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Rheumatology Advance Access published August 9, 2013

RHEUMATOLOGY

53, 258, 268

Concise report

doi:10.1093/rheumatology/ket264

Yoga for rheumatic diseases: a systematic review


Holger Cramer1, Romy Lauche1, Jost Langhorst1 and Gustav Dobos1
Abstract
Objective. To evaluate the quality of evidence and the strength of recommendation for yoga as an
ancillary intervention in rheumatic diseases.

Conclusion. Based on the results of this review, only weak recommendations can be made for the
ancillary use of yoga in the management of FM syndrome, OA and RA at this point.
Key words: yoga, complementary therapies, rheumatology, rheumatoid arthritis, osteoarthritis, fibromyalgia,
carpal tunnel syndrome, review.

Introduction
Yoga is widely used by patients with a variety of rheumatic
diseases. According to the 2002 National Health Interview
Survey, patients with rheumatic diseases were 1.56 times
more likely to have practiced yoga within the last
12 months compared with the general population [1].
Deriving from ancient Indian philosophy, yoga comprises
physical exercise, relaxation and lifestyle modification [2].
In North America and Europe, yoga is most often associated with physical postures, breathing techniques and
meditation [3]. Systematic reviews have shown that yoga
seems to be a safe and effective intervention for patients
with arthritis [4] or FM [5]. However, no systematic review
has thoroughly investigated the effects of yoga on rheumatic diseases as a whole. The aim of this systematic

1
Department of Internal and Integrative Medicine, Kliniken EssenMitte, Faculty of Medicine, University of Duisburg-Essen, Essen,
Germany.

Submitted 13 March 2013; revised version accepted 20 June 2013.


Correspondence to: Holger Cramer, Kliniken Essen-Mitte, Klinik fur
Naturheilkunde und Integrative Medizin, Knappschafts-Krankenhaus,
Am Deimelsberg 34a, 45276 Essen, Germany.
E-mail: h.cramer@kliniken-essen-mitte.de

review was to evaluate the quality of available evidence


and the strength of the recommendation for yoga as
a therapeutic means in the management of rheumatic
diseases.

Methods
Preferred Reporting Items for Systematic Reviews
and Meta-Analyses (PRISMA) guidelines [6] and the
recommendations of the Cochrane Collaboration [7]
were followed.

Eligibility criteria
Types of studies
Randomized controlled trials (RCTs) and randomized
crossover studies were eligible. No language restrictions
were applied.
Types of participants
Patients with rheumatic diseases (e.g. RA, OA, FM, osteoporosis, gout, lupus erythematosus, Pagets disease, PsA,
Raynauds disease, reactive arthritis, bursitis, tendinitis,
CTS, tarsal tunnel syndrome, plantar fasciitis, SpA, SSc
and vasculitis) were eligible.

! The Author 2013. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oup.com

CLINICAL
SCIENCE

Results. Eight RCTs with a total of 559 subjects were included; two RCTs had a low risk of bias. In two
RCTs on FM syndrome, there was very low evidence for effects on pain and low evidence for effects on
disability. In three RCTs on OA, there was very low evidence for effects on pain and disability. Based on
two RCTs, very low evidence was found for effects on pain in RA. No evidence for effects on pain was
found in one RCT on CTS. No RCT explicitly reported safety data.

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Methods. Medline/PubMed, Scopus, the Cochrane Library and IndMED were searched through February
2013. Randomized controlled trials (RCTs) comparing yoga with control interventions in patients with
rheumatic diseases were included. Two authors independently assessed the risk of bias using the
Cochrane Back Review Group risk of bias tool. The quality of evidence and the strength of the recommendation for or against yoga were graded according to the GRADE recommendations.

Holger Cramer et al.

