Yoga and MPA

original researchYoga Reduces Performance Anxiety in Adolescent Musicians Sat Bir S. Khalsa, PhD; Bethany Butzer, PhD; Stephanie M. Shorter, PhD; Kristen M. Reinhardt, BM; Stephen Cope, MSW ABSTRACT Context • Professional musicians often experience high levels of stress, music performance anxiety (MPA), and performance-related musculoskeletal disorders (PRMDs). Given the fact that most professional musicians begin their musical training before the age of 12, it is important to identify interventions that will address these issues from an early age. Objective • This study intended to replicate and expand upon adult research in this area by evaluating the effects of a yoga intervention on MPA and PRMDs in a population of adolescent musicians. The present study was the first to examine these effects. Design • The research team assigned participants, adolescent musicians, into two groups. The intervention group (n = 84) took part in a 6-wk yoga program, and the control group (n = 51) received no treatment. The team evaluated the effects of the yoga intervention by comparing the scores of the intervention group to those of the control group on a number of questionnaires related to MPA and PRMDs. Setting • The study was conducted at the Boston University Tanglewood Institute (BUTI). BUTI is a training academy for advanced adolescent musicians, located in Lenox, Massachusetts. Sat Bir S. Khalsa, PhD, is assistant professor of medicine in the Department of Medicine at Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and research director at the Kripalu Center for Yoga and Health in Lenox, Massachusetts. Bethany Butzer, PhD, is a postdoctoral research fellow at Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts. Stephanie M. Shorter, PhD, Founder, Mind-Body Collective, Austin, Texas. Kristen M. Reinhardt, BM, is a doctoral student in the Department of Psychology at the University of Oregon in Eugene, Oregon. Stephen Cope, MSW, is director of the Institute for Extraordinary Living and Senior Scholar in Residence at the Kripalu Center for Yoga and Health in Lenox, Massachusetts. Corresponding author: Bethany Butzer, PhD E-mail address: [email protected] 34 Participants • Participants were adolescent, residential music students (mean age = 16 y) in a 6-wk summer program at the BUTI in 2007 and 2008. Intervention • Participants in the yoga intervention group were requested to attend three, 60-min, Kripalustyle yoga classes each wk for 6 wk. Outcome Measures • MPA was measured using the Performance Anxiety Questionnaire (PAQ) and the Music Performance Anxiety Inventory for Adolescents (MPAI-A). PRMDs were measured using the Performance-Related Musculoskeletal Disorders Questionnaire (PRMD-Q). Results • Yoga participants showed statistically significant reductions in MPA from baseline to the end of the program compared to the control group, as measured by several subscales of the PAQ and MPAI-A; however, the results for PRMDs were inconsistent. Conclusion • The findings suggest that yoga may be a promising way for adolescents to reduce MPA and perhaps even prevent it in the future. These findings also suggest a novel treatment modality that potentially might alleviate MPA and prevent the early disruption and termination of musical careers. (Altern Ther Health Med. 2013;19(2):3445.) rofessional musicians face many career stressors, such as music performance anxiety (MPA), the unpredictability of schedules for work and travel, and performance-related musculoskeletal disorders (PRMDs) resulting from demanding hours of training and practice.1 Survey studies estimate that as many as 69% of musicians are negatively impacted by MPA2,3 and as many as 87% of musicians experience PRMDs.3-5 Considering that most professional musicians begin their training before the age of 12,6 it would be advantageous to develop preventive interventions for MPA and PRMDs for young musicians. Early implementation of such interventions might support longer as well as more productive and satisfying musical careers. Based on recent research on the effectiveness of yoga and meditation for MPA in adults,7,8 the present study examines whether yoga would be a valuable preventive measure for adolescent musicians, particularly for MPA and PRMDs. P ALTERNATIVE THERAPIES, mar/apr 2013, VOL. 19, NO.2 Khalsa—Yoga Reduces Anxiety in Adolescent Musicians endocrine disorders such as diabetes. and/or pharmacological approaches. adolescent musicians can also suffer from PRMDs. NO. these approaches successfully alleviate MPA in the majority of cases.25 Despite their youth. and (3) improve performance on a variety of cognitive. MPA may become so overwhelming that it eclipses the motivation to continue performing and leads to career termination.18. physical or occupational therapy. obsessive behaviors to counteract anxiety. breathing. control of attention. Ultimately.17. pharmacological agents. however.32. cardiovascular disorders such as hypertension. 2-3 minutes of massage. breath regulation. VOL.37 Yoga therapy—tailoring a custom yoga regimen to treat a client’s specific psychological or physical health concerns—is increasing in popularity and acceptance. modifications to the playing technique or adjustments to posture. The survey also found that 6.5. Galantino.26 Yoga and meditation techniques have been shown to (1) improve mood28. surgery. and 30 minutes of progressive relaxation techniques) was implemented for children in a psychiatric facility.26 Due to the stigma that surrounds PRMDs Khalsa—Yoga Reduces Anxiety in Adolescent Musicians within the realm of professional music.10.1% of adults in the United States (approximately 13 million people) and 2. In 2005.12-15 Anxiety can be crippling to the lives and development of adolescents. is ideal for preventing or counteracting the psychological and physical stressors that professional musicians face. Kenny suggested that the perceived social evaluation of music performance by teachers and audience members may account for the similarity between social