Yoga versus education for Veterans with chronic low back pain: study protocol for a randomized controlled trial

Background Chronic low back pain is the most frequent pain condition in Veterans and causes substantial suffering, decreased functional capacity, and lower quality of life. Symptoms of post-traumatic stress, depression, and mild traumatic brain injury are highly prevalent in Veterans with back pain. Yoga for low back pain has been demonstrated to be effective for civilians in randomized controlled trials. However, it is unknown if results from previously published trials generalize to military populations. Methods/design This study is a parallel randomized controlled trial comparing yoga to education for 120 Veterans with chronic low back pain. Participants are Veterans ≥18 years old with low back pain present on at least half the days in the past six months and a self-reported average pain intensity in the previous week of ≥4 on a 0–10 scale. The 24-week study has an initial 12-week intervention period, where participants are randomized equally into (1) a standardized weekly group yoga class with home practice or (2) education delivered with a self-care book. Primary outcome measures are change at 12 weeks in low back pain intensity measured by the Defense and Veterans Pain Rating Scale (0–10) and back-related function using the 23-point Roland Morris Disability Questionnaire. In the subsequent 12-week follow-up period, yoga participants are encouraged to continue home yoga practice and education participants continue following recommendations from the book. Qualitative interviews with Veterans in the yoga group and their partners explore the impact of chronic low back pain and yoga on family relationships. We also assess cost-effectiveness from three perspectives: the Veteran, the Veterans Health Administration, and society using electronic medical records, self-reported cost data, and study records. Discussion This study will help determine if yoga can become an effective treatment for Veterans with chronic low back pain and psychological comorbidities. Trial Registration ClinicalTrials.gov: NCT02224183 Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1321-5) contains supplementary material, which is available to authorized users.

Welcome to the Veterans Back to Health study! Veterans Back to Health is a comparative effectiveness randomized controlled trial (RCT) funded by the National Institutes of Health (NIH) and National Center for Complementary and Integrative Health (NCCIH). The study compares two interventions -yoga and education -for the treatment of chronic low back pain (cLBP) in a U.S. Veteran population. CLBP is a widespread issue that affects up to 10% of U.S. adults and results in over $50 billion per year in direct health care costs. CLBP is especially prevalent in Veterans; it is the most common pain condition in the military, and causes substantial physical and psychological suffering, reduction in force readiness, and high economic cost to the military. Several recent studies suggest yoga is an effective treatment for the physical pain caused by cLBP, but yoga may have additional psychological and economic benefits. These benefits include improved mood, stress reduction, and lower health care costs. Education on self-care for cLBP has also been studied and has been found to improve patient outcomes. Education can come in various forms, such as provider counseling, written materials, and/or support. While both yoga and education have been shown to be effective in treating cLBP in civilians, no study has compared the effects of yoga and education in a Veteran population. Identifying new safe and effective alternatives to pain medications that address the physical and psychosocial dimensions of cLBP in the highly affected Veteran population is urgently needed. This study was designed to address this important gap in research. Veterans Back to Health will compare two treatment groups: 1. A standardized 12-week yoga protocol delivered in a class format and supplemented by home practice 2. An education program that includes a comprehensive book on evidence-based self-care approaches for management of LBP supplemented by newsletters The major outcomes of interest in the study are back pain intensity and back-related function.
Medication use, quality of life, satisfaction, psychological parameters, and cost are some of the other important outcomes that will be measured.
We have designed a hatha yoga protocol specifically for this study. An earlier version of the yoga protocol was developed in 2006-07 by an expert panel after a systematic review of lay and scientific literature on yoga and low back pain. Panel members had experience in several styles of hatha yoga. This protocol was used in a 2007 pilot study of yoga versus usual care for 30 patients with cLBP. It was further refined through a 2012 yoga dosing study, where 95 participants were randomized to either once-weekly or twice-weekly yoga classes. This protocol was then adapted for use in a large study for 320 participants that compared yoga, physical therapy, and education. In order to further adapt the yoga protocol to a Veteran population, a panel of individuals with expertise in working with Veterans met to discuss additional modifications. Learning how to teach the protocol and adhering to the protocols described herein are essential for the study to be valid and the results generalizable.
In order to give your best effort to the study, it is critical to take care of yourself by taking the time to eat properly, get enough sleep and taking personal time. Make sure you have time before class to prepare yourself so you are ready to give each class your best. Reading this manual thoroughly and making sure you know the lessons, postures and modifications will help you to guide Veterans safely through the study. For interested instructors, this manual provides The Veterans Back to Health study is a 24-week comparative effectiveness randomized controlled trial of once per week yoga classes versus an educational book on self-care for chronic low back pain (cLBP) in 120 Veterans recruited from the Bedford VA Hospital. week trial starts with an initial 12-week intervention period followed by a 12-week follow-up period.
For the 12-week intervention period, Veterans are randomized in a 1:1 ratio into (1) a standardized once-per-week hatha yoga class supplemented by home practice; or (2) education delivered through a self-care book supplemented by newsletters. The study co-primary endpoints are the Defense and Veterans Pain Rating Scale and back-related function measured using the 23-question modified Roland Morris Disability Questionnaire. Yoga participants receive yoga materials (i.e., mat, block, strap) and videos to help them with home practice. Education participants receive The Back Pain Helpbook and newsletters every 3 weeks.
For the 12-week follow-up period, Veterans will be encouraged to continue with their yoga home practice or following the recommendations from the book on their own, without direct instruction.
The diagram below illustrates the overall study design:

Study-Specific Training
All yoga teachers on the yoga study team have substantial professional experience in teaching yoga and specifically those with back pain. Training specifically for this study therefore is mostly focused on learning the specific treatment protocols used and how to best teach to Veterans. These may be more or less familiar to each yoga teacher, depending on his or her own educational background and professional experience. This manual is only a part of the preparation for this study. Study-specific training each yoga teacher must complete to participate in the study includes the following steps: 1. Read this training manual thoroughly.
2. Complete training webinars provided by Warriors at Ease and participate in a live group discussion about low back pain and teaching yoga to Veterans.
3. Attend a day-long in-person training on the study yoga protocol.

Data Collection
The data for this study will be collected by the study staff, not the yoga teachers. Data collection by the research staff usually occurs before yoga class and is conducted in such a way to minimize any interference to the class. However, we do ask participants to fill out a Home Practice Log each week and submit it when they attend class (see p. 7). Study staff will be available to collect these logs, but yoga teachers should collect any remaining logs that are not given directly to staff or are completed after class. Yoga teachers should encourage participants to complete logs truthfully and regularly. They can explain that these logs help staff get a better idea of how much practice participants are able to do and better understand how yoga helps back pain. Blank logs will be available.
Yoga teachers will also be responsible for taking attendance at each class. Veterans in this study will receive transportation reimbursement for each yoga class they attend. Study staff will hand out travel reimbursements (in the form of gift cards) each week at yoga classes. Keeping track of attendance and transportation allowances is very important for the research study and every effort should be made to ensure it is done accurately.
After class, yoga teachers will have an opportunity to fill out a Yoga Teacher Notes sheet. Teachers can write down any relevant notes and observations about the participants, the yoga protocol, and/or their own reflections about the progress of the class. These may be read by research staff but will be kept with the yoga supplies for teachers to refer back to, if needed.
Lastly, yoga teachers will be responsible for contacting research staff if they learn of any potential adverse events. An "adverse event" is defined as any untoward medical occurrence, such as illness or injury, regardless of relation to the study or yoga practice. Teachers are encouraged to call staff immediately if they become aware of any adverse events, whether they have occurred during class or outside of class.
Veterans will be encouraged to practice for 30 minutes each day on days when they do not attend class. They will be provided with a participant handbook, yoga mat, block(s), and strap to aid home practice. Members of our study team have worked with NKP Media, Inc. to write, film, and produce a series of yoga home practice videos specifically featuring Veterans practicing the yoga study protocol. Yoga participants will be given a specific link to where the videos will be placed online. If Veterans report that they do not have consistent internet access at home, DVDs will be provided with the videos.
We will ask yoga participants to record their home practice on a Home Practice Log and turn in their completed logs each week when they attend yoga class. Home Practice Logs will be given to yoga participants with their home practice supplies after randomization, so participants should have enough logs to fill out at home. However, yoga teachers should have blank logs on hand when participants come to class, in case they forgot to bring them from home or need to take more to fill out.
After class, yoga teachers should remind participants to turn in their completed Home Practice Logs and practice at home each day if possible. Yoga teachers should also encourage participants that did not already turn in a completed log to fill one out before leaving. All collected logs should have the participant's name written at the top, otherwise the staff will not be able to tell who the log belongs to.
Here is an example of what a completed Home Practice Log might look like:

Foreseeable Absences
Your commitment to be present and teach at all assigned yoga class is critical for the participants and success of the study. However, we do understand there may be unusual or unforeseen circumstances necessitating that you miss class. Should you need to be absent from a class, please notify Dorothy Plumb (contact information on p. 4) at least two weeks prior to the class date. She will send a substitute request email to the participating yoga teachers to arrange for an alternate. If no one has responded within 48 hours, she will follow up with phone calls to find a fill-in.

