Helen E. Tilbrook, BSc, MSc; Helen Cox, BSc, MSc; Catherine E. Hewitt, BSc, MSc, PhD; Arthur Ricky Kang'ombe, BSc, MSc; Ling-Hsiang Chuang, BSc, MSc, PhD; Shalmini Jayakody, BSc, MSc; John D. Aplin, MA, PhD; Anna Semlyen, BA, MSc; Alison Trewhela, DBL, CSL; Ian Watt, BSc (Med Sci), MB, ChB, MPH; David J. Torgerson, MSc, PhD
Previous studies indicate that yoga may be an effective treatment for chronic or recurrent low back pain.
To compare the effectiveness of yoga and usual care for chronic or recurrent low back pain.
Parallel-group, randomized, controlled trial using computer-generated randomization conducted from April 2007 to March 2010. Outcomes were assessed by postal questionnaire. (International Standard Randomised Controlled Trial Number Register: ISRCTN 81079604)
13 non–National Health Service premises in the United Kingdom.
313 adults with chronic or recurrent low back pain.
Yoga (n = 156) or usual care (n = 157). All participants received a back pain education booklet. The intervention group was offered a 12-class, gradually progressing yoga program delivered by 12 teachers over 3 months.
Scores on the Roland–Morris Disability Questionnaire (RMDQ) at 3 (primary outcome), 6, and 12 (secondary outcomes) months; pain, pain self-efficacy, and general health measures at 3, 6, and 12 months (secondary outcomes).
93 (60%) patients offered yoga attended at least 3 of the first 6 sessions and at least 3 other sessions. The yoga group had better back function at 3, 6, and 12 months than the usual care group. The adjusted mean RMDQ score was 2.17 points (95% CI, 1.03 to 3.31 points) lower in the yoga group at 3 months, 1.48 points (CI, 0.33 to 2.62 points) lower at 6 months, and 1.57 points (CI, 0.42 to 2.71 points) lower at 12 months. The yoga and usual care groups had similar back pain and general health scores at 3, 6, and 12 months, and the yoga group had higher pain self-efficacy scores at 3 and 6 months but not at 12 months. Two of the 157 usual care participants and 12 of the 156 yoga participants reported adverse events, mostly increased pain.
There were missing data for the primary outcome (yoga group, n = 21; usual care group, n = 18) and differential missing data (more in the yoga group) for secondary outcomes.
Offering a 12-week yoga program to adults with chronic or recurrent low back pain led to greater improvements in back function than did usual care.
Arthritis Research UK.
Is yoga an effective therapy for low back pain?
In this trial, adults with chronic or recurrent low back pain were randomly assigned to a 12-session, 3-month yoga program (n = 156) or usual care (n = 157). The yoga group had better back function but similar back pain and general health scores at 3, 6, and 12 months compared with the usual care group. Eight participants reported adverse events, such as increased pain, that were perhaps related to yoga.
Compliance with yoga was incomplete, and some outcome data were missing.
Yoga can improve some outcomes in adults with chronic low back pain.
GP = general practitioner.
* An indicator of a more serious medical condition.
† Baseline questionnaires were sent out after randomization to the first-wave participants (n = 165) and before randomization to the second-wave participants (n = 148). Participants who did not return a baseline questionnaire in the second wave were not randomly assigned.
‡ Participants who did not return a questionnaire at that time point but completed questionnaires at subsequent follow-ups. Therefore, the numbers given for “questionnaire not returned” are not cumulative. Number included in analysis refers to numbers included in the main mean Roland–Morris Disability Questionnaire analyses.
Mean changes from baseline are all predicted means and 95% CIs, estimated from the mixed-effects models, and were adjusted by month, age, sex, eligibility score, class availability, and duration of back pain as fixed effects and random intercepts as random effects. RMDQ = Roland–Morris Disability Questionnaire.
Appendix Table 1.
Appendix Table 2.
RMDQ = Roland–Morris Disability Questionnaire; UK BEAM = United Kingdom Back Pain Exercise and Manipulation.
