Hindawi Publishing Corporation

Evidence-Based Complementary and Alternative Medicine

Volume 2012, Article ID 408727, 9 pages
doi:10.1155/2012/408727

Research Article
Iyengar Yoga for Distressed Women: A 3-Armed Randomized
Controlled Trial

Andreas Michalsen,1, 2 Michael Jeitler,1, 2 Stefan Brunnhuber,3 Rainer Lüdtke,4

Arndt Büssing,5 Frauke Musial,6 Gustav Dobos,7 and Christian Kessler1, 2
1 Instituteof Social Medicine, Epidemiology and Health Economics, Charité University Medical Centre,
10098 Berlin, Germany
2 Department of Internal and Complementary Medicine Immanuel Hospital Berlin, 14109 Berlin, Germany
3 National Research Center in Complementary and Alternative Medicine, University of Tromsø, 9037 Tromsø, Norway
4 Karl und Veronica Carstens-Foundation, 45276 Essen, Germany
5 Department of Psychiatry, University of Salzburg, 5020 Salzburg, Austria
6 Chair of Quality of Life, Spirituality and Coping, Center of Integrative Medicine, University Witten/Herdecke,

58313 Witten-Herdecke, Germany

7 Chair of Integrative Medicine, University Duisburg-Essen, 45276 Essen, Germany

Correspondence should be addressed to Andreas Michalsen, a.michalsen@immanuel.de

Received 25 May 2012; Revised 7 August 2012; Accepted 9 August 2012

Academic Editor: Shirley Telles

Copyright © 2012 Andreas Michalsen et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.

Distress is an increasing public health problem. We aimed to investigate the effects of an Iyengar yoga program on perceived
stress and psychological outcomes in distressed women and evaluated a potential dose-effect relationship. Seventy-two female
distressed subjects were included into a 3-armed randomized controlled trial and allocated to yoga group 1 (n = 24) with twelve
90 min sessions over 3 months, yoga group 2 (n = 24) with 24 sessions over 3 months, or a waiting list control group (n = 24).
The primary outcome was stress perception, measured by Cohen Stress Scale; secondary outcomes included state trait anxiety,
depression, psychological and physical quality of life (QOL), profile of Mood States, well being, and bodily complaints. After three
months, women in the yoga groups showed significant improvements in perceived stress (P = 0.003), state trait anxiety (P = 0.021
and P = 0.003), depression (P = 0.008), psychological QOL (P = 0.012), mood states being (P = 0.007), and bodily complaints
well(P = 0.012) when compared to controls. Both yoga programs were similarly effective for these outcomes; however, compliance
was better in the group with fewer sessions (yoga group 1). Dose effects were seen only in the analysis of group-independent effects
for back pain, anxiety, and depression. These findings suggest that Iyengar yoga effectively reduces distress and improves related
psychological and physical outcomes. Furthermore, attending twice-weekly yoga classes was not superior to once-weekly classes,
as a result of limited compliance in the twice-weekly group.

1. Background may be due to stress-related complaints or disease [2–4].

Experimental and epidemiological studies have shown that
Several recent studies indicate there is an increasing number stress considerably contributes to cardiovascular disease,
of people of Western societies that suffer from distress and degenerative neurological disease, chronic pain syndromes,
stress-related disease. For example, a recent survey of a large delayed wound healing, depression, and cancer [5–8].
German health insurance company found that up to 80% of Data from the INTERHEART study indicate that 30% of
the general population feel distressed frequently, and 30% myocardial infarctions might be caused by stress in the
feel distressed most of the time [1]. Other studies have recent past [9]. Experimental research has further shown
reported that up to 50–60% of all physician consultations that psychosocial stress can increase cellular oxidative stress,
2 Evidence-Based Complementary and Alternative Medicine

