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March 2012 | Volume 22 | Number 2 PRIMARY HEALTH CARE16

Self-care

This arTicle aims to share evidence in support of prescribing yoga to patients in primary care as a method of stress management. a study review by hayes and chase (2010) found evidence that the regular practice of yoga helps reduce anxiety and stress. Given that there are few to no side effects, it is relatively inexpensive and can be performed anywhere by nearly everyone, it is difficult to find reasons not to prescribe yoga to patients.

Yoga possibly began more than 2,500 years ago in the hindu culture (seaward 2009). Translated from the sanskrit word, yoga means union of body, mind and spirit. The postures, asana (sanskrit for ‘sitting down’), were developed by Pantanjali, compiler of the yoga sutras, as a path to quiet the mind for meditation (seaward 2009). When swami rama, a yoga master from the himalayan institute, participated in a clinical trial in the 1970s, he amazed investigators with his ability to control autonomic nervous system functions such as respiratory and heart rate. This led researchers to consider whether the mind could control what were previously thought to be involuntary bodily functions (seaward 2009).

The benefiTs of YoGa in imProvinG healTh Lisa Diamond recommends the prescription of yoga to improve patients’ physical and mental wellbeing with little cost to the health service

abstract Many primary care presentations are related to stress. Yoga has been shown to improve many health issues including anxiety and stress. It is affordable and can be done by nearly anyone of any age or ability. Yoga has also been shown to improve immune function and allows patients a way to engage in self-management.

Keywords Anxiety, stress, self-management, yoga

The practice of yoga appears to have an anti-inflammatory effect on the endocrine system. links have been found to higher cortisol levels, but lower catecholamine levels, in people who engage in regular yoga practice (Daruna 2004). The body appears to view exercise as self-imposed stress, leading to transient modifications in immune function. however, this does not lead to disease but to a reduction in morbidity along with advanced longevity (Daruna 2004).

in states of stress, white blood cell counts are affected adversely; chronic stress and depression lead to the production of higher neutrophil counts, while a person’s inability to cope with anxiety can cause an increase in monocyte and eosinophil counts (Daruna 2004). Given the importance of the body’s ability to use its natural killer (nK) cells in antigen production and disease prevention, Daruna (2004) postulated that managing stress is paramount to achieving an overall state of wellness.

nK cells increase after exercise, giving the body an immune function boost to ward off invaders and enhance the search and destroy mission of these vital white blood cells (Daruna 2004). individuals who experience chronic stress are shown to have not only a reduction in their nK cells, but also an alteration in their cytotoxicity (Daruna 2004). Daruna found that people experiencing stress who did not perceive it as high, did not have a reduction in their nK cells’ ability to do their job properly. instead, their nK cells are enhanced (Daruna 2004).

ross and Thomas (2010) found that people who reported being lonely or depressed had a reduction in their nK cells, while people who described themselves as social introverts had an increase in nK cells. This suggests that it

Correspondence [email protected]

Lisa Diamond is nurse practitioner, Pikes Peak Regional Hospital, Colorado, United States, and health and wellness coach, Journey Into Wellness

Date of acceptance November 15 2011

Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software

Author guidelines www.primaryhealthcare.net

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is the perception of state of mind that affects how well our immune system functions.

studies suggest that yoga can reverse the negative impact on our immune system by increasing levels of immunoglobulin a (iga) and nK cells (ross and Thomas 2010). although the exact mechanism of action that yoga prompts is yet to be determined, it is hypothesised that it has an immediate effect on the sympathetic nervous system along with the hypothalmic-pituitary-adrenal axis (ross and Thomas 2010). Yoga has been shown ‘to have immediate psychological effects by decreasing anxiety along with increasing feelings of emotional, social, and spiritual wellbeing’ (ross and Thomas 2010).

The body’s physiological response to stress includes the activation of the autonomic nervous system (ans) along with the endocrine system (Kerr 2000). The sympathetic component of the ans activates the fight or flight mechanism, preparing the body for survival by increasing heart and respiratory rate, increasing blood sugar levels, shunting blood to the periphery for use by the muscles, and an increased ability of the blood to coagulate (Kerr 2000). The parasympathetic nervous system (Pns) is activated at the same time but its job is to counteract the ans back to its resting state.

