Recommending yoga to your patients? Consider this first.

The COVID-19 pandemic has exacerbated and highlighted many health issues, particularly those suffering from chronic pain.

An estimated 50 million people in the U.S. live with chronic pain, of which approximately 19.6 million experience high-impact chronic pain that interferes with life, social, and occupational activities. Regardless of the pathology of pain, chronic pain may involve comorbidities of depression, anxiety, sleep disturbances, and fatigue. A crisis, such as the COVID-19 pandemic, worsens these issues and further negatively impacts social isolation and financial stress related to chronic pain. Evolving pain guidelines include a combination of pharmacologic and non-pharmacologic methods to manage complex pain syndromes and their deleterious effects.

One of the most common non-pharmacologic recommendations is yoga, usually suggested and understood in the context of contemporary yoga which focuses primarily on physical postures as a form of exercise in a community group setting. However, for the purpose of reducing symptom burden, alleviating suffering, and improving quality of life in the midst of chronic conditions resulting in persistent pain, medical providers should instead consider recommending therapeutic yoga for their patients, as the intent and scope of practice differs significantly from contemporary yoga.

Yoga was developed over 5,000 years ago as a comprehensive system of health and wellbeing for the mind, body, and soul, and consists of a wide variety of traditions and practices. The word yoga is believed to derive from the Sanskrit root “yuj” meaning union, to bind, or concentrate one’s attention. Yoga continues to be the most commonly used complementary therapy by adults in the United States, with rates increasing each year.

A rapidly evolving profession called yoga therapy or therapeutic yoga interfaces with comprehensive, integrative pain management to provide a patient-centered, multi-faceted approach to complex pain management. Comprehensive, integrative pain management (CIPM) takes an individualized, multimodal and multidisciplinary approach to pain through the use of medications, restorative therapies, interventional procedures, behavioral health strategies, and complementary and integrative therapies. Akin to how CIPM incorporates a biopsychosocial approach to pain management, yoga therapy applies traditional yoga practices, like philosophy, meditation, and mindfulness with adaptive physical postures to promote well-being, optimize daily function, and alleviate physical, psycho-emotional, and existential suffering in people experiencing chronic conditions within a therapeutic relationship.

Yoga therapists typically see clients one-to-one or in small groups with specific conditions across a variety of settings, including schools, worksites, clinics, hospitals, halfway houses, substance-use disorder centers, and prisons. An increasing number of health care facilities and hospital systems, such as Mayo Clinic Health System and Columbia University Irving Medical Center, offer therapeutic yoga, in group and individualized settings. In 2015, the University of Rochester Cancer Center (URCC) Community Clinical Oncology Program (CCOP) led a nationwide, multicenter, randomized clinical trial to examine the effects of yoga on symptoms of sleep disturbances, cognitive changes, fatigue, musculoskeletal pain, and overall quality of life in adult cancer survivors. In regards to pain, breast cancer survivors with treatment-related induced musculoskeletal aches from estrogen blockers showed improvement in pain and daily function.

Yoga therapy differs from contemporary yoga in that the profession has a defined scope of practice based on educational standards and accreditation requirements for training schools and yoga therapists. In dealing with pain conditions, certified yoga therapists possess understanding and knowledge of pain theories and pain physiology and may collaborate with a patient’s health care team to develop an individualized care plan. While pain and musculoskeletal conditions represent the most common reasons for referral, yoga therapists may also see clients with chronic conditions, such as diabetes, heart disease, post-traumatic stress disorder, and addiction.

In contrast to a community, contemporary yoga class where an instructor determines the content and delivers it in an often vigorous pace to large, mostly healthy, groups of varying experience, yoga therapy sessions are adapted to the individual and his or her conditions to meet their wellness goals, and at a less strenuous pace. Yoga therapy empowers the patient toward positive behavioral changes and an active role in his or her self-care. Whereas the focus of a yoga class is on the yoga techniques, the focus of a yoga therapy session is on the individual and his or her conditions.

A common barrier to yoga therapy in medical care is access to quality therapeutic yoga services, particularly in underserved areas. This is compounded by the fact that health insurance often does not cover yoga therapy, despite it being shown to be a cost-effective health care service and non-inferior to physical therapy, which is covered by most health insurances, in regards to benefitting chronic pain and function. Increasing the number of replicable research studies among large, diverse populations and showing effectiveness of therapeutic yoga practices through proposed dosage and frequency may support a movement toward health insurance coverage in the future. Recent advances in telemedicine also present an opportunity for health care facilities to offer virtual therapeutic yoga to their patients in efforts to increase access to pain management services while minimizing risk of exposure to COVID-19.

As the field of yoga therapy increasingly integrates within our health care system and expands in research evidence, medical providers can strengthen their recommendations for yoga to patients by specifically informing them about therapeutic yoga which offers a more patient-centered approach than contemporary yoga does.

Jaime Lewis is an internal medicine and palliative care physician.

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