THE FACTS

For many people, yoga is more than just exercise: Studies show it is one of the most commonly used forms of alternative therapy in the country. Many rely on yoga to relieve chronic and acute pain.

The reasons for this are varied. Some researchers believe that yoga may alleviate pain through relaxation and the release of endorphins. Others say it may reduce inflammation and promote positive emotions.

Plenty of studies have tried to determine whether taking up yoga can actually help lessen pain. In a recent report, a team of researchers sifted through the science and identified 10 randomized clinical trials on the subject involving hundreds of patients.

The studies looked at yoga’s effect on pain stemming from ailments like arthritis, low back problems, pregnancy symptoms and migraines. The control conditions were standard treatments and exercise, diet and lifestyle changes.

Nine out of the 10 clinical trials found yoga could help provide relief from pain, which the authors called “encouraging.” But they also noted that no definitive conclusion could be reached, for a number of reasons.

The studies involved patients experiencing pain from a wide variety of conditions, and they looked at several types of yoga that had some similarities, like breathing, stretching and relaxation exercises — but also many differences. Complicating matters was that the intensity, amount of time and frequency of the yoga sessions differed from one study to the next.

While the evidence suggests that yoga has the potential to alleviate pain, they wrote, the science is not firm enough to say for certain.

THE BOTTOM LINE

A review of the research on yoga suggests that it may have some usefulness in relieving pain, but more research is needed.

FLEX TIME Lynn Hughes, left, an assistant therapeutic yoga instructor, and a client, Barbara Morgan, at the Yoga Barn in Issaquah, Wash. Ms. Morgan’s goal is to restore full motion in her upper body after a double mastectomy.

By NORA ISAACS

Published: May 10, 2007

FOR three years after a car crash left her with chronic pain, Deanna Adams searched high and low for relief. Mrs. Adams, 41, a stay-at-home mother in West Palm Beach, Fla., consulted a physical therapist, a chiropractor, two doctors (a pain specialist and a neurologist) and an acupuncturist — to no avail.

She also went to basic yoga, hoping asanas would ease the debilitating back pain, neck spasms and migraines that plagued her. After each class at LA Fitness, Mrs. Adams felt better for a few hours, but her symptoms inevitably returned.

It was only after her first yoga therapy session with Emily Large, who runs Living Large Therapeutics, that she realized why group yoga left her cold. “When you go to a yoga class, everybody is doing the same thing,” Mrs. Adams said. “If you have a neck or back injury, the instructor doesn’t know.”

Yoga therapy — one-on-one visits which take place in medical clinics, physical therapist offices and yoga studios — takes into account pain and injuries for a customized experience.

As her client did yoga postures she had handpicked, Mrs. Large, a yoga therapist with a physical therapy license, lightly touched her to sense where Mrs. Adams was tense or weak. Then she designed a sequence of poses to target those areas, including a lying twist with the knees bent and a repetitive variation of triangle pose. As Mrs. Adams grew stronger and more flexible doing poses at home, her routine was updated, and after three months, her pain has largely subsided.

People often turn to yoga when they are injured because they want gentle exercise that’s easy on the joints. But, most yoga teachers don’t have time to address individual problems, nor do they regularly deal with special needs.

Enter yoga therapy, an emerging field in the United States, although commonplace in India. Therapists work in small groups or privately, adapting poses for musculoskeletal problems that have been diagnosed by doctors. Other therapists help people deal with the anxiety of living with illnesses as varied as cancer and chronic fatigue.

“We recognize that not every pose is for everybody,” said Robin Rothenberg, a yoga therapist who runs the Yoga Barn studios outside of Seattle. “If you are a 20-something dancer, that is one thing and if you are a 50-year-old computer programmer, that’s a different thing.”

Yoga therapy is nowhere near as popular as one-pose-fits-all classes. Still, in the last three years, membership in the International Association of Yoga Therapists, a trade group based in Prescott, Ariz., has almost tripled to 2,060, from 760.

