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Yoga for Anxiety

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Yoga for Anxiety Yoga and Low Back Pain EVIDENCE AND PRACTICE Rachel Weiner, MD, MPH R3 March, 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 yoga 1. The Yamas – ethical guidelines Yama: 2. The Niyamas – spiritual observances • Ahimsa – non-harming • Asteya– non-steaing 3. Asana– postures • Satya– truthfulness 4. Pranayama– breathing exercises • Brahmacharya– right use of sexual energy 5. Pratyahara– withdrawal of senses, turning • Aparigraha– not grasping the senses inward Niyama: 6. Dharana– one pointed awareness, • Sauca– purity, cleanliness maintaining focus • Santosha– contentment 7. Dhyana– meditation • Tapas– discipline, enthusiasm • Svadhyaya– self-study 8. Samadhi–connection to oneness, non- • Ishvarapranidhana- celebration of the dualistic, enlightenment 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% • 2012 NHIS in US: ◦ Among people with resolved episode of • Over 21 million adults had tried low back pain, 24%-74% will have yoga in previous year recurrent episode in 1 year. • 19.7% of these yoga users ◦ Sometimes known etiology, but more reported it was specifically for frequently it is non-specific. back pain ◦ Chronic low back pain > 3 months 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. 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. Therapeutic Yoga for Back Pain HOLISTIC STRENGTH AND FLEXIBILITY MENTAL AND PHYSICAL RELAXATION ◦Meditation ◦Attention to breath ◦Balancing effort and surrender ◦Acceptance not cure 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 Therapeutic Yoga for Back Pain HOLISTIC 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. Evidence Several 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 Certainty Mean difference in pain Roland-Morris Disability of (0-100 scale)** Questionnaire* Evidence At 3-4 -2.18 (95% -3.60 to -0.76) -4.55 (95% -7.04 to -2.06) Low Months 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 Mean difference in pain Certainty Disability Questionnaire (0-100 scale)* 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 Very Low -15.32) *Smallest effect that is likely clinically significant is 1-3 **Clinically significant predefined as a change greater than 15 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 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 Benefits: • Flexibility in the hips Figure Four Stretch (external rotators) Bridge Benefits: • Flexibility of psoas, chest • Strengthen spinal extensors, gluteus maximus, hamstrings Relaxation 1. Breathing techniques 2. Deep relaxation (Savasana 1. 1:2 Breathing or Corpse Pose) 2. Alternate Nostril Breathing 3. Meditation (Quiet focus) 3. Chanting 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: - www.iayt.org “Take a step, Online Options: no matter - YouTube: Yoga with Adrienne how small.” - Yoga International -B.K.S. Iyengar Try sharing one of the poses we discussed today. Questions? Sources Light 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 for chronic 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..
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