An evidence map of yoga for low back pain

Effects of mind-body therapies on schizophrenia: A systematic review and network meta-analysis

OBJECTIVE

The objective of this meta-analysis is to evaluate and compare the effectiveness of different mind-body therapies in reducing the symptoms of schizophrenia.

METHODS

A systematic search was performed using databases such as PubMed, Embase, Cochrane Library, Web of Science, and Scopus. Randomized controlled trials that assessed the effects of mind-body therapies on patients with schizophrenia were included. The search covered the period between the inception of each database and November 17th, 2022. The methodological quality of the trials was assessed using the Cochrane risk of bias tool. A network meta-analysis was conducted to compare the effects of various mind-body therapies, including Yoga, Mindfulness, Tai Chi, Baduanjin, and Yijinjing.

RESULTS

The analysis included 22 randomized controlled trials involving a total of 2064 subjects. The network meta-analysis revealed that Yoga and Mindfulness interventions were more effective than other mind-body therapies in reducing the symptoms of schizophrenia. Specifically, Yoga improved PANSS-positive symptom scores (SUCRA: 74.8 %) and PANSS-negative symptom scores (SUCRA: 80.4 %), whereas Mindfulness improved PANSS-positive symptom scores (SUCRA: 85.6 %).

CONCLUSION

The findings of this study indicate that Yoga may be a promising intervention for the treatment of schizophrenia. However, the small sample size and the low quality of the included studies have limited the generalizability of our findings Therefore, this study must be understood with caution, and further investigation is warranted when more relevant studies emerge.

Āsana for Back, Hips and Legs to Prevent Musculoskeletal Disorders among Dental Professionals: In-Office Yóga Protocol

Dental professionals are exposed to significant unavoidable physical stress, and theoretical ergonomic recommendations for a sitting workplace are inapplicable in many dental activities. Work-related musculoskeletal disorders (WMSDs) represent a serious health problem among dental professionals (prevalence: 64-93%), showing involvement of 34-60% for the low back and 15-25% for the hips. Muscle stress; prolonged sitting; forward bending and twisting of the torso and head; unbalanced working postures with asymmetrical weight on the hips and uneven shoulders; and others are inevitable for dental professionals. Therefore, the approach for the prevention and treatment of WMSDs must be therapeutic and compensatory. This project was conceived to provide a Yoga protocol for dental professionals to prevent or treat WMSDs from a preventive medicine perspective, and it would represent a Yoga-based guideline for the self-cure and prevention of musculoskeletal problems.

METHODS

Specific Yoga positions (āsana, such as Virāsana, Virabhadrāsana, Garudāsana, Utkatāsana, Trikonāsana, Anuvittāsana, Chakrāsana, Uttanāsana, Pashimottanāsana) have been selected, elaborated on and adapted to be practiced in a dental office using a dental stool or the dental office walls or a dental unit chair. The protocol is specifically devised for dental professionals (dentists, dental hygienists and dental assistants) and targeted for the low back, hips and legs (including knees and ankles). The protocol includes Visranta Karaka Sthiti (supported positions) in sitting (Upavistha Sthiti) and standing (Utthistha Sthiti) positions, twisting/torsions (Parivrtta), flexions/forward bend positions (Pashima) and extensions/arching (Purva) for musculo-articular system decompression and mobilization.

RESULTS

Over 60 Yogāsana-specifically ideated for back detensioning and mobilization, lumbar lordosis restoration, trunk side elongation, hip release and leg stretches and decontraction-are shown and described. The paper provides a meticulous description for each position, including the detailed movement, recommendations and mistakes to avoid, and the breathing pattern (breath control) in all the breath-driven movements (āsana in vinyāsa). An exhaustive analysis of posture-related disorders affecting the lower body among dental professionals is reported, including low-back pain, hip pain and disorders, piriformis syndrome and quadratus femoris dysfunction (gluteal pain), iliopsoas syndrome, multifidus disorders, femoroacetabular and ischiofemoral impingement, spinopelvic mobility, lumbopelvic rhythm, impairment syndromes, lower crossed syndrome, leg pain, knee pain and ankle disorders.

CONCLUSIONS

A detailed guideline of āsana for low-back decompression, hip joint destress, piriformis and gluteal muscle release, lumbar lordosis recovery and a spinopelvic mobility increase has been elaborated on. The designed Yogāsana protocol represents a powerful tool for dental professionals to provide relief to retracted stiff muscles and unbalanced musculoskeletal structures in the lower body.

Yoga Plus Mantram Repetition to Reduce Chronic Pain in Veterans With Post-Traumatic Stress Disorder: A Feasibility Trial

Background

Veterans with post-traumatic stress disorder (PTSD) are more likely to report chronic pain than veterans without PTSD. Yoga has been shown to reduce both chronic pain and PTSD symptoms in clinical trials. The goal of our study was to assess the feasibility and acceptability of conducting a randomized controlled trial (RCT) that combined yoga and mantram repetition (Yoga + MR) into one program for military veterans with both chronic pain and PTSD.

Methods

In this feasibility RCT, 27 veterans were randomized to either Yoga + MR or a relaxation intervention. Due to the COVID-19 pandemic, in-person recruitment, assessments, and intervention attendance were re-evaluated. Although remote delivery of aspects of the study were utilized, interventions were delivered in-person. Feasibility benchmarks met included full recruitment in 12 months or less, 75%+ retention at initial follow-up assessment, 50%+ attendance rate, and 75%+ of participants satisfied with the interventions.

