A Combined Kundalini Yoga and Cognitive Behavioral Therapy Program for Posttraumatic Stress Disorder: A Pilot Study.

Cognitive behavioral therapy (CBT) is one of the standard conventional treatments for posttraumatic stress disorder (PTSD). However, recent studies have reported the benefits of yoga for reducing PTSD symptoms including a Kundalini Yoga (KY) intervention. The purpose of this study was to test the efficacy of a novel combined 8-week CBT and KY program for treating PTSD symptoms and improving sleep quality in a single group trial of 26 adults with PTSD. PTSD symptoms (PTSD checklist-5) and sleep quality (Pittsburgh Sleep Quality Index) were assessed at baseline, post intervention, and at 2-month follow-up. Both CBT and yoga homework compliance were also measured. Total PTSD symptom scores as well as the cluster symptoms (intrusion, avoidance, arousal/reactivity, and negative alterations in cognitions and mood) were significantly improved following the program, all p < .01. The improvements in total PTSD scores, intrusion, avoidance, arousal/reactivity were maintained at follow-up, with all values still less (p < .01) than baseline. The negative alterations in cognitions and mood symptom cluster continued to improve further at follow-up compared to post-intervention values (p < .05). Total sleep score (p < .05) and the subscales of sleep disturbance (p < .01), daytime dysfunction (p < .05), and sleep quality (p < .01) were significantly improved after the program and these improvements were maintained at follow-up compared to baseline. Sleep medication use was decreased (p < .05) and sleep latency was improved (p < .01) at follow-up only compared to baseline. There was a significant positive correlation (p < .05) between the completion of the yoga home practice and post change in total sleep scores. These results show that a combined KY and CBT intervention resulted in decreased PTSD symptoms and improved sleep quality and suggest this program may constitute an additional treatment option for PTSD.

Effect of cognitive behavioural therapy and yoga for generalised anxiety disorder on sleep quality in a randomised controlled trial: the role of worry, mindfulness, and perceived stress as mediators.

Sleep disturbances are present in ~65% of individuals with generalised anxiety disorder (GAD). Although both Kundalini yoga (KY) and cognitive behavioural therapy (CBT) are effective treatment options for GAD, little is known about how these treatments compare in improving sleep for GAD and what drives these changes. Accordingly, we examined the effects of CBT, KY, and stress education (SEdu; an attention control condition) on subjective sleep quality (as measured by the Pittsburgh Sleep Quality Index [PSQI] and Insomnia Severity Index [ISI]) in a randomised controlled trial of 226 adults with GAD (mean age 33.37 years; 70% female; 79% White). We hypothesised that both CBT and KY would outperform SEdu in improving sleep disturbances. Three potential mediators of sleep improvement (worry, mindfulness, perceived stress) were also examined. In line with hypotheses, PSQI and ISI scores significantly improved from pre- to post-treatment for all three treatment groups (all p < 0.001, all d > 0.97). However, contrary to predictions, sleep changes were not significantly greater for CBT or KY compared to SEdu. In mediation analyses, within-person deviations in worry, mindfulness, and stress each significantly mediated the effect of time on sleep outcomes. Degree of change in sleep attributable to worry (CBT > KY > SEdu) and perceived stress (CBT, KY > SEdu) was moderated by treatment group. Personalised medicine as well as combined treatment approaches should be studied to help reduce sleep difficulties for patients with GAD who do not respond.

Comparing Kundalini Yoga, cognitive behavioral therapy, and stress education for generalized anxiety disorder: Anxiety and depression symptom outcomes.

Increasingly, individuals with anxiety disorders are seeking mind-body interventions (e.g., yoga), but their effectiveness is unclear. This report summarizes seven additional, secondary outcomes measuring anxiety and depression symptoms from a study of 226 adults with generalized anxiety disorder who were randomized to 12-week Kundalini Yoga, Cognitive-Behavior Therapy (CBT) or stress education (control). At post-treatment, participants receiving CBT displayed significantly lower symptom severity, compared to those in the control group, on 6 of the 7 measures. Participants who received Yoga (vs. those in the control group) displayed lower symptom severity on 3 of the 7 measures. No significant differences were detected between participants receiving CBT vs those receiving Yoga. At the 6-month follow-up, participants from the CBT continued to display lower symptoms than the control group.

