Suzanne L. Slocum, PhD, RYTCenter for Community Health

UCLA Semel Institute for Neuroscience and Human BehaviorCHIPTS Methods Core

Lisa Walford, ERYTSenior Certified Iyengar Yoga Instructor

Yoga Works Teacher Training

Fawntice McCain, MFA, RYTYoga Works Instructor

Utilizing Yoga Therapy as a Biomedical and Biobehavioral Intervention

for HIV/AIDS Prevention &Treatment

To present the following:

Current HIV/AIDS InterventionsDefinition of Yoga TherapyYoga Therapy in Clinical ResearchWhy Yoga Therapy for HIV?Theoretical FoundationMedia DemonstrationResearch Methods and DesignResearch Challenges Future Steps

Goals of Today’s Presentation

Vaccine TrialsPrEPHAARTCircumcisionMicrobicidesCognitive Behavioral TherapyCommunity Led Structural InterventionsHuman Rights and Social Justice MovementsYoga Therapy (today’s feature)

Current Biomedical & Behavioral Interventions for HIV/AIDS Prevention & Treatment

Definition of Yoga TherapyYoga 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 TherapyComponents

Structural Imbalances (e.g., anatomical)Neuromuscular Patterning (i.e., pain and pain management)Physiological

Psycho-emotionalSpiritual /mindful awarenessClinical and therapeutic (i.e., assessment, diagnosis, treatment, follow-up)

5. Respiratory6. Reproductive7. Nervous

1. Digestive2. Cardiovascular3. Immune system4. Endocrine system

Definition of Yoga Therapy

HolisticKoshas: 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, chakrasManomaya kosha: psycho-emotional, personality types Vijnamaya kosha: wisdom body, discrimination

Causal body:Anandamaya kosha: bliss body, meditation

CancerAsthmaStress-reduction DepressionMultiple Sclerosis (MS)AddictionsFertilityHIV/AIDS

Yoga Therapy Research

Parkinson’sDiabetesArthritisEpilepsyHepatitis CMenopausal symptomsMigrainesKyphosis

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 DepressionEvidence Based Complementary and Alternative Medicine, In Press.

Gale Greendale, MD, UCLA School of Medicine; Division of Geriatrics.Yoga Therapy and HyperkyphosisAmerican Journal of Public Health, 92, 10, 1611.

Current Research

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

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

Biomedical Perspective:Strengthens the immune system by directly impacting several systems:

DigestiveCirculatoryNervous/ Neurological – CNS, PNSRespiratoryMuscular-skeletal

Why Yoga Therapy for HIV?

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 SystemNIH/NCCAM R21. Several Pilot Studies, RCTs.

Washington University, Internal Medicine. St. Louis, MO.:Living By DesignYoga Therapy/ HIV Side Effects of HAART: Metabolic syndrome/CVDNIH/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

Current HIV Research

Integrative Approach

HolisticKoshas: 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 forceManomaya 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

Yoga is one of the oldest holistic health-care systems in existence, focusing on both the mind and body. The roots of yogadate 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 Patanjali’s 8 limb path of yoga:

1. yamas (cultivate healthy attitudes in relationship to others)2. niyamas (cultivate positive rapport with self)3. asana (physical postures)4. pranayama (breath work)5. pratyahara (sense withdrawal, turning inward)6. dharana (internal focus, concentration)7. dhyana (meditation)8. samadhi (liberation, freedom from suffering)

Theoretical Foundation

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

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

Digestive: acid reduction; internal organs massaged  which enhances insulin sensitivity Circulatory: inverted: Venous return to heart enhancedNervous/ Neurological – PNSRespiratory: 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.

