‘‘I’m More in Balance’’: A Qualitative Study of Yoga
for Patients with Chronic Neck Pain
Holger Cramer, PhD,1Romy Lauche, PhD,1Heidemarie Haller, MSc,1Jost Langhorst, MD,1
Gustav Dobos, MD,1and Bettina Berger, PhD2
Objectives: This study investigated the perceived influence of yoga on body perception and psychosocial aspects
of life for patients with chronic neck pain.
Design: This qualitative study was conducted using semistandardized interviews.
Setting: The interventions and interviews took place in a referral center’s research department.
Subjects: Eighteen (18) patients with chronic nonspecific neck pain were recruited from a larger randomized
controlled trial of yoga for chronic neck pain.
Interventions: Participants attended 90 minutes of Iyengar yoga once a week for 9 weeks.
Outcome measures: Participants completed a drawing of their neck and shoulder regions to reflect their sub-
jective body perceptions before and after their yoga program. Semistandardized interviews were used to explore
their body perception, emotional status, everyday life and coping skills, as well as any perceived changes in
these dimensions postparticipation. An interdisciplinary group analyzed the study data using content analysis
Results: Participants reported change on five dimensions of human experience: physical, cognitive, emotional,
behavioral, and social. Physically, most participants cited renewed body awareness, both during their yoga
practice and in their daily lives. Such change was echoed in their postparticipation body drawings. Cognitively,
participants reported increased perceived control over their health. Emotionally, they noted greater acceptance
of their pain and life burdens. Behaviorally, they described enhanced use of active coping strategies. Finally,
socially, they reported renewed participation in an active life.
Conclusions: Participants linked yoga to change on all dimensions of human experience, attributing reduced
pain levels, increased coping ability, better pain acceptance and increased control to it. Body awareness ap-
peared a key mechanism in these changes.
related quality of life.2A recent qualitative study found that it
also influences body perception. In this study, patients com-
pleted drawings of their upper back and neck, showing ap-
parent distortions of body perception, with elements that were
missing or deformed. Patients saw their pain as predominant
and beyond their control, influencing their body perception.3
Yoga is a commonly used complementary treatment for
neck and back pain,4with an estimated 3 million American
hronic neck pain causes substantial personal suffering
adults using it explicitly to treat such pain.5Deriving from
ancient Indian philosophy, yoga comprises lifestyle advice,
spiritual practice, and physical postures.6It is thought to
create physical, emotional, and spiritual balance, with the
infinite goal of uniting body, mind, and spirit.7In North
America and Europe, yoga is most often associated with
physical postures (asanas), breathing techniques (pranayama),
and meditation (dyana).6
Yoga has proven effectiveness in randomized controlled
trials on musculoskeletal disorders including osteoarthritis,8
carpal tunnel syndrome,9and low back pain.10–15A recent
clinical trial demonstrated the effectiveness of Iyengar yoga
1Department of Internal and Integrative Medicine, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany.
2University of Witten-Herdecke, Gerhard Kienle Chair of Medicinal Theory, Integrative and Anthroposophic Medicine, Herdecke,
THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE
Volume 19, Number 00, 2013, pp. 1–7
ª Mary Ann Liebert, Inc.
for chronic neck pain.16In this trial, yoga proved more ef-
fective than a home-based stretching program in reducing
pain intensity and functional disability. It also improved
cervical proprioceptive acuity (i.e., patients’ ability to accu-
rately perceive the positions of their head in space). As yoga
focuses on increasing awareness of muscle tone and joint
position,17it is also thought to help in recognizing and
changing habitual patterns of posture and muscle tension in
daily life.18It has been hypothesized that this increased body
awareness in daily life might be a mechanism by which yoga
helps to relieve neck pain.18
Randomized controlled trials are most suitable for investi-
gating effectiveness of yoga interventions. On the other hand,
complex experiences during yoga practice, such as subtle
changes in body awareness,19but also psychosocial correlates
of chronic pain conditions, such as fear of activities and sub-
sequent social withdrawal,20might be better addressed with
qualitative approaches.21–23Qualitative research strives to
explore participants’ complex subjective experiences during
the intervention and how she or he gives meaning to these
experiences.22Since complementary therapies, such as yoga,
are often complex in nature themselves, qualitative methods
have been proposed to investigate the perceived mechanisms
and the process of complementary treatments.21,22
Therefore, the current qualitative study aimed to investi-
gate the perceived influence of yoga on body awareness and
psychosocial aspects of life for patients with chronic neck pain.