activate signal transduction, and modify gene expression [5]. stress a cost-free three-month yoga course. Subjects were
Others have shown that objective stress (e.g., years of care included if they (1) were female in the age 20–60 years,
giving) and perceived life stress were both related to shorter (2) had current distress with a sum score > 18 on the
telomere length, indicating replicative senescence and thus CPSS, (3) were experiencing at least 3 of 8 of the following
bodily aging [10]. self-reported known stress-related symptoms: insomnia, dis-
Yoga is an increasingly used self-care and health- turbed appetite, back or neck pain, tension-type headache,
promoting technique in the US and Europe. An estimated 30 decreasing daytime alertness, digestive problems, frequent
million persons, mostly women (72%), had practiced yoga cold hands/feet, and (4) were not currently practicing yoga
in the US according to a recent survey [11]. Iyengar yoga is or any related form of stress reduction. They were excluded
one of the most prevalent styles taught in the US and Europe if they (1) reported a current psychiatric diagnosis, (2)
(44%) [12]. It is based on the teachings of the yoga master indicated any medical contraindications to physical exercise,
Iyengar who has applied yoga specifically to health problems (3) were on current medication for any disease, (4) had
[13]. Yoga intervention studies have shown promising find- manifest problems with alcohol or substance abuse and (5)
ings, including enhanced emotional well being and resilience were pregnant.
to stress in the workplace [14], improved inflammatory After signing an informed consent and collection of
and endocrine responses [15], enhanced mindfulness [16], baseline data, subjects were randomized to moderate yoga
improvements both in physical/emotional well being [17, 18] (group 1 = once weekly 90 min yoga class for 3 months;
and in anxiety and health status [19]. n = 24), intensified yoga (group 2 = twice weekly 90 min
Despite its potential benefits and popularity among yoga class for 3 months; n = 24), or the waiting list control
distressed people, the effectiveness of yoga in relieving group (n = 24). Subjects in the waiting list control group had
perceived stress has been addressed only in a few randomized the option of participating in yoga classes after termination
controlled trials. One systematic review describes the effects of the study. The study protocol was approved by the
of yoga on stress-associated symptoms; here Chong et Institutional Review Board of the Essen University Hospital
al. [20] identified 8 controlled trials, 4 of which were and all study participants gave their informed consent.
randomized and fulfilled the authors’ selection criteria. The
results indicated a positive effect of yoga in reducing stress 3. Outcomes and Measurements
levels or stress symptoms; however in their conclusions,
the authors underlined the need for further trials. In a 3.1. Primary Outcome. All subjects were asked to complete
previous controlled nonrandomized pilot study we found standardized questionnaires at the outset of the study
a pronounced stress-relieving effect of a 3 month-Iyengar (baseline), and after 3 months. The primary outcome was
Yoga intervention in distressed women [21]. We conducted change of the mean score of the Cohen Perceived Stress Scale
the present randomized controlled trial to evaluate the (CPSS) asking for subjective stress within the last week. The
effectiveness of Iyengar yoga, including different “doses” CPSS consists of 14 items about current levels of experienced
(levels) of yoga practice, on perceived stress and related and perceived stress [22].
physical and psychological well being. We hypothesized that
yoga practice would reduce stress perception and related 3.2. Secondary Outcomes. Secondary outcomes included the
symptoms as compared to a waiting list control group. A following:
secondary aim of the study was to evaluate a potential dose-
effect relationship in yoga practice. We hypothesized that a (1) the German Version of the Spielberger State-Trait
yoga class twice a week would lead to greater improvements Anxiety Inventory (STAI), which consists of 20 items
than a yoga class once a week. relating to state anxiety and 20 items relating to trait
anxiety [23];
(2) the German translation of the Profile of Mood States
2. Methods (POMS) [24], which is a 35-item instrument that
2.1. Design. A 3-armed randomized controlled trial was measures four domains of mood disturbance includ-
conducted in which female distressed individuals were ing vigor, fatigue, depression anxiety, and anger [25];
randomized to three groups: (1) once-weekly yoga classes (3) the German version of the Brief Symptom Inventory
(12 sessions of 90 min in three months), (2) twice-weekly (BSI), which includes 53 items and provides scores
yoga classes (24 sessions of 90 min in three months), and (3) for 9 psychological symptom scales and a general
waiting list control. severity index (GSI) [26];
(4) the German version of the Center for Epidemiolog-
2.2. Subjects. The study is based on the results of a previous ical Studies Depression Inventory (CES-D), a 20-
pilot study [21]. Screening revealed that among distressed item scale designed for the general population [27,
subjects more than 90% of call-ins were women; therefore, 28]. The long German version of the CES-D is the
we decided to include only women for this study to ensure “Allgemeine Depressionsskala” (ADS-L);
a homogeneous sample. Community-dwelling female vol- (5) quality of life (QOL) was measured by the German
unteers were recruited from local newspaper advertisements version of the Medical Outcomes Study 36-Item-
and flyers that offered women with high levels of perceived Short Form (SF-36) with its 8 dimensions of health:
Evidence-Based Complementary and Alternative Medicine 3

