Journal of Bodywork & Movement Therapies (2013) 17, 469e474

Available online at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

YOGA THERAPY AND PAIN

The immediate effects of modified Yoga

positions on musculoskeletal pain relief
Lus Pimentel do Rosa
rio, PT, Ph.D. b,*,
Jose
lder Orcesi, PT a, Fernanda Naomi Kobayashi,
Larissa Schwarzwa
PT a, Alexandre Nicolau Aun, PT a, Iane Tavares Diolindo
Assumpc

ao, PT a, Gisele Janaina Blasioli, PT a,

Erica Sato Hanada, PT a

a

Physion Institute, Brazil

State University of the Center-West e UNICENTRO, Rua Padre Salvador, 875, CEP 85015-430
Guarapuava, PR, Brazil1

Received 6 January 2013; received in revised form 4 March 2013; accepted 20 March 2013

KEYWORDS
Posture;
Pain;
Yoga;
Analog scale

Summary Many musculoskeletal pains are related to poor posture. Thus, the aim of the present study was to assess the efficiency of a single session of two modified Yoga positions with 110
subjects and their 147 pain-related complaints. The participants were divided into two groups:
The Yoga Group, which received treatment of two 20-min postures and the Control Group, which
received a placebo treatment of 15 min with a turned off ultrasound. All volunteers experienced
some pain before treatment and were assessed before and after treatment using the analog pain
scale. A score of 0 indicated no pain whereas 10 was the maximum degree of pain on the scale.
The difference before and after treatment was compared between the groups with a p-value of
0.0001, as measured by the Students t-test. It is possible to conclude that one therapy session is
effective in the treatment of various musculoskeletal problems.
2013 Elsevier Ltd. All rights reserved.

Introduction

* Corresponding author. Rua das Rosas 620, Mirando

polis, CEP
04048-001, Sa
o Paulo, SP, Brazil. Tel.: 55 42 9992 9992.
E-mail address: ze.fisio@gmail.com (J.L.P. do Rosa
rio).
1
Tel.: 55 42 3621 1000.

A number of authors have stated that if body segments are

kept out of alignment for extended periods, some of the
muscles involved are used in a shortened position as a consequence (Kendall et al., 2010; Novak and Mackinnon, 1997).
These muscles are usually seen as strong, while their antagonists are taken to be elongated and weak; one of the effects of

1360-8592/$ - see front matter 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jbmt.2013.03.004

470
poor posture. These deviations can be unsightly and can
adversely affect muscular efficiency, predisposing individuals
to musculoskeletal dysfunction. One of the major symptoms of
postural change is pain (Rosa
rio and Marques, 2004).
According to Lee (1994), good posture creates the least
amount of joint stress and requires the least amount of
muscle activity. Consequently, it is the position of maximum
efficiency. The same author also described how a deviation
from optimal positioning should be compensated by changes
in the joint position which, in turn, must be maintained by an
increase in muscle activity. Therefore, postural instability
can be seen to potentially result in an excess of energy
consumption. This change in joint position, as described by
Lee (1994), is very similar to the concept of chiropractic
subluxation. Generations of chiropractors have ascribed
multiple symptoms to this type of dysfunction. (Mirtz et al.,
2009). Indeed, Moreno et al. (2007) submitted a group of
women to physical therapy to correct their posture and to
reduce the pain related to postural abnormalities. The patients were radiographed one week after therapeutic
discharge. The postural improvement was demonstrated by
the retraction of the shoulder and a decrease in pain.
Hoppenfeld (1999) reported that a referred pain in a joint
can have its cause in adjacent joints. Franc
oise Me
zie
`res, the
mother of therapies based in muscular chain (Teodori et al.,
2011; Rosa
rio, 2011, 2012) demonstrated that there is not
just a single muscle that causes bad posture, but rather
chains of muscles that can end up causing a dysfunction in a
specific place from generalized tension. Therefore, a localized muscular action provokes reactions at a distance.
Considering that poor posture is associated with joint
positioning changes, and that this malposition can be
associated with pain, the origin of which is far from the
location, the aim of the present study was to assess the
efficiency of a single application of modified Yoga positions.
These Yoga positions were modified aiming to stretch all
the muscles of the posterior or anterior chains at the same
time, based on Me
zie
`res work (Rosa
rio et al., 2012).

