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Integrating Yoga and Physical Therapy for the Management of Knee Osteoarthritis

 

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BACKGROUND:

Osteoarthritis (OA) has been a clinical interest of mine since I first began to consider physical therapy as a profession. I have witnessed just how debilitating OA can be, as I have had friends, family members, and of course many patients who have suffered from this disease. Personally, I strive for a well-balanced lifestyle by staying active, exercising my muscles, eating a healthy diet, managing my stress, getting enough sleep, and more. Avoiding OA and the associated pain and functional decline is at the top of my list for why I try to stay so healthy! I want to be able to continue to do what I love for as long as possible while avoiding pain, injury, medication, and surgery.

When I began practicing yoga around five years ago, I slowly noticed many benefits that began popping up in my life. Yoga gave me an excellent yet low-impact workout that allowed me to practice complex physical movements while remaining mindful and aware of bodily sensations and restrictions. Over time, I noticed improvements in my strength, balance, flexibility, and mobility, which was apparent in my daily life and when I began to achieve certain poses that had originally been too difficult. I noticed yoga also helped me manage my stress, improved my sleep quality, and even improved my self-confidence and perspective on life. So many birds with one stone. Yoga was highly motivating for me- the more I did yoga, the more I kept coming back! I always had goals to work towards, I enjoyed practicing both by myself and in a group setting, and I felt so good during and after yoga. The perfect recipe for self-efficacy and long-term adherence! Yoga has been such a powerful tool in my own life, so it is my goal to share my knowledge with others to help prevent or manage knee OA and other chronic conditions.

Over the past year, I have focused my coursework and extracurricular studies on therapeutic yoga for a variety of chronic conditions. My in-service presentation for my outpatient neurological clinical rotation in June of 2019 investigated yoga for the treatment of neurological disorders, including Parkinson’s Disease, Multiple Sclerosis, and stroke. I also chose topics relating to the integration of PT and yoga for many assignments throughout 3rd year of PT school. For my Critically Appraised Topic (CAT) as part of Evidence-Based Practice II, I investigated the effectiveness of yoga-based exercise programs compared to traditional exercise for senior citizens with knee OA, which helped to establish a framework for my Capstone. Additionally, I began my yoga teacher training (YTT) in September of 2019. This program was taught by Laura Terry, PT and yoga teacher, who I have worked closely with since beginning this training. Under the guidance of Jon Hacke, I have been supplementing my yoga teacher training with additional research and continuing education as part of an independent study course. My experience throughout PT school, YTT, and independent research led me to choose this topic, as I firmly believe there is a gap between PT and yoga that should be addressed in order to improve the overall health and well-being of people around the world.

STATEMENT OF NEED:

Knee OA is an extremely prevalent and disabling disease, especially among the elderly. OA is the most common articular disease, and the incidence is rising as the age of the population increases.1 In addition to structural impairment, OA can lead to psychosocial burdens such as severe pain, fear of physical activity, and depression.2 This sets in motion a negative feedback loop characterized by decreased activity and participation, leading to further structural impairment, pain, and progressive disability. OA also has a profound economic burden from healthcare costs, lost productivity, and social impacts on the individuals and their families.1 In 2013, the cost of arthritis in the United States was $304 billion ($140 billion in medical costs, $164 billion in lost wages).3 Patients with OA are often treated with high-cost surgery, injections, and addictive opioid medications. Amidst the opioid epidemic, complementary and alternative health approaches are being investigated for painful conditions such as OA.4 Complementary and alternative medicine (CAM) therapies such as yoga have shown great promise for the treatment of OA, as this mind-body therapy can decrease pain and improve function for individuals with this disease. The physical practice of yoga shares many similar features with therapeutic physical therapy exercises. However, traditional physical therapy tends to lack the mindfulness, meditation, breathing, self-compassion, relaxation, and kinesthetic awareness that is central to yoga. While both traditional exercise and yoga can improve physical function, the latter may be more beneficial for the psychological aspects of the disease, including fear of falling, self-efficacy, depression, anxiety, and coping mechanisms, all of which can impact activity and participation.5,6 Additionally, as OA is a chronic disease that can be impacted by lifestyle factors (e.g. weight, diet), a lifestyle solution is required that patients will stick to. Many home exercise programs given in physical therapy are not continued, as patients may find them boring and repetitive. Yoga is creative, engaging, functional, and is different every time. It has been shown to increase self-efficacy, which is the number one predictor of long-term adherence and prognosis for chronic diseases.7 If done in group settings, it can also increase social support, which can further improve adherence and motivation.

