Understanding the Benefits of Yoga for Chronic Pain of Musculoskeletal Origin through the Neuromatrix Model
Created by: Molly Miller, SPT
_____________________________________________________________________________________
Background
This project is a culmination of several personal and professional interests that I am passionate about. I am excited to share this evidence-based project with professional peers and future patients. My undergraduate degrees in Psychology and Exercise and Sport Science built a foundation of knowledge regarding the science of both the body and mind, leading me to explore a career in physical therapy. Throughout the UNC program, I have studied components of overall health and wellness, including the influence of social determinants, as well as personal and environmental factors through the ICF model of health. My interest in the intersection of neuromuscular and psychosocial processes drew me to the complexity of chronic pain, which is multifactorial and difficult to manage from both the patient and therapist perspective. Yoga has been shown to be beneficial for physical as well as mental health, employing movement and techniques aimed at improving bodily awareness, strength, flexibility, and control of breathing. Having practiced yoga consistently for the past four years, I was curious to investigate the benefits of yoga interventions for chronic pain management.
Assessment of Need
Chronic musculoskeletal conditions are the leading cause of disability in the United States. (1-3) Nonspecific low back pain and forms of arthritis (osteoarthritis and rheumatoid arthritis) are the top two most common musculoskeletal conditions and are not currently well managed in our healthcare system. (1-3) Not only do they place a major economic burden on society, there is also an opioid epidemic causing addiction, abuse, and death from overdose. (1,4) There is a need for non-pharmacological interventions that are safe, cost-effective, and evidence-based for the treatment of chronic pain. (1,2) Yoga has been shown to improve health-related quality of life, but the neurophysiological mechanisms for yoga’s benefits for chronic pain need to be more thoroughly investigated. (5)
The Project
My intention was to reach both physical therapists and patients with this capstone project so I created a VoiceThread for DPT Students and an informational brochure for patients about the benefits of yoga for chronic pain. The VoiceThread will be available to entry-level DPT students in the UNC program and will be recommended as an additional lecture for the MSK II class when they discuss the topic of chronic pain. The brochure will be available to patients at ATI Physical Therapy in Carrboro and Pivot Physical Therapy in Cary, NC where there has been a confirmed need.
VoiceThread: Understanding the Benefits of Yoga for Chronic Musculoskeletal Pain Through the Neuromatrix Model
Yoga for Chronic Pain Brochure
Relevant Coursework
“In an adult patient with chronic musculoskeletal pain, is yoga more effective than pharmaceutical intervention at reducing pain?”
- I investigated the P.I.C.O. question above in Evidence Based Practice II by analyzing the research and finding the best evidence; however, there were no studies directly comparing yoga and opiates for the treatment of chronic pain. The available evidence for each suggests that yoga has a moderate treatment effect on chronic musculoskeletal pain, while opiates have a minimum treatment effect. My conclusions are thoroughly discussed in my CAT attached below.
- In Health and Wellness, I was given the opportunity to brainstorm and create a hypothetical health promotion program. My program was called RAD Yogi (Yoga for individuals with Rheumatoid Arthritis Dysfunction), and the proposal I wrote includes evidence supporting the benefits of yoga in this population and how to implement a tailored program. For more details about the program, click on the link below.
- In the Advanced Orthopedics elective, our final paper required investigation of a musculoskeletal tissue in regard to a clinical situation. I investigated the impact of arthritis on articular cartilage, specifically comparing osteoarthritis and rheumatoid arthritis. Arthritis is the second most common cause of chronic musculoskeletal pain in the United States. My paper can be found below.
CAT (Critically Appraised Topic)
OA and RA effects on Articular Cartilage
Evaluation & Health Literacy Assessment
To evaluate the components of this capstone, I utilized my committee members at both midterm and final to incorporate suggested revisions. I met with all committee members in person to discuss the goals of the project, intended audience, and adequate synthesis of evidence. Evaluation forms were sent to committee members to review the final project components discussed above.
Evaluation Form for Molly Miller
The VoiceThread presentation is intended for DPT students, so I sought peer feedback from two students in my program who provided advice and validation regarding clarity and comprehension of content. Jean Masse, who is on my committee was a guest lecturer on chronic pain in MSK II, and Jon Hacke, who teaches the class, provided feedback for the presentation. From their feedback, I was able to evaluate the appropriateness of the material for DPT students.
The brochure is intended for patients and feedback was sought from two physical therapists who will be carrying the brochure in their practices, as well as feedback from two individuals from the community who served as “potential patients.” Feedback has already been incorporated. These two community members provided recommendations for the brochure in terms of layout and language. Health literacy was assessed from the provided online lectures and resources. The NC Health Literacy website provided tools to improve written communication including a thesaurus of alternative words that patients can understand.
Self-Assessment
My personal goals for this capstone were to be able to effectively discuss the neuroscience of chronic pain and understand the mechanisms underlying the benefits of yoga intervention for these complex patients. I have succeeded in being able to talk knowledgeably about risk factors and causes of chronic pain, and I will utilize this skill in the clinic. It was important to me to dissect the research and scientific evidence for the use of yoga in physical therapy and I am proud of this project as a demonstration of my understanding.
