Yoga Improves Multiple Quality of Life Domains for People with Chronic Stroke

Clinical Research

Yoga Improves Multiple Quality of Life Domains for People with Chronic Stroke

Corresponding authorDr. Arlene Schmid, Ph.D., OTR, 1573 Campus Delivery Colorado State University, 80523, USA, Tel: 970-491-7562; Email: arlene.schmid@colostate.edu

 

Abstract

Objective: We assessed the impact of yoga on individual domains of quality of life (QoL).

Methods: This was a secondary data analysis of data from a randomized pilot study of yoga for people with stroke. Participants were randomized to an 8-week yoga (2x week) or control group and assessed at baseline and 8 weeks. Due to including multiple domains and a limited data set, α was set at .10.

Results: Forty-seven people completed the study (37 in yoga). At 8 weeks, there was a significant difference in Mobility and Social Roles scores between groups (Mobility, yoga 4.22±.65vs control 3.43±.95, p=.007; Social Roles, yoga 3.21±1.18 vs. control 2.6±.68, p=.058). In the yoga group, significant improvement occurred in Language (p=.059); Mobility (p=.023); Family Roles (p=.035); and Energy (p=.078).

Conclusion: Stroke is commonly treated by occupational therapists and yoga may be a modality to include as a beneficial aspect of therapy.

Keywords: Occupational therapy, Quality of life, Stroke, Yoga

List of Abbreviations

CAM: Complementary and Alternative Therapies;

OT: Occupational Therapy;

QoL: Quality of Life;

ROM: Range of motion;

SSQoL: Stroke Specific Quality of Life

Introduction

Complementary health approaches (previously named complementary and alternative therapies (CAM)) are defined as practices and approaches that are of ‘non-mainstream origin’ and include natural products and mind and body practices [1]. Yoga or therapeutic yoga is housed under mind and body practices as holistic and treats the whole person (physical, emotional, cognitive) [2]. Such a holistic practice is considered to be within the scope of rehabilitation, and specifically in occupational therapy (OT), the OT Practice Framework (AOTA,  014) and can be used as an approach to enhance performance and participation in meaningful occupations or activities [2].

Yoga is increasingly popular in general and as a rehabilitation intervention [4]. Traditionally, and in our research, yoga includes physical postures (asana), diaphragmatic breathing (pranayama), and meditation (dhyana). There is growing evidence for the use of yoga by people with chronic stroke; for example, authors of two case-studies found yoga to improve post-stroke aspects of quality of life (QoL), balance, and dexterity [5, 6]. Additionally, data from a qualitative study demonstrated perceived improvements in multiple aspects of physical functioning, including strength, the range of motion (ROM), and walking [7]. Immink et al. found improvements in perceived motor and memory function and anxiety [8]. We completed a randomized pilot study of yoga for people with chronic stroke and found that people who engaged in yoga had significant improvements in multiple outcome measures compared to those not engaging in yoga, including QoL; balance; balance self-efficacy; fear of falling; strength; ROM; pain; and endurance [9, 10].

This line of inquiry into yoga after stroke is of great importance as 800,000 Americans sustain a stroke annually and 86% do not attain full recovery [11]. In general, the majority of people who sustain a stroke live their lives with some enduring cognitive, emotional, and/or physical impairment. Such longterm disability leads to impaired occupational performance and QoL; up to 83% of people with stroke report decreased QoL four years post-stroke [12]. QoL is commonly decreased in people with stroke, likely because it is both complex and multidimensional, comprised of physical, cognitive, emotional, and social well-being variables [13]. While our study and others showed improvement in overall post-stroke QoL after yoga [9], that was a one-dimensional examination of QoL, which does not allow for a broader understanding of this complex outcome. Thus, the objective of this study was to assess the impact of yoga on the individual domains of QoL.

Methods

Design

This was a secondary data analysis of data derived from a randomized pilot study of yoga for people with stroke [9]. The primary
objective of the parent study was to test the efficacy of a yoga intervention to improve post-stroke balance.

