Library of Research Articles on Veterans and CIH Therapies
Library of Research Articles on Veterans and Complementary and Integrative Health Therapies and Chiropractic Care
January 2021 Edition
Avery T, Blasey C, Rosen C, Bayley P. Psychological Flexibility and Set-Shifting Among Veterans Participating in a Yoga Program: A Pilot Study. Mil Med. 2018 Nov 1;183(11-12):e359-e363.
Trauma-focused psychotherapies do not meet the needs of all veterans. Yoga shows some potential in reducing stress and perhaps even PTSD in veterans, although little is understood about the mechanisms of action. This study identifies preliminary correlates of change in PTSD and perceived stress for veterans participating in yoga.
MATERIALS AND METHODS
Nine veterans (seven males and two females) were recruited from an existing clinical yoga program and observed over 16 wk. Severity of PTSD symptoms (PCL-5) and perceived stress (PSS-10) were collected at baseline and weeks 4, 6, 8, and 16. Psychological flexibility (AAQ-II) and set-shifting (ratio of trail making test A to B) were collected at baseline and at week 6. Subjects attended yoga sessions freely, ranging from 1 to 23 classes over the 16 weeks. The Stanford University Institutional Review Board approved this research protocol.
Self-reported PTSD symptoms significantly reduced while perceived stress did not. Lower baseline set-shifting predicted greater improvements in PTSD between baseline and 4 weeks; early improvements in set-shifting predicted overall reduction in PTSD. Greater psychological flexibility was associated with lower PTSD and perceived stress; more yoga practice, before and during the study, was associated with greater psychological flexibility. Other predictors were not supported.
In a small uncontrolled sample, psychological flexibility and set-shifting predicted changes in PTSD symptoms in veterans participating in a clinical yoga program, which supports findings from prior research. Future research should include an active comparison group and record frequency of yoga practiced outside formal sessions.
Avery TJ, Schulz-Heik RJ, Friedman M, Mahoney L, Ahmed N, Bayley PJ. Clinical yoga program utilization in a large health care system. Psychol Serv. 2020 Mar 5. doi: 10.1037/ser0000420.
The U.S. Department of Veterans Affairs (VA) offers yoga for multiple conditions. Little information is available regarding how frequently yoga is utilized, by whom, or for which medical conditions. Here we describe referral patterns and patient adoption rates in a clinical yoga program, including telehealth yoga, at VA Palo Alto Health Care System (VAPAHCS). Referral and demographic data were extracted from the electronic medical records of 953 veterans (692 male, 261 female) referred to the outpatient clinical yoga program between 2010 and 2016. Attendance data were extracted from the same time plus 1 year. Referee demographics were compared to the overall VAPAHCS population. Twenty-two of the 187 referring providers accounted for half (50.4%) of referrals, predominantly from primary care and mental health clinics. Compared to the overall VAPAHCS patient population, referees were similar age and more likely to be female. Attendance was associated with age (older veterans were more likely to attend) but not gender. Those referred for mental health reasons were more likely to attend yoga compared to those referred for physical symptoms or for wellness (e.g., strength, health, mindfulness). Telehealth yoga follow through was lower but attendance rate similar to in-person yoga. These data provide an overview of referral and uptake in a large VA setting. Overall, referral was performed by a few providers in mental health and primary care clinics. The typical demographic of attendee was a White male from the Vietnam War era, reflective of the VA population. (PsycINFO Database Record (c) 2020 APA, all rights reserved).
Baker MR, Tessier JM, Meyer HB, Sones AC, Sachinvala N, Ames D. Yoga-Based Classes for Veterans With Severe Mental Illness: Development, Dissemination, and Assessment. Fed Pract. 2015 Oct;32(10):19-25.
There is growing interest in developing a holistic and integrative approach for the treatment of severe mental illnesses (SMI), such as schizophrenia, major depression, posttraumatic stress disorder (PTSD), and anxiety disorders. Western medicine has traditionally focused on the direct treatment of symptoms and separated the management of physical and mental health, but increasing attention is being given to complementary and alternative medicine (CAM) for patients with SMI. Throughout 8 weeks of yoga-based wellness classes, veterans were assessed for perceived benefits, pain, stress, and biological, psychological, social, and spiritual wellness.
Bayley PJ, Schulz-Heik RJ, Cho R, Mathersul D, Collery L, Shankar K, Ashford JW, Jennings JS, Tang J, Wong MS, Avery TJ, Stanton MV, Meyer H, Friedman M, Kim S, Jo B, Younger J, Mathews B, Majmundar M, Mahoney L. Yoga is effective in treating symptoms of Gulf War illness: A randomized clinical trial. J Psychiatr Res. 2020 Nov 11:S0022-3956(20)31083-9. doi: 10.1016/j.jpsychires.2020.11.024.
Many Veterans of the 1990-1991 Gulf War report symptoms of Gulf War Illness, a condition involving numerous chronic symptoms including pain, fatigue, and mood/cognition symptoms. Little is known about this condition's etiology and treatment. This study reports outcomes from a randomized controlled single-blind trial comparing yoga to cognitive behavioral therapy for chronic pain and other symptoms of Gulf War Illness. Participants were Veterans with symptoms of GWI: chronic pain, fatigue and cognition-mood symptoms. Seventy-five Veterans were randomized to treatment via selection of envelopes from a bag (39 yoga, 36 cognitive behavioral therapy), which consisted of ten weekly group sessions. The primary outcomes of pain severity and interference (Brief Pain Inventory- Short Form) improved in the yoga condition (Cohen's d = .35, p = 0.002 and d = 0.69, p < 0.001, respectively) but not in the CBT condition (d = 0.10, p = 0.59 and d = 0.25 p = 0.23). However, the differences between groups were not statistically significant (d = 0.25, p = 0.25; d = 0.43, p = 0.076), though the difference in an a-priori-defined experimental outcome variable which combines these two variables into a total pain variable (d = 0.47, p = 0.047) was significant. Fatigue, as indicated by a measure of functional exercise capacity (6-min walk test) was reduced significantly more in the yoga group than in the CBT group (between-group d = .27, p = 0.044). Other secondary outcomes of depression, wellbeing, and self-reported autonomic nervous system symptoms did not differ between groups. No adverse events due to treatment were reported. Yoga may be an effective treatment for core Gulf War Illness symptoms of pain and fatigue, making it one of few treatments with empirical support for GWI. Results support further evaluation of yoga for treating veterans with Gulf War Illness.
Bolton RE, Fix GM, VanDeusen Lukas C, Elwy AR, Bokhour BG. Biopsychosocial benefits of movement-based complementary and integrative health therapies for patients with chronic conditions. Chronic Illn. 2018 Jan 1:1742395318782377. doi: 10.1177/1742395318782377. [Epub ahead of print] PubMed PMID: 29914264.
Complementary and integrative health practices are growing in popularity, including use of movement-based therapies such as yoga, tai-chi, and qigong. Movement-based therapies are beneficial for a range of health conditions and are used more frequently by individuals with chronic illness. Yet little is known about how patients with chronic conditions characterize the health benefits of movement-based therapies.
We conducted focus groups with 31 patients enrolled in yoga and qigong programs for chronic conditions at two VA medical centers. Transcripts were analyzed using conventional content analysis with codes developed inductively from the data. Participants' descriptions of health benefits were then mapped to Engel's biopsychosocial model.
Participants described improvements in all biopsychosocial realms, including improved physical and mental health, reduced opiate and psychotropic use, enhanced emotional well-being, and better social relationships. Changes were attributed to physical improvements, development of coping skills, and increased self-awareness.
Patients with chronic illnesses in our sample reported multiple benefits from participation in movement-based therapies, including in physical, mental, and social health realms. Providers treating patients with complex comorbidities may consider referrals to movement-based therapy programs to address multiple concerns simultaneously, particularly among patients seeking alternatives to medication or adjunctive to an opiate reduction strategy.
Chopin SM, Sheerin CM, Meyer BL. Yoga for warriors: An intervention for veterans with comorbid chronic pain and PTSD [published online ahead of print, 2020 Jul 23]. Psychol Trauma. 2020;10.1037/tra0000649.
Comorbid chronic pain and posttraumatic stress disorder (PTSD) is common in veterans; this comorbidity is associated with increased severity and poorer prognosis when compared to each outcome alone. Yoga has been shown to be effective for chronic pain and promising for PTSD, but yoga for comorbid pain and PTSD has not been examined. This article offers empirical support for a yoga intervention for comorbid chronic pain and PTSD in a veteran population.
Results are presented from a 4-year pilot yoga intervention for comorbid chronic pain and PTSD at a large, urban Veterans Affairs Medical Center. Based on the fear avoidance model of pain, the intervention used a cross-sectional, open-trial design with pre- and postmeasures. T test analyses were conducted on program completers (N = 49; out of 87 initially enrolled, 44% attrition rate), who were primarily African American (69%) and male (61%) and had a mean age of 51.41 years (SD = 11.32).
Results indicated trend-level reductions in overall PTSD symptoms, as measured by the PTSD Checklist for DSM-5 (p = .02, d = 0.38) and in symptom cluster scores of negative alterations of cognitions and mood (p = .03, d = 0.36) and arousal and reactivity (p = .03, d = 0.35). Veterans reported significant improvement in ability to participate in social activities (p < .001, d = 0.44) and significant reductions in kinesiophobia (fear of movement or physical activity; p < .001, d = 0.85). On a satisfaction measure with a range of 1 (quite dissatisfied) to 4 (extremely satisfied), the mean rating was 3.74 (SD = 0.33).
