Effectiveness of an Unsupervised Online Yoga Program on Pain and Function in People With Knee Osteoarthritis: A Randomized Clinical Trial
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Visual Abstract. Effectiveness of an Online Yoga Program in People With Knee Osteoarthritis.
This randomized trial evaluated the effectiveness of yoga among adults with symptomatic knee osteoarthritis. The investigators assessed changes in knee pain during walking, physical function, and other outcomes over 12 weeks among adults who received online osteoarthritis information plus access to an unsupervised online yoga program versus information alone.
Abstract
Background:
Yoga is a mind–body exercise typically done in groups in person, but this delivery method can be inconvenient, inaccessible, and costly. Effective online programs may increase access to exercise for knee osteoarthritis.
Objective:
To evaluate the effectiveness of an unsupervised 12-week online yoga program.
Design:
Two-group superiority randomized trial. (Australian New Zealand Clinical Trials Registry: ACTRN12620000012976)
Setting:
Community.
Participants:
212 adults with symptomatic knee osteoarthritis.
Intervention:
Both groups received online osteoarthritis information (control). The yoga group also received access to an unsupervised online yoga program delivered via prerecorded videos over 12 weeks (1 video per week, with each session to be performed 3 times per week), with optional continuation thereafter.
Measurements:
Primary outcomes were changes in knee pain during walking (0 to 10 on a numerical rating scale) and physical function (0 to 68 on the Western Ontario and McMaster Universities Osteoarthritis Index) at 12 weeks (primary time point) and 24 weeks, analyzed using mixed-effects linear regression models. Secondary outcomes were self-reported overall knee pain, stiffness, depression, anxiety, stress, global change, quality of life, self-efficacy, fear of movement, and balance confidence. Adverse events were also collected.
Results:
A total of 195 (92%) and 189 (89%) participants provided 12- and 24-week primary outcomes, respectively. Compared with control at 12 weeks, yoga improved function (between-group mean difference in change, −4.0 [95% CI, −6.8 to −1.3]) but not knee pain during walking (between-group mean difference in change, −0.6 [CI, −1.2 to 0.1]), with more yoga participants than control participants achieving the minimal clinically important difference (MCID) for both outcomes. At 12 weeks, knee stiffness, quality of life, and arthritis self-efficacy improved more with yoga than the control intervention. Benefits were not maintained at 24 weeks. Adverse events were minor.
Limitation:
Participants were unblinded.
Conclusion:
Compared with online education, an unsupervised online yoga program improved physical function but not knee pain at 12 weeks in people with knee osteoarthritis, although the improvement did not reach the MCID and was not sustained at 24 weeks.
Primary Funding Source:
National Health and Medical Research Council and Centres of Research Excellence.
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References
1.
GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392:1789-1858. [PMID: 30496104] doi: 10.1016/S0140-6736(18)32279-7
2.
Stubbs B, Aluko Y, Myint PK, et al. Prevalence of depressive symptoms and anxiety in osteoarthritis: a systematic review and meta-analysis. Age Ageing. 2016;45:228-35. [PMID: 26795974] doi: 10.1093/ageing/afw001
3.
Manlapaz DG, Sole G, Jayakaran P, et al. Risk factors for falls in adults with knee osteoarthritis: a systematic review. PM R. 2019;11:745-57. [PMID: 30609282] doi: 10.1002/pmrj.12066
4.
Doré AL, Golightly YM, Mercer VS, et al. Lower-extremity osteoarthritis and the risk of falls in a community-based longitudinal study of adults with and without osteoarthritis. Arthritis Care Res (Hoboken). 2015;67:633-9. [PMID: 25331686] doi: 10.1002/acr.22499
5.
van Schoor NM, Dennison E, Castell MV, et al; EPOSA research group. Clinical osteoarthritis of the hip and knee and fall risk: the role of low physical functioning and pain medication. Semin Arthritis Rheum. 2020;50:380-6. [PMID: 32199610] doi: 10.1016/j.semarthrit.2020.02.006
6.
Eyles JP, Hunter DJ, Briggs AM, et al. National Osteoarthritis Strategy brief report: living well with osteoarthritis. Aust J Gen Pract. 2020;49:438-42. [PMID: 32600001] doi: 10.31128/AJGP-08-19-5051-02
7.
Fransen M, McConnell S, Harmer AR, et al. Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev. 2015;1:CD004376. [PMID: 25569281] doi: 10.1002/14651858.CD004376.pub3
8.