Theoretical Foundation Applied

HIV Conditions & Characteristics

Medical Terms

Hepatitis Peripheral NeuropathyLypodystrophyLypoatrophy (wasting)Rise in triglyceride levels (Metabolic Syndrome)AnemiaLiver toxicities

Common Complaints

FatigueDepression, anxietyLoss of libidoNausea, acid refluxMuscle crampsNight sweatsDigestive imbalances

Balance of the Autonomic Nervous System: Stress and Yoga Therapy

Sympathetic Arousal(Fight/Flight Syndrome)

Blood pressure increasesRespiration increasesMuscle tone increasesDigestive processes pauseEpinephrine levels increaseEyes dilate

- MP Schatz, MD, Yoga Journal, 1987

Parasympathetic Tone(Relaxation Response)

Decrease in heart rateBlood pressure dropsMuscles relaxPeristalsis increasesInsulin production increasePupils 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

Active approach to illnessOptimistic outlookInternal locus of controlInner stability, tranquilAppropriate self confidenceSense of purposeSocial support systemInvolvement

- MP Schatz, MD, Yoga Journal, 1987

Lack of Healthcare or Services

Resigned, helpless PessimismChange seen as threatExternal locus of controlAgitation, volatileToo much or too little self confidenceApathyIsolation, alienation

VS.

Key Components of Yoga Therapy for HIV

Creates self-reliance Modify and adapt to personal needsDevelops a healthy relationship between mind and bodyHighly intimate and personalNon-invasiveSupports other treatments Enhances self-awarenessEncourages healthy choicesIntroduces spiritualityProvides 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 YogaRestorative 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“child’s pose”

Triggers that initiate the PNS

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

InversionsAdho 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, VagalNerve 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

Duration: 4 months1 Session of asana a week (approaches using Iyengar Yoga: props)1 Session of pranayama a week1 Session of meditation a week1 Group session a month (Yama’s, Niyama’s)

Narratives/story telling (Bhagavad Gita)Role playingPersonal Home Practice Education and Tools (i.e., props,

DVD)Nutrition, Getting Services, Moral/Ethical codesTalking-stick

Intervention Design for HIV+

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 onlyControl – Standard of Care

Participants: HIV+ females (18 yrs of age and older)Eligibility: screen for severe mental disorders and pregnancy

Recruitment:Community Based Organizations/AgenciesCommunity Based Health ClinicsCHIPTS affiliates/organizations

Study Design

Baseline Follow-ups: 6 months, 12 months CASI, PDA’s – Questionnaire Development System 2.1

Outcomes:Including clinical markers of disease and risk progression

PrimaryHIV Risk Behaviors (Substance Use and Sexual Risk Behavior)Adherence to Medications and Health ServicesCD4/Viral Load

Secondary Mental Health (i.e., Depression)Emotional RegulationMetabolic (Body composition)Pain Quality of LifeCortisolCardiovascular Risk

Assessment

PrimaryARBADAST, MASTCD4/Viral Load

Secondary Mental health: BSI, UCLA PTSD (depression, anxiety, trauma)EEGs – emotional regulationMetabolic (Body composition) (BMI, waist circumference)Pain (SF36)SF36 & HIV/AIDS-Targeted Quality of Life Instrument Cortisol (urinary) – stress levelsCardiovascular Assessment - lipoprotein buoyancy

Potential Assessments

Acceptability: Price, emotional costs, timeline of healing

Recruitment challenges Adherence challengesAdaptation and adoption Replication of intervention Sustainability of interventionCross-culturally challenges in assessment

Questions and Concerns

Future StepsSubmit 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, RYTSSlocum@mednet.ucla.edu

Lisa Walford, ERYTlisa@walford.com

Fawntice McCain, M.F.A, RYTasanaangel@earthlink.net

Center for HIV Identification, Prevention and Treatment Services

www.chipts.ucla.edu

Namaste

Thank You’sAdriana De Franco (with permission)

Gary Guillot (with permission) Iyengar Institute

Yoga WorksYogacharya B.K.S. Iyengar

International Association of Yoga TherapistsCHIPTS

CCH

Matthew TaylorSat Bir S. KhalsaAnnie Carpenter

(Editorial staff)Alan SeemanAmy ElkavichBonal Samreth