Yoga is a feasible and effective intervention for veterans with comorbid chronic pain and PTSD.
Coeytaux RR, McDuffie J, Goode A, Cassel S, Porter WD, Sharma P, Meleth S, Minnella H, Nagi A, Williams JW Jr. Evidence Map of Yoga for High-Impact Conditions Affecting Veterans [Internet]. Washington (DC): Department of Veterans Affairs (US); 2014 Aug.
Patient-centered care supports the active involvement of patients and their families in the decision-making process between options for treatment. Part of this mission is to identify, develop, and implement new practices and approaches that are found to be effective in promoting the transformation to a patient-centered model and improved patient care. Complementary and alternative medicine (CAM) strategies such as yoga are widely available in the private sector, and some Veterans would like access to these strategies through the Veterans Affairs (VA) system. Determining the state of evidence on the benefits and harms of yoga and other CAM modalities is a priority for the Veterans Health Administration (VHA). To fulfill the joint research needs of the Office of Patient Centered Care and the Field Advisory Committee on Complementary and Alternative Medicine, and to help VA leadership determine the most appropriate guidelines/policy for the implementation of CAM therapies within the VA, the Evidence-based Synthesis Program Coordinating Center proposed a CAM evidence mapping project to evaluate the existing evidence on yoga for common clinical conditions in Veterans.
Combs MA, Critchfield EA, Soble JR. Relax while you rehabilitate: A pilot study integrating a novel, yoga-based mindfulness group intervention into a residential military brain injury rehabilitation program. Rehabil Psychol. 2018 May;63(2):182-193. doi: 10.1037/rep0000179. Epub 2018 Mar 12.
This preliminary, pilot study assessed the effectiveness of a group-based, mindfulness intervention in a residential, rehabilitation setting with specific focus on assessing participants' self-report of perceived benefit of the intervention on overall health, pain, sleep, mood/anxiety, attention, and self-awareness, as well as implementing modifications needed for successful intervention application among a diverse, clinical military population.
Participants were 19 veterans and active duty service members with a history of traumatic brain injury (TBI; 63% severe) who completed a mindfulness-based group intervention during inpatient admission at a Veterans Affairs Polytrauma Transitional Rehabilitation Program (PTRP). Mindfulness and yoga skills were taught in a required, weekly group incorporated into participants' rehabilitation schedule. Opinions and attitudes about mindfulness, as well as pertinent self-report outcome measures, were obtained pre- and postgroup participation.
Results suggested that participation in the group was positively associated with individuals' self-reported belief about the benefit of mindfulness in the areas of overall health, physical health, mood, focus, and self-awareness. The more groups attended, the more positive the participants' beliefs about potential impact on overall health and mood became, even while controlling for length of rehabilitation stay. Additionally, several specific group modifications relevant to this population (e.g., physical/environmental modifications, repetition, ignoring/reorienting) were implemented to support successful participation.
These preliminary and exploratory findings suggest that it may be worthwhile for psychologists, clinicians, and other health care providers working with a mixed TBI population, and more specifically a military population with TBI, to consider introducing mindfulness skills as part of multidisciplinary rehabilitation.
Cushing RE, Braun KL, Alden C-Iayt SW, Katz AR. Military-Tailored Yoga for Veterans with Post-traumatic Stress Disorder. Mil Med. 2018 May 1;183(5-6):e223-e231. doi: 10.1093/milmed/usx071. PubMed PMID: 29415222; PubMed Central PMCID: PMC6086130.
Among veterans of post-9/11 conflicts, estimates of post-traumatic stress disorder (PTSD) range from 9% shortly after returning from deployment to 31% a year after deployment. Clinical and pharmaceutically based treatments are underutilized. This could be due to concerns related to lost duty days, as well as PTSD patients' fears of stigma of having a mental health condition. Yoga has been shown to reduce PTSD symptoms in the civilian population, but few studies have tested the impact of yoga on veterans of post-9/11 conflicts. The purpose of this study is to test the impact of yoga on post-9/11 veterans diagnosed with PTSD.
Cushing RE, Braun KL, Alden S. A Qualitative Study Exploring Yoga in Veterans with PTSD Symptoms. Int J Yoga Therap. 2018 Nov
Quantitative studies of yoga have reported reduced posttraumatic stress disorder (PTSD) symptoms in veterans, but little is known about how and why veterans are attracted to and stick with a yoga practice. Guided by the Health Belief Model, this study examined veterans' perceptions of the benefits, barriers, and motivations to continue practicing trauma-sensitive yoga. Interviews were conducted with nine individuals, five of whom completed a 6-week trauma-sensitive yoga intervention designed for veterans and four who did not complete the intervention. Transcripts were analyzed for themes. The benefits identified by veterans were finding mental stillness, body awareness, and social connection. The barriers were perceptions that yoga is socially unacceptable, especially for men, and physically unchallenging. Understanding these benefits and barriers can help to make yoga more attractive to service members and veterans. For example, medical personnel can refer service members and veterans to yoga not only for PTSD symptoms, but also to address back pain and to reduce isolation. Access to male yoga instructors, especially those who are themselves service members or veterans, could be expanded, and classes could be integrated into physical activity routines required of active-duty personnel. Promotional materials can feature male service members and veterans with captions related to yoga as a way to increase resiliency, self-sufficiency, and physical and mental mission readiness. Findings from this study can help the Department of Defense and the Veterans Health Administration implement yoga as an adjunct or alternative treatment for veterans with PTSD symptoms.
Davis LW, Schmid AA, Daggy JK, Yang Z, O'Connor CE, Schalk N, Do AL, Maric D, Lazarick D, Knock H. Symptoms improve after a yoga program designed for PTSD in a randomized controlled trial with veterans and civilians. Psychol Trauma. 2020 Apr 20. doi: 10.1037/tra0000564.
Although yoga shows promise as a treatment for posttraumatic stress disorder (PTSD), there are few randomized controlled trials that demonstrate significant benefits for individuals with PTSD. The present study addresses this need by comparing the effects of a holistic yoga program (HYP) to that of a wellness lifestyle program (WLP) on PTSD symptom severity with a randomized clinical trial.
The sample consisted of 209 participants (91.4% veterans; 66% male; 61.7% White) who met diagnostic criteria for PTSD at baseline. Participants were randomly assigned to attend one of the 2 weekly interventions for 16 weeks. The HYP consisted of yoga instruction, while the WLP consisted of didactics, discussions, and walking. PTSD severity was measured using the Clinician Administered PTSD Scale (CAPS-5) and the PTSD Checklist (PCL-5).
Analyses revealed that the HYP reduced PTSD severity measured by the CAPS-5 significantly more than the WLP at treatment end (mean difference = -5.4, effect size = 0.46, p < .001), but not at 7-month follow up (mean difference = -0.9, p = .603). Similarly, the HYP reduced PTSD severity measured by the PCL-5 significantly more than the WLP at treatment end (difference = -6.0, p = .001), but not at 7-month follow up (mean difference = -1.0, p = .682).
Yoga may be an effective intervention for PTSD in addition to standard treatments. Future yoga trials should consider adding a social component to interventions or booster classes to maintain effects long term. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
Donaldson MT, Neumark-Sztainer D, Gaugler JE, et al. Yoga Practice Among Veterans With and Without Chronic Pain: A Mixed Methods Study. Med Care. 2020;58 Suppl 2 9S(Suppl 2 9 Suppl):S133-S141.
The primary aim of this study was to examine differences in yoga practice between persons with and without chronic pain. Secondarily, we describe use of the Essential Properties of Yoga Questionnaire, Short Form (EPYQ-SF) for self-report.
Participants were members of an existing cohort of veterans who completed a 2015-2016 survey focused on pain and nonpharmacological health practices. Cohort members who reported yoga in the past year [n=174 (9.4%) of 1850] were eligible for the present study, which used multiple-contact mixed-mode survey methodology to collect data on yoga practices. The EPYQ-SF was used to assess properties and context of yoga practice. Practice patterns were compared for participants with and without chronic pain. To explore potential reasons for reported yoga practice patterns, focused semistructured interviews were conducted with a subset of participants.
Of 174 participants contacted, 141 (82%) returned the yoga questionnaire and 110 (78% of respondents) were still practicing yoga. Among yoga practitioners, 41 (37%) had chronic pain. Practitioners with chronic pain reported gentler (2.8 vs. 3.1, 5-point scale) and less active (2.9 vs. 3.3) yoga practice than those without. Those with chronic pain attended yoga studios less frequently and reported shorter yoga practices than those without. Most yoga practice was self-directed and at home.
Differences in yoga practice of persons with and without chronic pain have implications for implementation of yoga interventions for chronic pain. Future interventions should focus on alternative individual delivery formats or addressing barriers to group practice among people with chronic pain.
Duan-Porter W, Coeytaux RR, McDuffie JR, Goode AP, Sharma P, Mennella H, Nagi A, Williams JW Jr. Evidence Map of Yoga for Depression, Anxiety, and Posttraumatic Stress Disorder. J Phys Act Health. 2016 Mar;13(3):281-8. doi: 10.1123/jpah.2015-0027. PubMed PMID: 26181774.
