Teaching and

Learning Discovery

Integration Application

Community of

Scholarship

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Examining the Perceptions of Occupational Therapists and Yoga Practitioners Regarding the Effects of Yoga on Health and Wellness

Julia Graham, MFA, CYT, OTD/S Faculty Advisor: Dr. Teresa Plummer, PhD, MSOT, OTR/L, CAPS, CEAS, ATP

This project was supported by the faculty and resources of the School of Occupational Therapy at Belmont University. The School of Occupational Therapy provides comprehensive graduate education within a Christian learning environment to enable students from diverse backgrounds to positively impact the community at large and enhance the human condition through appreciation of diversity, problem solving, and utility of meaningful and purposeful occupations. It is the vision of the department to prepare graduate students to become and continue to be occupational therapy practitioners who are committed to evidence and occupation-based practice, life-long learning, service, and advocacy (Belmont University School of Occupational Therapy, n. d.). Interwoven in the Doctorate of Occupational Therapy (OTD) curriculum are four themes: Service, Scholarship, Clinical Excellence, and Leadership. This research-based project was designed to integrate all of the identified curricular themes, with a primary focus on Scholarship. Scholarship is:

²  “A systematic investigation…designed to develop or contribute to generalizable knowledge” (United States Department of Health and Human Services, 2009).

²  Made public, subject to review, and part of the discipline or professional knowledge base (Glassick, Huber, & Maernoff, 1997).

²  It allows others to build on it and further advance the field (American Occupational Therapy Association [AOTA], 2009).

Scholarly activities in the OTD program require systematic inquiry and clinical reasoning to “describe and interpret the scope of the profession, establish new knowledge, interpret and appropriately apply this knowledge to practice, and engage learners in their development and understanding of the profession” (ACOTE, 2012; Gibbs & Plummer, 2014). Ernest Boyer (1990) presented four scholarly approaches that should be utilized for optimal student learning:

²  The Scholarship of Discovery: Engagement in activity that leads to the development of “knowledge for its own sake,” and encompasses original research that contributes to the knowledge base of a discipline.

²  The Scholarship of Integration: Investigations making creative connections both within and across disciplines to integrate, synthesize, interpret, and create new perspectives and theories.

²  The Scholarship of Application: The application of knowledge generated by scholarship of discovery or integration to address real problems at all levels of society.

²  The Scholarship of Teaching and Learning: “Involves the systematic study of teaching and/or learning and the public sharing and review of such work through presentations, publications, and performances” (McKinney, 2007).

As highlighted by the AOTA (2009), every occupational therapy practitioner has a professional responsibility to engage in scholarship and should contribute independently or collaboratively to building evidence base for occupational therapy practice and occupational therapy education. This project explored each of the four interdependent and interrelated functions of scholarship outlined by Boyer (1990), as a means to contribute to the body of knowledge supporting occupational participation and engagement for individuals, groups, and the population at large.

²  To demonstrate innovation and professional reasoning by designing a research project that explores the tenets of yoga and occupational therapy.

²  To advocate for the occupational participation, performance, and engagement of clients, including individuals, organizations or populations, and those in complex situations, through the exploration of yoga as a strategy to improve health and wellness.

²  To synthesize multiple sources of information, such as AOTA official documents or practice guidelines, to enhance the research process and development of the research manuscript.

²  To integrate best evidence and distribute new knowledge through presentations for a variety of audiences. ²  To communicate and collaborate with project stakeholders to identify meaningful ways to overcome the gaps

in knowledge and barriers to implementing yoga within the scope of occupational therapy practice. ²  To contribute to the body of literature regarding yoga and occupational therapy by preparing a scholarly

research manuscript that is worthy of publication in a peer-reviewed journal. ²  To expand knowledge and understanding of yoga as a therapeutic medium or strategy that supports

individuals in the self-management of their own health and wellness behaviors.

(Adapted from Boyer, 1990)

!

