Yoga for Anxiety and Mind
Yoga as therapy uses yoga as exercise, consisting mainly of postures called asanas, as a gentle form of exercise and relaxation applied specifically to improve health. This form of yoga is widely practiced in classes and may involve meditation, imagery, breathwork (pranayama), and calming music.
The primary analysis was completed in February and included noninferiority testing of Kundalini yoga vs. CBT(Cognitive behavior therapy) and superiority testing of this yoga type and CBT vs. stress education. Response at 12 weeks, as measured by the Clinical Global Impression–Improvement Scale, was the primary outcome.
Moderately Potent
Results showed that response rates at 12 weeks were greater in the yoga group (54.2%) than in the stress education group (33.0%; odds ratio [OR], 2.45; 95% CI, 1.1 – 5.4; P = .03), as well as in the CBT (70.8%) vs stress education group (OR, 5.0; 95% CI, 2.2 – 11.82; P < .001).
The numbers needed to treat the yoga and CBT groups vs. the stress education group were 4.59 and 2.62.
However, on further testing, the researchers were unable to conclude that yoga was non-inferior to CBT. “Conversely, we were unable to conclude that the [response rate] of CBT was significantly higher” than yoga in a superiority test, they write.
At the 6-month follow-up, the response rate was significantly higher for CBT vs stress education (OR, 3.56; P = .04) but not for yoga vs stress education (OR, 1.86; P = .34).
Any of the participants reported any treatment-related serious adverse events (AEs). Regarding nonserious AEs that were “possibly” related to treatment, there were three reports of joint pain and one report each of tingling and vertigo in the yoga group; three reports of anxiety, two bulimia episodes, and one report of depression in the CBT group; and one report of anxiety in the education group.
“Overall, the available literature and our data support that [yoga] may be a helpful but only moderately potent intervention for GAD,” the investigators write.”Given the increasing costs of health care and barriers to accessing trained mental health care professionals, however, yoga may still have a role to play in GAD management as an intervention that is more easily accessible,” they add.
Simon agreed, noting that yoga may be beneficial for at least some patients in the short term.
“More research is needed to understand who really can benefit the most from yoga and what can be done to help those responses last for a longer term,” she said.
Asked whether other types of yoga might be more effective or whether yoga plus CBT could be more effective than CBT alone, Simon said those are “open questions” that future studies should investigate.
“Good Signal”
Commenting on the study for Medscape Medical News, Michelle B. Riba, MD, professor of psychiatry at the University of Michigan and past president of the American Psychiatric Association, noted that it is important to look at the size of a study’s patient population, the type of patient being evaluated, and the length of treatment.
Dr. Michelle B. Riba
“The devil’s always in the details,” said Riba, who was not involved with the research. She noted that the current participants were relatively young, mostly white, and mostly employed.
“This was a select group of people, many of whom had been on a psychotropic medication before coming in, so this group wanted to get some help. And even though this type of yoga didn’t do as well as CBT, it clearly could be an adjunct or for those who have financial difficulties or don’t want formal psychiatric care,” she said.
Riba pointed out that this was a small, “well-done pilot study of a critical diagnosis and evidence-based treatments for it.”
Future studies can investigate whether yoga is better at the beginning of treatment for GAD (Generalized Anxiety disorder) or after CBT has been provided, she noted. The current study “is useful for further research,” she added.
“This type of yoga did pretty well in this population of people for a particular range of time. That was a good signal,” said Riba.
The study was funded by the National Center for Complementary and Integrative Health. Simon reports having received grants from the National Institutes of Health, the US Department of Defense, the American Foundation for Suicide Prevention, the Patient-Centered Outcomes Research Institute, the Highland Street Foundation, and Janssen; personal fees from Vanda, Axovant Sciences, Springworks, Praxis Therapeutics, Aptinyx, Genomind, Wiley, and the Massachusetts General Hospital Psychiatry Academy; and royalties from Wolters Kluwer for contributions to UpToDate. She has also performed grant reviews for the American Foundation for Suicide Prevention and reports having a spousal stock from G1 Therapeutics unrelated to the submitted work. Disclosures for the other study authors are listed in the original article. Riba is editing a psychiatry textbook in which Simon is contributing a chapter.
JAMA Psychiatry. Published online August 12, 2020. Abstract
At least three types of health claim have been made for yoga: magical claims for medieval haṭha yoga, including the power of healing; unsupported claims of benefits to organ systems from the practice of asanas; and more or less well-supported claims of specific medical and psychological benefits from studies of different sizes using a wide variety of methodologies.
