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Yoga and guided meditation in emergency medicine: Impact on stress, anxiety, and well-being
Correspondence to MERVE EKSIOGLU; mervekoyunoglu@gmail.com
[To cite: Ograk OE, Eksioglu M, Ozturk TC, Kaymak BA. Yoga and guided meditation in emergency medicine: Impact on stress, anxiety, and well-being. Natl Med J India. DOI: 10.25259/NMJI_107_2024]
Abstract
Background
We aimed to evaluate the effects of yoga and guided meditation on stress, anxiety, and well-being in emergency medicine residents.
Methods
We randomly assigned 81 participants to yoga, guided meditation, or control using a single-level block randomization design. The yoga group attended Hatha yoga classes twice a week, the meditation group learned the technique with audio recordings for independent practice, while the control group received no training. Anxiety (Beck Anxiety Inventory), perceived stress (Perceived Stress Scale), and general well-being (Adult APGAR [Adult access, priorities, growth, assistance, respon-sibility]) were assessed at baseline, week 3, and week 6.
Results
Significant differences between groups were observed in anxiety scores at the end of 6 weeks (H:15.35, p<0.001). The control group had the highest mean (SD) anxiety score 20.63 (7.70). The yoga and meditation groups showed a significant difference in change in anxiety scores at week 6 (p=0.031). Both intervention groups showed a significant reduction in perceived stress levels compared to the control group (U:22.0, p<0.001; U:147.0, p<0.001) independently. For the APGAR score, the yoga group showed a significant increase from baseline compared to the control group (U:76.0, p<0.001).
Conclusion
Our study suggests that both regular yoga and guided meditation interventions are effective in reducing anxiety and stress levels while improving the well-being of emergency medicine residents. Signifi-cantly, the yoga group showed even greater improvement, underscoring the efficacy of this approach.
INTRODUCTION
Residency training in emergency medicine is a demanding phase of a physician’s career, marked by major physical and psychological challenges. Stress and anxiety are ubiquitous problems among emergency medicine residents, resulting from extended work hours, emotionally charged situations, and the need for rapid decision-making.1,2 Despite the abundance of research highlighting the stressors inherent in emergency medicine, there is a notable gap in comprehensive information regarding effective interventions aimed at improving the emergency medicine residents’ well-being.3
In recent years, cognitive and physical relaxation techniques, such as regular meditation, yoga, and breathing exercises, have been widely studied to support a range of beneficial effects, including stress management, emotional balance, and mental focus.4–6 In the general population, evidence supports the benefits of mind-body interventions such as meditation, mindfulness, and yoga, and their potential to positively impact the health and well-being of healthcare professionals.7,8 A study examining the effects of yoga on the well-being of healthcare workers during the Covid-19 pandemic found significant reductions in stress, anxiety, and depression immediately following the program.5 Studies prove that such practices show promise in helping university students cope with stress, anxiety, and depression.9–11 These methods have been shown to be effective in as less as 6 weeks.12,13 However,research on the effects of these techniques on emergency medicine residents is limited.
Our primary objective was to determine whether sustained guided meditation and yoga over 6 weeks could lead to a reduction in perceived stress and anxiety levels among emergency medicine residents, ultimately contributing to an improvement in their personal well-being.
METHODS
This randomized controlled trial was approved by the Ethics Committee of University of Health Sciences, Fatih Sultan Mehmet Education and Research Hospital (Ethics Approval Protocol Number: 2022/7, Approval Date: 14.04.2022).
First, electronic invitations were distributed to emergency medicine residents via email, using the National Emergency Medicine Association mailing lists, following ethical approval. We targeted emergency medicine residents actively practicing in emergency departments of tertiary care facilities (university hospitals and teaching and research hospitals) in Istanbul.
A reminder email was sent 15 days after the initial invitations to maintain communication. Eligibility of volunteer respondents was assessed after 1 month, when exclusion criteria were established. Exclusion criteria included a history of neoplasia, ongoing cancer treatment, pregnancy or lactation, advanced muscular disease, diagnosed psychiatric illness, chronic medical conditions that limit physical activity (e.g. chronic obstructive pulmonary disease, asthma, coronary artery disease, heart failure), certain medications (psycho-tropics, bronchodilators, beta-blockers), physical limitations that preclude participation in yoga, recent participation in meditation programs, independent meditation practice within the past year, and active participation in yoga and breathing exercises.
