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YOGA THERAPY AND PAIN

The immediate effects of modified Yogapositions on musculoskeletal pain relief 

Jose Luıs Pimentel do Rosario, PT, Ph.D. b,*,Larissa Schwarzwalder Orcesi, PT a, Fernanda Naomi Kobayashi,

PT

a

, Alexandre Nicolau Aun, PT

a

, Iane Tavares DiolindoAssumpcao, PT a, Gisele Janaina Blasioli, PT a,Erica Sato Hanada, PT a

a Physion Institute, Brazilb State University of the Center-West  e  UNICENTRO, Rua Padre Salvador, 875, CEP 85015-430 

Guarapuava, PR, Brazil1

Received 6 January 2013; received in revised form 4 March 2013; accepted 20 March 2013

KEYWORDSPosture;Pain;Yoga;Analog scale

Summary   Many musculoskeletal pains are related to poor posture. Thus, the aim of the pre-sent study was to assess the efficiency of a single session of two modified Yoga positions with 110

subjects and their 147 pain-related complaints. The participants were divided into two groups:

The Yoga Group, which received treatment of two 20-min postures and the Control Group, which

received a placebo treatment of 15 min with a turned off ultrasound. All volunteers experiencedsome pain before treatment and were assessed before and after treatment using the analog pain

scale. A score of 0 indicated no pain whereas 10 was the maximum degree of pain on the scale.

The difference before and after treatment was compared between the groups with a  p-value of

0.0001, as measured by the Student’s  t-test. It is possible to conclude that one therapy session is

effective in the treatment of various musculoskeletal problems.

ª 2013 Elsevier Ltd. All rights reserved.

Introduction

A number of authors have stated that if body segments arekept out of alignment for extended periods, some of themuscles involved are used in a shortened position as a conse-quence (Kendall et al., 2010; Novak and Mackinnon, 1997).These muscles are usually seen as strong, while their antago-nists aretaken to be elongated andweak; one of the effects of

* Corresponding author. Rua das Rosas 620, Mirandopolis,   CEP04048-001, Sao Paulo, SP, Brazil. Tel.:  þ55 42 9992 9992.

E-mail address: ze.fisio@gmail.com (J.L.P. do Rosario).1 Tel.:  þ55 42 3621 1000.

1360-8592/$ - see front matter  ª 2013 Elsevier Ltd. All rights reserved.http://dx.doi.org/10.1016/j.jbmt.2013.03.004

 Available online at  www.sciencedirect.com

j o u r n a l h o m e p a g e :   w w w . e l s e vi e r . c o m / j b m t

Journal of Bodywork & Movement Therapies (2013)  17, 469e474

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poor posture. These deviations can be unsightly and canadversely affect muscular efficiency, predisposing individualsto musculoskeletaldysfunction. Oneof themajorsymptoms ofpostural change is pain (Rosario and Marques, 2004).

According to Lee (1994), good posture creates the leastamount of joint stress and requires the least amount ofmuscle activity. Consequently, it is the position of maximumefficiency. The same author also described how a deviation

from optimal positioning should be compensated by changesin the joint position which, in turn, must be maintained by anincrease in muscle activity. Therefore, postural instabilitycan be seen to potentially result in an excess of energyconsumption. This change in joint position, as described byLee (1994), is very similar to the concept of chiropracticsubluxation. Generations of chiropractors have ascribedmultiple symptoms to this type of dysfunction. (Mirtz et al.,2009). Indeed,  Moreno et al. (2007)   submitted a group ofwomen to physical therapy to correct their posture and toreduce the pain related to postural abnormalities. The pa-tients were radiographed one week after therapeuticdischarge. The postural improvement was demonstrated bythe retraction of the shoulder and a decrease in pain.

Hoppenfeld (1999) reported that a referred pain in a jointcanhave itscause in adjacent joints. Francoise Mezieres, themother of therapies based in muscular chain (Teodori et al.,2011; Rosario, 2011, 2012) demonstrated that there is notjust a single muscle that causes bad posture, but ratherchains of muscles that can end up causing a dysfunction in aspecific place from generalized tension. Therefore, a local-ized muscular action provokes reactions at a distance.

Considering that poor posture is associated with jointpositioning changes, and that this malposition can beassociated with pain, the origin of which is far from thelocation, the aim of the present study was to assess theefficiency of a single application of modified Yoga positions.

These Yoga positions were modified aiming to stretch allthe muscles of the posterior or anterior chains at the sametime, based on Mezieres work (Rosario et al., 2012).

