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Journal of Natural & Ayurvedic Medicine

ISSN: 2578-4986

Committed to Create Value for ResearchersPariṇāma Model: Contextualizing Experiences of Change inParticipants of Pilot Study to Determine Efficacy of Individualized
Yoga Therapy in Rheumatoid Arthritis and Anxiety
Vidhi Sadana*

Perspective

London Northwest Hospital Trust, UK

Volume 4 Issue 3*Corresponding author: Vidhi Sadana, London Northwest Hospital Trust, Central Middlesex
Hospital Acton Lane Park Royal London-NW10 7NS, UK, Tel: 00447462813937; Email: vidhi.
sohdi@nhs.net

Received Date: June 27, 2020

Published Date: July 09, 2020

DOI: 10.23880/jonam-16000255

Abstract
There is been surge of interest in yoga as a tool to improve health and wellbeing in the last decade or two. There have been
a number of research papers that have been published on efficacy of yoga in rheumatoid arthritis offered in a group setting.
However, there haven’t been any studies offered in an individualized setting. We conducted, first in the UK pilot study at Central
Middlesex Hospital, to study the efficacy of individualized yoga therapy in Rheumatoid Arthritis. The present article addresses
unique conceptual mechanisms found in our study. In-depth, experiential accounts through feedbacks were completedwith 10 patients with Rheumatoid Arthritis along with anxiety and depression. Feedback invited participants to recounttheir experiences of the intervention, and the service in a hospital setting. Aspects of the experiential accounts pertained tointervention experience and positive benefits were analysed to provide generation of a provisional model of how positivechange occurred. The model suggests that distinct, temporal experiences build on each other to generate multiple, positive
benefits. This article is an attempt to integrate the precious wisdom of the yoga sutra in a language that can be understoodby the western medical profession. As pointed out in yoga sutra text enhanced attentional capacity was important, and it
validated the mechanisms of healing proposed by the yoga sutra-s of attunement, empathy, supporting self-care, awareness,
introception and experiential learning to states of empowerment, self-discovery and acceptance, which may be central topositive outcomes. Understanding mechanisms of change may help support participant engagement and trust in yoga therapy
and enhance participants’ ability to apply tools offered within yoga therapy to their daily life.

Keywords: Yoga Therapy; Rheumatoid Arthritis; Introception
Introduction

A number of research studies have found yoga to beeffective as a curative and preventative approach to physicaland psychological health. However, very little work has been
done to study and analyze the experiences of participantsby which positive outcomes are secured when delivered
to a physical condition such as Rheumatoid Arthritis withpsychological impact.

The aim of the pilot was to investigate experiences ofViniyoga® Intervention specifically in terms of acceptability
and impact on the patient outcomes. Ten Participants were
offered ten one to one Viniyoga® sessions over 16 weeks ina hospital setting in West London. The tools offered wereadapted and tailored to individual needs, abilities, context
and beliefs. Tools included not only breath focused āsana-s(physical postures); prāṇāyāma (breathing techniques) but
also mantra-s, visualizations and yogic counseling. Results of

Parinama Model: Contextualizing Experiences of Change in Participants of Pilot Study to Determine
Efficacy of Individualized Yoga Therapy in Rheumatoid Arthritis and Anxiety

Nat Ayurvedic Med

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Journal of Natural & Ayurvedic Medicine

this found that there was significant reduction in depression,anxiety, pain and improvements in quality of life and general
health at post intervention and 12 months (p<0.05) [1]. The
qualitative analysis through semi-structured interviews
also reported positive outcomes in terms reduction of
medications, improved sleep, mood, energy and greater
engagement and reengagement in life [1].
Rheumatoid Arthritis is one of the most prevalent
inflammatory chronic conditions that not only affects thephysical body but also has huge psychological impact leading
to depression and anxiety [2,3]. A growing body of research
indicates that the stress system, and its interactions with
the immune system, plays a pivotal role in the aetiology andprogression of rheumatoid arthritis (RA) [4].
Mechanistic explanations for yoga’s potential mental
and physical health benefits include down-regulation of the
hypothalamic-Pituitary adrenal (HPA) axis and sympathetic
nervous system [5-7] that gets activated by stress triggers.
Most studies so far have focused on outcomes rather than theprocess.

This perspective paper aims to bridge this gap and elicit
the experiential accounts offered during in-depth feedbackof participants taken during follow-up sessions to generatea model of Change (Pariṇāma) by analyzing the intervention
experience and positive benefits experienced by theparticipants. This article is also an attempt to integrate theprecious pearls of wisdom offered in Patanjali yoga sutra ina language that can be understood by the western medical
profession as an educational tool on acceptability of theViniyoga® intervention to manage the current burden ofchronic disease.

