Running head: HOT WITH PHYSICAL THERAPY FOR LOW BACK PAIN

HOT YOGA AS A SUPPLEMENT TO PHYSICAL THERAPY FOR LOW BACK PAIN

AS A WORK-ACQUIRED MUSCULOSKELETAL INJURY

______

A Case Report

Presented to

Marieb College of Health and Human Services

Florida Gulf Coast University

In Partial Fulfillment

of the Requirement for the Degree of

Doctor of Physical Therapy

______

By

Cheryl Theresa Montecer, PT

2017

HOT YOGA WITH PHYSICAL THERAPY FOR LOW BACK PAIN

APPROVAL SHEET

This Case Report

is submitted in partial fulfillment of the requirements for

the degree of

Doctor of Physical Therapy

______Cheryl Theresa Montecer, PT

Approved: June 2017

______Kathy Swanick, DPT, MS, OCS Committee Chair / Advisor

______Ellen Donald, PhD, PT Committee Member

The final copy of this case report has been examined by the signatories, and we find that both the content and the form meet acceptable presentation standards of scholarly work in the above-mentioned discipline. HOT YOGA WITH PHYSICAL THERAPY FOR LOW BACK PAIN

ACKNOWLEDGEMENTS

The completion of this case report was made possible through the generous participation of Joe Degonia, PTA as the subject in this study. I would also like to thank

Morgan Lemos PT, DPT for her expertise in the examination of the participant and also for allowing me to observe a treatment session.

I would also like to extend my gratitude to my professors Dr. Kathy Swanick and

Dr. Ellen Donald for their mentorship in the accomplishment of this case report.

HOT YOGA WITH PHYSICAL THERAPY FOR LOW BACK PAIN 1

Table of Contents

Abstract ……………………………………………………………………………………………………………………. 2

Introduction ……………………………………………………………………………………………………………… 3

Patient History and Systems Review …………………………………………………………………………. 6

Clinical Impression 1 …………………………………………………………………………………………………. 7

Examination ……………………………………………………………………………………………………………… 8

Table 1 ………………………………………………………………………………………………………………. 10

Clinical Impression 2 ………………………………………………………………………………………………… 12

Intervention ……………………………………………………………………………………………………………. 12

Physical Therapy …………………………………………………………………………………………………. 13

Hot Yoga ……………………………………………………………………………………………………………. 14

Outcome ………………………………………………………………………………………………………………… 15

Table 2 ………………………………………………………………………………………………………………... 17

Discussion ………………………………………………………………………………………………………………. 21

References ……………………………………………………………………………………………………………… 23

HOT YOGA WITH PHYSICAL THERAPY FOR LOW BACK PAIN 2

ABSTRACT

Background and Purpose. Low back pain, as a work-acquired musculoskeletal injury (WAMI) is prevalent among physical therapists. Research suggests that yoga is a growing practice that is used as an effective therapeutic tool in alleviating pain through postures that increase flexibility and improve function. The objective of this case report is to illustrate the establishment and application of an approach of hot yoga in combination with physical therapy in the management of low back pain on a physical therapist assistant (PTA) who sustained a work-acquired musculoskeletal injury.

Case Description. A 47 year-old male PTA with a five week history of low back pain participated in this case report. The PTA was chosen based on a musculoskeletal injury sustained at work who demonstrated low back pain with numbness on his right anterolateral thigh, tightness and tenderness of his lower thoracic and lumbar spine.

The intervention consisted of seven physical therapy sessions and seven hot yoga classes.

Outcomes. After four weeks of intervention, low back pain resolved, right thigh numbness significantly decreased from 100% to 10%, and trunk flexibility increased with absence of tenderness at the thoracolumbar junction.

