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

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

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

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

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

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

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

Randomized Controlled Trials of Yoga Osteoarthritis* Carpel tunnel syndrome* Multiple sclerosis* Bronchial asthma Pulmonary tuberculosis Drug addiction Hypertension Diarrhea-predominant IRB Lymphoma Mild Depression*

Osteoarthritis*

Carpel tunnel syndrome*

Multiple sclerosis*

Bronchial asthma

Pulmonary tuberculosis

Drug addiction

Hypertension

Diarrhea-predominant IRB

Lymphoma

Mild Depression*

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

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

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

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

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

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

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

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

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

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

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

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

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)‏

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)‏

Jacobs et al (2004) Altern. Ther. Health Med. 10:80-3. Outcomes Pain intensity Quality of life Functional disability Depression Anxiety Global expectation

Outcomes

Pain intensity

Quality of life

Functional disability

Depression

Anxiety

Global expectation

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

Adherence to yoga intervention

64% attended yoga intervention

84% completed the study

Efficacy of Iyengar yoga intervention

Not published

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

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

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

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.

1. Yoga therapy will decrease pain intensity, functional disability and pain medication usage.

2. Yoga therapy will decrease maladaptive pain-related attitudes and behaviors.

Inclusion Criteria mechanical low back pain recurrent symptoms lasting more than 3 months ambulatory 18 years and older english speaking

mechanical low back pain

recurrent symptoms lasting more than 3 months

ambulatory

18 years and older

english speaking

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

Non-mechanical low back pain due to:

nerve root compression

disc prolapse

spinal stenosis (Cauda Equina Syndrome)‏

spinal infection

tumor

alkylosing spondylisis

spondylolisthesis

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

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

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

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.

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.

Restorative Poses Savasana II Prone savasana Lumbar traction Prone Supta padangusthasana Supta Pavanmuktasana Supta Padangusthasana I and II Supported Baddha Konasana Adho Mukha Virasana

Savasana II

Prone savasana

Lumbar traction

Prone Supta padangusthasana

Supta Pavanmuktasana

Supta Padangusthasana I and II

Supported Baddha Konasana

Adho Mukha Virasana

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)‏

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)‏

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)‏

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)‏

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

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

Inversions Urdhva Prasarita Padasana Supported Halasana

Urdhva Prasarita Padasana

Supported Halasana

Adherence Rates 70% completion rate 92% attendance to yoga classes amongst completers in the yoga group

70% completion rate

92% attendance to yoga classes amongst completers in the yoga group

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)‏

Pain intensity

Measured by rating of present pain on SF-McGill Questionnaire

Pain Medication Usage

Functional disability

Measured with the Pain Disability Index (PDI)‏

Secondary Outcomes Self-reported measures of pain-related psychological and behavioral factors including: pain attitudes fear of movement coping with pain self-efficacy

Self-reported measures of pain-related psychological and behavioral factors including:

pain attitudes

fear of movement

coping with pain

self-efficacy

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

Results of Multivariate Analysis Significant between group differences for: Present pain Functional disability Pain medication usage

Significant between group differences for:

Present pain

Functional disability

Pain medication usage

: * Figure 1: Present Pain Intensity : *

Figure 3: Functional Disability : * : *

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

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.

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.

Conclusions Subjects who participated in yoga therapy reported: 65% less pain. 77% less functional disability. 88% decrease in pain medication usage.

Subjects who participated in yoga therapy reported:

65% less pain.

77% less functional disability.

88% decrease in pain medication usage.

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

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

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)‏

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)‏

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

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

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

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

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

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

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)‏

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)‏

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

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

Mean Age

Cohort 1: Gender

Cohort 1: Race/Ethnicity

Cohort 1: Highest Level of Education

Cohort 1: Employment

Cohort 1: Household Income

Years of Back Pain *n = 24

Back Pain Diagnoses *please note, subjects may be assigned more than one diagnosis (total = 50)‏

To find out if you are eligible Call 293-back (2225)‏

Call 293-back (2225)‏