Examining the Perceptions of Occupational Therapists and Yoga Practitioners Regarding the Effects of Yoga on Health and Wellness

Julia Graham, MFA, CYT, OTD/S

Introduction: The number of individuals practicing yoga in America has increased from 20.4 million in 2012 to 36 million in 2016 (Yoga Journal & Yoga Alliance, 2016). Given the drastic increase in participation in yoga, it is important for healthcare practitioners to be informed about the nature of yoga and the evidence of its many therapeutic effects (Woodyard, 2011). Purpose: The purpose of this study was to explore descriptive and phenomenological data on the perceptions that both occupational therapists and yoga practitioners have regarding the use of yoga within personal and professional practice; as well as, the potential for yoga to be used as a self-management strategy for health and wellness behaviors. Methods: A mixed-methods design was used to collect data from 20 occupational therapists and 23 yoga practitioners. All data was collected from anonymous online surveys and coded with the data analysis software Nvivo 10 (QSRInternational, n.d.). Results: Four central themes were discovered: (1) the practice of asana (postures), pranayama (breathing), and dhyana (meditation) positively impacts the workings of the body, mind, and spirit; (2) yoga increases self-awareness; (3) practicing yoga affects overall well-being; and, (4) there is a role for yoga in Western healthcare; however, there are barriers to implementing yoga within occupational therapy practice. All participants agreed that yoga was a strategy that could help individuals better self-manage their health and wellness behaviors. Conclusion: In light of the vast history of yoga as a self-care strategy, the identified health benefits, and the innate similarities between yoga and occupational therapy, there is a need to explore role of yoga within the scope of occupational therapy practice. With increased knowledge of yoga, occupational therapy practitioners may be more prepared to utilize elements of yoga responsibly as part of a comprehensive approach to enhance engagement in occupation by people, organizations, and populations to promote their health and participation in life.

Ø  Yoga, a mind-body form of complementary health approaches and integrative health (CHAIH), is designed to bring balance and health to the physical, mental, emotional, and spiritual dimensions of the individual (Iyengar, 1979; Ross & Thomas, 2010; Sharma, Khanna, Bhardwaj, & Raina, 2016).

Ø  Patanjali’s Yoga Sutra outlines an eight limbed path comprised of ethical and moral principles that provide a prescription for living a meaningful and purposeful life (Gard, Noggle, Park, Vago, & Wilson, 2014; Woodyard, 2011).

Ø  In clinical trials, elements of yoga have had positive impacts on neuromuscular and cardiorespiratory conditions (Field, 2011; Galantino, Galbavy, & Quinn, 2008), mental health (Balasubramaniam, Telles, & Doraiswamy, 2013), chronic disease risk factors (Yang, 2007), and overall quality of life (Oken et al., 2006).

Ø  The holistic foundations of occupational therapy and the tenets of yoga parallel with Robert Engel’s (1977) biopsychosocial model of health in that both address the spiritual, psychological, and physical dimensions of health (Brown, 2012; Ross, Bevans, Friedman, Williams, & Thomas, 2014).

Ø  There is a general lack of knowledge regarding the use of CHAIH modalities, such as yoga, among healthcare professionals (Dalmayrac, Quignong, & Baurfreton, 2016).

Ø  Currently, ACOTE® does not require the inclusion of CHAIH content in occupational therapy curricula; however, it is the AOTA’s position that the occupational therapy profession’s philosophical background and client-centered approach to practice supports the use of CHAIH modalities, such as yoga, in practice (ACOTE®, 2012; AOTA, in press; Bradshaw, 2016).

Ø  Without increased knowledge of CHAIH modalities, such as yoga, occupational therapy practitioners may risk being unprepared to meet the occupational needs of clients in today’s evolving healthcare environment (Bradshaw, 2016).

Based on the many potentials for yoga to enhance engagement in occupations, the identified lack of knowledge amongst healthcare practitioners, and the AOTA’s position on the use of yoga within the scope of occupational therapy practice, this study aimed to answer the following research questions: (1) How are occupational therapists and yoga practitioners incorporating yoga into their personal and professional practices; and, (2) What are the perceptions of occupational therapists and yoga practitioners regarding the use of yoga as a self-management strategy to influence health and wellness behaviors?