anxiety and MPA. carpal tunnel syndrome). and intense arousal of the autonomic nervous system leading to various physical discomforts. and Quinn39 reviewed 24 studies that evaluated the neuromuscular.16 Among the many anxiety disorders that plague adolescents.1% of children and adolescents (aged 0-17) had practiced yoga in the past 12 months. mar/apr 2013.18 Psychological and behavioral approaches include cognitive behavioral therapy. hypnosis.12. psychotherapy.4. and in extreme cases.33. Performance-related Musculoskeletal Disorders (PRMDs) Musicians also commonly experience performance-related musculoskeletal disorders (PRMDs) that diminish their ability to perform. Galbavy. ranging from generalized anxiety disorder to panic disorder. Common PRMDs include pain from overuse and repetitive movements. and musculoskeletal effects of yoga in children and adolescents aged 4 to 17. few musicians seek treatment before their problems become debilitating. including catastrophic and self-defeating thought patterns. and meditation. The widespread benefits of yoga have led to a rapid increase in yoga practice among the general population. other key elements of yoga are meditation. MPA is most similar to social anxiety. most-used complementary and alternative medicine (CAM) practices as well as among the four CAM modalities that demonstrated the greatest increase in prevalence between 2002 and 2007. exercise. In their recent review of adolescent anxiety disorders. and involuntary contractions.19-21 Generally speaking.whereas in 2009 Birdee et al40 reviewed 34 studies on the clinical applications of yoga for both physical health and psychological disorders in the pediatric population (aged 0-21). Beesdo. systematic desensitization. Of particular relevance to the present study. Knappe. potentially resulting in missed professional opportunities.29. Research documenting the therapeutic benefits of yoga has grown steadily over the past 4 decades and now includes controlled clinical trials on psychiatric conditions such as depression and anxiety.15 Treatments to prevent or heal PRMDs include rest.38 Two recent review papers have detailed the growing body of research on the benefits of yoga for children and adolescents. progressive muscle relaxation. Evidence on the psychophysiological benefits of longterm yoga practice supports its use as a therapeutic treatment for many medical conditions. interfering with the very skills necessary to play an instrument.27. Existing treatments for MPA consist of psychological. some evidence suggests that musculoskeletal discomfort and MPA exacerbate one another. In 2008. peripheral nerve disorders (eg.16 MPA’s symptoms in the adolescent population are identical to those seen in adults. Birdee et al outlined a 1992 study by Platania-Solazzo et al41 in which a relaxation-therapy intervention (30 minutes of yoga. and a variety of musculoskeletal and neurological conditions.Music Performance Anxiety (MPA) MPA can involve both cognitive and physical symptoms.36.2 . breathing disorders such as asthma. muscle cramping.9-11 The deleterious effects of persistent anxiety can extend beyond perceived discomfort and can compromise the quality of performance and/or stage presence.23 because many anxiolytic drugs disrupt fine motor control.17. with as many as 17% of music students in secondary schools reporting moderate to severe PRMDs. While physical postures and movements most commonly characterize yoga for the general public.5. the Alexander technique.35 tasks. including biofeedback.34 and physical28. and deep-relaxation exercises. however. (2) increase resiliency from both acute and chronic stress30. In self-reported and observer-rated anxiety scores obtained before and after the intervention. Platania-Solazzo et al found greater declines for the yoga group as opposed to the 35 ALTERNATIVE THERAPIES. A recent survey by the Centers for Disease Control and Prevention38 revealed that yoga was among the top 10.12. cardiopulmonary. behavioral.33. has not proven to be a viable option for many musicians10. and a variety of mind-body techniques.24.33 psychomotor. a holistic mind-body practice.31. The Beneficial Effects of Yoga Yoga. 19.22 Pharmacological treatment. Not surprisingly.17. and Pine reported that 15% to 20% of the adolescent population suffers from an anxiety disorder. such as chest pain and profuse sweating. The children participated in the intervention for one 60-minute session. 11. Relative to the control group. mar/apr 2013. 6-week summer program of the Boston University Tanglewood Institute (BUTI) in 2007 and 2008. in 2009 Khalsa et al8 extended these findings using additional outcome measures and a larger sample of adult musicians attending the same musictraining program. n = 31 or 28. BUTI hosts many internationally renowned. music-training curriculum showed a significant reduction in solo MPA relative to a no-treatment control group.5. Control participants were remunerated with $25 gift certificates to a local shop after the study. both yoga groups showed a trend toward decreased levels of MPA and significant decreases in general anxiety/tension. depression. considered a meditation in motion. have examined the effects of yoga as an intervention for MPA and PRMDs.43-46 A handful of studies have also examined the effects of isolated components of a yoga practice on MPA and musculoskeletal conditions.42.8 In a preliminary controlled study on the effects of an 8-week yoga program for MPA and PRMDs.2 . young adult musicians in an intensive. Demonstrating the efficacy of yoga for adolescent musicians can provide a novel treatment modality to alleviate MPA and PRMDs and potentially prevent the early disruption and termination of musical careers. in some of the classes to engage a sense of fun and to make the yoga practice accessible to a younger population. n = 26 or 12. such as partnered yoga poses and the playing of popular music. VOL. as opposed to the 8 weeks of time available at the Tanglewood Music Center. Each 60-minute class began with