Case study and evidence
Clinical yoga can be practiced at any age, and also applied as a pain management treatment at any age. Here is Penny practicing at age 79. Several years ago, as a result of persistent shoulder pain, Penny was advised by one surgeon (rather stridently) that she needed bilateral shoulder replacements, and another "more conservative" physician recommended bilateral arthroscopy.
However, through multifactorial treatment, including education, and a graded yoga program, she is now pain free; swimming daily, practising yoga and golf regularly. As Professor Peter O’Sullivan describes, there is no benefit from threatening language, but “there is for [medical] business.
Non-evidence based scare-mongering does so much harm.”
In situations like this, there are many factors at play.
The first component concerns the client’s interaction with the biomedical model, resulting in imaging, specialist referral and subsequent surgical recommendation.
The second variable is the expectation of the client to receive a diagnosis for pain that makes sense, and subsequent treatment through the medical paradigm.
Third is the eventual decision to trial a conservative treatment approach, an approach which then has to (through necessity) challenge the previous recommendations given to the patient, by drawing on scientific evidence, and then proceed to achieve the patient’s goals.
In this case study we can observe the following:
- Imaging practices that contradict clinical guidelines
- Unwarranted specialist referral
- Non-evidence based surgical recommendations, and;
- Outcome achievement with conservative management.
All of the above can be logically understood and rationalised by examining the literature
CHRONIC PAIN AND INTERACTING WITH THE BIOMEDICAL MODEL
The behaviour by some physicians to engage in evidence discordant care has many explanations. For example, inappropriate use of scanning technology in pain patients, and subsequent diagnostic labelling has been linked to:
- Lack of education: A recent study demonstrated that patients were less likely to receive narcotics prescriptions from primary care providers when epidemiologic information was included in their lumbar spine MRI reports . Patent lack of basic epidemiological knowledge is a major problem, given that chronic pain remains a major reason for physician visits 
- Time poor 
- Fear of litigation 
- Financial incentives: One study demonstrated a 38% increase in referral for MRI if the physician had purchased their own MRI equipment, and could bill for MRI .
Evidence demonstrates that some GP’s make more than five times as many referrals per patient as others do , and this variability is based on provider training, years of experience, and experience with the presenting condition .
There is also compelling evidence to suggest that a referral to an orthopaedic surgeon so early in pain management is unnecessary and may be iatrogenic . Evidence for chronic pain clearly indicates that staying active, improving one’s understanding of pain, and identifying risk factors for persistent pain results in improved outcomes for most people . However, given that results for shoulder surgery are, on average, no better than conservative interventions , plus individuals with high score on psychometric testing typically do not benefit from surgery at all , and (dubiously) rates of surgery vary geographically according to the surgeon’s enthusiasm for surgery and the availability of MRI , the GP’s decision to expeditiously refer to an orthopaedic surgeon can be put into question.
Notwithstanding, there is also evidence to suggest that the language involved in simply referring someone to an “orthopaedic surgeon” so early in management can inflame the perceived threat and sense of danger around their site of pain (for a vulnerable person) ; this is particularly relevant here given the concomitant psychosocial status of the client.
Evidence discordant treatment recommendations for pain patients
These have been linked to:
- As described by Levy (2012), the existence of a Medical-Industrial-Complex that monopolises medical pain education, and focuses on influencing doctors (through continuing medical education (CME)), to bias treatments towards high cost, low value interventions .
- A lack of adequately trained health professionals, as pain education is insufficient  or (as stated above) corrupted by industrial influence .
There is an underlying expectation by patients to receive a scan for their chronic pain . The perceptions of a biomedical cause of chronic pain (e.g. underlying structural/anatomical problem) drives this. This can be alleviated through education to patient build health literacy by primary care physicians. Unfortunately, this is not happening however, and the reasons for it are outlined further below.
Improvement in pain patient outcomes, through targeted education and graded yoga, can be explained by examining the evidence from multiple lines of inquiry, such as;
- Epidemiological data on the prevalence of degenerative pathology on scans in asymptomatic individuals 
- Pain science research into fear, anxiety and expectations 
- Mindfulness and meditation research 
- Sham surgery studies 
- Placebo/nocebo mechanisms 
- Graduated exercise and graded activity exposure treatments for chronic pain 
- Rapport building, and the neuroscience of the therapeutic relationship ,
- Stress reduction mechanisms through regulated breathing and posture  and;
- By applying some basic reasoning, and a critical appraisal of the data.