Most physical therapists are not aware of the benefits of yoga for OA, and lack the education required to incorporate therapeutic yoga or make appropriate recommendations to patients regarding participation in this practice. Additionally, most yoga teachers are unaware of pathophysiological principles involved in knee OA, and how to consider biomechanical variables that can impact loading of the articular cartilage. For the knee OA population, it is important to know how to modify the movements based on biomechanics, pain, disability, and balance issues, and be able to teach patients how to self-modify by improving kinesthetic awareness and offering props and/or alternatives to aggravating poses or transitions. Most yoga classes in the community are not meant for people with pain and mobility restrictions, which can deter older adults from participating and even lead to injuries. Many patients who may benefit greatly from yoga may also be hesitant to begin because of societal connotations regarding yoga (e.g. only for the young and fit), or perhaps they may lack the health literacy or health-related beliefs necessary to begin practice. There is a major gap between healthcare providers, yoga teachers, and people with knee OA that is leading to unnecessary suffering and an extreme economic burden. By bridging the gap between PT and yoga, many more people with knee OA and other chronic conditions may be able to achieve the monumental and lasting benefits that can come from a safe and consistent yoga practice.

PROJECT OVERVIEW & PURPOSE:

The purpose of this project is to educate clinicians and student physical therapists on the evidence-based benefits of yoga for knee OA. This project will distinguish between traditional exercise and yoga, and describe how the latter may be used to address clinical features of the disease that the former may not. The learner will understand how to safely and effectively incorporate yoga as part of a PT plan of care based on the International Classification of Functioning, Disability, and Health (ICF) Model, pain neuroscience, biomechanical principles, and patient-centered care.

This project will also be useful for yoga teachers, particularly the sample “Yoga for Knee OA” class, pose handout with modifications, and background info on knee OA. My fellow yoga teacher training students were provided with all materials, instructed in a 40-minute therapeutic yoga practice specifically for knee health, and given a brief presentation on bridging the gap between yoga and PT management for knee OA. They were encouraged to reference this information throughout their future yoga teaching experiences to help improve accessibility of their classes for people with OA or other painful lower extremity conditions. They were also encouraged to send copies of my patient brochure to people they know who are suffering from knee OA, as this brochure contains lay-person friendly information regarding yoga for knee OA.

It is my goal to help bridge the gap between clinicians, yoga teachers, and people suffering from OA. I also hope that the information provided in my project will help spread awareness about how to prevent knee OA, as I provide guidance on how to modify certain risk factors (e.g. alignment, self-efficacy, physical activity) and facilitate long-term knee health, which is relevant to all people who wish to avoid OA or halt its progression.

PRODUCTS:

The products I have created are as follows:

EVALUATION:

Throughout the spring semester, I was able to communicate often with my committee members (Jon Hacke and Laura Terry). They provided valuable information from a clinical perspective which helped guide the development of my project. I was also able to practice teaching adaptive yoga throughout my yoga teacher training with one of my classmates who has knee OA, which was extremely helpful. She provided useful feedback regarding which poses were inaccessible to her, and which modifications and variations allowed her to practice with ease and comfort.

To assess the quality and effectiveness of my products, I created an evaluation form for my committee members to complete. The evaluation requested feedback on the structure and aesthetics of my products, the effectiveness of my research and argument, the clinical usefulness, and general strengths and weaknesses of my project. I received useful feedback on my video presentation, brochure, and pose handout, which I incorporated into the development of my final products.

