One of our priorities at Umbrella Yoga is to be informed by scientific evidence. We aim to work with the research community to promote our understanding and practice of how yoga can support people with additional needs. Of course, the scientific evidence is constantly evolving and developing, and yoga is a fairly ‘hot topic’ at the moment (exciting!), so the experts don’t always agree! To help us all stay up to date, we will review scientific evidence and share relevant findings and summaries here. This one is a fairly long and detailed read; it’s a summary of a book chapter I wrote (Wilson, 2019).

Autism is a lifelong condition that affects around 1 in 100 people in the UK [1]. The characteristics are both cognitive and physical, i.e. they span both the mind and the body. I’ve been involved in research aiming to understand traits of this condition for over 15 years, and more recently, I have turned my attention to how mind-body interventions – particularly yoga – can benefit the lives and wellbeing of people on the autistic spectrum.

Before I continue, I want to be clear about something: autism is not a ‘disease’ that a person needs (or wants) to be cured from. It is a developmental condition; it is a part of that person – their essence, personality, individuality, soul. So, ‘getting rid of the autism’ is never the goal. However, ask any parent of, or individual with, autism if there are things that they wish could be easier, and I am confident they would say ‘yes’. Many symptoms cause anxiety and frustration, meaning that the person is in a constant state of ‘fight-flight’ mode. This has knock-on effects on quality of sleep, digestion, ability to engage with others, overall wellbeing and quality of life. Combinations of medication and behavioural therapies are generally recommended to manage symptoms; however, effectiveness is highly variable, leading many people to look elsewhere for help.

An estimated 24% of people with autism in Europe [2], and 30% in the US [3], take part in some kind of mind-body practice. Whilst yoga teachers working with people with special needs report compelling outcomes, advice from medical professionals is unclear. Western science and medicine is only just beginning to explore the mechanisms of change and the effects of yoga in the general population (for an excellent review of the physiological and cognitive effects of yoga see Schmalzl et al. 2015 [4]); research with some of the most vulnerable groups in our society – those with additional physical and mental needs – is some way behind. It is time to assess the evidence for the impact of yoga on people with additional needs, so that healthcare providers and yoga teachers alike can provide informed recommendations and offer the best available interventions.

So, what is the evidence for the benefits of yoga in the context of autism?

To date, only 12 studies published in peer-reviewed scientific journals have directly investigated change following yoga intervention [5-16]. Vastly different methods were used, and the purpose of the studies (i.e. expected areas of change) also varied enormously. Sample size ranged from 110 to 7216 participants; timescale of yoga intervention ranged from 4 [10,13] to 82 [7] weeks; control groups (i.e. a comparison group of participants, who were either autistic but did not practice yoga, or were not autistic but did take part in the yoga practice) were included in 6 of the 12 studies. Experimental methods varied from clinical case-study observations [6,7,10,13] to a Randomised Control Trial [15] (the gold-standard of clinical research where participants are randomly assigned to intervention and control groups). All the studies assessed children (age range 5 – 16 years), with none so far focussing on adults. Methods generally involved questionnaires administered before and after intervention, although recent studies included more objective methods such as change in heart-rate variability [14], physical performance [15], and oral hygiene [16]. Various yoga styles were selected; all including some element of asana (posture), breathing exercise, and relaxation. To identify patterns and potential future directions for research and practice, I have compiled results according to four broad outcome goals that, in combination, capture the purpose of each study. [A full table of results of the systematic review is published in Wilson (2018) [17] and available on request].

1. Impact on emotional and psychological function. Three studies investigated change in this domain, with two reporting positive outcomes relating to mood and emotional expression [10,13], and the third reporting no change in either hyperactivity or lethargy [9].

2. Impact on motor performance and physiological function. Six studies measured change in this domain, all of which documented some improvement after intervention [10,11,12,14,15,16]. In comparison to control groups, improvements were reported relating to sleep quality and gastrointestinal problems (including eating habits, diarrhoea, constipation, incontinence) [11,12], heart-rate variability [14], and oral hygiene [16]. One study reported mixed results, with the yoga group showing greater improvements in bilateral coordination and the control group (who completed table-top activities such as construction) showing more improvement in fine motor skills; neither group improved in balance [15]. The fifth study was a case-study, without a control group, and reported improvements in balance and co-ordination of upper and lower extremities [10].

3. Impact on core-features of autism and sensory behaviours. Four studies measured change in core-features and sensory behaviours. One study reported improvements in the yoga group in terms of speech and language, cognitive and sensory awareness, and total autistic symptomology, but no change in either the yoga-intervention group or the control group in terms of sociability [11]. Two further studies reported positive outcomes, although no control groups were included and statistics were not provided [6,7]. The final study reported no changes following intervention in terms of social withdrawal or stereotypic behaviours [9].