This study describes evidence of yoga's effectiveness for depressive disorders, general anxiety disorder (GAD), panic disorder (PD), and posttraumatic stress disorder (PTSD) in adults. We also address adverse events associated with yoga.
We searched multiple electronic databases for systematic reviews (SRs) published between 2008 and July 2014, randomized controlled trials (RCTs) not identified in eligible SRs, and ongoing RCTs registered with ClincalTrials.gov.
We identified 1 SR on depression, 1 for adverse events, and 3 addressing multiple conditions. The high-quality depression SR included 12 RCTs (n = 619) that showed improved short-term depressive symptoms (standardized mean difference, -0.69, 95% confidence interval, -0.99 to -0.39), but there was substantial variability (I2 = 86%) and a high risk of bias for 9 studies. Three SRs addressing multiple conditions identified 4 nonrandomized studies (n = 174) for GAD/PD and 1 RCT (n = 8) and 2 nonrandomized studies (n = 22) for PTSD. We separately found 1 RCT (n = 13) for GAD and 2 RCTs (n = 102) for PTSD. Collectively, these studies were inconclusive for the effectiveness of yoga in treating GAD/PD and PTSD. The high-quality SR for adverse events included 37 primary reports (n = 76) in which inversion postures were most often implicated. We found 5 ongoing trials (3 for PTSD).
Yoga may improve short-term depressive symptoms, but evidence for GAD, PD, and PTSD remain inconclusive.
Fletcher CE, Mitchinson AR, Trumble EL, Hinshaw DB, Dusek JA. Perceptions of providers and administrators in the Veterans Health Administration regarding complementary and alternative medicine. Med Care. 2014
The integration of complementary and alternative medicine (CAM) therapies into a large organization such as the Veterans Health Administration (VHA) requires cultural change and deliberate planning to ensure feasibility and buy-in from staff and patients. At present, there is limited knowledge of VHA patient care providers' and administrators' viewpoints regarding CAM therapies and their implementation.
Our purpose was to qualitatively examine knowledge, attitudes, perceived value and perceived barriers, and/or facilitators to CAM program implementation among VHA providers and administrators at a large VHA facility.
We are reporting the qualitative interview portion of a mixed-methods study.
Twenty-eight participants (patient care providers or administrators) were purposely chosen to represent a spectrum of positions and services. Participants' experience with and exposure to CAM therapies varied.
Individual interviews were conducted using a semi-structured format and were digitally recorded, transcribed, and coded for themes.
Recurrent themes included: a range of knowledge about CAM; benefits for patients and staff; and factors that can be facilitators or barriers including evidence-based practice or perceived lack thereof, prevailing culture, leadership at all levels, and lack of position descriptions for CAM therapists. Participants rated massage, meditation, acupuncture, and yoga as priorities for promotion across the VHA.
Despite perceived challenges, providers and administrators recognized the value of CAM and potential for expansion of CAM within the VHA. Interview results could inform the process of incorporating CAM into a plan for meeting VHA Strategic Goal One of personalized, proactive, patient-driven health care across the VHA.
Flynn DM, McQuinn H, Fairchok A, Eaton LH, Langford DJ, Snow T, Doorenbos AZ. Enhancing the success of functional restoration using complementary and integrative therapies: Protocol and challenges of a comparative effectiveness study in active duty service members with chronic pain. Contemp Clin Trials Commun. 2018
Chronic pain significantly impairs physical, psychological and social functioning. Among military populations, pain due to injuries sustained both on and off the battlefield is a leading cause of short and long-term disability. Improving the quality of pain care for active duty service members is a major priority of the Department of Defense. This article describes an ongoing comparative effectiveness study which aims to (1) evaluate the benefit of a multimodal complementary and integrative health (CIH) pain management program when added to standard rehabilitative care (SRC) prior to an intensive functional restoration (FR) program compared to SRC alone, and (2) identify factors that predict improvement in pain impact following treatment completion. Using a randomized controlled trial design, active duty service members with pain related to musculoskeletal injury are assigned to a 3-week course of either SRC or SRC combined with CIH therapies prior to beginning a 3-week course of FR. Outcomes are collected at baseline, at the end of stage 1 treatment, post-FR, and at 3- and 6-months post-FR. Outcome measures include provider-measured functional assessments and patient-reported assessment through the Pain Assessment Screening Tool and Outcomes Registry (PASTOR). The military health system provides a supportive environment for implementation of this research protocol. Challenges to conducting the study have included new technology systems at the study site, slower than projected enrollment, and program delivery issues. These challenges have been successfully managed and have not significantly impacted study participant enrollment and completion of study treatments.
Gaddy MA. Implementation of an integrative medicine treatment program at a Veterans Health Administration residential mental health facility. Psychol Serv. 2018
A 4-week interdisciplinary integrative medicine program was recently added to the core treatment offerings for veterans participating in the Mental Health Residential Rehabilitation Program at the Dwight D. Eisenhower Veterans Affairs Medical Center. The new integrative medicine program teaches veterans about using meditative practices, nutrition, creative expression, tai chi, hatha yoga, sensory and breathing techniques, and lifestyle changes to enhance well-being. The groups are run by professionals from a variety of disciplines including recreation therapy, art therapy, occupational therapy, psychology, and nutrition. For the first 42 veterans to complete the program, the Short Form 12-item Health Survey was administered before and after participation in the integrative medicine program to assess the potential effectiveness of the program in enhancing physical and psychological well-being. In addition, a brief semistructured interview was used to assess veteran opinions about the program. Results suggest that the program was well received and that both physical and mental health scores improved from before to after treatment in this sample of veterans with complex behavioral health concerns. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
Gallegos AM, Crean HF, Pigeon WR, Heffner KL. Meditation and yoga for posttraumatic stress disorder: A meta-analytic review of randomized controlled trials. Clin Psychol Rev. 2017 Dec;58:115-124. doi: 10.1016/j.cpr.2017.10.004. Review. PubMed PMID: 29100863; PubMed Central PMCID: PMC5939561.
Posttraumatic stress disorder (PTSD) is a chronic and debilitating disorder that affects the lives of 7-8% of adults in the U.S. Although several interventions demonstrate clinical effectiveness for treating PTSD, many patients continue to have residual symptoms and ask for a variety of treatment options. Complementary health approaches, such as meditation and yoga, hold promise for treating symptoms of PTSD. This meta-analysis evaluates the effect size (ES) of yoga and meditation on PTSD outcomes in adult patients. We also examined whether the intervention type, PTSD outcome measure, study population, sample size, or control condition moderated the effects of complementary approaches on PTSD outcomes. The studies included were 19 randomized control trials with data on 1173 participants. A random effects model yielded a statistically significant ES in the small to medium range (ES=-0.39, p<0.001, 95% CI [-0.57, -0.22]). There were no appreciable differences between intervention types, study population, outcome measures, or control condition. There was, however, a marginally significant higher ES for sample size≤30 (ES=-0.78, k=5). These findings suggest that meditation and yoga are promising complementary approaches in the treatment of PTSD among adults and warrant further study.
Goode AP, Coeytaux RR, McDuffie J, Duan-Porter W, Sharma P, Mennella H, Nagi A, Williams JW Jr. An evidence map of yoga for low back pain. Complement Ther Med. 2016 Apr;25:170-7. doi: 10.1016/j.ctim.2016.02.016. Review. PubMed PMID: 27062965.
Yoga is being increasingly studied as a treatment strategy for a variety of different clinical conditions, including low back pain (LBP). We set out to conduct an evidence map of yoga for the treatment, prevention and recurrence of acute or chronic low back pain (cLBP).
We searched Medline, Cochrane Database of Systematic Reviews, EMBASE, Allied and Complementary Medicine Database and ClinicalTrials.gov for randomized controlled trials (RCT), systematic reviews or planned studies on the treatment or prevention of acute back pain or cLBP. Two independent reviewers screened papers for inclusion, extracted data and assessed the quality of included studies.
Three eligible systematic reviews were identified that included 10 RCTs (n=956) that evaluated yoga for non-specific cLBP. We did not identify additional RCTs beyond those included in the systematic reviews. Our search of ClinicalTrials.gov identified one small (n=10) unpublished trial and one large (n=320) planned clinical trial. The most recent good quality systematic review indicated significant effects for short- and long-term pain reduction (n=6 trials; standardized mean difference [SMD] -0.48; 95% CI, -0.65 to -0.31; I(2)=0% and n=5; SMD -0.33; 95% CI, -0.59 to -0.07; I(2)=48%, respectively). Long-term effects for back specific disability were also identified (n=5; SMD -0.35; 95% CI, -0.55 to -0.15; I(2)=20%). No studies were identified evaluating yoga for prevention or treatment of acute LBP.
Evidence suggests benefit of yoga in midlife adults with non-specific cLBP for short- and long-term pain and back-specific disability, but the effects of yoga for health-related quality of life, well- being and acute LBP are uncertain. Without additional studies, further systematic reviews are unlikely to be informative.
Groessl EJ, Liu L, Chang DG, Wetherell JL, Bormann JE, Atkinson JH, Baxi S, Schmalzl L. Yoga for Military Veterans with Chronic Low Back Pain: A Randomized Clinical Trial.Am J Prev Med. 2017 Nov;53(5):599-608. doi: 10.1016/j.amepre.2017.05.019. Epub 2017 Jul 20. PubMed PMID: 28735778; PubMed Central PMCID: PMC6399016.
