|Year : 2020 | Volume
| Issue : 1 | Page : 1-4
Positioning yoga in the COVID-19 pandemic
Director, Patanjali Research Foundation, Haridwar, Uttarahand, India
|Date of Submission||03-May-2020|
|Date of Acceptance||07-May-2020|
|Date of Web Publication||11-Jun-2020|
Director, Patanjali Research Foundation, Haridwar, Uttarahand
|How to cite this article:|
Telles S. Positioning yoga in the COVID-19 pandemic. Yoga Mimamsa 2020;52:1-4
The Government of India as well as various yoga organizations worldwide have recommended yoga and yoga-based lifestyle suggestions to help persons remain mentally healthy, as well as promote optimal immune functions during the current pandemic (Ministry of AYUSH, 2020). To contain the COVID-19 pandemic and resume activity, there will be new norms, such as social distancing, increased numbers of persons working from home, and other obvious reminders of the pandemic (e.g., wearing masks in public). In order to reduce the negative impact this could have, there is an increasing role for yoga in public health.
The COVID-19 pandemic has impacted everyone's life. The range of impact differs according to whether a person is (i) healthy and in lockdown, (ii) COVID-19 positive yet asymptomatic and in mandatory quarantine, (iii) COVID-19 positive with mild symptoms in quarantine and surveillance, and (iv) COVID-19 positive with moderate-to-severe symptoms being treated in a designated hospital. Along this spectrum, persons would face varying degrees of social isolation. Symptomatic patients have been reported to experience the symptoms of respiratory distress and if the condition worsens, to develop respiratory distress which would be a cause for concern (WebMD, 2020). These symptoms are further heightened by the unusual situation which could seem threatening, namely, health-care providers in hazardous material (HAZMAT) suits, the stress associated with sounds associated with an intensive care unit (Dias, Resende, & Diniz, 2015), knowledge of fatal outcomes, and social isolation as an additional factor.
Psychological distress during quarantine (and indeed any form of isolation) has been reported in a review of 3166 studies (Brooks et al., 2020). All quantitative studies reported a high prevalence of symptoms of psychological disorder and distress. More specific details were collected during the severe acute respiratory syndrome (SARS) epidemic of 2003 (Pan, Chang, & Yu, 2005). At this time, people who were quarantined related to their contact with SARS cases, reported fear (20%), nervousness (18%), sadness (18%), and in the case of 10% of cases, there were reports of guilt (Reynolds et al., 2008). Qualitative studies identified other psychological consequences of being in quarantine, such as fear (DiGiovanni, Conley, Chiu, & Zaborski, 2004) and sleep disorders related to anxiety (Pan et al., 2005).
Commonly used anti-anxiety and hypnotic medications have a respiratory depressant effect (Garner, Eldridge, Wagner, & Dowell, 1989). For this reason, nonpharmacological interventions have been tried in people with anxiety or insomnia considered to be at risk of developing respiratory symptoms.
Recently, a randomized controlled trial assessed 51 asymptomatic COVID-19-positive cases in an isolation ward located in Hainan General Hospital, China, who were randomly assigned to progressive muscle relaxation as the experimental group and to a control group (Liu et al., 2020). Progressive muscle relaxation sessions were for ½ h a day for 5 consecutive days, whereas the control group received routine treatment alone. The average anxiety and sleep quality scores of the two groups were significantly different after the interventions.
Based on the benefits of practicing progressive muscle relaxation (above), yoga may be a potential psycho-social intervention to reduce anxiety and insomnia and positively impact immune responses in COVID-19 cases. A review evaluated yoga for anxiety disorders or elevated levels of anxiety (Cramer et al., 2018). Eight randomized controlled trials (RCTs) covering 319 participants showed that in individuals with elevated levels of anxiety, there was evidence for small short-term effects of yoga on elevated anxiety compared to no treatment (standardized mean difference [SMD] = −0.43; 95% confidence interval [CI] = −0.74, −0.11; p = 0.008) and for large effects compared to active comparators (SMD = −0.86; 95% CI = −1.56, −0.15; p = 0.02). Apart from these effects on reducing elevated anxiety levels, yoga practice helps correct sleep disorders, particularly insomnia. Electronic searches of the Cochrane Central Register of controlled trials and of standard bibliographic databases such as MEDLINE, EMBASE, and PsycINFO were performed until April 2011 (Balasubramaniam, Telles, & Doraiswamy, 2013). Based on three RCTs, there was considered to be adequate Grade C evidence to use yoga for sleep disorders (i.e., optional use based on the clinician's discretion and the patient's preference). This supports beliefs about the benefits of yoga for sleep disorders.
