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A Randomized Trial of Yoga for Children Hospitalized With Sickle Cell Vaso-Occlusive Crisis

Open ArchivePublished:February 10, 2017DOI:https://doi.org/10.1016/j.jpainsymman.2016.12.351

      Abstract

      Context

      Sickle cell disease (SCD) vaso-occlusive crisis (VOC) remains an important cause of acute pain in pediatrics and the most common SCD complication. Pain management recommendations in SCD include nonpharmacological interventions. Yoga is one nonpharmacological intervention that has been shown to reduce pain in some populations; however, evidence is lacking in children with VOC.

      Objectives

      The primary objective of this study was to compare the effect of yoga vs. an attention control on pain in children with VOC. The secondary objectives were to compare the effect of yoga vs. an attention control on anxiety, lengths of stay, and opioid use in this population.

      Methods

      Patients were eligible if they had a diagnosis of SCD, were 5–21 years old, were hospitalized for uncomplicated VOC, and had an admission pain score of ≥7. Subjects were stratified based on disease severity and randomized to the yoga or control group.

      Results

      Eighty-three percent of patients approached (N = 73) enrolled on study. There were no significant differences in baseline clinical or demographic factors between groups. Compared with the control group, children randomized to yoga had a significantly greater reduction in mean pain score after one yoga session (−0.6 ± 0.96 vs. 0.0 ± 1.37; P = 0.029). There were no significant differences in anxiety, lengths of stay, or opioid use between the two groups.

      Conclusion

      This study provides evidence that yoga is an acceptable, feasible, and helpful intervention for hospitalized children with VOC. Future research should further examine yoga for children with SCD pain in the inpatient and outpatient settings.

      Key Words

      Introduction

      Sickle cell disease (SCD) represents a genetically heterogeneous group of disorders with a common phenotype—a red blood cell prone to sickling on deoxygenation. SCD vaso-occlusive crisis (VOC) remains one of the most important causes of acute pain in children and is the most common complication of SCD.
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      Evidence, although limited, has shown yoga to reduce pain in children with chronic fatigue syndrome,
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      headache,
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      In adults, yoga has been shown to reduce pain caused by osteoarthritis, carpel tunnel syndrome, back/neck pain, migraine headache, and hemodialysis.
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      Yoga has been shown to improve symptoms of anxiety, depression, and distress in adults and adolescents.
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      This is important because SCD affects all ages and predominantly people of African American descent. Yoga utilization nationwide, and the number of yoga providers, has had an upward trend over the last few years including an increased provision of yoga offered in medical clinics as well as mental health and public school settings.
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      Because of the multimodal nature of yoga, it is not known which component or components are necessary to produce therapeutic effects. Breathing exercises used to induce relaxation, such as those used in yoga, have been shown to reduce pain and anxiety in hospitalized patients with musculoskeletal trauma.
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      and to reduce anxiety in college students.
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      In addition, physical therapies, similar to yoga asanas, are recommended for a variety of chronic pain problems in children.
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      Centers for Disease Control and Prevention, American Pain Society, and a systematic Cochrane review recommend the use of nonpharmacological strategies for sickle cell pain management; however, little data exist to specifically guide clinical recommendations for these interventions in children with SCD during acute VOC.
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      Furthermore, limited availability of providers to instruct patients in behavioral interventions and lack of insurance reimbursement for these services necessitate the study of interventions that are easily accessible and have high potential for self-administration.
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      The primary objective of this study was to compare the effects of yoga vs. a control condition on reducing pain in children with SCD VOC. The secondary objectives were to compare the effects of yoga vs. control on reducing anxiety, lengths of stay (LOS), and opioid use in children with VOC. Our primary hypothesis was that yoga would be superior to the control on reducing pain in children hospitalized with VOC. Our secondary hypotheses were that participants on the yoga arm would have less anxiety, shorter LOS, and require less opioids when compared with the control group.

