Published in JHH17.2 – Mind-body self-care

…it has been challenging to draw a hard line between what constitutes yoga and what is yoga therapy Click To Tweet

Yoga is an ancient multi-tiered mind– body practice that includes specific techniques for cognitive, behavioural, breath, physical and mental transformation, which collectively give rise to systemic change for the individual. Although not originally crafted as a health intervention its various elements, known as the eightlimbs of yoga’, make yoga a seamless fit for the task.

References to the therapeutic practices of yoga date back as far as the hatha yoga literature from the 13th to 15th centuries including in the influential text Hatha Yoga Pradipika which claims that the practice of asana – the physical postures – leads to steadiness, health and lightness of body’ (Akers, 2002). The subsequent history of yoga as therapy is nebulous but its current iteration seems to have its origin in the work of Swami Kuvalayananda and Shri Yogendra in India during the 1920s. Kuvalayananda established the research centre Kaivalyadhama and its house journal Mimamsa, both still active today, which pioneered yoga research
investigating the physiological effects of practices, and invited esteemed international scientists to examine yoga’s discrete and combined effects. Many see their work as the necessary foundation for yoga as a treatment for health conditions, a discipline that would later become known as yoga therapy.

The idea of yoga as a practice with benefits for health and wellbeing, with its efficacy verifiable by science, was then propagated in the West by a number of influential Indian teachers including former medical doctor Swami Sivananda, TKV Desikachar, founder of Viniyoga, an individualised form of yoga therapy, and BKS Iyengar, whose experience of ill health in early life led him to experiment with the practices of yoga to manage his conditions. While it could not be described as yoga therapy, Iyengar developed a form of ‘remedial yoga’ in which he worked one-to-one with individuals to prescribe specific practices, particularly the physical poses of the yoga tradition. His highly influential book Light on Yoga published in 1966 outlines more than 200 of these postures, attributing claims of specific health benefits and possible contraindications to many (Newcombe, 2019).

In the US, many note the yoga-based Ornish programme as the pivotal point in the establishment of yoga therapy (Kulkarni, 2020). In 1998 Ornish published
his iconic study Intensive Lifestyle Changes for the Reversal of Coronary Heart Disease. The notion that lifestyle could actually reverse heart disease was groundbreaking and the research, which effectively transformed the field of mind–body medicine, also became a benchmark moment for the emerging field of yoga therapy.

Yoga therapy in the UK

In the UK, Patel’s lesser known 1975 trial on yoga’s ability to reduce hypertension (Patel, 1975) was an early catalyst for the work of a number of individuals and organisations who became champions for the emerging field of yoga therapy in the UK. These included the Yoga for Health Foundation, established by Howard Kent in 1976, whose group programmes ran for many years at a manor house in Ickwell Bury in Bedfordshire, focusing initially mainly on those suffering from ME. In 1982 Paul Harvey, a student of TKV Desikachar, founded the Centre for Yoga Studies, which advanced Desikachar’s individualised approach to working one-to-one, while in 1983 Dr Robin Monro founded the Yoga Biomedical Trust (YBT). Monro is often revered as the father of yoga therapy in the UK having left
a successful career in molecular biology to dedicate his life to the promotion and advancement of the therapeutic benefits of yoga to all sectors of the population. Inspired by the research into yoga practices he saw happening in India in the early 1980s, Monro set about applying for funding to undertake yoga research trials in the UK, at first with limited success. In 1987, the YBT developed a yoga therapy training course initially in partnership with the Bangalore-based institution Vivekananda Kendra, which sought to offer yoga teachers the equivalent of a nurselevel knowledge of anatomy and physiology, alongside an
understanding of how yoga was being applied therapeutically for a range of conditions.

The field of yoga therapy continued to professionalize in this period with the establishment by Larry Payne and Richard Miller in 1989 of the International Association of Yoga Therapists (IAYT), a professional body which now numbers more than 5,000 individual members and 170 accredited schools worldwide. The UK has its own unique body in the form of the British Council of Yoga Therapy (BCYT) established in 2002. Due to the lobbying and advocacy of this organisation, yoga therapy is now recognised as a career in the UK on the .gov website.

