Pauline Anderson

September 29, 2016

SAN ANTONIO — Yoga is as good as physical therapy (PT) in reducing chronic low back pain, the most common pain problem in the United States, new research shows.

"Our study showed that yoga was noninferior to physical therapy for a diverse group of low-income patients," said Robert B. Saper, MD, director of integrative medicine, Boston Medical Center, Massachusetts. "Its effectiveness was most obvious in the most adherent patients."

Dr Saper presented his study at the American Academy of Pain Management (AAPM) 2016 Annual Meeting. The AAPM recently changed its name to the Academy of Integrative Pain Management.

Previous research has shown that yoga improves pain and function and reduces medication use. For example, a 2013 meta-analysis demonstrated small to medium effect sizes for yoga in short-term and long-term back pain–related disability. Research also shows that PT is effective in treating patients with back pain.

"We know that yoga is effective, we know that PT is effective, but we don't know their comparative effectiveness," said Dr Saper. "To get a complementary health practice into mainstream healthcare, I would say that a minimal bar is that it has to be as effective as the conventional therapy, and perhaps offer other benefits, like cost-effectiveness."

PT is considered a conventional therapy and is the most common nonpharmacologic referral by physicians for chronic low back pain, Dr Saper said. About 22% of patients with low back pain in primary care get referred for PT.

For this new study, researchers enrolled 320 adult patients from Boston-area community health centers who had chronic back pain with no obvious anatomic cause, such as spinal stenosis. The patients were predominantly nonwhite and low income, with a relatively low education level.

The patients had "quite high" pain scores (average of 7 out of 10 on a pain scale) and were "quite disabled" in terms of their back pain, said Dr Saper. Almost three quarters were using pain medication, with about 20% taking opioids.

"We had absolutely no problem recruiting patients" for this study, said Dr Saper. "That's because people are suffering with chronic pain and their needs are not being met."

Patients were randomly assigned to one of three groups: yoga, PT, or education.

To develop the structured yoga protocol, Dr Saper and his colleagues organized an expert panel, which reviewed the literature on the topic. The final product was a 75-minute weekly class with a very low student-to-teacher ratio.

The classes began with short segment on yoga philosophy (nonviolence, moderation, self-acceptance). Participants were then given mats on which to do the simple yoga poses. They received a DVD to practice these at home.

Fear of Injury

Asked by a delegate how he encouraged patients with pain to get down on the floor when many are afraid of injury, Dr Saper said that some patients did have difficulty, especially those who were obese. "But these classes go slow and gentle; the first class may be just getting people on the floor, knees to chest, or in a table position."

The PT group had 15 one-on-one 60-minute sessions that included aerobic exercise. PT personnel were trained to help coach patients on fear avoidance.

The education group got a comprehensive book on back pain.

Both the PT and yoga sessions continued for 12 weeks, after which patients were followed to 52 weeks. During this postintervention period, patients in both the yoga and PT groups were randomly assigned to maintenance (drop in yoga classes or more PT sessions) or just at-home practice.

Overall adherence was not great. The mean number of yoga classes and PT sessions attended during the initial phase was 7.

The primary question being addressed was whether yoga is not inferior to PT at 12 weeks.

The study showed that for function (score on the Roland-Morris Disability Questionnaire), yoga and PT "are exactly the same, ie noninferior," said Dr Saper, adding that, "they are not terribly different from education at 12 weeks."

However, looking at just those patients who actually went to the yoga classes, he said, "you see yoga and PT are still quite similar, but the difference with education is quite high."

There were similar results for pain scores. "You see that yoga and PT are essentially the same: a little bit better than education, but much better when you look at the per protocol analysis."

As for the percentage of participants who had at least a 30% reduction, "if you look at Roland [Morris Disability Questionnaire], it's 48% for yoga, 37% for PT, and 23% for education," said Dr Saper. "What that means is that for every two patients who go to yoga, about 50% of them are going to have a clinical response."

Looking at odds ratios for function, comparing the various interventions, "yoga is actually superior" to PT and is "quite a bit" superior to education, said Dr Saper.

At baseline, about 70% of participants were using medication. At 12 weeks, such use was down by about 20% in both the yoga and PT groups, and hadn't changed in the education group.

A similar number of yoga and PT subjects reported being "very improved" and "very satisfied," said Dr Saper.

Yoga proved to be safe, with only mild, usually transient exacerbations of back pain.

In addition to the low adherence rate, another possible limitation of the study is that its findings may not be generalizable. "This was a very structured standardized yoga program," said Dr Saper. "We don't know how patients will do if they go to the yoga studio down the street."

Larger studies are needed to develop better strategies to enhance adherence, he said.


Researchers will now analyze costs involved with yoga, Dr Saper told Medscape Medical News after his presentation.

"We are collecting data to assess the cost-effectiveness of yoga for clinical back pain, from the perspective of the payer, society and the patient. We will see what those analyses show; potentially it will justify, in combination with the efficacy data, coverage by hospital or a payer system for structured yoga programs."

Asked to comment on this new study, Robert Bonakdar, MD, Scripps Center for Integrative Medicine, La Jolla, California, said it's asking "an important question:" how something "new and upcoming like yoga" compares to a standard therapy.

"Every family physician, every front line physician, with low back pain patients is looking at nonpharmacological care, and one of the initial things is physical therapy. But unfortunately, this does not work in all pain patients."

In some cases, said Dr Bonakdar, PT may not be accessible or covered by insurance, in which case it can be prohibitively expensive. Alternatively, "there are yoga classes that cost $10 or $15 a week," said Dr Bonakdar, and yoga "can be transitioned into a home practice."

The new study "adds to our knowledge in suggesting that a) yoga is as good as the standard of care, non pharmacologic therapy, and b) it can be done in a diverse population, including a low income, non-English speaking population in Boston. So it takes away some of those barriers to recommending it."

The beauty of yoga, said Dr Bonakdar, is that "it's very well packaged" and includes not only body awareness, but mind awareness and breathing awareness. "And it feels good to do it; you don't feel like you're doing a medical intervention."

There's also evidence that yoga has a positive impact on the brain. According to M. Catherine Bushnell, PhD, National Center for Complementary and Integrative Health, National Institutes of Health, long-time yoga practitioners have more gray matter than matched physically active controls.

"Gray matter goes down with age, but yoga practitioners have a flat line; you don't see this age-related decrease in gray matter that you see in other healthy people," Dr Bushnell told delegates during a separate plenary presentation.

And there seems to be "quite a robust" relationship between how long a person has done yoga and positive brain changes, she said. "The number of years a person has practiced yoga, the more gray matter at multiple sites in the brain."

Yoga influences areas of the brain that are important for pain modulation, said Dr Bushnell.

It is a "complex activity" that involves not only exercise but also breath control and meditation. And although analyses show that exercise is the biggest contributor to gray matter, all the other elements of yoga also play a role, she said.

Another study cited by Dr Bushnell measured the amount of time participants could keep their hand in cold water. It showed that yoga practitioners have a higher pain tolerance than other people.

In one area of the brain — the insula cortex — there was a relationship between pain tolerance and amount of gray matter, she said.

The study was supported by a grant from the National Center for Complementary and Integrative Health. Dr Saper and Dr Bushnell have disclosed no relevant financial relationships. . Dr Bushnell's views are her own and do not reflect the position or policy of the National Institutes of Health, the Public Health Service, or the US Department of Health and Human Services.

American Academy of Pain Management (AAPM) 2016 Annual Meeting. Presented September 23, 24, 2016.

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