Chronic low back pain (cLBP) is prevalent, especially among military veterans. Many cLBP treatment options have limited benefits and are accompanied by side effects. Major efforts to reduce opioid use and embrace nonpharmacological pain treatments have resulted. Research with community cLBP patients indicates that yoga can improve health outcomes and has few side effects. The benefits of yoga among military veterans were examined.
Participants were randomized to either yoga or delayed yoga treatment in 2013–2015. Outcomes were assessed at baseline, 6 weeks, 12 weeks, and 6 months. Intention-to-treat analyses occurred in 2016.
Participant characteristics were mean age 53 years, 26% were female, 35% were unemployed or disabled, and mean back pain duration was 15 years. Improvements in Roland Morris Disability Questionnaire scores did not differ between the two groups at 12 weeks, but yoga participants had greater reductions in Roland Morris Disability Questionnaire scores than delayed treatment participants at 6 months 2.48 (95% CI¼ 4.08, 0.87). Yoga participants improved more on pain intensity at 12 weeks and at 6 months. Opioid medication use declined among all participants, but group differences were not found.
Yoga improved health outcomes among veterans despite evidence they had fewer resources, worse health, and more challenges attending yoga sessions than community samples studied previously. The magnitude of pain intensity decline was small, but occurred in the context of reduced opioid use. The findings support wider implementation of yoga programs for veterans.
Groessl EJ, Liu L, Richard EL, Tally SR. Cost-effectiveness of Yoga for Chronic Low Back Pain in Veterans. Med Care. 2020;58 Suppl 2 9S:S142-S148. doi:10.1097/MLR.0000000000001356
Yoga interventions can improve function and reduce pain in persons with chronic low back pain (cLBP).
Using data from a recent trial of yoga for military veterans with cLBP, we analyzed the incremental cost-effectiveness of yoga compared with usual care.
Participants (n=150) were randomized to either 2× weekly, 60-minute yoga sessions for 12 weeks, or to delayed treatment (DT). Outcomes were measured at 12 weeks, and 6 months. Quality-adjusted life years (QALYs) were measured using the EQ-5D scale. A 30% improvement on the Roland-Morris Disability Questionnaire (primary outcome) served as an additional effectiveness measure. Intervention costs including personnel, materials, and transportation were tracked during the study. Health care costs were obtained from patient medical records. Health care organization and societal perspectives were examined with a 12-month horizon.
Incremental QALYs gained by the yoga group over 12 months were 0.043. Intervention costs to deliver yoga were $307/participant. Negligible differences in health care costs were found between groups. From the health care organization perspective, the incremental cost-effectiveness ratio to provide yoga was $4488/QALY. From the societal perspective, yoga was "dominant" providing both health benefit and cost savings. Probabilistic sensitivity analysis indicates an 89% chance of yoga being cost-effective at a willingness-to-pay of $50,000. A scenario comparing the costs of yoga and physical therapy suggest that yoga may produce similar results at a much lower cost.
Yoga is a cost-effective treatment for reducing pain and disability among military veterans with cLBP.
Groessl EJ, Liu L, Schmalzl L, Chang DG, McCarthy A, Chun WI, Sinclair C, Bormann JE. Secondary Outcomes from a Randomized Controlled Trial of Yoga for Veterans with Chronic Low-Back Pain. Int J Yoga Therap. 2019 Sep 11. doi: 10.17761/2020-D-19-00036. [Epub ahead of print]
Chronic low-back pain (cLBP) is a prevalent condition, and rates are higher among military veterans. cLBP is a persistent condition, and treatment options have either modest effects or a significant risk of side-effects, which has led to recent efforts to explore mind-body intervention options and reduce opioid medication use. Prior studies of yoga for cLBP in community samples, and the main results of a recent trial with military veterans, indicate that yoga can reduce back-related disability and pain intensity. Secondary outcomes from the trial of yoga with military veterans are presented here. In the study, 150 military veterans (Veterans Administration patients) with cLBP were randomized to either yoga or a delayed-treatment group receiving usual care between 2013 and 2015. Assessments occurred at baseline, 6 weeks, 12 weeks, and 6 months. Intent-to-treat analyses were conducted. Yoga classes lasting 60 minutes each were offered twice weekly for 12 weeks. Yoga sessions consisted of physical postures, movement, focused attention, and breathing techniques. Home practice guided by a manual was strongly recommended. The primary outcome measure was Roland-Morris Disability Questionnaire scores after 12 weeks. Secondary outcomes included pain intensity, pain interference, depression, fatigue, quality of life, self-efficacy, and medication usage. Yoga participants improved more than delayed-treatment participants on pain interference, fatigue, quality of life, and self-efficacy at 12 weeks and/or 6 months. Yoga participants had greater improvements across a number of important secondary health outcomes compared to controls. Benefits emerged despite some veterans facing challenges with attending yoga sessions in person. The findings support wider implementation of yoga programs for veterans, with attention to increasing accessibility of yoga programs in this population.
Groessl EJ, Maiya M, Elwy AR, Riley KE, Sarkin AJ, Eisen SV, Braun T, Gutierrez I, Kidane L, Park CL. The Essential Properties of Yoga Questionnaire: Development and Methods. Int J Yoga Therap. 2015;25(1):51-9. doi: 10.17761/1531-2054-25.1.51. PubMed PMID: 26667289.
Yoga interventions have considerable heterogeneity, are multi-dimensional, and may impact health in different ways. However, most research reports regarding the effects of yoga on health and wellbeing do not adequately describe the components of the yoga interventions being used. Thus, drawing comparisons across studies or understanding the relative effects of specific aspects of a yoga intervention are rarely possible. To address this problem, we created the Essential Properties of Yoga Questionnaire (EPYQ) Project, an NCCAM-funded set of studies to develop a translational tool for yoga researchers. Here we describe the methods and developmental processes used in the EPYQ Project in detail. The project consists of four main phases. Phase I was designed to gain a comprehensive understanding of the relevant aspects of yoga by conducting a comprehensive systematic literature review and conducting focus groups with stakeholders including a wide variety of yoga teachers and students. In Phase II, a pool of potential questionnaire items was developed for the prototypic questionnaire using information from Phase I. Cognitive interviews were conducted with the preliminary EPYQ items to assess the perceived clarity, meaning, and importance of each item. In Phase III, the prototypic questionnaire was administered to two large samples of yoga students and instructors. Military personnel and veterans who practiced or taught yoga (n = 329) were recruited to participate. Factor analysis and item response theory were used to identify factors and select the final questionnaire items. Phase IV is ongoing and will collect reliability and validity data on the final instrument. Results are expected to be available in 2016. The EPYQ will provide an objective tool for describing the amount of various components of yoga interventions, eventually allowing researchers to link specific yoga components to health benefits, and facilitating the design of yoga interventions for specific health conditions.
Groessl EJ, Weingart KR, Johnson N, Baxi S. The benefits of yoga for women veterans with chronic low back pain. J Altern Complement Med. 2012 Sep;18(9):832-8. doi: 10.1089/acm.2010.0657. Epub 2012 Jul 19.
Chronic low back (CLBP) pain is prevalent among military veterans and often leads to functional limitations, psychologic symptoms, lower quality of life, and higher health care costs. An increasing proportion of U.S. veterans are women, and women veterans may have different health care needs than men veterans. The purpose of this study was to assess the impact of a yoga intervention on women and men with CLBP. SUBJECTS/SETTING/INTERVENTION: VA patients with CLBP were referred by primary care providers to a clinical yoga program.
Research participants completed a brief battery of questionnaires before their first yoga class and again 10 weeks later in a single-group, pre-post study design.
Questionnaires included measures of pain (Pain Severity Scale), depression (CESD-10), energy/fatigue, and health-related quality of life (SF-12). Yoga attendance and home practice of yoga were also measured. Repeated-measures analysis of variance was used to analyze group differences over time while controlling for baseline differences.
The 53 participants who completed both assessments had a mean age of 53 years, and were well educated, 41% nonwhite, 49% married, and had varying employment status. Women participants had significantly larger decreases in depression (p=0.046) and pain "on average" (p=0.050), and larger increases in energy (p=0.034) and SF-12 Mental Health (p=0.044) than men who participated. The groups did not differ significantly on yoga attendance or home practice of yoga.
These results suggest that women veterans may benefit more than men veterans from yoga interventions for chronic back pain. Conclusions are tentative because of the small sample size and quasi-experimental study design. A more rigorous study is being designed to answer these research questions more definitively.
Highland KB, et al. Benefits of the Restorative Exercise and Strength Training for Operational Resilience and Excellence Yoga Program for Chronic Low Back Pain in Service Members: A Pilot Randomized Controlled Trial. Arch Phys Med Rehabil. 2018 Jan;99(1):91-98. doi: 10.1016/j.apmr.2017.08.473. Epub 2017 Sep 14.
To examine the feasibility and preliminary effectiveness of an individualized yoga program.
Pilot randomized controlled trial.
Military medical center.
Patients (N=68) with chronic low back pain.
Restorative Exercise and Strength Training for Operational Resilience and Excellence (RESTORE) program (9-12 individual yoga sessions) or treatment as usual (control) for an 8-week period.