      Methods

      Development of the Yoga Program

      This research team conducted a pilot study to evaluate feasibility of using yoga to reduce pain and anxiety in a small sample of pediatric hematology/oncology patients who engaged in a one-time, one-on-one, hospital-or clinic-based yoga session with an instructor. Nine of the children studied had SCD VOC. The mean change in pain score as measured by the Wong-Baker FACES® Pain Rating Scale

      Wong-Baker FACES Foundation. Wong-Baker FACES Pain Rating Scale. Available at http://www.WongBakerFACES.org. Accessed November 4, 2015.

      after one yoga session was −0.94 (P = 0.005), whereas the mean change in anxiety score measured by the State Trait Anxiety Inventory-State (STAI-S) was −9.62 (P = 0.001).
      • Moody K.
      • Daswani D.
      • Abrahams B.
      • Santizo R.
      Yoga for pain and anxiety in pediatric hematology-oncology patients: case series and review of the literature.
      The yoga instructor from the pilot study devised this yoga protocol based on her yoga training and experience with hospitalized children with SCD VOC. The protocol incorporates four key elements of yoga: mindfulness, asanas, breathing exercises, and guided relaxation. Asanas were selected based on the ease of performing them in a hospital bed, adaptability to persons with pain, and to include multiple body areas. Yoga props (e.g., bolsters, blankets, belts, etc.) were used to facilitate muscle stretch and/or to provide joint support during the asana as needed. Participants could choose to participate in each asana either actively (i.e., perform the asana on their own) or passively (i.e., instructor moved participant's body into the asana). Participants were encouraged to provide feedback to the instructors regarding their physical sensations while in the asanas. If, during an asana, the participant reached his or her pain tolerance or limit of endurance, the therapist would modify the participant's body position to re-establish comfort. This could be done by decreasing the extension and/or flexion of muscle groups with or without the use of props.
      Patients did not begin their yoga intervention or control condition until after 24 hours of admission. This provision was made based on our observations during the pilot study
      • Moody K.
      • Daswani D.
      • Abrahams B.
      • Santizo R.
      Yoga for pain and anxiety in pediatric hematology-oncology patients: case series and review of the literature.
      that some children with SCD VOC had difficulty participating in yoga in the first 24 hours of admission because of the necessary tests and admission processes required, pain severity, and increased somnolence.
      To maximize safety, a pediatric hematology nurse practitioner provided yoga instructors with a 60-minute education session about SCD, including pathophysiology and clinical manifestations. In addition, instruction regarding infection control, central and peripheral venous lines, patient-controlled analgesia pumps, and general hospital standards of conduct were provided. Yoga instructors were educated on the research protocol by the principal investigator and completed basic requirements to the conduct of research in human subjects. Both yoga instructors had more than one year of experience working with hospitalized children with SCD VOC before their participation in this study.
      Notably, the launching of this study coincided with the development of a pain treatment protocol for patients admitted with SCD VOC ensuring a uniform approach to the pharmacological management of this patient population at this center. Key components of this pain treatment protocol included an opioid patient controlled analgesia (PCA) for patients more than four years old, no continuous opioid infusions, and consultation with a pain specialist.
      • Carullo V.
      • Murphy M.
      • Choi J.
      • et al.
      Combination of demand only PCA and short term methadone for the treatment of sickle cell disease vaso-occlusive acute pain.
      Support from physician and nurse leaders was obtained by the principal investigator through discussion and presentation of pilot data. An anonymous philanthropic grant supported the yoga instructor salaries. To gain the support of floor nurses, on-site informational sessions were provided to nursing staff during their breaks before launching the study. To familiarize nurses with yoga, instructional yoga sessions were offered to nurses in chairs at their stations and in the conference room throughout the day. In addition, handouts on breathing exercises and meditation techniques were made available to staff.

