The Effects of Yoga on Symptoms of Posttraumatic Stress Disorder (PTSD) for Military Populations Who Have Sustained a Mild Traumatic Brain Injury (mTBI)
Prepared by: Amy Gwynn, SPT
Background:
I’ve been practicing yoga consistently for the past five years, and have noticed not only physical, but also mental/emotional benefits in my own life. I wondered about how much literature is actually available on this topic, and started with an evidence table about the effects of yoga on knee osteoarthritis back in EBP1. When trying to figure out a topic for my capstone, my advisor, Prue Plummer made me aware of a research project Karen McCulloch was working on establishing regarding the effects of yoga on PTSD symptoms, quality of sleep, and heart-rate variability in military personnel who have sustained a mTBI. I was very excited to have the opportunity to work on not only appraising the current literature on this topic, but also helping work on and learn about what it takes to write grants and start working on a research project.
Overview
PTSD, which typically involves physical, mental, and emotional symptoms including difficulty sleeping, nightmares, avoidance, exhaustion, and emotional numbing unfortunately often leads to personal, familial, and even societal disruptions.2,3,5 Combat-related PTSD occurs frequently in the military, and unfortunately treatment is not always sought out due to fear of consequences and stigma.3 Yoga has been identified as an alternative treatment option for PTSD as talk therapies and pharmaceutical interventions are not always effective. Yoga has been shown to stimulate the parasympathetic nervous system, which reduces heart-rate variability, increase production of GABA, both which decrease allostatic load–an imbalance in the autonomic nervous system–and may trigger episodes of PTSD symptoms.6
While yoga has been shown to be helpful in significantly reducing PTSD symptoms in a few different populations, it is still not a well-established or reimbursed intervention. This is largely potentially due to the variability in yoga intervention in terms of type, elements, duration, frequency, population, and also the generally poor quality of studies available, with small sample sizes, often lack of control group, and non-blind investigators. Additionally, a lack of quantitative data from validated outcome measures, and for example, HRV devices further weakens this literature. There are still many questions as to the value of the use of yoga for this population. The good news is, this leaves plenty of room for projects such as this one.
Gathering the Evidence
So, in EBPII, my PICO question was: “In military personnel with mild traumatic brain injury and post-traumatic stress disorder, does yoga improve sleep quality and increase heart-rate variability?” I created an evidence table on this topic during EBPII, and updated it for this project to ensure I was using the most current literature available. Critically appraising this topic (CAT) in EBP II helped me identify the best literature available, and understand more about how weak the current literature is. This made me all the more motivated to help contribute further and pursue working with Kmac on her project.
The Project
After Kmac worked to respond to different calls and on writing pre-proposals for this project all winter, we were sad to hear that no proposals had been requested, nor funding approved for this particular project. That said, we decided it would be best for me to go ahead and write the research background paper to be included in future proposals. Kmac is still collaborating with many other disciplines on this topic, and helped me recognize this slow, trial-and-error process is just the way the research world works.
The paper I wrote discusses the current state of the literature, which is weak and limited, on the effects of yoga on PTSD symptoms not only in military populations, both active-duty, and veteran, but also for women who were victims of interpersonal violence, and flood victims in India. There is no literature available on the effects of yoga on PTSD symptoms, HRV, and sleep quality for military populations who have sustained a mTBI. I also sought to highlight the frequency, duration, elements, and timeline of the strongest studies, identified in my CAT, as research design has been a limiting factor in the approval of project pre-proposals on this topic.
Evaluation
I sought evaluation from Kmac most directly through in-person meetings, phone calls, and e-mails. Kmac’s feedback has already been integrated into my final products.
I’m hopeful my work will be helpful in the future to further research on this topic, about which I’m very passionate. I intend on continuing to work with Kmac on this during clinical, and potentially even post-graduation, if she’ll have me.
Self-Assessment:
This process has taught me a lot about how much time and energy goes into seeking out and applying for grant funding for research projects. Understanding about what companies or the government is calling for, and how many different sources of funding are available has surprised and challenged me. I didn’t realize getting funding was such a long trial-and-error process, and that’s before you even start the research. I feel like I only played a very small part in what could become eventually a large project, and I can’t imagine trying to coordinate an entire study, writing a manuscript, and getting published–that seems so far off! I was fairly independent with the project, and would just check in with Kmac on the phone or in person about once a month on my progress. While I had a little bit of accountability, I also learned about what it means to be accountable to myself. I set deadlines for the evidence review, evidence table, paper, and integrating feedback, and stuck to them. I’m glad to know I have this skill, as I anticipate I’ll need to use it for the rest of my life as I become a more independent therapist. I’ve also learned I’d like to be involved in research in some way as a clinician, and want to be able to help contribute to our field in that way, whether it’s doing literature reviews, which seems unlikely, or implementing a particular intervention in the clinic for a researcher. I’d like to look into more ways that I could be active in research while in clinical practice.