Intervention groups: Design and implementation
Before the study began, all participants provided written informed consent and were informed that they could withdraw at any time. The investigator, blinded to participants’ identities, used a computerized random number generator to stratify participants into three groups: the yoga, the guided meditation, and the control groups. The selection of hatha yoga and guided meditation was based on evidence from previous research, instructor qualifications, participant comfort, and a structured approach to practice.13–15
The yoga group participated in twice-weekly, 60-minute gentle Hatha yoga sessions led by experienced yoga teachers with 200-hour International Yoga Alliance certification. Sessions included sun salutations, controlled breathing (pranayama), and mindfulness meditation (dhyana), and concluded with approximately 10 minutes of relaxation (savasana). Participation was recorded via online platforms.
Participants in the guided meditation group underwent online training and received audio recordings for daily guided meditation practice, gradually increasing from 10 to 30 minutes over 6 weeks. Regular online group sessions and individual interviews provided ongoing support and facilitated discussion of participants’ meditation experiences.
The residents in the emergency medicine programme work in shifts. During the study, yoga practices were scheduled on days when they were free from hospital duties. The participants could determine the most suitable time and location for their meditation sessions.
The control group did not receive any specific interventions but participated by completing questionnaires. At the end, they were offered the opportunity to engage in the most effective training program from the intervention groups, acknowledging their contribution. Fig. 1 illustrates the study design.
Variables and measures
All participants used Google forms to complete a survey assessing changes in stress, anxiety, and well-being. The survey included 3 inventories: the Beck Anxiety Inventory (BAI), the Perceived Stress Scale (PSS), and the Adult APGAR (Access, Priorities, Growth, Assistance, Responsibility). The BAI and APGAR were administered at baseline, week 3, and week 6, and the PSS was administered at baseline and week 6.
The BAI is a self-report instrument designed to evaluate the severity of common anxiety symptoms, focusing specifically on somatic manifestations.16 Comprising 21 items, respondents provide their feedback on a 4-point Likert scale, ranging from 0 (indicating the absence of symptoms) to 3 (reflecting severe symptoms). The cumulative score, with a maximum of 63 points, enables a comprehensive assessment of anxiety severity. The suggested clinical classification based on total scores is categorized as follows: 0–7 (minimal anxiety), 8–15 (indicative of mild anxiety), 16–25 (suggesting moderate anxiety), and 26–63 (indicating severe anxiety). Importantly, a clinically significant symptom of anxiety was identified with a suggested cutoff score of 16.17
The PSS functions as a tool to capture an individual’s experience of stress, emphasizing the psychological symptoms associated with it.18 It is designed to assess the extent to which individuals perceive situations in their lives to be stressful. Using a 5-point Likert scale, responses range from 0 (indicating never) to 5 (indicating very often). This study used the PSS-10 variant, which is recognized for its ability to provide a nuanced understanding of respondents’ stress experiences by incorporating a temporal dimension into symptom assessment.19,20 The PSS-10 scoring system categorizes individuals into different levels of stress based on their cumulative scores: 0–7 indicates much lower-than-average stress levels, 8–11 indicates slightly lower than average stress levels, 12–15 indicates average stress levels, 16–20 indicates slightly higher than average stress levels, and >21 indicates much higher than average stress levels.20
The APGAR scoring system was chosen for its ability to effectively predict changes in well-being and because physicians are familiar with a similarly structured assessment that is commonly used to assess the health of newborns. Within the APGAR scoring system, a set of expressions ranging from 1 to 5 was developed for scoring and monitoring, and as an educational tool to increase physician awareness of well-being.21 A cumulative APGAR score in the range of 9 to 10 indicates complete wellness, while 6–8 indicates some imbalances and stresses requiring attention; <5 indicates significant distress or pain and the need for significant adjustments to redirect life toward a focus on healthy living.
Data analysis
Sample size (n=64) was determined using G Power 3.1.9.7 software with α=0.05, effect size=0.37, and power=0.90. The normal distribution of variables was assessed using the Shapiro-Wilk test. For normally distributed data, independent samples t-tests and one-way ANOVA were used for comparisons between groups, while non-normally distributed data were analysed using the Mann–Whitney U and Kruskal-Wallis tests. Comparisons between dependent pairs were made using the non-parametric Wilcoxon Signed Rank Test. Statistical significance was set at p<0.05. The Bonferroni correction was used to control for type I errors in multiple comparisons (α/3=0.017).