Discussion. A significant decrease in back impairment was observed on a patient with sub-acute low back pain after participation in the intervention of physical therapy and hot yoga. Clinical trials in the future are required to evaluate the thermoregulatory mechanism, the physiological and biomechanical effects of hot yoga, and whether it is a beneficial complement to physical therapy in the rehabilitation of low back pain. HOT YOGA WITH PHYSICAL THERAPY FOR LOW BACK PAIN 3

INTRODUCTION

Physical therapists are at a substantial risk for work-acquired musculoskeletal injury (WAMI). In a prior study by Campo et al,1 susceptibility to hazardous elements for

WAMI is due to patient encounter that involves lifting, repositioning, transferring and performing manual therapy. High levels of force application are involved in these activities which may have to be completed in unhealthy postures. These movements facilitate the risk for low back injury especially when executed on a bent, twisted or awkward positions, and repetitive tasks. Age is also associated with WAMI. As physical therapists age, focus should be geared in the development of strategies that will promote injury-free environment. In another study by Darragh et al,2 physical therapists who sustained an injury to the low back area had the highest incidence of 41% in comparison to injury of the neck which was 35%, hand 28%, shoulder 24% and the upper back 28%.

Yoga utilizes postures for stretching, strengthening and flexibility that could be advantageous to the management of low back pain.3 Yoga has affirmative results in general with pain reduction and the improvement of spine function as indicated by recent studies.4 Yoga integrates physical movement with mindful practices. Chronic pain is a mind-body experience so several researchers and people who experience chronic pain practice yoga for remedy and comfort.5 Breathing exercises (), postures

() and meditation (dhyana) are key elements in which is an ancient practice in the management of persistent pain. Randomized clinical trials are growing suggestive of yoga as an approach to address this issue.6 Current evidence based on a HOT YOGA WITH PHYSICAL THERAPY FOR LOW BACK PAIN 4 systematic review on non-pharmacological therapies for chronic low back pain indicates that yoga, as a form of mind-body intervention, has a moderate strength of evidence.

This study is for the American College of Physicians Clinical Practice Guideline.7 Physical therapists who have extensive credibility can also advocate yoga as an adjunct in the management of low back pain thus contributing to the effectiveness of the practice.

Low back pain interventions of physical therapy consist of therapeutic exercises, manual therapy, motor control exercises, spinal manipulative therapy, aerobic conditioning, physical modalities and advice on ergonomics. In a study by Azevedo et al,8 there is strong evidence that physical therapy implementation of dynamic exercises provides efficacious treatment of chronic low back pain (CLBP). This study also implies these exercises have been advocated by majority of clinical practice guidelines in the management of this condition together with results of several systematic reviews.

Heat is a therapeutic modality utilized for the treatment of paraspinal muscles and simple muscle strain disorders. Heat is efficacious on an injured muscle that is appropriate to be stretched, as it enhances the viscoelasticity of collagen in the tissues.

Moist heat is recommended since heat is absorbed deeper into the muscle tissue. Heat increases blood flow that causes vasodilatation which in turn contributes to the elimination of metabolic wastes. This also leads to the absorption of nutrients that aids in tissue repair. The metabolic by-products from injured muscles that particularly activate pain fibers are expelled so analgesia is experienced.9

The integrative approach in the assessment and treatment of chronic pain is a growing recognition in the physical therapy profession that acknowledges both HOT YOGA WITH PHYSICAL THERAPY FOR LOW BACK PAIN 5 biomedical and psychosocial obstacles to the return of function.10 Since the biopsychosocial approach is the gold standard for the management of chronic pain, yoga with a holistic path may appeal in the rehabilitation of WAMI.11 There are several studies on yoga that address low back pain, but yoga combined with heat has not been thoroughly researched. For the purpose of this case report, yoga is performed in a hot and moist environment with temperature of 105oF and 40% humidity. This type of atmosphere will facilitate sweating that may enhance the beneficial effects of yoga as a non-pharmacological solution to low back pain. Caution should be taken by those who take medications and also have conditions that may lead to heat intolerance.

