The Road to Incorporating Yoga Therapy Into Healthcare: The Role of Science and Research

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Aubrie Price
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Assistant Professor of Medicine, Harvard Medical School Director of Research, Kundalini Research Institute Research Director, Kripalu Center

1 Brigham & Women s Hospital Harvard Medical School The Road to Incorporating Yoga Therapy Into Healthcare: The Role of Science and Research IAYT Symposium on Yoga Therapy and Research June 16, 2017 Sat Bir S. Khalsa, Ph.D. Assistant Professor of Medicine, Harvard Medical School Director of Research, Kundalini Research Institute Research Director, Kripalu Center for Yoga and Health Editor in Chief, International Journal of Yoga Therapy Research Associate, Benson Henry Institute for Mind Body Medicine Research Affiliate, Osher Center for Integrative Medicine

2 Yoga and Yoga Therapy

3 Yoga Alliance/Yoga Journal Survey 2016 From:

4 Yoga Alliance/Yoga Journal Survey 2016 From:

5 The Professional Transformation of Yoga into Mainstream Society Public Schools, Workplaces, Healthcare Ashrams, Studios, Yoga Centers, Gyms, Spas

6 The Professional Transformation of Yoga into Mainstream Society Public Schools, Workplaces, Healthcare Research Ashrams, Studios, Yoga Centers, Gyms, Spas

7 Rationale for Yoga in Modern Healthcare

8 Non-communicable Diseases (NCDs) NCDs are the leading cause of death in the world In most middle- and high-income countries NCDs were responsible for more deaths than all other causes of death combined... Noncommunicable Diseases, Country Profiles, World Health Organization, 2011 NCD deaths are projected to increase by 15% globally between 2010 and 2020 (to 44 million deaths). Global status report on noncommunicable diseases 2010 World Health Organization

9 Stress Awareness Worldview

10 The Acute Care Model Focused on treatment and/or intentional suppression of symptoms at the expense of underlying causes and contributing factors Dominated by a disease-focused approach rather than a patient-centered holistic approach Highly invested in pharmaceutical, surgical and other highly technological diagnostic and treatment strategies Incentivized to emphasize speed, high volume, and immediate symptom relief Responsibility for healthcare is primarily on the provider Prevention and health maintenance is not emphasized

12 From:

14 From: Developmental origins of noncommunicable disease: population and public health implications, Hanson M, Gluckman P, American Journal of Clinical Nutrition, 94:1754S 8S, 2011.

15 Research on Yoga for Stress, Awareness, Worldview

16 Reasons for Practice in a Beginners Program From: Yoga in the real world: Perceptions, motivators, barriers, and patterns of use, Quilty MT, Saper RB, Goldstein R, Khalsa SBS, Global Advances in Health and Medicine, 2:44-49, 2013.

17 Stress in Beginner Yoga Students 18 Perceived Stress Average Score PSS p < Baseline End Program From: Yoga as a stress reduction technique for women, Quilty M, Khalsa SBS, Saper R, Abstract submitted to 137th APHA Annual Meeting & Exposition, 2009.

18 Stress in Occupational Setting From: Yoga for reducing perceived stress and back pain at work, Hartfiel N, Burton C, Rycroft-Malone J, Clarke G, Havenhand J, Khalsa SB, Edwards RT, Occupational Medicine 62: , 2012.

Stress in Frontline Professionals 20 15 10 Perceived Stress N=71 from fields

program 5 92 90 88 86 Baseline Post Follow-up Resilience 84 From: Trent N,

19 Stress in Frontline Professionals Perceived Stress N=71 from fields of education, healthcare, and corrections in a residential 5-day Kripalu program Baseline Post Follow-up Resilience 84 From: Trent N, Dusek J, 82 Miraglia M, Pasalis E, Khalsa SBS, in preparation. 80 Baseline Post Follow-up

21 Mindfulness in Yoga Practitioners Average Change Score Freiburg Mindfulness Inventory Controls Marginal Moderate High Intensity of Yoga Practice From: The relationship between yoga involvement, mindfulness & psychological well-being, Gaiswinkler L, Unterrainer HF, Complementary Therapies in Medicine, 26:123-7, 2016.

22 Positive Psychological Changes in Musicians with Kripalu Yoga FFMQ Average Score Total Mindfulness Yoga Controls Observing Average Score Observing Yoga Controls Awareness Average Score Awareness Yoga Controls From: Yoga Enhances Positive Psychological States in Young Adult Musicians, Butzer B, Ahmed K, Khalsa SB, Applied Psychophysiology and Biofeedback, 41, , 2016.

