Dr. Taibi is Assistant Professor, Departments of Biobehavioral Nursing and Health Systems, and Dr. Vitiello is Professor, Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington.
The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity. This study was funded by grant NR 011400 from the Center for Research on the Management of Sleep Disturbance. This was not an industry-supported study.
Address correspondence to Diana M. Taibi, PhD, RN, Assistant Professor, Departments of Biobehavioral Nursing and Health Systems, University of Washington, School of Nursing, Box 357266, Seattle, WA 98195-7262; e-mail: firstname.lastname@example.org.
Osteoarthritis (OA) is a leading public health concern, particularly with the aging of the U.S. population (Leveille, Wee, & Iezzoni, 2005). OA is highly prevalent and increases with age; it affects 25% to 30% of people ages 45 to 65 and more than 50% of those older than 65 (Buckwalter & Martin, 2006). Approximately 80% of people with OA have movement limitations and 25% cannot perform major daily activities (World Health Organization, 2012).
Disability in OA is caused in part by loss of joint function and muscle strength, as well as OA symptoms including pain and sleep disturbance (Miller, Rejeski, Messier, & Loeser, 2001; Sharma et al., 2003). The most commonly affected joints in OA are the hip and knee, joints essential to mobility, which explains a large proportion of OA-related disability (Lawrence et al., 2008; Loeser & Shakoor, 2003). Joint degeneration related to OA is currently irreversible, and treatments primarily target palliation of symptoms and prevention of progression. Given the high prevalence and chronicity of OA, it imposes substantial health care costs estimated to exceed $60 billion annually in the United States (Buckwalter & Martin, 2006).
Nonpharmacological therapies are considered firstline OA symptom management by the American College of Rheumatology, Subcommittee on Osteoarthritis Guidelines (2000) because of their favorable safety profiles compared with medications. It is within the scope of nursing practice to recommend—and with proper training provide—nonpharmacological interventions for managing symptoms and quality of life in conditions such as OA.
Yoga is a nonpharmacological intervention that is commonly listed as beneficial for OA but for which there is little research support (Haaz & Bartlett, 2011). Yoga is a complete system of lifestyle, philosophy, and personal health practices based on ancient Indian traditions (Garfinkel & Schumacher, 2000). In the United States, yoga practice tends to primarily focus on physical postures, often with some time spent in breathing practices or meditation. Yoga poses (asanas) include standing, seated, or supine postures intended to promote strength and flexibility. Deep, regulated breathing practices (pranayama) may promote relaxation and reduce sympathetic nervous system activation (Brown & Gerbarg, 2005; Motivala, Sollers, Thayer, & Irwin, 2006; Mourya, Mahajan, Singh, & Jain, 2009).
Before nurses recommend yoga for people with OA or refer patients to specific yoga programs, they must have a basic understanding of the potential benefits and risks of yoga, along with the current state of the science. Thus, the goals of this article are to (a) to review evidence on potential benefits and risks of yoga for OA, (b) present a conceptual model for much-needed research on yoga for OA, and (c) review factors that nurses should consider when evaluating yoga programs for potential usefulness to patients.
Potential Benefits and Risks of Yoga for OA
Current research on the benefits of yoga for OA is scant but promising. The evidence may be supplemented with findings available from related study populations (e.g., yoga for other kinds of musculoskeletal pain). A search of literature on yoga for OA revealed three published studies (Garfinkel, Schumacher, Husain, Levy, & Reshetar, 1994; Kolasinski et al., 2005; Taibi & Vitiello, 2011), as well as one case study that included only 3 participants (Bukowski, Conway, Glentz, Kurland, & Galantino, 2006). Only one of these studies was controlled (Garfinkel et al., 1994), and none was a fully randomized controlled trial. The study details are presented in the Table. These small trials showed reductions of joint pain, sleep disturbance, mood disturbance, and self-report disability.
Table: Clinical Studies of Yoga for Osteoarthritis (OA)
Yoga has been shown to reduce pain in other musculoskeletal conditions, including back pain (Groessl, Weingart, Aschbacher, Pada, & Baxi, 2008; Sherman, Cherkin, Erro, Miglioretti, & Deyo, 2005; Tekur, Singphow, Nagendra, & Raghuram, 2008; Williams et al., 2005, 2009), rheumatoid arthritis (Bosch, Traustadóttir, Howard, & Matt, 2009; Evans et al., 2010), and carpal tunnel syndrome (Garfinkel et al., 1998). Studies have also shown improved functional ability in back pain (Sherman et al., 2005; Tekur et al., 2008). Sleep disturbance is a common problem in OA; studies have found varied yoga interventions improved sleep in people with insomnia (mostly young adults) and in general community samples of older adults (Chen et al., 2008, 2009; Khalsa, 2004; Manjunath & Telles, 2005).