This qualitative study was embedded in a randomized con-
trolled trial of yoga for patients with chronic nonspecific neck
pain.16The study protocol was approved by the institutional
ethics committee of the University Duisburg-Essen Medical In-
stitutions (Approval No.: 10-4358) prior to participant recruit-
ment. All participants gave written informed consent.
All participants who participated in the yoga arm of the
aforementioned randomized controlled trial16were invited
to take part in this qualitative study. Prior to inclusion, par-
ticipants were assessed by a study physician to ensure that
their neck pain was muscular in origin and not due to other,
more serious, causes (e.g., disc protrusion or neoplasm).
Participants participated in weekly 90-minute yoga classes
for 9 weeks. Classes were based on the teachings of yoga
master B.K.S. Iyengar.7The program was designed specifi-
cally for people who have chronic neck pain and who were
without previous experience of yoga. Classes were led by a
certified Iyengar yoga instructor and physiotherapist, as-
sisted by a graduate psychologist.
The yoga program consisted of standing, sitting, and su-
pine postures, starting with simple postures and moving to
more complex ones7(Table 1). Props, including belts, blocks,
and blankets, were used to improve safety and alignment.
Participants were asked to focus on their posture, joint po-
sitions, and muscle tension in each yoga pose. No formal
breathing techniques were used, but participants were in-
structed to align their breathing with their movements. Each
class ended with the ‘‘corpse’’ pose, a 15-minute guided re-
laxation. Participants were asked to calm their thoughts and
focus their attention on their body and body perception
Besides yoga classes, participants were asked to practice
yoga at home each day.
participants were guided to focus on perceiving their necks
and upper backs, using guided imagery. They were then
given line drawings of the posterior lower and upper back,
with the area from the shoulders to the neck left blank3(Fig.
1). Participants were asked to fill in the missing lines to re-
flect the perceived outlines of their own bodies at that
moment. They were also encouraged to indicate on their
drawings any other perception or pain felt, in color as
Before and after the yoga program,
Table 1. Yoga Postures (Alphabetical Order) Practiced During Weekly Classes and at Home
Downward facing dog
Downward facing hero
Extended side angle
Reclining big toe
Standing half forward
bend (at wall)
Upward hand pose
Warrior pose II
Yes YesYesYesYes Yes YesYes Yes
2CRAMER ET AL.
Participants were interviewed after completing their sec-
ond body drawings at the end of the 9-week program. In-
terviewers were neither involved in planning nor conducting
of the yoga intervention. Participants were initially asked to
share the meanings of their before and after body drawings
with interviewers and then to compare and contrast these
drawings. Subsequent interviews queried participants’ body
perceptions before and after the yoga program and any
perceived influences on these perceptions. Participants were
also interviewed about their emotional status, everyday life,
and preferred coping strategies before and after the yoga
program. Main questions are presented in Table 2. Further
open-ended questions on each topic were possible.
These interviews, which lasted about 30 minutes, were
conducted in private at the study center. They were audio-
recorded, professionally transcribed verbatim, anonymized,
and translated into English for publication purposes.
The participants’ quotations were assigned a number that
consisted of a ‘P’ (for participant), the participant’s rando-
mization number, and the line numbers of the quotation
within each transcript (e.g. P1/1-2 for Participant 1, Lines 1-2).
An interdisciplinary group of scientists and practitioners
from psychology, medicine, pain therapy, nursing, and cul-
tural science analyzed the interview data using content
analysis techniques.24Interviews were coded using Atlas.ti
software (Version 6.2; Atlas.ti Scientific Software Develop-
ment GmbH, Berlin, Germany), with their content being
paraphrased, reduced, and summarized. Five (5) broad cate-
gories were developed from the inductive analysis of the first
six interviews. These categories, which reflected five dimen-
sions of human experience (physical, cognitive, emotional,
behavioral, and social), were then applied to the remaining
interviews. Results of this analysis process were discussed in
this group. Disagreements were discussed until consensus
was achieved. Participants’ body drawings were not inde-
pendently analyzed, but were presented to the participants
generating them, at interview, for their interpretation.