Sickness
If you are ill and unable to teach a class, please do your best to contact Dorothy Plumb at least 24 hours in advance. If this is not possible, notify Dorothy no later than 9:00 AM the day of class if you teach in the evening or no later than 12:00 PM the day before class if you teach in the morning. She will try to arrange for a substitute teacher for your class.

Emergency
In the rare event of an emergency the day of a class, please call Dorothy Plumb. Please do not use email, text messages, or voicemail in the event of an emergency.

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© Boston Medical Center Veterans Back to Health Trial Low back pain (LBP) is the most common type of pain in the United States, 1,2 resulting in substantial morbidity, 3 disability, 4,5 and cost 6,7 to society. Approximately one-fourth of U.S. adults experience LBP at least one day over a three-month period. 2 LBP accounts for 34 million doctor visits with family physicians and primary care internists each year. 3 Annual direct costs for LBP care in the U.S. are more than $50 billion and indirect costs (e.g., limited productivity) are estimated to be even greater. 8 Back pain patients incur up to 75% more medical expenditures than patients without back pain. 6,7 Back injury is the leading and most expensive cause of workers' compensation claims in the U.S. 4,5 The cost of chronic pain in the U.S. is an estimated at $560 to $635 billion annually. 9 Chronic low back pain (cLBP) lasting more than 12 weeks affects an estimated 5-10% of U.S. adults. 1,2,5 Physicians identify a definite anatomic source for back pain in only a small minority of patients. Examples include a large herniated disc, spinal canal stenosis, or vertebral compression fracture. The majority of patients however are classified as having non-specific cLBP. 1 Non-specific cLBP accounts for a majority of back-related health expenditures.
CLBP is a complex condition; 1 the causes, mediators and mechanisms are multiple but poorly defined. CLBP results from factors in multiple interrelated domains (e.g., physical, mental, emotional, social, cultural, spiritual), and also has symptomatic manifestations in multiple domains. 10 To best treat cLBP and its related conditions, a treatment that can address more than one domain may be more helpful than a treatment such as pain medication that addresses only the physical domain. Thus, the role that psychology plays in treatment, especially for those individuals without a clear explanation for the cause of their pain, should be addressed.

Anatomy of Non-Specific Low Back Pain for Yoga Teachers
Muscles in the back, abdominals, hip, and legs work together to support the spine. Back muscles and abdominal muscles tend to weaken with age since many of them are not used often in day-to-day activities. Similarly, an LBP episode that lasts for more than two weeks can lead to muscle weakness if the individual avoids using the painful muscles. This can end up causing more LBP because the muscles of the back are less able to help support the spine.
Tight or tense muscles can also cause LBP. Chronic stress causes back muscles to tighten in a "fight-or-flight" response. Tight hamstring muscles in the back of the thighs can pull down on the pelvis, which in turn increases stress on the low back. Patients with tight hamstrings tend to develop LBP, and those with LBP tend to develop tight hamstrings. Weak abdominal muscles can cause hip flexor muscles (iliopsoas, inner thigh muscles, piriformis) to tighten in response, which then causes an increase in the normal curve of the low back and worsening pain.
Given the complex relationship between muscles in the back and surrounding areas of the body, it is important to emphasize both stretching and strengthening these muscles in order to address LBP caused by muscle problems.

Chronic Low Back Pain in Military Veterans
Musculoskeletal pain conditions are the most commonly diagnosed medical problems among the more than two million Veterans from Operations Enduring Freedom, Iraqi Freedom, and New Dawn (OEF/OIF/OND), far surpassing other medical and mental health disorders. [11][12][13] In a study of 91,000 Veterans receiving care from the Veterans Health Administration (VHA), 43%

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© Boston Medical Center Veterans Back to Health Trial reported "any" pain and among those reporting pain, 63% reported moderate to severe pain. 14 Eighty percent of VHA visits include pain-related complaints. 15 Twenty percent of returning military require prescription pain medication. 16 Over reliance on opioids is common, which can lead to adverse effects ranging from sedation to dependence, addiction, and death due to accidental or intentional overdose. 16,17 Among pain conditions, cLBP is the most frequent (58%) 14 and causes substantial suffering, decreased functional capacity, 4 and lower quality of life. 18,19 Back pain is a leading cause of disability among Veterans (21%). 20,21 The types of injuries and pain common among the Veteran population differ significantly from those commonly seen in the general population. The etiologies of LBP are incredibly varied and no broad general statements can be made. However, there are a few causes worth mentioning. The literature on injuries in Veterans focuses primarily on injuries that occur during basic training, as these injuries are common and cause many people to discontinue service. The majority of these injuries are lower extremity musculoskeletal injuries, involving the hip, knee, ankle, and foot. 22 Much of military training centers on weight-bearing physical activities, such as marching or running. Thus, the most common types of musculoskeletal injuries are associated with overuse from repetitive physical activity. 22 Running can also contribute to knee problems as well as tightness in the hip flexors and extensors.
Beyond initial training, injuries in the military are often very occupation-specific. For example, those who carry heavy packs on patrol commonly incur injuries to the knees and ankles. The population that has served in aviation tends to have issues with severe early-onset arthritis and disc disease due to frequent experience of high G-force and hard landings. These acute issues continue to persist even after leaving active duty, leading to chronic pain. Older Veterans are becoming increasingly similar to the general U.S. aging population who suffer from typical chronic diseases of aging adults, including heart disease, diabetes, and obesity.

Psychological Comorbidities and the Polytrauma Triad
Psychological distress, back pain, and disability are strongly correlated. Symptoms of posttraumatic stress, 23 depression (anhedonia, low self-esteem, irritable, sadness, lethargy), 17 and traumatic brain injury (memory problems, poor concentration, change in executive function) 12 are highly prevalent in Veterans with cLBP. 24 As a result, more than 22 Veterans commit suicide every day. 25 Sleep disorders are also invariably associated with chronic pain and mental distress. 16,26 Over 95% of prescription sedatives are used for pain and sleep. 16 Low pain selfefficacy, maladaptive pain coping behaviors (e.g., catastrophizing, 27 fear avoidance, 28 substance use 29 ), and barriers to seeking evidence-based mental health care compound back pain recovery. 30,31 Among Veterans receiving care from Polytrauma Network Sites, 42% of OEF/OIF Veterans had the clinical triad of chronic pain, post-traumatic stress disorder (PTSD), and persistent post-concussive symptoms. 16,32 Given the high rate of co-occurrence, it is not surprising that many post-concussive and PTSD symptoms overlap such as depression, anxiety, insomnia, appetite changes, irritability, concentration difficulty, and fatigue. 33 The polytrauma triad is considered the "signature injury" in returning OEF/OIF/OND military personnel. 34 The hallmarks of PTSD are re-experiencing (flashbacks, nightmares), avoidance (feeling emotionally numb, losing interest in activities), and hyperarousal (being jumpy, on-edge, insomnia) symptoms. 23 35 In a yoga class, PTSD would most likely manifest as irritable behavior, possible angry outbursts with minimal or no obvious provocation, difficulty with concentration, or an exaggerated startle response. Yoga can promote effective sensory, motor, and cognitive processing, which greatly aids the healing process. A direct and powerful way for Veterans to better self-regulate is through control of the breath.
Moral injury is a relatively new concept in the conversation about the effects of war. 36 Moral injury has been defined as "perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations." 37 This is not a diagnosis, but rather an explanation for many Veterans' emotional responses to the effects of war that are not sufficiently captured by PTSD.
The increased use of high energy explosive devices and repetitive exposure to blasts in recent conflicts has yielded an unprecedented level of blast-related injuries. A blast (or pressure) wave can cause a traumatic brain injury (TBI), which varies from very obvious external head injuries to mild concussions that show no immediate visible effects. 12 The vast majority of people who sustain a mild traumatic brain injury (mTBI), also known as a concussion, recover completely with little or no intervention. Sustaining multiple concussions, not all of which may cause significant alteration of consciousness, can cause long-term subtle effects including difficulty concentrating, irritability, slight personality changes, or perhaps impaired judgment wherein the brain does not properly filter out inappropriate comments. 38 Severe or repetitive brain injuries can lead to persistent post-concussive symptoms, including headache, heightened sensitivity to light and sound, dizziness, and memory impairment. 33 Individuals with a recent or severe history of brain injury should be cautious about lowering their head below their heart during daily or physical activities, as this may cause a headache. A blast wave can also cause injuries to the inner and middle ear, even if there are not any obvious external injuries or if hearing protection devices are worn. In addition to hearing loss, damage to the structures in the inner ear can cause dizziness and issues with balance. 39 This may be especially pronounced if the head is turned far away from the midline of the body (e.g., a far side-bend in Triangle Pose or Crescent Moon Pose). Veterans that have sustained a brain injury benefit from a sense of safety in group settings with a regular routine, firm start and stop times, and the absence of criticism. In this case, this is best achieved by close adherence to the protocol as designed.

