BACKGROUND/RATIONALE:
Approximately 780,000 people suffer a stroke annually in the United States; 200,000 are recurrent strokes. The 17,000 veterans who suffer a stroke yearly are at great risk for a second stroke and therefore should be targeted for stroke risk factor management and prevention interventions.
Balance and fear of falling negatively impact activity and function. Decreased activity and blood pressure (BP) are important modifiable stroke risk factors. These can be addressed through a yoga exercise intervention. Yoga, like tai-chi, is old world alternative medicine that has the potential to greatly impact the lives of older adults.

OBJECTIVE(S):
Our long term goal is to develop and test a yoga exercise intervention in a large VA trial for veterans who have survived a stroke. The objective of this pilot application was to obtain necessary information to support such a trial through the following specific aims: 1) determine the feasibility (including recruitment) of an 8 week yoga based intervention for veterans with stroke; 2) establish an appropriate dosing strategy for a post-TIA 8 week yoga exercise intervention for a future VA yoga implementation trial (Yoga Group, bi-weekly in-person vs Yoga Group Plus, bi-weekly in-person paired with almost daily at home yoga); and 3) estimate the effect size of yoga on variables of interest to determine the appropriate VA trial sample size.

METHODS:
We completed a mixed methods study to address the feasibility, dosing strategy, and estimation of effect size for the current pilot study. We recruited 45 people with stroke to participate in the Yoga Group or Yoga Group Plus; 15 participants were wait-listed to be used as a control. A registered yoga therapist (RYT) taught all classes. Qualitative data include semi-structured interviews after completion of the intervention regarding: perceived ability to do yoga exercise; satisfaction with the yoga intervention; satisfaction with the RYT; general health benefits for the intervention; and whether they would continue yoga practice. Quantitative data included compliance and recruitment information as well as multiple standardized assessments before and after the 8 week intervention including: blood pressure readings; fear of falling; balance; balance confidence; gait and mobility assessments; and quality of life. We compared those in yoga to those wait-listed and also completed within group analyses to determine change between baseline and 8 week scores.

FINDINGS/RESULTS:
We recruited 47 people, and 38 completed the study; 29 were randomized to yoga, and 9 to the wait-list control group. We found no change in BP over the 8 week trial. There were not any differences between groups at baseline or for the 8 week follow up. However, because this was a pilot study, we were not powered to see such differences. There were also not any significant differences between the Yoga Group or Yoga Plus Group, thus these data were merged as the Yoga Group. The control group demonstrated no significant changes between baseline and 8 week testing. However, those individuals randomized to the Yoga group demonstrated significant improvement in balance (Berg Balance Score 40.7 12.1 vs 479.6, p<.001, effect size .58) and balance self-efficacy (Activities Balance Confidence Scale 61.25 21.8 vs 67.2 23.1, p=.035, effect size .26). Those who completed yoga also demonstrated significant improvement in QoL (33 vs 36, p=.037), 10 meter walk (.9 vs .96, p=.030), and 6 minute walk (feet walked in 6 minutes, 869 vs 949, p=.002). There was a significant decrease in the number of individuals in the yoga group who endorsed a fear of falling (yes/no, 60% vs 43%, p=.002) and a significant increase in the number of people considered 'indepdent' on the modified Rankin (15 vs 19, p<.001). There was no change in blood pressure.

We collect qualitative comments through a focus group toward the end of the 8 week intervention as well as daily through a continuous log during the yoga sessions. Salient qualitative comments support both feasibility of yoga after stroke and changes to function and quality of life.

Feasibility:

-"Should definitely be added into anybody's therapy"
-"This is the best therapy I received after my stroke"
-'This is so simple yet so powerful'
-"Thank you for investing in our lives",
-"You got to be balanced. And know how far you can go. This couldn't have been any better"
-"First of all, coming here. That helps. Second of all, it was something new. Stretches were something new. I wasn't used to stretching and things. Now, at the house I'm stretching before I work out. So, it's working along with what I'm doing at the house"
- "This was great, it was important to the whole therapy process.it should definitely be added to other therapies"
-"Now I tell everyone they should do yoga, it has helped everything"
-"After therapy.basically send you out the door.something after like this should be mandatory. There I felt like half a person. Here I feel like 90-95% of a person. I'd like to see the program extended"
-"It's probably one of the best things that (has) ever come to me"

Quality of life:

-"I am doing better than I ever have since my stroke"
-"I've gone up stairs in my house about three times in the past week, and I hadn't been upstairs in a couple months. I have a real fear of stairs, and this gave me more confidence in balance and holding on"
-"I'm getting ready to move back into my standup shower"
-"I remember first getting home from the hospital...I would get so anxious and so nervous about stuff you know .thinking how am I going to do that? I think with this program that doesn't even enter into it anymore"
-"My washing, sweeping, and cleaning has improved. Now I can mow my yard.I can do more and more every day"
-"I'm able to walk down the stairs, used to slither down...It's given me confidence"
-"I'm gonna cry..it's improved my life, I can take a shower, before I couldn't. I was scared"
-One veteran and his wife have talked about his improvement in gait,that he previously would go to a grocery store and drive around in a scooter, he now walks around the entire store pushing a shopping cart. We also know that study participants are increasing their social participation, as they discuss outings, going out to lunch, helping each other at their homes, car pooling, etc. This likely will support improved quality of life.

