664682

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JPCXXX10.1177/2150131916664682Journal of Primary Care & Community HealthPatwardhan

Commentaries
Journal of Primary Care & Community Health

Yoga Research and Public Health: Is

2017, Vol. 8(1) 31­–36
© The Author(s) 2016
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DOI: 10.1177/2150131916664682

Stakeholders’ Needs? jpc.sagepub.com

Avinash R. Patwardhan1

Abstract
Research on yoga is witnessing an unprecedented proliferation currently, partly because of great interest in yoga’s health
utility. However, yoga research does not seem to be sufficiently public health oriented, or its quality corresponding to its
quantity. Yoga research is falling short to enable key stakeholders like end users, prescribers, and payers to meaningfully,
confidently, and fruitfully answer the questions like: Is it generalizable? Is it standardizable? Which yoga style should be used/
recommended/paid for? Or will it be worth the money? Therefore, it is important to examine the alignment to purpose or
value of yoga research from a public health point of view so as to make it more practical. The issues such as lack of clear
definition of yoga, wide variation in its dosage, cacophony of lineage-based styles, no data about comparative effectiveness
between the yoga components, confounders and biases clouding the evidence regarding its benefits, too little data on long-
term adherence, equivocal results about its cost effectiveness, discussions lacking embrace of better methods in research,
and absence of a theory of yoga are examined. This is not a detailed discussion of every issue yoga research faces, but a
high-level overview of those that have direct practical bearing. In the end, a few pragmatic approaches are offered. The
article suggests that yoga-component analysis, development of a theory of yoga, adoption of a health-aligned functional
typology of yoga, development and testing of a simple universal basic prototype of yoga intervention, emphasis on research
about long-term adherence, and discouragement for mere proof of concept research might make yoga research serve the
stakeholders better. It urges the research community to practice “context cognizant scholarship” to disentangle health
compatible yoga from its historical-cultural-social body before examining it for health or medical application.

Keywords
yoga, yoga research, medicalized yoga, public health, meditation, adherence to yoga, health economics, yoga theory, yoga
typology.