But experts inside and outside the industry say yoga therapy should be approached with caution. In general, a person can practice as a yoga therapist after 200 hours of yoga teacher training, which might include basic training in anatomy, breathing, meditation and giving adjustments.

“Anybody can hang their shingle and say they are a yoga therapist,” said Julie Gudmestad, a physical therapist who also practices yoga therapy in Portland, Ore. “Buyer beware. I’ve seen some strange things done in the name of yoga therapy.”

Most reputable yoga therapists have additional credentials. Some are physical therapists or nurses or have completed two years of training in Iyengar yoga, which emphasizes anatomy and kinesiology.

Others have been certified as therapists by schools like Integrative Yoga Therapy or American Viniyoga Institute. The institute is run by Gary Kraftsow; applicants must have completed 500 hours of his teacher training. His course teaches the clinical applications of yoga for spine, joint and muscle problems.

There is no national credentialing system, and the lack of industry-wide standards worries doctors. “You need some core set of certification that allows a patient to know that they are going to someone from whom they can reliably get appropriate treatment,” Dr. James Weinstein, chairman of the department of orthopedic surgery at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., and the editor of the medical journal Spine. “I have certainly seen patients asked to do positions that have made them worse.”

Just as certain conditions can be helped by extension, flexion, twisting or side bending, they can also be aggravated, said Robert Forster, a physical therapist in Santa Monica, Calif.

Some doctors advocate its use, however. “I deeply believe in yoga and know the therapeutic value of yoga for health care,” said Dr. Michael Sinel, an assistant professor of physical medicine and rehabilitation at the University of California, Los Angeles, who has a private practice in Santa Monica. In the next six months, he plans to start YogaMed, a company that will offer medical care and therapeutic yoga within the Yoga Works chain of studios.

There is some evidence that certain yoga poses help alleviate chronic back pain. A randomized, controlled study published in the Annals of Internal Medicine in 2005 found that participants who followed a pose sequence designed by a yoga therapist improved function more than those given a self-care book or sent to exercise class. (The 101 participants did not include patients with sciatica, previous back surgery or pregnant women.) Now, the National Institutes of Health has allocated $1.2 million for a second study to see, in part, if the results can be replicated on a larger scale.

Yoga therapists are not qualified to diagnose injuries, although some do, said Leslie Bogart, a yoga therapist in Santa Monica, who has worked as a nurse. “Everybody should be seen by a medical person first, without question,” Ms. Bogart said. “Yoga should be an adjunct to” treatment, not “a replacement.”

A handful of doctor’s offices already offer therapeutic yoga. Dr. Loren Fishman, who runs a physical medicine and rehabilitation practice in Manhattan, studied Iyengar yoga in India before medical school, and now recommends poses to patients like Sharon Williams.

Ms. Williams, 46, a development director at Dance Theater of Harlem, suffered from chronic shoulder pain. An M.R.I. revealed a torn rotator cuff, for which Dr. Fishman prescribed, among other things, a variation of a headstand using a chair. This pose can help relieve pain and restore range of motion, yoga therapists say, because of a method called muscular substitution — training the body to avoid aggravating an existing problem by using other muscles.

This is plausible, said Dr. J. Hearst Welborn, an orthopedic surgeon in San Pablo, Calif. He added that actively trying to recover helps: “Mind over matter has a huge effect on people’s pain.”

Longtime yoga therapists say the next step for them is learning to work with doctors. Larry Payne, who has practiced since 1982 and is the founding president of the yoga therapist association, said therapists need to learn to read medical reports and to work in clinical settings. “The doctors aren’t interested in Sanskrit, they just want to be sure that yoga therapists they work with are properly trained,” he said.

To that end, Dr. Payne created a yoga therapy teacher training course at Loyola Marymount University in Los Angeles, where students learn yoga therapy for both systemic and muscular ailments.

