yoga as an effective treatment for chronic low back pain
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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
GROUP
Characteristic Control (N=24) Yoga (N=20) All (N=44) -value
Mean age -yr ( ± SE ) 48.0 ± 1.96 48.7 ± 2.38 48.3 ± 1.50 0.8094
Gender (%)
Female 70.8 65.0 68.2 0.6791
Male 29.2 35.0 31.8
Education level (%)
High School 29.2 20.0 25.0 0.4844
College 70.8 80.0 75.0
Income (%)
$10 – 19,000 16.7 5.0 11.4 0.3491
$20 – 49,000 50.0 45.0 47.7
$50 – 100,000 33.3 50.0 40.9
History of LBP
Years 11.0 ± 2.07 11.3 ± 2.37 11.2 ± 1.54 0.9232
%Taking Meds 50.0 45.0 47.7 0.7049
% using CAM 25.0 35.0 29.5 0.4891
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
Group
Assessment Outcome Control Yoga P-value(n) (n)
Post Success 6 14 0.002*
Failure 11 2
3-Month Follow Up Success 10 15 0.007*
Failure 9 1Success = Stopped or decreased medication use
Failure = No change or increased medication use
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)