Ø  Design: This study utilized a mixed methods approach to collect phenomenological data from occupational therapists and yoga practitioners.

Ø  Participants: 20 occupational therapists and 23 yoga practitioners were purposively recruited from

relevant online bulletins, forums, and social media platforms.

Ø  Instrument: Two separate surveys were designed by the researcher and aligned with the purpose of addressing knowledge gaps identified in the literature. Survey questions were inspired by the findings of previous research exploring perceived health benefits of yoga and perceptions of occupational therapists regarding CHAIH inclusion in occupational therapy education (Bradshaw, 2016; Ross, Friedman, Bevans, & Thomas, 2013; Yoga Journal and Yoga Alliance, 2016). A committee of two certified yoga instructors, a licensed occupational therapy faculty mentor with in depth knowledge of yoga, and a licensed occupational therapist certified as a yoga instructor and integrated movement therapist reviewed the survey questions prior to administration for construct validity.

Ø  Data collection and procedures: Prior to data collection, exempt IRB approval was granted by

Belmont University’s Institutional Review Board. Data was collected over the course of one month using anonymous online surveys created with Qualtrics®. Participants were required to provide electronic consent and meet inclusion criteria prior to completing the surveys.

Ø  Data analysis: Quantitative data, including demographic data and responses to dichotomous yes/no questions, were analyzed for descriptive and comparative statistics. Qualitative data collected from open-ended survey questions were coded into themes and subthemes using the data analysis computer software NVivo 10 (QSRInternational, n. d.).

Sample Open-Ended Questions for Occupational Therapists

Sample Open-Ended Questions for Yoga Practitioners

What is your definition of yoga?

In what ways do you incorporate yoga into your personal life?

In what ways do you incorporate yoga into your professional life?

What are some ways that yoga can help individuals improve their quality of life?

What are the barriers to utilizing yoga as a therapeutic intervention within occupational therapy practice?

Quantitative: Based on dichotomous yes/no questions

Figure 1. Yoga Practitioners’ Survey Responses (n=23)

Figure 2. Occupational Therapists’ Survey Responses (n=20)

Qualitative: Four central themes were discovered regarding the use of yoga, which included: (1) the practice of asana, pranayama, and dhyana positively impact the workings of the body, mind, and spirit; (2) yoga increases self-awareness; (3) the practice of yoga affects overall well-being; and, (4) there is a role for yoga in Western healthcare; however, there are barriers to implementing yoga within occupational therapy practice.

Yoga positively

impacts the mind, body, and spirit

• "The effects on general mental health, physical impact and spiritual enrichment motivate me to continue practicing."

Yoga increases

self-awareness

• "Yoga helps individuals improve sense of control over self, get out of the head and into the body, and improve body awareness."

Yoga improves perceived well-being

• “I am more patient, open, and loving. I have more tolerance and I physically am strong with a ton of energy!”

There is a role for yoga in Western healthcare practices

• "Until it’s available through health insurance, many cannot afford it. Also, until it’s ‘approved’ by medical professionals, many still won’t believe in its benefits.”

What motivated you to begin practicing yoga?

What motivates you to continue practicing yoga?

In what ways has yoga influenced your lifestyle choices?

How has yoga influenced your health and medical conditions?

In what ways would you like to see yoga incorporated into Western healthcare practices?

Literature Review

Ø  All participants agreed that yoga was a strategy that could help individuals better self-manage their health and wellness behaviors. They felt that practicing yoga improved mental, physical, and spiritual functions, as well as increased self-awareness, all resulting in positively perceived health and wellness. Moreover, participants believed that there is a role for yoga in Western healthcare practices, including the use of yoga within the scope of occupational therapy practice.

