Yoga & Mechanical Diagnosis and Treatment (MDT)

Robin McKenzie, a physical therapist from New Zealand, revolutionized the treatment for LBP in the 1950s. McKenzie discovered symptom centralization by using repeated movements or sustained postured.  Mechanical Diagnosis and Treatment (MDT) is a tool for assessment, treatment and prevention of musculoskeletal disorders.  McKenzie is an advocate for independent management of a person’s own back pain.  He said,

“I believe the treatment dependency is undesirable and should be avoided where possible. Therefore, in addition to whatever treatment is necessary for present symptoms, the patient should be taught to become self-reliant and independent of the therapist in the management of future low back pain” RA McKenzie, 19811

McKenzie advocates patient education to prevent the recurrence of low back pain. It can be safe to assume that he would support the daily yoga practice as long as it is individualized to the student’s needs. MDT consists of three categories for diagnosing back pain: Postural, Dysfunction and Derangement. A specific style yoga may be the key to a person’s self-management of their back condition.  By understanding the treatment strategies of physical therapists, yoga can be applied appropriately.

Postural Syndrome

Postural Syndrome is when normal tissues are placed on end range stretch for prolonged periods of time. It is insidious in nature and can be hard to reproduce.  The yoga student with a postural syndrome will have pain or symptoms that increase throughout the day. They may have a job where they sit for long periods of time or have a medical condition that causes abnormal posture.  Postural Syndrome is from sustained poor posture.

Postural education and exercises can address any muscle strength imbalances which underlie postural dysfunctions. Postures that open up the chest and strengthen antigravity muscles will help address these deficits.  Specific yoga classes that focus on posture, such as Iyengar yoga, are appropriate.  A study completed in 2009 compared 24 weeks of Iyengar Yoga to conventional interventions for LBP. The yoga group had greater improvements in functional disability, pain, depression and a reduction in pain medication.2 A yoga teacher who understands muscle imbalance and compensatory movement patterns will help a student overcome their postural syndrome.

Dysfunction

Abnormal or dysfunctional tissues often cause low back pain.  Dysfunctional tissues cause pain when placed on end range stretch or placed under mechanical deformation (palpation). A physical therapist uses repeated movements to determine if their client has dysfunctional tissues. Symptoms will either decrease or stay the same with repeated motion into the painful direction. Muscle guarding and spasms, facet joint restrictions or adhesions in the fascia can cause dysfunction of the back. These restrictions may result from previous trauma, inflammatory or degenerative processes.3  Research agrees that compensatory strategies may develop as a result of habits formed due to previous injury4,5.  This may cause habituated abnormal movement patterns that perpetuate the dysfunctional tissues.

The repeated motion that is used to diagnose dysfunction in the clinic is also used to treat.  This can easily be applied to a yoga class, but difficulty arises when there is a mixed class of dysfunctions.  Someone may have a flexion dysfunction due to quadratus lumborum (back) spasm.  They need a gentle class consisting of forward folds and twists.  Those with tight iliopsoas (hip flexor) will enjoy erected postures, gentle extension and lunges. Most yoga asanas can be placed into a direction specific exercise group and can be used to treat specific dysfunctions (Specific Exercise PDF). Back Care, restorative and a beginner yoga class will help a majority of people with dysfunction. Themed classes, such as psoas release or stiff back classes, might help to separate people into groups based off of their dysfunction.  Class should consist of hands on assists that are massage-like and repetitive movements that flow with the breath.

Derangement

Derangements are often thought to be discogenic in nature.  Discogenic in nature implies that a nerve root is being pinched, either due to decreased vertebral disc height or a bulge or herniation.  A crucial symptom for diagnosing a derangement is the migration of pain in response to repeated motions.  Centralization occurs when a movement or position relieves the pain or causes it to move towards the spin.  If the pain centralizes with a forward fold, that means it migrates proximally.  If it peripheralizes, the pain migrates distally from the spine, down the leg or to the foot.  Directional Preference is similar to centralization, but more specific to a position in which one finds relief from pain.  Centralization with movement indicates a better prognosis than directional preference alone.6 Despite this finding, directional preference is used for exercise prescription. A study found matching directional preference with specific exercise decreased pain and medication use.7  For treatment of derangement, it first must be reduced.  This is done using either specific movements, manipulation or mobilizations by a trained professional.  Next, the patient needs to perform exercises to increase the stability of the spine and normalize posture.

Individualized yoga classes will help a person with a derangement recover faster and manage their symptoms better, although direct communication with a physical therapist is recommended.  Understanding their directional preference and what movements cause the symptoms to centralize will help the teacher tailor the practice to meet their needs.  Often, a person can go from a derangement to dysfunction.  In order to prevent this, yoga as therapy must be applied appropriately.