Recruitment and participants

In the parent study, we recruited people from the Midwest in the United States through medical chart reviews and from local stroke support groups and research studies. Participants all met the following inclusion criteria for the parent study: chronic stroke (>6 months); >18 years old; completed all stroke-related rehabilitation; self-report of mobility impairment and able to stand with or without a device; ability to speak and understand English; >4 out of 6 on the short 6 item Mini-Mental State Examination (indicates minimal cognitive abilities to follow directions) [14]; and commitment to attend two assessments and 16 sessions of group yoga. Exclusion criteria included: receiving palliative care, lack of transportation; diagnosis of a medical contraindication (i.e. serious cardiac conditions or serious chronic obstructive pulmonary disease; severe weight-bearing pain; history of significant psychiatric illness; uncontrollable diabetes with recent weight loss); or currently enrolled in another research trial. No additional criteria were used for these analyses. Human subject approval was received and all participants consented to the study. Once baseline assessments were completed, participants were randomized to the yoga group or a wait-list control group (no intervention for 8 weeks) in a 2:1 ratio. We used a 2:1 ratio as we were exploring the efficacy and feasibility of delivering yoga to people with chronic stroke.

Measures

A trained research assistant collected assessment data at baseline (directly before the study) and at 8 weeks (after 8 weeks of yoga or 8 weeks of being on the wait-list). All data were collected during in-person assessments in a university research lab in the Midwest. We collected demographic and stroke characteristic information, including time since stroke.

We assessed QoL with the Stroke Specific Quality of Life (SSQoL) scale. The SSQoL is used to measure post-stroke QoL and is valid and reliable [15]. The SSQoL includes 12 domains and the use of a total score or individual domain mean scores are valid [16, 17]. Domains include Self-care; Vision; Language; Mobility; Work; Upper-extremity; Thinking; Personality; Mood; Family; Social; And Energy. Greater scores indicate higher QoL.

Intervention

Yoga was taught by a certified yoga therapist and delivered in a group format, not exceeding 10 individuals in a group. Yoga sessions were one hour, twice a week for 8 weeks. Due to a lack of knowledge about dosing of yoga or post-stroke rehabilitation [18], sixteen sessions over eight weeks was chosen based on clinical judgment. The yoga intervention was developed for this study through a collaboration of the yoga therapist and the rehabilitation scientists. As the primary outcome of the study was an improvement in balance, the protocol was developed to improve post-stroke balance by addressing strength and flexibility at the ankles and the hips [19]. Yoga was delivered via a standardized and progressive protocol that included modified yoga postures, breathing, and relaxation/meditation in sitting, standing, and supine positions (Table 1).

Table 1. Modified yoga postures.

Meditation included full body scans and body relaxation with a focus on the breath. As this was a federally funded research study, we did not fully address spiritually during the intervention.  However, when appropriate, participants were told that they may feel a spiritual connection (to whatever their personal belief might be) and that the connection might be enhanced through the practice. As many of the participants were veterans (mostly Vietnam and World War II), we completed body scans and relaxation over a true meditation as there was concern that the study staff was not equipped for addressing such psychological or emotional needs or trauma that may result from meditation (for example, some participants were prisoners of war in Nazi war camps). Yogic philosophies or teachings were not included, but affirmations were included. Individuals who were randomized to the wait-list control group received no intervention for the 8 weeks but were offered yoga after the 8-week assessment.

Data analysis

We used SPSS 22 for all data analyses (SPSS, Inc., Chicago). We included descriptive statistics for demographics and stroke characteristics. We assessed normality of data with the ShapiroWilk Test. Independent t-tests (or Mann-Whitney U non-parametric tests) were used to compare SSQoL domain scores between groups. We used paired t-tests (or Wilcoxon non-parametric tests) to compare baseline and 8-week SSQoL domain scores data for yoga and wait-list control groups. Due to looking at many variables of interest and a limited data set with exploratory data, α was set at .10.

Results

Forty-seven people enrolled in the study (37 in yoga and 10 in control), the average age was 63±8.8, 81% were male, 60% were white, and participants were 51±40.4 months poststroke event. There were no baseline differences between the yoga and control groups in demographics, stroke characteristics, or SSQoL domain mean scores. Following the intervention, there was a significant difference in the Mobility and Social Roles mean scores between the yoga and control group (Mobility, yoga 4.22±.65 vs control 3.43±.95, p=.007; Social Roles, yoga 3.21±1.18vs. control 2.6±.68, p=.058). In the yoga group, significant improvement occurred in multiple domains: Language (p=.059); Mobility (p=.023); Family Roles (p=.035); and Energy (p=.078) (See Table 2 for mean scores and p-value for each QoL domain). The mobility score for the control group significantly decreased (3.87±.78 vs 3.43±.95, p=.010) over the 8 weeks.