physical functioning (10 items), social functioning (2 α = 5% t-test a sample size of n = 46 (23 per group) was
items), role limitations due to physical problems (4 calculated. Accordingly, this yields a sample size of n = 23
items), role limitations due to emotional problems per group within a three-group comparison when using a
(3 items), mental health (5 items), energy/vitality (4 hierarchical test procedure on a level of α = 5% (total sample
items), pain (2 items), and general health perception n = 69). Here, the power to detect a difference between
(5 items) and the physical and mental sum score; the moderate and intensified yoga group amounts to 26.4%
(6) the Bf-S Zerssen well being scale measures momen- on the basis of between-group difference of 0.4 standard
tary emotional well being and consists of three deviations. The number of dropouts was rather small (<5%)
answer categories, with higher scores indicating lower in the pilot study [21]. We therefore decided to include a
well being [29]. The Bf-S is sensitive to clinically rel- sample of n = 72 patients into the trial with n = 24 in each
evant, short-term changes in general well being and of the three groups.
overall health-related symptoms and its salutogenetic Outcomes were analysed on an intention-to-treat (ITT)
dimensions of health can serve as an indicator for basis by univariate analyses of covariance (ANCOVA) which
changes in quality of life [29]. included group and baseline values as well as outcome
expectation as covariates. From these models we estimated
In addition, we measured general physical well being and baseline-adjusted treatment effects and their 95% confidence
symptoms and severity of headache, neck, and back pain, intervals (CI). ANCOVA was also used for ordinal data
using 10-point Likert scales for each category, with a derived from the Likert scales. All reported P values are based
reference period of the past week. Finally, general and specific on a two-sided test, and a P value <0.05 was considered
physical complaints were measured with the well-validated, significant. Missing data of case record forms were multi-
70-item Freiburg Somatic Complaints (FBL) Questionnaire, imputed, that is, multiple copies of the original data set
that inventories subjective evaluation of physical complaints were generated, hereby replacing missing values by randomly
across the major physiological functional domains [30]. gene-rated values.
The primary analysis compared the outcomes between
the 3 groups. Due to the compromised adherence in the yoga
3.3. Interventions. Participants in the yoga groups were asked
classes, we conducted secondary analyses in which the yoga
to participate in once- or twice-weekly 90 min yoga classes
groups were pooled and outcomes were analysed according
according to the Iyengar style [31] in a fully equipped
to yoga class adherence. Here, participants were stratified
yoga studio for 3 months. Subjects were taught by a
according to the number of visits of yoga classes: 1–6 (n =
certified Iyengar yoga instructor who had been trained
7), 7–12 (n = 18), and 13–24 (n = 15). ANCOVA was
in the method for over 15 years. The classes emphasized
applied, respectively. All statistical analyses were done with
postures that, according to the Iyengar yoga teachings, are
the statistical analysis package SAS (version 9.2).
supposed to alleviate stress, particularly back bends, standing
poses, and forward bends and inversions (list of poses,
see Table S5 in Supplementary Material available online at 4. Results
doi:10.1155/2012/408727). Each Yoga class was finished by
15 min of meditation in Shavasana. No explicit breathing 238 subjects responded to the advertisement. About 25 indi-
techniques were used. Throughout the program, subjects viduals declined participation, citing unavailability because
were encouraged to continue yoga practice at home. Subjects of scheduling problems, time demands, travel requirements,
in the control group were asked to maintain their routine or unspecified reasons. A total of 72 subjects fulfilled all
activities and not to begin any other exercise or stress entry criteria and were enrolled into the study. Subjects were
reduction program during the following 3 months. recruited between March 2006 and January 2008 and were
randomly allocated to the yoga group 1 (n = 24) with 12
3.4. Randomization. Patients were randomly allocated to a scheduled sessions, the yoga group 2 (n = 24) with 24
treatment group by a nonstratified block randomization sessions, or the waiting list control group (n = 24) and
with varying block lengths and by prepared sealed, sequen- included in the ITT analysis (see Figure 1).
tially numbered opaque envelopes containing the treatment Two participants in the control group and 4 subjects in
assignments. Randomization was based on the “RANUNI” each yoga group dropped out due to causes not related to the
pseudo-random number generator of the SAS/Base statistical study intervention, for example, unwillingness to stay in the
software (SAS Inc., Cary, NC, USA), and the envelopes were study or return to the study center, lack of time, and minor
prepared by the study biostatistician. When a patient fulfilled medical problems (common cold).
all enrolment criteria, the study physician opened the lowest
numbered envelope to reveal that patient’s assignment. 4.1. Baseline Characteristics. Subjects’ ages ranged from 19
to 52 years (mean age 39.6 ± 8.3 years) (Table 1). Baseline
3.5. Sample Size and Statistical Analysis. Sample size calcu- characteristics were balanced between groups with exception
lation was based on the results of the pilot study [21]. To of significantly less smokers in the yoga group 1 (P =
detect a difference of 0.85 standard deviations of the Cohen 0.046) and significantly less persons practicing exercise on a
Perceived Stress score between the yoga and the wait-list regular basis in group 2 (P = 0.028). Few persons practiced
group with a power of 80% by means of a two-sided level relaxation techniques before study entry (control group: 1;
4 Evidence-Based Complementary and Alternative Medicine