MAIN OUTCOME MEASURES
The primary outcome was past 24-hour pain (Defense & Veterans Pain Rating Scale 2.0). Secondary outcomes included disability (Roland-Morris Disability Questionnaire) and physical functioning and symptom burden (Patient-Reported Outcomes Measurement Information System-29 subscales). Assessment occurred at baseline, week 4, week 8, 3-month follow-up, and 6-month follow-up. Exploratory outcomes included the proportion of participants in each group reporting clinically meaningful changes at 3- and 6-month follow-ups.
Generalized linear mixed models with sequential Bonferroni-adjusted pairwise significance tests and chi-square analyses examined longitudinal outcomes. Secondary outcome significance tests were Bonferroni adjusted for multiple outcomes. The RESTORE group reported improved pain compared with the control group. Secondary outcomes did not retain significance after Bonferroni adjustments for multiple outcomes, although a higher proportion of RESTORE participants reported clinically meaningfully changes in all outcomes at 3-month follow-up and in symptom burden at 6-month follow-up.
RESTORE may be a viable nonpharmacological treatment for low back pain with minimal side effects, and research efforts are needed to compare the effectiveness of RESTORE delivery formats (eg, group vs individual) with that of other treatment modalities.
Hilton LG, Libretto S, Xenakis L, Elfenbaum P, Boyd C, Zhang W, Clark AA. Evaluation of an Integrative Post-Traumatic Stress Disorder Treatment Program. J Altern Complement Med. 2019
Post-traumatic stress disorder (PTSD) and combat-related stress can be refractory, pervasive, and have a devastating impact on those affected, their families, and society at large. Challenges dealing with symptoms may in turn make a servicemember more susceptible to problems, including alcohol abuse, interpersonal conflict, and occupational problems. An effective treatment strategy will address multifactorial issues by using a holistic multimodal approach. Back on Track is an intensive outpatient program utilizing a holistic philosophy and multimodal treatments to provide a whole systems approach for the treatment of combat-related stress reactions and PTSD in active duty servicemembers.
An explanatory, sequential, mixed-methods program evaluation was conducted to assess the effectiveness of a PTSD and combat stress treatment program. Quantitative outcomes were collected and analyzed on 595 participants at pre- and postinterventions and 6-week follow-up and qualitative data were gathered through participant interviews.
The manualized program uses a multimodal, psychoeducational group therapy format with a holistic approach for treating combat stress, increasing resiliency, and assisting with reintegration. Rotating providers visit from other programs and services to deliver content in bio–psycho–social–spiritual domains, including didactic lectures on mindfulness and the relaxation response and daily sessions of yoga nidra and meditation.
The primary outcome measure was PTSD symptom severity assessed with the PTSD Checklist-Military Version (PCL-M). Secondary outcomes included self-efficacy, knowledge, use, and satisfaction. Quantitative data were contextualized with interview data.
Results demonstrated a highly statistically significant effect of the program when comparing within-subject PCL-M scores before and after program participation, signed rank S (N= 595) = -47,367, p < 0.001. This translates to a moderate effect size, Cohen's d (N= 595) = -0.55, 95% confidence interval = -0.62 to -0.47, and a mean decrease of 7 points on the PCL-M at postintervention, demonstrating response to treatment. There were significant increases in knowledge and self-efficacy and high levels of satisfaction with the program overall, content, materials, and delivery.
The treatment program has served *800 servicemembers since inception and has since expanded to five installations. The provision of whole systems care where the approach is holistic, multimodal, and multidisciplinary may be a way forward for the successful treatment of PTSD and other debilitating behavioral health conditions in military contexts and beyond.
Hull A, Holliday SB, Eickhoff C, Rose-Boyce M, Sullivan P, Reinhard M. The Integrative Health and Wellness Program: Development and Use of a Complementary and Alternative Medicine Clinic for Veterans. Altern Ther Health Med. 2015 Nov-Dec;21(6):12-21. PubMed PMID: 26567446.
A movement exists within the Veterans Health Administration (VHA) toward incorporating complementary and alternative medicine (CAM) as an integrative complement to care for veterans. The Integrative Health and Wellness (IHW) Program is a comprehensive CAM clinic offering services such as integrative restoration (iRest) yoga nidra, individual acupuncture, group auricular acupuncture, chair yoga, qigong, and integrative health education.
The current study intended to detail the development of the CAM program, its use, and the characteristics of the program's participants.
Using a prospective cohort design, this pilot study tracked service use and aspects of physical and mental health for veterans enrolled in the program.Participants: During the first year, the IHW Program received 740 consults from hospital clinics; 325 veterans enrolled in the program; and 226 veterans consented to participate in the pilot study.
Outcome measures included data from self-report questionnaires and electronic medical records.
Veterans enrolled in the program reported clinically significant depression, stress, insomnia, and pain-related interference in daily activities and deficits in health-related quality of life. Regarding use of the program services, individual acupuncture showed the greatest participation by veterans, followed by group auricular acupuncture and iRest yoga nidra. Of the 226 veterans who enrolled in the program and consented to participate in this study, 165 (73.01%) participated in >1 services in the first year of programming. Broadly speaking, enrollment in services appeared to be associated with gender and service branch but not with age or symptom severity.
Results have assisted with a strategic planning process for the IHW Program and have implications for expansion of CAM services within the VHA..
Hurst S, Maiya M, Casteel D, Sarkin AJ, Libretto S, Elwy AR, Park CL, Groessl EJ. Yoga therapy for military personnel and veterans: Qualitative perspectives of yoga students and instructors. Complement Ther Med. 2018 Oct;40:222-229. doi: 10.1016/j.ctim.2017.10.008. Epub 2017 Nov 8. PubMed PMID: 30219455.
Millions of military personnel and veterans live with chronic mental and physical health conditions that often do not respond well to pharmacological treatments. Serious side effects and lack of treatment response have led to widespread efforts to study and promote non-pharmacological and behavioral health treatments for many chronic health conditions. Yoga is an increasingly popular mind-body intervention that has growing research support for its efficacy and safety. Our objective was to explore the attitudes, perspectives, and preferences of military personnel and veterans toward yoga as a therapeutic modality, thus providing needed information for designing and promoting yoga interventions for this population.
Participants included 24 individuals with yoga experience and current or past military service and 12 instructors who have taught yoga for military personnel and/or veterans. A semi-structured set of questions guided interviews with each participant.
Five themes emerged from the interviews: (1) mental health benefits experienced from yoga practice; (2) physical health benefits experienced from yoga practice; (3) important yoga elements and conditions that support effective practice; (4) facilitators for engaging military in yoga practice; and (5) challenges and barriers to yoga practice for military.
The study highlights consistent reports of mental and physical benefits of yoga practice, ongoing stigma resulting in the need for combatting and demystifying yoga and other complementary and integrative health (CIH) practices, the importance of designing interventions to address the unique mental health issues and perspectives of this population, and the importance of efforts by military leadership to bring CIH to military personnel and veterans. Rigorous research addressing these findings, along with further research on the efficacy and effectiveness of yoga interventions for treating various conditions are needed.
Justice L, Brems C. Bridging Body and Mind: Case Series of a 10-Week Trauma-Informed Yoga Protocol for Veterans. Int J Yoga Therap. 2019 Apr 8;. doi: 10.17761/D-17-2019-00029. [Epub ahead of print] PubMed PMID: 30958711.
This case series explored the feasibility and preliminary efficacy of therapeutic yoga as a complementary form of treatment for combat-related trauma. The series recruited for and implemented a 10-week Trauma-Informed Yoga protocol for veterans in an interprofessional community health treatment setting. Participants were enrolled in a series of 90-minute therapeutic yoga classes adapted to be trauma-informed. Feasibility was measured by recruitment, retention, and level of participation in the study. Preliminary efficacy was explored via the Posttraumatic Stress Disorder Checklist, Scale of Body Connection, PROMIS-29, P ROMIS Alcohol Use, PROMIS Substance Use, Difficulties in Emotional Regulation Scale, and Self-Compassion Scale-Short Form. All measures were administered at baseline, week 5, week 10, and at a 5-week follow-up. A qualitative Feasibility Questionnaire was administered weekly and at the 5-week follow-up to assess barriers and motivators for home practice and to collect feedback about session content. Recruitment challenges resulted in only seven interested individuals. Four participants (three males, one female) were successfully enrolled in the study after seven phone screenings and five in-person interviews. The four enrolled clients had a 100% follow-up retention rate, reported no adverse events, and on average participated in 85% of classes. Clinically significant enhancements were observed on trauma- and body connection-related scales for three participants from baseline to follow-up. Qualitative data revealed that motivators to practice include in-session philosophical discussions based on psychological themes; breathwork; mindfulness; and physical, social, work/academic, and mental health impact. Barriers included motivation, time, and location. Important themes emerged related to cultural considerations for veterans. Although this 10-week trauma-informed protocol faced challenges to recruitment, retention and participation were high. Efficacy measures yielded promising results for reducing reducing trauma-related symptoms.
King K, Gosian J, Doherty K, Chapman J, Chapman J, Walsh C, Pokaski Azar J, Pokaski Azar J, Danhauer SC, Moye J.. Implementing yoga therapy adapted for older veterans who are cancer survivors. Int J Yoga Therap. 2014;24:87-96.
