CAM Practices Paper

‘‘I’m More in Balance’’: A Qualitative Study of Yoga for Patients with Chronic Neck Pain

Holger Cramer, PhD, 1

Romy Lauche, PhD, 1

Heidemarie Haller, MSc, 1

Jost Langhorst, MD, 1

Gustav Dobos, MD, 1

and Bettina Berger, PhD 2

Abstract

Objectives: This study investigated the perceived influence of yoga on body perception and psychosocial aspects of life for patients with chronic neck pain. Design: This qualitative study was conducted using semistandardized interviews. Setting: The interventions and interviews took place in a referral center’s research department. Subjects: Eighteen (18) patients with chronic nonspecific neck pain were recruited from a larger randomized controlled trial of yoga for chronic neck pain. Interventions: Participants attended 90 minutes of Iyengar yoga once a week for 9 weeks. Outcome measures: Participants completed a drawing of their neck and shoulder regions to reflect their sub- jective body perceptions before and after their yoga program. Semistandardized interviews were used to explore their body perception, emotional status, everyday life and coping skills, as well as any perceived changes in these dimensions postparticipation. An interdisciplinary group analyzed the study data using content analysis techniques. Results: Participants reported change on five dimensions of human experience: physical, cognitive, emotional, behavioral, and social. Physically, most participants cited renewed body awareness, both during their yoga practice and in their daily lives. Such change was echoed in their postparticipation body drawings. Cognitively, participants reported increased perceived control over their health. Emotionally, they noted greater acceptance of their pain and life burdens. Behaviorally, they described enhanced use of active coping strategies. Finally, socially, they reported renewed participation in an active life. Conclusions: Participants linked yoga to change on all dimensions of human experience, attributing reduced pain levels, increased coping ability, better pain acceptance and increased control to it. Body awareness ap- peared a key mechanism in these changes.

Introduction

Chronic neck pain causes substantial personal sufferingdue to pain, functional impairment1 and decreased health- related quality of life.2 A recent qualitative study found that it also influences body perception. In this study, patients com- pleted drawings of their upper back and neck, showing ap- parent distortions of body perception, with elements that were missing or deformed. Patients saw their pain as predominant and beyond their control, influencing their body perception.3

Yoga is a commonly used complementary treatment for neck and back pain,4 with an estimated 3 million American

adults using it explicitly to treat such pain.5 Deriving from ancient Indian philosophy, yoga comprises lifestyle advice, spiritual practice, and physical postures.6 It is thought to create physical, emotional, and spiritual balance, with the infinite goal of uniting body, mind, and spirit.7 In North America and Europe, yoga is most often associated with physical postures (asanas), breathing techniques ( pranayama), and meditation (dyana).6

Yoga has proven effectiveness in randomized controlled trials on musculoskeletal disorders including osteoarthritis,8

carpal tunnel syndrome,9 and low back pain.10–15 A recent clinical trial demonstrated the effectiveness of Iyengar yoga

1Department of Internal and Integrative Medicine, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany. 2University of Witten-Herdecke, Gerhard Kienle Chair of Medicinal Theory, Integrative and Anthroposophic Medicine, Herdecke,

Germany.

THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE Volume 19, Number 6, 2013, pp. 536–542 ª Mary Ann Liebert, Inc. DOI: 10.1089/acm.2011.0885

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for chronic neck pain.16 In this trial, yoga proved more ef- fective than a home-based stretching program in reducing pain intensity and functional disability. It also improved cervical proprioceptive acuity (i.e., patients’ ability to accu- rately perceive the positions of their head in space). As yoga focuses on increasing awareness of muscle tone and joint position,17 it is also thought to help in recognizing and changing habitual patterns of posture and muscle tension in daily life.18 It has been hypothesized that this increased body awareness in daily life might be a mechanism by which yoga helps to relieve neck pain.18

Randomized controlled trials are most suitable for investi- gating effectiveness of yoga interventions. On the other hand, complex experiences during yoga practice, such as subtle changes in body awareness,19 but also psychosocial correlates of chronic pain conditions, such as fear of activities and sub- sequent social withdrawal,20 might be better addressed with qualitative approaches.21–23 Qualitative research strives to explore participants’ complex subjective experiences during the intervention and how she or he gives meaning to these experiences.22 Since complementary therapies, such as yoga, are often complex in nature themselves, qualitative methods have been proposed to investigate the perceived mechanisms and the process of complementary treatments.21,22

Therefore, the current qualitative study aimed to investi- gate the perceived influence of yoga on body awareness and psychosocial aspects of life for patients with chronic neck pain.