These findings are relevant in the management of COVID-19 because the field of affective immunology supports the cellular and molecular connections between the emotional and immunological systems (D'Acquisto, 2017). It is also recognized that sleep influences immunity, especially the production and release of cytokines (Besedovsky, Lange, & Born, 2012). Kiecolt-Glaser et al. (2010) demonstrated that when novices were compared to experts in yoga (i.e., those who practiced two sessions of 90 min of yoga for 12 weeks), the novices had 41% higher interleukin (IL)-6 levels than experts and were 4.75 times more likely to have detectable C-reactive protein levels (Kiecolt-Glaser et al., 2010). This trend of lower pro-inflammatory markers in experts of yoga continued to be evident in 200 breast cancer survivors, where the levels of IL-6, tumor necrosis factor-α, and IL-1β were 10%–15% lower in experts (Kiecolt-Glaser et al., 2014).
A retrospective multicentric cohort study reported significantly higher IL-6 levels in nonsurvivors of COVID-19 than those who survived (Zhou et al., 2020). Several other reports also confirmed higher levels of IL-6 in critically unwell patients with COVID-19 (Zhang et al., 2020). These findings support the benefits of yoga to reduce the harmful levels of chronic inflammation in COVID-19 cases.
The main difficulty faced in proposing yoga as an intervention is that the level of evidence does not meet the strict criteria required for complementary and alternative therapies to be adopted as clinical interventions (Weiger et al., 2002). The reasons for this include: (i) small sample sizes, (ii) variable or inconsistent results across different studies; (iii) research designs which lack attention to randomization, blinding, allocation; as well as (iv) reporting without sufficient details regarding withdrawals from the study and reporting of adverse events (Weiger et al., 2002). The other inadequacies are: (v) insufficient statistical power (possibly due to the small sample sizes), (vi) poor controls, (vii) inconsistency of descriptions of the yoga practices, and (viii) lack of comparisons with other treatments or with a placebo or with both.
Inconsistency of descriptions is related to the complexity of yoga, which includes physical postures (asanas), voluntarily regulated breathing (pranayamas), cleansing practices (kriyas), and meditation and philosophical principles (Nagarathna, & Nagendra, 2001). Clinical trials have included these practices as part of a lifestyle change intervention (Bijlani et al., 2005; Nagarathna & Nagendra, 2001) and have also tested the effects of individual practices (e.g., physical postures for anxiety) (Streeter et al., 2010). These differences in the techniques practiced, approaches to yoga by different schools of yoga, and nature (duration and intensity) of treatment, make it difficult to describe yoga therapy concisely, in a way which would be understood to mean the same method by all people, everywhere. In the absence of such standardization, research on yoga therapy requires detailed descriptions of the interventions.
Also, yoga therapy advocates individual diagnosis and treatment; emphasizing optimizing the body's innate capability to heal itself and a “whole systems” approach, wherein the physical, mental, and spiritual attributes of a patient are included (Nahin & Straus, 2001). The criteria for including and excluding persons in a RCT differ between conventional medicine and yoga therapy. For example, in a yoga therapy trial, having selected yoga as a therapy could be a criterion for exclusion, to reduce bias. If these exclusions are not observed, the value of the RCT would be lowered. Other difficulties encountered are in randomization, use of a placebo, and/or a comparable alternate intervention, as well as in masking and blinding. Randomizing persons to yoga as a therapy is limited by the fact that yoga therapy is often delivered in specialized residential settings, under the supervision of a trained yoga therapist (Telles, Sharma, Yadav, Singh, & Balkrishna, 2014). Often, the residential center is in quiet surroundings, which have their own healing effects (Kuo, 2015). If the comparison group receives conventional treatment in a hospital setting or in their homes, it is questionable whether the comparison between the two has any meaning, as administering yoga therapy in a quiet setting (Manjunath & Telles, 2004) with the attention of a yoga therapist could positively impact the way the person feels and hence influence the reported outcome (Kuo, 2015). Another problem encountered with yoga therapy is selecting a suitable placebo. Interaction between the yoga therapist and the participant could have a placebo effect (Roberts, Kewman, Mercier, & Hovell, 1993; Brody, 2000). The participant is actively involved in yoga therapy. A single study attempted to use a device to simulate yoga breathing, because breathing through the device altered the ratio of inhalation and exhalation to the 1:2 ratio, characteristic of yoga breathing (Singh, Wisniewski, Britton, & Tattersfield, 1990). A placebo device was used, which was identical to the active device but did not change respiration. However, practitioners of yoga may well question whether yoga breathing can be limited to a change in the inhalation-to-exhalation ratio alone. Most of these techniques require subtle mental changes as well (Taimni, 1999), hence attempting to find a placebo for yoga therapy may result in evaluating limited components of the intervention.