Kripalu Rise Program in the Workplace 150 140 130 Total Mindfulness

065 120 Pre-RISE Post-RISE Mindfulness Factors 35 30 25 From: Trent N,

23 Kripalu Rise Program in the Workplace Total Mindfulness Score p = Pre-RISE Post-RISE Mindfulness Factors From: Trent N, Dusek J, Miraglia M, Pasalis E, Khalsa SBS, unpublished data Observe Describe Awareness Non-Judge Non-React Pre-RISE Post-RISE

24 Survey Studies in Practitioners Subjective Effects Non-Ashram Respondents Ashram Respondents Became aware of a new reality Felt a personality change Experience resulted in change in life Experience of oneness In touch with divine or spiritual Percent with Positive Response From: Intense personal experiences: Subjective effects, interpretations, and aftereffects, Wilson SR, Spencer RC, Journal of Clinical Psychology 46: , 1990.

25 Psychology of Yoga Practitioners From: Yoga experience as a predictor of psychological wellness in women over 45 years, Moliver N, Mika E, Chartrand M, Haussmann R, Khalsa S, International Journal of Yoga, 6:11-9, 2013.

26 Self-transcendence in Yoga Practitioners Transpersonal Identification vs. Self-Differentiation 7 6 AY Practitioners Score p= Controls 1 From: Processing of proprioceptive and vestibular body signals and self-transcendence in Ashtanga yoga practitioners, Fiori F, David N, Aglioti SM, Frontiers in Human Neuroscience, 8:734, 2014.

27 Spirituality in Yoga Practitioners Multidimensional Inventory for Religious/Spiritual Well-Being (RSWB) Average Change Score RSWB Total Average Change Score Hope Immanent Controls Marginal Moderate High Controls Marginal Moderate High Average Change Score Connectedness Average Change Score Experiences of Sense and Meaning Controls Marginal Moderate High Controls Marginal Moderate High From: The relationship between yoga involvement, mindfulness & psychological well-being, Gaiswinkler L, Unterrainer HF, Complementary Therapies in Medicine, 26:123-7, 2016.

28 Positive Psychological Changes in Musicians with Kripalu Yoga Dispositional Flow - Total Autotelic Experience Average Difference Scores Yoga Control Yoga Control From: Yoga Enhances Positive Psychological States in Young Adult Musicians, Butzer B, Ahmed K, Khalsa SB, Applied Psychophysiology and Biofeedback, 41: , 2016.

29 Yoga Practices Postures, Breathing, Relaxation, Meditation Fitness Self-Regulation Awareness Spirituality Flexibility Strength Coordination/Balance Respiratory Function Self-Efficacy Emotion Regulation Stress Regulation Resilience Equanimity Self-Efficacy Attention Mindfulness Concentration Cognition Meta-cognition Transcendence Unitive State Flow Transformation Life Meaning/Purpose Global Human Functionality Physical & Mental Health, Physical, Mental, Emotional Performance, Positive Behavior Change, Social Responsibility, Values, Relationships, Quality of Life, Life Purpose & Meaning, Spirituality

30 Yoga Therapy Research

31 Chronology of Yoga Therapy Research # of Peer-Reviewed Publications Yoga Therapy Research Publications All RCT Year Windows From: Yoga as a therapeutic intervention: A bibliometric analysis of published research studies from , Jeter PE, Slutsky J, Singh N, Khalsa SBS, Journal of Alternative and Complementary Medicine, 21:586-92, 2015.

32 Yoga Research Journals Yoga Mimamsa (1924) International Journal of Yoga Therapy (1990) International Journal of Yoga (2008) Indian Journal of Ancient Medicine and Yoga (2008) Journal of Yoga and Physical Therapy (2011) International Scientific Yoga Journal SENSE (2011) International Journal of Yoga and Allied Sciences (2012) International Journal of AYUSH: Ayurveda, Yoga, Unani,Siddha and Homeopathy (2012) Journal of Advanced Research in Ayurveda, Yoga, Unani, Siddha and Homeopathy (2014) Journal of Yoga and Physiotherapy (2016) International Journal of Advanced Ayurveda, Yoga, Unani, Siddha and Homeopathy (2016) International Journal of Yoga, Physiotherapy and Physical Education (2016) MOJ Yoga & Physical Therapy (2016) International Journal of Yoga Natural Therapy (newly founded)

33 Yoga Therapy Research by Disorders Mental Health Cardiovascular Respiratory Musculoskeletal Cancer Diabetes Neurological Women's Health Obesity Other Number of Publications From: Yoga as a therapeutic intervention: A bibliometric analysis of published research studies from , Jeter PE, Slutsky J, Singh N, Khalsa SBS, Journal of Alternative and Complementary Medicine, 21:586-92, 2015.

35 23 chapters with theory, rationale, research & practice ~60 chapter contributors, ~30 yoga therapist contributors

36 decrease use of medications, resulting in substantial cost savings for hospitals in the care of oncology patients.