This goal of this paper is to describe the reach, application, and effectiveness of an 8-week yoga therapy protocol with older cancer survivors within a Veterans Health Administration setting.
To document the reach of this intervention, recruitment efforts, attendance, and practice rates were tracked. To explore the application of the protocol to this population, physical therapy preassessment and observations by the yoga therapist were recorded to ascertain necessary pose modifications. Effectiveness was measured through pre- and post-course structured interviews, tracking self-reported symptoms of combat-related posttraumatic stress disorder, depression, anxiety, fatigue, insomnia, and pain.
Regarding reach, 15% of eligible veterans (n = 14) enrolled, participated in 3-16 classes (M±SD = 11.64±3.39), and practiced at home for 0-56 days (M±SD = 26.36±17.87). Participants were primarily Caucasian (n = 13), male (n = 13), ranged in age from 55 to 78 years (M±SD = 65.64±5.15), and had multiple medical problems. During application, substantial individualized modifications to the yoga therapy protocol were necessary. Effectiveness of the intervention was mixed. During post-course interviews, participants reported a variety of qualitative benefits. Notably, the majority of participants reported that breathing and relaxation techniques were the most useful to learn. Group comparisons of mean pre- and post-course scores on standardized measures showed no significant differences.
A minority of older veterans express an interest in yoga, but those who do have high rates of class attendance and home practice. Careful physical pre-assessment and attentive therapists are required to undertake the adaptations required by participants with multiple comorbidities. The effectiveness of yoga in this setting requires additional study.
Libby DJ1, Reddy F, Pilver CE, Desai RA. The use of yoga in specialized VA PTSD treatment programs. Int J Yoga Therap. 2012;(22):79-87.
Posttraumatic stress disorder (PTSD) is a chronic, debilitating anxiety disorder that is highly prevalent among U.S. military veterans. Yoga, defined to include physical postures (asana) and mindfulness and meditation, is being increasingly used as an adjunctive treatment for PTSD and other psychological disorders. No research or administrative data have detailed the use of these services in Department of Veterans Affairs' (VA) 170 PTSD treatment programs.
One hundred twenty-five program coordinators or designated staff completed an 81-item survey of their program's use of complementary and alternative medicine modalities in the past year. This report describes data from a subset of 30 questions used to assess the prevalence, nature, and context of the use of yoga, mindfulness, and meditation other than mindfulness practices.
Results revealed that these practices are widely offered in VA specialized PTSD treatment programs and that there is great variability in the context and nature of how they are delivered.
Understanding how yoga is used by these programs may inform ongoing efforts to define and distinguish yoga therapy as a respected therapeutic discipline and to create patient-centered care models that mindfully fulfill the unmet needs of individuals with mental health issues, including veterans with PTSD.
Martin EC, Dick AM, Scioli-Salter ER, Mitchell KS. Impact of a Yoga Intervention on Physical Activity, Self-Efficacy, and Motivation in Women with PTSD Symptoms. J Altern Complement Med. 2015 Jun;21(6):327-32. doi: 10.1089/acm.2014.0389. Epub 2015 May 14.
Studies using yoga have demonstrated initial efficacy for treating symptoms across anxiety disorders, including posttraumatic stress disorder.
Understanding how interventions influence participants' physical activity and what determinants affect continued physical activity behavior change is important because maintenance of the behavior may be critical to continued mental health gains and symptom reduction.
This study investigated change in physical activity and possible psychological mechanisms of physical activity behavior change, including self-efficacy and regulatory motivation, in a randomized controlled trial of yoga for women with post-traumatic stress disorder symptoms (n=38).
Growth curve modeling results showed no significant changes in physical activity or self-efficacy for either group, whereas external motivation decreased significantly in the yoga group but not in the control group.
Investigators of future yoga interventions may want to focus on increasing self-efficacy and internal regulatory motivation, so that physical activity and resultant symptom relief can be maintained.
Mathersul DC, Mahoney LA, Bayley PJ. Tele-yoga for Chronic Pain: Current Status and Future Directions. Glob Adv Health Med. 2018 Apr 2;7:2164956118766011. doi: 10.1177/2164956118766011. eCollection 2018. PubMed PMID: 29637012; PubMed Central PMCID: PMC5888810.
Pain is a pervasive, debilitating disorder that is resistant to long-term pharmacological interventions. Although psychological therapies such as cognitive behavior therapy demonstrate moderate efficacy, many individuals continue to have ongoing difficulties following treatment. There is a current trend to establish complementary and integrative health interventions for chronic pain, for which yoga has been found to have exciting potential. Nevertheless, an important consideration within the field is accessibility to adequate care. Telehealth can be used to provide real-time interactive video conferencing leading to increased access to health care for individuals located remotely or who otherwise have difficulty accessing services, perhaps through issues of mobility or proximity of adequate services. This article assesses the current status and feasibility of implementing tele-yoga for chronic pain. Methodological limitations and recommendations for future research are discussed.
Mehling WE, Chesney MA, Metzler TJ, Goldstein LA, Maguen S, Geronimo C, Agcaoili G, Barnes DE, Hlavin JA, Neylan TC. A 12-week integrative exercise program improves self-reported mindfulness and interoceptive awareness in war veterans with posttraumatic stress symptoms. J Clin Psychol. 2018 Apr;74(4):554-565. doi: 10.1002/jclp.22549.
Innovative approaches to the treatment of war-related posttraumatic stress disorder (PTSD) are needed. We report on secondary psychological outcomes of a randomized controlled trial of integrative exercise (IE) using aerobic and resistance exercise with mindfulness-based principles and yoga. We expected-in parallel to observed improvements in PTSD intensity and quality of life-improvements in mindfulness, interoceptive bodily awareness, and positive states of mind.
A total of 47 war veterans with PTSD were randomized to 12-week IE versus waitlist. Changes in mindfulness, interoceptive awareness, and states of mind were assessed by self-report standard measures.
Large effect sizes for the intervention were observed on Five-Facet Mindfulness Questionnaire Non-Reactivity (d = .85), Multidimensional Assessment of Interoceptive Awareness Body Listening (d = .80), and Self-Regulation (d = 1.05).
In a randomized controlled trial of a 12-week IE program for war veterans with PTSD, we saw significant improvements in mindfulness, interoceptive bodily awareness, and positive states of mind compared to a waitlist.
Nolan CR. Bending without breaking: A narrative review of trauma-sensitive yoga for women with PTSD. Complement Ther Clin Pract. 2016 Aug;24:32-40. doi: 10.1016/j.ctcp.2016.05.006. Epub 2016 May 8. Review.
The purpose of this review is to evaluate the peer-reviewed empirical evidence on the use of Trauma-Sensitive Yoga (TSY) for the treatment of women with post-traumatic stress disorder (PTSD): specifically interpersonal trauma such as intimate partner violence. To date, no such review has been conducted.
Articles meeting study inclusionary criteria were identified through electronic database searches. A total of five studies (N = 5) were selected and reviewed. These studies included two randomized controlled trials (RCT), one follow-up of an RCT, one quasi-experimental study, and one qualitative study.
There is tentative evidence to support the efficacy of TSY in reducing PTSD, depression, and anxiety symptomatology for women with PTSD; there is also tentative evidence confirming the feasibility of implementing TSY as an adjunctive mental health intervention, particularly for individuals who are non-responsive to cognitive-based psychotherapies. The qualitative findings speak to a number of benefits of yoga practice stimulated by TSY participation centering on the phenomenon of peaceful embodiment.
Replication of these results using larger and more diverse samples and rigorous study designs by independent researchers would add credibility to these findings and contribute to the growing body of knowledge on TSY. Additionally, there is a dearth of studies on this nascent form of therapeutic yoga. Therefore, further research is needed to explore the potential efficacy of TSY with other types of trauma, populations, and settings.
Pence PG, Katz LS, Huffman C, Cojucar G. Delivering Integrative Restoration-Yoga Nidra Meditation (iRest®) to Women with Sexual Trauma at a Veteran's Medical Center: A Pilot Study. Int J Yoga Therap. 2014
This pilot study examines iRest, a form of guided mindfulness meditation, and its ability to reduce symptoms associated with sexual trauma, including military sexual trauma (MST), in a sample of women seeking psychotherapy services at a Department of Veterans Affairs (VA) medical center.
90-minute sessions were held 19 times, twice a week for 10 weeks, except for the week with a holiday. Participants completed self-report measures Brief Symptom Inventory-18 (BSI), Posttraumatic Cognitions Inventory (PTCI), and the Post-traumatic Stress Disorder Check List (PCL) pre- and post-treatment. Sixteen women were recruited: 15 enrolled, 5 dropped due to transportation issues, and 10 completed the protocol.
Completers reported significant decreases in symptoms of posttraumatic stress disorder (PCL, t (9) = 3.17, p < 0.01, d = 0.66), negative thoughts of self-blame (PTCI t (9) = 2.96, p < 0.05, d = 0.52), and depression (BSI, t (9) = 2.33, p < 0.05, d = 0.64). Participants also offered verbal reports of decreased body tension, improved quality of sleep, improved ability to handle intrusive thoughts, improved ability to manage stress, and an increased feeling of joy. Participants also enthusiastically endorsed the class and stated they would take it again and recommend it to others.
This small pilot study showed promising results for delivering iRest to women with sexual trauma in a VA medical center. Further research is warranted.