Dr. Payne and Dr. Richard P. Usatine also started yoga classes for medical students at the David Geffen School of Medicine at U.C.L.A. “Once they understand and can feel the value of yoga personally, they can then suggest and prescribe it for their patients,” said Dr. Usatine, a professor of family medicine at the University of Texas Health Science Center at San Antonio.

Nationwide, yoga is provided at 93 percent of 755 integrative medical centers, facilities offering under one roof both traditional medicine and other approaches to health and wellness. But it’s unclear how many offer yoga therapy, said Cary Wing, the executive director of the Medical Fitness Association, a nonprofit group.

Starting Monday, Donna Karan, the designer, is sponsoring a 10-day Well-Being Forum in Manhattan to bring together doctors, yoga therapists and yoga teachers. The hope is to integrate alternatives like yoga into patient care, Ms. Karan wrote in an e-mail message.

Open Mon,Wed 8am-6pm; Tue,Thu-Fri 8am-4pm

Subway: Farragut North Metro Station

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Open Mon-Thu 9am-8pm; Fri 9am-5pm; Sat 9:30am-2:30pm

This week the New York Times depicted one doctor’s approach to using a simple yoga-extracted move to heal shoulders. The move described in the article below is similar to some of the scapular stabilization exercises (essential for ANY shoulder injury or diagnosis) I learned in a weekend-long continuing education class in April with Todd Ellenbecker, DPT, MS, SCS, OCS, CSCS, USPTA, THE physical therapist for the United States Professional Tennis Association. (Ok, I lucked out being able to participate in that one. Thank you Sarah Amesbury!). I wouldn’t say, therefore, that the approach used by the physician below is as revolutionary as it sounds on paper. But good treatment grounded in simplicity and a holistic approach is, unfortunately, not the norm.

Read on and tell me what you think by email or in the comments below. If you or someone you know is in physical pain that can be addressed with physical therapy, don’t hesitate to contact me. If I can’t treat you, I can refer you to additional incredible physical therapists around town.

original link here: http://www.nytimes.com/2011/08/02/health/02brody.html?_r=2&scp=1&sq=yoga%20therapy&st=cse

With the costs of medical care spiraling out of control and an ever-growing shortage of doctors to treat an aging population, it pays to know about methods of prevention and treatment for orthopedic problems that are low-cost and rely almost entirely on self-care. As certain methods of alternative medicine are shown to have real value, some mainstream doctors who “think outside the box” have begun to incorporate them into their practices.

One of them is Loren Fishman, a physiatrist — a specialist in physical and rehabilitative medicine affiliated with NewYork-Presbyterian/Columbia hospital. Some in the medical profession would consider Dr. Fishman a renegade, but to many of his patients he’s a miracle worker who treats their various orthopedic disorders without the drugs, surgery or endless months of physical therapy most doctors recommend.

Many years ago, I wrote about Dr. Fishman’s nonsurgical treatment of piriformis syndrome, crippling pain in the lower back or leg caused by a muscle spasm in the buttocks that entraps the sciatic nerve. The condition is often misdiagnosed as a back problem, and patients frequently undergo surgery or lengthy physical therapy without relief.

Dr. Fishman developed a simple diagnostic technique for piriformis syndrome and showed that an injection into the muscle to break up the spasm, sometimes followed by yoga exercises or brief physical therapy, relieves the pain in an overwhelming majority of cases.

Nowadays yoga exercises form a centerpiece of his practice. Dr. Fishman, a lifelong devotee of yoga who studied it for three years in India before going to medical school, uses various yoga positions to help prevent, treat, and he says, halt and often reverse conditions like shoulder injuries, osteoporosis, osteoarthritis and scoliosis. I rarely devote this column to one doctor’s approach to treatment, and I’m not presenting his approach as a cure-all. But I do think it has value. And he has written several well-illustrated books that can be helpful if used in combination with proper medical diagnosis and guidance.