Of additional note, all participants in the focus group have confirmed that 1) they would recommend the program to other people with stroke, 2) they would like to have the option to continue in the program after the 8 week intervention is over, and 3) they were satisfied with the yoga therapist and the yoga program.

IMPACT:
We completed a yoga exercise intervention to manage blood pressure, balance, fear of falling, and mobility after stroke. Those in the yoga intervention enjoyed significant improvement in balance, fear of falling, stroke related disability, balance confidence, quality of life, 10 meter walk (speed), and 6 minute walk (endurance). We significantly improved the lives of veterans included in this study We have used preliminary data to support a Merit Award submission to VA RRD. Continued testing with a larger sample is warranted to determine the impact of yoga on balance and other important post-stroke variables.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Schmid AA, Van Puymbroeck M, Altenburger PA, Schalk NL, Dierks TA, Miller KK, Damush TM, Bravata DM, Williams LS. Poststroke balance improves with yoga: a pilot study. Stroke. 2012 Sep 1; 43(9):2402-7. [view]
2. Schmid AA, Willis LA, Miller KK, Van Puymbroeck M, Williams LS. Yoga Improves Multiple Quality of Life Domains for People with Chronic Stroke. Jacobs Journal of Yoga and Natural Medicine. 2016 Jul 11; 1(1):1. [view]

Conference Presentations

1. Schmid AA, Van Puymbroeck M, Altenburger P, Dierks T, Miller K, Damush TM, Crabtree J, Neumann D, Williams LS. Eight-Week Yoga Improves Quality of Life, Activity, and Social Participation after Stroke. Poster session presented at: International Association of Yoga Therapists / Kripalu Institute for Extraordinary Living Symposium on Yoga Research; 2011 Sep 15; Lenox, MA. [view]
2. Schmid AA, DeBaun E, Van Puymbroeck M, Altenburger P, Dierks T, Miller K, Schalk N, Damush TM, Crabtree J, Neumann D, Williams LS. Eight-Week Yoga Improves Quality of Life, Activity, and Social Participation after Stroke. Poster session presented at: Indiana Occupational Therapy Association Annual Conference; 2011 Sep 1; Indianapolis, IN. [view]
3. Schmid AA, Van Puymbroeck M, Altenburger P, Dierks T, Miller K, Schalk N, Damush TM, Crabtree J, Neumann D, Williams LS. Eight-week yoga intervention improves quality of life, activity, and social participation after stroke. Poster session presented at: American Congress of Rehabilitation Medicine Annual Meeting; 2011 Oct 1; Atlanta, GA. [view]
4. Schalk N, Gerwig AN, Miller KK, Van Puymbroeck M, Altenburger P, Dierks T, Schmid AA. Preliminary Evidence of Yoga on Balance and Endurance Outcomes for Veterans with Stroke. Poster session presented at: American College of Sports Medicine Annual Meeting; 2011 Jun 4; Denver, CO. [view]
5. Miller KK, Dierks T, Van Puymbroeck M, Schalk N, Williams LS, Damush TM, Schmid AA. Therapeutic-yoga: Impact on pain and physical impairments after stroke. Paper presented at: American Congress of Rehabilitation Medicine / American Society of Neuroradiology Annual Meeting; 2011 Oct 15; Atlanta, GA. [view]
6. Schmid AA, Altenburger P, Dierks T, Van Puymbroeck M, Schalk N, Miller K, Williams LS, Damush TM. Yoga improves balance and balance confidence after stroke. Paper presented at: American Congress of Rehabilitation Medicine / American Society of Neuroradiology Annual Meeting; 2011 Oct 15; Atlanta, GA. [view]
7. Schmid AA, Van Puymbroeck M. Yoga: A tool to improve wellness in your recreational therapy practice. Paper presented at: Recreation Therapists of Indiana Annual Conference; 2011 Nov 15; Bloomington, IN. [view]

DRA: Brain and Spinal Cord Injuries and Disorders
DRE: Prevention, Treatment - Efficacy/Effectiveness Clinical Trial
Keywords: Complementary & alternative therapy, Risk adjustment, Stroke
MeSH Terms: none