Yoga as an Effective Treatment for Chronic Low Back Pain

Kimberly Williams, Ph.D, Certified Iyengar Yoga Instructor

Research Assistant Professor

Community Medicine

West Virginia University

• Public health problem of epidemic proportions• 80% of adults will have low back pain• 5th most frequent reason for doctor’s visit• most expensive musculoskeletal disorder• largest category of medical claims • absenteeism and disability payments for work-

related low back pain cost 3x medical treatment for low back pain

Low Back Pain

Complementary Alternative Medicine

In 1990, 1 in 3 Americans were treated by CAM ProvidersCAM Usage increased from 33.8% to 42.1 % from 1990 to 1997Yoga is regarded as a CAM modality by NIHYoga falls outside standard medical education and practice in the US

Stiff muscles due to poor posture, lack of exercise, genetic conditions or mental stressStiffness could be in rotational, flexion, lateral bending or back bending movementsSudden strenuous activity may tear or overstrain stiff muscles

Mechanical Low Back Pain

Randomized Controlled Trials of Yoga

Osteoarthritis*Carpel tunnel syndrome*Multiple sclerosis*Bronchial asthmaPulmonary tuberculosisDrug addictionHypertensionDiarrhea-predominant IRBLymphoma Mild Depression*

Scientific Studies of Yoga and Chronic LBP

Vidyasagar et al. 1989Effect of Hatha Yoga on nonspecific LBP

(n=35)76% of the cases reported pain reliefThree phases, each three weeks longBased on performance of classical back

bending postures for 45 minutes per day with 10 min rest in between poses

Vidyasagar et al. (1989)Clin Proc NIMS (1989) 4:160

Poses modified in 5 cases because of severe pain to include Pavana Mukthasana and Ardha uttanasana in phase 1

7 cases were discontinued because no pain relief was obtained

Vidyasagar et al. (1989)Clin Proc NIMS (1989) 4:160

Limitations of the study No control group Small sample size Method for assessing pain was not described No long term follow-up According to BKS Iyengar back extensions used

are harmful to persons with LBP who are not trained in the intricate movements of the pose

Galantino et al. (2004)Altern. Ther. Health Med. 10:60-3.

n=22 self-referred persons with CLBP

Randomized to a 6-week modified hatha yoga program (2x/week) or to a wait list control

Yoga program included diaphragmatic breathing, postures and meditation

Galantino et al. (2004)Altern. Ther. Health Med. 10:60-3.

Disability – 40% control and 46% of yoga group reported less disabilityDepression – 20% control and 54% of yoga group had lower depressionFunctional reach – 20% control and 64% yoga group improvedSit and reach – 20% control and 90% yoga group improved

Galantino et al. (2004)Altern. Ther. Health Med. 10:60-3.

Limitations of the studyNot powered to obtain statistical

differences between groupsHigh drop out rate in control groupLarge baseline differences in secondary

measures

Jacobs et al (2004)Altern. Ther. Health Med. 10:80-3.

N=52 persons with CLBP

randomized into Iyengar yoga or wait list control group.

Yoga Program Classes (2x/week for 12 weeks) plus home

practice (30 min x 5 days/week)

Jacobs et al (2004)Altern. Ther. Health Med. 10:80-3.

OutcomesPain intensityQuality of lifeFunctional disabilityDepressionAnxietyGlobal expectation

Jacobs et al (2004)Altern. Ther. Health Med. 10:80-3.

Adherence to yoga intervention64% attended yoga intervention84% completed the study

Efficacy of Iyengar yoga interventionNot published

Differences between two studies of Iyengar Yoga

Different selection of poses usedJacobs et al. (2004) study:

Lack of resting phase of treatment prior to more active corrective phase

Inclusion of back bending poses

Length of the studyJacobs et al. 12 weeks @ 2x/weekCurrent study 14 weeks @ 1x/week

Fear of Movement / re-injury

DisabilityDisuseDepression

Painful experiences

Catastrophizing

Injury

Non-catastrophizing

Confrontation

Recovery

Avoidance

 

Cognitive-behavioral model of fear of movement/(re)injury 

Hypotheses

1. Yoga therapy will decrease pain intensity, functional disability and pain medication usage.

2. Yoga therapy will decrease maladaptive pain-related attitudes and behaviors.

Inclusion Criteria

mechanical low back pain

recurrent symptoms lasting more than 3 months

ambulatory

18 years and older

english speaking

Exclusion CriteriaNon-mechanical low back pain due to:nerve root compressiondisc prolapsespinal stenosis (Cauda Equina Syndrome)spinal infection tumoralkylosing spondylisis spondylolisthesis

