Yoga as Therapy

Yoga is a traditional exercise form which is said to have existed for thousands of years, but over the last 20 years we have seen a rapid grown in yoga classes in the Western world with this type of exercise becoming the latest exercise fashion. In parallel with this growth has been an interest in the use of yoga as therapy, building yoga exercises into a structured rehabilitation program. Let’s take a brief look at yoga and the evidence of its use in rehabilitation, focussing on the modifications required to bring this ancient exercise form into the fold of evidence based practice as used by NHS trained physiotherapists.

What is yoga?

The term yoga literally means union (yoke) and refers to the union between body, mind, emotion, and breath. It is a system of exercise originally based on Hindu teaching, but nowadays a modified form of yoga is normally practised, which falls into the category of mind-body exercise alongside activities such as Pilates, and Tai chi.

Yoga can be seen as mindful activity, in that it combines both physical exercise and a mindfulness approach to movement. Participants are encouraged to pay attention to the feeling of their body during exercise.

When we perform a physical action such as exercise, we gain information about our movement to fine tune actions and make them more efficient. This process is called cueing, and cues themselves may be external (in the local environment) or internal (within our body). External cues are often used in gym based exercise. Working harder to the beat of music, modifying our posture by looking in the mirror, running on a treadmill for a specific time, lifting a certain amount of weight – these are all external cues giving us information about our performance. External cues of this type focus on achievement and are said to be outcome based. Internal cues focus on what we are feeling. Can you feel your knee passing over your foot, have you tightened your thigh muscles, how is your breathing? The attention is internal, and focused on the process of carrying out the exercise rather than the outcome.

In yoga practice, there is also an emphasis on paying special attention to the breath. This concept of awareness of the breath is central to the mindfulness approach used nowadays in stress management, and as such yoga is often used to target psychological conditions such as stress and depression, and well as physical conditions such as joint and muscle pain. Constant external stimuli such as computers, TVs, smart phones, and advertising all affect us by generating an emotional effect. An extreme example of this is how your heart rate and blood pressure can change by simply watching a frightening movie for example. Stress often increases as external stimuli become stronger and more frequent. One of the focusses of relaxation training is to draw the attention back into the body, and in yoga this is done naturally as part of the physical practice of yoga postures.

In classical yoga postures (asana) are performed either in isolation or linked into a sequence. Students are encourage to breath normally and not hold their breath, and this awareness of the breath later leads into breath control (pranayama) which utilises breathing exercises in specific postures. Internal cueing is also encouraged, and this progresses to concentration (dharana) and finally relaxation / meditation (dhyana).

A typical yoga class begins with a centring activity designed to act as a gap between the activities of daily living and the focus required in the yoga class. This is classically a seated posture requiring the participant to close their eyes and focus on their breathing for example, thus turning their attention inward towards their body and away from environmental stimuli. The body of the yoga class uses exercises typically practised on a non-slip (sticky) mat and often uses basic props such as foam blocks, wooden bricks, and webbing belts. Exercises are practised in a number of starting positions including lying, floor sitting, chair sitting, kneeling and both free and wall support standing. Yoga poses are normally taught within a class format but may also be practiced on a one-to-one personal training basis, a style more appropriate to early rehabilitation. Exercises are typically practised individually but partner work can also be used.

Normally a yoga class will involve several postures progressing in intensity, and finishing with a relaxation and / or meditation session. The postures are often held for a number of seconds, and clients are encouraged to relax and breathe normally throughout performance. Breath holding (Valsalva manoeuvre), straining, facial expressions of effort, and verbal responses are discouraged, clearly differentiating yoga practice from a gym workout for example. Postures are normally practised symmetrically with emphasis on good alignment as well as range of motion. In addition counter poses are often used to prevent stress accumulation within the tissues. For example postures emphasising spinal flexion are often countered by those which emphasise extension.

Body alignment when performing poses is usually compared to an idealised version typically presented by a yoga book, organisation, or senior practitioner. Sometimes the reasoning behind the idealised postures lacks clear scientific evidence.

Classical yoga usually claims that poses are passed down over the centuries from teacher (master) to pupil, and many organisations claim to represent the true postures. Scientific scrutiny has challenged the claim of all yoga postures being ancient and the techniques unchanged over millennia (Singleton 2010). Where yoga poses are used for rehabilitation it is essential that an emphasis is placed on good body alignment using knowledge of anatomy, physiology, and body mechanics.

Yoga postures

Yoga postures (asanas) have individual names which may describe the general body shape, an animal which the posture is said to resemble, or an individual after whom the pose is named. Poses have both Western and Sanskrit names, so for example Mountain pose is also called Tadasana, from the Sanskrit Tada meaning mountain and asana meaning posture.

