Yoga as a therapeutic intervention for adults with arthritis: A Systematic Review

Gerilynn GobuyanOCCT 643

Yoga• A form of mind-body practice that originated in ancient

Indian philosophy

• Goal is to achieve a state of unified consciousness

(Büssing, et al., 2012a; Büssing et al., 2012b; Garfinkel & Schumacher, 200; Haaz & Bartlett, 2011; NCCAM, 2013)

Asanas = specific

sequence of postures

Pranayams = breathing exercises

Dhyana = mental

concentration or meditation

Yoga• Numerous modern schools or

styles of yoga that are based off traditional Hatha yoga, which focuses on the mind and body• Iyengar yoga (IY) – focuses on

structural alignment of the physical body through the development of asanas; uses props to help individuals perform asanas correctly

• Raj (or rāja) yoga – meditation for spiritual self-realization; mind is the instrument of perception

• Typically lasts between 1-2 hours

(Büssing, et al., 2012a; Büssing et al., 2012b; Garfinkel & Schumacher, 200; Haaz & Bartlett, 2011; NCCAM, 2013)

Iyengar yoga

Raj yoga

Yoga & Arthritis• Regular engagement in physical activity helps preserve

physical function, increase strength and improve endurance in individuals with arthritis

• Benefits of yoga for individuals with arthritis• Engagement of muscles in isometric contraction• Strengthen stabilizing muscles to help promote balance and

improve proprioception• Increase flexibility throughout the body

• One of the most commonly used CAM therapies in the U. S. • Alternative to traditional exercises • Opportunity to remain active and engaged in health-promoting

behaviors

(American College of Rheumatology, 2002; Barnes, Bloom, & Nahin, 2008; Haaz & Bartlett, 2011)

MethodsSearch Terms• Yoga• Arthritis• Adults• Older adults• Rheumatoid arthritis (RA)• Osteoarthritis (OA)• Occupational therapy

Databases• CINHAL• OTSeeker• Scopus• PubMed• PsycINFO

Inclusion Criteria• Peer-reviewed scientific literature

published in English since 1990• Target study population being adults (≥18

years old) with arthritis• Yoga as the primary form of intervention• Sample sizes >5• Level I, II, and III evidence

Exclusion Criteria• Presentations, non-peer reviewed research,

dissertations, and theses• Addressed multiple health conditions• Use of allied health or healing arts similar to,

but not called yoga• Qualitative studies• Protocol studies• Target study population being children (<18

years old)

Results11 articles examined

4 excluded

2 qualitative studies

1 with children as target

population

2 protocol studies

7 included

5 RA studies

2 OA studies

Level of EvidenceLevel of Evidence Number of Articles

I – Randomized Controlled Trials (also systematic reviews, meta-analyses)

1

II – Two groups, non-randomized (cohort, case-control)

4

III – one group, non-randomized (pre- and post-test, before and after)

2

IV – Descriptive studies that include analysis of outcomes (single-subject design, case series)

0

V – Case reports and expert opinion that include narrative literature reviews and consensus statements

0

Results• Study Design• 1 RCT• Waitlist control

• 7 NRCTs• 1 waitlist control• 1 convenience control• 4 before and after design

• Sample Size• Ranged from 7 to 64

intervention participants• Similar comparable group

numbers• 2 studies used single groups

with no controls

• Intervention Protocol• Frequency & Duration• Ranging from 60 minutes to

5 hours for 1 week to 10 weeks

• All studies were developed and/or taught by a licensed or certified yoga professional

• Style of yoga• Hatha yoga (3 studies)• IY (3 studies)• Raj yoga (1 study)

Results• Functional Ability• Health Assessment Questionnaire (HAQ) was used in 4 of the 5 RA studies

(Badsha et al., 2009; Bosch et al., 2009; Evans et al., 2010; Telles et al., 2011)• Significant improvements (decrease in HAQ scores) found in all 4 studies

• Improvements found in 2 OA studies using the Visual Analog Scale (VAS) of pain, part of the HAQ (Garfinkel et al., 1994; Kolasinski et al., 2005)

• Clinical Outcomes• Badsha et al. (2009) – adults with RA• Disability Activity Score using 28 joint count (DAS-28) – improvements in disease

activity for the intervention group compared to control group• JAMR hydraulic hand dynamometer• No significant differences between the treatment and control groups

improvements on hand grip strength (Garfinkel et al., 1994)• Improved grip strength for male participants (Telles et al., 2011)• Improved hand grip strength for adult patients with RA post-yoga (Dash & Telles,

2001)• Kolasinski et al. (2005) – knee OA• No significant improvement in stiffness using the Western Ontario and McMaster

Universities Arthritis Index (WOMAC)

Results• Psychosocial Outcomes• Kolasinski et al. (2005) – knee OA• WOMAC pain and physical function subscales declined • Arthritis Impact Measurement Scale 2 (AIMS 2) – improvement in

AIMS2 psychological subscale, specifically affect• Beck Depression Inventory (BDI) – fewer symptoms of

depression post-yoga (Bosch et al., 2005; Evans et al., 2010)• Badsha et al. (2009) – adults with RA• Medical Outcomes Study Short Form-36 (SF-36) – no changes in

psychological health

• Medication Use• Badsha et al. (2009) – adults with RA• Reduction in medications for 3 persons with RA in the yoga group

• Dash and Telles (2001) – adults with RA• Reduction in NSAID use for the intervention group of person with

RA

Significance for Occupational Therapy

• Yoga practices improve all the body systems simultaneously• Decreases depression, pain, and anxiety • Reduces stress and increases cardiopulmonary capacity and endurance • Increases muscle strength and flexibility, endurance, balance, and

overall coordination• Strengthens bones• Increases attention, concentration, and memory

• Yoga-based interventions can be practiced one-on-one or in a group setting

• Can be used as a preparatory method or as a purposeful activity

• Can be integrated into everyday life to enhance health and wellness

Limitations of Systematic Review• Small sample sizes, especially in the pilot studies• Not generalizable to the entire population

• A majority of the studies used non-randomized controls

• Lack of control groups

• Studies did not always explain how they reduced or avoided bias

• No studies focused on occupational therapy nor were any of the certified yoga instructors also occupational therapists

Recommendations for Future Research• Create standardized protocols that enhance safety,

enjoyment, and long-term adherence• Specific poses and modifications

• Thoroughly describe the practice of yoga utilized in the study

• Sample sizes larger than 20 persons

• Interdisciplinary collaboration in the design of yoga interventions

ReferencesBadsha, H., Chhabra, V., Leibman, C., Mofti, A., Kong, K. O. (2009). The benefits of yoga for rheumatoid arthritis:

results of a preliminary, structured 8-week program. Rheumatology International, 29(12), 1417-1421.

doi: 10.1007/s00296-009-0871-1

Barnes, P. M., Bloom, B., & Nahin, R. L. (2008). Complementary and alternative medicine use among adults and

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http://www.cdc.gov/nchs/data/nhsr/nhsr012.pdf.

Bosch, P. R., Traustadottir, T., Howard, P., & Matt, K. S. (2009). Functional and physiological effects of yoga in

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National Center for Complementary and Alternative Medicine [NCCAM]. (2013). Yoga. Retrieved from

http://nccam.nih.gov/health/yoga

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