Occupational therapists’ use of yoga in post-stroke care: A descriptive qualitative study

Abstract

Introduction

Over the past decade, yoga has gained popularity in health care. The benefits of yoga can go beyond the physical to address the psychosocial and emotional. Such gains can be beneficial for people who have had a stroke. As a leading cause of disability, stroke can lead to challenges returning to daily activities. Occupational therapists may use yoga to promote engagement in daily activities after stroke. This study aimed to understand how and why occupational therapists integrate yoga into stroke rehabilitation.

Methods

This study involved occupational therapists practicing in the United States. Ten occupational therapists using yoga in practice participated in a semi-structured interview. Interview data were transcribed and analyzed using deductive and inductive coding. Themes emerged from the data related to the benefits of using yoga in stroke rehabilitation.

Results

According to this study, yoga is currently being used as a treatment technique and merged with occupational therapy. Yoga may promote client-centered recovery; bring “context” to therapy; and address physical, emotional, and psychosocial needs following stroke.

Conclusion

Individuals who have had a stroke may face challenges related to both physical and psychosocial engagement. The use of yoga in occupational therapy may be beneficial after stroke for both physical and psychosocial rehabilitation.

Keywords

Occupational therapy occupational therapist CVA stroke yoga complementary medicine alternative medicine

Introduction

Each year, about 800,000 people experience a new or recurrent stroke (AHA, 2017). Globally, stroke is a leading cause of disability (Thrift et al., 2017), and may lead to: hemiparesis or decreased movement on one side of the body (National Stroke Association, 2017); deficits in communication, cognition, and vision (Gall et al., 2010; Mohapatra et al., 2014); higher instances of mental health challenges (Hackett et al., 2005); and difficulty with emotional regulation and socialization (Garrett et al., 2011). Such deficits impact the whole person and can lead to difficulty participating in daily activities (AHA, 2016). Yoga is a holistic process that is thought to treat the whole person, and may be used for people who have had a stroke as an aspect of rehabilitation. Occupational therapy, being a holistic profession focused on promoting participation in meaningful occupations, may be one profession situated to use yoga in rehabilitation. However, little is yet known about how to integrate yoga into stroke rehabilitation, and especially occupational therapy. The purpose of this study was to survey and interview occupational therapists who use yoga to examine why and how it is used.

Literature review

People who have had a stroke commonly require rehabilitation. Rehabilitation teams consist of several professionals, including occupational therapists. The main focus of occupational therapy is to promote engagement in occupations, or activities that are important to an individual (AOTA, 2014). After having a stroke, many individuals have difficulty participating in occupations that were once easily completed, potentially leading to occupational deprivation (Whiteford, 2000). Occupational therapy following stroke focuses on reestablishing, improving, or compensating for motor, cognitive, and psychological abilities to increase participation in occupations (Gillen, 2015).

There is a growing body of evidence supporting the use of yoga for stroke symptoms (Desveaux et al., 2015; Lazaridou et al., 2013). Individuals who have had a stroke comment on both physical and psychosocial outcomes following yoga (Garrett et al., 2011), for example, yoga is associated with improved balance, mobility, endurance, strength, and dexterity after stroke (Bastille and Gill-Body, 2004; Lazaridou et al., 2013; Lynton et al., 2007;Schmid et al., 2012, 2014). Yoga also has the potential to mitigate mental health challenges, including anxiety and depression (Chan et al., 2012; Schmid et al., 2015). Practitioners using yoga in stroke rehabilitation can modify yoga practices to meet the specific abilities or needs of the individual to promote self-efficacy (Bastille and Gill-Body, 2004). Therefore, the use of yoga after stroke may be a feasible option to include within occupational therapy. Researchers are already exploring the benefits of using yoga in occupational therapy for individuals who have had a stroke (Schmid et al., 2014). According to the American Occupational Therapy Association (AOTA), yoga can be a preparatory task or modality as well as an activity to support engagement in meaningful occupations (AOTA, 2017).

The literature supports the benefits of yoga after stroke; however, studies vary in setting and provide limited description of yoga in treatment. Yoga is currently being used in occupational therapy, but there is limited explanation of why or how occupational therapists use yoga in everyday practice. Therefore, the purpose of this study was to (a) provide insight into occupational therapists’ rationale for choosing to use yoga for rehabilitation after stroke and (b) understand how yoga is viewed and used within occupational therapy.