breath work. Then Khalsa—Yoga Reduces Anxiety in Adolescent Musicians ALTERNATIVE THERAPIES. The summer schedule spanned only 6 weeks. and it was determined that BUTI’s administration would not respond favorably to a random assignment of students to a no-treatment control group.49 or meditation/guided imagery49 can ameliorate MPA and PRMDs. master-level musicians to instruct its students. in 2008. BUTI is a training academy for advanced adolescent musicians. is an emphasis on an introspective focus as breath and body movements are coordinated. Following this experimental group assignment.9%).50 All yoga classes for both years of the study were led by the same instructor (author Kristen Reinhardt). (2) a yogaand-meditation-only group. and anger at the end of the program. provided by yoga students. All students who responded to this initial invitation were assigned 36 to the yoga group (in 2007.47. The 8-week yoga curriculum used in Khalsa et al’s 2009 study8 was modified to a 6-week program for the present study. n = 53 or 25.4% of BUTI’s total student population. and meditation. located in Lenox. n = 25 or 23.48 regulation of breathing.9% of BUTI’s total student population. Purpose of the Present Study The purpose of the present study is to replicate and expand upon adult research on yoga by evaluating the effects of a yoga intervention on MPA and PRMDs in an adolescent population. mainly to fit into the shorter period of BUTI’s summer schedule. Both Galantino et al and Birdee et al concluded that yoga has beneficial physical and psychological effects for children and adolescents but cautioned that more research is needed due to methodological constraints of the reviewed studies. breathing techniques. a second e-mail announcement recruited control participants (in 2007.7. METHOD Participants Participants were residential music students of a prestigious. and all participants and guardians signed informedconsent forms before the study.10.12. Massachusetts. These studies have suggested that relaxation techniques. Only two studies. accomplished chiefly (1) through the use of different language. in 2008. NO. all students interested in participating in the yoga intervention were placed in the yoga group within the logistical limitations of the available space for yoga practice and of the timing during the summer music program. which was the site of Khalsa et al’s 2009 study. Control participants were recruited separately from students in BUTI’s same summer music program who had not volunteered to participate in the yoga intervention but who were willing to complete the study’s questionnaires in return for a modest remuneration.7 More recently. or (3) a no-treatment control group.47. The hallmark of this style of yoga. Kripalu yoga is a comprehensive set of yoga practices that includes classical yoga postures. BUTI’s students (N = 107 in 2007. Therefore. The researchers assigned participants to one of three groups: (1) a yoga lifestyle group. and (2) the inclusion of yoga games and fun time. The current research team modified the 2009 curriculum to fit a younger population. An affiliate of the Tanglewood Music Center and the Boston Symphony Orchestra. Yoga as an Intervention for MPA and PRMDs Many papers have suggested that maintaining a regular yoga and/or meditation practice prevents or alleviates the psychological and physical problems encountered by musicians. The use of one instructor allowed for the elimination of potential variability in the results that could have arisen from the use of multiple instructors. The research team’s relationship with BUTI’s administration was focused on the benefits of providing the yoga program to the students.control group. Procedure Yoga Protocol. The research component of the program was approved by the institutional review board of Brigham and Women’s Hospital. N = 204 in 2008) were invited through e-mail announcements to participate in Kripalu yoga classes on BUTI’s campus at no cost. however. such as the use of English words only to describe yoga postures as opposed to the 2009 curriculum’s use of Sanskrit names for postures with an older population.5.26. who was skilled in teaching Kripalu yoga and also trained as a classical musician. 19.7%) from BUTI’s remaining population of students. ” Participants rated each item on a 5-point scale (1 = never. one that measures temporary feelings of anxiety (ie. linear.53 The Music Performance Anxiety Inventory for Adolescents (MPAI-A). 5 = always). spine. such as the Wheel pose (Urdhva Dhanurasana). This questionnaire was created specifically for and normalized on adolescents and displays high reliability as well as strong construct and divergent validity.2. such as “I worry that my parents or teacher might not like my performance. 19.4 consists of two separate components with questions evaluating (1) detailed time reporting of daily frequency. long-standing anxiety (ie. visual analogue scales to assess the frequency (0 = never. such as “I try to avoid playing on my own at a school concert.” (2) performance context preference. which allowed her to create an environment in which the students felt at ease. 4 = very much so). Seven of the questions were rated on a 10-cm.participants performed a sequence of yoga postures followed by 5 minutes of supine rest on the floor. can be applied separately (Ackermann. and (3) Khalsa—Yoga Reduces Anxiety in Adolescent Musicians solo performance.” Participants rated each item on a 7-point scale (0 = not at all. Evaluation of the Yoga Program. The control group did not participate in the yoga intervention but was recruited from the same population of BUTI’s summer students. and the group completed the same outcome measures.55 The Performance-related Musculoskeletal Disorders Questionnaire (PRMD-Q).” and (3) performance evaluation anxiety. (2) two 100-mm. cognitive and somatic. participants were asked to consider each item in terms of how they were feeling right now. participants were asked to rate the frequency with which they experienced 20 common. with