37 Mind body interventions have the potential to substantially reduce healthcare utilization at relatively low cost and thus can serve as key components in any population health and health care delivery system.

39 if all 3 interventions are constrained by resources, medical yoga treatment is the optimal choice.

40 Yoga for Health and Prevention

benefits, Ross A, Friedmann E, Bevans M, Thomas

41 Yoga Practice Associations From: National survey of yoga practitioners: mental and physical health benefits, Ross A, Friedmann E, Bevans M, Thomas S, Complementary Therapies Medicine, 21:313-23, 2013.

42 Perceptions of Yoga on Health Belief about Yoga and Health Yoga has helped me to attain or maintain a healthier weight My energy level is better because of yoga My sleep is better because of yoga I am happier because of yoga My health has improved because of yoga Percent of Respondents Agreeing or Strongly Agreeing with the Belief From: National survey of yoga practitioners: mental and physical health benefits, Ross A, Friedmann E, Bevans M, Thomas S, Complementary Therapies Medicine, 21:313-23, 2013.

43 Medications in Yoga Practitioners From: Increased Hatha yoga experience predicts lower body mass index and reduced medication use in women over 45 years, Moliver N, Mika E, Chartrand M, Burrus S, Haussmann R, Khalsa S, International Journal of Yoga, 4:77-86, 2011.

Yoga for Exercise Adherence The acute-feeling responses to the yoga classes were favorable and may have been a key contributor to participants' improved perceptions of ability, which may have further

44 Yoga for Exercise Adherence The acute-feeling responses to the yoga classes were favorable and may have been a key contributor to participants' improved perceptions of ability, which may have further fostered adherence. The participants reported an increased self-awareness as a result of their experience. From: The effects of yoga on psychosocial variables and exercise adherence: a randomized, controlled pilot study, Bryan S, Pinto Zipp G, Parasher R, Alternative Therapies in Health and Medicine, 18:50-9,

45 Yoga in Medicine United States

49 NCCIH Interactions

51 Yoga in Medicine Veterans Administration

52 Yoga as a Tier 1 Intervention for Pain

53 The topic was therapies such as meditation, massage, and yoga to help Veterans with [PTSD]. The goal was to explore the existing evidence on complementary and alternative medicine (CAM) for PTSD and forge a future research agenda.

55 Meditation, imagery, acupuncture, and yoga are the most frequently offered mind and body practices in the Department of Veterans Affairs. Future research should include yoga as it is currently understudied among veterans and military personnel. [6 of 89 studies reviewed]

56 Participants rated massage, meditation, acupuncture, and yoga as priorities for promotion across the VHA.

specific complementary therapies can help to alleviate symptoms such as pain and fatigue as well as help with psychological issues like post traumatic stress disorder (PTSD) and

57 specific complementary therapies can help to alleviate symptoms such as pain and fatigue as well as help with psychological issues like post traumatic stress disorder (PTSD) and depression. Recognizing this, Veterans Administration (VA) hospitals and the War Related Illness and Injury Study Center (WRIISC) have made Integrative Medicine a high priority.

[CAM] strategies such as yoga are widely

Determining the state of evidence on the

63 [CAM] strategies such as yoga are widely available in the private sector, and some Veterans have requested that the VHA make them available in the VA system. Determining the state of evidence on the benefits and harms of yoga and other CAM modalities is a priority for the VHA.

72 Yoga in Medicine United Kingdom

73 An open letter to the NHS by Dr. Matt Joslin: I want to see whether there is a way to marry the amazing healing sustaining practice that is Yoga with the services offered by the NHS.

Programs and Activities Started October, 2016: in association with All Party Parliamentary Group on Indian Traditional Sciences Support of Lord Andrew Stone of Blackheath, increasing awareness in

74 Programs and Activities Started October, 2016: in association with All Party Parliamentary Group on Indian Traditional Sciences Support of Lord Andrew Stone of Blackheath, increasing awareness in Parliament of the value of yoga Motion read in the House of Commons A 10-week social prescribing course for patients as early intervention An NHS staff well-being program Heather Mason Brochures for all GPs and GP associations Yoga program for junior doctors All Party Parliamentary Group on Yoga

75 Research Activities Governmental funding for research on the prescribing program on patients (N>200) Research on the prescribing program on NHS staff A completed consumer survey (N = 2,000) on perceptions of therapeutic benefits of yoga (50% indicated that if yoga was available on the NHS they would gladly try it) Yoga survey to social prescribing network (N~4,000) NHS staff, researchers, patients

77 Research Funding

78 Kripalu center for yoga & health

Kripalu Yoga in the Schools Evidence-Based Curriculum

Kripalu Yoga in the Schools Evidence-Based Curriculum KYIS Definition of Yoga Breathing exercises, postures and relaxation techniques for self-care KYIS Curriculum Overview Three Modules 24 Lessons 35