Methods

In total, 110 patients were treated. As some individualsreported pain in more than one place, 147 complaints weretreated. The inclusion criteria for the present studyinvolved subjects with at least one complaint of musculo-skeletal pain. Volunteers signed a statement of informedconsent and were assessed and treated with muscularchains therapy, as described by Rosario (2011). The present

study received approval from the Human Research EthicsCommittee of the State University of the Center-West(UNICENTRO) under protocol number 289/2011.

The subjects were divided into two groups of 55 par-ticipants each: The Yoga Group, which received posturaltreatment and the Control Group, which received a placebotreatment of 15 min with turned off ultrasound. Bothgroups were treated by a Physical Therapist that had beentrained in both of these altered Yoga positions.

Yoga Group assessment and comparison of chains

The anterior and posterior chains were assessed followingthe description by   Rosario (2012)   to identify the most

compromised chain, which exhibited the highest compen-sation in the test. This chain was the first to be treated.

A Examination of the anterior chain

The Tadasana  e   Mountain Pose  e   is used to assess theanterior chain (Fig. 1). Patients who have either shorteningor tension in this chain exhibit compensatory changes.

Assessment steps:

1 Place the individual standing.2 Place the pelvis in retroversion until the lumbar spine

becomes flat.3 Observe the compensation, which may be one of the

following:- Leaning the torso back;- Bending the knees. A small flexion is normal (Fig. 1);- Chest held in an inspiratory position (Fig. 1);- Protrusion of the head and shoulders.

4 Examination of the posterior chain

The Shaktyasana e The Shakty goddess pose e is used toassess this chain (Figure 2).

Assessment steps:

1 The subject must lean forward with the knees straight.2 Align the lumbar spine, requesting a small lumbar

lordosis.3 In order to achieve the spinal alignment, a shortened in-

dividual extends thetrunk, opening thehip angle of flexion(Fig. 2). Another possible abnormality is an opening of theankle angle (Fig.2), whichis theangle formed between thefoot andthe tibia.In both cases,theoptimalangles are90.

Figure 1   Assessment of the anterior chain with Tadasana emountain pose. This figure displays a shortening in the anterior

chain in the form of an inspiratory blockage and increased knee

flexion.

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Yoga treatment

Treatment consisted of two postures adopted for 20 mineach. Before treatment, the subjects were taught how toseparate breathing by region: apical; lower ribs and dia-phragmatic breathing, in order to help maintain posture.The selection of posture was based on the assessmentdescribed above. If the therapist found more alterations inthe posterior chain, two postures of the posterior chainwere performed. If more alterations were found in theanterior chain, two postures of the anterior chain wereperformed. If the two chains exhibited similar alterations,the treatment included one posture of each chain. Both ofthe postures were performed as described by   Rosario(2012).

1 Supta Baddha Konasana  e  Reclining Bound Angle Pose(anterior chain) (Fig. 3)- The patient is positioned in supine decubitus, with the

arms against the body;- The patient puts the soles of the feet together;- As a rule, full external rotation of the femur should be

sought. If the patient has excessive external rotationof the femur, a neutral position should be adopted,with no rotation at all.

- Neck traction should be applied while maintaining

physiological neck lordosis;- The tension point of the posture can be found by

bringing the heels forward and extending the knees,leading to more difficulty in keeping the patient’slower back flat against the table. The tension point isthe maximum eccentric stretch the patient can holdwithout inverting the spinal curves. If the lumbarspine is not in full contact with the table, the patientshould be requested to perform an abdominalcontraction. If this does not work, it is a sign of toomuch knee extension.

- In order to help the patient to contract the correctmuscles, it is important to provide proprioception

hints (Fig. 3). Thus, the therapist’s hand touches thethoracic region, or lumbar/abdominal region, in orderto help the maintenance of the natural spinal curves.

2 Viparita Karani  e  Inverted Legs Pose (posterior chain)(Fig. 4)

- The patient is positioned in supine decubitus, with thearms against the body;

- The patient puts the soles of the feet together;- As a rule, full external rotation of the femur should be

sought. If the patient has excessive external rotationof the femur, a neutral position should be adopted,with no rotation at all.

- Neck traction should be applied while maintainingphysiological neck lordosis;

- The therapist flexes the patient’s hip holding them bythe heels. Alternatively, the therapist can use a sup-port for the heels (Fig. 4) in order to free the handsfor treatment;

- The tension point can be found by extending theknees and flexing the hip, leading to more difficulty inkeeping the patient’s sacrum flat against the table.The tension point is the maximum eccentric stretchthe patient can hold without inverting the spinalcurves. If the sacrum is not in full contact with thetable, the patient should be requested to perform aparavertebral contraction. If this does not work, it is asign of too much knee extension or hip flexion.