Participants experiential accounts suggest a clear staged
process with a beginning, middle and an end states withshifts and changes occurring in one stage that lead to newforms of patterns of thinking, behaving and experiencing.
As presented in the yoga sutra-s chapter III-9-15, mind iscapable of two states based on two distinct tendencies.
These are distraction (vyuthāna) and attention (nirodha).
Participants of this study choose to apply the ability to focus
towards attention through the tools offered in the Viniyoga®
intervention.
This gives rise to a linear, broadly temporal model(Figure 1) with interdependent relationships. This model
proposes that the arising of new experiences were built on
previously gained positive insight and experiences leading tosmṛtipariśuddau as presented in the yoga sutra chapter 1-43.

Figure 1: PARIṆĀMA Model.

Pre Pilot StateSDM or Shared Decision Making was the reason
for attending the intervention and National Institutefor HealthCare Excellence also recommends SDM for

management of Rheumatoid Arthritis [8]. SDM is the trust
between a clinician and patients that requires patients to
be involved in the decisions about the interventions they
undertake for their chronic condition. The state of trust andsafety was the key state that was achieved through trust of theVidhi Sadana. Parinama Model: Contextualizing Experiences of Change in Participants of Pilot Studyto Determine Efficacy of Individualized Yoga Therapy in Rheumatoid Arthritis and Anxiety. Nat
Ayurvedic Med 2020, 4(3): 000255.

Copyright© Vidhi Sadana.

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clinicians in the Viniyoga® intervention which was passed
to the participants of the study during recruitment. Tenpatients were recruited within ten days. As Patañjali statesin the yoga sūtra the essential ingredient for yoga therapy
to work is Śraddha (trust) which leads to courage. (Y.S I.21).
Education about Yoga Therapy becomes an imperative future
direction for its integration into healthcare system.

Attunement and Empathy

This was the first and one of the important states thatwas created with the participants of the study. Participants’feedback provided an insight that early attunement andthe empathetic therapeutic relationship created during
the first session was even more foundational element forchange before awareness and attention was developed. The
connection between the yoga therapist and the participants
offered a space where they felt safe and non-judged which
in turn helped to establish trust and enhance pro-social
behaviours.

A heart to heart connection was created resulting in atherapeutic partnership between the patient and therapist.
This was the point therapists acknowledged that theirstories were real, and there was a genuine interest from thetherapist to know what is the story behind the disease andhow it manifested. “After our first session, I felt a bit tired
but very light. It made me realize that the situation with mymum brings about my anxiety and that I have ‘no space’ formyself” (P7). Therapist was able to meet the patients at the
point where they were and help them move towards change.

Participants also felt heard and listened to which
triggered a ‘care/healing response’. Research has shown thatthrough detection of safety there is activation of vagal activity,
which reduces stress [9] helping to mobilize motivation andoffer hope. “Yoga has motivated me to get up in the morning
to do my exercise” (P3).

Supporting Self Care

The second stage of supporting Self-Care captured
participants need to legitimize active care for themselves.
This was found to be a building block to experience later
benefits and was in-fact an on-going process throughout the
study and beyond. It has been reported in many studies thatpeople experience a sense of reluctance and guilt for engaging
in self-care in diverse context and countries [9-11]. For some,attending the sessions regularly reflected a decision to invest
in their own well-being. And for others, a realization ofimportance of self-care as described by Participant (10) “I
never used to walk but now I realize that I am taking careof myself and taking health into my own hands. I rather dosomething than get a flare”.

Journal of Natural & Ayurvedic Medicine
Awareness, Introception-Experiential Learning
In our model, supporting Self-Care directly fosteredawareness. Participants in our study talked about awareness(of self) and their state of mind and body along with
habitual ways of responding. Directing their attention in asustained (Y.S1.II) manner towards the tools offered during
the Viniyoga® intervention developed an experience ofawareness. They developed proprioceptive and introception
skills that allowed them to know what they were feelingphysically as well as their internal feelings. Evidence has
shown that interoceptive sensitivity is correlated withemotional stability, emotion regulation, and emotional
intensity (the tendency to experience more extreme emotions
with greater awareness and depth of experience) [13-15].

This opened up new choices for response and new
ways of being, bringing the fourth stage of change. This new
relationship of awareness, proprioception and introception,
experiential leaning developed facilitating detection ofphysiological and psychological stressors and their triggers.
“I am quicker in detecting my stress when I see my daughter’s
room all untidy” (P6). This earlier detection of state of mind
when exposed to a stress trigger and practicing new ways
to response to conscious new experiences was fundamental
part of the intervention. The teachings of friendliness,compassion, equanimity, detachment as taught in the yogasutra allowed them to engage in different potential for action
cognitively, affectively or behaviorally. “I now after seeing herroom, go to the lounge, recite few times my mantra given andthen return to my daughter and ask her to clean up. We haveless blow up’s now” (P6). Thus participants expressed boththe motivation and ability to apply the “yoga off the mat”
across their life to enable them to choose new responses andcreating a change. This is shown in our model of experiential
learning. Our model also through feedback reported thatthe dynamic processes whereby as awareness, introception
became more routine, so did self-care. These made theminterrupt their stress experience with a beneficial activity
building resilience.