Types of intervention
Studies that compared yoga interventions with no treatment or any active treatment were eligible. Studies were
excluded if yoga was not the main intervention but part of
a multimodal intervention. No restrictions were made regarding yoga tradition, length, frequency or duration of the
program. Co-interventions were allowed.
Types of outcome
For inclusion, RCTs had to assess at least one primary
outcome, i.e. pain intensity orfunction. Secondary outcomes included quality of life, psychological distress
and safety of the intervention.

Search methods

Data extraction and management


Data on patients, methods, interventions, control interventions, outcomes and results were extracted by two
authors independently using an a priori developed data
extraction form. Discrepancies were discussed with a
third review author until consensus was reached.

Risk of bias in individual studies


The risk of bias was assessed by two authors independently using the risk of bias tool proposed by the Cochrane
Back Review Group [8]. This tool assesses the risk of
selection bias, performance bias, attrition bias, reporting
bias and detection bias using 12 criteria (ratings: low, unclear or high risk of bias). Differences of opinion were discussed with a third review author until a consensus was
reached. Studies that met at least 6 of the 12 criteria and
had no serious flaw were rated as having a low risk of
bias. Studies that met fewer than six criteria or had a serious flaw were rated as having a high risk of bias [8].

Quality of evidence
Based on the methodological quality and the confidence
in the results, the quality of evidence for each outcome in
each specific disease was assessed according to the
GRADE recommendations as high quality, moderate quality, low quality or very low quality [9].

Strength of recommendation
Based on the direction and quality of the evidence and
the risk of undesirable effects of the intervention, the

Results
Literature search
The literature search revealed 269 non-duplicate records,
of which 250 were excluded because they were not RCTs,
did not include patients with rheumatic diseases and/or
did not include yoga as an intervention. Of 19 full texts
assessed for eligibility, 5 articles were excluded because
they were either not randomized [1013] or did not include
yoga interventions [14]. Another article was excluded that
compared yoga with yoga combined with massage [15].
Thirteen full-text articles reporting on eight RCTs were
finally included in the analysis [1628] (Fig. 1).
The characteristics and overall risk of bias of the
included studies are shown in Table 1. In-depth information on the characteristics and results of the included
studies can be found in supplementary Table S2, available
as supplementary data at Rheumatology Online.
Supplementary Table S3, available as supplementary
data at Rheumatology Online, shows a detailed risk of
bias assessment of the included studies. GRADE criteria
for each disease and outcome are shown in supplementary Table S4, available as supplementary data at
Rheumatology Online.

FM syndrome
An RCT with low risk of bias from the USA assessed the
effects of an 8-week Yoga of Awareness intervention
compared with usual care in 56 female FM patients
(mean age 53.7 years) [17, 18]. The yoga intervention
included yoga postures, meditation, breathing techniques
and lessons on yogic coping strategies. Outcome measures included pain, using number of tender points and
extent of tenderness, and disability, using the
Fibromyalgia Impact Questionnaire (FIQ). Significant
group differences were found for disability only; no
safety data were reported.
A second RCT originated from Brazil, had low risk of
bias and assessed the effects of a water-based breathing
yoga intervention, 60 min four times a week over a period
of 4 weeks, in 40 female FM patients (mean age 46.06
years) [26]. The intervention included breathing techniques, but no yoga postures or meditation. Both the
intervention and the control group participated in recreational activities once weekly. This RCT reported significant group differences favouring the yoga group in pain
on a visual analogue scale (VAS), disability on the FIQ and
anxiety on the Hamilton Anxiety Scale (HAS). No safety
data were reported.
Using the GRADE approach, the quality of evidence for
pain in FM syndrome was very low and the quality of evidence for disability was low. Overall, a weak recommendation can be made for the use of yoga in FM syndrome.

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Medline/PubMed, Scopus, the Cochrane Library and


IndMED were searched from their inception through
11 February 2013. The complete search strategies for
each database are shown in supplementary Table S1,
available as supplementary data at Rheumatology
Online. Reference lists of identified original articles or reviews and the tables of contents of the International
Journal of Yoga Therapy and the Journal of Yoga &
Physical Therapy were searched manually. Two review
authors independently screened abstracts identified
during the literature review and potentially eligible articles
were read in full to determine whether they met the eligibility criteria.

strength of the recommendation for or against yoga as a


therapeutic option for each specific disease was judged
according to the GRADE recommendations as either
strong or weak [9].

