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Meta-Analysis
. 2017 Jan 12;1(1):CD010671.
doi: 10.1002/14651858.CD010671.pub2.

Yoga treatment for chronic non-specific low back pain

L Susan Wieland  1 , Nicole Skoetz  2 , Karen Pilkington  3 , Ramaprabhu Vempati  4 , Christopher R D'Adamo  1 , Brian M Berman  1
Affiliations
Meta-Analysis

Yoga treatment for chronic non-specific low back pain

L Susan Wieland et al. Cochrane Database Syst Rev. .

Update in

  • Yoga for chronic non-specific low back pain.
    Wieland LS, Skoetz N, Pilkington K, Harbin S, Vempati R, Berman BM. Wieland LS, et al. Cochrane Database Syst Rev. 2022 Nov 18;11(11):CD010671. doi: 10.1002/14651858.CD010671.pub3. Cochrane Database Syst Rev. 2022. PMID: 36398843 Free PMC article.

Abstract

Background: Non-specific low back pain is a common, potentially disabling condition usually treated with self-care and non-prescription medication. For chronic low back pain, current guidelines state that exercise therapy may be beneficial. Yoga is a mind-body exercise sometimes used for non-specific low back pain.

Objectives: To assess the effects of yoga for treating chronic non-specific low back pain, compared to no specific treatment, a minimal intervention (e.g. education), or another active treatment, with a focus on pain, function, and adverse events.

Search methods: We searched CENTRAL, MEDLINE, Embase, five other databases and four trials registers to 11 March 2016 without restriction of language or publication status. We screened reference lists and contacted experts in the field to identify additional studies.

Selection criteria: We included randomized controlled trials of yoga treatment in people with chronic non-specific low back pain. We included studies comparing yoga to any other intervention or to no intervention. We also included studies comparing yoga as an adjunct to other therapies, versus those other therapies alone.

Data collection and analysis: Two authors independently screened and selected studies, extracted outcome data, and assessed risk of bias. We contacted study authors to obtain missing or unclear information. We evaluated the overall certainty of evidence using the GRADE approach.

Main results: We included 12 trials (1080 participants) carried out in the USA (seven trials), India (three trials), and the UK (two trials). Studies were unfunded (one trial), funded by a yoga institution (one trial), funded by non-profit or government sources (seven trials), or did not report on funding (three trials). Most trials used Iyengar, Hatha, or Viniyoga forms of yoga. The trials compared yoga 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). All trials were at high risk of performance and detection bias because participants and providers were not blinded to treatment assignment, and outcomes were self-assessed. Therefore, we downgraded all outcomes to 'moderate' certainty evidence because of risk of bias, and when there was additional serious risk of bias, unexplained heterogeneity between studies, or the analyses were imprecise, we downgraded the certainty of the evidence further.For yoga compared to non-exercise controls (9 trials; 810 participants), there was 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, 95% confidence interval (CI) -0.66 to -0.14; corresponding to a change in the Roland-Morris Disability Questionnaire of mean difference (MD) -2.18, 95% -3.60 to -0.76), moderate-certainty evidence for small to moderate improvements at six months (SMD -0.44, 95% CI -0.66 to -0.22; corresponding to a change in the Roland-Morris Disability Questionnaire of MD -2.15, 95% -3.23 to -1.08), and low-certainty evidence for small improvements at 12 months (SMD -0.26, 95% CI -0.46 to -0.05; corresponding to a change in the Roland-Morris Disability Questionnaire of MD -1.36, 95% -2.41 to -0.26). On a 0-100 scale there was very low- to moderate-certainty evidence that yoga was slightly better for pain at three to four months (MD -4.55, 95% CI -7.04 to -2.06), six months (MD -7.81, 95% CI -13.37 to -2.25), and 12 months (MD -5.40, 95% CI -14.50 to -3.70), however we pre-defined clinically significant changes in pain as 15 points or greater and this threshold was not met. Based on information from six trials, there was moderate-certainty evidence that the risk of adverse events, primarily increased back pain, was higher in yoga than in non-exercise controls (risk difference (RD) 5%, 95% CI 2% to 8%).For yoga compared to non-yoga exercise controls (4 trials; 394 participants), there was very-low-certainty evidence for little or no difference in back-related function at three months (SMD -0.22, 95% CI -0.65 to 0.20; corresponding to a change in the Roland-Morris Disability Questionnaire of MD -0.99, 95% -2.87 to 0.90) and six months (SMD -0.20, 95% CI -0.59 to 0.19; corresponding to a change in the Roland-Morris Disability Questionnaire of MD -0.90, 95% -2.61 to 0.81), and no information on back-related function after six months. There was very low-certainty evidence for lower pain on a 0-100 scale at seven months (MD -20.40, 95% CI -25.48 to -15.32), and no information on pain at three months or after seven months. Based on information from three trials, there was low-certainty evidence for no difference in the risk of adverse events between yoga and non-yoga exercise controls (RD 1%, 95% CI -4% to 6%).For yoga added to exercise compared to exercise alone (1 trial; 24 participants), there was very-low-certainty evidence for little or no difference at 10 weeks in back-related function (SMD -0.60, 95% CI -1.42 to 0.22; corresponding to a change in the Oswestry Disability Index of MD -17.05, 95% -22.96 to 11.14) or pain on a 0-100 scale (MD -3.20, 95% CI -13.76 to 7.36). There was no information on outcomes at other time points. There was no information on adverse events.Studies provided limited evidence on risk of clinical improvement, measures of quality of life, and depression. There was no evidence on work-related disability.

