Yoga and Low Back PainEVIDENCE AND PRACTICE

Rachel Weiner, MD, MPH R3March, 2018

Objectives:1. Introduction to yoga and what yoga has to offer in it’s approach to low back pain

2. Briefly review the evidence

3. Teach yoga poses for low back pain that you can share with patients

4. Practice yoga together

5. Discuss strategies for bringing yoga to your patients.

What is yoga?

What is yoga?

What is yoga?A path of spiritual enlightenment.◦ From India, around the 7000 BCE.◦ Close ties to Hinduism and to Ayurvedic medicine◦ Illusion of separate self is source of suffering◦ Disease and discomfort are an obstacle to

enlightenment.

“A systematic technology to improve the body, understand the mind, and free the spirit.”

Therapeutic yoga = the use of yoga to help manage health problems and reduce symptoms

Eight limbs of yoga1. The Yamas – ethical guidelines

2. The Niyamas – spiritual observances

3. Asana– postures

4. Pranayama– breathing exercises

5. Pratyahara– withdrawal of senses, turning the senses inward

6. Dharana– one pointed awareness, maintaining focus

7. Dhyana– meditation

8. Samadhi–connection to oneness, non-dualistic, enlightenment

Yama:• Ahimsa – non-harming• Asteya– non-steaing• Satya– truthfulness• Brahmacharya– right use of sexual energy• Aparigraha– not graspingNiyama:• Sauca– purity, cleanliness• Santosha– contentment• Tapas– discipline, enthusiasm• Svadhyaya– self-study• Ishvarapranidhana- celebration of the

spiritual

Yoga For Low Back Pain

Low Back Pain and Yoga

◦ Estimates of lifetime prevalence of back pain vary from 40-85%

◦ Among people with resolved episode of low back pain, 24%-74% will

have recurrent episode in 1 year.

◦ Sometimes known etiology, but more frequently it is non-specific.

◦ Chronic low back pain > 3 months

◦ Predictors are primarily psychosocial: mental illness, poor coping like fear

avoidance or catastrophizing, high baseline functional impairment

Low Back Pain and Yoga◦ Estimates of lifetime prevalence of

back pain vary from 40-85%

◦ Among people with resolved episode of

low back pain, 24%-74% will have

recurrent episode in 1 year.

◦ Sometimes known etiology, but more

frequently it is non-specific.

◦ Chronic low back pain > 3 months

• 2012 NHIS in US:

• Over 21 million adults had tried

yoga in previous year

• 19.7% of these yoga users

reported it was specifically for

back pain

Therapeutic Yoga for Back PainHOLISTIC◦Look at entire web of causation

◦ Flexibility, strength, posture, job, emotions, social connections, sense of purpose

◦Health is optimizing physical, emotional, and spiritual well being.

Therapeutic Yoga for Back PainHOLISTIC

STRENGTH AND FLEXIBILITY◦Balance between strength and flexibility

◦Low back pain may be due to:◦ Tight hip rotators, psoas, or hamstrings

◦ Weak spinal extensors or abdominal muscles.

Therapeutic Yoga for Back PainHOLISTIC

STRENGTH AND FLEXIBILITY

MENTAL AND PHYSICAL RELAXATION◦Meditation

◦Attention to breath◦Balancing effort and surrender

◦Acceptance not cure

Therapeutic Yoga for Back PainHOLISTIC

STRENGTH AND FLEXIBILITY

MENTAL AND PHYSICAL RELAXATION

IMPROVED AWARENESS◦See what is harmful or helpful

◦Bring awareness into day to day activities

◦Catch early warning signs◦Patient empowerment

Therapeutic Yoga for Back PainHOLISTIC

STRENGTH AND FLEXIBILITY

MENTAL AND PHYSICAL RELAXATION

IMPROVED AWARENESS

POSTURE◦Balanced posture= less stress on muscles and spine

Evidence and Yoga

Evidence and yoga. . . Limitations

Proof of yoga is observational.

There is no standard treatments in yoga.

EvidenceSeveral recent reviews on yoga for non-specific low back pain.

