Yoga and Low Back Pain. Rachel Weiner, MD, MPH R3 March, 2018

Transcription

1 Yoga and Low Back Pain EVIDENCE AND PRACTICE Rachel Weiner, MD, MPH R3 March, 2018

2 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.

3 What is yoga?

4 What is yoga?

5 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

6 Eight limbs of yoga 1. 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, nondualistic, enlightenment Yama: Ahimsa non-harming Asteya non-steaing Satya truthfulness Brahmacharya right use of sexual energy Aparigraha not grasping Niyama: Sauca purity, cleanliness Santosha contentment Tapas discipline, enthusiasm Svadhyaya self-study Ishvarapranidhana- celebration of the spiritual

7 Yoga For Low Back Pain

8 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

9 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

10 Therapeutic Yoga for Back Pain HOLISTIC 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.

11 Therapeutic Yoga for Back Pain HOLISTIC 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.

12 Therapeutic Yoga for Back Pain HOLISTIC STRENGTH AND FLEXIBILITY MENTAL AND PHYSICAL RELAXATION Meditation Attention to breath Balancing effort and surrender Acceptance not cure

13 Therapeutic Yoga for Back Pain HOLISTIC 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

14 Therapeutic Yoga for Back Pain HOLISTIC STRENGTH AND FLEXIBILITY MENTAL AND PHYSICAL RELAXATION IMPROVED AWARENESS POSTURE Balanced posture= less stress on muscles and spine

15 Evidence and Yoga

16 Evidence and yoga... Limitations Proof of yoga is observational. There is no standard treatments in yoga.

17 Evidence Several recent reviews on yoga for non-specific low back pain. Cochrane review from January 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 minute classes per week (1 study was residential with daily practice) Comparison: No intervention Educational intervention Exercise intervention

18 Lacked blinding: Participants Providers Outcome assessment

19 Yoga Compared to Non-Exercise Controls (9 trials, N=810) At 3-4 Months Mean difference in Roland-Morris Disability Questionnaire* Mean difference in pain (0-100 scale)** (95% to -0.76) (95% to -2.06) Low Certainty of Evidence 4-6 Months (95% to -1.08) (95% to -2.25) Moderate 12 Months (95% to -0.26) (95% to -3.70) Low *Smallest effect that is likely clinically significant is 1-3 **Clinically significant predefined as a change greater than 15

20 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 (95% to 0.90) Very low 6-7 Months (95% to 0.19) MD (95% to ) Very Low *Smallest effect that is likely clinically significant is 1-3 **Clinically significant predefined as a change greater than 15

21 Conclusion Findings 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

22 Cat/Cow

23 Cat/Cow- side bend

24 Cat/Cow- twist

25 Cat/Cow Benefits: Mobility in neck, spine, shoulders, pelvis Awareness of spine Learning to move with breath-> very calming!

26 Cobra

27 Cobra Benefits: Great for improving slouching posture Strengthening spinal extensors Chest opening Stretching psoas

28 Figure Four Stretch Benefits: Flexibility in the hips (external rotators)

29 Bridge Benefits: Flexibility of psoas, chest Strengthen spinal extensors, gluteus maximus, hamstrings

30 Relaxation 1. Breathing techniques 1. 1:2 Breathing 2. Alternate Nostril Breathing 3. Chanting 2. Deep relaxation (Savasana or Corpse Pose) 3. Meditation (Quiet focus)

31

32 Tips for Patients Finding 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: - 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

33 Questions?

34 Sources Light on yoga: the definitive guide to yoga practice, B. Iyengar - Thorsons 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 Wieland L, Skoetz N, Pilkington K, Vempati R, D'Adamo CR, Berman BM. Yoga treatment for chronic non-specific low back pain. Cochrane Database of Systematic Reviews 2017, Issue 1. Art. No.: CD DOI: / CD pub2 Roland M, Fairbank J. The Roland-Morris disability questionnaire and the Oswestry disability questionnaire. Spine. 2000;25: