Yoga for functional ability, pain and psychosocial outcomes in musculoskeletal conditions: a systematic review and meta-analysis

Efficacy, tolerability, and safety of non-pharmacological therapies for chronic pain: An umbrella review on various CAM approaches

BACKGROUND

Complementary and alternative medicine (CAM) therapies may be used as a non-pharmacological approach to chronic pain management. While hundreds of trials about individual CAM modality have been conducted, a comprehensive overview of their results is currently lacking for pain clinicians and researchers.

AIM

This umbrella review synthesized the quality of meta-analytic evidence supporting the efficacy, tolerability and safety of CAM therapies for the management of chronic pain.

MATERIALS & METHODS

MEDLINE, EMBASE, CINAHL, and CENTRAL were searched from October 1991 to November 2016. Reviews of clinical trials (randomized and non-randomized) with meta-analysis investigating the utility of any CAM modality for chronic pain were eligible. Pain relief post-intervention was the main outcome and secondary outcomes included patients' adherence and incidence of adverse effects during CAM protocol.

RESULTS

Twenty-six reviews (207 clinical trials, >12,000 participants) about 18 CAM modalities, falling under natural products, mind and body practices or other complementary health approaches were included. Inhaled cannabis, graded motor imagery, and Compound Kushen injection (a form of Chinese medicine) were found the most efficient (with moderate-to-high effect sizes and low heterogeneity) and tolerable (≥80% of adherence to study protocols) for chronic pain relief. When reported, adverse effects related to these CAM were minor.

CONCLUSION

Although several CAM were found effective for chronic pain relief, it remains unclear when these modalities are a reasonable choice against or in conjunction with mainstream treatments. In that sense, future research with a clear emphasis on concurrent evaluation of CAM overall efficacy and patient adherence/tolerance is needed.

Evaluation of a specialized yoga program for persons with a spinal cord injury: a pilot randomized controlled trial

Objectives

The purpose of this randomized controlled trial was to evaluate the effects of a specialized yoga program for individuals with a spinal cord injury (SCI) on pain, psychological, and mindfulness variables.

Materials and methods

Participants with SCI (n=23) were outpatients or community members affiliated with a rehabilitation hospital. Participants were randomized to an Iyengar yoga (IY; n=11) group or to a 6-week wait-list control (WLC; n=12) group. The IY group participated in a twice-weekly 6-week seated IY program; the WLC group participated in the same yoga program, after the IY group’s yoga program had ended. Pain, psychological, and mindfulness measures were collected at two time points for both groups (within 1–2 weeks before and after program 1 and at a third time point for the WLC group (within 1 week after program 2).

Results

Linear mixed-effect growth models were conducted to evaluate the main effects of group at T2 (postintervention), controlling for T1 (preintervention) scores. T2 depression scores were lower (F_1,18=6.1, P<0.05) and T2 self-compassion scores higher (F_1,18=6.57, P< 0.05) in the IY group compared to the WLC group. To increase sample size and power, the two groups were combined and analyzed across time by comparing pre- and postintervention scores. Main effects of time were found for depression scores, (F_1,14.83=6.62, P<0.05), self-compassion, (F_1,16.6=4.49, P<0.05), mindfulness (F_1,16.79=5.42, P<0.05), mindful observing (F_1,19.82=5.06, P<0.05), and mindful nonreactivity, (F_1,16.53=4.92, P<0.05), all showing improvement after the intervention.

Discussion

The results indicated that a specialized 6-week yoga intervention reduced depressive symptoms and increased self-compassion in individuals with SCI, and may also have fostered greater mindfulness.

Feasibility and Efficacy of a Shared Yoga Intervention for Sleep Disturbance in Older Adults With Osteoarthritis

The purpose of the current study was to test the feasibility and efficacy of a shared yoga (SY) program for sleep disturbance in older adults with osteoarthritis (OA). Participants (ages 50 to 72) with insomnia related to OA were randomized to 12 weeks of SY (n = 9) or individual yoga (IY; n = 7). The sample was 53% male and 41% self-identified as a race other than White/Caucasian. The groups did not significantly differ in class attendance, home practice, or change scores on efficacy outcomes. Pre-post comparisons in all participants showed statistically significant improvements on the Insomnia Severity Index and Patient-Reported Outcomes Measurement System sleep disturbance scale. Findings support the overall feasibility of the program, both in the shared and individual formats. Efficacy data suggest that this yoga program may improve sleep, but given the study limitations, further research is needed to draw conclusions. [Journal of Gerontological Nursing, xx(x), xx-xx.].

