Strategies for Implementing Safe and Effective Yoga Programs

Yoga—an ancient Hindu practice that integrates physical movements, breathing, and meditation to attain spiritual fulfillment—has become widely practiced in the United States. Yoga is practiced for a variety of physical, mental, emotional, social, and spiritual reasons, and reflects the growing holistic approach to “mind and body wellness.” Improvements in flexibility, stress relief, general wellness, overall health, and physical fitness are among the primary benefits people cite for adopting and maintaining a practice (1). Hatha yoga typically incorporates asanas (poses or postures) into a flow (sequence of poses) while practicing mindful breathing (pranayama) and meditation. Further, bandhas (muscular contractions), mudras (seals and gestures), kriyas (internal cleansing techniques), and spirituality also can be included into a practice (2). Approximately 36 million Americans practice yoga, and of those, more than 75% also engage in other forms of exercise, such as running and weightlifting (1). Yoga can be practiced as an individual or in a group in a variety of settings such as at home, in the workplace, or at the gym. Although practicing yoga can require little expense for equipment or space, yoga is a multibillion-dollar industry, with practitioners spending $16 billion on instruction and classes in addition to clothing, equipment, and accessories (1). Given the increases in popularity and prevalence of yoga practices in the nation, it is important that health and fitness professionals understand what constitutes a healthy yoga practice while offering evidence-based exercise science expertise (refer to the Table for yoga terms and definitions).TABLE: Yoga Terms and DefinitionsPurpose The purposes of this Clinical Applications column are to define yoga, provide examples of research conducted with yoga, and describe strategies for implementing safe and effective yoga programs. YOGA AS A FORM OF PHYSICAL ACTIVITY AND/OR EXERCISE It is recommended that adults accumulate at least 150 minutes (2 hours and 30 minutes) each week of moderate-intensity aerobic physical activity or 75 minutes (1 hour and 15 minutes) each week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic activity. It also is recommended that adults maintain or increase muscular strength and endurance at least two days each week and engage in flexibility exercises at least two to three times a week (3–5). Adults who are unable or unwilling to meet the exercise targets outlined here still can benefit from engaging in amounts of exercise less than recommended (3). The frequency, intensity, and duration of a yoga practice can be developed or selected by the practitioner or an instructor. A yoga practice has the potential to meet moderate- or vigorous-intensity aerobic activity, muscular strength and endurance, and flexibility requirements, depending on the poses and flow selected. Typical yoga sessions last from 60 to 90 minutes but also are offered for as few as 15 minutes. Some flows, such as surya namaskar (sun salutation), consist of a specific sequence of poses. The flow can be repeated several times, and the duration of the poses can be shortened or lengthened. Further, a wide range of progressions and regressions for each pose can increase or decrease the intensity of the pose. In a systematic review of the energy cost and metabolic intensity of yoga, authors concluded that the majority of poses and flows were considered light intensity (e.g., adho mukha svanasana [down dog] and virabhadrasana I [warrior I]); however, some poses and flows qualified as moderate- to vigorous-intensity physical activity (e.g., sun salutation) (2). The authors recommended that yoga be considered among the examples of moderate-intensity physical activities in American College of Sports Medicine Position Stands (3,6). Conversely, in a letter to the editor regarding the findings, Sherman et al. (6) explained that caution is to be exercised when creating poses and flows to adequately prepare the body for the next pose in the flow, not to simply select poses based on energy expenditure, but to select poses based upon an appropriate flow. Depending on the length of the class and type of poses engaged (dynamic sun salutation vs. gentler vrksasana [tree]), yoga may qualify as part of an individual's weekly amount of moderate physical activity, or it may qualify as low-intensity physical activity, which still has health benefits through limiting sedentary behavior (2). The number and rigor of research studies incorporating yoga as an intervention to prevent, ameliorate, or treat a variety of health-related outcomes is gaining momentum. RESEARCH Systematic reviews and meta-analyses can be found for yoga interventions in older adults for improved balance and mobility (7), for short-term effects on chronic neck pain (8), for children in gross motor development (9), and for