Ø  Several occupational therapists reported utilizing yoga in their professional practice; however, identified lack of space, concerns with billing, and preconceived notions of yoga as barriers to utilizing yoga as a therapeutic intervention.

Ø  Given the vast history of yoga as a self-care strategy, the health benefits identified by participants and the review of the literature, and the innate similarities between yoga and occupational therapy, there is a need to further explore the role of yoga within the scope of occupational therapy practice.

Ø  With increased knowledge of yoga, occupational therapists may be more prepared to suggest yoga to clients as a complement to therapeutic activity, refer clients to qualified yoga teachers and yoga therapists, utilize elements of yoga with clients as a therapeutic medium, and/or address functional limitations that occur for individuals who value yoga as a meaningful occupation.

Implications Clinical practice: Ø  The use of yoga within the scope of occupational therapy practice must be done in the context of

an overall occupational therapy process and plan of care. This requires the occupational therapist to determine if specific elements of yoga practice are congruent with the client’s cultural practices, priorities, or needs; and, that they positively affect health, well-being, and participation in life (AOTA, in press).

Ø  In order to utilize principles of yoga within the occupational therapy process, practitioners are responsible for acquiring specific CHAIH knowledge and the requisite training and credentials required to meet the ethical standards set forth by AOTA’s Occupational Therapy Code of Ethics (AOTA, in press; AOTA, 2015).

Research: Ø  Ongoing research will help to validate the viability of yoga as a therapeutic option suggested or

offered by occupational therapy practitioners to promote individual health and wellbeing. Ø  Occupational performance measures, such as the Canadian Model for Occupational Performance

and Engagement (CMOP-E), could be used to track changes related to yoga practice and provide empirical evidence that supports the use of yoga as an intervention utilized among occupational therapists.

Ø  Future studies are warranted that explore how the inclusion of CHAIH modalities, such as yoga, in occupational therapy education might benefit stakeholders including clients, students, educators, healthcare teams, and the profession as a whole.

Recommendations For foundational knowledge on yoga the following texts are a good place to start: Ø  Bryant, E. F. (2009). The Yoga Sutras of Patanjali. New York: North Point Press. Ø  Iyengar, B. K. S. (1979). Light on yoga. New York: Schocken. Ø  Khalsa, S. B. S., Cohen, L., McCall, T., & Telles, S. (Eds.). (2016). The principles and practice of

yoga in health care. Edinburg: Handspring Publishing. For occupational therapy practitioners interested in integrating yoga and OT practice: Ø  Consider taking a yoga teacher training program. Yoga Alliance offers a comprehensive list of

recommended programs. (https://www.yogaalliance.org/Directory) Ø  Check out continuing education programs that define the benefits of yoga and how it can be

utilized as part of a therapeutic program. (https://otcourses.com/course.php?id=92)

Faculty Advisor: Dr. Teresa Plummer, PhD, MSOT, OTR/L, CAPS, CEAS, ATP

23

20

23

21

23

16

3

2

7

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Could yoga help individuals better self-manage their health and wellness behaviors?

Should yoga be incorporated into Western healthcare practices?

Has yoga affected your quality of life?

Do you suggest yoga to others?

Has yoga influenced your health and medical conditions?

Do you currently incorporate yogic principles as outlined by Patanjali's Yoga Sutra into your life?

Yes No

20

18

15

16

14

9

2

5

4

6

11

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Is yoga a strategy that could help individuals better self-manage health and wellness behaviors?

Do you offer clients self-management techniques to help them manage their health and wellness behaviors?

Do you incorporate yoga into your personal practice?

Do you incorporate yoga into your professional practice?

Do you regularly attend yoga classes or practice yoga at home?

Are you familiar with Patanjali's 8 limbs of yoga?

