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Management eBrief no. 86

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Management eBriefs
Issue 86October 2014

A Systematic Review: Evidence Map of Yoga for High-Impact Conditions Affecting Veterans

Complementary and alternative medicine (CAM) strategies, such as yoga, are widely available in the private sector, and some Veterans would like access to these strategies through the VA healthcare system. Determining the state of evidence on the benefits and harms of yoga and other CAM modalities will help fulfill the joint research needs of the Office of Patient-Centered Care and the Field Advisory Committee on Complementary and Alternative Medicine – and will assist VA leadership in determining the most appropriate guidelines/policy for the implementation of CAM therapies within the VA healthcare system.

The Evidence-based Synthesis Program located in Durham, NC, proposed a CAM evidence mapping project to evaluate the existing evidence on yoga for common clinical conditions in Veterans. Investigators reviewed the literature database, as well as ClincialTrials.gov for ongoing systematic reviews or trials through July 2014, and identified 10 articles, including 9 systematic reviews, which fit the study criteria and addressed yoga treatment as related to: low back pain, prevention of falls, mental illness, insomnia, and adverse effects. These conditions and issues are considered to be high-impact due to their prevalence among Veterans, causing considerable functional impairment, and their association with increased use of medical resources.

Analyses of review data were used to provide the Summary, which is followed by more detailed information.

Summary:
Evidence from good-quality systematic reviews suggests that yoga can improve functional outcomes in patients with non-specific chronic low back pain. Existing evidence is less clear about the effectiveness and safety of yoga for the other conditions of interest. There is potential benefit for yoga in young to mid-life adults with depressive disorders or elevated depressive symptoms. Investigators also found only preliminary evidence that yoga may have short-term benefit for patients with symptoms of anxiety or insomnia. Few or no trials were found that evaluated the effectiveness and safety of yoga for prevention of falls, PTSD, or insomnia. These findings and conclusions are generally consistent with those of a recent (2013) published review of systematic reviews of yoga for acute and chronic health conditions, which concluded that yoga appears most effective for reducing symptoms in anxiety, depression, and pain. The authors of the 2013 review concluded, as do the investigators of the current review, that the quality of existing systematic reviews is generally good, whereas the quality of the primary studies is generally poor.

Results:
Effectiveness of Yoga on Selected Conditions
Nine systematic reviews evaluated the effectiveness of yoga for one or more of the selected conditions. These reviews identified and summarized 23 unique randomized controlled trials (RCTs), which were conducted primarily in North America and Asia. Typical enrollment was 25 to 50 adults, and the majority of subjects were white, female, and middle-aged. Findings include:

  • Meta-analyses showed consistent short-term benefits of yoga for low back pain and more variable benefits for back-specific disability.
  • Compared with usual care, yoga improved short-term depressive symptoms, but effects varied substantially across studies.
  • For the other conditions, the lack of RCTs precluded estimates of treatment effects.
  • Other outcomes, such as health-related quality of life, were reported infrequently.

Adverse Effects Associated with Yoga
Investigators identified a single good-quality systematic review of adverse effects associated with yoga (for any clinical condition). This review identified 37 case reports or case-series of adverse effects, representing 76 individual adverse effects occurring in patients engaged in yoga, such as:

  • The headstand was associated most commonly with adverse outcomes, but most reports of adverse effects did not have clear descriptions of the postures involved.
  • Musculoskeletal injuries (reported in 27 cases), orbital involvement (reported in 9 cases), and headache (reported in 7 cases) were the most common adverse effects.

In the systematic reviews identified for clinical conditions of interest, only the studies of yoga for low back pain reported adverse effects.

Future Research:
If VA or other organizations were to prioritize further research on yoga for the conditions discussed in this systematic review, investigators would recommend careful attention be paid to study design and reporting. For example, since RCTs and high-quality systematic reviews examining yoga for low back pain and depression already exist, new or more in-depth evidence syntheses in this vein are not currently needed; however, trials comparing yoga to other active comparators (e.g., other forms of exercise or different types of yoga) may be helpful. For all of the conditions for which yoga may be effective, longer-term, validated, patient-reported outcomes should be assessed, and stakeholders, including patients, should be involved in prioritizing outcomes to be measured for future studies. Feasibility and acceptability studies also could be conducted to identify potential barriers and facilitators for learning and practicing yoga among various Veteran populations, as well as availability and training of VA providers in yoga across different settings. In addition, enhancement of the applicability of findings to Veterans could be achieved by including Veterans – or patients with similar demographic characteristics to achieve better representation of men and older adults.

Reference:
Coeytaux RR, McDuffie J, Goode A, Cassel S, Porter WD, Sharma P, Meleth S, Minnella H, Nagi A, Williams Jr. JWW. Evidence Map of Yoga for High-Impact Conditions Affecting Veterans. VA ESP Project #09-010; 2014.

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This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.

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This report is a product of VA/HSR&D's Quality Enhancement Research Initiative's (QUERI) Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers – and to disseminate these reports throughout VA.

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