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By Sharon L. Kolasinski, MD, FACP, FACR
The critical role of exercise in the management of chronic musculoskeletal disorders is increasingly evident.1 Yoga is one of several traditional practices that may be useful in treating chronic conditions such as degenerative joint disease. Although yogic philosophy addresses numerous aspects of well being that might affect health and disease, the use of the physical postures, or asanas, has received some recent, noteworthy attention. Documented improvement in symptoms related to both osteoarthritis of the hands and carpal tunnel syndrome has been attributed to yoga.2,3
Yoga derives from the more than 2,000-year-old writings of Patanjali, who identified the eight disciplines of yoga.4 One of these eight disciplines is hatha yoga, or the practice of asanas.
In traditional Eastern practice, the aim of hatha yoga is to prepare the practitioner for the spiritual experience of purifying the body. Ultimately, the goal is the achievement of harmony of body, mind, and spirit. It is purported that because no single asana meets all needs in this process, a balanced program of asanas is intended to address the physiologic functioning of the nerves, muscles, and internal organs. No postures are rigidly prescribed since they may be modified depending on the practitioner’s abilities. Assistive devices may be used as needed to achieve proper positioning and later may be discarded as the practitioner becomes more adept.
In modern Western practice, however, the use of hatha yoga techniques has emphasized achieving strength, flexibility, and relaxation.5 Pranayama, or breathing control techniques, often are used in conjunction with asanas. The guiding principle behind pranayama is that if the breath is controlled, the mind will be calm. Pranayama and meditation frequently are included in Western yoga instruction.5
Although yoga was introduced in the United States in the late 1800s, the medical literature included little about the physiologic effects of yoga until the past decade. (See "Physiologic Effects of Yoga.")
Specific studies evaluating the role of yoga in treating musculoskeletal disorders have been performed by Garfinkel and associates. The first of these evaluated the use of yoga in treating osteoarthritis of the hands.2 In this randomized, controlled trial (RCT), the investigators followed a population of patients with pain and/or stiffness of the distal and proximal interphalangeal joints of the hands. Patients in the yoga intervention group participated in a 10-week program, which included eight 60-minute instructional sessions, as well as pre- and post-treatment testing. During the sessions, patients were instructed in asanas aimed at stretching and strengthening. Extension and alignment were emphasized. In addition to group discussion during sessions, written instructions were provided at the end of each session. Statistically significant differences were seen in finger joint tenderness, range of motion, and hand pain during activity. Non-significant trends toward improvement were noted for hand pain at rest and hand function measured by the Stanford Hand Assessment Questionnaire.
No participant experienced any adverse effects. The study was limited by its small size; 11 patients served as controls and 19 were evaluated in the experimental group. It also lacked an active intervention control, an important criticism since it has been demonstrated repeatedly that arthritis patients have improvements in symptoms with interventions such as telephone calls and other forms of psychosocial support.
In one trial of yoga for osteoarthritis of the hands, researchers did not find statistically significant differences in:
The second RCT by Garfinkel et al used a series of asanas to treat carpal tunnel syndrome in a group of participants recruited through newspaper advertising and among workers with heavy occupational computer use.3 The control group received wrist splints. The yoga intervention group received instruction in asanas aimed at improving flexibility, correcting alignment, stretching, and increasing awareness of optimal joint position during use. Sessions were held for 60-90 minutes twice weekly for eight weeks. Pre-and post-intervention testing was carried out for grip strength, pain measured by visual analog scale, and median nerve sensory and motor conduction measured by electroneurometer. Statistically significant improvements in grip strength and pain were found in the yoga group. Criticisms of this study include the small sample size and a failure to demonstrate a change in nerve conduction studies that correlated with symptom improvement.
One additional trial, carried out in patients with longstanding rheumatoid arthritis, addressed the use of yoga in those with musculoskeletal disease.6 Twenty patients with rheumatoid arthritis of "sufficient severity to require disease-modifying therapy" had mean disease duration of 15-20 years and were non-randomly assigned to a yoga intervention group or to receive usual medical care only. The yoga group participated in daily two-hour sessions five days a week for three weeks, then weekly for three months. Daily home practice was expected. The only variable to differ significantly between the two groups at the end of the trial was left hand grip strength. Criticisms of this study include its small size (10 participants in each group) and short duration. Furthermore, the report lacks information regarding specific clinical aspects of these patients’ disease. Given the longstanding disease duration, the yoga intervention may have treated aspects of secondary degenerative disease.