Exclusion Criteria cont’dwidespread neurological disordermajor depression substance abuseunstable anginaPregnantBMI > 35pre-surgical candidatesinvolved in litigation or compensationUndergoing other non-medical or CAM treatment

196 - Self Referred From Local Advertisements14 – Referred by Physician

210 – Interested in Participation140 – Excluded: 38 – did not meet inclusion criteria. 102 – unable participate70 - Eligible

60 – Randomized at Baseline

30 – Randomly Assigned to Educational Control Group

30 – Randomly Assigned to Yoga Treatment Group

6 – Dropouts: 3 – lost to follow-up 2 – ineligible to other CAM use 1 – no show at baseline

10 – Dropouts: 3 –no shows after baseline 2 – medically ineligible 3 – quit 1 – adverse event 1 – unwilling to perform active postures

24 – Assessed at 16 Week Post Test 20 – Assessed at 16 Week Post Test

22 – Assessed at 3 Month Follow-up 20 – Assessed at 3 Month Follow-up

10 – Unable to participate

1 – lost to follow up1 - died

Interventions

Both groups attended 2 lectures by PT and OT and received 16 weekly newsletters with tips for recovery from LBP

Yoga group attended 90 min yoga therapy class once per week for 16 weeks and encouraged to practice 30 mins per day at home.

Restorative Poses

Savasana II

Prone savasana

Lumbar traction

Prone Supta padangusthasana

Supta Pavanmuktasana

Supta Padangusthasana I and II

Supported Baddha Konasana

Adho Mukha Virasana

Standing and Seated Forward Bends

Pavanmuktasana (bench) Uttanasana (stool)Ardha uttanasana (halasana box)Adho Mukha Svanasana (upper wall ropes; lower wall ropes)Concave Prasarita Padottanasana (bench)Concave Parsvottanasana (lower rope) Utthita Padmasana (stool)Adho Muhka Sukasana (bolster)

Standing poses

Tadasana with block between the legsUtthita Hasta Padangusthasana I and II with bent knee and straight legTrikonasana (at trestler with traction)Virabdrasana II (at trestler with traction)Parsvakonasana (at trestler)Parivritta Trikonasana (trestler)

Lateral Forward Bends and Twists

Parsva Pavanmuktasana on the benchMaricyasana III at trestlerBharadvajasana (chair)Parivritta Hasta Padangusthasana III straight leg supported on stool at trestlerUtthita Parsva Padmasana Parsva Sukasana

Inversions

Urdhva Prasarita Padasana

Supported Halasana

Adherence Rates

70% completion rate

92% attendance to yoga classes amongst completers in the yoga group

Primary Outcomes

Pain intensityMeasured by rating of present pain on SF-

McGill Questionnaire

Pain Medication Usage

Functional disabilityMeasured with the Pain Disability Index (PDI)

Secondary Outcomes

Self-reported measures of pain-related psychological and behavioral factors including:

pain attitudes fear of movementcoping with painself-efficacy

0.489129.535.025.0 % using CAM

0.704947.745.050.0 %Taking Meds

0.923211.2 ± 1.5411.3 ± 2.3711.0 ± 2.07 Years

History of LBP

40.950.033.3 $50 – 100,000

47.745.050.0 $20 – 49,000

0.349111.45.016.7 $10 – 19,000

Income (%)

75.080.070.8 College

0.484425.020.029.2 High School

Education level (%)

31.835.029.2 Male

0.679168.265.070.8 Female

Gender (%)

0.809448.3 ± 1.5048.7 ± 2.38 48.0 ± 1.96 Mean age -yr ( ± SE )

-valueAll (N=44)Yoga (N=20)Control (N=24)Characteristic

GROUP

Demographic and Medical Characteristics of Participants

Results of Multivariate Analysis

Significant between group differences for:Present painFunctional disabilityPain medication usage

0.0

0.5

1.0

1.5

2.0

Pre Post 3FA

Control Group Yoga Group

McG

ILL

PP

:*

Figure 1: Present Pain Intensity

:*

-5

0

5

10

15

20

25

30

PD

I

Pre Post 3FA

Control Group Yoga Group

Figure 3: Functional Disability

:*:*

Table 3: Change in Pain Medication Usage for CLBP

(n)(n)

Group

P-valueYogaControlOutcomeAssessment

Success = Stopped or decreased medication use

Failure = No change or increased medication use

19Failure

0.007*1510Success3-Month Follow Up

211Failure

0.002*146SuccessPost

Conclusions

Adults with CLBP volunteered for and adhered to a 16–week Iyengar yoga therapy program.

Significant between group differences were reported after completion of the program. Improvements were maintained at 3-month follow-up.

Conclusions

Subjects who participated in yoga therapy reported:

65% less pain.77% less functional disability.88% decrease in pain medication usage.

