaxation, and meditation, and recollection of the frequency of these behaviors performed in the past week. Results: Statistically significant difference was noted only for increase in frequency of performing certain Yoga behaviors (âsanas, relaxation, and meditation) (p<0.001). Process evaluation results were positive. Conclusion: The present study offers limited support regarding the feasibility of Yoga for arthritis patients. There is need for a larger trial.

Introduction
Arthritis and chronic joint symptoms affect nearly 70 million Americans, or about one out of three adults, making it the most prevalent disease in the United States.[ 1][ 2] One of the important goals in treating arthritis is improving the functional status of the patient through symptomatic relief. Treatment typically involves use of anti-inflammatory drugs, increasing physical activity, maintenance of ideal body weight, avoidance of joint injuries, protection during weight-bearing activities, and range of motion exercises.[ 3][ 4] Treatment of arthritis relies heavily on self-management, and the ancient system of Yoga has been recommended as a supportive self-management therapy.[ 5][ 6][ 7]

The word yoga is derived from the Sanskrit word yuj, meaning "union." Yoga is an ancient system of physical and psychic practice that originated during the Indus Valley civilization in South Asia. The first detailed written records of this methodology appeared around 200 BC in the Yoga-Sûtra of Patanjali.[ 8] The system consisted of the eight-limbed path, or Ashtanga-Yoga (not to be confused with the modern Ashtanga-Yoga developed by Pattabhi Jois).

In contemporary literature, Yoga is described in various ways. For purposes of the current study, a modern interpretation of Yoga was used that includes the systematic application of techniques to promote the union and harmony of the human body, mind, and environment. In this context, Yoga is defined as "a systematic practice and implementation of mind and body in the living process of human beings to keep harmony within self, within society, and with nature."[ 9][ 10]

The traditional practice of Yoga was quite rigorous and arduous and entailed lifelong devoted practice with adherence to strict austerities. Today, many schools of Yoga have simplified the techniques, making them more suitable for users in many different walks of life.

The eight traditional steps of Patanjali's Ashtanga-Yoga include yama (rules for living in society), niyama (self-restraining rules), asâna (low physical impact postures), prânâyâma (breathing techniques), pratyâhâra (detachment of the mind from senses), dhâranâ (concentration), dhyâna (meditation), and samâdhi (complete union with super consciousness).[ 11] Several schools of Yoga exist today, and few utilize all of the above limbs of practice. One well-established school of Yoga is Kundalinî-Yoga, or the system of "primordial energy unification."[ 9][ 12] The hallmark of this school is that it starts with the seventh step of Patanjali's Ashtanga-Yoga, that of dhyâna, or meditation.

In Kundalinî-Yoga the fundamental meditation technique involves performing a "formless" contemplation at different points in the body, including the pituitary gland and the hypothalamus gland. In addition to this meditation, selected âsanas, breathing techniques, relaxation geared primarily toward muscle strain reduction, enhancement of the vital capacity of the lungs, and balancing of the endocrine system and central nervous system also are practiced.[ 13] The techniques of this school have been popularized by the Universal Peace Sanctuary (Erode, India), which was established in 1937, and the World Community Service Centre (Chennai, India), which was established in 1958. Both organizations have branches all over the world and have taught these techniques to several thousand practitioners.

Although Yoga is often recommended for arthritis, very few studies have been conducted to examine its effects.[ 4][ 14][ 15] A ten-week randomized controlled trial done in the United States with osteoarthritis patients found improvement in pain, tenderness, and range of motion.[ 4] Another small controlled trial was conducted with 20 volunteers--10 in a Yoga group and 10 in a control group.[ 14] The grip strength in both hands, the Stanford Health Assessment Questionnaire Disability Index (HAQ) score, and ring sizes increased in the Yoga group as compared to the controls. Another controlled trial done in India with rheumatoid arthritis patient found improvement in hand grip strength of both hands as measured by grip dynamometer.[ 15] The study also found that the magnitude of improvement was higher in women and in younger patients. All three of these interventions were conducted in clinical settings, were done on a small scale, and did not reify a behavioral theory for adoption of Yoga-related behaviors. All three only established tenuous support for the self-management of arthritis through the practice of Yoga.

The present study was designed to pilot test a Yoga intervention that would be feasible in public health settings, that utilized a behavioral theory, and that underscored self-management of arthritis through self-directed practice of Yoga. The purpose of the study was to examine the effects of a Social Cognitive Theory-based Kundalinî-Yoga intervention on volunteer arthritis patients. The Yoga-based program included low physical impact postures (âsana), breathing techniques (prânâyâma), meditation (dhyâna), and relaxation (shavâsana).

