Iyengar Yoga and The Use of Props For Padiatric Chronic Pain

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Altern Ther Health Med. Author manuscript; available in PMC 2013 November 21.
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Altern Ther Health Med. 2013 ; 19(5): 66–70.
Iyengar Yoga and the Use of Props for Pediatric Chronic Pain: A
Case Study
Subhadra Evans, PhD [assistant professor], Beth Sternlieb, BFA [yoga teacher], Lonnie
Zeltzer, MD [distinguished professor], and Jennie C. I. Tsao, PhD [professor]
Pediatric Pain Program in the Department of Pediatrics at the David Geffen School of Medicine,
University of California, Los Angeles
Abstract
Iyengar yoga uses postures and props to support the body so that practitioners can engage in poses
that would otherwise be more difficult. This type of yoga may be useful in treating children and
adolescents who have chronic pain and disability. In this case study, the authors discuss a 14-y-old
girl who had two surgeries for gastro-esophageal reflux disease (GERD) and who had continued
chest and abdominal pain, as well as vomiting, difficulty eating, weight loss, and anxiety. Having
significantly impaired functioning, she was unable to attend school, sleep, socialize, or eat, and
she had become wheelchair-bound. Despite evaluations and treatments by specialists over an
extended period of time, her symptoms had not improved. This case history describes how the
authors used a 4-mo treatment of Iyengar yoga to help the adolescent resume activities and re-
engage with her environment. The authors intend this report to stimulate scientific study of this
form of treatment for children and adolescents with chronic pain.
Iyengar yoga is a tradition of yoga that B. K. S. Iyengar developed to ensure that all
individuals, including those with medical complications and pain, have access to the
postures, breath work, and meditative practices of yoga. Within this form of yoga, an
individual uses props to facilitate the practice of therapeutic poses and to support the body.1
Iyengar yoga also uses specific body poses that practitioners hold for varying amounts of
time, as opposed to a flow yoga where the practitioner often moves rapidly in and out of
poses.2 As the authors have noted previously, Iyengar yoga may be particularly suitable for
patient populations due to its standardized and rigorous teacher training and to the emphasis
on props to support poses, protecting the joints, promoting circulation, and compensating for
limitations in strength, flexibility, and mobility.3 As with a prescription, the yoga teacher
teaches a therapeutic yoga practice with a particular patient’s medical condition in mind,
including any comorbidities.
To date, scientific studies examining yoga for pain in children are rare. In one study, 25
patients aged 11 to 18 years with irritable bowel syndrome (IBS) participated in a 4-week
home practice of yoga, subsequent to an initial training session. When compared with a
waitlist control group, the yoga group exhibited significantly improved poststudy IBS
symptoms and significantly reduced disability and anxiety, along with improved coping
behaviors.4
Although research for children is scant, studies with adults have shown Iyengar yoga to
improve a number of conditions characterized by persistent pain, including rheumatoid
arthritis,5 carpal tunnel syndrome,6 osteoarthritis of the hand7 and knee,8 chronic low back
pain,9,10 multiple sclerosis,11 and chronic pancreatitis.12 Two recent reviews of yoga for
Corresponding author: Subhadra Evans, PhD, suevans@mednet.ucla.edu.

Evans et al. Page 2
pain have described these studies and concluded that despite limitations to the design and
execution of many yoga studies to date, yoga holds promise for alleviating pain.13,14 Other
studies have shown Iyengar yoga to improve mood15,16 and fatigue in breast cancer
survivors.17,18
Medical practitioners in the Pediatric Pain Program at the University of California, Los
Angeles (UCLA) use Iyengar yoga, including the use of props, in the treatment of children
with chronic pain and other health problems. In this case report, the authors describe the
treatment plan that they developed and carried out using yoga props to help a 14-year-old
female with chronic pain. This article provides findings on her functional changes over time.
CASE HISTORY
Mary (pseudonym), a 14-year-old girl, entered the pediatric pain program (PPP) with a
history of gastro-esophageal reflux disease (GERD), including two previous Nissen
fundoplication surgeries for her GERD, dysphagia, and chest and abdominal pain. Because
of her severe chest and abdominal pain and vomiting, she had been unable to eat and
received total parenteral nutrition through a central, vascular access line placed in a vein in
her arm. She had had two recent hospitalizations for blood clots in the vein with the central
line, and her physicians had placed a second central line. One of the authors initially saw her
while she was a patient in the hospital, where she was continuing to have abdominal pain.
Subsequently, at the time of her first visit to the clinic, she was very weak, used a
wheelchair as her primary form of mobility, and had been unable to attend school for several
months.
Mary had reported constant abdominal pain as well as difficulty swallowing and had a
gagging sensation with swallowing that made it difficult for her to eat. She had had several
evaluations by senior, pediatric gastroenterology faculty at two different academic
institutions. These evaluations included multiple endoscopies, barium swallow studies under
fluoroscopy, radiographic chest and abdominal studies, and blood tests for metabolic
disorder, blood counts, and liver function as well as stool and urine cultures, but the
physicians found nothing pathologic. She was seriously underweight and anxious about her
condition, as was her family. Initial evaluation at the PPP found no evidence of an eating
disorder; she was not using laxatives and did not exercise, and her body was extremely thin.
She appeared anxious and depressed and had become socially isolated.
The patient was diagnosed as having IBS, with esophageal hyperalgesia subsequent to
sensitization following her GERD and two gastroenterological procedures (Nissen
fundoplications) and with conditioned food aversion secondary to a conditioned association
of eating and pain.19,20 While the GERD had resolved, Mary’s fear of eating and her
conditioned association of vomiting with food remained as did a hypersensitive esophagus