A definition of yoga therapy

While many emerging definitions attempt to capture this budding field, we feel that this one, by TKV Desikachar, best encapsulates its breadth:

A self-empowering process, where the careseeker, with the help of the yoga therapist, implements a personalized and evolving yoga practice, that not only addresses the illness in a multi-dimensional manner, but also aims to alleviate his/her suffering in a progressive, non-invasive and complementary manner. Depending on the nature of the illness, yoga therapy can not only be preventative or curative, but also serve as a means to manage the illness, or facilitate healing in the person at all levels.

Although thought leaders in the field continue to tease out distinctions, in practice it has been challenging to draw a hard line between what constitutes yoga and what is yoga therapy. Both can be delivered either in group sessions or one-on-one, the difference being that a yoga therapist will undertake a detailed client assessment before embarking on the practice, and an individualised treatment plan will be drawn up that is modified periodically according to the response to treatment. The training of a yoga therapist is far more in-depth than that of a yoga teacher. The therapist has to be familiar with a range of physical and mental health conditions, be able to read and understand a medical diagnosis, and have the knowledge of what yoga practices to prescribe, relevant to that diagnosis. The yoga therapist seeks to empower a person – over time – to take an active and engaged role in managing their own health, to improve their health outcomes, enable better patient care, and reduce costs (Berwick et al, 2008).

However, if someone is using yoga as part of their treatment for a health condition, it could arguably be deemed yoga therapy. So if we adopt this more flexible
definition, then the field is truly flourishing, because in recent years yoga’s popularity has increased exponentially: according to the International Yoga Federation, 300 million people are now practising worldwide. Many take up the practice to enhance their general wellbeing and to improve flexibility, but a significant number do so to help manage or improve a specific physical or mental health condition. Clearly, the idea that yoga practice confers benefits to overall health and wellbeing is firmly established in the public psyche.

Yoga therapy in the mainstream?

Yet yoga and yoga therapy is by no means mainstream in conventional healthcare, and if we accept the stricter definition of yoga therapy, its use in healthcare settings is by no means burgeoning to the same degree. However, certain segments of the medical and psychological community see it as potentially complementing the conventional treatment of some non-communicable diseases. The NHS Choices website for instance mentions it in high blood pressure and heart disease, for relieving aches and pains, managing lower back pain and alleviating the symptoms of depression and stress. Public Health England recommends yoga as a bone strengthening exercise.

India, the home of yoga, established The Ministry of AYUSH (ayurveda, yoga, unani, siddha and homeopathy) in 2014, which has delivered, among other initiatives, a major study on the effectiveness of a programme into the effects of yoga (alongside ayurvedic treatments) on diabetes, which is a massive health issue in the country, affecting around 422 million people. In Sweden, MediYoga, developed by Göran Boll, is firmly established within the country’s healthcare system. From the first scientific research study in 1998, in partnership with Stockholm’s Karolinska Institute, one of the world’s most prestigious medical universities, MediYoga rolled out its training programme for healthcare workers across the country, with 1,700 instructors graduating over the next three years. Today more than 150 hospitals, primary care and specialist clinics use practices from the MediYoga programme. Studies have shown significant reductions in
levels of stress and anxiety, improved sleep patterns and reductions in back pain as well as lowering blood pressure and heart rate.

The aforementioned Ornish programme is probably the best researched and most pervasive yoga therapy intervention in the world. The evidence base for this programme is so convincing that it is still the only lifestyle programme covered by Medicare in the United States. Australia has taken a particularly forward-thinking approach to yoga, and many private health insurance companies cover the regular costs of yoga (alongside other complementary medicines), and some offer a special ‘yoga discount’ for clients who can show they regularly attend classes.

TheYoga4Health programme

The Yoga in Healthcare Alliance (YIHA) formed in 2017 to promote the benefits of yoga and work in collaboration with the NHS to develop a model that could be applied to healthcare systems around the world. YIHA was commissioned to develop a 10-week programme of gentle yoga for the West London Clinical Commissioning Group, to lower stress levels and improve relaxation skills, to enhance mental wellbeing, and support people with pre-diabetes or those at risk of heart disease. Though
technically not framed as yoga therapy, as a therapeutic intervention using yoga the programme bridges the two worlds of yoga and medicine.