Evaluation Form

SELF-ASSESSMENT/REFLECTION:

My professional goals are to develop the knowledge, skills, and confidence to incorporate mind-body techniques central to yoga into my own clinical practice, as well as the teaching skills required to educate fellow clinicians, yoga teachers, and individuals seeking this alternative health approach. I believe my Capstone, independent studies, and relevant coursework have all helped prepare me to achieve these goals. The content of my Capstone will help to bridge the gap between PT and yoga by providing valuable information and resources to clinicians, yoga teachers, and people with OA. Ultimately, bridging this gap was my intent of this project, and I believe I have succeeded in this regard. I am proud of the work that I have done, as I was able to argue a solid case for the incorporation of yoga into the management of knee OA, and I provided ample evidence supporting this integration. My Capstone experience has allowed me to develop professionally, educate others, and has set me up for a seamless integration of yoga into PT practice after graduation.

ACKNOWLEDGMENTS:

I would like to thank Jon Hacke, my advisor for this project, for all of the helpful feedback and guidance you have provided. I really enjoyed our “brainstorming” sessions, as this helped to fuel my passion for this project. You offered extremely valuable wisdom from your experience as a clinician and a professor, which helped guide my research and structure of my presentation. Thank you so much, I appreciate all you have done!

I would also like to thank my committee member Laura Terry, PT and yoga teacher for your passion, dedication, and wisdom. Laura’s synergy of clinical experience and yoga teaching gives her a unique and valuable perspective. I was lucky enough to find a PT in the area that not only integrates PT and yoga, but also offers a YTT to help pave the way for young professionals like myself! I am very fortunate I have been able to learn from Laura’s expertise and wisdom over the past eight months. She provided many valuable insights throughout YTT, during our Capstone meetings, and on the evaluation form. Thank you, Laura! You are so inspiring.

To all of my fellow YTT students- thank you! I really enjoyed learning from each of you over the past eight months, and having the opportunity to teach each of you more about my perspective and background. It was very useful having this safe space to practice teaching and educating, and each of you provided me with very helpful feedback on my knee OA yoga practice and Capstone ideas. Thank you!

REFERENCES:

  1. Heidari B. Knee osteoarthritis prevalence, risk factors, pathogenesis and features: Part I. Caspian J Intern Med 2011;2(2):205-212.
  2. Hawker GA, Gignac MAM, Badley E, et al. A longitudinal study to explain the pain-depression link in older adults with osteoarthritis. Arthritis Care Res (Hoboken) 2011;63(10):1382-1390. doi:10.1002/acr.20298.
  3. Arthritis Cost Statistics | CDC. Available at: https://www.cdc.gov/arthritis/data_statistics/cost.htm. Accessed March 17, 2020.
  4. Abbasi J. As Opioid Epidemic Rages, Complementary Health Approaches to Pain Gain Traction. 2016;316(22):2343–2344. doi:10.1001/jama.2016.15029
  5. Cheung C, Wyman JF, Bronas U, McCarthy T, Rudser K, Mathiason MA. Managing knee osteoarthritis with yoga or aerobic/strengthening exercise programs in older adults: a pilot randomized controlled trial. Rheumatol Int 2017;37(3):389-398. doi:10.1007/s00296-016-3620-2.
  6. Kuntz AB, Chopp-Hurley JN, Brenneman EC, et al. Efficacy of a biomechanically-based yoga exercise program in knee osteoarthritis: A randomized controlled trial. PLoS ONE 2018;13(4):e0195653. doi:10.1371/journal.pone.0195653.
  7. Bryan S, Pinto Zipp G, Parasher R. The effects of yoga on psychosocial variables and exercise adherence: a randomized, controlled pilot study. Altern Ther Health Med 2012;18(5):50-59.

 

10 Responses to “Integrating Yoga and Physical Therapy for the Management of Knee Osteoarthritis”

  1. Jake Tyson

    Hi Katie,
    Thank you so much for your thoughtful comments and questions. I am glad that you learned a lot and are considering incorporating some of this into your clinical practice!
    I did come across many other mind-body therapies that are very helpful for management of chronic conditions/pain syndromes. Pretty much any practice that combines mindfulness and breath with movement tends to have powerful results! While I chose to focus my project on yoga, other mind-body therapies (known as complementary and alternative medicine or CAM) that have been backed by research are tai chi, qi gong, and Pilates. 
    Here are some articles for your perusal:
    Tai Chi for knee OA:
    https://onlinelibrary.wiley.com/doi/full/10.1002/art.24832

