Overall Statement

The aim is clearly stated as an investigation for the feasibility and safety of a relaxation-focused yoga intervention on pain and sleep disturbances as a non-therapeutic intervention for patients with rheumatoid arthritis. The study was designed with two groups: 1) patients on standard treatments and yoga for 8 weeks; 2) patients on standard treatments. Participants experienced satisfaction in the yoga intervention with the use of therapeutic tables, props, and teacher-led yoga sessions. Secondary results included improvement in anxiety and depression scores indicating additional benefits in the quality of life for rheumatoid arthritis patients.

Strengths

The strengths of the study include the diversity in references on the topics presented to include 17 referenced yoga studies, 3 on physical activity, 11 on rheumatoid arthritis, and others on study validity, statistical methods, and depression scales to provide a well-rounded approach highlighting the biopsychosocial approach. There are 6 references published in the past 5 years, focused on disability-adjusted life years, statistical computing, yoga for functionality, yoga for pain and sleep, the Delphi survey, and yoga for back pain providing new research supporting the aim of the paper.

Utilizing Ward et al. (2014) and the Delphi standards of musculoskeletal engagement for yoga provides a systematic approach to providing yoga as an intervention. The emphasis in the yoga intervention group on building progressive postures with new postures introduced every 2 weeks and adopting postures with accommodations for participants emphasizes the importance of recognizing disability while providing accessibility to yoga interventions. This is an ongoing challenge in many community yoga classes and this establishes the rigorous training of the yoga instructors. The methodology charts are clear, easy to reference and provide guidance on participation from recruitment to follow up at the end of the study.

The discussion led to additional aspects to the study including participant satisfaction, the use of therapeutic tables and props, yoga teacher engagement and socialization, and the continued desire of participants to seek additional yoga instruction.

Providing suggestions on how to improve methodology provided a clear understanding of weaknesses from the researchers which included difficulty with home practice, adverse events, and difficulty with time management for participants to engage in meditation.

Impact on Yoga as an Integrative Medicine Modality

Due to the high rate of adverse events in rheumatic interventions and low quality of life due to long term disability in rheumatoid arthritis, providing yoga as a non-pharmacological intervention provides autonomy, self-awareness, and engagement in patients’ lives. Yoga is the practice of mind, body, and spirit providing patient-centered care on a holistic model in which many rheumatoid arthritis patients are not exposed to, or given the option to explore. Providing community, a sense of connection, and self-regulated modalities give patients empowerment outside of the difficulties of long-term disability and chronic pain associated with rheumatoid arthritis including an integrative approach to care. By providing standardized interventions in yoga, more providers can become involved, will support the validity, and will refer patients to multi-disciplinary teams to include yoga instructors and yoga therapists. Utilizing multiple modalities from both standard care and alternative methods based on patients’ needs is the foundation of Integrative Medicine.

Improvements

Major Points

1. In paragraph 1, p. 39 of the Introduction, rheumatoid arthritis is briefly and broadly explained. While this is effective for experts in the field of rheumatic disease, providing a clear picture of pathophysiology, symptoms, and impact of rheumatoid arthritis should be included for clarity. This allows the reader to understand the dimensions of the disease state and how the study applies effectively.

2. In paragraph 2 in the Introduction, yoga is briefly and broadly explained with reference to two studies on how the role of yoga impacted post-menopausal women and depression as well as a group of women with RA and pain. I suggest adding a paragraph on the impact of yoga on the biopsychosocial model providing evidence on the HPA-axis system, parasympathetic nervous system, pain, and mood/s utilizing this research and its proposed secondary findings in the study. This will provide a clear understanding of the underlying mechanisms yoga can have as an intervention for other providers. This background information also suggests a secondary aim for the study

3. I am not qualified to comment on the statistical methods.

4. Since the study was done with the aims of improving sleep, I expected to observe more data on the improvement of quality of sleep and reduction of pain at night in the discussion. I suggest capturing this in the discussion as it is important to the aims of the study. For example, this could look like the number of times a participant wakes up, a composite score of pain at night, the # of hours slept, and the ease of falling asleep at night from baseline to completion of the intervention utilizing a self-reported questionnaire. Consider, what is the impact of guided meditation and relaxing-yoga on sleep?

Minor Parts

1. The paper had no errors in accordance with references, typos, missing charts, or grammar.

2. Of interest is the style of yoga used for the relaxation/restorative postures to help gauge musculoskeletal engagement. While the Delphi yoga standards by Ward et al. (2014) are mentioned, according to Ward, “Names of all yoga practices should be clearly detailed in the study write-up,” the type of yoga is not clearly indicated in this study. An example would include a chart using a breakdown of the postures used and the physiological impact/intention of those postures. This could also help evaluate prevention for adverse events, since the study mentioned participants were mostly impacted by increased shoulder pain, providing alterations to lower these occurrences in the future. Without specifics about the yoga intervention, it is difficult to replicate for other studies, or for yoga practitioners to apply to a similar population. Providing additional details also helps practitioners that are not familiar with yoga to understand the mechanisms toward an informed referral for their patients. Since this is a pilot study, I would encourage including specific yoga postures and the progression of practice for future studies to help improve the understanding and applicability of specific yoga styles and postures for patients with rheumatoid arthritis.