Results

The sample was racially and ethnically diverse, and 15% of participants were women. Participant recruitment lasted approximately 11 months. Out of 32 participants initially randomized, two participants asked to be dropped from the study and three did not meet PTSD symptom criteria. For the remaining 27 participants, retention rates were 85% at 12 weeks and 81% at 18 weeks. Participants attended 66% of in-person yoga and 55% of in-person relaxation sessions. Satisfaction was high, with 100% of yoga participants and 75%/88% of relaxation participants agreeing or strongly agreeing they were satisfied with the intervention/instructors. After 12 weeks (end of intervention), Yoga + MR participants reported reduced back-pain related disability (primary outcome), reduced alcohol use, reduced fatigue, and increased quality of life, while relaxation group participants reported reductions in pain severity, PTSD symptoms, and fatigue.

Conclusions

Amidst many research challenges during the pandemic, recruitment, retention, and efficacy results from this feasibility trial support advancement to a larger RCT to study Yoga + MR for chronic pain and PTSD.

The Effects of Mind-Body Exercises on Chronic Spinal Pain Outcomes: A Synthesis Based on 72 Meta-Analyses

An umbrella review of systematic reviews with a meta-analysis was developed to summarize the evidence on the effectiveness of qigong, tai chi, and yoga in chronic spinal pain outcomes. The CINAHL, Cochrane Library, Embase, PsycINFO, PubMed and SPORTDiscus databases were searched. Pain, psychological factors, and quality of life (QOL) were the outcomes of interest. The methodological quality of the reviews was evaluated using the AMSTAR-2 tool. The overlap was calculated using the corrected covered area. A total of 72 meta-analyses drawn from 20 systematic reviews were included and often were rated at a critically low quality. The effects of qigong on chronic low back and neck pain (CLBP and CNP, respectively) were inconsistent, although it improved the physical component of QOL after 12 weeks for CNP. Tai chi was superior to the controls in reducing CLBP; no reviews of interest were found on CNP. Yoga was superior to multiple controls in reducing CLBP, but no relevant effects on depression or QOL were found. QOL, anxiety, depression, and general mood improved with yoga for CNP. Inconsistencies arose related to yoga and CNP. Our findings mainly supported the potential effects of yoga and tai chi on pain-related outcomes, psychological factors, and QOL in populations with CLBP and NP. Clinical and methodological considerations were discussed.

Effectiveness of a whole health model of care emphasizing complementary and integrative health on reducing opioid use among patients with chronic pain

Background

The opioid crisis has necessitated new approaches to managing chronic pain. The Veterans Health Administration (VHA) Whole Health model of care, with its focus on patient empowerment and emphasis on nonpharmacological approaches to pain management, is a promising strategy for reducing patients’ use of opioids. We aim to assess whether the VHA’s Whole Health pilot program impacted longitudinal patterns of opioid utilization among patients with chronic musculoskeletal pain.

Methods

A cohort of 4,869 Veterans with chronic pain engaging in Whole Health services was compared with a cohort of 118,888 Veterans receiving conventional care. All patients were continuously enrolled in VHA care from 10/2017 through 3/2019 at the 18 VHA medical centers participating in the pilot program. Inverse probability of treatment weighting and multivariate analyses were used to adjust for observable differences in patient characteristics between exposures and conventional care. Patients exposed to Whole Health services were offered nine complementary and integrative health therapies alone or in combination with novel Whole Health services including goal-setting clinical encounters, Whole Health coaching, and personal health planning.

Main measures

The main measure was change over an 18-month period in prescribed opioid doses starting from the six-month period prior to qualifying exposure.

Results

Prescribed opioid doses decreased by -12.0% in one year among Veterans who began complementary and integrative health therapies compared to similar Veterans who used conventional care; -4.4% among Veterans who used only Whole Health services such as goal setting and coaching compared to conventional care, and -8.5% among Veterans who used both complementary and integrative health therapies combined with Whole Health services compared to conventional care.

Conclusions

VHA’s Whole Health national pilot program was associated with greater reductions in prescribed opioid doses compared to secular trends associated with conventional care, especially when Veterans were connected with complementary and integrative health therapies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08388-2.

Whole Health Use and Interest Across Veterans With Co-Occurring Chronic Pain and PTSD: An Examination of the 18 VA Medical Center Flagship Sites

Objective

Veterans Healthcare Administration (VHA) conducted a large demonstration project of a holistic Whole Health approach to care in 18 medical centers, which included making complementary and integrative health (CIH) therapies more widely available. This evaluation examines patterns of service use among Veterans with chronic pain, comparing those with and without PTSD.

Methods

We assessed the use of Whole Health services in a cohort of Veterans with co-occurring chronic pain and PTSD (n = 1698; 28.9%), comparing them to Veterans with chronic musculoskeletal pain only (n = 4170; 71.1%). Data was gathered from VA electronic medical records and survey self-report. Whole Health services were divided into Core Whole Health services (e.g., Whole Health coaching) and CIH services (e.g., yoga). Logistic regression was used to determine whether Veterans with co-occurring chronic pain and PTSD utilized more Whole Health services compared to Veterans with chronic pain but without PTSD.

Results

A total of 40.1% of Veterans with chronic pain and PTSD utilized Core Whole Health services and 53.2% utilized CIH therapies, compared to 28.3% and 40.0%, respectively, for Veterans with only chronic pain. Adjusting for demographics and additional comorbidities, Veterans with comorbid chronic pain and PTSD were 1.24 ( 95% CI: 1.12, 1.35, P ≤ .001) times more likely than Veterans with chronic pain only to use Core Whole Health services, and 1.23 ( 95% CI: 1.14, 1.31, P ≤ .001) times more likely to use CIH therapies. Survey results also showed high interest levels in Core Whole Health services and CIH therapies among Veterans who were not already using these services.

Conclusion

Early implementation efforts in VHA led to high rates of use of Core Whole Health and CIH therapy use among Veterans with co-occurring chronic pain and PTSD. Future assessments should examine how well these additional services are meeting the needs of Veterans in both groups.

Effectiveness and safety of yoga to treat chronic and acute pain: a rapid review of systematic reviews

Background

Pain is a sensation of discomfort that affects a large part of the population. Yoga is indicated to treat various health conditions, including chronic and acute pain.