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Note: Yoga shown in this b-roll package is stock footage. To see yoga techniques used in the 'Yoga for Healthy Lower Backs' intervention, view the article's video supplement.
Stephen PWard, Hospital Consultant
Brighton and Sussex University Hospitals NHS Trust
November 12, 2011
When I read the headlines about this trial in the popular press and then went on to read the publication, I thought for a moment that some mistake had been made. By and large the media have reported this trial as demonstrating that yoga is a 'cure' for back pain. The researchers own website declares yoga a 'triumph' (https://hscisrv07.york.ac.uk/yoga/html/index.html). It is, of course, no such thing. The authors find a very modest but short term improvement in Roland Morris disability score which clearly does not achieve clinical significance. They state rather disingenuously that 'Although there is no consensus, a change of 1.1 to 2.5 on the RMDQ has been recommended as clinically important' citing two trials who used this range in their conclusions. Roland recommended at least a 2-3 point change should be considered the minimum clinically important change (1). Contrary to the authors view, there is a good deal of consensus as to what constitutes a minimum clinically important change in the Roland Morris score. Ostelo and co-workers for example, in an effort to reach an international consensus, proposed at least a 5 point difference (2). In this context, yoga is no triumph. One could even argue that given that this sort of pragmatic trial ('treatment + usual care vs. usual care') will almost never generate a negative result, one would have expected yoga to fair rather better. The real message here is that yoga does not make back pain any better. A small but clinically meaningless and shortlived improvement in function, almost certainly the result of the inherent biases of this sadly popular trial design is not the stuff of headlines.
Dr S P Ward FRCA FFPMRCA Consultant in Pain Medicine
1. Bombardier C, Hayden J, Beaton DE. Minimal clinically important difference. Low back pain: outcome measures.J Rheumatol. 2001 Feb;28(2):431-8. 2. Ostelo RW et al. Interpreting change scores for pain and functional status in low back pain: towards international consensus regarding minimal important change. Spine (Phila Pa 1976). 2008 Jan 1;33(1):90-4.
Erica MDonnison, Alexander Technique Teacher
Society of Teachers of the Alexander Technique (STAT)
November 16, 2011
The comparision of this trial with the ATEAM trial
This well-conducted trial contributes to the growing body of knowledge about interventions that can complement usual GP care for those suffering from chronic low back pain. I was interested to see the post- hoc comparison with the outcome of the ATEAM trial, which evaluated the effectiveness of lessons in the Alexander Technique for chronic low back pain patients, but it is worth noting that the Roland Morris disability score is the only outcome measure in common between these two studies. In the ATEAM trial there was a second main outcome measure - of the number of days in pain during the past 4 weeks - which demonstrated significant long -term (1 year) reductions in the number of days in pain following lessons.
In the yoga trial there was no significant effect on back pain scores although some improvement was noted in a pain self-efficacy measure at the 3 and 6 month timepoints. Unfortunately the benefit in Roland Morris score tailed off over time, whereas in the ATEAM trial, improvement in both the Roland Morris and days in pain scores of participants receiving Alexander lessons was maintained at 12 months. This outcome appears to be in keeping with the primarily educational nature of Alexander Technique lessons, and suggests that a majority of participants continued to apply what they had learnt and use the Alexander Technique to maintain their recovery after the lessons had ceased.
A direct comparative trial of these two interventions, or indeed, a trial of yoga and Alexander Technique lessons compared with usual care, would be of interest. They are not incompatible and each has something different to contribute.
1. Little P, Lewith G, Webley F et al. Randomised controlled trial of Alexander Technique lessons, exercise and massage (ATEAM) for chronic and recurrent back pain. BMJ 2008; 337: a884.
2. Yardley L, Dennison L, Coker R, Webley F, Middleton K, Barnett J, Beattie A, Evans M, Smith P, Little P. Patients' views of receiving lessons in the Alexander Technique and an exercise prescription for managing back pain in the ATEAM trial. Fam Pract. 2009 Dec 23.
3. Beattie A, Shaw A, Yardley L, Little P, Sharp D. Participating in and delivering the ATEAM trial (Alexander technique lessons, exercise, and massage) interventions for chronic back pain: A qualitative study of professional perspectives. Complementary Therapies in Medicine 2010;18:119 -27.