Methods

This qualitative study was embedded in a randomized con- trolled trial of yoga for patients with chronic nonspecific neck pain.16 The study protocol was approved by the institutional ethics committee of the University Duisburg-Essen Medical In- stitutions (Approval No.: 10-4358) prior to participant recruit- ment. All participants gave written informed consent.

Participants

All participants who participated in the yoga arm of the aforementioned randomized controlled trial16 were invited

to take part in this qualitative study. Prior to inclusion, par- ticipants were assessed by a study physician to ensure that their neck pain was muscular in origin and not due to other, more serious, causes (e.g., disc protrusion or neoplasm).

Yoga program

Participants participated in weekly 90-minute yoga classes for 9 weeks. Classes were based on the teachings of yoga master B.K.S. Iyengar.7 The program was designed specifi- cally for people who have chronic neck pain and who were without previous experience of yoga. Classes were led by a certified Iyengar yoga instructor and physiotherapist, as- sisted by a graduate psychologist.

The yoga program consisted of standing, sitting, and su- pine postures, starting with simple postures and moving to more complex ones7 (Table 1). Props, including belts, blocks, and blankets, were used to improve safety and alignment. Participants were asked to focus on their posture, joint po- sitions, and muscle tension in each yoga pose. No formal breathing techniques were used, but participants were in- structed to align their breathing with their movements. Each class ended with the ‘‘corpse’’ pose, a 15-minute guided re- laxation. Participants were asked to calm their thoughts and focus their attention on their body and body perception during relaxation.

Besides yoga classes, participants were asked to practice yoga at home each day.

Data assessment

Body drawings. Before and after the yoga program, participants were guided to focus on perceiving their necks and upper backs, using guided imagery. They were then given line drawings of the posterior lower and upper back, with the area from the shoulders to the neck left blank3 (Fig. 1). Participants were asked to fill in the missing lines to re- flect the perceived outlines of their own bodies at that moment. They were also encouraged to indicate on their drawings any other perception or pain felt, in color as appropriate.

Table 1. Yoga Postures (Alphabetical Order) Practiced During Weekly Classes and at Home

Class

Yoga posture 1 2 3 4 5 6 7 8 9 Home

practice

Bharadvaja’s twist Yes Yes Yes Bridge pose Yes Yes Yes Yes Corpse pose Yes Yes Yes Yes Yes Yes Yes Yes Yes Downward facing dog Yes Yes Yes Yes Yes Yes Yes Yes Downward facing hero Yes Yes Yes Yes Yes Extended side angle Yes Yes Yes Yes Yes Yes Yes Extended triangle Yes Mountain pose Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Prosperous pose Yes Yes Yes Yes Yes Yes Yes Yes Reclining big toe Yes Yes Yes Yes Yes Yes Yes Standing half forward

bend (at wall) Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Thunderbolt pose Yes Yes Yes Yes Yes Yes Upward hand pose Yes Yes Warrior pose II Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

QUALITATIVE STUDY OF YOGA FOR NECK PAIN 537

Semistructured interviews

Participants were interviewed after completing their sec- ond body drawings at the end of the 9-week program. In- terviewers were neither involved in planning nor conducting of the yoga intervention. Participants were initially asked to share the meanings of their before and after body drawings with interviewers and then to compare and contrast these drawings. Subsequent interviews queried participants’ body perceptions before and after the yoga program and any perceived influences on these perceptions. Participants were also interviewed about their emotional status, everyday life, and preferred coping strategies before and after the yoga program. Main questions are presented in Table 2. Further open-ended questions on each topic were possible.