238 contacted study center

156 did not met

inclusion criteria

82 assessed for eligibility

10 did not meet inclusion
criteria

72 randomized

24 yoga group 1 24 yoga group 2 24 waiting list control

1 dropout due to 2 dropouts due to

unrelated health unrelated health
problems problems 2 study noncompliance

3 study noncompliance 2 study noncompliance

24 ITT analysis 24 ITT analysis 24 ITT analysis

Figure 1: Trial flow chart.

Table 1: Baseline characteristics. Mean ± SD if not indicated otherwise.

Characteristic Yoga group 1 (n = 24) Yoga group 2 (n = 24) Control group (n = 24) P value
Mean age, y 39.5 ± 7.8 40.0 ± 8 39.3 ± 9.2 0.991
BMI (kg/m2 ) 25.61 ± 3.7 25.7 ± 6 24.7 ± 6 0.357
Smokers, n (%) 2 (8.3) 9 (37.5) 8 (33.3) 0.046
Weight, kg 74.4 ± 13.7 70.4 ± 18.5 70.8 ± 18.2 0.139
Exercise practice n (%) 15 (62.5) 7 (29.2) 15 (62.5) 0.028
Insomnia, n (%) 19 (79.2) 18 (75) 21 (87.5) 0.813
CPSS score 34.0 ± 8.0 35.8 ± 6.3 31.2 ± 6.8 0.067
CES-D score 22.3 ± 8.4 23.0 ± 8.1 21.0 ± 8.8 0.598
S-STAI 45.5 ± 10.6 49.0 ± 9.3 43.5 ± 11.0 0.169
T-STAI 53.6 ± 10.7 53.7 ± 9.1 50.2 ± 8.6 0.51
Bf-S 24.9 ± 14.1 23.8 ± 13.8 23.5 ± 14.0 0.948
GSI-score 67.6 ± 9.8 67.9 ± 7.2 67.4 ± 9.0 0.991
POMS vigor 2.2 ± 0.8 2.2 ± 1.1 2.8 ± 1.3 0.194
POMS fatigue 2.8 ± 1.5 2.5 ± 1.3 2.7 ± 1.4 0.613
POMS depression 1.6 ± 1.5 1.1 ± 0.8 1.5 ± 1.2 0.649
POMS anger 1.5 ± 1.6 1.0 ± 1.2 1.4 ± 1.3 0.418
QOL mental health −0.8 ± 0.8 −0.6 ± 0.8 −0.7 ± 0.9 0.575
QOL physical score 0.0 ± 0.8 −0.1 ± 0.7 −0.3 ± 0.8 0.542
QOL mental score −1.7 ± 0.9 −2.0 ± 0.7 −1.6 ± 0.8 0.143
Freiburg complaint list 2.7 ± 0.5 2.7 ± 0.5 2.6 ± 0.6 0.578
CPSS: Cohen Perceived Stress Scale; CES-D: Center for Epidemiological Studies Depression Scale; S-STAI: State Anxiety; T-STAI: Trait Anxiety; Bf-S: Zerssen
