Lower Psoas Muscle Area is associated with increased mortality after endovascular aneurysm repair in older adults - Juniper Publishers

 

Gerontology & Geriatric Medicine - Juniper Publishers

Abstract

Lower Psoas Muscle Area is associated with increased mortality after endovascular aneurysm repair in older adults.

Introduction: Psoas muscle area (PMA) is an easily measurable surrogate of sarcopenia, which may be associated with mortality and other adverse post-operative outcomes. This study aimed to further explore the relationship between PMA and outcomes post elective infrarenal aortic aneurysm (AAA) endovascular repair of (EVAR) in older adults.

Methods: A retrospective observational study of people aged over 65 years undergoing EVAR for asymptomatic AAA over 5 years. Patients with connective tissue disease, mycotic or inflammatory AAA, emergency or non-elective cases were excluded. The primary outcome was 5-year mortality. Secondary outcomes were 30-day readmissions, post-operative complications, and length of stay.

Results: Ninety-seven patients (mean age 77.5 years, 78% male) were assessed. Adjustment for age, sex and body mass index also showed that patients in the lowest PMA tertile had an increased 5-year mortality (HR 2.76, 95%CI 1.08, 7.03; P=0.034). Adjustment for frailty, measured by modified frailty index, showed only a minimal attenuation of the association (HR 2.30, 95%CI 0.99, 5.34; p=0.054). Being in the lowest PMA tertile did not increase LOS, 30-day readmissions, complications, or influence discharge destination.

Conclusion: The lowest tertile of PMA, as a surrogate marker for sarcopenia, was associated with increased mortality in patients undergoing EVAR for asymptomatic infrarenal AAA, which was only marginally attenuated by frailty adjustment. Although sarcopenia is a complex phenomenon and the literature surrounding it is still evolving, PMA may form one component of risk assessment in patients undergoing EVAR.

Keywords: Frailty; Psoas Muscle Area; Sarcopaenia; Vascular Surgery

Keywords: PMA: Psoas Muscle Area; AAA: Abdominal Aortic Aneurysm; EVAR: Endovascular Aneurysm Repair; LOS: Length of Stay; PMA: Psoas Muscle Area; CT: Computed Tomography; GEKO: Governance Evidence Knowledge Outcomes; SPSS: Statistical Package for the Social Sciences

Introduction

The evolution of abdominal aortic aneurysm (AAA) repair from open to endovascular aneurysm repair (EVAR) has great relevance in older adults, who often have more comorbid conditions, are frailer and have higher levels of sarcopenia. EVAR, where technically feasible and where the maximum aortic diameter has reached threshold (>5.5cm in men and >5.2cm in women) is minimally invasive and involves the deployment of a stent graft inside the aneurysm via percutaneous femoral access, and has several advantages including avoidance of general anesthesia, reduced length of stay (LOS) and reduced postoperative mortality [1].

Sarcopenia and frailty are distinct but overlapping conditions. Frailty is “a biologic syndrome of decreased reserve and resistance to stressors, resulting from cumulative declines across multiple physiologic systems, and causing vulnerability to adverse outcomes” [2]. There have been multiple screening tools developed in an attempt to assess frailty, which usually follow either a phenotypic or cumulative deficits model [3]. Despite the differing tools used to measure frailty, higher frailty scores are associated with increased mortality, post-operative complications, and length of stay in surgical patients [4], higher mortality following open AAA repair and carotid endarterectomy [5] and vascular surgery [6], and LOS and discharge destination in vascular ward patients [7].

Sarcopenia, on the other hand, is defined as “a progressive and generalised skeletal muscle disorder that is associated with an increased likelihood of adverse outcomes including falls, fractures, physical disability and mortality” and “confirmed by the presence of low muscle quantity or quality” [8,9]. Several parameters have been used to define muscle quantity, including psoas muscle area (PMA). A decline in PMA seems to be representative of decreased lean body muscle mass and sarcopenia, at least in haemodialysis patients. However, the European guidelines suggest more research is required to formalise whether PMA is a reasonable surrogate for skeletal muscle mass [10].