Systematic reviews have found beneficial effects of yoga on low back pain and depression, but despite much investigation, little or no evidence for benefit for specific medical conditions. The study of trauma-sensitive yoga has been hampered by weak methodology.
Different schools teach yoga with an emphasis on aerobic exercise (such as Bikram Yoga), precision in the asanas (like Iyengar Yoga), or spirituality (like Sivananda Yoga) Unbranded “hatha yoga” (not to be confused with medieval haṭha yoga) may teach any combination of these.
Yoga classes used as therapy usually consist of asanas (postures used for stretching), pranayama (breathing exercises), and relaxation in savasana (lying down). The physical asanas of modern yoga are related to medieval haṭha yoga tradition, but they were not widely practiced in India before the early 20th century.
The number of schools and styles of yoga in the Western world has grown rapidly since the late 20th century. By 2012, there were at least 19 widespread styles from Ashtanga Vinyasa Yoga to Viniyoga. These emphasize different aspects, including aerobic exercise, precision in the asanas, and spirituality in the haṭha yoga tradition. Schools with distinctive styles can illustrate these aspects. Thus, Bikram Yoga has an aerobic exercise style with rooms heated to 105 °F (41 °C) and a fixed sequence of 2 breathing exercises and 26 asanas performed in every session. Iyengar Yoga emphasizes correct alignment in the postures, working slowly, if necessary with props, and ending with relaxation. Sivananda Yoga focuses more on spiritual practice, with 12 basic poses, chanting in Sanskrit, pranayama breathing exercises, meditation, relaxation in each class, and importance placed on a vegetarian diet.
Types of claim
At least three different types of claims of therapeutic benefit have been made for yoga from medieval times onwards, not counting the more general claims of good health made throughout this period: magical powers, biomedical claims for marketing purposes, and specific medical claims. Neither of the first two is supported by reliable evidence. The medical claims are supported by evidence of varying quality, from case studies to controlled trials and a systematic review of multiple trials.
Magical powers
Medieval authors asserted that Haṭha yoga brought physical (and spiritual) benefits and provided magical powers, including healing. The Hatha Yoga Pradipika (HYP) states that asanas in general, described as the first auxiliary of haṭha yoga, give “steadiness, good health, and a lightness of limb.” (HYP 1.17) Specific asanas, it claims, bring additional benefits; for example, Matsyendrasana awakens Kundalini and helps to prevent semen from being shed involuntarily; (HYP 1.27) Paschimottanasana “stokes up the digestive fire, slims the belly and gives good health”; (HYP 1.29) Shavasana “takes away fatigue and relaxes the mind”; (HYP 1.32) while Padmasana “destroys all diseases” (HYP 1.47). These claims lie within a tradition across all forms of yoga that practitioners can gain supernatural powers. Hemachandra‘s Yogashastra (1.8–9) lists magical powers, including healing and poisons’ destruction.
Biomedical claims for marketing purposes
Styles of yoga differ in their approach to the asanas. Iyengar Yoga emphasizes correctness, seen here as a practitioner uses a yoga brick to attain correct alignment in Utthitha Trikonasana.
Twentieth-century advocates of some yoga schools, such as B. K. S. Iyengar, have for various reasons made claims for the effects of yoga on specific organs without adducing any evidence. The yoga scholar Suzanne Newcombe argues that this was one of several visions of yoga as, in some sense, therapeutic, ranging from medical to a more popular offer of health and well-being. The yoga scholar Andrea Jain describes these claims of Iyengar’s in terms of “elaborating and fortifying his yoga brand” and “mass-marketing,” calling Iyengar’s 1966 book Light on Yoga “arguably the most significant event in the process of elaborating the brand.” The yoga teacher Bernie Gourley notes that the book neither describes contraindications systematically nor provides evidence for the claimed benefits. Jain suggests that “Its biomedical dialect was attractive to many.” For example, in the book, Iyengar claims that the asanas of the Eka Pada Sirsasana cycle
…tone up the muscular, nervous and circulatory systems of the entire body. The spine receives a rich supply of blood, which increases the nervous energy in the chakras (the various nerve plexuses situated in the spine), the flywheels in the human body machine. These poses develop the chest and make the breathing fuller and the body firmer; they stop nervous trembling of the body and prevent the diseases which cause it; they also help to eliminate toxins by supplying pure blood to every part of the body and bringing the congested blood back to the heart and lungs for purification.