Since then, more than 250 yoga teachers have been trained to deliver the Yoga4Health programme, which is being evaluated by the University of Westminster and will be aiming to roll out in healthcare settings across the UK. In one recent study of 45 participants who completed the 10-week programme with teacher Jo Burningham in January 2020, 100% reported an improvement in their physical and mental health, with 80% saying their sleep had improved and 90% reporting a reduction in stress, including greater acceptance of longstanding medical conditions. 72% said they were exercising more and 80% had made positive changes to their lifestyle.

Participants on the programme have said:

My life has been transformed already…I feel so much better in all respects, mood, sleep, mobility, patience.’ My mood has improved. My anxiety is better than it used to be…I’m having more tolerance now. It has been a change in everything. I’ve lost weight. I’ve learned to control my stress levels – at work, at home and at play. I can control my body now whereas I used to get a lot of muscle tension… The relaxation is also fantastic. It’s like I’ve had a full eight hours’ sleep.

Presumably one of the primary reasons that yoga therapy is increasingly finding its way into public healthcare systems is that many of the values and ethos, as well as the underlying structure, are aligned. The models of physical, psychological, and spiritual wellbeing from the yoga tradition chime with, and may even enhance, paradigms of modern biopsychosocial healthcare, and the NHS constitution whose opening lines say the NHS:

…is there to improve our health and wellbeing, supporting us to keep mentally and physically well, to get better when we are ill and, when we cannot fully recover, to stay as well as we can to the end of our lives…

The kosha system is a model of the individual widely used in contemporary schools of yoga therapy as an assessment and diagnostic tool. It distinguishes different aspects (sheathes) of the whole person, which are interconnected and interdependent on each other. To achieve a state of wellbeing, each aspect must be in balance. As in the biopsychosocial model, a person’s presenting condition is believed to arise from a confluence of different factors, and the therapeutic plan aims to impact positively on all these areas of wellbeing. This might include yoga postures to reduce muscular tension, build strength and enhance
flexibility alongside breath practices which help to calm the nervous system, thereby managing stress. Meditation and mindfulness techniques can help stabilise a ruminating mind and – over time – help someone manage challenging thoughts and emotions and so potentially shift ingrained patterns of negative thinking. Recommendations of habits to promote a healthier lifestyle and sleep stewardship suggestions might also be included, as well as exploring ways in which individuals can foster a greater sense of connection, whether to other people or to nature, in order to inspire a sense of greater meaning and purpose.

The evidence for yoga and yoga therapy

Significant research now corroborates the health benefits of yoga practices for non-communicable diseases. Although earlier research has been plagued by bias, poor study design, and small sample sizes, the field of yoga research is becoming more rigorous and accordingly the findings more meaningful. Arguably, the strongest evidence is for yoga’s efficacy in treating depression and mental health conditions in general (Balasubramanian, 2013; Field, 2016). Clinical trials report improvements in perceived stress, mood, emotion regulation, social cognition, social connectedness, sleep quality, and interoception (the sense of the internal state of the body) and the related value in anxiety disorders, PTSD, substance abuse disorders, eating disorders, sleep disorders, and schizophrenia (Bhargav et al, 2020; Berman et al, 2020). Given that improvement in mental health will generally have a positive impact on physical health, such changes in
psychological parameters tend to confer benefits on a host of other health conditions – Parkinson’s disease, dementia, HIV, chronic pain, and COPD to name just a few. Research also suggests the therapeutic application of yoga has potential in management of cardiovascular conditions, lower back pain, type 2 diabetes, asthma, traumatic brain injury, and musculoskeletal conditions.

Meditation and mindfulness techniques can help stabilise a ruminating mind

A body of research investigates the discrete mechanisms underpinning yoga’s salutary effects. A series of trials (Streeter et al, 2007, 2010, 2020) found that yoga
increased levels of GABA, the primary inhibitory neurotransmitter in the brain. This may have a bearing on yoga therapy’s impact in anxiety disorders, depression, epilepsy, PTSD and chronic pain. Notably, this research found yoga elevated GABA levels significantly more than metabolically matched exercise. The researchers hypothesised that the holding of yoga postures and techniques of breath control may upregulate vagal messaging to the brain. In other studies yoga has been shown to reduce cortisol levels, increase oxytocin (the cuddle hormone), inhibit proinflammatory cytokines, decrease amygdala volume, and enhance heartrate variability and baroreflex sensitivity (Gangadhar et al, 2013; Mason et al, 2013; Cahn et al, 2017; Gotink et al, 2018). All these mechanisms imply that yoga may upregulate vagal messaging to the brain and enhance the calming effect of parasympathetic nervous and hormonal systems for ‘resting and digesting, and tending and befriending.

Uniformity or diversity in yoga practice and therapy?

However, all of this encouraging evidence of the therapeutic benefits of yoga is complicated by the fact that there are so many different styles – from dynamic ‘power’ yoga to gentle remedial movement and many variations in between. These different styles of yoga may have been studied in different combinations, or different aspects and practices are studied even within the same style, and the lengths and ‘dosage’ of interventions differ too. Reviewers have emphasised the variety of yoga practices as an obstacle to its integration in healthcare. Nor can we yet claim a genuine understanding of how to apply yoga consistently as a therapy. Responding to this issue, in 2018 Park published the Essential Properties of Yoga Questionnaire so that studies could use this questionnaire to compare outcomes even if the interventions are profoundly different (Park et al, 2018). Hopefully, this will help elucidate how best to employ yoga practice for different health populations and so support the use of yoga therapy.

Many within the yoga community insist that interventions must be individualised to the patient, and that consequently a codified protocol, which would lend itself to regular research, is not unanimously supported. This may be an obstacle to the spread of yoga therapy, because health systems with tight budgets are unlikely to finance a therapy without clear evidence of its application and outcomes. For its wider adoption, a clear evidence base for specific programmes will be needed, so that commissioners can more precisely consider its safety, efficacy, and value in relationship to other interventions. Additionally, upholding traditional elements of yogic philosophy within yoga therapy is often perceived as a cornerstone of the discipline within the field of practitioners. So debate is rife about how to translate yogic concepts and philosophy to a wide audience unfamiliar with the underlying concepts or the Sanskrit words so often used to describe them. Just as with other non-western systems there is an inevitable paradigm tension wherever their integration into healthcare systems is under consideration. For example, in the NHS there is a resistance to commissioning a yoga programme that included these elements. The aforementioned Yoga4Health programme, commissioned by the West London CCG, had to remove any Sanskrit words from its teaching in order to be deemed suitable for people of all backgrounds.

Is standardisation of yoga therapy feasible?

We maintain that if the programme has been devised for a specific health condition, a pre-designed yoga programme for a health population may still be legitimate yoga therapy. However it would also have to include an intake form and patient assessment that identifies clear inclusion and exclusion criteria, that the programme provides offthe-mat learning to participants, has definable methods for inspiring self-care, and is elastic enough to meet unique needs while still upholding its core tenets.

The Yoga for Healthy Lower Backs Course (YHLB), a 12-week programme for improving chronic lower back pain, is one such example, highlighting the success of yoga therapy’s adoption in the UK. The programme, developed by Alison Trewhela, features a weekly session over three to four months, in small groups (6–12 people). It has a comprehensive manual, with pre- and post-course support and advice for maintaining results. The programme begins by introducing simple pain-relieving techniques, progressing at a gradual pace to introduce strengthening and stretching poses and movements, alongside breath practices and simple mindfulness and relaxation exercises.

The course’s effectiveness lies in not simply addressing acute symptoms of long-term back issues, but in encouraging long-term lifestyle and behavioural changes. It also addresses other biopsychosocial aspects that might exacerbate symptoms and reduce quality of life, including stress and anxiety, and low mood. Workplace issues and concerns about returning to work after long absence, as well as strategies to support living with chronic pain, are included too. By handing back control, the YHLB promotes self-reliance, empowering people to help themselves, without the constant need for external interventions.

Participants in the programme speak to its efficacy in both dealing with the physical effects of chronic long-term back pain issues:

I had thought my life would never be the same again after my back condition was diagnosed, but I cannot say how much this has helped. I have a new lease of life and have no back pain now.’ ‘With my back condition I was afraid to do any exercise, but this gradually progressing yoga has been perfect as there is absolute control of movement.