improving glycemic control for individuals with type 2 diabetes (10). The list of studies supporting yoga as a benefit for special populations can go on ad infinitum. For example, in a recent randomized controlled trial with 320 adults with chronic low back pain randomly assigned to one of three groups—yoga classes every week for 3 months, 15 visits with a physical therapist over 3 months, or education (which involved getting a back pain self-help book and mailed newsletters)—the yoga and physical therapy groups showed almost the same amount of improvement in pain and activity limitation after 1 year, and participants in both the yoga and physical therapy groups were less likely to use pain medications at 3 months compared with the education group (11). Researchers concluded that yoga may be a reasonable option for treating chronic low back pain. Yoga can potentially serve as a nonpharmacological approach to addressing chronic pain, thus combating the rising epidemic of overdose of opioids in the United States (12). Yoga could provide an alternative to pharmacological intervention or a more appropriate first step for chronic low back pain management (13). In a randomized controlled trial with 68 military service members with chronic low back pain, physical functioning and symptom burden and pain were assessed at baseline, 4 weeks, 8 weeks, 3-month follow-up, and 6-month follow-up. The intervention group participated in a 1-hour, instructor-led, group yoga class twice a week for the first 4 weeks then once a week for the second 4 weeks. The control group received their normal treatment for back pain. The results indicated that there was excellent compliance in the intervention group with most of the participants completing 9 to 12 of the yoga sessions. The intervention group reported significantly lower pain scores than the control group during the intervention. However, at 3- and 6-month follow-up, the pain scores were not significantly different. The authors suggested that a yoga practice should be continued to sustain pain alleviation. Yoga also may be more effective than more intense physical activity for getting previously sedentary individuals to engage in structured exercise. Physical activity is recommended to all people, including those with disabilities, and may be adapted according to ability (14,15). As with any physical activity, yoga movements can be modified as a lower-intensity form of exercise that may be more suitable for some populations—such as older adults, unconditioned individuals, or individuals with disabilities—who find other forms of moderate- or high-intensity exercise too strenuous, painful, or otherwise difficult to maintain. Yoga also offers an alternative method of exercise for individuals living with certain physical constraints. For instance, yoga can be adapted for people in wheelchairs or for those who have difficulty standing or sitting (i.e., chair yoga). It has been established that older adults show decreases in dynamic balance; however, healthy active older adults have significantly better balance than disabled older adults and older adults with vestibular impairment (16). In fact, to determine if yoga was equally beneficial to walking, a study conducted with older adults who practiced yoga and those who engaged in walking showed no significant differences in balance. However, participants in the yoga group showed more stable gait patterns (17). Lastly, different types of yoga have been explored as treatments for specific conditions. Participants who engaged in studies testing the efficacy of bikram yoga, otherwise known as “hot yoga,” a set of hatha yoga poses practiced in a hot and humid environment (40.5°C heat with 40% to 60% humidity), have shown improvements in vascular function (18,19). Interestingly in more recent findings, the authors suggest that “hot yoga” is not required for improvements, and that hatha yoga alone is beneficial (20). In summary, as with any research in the health and fitness realm, more is needed. It is recommended that more studies be conducted while clearly defining the type of yoga practice prescribed (6). STRATEGIES FOR IMPLEMENTING SAFE AND EFFECTIVE YOGA PROGRAMS Health and fitness professionals are uniquely positioned to provide support for yoga programs. However, consideration must be taken regarding the identification of an instructor, ensuring participants’ safety, structuring a class, and choosing a setting. For the purposes of this Clinical Applications column, the physical component of yoga will be the primary focus. The following strategies can be implemented for safe and effective yoga programs. Identifying an Instructor According to the Yoga Alliance, the largest nonprofit organization representing the yoga community, to be an officially registered yoga teacher, one must attend a qualified, registered yoga school and complete 200 to 500 hours of training, including working under a mentor (20). Furthermore, the