Running head: YOGA FOR CHRONIC LOW BACK PAIN

Yoga for the Reduction of Chronic Low Back Pain

Pamela Chong
University of South Florida

YOGA FOR CHRONIC LOW BACK PAIN

2
Abstract

Clinical Problem: Patients with chronic low back pain (CLBP) have very few complementary or
alternative therapies that can be used to reduce back pain and increase functionality.
Objective: To determine if using yoga in addition to or in place of current therapy will reduce the
intensity of back pain and increase functionality. Data bases that were accessed included
CINAHL, PubMed, Ovid MEDLINE, and the National Guideline Clearinghouse in order to
obtain randomized controlled trials and one clinical guideline for the treatment and management
of low back pain (LBP). Yoga, back pain, and chronic low back pain were the key terms used to
locate the resources.
Results: Recommendations from The American College of Physicians and American Pain
Society included exercise, back manipulation, and other multidisciplinary rehabilitation for
chronic low back pain (CLBP) lasting more than twelve weeks (2011). All clinical guidelines
that were reviewed recommended patient education and exercise, yet there was no consensus on
the type of exercise being recommended (2011). Toward Optimized Practice (2011) included
yoga therapy in their recommendations for the treatment of CLBP. In the literature, it was found
that patients who participated in yoga experienced less pain and increased functionality than
those who participated in usual care.
Conclusion: Patients who incorporated yoga into the treatment of their CLBP reported less pain
and increased functionality. Many of these studies included large sample sizes in several different
geographic areas, inferring that yoga is both safe and effective for the treatment of LBP in the
majority of the population.

YOGA FOR CHRONIC LOW BACK PAIN

Yoga for the Reduction of Chronic Low Back Pain

Back pain is a very common condition affecting over 50% of adults each year. In addition
to its effect on physical ability, it can also be financially crippling to those affected. It is
estimated that $33 billion is spent on medical care alone and $19.8 billion is lost due to
decreased productivity at work (Sherman et al., 2010). Back pain may be caused by several
different reasons including physiological and psychological stressors. Additionally,
psychological disturbances may also result from chronic low back pain (CLBP) since any form
of functional disability is likely to have a psychological impact (Tekur et al., 2012). Chronic back
pain is typically considered back pain that lasts greater than 12 weeks while acute back pain
typically lasts less than 12 weeks. Although there are many readily available therapies to treat
back pain, there is little consistent evidence proving their efficacy (Sherman et al., 2010). Some
of these treatments include pharmacological, exercise regimens, and education. This being said,
there is a need for evidence-based recommendations that are both easily accessible and costeffective for the treatment and management of low back pain (LBP). Currently, the
recommendations for chronic low back pain include diagnostic and laboratory testing, exercise,
including physical, therapeutic, and aquatic as well as yoga therapy. The purpose of this paper is
to evaluate if yoga is both safe and effective for the treatment of CLBP. A review of evidence
about this topic was guided by the following PICOT question: In patients that suffer from
chronic low back pain, how does the use of yoga, compared to standard care, affect the pain
intensity and spinal motility over a twelve week period?
Literature Search
Databases that were accessed to obtain the randomized clinical trials and the guidelines
for the treatment and management of CLBP include CINAHL, PubMed, Ovid MEDLINE, and

YOGA FOR CHRONIC LOW BACK PAIN

the National Guideline Clearinghouse. Some key words used to search the databases included
yoga, back pain, and chronic low back pain.
Literature Review
In order to assess how effective yoga is for the treatment and management of CLBP, three
randomized controlled trials and one clinical guideline were used (see Table 1). Sherman et al.
(2011) used a 3-arm parallel group randomized controlled trial to examine the effect of yoga,
regular stretching exercises, and a book on the self-care of chronic low back pain (CLBP).
Participants (N=228) were randomly assigned to weekly yoga classes (n=92), regular stretching
(n=91), or a self-care book (n=45) group via software. The functional status of the patients
backs was measured on a modified version of the Roland Disability Questionaire (RDQ) (23
point scale) and the severity of pain was measured on a 0-10 numeric scale. These measures were
first assessed at baseline, then again at 6, 12 and 26 weeks by masked interviewers. Baseline
characteristics were similar throughout all groups, with the exception of the yoga group which
had more back pain dysfunction than the other groups. Follow up rates were good at 90% or 91%
at all times. Patients in both the yoga and stretching classes had similar attendance rates and both
groups reported practicing at home. All groups had a decline in back related dysfunction (RDQ
score) throughout all follow-ups (6 weeks: p=.04; 12 weeks: p=<.001; 26 weeks: p=.03). Week
12 was considered the primary end point. At this time, outcomes for the yoga group were much
better than that of the self-care group in both function (p<.001) and symptoms (p<.001). Yoga
had better results than the self-care book at both 12 and 26 weeks, and stretching had superior
results at the 6 week mark. Throughout the trial, there was no statistically significant difference
between the yoga and the stretching groups. Participants in both the yoga and stretching groups
had substantial improvement from baseline (52-56% improved at least 50% on the RDQ) as