      Participants

      Between April 2011 and October 2013, after approval was obtained by the Montefiore Medical Center Institutional Review Board, patients were recruited for study participation from the inpatient ward of the pediatric hematology service at Children's Hospital at Montefiore in Bronx, New York. Patients were eligible if they had a diagnosis of SCD, were 5–21 years of age, were admitted to the hospital for uncomplicated VOC, and had an initial pain score of ≥7.
      Patients were excluded if they had signs or symptoms of acute stroke, acute chest syndrome, sepsis, platelets less than 20 k/mm3, hemoglobin <5 g/dL, pregnancy, developmental delay, or psychiatric illness that would preclude participation. Patients began their intervention (or control) after 24 hours and before 72 hours from the time of admission.

      Study Procedures

      Consent

      If a patient met eligibility, written informed consent was obtained by dedicated study personnel from at least one parent (or legal guardian) for children 5–18 years old and by the participant if 13 years old and greater. Assent was obtained from all children between the ages of 7–12 years. When parents were not at bedside, they were contacted by phone to arrange a mutually convenient time to obtain informed consent. During enrollment and intervention delivery, study personnel found that younger patients tended to be awake and available in the morning and adolescent patients in the afternoon. As such, consent and assent from young patients were often obtained in the morning, and the first session was conducted that same day. For adolescents, if consent took place later in the day, the first session took place later that day or the next day at a predetermined time.

      Randomization

      A randomization procedure was performed to prevent selection bias, and patients were stratified by disease. Disease stratification divided the participants into three strata: 1) severe disease: chronic opioid users; 2) moderate disease: three admissions and more for VOC in the past year or prolonged hospitalization more than seven days in the past year; and 3) mild disease: less than three admissions for VOC in the past year. The statistician generated a randomization list within each stratum and severity category, and patients were assigned to either the yoga or control intervention.

      Blinding

      The list of treatment assignments was kept on file with the designated study coordinator. The patients' group assignment was concealed until after the patient consented to avoid bias. The research assistant administering pre- and postintervention scales was blinded to which intervention the patient was assigned.

      Data Collection

      Clinical and demographic data, including admission pain score, were collected at the time of initial consent. Baseline pain scores and the STAI-S (and -Trait [T]) were collected just before the first yoga or control session. Pain scores were collected again within 30 minutes after each subsequent yoga or control session. The STAI-S was collected again after the first session; however, because of the length and time to complete this scale, it was not collected again during the admission.

      Outcomes

      The primary outcome was change in pain score after the first session and measured by the Wong-Baker FACES® Pain Rating Scale for children. This scale was chosen because it is validated in children with SCD aged 3–18 years and in hospitalized children.
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      In addition, it is used extensively at Children's Hospital at Montefiore, and this population was familiar with its use.
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      It is a visual scale with six anchors (pictures of faces) at even integer intervals and ranges from 0 (no pain) to 10 (worst possible pain) and is the most preferred scale by children with SCD.
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      Pain in children: comparison of assessment scales.
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      We designated a change of −1 point to be clinically significant based on literature review.
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      The secondary outcome, change in anxiety, was measured by the STAI-S, a reliable and validated anxiety scale for children and young adults.
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      The S-subscale measures anxiety at one point in time (now). The T-subscale refers to relatively stable individual differences in anxiety and was administered only at baseline.
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      Data regarding IV opioid use, LOS, and adverse events were collected for both groups for the entire hospitalization.

