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Flexible? Yoga and Rheumatoid Arthritis
Abstract & Commentary
By Russell H. Greenfield, MD
Synopsis: Results of this pilot trial of structured yoga therapy for people with rheumatoid arthritis suggest potential therapeutic benefits, but severe methodological flaws relegate the findings to the realm of suggesting the need for further research, not that of a change in therapeutic approach.
Source: Badsha H, et al. The benefits of yoga for rheumatoid arthritis: Results of a preliminary, structured 8-week program. Rheumatol Int 2009 Jan 31; Epub ahead of print.
To determine the effects of a structured yoga program on measures of rheumatoid arthritis (RA) disease activity, disability, and quality of life, the authors of this eight-week pilot controlled intervention trial recruited patients with the disorder from an RA database as developed by two regional rheumatology centers. Potential participants older than age 18 years were contacted by e-mail and asked to join the study, and a total of 47 people did. They were then divided into two groups; a control group who were wait-listed for yoga therapy to be provided at a later date, and who received only information about yoga therapy and RA support groups (n = 21); and an active intervention group who twice weekly, for a total of 12 sessions, received a structured program of yoga that emphasized stretching, strengthening, meditation, and deep breathing (n = 26). Subjects in the active intervention group were also required to perform yoga exercises at home.
Yoga is a mind-body practice with origins in ancient Indian philosophy. The various styles of yoga that people use for health purposes typically combine physical postures, breathing techniques, and meditation or relaxation. There are numerous schools of yoga. Hatha yoga, the most commonly practiced in the United States and Europe, emphasizes postures (asanas) and breathing exercises (pranayama). Some of the major styles of hatha yoga include Iyengar, Ashtanga, Vini, Kundalini, and Bikram yoga.
The 2002 National Health Interview Survey found that yoga is one of the top 10 CAM modalities used. Nearly 8% percent of those surveyed (more than 15.2 million adults) have used yoga for health purposes.
Source: National Center for Complementary and Alternative Medicine. Available at: http://nccam.nih.gov/health/yoga/.
All subjects received standard rheumatologic care by their doctors throughout the study. Rheumatologists collected data at baseline and at study completion on the use of disease-modifying anti-rheumatic drugs (DMARDs), disease duration, demographics, disease activity score using the 28 joint count (DAS28), and erythrocyte sedimentation rate. Subjects completed questionnaires at baseline and at 12 weeks, including health assessment questionnaires (HAQ) and the SF-36 quality of life (QOL) measure. They were also asked to fill in visual analog scales relating to pain, global assessment, and fatigue indices. The primary outcomes of interest were changes in DAS28 and HAQ.
At trial's end, those who had participated in the structured yoga program reported improvements in most measures of disease activity, especially on the HAQ. Interestingly, however, QOL measures were no different between the two groups. Two subjects in the control group developed RA flares requiring medical attention, while none in the intervention group experienced a disease flare. Three people in the yoga group were taken off some of their medications due to significant clinical improvement. The researchers conclude that a structured yoga program may reduce disease activity scores, the need for medication, and levels of fatigue in people with RA.
Prior small trials of yoga therapy in the treatment of RA have likewise suggested therapeutic benefit, and studies of dynamic exercise and Tai Chi have also pointed to clinical efficacy in this setting. Improvements in mood and functional capacity have been associated with fitness activities in people with RA, but the problem is that many people with RA do not exercise regularly. The current article adds to the evidence of physical motion's benefits for those with autoimmune disorders, but only slightly, as the results are tainted by severe methodological flaws.
The study sample size is quite small, and the subjects that did enter into the trial were recruited via e-mail contact. Of the 320 people in the RA database only 87 replied to the e-mail, and only the final 47 agreed to participate. Those who became part of the control group did so because they were interested in yoga but could not commit to regular practice, largely due to time constraints. At baseline a larger proportion of subjects in the control group were on DMARDs, suggesting that they may have had more active disease. Subjects who were unable to perform the yoga exercises were not permitted entry into the study, but the authors later state that modifications to the program were suggested for those who could not complete certain exercises. This latter point is important, as most yoga therapists believe that almost anyone can participate in yoga therapy, whether the focus be on postures, breath work, and/or meditation, provided the approach is individualized. While those in the active group came together regularly, members of the control group had no added interpersonal intervention. In addition, there was no blinding of the rheumatologists, so bias is an issue. It should be noted that the authors of this study were up front about its shortcomings.
Of interest is where this study was performedDubai. The United Arab Emirates is home to a multi-ethnic population, yet the participants in the study included only one Arab together with 26 Indians and 15 Caucasians, among others. The individuals' frame of reference could have had an impact on the decision to participate in the trial, as well as the trial's results.
On the up side, the program was jointly developed by the yoga therapist and rheumatologists, intention-to-treat analysis was employed, and even though the trial was of short duration there were suggestions of meaningful clinical improvement for some of the participants. Questions regarding generalizability would be appropriate (the yoga therapist was Master's qualified in Yoga and Ayurveda) except for the fact that the authors kindly provide all the postures and other interventions used during the study for readers to use for themselves and their patients, or to modify as deemed appropriate.
Yoga therapy has been recommended as an adjunctive treatment for mild-to-moderate musculoskeletal disorders on the basis of experience and, in some instances such as carpal tunnel syndrome, good data. The current article in question plants the seed of using yoga therapy for more severe musculoskeletal dis-orders but little more. Then again, what are pilots for? In and of themselves they are not meant to alter treatment but to kindle a spark for further investigation. It is fair to say that in this regard, at least, these authors succeeded.