Empowerment

Participants reported improved confidence in one’s
own ability to manage their long-term conditions. This was
expressed as evolving over-time, which was supported byexperiential leanings and resulted in positive experiences
and further self-care. They reported as now having a “newtoolbox” to manage their stress triggers and stressful
episodes. “I can manage now” (P6). “I no longer feel a victimof my condition” (P9). This empowerment is the fifth stage ofchange. One of the most important take-away for participants
was the new relationship they found with their thoughts that
resulted in negative states of being. “I feel tired today and aVidhi Sadana. Parinama Model: Contextualizing Experiences of Change in Participants of Pilot Studyto Determine Efficacy of Individualized Yoga Therapy in Rheumatoid Arthritis and Anxiety. Nat
Ayurvedic Med 2020, 4(3): 000255.

Copyright© Vidhi Sadana.

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bit down but I do not go into overdrive of worry and anxiety
as I know now that sometimes I just need to rest and it takes
time“ (P2). This new ways of observing their own self andtheir mental chatter was helpful in reappraising emotionaland cognitive states. “I still have stress from work and inlaws but I now know to let things go. Not lettings things
get to me. No pain when rolling roti’s now” (P1). Thus, they
were empowered to use the yogic counseling principles ofsvādhāya (heightened awareness through self-reflection;
Y.SII 1.,32) and vairāgyam (detachment; Y.S I.15) leading to achanged state of being empowered.

Self-Discovery & Self-AcceptanceThrough the process of Kriyā Yoga (Y.S II.1), tapas,
svādhyāya (self-reflection) fostered change overtime. The‘end’ state of the participants at the end of study differedfrom the starting state. After the end of the intervention,
participants reported “being at ease with who I am without
the tigers around me” (P5). “Medication has dropped. Some
pain was there during Diwali time but I am enjoying life.“(P2). “Sleep is better as I am at peace for doing my bestat my job. There is nothing more I can do” (P9). “Sleeping
better and I am aware that when I rush, I get anxious” (P5).
“I feel more confident and a lot better now” (P4). “I feelbetter in myself. I have more energy and my methotrexate
has dropped and less pain in my fingers” (P8). Participants
reported feeling at peace and calm in the mind as they
accepted the ways things are and disconnecting themselvesfrom their pain or their disability. In Y.S 1.33, Patañjali offers
the solution for a peaceful mind is a result of mental attitudeof upekaṣāṇaām (equanimity). Research has shown thatequanimity, defined as an even-minded mental state toward
all experiences, internal and external becomes an effective
counter to allostatic load following chronic stress [16]. Stressplays an important role in increased inflammation resulting
in rheumatic conditions such as Rheumatoid Arthritis.
This provisional model proposes stages of changes,pariṇāma, experienced by the participants of rheumatoid
arthritis with anxiety and depression through the Viniyoga®
intervention. This was the first pilot in the UK that has
demonstrated both positive qualitative and quantitative
results. The in-depth feedback collected during the follow-up
sessions suggests that the intervention provided participants
tools to change from vyutthāna into nirodhaḥ patterns(Y.S 111.9) of de-automization of negative responses (seenin Introception- Experiential Learning stage), increased
confidence in dealing with stressful situations and greater
positive emotions(seen in Empowerment, self- acceptancestages). More importantly, Self-Care was foundational increating these stages of changes. A six months and twelve
month questionnaire showed that participants were stillengaging in physical, mental and behavioral practices offered

Journal of Natural & Ayurvedic Medicine
in the active phase of the pilot study.

A number of limitations to this study should be noted.
The retrospective narratives produced via the feedbacks inthe present study are likely to have involved recollection,
reconstruction and co-construction. Thus, the proposedmodel of change is subjective although we were nonethelessable to identify patterns across participants of experiencesof change that are concurrent to Patañjali’s yoga sutra-s. In
addition, participants had opted in the pilot and feedback
because of the belief of the consultant in the intervention,and it is likely that participants were positively biased.
However, although this may be seen as a bias in research
literature, changing behaviours towards self-efficacy
requires changes to beliefs and attitudes in participants [17].
This requires a change in belief from the medical profession
towards acceptance of more complementary therapies suchas yoga therapy in management of chronic diseases such as
Rheumatoid Arthritis, and lastly, this was relatively smaller
study and we recommend that this pilot be extended tolarger trials. Nonetheless, this provisional model could be
used as a teaching tool for yoga therapist to present to multidisciplinary teams in a healthcare setting especially thoseworking with chronic condition with co-morbidities such as
depression and anxiety.

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Vidhi Sadana. Parinama Model: Contextualizing Experiences of Change in Participants of Pilot Studyto Determine Efficacy of Individualized Yoga Therapy in Rheumatoid Arthritis and Anxiety. Nat
Ayurvedic Med 2020, 4(3): 000255.

Copyright© Vidhi Sadana.