Abstract

Study Aim: Yoga is a form of physical activity with beneficial effects both in the physical sphere and the psychological sphere. In the literature there are fewer reports, on yoga-related injuries. The aim of the study was to determine the characteristics of yoga-related injuries among yoga practitioners.
Material and Method: The study population consisted of 46 subjects aged 32.17 ± 9.75 who had suffered from yoga-related injury. The control group consisted of 153 subjects aged 29.33 ± 9.09 who had not suffered from yoga-related injuries. The study used our proprietary online questionnaire. The subjects had been practicing yoga for a minimum of 1 month, with mean of 2.51 ± 3.11 years.
Results: Eleven subjects had suffered from overload to the spine; 22 subjects had suffered from overload to lower limb and 13 subjects had suffered from overload to upper limb. 15 study population subjects had suffered from injuries in yoga positions that required extensive range of flexion/ straightening/ rotation within the spine. The participants who had suffered from injuries had practiced yoga significantly longer (p=0.037) than the participants who did not report overloads.
Conclusions: There is a risk of injury to the musculoskeletal system related to practicing yoga. The spine seems to be particularly prone to yoga-related overloads and this information should be carefully considered with patients with spine related problems. Yoga may be used as an alternative therapeutic method.

Keywords: Yoga; Injury; Musculoskeletal System; Physiotherapy

Introduction

The traditional yoga is a complex system, yet as a form of physical activity it is usually associated with performing static positions as well as with using breathing and meditation techniques [1]. Yoga is practiced by both healthy individuals and by individuals with various health issues [2]. Degenerative peripheral joint disease, back pain and increased stress were common motivations for taking up yoga [3]. Particular attention is given to aspects that contribute to improving the physical health and the overall mental well-being, which is why yoga is often used as an alternative therapeutic method4,5. Numerous studies have shown that yoga was used as a part of physiotherapeutic programs in disorders of various systems [4-8]. Liu et al. [9] conducted biomechanical analysis using EMG to determine the involvement of particular muscles of lower limbs in exercises that focused on standing positions.

The assessment of load during the five poses performed: chair, tree, warrior 1, 2, and 3, showed muscle activation in detail, which may help physiotherapists in including yoga in the physiotherapeutic programs. The assessments also checked potential risk related to overload of individual body parts. The authors noted a decrease in pain and an increase in joint mobility in patients with degenerative knee disease [7]. Moonaz et al. [6] found that yoga can help to increase physical activity and to improve quality of life in physically inactive patients with rheumatoid arthritis. Adamczyk et al. [8] studied patients with low back pain and found that pain decreased after yoga. Yoga proved beneficial for patients with Parkinson’s disease who had one-to-one tele-rehabilitation meetings with an instructor [10]. In a questionnaire-based study by Telles et al 94.5% of respondents reported the following benefits: their subjective physical ability, mental well-being and cognitive functions improved [11]. The above-mentioned studies confirm benefits related to yoga practice.

The available literature mentions some limitations of using yoga. These limitations were related to injuries of the musculoskeletal system, as well as its other undesirable effects [12]. Yoga can be widely used in the physiotherapeutic process, and there is a need to obtain accurate data on how it can be applied and what negative effects it may have. This is why it seems crucial to obtain information on the causes of injuries. Cramer et al. and Wiese et at. used questionnaires to analyse undesirable effects of yoga practice. They obtained information on socio-geographic determinants, the character of yoga practice and details of injuries suffered. The authors used this information to identify risk factors [13,14]. They used another questionnaire to obtain information on injuries suffered on the day on which answers were provided. They focused closely on the physical and mental state on the day of the incident. The questionnaires were filled out by participants of yoga classes and by yoga instructors who reported the symptoms that the participants experienced [5].

A following questionnaire-based study focused on pain to the locomotor system. The questionnaire was filled at the beginning of the study and then a year later. The aim was to determine whether the appearance or the diminishing of pain was related to yoga practice. Pain directly related to yoga practice was reported by 10.7% of participants [2]. Swain et al. determined the number and type of injuries experienced by individuals in the United States between 2001 and 2014 on the basis of medical documentation [15]. Another study analyzed data collected within the space of several years based on medical imaging of yogarelated injuries. On this basis, the authors determined which yoga positions most often resulted in injuries [16]. There are also some reports (descriptions) of rare case of musculoskeletal injuries such as rupture of the quadratus femoris muscle or femoral bone fracture [17,18]. Information on the safety of yoga practice was summarized in review articles which, among others, identified the incidence of the most common injuries [1,19]. The literature on the negative effects of yoga advises caution in patients with osteoporosis [20]. The main aim of the study was to determine the incidence and the character of musculoskeletal injuries related to yoga in yoga practitioners with particular focus on individuals before 60 years of age.