A qualitative approach exploring the acceptability of yoga for minorities living with arthritis: 'Where are the people who look like me?'

OBJECTIVES

To examine the acceptability of yoga research tailored to recruit and retain a minority population (both English and Spanish speaking) with arthritis. Yoga research for arthritis often underrepresents minorities and acceptability for this population has not previously been investigated.

DESIGN

Acceptability was evaluated using retention, adherence, journals, and semi-structured exit interviews from twelve participants with osteoarthritis or rheumatoid arthritis undergoing an 8-week yoga intervention. Journal quotes were analyzed using content analysis techniques. NVivo software was used to organize transcripts and assemble themes. Two methods of triangulation (data and investigator) were used to overcome potential bias from a single-perspective interpretation. Exit interview comments were content analyzed using a card sort method. The study was designed with a cultural infrastructure including a multicultural research team, translators, and bilingual materials and classes, to facilitate trust and acceptability for primarily Hispanic and Black/African-American adults.

SETTING

Washington, D.C. metropolitan area, USA.

RESULTS

On average participants attended 10 of 16 classes, with home practice 2-3days a week. All who completed were still practicing yoga three-months later. Qualitative narrative analysis identified major themes related to facilitating factors and barriers for yoga practice, self-efficacy, and support. Participant comments indicated that offering an arthritis-based yoga intervention and using a culturally congruent research design was found to be acceptable.

CONCLUSIONS

As yoga research grows, there is a need to understand and promote acceptability for typically under-represented populations. This study attempts to inform the expansion of multicultural research designed to recruit and retain those from diverse backgrounds.

Factors associated with complementary medicine use in pediatric musculoskeletal conditions: Results from a national survey

OBJECTIVES

Complementary and alternative medicine (CAM) use is common in children, but its use has only been investigated in children with musculoskeletal conditions (MSK) to a limited extent. We aimed to characterize factors associated with CAM use in children with MSK conditions.

METHODS

Within the 2012 National Health Interview Survey dataset (including its child CAM supplement), we examined factors associated with CAM use in children with MSK conditions and performed an analysis examining the perceived usefulness of CAM therapies for MSK conditions.

RESULTS

Overall, there were 10,218 children in the dataset. 28.0% of children with MSK conditions used CAM, compared to 8.8% of children without MSK conditions. Gender (p=0.003), region (p=0.001), race (p=0.001), parental CAM use (p<0.001), education (<0.001), and having anxiety, stress or depression (p=0.030) were correlated with CAM use. Among 90 children who reported on CAM use, 89.7% said that CAM helped some or a great deal for their MSK condition.

CONCLUSIONS

Several factors, particularly parental education and parental CAM use, were associated with CAM use, and self-reported improvement rates were high. Interventional trials are needed to determine the efficacy of specific CAM therapies for treating different MSK conditions in children.

Effects of yoga, strength training and advice on back pain: a randomized controlled trial

Background

Among the working population, non-specific low-back pain and neck pain are one of the most common reasons for sickness absenteeism. The aim was to evaluate the effects of an early intervention of yoga - compared with strength training or evidence-based advice - on sickness absenteeism, sickness presenteeism, back and neck pain and disability among a working population.

Methods

A randomized controlled trial was conducted on 159 participants with predominantly (90%) chronic back and neck pain. After screening, the participants were randomized to kundalini yoga, strength training or evidence-based advice. Primary outcome was sickness absenteeism. Secondary outcomes were sickness presenteeism, back and neck pain and disability. Self-reported questionnaires and SMS text messages were completed at baseline, 6 weeks, 6 and 12 months.

Results

The results did not indicate that kundalini yoga and strength training had any statistically significant effects on the primary outcome compared with evidence-based advice. An interaction effect was found between adherence to recommendations and sickness absenteeism, indicating larger significant effects among the adherers to kundalini yoga versus evidence-based advice: RR = 0.47 (CI 0.30; 0.74, p = 0.001), strength training versus evidence-based advice: RR = 0.60 (CI 0.38; 0.96, p = 0.032). Some significant differences were also found for the secondary outcomes to the advantage of kundalini yoga and strength training.

Conclusions

Guided exercise in the forms of kundalini yoga or strength training does not reduce sickness absenteeism more than evidence-based advice alone. However, secondary analyses reveal that among those who pursue kundalini yoga or strength training at least two times a week, a significantly reduction in sickness absenteeism was found. Methods to increase adherence to treatment recommendations should be further developed and applied in exercise interventions.

