The
undisputed ubiquity of arthritis does not soften the blow of this crippling
disease when it hits. Who hasn’t seen the toll arthritis takes on a loved one
or a colleague, relentlessly chipping away at vitality sometimes in the prime
of one’s life? As a registered yoga teacher (RYT), I can vouch for the
prevalence of arthritis in the population where I live; fully one half of the
students I teach have come to class reporting some form of arthritis, either
doctor or self-diagnosed. A quick look at national statistics bears it out much
better than anecdotal evidence could:
·
An estimated 52.5 million adults in the
United States were told by a doctor that they have some form of arthritis, rheumatoid
arthritis, gout, lupus or fibromyalgia.
·
One in five (22.7%) adults in the United
States report having doctor-diagnosed arthritis.
·
By 2030, an estimated 67 million Americans
ages 18 years or older are projected to have doctor-diagnosed arthritis.
(Arthritis-Related Statistics. (2016).
Retrieved March 14, 2016, from http://www.cdc.gov/arthritis/data_statistics/arthritis-related-stats.htm)
Seeing yoga students with arthritis
improve over time with regular class attendance and home practice personally
motivates me to learn about therapeutic applications for yoga in the treatment
of arthritis. Rheumatoid arthritis (RA) interests me specifically, since I have
a family member who has suffered for many years with RA, and, one of the more successful yoga teachers I know uses yoga as a
powerful self-healing tool for her recently diagnosed RA.
Is there existing scientific evidence
demonstrating my hunch that yoga is indeed beneficial as a complementary
medical treatment for RA? The news is both good and bad: yes, there are recent
and very promising preliminary studies pointing to yoga as an effective
complementary treatment, but unfortunately the evidence base is limited and existing
studies preclude drawing scientifically definitive conclusions (Haaz, Bingham,
Wissow & Bartlett, 2015). It is currently safe to assert that yoga practice
is, at the very least, feasible as a complementary approach for people with RA
(Evans, Moieni, Taub, Subramanian, Tsao, Sternlieb & Zeltzer, 2010). Had
certain improvements been made in the quality of the studies, particularly in
their size, scope, normalization and transparency of intervention protocols, there
would be no question remaining as to yoga’s proven efficacy in successfully treating
RA (Haaz & Bartlett, 2011). The lack of definitive proof notwithstanding,
those who suffer from RA can look to the most positive and consistent findings
to date as encouragement to add yoga practice to their current treatment regimen
for a generally improved outcome.
According to statistics from the
Centers for Disease Control and Prevention (CDC), an estimated 1.5 million
adults in the US suffered from RA in 2007. New evidence suggests a recent rise
in the incidence of RA, specifically in females (Rheumatoid Arthritis Incidence
on the Rise in Women, PubMed n.d.). Coincidentally, yoga practice among women in
the US continues to increase; women with RA who are well enough to stay active
are already choosing yoga as a therapeutic form of exercise (Bernstein, n.d.).
A particularly debilitating form of
arthritis, RA is a chronic disease that significantly impacts quality of life (Evans,
Moieni, Taub, Subramanian, Tsao, Sternlieb & Zeltzer, 2010). RA is “an inflammatory,
autoimmune disorder resulting in a degeneration of the synovial lining in
joints, making them swollen, stiff and less functional” (Telles & Singh,
2012).
RA impacts not only the joints, but
the entire mind-body system, having a strong correlation with deteriorating mental
health. As with other autoimmune disorders, previous studies have found that RA
is associated with psychological stress (Telles & Singh, 2012). Increased
stress hormones have been found in the blood of patients who developed
rheumatoid arthritis and systemic lupus. In one study, people with
post-traumatic stress disorder were found to have a higher risk of developing
autoimmune disorders (Telles & Singh, 2012). Continued mental and emotional
stress is known to worsen RA symptoms, and the pain experienced in the body as
a result of the disease contributes to mental health symptoms such as
depression and anxiety (Telles & Singh, 2012). According to data compiled
by the CDC, arthritis (all types, not just RA) is strongly associated with
major depression (attributable risk of 18.1%), linked to the patient’s
experience of functional limitation. Nearly 7% of adults with arthritis report
severe psychological distress (Arthritis Related Statistics, 2016).
