yoga and mpa

khalsaYoga Reduces Anxiety in Adolescent Musicians34 ALTERNATIVE THERAPIES, mar/apr 2013, VOL. 19, NO.2

Yoga Reduces Performance Anxiety in Adolescent Musicians

Sat Bir S. khalsa, PhD; Bethany Butzer, PhD; Stephanie M. Shorter, PhD; kristen M. Reinhardt, BM; Stephen Cope, MSW

original research

abstRactContext Professional musicians often experience high levels of stress, music performance anxiety (MPA), and performance-related musculoskeletal disorders (PRMDs). Given the fact that most professional musicians begin their musical training before the age of 12, it is important to identify interventions that will address these issues from an early age. Objective This study intended to replicate and expand upon adult research in this area by evaluating the effects of a yoga intervention on MPA and PRMDs in a population of adolescent musicians. The present study was the first to examine these effects. Design The research team assigned participants, adolescent musicians, into two groups. The intervention group (n = 84) took part in a 6-wk yoga program, and the control group (n = 51) received no treatment. The team evaluated the effects of the yoga intervention by comparing the scores of the intervention group to those of the control group on a number of questionnaires related to MPA and PRMDs. Setting The study was conducted at the Boston university Tanglewood Institute (BUTI). BUTI is a training academy for advanced adolescent musicians, located in Lenox, Massachusetts.

Participants Participants were adolescent, residential music students (mean age = 16 y) in a 6-wk summer program at the BUTI in 2007 and 2008. Intervention Participants in the yoga intervention group were requested to attend three, 60-min, kripalu-style yoga classes each wk for 6 wk.Outcome Measures MPA was measured using the Performance Anxiety Questionnaire (PAQ) and the Music Performance Anxiety Inventory for Adolescents (MPAI-A). PRMDs were measured using the Performance-Related Musculoskeletal disorders Questionnaire (PrMd-Q).Results yoga participants showed statistically significant reductions in MPA from baseline to the end of the program compared to the control group, as measured by several subscales of the PAQ and MPAi-A; however, the results for PRMDs were inconsistent.Conclusion The findings suggest that yoga may be a promising way for adolescents to reduce MPA and perhaps even prevent it in the future. These findings also suggest a novel treatment modality that potentially might alleviate MPA and prevent the early disruption and termination of musical careers. (Altern Ther Health Med. 2013;19(2):34-45.)

Sat Bir S. Khalsa, PhD, is assistant professor of medicine in the Department of Medicine at Brigham and Womens Hospital, Harvard Medical School, Boston, Massachusetts; and research director at the Kripalu Center for Yoga and Health in Lenox, Massachusetts. Bethany Butzer, PhD, is a postdoctoral research fellow at Brigham and Womens Hospital, Harvard Medical School, Boston, Massachusetts. Stephanie M. Shorter, PhD, Founder, Mind-Body Collective, Austin, Texas. Kristen M. Reinhardt, BM, is a doctoral student in the Department of Psychology at the University of Oregon in Eugene, Oregon. Stephen Cope, MSW, is director of the Institute for Extraordinary Living and Senior Scholar in Residence at the Kripalu Center for Yoga and Health in Lenox, Massachusetts.

Corresponding author: Bethany Butzer, PhDE-mail address: [email protected]

Professional musicians face many career stressors, such as music performance anxiety (MPA), the unpredict-ability of schedules for work and travel, and perfor-mance-related musculoskeletal disorders (PRMDs) resulting from demanding hours of training and practice.1 Survey studies estimate that as many as 69% of musicians are nega-tively impacted by MPA2,3 and as many as 87% of musicians experience PRMDs.3-5 Considering that most professional musicians begin their training before the age of 12,6 it would be advantageous to develop preventive interventions for MPA and PRMDs for young musicians. Early implementa-tion of such interventions might support longer as well as more productive and satisfying musical careers. Based on recent research on the effectiveness of yoga and meditation for MPA in adults,7,8 the present study examines whether yoga would be a valuable preventive measure for adolescent musicians, particularly for MPA and PRMDs.

khalsaYoga Reduces Anxiety in Adolescent Musicians ALTERNATIVE THERAPIES, mar/apr 2013, VOL. 19, NO.2 35

Music Performance Anxiety (MPA)MPA can involve both cognitive and physical symptoms,

including catastrophic and self-defeating thought patterns, obsessive behaviors to counteract anxiety, and intense arous-al of the autonomic nervous system leading to various physical discomforts, such as chest pain and profuse sweating.9-11 The deleterious effects of persistent anxiety can extend beyond perceived discomfort and can compromise the quality of performance and/or stage presence, potentially resulting in missed professional opportunities. Ultimately, MPA may become so overwhelming that it eclipses the moti-vation to continue performing and leads to career termination.5,12-15

Anxiety can be crippling to the lives and development of adolescents. In their recent review of adolescent anxiety dis-orders, Beesdo, knappe, and Pine reported that 15% to 20% of the adolescent population suffers from an anxiety disor-der.16 Among the many anxiety disorders that plague adoles-cents, ranging from generalized anxiety disorder to panic disorder, MPA is most similar to social anxiety. In 2005, kenny suggested that the perceived social evaluation of music performance by teachers and audience members may account for the similarity between social anxiety and MPA.16 MPAs symptoms in the adolescent population are identical to those seen in adults.