Acknowledgements:
I would like to thank Prue for pointing me in this direction, and for her very thorough feedback on my EBPII materials. I’d also like to thank Kmac for providing helpful feedback and guidance throughout this process, which started in June 2014. I learned a lot about how much patience and research goes into research before the project even gets funded and started from you, Kmac. I’d also like to thank Ginger Garner, PT, MPT, ATC, PYT, CPI, Camp Lejeune, Jacksonville, NC, and Amy Cecchini, MS, PT, Fort Bragg, Fayetteville, NC, for their feedback as well.
References:
- Stankovic L. Transforming trauma: a qualitative feasibility study of integrative restoration (iRest) yoga Nidra on combat-related post-traumatic stress disorder. Int J Yoga Therap. 2011;21(21):23-37. http://www.ncbi.nlm.nih.gov/pubmed/22398342.
- Carter J, Byrne G. A Two Year Study of the use of Yoga in a series of pilot studies as an adjunct to ordinary psychiatric treatment in a group of Vietnam War Veterans suffering from Post Traumatic Stress Disorder . Depression. 2002:1-11.
- Stoller CC, Greuel JH, Cimini LS, Fowler MS, Koomar JA. Effects of Sensory-Enhanced Yoga on Symptoms of Combat Stress in Deployed Military Personnel. Am J Occup Ther. 2011;66(1):59-68. doi:10.5014/ajot.2012.001230.
- Staples JK, Hamilton MF, Uddo M. A yoga program for the symptoms of post-traumatic stress disorder in veterans. Mil Med. 2013;178(8):854-860. http://www.ncbi.nlm.nih.gov/pubmed/23929045.
- Kim SH, Schneider SM, Kravitz L, Mermier C, Burge MR. Mind-body practices for posttraumatic stress disorder. J Investig Med. 2013;61(5):827-834. doi:10.231/JIM.0b013e3182906862.
- Streeter CC, Gerbarg PL, Saper RB, Ciraulo D a., Brown RP. Effects of yoga on the autonomic nervous system, gamma-aminobutyric-acid, and allostasis in epilepsy, depression, and post-traumatic stress disorder. Med Hypotheses. 2012;78(5):571-579. doi:10.1016/j.mehy.2012.01.021.
- Van Der Kolk B a. Clinical implications of neuroscience research in PTSD. Ann N Y Acad Sci. 2006;1071:277-293. doi:10.1196/annals.1364.022.
- Cabral P, Meyer HB, Ames D. Effectiveness of yoga therapy as a complementary treatment for major psychiatric disorders: a meta-analysis. Prim Care Companion CNS Disord. 2011;13(4). doi:10.4088/PCC.10r01068.
- Dick AM, Niles BL, Street AE, Dimartino DM, Mitchell KS. Examining mechanisms of change in a yoga intervention for women: The influence of mindfulness, psychological flexibility, and emotion regulation on PTSD symptoms. J Clin Psychol. 2014;00(0):1-13. doi:10.1002/jclp.22104.
- Mitchell KS, Dick a M, Dimartino DM, et al. A Pilot Study of a Randomized Controlled Trial of Yoga as an Intervention for PTSD Symptoms in Women. J Trauma Stress. 2014;(April):121-128. doi:10.1002/jts.
- Libby DJ, Reddy F, Pilver CE, Desai R a. The use of yoga in specialized VA PTSD treatment programs. Int J Yoga Therap. 2012;22(22):79-87. http://www.ncbi.nlm.nih.gov/pubmed/23070675.
- Van der Kolk BA, Stone L, West J, et al. Yoga as an adjunctive treatment for posttraumatic stress disorder: A randomized controlled trial. J Clin Psychiatry. 2014;75(6):e559-e565. doi:10.4088/JCP.13m08561.
- Telles S, Singh N, Joshi M, Balkrishna A. Post traumatic stress symptoms and heart rate variability in Bihar flood survivors following yoga: a randomized controlled study. BMC Psychiatry. 2010;10:18.
- Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health. 1998;52(6):377-384. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1756728&tool=pmcentrez&rendertype=abstract.
5 Responses to “The Effects of Yoga on Symptoms of Posttraumatic Stress Disorder (PTSD) for Military Populations Who Have Sustained a Mild Traumatic Brain Injury (mTBI)”
Amy Gwynn
Hey, Michael.
Thanks for your interest! While I’ve attended studios that offer PTSD trainings, I’ve never attended one myself, nor have I directly encountered veterans or AD military in classes I’ve taken unfortunately. There are programs specifically for this population already established for example at the Durham VA. None of the studies I read mentioned more subjectively about AD or veterans approach to yoga specifically. Sorry, I wish I had a better answer to your question.
