research article evaluation of a specialized yoga...

Research ArticleEvaluation of a Specialized Yoga Program for Persons Admittedto a Complex Continuing Care Hospital A Pilot Study

Kathryn Curtis1 Kerry Kuluski23 Gitte Bechsgaard4 Jennifer Ridgway5 and Joel Katz1

1Department of Psychology Faculty of Health York University 4700 Keele St Toronto ON Canada M3J 1P32Lunenfeld-Tanenbaum Research Institute Sinai Health System 982-600 University Avenue Toronto ON Canada M5G 1X53Institute of Health Policy Management and Evaluation University of Toronto 4th Floor 155 College St Toronto ONCanada M5T 3M64Vidya Institute 253 Christie St Toronto ON Canada M6G 3B85Therapeutic Recreation Sinai Health System-Bridgepoint Site 1 Bridgepoint Drive Toronto ON Canada M4M 2B5

Correspondence should be addressed to Kathryn Curtis kjbcyorkuca

Received 27 May 2016 Revised 7 October 2016 Accepted 7 November 2016

Academic Editor Bangalore N Gangadhar

Copyright copy 2016 Kathryn Curtis et alThis is an open access article distributed under the Creative Commons Attribution Licensewhich permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

Introduction The purpose of this study was to evaluate a specialized yoga intervention for inpatients in a rehabilitation andcomplex continuing care hospital Design Single-cohort repeated measures design Methods Participants (119873 = 10) admitted toa rehabilitation and complex continuing care hospital were recruited to participate in a 50ndash60min Hatha Yoga class (modified forwheelchair usersseated position) once aweek for eightweeks with assigned homework practiceQuestionnaires on pain (pain paininterference and pain catastrophizing) psychological variables (depression anxiety and experiences with injustice) mindfulnessself-compassion and spiritual well-being were collected at three intervals pre- mid- and post-intervention Results Repeatedmeasures ANOVAs revealed a significant main effect of time indicating improvements over the course of the yoga program on the(1) anxiety subscale of the Hospital Anxiety and Depression Scale 119865(2 18) = 474 119901 lt 05 and 120578119901

2 = 35 (2) Self-CompassionScale-Short Form 119865(2 18) = 371 119901 lt 05 and 120578119901

2 = 29 and (3) Magnification subscale of the Pain Catastrophizing Scale 119865(2 18)= 3 66 119901 lt 05 and 120578119901

2 = 29 Discussion The results suggest that an 8-week Hatha Yoga program improves pain-related factorsand psychological experiences in individuals admitted to a rehabilitation and complex continuing care hospital

1 Introduction

Yoga is an ancient mind-body practice that is embedded inVedic traditions dating back to 3000BC [1] andwhich is beingapplied in developed countries as a broad remedy to attenuatehealth-related symptoms in clinical populations [2 3] acrossinstitutional community commercial and private settingsYoga is traditionally understood as cultivating concentrativeawareness and a unified experience of the self through phys-ical postures (asana) breathing exercises (pran ayama) innerawareness (pratyahara) concentration (dharan a) and med-itation (dhyana) with consequent improved health througha separation process from afflictive cognitive emotionalbehavioural and autonomic patterns and a shift towardsadaptive coping skills [4 5]

Yoga is garnering attention for its ability to simultane-ously address multiple body systems (eg circulatory neu-roendocrine musculoskeletal respiratory viscerosomaticand immunological) through a dynamic and bidirectionalprocess consisting of both top-down and bottom-up con-stituents and to yield benefits in well-being and symptomreduction [3 5] Burgeoning interest in yoga as a therapeuticintervention for a variety of health conditions has resultedin an expansion of research over the past decade with thevolume of publications increasing by threefold with up to 312randomized controlled studies noted in 2013 [6 7] There area plethora of lineages and schools of yoga that are evaluatedin yoga research trials but the style of yoga (eg astangaiyengar and hatha) does not impact the odds of producingpositive outcomes for different conditions [8] Acrossmany of

Hindawi Publishing CorporationEvidence-Based Complementary and Alternative MedicineVolume 2016 Article ID 6267879 16 pageshttpdxdoiorg10115520166267879

2 Evidence-Based Complementary and Alternative Medicine

these studies yoga is extolled for its many benefits Howeverthe literature is plagued by studies of poor methodologicalquality and there has been a call for improving the caliber ofresearch in this area [9]

There is evidence that yoga is effective in the treatment ofa variety of acute and chronic conditions [9] either as a stand-alone treatment or as an adjuvant therapy including low backpain [10 11] arthritis [12] rheumatic disease and fibromyalgia[13 14] diabetes [15 16] cancer and related fatigue [17ndash21] stroke and related disability [22 23] sleep disorders[24] renal disease [25 26] hypertension [27 28] asthma[29 30] chronic obstructive pulmonary disease (COPD) [31]psychiatric conditions [32] obesity [33] and neurologicalconditions [34 35] Although there is an abundance ofresearch evaluating the impact of yoga on disease-specificsymptoms or quality of life for many chronic conditions todate there has not been one trial evaluating the effects ofa yoga intervention on individuals who are receiving careor rehabilitation for complex chronic disease and disability(CCDD)

CCDD is a term that identifies individuals who have beendiagnosed with multimorbidities that affect psychologicalsocial physical and vocational functioning and requireongoing health care resource utilization [36ndash38] Individualswith complex health conditions have been identified asunique in terms of their specific health care needs and health-related experiences [36] Although the disease combinationsreported in multimorbidity are diverse the most commondiagnoses are diabetes stroke hypertension cancer arthritisasthma fractures the presence of an artificial knee or hipfatigue multiple sclerosis demyelinating diseases of the cen-tral nervous system gonarthrosis ataxia COPD dependenceon renal dialysis malignant neoplasm of breastprostatedepressive episodes and pure hypercholesterolemia [39 40]Consistent across studies of this population is the severity ofthe impact of having multiple conditions [41] Patients withCCDD have an average of five health conditions (comorbidi-ties) [40] and frequently reported pain weakness illness-related symptoms functional challenges (mobility activitiesof daily living equipment devices etc) symptoms of anxietyand depression and disruptions in independence recre-ational activities occupation social roles and self-identity

Multimorbidity has been associated with low socioeco-nomic status female gender and older age in both lon-gitudinal and cross-sectional studies with prevalence andincidence rates in older age reported at 55 and 12ndash33respectively and prevalence rates in young-middle age at113ndash154 [42ndash45] Multimorbidity is a complex and het-erogeneous disease state with many of the most prevalentconditions being of global concern and is increasinglybecoming the norm rather than the exception resulting inhigh health care resource use [45 46] In Canada 42 of totaldirect medical care expenses are allotted to the treatment ofchronic diseases [47] with up to $52661 per patient spent onaverage for the last year of life in part due to inpatient andlong-term care costs [48] Despite the clear priority of themedical community to address the needs of individuals withchronic disease the orientation of the health care system asan acute-care focused model means that care for individuals

with chronic disease is often ineffective leaving those withmany chronic conditions underserviced [49]

A structural shift towards care that is not diseaseinjuryfocused but emphasizes addressing many needs at once hasbeen recommended [50 51] Understanding the relationshipsbetween physical psychological and social factors of healthin multimorbidity has been identified as necessary for cre-ating effective treatment [38 52] A remodeling of chronicdisease services has been proposed to create interventionsthat harmoniously integrate patient-centered and systemicfactors and that also target risk factors such as depression orfunctional ability with the end goal of improving patient self-efficacy functional health status health-related behavioursand psychological well-being [49 53] Despite an increasein research over the past two decades on multimorbiditythere is still limited research on effective interventions toadequately service this population [53 54] which highlightsa need for programs that are designed to address the needsof individuals who are managing multiple intersecting healthimpacts of a chronic nature

Given the evidence supporting the use of yoga for manyof the common primary and secondary diagnoses of patientswith CCDD (eg musculoskeletal conditions multiple scle-rosis hypertension arthritis renal disease depression dia-betes COPD cholesterol levels and breast and prostatecancer) it is possible that yoga may be able to addressmany of the multiple health needs these individuals report asbeing important [40] Other frequently reported symptoms(eg pain fatigue emotional upset nausea and difficultybreathing) and facets of living that are disrupted (egmobility activities of living and social well-being) have alsobeen shown to improve with yoga practice [2 19 21 55 56]Moreover yoga provides a lasting behavioural skill set thatincreases confidence and self-efficacy and shows mainte-nance of functional and coping gains in chronic pain patientsat follow-up [57] It can be used in the treatment of chronicconditions for both low- and high-income populations isassociated with treatment adherence in sedentary adultsand holds promise as a cost-effective treatment for chronicconditions [58ndash61] Complementary and alternative therapiessuch as yoga have been recommended for integration intoclinical health psychology settings in order to more broadlyaddress well-being spirituality multiple health problemsdissatisfaction with orthodox medicine and disease preven-tion [62]

Although there is evidence that yoga provides mentaland physical health benefits for many of the disease statesand psychosocial impacts that are prevalent in individualswithmultimorbidity there have been no studies evaluating itsuse for this population Medical rehabilitation and complexcontinuing care support tend to focus on addressing physicalailments and neglect integrating mental health support Yogais an example of a strategy that addresses both thus itmay impart benefits in multiple areas of health rendering itparticularly useful for this population Hospital and tertiarycare settings typically implement evidence-based practice sothere is a need for information regarding the benefits andsafety of yoga when used in the treatment of individuals withCCDD or multimorbidity

Evidence-Based Complementary and Alternative Medicine 3

Table 1 Demographics of the sample (119873 = 10)

Demographic 119873 ()119872 (sd)Age (years) 631 (166)Height (cm) 1636 (154)Weight (kg) 707 (171)Raceethnicity

African Canadian 2 (20)European (ItalianCroatian) 2 (20)Caucasian 6 (60)

Socioeconomic classHigh 1 (10)Middle-high 1 (10)Middle 1 (10)Middle-low 2 (20)Low 5 (50)

Level of education (119899 = 9)Grade school 2 (222)High school 2 (222)Universitycollege 5 (556)Postgraduate school 0 (0)

This study evaluated the impact of a specialized yogaprogram on pain psychological functional and spiritualconstructs in individuals receiving complex continuing careor medical rehabilitation Given the complex presentation ofimpacts for this population multiple measures were used tofully explore the possible effects of yoga across various aspectsof experience The study used a pilot cohort study designto test the following hypotheses (1) scores on measures ofpain pain catastrophizing stress anxiety depression andexperiences of injustice will decrease from pre- to post-intervention and (2) scores onmindfulness self-compassionand spiritual well-being will increase from pre- to post-intervention

2 Materials and Methods

21 Participants In order to be included in the study partic-ipants had to be inpatients at Sinai Health System (Bridge-point Hospital (BH) Site) be able to understand and speakEnglish and be cognitively able to understand instructionsExclusion criteria included a regular yoga practice in thesix months prior to the commencement of the study anexpected discharge date before the completion of the yogaprogram or moderate cognitive impairment as indicated bya cognitive screen done by BH care team Participants eitherwere wheelchair users or were comfortable doing yoga froma seated position

