October 27, 2011 — Stretching, regardless of whether it is achieved via yoga classes or conventional stretching exercises, has moderate benefits in adults with moderately impairing chronic low back pain.
In a comparative effectiveness study, researchers found that yoga classes were more effective than a self-help book, but not more effective than stretching classes, in improving function and reducing symptoms resulting from chronic low back pain, with benefits lasting at least several months.
"Finding similar effects for both approaches suggests that yoga's benefits were largely attributable to the physical benefits of stretching and strengthening the muscles, and not to its mental components," Karen J. Sherman, PhD, MPH, from Group Health Research Institute, Seattle, Washington, and colleagues report.
The study was published online October 24 in the Archives of Internal Medicine.
"Actionable" Findings
The author of a linked commentary says the results from this trial are "actionable" for practice because they reinforce the evidence that exercise is safe and moderately beneficial for chronic low back pain.
"Health care providers should feel comfortable referring patients to either yoga or [physical therapy–]led classes; either seems to be helpful," writes Timothy S. Carey, MD, MPH, from the Sheps Center for Health Services Research, University of North Carolina, Chapel Hill.
The study involved 228 adults with chronic low back pain that was moderately impairing, as judged by baseline Roland-Morris Disability Questionnaire (RDQ) scores between 8.6 and 9.8 on a 23-point scale. The investigators randomly assigned study participants to 3 commonly used treatments for chronic low back pain:
A self-care book (The Back Pain Helpbook), which provides information on the causes of back pain and advice on exercising, making helpful lifestyle changes, and managing flare-ups.
Twelve weekly yoga classes based on the principles of viniyoga and including 17 relatively simple postures with variations and adaptations, as well as breathing exercises and guided deep relaxation.
Twelve weekly stretching classes led by a licensed physical therapist who had completed a 2-hour teacher training program. The classes included aerobic exercises, 10 strengthening exercises, and 12 stretches held for 30 seconds each. The stretches were designed to stretch the major muscle groups, with a focus on the trunk and legs.
Back-related pain and functional status were assessed at baseline and at 6, 12, and 26 weeks after randomization.
Sixty-five percent of yoga class participants and 59% of stretching class participants attended at least 8 classes. The median number of classes attended among those attending at least 1 class was similar (10 yoga and 9 stretching); 63% of yoga class attendees and 82% of stretching class attendees said they practiced at home 3 or more days per week.
Less Pain With Fewer Medications
Back-related dysfunction (RDQ score) declined over time in all groups, with significant differences in the adjusted analyses among the 3 groups at 6 weeks (P = .04), 12 weeks (P < .001), and 26 weeks (P = .03), the investigators report.
Compared with self-care, the yoga group reported superior function at 12 and 26 weeks, and the stretching group reported superior function at 6, 12, and 26 weeks.
Table 1. Between-Group Differences (95% Confidence Interval)
| RDQ Week | Yoga vs Self-Care | Yoga vs Stretching |
| 6 | −1.2 (−2.7 to 0.23) | −1.7 (−3.0 to −0.4) |
| 12 | −2.5 (−3.7 to −1.3) | −2.2 (−3.4 to −1.0) |
| 26 | −1.8 (−3.1 to −0.5) | −1.5 (−2.8 to −0.2) |
There were no statistically or clinically significant differences between the yoga and stretching groups. There were no meaningful differences among the treatment groups for bothersomeness of pain on an 11-point numerical scale, except at 12 weeks, when yoga participants were significantly less bothered by symptoms than the self-care group.
Table 2. Differences in Bothersomeness of Pain at Week 12 (95% Confidence Interval)
| Outcome | Yoga vs Self-Care | Stretching vs Self-Care | Yoga vs Stretching |
| Bother at 12 weeks | − 1.07 (1.75 to −0.41) | − 0.59 (−1.30 to 0.11) | − 0.49 (−1.06 to 0.08) |
Participants in both exercise groups cut back on their medication use over time. Compared with self-care, twice as many participants in the yoga and stretching groups (roughly 40% vs 20%) reported using less medication at the 12- and 26-week follow-up interviews.
Results of 2 secondary outcomes (30% and 50% improvement from baseline in RDQ scores and bothersome scores, representing "substantial improvement") also favored yoga and stretching over the self-help book. "For example, 52% to 56% of participants in the yoga and stretching groups improved by a least 50% on the RDQ compared with only 23% in the self-care group (P < .001)," the authors report.
More participants in the yoga and stretching groups were "very satisfied" with their overall care for back pain.
Dr. Sherman and colleagues say their study builds on prior studies of yoga for chronic back pain. They say they identified 8 published clinical trials of yoga for chronic back pain, and that "[d]espite their diversity, all trials concluded that yoga improved back-related function, symptoms and/or reduced medication usage."
Recent meta-analyses of exercise for chronic low back pain sufferers reported "modest but clinically questionable" effects of exercise compared with usual care, the researchers point out. However, further analyses found that stretching and strengthening exercises, supervised exercise, and individual tailoring of the exercises were associated with the best outcomes. "Apart from tailoring, these features were part of our stretching classes," they note.
"Excellent" Study
In his commentary, Dr. Carey notes that the number of adults with chronic low back pain is rising, along with its medical and social costs. A large number of treatments are available, yet "we have relatively poor information regarding how these treatments compare with each other."
The study by Dr. Sherman's team is "an excellent example of a pragmatic comparative effectiveness trial," Dr. Carey writes. He notes that the findings are generalizable to patients with no sciatica and mild to moderate impairment. Although direct costs were not reported, "group treatments are relatively inexpensive."
"We physicians should refer our patients for exercise, practitioners should work to standardize treatments, and payers should encourage these treatments through minimization of copayments for therapies that have both effectiveness and modest cost," Dr. Carey concludes.
The authors and Dr. Carey agree that future trials testing stretching and yoga classes in patients with more severe chronic low back pain are needed.
The study was funded by the National Center for Complementary and Alternative Medicine, part of the National Institutes of Health. The authors and Dr. Carey have disclosed no relevant financial relationships.
Arch Intern Med. 2011. Published online October 24, 2011. Abstract, Editorial
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Cite this: Yoga, Stretching Ease Chronic Low Back Pain - Medscape - Oct 27, 2011.
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