There is emerging evidence to suggest that PMA is associated with mortality in older vascular surgical patients following endovascular aortic surgery, and to a lesser extent post-operative complications. Some, but not all studies [11,12], have shown that a reduction in PMA correlated with higher mortality following EVAR, open AAA repair or other vascular intervention [13-21]; but none of the studies to date have included frailty scoring in conjunction with PMA in this setting.

In the AAA population, widespread use of computer tomography (CT) imaging enables easy measurement of PMA as a representation of sarcopenia. PMA could therefore be an easy to obtain predictive tool for outcomes following EVAR, and to determine whether the procedure is in the patient’s favour or not. Our study further explored the relationship between PMA with post-operative outcomes and mortality in older adults undergoing asymptomatic infrarenal EVAR, seeking to assess whether similar correlations between PMA and mortality were found in the local surgical population in Western Australia. We chose to include frailty to further clarify this issue.

Methods

A retrospective observational study of patients 65 years and older who had undergone an elective EVAR for asymptomatic infrarenal AAA, in a tertiary metropolitan centre in Western Australia, from 1st January 2013 to 31st December 2017. Patients were excluded if the cause of the AAA was connective tissue disease, mycosis, or inflammation, and if EVAR was performed as an emergency or non-elective procedure for symptomatic AAA.

Retrospective data was collected from chart review and electronic medical records. Baseline patient characteristics included age, sex, current smoking status, Charlson comorbidity index, the presence of coronary artery disease (history of previous myocardial infarction, coronary artery bypass graft surgery or percutaneous coronary intervention), cerebrovascular disease, chronic kidney disease, diabetes, hypertension, peripheral vascular disease (intermittent claudication, critical limb ischemia, revascularisation or lower limb arteries), as well as, maximum antero-posterior AAA diameter, BMI, and preoperative haemoglobin levels. A modified frailty index (following a cumulative deficits model of frailty) was also calculated for each patient based on information found in medical records. This provided a score out of 11, with a score of 0 indicating an absence of frailty, and a score of 11 indicating the highest level of frailty [22].

PMA was measured at the mid L4 vertebral body on preoperative computed tomography (CT) scans. Where possible, 3mm slice thickness was chosen for measurement, however if this was not possible, 5mm or 1mm slice thickness was chosen. 3mm slice thickness was the most common and thus was the preferred slice thickness for consistency. A radiologist assisted with initial training of one researcher. Following this, the researcher proceeded to calculate the PMA for the rest of the patients. If there were any uncertainties regarding the psoas muscle calculation, the primary researcher verified the measurement with the radiologist.

The primary outcome was survival (calculated as days from operation). Follow up date selected was 31/10/2020. Study end date, the date of final data collection, was 23/02/2021. Determining the survival was based on hospital death records. This was also checked by means of seeing whether the patient had attended subsequent appointments or had subsequent admissions in patients without hospital record of death. This was essential as in Western Australian hospital records as patient death is not always recorded unless the patient has died during a subsequent public hospital admission, or the hospital is formally informed. Patients who could not be confirmed to be alive (or dead) as of the 31/10/2020 were censored in the survival analysis at the last known date that they were alive.

Secondary outcomes were 30-day readmissions related to EVAR, discharge destination (home, residential care, rehabilitation), post-operative complications, and length of stay (LOS) measured in days. This project was approved under the GEKO (Governance, Evidence, Knowledge, Outcomes database used to register information about quality improvement studies and clinical governance) system of WA Health, for projects deemed low- to negligible-risk to patients (GEKO#: 27118).

Statistical Analysis

Results were presented as a measure of central tendency, i.e., median with inter-quartile range, mean with standard deviation or as frequency and proportion. Differences between groups assessed with an independent t-test, non-parametric Mann-Whitney U test, and Fisher’s exact test, where appropriate. Univariate correlations were quantified by Spearman’s (rho) correlation coefficients (Rs). Linear and logistic regression analysis determined the crosssectional association between exposure (PMA) and outcomes. Cox proportional hazards regression analysis determined the uniand multi-variate association between the lowest tertile of psoas size for either sex with mortality. Multivariate models included further adjustment for age, body mass metrics, sex, and other comorbidities associated with mortality.