Demographic information and clinical characteristics ofthe sample are summarized in Table 1 Participants had allbeen admitted to BH in 2014 and were receiving either com-plex continuing care (CCC 119899 = 9) or medical rehabilitation(MR 119899 = 1) The one patient that was admitted for MR wasinformally transferred to CCC partway through the hospital

stay for more intensive care Examination of hospital recordsacross a range of assessment dates indicated that participantshad different levels of independence for tasks of daily livingand mobility such as transferring from a bed to a wheelchairInformation recorded within the hospital system is differentfor the complex continuing care and medical rehabilitationstreams

Bothmales (119899 = 4) and females (119899 = 6) participated in theyoga program Height and weight were taken from hospitalrecords for participants receiving CCC and if multiple weightassessments were provided the weight assessment time clos-est to the start date of the yoga programwas usedWeight andheight were taken from self-report data for the participantreceiving MR secondary conditions were not reported forthis patient Participants had been diagnosed with at leastone medical condition (see Table 2) and on average 76 plusmn28 conditions Although most conditions were accompaniedby a formal disease diagnosis some documented conditionswere not necessarily accompanied by diagnoses (eg weightissues allergies pain and instability) Participant use ofvarious pain treatments (pharmacological natural healthproducts physical treatments psychological treatments andmedical interventions) are displayed in Table 3 The studyresearchers worked with hospital staff to obtain medicalclearance notes for all participants indicating that it wassafe for participants to participate in an eight-week yogaprogram Participants did not receive financial compensationfor participating in the study

22 Procedure The research protocol was reviewed andapproved by the Human Participants Review Committee atYork University and by the Joint Bridgepoint Health WestPark Healthcare Centre Toronto Central Community CareAccess Centre (CCAC) and Toronto Grace Health CentreResearch Ethics Board

23 Research Design This prospective pilot study consistedof two parts a Codesign Phase and a Research InterventionPhase The Codesign Phase involved consultation with BHstaff (Therapeutic Recreation staff research scientists theChair of Complex Chronic Disease Research the Directorof Professional Practice and a liaison to the research ethicsboard) to discuss the best approach to the yoga programdevelopment delivery and evaluation so that it wouldcontribute to meeting the complex needs of the patientsAs depicted in Figure 1 the Research Intervention Phaseconsisted of several components an information sessionyoga classes follow-up meetings and administration of self-report questionnaires Questionnaires concerning pain andrelated variables psychological factors andmindfulness wereadministered at three time (T) points pre- (T1) mid- (T2)and postintervention (T3) There were no subsequent datacollection points in the time following the yoga interventionThe information session was held seven days before the yogaprogram began The yoga program ran for eight weeks (oneclassweek) and the follow-up meetings took place after thefinal class and in the following few days The informationsession and yoga classes were held in one of two auditoriumsat the hospital


Table 2 Primary and secondary conditions by participant (119873 = 10)

Participant Primary diagnoses Secondary diagnoses1 Multiple sclerosis Instability (report of having fallen)

2 End stage renaldisease

Diabetes hypertension ischemic disease (unspecified) gastrointestinal issues renal failuremoderate pain (less than daily) general instability (report of having fallen)

3 Klippel-Feilsyndrome Asthma emphysema moderate pain (daily) general instability (report of having fallen)

4 Superficial injury Hypotension cerebrodisease arthritis Parkinsonrsquos disease asthma moderate pain (both dailyand less than daily) general instability (report of having fallen)

5 Cervical spondylosisOsteoporosis hemiplegia anxiety allergies anemia gastrointestinal issues pneumonia moderatepain (daily) general and acute instability (report of having fallen) skin issues (pressure ulcersrash)

6Intracranialhemorrhage (NOSnontraumatic)

Hypertension cardiovascular disease aphasia cerebrodisease hemiplegia allergies pneumoniaurinary tract infection weight issue edema moderate pain (daily) general and acute instability

7 Hyperkalemia Diabetes arthritis pneumonia moderate pain (daily) report of having falling

8Neuromuscularbladder dysfunction(NOS)

Hypothyroidism sclerosis (type not indicated) depression mild pain (daily) general instabilityskin issues (pressure ulcers rash desensitized skin)

9 Syncope and collapse Hypertension osteoporosis depression emphysema gastrointestinal issues moderate pain (lessthan daily) report of having fallen anxiety

10 NeuromyelitisopticaDevicrsquos disease

Hemiplegia sclerosis depression gastrointestinal urinary tract infection moderate pain (daily)general instability skin issues (rash)

Table 3 Pain medications and pain treatments previously orcurrently used (119873 = 7lowast)

Pain medications and treatments 119873 () Participantnumber

Pharmacological medications (egopioid-based medicationsacetaminophen and antidepressants)

7 (100) 1 3 4 5 7 8 10

Natural health products (egsupplements and vitamins) 5 (7143) 1 3 4 5 8

Physical treatments (eg massageacupuncture physiotherapy andexercise)

5 (7143) 1 3 4 58

Psychological treatments (egmeditation psychotherapydistraction and relaxation)

3 (4286) 3 4 8

Note lowastThree participants did not record the use of pain medications ortreatments

24 Information Session and Data Collection Interested indi-viduals were informed about the yoga study by hospitalstaff (Therapeutic Recreation team members and supportstaff) and were screened for eligibility Eligible participantsattended the information session (T1) where they weregiven information about the investigators the content ofthe yoga program expectations for attendance and commit-ment possible initial increases in pain due to exertion andthe homework component Interested individuals had theopportunity to ask questions or voice concerns and thosewho decided to participate completed the consent processAfter written informed consent was obtained participants

Yoga program

Time(days)

sessionInformation

meetingsFollow-up

minus7 0 28ndash34 56 56ndash60

T1 T2questionnaires questionnaires

T3questionnaires

1 classweek for 8weeks

Figure 1 Time sequence of the study interventionThe informationsession was held seven days before the yoga program began Theyoga program was held once weekly for 8 weeks Questionnairesmeasuring pain pain-related variables psychological factors andmindfulness were evaluated at three time points T1 T2 and T3

were provided with a canvas tote folder which includedan MP3 player with the homework audio files (see yogaprogram description) a copy of the consent form for theirrecords and a handwritten instruction guide to using theMP3 player with accompanying illustrations Participantsfilled out a form with questions regarding demographicinformation health history and current health status and thequestionnaire package At T2 participants had the option ofremaining after the yoga class to fill out questionnaires ortaking the questionnaires back to their hospital room to fillout prior to the following class At T3 participants filled outthe questionnaire package after the final class

25 The Yoga Program The specialized yoga program con-sisted of an integrated approach to Hatha Yoga postures(asana) breath awareness exercises (pran ayama) concentra-tive meditative and relaxation practices (dharan a dhyana)


Table 4 Yoga philosophy concepts by class

Class number Concept Explanation

1 Witness consciousness andahimsa (nonviolence) Sutra 235

Practicing ldquobeing withrdquo challenging experiences without pushing them awayor clinging to personal narratives Practicing in a way that is safe andsupportive

2 Satya (truthfulness) Sutra 236 Honestly examining onersquos experience to better understand onersquos ldquostartingpointrdquo and using yoga practice as a springboard for positive change

3Breath awareness to balance thenervous system and calm themind Sutra 134

Pain management through relaxation training the attention to see tensionpatterns in the body and using imagery and visualization

4 Sthira sukham asanam Sutra246 Finding a balance between steadinessstabilityeffort with easejoyrelaxation

5 Eka gra (one pointedconcentration) Sutra 132

Training attention and concentration by returning to a point of focusrepeatedly

6 Contemplation on the heartSutra 136 The heart as a resource refuge and source of inner luminosity

7 Contemplation of kosas(sheathslayers)

Five sheaths of the self physical (annamaya) breath (pran amaya) mind(manomaya) wisdom (vijnanamaya) and joy (anandamaya) Practicingexperiencing parts of the self without identifying with them

8 Savasana and the kosas Consolidation of all concepts Cultivation of awareness of the layers of the selfand a deeper part that can rest back and witness

and yoga philosophy (jnana) [63ndash65] One of the mostancient scriptures of Hatha Yoga outlines yoga as a purifi-catory practice that balances the activities and processesof the physical body the mind and the overall energylevel in order to cultivate health self-awareness and innerdevelopment [65] Hatha Yoga was selected as an appro-priate form of yoga for individuals with chronic conditionsand mobility restrictions as it is gentle and can be easilymodified The yoga philosophy component (see Table 4) wasbased on relevant contemplative and reflective practices fromPatanjali Yoga Sutras that focused on self-study personaldevelopment observances yamas (ethical discipline) andattitudes of acceptance among others [4 64 66] Conceptsfound in classical scripture such as the kosas theory ofself are being integrated in protocols for yoga interventionsfor chronic illness with a mind-body component [67] Theclasses were one-third asana one-third relaxation trainingand one-third yoga philosophy The class format structureand content were designed in accordance with the yogaliterature A BH Recreation Therapy Assistant was presentat each session All participants practiced from a seatedposition using either a wheelchair or a table chair toallow for uniform practice of the asanas across partici-pants

Participants were provided with two recordings andwere instructed to practice using the MP3 player twice aweek The first recording was a guided body scan awarenesspractice (sim30 minutes) and the second recording was anasana practice (sim15 minutes)The participants were not giventhe second recording until they were familiar with the yogaasanas and the teacher decided that they were safe to practicethem on their own

26 Measures

261 Brief Pain Inventory-Short Form (BPI-SF) [68] TheBPI-SF is a 9-item self-report questionnaire that measuresvarious aspects of pain and pain interference with dailyactivities The Brief Pain Questionnaire [69] and the BriefPain Inventory [70 71] were originally developed to evaluatecancer-related pain and have since been validated for othertypes of pain [72 73] In the BPI-SF individuals are queriedon pain history are asked to visually depict pain locationson a human body diagram and are asked to indicate bestworst average and current pain levels according to 11-pointLikert scales ranging from 0 (no pain) to 10 (pain as bad asyou can imagine) Participants are also queried about painmedications and treatments and the perceived effectivenessof those medications Finally individuals respond to itemsregarding how pain interferes with seven domains of func-tioning general activity mood walking ability normal workrelations with other people sleep and enjoyment of lifeaccording to 11-point scales ranging from0 (does not interfere)to 10 (completely interferes)

The BPI has strong internal consistency (Cronbachrsquos 120572 =85 and 88 for the intensity and interference scales resp)adequate construct validity (scores on the interference scalecorrelate with other pain disability measures) and is sensitiveto treatment [70]The BPI-interference items have been usedin studies evaluating pain in individuals with SCI [74 75] andhave been recommended for use in this population thoughitem 9c which refers to ldquoWalking Abilityrdquo should be changedto ldquoAbility to Get Aroundrdquo [76] It has excellent internalconsistency (120572 gt 90) and is positively associated with painintensity (119903 gt 60) [77]