      Description of Intervention and Control

      Yoga Intervention Group

      Patients randomized to yoga were provided daily, Monday through Friday (M-F) with the yoga intervention, 1:1 with a yoga instructor in their hospital room. The yoga intervention was divided into four segments applied sequentially over 30 minutes. The segments were designed to introduce patients to four aspects of yoga: 1) mindfulness, 2) asanas, 3) breathing techniques, and 4) guided relaxation (see intervention details in Table 1).
      Table 1Study Protocol for Yoga Intervention
      Segment 1: Mindfulness
      • 1.
        Mindfulness exercise 1/shavasana (active or passive positioning): Body in supine position with relaxed, extended, and supinated arms, and relaxed extended legs, slightly externally rotated at the hip joints, heels touching. Props were used to support the patient's head and joints.
      • 2.
        Mindfulness exercise 2/conscious breathing: Once the participant was comfortable in shavasana, he or she was instructed to become aware of his or her breath and to notice when each inhalation and exhalation were complete.
      • 3.
        Mindfulness exercise 3/conscious breathing into chest or abdomen: Participants were guided to continue to focus on their breath while their hands were placed (either by the participants or the instructor, at the participant's request) on either the abdomen or chest, and the participant was asked to pay attention to these locations during inhalation and exhalation. Verbal cues were given by the yoga instructor to assist the participant in noticing the movement of breath in these areas.
      Segment 2: Asanas (done with awareness of breath or in tandem with breathing if possible)
      • 1.
        Ankle rolls and ankle flexion/extension
      • 2.
        Supine hamstring stretch (leg lifts), inner groin stretch (passive movement of hip laterally), and supine spinal twist with bent knees across
      • 3.
        Supine position, leg extended upward, and instructor supported lowering of the leg timed to each exhale
      • 4.
        Knee to chest (single and double). Gentle traction of legs away from pelvis by instructor
      • 5.
        Chest opening (passive) by placing props under the full length of the spine. Reclining with legs straight or soles of feet together and knees bent to side (props used to support back and hips)
      • 6.
        Face/neck/shoulders: Contract/release face, lion pose (head of bed 45°, inhale-exhale open eyes, mouth wide, and extend tongue out exhale with ha sound), neck side to side flex/extend, and shoulder shrugs
      Segment 3: Pranayama and valoma (lengthening and regulation of the breath)
      • 1.
        Pranayama: The yoga instructor gave a verbal description of the three-dimensional shape of the rib cage (side/side, up/down, and front/back) to help participants visualize and optimize their lung capacity.
      • 2.
        Valoma 1: It involves a three-part sequential inhalation in each dimension (side/side, up/down, and front/back) until inspiratory capacity is reached and then exhalation. To facilitate this exercise, the yoga instructors developed a script that used the metaphor of slowly filling the lower, middle, and upper lungs as if filling a glass of water and then pouring the water out.
      Segment 4: Guided relaxation
      • Three exercises to promote mindfulness and relaxation.
        • 1.
          Exercise 1: The participant was invited to count his or her own breaths backward from 10 to 1.
        • 2.
          Exercise 2: The participant was asked to notice the internal and external sensations in the body and to notice his or her thoughts. S/he was then asked to let go of observing thoughts and sensations and to just relax into a state of mindful nonjudgmental awareness without following thoughts or body sensations.
        • 3.
          Exercise 3: A progressive guided relaxation exercise led by the instructor that ended with the instructor being silent for a minimum of 3 minutes.
      To dampen ambient hospital noise and foster transformation of the hospital room into a more serene environment for yoga practice, a nature sounds compact disc (CD),
      titled Morning in the Mountains, was played during the first two yoga segments. Segments 3 and 4 were done in silence to allow participants to focus on the specific breathing techniques and attend to the guided relaxation segment.

      Control Group

      The control condition was matched to the yoga intervention for time, attention, and ambiance. Patients randomized to the control group were provided with a daily (Monday through Friday) 30-minute session wherein the yoga instructor played the Morning in the Mountains nature sounds CD at a volume of the patients choosing. During each session, the yoga therapist offered to stay with the patient for the duration of the CD, but no movement exercises, breathing exercises, or guided relaxation were offered.

      Sample Size

      Based on our pilot data, the estimated SD of the change in pain score in children with SCD and cancer after yoga was 1.5.
      • Moody K.
      • Daswani D.
      • Abrahams B.
      • Santizo R.
      Yoga for pain and anxiety in pediatric hematology-oncology patients: case series and review of the literature.
      Therefore, to detect a change in pain score of 1.0 with 80% power, at a two-sided 0.05 level, 36 patients per arm were needed.