Fifteen (15) women and 3 men aged 19–59 years were
interviewed. None had ever practiced yoga before. Partici-
shown in Table 3.25Adherence to yoga practice is shown
in Table 4.
tention on their bodies and perceptions during yoga as an
important part of the yoga program. They cited intensified
perceptions of their bodies’ sensations and renewed aware-
ness of their bodies’ parts and functions during yoga. One (1)
participant said: ‘‘I was feeling muscles or areas of my body, of
which I didn’t even know that I had muscles there.’’ (P40/188–
191) She described taking ‘‘a different approach to my body,
because I realized how it all works.’’ (P40/321–323) Participants
saw this intensity of inner participation and attention dif-
ferentiating yoga from conventional exercise. In daily life,
they reported a more balanced and natural body perception
Participants saw focusing their at-
Incomplete body drawing.
Table 2. Interview Topics and Main Questions
Drawings1. Please tell me about today’s drawing.
2. In how far does the drawing reflect your
3. What similarities and differences do you
see between this drawing and the first
drawing you made 10 weeks ago?
1. How do you perceive your body in the
2. In how far has your body perception
changed since the start of the yoga course?
1. What emotions do you connect to your
neck–shoulder area at this moment?
2. In how far have your emotions towards
your neck–shoulder area changed since
the start of the yoga course?
Everyday life 1. In how far do your neck–shoulder
complaints influence your daily life?
2. In how far has your daily life changed
since the start of the yoga course?
QUALITATIVE STUDY OF YOGA FOR NECK PAIN3
their attention on the yoga poses enabled them to calm their
minds and to block out extraneous cognitions while doing
yoga. They thus experienced yoga not only as physical ex-
ercise, but also as a form of meditation. One participant saw
it as ‘‘letting go.that is, while doing yoga, you really forget about
anything else because you’re so busy.to stand right or to stand
Participants reported that focusing
well. Not really to do the pose properly, but to make yourself feel
good. There’s no space left for anything else. I believe that this is a
reason, for me, why yoga is good for me.’’ (P45/329–334)
Participants also cited more perceived control over their
general well-being in daily life, noting that their newfound
body awareness helped them to see how their behaviors and
well-being were linked. This gave them a renewed sense of
control over their bodies and health, freeing them from
feeling controlled by their pain, as before. ‘‘Yes, I’m more
aware about the association between my own actions and the way I
feel.awareness, that you can change a lot yourself [.] and that
you can achieve something this way. That you can.strengthen
your body.’’ (P09/173–181)
Many participants said that they had avoided physical
activity before their yoga program, fearing pain and re-
injury. Participants’ experience of being able to influence
their well-being through such activity, however, led many to
reinterpret it cognitively. ‘‘By doing yoga I have to say, for the
first time in a while I felt able to do sports. I‘ve lost a lot of fear of
making a wrong move.’’ (P48/68–71)
emotional distance from burdensome situations during yoga.
This led to a sense of deep relaxation and, for some, a dif-
ferent way of seeing their emotions. As one participant said
‘‘During [yoga] practice, I really listen into myself.I realized two
or three times that, while I was doing that, I’m now – I don’t
know – totally angry because of something completely different,
but I wasn’t aware of that before [.] I discovered a different
emotional starting point by concentrating on myself for a time
and blocking out anything else.’’ (P40/349–360)
Body awareness seems to be an important precondition for
relaxation during yoga. One participant described how his
lack of body awareness had hindered relaxation: ‘‘I don’t have
such a connection to my body, that I, yes.can perceive my body,
that I keep my shoulders down and things. That’s an effort for me.’’
(P36/233–235) He described that in everyday life ‘‘I don’t see
any.any big differences or emotional changes.’’ (P36/165–166)
Other participants reported using their newfound relaxa-
tion skills in their everyday lives, noting that they had be-
come more even-tempered about their pain and more
accepting of it and their disability. Participants spoke less
negatively about their necks and seemed better able to accept
this body part and their pain. ‘‘It’s OK, [my neck] is a part of
me, even if it hurts a bit once in a while.But I’m not a robot, you
see. And.yes.it’s OK just the way it is.’’ (P40/150–152)
Participants also saw themselves becoming generally more
relaxed and less irritable over time, as well as more able to
accept and cope with life’s burdens. ‘‘I am more in balance. And
that doesn’t just mean [that my body is more balanced] but also this
equanimity. That I not always go through the roof [.] and then
calm down again and I am normal again, but, you know, that my
mood swings are generally less intense.’’ (P40/278–283)
ipants tended to ignore their pain due to its seeming in-
escapability. They generally used endurance strategies to
cope or, when pain became unbearable, sought help from
others such as health professionals. Study participants saw
yoga as an active self-help strategy, using yoga poses in
stressful situations to relieve or even prevent pain. As one
participant said, ‘‘I notice, when the pain increases that, from the
Before the yoga program, partic-
Table 3. Sample Characteristics
Neck pain characteristics
Less than 6 months
6 months–1 year
More than 5 years
aParticipants rated their neck pain intensity on a 100-mm visual
analog scale (VAS) before and after the yoga program. Categories for
pain intensity given according to Jensen et al.25: mild pain, <45mm
VAS; moderate pain, 45–74mm VAS; severe pain, 75–100mm VAS.