262 Pain Catastrophizing Scale (PCS) [78] The PCS is a13-item self-report questionnaire that measures catastrophicthinking in relation to experienced or anticipated painParticipants are asked to read each item and indicate theextent to which they experience certain thoughts and feelingswhen experiencing pain by selecting a number from 0 (not atall) to 4 (all the time) Scores range from 0 to 52 with higherscores reflecting higher levels of pain catastrophizing ThePCS yields a total score and three subscale scores assessingrumination (focus on pain sensations) magnification (exag-gerating the threat value of pain sensations) and helplessness(perceiving oneself as unable to cope with pain symptoms)The PCS has high internal consistency (coefficient 120572 totalPCS = 87 rumination = 87 magnification = 66 and help-lessness = 78) [78]

263 Perceived Stress Scale (PSS) [79] The PSS is a 10-itemself-report questionnaire that measures symptoms of stressover the past month in relation to life events and relation-ships Participants indicate how much they are experiencingtheir life as unpredictable and uncontrollable and how muchthey have felt overloaded Each item is rated on a 5-pointscale ranging from 0 (never) to 4 (very often) with a highestpossible score of 40 such that higher scores are indicative ofhigher levels of stress It correlates well with other measuresof stress such as life events and depression and anxiety scalesand has satisfactory internal reliability (120572 = 78ndash82) and test-retest reliability (119903 = 55ndash85) [79 80]

264 Hospital Anxiety and Depression Scale (HADS) [81]The HADS is a 14-item self-report questionnaire that mea-sures symptoms of anxiety (7 items) and depression (7 items)For each item participants are asked to select one fromamong four possible choices (scored from 0 to 3) that bestdescribes how they have been feeling over the past weekThe HADS yields an anxiety (HADS-A) and a depression(HADS-D) subscale score each with a maximum total scoreof 21 where higher scores indicate higher levels of anxietyand depression Scores of 8ndash10 are considered cut-off pointsthat are clinically meaningful for symptoms of anxiety anddepression [81] Internal consistency is high for both theHADS-A (120572 = 83) and HADS-D (120572 = 82) subscales [82]Concurrent validity of the HADS is very good as measuredby correlation coefficients of between 62 and 73 for theHADS-D with various well-validated depression scales andcorrelation coefficients of between 49 and 81 for the HADS-A with various well-validated anxiety measures [82]

265 Injustice Experiences Questionnaire (IEQ) [83] TheIEQ is a 12-item questionnaire that evaluates feelings andthoughts of perceived injustice and severity of loss in relationto injury or pain This scale is designed to evaluate cogni-tive appraisals that contribute to pain-related occupationaldisability Individuals answer each item using a 5-pointscale ranging from 0 (never) to 4 (all the time) This scalehas a total score and two subscales blameunfairness andseverityirreparability of lossThe total scale has good internalconsistency (120572 = 92) and all items correlated above 05 withthe total score [83] This scale has been correlated with pain

severity pain catastrophizing fear of movement perceiveddisability and depression (119903 = 54ndash75 119901 lt 01) indicatinggood construct validity Cross-sectional regression analysishas shown good discriminant validity in that IEQ contributesto the variance of the predication of pain severity (120573 = 44119901 lt 05) [83] Test-retest variability of the IEQ is good andscores across time are stable (119903 = 90 119901 lt 01) authors notethat the test-retest scores were more stable than scores onmeasures of pain and related constructs (eg PCS PainDisability Index and McGill Pain Questionnaire) [83]

266 Five-Facet Mindfulness Questionnaire-Short Form(FFMQ-SF) [84] The FFMQ-SF is a 24-item version of theoriginal 39-item FFMQ and has been validated in individualswith depression anxiety and fibromyalgia [84] It is aself-report questionnaire that measures levels of mindfulnessaccording to five facets which have acceptable model fitwith the five-factor structure of the FFMQ Those facets areobserving describing acting with awareness nonjudgingof inner experience and nonreactivity to inner experienceParticipants respond to each item by selecting the numberthat is ldquomost generally truerdquo of hisher experience on a scaleof 1 (never or rarely true) to 5 (very often or always true)Total scores range from 0 to 120 and higher scores indicategreater levels of mindfulness The FFMQ is based on a factoranalytic study of five independently developed mindfulnessquestionnaires with good internal consistency and constructvalidity [85 86] Total facet scores of the FFMQ-SF arehighly correlated with the original version 119903 = 89 89 9296 and 95 for observing describing acting with awarenessnonjudging and nonreactivity respectively [84] The corre-lation alphas are all above the defined criterion of 7 and allintercorrelations between facets and with other constructsare very virtually the same as the FFMQ All the facets of theFFMQ-SF are sensitive to change and had moderate-largeeffect sizes [84]

267 Self-Compassion Scale-Short Form (SCS-SF) [87] TheSCS-SF is a self-report 12-item version of the original 26-itemquestionnaire [88] that measures levels of self-compassionSelf-compassion as measured by this scale is defined asthe ability to hold onersquos feelings of suffering with a sense ofwarmth security or concern [87] This short form has beendemonstrated to have a unidimensional construct of self-compassion and also amultidimensional construct consistingof 6 subscales including self-kindness self-judgement com-mon humanity isolation mindfulness and overidentifiedhowever it is not recommended to use subscales for theshort form version The questionnaire queries respondentsto indicate ldquohow I typically act towards myself in difficulttimesrdquo according to a scale of 1 (almost never) to 5 (almostalways) This scale has been shown to have adequate internalconsistency (Cronbachrsquos 120572 ge 86 for three different samples)and good correlation with the full version (119903 ge 97 for threesamples) The total score for the short form is calculatedby dividing the total score by 12 (for each item) to producea mean score (personal communication with Kristen NeffApril 19 2016)


Participants screened for eligibility and attended information session (N = 11)

Filled out consentdemographic information

and T1 questionnaires(n = 10)

Completed the yogaprogram and filled out T3

questionnaires (n = 6)

Decided to not participate (n = 1)

Attended the yogaintervention (n = 10)

Filled out T2questionnaires (n = 8)

Dropped out (n = 2)(i) Not interested attended 1 (n = 1) and 2 (n = 1)

classes

Dropped out (n = 2)(i) Discharged attended 4 classes (n = 1)(ii) Medical reasons attended 2 classes (n = 1)

Figure 2 Participant flow through the study

268 Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACIT-SpWB) [89] The FACIT-SpWBis a 12-item self-report questionnaire that evaluates expe-riences of spirituality in individuals with chronic illnessesThe original scale has a total score and two subscales mean-ingpeace and faith although confirmatory factor analysishas validated the three-factor model in which meaning andpeace are unique subscales [90] Questions query themesof harmony and peacefulness and a sense of strength andcomfort in onersquos beliefs Participants answer each item using5-point Likert scale from 0 (not at all) to 4 (very much)This scale has good internal consistency for the overall indexand for the two subscales (120572 = 81ndash88) This scale also showsgood validity both the total scale and each subscales werepositively correlated with measures of quality of life in cancerpatients (Functional Assessment of CancerTherapy-General)and negativelywithmeasure ofmood (Profile ofMood States)[89]

27 Data Analysis Statistical Analysis was performed usingSPSS Version 23 and SAS Version 94 Exploratory analysiswas conducted to evaluate missing data and assumptions ofnormality Raw data were evaluated for skew and kurtosisAll self-report measures were assessed for normality usingthe Shapiro-Wilk test The self-report data were analyzedusing repeated measures ANOVAs (T1 T2 and T3) andBonferroni post hoc analysis in the presence of a significantmain effect of time Sphericity was evaluated usingMauchlyrsquosTest of Sphericity and in the case of violations Huynh-Feldt adjustments were used Simple mediation analysis wasconducted using a bootstrapping approach (2000 resamples)as recommended for small sample sizes which may haveviolations of normality [91] to evaluate the mediating effectof total SCS scores at T2 on the relationship betweenHADS-Ascores at T1 and T3

3 Results

31 Preparation of Data Data were analyzed by a protocolcompliance (PC 119899 = 6) and intention-to-treat approach(ITT119873 = 10) Although one of the participants had missedyoga classes 3 and 4 due to medical reasons data werecollected for this participant at T2 as they had not formallywithdrawn from the study by that time Therefore for ITTanalysis data were carried forward from T1 for two partici-pants and from T2 for two participants One participant didnot fill out theHADS questionnaire at T1 so T2 scores for thisparticipant were used as a baseline score

Data were explored for assumptions of normality Valuesof kurtosis and skewness for all total scale scores at each timepoint were converted to 119911-scores for both PC and ITT dataAt T1 all werewithin normal limits (lt|196| at119901 lt 05) exceptBPI-3 (significant skew) For PC data all were within normallimits (lt|196| at 119901 lt 05) except BPI-3 at T3 (significantkurtosis and skew) and BPI-5 at T3 (significant skew) ForITT data all were within normal limits (lt|196| at 119901 lt 05)except BPI-3 at T3 (and significant skew) and SCS-SF at T3(significant skew) Similarly the Shapiro-Wilk test revealedthat all total scale scores were normal at 119901 lt 05 with theexception of violations of normality for BPI-3 119882(10) = 81119901 lt 05 and BPI-6 at T1119882(10) = 84 119901 lt 05 BPI-3-PC atT2119882(8) = 80 119901 lt 05 BPI-3-PC at T3119882(5) = 55 119901 lt 05BPI-3-ITT at T3119882(10) = 81 119901 lt 05 BPI-4-PC at T3119882(5)= 75 119901 lt 05 BPI-4-ITT at T3119882(10) = 84 119901 lt 05 BPI-5-ITT at T3 119882(10) = 81 119901 lt 05 and SCS-SF-total-ITTat T3 119882(10) = 74 119901 lt 05 Table 5 shows the means andsds for each measure across the three time points as well assignificant 119901 values and effect sizes

32 Demographic and Clinical Variables Figure 2 shows theflow of participants through the study which ran fromOctober 28 to December 16 2014 Eleven participants were


Table 5 Mean (sd) values for pain psychological and mindfulness variables across time using Intent-to-treat sample (119873 = 10)

Measure Preintervention (T1) Midintervention (T2) Postintervention (T3) Significance (119901 value)BPI-SF-3 690 (314) 680 (266) 690 (281) nsBPI-SF-4 450 (357) 360 (320) 270 (254) nsBPI-SF-5 520 (349) 450 (295) 500 (291) nsBPI-SF-6 680 (333) 530 (371) 460 (347) nsBPI-9-SF-total 2910 (2127) 2370 (1640) 2550 (1782) nsPCS-total 2530 (1562) 2130 (1477) 1930 (1219) 099PCS-helplessness 1140 (858) 920 (820) 870 (645) nsPCS-magnification 450 (372) 270 (374) 240 (259) 047b