      Statistical Analysis

      The mean change in pain and anxiety scores from baseline to after the first yoga or control session was calculated and compared with either the Student's t-test or Wilcoxon rank sum test, depending on the distribution of the data. In addition, the effects of group and time were evaluated using repeated-measures analysis of variance, where time was repeated within subject, times were allowed to have different variances, and correlations between times were not assumed to be constant.
      LOS, total IV opioid use in milligrams of morphine equivalent dose per kilogram per hour, and adverse events for the entire hospitalization were evaluated and compared between groups using similar approaches. Of note, participants were offered to continue participation on the study for subsequent admissions; however, data were only analyzed for the first admission.

      Results

      Sample

      Eighty-eight percent of patients approached for study inclusion consented to participate, resulting in 73 patients enrolled (Fig. 1). Intervention and control groups were balanced with respect to all clinical and demographic variables. Admission pain scores as well as baseline pain and anxiety scores were similar between groups (Table 2). Many patients self-identified their race as a culture or ethnic identity (e.g., Hispanic, Guyanese), and these are listed as other in Table 2. Thirty-five patients participated in 115 yoga sessions; 95% of these yoga sessions were done to completion (included all four segments). The average number of sessions completed by yoga and control subjects was 2.5 (±1.6) and 2.4 (±1.4) (nonsignificant), respectively (Table 3). No patients dropped out of the study or refused the intervention once enrolled. Patients generally responded positively to the yoga intervention (Table 5).
      Table 2Baseline Demographic and Clinical Characteristics (Yoga vs. Control)
      Demographic CharacteristicsYoga (N = 35)Control (N = 35)P
      Age, yrs (range)6–206–21NS
      Age, yrs (mean)1514NS
      Male sex1415NS
      English language3432NS
      Race
       Caucasian11NS
       African American2020NS
       Other1414NS
      Ethnicity
       Hispanic79NS
       Non-Hispanic2827NS
      Medicaid1821NS
      Household income
       <10,00057NS
       10,000–20,00055NS
       20,000–30,00053NS
       30,000–40,00043NS
       40,000–60,00011NS
       >60,00022NS
      Clinical characteristics
       Severity of SCD
      Mild1919NS
      Moderate1414NS
      Severe22NS
       SCD genotype
      HbSS2127NS
      HbSC76NS
      Beta + thalassemia (HbS/β+)52NS
      Beta zero thalassemia (HbS/β0)20NS
       Comorbidity
      None2928NS
      Retinopathy00NS
      Cardiac disease00NS
      Pulmonary disease21NS
      Stroke11NS
      Other35NS
       Mean admission pain score8.79.1NS
       Mean trait anxiety46.650.3NS
      Prior yoga experience
       No2225NS
       Yes99NS
      NS = nonsignificant; SCD = sickle cell disease.
      Table 3Number of Yoga and Control Sessions Completed by Participants by Group
      Number of SessionsYogaControl
      13535
      22523
      31213
      4105
      543
      621
      701
      801