Impact of preference for yoga or cognitive behavioral therapy in patients with generalized anxiety disorder on treatment outcomes and engagement.

There is some, but inconsistent, evidence to suggest that matching patient treatment preference enhances treatment engagement and outcome. The current study examined differential preferences and factors associated with treatment preference for 12-week group cognitive behavioral therapy (CBT), yoga, or stress education in 226 adults with generalized anxiety disorder (GAD; 70% female, Mean age = 33 ± 13.5). In a subsample of 165 patients who reported an intervention preference and were randomized to yoga or CBT, we further examined whether match to preferred intervention improved the primary treatment outcome (responder status on Clinical Global Impressions Scale) and engagement (dropout, homework compliance). Preferences for CBT (44%) and yoga (40%) were similar among patients. Women tended to prefer yoga (OR = 2.75, p = .01) and CBT preference was associated with higher baseline perceived stress (OR = 0.92, p = .04) and self-consciousness meta-cognitions (OR = 0.90, p = .02). Among those not matched to their preference, treatment response was higher for those receiving CBT than yoga (OR = 11.73, p = .013); there were no group differences for those matched to their treatment preference. In yoga, those who received their preference were more likely to drop than those who did not (OR = 3.02, 95% CI = [1.20, 7.58], p = .037). This was not the case for CBT (OR = 0.37, 95% CI = [0.13, 1.03], p = .076). Preference match did not predict homework compliance. Overall, results suggest that treatment preference may be important to consider to optimize outcome and engagement; however, it may vary by treatment modality. Future research incorporating preference, especially with yoga for anxiety, is aligned with personalized medicine. TRIAL REGISTRATION: clinicaltrials.gov: NCT01912287; https://clinicaltrials.gov/ct2/show/NCT01912287.

The Yoga Instructor Beliefs Scales Epistemic (YIBS-E) and Pedagogic (YIBS-P): Development and Initial Assessment of the Factor Structure.

Yoga is a multidimensional and heterogeneous mind-body practice led by a therapist or teacher (e.g., yoga instructor). Although they constitute an integral part of delivery, content, and curriculum, factors that influence yoga instructors' choices have yet to be explored. Using a mixed methods sequential design for development of an instrument that identifies measurable epistemic (YIBS-E) and pedagogic (YIBS-P) beliefs, the Yoga Instructor Beliefs Scale (YIBS) reports validity evidence from four distinct phases. Phase I presents qualitative findings from literature-informed semistructured interviews to give a comprehensive construct model of yoga instructor beliefs from diverse styles/ schools/lineages of yoga (nine content-specific clusters). In Phase II, focus group panels of experts evaluated construct novelty and importance of themes, resulting in a pool of potential questionnaire items. Phase III employed cognitive interviews to assess the perceived meaning and clarity of using the preliminary YIBS items. Phase IV included exploratory factor analysis and correlational analyses using 204 yoga instructor responses, suggesting a 44-item instrument with distinct epistemic (Experiential, Energetic, Systems-Based, Affectual, Mindful, and Physical) and pedagogic (Curricular Integration, Student Awareness, Accessibility, and Differentiated Instruction) factors (YIBS- E α = 0.90, YIBS-P α = 0.85). Measurable belief constructs can inform research on individual yoga instructor differences that may influence curriculum content choices and delivery. The purpose of this instrument is to enable research linking instructor beliefs to the presence of various components of a yoga program and to contextualize defining qualities of yoga programs. Long-term use of this instrument should enable in-depth analyses such as mediation or moderation of yoga instructor beliefs on intervention components/content or outcomes.

A systematic review of in vivo stretching regimens on inflammation and its relevance to translational yoga research.