RESULTS
Characteristics of participants
After the initial email invitation, 126 volunteers agreed to participate in the study. After 1 month, 45 participants not meeting the study criteria were excluded. Finally, 81 emergency medicine residents met the criteria and actively participated in the study. These participants were randomly assigned to 3 groups using single-level block randomization: yoga (n=27), guided meditation (n=27), and control (n=27). No participants withdrew during the study period. The mean (SD) age of the included participants was 28.64 (2.02) years, there were 44 (54.3%) females. The mean tenure of the participants was 25.91 (14.91) months, and the mean number of working hours per week was 58.38 (9.35).
At the study’s outset, the baseline scores of the participants demonstrated no statistically significant differences in initial BAI (H: 0.44; p=0.802) and Apgar scores (H: 1.57; p=0.457) among the groups. Nevertheless, a significant difference in initial perceived stress levels was observed (F: 4.57; p=0.013), with the control group having the lowest PSS scores (Table 1).
| Scores | Assessment timepoint | Yoga group | Meditation group | Control group | p value |
|---|---|---|---|---|---|
| Beck anxiety inventory | Baseline | 19.67 (10.93) | 18.48 (7.12) | 19.89 (7.75) | 0.802a |
| 3 weeks | 17.48 (9.97) | 17.56 (7.03) | 19.78 (8.16) | 0.350a | |
| 6 weeks | 13.15 (7.05) | 14.70 (5.87) | 20.63 (7.70) | <0.001a | |
| Perceived stress scale | Baseline | 21.26 (6.22) | 20.52 (5.15) | 16.96 (5.32) | 0.013b |
| 6 weeks | 15.96 (6.29) | 18.00 (4.44) | 17.19 (5.15) | 0.375b | |
| Adaptation, partnership, growth, affection, resolve | Baseline | 5.48 (1.31) | 5.74 (1.40) | 5.63 (1.45) | 0.457a |
| 3 weeks | 6.00 (1.24) | 5.85 (1.35) | 5.74 (1.02) | 0.779a | |
| 6 weeks | 7.33 (1.07) | 6.59 (1.25) | 5.78 (1.05) | <0.001a |
a Kruskal-Wallis test b one-way analysis of variance
Post-intervention outcomes
After 6 weeks of intervention, BAI scores were 20.63 (7.70) (control), 14.70 (5.87) (meditation), and 13.15 (7.05) (yoga), indicating a statistically significant difference between groups (H: 15.35; p<0.001), with the control group having the highest mean score. PSS scores at week 6 were 17.19 (5.15) (control), 18.00 (4.44) (meditation), and 15.96 (6.29) (yoga), showing no significant difference between groups (F: 0.99; p=0.375). Mean APGAR scores post-intervention were 5.78 (1.05) (control), 6.59 (1.25) (meditation), and 7.33 (1.07) (yoga), demonstrating a significant difference between groups (H: 21.23; p<0.001; Table 1).
Yoga group. Baseline BAI scores decreased from 19.67 (10.93) to 17.48 (9.97) at week 3 and further to 13.15 (7.05) at week 6. Statistically significant differences were observed between baseline and mid-study (Z: –3.56; p<0.001) and between baseline and week 6 (Z: –4.46; p<0.001; Table 2). PSS scores reduced from 21.26 (6.22) at baseline to 15.96 (6.29) post-intervention, with a significant difference between baseline and week 6 (Z: –4.53; p<0.001; Table 3). APGAR scores increased from 5.48 (1.31) at baseline to 6.00 (1.24) at week 3 and 7.33 (1.07) at week 6, with significant differences between baseline and week 3 (Z: –3.50; p<0.001) and between baseline and week 6 (Z: –4.61; p<0.001; Table 4).