Method

Design

This was a descriptive qualitative study exploring the experiences of occupational therapists using yoga in practice for clients who have had a stroke in order to understand why and how yoga is used after stroke. The aim was to generate a comprehensive summary of events or experiences as understood by individuals; therefore, a descriptive qualitative study was appropriate (Lambert and Lambert, 2012).

Recruitment and participants

This study involved occupational therapists practicing in the United States. All participants were occupational therapists using yoga with their clients who have had a stroke. Participants were recruited through an online survey shared with yoga and occupational therapy groups and through convenience sampling. All participants were volunteers. To be included in this study, participants had to be practicing occupational therapists for at least 1 year, who identified as someone regularly using yoga in practice following stroke. Occupational therapists who met inclusion criteria and provided electronic consent through the survey were contacted via email for an interview. Ten occupational therapists were recruited through the survey and three additional occupational therapists were recruited through snowball sampling. A total of 10 occupational therapists provided electronic consent and were interviewed for this study. This study was approved by the University Institutional Review Board and all participants consented to this study through the online survey.

Data collection

Data collection occurred during a period of 6 months. Participants first completed the “Yoga in Clinical Practice” online survey, which was created to obtain information on how and why practitioners used yoga in treatment. The survey was distributed through the internet and targeted professional groups including occupational therapists. The survey is part of an ongoing data collection process that will be reported elsewhere; however, for the purpose of this study, the survey served as a recruitment tool and provided participant demographic information.

After completing the survey, participants completed a 30- to 60-minute semi-structured interview. Nine interviews were conducted over the phone and one was conducted in person. Participants were asked 15–20 questions focused on their experience using yoga for their clients who have had a stroke, including why and how the occupational therapists integrated yoga into rehabilitation and changes observed in clients after yoga (Table 1).

Table 1.

Questions used during interviews with occupational therapists.

Interview questions
1. What has influenced your choice to incorporate yoga into practice?
2. How long have you been using yoga in your occupational therapy practice?
3. How is it you came to incorporate yoga into intervention for individuals who have had a stroke?
4. What is your experience with yoga and how has that influenced you?
5. How does your experience influence how you think about/administer yoga?
6. Describe a treatment session where you were using yoga with a client who has had a stroke.
7. How do you incorporate yoga into your session?
8. What has yoga done for your clients who have had a stroke? What are the outcomes that you’ve seen?
9. What may be the benefits and disadvantages of incorporating yoga into treatment for individuals with stroke?
10. What yoga practices/principles do you find most beneficial in treatment sessions for clients who have had a stroke?
a. Are there certain aspects of yoga you use or do not use?
b. What leads you to make these decisions?
11. Do you notice any changes aside from physical following yoga for your clients?
12. Based on your client population, do you feel you have to reframe how you use yoga?
13. How does your setting influence your choice to use yoga/others’ acceptance of yoga in practice?
14. How do your clients respond when you present yoga?
15. What types of reactions do you get from clients when incorporating yoga into interventions?
16. How do you explain what yoga is/how it works? Do you think that is important?
17. Do you prefer to implement yoga in group settings or one on one?
a. If they do both: what do you see as the benefits of one versus the other?
b. If they do group settings: how does the influence of others change outcomes?
18. How do you view the use of yoga within occupational therapy?
19. Do you see any connections between occupational therapy and yoga?
20. Do you talk about yoga theory during intervention? If so, what parts do you use?
21. If you could give any tips to other occupational therapists wanting to use yoga in practice, what would those be?
22. What (if any) knowledge or experience do you recommend practitioners have before incorporating yoga into therapy?

Data management and analysis

All interviews were audio-recorded and transcribed verbatim. An iterative process was used for coding. Researchers included two professors in occupational therapy and two occupational therapy research students. All researchers independently read through and coded each transcript. Codes were created from interview questions, using a deductive approach (Creswell, 2013) (Table 2). Then, researchers came together to discuss codes, further refining the codebook. Disagreements on codes were discussed until researchers reached consensus. As analyses continued, an inductive approach was applied, allowing additional codes to emerge from the data (Creswell, 2013) (Table 3). Once the coding process was complete, researchers came together again to identify reoccurring codes across all interviews. These reoccurring codes were combined into meaningful categories or themes. Direct quotes from participants were used to exemplify themes; pseudonyms were used for each participant.