Treatment for Chronic Low Back Pain
Although there are a range of conventional pharmacologic, non-pharmacologic, and surgical procedures used for non-specific cLBP, most patients report only modest or moderate relief at best. Evidence-based clinical practice guidelines recommended initial management for nonspecific cLBP should include advice to remain physically active and education on back selfcare. 40 These guidelines recommend several conventional non-pharmacologic therapies including exercise therapy and cognitive-behavioral therapy as well. If necessary, medication with strong evidence for benefitting cLBP, such as acetaminophen or non-steroidal anti-

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© Boston Medical Center Veterans Back to Health Trial inflammatory drugs (e.g., ibuprofen, naproxen), may be judiciously used. Nonetheless, patient satisfaction with the effectiveness of conventional cLBP treatment is relatively low. 41 The 2010 Army Surgeon General's Pain Management Task Force Report stressed the importance of a Department of Defense-Veterans Administration (DoD-VA) partnership to develop an "integrative and interdisciplinary approach" to pain management, including incorporating "integrative and alternative therapeutic modalities into a patient-centered plan of care." 42 The Report emphasized "pain cannot be managed without addressing its relationship to stress" and shifting to more active than passive treatments "improves the outcome, decreases provider dependent care, and empowers the patient with a sense of control over his or her condition." The Task Force identified yoga as one of several "Tier 1" complementary modalities as priorities for DoD-VA research and possible integration. 42 Yoga was also included as an evidence-based therapy in DoD-VA clinical guidelines for cLBP.

Yoga for Low Back Pain
Yoga is increasingly common 43 with over 8.7% of U.S. adults reporting use in 2012. 44 Yoga is a "mind-body" practice consisting of three main components: (1) physical postures (asanas); (2) specialized breathing techniques (pranayama); and (3) meditation. A 2005 RCT found a moderate benefit of yoga for improving back-related function in civilian adults with cLBP. 45 This prompted the VHA, American College of Physicians, and American Pain Society to list yoga in clinical practice guidelines as an evidence-based treatment for cLBP. 40 Subsequently, four moderate-large RCTs (n=90-313) [46][47][48][49] and five smaller RCTs (n=20-60) [50][51][52][53][54] have also shown yoga to be effective for reducing pain and improving function in civilian adults with cLBP. Metaanalyses support these conclusions. 55,56 Several yoga-cLBP studies found associated psychological benefits in mood 46,54 and self-efficacy. 48,57 Yoga research on psychological health is growing, showing promising evidence for benefit in depression, [58][59][60][61][62][63][64][65][66] post-traumatic stress, 67,68 anxiety, 66,69-71 and insomnia. 72,73 Yoga classes can also increase social connectedness and spirituality. 74 Current clinical management of cLBP in Veterans is predominantly a provider-centered, pharmacologic, passive approach with the goal of reducing perceived pain intensity. This is in contrast to the VHA Strategic Goal #1 for 2013-2018: "Provide Veterans personalized, proactive, and patient-driven health care." 75 To move closer to this vision, the VHA established the Office of Patient-Centered Care and Cultural Transformation in 2011. 76 According to Director Tracy W. Gaudet, MD, "Until we employ a personalized strategy that considers the Veteran's unique conditions, needs and circumstances, addressing the full range of physical, emotional, mental, social, spiritual and environmental influences, we will not optimally help our Veterans to minimize disease or regain and maintain their health. Our goal is to design a system where we partner with our Veterans to be mission ready for their lives, optimizing their health in service of what matters to them." 77 Many studies suggest yoga may favorably impact physical as well as psychosocial problems, offering the more patient-centered, integrative approach to cLBP treatment that the VHA strives to offer.

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© Boston Medical Center Veterans Back to Health Trial

Studies of Yoga for Veterans with Low Back Pain
The IOM report Pain in America recognized that protocols for pain management approaches must be adapted to the unique needs of Veterans 13 and undergo rigorous testing for clinical effectiveness and cost effectiveness. It is unknown if results from previously published civilian yoga-cLBP trials will generalize to military populations. In contrast to participants in civilian studies, Veterans with cLBP are more likely to be men with different mechanisms of injury (e.g., direct combat-related trauma; severe non-combat back loading from carrying 100 pound gear), greater pain severity and disability; and more serious comorbid psychological symptoms. There are currently two published reports of yoga for cLBP in military settings, both conducted at the VHA San Diego. 78,79 These uncontrolled yoga-cLBP clinical programs in Veterans showed promising improvements in pain and depression.
Despite enthusiasm for offering yoga to Veterans, yoga instruction to date is not well standardized or implemented widely in the VA. More importantly, there is little evidence for yoga's effect on cLBP, PTSD, depression, or other psychosocial concerns in Veterans. Thus, Veterans Back to Health will (1) establish a structured reproducible yoga protocol uniquely suited to Veteran populations with cLBP and associated psychological comorbid symptoms; (2) develop web-based delivery systems to assist Veterans in practicing yoga at home; (3) increase our knowledge of the feasibility and impact of yoga for Veterans' cLBP, psychological comorbidities, and family functioning; and (4) provide a strong foundation for larger multi-site studies and implementation projects. Achievement of these aims has the potential to impact the approach and management of cLBP in accordance with the DoD-VA vision, i.e., a more integrative, interdisciplinary, focus on active self-care approaches that empower patients to have greater control of their condition. 42 For these reasons, our study will determine if yoga can become a safe, clinically effective, cost-effective, and scalable non-pharmacologic approach to address the physical and psychosocial dimensions of cLBP in Veterans. 80

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© Boston Medical Center Veterans Back to Health Trial As any experienced yoga teacher knows, it is important to always be aware of the population you are teaching. It is always a good idea to come to class prepared with knowledge about the population's culture, needs, strengths, and limitations. This is especially true when working with a unique population such as Veterans. Most, if not all, Veterans in this study will have never practiced yoga before. Teachers can help them learn by encouraging them to explore new movements, educating them about these movements, and providing them with choices to personalize their practice. Teachers should also be prepared to handle an adverse reaction, especially during breathing and relaxation exercises.
Teachers may tell Veterans why we move a certain way in a yoga pose and why certain movements may be beneficial for the back while others may not be. Teachers may explain that back pain may be made worse by tight muscles in the low back, hips, and legs, and explain how the poses may address this issue. For example, teachers may wish to point out that Baby Dancer Pose emphasizes a stretch of quadriceps (a.k.a. "quads") in the front of the thigh and how other poses stretch "opposing" muscles in the back of the thighs (e.g., Downward Dog and Forward Bends stretch hamstrings). It is also beneficial for Veterans to understand how integrating breathing techniques with movements as taught by teachers can help prevent injury and prompts the nervous system to induce relaxation. Many Veterans will want to understand how and why yoga works for them so that they can apply this knowledge outside of class and maybe even pass it on. Veterans may have negative preconceptions about yoga, which teachers should be prepared to respond to during class. Providing the Veterans in this study with specific information about yoga practice empowers them, presents yoga as a legitimate activity for Veterans, and even gives them something concrete to tell others who may not be as willing to try yoga.
When teaching yoga to Veterans, the yoga teacher is responsible for creating a safe, caring, and non-judgmental yoga class environment. One important aspect of this environment is offering validation and acknowledgement to the Veterans. For those that are skeptical of yoga practice or have heard negative or false rumors about yoga practice, it is okay to acknowledge that yoga practice can be different, challenging, and sometimes strange ("woo-woo" or "new-agey") to them. Teachers can use the theme of Segment 1 ("Opening to Something New") to encourage Veterans to give yoga a try, even if it is different than what they are used to. Sanskrit words should not be used during the yoga classes for this study.

