Yoga and Science in Pain Care

How might we blend yoga with science to provide pain care to people? A new book just released provides a way forward.

“Our vision is for this book to improve care for people living in pain, whether acute or chronic pain. We believe health care professionals and yoga therapists can enhance care through deeper understanding of pain, science and evidence-informed interventions. We also believe that professionals can enhance their work through integrating yoga concepts, practices and philosophies. As such, this book is meant to bridge yoga, pain science and evidence-informed rehabilitation … and will inform those committed to helping people with this largely undertreated issue that causes so much suffering in the world.” –  Preface, Yoga and Science in Pain Care; Edited by Neil Pearson, Shelly Prosko, Marlysa Sullivan

The first chapter by Joletta Belton is about the “Lived Experience of Pain” highlighting to me the need to listen to, acknowledge and consider first, the person and their experience.

“The authors provide an integrated, in-depth understanding of how yoga therapy can be incorporated within a modern understanding of pain as an experience. The book encompasses perspectives from people living with pain, summarises research progress in the field, debates theories of pain and pain management, considers the many different yoga practices, describes pain biology, self-regulation and examines breath, body awareness, nutrition, emotions and response to pain, and above all, integrates concern for practitioners and people in pain as humans sharing an intangible experience together. The authors write about how yoga therapy can provide a uniting and compassionate approach to helping people learn to live well.”

– Bronwyn Lennox Thompson, PhD, MSc, DipOT, Postgraduate Academic Programme Leader, Pain and Pain Management, Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, Christchurch, NZ

There are a lot of yoga books on shelves these days. Yoga for this, yoga for that. You name it; it’s being written about. The trouble with this and certainly when talking about pain is the approach is about the condition, the problem, the illness or disease. What’s often left out is the person. Which may be one of the reasons why we fail in helping people.

After all, your pain is not the same as my pain. Not only is the physical aspect different, my body different, my genetics, my structure. Almost more important is the rest of ‘me’ that’s different from ‘you’.

My life history is different from yours. My environment is different from yours. My stressors are probably not your stressors. My understanding of pain probably differs from yours. My expectations, beliefs and thoughts about my pain will be different from yours. My social structures, friends, family, work-life will all be different. So how might we believe we can just apply this ‘fix’ to everyone who experiences pain? It just doesn’t make sense, when you think about it. Particularly when we understand that pain… is… complex.

We, therefore, should look to explore and be curious about all the things that might be contributing to your particular experience of pain. Similarly, individualize the care, tools, techniques and practices with what research tells us might be useful, to change your pain.

You may have had pain for years. Like 30+ years or more. Still, there is an opportunity for change based on what we know about pain and how it works. There is much still to learn but we can change the nervous system, We can change the brain. We can change physiology and most likely all three of these have been changed if your pain has been ongoing.

Pain can change. There is hope. I will keep saying this over and over and over again …

If you’re the type that likes read and learn about this yourself, order a copy of the book, here.

If you’re the type that would like to learn from me in person or in a class setting with others, check out my updated schedule for the fall, here. New classes starting in September!

Additional notes:

Joletta Belton, as noted above, writes a blog “My Cuppa Joe” about the lived experience of pain. Among other things, she is a speaker, educator and advocate for people in pain. You can read her blog, here.

Bronwyn Lennox Thompson also writes a blog “Healthskills: For health professionals supporting chronic pain self management.” An exceptional resource for information, research, and discussion. You can check it out here.

Great programs but why the disconnect?

disconnectAfter receiving basic information about the University of Ottawa Heart Institute’s Heart Wise Exercise program, presented at my yoga therapy training, I wanted to go back to learn more so paid them a visit earlier this week. Theirs is a program that helps to connect patients who have been through initial rehab programs after diagnosis, illness, surgery from heart disease, to community-based exercise programs and fitness professionals. It served primarily Ottawa but over the years has expanded in/around Ontario and a little into Quebec.

I mentioned a program in Alberta that I’d found on the internet a year or so ago. In Alberta the Prescription to Get Active Program allows you to visit your doctor, receive a ‘prescription to get active’ and then find a facility in your community offering all kinds of activities from walking, strength training, yoga, cycling, swimming, dancing, etc. The ‘prescription’ allows for free access (often a series like a 10-pass visit, free month, etc.) to get you started.

I often reference the excellent program the province of BC provides to health care providers and those living with chronic pain. The Pain BC program is one of the of the best (well, the only one of its kind I know of) in Canada in terms of information, resources and programs.