Several factors should be considered when performing a yoga asana (table 1). Some of these concern body mechanics and are fairly universal to good exercise practice. Others differ from standard exercise practice due to the mind-body nature of yoga. One of the similarities with modern practice is the use in yoga of Bandas or body locks. These will be familiar to any therapist or exercise professional, although perhaps not in name. Mula Bandha (root lock) is essentially engaging the pelvic floor, Uddiyana Bandha (abdominal lock) the lower abdominal muscles, and Jalandhara Bandha (throat lock) the deep neck flexors through the use of a chin tuck action. Bandhas are often used during exercise to aid firmness of a posture and to provide its root; expressions familiar to any exercise professional using core stability for example.

Table 1. Important factors in Yoga posture practice

Good alignment is essential to yoga practice, and often props are used to allow an individual to perform a yoga pose even where they have physical characteristics which would limit them. So for example when reaching into a forward bend (Utanasana) an individual with tight hamstring muscles is unable to touch the floor to take their bodyweight. Wooden yoga bricks may be used to bring the floor up to the student so they can take their weight onto their hands even though their flexion range is limited. Similarly is sitting forward bend (Pashimotonasana) an individual who cannot reach their feet can be given a yoga belt, and someone you cannot rest their head onto their legs a folded blanket or bolster to allow them to rest is a higher (less flexed) body position.

Yoga is described as a mind-body activity, and mindfulness is an awareness of body sensations and the breath as you practice the asanas. As highlighted above, traditional gym training there are often distractions which take a users attention outside their body. Music, TV screens playing music videos, and mirrors, are all features which take the attention away from the body. By focusing on bodily sensations such as the firmness of a muscle or the precise position of the limb, as well as noticing the breath and the effect that this has on the posture, the users attention is drawn within themselves. Further, anxiety can occur in general life by constantly thinking of what the future may bring or regretting what the past has already brought. One of the aims of mindfulness meditation is to focus attention on the present moment. Again yoga can help with this by stressing to the user that they focus on the body sensations of the exercise stage they are in at the moment, rather than being goal focused on the end result of an asana performance.

Focusing the attention on body sensation also aids proprioception. This can be further enhanced by the yoga emphasis on movement precision during practice. It is interesting to note that exercises which contain “an intuitive search for elegance, pleasure and beauty” (Schleip and Muller 2013) such as yoga, martial arts and dance have been found to be amongst the most effective at enhancing proprioception.

Yoga is obviously an exercise associated with stretching and a high degree of flexibility in practitioners. In addition to range of motion, the emphasis on extension of an asana, is important. Reaching upwards and outwards to lengthen the body and limbs during a pose, and allowing unrestricted chest movement to facilitate unhindered breathing should be emphasised throughout yoga practice.

Yoga posture examples

To illustrate the points introduced above, let’s look at two yoga postures and their modifications for use within rehabilitation.

Mountain pose (Tadasana)

Purpose: To teach standing body alignment is a preparation for further poses, and to increase appreciation of optimal posture.

Preparation: Begin standing with your feet together and hands by your sides, palms facing inwards.

Action: Take your weight equally between your right and left foot, and between the toes and heel on each foot. Tighten your thigh muscles (quadriceps) to draw your knees straight and together. Lengthen your spine reaching the crown of your head upwards, draw your shoulder blades together slightly to open your chest. Straighten your arms reaching your fingertips downwards towards your outer ankle bones (lateral malleolus). Maintain the position breathing normally.

Tips: Some individuals hyperextended their knees when they tighten the quadriceps muscles. To avoid this action focus on maintaining a straight vertical line from your hips through your knees to your ankles (posture line). In addition avoid over arching your lumbar spine (hollow back posture) by gently drawing your abdominal muscles inwards and tailbone downwards (minimal posterior pelvic tilt towards neutral lumbar position). Tactile (touch) cueing can be used by placing a slim yoga block between the inner thighs. The action is a simultaneous contraction of the quadriceps and hip adductors to squeeze onto the block and draw the knees together

For those with very tight, rounded shoulders it is helpful to practice the pose with your back against a wall. Focus on drawing the shoulders back to press against the wall (retraction) before reaching the fingertips downwards to the outer ankles. An additional method is to grip a yoga belt in each hand and loop it beneath the feet. The belt holds the scapulae in a depressed position, preventing elevation as the shoulders are braced.

Triangle (Trikonasana)

Purpose: To lengthen the side trunk and outer hip.

Preparation: Begin standing on a yoga mat with your feet approximately one leg length apart toes facing forwards. Stretch your arms out sideways (shoulder abduction) keeping your elbows straight and palms facing the floor.