Objective

To evaluate the effectiveness and safety of yoga to treat acute or chronic pain in the adult and elderly population.

Study selection

A rapid review was carried out, following a protocol established a priori. Searches were carried out in September 2019, in six databases, using PICOS and MeSH (Medical Subject Headings) and DeCS (Descritores em Ciências da Saúde) terms. Systematic reviews were included, and methodological quality was assessed using Assessing the Methodological Quality of Systematic Reviews. The results were presented in a narrative synthesis.

Findings

Ten systematic reviews were selected. Two reviews were assessed as of high methodological quality, two as of low quality, and six of critically low quality. Results were favourable to yoga compared with usual daily care, particularly in low back and cervical pain cases. There was little evidence about the superiority of yoga compared with active interventions (exercises, pilates or complementary and complementary medicine). It was also less consistent in pain associated with fibromyalgia, osteoarthritis, rheumatoid arthritis, carpal tunnel and irritable bowel syndromes. There was an improvement in the quality of life and mood of the participants, especially for yoga compared with usual care, exercises and waiting list.

Conclusions

Overall, the results were favourable to yoga compared with usual care in low back and cervical pain cases. The evidence is insufficient to assert yoga’s benefits for other pain conditions, as well as its superiority over active interventions. The findings must be considered with caution, given their low methodological quality and the small samples in the primary studies reported in the included systematic reviews. Thus, more studies must be carried out to improve the reliability of the results.

Yoga is effective in treating symptoms of Gulf War illness: A randomized clinical trial

Many Veterans of the 1990-1991 Gulf War report symptoms of Gulf War Illness, a condition involving numerous chronic symptoms including pain, fatigue, and mood/cognition symptoms. Little is known about this condition's etiology and treatment. This study reports outcomes from a randomized controlled single-blind trial comparing yoga to cognitive behavioral therapy for chronic pain and other symptoms of Gulf War Illness. Participants were Veterans with symptoms of GWI: chronic pain, fatigue and cognition-mood symptoms. Seventy-five Veterans were randomized to treatment via selection of envelopes from a bag (39 yoga, 36 cognitive behavioral therapy), which consisted of ten weekly group sessions. The primary outcomes of pain severity and interference (Brief Pain Inventory- Short Form) improved in the yoga condition (Cohen's d = .35, p = 0.002 and d = 0.69, p < 0.001, respectively) but not in the CBT condition (d = 0.10, p = 0.59 and d = 0.25 p = 0.23). However, the differences between groups were not statistically significant (d = 0.25, p = 0.25; d = 0.43, p = 0.076), though the difference in an a-priori-defined experimental outcome variable which combines these two variables into a total pain variable (d = 0.47, p = 0.047) was significant. Fatigue, as indicated by a measure of functional exercise capacity (6-min walk test) was reduced significantly more in the yoga group than in the CBT group (between-group d = .27, p = 0.044). Other secondary outcomes of depression, wellbeing, and self-reported autonomic nervous system symptoms did not differ between groups. No adverse events due to treatment were reported. Yoga may be an effective treatment for core Gulf War Illness symptoms of pain and fatigue, making it one of few treatments with empirical support for GWI. Results support further evaluation of yoga for treating veterans with Gulf War Illness. CLINICAL TRIAL REGISTRY: clinicaltrials.gov Registration Number NCT02378025.

Yoga for treating low back pain: a systematic review and meta-analysis

ABSTRACT

Yoga is frequently used for back pain relief. However, evidence was judged to be of only low- or moderate. To assess the efficacy and safety of yoga in patients with low back pain a meta-analysis was performed. Therefore Medline/PubMed, Scopus, and the Cochrane Library was searched to May 26 2020. Only randomized controlled trials (RCTs) comparing Yoga with passive control (usual care or waitlist), or an active comparator, for patients with low back pain, that assessed pain intensity or pain-related disability as a primary outcome were considered to be eligible. Two reviewers independently extracted data on study characteristics, outcome measures, and results at short-term and long-term follow-up. Risk of bias was assessed using the Cochrane Risk of Bias Tool. 30 articles on 27 individual studies (2702 participants in total) proved eligible for review. Compared to passive control, yoga was associated with short-term improvements in pain intensity (15 RCTs; Mean Difference (MD)=-0.74 points on a numeric rating scale; 95%CI=-1.04,-0.44; Standardized Mean Difference (SMD)=-0.37 95%CI=-0.52,-0.22), pain-related disability (15 RCTs; MD=-2.28; 95%CI=-3.30,-1.26; SMD=-0.38 95%CI=-0.55,-0.21), mental health (7 RCTs; MD=1.70; 95%CI=0.20,3.20; SMD=0.17 95%CI=0.02,0.32) and physical functioning (9 RCTs; MD=2.80; 95%CI=1.00,4.70; SMD=0.28 95%CI=0.10,0.47). Except for mental health all effects sustained long-term. Compared to an active comparator, yoga was not associated with any significant differences in short- or long-term outcomes.In conclusion, yoga revealed robust short- and long-term effects for pain, disability, physical function and mental health, when compared to non-exercise controls. However these effects were mainly not clinically significant.