well being scale; GSI: General Severity Index; POMS: Profile of Mood States; QOL: short form-36 Quality of Life.
Evidence-Based Complementary and Alternative Medicine 5

Table 2: Between-group differences of treatment effects on perceived stress and psychological outcomes, mean (95% CI).

Yoga group 1 versus control Yoga group 2 versus control Yoga group 1 + 2 versus control
Change P value Change P value Change P value
CPSS −6.7 (−10.9; −2.5) 0.002 −4.7 (−9.2; −0.3) 0.036 −5.7 (−9.5; −2.0) 0.003
CES-D −4.2 (−7.9; −0.5) 0.028 −4.6 (−8.5; −0.7) 0.02 −4.4 (−7.6; −1.2) 0.008
S-STAI −5.2 (−10.6; 0.1) 0.056 −6.0 (−11.6; −0.4) 0.037 −5.6 (−10.4; −0.9) 0.021
T-STAI −5.8 (−10.1; −1.6) 0.007 −5.3 (−9.5; −1.1) 0.014 −5.6 (−9.2; −1.9) 0.003
GSI-score −7.5 (−12.9; −2.2) 0.006 −8.2 (−13.5; −3.0) 0.002 −7.9 (−12.5; −3.3) 0.001
Bf-S −7.0 (−14.2; 0.2) 0.057 −6.2 (−13.3; 0.9) 0.087 −6.6 (−12.8; −0.4) 0.036
POMS vigor 0.8 (0.1; 1.4) 0.022 0.6 (0.0; 1.3) 0.06 0.7 (0.1; 1.3) 0.017
POMS fatigue −1.3 (−2.1; −0.6) 0.001 −1.0 (−1.8; −0.3) 0.009 −1.2 (−1.8; −0.5) 0.001
POMS depression −0.4 (−1.0; 0.2) 0.20 −0.3 (−0.9; 0.2) 0.239 −0.4 (−0.9; 0.1) 0.154
POMS anger −0.8 (−1.3; −0.2) 0.007 −0.5 (−1.1; 0.1) 0.084 −0.6 (−1.1; −0.1) 0.012
QOL mental health 0.8 (0.3; 1.3) 0.002 0.6 (0.1; 1.1) 0.022 0.7 (0.2; 1.1) 0.002
QOL physical sum score 0.1 (−0.3; 0.4) 0.72 −0.2 (−0.6; 0.2) 0.269 −0.1 (−0.4; 0.2) 0.653
QOL mental sum score 0.6 (0.1; 1.2) 0.024 0.6 (0.0; 1.1) 0.044 0.6 (0.1; 1.1) 0.012
CPSS: Cohen Perceived Stress Scale; CES-D: Center for Epidemiological Studies Depression Scale; S-STAI: State Anxiety; T-STAI: Trait Anxiety; Bf-S: Zerssen
well being scale; GSI: General Severity Index; POMS: Profile of Mood States; QOL: short form-36 Quality of Life.