Teaching Yoga Poses: Language, Modifications, Supporting Self-Awareness
Military culture places an emphasis on following orders, never giving up or showing weakness, and mottos such as "getting it right the first time" and "no pain, no gain." This type of thinking is not helpful when learning to practice yoga. When Veterans enter a VA where there are trappings of that "prior life," many may subconsciously revert back to some of their old thinking patterns. The yoga teachers in this study should use calm and inviting language that is friendly, clear, strong, and never condescending. Veterans may not respond well to flowery language and metaphors during yoga practice. Plain and easy to comprehend directions are more likely to be well-received. Even as teachers modify their instruction to suit their class of Veterans, it is important to be genuine in your choice of words. Veterans will immediately recognize and appreciate your authenticity.
One way to create a safe and trusting environment is to encourage Veterans to feel in control of their own body and yoga practice. All poses in this study have modifications and variations to choose from. Teachers should emphasize that a modification to a pose (e.g., adding a prop, repositioning the arms) does not mean that they are doing it wrong or that they have to settle for an easier version. Veterans could make negative associations with the word "modification" so teachers may want to offer them as "options" available to make the pose more comfortable or accessible. It may serve the group better to have everyone try a modification and then tell the class, "Do the version that feels best to you." The Veteran will feel more in control of their movements and will be encouraged to become familiar with their own strengths and limitations, which may vary from day-to-day. Teachers should notice if individuals are actually opting for modifications that they truly need or seem to be averse to modifications altogether. Language that allows the Veteran to have control includes invitatory phrases such as "if you'd like," or "when you are ready." During yoga poses, teachers might also say, "If you are experiencing any discomfort or pain, please be willing to come out of the pose" or, "As we hold the pose, remember that you are welcome to bring yourself out of the pose whenever you are ready." 81 A common misconception about yoga is that it is only for "flexible people" that "stand on their heads." Consistent with the military culture to "get it right" and conceal weakness, Veterans may become discouraged by their lack of flexibility or limitations in some poses. Teachers should acknowledge these frustrations and encourage Veterans to become more familiar with their bodies' sensations. Teachers may also need to continually emphasize that yoga practice is unique for each person and Veterans should not compare their personal abilities or preferences to others. This will help remove any competition from the class, which is prominent in military culture. Some example language or phrases that teachers can use are:  Notice how this pose feels and say "hello" to any sensations in your body  You may feel this or you may not, just observe (instead of telling them what they should notice or feel)  Think of these sensations as your body talking to you, telling you what is okay for today (letting them know that what does not work today might be easier later on)  If this difficult for you right now, that is okay. You can consider trying… (offering an option to customize the pose) It is important for Veterans to build body awareness through their yoga practice. This includes changing their relationship with their pain. Yoga teachers should encourage them to get to know their body by identifying where pain or discomfort is located, what positions naturally feel good for them, and what emotions may be connected to their physical feelings. Acceptance of pain may be a completely new concept. Through yoga practice, Veterans will be able to learn how to understand their body and differentiate pain (e.g., from an injury) from the feeling of a stretch, soreness, or other expected sensations.
Some Veterans may not be comfortable with teachers touching them to help adjust their poses. Never assume it is permissible to touch, even if you have helped the person in previous classes. Teachers can ask by saying things like, "Can I help you adjust your right leg?" General questions such as "Can I touch you?" are not recommended. Always let the Veteran know it is fine if they

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© Boston Medical Center Veterans Back to Health Trial are not comfortable with touch and they can adjust their poses with verbal direction if they prefer.

Guiding Breathing and Relaxation Exercises
Teachers should always be cognizant of the possibility of post-traumatic stress reactions in a yoga class and should understand the relationship between trauma and the body. This is more likely to come up during breathing or relaxation exercises than during yoga postures. Yoga teachers can use the following techniques to help Veterans feel relaxed:  As opposed to a yoga class in the general population, do not give Veterans a lot of quiet space without guidance. Otherwise, their minds could drift to a traumatic or stressful experience in the past.
 Tell them to anchor themselves to their breath or following the instructor's voice.
Remind them to stay present in the moment and return to their anchor if they have drifted. Teachers may like to give little rocks or crystals to Veterans as a tangible reminder to be present and to stop intrusive thoughts.  Know what to do if a Veteran has an abreaction. Use a gentle but firm voice to help them come back to the present moment. Encourage them to return to their focus on their breath. A teacher could say, "Return to the focus on your breathing. Breathe in through the nose and out through the mouth, noticing the temperature of the air as you breath in, noticing the rib cage expanding and contracting with each breath…" In general, teachers should encourage Veterans to use techniques they learn outside of class to help them recognize how they deal with the world (e.g., using breathing techniques when they get angry, inpatient, etc.). This is a good reminder for the end of class.

After Class Reflections
After the relaxation exercise in class, teachers should prompt Veterans to share their thoughts or reflections about their personal yoga practice if they feel comfortable. Encourage Veterans to offer honest feedback and let them know it is okay to perceive that they "did not do it right" or "could have done it better." Validate that they are exactly where they are supposed to be and the body will open when it is ready. Hearing other Veterans in the class describe how they feel can help others that might not be able to find the words to describe their feelings. It can also help normalize the challenges of yoga practice. Teachers may even choose to offer stories about their own challenges with specific yoga poses. For example, "I use to get really frustrated when I fell out of balance poses. Then I realized that's how I deal with life off the mat. It provided me with great insight." This can encourage trust and help the Veterans feel a connection with others, both of which may not come easily to them. Always let Veterans know it is fine if they do not want to say anything. Teachers can also use this reflection time to draw

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© Boston Medical Center Veterans Back to Health Trial comparisons to last class and highlight change, especially after many weeks have passed. It may be helpful for teachers to let Veterans know that it is normal for their back to feel a bit worse before it gets better. A teacher could say, "In yoga practice, you are waking up muscles that might not have been used in a long time. It is normal for these muscles to be a bit sore while they get used to being used again."

Yoga Teacher Roles and Responsibilities
Page 18 © Boston Medical Center Veterans Back to Health Trial Typically, two yoga teachers will teach each class. One teacher will be responsible for leading the class through the poses for the week. The other teacher will help individual participants with modifications as appropriate. Teachers may choose to alternate roles week to week; this is left up to teacher discretion based on experience and preference. As a reminder, yoga teachers should always dress appropriately for the population they are teaching. Do not wear revealing attire and avoid clothing or jewelry with symbols (e.g., peace signs, religious symbols, etc). Teacher roles and responsibilities are outlined as follows:

On the First Day of Class (Arrive 45 minutes early)
 Have one chair behind each mat so that can start by sitting down.  Welcome participants into the space and introduce yourselves.  Inform participants about logistics (e.g., location of bathrooms, where to put their items), taking off shoes, not eating in class, cleaning mats, turning off cell phones, etc.  Assure participants about confidentiality within the group, letting them know they can talk outside of class about their own experience, but not about other classmates.  Review "Before Each Class" below.

Before Each Class (arrive at least 15 minutes early)
 Check in with the other yoga teacher to share any relevant information about participants as well as any other issues or concerns.  Turn on lights, clear space, and set up the props (mats, straps, blocks, blankets, chairs).
Make sure there is sufficient room between mats for a teacher to be able to walk around and model postures. Create space for participants' belongings away from the yoga space.  Have attendance sheet, pens, and extra Home Practice Logs near the door and in the same place each week.  Be sure everyone signs the attendance sheet legibly and remind participants to note if contact information has changed. Make sure the attendance sheet is dated and that all participants present are recorded.  Place index cards with participants' first names next to their mat. Consider placing participants who need extra help closer to the teacher or near a wall for support.