These interviews, which lasted about 30 minutes, were conducted in private at the study center. They were audio- recorded, professionally transcribed verbatim, anonymized, and translated into English for publication purposes.

The participants’ quotations were assigned a number that consisted of a ‘P’ (for participant), the participant’s rando- mization number, and the line numbers of the quotation within each transcript (e.g. P1/1-2 for Participant 1, Lines 1-2).

Data analysis

An interdisciplinary group of scientists and practitioners from psychology, medicine, pain therapy, nursing, and cul-

tural science analyzed the interview data using content analysis techniques.24 Interviews were coded using Atlas.ti software (Version 6.2; Atlas.ti Scientific Software Develop- ment GmbH, Berlin, Germany), with their content being paraphrased, reduced, and summarized. Five (5) broad cate- gories were developed from the inductive analysis of the first six interviews. These categories, which reflected five dimen- sions of human experience (physical, cognitive, emotional, behavioral, and social), were then applied to the remaining interviews. Results of this analysis process were discussed in this group. Disagreements were discussed until consensus was achieved. Participants’ body drawings were not inde- pendently analyzed, but were presented to the participants generating them, at interview, for their interpretation.

Results

Study sample

Fifteen (15) women and 3 men aged 19–59 years were interviewed. None had ever practiced yoga before. Partici- pants’ sociodemographic and pain characteristics are shown in Table 3.25 Adherence to yoga practice is shown in Table 4.

Perceived changes

Physical dimension. Participants saw focusing their at- tention on their bodies and perceptions during yoga as an important part of the yoga program. They cited intensified perceptions of their bodies’ sensations and renewed aware- ness of their bodies’ parts and functions during yoga. One (1) participant said: ‘‘I was feeling muscles or areas of my body, of which I didn’t even know that I had muscles there.’’ (P40/188– 191) She described taking ‘‘a different approach to my body, because I realized how it all works.’’ (P40/321–323) Participants saw this intensity of inner participation and attention dif- ferentiating yoga from conventional exercise. In daily life, they reported a more balanced and natural body perception (Fig. 2).

FIG. 1. Incomplete body drawing.

Table 2. Interview Topics and Main Questions

Topic Questions

Drawings 1. Please tell me about today’s drawing. 2. In how far does the drawing reflect your

body perception? 3. What similarities and differences do you

see between this drawing and the first drawing you made 10 weeks ago?

Body perception

1. How do you perceive your body in the neck/shoulder area?

2. In how far has your body perception changed since the start of the yoga course?

Emotions 1. What emotions do you connect to your neck–shoulder area at this moment?

2. In how far have your emotions towards your neck–shoulder area changed since the start of the yoga course?

Everyday life 1. In how far do your neck–shoulder complaints influence your daily life?

2. In how far has your daily life changed since the start of the yoga course?

538 CRAMER ET AL.

Cognitive dimension. Participants reported that focusing their attention on the yoga poses enabled them to calm their minds and to block out extraneous cognitions while doing yoga. They thus experienced yoga not only as physical ex- ercise, but also as a form of meditation. One participant saw it as ‘‘letting go.that is, while doing yoga, you really forget about anything else because you’re so busy.to stand right or to stand

well. Not really to do the pose properly, but to make yourself feel good. There’s no space left for anything else. I believe that this is a reason, for me, why yoga is good for me.’’ (P45/329–334)

Participants also cited more perceived control over their general well-being in daily life, noting that their newfound body awareness helped them to see how their behaviors and well-being were linked. This gave them a renewed sense of control over their bodies and health, freeing them from feeling controlled by their pain, as before. ‘‘Yes, I’m more aware about the association between my own actions and the way I feel.awareness, that you can change a lot yourself [.] and that you can achieve something this way. That you can.strengthen your body.’’ (P09/173–181)

Many participants said that they had avoided physical activity before their yoga program, fearing pain and re- injury. Participants’ experience of being able to influence their well-being through such activity, however, led many to reinterpret it cognitively. ‘‘By doing yoga I have to say, for the first time in a while I felt able to do sports. I‘ve lost a lot of fear of making a wrong move.’’ (P48/68–71)