Authors' conclusions: There is low- to moderate-certainty evidence that yoga compared to non-exercise controls results in small to moderate improvements in back-related function at three and six months. Yoga may also be slightly more effective for pain at three and six months, however the effect size did not meet predefined levels of minimum clinical importance. It is uncertain whether there is any difference between yoga and other exercise for back-related function or pain, or whether yoga added to exercise is more effective than exercise alone. Yoga is associated with more adverse events than non-exercise controls, but may have the same risk of adverse events as other back-focused exercise. Yoga is not associated with serious adverse events. There is a need for additional high-quality research to improve confidence in estimates of effect, to evaluate long-term outcomes, and to provide additional information on comparisons between yoga and other exercise for chronic non-specific low back pain.

PubMed Disclaimer

Conflict of interest statement

DECLARATIONS OF INTEREST No known conflicts of interest. RV is a volunteer researcher with Yoga Sangeeta, a non-profit organization which promotes music for meditation and healing.

Figures

1
1
Study flow diagram.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Yoga versus non‐exercise control, Outcome 1 Back‐specific function.
1.2
1.2. Analysis
Comparison 1 Yoga versus non‐exercise control, Outcome 2 Pain.
1.3
1.3. Analysis
Comparison 1 Yoga versus non‐exercise control, Outcome 3 Clinical improvement.
1.4
1.4. Analysis
Comparison 1 Yoga versus non‐exercise control, Outcome 4 Physical quality of life.
1.5
1.5. Analysis
Comparison 1 Yoga versus non‐exercise control, Outcome 5 Mental quality of life.
1.6
1.6. Analysis
Comparison 1 Yoga versus non‐exercise control, Outcome 6 Depression.
1.7
1.7. Analysis
Comparison 1 Yoga versus non‐exercise control, Outcome 7 Adverse events.
2.1
2.1. Analysis
Comparison 2 Yoga versus exercise, Outcome 1 Back‐specific function.
2.2
2.2. Analysis
Comparison 2 Yoga versus exercise, Outcome 2 Pain.
2.3
2.3. Analysis
Comparison 2 Yoga versus exercise, Outcome 3 Clinical improvement.
2.4
2.4. Analysis
Comparison 2 Yoga versus exercise, Outcome 4 Physical quality of life.
2.5
2.5. Analysis
Comparison 2 Yoga versus exercise, Outcome 5 Mental quality of life.
2.6
2.6. Analysis
Comparison 2 Yoga versus exercise, Outcome 6 Adverse events.
3.1
3.1. Analysis
Comparison 3 Yoga plus exercise versus exercise alone, Outcome 1 Back‐specific function at short‐intermediate term (10 weeks).
3.2
3.2. Analysis
Comparison 3 Yoga plus exercise versus exercise alone, Outcome 2 Pain at short‐intermediate term (10 weeks).
4.1
4.1. Analysis
Comparison 4 Sensitivity and subgroup analyses for yoga versus non‐exercise control, Outcome 1 Back‐specific function sensitivity analyses (complete case).
4.2
4.2. Analysis
Comparison 4 Sensitivity and subgroup analyses for yoga versus non‐exercise control, Outcome 2 Back‐specific function sensitivity analyses (change values).
4.3
4.3. Analysis
Comparison 4 Sensitivity and subgroup analyses for yoga versus non‐exercise control, Outcome 3 Back‐specific function sensitivity analyses (higher‐quality studies).
4.4
4.4. Analysis
Comparison 4 Sensitivity and subgroup analyses for yoga versus non‐exercise control, Outcome 4 Back‐specific function sensitivity analyses using generic inverse variance.
4.5
4.5. Analysis
Comparison 4 Sensitivity and subgroup analyses for yoga versus non‐exercise control, Outcome 5 Pain sensitivity analyses (complete case).
4.6
4.6. Analysis
Comparison 4 Sensitivity and subgroup analyses for yoga versus non‐exercise control, Outcome 6 Pain sensitivity analyses (change values).
4.7
4.7. Analysis
Comparison 4 Sensitivity and subgroup analyses for yoga versus non‐exercise control, Outcome 7 Pain sensitivity analyses (higher‐quality studies).
4.8
4.8. Analysis
Comparison 4 Sensitivity and subgroup analyses for yoga versus non‐exercise control, Outcome 8 Pain sensitivity analyses (standardized mean difference).
4.9
4.9. Analysis
Comparison 4 Sensitivity and subgroup analyses for yoga versus non‐exercise control, Outcome 9 Physical quality of life sensitivity analyses (change values).
4.10
4.10. Analysis
Comparison 4 Sensitivity and subgroup analyses for yoga versus non‐exercise control, Outcome 10 Physical quality of life sensitivity analyses (higher‐quality studies).
4.11
4.11. Analysis
Comparison 4 Sensitivity and subgroup analyses for yoga versus non‐exercise control, Outcome 11 Mental quality of life sensitivity analyses (change values).
4.12
4.12. Analysis
Comparison 4 Sensitivity and subgroup analyses for yoga versus non‐exercise control, Outcome 12 Depression sensitivity analyses (complete case).
4.13
4.13. Analysis
Comparison 4 Sensitivity and subgroup analyses for yoga versus non‐exercise control, Outcome 13 Depression sensitivity analyses (change values).
4.14
4.14. Analysis
Comparison 4 Sensitivity and subgroup analyses for yoga versus non‐exercise control, Outcome 14 Subgroup analysis by socioeconomic status (SES) for back‐specific function and pain.
5.1
5.1. Analysis
Comparison 5 Sensitivity analyses for yoga versus exercise, Outcome 1 Back‐specific function sensitivity analyses (complete case).
5.2
5.2. Analysis
Comparison 5 Sensitivity analyses for yoga versus exercise, Outcome 2 Back‐specific function sensitivity analyses using generic inverse variance.
5.3
5.3. Analysis
Comparison 5 Sensitivity analyses for yoga versus exercise, Outcome 3 Pain sensitivity analyses (standardized mean difference).
6.1
6.1. Analysis
Comparison 6 Sensitivity analyses for yoga plus exercise versus exercise alone, Outcome 1 Pain sensitivity analysis (standardized mean difference).
See this image and copyright information in PMC