Figure 2   Assessment of the posterior chain with Shaktyasana

e The shakty goddess pose. This figure displays a shortening in

the posterior chain in the form of an opening in the hip and

ankle angles.

Figure 3   Supta Baddha Konasana  e   reclining bound angle

pose.

Figure 4   Viparita Karani  e  inverted legs pose.

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- In order to help the patient to contract the correctmuscles, it is important to provide proprioceptivehints (Fig. 4). Thus, the therapist’s hand touches thethoracic region or sacral region in order to help themaintenance of the spinal natural curves.

Postures evolution

During the 20-min posture period, the therapist seeks to

maintain the symmetry of the patient. When the patientmaintains a posture for a certain time, muscular visco-elasticity decreases. As a result, the posture becomeseasier to sustain. Thus, the difficulty of achieving theposture must be gradually increased. This process is called“posture evolution”. In other words, evolution involvesfinding a new tension point each time the position starts tobecome easier. The following rules must be respected:

- At no time is it permissible to reverse the spinal phys-iological curves;

- Both anterior and posterior postures require gradualextension of the knees;

- The posture of the posterior chain requires a gradual

increase in hip flexion;

Pain assessment

Pain is a symptom that accompanies the majority of patho-logical conditions that require medical care. Among the inter-nationally validated scales for measuring the intensity of pain,theanalogscaleisoneofthemostutilized(Gracely etal., 1996;Aicher et al., 2012; Bailey et al., 2012). In the present study, aline, scored from 0 to 10, was shown to the subject, whoverballyidentifiedthe degree of their pain,with zeroindicatingno pain and ten indicating the most intense pain possible.

Statistical analysis

Besides the descriptive analysis, ANOVA was also used, with

the significance level set at  p Z 0.05. In this test, the levelof pain reported by the subject on the analog scale beforetreatment was compared to the level of pain after the Yogasession. The groups were also compared before treatmentto investigate the similarity between them.

Results

Table 1  displays the mean and standard deviations beforeand after treatment in both groups. It also shows the inter-group   p-value and the   p-value between the groups aftertreatment.

No statistical differences were found (ANOVA) between

the groups before treatment ( p Z 3.2).Before the Yoga session, the majority of complaints in

the Yoga Group were between the values 3 to 8. After the

session, the majority of values were between 0 and 2, witha significant number of complaints also found at value 4 ofthe scale. On the scale, the value of zero (no pain)increased from zero reports to twenty-four, from the totalof seventy-one complaints.

Themean of the71 valuesbeforetreatment was 5.49 witha standard deviation of 1.91. After treatment, these valuesdropped to a mean of 1.78 and a standard deviation of 2.04.

The number of complaints with some improvement was 67,which is equal to 94.4% of cases. The Yoga treatment had noeffect in only 2 cases (2.8%), whereas there were also 2 cases(2.8%) that worsened. The significance of these data in theStudent’s t-test was p Z 0.001. Thus, it is possible to rejectthe equality between values before and after treatment.

Before the placebo session, the largest number ofcomplaints in the Control Group was between the values 3to 7. After the session, the majority of values were be-tween 3 and 8. On the scale, the value of zero (no pain)increased from zero reports to one.

The mean of the 76 values before treatment was 6.50with a standard deviation of 1.81. After treatment, thesevalues dropped to a mean of 4.75 and a standard deviation

of 1.92. The number of complaints with some improvementwas 29, which is equal to 38% of cases. The placebo therapyhad no effect in 38 cases (50%) and there were also 9 cases(12%) that worsened. The significance of these data in theStudent’s   t-test was   p   Z   0.0001. Thus, it is possible toreject the equality between the values before and aftertreatment.

When comparing the difference between the groupsbefore and after treatment using ANOVA, the  p-value was0.0001 (Table 1).

Discussion

Both Groups showed significant relief of undiagnosed spinalpain. The placebo exhibited a   p-value of 0.0001, whereasthe value for Yoga was 0.00001 after treatment. Comparingthe groups, Yoga was significantly better with a  p-value of0.0001. The Control Group had a mean pain level of 5.50before treatment and 4.70 after (a difference of 0.80). Themean pain level in the Yoga Group was 5.52 before treat-ment and 1.50 after (a difference of 4.02). Treatment withYoga provided some sort of pain relief in 96% of cases,whereas this figure was 36% in the control group.

Although there are relatively few scientific studiesinvestigating these Yoga postures or similar techniquesbased on Mezieres stretching techniques (MST), they have

produced results in treating various musculoskeletal con-ditions (Basso et al., 2010;   Canto et al., 2010;   Fozzattiet al., 2008;   Gil et al., 2011;   Luz et al., 2008;   Marques

Table 1   Mean and standard deviations before and after treatment. Inter-group p-value and  p-value between the groups.

