Can Yoga and Stretching Exercises Relieve Chronic Low Back Pain?
Yoga and stretching interventions that emphasize the safe performance of individual poses and special breathing techniques can minimize the risk for injury and discomfort in patients experiencing chronic low back pain.
Karen J. Sherman, PhD, MPH, is a senior investigator at Group Health Research Institute, Seattle, Washington, and affiliate associate professor in the Department of Epidemiology at University of Washington School of Public Health, also in Seattle. Practical Pain Management talked with Dr. Sherman about her recently published study, which investigated whether yoga is more effective than stretching or self-care for chronic low back pain.1
PPM: What are the key findings from your study?
Dr. Sherman: Compared with a self-care book, yoga classes and intensive stretching classes were linked to significantly better back-related function and decreased symptoms from chronic low back pain at the end of a 12-week class series. Improvements in back-related function continued for at least 14 more weeks, and the benefits seen were clinically relevant. Yoga was not more effective than stretching at any time point, which contradicted our hypothesis.
Compared with the self-care group (n=45), patients in the yoga group (n=92) showed superior function at 12 and 26 weeks (mean difference, –2.5 and –1.8, respectively). Similarly, the stretching group (n=91) reported superior function at 6, 12, and 26 weeks (–1.7, –2.2, and –1.5, respectively) compared with the self-care group.
PPM: What implications can be made regarding the similar effect of both yoga and exercise on primary outcomes?
Dr. Sherman: Most importantly, from a clinical perspective, both of these interventions had benefits for patients. From a mechanistic perspective, it’s conceivable that the benefits from both of these interventions were largely physical or that both therapies had some benefits on the mind as well.
PPM: What exercise protocols were used in the yoga and stretching interventions? What areas of the body did the interventions target?
Dr. Sherman: In the yoga intervention, we used a therapeutically oriented style of yoga that emphasizes safety, is easy to learn, and has rigorous teacher-training standards. This style, developed originally by Sri Tirumalai Krishnamacharya and taught to his son T.K.V. Desikachar, is sometimes called viniyoga. Because viniyoga focuses on the purpose of each posture rather than on its precise form, it tailors the postures to the abilities of each individual’s body. This emphasis on safe performance of individual poses and careful sequencing of the poses minimizes the risk for injury and discomfort.
Each yoga class included postures from a list of 17 relatively simple postures designed for people with low back pain who have no previous experience with yoga, with minor variations and adaptations.2,3 Examples of postures used include cobra pose, knee to chest, and chakravakasana (see Figure 1). There were 6 different progressive classes, each with a different focus. Each posture sequence was used in two adjacent classes. All classes emphasized the use of postures and breathing for managing low back symptoms, so they focused on the low back and legs, as well as muscles that would impact these sites.
Figure 1. An example of a patient performing part of the chakravakasana posture sequence. (Image courtesy of Karen J. Sherman, PhD, MPH.)
The classes began with a breathing exercise followed by a sequence of five to 11 postures, a guided deep relaxation, and a final breathing exercise. All postures were repeated three or six times sequentially in a flow rather than held for an extended period. Many postures and basic concepts were repeated throughout the series to facilitate and encourage home practice, which was intended to be done for 20 minutes on all non-class days. Participants were given a handout of the sequence of poses and a corresponding CD to guide their home practice. Classes were taught by certified yoga instructors with at least 500 hours of viniyoga training and 5 years of teaching experience who were familiar with all the postures prior to the study. All instructors received training in the protocol by one of the yoga teachers who developed the intervention.
The exercise intervention involved stretching and strengthening exercises only, with no extreme movement. Most of the class involved conventional stretching exercises that are appropriate for patients with chronic back pain, including a comprehensive set of exercises that stretch all the major muscle groups, with an emphasis on the trunk and legs. The intervention included 12 stretching exercises used in our previous study3 that target the gastrocnemius, soleus, quadriceps, posterior and inferior shoulder, upper trapezius, hip flexor, back extension, back rotation, hamstrings, hip external rotators, and back flexion, plus three additional stretches that target the hip internal rotators, hip adductors, and hip flexors. Stretches were held for approximately 60 seconds and repeated once for a total of 52 minutes of stretching.
The class began with a 5-minute warm-up period consisting of basic aerobic steps and also included four strengthening exercises from our previous study that target the back, abdomen, and hips.3 We began with eight repetitions of the strengthening exercises and increased by two each week for a total of 30 repetitions at week 12. The classes were taught by licensed physical therapists with previous experience teaching classes who had completed a 2-hour teacher-training program. Home practice consisted of 20 minutes of exercise on non-class days and was based on printed handouts and a DVD of the exercises.
The self-care group received The Back Pain Helpbook, which provided information on the causes of back pain and suggestions on appropriate exercise, lifestyle modifications, and management of flare-ups.
PPM: How were the interventions similar and how were they different?
Dr. Sherman: Similarities between the interventions included length of intervention (75 minutes), number of classes (12), home practice requirements and aids, physical movement of comparable exertion (gentler), and lack of music. Differences between the interventions included a short check-in period to ask about home practice, breathing exercises, a guided deep relaxation, reminders to practice awareness in the yoga group, and 5 minutes of warm-up exercises and attempts to facilitate conversation about non–back pain related topics in order to create group cohesion in the exercise group.
PPM: What is the clinical significance of these findings for pain practitioners and primary care providers? How can they translate this research into clinical practice?