Background report that the methodological quality of researches is low,2

There is an unprecedented proliferation in research publica-
tions on yoga.1,2 Probably, the trend of its medicalization is
driving this surge.3 While it is encouraging that medicalized
yoga is being subjected to increasing scientific scrutiny,
yoga research does not seem to be sufficiently public health
oriented. Furthermore, its quality does not correspond to its
quantity. A search for “yoga” AND “public health,” in the
article title in PubMed, returns mere 2 citations, and a search
for “yoga” AND “health economics” returns zero articles.
This paucity provides a sense about the importance scholar-
ship accords to these topics. Likewise, highlighting the
quality-quantity chasm, Sherman laments that the current
efficacy studies serve only as proofs of concept,4 Cook-
Cottone complains about the lack of understanding on thera-
peutic dosage,5 Fischer-White and Taylor admonish that
until a structured, uniform approach to yoga research exists,
research results will have minimal impact,3 Elwy et al2
Park et al1 observe that the literature is replete with contra-
dictions and is inconclusive, and the Canadian Agency for
Drugs and Technologies in Health6 concludes that there is
insufficient evidence to comment on the safety and long-
term efficacy of yoga. These observations stand out, given
the fact that modern research on yoga began 96 years ago.7
End users of yoga, prescriber providers, and insurer payers
are the 3 key stakeholders whose interest in yoga research is
practical. They seek research to meaningfully, confidently, and
fruitfully answer the following questions about medicalized
1
George Mason University, Fairfax, VA, USA
Corresponding Author:
Avinash R. Patwardhan, Department of Global & Community Health,
George Mason University, 4400 University Dr, Fairfax, VA 22030 USA.
Email: apatward@gmu.edu
32
yoga: (1) Is it useful for health promotion? (2) Is it useful for
disease mitigation? (3) Can there be harm? (4) Is it generaliz-
able? (5) Is it standardizable? (6) Which yoga style should be
used/recommended/paid for? (7) Can it be clearly identified?
(8) Will it be worth the money spent? and, (9) Will it work reli-
ably? It seems that except for the first 3, yoga research is not
very helpful with the rest of the questions.
Therefore, it is important and necessary to subject yoga
research to critical scrutiny. There is no dearth of literature
that discusses challenges related to methodology and meth-
ods; however, publications that discuss meaningfulness,
alignment to purpose, or value are very few.3,8,9 This article
is not to say that yoga research is devoid of utility or quality,
but it is a commentary on its practicability. With a focus on
public health issues and practical application of medical-
ized yoga in the western societies, this article is an attempt
to fill the gap. At the end of the article, suggestions are
made for remedial approaches.
Issues in Yoga Research
Definition of Yoga
Yoga is defined as a mind-body practice composed of phys-
ical postures, breathing techniques, and meditation.10,11 One
would then expect that to call a practice as yoga, all the 3
components should be present in it. However, one study
examines meditation-only (karma) yoga, with no compo-
nents of breathing or postures12; another examines breath-
ing exercises–only (pranayama) yoga, with no components
of postures or meditation13; another examines postures-
only (Hat.ha) yoga, with no components of breathing or
meditation14; and still another studies laughter-only (laugh-
ter) yoga, with no components of breathing, postures or
meditation.15 Furthermore, all these 4 disparate scientifi-
cally well-designed studies draw a common generalized
conclusion that “yoga works.” Such reports may potentially
bewilder and confuse stakeholders.11
Dose
Usefulness of yoga depends on its dose. Dose may include,
exposure during intervention, home practice, information
gathering outside of intervention, and cumulative effect of
prior exposures. Currently no data exist that capture the
latter 2. A few studies offer diffuse glimpses into home prac-
tice component16,17; however, a review found that 72% of the
studies do not report on the duration or details about the home
practice.2 On the magnitude of dosage, only the duration of
sessions (60-90 minutes) provides data that are practically
useful.4 The frequency of sessions varies from once a week
to 6 times a week and the total intervention durations vary
from 1 day to 2 years, rendering these data impracticable.2,5,11
Journal of Primary Care & Community Health 8(1)
Saper et al17 find that once-weekly or twice-weekly yoga
classes have practically no difference in efficacy. Overall
dose data are too incoherent for guiding users.
Styles and Details of the Components
One bibliometric analysis of yoga reports that “more than
40 different yoga styles were used in their analyzed ran-
domized controlled trials (RCTs)” and comments that with
such diversity, comparison is difficult.11 A systematic scop-
ing review states that 54% of the studies on yoga do not
provide details about the components within the style.2 A
study comparing styles says that there is little correlation
between styles and positive conclusions.18 A user cannot
decide about the style based on these findings.
Relative Contribution of Components
Measurement of relative contribution of components (eg, pos-
tures, breathing exercises, meditation) is desired but is missing
in the current literature.11,19 Studies have shown that medita-
tion has health benefits,20-22 and studies have also shown that
contribution of postures in maintaining health and fitness is
small to insufficient.23-26 However, with one exception,27 litera-
ture does not document research that compares and contrasts
the utilities of postures, breathing exercises, and mediation in
health promotion or disease management. These findings
showcase vividly the research practice divide.
Confounders
A systematic review of yoga practices notes that most studies
do not control for potential confounds and therefore do not
inform much about causality.28 Similarly, an article com-
ments that yoga effects often become insignificant when fac-
tors like education or income are taken into consideration.29
With reference to complementary medicine, Greco et al30
provide a detailed treatment of nonspecific factors in healing
such as practitioner attitudes, outcome expectancies, and so
on, which are scantily addressed by current yoga research.
Confounders make claims about yoga efficacy dubious.
Adherence
For chronic diseases, long-term adherence to yoga is
crucial.28 There are a very few studies that have examined
adherence to yoga, and that too, over no longer than 6
months.31-35 Currently, we do not know if yoga can be suc-
cessfully applied for chronic conditions in the real world.
Health Economics
Fischer-White and Taylor3 write, “In the current health care
climate, every dollar spent on research is scrutinized. Thus,
Patwardhan
yoga/yoga therapy research that is not . . . cost savings will
be replaced by . . .” Studies about cost-effectiveness of yoga