PCS-rumination 940 (506) 960 (470) 820 (498) nsPSS 2020 (783) 1900 (827) 1570 (817) nsIEQ-total 2350 (711) 2010 (955) 2110 (1149) nsIEQ-blameunfairness 1020 (413) 810 (446) 860 (610) nsIEQ-severityirreparability 1330 (435) 1200 (591) 1250 (600) nsHADS-A 900 (564) 770 (519) 650 (438) 022HADS-D 670 (499) 570 (383) 580 (405) nsFFMQ-SF-total 8440 (766) 8660 (1005) 8740 (1240) nsFFMQ-SF-observing 1570 (216) 1680 (220) 1680 (215) nsFFMQ-SF-describing 1950 (264) 1910 (387) 1910 (409) nsFFMQ-SF-acting with awareness 1810 (179) 1960 (306) 1860 (420) nsFFMQ-SF-nonjudging 1690 (418) 1670 (437) 1710 (502) nsFFMQ-SF-nonreactivity 1420 (220) 1440 (310) 1580 (487) nsSCS-SF 328 (077) 357 (063) 344 (058) 047a

FACIT-SpWB-total 3380 (813) 3500 (901) 3600 (745) nsFACIT-SpWB-faith 1180 (457) 1100 (529) 1200 (529) nsFACIT-SpWB-meaning 1270 (245) 1350 (284) 1270 (216) nsFACIT-SpWB-peace 930 (362) 1050 (255) 1130 (250) nsNote Greenhouse-Geisser adjusted 119865-tests for significant main effects of time were conducted for SCS-SFNote BPI-SF Brief Pain Inventory-Short Form PCS PainCatastrophizing Scale PSS Perceived Stress Scale-10 Items IEQ Injustice ExperiencesQuestionnaireHADS-A Hospital Anxiety and Depression Scale-Anxiety HADS-D Hospital Anxiety and Depression Scale-Depression FFMQ-SF Five-Facet MindfulnessQuestionnaire-Short Form SCS-SF Self-Compassion Scale-Short Form FACIT-SpWB Functional Assessment of Chronic IllnessTherapy-SpiritualWellbeingNote a119901 lt 01 for T1 versus T2 b119901 lt 01 for T1 versus T3

recruited by hospital staff and attended the informationsession 10 of whom provided consent filled out T1 ques-tionnaires and participated in at least one class of the yogaprogram One participant decided not to participate afterlearning more about the questionnaire component of theresearch study Data for eight and six participants wereobtained at T2 and T3 respectively

33 Yoga Program Attendance Of the 10 participants whostarted the yoga program six (60) completed it Threeparticipants attended 1-2 classes and withdrew for personalor medical reasons while one participant attended 4 classesafter which she withdrew as she was discharged early fromthe hospital The mean plusmn sd number of yoga classes attendedfor all participants who entered the program (119873 = 10) was372 plusmn 254 (out of 8 classes) and the mean plusmn sd number ofyoga classes attended for all participants who completed theprogram (119899 = 6) was 683 plusmn 075 (out of 8) The mean plusmn sdnumber of participants who did some homework each week(listened to a recording 1ndash4 times) was 40 plusmn 183

34 Treatment Results

341 Pain and Related Variables Psychological Factors andMindfulness Repeated measures ANOVAs did not revealsignificant changes in any variable across time for the PCanalyses All analyses are reported according to the ITTprinciple as outlined above Repeated measures ANOVAsrevealed a significant main effect of time for HADS-A119865(2 18) = 474 119901 lt 05 and 120578119901

2 = 35 for SCS-SF-total(Greenhouse-Geisser adjusted 119865-test) 119865(2 18) = 371 119901 lt05 and 120578119901

2 = 29 and for PCS-magnification119865(2 18) = 366119901 lt 05 and 120578119901

2 = 29 Bonferroni comparisons revealed atrend for improvement from T1 to T2 for SCS-SF-total 119901 lt07 and for PCS-magnification from T1 to T3 119901 = 08A repeated measures ANOVA also revealed a trend ofimprovement for main effects of time for PCS-total 119865(2 18)= 263 119901 = 099 and 120578119901

2 = 23 Individual score trajectoriesfor scales with significant changes or trends for improvementare shown in Figure 3


T2 T3T1Time

000

100

200

300

400

500

600SC

S-SF

scor

es

Participant 1Participant 2Participant 3Participant 4Participant 5


(a)

T2 T3T1Time

000

200

400

600

800

1000

1200

1400

1600

1800

2000

HA

DS-

A sc

ores



(b)

T2 T3T1Time

000

200

400

600

800

1000

1200

1400

PCS-

mag

nific

atio

n sc

ores



(c)

T2 T3T1Time

000

1000

2000

3000

4000

5000

6000

PCS-

tota

l sco

res



(d)

Figure 3 (a) Individual participant Self-Compassion Scale-SF (SCS-SF) scores by time (b) Individual participant Hospital Anxiety andDepression Scale-Anxiety (HADS-A) scores by time (c) Individual participant Pain Catastrophizing Scale (PCS)-magnification subscalescores by time (d) Individual participant Pain Catastrophizing Scale (PCS)-total scores by time

In terms of clinically meaningful cut-off points 6 par-ticipants had scores above 8 on the HADS-A subscale at T1and 4 participants had scores at or above 8 on the HADS-Dsubscale at T1 Out of the six true completers at the end ofthe study there were 2 participants with scores above 8 on

the HADS-A subscale and 1 participant with a score above8 for the HADS-D subscale Using the ITT scores for allparticipants there were 5 participants with scores above 8 onthe HADS-A subscale and 2 participants with a score above8 for the HADS-D subscale Visual inspection of the ITT


data revealed that each participantrsquos score for HADS-A andHADS-D remained the same or decreased with the exceptionof 1 participant whose score increased 2 points from T1 to T3on HADS-D

342 Mediation Analysis Nonparametric bootstrappinganalysis showed that the total effect of HADS-A scores atbaseline onHADS-A scores at the end of the interventionwassignificantly reduced when SCS-SF scores at midintervention(the mediator) were added to the model (mean = 035 SEM= 033 CI95 = 005 141) As such the true indirect effect isestimated to lie between 05 and 141 with 95 confidence aszero is not within the CI interval it can be concluded that theindirect effect is significantly different than zero 119901 lt 05 andthat mid-treatment SCS-SF scores mediated the relationshipbetween baseline and end-of-treatment HADS-A scores

4 Discussion

This pilot study is the first reported trial to evaluate theeffects of a yoga intervention on pain and related vari-ables psychological constructs spirituality and mindfulnessin a sample of inpatients receiving complex continuingcarerehabilitation for multimorbidities The results demon-strate post-intervention improvements in anxiety symptomsthe magnification aspect of pain catastrophizing and self-compassion As well self-compassion was found to mediateimprovements in anxiety from pre- to postinterventionThese results suggest that a Hatha Yoga program specificallytailored to the needs of a hospitalized population experi-encing multimorbidities may provide some psychologicalbenefits

The finding that anxiety scores were significantly lowerafter the eight-week program is consistent with RCTs thatdemonstrated improvements in anxiety and health outcomesin individuals with chronic diseases (diabetes or chronic lowback pain) who participated in a yoga intervention whencompared to walking or exercisecounselling control groups[92 93] A recent cross-sectional assessment of a large sampleof individuals with a range of chronic illnesses found thatself-reported duration of practice (practice session lengthand number of months practicing) predicted anxiety and theauthors concluded that increased doses of yoga practice mayhelp individuals respond to illness with lower levels of anxiety[94] As well systematic reviews document improvements inanxiety for several health populations that have participatedin a yoga intervention such as cancer stroke and irritablebowel syndrome [19 31 95] In addition low-income ornoninsured individuals who participated in an integratedprogram involving mindfulness self-compassion and yogaaccording to a single-group repeated measures design werefound to have lower levels of anxiety and depression afterintervention [96] It is apparent that yoga provides psycho-logical symptom improvement in both health populationsand those who are impacted by low health care resourcesThis combination of experiences (health concerns anxietysymptoms financial strain and a lack of resources) parallelsthe presentation of individuals with CCDD and indicates that

yoga may reduce anxiety in the context of multiple health-related impacts

Although pain catastrophizing has been less well studiedin yoga trials two studies (one pilot one RCT) found thatlevels of pain catastrophizing were reduced from pre- to post-yoga interventions in samples of women with fibromyal-gia [97 98] The present results are consistent with thesestudies in that we found the magnification aspect of paincatastrophizing (eg ldquoI wonder whether something seriousmight happenrdquo) decreased from pre- to post-interventionPain catastrophizing is a strong predictor of pain severitypain-related interference disability depression and alteredsocial support networks [99] and is associated with physicalfunction deterioration in individuals with joint pain andcomorbidity [100] highlighting it as a useful target forinterventions that intend to increase functional ability inindividuals with multimorbidity or CCDD Other pain-related psychosocial factors such as pain disability and painacceptance have been shown to improve with yoga practice[101] Taken together these findings provide some evidencethat yoga may help to reduce the threat value attributed topain stimuli or alter pain-related experiences in individualswith medical conditions in which pain is a predominantfeature As well the potentially debilitating impact of pain-related disability or chronic health stress on financial andsocial independence for individuals with CCDDmay amplifymagnification cognitions pointing to the utility of targetingthis construct in yoga interventions

The benefits of yoga extend beyond decreasing nega-tive cognitive-affective experiences and can also serve togenerate or augment a nurturing positive and discrimi-native approach to engaging with inner experiences Self-compassion is a Buddhist concept that is increasingly beingconsidered as an important mental health construct inWestern Psychology and entails threemain components self-kindness common humanity and mindfulness [102] Thepresent findings that self-compassion increased significantlyfrom pre- to post-intervention parallel the results from ayoga research trial in individuals living with an implantablecardioverter defibrillator [103] The results of that studyshowed that participants who were randomized to a onceweekly eight-week yoga intervention reported increased self-compassion at the end of the trial compared to a usual caregroup [103] For individuals with severe health impacts whotypically use avoidance or distancing as coping strategiesa yoga practice may enable them to contact suffering andpain without judgmental or comparative thoughts [102]Yoga philosophy didactics which explain that inadequaciesfailings and suffering are considered part of the humancondition (shared humanity) may normalize challengingexperiences and enable individuals with CCDD to extendforgiveness towards their own short-comings and pain ratherthan orienting from the stigma and marginalization that canaccompany disability

41 Mechanisms of Action The finding that self-compassionmediated decreases in anxiety provides some support for self-compassion as a protective agent in distressing psychologicalexperience and in helping to understand how yoga may be


exerting its mechanism of action This construct has beenidentified in the yoga literature as one of seven possiblemediators of yoga and stress othermediators include psycho-logical (positive self-affect and mindfulness) and biological(activity in the posterior hypothalamus and inflammatoryand endocrine responses C-reactive protein Interleukin-6and cortisol) pathways for therapeutic effects [104] This isthe first study to date that demonstrated the mediating roleof self-compassion on psychological changes in a populationexperiencing medical concerns who participate in a yogaprogram There is one previous trial that has demonstratedself-compassion and mindfulness as mediators of quality oflife and stress in healthy young adults who participated in afour-month residential yoga intensive [105] By contrast self-compassion andmindful attentionwere not found tomediatechanges in emotional stability in high school students whoparticipated in a 16-week yoga program when comparedto students who participated in physical education as usual[106]