Applying clinical reasoning in light of recent pain science
Contemporary pain science has advanced our understanding of the neuroscientific and psychological mechanisms prevalent in chronic pain conditions. Unfortunately this has yet to filter through sufficiently to university curriculums, professional organisation trainings, or current practicing physicians/health care workers. Therefore, the end user, in this case the medical consumer, is routinely denied best-practice evidence-based care for their pain.
We can use Penny’s surgical recommendations as a case study to unpack a standard case of failed clinical reasoning;
- Her scan results were significantly worse on the left shoulder, yet all of her pain was in the right. That alone should give a clue as to the significance of the relationship between joint degeneration on MRI and pain. Yet the surgeon was unmoved by this insight, and similarly unmoved by supporting epidemiological data.
- The pain was mostly in the region of the upper trapezius muscle, not the glenohumeral joint.
- It coincided with psychosocial stressors, though these were not addressed, measured or even considered.
- This stress was incidentally exacerbated by interaction with the biomedical model; the expectation of clinical worsening suggested by one physician, and the iatrogenic language used to describe her joints (degeneration, damage etc), rather than language such as “this is epidemiologically normal for your age”.
- Negative beliefs about persistent pain, (such as the perceptions of a biomedical cause of pain (eg, underlying structural/anatomical problem), that pain will be permanent or get worse in the future, and excessive fear of activity or movement out of concern of causing damage) have been reported to independently predict disability . Additionally, expectations and worry have been found to be more predictive of recovery than both scan results and type of injury .
- Most notably, there is the disconcerting fact that there have been absolutely “no controlled trials of surgery versus placebo or nonsurgical interventions” , meaning of a lack of quality evidence supporting shoulder arthroplasty for chronic pain , together with a complication rate of 14%, including intraoperative fracture, nerve injury, infection, and humeral component loosening .
This is an unacceptably high complication rate for a procedure that has never been properly tested against sham, or even conservative treatment. Secondly, it is in diametrical opposition to the principles of the biopsychosocial model, and the justification used for its use contradicts the current neuroscientific understanding of pain science.
To insert some further context, it may be helpful to digest the following quote by academic surgeon Professor Ian Harris, who deconstructs the problem from an orthopaedic surgeon’s perspective:
“A confession: I perform surgery that doesn’t work.
In my career, I have done surgery for ‘ununited’ fractures that had already healed, removed implants that were not causing a problem, fused sore backs and ‘scoped sore knees. I have even re-operated on people with ineffective procedures after the first ineffective procedure was, well, ineffective.
I will go one further: I have operated on people that didn’t have anything wrong with them in the first place. This happens because if a patient complains enough to a surgeon, one of the easiest ways of satisfying them is to operate. You can convince yourself that there must be something wrong for them to complain so much, even if the tests are normal.
I have learnt that there are many unhappy people out there with severe symptoms who have nothing physically wrong with them (nothing that is causing the symptoms anyway) - they don’t prepare you for that in medical school. These patients are not malingerers, but people who are caught in complicated compensation and legal systems, who have been wronged, or have other psychological factors that are manifesting with physical symptoms. For example, the biggest predictor of reporting back pain at work is job satisfaction. And you wonder why surgery doesn’t work for back pain.
And if you are wondering how doctors can treat people with no identifiable pathology, they do this by first labelling a patient with a condition.” 
In reality, pain is a multifactorial sensation, with numerous biological, psychological and social inputs . Subsequently, assessment and treatment approaches need to address and appreciate this. Even more importantly, clients require (and deserve) education and a treatment approach that aims to build health literacy, with intellectual honesty being the bedrock of this interaction .
However, a client’s prognosis can be significantly undermined through interactions where this education is not addressed. For example, multiple studies have revealed that GP management and knowledge of musculoskeletal pain is typically inconsistent with evidence based guidelines. .
Studies suggests that many GP's (and physios) share their patients beliefs that the spine (and the body generally) is a vulnerable structure that needs to be protected . As a result, they may not be in an ideal position to provide their patients with updated information which empowers an active and confident recovery .