Statistical significance was set at α=0.05 or 5% level. The statistical analysis was performed on Statistical Package for the Social Sciences (SPSS) Version 22.0 (IBM Corp.; Armonk, NY, USA).

Results

Of the 122 patients identified as having undergone an EVAR procedure, complete data was available for 97 (79.5%). Five patients were excluded as they did not meet inclusion criteria (3 due to age, 2 due to missing information about the type of operation performed). Eighteen patients were excluded as imaging was not available to ascertain PMA data. Although these patients had similar demographics and clinical characteristics to those who were included, the exception was a lower complication rate in the excluded patients, although this failed to reach statistical significance (44% vs. 22%, p=0.06).

The study sample had a median age of 78 years, male preponderance (78.4%), and 79% were ex- or current smokers. Participants had a high prevalence of cardiovascular disease (85%, n=82/97), including coronary disease, cerebrovascular disease, hypertension, and peripheral vascular disease. Complications occurred in 44% of patients - the majority of which were categorized as ‘other’ (that is, not a fall, delirium, venous thromboembolism, bleeding, or infection). Most common was type 1 and 2 endoleak (n=8, with one requiring surgical intervention) and ischaemic complications (n=6 -testicular infarct, 3 non- ST elevation myocardial infarct, ischaemic lower limb, splenic infarct). Twenty-six (27%) patients had died by end of follow up. Twenty-six patients were unable to be confirmed to be alive at the time of follow up (31/10/2020). Median follow-up was 3.7 years with IQR 2.51 to 5.3 years (Range: 0.01 - 8.84 years) (Table 1).

PMA exhibited pronounced age- and gender-specific differences. Female patients and those over >80 years of age had lower PMA. However, median PMA was similar for females patients regardless of age group. PMA was also shown to vary significantly by body mass index, with a higher BMI significantly associated with a higher than median PMA for sex and age. PMA was divided into tertiles, with comparison made between the lower tertile and upper 2 tertiles. Those in the lower tertile (PMA less than 1938 mm2 in males and less than 1202 mm2 in females) tended to be older, with a lower weight and BMI. Degree of frailty as per modified frailty index and comorbidities including cardiovascular disease, hypertension, renal failure, diabetes, and smoking status were similar in both groups. There was no significant difference in complications, readmissions, or LOS between the two groups, and no significant difference in length of follow-up. There was however a significant difference in crude 5-year mortality following operation, with 35% (12) of those in the lowest tertile having died after 5 years compared with 17.5% (11) of those in the upper two tertiles (p=0.049), (Table 2). The lowest tertile of PMA for either sex was associated with 5-year mortality after elective EVAR surgery for asymptomatic infrarenal AAA, as demonstrated by Kaplan Meier survival curve. This was maintained after adjustment for age, sex and BMI as per (Figure 1).

There was a significant association also noted between the lower tertile of PMA for either sex, when adjusted for BMI, for increased risk of death (OR 3.53, 95%CI 1.21 -10.27, p=0.021) and increased LOS (β 0.33, 95%CI 0.04-0.63, p=0.028). However, there was no association between lower tertile PMA for complications in either gender (Table 3).

Sensitivity Analysis

The lowest tertile of PMA for either sex after EVAR was associated with increased risk of 5-year mortality in the unadjusted model (HR 2.31, 95%CI 1.02, 5.24; P=0.045), which remained after adjustment for BMI (HR 2.91, 95%CI 1.16, 7.34; P=0.023) and after adjustment for age, sex, and BMI (HR 2.50, 95%CI 1.03, 6.07; P=0.043). The association between the lowest tertiles of PMA for either sex was attenuated by age-adjustment alone, but the association was strengthened after the inclusion of sex and body mass metrics. Lowest tertile PMA associated with an increased risk of 5-year mortality after adjustment for prevalent diabetes, cardiovascular disease and complications during admission. Modified Frailty Index minimally attenuated the association between lowest tertile of PMA and risk of 5-year mortality after EVAR procedure (Table 4).