are conflicting. Two trials for low back pain showed that
there was potential cost-effectiveness based on quality-
adjusted life years.36,37 However, a trial for maintaining
vitality in older workers showed that yoga was not cost-
effective.38 No health modality is worth much if it fails to
convincingly pass the litmus test of health economics.
Biases
Yoga research is inundated with biases. Cramer et al39 sug-
gest that the yoga RCTs are highly vulnerable to selection
bias. Smith and Pukall40 and Keshavan et al41 allude to file-
drawer problem in passing. Negative results are meagerly
reported42-44; even a popular article discusses about the pub-
lication bias in yoga research.45 A yoga “self-efficacy
scale”46 or a “yoga questionnaire”47 suggests a possibility of
ethnicity and gender biases in them making their universal
applicability questionable.11,41 Most yoga interventions and
their outcomes measures are over short durations, which
creates a time-term bias.2,11 Nudging the issue of causality
of these biases, it must be noted that these biases come at a
cost.
Research Methodology and Methods
Despite a talk about the utility of whole system research,48-50
complexity science,51 Bayesian method,52 or composite
measures of healing,53 the actual use of these methods is
little. Furthermore, due to methodological issues, some-
times results on the same outcome are contradictory.26,54
Theory of Yoga
Despite numerous excellent publications pertaining to
mechanism of action of yoga, a cogent theory of yoga
stands out in yoga research by its absence.
How Can Yoga Research Be Made
More Practical?
Medicalized yoga’s contribution in public health is proba-
bly subpar mainly because of its cacophony and fuzziness.
Based on the issues discussed above, the following
approaches in research might facilitate to bring coherence
and order in the field of yoga intervention.
Conduct Component Analysis of Yoga
Currently yoga is not subjected to component analysis,
which is a method, different and distinct from the statistical
procedure “principal component analysis,” and entails a sys-
tematic assessment of 2 or more components that comprise a
33
treatment package.55 A 1981 component analysis of yoga
showed that when postures and breathing exercises were
compared side by side, postures did not measure up for the
beneficial effects.27 Comparative component analyses of
yoga should be conducted on the highest priority.
Develop a Theory of Yoga
Around 1993, the idea of theory-based evaluation became
popular in the field of evaluation research.56 In that stride,
Sechrest and Figueredo57 wrote, “Under many circum-
stances, strong theory can compensate for relatively weak
method.” Twenty years later, theory based evaluation might
prove handy in solving many a problem in yoga research. A
good theory of yoga can provide a logical blueprint and a
robust skeletal framework for yoga research and can spare
numerous wasteful dashes into blind alleys.
Adopt a Health-Oriented Typology Instead of
Lineage-Based Yoga Taxonomy
Attempts have been made in anthropology to create typol-
ogies of yoga.58,59 Though better than lineage-based styles
of yoga, which anyway do not matter for results,18 those
typologies are still insufficient for medicalized yoga. This
article proposes a functional typology with 3 domains: (1)
behavioral, (2) physical, and (3) mental. Under the pro-
posed typology, Hat.ha yoga would fit under physical
domain, Karma yoga would fit under behavioral domain,
and Jñāna yoga would fit under mental domain. Similarly,
limbs such as Yama and Niyama would fit under behav-
ioral domain, postures and breathing exercises would fit
under physical domain, and meditative exercises would fit
under mental domain. This typology will reduce confusion
and bring a common uniform language in practice and
research of yoga.
Build a Simple Universal Basic Prototype of Yoga
Intervention With a Provision for Modular Add-ons
A systematic review of yoga found that 89% of RCTs
reached positive conclusion.39 These results, in spite of
huge variability in styles, dosage, and contents suggest that
beneath diversity there is a simple core model of yoga. One
can imagine such a strawman model, 30 minutes a session
thrice a week, composed of a handful of easy postures and
a comfortable plain deep breathing exercise that lead up to
a meditation session that aims at reducing thought density.
Researchers can start testing efficacy with this base model
in various settings and conditions. Thereafter, they can add
or subtract components and durations in modular blocks as
per the situational demands, while simultaneously collect-
ing and refining evidence. This approach might provide a
better algorithm for standardizing yoga.
34
Conduct In-depth Research About Home
Practice and Long-Term Adherence to Yoga
Home practice plays a significant role in the effectiveness of
yoga16,17,31,60 to a point that it might be more important than
intervention exposure.44 However, it is minimally accounted
for in the yoga research.2,5 Therefore this attribute should be
examined in depth. Additionally, adherence to yoga is gener-
ally low and only measured over short durations. More
research is required to assess long-term adherence to yoga.
Reduce the “Proof of Concept” Research
With dwindling research funding for complementary thera-
pies, proof of concept researches that abound in yoga
research, should be strongly discouraged.
Although every research is supposed to serve the needs
of its stakeholders, yoga research seems clearly not measur-
ing up. Yoga brings with it a substantial sociopolitical bag-
gage. The author believes that the predicament of yoga
research has a lot to do with it. Researchers are either igno-
rant of the historical, cultural, or sociopolitical context of
yoga or they are reluctant to disentangle health-compatible
yoga from its current muddle. Pathbreaking works like The
Structure of Scientific Revolutions61 or the “Dartmouth
studies”62 admonish that science needs to reckon with such
contextual barriers, lest it should be accused of, in the words
of Mark Lipsey, malpractice.63 In tumultuous times such as
ours, yoga can be a gift. It is not so much a matter of talent,
tools, techniques, or methods-methodologies, as it is that of
will. For medicalized yoga, anything less will not do.
Acknowledgments
I wish to thank Swati Patwardhan, my wife, for serving as a sound-
ing board, a reviewer, and a proofreader throughout the develop-
ment of this article.
Author’s Note
The research presented in this article is that of the author and does
not reflect the official position or policy of his employer.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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Author Biography
Avinash R. Patwardhan is a modern medicine trained physi-
cian who spent equal amount of time out of 39 years divided
between active medical practice and research in public health
and health system delivery. In addition, author knows Sanskrit,
the language of yoga (scriptures), and having grown in India,
has studied yoga philosophy and immersed in its practice for
almost half a century.