Yoga and Physiotherapy - Juniper Publishers
Abstract
Anxiety remains one of the most common mental health disorders in the United States. Many university’s students report having a high level of anxiety, with additional life stressors that might include being away from home for the first time, being around unfamiliar people, having new expectations placed on them, and often have financial struggles. Universities have the ability and opportunity to form programs that can involve students with activities that reduce stress and teach coping skills. This research includes one example of using a therapeutic yoga class to teach these skills and assist students in applying these strategies to their daily lives. This study compared a group of 17 students participating in weekly yoga classes to 34 students who did not attend the program. The students who attended the program reported a larger reduction of anxiety on both the Beck Anxiety Inventory and Generalized Anxiety Disorder 7-Item Scale than the control group, and verbally reported additional benefits in relaxation and coping skills.
Keywords: Anxiety; Yoga; Therapeutic yoga; Students
Abbreviations: BAI: Beck Anxiety Inventory; IRB: Institutional Review Board; GAD-7: Generalized Anxiety Disorder 7
Introduction
Anxiety and stress-related issues are on the rise in the United States, particularly among young adults [1]. While the DSM-5 states that the diagnosable 12-month prevalence for Generalized Anxiety Disorder is 2.9% among adults, with a lifetime risk of 9.0% [2], it does appear that rates of anxiety are particularly high and growing in the 18-25-year-old age range. In addition, non- diagnosable anxiety or high levels of stress can cause a great deal of distress to individuals. For example, there is a high number of medical visits and medications specifically related to anxiety or stress related issues. Up to 70% of medical visits may be for challenges related to stress [3]. Today’s university students report high levels of anxiety and other mental health challenges. These students are often during a high number of life changes. They may be away from home for the first time, may be exposed to new people and new cultures, have new expectations being placed on them, and may have the financial stressors associated with attending college with little time for employment [4]. Students may also experience performance anxiety in the classroom such as test anxiety and in internships [5], which can challenge their ability to learn [6]. explored issues around stress and anxiety in social work students. They found that first year and final year students had particularly high levels of stress and anxiety. It may be that students who are adjusting to their new roles at university and students who are preparing to graduate and who may have anxiety relating to leaving school and finding work may have particularly high needs. A significant number of college students are seeking help for mental health issues. As we are in the second full year of COVID-19, it is likely that the long-term stress of living in a pandemic may have caused some of these mental health challenges to increase in the student population. One study showed that early in the COVID-19 pandemic, individuals aged 18-24 experienced stress, anxiety, and depression. This study reported signs of anxiety in adults to be 50.9%, and signs of stress to be at 57.4% [7]. In addition to students reporting isolation and lack of interaction, financial concerns, challenges with online classes and technology issues, and an overall sense of fear and insecurity, Gupta and Agrawal (2021) found that students who already have mental health concerns report an aggravated level of both anxiety and depression during this pandemic [8].
Unfortunately, many students who have mental health needs do not obtain services Elbert et al. [9] completed a cross-national survey that showed that less than one in four students who have needs seek and obtain treatment. There are significant barriers to students obtaining mental health services that may be able to assist them with anxiety or other mental health challenges. Many university students may be unaware of formal mental health supports such as counseling or are not willing or not able to make use of these services. Mental health services may be difficult to obtain, even for students who would like to attend counseling. Financial strains, long wait times to get in to see a campus therapist, or the low number of sessions offered by many universities may be barriers to formal counseling services [10]. Even if resources are available and the students are aware of them, the stigma attached to utilizing the services can keep students from being willing to use them. Students report that they prefer to try to handle their problems on their own [11]. The perception that help is not needed and constraints around time are also cited as reasons for not obtaining services Ennis et al. [12]. There are a variety of clinical strategies that may be implemented to assist individuals in coping with anxiety. Traditional talk-based psychotherapy, sometimes combined with the use of medication, is often used for anxiety and other mental health challenges that college students may face [13]. Common forms of psychotherapy may include Cognitive Behavioral Therapy [14], Acceptance and Commitment Therapy [15,16], and Exposure Therapy [17]. These treatments are evidence-based practices used by clinicians across the United States. Yoga and mindfulness techniques have also emerged as beneficial treatments in more recent years [18]. Most forms of exercise have benefits on both physical and mental health, including anxiety disorders. Yoga as a physical exercise may reduce anxiety and stress. Yoga classes are typically offered at gyms and yoga studios and typically focus on helping participants practice this physical exercise in a safe way. However, yoga can also be incorporated into mental health treatment, typically as an adjunctive treatment for an individual who is also in therapy. When therapeutic yoga is used as an adjunctive treatment, the focus is on assisting the client in finding relief from specific symptoms. The yoga therapist will assess the client and implement an appropriate therapeutic yoga intervention. This may be in either individual or group sessions.
