Yoga as therapy: When is it helpful?

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Applied Evidence

Yoga as therapy: When is it helpful?

J Fam Pract. 2014 September;63(9):E1-E6

Good evidence supports the use of specific types of yoga for low back pain, depression, and anxiety. Fair evidence is available for 4 other indications.

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References

1. Yoga Journal. Yoga in America study 2012 [press release]. Santa Cruz, CA: Santa Cruz Bay Publishing; 2008. Available at: http://www.yogajournal.com/press/yoga_in_america. Accessed August 19, 2014.

2. Broad WJ. The Science of Yoga: The Risks and Rewards. New York, New York: Simon & Schuster; 2012.

3. Lamb T. Health Benefits of Yoga. International Association of Yoga Therapists Web site. Available at: http://www.iayt.org/?page=HealthBenefitsofYoga. Accessed August 21, 2014.

4. Yoga Alliance. 200-hour standards for yoga teacher trainings. Yoga Alliance Web site. Available at: http://yogaalliance.org/content/200-hour-standards. Accessed August 19, 2014.

5. Wren AA, Wright MA, Carson JW, et al. Yoga for persistent pain: New findings and directions for an ancient practice. Pain. 2011;152:477-480.

6. Chou R, Huffman LH; American Pain Society; American College of Physicians. Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007;147:492-504.

7. Sherman KJ, Cherkin DC, Erro J, et al. Comparing yoga, exercise, and a self-care book for chronic low back pain: a randomized, controlled trial. Ann Intern Med. 2005;143:849-856.

8. Posadzki P, Ernst E. Yoga for low back pain: a systematic review of randomized clinical trials. Clin Rheumatol. 2011;30:1257-1262.

9. Graves N, Krepcho M, Mayo HG, et al. Does yoga speed healing for patients with low back pain? J Fam Pract. 2004;53:661-662.

10. Cramer H, Lauche R, Haller H, et al. A systematic review and meta-analysis of yoga for low back pain. Clin J Pain. 2013;29:450-460.

11. Skowronek IB, Mounsey A, Handler L. Can yoga reduce symptoms of anxiety and depression? J Fam Pract. 2013;63:398-399,407.

12. Cramer H, Lauche R, Langhorst J, et al. Yoga for depression: a systematic review and meta-analysis. Depress Anxiety. 2013;30: 1068-1083.

13. D’Silva S, Poscablo C, Habousha R, et al. Mind-body medicine therapies for a range of depression severity: a systematic review. Psychosomatics. 2012;53:407-423.

14. Balasubramaniam M, Telles S, Doraiswamy PM. Yoga on our minds: a systematic review of yoga for neuropsychiatric disorders. Front Psychiatry. 2013;3:117.

15. Kirkwood G, Rampes H, Tuffrey V, et al. Yoga for anxiety: a systematic review of the research evidence. Br J Sports Med. 2005;39: 884-891.

16. Li AW, Goldsmith CA. The effects of yoga on anxiety and stress. Altern Med Rev. 2012;17:21-35.

17. Posadzki P, Ernst E. Yoga for asthma? A systematic review of randomized clinical trials. J Asthma. 2011;48:632-639.

18. Cramer H, Posadzki P, Dobos G, et al. Yoga for asthma: a systematic review and meta-analysis. Ann Allergy Asthma Immunol. 2014;112:503-510.e5.

19. Daley A, Stokes-Lampard H, Macarthur C. Exercise for vasomotor menopausal symptoms. Cochrane Database Syst Rev. 2011;(5):CD006108.

20. Chattha R, Nagarathna R, Padmalatha V, et al. Effect of yoga on cognitive functions in climacteric syndrome: a randomised control study. BJOG. 2008;115:991-1000.

21. Lee MS, Kim JI, Ha JY, et al. Yoga for menopausal symptoms: a systematic review. Menopause. 2009;16:602-608.

22. Cramer H, Lauche R, Langhorst J, et al. Effectiveness of yoga for menopausal symptoms: a systematic review and meta-analysis of randomized controlled trials. Evid Based Complement Alternat Med. 2012;2012:863905.

23. Newton KM, Reed SD, Guthrie KA, et al. Efficacy of yoga for vasomotor symptoms: a randomized controlled trial. Menopause. 2014;21:339-346.

24. Hagins M, States R, Selfe T, et al. Effectiveness of yoga for hypertension: systematic review and meta-analysis. Evid Based Complement Alternat Med. 2013;2013:649836.

25. Posadzki P, Cramer H, Kuzdzal A, et al. Yoga for hypertension: a systematic review of randomized clinical trials. Complement Ther Med. 2014;22:511-522.

