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Three Part Question

In [patients with chronic lower back pain] would [yoga] help in [treatment of pain relief and functional ability?]

Clinical Scenario

A 40 year old man presents with an acute on chronic exacerbation of lower back pain after lifting. He has no other symptoms. He has suffered minor injuries to his back while playing rugby in his twenties and thirties. He spends most of his working time at a desk. The pain is usually improved with pain relief. He wishes to know if yoga can help to improve the chronic pain.

Search Strategy

An advanced Medline search (1996 - Jan 2007) using lower back pain and yoga as thesaurus mapped terms via an Athens portal.
{low back pain OR lumbar vertebrae OR intervertebral disk displacement OR pain OR spinal diseases} AND {yoga}

Search Outcome

39 articles were found of which only 4 related to the use of yoga in the treatment of lower back pain.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Galantino et al Mar-Apr 2004 USA	Patients with chronic lower back pain presenting between the ages of 30 and 65	Randomised pilot study	Forward reach and sit reach tests	Improved flexibility	Pilot group not powered to reach statistical significance. There was a high dropout in the control group and large differences in the baseline for the seconday measures ie depression and disability.
			Oswestery disability index	Decreased disability
			Beck depression inventory	Decreased depression
Graves et al Aug 2004 USA		Review article of evidence based literature	Review of articles	Limited studies - overall encourages yoga	Limited evidence based studies
			Recommendations from other sources	Poor - some recommendations of exercise but no mention of yoga
Williams et al May 2005 USA	Patients with lower back pain for 11.2+/-1.54 years with 48% of the group using pain medication.	Randomised control trial.	Functional disability	Improved	30% drop-out rate from study.
			Pain intensity	Decreased
			Pain medication	Requirements decreased
			Psychological and behavioral outcomes	No significant difference
Sherman et al Dec 2005 USA	101 patients with chronic low back pain aged between 20 and 64 years old who had presented to primary care 3-15 months before the study.	Randomised control study of yoga classes vs exercise vs a self care book	Back related functional status (modified 24 point Roland Disability scale)	yoga group superior improvement to exercise and self care group	Participants were only followed for 26 weeks following randmisation. Only one instructor was used in each intervention.
			general health status	no significant difference
			medication use	decreased in the yoga group more than the other 2 groups

Comment(s)

The current work on yoga and back pain is limited. However, the aforementioned papers show level 1 evidence in their main primary objectives of improved movement and decreased requirements of pain medication. The studies are all relatively short term and the outcome is patient compliance related.

Clinical Bottom Line

With a well motivated patient regular yoga can show improvement in pain and improve functional movement.

References

1. Galantino M-L. Bzdewka TM. Eissler-Russo JM. Holbrook ML. Mogck EP. Geigle P. Farrar JT. The impact of modified Hatha yoga on chronic lower back pain : a pilot study Alternative therapies in health and medicine Mar-Apr 2004; vol. 10 no. 2 : p 56-9
2. Graves N. Krepcho M. Mayo H.G. Hill J. Clinical enquires. Does yoga speed up healing for patients with lower back pain? The Journal of Family Practice Aug 2004, vol. 53, no. 8, p661-2
3. Williams K. A. Petronis J. Smith D. Goodrich D. Wu J. Ravi N. Doyle E.J.Jr Gregory J.R. Munoz K.M. Gross R. Steinberg L. The effect of Iyengar yoga therapy for chronic low back pain Pain May 2005, vol.115, no. 1-2, p107-17
4. Sherman K.J. Cherkin D.C. Erro J. Miglioretti D.L. Deyo R.A. Comparing yoga, exercise and a self-care book for chronic low back pain: a randomised control trial Annals of internal medicine 20 Dec 2005, vol. 143, no. 12, p849-56