Action: In stages –

Turn your right leg outwards (lateral rotation of the hip) so that your toes face the short edge of the mat, and turn your leg in slightly (minimal medial rotation of the hip). Reach your right hand out to the side, and then downwards placing it onto your right shin, while at the same time reaching your left hand upwards towards the ceiling. Avoid allowing the left side of your pelvis to roll forwards, or the lower side of your trunk to shorten (side flexion, concave towards the floor). The action of reaching out horizontally with the arm is a useful tactile cue to avoid shortening the lower side of the trunk. Keep the pelvis aligned so that the hip joints are stacked (right and left joints aligned in a vertical position). Open your chest and extend your thoracic spine into a light shoulder retracted position. Reach with your left arm upwards and press with your right hand onto your shin to come out of the pose. Repeat the action on the left side of the body.
Perform a limited range action taking the right hand down to a chair, placing your hand in the centre of the chair and keeping your arm straight. The upper arm may be straightened as in the classic pose, or kept bent to aid balance. To increase range further use a wooden yoga block placed with its long edge aligned vertically. The block should be aligned with your centre shin.
To improve alignment perform the with your back towards the wall, trying to press the upper pelvis backwards against the wall to maintain the stacked hip position.
To reduce balance demand, perform the standard pose but keep your left hand on your hip, or place your hand behind your tailbone (sacrum) to encourage chest opening.
To perform the revolved triangle pose (parvritta trikonasana), begin with your feet wide apart and your arms stretched out horizontally in line with the long edge of a yoga mat. Turn your back (left) foot in well (60°) and your right foot out fully (90°) and at the same time turn your body to the right to bring your chest and outstretched arms to face the short end of your mat. Place your right hand on your hip and reach your left hand down to the floor on the outside of your leading foot. To maintain the alignment of your spine you may chose to place your hand onto a yoga block, your finger tips, or the flat of your hand depending on your flexibility. Finally, reach your right arm upwards keeping it straight and point your fingertips to the ceiling.

Tips: The triangle pose requires a combination of leg firmness and stability, with flexibility of the lateral trunk. The
pose can be effectively split into two portions, practising leg stability with the hands on the hips initially. Once this has been attained the trunk movement and arm stretch may be brought in.

Yoga for Back Rehabilitation

As an illustration of the effective use of Yoga as therapy, let’s take a brief look at its use in the management of low back pain (LBP). A major systematic review of yoga for low back pain was conducted in Essen, Germany in 2013 looking at a total of 967 chronic low back pain patients over 10 scientific studies. The analysis showed that there was strong evidence for short-term effects of yoga on pain, back-specific disability, and global improvement. There was strong evidence for a long-term effect on pain and moderate evidence for a long-term effect on back-specific disability. This major study concluded that yoga can be recommended as an additional therapy to chronic low back pain patients (Cramer et al 2013). A meta analysis of 8 Randomised Controlled Trials (RCT) looking at yoga for chronic low back pain by Holtzman and Beggs (2013) showed yoga to have a medium to large effect on functional disability and pain, with follow-up effect sizes remaining significant. The studies involved a total of 743 patients.

Individual studies have shown yoga to be an effective tool in the management of low back pain. In a study looking at 313 adults with chronic low back pain, (Tilbrook et al 2011), yoga was given as a 12 week programme and included postures, breathing exercises and guided relaxation. The yoga group recorded better back function at follow-up measured at 3, 6, and 12 months following intervention. A study of a 1 week intense period of yoga for 80 chronic low back pain patients showed it to be superior to a physical exercise programme when measured as spinal flexibility (Tekur et al 2008). Yoga has been shown to be effective for war veterans with low back pain, improving pain, energy levels and mental health after a 10 week programme (Groessl et al 2012). A randomised controlled trial (RCT) in the USA showed a 14 week yoga programme to give a clear improvement measured on a standard clinical research scale (Roland and Morris Disability Questionaire or RMDQ)(Sherman et al 2005) and a study which followed participants for 48 weeks shown improvement in functional disability measures, pain intensity and depression scores (Williams et al 2009).

Dr Chris Norris runs a 3 day CPD course called Yoga as Therapy for therapists & Pilates teachers, for details click here

References

Cramer H, Lauche R, Haller H, Dobos G (2013) A systematic review and meta-analysis of yoga for low back pain. Clinical Journal of Pain. 29(5):450-60.

Groessl EJ, Weingart KR, Johnson N, Baxi S (2012) The benefits of yoga for women veterans with chronic low back pain. Journal of Alternative and Complementary Medicine. 18(9):832-8.

Holtzman S and Beggs RT (2013) Yoga for chronic low back pain: a meta analysis of randomized controlled trials. Pain Research Management 18(5): 267-72.

Schleip, R and Muller, DG (2013) Training principles for fascial connective tissues: Scientific foundation and suggested practical applications. Journal of Bodywork and Movement Therapies 17, 103-15

Sherman KJ, Cherkin DC Erro J et al (2005) Comparing yoga, exercisem and a self care book for chronic low back pain: a randomised controlled trial.. Annals of Internal Medicine 143: 849-856

Singleton, M (2010) Yoga body. The origins of modern posture practice. Oxford University Press.

Tekur, P. ingphow, C., Ramarao Nagendra, H. and Raghuram R (2008) . Effect of Short-Term Intensive Yoga Program on Pain, Functional Disability and Spinal Flexibility in Chronic Low

Tilbrook HE, Cox H, Hewitt CE, Chuang L-H et al (2011) Yoga for chronic low back pain: a randomised trial. Annals of Internal Medicine, November.

Williams K, Abildso C, Steinberg L et al (2009) Evaluating the effectiveness and efficacy of Iyengar yoga therapy on chronic low back pain. Spine 34(19): 2066-2076.