The Essential Properties of Yoga Questionnaire: Development and Methods

Perceived delivery of essential yoga properties within in-person and remote weight loss maintenance interventions

OBJECTIVES

While previous research has utilized remote delivery of yoga interventions, no research has specifically interrogated the effectiveness of remote yoga intervention delivery. In this secondary analysis of weight-maintenance trial data, we examined participant perceptions of essential yoga properties across in-person and remote formats, hypothesizing that perceptions would not differ following remote delivery.

METHODS

24 women with overweight or obesity (34.6±4.1 kg/m2, 48.2±9.9 years) received a 12-week Iyengar yoga intervention (2x/week) following a 3-month behavioral weight loss program. Of 23 participants who completed follow-up questionnaires, 12 received the planned in-person intervention and 11 received a remote intervention (delivered live) due to the COVID-19 pandemic. The Essential Properties of Yoga Questionnaire (EPYQ) was completed online by participants and by the instructors to measure the perceptions of the relative emphasis placed on the essential components of the yoga intervention via 14 subscales. Linear regression models were used to compare perceptions of each EPYQ dimension across in-person and remote delivery methods, as well as between participants and instructors, independent of delivery method.

RESULTS

13 of the 14 subscales did not differ between delivery modalities (p>0.05). Participants perceived more individual attention within in-person yoga (p = 0.003). For both delivery methods, instructors perceived breathwork, restorative postures, and body locks to be incorporated to a lesser degree compared to participants (β = -1.28, p = 0.003; β = -1.57, p = 0.019; β = -1.39, p = 0.036; respectively). No other significant differences across the participant and instructor scores were observed.

CONCLUSIONS

Findings provide preliminary support for the use of live remote delivery of yoga, effectively communicating most essential yoga properties when compared to in-person classes. However, participants perceived more individual attention with in-person versus remote delivery; thus, future remote-based yoga interventions may benefit from providing additional individualized feedback.

The influence of hatha yoga on stress, anxiety, and suppression: A randomized controlled trial

Engaging in yoga may mitigate stress and anxiety in individuals while potentially enhancing one's capacity to manage distractions. Our research aimed to explore the relation between these two outcomes: Can an eight-week yoga program foster distraction suppression, thereby reducing stress and discomfort? To answer this question, we used Hatha Yoga, the most commonly practiced form of yoga. We tested if the intervention improved participants' ability to suppress distractions and selectively decrease self-reported stress and stress reactivity. In Addition, we investigated whether such an intervention would increase participants' mindfulness. Our study included 98 healthy yoga novices between 18 and 40 years who were randomly assigned to either an experimental or a waitlist condition, with each participant completing pre- and post-intervention assessments, including questionnaires, as well as electrophysiological and behavioral measures. After eight weeks of yoga practice, significant reductions in self-reported stress and stress reactivity levels, as well as increased mindfulness, were observed among those participating in the intervention relative to those in the waitlist control group. There were, however, no significant changes in state or trait anxiety due to the intervention. Changes in stress measures could not be explained by changes in participants' ability to suppress distractors, which was not affected by the intervention. Overall, our findings suggest that regular participation in Hatha Yoga can improve mental health outcomes without impacting cognitive functioning directly related to distractor suppression. CLINICAL TRIAL REGISTRATION NUMBER: NCT05232422.

Developing Resilience During the COVID-19 Pandemic: Yoga and Mindfulness for the Well-Being of Student Musicians in Spain