I am the Chair of the Scientific Research Committee of the Society of Teachers of the Alexander Technique (STAT) which is the largest and oldest professional body for Alexander Technique teachers in the UK
Gen-MinLin, M.D., Yi-Hwei Li
Hualien-Armed Forces General Hospital, Hualien, Taiwan
November 29, 2011
Body-Mind Exercise For Chronic Low Back Pain.
Yoga is a well known body-mind exercise which has been proven to stabilize mind and further improve physical inability. With some evidence, yoga may reduce inflammatory markers such as interleukin-6 and this can support the relief for chronic back pain. In comparison to another body-mind exercise, tai-chi exercise, a number of similar studies have been done. Many reports indicated that tai-chi exercise can improve self-estimated quality of life, mood and physical tolerance for patients with heart failure.(1) In a recent study by Hall et al, tai-chi exercise reduced bothersomeness of back symptoms by 1.7 points on a 0-10 scale, reduced pain intensity by 1.3 points on a 0-10 scale, and improved self-report disability by 2.6 points on the 0-24 Roland-Morris Disability Questionnaire scale over a 10- week period.(2) This finding is very close to the results of yoga. Accordingly, we believe that, body-mind exercise like yoga or tai-chi exercise may relieve people with chronic back pain via stabilizing their mood and then affect the performance of physical activity.
1. Yeh GY, McCarthy EP, Wayne PM, Stevenson LW, Wood MJ, Forman D, Davis RB, Phillips RS. Tai chi exercise in patients with chronic heart failure: a randomized clinical trial. Arch Intern Med. 2011;171:750-7.
2. Hall AM, Maher CG, Lam P, Ferreira M, Latimer J. Tai chi exercise for treatment of pain and disability in people with persistent low back pain: A randomized controlled trial. Arthritis Care Res (Hoboken). 2011;63:1576-83
BonnieBerk, MS, RN, E-RYT, HNB-BC
Missing and Confusing information
I read with interest your article on "Yoga for Chronic Low Back Pain." There is no doubt in my mind that continuing the yoga intervention would have improved the longterm benefits like any fitness program. However, there are some missing and confusing information about this study. First of all, there was no description of what kind of yoga was practiced as well as what information was given to the control group. I specialize in teaching yoga to special populations and offer classes that are specifically tailored for the people I teach. Of course, one size never fits all, I would be interested in knowing what poses they were teaching. Did they incorporate core strengthening? Did they use props? Also, on page 572, table 1, there is mention that all subjects were male and yet in the body of the text, the authors refer to research participants as 'individual adults' and do not mention gender. can you clarify as to what gender was researched? This research is an important piece in validating the therapeutic aspects of yoga, however, it would be helpful to fully understand how the research was conducted. Thanks.
Alison M.Trewhela, Yoga Teacher/Therapist
The University of York & Peninsula College of Medicine and Dentistry
December 2, 2011
Re:Missing and Confusing information
Firstly, please note that two thirds of our 313 trial participants were female.
Secondly, the first point of reference for anyone wishing to find out more about the yoga programme and its educational resources developed for this research trial should be a new website dedicated to this www.yogaforbacks.co.uk. Please also note that there is an informative video supplement for viewing accompanying our published paper on this Annals of Internal Medicine website, which gives a good overview of the 'Yoga for Healthy Lower Backs' programme used in the trial.
A new interesting systematic review by Posadzki et al shows yoga as being a useful treatment option for pain relief.
Along with another yoga teaching consultant on this trial, I have set up a Social Enterprise with the aim of educating and promoting the yoga programme used in this RCT and its educational resources
Tilbrook HE, Cox H, Hewitt CE, Kang'ombe AR, Chuang L, Jayakody S, et al. Yoga for Chronic Low Back Pain: A Randomized Trial. Ann Intern Med. 2011;155:569–578. doi: 10.7326/0003-4819-155-9-201111010-00003
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Published: Ann Intern Med. 2011;155(9):569-578.
Back Pain, Rheumatology.
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