Utilizing Yoga Therapy as a Biomedical and Biobehavioral Intervention for HIV/AIDS Prevention &Treatment

Suzanne L. Slocum, PhD, RYT Center for Community Health UCLA Semel Institute for Neuroscience and Human Behavior CHIPTS Methods Core Lisa Walford, ERYT Senior Certified Iyengar Yoga Instructor Yoga Works Teacher Training Fawntice McCain, MFA, RYT Yoga Works Instructor

Goals of Todays Presentation Topresentthefollowing:

Current HIV/AIDS Interventions Definition of Yoga Therapy Yoga Therapy in Clinical Research Why Yoga Therapy for HIV? Theoretical Foundation Media Demonstration Research Methods and Design Research Challenges Future Steps

Current Biomedical & Behavioral Interventions for HIV/AIDS Prevention & Treatment
Vaccine Trials PrEP HAART Circumcision Microbicides Cognitive Behavioral Therapy Community Led Structural Interventions Human Rights and Social Justice Movements Yoga Therapy (todays feature)

Definition of Yoga Therapy

Yoga therapy adapts classic yoga practices to facilitate healing.

It encompasses a wide range of practices including physical postures, breathing sequences, and mind based exercises (i.e., meditation) to reduce symptoms, eliminate stress, increase vitality, and to enhance many basic physical and mental processes.

Includes and transcends aspects of psychology, philosophy, physiology, anatomy and spirituality.

Definition of Yoga Therapy

Components

Structural Imbalances (e.g., anatomical) Neuromuscular Patterning (i.e., pain and pain management) Physiological
1. 2. 3. 4. Digestive Cardiovascular Immune system Endocrine system 5. Respiratory 6. Reproductive 7. Nervous

Psycho-emotional Spiritual /mindful awareness Clinical and therapeutic (i.e., assessment, diagnosis, treatment, follow-up)

Definition of Yoga Therapy

Holistic Koshas: Sheaths of the body Gross body: Annamaya kosha: food body, anatomical & physiological systems subject to the biological processes of aging. Subtle body: Pranamaya kosha: vital energy, subtle life force, chakras Manomaya kosha: psycho-emotional, personality types Vijnamaya kosha: wisdom body, discrimination Causal body: Anandamaya kosha: bliss body, meditation

Yoga Therapy Research

Cancer Asthma Stress-reduction Depression Multiple Sclerosis (MS) Addictions Fertility HIV/AIDS

Parkinsons Diabetes Arthritis Epilepsy Hepatitis C Menopausal symptoms Migraines Kyphosis

Current Research

Karen Sherman, PhD, Group Health Cooperative, University of Washington. Yoga Therapy for Chronic Back Pain Annals of Internal Medicine, 143, 849. Dr. Shapiro, PhD, UCLA Semel Institute of Neuroscience and Human Behavior, Moscow Research Center, University of Bologna, Italy. Yoga Therapy as a Complementary Treatment of Depression Evidence Based Complementary and Alternative Medicine, In Press. Gale Greendale, MD, UCLA School of Medicine; Division of Geriatrics. Yoga Therapy and Hyperkyphosis American Journal of Public Health, 92, 10, 1611.

Why Yoga Therapy for HIV?

BehavioralPerspective: Acts as a mediator and/or impacts a multitude of biobehavioral factors:

Cognitive functioning (e.g., decision making, coping) Mental health Substance use

BiomedicalPerspective: Strengthens the immune system by directly impacting several systems:

Digestive Circulatory Nervous/ Neurological CNS, PNS Respiratory Muscular-skeletal

Current HIV Research

UCSF, Osher Center for Integrative Medicine (OCIM)

Swami Vivekanada Yoga Anusandhana Samsthana (SVYASA) Bangalore, India. Yoga Therapy/HIV+: Recruitment and Acceptability, Preliminary Data Mindfulness Based Stress Reduction: HIV Education, Stress, Immune System NIH/NCCAM R21. Several Pilot Studies, RCTs.

Washington University, Internal Medicine. St. Louis, MO.:

Living By Design Yoga Therapy/ HIV Side Effects of HAART: Metabolic syndrome/CVD NIH/NCCAM R21. Pilot RCT.

Addictive Behaviors Research Center, University of Washington, Seattle:

Mindfulness Meditation/Substance Use with Incarcerated Population. NIH/NIDA R21. RCT. Psychology of Addictive Behaviors, 20, 343.

