Kim Bennell, PhD: Benefits of an Online Yoga Program for Patients with Knee Osteoarthritis

As previously reported on Rheumatology Network, results of a 12-week, randomized, controlled trial indicated that physical function was improved in patients with knee osteoarthritis who participated in an unsupervised online yoga program when compared with patients who received online education alone. Using a 2-group superiority parallel design method, patients were assigned to receive either education about osteoarthritis or education plus an online yoga program, in which patients were given 1 new video per week, to be performed 3 times per week. After week 12, patients were given the option to continue the practice up to 24 weeks.

In the following Q&A, Kim Bennell, PhD, co-lead author, discusses the study “Effectiveness of an Unsupervised Online Yoga Program on Pain and Function in People With Knee Osteoarthritis: A Randomized Clinical Trial.” Bennell is Director of the Centre for Health, Exercise and Sports Medicine, Department of Physiotherapy at the University of Melbourne.

Kim Bennell, PhD

Rheumatology Network: What first sparked your team's interest in studying the effects of yoga in patients with knee osteoarthritis?

Kim Bennell, PhD: Our research has been concentrated on different types of non-drug management strategies to help people manage osteoarthritis with a particular focus on exercise. We've done a lot of research on different types of exercise, as well as looking at telehealth-delivered interventions (even before COVID). We were looking at ways to deliver them remotely to increase access to programs because Australia's a big country and you want to be able to access services. We had also been interested in programs and services that didn't need a therapist’s input and being able to make them freely available because a lot of people can't necessarily afford to pay for care. We had also been looking at different forms of online exercise interventions and, as there hadn't been research much looking at yoga, we thought we should determine how effective yoga is.

At first, we were talking about doing your typical face-to-face in-person yoga. But then we thought it would be good to do a yoga program that we could kind of roll out. We could do a program that we've modified, developed specifically for people with osteoarthritis, and then do it online so it could be freely available to people. That was how we began looking into an online unsupervised yoga program. Firstly, as I said, because there wasn't a lot of evidence around yoga. And secondly, we were interested in how we might have a program that was more easily accessible to people.

RN: Do you believe that the unsupervised aspect of the program was a hindrance in any way?

KB: I think we know from any sort of online programs that adherence can be problematic because you don't have the therapist or someone helping you with adherence. So, here, adherence is lower. Having said that, ours was probably better than a lot of programs you see out there and that may be because we had people join the study who were motivated to take part in the first place.

We also saw that adherence does affect results. We did perform a secondary exploratory analysis, which was removed, where we looked at hypothetical adherence and the effect of being more adherent. We found that if you had more adherence, if you did the program 2 times or more a week, there were better improvements in pain and improvements in function compared with if you didn't do it. Adherence plays a part and you're going to get better results if you stick to the program. It'll certainly reduce the results in terms of reducing the benefits that you can get, but if it's something that you want to do or want to try it, and you haven't got access to go and see a therapist, I think it's a good option for people to try.

RN: Absolutely. Not to mention, you're also giving them the education aspect of it as well, in addition to the yoga instruction. Results indicated that physical function was improved at week 12 but wasn't sustained at week 24. Do you think that that has to do with adherence?

KB: Yes, and we weren't surprised by that. In fact, we were wondering if we should have included that time point at all. In previous studies, we give the patients a program and then tell them to keep going with it. But in this one we didn't really emphasize that we wanted them to continue, we just made it optional. Generally, people complete the 12 weeks and don't do it anymore. And then, as you would expect, they lose the benefits. It’s no different from if a strengthening program or a walking program; if you stop doing the exercise, you're going to lose the benefits.

RN: Regardless, improvements in physical function were seen within the 12-week study period. What are the clinical implications of these results?

KB: We didn't find that, as a group, there was a statistical improvement in pain. However, the percentage of people who had clinically relevant improvements in pain was better in the older group. So, I do think there's something there from a pain perspective for some people that that more are more likely to show some benefits for pain and, as you said, physical function did improve. Physical function is a key problem for people with osteoarthritis, so if you can improve physical function, it’s highly recommended.

Clinically, it's another exercise option for patients to try that can help improve physical function. We also found other secondary outcomes like improvements in knee stiffness, quality of life, and self-efficacy. Exercise is a core recommended treatment for people with osteoarthritis.

RN: Does your team plan on doing any further research on the impact of yoga in this patient population?

KB: We were very fortunate when we were designing the study that 1 of our research assistants, Sarah Schwartz, MScPT, was a physical therapist and yoga instructor. She did a large part in assembling the yoga panel of yoga therapists and getting the patients with osteoarthritis to help design the program and ensure that it was safe for people to do. So, we may look at some other different types of yoga because we looked at a form that was more concentrated on the physical aspects. But as you would be aware, there are lots of different types of yoga, including ones that are more focused on the meditative aspect. Regarding other ways boost adherence, we could also look at how we might get people to stick to programs.