yoga and low back pain - uw blogs...
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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.