Tai Chi vs PT for knee OA:
    https://annals.org/aim/article-abstract/2522435/comparative-effectiveness-tai-chi-versus-physical-therapy-knee-osteoarthritis-randomized
    Mind body therapies and chronic pain:
    https://academic.oup.com/painmedicine/article/15/S1/S21/1823803
    Mindfulness/meditation for LBP:
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4479890/
    Yoga and Pilates for LBP:
    https://link.springer.com/article/10.1007/s12178-007-9004-1
     
    I didn’t find any specific research adding breathing techniques into traditional exercise, but it should be noted that breathing is always incorporated into tai chi and yoga. I am similar benefits would occur if mindfulness and breathing was incorporated into traditional PT exercises as I described in my presentation.
     
    In response to your question, I think the following options can be included into PT clinical practice without actually having to go to yoga teacher training:
    1. As you said, start practicing yourself! As with any intervention we recommend, it is best if we truly know how it feels in our own body in order to teach it effectively. Not only will this help improve our interventions, but it will also help us physically and mentally to avoid burnout and improve our job longevity (e.g. the physical demands of the job, as yoga is so great for improving mechanics of movement, posture, etc).
    2. Attend yoga continuing education. Many continuing ed courses regarding integrating yoga and PT are available. Laura Terry, PT & yoga teacher offers such courses.
    3. Become familiar with yoga teachers in the area, and understand which yoga classes will be good for which patients. I discussed in the presentation how restorative, yin, gentle, and hatha would be fitting choices for seniors with knee OA.
    4. Teach patients some basic postures, proper alignment, and principles such as breathing and mindfulness, and then supplement their HEP with Down Dog yoga app, youtube videos, etc.
    5. Refer them to a PT that specializes in yoga, like me 🙂
    6. If all else fails, just incorporate breath, mindfulness, meditation, and/or relaxation into traditional HEP.
     
    Hope this is helpful! Thanks again for your comment.
    -Jake

    Reply

  2. kcfabian

    Jake, great job taking such a personal interest and creating such a thorough and informative project!! I myself have been to my fair share of yoga classes, but have not made it a consistent part of my exercise regimen and therefore lack a lot of confidence in my ability to refer appropriately or even integrate the concepts into my PT plan of care! For starters, phenomenal job with the presentation! I learned so much and really enjoyed that I could hear every bit of your passion and enthusiasm for this topic throughout the presentation. I think one of the most important things (which you emphasized so well) is the way yoga can be used to address so many different areas of the ICF model. I feel like we have talked at length about the impact that mental health and affect have on physical function outcomes, which made this aspect of your project all the more moving! Although the bulk of your comparisons were between yoga and standard exercise, I was wondering if you came across any other forms of exercise or interventions that also addressed mental health or affect? For example, would addition of breathing techniques to standard exercise or maybe an alternate form of exercise such as tai chi be as successful as yoga? For what it is worth, I think you hit the nail on the head with the potential longevity of establishing a yoga practice, but I was just curious about your thoughts on some other ways to address this!

    Also, I cannot express enough how much I love the handout you made! I have already added it to my file of clinical tips and tricks and am beyond excited to add these to my clinical practice. Other than through training to be a yoga instructor myself, do you have any resources on how one can best integrate these yoga practices (specifically the wording/language for instructing or directing aspects such as the mindfulness, meditation, relaxation, and kinesthetic awareness) in the clinic? Or rather, is your recommendation to refer patients to a particular beginner yoga or a PT yoga instructor if we are untrained? I guess I should take your advice and start practicing yoga for myself!

    Well done Jake, this is truly amazing!