higher scores indicating greater performance anxiety.51 Over time. such as the Half Pigeon pose (Eka Pada Rajakapotasana) and the Bound Angle pose (Baddha Konasana) as well as more intermediate back-bending poses.54 The State-Trait Anxiety Inventory (STAI). Yoga participants were requested to attend three Kripalu yoga classes each week (out of a possible five weekly classes offered during the 2007 summer session and out of a possible six weekly classes offered during the 2008 session). participants considered each item in terms of how they generally feel. The PRMD-Q displays high reliability and validity in musicians across a range of ages. 20 = maximum effort). OUTCOmE MEASUrES Yoga and control participants completed each of the following self-report questionnaires just prior to the start of the yoga intervention and about 3 days before its end: The Performance Anxiety Questionnaire (PAQ). This final segment included longer holds of all previously taught poses as well as longer hip-opening poses. This questionnaire. I get butterflies in my stomach. mar/apr 2013. 6 = all of the time). such as the Eagle pose (Garudasana) and the Dancer pose (Natarajasana). To measure trait anxiety. intensity. In the final segment of the program. All three components are scored separately. During the second segment. Sample items included: “I feel that I lack confidence” and “I find that I shake. This 15-item questionnaire assesses three components of performance anxiety in adolescents: (1) somative and cognitive symptoms. state anxiety) and another that measures more general. Control Protocol. Meditation (Vipassana style. focusing on awareness of the breath without any Buddhist philosophy or references) was introduced in the third segment of the 6-week curriculum. 100 = maximally severe) of PRMDs. All yoga poses were selected to support and potentially alleviate pain in the main areas of PRMDs (shoulders.52. This questionnaire displays excellent construct validity. performance anxiety symptoms in three contexts: (1) practice. The justification for this late inclusion of meditation is that yoga poses in most yoga philosophies are meant to prepare the body to be still for meditation. 100 = constantly) and severity (0 = none. e-mail). This 40-item questionnaire is made up of two 20-item subscales.4 The full instrument has no overall composite score. The second segment included longer holds of previously taught standing poses as well as more challenging balancing postures. The STAI displays excellent test-retest reliability and internal consistency. The research protocol was identical for students attending both the 2007 and 2008 sessions of BUTI’s training program. wrists. Sample items include “I am tense” and “I am worried. (2) group performance. flow state). VOL. with higher scores indicating greater music performance anxiety. The yoga curriculum was roughly divided into three 2-week segments.” Participants rate each item on a 4-point scale (1 = not at all. visual analogue scale with extremes of 0 = “not at all” to 10 = “very 37 ALTERNATIVE THERAPIES. and duration of practice and performance. and a growing literature exists on the use of this measure. On this 60-item questionnaire. the instructor was able to develop a familiarity and rapport with the students. All yoga participants evaluated the program at its completion by filling out an “Evaluation of the Yoga Program” questionnaire that was specifically created for the purposes of the present study. joint-opening exercises. The first segment of the 6-week curriculum included an emphasis on deep breathing (three-part breath or Dirgha Pranayam). alternate nostril breathing (Nadi Shodhana) was introduced as a stress-relieving breathing practice. The current research team employed only the visual analogue scales and the Borg scale of this instrument to increase simplicity and reduce participants’ burdens.2 . The first segment also included basic standing postures such as Downward Facing Dog pose (Adho Mukha Svanasana) and Warrior I and II poses (Virabhadrasana I and II). created by Ackermann and Adams in 2004. the instructor also incorporated a discussion about optimal performance techniques (ie. at this moment. with a final brief meditation. experience levels. and (3) a numerical Borg scale for perceived exertion during musical practice (from 6 = no effort. such as the Figure Four pose to stretch the hips and low back and supine spinal twists to relieve tension in the low back and hips. and therefore. NO. and performance contexts. To measure state anxiety. such as “Before I perform. and supine postures. and hips). trait anxiety). 2 .9 30:54 63:11:5:3:1:1 42 8 6 4 22 2 7. The qualitative item asked participants to comment on their experience of the program and on anything else they wished to share. These results suggest that the yoga intervention had largely the same effect in both years. the results for the separate analyses are also included in the results section below. For example. Khalsa—Yoga Reduces Anxiety in Adolescent Musicians ALTERNATIVE THERAPIES.3 23 6 6 3 13 7.9 were conducted in the same fashion. baseline score and experimental condition (coded as yoga group = 1.5 29:22 36:9:5:1:0:0 16. 