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Yoga as an Effective Treatment for Chronic Low Back Pain

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  • 1. Yoga as an Effective Treatment for Chronic Low Back Pain Kimberly Williams, Ph.D, Certified Iyengar Yoga Instructor Research Assistant Professor Community Medicine West Virginia University
  • 2. Low Back Pain
    • Public health problem of epidemic proportions
    • 80% of adults will have low back pain
    • 5th most frequent reason for doctor’s visit
    • most expensive musculoskeletal disorder
    • largest category of medical claims
    • absenteeism and disability payments for work-related low back pain cost 3x medical treatment for low back pain
  • 3. Complementary Alternative Medicine
    • In 1990, 1 in 3 Americans were treated by CAM Providers
    • CAM Usage increased from 33.8% to 42.1 % from 1990 to 1997
    • Yoga is regarded as a CAM modality by NIH
    • Yoga falls outside standard medical education and practice in the US
  • 4.
    • Stiff muscles due to poor posture, lack of exercise, genetic conditions or mental stress
    • Stiffness could be in rotational, flexion, lateral bending or back bending movements
    • Sudden strenuous activity may tear or overstrain stiff muscles
    Mechanical Low Back Pain
  • 5. Randomized Controlled Trials of Yoga
    • Osteoarthritis*
    • Carpel tunnel syndrome*
    • Multiple sclerosis*
    • Bronchial asthma
    • Pulmonary tuberculosis
    • Drug addiction
    • Hypertension
    • Diarrhea-predominant IRB
    • Lymphoma
    • Mild Depression*
  • 6. Scientific Studies of Yoga and Chronic LBP
    • Vidyasagar et al. 1989
      • Effect of Hatha Yoga on nonspecific LBP (n=35)
      • 76% of the cases reported pain relief
      • Three phases, each three weeks long
      • Based on performance of classical back bending postures for 45 minutes per day with 10 min rest in between poses
  • 7. Vidyasagar et al. (1989) Clin Proc NIMS (1989) 4:160
    • Poses modified in 5 cases because of severe pain to include Pavana Mukthasana and Ardha uttanasana in phase 1
    • 7 cases were discontinued because no pain relief was obtained
  • 8. Vidyasagar et al. (1989) Clin Proc NIMS (1989) 4:160
    • Limitations of the study
      • No control group
      • Small sample size
      • Method for assessing pain was not described
      • No long term follow-up
      • According to BKS Iyengar back extensions used are harmful to persons with LBP who are not trained in the intricate movements of the pose
  • 9. Galantino et al. (2004) Altern. Ther. Health Med. 10:60-3.
    • n=22 self-referred persons with CLBP
    • Randomized to a 6-week modified hatha yoga program (2x/week) or to a wait list control
    • Yoga program included diaphragmatic breathing, postures and meditation
  • 10. Galantino et al. (2004) Altern. Ther. Health Med. 10:60-3.
    • Disability – 40% control and 46% of yoga group reported less disability
    • Depression – 20% control and 54% of yoga group had lower depression
    • Functional reach – 20% control and 64% yoga group improved
    • Sit and reach – 20% control and 90% yoga group improved
  • 11. Galantino et al. (2004) Altern. Ther. Health Med. 10:60-3.
    • Limitations of the study
      • Not powered to obtain statistical differences between groups
      • High drop out rate in control group
      • Large baseline differences in secondary measures
  • 12. Jacobs et al (2004) Altern. Ther. Health Med. 10:80-3.
    • N=52 persons with CLBP
    • randomized into Iyengar yoga or wait list control group.
    • Yoga Program
      • Classes (2x/week for 12 weeks) plus home practice (30 min x 5 days/week)
  • 13. Jacobs et al (2004) Altern. Ther. Health Med. 10:80-3.
    • Outcomes
      • Pain intensity
      • Quality of life
      • Functional disability
      • Depression
      • Anxiety
      • Global expectation
  • 14. Jacobs et al (2004) Altern. Ther. Health Med. 10:80-3.
    • Adherence to yoga intervention
      • 64% attended yoga intervention
      • 84% completed the study
    • Efficacy of Iyengar yoga intervention
      • Not published
  • 15. Differences between two studies of Iyengar Yoga
    • Different selection of poses used
      • Jacobs et al. (2004) study:
        • Lack of resting phase of treatment prior to more active corrective phase
        • Inclusion of back bending poses
    • Length of the study
      • Jacobs et al. 12 weeks @ 2x/week
      • Current study 14 weeks @ 1x/week
  • 16. Fear of Movement / re-injury Disability Disuse Depression Painful experiences Catastrophizing Injury Non-catastrophizing Confrontation Recovery Avoidance   Cognitive-behavioral model of fear of movement/(re)injury  
  • 17. Hypotheses
    • 1. Yoga therapy will decrease pain intensity, functional disability and pain medication usage.
    • 2. Yoga therapy will decrease maladaptive pain-related attitudes and behaviors.
