Yay Yoga! More Evidence for Helping Low Back Pain
Yay Yoga! More Evidence for Helping Low Back Pain
Abstract & Commentary
By Nancy Selfridge, MD, Associate Professor, Department of Integrated Medical Education, Ross University School of Medicine, Commonwealth of Dominica, West Indies. Dr. Selfridge reports no financial relationships relevant to this field of study.
Synopsis: Yoga, a stretching program, and a self-care book on low back pain were compared in a three-armed randomized trial for patients with chronic low back pain. The findings showed that yoga was significantly more effective than was using the self-care book, whereas yoga and stretching classes were equally effective. The benefits lasted for at least 26 weeks.
Source: Sherman K, et al. A randomized trial comparing yoga, stretching, and a self-care book for chronic low back pain. Arch Intern Med 2011;171:2019-2026.
The costs of chronic low back pain in terms of human suffering, disability, and economic impact are inarguably large. Long-term evidence of efficacy and safety for analgesic use is still lacking, and although there is some evidence to support the recommendation of non-drug treatments such as acupuncture, chiropractic, and massage none have been proven to be highly effective.1 A number of studies have shown that yoga may be an effective treatment for chronic or recurrent low back pain. A recent meta-analysis of controlled studies concluded that yoga is a useful approach with moderate effect sizes on pain and associated disability.2 In this new study of yoga for low back pain, using a larger sample size, the authors set out to confirm previous findings that yoga is helpful for reducing pain and increasing function for patients with low back pain. Because yoga training includes a mental component in addition to the physical stretching and strengthening, the authors also designed the study to determine if yoga was superior to a stretching only program.
Methods
Patients with low back pain were recruited primarily from a large western Washington health care organization and augmented with outreach to the general population. Exclusion criteria included back pain due to structural or underlying medical conditions, a history of previous back surgery, a history of litigation, pain less than 3 months' duration, or minimal pain at the time of screening. Participants also had to be able to attend classes and had to express willingness to do home practice. A total of 228 participants were randomized to three treatment arms in a 2:2:1 distribution: yoga, stretching, and self-care. The study staff was blinded to treatment assignments. The yoga and stretching classes consisted of 12 standardized weekly 75-minute classes. Adherence to treatment protocols was monitored. Participants in both classes were asked to practice for 20 minutes on non-class days and were given written and video practice guides to assist them. A third cohort of participants received a self-care book detailing causes of low back pain and advice on exercising, lifestyle modifications, and managing flares of pain.
Telephone interviewers collected study data at baseline and at 6, 12, and 24 weeks. Primary outcomes were scores on self-rated symptom "bothersomeness" (0-10 scale) and scores on the Roland Morris Disability Questionnaire (RDQ), a widely used, validated instrument for measuring health status in low back pain patients. Secondary outcomes included activity restriction, global rating of improvement, and patient satisfaction. Participants also were asked about adverse events. Primary and secondary outcomes were analyzed using regressions and generalized estimating equations. All analyses were subjected to intent-to-treat principles.
Results
Adherence in the yoga and stretching cohorts was similar: The proportion of participants attending at least eight classes was 65% for yoga and 59% for stretching. Home practice times were similar in both of these active groups for the duration of the study. Of the self-care participants, 86% reported reading at least some of the book. Connection with class instructor was rated similarly in the yoga and stretching groups, as was support from classmates.
RDQ scores showed superior function in the yoga group compared with self-care at 12 weeks (95% confidence interval [CI], -3.7 to -1.3) and 26 weeks (95% CI, -3.1 to -0.5). The stretching group also demonstrated superior function compared to self-care at 6 weeks (95% CI, -3.0 to -0.4), 12 weeks (95% CI, -3.4 to -1.0), and 26 weeks (95% CI, -2.8 to -0.2). Adjusted Relative Risk (RR-95% CI) for pairwise comparisons of RDQ scores of at least 50% improvement at 26 weeks was 1.90 for yoga vs self care; 1.63 for stretching vs self care; and 1.17 for yoga vs stretching. Differences in outcomes between the yoga and stretching groups were not statistically significant. The only meaningful differences between groups for symptom "bothersomeness" occurred at 12 weeks wherein the yoga group was significantly less bothered by symptoms than the self-care group (95% CI, -1.74 to -0.41). Thirteen participants in the yoga group and 13 in the stretching group reported mild-to-moderate adverse experiences, mostly increased back pain. Only one self-care participant reported increased pain after doing recommended exercises. However, compared to self-care, yoga and stretching participants reported higher satisfaction with care and were more likely to rate their back pain as better, much better, or completely resolved at all follow-up intervals.
The authors concluded from this study that yoga is an effective intervention for improving symptoms and disability due to chronic low back pain and that the effect is most likely due to the physical components of a yoga practice, since stretching appears to offer similar benefits.
Commentary
This study supports a growing body of research that suggests that yoga is a viable and effective treatment option for patients with chronic low back pain. The sample size for this study was about twice that of those in previous published clinical trials, a frequent criticism of the prior research. Another strength of this study is that the authors attempted to separate the physical and mental effects of yoga on back pain with the use of the stretching class treatment group, working under the assumption that yoga might have therapeutic effect due to the breathing and mental training that is part of traditional yoga practice, and is not a part of conventional stretching classes. The yoga method used in this study was a viniyoga style that is therapeutically oriented. The yoga instructors were comfortable with modifying postures for persons with physical limitations. Simply suggesting a yoga class to chronic low back pain patients without considering the style and instructor orientation appears to be unwise because of the wide variation in styles, levels of difficulty, and instructor training and experience in yoga classes available at large.
Further, the various styles of yoga for low back pain have not been compared for efficacy and safety. An additional drawback is that classes can be expensive, though DVDs and online instruction offer low-cost alternatives. Unsupervised instruction may be fraught with hazards, and there is a beneficial effect from the social support that prevails in a class format, which remains challenging to measure. Though yoga and stretching exercises seem similarly effective in this study, most stretching exercise classes available in community settings are not of 75 minutes duration. Comparing yoga to a more typical stretching class of 30-45 minutes would yield valuable information and thus should be considered as a future study. Adherence to any physically active intervention for chronic pain remains problematic even in the present study, where the adherence rate is similar to past studies on exercise for back pain.
Thus, recommendions of yoga for back pain patients must take into consideration the patients' willingness to pursue a physically active course of treatment that requires at least some motivation and self-efficacy. Fear of movement and exercise in patients with chronic low back pain may be an obstacle to overcome for them to benefit from yoga and stretching, both of which were shown to be effective in this study.
References
1. Chou R, et al. Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007;147:478-491.
2. Bussing A, et al. Effects of yoga interventions on pain and pain-associated disability: A meta-analysis. J Pain 2011;doi:10.1016/j.jpain.2011.10.001. Accessed Dec. 29, 2011.
Yoga, a stretching program, and a self-care book on low back pain were compared in a three-armed randomized trial for patients with chronic low back pain. The findings showed that yoga was significantly more effective than was using the self-care book, whereas yoga and stretching classes were equally effective. The benefits lasted for at least 26 weeks.Subscribe Now for Access
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