Table 2.

Preliminary codes based on interview questions.

Question	Deductive code	Quote
What has influenced you to incorporate yoga into your practice?	Initial draw	“I’ve been doing yoga for…10 or 11 years now and it just makes sense to me…I’m just like a big proponent of using modalities that are meaningful”—Kathy
What outcomes have you noticed for people with stroke after using yoga?	Outcomes	“She actually regained sensory functions”—Heather
How do you incorporate yoga into your sessions?	Implement	“Providing a handout for them with pictures is helpful for continuing it in the home program”—Heather
What knowledge or experience do you recommend?	Knowledge/experience	“Understanding which muscles are being active, ways of protecting the body”—Kathy

Table 3.

Sample inductive codes and themes.

Quote	Inductive code	Theme
“Make a modification that’s appropriate for where the individual’s at based on their…flexibility, their balance”—Dalia	How: modify	Yoga promotes client-centered recovery
“It really depends on the person…I let it be client led, what’s most important to them?”—Jessica	How: individualize	Yoga promotes client-centered recovery
“It’s that holistic approach that creates that meaningful activity”—Megan	Influence: meaningful	Yoga brings “context” to therapy
“I use it as a way for [the] client to…continue rehab after their number of visits…to incorporate their affected side into everyday life”—Dara	Influence: continued recovery
“I want them to…take on the work themselves…try to go to a yoga class in the area”—Beth	Influence: community reintegration
“It is really kind of amazing to watch people start to become more in control…getting them out of that fight or flight response”—Angie	Used for: psychosocial	Yoga addresses multiple needs after stroke
“Balance improvements…increased functional use of a hemiparetic limb”—Megan	Used for: physical
“Start with…attention training and mindfulness…using the breath as a tool for attention”—Jessica	Used for: attention

Findings

All (N = 10) participants were white and female and reported having personal yoga experience. Participants’ ages ranged from 30–48 years and participants were from seven different states. The majority of participants identified as registered yoga teachers (80%) and one (Beth) was also a yoga therapist (Table 4). A yoga therapist is trained to use yoga teachings and practices to progress clients with varying disabilities or disorders toward health and wellbeing. Occupational therapists in this sample recommended additional training and knowledge prior to implementing yoga into occupational therapy. Additionally, several occupational therapists discussed how a personal yoga practice for the practitioner was important if choosing to use yoga with clients.

Table 4.

Demographic information.

Participant	Setting	Yoga instructor	Years personally practicing yoga	Years an occupational therapist	Years using yoga in occupational therapy
Heather	OutpatientCommunity	Yes	10–20	1–3	1–3
Amber	Acute	Yes	10–20	4–10	4–10
Mindy	Acute	No	10–20	1–3	1–3
Megan	Inpatient	No	>20	1–3	1–3
Dalia	AcuteInpatientSNFOutpatientCommunityPsychiatric	Yes	>20	1–3	1–3
Angie	AcuteOutpatientPrivate practice	Yes	4–10	10–20	1–3
Beth	Private practice	Yes	>20	>20	10–20
Claire	InpatientCommunity	Yes	10–20	10–20	4–10
Kathy	Inpatient and outpatient neuro-rehab	Yes	10–20	4–10	1–3
Jessica	Outpatient	Yes	10–20	10–20	N/A

Pseudonyms were used for all therapists.

SNF: skilled nursing facility.

Thematic analysis of the data revealed three key themes: (a) yoga promotes client-centered recovery; (b) yoga brings context to occupational therapy; and (c) yoga addresses multiple needs after stroke. Each key theme contained 3–4 sub-themes (Table 5). Themes and sub-themes, illustrated by quotes, address why and how occupational therapists used yoga in stroke rehabilitation and the perceived benefits of yoga from the occupational therapist’s perspective.

Table 5.

Key themes and sub-themes.