It is a challenge for a yoga teacher to meet the needs of every student. A partnership between the teacher and a physical therapist may help alleviate the burden.  If a studio offers back care classes, they must accept the responsibility of providing the best care possible.  An understanding of the student’s symptom behavior is necessary to determine the best class for them.  A thorough intake form may be helpful in screening a student for a serious condition and to understand the nature of the student’s symptoms (Intake Form).  Keeping classes small and offering them in a series may help reduce the unnecessary risk of exacerbating symptoms. It is possible for physical therapy and yoga to partner in providing long term care for low back patients using the principles of MDT. Understanding MDT and the terms will improve communication between yoga teachers and physical therapists.

References

  1. Moore, Jeff, DPT. Incorporating Repetitive Movement. (Power Point Presentation) Masterminds Mentorship Group. 4 November 2015.
  2. Williams, K., Abildso, C., Steinberg, L., Doyle, E., Epstein, B., Smith, D., … Cooper, L. (2009). Evaluation of the effectiveness and efficacy of Iyengar yoga therapy on chronic low back pain. Spine, 34(19), 2066–76. http://doi.org/10.1097/BRS.0b013e3181b315cc
  3. McKenzie and May, The Lumbar Spine, Mechanical Diagnosis and Therapy, Vol I & II, Spinal Publications Limited, P.O. Box 2, Waikanae, New Zealand, 2003.
  4. Lee DG, Lee LJ, McLaughlin L. Stability, continence and breathing: The role of fascia following pregnancy and delivery. J Body Move Ther. 2008;12(4):333-348. doi:10.1016/j.jbmt.2008.05.003.
  5. Moseley GL, Hodges PW. Reduced variability of postural strategy prevents normalization of motor changes induced by back pain: a risk factor for chronic trouble? Behav Neurosci. 2006;120(2):474-476. doi:10.1037/0735-7044.120.2.474.
  6. Werneke MW, Hart DL, Cutrone G, et al. Association between directional preference and centralization in patients with low back pain. J Orthop Sports Phys Ther. 2011;41(1):22-31. doi:10.2519/jospt.2011.3415.
  7. Long A, Donelson R, Fung T. Does it matter which exercise? A randomized control trial of exercise for low back pain. Spine (Phila Pa 1976). 2004;29(23):2593-2602. doi:00007632-200412010-00002

Yoga for Chronic Low Back Pain

Chronic Low Back Pain (cLBP) is a subset of back pain which may be alleviated with the practice of yoga. A study found that 85-95% of patients with LBP are diagnosed as having “nonspecific low back pain”.1 This means that the doctor doesn’t know the specific patho-anatomical cause of the pain.  A majority of patients with chronic pain fall outside the typical healing time frame.  This is one of the reasons chronic conditions have stumped the medical community for so long.   There has been a recent increase in research that looks at the central nervous system’s role in cLBP. It is widely accepted that a person’s history and beliefs about pain can influence the outcome of treatment. Recently discovered insights on central sensitization and neuroplasticity have allowed for the development of more effective treatments.

A physician may refer their patient for an MRI or radiograph to diagnose the cause of cLBP. These can be useful in identifying serious conditions, such as vertebral fractures or a spinal cord impingement.  Most often, imaging causes unnecessary stress over normal changes that occur in the spine.  A recent study found that disc degeneration was present in close to 90% of individuals 60 years of age or older.  More than 50% of asymptomatic people ages 30-39 also had degenerative change of their spine.2  Degenerative changes, such as disc degeneration disease, are part of the normal aging process and cause unnecessary anxiety when used as a diagnosis.  This counter-acts the healing process by activating the autonomic nervous system.  There are many structures in the back that can cause pain that may or may not be related to what the imagining shows. A patient’s belief about the cause of the pain and diminished sense of body awareness can play a role in managing chronic pain.

Traditional and non-traditional interventions for chronic low back care have fallen short.  A recent study found that interventions, such as manual therapy, exercise, acupuncture, and spinal injections, are not superior to one another and all have limited long-term impacts on the disorder.3  This might be due to interventions failing to address cLBP within a multidimensional framework. A multi-disciplinary approach to cLBP is one solution. Physical therapists and yoga teachers have complementary skills that can be utilized to help counteract chronic pain.