Liao CD, Chen HC, Kuo YC, et al. Effects of muscle strength training on muscle mass gain and hypertrophy in older adults with osteoarthritis: a systematic review and meta-analysis. Arthritis Care Res (Hoboken). 2020;72:1703-18. [PMID: 31628720] doi: 10.1002/acr.24097
9.
Bannuru RR, Osani MC, Vaysbrot EE, et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage. 2019;27:1578-89. [PMID: 31278997] doi: 10.1016/j.joca.2019.06.011
10.
Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis Rheumatol. 2020;72:220-33. [PMID: 31908163] doi: 10.1002/art.41142
11.
Zhang Y, Lauche R, Cramer H, et al. Increasing trend of yoga practice among U.S. adults from 2002 to 2017. J Altern Complement Med. 2021;27:778-85. [PMID: 34076530] doi: 10.1089/acm.2020.0506
12.
Elwy AR, Groessl EJ, Eisen SV, et al. A systematic scoping review of yoga intervention components and study quality. Am J Prev Med. 2014;47:220-32. [PMID: 24996759] doi: 10.1016/j.amepre.2014.03.012
13.
Lauche R, Hunter DJ, Adams J, et al. Yoga for osteoarthritis: a systematic review and meta-analysis. Curr Rheumatol Rep. 2019;21:47. [PMID: 31338685] doi: 10.1007/s11926-019-0846-5
14.
Brinsley J, Smout M, Davison K. Satisfaction with online versus in-person yoga during COVID-19. J Altern Complement Med. 2021;27:893-6. [PMID: 34339262] doi: 10.1089/acm.2021.0062
15.
Australian Bureau of Statistics. Household use of information technology. 28 March 2018.
16.
Dobson F, Bennell KL, French SD, et al. Barriers and facilitators to exercise participation in people with hip and/or knee osteoarthritis: synthesis of the literature using behavior change theory. Am J Phys Med Rehabil. 2016;95:372-89. [PMID: 26945211] doi: 10.1097/PHM.0000000000000448
17.
Brosnan P, Nauphal M, Tompson MC. Acceptability and feasibility of the online delivery of Hatha yoga: a systematic review of the literature. Complement Ther Med. 2021;60:102742. [PMID: 34144493] doi: 10.1016/j.ctim.2021.102742
18.
Martin AC, Candow D. Effects of online yoga and tai chi on physical health outcome measures of adult informal caregivers. Int J Yoga. 2019;12:37-44. [PMID: 30692782] doi: 10.4103/ijoy.IJOY_5_18
19.
Huberty J, Eckert R, Larkey L, et al. Perceptions of myeloproliferative neoplasm patients participating in an online yoga intervention: a qualitative study. Integr Cancer Ther. 2018;17:1150-62. [PMID: 30352518] doi: 10.1177/1534735418808595
20.
Uebelacker L, Dufour SC, Dinerman JG, et al. Examining the feasibility and acceptability of an online yoga class for mood disorders: a MoodNetwork study. J Psychiatr Pract. 2018;24:60-67. [PMID: 29320386] doi: 10.1097/PRA.0000000000000286
21.
Zernicke KA, Campbell TS, Speca M, et al. A randomized wait-list controlled trial of feasibility and efficacy of an online mindfulness-based cancer recovery program: the eTherapy for Cancer Applying Mindfulness trial. Psychosom Med. 2014;76:257-67. [PMID: 24804884] doi: 10.1097/PSY.0000000000000053
22.
Osteoarthritis Action Alliance; Centers for Disease Control and Prevention; Arthritis Foundation. A National Public Health Agenda for Osteoarthritis: 2020 Update. 2020.
23.
Moonaz S, Nault D, Cramer H, et al. CLARIFY 2021: explanation and elaboration of the Delphi-based guidelines for the reporting of yoga research. BMJ Open. 2021;11:e045812. [PMID: 34353794] doi: 10.1136/bmjopen-2020-045812
24.
National Institute for Health and Care Excellence. Osteoarthritis: care and management. Clinical guideline [CG177]. 12 February 2014.
25.
Exercise & Sports Science Australia. Adult Pre-Exercise Screening System (APSS). Accessed at www.essa.org.au/Public/ABOUT_ESSA/Pre-Exercise_Screening_Systems.aspx on 29 September 2020.
