Yoga May Be More Effective Than Self-Care for Chronic Back Pain

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Yoga May Be More Effective Than Self-Care for Chronic Back Pain News Author: Laurie Barclay, MDCME Author: Charles Vega, MD, FAAFPDec. 20, 2005 — Yoga is more effective than use of a self-care book for improving

function and reducing pain in patients with chronic back pain, according to the results of a randomized trial reported in the December 20 issue of the Annals of Internal Medicine. "Chronic low back pain is a common problem that has only modestly effective treatment options," write Karen J. Sherman, MD, from the Group Health Cooperative and University of Washington in Seattle, and colleagues. "Yoga may benefit patients with back pain simply because it involves exercise or because of its effects on mental focus. We found no published studies in western biomedical literature that evaluated yoga for chronic low back pain; therefore, we designed a clinical trial to evaluate its effectiveness and safety for this condition." At a nonprofit, integrated healthcare system, 101 adults

with chronic low back pain were randomized to receive 12-week sessions of yoga or conventional therapeutic exercise classes or a self-care book. The main endpoints, both determined at 12 weeks, were back-related functional status, measured with the modified 24-point Roland Disability Scale, and "bothersomeness" of pain on an 11-point numerical scale. Clinically significant change was defined as 2.5 points on the functional status scale and 1.5 points on the bothersomeness scale. Secondary endpoints were days of restricted activity, general health status, and medication use. After adjustment for baseline values, back-related function at 12 weeks was better in the yoga group than in the book and exercise groups (yoga vs book: mean difference, -3.4; 95% confidence interval [CI], -5.1 to -1.6; P < .001; yoga vs exercise: mean difference, -1.8; 95% CI, -3.5 to -0.1; P = .034]). At 12 weeks, no significant differences in symptom bothersomeness were

detected between any 2 groups, but at 26 weeks, this measure was better in the yoga group than in the book group (mean difference, -2.2; 95% CI, -3.2 to -1.2; P < .001). At 26 weeks, back-related function in the yoga group was also better than in the book group (mean difference, -3.6; 95% CI, -5.4 to -1.8; P < .001). "Yoga was more effective than a self-care book for improving function and reducing chronic low back pain, and the benefits persisted for at least several months," the authors write. "It is important to note that some styles, such as Bikram and vinyasa, may be too vigorous for patients with back pain who are unfamiliar with yoga whereas other styles (for example, Iyengar) may need modification from normal practice to be appropriate for patients with back pain." Study limitations include follow-up limited to 26 weeks; modest sample sizes; inclusion of relatively well-educated, functional participants; lack of blinding; and use

of only 1 instructor to deliver each intervention. "Physicians should encourage their patients to choose instructors who have experience working with individuals who have back pain and who can help them manage the symptom flare-ups that may occur as a result of physical activity," the authors conclude. "Future research evaluating yoga for chronic back pain should investigate its mechanisms of action and whether similar results are seen in more diverse populations and in patients with more severe back pain." The National Center for Complementary and Alternative Medicine and the National Institute for Arthritis and Musculoskeletal and Skin Diseases supported this study. The authors have disclosed no relevant financial relationships. Ann Intern Med. 2005;143:849-856 Clinical Context Back pain

is one of the most common complaints that patients describe to clinicians, and yoga offers some hope for patients with this difficult condition. In a study by Williams and colleagues, published in the May 2005 issue of Pain, Iyengar yoga proved superior to an educational program in terms of pain intensity, functional disability, and pain medication usage among a cohort of patients with chronic back pain. However, yoga did not improve psychological or behavioral outcomes when compared with the control treatment. Only 42 subjects completed the study by Williams and colleagues. The authors of the current study perform a randomized, controlled trial of yoga in a larger cohort of patients with back pain. Study Highlights Patients eligible for study participation had visited their physician for treatment of back pain in the 3 to 15 months prior to the study. All subjects had back pain of at least 12 weeks' duration. Patients with a history of spinal complications, back pain secondary to other systemic disease, or who had received yoga or exercise therapy in the year prior to the study were excluded from participation. Study participants were randomized to groups receiving yoga, a standard exercise program, or recommendations for self-management of back pain from a book. The yoga and standard exercise groups attended weekly 75-minute classes for 12 weeks and were instructed on home exercises as well. The yoga classes

emphasized viniyoga, which was relatively easy to learn and implement. The standard exercise classes emphasized aerobic exercise and increasing strength. Outcomes were measured at 6, 12, and 26 weeks. The main study outcome was back dysfunction and symptoms, as measured by validated scales. The authors also measured general health status, limitations on activity, and the use of analgesic medications. Analysis of outcomes was by intent-to-treat. 101 subjects were enrolled in the study. The mean age of

subjects was 44 years, and 66% of the cohort was female. 83% of subjects reported that their pain began for more than 1 year prior to the study, but most participants had not experienced a significant limitation at work secondary to pain. In general, disease characteristics were similar at baseline between groups, although leg pain below the knee was more common in the standard exercise and yoga groups than the book group. Compliance with all study treatments was good, and the rates of "connecting" with the exercise and yoga instructors were similar among these patient cohorts. Disability and symptoms of back pain improved with time in all treatment groups during the trial. The yoga group experienced significantly better evaluations of disability at all follow-up points compared with the book group, but the improvement in disability in the yoga group over the standard exercise cohort was judged not to be clinically significant. Back-related symptoms were also improved in the yoga vs the book group at 6 and 26 weeks, but there was not difference in back-related symptoms between the yoga and standard exercise groups. Medication use decreased in the yoga groups vs both the standard exercise and book groups. There was no difference between treatment groups in terms of limitation of activity secondary to back pain or overall quality of life. Pearls for Practice Previous research has demonstrated that yoga can improve pain intensity, functional disability, and pain medication usage among patients with chronic back pain, but it was less successful in improving behavioral or psychological outcomes. The current study demonstrates that yoga and standard exercise are both effective in the management of chronic back pain, although patients receiving yoga used less medication for back pain than those randomized to standard exercise.

 

 

 

 

 

 

 

 

 

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