Medications to control hypertension such as vasodilating agents, alpha blockers and calcium channel blockers may lead to orthostatic hypotension when a person is exposed to systemic heat. An individual with hyperthyroidism may have heat intolerance. It is advisable to receive clearance from a health care professional. Hydration hours prior to hot yoga is also highly recommended. The objective of this case report is to demonstrate how hot yoga with physical therapy assisted in the rehabilitation of a physical therapist assistant (PTA) who suffered a work-related musculoskeletal disorder.

PATIENT HISTORY AND SYSTEMS REVIEW

The patient in this case report was selected based on the mechanism of low back injury considered as a WAMI on physical therapists. The patient was a PTA in an acute care setting who injured his low back while conducting a joint camp class. The injury occurred when the PTA assumed forward flexion in squat position while stretching the knee of a patient. On the same week of injury, the PTA was assessed by a nurse HOT YOGA WITH PHYSICAL THERAPY FOR LOW BACK PAIN 6 practitioner in the employee health clinic in the hospital. An X-ray and an MRI of the lumbar spine were ordered. The X-ray revealed normal findings, whereas the MRI indicated a small foramen protrusion of disc at L3-L4 on the right side which contributed to right L3 radiculopathy. Four weeks post injury, the patient had an appointment with the neurosurgeon who made the referral to physical therapy. The patient started physical therapy and hot yoga on the fifth week. The patient reported that the injury affected his ability to manage everyday activities. Certain activities of daily living (ADL) such as showering and dressing caused discomfort. The subject continued with his employment but was cautious in lifting and assisting heavy patients due to pain. The

PTA had no prior injuries and was recreationally active, exercised at the gym several days a week, lifted weights and engaged in aerobic activities. The patient had a body mass index (BMI) in the 20th percentile. Prescribed medications for the low back injury,

Flexeril which is a muscle relaxant and Sterapred which is a corticosteroid were not taken by choice. There was no participation in any prior treatments. The goals of the patient were to be pain-free and regain 100% sensation on his right thigh, so he can perform his job and ADL with ease and comfort. The PTA also expressed desire to return to his recreational activities without restrictions.

CLINICAL IMPRESSION 1

The subject was chosen as a good candidate for the approach of physical therapy and hot yoga based on a low back injury sustained at work. Symptoms included localized, intermittent pain with intensity of 3 out 10 located on the right lower quadrant of the lumbar paraspinals. There was also mild tenderness in the HOT YOGA WITH PHYSICAL THERAPY FOR LOW BACK PAIN 7 thoracolumbar junction upon palpation. Hypertonicity in this area limited the active range of motion (AROM) of the spine which led to minor postural impairments.

Neurological examination consisted of tests for the dermatomes, myotomes and deep tendon reflexes. Sensory test revealed severe, constant numbness on the right anterolateral thigh at the L3 dermatome with 100% numbness to light touch. This symptom was of utmost concern to the patient and was most dominant when in the shower. This test result was consistent with the diagnosis of L3 radiculopathy. Muscle test indicated slight weakness of the right psoas and quadriceps femoris with increased difficulty at maximal resistance. Knee and ankle deep tendon reflexes (DTR) were symmetrical and normal. Special tests such as the prone instability test (PIT), active straight leg raise test (ASLR), sit-slump test to rule out other potential neurological pathologies were also executed with negative findings. A disease-specific disability questionnaire was beneficial to establish the level of impairment and monitor change over time. The total percentage of disability on post-intervention significantly improved.

Given that the patient had no prior back injuries and the knowledge of his condition as a

PTA, prognosis was good. However, speed of recovery and prevention of future WAMI were considered as significant factors.

