This qualitative study explored the experiences of a young group of people with RA undertaking a 6-week course of yoga. As anticipated, the interviews proved to be a rich source of viewpoints regarding how functioning and well-being had been impacted. Baseline questions asking about expectations proved to be fruitful in understanding patient barriers to pursuing yoga. Follow-up interviews revealed changes in patient expectations regarding their suitability for yoga, as well as perceptions of physical and psychospiritual benefits of yoga practice.
Before the intervention, participants anticipated that yoga had much to offer practitioners, but they did not feel that a regular yoga class, full of supple and able-bodied students, could provide the level of support and medical expertise they would require. While some participants had considered attending a regular class, this had resulted in sitting at the back for the duration of the class or wandering by a class and leaving disheartened. This was in contrast to patient experiences undertaking the IY intervention in the present study. By the completion of the program participants realized they could practice yoga, provided that sufficient props, modifications and teacher expertise were available. Indeed, some participants noted a change in their expectations that yoga could only benefit those without physical limitations after the first class.
An important distinction exists between yoga practiced in the Iyengar tradition and other styles of yet available. Yoga is one of the fastest growing activities in the exercise industry and currently 6.1% of the adult US population practices yoga [16
]. There has been little comparative work examining the safety and suitability of the various traditions offered. Not all yoga classes provide an assurance of rigorous and systematized teacher training, supportive props and modifications for health conditions that patients with chronic conditions such as RA require. It may be argued that the initial reservations held by patients regarding the suitability of yoga for their health issues are justified. It is possible that without a sufficiently trained teacher knowledgeable about RA, patient safety may be compromised. Therefore we caution against generalizing the study findings to classes not within the IY tradition or other suitable medical classes.
The post-intervention interviews revealed a number of favorable outcomes. Participants consistently reported improved range of motion, energy, relaxation, sleep and mood. These benefits translated into enhanced daily functioning for the group, including relative ease in work, school and home life. The depth of participants’ responses offered clues as to possible underlying mechanisms explaining the association between yoga and enhanced well-being in this group. Participants expressed both physical and psychospiritual changes underpinning their improved functioning. Common physical changes that were reported included increased strength and flexibility which likely impacted range of motion and the perceived release of ‘feel good’ hormones which may have impacted states of relaxation indicative of parasympathetic system activation. Potential psychospiritual mechanisms evoked by participants’ responses included a new found sense of self-efficacy and acceptance of oneself, as well as elevated mood. Improved mood was evident in reports of feeling emotionally uplifted, hopeful and less depressed. Participants’ self-efficacy not only related to increased confidence in performing yoga poses and taking charge of their bodies; at least one participant demonstrated self-efficacy for other forms of exercise. This finding is consistent with research suggesting that yoga practice leads to improved confidence to engage in general physical activity [17
An emerging sense of awareness or mindfulness was also evident and extended from physical functioning – in the form of being mindful of escalating stress and correcting body posture - to psychospiritual awareness such as feeling more ‘enlightened’ and letting go of fear, pain and stress. In yoga practice, increased mindfulness is indicative of progress, as developing the skills to be aware of tension in the body and mind allows one to release this tension and associated pain [18
]. A significant increase in trait mindfulness following yoga has been reported previously in healthy individuals [19
], and the present results suggest a similar process for people with physical limitations.
The outcomes and perceived mechanisms reported here are consistent with our recent work conceptualizing the beneficial action of yoga on functioning [20
]. Our model, based on the extant yoga research and derived from the biopsychosocial view of pain and health, posits that yoga confers benefits on disease-specific and general health-related outcomes through physiological/structural and psychospiritual changes. The present study supports the relevance of such mechanisms as autonomic nervous system regulation, endocrine balance, musculoskeletal strength and flexibility, and a host of psychospiritual developments. We caution that this study is small and focuses on only one disease population, although the consistency with which participants reported such perceived mechanisms in response to open-ended questions regarding general functioning is initially compelling. The mechanisms identified by participants, including mind-body awareness, should be explored in future studies understanding how yoga may impact functioning.
One area that particularly deserves further investigation is the role of biological changes following yoga. In order to provide the level of evidence and understanding required for yoga to be recommended alongside conventional medicine, research needs to elucidate physiological mechanisms. Tests of autonomic nervous system arousal and disease markers are needed to understand how yoga impacts stress and disease activity within this population. Nevertheless, patient self-reports of improved well-being have an important place in the determination of treatment efficacy. Self-reported HRQOL is perhaps the most significant construct in monitoring a chronic disease’s impact [21
]. Improvements in HRQOL may be more telling than traditional medical symptoms such as joint counts and sedimentation rates when evaluating treatments for arthritis [22
]. The present findings, while limited to a small sample, therefore indicate the promise of IY for improving quality of life in young people with RA.
Although further research is required using a larger sample size and a randomized controlled design to rule out possible improvements due to nonspecific effects such as group membership and patient expectations, the present study underscores the promise of IY in addressing the physical and psychospiritual functioning of young people with RA. Previous research has found beneficial effects of yoga for older patients, but this is the first time we are aware of research documenting young patient experiences. These qualitative findings are consistent with our quantitative outcomes related to improved functioning, energy, mental health, and self-efficacy with this group [14
]. Given the open-ended nature of the interviews, the present findings provide a detailed, rich account of how yoga may impact wellbeing. It is our intention that the mechanisms identified by patients in this study highlight the importance of qualitative work – particularly for emerging research – and will help drive the selection of quantitative measure in future yoga research.