Emotional dimension. Participants also experienced emotional distance from burdensome situations during yoga. This led to a sense of deep relaxation and, for some, a dif- ferent way of seeing their emotions. As one participant said ‘‘During [yoga] practice, I really listen into myself.I realized two or three times that, while I was doing that, I’m now – I don’t know – totally angry because of something completely different, but I wasn’t aware of that before [.] I discovered a different emotional starting point by concentrating on myself for a time and blocking out anything else.’’ (P40/349–360)

Body awareness seems to be an important precondition for relaxation during yoga. One participant described how his lack of body awareness had hindered relaxation: ‘‘I don’t have such a connection to my body, that I, yes.can perceive my body, that I keep my shoulders down and things. That’s an effort for me.’’ (P36/233–235) He described that in everyday life ‘‘I don’t see any.any big differences or emotional changes.’’ (P36/165–166)

Other participants reported using their newfound relaxa- tion skills in their everyday lives, noting that they had be- come more even-tempered about their pain and more accepting of it and their disability. Participants spoke less negatively about their necks and seemed better able to accept this body part and their pain. ‘‘It’s OK, [my neck] is a part of me, even if it hurts a bit once in a while.But I’m not a robot, you see. And.yes.it’s OK just the way it is.’’ (P40/150–152)

Participants also saw themselves becoming generally more relaxed and less irritable over time, as well as more able to accept and cope with life’s burdens. ‘‘I am more in balance. And that doesn’t just mean [that my body is more balanced] but also this equanimity. That I not always go through the roof [.] and then calm down again and I am normal again, but, you know, that my mood swings are generally less intense.’’ (P40/278–283)

Behavioral dimension. Before the yoga program, partic- ipants tended to ignore their pain due to its seeming in- escapability. They generally used endurance strategies to cope or, when pain became unbearable, sought help from others such as health professionals. Study participants saw yoga as an active self-help strategy, using yoga poses in stressful situations to relieve or even prevent pain. As one participant said, ‘‘I notice, when the pain increases that, from the

Table 3. Sample Characteristics

Women Men Total

Sociodemographic characteristics Age

18–30 years 2 0 2 31–40 years 2 1 3 41–50 years 5 0 5 51–60 years 6 2 8

Education < High school 6 0 6 High school 5 0 5 University degree 4 3 7

Employment Employed 11 2 13 Homemaker 3 0 3 Retired 0 1 1 Student 1 0 1

Neck pain characteristics Duration

Less than 6 months 0 0 0 6 months–1 year 2 2 4 1–5 years 2 0 2 More than 5 years 8 0 8

Baseline intensitya

Mild pain 6 0 6 Moderate pain 8 2 10 Severe pain 1 1 2

Postintervention intensitya

Mild pain 13 3 16 Moderate pain 2 0 2 Severe pain 0 0 0

aParticipants rated their neck pain intensity on a 100-mm visual analog scale (VAS) before and after the yoga program. Categories for pain intensity given according to Jensen et al.25: mild pain, < 45 mm VAS; moderate pain, 45–74 mm VAS; severe pain, 75–100 mm VAS.

Table 4. Adherence to Yoga Practice

Women Men Total

Attended yoga classes (out of 9) 0–1 classes 0 0 0 2–3 classes 0 0 0 4–5 classes 1 0 1 6–7 classes 8 3 11 8–9 classes 6 0 6

Mean days of home practice/weeka

0–1 days 0 1 1 2–3 days 8 2 10 4–5 days 5 0 5 6–7 days 2 0 2

aParticipants noted home practice in a diary.

QUALITATIVE STUDY OF YOGA FOR NECK PAIN 539

yoga classes, I know for example that this half forward bend, that is now like a painkiller for me. That’s so brilliant! I just stand against a wall and try to do the half forward bend three, four, five times in a row, and that helps me dramatically.’’ (P48/75–81) Some participants said that they had reduced their reliance on pain medication, and other passive treatments, through such behaviors. Yoga was also used as a stress management strategy. ‘‘[I felt] very tense.and very stressed, at a normal level though. That’s life, but I have.the feeling now, that with yoga I’ve found a good way to cope with this and to come to rest.’’ (P40/112–115).