  • 18. Inclusion Criteria
    • mechanical low back pain
    • recurrent symptoms lasting more than 3 months
    • ambulatory
    • 18 years and older
    • english speaking
  • 19. Exclusion Criteria
    • Non-mechanical low back pain due to:
      • nerve root compression
      • disc prolapse
      • spinal stenosis (Cauda Equina Syndrome)
      • spinal infection
      • tumor
      • alkylosing spondylisis
      • spondylolisthesis
  • 20. Exclusion Criteria cont’d
    • widespread neurological disorder
    • major depression
    • substance abuse
    • unstable angina
    • Pregnant
    • BMI > 35
    • pre-surgical candidates
    • involved in litigation or compensation
    • Undergoing other non-medical or CAM treatment
  • 21. 196 - Self Referred From Local Advertisements 14 – Referred by Physician 210 – Interested in Participation 140 – Excluded: 38 – did not meet inclusion criteria. 102 – unable participate 70 - Eligible 60 – Randomized at Baseline 30 – Randomly Assigned to Educational Control Group 30 – Randomly Assigned to Yoga Treatment Group 6 – Dropouts: 3 – lost to follow-up 2 – ineligible to other CAM use 1 – no show at baseline 10 – Dropouts: 3 –no shows after baseline 2 – medically ineligible 3 – quit 1 – adverse event 1 – unwilling to perform active postures 24 – Assessed at 16 Week Post Test 20 – Assessed at 16 Week Post Test 22 – Assessed at 3 Month Follow-up 20 – Assessed at 3 Month Follow-up 10 – Unable to participate 1 – lost to follow up 1 - died
  • 22. Interventions
    • Both groups attended 2 lectures by PT and OT and received 16 weekly newsletters with tips for recovery from LBP
    • Yoga group attended 90 min yoga therapy class once per week for 16 weeks and encouraged to practice 30 mins per day at home.
  • 23. Restorative Poses
    • Savasana II
    • Prone savasana
    • Lumbar traction
    • Prone Supta padangusthasana
    • Supta Pavanmuktasana
    • Supta Padangusthasana I and II
    • Supported Baddha Konasana
    • Adho Mukha Virasana
  • 24.  
  • 25.  
  • 26.  
  • 27.  
  • 28.  
  • 29. Standing and Seated Forward Bends
    • Pavanmuktasana (bench)
    • Uttanasana (stool)
    • Ardha uttanasana (halasana box)
    • Adho Mukha Svanasana (upper wall ropes; lower wall ropes)
    • Concave Prasarita Padottanasana (bench)
    • Concave Parsvottanasana (lower rope)
    • Utthita Padmasana (stool)
    • Adho Muhka Sukasana (bolster)
  • 30.  
  • 31.  
  • 32.  
  • 33.  
  • 34.  
  • 35.  
  • 36. Standing poses
    • Tadasana with block between the legs
    • Utthita Hasta Padangusthasana I and II with bent knee and straight leg
    • Trikonasana (at trestler with traction)
    • Virabdrasana II (at trestler with traction)
    • Parsvakonasana (at trestler)
    • Parivritta Trikonasana (trestler)
  • 37.  
  • 38.  
  • 39.  
  • 40.  
  • 41.  
  • 42.  
  • 43. Lateral Forward Bends and Twists
    • Parsva Pavanmuktasana on the bench
    • Maricyasana III at trestler
    • Bharadvajasana (chair)
    • Parivritta Hasta Padangusthasana III straight leg supported on stool at trestler
    • Utthita Parsva Padmasana
    • Parsva Sukasana
  • 44.  
  • 45.  
  • 46.  
  • 47.  
  • 48.  
  • 49. Inversions
    • Urdhva Prasarita Padasana
    • Supported Halasana
  • 50.  
  • 51.  
  • 52. Adherence Rates
    • 70% completion rate
    • 92% attendance to yoga classes amongst completers in the yoga group
  • 53. Primary Outcomes
    • Pain intensity
        • Measured by rating of present pain on SF-McGill Questionnaire
    • Pain Medication Usage
    • Functional disability
        • Measured with the Pain Disability Index (PDI)
  • 54. Secondary Outcomes
    • Self-reported measures of pain-related psychological and behavioral factors including:
        • pain attitudes
        • fear of movement
        • coping with pain
        • self-efficacy
  • 55. Demographic and Medical Characteristics of Participants 0.4891 29.5 35.0 25.0 % using CAM 0.7049 47.7 45.0 50.0 %Taking Meds 0.9232 11.2 ± 1.54 11.3 ± 2.37 11.0 ± 2.07 Years History of LBP 40.9 50.0 33.3 $50 – 100,000 47.7 45.0 50.0 $20 – 49,000 0.3491 11.4 5.0 16.7 $10 – 19,000 Income (%) 75.0 80.0 70.8 College 0.4844 25.0 20.0 29.2 High School Education level (%) 31.8 35.0 29.2 Male 0.6791 68.2 65.0 70.8 Female Gender (%) 0.8094 48.3 ± 1.50 48.7 ± 2.38 48.0 ± 1.96 Mean age -yr ( ± SE )  -value All (N=44) Yoga (N=20) Control (N=24) Characteristic GROUP
  • 56. Results of Multivariate Analysis
    • Significant between group differences for:
      • Present pain
      • Functional disability
      • Pain medication usage
  • 57. : * Figure 1: Present Pain Intensity : *
  • 58. Figure 3: Functional Disability : * : *
  • 59. Table 3: Change in Pain Medication Usage for CLBP (n) (n) Group P-value Yoga Control Outcome Assessment Success = Stopped or decreased medication use Failure = No change or increased medication use 1 9 Failure 0.007* 15 10 Success 3-Month Follow Up 2 11 Failure 0.002* 14 6 Success Post
  • 60. Conclusions
    • Adults with CLBP volunteered for and adhered to a 16–week Iyengar yoga therapy program.