YOGA FOR CHRONIC LOW BACK PAIN

opposed to the 23% improvement in the group practicing self-care (p=<.001). Randomization of
assignment, large, well balanced sample size, masked interviewers, and high follow up rates are
strengths of this trial. Yoga and stretching were found to be a more effective treatment than the
use of a self-care book for the improvement of back function and reduction of symptoms.
Despite this, yoga was not found to be any more effective than conventional stretching. Since the
yoga group had higher dysfunction at baseline than the other groups, this is a potential limitation.
Tilbrook and colleagues (2011) used a parallel-group, randomized controlled trial
(N=313) to compare how effective yoga is with traditional care for the treatment of chronic or
recurrent LBP. Those who participated in this study were primarily middle-aged, working
females with an overall length of back pain being 10 years. Both the control (n=157) and
intervention groups (n=156) were offered The Back Book, an educational back pain book as well
as usual care while the intervention group was additionally offered a 12 week yoga program.
Back function was measured at 3 months and was considered the pre-specified primary outcome.
A 24- item questionnaire, the Roland-Morris Disability Questionnaire (RMDQ), was used to
assess back function before randomization, at baseline, and at 3, 6, and 12 months. Secondary
outcomes were also measured which included 6 and 12 month measures of the primary outcome,
physical and mental health via Short Form-12 (SF-12), health survey component summary
scores, back pain scores on the Aberdeen Back Pain Scale (ABPS), self-efficacy scores on the
Pain Self-Efficacy Questionnaire (PSEQ), among others. The intervention group had an
improvement in back function (RMDQ score) at 3, 6, and 12 months with the best results at 3
months directly after the intervention. The adjusted mean RMDQ scores were as follows: At
month 3, the score was 2.17(p=<.001), at month 6, the score was 1.48 (p=.011), and at month 12,
the score was 1.57 (p=.007) points fewer in the yoga group. At three months, there was little

YOGA FOR CHRONIC LOW BACK PAIN

difference in pain (ABPS; p=.062) between the usual care group and the yoga group.
Strengths of this study include randomization of assignment, large sample size with
similar baseline demographics, and long-term follow up. Weaknesses of this study include no
provided reasons for not completing the study. There was some missing data for the primary
outcome in both the yoga group (n=21) and the usual care group (n=18). The use of the missingat-random assumption may also be a potential weakness. Lack of compliance (15% did not
attend any classes) to the intervention is also a potential limitation.
Tekur et al. (2012) conducted a RCT comprised of 80 chronic low back pain (CLBP)
patients aged 18-60 who were seen between April 2005 and June 2006. The purpose of this trial
was to compare changes in symptoms in a short-term, residential yoga and physical exercise
program. Some of the symptoms being measured included pain, anxiety, depression, and spinal
motility. This was a 7 day single-blind trial with side by side comparison of the intervention
group attending yoga and meditation classes (n=40) and the control group attending standard
physical therapy activities (n=40). All participants had similar baseline data with respect to
socio-demographic and medical presentation. A numerical rating scale (NRS) 0-10 was used to
measure pain. Pain reduction was found to be statistically significant. The intervention groups
NRS for pain decreased 49% (p<.001) while the control group decreased 17.5% (p=.005). Other
measures, including anxiety, depression, and lower back flexibility were also assessed and
statistically significant. Although these items were also significant, pain was the major focus for
this paper. A weakness of this study is that the intervention only lasted 7 days compared to 3
months noted in other studies with no long-term follow up. Another weakness of the trial is that
it was not double-blind. Strengths include randomization of participants and side-by-side
comparison of both groups.