Key theme	Subtheme
Yoga promotes client-centered recovery	Yoga is individualized to meet the client’s needs
	Yoga encourages client reflection
	Client-centeredness is influenced by yoga philosophy
Yoga brings context to occupational therapy	Yoga is meaningful
	Yoga is active
	Yoga promotes a lifelong approach to recovery
Yoga addresses multiple needs after stroke	Yoga prepares the body for movement
	Yoga reconnects the mind and body to bring body awareness
	Yoga addresses psychosocial elements
	Yoga supports self-acceptance

Key theme: yoga promotes client-centered recovery

Occupational therapists in this study felt that yoga assisted with individualized treatment. Being client-centered implies promoting autonomy and choice, creating a partnership between client and therapist. Using a client-centered focus, occupational therapists discussed individualizing yoga to each client based on presentation of symptoms, daily environments, and personal needs. Yoga is not “one size fits all”; occupational therapists always brought the focus back to their client and how they felt and experienced symptoms, then used this information to tailor yoga to their client’s current needs. As Jessica said:

It really depends on the person … I do … an in-depth evaluation to see how are they moving … then use that … to create … a change in their body … I let it be client led, what’s most important to them? What do they want to be doing?

Three sub-themes emerged under client-centered recovery: (a) yoga is individualized to meet the client’s needs; (b) yoga encourages client reflection; and (c) client-centeredness is influenced by yoga philosophy.

Yoga is individualized to meet the client’s needs

The unique needs and environments of each client influenced the occupational therapists’ choice to use yoga, and how to introduce and progress through yoga in treatment. Angie shared:

Meet people where they’re at … if someone’s been stuck in a wheel chair … start in the wheel chair … then maybe go to the edge of the mat and do … modified quadruped [table top] … then from there … graduate to standing.

Individualizing yoga involved the use of modifications to match the client’s ability with the yoga pose, allowing the client to feel successful. Occupational therapists suggested making treatment relevant to each client by using specific yoga elements and tailored modifications. For example, Dalia evaluated “flexibility, balance, perception of where they are in space, and body awareness,” then made modifications that aligned with the client’s unique characteristics. Modifications also included the use of props to support participation.

Occupational therapists understood that their client’s abilities and emotional states were subject to change. Megan altered her expectations on a day to day basis to make each session relevant to the client’s present needs. She said:

Meet your patient where they are that day … just because they got up into a great posture [yesterday] … doesn’t mean they’re going to do it the next day … that’s part of yoga … meeting them, and yourself, where you are that day.

Yoga encourages client reflection

Occupational therapists described how yoga supported self-learning by encouraging personal reflection for clients. By allowing clients to communicate and understand feelings, occupational therapists felt they could empower their clients to be in control of their bodies. Client reflection promotes autonomy and permits clients to be the “experts.” Jessica said:

Teach them this process of self-reflection … switch your view point … so they are the expert of their body and you are the learner … ask them questions continually … they become the expert … it really empowers that person.

Similarly, Angie felt that yoga is less about the actual pose and more about “how they feel in it.” She encouraged awareness and attention in her clients by prompting personal reflection both during and after yoga. Occupational therapists used specific cues to cultivate awareness and influenced the client to reflect on how they feel both physically and emotionally during yoga.

Client-centeredness is influenced by yoga philosophy

Several occupational therapists explained the relationship between the philosophies and values of yoga and occupational therapy. Overlapping values included maintaining a holistic view of the individual, promoting community, and encouraging self-acceptance. Angie commented:

Yoga philosophy … does run pretty much parallel to what we do as occupational therapists … the holism, looking at the whole person and in their environment and in their bodies … getting people back into their community and not stuck inside in their homes.

Several occupational therapists felt yoga was intertwined into what they do in treatment and therefore could not be separated from what they did as occupational therapists. For Amber, yoga promoted a “presence” with her clients and influenced how she individualizes yoga. She said:

If someone’s going to sit at the edge of the bed I would … quiet down and talk to them about our goal … ask them to set aside everything … I might say … let’s just practice … in your mind … I want you to completely relax your body and then … guide them step by step.

Key theme: yoga brings context to occupational therapy

Many occupational therapists felt yoga brought context to the rehabilitation process. Context provides a setting or understanding behind a mode of therapy used in treatment. Yoga also provided a background and purpose for what the therapists aimed to accomplish with their clients. For these occupational therapists, yoga brought context to rehabilitation because it provided meaning, was a form of active recovery, and gave the client an activity to continue after rehabilitation. Heather reflected:

I consider yoga to be that purposeful activity … they could do [yoga] at home … it becomes part of their repertoire of what they’re doing in their life to get better.