Yoga for rheumatic diseases

FIG. 1 Flowchart of the results of the literature search.

An Indian trial with a high risk of bias included 250 patients


with OA of the knee (69.9% female; mean age 59.49
years). This RCT compared a 2-week hatha yoga intervention including yoga postures, meditation, relaxation,
breathing techniques and lectures for 40 min each day
with an aerobic exercise intervention of matched intensity
[1922]. Significant group differences were found for pain
at rest and while walking assessed on a VAS, disability on
the WOMAC, all subscales of health-related quality of life
on the Short Form 36 Health Survey (SF-36) and anxiety
on the State-Trait Anxiety Inventory (STAI). While safety
data were not included, three drop-outs due to adverse
events in the control group and none in the yoga group
were reported [1922].
An RCT from the USA included 25 patients with OA of
the interphalangeal joints. The RCT had a risk of bias. Age
ranged from 52 to 79 years and 56% were female [24].
Compared with usual care, a 10-week Iyengar yoga intervention including 60 min of yoga postures, relaxation and
education twice weekly resulted in significant group differences in hand pain during activities on a VAS but not
in pain at rest on a VAS or disability on the Stanford
Hand Assessment Questionnaire. Safety data were not
reported [24].
Originating from the USA, a third RCT compared chair
yoga (sitting meditation) twice weekly for 45 min over
8 weeks with Reiki (a spiritual healing intervention) once
weekly for 30 min over 8 weeks [27]. Twenty-one patients
with OA of different joints were included (mean age 80.0

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years). Significant group differences were found for the


WOMAC disability scale but not for the WOMAC pain
scale or depression on the Center for Epidemiologic
Studies Depression Scale (CES-D). No safety data were
reported [27].
According to the GRADE approach, the overall quality
of evidence for effects of yoga on pain and disability in OA
was graded very low. A weak recommendation can be
made for the use of yoga in OA.

RA
An RCT with a high risk of bias from the USA compared a
6-week Iyengar yoga intervention including yoga postures
and relaxation 90 min twice weekly with usual care [23].
The RCT included 30 young women (mean age 29.9 years)
with RA. The RCT found no group differences in bodily
pain on the SF-36. Significant effects were reported for
disability using the Health Assessment Questionnaire
Disability Index (HAQ-DI) and the Pain Disability Index
(PDI), for vitality and general health on the SF-36 and for
distress on the Brief Symptom Inventory. Safety was not
reported.
A second RCT originating from India had a high risk of
bias [28]. This RCT included 80 patients with RA (mean
age 35.08 years, 70% female). The yoga intervention
included postures, cleansing practices, breathing techniques, meditation and lifestyle advice for 90 min six
times each week for 7 weeks. Compared with usual
care, yoga significantly reduced pain on the Simple

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OA

RA

OA of the hand

CTS
FM syndrome

OA of the hip
or knee
RA

Evans et al. [23]

Garfinkel et al. [24]

Garfinkel et al. [25]


Ide et al. [26]

Park et al. [27]

FIQ-R: Revised FIQ.

Singh et al. [28]

OA of the knee

Ebnezar et al.
[1922]

Carson et al. [17, 18] FM syndrome

Rheumatic
disease

80

29

51
40

25

30

250

56

8
4

10

12

8
Exercise,
280 min/week

Usual care

Control
intervention

Yoga, 540 min/week

Chair yoga, 90 min/week

Iyengar yoga, 90 min/week


Yoga breathing exercise,
240 min/week

Iyengar yoga, 60 min/week

6 weeks
14 weeks
10 weeks

8 weeks
5 months
2 weeks
14 weeks

Outcome
assessment

Usual care

7 weeks

Wrist splint
8 weeks
Recreational
4 weeks
activities,
60 min/week
Reiki, 30 min/week 8 weeks