During Class
 Position yourself so that participants can see you and you can see them during class.  Assist participants with props and provide support to participants when needed.

After Class
 Remind participants to practice at home and fill out Home Practice Logs.  Share cleaning materials with participants and show them how to clean their mats. Store yoga supplies and forms securely, and leave the space as it was found.  Use the Yoga Teacher Notes sheet to record any relevant information and/or observations from the class. Call study staff directly if any supplies or forms need to be replenished or if you need to report any potential adverse events.

Protocol Development
Veterans are encouraged to participate in this study if they are experiencing chronic low back pain (cLBP) and wish to achieve a higher level of functioning and minimization or alleviation of pain. We have designed a hatha yoga protocol specifically for this study. An earlier version of the yoga protocol was developed in 2006-07 by an expert panel led by the Principal Investigator, Dr. Saper, after a systematic review of lay and scientific literature on yoga and low back pain. Panel members had experience in several styles of hatha yoga including Anusara, Ashtanga, Iyengar, and Kripalu. This protocol was used in a 2007 pilot study of yoga compared to usual care for 30 patients with cLBP. It was further refined through a 2012 yoga dosing study where 95 participants attended either once or twice-weekly yoga classes. The yoga dosing study found both class frequencies similarly effective for improving back pain and function. A version of this yoga protocol was also used in the original Back to Health study, a large study for 320 participants that compared yoga, physical therapy, and education. Additional changes have been made to the protocol based on yoga teacher and participant feedback from previous studies. In order to adapt the yoga protocol to a Veteran population, a panel of individuals with expertise in yoga and working with Veterans had a daylong convening to discuss additional modifications.

Adherence to Protocol
As a member of the yoga team, your participation in the study is extremely appreciated. Your commitment to providing the best possible yoga intervention to the participants is critical for the success of the study. We acknowledge that yoga teachers' preferences and teaching styles may vary significantly, and it may be difficult sometimes to follow a prescribed treatment protocol when you may think someone could benefit from something different. For the purposes of this study, however, we ask you to please try to follow this protocol as closely as possible. However, teachers should always prioritize the safety and comfort of Veterans when teaching a yoga class. As questions about the protocol, study, or logistics arise, please feel free to speak with anyone involved in the study (see contact information on p. 4) and we will do our best to assist in an appropriate and timely manner.
These yoga classes for cLBP are different from regular yoga classes in that the curriculum includes standardized format and teaching directives that can be replicated and delivered by any qualified yoga teacher. The intervention phase is 12 weeks long. Participants in the yoga group will take one 75-minute yoga class per week. The twelve weeks are divided into four segments. Each segment has a name and lasts three weeks. The segments build upon what participants have learned in previous segments. Each segment has a unique set of poses and yoga philosophies. The goal of the four segments is to teach basic hatha yoga postures in a carefully calibrated sequence that supports healing of the back. In this first segment, participants are introduced to yoga and the possibility of change in their back pain and change in themselves. They are taught how controlled breath work is the foundation for yoga. Participants practice a variety yoga breathing exercises. They are introduced to intentional relaxation and practice several poses such as Child's Pose, Bridge Pose, Knees to Chest, Knees Together Twist, and Pelvic Tilts. Each week briefly highlights an aspect of yoga philosophy (defining yoga, self-compassion, awareness). How the yoga philosophy concept applies both to yoga practice and daily life is emphasized.

Segment 2: Listening to your Back (Weeks 4-6)
Participants are taught how to listen to their individual bodies and their back and to continue to develop self-compassion. They are encouraged to begin building strength in standing postures, developing stability in balancing poses, stretching in gentle backbends, and learning to use the muscles to support the spine-all elements to help their low back pain. Participants are taught to use their experience on the mat to create a foundation of balance in their lives by trusting their own experience and listening to their bodies. Participants continue with postures learned in the first segment and learn new postures such as Big Toe Pose, Side Hip Strengtheners, and Eye of the Needle Pose. Yoga philosophy principles highlighted in Segment 2 include acceptance, self-control, and honesty.

Segment 3: Engaging Your Power (Weeks 7-9)
Participants are challenged to apply the strength and self-awareness that they have started to discover in more challenging standing, twisting, and back bending postures. They are encouraged to focus on the strength and mobility in their low back as they try more difficult postures such as Plank Pose, Side Plank Pose, and Warrior II. Participants are introduced to the yogic concepts of gratitude, balance, and moderation.

Introduction to Yoga Principles
This section is intended to familiarize participants with the philosophical principles of yoga. These principles provide the participants with a framework for health and wellness while promoting awareness and self-discipline. Teachers utilize poems, readings, and commentaries related to principles to inspire participants to practice greater self-care. Suggested readings for each week are in this manual and supplementary readings are in Appendix 1. The manual gives "talking points" that can be used either verbatim or as suggestions to guide your teachings. The principles are discussed in a completely secular manner and using language that Veterans will be receptive to. We will cover the following topics: Please see a summary of The 12 Yoga Principles on pg. 23.

Breathing Exercise
Over the course of the 12-week curriculum, awareness of normal breathing, lengthening the inhale and exhale, and the ocean breath are taught. Teachers should model and demonstrate

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© Boston Medical Center Veterans Back to Health Trial all breathing techniques. Yoga breathing techniques must be emphasized with every posture as well as during breathing exercises.

Yoga Postures
The yoga postures have been selected for their safety and potential to help chronic low back pain. They gradually increase in difficulty over the 12-week intervention. Support the participants through individual attention, yoga props as needed, and modifications to accommodate individual needs. Help participants learn that props are their friends. The postures are intended to transition participants from more strenuous poses to the closing relaxation. Do not introduce poses that are not included in this manual.
This manual lists a menu of poses for each week for teachers to use as a reference during class (pp. [24][25][26][27][28][29][30][31][32][33][34][35]. It is not expected that all poses will be taught in each individual class. These menus provide a range of opportunities for teaching to Veterans. Highly mobile Veterans may be able to progress to do the full range of poses in this manual. A more disabled Veteran may never be able to do certain poses. Therefore, it is up to teachers' discretion to lead the Veterans through the protocol as appropriate.

Relaxation Exercise
The relaxation exercise is led by the yoga teacher while the participants are in Final Resting Pose (Savasana) or another comfortable position. Never use the term "corpse pose" for this position. Relaxation provides participants an opportunity to integrate the different experiences of yoga practice. This part of the practice is meant to draw participants into a deeper state of relaxation. Particularly at the beginning of the study, yoga teachers should give clear guidance to participants throughout the relaxation section.
Relaxation is a crucial component of the program, providing participants with regularly occurring opportunities to renew, restore and recharge with yoga. Participants are encouraged to set aside actions, thoughts, stress, worries and the events of the day and focus on the present moment in class. Different relaxation techniques can be used, including muscle relaxation and body scan. There is a menu of relaxation exercises listed in this manual. In contrast to classes with civilians, long periods of silence should be avoided with Veterans.

Closing
The purpose of the closing is to allow time for reflection and sharing of the Veterans' yoga experience. Ask participants in a non-judgmental way if they would like to share their thoughts, experiences, or feelings after the class. Let them know it is okay if they do not want to speak. Each week, teachers should remind participants to practice at home and fill out Home Practice Logs. Encourage participants that did not bring a completed log to fill one out for the previous week before leaving class, even if they were not able to practice at home. Say goodbye to everyone by name, making eye contact. These principles are explicitly introduced at the beginning of each class through yoga philosophy. Below are talking points to guide you. You may use these verbatim or supplement these topics based on your own experience. There are also specific supplemental readings for each week (p. 75) that reinforce these principles. Incorporate these principles throughout the class as appropriate. If you would like more guidance than the below, please speak with study staff.  Week 1 (Defining Yoga): Veterans are given a context of the yoga intervention. They are introduced to yoga as tool to help relieve their back pain through a union of body, mind, and breath. They learn how to enter, be in, and exit postures safely and mindfully. Introduce the concept that lessons learned on the yoga mat may be helpful off the mat for overall health and wellbeing.  Week 2 (Self-Compassion): Veterans are encouraged to practice compassion toward themselves and others. The difference between harmful pain and healthy discomfort in poses is discussed to help guide their relationship with pain. This gives a sense of common ground and connection not only within ourselves but with all people. .  Encouraged participants to set aside actions, thoughts, stress, worries and the events of the day and focus on the present moment in class.