19.5 ± 1. participants were asked (1) about the perceived benefit of yoga and/or meditation in general and as a musician. a series of 12 multiple regression analyses were performed on the subscales of the four outcome variables: (1) PAQ (three subscales). (2) the STAI trait anxiety subscale. Summary of Demographic Data Yoga (n = 84) Age. with baseline scores and condition predicting scores at the end of the program. control group = -1) served as predictors of the scores at the end of the program. Baseline scores for the yoga and control participants in the combined sample were compared using independent samples t tests to ensure that participants were statistically equivalent on all of the study’s measures at baseline. the study protocol was identical for both the 2007 and 2008 samples. in one of the multiple regressions. much so.4 ± 0. RESUlTS Amalgamation of the 2007 and 2008 Samples As described previously. and (4) about their intent to continue practicing yoga and/or meditation. No questions regarding the instructor’s quality or inclusion/exclusion of particular elements of yoga practice were included. NO. STAI trait anxiety.0 ± 2. however. only three instances of differences occurred between the results for the 2007 and 2008 samples that were related to the effect of the experimental condition (ie. y (mean ± SD) Gender. Through the quantitative items. the data from both years were combined into one sample for all of the study’s variables except the PAQ group subscale. (3) STAI (two subscales). VOL. To be inclusive. and (3) the PRMD-Q severity subscale. the participant’s baseline somative/cognitive subscale scores on the MPAI-A and his or her condition were used to predict the participant’s somative/cognitive subscale scores on the MPAI-A at the end of the program. Thus. All of the other multiple regression analyses 38 Control (n = 51) 16. y (mean ± SD) Note: Percussion includes classical percussion. and (4) PRMD-Q (three subscales). (2) about the impact of the practice on overall musical performance as well as on the technical and creative elements of musical performance. n Strings Woodwind Brass Percussion Voice Blank Musical training. mar/apr 2013. The three instances involved (1) the PAQ group subscale. and PRMD-Q severity. (3) about their willingness to recommend yoga to other students at Tanglewood. When the multiple regression analyses (described above) were conducted separately for each year. including baseline scores as a predictor controlled for participants’ baseline scores on each measure and the potential for regression to the mean.7 ± 3. (2) MPAI-A (four subscales). Data Analysis To examine whether end-of-program scores differed significantly between participants in the yoga and control groups. In each analysis.Table 1. which was the case for all of the study’s variables. harp. n (male:female) Race. n (Caucasian:Asian:black:Hispanic:American Indian/ Alaskan Native:other) Instrument.” while the eighth question was open-ended. and piano. yoga group vs control group). to increase statistical power. 60a 13.21 60.99 35.15 ± 24.06 42. Figure 1 shows mean baseline and end-of-program scores for the yoga and control groups in the combined sample on the practice. For the 2007 sample.12 ± 9.61 24. At baseline.39 ± 4.67 ± 22.55 53. and solo subscales of the PAQ as well as scores for the MPAI-A Somative/Cognitive Performance Anxiety subscale.0 ± 2. STAI = State-Trait Anxiety Inventory. Due to the significant differences between the 2007 and 2008 samples on trait anxiety and PRMD-Q-severity difference scores.00 ± 14.04 ± 12.46 ± 9.22a 13.04 ± 10.94 ± 4.01 ± 10.32 ± 11.51a 42.92a 24.72 24.16 ± 18.63a 12.70 ± 11.51 ± 24. a Demographic Data and Descriptive Statistics Table 1 presents a demographic summary of the combined sample. The yoga participants attended an average of 17 classes in total over the 6-week period.66 a Control Baseline Mean ± SD n = 51 38.18 46.11 ± 9.58 ± 26.56 ± 10.48 ± 2.89 46.31a 12. MPAI-A.92 ± 12. STAI.49 41. VOL.51 ± 8.65 ± 9.66 ± 15.36 ± 14.40 ± 4.36 ± 18.88a 41.55 ± 28.33 ± 17.Table 2.3 years.33 8. Seventy-five of the yoga group (89%) and 44 of the control group (86%) completed the Khalsa—Yoga Reduces Anxiety in Adolescent Musicians questionnaires both at baseline and at the end of the program.33 ± 2.58 ± 10.02 ± 3.5 ± 1.05 45. For the 2008 sample. The mean years of musical training for yoga participants were 7. Regression Analyses Table 2 shows the means and standard deviations for the yoga and control groups in the combined sample (2007 and 2008 participants) on the PAQ. group.5 years.58 ± 24.49 40.41 57.45 ± 2.86 59.96 ± 18.01a 18.98 ± 10.20 22.06 20. the combined sample for the 2 years consisted of 84 participants in the yoga group (54 female and 30 male) and 51 participants in the control group (22 female and 29 male). Means and Standard Deviations on Anxiety Measures and PRMD-Q for Combined 2007 and 2008 Samples Yoga Baseline Mean ± SD n = 84 PAQ Practice Group Solo MPAI-A Somative/Cognitive Performance Context Performance Evaluation Total STAI State Anxiety Trait Anxiety 2007 Trait Anxiety 2008 PRMD-Q Frequency Severity 2007 Severity 2008 Exertion 23.76a 17.9 years. The majority of the participants were Caucasian (73% of the total sample).09 21. yoga n = 53 and control n = 26.77 38. Abbreviations: PAQ = Performance Anxiety Questionnaire.25 7.76 ± 11.79 ± 14.58 ± 22.81 ± 11.23 10.9 years.41 ± 4. NO.27 45.11 ± 9.70 45.16 ± 10.40 ± 9.06 27.2 . mar/apr 2013.08 22. MPAI-A = Music Performance Anxiety Inventory for Adolescents. PRMD-Q = Performance-Related Musculoskeletal Disorders Questionnaire.21 ± 12.13 10.96 47.76 ± 4.31 38. 19.89 ± 24.41 37.02 40.67a 39.27 37.26 ± 4.12 17.04a Note: All descriptive statistics are reported as means ± standard deviations for the combined 2007/2008 sample unless otherwise noted by a.53 47.91 ± 11.44 ± 4. these descriptive statistics are presented separately for each sample.37 28.23 19. and the mean years of musical training for control participants were 7. and the mean age of the control participants was 16.07a 36.66 ± 11.02 ± 2.59 7.36 a End of Program Mean ± SD n = 44 35. 39 ALTERNATIVE THERAPIES.4 ± 0.88 47.7 ± 3.70 ± 16.09 ± 12.35 a End of Program Mean ± SD n = 75 33. and PRMD-Q at baseline and at the end of the program.85 27.39 ± 14.41 ± 11.84 ± 25. The mean age of the yoga participants was 16.51 10.89 7.07 ± 8.70a 18. yoga n = 31 and control n = 25.39 8. 68. and Solo subscales of the Performance Anxiety Questionnaire (PAQ) as well as scores for the Somative/Cognitive Performance Anxiety subscale. between the yoga and control participants on end-of-program performance anxiety in practice contexts (b = -.2 . t[62] = -. M = 46. MPAI-A. end-of-program performance anxiety in solo-performance contexts. 