Complementary and Integrative Health Approaches Offered in the Veterans Health Administration: Results of a National Organizational Survey

Introduction: Certain complementary and integrative health (CIH) approaches have increasingly gained attention as evidence-based nonpharmacological options for pain, mental health, and well-being. The Veterans Health Administration (VA) has been at the forefront of providing CIH approaches for years, and the 2016 Comprehensive Addiction and Recovery Act mandated the VA expand its provision of CIH approaches. Objective/Design: To conduct a national organizational survey to document aspects of CIH approach implementation from August 2017 to July 2018 at the VA. Participants: CIH program leads at VA medical centers and community-based outpatient clinics (n = 196) representing 289 sites participated. Measures: Delivery of 27 CIH and other nonpharmacologic approaches was measured, including types of departments and providers, visit format, geographic variations, and implementation challenges. Results: Respondents reported offering a total of 1,568 CIH programs nationally. Sites offered an average of five approaches (range 1-23), and 63 sites offered 10 or more approaches. Relaxation techniques, mindfulness, guided imagery, yoga, and meditation were the top five most frequently offered. The most approaches were offered in physical medicine and rehabilitation, primary care, and within integrative/whole health programs, and VA non-Doctor of Medicine clinical staff were the most common type of CIH provider. Only 13% of sites reported offering CIH approaches through telehealth at the time. Geographically, southwestern sites offered the smallest number of approaches. Implementation challenges included insufficient staffing, funding, and space, hiring/credentialing, positioning CIH as a priority, and high patient demand. Conclusions: The provision of CIH approaches was widespread at the VA in 2017-2018, with over half of responding sites offering five or more approaches. As patients seek nonpharmacologic options to address their pain, anxiety, depression, and well-being, the nation's largest integrated health care system is well-positioned to meet that demand. Providing these therapies might not only increase patient satisfaction but also their health and well-being with limited to no adverse events.

Musculoskeletal Disorders among Italian Dentists and Dental Hygienists

Dental professionals often perform physically and mentally demanding therapeutical procedures. They work maintaining muscular imbalance and asymmetrical positions for a long time. The aim of the study was to describe the prevalence and the factors associated to work-related musculoskeletal disorders (WMSD) among Italian dental professionals and the most affected body regions. A cross-sectional observational study was conducted between March 2019 and February 2020. The Nordic Musculoskeletal questionnaire (NMQ) was implemented with questions related to working habits (dental occupation, working hours per week and per days, years of work) and lifestyle (practiced physical activity, including frequency and duration, mobilization activities, and knowledge of ergonomic guidelines) was used. The-chi square test was carried out to detect any statistically significant difference (p < 0.05). Logistic regression was carried out to detect the most significant factors associated to WMSD occurrence. A total of 284 questionnaires have been used for the analysis. A high proportion of dental professionals (84.6%) were affected by WMSD in the last 12 months. A higher prevalence was found in females (87%) when compared to males (80%). The prevalence of WMSD was correlated to the working hours/day and hour/week, with a higher risk for operators working >5 h/day and >30 h/week. In addition, a high prevalence was found in operators working for 2–5 years after graduation. Most of the surveyed dental professionals practiced physical activity (70.1%) but only a few had satisfactorily knowledge of ergonomic guidelines (12.7%). Interestingly, participants who practiced yoga or stretching as physical activities demonstrated lower WMSD (77%) when compared to other physical activities (84%). We can highlight that generic physical activities have no functional effect on WMSD for dental professionals. The most affected body areas were neck (59.9%), shoulders (43.3%), lumbar region (52.1%), dorsal region (37.7%) and wrists (30.6%). Considering the magnitude of the problem, there is an urgent need to implement the education in ergonomics among dental professionals, that may be achieved by teaching biomechanics, posturology and integrative functional therapies (such as yoga) during the university education and by promoting holistic health of dental operators.

Yoga vs Stretching in Veterans With Chronic Lower Back Pain and the Role of Mindfulness: A Pilot Randomized Controlled Trial

Objective

The purpose of this study was to investigate the feasibility of recruiting, randomizing, enrolling, and collecting outcome data on veteran patients with chronic low back pain (CLBP) who undergo an 8-week, active exercise class with mindfulness (yoga class) and without (stretching class).

Methods

United States veterans with CLBP based on inclusion/exclusion criteria were randomized to 1 of 2 groups. The study design was a pilot randomized controlled trial. Twenty CLBP patients attended a yoga class or stretching class once per week for 8 weeks at the Veterans Affairs Rochester Outpatient Center, Rochester, New York. The following measurements were obtained: recruitment or enrollment data, compliance data to include class attendance and home exercise, and compliance data regarding ability to collect outcome measures at baseline and at completion. Outcome measures included pain (PEG), quality of life (PROMIS Global Health Survey), self-efficacy (2-item questionnaire), fear avoidance belief, catastrophizing, and social engagement in addition to qualitative clinician open-ended questions postintervention.

Results

Forty-five veterans were queried regarding interest in participation. Of these, 34 (76%) met the study's criteria. Twenty (44%) agreed to participate and were consented, randomized, and enrolled in the study. Initial and final outcome measures were obtained for each participant (100%). Forty percent attended more than 80% of the sessions for both yoga and stretching groups.

Conclusion

This pilot study demonstrated feasibility of recruiting, enrolling, and collecting outcome data on CLBP veteran patients participating in yoga and stretching class. The data from this pilot will inform the development of a randomized, comparative effectiveness study of yoga with and without mindfulness in the management of CLBP.

Assessing the Relative Effectiveness of Combining Self-Care with Practitioner-Delivered Complementary and Integrative Health Therapies to Improve Pain in a Pragmatic Trial

BACKGROUND

Many health care systems are beginning to encourage patients to use complementary and integrative health (CIH) therapies for pain management. Many clinicians have anecdotally reported that patients combining self-care CIH therapies with practitioner-delivered therapies report larger health improvements than do patients using practitioner-delivered or self-care CIH therapies alone. However, we are unaware of any trials in this area.