Existing treatments for MPA consist of psychological, behavioral, and/or pharmacological approaches.10,17,18 Psychological and behavioral approaches include cognitive behavioral therapy, systematic desensitization, hypnosis, psychotherapy, and a variety of mind-body techniques, including biofeedback, the Alexander technique, progressive muscle relaxation, breath regulation, and meditation.17,19-21 Generally speaking, these approaches successfully alleviate MPA in the majority of cases.17,22 Pharmacological treatment, however, has not proven to be a viable option for many musicians10,18,23 because many anxiolytic drugs disrupt fine motor control, interfering with the very skills necessary to play an instrument.

Performance-related Musculoskeletal Disorders (PRMDs)

Musicians also commonly experience performance-re-lated musculoskeletal disorders (PRMDs) that diminish their ability to perform. Common PRMDs include pain from overuse and repetitive movements, peripheral nerve disor-ders (eg, carpal tunnel syndrome), muscle cramping, and involuntary contractions. Not surprisingly, some evidence suggests that musculoskeletal discomfort and MPA exacer-bate one another.12,24,25 Despite their youth, adolescent musi-cians can also suffer from PRMDs, with as many as 17% of music students in secondary schools reporting moderate to severe PRMDs.15 Treatments to prevent or heal PRMDs include rest, modifications to the playing technique or adjustments to posture, physical or occupational therapy, exercise, pharmacological agents, and in extreme cases, surgery.4,5,12,26 Due to the stigma that surrounds PRMDs

within the realm of professional music, however, few musi-cians seek treatment before their problems become debilitat-ing.

The Beneficial Effects of YogaYoga, a holistic mind-body practice, is ideal for prevent-

ing or counteracting the psychological and physical stressors that professional musicians face. While physical postures and movements most commonly characterize yoga for the gen-eral public, other key elements of yoga are meditation, con-trol of attention, breathing, and deep-relaxation exercises. Research documenting the therapeutic benefits of yoga has grown steadily over the past 4 decades and now includes controlled clinical trials on psychiatric conditions such as depression and anxiety, breathing disorders such as asthma, cardiovascular disorders such as hypertension, endocrine disorders such as diabetes, and a variety of musculoskeletal and neurological conditions.26 Yoga and meditation tech-niques have been shown to (1) improve mood28,29; (2) increase resiliency from both acute and chronic stress30,31; and (3) improve performance on a variety of cognitive,32,33 psychomotor,33,34 and physical28,33,35 tasks.

Evidence on the psychophysiological benefits of long-term yoga practice supports its use as a therapeutic treat-ment for many medical conditions.27,36,37 Yoga therapytai-loring a custom yoga regimen to treat a clients specific psy-chological or physical health concernsis increasing in popularity and acceptance. The widespread benefits of yoga have led to a rapid increase in yoga practice among the gen-eral population. A recent survey by the Centers for Disease Control and Prevention38 revealed that yoga was among the top 10, most-used complementary and alternative medicine (CAM) practices as well as among the four CAM modalities that demonstrated the greatest increase in prevalence between 2002 and 2007. The survey also found that 6.1% of adults in the United States (approximately 13 million people) and 2.1% of children and adolescents (aged 0-17) had practiced yoga in the past 12 months.38

Two recent review papers have detailed the growing body of research on the benefits of yoga for children and adolescents. in 2008, galantino, galbavy, and Quinn39 reviewed 24 studies that evaluated the neuromuscular, car-diopulmonary, and musculoskeletal effects of yoga in chil-dren and adolescents aged 4 to 17,whereas in 2009 Birdee et al40 reviewed 34 studies on the clinical applications of yoga for both physical health and psychological disorders in the pediatric population (aged 0-21). Of particular relevance to the present study, Birdee et al outlined a 1992 study by Platania-Solazzo et al41 in which a relaxation-therapy inter-vention (30 minutes of yoga, 2-3 minutes of massage, and 30 minutes of progressive relaxation techniques) was imple-mented for children in a psychiatric facility. The children participated in the intervention for one 60-minute session. In self-reported and observer-rated anxiety scores obtained before and after the intervention, Platania-Solazzo et al found greater declines for the yoga group as opposed to the


control group. Both Galantino et al and Birdee et al con-cluded that yoga has beneficial physical and psychological effects for children and adolescents but cautioned that more research is needed due to methodological constraints of the reviewed studies.

Yoga as an Intervention for MPA and PRMDs Many papers have suggested that maintaining a regular

yoga and/or meditation practice prevents or alleviates the psychological and physical problems encountered by musicians.12,26,42,10,11,43-46 A handful of studies have also exam-ined the effects of isolated components of a yoga practice on MPA and musculoskeletal conditions. These studies have suggested that relaxation techniques,5,47,48 regulation of breathing,5,47,49 or meditation/guided imagery49 can amelio-rate MPA and PRMDs. Only two studies, however, have examined the effects of yoga as an intervention for MPA and PRMDs.7,8

In a preliminary controlled study on the effects of an 8-week yoga program for MPA and PRMDs, young adult musicians in an intensive, music-training curriculum showed a significant reduction in solo MPA relative to a no-treatment control group.7 More recently, in 2009 khalsa et al8 extended these findings using additional outcome measures and a larger sample of adult musicians attending the same music-training program. The researchers assigned participants to one of three groups: (1) a yoga lifestyle group, (2) a yoga-and-meditation-only group, or (3) a no-treatment control group. Relative to the control group, both yoga groups showed a trend toward decreased levels of MPA and signifi-cant decreases in general anxiety/tension, depression, and anger at the end of the program. Purpose of the Present Study

The purpose of the present study is to replicate and expand upon adult research on yoga by evaluating the effects of a yoga intervention on MPA and PRMDs in an adolescent population. Demonstrating the efficacy of yoga for adoles-cent musicians can provide a novel treatment modality to alleviate MPA and PRMDs and potentially prevent the early disruption and termination of musical careers.