William J. Broad reviewed the history of such claims in his 2012 book The Science of Yoga. Broad argues that while the health claims for yoga began as Hindu nationalist posturing, it turns out that there is ironical “a wealth of real benefits.”
Evidence-based medical claims
Researchers have studied yoga’s medical and psychological effects as an exercise in a wide range of trials and observational studies, sometimes with careful controls, providing evidence of differing quality about yoga’s possible benefits. The physician and yoga therapist Timothy McCall has assembled an extensive list of studies, grouped by condition, providing evidence of varying quality for “117 Health Conditions Helped by Yoga”; he notes the “irony” that “in yoga therapy, we don’t treat medical conditions per se. We treat individuals.” The various types of claims, and the evidence for them, are discussed below.
Types of activity
Remedial yoga
Newcombe notes that Iyengar was sickly as a child and that yoga with his brother-in-law Krishnamacharya had improved his health; it had also helped his daughter, Geeta, so his response to his students’ health issues “was an intense and personal one.” In effect, Newcombe argues, Iyengar was treating “remedial yoga” as analogous to Henrik Ling‘s medical gymnastics. As early as 1940, Iyengar used yoga to treat common conditions such as sinus problems, backache, and fatigue. Iyengar was willing to push people through the pain “to [show] them new possibilities.” In the 1960s, he trained a few people such as Diana Clifton and Silva Mehta to deliver this remedial yoga; particular asanas were used for different conditions, and non-remedial Iyengar Yoga teachers were taught to tell students that ordinary classes were not suitable for “serious health issues” Mehta taught a remedial yoga class in the Iyengar Yoga Institute in Maida Vale from its opening in 1984; she contributed “Remedial Programs” for conditions such as arthritis, backache, knee cartilage problems, pregnancy, sciatica, scoliosis and varicose veins in the Mehtas’ 1990 book Yoga the Iyengar Way. However, Iyengar was deferential to Western medicine and its assessments, so in Newcombe’s view, Iyengar Yoga is “positioned as complementary to standard medical treatment rather than as an alternative.”
Newcombe argues that yoga “largely avoided overt conflict with the medical profession in Britain by simultaneously professionalizing with educational qualifications and deferring to medical expertise.” After Richard Hittleman‘s Yoga for Health series on ITV from 1971 to 1974, the series producer Howard Kent founded a charity, the Yoga for Health Foundation, to “Research into the therapeutic benefits to be obtained by the practice of yoga”; residential courses began in 1978 at Ickwell Bury in Bedfordshire. The Foundation stated that yoga was not a therapy or cure but had “therapeutic benefits,” whether physical, mental, or emotional, and it worked especially with “the physically handicapped.” Newcombe notes that a third organization, the Yoga Biomedical Trust, was founded in Cambridge in 1983 by a biologist, Robin Monro, to research complementary therapies. He found it hard to obtain research funding. In the 1990s, they moved to London, focusing on training yoga teachers in yoga as therapy and providing yoga as individualized therapy, using pranayama, relaxation, and asanas.
Sports medicine
From the point of view of sports medicine, asanas function as active stretches, helping to protect muscles from injury; these need to be performed equally on both sides, the stronger side first if used for physical rehabilitation.
Research
Much of the research on the therapeutic use of yoga has been in preliminary studies or clinical trials of low methodological quality, including small sample sizes, inadequate control, blinding, lack of randomization, and high risk of bias. Further research is needed to quantify the benefits and to clarify the mechanisms involved.
For example, a 2010 literature review on the use of yoga for depression stated, “although the results from these trials are encouraging, they should be viewed as very preliminary because the trials, as a group, suffered from substantial methodological limitations.”A 2015 systematic review on the effect of yoga on mood and the brain recommended that future clinical trials apply more methodological rigor.
Mechanisms
A yoga class relaxing in Supta Baddha Konasana. There is evidence that yoga relieves stress by multiple mechanisms.
The practice of asanas has been claimed to improve flexibility, strength, and balance, alleviate stress and anxiety, and reduce the symptoms of lower back pain without necessarily demonstrating the precise mechanisms involved. A review of five studies noted that three psychological (positive affect, mindfulness, self-compassion) and four biological mechanisms (posterior hypothalamus, interleukin-6, C-reactive protein, and cortisol) that might act on stress had been examined empirically, whereas many other potential mechanisms remained to be studied; four of the mechanisms (positive affect, self-compassion, inhibition of the posterior hypothalamus and salivary cortisol) were found to mediate yoga’s effect on stress.