The endocrine system responds to stressors by activating the adrenals to release cortisol, epinepherine and norepinepherine, and glucocorticoids, maintaining blood sugar to the muscles. These mechanisms work to enhance the fight or flight response (Kerr 2000). our emotions play a large part in the stress response and can activate the ans with physiological stress much like physical stress. short-term stress is designed to allow the individual to learn coping mechanisms for future use. however, if the physiological stressors become chronic, it can result in physical and mental illness.

our ability to engage the relaxation response is believed to come from the limbic system, particularly the hypothalamus – our pleasure centre in the brain. it is here that most research on relaxation is done to determine a person’s psychological health in outcome measures such as mood, anger, fatigue and anxiety (Kerr 2000).

between 75 and 90 per cent of visits to primary care services are related to stress (seaward 2009). it has been linked to nearly every major cause of death, such as heart disease, cancer, lung ailments, accidents, cirrhosis, and suicide (seaward 2009). many of these can be related to lifestyle. The implications for primary care and mental health practitioners are many. having knowledge of complementary alternative medicine (cam) to provide patients with the ability to increase their own self-care can be helpful.

Prescribing hayes and chase (2010) reviewed the literature and made recommendations to primary care providers for prescribing yoga. Yoga was found to: ■■ Decrease stress and anxiety. ■■ improve functional status and symptoms in low back pain.

■■ improve subjective and objective outcomes in asthma.

■■ improve physical and quality of life measures in older people.

■■ shorten duration of labour. ■■ benefit the management of eating disorders. ■■ improve birth outcomes.

an important trend to emerge is that of yoga therapy, which differs from a usual yoga practice. Georg feuerstein, former head of the international association of Yoga Therapists, states: ‘Yoga therapy aims at the holistic treatment of various kinds of psychological or somatic dysfunctions ranging from back problems to emotional distress’ (feuerstein 2012).

People who practice yoga on a regular basis report increased feelings of happiness, enhancement of meaning in their lives, and a stronger connection to others (hayes and chase 2010). The exact effect yoga has on the body is still in its empiric infancy in the Western world, but there is a large body of work in india. We have only begun to scratch the surface on all the effects regular yoga practice can have, not only on the body by way of flexibility, strengthening, balance, and breathing, but on the mind and its impact at a cellular level, specifically our white blood cells and immune function.

Styles it is important for the practitioner to be aware of the programmes in their local community and the qualifications of instructors. The british Wheel of Yoga is an excellent resource for classes and qualified instructors (www.bwy.org.uk). Doctors and nurses should acquaint themselves with the different styles of yoga and available venues in their community to prescribe the exercise appropriately. as with any exercise regimen, yoga can be dangerous if not done properly. it is important for practitioners who recommend yoga to encourage their patients to use only certified instructors to minimise injury. it is important to explain to patients the entire mind, body and spirit experience that yoga encompasses. Telles et al (2009) found that yoga practice, along with learning the theoretical framework of yoga, appeared to decrease anxiety.

Psychological measurements were taken in a study on stress management where members

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of a yoga group showed higher scores in life satisfaction, lower excitability, aggression, openness and emotion (Kerr 2000). somatic symptoms were lower, although not statistically significant. The yoga group scored higher in extroversion personality traits and had higher spirits. although earlier studies have been unable to validate physical improvements with yoga in areas such as hypertension, heart rate, and respiratory rate, ross and Thomas (2010) found a significant reduction in heart rate and blood pressure.

flisek (2001) provides encouraging anecdotal reports in children who have performed yoga, such as calmness, and a reduction in obesity and discipline problems, anger, and panic attacks, along with enhanced imagination, concentration, and academic performance. a decrease in the need for attention deficit hyperactivity disorder medication was also identified.

current literature supports yoga’s impact on improving metabolic rate and increasing lean muscle mass (Guarracino et al 2006). The link between obesity and mental illness includes depression, anxiety, post-traumatic stress disorder, binge eating disorder, and night eating syndrome (Diamond 2010).

in a study by smith et al (2007), yoga was found to be more effective at improving mental health than relaxation techniques, and as effective at reducing anxiety, stress and increasing physical and mental health and sleep ability. smith et al (2007) assert that patients who are interested in self-care to manage stress consider yoga to be a viable treatment option.