Yoga Therapy for HIV/AIDS (RCT): BC, Canada. Tzu Chi Institute for CAM.
American Journal of Health Promotion, 20, 192. BC Ministry of Health

Integrative Approach
Holistic Koshas: Sheaths of the body Physical Body: Annamaya kosha: anatomical & physiological systems subject to the biological processes of aging. Subtle body: Pranamaya kosha: energy-level management, subtle life force Manomaya kosha: psycho-emotional, personality types Vijnamaya kosha: cognitive functioning, discrimination Causal body: Anandamaya kosha: spiritual awareness, meditation

International Association of Yoga Therapists (IAYT) Symposium of Yoga Therapy and Research (SYTAR), 2007

Theoretical Foundation
Yoga is one of the oldest holistic health-care systems in existence, focusing on both the mind and body. The roots of yoga date back almost 5,000 years. About 2,000 years ago the Indian sage Patanjali developed the basis of yoga philosophy as practiced today. The Yoga Sutras outline Patanjalis 8 limb path of yoga: 1. 2. 3. 4. 5. 6. 7. 8. yamas (cultivate healthy attitudes in relationship to others) niyamas (cultivate positive rapport with self) asana (physical postures) pranayama (breath work) pratyahara (sense withdrawal, turning inward) dharana (internal focus, concentration) dhyana (meditation) samadhi (liberation, freedom from suffering)

Theoretical Foundation Applied

1. Yamas - Cultivate: respect/cherish all life (non-violence), honesty, gratitude (non-stealing), energy management (abstinence), generosity (non-hoarding). 2. Niyamas - Observances: cleanliness, contentment, discipline, moral/ethic system, introspection, spiritual awareness.

Self-empowerment, confidence. Assists with developing healthy relationships with others. Creates and maintains harmony in relationships. Purifies and enhances strength on an emotional, physical and spiritual level.

Theoretical Foundation Applied

3. 4. 5. 6. Asana (physical postures) Pranayama (breath work) Pratyahara (sense withdrawal, turning inward) Dharana (concentration)

Biomedical impact -- These limbs help strengthen the immune system and connect the body and mind:

Digestive: acidreduction;internalorgansmassaged whichenhancesinsulinsensitivity Circulatory: inverted:Venousreturntoheartenhanced Nervous/ Neurological PNS Respiratory: excrete sputum, aerate the lungs & oxygenate cells Muscular-skeletal

Theoretical Foundation Applied

7. Dhyana (meditation) 8. Samadhi (liberation) These last two limbs indicate a deeper spiritual awareness:

Universal oneness/non-duality: service to others, integration of the community, creation of social network/community. Freedom from suffering: connection to a divine nature.

HIV Conditions & Characteristics

Medical Terms

Common Complaints

Hepatitis Peripheral Neuropathy Lypodystrophy Lypoatrophy (wasting) Rise in triglyceride levels (Metabolic Syndrome) Anemia Liver toxicities

Fatigue Depression, anxiety Loss of libido Nausea, acid reflux Muscle cramps Night sweats Digestive imbalances

Balance of the Autonomic Nervous System: Stress and Yoga Therapy

Sympathetic Arousal (Fight/Flight Syndrome)

Parasympathetic Tone (Relaxation Response)

Blood pressure increases Respiration increases Muscle tone increases Digestive processes pause Epinephrine levels increase Eyes dilate
- MP Schatz, MD, Yoga Journal, 1987

Decrease in heart rate Blood pressure drops Muscles relax Peristalsis increases Insulin production increase Pupils of eyes contract

What is yoga? Why yoga?

.

Yoga is the cessation of movements in consciousness. Yoga is the resolution of the mind into silence.

Yogas citta vrtti nirodhah - Y.S. I. 2

A Healthy Approach to Life

Yoga Therapy

VS.

Lack of Healthcare or Services

Active approach to illness Optimistic outlook Internal locus of control Inner stability, tranquil Appropriate self confidence Sense of purpose Social support system Involvement
- MP Schatz, MD, Yoga Journal, 1987

Resigned, helpless Pessimism Change seen as threat External locus of control Agitation, volatile Too much or too little self confidence Apathy Isolation, alienation

Key Components of Yoga Therapy for HIV

Creates self-reliance Modify and adapt to personal needs Develops a healthy relationship between mind and body Highly intimate and personal Non-invasive Supports other treatments Enhances self-awareness Encourages healthy choices Introduces spirituality Provides a supportive community

Yoga and HIV

Yoga is self reliant and practical Yoga therapy can be modified to the individual Asymptomatic people and those who are immune compromised need different kinds of support

Iyengar Yoga
Restorative Yoga Practice
Supportive environment for total relaxation Minimal physical exertion Some poses effect whole body, while others effect specific target areas Alternately stimulates and soothes the internal organs Relaxation response is a chemical process which breaks down the effect of sympathetic arousal. Postures are held longer to encourage this.