Discussion

This study reported a two-to-three-fold increase in 5-year mortality in the lowest tertile of PMA, which was strengthened after adjusting for age, sex, and BMI, in elderly patients undergoing elective EVAR for asymptomatic infrarenal AAA, in a single tertiary centre in Western Australia. This association was also strengthened after adjusting for cardiovascular disease, diabetes, and obesity, but was marginally attenuated with adjustment for frailty. The association between mortality and PMA has been observed in several studies before, showing a similar association between low PMA and higher mortality in the diverse EVAR population. Most studies are single centre, retrospective and heterogenous in nature. Drudi et al (open repair of AAA and EVAR) showed decreased 5-year mortality by 14% for a 1cm2 increase in PMA [14]. Lindstrom et al. (elective and emergency EVAR for infrarenal and more complex AAA) showed a lean PMA (calculated by Hounsfield units multiplied by total PMA) was independently associated with 26% reduced mortality per standard deviation increase of lean PMA, and more strongly associated with mortality than total PMA at L3 (22%) [18] respectively. Newton et al and Oliveira et al, (elective EVAR), also showed an association between the lowest tertile of PMA with increased mortality, with OR of 3.9 [15] and HR of 4.1 respectively [19]. Similarly, Huber et al showed the lowest quartile of PMA was associated with reduced median survival time (65 months vs 91 months) (25). Karkkainen et al (fenestrated-branched EVAR) found reduced lean PMA had inverse correlations with major adverse events and mortality, and further showed in a prospective cohort similar correlation with mid-term survival and quality of life [16,17].

In opposition, Chowdury et al, (vascular patients admitted to vascular unit having had CT abdomen) did not show a link between PMA and mortality and readmission [11]. This opposing result may be due to the heterogeneity of the patient population examined - roughly 52% did not undergo EVAR, lower duration of follow up (12-24 months), and BMI not being accounted for as potential confounder. Indrakusuma et al (asymptomatic infrarenal AAA) did not find an association between PMA and survival in either EVAR/open repair or conservative management groups [12]. However, the surgical cohort was generally younger than other studies and again BMI was not accounted for as a potential confounding factor.

The effect size of our study was smaller than in most other studies. This may be explained by our calculation of PMA by dimension, rather than lean PMA. Lindstrom et al. indicated that a stronger association is found with lean PMA rather than total PMA [18]. Frailty was not assessed in previous studies and differences in outcomes may be explained by differences in frailty. Furthermore, our study was specific to elective infrarenal AAA, whereas other studies had a significantly more heterogenous population, ranging from vascular surgery patients admitted who had CT abdomen, to patients undergoing EVAR for aortic aneurysmal disease in general.

The association between lowest tertile of PMA in either sex with 5-year mortality was attenuated by age-adjustment alone. This may be due to a narrowing of the differences in PMA with increasing age for either sex, or a lack of sufficient study power. The actual number of deaths in each arm was small and the older cohort and expected life expectancy make interpretation difficult. Additionally, “old age mortality advantage”, a phenomenon describing relative improved mortality in those 70-79 years, as compared to younger ages and other countries, may also explain the attenuation [23]. This result is also reflected in other studies [15,16]. Similarly, smoking status (seen in Karkkainen et al.) and the presence of underlying renal disease appeared to attenuate the association of PMA and mortality, again suggesting that PMA may be less useful in predicting mortality outcome in smokers or those with underlying renal disease [16].