Cognitive Behavior Therapy (CBT) addresses the biopsychosocial issues that often go with chronic pain.  Biopsychosocial issues include:

  • Cognitive Factors: negative beliefs, fear avoidance behaviors, anxiety, depression, poor coping skills
  • Physical Factors: pain provocative postures and movement patterns
  • Lifestyle factors: sedentary behavior, sleep deficits11

Yoga interventions found in Mindful-based Stress Reduction (MBSR) address the same factors as CBT.  MBSR is a “mind-body approach that focuses on increasing awareness and acceptance of moment to moment experiences, including physical discomfort and difficult emotions.”4  MBSR uses meditation, pranayama, yoga and patient education to help a person cope (MBSR Protocol).  A recent study compared this approach to CBT and normal medical treatment and found MBSR had similar results as CBT.  Both had significant improvement when compared to standard medical treatment.5  There are many similarities between the two approaches.  Both have elements of body awareness, addressing movement and cognitive deficits, imagery and coping skills.  However, both practices come from different schools of thought, which becomes clear after looking at the comparative chart (Comparison Chart). Those who come to a yoga back care class will likely respond well to the MBSR approach described in this study.

 

The brain is an amazing structure of the body due to its ability to adapt to stresses placed on the body. Neuroplasticity is “the ability of the nervous system to respond to intrinsic or extrinsic stimuli by reorganizing its structure, function and connections.”6 There are structural and functional changes in the brains of people with chronic musculoskeletal pain. These changes contribute to the development and maintenance of the chronic pain state.7 An example of these changes is central sensitization.  This is an adaption of the nervous system to noxious stimuli: stimuli that are non-painful, but are perceived to be painful.  Studies show that a person who experiences cLBP undergoes anatomical changes to the brain, including decreased cortical thickness, hippocampus (memory center) and medial prefrontal cortex (learning and memory) and increased amygdala (fear center) size.8 Changes to the cerebral cortex can cause changes to the homunculus, the “sensory map” in the brain (Noi Group).  This map of the body can change when a person experiences chronic pain.  The mind “smudges out” that body part and creates a distorted body image.  The Noi Group has developed a method called “Graded Motor Imagery.”16 This uses Left/Right Discrimination, Motor Imagery and Mirror Therapy to re-introduce the area of the body back to the brain.  Both these intervention uses neuroplasticity as a catalyst to induce change in the brain caused by chronic pain conditions.

The medical community has realized the importance of the brain’s neuroplastic ability in treating chronic pain.  Recent studies have shown that meditation used in MBSR has the ability induce neuroplasticity.  A recent study took people who had never meditated before and put them through the eight week MBSR program.  This study found that five regions of the brain experienced a change in volume after 8 weeks.  Four areas thickened: posterior cingulate (mind wandering and self-relevance), the left hippocampus (learning, cognition, memory and emotional regulation), the temporoparietal junction (perspective taking, empathy and compassion), and the pons (regulatory neurotransmitters production). One area, the amygdala, got smaller, which is the center that stores negative memories and feelings.9   This is a groundbreaking discovery for MBSR in management of chronic pain.  Yoga for chronic pain has a place at yoga studios.  Studios can offer a series that is completed over eight weeks and follows the MBSR protocol (Appendix 3).  Yoga as Therapy has research behind it to legitimize its use for treatment in the clinic, especially for chronic pain.

Bibliography

  1. Apeldoorn AT, van Helvoirt H, Meihuizen H, et al. The Influence of Centralization and Directional Preference on Spinal Control in Patients With Nonspecific Low Back Pain. J Orthop Sport Phys Ther. 2016;46(4):258-269. doi:10.2519/jospt.2016.6158.
  2. Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. a, … Jarvik, J. G. (2014). Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. Spine, 36(4), 811–6. http://doi.org/10.3174/ajnr.A4173
  3. Fersum,Vibe K, et al. Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: A randomized controlled trial. Eur J Pain (United Kingdom). 2013;17(6):916-928. doi:10.1002/j.1532-2149.2012.00252.x.
  4. Cherkin, D. C., et al. (2016). Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain. Jama, 315(12), 1240. http://doi.org/10.1001/jama.2016.2323
  5. Cramer, S. C., et al. (2011). Harnessing neuroplasticity for clinical applications. Brain, 134(6), 1591–1609. http://doi.org/10.1093/brain/awr039
  6. Wand, B.M., et al. (2011). Cortical changes in chronic low back pain: Current state of the art and implications for clinical practice. ManualTherapy, 16: 15-20
  7. Lucas, PH. Practical Application of Yoga-based Techniques in the Treatment of Chronic Pain. Power Point Presentation. CSM 2014 (Las Vegas, NV).
  8. Butler, David and Moseley, Lorimer. (2014). Explain Pain. Noigroup Publications, Adelaide, Austrailia. Pg. 76
  9. Lazar SW, Kerr CE, Wasserman RH, et al. Meditation experience is associated with increased cortical thickness. Neuroreport. 2005;16(17):1893-1897. doi:10.1097/01.wnr.0000186598.66243.19.