Comment in

References

References to studies included in this review

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Tekur 2008 {published data only}
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Tilbrook 2011 {published and unpublished data}
    1. Chuang LH, Soares MO, Tilbrook H, Cox H, Hewitt CE, Aplin J, et al. A pragmatic multicentered randomized controlled trial of yoga for chronic low back pain: economic evaluation. Spine 2012;37(18):1593‐601. [PUBMED: 22433499] - PubMed
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    1. Tilbrook HE, Hewitt CE, Aplin JD, Semlyen A, Trewhela A, Watt I, et al. Compliance effects in a randomised controlled trial of yoga for chronic low back pain: a methodological study. Physiotherapy 2014;100(3):256‐62. [PUBMED: 24530169] - PMC - PubMed
Wattamwar 2013 {published data only (unpublished sought but not used)}
    1. Wattamwar RB, Nadkarni K. Effect of conventional occupational therapy and yoga in chronic low back pain. Indian Journal of Occupational Therapy 2013;45(3):13‐20.
Williams 2005 {published data only}
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Williams 2009 {published data only}
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References to studies excluded from this review

Aboagye 2015 {published data only}
    1. Aboagye E, Karlsson ML, Hagberg J, Jensen I. Cost‐effectiveness of early interventions for non‐specific low back pain: a randomized controlled study investigating medical yoga, exercise therapy and self‐care advice. Journal of Rehabilitation Medicine 2015;47(2):167‐73. [PUBMED: 25403347] - PubMed
Anon 2006 {published data only}
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Anon 2009 {published data only}
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Biggs 2012 {published data only (unpublished sought but not used)}
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Bindal 2007 {published data only (unpublished sought but not used)}
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Borg‐Olivier 2005 {published data only}
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CTRI/2012/11/003094 {published data only}
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Groessl 2012 {published data only}
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Haldavnekar 2014 {published data only}
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Hartfiel 2012 {published data only}
    1. Hartfiel N, Burton C, Rycroft‐Malone J, Clarke G, Havenhand J, Khalsa SB, et al. Yoga for reducing perceived stress and back pain at work. Occupational Medicine (Oxford, England) 2012;62(8):606‐12. [PUBMED: 23012344] - PubMed
Horng 2006 {published data only}
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Lee 2014 {published data only}
    1. Lee M, Moon W, Kim J. Effect of yoga on pain, brain‐derived neurotrophic factor, and serotonin in premenopausal women with chronic low back pain. Evidence‐based Complementary and Alternative Medicine : eCAM 2014;2014:203173. [PUBMED: 25120574] - PMC - PubMed
Michalsen 2012 {published data only}
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Monro 2014 {published data only}
    1. Monro R, Bhardwaj AK, Gupta RK, Telles S, Allen B, Little P. Disc extrusions and bulges in nonspecific low back pain and sciatica: exploratory randomised controlled trial comparing yoga therapy and normal medical treatment. Journal of Back and Musculoskeletal Rehabilitation 2015;28(2):383‐92. [PUBMED: 25271201] - PubMed
Patil 2015 {published data only}
    1. Patil NJ, Nagarathna R, Tekur P, Patil DN, Nagendra HR, Subramanya P. Designing, validation, and feasibility of integrated yoga therapy module for chronic low back pain. International Journal of Yoga 2015;8(2):103‐8. [PUBMED: 26170588] - PMC - PubMed
Pushpika 2010 {published data only}
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Sakuma 2012 {published data only}