Here, we report on a quasi-experimental study to explore the applicability and perceived benefits of the CRAFT program, which is based on mindfulness, yoga, positive psychology, and emotional intelligence, to improve higher education student musicians' health and well-being during the lockdown. A subset of student musicians at a Higher Conservatory of Music in Spain followed the CRAFT program during the academic year 2019/2020, 1 h per week as part of their curriculum. Students enrolled in CRAFT-based elective subjects formed the CRAFT program group (n = 40), while other students represented the control group (n = 53). The onset of the national lockdown elicited by the COVID-19 pandemic occurred halfway through the program, which was subsequently delivered in an online format. We administered an online survey to explore the effect that the exposure to the CRAFT program had in terms of how participants dealt with various health and well-being concerns arising from the COVID-19 lockdown. There was a significantly higher proportion of proactive participants in the CRAFT program group, 92%, than in the control group, 58%, in terms of implementing practices to improve their health and well-being during the lockdown. Additionally, significantly more participants acknowledged perceived benefits from their practices in the CRAFT program group, 78%, than in the control group, 52%. Among proactive participants, yoga/meditation was the most implemented in the CRAFT program group, followed by exercise, and other yoga/meditation practices, whereas in the control group, exercise and Alexander technique-based practices were the most applied. In the CRAFT program group, the highest rate of perceived benefits was from yoga/meditation CRAFT-based practices, 51%, followed by exercise, 32%, and other yoga/meditation practices, 27%, whereas in the control group, benefits were reported by 29% of exercising participants and 16% for those having practiced the Alexander technique. A similar pattern was observed when excluding participants with previous yoga/meditation experience. This study revealed how participants can independently apply learned skills from the CRAFT program in response to a naturally occurring life event of unprecedented global impact, suggesting that previous exposure to mindfulness and yoga is likely to have a beneficial effect on how young adults react towards exceptionally stressful conditions.

A systematic review of yoga interventions for helping health professionals and students

Helping Health Professionals (HHP) and HHP students are among the highest risk occupational groups for compromised mental and physical health. There is a paucity of information regarding preventive interventions for mental and physical health in this group of healthcare providers.

OBJECTIVE

The objective of this review was to examine the effectiveness of yoga interventions for the prevention and reduction of mental and physical disorders among HHPs and HHP students.

DESIGN

An exhaustive systematic search was conducted in May 2020. Databases searched in the OVID interface included: MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily, Embase, and PsycINFO. EbscoHost databases searched included: CINAHL Plus with Full Text, SPORTDiscus with Full Text, Alt HealthWatch, Education Research Complete, SocINDEX with Full Text, ERIC, and Academic Search Complete. Scopus was also searched.

RESULTS

The search yielded 4,973 records, and after removal of duplicates 3197 records remained. Using inclusion and exclusion criteria, titles and abstracts were screened and full text articles (n = 82) were retrieved and screened. Twenty-five studies were identified for inclusion in this review. Most frequently reported findings of yoga interventions in this population included a reduction in stress, anxiety, depression, and musculoskeletal pain.

CONCLUSION

It is our conclusion that mental and physical benefits can be obtained through implementation of yoga interventions for HHPs and HHP students across a variety of settings and backgrounds. However, researchers would benefit from following recommended guidelines for the design and reporting of yoga interventions to improve study quality and rigour.

Yoga Practice Among Veterans With and Without Chronic Pain: A Mixed Methods Study

OBJECTIVES

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.

DESIGN

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.

RESULTS

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.

CONCLUSIONS

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.

Strategies for evaluating self-efficacy and observed success in the practice of yoga postures for therapeutic indications: methods from a yoga intervention for urinary incontinence among middle-aged and older women

BACKGROUND

Most clinical investigations involving yoga lack adequate description of the specific yoga elements, including physical postures. Few studies have measured self-efficacy regarding the performance of yoga postures or assessed observed success in performing postures.

METHODS

We developed and piloted several tools to evaluate self-efficacy and observed success in practicing yoga in the context of a randomized feasibility trial of an Iyengar-based yoga intervention for urinary incontinence in ambulatory women ≥50 years. At the end of the 12-week yoga intervention involving twice weekly group yoga classes and once weekly home practice, participants rated their self-efficacy in performing each of the included 15 yoga postures on a 5-point Likert scale. During the 12th week, an expert yoga consultant observed participants and rated their competency in performing postures on a 5-point scale. Participants completed a questionnaire about self-efficacy in adhering to home yoga practice. We examined the distribution of and correlations between scores on the above measures.