Closing 2-4 minutes
 Praise participants for doing their first yoga class and ask them to share their initial thoughts or reflections if they are comfortable. Let them know all classes will end with an opportunity to share with the group and explain how this can be helpful.  Remind participants to practice yoga at home for 30 minutes each day as they are able and to fill out a Home Practice Log to turn in at the next class. Have blank logs out for participants to take if they need to.  Remind participants to be aware of their breath during their yoga practice and also throughout the day.  Say good-bye to all participants by name.  Encouraged participants to set aside actions, thoughts, stress, worries and the events of the day and focus on the present moment in class.

Closing 2-4 minutes
 Praise participants for today's yoga practice and ask them to share their thoughts or reflections if they are comfortable. Reiterate how this can be helpful as everyone is learning yoga together.  Remind participants to practice yoga at home and to fill out Home Practice Logs to turn in at the next class. Have blank logs out for participants to take.  Collect completed Home Practice Logs and ask those that did not turn one in to fill it out before leaving, even if they were not able to practice.  Say good-bye to all participants by name.  Encouraged participants to set aside actions, thoughts, stress, worries and the events of the day and focus on the present moment in class.

Closing 2-4 minutes
 Allow participants to share thoughts or reflections if they are comfortable.  Remind participants to practice yoga at home and to fill out Home Practice Logs to turn in at the next class. Have blank logs out for participants to take.  Collect completed Home Practice Logs and ask those that did not turn one in to fill it out before leaving, even if they were not able to practice.  Say good-bye to all participants by name.  Encouraged participants to set aside actions, thoughts, stress, worries and the events of the day and focus on the present moment in class.

Closing 2-4 minutes
 Allow participants to share thoughts or reflections if they are comfortable.  Remind participants to practice yoga at home and to fill out Home Practice Logs to turn in at the next class. Have blank logs out for participants to take.  Collect completed Home Practice Logs and ask those that did not turn one in to fill it out before leaving, even if they were not able to practice.  Say good-bye to all participants by name.  Encouraged participants to set aside actions, thoughts, stress, worries and the events of the day and focus on the present moment in class.

Closing 2-4 minutes
 Allow participants to share thoughts or reflections if they are comfortable.  Remind participants to practice at home and complete Home Practice Logs.  Ask participants that did not turn in a Home Practice Log to fill one out before leaving, even if they were not able to practice in the past week.  Say good-bye to all participants by name.  Encouraged participants to set aside actions, thoughts, stress, worries and the events of the day and focus on the present moment in class.

Closing 2-4 minutes
 Allow participants to share thoughts or reflections if they are comfortable.  Remind participants to practice at home and complete Home Practice Logs.  Ask participants that did not turn in a Home Practice Log to fill one out before leaving, even if they were not able to practice in the past week.  Remind participants to allow their bodies to lead them to the postures that feel good to their bodies during home practice.  Say good-bye to all participants by name.  Encouraged participants to set aside actions, thoughts, stress, worries and the events of the day and focus on the present moment in class.

Closing 2-4 minutes
 Allow participants to share thoughts or reflections if they are comfortable.  Remind participants to practice at home and complete Home Practice Logs.  Ask participants that did not turn in a Home Practice Log to fill one out before leaving, even if they were not able to practice in the past week.  Say good-bye to all participants by name.  Encouraged participants to set aside actions, thoughts, stress, worries and the events of the day and focus on the present moment in class.

Closing 2-4 minutes
 Allow participants to share thoughts or reflections if they are comfortable.  Remind participants to warm up at home before doing more energetic postures.  Remind participants to practice at home and complete Home Practice Logs.  Ask participants that did not turn in a Home Practice Log to fill one out before leaving, even if they were not able to practice in the past week.  Say good-bye to all participants by name.  Encouraged participants to set aside actions, thoughts, stress, worries and the events of the day and focus on the present moment in class.

Closing 2-4 minutes
 Allow participants to share thoughts or reflections if they are comfortable.  Encourage participants to take any feelings of ease and calm they find in class into other areas of their lives.  Remind participants to practice at home and complete Home Practice Logs.  Ask participants that did not turn in a Home Practice Log to fill one out before leaving, even if they were not able to practice in the past week.  Say good-bye to all participants by name.  Encouraged participants to set aside actions, thoughts, stress, worries and the events of the day and focus on the present moment in class.

Closing 2-4 minutes
 Allow participants to share thoughts or reflections if they are comfortable.  Remind participants to practice at home and complete Home Practice Logs.  Ask participants that did not turn in a Home Practice Log to fill one out before leaving, even if they were not able to practice in the past week.  Say good-bye to all participants by name.

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Check-in 8 minutes
 Welcome participants by name and take attendance.  Ask participants how their home practice is going. Acknowledge the challenges of learning to listen to their bodies and keeping up with yoga practice.  Discuss Community: Encourage Veterans to look to each other for support in their practice.
This gives a sense of common ground and connection not only within ourselves but with all people.  Breathing exercise (p. 69)  Encouraged participants to set aside actions, thoughts, stress, worries and the events of the day and focus on the present moment in class.

Closing 2-4 minutes
 Ask participants to share what yoga has done for them and what they are taking home from the lessons, if they are comfortable.  Ask participants that did not turn in a Home Practice Log to fill one out before leaving, even if they were not able to practice in the past week.  Say good-bye to all participants by name and encourage them to continue yoga practice on their own. Remind them of how much they have learned and the tools they have gained to manage pain and other concerns. Also remind them that the study is not over for another three months. You can mention that study staff will follow-up with them periodically and that they can call staff at any time.

Baby Dancer Pose
Description: Standing quadriceps (front-thigh muscles) and hip flexor stretch that helps release tension in the lower back and hips.
How to teach: Stand with the left side of your body against the wall and your left hand on the wall (or on the back of a chair). Find a steady point in front of you to focus on to help you balance. Gradually shift your weight to the left leg. Inhale and bend right knee so the right foot is behind you. Hold the right foot or ankle with the right hand or belt. Stand firmly on the left leg, keeping it straight. Take a moment to balance yourself so that knees are in alignment with your hips. Hold here and breathe into the stretch lifting from your abdominal muscles, stretching down the front of the thigh, and tucking the tailbone. Slowly release bent leg to the floor. Come back to Mountain Pose. Repeat on opposite side.

Modifications:
1. If you have difficulty reaching back far enough to hold your foot due to tight shoulders or quads, wrap a strap around the right foot and hold the other end of the strap with the right hand. If the strap is long enough, you can put it over your shoulder so that when you pull it down in front of you, your leg comes up further. 2. Participants can transition to removing their hand from the wall but still standing close to the wall in case they need to lean on it for support. 3. Sitting in Chair: Sit on edge of chair, take one foot back to the side of the chair and let the knee drop down to face the floor. If able, hold ankle or place a belt around ankle.

Big Toe Pose
Description: Supine pose to stretch hips (psoas muscles), thighs, and hamstrings.
How to teach: Lie supine (on the back) on the floor with knees bent and soles of feet flat on the mat. A folded blanket can be placed under the head for support. Place belt on sole of right foot and straighten leg. Allow shoulders to relax down toward floor and keep tailbone on floor. Press right foot up overhead while pulling arms and shoulders down. Inhale, straighten leg. Take belt in right hand, bring left hand to floor. Exhale, move right leg out to right side while keeping opposite hip on floor and let left knee move out to the left. Inhale, bring leg back up straight. Repeat, moving leg out and up again three times, keeping leg straight and hips on the floor, moving with each breath. End with leg straight up. Bend knee and take belt off and repeat on left leg.

Modifications:
1. Bend and straighten leg several times using a belt for support. 2. With leg straightened, circle leg in one direction and then in the other direction several times using a belt for support. 3. Lying on back at wall with feet facing wall, knees bent, place one leg up on wall as straight as possible using the wall for support. 4. Lying on back with feet facing chair seat, knees bent, rest right foot on edge of chair seat. Raise right leg up as straight as possible. Repeat on other side using the chair for support. 5. Sitting in Chair: Sit in a chair, with legs bent and feet on floor, place one leg straight up onto block or another chair seat (or whatever height will give a comfortable stretch depending on ability).

