Exciting News for People with Chronic Low Back Pain

by Baxter

Joy Sassoon Age 61 by Tanya Constantine

For the last 15 years, I have been teaching an ongoing Back Care Yoga class for people with low back pain, so gotta say I was pretty excited to see the results of a recent study Yoga as Good as Physical Therapy for Back Pain that we linked to last week on our YFHA Facebook page. I even had a chance this spring to hear in person the study’s lead researcher, Robert Sager, MD, talk about the preliminary findings of the study. This study was looking to see if yoga was as effective for those with chronic low back pain as physical therapy. We know from multiple earlier studies that yoga can lower pain, decrease pain medication use, and improve function in those with chronic low back pain. However, physical therapy is considered the gold standard physical modality for those with chronic back pain, meaning that it has been studied and proven to be effective at lowering pain and increasing function, and is widely accepted for use for those with this condition. Apparently, family doctors refer about 20% of their patients with chronic low back pain to physical therapy as an adjunct to their treatment plan. One drawback of this approach is that physical therapy sessions can be expensive, and if you don’t have insurance, it’s unlikely you will actually go to see the therapist. Yoga could be a good low cost alternative, if it measures up to the effectiveness of physical therapy. 

And this is why I am excited: this study says that it does indeed measure up! It was found to be equally effective to physical therapy. The study compared 320 participants, who were divided into three groups: those who did yoga, those who did physical therapy, and those given educational materials. Also of interest was that the study group, who were all low-income, low-education, and non-white residents of Boston, Mass., represent a large portion of the population that could use an effective, low-cost option for improving their back pain. And in some areas the researchers looked at, yoga may be superior to physical therapy, such as pain reduction. 

My takeaway from this study, (which like all such studies has some downsides, too, which the article highlights for those interested), is that we now have evidence that yoga is on equal footing with physical therapy as an adjunct treatment option for generalized (low back pain with no definitive diagnosis, such as spinal stenosis or ruptured disc, as the underlying cause) chronic low back pain. I’ll be encouraging my students who are able to take advantage of physical therapy referrals by the docs to continue to take advantage of that proven treatment option. However, I will also now feel more confident than ever to have them add yoga to the mix when back pain is chronic. 

If you decide to give yoga for back pain a try and you are also seeing a physical therapist, it is important to let your physical therapist know that you are doing yoga, so everyone knows what you are doing to address your condition. And for those who, for whatever reason, are unable to do physical therapy, I’ll suggest trying an appropriate back care yoga class, such as one like my ongoing class, or scheduling a yoga private with an experienced teacher or yoga therapist to develop an appropriate home practice. Thank you, Dr. Sager for your important contribution to our understanding of yoga’s benefits compared with physical therapy.  

Caution: if you have a newer case of chronic low back pain and have not seen your doctor to have it evaluated, it would be a good idea to do so before initiating any yoga program to rule out more serious causes of low back pain. 

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News on Balance Falling and Yoga

by Baxter

In preparation for my Yoga U Online webinar Yoga for Core Integrity and Balance that started last Tuesday and finishes this Thursday, December 18, 2014, I was reading two papers that shed some interesting light on why we should to be concerned about balance and how to improve it. The first was a 2008 study Shifting the focus in fracture prevention from osteoporosis to falls that appeared in the British Medical Journal, and the second was a 2008 paper "Integrated Balance Training" by the National Academy of Sports Medicine (NASM). Since balance is one of our four essential skills of Yoga for Healthy Aging, I was excited to read about these takes on how to best improve balance. And as I was hiking around New Zealand last week and doing some yoga outdoors, some of these ideas started to make more sense to me.

Before I get to some of the unique recommendations for balance training from the NASM article, I want to share some other fascinating assertions the first group of researchers bring up for why balance training is so important as we age. The authors of the study on falling note this blockbuster fact:

“Numerous studies show that among older people falling, not osteoporosis, is the strongest risk factor for fracture.”

They also make a very interesting and important point:

“When a person falls, the type and severity of the fall (including fall height, energy, and direction) largely determine whether a fracture occurs.”

They point out that statistically a person whose dexascan numbers are higher by 1 Standard Deviation increases the chance of a fracture by about two times normal, whereas:

“By contrast, a sideways fall increases the risk of hip fracture three to five times, and when such a fall causes an impact to the greater trochanter of the proximal femur, hip fracture risk is raised about 30 times. These fall induced fracture risks are “strong” associations—comparable to those between smoking and lung cancer.”

The study concluded:

• "Falling, not osteoporosis, is the strongest single risk factor for fractures in elderly people
• Bone mineral density is a poor predictor of an individual’s fracture risk
• Drug treatment is expensive and will not prevent most fractures in elderly people
• Randomized controlled trials show that falls in older people can be reduced by up to 50% with balance training"

Finally, they recommend that the medical community—and family doctors in particular—should "shift the focus in fracture prevention by systematically assessing risk of falling and providing appropriate interventions to reduce the risk of falling." For those of us who practice or teach yoga, we can take this as encouragement to be mindful of our relative balance abilities as we practice yoga and look for ways to use our asana practice to maintain and improve our balance.