2008: b = -. P < . ns).55. P < . Superscript a (a) indicates that the differences between the yoga and control groups for the change in scores from baseline to end of program are statistically significant.12 ± 13. Yoga participants in the 2008 40 sample showed significantly lower end-of-program performance anxiety in group performance contexts.33.19. in group-performance contexts than control participants.01).51.46 ± 9. t[55] = -.05.79.46. than control participants. M = 24. Group.80.01). M = 27.82.91 ± 11.19. except for the PAQ group subscale (data not shown in tables or figures). M = 40. P < .25 (b = -2.15. ns. than control participants. M = 53. yoga participants showed significantly lower end-of-program somative/cognitive performance anxiety.22. When baseline PAQ scores and the participant’s condition (yoga vs control) served as predictors of end-ofprogram PAQ scores for the combined sample.41 (b = -2.001). M = 46. however.39 ± 14. ns). participants in the yoga group showed significantly lower performance anxiety.48. and the total score on the Music Performance Anxiety Inventory for Adolescents (MPAI-A). When baseline MPAI-A scores and condition served as predictors of end-of-program MPAI-A scores in the combined sample. t[55] = . t[118] = -2. Practice Music Performance Anxiety 40 38 36 34 32 48 46 Group Music Performace Anxiety Control a Solo Music Performance Anxiety 62 60 Control Yoga a Control Yoga 44 42 40 Yoga 58 56 54 Baseline End Program 30 28 Baseline End Program 52 Baseline End Program 50 48 46 44 42 40 MPAI-A Total Control MPAI-A Somative/Cognitive Control a MPAI-A Performance Evaluation 11 Control a Yoga a 26 24 Yoga 10 Yoga 9 Baseline End Program Baseline End Program Baseline End Program scores for the MPAI-A Performance Evaluation Anxiety subscale. than control participants.98 ± 10. t[62] = -2.53.09 ± 12.32. Table 3 presents a summary of the regression results for all of the study’s variables. Error bars represent the standard error of the mean. 19.41 ± 10.83. P < . All effects are reported as unstandardized regression coefficients. and total scores on the MPAI-A. M = 40. P < . mar/apr 2013. P < .05). t[62] = -2.50. When the regression analyses were run separately for the PAQ on the 2007 and 2008 samples. t[55] = -2. Mean Baseline and End-of-program Scores Shows the mean baseline and end-of-program scores for participants in the yoga and control groups in the combined 2007/2008 sample on the Practice.40.12. PAQ. Similar to the amalgamated sample.05).Figure 1.89.72. t[118] = -.50 (b = -3. M = 57. Yoga participants Khalsa—Yoga Reduces Anxiety in Adolescent Musicians ALTERNATIVE THERAPIES.36. the effects were largely the same. 2008: b = -2.85 (b = -2. t[118] = -3. both the 2007 and 2008 samples showed no significant differences between the yoga and control participants on end-of-program performance anxiety in practice contexts (2007: b = . No significant differences emerged. Yoga participants also showed significantly lower. however between the yoga and control participants on endof-program performance anxiety in group contexts for the 2007 sample (b = -1. No significant differences emerged. ns). both the 2007 and 2008 participants in the yoga group showed significantly lower end-of-program performance anxiety in solo-performance contexts than participants in the control group (2007: b = -2.13. NO.92 ± 12.03. VOL. t[118] = -3. In addition. scores for the Performance Evaluation Anxiety subscale. 08b 2.06d MPAI-A Performance Context Subscale .59 ± 0.74 ± 0.69 -2. MPAI-A = Music Performance Anxiety Inventory for Adolescents.06d PAQ Group Subscale .07d PAQ Solo Subscale . d P < .10d End-of-program PRMD-Q predicted by baseline PRMD-Q Yoga vs control .21 ± 0. Regression Analysis Results for Combined 2007 and 2008 Samples Scores at End of Program PAQ Practice Subscale PAQ at end of program as predicted by baseline PAQ Yoga vs control .21 ± 0.27 STAI Trait Anxiety Subscale --a -1.90b -2. mar/apr 2013. Khalsa—Yoga Reduces Anxiety in Adolescent Musicians ALTERNATIVE THERAPIES.25 ± 1.86c MPAI-A Performance Evaluation Subscale .12 ± 0.29d -3. b P < .40 ± 0.73 ± 0. VOL. STAI = State-Trait Anxiety Inventory.06d -2.20 Note: All effects are reported as unstandardized regression coefficients ± standard errors. 19.74 ± 0.68 ± 0.52 ± 0.001.88 PRMD-Q Frequency Subscale --a PRMD-Q Severity Subscale --a PRMD-Q Exertion Subscale .22 ± 0.01. NO.52 ± 0.63d STAI State Anxiety Subscale -.79 --a -. these regression results are presented separately for each sample in the Results section.06d MPAI-A Somative/ Cognitive Subscale MPAI-A at end of program as predicted by baseline MPAI-A Yoga vs control . Condition is coded as yoga group = 1.05.53 ± 0. Abbreviations: PAQ = Performance Anxiety Questionnaire.06d MPAI-A Total Score .Table 3. PRMD-Q = Performance-Related Musculoskeletal Disorders Questionnaire.06d -1.70 ± 0.96d STAI at end of program as predicted by baseline STAI Yoga vs control .2 41 .50 ± 1.07 ± 0. c P < . a Due to the significant differences between the 2007 and 2008 samples on trait anxiety and PRMD-Q severity difference scores.06d -.77 ± 0. control group = -1.53 ± 0.02 ± 0. 02.63. t[62] = -. t[116] = -. performance context preference (b = -. When the regression analyses were run separately for the PRMD-Q on the 2007 and 2008 samples.also showed significantly lower end-of-program performance evaluation anxiety. a 6-week yoga and meditation intervention was associated with reduced MPA in adolescent musicians.20.93 cm (data not shown).19. than control participants. Many students also reported that yoga helped them handle the stress of the music program and reduced fatigue as the program became more intense. ns). the technical proficiency aspects of their musical performance—M = 5. t[117] = -.20. When the regression analyses were run separately for the STAI on the 2007 and 2008 samples.2. M = 18. the results revealed that the yoga participants in the 2007 sample showed significantly lower. t[55] = -2.05 [Table 3 does not show data]).16 ± 18. P < . t[53] = -.54. P < . between the yoga and control participants on end-of-program PRMD severity in the 2007 sample (b = -. STAI.12.31. t[62] = -2.31 (b = -4.29. Yogic breathing techniques were particularly helpful in maintaining their stamina during long rehearsal days while also helping them manage performance anxiety and enhance self-confidence. 