Occupational therapists chose to use yoga because it could be “fun,” “meaningful,” and “purposeful” compared to other forms of therapy or exercise often used after stroke. Occupational therapists were purposeful in the poses or movements they used to elicit a specific response or target a specific need. Dalia used yoga to be intentional about the muscles she wanted to activate or stretch while also providing variety for the client. For her, yoga was a more engaging activity that targeted the same benefits offered through repetitive movement. She said:

Try yoga as a way to really be specific … and offer repetition … [the patient is] not really focused on “oh my gosh this one muscle is just getting hammered” … they think “gosh we did all these things.”

Context is reflected in three sub-themes: (a) yoga is meaningful; (b) yoga is active and participatory; and (c) yoga promotes a lifelong approach to recovery.

Yoga is meaningful

Several occupational therapists referred to yoga as a meaningful treatment technique because yoga is fun and enjoyable, but also touches on self-care and acceptance. Occupational therapists frequently discussed that they chose to use yoga over other modalities or approaches because yoga created meaning for the client. As Kathy stated:

I’m a big proponent of using modalities that are meaningful to people … I think [yoga is] more enjoyable for patients … it’s so all-encompassing … no matter what my goal is, if I’m doing yoga there’s a way to bring it into it and to them it feels more natural.

Yoga is active

Occupational therapists referred to yoga as an active rather than passive approach. When these occupational therapists spoke about passive approaches, they referred to activities where the client had less control and the therapist was in charge (passive range of motion, repetitious movements). Occupational therapists referred to active approaches as those where the client was physically and mentally engaged in the activity and had greater control of their body. Actively engaging the client also seemed to promote self-efficacy and confidence. Megan used yoga as a way for her clients to actively participate in therapy. For her, yoga was “more than a modality,” but a way for her to empower her clients during therapy. Similarly, Claire said:

We’re going to provide range of motion, but we’re going to have them … aware of what we’re doing … beginning stages would look like gentle range of motion, but over time they will start to assist … learning … “hey I can do this” versus a therapist coming in and physically manipulating.

Yoga promotes a lifelong approach to recovery

Many occupational therapists referenced the extended benefits of yoga, should clients continue to practice. In fact, some occupational therapists introduced yoga to clients with the goal of it becoming a personal practice to promote continued recovery. Occupational therapists also alluded to the barriers of insurance coverage during stroke rehabilitation, discussing how yoga could be a means to continue recovery when insurance coverage ends. Dalia explained:

I use [yoga] as a way for clients … to continue rehab … to make gains and to incorporate their affected side into everyday life.

Megan even included yoga in home exercise programs. She said:

Somebody is not going to go home and … lift their arm above their head 14 times, but they might go home and try and get into warrior two … it’s more of a lifelong approach.

Beth’s main goal was that clients “take on the work themselves” and integrate yoga into their daily routine. She described yoga as an “all day treatment” and taught her clients to use yoga “from the minute they get up” and throughout the day.

Key theme: yoga addresses multiple needs after stroke

Occupational therapists in this study used yoga because it addressed multiple deficits common after stroke, such as changes in physical, emotional, cognitive, sensory, and physiological abilities. As Kathy stated:

When we started doing yoga … she [patient] understood where her body was … she felt like she was able to do more … her balance improved, her coordination improved … the combination of all of them together is a huge benefit of yoga.

Occupational therapists determined which elements of yoga to use based on their client’s stage of stroke recovery. For example, occupational therapists working with individuals after acute stroke primarily focused on breathing, coping strategies, relaxation techniques, and simple movements and stretches. Mindy commented:

Yoga is, for some, a form of exercise that they can conceive of doing in the hospital … anxiety, pain, and low oxygen … that need for stretch for somebody who has been in bed.

Sub-themes identified under this theme included: (a) yoga prepares the body for movement; (b) yoga reconnects the mind and body after stroke to bring body awareness; (c) yoga addresses psychosocial elements; and (d) yoga supports self-acceptance.

Yoga prepares the body for movement

Occupational therapists used yoga to promote and reestablish functional movement after stroke. For Megan, functional, rather than compensatory, movement patterns reestablished movement used in daily occupations. She discussed how functional patterns protect the client’s body and increase their ability to perform necessary movements. She said people after stroke “need to be able to use their arm” in a “normal pattern, not a compensatory pattern.” For Beth, the main purpose of her yoga interventions was “brain retraining” to establish functional movement following stroke. She said:

Let’s say … they want to put a shirt on … a big part of that is the seated yoga … let’s say … we’re working on standing balance … we would be working on warrior one at the sink … as they’re washing dishes.