Limitations of the Study

Population with less severe pain and disability

Too many outcomes

Lack of attention control

No long term follow-up

Too many complex postures in too little time in yoga therapy intervention

NIH-funded study

90 subjects with moderate to severe CLBPSame primary outcomes plus medical utilizationReplaced analysis by protocol by intention to treat data analysisLengthened intervention (from 16 to 24 weeks) with more frequent classes (2x/week) Compare 24 weeks of yoga therapy to standard medical care (wait list control)

Study DesignTelephone Screening by RA

Eligible

Meeting with RA at HSCScreening Consent FormScreening Questionnaires

(BDI, CAGE, TSK, PCS, VAS, ODQ)

Meeting with MDs at POCPhysical Exam

Diagnosis of LBP

Ineligible

ExclusionCriteria

InclusionCriteria

Eligible

Ineligible

Study Design (cont.)Baseline Assessment by RA

Consent & PHI forms, BDI, VAS, ODQPain Medication Usage Interview

Expectation of Outcome of Treatment Options

RandomizationExpectation of Outcome of Treatment Options

Yoga Therapy Intervention2 classes/week; 90 minutes/class30 minute home practice 5x/week

Wait List ControlReceive Standard Medical Care

Monthly Phone Calls

12 Week Assessment at HSC by RAVAS, ODQ, BDI, Pain Medication Usage Interview

24 Week Assessment at HSC by RAVAS, ODQ, BDI, Pain Medication Usage InterviewCompare Retrospective Medical Claims Analysis

Inclusion Criteria

Chronic low back pain for 3 months or more due to: SI Sprain Sciatica Scoliosis Kyphosis Osteoarthritis / degenerative disc disease Bulging & herniated disc w/o foot drop, weakness

or loss of reflexes

Inclusion Criteria (cont.)

18 – 65 years of ageEnglish speakingAmbulatoryPEIA, The Health Plan (WVUH), Mountain State BC/BS, Mon Health System insuredLive within 60 minute drive of MorgantownAgree not to use acupuncture, massage therapy, Pilates, or chiropractic treatmentAgree not to do yoga if in non-yoga groupAgree to participate in 20 of 24 classes & not miss more than 2 consecutive classes

Exclusion Criteria

Spinal stenosis with neurogenic painAbdominal or spinal tumorSpinal infectionOsteoporosisAnkylosing spondylitisSpondylolisthesisRadicular pain w foot drop, weakness, or loss of reflexesChronic fatigue or other pain syndromesWidespread neurological disorderUncontrolled BP (SBP > 180; DSP > 110)

Exclusion Criteria (cont.)

Exertional chest discomfort and/or shortness of breathInability to climb 1 flight of stairs or walk 50 yards w/o discomfortInability to lie flat w/o shortness of breathPre surgical candidateInvolved in litigation or compensationSubstance abuseMajor depressionPregnantBMI > 37Practice yoga in past year

Mean Age

42.9

0

5

10

15

20

25

30

35

40

45

Cohort

Age (years)

Cohort 1: Gender

3

21

0

5

10

15

20

25

Cohort

Male

Female

Cohort 1: Race/Ethnicity

1

22

1

0

5

10

15

20

25

Cohort

Asian AmericanCaucasian/WhiteOther

Cohort 1: Highest Level of Education

1

6

10

7

0

2

4

6

8

10

12

Cohort

HS graduate or GED

Some college or technical school

College graduate

Graduate school

Cohort 1: Employment

6

10

4

21 1

0

2

4

6

8

10

12

Cohort

Management/supervisoryProfessional/non-supervisoryClerical/administrative supportHomemakerRetiredOther

Cohort 1: Household Income

2

3

7

4

3

4

0

1

2

3

4

5

6

7

8

Cohort

$10,000 to < $20,000 $20,000 to < $35,000$35,000 to < $50,000$50,000 to < $75,000$75,000 to < $100,000> $100,000

Years of Back Pain

7

5

2 2

5

3

0

1

2

3

4

5

6

7

8

Cohort 1

1-5 years

6-10 years

11-15 years

16-20 years

21-30 years

30+ years

*n = 24

Back Pain Diagnoses

1

5

3

11

1 1

4

2

9

67

0

2

4

6

8

10

12

Cohort 1

Piriformis Syndrome

Sacroiliitis

Lumbar HNP w/o Myelopathy

Lumbar DDD (Degen, Disc Disease)

Lumbago

Sciatica

Myofascial Syndrome

Kyphos-scoliosis and Scoliosis

Lumbar Sprain

L-S Sprain

SI Sprain

*please note, subjects may be assigned more than one diagnosis (total = 50)

To find out if you are eligible

Call 293-back (2225)