| Group | Pre-mid assessments mean (SD) | Pre-post assessments mean (SD) | ||||
|---|---|---|---|---|---|---|
| Baseline | 3 weeks | p value | Baseline | 6 weeks | p value | |
| Yoga | 19.67 (10.93) | 17.48 (9.97) | <0.001 | 19.67 (10.93) | 13.15 (7.05) | <0.001 |
| Meditation | 18.48 (7.12) | 17.56 (7.03) | 0.100 | 18.48 (7.12) | 14.70 (5.87) | <0.001 |
| Control | 19.89 (7.75) | 19.78 (8.16) | 0.965 | 19.89 (7.75) | 20.63 (7.70) | 0.482 |
| Group | Pre-post assessments mean (SD) | p value | |
|---|---|---|---|
| Baseline | Post intervention | ||
| Yoga | 21.26 (6.22) | 15.96 (6.29) | <0.001 |
| Meditation | 20.52 (5.15) | 18.00 (4.44) | <0.001 |
| Control | 16.96 (5.32) | 17.19 (5.15) | 0.400 |
| Group | Pre-mid assessments mean (SD) | Pre-post assessments mean (SD) | ||||
|---|---|---|---|---|---|---|
| Baseline | 3 weeks | p value | Baseline | 6 weeks | p value | |
| Yoga | 5.48 (1.31) | 6.00 (1.24) | <0.001 | 5.48 (1.31) | 7.33 (1.07) | <0.001 |
| Meditation | 5.74 (1.40) | 5.85 (1.35) | 0.257 | 5.74 (1.40) | 6.59 (1.25) | <0.001 |
| Control | 5.63 (1.45) | 5.74 (1.02) | 0.491 | 5.63 (1.45) | 5.78 (1.05) | 0.425 |
Meditation group. Statistically significant differences were found between baseline and week 6 in both BAI and PSS scores (Z: –4.21; p<0.001; Z: –3.68; p<0.001, respectively; Tables 2, 3). Additionally, a significant increase in APGAR scores was observed between baseline and week 6 (Z: –3.63; p<0.001; Table 4).
Inter-group analysis. The BAI score in the yoga group showed a significant decrease from baseline to week 3 compared to the control group (U: 203.5; p=0.005; Table 5).
The yoga group showed a significant mean decrease of 2.18 points, while the control group showed a mean decrease of 0.11 points over the same period. At week 3, the change in anxiety levels between the yoga and meditation groups showed a significant change (p=0.023). When the control and intervention groups were compared separately (yoga and meditation groups), the BAI scores in the intervention groups decreased significantly from baseline to final measurement (U: 60.5; p<0.001, and U: 121.5; p<0.001, respectively). At week 6, the control group had a mean decrease in anxiety of 0.74 points. The yoga group had a mean decrease in anxiety of 6.52 points. The meditation group also showed a significant mean decrease in anxiety of 3.78 points. At week 6, the change in anxiety scores was also significantly different between the yoga and meditation groups (p=0.031).
When compared separately with the control group, significant changes in PSS scores from baseline to final measurements were observed in both the yoga and meditation groups (U: 22.0; p<0.001 and U: 147.0; p<0.001, respectively; Table 6). At week 6, stress levels decreased by a mean of 2.52 points in the meditation group, by a mean of 5.29 points in the yoga group, and increased by a mean of 0.22 points in the control group. There was also a statistically significant difference between the yoga and meditation groups in the change in stress levels at week 6 (U: 156.0; p<0.001).
The APGAR score increased significantly in both the intervention groups compared to the control group (Table 7). In the yoga group, the score increased significantly from baseline to final measurement (U: 76.0; p<0.001). Similarly, the meditation group showed a significant increase from baseline to final scores (U: 229.5; p=0.015). A statistically significant difference in the change in APGAR scores at week 6 was observed between the yoga and meditation groups (U: 151.5; p<0.001). The mean increase in APGAR scores was 1.85 points in the yoga group, 0.85 points in the meditation group, and 0.15 points in the control group.
| Group | 3 weeks v. baseline | 6 weeks v. baseline | ||||
|---|---|---|---|---|---|---|
| Mean (SD) | Median (IQR) | Pairwise p values | Mean (SD) | Median (IQR) | Pairwise p values | |
| Yoga1 | 0.51 (0.58) | 0 (1) | p1-2: 0.011 | 1.85 (0.77) | 2 (1) | p1-2: <0.001 |
| Meditation2 | 0.11 (0.51) | 0 (0) | p2-3: 0.961 | 0.85 (0.86) | 1 (1) | p2-3: 0.015 |
| Control3 | 0.11 (0.85) | 0 (2) | p1-3: 0.058 | 0.15 (0.99) | 0 (2) | p1—3: <0.001 |
DISCUSSION
Our study demonstrates the impact of yoga and meditation interventions on anxiety and stress levels, providing insight into the outcomes of these mind-body practices. Both intervention groups showed a shift from moderate to mild anxiety after the intervention, in contrast to the control group’s continued moderate anxiety. Clinically significant symptoms, as identified by a BAI cutoff score of 16, were initially present in all groups but decreased after the intervention. Both the yoga and meditation groups had scores below this critical threshold, indicating a significant reduction in clinically significant anxiety symptoms. Baseline APGAR scores indicated potential imbalances and stressors in all groups. Post-intervention improvements, particularly in the yoga group with the highest mean APGAR score, highlight the effects of yoga and meditation and provide valuable insights for personalized intervention approaches.