Occupational therapists chose specific yoga poses to prepare for movements their clients would likely do throughout their day to reinforce muscle memory. Dalia said:

If they have to bend over and get clothing out of the dryer, I might give them a preparatory yoga pose. I say, let’s do this yoga pose … reach in the dryer … pull out some clothes, and you’re going to use that [pose].

Yoga reconnects the mind and body to bring body awareness

Body awareness can be described as understanding where one’s body is in relation to surroundings. This includes midline orientation, proprioception, and kinesthesia. Body awareness deficits may lead to what some occupational therapists refer to as a mind–body disconnect. Heather said:

[Yoga is] a really good opportunity to have them [patient] pay attention … every pose … they can just constantly be checking in with that left hand and then also getting that proprioceptive awareness by weight bearing.

Amber promoted body awareness by using specific language and cues that she attributed to her experience as a yoga teacher. She used cues to help her clients attend to different areas of their bodies before a transfer or action. For example, she discussed cuing her clients to bring their attention to their feet if they are standing at the sink to help with grounding. Many occupational therapists used breath to help with awareness and attention. Jessica said:

Bringing their attention to different sensations … using mindfulness and breath to really try to get the person to respond and improve their awareness and attention … by cultivating that mindfulness … you’re more aware of where your body is in space.

Yoga addresses psychosocial elements

Many occupational therapists used yoga for emotional regulation and management of psychosocial challenges, such as anxiety, depression, stress, anger, or sadness. Occupational therapists promoted emotional regulation by merging breath with movement, relaxation through meditation, and integrating various breathing techniques to control emotions, allowing clients to work through their emotions. Angie said:

People start to become more in control. The first thing is parasympathetic dominance, getting them out of that fight or flight response … and into that relaxation, which actually gives them the ability to do more.

Occupational therapists discussed how emotional regulation strategies are tied to the holistic approach shared between yoga and occupational therapy. As Amber said:

It’s getting back to some of the roots of [occupational therapy] in terms of mental health and the holism and that it’s not just … hemiplegia affecting the reason why they can’t get out of the bed.

Several acute care occupational therapists used yoga for its psychosocial benefits, including attention to breath, mindfulness, and meditation, to reduce anxiety and stress. While these occupational therapists noted that physical movements can be less accessible in acute care, they reported that clients can still benefit from yoga practices, including meditation and breathing, that are beneficial during the early stage of stroke.

Yoga supports self-acceptance

Occupational therapists used yoga as a way to help clients accept a new diagnosis and re-form a personal identity. Yoga promoted self-acceptance through mantras, meditation, and modifications to feel successful. Megan said:

They’re able to handle their panic and their sense of crisis … they’re able to say “all right, this is what happened, this is what is today” … they’re able to give themselves a little grace … meet themselves where they are.

Yoga provided clients with the tools to manage stress and negative emotions which, in turn, increased self-efficacy. Andy said:

Before doing yoga, there was a lot of self-limiting … “no I can’t do that” … a lot of resistance … when we brought the focus back into the breath … they were more open to trying things.

Occupational therapists observed that yoga addressed more than physical movement, which was beneficial during post-stroke recovery to promote self-efficacy when participating in valued occupations.

Discussion and implications

This study provides insight into why occupational therapists use yoga in stroke rehabilitation. To our knowledge, this is the first study describing why and how occupational therapists view and use yoga in stroke rehabilitation. Interestingly, 9 out of 10 occupational therapists in this study were practicing yoga prior to becoming occupational therapists. In fact, several occupational therapists referenced the benefits that yoga offers for them personally as they work with clients, which could influence their decision to use yoga. Many occupational therapists in this study strongly recommended a personal practice for others choosing to use yoga in practice. Additionally, most occupational therapists in this study were also yoga teachers and one was also a yoga therapist. Yoga seemed to not only provide a means of therapy, but also influence the occupational therapists to be present with their clients. This focus on mindfulness for both client and practitioner could be one way yoga is different from other modalities used in treatment.

