Chapter 1: Introduction

1.1 Background

Chronic low back pain is one of the most commonly reported chronic pain condition worldwide (Picavet et al., 1996). According to several studies, the lifetime prevalence of chronic back pain ranges between 49% and 80 % (Maniadakis & Gray, 2000; Andersson, 1999). Although chronic back pain is not a life- threatening condition, it affects many aspects of patients’ lives, leading to disability, functional limitations and decreased quality of life (Chok et al., 1999). It is estimated that low back pain (LBP) affects as many as one third of UK adult population and accounts for 20 % of the UK’s total health expenditure (Croft et al, 2010). Thus, Chronic back pain is not only a medical problem but it also put a huge burden on the society through its direct as well as indirect cost, including lost work productivity and medical care (Watson et al., 2008; Ravenek et al., 2010). The current treatment options include exercise and manipulative treatments, commonly delivered by osteopaths, chiropractors or physiotherapists. These are however more expensive and not widely available through NHS (Cox et al, 2010) with very limited and disputable effectiveness as they have shown various and rather modest success leading to the low satisfaction rate of the patients (UK BEAM trial Team, 2004). As none of the current treatments were proven to be effective, it is essential to find a more suitable and cost-effective therapy with better satisfaction rate and long-time effects.

Yoga is an ancient discipline from India (probably -5000 BC) (Garfinkel & Schumacher, 2000). The first book that has systematized this practice is the classic treatise on Yoga Sutra (or aphorisms) of Patanjali, dating from -200 BC. Yoga originated in ancient Indian philosophy and is believed to preserve and restore health through combination of physical postures (asanas), breathing exercises (Pranayama), meditation and relaxation techniques (Garfinkel & Schumacher, 2000).Yoga exercises are considered to have a holistic effect and bring body and mind into balance as in accordance with the actual meaning of the Sanskrit word Yoga, which means “to join, to unite” (Garfinkel & Schumacher, 2000). The mental focus combined with physical exercise favor Yoga for back pain in comparison with other intervention such as stretching or self-care book (Sherman, 2011). Additionally, it is hypothesised that the effects of Yoga might be long- lasting and more cost-effective as participants in Yoga group are usually encouraged to continue with Yoga practice at home between the individual classes and once the classes are completed and can be delivered in-group sessions unlike manipulative treatments.

Although current research suggests the efficacy of Yoga in chronic back pain management, its mechanism remains unclear. There are several hypotheses explaining the efficacy of Yoga including combination of relaxation and stretches leading to improved flexibility and oxidation of the tissues, release of endorphins as well as modulation of sympathetic nervous system activity which results in soothing of nerves and relief to chronic back pain (Posadzki et al, 2011). The psychological aspect plays also an important role, as Yoga can have positive impact on mood and improve mental focus enhancing body mind affinity (Posadzki et al, 2011), which in turn can have a positive impact on the perception of pain (Posadzki et al, 2011).

1.2 Statement of the Problem

Yoga is considered as a very promising intervention for patients with chronic back pain (Jacobs et al., 2004). This paper presents yoga as a technique to control body and mind which helps to provide physical health and a very effective treatment for chronic back pain

1.3 Justification of Research

The concept of chronicity is a complex phenomenon, it is difficult to define. In general, a chronic illness is an acute pain that is slow to heal in a normal period of time or injury associated with poor health. These cause a persistent or intermittent pain that lasts for months or years. As discussed earlier, chronic back pain is one of the most commonly found chronic diseases. In most people, back pain is cyclical discomfort that occurs more frequently with age. At this stage, some preventive measures and a system of balanced lifestyle are the best guarantee of a healthy back. The physical condition deteriorates, bringing with it a host of social and psychological problems: stop some leisure temporary or permanent job loss, relationship difficulties, psychological abuse can even lead to depression.

Research has shown that the practice of yoga adapted to the specific situation of persons with chronic low back pain could be a valuable complement to conventional treatments. The number of potential benefits: improved flexibility and balance and decrease the symptoms associated with depression. Yoga provides health and treatment for many diseases and works simultaneously for several diseases. No medicine can claim that. Given that the American medical system is ruined, there is a strong drug addiction, alcoholism, stress related illnesses, depression, more and more students drop studies and an aging population, yoga sounds an effective intervention for diseases like chronic back pain. This study, therefore, opens room for more research regarding the effective role of yoga for the treatment of chronic back pain. This will not only occur through increased knowledge about this subject, but also, through the development of new research areas by addressing research gaps that may emanate from this research. People are bound to benefit significantly from the research which will determine whether the use of yoga is an effective intervention strategy for chronic back pain or whether there should be other alternatives to be considered.

1.4 Aim of the Study

The aim of this critical review is to investigate whether there is sufficient evidence to support the efficacy of Yoga in treating chronic lower back pain in order to assist patients and health care practitioners with informed decision making. This will be achieved by analysing the selected research paper using a specially designed framework adapted from SIGN (2011) and discussing key themes and their implications.

1.5 Objectives of the Study

  • To discuss the risk of chronic back pain
  • To discuss the effectiveness and efficacy of Yoga as the treatment of Chronic back pain

1.6 Research Questions

  • Does chronic back pain poses as severe danger for health?
  • What is yoga and what is its role in providing a healthy life?
  • Is it a good strategy to use Yoga for the treatment of Chronic back pain?

Chapter 2: Literature Review

IASP (International Association for the Study of Pain) defines pain as "an unpleasant sensory and emotional experience associated with injury tissue present or potential, or described in terms of such damage” (Clarke & Iphofen, 2005; p.490). Pain is described as chronic when it persists for more than three to six months. It is pain that affects quality of life of the patient. The definition given to us by IASP highlights the fact that we can distinguish two types of pain: The dominant organic component to pain. The pain is caused by a true organic lesion, objectified as the dominant psychological component to pain, or psycho pain – somatic which is the translation of the suffering of the individual.

Chronic pain can be an expression of depression, anxiety or personal problems. On the other hand, this definition reminds us that pain, whatever its origin, is the psychological aspects (Godfrey, 2005). This induces it is an experience unique to each, and influenced by a number of factors. These factors can be broken down through the components of pain. Chronic pain can cause suffering, loss of self-control and a diminished quality of life (Godfrey, 2005). Chronic Pain and exhaustion diminishes the vital energy, threatens the physical and psychological well being and may even harm personal relationships and influence the concept of the existence of the person who supports it (Jeffrey, 2006). The consequences of chronic pain are multiple and their impacts on the patient are obvious: They can be physical (decreased functional capacity and resistance, poor sleep), psychological (anxiety, gloom, distress, loss of autonomy) and social (reduction activities Relational) etc (Jeffrey, 2006). The person has an extremely unpleasant feeling, even unbearable, which can cause reflex movement withdrawal or a change of body position. Chronic pain is considered a warning signal that allows the patients to know that there is a threat to the physical integrity (Jeffrey, 2006).

The origins of Yoga in India lost in the mists of time, more than 5000 years ago (Iyengar, 1976). In 5000 years, a lot of charlatans and crooks have put everything and anything behind the Yoga label. Yoga keeps the big machine that is our body in working and allows us to put an end to all the worries of everyday health. At the highest level, yoga can even cure serious diseases. Yoga practice also has a direct effect on the mind: some postures have a calming effect.

Overall, a yoga class consists of postural practice followed by a relaxation session. Postures can be divided into five groups:

  • Standing postures: they form the basis of any practice. They are very strong physically. They allow the body to open, build muscles and soften, thus preparing them for more advanced postures;
  • The reverse: This category contains all the postures where the pelvis is higher than the head. This includes the effort and the posture of the head (a variant of pear). They are the heart of any practice. They allow the body to de-stress;
  • The back bending: this category includes bridges and their variations. Their practice strengthens the spine and brings a positive mindset;
  • Twists: these postures are those where printing a rotation to the spine. They relieve lower back and create a true `` spin'' of the digestive system;
  • Forward bends: it applies to all positions where the bust on the legs is stretched. They provide a large indoor relaxation.

For centuries, the transmission of yoga, its postures and their effect was mainly oral, from teacher to student. The principle of teaching was simple: the teacher knew what was good for the student and he distilled his teaching. For its part, the student never questioned the teaching of his master. A direct consequence of this teaching is that the effects of postures have hardly been studied in scientific and systematic manner. When the teacher says that posture is very good for blood circulation, strengthens the heart and makes a good recovery after exercise, it is because an Indian master told him so. Nobody asked questions, and no testing is considered.

Today there are many styles of yoga. Some are intended for precision, others to the dynamic, few apply restoration and some pure and simple exercise to relieve stress. There is yoga for pregnant women, for children, athletes, etc. Either style of yoga that currently proposed are valid if your main goal remains the transformation of the person, their physical and mental health and, ultimately, the awakening of their potential. A good education begins with yoga breathing. The goal is to recover the natural breathing carefully and incorporate into everyday life. Moreover, we must keep in mind that yoga shows how to include patterns and mental together to different exercises, movements and postures of revitalization "states.

Research has revealed that Yoga relieves and soothes ailments teaches manage pain, improve breathing, eliminates the signs of stress and creates flexibility in both body and mind (Gura, 2002). It also increases the energy and vitality, increases resistance, improves circulation of the blood and cardiovascular conditions. Also highlights the ability Raised yoga to create greater attention, awareness of self and the world and, ultimately, inner peace. People with spinal scoliosis must learn to compensate and stabilize posture and full body. A herniated disc which have come to be treated with care to teach them to stretch and find the ideal position decompression. Moreover, to Contracture people have to propose loosening postures that relax the affected areas.

Beyond the hype, the practice of Yoga seems increasingly settle in Western countries. In the United States, Barnes et al (2004) finds that in 12 months, 5.1% of Americans started doing yoga (against 3.8% in 1998 [Saper et al., 2004). Yoga and meditation topped alternative therapies (Wolsko et al., 2004). Yoga is a highly relaxing, anti-stress (Gura, 2002) and meditative (Kabat-Zinn, 1982). Yoga is mostly used to improve overall health or adjunctive technique to specific problems (Saper et al., 2004; Wolsko et al., 2004) . There are also insomniacs looking for a little rest [Wolsko et al., 2004], preparations for childbirth through yoga. Generally, yoga increases the quality of life (Lee et al., 2004). In particular, it is used for accompaniment for serious diseases such as cancer (Rosenbaum et al., 2004). Another field of application is the fight against pain, especially, Yoga is proposed as a technique to relieve back pain (Jacobs et al., 2004).

Beyond the treatment and management of pain, there are several lines of research. Unfortunately, they are not much cited by the review. Meditation increases alpha waves during meditation and theta waves after meditation (Arambula et al., 2001). Yoga increases the "vital capacity" (Birkel & Edgren, 2000), Hormone production and the impact on the morale of running and yoga are comparable (Jane et al., 1995). Meditation induces a change in the levels of dopamine which causes a change in state of consciousness (Kjaer et al., 2002). Yoga delays (and is even regress in some cases) the "coronary atherosclerosis" (Manchanda, 2000). To increase the "aerobic capacity and Perceived exertion," yoga is more effective than conventional exercises (Ray et al., 2001). Similarly yoga also increases the "joie de vivre", decreases excitability, aggression and complaints about the body (Schell et al., 1994).

After undertaking a systematic search of the Cochrane database, the relevant research articles referring to Yoga and back pain have been selected and a total of four full-scale RCTs (Sherman et al., 2011; Tekur et al., 2008; Tilbrook et al., 2011; Williams et al., 2009) and three pilot RCTs (Saper et al., 2009; Williams et al., 2005; Cox et al., 2010) has been identified. All of the trials were reported as having mixed but positive results. For example, Williams et al. (2009) reported significant improvements with regards to the pain reduction and functional disability after 4 and 8 months of Iyengar Yoga therapy, Tilbrook et al. (2011) reported improved back function at 12, 24 and 48 weeks in comparison with the conventional treatment group and Sherman et al. (2011) reported better results in yoga group compared with self-care group at 12 and 26 weeks but with no significant differences between yoga and stretching groups. Although all of the above research papers have shown statistically significant results suggesting that Yoga can be very useful and effective in chronic back pain, the positive results should be considered very carefully as there is high probability of bias pertaining to low quality of some of the studies due to poor study design, small sample size and short-term follow-up (Cox et al, 2010; Posadzki et al, 2011).