This is where the second paper by the NASM comes in. It was specifically looking at providing a better understanding of the complexities of what goes into having good balance as well as how to train individuals to improve balance. There were two intriguing ideas presented that I want to share with you today.

The first has to do with a special approach to balance. According to the authors of this paper, “the main goal of balance training is to continually increase your client’s awareness of his or her balance threshold or limits of stability by creating controlled instability.” To give you a better idea of what they mean, they go on to define “balance threshold” as follows:

“Integrated (balance) training should constantly stress an individual’s limits of stability (balance threshold). An individual’s limits of stability are the distance outside of his or her base of support he or she can go without losing control of the center of gravity.”

This idea can apply to static poses as well as dynamic movements in your yoga practice. For yoga practitioners, this means that instead of merely doing our regular routine balance poses and dynamic sequences each day or week, we should consider challenging ourselves or our students by adding in “controlled instability.” Of course, you could try practicing your balance poses outside on uneven ground, as I did in New Zealand. That definitely adds some controlled instability!

But even in the yoga room, you can use your creativity to add some instability into your practice. An example of this might be to move from doing Tree pose (Vrksasana) on the floor to trying it while standing on a wooden block on the lowest height, gradually working towards a longer hold of the pose there. So, the first time I try it, I might shoot for 30 seconds on each side. Once that seems stable and easy, perhaps after several days or a week of practice, I’d advance to 60 seconds. Once I’ve mastered that variable, I might then try the same thing on a slightly softer foam block. From there, I might add in the challenge of holding an additional block between my hands and dynamically moving it not just up and overhead as is sometimes more traditionally done, but taking over to the right side (not side bending, just angling the arms up and to the right), then the left side, then down and to the right and down and to the left while maintaining balance in Tree. As this example demonstrates, a certain amount of creativity will be involved in providing yourself with more challenges over time. Keep in mind that even small changes in the way you do your “normal” poses can add this element of “controlled instability” into your practice.

As for dynamic sequencing, you might change up a Sun Salutation by adding in a pose you don’t normally do while flowing in and out of the usual sequence, such as, from transition from Lunge pose into Standing Splits (Urdhva Prasarita Eka Padasana) for a breath or two before stepping back to Lunge and onto Downward Dog and all the rest. When that new sequence gets easy to do in the flow, add in another pose that challenges your balance a bit more, and so on and so forth. Again, be creative and systematic in how you do this and have some fun with it!

Improving balance not only can reduce your chances of falling and therefore reduces your chance of a fractured bone, but it has also been shown to reduce the chances of other sorts of injuries as well, such as anterior cruciate ligament tears in the knees and ankle sprains. So start playing around with these ideas in your home practice or for the teachers out there, let these ideas add some more variety and creativity to your sequencing of classes. And as always, we love to hear what you discover along the way! Happy, balanced trails!

And for those want more details on these ideas, check out my Yoga U Online webinar. Part 2 is live this Thursday, December 18th, at 5:30PST, 8:30EST.  Even if you missed Part 1 last week, it is now archived and if you sign up for the program (see yogauonline.com), you can listen and watch either one anytime you want. The package also includes a one-hour practice video on Core Integrity and Balance. The perfect holiday gift for yourself!

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Yoga and Dementia Welcome News

by Nina

A Rainbow at the Dam by Melina Meza

"Dementia Rate Is Found to Drop Sharply, as Forecast”

Now that’s the kind of headline I like to see! Yes, an article in the New York Times this week Dementia Rate Is Found to Drop Sharply, as Forecast announced the results of two different studies that showed that the incidence of dementia—in one case in England and Wales and in the other case in Denmark—was declining. And the reasons for this are very exciting to us here at Yoga for Healthy Aging.

“Yet experts on aging said the studies also confirmed something they had suspected but had had difficulty proving: that dementia rates would fall and mental acuity improve as the population grew healthier and better educated. The incidence of dementia is lower among those better educated, as well as among those who control their blood pressure and cholesterol, possibly because some dementia is caused by ministrokes and other vascular damage. So as populations controlled cardiovascular risk factors better and had more years of schooling, it made sense that the risk of dementia might decrease.”

So what they are saying here is that, along with being better educated, controlling blood pressure and cholesterol can help prevent dementia. And that means yoga can help. Foremost, yoga’s stress management tools can help you keep your blood pressure low. As I discussed in Chronic Stress: An Introduction, living with chronic stress can cause high blood pressure. So practicing stress management (see The Relaxation Response and Yoga and Stress, Your Health and Yoga will help you keep your blood pressure in check as it benefits your health in many other ways. Stress management can also help you maintain a low cholesterol diet by reducing stress eating and giving you more willpower to stay away from high cholesterol foods (see Yoga, Stress and Weight Management and Healthy Eating, Stress and Self Control). Healthy eating is also fostered by mindfulness (see Meditation and Healthy Eating) so if staying away from high-cholesterol foods is a problem for you, a meditation practice may be helpful.