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Saper 2013 {published data only}
    1. Boah A, Kwong L, Weinberg J, Sherman K, Saper R. P02.60. Characteristics of treatment adherence in low‐income minority participants in a yoga dosing study for chronic low back pain. BMC Complementary and Alternative Medicine 2012;12 (Suppl 1):116. [DOI: 10.1186/1472-6882-12-S1-P116] - DOI
    1. Cerrada C, Weinberg J, Dresner D, Boah A, Sherman K, Saper R. P05.10 Comparison of paper surveys and computer‐assisted telephone interviews in a randomized controlled trial of yoga for low back pain. BMC Complementary and Alternative Medicine 2012;12 (Suppl 1):370. [DOI: 10.1186/1472-6882-12-S1-P370] - DOI
    1. Cerrada CJ, Weinberg J, Sherman KJ, Saper RB. Inter‐method reliability of paper surveys and computer assisted telephone interviews in a randomized controlled trial of yoga for low back pain. BMC Research Notes 2014;7:227. [PUBMED: 24716775] - PMC - PubMed
    1. Keosaian J, Dresner D, Cerrada C, Kwong L, Goodman N, Tam M, et al. P02.127. Recruitment strategies for community‐based yoga research in a predominant minority population. BMC Complementary and Alternative Medicine 2012;12 (Suppl 1):183. [DOI: 10.1186/1472-6882-12-S1-P183] - DOI
    1. Keosaian JE, Lemaster CM, Dresner D, Godersky ME, Paris R, Sherman KJ, et al. "We're all in this together": a qualitative study of predominantly low income minority participants in a yoga trial for chronic low back pain. Complementary Therapies in Medicine 2016;24:34‐9. [PUBMED: 26860799] - PMC - PubMed
Selfridge 2012 {published data only}
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Telles 2009 {published data only}
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References to studies awaiting assessment

Kim 2014 {published data only}
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Kumar 2011 {published data only}
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NCT01303588 {published data only}
    1. NCT01303588. Yoga and Qigong for elderly patients with chronic low back pain. clinicaltrials.gov/ct2/show/NCT01303588 Date first received: 24 February 2011.
Saper 2015 {published data only}
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    1. Egan S, Saper R. P02.47 Predictors of adherence to treatment for chronic low back pain in a 12‐week RCT comparing yoga, physical therapy, and education. Journal of Alternative and Complementary Medicine (New York, N.Y.) 2014;20(5):A56.
    1. Lemaster C, Keosaian J, Dorman E, Paris R, Saper R. P02.56 Qualitative study in a randomized trial comparing yoga, physical therapy, and education for low back pain in a predominantly minority population. Journal of Alternative and Complementary Medicine (New York, N.Y.) 2014;20(5):A59.
    1. NCT01343927. Yoga vs. physical therapy vs. education for chronic low back pain in minority populations (Back to Health). clinicaltrials.gov/ct2/show/NCT01343927 Date first received: 20 April 2011.
    1. Saper R, Weinburg J, Delitto A, Lemaster C, Herman P, Sherman K. A randomized controlled trial comparing yoga, physical, therapy, and education for chronic low back pain in predominantly low income minorities. Integrative Medicine Research 2015;4(1):24.

References to ongoing studies

NCT02224183 {published data only}
    1. NCT02224183. Veterans Back to Health: a study comparing yoga and education for veterans with chronic low back pain. clinicaltrials.gov/ct2/show/NCT02224183 Date first received: 20 August 2014.
NCT02524158 {published data only}
    1. NCT02524158. Yoga therapy to improve function among veterans with chronic low back pain. clinicaltrials.gov/ct2/show/NCT02524158 Date first received: 10 August 2015.
NCT02552992 {published data only}
    1. NCT02552992. Yoga for chronic low back pain and its mechanism of action: impact of strength and stretch (YoMA II). clinicaltrials.gov/ct2/show/NCT02552992 Date first received: 18 August 2015.

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