DESIGN

The APPROACH Study (Assessing Pain, Patient-Reported Outcomes and Complementary and Integrative Health) assesses the value of veterans participating in practitioner-delivered CIH therapies alone or self-care CIH therapies alone compared with the combination of self-care and practitioner-delivered care. The study is being conducted in 18 Veterans Health Administration sites that received funding as part of the Comprehensive Addiction and Recovery Act to expand availability of CIH therapies. Practitioner-delivered therapies under study include chiropractic care, acupuncture, and therapeutic massage, and self-care therapies include tai chi/qi gong, yoga, and meditation. The primary outcome will be improvement on the Brief Pain Inventory 6 months after initiation of CIH as compared with baseline scores. Patients will enter treatment groups on the basis of the care they receive because randomizing patients to specific CIH therapies would require withholding therapies routinely offered at VA. We will address selection bias and confounding by using sites' variations in business practices and other encouragements to receive different types of CIH therapies as a surrogate for direct randomization by using instrumental variable econometrics methods.

SUMMARY

Real-world evidence about the value of combining self-care and practitioner-delivered CIH therapies from this pragmatic trial will help guide the VA and other health care systems in offering specific nonpharmacological approaches to manage patients' chronic pain.

Increasing Access to Medications for Opioid Use Disorder and Complementary and Integrative Health Services in Primary Care

OBJECTIVES

Evidence-based therapies for opioid use disorder (OUD) and chronic pain, such as medications for OUD (MOUD) and complementary and integrative health (CIH; e.g., acupuncture and meditation) therapies, exist. However, their adoption has been slow, particularly in primary care, due to numerous implementation challenges. We sought to expand the use of MOUD and CIH within primary care by using an evidence-based quality improvement (EBQI) implementation strategy.

METHODS

We used EBQI to engage two facilities in the Veterans Health Administration (VHA) from June 2018 to September 2019. EBQI included multilevel stakeholder engagement, with external facilitators providing technical support, practice facilitation, and routine data feedback. We established a quality improvement (QI) team at each facility with diverse stakeholders (e.g., primary care, addiction, pain, nursing, pharmacy). We met monthly with regional stakeholders to address implementation barriers. We also convened an advisory board to ensure alignment with national priorities.

RESULTS

Pre-implementation interviews indicated facility-level and provider-level barriers to prescribing buprenorphine, including strong primary care provider resistance. Both facilities developed action plans. They both conducted educational meetings (e.g., Grand Rounds, MOUD waiver trainings). Facility A also offered clinical preceptorships for newly trained primary care prescribers. Facility B used mass media and mailings to educate patients about MOUD and CIH options and dashboards to identify potential candidates for MOUD. After 15 months, both facilities increased their OUD treatment rates to the ≥ 90th percentile of VHA medical centers nationally. Exit interviews indicated an attitudinal shift in MOUD delivery in primary care. Stakeholders valued the EBQI process, particularly cross-site collaboration.

IMPLICATIONS

Despite initial implementation barriers, we effectively engaged stakeholders using EBQI strategies. Local QI teams used an assortment of QI interventions and developed tools to catapult their facilities to among the highest performers in VHA OUD treatment.

IMPACTS

EBQI is an effective strategy to partner with stakeholders to implement MOUD and CIH therapies.

Is yoga considered exercise within systematic reviews of exercise interventions? A scoping review

OBJECTIVE

Yoga is an increasingly popular choice of exercise for the Western population, with people engaging in yoga for a range of physical and mental health and well-being reasons. The aim of this scoping review is to examine whether yoga is considered an exercise modality within relevant leading journals, as evidenced by its consideration in systematic reviews (SRs) of exercise interventions for health-related outcomes.

METHODS

Design: Scoping review.

DATA SOURCES

Three leading sources (Sports Medicine, British Journal of Sports Medicine and Cochrane Collaboration) were searched. Eligibility criteria for selecting studies: The ten most recently published systematic reviews of exercise interventions for health-related outcomes from each journal were included (N = 30) that met these criteria: systematic review studying humans participating in general exercise and measuring a health-related outcome. Exercise interventions with any specific qualifying terms (e.g. aquatic, strength, aerobic) were excluded.

RESULTS

The articles retrieved were published between 2007 and 2019, and collectively included 991 interventions. Seven reviews explicitly stated that yoga was to be included/excluded while twenty-three studies made no mention of how yoga was being considered in the methodology. Five studies included yoga in the search strategy, implying its inclusion. Post-hoc analyses found that the definitions of exercise in general were also variable. Exercise definition specificity was not associated with whether or not yoga was assessed for inclusion.

CONCLUSIONS

Systematic reviews of exercise and physical activity interventions for health-related outcomes do not consistently make clear whether or not they include or exclude yoga as a form of exercise.

The APPROACH trial: Assessing pain, patient-reported outcomes, and complementary and integrative health

Electronic health record data can be used in multiple ways to facilitate real-world pragmatic studies. Electronic health record data can provide detailed information about utilization of treatment options to help identify appropriate comparison groups, access historical clinical characteristics of participants, and facilitate measuring longitudinal outcomes for the treatments being studied. An additional novel use of electronic health record data is to assess and understand referral pathways and other business practices that encourage or discourage patients from using different types of care. We describe an ongoing study utilizing access to real-time electronic health record data about changing patterns of complementary and integrative health services to demonstrate how electronic health record data can provide the foundation for a pragmatic study when randomization is not feasible. Conducting explanatory trials of the value of emerging therapies within a healthcare system poses ethical and pragmatic challenges, such as withholding access to specific services that are becoming widely available to patients. We describe how prospective examination of real-time electronic health record data can be used to construct and understand business practices as potential surrogates for direct randomization through an instrumental variables analytic approach. In this context, an example of a business practice is the internal hiring of acupuncturists who also provide yoga or Tai Chi classes and can offer these classes without additional cost compared to community acupuncturists. Here, the business practice of hiring internal acupuncturists is likely to encourage much higher rates of combined complementary and integrative health use compared to community referrals. We highlight the tradeoff in efficiency of this pragmatic approach and describe use of simulations to estimate the potential sample sizes needed for a variety of instrument strengths. While real-time monitoring of business practices from electronic health records provides insights into the validity of key independence assumptions associated with the instrumental variable approaches, we note that there may be some residual confounding by indication or selection bias and describe how alternative sources of electronic health record data can be used to assess the robustness of instrumental variable assumptions to address these challenges. Finally, we also highlight that while some clinical outcomes can be obtained directly from the electronic health record, such as longitudinal opioid utilization and pain intensity levels for the study of the value of complementary and integrative health, it is often critical to supplement clinical electronic health record-based measures with patient-reported outcomes. The experience of this example in evaluating complementary and integrative health demonstrates the use of electronic health record data in several novel ways that may be of use for designing future pragmatic trials.

