Yoga 'may improve lower back pain'

"Yoga can help relieve the agony of back pain, a major review of medical evidence found," the Daily Mail reports.

The review concluded there is evidence yoga may help improve function and relieve pain associated with chronic lower back pain in some people.

The review looked at 12 studies that compared the effects of yoga with other treatments, such as physiotherapy, as well as no treatment.

Researchers found yoga had some benefit for people with lower back pain compared with people who did no exercise for their back.

The results were less convincing for those who were already engaged in some other form of exercise.

Yoga includes the integration of physical poses and controlled breathing, sometimes also with meditation.

The results also demonstrated that a minority of participants had worse back pain after following a yoga regime, but the authors suggest this may be the same for any exercise.

The researchers cautioned that all of the results could have been affected by bias as it was impossible to blind the effects of yoga from the participants. This means a possible placebo effect could have been at play.

There are currently a number of recommended treatments for long-term back pain, including painkillers, exercise classes, physiotherapy or cognitive behavioural therapy (CBT). Talk to your GP about the best option for you.

What is important is to keep active as much as possible. It's now recognised that people who remain active are likely to recover from their pain more quickly.

Where did the story come from?

The study was carried out by researchers from the University of Maryland School of Medicine in the US, the University Hospital of Cologne in Germany, the University of Portsmouth in the UK, and Yoga Sangeeta in the US.

It was supported by the National Institutes of Health National Center for Complementary and Integrative Medicine in the US. The authors declared no conflict of interest.

The study was published in the peer-reviewed online journal, The Cochrane Database of Systematic Reviews. It is open access, so it's free to read the study online.

The UK reporting of the review was much more enthusiastic than the Cochrane researchers, who are known to err on the side of caution.

The Daily Telegraph excitedly reported that, "people who could most benefit from adopting the lotus position while locating their spiritual core are in fact those immobilised by pain".

But the reviewers actually concluded that, "There is low- to moderate-certainty evidence that yoga compared to non-exercise controls results in small to moderate improvements in back-related function at three and six months. Yoga may also be slightly more effective for pain at three and six months."

What kind of research was this?

This systematic review assessed the evidence of the effects of yoga for treating chronic non-specific lower back pain, compared with no specific treatment, minimal intervention (such as education) or another active treatment.

The outcomes focused on pain, back function, quality of life and adverse events. The studies included were all randomised controlled trials (RCTs)

RCTs are one of the best ways of looking at the effect of an intervention – in this case, the effect of yoga for treating chronic non-specific lower back pain.

However, while a systematic review is useful in bringing together the evidence on a specific topic, it can only ever be as good as the studies included. Any shortfalls of the studies included will be brought forward into the systematic review.

What did the research involve?

Researchers carried out a systematic review of RCTs including adults (aged 18 or older) with current chronic non-specific lower back pain for three months or more.

Twelve studies were included, involving a total of 1,080 participants from the US, India and the UK, mostly aged between 43 and 48 years old.

Researchers included studies with yoga as an intervention for lower back pain. Yoga classes included exercises specifically for lower back pain and were carried out by experienced practitioners.

The researchers compared:

yoga versus no treatment, or a waiting list, minimal intervention (such as booklets, lectures or other educational interventions) or usual care (i.e. no exercise)
yoga versus another active intervention (such as drugs or manipulation) – different types of active interventions were considered separately
yoga plus any intervention versus that intervention alone – different types of intervention were considered, such as yoga plus exercise versus exercise alone

Outcome measures were looked at in the short term (around four weeks), short to intermediate term (around three months), intermediate term (around six months) and long term (around one year).

Outcomes analysed included back-specific functional status (measured by a questionnaire), pain (measured by self-assessment on a scale), and measures of quality of life, clinical improvement, work disability and adverse events.

What were the basic results?

For yoga compared with no-exercise, there was:

low-certainty evidence that yoga produced small to moderate improvements in back-related function at three to four months – standardised mean difference (SMD) – as assessed by the functional status questionnaire (0.40, 95% confidence interval [CI] 0.66 to 0.14)
moderate-certainty evidence that yoga produced small to moderate improvements in back-related function at six months (SMD 0.44, 95% CI 0.66 to 0.22)
moderate-certainty evidence that the risk of adverse events, mostly back pain, was higher in yoga than in non-exercise controls (risk difference [RD] 5%, 95% CI 2% to 8%)

There were no clinically significant differences in pain at three to four months, six months or 12 months for yoga compared with no exercise.

For yoga compared with non-yoga exercise controls, there was:

little or no difference in back-related function at three months and six months, and no information for back function after six months
very low-certainty evidence for reduced pain at seven months on a scale of 0-100 (mean difference [MD] 20.40, 95% CI 25.48 to 15.32)
no difference in adverse events between yoga and non-yoga exercise controls

For yoga added to exercise compared with exercise alone, there was little or no difference in back-related function or pain, and no information on adverse events.

How did the researchers interpret the results?

The authors concluded that, "There is low- to moderate-certainty evidence that yoga compared to non-exercise controls results in small to moderate improvements in back-related function at three and six months."

They added: "It is uncertain whether there is any difference between yoga and other exercise for back-related function or pain, or whether yoga added to exercise is more effective than exercise alone.

"Yoga is associated with more adverse events than non-exercise controls, but may have the same risk of adverse events as other back-focused exercise. Yoga is not associated with serious adverse events."

Conclusion

There was some evidence people doing yoga – compared with those doing no exercise – saw some improvement in back-related function at three and six months.

It was not clear if those undertaking yoga, compared with other exercise or adding yoga to exercise, was any better than exercise alone.

The study does, however, have some downfalls:

Only 12 trials were included, the majority of which were in the US. This may mean results are less generalisable to other countries.
Not all trials looked at all reported outcomes. For example, only four trials were included when comparing yoga with non-yoga exercise, increasing the risk of bias.
All outcomes were self-reported, therefore all of the studies included were at risk of bias as participants may have wanted to demonstrate a difference to please researchers without there actually being any difference.
Some participants who agreed to participate in the studies would have consented to being randomised but with a preference for the yoga treatment. This may have affected their willingness to comply if they were then not allocated to their preferred group.
All faults with the original studies – for example, people dropping out halfway through treatment – were carried forward into the systematic review, and it is therefore difficult to say how much this would have affected the findings.

When it comes to lower back pain, it is important to stay as mobile as possible – yoga could be one of a range of possibly beneficial exercise-based treatments for back pain.

Read more about taking care of back pain.