Studies have shown that yoga as an exercise as well as therapeutic yoga can be an effective tool in reducing symptoms of mental health disorders for many people. Gladden et al. [20] noted that students in a six-week therapeutic yoga class had a variety of positive impacts on the participants, particularly in the areas of self-care, embodiment, and mood. Harkess et al. [21] conducted a study implementing a 16- session, 8-week yoga class to mostly middle-aged women who generally worked in professional settings. The researchers’ findings demonstrated that participants in the study had overall improvements in positive affect, decreased levels of psychological distress and perceived stress. Hofmann et al. [22] completed a meta-analysis on the impact of yoga on anxiety, and explored the data provided by 17 different studies (n=501). This meta-analysis showed two important factors: that the efficacy of the use of yoga was associated with the amount of time spent practicing yoga, and that people with elevated levels of anxiety benefited the most. Similar studies have shown positive results of yoga on stress and anxiety. There are few studies that examine the use of yoga for university students. The preliminary evidence shows that yoga may have positive results on the mental health of university students, particularly for issues relating to anxiety and stress [23]. Godse et al. [24] conducted research in Pune, India to study the effects yoga on college students. The students’ age ranged from 17-22 and had reported experiencing high levels of stress. The study concluded that the use of yoga reduced students’ stress, increased mental calmness and joy, as well as reduced sleepiness, worry and negative emotions. Kim [25] conducted a study with undergraduate nursing students and the effects of yoga on stress. In this study, life stress was measured by the Life Stress Scale for college students. It was found that the Life Stress Score significantly differed between the control and intervention groups. For the yoga group, post- Life Stress Score was significantly decreased compared with the mean pre-Life Stress Score. The control group reported an increase in their stress levels. This study continues to lend data towards the benefit of yoga for college students in reducing the stress and anxiety they are experiencing. Similarly, [26] explored the use of yoga within a college class and found that yoga can assist college students in slowing down and gaining greater ability to deal with busy lives. This research study was conducted to explore the effects of a therapeutic yoga class on students’ perceived levels of anxiety. The previous studies discussed on yoga for college students appeared to be primarily focused on the impact of a nontherapeutic yoga class, which is primarily a form of exercise. A therapeutic yoga class is typically conducted in a different manner than a therapeutic class that is specifically created for groups who have anxiety of other mental health diagnoses or challenges [27]. We hoped to discover whether the therapeutic yoga classes were able to reduce the students’ levels of stress and anxiety, and to hear from the students in their own words how the experience may have been helpful to them.
Materials and Methods
This research uses a merging data mixed methods design to combine quantitative data from pre- and post- surveys with the data from several focus groups to explore the students’ own words and reported experiences, as recommended by Creswell et al. [28]. Our research questions included: 1. Is there a difference in changes of scores from the Beck Anxiety Inventory (BAI) and Generalized Anxiety Disorder 7-Item Scale (GAD-7) between the intervention and control groups?, 2. What impact do the students in the intervention group report the therapeutic style yoga classes had on their perceived anxiety or on other parts of their life?, and 3. How can the reports from the students in the focus groups help the researchers understand any changes in the BAI and GAD-7 scores? This research was conducted as a pilot study with the hopes of offering continued services to the students if the results indicated a positive impact. The researchers completed all required steps from the university before beginning the study, which included receiving the Institutional Review Board (IRB) approval. Any registered student was eligible to participate, including undergraduate and graduate levels. Recruitment for the therapeutic yoga class intervention was through email, flyers on campus, and announcements in classes when possible. Students were requested to pay a $25 fee for the series to encourage commitment, however ‘scholarships ‘or fee waivers were offered and provided to any student who cited cost as a barrier. Funds collected were used towards paying for the room for the class. No students were turned away from participating in the yoga intervention. The class was offered at several locations on campus, including the fitness center and a community center. Seventeen students, primarily undergraduate students at the sophomore and junior levels, completed the intervention. All the participating students identified as female. Thirty-four undergraduate students completed the pre- and post- tests for the anxiety scales. These students identified as both male and female. The participants in the therapeutic yoga intervention completed a pre-survey questionnaire to identify the levels of previous engagement in yoga, physical limitations, and goals for taking the yoga class. The intervention group and a control group made up of students in two university classes who chose not to participate in the therapeutic yoga series completed the Beck Anxiety Inventory (BAI) and the Generalized Anxiety Disorder 7-Item (GAD-7) scales at the beginning and end of the yoga series, which roughly corresponded with approximately week 5 and the week before finals in the semester. In addition to the completing these scales, several focus groups of made of up individuals who completed the therapeutic yoga series intervention were completed to provide the students’ own perspectives on the intervention and its impact on their anxiety as well as other areas of their lives. The combination of scores from reliable anxiety scales and the participants own words on their experience was designed to provide a deeper level of understanding on the impact of the intervention. Data analysis included the comparison of quantitative scores from the BAI and GAD-7 in the intervention and control group. An excel spreadsheet was created comparing the two groups and their changes in scores. In addition, all data from focus groups was recorded and transcribed, then analyzed by hand for similar themes.