    • Significant between group differences were reported after completion of the program. Improvements were maintained at 3-month follow-up.
  • 61. Conclusions
    • Subjects who participated in yoga therapy reported:
        • 65% less pain.
        • 77% less functional disability.
        • 88% decrease in pain medication usage.
  • 62. Limitations of the Study
    • Population with less severe pain and disability
    • Too many outcomes
    • Lack of attention control
    • No long term follow-up
    • Too many complex postures in too little time in yoga therapy intervention
  • 63. NIH-funded study
    • 90 subjects with moderate to severe CLBP
    • Same primary outcomes plus medical utilization
    • Replaced analysis by protocol by intention to treat data analysis
    • Lengthened intervention (from 16 to 24 weeks) with more frequent classes (2x/week)
    • Compare 24 weeks of yoga therapy to standard medical care (wait list control)
  • 64. Study Design Telephone Screening by RA Eligible Meeting with RA at HSC Screening Consent Form Screening Questionnaires (BDI, CAGE, TSK, PCS, VAS, ODQ) Meeting with MDs at POC Physical Exam Diagnosis of LBP Ineligible Exclusion Criteria Inclusion Criteria Eligible Ineligible
  • 65. Study Design (cont.) Baseline Assessment by RA Consent & PHI forms, BDI, VAS, ODQ Pain Medication Usage Interview Expectation of Outcome of Treatment Options Randomization Expectation of Outcome of Treatment Options Yoga Therapy Intervention 2 classes/week; 90 minutes/class 30 minute home practice 5x/week Wait List Control Receive Standard Medical Care Monthly Phone Calls 12 Week Assessment at HSC by RA VAS, ODQ, BDI, Pain Medication Usage Interview 24 Week Assessment at HSC by RA VAS, ODQ, BDI, Pain Medication Usage Interview Compare Retrospective Medical Claims Analysis
  • 66. Inclusion Criteria
    • Chronic low back pain for 3 months or more due to:
      • SI Sprain
      • Sciatica
      • Scoliosis
      • Kyphosis
      • Osteoarthritis / degenerative disc disease
      • Bulging & herniated disc w/o foot drop, weakness or loss of reflexes
  • 67. Inclusion Criteria (cont.)
    • 18 – 65 years of age
    • English speaking
    • Ambulatory
    • PEIA, The Health Plan (WVUH), Mountain State BC/BS, Mon Health System insured
    • Live within 60 minute drive of Morgantown
    • Agree not to use acupuncture, massage therapy, Pilates, or chiropractic treatment
    • Agree not to do yoga if in non-yoga group
    • Agree to participate in 20 of 24 classes & not miss more than 2 consecutive classes
  • 68. Exclusion Criteria
    • Spinal stenosis with neurogenic pain
    • Abdominal or spinal tumor
    • Spinal infection
    • Osteoporosis
    • Ankylosing spondylitis
    • Spondylolisthesis
    • Radicular pain w foot drop, weakness, or loss of reflexes
    • Chronic fatigue or other pain syndromes
    • Widespread neurological disorder
    • Uncontrolled BP (SBP > 180; DSP > 110)
  • 69. Exclusion Criteria (cont.)
    • Exertional chest discomfort and/or shortness of breath
    • Inability to climb 1 flight of stairs or walk 50 yards w/o discomfort
    • Inability to lie flat w/o shortness of breath
    • Pre surgical candidate
    • Involved in litigation or compensation
    • Substance abuse
    • Major depression
    • Pregnant
    • BMI > 37
    • Practice yoga in past year
  • 70. Mean Age
  • 71. Cohort 1: Gender
  • 72. Cohort 1: Race/Ethnicity
  • 73. Cohort 1: Highest Level of Education
  • 74. Cohort 1: Employment
  • 75. Cohort 1: Household Income
  • 76. Years of Back Pain *n = 24
  • 77. Back Pain Diagnoses *please note, subjects may be assigned more than one diagnosis (total = 50)
  • 78. To find out if you are eligible
    • Call 293-back (2225)

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