Up to date evidence should be transparently discussed with clients to reduce fear based muscle guarding, and uncertainty about the safety of activity, which can further exacerbate pain and reduce movement .
In the acute phase, progression to chronicity can be avoided by simply improving a patients understanding and knowledge base. This gives patients the power of self-efficacy, and moves clients away from treatment models predicated on passive intervention, and outdated/ineffective (potentially iatrogenic) methods of treatment .
The scientific basis and rationale for an evidence-based approach to clinical yoga has been published many times on our website. Targeted individualised education, graduated movement, mindfulness training, relaxation training- all tailored privately to individual needs, with a biopsychosocial focus; these are some of the elements that comprise an evidence based yoga treatment.
Crucially, therapists need to be examples for their patients, and practice with dedication what they preach. Not only is this ethical, but insights gained from disciplined practice can be transferred to patients in genuine way, and then corroborated with evidence.
NAVIGATING THIS TERRAIN
In the field of pain management, evidence for best practice is routinely at odds with the recommendations given by client’s physicians and surgeons. This is a fairly unique area of medicine to interact with.
Imagine frequently being faced with the prospect of having to advise a client that almost everything they have been told for the last 6 years, through 4 failed back operations and countless scans, injections and appointments, is not evidenced based, and has likely caused harm, prolonged recovery, wasted resources, exposed them to risk of complications and been unnecessarily costly. And that the actual cause of their ongoing pain is something altogether different. This is a very problematic conversation to have. But, if we care about intellectual and scientific honesty, a necessary one.
It’s necessary because therapists do not see clients in a vacuum, as all patients have been influenced, for better or worse, by their prior interactions, beliefs, preconceived notions, and the ‘cognitive artefacts’ embedded in biomedical culture.
Additionally (and inconveniently), the situation is further complicated for allied health professionals, as their message typically isn’t given the same weighting in terms of importance compared to medical practitioners.
As pain researcher Professor Lorimer Moseley, author of Explain Pain, relates: “I completely understand and empathise with the problem of telling an apparently different story to someone who’s perceived to be more important and more powerful… When they go and see their next clinician, who might have a different qualification, who says ‘I saw someone like this the other day; we’ll operate on that, we’ll take it out’, then you’ve lost them. That’s a difficult problem.” 
The irreconcilability of treatment recommendations is, in itself, a source of confusion and stress for patients, which increases uncertainty and fear, and can be detrimental to efforts at conservative management. It is, in essence, another insidious form of iatrogenesis.
There are strategies to address these shortcomings, however. Namely:
- Focus on providing true and accurate information to clients, but not be attached, necessarily, to the outcome
- Emphasise rapport building
- Engage diplomatically and non-coercively and respect patient preference
- Provide actual written data, references and focus on building health literacy in clients so they are well informed medical consumers
- Confidently practice evidence based treatment, in spite of the destabilising fact that this often (but not always) isn’t being adopted or recommended by patients’ physicians.
Defiance to new evidence
PHYSIOS ARE PART OF THE PROBLEM
There is alarming evidence to demonstrate that many physios (a profession which, on balance, is actually the most well positioned to manage musculoskeletal pain) spend most of their time using passive, non-evidence based treatments for pain patients .
Additionally, many physios utilise the biomedical model due to outdated training, and a failure to keep abreast of new evidence. Ironically, as shown in previous literature, a biomedical focus often fails to get the results that physiotherapists actually need for their professional satisfaction [40-43].
The research has revealed repeatedly and consistently that physiotherapists have difficulty working in a holistic way with people with chronic pain [44, 45]. The inability to look past the immediate physical presentations and take into account the neurophysiological and biopsychosocial factors is widespread amongst outpatient physiotherapists .
As Barlow’s (2015) research on retraining physios in pain science reveals: “From the professional level, the biggest barrier is that a lot of physios see themselves as technicians, highly skilled mechanics who can diagnose and assess structures [and] fix them… Physios who hold onto manual therapy fear not having a job or purpose in life, they pride themselves on their manual skills, to find out what is wrong and use their hands to cure. Evidence that starts to point out that manual therapy doesn’t make a difference may be [perceived as] threatening.” 
Barlow describes how physiotherapists who have confidence in their manual therapy skills tend to “fall back on them in situations of doubt, rather than trying interventions that they are less certain about”. 