OBJECTIVE: To conduct a systematic review evaluating the impact of stretching on inflammation and its resolution using in vivo rodent models. Findings are evaluated for their potential to inform the design of clinical yoga studies to assess the impact of yogic stretching on inflammation and health. METHODS: Studies were identified using four databases. Eligible publications included English original peer-reviewed articles between 1900-May 2020. Studies included those investigating the effect of different stretching techniques administered to a whole rodent model and evaluating at least one inflammatory outcome. Studies stretching the musculoskeletal and integumentary systems were considered. Two reviewers removed duplicates, screened abstracts, conducted full-text reviews, and assessed methodological quality. RESULTS: Of 766 studies identified, 25 were included for synthesis. Seven (28%) studies had a high risk of bias in 3 out of 10 criteria. Experimental stretching protocols resulted in a continuum of inflammatory responses with therapeutic and injurious effects, which varied with a combination of three stretching parameters--duration, frequency, and intensity. Relative to injurious stretching, therapeutic stretching featured longer-term stretching protocols. Evidence of pro- and mixed-inflammatory effects of stretching was found in 16 muscle studies. Evidence of pro-, anti-, and mixed-inflammatory effects was found in nine longer-term stretching studies of the integumentary system. CONCLUSION: Despite the overall high quality of these summarized studies, evaluation of stretching protocols paralleling yogic stretching is limited. Both injurious and therapeutic stretching induce aspects of inflammatory responses that varied among the different stretching protocols. Inflammatory markers, such as cytokines, are potential outcomes to consider in clinical yoga studies. Future translational research evaluating therapeutic benefits should consider in vitro studies, active vs. passive stretching, shorter-term vs. longer-term interventions, systemic vs. local effects of stretching, animal models resembling human anatomy, control and estimation of non-specific stresses, development of in vivo self-stretching paradigms targeting myofascial tissues, and in vivo models accounting for gross musculoskeletal posture.

"Making it okay": professionals in high-stress environments construct their understanding of the impact of a yoga-based retreat designed to build resilience.

PURPOSE: While there is growing evidence for resilience building programmes, to date research has not explored how professionals construct understanding of programme impact. RISE (resilience, integration, self-awareness, engagement), a 5-day yoga-based retreat programme, has been linked with positive wellness outcomes. This qualitative inquiry explores participants' reflection and experience 3 months after programme completion. METHODS: Through a grounded constructivist lens, in-depth semi-structured phone interviews were conducted with 17 adult professionals in high-stress work environments who attended RISE. Initial hand-coding informed codebook development for systematic coding using directed content analysis using sensitizing structuring. RESULTS: Two integrated perceptions woven through five themes. Persistent threads of experiential learning and sense of permission provided structure for themes found. Five interrelated themes related to psychological health and workplace dynamics were (1) use of acquired behavioural skills and practices; (2) lived mindfulness; (3) resilience to stress and emotion regulation (4) self-care and self-compassion, and (5) sharing with others. CONCLUSION: Findings provide meaningful interpretation of previously reported programme efficacy by contextualizing perceived benefits within participants' constructed understanding of change. Specifically, environmental, social, and experiential considerations have suggested implications for resilience building programmes.Abbreviations: RISE (resilience, integration, self-awareness, engagement).

Treatment of chronic primary sleep onset insomnia with Kundalini yoga: a randomized controlled trial with active sleep hygiene comparison.

STUDY OBJECTIVES: Prior studies have suggested a benefit of yoga for alleviating sleep disturbance; however, many studies have had methodological limitations. This trial study aimed to extend that literature by including an active sleep hygiene comparison. METHODS: Participants aged 25-59 years with a primary complaint of sleep onset insomnia lasting at least 6 months were block randomized to an 8-week Kundalini yoga or sleep hygiene intervention, both consisting of initial 60-minute instruction and weekly check-ins. Daily sleep diaries and questionnaires were collected at baseline, throughout the intervention, and at 6-month follow-up. Data were analyzed using linear mixed models (n = 20 in each group). RESULTS: Participant ratings of the interventions did not significantly differ. Sleep hygiene improved several diary and questionnaire outcomes, however, yoga resulted in even greater improvements corresponding to medium-to-large between-group effect sizes. Total sleep time increased progressively across yoga treatment (d = 0.95, P = .002), concurrent with increased sleep efficiency (d = 1.36, P < .001) and decreased sleep onset latency (d = -1.16, P < .001), but without changes in pre-sleep arousal (d =-0.30, P = .59). Remission rates were also higher for yoga compared to sleep hygiene, with ≥ 80% of yoga participants reporting average sleep onset latency < 30 minutes and sleep efficiency > 80% at 6-month follow-up. For over 50% of yoga participants, the insomnia severity index decreased by at least 8 points at end of treatment and follow-up. CONCLUSIONS: Yoga, taught in a self-care framework with minimal instructor burden, was associated with self-reported improvements above and beyond an active sleep hygiene comparison, sustained at 6-month follow-up. Follow-up studies are needed to assess actigraphy and polysomnography outcomes, as well as possible mechanisms of change. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Name: Yoga as a Treatment for Insomnia; URL: https://clinicaltrials.gov/ct2/show/NCT00033865; Identifier: NCT00033865. CITATION: Khalsa SBS, Goldstein MR. Treatment of chronic primary sleep onset insomnia with Kundalini yoga: a randomized controlled trial with active sleep hygiene comparison. J Clin Sleep Med. 2021;17(9):1841-1852.

