Running head: REDUCING LOW BACK PAIN AND INCREASING FUNCTION 1

Reducing Low Back Pain and Increasing Functionality Using Yoga

Ramsey Valdes

University of South Florida

REDUCING LOW BACK PAIN AND INCREASING FUNCTION 2

Abstract

Clinical Problem: For adult patients with chronic low back pain (CLBP), current treatment such

as analgesic medications, physical therapy, and surgery lack effectiveness (Sherman et al., 2011).

Objective: The objective of this synthesis is to discuss if yoga can increase back functionality

and decrease level of pain among patients suffering from CLBP. PubMed was used to discover

randomized controlled trials (RCT) concerning the use of yoga to treat pain and increase

function. The key search terms included: chronic low back pain and yoga.

Results: In patients with CLBP, those who used yoga as a treatment method showed a

statistically significant increase in back function and a decrease in overall pain. Sherman et al.

(2011) found that participants who did yoga had improved function (p<.004) and were less

bothered by their pain (p<.05). Tekur, Nagarathna, Chametcha, Hankey, and Nagendra (2012)

established that CLBP patients who joined a yoga program decreased their pain by 49% and

increased sit and reach spinal mobility scores compared to physical therapy patients. In Tilbrook

et al. (2011), patients who attended yoga classes decreased Roland Morris Disability

Questionnaire (RMDQ) by 2.17. Finally in Monro et al. (2015), the yoga group saw a decrease

in RMDQ by 3.29 points and pain (p=.006). Yoga has a mental and physical approach that can

be beneficial in patients with CLBP.

Conclusion: Yoga, with its mental and physical approach to well-being, has been shown to

increase back functionality; however, the results of yoga to reduce back pain differ depending on

the study. Due to this difference and lack of research on yoga’s effect on back pain, more

investigation is required to determine the absolute effectiveness of yoga on CLBP patients.

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Reducing Low Back Pain and Increasing Functionality Using Yoga

Chronic low back pain (CLBP), a physically and mentally challenging condition, is a

prevalent problem with one in five adults being affected in their lifetime (Tekur, Nagarathna,

Chametcha, Hankey, & Nagendra, 2012). Current treatment options lack effectiveness but

include analgesic medication, physical therapy, and in some cases, surgery (Sherman et al.,

2011). Yoga is an exercise program with a mental focus on self-awareness, good posture, self-

care, stretching, and relaxation (Tilbrook et al., 2011). Yoga, with its mental and physical

approach to well-being, is postulated to be an effective treatment to reduce pain and increase

back functionally for those tormented with CLBP (Tilbrook et al., 2011). In adults with CLBP,

how does yoga, compare to traditional treatment in reducing back pain and increasing

functionality over three months?

Literature Search

PubMed was used to locate randomized controlled trials (RCT) containing information

about the use of yoga to decrease pain and increase back function in patients with CLBP. The

key search terms were yoga and chronic low back pain. The publication years were set to the

last 10 years (2008-2018) and the RCT setting was engaged. Studies were excluded if

participants were children and included if participants were adults.

Literature Review

In order to assess the effectiveness of yoga on the reduction of pain and increase in back

function for CLBP patients, four RCT were retrieved and evaluated for yoga’s outcomes.

Sherman et al. (2011) aimed to establish whether performing yoga was more effective in

improving function and reducing low back pain symptoms than stretching exercises or handing

out a self-care book to patients with CLBP. This trial was a randomized three-arm parallel

group stratified control trial that used a modified 23-point Roland Disability Questionnaire
REDUCING LOW BACK PAIN AND INCREASING FUNCTION 4

(RDQ) and an eleven-point bothersomeness pain scale. The bothersomeness scale is the

researchers pain measurement tool and the RDQ measures ability based on the perception of the

participant. The researchers studied 228 adults with CLBP, separated into three groups: a 12

weekly yoga class group (n=92), a conventional stretching exercise class group (n=91), and a

self-care book group (n=45). The adults who participated in this study had to have CLBP not

due to an underlying cause, and pain greater than a 3 on the pain scale at screening. Participants

attended weekly classes and reported their outcomes on the RDQ and the bothersomeness scale.

The outcomes were measured at baseline, 6, 12, and 26 weeks through a masked interview. At

the three-month mark (12 weeks), the participants in classes, both yoga and stretching, improved

on their RDQ scores by 50% compared to the self-care book group who had an improvement of

23% (p<.004). The yoga group also reported that they were less bothered by their pain than the

self-care group (p<.05). The strengths of this RCT included: participants being randomly

assigned to their groups, enrolling subjects not having knowledge of participants, reasons for not

completing study were included, and single-blinding researchers. Other strengths included:

participants were analyzed in their groups and demographics of each group were similar, and the

intervention each person participated in was the only difference between the groups; the

participants were compared to their original. The weaknesses of the study included: no follow

up past 26 weeks, and measures were valid but not reliable as answers can vary based on any

given day.

Tekur, Nagarathna, Chametcha, Hankey, and Nagendra (2012) aimed to study the effects

of yoga compared to traditional physical therapy exercises on pain, anxiety, depression, and

spinal mobility in patients with CLBP. The study’s design was a RCT that used a numerical pain

scale and a ‘sit and reach’ spinal mobility instrument to measure results. Eighty adults, aged 16-

60 years, with CLBP, participated in the trial. The participants were split into two groups a yoga
REDUCING LOW BACK PAIN AND INCREASING FUNCTION 5

program (n=40) and a control physical therapy program (n=40). Adults whose CLBP was due to

organic pathology were not considered for the study. Participants were measured prior to the

beginning of the study and then attended seven days of classes of their specified program. They

were then interviewed in their groups on the measurement scales after completion of the seven

days. The adults in the yoga group showed reduced pain by 49% (p<.001), while the physical

therapy group showed a 17.5% decrease compared to the original scores. The yoga group and

physical therapy group both showed an increase sit and reach score but the difference between

the groups was not significant. The strengths of this RCT included: randomly assigned

participation, concealment of assignment from enrolling party, single-blind study used,

participants were analyzed in their groups and the groups had similar demographics, an

appropriate control, and no participants dropped out. The weaknesses include lack of follow up

assessment and methods were valid but not reliable as answers to the pain scale may vary based

on individual day.