YOGA FOR CHRONIC LOW BACK PAIN

The guideline for the evidence-informed primary care management of low back pain
(2011) does include yoga therapy in the recommended treatment for CLBP among many other
recommendations. The guidelines state that there is some evidence suggesting that Viniyoga and
Iyengar yoga may be beneficial in the treatment of CLBP, yet no other types of yoga are
currently supported for this purpose. The guidelines also suggest finding a yoga instructor who
is experienced in working with individuals with back pain to prevent additional injuries.
Although research supports certain types of yoga for the reduction of pain and increased back
functionality, additional research should be conducted to see if additional benefits can be found
including financial and psychological.
Using the USPSTF scale, the overall grade for these trials is B. There is moderate
evidence showing substantial benefits resulting frome the evidence. Overall, the evidence within
these trials is good since all trials are well-designed, and well-conducted. These trials directly
look at the effect that the intervention has on health outcomes.
Synthesis
All clinical trials that were reviewed showed statistically significant evidence that using
yoga for the treatment of CLBP was effective in reducing pain and increasing functionality. The
majority of the trials used a version of the Roland-Morris Disability Questionnaire to measure
back-related disability. This was beneficial to analyze the results of different trials on a
comparable scale. The trials did not all use the same type of yoga for each study, which may be a
potential limitation when comparing evidence since there is a broad variety of yoga styles.
Although the studies conducted by Sherman et al. (2010) and Tilbrook et al. (2011) both had
large sample sizes with long-term follow up, the study conducted by Tekur et al. (2012) used a 7day residential yoga program with no long-term follow up. In this particular study, it is difficult

YOGA FOR CHRONIC LOW BACK PAIN

to determine if the benefits seen at the end of the trial continued long-term. Additionally, the two
other trials did not use a residential program, and patients were given the freedom to attend yoga
classes as they pleased. This provides a possible gap in the evidence since in these types of
studies each participant is not receiving the exact same intervention. There is clear evidence in
the literature that yoga is a more effective treatment than the use of a self-care book yet
additional studies need to be done to determine if yoga is more effective than conventional
stretching for the treatment and management of CLBP. Lastly, the guideline for the evidenceinformed primary care management of low back pain does include yoga therapy for the treatment
and management of CLBP which demonstrates that there is substantial evidence to recommend
this treatment (Toward Optimized Practice, 2011).
Research demonstrates that practicing yoga decreases pain and increases functionality for
patients suffering from CLBP. With these results, we should see a reduction in both medical costs
and lost wages from missed work. Some patients experienced adverse events while participating
in the intervention, with the majority being increased pain (Tilbrook et al., 2011). Additional
research should be conducted to verify that yoga is both a safe and effective treatment for those
living with chronic low back pain.
Clinical Recommendations
Since the guideline for the evidence-informed primary care management of low back pain
(2011) does include yoga therapy for the treatment and management of CLBP, it would be wise
to implement these recommendations at the James A. Haley Veterans Hospital as well as other
VA facilities. For patients seeking primary care for CLBP or who have been hospitalized for
debilitating LBP may be recommended for this treatment. The VA should offer veterans with
LBP complimentary yoga classes taught by certified instructors who have experience working

YOGA FOR CHRONIC LOW BACK PAIN

with patients with LBP. This would ensure that the veterans are getting the best possible care and
may aid in reducing pain and increasing back-related functionality in veterans who suffer from
CLBP.

References

YOGA FOR CHRONIC LOW BACK PAIN

Ladeira, C.E. (2011). Evidence based practice guidelines for management of low back pain:
physical therapy implications.Brazilian Journal of Physical Therapy, 15(3), 190-199.
http://dx.doi.org/10.1590/S1413-35552011000300004
Sherman,K.J., Cherkin, D.C., Wellman, R.D., Cook, A.J., Hawkes, R.J., Delaney, K., & Deyo,
R.A. (2011). A randomized trial comparing yoga, stretching, and a self-care book for
chronic low back pain. Archives of Internal Medicine, 171(22), 2019-2026. doi:
0.1001/archinternmed.2011.524
Sherman, K.J., Cherkin, D.C., Cook, A.J., Hawkes, R.J., Deyo, R.A., Wellman, R., &
Khalsa, P.S. (2010). Comparison of yoga versus stretching for chronic low back pain:
Protocol for the Yoga Exercise Self-care (YES) trial. Trials, (11)36. doi:10.1186/17456215-11-36
Tekur, P., Nagarathnaa, R.,Chametchaa, S., Hankeya, A., & Nagendrab, H.R. (2012). A
comprehensive yoga programs improves pain, anxiety, and depression in chronic low
back pain patients more that exercise: An RCT. Complementary Therapies in Medicine,
20(3):107-118. doi: 10.1016/j.ctim.2011.12.009
Tilbrook, H.E., Cox, H., Hewitt, C.E., Kangombe, A.R., Chuang, L.H., Jayakody, S., . .
.Torgerson, D.J. (2011). Yoga for chronic low back pain: A randomized trial. Annals of
Internal Medicine, 155(9), 569-578. doi: 10.7326/0003-4819-155-9-201111010-00003
Toward Optimized Practice. (2011). Guideline for the evidence-informed primary care
management of low back pain. Retrieved from
http://www.guideline.gov/content.aspx?id=37954&search=chronic+low+back+pain