Evaluation of a Yoga-Based Mind-Body Intervention for Resident Physicians: A Randomized Clinical Trial.

BACKGROUND AND OBJECTIVE: Mind-body interventions (MBIs) have been shown to be effective individual-level interventions for mitigating physician burnout, but there are no controlled studies of yoga-based MBIs in resident physicians. We assessed the feasibility of a yoga-based MBI called RISE (resilience, integration, self-awareness, engagement) for residents among multiple specialties and academic medical centers. METHODS: We conducted a waitlist controlled randomized clinical trial of the RISE program with residents from multiple specialty departments at three academic medical centers. The RISE program consisted of six weekly sessions with suggested home practice. Feasibility was assessed across six domains: demand, implementation, practicality, acceptability, adaptation, and integration. Self-reported measures of psychological health were collected at baseline, post-program, and two-month follow-up. RESULTS: Among 2,000 residents contacted, 75 were assessed for eligibility and 56 were enrolled. Forty-four participants completed the study and were included in analysis. On average, participants attended two of six sessions. Feasibility of in-person attendance was rated as 28.9 (SD 25.6) on a 100-point visual analogue scale. Participants rated feasibility as 69.2 (SD 26.0) if the program was offered virtually. Those who received RISE reported improvements in mindfulness, stress, burnout, and physician well-being from baseline to post-program, which were sustained at two-month follow-up. CONCLUSION: This is the first controlled study of a yoga-based MBI in residents. While the program was not feasible as delivered in this pilot study, initial analyses showed improvement in multiple measures of psychological health. Residents reported that virtual delivery would increase feasibility.

A 3-Day residential yoga-based program improves education professionals' psychological and occupational health in a single arm trial.

OBJECTIVE: This study examined changes in psychological and occupational health in urban education professionals after attending a brief yoga-based program. METHODS: Education professionals from the New York City Department of Education (NYC DOE) who were attending a residential 3-day yoga-based program at Kripalu Center for Yoga & Health were recruited to participate in the study. Measures of psychological and occupational health and health-related behaviors were completed before (baseline), after (post), and two months after the program (follow-up). Paired samples t-tests were used to compare scores between time points. RESULTS: At post, participants (N = 74) showed improvements in stress, resilience, affect, mindfulness, empowerment, self-compassion, satisfaction with life, work engagement, burnout, exercise, and vegetable intake (all p values < 0.05) compared to baseline. At the follow-up (N = 33), showed improvements in resilience, affect, mindfulness, empowerment, self-compassion, work engagement, and burnout (all p values < 0.05) compared to baseline. There were significant correlations between the degree of home practice of the skills and techniques learned in the program and improvements in multiple measures of psychological and occupational health at follow-up (all p values < 0.05). CONCLUSIONS: These findings suggest that the yoga-based program improves psychological and occupational health and healthy behaviors in education professionals immediately following the program and up to two-months following the program, however, more data with larger sample sizes are needed to confirm sustained benefits over the longer term.

Efficacy of Yoga vs Cognitive Behavioral Therapy vs Stress Education for the Treatment of Generalized Anxiety Disorder: A Randomized Clinical Trial.

