A Delicious Stretch

Abstract & Commentary

By Allan J. Wilke, MD, Professor, Department of Introduction to Clinical Medicine, Ross University School of Medicine, Commonwealth of Dominica. Dr. Wilke reports no financial relationships relevant to this field of study.

Synopsis: Yoga and stretching are effective in treating chronic low back pain.

Sources: Sherman KJ, 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; Tilbrook HE, et al. Yoga for chronic low back pain: A randomized trial. Ann Intern Med 2011;155:569-578.

Two recent studies looked at the effect of yoga on low back pain (LBP). In the first one, Sherman and colleagues (including Dr. Richard Deyo, the guru of low back pain) from Group Health in Seattle, WA, randomized 229 patients (from 757 who were assessed for eligibility) to a yoga class, a stretching class, or a self-care book (The Back Pain Helpbook) in a ratio of 2:2:1. Almost all of the patients (203) were recruited from Group Health practices. They excluded patients who had unusual back pain, such as from vertebral fracture, pregnancy, and metastatic cancer, and "complex" back pain, such as pain complicated by radiculopathy, medico-legal issues, and previous back surgery. They also excluded patients who had minimally bothersome pain (i.e., scoring ≤ 2 on a 10-point Likert scale), patients who had pain for < 3 months, and patients who would have had difficulty participating in the classes or home program (for example, major depression, dementia, and severe disc disease). The patients in the three groups were well matched. Average age was 48, 64% were women, 87% were white, and 59% were using medication at baseline. Forty-four percent had prior yoga experience. Despite randomization, the participants in the yoga classes had higher baseline Roland-Morris Disability Questionnaire (RMDQ),1,2 scores (9.8 vs 8.6 vs 9.0 — out of 24 — for yoga, stretching, and self-care, respectively). The average duration of LBP was 10.8 years.

The yoga and stretching classes met weekly for 75 minutes for 12 weeks. Experienced yoga instructors and physical therapists conducted the classes. In the yoga classes, patients practiced breathing exercises, up to 11 poses (or postures), and guided deep relaxation. In the stretching classes, patients had aerobic and strengthening exercises and 12 different major muscle group stretches, each held for 30 seconds.

The primary outcomes were scores on the RMDQ and the "bothersomeness" Likert scale at 12 weeks. Secondary outcomes were the same scores at 6 and 26 weeks, activity restriction, patient global ratings of improvement, and patient satisfaction.

At study's end (12 weeks), all groups had lower RMDQ scores (4.6 vs 4.4 vs 6.6 for yoga, stretching, and self-care, respectively). The yoga and stretching scores were significantly lower than the self-care score. This was true for the scores at 6 and 26 weeks, too. There was no statistically significant difference between the yoga and stretching groups at 12 weeks. Patients in the yoga group were less bothered by symptoms than the patients in the self-care group. Patients in the yoga and stretching groups were more satisfied with their care and rated their LBP as better, much better, or completely gone when compared to the self-care group. There were no differences in activity restriction. Except for one yoga patient developing a herniated disc, adverse events were mild to moderate across the board.

In the second study, Tilbrook and colleagues from the United Kingdom randomized 331 general practice patients (from 1093 recruited) to a 12-week yoga program or usual care. These patients were invited if they had visited their general practitioner for back pain within the past 18 months. They were slightly younger (46 years) and more were female (70%) than the group from Seattle. Their medication use was similar. The average duration of LBP was 10.2 years. These investigators also used the RMDQ. They excluded patients with scores ≤ 3. They also excluded patients who had done yoga in the last 6 months, who were physically unable to perform yoga, were pregnant, or had surgery on their backs. All subjects received a self-care book (The Back Book). The control group was offered one yoga session after the study's end. Experienced instructors also conducted these yoga classes. Seventy-five minute classes were held weekly for 12 weeks. Subjects were encouraged to practice yoga at home. The primary outcome was the RMDQ score at 3 months. Secondary outcomes included the scores at 6 and 12 months, measures of restricted activity, and back pain scores using the Aberdeen Back Pain Scale (ABPS).

At baseline, these subjects had lower average RMDQ scores (7.8), better than the Seattle subjects. At 3 months, the average score had dropped 2.2 for the yoga group and was essentially unchanged for the usual care group. Although both groups saw a drop in their scores at 6 and 12 months, the yoga group consistently had a lower average score. Unexpectedly, the two groups had similar (although lower) ABPS and general health scores at each assessment. The yoga group had better pain self-efficacy scores at 3 and 6 months, but not at 12 months. Adverse events were few in number for both groups.

