1. YOGA & STRUCTURAL LOW BACK PAIN Robin Monro Yoga Biomedical Trust Registered Charity 285 265 www.yogatherapy.org enquiries@yogatherapy.org

2. Summary 1.Introduction 2.CALBA 3.Sample cases 4.Further development 5.Applications 6.Research

3. Introduction  At least 50 per cent of people suffer from serious low back pain (LBP) during their lives  Back problems are the greatest cause of disability for people under the age of 45 years

4. Introduction  LBP costs the UK £4B per year in terms of - medical care - time off work - disablement

5. Introduction The Dongaonkar Approach to LBP Prof. D. Dongaonkar Former Head of Orthopedics Grant Medical College, Mumbai, India [Deceased January 2009]

6. Introduction There are several different types of LBP These have different characteristics and risk factors The Dongaonkar Approach tailors the yoga to the type of LBP thus avoiding exacerbation and maximising therapy

7. Introduction The most serious, common type in people aged 30-50 is Herniated Disk This is also known as Prolapsed Disk and as ‘Slipped Disk’

8. Introduction Herniated disk  peaks in prime working ages (30-50 years)  Is a common condition for spinal surgery  Is a common cause of long-term disability

9. Introduction Herniated disk  Can heal naturally but takes many months  Symptoms gradually diminish and disappear  Healing can be enhanced, and the risk of relapse reduced, by suitable precautions and therapeutic exercises

10. Introduction Herniated Disk  Identification is necessary for design of precautions and therapy  Without these, there is increased risk of relapse and long-term disability

11. Introduction Herniated Disk  Identification requires analysis of many different factors  This requires considerable time and skill  Consequently, herniated disk often goes undiagnosed

12. Yoga Herniated Disk  Yoga can be safe and therapeutic, if used appropriately  Certain yoga postures can exacerbate herniated disk and should be avoided

13. Yoga Herniated Disk  Precautions should be tailored to the stage of healing  In early stages only very gentle postures should be practised  In later stages general classes can often be safe, providing certain postures are avoided

14. Yoga Herniated Disk  Some yoga teachers and yoga students have herniated disk which is being perpetuated by their practice  Many yoga teachers are uncertain when to accept a person with LBP into their class

15. Yoga Herniated Disk  Identifying whether herniated disk is present could help them decide  Assessment of LBP is too specialised for most yoga teachers to attempt

16. CALBA  CALBA is an Internet-based system for Computer-Aided Low Back Assessment  It is a simple, economic means to detect herniated disk and decide on precautions  The present version identifies herniated disk and facilitates appropriate care

17. CALBA Factors taken into account include:  Age and gender  Site and type of the pain  Numbness, altered sensation  Muscle weakness  History of the pain  Cyclical changes in the pain  Exacerbating and relieving factors  Past treatments  Self assessment tests  Past medical investigations

18. CALBA  Client’s data collected on a user-friendly set of forms on the Internet  Branching questions enable the text to be shorter than on paper-based forms

19. CALBA  The “Data Capture” consists of five, easy-to- answer forms  Demo on Internet [www.calba.net] (There is a fee of $15 for use of CALBA to help cover costs of research and development. Free demonstrations are available on request.)

20. CALBA  Note the examples of branching questions, e.g.  Medical History: Compare the answers to “x- ray” and “MRI scan”  About Back Pain (1): Question 6

21. CALBA Data analysis provides likelihood estimates for:  Dangerous conditions  Herniated disk in various stages of recovery

22. CALBA  Distinguishes stages of herniated disk, requiring different treatments  Provides lifestyle and treatment advice

23. CALBA Inclusion criteria for use of current version:  Symptoms: LBP  Age range: 20-50 years  Gender: Female and male An extended version of CALBA is being developed for people over 50 years, where herniated disk is often complicated by conditions with other requirements

24. Sample Cases: Emergencies CENTRAL CANAL STENOSIS  Narrowing of the central canal traps nerves to the legs and excretory organs  Can cause permanent damage to vital nerves  May require urgent surgical intervention

25. Sample Cases: Emergencies CENTRAL CANAL STENOSIS Score (1=Minimum 100=Maximum Conditions >49 are likely) Central canal stenosis90 (This was a recent case of ours, which was confirmed and operated on successfully)