EXAMINATION

Visual evaluation of the head and spine posture was done in the standing position. The inclinometer was utilized to measure forward bend AROM. The inclinometer was placed at the level of L2 in the mid-back, and the patient was instructed to bend forward as far as possible. The amount of forward bend AROM HOT YOGA WITH PHYSICAL THERAPY FOR LOW BACK PAIN 8 was recorded. The high intrarater reliability (ICC=0.92) of the inclinometer found in the study of Barrett et al,12 is also in agreement with previous studies. Back bend, side bend and active straight leg raise (ASLR) were measured with the use of a standard dual- armed goniometer. The influence of movement on symptoms such as increased pain, tightness or no change were recorded by the examiner.

Passive intervertebral motion testing (PIVM) was performed to evaluate segmental mobility and pain reproduction. PIVM was completed to detect the influence of joint mobility to deficits in AROM.10 The patient assumed the prone position with neck in neutral rotation. Posterior to anterior spring test of the lower thoracic and lumbar spine was executed centrally over the spinous processes to the vertebrae. The perception and experience of the examiner of normal movement above and below the tested segment influenced the interpretation of spinal mobility.13 PIVM has a scale from

0-6. Grade 0 ankylosed (no detectable movement), grade 1 hypomobility (considerable restriction), grade 2 hypomobility (slight restriction), grade 3 normal (expected range for body type), grade 4 hypermobility (slight increase), grade 5 hypermobility (considerable increase) and grade 6 unstable (excessive range).14

Manual muscle test (MMT) was done on the key muscles that consisted of the psoas, quadriceps femoris, tibialis anterior, extensor hallucis longus, flexor hallucis longus and hamstring in accordance to the descriptions provided by Hislop.15 Deep tendon reflexes assist in the determination of specific nerve and root affectation when accomplished as part of a neurological examination which includes sensory and motor investigation elucidated by Walker.16 Localized regions of tenderness were identified by HOT YOGA WITH PHYSICAL THERAPY FOR LOW BACK PAIN 9 manual palpation. Special tests were also completed. The manual test for lumbar joint shear instability is the prone instability test (PIT).17 Researchers have commented more recently on the potential usefulness of the ASLR in the evaluation of the lumbopelvic region neuromuscular control system in the general low back pain population.18 The slump test has been extensively recommended as a neural provocation test for the examination of patients who suffer from lower limb and spinal pain.19. The numerical pain rating scale (NPRS) which is an 11-point scale ranging from 0, no pain to 10, worst pain was used to indicate the level of pain. The NPRS has been recommended as an acceptable outcome measure for pain studies, and change thresholds have been reported for the NPRS.20 Table 1 summarizes the results of the physical examination. HOT YOGA WITH PHYSICAL THERAPY FOR LOW BACK PAIN 10

Table 1. Results of the Physical Examination Test Item Pre-intervention Post-intervention

Standing Posture Head Neutral Neutral Cervical Spine Forward head Slightly decreased forward head Thoracic Spine Kyphosis decreased No change Lumbar Spine Lordosis decreased No change Iliac Crests Level No change

Spine AROM/Symptoms Forward bend 41o/lumbar tightness 81o/no tightness Back bend 5o/pain 20o/no pain Side bend left 10o/right side tightness 20o/no tightness right 20o/no symptoms 24o/no symptoms ASLR left 75o/no symptoms 90o/no symptoms right 70o/no symptoms 90o/no symptoms

PIVM Normal from segments Normal from segments T11-S1; 3/6 grade T11-S1; 3/6 grade

MMT of Key Muscles Psoas left 5/5 5/5 right 4+/5 with increased 5/5 difficulty Quadriceps left 5/5 5/5 right 4+/5 with increased 5/5 difficulty Tibialis anterior left 5/5 5/5 right 5/5 5/5 Extensor Hallucis Longus left 5/5 5/5 right 5/5 5/5 Flexor Hallucis Longus left 5/5 5/5 right 5/5 5/5

Hamstrings left 5/5 5/5 right 5/5 5/5

DTR Knee jerk left/right normal/normal normal/normal Ankle jerk left/right normal/normal normal/normal HOT YOGA WITH PHYSICAL THERAPY FOR LOW BACK PAIN 11