and stomach. The latter caused pain with eating and further intensified her fear of eating and
association of vomiting with any oral intake. She was also diagnosed with a generalized
anxiety disorder, which may have preceded or been subsequent to the IBS and vomiting. As
she had become more isolated, she began to feel depressed, helpless, and dependent, and she
had regressed developmentally. Clinic physicians prescribed escitalopram, a selective,
serotonin reuptake inhibitor, for her as well as initial individual psychotherapy and Iyengar
yoga. This report describes the process of treatment and the patient’s responses that took
place in the course of her 16-week Iyengar yoga intervention.
IYENGAR YOGA INTERVENTION

The yoga intervention involved 1-hour classes that Mary attended twice per week for the
first month, three times per week for the second month, and twice per week for the last 2
Evans et al. Page 3
months. Sequencing is critical to the Iyengar yoga therapeutic process and is one of the
hallmarks of the tradition. Practitioners believe that they achieve a powerful cumulative
effect by practicing poses in particular sequences. Patients at the pediatric pain program are
given specific Iyengar yoga practices that target the individual’s health concerns. Increasing
in complexity over time, Mary’s program included sequences prescribed by B. K. S. Iyengar
designed to develop strength, elevate mood, and ease symptoms by extending the abdomen
and increasing tolerance for abdominal sensations. The use of props enabled Mary to hold
the postures without strain or fatigue. The authors believed it was first critical to address her
esophageal pain and the gagging sensation she had in her throat, without taxing her limited
reserves of energy.
General Outline of the Program

The first meeting with the Iyengar yoga teacher (BS) focused on what are known in the
Iyengar yoga system as L-shaped poses. These poses are upright, seated passive spinal
extensions. They enabled Mary to relax and extend her throat and abdomen, which was an
important first step in treating her symptoms. She was surprised to discover that the position
brought relief from pain. She could see that relaxing and extending her throat stopped the
burning sensation and that the extension of her abdomen was soothing and provided some
relief. These postures offered the added benefit of several leg variations that increased the
range of motion in her legs and hips that were weak and atrophied from months of being
bedridden. As she began to feel stronger and more comfortable, the yoga teacher added
poses to the sequence, including (1) inversions, designed to provide a sense of freedom and
confidence and to extend the abdomen and circulate the lymphatic system and (2) supported
backbends that more deeply extended the abdomen. The inversions and backbends
encouraged Mary to use the strength of her legs to extend her abdomen and spine. The final
4 weeks included poses that were more challenging, and therefore confidence-building, as
well as poses designed to further extend her throat and strengthen her body, which was
critical given that Mary had been wheelchair-bound. The sequence is detailed below, with a
depiction of selected poses. These poses represent a sequence working list, and Mary did not
attempt all poses at each class.
Yoga Postures Included Over the 4-month Period