J.L.P. do Rosa
rio et al.
compromised chain, which exhibited the highest compensation in the test. This chain was the first to be treated.
A Examination of the anterior chain
The Tadasana e Mountain Pose e is used to assess the
anterior chain (Fig. 1). Patients who have either shortening
or tension in this chain exhibit compensatory changes.
Assessment steps:
1 Place the individual standing.
2 Place the pelvis in retroversion until the lumbar spine
becomes flat.
3 Observe the compensation, which may be one of the
following:
- Leaning the torso back;
- Bending the knees. A small flexion is normal (Fig. 1);
- Chest held in an inspiratory position (Fig. 1);
- Protrusion of the head and shoulders.
4 Examination of the posterior chain
The Shaktyasana e The Shakty goddess pose e is used to
assess this chain (Figure 2).
Assessment steps:
1 The subject must lean forward with the knees straight.
2 Align the lumbar spine, requesting a small lumbar
lordosis.
3 In order to achieve the spinal alignment, a shortened individual extends the trunk, opening the hip angle of flexion
(Fig. 2). Another possible abnormality is an opening of the
ankle angle (Fig. 2), which is the angle formed between the
foot and the tibia. In both cases, the optimal angles are 90 .

Methods
In total, 110 patients were treated. As some individuals
reported pain in more than one place, 147 complaints were
treated. The inclusion criteria for the present study
involved subjects with at least one complaint of musculoskeletal pain. Volunteers signed a statement of informed
consent and were assessed and treated with muscular
chains therapy, as described by Rosa
rio (2011). The present
study received approval from the Human Research Ethics
Committee of the State University of the Center-West
(UNICENTRO) under protocol number 289/2011.
The subjects were divided into two groups of 55 participants each: The Yoga Group, which received postural
treatment and the Control Group, which received a placebo
treatment of 15 min with turned off ultrasound. Both
groups were treated by a Physical Therapist that had been
trained in both of these altered Yoga positions.
Yoga Group assessment and comparison of chains
The anterior and posterior chains were assessed following
the description by Rosa
rio (2012) to identify the most

Figure 1 Assessment of the anterior chain with Tadasana e

mountain pose. This figure displays a shortening in the anterior
chain in the form of an inspiratory blockage and increased knee
flexion.

The immediate effects of modified Yoga positions on musculoskeletal pain relief

Figure 3
pose.

Figure 2 Assessment of the posterior chain with Shaktyasana

e The shakty goddess pose. This figure displays a shortening in
the posterior chain in the form of an opening in the hip and
ankle angles.

Yoga treatment
Treatment consisted of two postures adopted for 20 min
each. Before treatment, the subjects were taught how to
separate breathing by region: apical; lower ribs and diaphragmatic breathing, in order to help maintain posture.
The selection of posture was based on the assessment
described above. If the therapist found more alterations in
the posterior chain, two postures of the posterior chain
were performed. If more alterations were found in the
anterior chain, two postures of the anterior chain were
performed. If the two chains exhibited similar alterations,
the treatment included one posture of each chain. Both of
the postures were performed as described by Rosa
rio
(2012).
1 Supta Baddha Konasana e Reclining Bound Angle Pose
(anterior chain) (Fig. 3)
- The patient is positioned in supine decubitus, with the
arms against the body;
- The patient puts the soles of the feet together;
- As a rule, full external rotation of the femur should be
sought. If the patient has excessive external rotation
of the femur, a neutral position should be adopted,
with no rotation at all.
- Neck traction should be applied while maintaining
physiological neck lordosis;
- The tension point of the posture can be found by
bringing the heels forward and extending the knees,
leading to more difficulty in keeping the patients
lower back flat against the table. The tension point is
the maximum eccentric stretch the patient can hold
without inverting the spinal curves. If the lumbar
spine is not in full contact with the table, the patient
should be requested to perform an abdominal
contraction. If this does not work, it is a sign of too
much knee extension.
- In order to help the patient to contract the correct
muscles, it is important to provide proprioception

471

Supta Baddha Konasana e reclining bound angle

hints (Fig. 3). Thus, the therapists hand touches the

thoracic region, or lumbar/abdominal region, in order
to help the maintenance of the natural spinal curves.
2 Viparita Karani e Inverted Legs Pose (posterior chain)
(Fig. 4)
- The patient is positioned in supine decubitus, with the
arms against the body;
- The patient puts the soles of the feet together;
- As a rule, full external rotation of the femur should be
sought. If the patient has excessive external rotation
of the femur, a neutral position should be adopted,
with no rotation at all.
- Neck traction should be applied while maintaining
physiological neck lordosis;
- The therapist flexes the patients hip holding them by
the heels. Alternatively, the therapist can use a support for the heels (Fig. 4) in order to free the hands
for treatment;
- The tension point can be found by extending the
knees and flexing the hip, leading to more difficulty in
keeping the patients sacrum flat against the table.
The tension point is the maximum eccentric stretch
the patient can hold without inverting the spinal
curves. If the sacrum is not in full contact with the
table, the patient should be requested to perform a
paravertebral contraction. If this does not work, it is a
sign of too much knee extension or hip flexion.