Cochrane review from January 2017.◦ 12 RCTs (1080 partcipants)

◦ Ages 43 to 48., mostly white, many with college educations

◦ Intervention: ◦ All included meditation, relaxation, or breathing in combination with physical postures

◦ 1-3 45-90 minute classes per week (1 study was residential with daily practice)

◦ Comparison: ◦ No intervention

◦ Educational intervention

◦ Exercise intervention

Lacked blinding:◦Participants

◦Providers

◦Outcome assessment

Yoga Compared to Non-Exercise Controls(9 trials, N=810)

Mean difference in

Roland-Morris Disability

Questionnaire*

Mean difference in pain

(0-100 scale)**

Certainty

of

Evidence

At 3-4

Months-2.18 (95% -3.60 to -0.76) -4.55 (95% -7.04 to -2.06) Low

4-6 Months -2.15 (95% -3.23 to -1.08) -7.81 (95% -13.37 to -2.25) Moderate

12 Months -1.36 (95% -2.42 to -0.26) -5.40 (95% -14.50 to -3.70) Low

*Smallest effect that is likely clinically significant is 1-3**Clinically significant predefined as a change greater than 15

Yoga Compared to Non-Yoga Exercise Controls(4 trials, N=394)

Mean difference in Roland-Morris

Disability Questionnaire

Mean difference in pain

(0-100 scale)*

Certainty

At 4 months -0.99 (95% -2.87 to 0.90) Very low

6-7 Months -0.20 (95% -0.59 to 0.19) MD 20.40 (95% -25.48 to

-15.32)

Very Low

*Smallest effect that is likely clinically significant is 1-3**Clinically significant predefined as a change greater than 15

ConclusionFindings consistent with previous reviews.

Yoga likely:◦ more effective than non-exercise interventions (low to moderate certainty)

◦ at least as effective than non-yoga exercise interventions (very low certainty).

There is not good evidence to say:◦ That one style of yoga is superior to another

◦ Which postures or tools in yoga are most helpful

◦ If the benefit is derived mainly from physical postures or the meditation/relaxation

Cat/Cow

Cat/Cow- side bend

Cat/Cow- twist

Cat/Cow

Benefits:• Mobility in neck, spine,

shoulders, pelvis• Awareness of spine• Learning to move with

breath-> very calming!

Cobra

Cobra

Benefits:• Great for improving

slouching posture• Strengthening spinal

extensors• Chest opening• Stretching psoas

Figure Four Stretch

Benefits:• Flexibility in the hips

(external rotators)

Bridge

Benefits:• Flexibility of

psoas, chest• Strengthen spinal

extensors, gluteus maximus, hamstrings

Relaxation1. Breathing techniques

1. 1:2 Breathing

2. Alternate Nostril Breathing

3. Chanting

2. Deep relaxation (Savasanaor Corpse Pose)

3. Meditation (Quiet focus)

Tips for PatientsFinding a public class:

- Restorative, gentle, beginner, Iyengar, Hatha, Viniyoga

- Encourage patient to contact teacher or studio ahead of class

- Listen to your own cues

Yoga therapist:

- www.iayt.org

Online Options:

- YouTube: Yoga with Adrienne

- Yoga International

Try sharing one of the poses we discussed today.

“Take a step, no matter

how small.”-B.K.S. Iyengar

Questions?

SourcesLight on yoga: the definitive guide to yoga practice, B. Iyengar - Thorsons - 2015

Yoga as medicine: the yogic prescription for health & healing, Timothy McCall - Bantam – 2012

Yoga anatomy, Leslie Kaminoff-Amy Matthews-Sharon Ellis - Human Kinetics – 2012

Yoga mind, body & spirit: a return to wholeness, Donna Farhi-Sonya Rooney - St. Martin's Griffin - 2000

Wieland L, Skoetz N, Pilkington K, Vempati R, D'Adamo CR, Berman BM. Yoga treatment forchronic non-specific low back pain. Cochrane Database of Systematic Reviews 2017, Issue 1. Art. No.: CD010671. DOI: 10.1002/14651858.CD010671.pub2

Roland M, Fairbank J. The Roland-Morris disability questionnaire and the Oswestry disability questionnaire. Spine. 2000;25:3115-3124.