An Innovative Electronic Health Toolkit (Our Whole Lives for Chronic Pain) to Reduce Chronic Pain in Patients With Health Disparities: Open Clinical Trial

Background

Chronic pain affects millions of Americans. Our Whole Lives, an electronic health (eHealth) toolkit for Chronic Pain (Our Whole Lives for Chronic Pain [OWLCP]), is a mind-body chronic pain management platform that teaches self-management strategies to reduce pain impact and pain medication use.

Objective

The primary goal of this study was to evaluate the feasibility of OWLCP in reducing pain impact and pain-related outcomes.

Methods

We conducted a pre-post clinical study (2 cohorts) to assess the feasibility of OWLCP usage among low-income patients with chronic pain. Outcome data, collected at baseline and 9 weeks, included Patient-Reported Outcomes Measurement Information System (PROMIS-29), pain self-efficacy, and pain medication use. In the statistical analysis, we used descriptive statistics, logistic regression, linear regression, and qualitative methods.

Results

Among the enrolled 43 participants, the average age was 50 years, (39/43) 91% were female, (16/43) 37% were black, and (7/43) 16% were Hispanic. From baseline to follow-up, the PROMIS measures showed a reduction in depression (P=.02), pain interference (P=.003), and average pain impact score (P=.007). Pain self-efficacy increased ((P<.001), whereas opioid use had a 13% reduction (P=.03).

Conclusions

The eHealth chronic pain management platform, OWLCP, is a potential tool to reduce the impact of chronic pain for low-income racially diverse populations.

Physical and Physiological Effects of Yoga for an Underserved Population with Chronic Low Back Pain

Background

Yoga has been shown useful in reducing chronic low back pain (CLBP) through largely unknown mechanisms. The aim of this pilot study is to investigate the feasibility of providing yoga intervention to a predominantly underserved population and explore the potential mechanisms underlying yoga intervention in improving CLBP pain.

Methods

The quasi-experimental within-subject wait-listed crossover design targeted the recruitment of low-income participants who received twice-weekly group yoga for 12 weeks, following 6-12 weeks of no intervention. Outcome measures were taken at baseline, preintervention (6-12 weeks following baseline), and then postintervention. Outcome measures included pain, disability, core strength, flexibility, and plasma tumor necrosis factor (TNF)-α protein levels. Outcomes measures were analyzed by one-way ANOVA and paired one-tailed t-tests.

Results

Eight patients completed the intervention. Significant improvements in pain scores measured over time were supported by the significant improvement in pre- and post-yoga session pain scores. Significant improvements were also seen in the Oswestry Disability Questionnaire scores, spinal and hip flexor flexibility, and strength of core muscles following yoga. Six participants saw a 28.6%-100% reduction of TNF-α plasma protein levels after yoga, while one showed an 82.4% increase. Two participants had no detectable levels to begin with. Brain imaging analysis shows interesting increases in N-acetylaspartate in the dorsolateral prefrontal cortex and thalamus.

Conclusion

Yoga appears effective in reducing pain and disability in a low-income CLBP population and in part works by increasing flexibility and core strength. Changes in TNF-α protein levels should be further investigated for its influence on pain pathways.

Complementary and Integrated Health Approaches: What Do Veterans Use and Want

OBJECTIVES

Non-pharmacological treatment options for common conditions such as chronic pain, anxiety, and depression are being given increased consideration in healthcare, especially given the recent emphasis to address the opioid crisis. One set of non-pharmacological treatment options are evidence-based complementary and integrative health (CIH) approaches, such as yoga, acupuncture, and meditation. The Veterans Health Administration (VHA), the nation's largest healthcare system, has been at the forefront of implementing CIH approaches, given their patients' high prevalence of pain, anxiety, and depression. We aimed to conduct the first national survey of veterans' interest in and use of CIH approaches.

METHODS

Using a large national convenience sample of veterans who regularly use the VHA, we conducted the first national survey of veterans' interest in, frequency of and reasons for use of, and satisfaction with 26 CIH approaches (n = 3346, 37% response rate) in July 2017.

RESULTS

In the past year, 52% used any CIH approach, with 44% using massage therapy, 37% using chiropractic, 34% using mindfulness, 24% using other meditation, and 25% using yoga. For nine CIH approaches, pain and stress reduction/relaxation were the two most frequent reasons veterans gave for using them. Overall, 84% said they were interested in trying/learning more about at least one CIH approach, with about half being interested in six individual CIH approaches (e.g., massage therapy, chiropractic, acupuncture, acupressure, reflexology, and progressive relaxation). Veterans appeared to be much more likely to use each CIH approach outside the VHA vs. within the VHA.

CONCLUSIONS

Veterans report relatively high past-year use of CIH approaches and many more report interest in CIH approaches. To address this gap between patients' level of interest in and use of CIH approaches, primary care providers might want to discuss evidence-based CIH options to their patients for relevant health conditions, given most CIH approaches are safe.

Synthesizing the Strength of the Evidence of Complementary and Integrative Health Therapies for Pain

Objective

Pain and opioid use are highly prevalent, leading for calls to include nonpharmacological options in pain management, including complementary and integrative health (CIH) therapies. More than 2,000 randomized controlled trials (RCTs) and many systematic reviews have been conducted on CIH therapies, making it difficult to easily understand what type of CIH therapy might be effective for what type of pain. Here we synthesize the strength of the evidence for four types of CIH therapies on pain: acupuncture, therapeutic massage, mindfulness techniques, and tai chi.