Child's Pose
Description: Resting pose to stretch the hips, thighs, and ankles while gently relaxing the muscles on the front of the body and passively stretching the muscles of the back torso.
How to teach: Start by kneeling, then sit comfortably on heels. Take knees apart while keeping toes together. Bend forward bringing head to floor. Extend arms forward on the floor overhead or to the sides reaching towards the ankles with palms facing up.

Modifications:
1. If there is knee discomfort, place a folded blanket behind knees between shin and thigh, or place a folded blanket under the knees for additional padding. With hands on thighs, palms down, slowly bend forward between legs. Hands can stay on thighs or move to the floor or blocks. Another chair can be placed in front to allow head to rest on back or seat of chair.

Cobra Pose
Description: Beginning backbend that stretches the chest, increases flexibility of spine, and strengthens the spine and shoulders How to teach: Lie flat on stomach, with legs slightly wider than hip distance apart. Place tops of feet on the floor and keep toes pressed into floor throughout pose. Relax shoulders and put forehead on the mat. Place palms face down at armpit level, with fingers facing forward. Keep elbows bent at side. Inhale, push palms down against the floor and use back muscles to lift head and then chest, slowly, gazing forward. Minimize weight on hands or wrists by engaging back muscles. Press pelvic bones into the floor. Move the shoulders and shoulder blades down away from neck. Keep elbows bent. There should be no strain on the lower back. Exhale, as you lower the upper back and head down to return to beginning position.
To prevent injury, caution participants to not overextend the neck. Encourage them to keep the spine of the neck in line with the spine of the upper back and to look forward (not up) or slightly down.

Crescent Moon Pose
Description: Standing pose that stretches the torso (intercostal muscles between the ribs), opens up the spine and shoulders, improves posture, and helps prepare the spine for deeper stretches.
How to teach: From Mountain Pose, separate the feet wider than the hips, inhale and extend arms up straight up overhead. While bending to the right, take left arm up and overhead toward the right with the palm facing the floor, keeping the right hand on the waist. Repeat on the left side.

Downward Dog Pose
Description: Standing pose and mild inversion that builds strength while stretching the hamstrings, shoulders, calves, hands, and spine.
How to teach: Start on hands and knees and walk hands in front of shoulders with hands shoulder-distance apart. With knees in line with palms, move knees backwards. Inhale, lift hips up toward ceiling and straighten legs, pressing the front of the legs back. Spread fingers and press them evenly on the floor. Exhale, stretch arms keeping elbows straight, lengthening arms, torso, and back toward legs. With legs straight, inhale, lift hips higher while pressing heels down toward the floor. Your upper arms should be alongside your ears. Exhale, come back to Table  Top

Eye of the Needle Pose
Description: Supine pose that stretches the outer hips (piriformis muscles) and low back How to Teach: Start by lying on back with both feet on the floor. Place the right ankle on the left knee and flex the right foot. For some participants, this may be enough of a stretch to start with. If there is no pain in the hip in this starting position, with your right hand, gently push the right thigh, just below the knee, away from your head. Keep your hips, spine, and head on the floor and relax your neck. For a deeper stretch, clasp your hands behind your left hamstring and hug it in toward your torso, with your head still on the ground. Hold for a minute, and repeat on the other side. Modifications: 1. Sitting in Chair: Place the right ankle on the left knee. If it does not cause discomfort, lean forward for stretch while keeping back and neck straight. Repeat with left ankle on right knee. The chair version of this pose usually offers a more difficult stretch than on the mat.

Eye of the Needle in Chair
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Wide-Leg Bend Pose
Description: Standing pose to stretch the back and hamstring muscles.
How to teach: Move the feet apart into a wide but comfortable stance, keeping toes pointing forward. Inhale and lift your chest, making the front torso slightly longer than the back. Bend forward from the hips, keeping the back straight and the neck in line with the backbone. Many participants will not be able to make their torso parallel with the floor, so hands can be placed on the back of a chair, move down to the seat of a chair, or rest on blocks. Or hands can be placed on the wall at shoulder-height to start, and then moved down gradually over time. Keep the weight balanced evenly on both feet and keep the legs straight. Stay in the pose for a few breaths. To come out, lift and lengthen your front torso, keeping a flat back, into Mountain Pose.
In forward bends, the angle between the legs and torso should never be below ~70° (a right angle is 90°).

Preparing for Breathing Exercises
Specific training in breathing exercises is done at the beginning of each yoga class and should last for about 5-6 minutes. Of course, this is not the only part of the class where breathing is emphasized. Teachers should continually encourage and remind participants to maintain yoga breathing throughout the class, and in particular try to coordinate the breath with the yoga postures. Given that many Veterans may have little or no experience with consciously controlling the breath for yoga, a special period in the beginning of each class is set aside to gain greater confidence in this. During the first few weeks, explain the purpose of the breathing exercises, for example, as follows: We begin class this way to help us release all the activities of the day and shift the focus on yourself -your body, breath, and movement. The breathing and centering exercise allows you to let go of everything that happens off your mat and begin to focus on your body and the present moment. Breathing exercises can also help ease pain, reduce stress and anxiety, promote restful sleep, and increase attention and focus.
Breathing exercises may be done sitting in a chair, sitting against a wall or on the floor, lying down on the back, or in any other comfortable position. For participants lying on the mat, consider setting up 2 blankets, one folded in a long rectangular shape to go the length of the spine from the waist to the top of the head. The other folded like a pillow can be placed on top of the first blanket, going under the neck and head. A bolster or rolled blanket(s) can be placed under the knees. Participants may also choose to keep the knees bent and feet flat on the floor hip-width apart.

Guiding Participants through Breathing Exercises
Use the breathing exercises listed on the following pages to guide participants. Of the many yoga breathing exercises available, the core breathing exercise to be taught in this study is slow deep paced diaphragmatic breathing. This is termed 'Yoga Breathing' or 'The Yoga Breath' for the participants. For many of the participants, it may take several weeks for Veterans to become comfortable with this new practice. Encourage participants to practice breathing at home with the home practice video. For Veterans who become comfortable with The Yoga Breath, you can introduce the Ujjayi Breath. This should be termed 'The Ocean Breath' for participants. The instructions below are meant as a guide. Teachers can use their discretion in how they teach Yoga Breathing and the pace by which they progress through the instructions. These exercises do not necessarily have to be fully introduced all at once. Since consciously learning how to control the breath may be new, teachers should encourage participants to practice yoga breathing without self-judgment or criticism.
Once participants have found a comfortable position, start with relaxation, closing eyes lightly or keeping them open if preferred. Always begin by giving a moment for participants to become aware of their normal breathing. Emphasize that it is very important that breathing always remains comfortable, never forcing it or pushing it. If there is any struggle, return to normal breathing to recover.

Ending the Breathing Exercise
To end a breathing exercise, instruct participants to let go of the attention to the breath and let natural breathing resume when they are ready. Have them open their eyes, if they chose to

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Yoga Breathing or The Yoga Breath
Purpose and Benefits: Increases oxygen levels by expanding lung capacity, quiets and calms the nervous system, reduces stress and anxiety, and improves self-awareness.

Awareness of the Normal Breath
Breathing through the nose with the mouth closed, notice the feel of the air as it comes into your body and then goes out. If you are unable to breathe through the nose, it is fine to breathe through the mouth. Be aware of your body breathing in, saying to yourself, 'I am breathing in.' Be aware of your body breathing out and saying, 'I am breathing out.' Repeat. Just allow the breath to come. Do not try to control the breath, just be aware of your body breathing without any effort.
Allow the mind and its thoughts to come and go like clouds drifting by. If you notice you have drifted off with a thought, bring your attention back to the breath, noticing your inhale and your exhale.
As you pay attention to your breath, think about the following questions. These questions do not necessarily need answers, they are meant to focus your attention and observe the breath without judgment.
 Notice the quality of the breath. Does the breath feel even? Choppy? Shallow? Is the breath getting stuck in the belly or chest? Tense? Is the breath bumpy or smooth, light or heavy, starting and stopping?
 Notice the feel of the air as it comes into your body and then goes out. Where do you feel the breath in your body the most?
 Notice the temperature of the air as it comes into the nose at the nostrils and again as the air goes out. Does the temperature of the air change from the inhale to the exhale?
 Notice the length of the inhale and exhale. Is the inhale longer or shorter than the exhale?