Material and Method

The study was positively assessed by the Senate Committee for Scientific Research of the Józef Piłsudski University of Physical Education in Warsaw, decision number 01-27/2020. The study involved 199 individuals aged 29.99 ± 9.30 (186-F, 13-M). The group consisted of individuals who did yoga at the time of conducting the study or in the past. The study population consisted of 46 individuals aged 32.17 ± 9.75, who had experienced yogarelated musculoskeletal injuries, and the control group consisted of 153 individuals aged 29.33 ± 9.09, who had never experienced yoga-related musculoskeletal injuries.

• The inclusion criteria of the study population were: yoga practice at the time of the study or in the past for a minimum of one month, age 18-60 years, yoga-related musculoskeletal injury.
• The criteria for exclusion from the study population were: persons who had never practiced yoga, age below 18 years or over 60 years, no prior yoga-related musculoskeletal injury.
• The criteria for inclusion to the control group were: yoga practice at the time of the study or in the past, age 18-60 years, no prior yoga-related musculoskeletal injury.
• The criteria for exclusion from the control group were: persons who had never practiced yoga, age below 18 years or over 60 years, prior yoga-related musculoskeletal injury.

(Table 1) presents characteristics of the study subjects. (Table 2) presents detailed characteristics of the study population and of the control group.

Table 1 Characteristics of the Study Subjects

Table 1. Detailed characteristics of the study population and of the control group. The study used a proprietary questionnaire in the Google Forms application. The questionnaire consisted of five parts. The first part collected basic information about the study participant such as: sex, age, body mass, body height. The second part consisted of questions on the individual yoga practice of the participant. The obtained information concerned being a yoga instructor, years of practice, leading yoga style, main type of yoga practice, its frequency, and the impact on the respondent’s health. The third part concerned general heath and any present chronic diseases. The fourth part consisted of one question only which read “Have you ever experienced any injury/ adverse effects/ symptoms during your yoga practice?” A positive answer directed the respondent to a following part, which consisted of detailed questions on musculoskeletal injuries.

The information obtained in this part concerned the type of injury, its location, time scope at which the injury appeared since the beginning of one’s yoga practice, the position which the respondent believed resulted in the injury, whether the respondent continued to do yoga after injury or not. In addition, it was established whether injury related symptoms abated and whether the respondent sought consultation from a doctor or from a physiotherapist. In total, a respondent could report information on a maximum of three injuries they had experienced. The questionnaire was distributed on the social media platform Facebook and by email. Initially, a pilot study was conducted on 14 respondents. The fourteen responses allowed us to determine how correctly were the questionnaires built and how clear the questions were. Then we commenced the main study - it lasted from October to November 2020.

Statistical Analysis

Statistical analysis was conducted using the statistical environment R version 3.6, the PSPP programmer and MS Office 2019. Information from the questionnaires was collected in the Excel 2019 spreadsheet. Qualitative data from open-ended questions was appropriately categorized and coded as numbers. Ordinal and nominal variables were presented as numbers and percentages. Quantitative variables were represented using descriptive statistics, including frequency, arithmetic mean, standard deviation, minimum value and maximum value. To check the presence of relationships, for the quantitative data we used the Mann-Whitney U-test for independent trials after verifying the normal distribution, and for the qualitative data we used the chisquared test. We used 2x2 tables, for which we applied continuity correction. We conducted Fisher’s exact test for tables larger than 2x2 when chi-squared tests’ conditions were not met. We set statistical significance at p<0.05.

Results

Characteristics of Yoga Practice

The results were analyzed first for all participants of the study and then again, after the whole study population was divided into two subgroups, depending on the experience of injury. The mean time of yoga practice for all the participants was 2.51 ± 3.11 years, with the mean frequency of 3.95 ± 1.76 times per week. The leading yoga styles were the following: Hatha 12 (6%), Vinyasa 38 (19.1%), Ashtanga 13 (6%), Iyengar 10 (5%), other 5 (2.5%), various styles 71 (35.7%), 50 participants were not aware of the style (25.1%). As many as 64 participants practised yoga on their own (32.2%), while others joined traditional face-to-face courses or followed an online recorded course. (Table 3) presents results for the study population and the control group.