Few adverse effects of yoga have been reported. Two case reports suggest that left vertebral artery occlusion, documented angiographically, occurred in two young adults following yoga exercises involving weight bearing on and maximal range of motion of the cervical spine.7,8 A third case of arterial occlusion recently was reported involving the basilar artery and leading to multiple infarcts in a healthy 34-year-old who developed symptoms after head standing.9 One case of precipitation of symptoms of closed angle glaucoma was reported in a 47-year-old after performing salabhasana, a posture in which the practitioner lies prone with the cervical spine in extension and the legs elevated by extension at the hips.10 The authors hypothesized that this posture increased intraocular pressure in this subject predisposed to glaucoma, but the authors did not believe that yoga caused the glaucoma. A benign finding of asymptomatic, bilateral conjunctival varix thromboses in a 60-year-old who had practiced head standing 10 times/d for 10 years also has been reported.11 Finally, reversible foot drop was diagnosed in a 22-year-old who assumed a kneeling position during chanting for up to six hours/d.12 The degree of supervision of these practitioners was not made clear in the case reports, but only the case of symptoms related to glaucoma appeared to have occurred while a practitioner attended regular instruction. The others apparently occurred during unsupervised home practice.
Contraindications and Precautions
Patients embarking on a new exercise program should seek prior medical evaluation, especially if they previously have been sedentary or have cardiovascular risk factors. Physicians should question patients about their exercise habits. Patients with arthritis or other musculoskeletal complaints should be asked to discuss the specifics of their exercise regimen, particularly if the patient undertakes an exercise program to treat symptoms.
Yoga complications involving the cervical spine have occurred in practitioners without known history of neck problems. It would be prudent to avoid exercises requiring prolonged flexion and extension or extremes of rotational motion in patients with known cervical spine osteoarthritis, cervical degenerative disc disease, or known atherosclerotic or other vascular disease.
Yoga is an ancient and complex practice, one aspect of which involves physical exercise that reportedly has a variety of benefits. The benefits to the musculoskeletal system itself are perhaps the least well documented. Some work suggests that yoga can be helpful in overall conditioning, as well as in treating specific complaints including those related to degenerative joint disease and carpal tunnel syndrome. How yoga should best be used as an intervention to treat musculoskeletal disorders remains unclear. However, if the goals of treatment include pain reduction, improvement in grip strength, and improvement in joint range of motion, data from well-designed clinical trials support the use of yoga.
If the physician wishes to prescribe yoga to treat symptoms, the goals of therapy and the type of hatha yoga should be made clear to the patient. In particular, in those patients with inflammatory arthritis, it is unlikely that aspects of inflammation such as warmth or erythema are likely to respond. For those patients with degenerative joint disease, however, a two-month trial of weekly supervised yoga instruction may be beneficial.
Physicians should be familiar with Western variations on traditional hatha yoga, including "power yoga" classes that involve vigorous participation, often in highly heated rooms. Yoga practice should be medically supervised in the same manner as any other exercise program. Particular attention should be paid to the actual asanas to be performed. Common sense precautions for those with degenerative arthritis include not performing postures beyond the limits of comfort and avoiding excessive repetitions. Patients should be encouraged to inform their yoga instructors of their medical history prior to the start of the class and to point out any difficulty they may have in assuming certain asanas during class. v
Dr. Kolasinski is an Assistant Professor of Medicine, Division of Rheumatology at the University of Pennsylvania in Philadelphia.
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7. Nagler W. Vertebral artery obstruction by hyperextension of the neck: Report of three cases. Arch Phys Med Rehabil 1973;54:237-240.
8. Hanus SH, et al. Vertebral artery occlusion complicating yoga exercises. Arch Neurol 1977;34:574-575.
9. Fong KY, et al. Basilar artery occlusion following yoga exercise: A case report. Clin Exp Neurol 1993;30: 104-109.
10. Fahmy JA, Fledelius H. Yoga-induced attacks of acute glaucoma. A case report. Acta Ophthalmol 1973;51: 80-84.
11. Margo CE, et al. Bilateral conjunctival varix thromboses associated with habitual headstanding. Am J Ophthalmol 1992;113:726-727.
12. Chusid J. Yoga foot drop. JAMA 1971;217:827-828.