yoga instructor should be well-educated in anatomy, physiology, and exercise science. Ideally, a yoga instructor also would be certified in personal training or exercise instruction, such as through the American College of Sports Medicine’s criterion standard certifications (21). It is important that instructors who teach yoga are trained in exercise science, or at least supervised by someone who is. It is not always the case, however, that yoga instructors are equipped with the knowledge, abilities, and skills of a health and fitness professional; therefore, it is important that the yoga instructor collaborate with a certified health and fitness professional to ensure the health and safety of the participants in a yoga program. Ensuring Participants’ Safety and Structuring a Class As with any exercise program, the safety of the participants should be at the forefront of the health and fitness professional’s mind. It is appropriate to administer Par-Q questionnaires, experience level questionnaires, and baseline testing to fully understand each participant’s fitness levels and goals. A popular idea is that yoga “meets you where you are,” physically, mentally, emotionally, socially, and spiritually, and allows practitioners to maintain or build upon that foundation. It may be appropriate to offer different types of yoga classes, such as a “gentle yoga” class focusing on lower-intensity poses and slower flows or a “power yoga” class focusing on higher-intensity, more challenging poses (especially sun salutations) and a quicker flow. Foundational exercise program protocol calls for the instructor to “start small.” Instructors should be competent with progression, periodization, and intensity manipulation throughout a yoga program and trained to coach participants through progressions and regressions for each pose. See the Figure for a demonstration of the progression of a cobra pose. Although not required, instructors may suggest the use of equipment such as mats since many poses require spending significant time sitting or lying on the floor. Blocks, blankets, and straps also can aid the practitioner in healthy pose positioning.Figure: Progression for cobra pose: A, Chair cobra. B, Sphinx I. C, Sphinx II (lumbar spine is more engaged). D, Half cobra. E, Cobra. F, Upward dog.Yoga instructors should pay particular attention to spine safety. Some poses included in a practice may involve twisting and flexion of the spine, which may prove difficult or harmful for participants with preexisting spinal injury. For instance, if a participant cannot perform all eight of the poses associated with a sun salutation, the instructor may suggest pausing in one of the poses and resting while the rest of the class moves into the next pose in the flow or meeting with the individual to help the participant find a comfortable, safe alternative. The application of the principles of training (progression, overload, individuality) is important. In addition to the physical benefits of yoga, engaging in breathing and meditation exercises is central to yoga instruction. Furthermore, breathing and meditation promote overall body awareness that can increase the safety of the exercise. Individuals participating in yoga should be encouraged to pay attention to how their bodies are responding to each pose and make adjustments as necessary. Lastly, liability waivers may be an additional precaution to administer to participants in the case that the instructor does not have access to the health history of the participants. Choosing a Setting Choosing a setting for a yoga class also requires careful consideration. Settings may include a nontraditional community space (e.g., community center, school, or workplace) or a familiar space such as a fitness center, gym, yoga studio, or at home through an online yoga class. If implementing a yoga program with many participants in a limited space, the practitioner should adjust the program accordingly, making sure each pose could be conducted on one’s own mat, or that partner work does not stretch beyond two mats. Compact spaces with little room for movement would not be appropriate as it could hinder the ability to flow from one pose to the next, causing exercises to be completed incorrectly, thus increasing the risk of injury. CONCLUSIONS Yoga represents an increasingly popular form of exercise that offers many health benefits, particularly to special populations, such as older adults, sedentary individuals, or people with chronic pain. Participating in a yoga practice has the potential to provide nonpharmacological approaches to alleviating pain, increase physical activity and fitness, and reduce sedentary time. By implementing the safe and effective strategies discussed previously, health and fitness professionals can help promote yoga as a valuable form of physical activity in a safe and effective manner.

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