Acknowledgements
I would like to thank my committee members, Jean Masse, PT, DPT, PRC, OCS, ATC, Amy Gwynn, PT, DPT and Jyotsna Gupta, PT, PhD. Jean, you provided invaluable information on managing patients with chronic pain and originally inspired me to investigate this complex phenomenon, which requires holistic and compassionate care. Amy, thank you for being a constant friend and mentor throughout this process and during PT school and demonstrating creative and successful ways to integrate yoga into physical therapy practice. Jo, I want to thank you for challenging me in the clinic and coaching me to be a better physical therapist; your advice on this project was greatly appreciated.
I would like to thank my advisor, Karen McCulloch, PT, PhD, NCS, for encouraging me to further research this topic and its relevance to physical therapy. Your guidance throughout the semester was instrumental in shaping my final products. Thank you to Jon Hacke, who agreed to review the materials for his class. Thank you also to Rob Schneider, MS, PT, ATC, LAT, SCS for agreeing to place my brochure in your clinic at ATI Physical Therapy in Carrboro, where it will aim to encourage patients to try yoga as an adjunct to therapy. Thank you to Laura Rapp, DPT, PT for introducing me to chronic pain resources that were incorporated into this project and for modeling holistic treatment of patients living with chronic pain. Finally, thank you to my classmates, Chloe Smith, Julianne Runey, and Hannah Leshin for your sage advice and unending support.
_____________________________________________________________________________________
References
- McCaffrey R. The benefits of yoga for musculoskeletal disorders: A systematic review of the literature. Journal of yoga & physical therapy. 2012;02(05)
- Crow EM, Jeannot E, Trewhela A. Effectiveness of Iyengar yoga in treating spinal (back and neck) pain: A systematic review. International journal of yoga. 2015 Jan;8(1):3–14.
- Cramer H, Lauche R, Haller H, Dobos G. A systematic review and meta-analysis of yoga for low back pain. Clin J Pain. 2013 May;29(5):450–460.
- Centers for Disease Control and Prevention (CDC). Vital signs: overdoses of prescription opioid pain relievers—United States, 1999–2008. MMWR Morb Mortal Wkly Rep. 2011 Nov 4;60(43):1487–1492.
- Woodyard C. Exploring the therapeutic effects of yoga and its ability to increase quality of life. International journal of yoga. 2011 Jul;4(2):49–54.
6 Responses to “Yoga for Chronic Pain”
Molly Miller
KMac, I agree that ATI Carrboro will filter patients up to Balanced Movement Studio and I plan to follow up with the physical therapist there to inquire about patient response to my brochure!
Amanda, I made the VoiceThread public…hopefully now you can listen to it! I am happy to hear that you have experienced the benefits of yoga firsthand. It speaks for itself… but I am ecstatic that there is evidence to back it up! Let me know if you have any questions after listening to the lecture.
Honoree, thank you for your kind comments! It means a lot to me that you enjoyed my project materials. This is a topic that is near and dear to my heart and I am passionate about spreading the message to other interested individuals. The current evidence on yoga focuses more on Hatha yoga which is a gentler form, but it would be interesting to understand the clinical benefits of other types. Yoga is a really efficient form of exercise as it combines strength, balance, and breathing techniques – all you need is an aerobic component, which could be completed with more physically demanding types. I definitely see myself incorporating yogic principles into my practice, whether it is teaching a patient how to breathe with their diaphragm, or recommending a restorative pose that provides relief of pain and calms down the nervous system of a patient living with chronic pain. There are endless possibilities for incorporation but I am interested in possibly pursuing a certification in Professional Therapeutic Yoga, which was created by Ginger Garner, who is a physical therapist and yoga therapist. You may be interested in her book, Medical Therapeutic Yoga, as it covers evidence of yoga for chronic pelvic pain in females! Maybe we can collaborate on this in our future careers!
Chris, I loved reading your inservice materials on Therapeutic Neuroscience Education. There was so much more I could have covered in the realm of chronic pain research, and I am happy that you are passionate about this topic as well! We definitely need to do a better job of managing these complex patients and the first step is believing that their pain is real. There are several options for incorporating yoga for patients – it could be that I recommend specific restorative poses or poses for therapeutic exercise and neuromuscular re-education. It could be that the physical therapy clinic has a relationship with a yoga studio or yoga teacher that offers restorative classes as an adjunct to therapy or for after discharge. It is important that the yoga teacher provide necessary instructions for adaptations in order to help patients be successful. For therapists who are not familiar with yoga, this presentation and evidence can provide a template for components of chronic pain management; for instance, decreasing central sensitization through proprioception exercises, or restoring autonomic regulation through paced breathing. Understanding the inputs and outputs of the neuromatrix model is the most important take away. Yoga provides a framework for an effective, holistic, program for patients living with chronic pain, but this does not necessarily mean that therapists need to be yoga teachers or practice yoga themselves in order to employ yogic principles.