Most studies of yoga have been characterized by interventions of short duration (6 to 8 weeks), lack of control/comparison groups, and small samples. Few have been followed by larger, more rigorous efficacy trials (Chen et al., 2009; Sherman et al., 2010; Williams et al., 2009). Results provide some support for the efficacy of yoga in reducing pain and sleep disturbance and improving function, but there remains a lack of rigorous randomized, controlled trials, particularly for OA. With yoga being commonly recommended as a useful practice for OA, research in this area is greatly needed.
With any program for older adults involving physical activity, safety is an important consideration. Yoga programs that are not designed to account for the needs of older adults and those with OA pose potential risk of injury, although there are currently no data on the extent of this problem. For yoga programs that appropriately account for the needs of people with OA, potential risks are generally modest and are consistent with other gentle forms of exercise. Few adverse effects have been reported in previous studies of yoga for OA. In one study, more than half the sample (8 of 13) reported mild, transient side effects of yoga (Taibi & Vitiello, 2011). All symptoms resolved either with continued practice (musculoskeletal soreness, calf cramps) or modification of the poses (hand numbness, dizziness). Other potential physical risks include muscle soreness, bruising, joint pain, tiredness or fatigue, dizziness, unintentional fall, blood pressure changes, and shortness of breath (Liu & Latham, 2010). Psychological risks specific to older adults may include fear of injury, discomfort, or embarrassment. Yoga classes for OA should account for the psychological, as well as physical, safety needs of older adults.
A Conceptual Model of Yoga for OA
The potential range of benefits and the general appeal of yoga are largely based in the multimodal nature of this practice. Yoga integrates factors that may be found in other health promotion practices and therapies, including strength training, balance training, meditation, mindfulness, and cognitive restructuring. Little existing research has examined the theoretical mechanisms by which yoga might affect important factors contributing to OA symptoms and disability. In this article, we propose a conceptual model, outlining potential mechanisms and effects of yoga as a multimodal therapy for OA (Figure). The model is based on current evidence of factors contributing to pain, disability, and sleep disturbance in OA.
Figure. Proposed conceptual model, outlining potential mechanisms and effects of yoga as a multimodal therapy for osteoarthritis (OA). The model is based on current evidence of factors contributing to pain, disability, and sleep disturbance in OA.
Physical Pathology and Symptoms
Joint pain in OA is related to weakness and strength imbalances in joint-stabilizing muscles, leading to joint laxity (Loeser & Shakoor, 2003; Sharma et al., 2003). People with OA also experience limited range of motion related to general effects of aging, reduced activity, and guarding of painful joints (Sharma, Kapoor, & Issa, 2006). Studies have shown reduction of joint pain through exercises to strengthen joint-stabilizing muscles (Pelland et al., 2004; Seguin & Nelson, 2003). Improved strength and flexibility could also reduce sleep disturbance by reducing the interruption of sleep by joint pain and accompanying muscle tension (Singh, Clements, & Fiatarone, 1997; Tworoger et al., 2003).
Most yoga programs for older adults exercise the entire body but not specific muscle groups; however, those with OA may benefit from programs targeting the specific joint(s) affected (e.g., knee) or the most affected region. In particular, the hip and knee are the joints most affected by OA, which results in significant impairment of mobility and independence (Lawrence et al., 2008; Loeser & Shakoor, 2003). A program equally emphasizing upper and lower body may not maximize potential benefits to those with hip or knee OA. Such individuals may derive greater therapeutic benefit from programs focusing on poses for strength and flexibility in the muscle groups most important for lower extremity joint stability: hip abductors, adductors, flexors, extensors, and rotators; and quadriceps (Bennell, Hunt, Wrigley, Hunter, & Hinman, 2007; Hinman et al., 2010). Yoga studies including such poses have shown improvement in leg strength, endurance, and flexibility in both young and older adults (Chen et al., 2008; Fan & Chen, 2011; Field, 2011; Hart & Tracy, 2008; Roland, Jakobi, & Jones, 2011).