      Pain and Anxiety

      The change in pain scores was normally distributed across both arms. Children randomized to the yoga intervention had a significantly greater reduction in mean pain score after the first yoga session compared with those randomized to the control in univariate and multivariate analyses (−0.6 ± 0.96 vs. 0.0 ± 1.37; P = 0.029). There was a significant effect of time in the yoga group only (P ≤ 0.0001). Thirteen patients (37%) on the yoga arm had a decrease in pain score of ≥1 point below baseline vs. six (17%) patients on the control arm; however, this did not reach statistical significance (P = 0.059). No group differences were identified in pain scores after subsequent yoga sessions; Postsession 1 analyses were limited by sample size attrition because of hospital discharge (Table 3).
      The mean state anxiety scores for both groups of children were in the clinically significant range for anxiety (>40) at baseline and follow-up. Both the yoga and control groups experienced similar decreases in anxiety that were slightly greater than .5 SD; however, these differences were not statistically significant (Table 4).
      Table 4The Effects of Yoga vs. Control on Pain, Anxiety, Lengths of Stay, and IV Morphine Equivalent Dose
      OutcomesArm 1, Yoga (N = 35)Arm 2, Control (N = 35)P
      Pain
       Presession 1 score5.65.9NS
       Δ Pain−0.6 (±0.96)0.0 (±1.37)0.029
      STAI anxiety (state)
       Presession 1 score50.654.8NS
       Δ State anxiety−7.7 (±9.6)−6.2 (±7.3)NS
      Mean LOS5 (±2.8)5 (±2.4)NS
      IV morphine equivalent dose (mg/kg/hour)0.033 (±0.016)0.037 (±0.018)NS
      IV = intravenous; NS = nonsignificant; STAI =State Trait Anxiety Inventory; LOS = lengths of stay.
      There were no significant differences in total IV opioid (morphine equivalent dose milligrams/kilograms/hour) used during hospitalization or in overall LOS between the two groups (Table 4).
      Five adverse advents were observed: two on the yoga arm (avascular necrosis and acute splenic sequestration) and three on the control arm (two patients with acute chest syndrome and one patient with suicidal ideation). All events were reported as unlikely caused by the study procedure.