Trial Registration

Clinicaltrials.gov NCT01653782, date of registration: June, 28, 2012, retrospectively registered.

The North American yoga therapy workforce survey

OBJECTIVE

To describe the personal, professional, practice, service and consumer characteristics of the North American yoga therapy workforce.

DESIGN

Cross-sectional, descriptive survey developed and informed by the contemporary workforce literature. A link to the e-survey was distributed to members of the International Association of Yoga Therapists.

RESULTS

367 members responded (∼20% of eligible participants). Most were aged 40-69 years (88%) and female (91%). Almost half (42%) identified as a "seasoned yoga therapist" and few (9%) graduated from an accredited 800-h yoga therapy program. An average of 8h/week was spent in clinical practice with many (41%) earning an annual income of <US$10,000 from yoga therapy. Practice was informed by twenty different styles of yoga. Urban (39%) and suburban (38.1%) regions were the most common locations of practice. Most therapists conducted therapeutic yoga classes (91%) and 1:1 sessions (94%), with more than half delivering 1-10 therapeutic classes/month (53%) and 1-10 1:1 sessions/month (52%). Conditions seen most frequently were anxiety (77%), back/neck pain (77%) and joint pain/stiffness (67%).

CONCLUSION

While yoga therapists shared demographic characteristics with other complementary and integrative health (CIH) providers, they tended to work less and earn less than their CIH counterparts. Yoga therapists were less likely to work in rural settings, possibly contributing to the underutilization of yoga in underserved populations. Improving access to yoga therapy services, identifying common core components across the various styles of yoga, and building a stronger evidence-base for key health indications may increase acceptance of, and demand for, yoga therapy.

Yoga treatment for chronic non-specific low back pain

BACKGROUND

Non-specific low back pain is a common, potentially disabling condition usually treated with self-care and non-prescription medication. For chronic low back pain, current guidelines state that exercise therapy may be beneficial. Yoga is a mind-body exercise sometimes used for non-specific low back pain.

OBJECTIVES

To assess the effects of yoga for treating chronic non-specific low back pain, compared to no specific treatment, a minimal intervention (e.g. education), or another active treatment, with a focus on pain, function, and adverse events.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, five other databases and four trials registers to 11 March 2016 without restriction of language or publication status. We screened reference lists and contacted experts in the field to identify additional studies.

SELECTION CRITERIA

We included randomized controlled trials of yoga treatment in people with chronic non-specific low back pain. We included studies comparing yoga to any other intervention or to no intervention. We also included studies comparing yoga as an adjunct to other therapies, versus those other therapies alone.

DATA COLLECTION AND ANALYSIS

Two authors independently screened and selected studies, extracted outcome data, and assessed risk of bias. We contacted study authors to obtain missing or unclear information. We evaluated the overall certainty of evidence using the GRADE approach.