yoga group 1: 2; yoga group 3: 2). The baseline CPSS scores 45

were 34.0 ± 8.0 for yoga group 1, 35.8 ± 6.3 for group 2,
and 31.2 ± 6.8 for the control group (P = 0.067). Baseline 40
Cohen Perceived Stress Score

scores of the strees, depression (CES-D) and anxiety (STAI)

scores were in a range that is commonly regarded to indicate 35
relevant distress.
30
4.2. Adherence. Adherence to the yoga classes was moderate,
with participants of yoga group 1 visiting 71 ± 29% and 25
participants of yoga group 2 visiting 63 ± 36% of offered
classes. Half of the subjects in both yoga classes visited more 20
than 80% of offered classes, 17% of women in yoga group 1
and 25% of women in yoga group 2 visited less than 20% of 15
offered classes. Baseline 3 months

Control group
4.3. Primary Outcome. Both yoga programs were beneficial Yoga group 1
with regard to the course of perceived stress while the control Yoga group 2
group showed no relevant changes (Figure 2). The CPSS
Figure 2: Perceived stress. Mean (±SD) CPSS score on study entry
score was reduced from 34.0 ± 8.0 at baseline to 24.9 ± 7.1
and at three months in the yoga and control groups. Significant
after the intervention for yoga group 1, and from 35.8 ± 6.3 between-group treatment effect of −6.7 (−10.9; −2.5) (adj., 95%
to 28.1 ± 6.9 for yoga group 2. After intervention, the mean CI), P = 0.002 in yoga group 1 (versus control) and −4.7 (−9.2;
group difference in CPSS score between yoga group 1 and the −0.3), P = 0.036 (Table 2) in yoga group 2 (versus control). The
control group was −6.7 (95% CI: −10.9, −2.5; P = 0.002) pooled group difference reached −5.7 (−9.5; −2.0), P = 0.003
and the mean group difference between yoga group 2 and (versus control).
the control group was −4.7 (−9.2, −0.3; P = 0.036). If the
CPSS scores of the 2 yoga groups were pooled, the difference
between the pooled yoga group CPSS scores compared to
the CPSS score of the control group was −5.7 (−9.5, −2.0; SF-36 showed significant group differences for each yoga
P = 0.003) after intervention (Table 2). group compared to controls, while other subscales of the SF-
36 showed no significant between group differences (data not
4.4. Secondary Outcomes. Both yoga intensities were simi- shown).
larly effective for most predefined secondary outcomes. Comparing both pooled yoga interventions to controls,
the psychological outcomes as state and trait anxiety, the
4.5. Psychological Outcomes. Results on psychological out- GSI-score, the CES-D depression score, well being, and three
comes are summarized in Table 2. Regarding quality of life, dimensions of the POMS (vigor, fatigue, and anger) were
the mental sum score and the mental health subscale of the better with yoga.
6 Evidence-Based Complementary and Alternative Medicine