26. Cramer H, Lauche R, Haller H, et al. Effects of yoga on cardiovascular disease risk factors: a systematic review and meta-analysis. Int J Cardiol. 2014;173:170-183.

27. Cohen DL, Bloedon LT, Rothman RL, et al. Iyengar yoga versus enhanced usual care on blood pressure in patients with prehypertension to stage I hypertension: a randomized controlled trial. Evid Based Complement Alternat Med. 2011;2011:546428.

28. Cohen DL, Bowler A, Fisher SA, et al. Lifestyle Modification in Blood Pressure Study II (LIMBS): study protocol of a randomized controlled trial assessing the efficacy of a 24 week structured yoga program versus lifestyle modification on blood pressure reduction. Contemp Clin Trials. 2013;36:32-40.

29. Hagins M, Rundle A, Consedine N, et al. A randomized controlled trial comparing the effects of yoga with an active control on ambulatory blood pressure in individuals with pre- and stage 1 hypertension. J Clin Hypertens (Greenwich). 2014;16:54-62.

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PRACTICE RECOMMENDATIONS

› Consider recommending Iyengar yoga or Viniyoga for the treatment of chronic low back pain in patients who express an interest in this modality. B
› Consider recommending yoga for the treatment of depression and anxiety symptoms in patients who are interested in exploring this approach. B

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

Yoga is practiced by 15.8 million Americans,¹ and is often recommended as therapy for a variety of medical conditions. However, the scientific literature on yoga is limited in scope and quality. This article presents good evidence for yoga as treatment for chronic back pain, depression, and anxiety, and fair evidence for treating asthma, symptoms of menopause, hypertension, and mobility issues in the elderly.

Yoga’s rising popularity as therapy

Yoga is a system of movement and breathing exercises meant to foster mind-body connection. Its roots are in ancient Indian practices codified by the writer Patanjali in the first or second century BCE.²

The practice of yoga was introduced to the Western world by a series of popular gurus from the 1930s to 1970s and consists primarily of asanas, or postures, and breathing exercises known as pranayama. Since then, yoga has been further subdivided into different schools and brands (TABLE^1,2), some of which are extremely taxing and vigorous and should be performed 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 conditions 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. Interventions range from a single 1-hour session to weekly sessions over several months to inpatient treatment that includes many lifestyle modifications. Some studies required subjects to practice physically demanding asanas, while others focused on pranayama or practices similar to guided relaxation.

Helping patients navigate the yoga domain

 The variability in practices described as “yoga” and the lack of a standardized credentialing for yoga teachers make it challenging for patients to find a source suitable for their particular needs. Although choosing a style of yoga appropriate to one’s fitness level and finding an experienced instructor are not straightforward undertakings, physicians familiar with the styles, risks, and benefits of yoga can help direct patients seeking this type of therapy.

The Yoga Alliance is the best-known credentialing organization; it offers a 200-hour and 500-hour curriculum covering anatomy, yoga philosophy, and hands-on practice, and grants credit for years of experience in teaching.⁴However, the Yoga Alliance began its current credentialing project just 7 years ago, and it is far from ubiquitous in the industry. Some types of yoga, such as Iyengar and Bikram, have their own certification systems that teachers may preferentially use.

Therapy credentialing. The International Association of Yoga Therapists (IAYT) was founded in 1989 to define yoga therapy and to organize practitioners attempting to use yoga to treat health conditions. As of July 2012, it had published suggested curricula for yoga therapists requiring 800 hours of study.4 Clearly, it will take time for these standards to become disseminated through the industry. At this point, IAYT membership does not require any certification or credentials.4 Moreover, the broad and decentralized nature of yoga practice means that any type of teacher and therapist credentialing or licensure will be controversial and not universally accepted among practitioners. Because of the relative newness of teacher and therapist licensing programs, many experienced and well-respected instructors may lack formal credentials or certifications.

Patients should do extensive research before choosing a type of yoga and an instructor (see “Finding a yoga instructor”). They should choose a type of yoga suited to their fitness level and general health (TABLE^1,2) to avoid serious injury, which can include fractures, neuralgia, and arterial dissection.²

Finding a yoga instructor

Two organizations may be useful in helping your patient locate a yoga instructor or therapist in your area. The International Association of Yoga Therapists (IAYT) and the Yoga Alliance both offer online search tools: http://iayt.site-ym.com/search/custom.asp?id=1156 IA (IAYT) and https://www.yogaalliance.org/yogaregistry (Yoga Alliance). Important areas of questioning for potential therapists include length of teaching experience, training programs completed, and the amount of experience the instructor or therapist has had in working with individuals with a specific medical condition. It may be prudent in certain situations to refer patients to a physical therapist for evaluation before beginning yoga study.