Several occupational therapists in this study viewed yoga as a medium or treatment technique used in occupational therapy. Yoga was used as a medium presented in one way as a gentle form of exercise adapted to meet the needs of the client. For example, yoga used for gentle stretching or balance. Yoga as a medium was also described as a preparatory activity. Preparatory activities, such as targeting specific muscles during an activity, are those that prepare the client for participation in daily occupations (AOTA, 2014). Describing yoga as a preparatory activity appeared to provide a closer link to daily occupations (for example guiding clients through poses that mimic doing laundry).

Conversely, other occupational therapists spoke about using yoga in combination with occupational therapy, seeming to merge the two together. In this sense, yoga appeared to be intertwined into what these occupational therapists did as therapists and the two practices became inseparable. Yoga seemed to be more than a treatment technique, but a focus for the therapist, influencing their decisions on progression and care. Several spoke about the philosophies of both yoga and occupational therapy, how they seem to go hand in hand and how yoga philosophy was inseparable from how they practiced as occupational therapists. In one qualitative study, Atler et al. (2017) discovered that when yoga was merged with a group occupational therapy intervention (merging yoga and occupational therapy [MY-OT]) following stroke, participants noted increased engagement in everyday activities, a common goal in occupational therapy.

Occupational therapists in this study used yoga in a variety of settings ranging from acute care to home health, indicating yoga could be feasible at all stages of stroke recovery. Occupational therapists adapted yoga based on their client needs (for example by using props, modifying postures, or including seated poses), which appeared to expand the possibilities for using yoga. According to Harris et al. (2019), practitioners using yoga must be able to adapt yoga for people with varying abilities following stroke. Also, Schmid and colleagues (2012) found individuals who received yoga in the chronic phases of stroke reported they would have liked to receive yoga soon after the onset of their stroke. Several occupational therapists in this current study used yoga during acute and inpatient rehabilitation stages of stroke to help with stress and emotional challenges (such as anxiety and depression), improve relaxation through meditation and breathing, and promote simple physical movements. In one qualitative study conducted in inpatient rehabilitation, participants noted how yoga influenced recovery in areas of breathing, relaxation, and psychological wellbeing (Schmid et al., 2015), indicating yoga can be used for more than just physical benefits. Several occupational therapists discussed the eight limbs of yoga (asana, pranayama, etc.), maintaining that bringing focus to the breath is accessible for almost any clients and is an important part of yoga. Often, during acute stages of stroke recovery, the mind and the breath were the first focus for occupational therapists, to help regulate stress and emotions.

The onset of a stroke has been described as a sudden and devastating experience that leads to feelings of loss of control (Garrett et al., 2011). While the most common impairment noted by people who have had a stroke is hemiparesis (NSA, 2017), many individuals also experience cognitive, psychosocial, and emotional challenges (Hackett et al., 2005; Metz, 2007). Yoga may address not only physical, but emotional, cognitive, and personal challenges that are beneficial following any acute event, including, but not limited to, stroke. With stroke, as with many diagnoses, it is not always physical impairments limiting the individual’s ability to participate in daily activities. Also, because yoga targets many impairments, including the physical and psychosocial, it could be appropriate for other acute diagnoses.

The choice to use yoga was a personal one for the occupational therapists, based on their professional experience and the needs of their clients. While the occupational therapists in this study reported positive experiences with yoga, it is important to contemplate that yoga might not be accepted by everyone and practitioners should take care when introducing yoga. According to AOTA (2017), integrating yoga into practice should be done within the context of the setting as well as the values of the profession and the client. It is important as occupational therapists to keep the client’s needs and beliefs in mind when deciding to use yoga. As occupational therapists in this study suggest tailoring yoga to the client, it is equally as important to honor clients who do not wish to use yoga. Also, currently there is no published information about negative views of using yoga held by occupational therapists, and this sample was purposefully chosen because the participants were using yoga in practice. Therefore, we cannot comment on negative views of using yoga in practice.

Several occupational therapists in this study first introduced their clients to yoga as a treatment technique with the end goal of yoga becoming an activity for clients to continue after rehabilitation. While most individuals who have had a stroke are discharged home, only about 25% of those who return home return to prior functioning (Lai et al., 2002). As several occupational therapists discussed, if clients continued yoga, they could continue to work on strength, balance, and emotional regulation, which in turn could lead to increased participation in other activities. Additionally, in one qualitative study, individuals who had had a stroke reported feeling that rehabilitation following their stroke ended abruptly (Garrett et al., 2011). Yoga could provide an opportunity to continue rehabilitation, reintegrate into the community, and engage in activity after clients who have had a stroke are discharged home or when therapy ends. Interestingly, several occupational therapists in this study even viewed yoga as a possible valued occupation for their clients to incorporate into daily routines. People who have had a stroke report how deficits impact all areas of life, including social and leisure opportunities (Hoffmann et al., 2003). Therefore, the inclusion of social and leisure opportunities offered through continued yoga practice could be beneficial for individuals who have had a stroke.