Terra, thank you for your comments! Jean is on my capstone committee and her lecture piqued my interest and I have become passionate about this topic. I agree that yoga culture in the US can associated with privilege and is not always accessible to people outside of the mainstream. However, there are resources online that provide free yoga classes so that patients are able to practice within the comfort of their own homes. I am really glad you liked my project!
Terra D. Osmon
Molly,
You did such a great job with your presentation and all of your capstone projects! Chronic pain in itself is a challenging subject to understand as a clinician, and even more difficult to convey to patients. I think this is very important and certainly needed especially given that there are practicing clinicians who still feel that chronic pain is not ‘real pain’ — as this has been suggested to me before, however, I was fortunate to know better and with the help of Dr. Jean Masse’s PT, DPT guest presentation where she discussed chronic pain during one of our class sessions. Your materials on chronic pain alone are a helpful adjunct that should help clinicians explain and educated and for patients better understanding.
With respect to the yoga portion — I think this is service to future patients. I think your contribution is wonderful as there is little evidence on the effectiveness of yoga despite a robust history of alternative medicine. Further, as yoga has become so popularized and commercialized, some of the traditional principles of yoga have been lost and not all people are able to access yoga due to cost or lack of access to local yoga classes. Unfortunately, this means low socioeconomic backgrounds often are unable to participate. I applaud you on your brochure and taking the time to provide free and reduced price resources in order to make yoga accessible for all people. Absolutely wonderful job! Thank you for all your hard work!
Chris Green
Molly,
I am thrilled that you chose to study yoga and chronic pain for your Capstone. I think you are doing a real service for the future DPT students by having this VoiceThread as an adjunct to the chronic pain material given in MSK 2. In both your VoiceThread and brochure, you have found an elegant way to better explain chronic pain and bring to light evidence that supports the role of yoga as a legitimate option for those suffering from chronic pain. I feel that students and clinicians who familiarize themselves with your products will feel more comfortable in talking about chronic pain with their patients. I hope they are also more open to discussing different aspects of yoga and how the evidence shows its efficacy for this patient population. I am curious if you considered going to private practice where you could incorporate offering restorative yoga classes in addition to physical therapy? Would you be interesting in teaching such classes, or would you be more inclined to higher out for yoga teachers who have the requisite experience? Finally, what would be your advice to clinicians who aren’t familiar with yoga but feel like they need better options for patients in chronic pain? I think you’ve done a wonderful job on your Capstone, Molly, and that it will serve as an important adjunct to the DPT curriculum!
Honoree Mcgraw
Molly,
I loved everything about your project! The topic you chose is fascinating and your project components kept me enthralled! From the descriptions of pain theories to the calming and soothing colors you chose in the materials, it was all great. I have always been interested understanding chronic pain’s role in dysregulation of stress system functioning and allostatic load. Your presentation did a great job of illustrating the many factors associated with chronic pain, which affect inputs and outputs of the body self neuromatrix. It was amazing to learn about the myriad of ways in which yoga can positively influence pain perception, physiological functioning, and stress indicators. I think future students will really enjoy your materials and will be amazed by the findings you compiled.
Your project got me wondering how certain restorative yoga poses bring about specific changes in the body. I’ve often wondered what the benefits were of one type of yoga over others. I’ve always been more interested in restorative (and relaxing) types of yoga while some people I know seem to get more out of more physically demanding forms of practice. I wonder how these forms impact the body differently. Now that you have had the opportunity to explore the current evidence on the effects of yoga on chronic pain, do you see yourself incorporating this knowledge into your future career as a physical therapist? If so, how? Correct me if I’m wrong but it seems like you have been developing your yoga knowledge and skill quite a bit over the duration of our program. Do you think you will keep this up and potentially become a yoga therapist or other form of certified instructor? Anyway, absolutely wonderful job on you presentation. I know that you will help many, many patients. Your calming demeanor and interest in the mind body relationship will open many doors for you in the future. Best of luck in your career, and life Molly!
Amanda Doty
Hi Molly,
Great job on your capstone! I really enjoyed looking through your materials and handouts on yoga for chronic pain. I am very interested in learning more about chronic pain and different interventions to use to help my future patients. I LOVE yoga and definitely have seen the benefits in my life in helping with stress relief and my overall health and wellbeing. Your brochure is very well done and I like how you included online resources for patients. I wasn’t able to access your voice thread, but I would really like to listen to it! I would like to learn more about the different types of yoga and how they relate to the neuromatrix theory. Awesome job! I can tell you have worked hard on this capstone!
KMac
Hi Molly – I love the presentation – I still need to listen to the Voicethread, but will do so prior to sending you final feedback. You did a great job of illustrating the different pain theories and how yoga relates to the neuromatrix theory. Your brochure does a nice job of translating the key points that a patient would need to know.
I’m glad that you sought out a place for the brochure to be distributed – ATI Carrboro is perfect as a location, they can go upstairs 🙂
kmac