The role of yoga in the symptom management of musculoskeletal conditions

Background. Musculoskeletal conditions comprise a diverse group of disorders, united by a commonality of biopsychosocial symptoms including pain, functional disability, and decreased quality of life. Yoga is a popular form of non-pharmacological management for musculoskeletal conditions; providing an array of techniques adaptable to the physical and psychosocial symptoms of these conditions. The aim of this thesis was to investigate the effectiveness and feasibility of yoga for the biopsychosocial symptom management of musculoskeletal conditions. Methods. Based on the Medical Research Council guidelines for the development and evaluation of randomised controlled trials for complex interventions, this thesis involved two processes of development and feasibility. In the development process, a systematic review and meta-analysis was conducted to identify the effectiveness of yoga for musculoskeletal conditions; and to investigate components and reporting of randomised controlled trials of yoga for musculoskeletal conditions. An international Delphi survey, comprising recognised experts (N=36) in the field of yoga for musculoskeletal conditions, was then conducted to develop consensus on which components of these complex yoga interventions were amenable to standardisation. In the feasibility process of the thesis, a pilot randomised controlled trial (N=26), based on the Delphi recommendations of the development process, was conducted to assess the feasibility and safety of a relaxation-focussed yoga intervention for rheumatoid arthritis-related pain and sleep disturbance. Results. The systematic review and meta-analysis provided evidence suggesting yoga is safe, and moderately effective at improving pain and functional ability in a range of musculoskeletal conditions. However, areas of heterogeneity in study design and reporting of these complex interventions impedes both the evaluation of dosage effects of yoga, and protocol replication. Group consensus of experts in the Delphi survey subsequently resulted in the development of a 33-item Delphi list, recommending key intervention components for the design and reporting of yoga interventions for musculoskeletal conditions. Thirty-two of these Delphi recommendations then informed the design and reporting of the subsequent pilot randomised controlled trial. Acceptable levels of recruitment, retention, and adherence were reported in the pilot study; with high participant satisfaction and no associated serious adverse events. Individual variability in a range of biopsychosocial outcomes was high in both yoga and usual care participants across the intervention period; no effects of yoga compared to usual care were indicated. Conclusions. The current thesis has provided evidence for the effectiveness of yoga for the biopsychosocial symptom management of musculoskeletal conditions. Collectively, results suggest the feasibility of proceeding to a future main trial, based on the standardised Delphi recommendations. Standardisation of these complex, multi-component interventions may provide future guidelines for the dosage of yoga practice required to produce a therapeutic effect. These guidelines would provide an important accompaniment to current recommendations for the use of mind-body therapies in the non-pharmacologic management of musculoskeletal conditions