26.
Michie S, Ashford S, Sniehotta FF, et al. A refined taxonomy of behaviour change techniques to help people change their physical activity and healthy eating behaviours: the CALO-RE taxonomy. Psychol Health. 2011;26:1479-98. [PMID: 21678185] doi: 10.1080/08870446.2010.540664
27.
Nicolson PJA, Hinman RS, French SD, et al. Improving adherence to exercise: do people with knee osteoarthritis and physical therapists agree on the behavioral approaches likely to succeed. Arthritis Care Res (Hoboken). 2018;70:388-97. [PMID: 28575544] doi: 10.1002/acr.23297
28.
Hawker GA, Mian S, Kendzerska T, et al. Measures of adult pain: visual analog scale for pain (VAS pain), numeric rating scale for pain (NRS pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care Res (Hoboken). 2011;63 Suppl 11:S240-52. [PMID: 22588748] doi: 10.1002/acr.20543
29.
McHugh M, Droy E, Muscatelli S, et al. Measures of adult knee function. Arthritis Care Res (Hoboken). 2020;72 Suppl 10:219-49. [PMID: 33091264] doi: 10.1002/acr.24235
30.
McAlindon TE, Driban JB, Henrotin Y, et al. OARSI Clinical Trials Recommendations: design, conduct, and reporting of clinical trials for knee osteoarthritis. Osteoarthritis Cartilage. 2015;23:747-60. [PMID: 25952346] doi: 10.1016/j.joca.2015.03.005
31.
Bellamy N, Kirwan J, Boers M, et al. Recommendations for a core set of outcome measures for future phase III clinical trials in knee, hip, and hand osteoarthritis. Consensus development at OMERACT III. J Rheumatol. 1997;24:799-802. [PMID: 9101522]
32.
Bellamy N, Carette S, Ford PM, et al. Osteoarthritis antirheumatic drug trials. III. Setting the delta for clinical trials—results of a consensus development (Delphi) exercise. J Rheumatol. 1992;19:451-7. [PMID: 1578462]
33.
Bellamy N, Buchanan WW, Goldsmith CH, et al. Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol. 1988;15:1833-40. [PMID: 3068365]
34.
Tubach F, Ravaud P, Baron G, et al. Evaluation of clinically relevant changes in patient reported outcomes in knee and hip osteoarthritis: the minimal clinically important improvement. Ann Rheum Dis. 2005;64:29-33. [PMID: 15208174]
35.
Bellamy N. Osteoarthritis clinical trials: candidate variables and clinimetric properties. J Rheumatol. 1997;24:768-78. [PMID: 9101516]
36.
Delbaere K, Hauer K, Lord SR. Evaluation of the incidental and planned activity questionnaire (IPEQ) for older people. Br J Sports Med. 2010;44:1029-34. [PMID: 19474003] doi: 10.1136/bjsm.2009.060350
37.
Osborne RH, Hawthorne G, Lew EA, et al. Quality of life assessment in the community-dwelling elderly: validation of the Assessment of Quality of Life (AQoL) Instrument and comparison with the SF-36. J Clin Epidemiol. 2003;56:138-47. [PMID: 12654408]
38.
Lorig K, Chastain RL, Ung E, et al. Development and evaluation of a scale to measure perceived self-efficacy in people with arthritis. Arthritis Rheum. 1989;32:37-44. [PMID: 2912463]
39.
Shelby RA, Somers TJ, Keefe FJ, et al. Brief Fear of Movement Scale for Osteoarthritis. Arthritis Care Res (Hoboken). 2012;64:862-71. [PMID: 22290689] doi: 10.1002/acr.21626
40.
Talley KM, Wyman JF, Gross CR. Psychometric properties of the Activities-Specific Balance Confidence Scale and the Survey of Activities and Fear of Falling in older women. J Am Geriatr Soc. 2008;56:328-33. [PMID: 18179492] doi: 10.1111/j.1532-5415.2007.01550.x
41.
Meade LB, Bearne LM, Godfrey EL. Comprehension and face validity of the Exercise Adherence Rating Scale in patients with persistent musculoskeletal pain. Musculoskeletal Care. 2018;16:409-12. [PMID: 29575381] doi: 10.1002/msc.1240
42.
Fransen M, McConnell S, Harmer AR, et al. Exercise for osteoarthritis of the knee: a Cochrane systematic review. Br J Sports Med. 2015;49:1554-7. [PMID: 26405113] doi: 10.1136/bjsports-2015-095424
43.