Current evidence suggests that both pain and sleep disturbance are exacerbated by persistent physiological arousal (i.e., activation of the sympathetic nervous system, SNS). Pain transmission is augmented by stress and resulting SNS activation, and pain itself acts as a stressor, further increasing pain sensitivity (Lee et al., 2011). Sleep disturbance in OA may be exacerbated by rumination on symptoms during nighttime periods of wakefulness, leading to physical tension and subsequent SNS activation (Riemann et al., 2010). Yogic slow deep breathing exercises may shift the balance of autonomic activity from the sympathetic toward the parasympathetic. Numerous studies of relaxing yogic breathing practices have shown increased parasympathetic and reduced sympathetic activity (Bernardi et al., 2001; Brown & Gerbarg, 2005; Patra & Telles, 2010; Pramanik et al., 2009; Vempati & Telles, 2002). This shift toward reduced physiological activation may reduce stress and tension-related musculoskeletal pain (Chalaye, Goffaux, Lafrenaye, & Marchand, 2009), as well as SNS-related disruption of sleep onset and maintenance (De Zambotti, Covassin, De Min Tona, Sarlo, & Stegagno, 2010). In addition, many yoga programs end with a deep relaxation exercise (savasana, called “resting pose” or “corpse pose”). Various relaxation approaches similar to resting pose (e.g., progressive muscle relaxation) have been shown to reduce pain and improve sleep (Baird, Murawski, & Wu, 2010; Baird & Sands, 2004; Lichstein et al., 1999; Lichstein, Riedel, Wilson, Lester, & Aguillard, 2001; Means, Lichstein, Epperson, & Johnson, 2000).
Research supports the role of maladaptive cognitive patterns in pain, disability, and sleep disturbance (Harvey, Tang, & Browning, 2005; Morin, 2004). Studies have shown that pain catastrophizing (rumination on and magnification of the pain experience) predicts worse pain and disability (Campbell et al., 2010; Keefe & Somers, 2010). Training in pain coping skills has been shown to be effective in reducing catastrophizing in people with OA (Keefe & Somers, 2010; Riddle et al., 2011). Maladaptive cognitions may also contribute to sleep disturbance in those with OA. Many individuals who experience difficulty sleeping develop cognitive patterns that disrupt sleep, including worrying, attending to physical sensations, ruminating about their inability to sleep, or catastrophizing about daytime consequences of poor sleep (Harvey et al., 2005). Distraction approaches have been shown to reduce the interference of cognitive patterns with sleep (Harvey & Payne, 2002; Ree, Harvey, Blake, Tang, & Shawe-Taylor, 2005). Relaxation therapies may also improve sleep by requiring cognitive focus that interrupts disruptive cognitions (Harvey et al., 2005), in addition to reducing muscular tension.
Yogic techniques that require concentration may provide a form of distraction that could be useful for stopping disruptive cognitive patterns related to pain and sleep disturbance in OA. In yoga, it is common to cultivate mental focus on the present through awareness of thoughts and guided attention to physical sensations (e.g., coordinating movements with inhalation and exhalation). Yogic breathing exercises, which require focused attention, have been shown to reduce anxiety and improve sleep in a limited number of studies (Brown & Gerbarg, 2005; Khalsa, 2004; Kirkwood, Rampes, Tuffrey, Richardson, & Pilkington, 2005).
Another important cognitive process in yoga is mindfulness. Mindfulness is defined as nonjudgmental attention to physical experiences in the present moment (Ludwig & Kabat-Zinn, 2008). In yoga practice, mindfulness is cultivated by the mental focus needed to perform nuanced practices, such as engaging core muscles to support movement or coordinating inhalation/exhalation with specific movements. Two studies of yoga for fibromyalgia that emphasized mindfulness in the intervention demonstrated significantly reduced pain catastrophizing, and one of these studies showed a significant increase in mindfulness (Carson et al., 2010; Curtis, Osadchuk, & Katz, 2011). A mindfulness-based stress reduction program has been shown to reduce arthritis pain (Rosenzweig et al., 2010). Another mindfulness-based cognitive-behavioral therapy program for insomnia was shown to produce sustained reduction of sleep disturbance over 12 months (Ong, Shapiro, & Manber, 2009). Thus, the cultivation of mindfulness in yoga practice could improve management of both pain and sleep disturbance. The nonjudgmental orientation of mindful awareness has potential to engage older adults who may experience frustration with exercise programs due to self-criticism related to their physical limitations.