Subsequently, it’s clear that there is a desperate need to “enhance the competencies of primary care providers, nurses, and associated health professionals in the domains of pain assessment and management”, as described by Kerns .
One of the central messages from Australia’s National Pain Summit (2010) was that there are “major deficits in the knowledge of all health care professionals regarding the mechanisms and management of pain”. Consequently, one recommendation was that comprehensive education and training in pain management will give medical, nursing and allied health professionals in the public and private sectors the knowledge and resources to deliver best-practice evidence-based care .
This defiance to evidence is notably prevalent among GP’s as well. David Bulter, pain researcher and co-author of Explain Pain, states that; “Doctors don’t want to pay to come to courses. And yet most of the allied health professionals there, on half the income of a GP pay to come along. Most GPs are too cossetted, tight, indulged by drug companies and still many think it is beneath them to learn from a physiotherapist. And increasingly it is becoming clear they are a critical weak link in overall pain treatment.” 
Theory is not enough: Practical movement based training for physios
The Health Change model suggests that simply providing treatment advice and education or simply telling people what to do is not effective in creating and sustaining long-term behaviour change. (50)
Pain management training programs often give voice to the importance of self-care strategies for clients. However, few programs practically address this issue in their curricula. To address this perceived need, pragmatic training courses should be developed to provide practitioners with:
- Personal growth opportunities through gaining proficiency in the self-management practices that they actually wish to instruct, and;
- Professional growth through mindfulness and movement practices that can help prevent burnout. Occupational research on the impact of yoga and mindfulness courses reports significant changes in personal lives, stress levels, and levels of professional satisfaction
Some research supports the efficacy multidisciplinary pain treatment . However, given that research also indicates that early aggressive psychological interventions in the acute phase of injury may actually undermine recovery [52, 53, 54], physiotherapists should implement an interdisciplinary approach (such as Stress Inoculation Training (SIT)), to assist in coping and problem-solving strategies to reduce stress-related anxiety .
Additionally, allied health professionals can package treatment to provide essential information to about the impact of stress on physical and psychological wellbeing; thus facilitating improved insight, reducing the risk of subsequent chronicity .
This, combined with a ‘classification-based cognitive functional therapy’ approach, (which includes a graduated, mindful movement based approach to exercise that emphasises decreasing fear about movement, increasing self-efficacy, self-understanding and self-empowerment, explaining pain physiology, empathetic patient-centred communication, demystifying beliefs about pain (beliefs which would have come from her interactions with previous health care practitioners), and thus increasing health/scientific literacy) is well supported by evidence  for preventing progression to chronicity.
Stress reduction through yoga
By reducing perceived stress and anxiety, yoga appears to modulate stress response systems. This, in turn, decreases physiological arousal — for example, reducing the heart rate, lowering blood pressure, and easing respiration. There is also evidence that yoga practices help increase heart rate variability, an indicator of the body's ability to respond to stress more flexibly.
A small but intriguing study further characterizes the effect of yoga on the stress response. In 2008, researchers at the University of Utah  presented preliminary results from a study of varied participants' responses to pain. They note that people who have a poorly regulated response to stress are also more sensitive to pain. Their subjects were 12 experienced yoga practitioners, 14 people with fibromyalgia (a condition many researchers consider a stress-related illness that is characterized by hypersensitivity to pain), and 16 healthy volunteers.
When the three groups were subjected to more or less painful thumbnail pressure, the participants with fibromyalgia — as expected — perceived pain at lower pressure levels compared with the other subjects. Functional MRIs showed they also had the greatest activity in areas of the brain associated with the pain response. In contrast, the yoga practitioners had the highest pain tolerance and lowest pain-related brain activity during the MRI. The study underscores the value of techniques, such as yoga, that can help a person regulate their stress and, therefore, pain responses.
There is a need for comprehensive and up-to-date pain education in pre-registration physiotherapy and medical programs. Curricula need to be designed to support students to develop clinical competencies based on current pain neuroscience .
To enhance the subjective understanding of practitioners, curricula should include practical mindfulness, contemplative and movement based approaches, so that practitioners can become well versed in the techniques, so that can they can actually relate techniques to clients in an authentic way, drawing on competency and proficiency of the art form.
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