Importance: Generalized anxiety disorder (GAD) is common, impairing, and undertreated. Although many patients with GAD seek complementary and alternative interventions, including yoga, data supporting yoga's efficacy or how it compares to first-line treatments are lacking. Objectives: To assess whether yoga (Kundalini yoga) and cognitive behavioral therapy (CBT) for GAD are each more effective than a control condition (stress education) and whether yoga is noninferior to CBT for the treatment of GAD. Design, Setting, and Participants: For this randomized, 3-arm, controlled, single-blind (masked independent raters) clinical trial, participants were recruited from 2 specialty academic centers starting December 1, 2013, with assessment ending October 25, 2019. Primary analyses, completed by February 12, 2020, included superiority testing of Kundalini yoga and CBT vs stress education and noninferiority testing of Kundalini yoga vs CBT. Interventions: Participants were randomized to Kundalini yoga (n = 93), CBT for GAD (n = 90), or stress education (n = 43), which were each delivered to groups of 4 to 6 participants by 2 instructors during twelve 120-minute sessions with 20 minutes of daily homework. Main Outcomes and Measures: The primary intention-to-treat outcome was acute GAD response (Clinical Global Impression-Improvement Scale score of much or very much improved) after 12 weeks as assessed by trained independent raters. Results: Of 538 participants who provided consent and were evaluated, 226 (mean [SD] age, 33.4 [13.5] years; 158 [69.9%] female) with a primary diagnosis of GAD were included in the trial. A total of 155 participants (68.6%) completed the posttreatment assessment. Completion rates did not differ (Kundalini yoga, 60 [64.5%]; CBT, 67 [74.4%]; and stress education, 28 [65.1%]: χ2 = 2.39, df = 2, P = .30). Response rates were higher in the Kundalini yoga group (54.2%) than in the stress education group (33.%) (odds ratio [OR], 2.46 [95% CI, 1.12-5.42]; P = .03; number needed to treat, 4.59 [95% CI, 2.52-46.19]) and in the CBT group (70.8%) compared with the stress education group (33.0%) (OR, 5.00 [95% CI, 2.12-11.82]; P < .001; number needed to treat, 2.62 [95% CI, 1.91-5.68]). However, the noninferiority test did not find Kundalini yoga to be as effective as CBT (difference, 16.6%; P = .42 for noninferiority). Conclusions and Relevance: In this trial, Kundalini yoga was efficacious for GAD, but the results support CBT remaining first-line treatment. Trial Registration: ClinicalTrials.gov Identifier: NCT01912287.

A Pragmatic Controlled Trial of a Brief Yoga and Mindfulness-Based Program for Psychological and Occupational Health in Education Professionals.

OBJECTIVES: To examine changes in psychological and occupational wellbeing in education professionals that attended a brief yoga and mindfulness-based program. DESIGN: Pragmatic controlled trial comparing education professionals that attended a yoga mindfulness-based program (n = 9) to a waitlist control group (n = 22). SETTING: The 3-day program was delivered at the Kripalu Center for Yoga & Health in Massachusetts. INTERVENTION: The 3-day yoga mindfulness program included 5 hours per day of yoga, mindfulness exercises, formal meditation, didactic, and experiential activities. MAIN OUTCOME MEASURES: Measures of psychological and occupational wellbeing were completed before (baseline), immediately after (post-program), and two months after the program (follow-up). RESULTS: Relative to controls (n = 21), the RISE group (n = 9) showed significant improvements in positive affect (p = .033), negative affect (p = .044), mindfulness (p = .001), empowerment (p = .022), self-compassion (p = .001), and work engagement from baseline to post-program. From baseline to follow-up, the RISE group showed significant improvements in stress (p = .008), negative affect (p = .013), mindfulness (p = .001), empowerment (p = .007), and self-compassion (p = .001) compared to the control group. CONCLUSIONS: The yoga mindfulness program was associated with improvements in educators' psychological and occupational wellbeing immediately following and 2-months following the program. Future research with a larger sample size is needed to confirm these results.

A Yoga-Based Program Decreases Physician Burnout in Neonatologists and Obstetricians at an Academic Medical Center.