The novelty of our study was the simultaneous measurement of frailty which minimally attenuated the association between 5-year mortality and the lowest tertile of PMA suggesting that despite adjusting for frailty, the association between PMA and mortality remains. The impact of frailty, as mentioned previously, has not been formally assessed previously in any other study of PMA and outcomes in vascular patients. This reinforces the message that although there is intuitively a link between PMA / sarcopenia and frailty, the concepts are not interchangeable. It may imply that sarcopenia as assessed by PMA may be a better marker of mortality risk than measures of frailty. Our study did not show statistically significant associations between PMA and postoperative complications, discharge destination and readmissions within 30 days. This may relate to many of the complications being technical or procedure related rather than due to lack of physiological reserve. The only studies looking at PMA and have published complication rates show overall surgical complication rates of 21.9% [18] and ‘post-operative complication’ of 27% [15]. Although this is much lower than our study, it is difficult to compare these as the former study references both open and endovascular aneurysm repair and the latter study does not describe what they mean by ‘post-operative complications’. The lack of association with complications would more likely be reinforced by the difference noted in complication rate in those patients who were excluded from the study due to lack of PMA data

There was a statistically significant association found between PMA and LOS after adjusting for BMI, however it is unlikely to be clinically significant at 8 hours or approximately one third of a day. Chowdury et al. did not show correlation with LOS or discharge destination, similar to this study [11]. However, this does contrast with Karkkainen et al [16]. The increased complexity of the operation (fenestrated-branched EVAR for thoracic and pararenal aneurysms) may account for this, as well as the larger sample size (n=504).

There is no clear consensus as to which value of PMA leads to increased mortality and poorer outcomes (8). In this study, the lowest tertile of PMA for men was less than 19.4 cm2 and for women, less than 12cm2. Other studies that have examined total psoas muscle area have a cut off for the lowest tertile of PMA at 13cm2 and 24cm2, both measured at L4, which is the level we chose [14,15]. We also showed that PMA to be associated with age, sex and BMI as did all previous studies mentioned. The limitations to our study include: the retrospective nature of the study at a single metropolitan centre; the small sample size which contributes to lower statistical power; and missing data as a potential source of bias. Furthermore, European consensus guidelines on sarcopenia have been recently updated to place more emphasis on muscle strength (potentially measured by grip strength or chair stand test), with poor muscle performance (potentially measured by low gait speed) defining severe sarcopenia [8]. These new measures should be included in future studies [24-30].

Conclusions

Lower PMA is associated with 2.76 times increased mortality in patients undergoing EVAR for asymptomatic infrarenal AAA. However, it did not predict shorter term outcomes. Despite adjusting for frailty, this association with PMA and mortality remains, which has not previously been assessed in other studies. Low PMA would be considered as less than 19.4cm2 in men and less than 12cm2 in women in this study, however further studies are required to determine what PMA would be best representative of sarcopenia and significantly worse mortality. As patients undergoing EVAR routinely have pre-operative CT scanning, PMA is an easy way to assess sarcopenia and to determine risk for operative management of these patients adding additional valuable information to risk stratification and indication for treatment in this group.

To Know more about   Open Access Journal of Gerontology & Geriatric Medicine

Click here:    https://juniperpublishers.com/oajggm/index.php

To Know more about our Juniper Publishers

Click here: https://juniperpublishers.com/index.php

 

The Interrelationship between Perceived Stress Level, Sleep Quality, and Academic Performance among Students of a Caribbean Medical School - Juniper Publishers

Anatomy Physiology & Biochemistry - Juniper Publishers

Abstract

Objective: Stress and sleep are essential elements of life and how these two factors affect academic performance of medical students must be studied properly in order to maximally and efficiently facilitate the medical training of future physicians.

Methods: 77 medical students who had similar work-load participated in this study. Participants were asked to answer the Pittsburgh Sleep Quality Index (PSQI) questionnaire and the Perceived Stress Scale questionnaire. The analyzed variables, quality of sleep and individual subjective perception of stress were linked to students’ grade point average (GPA). The SPSS version 24 was used for the regression analysis and determination of a Pearson correlation coefficient between perceived stress level, sleep quality, and academic performance.