Reddy S, Dick AM, Gerber MR, Mitchell K. The effect of a yoga intervention on alcohol and drug abuse risk in veteran and civilian women with posttraumatic stress disorder. J Altern Complement Med. 2014 Oct;20(10):750-6. doi: 10.1089/acm.2014.0014. Epub 2014 Sep 11. PubMed PMID: 25211372; PubMed Central PMCID: PMC4195227
Individuals with posttraumatic stress disorder (PTSD) often exhibit high-risk substance use behaviors. Complementary and alternative therapies are increasingly used for mental health disorders, although evidence is sparse.
Investigate the effect of a yoga intervention on alcohol and drug abuse behaviors in women with PTSD. Secondary outcomes include changes in PTSD symptom perception and management and initiation of evidence-based therapies.
MATERIALS AND METHODS
The current investigation analyzed data from a pilot randomized controlled trial comparing a 12-session yoga intervention with an assessment control for women age 18 to 65 years with PTSD. The Alcohol Use Disorder Identification Test (AUDIT) and Drug Use Disorder Identification Test (DUDIT) were administered at baseline, after the intervention, and a 1-month follow-up. Linear mixed models were used to test the significance of the change in AUDIT and DUDIT scores over time. Treatment-seeking questions were compared by using Fisher exact tests.
The mean AUDIT and DUDIT scores decreased in the yoga group; in the control group, mean AUDIT score increased while mean DUDIT score remained stable. In the linear mixed models, the change in AUDIT and DUDIT scores over time did not differ significantly by group. Most yoga group participants reported a reduction in symptoms and improved symptom management. All participants expressed interest in psychotherapy for PTSD, although only two participants, both in the yoga group, initiated therapy.
Results from this pilot study suggest that a specialized yoga therapy may play a role in attenuating the symptoms of PTSD, reducing risk of alcohol and drug use, and promoting interest in evidence-based psychotherapy. Further research is needed to confirm and evaluate the strength of these effects.
Reinhardt KM, Noggle Taylor JJ, Johnston J, Zameer A, Cheema S, Khalsa SBS. Kripalu Yoga for Military Veterans With PTSD: A Randomized Trial. J Clin Psychol. 2018 Jan;74(1):93-108.
This randomized controlled trial of yoga for military veterans and active duty personnel with posttraumatic stress disorder (PTSD) evaluated the efficacy of a 10-week yoga intervention on PTSD.
Fifty-one participants were randomized into yoga or no-treatment assessment-only control groups. Primary outcome measures included questionnaires and the Clinician Administered PTSD Scale.
Both yoga (n = 9) and control (n = 6) participants showed significant decreases in reexperiencing symptoms, with no significant between-group differences. Secondary within-group analyses of a self-selected wait-list yoga group (n = 7) showed significant reductions in PTSD symptoms after yoga participation, in contrast to their control group participation. Consistent with current literature regarding high rates of PTSD treatment dropout for veterans, this study faced challenges retaining participants across conditions.
These results are consistent with recent literature indicating that yoga may have potential as a PTSD therapy in a veteran or military population. However, additional larger sample size trials are necessary to confirm this conclusion.
Saper RB, Lemaster CM, Elwy AR, Paris R, Herman PM, Plumb DN, Sherman KJ, Groessl EJ, Lynch S, Wang S, Weinberg J. Yoga versus education for Veterans with chronic low back pain: study protocol for a randomized controlled trial. Trials. 2016 Apr 29;17(1):224. doi: 10.1186/s13063-016-1321-5. PubMed PMID: 27129472; PubMed Central PMCID: PMC4850721.
Chronic low back pain is the most frequent pain condition in Veterans and causes substantial suffering, decreased functional capacity, and lower quality of life. Symptoms of post-traumatic stress, depression, and mild traumatic brain injury are highly prevalent in Veterans with back pain. Yoga for low back pain has been demonstrated to be effective for civilians in randomized controlled trials. However, it is unknown if results from previously published trials generalize to military populations.
This study is a parallel randomized controlled trial comparing yoga to education for 120 Veterans with chronic low back pain. Participants are Veterans ≥18 years old with low back pain present on at least half the days in the past six months and a self-reported average pain intensity in the previous week of ≥4 on a 0-10 scale. The 24-week study has an initial 12-week intervention period, where participants are randomized equally into (1) a standardized weekly group yoga class with home practice or (2) education delivered with a self-care book. Primary outcome measures are change at 12 weeks in low back pain intensity measured by the Defense and Veterans Pain Rating Scale (0-10) and back-related function using the 23-point Roland Morris Disability Questionnaire. In the subsequent 12-week follow-up period, yoga participants are encouraged to continue home yoga practice and education participants continue following recommendations from the book. Qualitative interviews with Veterans in the yoga group and their partners explore the impact of chronic low back pain and yoga on family relationships. We also assess cost-effectiveness from three perspectives: the Veteran, the Veterans Health Administration, and society using electronic medical records, self-reported cost data, and study records.
This study will help determine if yoga can become an effective treatment for Veterans with chronic low back pain and psychological comorbidities.
Scheid A, Dyer NL, Dusek JA, Khalsa SBS. A Yoga-Based Program Decreases Physician Burnout in Neonatologists and Obstetricians at an Academic Medical Center [published online ahead of print, 2020 Aug 19]. Workplace Health Saf. 2020;2165079920930720.
Nearly half of U.S. pediatricians have symptoms of burnout. This pilot study examined the feasibility of a 6-week yoga-based program (RISE) for neonatologists and obstetricians at Brigham and Women's Hospital and studied the effects on burnout, professional fulfillment, and psychological health.
Participants were recruited via email to participate either in both program and research study, or exclusively the program. RISE was delivered 1 hour/week during the workday for 6 consecutive weeks either in-person or remotely; 18 physicians participated, 12 completed post-program, and 11 completed 2-month follow-up. The questionnaires assessed burnout and measures of psychological health, professional fulfillment, work exhaustion, interpersonal disengagement/burnout (PFI), mindfulness (FFMQ), perceived stress (PSS), positive/negative affect (PANAS), resilience (RS), anxiety/depression/sleep disturbances (PROMIS), at baseline, post-program, and 2 months after RISE.
Average attendance in-person was 2.8 sessions and remotely 1.4 sessions (4.2/6 sessions). Participants demonstrating total burnout reduced from 50.0% at baseline to 9.1% post-program. Participants demonstrating professional fulfillment were 8.3% at baseline and 27.3% post-program. Paired samples t-tests revealed statistically significant improvements in burnout, professional fulfillment, interpersonal disengagement, stress, resilience, anxiety, and depression at post-program compared with baseline (N = 12, all ps < .05). At 2-month follow-up, statistically significant improvements in interpersonal disengagement, resilience, and mindfulness (N = 11, all ps < .05) compared with baseline were reported.
Conclusions/application to practice:
RISE is feasible within a workday and may address burnout and other psychological health measures in physicians with effects potentially sustainable over 2 months. Occupational health practitioners in health care should consider this type of intervention for their workers.
Schulz-Heik RJ, Meyer H, Mahoney L, Stanton MV, Cho RH, Moore-Downing DP, Avery TJ, Lazzeroni LC, Varni JM, Collery LM, Bayley PJ. Results from a clinical yoga program for veterans: yoga via telehealth provides comparable satisfaction and health improvements to in-person yoga. BMC Complement Altern Med. 2017 Apr 4;17(1):198. doi: 10.1186/s12906-017-1705-4. PubMed PMID: 28376861; PubMed Central PMCID: PMC5381127.
Yoga is increasingly popular, though little data regarding its implementation in healthcare settings is available. Similarly, telehealth is being utilized more frequently to increase access to healthcare; however we know of no research on the acceptability or effectiveness of yoga delivered through telehealth. Therefore, we evaluated the feasibility, acceptability, and patient-reported effectiveness of a clinical yoga program at a Veterans Affairs Medical Center and assessed whether these outcomes differed between those participating in-person and those participating via telehealth.
Veterans who attended a yoga class at the VA Palo Alto Health Care System were invited to complete an anonymous program evaluation survey.
64 Veterans completed the survey. Participants reported high satisfaction with the classes and the instructors. More than 80% of participants who endorsed a problem with pain, energy level, depression, or anxiety reported improvement in these symptoms. Those who participated via telehealth did not differ from those who participated in-person in any measure of satisfaction, overall improvement (p = .40), or improvement in any of 16 specific health problems.
Delivering yoga to a wide range of patients within a healthcare setting appears to be feasible and acceptable, both when delivered in-person and via telehealth. Patients in this clinical yoga program reported high levels of satisfaction and improvement in multiple problem areas. This preliminary evidence for the effectiveness of a clinical yoga program complements prior evidence for the efficacy of yoga and supports the use of yoga in healthcare settings.
Staples JK, Hamilton MF, Uddo M. A yoga program for the symptoms of post-traumatic stress disorder in veterans. Mil Med. 2013 Aug;178(8):854-60. doi: 10.7205/MILMED-D-12-00536.
The purpose of this pilot study was to evaluate the feasibility and effectiveness of a yoga program as an adjunctive therapy for improving post-traumatic stress disorder (PTSD) symptoms in Veterans with military-related PTSD. Veterans (n = 12) participated in a 6 week yoga intervention held twice a week. There was significant improvement in PTSD hyperarousal symptoms and overall sleep quality as well as daytime dysfunction related to sleep. There were no significant improvements in the total PTSD, anger, or quality of life outcome scores. These results suggest that this yoga program may be an effective adjunctive therapy for improving hyperarousal symptoms of PTSD including sleep quality. This study demonstrates that the yoga program is acceptable, feasible, and that there is good adherence in a Veteran population.