Yes No References Available Upon Request

Abstract Discussion/Conclusions

Table 2. Demographic Data Summary of Occupational Therapists Frequency Variable No.* % Age (yrs)

18-24 1 5.00 25-34 4 20.00 35-44 5 25.00 45-54 3 15.00 55-64 6 30.00 65-74 1 5.00

Gender Female 19 95.00 Male 0 0.00 Not listed 1 5.00 Primary Ethnic Identity White 18 90.00

Asian 1 5.00 Other 1 5.00 Degree

Associates 1 5.00 Bachelors 4 20.00Masters 7 35.00

Doctorate 7 35.00 Other 1 5.00 Current occupation Occupational therapist 19 95.00 Occupational therapy assistant 1 5 Work setting School 3 15.00 Acute care 4 20.00 Inpatient rehabilitation 3 15.00 Outpatient rehabilitation 2 10.00 Community setting 10 50.00 Other 10 50.00 *Total no. = 20

Table 1. Demographic Data Summary of Yoga Practitioners Frequency Variable No.* % Age (yrs)

18-24 1 4.35 25-34 4 17.39 35-44 12 52.17 45-54 1 4.35 55-64 5 21.74

Gender Female 20 86.96 Male 2 8.70 Not listed 1 4.35 Primary Ethnic Identity White 19 82.61

Asian 1 4.35 Native Hawaiian or Pacific Islander 2 8.70 Other (Multiracial) 1 4.35 Degree

High school diploma 1 4.35 Associates 4 17.39 Bachelors 5 21.74Masters 10 43.48

Doctorate 1 4.35 Professional degree 2 8.70 Years of yoga practice 5-10 9 39.13 10-15 4 17.39 15-20 6 26.09 20-25 2 8.70

>25 2 8.70 Frequency of yoga practice Daily 4 17.39 1-3 times/week 8 34.78 4-6 times/week 6 26.09 I am always practicing yoga 5 21.74 *Total no. = 23

Methods Results

Research Questions

² Research poster presented at the 2017 AOTA conference in Philadelphia, PA. (Figure 1) ² Research manuscript will be submitted to the Annals of International Occupational Therapy in May of 2017. ² In-service presentation created to share occupational therapy concepts, the tenets of yoga, and the innate

similarities between the two practices for a wide variety of audiences. (Figure 2) ² Providing ongoing community-based yoga classes with various populations at non-profit agencies in Seattle,

WA.

Introduction: The number of individuals practicing yoga in America has increased from 20.4 million in 2012 to 36 million in 2016 (Yoga Journal & Yoga Alliance, 2016). Given the drastic increase in participation in yoga, it is important for healthcare practitioners to be informed about the nature of yoga and the evidence of its many therapeutic effects (Woodyard, 2011). Purpose: The purpose of this study was to explore descriptive and phenomenological data on the perceptions that both occupational therapists and yoga practitioners have regarding the use of yoga within personal and professional practice; as well as, the potential for yoga to be used as a self-management strategy for health and wellness behaviors. Methods: A mixed-methods design was used to collect data from 20 occupational therapists and 23 yoga practitioners. All data was collected from anonymous online surveys and coded with the data analysis software Nvivo 10 (QSR International, n.d.). Results: Four central themes were discovered: (1) the practice of asana (postures), pranayama (breathing), and dhyana (meditation) positively impacts the workings of the body, mind, and spirit; (2) yoga increases self-awareness; (3) practicing yoga affects overall well-being; and, (4) there is a role for yoga in Western healthcare; however, there are barriers to implementing yoga within occupational therapy practice. All participants agreed that yoga was a strategy that could help individuals better self-manage their health and wellness behaviors. Conclusion: In light of the vast history of yoga as a self-care strategy, the identified health benefits, and the innate similarities between yoga and occupational therapy, there is a need to explore role of yoga within the scope of occupational therapy practice. With increased knowledge of yoga, occupational therapy practitioners may be more prepared to utilize elements of yoga responsibly as part of a comprehensive approach to enhance engagement in occupation by people, organizations, and populations to promote health and participation in life.

Complete and submit an IRB application to gain ethical approval from Belmont University's Institutional Review Board.

Construct and administer survey materials that explore the perceptions of occupational therapists and yoga practitioners.