Results: The majority of participants (80%) experienced a moderate level of stress but the correlation between a perceived stress level and GPA was not found (p>0.7). The distribution of sleep quality among showed that 58% of students described good quality of sleep. There was a correlation (R= -0.67) between the PSQI and GPA (p<0.03), supporting a relationship between higher GPA and good sleep quality.

Conclusion: Adequate sleep is imperative to learning and it is evidenced that a reasonable amount of stress is not only realistic but may also be advantageous to the learning process. Therefore, both sleep and stress interact in a mutual fashion and affect memory retention, and by extension, learning.

Keywords: Preceived stress; Oxidative stress; Physicians; Long-term memory; Physiological responses

Abbrevations: PSQI: Pittsburgh Sleep Quality Index; GPA: Grade Point Average; TSOM: Trinity School of Medicine

Introduction

Stress is a part of our life, since the most elementary bodily reactions produce oxidative stress. Psychologist Richard Lazarus defined stress as a moment in which a person perceives that the “demands exceed the personal and social resources that the individual is able to mobilize” [1]. It would be wrong to say that stress is completely bad, since some stress is beneficial in the learning process and memory consolidation [2]. However, the problem arises when there is too much stress, which ironically becomes counter-productive in the learning process and in long-term memory retrieval [2].

In a similar fashion, sleep is also a vital part of life as well [3,4]. The National Sleep Foundation has found that staying awake for twenty-four hours yields reaction times equivalent to having a blood alcohol concentration of 0.10, which is greater than the legal driving limit in the United States [5]. Sleep also plays a crucial role in memory consolidation, or stabilization, which includes integrating recently encoded memories into existing memory networks, as well as the development of hippocampal independence for declarative memories [6]. So, stress and sleep are essential elements of life and we may stand to benefit from studying how the two factors affect the mind and memory in medical students, in order to maximally and efficiently facilitate the medical training of future physicians.

Materials and Methods

The study was conducted at Trinity School of Medicine (TSOM), Saint Vincent & the Grenadines. The subjects were seventy-seven medical students with mean age of 24.7 years (SD=2.3), 33 male and 44 females, who had a similar academic load. Participation in the study was voluntary, and informed consent was obtained from all participants. Students who did not give consent and those who filled the questionnaire incompletely were excluded from this study. The analyzed variables, quality of sleep and individual subjective perception of stress were linked to students’ grade point average (GPA). Participants were asked to answer the Pittsburgh Sleep Quality Index (PSQI) questionnaire [7], which consisted of 10 questions related to their normal sleep habits. Sleep quality was considered bad for individuals who obtained a score higher than 5. The Perceived Stress Scale [8] was used for an evaluation of the level of stress. This scale includes 10 items and uses 5 points, rating scale ranging from 0 to 4: 0 – never; 1- almost never; 2- sometimes; 3- fairly often; 4 - very often; items 4, 5, 6, 7, and 8 are reversed scored. Data obtained were interpreted regarding the following scale: 0-13 - low-stress level; 14-26 - moderate stress level; 27- 40 - high-stress level. All data were tabulated in Microsoft Excel. The SPSS version 24 was used for the regression analysis and determination of a Pearson correlation coefficient between perceived stress level, sleep quality, and academic performance. A P<0.05 was considered as statistically significant.

Results

The distribution of perceived stress level among TSOM students showed that the majority of participants (80%) experienced a moderate level of stress, 13% of participants had a high stress level and only 7% of students were not stressed out (Figure 1) Several studies were conducted to identify the sources of stress among medical students and the most stressful conditions were found to be related also to medical training rather than social or personal issues [3,9]. Stress in medical students has been a global problem [10].

We also found that there is no correlation between a perceived stress level and GPA (p>0.7). Figure 2 indicates that students with moderate stress level (14-26) had a GPA which ranged from 4.0 to 1.0. These data also supported by several reports in the published literature as stress has physical and emotional effects and can create a positive or negative influence on us [3,11]. The stress responses differ depending on the type of stress and the individual’s physiological responses. Some researchers have explored the impact of stress on student’s performance with respect to change in time period and identified that initially there exists a positive relationship between stress and students’ performance to some specific limit after which stress impacts an academic performance negatively [12].