MethodParticipants

Participants were residential music students of a prestigious, 6-week summer program of the Boston University Tanglewood Institute (BUTI) in 2007 and 2008. BUTI is a training academy for advanced adolescent musicians, located in Lenox, Massachusetts. An affiliate of the Tanglewood Music Center and the Boston Symphony Orchestra, BUTI hosts many internationally renowned, master-level musicians to instruct its students.

BUTIs students (N = 107 in 2007; N = 204 in 2008) were invited through e-mail announcements to participate in kripalu yoga classes on BUTIs campus at no cost. All stu-dents who responded to this initial invitation were assigned

to the yoga group (in 2007, n = 31 or 28.9% of BUTIs total student population; in 2008, n = 53 or 25.9%). Following this experimental group assignment, a second e-mail announce-ment recruited control participants (in 2007, n = 25 or 23.4% of BUTIs total student population; in 2008, n = 26 or 12.7%) from BUTIs remaining population of students. The research teams relationship with BUTIs administration was focused on the benefits of providing the yoga program to the stu-dents, and it was determined that BUTIs administration would not respond favorably to a random assignment of students to a no-treatment control group. Therefore, all stu-dents interested in participating in the yoga intervention were placed in the yoga group within the logistical limita-tions of the available space for yoga practice and of the tim-ing during the summer music program. Control participants were recruited separately from students in BUTIs same sum-mer music program who had not volunteered to participate in the yoga intervention but who were willing to complete the studys questionnaires in return for a modest remunera-tion.

The research component of the program was approved by the institutional review board of Brigham and Womens Hospital, and all participants and guardians signed informed-consent forms before the study. Control participants were remunerated with $25 gift certificates to a local shop after the study.

ProcedureYoga Protocol. The 8-week yoga curriculum used in

khalsa et als 2009 study8 was modified to a 6-week program for the present study, mainly to fit into the shorter period of BUTIs summer schedule. The summer schedule spanned only 6 weeks, as opposed to the 8 weeks of time available at the Tanglewood Music Center, which was the site of khalsa et als 2009 study. The current research team modified the 2009 curriculum to fit a younger population, accomplished chiefly (1) through the use of different language, such as the use of English words only to describe yoga postures as opposed to the 2009 curriculums use of Sanskrit names for postures with an older population, and (2) the inclusion of yoga games and fun time, such as partnered yoga poses and the playing of popular music, provided by yoga students, in some of the classes to engage a sense of fun and to make the yoga practice accessible to a younger population.

kripalu yoga is a comprehensive set of yoga practices that includes classical yoga postures, breathing techniques, and meditation. The hallmark of this style of yoga, consid-ered a meditation in motion, is an emphasis on an introspec-tive focus as breath and body movements are coordinated.50 All yoga classes for both years of the study were led by the same instructor (author kristen Reinhardt), who was skilled in teaching kripalu yoga and also trained as a classical musi-cian. The use of one instructor allowed for the elimination of potential variability in the results that could have arisen from the use of multiple instructors.

Each 60-minute class began with breath work. Then


participants performed a sequence of yoga postures followed by 5 minutes of supine rest on the floor, with a final brief meditation. The yoga curriculum was roughly divided into three 2-week segments. All yoga poses were selected to sup-port and potentially alleviate pain in the main areas of PRMDs (shoulders, wrists, spine, and hips). The first seg-ment of the 6-week curriculum included an emphasis on deep breathing (three-part breath or Dirgha Pranayam), joint-opening exercises, and supine postures, such as the Figure Four pose to stretch the hips and low back and supine spinal twists to relieve tension in the low back and hips. The first segment also included basic standing postures such as Downward Facing Dog pose (Adho Mukha Svanasana) and Warrior i and ii poses (Virabhadrasana I and II).

The second segment included longer holds of previously taught standing poses as well as more challenging balancing postures, such as the Eagle pose (Garudasana) and the Dancer pose (Natarajasana). During the second segment, alternate nostril breathing (Nadi Shodhana) was introduced as a stress-relieving breathing practice.

Meditation (Vipassana style, focusing on awareness of the breath without any Buddhist philosophy or references) was introduced in the third segment of the 6-week curricu-lum. The justification for this late inclusion of meditation is that yoga poses in most yoga philosophies are meant to pre-pare the body to be still for meditation. This final segment included longer holds of all previously taught poses as well as longer hip-opening poses, such as the Half Pigeon pose (Eka Pada Rajakapotasana) and the Bound Angle pose (Baddha Konasana) as well as more intermediate back-bending poses, such as the Wheel pose (Urdhva Dhanurasana). In the final segment of the program, the instructor also incorporated a discussion about optimal performance techniques (ie, flow state).51 Over time, the instructor was able to develop a famil-iarity and rapport with the students, which allowed her to create an environment in which the students felt at ease.