Methods
The pilot study was implemented through a wellness committee at the worksite of a Midwestern state health and human services department. All employees were sent an email message regarding possible participation in the study. The inclusion criteria for participation were: ( 1) having been diagnosed with arthritis and ( 2) a desire and willingness to adhere to the Yoga-based intervention for six weeks. Excluded from the study were people with: ( 1) any major disorder that limited performance of activities of daily living, ( 2) any overt disorder that limited ability to understand and give informed consent, ( 3) history of heart attack within the past six months, ( 4) history of any major surgery or hospitalization within the past six months, or ( 5) uncontrolled ailment of muscles or bones that produced severe pain. Permission from the University Institutional Review Board was obtained to conduct the study, and written informed consent from all participants was obtained.

A 17-item self-report questionnaire for pre-test and a 23-item self-report questionnaire for post-test were designed. Face validation and content validation of the instruments were done by a panel of three experts--two university professors and one administrator. Two of the subscales were taken from an earlier questionnaire[ 16] developed by the researcher and had acceptable validity and reliability (Cronbach's alpha = 0.89 and 0.93). The first five questions at pre-test pertained to duration of diagnosis and self-rating of pain, swelling, stiffness, and functional independence on a scale of 0 (least) to 10 (highest). The next four questions were about self-efficacy (or the confidence that one has in his or her ability to perform a given behavior) for Yoga-related behaviors consisting of low physical impact postures (âsana), breathing techniques (prânâyâma), meditation (dhyâna), and relaxation (shavâsana). The rating scale consisted of not at all sure (0), slightly sure ( 1), moderately sure ( 2), very sure ( 3), and completely sure ( 4). A total score was derived with a possible range from 0-16. The next four questions were about past-week recall of performing the four Yoga-related behaviors using the following rating scale: never (0), hardly ever ( 1), sometimes ( 2), almost always ( 3), and always ( 4). The final four questions were about demographics pertaining to age, gender, race, and educational level. For post-test the demographic questions were replaced by eight close-ended process-rating questions that asked about satisfaction with learning, program organization, instructor knowledge, techniques, instructor enthusiasm, program duration, video usefulness, and venue logistics using a rating scale of excellent ( 4), very good ( 3), good ( 2), poor ( 1), and very poor (0). Also at post-test two open-ended questions were asked requesting participants to identify any two strengths and any two areas of improvement for the program.

The intervention consisted of six 75-minute sessions meeting on consecutive Fridays during the lunch hour. Participants were instructed to practice the techniques at home with the help of a video provided to all subjects. They also were instructed to be attentive to their body, and if any process was too difficult or contraindicated for them they were instructed not to perform it. In the first week, participants were given an overview of Yoga and taught a set of âsanas. These âsanas included movements of the eyes, neck, shoulders, and fine motor muscles of the hands, spinal rotations, spinal rocking with flexion, extension/hyperextension of the spine, hip movements, knee movements, and leg postures. In the second week, the practice from the first week was continued and prânâyâma techniques were taught. These included abdominal breathing in different postures, alternate nostril breathing, bending breathing (bending forward during exhalation and returning to the upright position during inhalation), and inhalation:breath holding:slow exhalation following a 1:4:2 ratio. In the third week, the practice from the second week was continued and participants were taught a meditation on the pituitary gland utilizing the "touch technique."[ 12] In the fourth week, the practice from the third week continued. In the fifth week, participants were taught the "base of the spine" meditation utilizing the "touch technique."[ 12] In the final week the practices from previous weeks were repeated and directions for future practice were given. In this intervention, self-efficacy, which is a construct of Social Cognitive Theory, was developed with regard to four Yoga behaviors. This was done by teaching the behaviors in small steps (to ensure mastery) utilizing modeling by the instructor.[ 17][ 18] The instructor also provided ongoing verbal persuasion by checking that participants were performing the steps correctly, and a stress-free environment was maintained throughout each session.

Results
A total of 24 participants enrolled in the Yoga program and signed the informed consent intake form. Of these, 23 were women (95.8%) and one was a man. All the participants were Caucasian. Eight (33.3%) had completed high school and 16 (66.7%) had college education or more. The age of the participants ranged from 45 to 66 years with a mean age of 55.13 (s.d. 5.41) years. The participants had been diagnosed with arthritis with a range in duration of 2 to 204 months and a mean of 60.39 (s.d. 57.15) months.