Bennell KL, Campbell PK, Egerton T, et al. Telephone coaching to enhance a home-based physical activity program for knee osteoarthritis: a randomized clinical trial. Arthritis Care Res (Hoboken). 2017;69:84-94. [PMID: 27111441] doi: 10.1002/acr.22915
44.
Wasserstein RL, Schirm AL, Lazar NA. Moving to a world beyond “p < 0.05”. Am Stat. 2019;73(suppl 1):1-19. doi: 10.1080/00031305.2019.1583913
45.
Fitzmaurice G, Laird NM, Ware JH. Applied Longitudinal Analysis. 2nd ed. J Wiley; 2011.
46.
Alaiti RK, Castro J, Lee H, et al. What are the mechanisms of action of cognitive-behavioral, mind-body, and exercise-based interventions for pain and disability in people with chronic primary musculoskeletal pain? A systematic review of mediation studies from randomized controlled trials. Clin J Pain. 2022;38:502-9. [PMID: 35686580] doi: 10.1097/AJP.0000000000001047
47.
Lima YL, Lee H, Klyne DM, et al. How do non-surgical interventions improve pain and physical function in people with osteoarthritis? A scoping review of mediation analysis studies. Arthritis Care Res (Hoboken). 2022. [PMID: 35866717] doi: 10.1002/acr.24983
48.
Zhang W, Robertson J, Jones AC, et al. The placebo effect and its determinants in osteoarthritis: meta-analysis of randomised controlled trials. Ann Rheum Dis. 2008;67:1716-23. [PMID: 18541604] doi: 10.1136/ard.2008.092015
49.
Moustgaard H, Clayton GL, Jones HE, et al. Impact of blinding on estimated treatment effects in randomised clinical trials: meta-epidemiological study. BMJ. 2020;368:l6802. [PMID: 31964641] doi: 10.1136/bmj.l6802
50.
Sakellariou G, Conaghan PG, Zhang W, et al. EULAR recommendations for the use of imaging in the clinical management of peripheral joint osteoarthritis. Ann Rheum Dis. 2017;76:1484-94. [PMID: 28389554] doi: 10.1136/annrheumdis-2016-210815
51.
Quicke JG, Runhaar J, van der Windt DA, et al. Moderators of the effects of therapeutic exercise for people with knee and hip osteoarthritis: a systematic review of sub-group analyses from randomised controlled trials. Osteoarthr Cartil Open. 2020;2:100113. doi: 10.1016/j.ocarto.2020.100113
52.
Cheung C, Wyman JF, Savik K. Adherence to a yoga program in older women with knee osteoarthritis. J Aging Phys Act. 2016;24:181-8. [PMID: 26214142] doi: 10.1123/japa.2015-0048
53.
Pisters MF, Veenhof C, Schellevis FG, et al. Exercise adherence improving long-term patient outcome in patients with osteoarthritis of the hip and/or knee. Arthritis Care Res (Hoboken). 2010;62:1087-94. [PMID: 20235201] doi: 10.1002/acr.20182
54.
Meade LB, Bearne LM, Sweeney LH, et al. Behaviour change techniques associated with adherence to prescribed exercise in patients with persistent musculoskeletal pain: systematic review. Br J Health Psychol. 2019;24:10-30. [PMID: 29911311] doi: 10.1111/bjhp.12324
55.
Park J, Sherman DG, Agogo G, et al. Frailty modifies the intervention effect of chair yoga on pain among older adults with lower extremity osteoarthritis: secondary analysis of a nonpharmacological intervention trial. Exp Gerontol. 2020;134:110886. [PMID: 32088398] doi: 10.1016/j.exger.2020.110886
56.
Bossen D, Veenhof C, Van Beek KE, et al. Effectiveness of a web-based physical activity intervention in patients with knee and/or hip osteoarthritis: randomized controlled trial. J Med Internet Res. 2013;15:e257. [PMID: 24269911] doi: 10.2196/jmir.2662
57.
Allen KD, Arbeeva L, Callahan LF, et al. Physical therapy vs internet-based exercise training for patients with knee osteoarthritis: results of a randomized controlled trial. Osteoarthritis Cartilage. 2018;26:383-96. [PMID: 29307722] doi: 10.1016/j.joca.2017.12.008
58.