The research protocol was identical for students attend-ing both the 2007 and 2008 sessions of BUTIs training pro-gram. Yoga participants were requested to attend three kripalu yoga classes each week (out of a possible five weekly classes offered during the 2007 summer session and out of a possible six weekly classes offered during the 2008 session).

Control Protocol. The control group did not participate in the yoga intervention but was recruited from the same population of BUTIs summer students, and the group com-pleted the same outcome measures.

outcoMe MeasuResYoga and control participants completed each of the fol-

lowing self-report questionnaires just prior to the start of the yoga intervention and about 3 days before its end:

The Performance Anxiety Questionnaire (PAQ). On this 60-item questionnaire, participants were asked to rate the frequency with which they experienced 20 common, cognitive and somatic, performance anxiety symptoms in three contexts: (1) practice, (2) group performance, and (3)

solo performance. Sample items included: I feel that I lack confidence and I find that I shake. Participants rated each item on a 5-point scale (1 = never; 5 = always), with higher scores indicating greater performance anxiety. This ques-tionnaire displays excellent construct validity, and a growing literature exists on the use of this measure.2,52,53

The Music Performance Anxiety Inventory for Adolescents (MPAI-A). This 15-item questionnaire assesses three components of performance anxiety in adolescents: (1) somative and cognitive symptoms, such as Before I per-form, i get butterflies in my stomach, (2) performance con-text preference, such as I try to avoid playing on my own at a school concert, and (3) performance evaluation anxiety, such as I worry that my parents or teacher might not like my performance. Participants rated each item on a 7-point scale (0 = not at all; 6 = all of the time), with higher scores indicat-ing greater music performance anxiety. This questionnaire was created specifically for and normalized on adolescents and displays high reliability as well as strong construct and divergent validity.54

The State-Trait Anxiety Inventory (STAI). This 40-item questionnaire is made up of two 20-item subscales, one that measures temporary feelings of anxiety (ie, state anxiety) and another that measures more general, long-standing anxiety (ie, trait anxiety). To measure state anxiety, participants were asked to consider each item in terms of how they were feeling right now, at this moment. To measure trait anxiety, partici-pants considered each item in terms of how they generally feel. Sample items include I am tense and I am worried. Participants rate each item on a 4-point scale (1 = not at all; 4 = very much so). The STAI displays excellent test-retest reli-ability and internal consistency.55

The Performance-related Musculoskeletal Disorders Questionnaire (PRMD-Q). This questionnaire, created by Ackermann and Adams in 2004,4 consists of two separate components with questions evaluating (1) detailed time reporting of daily frequency, intensity, and duration of prac-tice and performance; (2) two 100-mm, linear, visual ana-logue scales to assess the frequency (0 = never; 100 = con-stantly) and severity (0 = none; 100 = maximally severe) of PRMDs; and (3) a numerical Borg scale for perceived exer-tion during musical practice (from 6 = no effort; 20 = maxi-mum effort). The PrMd-Q displays high reliability and validity in musicians across a range of ages, experience levels, and performance contexts.4 The full instrument has no over-all composite score. All three components are scored sepa-rately, and therefore, can be applied separately (Ackermann, e-mail). The current research team employed only the visual analogue scales and the Borg scale of this instrument to increase simplicity and reduce participants burdens.

Evaluation of the Yoga Program. All yoga participants evaluated the program at its completion by filling out an Evaluation of the Yoga Program questionnaire that was specifically created for the purposes of the present study. Seven of the questions were rated on a 10-cm, visual ana-logue scale with extremes of 0 = not at all to 10 = very


much so, while the eighth question was open-ended. Through the quantitative items, participants were asked (1) about the perceived benefit of yoga and/or meditation in general and as a musician; (2) about the impact of the prac-tice on overall musical performance as well as on the techni-cal and creative elements of musical performance; (3) about their willingness to recommend yoga to other students at Tanglewood; and (4) about their intent to continue practic-ing yoga and/or meditation. The qualitative item asked par-ticipants to comment on their experience of the program and on anything else they wished to share. No questions regard-ing the instructors quality or inclusion/exclusion of particu-lar elements of yoga practice were included.

Data Analysis To examine whether end-of-program scores differed

significantly between participants in the yoga and control groups, a series of 12 multiple regression analyses were per-formed on the subscales of the four outcome variables: (1) PAQ (three subscales), (2) MPAi-A (four subscales), (3) STAi (two subscales), and (4) PrMd-Q (three subscales). in each analysis, baseline score and experimental condition (coded as yoga group = 1, control group = -1) served as pre-dictors of the scores at the end of the program. For example, in one of the multiple regressions, the participants baseline somative/cognitive subscale scores on the MPAI-A and his or her condition were used to predict the participants soma-tive/cognitive subscale scores on the MPAI-A at the end of the program. All of the other multiple regression analyses

were conducted in the same fashion, with baseline scores and condition predicting scores at the end of the program, including baseline scores as a predictor controlled for par-ticipants baseline scores on each measure and the potential for regression to the mean.

ResuLtsAmalgamation of the 2007 and 2008 Samples

As described previously, the study protocol was identical for both the 2007 and 2008 samples. When the multiple regression analyses (described above) were conducted sepa-rately for each year, only three instances of differences occurred between the results for the 2007 and 2008 samples that were related to the effect of the experimental condition (ie, yoga group vs control group). These results suggest that the yoga intervention had largely the same effect in both years. The three instances involved (1) the PAQ group sub-scale, (2) the STAI trait anxiety subscale, and (3) the PrMd-Q severity subscale. Thus, to increase statistical power, the data from both years were combined into one sample for all of the studys variables except the PAQ group subscale, STAi trait anxiety, and PrMd-Q severity. To be inclusive, however, the results for the separate analyses are also included in the results section below.