However, if participants were unaware of their body, yoga was not perceived suitable for pain or stress relief. The aforementioned participant with low body awareness stated: ‘‘For me, yoga is no such form [of exercise], I have a strong mo- tivation to continue.’’ (P36/230–231)

Other participants’ new body awareness also enabled them to actively monitor and control their posture in daily life, further relieving their pain. As one participant said, ‘‘It doesn’t take much. ‘OK, keep your shoulders down’. That’s not.that’s not yoga, but during the day, if I’m in the tram or in the car, or wherever I sit or stand, I can remember that. And it helps.’’ (P49/ 274–278) Such changes also influenced participants’ views of their personal capabilities; enhancing their perceived ability to identify and respect their physical and mental limits.

Social dimension. Many participants initially saw themselves as disabled by their pain, describing how they had limited their daily activities for physical or emotional reasons, and had increasingly withdrawn from activity and/ or society for fear of worsening their pain. Yoga allowed participants to re-engage with their preferred activities and to lead more self-determined lives by relieving their pain and disability. One (1) participant (a student) described the social benefits of yoga as ‘‘That I could participate in training regu-

larly, and didn’t miss lessons at school because of the pain, that I could do school sports normally. That I’m not disabled in my daily routines any more, in school, but also out of school. That I could meet my friends, or go to the cinema without having pain.’’ (P35/ 125–131) Participants saw that yoga helped not only despite, but because it involved physical activity, actively countering their fears. As one participant said, ‘‘I’m no longer so anxious in some situations or in some activities.’’ (P51/71–72)

Participants saw themselves as more efficient in their work and social lives. ‘‘I did my work before [yoga] too, but.it was really, really difficult for me. And.now I’ve found a new ease at work. I enjoyed work then and now, but it’s different.now it’s not so tense anymore, because it’s easier when you don’t feel pain anymore.’’ (P51/118–124) Participants saw their work and social lives as enriched, and enjoyed them more, as they felt less tired and less in pain.

Discussion

Study participants reported experiences on physical, cog- nitive, emotional, behavioral and social dimensions. They described an active inner involvement during yoga practice, as well as renewed body awareness, a perceived internal locus of control, the cognitive reappraisal of physical activity and an increased acceptance of pain and disability.

Inner involvement

A distinct feature of Iyengar yoga is the awareness of muscle tension, joint position, and breathing patterns during practice.17 In the current study, participants experienced an intensified self-perception, seeing this as a precondition for relaxation during yoga practice. Yoga originally developed as a spiritual practice, with meditative involvement as an integral part.7,26 The importance of this active inner in- volvement in yoga practice has also been scientifically

FIG. 2. One participant’s drawings. Left: Drawing before the yoga program: ‘‘The right side has been in the background for me and the left side in the foreground [.] as if the left shoulder was on the top or really hunched up.’’ (P47/53–57)a Right: Drawing after the yoga program: ‘‘Two congruent areas.the left and the right neck-shoulder area, which for me are both unre- markable in this resting posi- tion.’’ (P47/12–14).a aThe numbers following the quotations indicate the participant’s randomiza- tion number and transcript line numbers.

540 CRAMER ET AL.

demonstrated, since it has been linked to increased life sat- isfaction and mindfulness and lower symptom burden.27

Such links suggest that inner involvement during yoga practice may be an important factor in mental stabilization and emotional regulation; to practitioners’ benefit.27