RESULTS

Among 27 participants (mean age 65 years), the range of means for self-efficacy ratings for individual postures was 3.6 to 4.5. The range of means for observed competency ratings for individual postures was 3.3 to 5.0. Mean self-efficacy rating for confidence in adhering to the assigned once-weekly home yoga practice was 2.8 (range 1 to 5). Posture self-efficacy was inversely correlated with participant age (p = 0.01) and positively correlated with self-reported physical function (p = 0.03) and mobility (p = 0.01). No significant correlations were found between posture self-efficacy scale scores and expert-observed yoga competency ratings or practice adherence self-efficacy scores.

CONCLUSIONS

These measures hold promise for advancing yoga research and practice by describing methods to: 1) measure self-efficacy in performing specific yoga postures; 2) use an expert observer to assess participants' competence in performing yoga postures; and 3) measure self-efficacy in adhering to home practice. These proposed measures can be used to describe specific components of yoga interventions, to assess whether study participants are able to learn to practice physical aspects of yoga and/or maintain this practice over time, as well as to investigate relationships between self-efficacy and competency in performing yoga postures to achieve specific health outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02342678, January 21, 2015.

Yoga for the treatment of depression: Five questions to move the evidence-base forward

Yoga-based practices, derived from ancient Eastern mind-body practices, have grown in popularity in the West over the past several decades. Increasing evidence supports the antidepressant effects of yoga-based interventions (YBIs). However, despite yoga's promise as a potential treatment for depression, the literature to date is marked by substantial methodological limitations, which remain a barrier to the integration of YBIs into conventional clinical care. We highlight five key areas of study that need further investigation to fill crucial gaps in the literature-base to advance yoga research and yoga's potential as an effective evidence-based treatment for depression.

Yoga for systemic lupus erythematosus (SLE): Clinician experiences and qualitative perspectives from students and yoga instructors living with SLE

Systemic lupus erythematosus (SLE) is an autoimmune disease associated with widespread inflammation and tissue damage. It is more common and severe among Blacks, Hispanics, and Asians; with higher incidence in women. While the goals of medical treatment are to prevent flares and reduce organ damage, up to 50% of patients perceive their health to be suboptimal with unaddressed needs including fatigue and pain. Recent SLE treatment guidelines focus on improving quality of life. Yoga has shown improvements in quality-of-life and fatigue in various diagnoses. While there is growing evidence that yoga therapy may help osteoarthritis and rheumatoid arthritis symptoms, there is only one reference in the literature related to SLE.

METHODS/SETTING

An adjunct study was undertaken to evaluate adapting the Yoga as Self Care for Arthritis in Minority Communities study for a bilingual population living with SLE in the Washington, DC area. Informants included 7 patients enrolled onto the study, and 3 yoga instructors living with SLE. Qualitative methods included journals and semi-structured interviews.

RESULTS

Enrolling patients clarified revisions for intake questionnaires, and symptoms that may impact class participation. Participants demonstrated increased balance, body awareness, and tolerated a faster-paced yoga class when compared to those in the parent study. Yoga instructors' recommendations included modifying yoga based on energy levels and frequent changes in physical ability.

CONCLUSION

This paper shares perspectives from various informants and affirms the feasibility of progressing to a larger study. It summarizes our findings and recommendations towards creating a randomized controlled trial, as there are currently none in the literature.

A systematic review of randomized trials of mind-body interventions for PTSD

OBJECTIVE

To systematically review outcomes from randomized controlled trials (RCTs) of mind-body treatments for PTSD.

METHODS

Inclusion criteria based on guidelines for assessing risk of bias were used to evaluate articles identified through electronic literature searches.

RESULTS

Twenty-two RCTs met inclusion standards. In most of the nine mindfulness and six yoga studies, significant between-group effects were found indicating moderate to large effect size advantages for these treatments. In all seven relaxation RCT's, relaxation was used as a control condition and five studies reported significant between-group differences on relevant PTSD outcomes in favor of the target treatments. However, there were large within-group symptom improvements in the relaxation condition for the majority of studies.