Carpenter JR, Kenward MG. Multiple Imputation and Its Application. J Wiley; 2013. doi: 10.1002/9781119942283
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Published In
Annals of Internal Medicine
Volume 175 • Number 10 • October 2022
Pages: 1345 - 1355
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Published online: 20 September 2022
Published in issue: October 2022
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© 2022 American College of Physicians.
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Effectiveness of an Unsupervised Online Yoga Program on Pain and Function in People With Knee Osteoarthritis: A Randomized Clinical Trial. Ann Intern Med.2022;175:1345-1355. [Epub 20 September 2022]. doi:10.7326/M22-1761
Effectiveness of an Unsupervised Online Yoga Program on Pain and Function in People With Knee Osteoarthritis: A Randomized Clinical Trial. Ann Intern Med.2022;175:1345-1355. [Epub 20 September 2022]. doi:10.7326/M22-1761
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Better physical result than expected; with an important issue
The physical result of such a short and delimited practice was actually better than expected.
However, this was not yoga.
Yoga is not a delimited practice of a certain period of time for a certain period of time. Yoga is a state of mind and is extended over time. Yoga requires the relinquishing of expectations, judgment, and competition, and even the very reason for which the practice was begun. Thus it would be extremely difficult to use standard statistical assessment analysis to measure improvements in simple physical symptoms or findings. One half an hour, three times a week for twelve weeks, may seem like a standard for physical therapy, but it is merely an initiation for yoga. Yoga is not an exercise, it becomes a lifestyle. Patanjali, said to have been a sage, grammarian, mathematician and physician of the early centuries of the first millennium of this era codified yoga, from a Sanskrit root which means yoke as it connects mind and body, gaze, and breath, in a series of 196 aphorisms the most important of which include advice to the present Anna and that yoga reduces the fluctuations of consciousness in the practitioner and that the pastures should be sweet and stable. That's exactly what takes the most practice. The physical healing is not the emphasis of yoga practice; it is almost a byproduct or side effect. Too many people go to single yoga practices with expectations and are disappointed.
Go in with no expectations. You might like it.
Effectiveness of an Unsupervised Online Yoga Program on Pain and Function in People With Knee Osteoarthritis
We read the original research entitled “Effectiveness of an Unsupervised Online Yoga Program on Pain and Function in People With Knee Osteoarthritis,” published by Bennell and colleagues (1) with the most interest. The group compared the effectiveness of an unsupervised 12-week Yoga intervention and online education with the non-Yoga group consisting of 212 adults with symptomatic knee osteoarthritis in a pragmatic randomized trial. The primary outcome was an improvement in the knee pain during walking and physical function post-12 weeks of intervention. Although the results are reassuring, we believe that the recruitment of the participants and the yoga protocol could have been improved.
Increased body weight plays a significant role in osteoarthritis (2). A person with a similar BMI could be an inclusion criterion for participation. Recruitment of patients with similar etiology of osteoarthritis (e.g., stress, overweight, aging, sedentary lifestyle, etc.) could create a firm conclusion (2). Obesity, a co-morbid condition, leads to the wasting of muscles around the joint. Muscle wasting directly affects joint stability and leads to loss of mobility and cartilage degeneration (3). The module followed needs to be more specific as the practices of asana, pranayama, breathing, relaxation, and meditation are not clearly mentioned. As the patients were new to yoga, the breathing followed by practices was difficult to follow. That could directly affect the results. Yoga practice might help to reduce pain as per the pain gate theory, but the results of this paper do not support this theory. The study showed improvement in mobility, but no improvement in pain on walking, which are directly correlated to each other. The joint movement would improve after the pain reduction (4). The study also lacks biochemical and molecular markers-based analysis.
To add more to the discussion, the underlying molecular mechanism of yoga in osteoarthritis is not known. However, the multidimensional approach of yoga, which consists of asanas, pranayama, meditation, and spiritual, may help relieve osteoarthritis symptoms. Such physical interventions may prevent the degeneration of cartilage. The physical postures in Hatha yoga practice may help strengthen the periarticular muscles, which contract to stabilize the knee pain. Further, the yoga postures stretch and strengthen different body internal organs and help lubricate the muscles, joints, and ligaments, thereby preventing the deterioration of synovial fluid volume (5). The pain perception and functional status improve after the yoga practice through the HPA axis by down-regulating the sympathetic nervous system.
References