2 weeks shorter than the interventions used previously. however. For both the 2007 and 2008 samples.61.99.05).84. Several individuals continued yoga practice after the program ended and kept in touch with the instructor to relay the benefits of their practice over time. When baseline state anxiety and condition served as predictors of end-of-program state anxiety in the combined sample.001). t[62] = -2.58 ± 24.51 ± 2. participants reported the lowest levels of performance anxiety while playing in a practice context. mar/apr 2013. both the 2007 and 2008 yoga participants showed significantly lower end-of-program scores than control participants on somative/cognitive performance anxiety (2007: b = -2.8 suggests that it is possible that improvements in MPA might be achieved in relatively short order.82. and planned to continue with a yoga and/or meditation practice as a result of the program—M = 7.63 ± 2. t[55] = -2.07. than control participants.01. The yoga instructor’s qualitative observations.07 cm. 2008: b = -2.77.05) and total MPAI-A scores (2007: b = -3.67.70 ± 16. Music Performance Anxiety (MPA) Not surprisingly.001). however.88.67. t[62] = -2. end-ofprogram.83 cm.12. ns.11 Compared to participants in the control group. 2008: b = -3. The 95% confidence intervals for the average answers to these three questions did overlap with the midpoint of 5 cm.84.48 ± 2. a pattern that is consistent with previous literature in this area. ns) or on the perceived effort required to complete a typical.93.36.05 [Table 3 does not show data]). t[62] = -2.86 ± 2. Participants reported slightly lower scores on the questions that asked if the yoga program improved their musical performance in general—M = 5. ns). total MPAI-A scores. Evaluation of the Yoga Program 42 Most participants found the yoga program beneficial in general—M = 7. ns). based largely on her conversations with the students. performance context preference (2007: b = -. the effects were the same as for the amalgamated sample (data not shown in tables or figures). 2008: b = -.01. No significant differences emerged. and the highest levels of performance anxiety in a solo context. t[78] = -. M = 18.05). P < . than control participants. ns). no significant differences emerged between the yoga and control participants (b = 2.7.21. t[118] = -3. end-of-program. performance evaluation anxiety (2007: b = -1. Yoga participants did not show significantly lower. Yoga participants also showed significantly lower end-of-program.79.05 (b = -1.08. PRMD-Q. were that most participants improved in flexibility and strength and reported diminished physical tension.88 (Table 2) (b = -1. NO.60. ns [Table 3 does not show data]). P < .01.58. would recommend it to other musicians—M = 8. no significant differences emerged between the yoga and control participants on the frequency of end-of-program PRMDs (b = -1. than control participants. M = 40.39 ± 4.70 cm.7. The 95% confidence intervals for each of these questions did not overlap with the midpoint of 5 cm. M = 38. participants in the yoga group reported significantly lower end-of-program performance anxiety in group and solo contexts on the PAQ.94. and the creative/experiential aspects of their musical performance—M = 5. a moderate level of performance anxiety in a group context. 2008: b = -. M = 8.66 ± 15.25.01. the results revealed that the yoga participants in the 2008 sample showed significantly less severe end-of-program PRMDs.18.11 ± 9.02.83. M = 45. P < .76 ± 4. In addition.2 . no significant differences emerged between the yoga and control participants on end-of-program. t[118] = -.27 (b = -3.68 ± 2. P < .50.52 cm and as musicians—M = 6.90. M = 41. t[55] = -. t[55] = -2.87 ± 2.52 cm (data not shown). performance anxiety on the PAQ in a practice context compared to control participants.31 cm.8 This result suggests that yoga may be an acceptable. When the regression analyses were run separately for the MPAI-A on the 2007 and 2008 samples. t[118] = -3. ns [Table 3 does not show data]).05. P < .71. P < . No significant differences emerged. and even enjoyable way for adolescent musicians to manage and perhaps even prevent MPA early in their musical careers. daily. VOL. music-practice routine at end-of-program (b = -. t[55] = -2.79. M = 10. P < . P < .56 ± 10. No significant differences emerged between the yoga and control participants on end-of-program trait anxiety in the 2008 sample (b = -.27. DISCUSSION Consistent with and extending prior research on adult musicians. Because participants reported the lowest levels of performance anxiety on the practice PAQ subscale. When baseline PRMD-Q scores and condition served as predictors of end-of-program PRMD-Q scores in the combined sample. between the yoga and control participants on end-of-program. useful. a floor effect might exist that precluded Khalsa—Yoga Reduces Anxiety in Adolescent Musicians ALTERNATIVE THERAPIES. The 6-week timeframe for the yoga intervention.86. t[134] = 1.21 ± 3. 