Figure 4

Viparita Karani e inverted legs pose.

472

J.L.P. do Rosa
rio et al.
- In order to help the patient to contract the correct
muscles, it is important to provide proprioceptive
hints (Fig. 4). Thus, the therapists hand touches the
thoracic region or sacral region in order to help the
maintenance of the spinal natural curves.

Postures evolution
During the 20-min posture period, the therapist seeks to
maintain the symmetry of the patient. When the patient
maintains a posture for a certain time, muscular viscoelasticity decreases. As a result, the posture becomes
easier to sustain. Thus, the difficulty of achieving the
posture must be gradually increased. This process is called
posture evolution. In other words, evolution involves
finding a new tension point each time the position starts to
become easier. The following rules must be respected:
- At no time is it permissible to reverse the spinal physiological curves;
- Both anterior and posterior postures require gradual
extension of the knees;
- The posture of the posterior chain requires a gradual
increase in hip flexion;
Pain assessment
Pain is a symptom that accompanies the majority of pathological conditions that require medical care. Among the internationally validated scales for measuring the intensity of pain,
the analog scale is one of the most utilized (Gracely et al., 1996;
Aicher et al., 2012; Bailey et al., 2012). In the present study, a
line, scored from 0 to 10, was shown to the subject, who
verbally identified the degree of their pain, with zero indicating
no pain and ten indicating the most intense pain possible.
Statistical analysis
Besides the descriptive analysis, ANOVA was also used, with
the significance level set at p Z 0.05. In this test, the level
of pain reported by the subject on the analog scale before
treatment was compared to the level of pain after the Yoga
session. The groups were also compared before treatment
to investigate the similarity between them.

Results
Table 1 displays the mean and standard deviations before
and after treatment in both groups. It also shows the intergroup p-value and the p-value between the groups after
treatment.
No statistical differences were found (ANOVA) between
the groups before treatment (p Z 3.2).
Before the Yoga session, the majority of complaints in
the Yoga Group were between the values 3 to 8. After the
Table 1

session, the majority of values were between 0 and 2, with

a significant number of complaints also found at value 4 of
the scale. On the scale, the value of zero (no pain)
increased from zero reports to twenty-four, from the total
of seventy-one complaints.
The mean of the 71 values before treatment was 5.49 with
a standard deviation of 1.91. After treatment, these values
dropped to a mean of 1.78 and a standard deviation of 2.04.
The number of complaints with some improvement was 67,
which is equal to 94.4% of cases. The Yoga treatment had no
effect in only 2 cases (2.8%), whereas there were also 2 cases
(2.8%) that worsened. The significance of these data in the
Students t-test was p Z 0.001. Thus, it is possible to reject
the equality between values before and after treatment.
Before the placebo session, the largest number of
complaints in the Control Group was between the values 3
to 7. After the session, the majority of values were between 3 and 8. On the scale, the value of zero (no pain)
increased from zero reports to one.
The mean of the 76 values before treatment was 6.50
with a standard deviation of 1.81. After treatment, these
values dropped to a mean of 4.75 and a standard deviation
of 1.92. The number of complaints with some improvement
was 29, which is equal to 38% of cases. The placebo therapy
had no effect in 38 cases (50%) and there were also 9 cases
(12%) that worsened. The significance of these data in the
Students t-test was p Z 0.0001. Thus, it is possible to
reject the equality between the values before and after
treatment.
When comparing the difference between the groups
before and after treatment using ANOVA, the p-value was
0.0001 (Table 1).

Discussion
Both Groups showed significant relief of undiagnosed spinal
pain. The placebo exhibited a p-value of 0.0001, whereas
the value for Yoga was 0.00001 after treatment. Comparing
the groups, Yoga was significantly better with a p-value of
0.0001. The Control Group had a mean pain level of 5.50
before treatment and 4.70 after (a difference of 0.80). The
mean pain level in the Yoga Group was 5.52 before treatment and 1.50 after (a difference of 4.02). Treatment with
Yoga provided some sort of pain relief in 96% of cases,
whereas this figure was 36% in the control group.
Although there are relatively few scientific studies
investigating these Yoga postures or similar techniques
based on Mezie
re
`s stretching techniques (MST), they have
produced results in treating various musculoskeletal conditions (Basso et al., 2010; Canto et al., 2010; Fozzatti
et al., 2008; Gil et al., 2011; Luz et al., 2008; Marques

Mean and standard deviations before and after treatment. Inter-group p-value and p-value between the groups.