Participate in a variety of yoga workshops, classes, and events as a means to collect ethnographic data.

Complete a thorough review of evidence-based, peer-reviewed literature that explores yoga as a therapeutic intervention utilized within Western healthcare.

Investigate a variety of resources, such as podcasts, TED talks, online summits, and videos, to inform the research process.

Figure 2. In-Service Presentation

Figure 1. Poster Presentation

“The aim of education is not only to prepare students for productive careers, but also to enable them to live lives of dignity and purpose; not on ly to genera te new knowledge, but to channel that knowledge to humane ends; not merely to study government but to help shape a citizenry that can promote the public good.”

-Ernest L. Boyer

Belmont University’s OTD Program has incorporated the principles of the Social Change Model of Leadership Development into its curriculum. The Social Change Model views leadership as a purposeful, collaborative, value-based process that results in positive social change. The ultimate goal of the model is CHANGE, which gives meaning to the seven Core Values (7 C’s) outlined in the model (Belmont

²  This project was made possible through the ongoing support and guidance of: ²  Faculty mentor Dr. Teresa Plummer, PhD, MSOT, OTR/L, CAPS, CEAS, ATP ²  Expert mentor Karen Oberg, OTR/L, RYT, IMT (O Therapy Services, LLC) ²  The faculty and resources of the School of Occupational Therapy at Belmont University

² Additional support was provided by: ²  The American Occupational Therapy Association ²  The American Occupational Therapy Foundation

Transacting Valuing

Interacting

Transforming

Figure 3. Reflection on EC

(Adapted from Wagner, Ostick, & Komives, n. d.)

Accreditation Council for Occupational Therapy Education. (2012). 2011 Accreditation Council for Occupational Therapy Education (ACOTE®) standards. American Journal of Occupational Therapy, 66(Suppl._6), S6–S74. doi: 10.5014/ajot.2012.66S6

American Occupational Therapy Association. (2009). Scholarship in occupational therapy. American Journal of Occupational Therapy, 63, 790-796. doi:10.5014/ajot.63.6.790 Belmont University School of Occupational Therapy. (2016). OTD program manual 2016-2017. Retrieved from http://www.belmont.edu/ot/pdf/OTD%20Program%20Manual%202016-20171.pdf Belmont University School of Occupational Therapy. (n. d.) Mission and vision. Retrieved from http://www.belmont.edu/ot/about/mission,_vision_and_goals/index.html Boyer, E. L. (1990). Scholarship reconsidered: Priorities of the professoriate. San Francisco: Jossey-Bass. Gibbs, D., & Plummer, T. (2014). Introduction to scholarship. [PowerPoint slides]. Glassick, C. E., Huber, M. T., & Maeroff, G. I. (1997). Scholarship assessed: Evaluation of the professoriate. San Francisco: Jossey-Bass. McKinney, K. (2007). Enhancing learning through the scholarship of teaching and learning. San Francisco: Jossey-Bass. United States Department of Health and Human Services. 45 CFR § 46: Protection of human subjects. Retrieved from https://www.hhs.gov/ohrp/regulations-and-policy/regulations/45-cfr-46/#46.102 Wagner, W., Ostick, D. T., & Komives, S. R. (n. d.). Leadership for a better world: Understanding the Social Change Model of Leadership Development. College Park, MD: National Clearinghouse for

Leadership Programs. Retrieved from https://nclp.umd.edu/include/pdfs/publications/leadership_for_a_better_world.pdf Woodyard, C. (2011). Exploring the therapeutic effects of yoga and its ability to increase quality of life. International Journal of Yoga, 4(2), 49-54.

doi: 10.4103/0973-6131.85485 Yoga Journal, & Yoga Alliance. (2016). 2016 yoga in America study. Retrieved from https://www.yogaalliance.org/Portals/0/2016%20Yoga%20in%20America%20Study%20RESULTS.pdf

University School of Occupational Therapy, 2016). I have reflected on my Exper ien t ia l Component process using the 7 C’s. (Figure 3)