4.6. Physical Complaints and Physical Well Being. Mean physical outcome parameters. Compliance with the twice-
changes in self-rated values of severity of general physical weekly yoga classes was better in this pilot study than in the
well being, neck and back pain (all Likert scaled), and the present randomized trial, which may account for the larger
summarized complaint list score of the FBL are given in effects seen in the pilot study.
Table 3. Both yoga intensities were similarly effective for A recent systematic review has looked at the ability of
all physical outcomes and showed significant improvement yoga to reduce stress levels in healthy adult populations and
compared to controls. Pooled analysis of both yoga groups was based on eight trials that indicated a positive effect
showed significant improvements compared to controls. of yoga in reducing stress levels or stress symptoms [20];
Also, outcomes for the pooled yoga groups on the however, the quality and design of the included studies
6 subscales of the FBL showed significant improvements revealed stronger methodological weaknesses. The results of
compared to controls (data not shown in tables): tenseness our randomized clinical trial parallel previous studies that
(P = 0.009), pain (P = 0.035), motor activity (P = 0.005), demonstrated beneficial effects of yoga in stress reduction,
emotional reactivity (P = 0.005), and sensory (P = 0.013). mood enhancement, and improvements in depression and
anxiety in patients with depressive syndromes and with
musculoskeletal pain [21, 32, 33]. Other studies suggest
4.7. Dose Effects of Yoga Unrelated to Group Allocation. As that even a short program of yoga might be effective for
comparison between both yoga groups revealed no relevant enhancing emotional well being and resilience to stress in
group differences while adherence was better in yoga group the workplace [34] and for improving stress, anxiety, and
1 compared to yoga group 2, we conducted a further analysis health status in subjects with mild to moderate levels of
to identify potential dose effects of yoga practice independent stress [19]. Furthermore, our findings are consistent with
of group allocation. those of other studies, that demonstrated the effectiveness
Here, we found group-independent dose effects for back of yoga in the treatment of chronic low back pain [35–
pain severity, the GSI-Score, the CES-D depression score, 40], a physical symptom frequently associated with dis-
and state-trait anxiety (Table 4). None of the other significant tress.
parameters showed group-independent dose effects. Our current study had multiple strengths including the
use of recommended and validated assessment tools and
4.8. Safety. There were no clinically relevant adverse effects outcome measures, the high-quality yoga teaching, well-
associated with yoga practice for all subjects. defined inclusion and exclusion criteria, an observation
period of 3 months, and the comparison of two yoga
5. Discussion intensities.
Nevertheless, the study has limitations, including modest
We conducted this 3-armed randomized controlled trial with sample sizes and no long-term followup. Furthermore,
distressed women to investigate the effects of 2 different as with all studies with self-applied nonpharmacological
intensities of Iyengar yoga practice for 3 months on perceived interventions, it was impossible to blind treatments. We
stress and related psychological and physical outcomes. cannot estimate the extent to which the observed yoga effects
Compared to controls, women who participated in the yoga were nonspecific due to the influence of setting, the attention
practice groups demonstrated pronounced and significant of yoga teachers, the participants’ beliefs about the health-
improvements in perceived stress and most related psy- related effects of yoga and meaning responses [41] and
chological and physical outcome measures. In contrast to social interaction within the groups. The benefits are not
our hypothesis, yoga classes twice a week were no more attributable to differences in covariates as prognostic factors
effective than a yoga class visit once a week; however, for which the analyses were statistically adjusted. We further
lower compliance in the intensified yoga group reduced the conducted an analysis adjusting for outcome expectation,
difference in yoga intensity between the two yoga groups. which did not change the overall results. Furthermore,
Nevertheless, in a separate analysis of the impact of yoga our analysis included baseline values as covariates, thus
intensity independent of group allocation some dose effects regression to the mean effects can be ruled out as an
were found for back pain, the GSI-Score, depression, and explanation for the results.
anxiety. A final possible limitation of this study relates to recruit-
Baseline scores of perceived stress and depression and ment of self-described distressed women for a study in which
anxiety scores indicated the studied population having clini- the primary purpose was to evaluate the effects of B.K.S.
cally relevant distress on study entry. Despite randomization Iyengar yoga on stress reduction. Admittedly, enrollment of
of subjects, there were a number of significantly different subjects who rated themselves as “distressed,” but otherwise
baseline characteristics, including smoking and exercise healthy, was subjective. Yet, this limitation is arguable, as
habits. These differences were adjusted in the data analysis. baseline data from multiple validated instruments for stress
This trial adds further evidence for the use of Iyengar assessment indicated that the women enrolled were, indeed,
yoga as an effective stress reduction tool. We replicated the distressed.
findings of our previous nonrandomized controlled pilot Adherence to the yoga classes was worse than anticipated,
study [21], in which subjects (n = 16) attended two especially in the group that was offered yoga twice weekly.
weekly 90 min Iyengar yoga classes. In this pilot study we The reduction of adherence started within the first weeks
found even larger treatment effects for the psychological and of the offered yoga classes. One may speculate that for the
Evidence-Based Complementary and Alternative Medicine 7

Table 3: Between-group differences of treatment effects on physical symptoms and complaints (when present), mean (95% CI).