MAIN RESULTS

We included 12 trials (1080 participants) carried out in the USA (seven trials), India (three trials), and the UK (two trials). Studies were unfunded (one trial), funded by a yoga institution (one trial), funded by non-profit or government sources (seven trials), or did not report on funding (three trials). Most trials used Iyengar, Hatha, or Viniyoga forms of yoga. The trials compared yoga to no intervention or a non-exercise intervention such as education (seven trials), an exercise intervention (three trials), or both exercise and non-exercise interventions (two trials). All trials were at high risk of performance and detection bias because participants and providers were not blinded to treatment assignment, and outcomes were self-assessed. Therefore, we downgraded all outcomes to 'moderate' certainty evidence because of risk of bias, and when there was additional serious risk of bias, unexplained heterogeneity between studies, or the analyses were imprecise, we downgraded the certainty of the evidence further.For yoga compared to non-exercise controls (9 trials; 810 participants), there was low-certainty evidence that yoga produced small to moderate improvements in back-related function at three to four months (standardized mean difference (SMD) -0.40, 95% confidence interval (CI) -0.66 to -0.14; corresponding to a change in the Roland-Morris Disability Questionnaire of mean difference (MD) -2.18, 95% -3.60 to -0.76), moderate-certainty evidence for small to moderate improvements at six months (SMD -0.44, 95% CI -0.66 to -0.22; corresponding to a change in the Roland-Morris Disability Questionnaire of MD -2.15, 95% -3.23 to -1.08), and low-certainty evidence for small improvements at 12 months (SMD -0.26, 95% CI -0.46 to -0.05; corresponding to a change in the Roland-Morris Disability Questionnaire of MD -1.36, 95% -2.41 to -0.26). On a 0-100 scale there was very low- to moderate-certainty evidence that yoga was slightly better for pain at three to four months (MD -4.55, 95% CI -7.04 to -2.06), six months (MD -7.81, 95% CI -13.37 to -2.25), and 12 months (MD -5.40, 95% CI -14.50 to -3.70), however we pre-defined clinically significant changes in pain as 15 points or greater and this threshold was not met. Based on information from six trials, there was moderate-certainty evidence that the risk of adverse events, primarily increased back pain, was higher in yoga than in non-exercise controls (risk difference (RD) 5%, 95% CI 2% to 8%).For yoga compared to non-yoga exercise controls (4 trials; 394 participants), there was very-low-certainty evidence for little or no difference in back-related function at three months (SMD -0.22, 95% CI -0.65 to 0.20; corresponding to a change in the Roland-Morris Disability Questionnaire of MD -0.99, 95% -2.87 to 0.90) and six months (SMD -0.20, 95% CI -0.59 to 0.19; corresponding to a change in the Roland-Morris Disability Questionnaire of MD -0.90, 95% -2.61 to 0.81), and no information on back-related function after six months. There was very low-certainty evidence for lower pain on a 0-100 scale at seven months (MD -20.40, 95% CI -25.48 to -15.32), and no information on pain at three months or after seven months. Based on information from three trials, there was low-certainty evidence for no difference in the risk of adverse events between yoga and non-yoga exercise controls (RD 1%, 95% CI -4% to 6%).For yoga added to exercise compared to exercise alone (1 trial; 24 participants), there was very-low-certainty evidence for little or no difference at 10 weeks in back-related function (SMD -0.60, 95% CI -1.42 to 0.22; corresponding to a change in the Oswestry Disability Index of MD -17.05, 95% -22.96 to 11.14) or pain on a 0-100 scale (MD -3.20, 95% CI -13.76 to 7.36). There was no information on outcomes at other time points. There was no information on adverse events.Studies provided limited evidence on risk of clinical improvement, measures of quality of life, and depression. There was no evidence on work-related disability.

AUTHORS' CONCLUSIONS

There is low- to moderate-certainty evidence that yoga compared to non-exercise controls results in small to moderate improvements in back-related function at three and six months. Yoga may also be slightly more effective for pain at three and six months, however the effect size did not meet predefined levels of minimum clinical importance. It is uncertain whether there is any difference between yoga and other exercise for back-related function or pain, or whether yoga added to exercise is more effective than exercise alone. Yoga is associated with more adverse events than non-exercise controls, but may have the same risk of adverse events as other back-focused exercise. Yoga is not associated with serious adverse events. There is a need for additional high-quality research to improve confidence in estimates of effect, to evaluate long-term outcomes, and to provide additional information on comparisons between yoga and other exercise for chronic non-specific low back pain.

Evaluation of a Specialized Yoga Program for Persons Admitted to a Complex Continuing Care Hospital: A Pilot Study

Introduction. The purpose of this study was to evaluate a specialized yoga intervention for inpatients in a rehabilitation and complex continuing care hospital. Design. Single-cohort repeated measures design. Methods. Participants (N = 10) admitted to a rehabilitation and complex continuing care hospital were recruited to participate in a 50–60 min Hatha Yoga class (modified for wheelchair users/seated position) once a week for eight weeks, with assigned homework practice. Questionnaires on pain (pain, pain interference, and pain catastrophizing), psychological variables (depression, anxiety, and experiences with injustice), mindfulness, self-compassion, and spiritual well-being were collected at three intervals: pre-, mid-, and post-intervention. Results. Repeated measures ANOVAs revealed a significant main effect of time indicating improvements over the course of the yoga program on the (1) anxiety subscale of the Hospital Anxiety and Depression Scale, F(2,18) = 4.74, p < .05, and η_p² = .35, (2) Self-Compassion Scale-Short Form, F(2,18) = 3.71, p < .05, and η_p² = .29, and (3) Magnification subscale of the Pain Catastrophizing Scale, F(2,18) = 3. 66, p < .05, and η_p² = .29. Discussion. The results suggest that an 8-week Hatha Yoga program improves pain-related factors and psychological experiences in individuals admitted to a rehabilitation and complex continuing care hospital.