Baseline scores for the yoga and control participants in the combined sample were compared using independent samples t tests to ensure that participants were statistically equivalent on all of the studys measures at baseline, which was the case for all of the studys variables.

Table 1. Summary of Demographic DataYoga

(n = 84) Control(n = 51)

Age, y (mean SD) 16.4 0.9 16.5 1.5Gender, n (male:female) 30:54 29:22Race, n (Caucasian:Asian:black:Hispanic:American Indian/Alaskan Native:other)

63:11:5:3:1:1 36:9:5:1:0:0

Instrument, n

Strings 42 23Woodwind 8 6Brass 6 6Percussion 4 3Voice 22 13Blank 2

Musical training, y (mean SD) 7.7 3.3 7.0 2.9

Note: Percussion includes classical percussion, harp, and piano.


Demographic Data and Descriptive Statistics Table 1 presents a demographic summary of the com-

bined sample. At baseline, the combined sample for the 2 years consisted of 84 participants in the yoga group (54 female and 30 male) and 51 participants in the control group (22 female and 29 male). The mean age of the yoga partici-pants was 16.4 0.9 years, and the mean age of the control participants was 16.5 1.5 years. The mean years of musical training for yoga participants were 7.7 3.3 years, and the mean years of musical training for control participants were 7.0 2.9 years. The majority of the participants were Caucasian (73% of the total sample). Seventy-five of the yoga group (89%) and 44 of the control group (86%) completed the

questionnaires both at baseline and at the end of the pro-gram. The yoga participants attended an average of 17 classes in total over the 6-week period.

Regression AnalysesTable 2 shows the means and standard deviations for the

yoga and control groups in the combined sample (2007 and 2008 participants) on the PAQ, MPAi-A, STAi, and PrMd-Q at baseline and at the end of the program. Figure 1 shows mean baseline and end-of-program scores for the yoga and control groups in the combined sample on the practice, group, and solo subscales of the PAQ as well as scores for the MPAI-A Somative/Cognitive Performance Anxiety subscale,

Table 2. Means and Standard deviations on Anxiety Measures and PrMd-Q for Combined 2007 and 2008 Samples Yoga Control

BaselineMean SD

n = 84

End of ProgramMean SD

n = 75

BaselineMean SD

n = 51

End of ProgramMean SD

n = 44PAQ

Practice 36.01 10.27 33.65 9.49 38.21 12.18 35.07 8.89Group 45.04 12.21 40.98 10.55 46.41 11.86 46.09 12.41Solo 60.79 14.37 53.92 12.72 59.00 14.06 57.39 14.85

MPAI-A

Somative/Cognitive 28.70 11.39 24.46 9.89 27.40 9.59 27.91 11.25Performance Context 8.26 4.51 7.44 4.33 7.94 4.13 7.41 4.23Performance Evaluation 10.40 4.88 8.76 4.02 10.02 3.70 10.39 4.05Total 47.36 18.06 40.66 15.99 45.36 14.41 45.70 16.27

STAI

State Anxiety 38.16 10.53 35.58 10.31 37.81 11.96 37.76 11.49Trait Anxiety 2007 47.66 11.66a 38.11 9.36a 47.32 11.35a 41.56 10.88a

Trait Anxiety 2008 42.11 9.67a 39.51 8.51a 42.04 10.04a 41.12 9.07a

PRMD-Q

Frequency 23.55 28.23 21.67 22.61 20.51 24.12 22.84 25.20Severity 2007 19.58 26.92a 24.58 22.01a 17.33 17.76a 22.96 18.70a

Severity 2008 24.89 24.60a 18.16 18.63a 17.15 24.22a 18.58 24.31a

Exertion 13.02 2.09 12.48 2.06 13.33 2.08 12.45 2.77

Note: All descriptive statistics are reported as means standard deviations for the combined 2007/2008 sample unless oth-erwise noted by a.

Abbreviations: PAQ = Performance Anxiety Questionnaire; MPAi-A = Music Performance Anxiety inventory for Adolescents; STAi = State-Trait Anxiety inventory; PrMd-Q = Performance-related Musculoskeletal disorders Questionnaire.

adue to the significant differences between the 2007 and 2008 samples on trait anxiety and PrMd-Q-severity difference scores, these descriptive statistics are presented separately for each sample. For the 2007 sample, yoga n = 31 and control n = 25. For the 2008 sample, yoga n = 53 and control n = 26.


scores for the MPAI-A Performance Evaluation Anxiety sub-scale, and total scores on the MPAI-A. Table 3 presents a summary of the regression results for all of the studys vari-ables. All effects are reported as unstandardized regression coefficients.

PAQ. When baseline PAQ scores and the participants condition (yoga vs control) served as predictors of end-of-program PAQ scores for the combined sample, participants in the yoga group showed significantly lower performance anxiety, M = 40.98 10.55, in group-performance contexts than control participants, M = 46.09 12.41 (b = -2.12, t[118] = -2.36, P < .05). Yoga participants also showed significantly lower, end-of-program performance anxiety in solo-perfor-mance contexts, M = 53.92 12.72, than control participants, M = 57.39 14.85 (b = -2.68, t[118] = -3.13, P < .01). No sig-nificant differences emerged, however, between the yoga and control participants on end-of-program performance anxi-ety in practice contexts (b = -.22, t[118] = -.32, ns).

