OT Research Article Spotlight: Occupational therapy’s use of yoga in post-stroke care—a mixed-methods study.

Article:

Self-management and Yoga for Older Adults with Chronic Stroke: A Mixed-Methods Study of Physical Fitness and Physical Activity.

Authors:

Jennifer Dickman Portz, PhD, MSW, Emily Waddington, MSW, Karen E. Atler, PhD, Marieke Van Puymbroeck, PhD, CTRS, FDRT, RYT-200, and Arlene A. Schmid, PhD, OTR, RYT-200.

Journal:

Clinical Gerontologist

Research Design:

Convergent parallel mixed methodology design was used. The quantitative phase used a non-experimental pretest-posttest design with all participants. The qualitative phase used a case study analysis.

Purpose:

• Study changes to physical fitness of subjects after participation in a yoga-infused self-management (SM) intervention. Physical fitness was determined using the following indicators: endurance, strength, and gait speed.
• Investigate subjects’ perceptions of change in physical fitness and participation in physical activity after intervention period.
• Compare subjects’ perceptions and quantified findings of change in physical fitness.

Methods:

Participants:

13 participants

Demographics:

Majority of participants were female, married (or in a relationship), some college/college degree, had stroke for more than 5 years.

Intervention:

Time Frame: 8 weeks, 2x per week, 2 hours per session—1 hour of self-management followed by 1 hour of yoga.

Self-Management: group discussions, lectures, activities, and work to complete at home for self-efficacy and problem solving to reduce falls following stroke. The focus was on how balance, endurance, and strength were needed for fall prevention.

Yoga Sessions: program consisted of centering at the start of the session, then meditation, and ended with a final relaxation. Between meditation and relaxation, subjects participated in seated positions in the beginning and progressed to standing and floor positions as the study continued.

Measures:

Quantitative Measures:

• Physical fitness was determined by performance in three key areas: (1) Endurance (2) Strength and (3) Gait Speed.
• Endurance was measured using the 6-minute walk test.
• Strength was measured using two tests. To test lower body strength, the researchers used the 30-second chair test. To test upper body strength, the researchers used the 30-second arm curl test.
• Gait speed was measured using the 10-meter walk test.
• Pre and post-test were completed by occupational therapy student researchers.

Qualitative Measures:

• Participant perceptions of differences in physical fitness and physical activity were collected using two semi-structures focus groups and one-on-one interviews with all participants.
• Focus groups lasted 60-minutes. No information was provided by the researchers on the number of focus groups or whether all 13 participants were in one focus group.
• One-on-one interviews lasted approximately 15 minutes and completed by research assistants. A semi-structured interview guide was used to learn participants’ perceptions on topics of interest to research outcomes.  Questions asked were, “related to expectations of yoga, SM, opinions regarding the intervention, and reported changes in health and function (p. 377).”

Data Analysis:

• Quantitative data: Differences between pre- and post-test results with endurance, strength, and gait speed was analyzed using the non-parametric Wilcoxon Matched Pairs Signed Rank.
• Qualitative data: a priori approach to results from focus groups and one-on-one interviews.
  • Coding of quotes from participants were based on three research questions: (1) change in physical fitness (2) changes in physical activity and (3) connection between physical fitness and physical activity.
  • With each of the three research question categories, coding included assignment of responses into three areas: (1) positive change (2) negative change or (3) no change.
  • Frequency of responses was used to determine differences in outcome with the three questions being analyzed.
  • Convergence and divergence of data was also determined.

Results:

Quantitative:

• Based on pre-and post-test data, improvements were seen in all areas used to determine physical fitness: endurance, strength, and gait speed.
• Statistically significant differences with endurance (using the 6-minute walk test) and strength (using 30-second stand and 30-second arm curl test). With endurance, on average participants walked an additional 50.42 feet. With strength, on average, participants improved to an additional 2.51 chair stands and 2.83 arm curls.
• Though there was an improvement with gait speed of an average of .91 seconds between pre- and post-test scores, the difference was not statistically significant. 

Qualitative:

• Three major themes from participants: positive change, no change, and continued exercise.
• 7 out of the 13 participants indicated a positive change in physical fitness and physical activity from participation in the MYOT Program, noting improvements in walking ability and duration.
• 4 out of the 13 participants reported no change in physical fitness and physical activity.
• No information was provided on the remaining 2 participants. This lack of information may be related to the 2 of 13 participants who did not participate in the endurance and gait speed posttest.
• Every participant (7) whose responses indicated a “positive change” in the physical activity and physical fitness demonstrated improvements in endurance and strength. Researchers indicated that: “On average, the “positive change” group increased their six-minute walk by 69 feet, lower body strength by two chair sit-stands, and upper body strength by 3 arm curls.”
• 3 out of the 4 participants who responses indicated “no change” demonstrated a slight decrease or zero-change in endurance and upper body strength, and an increase in their lower body strength by an average of three chair sit-stands.

