written by Jess G. Fiedorowicz, Editor-in-Chief, Journal of Psychosomatic Research, March 2020
The Editor’s Choice – Yoga for Ulcerative Colitis
This quarter’s Editor’s Choice from the Journal of Psychosomatic Research is a secondary analysis to assess a mechanism by which yoga may improve health-related quality of life and disease activity for those with ulcerative colitis. The article, “Perceived stress mediates the effect of yoga on quality of life and disease activity in ulcerative colitis. Secondary analysis of a randomized controlled trial,” by Ana Koch of the University of Duisburg-Essen and her German collaborators used data from a 12 week trial of yoga and meditation to determine whether perceived stress, measured by the Perceived Stress Questionnaire, appeared to mediate the benefits of yoga on outcome (1). The authors provided the following brief summary of their work:
Yoga promotes health-related quality of life and reduces disease activity in ulcerative colitis. However, the modes of action are not fully understood. Within a randomized controlled trial, 77 patients with inactive ulcerative colitis participated in either 12 supervised weekly traditional 90-minute Hatha yoga sessions (N = 39) or in written self-care advice (N = 38). Mediation analyses showed that perceived stress fully mediated the effects of yoga on health-related quality of life and disease activity. Hence, psychosocial risks should be acknowledged and yoga should be considered as a complementary intervention for stressed patients with inactive ulcerative colitis.
Their mediation model assessed the extent to which the effects of the yoga intervention were mediated through an indirect path involving improvements in perceived stress measured at week 12, at the close of the intervention. The outcomes were measured at week 24 and involved health-related quality of life as measured by the Inflammatory Bowel Disease Questionnaire (IBDQ) (2) and disease activity measured by the Clinical Activity Index (3). The results of both models were striking. Perceived stress at week 12 appeared to fully mediate the effect of yoga on both health-related quality of life and disease activity at week 24.
In the original publication of the trial, the yoga intervention produced significant improvements in the primary outcome of health-related quality of life at 12 weeks. The effect size was moderate and sustained over 24 weeks. Similar and sustained effects were observed for the disease activity secondary outcome measure (4). Koch et al. discuss two mechanisms by which yoga may improve health-related quality of life and disease activity in ulcerative colitis (1). The first model involves psychoneuroimmunological pathways triggering inflammation and the second involves perceived stress. The supporting information of the original trial paper reported no changes in measured inflammatory markers (C-reactive protein and erythrocyte sedimentation rate) with the yoga intervention in those with inactive disease (4). This lead Koch and colleagues to conclude that perceived stress may be a more relevant mechanism, which they demonstrated in their Journal of Psychosomatic Research paper. There is other support for this in the literature. A clinical trial by Jedel et al. found that Mindfulness-based stress reduction reduced the severity and frequency of flareups in ulcerative colitis only in the group with high baseline perceived stress (5).
The Journal of Psychosomatic Research is very interested in analyses of experimental data to discern causal mechanisms underlying psychosomatic treatments. Through better understanding of mechanisms, we have the potential to better individualize treatments by recognizing the patients most likely to benefit from a given therapy. Understanding mechanisms also can foster the development and refining of therapeutic interventions. It is much easier to design and power a study to detect changes in perceived stress than clinical outcomes such as flare-ups in a disease like ulcerative colitis. Establishing perceived stress as a full mediator of change facilitates dismantling or optimization studies to develop more effective and efficient therapies to reduce perceived stress. These interventions can then be confirmed in follow-up studies in conditions like ulcerative colitis. Our journal welcomes submissions of any randomized controlled trials and any secondary analyses of such trials to advance the field. For those designing studies, please remember that the International Committee of Medical Journal Editors (ICMJE) requires that clinical trials be publicly registered prior to enrollment of the first participant. The ICMJE utilizes a broad definition of clinical trials. This definition even includes studies without a comparison or a control group. We have had several authors investigating interventions for health outcomes surprised that their submitted work met this definition. For more information to prevent you from being surprised by this requirement, please visit http://www.icmje.org/recommendations/browse/publishing-and-editorial-issues/clinical-trial-registration.html.
- Koch AK, Schols M, Langhorst J, Dobos G, Cramer H. Perceived stress mediates the effect of yoga on quality of life and disease activity in ulcerative colitis. Secondary analysis of a randomized controlled trial. J Psychosom Res. 2020;130:109917.
- Janke KH, Steder-Neukamm U, Bauer M, Raible A, Meisner C, Hoffmann JC, et al. [Quality of life assessment in Inflammatory Bowel Disease (IBD): German version of the Inflammatory Bowel Disease Questionnaire (IBDQ-D; disease-specific instrument for quality of life assessment) — first application and comparison with international investigations]. Gesundheitswesen. 2005;67(8-9):656-64.
- Rachmilewitz D. Coated mesalazine (5-aminosalicylic acid) versus sulphasalazine in the treatment of active ulcerative colitis: a randomised trial. BMJ. 1989;298(6666):82-6.
- Cramer H, Schafer M, Schols M, Kocke J, Elsenbruch S, Lauche R, et al. Randomised clinical trial: yoga vs written self-care advice for ulcerative colitis. Aliment Pharmacol Ther. 2017;45(11):1379-89.
- Jedel S, Hoffman A, Merriman P, Swanson B, Voigt R, Rajan KB, et al. A randomized controlled trial of mindfulness-based stress reduction to prevent flare-up in patients with inactive ulcerative colitis. Digestion. 2014;89(2):142-55.