26. Sample Cases: Herniated Disk STAGES 1.Acute/Active 2.Early recovery 3.Early mid-recovery 4.Late mid-recovery

27. Sample Cases: Herniated Disk STAGE 1. ACUTE/ACTIVE  Nerve root trapping in the lower lumbar spine  Sciatica and other neurological symptoms and signs  Usually diagnosed by general practitioners but often not identified by complementary therapists and yoga teachers

28. Sample Cases: Herniated Disk STAGE 1. HERNIATED DISK: ACUTE/ACTIVE Herniated Disk Scores (1=Minimum 100=Maximum Conditions >49 are likely) Acute 90 Active (less severe) 90 Early mid-recovery phase 5 Late mid-recovery phase 5 Late recovery phase 5 Recovered 5 Chronic 45 Central canal stenosis 7

29. Sample Cases STAGE 2: EARLY MID RECOVERY  The disk bulge has retracted to the point where there has been no nerve root trapping for at least 2 weeks  The disk has only begun to retract and heal, and relapse to nerve root trapping can easily be brought on by certain actions  Quite often not diagnosed by general practitioners and often not identified by complementary therapists and yoga teachers

30. Sample Cases: Herniated Disk STAGE 2: EARLY MID RECOVERY Herniated Disk Scores (1=Minimum 100=Maximum Conditions >49 are likely) Acute 35 Active (less severe) 80 Early mid-recovery phase 60 Late mid-recovery phase 5 Late recovery phase 5 Recovered 5 Chronic 40 Central canal stenosis 0

31. Sample Cases: Herniated Disk STAGE 3: LATE MID RECOVERY  The disk bulge has retracted to the point where there has been no nerve root trapping and reduced LBP for at least 6 weeks  Healing of the disk has progressed, but relapse to nerve root trapping can still be brought on by certain actions  Often not diagnosed by general practitioners and rarely identified by complementary therapists and yoga teachers

32. Sample Cases: Herniated Disk STAGE 3: LATE MID RECOVERY Herniated Disk Scores (1=Minimum 100=Maximum Conditions >49 are likely) Acute 25 Active (less severe) 25 Early mid-recovery phase 40 Late mid-recovery phase 75 Late recovery phase 25 Recovered 25 Chronic 25 Central canal stenosis 0

33. Sample Cases: Herniated Disk STAGE 4: CHRONIC  Recurring nerve root trapping in the lower lumbar spine and sciatica  Neurological symptoms & signs will be present in relapse (as here) but largely absent in remission  General practitioners usually diagnose the condition in relapse but often not in remission. Complementary therapists and yoga teachers rarely identify it in remission

34. STAGE 4: CHRONIC Herniated Disk Scores (1=Minimum 100=Maximum Conditions >49 are likely) Acute 9 Active (less severe) 80 Early mid-recovery phase 1 Late mid-recovery phase 1 Late recovery phase 1 Recovered 1 Chronic 72 Central canal stenosis 7

35. Sample Cases: Other Conditions  CALBA distinguishes herniated disk from other common types of LBP  CALBA avoids common errors, such as interpretation of a diffuse ache in the thigh as due to herniated disk  The next case illustrates this with facet pain

36. Sample Cases: Other Conditions FACET PAIN  A common source of LBP, coming from the tiny joints at the back of the spine  The following slide shows CALBA results for a recent case of severe facet pain  Note the low likelihood estimates for all the phases of herniated disk

37. Sample Cases: Other Conditions FACET PAIN Herniated Disk Scores (1=Minimum 100=Maximum Conditions >49 are likely) Acute 5 Active (less severe) 5 Early mid-recovery phase 5 Late mid-recovery phase 5 Late recovery phase 5 Recovered 5 Chronic 5 Central canal stenosis7

38. Sample Cases: Other Conditions OTHER CONDITIONS  CALBA also distinguishes herniated disk from most other forms of LBP

39. Development of CALBA  The present version of CALBA focuses on herniated disk  Later versions will extend this to most other conditions of mechanical LBP

40. Applications of CALBA Yoga teachers screen applicants for their classes, existing students and themselves for herniated disk and risk factors Researchers on LBP screen participants in their trials for herniated disc to investigate possible differences in response to treatment

41. Research  We are planning a trial of yoga therapy for herniated disc  CALBA will be used to screen for selection of participants  MRI scanning will be used to provide definitive characterisation of herniated disks  CALBA will be fine-tuned by correlation with MRI scans