Originally rooted in spiritual and meditative principles, the concept of yoga has evolved into a comprehensive framework that addresses both the mental and physical dimensions of wellness.22 Research has demonstrated the positive effects of yoga on emotional well-being. One randomized controlled trial compared yoga and mindfulness practices and found significant reductions in depression, anxiety, and stress symptoms among college students.23 Another study examined the effects of a 6-week yoga and meditation intervention on stress, anxiety, and mindfulness in university students using the BAI, PSS, and five facet mindfulness questionnaire (FFMQ). Results showed a significant decrease in anxiety and stress scores after the intervention.15 In our study focusing on emergency physicians, we observed a notable reduction in anxiety scores within the yoga group, suggesting the potential benefits of short-term yoga practice in reducing anxiety levels. This underscores the broader applicability of yoga in addressing the specific challenges faced by healthcare professionals, such as emergency physicians, in managing stress and promoting mental well-being.
There is no clear consensus on the optimal duration and frequency of yoga practice, but more frequent sessions tend to correlate with greater anxiety reduction.24 Previous studies have varied in the duration of intervention (6–24 weeks) and frequency (once a week to daily), with sessions lasting 60–90 minutes.15,24,25 In our study, the yoga group participated in two 60-minute Hatha yoga classes per week for 6 weeks, resulting in perceived stress reduction. Similar studies, with nursing students26 and medical students,27 demonstrated stress reduction with structured yoga programs. Another study evaluating a yoga-based intervention for stress and back pain reported lower stress and pain scores in the yoga group compared to the control group after an 8-week program.28 These findings highlight the use of yoga to reduce stress, although variations in duration and frequency warrant further investigation through large randomized controlled trials.
Emphasizing mental, emotional, and physical states, we selected the adult APGAR scoring system as our primary measure because of its ability to holistically assess well-being.21 Given its empirical derivation and prior use in medical contexts, our review ensured alignment with the goals of capturing participants’ real-life experiences. The use of the adult APGAR scoring system was designed to assess physician satisfaction across key dimensions—emotional access, life priorities, personal growth, help-seeking behaviour, and accountability. The total APGAR score served as a quantitative indicator, providing insight into the overall wellness of the participants. Our study, based on this assessment, sought to understand the impact of yoga and meditation interventions on physician well-being, consistent with our broader goal of promoting holistic health among physicians.
Numerous studies, including randomized controlled trials of nurses and ICU nurses, consistently highlight the positive impact of regular yoga practice on quality of life.26,29,30 Our study is consistent with these findings, showing greater improvements in APGAR well-being scores in the intervention groups practicing yoga and meditation compared to the control group. Notably, the yoga group showed greater improvements, prompting questions about the unique synergistic effects of combining physical postures, breathing techniques, and meditation. Future research should explore these nuances and elucidate the distinct contributions of each component.
Limitations
Our study has several limitations. The use of a randomized, open-label design may introduce subjective effects, potentially influencing partici-pant responses. The relatively brief 6-week follow-up period may limit the depth of understanding of the sustained effects of the interventions. Additionally, the use of subjective self-report measures introduces the potential for response variability, as participants’ ratings may be influenced by personal perceptions. Another limitation is the absence of objective data, such as biological or neurological measures, which could enhance the overall assessment and provide a more comprehensive understanding of the out-comes. Some participants reported difficulties in identifying an appropriate time frame for meditation and a suitable space to meditate at the workplace, leading most to engage in meditation outside of their work hours. Furthermore, a potential limitation is that participants in the intervention groups may have been more enthusiastic, which could affect the generalizability of the findings.
Conclusion
Our study highlights the efficacy of hatha yoga and guided meditation interventions in reducing anxiety and stress levels in emergency medicine residents. Comparison with the control group demonstrated that both interventions were effective and provided benefits to participants. Notably, the yoga group showed a more pronounced improvement, suggesting that Hatha yoga may offer unique advantages in promoting mental well-being among healthcare professionals facing the demanding and stressful environment of emergency medicine.
Conflicts of Interest.
None declared
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