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12 Articles in Volume 12, Issue #1
Ask the Expert: Escalating Opioids
Can Yoga and Stretching Exercises Relieve Chronic Low Back Pain?
Cortisol Screening in Chronic Pain Patients
Editor's Memo: FDA Removes Homeopathic HCG; Helps Legitimate Use In Pain Treatment
Formulation: The Four Perspectives of a Patient in Chronic Pain
Guide to Chronic Pain Assessment Tools
How to Select an In-Office Electromagnetic Field Device
Letters to the Editor: Hormone Therapies
Managing Pain in Active or Well-Controlled Systemic Lupus Erythematosus
PPM Editorial Board Examines Steps to Prevent Accidental Overdoses
Saliva Drug Screening in the Office Setting: Detection of Drug Use and Abuse
Understanding the Toxicology of Diazepam

Can Yoga and Stretching Exercises Relieve Chronic Low Back Pain?

Q&A with Karen J. Sherman, PhD, MPH

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?

Dr. Sherman: We’ve found that both classes are safe and moderately beneficial (but to a clinically meaningful degree). Thus, they provide a rationale for recommending appropriate yoga or stretching classes for patients with chronic back pain, especially of moderate severity.

PPM: Can you offer practical tips on how to incorporate yoga and stretching into clinical practice?

Dr. Sherman: I think our study provides a reasonable rationale for referring patients to physical therapists and yoga classes, if the classes are appropriate. For yoga, practitioners should find therapeutically oriented and experienced yoga instructors in their area and ask to attend a class or talk with them about the types of results the instructors have achieved. Practitioners should know that the broad kinds of issues addressed in our class were part of the back-focused class and that those classes are designed for people with back pain who have no knowledge of yoga. For the stretching classes, practitioners should find physical therapists who are willing to offer classes that conform broadly to the one we created.

PPM: Could practitioners offer classes in their offices?

Dr. Sherman: We offered our classes in large classroom spaces in Group Health facilities, so if appropriate space is available, there’s no reason why they could not be offered in medical facilities.

PPM: Are there subgroups of patients with low back pain who may not benefit from yoga or stretching or in whom these interventions are contraindicated?

Dr. Sherman: Our intervention was designed for individuals with chronic, nonspecific low back pain. It was not designed for individuals with sciatica or herniated discs, and our intervention is not appropriate for them. Other exercises or other yoga classes might be appropriate, but classes would need to include different postures.

PPM: Did patients in the yoga and stretching groups experience any adverse events?

Dr. Sherman: Yes, we did see some adverse events in both classes, largely mild to moderate transient increases in pain, from which everyone recovered. These were reported by 15% of participants in the yoga classes and 17% of those in the stretching classes. This is entirely expected when patients with back pain begin to exercise. In fact, one individual randomized to the self-care book reported increased pain after engaging in recommended exercises. We also had one participant with a severe herniated disc. Although unexpected, the fact that this occurred after the first class—when very gentle movements were performed—suggested that the participant was predisposed to this type of injury. Physicians should not hesitate to recommend exercise, including yoga, but should remind patients that their pain may increase temporarily. Patients should always tell the class instructor if they experience an increase in pain. Sometimes it means they have not performed the exercises correctly, and sometimes it reflects the fact that patients are “overdoing it” in other parts of their lives. Of course, sometimes this suggests there is a posture or stretch that is inappropriate for that individual.

PPM: What are the strengths and limitations of your study?

Dr. Sherman: Principal strengths of our study were its relatively large size, very well-characterized yoga and stretching interventions, inclusion of three arms so yoga and stretching could be compared with each other and a better-than-usual-care control group, high rates of follow-up, use of interviewers who were unaware of the treatment group, and reasonable adherence to the intervention.

Limitations included the following: the self-care participants might have been more likely to report worse outcomes (though less likely for back-related function); participants came from one health plan located in western Washington State; participants were relatively well educated and functional; there was a lack of follow-up beyond 26 weeks; and the amount of stretching included in our stretching classes would be hard to find in most current back exercise classes.

PPM: How do your findings compare with previous studies on this topic, specifically the recently published trial by Tilbrook et al?

Dr. Sherman: Our findings are quite consistent with other studies, including those of Tilbrook et al.4 Our study showed slightly better outcomes and slightly better adherence to the classes. But, on the whole, our results are markedly similar. The previously conducted, and much smaller, studies are broadly consistent with our findings.

PPM: Do you plan to test the yoga and stretching interventions in more severely impaired patients with chronic low back pain?

Dr. Sherman: We have a number of ancillary papers to write and are still thinking about our next studies, but of course, this is a logical next step.

More Yoga Poses from Dr. Sherman's Study

(Reprinted with permission from Sherman KJ et al. Ann Intern Med. 2005;143(12):849-856)

(Reprinted with permission from Sherman KJ et al. Ann Intern Med. 2005;143(12):849-856)

Last updated on: July 10, 2015
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