Yoga in Pain Care- what's the evidence?
Physician must insert or convert wisdom to medicine and medicine to wisdom Hippocrates
In an era of evidence-based practice (EBP), we are all called upon to show the evidence for what we practice in patient care, particularly when health services and insurance companies are footing the bill. As a passionate advocate of evidence-based practice, I don’t think this is a bad thing but I do think engaging in this conversation with an understating of what EBP is and from an honest but balanced perspective is crucial.
Did you know that EBP models have always incorporated integration of the how the person presents and their values, the skills and expertise of the clinician or care provider as well as the best available research evidence?
This is a point that I sense is often missed. On one extreme some people only consider research trials as ‘admissible evidence’ and reject patient preferences or nuances in their presentation, such as, how ready for, or capable of, change the person is. On the other extreme live those who reject the research evidence, saying things like ‘research changes all the time’ or ‘that it doesn’t reflect the people they see’. To me, the balance is like the image - it's never quite perfect and will be a little different every time. With this in mind and practicing yoga elements like Satya (truthfulness),and Svadhyaya (study of the self), I think we should consider an integration of all these things: 1) the research as it stands but ever evolving, 2) the individual I’m working with and their unique journey and values, and 3) my skills, expertise, values, knowing their limits and my own strengths and biases.
From this perspective I think we can enter into a balanced conversation about what the evidence for yoga is. Here a few points to consider first:
• Evidence to support yoga in pain care is growing but still considered low quality due to study limitations such as small sample sizes and short follow ups
• More studies needed across various pain conditions and comparing yoga to other active interventions
• How yoga interventions are implemented and what they contain is often not very clear or consistent in study descriptions
• More studies are needed to investigate how yoga works i.e. what are the biological mechanisms underlying the effects of yoga either as a holistic practice or for individual aspects.
That said here is a brief summary of the effects of yoga in pain care. Systematic reviews* on the effects of yoga show small positive effects on pain and disability in fibromyalgia, chronic low back pain, chronic neck pain and osteoarthritis (1-4). They show medium effect sizes on depression over the short term (compared with usual care) and limited evidence of short-term small effects for anxiety (versus relaxation) (5,6).
My two-cents-worth for talking about the effectiveness of yoga in pain care….
• Take care with big claims: ‘yoga is amazing for….’
• Take care with strong comparisons: ‘yoga is better than x for….’
• A modest, balanced interpretation may be more reflective of our current knowledge base and therefore more credible.
For example: “While the quality of evidence needs to improve, early evidence shows yoga can yield positive effects on pain, disability and mood. We recognize that for many, yoga may form part of overall pain care.”
As we advocate for yoga in pain care, it’s important to highlight some of the potential benefits that actually closely align with contemporary ‘standard’ or ‘best practice’ pain care. These include:
· Yoga an active approach- the individual is at the centre of their own care
· Yoga includes physical activity that can be tailored to promote fitness, strength, improved coordination and can be paced/ adjusted according to the needs of the individual.
· Depending on how asana practice is tailored it can improve body confidence and promote self efficacy for physical activity and movement => pain care.
· Yoga incorporates breath work, meditation and mindfulness practices, all of which have evidence for promoting stress reduction and pain relief.
· Yoga incorporates a philosophy or principles that can promote self care for pain- self-reflection, non-harming, motivation for change etc.
Yoga is an extremely valuable practice for health and wellbeing. As we advocate for its use in healthcare, perhaps taking a balanced but well-informed perspective that is credible, and steering away from big claims is likely to better serve the practice of yoga and facilitate its acceptance and integration into healthcare. Ultimately it is the people in pain we want to serve most and enabling access through healthcare is one key way we can do this.
*systematic reviews try to follow strict guidelines to synthesize a body of research on a topic for example they might summarise or analyze the results of randomized controlled trials from multiple studies.
1. Langhorst et al. Rheumatology Int, 2013
2. Holtzman & Beggs. Pain Res Mgt, 2013
3. Cramer et al. Clin Rehabil, 2017
4. Lauche et al. Curr Rheumatol Rep, 2019
5. Zou et al. J Clin Med, 2018
6. Cramer et al. Depression & Anxiety 2013
Image by A Different Perspective from Pixabay