Klatt et al (2009) found that 20 minutes of yoga and meditation at a person’s desk each day, along with a one-hour weekly group class, lowered stressful feelings by more than 10 per cent and improved quality of sleep.

in a study on adolescents’ acute perceptions of stress, beets and mitchell (2010) found an improvement in physical health and overall

feelings of wellbeing and self-esteem. moreover, these benefits continued after the intervention. researchers postulated that yoga, along with family involvement therapies, may prove even more beneficial in alleviating stress in adolescents.

Dr beth cohen, an internist at the University of california, conducted a small pilot study in 2005 on peri-menopausal symptoms and found participants had a 30 per cent reduction in hot flushes after eight weeks of yoga (cohen et al 2007). in addition, participants were found to have improved patterns of sleep. a similar study, albeit with a control group, was conducted in india by chattha et al (2008); following eight weeks of yoga subjects reported fewer hot flushes, memory problems, and disturbed sleep, and less perceived stress (Griffin 2009).

Conclusion Yoga has been found to improve not only the perception of stress but its physiological impact on the ans, endocrine system, and the immune system. all of which can, over time, lead to disease, illness, and potentially death. it is vital that health practitioners find methods of stress reduction to offer their patients.

Yoga has few side effects, is low-cost, and can be done almost anywhere by anyone regardless of physical ability or age. it can also reduce the need for healthcare services and hence cost. Yoga is also a component of self-care where patients can take an active role in their own health and wellbeing instead of being an inactive participant in interventions given to them, such as tests, medications, or other therapies.

research to date proffers convincing evidence of yoga’s multiple health benefits, particularly in stress management. most patient encounters in a typical GP surgery or mental health clinic are believed to be related to stress, therefore building a range of stress-management modalities that patients can use as part of self-care is vital.

References Beets M, Mitchell E (2010) effects of yoga on stress, depression, and health-related quality of life in a nonclinical, bi-ethnic sample of adolescents: a pilot study. Hispanic Health Care International. 8, 1, 47-53.

Chattha R, Raghuram N, Venkatram P et al (2008) Treating the climacteric symptoms in indian women with an integrated approach to yoga therapy: a randomized control study. Menopause. 15, 5, 862-870.

Cohen BE, Kanaya AM, Macer JL et al (2007) feasibility and acceptability of restorative yoga for treatment of hot flushes: a pilot trial. Maturitas. 56, 2, 198-204.

Daruna J (2004) Introduction to Psychoneuroimmunology. elsevier academic Press, burlington ma.

Diamond L (2010) links between obesity and mental health. Clinical Advisor. march 2010.

Feuerstein G (2012) Contemporary Definitions of Yoga Therapy. international association of Yoga Therapists. Prescott aZ. www.iayt.org/ site_vx2/publications/articles/defs.aspx (last accessed: february 6 2012.)

Flisek L (2001) Teaching yoga to young schoolchildren. Positive Health. 70, 50-54.

Griffin K (2009) open to change. Yoga Journal. www.yogajournal.com/health/2580 (last accessed: January 31 2012.)

Guarracino J, Savino S, Edelstein S (2006) Yoga participation is beneficial to obesity prevention, hypertension control and positive quality of life. Topics in Clinical Nutrition. 21, 2, 108-113.

Hayes M, Chase S (2010) Prescribing yoga. Primary Care. 37, 1, 31-47.

Kerr K (2000) relaxation techniques: a critical review. Critical Reviews in Physical and Rehabilitation Medicine. 12, 1, 51-89.

Klatt M, Buckworth J, Malarkey W (2009) effects of low-dose mindfulness-based stress reduction (mbsr-ld) on working adults. Health Education and Behavior. 36, 3, 601-614.

Ross A, Thomas S (2010) The health benefits of yoga and exercise: a review of comparison studies. Journal of Alternative and Complementary Medicine. 16, 1, 3-12.

Seaward B (2009) Managing Stress: Principles and Strategies for Health and Wellbeing. sixth edition. Jones and bartlett, sudbury, ma.

Smith C, Hancock H, Blake-Mortimer J et al (2007) a randomised comparative trial of yoga and relaxation to reduce stress and anxiety. Complementary Therapies in Medicine. 15, 2, 77-83.

Telles S, Gaur V, Balkrishna A (2009) effect of a yoga practice session and a yoga theory session on state anxiety. Perceptual and Motor Skills. 109, 3, 924-930.

Conflict of interest None declared

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