The distribution of sleep quality among TSOM students showed that a majority of participants (58%) had a good sleep quality (Figure 3), which had a positive effect on a students’ GPA (Figure 4). There was a correlation (R= -0.67) between the PSQA and GPA (p<0.03), supporting a relationship between higher GPA and good sleep quality (Figure 4). There is a correlation (R= -0.37) between the PSQA and perceived stress level (p<0.001), which is an indication that heightened levels of perceived stress and poor sleep quality are inter-related (Figure 5).

Discussion

Previous studies have reported a high prevalence of stress in medical students, ranging from 30% to 50% [13, 14]. A student can be stressed due to different reasons or stressors such as academic, financial or health problems, loss of a close family member or friend. Stress in academic situation can have both positive and negative consequences and can be viewed as the bodies’ reaction both neurologically and physiologically to adapt to the new circumstance [15]. Academic stress is the product of a combination of academic related demands that exceed the adaptive resources available to an individual. If a student is unable to cope effectively with academic stress, then serious psychosocial emotional health consequences may result [16,17]. Students who experience mental and physical health problems are then at greater risk for poor academic performance, thus increasing academic stress and perpetuating a cycle of stress, maladaptive coping, and compromised health [3,18]. In addition, some studies have shown that stress can induce a change in the way that memories are recorded and consolidated, namely going from a “cognitive” hippocampal bias toward a “habitual” dorsal striatal pathway [19].

Among several hypotheses [10,20,21], it was suggested that sleep is involved in the processes of brain plasticity for memory consolidation. Memory consolidation is defined as the time dependent process that converts labile memory traces into more permanent and or enhanced forms [22]. In this hypothesis, the information acquired during wakefulness would be actively altered, restructured and strengthened during sleep. Consolidation and encoding of memories are very important for medical education, as medical students need to retain a substantial amount of complex factual knowledge within short period of time [23]. A review by Curcio et al. in 2006 suggested that student learning and academic performance are closely linked to sleep quality and quantity [24]. A study conducted among medical students in King Saud University of Saudi Arabia showed that decreased nocturnal sleep time, late bedtimes during weekdays, and increased daytime sleepiness were negatively associated with their academic performance [25]. These results and results of our research suggested that students with later sleep phase, disorganized daily schedule/ time management and poorer sleep quality are at a higher risk of impaired academic performance [3,26,27]. The University of Munich (Germany) also detected that the timing of sleep-wake behavior was an important predictor of medical school performance [27].

Conclusion

Considering the data of this study and literature review, it is clearly apparent that the learning process and memorization of information require a certain amount of good quality sleep [3,6,23- 27]. The sleep quality and its duration play a tremendous role in the consolidation of procedural memory (a part of a long-term memory) and episodic memory and is a key point in the academic success [24]. Therefore, medical students must not neglect sleep during their academic life, and they should also try to minimize unnecessary stress, as the results of this study showed a negative effect of increased stress level on sleep quality and academic performance. According to this study, students whose stress level exceeded an adaptive threshold experienced academic difficulties and lowered GPA, but for another cohort of students the moderate stress level helped to enhance learning ability and GPA.

Adequate sleep is imperative to learning and it is evidenced that a reasonable amount of stress is not only realistic but may also be advantageous to the learning process. Therefore, both sleep and stress interact in a mutual fashion and affect memory retention, and by extension, learning.

To Know more about   Anatomy Physiology & Biochemistry International Journal

Click here:    https://juniperpublishers.com/apbij/index.php

To Know more about our Juniper Publishers

Click here: https://juniperpublishers.com/index.php

 

A Therapeutic Yoga Program for University Students with Anxiety: A Mixed Methods Study - Juniper Publishers

 

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.

To Know more about   Journal of Yoga and Physiotherapy

Click here:    https://juniperpublishers.com/jyp/index.php

To Know more about our Juniper Publishers

Click here: https://juniperpublishers.com/index.php