Discussion

In this secondary analysis, we found significant improvements in multiple domains of QoL for this sample of people with chronic stroke who completed an 8-week yoga intervention. The analysis of change in the individual domains of QoL provides additional information about the potential benefits of yoga for people with stroke and potentially other neurological disabilities. While we previously reported a significant improvement in the total SSQoL score (33.7±9.2 vs 35.8±9.1, p=.03) [9], these current analyses provide supplemental information about which specific QoL domains are changing. This allows us a better understanding of the impact of yoga in this study population.

Table 2 . Stroke Specific Quality of Life Domain scores before and after 8 weeks.

The SSQoL Mobility domain includes 6 items that address balance, walking, standing, strength, and endurance. In these analyses, the scores in the Mobility domain were: significantly different between the yoga and the wait-list control group; were significantly improved for people in the yoga group, and significantly decreased for the people in the wait-list control group. It is interesting that the people in the control group exhibited a significant decrease in mobility in just 8 weeks. This may demonstrate a need for continued intervention for people with chronic stroke. It is well known that decreased mobility is associated with decreased QoL, activity, and participation [20]. Additionally, the balance was included in this domain and decreased balance has been associated with decreased QoL, activity, and participation in people with stroke [21, 22]. As our focus was balance improvement, the differences in mobility were not surprising in these analyses.

Multiple other SSQoL domains also improved. Social Roles significantly improved in the yoga group compared to the waitlist control group and Family Roles significantly improved in the yoga group. The Social Role domain includes 6 items, addressing going out, seeing friends and family, hobbies, and general social life. The three Family Role items ask whether the stroke interfered with family activities and life, including whether the individual feels as though they were a burden. Some changes in both of these domains may be related to yoga, such as increased strength and ROM and decreased fatigue and pain, better-allowing participants to engage in their social and family roles. However, the changes in these domains are also likely linked to the therapeutic effects of group interventions, such as instillation of hope; group interaction; group cohesiveness; and interpersonal learning [23]. We noted that there was a concern for individuals when someone missed a yoga session and that person formed friendships that included meeting each other for coffee and helping each other with household tasks that could not be completed individually. It may also be that the yoga intervention helped to decrease the rumination on the lack of abilities. It is established that yoga improves positive emotions, attention, and thought-action performance [24]; for this sample, it is possible that by decreasing rumination on the past and on prior abilities, participants had improved positive emotions and social connectedness [25].

We also found a significant improvement in the SSQoL Energy domain for people in the yoga group. These three SSQoL items are related to fatigue, needing rest, and endurance. We found significant improvements in endurance, as measured by the 6-minute walk [10]; such changes in endurance were likely linked to improved physical functioning, but also because some of the specific yoga postures. For example, we included light back bending or extension in sitting, standing, and supine. Back extension is considered energizing [26] and may be associated with improved energy. Additionally, we included the Warrior I pose, which is a standing posture that includes slight back extension and a prolonged stretch of the hip flexors. Participants reported that the Warrior I posture was one of the most helpful postures for them, likely because it stretched out the hip flexors and helped them to stand taller (axial extension) and increased their ability to walk using a more normal and efficient gait pattern.

Study limitations

Limitations of the current analyses include: the study was randomized but not blinded; a small sample size; the control group was planned to include fewer individuals than the yoga group; sustainability was not assessed after the 8 week intervention; use of a self-report of QoL which is influenced by peoples’ own perceptions and ability to understand the questions; there is not an established minimally important difference for the SSQoL or the domains; and the primary outcome of the intervention was balance, thus the intervention likely had greater impact on the mobility domain of QoL than if the intervention was developed to addressed cognitive or emotional aspects of post-stroke disability. While these are important limitations to be addressed in a future yoga intervention study, these results do indicate that yoga may be a modality to be used by OTs and other health care practitioners to address multiple aspects of QoL.

Conclusion

In conclusion, yoga is a holistic intervention that addresses the whole person and is increasingly used by rehabilitation therapists with clients from multiple diagnostic populations. There has been a call for evidence for the use of yoga and other complementary health approaches within OT practice [2].  These data and analyses provide preliminary data for the use of yoga to improve multiple domains of QoL for people with stroke. Rehabilitation therapists, and health care practitioners in general, who wish to include yoga as a modality for treatment should receive advanced-level training or education to best use and understand yoga for people with disabilities.

Acknowledgements

This project was supported by VA QUERI RRP 09-095. Dr. Schmid was supported by a VA Career Development Award (VA RR&D CDA D6174W).

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