The yoga poses included (1) L-shaped poses (Figure 1)—uppavista legs, baddha konasana,
sukhasana legs, and dandasana legs; (2) supta padangusthasana to the side with leg
supported on a chair; (3) purvottanasana on two chairs (Figure 2);(4) supta baddha
konasana; (5) supta sukhasana; (6) supta virasana; (7) setu bhanda on a bench with a box;
and (8) viparita karani. Mary held these poses for 5 to 10 minutes each.
Mary first learned seated L-shaped poses, which enabled her to relax and extend her throat
and abdomen. The leg extensions involved in the poses also allowed her to increase the
range of motion in her legs and hips.
The yoga teacher also helped Mary to practice supported purvottanasana on two chairs
(Figure 2). This pose is a passive backbend that opened her chest and extended her
abdomen. Mary, like many children who have chronic pain that the authors see, was
anxious, discouraged, and depressed. Researchers have demonstrated that back bends can
improve mood.16 The authors introduced purvottanasana to Mary’s program for its
beneficial emotional as well as physical effects.
During the second month of classes, the program added the following poses: (1) backbend
over a backbender with legs straight wide apart and legs in baddha konasana (Figure 3); (2)
back bend over chairs (Figure 4); (3) chair shoulder stand (Figure 5); (4) hanging rope
Evans et al. Page 4
sirsasana (Figure 6); (5) down dog on the ropes; and (6) standing back bend (chest
supported, head supported above chest). Mary held these poses for 5 to 10 minutes each.
After Mary learned to relax her neck and throat with her head upright in the first month, the
yoga teacher introduced supportive backbends where her head was hanging below her chest
(Figures 3 and 4). To aid in the relaxation of her throat, the yoga teacher placed bolsters and
blankets under her head for support. Again, various leg positions helped to open the
abdomen, exercise her legs and hips, and bring circulation into the pelvic area. Mary had a
great deal of tension in her diaphragm, and passive backbends appeared to ease her
breathlessness and improve her mood.
In a backbend over two chairs (Figure 4), the yoga teacher took care to support Mary’s
thoracic spine. The yoga teacher used this posture to open Mary’s chest, promote circulation
in the heart area, and train her back muscles to engage so that she could stand up straighter
rather than stand with her chest collapsed and abdomen gripped.
In the second month, the yoga teacher began introducing Mary to additional passive
inversions such as chair shoulder stand (Figure 5); hanging rope sirsasana (Figure 6); and
halasana, with further inversions to follow in the third month. With the help of ropes, chairs,
blankets, etc, Mary was able to go upside down. Inversions are important in the Iyengar
yoga system because practitioners believe they promote circulation of the lymph system, aid
blood flow, ease breathlessness, and help the individual develop a sense of freedom and
confidence. For children with illness, these poses mark the experience of a return to
childlike fun and playfulness.
During the final month of classes, the yoga teacher added the following poses: (1) handstand
at the wall, (2) headstand at the wall, (3) ardha chandrasana at the wall (Figure 7), (4) pincha
mayurasana at the wall (Figure 8), (5) prasarita padangusthasana, (6) shoulder stand, (7)
supta konasana with legs wide and supported on the chair, and (8) karnapidasana with knees
on the chair. Mary held these poses for 30 seconds to 5 minutes each.
Mary practiced ardha chandrasana against a wall for balance (Figure 7). This pose
strengthened and toned her legs and provided for an opening in the abdomen rather than her
gripped and tentative posture without support.
Mary attempted pincha mayurasana next (Figure 8). This pose built on the first poses she
completed that extended her throat, but now she used her strength to support herself on her
arms. The authors also intended the pose to build her confidence and strength. Mary
controlled the extension through her efforts. The block between her hands and the strap
around her elbows helped keep her arms in the right position, and with the support of the
wall, she reported no fear of falling.
Props allowed Mary to hold the poses for periods of time long enough to promote circulation
and develop strength and awareness. Mary learned to distinguish between pain that indicated
something is wrong and pain that comes from healthy movement as a result of breaking up
of scar tissue, weakness, and restricted movement. She was understandably guarded in her
throat and abdomen, but her posture and tension was not healthy. The support of props
allowed her to be less vigilant about protecting her throat.
The authors did not formally prescribe home practice; however, Mary received props after
the first few weeks of classes, and she regularly practiced restorative poses at home.
Evans et al. Page 5
OUTCOME
Midway through the intervention, Mary’s abdominal pain eased, and she was able to eat in
increasing amounts and to gain weight. She was able to stand on her own, and no longer
needed a wheelchair for mobility. To build strength, she also started to engage in poses that
were more physically demanding. Yoga is based on skills, and the practitioner participates in
her own healing. Although she was traumatized by her medical crisis, the practice of Iyengar
yoga with the help of props allowed Mary to take charge of her own healing process and
helped her to feel more optimistic and empowered. Mary reported that she was learning to
face her fears and had found relief from pain. Her range of motion visibly increased, and she
was able to extend and relax through supported postures.
By the end of the yoga treatment plan and her sessions, Mary was no longer using a
wheelchair, was sleeping well at night, reported energy during the day, and had gained
enough weight to put her at her normal body weight for her height. She reported that her
esophageal and abdominal pain had resolved completely and her eating patterns had
returned to normal, with no vomiting or food aversion. Mary’s mood had improved, and she
reported feeling more content and less anxious. she had also developed a plan with her
school to make a gradual return. By the following year, she was symptom-free and had an