Table 4. Adherence to Yoga Practice
Attended yoga classes (out of 9)
Mean days of home practice/weeka
aParticipants noted home practice in a diary.
4 CRAMER ET AL.
yoga classes, I know for example that this half forward bend, that is
now like a painkiller for me. That’s so brilliant! I just stand against
a wall and try to do the half forward bend three, four, five times in
a row, and that helps me dramatically.’’ (P48/75–81) Some
participants said that they had reduced their reliance on
pain medication, and other passive treatments, through such
behaviors. Yoga was also used as a stress management
strategy. ‘‘[I felt] very tense.and very stressed, at a normal
level though. That’s life, but I have.the feeling now, that with
yoga I’ve found a good way to cope with this and to come to rest.’’
However, if participants were unaware of their body,
yoga was not perceived suitable for pain or stress relief. The
aforementioned participant with low body awareness stated:
‘‘For me, yoga is no such form [of exercise], I have a strong mo-
tivation to continue.’’ (P36/230–231)
Other participants’ new body awareness also enabled them
to actively monitor and control their posture in daily life,
further relieving their pain. As one participant said, ‘‘It doesn’t
take much. ‘OK, keep your shoulders down’. That’s not.that’s not
yoga, but during the day, if I’m in the tram or in the car, or
wherever I sit or stand, I can remember that. And it helps.’’ (P49/
274–278) Such changes also influenced participants’ views of
their personal capabilities; enhancing their perceived ability
to identify and respect their physical and mental limits.
themselves as disabled by their pain, describing how they
had limited their daily activities for physical or emotional
reasons, and had increasingly withdrawn from activity and/
or society for fear of worsening their pain. Yoga allowed
participants to re-engage with their preferred activities and
to lead more self-determined lives by relieving their pain and
disability. One (1) participant (a student) described the social
benefits of yoga as ‘‘That I could participate in training regu-
larly, and didn’t miss lessons at school because of the pain, that I
could do school sports normally. That I’m not disabled in my daily
routines any more, in school, but also out of school. That I could
meet my friends, or go to the cinema without having pain.’’ (P35/
125–131) Participants saw that yoga helped not only despite,
but because it involved physical activity, actively countering
their fears. As one participant said, ‘‘I’m no longer so anxious
in some situations or in some activities.’’ (P51/71–72)
Participants saw themselves as more efficient in their work
and social lives. ‘‘I did my work before [yoga] too, but.it was
really, really difficult for me. And.now I’ve found a new ease at
work. I enjoyed work then and now, but it’s different.now it’s not
so tense anymore, because it’s easier when you don’t feel pain
anymore.’’ (P51/118–124) Participants saw their work and
social lives as enriched, and enjoyed them more, as they felt
less tired and less in pain.
Study participants reported experiences on physical, cog-
nitive, emotional, behavioral and social dimensions. They
described an active inner involvement during yoga practice,
as well as renewed body awareness, a perceived internal
locus of control, the cognitive reappraisal of physical activity
and an increased acceptance of pain and disability.
A distinct feature of Iyengar yoga is the awareness of
muscle tension, joint position, and breathing patterns during
practice.17In the current study, participants experienced an
intensified self-perception, seeing this as a precondition for
relaxation during yoga practice. Yoga originally developed
as a spiritual practice, with meditative involvement as an
integral part.7,26The importance of this active inner in-
volvement in yoga practice has also been scientifically
drawings. Left: Drawing
before the yoga program:
‘‘The right side has been in the
background for me and the left
side in the foreground [.] as
if the left shoulder was on the
top or really hunched up.’’
