Interview with a Yoga Teacher about Yoga and Back Pain
January 18, 2013 - Mike Dilke
Interview with a Yoga Teacher
Alison Trewhela is a very experienced and highly qualified yoga teacher. She began teaching over 30 years ago and in 2006-7 designed the yoga programme for the largest piece of research work into the effects of yoga on back pain to date.
As an interest in yoga lead me into the world of ergonomics and back pain I was keen to ask Alison a few questions and she was good enough to spend some time answering them.
The research, led by The University of York and funded by Arthritis Research UK, recruited and trained 20 experienced yoga teachers (British Wheel of Yoga and Iyengar Yoga) and 313 participants. Could you briefly summarize the findings of the study?
Appropriate specialized yoga (comprising of ‘Yoga for Healthy Lower Backs’ 12-week course, book, 4-track Relaxations CD and Home Practice Sheets) is safe and effective for back pain. It gives patients with non-specific chronic or recurring low back pain 30% better function than ‘usual care’.
Our published research compared our yoga to other similarly rigorously-tested treatment options and it was shown to be better than manipulation by osteopaths/chiropractors/physiotherapists; exercise classes taught by physiotherapists; manipulation followed by exercise classes; back-care book; back health education booklet; usual GP care; massage; cognitive behavioural therapy; 6 Alexander Technique individual sessions (not as good as 24 individual sessions).
Our published Economic Evaluation showed that the ‘Yoga for Healthy Lower Backs’ yoga programme would be likely to be cost-effective within the NHS compared to treatments used currently.
On average those in the yoga group only had 3.83 days off work compared to 12.29 in the non-yoga group over the 12 months studied. This makes it a great option for employers to reduce absenteeism and support the health and well-being of staff. It also shows that we had empowered people to self-manage.
As an experienced yoga teacher were the study results a surprise to you?
More than 20 years ago, I searched for more knowledge about how to deal with back pain in the yoga class situation, and found teaching small group specialized yoga to enable people to begin yoga gently with good foundational teaching worked better. Of course the results of the RCT were not a surprise, as many yoga teachers know from anecdotal evidence that appropriate yoga can work. However, I was aware that this was ground-breaking, high-profile research. Only ‘the results’ would show:- 1. whether the programme would work when taught by multiple teachers and 2. whether we had given people sufficient yoga tools to improve their back condition, maintain good postural awareness, keep stress at bay and improve their mental health for the long-term. There was a nail-biting moment waiting for the results in December 2010, because I realized that the York Trials Unit with its rigorous trial design methodologies and the medical journals with their international peer-reviewing and extra analyses requests are exceptionally good at proving that things DO NOT work rather than that they do. After all our hard work since 2006, it was a wonderful moment in November 2011 after our ‘results launch’ when we realized that we had done yoga proud and that globally the academic, medical, scientific and media worlds accepted that this was significantly important research.
How have the study results been accepted by the clinical and medical world?
Because our research trial was a randomized controlled trial (RCT) with good statistical power and clinically significant results, the medical world cannot ignore this piece of research. On November 1st 2011, our research results were published in one of the top four international, peer-reviewed, scientific medical journals, the ‘Annals of Internal Medicine’ (American College of Physicians). Online medical and scientific websites cite our research showing yoga to be a good treatment option for the prevalent condition of chronic low back pain. Within the research paper, it states that physicians and clinicians should feel comfortable recommending appropriate specialized yoga to those with a history of back pain. Most other yoga trials have been comparatively small and studied yoga taught by one teacher, whereas ours was taught effectively by several.
Our RCT was an ‘intention to treat’ model where we were testing ‘offering yoga’ (rather than just studying the results of those who actually did yoga) and yet our results were still significant. This means it would be likely to work well in practical terms within a health service (e.g. NHS) referral environment. Analysis included 21 people who did not attend any yoga classes nor spoke to a yoga teacher, (although they did receive the 4-track ‘Yoga for Healthy Lower Backs Relaxations CD’). For several years, yoga has been a recommended treatment option for low back pain in the USA due to previous US trials and its cost-effectiveness, but is a relatively new concept here in the UK. (See NICAAM, NIH.)
GPs who know about the ‘Yoga for Healthy Lower Backs’ programme and the research are almost exclusively backing this 12-week course, because it is safe, cost-effective and effective as a health promotional, long-term, single treatment option. It is helpful for them and for NHS commissioners to know that they will have the opportunity to refer to something specific, appropriate and suitable for beginners to yoga, as they would quite rightly be wary of referring to ‘any yoga’. The fact that there are experienced yoga teachers being trained to teach the very same fully-resourced yoga programme as used in the trial (with training, governance and CPD) encourages them to feel even more confident.
We are pursuing opportunities to bring innovation into the NHS nationally – they can take us seriously because of this evidence-base of long-term effectiveness (‘Annals of Internal Medicine’) and cost-savings (‘Spine’). Arthritis Research UK support the fact that we are ‘rolling out’ the yoga programme, meaning that the medical profession can not only take note of our research, but can also signpost patients to the same yoga for benefit. There has been a problem with past CAM research where a framework has not been put in place for referring physicians to know where to find the same evidence-based treatment. www.yogaforbacks.co.uk has been set up as a professional social enterprise to optimize benefit to patients and health professionals alike. We were extremely lucky to have been granted generous funding by Arthritis Research UK to carry out such large research into yoga and to have had the expertise of the renowned York Trials Unit and other international academics steering it.
Do you think that this work could lead to large savings for the NHS?
Absolutely, Yes. There would undoubtedly be huge savings for the NHS if they were to roll out ‘Yoga for Healthy Lower Backs’ for the benefit of patients. In our published ‘Spine’ journal paper (15th August 2012) it showed that our yoga programme would to be likely to be cost-effective for the NHS. Back pain costs the NHS approx. £30 million per day. ‘Yoga for Healthy Lower Backs’ is a one-off treatment option that has been shown to give long-term improvements. Although most patients who undertook some yoga benefitted significantly, over 50% were still practicing yoga (approx. twice a week for 30 minutes) 9 months after finishing their yoga course. Other yoga research shows that yoga can improve many other conditions, and as the yoga programme addresses the condition of the person holistically (whole body and mental health), it is likely that future illnesses may be prevented and other co-existing symptoms decreased. This would be especially likely for the patients who were motivated to either continue practicing yoga at home or to join general or Beginners’ yoga classes. The ‘Spine’ journal finding that those offered yoga had far fewer days off work adds further weight to the probability of the longer-term effectiveness of yoga.
Chronic low back pain is a difficult-to-treat, biopsychosocial condition, so offering evidence-based group yoga with its multi-layered approach to health promotion makes sense. Yoga could help to prevent many people unnecessarily ‘falling into’ the Pain Clinics and secondary care where they cost more than 85% of the total approx. £1.5 billion NHS back pain bill.
How could yoga benefit the UK economy and society?
Those in the yoga group had on average only 3.83 days off work compared to 12.29 in the non-yoga group over the 12 months studied. This equates to approx. £800 per year (productivity loss) for each person offered the ‘Yoga for Healthy Lower Backs’ yoga programme. Employers would not only be helping staff reduce absenteeism, but with yoga they would be further supporting staff by addressing stress reduction, mental health and general well-being. There is evidence to suggest that attending group activities can improve multi-disciplinary team-working. Our ‘Spine’ journal published paper showed that the yoga programme would be a ‘dominant’ treatment for the economy and from the societal perspective. Jobs where skill-sets are specific would benefit especially from this yoga. Communities needing a more positive mental perspective could be helped.
Is there more research work that you would like to do concerning yoga and health?
I am still on a research team applying for funding for more yoga research and although there may be more on the lines of back pain, it would be good for yoga to study a different type of condition. We submitted a bid for mild to moderate depression a while ago. Diabetes or blood pressure would be interesting to study as they have measurable symptoms. Keeping our aging population active and physically and mentally healthy would be another worthwhile project. Helping women with menstrual and menopausal problems is rewarding, but would be a challenging and complex research subject.
Yogaforbacks is a social enterprise set up (by myself and my colleague Anna Semlyen) to educate about and promote the yoga used in the research. It will require still more work to reach the highest potential impact for the benefit of yoga, yoga teachers and those with back pain. There are possibilities of gathering more evidence, e.g. finding out how the yoga programme performs in specific practical environments.
During your time teaching, what other benefits have you noticed for your students?
Back pain is perhaps one of the most common visible conditions presenting in yoga classes. Beneath this back pain there are most often other layers of discontent or discomfort and yoga is ideally suited to improving conditions where the physical problem is linked with mental, social or emotional problems. Although I have had a special interest in back pain, I have also helped students with many other conditions, such as women’s problems, hip/shoulder/knee problems, high blood pressure, diabetes, prostrate problems, MS, ME, fatigue, IBS, anxiety, depression. Sometimes general yoga classes have helped these conditions, but more often small group classes have shown better outcomes as these students with individualized specific needs then learn how to help themselves better within, and outside of, the class. Often students gain benefits that they were not expecting, e.g. more tolerance to others.
Which type of yoga do you practice?
I began classes with a British Wheel of Yoga Teacher who said that ‘Light on Yoga’ by BKS Iyengar was her ‘bible.’ I soon studied, trained and qualified in the Iyengar Yoga method and have been dedicated to that method since 1983. Iyengar Yoga is named after Sri B.K.S. Iyengar, who is one of the foremost proponents of adapting yoga for therapeutic purposes. (Ironically, due to recent UK new rulings there are very few Iyengar Yoga teachers permitted to teach therapeutic yoga.) ‘Yoga for Healthy Lower Backs’ was designed as a standardized programme that can be shared and taught by a variety of experienced yoga teachers with differing, high quality, teaching training backgrounds in order to reach as many people as possible. With gratitude to this research project, one hopes that all of us who love and practise yoga are pleased to have this current opportunity of taking yoga to a new level.
Do you suggest different types of yoga for different people with different needs?
Yoga is essentially yoga, but there are huge variations in approach, style, emphasis and methodology. As it is an experiential subject, the best way to know what suits one is to read a bit, speak to teachers, and then try it. You should never be asked to do something that you are uncomfortable doing and there should be mutual respect between the teacher and the student. Some forms of yoga are for those who are already fit and flexible; some practise very advanced practices; some follow esoteric practices or gurus.
Would you suggest anyone of any age or health taking up yoga?
The wonderful thing about yoga is that it is something that can be done by anyone. Yoga is a skill in action and it is best learnt under the guidance of a good teacher. One can encounter the problem that it is not easy to find a good entry-point class and you may need to search to find a well-qualified, experienced yoga teacher who can give you the help you need for a satisfactory start. There has recently been some bad press about problems occurring from the fact that yoga is the latest fitness fad with injuries occurring from attending classes with insufficiently trained teachers and/or classes that are too hard or too strenuous for them. Everyone has a lower back and 80% of the population will suffer from back pain at some point in their lives, meaning that many teachers believe the ‘Yoga for Healthy Lower Backs’ 12-week course can offer an ideal beginning for anyone wishing to start yoga. It not only teaches the foundations of good spinal movement and function, but also encourages home practice as a preventative measure. Although it has the ‘lower back’ label, it does offer much more than this, because yoga always treats the whole person. One learns how to be aware of the breath, postural alignment and mental attitude throughout daily life for all-round well-being. Our ‘Yoga for Healthy Lower Backs’ teacher training course for already-experienced yoga teachers shares knowledge of how to deliver the research’s yoga programme, along with extra back health, function, medical terminology and additional yoga teaching skills.
What do you enjoy about being a yoga teacher and would you advise others to follow the same career path as you?
I started practicing yoga at the age of 20 and within a year knew that I wanted to share this with others by learning to become a yoga teacher. Rather than a career or a job, it is a lifestyle choice that seeps into everything that you do, say or think. One can only teach yoga if you are passionate about it and if you practise lots of yoga. To be a professional teacher one has to aspire to reach ever higher standards and quality, and this continual learning process can be exciting and motivational. I believe that the moment you step onto your yoga mat it is therapeutic. Yoga teaching is about sharing, by showing people how to live positively, happily, comfortably in order to live to their fullest human potential.
To find out more about the ‘Yoga for Healthy Lower Backs’ programme, to find a yoga teacher who has been trained to teach the programme near you, to link to videos or research, or to contact Alison go to http://www.yogaforbacks.co.uk/