Limitations of study:

• Small sample size, with little information provided on the 2 participants who did not complete the post-test for gait speed and endurance.
• Yoga is done as part of a self-management program that has many components that could be a confounding variable to the impact of the yoga intervention. The self-management program has discussion, homework, etc. that may have impacted the outcome in the physical fitness and not the yoga.
• No information is provided on the breakdown of the 1-hour yoga intervention. Logically, if the one-hour session is 10 minutes warm up/meditation and 10 minutes cool down, that would be 40 minutes of time for more involved yoga flows, which would impact areas such as endurance and strength (and ultimately gait speed). However, if there is 20 minutes of yoga, the outcome could conceivably be different and the outcome is more likely due to the self-management component and not the yoga.
• The focus of the self-management program was fall prevention. The measures are focused on skills that are needed to prevent falls and not necessarily measures that would allow for more optimal function. It would have been more beneficial to look at more functional skills or refined abilities. 
• There was no control group with this study. Therefore, though pre-and post-test results show positive outcomes with the addition of the yoga program to the self-management program, with no control the conclusion cannot be reached that the yoga program was the main reason the outcomes were seen.

Takeaways for Clinician:

• One result that stood out was the convergence data with participants’ perception of positive change and their performance on physical fitness measures. Results found that every participant (7) whose responses indicated a “positive change” in the physical activity and physical fitness demonstrated improvements in endurance and strength while 3 out of the 4 participants who responses indicated “no change” demonstrated a slight decrease or zero-change in endurance and upper body strength. The results support that if a participant perceives activities as beneficial, the participant’s outcomes in performance measures are in line with those perceptions. In short, a positive view of an intervention positively impacts outcomes, whereas a negative view of an intervention impacts outcomes.
• The use of yoga provided by an occupational therapy practitioner as part of an intervention program has been found to positively impact endurance, strength, and gait speed. Further education with this type of intervention could be beneficial to client outcomes with proper training and modifications for client safety.
• With the majority of the participants being 5 or more years post stroke, occupational therapy practitioners that have a yoga background can use yoga as part of an intervention program for positive physical outcomes with this population.

Takeaways for Student:

• Implications for research design—as a future study, using a yoga only program may increase the validity of the outcomes with respect to the impact on physical fitness and physical activity. Another modification to the research design could be to have a control group that does not receive yoga as part of the intervention. Provide specific information on the yoga program to help clinicians understand what is needed to impact physical performance.
• Yoga can be a specialty area. Positive outcomes point to the importance of specialized training in yoga to impact outcomes or to have a basic understanding of yoga practice. This provides a good direction of study post-graduation as a new clinician begins to think about specialty areas of continuing education.  

Takeaway for academic instructors:

• Presenting evidence on the impact of yoga on the physical fitness outcomes of clients with strokes.
• Research design changes above that relates to student can also be completed by a faculty member to grow the body of research.
• Ensuring that future clinicians have the training information needed to be effective from classroom lessons to continuing education opportunities post-graduation.
• Connecting with occupational therapy practitioners in the community that use yoga in their occupational therapy practice. Have this individual present a lecture on the topic and their experience. 
• Recognizing that yoga can be modified for clients post-stroke and this intervention can have an impact on physical outcomes. A lab activity can be organized to support treatment planning using yoga as part of the intervention plan.

Citation:

Jennifer Dickman Portz, Emily Waddington, Karen E. Atler, Marieke Van Puymbroeck & Arlene A. Schmid (2018) Self-Management and Yoga for Older Adults with Chronic Stroke: A Mixed-Methods Study of Physical Fitness and Physical Activity, Clinical Gerontologist, 41:4, 374-381, DOI: 10.1080/07317115.2016.1252453

Access to this article can provide more information on demographic information, data results, and discussion from the authors of the findings. One of the authors of the reviewed article, Arlene A. Schmid, Ph.D., OTR, FAOTA, has an ACMR webinar available on the use of yoga in rehabilitation and can be found here: Merging Yoga and Rehabilitation Therapy for Best Results – ACRM