Table 2 Results for the Study Population (With Injuries) and Control Group (Without Injuries).

Subjective health and yoga’s impact on health Subjective health was assessed as very good by 79 participants (39.7%), good by 91 participants (45.7%), moderate by 26 participants (13.1%) and poor by 3 participants (1.5%). The presence of one or more chronic diseases was reported by 45 participants (22.6%) (28 participants had musculoskeletal system disorders, and 27 had other diseases). The respondents assessed yoga’s impact on their health the following: improvement of physical health - 137 respondents (68.8%), improvement of mental health - 109 respondents (54.85%), improvement of breathing - 14 respondents (7%). (Table 4) presents detailed information on subjective health.

Table 3 Subjective health

Yoga-related musculoskeletal injuries. Injuries or pain directly related to yoga practice were reported by 46 respondents (23,1%). 11 respondents (23.9%) reported injuries to the spine, 22 respondents (47.8%) - to the lower limb, and 13 respondents (28.3%) - to the upper limb. Injuries most commonly occurred in positions which required large scope of flexion/ extension/ rotation of the spine - 15 injuries (32.6%), in sitting positions - 4 injuries (8.7%), in head/ forearm/ shoulder stand - 4 injuries (8.7%), other injuries - 13 (28.3%), and irregular positions 21.7%. Most of the respondents (37 persons, 80.4%) did not seek medical consultation in relation to the injury, 8 respondents (17.39%) consulted a physiotherapist, and 3 respondents (6.5%) contacted a doctor. After the injury, two respondents (4.3%) stopped practicing yoga entirely; 17 respondents (37%) returned to yoga exercise after some time, while 27 respondents (58.7%) continued doing yoga without any break.

Chosen relationships between variables and incidence of musculoskeletal injury We identified relationships between musculoskeletal injury and yoga practice at the time of the study or in the past, respondents’ BMI, years of yoga practice, frequency of practice, leading yoga style, chronic illnesses. Among these variables, we found a significant relationship between musculoskeletal injury and the years of practice and practicing at the time of the study. Respondents who had experienced injuries had been practicing yoga significantly longer (p=0.037) that respondents who did not report injuries. Respondents who reported practicing yoga at the time of the study had experienced injuries significantly more often (p=0.078). Adverse effects were reported by 21.1% of underweight respondents, by 22.9% of respondents with normal weight and 25% of overweight or obese respondents. We did not find significant relationships between injuries and respondents’ BMI (p=0.941). For the purpose of the statistical test, we divided data on the frequency of yoga practice into three subgroups: up to twice a week, three to four times a week, or 5 times a week or more. We did not find significant relationships between the frequency of yoga practice per week and injuries (p=0.274). We did not find relationships between injuries and the leading yoga style (p=0.684) or chronic diseases 28.9% vs. 21.4% (p=0.399).

Discussion

Some of the respondents in the study had experienced injuries or pain that had been directly related to their yoga practice. Respondents often reported their lower limb to be affected. We identified relationships between musculoskeletal injury and yoga practice at the time of the study or in the past, respondents’ BMI, years of yoga practice, frequency of practice, leading yoga style, chronic illnesses. Among these variables, we found a significant relationship between musculoskeletal injury and the years of practice and practicing at the time of the study. Respondents who practiced yoga at the time of the study experienced injuries significantly more often.

Most of the study population were females (93.5%). There was similar proportion of sexes in other analyses that discussed the topic of yoga-related musculoskeletal injuries. In the study by Cramer et al. females constituted 88.9% of the study population, and in the study by Campo et al. the proportion was 94%. This data shows a significant domination of the female sex in taking up this form of physical activity [13]. For this reason, information on the incidence of musculoskeletal injuries concerns mainly women.

Respondents’ age may prove to be a significant factor for injury incidence. The mean age in our study was low (it was less than 30 years of age) in comparison to other studies. Other studies had older participants whose age was 47.2 years or 45.7 years [13]. Matsushita et al. divided their participants into two subgroups according to the decades of their lives and most of the participants were between 40 and 60 years of age [5]. Yoga may be significantly modified, and these modifications serve adjusting the therapy for the individual or making yoga practice more appropriate for senior citizens. In their study, Krejci et al conducted chair yoga classes for participants over 65 years of age. They reported improvement in static and dynamic balance, and decrease in risk of falls [21]. Evolutionary changes related to ageing processes may result in higher susceptibility of the human body to injuries. They may manifest in higher incidence of injuries in older participants [15].