Three Part Diaphragmatic Breathing
Part 1: The diaphragm is a muscle that is at the base of your lungs and divides your lung cavity from your abdominal cavity. When you take a deep breath during inhalation, the lungs expand. The expansion of the lungs will naturally push down on the diaphragm. As the diaphragm pushes down on the contents of the abdominal cavity, the pressure of the abdominal cavity increases. This increase in pressure causes the belly to rise or expand during the inhale. Place a hand on your belly and notice the movement of the belly. As you inhale, the abdomen naturally rises like a balloon is inside and it is slowly expanding. By doing this during your inhalation, the air initially fills your lower lungs.
As you exhale, the opposite occurs. The lungs deflate as the air leaves. This causes the diaphragm to rise. As the diaphragm rises, the pressure within the abdominal cavity decreases, and the belly falls. Feel the abdomen as you exhale. It should fall as if a balloon inside is slowly deflating.
If you look at a newborn babies, they naturally breathe like this. However, as adults we forget this natural breath. So do not be disappointed if it takes some practice to retrain yourself.
Part 2: The second part of the three part breath refers to the expansion of the mid-chest with inhalation and contraction of the mid-chest with exhalation. Place your hands on the ribs on each side of your chest. With a relaxed belly, gently breathe in and feel the rib cage expand out into your hands. As you breathe out, feel the rib cage contract away from your hands. Practice breathing, moving the rib cage out into hands and back in, like an accordion-going in and out. By doing this during your inhalation, the air will fill your middle lungs.
Part 3: The third part of the three part breath refers to the expansion and contraction of the upper chest with the breath. The upper part of the lungs are often not used in normal, more shallow breathing. Place your hands on the upper chest, right under the collarbones. Notice if the upper chest has any movement with easy, normal breaths, being careful not to tense the neck and shoulders. If you do this, you will feel the upper chest rise with inhalation. As you breathe out you should feel the upper chest fall. By doing this third part during your inhalation, the air will fill your lower lungs.
Putting It All Together: Breathing of course is a continuous process and cannot truly be broken into discreet and different parts. However, it can be helpful to imagine your inhale as starting with Part 1-rise and expansion of the belly while the lower lungs fill; then beginning Part 2-rise and expansion of your ribcage to allow the mid-lungs to fill with air; and then finally Part 3-rise and expansion of the upper chest allowing the very top of the lungs to fill.
Exhaling can be thought of as a continuous process also but in reverse. The exhale begins with the upper chest contracting or falling as the upper lungs empty out their air. The ribcage then begins to contract emptying out the air from the mid-lungs. And finally, the belly falls and abdominal wall contracts, causing the lower lungs to compress and push out their air. And the inhalation -exhalation cycle repeats.

Lengthening the Exhale
Once participants are comfortable with the mechanics of the three part breath, pacing the breath and ultimately lengthening the exhale to be greater than the inhale can be introduced.
Inhale using the three part breath through the nose. Slowly, deeply, and steadily inhale until you feel full. Lengthening the inhale helps to invigorate and energize us. Notice that there is a slight natural pause at the end of an inhale before a new exhale begins. Exhale slowly, easily but not all at once.
Continue with three part inhales. Begin to attempt to comfortably lengthen the exhale so it is slow, deep, and steady. Notice that there is a slight natural pause at the end of the exhale before a new inhale begins. Lengthening the exhale helps us relax and release tension and stress. The short natural pause at the end of exhalation can symbolize for you an internal sense of peace and calm.

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© Boston Medical Center Veterans Back to Health Trial Note to Teachers: Let participants choose to either stay with a count of 3 on the in-breath and out-breath, or try to lengthen the in-breath and out-breath to a count of 4. If and when they are ready, introduce the idea of lengthening the exhale to a count of 5, while maintaining the out-breath count to 4. Participants can further lengthen the exhale in relation to the inhale using a counting ratio of 6 to 4.
Remind participants to keep their breathing comfortable, never forcing or pushing it. Stay with the rhythm of this breath for a few minutes. Ultimately, if participants feel they master this, they can have the option of not formally counting to themselves.

Ocean Breath
Purpose and Benefits: This is an advanced yoga breathing exercise which can be introduced to Veterans who master the three part breath as described above. It can create smooth, slower, and more controlled inhalations and exhalations. It may allow participants to hold poses longer and receive a greater calming effect from the breath. Do not use Sanskrit names of exercises with the Veterans. In this case, refer to it as 'Ocean Breath.'

Suggested Instruction
Exhale through the nose if possible. If not, you can exhale through an opened mouth. Slightly close or contract the back of the throat while exhaling to make a soft quiet "hhh" sound. Keep the back of the throat contracted while inhaling to quietly make a soft quiet "sss" sound.
To learn to make the sound, start an exhale through the mouth. Try using one or several of these images to teach the sound:  Breathe out as you would to fog a hand mirror.
 Breathe like when you whisper.
 Breathe as you would if you were trying to see your breath on a cold day.
 Breathe so it sounds like a quieter Darth Vader of Star Wars fame.
If the sound is not coming, let it go. It will come on its own with practice.
Listening to the sound of the breath helps us stay focused and also gives information about its quality, rhythm and pace. Continue with this breath for several minutes as you notice the sound and sensation at the back of your throat.

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© Boston Medical Center Veterans Back to Health Trial

Preparing for Relaxation Exercises
Relaxation is done at the end of yoga class and should last, in combination with closing, for about 12 minutes. For the first few weeks, explain the purpose of the relaxation exercise. For example, teachers could say: These practices allow us to find a deep sense of relaxation while still remaining awake and alert. It is a guided meditation that takes us on a tour of our body while maintaining an inner state of awareness. You may find the experience as one of being a being asleep and awake at the same time. The practice settles the mind and relaxes and restores the body.
Let participants know that if they fall asleep during the relaxation exercise, they should not feel bad. It is common and can be a sign of not getting adequate rest or sleep for the day.
Relaxation exercises are typically done while in Final Resting Pose but this might not necessarily be a relaxing position for some participants. Yoga teachers may present Reclined Chest Opener Pose (p. 56), Legs up the Wall Pose (p. 51), or any of the modifications for Final Resting Pose (p. 76) so all participants can find a comfortable position. Invite participants to choose a position that is most comfortable for them. For some, this could even be sitting up against a wall if they prefer not to lay on their back. Participants may choose to use a blanket to keep warm, as the body temperature tends to drop during the practice when lying down. Teachers may make the following points to help participants find a relaxing position:

Intentions and Anchors
As the relaxation practice starts, invite participants to begin by setting an intention. Teachers can explain this by saying: An intention is something that you may want to let go of. It can be a quality or situation that you would like to bring into your life or even a dedication to a loved one.
Also invite them to connect with an anchor. Teachers can explain this by saying: An anchor is a person, object, or event that helps ground you and evokes a sense of joy, love, or compassion.

Poems and Readings
Week 2: Self-Compassion

CONSCIOUS BREATHING
There are a number of breathing techniques you can use to make life vivid and more enjoyable.
The first exercise is very simple. As you breathe in, you say to yourself, 'Breathing In, I know that I am breathing in.' And as you breathe out say, 'Breathing out, I know that I am breathing out.' Just that. You recognize your in-breath as an in-breath and your out-breath as an out-breath.
This technique can help you keep your mind on your breath.
As you practice, your breath will become peaceful and gentle, and your mind and body will also become peaceful and gentle.

Breathing in and out is very important, and it is enjoyable.
Our breathing is the link between our body and our mind.
By concentrating on our breathing, 'In' and 'Out,' we bring body and mind back together and become whole again.
Conscious breathing is an important bridge.
-Thich Nhat Hanh from Peace is Every Step

Poems and Readings
Week 5: Self-Control

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© Boston Medical Center Veterans Back to Health Trial Our true home is in the present moment.
To live in the present moment is a miracle.
The miracle is not to walk on water.
The miracle is to walk on the green Earth in the present moment, to appreciate the peace and beauty that are available now.
Peace is all around us-In the world and in nature-And within us-In our bodies and our spirits.
Once we learn to touch this peace, We will be healed and transformed.

It is not a matter of faith;
It is a matter of practice.
-Thich Nhat Hanh from Touching Peace: Practicing the Art of Mindful Living  I know this is a wonderful moment.