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.
Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s