Effects of Yoga on Symptoms, Physical Function, and Psychosocial Outcomes in Adults with Osteoarthritis: A Focused Review

Osteoarthritis (OA) is a highly prevalent and disabling chronic condition. Because physical activity is a key component in OA management, effective exercise interventions are needed. Yoga is an increasingly popular multimodal mind-body exercise that aims to promote flexibility, strength, endurance, and balance. Its gentle approach is potentially a safe and effective exercise option for managing OA. The purpose of this focused review is to examine the effects of yoga on OA symptoms and physical and psychosocial outcomes. A comprehensive search was conducted using seven electronic databases. Twelve reports met inclusion criteria involving a total of 589 participants with OA-related symptoms. A variety of types, frequencies, and durations of yoga interventions were reported; Hatha and Iyengar yoga were the most commonly used types. Frequency of intervention ranged from once a week to 6 days a week. Duration of the interventions ranged from 45 to 90 mins per session for 6 to 12 wks. Yoga intervention resulted in reductions in pain, stiffness, and swelling, but results on physical function and psychosocial well-being were inconclusive because of a variety of outcome measures being used.

On and Off the Mat: Yoga Experiences of Middle-Aged and Older Adults

Cet article examine les différences potentielles dans la pratique du yoga entre les adultes d’âge moyen et les adultes plus âgés. Un modèle Croyance à Santé/Parcours de Vie encadre cette recherche, et une stratégie analytique de méthodes mixtes est utilisée pour examiner les voies de parcours de vie dans le yoga, et la motivation à la pratique, ainsi que les obstacles perçus et les bénéfices pour la santé. Pour les analyses quantitatives, un échantillon de convenance de 452 participants a été recueilli au moyen d’un questionnaire en ligne. Pour les analyses qualitatives, des entrevues en face-à-face ont été menées auprès d’un sous-ensemble de 20 participants. Des différences uniques se sont manifestées entre les groupes d’âge (à la fois à l’âge actuel et à l’âge du démarrage de yoga), ainsi que par sexe pour certaines voies, les raisons / motivations, et les obstacles à s’engager dans le yoga, ainsi que pour les bénéfices de santé perçues. En outre, les résultats soulignent l’importance des points de repère d’information et des liens sociaux qui affectent la façon dont les individus adoptent et éprouvent le yoga. On discute les implications en ce qui concern les programmes à la promotion de la santé qui ciblent les adultes âgés.

Prevalence, Patterns, and Predictors of Yoga Use: Results of a U.S. Nationally Representative Survey

INTRODUCTION

The purpose of this study was to investigate the prevalence, patterns, and predictors of yoga use in the U.S. general population.

METHODS

Using cross-sectional data from the 2012 National Health Interview Survey Family Core, Sample Adult Core, and Adult Complementary and Alternative Medicine questionnaires (N=34,525), weighted frequencies for lifetime and 12-month prevalence of yoga use and patterns of yoga practice were analyzed. Using logistic regression analyses, sociodemographic predictors of lifetime yoga use were analyzed. Analyses were conducted in 2015.

RESULTS

Lifetime and 12-month prevalence of yoga use were 13.2% and 8.9%, respectively. Compared with nonpractitioners, lifetime yoga practitioners were more likely female, younger, non-Hispanic white, college educated, higher earners, living in the West, and of better health status. Among those who had practiced in the past 12 months, 51.2% attended yoga classes, 89.9% used breathing exercises, and 54.9% used meditation. Yoga was practiced for general wellness or disease prevention (78.4%), to improve energy (66.1%), or to improve immune function (49.7%). Back pain (19.7%), stress (6.4%), and arthritis (6.4%) were the main specific health problems for which people practiced yoga.

CONCLUSIONS

About 31 million U.S. adults have ever used yoga, and about 21 million practiced yoga in the past 12 months. Disease prevention and back pain relief were the most important health reasons for yoga practice. Yoga practice is associated with age, gender, ethnicity, SES, and health status.