Table 1. Results of the Physical Examination (Continued) Test Item Pre-intervention Post-intervention

Manual Palpation Paraspinals left No tenderness No tenderness right Hypertonicity with mild No tenderness tenderness at the thoracolumbar junction

Sensory Testing Light touch on the left thigh No numbness No numbness Light touch on the right thigh Severe, constant numbness Minimal numbness at L3 dermatomea at L3 dermatome 100% numbness 10% numbness

Special Tests PIT Negative Negative ASLR Negative Negative Sit-Slump Test Negative Negative

NPRS Lumbar Paraspinals lower quadrant left 0/10 0/10 lower quadrant right 3/10 0/10

Abbreviations: AROM, active range of motion measured in degrees; ASLR, active straight leg raise; PIVM, passive intervertebral motion test; MMT, manual muscle test; DTR, deep tendon reflex; PIT, prone instability test; NPRS, numeric pain rating scale. aL3 dermatome corresponds to the anterolateral thigh region.

HOT YOGA WITH PHYSICAL THERAPY FOR LOW BACK PAIN 12

CLINICAL IMPRESSION 2

The patient presentation upon physical examination was a qualifying consideration in the participation of this patient in the study. The patient exhibited limitation in trunk flexibility, decreased strength of the right psoas and quadriceps muscles and numbness on the right anterolateral thigh indicative of the side of injury.

There were also mild postural deficits. These findings suggested that excessive biomechanical demands utilized at work and performed in awkward postures contributed to the low back injury. Literature defines the duration of symptoms as acute when the length of the occurrence is less than 6 weeks, sub-acute between 6 to 12 weeks and chronic if symptoms exist for more than 3 months.8 The chronic phase should be prevented as people in this stage will probably feel discouraged to go back to work.

For the purpose of this case report, hot yoga which is known to increase flexibility and strength may contribute to a faster recovery with lasting effects and may also avoid the chronic phase. This approach may also avert the recurrence of low back injury and possible future WAMI.

INTERVENTION

The intervention lasted for four weeks. The patient attended physical therapy twice a week for 45 minutes each session. Hot yoga was also twice a week for 90 minutes each class. The patient missed one physical therapy session on the second week and one hot yoga class on the third week. The patient attended a total of seven physical therapy sessions and seven hot yoga classes. HOT YOGA WITH PHYSICAL THERAPY FOR LOW BACK PAIN 13

Physical Therapy

Manual therapy and therapeutic exercises comprised the physical therapy interventions. Low back pain rehabilitation that incorporated soft tissue mobilization and exercises have been advocated as evidence-based treatment in practice guidelines and systematic reviews.21 The patient walked briskly forward and backward on the treadmill for five minutes prior to commencing each session as a dynamic warm up.

Manual Therapy. Manual therapy technique included soft tissue mobilization through multidirectional myofascial stretching of the paralumbars. Patients with low back pain are also managed with a familiar treatment of manual fascial-muscular lengthening therapy (FMLT). Based on the study by Avrahami et al,22 maximum voluntary trunk extension increased for low back pain patients with a modest but meaningful decrease in disability and pain when FMLT was applied as a treatment approach. The tender right lumbar paraspinals with length restriction were targeted for soft tissue mobilization.

Therapeutic Exercise. Therapeutic exercises were designed for the core, hip and lumbar stabilization. There is some evidence that the exact biological efficacy of motor control exercises, also referred to as specific stabilization exercises can alter the behavior of deep trunk muscles, the transversus abdominis and the multifidus during functional tasks.23 This improvement in coordination of trunk muscles due to the reduction in load and the refinement in the quality of movement illustrate the effects of stabilization exercises during activity. The general response to rehabilitation and pain are also better. The deep trunk muscles in low back pain sufferers tend to lag in HOT YOGA WITH PHYSICAL THERAPY FOR LOW BACK PAIN 14 contraction during strenuous labor which causes spinal rigidity, instability and future recurrence of the condition.23 These exercises were performed by the patient during physical therapy. On the third and fourth weeks, the patient started stretching the right psoas and quadriceps muscles. The patient was also provided a copy of his home exercise program (HEP) and was encouraged to adhere to this exercise regimen.