BACKGROUND: Nearly half of U.S. pediatricians have symptoms of burnout. This pilot study examined the feasibility of a 6-week yoga-based program (RISE) for neonatologists and obstetricians at Brigham and Women's Hospital and studied the effects on burnout, professional fulfillment, and psychological health. METHODS: Participants were recruited via email to participate either in both program and research study, or exclusively the program. RISE was delivered 1 hour/week during the workday for 6 consecutive weeks either in-person or remotely; 18 physicians participated, 12 completed post-program, and 11 completed 2-month follow-up. The questionnaires assessed burnout and measures of psychological health, professional fulfillment, work exhaustion, interpersonal disengagement/burnout (PFI), mindfulness (FFMQ), perceived stress (PSS), positive/negative affect (PANAS), resilience (RS), anxiety/depression/sleep disturbances (PROMIS), at baseline, post-program, and 2 months after RISE. FINDINGS: Average attendance in-person was 2.8 sessions and remotely 1.4 sessions (4.2/6 sessions). Participants demonstrating total burnout reduced from 50.0% at baseline to 9.1% post-program. Participants demonstrating professional fulfillment were 8.3% at baseline and 27.3% post-program. Paired samples t-tests revealed statistically significant improvements in burnout, professional fulfillment, interpersonal disengagement, stress, resilience, anxiety, and depression at post-program compared with baseline (N = 12, all ps < .05). At 2-month follow-up, statistically significant improvements in interpersonal disengagement, resilience, and mindfulness (N = 11, all ps < .05) compared with baseline were reported. CONCLUSIONS/APPLICATION TO PRACTICE: RISE is feasible within a workday and may address burnout and other psychological health measures in physicians with effects potentially sustainable over 2 months. Occupational health practitioners in health care should consider this type of intervention for their workers.

A sleep hygiene and yoga intervention conducted in affordable housing communities: Pilot study results and lessons for a future trial.

BACKGROUND: and purpose: Inadequate sleep is highly prevalent among socioeconomically disadvantaged and racial/ethnic minority communities and is often related to maladaptive sleep behaviors and stress. There is scant research investigating the delivery of these interventions in underserved communities. The purpose of this study was to develop and test the feasibility and acceptability of a sleep education and yoga intervention for socioeconomically disadvantaged and racial/ethnic diverse adults. MATERIALS AND METHODS: We present quantitative and qualitative data from a single-arm sleep education and yoga pilot study (n = 17) conducted in two affordable housing communities, and the multi-modal process we employed to refine the intervention for a future trial. RESULTS: Participants were age 43.6 years on average (±19.3 years) and 88.2% were female. Nearly 56% identified as non-Hispanic Black and 19% as Hispanic/Latino. Results showed significant pre/post-intervention improvements in sleep duration (5.4 ± 1.2 h/night vs 6.9 ± 1.7 h/night; p < 0.01), sleep-related impairment (-8.15; p < 0.01), sleep disturbance (-5.95; p < 0.01), and sleep hygiene behaviors (-5.50; p < 0.01). CONCLUSION: This study indicates intervention acceptability and improvements in sleep and sleep hygiene. Future randomized controlled trials are needed to assess efficacy.

Improvements in Psychological and Occupational Well-being Following a Brief Yoga-Based Program for Education Professionals.

OBJECTIVE: The purpose of this study was to examine changes in psychological and occupational well-being in education professionals who attended a yoga-based program. METHODS: Education professionals who attended a 3-day yoga-based RISE (resilience, integration, self-awareness, engagement) program were recruited to participate. RISE was administered at the Kripalu Center for Yoga & Health. Measures of psychological and occupational well-being, and health-related behaviors were completed before (baseline), after (post), and 2 months after RISE (follow-up). Forty-four participants completed baseline and post and were included in the analysis. Of those, 33 participants also completed the follow-up. Paired samples t tests were used to compare scores between time points. RESULTS: Compared to baseline, at post, participants showed improvements in perceived stress, mindfulness, empowerment, positive affect, negative affect, self-compassion, total work engagement, vigor, sleep quality (all P values < .001), resilience, satisfaction with life, as well as exhaustion and professional efficacy which are dimensions of burnout (all P values < .01). At the follow-up, significant improvements were maintained for mindfulness, empowerment, self-compassion, sleep quality (all P values < .001), resilience, vigor, and exhaustion (all P values < .01) and positive affect, satisfaction with life, and work engagement (all P values < .05). CONCLUSIONS: These findings suggest that the yoga-based RISE program improves psychological and occupational well-being in education professionals. In addition, participants reported that attending RISE was feasible, they could continue using RISE practices long-term, shared them with work colleagues, and reported that RISE positively impacted both their daily lives and workplace environment. With these promising results, additional controlled research is warranted.