    Best, Katie

    Reply

  3. Jake Tyson

    Hi Matt,
    Thanks for your comment! I appreciate what you said about yoga and PT becoming a speciality area… it is my goal to pave the way for this to happen!
    Yes, modifying yoga to fit someone’s physical ability levels, as well as their emotional state (intimidated about yoga, vulnerable for whatever reason) is INCREDIBLY important. Yoga is only effective if you actually do it consistently and feel good while doing it, so it is crucial to match yoga to the individual’s needs, preferences, and abilities. Using props and modifications is one way to accomplish this.
    As for your questions/considerations…
    1) I think education is key here, making sure patients are aware that these treatments are simply bandaids that do not fix the underlying cause. In fact, they are worse than bandaids because these injections actually weaken the tissues of the body. I think if patients were to truly understand that they are going to suffer more in the long term if they continue to get these treatments, they will be less likely to choose them.
    2) This is a tough one- as we learned in Health & Wellness, behavioral change is a difficult and long process. I believe using some of the tactics learned in this class such as motivational interviewing, goal setting, social cognitive theory, and other methods to enhance self-efficacy will help overcome these barriers. Also, incorporating “feel-good” yoga can help with this. Sometimes yoga can truly make you feel very good in the moment and right after the practice, as it can be calming, restorative, and help people feel “in control”. So choosing a yoga practice/certain poses that patients really enjoy may help with this, and having them think about how their knee feels before and after such a practice may be reinforcing.
    Thanks again!
    -Jake

    Reply

  4. Jake Tyson

    Hi Amelia,
    Thank you so much for your supportive comment. I am glad you found my project to be helpful and informative!
    Here is the link to my yoga for neurological disorders Prezi: https://prezi.com/view/CBtEBCLnAJaO5QZAb3PP/
    I hope that link works… let me know if it doesn’t! There is a good amount of overlap here. To reveal my secret, yoga is great for pretty much everything! As long as it is practiced safely, consistently, and with the appropriate exercise parameters. Yoga is excellent for neurological conditions as it helps us maintain control over the autonomic nervous system through the focus on breath, relaxation, and deep stretching to inhibit tone.
    Great note about the brochure… I admit it is a bit wordy! I took your advice about staying away from labeling things as “good” or “bad”. I agree this is not supportive and can actually be destructive. I have rephrased it as “Gradual damage to knee due to a variety of factors relating to movement, alignment, and physical activity.” and “Teaches “mind-body awareness” to move safely and mindfully in order to protect knee during physical activity.”
    Thanks again,
    Jake

    Reply

  5. Jake Tyson

    Austin,
    Thank you so much for your comment! I am so glad that you enjoyed my capstone, and you appreciate my argument regarding the importance of the mind-body connection! Pilates is an EXCELLENT form of exercise, kinesthetic education, and adjunct to physical therapy. That would be amazing if you pursued this interest further! Would love to combine yoga and pilates forces with you! Excited to continue to learn from you in the years to come.
    -Jake

    Reply

  6. Jake Tyson

    Debbie,
    Thank you so much for your kind words and support. I am glad you enjoyed this project and find it to be beneficial to both clinicians and patients.
    -Jake

    Reply

  7. mchaus

    Hi Jake,
    Excellent job on your capstone presentation. I thought that the overall presentation was very informative, engaging, and covered an important topic. OA affects a considerable amount of individuals and it’s important to have multiple tools to be able to help these patients. I believe that PT and yoga will become a specialty area that you are well on your way to incorporate this type of treatment into practice. One of the areas that I especially enjoyed throughout your presentation is how you clarified that the practice of yoga can be adjusted based on an individual’s experience level. As someone who is intimidated by yoga due to a preconceived notion of what yoga is. I thought that your presentation did an excellent job of applying the ICF model to patients with knee OA. One of the key benefits I saw with applying yoga is kinesthetic awareness and the focus on mindfulness. Both of these are crucial for long term management of any form of musculoskeletal impairment. I also thought that your handout with the pictures of different yoga poses and modifications was helpful for someone like me with little knowledge of yoga. These pictures allow insight into how to begin to think about modifying positions. Overall great presentation and best of luck in the future. It will be exciting to see where you end up in your career. Keep up the good work!
    Questions/considerationsn
    What can we do as clinicians to help patients avoid unnecessary medical procedures such as repeated cortisone injections?
    How can we get patients to buy-in to the process of yoga as it is more of a long term intervention and often these patients are looking for the solution with the fastest relief in pain?
    The only area I would change is the handout as Amelia eluded to I think that the brochure could be shortened down and simplified slightly but overall it was really good unfortunately the majority of patients want simplicity over informative and I think this may help target more people.
    Thanks again for sharing your presentation and educating us on the benefits of incorporating yoga into PT practice.