The difficulties mentioned above suggest the need for new methods to conduct research on yoga therapy. These future directions include (i) standardization; (ii) training of researchers in yoga therapy, to combine conventional research methods and those relevant to yoga therapy alone; (iii) financing research on yoga as a therapy with suitably modified guidelines to write and review research grant proposals; and (iv) planning and designing studies in yoga therapy, with attention to the required standards for efficacy and safety, but with the necessary modifications to include most aspects of yoga therapy.
(i) Standardization is perhaps the most difficult challenge in yoga therapy (Payyappallimana, 2010). There are differences across schools of yoga in the description of yoga interventions and in the way yoga therapists are trained. For example, some courses may emphasize the physical aspects of yoga therapy, whereas courses conducted elsewhere may emphasize mental and spiritual aspects. To make it possible for yoga therapy to be integrated into mainstream medical care, it is essential to attempt to standardize yoga therapy and courses involved in training those who deliver it. This would require having policies and specific nodal agencies to control and provide guidelines for this to be done uniformly.
(ii) Training of researchers in yoga therapy in research methods and those especially relevant to yoga therapy is an essential step to increasing the standards of research in yoga and yoga therapy. It is important to realize that many persons trained in using yoga have a deep and abiding belief in the system of healing. This fact and the fact that they may not be trained in a basic understanding about physiology and anatomy may make them less suitable to carry out unbiased research on yoga therapy. Hence, an important step is to select motivated yet unbiased persons who preferably have a basic knowledge of human anatomy and physiology. Many researchers in conventional medicine are trained to practice conventional medicine. Similarly, if motivated persons trained in yoga therapy are trained in research methods with the adaptations needed for yoga therapy (Bijlani, 2008), these trained persons would be ideal to conduct research on yoga.
(iii) Obtaining funds for research on yoga and yoga therapy is another essential step. Just as the National Center for Complementary and Integrative Health of the National Institutes of Health has allocated separate funds for research in traditional medicine, this is true for other countries as well. For example, the Department of AYUSH, Government of India, India, has separate funds allocated for research in Ayurveda, Yoga, Unani, Siddha, and Homeopathy (AYUSH) (Ministry of AYUSH, n.d.). However, the format for research proposals is often more suited to research in conventional medicine. Apart from this, the reviewers often have a distinguished career in conventional medicine with a partial or peripheral interest in traditional medicine. Hence, only those research projects which investigate yoga therapy using the standards and norms set for conventional medicine are considered worth financing. Many areas related to understanding the mechanisms underlying the benefits of yoga therapy may be considered “unscientific” or “dubious” by conventional researchers, as they involve concepts such as the subtle energy (prana in Indian medicine and chi in Chinese medicine). Nonetheless, these concepts are a part of yoga therapy and if they are disregarded as scientifically unacceptable, the risk is that yoga therapy would not be understood in its entirety. Hence, an effort should be made to review all research grant proposals on yoga therapy by a panel comprising of experts in research on conventional medicine, researchers in yoga therapy, and persons with an in-depth knowledge of yoga therapy who are not biased in their approach to investigating yoga therapy.
(iv) Planning and designing a research study on yoga therapy is challenging and requires a modified approach. When planning efficacy trials, it is necessary to accept that randomization and finding the proper controls are difficulties peculiar to yoga therapy and not found in efficacy trials in conventional pharmacotherapy. Hence, instead of randomization and attempting to have placebo-controlled trials, research on yoga therapy has to take into account various issues. For example, (i) if a patient who selects yoga therapy with a belief in the treatment, this could have its own placebo effect; (ii) the complexity of the interventions in yoga therapy often does not allow for a placebo; and (iii) there is a basic difficulty of comparing a whole lifestyle change with the approach of evaluating specific prescribed medicines in conventional medicine. Probably, the only way forward in the efficacy trials of yoga therapy as a lifestyle intervention, is to adopt a “all-systems approach” where the entire set of practices which make up a yoga therapy module are compared with the conventional treatment, without any attempt to consider different aspects of the treatment, separately. Separate trials can be designed to evaluate individual practices. Research on the mechanisms underlying the effects of yoga also requires a shift in the way of thinking so as to include complex concepts not used in conventional medicine such as “subtle energy” and “psychological and even spiritual benefits.”
The ultimate goal would be to arrive at standardized systems of yoga therapy which can be integrated into mainstream health care, after having sufficient research-based information about their efficacy, safety, and mechanisms of action. With such research, yoga would receive the position it deserves as a prophylactic intervention, and much more, as a therapeutic intervention for COVID-19.
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