Taylor SL, Hoggatt KJ, Kligler B. Complementary and Integrated Health Approaches: What Do Veterans Use and Want. J Gen Intern Med. 2019 Jul;34(7):1192-1199. doi: 10.1007/s11606-019-04862-6. Epub 2019 Apr 22.
Non-pharmacological treatment options for common conditions such as chronic pain, anxiety, and depression are being given increased consideration in healthcare, especially given the recent emphasis to address the opioid crisis. One set of non-pharmacological treatment options are evidence-based complementary and integrative health (CIH) approaches, such as yoga, acupuncture, and meditation. The Veterans Health Administration (VHA), the nation's largest healthcare system, has been at the forefront of implementing CIH approaches, given their patients' high prevalence of pain, anxiety, and depression. We aimed to conduct the first national survey of veterans' interest in and use of CIH approaches.
Using a large national convenience sample of veterans who regularly use the VHA, we conducted the first national survey of veterans' interest in, frequency of and reasons for use of, and satisfaction with 26 CIH approaches (n = 3346, 37% response rate) in July 2017.
In the past year, 52% used any CIH approach, with 44% using massage therapy, 37% using chiropractic, 34% using mindfulness, 24% using other meditation, and 25% using yoga. For nine CIH approaches, pain and stress reduction/relaxation were the two most frequent reasons veterans gave for using them. Overall, 84% said they were interested in trying/learning more about at least one CIH approach, with about half being interested in six individual CIH approaches (e.g., massage therapy, chiropractic, acupuncture, acupressure, reflexology, and progressive relaxation). Veterans appeared to be much more likely to use each CIH approach outside the VHA vs. within the VHA.
Veterans report relatively high past-year use of CIH approaches and many more report interest in CIH approaches. To address this gap between patients' level of interest in and use of CIH approaches, primary care providers might want to discuss evidence-based CIH options to their patients for relevant health conditions, given most CIH approaches are safe.
Walker J 3rd, Pacik D. Controlled Rhythmic Yogic Breathing as Complementary Treatment for Post-Traumatic Stress Disorder in Military Veterans: A Case Series. Med Acupunct. 2017 Aug 1;29(4):232-238. doi: 10.1089/acu.2017.1215.
Post-traumatic stress disorder (PTSD) is a cluster of symptoms in which a person persistently relives a traumatic event, through recurring thoughts, nightmares, and flashbacks for at least 1 month or more. There are various behavioral and medical treatment options for PTSD. Mind-body techniques, such as biofeedback and breathing-based stress reduction, have shown some promise in the treatment of PTSD symptoms. The purpose of this case series was to examine controlled yogic breathing as a complementary treatment of PTSD in military veterans. A retrospective review was performed from 2012 to 2016 in 3 cases, and participant demographics, member statements, and PTSD Checklist-Military Version (PCL-M) scores, pre-and-post course, were extracted. Cases: Three military veterans with PTSD participated in a standardized 5-day course designed to teach them controlled rhythmic yogic breathing exercises.
Subjectively, all 3 participants reported a decrease in PTSD symptoms after the course. Objectively, all 3 participants had a reduction in their overall PCL-M scores after the course. Among all 3 participants, there were score decreases in the Avoidance and Increased Arousal categories. The most dramatic improvement occurred in the participant with the most severe symptoms.
Controlled yogic breathing, specifically Sudarshan Kriya (SKY), appeared to reduce the symptoms of PTSD in 3 veterans of the Armed Services.
Zaccari B, Callahan ML, Storzbach D, McFarlane N, Hudson R, Loftis JM. Yoga for veterans with PTSD: Cognitive functioning, mental health, and salivary cortisol [published online ahead of print, 2020 Aug 10]. Psychol Trauma.
Research indicates that cognitive functioning is negatively impacted by exposure to chronic stress due to overactivation of the stress response. Yoga has demonstrated benefits when practiced by individuals diagnosed with posttraumatic stress disorder (PTSD). This quasi-experimental pilot study examined the impact of a yoga intervention on cognitive functioning, symptoms of PTSD, and the biological stress response in Veterans diagnosed with PTSD.
Cognitive functioning, self-report measures of mental health symptoms, and salivary cortisol were measured within two weeks prior to beginning and following completion of a 10-week yoga protocol. Veterans with PTSD participated in gender-specific groups of the yoga intervention. Paired t tests and correlational analyses were used to analyze quantitative data.
Statistically significant improvements were observed between baseline and postintervention scores on measures of response inhibition, PTSD, depression, sleep, quality of life, and subjective neurocognitive complaints. Positive correlations were found between baseline and postintervention changes in sleep and depression, and between change in cortisol output and a measure of life satisfaction. Statistically significant differences (baseline to postintervention) for other objective measures of cognitive performance and cortisol were not detected.
Results provide preliminary support for the practice of yoga to improve cognitive functioning (response inhibition) related to symptoms of PTSD while also improving mental health symptoms, sleep, and quality of life. Positive correlations affirm the role of sleep in mood symptoms and indicate the need for further examination of the role of cortisol in life satisfaction.
Zalta AK, Held P, Smith DL, Klassen BJ, Lofgreen AM, Normand PS, Brennan MB, Rydberg TS, Boley RA, Pollack MH, Karnik NS. Evaluating patterns and predictors of symptom change during a three-week intensive outpatient treatment for veterans with PTSD. BMC Psychiatry. 2018 Jul 27;18(1):242. doi: 10.1186/s12888-018-1816-6.
Intensive delivery of evidence-based treatment for posttraumatic stress disorder (PTSD) is becoming increasingly popular for overcoming barriers to treatment for veterans. Understanding how and for whom these intensive treatments work is critical for optimizing their dissemination. The goals of the current study were to evaluate patterns of PTSD and depression symptom change over the course of a 3-week cohort-based intensive outpatient program (IOP) for veterans with PTSD, examine changes in posttraumatic cognitions as a predictor of treatment response, and determine whether patterns of treatment outcome or predictors of treatment outcome differed by sex and cohort type (combat versus military sexual trauma [MST]).
One-hundred ninety-one veterans (19 cohorts: 12 combat-PTSD cohorts, 7 MST-PTSD cohorts) completed a 3-week intensive outpatient program for PTSD comprised of daily group and individual Cognitive Processing Therapy (CPT), mindfulness, yoga, and psychoeducation. Measures of PTSD symptoms, depression symptoms, and posttraumatic cognitions were collected before the intervention, after the intervention, and approximately every other day during the intervention.
Pre-post analyses for completers (N = 176; 92.1% of sample) revealed large reductions in PTSD (d = 1.12 for past month symptoms and d = 1.40 for past week symptoms) and depression symptoms (d = 1.04 for past 2 weeks). Combat cohorts saw a greater reduction in PTSD symptoms over time relative to MST cohorts. Reduction in posttraumatic cognitions over time significantly predicted decreases in PTSD and depression symptom scores, which remained robust to adjustment for autocorrelation.
Intensive treatment programs are a promising approach for delivering evidence-based interventions to produce rapid treatment response and high rates of retention. Reductions in posttraumatic cognitions appear to be an important predictor of response to intensive treatment. Further research is needed to explore differences in intensive treatment response for veterans with combat exposure versus MST.
Zalta AK, Pinkerton LM, Valdespino-Hayden Z, Smith DL, Burgess HJ, Held P, Boley RA, Karnik NS, Pollack MH. Examining Insomnia During Intensive Treatment for Veterans with Posttraumatic Stress Disorder: Does it Improve and Does it Predict Treatment Outcomes? J Trauma Stress. 2020 Mar 26. doi: 10.1002/jts.22505. [Epub ahead of print]
Previous research has demonstrated that sleep disturbances show little improvement with evidence-based psychotherapy for posttraumatic stress disorder (PTSD); however, sleep improvements are associated with PTSD treatment outcomes. The goal of the current study was to evaluate changes in self-reported insomnia symptoms and the association between insomnia symptoms and treatment outcome during a 3-week intensive treatment program (ITP) for veterans with PTSD that integrated cognitive processing therapy (CPT), mindfulness, yoga, and other ancillary services. As part of standard clinical procedures, veterans (N = 165) completed self-report assessments of insomnia symptoms at pre- and posttreatment as well as self-report assessments of PTSD and depression symptoms approximately every other day during treatment. Most veterans reported at least moderate difficulties with insomnia at both pretreatment (83.0%-95.1%) and posttreatment (69.1-71.3%). Statistically significant reductions in self-reported insomnia severity occurred from pretreatment to posttreatment; however, the effect size was small, d = 0.33. Longitudinal mixed-effects models showed a significant interactive effect of Changes in Insomnia × Time in predicting PTSD and depression symptoms, indicating that patients with more improvements in insomnia had more positive treatment outcomes. These findings suggest that many veterans continued to struggle with sleep disruption after a 3-week ITP, and successful efforts to improve sleep could lead to better PTSD treatment outcomes. Further research is needed to establish how adjunctive sleep interventions can be used to maximize both sleep and PTSD outcomes.