Review: Prospective Cohort StudyMusculoskeletal pain associated with recreational yoga participation: A prospective cohort study with 1-year follow-up
Introduction
Yoga is a form of exercise that involves adopting specific bodily positions, accompanied by focused awareness and breathing. In the United States National Health Interview Survey in 2012, 9.6% of adults reported practicing yoga (Clarke et al., 2015). Its popularity keeps growing, likely due to the common belief that yoga benefits health and wellness (Birdee et al., 2008, Peregoy et al., 2014, Wren et al., 2011).
Yoga is an increasingly popular complementary or alternative therapy for musculoskeletal disorders. Recent studies have demonstrated that yoga can improve neck pain, low back pain and osteoarthritis (Cramer et al., 2013b, Ebnezar et al., 2012, Groessl et al., 2012, Hartfiel et al., 2012, Michalsen et al., 2012, Park et al., 2014, Sherman et al., 2005, Sherman et al., 2011, Tekur et al., 2012, Tilbrook et al., 2011, Williams et al., 2009). Systematic reviews and meta-analyses largely support these findings (Crow et al., 2015, Ward et al., 2013). While the exact therapeutic mechanism still needs to be determined, pain relief from musculoskeletal disorders may be associated with improvements in posture, strength, muscle control and flexibility, decreased fear of movement-related pain, and general benefits to the cardiovascular or neuromuscular system (Wren et al., 2011).
Yoga participation in experimental studies appears to be safe. In a meta-analysis of randomized controlled trials examining adverse events associated with yoga participation, Cramer et al. (2015) found no evidence of an increased risk of serious and non-serious adverse events compared to usual care or exercise. In these studies, yoga was practiced under structured experimental conditions, with careful delivery and multiple observations. In real life, millions participate in yoga in recreational studios, where quality and standardization vary. Thus, it is important to understand the extent of risks for musculoskeletal pain associated with recreational yoga participation.
There have been several observational, cross-sectional studies of injuries associated with yoga in non-experimental conditions. In a national survey of yoga participants in Australia (n = 2567), Penman et al. (2012) defined an injury as an event requiring medical treatment or causing prolonged pain, discomfort, suffering or resulting in time off from work. Using this definition, there was a 2.4% annual incident rate for injuries during yoga classes (or under supervision). The lifetime injury prevalence was higher (21.3%). In a secondary analysis of data from the National Health Interview Survey in the US (n = 2230), Holton and Barry (2014) defined yoga injuries as events leading to lost yoga participation time. The prevalence rate for injuries was <1% (9 individuals total). Of those, only four required medical attention. In a survey of 3 yoga centers in Finland (n = 110), Mikkonen et al. (2008) defined yoga injuries as musculoskeletal injuries with pain that lasted longer than 1 month and reported a prevalence rate of 62%. This case definition, however, did not specify a timeframe, and some injuries were incurred prior to participating in their current yoga style (Ashtanga Vinyasa).
This variability in injury rates, ranging from 1% to 62% reflects heterogeneity in study designs, samples, settings and case definitions. Case definitions can have a dramatic effect on the rates of injury. Styles of yoga vary widely and impose different physical demands. The experience, training and philosophy of teachers varies widely. For some participants and teachers, yoga is a way of life. For others, it is a good way to work out.
There is little research on the types of injuries in yoga. Most published papers are case reports and case series, with only one study retrospectively analyzing data on yoga injuries from a medical center (Cramer et al., 2013a, Le Corroller et al., 2012). The most common injuries were tendon lesions and tears, meniscal tears, hip and shoulder labral tears and lumbar disc lesions.
Considering the variability of findings and limitations of studies to date, the rate of injuries from yoga cannot be determined. With the increasing popularity of yoga and with the lack of studies on this topic, additional research is needed.
Unlike sports characterized by high speeds, trauma and sudden forceful loading, the risks in yoga are different. Attainment of poses can be (but are not always) gradual and participants can move out of poses if they are uncomfortable. Indeed, yoga is an activity that participants use therapeutically. Research that examines the broader construct of musculoskeletal pain (rather than acute injury) is needed to determine the risks of participation. If yoga is used to treat musculoskeletal pain, then participants should know what the risk for causing or exacerbating musculoskeletal pain is. Healthcare providers working with patients with musculoskeletal pain who are considering or practicing yoga should be aware of both the benefits and risks of participation when discussing the issue with their patients.
The purpose of this study was to characterize musculoskeletal pain caused by recreational yoga in terms of timing relative to class, location in specific body regions, and frequency, duration, and intensity of pain. To provide context, we examined the broader relationship between pain and yoga participation by determining prevalence of pain exacerbated, unaffected, and improved by yoga. We analyzed the effect of specific risk factors that could have increased the risk for pain caused by yoga. To our knowledge, this is the first prospective study of musculoskeletal pain associated with recreational yoga practice. The prospective design allowed us to determine the incidence rate of pain caused by recreational yoga participation.
Section snippets
Design
This was a prospective cohort study with a one-year follow-up. Data were collected with online questionnaires sent via email, one year apart.
Sample
Participants were identified through the mailing list of a suburban yoga studio with two locations. Participants had to be at least 18 years old and had to have participated in recreational yoga in the previous 12 months. The studio offered 4 levels of Vinyasa-style yoga (from gentle to advanced), 2 levels of Iyengar yoga, and restorative and prenatal
Participant characteristics
Recruitment and participation are detailed in Fig. 2. At baseline, 566 members responded to the recruitment email and 487 (86%) completed the initial questionnaire. One year later, the follow-up questionnaire was sent to 487 participants, and responses were received from 354 (75%). Therefore, the final sample included 354 participants (n = 354). Overall, data were complete, with only three or fewer missing values for most variables.
Table 1 summarizes characteristics of those who followed up and
Discussion
The current findings suggest that musculoskeletal pain can result from recreational yoga practice. New cases of musculoskeletal pain attributed to yoga participation were reported by 10.7% of participants. More than one-third of participants with incident cases reported lost participation from yoga and/or symptoms that lasted more than 3 months.
Yoga involves attaining and maintaining challenging poses, which place specific joints and muscles at the limits of flexibility and stability. If not
Conclusion
While yoga can be beneficial for musculoskeletal pain, like any form of exercise, it can also result in musculoskeletal pain. Yoga can also exacerbate cases of existing pain. In the current study, 10.7% of participants reported incident cases of pain attributed to yoga. These rates can be useful for clinicians and individuals to compare the risks of yoga to other exercise activities enabling them to make informed decisions. Pain caused by yoga might be prevented by careful performance and full
Role of the funding source
This study was not funded.
Acknowledgments
The authors would like to thank Betsy Kase and Margaret Duggan for supplying the studio email list, sending survey emails, providing details on their yoga studios, and for giving feedback on our questionnaire. Dr. Kean and Dr. Roberts were students in the Doctor of Physical Therapy Program at Mercy College at the time of this research.
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