Customized and supervised exercise programs with emphasis on compliance that include strengthening and stretching are the most beneficial in alleviating pain and facilitating function in patients with low back injury.24

Hot Yoga

Hot yoga is a trend in Hatha yoga practice which involves exposure to ambient temperature to promote health benefits through acclimatization. There are limited reports on the health benefits of hot yoga and the mechanisms involved are still unclear. There are numerous research studies showing positive influence of traditional

Hatha yoga practice on human health.25

Hot yoga was performed in a carpeted room with an average temperature of

105oF and 40% humidity for 90 minutes. There were 26 traditional poses assumed in the same sequence which incorporated the practice of breathing, balance, strength, flexibility and focus. The postures consisted of spinal flexion, extension, lateral bending and rotation. Each posture was repeated twice, held for approximately 10 to 30 seconds each time. The class comprised of 12 poses in the standing series and 14 poses in the floor series. In the floor series, each posture was followed by the dead man’s posture

(savasana) assumed for 20 seconds. Quietude was strictly enforced during class as part HOT YOGA WITH PHYSICAL THERAPY FOR LOW BACK PAIN 15 of energy conservation and undistracted focus. Breathing was through the nose. Mouth breathing was discouraged. Essentials included a , large towel and water.

Instructions were provided by the teacher who walked around the room. Corrections, insights and benefits of each posture were also explained.

OUTCOME

The measured outcomes indicated improvements experienced by the patient.

The absence of low back pain and the significant increase in spine AROM allowed the patient to bend, lift and squat with ease and comfort with no tightness observed. The patient was more aware in the implementation of proper body mechanics at work and with ADL to prevent re-injury. The marked decrease in numbness on the right anterolateral thigh from 100% to 10% was much appreciated by the patient as this has contributed to less concern about the symptom and also provided assurance in the effectiveness of the treatment protocol.

On the first yoga class, the patient reported that extension postures elicited tightness on the low back area and found this to be more challenging than the flexion postures. Heat was a significant and noticeable factor. On the second yoga class, the patient noted a slight increase in the soreness of his low back which was attributed in an attempt to assume the postures without modification. The patient had not adapted to the heat yet. There was still 100% numbness on the right thigh described as bothersome. On the third yoga attendance, heat was an extreme factor which increased the struggle to finish the class reported as the hottest experience ever. On the fourth yoga class, the patient still perceived tightness on the low back although with slight HOT YOGA WITH PHYSICAL THERAPY FOR LOW BACK PAIN 16 improvement. It was a challenge to assume extension postures. On the fifth, sixth and seventh classes, the patient observed a decrease in tightness during extension postures and was able to complete some of the difficult postures with less discomfort. The patient had also acclimated to the heat. On the last yoga class, the patient admitted to absence of pain and the numbness on the right thigh had notably reduced.

The Oswestry Disability Index (ODI) has been developed to assess pain-related disability in people with acute, sub-acute or chronic low back pain. The ODI has high internal consistency Cronbach’s a=0.71-0.87 and test-retest reliability with intraclass correlation coefficient of 0.84, 95% confidence interval 0.73-0.91.26 The ODI consists of

10 items wherein one item is on pain and nine items are on ADL. The score of the patient decreased from 36% considered to have moderate disability to 2% considered to have minimal disability. Upon completion of the modified ODI questionnaire in pre- intervention, the patient had pain when lifting, walking, sitting, standing, sleeping and traveling. After four weeks of intervention, the patient was pain-free. The patient slowly returned to engaging in recreational activities and signed up for gym membership. The patient also claimed to have safely resumed normal social life and employment without restrictions.