Tilbrook et al. (2011), an RCT, aimed to compare the effectiveness of yoga and

traditional care on CLBP and back function. The researchers gathered data using a Roland-

Morris Disability Questionnaire (RMDQ) and a pain self-efficacy and general health measures

assessment at 3, 6, and 12 months. A study of 313 adults with CLBP were split into a yoga

group (n=156) and a usual care group (n=157). All adults received an education booklet and the

yoga group attended 12 classes over three months, while the control group continued their usual

care. Participants then sent in their questionnaires by mail at the beginning of the study and at

the end of the 3, 6, and 12-month marks. The RMDQ scores for the yoga participants were an

average of 2.17 lower than at the beginning of the study. At the three months, the yoga and

control groups had similar back pain scores. The strengths of the RCT included: random

assignment, reasons for noncompletion were included, follow up assessment were done up to a
REDUCING LOW BACK PAIN AND INCREASING FUNCTION 6

year, analysis was done in assigned group, and control was appropriate. The weaknesses of the

study included: valid but unreliable measures, random assignment was not concealed from

enrolling party, and participants and providers were not blinded to group allocation.

Monro et al. (2015) aimed to evaluate the efficacy of yoga on pain and disability for

those with nonspecific CLBP due to disc extrusions and bulges. This was a RCT that used the

RMDQ, Aberdeen Low Back Pain Scale, a straight leg raise test and structural changes as

outcome measurements at baseline and 3months. Researchers randomized 61 adults with CLBP,

aged 20-45 years, from a rural population into a yoga group (n=30) and a control group (n=31).

The yoga group did three months of classes and were given exercises for home practice, while

the control group received normal medical care. Measurements were taken at baseline and after

three months. The results showed that the yoga group had a 3.29-point decrease on the RMDQ

showing an increase in ability (p=.006) but there were no other significant differences in

measurements. The strengths of this study included: randomly assigned participants, analysis

was done in assigned groups, control was appropriate, and random assignment was concealed

from enrolling party. The weaknesses included: valid but unreliable measures, follow up was not

completed past the three-month mark, and participants were not blinded to their assigned groups.

Synthesis

Sherman et al. (2011) demonstrated that patients in the yoga group had a 50%

improvement on their RDQ scores showing increased function (p<.004) and were less bothered

by their pain (p<.05). Similarly, Tekur, Nagarathna, Chametcha, Hankey, and Nagendra (2012),

reported that CLBP patients in the yoga group had a decrease in pain by 49% (p<.001) and an

increase in sit and reach scores measuring ability. Tilbrook et al. (2011) showed that CLBP

participants that did yoga had RMDQ scores 2.17 points lower than at the start of the study but

pain scores had no statistically significant difference. Finally, Monro et al. (2015) showed that
REDUCING LOW BACK PAIN AND INCREASING FUNCTION 7

the yoga participants had a 3.29-point decrease on the RMDQ showing an increase in function

(p=.006).

These four studies compared yoga to other different normal medical treatment such as

physical therapy. While the studies support that yoga increases function, the results on pain are

inconclusive with most studies reporting a decrease in pain. Due to the discrepancy on yoga for

pain, more research should be conducted to find a connection between relief of pain and yoga.

New research focusing on the mental aspect in the relief of some pain would be beneficial.

Clinical Recommendations

Yoga has been demonstrated to be an effective regimen for those suffering from CLBP

compared to normal medical treatments such as analgesics and physical therapy. There are not

yet guidelines for yoga’s use as a treatment for CLBP, although it has been shown with certainty

to increase functionality and in some cases relieve pain (Sherman et al., 2011; Tekur,

Nagarathna, Chametcha, Hankey, & Nagendra, 2012; Tilbrook et al., 2011; Monro et al., 2015).

CLBP’s current treatment is ineffective with patients continually having pain and an inability to

move fluidly. Therefore, yoga with its approach to stretching and mindfulness could aid patients

to decrease pain and increase back function and should be considered as a treatment option for

those with CLBP.

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References

Monro, R., Bhardwaj, A. K., Gupta, R. K., Telles, S., Allen, B., & Little, P. (2015). 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, 28(2), 383-392. doi:10.3233/bmr-140531

Sherman, K., Cherkin, D., Wellman, R., Cook, A., Hawkes, R., Delaney, K., & Deyo, R. (2011).

A randomized trial comparing yoga, stretching, and a self-care book for chronic low back

pain. Archives of Internal Medicine, 171(22), 2019. doi:10.1001/archinternmed.2011.524

Tekur, P., Nagarathna, R., Chametcha, S., Hankey, A., & Nagendra, H. (2012). A comprehensive

yoga programs improves pain, anxiety and depression in chronic low back pain patients

more than exercise: An RCT. Complementary Therapies in Medicine, 20(3), 107-118.

doi:10.1016/j.ctim.2011.12.009

Tilbrook, H., Cox, H., Hewitt, C., Kang'ombe, A., Chuang, L., JayaKody, S., . . . Torgerson, D.

(2011). Yoga for chronic low back pain: A randomized trial. Ann Intern Med.

doi:10.7326/0003-4819-155-9-201111010-00003