Mean and standard

deviation before

treatment

Mean and standard

deviation after

treatment

Inter-group

 p-value

 p-value

between

the groups

YOGA group 6.72   1.74 1.23   1.69 0.00001 0.0001

Control

group

6.50   1.81 4.75   1.92 0.0001

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et al., 1994; Moreira and Soares, 2007; Moreno et al., 2007,2009;   Rossi et al., 2011). The present study corroboratesthese previous studies.

Canto et al. (2010) studied the efficiency of MST in in-dividuals with lower back pain using visual analog painscales at the time of the first and tenth treatment session.In total, 85.7% of the participants reported a decrease inthe level of pain at the end of treatment and 77.1% of the

subjects recorded a lower score on the Roland Morrisquestionnaire. The result of 85% is close to the 94.4% foundin the present study, although the main difference is thenumber of sessions: while these authors used ten sessions,the present study used only one. This brings into questionthe number of sessions necessary to perform the treat-ment. Most MST therapists perform ten sessions as a basisfor a treatment that provides results (Rosario, 2011).Moreover, since Canto et al. (2010) did not assess patientsbefore the eleventh session, but after the tenth, theseresearchers assessed the pain with the acute effect of thelast session and not with the chronic effect of the tensessions alone. The present study also did not assess theeffect of a single session after 24 or 48 h. These data would

be very useful in terms of finding a more effectivetreatment.

Another clue that postural correction may lead to painreduction can be found in the work of  Rossi et al. (2011),who obtained postural improvements with just one treat-ment session using a similar technique. The present studyrecorded pain reduction with one session, which can beassociated with the improved posture achieved in the veryfirst session.

Marques et al. (1994)   assessed the effect of posturaltreatment on fibromyalgia. Of the 20 patients treated, 18reported some improvement. Although fibromyalgia is lis-ted as a rheumatologic disease, these data are similar to

the results of the present study. Other studies have ob-tained positive results with this kind of treatment,demonstrating how different causes of musculoskeletalpain can be relieved by a postural treatment, similar to thepresent study.   Basso et al. (2010)   reported decreases inpain among 20 patients with temporomandibular disorders,using 10 muscular chain treatment sessions. Gil et al. (2011)decreased back pain in pregnant women in 8 weeks.Heredia and Rodrigues (2008)  relieved the pain of patientswith epidural fibrosis in post-operative lumbar discherniation.

Rosario  et al. (2008)   argued that this type of posturaltreatment technique does not affect posture simply bystretching, since a 15-min posture produced the same re-

sults for hamstring flexibility as a 30-s hamstring stretch.Body awareness and the active maintenance of better jointpositioning, reducing an existing dysfunction, can exerttheir influence on postural adjustment and consequentlysolve related pain (Beecher, 1955). Whatever the reason forthe effect, this study and previous studies have shown thatMST can result in improvement in the functionality of amusculoskeletal pain source. The relief of 94.4% of thecomplaints, with a complete absence of pain in 24 of the 71complaints, demonstrated the efficiency of modified Yogapostures when properly applied.

An interesting result in the present study was the un-expected success of the placebo therapy, which was

inferior to the Yoga treatment but still provided some painrelief in 36% of cases. These results corroborate the findingsof Beecher (1955)   who suggested that the placebo effectoccurs in 35% of the population. Placebo analgesia for post-operative dental pain was effective in 39% of cases (Levineet al., 1979).  Grelotti and Kaptchuk (2011) stated that theplacebo effect comes from an emotional response and canbe so strong that the patient feels better and members of

their family may also believe that the treatment is working,provoking a whole social effect.

Even well recognized, analog scales are subjective.Thus, the improvement obtained would be more accuratewith the use of other equipment such as dolorimeters.According to Moerman (2006), the placebo is effective as atreatment because it has a meaning. Therefore, when theultrasound is turned-off, it acts as a placebo therapybecause it has the meaning response of a therapy. However,the use of certain Yoga positions, which are unrelated tothese postural corrections, would be a better placebo witha similar meaning. Future studies should take this intoconsideration.

Conclusion

In the present study, modified Yoga positions were shown toreduce musculoskeletal pain in patients immediately afterthe intervention. However, it did not determine the short-term or long-term effects of just one intervention withYoga. Further studies are required to understand theseeffects and the disorders that could be treated effectivelyby this method, and those that could not, as well as theoptimal time and frequency of application for eachdisorder.

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