It’s too bad all these programs are rather piecemeal and for the most part unknown across Canada, rather than being coordinated. I give great credit to the people and work done to provide them.  It’s just our government or overriding systems that seem to be unable to provide the coordination, or funding or whatever might be needed so everyone can access them.

Regardless, for my Canadian friends and followers, feel free to check them out!

Links above, but for easy reference click on any of these links:

That never-ending pain in the a**

hip-painfulI originally posted this on the Yoga and Movement Research Community Facebook group earlier in the week and then realized I should probably do so for my own readers.

Hip pain, SI joint pain, osteoarthritis of the hip, scoliosis, etc. often come up for discussion as a topic of pain and injury and there’s new research that may be helpful to others experiencing these conditions or symptoms.

“Gluteal tendinopathy, often referred to as greater trochanteric bursitis or greater trochanteric pain syndrome, has a prevalence of 10-25% and is experienced by one in four women aged over 50 years. The disorder presents as pain and tenderness over the greater trochanter and often interferes with sleep and physical function. The level of disability and quality of life is equivalent to that of severe hip osteoarthritis, and effective management strategies are required.”

I’ve just been listening to a podcast, which led me to the guest’s (Tom Goom, physiotherapist) blog post, which led me to a new (May 2018) study he references, which then led me to some other information about hormones.

First, I find it interesting, that gluteal tendinopathy has commonly been misdiagnosed.

“GT typically presents as pain over the greater trochanter (the bony lump felt at the side of your hip). Symptoms may spread into the outside of the thigh and knee. It is commonly misdiagnosed as hip joint pathology, ITBS, sciatica or as being referred from the lumbar spine. GT is a good example of how clinical knowledge has progressed in recent years. Initially it was thought of as inflammation of the trochanteric bursa – a fluid filled sac that sits over the trochanter. However as research developed we realised 2 rather important things. The bursa may not be the issue and there isn’t really any inflammation. Later the condition was termed Greater Trochanteric Pain Syndrome (GTPS) but further research has enabled us to be more specific with the diagnosis. Bird et al. (2001) examined MRI findings of patients with GTPS, they found that nearly all patients had evidence of Gluteus Medius Tendinopathy. Swelling of the bursa was present in just 8% of cases and did not occur in the absence of gluteal tendinopathy.

The primary pathology of Gluteal Tendinopathy is most likely an insertional tendinopathy of the Gluteus Medius and/ or Gluteus Minimus tendons and enlargement of the associated bursa.”

Second, a study published in the BMJ (May 2010) shows its both education AND exercise which results in greater improvement at both 8 and 52 weeks (as compared to corticosteroid injections or ‘wait and see’ approach) in Gluteal tendinopathy. Again, how education is an important piece of the pain puzzle. Most often people experiencing pain do better with both education and movement, according to current research.

Third, right at the end of the podcast, Tom briefly mentions how hormones may play at part. Interesting again, as this is very common presentation for women who would be experiencing menopause. As noted above, 1 in 4 women over the age of 50 (myself included 🙂 )

In this systematic review and meta-analysis of 102 studies, published in the British Medical Bulletin, Jan 2016 they conclude “the role of hormones in tendinopathies is still controversial.”

However,

“The continuous modulation of female sex hormones during the menstrual cycle affects the composition of tendon collagen, because the connective tissues express receptors for both estrogen and progesterone. This leads to a clinically relevant condition in relation to physical training and musculoskeletal performance of female athletes.” 

Key points for me through all this is that education is a key component so “the patient” has some control. Our current systems typically leave out self-efficacy or agency of a person and rather encourages a dependence, passivity and ‘have someone else fix it’ situation. Knowing you have some understanding and influence over your health rather than the usual doubt, uncertainty and fear can go a long way.  Though this does involve engagement, commitment and doing the work.

On the topic of hormones, well let’s hope that future researchers will see the need to account for such differences rather than using only males for most health-related studies. I understand it’s difficult to do given the cyclic nature, but surely it makes a difference.

If you’re interested in this, suffer from on-going pain in your a**, or are curious about how hormones may play a part I encourage you to read further. Or, you can always comment below to discuss.

  1. Running Physio blog post: New study is a LEAP forward. He’s written a few over the last month, you may want to check out.
  2. BMJ (June 2018): Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial.
  3. British Medical Bulletin (Jan 2016): Hormones and tendinopathies: the current evidence

Low Back Pain: GAPS between Guidelines and Practice

bettingrealitycheck

Continuing with the second of three papers recently published in The Lancet regarding Low Back Pain. What guidelines are already in place, what’s actually occurring in practice and suggested solutions going forward.