CONCLUSIONS

Although many studies are limited by methodologic weaknesses, recent studies have increased rigor and, in aggregate, the results for mindfulness, yoga, and relaxation are promising. Recommendations for design of future mind-body trials are offered.

The Essential Properties of Yoga Questionnaire (EPYQ): Psychometric Properties

Yoga interventions are heterogeneous and vary along multiple dimensions. These dimensions may affect mental and physical health outcomes in different ways or through different mechanisms. However, most studies of the effects of yoga on health do not adequately describe or quantify the components of the interventions being implemented. This lack of detail prevents researchers from making comparisons across studies and limits our understanding of the relative effects of different aspects of yoga interventions. To address this problem, we developed the Essential Properties of Yoga Questionnaire (EPYQ), which allows researchers to objectively characterize their interventions. We present here the reliability and validity data from the final phases of this measure-development project. Analyses identified fourteen key dimensions of yoga interventions measured by the EPYQ: acceptance/compassion, bandhas, body awareness, breathwork, instructor mention of health benefits, individual attention, meditation and mindfulness, mental and emotional awareness, physicality, active postures, restorative postures, social aspects, spirituality, and yoga philosophy. The EPYQ demonstrated good reliability, as assessed by internal consistency and test-retest reliability analysis, and evidence suggests that the EPYQ is a valid measure of multiple dimensions of yoga. The measure is ready for use by clinicians and researchers. Results indicate that, currently, trained objective raters should score interventions to avoid reference frame errors and potential rating bias, but alternative approaches may be developed. The EPYQ will allow researchers to link specific yoga dimensions to identifiable health outcomes and optimize the design of yoga interventions for specific conditions.

Yoga therapy for military personnel and veterans: Qualitative perspectives of yoga students and instructors

OBJECTIVE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Mindfulness in PTSD treatment

In recent years, the field has witnessed considerable enthusiasm for the ancient practice of mindfulness. The skills derived from this experience, including focused attention, nonjudgmental acceptance of internal experiences and reduced autonomic reactivity, may be helpful in counteracting pathological responses to trauma. Several types of interventions that incorporate principles of mindfulness have been examined for treatment of posttraumatic stress disorder (PTSD). This nascent literature is inconsistent and methodologically limited but does suggest that mindfulness is a potentially important tool for creating psychological change. The interventions described herein generally would not yet be considered first-line treatments for PTSD. Nonetheless, evidence is building, and mindfulness may provide an impetus for better understanding how to personalize psychological interventions and to evaluate their outcomes.

Yoga Research and Public Health: Is Research Aligned With The Stakeholders' Needs?

Research on yoga is witnessing an unprecedented proliferation currently, partly because of great interest in yoga's health utility. However, yoga research does not seem to be sufficiently public health oriented, or its quality corresponding to its quantity. Yoga research is falling short to enable key stakeholders like end users, prescribers, and payers to meaningfully, confidently, and fruitfully answer the questions like: Is it generalizable? Is it standardizable? Which yoga style should be used/recommended/paid for? Or will it be worth the money? Therefore, it is important to examine the alignment to purpose or value of yoga research from a public health point of view so as to make it more practical. The issues such as lack of clear definition of yoga, wide variation in its dosage, cacophony of lineage-based styles, no data about comparative effectiveness between the yoga components, confounders and biases clouding the evidence regarding its benefits, too little data on long-term adherence, equivocal results about its cost effectiveness, discussions lacking embrace of better methods in research, and absence of a theory of yoga are examined. This is not a detailed discussion of every issue yoga research faces, but a high-level overview of those that have direct practical bearing. In the end, a few pragmatic approaches are offered. The article suggests that yoga-component analysis, development of a theory of yoga, adoption of a health-aligned functional typology of yoga, development and testing of a simple universal basic prototype of yoga intervention, emphasis on research about long-term adherence, and discouragement for mere proof of concept research might make yoga research serve the stakeholders better. It urges the research community to practice "context cognizant scholarship" to disentangle health compatible yoga from its historical-cultural-social body before examining it for health or medical application.