4. Impact on challenging behaviours. Six studies targeted some aspect of challenging behaviours [5,7,8,9,10,12]. All reported positive outcomes. Specific improvements were noted in terms of reduced frequency of tantrums, self-injurious behaviours, non-compliance and physical aggression. Four of these included no control group; of the two that did, one reported improvement in ‘behavioural problems’ (unspecified) in the children with autism that participated in yoga but not in the control group (children with autism that continued with usual interventions) [12]. The other reported improvement in the yoga group compared to controls (with autism) in maladaptive behaviours (irritability, agitation), and no group differences in inappropriate speech, non-compliance or off-task behaviours [9].

This initial work suggests that there may be valuable benefits for people with autism in a number of areas, including mood, sleep quality, physiological function, and challenging behaviours. But there is very little evidence for change in other areas, such as social issues and stereotyped behaviours. However, significant results and null results (i.e. no change after intervention, or no differences between participant groups) are important, because, in combination, they tell us which symptoms may be responsive to yoga interventions and which may not. This allows us to develop our understanding of where interventions will be most effective, and offer specific, well-informed advice to patients and parents.

It’s worth stating here that no negative outcomes have been reported. This means there is no evidence to suggest that people with (or without) autism should be discouraged from practicing yoga (although it is always recommended to practice with a trained teacher who can adapt for people with special needs).

Do we even need scientific evidence? If it seems to work – can’t we just keep doing it?

Yoga is an ancient art, science, and way of life, and millions of people practice today simply because it makes them feel good. That’s fantastic – and I don’t think people with autism are any different – so they should keep doing it. In the summary above, I mention ‘positive outcomes, but no control group’ several times. This means we don’t know what led to improvements. It could have been the yoga, or the fact the person was taking part in an activity, or that the person was simply improving over the course of time naturally. Does this matter? For that individual – no. They have experienced improvement in some respect, and it doesn’t really matter what caused it. But for the wider community, it matters very much. In the current economic and healthcare climate it’s essential to develop evidence-based practice if we are to see yoga effectively applied to vulnerable groups in communities, schools, and in the workplace. Also, if we are to gain funding for these practices, with healthcare providers recommending them as intervention options, we need to demonstrate that they work. If people are using yoga-based practices as interventions for life-affecting conditions, it is our responsibility to ensure we give the best possible advice.

In my view, the best way to figure out what works, for who, and when, is for the scientific and yoga communities to come together and conduct sound research in realistic settings. We need to identify the qualities of yoga that are feasible to maintain within rigorous scientific methodologies, and with people who may have limitations in attention, comprehension and physical control. Three achievable goals that will progress the field are:

1. To provide extremely clear, detailed, descriptions of the interventions. This will enable replication of studies (a high priority for developing evidence-based practice) and comparison across studies. Part of the reason for the mixed findings could be that specific aspects of yoga (stretching vs. breathing) have effects on particular symptoms (e.g. motor control vs. anxiety); without exact details of the interventions, it is impossible to accurately pick out which aspects that are having which effects.

2. To develop more objective, robust tools for measuring change. For this, inspiration can be found in studies of the effects of yoga in non-autistic participants. For example, markers of stress have been recorded by measuring salivary cortisol levels [18], or serum cortisol measurements [19]. Inventive methods have been used to investigate proprioception (awareness of physical position of own body) and performance on perceptual tasks [20]. Objective tests of executive function [21,22], visual attention [23], and visual reaction time tasks24, have also been used successfully. These studies have produced promising results indicating significant benefits of yoga that may well be applicable to people with autism – but the evidence is not there yet.

3. To clarify the intended outcome. Yoga is no panacea, and for the purposes of research we must be clear about which symptoms or general aspects of functioning we are expecting to change. Two avenues that are particularly worthy of research efforts are issues with sensory perception and proprioception in autism. Both are areas people with autism struggle with. Theory and clinical experience suggest yoga may be effective, but the research has yet to investigate this. Also, whilst there is mounting evidence that yoga can calm the central nervous system and reduce the experience of stress in the general population [25], evidence for these effects in the context of autism is still in its early stages. Finally, the benefits of yoga for adults on the autistic spectrum has yet to explored.

I’m a yoga teacher and a strong believer in the powerful and positive effects that this ancient practice can have on anyone. In my opinion, people with autism and other conditions may well be the people that could benefit the most from regular and appropriate engagement with mind-body practices. But I’m also a scientist, and I want to see the evidence. Anecdotal reports suggest that yoga can be an enjoyable and positive experience for people with autism. This breaks down one common barrier for scientific research, as participants are likely to be willing to get involved with trials and interventions. Gradual improvements in understanding the mechanisms of change, as well as in methodology, will go hand in hand with better agreement across the field to clarify goals and purposes of this research.

Ultimately, we strive to develop effective practices for people on the autistic spectrum, and continued research is essential in order to adequately test these effects and enable us to offer clear advice on the benefits of yoga in this population.

 

REFERENCES

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