What’s striking to me is the

clear evidence of substantial gaps between evidence and practice, that are pervasive

A few years after delving into this, I am still scratching my head how far behind we are in our medical and clinical practice given the evidence. Yet, I’m hopeful that as more and more of this gets into the public domain, much-needed momentum will begin to close the GAP. Particularly with the crisis we find ourselves in, the growing epidemic of opioid use which is literally, killing people.

What are the treatment guideline GAPS, as outlined in the paper?

Below are

study results of clinical practice and highlights the disparity between ten guideline recommendations and the reality of current health care.

Guideline Message: Low back pain should be managed in primary care.

Practice: in high-income, low-income, and middle-income settings, people with low back pain present to emergency departments or to a medical specialist.

Guideline Message: Provide education and advice.

Practice: in high-income, low-income, and middle-income settings this aspect of care is rarely provided.

Guideline Message: Remain active and stay at work.

Practice: in high-income, low-income, and middle-income settings, many clinicians and patients advocate rest and absence from work.

Guideline message: imaging should only occur if the clinician suspects a specific condition that would require different management to non-specific low back pain.

Practice: although such specific causes of low back pain are rare, in high-income, low-income, and middle-income settings, imaging rates are high.

Guideline message: first choice of therapy should be non-pharmacological.

Practice: surveys of care show that this approach is usually not followed.

Guideline message: most guidelines advise against electrical physical modalities (eg, short-wave diathermy, traction).

Practice: worldwide these ineffective treatments are still used by the professionals who administer physical therapies.

Guideline message: due to unclear evidence of efficacy and concerns of harm, the use of opioid analgesic medicines is now discouraged.

Practice: these medicines have been overused in some, but not all, high-income countries; low-income and middle-income countries seem to have very low rates of use.

Guideline message: interventional procedures and surgery have a very limited role, if any, in the management of low back pain.

Practice: these approaches are widely used in high-income countries, little evidence on their use is available for low-income and middle-income settings.

Guideline message: exercise is recommended for chronic low back pain.

Practice: clinician treatment preferences and health-care constraints limit uptake.

Guideline message: a biopsychosocial framework should guide management of low back pain.

Practice: the psychosocial aspects of low back pain are poorly managed in high-income, low-income, and middle-income settings.

As you can see, what’s recommended is not what’s being offered to people for treatment.

Though first line care is meant to be non-pharmacological,

a study from the USA showed that only about half of people with chronic low back pain are prescribed exercise. In Australian primary care and in the emergency department setting in Canada, the most common treatment is prescribed medication.

Then, there are the rates of imaging, even though it has a limited role to play (see previous post).

39% in Norway, 54% in the USA, 56% in Italy as three examples, presenting patients to emergency rooms are given imaging.

Even worse, opioids. Though data for effects of opioids for acute low back pain are sparse,

one study showed that they were prescribed for around 60% of emergency department presentations for low back pain in the USA.

And,

More than half the total number of people taking opioids long-term have low back pain though NO randomized controlled trial evidence is available about long-term effects. Well, we can see some of the short-term effects taking place across our countries at the moment.

In terms of surgery, which has “a limited role for low back pain”,

studies from the USA, Australia and the Netherlands show frequent use of spinal fusion.

So the waste to our healthcare system is apparent, but the bigger cost is what’s happening to the people who are provided these treatments that have shown to have little success. They seem stuck in what seems a never-ending loop of pain.

Key messages:

“Guidelines recommend self-management, physical and psychological therapies, and some forms of complementary medicine, and place less emphasis on pharmacological and surgical treatments, routine use of imaging and investigations is not recommended.

Little prevention research exists, with the only known effective interventions for secondary prevention being exercise, combined with education, and exercise alone.”

Where do we go from here?

“Promising solutions include focused implementation of best practice, the redesign of clinical pathways, integrated health and occupational care, changes to payment systems and legislation, and public health and prevention strategies.”

Current guidelines need to be utilized which we clearly see, they are not.  There needs to be better integrated education of health-care professionals including a change to the clinical-care model. Revamping the “current models of health-care reimbursement, which reward volume rather than quality”. Integration of health-care and occupation interventions so we can get people back to work and back to their lives. Changes to compensation and disability policies. Finally, public health interventions to change public’s beliefs and behaviors.

Which brings us to the last of the 3 papers, Low back pain: a call for action, up next on the blog.