Table 1

10

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11

Literature Review
Reference

Aims

Sample

To evaluate
changes in
pain, anxiety,
depression, and
spinal motility
in patients with
CLBP
comparing
yoga and
physical
exercise
program.

Design and
Measures
RCT:
3-arm parallel
group RCT
comparing
yoga,
stretching, and
self-care.
Randomization
was generated
by a statistician
using software.
Measures:
Back-related
functional
status
(modified
Roland
Disability
Questionaire,
23 point scale)
and
bothersomenes
s of pain (11
point numerical
scale)
RCT:
7 day single
blind RCT
comparing
yoga and
physical
activity.
Measures:
Numerical
rating scal
(NRS) 0-10 to
measure pain.

Sherman,K.J., Cherkin,
D.C., Wellman, R.D., Cook,
A.J., Hawkes, R.J., Delaney,
K., & Deyo, R.A. (2011).
A randomized trial
comparing yoga, stretching,
and a self-care book for
chronic low back pain.
Archives of Internal
Medicine, 171(22):20192026. doi:
0.1001/archinternmed.2011.
524

To determine if
yoga is a more
effective than
traditional
stretching
exercises or the
use of a selfcare book for
patients with
CLBP.

Tekur, P., Nagarathnaa,

R.,Chametchaa, S.,
Hankeya, A., Nagendrab,
H.R. (2012). A
comprehensive yoga
programs improves pain,
anxiety, and depression in
chronic low back pain
patients more that exercise:
An RCT. Complementary
Therapies in Medicine,
20(3):107-118. doi:
10.1016/j.ctim.2011.12.009
Tilbrook, H.E., Cox, H.,
Hewitt, C.E., Kangombe,
A.R., Chuang, L.H.,

To compare the
effectiveness of
both yoga and

RCT:
Parallel group
Measures:

N= 313
adults with
recurrent or

N=228
patients
were
randomized
n=92 in the
yoga group
n= 91 in
conventiona
l stretching
group
n=45 in
self-care
book group

N= 80
n= 40 in the
yoga and
meditation
classes
n= 40 in the
physical
therapy
activities

Outcomes /
statistics
Yoga was
superior to
self-care in
functionalit
y (p<.001)
and
bothersome
ness of pain
(p<.001) at
12 weeks.
No
statistical
significance
was found
between
yoga and
regular
stretching.

The
intervention
groups
NRS for
pain
decreased
49%
(p<.001)
while the
control
group
decreased
17.5%
(p=.005).
At month 3,
6, and 12
months

YOGA FOR CHRONIC LOW BACK PAIN

Jayakody, S., Aplin, J.D.,
Semlyen, A., Trewhela, A.,
Watt, I., & Torgerson, D.J.
(2011). Yoga for chronic
low back pain: A
randomized trial. Annals of
Internal Medicine,
155(9):569-578. doi:
10.7326/0003-4819-155-9201111010-00003

traditional care
for chronic or
recurrent LBP.

12
Roland-Morris
Disability
Questionaire,
pain scores on
the Aberdeen
Back Pain
Scale (ABPS),
pain selfefficacy, and
general health
measures.

chronic low
back pain
n= 156 in
yoga group
n= 157 in
usual care
group.
All
participants
received
The Back
Book (a
back pain
educational
booklet).

RMDQ
score was
2.17(p=<.00
1), 1.48
(p=.011),
and 1.57
(p=.007)
points lower
in the yoga
group
respectively.
At three
months,
there was
little
difference in
pain
(ABPS;
p=.062)
between the
usual care
group and
the yoga
group.