Fifteen participants (62.5%) completed the six-week course. Table 1 summarizes the post-test process ratings by the participants in the Yoga intervention. For all eight items, the means were over the midpoint of 2, with a range of 2.79 for duration of the program to 3.80 for instructor knowledge.

Table 2 compares the study variables before and after the Yoga course. Statistically significant difference was noted only for increase in frequency of performing certain Yoga behaviors (âsanas, relaxation, and meditation) (p<0.001). In response to the open-ended questions soliciting strengths and areas for improvement, 28 comments for strengths and 10 comments for areas of improvement were provided. All ten comments for improvement were about process aspects, especially about increasing the length of the program. The majority (75%) of the comments about strengths praised process aspects, while the remaining seven comments (25%) were about actual benefits from the program in terms of pain relief, improved mobility, stress reduction, improvement in breathing, and the ability to do home chores.

Discussion
The purpose of this pilot study was to develop and test a Yoga intervention based on Social Cognitive Theory that could be used as a supportive self-management therapy for arthritis patients. Social Cognitive Theory offers an effective framework for behavior change interventions and has been empirically tested for a variety of behaviors.[ 17][ 18] The emphasis of Social Cognitive Theory on the triadic reciprocity of behavior, environment, and personal attributes is robust in explaining behavior change. The constructs of outcome expectations, self-efficacy, and self-control have been found to explain a large proportion of variance in acquisition of several health behaviors.

The results of the process evaluation of the intervention found above-average ratings on all eight aspects of the program pertaining to the instructor, instruction, and the setting. This is indicative of the acceptance and feasibility of the program. Furthermore, no side effects or adverse reactions were reported in response to Yoga therapy. Qualitatively, several strengths for the process, as well as actual benefits from the program, were mentioned. The main area of suggested improvement was increasing the duration of the program.

Pain, stiffness, swelling, and functional independence did not show statistically significant improvement in the six-week time period. There are several possible reasons: ( 1) Yoga therapy for arthritis may not work, ( 2) the time period was too short for statistically significant changes to occur, ( 3) because of attrition the sample size at post-test was too small, and ( 4) the participants did not adequately practice Yoga at home in terms of quantity and frequency. Regarding the first reason, i.e., that "Yoga therapy may not work," this is unlikely given that previous studies have indicated the approach seems to work.[ 4][ 14][ 15] Furthermore, in the qualitative data collected about strengths of the present program, one fourth of the comments were about benefits accrued. The second reason, i.e., that the time period for the program was too short, seems likely. Previous studies have been done for 10 weeks[ 4] and 3 months[ 14][ 15]. Since arthritis is a chronic disease, a longer time period for measurement of effects would be justified. The third reason, i.e., that attrition led to a too small sample size, also is important.

The intervention reified only one construct of Social Cognitive Theory, namely self-efficacy, which did not change from pre- to post-intervention. Perhaps more constructs from Social Cognitive Theory, namely expectations (anticipatory outcomes of a behavior), expectancies (values a person places on these anticipatory outcomes), and self-control, need to be reified so that the intervention may be behaviorally robust. Finally, reason number four, i.e., that participants may not have practiced adequately at home, also needs further consideration.

A statistically significant (p<0.001) change in frequency of performing certain Yoga behaviors from pre-test (mean 1.5) to post-test (mean 8.8) was found. While this is a significant improvement, it is only midway in the possible range (0-16), indicating that more regularity and time commitment is achievable. Once again, better utilization of Social Cognitive Theory can improve this aspect and strengthen the intervention.

Even though the present study offers limited support, Yoga shows potential for use as a self-management supportive therapy in arthritis. A randomized controlled trial with adequate sample size, increased duration, and expanded utilization of Social Cognitive Theory should be done in the future.

Table 1 Ratings of the Process of the Yoga Intervention at Post-Test (n=15)
Legend for Chart:

A - Variable
B - n
C - Possible Range
D - Observed Range
E - Mean
F - Std. Dev.

A B C D E F

Satisfaction with learning 15 0-4 2-4 3.13 0.92
Program organization 15 0-4 1-4 3.07 1.03
Instructor knowledge 15 0-4 3-4 3.80 0.41
Techniques taught 15 0-4 3-4 3.60 0.51
Instructor enthusiasm 15 0-4 3-4 3.73 0.46
Duration 14 0-4 1-4 2.79 1.12
Video 15 0-4 2-4 3.20 0.77
Logistics at the venue 14 0-4 1-4 3.07 1.07
Table 2 Comparison of Means and Standard Deviations of Study Variables Before and After the Completion of the Yoga Course (n=15)
Legend for Chart:

A - Variable
B - Valid n
C - Possible Range
D - Pre-test Mean (std. dev.)
E - Post-test Mean (std. dev.)
F - p-value for t-test

A B C D

E F

Arthritis pain 15 0-10 4.87 (2.29)
4.87 (2.85) 0.99

Joint swelling 15 0-10 3.73 (2.09)
2.93 (2.39 0.10

Joint stiffness 15 0-10 4.53 (2.39)
4.00 (2.20) 0.13

Functional independence 14 0-10 6.79 (2.91)
6.64 (3.69) 0.82

Self-efficacy for Yoga 15 0-16 10.60 (4.26)
10.93 (3.56) 0.72

Yoga behaviors 15 0-16 1.5 (4.26)
8.8 (3.56) 0.001
Footnotes
[1]. Praemer, A., S. Furner, and D. P. Rice. Musculoskeletal Conditions in the United States. Rosemont, Ill.: American Academy of Orthopedic Surgeons, 1999.

[2]. Bolen, J., C. G. Helmick, J. J. Sacks, and G. Langmaid. Prevalence of self-reported arthritis or chronic joint symptoms among adults--United States, 2001. MMWR, 2002, 51:948-950.

[3]. Centers for Disease Control and Prevention. Arthritis. 22 April 2004. URL: http://www.cdc.gov/nccdphp/arthritis/index.htm [accessed 1 August 2004].

[4]. Garfinkel, M. S., R. Schumacher, A. Husain, M. Levy, and R. A. Reshetar. Evaluation of a yoga based regimen for treatment of osteoarthritis of the hands. Journal of Rheumatology, 1994, 21:2341-2343.

[5]. Garfinkel, M., and H. R. Schumacher. Yoga. Rheumatic Diseases Clinics of North America, 2000, 26:125-132.

[6]. Astin, J. A., S. L. Shapiro, D. M. Eisenberg, and K. L. Forys. Mind body medicine: State of the science, implications for practice. Journal of the American Board of Family Practice, 2003, 16:131-147.

[7]. Raub, J .A. Pschophysiologic effects of Hatha yoga on musculoskeletal and cardiopulmonary function: A literature review. Journal of Alternative and Complementary Medicine, 2002, 8:797-812.

[8]. Singh, K. Religions of India. New Delhi: Clarion Books, 1983, pp. 76-78.

[9]. Maharishi, Y. V. Journey of Consciousness. New Delhi: Macmillan India Limited,1992, pp. 2-50.

[10]. Maharishi, Y. V. Logical Solutions for the Problems of Humanity. Erode, India: Vethathiri Publications, 1998, p. 4.

[11]. Romas, J. A., and M. Sharma. Practical Stress Management: A Comprehensive Workbook for Managing Change and Promoting Health. 3rd ed. San Francisco: Benajamin Cummings, 2004, p. 65.

[12]. Mahan, G. P. Kundalini Yoga. Erode, India: Universal Peace Sanctuary, 1981, pp. 1-25.

[13]. Maharishi, Y. V. Simplified Physical Exercises. Erode, India: Vethathiri Publications, 1987, pp. 1-30.

[14]. Haslock, I., R. Monro, R. Nagarathna, H. R. Nagendra, and N. V. Raghuram. Measuring the effects of yoga in Rheumatoid arthritis. British Journal of Rheumatology, 1994, 33:787-788.

[15]. Dash, M., and S. Telles. Improvement in hand grip strength in normal volunteers and Rheumatoid arthritis patients following yoga training. Indian Journal of Physiology and Pharmacology, 2001, 45:355-360.

[16]. Sharma, M. Pilot test of a yoga intervention developing the mind-body connection. International Journal of Yoga Therapy, 2001, 11:85-91.

[17]. Bandura, A. Social Foundations of Thought and Action. Englewood Cliffs, N.J.: Prentice Hall, 1986, pp. 70-207.

[18]. Bandura, A. Self-Efficacy in Changing Societies. New York: Cambridge University Press, 1995, pp. 35-49.

© Manoj Sharma 2005

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By Manoj Sharma, M.B.B.S., C.H.E.S., Ph.D.

Manoj Sharma, M.B.B.S., C.H.E.S., Ph.D., is Associate Professor, Health Promotion & Education, at the University of Cincinnati. He is a physician by initial training and completed his doctorate in Preventive Medicine/Public Health at Ohio State University. He has worked in Community Health for more than 20 years, and his research interests include designing and evaluating theory-based health education and health promotion programs, alternative and complementary systems of health, and community-based participatory research. He can be contacted at manoj.sharma@uc.edu or 513-556-3873 (messages only).

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