The physical aspects of yoga—poses and breathing practices—could promote relaxation and reduce stress through physiological mechanisms, such as muscle relaxation and shifting the autonomic nervous system from sympathetic to parasympathetic predominance. Cognitive aspects of yoga, including meditative mental focus and mindfulness, may also contribute to reduction of pain and sleep disturbance through effects similar to conventional cognitive therapies but with the advantage of being integrated into the physical practice. Finally, this conceptual model provides a foundation for much-needed research on the mechanisms of yoga. It can also serve as a guide for tailoring yoga programs to patients’ specific needs.
Considerations for Recommendation of Yoga Programs
When health practitioners recommend that patients take up an activity such as yoga, patients may not know where to find programs, or even what program features would be preferred. Nurses can help educate patients who are interested in yoga about various considerations for finding an appropriate program.
Practice Style or Tradition
There are numerous styles of yoga originating from the traditions of various founders, both ancient and contemporary. These styles vary in the approach to physical postures and the overall flow of a yoga practice session. Therapeutic yoga programs are often based in the Iyengar or Viniyoga™ styles. In Iyengar yoga, practitioners move carefully and deliberately into and out of each individual pose, often using props such as yoga blocks or straps. Certification to teach Iyengar style requires extensive training, and teachers must adhere to the Iyengar approach to yoga poses (Ramamani Iyengar Memorial Yoga Institute, 2010). Thus, this tradition offers a high level of standardization of instruction across teachers. The use of supportive props is useful for older adults, who may have insufficient range of motion or strength to perform yoga poses without some form of assistance. Supportive props may also be reassuring to older adults if they are uncertain of their own capabilities.
The Viniyoga style is also well suited to therapeutic yoga because it does not focus on attainment of yoga poses but rather focuses on use of select poses to achieve a desired effect on the body (Kraftsow, 1999). Poses are commonly modified for varying physical capabilities to reduce muscle and joint strain. Whereas most styles of yoga have practitioners hold a pose for a time (e.g., several breath cycles), Viniyoga tends to emphasize repetition of postures (moving into and out of the pose with each breath cycle, generally repeated three to six times). The emphasis on repetition is intended to increase circulation to muscles and avoid strain-related injuries. Repetition of poses is also intended develop healthy habitual movement patterns, versus rigid and restricted movement that is common in modern, sedentary lifestyles (Kraftsow, 1999). Repetition of postures is useful for older adults who may not be able to hold prolonged yoga postures. Like Iyengar yoga, Viniyoga focuses on healthy musculoskeletal alignment, incorporates supportive props, and requires rigorous instructor training (American Viniyoga Institute, 2011; Kraftsow, 1999).
Numerous other yoga traditions are available in the United States. Some may be appropriately adapted to the needs of older adults and those with arthritis (e.g., Anusara, Integral), whereas others are strenuous and not advisable for people with arthritis (Haaz, 2009). In particular, Bikram yoga or other styles of “hot” yoga are not recommended. These styles are performed in rooms heated to as high as 105 °F. The heat may exacerbate circulatory problems in older adults, cause overheating, or risk joint injury by increasing tendon and ligament laxity. Ashtanga and “power” yoga are also not recommended. These styles incorporate strenuous poses and quick progression from one pose to the next. This approach risks injury in those with arthritis or other forms of joint instability.
Teacher qualifications are potentially confusing, particularly because yoga certification is not standardized or regulated. Individual training programs verify (i.e., certify) that the individual has completed that program’s required training. This training is usually either 200 or 500 hours and includes instruction of poses (asanas), breathing practices (pranayama), and to varying degrees, yoga theory and chanting (mantras). It is important to know from which program a yoga teacher received certification and what training that program provided. Yoga Alliance® ( http://yogaalliance.org) is a national organization that provides some standardization by maintaining a registry of 200- and 500-hour instructor programs (Registered Yoga Schools®) that meet or exceed certain Yoga Alliance-determined requirements. The Yoga Alliance does not certify yoga instructors, but it does register instructors who complete Yoga Alliance-approved training. These individuals are given the designation Registered Yoga Teacher®. The Yoga Alliance also registers highly experienced instructors (1,000+ hours of teaching), prenatal instructors, and children’s yoga instructors. Instructors do not always choose to be registered with the Yoga Alliance. It is not possible to know such instructors’ qualifications (many have attended reputable programs or even Yoga Alliance-registered schools) except by researching the program from which the individual received certification.