People who have had a stroke have described their experience as a separation of the mind and body (Ellis-Hill et al., 2000). This mind–body disconnect can also be understood in terms of decreased body awareness, especially if they are experiencing neglect, emotional attachment to one’s body, and acceptance of self (Garrett et al., 2011). Occupational therapists in this study used yoga to bring attention to clients’ emotions, sensations, and positions to reconnect the mind and body. Similarly, Schmid et al. (2014) discussed how yoga reconnects the mind and body to increase the individual’s perception of their body and abilities after stroke to improve recovery. In another qualitative study, clients who have had a stroke expressed how yoga helped to reestablish this connection between the mind and body, which promoted acceptance of self and engagement in activities (Garrett et al., 2011). The combination of mind and body is also what occupational therapists in this study saw as one connection between yoga and occupational therapy.

Limitations

The results in this study provide a description of the experiences of a group of occupational therapists using yoga in practice. While this study begins to open a discussion for using yoga in practice, data cannot be generalized to all occupational therapists and all clients who have had a stroke. These results do not aim to represent all occupational therapists, but to describe a sample that are using yoga in practice. Additionally, most occupational therapists in this study identified as registered yoga teachers and many had years of experience in yoga prior to integrating yoga into practice. While these findings serve to describe the experiences of these occupational therapists, the results are not enough to teach other occupational therapists how to integrate yoga into occupational therapy. This sample of occupational therapists recommended having training and experience prior to integrating yoga into practice.

Conclusion

Based on the findings in this study, yoga is currently being integrated into occupational therapy for individuals who have had a stroke. Occupational therapists in this study perceived that yoga is a beneficial addition to stroke rehabilitation because yoga addressed physical, emotional, and mental health while also promoting continued engagement and community reintegration. Yoga, for these occupational therapists, was viewed as both a medium of treatment and a philosophy merged with their occupational therapy practice. Client-centeredness, incorporation of psychosocial and mental health, and matching the activity with the abilities of the individual were regarded as just a few overlapping focuses between yoga and occupational therapy, which may be why these occupational therapists choose to use yoga.

According to the AOTA, integrating yoga into rehabilitation should be done within the context of the setting as well as the values of the profession and the client (AOTA, 2017). Like the occupational therapists in this study, the AOTA also recommends additional knowledge and training prior to implementing yoga into practice to ensure yoga is integrated safely and effectively. Future research should explore how yoga is integrated into different settings and stages of stroke rehabilitation to create guidelines for using yoga for stroke in occupational therapy.

Key findings

Occupational therapists use yoga as a treatment technique and in combination with occupational therapy to guide rehabilitation for people who have had a stroke.

Yoga may be beneficial for individuals who have had a stroke because it addresses the physical, psychosocial, and emotional.

What this study has added

This study describes that yoga may be used in occupational therapy because yoga provides gentle movement and mindfulness, can be adapted to meet individual needs, and offers continued rehabilitation and community integration.

Footnotes

Acknowledgments

We thank the occupational therapists that took the time to share their experience and insight into using yoga in practice. Your knowledge and experience are invaluable.

Research ethics

Ethical approval was obtained from the institutional review board at Colorado State University (38-18H 2017).

Consent

All participants provided written informed consent through the online survey to be interviewed for this study.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Contributorship

Arlene Schmid and Alexandra Andrews were responsible for the development of the research question and applied for IRB approval. All authors contributed to the development of the survey, methods used in the study, and research design. Arlene Schmid, Karen Atler, Caroline Rose, and Alexandra Andrews contributed to the data analysis and findings from the study. Alexandra Andrews wrote the first draft of the manuscript and was primarily responsible for continued edits. All authors were involved in revising the final manuscript and approved the final version for publication.

ORCID iDs

Alexandra P Andrews

Karen E Atler

Caroline M Rose

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