after the yoga program: ‘‘Two
congruent areas.the left and
the right neck-shoulder area,
which for me are both unre-
markable in this resting posi-
aThe numbers following
the quotations indicate
the participant’s randomiza-
tion number and transcript
QUALITATIVE STUDY OF YOGA FOR NECK PAIN 5
demonstrated, since it has been linked to increased life sat-
isfaction and mindfulness and lower symptom burden.27
Such links suggest that inner involvement during yoga
practice may be an important factor in mental stabilization
and emotional regulation; to practitioners’ benefit.27
Renewed body awareness
Patients with neck pain often sense their necks and/or
shoulder regions solely through pain.3Pain distorts indi-
viduals’ body perception by demanding attention, blocking
their awareness of nonpainful body parts.28This is even
measurable on the cortical level, where the painful body part
becomes overrepresented,29influencing perception of form
and position of the body in space.30In this study, partici-
pants reported increased body awareness during yoga and in
their everyday activities. Yoga gave participants a new ap-
proach to their bodies, a mindful awareness of their actions
and perceptions. Enhancing body awareness has been seen
as a common ground of mind/body–medicine.19A mindful,
nonjudgmental, experience of bodily perceptions is thought
to enhance connections between the body and the mind, and
to promote the acceptance of body symptoms.19,31Yoga, but
not conventional exercise, has been shown to increase indi-
viduals’ awareness and responsiveness to bodily cues,32with
such awareness being seen as an important factor in neck
pain relief due to yoga.18Regular practice is thought to in-
crease yoga practitioners’ awareness of bodily cues, helping
them to recognize and change habitual patterns of posture
and muscle tension.18In the current study, increased body
awareness helped participants to influence their body pos-
ture and muscle tension actively and thereby to reduce and
at times prevent their pain.
Internal locus of health control
Through their active control of their body posture and
tension, and experience of being able to relieve and prevent
their pain, participants in this study experienced a new sense
of control over their well-being. An internal locus of health
control33has been shown to promote individuals’ use of
internal, active, coping strategies such as active strategies for
lifestyle change. An external locus of health control instead is
linked to using external coping strategies such as consulting
health professionals.34Although many patients with chronic
pain use external coping strategies, such strategies result in
lower life satisfaction.34,35
Negative appraisals of pain and its consequences such as
pain catastrophizing lead individuals to avoid daily activi-
ties, worsening their pain rather than relieving it20: physical
inactivity causes muscular atrophy,36and social withdrawal
increases mood disturbances such as depression and distress,
known to be neck pain risk factors.37Graded exposure to
movement and activity is one way to overcome this ‘‘fear-
Experiencing activity as pain-
relieving rather than pain-inducing challenges negative
appraisals, so that social activities are seen positively once
again. Current study participants’ experiences (i.e., that yoga
helped them to overcome their fear of moving and resulting
social withdrawal) exactly echo these findings.
Pain acceptance, striving to maintain psychosocial function
regardless of pain, is linked to reduced pain, disability, inac-
tivity, and depression.39Such acceptance has been seen as one
mechanism for yoga’s pain-relieving actions. Yoga aims to
enhance participants’ compassionate understanding of their
health, enabling a nonjudgmental perception of pain without
avoidance or social withdrawal.40Pain acceptance can also
change patients’ perspectives: Current study participants saw
yoga as positive, even if it did not make them pain free.
This study used a convenience sample. While female
participants appeared to be a sufficiently heterogeneous
group, especially regarding age and pain characteristics, this
was not true for the few males who took part. The study’s
findings and conclusions may be more limited for the male,
than the female participants, as a result. Other limitations are
that results only reflect experiences during and immediately
after the yoga program and no long-term experiences and
that results might apply only for patients with muscular neck
pain but not for patients with other sources of pain.
Yoga was seen as a multidimensional intervention linked
to change in all dimensions of human experience. Body
awareness seems to be a key mechanism in these changes.
Further qualitative research should focus on exploring per-
ceived differences between yoga and other exercise or between
different yoga styles. Quantitative studies might assess chan-
ges in, for example, body awareness or fear-avoidance using
standardized instruments or even changes in cortical repre-
sentations after yoga practice using imaging techniques.
The authors thank Kai Scheffer, PT, certified Iyengar yoga
teacher, for assistance in designing the yoga protocol and
teaching yoga classes; Sonja Jaruszowic and Annette Ten-
gelmann for assistance in participant recruitment; and the
participants of the colloquium in qualitative research of the
Gerhard Kienle Chair, University Witten-Herdecke, Ger-
many, for assistance in data analysis. This study was sup-
ported by a research grant from the Karl and Veronica
Carstens Foundation, Essen, Germany.
No competing financial interests exist.
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Address correspondence to:
Holger Cramer, PhD
Department of Internal and Integrative Medicine
Faculty of Medicine
University of Duisburg-Essen
Am Deimelsberg 34a
QUALITATIVE STUDY OF YOGA FOR NECK PAIN7