Basic Supported Baddha Konasana

bound angle pose

Releases tension in the diaphragm, the low back and the gastrointestinal tract Enhances pulmonary and cardiac circulation by passively opening the chest Quiets the breath

Supta Padangustasana
intense side stretch pose

Peripheral Neuropathy
Increases range of motion in the hip joints Creates mild traction for the lower back Relieves compression on the sciatic nerve Lengthens the iliopsoas muscle

Cross Bolsters
Deeply quieting Improves elasticity to the lungs Balances hormones, helps avoid migraines Relieves indigestion
When the breath wanders, the mind also is unsteady. But when the breath is calmed, the mind too will be still.
- Hatha Yoga Pradipka 1400

Bharadvajasana
reclining twist

Relieves the back and intercostal muscles Relaxes the kidneys and adrenal glands Nourishes the inter vertebral discs

Balasana
childs pose

Triggers that initiate the PNS

Vagal Heart-slowing Reflex Center of For head Orbits of the eyes Breath

Inversions

Adho Mukha Svanasana

downward facing dog Supported Inverted poses lower blood pressure and alter hormonal levels Supporting the weight of the head will give gentle pressure around the eyes and stimulate the vagal heart slowing reflex Introduce gently and progressively

Inverted backbends
Supported Sirsasana

Passively stretches the vagus nerve and muscles of respiration, increases cardiac output Relieves tension in the shoulders and upper back and thus helps to avoid headaches.

Sarvangasana
shoulder stand Jalandhara Bandha, Vagal Nerve Reflex Inverted poses encourage venous return from the legs to the heart Redistributes body fluids Increases cardiac output Some inverted poses encourage pressure to the carotid sinus and the aortic arch.

Viparita Karani
legs up the wall pose

Relieves systemic fatigue and stress related headaches Alleviates constipation and diarrhea Can be maintained for up to twenty minutes effortlessly The practice should be done daily, gradually increasing the duration. Hatha Yoga Pradipka 1400

Savasana
corpse pose

Not-doing in doing. Practice this, and know the unknowable.

- Lao Tzu

Intervention Design for HIV+

Duration: 4 months 1 Session of asana a week (approaches using Iyengar Yoga: props) 1 Session of pranayama a week 1 Session of meditation a week 1 Group session a month (Yamas, Niyamas) Narratives/story telling (Bhagavad Gita) Role playing Personal Home Practice Education and Tools (i.e., props, DVD) Nutrition, Getting Services, Moral/Ethical codes Talking-stick

Study Design
Phase I Feasibility and Acceptability: Focus groups and Key Informant Interviews Phase II Pilot Study: Randomized Control Trial (3 levels): Treatment (full intervention design) Monthly group session only Control Standard of Care Participants: HIV+ females (18 yrs of age and older) Eligibility: screen for severe mental disorders and pregnancy Recruitment: Community Based Organizations/Agencies Community Based Health Clinics CHIPTS affiliates/organizations

Assessment
Baseline Follow-ups: 6 months, 12 months CASI, PDAs Questionnaire Development System 2.1 Outcomes: Including clinical markers of disease and risk progression Primary HIV Risk Behaviors (Substance Use and Sexual Risk Behavior) Adherence to Medications and Health Services CD4/Viral Load Secondary Mental Health (i.e., Depression) Emotional Regulation Metabolic (Body composition) Pain Quality of Life Cortisol Cardiovascular Risk

Potential Assessments
Primary ARBA DAST, MAST CD4/Viral Load Secondary Mental health: BSI, UCLA PTSD (depression, anxiety, trauma) EEGs emotional regulation Metabolic (Body composition) (BMI, waist circumference) Pain (SF36) SF36 & HIV/AIDS-Targeted Quality of Life Instrument Cortisol (urinary) stress levels Cardiovascular Assessment - lipoprotein buoyancy

Questions and Concerns

Acceptability: Price, emotional costs, timeline of healing Recruitment challenges Adherence challenges Adaptation and adoption Replication of intervention Sustainability of intervention Cross-culturally challenges in assessment

Future Steps
Submit proposal to conduct RCT using Yoga Therapy for HIV+ Latina Females to NIH/NCCAM Implement a community-led Yoga Therapy Program: Utilizing community leaders/spiritual leaders Utilizing healthy HIV+ females. Continue to instruct HIV+ individuals in Los Angeles via Yoga Works and the Iyengar Institute. Publish a Yoga Self-Care Book and an accompanying DVD for the HIV + population.

Contact Information
Suzanne L. Slocum, PhD, RYT SSlocum@mednet.ucla.edu Lisa Walford, ERYT lisa@walford.com Fawntice McCain, M.F.A, RYT asanaangel@earthlink.net Center for HIV Identification, Prevention and Treatment Services www.chipts.ucla.edu

Namaste Thank Yous

Adriana De Franco (with permission) Gary Guillot (with permission) Iyengar Institute Yoga Works Yogacharya B.K.S. Iyengar International Association of Yoga Therapists CHIPTS CCH
Matthew Taylor Sat Bir S. Khalsa Annie Carpenter (Editorial staff) Alan Seeman Amy Elkavich Bonal Samreth