Design

We conducted searches of English-language systematic reviews and RCTs in 11 electronic databases and previously published reviews for each type of CIH. To synthesize that large body of literature, we then created an “evidence map,” or a visual display, of the literature size and broad estimates of effectiveness for pain.

Results

Many systematic reviews met our inclusion criteria: acupuncture (86), massage (38), mindfulness techniques (11), and tai chi (21). The evidence for acupuncture was strongest, and largest for headache and chronic pain. Mindfulness, massage, and tai chi have statistically significant positive effects on some types of pain. However, firm conclusions cannot be drawn for many types of pain due to methodological limitations or lack of RCTs.

Conclusions

There is sufficient strength of evidence for acupuncture for various types of pain. Individual studies indicate that tai chi, mindfulness, and massage may be promising for multiple types of chronic pain. Additional sufficiently powered RCTs are warranted to indicate tai chi, mindfulness, and massage for other types of pain.

Resilient to Pain: A Model of How Yoga May Decrease Interference Among People Experiencing Chronic Pain

Chronic musculoskeletal pain is the leading cause of disability globally, yet for the majority of people who experience chronic pain, it does not seriously disable them or interfere with their life. People who experience severe pain yet low disability display a resilient course of pain. Yoga has been shown to decrease disability among people with pain, but it is not known how. Because even the most basic yoga practices possess many of the components thought to be important in fostering resilience, yoga is a promising means of improving resilience and clinical outcomes for people with chronic pain. A validated conceptual model of how the experience of chronic pain is affected by yoga is needed to guide a future research agenda and identify potential targets for chronic pain intervention. Ultimately, an explanatory model could guide the optimization of yoga and other non-pharmacological therapies for the treatment of chronic pain. I present a testable model.

What Should Health Care Systems Consider When Implementing Complementary and Integrative Health: Lessons from Veterans Health Administration

OBJECTIVES

Health care systems are increasingly interested in becoming whole health systems that include complementary and integrative health (CIH) approaches. The nation's largest health care system, the Veterans Health Administration (VA), has been transforming to such a system. However, anecdotal evidence suggested that many VA medical centers have faced challenges in implementing CIH approaches, whereas others have flourished. We report on a large-scale, research-operations partnered effort to understand the challenges faced by VA sites and the strategies used to address these to better support VAs implementation of CIH nationally.

DESIGN

We conducted semi-structured, in-person qualitative interviews with 149 key stakeholders at 8 VA medical centers, with content based on Greenhalgh's implementation framework. For analysis, we identified a priori categories of content aligned with Greenhalgh's framework and then generated additional categories developed inductively, capturing additional implementation experiences. These categories formed a template to aid in coding data.

RESULTS

VA sites commonly reported that nine key factors facilitated CIH implementation: (1) organizing individual CIH approaches into one program instead of spreading across several departments; (2) having CIH strategic plans and steering committees; (3) strong, professional, and enthusiastic CIH program leads and practitioners; (4) leadership support; (5) providers' positive attitudes toward CIH; (6) perceptions of patients' attitudes; (7) demonstrating evidence of CIH effectiveness; (8) champions; and (9) effectively marketing. Common challenges included are: (1) difficulties in hiring; (2) insufficient/inconsistent CIH funding; (3) appropriate patient access to CIH approaches; (4) difficulties in coding/documenting CIH use; (5) insufficient/inappropriate space; (6) insufficient staff's and provider's time; and (7) the health care cultural and geographic environments. Sites also reported several successful strategies supporting CIH implementation.

CONCLUSIONS

VA sites experience both success and challenges with implementing CIH approaches and have developed a wide range of strategies to support their implementation efforts. This information is potentially useful to other health care organizations considering how best to support CIH provision.

How does yoga reduce stress? Embodied cognition and emotion highlight the influence of the musculoskeletal system

Yoga is an increasingly popular activity, perhaps because of its association with stress reduction and relaxation - an association that is generally supported by empirical evidence. Understanding of the mediating variables is, however, limited. Given that, the purpose of this paper is to present a theoretical perspective that encourages systematic research regarding the relationship between yoga, stress, and musculoskeletal activity. This embodied perspective parallels popular interest in the mind-body connection and emphasizes the influence of body position on thinking as well as emotion. Those influences take on added meaning in the context of the Cognitive Appraisal Theory and the Biopsychosocial Model of Challenge and Threat. Investigations of embodied cognition suggest that yoga may reduce stress by affecting the way individuals appraise stressors. The combination of body position and common components of yoga practice may also contribute to that effect, particularly when considering thoughts about the self and feelings of confidence. Findings regarding embodied emotion make a similar contribution to understanding the implications of previous research findings and common yoga practices. Considering yoga and stress from an embodied perspective also highlights the role of the musculoskeletal system in the stress process, leading to the question of whether yoga influences stress by directly influencing the musculoskeletal system, indirectly by influencing awareness of that system, or through a combination of the two. Those questions, in turn, highlight the importance of expanding investigations of psychological processes, body position, musculoskeletal activity during yoga, and the interactions between those variables.

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

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

Implementing Yoga Into the Management of Patients With Refractory Low Back Pain in an Outpatient Clinic Setting

Purpose: To evaluate the effectiveness of implementing yoga into the treatment of patients with chronic low back pain. Design: Quantitative analysis with opportunity for qualitative feedback. Method: Effectiveness of this complementary treatment was assessed using a pretest/posttest design of patients who volunteered to participate in yoga classes as part of their back pain management. Measurements included low back pain rating, perception of back pain interference with daily activities, and self-efficacy in dealing with chronic low back pain. Findings: Although no statistically significant findings were found due to the small sample size, most participants demonstrated improved individual scores on all measurement surveys including qualitative comments. Conclusion: Based on the findings of this pilot study, further studies on implementing yoga into the treatment of chronic low back pain are encouraged.