Commentary

Yoga, originating in ancient India, has physical, mental, and spiritual dimensions; it was not developed to help LBP, but, rather, to help its practitioners attain a state of perfect spiritual insight and tranquility. It was introduced to the West in the 1890s. A 2008 study found that 6.9% of U.S. adults, or 15.8 million people, practice yoga.3 Despite its antiquity, it has been associated with the "New Age" movement. I suspect that its overt spirituality is off-putting to some people, along with the perception (borne out in the survey) that it is primarily a preoccupation of well-to-do, college-educated females. That is unfortunate, as many health benefits have been ascribed to its practice.4

These two studies, published online within a week of each other, provide strong evidence that yoga and stretching are effective in treating chronic LBP, especially considering the lengthy duration of LBP. Both were large, both used multiple instructors, and both had control groups. Follow-up was relatively long (26 weeks and 12 months). The U.K. group points out that the United Kingdom Back Pain Exercise and Manipulation trial showed that a change of 1.57 in the RMDQ score is cost-effective;5 both studies had greater differences than that for yoga and, in the Seattle study, for stretching.

Many questions came to mind as I read these articles. Both studies excluded more patients than they randomized. Are the subjects who remained fundamentally different than those who were excluded? Are patients enrolled in a health maintenance organization (such as Group Health) "different"? Almost half had prior experience with yoga. The U.K. trial did not document that variable. The participants were not ethnically/racially diverse and did not include young and elderly patients, although it could be argued that young people usually do not suffer from LBP. Can the results of the studies be applied broadly? How long lasting are the effects of yoga and stretching? Do patients need to maintain the practice, or will the symptoms eventually return if they stop? How did the interventions affect medication use? How should we interpret the findings from the U.K. study that the RMDQ scores differed between the yoga and usual care groups, but the pain scores did not?

Last summer the same Seattle group published a study of massage for LBP that found benefit;6 a Cochrane Review confirms this.7 Previously, they reported on the use of acupuncture.8 This is all good. Some patients are going to gravitate to yoga, others to stretching, and others to other alternative therapies. A study of placebo, echinacea, and belief,9 also published last summer, and reviewed by Dr. Scherger in these pages,10 demonstrated "that beliefs and feelings about treatments may be important," and "perhaps should be taken into consideration when making medical decisions." I agree. LBP is second only to upper respiratory complaints as a symptom that prompts a visit to a primary care physician.11 Having several evidence-based arrows in our quivers will allow us to customize therapy to what our patients will attempt, what they can afford, and what they believe will work for them. It would benefit our patients for us to seek out yoga instructors and physical therapists in our communities to assure that they understand what our patients need.

I took up yoga a couple years ago, hoping to maintain some flexibility and strength as I age. From personal experience, I can tell you that yoga classes can be very different, depending on the instructor. My first instructor, an otherwise very pleasant woman, was from the drill sergeant school of yoga. She would walk among us and "adjust" our poses if we failed to meet the standard. The current one is a "child of the '60s" who tells us not to pay attention to each other because it is acceptable for students in her classes to have different abilities. "Yoga shouldn't hurt. With each breath maybe you can settle an extra millimeter into the pose. Just go to that delicious stretch." Works for me.

References

1. Roland M, Morris R. A study of the natural history of back pain. Part I: Development of a reliable and sensitive measure of disability in low-back pain. Spine (Phila Pa 1976) 1983;8:141-144.

2. Roland Morris Disability Questionnaire. Available at www.rmdq.org/. Accessed Nov. 26, 2011.

3. "Yoga in America Study" (Press release). Yoga Journal. Feb. 26, 2008. Available at www.yogajournal.com/press/yoga_in_america. Accessed Nov. 27, 2011.

4. Woodyard C. Exploring the therapeutic effects of yoga and its ability to increase quality of life. Int J Yoga 2011;4:49-54.

5. UK BEAM Trial Team. United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: Effectiveness of physical treatments for back pain in primary care. BMJ 2004;329:1377.

6. Cherkin DC, et al. A comparison of the effects of 2 types of massage and usual care on chronic low back pain: A randomized, controlled trial. Ann Intern Med 2011;155:1-9.

7. Furlan AD, et al. Massage for low-back pain. Cochrane Database Syst Rev 2008:CD001929.

8. Cherkin DC, et al. A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain. Arch Intern Med 2009;169: 858-866.

9. Barrett B, et al. Placebo effects and the common cold: A randomized controlled trial. Ann Fam Med 2011;9: 312-322.

10. Scherger JE. A placebo the patient believes in is effective for the common cold. Internal Medicine Alert 2011;33:129-130.

11. U.S. Preventive Services Task Force. Primary care interventions to prevent low back pain in adults: Recommendation statement. February 2004. Agency for Healthcare Research and Quality, Rockville, MD. www.uspreventiveservicestaskforce.org/uspstf/uspsback.htm. Accessed Nov. 26, 2011.