The results from the control group concluded that the students had the slightest decrease in anxiety scores from the beginning to the end of the intervention time period based on the two measurement tools. The GAD-7 showed that the control group scores had decreased by an average 10% from the pre-test. Out of the 34 control group students, only ten students showed a decrease in scores ranging from 5% to 100%. The majority of the ten students showed a decrease in score for “relax” and “worry.” For 24 students their post scores either stayed the same or increased from 1%-10%. Out of the 24 who did have increased anxiety their scores for feeling “afraid” increased by 1%. Even though the average score had decreased by 10%, more students’ scores increased then decreased. The control group’s BAI posttest showed an average 4% decrease from the pre-test. Out of 34 students, only 12 showed a decrease in scores. Of the 12 students who had decreased scores, 91% decreased in having sweats, 75% decreased in having trouble relaxing, and 66% decreased in trembling. The remainder of the 22 people who had an increased in scores; 64% had an increase in feeling wobbly, and 45% had an increase in feeling relaxed, heart rate, being unsteady, and feeling terrified. Both the Gad-7 and BAI for the control group showed a decrease in the score, but the focus group resulted in a greater decreased score.
The results for the intervention group concluded that the students had decreased scores on both the measurement tools. On average the intervention group decreased by 35% from the GAD-7 test pre-test. Two people post-tests increased by 2%, with increases in the areas of “worrying too much” and “afraid.” Each of these students reported having major life changes that resulted in their increase in worry and fear. Out of 17 students, 15 students had decreased scores. Each of these 15 students’ scores decreased in “easily annoyed,” and 80% scores decreased in feeling “nervousness.” The intervention group showed a 25% difference between the decrease in scores for the GAD-7 control group post-test. For the intervention group, the BAI post-test showed an average 45% decrease from the pretest. There were three people who score had increased by 1%. The scores increased by two points on “feeling hot,” “dizzy,” “unsteady,” “scared,” and three points on “having sweats.” The remainder of the 14 students’ scores had decreased. 100% decreased in their report of “heart rate” and “nervousness,” 78% decreased in “losing control,” and 71% decreased in “trouble with relaxing.” The focus group showed a 41% difference between the decrease in scores for the BAI control group posttest. Thus, our first research question, is there a difference in changes of scores from the Beck Anxiety Inventory (BAI) and Generalized Anxiety Disorder 7-Item Scale (GAD-7) between the intervention and control groups? was answered. There is a distinct difference in scores between the two groups. The small size of the sample discouraged analytical statistics to determine if this difference was significant, so we then turned to our second research question. The transcription of the open dialogue between instructor and students at the end of the semester also provided valuable information, helping to answer the second and third research questions, “What impact do the students in the intervention group report the therapeutic style yoga classes had on their perceived anxiety or on other parts of their life?, and “How can the reports from the students in the focus groups help the researchers understand any changes in the BAI and GAD-7 scores?” At the beginning of the dialogue, the yoga therapist asked the students what had motivated them to complete the yoga class for the entire semester. All students reported it being “helpful.” Specifically, one student reported, “I knew it was good for me because I felt it during the whole week, at least during the day of our yoga on Tuesday. I just felt like, relaxed the whole day and kind of grounded and ready for the day”. Students also indicated it was more helpful during the end of the semester, stating the stress levels increase with the amount of work at the end of the semester. They stated yoga was a way to relax from that stress, at least during the period of the class.