Because of the prevalence and
severity of all forms of arthritis among adults in the US and the resultant
loss of functioning and lifestyle impairment, more people are seeking relief
beyond what they have found through traditional medicine in complementary and
alternative medicine (CAM). “CAM is a group of diverse medical and health care
systems, practices and products that are not presently considered to be part of
conventional medicine […] CAM practices may be grouped within five major
domains: alternative medical systems, mind-body interventions,
biologically-based treatments, manipulative and body-based methods and energy
therapies. A survey released in May 2004 by the National Center for
Complementary and Alternative Medicine, part of the National Institutes of
Health in the United States, found that in 2002, 36% of Americans used some
form of alternative therapy in the past 12 months, 50% in a lifetime. Most
people use CAM to treat and/or prevent musculoskeletal conditions or other conditions
associated with chronic or recurring pain” (Tabish, 2008). Ayurveda, which
originated in India more than 5,000 years ago, is an example of a complementary
and alternative healing system; yoga, meditation, massage, diet and herbs are
encompassed under the umbrella of Ayurveda, and all of these tools are being
used in the complementary treatment regimens of RA patients.
Medical doctors are increasingly open
to the CAM treatment trend for their patients suffering from the stress of
chronic pain: “Rheumatologic conditions such as osteoarthritis, rheumatoid
arthritis and fibromyalgia, provide an optimal disease framework for using CAM because
these conditions are prevalent, have no known cause or cure, are characterized
by chronic pain and variable disease course, and often adversely affect
functional status” (Rao, 1999).
As a CAM therapy, yoga’s mind-body emphasis
makes it especially suitable for the treatment of RA, since yoga provides
concrete tools for addressing the co-occurring mental health challenges tied to
RA’s autoimmune, inflammatory and pain-management components. Yoga practice
trains people to internally focus their attention, “pinpointing the sources of
pain or anxiety and learning to relax them” at will, and consciously
(Bernstein, n.d.). Yoga therapy “involves marshalling multiple techniques that
involve the mind, body and spirit. Treatment is individualized and dependent on
the presenting symptoms” (Tabish, 2008).
Yoga as a tool to manage both
musculoskeletal and mental symptoms of RA has shown promising effectiveness in
eight different studies completed before 2012. “After reviewing the eight
studies, the following points emerged: (i) each study indicated that yoga is a
useful add-on therapy for treating RA, (ii) the studies all had limiting
factors, (iii) the most significant benefits were observed when yoga was
practiced in a combination of physical postures, regulated breathing,
meditation, and yoga philosophy, and (iv) there have been no noteworthy
attempts to explain the mechanisms underlying the changes observed. […]
Sufficient evidence exists to suggest that yoga should be considered an add-on
therapy for RA, but further research is necessary to account for limitations”
(Telles & Singh, 2012).
For both yoga therapists and
researchers who continue to blaze the trail of yoga as a complementary
treatment for RA, it is useful to underscore the symptoms which have shown the
greatest improvement under a yoga regimen. Fortunately, recent results from
multiple studies have shown promise in addressing a broad array of RA symptoms.
In Yoga for Arthritis: A Scoping Review, we
find a summary of the most effective results up to 2011: “…the most consistent findings
were for tender or swollen joints in persons with RA, which improved for all 3
studies that used this outcome. Another common outcome was pain, which improved
in 6 out of 8 studies, measured by various tools. Disability improved in 3 out
of 4 studies. Self-efficacy improved in both studies in which it was measured.
Mental health and energy improved in 2 out of 3 studies. For grip strength,
improvements were in seen in both studies of RA” (Haaz & Bartlett, 2011). One
randomized controlled trial from 2015 analyzing yoga therapy outcomes in
patients with osteoarthritis and RA aptly summarizes the comprehensive treatment
outcome: Compared to a waitlisted group of participants, as early as the eighth
week of Integral-based hatha yoga practice, “adjusted analyses showed yoga
participants reported significantly less impairment on SF-36 role physical,
body pain, general health, vitality, and mental health scales, with trends (p
< 0.08) evident in physical function and role emotional” (Haaz, Bingham,
Wissow & Bartlett, 2015). Specifically with respect to mental health
symptoms, this study found that “the yoga group reported significantly fewer
depressive symptoms (CES-D) and higher positive affect (PANAS).” Underlying
this improvement could be the benefit of decreasing perceived pain, since the
yoga group reported that their pain significantly improved. Furthermore, “yoga
was associated with substantial improvements in physical and general health
perceptions, physical roles, walking […], energy and mood. Regular yoga
practice was not associated with worsening joint symptoms or adverse events;” specifically
for the 25 RA patients included in the study, “swollen and tender joint counts
decreased significantly with yoga” and “PtGA
scores improved” (Haaz, Bingham, Wissow & Bartlett, 2015). The authors believe
that yoga’s particular effectiveness for treating arthritis can be explained by
the combination of “physical activity with potent stress management techniques,
including breathing, relaxation, and mindfulness.”