      Discussion

      This is the first randomized controlled trial of yoga for children with acute pain, and specifically SCD VOC. The high rate of accrual (88%), ability to fully participate in the yoga intervention (95% of sessions), and positive feedback (Table 5) provide evidence that yoga is an acceptable and feasible intervention for hospitalized children with SCD VOC. Our results also indicate that yoga may provide a direct benefit on pain in this population. These findings are consistent with previous data supporting the usefulness of yoga in attenuating chronic pain conditions in children and data showing that yoga reduces both acute and chronic pain in adults.
      • Posadzki P.
      • Ernst E.
      • Terry R.
      • Lee M.S.
      Is yoga effective for pain? A systematic review of randomized clinical trials.
      • Chuntharapat S.
      • Petpichetchian W.
      • Hatthakit U.
      Yoga during pregnancy: effects on maternal comfort, labor pain and birth outcomes.
      • Korterink J.J.
      • Ockeloen L.E.
      • Hilbink M.
      • Benninga M.A.
      • Deckers-Kocken J.M.
      Yoga therapy for abdominal pain-related functional gastrointestinal disorders in children: a randomized controlled trial.
      The effect size, although smaller than our defined clinically significant change, is similar to previous findings of other nonpharmacological interventions to reduce nonheadache and chronic pain in children.
      • Eccleston C.
      • Palermo T.M.
      • Williams A.C.
      • et al.
      Psychological therapies for the management of chronic and recurrent pain in children and adolescents.
      • Fisher E.
      • Law E.
      • Palermo T.M.
      • Eccleston C.
      Psychological therapies (remotely delivered) for the management of chronic and recurrent pain in children and adolescents.
      Our study focused on a specific type of pain (VOC) in a specific population (children with SCD) and thus expands the available evidence base supporting the use of nonpharmacological interventions to reduce pain in this population.
      Table 5Patient Quotes Supporting Acceptability of Yoga in Pediatric SCD Population
      Quote
      • Yoga makes me happy. I want to do it again.
      • I feel like my body was on a hammock. It felt good.
      • I feel so relaxed (pt. fell asleep briefly during guided relaxation)
      • I liked it a lot. I did not want it to stop.
      • Yoga helped me poop. It helped me breathe better.
      • I want more Yoga.
      • The yoga helps me a lot
      • That was too good. Are you coming back tomorrow?
      • That felt so good. I forgot where I was at.
      SCD = sickle cell disease.
      Yoga is a multimodal intervention that includes relaxation, mindfulness, breathing exercises, and physical postures; therefore, the combination of these elements may account for our results on pain. In addition, yoga is associated with significant reductions in inflammatory markers (C-reactive protein, interleukin-6, and tumor necrosis factor) and with significant increases in β-endorphin that are positively and negatively related to pain, respectively.
      • Bower J.E.
      • Irwin M.R.
      Mind-body therapies and control of inflammatory biology: a descriptive review.
      • Yadav R.K.
      • Magan D.
      • Mehta N.
      • Sharma R.
      • Mahapatra S.C.
      Efficacy of a short-term yoga-based lifestyle intervention in reducing stress and inflammation: preliminary results.
      Both the yoga and control groups experienced a nonsignificant drop in state anxiety (>.5 SD change), which could be because of chance or to similar smaller effects on anxiety across groups. In contrast to previous studies that examined the role of yoga in addressing anxiety among children and adolescents,
      • Weaver L.L.
      • Darragh A.R.
      Systematic review of yoga interventions for anxiety reduction among children and adolescents.
      there were no significant changes in mean anxiety scores for those on either arm of our study. It could be hypothesized that we did not see significant reductions in anxiety in our population because the children were experiencing acute pain. It is interesting that trait and state anxiety were in the clinically significant range and suggests that screening for anxiety would be appropriate for this population.
      Yoga is cost-effective and can be learned through school programs, community-based classes, and instructional videos. It was acceptable to our primarily minority and pediatric population, and it can be practiced at home. Yoga can also be easily modified to accommodate persons with physical disabilities. Families of children with SCD report using nonpharmacological strategies such as relaxation and distraction at home to help manage their children's pain 85% of the time.
      • Dampier C.
      • Ely E.
      • Eggleston B.
      • Brodecki D.
      • O'Neal P.
      Physical and cognitive-behavioral activities used in the home management of sickle pain: a daily diary study in children and adolescents.
      • Williams H.
      • Tanabe P.
      Sickle cell disease: a review of nonpharmacological approaches for pain.
      Yoga is an intervention that parents and children can learn to use at home as an additional pain management tool and can be enjoyed by all family members. As patients with SCD age, their frequency of days in pain increases to greater than 50% of days on average for patients older than 17 years.
      • Smith W.R.
      • Penberthy L.T.
      • Bovbjerg V.E.
      • et al.
      Daily assessment of pain in adults with sickle cell disease.
      Yoga is a self-care practice that could be taught to children and used throughout adulthood as part of a comprehensive pain management plan that can be applied at home and during hospitalizations for acute pain crisis.
      This study has several limitations that warrant consideration. Because of the nature of the intervention, it was not possible to blind study subjects to which arm they had been randomized. In addition, this study is only representative of a single institution with a small sample size and a very limited number of yoga sessions per patient. Although statistically significant, the absolute reduction in mean pain score after one yoga session was small, although quite similar to the effect size of other psychological therapies on pain in children.
      • Eccleston C.
      • Palermo T.M.
      • Williams A.C.
      • et al.
      Psychological therapies for the management of chronic and recurrent pain in children and adolescents.
      • Fisher E.
      • Law E.
      • Palermo T.M.
      • Eccleston C.
      Psychological therapies (remotely delivered) for the management of chronic and recurrent pain in children and adolescents.
      Because yoga can be taught to be self-administered, even small effects may be worthwhile and cost-effective. In addition, yoga skills are likely to improve with time and practice; therefore, greater benefits may be achieved for those patients who subscribe to an ongoing yoga practice.
      In conclusion, our study is the first to report on yoga as a feasible, acceptable, and potentially beneficial adjunctive treatment for acute pain in hospitalized children with SCD VOC. Future research should further explore the effects of yoga on acute VOC pain in the inpatient setting in a larger multicenter population. In addition, a longitudinal study examining the effects of yoga on SCD-related pain is warranted in the outpatient setting.

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