19. trait anxiety.07. Future research is needed using a larger sample with higher levels of PRMDs as well as a longer yoga intervention to assess the degree and consistency with which yoga can benefit musicians’ musculoskeletal discomfort. Yoga participants. The limitations of nonrandom assignment. would recommend it to other musicians. participants were involved in an intense music fellowship program that became more challenging over time. performance evaluation anxiety. Other feedback on the postprogram evaluation suggested that yoga did not have as much of an impact on the technical and creative aspects of musical performance as it did on potentially alleviating MPA. somative/cognitive performance anxiety. PRMDs Yoga participants in the combined sample did not change from baseline to the end of the program in the frequency or severity of PRMDs or in the effort required to complete a daily music practice routine. such as trembling. one must exercise caution in drawing firm conclusions from this study. Regarding questions assessing whether participants found the yoga program beneficial to themselves as musicians. State and Trait Anxiety Yoga participants did not show significantly lower endof-program state anxiety compared to control participants. Six weeks may not be a long enough time for a yoga intervention to bring about consistent neuromuscular changes. and thus it was somewhat different from what would normally be encountered by musicians under more typical working circumstances. however. Thus. It is also possible that yoga might help reduce the fears that adolescent musicians may have about negative performance evaluations by authority figures such as teachers and parents. however. Yoga and meditation may not only be effective interventions for MPA but also for general. and total performance anxiety than the control group. Limitations The present study should be considered with several caveats in mind. mar/apr 2013. Interestingly. In addition. and fear of failure. While this effect was not statistically significant. demand characteristics. suggesting that the present sample was composed of young. Future studies should examine the effects of yoga and meditation on adolescent musicians in more naturalistic settings. long-standing trait anxiety. endof-program. participants’ low baseline scores may have produced a floor effect that precluded meaningful reductions in PRMDs. should be addressed in future randomized controlled studies. Yoga participants in the 2008 sample. and planned to continue with yoga as a result of the program. showed signifiKhalsa—Yoga Reduces Anxiety in Adolescent Musicians cantly less severe PRMDs at the end of the program compared to control participants. and all of the mean exertion scores were below 14 (possible range 6-20). Perhaps the relatively short intervention used in the present study simply did not allow enough time to fundamentally change preferences for performing in a group versus a solo context. although the results were in the expected direction and are consistent with a positive effect of the yoga intervention. or other nonspecific effects of involvement in an active yoga intervention could account for the findings. On the MPAI-A. and the groups did not differ on any of the measures at baseline. The drop in state anxiety for yoga participants might have reached statistical significance with a larger sample or a longer intervention. suggesting that the groups were very similar to each other. the yoga participants did not show significantly different performance-context preferences at the end of the program compared to control participants. and yoga participants self-selected to participate in the yoga intervention. This finding is consistent with previous studies that have found positive correlations between trait anxiety and MPA. Yoga participants in the 2007 sample showed significantly lower trait anxiety at the end of the program compared to control participants. but not the 2007 sample. a greater number of females (n = 76 for the 43 ALTERNATIVE THERAPIES. VOL. 19. Thus. Other factors. First. These results are also consistent with previous research highlighting the anxiety-reducing effects of yoga in children and adolescents41 and add further credence to the growing yoga-therapy movement The fact that yoga participants in the 2008 sample did not show significantly lower trait anxiety at the end of the program compared to control participants was unexpected and is difficult to explain. the response pattern suggests that yoga may represent a useful and enjoyable way for adolescent musicians to reduce MPA. All of the mean frequency and severity scores for PRMD were below 25 (possible range 0-100).meaningful reductions in performance anxiety. increased heart rate. Yoga Program Evaluation Participants responded positively to the yoga program in a number of ways. participants were not randomized into the control condition. showed a numerical drop in state anxiety from baseline to the end of the program.19. attention effects. such as expectation effects. healthy musicians. One strength of the current study is that the control participants were drawn from the same population of adolescent music students. NO. with the yoga group showing significantly lower.54 as well as the 2009 findings of Khalsa et al8 in which an 8-week yoga intervention was related to decreases in tension and anxiety in adult musicians as measured by the Profile of Mood States questionnaire.2 . whereas control participants showed no such drop. These findings suggest that yoga might be an effective intervention to deal with both the cognitive and somatic symptoms of MPA. The MPAI-A results confirmed those found with the PAQ. Future research should examine this possibility. PRMD severity scores increased from baseline to the end of the program in the 2007 yoga sample. it also warrants further research. Second. It will be important for future research to examine the effectiveness of tailored yoga interventions for trait anxiety as well as specific anxiety and mood disorders. Musikphysiol Musikermed. 26. Malhotra AS.34(3):279-289. Parry CW. 2004. Rampes H. Anxiety Stress Coping. Amadio PC. Psychother Theory Res Pract Train. Yoga and medical sciences. 2004. Medical Problems of the Instrumentalist Musician. Yoga ameliorates performance anxiety and mood disturbance in young professional musicians. J Clin Psychol. and melatonin secretion. A systematic review of treatments for music performance anxiety. 2004. 8. Fehm L. 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Learn at NIS seminars and transform your results · Quick to learn · Easy to integrate · Suitable for all patients · Structural: spinal. eds. and setting effects in instrumental music students. Kenny DT. Arts medicine editorial. 1997. 2000. digestive. Med Probl Perform Art 2005. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. .