YOGA group
Control
group

Mean and standard

deviation before
treatment

Mean and standard

deviation after
treatment

Inter-group
p-value

p-value
between
the groups

6.72  1.74
6.50  1.81

1.23  1.69
4.75  1.92

0.00001
0.0001

0.0001

The immediate effects of modified Yoga positions on musculoskeletal pain relief

et al., 1994; Moreira and Soares, 2007; Moreno et al., 2007,
2009; Rossi et al., 2011). The present study corroborates
these previous studies.
Canto et al. (2010) studied the efficiency of MST in individuals with lower back pain using visual analog pain
scales at the time of the first and tenth treatment session.
In total, 85.7% of the participants reported a decrease in
the level of pain at the end of treatment and 77.1% of the
subjects recorded a lower score on the Roland Morris
questionnaire. The result of 85% is close to the 94.4% found
in the present study, although the main difference is the
number of sessions: while these authors used ten sessions,
the present study used only one. This brings into question
the number of sessions necessary to perform the treatment. Most MST therapists perform ten sessions as a basis
for a treatment that provides results (Rosa
rio, 2011).
Moreover, since Canto et al. (2010) did not assess patients
before the eleventh session, but after the tenth, these
researchers assessed the pain with the acute effect of the
last session and not with the chronic effect of the ten
sessions alone. The present study also did not assess the
effect of a single session after 24 or 48 h. These data would
be very useful in terms of finding a more effective
treatment.
Another clue that postural correction may lead to pain
reduction can be found in the work of Rossi et al. (2011),
who obtained postural improvements with just one treatment session using a similar technique. The present study
recorded pain reduction with one session, which can be
associated with the improved posture achieved in the very
first session.
Marques et al. (1994) assessed the effect of postural
treatment on fibromyalgia. Of the 20 patients treated, 18
reported some improvement. Although fibromyalgia is listed as a rheumatologic disease, these data are similar to
the results of the present study. Other studies have obtained positive results with this kind of treatment,
demonstrating how different causes of musculoskeletal
pain can be relieved by a postural treatment, similar to the
present study. Basso et al. (2010) reported decreases in
pain among 20 patients with temporomandibular disorders,
using 10 muscular chain treatment sessions. Gil et al. (2011)
decreased back pain in pregnant women in 8 weeks.
Heredia and Rodrigues (2008) relieved the pain of patients
with epidural fibrosis in post-operative lumbar disc
herniation.
Rosa
rio et al. (2008) argued that this type of postural
treatment technique does not affect posture simply by
stretching, since a 15-min posture produced the same results for hamstring flexibility as a 30-s hamstring stretch.
Body awareness and the active maintenance of better joint
positioning, reducing an existing dysfunction, can exert
their influence on postural adjustment and consequently
solve related pain (Beecher, 1955). Whatever the reason for
the effect, this study and previous studies have shown that
MST can result in improvement in the functionality of a
musculoskeletal pain source. The relief of 94.4% of the
complaints, with a complete absence of pain in 24 of the 71
complaints, demonstrated the efficiency of modified Yoga
postures when properly applied.
An interesting result in the present study was the unexpected success of the placebo therapy, which was

473

inferior to the Yoga treatment but still provided some pain

relief in 36% of cases. These results corroborate the findings
of Beecher (1955) who suggested that the placebo effect
occurs in 35% of the population. Placebo analgesia for postoperative dental pain was effective in 39% of cases (Levine
et al., 1979). Grelotti and Kaptchuk (2011) stated that the
placebo effect comes from an emotional response and can
be so strong that the patient feels better and members of
their family may also believe that the treatment is working,
provoking a whole social effect.
Even well recognized, analog scales are subjective.
Thus, the improvement obtained would be more accurate
with the use of other equipment such as dolorimeters.
According to Moerman (2006), the placebo is effective as a
treatment because it has a meaning. Therefore, when the
ultrasound is turned-off, it acts as a placebo therapy
because it has the meaning response of a therapy. However,
the use of certain Yoga positions, which are unrelated to
these postural corrections, would be a better placebo with
a similar meaning. Future studies should take this into
consideration.

Conclusion
In the present study, modified Yoga positions were shown to
reduce musculoskeletal pain in patients immediately after
the intervention. However, it did not determine the shortterm or long-term effects of just one intervention with
Yoga. Further studies are required to understand these
effects and the disorders that could be treated effectively
by this method, and those that could not, as well as the
optimal time and frequency of application for each
disorder.

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