This construct may be more amenable to facilitatingsecondary mental health benefits in individuals experienc-ing illness-related duress and may impact how individualscope with chronic and debilitating illnesses It has beenshown to change emotional responses such as shame andincrease positive coping behaviours in individuals livingwith HIV and it predicts positive attitudes in the elderlypotentially serving as a buffer against the inevitable chal-lenges associated with age decline [107 108] In addition itis positively associated with both intentions to engage withand practice of health-promoting behaviours (eg eatinghabits stress management exercise and sleep) with indirecteffects through adaptive emotions (eg health self-efficacyand positive affect) in community samples of Canadianadults [109 110] As the risk of multimorbidity increaseswith age augmenting adaptive emotional responses to illnessand health-promoting behaviours may assist in the preven-tion of further health decline and the promotion of well-being

Although mindfulness was not a mediator of positivepsychological change in the present study previous yogatrials have reported that mid-intervention levels of mind-fulness mediated changes in pain catastrophizing from pre-to postyoga intervention in women with fibromyalgia [97]It may be that these constructs work by exerting differentmechanisms during a yoga practice or that one may be morepotent as a mediator for different populations or types ofmindfulness or yoga interventions Self-compassion has beendemonstrated to be a more robust predictor of symptomseverity (eg anxious and depressive symptoms) and qualityof life than mindfulness in a large community sample ofindividuals seeking self-help for anxious distress and predictsemotional well-being more consistently than mindfulnessin a sample of youth participating in a 5-day meditationretreat [111 112] Further examination between psychologicalwell-being mindfulness self-compassion and disability forindividuals with CCDD in the context of a yoga interventionis warranted

42 Attending to the Signals of the Body New Pathways Therole of interoception which is a complex and multimodalbodily system involving a sense of body parts in space(proprioception) and the act of attending appraising andresponding to afferent body signals [113] has been consideredas one of yogarsquos underlyingmechanisms of action through theprocess of interoceptive exposure and reconditioning [97]It is proposed that mind-body interventions such as yogamay interrupt habitual ways of perceiving and interpretingbody sensations within the context of higher-order cognitiveprocesses such as goals and intentions by connecting anindividual with the present moment and with their agencyfor personal change [113] In addition it has been proposedthat higher level brain networks that are activated by yogapractice may serve to inhibit negative appraisals ruminationand emotional reactivity while lower level neural networksmay downregulate physiological responses to stress suchas inflammatory markers and vasopulminary restrictionthrough the activation of the parasympathetic nervous sys-tem [5] This is relevant in interpreting the results that paincatastrophizing decreased from pre- to post-interventionsas this construct involves exaggerated or negative cognitive-emotional appraisal of painful stimuli as threatening isaccompanied by perceived helplessness (lack of power) andis associated with aberrant central nervous system pro-cesses such as cytokine or hypothalamic-pituitary-adrenalresponses to pain and activation of neural regions involvedin processing affective components of pain [99] It is clear thatpain catastrophizing is a construct involving both emotionaland biological processes and it may be that yoga helpsindividuals to reinterpret physical body signals for what theyare rather than as dangerous threats through two elements ofpractice practicing witness consciousness and then activelycreating positive change in the body which is then reinforcedwith practice through operant conditioning

Self-compassion mirrors these two elements of tradi-tional yoga practice in that it involves a truthful recognitionof onersquos inner state and selecting responses or behavioursthat will alleviate suffering It may be that through yogaindividuals discover safety in opening to distressing experi-ences circumventing or offering a protective buffer againstengrained ruminative or punitive ldquoself-talkrdquo and therebycreate new ways of relating to self and prioritizing actionsthat are consistent with well-being and values Higher levelsof self-compassion have been associated with lower levelsof catastrophizing avoidance and rumination in chronicpain patients who were presented with vignettes involvinga violation of social contract and have been found topredict affect pain disability and pain catastrophizing inobese patients with chronic pain [114 115] The relationshipsbetween self-compassion anxiety and disability have beenexplored in individuals with Generalized Anxiety Disorderthese individuals display lower levels of self-compassion andmindfulness than healthy stressed controls and mindfulnesswas a better predictor of disability than actual anxiety symp-toms drawing potential protective effects of mindfulness ondisability in individuals with chronic worry and physiologicalsymptoms [116] The relationship between self-compassionand anxiety should be further elucidated and it may be useful


to examine the relationships between the subscales of the SCSto better understand which components of self-compassionare most helpful in mediating changes in anxiety in clinicalpopulations

43 Limitations There are limitations to the present studyThe primary weakness is the absence of a control groupwhich is a shortcoming that is widespread in the yogaresearch literature and makes it impossible to attributethe improvements observed to the yoga practice itself Aswell the small sample size limits power and introduces thepossibility of type II error Logistical limitations includedparticipant difficulty in using theMP3 players and as a resultreducing homework engagement and completion whichmayhave reduced overall efficacy of the eight-week yoga inter-ventionThe difficulties that these patients experienced whenusing the technology are consistent with a previous reportindicating that this population has challenges in payingattention and in using assistive technology [117] Althoughthe research team carefully selected devices with few buttonsand minimal steps required to turn on and navigate thedevices and also provided large print diagram instructionsto accompany the devices the population still experienceddifficulty which illustrates that they may be better servicedby yoga interventions that do not involve assistive technologyfor homework components

44 Future Research Theresearchers hope that these findingswill be considered in the design and implementation of futureresearch projects for individualswho are experiencingCCDDand associated pain limited mobility loss of functionalability severe health impacts and psychological sequelaeFuture research trials should use a randomized controlledtrial study design with appropriate control conditions (egwait-list exercise walking or education) and a longitudinaldesign with follow-up intervals to determine lasting effectsof a yoga practice [118] Targeting self-compassion in thecontent and philosophy portions of the yoga interventionsmay enable researchers to further explore itsmediating role ofthis construct on other psychological or physical experiencesprevalent in this population Trials that seek to furtherilluminate processes that underlie therapeutic gainsmaywishto use measures of self-regulation self-compassion stressand positive affect alongside neuroendocrine-inflammatorymarkers of physiological status [104] Evaluation of how thesevariables interact with pain-related constructs associatedwith the fear-avoidance model of chronic pain (eg chronicpain acceptance pain-related disability fear of pain painanxiety and pain self-efficacy) may be warranted to betterunderstand the converging impacts that result in distress anddisability and with the end purpose to improve health andwell-being

5 Conclusions

The results of the present pilot project suggest that an eight-week specialized yoga program may help to reduce anxietyand the magnification component of pain catastrophizing

and to increase self-compassion in patients with multimor-bidity This study provides preliminary evidence for yoga asan auxiliary care service that may be amenable to institutionsthat are in the process of evolving from single-diseasetreatment frameworks and that are seeking to assimilateprograms and services that can address multiple intersectinghealth concerns for various ages The use of a randomizedcontrolled trial with a larger sample size and a more intensiveyoga intervention design (eg two or more classes a weekfor 10ndash12 weeks) is recommended to further explore therelationships among pain psychological experience andmindfulness or spiritual constructs in individuals who areseverely impacted by disease and disability

Competing Interests

The authors declare that they have no competing interests

Acknowledgments

Joel Katz is supported by a Canadian Institutes of HealthResearch (CIHR) Canada Research Chair in Health Psy-chology Kathryn Curtis is supported by a CIHR HealthProfessional Student Research Award This research projectwas conducted in partial fulfillment of the requirements forKathryn Curtisrsquo doctoral dissertation

References

[1] G Feuerstein The Yoga Tradition Its History Literature Phi-losophy and Practice Prescott Hohm Press Chino Valley ArizUSA 2008

[2] T Field ldquoYoga clinical research reviewrdquo Complementary Thera-pies in Clinical Practice vol 17 no 1 pp 1ndash8 2011

[3] A A Wren M A Wright J W Carson and F J Keefe ldquoYogafor persistent pain new findings and directions for an ancientpracticerdquo Pain vol 152 no 3 pp 477ndash480 2011

[4] G BechsgaardTheGift of Consciousness Patanjalirsquos Yoga Sutras(Book One Samadhi Pada) Cambridge Scholars PublishingNewcastle UK 2013

[5] T Gard J J Noggle C L Park D R Vago and A WilsonldquoPotential self-regulatorymechanisms of yoga for psychologicalhealthrdquo Frontiers in Human Neuroscience vol 8 article 7702014

[6] P E Jeter J Slutsky N Singh and S B S Khalsa ldquoYoga as atherapeutic intervention a bibliometric analysis of publishedresearch studies from 1967 to 2013rdquo Journal of Alternative andComplementary Medicine vol 21 no 10 pp 586ndash592 2015

[7] H Cramer R Lauche and G Dobos ldquoCharacteristics ofrandomized controlled trials of yoga a bibliometric analysisrdquoBMC Complementary and Alternative Medicine vol 14 article328 2014

[8] H Cramer R Lauche J Langhorst and G Dobos ldquoIs one yogastyle better than another A systematic review of associationsof yoga style and conclusions in randomized yoga trialsrdquoComplementaryTherapies inMedicine vol 25 pp 178ndash187 2016

[9] M C McCall A Ward N W Roberts and C HeneghanldquoOverview of systematic reviews yoga as a therapeutic inter-vention for adults with acute and chronic health conditionsrdquo


Evidence-based Complementary and Alternative Medicine vol2013 Article ID 945895 18 pages 2013

[10] C Hill ldquoIs yoga an effective treatment in the management ofpatients with chronic low back pain compared with other caremodalitiesmdasha systematic reviewrdquo Journal of Complementaryand Integrative Medicine vol 10 no 1 pp 211ndash219 2013

[11] S Holtzman and R T Beggs ldquoYoga for chronic low back paina meta-analysis of randomized controlled trialsrdquo Pain Researchand Management vol 18 no 5 pp 267ndash272 2013

[12] M Sharma ldquoYoga as an alternative and complementaryapproach for arthritis a systematic reviewrdquo Journal of Evidence-Based Complementary and Alternative Medicine vol 19 no 1pp 51ndash58 2014

[13] L Ward S Stebbings D Cherkin and G D Baxter ldquoYoga forfunctional ability pain and psychosocial outcomes in muscu-loskeletal conditions a systematic review and meta-analysisrdquoMusculoskeletal Care vol 11 no 4 pp 203ndash217 2013

[14] H Cramer R Lauche J Langhorst and G Dobos ldquoYoga forrheumatic diseases a systematic reviewrdquo Rheumatology vol 52no 11 pp 2025ndash2030 2013

[15] K E Innes and T K Selfe ldquoYoga for adults with type 2 diabetesa systematic review of controlled trialsrdquo Journal of DiabetesResearch vol 2016 Article ID 6979370 23 pages 2016

[16] V Kumar A Jagannathan M Philip AThulasi P Angadi andN Raghuram ldquoRole of yoga for patients with type II diabetesmellitus a systematic review and meta-analysisrdquo Complemen-tary Therapies in Medicine vol 25 pp 104ndash112 2016

[17] J Sadja and P J Mills ldquoEffects of yoga interventions onfatigue in cancer patients and survivors a systematic review ofrandomized controlled trialsrdquo Explore vol 9 no 4 pp 232ndash2432013