Furthermore, the yoga therapist asked the students if they found that participating in the yoga class had helped with anxiety and being able to relax. All students indicated they found it helpful. One student specified they were not only able to find it helpful during class but had also started implemented it in other areas of their week such as in other classes and at their internship. One student stated, “I feel it did help. I mean I had recent events that it just increased my anxiety. Like all the time, but I mean I feel like it would have been worse if I wasn’t doing yoga. So, I do feel like it helped even in just like a little bit so definitely for sure”. It was also reported there were additional benefits from participating in the yoga class, such as physical strength and learning to cope ahead for stressful situations. Specifically, a student reported, “It also helped me build my upper body strength, and I felt stronger not just my body, but my mind also felt stronger, and I was able to calm myself. If I felt the anxiety come, I’d just start doing some deep breathing or child pose in class. I’ve done that a couple of times”. The students specified being “more focused” and practicing “better self-care.” One student described taking time to put themselves first, instead of putting other people needs in front of their own. Another student reported they felt more comfortable in public, crowded areas and found themselves interacting more with others than they had in the past. Additionally, the yoga therapist asked the students if they noticed any significant changes after each yoga class relating to their anxiety. Each of the students reported they noticed changes that were helpful. One student stated, “I just felt much more grounded and calmer”, and “I was able to control my emotions where usually my anxiety feels out of control. But with yoga, I was able to control my breathing and control what was happening to me”. Another student stated, “Tuesdays are my busiest days, but after yoga, I was able to focus.”
The overall results of the study proved positive. Although both the focus and control group had a decrease in scores on each scale, the focus group had significantly decreased symptoms. Although not every student participating in the focus group had a reduction of anxiety symptoms, 15 of the 17 students had decreased symptoms. Two students reported a change in life events that contributed to their higher scores, even though they reported that the classes were helpful to them. The control group showed that students without the intervention of yoga had minimal symptom reduction. The open dialogue with the students showed positive results across the board. The students as a whole felt the yoga class was helpful and was useful in reducing anxiety and increasing focus and self-care.
Discussion
Anxiety has become widespread throughout the United States. Thousands of people struggle with symptoms of anxiety daily. There have been many coping methods implemented in clinical practice to assist individuals who are coping or struggling to cope, with anxiety. Researchers and clinicians have sought to find more effective methods to assist these individuals. Methods that have been adopted to assist with anxiety include yoga and therapeutic yoga. As the research shows, yoga and therapeutic yoga has benefited many people who struggle with stress and anxiety. University students are among this population of people. This research has indicated the vast benefits yoga can provide to these students, including increased physical health benefits, decreased stress, and increasing the ability to focus and care for oneself. Stress and anxiety tend to rise among college students toward the end of the semester. If students cannot find healthy ways to cope with stress and anxiety, their symptoms may increase. This was shown in the difference between the overall scores of the control group and intervention group in this study. The intervention group participated in a therapeutic yoga series, which helped them cope with stress and anxiety in a health manner, leading to overall scores on GAD-7 and BAI that either decreased or remained the same. The control group did not participate in the yoga class, as participants overall reported an increase in anxiety symptoms. Although the results were limited in this study, which may influence the reliability of the data, there was still valuable information obtained. Although the intervention group was half the size of the control group, the results showed a higher decrease in anxiety symptoms in the intervention group compared to the control group. The control group had no known interventions implemented in the study to assist in coping with their anxiety symptoms. It should be considered the timing of the post-test as it was the end of the semester and students had an increase of stress due to exams and projects or a decrease in stress because they have already finished the assignments. This indicates that students who did utilize therapeutic yoga as an intervention benefited by either reducing anxiety or remaining the same. Another contributing factor to the intervention group results may come from the indication that they not only participated in the therapeutic yoga class but also started implementing the techniques into everyday life. The literature and research in this study both show positive results for college students who utilize yoga as a coping tool to help deal with the symptoms of anxiety. Although the number of students who participated limited the intervention groups results, there does appear to be some evidence to show that the yoga class did have positive outcomes for the participants. This was proven through the data collected from the GAD-7 and the BAI, as well as the open dialogue between instructor and students. As clinicians strive to find the most effective treatments for anxiety, therapeutic yoga is certainly emerging as a potentially encouraging option.