active social and school life. She was discharged from the PPP.
DISCUSSION
When her physicians first saw Mary, they recognized that her depression, anxiety, learned
helplessness, dependency, and awareness of her family’s anxiety about her condition
contributed to her chronic pain and disability. Her functioning had greatly diminished in
terms of eating, sleeping, attending school, and engaging in either physical or social
activities. Her condition had spiraled into a pattern of pain and disability. Traditional
treatments alone, such as psychotherapy, nutritional support, and medications targeting
anxiety and depression had not addressed her physical limitations, including her reduced
range of motion and soft tissue shortening, and had not sufficiently changed her symptoms
or disability. The authors implemented Iyengar yoga as part of the treatment plan to reduce
pain and anxiety and to increase function. The addition of Iyengar yoga appealed to both
Mary and her parents, and the authors developed and carried out the treatment plan as
described above.
The authors based their choice of Iyengar yoga as an added, nontraditional treatment for this
adolescent on the contrast between her previous physically and socially active life and her
current status of being wheelchair-bound, isolated, anxious, and depressed. Yoga may have
benefits for young people with depression, as noted in the authors’ study of undergraduate
college students.16 Another study of yoga in women found a significant reduction in stress
and self-rated anxiety.21 Like the participants involved in those previous studies, the 14-
year-old girl described in the present case study reported and displayed considerable
improvement in her pain, psychological state, and day-to-day functioning following a 16-
week course of Iyengar yoga. Previously, standard treatments alone had not substantially
improved her outcome.
A number of methodological issues limit the conclusions that the authors can draw from this
single report. Primarily, it is not possible to parse out the nonspecific effects of the yoga
treatment itself, including an increase in general movement as demanded by the yoga
classes, and the development of a supportive relationship with the yoga teacher. Given her
multi-interventional treatment, it was also not possible to reliably differentiate the benefits
conferred by yoga from benefits conferred by the patient’s recent changes in medication and
Evans et al. Page 6
psychotherapy. The patient did report her improved outcomes, however, as being specific to
the yoga practice. Ideally, the authors would have administered the treatments individually
to best determine whether they could attribute the benefits to yoga. Within the yoga practice,
it was not possible to determine which postures may have provided which benefits or
whether different postures might have provided similar benefits. Given the naturalistic,
ecological nature of this report, scientific concerns were secondary to best clinical practice.
Little systematic research exists on the use of yoga for children with pain.22 Kuttner et al
completed one randomized controlled yoga study in children with IBS.4 Their findings
supported the successful outcome of our case study. The frustration of parents of children
with chronic pain who have failed to improve following traditional remedies, especially after
seeing many specialists, is an important consideration in treating children and adolescents
who have chronic pain. Unlike adults with chronic pain, children with chronic pain have
parents who influence treatment options and ultimately make the final treatment decisions.
When introducing nontraditional treatments, such as Iyengar yoga, the parents as well as the
child need to accept that the treatment may offer benefits, since the treatment involves more
effort than just taking a pill. Parents often provide the transportation to and from the yoga
sessions, and the child in pain must make an effort to carry out the poses. Parents and
children can have differences in expectations about complementary and alternative medicine
(CAM), both of which can impact outcomes.23
This report offers a case study to stimulate randomized controlled studies of Iyengar yoga in
children with chronic pain, including mechanisms of yoga and the effects of props on a yoga
practice to manage chronic pain. The authors have many anecdotal reports of Iyengar yoga
improving the symptoms and functioning of a wide range of chronic pain problems in
children, including children who have received little relief from conventional medicine.
Before medical practitioners can incorporate Iyengar yoga into standard medical care of
children with chronic pain, the field requires clinical trials to demonstrate the feasibility,
efficacy, and safety of such an intervention. At the PPP, researchers are currently
undertaking a program of scientific research investigating the purported benefits of Iyengar
yoga for a range of chronic health problems in young people, including rheumatoid arthritis,
IBS, and fatigue in cancer survivors.
Acknowledgments
In part, grant K01AT005093 (PI: S. Evans) from the National Center for Complementary and Alternative Medicine
(NCCAM) supported this study.
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Evans et al. Page 8
Figure 1.
L-shaped Poses
Note: (a) with crossed legs; (b) with extended legs.
Evans et al. Page 9
Figure 2.
Purvottanasana on Two Chairs
Evans et al. Page 10
Figure 3.
Back Bend Over Backbender
Figure 4.
Back Bend Over Two Chairs
Figure 5.
Chair Shoulder Stand
Figure 6.
Hanging Rope Sirsasana
Figure 7.
Ardha Chandrasana, Half-moon Posture
Figure 8.
Pincha Mayurasana

Iyengar Yoga and The Use of Props For Padiatric Chronic Pain

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Altern Ther Health Med. 2013 ; 19(5): 66–70.

Corresponding author: Subhadra Evans, PhD, suevans@mednet.ucla.edu.

conditioned association of vomiting with food remained as did a hypersensitive esophagus

IYENGAR YOGA INTERVENTION

General Outline of the Program

Yoga Postures Included Over the 4-month Period

wall, she reported no fear of falling.

review. Int J Disabil Hum Dev. 2008; 7(1):25–32.

11(12):CR555–CR561. [PubMed: 16319785]

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