When the regression analyses were run separately for the PAQ on the 2007 and 2008 samples, the effects were largely the same, except for the PAQ group subscale (data not shown in tables or figures). Yoga participants in the 2008

sample showed significantly lower end-of-program perfor-mance anxiety in group performance contexts, M = 40.41 10.19, than control participants, M = 46.12 13.50 (b = -3.33, t[62] = -2.80, P < .01). No significant differences emerged, however between the yoga and control participants on end-of-program performance anxiety in group contexts for the 2007 sample (b = -1.15, t[55] = -.83, ns). Similar to the amal-gamated sample, both the 2007 and 2008 samples showed no significant differences between the yoga and control partici-pants on end-of-program performance anxiety in practice contexts (2007: b = .51, t[55] = .53, ns; 2008: b = -.48, t[62] = -.50, ns). In addition, both the 2007 and 2008 participants in the yoga group showed significantly lower end-of-program performance anxiety in solo-performance contexts than par-ticipants in the control group (2007: b = -2.46, t[55] = -2.03, P < .05; 2008: b = -2.82, t[62] = -2.19, P < .05).

MPAI-A. When baseline MPAi-A scores and condition served as predictors of end-of-program MPAI-A scores in the combined sample, yoga participants showed significantly lower end-of-program somative/cognitive performance anx-iety, M = 24.46 9.89, than control participants, M = 27.91 11.25 (b = -2.40, t[118] = -3.79, P < .001). Yoga participants

Figure 1. Mean Baseline and End-of-program Scores

Shows the mean baseline and end-of-program scores for participants in the yoga and control groups in the combined 2007/2008 sample on the Practice, group, and Solo subscales of the Performance Anxiety Questionnaire (PAQ) as well as scores for the Somative/Cognitive Performance Anxiety subscale, scores for the Performance Evaluation Anxiety subscale, and the total score on the Music Performance Anxiety Inventory for Adolescents (MPAI-A). Superscript a (a) indicates that the differences between the yoga and control groups for the change in scores from baseline to end of program are statistically significant. Error bars represent the standard error of the mean.

40

38

36

34

32Baseline End Program

YogaControl

PracticeMusic Performance Anxiety

48

46

44

42

40

Baseline End Program

a

Yoga

Control

Group Music Performace Anxiety

62

60

58

56

54

52Baseline End Program

Control

SoloMusic Performance Anxiety

a

Yoga

11

10

9


Control

MPAI-A Performance Evaluation

a

Yoga

30

28

26

24


Control

MPAI-A Somative/Cognitive

a

Yoga

50

48

46

44

42

40


Control

MPAI-A Total

a

Yoga


Table 3. Regression Analysis Results for Combined 2007 and 2008 Samples

Scores at End of ProgramPAQ Practice

SubscalePAQ Group

SubscalePAQ SoloSubscale

PAQ at end of program as predicted by base-line PAQ

.52 0.06d .52 0.07d .70 0.06d

Yoga vs control -.22 0.69 -2.12 0.90b -2.68 0.86c

MPAI-A Somative/ Cognitive Subscale

MPAI-A Performance

Context Subscale

MPAI-A Performance Evaluation

SubscaleMPAI-A

Total ScoreMPAI-A at end of pro-gram as predicted by baseline MPAI-A

.74 0.06d .73 0.06d .59 0.06d .74 0.06d

Yoga vs control -2.40 0.63d -.21 0.27 -1.07 0.29d -3.77 0.96d

STAI StateAnxiety Subscale

STAI Trait Anxiety Subscale

STAI at end of pro-gram as predicted by baseline STAI

.21 0.08b --a

Yoga vs control 2.25 1.88 --a

PRMD-Q Frequency Subscale

PRMD-Q Severity Subscale

PRMD-Q Exertion Subscale

End-of-program PRMD-Q predicted by baseline PRMD-Q

.53 0.06d --a .53 0.10d

Yoga vs control -1.50 1.79 --a -.02 0.20

Note: All effects are reported as unstandardized regression coefficients standard errors. Condition is coded as yoga group = 1, control group = -1.

Abbreviations: PAQ = Performance Anxiety Questionnaire; MPAi-A = Music Performance Anxiety inventory for Adolescents; STAi = State-Trait Anxiety inventory; PrMd-Q = Performance-related Musculoskeletal disorders Questionnaire.

adue to the significant differences between the 2007 and 2008 samples on trait anxiety and PrMd-Q severity difference scores, these regression results are presented separately for each sample in the Results section.bP < .05.cP < .01.dP < .001.


also showed significantly lower end-of-program performance evaluation anxiety, M = 8.76 4.02, than control participants, M = 10.39 4.05 (b = -1.07, t[118] = -3.67, P < .001). Yoga participants also showed significantly lower end-of-program, total MPAI-A scores, M = 40.66 15.99, than control partici-pants, M = 45.70 16.27 (b = -3.77, t[118] = -3.93, P < .001). No significant differences emerged, however, between the yoga and control participants on end-of-program, perfor-mance context preference (b = -.21, t[118] = -.79, ns).