The use of exercise-based yoga classes or therapeutic yoga classes may be a viable option to help reduce anxiety in college students. Many of the barriers that student report regarding formal mental health supports such as psychotherapy may not be a concern for yoga. Yoga classes or therapeutic yoga classes typically do not hold the same kind of stigma that therapy has. Students may be less fearful of what others think about their attendance in a yoga class. The cost of offering these classes is likely less than the cost of providing therapy through a campus counseling program and could reach a higher number of students. While time and transportation could continue to be barriers, offering classes on campus and in a variety of location could at least partially reduce this barrier.
Limitations
There are limitations to this research. As the research targeted a population of students with many other obligations, the sample size was minimal. As college students have busy schedules and busy lives, many different factors may have interfered with their attendance and completion of the yoga class. Noting there was a small sample of participants, the researchers analyzed the data to reflect the most useful information, with a focus on the qualitative discussion. The limitations also include the lack of diversity within the sample. As this college’s population is primarily lower to middle class students who overwhelmingly identify as Caucasian, both the intervention and control group participants’ identities were similarly narrow. We are not able to generalize this data to other identity groups. In addition, most participants were undergraduate students, with few graduate level students and no doctoral level students. Researcher risk of bias is also a limitation. The yoga therapist/ primary researcher identifies as a middleclass Caucasian cis-gender heterosexual female. In addition, each of the graduate level student researchers identified as Caucasian cis-gender heterosexual females. The lack of diversity in the researchers’ identities may impact the perspectives from which the data was analyzed. Ethical issues to be considered include the yoga therapist and researchers’ roles in the yoga class. As the researchers are part of the student body and faculty of the university where the study took place, there was the possibility that participants might have felt obligated to complete the course and the surveys. To avoid these issues, the participants completed a consent form, which informed that their participation in the yoga class or research would not affect their grade or status as a student. The data was also collected anonymously and held in a secure area to prevent any breaches of confidentiality. No names were used on the pre- and post- tests, as students self- selected a code name. Names were not transcribed during the focus group after the yoga series was complete, although the researchers were present to complete the focus groups.
Implications for practice and research
The results of this study, along with other literature in this area, have shown at least preliminary positive results on the use of yoga and therapeutic yoga to reduce anxiety in university students. This intervention may be particularly useful for students who are unwilling or unable to attend psychotherapy sessions, due to the stigma or other constraints. While many colleges and universities offer yoga classes as a part of their curriculum, having additional classes offered outside of for-credit courses could be highly beneficial. These services could also be a cost-effective way of providing support for students. The group format and the cost of hiring a trained yoga instructor or yoga therapist (particularly compared to the cost of hiring additional psychotherapists) may reduce the overall cost of providing services for students. If students were able to access services to reduce their anxiety and stress, they may be able to increase their performance in their coursework. In addition, reducing anxiety may be able to prevent students from dropping out due to these mental health issues and increase the retention and graduation rates for the university. Further research in this area is indicated. While there is evidence to support that both yoga as an exercise class and therapeutic yoga can reduce anxiety in university students and other populations, there is not yet enough information to provide specifics regarding various formats of yoga and how many classes are needed to provide support for positive change. Studies vary in the number of weeks the courses are, and how many times a week they meet, in addition to the types of yoga used. Each of these areas should be explored to provide the best options for student mental health support. It could be particularly important to determine if yoga exercise classes are sufficient to reduce anxiety, or whether a trained yoga therapist providing therapeutic yoga classes might increase the positive results. In addition, much of the research in the United States has either not reported on the demographics of the research or the students are reported to overwhelmingly identify as Caucasian. No research was found on the effectiveness of yoga for students who identify as individuals of color. Research has shown that there may be barriers to participating in yoga for individuals of color [29], so this area should be explored in further research. Similarly, it is not known whether other oppressed identities, such as gender or sexual identities, may impact an individual’s participation in or experience of yoga in this setting. These areas should also be explored to determine if this intervention can be accessed in an equitable manner for all students.
Conclusion
Previous research has shown both yoga and therapeutic yoga to be effective interventions in assisting individuals to cope with anxiety and stress. This specific study sought to learn how therapeutic yoga may impact college students who experience anxiety. The findings showed overall positive results for the focus group compared to the control group in the study. Universities should consider adding interventions such as yoga and therapeutic yoga to their campus programing to reduce the barriers in providing support for students who may be experiencing anxiety and stress.
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