For me, yoga even provides an ongoing education. Yoga philosophy is food for my intellect as well as providing inspiration for living my life with greater equanimity. Why, just this week I learned a lot from Ram’s post Hindu, Hundism and Yoga, and the week before I learned from writing my own post Modern Yoga and Hinduism. So if yoga philosophy and history are of interest to you, a whole world of new knowledge and intellectual stimulation awaits you.

The New York Times quoted Dr. Anderson, of the National Institute on Aging, saying:

“With these two studies, we are beginning to see that more and more of us will have a chance to reach old age cognitively intact, postponing dementia or avoiding it altogether. That is a happy prospect.”

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Avastin Lucentis Update 7 BREAKING NEWS – NEI NIH Will Fund Comparative Study

Since posting this update on October11th, I have obtained further information about the upcoming clinical trial to be held to compare Lucentis with Avastin. For the details, see the Addendum below.

Avastin/Lucentis Update 7: BREAKING NEWS – NEI/NIH Will Fund Comparative Study

On October 6th, after the New England Journal of Medicine had gone to press, the National Eye Institute and the National Institute of Health announced that they will proceed with a comparative study of Avastin and Lucentis.

As noted in my previous three updates (see links below in the Author’s Note), I and others felt that common sense dictated that a comparative study be undertaken particularly because of the disparity in price between the two drugs – Lucentis priced at $1950 per dose, and Avastin (used off-label) at about a tenth of that price.

As stated on their web site: “The National Eye Institute (NEI) of the National Institutes of Health (NIH) will fund a new multicenter clinical trial to compare two drugs currently used to treat advanced age-related macular degeneration (AMD)... Lucentis (ranibizumab) and Avastin (bevacizumab).”

In addition, the announcement said: “In advanced AMD, abnormal new blood vessels grow beneath the retina. These abnormal blood vessels can leak blood and fluid, and can cause severe vision loss. NEI-supported research has helped establish that VEGF is an important part of the biological pathways involved in triggering and sustaining the growth of new blood vessels in the retina. Research also demonstrated that VEGF is present in higher levels in a number of eye diseases, such as AMD. NEI has supported more than 300 research studies at a cost of nearly $95 million to better understand the role of VEGF in eye diseases.”

At this point, two anti-VEGF therapies, Macugen (pegaptanib sodium) and Lucentis, have already been approved by FDA specifically for the treatment of advanced AMD. Paul A. Sieving, M.D., Ph.D., director of NEI, said, "We are pleased that NIH-supported research is stimulating the development and testing of new, effective treatments for AMD."

I contacted the NEI and learned that patient enrollment will begin after the first of the year.

As I learn more about this important clinical trial, I will continue to update my web site.

ADDENDUM

According to a report in the New York Times, if the drugs prove to be equivalent in treating age-related macular degeneration, it would probably mean that many eye doctors would switch to the cheaper drug, hurting Genentech's sales but saving the Medicare program hundreds of millions of dollars a year.

Both Avastin and Lucentis work in a similar way, and some eye doctors say they believe Avastin is equally as effective. However Avastin has not been tested in rigorous clinical trials as Lucentis has. So interest has been growing for a trial to compare the drugs. It is estimated that there are 200,000 new cases each year of the type of macular degeneration for which Lucentis is approved.

Dr. Maryann Redford, the administrator of the NEI grant for the study, said it will involve a two-year trial costing about $16 million. The trial will follow about 1,200 people divided into four groups: one group will get a Lucentis injection every four weeks, one group will get an Avastin injection every four weeks; and two groups will get either Lucentis or Avastin on an as-needed basis. Redford said the study will take four years to complete.

Dr. Redford added that cost is not the primary reason that NEI decided to fund the study. "Right now there is an uncontrolled experiment being done, in that many clinicians are using Avastin, but its safety and efficacy for this use hasn't been tested," adding, "If the fallout also is that it can be done much less expensively, great."

Hal Barron, Genentech's chief medical officer, said the company is not interested in paying for a study comparing Lucentis and Avastin because it is unlikely that Avastin is a superior treatment and because the company prefers to spend money developing new treatments. Barron added that 81% of patients pay less than $50 out of pocket for each Lucentis dose because they have Medicare or other insurance.


Author’s Note on Avastin

Since posting the original article on January 31, 2006, I have now posted eight updates on this important drug for treating age-related macular degeneration. In addition to the posting you are reading, here is a listing (with links) to the others:

Avastin: A New Hope for Treating AMD (January 2006)

Avastin Update: Medicare not Likely to Cover its Use (March 2006)

Avastin Update II: AAO supports Medicare Coverage for Off-label Avastin Use (April 2006)

ARVO 2006: A Further Update on Both Avastin and Lucentis for Treating AMD (May 2006)

Avastin/Lucentis Update 4: FDA Approves Lucentis for Treating Wet AMD (July 2006)

Avastin Update 5: NIH Considers Comparing Lucentis and Avastin (August 2006)

Avastin/Lucentis Update 6: Latest Results Published in NEJM and Another Call for a Trial Between Them (October 2006)

Newer Updates

Avastin/Lucentis Update 8: A Report of the Latest News from the 2006 AAO Meeting (November 2006)

Avastin/Lucentis Update 9: A Disturbing Report about the Upcoming Trial Between Avastin and Lucentis (December 2006)