Usual care

Iyengar yoga, 180 min/week Usual care

Yoga of awareness,
120 min/week
Hatha yoga, 280 min/week

Sample
Treatment
size, n duration, weeks Experimental intervention

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Reference

TABLE 1 Characteristics of the included studies

Disability (WOMAC), depression


(CES-D)
Pain (SDPIS)

Pain (myalgic tender points), disability


(FIQ-R)
Pain (pain at rest, pain while walking
on VAS), disability (WOMAC), quality
of life (SF-36), anxiety (STAI), safety
(drop-outs)
Disability (PDI, HAQ-DI), quality of life
(SF-36), distress (BSI)
Pain (pain at rest, pain during activity
on VAS), disability (Stanford Hand
Assessment Questionnaire)
Pain (VAS)
Pain (VAS), disability (FIQ), quality
of life (SF-36), anxiety (HAS)

Outcome measures

High

High

High
Low

High

High

High

Low

Risk of
bias

Holger Cramer et al.

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Yoga for rheumatic diseases

Descriptive Pain Intensity Scale (SDPIS). Safety data were


not reported.
Using GRADE, the quality of evidence for the effects of
yoga on pain was graded as very low. Only a weak recommendation can be made for the use of yoga in RA.

Only two RCTs had a low risk of bias. Therefore, while


the effects for FM found in this review seem to be robust
against methodological bias, the effects found for RA and
OA have to be interpreted with care.

Limitations
CTS
A US RCT with a high risk of bias included 51 CTS patients (mean age 48.08 years, 54.9% female). The RCT
compared an 8-week Iyengar yoga intervention, 90 min
twice weekly, including yoga postures and relaxation,
with a standard wrist splint [25]. As this RCT did not find
significant group differences in pain on a VAS and did not
report safety data, no recommendation can be made for
or against yoga in CTS.

Discussion

Agreements with prior systematic reviews


The findings of this review are partly in line with a prior
systematic review that found evidence of the effectiveness of yoga in improving pain and mental health in
patients with OA and RA but concluded that the heterogeneity of studies precluded preliminary conclusions [4].
Based on the same RCTs as the present review [17, 18,
26], a systematic review on meditative movement therapies for FM found evidence of the effectiveness of yoga on
pain, depression and quality of life [5]. Mainly based on
low back pain studies, two recent meta-analyses on yoga
for musculoskeletal conditions [29] or pain [30] concluded
that there was good quality evidence of effectiveness on
pain and disability. Based on the same single RCT as the
present review [25], systematic reviews on conservative
treatment of CTS concluded that there was very limited
[35] to limited [36] evidence of the effectiveness of yoga in
this condition. A recent Cochrane review statistically reanalysed this RCT and found favourable effects of yoga
on pain [37].

External and internal validity


Patients of a wide age range with rheumatic diseases
diagnosed mainly by the ACR criteria were recruited
from secondary and tertiary care centres in North and
South America and Asia. Especially in RCTs on FM and
RA, mainly female patients were included. The results of
this review therefore seem to be applicable to most patients with rheumatic diseases in clinical practice while the
small number of studies on each disease limits this interpretation. The results for FM and RA might not be fully
applicable to male patients.

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Conclusion
Based on the results of this review, weak recommendations can be made for the ancillary use of yoga in the
management of FM syndrome, OA and RA.
Rheumatology key messages
A limited number of randomized trials have investigated yoga as a treatment for rheumatic diseases.
. Yoga might be considered as an ancillary treatment
for FM syndrome, OA and RA.
.

Funding: This work was supported by the Rut- and KlausBahlsen-Foundation.


Disclosure statement: The authors have declared no
conflicts of interest.

Supplementary data
Supplementary data are available at Rheumatology
Online.

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This systematic review of eight RCTs on yoga for rheumatic diseases found very low to low quality evidence
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