Low back pain
Back pain is one reason people take up yoga, and since at least the 1960s, some practitioners have claimed that it relieved their symptoms.
A 2013 systematic review on the use of yoga for low back pain found strong evidence for short- and long-term effects on pain, and moderate evidence for long-term benefit in back-specific disability, with no serious adverse events. Ten randomized controlled trials were analyzed, of which eight had a low risk of bias. The outcomes measured included improvements in “pain, back-specific disability, generic disability, health-related quality of life, and global improvement.” The review stated that yoga could be recommended as an additional therapy for chronic low back pain patients.
Mental disorders
Trauma-sensitive yoga has been developed in the US in the hope of benefiting individuals suffering from psychological trauma.
Trauma-sensitive yoga has been developed by David Emerson and others of the Trauma Center at the Justice Resource Institute in Brookline, Massachusetts. The center uses yoga alongside other treatments to support recovery from traumatic episodes and enable healing from PTSD. Workers including Bessel van der Kolk and Richard Miller have studied how clients can “regain comfort in their bodies, counteract rumination, and improve self-regulation through yoga.”
Systematic reviews indicate that yoga offers moderate benefits in the treatment of PTSD. A 2017 systematic review of PTSD in post-9/11 veterans showed that participants in studies who had received mindfulness training, mind-body therapy, and yoga “reported significant improvements in PTSD symptoms.” Another systematic review on veterans the same year also found improvement in PTSD symptoms. Other systematic reviews postulate that designing the style and instructions to the needs of the veterans leads to better results and a larger impact on PTSD symptoms.
A 2013 systematic review on the use of yoga for depression found moderate evidence of short-term benefit over “usual care” and limited evidence compared to relaxation and aerobic exercise. Only 3 of 12 randomized controlled trials had a low risk of bias. The diversity of the studies precluded analysis of long-term effects. A 2015 systematic review on the effect of yoga on mood and the brain concluded that “yoga is associated with better regulation of the sympathetic nervous system and hypothalamic-pituitary-adrenal system, as well as a decrease in depressive and anxious symptoms in a range of populations.” A systematic review in 2017 found some evidence of benefit in major depressive disorder, examining outcomes primarily of improvements in remission rates and severity of depression (and secondarily of anxiety and adverse events), but considered that better randomized controlled trials were required.
Cardiovascular health
A 2012 survey of yoga in Australia notes that there is “good evidence” that yoga and its associated healthy lifestyle—often vegetarian, usually non-smoking, preferring organic food, drinking less or no alcohol–are beneficial for cardiovascular health, but that there was “little apparent uptake of yoga to address [existing] cardiovascular conditions and risk factors.” Respondents cited yoga as a cause of these lifestyle changes; the survey notes that the relative importance of the various factors had not been assessed.
Other conditions
There is little reliable evidence that yoga is beneficial for specific medical conditions, and an increasing amount of evidence is not, as follows.
A systematic review in 2013 found weak evidence for the use of yoga for rheumatic diseases, examining outcomes of pain and disability, with no evidence of its safety.
A 2015 systematic review found no evidence of benefit in the treatment of epilepsy or menopause-related symptoms.
According to the American Cancer Society, the practice of yoga can improve strength and balance in cancer patients, is “unlikely to cause harm,” and does not “interfere with cancer treatment.” Society notes that yoga “cannot cure cancer,” but that yoga may help to improve the quality of life in cancer survivors, as shown in a randomized controlled trial of women who had had breast cancer. Measured outcomes included fatigue, depression, and sleep quality.
A systematic review in 2015 found “promising” evidence that exercise helps people with dementia perform activities of daily living (ADLs), but no evidence that cognition, neuropsychiatric symptoms, or depression were benefited; yoga was not distinguished from other forms of exercise.
A 2010 systematic review showed no effect of yoga on attention deficit hyperactivity disorder, measured by teacher rating on the ADHD overall scale.
A systematic review in 2019 concluded that there was not enough evidence to assess the effectiveness of yoga for treating women with urinary incontinence.
Safety
Although relatively safe, yoga is not a risk-free form of exercise. Sensible precautions can usefully be taken – for example, the avoidance of advanced moves by beginners, not combining practice with psychoactive drug use, and avoiding competitiveness.
A small percentage of yoga practitioners each year suffer physical injuries analogous to sports injuries. The practice of yoga has been cited as a cause of hyperextension or rotation of the neck, which may be a precipitating factor in cervical artery dissection.
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