    Best, Matt

    Reply

  8. Amelia Cain

    Jake!

    Really excellent job. All of your resources are well thought-out and executed, and I love that you’ve created a variety of resources for the different audiences of physical therapists/PT students, yoga teachers, and people with knee OA. The prezi presentation is thorough and informative, the yoga video includes considerate instruction and incorporation of possible modifications, and the handouts for teachers and patients are both very helpful. I’m also interested in your yoga for neurological disorders in-service, would you be willing to share this with me? Also, Yoga with Adriene is my favorite and I’m glad you recommend it as a resource!

    My only comment for potential changes to this project would be related to the “live life to the fullest using mindful movement” handout. I wonder if it might be helpful to make it more concise so that the intended audience can quickly scan it for valuable information? I’m also a little hesitant about using phrases such as “poor posture” vs “good posture,” sometimes I find that qualifying movements or perspectives as “poor/bad” or “good” can lead to negative perceptions. These are really just my opinions though, not necessary changes. Regardless, job well done! You’ve clearly put of a lot of thought and effort into this project, and I am both impressed with your current work and excited to watch you continue to grow as a physical therapist and yoga teacher! I’m grateful to know you and to have learned from and with you throughout PT school.

    Reply

  9. Austin White

    Jake,
    Where do I even begin? I enjoyed so many things about your Capstone, but what I loved the most was knowing how passionate you are about this topic! I admire that this is something you have wanted to do for a long time and you pursued it until it came to fruition. Before starting the DPT program, I wanted to complete Pilates teacher training to be able to connect Pilates and neuro rehab. While I did not support my idea with evidence at the time, my theory was similar to the research you have provided here about the mind-body connection and the benefit that incorporating the breath would have for neuro patients. Although I did not have time to get trained prior to starting the program, your Capstone has reminded me that this is something I was and still am so interested in – thank you for that! Maybe in our future careers we could combine yoga and Pilates forces?
    I loved reading that you incorporated your yoga practice into an independent study! I love your dedication to bridging this gap. Your point about the knee OA population needing a lifestyle solution (i.e. yoga) is really powerful because self-efficacy is necessary for patients to experience long-term benefits. Our Health & Wellness course emphasized the importance of community programs, and I am thankful to now know about the research behind yoga practice for many chronic conditions, as I will feel more confident recommending yoga to my future patients as part of their long-term plan of care. Reading about mindfulness and its impact on psychological benefits, I could not help but think of the COPD population as anxiety from the shortness of breath is common. Liu et al. (link below) found that yoga practice results in improved lung function (FEV1) and exercise capacity (6MWD). This makes sense to me because the mindfulness component is able to target the psychological symptoms and the poses/movement is able to address the physical impairments – the perfect marriage of the mind-body connection.
    As you can see, I could go on and on about this topic – I now remember why I wanted to pursue research on Pilates and neuro rehab 🙂 Two last things I wanted to comment on: societal connotations and modifications. The idea that yoga is for the “young and fit” is a great point about a potential barrier. For this reason, I love the idea of presenting yoga classes as designed for particular impairments, as you have done here, to offset these assumptions and draw in audiences that might assume they are not “qualified” otherwise. I also loved the many modifications that you provided in your handout! Seeing pictures of the modifications as opposed to just written descriptions was especially helpful so that PT students or clinicians who are not familiar with yoga practice can still benefit from the handout.
    Thank you for such a thorough and meaningful Capstone project! I will certainly save and use this information in the future. Congrats on doing an amazing job, as always!
    Hope to see you again soon -Austin

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4073384/

    Reply

  10. Debbie Thorpe

    Jake
    Wow….what a fantastic project! You have produced some very informative and beneficial videos, voice threads and handouts for clinicians and patients on how to incorporate yoga for the management of Knee OA. I thoroughly enjoyed working my way through all the products you posted. You are well on your way to a niche practice. You should be very proud of this work!
    Best Wishes…

    Reply

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