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Table 2. Modified Oswestry Low Back Pain Questionnairea Item Pre-intervention Post-intervention Score A Score B

1 – Pain Intensity B The pain comes and goes and is mild.(0)b 0 __The pain is mild and does not vary much.(1) A The pain comes and goes and is moderate.(2) 2 __The pain is moderate and does not vary much.(3) __The pain comes and goes and is severe.(4) __The pain is severe and does not vary much.(5)

2 – Person Care __I do not have to change my way of washing or dressing to avoid pain. B I do not normally change my way of 1 washing or dressing even though it causes me pain. A Washing and dressing increases the pain, 2 but I manage not to change my way of doing it. __Washing and dressing increase the pain and I find it necessary to change my way of doing it. __Because of the pain, I am unable to do some washing and dressing without help. __Because of the pain, I am unable to do any washing and dressing without help.

3 – Lifting (skip if you have not attempted lifting since the onset of your low back pain) B I can lift heavy weights without extra low 0 back pain. __I can lift heavy weights but it causes extra pain. __Pain prevents me lifting heavy weights off the floor. A Pain prevents me lifting heavy weights off 3 the floor, but I can manage if they are conveniently positioned (ex. on the table). HOT YOGA WITH PHYSICAL THERAPY FOR LOW BACK PAIN 18

Table 2. Modified Oswestry Low Back Pain Questionnaire (Continued) Item Pre-intervention Post-intervention Score A Score B

3 – Lifting (skip if you have not attempted lifting since the onset of your low back pain) __Pain prevents me lifting heavy weights but I can manage light to medium weights if they are conveniently positioned. __I can only lift light weights at the most.

4 – Walking B I have no pain walking. 0 A I have some pain on walking, but I can still 1 walk my required normal distances. __Pain prevents me from walking long distances. __Pain prevents me from walking intermediate distances. __Pain prevents me form walking even short distances. __Pain prevents me from walking at all.

5 – Sitting B Sitting does not cause me pain. 0 __I can sit as long as I need provided I have my choice of sitting surface. A Pain prevents me from sitting more than 2 1 hour. __Pain prevents me from sitting more than ½ hour. __Pain prevents me from sitting more than 10 minutes. __Pain prevents me from sitting at all.

6 – Standing B I can stand as long as I want without pain. 0 __I have some pain while standing, but it does not increase with time. A I cannot stand for more than 1 hour 2 without increasing pain.

HOT YOGA WITH PHYSICAL THERAPY FOR LOW BACK PAIN 19

Table 2. Modified Oswestry Low Back Pain Questionnaire (Continued) Item Pre-intervention Post-intervention Score A Score B

6 – Standing __I cannot stand more than ½ hour without increasing pain. __I cannot stand for more than 10 minutes without increasing pain. __I avoid standing because it increases the pain immediately. 7 – Sleeping B I have no pain while in bed. 0 A I have pain in bed, but it does not 1 prevent me from sleeping well. __Because of pain I sleep only ¾ of normal time. __Because of pain I sleep only ½ of normal time. __Because of pain I sleep only ¼ of normal time. __Pain prevents me from sleeping at all.

8 – Social Life B My social life is normal and it gives me 0 no pain. __My social life is normal, but it increases the degree of pain. A Pain prevents me from participating in 2 more energetic activities (ex. sports, dancing). __Pain prevents me from going out very often. __Pain has restricted my social life to home. __I hardly have any social life because of pain.

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Table 2. Modified Oswestry Low Back Pain Questionnaire (Continued) Item Pre-intervention Post-intervention Score A Score B 9 – Traveling B I get no pain while traveling. 0 __I get some pain while traveling, but none of my usual forms of travel make it any worse. A I get some pain while traveling, but it 2 does not compel me to seek alternative forms of travel. __I get extra pain while traveling that requires me to seek alternative forms of travel. __Pain prevents all forms of travel except that done lying down. __Pain restricts all forms of travel.