Most of the respondents (60.8%) of our study practiced various yoga styles or were not aware of which category the yoga they practiced fell into. Wiese et al. had similar results, as 58.0% of their respondents declared doing various yoga styles [14]. Results by Cramer et al. on the basis of the number of registered injuries for 1000 hours of exercise showed that the type of yoga practiced had impact on the incidence of injuries. The mean index for yoga was 0.6 injuries per 1000 hours and showed significant differences depending on yoga style. Dynamic forms of yoga had higher numbers of incidents, and practice that focused on breathing exercises or meditation had lower values [13]. This index was not calculated for our study as there was no information on the total number of hours of yoga practice.

In our study more than 75% of respondents practice yoga without a teacher. In other analyses, practising yoga without a teacher was related to a higher risk of injury [10,13]. In their recommendation on safety and on minimizing injury incidence, Telles et al. focus on the presence of a therapist or yoga teacher during yoga exercise performed both by healthy individuals and individuals with various diseases [22]. 20% of persons involved our study population had had a minimum of one injury or overload to the musculoskeletal system. Cramer et al. had similar results. In their study, 21.4% respondents reported injuries related to a particular situation from their yoga practice [13]. The study by Campo et al. presented a broad scope of injury incidence percentage. It was from 1.0% to 62.0% which may suggest that there were several factors related to experiencing injuries.

Campo et al studied pain incidence among yoga practitioners over a course of one year: 10.7% of respondents reported pain directly related to yoga practice [22]. In a study by Matsushita et al, 27.4% of respondents reported experiencing an injury after a yoga class conducted by a yoga teacher [5]. Welford et al. evaluated benefits and adverse effects for yoga and for aerobic exercise. The incidence of injury among yoga practitioners was 22%, and the incidence in the group doing aerobics was 37% [23]. Practicing yoga is related to the risk of musculoskeletal overload, which needs to be considered especially when a therapist intends to include yoga in their physiotherapeutic plan. The most common anatomic location of injury reported in our study was the lower limb. These results are in line with the analysis by Wiese et al., where 21% of injuries affected the knee [14]. A study by Sekendiz which retrospectively analyzed medical documentation found that 30.5% of all injuries were to the knee and the shin [24]. Yoga positions involve lower limbs and this is the reason which the probability of injuring these body parts is greater.

A considerable group within the participants were not able to identify a specific position that resulted in the injury, yet positions most often reported in this context were the exercises which involved various movements of the spine. Participants of the study by Lee et al. reported experiencing overload during positions which required a large range of flexion or extension in the spine [25]. The spinal area seems to be particularly sensitive to yoga-related overload and this information should be considered in particular when dealing with patients with disc disorder or osteoporosis. We studied the relationship between musculoskeletal injury incidence and numerous variables. We have found a significant relationship between injury and the years of practicing yoga. Similar results were presented in the study by Wiese et al. The long experience of practicing yoga and being a yoga teacher were the most commonly predisposing factors for experiencing injuries. According to Cramer et al. a higher risk for experiencing injury was related to practicing more dynamic yoga forms. They also observed a relationship which concerned a higher incidence of injury among persons practicing yoga on their own, without any supervision from a teacher [10]. The longer the time of yoga practice, the higher the statistical possibility of experiencing an injury.

The main limitation of the study was the study tool we used. The questionnaire, containing numerous open-ended questions, allowed for providing subjective answers. This particularly affected information on the experienced injuries. The descriptions of the location of the injury or the position which caused were not specific enough and did not allow for a detailed analysis. The value of the study. A positive effect of yoga is noticeable both in the aspect of physical and of the mental health. This study proved that yoga is not a risk-free type of activity. The information from the study and the review of the literature helped to determine the elements which yoga teachers and physiotherapists should consider when including yoga as an alternative type of therapy.

Conclusions

1. There is a risk of injury to the musculoskeletal system related to practicing yoga.
2. The spine seems to be particularly prone to yoga-related overloads and this information should be carefully considered with patients with spine related problems.
3. Yoga may be used as an alternative therapeutic method.

References

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