Thanks,
Amy
Michael R. Murray
Hi Amy,
I remember talking to you about this a little bit and it sounds super interesting and conceivable that this would work for many military oriented patients especially if you are able to show them that they have weakness in a certain area. I also think that this could easily become a composition of strength and flexibility feats as opposite to straight up yoga practice. Have you worked with or seen anyone from this population in your practice of yoga? If so were there any considerations you had to make as they participated? I feel like people might respond differently or have variations in participation depending on whether the practice was on the base verse in the public domain. I only mention this because I lived with a former Army Ranger instructor who admittedly had some level of PTSD and he would do yoga, dancing, and crossfit but almost over do it, so I wonder how he might be different on the base verse in the public realm. Great job and I enjoyed your paper a lot. Have a great one!
-Michael R. Murray
Amy Gwynn
Blair–Kmac didn’t receive specific information about why the letters of intent weren’t approved for pre-proposals, but based on what was chosen she gathered that for one group the studies chosen were more epidemiological with a better description of problems prior to intervention, more focused on vestibular issues. For the private grant, they were prioritizing peds and other special groups over military. Overall, our project didn’t fit the priorities of the funding group or call specifically. We just met this week with a professor of nutrition from ECU and are going to be looking to smaller funding sources, potentially intercollegiately to start a small pilot study. We think including nutrition might help our chances of approval, as the military performance triad includes exercise, sleep, and nutrition. This is still in it’s infancy, but is still very exciting. Thanks for your question!
Deidra-
Yes, I couldn’t find any literature specifically on the effects of yoga on PTSD symptoms, HRV, and sleep quality for military populations who have sustained a TBI. The studies I was able to find that included a military population only had PTSD, and had not had a prior TBI. You’re right–these studies were much more broad, and so the generalizations that can be made about whether yoga is helpful only really target PTSD symptoms. There was only one study which included HRV data. There were a couple studies which looked at the effects of yoga on PTSD in women who experienced interpersonal violence as well. There are so many variables to consider, and because the mechanism by which yoga works(?) is unclear, this makes it even more challenging. Based on what I’ve read if future research could focus more on the biomarkers to understand more about the mechanism by which it works, as well as more quantitative measures (such as HRV), this could help us understand more about what other populations this may help most. Let me know if that answered your question. Thank you both for your responses!
Amy
Deidra Debnam
Amy,
I was particularly interested in your project as your it hits close to home for me. Being from Fayetteville, NC and my dad being retired military – I’ve developed a great sense of pride and appreciation for our active and veteran military men and women. I also have a personal awareness of the affects of PTSD on our troops. A guy I went to high school with battled PTSD following his return from the war and unfortunately took his own life. Additionally, my father works in mental health and is the military/veterans point of contact where he works to improve individuals’ access to mental health services and behavioral health treatment.
More recently, mental health is gaining more attention – primarily due to tragic events that have occurred throughout the country in which the suspects and/or guilty parties are described as having a mental condition. Mental health is also becoming an important issue as more and more troops continue to return from combat. One of the primary barriers to individuals accessing mental health services is due to the stigma associated with mental illness. Your research shows that yoga offers a unique way to address some of the symptoms of PTSD. The great thing about yoga is that it is an activity that mentally healthy individuals perform for similar reasons – thus taking away the shame and isolation some individuals may experience from other modes of treatment.
You stated that there is “no literature available on the effects of yoga on PTSD symptoms, HRV, and sleep quality for military populations who have sustained a mTBI.” However, there is weak and limited information on the effects of yoga on PTSD symptoms in the broader military population. Do these studies include individuals both with and without mTBI? Since the use of yoga is not a well-established intervention in the military population, perhaps the research community would first like to establish more quality studies in the broader military population before narrowing the scope to individuals with both mTBI and PTSD. I’m not an expert on how “research works,” but maybe proposing a study whose results could be applied to a larger population would increase the argument that there is a significant need for this information.
Thanks for the great information your research has provided. I am glad to hear that you will continue to work with Kmac on this project and I hope that others will recognize the importance and the need for additional studies on this topic!
Elizabeth Burnette
Amy,
I am sorry to hear that your project didn’t receive funding to move on to the next phase of research, I would have been really intrigued to see the results of a larger caliber study on this topic. I am curious if either you or KMAC received any feedback on exactly why the funding for the topic was not supported? I am not familiar with the research process, so I was interested in seeing if you were provided with feedback to help achieve funding for future proposals.
When reading through your discussion of the prevalence of military service members using alternative techniques to treat their PTSD I couldn’t help but think that yoga would be a perfect match. Considering the high proportion of this population that is extremely fit, it seems like common sense to me that an intervention that promotes physical activity rather than pharmacological agents would be a preferred treatment option. I completely with you that there is a huge potential for research on this topic, and I hope that you stay linked to the project and eventually get the answers you were looking for.
Blair