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Yoga as Therapy: When Is It Helpful?

Clinician Reviews. 2014 September;24(9):E1-E6

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.

30. Howe TE, Rochester L, Neil F, et al. Exercise for improving balance in older people. Cochrane Database Syst Rev. 2011;(11):CD004963.

31. Jeter PE, Nkodo AF, Moonaz SH, et al. A systematic review of yoga for balance in a healthy population. J Altern Complement Med. 2014;20:221-232.

32. Tiedemann A, O’Rourke S, Sesto R, et al. A 12-week Iyengar yoga program improved balance and mobility in older community-dwelling people: a pilot randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2013;68:1068-1075.

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Symptoms of menopause

Studies have focused on alternative or adjunctive therapies for menopause symptoms, primarily hot flashes, since hormone replacement therapy and other conventional medical therapies have been found to have a high incidence of adverse effects. However, evidence that yoga can reduce hot flashes is sparse.

A Cochrane review examined the effects of exercise on hot flashes and found 2 RCTs using yoga as a treatment modality. Neither one found statistically significant differences between the yoga groups and conventional exercise groups.¹⁹ The authors concluded there was insufficient evidence to show yoga was more effective than other forms of exercise on vasomotor symptoms of menopause. However, a large RCT included in the Cochrane review did show lower stress levels and decreased overall symptoms in the yoga arm.²⁰

The yoga intervention in this study consisted of pranayama, sun salutation (a repetitive sequence of 12 yoga postures), and cyclic meditation.²⁰ Lee et al²¹ reviewed the 2 studies used in the Cochrane paper as well as 5 other studies. Two were RCTs showing that yoga intervention was not superior to a no-treatment control. Four studies showed favorable results for yoga interventions; however, one was a nonrandomized controlled trial and 3 lacked control groups.

Cramer et al²² attempted pooled analysis of 5 studies, including those in the Cochrane paper, with similar results: Yoga interventions were not efficacious for somatic, vasomotor, or urogenital symptoms of menopause. Yoga was somewhat efficacious for psychological symptoms associated with menopause.²² More recently, an RCT (N=249) found that yoga reduces vasomotor symptoms no more frequently than non-yoga exercise.²³

Hypertension

Yoga is often said to reduce blood pressure (BP), which would make sense given the emphasis put on relaxation by many schools of yoga. In the past 2 years, 3 review articles have been published, as well as 2 relevant RCTs not included in those reviews.

Hagins et al²⁴ found 17 RCTs using yoga to treat adults with hypertension and prehypertension. These included both blinded and unblinded studies, and yoga interventions were compared with usual treatment, education, or non-yoga exercise. The authors included only studies of asanas intervention, and excluded interventions using only breathing or relaxation techniques.²⁴ In meta-analysis, pooled data showed the yoga treatment decreased both diastolic BP (DBP) and systolic BP (SBP) by 3 to 4 mm Hg compared with usual treatment, but not when compared with other exercise therapies.²⁴ Reviewers concluded that yoga was likely as effective for lowering BP as other types of physical activity.²⁴

In a review without meta-analysis, Posadzki et al²⁵ also found 17 blinded RCTs using yoga to treat hypertension or prehypertension in adults. Eleven of the 17 studies favored yoga, with 8 showing a decrease in SBP and 5 in DBP.²⁵ All but 2 studies were found to be of poor quality, especially with regard to blinding.²⁵ The authors noted that studies using subjects with prehypertension or hypertension with comorbidities were more likely to show significant results, speculating that yoga may be more effective for these populations.²⁵

In an ambitious review article on yoga as treatment for a variety of risk factors for cardiovascular disease, Cramer et al²⁶ located 28 RCTs that addressed effects of yoga on BP. Seven of the studies in the Posadzki review²⁵ were included. Meta-analysis showed a statistically significant decrease in SBP of 5.85 mm Hg and in DBP of 4.12 mm Hg.²⁶ Although wide in scope, this meta-analysis included many studies of healthy patients without hypertension who could conceivably have differing neuroendocrine responses to yoga practice.

Search engines offered by the Yoga Alliance and the International Association of Yoga Therapists can help patients to locate a yoga instructor or therapist in their area.In a pilot RCT, Cohen et al²⁷ found a significant decrease in BP among subjects randomized into Iyengar yoga classes for 24 weeks compared with a control group educated about lifestyle modification. A larger study with 102 subjects is currently underway.²⁸ These studies were unique in that no subjects were currently being treated with antihypertensive medications^27,28; most other trials on this subject enrolled participants on antihypertensive medications if their regimens had been stable for some time.

In an RCT published recently by Hagins et al,²⁹ 68 subjects with pre- or stage I hypertension were randomized into Ashtanga yoga classes or non-aerobic exercise classes formulated to burn equivalent METs. After 12 weeks of treatment, the yoga subjects’ BP had significantly decreased from starting values, but was not improved compared with the exercise subjects.²⁹ This further supports the assertion that yoga is equivalent to other forms of physical activity in decreasing BP among hypertensive subjects.

Balance and stability in the elderly

With its emphasis on strength, balance, and body awareness, yoga would seem a helpful intervention for older patients at risk of injury from falls. Unfortunately this area of research lacks significant numbers of controlled trails. In a Cochrane review of exercise interventions for improving balance in the elderly, the reviewers were unable find any studies specifically using yoga that met their criteria.³⁰ Jeter et al³¹ attempted a review more recently, and found 15 studies meeting inclusion criteria, 5 of which were RCTs. Overall, however, the poor quality of the studies and variation in both the type of yoga used as intervention and measurements of balance precluded pooled analysis, although some studies did have positive results.

A small but well-designed pilot RCT was recently published showing that an Iyengar yoga intervention significantly improved timed one-leg balancing among community dwelling older adults.³² However, this study did not show a significant difference in a standardized fall risk survey after the intervention.³²

Cautioning against yoga in this context are several articles chronicling increased risks of some yoga exercises, especially for those with osteoporosis or other risks for fractures.³³ At this point, the well-documented risks of yoga practice in this group probably outweigh the unsubstantiated rewards.

CORRESPONDENCE
Genevieve Verrastro, MD, MAHEC Family Health Center at Biltmore, 123 Hendersonville Road, Asheville, NC 28803; genevieve.verrastro@gmail.com