[18] M Sharma T Haider and A P Knowlden ldquoYoga as an alter-native and complementary treatment for cancer a systematicreviewrdquo Journal of Alternative and Complementary Medicinevol 19 no 11 pp 870ndash875 2013

[19] L M Buffart J G Z van Uffelen I I Riphagen et al ldquoPhysicaland psychosocial benefits of yoga in cancer patients andsurvivors a systematic review andmeta-analysis of randomizedcontrolled trialsrdquo BMC Cancer vol 12 article no 559 2012

[20] AN R Zahavich J A RobinsonD Paskevich and SNCulos-Reed ldquoExamining a therapeutic yoga program for prostatecancer survivorsrdquo Integrative CancerTherapies vol 12 no 2 pp113ndash125 2013

[21] H Harder L Parlour and V Jenkins ldquoRandomised controlledtrials of yoga interventions for women with breast cancer asystematic literature reviewrdquo Supportive Care in Cancer vol 20no 12 pp 3055ndash3064 2012

[22] W Chan M A Immink and S Hillier ldquoYoga and exercise forsymptoms of depression and anxiety in people with poststrokedisability a randomized controlled pilot trialrdquo AlternativeTherapies in Health and Medicine vol 18 no 3 pp 34ndash43 2012

[23] A Lazaridou P Philbrook and A A Tzika ldquoYoga and mind-fulness as therapeutic interventions for stroke rehabilitation asystematic reviewrdquo Evidence-Based Complementary and Alter-native Medicine vol 2013 Article ID 357108 9 pages 2013

[24] K M Mustian ldquoYoga as treatment for insomnia among cancerpatients and survivors a systematic reviewrdquo European MedicalJournal Oncology vol 1 pp 106ndash115 2013

[25] M Yurtkuran A Alp M Yurtkuran and K Dilek ldquoA mod-ified yoga-based exercise program in hemodialysis patientsa randomized controlled studyrdquo Complementary Therapies inMedicine vol 15 no 3 pp 164ndash171 2007

[26] L Gordon D McGrowder Y Pena E Cabrera and MLawrence Wright ldquoEffect of yoga exercise therapy on oxidativestress indicators with end-stage renal disease on hemodialysisrdquoInternational Journal of Yoga vol 6 no 1 pp 31ndash38 2013

[27] N R Okonta ldquoDoes yoga therapy reduce blood pressure inpatients with hypertension An integrative reviewrdquo HolisticNursing Practice vol 26 no 3 pp 137ndash141 2012

[28] P Posadzki H Cramer A Kuzdzal M S Lee and E ErnstldquoYoga for hypertension a systematic review of randomizedclinical trialsrdquo Complementary Therapies in Medicine vol 22no 3 pp 511ndash522 2014

[29] H Cramer P Posadzki G Dobos and J Langhorst ldquoYogafor asthma a systematic review and meta-analysisrdquo Annals ofAllergy Asthma and Immunology vol 112 no 6 pp 503e5ndash510e5 2014

[30] J Wise ldquoYoga may improve asthma symptoms Cochranereview findsrdquo BMJ vol 353 article i2462 p i2462 2016

[31] L Desveaux A Lee R Goldstein and D Brooks ldquoYoga in themanagement of chronic disease a systematic review and meta-analysisrdquoMedical Care vol 53 no 7 pp 653ndash661 2015

[32] M Balasubramaniam S Telles and P M Doraiswamy ldquoYogaon our minds a systematic review of yoga for neuropsychiatricdisordersrdquo Frontiers in Psychiatry vol 3 article 117 2013

[33] R Lauche J Langhorst M S Lee G Dobos and H Cramer ldquoAsystematic review and meta-analysis on the effects of yoga onweight-related outcomesrdquo Preventive Medicine vol 87 pp 213ndash232 2016

[34] Y Colgrove N Sharma K Robbins and K Wagner ldquoA ran-domized controlled pilot study of the therapeutic effects of yogain people with Parkinson1015840s diseaserdquo International Journal ofYoga vol 8 no 1 pp 74ndash79 2015

[35] H Cramer R Lauche H Azizi G Dobos and J LanghorstldquoYoga for multiple sclerosis a systematic review and meta-analysisrdquo PLoS ONE vol 9 no 11 Article ID e112414 2014

[36] K Kuluski C M Bensimon C Alvaro R F Lyons A KSchaink andR Tobias ldquoLife interrupted the impact of complexchronic disease from the perspective of hospitalized patientsrdquoIllness Crisis and Loss vol 22 no 2 pp 127ndash144 2014

[37] C Steele Gray A I Khan K Kuluski et al ldquoImproving patientexperience and primary care quality for patients with complexchronic disease using the electronic patient-reported outcomestool adopting qualitative methods into a user-centered designapproachrdquo JMIR Research Protocols vol 5 no 1 article e282016

[38] A Schaink K Kuluski R Lyons et al ldquoA scoping review andthematic classification of patient complexity offering a unifyingframeworkrdquo Journal of Comorbidity vol 2 pp 1ndash9 2012

[39] A J Pefoyo S E Bronskill A Gruneir et al ldquoThe increasingburden and complexity of multimorbidityrdquo BMC Public Healthvol 15 article 415 2015

[40] K Kuluski S N Hoang A K Schaink et al ldquoThe care deliveryexperience of hospitalized patients with complex chronic dis-easerdquo Health Expectations vol 16 no 4 pp e111ndashe123 2013

[41] C Diederichs K Berger and D B Bartels ldquoThe measurementof multiple chronic diseasesmdasha systematic review on existingmultimorbidity indicesrdquo Journals of Gerontology Series A Bio-logical Sciences and Medical Sciences vol 66 no 3 pp 301ndash3112011

[42] A Marengoni S Angleman R Melis et al ldquoAging withmultimorbidity a systematic review of the literaturerdquo AgeingResearch Reviews vol 10 no 4 pp 430ndash439 2011


[43] A Marengoni B Winblad A Karp and L Fratiglioni ldquoPreva-lence of chronic diseases andmultimorbidity among the elderlypopulation in Swedenrdquo American Journal of Public Health vol98 no 7 pp 1198ndash1200 2008

[44] R Melis A Marengoni S Angleman and L FratiglionildquoIncidence and predictors of multimorbidity in the elderly apopulation-based longitudinal studyrdquo PLoS ONE vol 9 no 7Article ID e103120 2014

[45] C Violan Q Foguet-Boreu A Roso-Llorach et al ldquoBurden ofmultimorbidity socioeconomic status and use of health servicesacross stages of life in urban areas A Cross-Sectional StudyrdquoBMC Public Health vol 14 no 1 article 530 2014

[46] K Barnett S W Mercer M Norbury G Watt S Wyke and BGuthrie ldquoEpidemiology of multimorbidity and implications forhealth care research and medical education a cross-sectionalstudyrdquoThe Lancet vol 380 no 9836 pp 37ndash43 2012

[47] MMirollaTheCost of Chronic Disease in CanadaTheChronicDisease Prevention Alliance of Canada Ottawa Canada 2004

[48] P Tanuseputro W PWodchis R Fowler et al ldquoThe health carecost of dying a population-based retrospective cohort study ofthe last year of life in Ontario Canadardquo PLoS ONE vol 10 no3 Article ID e0121759 2015

[49] M Fortin M-C Chouinard T Bouhali M-F Dubois CGagnon and M Belanger ldquoEvaluating the integration ofchronic disease prevention and management services intoprimary health carerdquo BMC Health Services Research vol 13 no1 article no 132 2013

[50] M K Andrew and K Rockwood ldquoMaking our health and caresystemsfit for an ageing population considerations forCanadardquoCanadian Geriatrics Journal vol 17 no 4 pp 133ndash135 2014

[51] A Kothari D Gore M MacDonald G Bursey D Allan and JScarr ldquoChronic disease prevention policy in British Columbiaand Ontario in light of public health renewal a comparativepolicy analysisrdquo BMC Public Health vol 13 no 1 article 9342013

[52] M Fortin C Hudon E A Bayliss H Soubhi and L LapointeldquoCaring for body and soul the importance of recognizing andmanaging psychological distress in persons with multimorbid-ityrdquo International Journal of Psychiatry in Medicine vol 37 no1 pp 1ndash9 2007

[53] S M Smith E Wallace T OrsquoDowd and M Fortin ldquoInter-ventions for improving outcomes in patients with multimor-bidity in primary care and community settingsrdquo The CochraneDatabase of Systematic Reviews no 3 Article ID CD0065602016

[54] G Onder K Palmer R Navickas et al ldquoTime to face thechallenge of multimorbidity A European perspective fromthe joint action on chronic diseases and promoting healthyageing across the life cycle (JA-CHRODIS)rdquo European Journalof Internal Medicine vol 26 no 3 pp 157ndash159 2015

[55] A Fulambarker B Farooki F Kheir A S Copur L Srinivasanand S Schultz ldquoEffect of yoga in chronic obstructive pulmonarydiseaserdquoAmerican Journal ofTherapeutics vol 19 no 2 pp 96ndash100 2012

[56] G A Ghasemi A Golkar and S M Marandi ldquoEffects of hatayoga on knee osteoarthritisrdquo International Journal of PreventiveMedicine vol 4 supplement 1 pp S133ndashS138 2013

[57] J W Carson K M Carson K D Jones S D Mist and RM Bennett ldquoFollow-up of yoga of awareness for fibromyalgiaresults at 3 months and replication in the wait-list grouprdquoClinical Journal of Pain vol 28 no 9 pp 804ndash813 2012

[58] S Bryan G P Zipp and R Parasher ldquoThe effects of yoga onpsychosocial variables and exercise adherence a randomizedcontrolled pilot studyrdquo Alternative Therapies in Health andMedicine vol 18 no 5 pp 50ndash59 2012

[59] A Bussing A Michalsen S B S Khalsa S Telles and K JSherman ldquoEffects of yoga on mental and physical health ashort summary of reviewsrdquoEvidence-BasedComplementary andAlternative Medicine vol 2012 Article ID 165410 7 pages 2012

[60] L-H Chuang M O Soares H Tilbrook et al ldquoA pragmaticmulticentered randomized controlled trial of yoga for chroniclow back pain economic evaluationrdquo Spine vol 37 no 18 pp1593ndash1601 2012

[61] R B Saper A R Boah J Keosaian C Cerrada J Weinbergand K J Sherman ldquoComparing once-versus twice-weeklyyoga classes for chronic low back pain in predominantly lowincome minorities a randomized dosing trialrdquo Evidence-BasedComplementary and Alternative Medicine vol 2013 Article ID658030 13 pages 2013

[62] C Park ldquoMind-body CAM interventions current status andconsiderations for integration into clinical health psychologyrdquoJournal of Clinical Psychology vol 69 no 1 pp 45ndash63 2013

[63] B K S Iyengar Light on Yoga HarperCollins PublishersLondon UK 2010

[64] B K S Iyengar Light on PranayamaThe Definitive Guide to theArt of Breathing Harper Thorsons London UK 2013