When the regression analyses were run separately for the MPAI-A on the 2007 and 2008 samples, the effects were the same as for the amalgamated sample (data not shown in tables or figures). For both the 2007 and 2008 samples, no significant differences emerged between the yoga and control participants on end-of-program, performance context prefer-ence (2007: b = -.29, t[55] = -.60, ns; 2008: b = -.07, t[62] = -.19, ns). In addition, both the 2007 and 2008 yoga partici-pants showed significantly lower end-of-program scores than control participants on somative/cognitive performance anx-iety (2007: b = -2.31, t[55] = -2.67, P < .05; 2008: b = -2.54, t[62] = -2.61, P < .05), performance evaluation anxiety (2007: b = -1.20, t[55] = -2.88, P < .01; 2008: b = -.94, t[62] = -2.18, P < .05) and total MPAI-A scores (2007: b = -3.86, t[55] = -2.83, P < .01; 2008: b = -3.71, t[62] = -2.58, P < .05).

STAI. When baseline state anxiety and condition served as predictors of end-of-program state anxiety in the com-bined sample, no significant differences emerged between the yoga and control participants (b = 2.25, t[134] = 1.20, ns). When the regression analyses were run separately for the STAI on the 2007 and 2008 samples, the results revealed that the yoga participants in the 2007 sample showed significantly lower, end-of-program, trait anxiety, M = 38.11 9.36, than control participants, M = 41.56 10.88 (Table 2) (b = -1.84, t[55] = -2.08, P < .05 [Table 3 does not show data]). No sig-nificant differences emerged between the yoga and control participants on end-of-program trait anxiety in the 2008 sample (b = -.82, t[78] = -.90, ns [Table 3 does not show data]).

PRMD-Q. When baseline PrMd-Q scores and condi-tion served as predictors of end-of-program PrMd-Q scores in the combined sample, no significant differences emerged between the yoga and control participants on the frequency of end-of-program PRMDs (b = -1.50, t[117] = -.84, ns) or on the perceived effort required to complete a typical, daily, music-practice routine at end-of-program (b = -.02, t[116] = -.12, ns). When the regression analyses were run separately for the PrMd-Q on the 2007 and 2008 samples, the results revealed that the yoga participants in the 2008 sample showed significantly less severe end-of-program PRMDs, M = 18.16 18.63, than control participants, M = 18.58 24.31 (b = -4.01, t[62] = -2.01, P < .05 [Table 3 does not show data]). No sig-nificant differences emerged, however, between the yoga and control participants on end-of-program PRMD severity in the 2007 sample (b = -.27, t[53] = -.12, ns [Table 3 does not show data]).Evaluation of the Yoga Program

Most participants found the yoga program beneficial in generalM = 7.68 2.52 cm and as musiciansM = 6.86 2.70 cm, would recommend it to other musiciansM = 8.51 2.31 cm, and planned to continue with a yoga and/or meditation practice as a result of the programM = 7.63 2.52 cm (data not shown). The 95% confidence intervals for each of these questions did not overlap with the midpoint of 5 cm. Participants reported slightly lower scores on the ques-tions that asked if the yoga program improved their musical performance in generalM = 5.87 2.83 cm, the technical proficiency aspects of their musical performanceM = 5.21 3.07 cm, and the creative/experiential aspects of their musical performanceM = 5.48 2.93 cm (data not shown). The 95% confidence intervals for the average answers to these three questions did overlap with the midpoint of 5 cm.

The yoga instructors qualitative observations, based largely on her conversations with the students, were that most participants improved in flexibility and strength and reported diminished physical tension. Many students also reported that yoga helped them handle the stress of the music program and reduced fatigue as the program became more intense. Yogic breathing techniques were particularly helpful in maintaining their stamina during long rehearsal days while also helping them manage performance anxiety and enhance self-confidence. Several individuals continued yoga practice after the program ended and kept in touch with the instructor to relay the benefits of their practice over time.

discussionConsistent with and extending prior research on adult

musicians, a 6-week yoga and meditation intervention was associated with reduced MPA in adolescent musicians.7,8 This result suggests that yoga may be an acceptable, useful, and even enjoyable way for adolescent musicians to manage and perhaps even prevent MPA early in their musical careers. The 6-week timeframe for the yoga intervention, 2 weeks shorter than the interventions used previously,7,8 suggests that it is possible that improvements in MPA might be achieved in relatively short order.

Music Performance Anxiety (MPA)Not surprisingly, participants reported the lowest levels of

performance anxiety while playing in a practice context, a moderate level of performance anxiety in a group context, and the highest levels of performance anxiety in a solo context, a pattern that is consistent with previous literature in this area.2,7-9,11 Compared to participants in the control group, participants in the yoga group reported significantly lower end-of-program performance anxiety in group and solo contexts on the PAQ. Yoga participants did not show significantly lower, end-of-program, performance anxiety on the PAQ in a practice con-text compared to control participants. Because participants reported the lowest levels of performance anxiety on the prac-tice PAQ subscale, a floor effect might exist that precluded


meaningful reductions in performance anxiety.The MPAI-A results confirmed those found with the

PAQ, with the yoga group showing significantly lower, end-of-program, somative/cognitive performance anxiety, per-formance evaluation anxiety, and total performance anxiety than the control group. These findings suggest that yoga might be an effective intervention to deal with both the cog-nitive and somatic symptoms of MPA, such as trembling, increased heart rate, and fear of failure. It is also possible that yoga might help reduce the fears that adolescent musicians may have about negative performance evaluations by author-ity figures such as teachers and parents. On the MPAI-A, the yoga participants did not show significantly different perfor-mance-context preferences at the end of the program com-pared to control participants. Perhaps the relatively short intervention used in the present study simply did not allow enough time to fundamentally change preferences for per-forming in a group versus a solo context.