For many years, yoga teachers and enthusiasts have touted the benefits to the body of this ancient practice, but it is the rare physician who both endorses it and documents its value in clinical tests. Dr. Fishman has done both. Rotator Cuff Relief

This year, Dr. Fishman received a prize at the International Conference on Yoga for Health and Social Transformation for a paper he presented on a surprising yoga remedy for rotator cuff syndrome, a common shoulder injury that causes extreme pain when trying to raise one’s arm to shoulder height and higher. He described a modified form of a yoga headstand that does not require standing on the head and takes only 30 seconds to perform, and presented evidence that it could relieve shoulder pain in most patients, and that adding brief physical therapy could keep the problem from recurring.

Rotator cuff injuries are extremely common, especially among athletes, gym and sports enthusiasts, older people, accident victims and people whose jobs involve repeated overhead motions.

For patients facing surgery to repair a tear in the rotator cuff and many months of rehabilitation, the yoga maneuver can seem almost a miracle. It is especially useful for the elderly, who are often poor candidates for surgery.

Dr. Fishman said he successfully treated a former basketball player, who responded immediately, and a 40-year-old magazine photographer who had torn his rotator cuff while on assignment. The photographer, he said, had been unable to lift his arm high enough to shake someone’s hand.

Instead of an operation that can cost as much as $12,000, followed by four months of physical therapy, with no guarantee of success, Dr. Fishman’s treatment, is an adaptation of a yoga headstand called the triangular forearm support. His version can be done against a wall or using a chair as well as on one’s head. The maneuver, in effect, trains a muscle below the shoulder blade, the subscapularis, to take over the job of the injured muscle, the supraspinatus, that normally raises the arm from below chest height to above the shoulder.

The doctor discovered the benefit of this technique quite accidentally. He had suffered a bad tear in his left shoulder when he swerved to avoid a taxi that had pulled in front of his car. Frustrated by an inability to practice yoga during the month he waited to see a surgeon, one day he attempted a yoga headstand. After righting himself, he discovered he could raise his left arm over his head without pain, even though an M.R.I. showed that the supraspinatus muscle was still torn.

Dr. Fishman, who has since treated more than 700 patients with this technique, said it has helped about 90 percent of them. “It doesn’t work on everyone — not on string musicians, for example, whose shoulder muscles are overtrained,” he said in an interview.

In a report published this spring in Topics in Geriatric Rehabilitation (an issue of the journal devoted to therapeutic yoga), he described results in 50 patients with partial or complete tears of the supraspinatus muscle. The initial yoga maneuver was repeated in physical therapy for an average of five sessions and the patients were followed for an average of two and a half years.

The doctor and his co-authors reported that the benefits matched, and in some cases exceeded, those following physical therapy alone or surgery and rehabilitation. All the yoga-treated patients maintained their initial relief for as long as they were studied, up to eight years, and none experienced new tears.

Yoga for Bone Disease

Perhaps more important from a public health standpoint is the research Dr. Fishman is doing on yoga’s benefits to bones. Bone loss is epidemic in our society, and the methods to prevent and treat it are far from ideal. Weight-bearing exercise helps, but not everyone can jog, dance or walk briskly, and repeated pounding on knees and hips can eventually cause joint deterioration.

Strength training, in which muscles pull on bones, is perhaps even more beneficial, and Dr. Fishman has observed that osteoporosis and resulting fractures are rare among regular yoga practitioners.

In a pilot study that began with 187 people with osteoporosis and 30 with its precursor, osteopenia, he found that compliance with the yoga exercises was poor. But the 11 patients who did 10 minutes of yoga daily for two years increased bone density in their hips and spines while seven patients who served as controls continued to lose bone. He noted that yoga’s benefits also decrease the risk of falls, which can result in osteoporotic fractures.

Medical guidance here is important, especially for older people who may have orthopedic issues that require adaptations of the yoga moves.