Yoga PI: adverse events

Yoga has a myriad of benefits but like any other physical activity it is not 100% risk-free. After combing through available yoga research to investigate the frequency & severity of adverse events (AEs) related to yoga practice, I found there have been no large randomized controlled trials (RCTs). The AEs listed below have been extracted from case reports, meta-analysis & small RCTs.

  • 4.0% of internal medicine patients (n=303) who practiced yoga for their primary medical complaint reported AEs.
  • US survey: out of 23,393 adult yoga practitioners, less than 1% (2230) of responders experienced yoga-related AEs that led to discontinuation of yoga practicing. Most common AE was back pain.
  • Case Review: 76 case series/studies reported yoga-associated AEs classified as serious. Case reports are anecdotal, do not include a control arm & cannot accurately estimate frequency. 
  • meta-analysis: comparing yoga to a control group (no treatment, usual care, or active treatment) only 94 of 301 RTCs (n=8,430) reported adverse events:
    • Participants in the yoga interventions reported a relatively low frequency in AEs: 2.2% intervention-related, 10.9% non-serious, 0.6% serious adverse events
    • Yoga was not associated with an increased frequency of AEs or dropouts due to AEs compared to control.
    • Yoga was associated with more intervention-related, non-serious adverse events compared to psychological/educational interventions (no physical activity). Serious AE & dropout frequencies were comparable between groups.
  • meta-analysis: out of 199 studies only 28 found safety data in which yoga participants experienced transient AEs ranging from 0.4-6.3% in frequency: 
    • 5 yoga as treatment: 6.3% yoga, 9.7% active control, 0.2% inactive control
    • 23 yoga as prophylaxis0.4% yoga, 1.6% active control
    • Most AEs were transient musculoskeletal injuries; 1 was serious (cervical radiculopathy). None required hospitalization.

Current literature indicates yoga is generally a safe intervention.  Further in-depth studies with a larger sample size are needed to truly determine both the benefits & risks associated with yoga practice. Yoga, like any other physical activity, should be practiced carefully and ideally under the guidance of qualified instructors.

 


Existing conditions aggravated by yoga practice: glaucoma (3), osteopenia (3), asthma (1), psychosis (1), affective disorder (1)

Most common yoga practices associated with AEs: breathing exercises (pranayama), Hatha yoga, Bikram yoga

Most common yoga poses associated with AEs: headstand (sirsasana), shoulder-stand (sarvangasana), lotus (padmasana)

Most of the reported AEs affected vision, the musculoskeletal & nervous systems:

  • cardiovascular: arterial dissections/occlusions (vertebral/basilar)
  • musculoskeletal: acetabular labrum tears, back pain, common flexor tendon tear, compressive cervical myelopathy, elevated muscle enzymes, epiphyseal fracture, fibrocartilaginous injuries, toe fracture, inguinal hernia, lumbar disc annular tears, medial meniscus tears, myositis ossificans, rectus sheath hematomas, solitary joint effusion, transient patellar dislocation
  • nervousbilateral peroneal neuropathy, cervical radiculopathy, lateral femoral cutaneous neuropathy, sciatic (lotus) neuropathy, seizure, transient headache
  • visual: acute/worsening glaucoma, central retinal vein occlusion, bilateral orbital varices, bilateral conjunctival varix thrombisis, progressive optic neuropathy
  • other  pigmentary purpura of the forehead

 


RESOURCES

BOOKS

The Principles and Practice of Yoga and Healthcare ~ Sat Bir Singh Khalsa
Yoga for Depression ~Amy Weintraub
Yoga as Medicine ~Timothy McCall MD
Yoga Rx ~Larry Payne PhD & Dr Richard Usatine
Yoga Skills for Therapists ~Amy Weintraub

STUDIES

Streeter CC et al. 2012. Effects of yoga on the ANS, gamma-aminobutyric-acid, and allostasis in epilepsy, depression & post-traumatic stress disorderMedical Hypothesis.
Bosma et al. Lotus Neuropathy. World J of Clin Cases. 2014. 2(2): 39-41
Cramer H. 2013. Adverse Events Associated with Yoga: A Systematic Review of Published Case Reports and Case Series. PLOS One
Cramer H, et al. The Safety of Yoga: A Systematic Review & Meta-analysis of RTCs. Am J Epidemiol. 2015;182(4):281-293
 Cramer H et al. Predictors of yoga use among internal medicine patients. BMC Complement Altern Med. 2013;13:172.
Fishbein D, et al. Is yoga really dangerous? A systematic review of adverse events reported in the medical literature. J Altern Complement Med. 2014;20(5):A21.
Fischman LM et al Understanding and preventing yoga injuries. International Journal of yoga therapy 2009. 19: 1-8
Holton MK, Barry AE. Do side-effects/injuries from yoga practice result in discontinued use? Results of a national survey. Int J Yoga. 2014;7(2):152–154
Le Corroller et al. Musculoskeletal injuries related to yoga: imaging observations. AJR Am J Roentgenol. 2012 Aug;199(2):413-8
Pryse-Phillips W. Infarction of medulla & cervical cord after fitness exercises. Stroke. 1989. 20: 292-4
Walker M et al. Yoga neuropathy: a snoozer. Neurologist. 2005.11(3): 176-8