Yoga group 1 versus control Yoga group 2 versus control Yoga group 1 + 2 versus control
Change P value Change P value Change P value
Physical well being −2.3 (−3.4; −1.0) 0.001 −0.7 (−2.0; 0.5) 0.256 −1.5 (−2.5; −0.4) 0.007
Back pain −1.7 (−3.1; −0.2) 0.025 −2.5 (−4.2; −0.8) 0.004 −2.1 (−3.5; −0.7) 0.004
Neck pain −2.2 (−3.6; −0.7) 0.003 −1.4 (−2.9; 0.1) 0.06 −1.8 (−3.1; −0.5) 0.005
Freiburg complaint list, sum score −0.3 (−0.5; −0.1) 0.006 −0.2 (−0.4; 0.0) 0.115 −0.2 (−0.4; 0.0) 0.012

Table 4: Group differences for group-independent effects of yoga according to frequency of visited yoga classes compared to controls, mean
(95% CI).

7–12 versus 0 yoga classes 13–24 versus 0 yoga classes∗

Change P value Change P value
Back pain −2.3 (−3.7; −1.0) 0.001 −3.5 (−5.5; −1.5) 0.001
GSI-Score −8.5 (−13.9; −3.0) 0.003 −10.2 (−15.9; −4.4) 0.001
CES-D −4.5 (−8.3; −0.6) 0.049 −5.9 (−10.5; −1.3) 0.011
S-STAI −6.5 (−12.0; −1.0) 0.02 −7.4 (−13.4; −1.4) 0.015
T-STAI −6.1 (−10.5; −1.7) 0.006 −6.5 (−11.2; −1.8) 0.007
GSI: General Severity Index; CES-D: Center for Epidemiological Studies Depression Scale; S-STAI: state anxiety; T-STAI: Trait Anxiety.
∗ Group differences between 7–12 and 13–24 classes not significant.

addressed study population with high demands in work and 6. Conclusion

family life practicing yoga twice weekly for 90 min in distant
centers might be not feasible in daily life. As our results In conclusion, this study suggests that Iyengar yoga is an
indicate that once-weekly participation in yoga led to pro- effective treatment for women in reducing mental distress
nounced and clinically relevant improvements in outcomes, and concomitant psychological and physical symptoms.
adhering to a more rigorous yoga practice schedule may Offering twice-weekly yoga classes is not superior to weekly
be not necessary for stress-symptom improvement. On the classes. To better evaluate the impact of yoga on prevention
other hand, the actual difference between the 2 yoga groups and treatment of stress and stress-related disease, further
was one 90 min yoga session per week. Thus, we do not know studies are needed, which include longer-term followup,
if a more intensive yoga practice with 3 or 4 weekly classes men, larger sample sizes, and control groups engaged in
would lead to more beneficial effects. activity.
Various aspects of the yoga intervention could account
for the observed beneficial effects on stress, mood, and Conflict of Interests
well being. The yoga classes were activating through their
vigorous postures, and participants may have experienced The authors do not have any conflict of interests with the
increasing feelings of mastery over time, as they were content of the paper.
challenged to learn difficult postures. In addition, the
commitment of an extra amount of time to concentrated
practice might induce beneficial effects on self-control and Acknowledgment
foster self-efficacy. The practice of Iyengar yoga comprises The study was supported by the Karl and Veronica Carstens
physical movements with isometric muscle strengthening, Foundation, Essen.
stretching, and flexibility, combined with a mental focus
and an emphasis on mindfulness of body movements
and consideration of breathing patterns [31]. Thus, the References
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