[65] S Muktibodhananda Hatha Yoga Pradipika Light on HathaYoga Yoga Publications Trust Bihar India 2005

[66] B K S Iyengar Core of the Yoga Sutras HarperThorsonsLondon UK 2012

[67] V Kavuri N Raghuram A Malamud and S R Selvan ldquoIrrita-ble bowel syndrome yoga as remedial therapyrdquo Evidence-BasedComplementary and Alternative Medicine vol 2015 Article ID398156 10 pages 2015

[68] T R Mendoza C Chen A Brugger et al ldquoThe utility andvalidity of the modified Brief Pain Inventory in a multiple-dosepostoperative analgesic trialrdquo Clinical Journal of Pain vol 20no 5 pp 357ndash362 2004

[69] R L Daut C S Cleeland and R C Flanery ldquoDevelopment oftheWisconsin Brief Pain Questionnaire to assess pain in cancerand other diseasesrdquo Pain vol 17 no 2 pp 197ndash210 1983

[70] C S Cleeland ldquoPain assessment in cancerrdquo in Effect of Canceron Quality of Life D Osaba Ed CRC Press Boca Raton FlaUSA 1991

[71] C S Cleeland and K M Ryan ldquoPain assessment global use ofthe Brief Pain Inventoryrdquo Annals of the Academy of MedicineSingapore vol 23 no 2 pp 129ndash138 1994

[72] S Keller C M Bann S L Dodd J Schein T R Mendoza andC S Cleeland ldquoValidity of the brief pain inventory for use indocumenting the outcomes of patients with noncancer painrdquoClinical Journal of Pain vol 20 no 5 pp 309ndash318 2004

[73] G TanM P Jensen J IThornby andB F Shanti ldquoValidation ofthe brief pain inventory for chronic nonmalignant painrdquo Journalof Pain vol 5 no 2 pp 133ndash137 2004

[74] M P Jensen A J Hoffman and D D Cardenas ldquoChronic painin individuals with spinal cord injury a survey and longitudinalstudyrdquo Spinal Cord vol 43 no 12 pp 704ndash712 2005

[75] M W Stroud J A Turner M P Jensen and D D CardenasldquoPartner responses to pain behaviors are associatedwith depres-sion and activity interference among persons with chronic painand spinal cord injuryrdquo Journal of Pain vol 7 no 2 pp 91ndash992006


[76] T N Bryce C N Budh D D Cardenas et al ldquoPain after spinalcord injury an evidence-based review for clinical practice andresearchmdashreport of the National Institute on Disability andRehabilitation Research Spinal Cord InjuryMeasuresMeetingrdquoJournal of Spinal CordMedicine vol 30 no 5 pp 421ndash440 2007

[77] KA Raichle T LOsborneM P Jensen andDCardenas ldquoThereliability and validity of pain interference measures in personswith spinal cord injuryrdquo Journal of Pain vol 7 no 3 pp 179ndash1862006

[78] M J L Sullivan S R Bishop and J Pivik ldquoThe pain catas-trophizing scale development and validationrdquo PsychologicalAssessment vol 7 no 4 pp 524ndash532 1995

[79] S Cohen T Kamarck and R Mermelstein ldquoA global measureof perceived stressrdquo Journal of Health and Social Behavior vol24 no 4 pp 385ndash396 1983

[80] E Andreou E C Alexopoulos C Lionis et al ldquoPerceived stressscale reliability and validity study in Greecerdquo InternationalJournal of Environmental Research and Public Health vol 8 no8 pp 3287ndash3298 2011

[81] A S Zigmond and R P Snaith ldquoThe hospital anxiety anddepression scalerdquo Acta Psychiatrica Scandinavica vol 67 no 6pp 361ndash370 1983

[82] I Bjelland A A Dahl T T Haug and D Neckelmann ldquoThevalidity of the hospital anxiety and depression scale an updatedliterature reviewrdquo Journal of Psychosomatic Research vol 52 no2 pp 69ndash77 2002

[83] M J L Sullivan H Adams S Horan D Maher D Boland andR Gross ldquoThe role of perceived injustice in the experience ofchronic pain and disability scale development and validationrdquoJournal of Occupational Rehabilitation vol 18 no 3 pp 249ndash261 2008

[84] E Bohlmeijer P M ten Klooster M Fledderus M Veehof andR Baer ldquoPsychometric properties of the five facet mindfulnessquestionnaire in depressed adults and development of a shortformrdquo Assessment vol 18 no 3 pp 308ndash320 2011

[85] R A Baer G T Smith J Hopkins J Krietemeyer and LToney ldquoUsing self-report assessment methods to explore facetsof mindfulnessrdquo Assessment vol 13 no 1 pp 27ndash45 2006

[86] R A Baer G T Smith E Lykins et al ldquoConstruct validityof the five facet mindfulness questionnaire in meditating andnonmeditating samplesrdquo Assessment vol 15 no 3 pp 329ndash3422008

[87] F Raes E Pommier K D Neff and D Van Gucht ldquoCon-struction and factorial validation of a short form of the Self-Compassion ScalerdquoClinical Psychologyamp Psychotherapy vol 18no 3 pp 250ndash255 2011

[88] K D Neff ldquoThe development and validation of a scale tomeasure self-compassionrdquo Self and Identity vol 2 no 3 pp223ndash250 2003

[89] A H Peterman G Fitchett M J Brady L Hernandez and DCella ldquoMeasuring spiritual well-being in people with cancerthe functional assessment of chronic illness therapymdashSpiritualWell-being Scale (FACIT-Sp)rdquo Annals of Behavioral Medicinevol 24 no 1 pp 49ndash58 2002

[90] P E Murphy A L Canada G Fitchett et al ldquoAn examina-tion of the 3-factor model and structural invariance acrossracialethnic groups for the FACIT-Sp a report from theAmerican Cancer Societyrsquos Study of Cancer Survivors-II (SCS-II)rdquo Psycho-Oncology vol 19 no 3 pp 264ndash272 2010

[91] K J Preacher and A F Hayes ldquoSPSS and SAS proceduresfor estimating indirect effects in simple mediation modelsrdquo

Behavior Research Methods Instruments and Computers vol36 no 4 pp 717ndash731 2004

[92] K A McDermott M R Rao R Nagarathna et al ldquoA yogaintervention for type 2 diabetes risk reduction a pilot ran-domized controlled trialrdquo BMCComplementary and AlternativeMedicine vol 14 article 212 2014

[93] P Tekur R Nagarathna S Chametcha A Hankey and H RNagendra ldquoA comprehensive yoga programs improves painanxiety and depression in chronic low back pain patients morethan exercise an RCTrdquo Complementary Therapies in Medicinevol 20 no 3 pp 107ndash118 2012

[94] S Telles S Pathak A Kumar P Mishra and A BalkrishnaldquoInfluence of intensity and duration of yoga on anxiety anddepression scores associated with chronic illnessrdquo Annals ofMedical and Health Sciences Research vol 5 no 4 pp 260ndash2652015

[95] D Schumann D Anheyer R Lauche G Dobos J Langhorstand H Cramer ldquoEffect of Yoga in the therapy of irritable bowelsyndrome a systematic reviewrdquo Clinical Gastroenterology andHepatology vol 14 no 12 pp 1720ndash1731 2016

[96] N Falsafi and L Leopard ldquoPilot study use of mindfulnessself-compassion and yoga practices with low-income andoruninsured patients with depression andor anxietyrdquo Journal ofHolistic Nursing vol 33 no 4 pp 289ndash297 2015

[97] K Curtis A Osadchuk and J Katz ldquoAn eight-week yoga inter-vention is associated with improvements in pain psychologicalfunctioning and mindfulness and changes in cortisol levels inwomen with fibromyalgiardquo Journal of Pain Research vol 4 pp189ndash201 2011

[98] J W Carson K M Carson K D Jones R M Bennett CL Wright and S D Mist ldquoA pilot randomized controlledtrial of the Yoga of Awareness program in the management offibromyalgiardquo Pain vol 151 no 2 pp 530ndash539 2010

[99] P J Quartana C M Campbell and R R Edwards ldquoPaincatastrophizing a critical reviewrdquo Expert Review of Neurothera-peutics vol 9 no 5 pp 745ndash758 2014

[100] L A H Hermsen J C van der Wouden S S Leone MSmalbrugge H E van der Horst and J Dekker ldquoThe longitu-dinal association of cognitive appraisals and coping strategieswith physical functioning in older adults with joint pain andcomorbidity A Cohort Studyrdquo BMC Geriatrics vol 16 article29 2016

[101] S Evans M Moieni K Lung et al ldquoImpact of iyengar yogaon quality of life in young women with rheumatoid arthritisrdquoClinical Journal of Pain vol 29 no 11 pp 988ndash997 2013

[102] K Neff ldquoSelf-compassion an alternative conceptualization of ahealthy attitude toward oneselfrdquo Self and Identity vol 2 no 2pp 85ndash101 2003

[103] S C F Toise S F Sears M H Schoenfeld et al ldquoPsychosocialand cardiac outcomes of yoga for ICD patients a randomizedclinical control trialrdquo Pacing and Clinical Electrophysiology vol37 no 1 pp 48ndash62 2014

[104] K E Riley and C L Park ldquoHow does yoga reduce stress Asystematic review of mechanisms of change and guide to futureinquiryrdquo Health Psychology Review vol 9 no 3 pp 379ndash3962015

[105] T Gard N Brach B K Holzel J J Noggle L A Conboy and SW Lazar ldquoEffects of a yoga-based intervention for young adultson quality of life and perceived stress the potential mediatingroles of mindfulness and self-compassionrdquo The Journal ofPositive Psychology vol 7 no 3 pp 165ndash175 2012


[106] L A Daly S C Haden M Hagins N Papouchis and P MRamirez ldquoYoga and emotion regulation in high school studentsa randomized controlled trialrdquo Evidence-Based Complementaryand Alternative Medicine vol 2015 Article ID 794928 8 pages2015

[107] J M Brion M R Leary and A S Drabkin ldquoSelf-compassionand reactions to serious illness the case of HIVrdquo Journal ofHealth Psychology vol 19 no 2 pp 218ndash229 2014

[108] A B Allen and M R Leary ldquoSelf-compassionate responses toagingrdquo Gerontologist vol 54 no 2 pp 190ndash200 2014

[109] F M Sirois ldquoA self-regulation resource model of self-com-passion and health behavior intentions in emerging adultsrdquoPreventive Medicine Reports vol 2 pp 218ndash222 2015

[110] FM Sirois R Kitner and J K Hirsch ldquoSelf-compassion affectandhealth-promoting behaviorsrdquoHealth Psychology vol 34 no6 pp 661ndash669 2015

[111] N T VanDam S C Sheppard J P Forsyth andM EarleywineldquoSelf-compassion is a better predictor than mindfulness ofsymptom severity and quality of life in mixed anxiety anddepressionrdquo Journal of Anxiety Disorders vol 25 no 1 pp 123ndash130 2011

