Yoga May Improve Functioning in Patients With Chronic Nonspecific Low Back Pain

Lead author L. Susan Wieland, PhD, MPH, and SpineUniverse Editorial Board member Isador H. Lieberman, MD, MBA, FRCSC, comment

Yoga may improve back-related function in patients with chronic nonspecific low back pain, according to a review of 12 randomized controlled studies reported in the January issue of Cochrane Database of Systematic Reviews. Because of the inherent nonblinded design of the studies, the study outcomes could only be graded with “moderate” certainty at best, the researchers noted in the January issue of Cochrane Database of Systematic Reviews.

“Compared to not doing exercise, yoga may improve back function slightly and probably slightly reduces pain,” said lead author L. Susan Wieland, PhD, MPH, Assistant Professor of Family and Community Medicine at the University of Maryland School of Medicine in Baltimore. “Yoga may also increase the number of people who report clinical improvement.”

yoga term defined“Compared to not doing exercise, yoga may improve back function slightly and probably slightly reduces pain” “Based on the limited information available from current studies, it is uncertain whether there is any difference between yoga and other forms of back-focused exercise for improving back-focused function,” Dr. Wieland told SpineUniverse. “If yoga is more effective than not doing exercise, and as effective as other exercise approaches, the choice to use yoga may depend on patient or provider preference.” 

Study Methodology
Dr. Wieland and colleagues reviewed 12 randomized controlled studies of yoga for low back pain, which included 1,080 adults with nonspecific low back pain for at least 3 months. The trials compared yoga (mostly Iyengar, Hatha, or Viniyoga) to no intervention or a non-exercise intervention such as education (seven trials), an exercise intervention (three trials), or both exercise and non-exercise interventions (two trials).

Back-Related Function Improved With Yoga Compared to No Exercise
Compared to non-exercise interventions, the analysis showed low-certainty evidence that yoga produced small to moderate improvements in back-related function at three to four months (standardized mean difference [SMD] -0.40, moderate-certainty evidence for small to moderate improvements at six months (SMD -0.44), and low-certainty evidence for small improvements at 12 months (SMD -0.26). These changes corresponded to mean changes in the Roland-Morris Disability Questionnaire of -2.18, -2.15, and -1.36.

In terms of pain, there was low to moderate certainty evidence that yoga was better than no exercise at all time points, but the change did not the meet predefined criteria for clinical significance on this measure. It is unclear from the evidence whether yoga improved function or pain over other back-specific exercises, or whether yoga added to exercise is more effective than exercise alone, the study authors noted.

Yoga was associated with more adverse events, most commonly exacerbation of back pain, than no exercise. The reason for this difference is unknown because of the limited reporting of adverse events and little information on their sequelae in the individual trials, Dr. Wieland said. No serious adverse events were associated with yoga.

“We did not see that yoga was associated with more or fewer adverse events than the usual back-focused exercises for low back pain,” Dr. Wieland noted. “I would counsel patients to check with their providers for more detailed advice on how to approach any exercise treatment safely when dealing with low back pain.”

“The overall report does verify that back pain can be treated by multiple modalities, and it appears yoga has a slight advantage over other exercise programs and no exercise at all, commented Isador H. Lieberman, MD, MBA, FRCSC, Director of the Scoliosis & Spine Tumor Center, Texas Back Institute, Texas Health Presbyterian Hospital Plano, Plano, Texas.

“I spend a lot of time encouraging my patients to initiate or enhance an exercise program for multiple benefits,” said Dr. Lieberman, who also is a member of the SpineUniverse Editorial Board. I firmly believe a regular exercise program is good for my patients’ mental, social, and physical health. I frequently recommend yoga and Pilates, in which the exercise philosophy is to work on muscle stamina as opposed to brute strength, without overwhelming the joints.

“I recommend low resistance, high repetition exercise programs and also encourage consistency,” Dr. Lieberman continued. “You must be religious and dedicated to the exercise program as an irregular program does not achieve benefits.”

“The study is a literature review, its strength is in the method of analysis, its weakness is that the literature is lacking on the benefits of yoga,” Dr. Lieberman said, adding that many more controlled studies are needed.

Many Unknowns Remain
“There is still a lot that isn’t known about the details of yoga treatment for low back pain,” Dr. Wieland explained. “For example, we don’t know what yoga styles or components might be most useful for treating back pain. However, the yoga treatments in the studies included in our review were specially designed for people with low back pain, and experienced instructors supervised the yoga classes. We would caution that our observations of benefit and lack of serious harms would not necessarily apply to all yoga practices or to yoga undertaken without trained guidance.”

In addition, “we can’t tell, based on this systematic review, whether yoga might be more helpful (or harmful) for certain people or in certain circumstances. This is something that should be a focus of further research,” Dr. Wieland concluded.

Updated on: 02/08/18
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