“Dose” of Yoga Practice
It is not currently known what “dose” of yoga (i.e., cumulative time spent in practice) is needed to achieve therapeutic effects. In yoga, dose is determined by the duration of each class/session, the number of classes and/or home practice sessions per week, and the length of the program (weeks, months). Our review of 18 previous studies of yoga for musculoskeletal conditions or older adults found that the studies varied significantly in the weekly dose (mean = 203 minutes, range = 45 to 600 minutes) and total (cumulative) dose of yoga received (mean = 3,050 minutes, range = 480 to 10,800 minutes) (Badsha, Chhabra, Leibman, Mofti, & Kong, 2009; Bosch et al., 2009; Brown, Koziol, & Lotz, 2008; Bukowski et al., 2006; Chen et al., 2008, 2009; Evans et al., 2010; Galantino et al., 2004; Garfinkel et al., 1994, 1998; Greendale, Huang, Karlamangla, Seeger, & Crawford, 2009; Groessl et al., 2008; Kolasinski et al., 2005; Manjunath & Telles, 2005; Sherman et al., 2005; Tekur et al., 2008; Williams et al., 2005, 2009). The longest times spent in practice were achieved either by multiple classes per week or by daily home practice. Because many individuals think of yoga as a practice that is only done in a class setting, it may be useful to educate them that they may benefit from home practice in addition to classes. This could reduce the financial burden of yoga practice to individuals. However, individuals planning to practice at home would require a class that provides instruction on how to safely practice independently.
The potential safety and benefit of a yoga program may depend not only on the poses, breathing practices, and meditative components, but also on the practice style, instructor training, and amount of practice. Health care providers may find it useful to research these factors in advance to have a list of potentially useful local programs available for patients.
Yoga is a multimodal, mind-body practice that originates in ancient traditions and has promise as a therapeutic approach to reducing symptoms and disability in people with OA. Little research has been done, but evidence from related fields is promising and supports further examination of yoga for OA. To help health care providers offer the best evidence-based recommendations for patients, rigorous research is needed, testing whether a yoga program for OA would indeed reduce symptoms, improve function, and enhance quality of life. This article presented a conceptual model that can guide the planning of yoga interventions, as well as selection of outcome measures for investigating the mechanistic effects of yoga. If efficacy were demonstrated, exploring the mechanisms presented in our model could guide further improvement of the yoga program to augment its therapeutic effects and maximize benefits for patient health. Finally, testing of efficacy should be followed by translational research: that is, research on implementing the program in real-life settings (versus highly controlled research applications) and examination of the impact on public health.
Yoga is commonly recommended as a useful practice for individuals with OA, but insufficient evidence exists to recommend specific programs, or even general yoga approaches. Thus, nurses must use caution when recommending yoga programs to patients. Nurses could help patients greatly by educating them about safety, appropriate yoga styles for people with OA, and instructor qualifications for selecting an appropriate program.
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Clinical Studies of Yoga for Osteoarthritis (OA)
||Design and Sample
|Garfinkel, Schumacher, Husain, Levy, & Reshetar (1994)
||Randomized partial crossover N = 26 with hand OA, ages 52 to 79 (mean age not reported)
||Iyengar yoga asanas, focus on respiration and body alignment
||One 60-minute class per week for 8 weeks. Total time = 8 hours. Home practice not mentioned.
||Significant differences between yoga and control groups on: reduction of finger joint tenderness, improvement of hand range of motion and hand pain during activity. No significant difference in grip strength, finger joint circumference, hand pain at rest, or self-report hand function pain. Adverse events not reported.
|Kolasinski et al. (2005)
||One-group pilot study N = 7a with knee OA, ages 50 to 68 (mean age = 58.6)
||Iyengar yoga asanas
||One 90-minute class per week for 8 weeks. Total time = 12 hours. Home practice not required.
||Statistically significant reduction in pain, disability, and mood disturbance. Reported no adverse events.
|Taibi & Vitiello (2011)
||One-group pilot study N = 14 with OA of any joint, mean age = 65.2 (SD = 6.9 years)
||Hatha yoga asanas and pranayama
||One 75-minute class per week for 8 weeks. 20-minute audio-guided home practice on non-class days. Total time = 26 hours.
||Statistically significant reduction in sleep disturbance and diary-reported sleep outcomes. Nonsignificant reduction of sleepiness, depressed mood, and pain. Eight participants had minor adverse events.