Aspects of the programme have shifted their perspective in dealing with their condition:

I notice when my breath or mental state changes now, which means I am more able to prevent the build-up of tension and stress that used to make me suffer back pain.

Such personal testimonials were subsequently backed up in a multi-centred randomised controlled trial (Tilbrook et al, 2014). This trial, which compared YHLB against conventional care, revealed YHLB outcomes to be significantly better. Since the control group took considerably more time off due to lower back pain, a
follow-up economic analysis predicted that the programme could offer valuable cost savings. The findings from this programme led to yoga’s inclusion in the NICE guidelines for non-specific lower back pain (NSLBP) in November 2016. These were the first international guidelines to recommend yoga for NSLBP. Later the US and Canada followed suit.

Another yoga therapy intervention that is increasingly gaining traction is The Minded Institute’s eight-week yoga therapy course for depression and anxiety. A melding of mindfulness and yoga therapy, each two-hour session begins with psycho-education of how to regulate psychological experience through particular aspects of yoga. The course relies heavily on the yogic tradition of pranayama – breath practices – threaded differently in each week through a fixed sequence of postures, plus an activity (often a meditation or relaxation practice) and group sharing of experience to close the session. Before the Covid-19 pandemic disrupted plans and timelines, a modified version of the original course was due to be rolled out as part of the Ayuryoga programme run through the College of Medicine and financed and supported by the Indian Ministry of AYUSH. Although it is not clear exactly how the course will now be delivered, the value of yoga therapy for mental health post-covid is likely to be more important than ever. The World Health Organization (WHO) has already highlighted that the pandemic poses major risks to public mental health, noting already elevated rates of stress or anxiety but also warning that as further impacts and quarantine measures are introduced the likelihood is that ‘levels of loneliness, depression, harmful alcohol and drug use, and self-harm or suicidal behaviour are also expected to rise.

Yoga post-covid

An MSc student at the University of Westminster is currently conducting a survey investigating the use of yoga during the Covid-19 pandemic. We hope this will
elucidate whether people are using it therapeutically to cope with mental health challenges as well as physical ones. Although statistics on further downturns in
population mental health have yet to be published, The Economist reported a 30% rise in the purchase of alcoholic beverages in the UK and the potential for a
burgeoning problem with alcohol misuse and addiction. An ongoing study led by the Mental Health Foundation, Coronavirus: mental health in the pandemic, cites unemployment as one of the biggest factors negatively impacting mental health and points to a large-scale increase in mental health problems in the short and long term due to the economic impacts of the disease.

Given yoga is at its best when working with mental health conditions, combined with its relative costeffectiveness and adaptability to any stage of life or health
condition, we consider it to be an important treatment for the NHS to consider both on and offline in the Covid era. There is a growing appreciation of what yoga may offer people with mental health conditions. A recent article in The Telegraph reported the potential for adding yoga to the list of NICE-recommended psychological therapies following the publication of a Australian study led by Jacinta Brinsley in the British Journal of Sports Medicine (Brinsley et al, 2020). This systematic review of 13 studies with 632 participants found yoga’s effects to be most noticeable for people with depression and schizophrenia, and to some extent, alcohol misuse. A 2019 review of studies involving 8,000 participants, found that 30 minutes of exercise a day, including yoga, can lower the risk of depression by 17% (Choi et al, 2019).

With this level of evidence alongside fast-growing need for effective selfcare and widespread recognition in yoga therapy’s relevance for mental health problems, we hope to see access to yoga therapy rapidly expand in NHS mental healthcare. Prospects look hopeful in that the British Psychological Society recently accredited two professional trainings, The Minded Institute’s Yoga Therapy Skills for Psychologists and Therapists and Lucy Clarke, Janine Hurley and Lana Jackson’s Yoga Therapy for Children.

A concluding quote from one of our course participants highlights how integrating yoga therapy in private, community-based and public healthcare settings can
promote physical and mental wellbeing:

Yoga therapy is changing my life; I began to work with discomfort in my lower back, but over time it became clear that there was so much more underneath. It’s given me a context to many of the other minor health problems that I’ve had. Nothing, though, has been more transformative than understanding the power of breath, especially ujjayi. I’m practising it every day and just feel more myself – who even knew I didn’t feel myself before? As a result my relationships are improving and I feel more confident in my everyday life.

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