Renewed body awareness

Patients with neck pain often sense their necks and/or shoulder regions solely through pain.3 Pain distorts indi- viduals’ body perception by demanding attention, blocking their awareness of nonpainful body parts.28 This is even measurable on the cortical level, where the painful body part becomes overrepresented,29 influencing perception of form and position of the body in space.30 In this study, partici- pants reported increased body awareness during yoga and in their everyday activities. Yoga gave participants a new ap- proach to their bodies, a mindful awareness of their actions and perceptions. Enhancing body awareness has been seen as a common ground of mind/body–medicine.19 A mindful, nonjudgmental, experience of bodily perceptions is thought to enhance connections between the body and the mind, and to promote the acceptance of body symptoms.19,31 Yoga, but not conventional exercise, has been shown to increase indi- viduals’ awareness and responsiveness to bodily cues,32 with such awareness being seen as an important factor in neck pain relief due to yoga.18 Regular practice is thought to in- crease yoga practitioners’ awareness of bodily cues, helping them to recognize and change habitual patterns of posture and muscle tension.18 In the current study, increased body awareness helped participants to influence their body pos- ture and muscle tension actively and thereby to reduce and at times prevent their pain.

Internal locus of health control

Through their active control of their body posture and tension, and experience of being able to relieve and prevent their pain, participants in this study experienced a new sense of control over their well-being. An internal locus of health control33 has been shown to promote individuals’ use of internal, active, coping strategies such as active strategies for lifestyle change. An external locus of health control instead is linked to using external coping strategies such as consulting health professionals.34 Although many patients with chronic pain use external coping strategies, such strategies result in lower life satisfaction.34,35

Cognitive reappraisal

Negative appraisals of pain and its consequences such as pain catastrophizing lead individuals to avoid daily activi- ties, worsening their pain rather than relieving it20: physical inactivity causes muscular atrophy,36 and social withdrawal increases mood disturbances such as depression and distress, known to be neck pain risk factors.37 Graded exposure to movement and activity is one way to overcome this ‘‘fear- avoidance-pain’’ circle.38 Experiencing activity as pain- relieving rather than pain-inducing challenges negative appraisals, so that social activities are seen positively once again. Current study participants’ experiences (i.e., that yoga helped them to overcome their fear of moving and resulting social withdrawal) exactly echo these findings.

Acceptance

Pain acceptance, striving to maintain psychosocial function regardless of pain, is linked to reduced pain, disability, inac- tivity, and depression.39 Such acceptance has been seen as one mechanism for yoga’s pain-relieving actions. Yoga aims to enhance participants’ compassionate understanding of their health, enabling a nonjudgmental perception of pain without avoidance or social withdrawal.40 Pain acceptance can also change patients’ perspectives: Current study participants saw yoga as positive, even if it did not make them pain free.

Limitations

This study used a convenience sample. While female participants appeared to be a sufficiently heterogeneous group, especially regarding age and pain characteristics, this was not true for the few males who took part. The study’s findings and conclusions may be more limited for the male, than the female participants, as a result. Other limitations are that results only reflect experiences during and immediately after the yoga program and no long-term experiences and that results might apply only for patients with muscular neck pain but not for patients with other sources of pain.

Conclusions

Yoga was seen as a multidimensional intervention linked to change in all dimensions of human experience. Body awareness seems to be a key mechanism in these changes.

Further qualitative research should focus on exploring per- ceived differences between yoga and other exercise or between different yoga styles. Quantitative studies might assess chan- ges in, for example, body awareness or fear-avoidance using standardized instruments or even changes in cortical repre- sentations after yoga practice using imaging techniques.

Acknowledgments

The authors thank Kai Scheffer, PT, certified Iyengar yoga teacher, for assistance in designing the yoga protocol and teaching yoga classes; Sonja Jaruszowic and Annette Ten- gelmann for assistance in participant recruitment; and the participants of the colloquium in qualitative research of the Gerhard Kienle Chair, University Witten-Herdecke, Ger- many, for assistance in data analysis. This study was sup- ported by a research grant from the Karl and Veronica Carstens Foundation, Essen, Germany.

Disclosure Statement

No competing financial interests exist.

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Address correspondence to: Holger Cramer, PhD

Department of Internal and Integrative Medicine Faculty of Medicine

University of Duisburg-Essen Am Deimelsberg 34a

Essen 45276 Germany

E-mail: [email protected]

542 CRAMER ET AL.

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