State and Trait AnxietyYoga participants did not show significantly lower end-

of-program state anxiety compared to control participants. Yoga participants, however, showed a numerical drop in state anxiety from baseline to the end of the program, whereas control participants showed no such drop. The drop in state anxiety for yoga participants might have reached statistical significance with a larger sample or a longer intervention. Future research should examine this possibility.

Yoga participants in the 2007 sample showed signifi-cantly lower trait anxiety at the end of the program com-pared to control participants. This finding is consistent with previous studies that have found positive correlations between trait anxiety and MPA,19,54 as well as the 2009 find-ings of khalsa et al8 in which an 8-week yoga intervention was related to decreases in tension and anxiety in adult musi-cians as measured by the Profile of Mood States question-naire. Yoga and meditation may not only be effective inter-ventions for MPA but also for general, long-standing trait anxiety. These results are also consistent with previous research highlighting the anxiety-reducing effects of yoga in children and adolescents41 and add further credence to the growing yoga-therapy movement

The fact that yoga participants in the 2008 sample did not show significantly lower trait anxiety at the end of the program compared to control participants was unexpected and is difficult to explain. It will be important for future research to examine the effectiveness of tailored yoga inter-ventions for trait anxiety as well as specific anxiety and mood disorders.

PRMDsYoga participants in the combined sample did not

change from baseline to the end of the program in the fre-quency or severity of PRMDs or in the effort required to complete a daily music practice routine. Yoga participants in the 2008 sample, but not the 2007 sample, showed signifi-

cantly less severe PRMDs at the end of the program com-pared to control participants. Six weeks may not be a long enough time for a yoga intervention to bring about consis-tent neuromuscular changes. All of the mean frequency and severity scores for PRMD were below 25 (possible range 0-100), and all of the mean exertion scores were below 14 (possible range 6-20), suggesting that the present sample was composed of young, healthy musicians. Thus, participants low baseline scores may have produced a floor effect that precluded meaningful reductions in PRMDs. Future research is needed using a larger sample with higher levels of PRMDs as well as a longer yoga intervention to assess the degree and consistency with which yoga can benefit musicians muscu-loskeletal discomfort. Interestingly, PRMD severity scores increased from baseline to the end of the program in the 2007 yoga sample. While this effect was not statistically sig-nificant, it also warrants further research.

Yoga Program EvaluationParticipants responded positively to the yoga program

in a number of ways. Regarding questions assessing whether participants found the yoga program beneficial to themselves as musicians, would recommend it to other musicians, and planned to continue with yoga as a result of the program, the response pattern suggests that yoga may represent a useful and enjoyable way for adolescent musicians to reduce MPA. Other feedback on the postprogram evaluation suggested that yoga did not have as much of an impact on the technical and creative aspects of musical performance as it did on potentially alleviating MPA.

LimitationsThe present study should be considered with several

caveats in mind. First, participants were involved in an intense music fellowship program that became more chal-lenging over time, and thus it was somewhat different from what would normally be encountered by musicians under more typical working circumstances. Future studies should examine the effects of yoga and meditation on adolescent musicians in more naturalistic settings. Second, participants were not randomized into the control condition, and yoga participants self-selected to participate in the yoga interven-tion. Thus, although the results were in the expected direc-tion and are consistent with a positive effect of the yoga intervention, one must exercise caution in drawing firm con-clusions from this study. Other factors, such as expectation effects, attention effects, demand characteristics, or other nonspecific effects of involvement in an active yoga interven-tion could account for the findings. One strength of the cur-rent study is that the control participants were drawn from the same population of adolescent music students, and the groups did not differ on any of the measures at baseline, sug-gesting that the groups were very similar to each other. The limitations of nonrandom assignment, however, should be addressed in future randomized controlled studies.

In addition, a greater number of females (n = 76 for the


combined sample) participated in the yoga intervention than males (n = 60). This finding is especially important in light of the fact that by age 6, females are already twice as likely to have experienced an anxiety disorder as males.56 Thus, it is possible that the results of the present study may have dif-fered if a more equal proportion of males and females had participated in the yoga intervention. Future research should examine this possibility.

Finally, only one instructor was used for all of the yoga-intervention classes. While this practice eliminated potential variability in teaching methods, it could also be the case that some of the participants might have experienced different results if different teachers were used. Future research should examine this possibility by using multiple yoga instructors and testing for possible instructor effects.

concLusionsTaken as a whole, the present study both replicates and

expands upon previous research by suggesting that a rela-tively short (6-week) yoga intervention may reduce MPA in adolescent musicians. Thus, it is possible that starting a yoga practice early and continuing to practice may help musicians prolong their musical careers and take increased pleasure in their craft throughout their lives. These findings also raise the question of whether yoga may be a beneficial interven-tion for other types of performance anxiety, such as speak-ing, sports-related, or sexual anxiety as well as other anxiety disorders like social anxiety. Future research should examine these possibilities.

acknoWLedgeMentsThe research team gratefully acknowledges the kripalu Center for Yoga and Health and the Boston University Tanglewood Institute for supporting this research.

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