[112] B M Galla ldquoWithin-person changes in mindfulness and self-compassion predict enhanced emotional well-being in healthybut stressed adolescentsrdquo Journal of Adolescence vol 49 pp204ndash217 2016

[113] N Farb J Daubenmier C J Price et al ldquoInteroception con-templative practice and healthrdquo Frontiers in Psychology vol 6article 763 2015

[114] F Purdie and S Morley ldquoSelf-compassion pain and breaking asocial contractrdquo Pain vol 156 no 11 pp 2354ndash2363 2015

[115] A A Wren T J Somers M A Wright et al ldquoSelf-compassionin patients with persistent musculoskeletal pain relationshipof self-compassion to adjustment to persistent painrdquo Journal ofPain and Symptom Management vol 43 no 4 pp 759ndash7702012

[116] E A Hoge B K Holzel L Marques et al ldquoMindfulness andself-compassion in generalized anxiety disorder examiningpredictors of disabilityrdquo Evidence-based Complementary andAlternative Medicine vol 2013 Article ID 576258 7 pages 2013

[117] R Lyons K Kuluski C Alvaro A Shaink B Bernstein and RTobias BridgepointCollaboratory for Research and InnovationThe Face of Complex Chronic Disease Understanding thePatient Population at Bridgepoint Health Toronto 2012

[118] C L Park E Groessl M Maiya et al ldquoComparison groups inyoga research a systematic review and critical evaluation of theliteraturerdquo Complementary Therapies in Medicine vol 22 no 5pp 920ndash929 2014

Submit your manuscripts athttpwwwhindawicom

Stem CellsInternational

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014


MEDIATORSINFLAMMATION

of


Behavioural Neurology

EndocrinologyInternational Journal of



Disease Markers


BioMed Research International

OncologyJournal of



Oxidative Medicine and Cellular Longevity


PPAR Research

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

ObesityJournal of



Computational and Mathematical Methods in Medicine

OphthalmologyJournal of


Diabetes ResearchJournal of



Research and TreatmentAIDS


Gastroenterology Research and Practice


Parkinsonrsquos Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom


these studies yoga is extolled for its many benefits Howeverthe literature is plagued by studies of poor methodologicalquality and there has been a call for improving the caliber ofresearch in this area [9]

There is evidence that yoga is effective in the treatment ofa variety of acute and chronic conditions [9] either as a stand-alone treatment or as an adjuvant therapy including low backpain [10 11] arthritis [12] rheumatic disease and fibromyalgia[13 14] diabetes [15 16] cancer and related fatigue [17ndash21] stroke and related disability [22 23] sleep disorders[24] renal disease [25 26] hypertension [27 28] asthma[29 30] chronic obstructive pulmonary disease (COPD) [31]psychiatric conditions [32] obesity [33] and neurologicalconditions [34 35] Although there is an abundance ofresearch evaluating the impact of yoga on disease-specificsymptoms or quality of life for many chronic conditions todate there has not been one trial evaluating the effects ofa yoga intervention on individuals who are receiving careor rehabilitation for complex chronic disease and disability(CCDD)

CCDD is a term that identifies individuals who have beendiagnosed with multimorbidities that affect psychologicalsocial physical and vocational functioning and requireongoing health care resource utilization [36ndash38] Individualswith complex health conditions have been identified asunique in terms of their specific health care needs and health-related experiences [36] Although the disease combinationsreported in multimorbidity are diverse the most commondiagnoses are diabetes stroke hypertension cancer arthritisasthma fractures the presence of an artificial knee or hipfatigue multiple sclerosis demyelinating diseases of the cen-tral nervous system gonarthrosis ataxia COPD dependenceon renal dialysis malignant neoplasm of breastprostatedepressive episodes and pure hypercholesterolemia [39 40]Consistent across studies of this population is the severity ofthe impact of having multiple conditions [41] Patients withCCDD have an average of five health conditions (comorbidi-ties) [40] and frequently reported pain weakness illness-related symptoms functional challenges (mobility activitiesof daily living equipment devices etc) symptoms of anxietyand depression and disruptions in independence recre-ational activities occupation social roles and self-identity

Multimorbidity has been associated with low socioeco-nomic status female gender and older age in both lon-gitudinal and cross-sectional studies with prevalence andincidence rates in older age reported at 55 and 12ndash33respectively and prevalence rates in young-middle age at113ndash154 [42ndash45] Multimorbidity is a complex and het-erogeneous disease state with many of the most prevalentconditions being of global concern and is increasinglybecoming the norm rather than the exception resulting inhigh health care resource use [45 46] In Canada 42 of totaldirect medical care expenses are allotted to the treatment ofchronic diseases [47] with up to $52661 per patient spent onaverage for the last year of life in part due to inpatient andlong-term care costs [48] Despite the clear priority of themedical community to address the needs of individuals withchronic disease the orientation of the health care system asan acute-care focused model means that care for individuals

with chronic disease is often ineffective leaving those withmany chronic conditions underserviced [49]

A structural shift towards care that is not diseaseinjuryfocused but emphasizes addressing many needs at once hasbeen recommended [50 51] Understanding the relationshipsbetween physical psychological and social factors of healthin multimorbidity has been identified as necessary for cre-ating effective treatment [38 52] A remodeling of chronicdisease services has been proposed to create interventionsthat harmoniously integrate patient-centered and systemicfactors and that also target risk factors such as depression orfunctional ability with the end goal of improving patient self-efficacy functional health status health-related behavioursand psychological well-being [49 53] Despite an increasein research over the past two decades on multimorbiditythere is still limited research on effective interventions toadequately service this population [53 54] which highlightsa need for programs that are designed to address the needsof individuals who are managing multiple intersecting healthimpacts of a chronic nature

Given the evidence supporting the use of yoga for manyof the common primary and secondary diagnoses of patientswith CCDD (eg musculoskeletal conditions multiple scle-rosis hypertension arthritis renal disease depression dia-betes COPD cholesterol levels and breast and prostatecancer) it is possible that yoga may be able to addressmany of the multiple health needs these individuals report asbeing important [40] Other frequently reported symptoms(eg pain fatigue emotional upset nausea and difficultybreathing) and facets of living that are disrupted (egmobility activities of living and social well-being) have alsobeen shown to improve with yoga practice [2 19 21 55 56]Moreover yoga provides a lasting behavioural skill set thatincreases confidence and self-efficacy and shows mainte-nance of functional and coping gains in chronic pain patientsat follow-up [57] It can be used in the treatment of chronicconditions for both low- and high-income populations isassociated with treatment adherence in sedentary adultsand holds promise as a cost-effective treatment for chronicconditions [58ndash61] Complementary and alternative therapiessuch as yoga have been recommended for integration intoclinical health psychology settings in order to more broadlyaddress well-being spirituality multiple health problemsdissatisfaction with orthodox medicine and disease preven-tion [62]

Although there is evidence that yoga provides mentaland physical health benefits for many of the disease statesand psychosocial impacts that are prevalent in individualswithmultimorbidity there have been no studies evaluating itsuse for this population Medical rehabilitation and complexcontinuing care support tend to focus on addressing physicalailments and neglect integrating mental health support Yogais an example of a strategy that addresses both thus itmay impart benefits in multiple areas of health rendering itparticularly useful for this population Hospital and tertiarycare settings typically implement evidence-based practice sothere is a need for information regarding the benefits andsafety of yoga when used in the treatment of individuals withCCDD or multimorbidity


































7 (100) 1 3 4 5 7 8 10



5 (7143) 1 3 4 58


3 (4286) 3 4 8



Yoga program

Time(days)

sessionInformation

meetingsFollow-up



T3questionnaires






















26 Measures





















classes





3 Results


















T2 T3T1Time

000

100

200

300

400

500

600SC

S-SF

scor

es



(a)

T2 T3T1Time

000

200

400

600

800

1000

1200

1400

1600

1800

2000

HA

DS-

A sc

ores



(b)

T2 T3T1Time

000

200

400

600

800

1000

1200

1400

PCS-

mag

nific

atio

n sc

ores



(c)

T2 T3T1Time

000

1000

2000

3000

4000

5000

6000

PCS-

tota

l sco

res



(d)







4 Discussion

















5 Conclusions



Competing Interests


Acknowledgments


References


































































































































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

















































7 (100) 1 3 4 5 7 8 10



5 (7143) 1 3 4 58


3 (4286) 3 4 8



Yoga program

Time(days)

sessionInformation

meetingsFollow-up



T3questionnaires






















26 Measures





















classes





3 Results


















T2 T3T1Time

000

100

200

300

400

500

600SC

S-SF

scor

es



(a)

T2 T3T1Time

000

200

400

600

800

1000

1200

1400

1600

1800

2000

HA

DS-

A sc

ores



(b)

T2 T3T1Time

000

200

400

600

800

1000

1200

1400

PCS-

mag

nific

atio

n sc

ores



(c)

T2 T3T1Time

000

1000

2000

3000

4000

5000

6000

PCS-

tota

l sco

res



(d)







4 Discussion

















5 Conclusions



Competing Interests


Acknowledgments


References


































































































































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

































26 Measures





















classes





3 Results


















T2 T3T1Time

000

100

200

300

400

500

600SC

S-SF

scor

es



(a)

T2 T3T1Time

000

200

400

600

800

1000

1200

1400

1600

1800

2000

HA

DS-

A sc

ores



(b)

T2 T3T1Time

000

200

400

600

800

1000

1200

1400

PCS-

mag

nific

atio

n sc

ores



(c)

T2 T3T1Time

000

1000

2000

3000

4000

5000

6000

PCS-

tota

l sco

res



(d)







4 Discussion

















5 Conclusions



Competing Interests


Acknowledgments


References


































































































































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of


































classes





3 Results


















T2 T3T1Time

000

100

200

300

400

500

600SC

S-SF

scor

es



(a)

T2 T3T1Time

000

200

400

600

800

1000

1200

1400

1600

1800

2000

HA

DS-

A sc

ores



(b)

T2 T3T1Time

000

200

400

600

800

1000

1200

1400

PCS-

mag

nific

atio

n sc

ores



(c)

T2 T3T1Time

000

1000

2000

3000

4000

5000

6000

PCS-

tota

l sco

res



(d)







4 Discussion

















5 Conclusions



Competing Interests


Acknowledgments


References


































































































































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of






























T2 T3T1Time

000

100

200

300

400

500

600SC

S-SF

scor

es



(a)

T2 T3T1Time

000

200

400

600

800

1000

1200

1400

1600

1800

2000

HA

DS-

A sc

ores



(b)

T2 T3T1Time

000

200

400

600

800

1000

1200

1400

PCS-

mag

nific

atio

n sc

ores



(c)

T2 T3T1Time

000

1000

2000

3000

4000

5000

6000

PCS-

tota

l sco

res



(d)







4 Discussion

















5 Conclusions



Competing Interests


Acknowledgments


References


































































































































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of



















4 Discussion

















5 Conclusions



Competing Interests


Acknowledgments


References


































































































































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of


























5 Conclusions



Competing Interests


Acknowledgments


References


































































































































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of








































































































































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















research article evaluation of a specialized yoga...

Documents