Trunk and hip muscle activation during yoga poses: Do sex-differences exist?

OBJECTIVE

To compare core activation during yoga between males and females.

METHODS

Surface electromyography was used to quantify rectus abdominis (RA), abdominal obliques (AO), lumbar extensors (LE), and gluteus maximus (GMX) activation during four yoga poses. Data were expressed as 100% of a maximum voluntary isometric contraction. Mixed-model 2 × 2 analyses of variance with repeated measures were used to determine between-sex differences in muscle activity.

RESULTS

Females generated greater RA activity than males during the High Plank (P < 0.0001) and Dominant-Side Warrior 1 (P = 0.017). They generated greater AO (P < 0.0001) and GMX (P = 0.004) activity during the High Plank (P < 0.0001). No between-sex EMG activity differences existed for the Chair and Upward Facing Dog.

CONCLUSION

Findings have provided preliminary evidence for between-sex differences in muscle activation during yoga poses. Clinicians should consider such differences when prescribing yoga to improve muscle strength and endurance.

Yoga for Military Veterans with Chronic Low Back Pain: A Randomized Clinical Trial

INTRODUCTION

Chronic low back pain (cLBP) is prevalent, especially among military veterans. Many cLBP treatment options have limited benefits and are accompanied by side effects. Major efforts to reduce opioid use and embrace nonpharmacological pain treatments have resulted. Research with community cLBP patients indicates that yoga can improve health outcomes and has few side effects. The benefits of yoga among military veterans were examined.

DESIGN

Participants were randomized to either yoga or delayed yoga treatment in 2013-2015. Outcomes were assessed at baseline, 6 weeks, 12 weeks, and 6 months. Intention-to-treat analyses occurred in 2016.

SETTING/PARTICIPANTS

One hundred and fifty military veterans with cLBP were recruited from a major Veterans Affairs Medical Center in California.

INTERVENTION

Yoga classes (with home practice) were led by a certified instructor twice weekly for 12 weeks, and consisted primarily of physical postures, movement, and breathing techniques.

MAIN OUTCOME MEASURES

The primary outcome was Roland-Morris Disability Questionnaire scores after 12 weeks. Pain intensity was identified as an important secondary outcome.

RESULTS

Participant characteristics were mean age 53 years, 26% were female, 35% were unemployed or disabled, and mean back pain duration was 15 years. Improvements in Roland-Morris Disability Questionnaire scores did not differ between the two groups at 12 weeks, but yoga participants had greater reductions in Roland-Morris Disability Questionnaire scores than delayed treatment participants at 6 months -2.48 (95% CI= -4.08, -0.87). Yoga participants improved more on pain intensity at 12 weeks and at 6 months. Opioid medication use declined among all participants, but group differences were not found.

CONCLUSIONS

Yoga improved health outcomes among veterans despite evidence they had fewer resources, worse health, and more challenges attending yoga sessions than community samples studied previously. The magnitude of pain intensity decline was small, but occurred in the context of reduced opioid use. The findings support wider implementation of yoga programs for veterans.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT02524158.

Trunk and hip muscle activation during yoga poses: Implications for physical therapy practice

OBJECTIVE

To determine and compare activation of core muscles during yoga to traditional back exercises.

METHODS

Surface electromyography was used to quantify activation of the rectus abdominis (RA), abdominal obliques (AO), lumbar extensors (LE), and gluteus maximus (GMX) during four yoga poses. Data were expressed as 100% of a maximum voluntary isometric contraction. Separate analyses of variance with repeated measures were used to compare muscle activity across each exercise.

RESULTS

Subjects generated greater RA (P < 0.0001) and AO (P < 0.0001) activity during the Plank. They generated greater AO activity (P < 0.0001) during the Upward-Facing Dog than the Chair and Dominant-Side Warrior 1. LE activity was greatest (P < 0.0001) during the Chair. GMX activity was similar (P = 0.09) during all exercises.

CONCLUSION

Yoga poses may help improve core endurance and strength. Clinicians may use these data when developing and implementing an evidence-based core exercise program for individuals who prefer a yoga treatment strategy.

What Patients and Providers Want to Know About Complementary and Integrative Health Therapies

OBJECTIVES

We conducted a quality improvement project to determine (1) what information providers and patients most wanted to learn about complementary and integrative health (CIH) therapies and (2) in what format they wanted to receive this information. The overall aim was to develop educational materials to facilitate the CIH therapy decision-making processes.

DESIGN

We used mixed methods to iteratively pilot test and revise provider and patient educational materials on yoga and meditation. We conducted semistructured interviews with 11 medical providers and held seven focus groups and used feedback forms with 52 outpatients. We iteratively developed and tested three versions of both provider and patient materials. Activities were conducted at four Veterans Administration medical facilities (two large medical centers and two outpatient clinics).

RESULTS

Patients want educational materials with clearly stated basic information about: (1) what mindfulness and yoga are, (2) what a yoga/meditation class entails and how classes can be modified to suit different abilities, (3) key benefits to health and wellness, and (4) how to find classes at the hospital/clinic. Diverse media (videos, handouts, pocket guides) appealed to different Veterans. Videos should depict patients speaking to patients and demonstrating the CIH therapy. Written materials should be one to three pages with colors, and images and messages targeting a variety of patients. Providers wanted a concise (one-page) sheet in black and white font with no images listing the scientific evidence for CIH therapies from high-impact journals, organized by either type of CIH or health condition to use during patient encounters, and including practical information about how to refer patients.

CONCLUSIONS

Providers and patients want to learn more about CIH therapies, but want the information in succinct, targeted formats. The information learned and materials developed in this study can be used by others to educate patients and providers on CIH therapies.