Moving forward from the successes of
the studies cited above, those of us working with RA clients would benefit from
agreement upon a generally applicable yoga intervention protocol which is
readily adaptable to individuals. As has been previously noted, in prior
studies using yoga to treat RA, “the styles, doses and format varied.” We need
to agree on “the delivered intervention” making sure it is “population
appropriate,” since “patients who have considerable musculoskeletal limitations
and symptoms” require specific modifications (Haaz & Bartlett, 2011).
As a newer RYT (I’m a 3 year
veteran), I have already noticed that too much too soon, for any yoga
practitioner, can quickly lead to burnout and an abandonment of the practice of
yoga, temporarily if not permanently. In the studies I reviewed for this
project, several authors commented on the difficulty in keeping enough
participants in programs which met very frequently (more than twice per week),
due to scheduling conflicts. Certain of the studies under review in the journal
articles cited above required the participants to do yoga daily for an extended
period of time, in a controlled setting. Clearly, this sort of regimen would
not be adaptable to most RA patients’ lifestyles. There are definite advantages
to practicing in a group (camaraderie, encouragement) with a well-qualified
teacher (safety, efficacy), however: I strongly believe that some of the
greatest breakthroughs in healing are facilitated by home practice, with the
yoga practitioner self-applying and adapting methods he/she has previously learned
under a teacher. For these reasons, I suggest that RYTs and yoga therapists
work with newer RA clients one-on-one or in a small group yoga class once per
week on an ongoing basis, while helping the clients to create a safe and
reliable home yoga practice they can repeatedly adapt according to their needs.
This is, of course, the standard yoga therapy model widely used by most all
yoga professionals. The clients who are willing and able to attend private or
group sessions more regularly can choose to do so when appropriate, without
feeling pressured to create more stress for themselves by constraining their
schedules.
With respect to the content of the
yoga sessions, given the preponderance of evidence, postural yoga alone is not
an effective intervention for RA. The most effective tool to reduce stress and
mental health symptoms is breath work; each session should begin and end with a
focus on helping the client to connect to the healing power of regulated
breathing. The postures should be introduced as therapeutic movement which is
rooted in and facilitated by the breath. Meditation and relaxation techniques
such as supported savasana and other restorative
yoga postures should be practiced in sessions with the teacher and adapted to
the client’s home practice at his/her discretion. Finally, as the existing
literature on the topic reveals, yoga philosophy should be included as a tool
to assist those suffering from RA to cope with the mental stress of
unpredictable flares and chronic pain. The home practice element of yoga
philosophy could include assigned reading of yogic texts, and journaling to
keep track of symptoms and mental reactions to disease progression.
Improvements in mental health symptoms are likely to be seen with increased self-awareness
and self-regulation.
Predictably, my particular yoga for
RA regimen harmonizes with current yoga therapy and CAM models in its holistic
and patient-driven emphasis. Many previous developments in the fields of yoga
therapy and rheumatologic medicine have contributed to the beginning success we
now see in the research cited herein. The interdisciplinary collaboration of medical
and yoga professionals in the treatment of RA patients, though already steadily
progressing, merits increased attention and support from the wider medical and
yoga communities.
REFERENCE
LIST
Arthritis-Related
Statistics. (2016, January 25). Retrieved March 14, 2016, from
http://www.cdc.gov/arthritis/data_statistics/arthritis-related-stats.htm
Bernstein,
S. (n.d.). Yoga Benefits for Arthritis. Retrieved March 14, 2016, from
http://www.arthritis.org/living-with-arthritis/exercise/workouts/yoga/yoga-benefits.php
Evans,
S., Moieni, M., Taub, R., Subramanian, S.K., Tsao, J.C.I., Sternlieb, B., &
Zeltzer, L.K. (2010). Iyengar Yoga for Young Adults with Rheumatoid Arthritis:
Results From a Mixed-Methods Pilot Study. Journal
of Pain and Symptom Management, 39(5), 904-913.
Haaz,
S., Bingham, C.O., Wissow, L., & Bartlett, S.J. (2015, July). Yoga in
Sedentary Adults with Arthritis: Effects of a Randomized Controlled Pragmatic
Trial. The Journal of Rheumatology,
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Haaz,
S., & Bartlett, S.J. “Yoga for Arthritis: A Scoping Review.” Rheumatic Disease Clinics North America, 37.1
(2011): 33-46.
Rao, J. K.
(1999). Use of Complementary Therapies for Arthritis among Patients of
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S. A. (2008, January). Complementary and Alternative Healthcare: Is it
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