10 – Employment/Homemaking B My normal job/homemaking duties do 0 not cause pain. A My normal job/homemaking duties 1 cause me extra pain but I can still perform all that is required of me. __I can perform most of my job/ homemaking duties, but pain prevents me from performing more physically stressful activities (ex. lifting, vacuuming, etc). __Pain prevents me from doing anything but light duties. __Pain prevents me from doing even light duties. __Pain prevents me from performing any job or homemaking chores.

Total Percent of Disabilityc 36%d 2%

HOT YOGA WITH PHYSICAL THERAPY FOR LOW BACK PAIN 21

Table 2. Modified Oswestry Low Back Pain Questionnaire (Continued) Abbreviations: A, Pre-intervention answer; B, Post-intervention answer. a Data adapted from Fairbank JC and Pynsent PB.27 b Point value for each item. c All 10 sections were completed and scores were doubled to indicate percentage of disability. d Interpretation of Scores: 0-20% minimal disability. The patient can cope with most living activities. Usually no treatment is indicated apart from advice on lifting, sitting and exercise; 21-40% moderate disability. The patient experiences more pain and difficulty in sitting, lifting and standing. Travel and social life are more difficult and they may be disabled from work. Personal care and sleeping are not grossly affected and the patient can usually be managed by conservative means; 41-60% severe disability. Pain remains the main problem in this group but ADL are affected. These patients require a detailed investigation; 61-80% crippled. Back pain impinges on all aspects of the patient’s life. Positive intervention is required; 81-100% of these patients are bed-bound or exaggerating their symptoms.

DISCUSSION

Research indicates that there is a 91% work-related musculoskeletal injury and pain among physical therapists.2 Like other chronic pain condition, CLBP can advance further from a symptomatic condition to a complicated one that involves continuous anatomic and functional alterations in the central nervous system that may go beyond structural adjustments in the back. There have been various techniques implemented for CLBP sufferers with some clinical gain but recurrent episodes are possible within one year.8

This case report sought to address hot yoga as a supplemental treatment to low back pain that may have lasting effects on the recovery phase, avoid recurrence and also offer preventative advantages for other future WAMI. Patients with low back pain have muscle spasm, decreased flexibility and strength with postural deficits. Yoga is a growing practice that addresses these concerns. In a study by Koneru and Tanikonda,28 yoga was found to be more effective than other modes of physical activities in the treatment of work-acquired musculoskeletal disorder among dentists because of its HOT YOGA WITH PHYSICAL THERAPY FOR LOW BACK PAIN 22 more controlled nature and positive effects on the psychological stress and strain. This case report has shown how hot yoga combined with physical therapy was used to rehabilitate a male PTA with history of low back pain sustained at work. There were physical and radiological evidence of disc protrusion at L3-L4 on the right side with L3 radiculopathy. Yoga has been shown to be an effective non-pharmacological treatment for low back pain,4,5,6 but its efficacy when performed in a hot, humid environment is yet to be explored. The patient in this case report demonstrated meaningful improvements in spine AROM, strength, sensory deficits, tenderness and ODI score manifested by increase in function. The quality of life of the patient was also upgraded due to absence of pain in the performance of ADL and work. Within a month of intervention, the symptoms have substantially resolved with only 10% residual sensory deficit on the right thigh. These changes suggest that hot yoga may be an efficacious approach in the management of low back pain when combined with physical therapy. It is therefore imperative to balance flexibility and lumbar stability for a successful rehabilitation of low back injury.

This study only involved a single patient and the duration was only for a month.

Future research is necessary to determine the physical and physiological effects, the biomechanical parameters and the thermoregulatory mechanism of hot yoga. Future clinical trials may involve a large number of participants and a longer duration of the intervention.

HOT YOGA WITH PHYSICAL THERAPY FOR LOW BACK PAIN 23

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