The Safety of Yoga: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

As yoga has gained popularity as a therapeutic intervention, its safety has been questioned in the lay press. Thus, this review aimed to systematically assess and meta-analyze the frequency of adverse events in randomized controlled trials of yoga. MEDLINE/PubMed, Scopus, the Cochrane Library, and IndMED were screened through February 2014. Of 301 identified randomized controlled trials of yoga, 94 (1975-2014; total of 8,430 participants) reported on adverse events. Life-threatening, disabling adverse events or those requiring intensive treatment were defined as serious and all other events as nonserious. No differences in the frequency of intervention-related, nonserious, or serious adverse events and of dropouts due to adverse events were found when comparing yoga with usual care or exercise. Compared with psychological or educational interventions (e.g., health education), more intervention-related adverse events (odds ratio = 4.21, 95% confidence interval: 1.01, 17.67; P = 0.05) and more nonserious adverse events (odds ratio = 7.30, 95% confidence interval: 1.91, 27.92; P < 0.01) occurred in the yoga group; serious adverse events and dropouts due to adverse events were comparable between groups. Findings from this review indicate that yoga appears as safe as usual care and exercise. The adequate reporting of safety data in future randomized trials of yoga is crucial to conclusively judge its safety.

Establishing key components of yoga interventions for musculoskeletal conditions: a Delphi survey

BACKGROUND

Evidence suggests yoga is a safe and effective intervention for the management of physical and psychosocial symptoms associated with musculoskeletal conditions. However, heterogeneity in the components and reporting of clinical yoga trials impedes both the generalization of study results and the replication of study protocols. The aim of this Delphi survey was to address these issues of heterogeneity, by developing a list of recommendations of key components for the design and reporting of yoga interventions for musculoskeletal conditions.

METHODS

Recognised experts involved in the design, conduct, and teaching of yoga for musculoskeletal conditions were identified from a systematic review, and invited to contribute to the Delphi survey. Forty-one of the 58 experts contacted, representing six countries, agreed to participate. A three-round Delphi was conducted via electronic surveys. Round 1 presented an open-ended question, allowing panellists to individually identify components they considered key to the design and reporting of yoga interventions for musculoskeletal conditions. Thematic analysis of Round 1 identified items for quantitative rating in Round 2; items not reaching consensus were forwarded to Round 3 for re-rating.

RESULTS

Thirty-six panellists (36/41; 88%) completed the three rounds of the Delphi survey. Panellists provided 348 comments to the Round 1 question. These comments were reduced to 49 items, grouped under five themes, for rating in subsequent rounds. A priori group consensus of ≥80% was reached on 28 items related to five themes concerning defining the yoga intervention, types of yoga practices to include in an intervention, delivery of the yoga protocol, domains of outcome measures, and reporting of yoga interventions for musculoskeletal conditions. Additionally, a priori consensus of ≥50% was reached on five items relating to minimum values for intervention parameters.

CONCLUSIONS

Expert consensus has provided a non-prescriptive reference list for the design and reporting of yoga interventions for musculoskeletal conditions. It is anticipated future research incorporating the Delphi guidelines will facilitate high quality international research in this field, increase homogeneity of intervention components and parameters, and enhance the comparison and reproducibility of research into the use of yoga for the management of musculoskeletal conditions.

Psychological processing in chronic pain: a neural systems approach

Our understanding of chronic pain involves complex brain circuits that include sensory, emotional, cognitive and interoceptive processing. The feed-forward interactions between physical (e.g., trauma) and emotional pain and the consequences of altered psychological status on the expression of pain have made the evaluation and treatment of chronic pain a challenge in the clinic. By understanding the neural circuits involved in psychological processes, a mechanistic approach to the implementation of psychology-based treatments may be better understood. In this review we evaluate some of the principle processes that may be altered as a consequence of chronic pain in the context of localized and integrated neural networks. These changes are ongoing, vary in their magnitude, and their hierarchical manifestations, and may be temporally and sequentially altered by treatments, and all contribute to an overall pain phenotype. Furthermore, we link altered psychological processes to specific evidence-based treatments to put forth a model of pain neuroscience psychology.

Yoga in rheumatic diseases

Yoga is a popular activity which may be well suited to some individuals with specific rheumatic disorders. Regular yoga practice can increase muscle strength and endurance, proprioception, and balance, with emphasis on movement through a full range of motion to increase flexibility and mobility. Additional beneficial elements of yoga include breathing, relaxation, body awareness, and meditation, which can reduce stress and anxiety and promote a sense of calmness, general well-being, and improved quality of life. Yoga also encourages a meditative focus, increased body awareness and mindfulness; some evidence suggests yoga may help reduce inflammatory mediators including C-reactive protein and interleukin-6. Yoga is best learned under the supervision of qualified teachers who are well informed about the potential musculoskeletal needs of each individual. Here, we briefly review the literature on yoga for healthy, musculoskeletal, and rheumatic disease populations and offer recommendations for discussing ways to begin yoga with patients.