Yoga for chronic low back pain: a randomized trial

Effectiveness of Virtual Yoga for Chronic Low Back Pain: A Randomized Clinical Trial

Importance

Chronic low back pain (CLBP) is a common condition with substantial impact on patients, in the form of physical and emotional suffering; health care costs; productivity; and health care professional burden. Although clinical guidelines recommend use of nonpharmacologic treatments first, such as yoga, there is a gap between guidelines and implementation in clinical practice.

Objective

To compare the effects of virtual yoga classes vs a wait-list control on CLBP intensity, back-related function, sleep quality, and pain medication use.

Design, Setting, and Participants

Single-blinded, 24-week, 2-arm, randomized clinical trial conducted from May 3, 2022, through May 23, 2023, comparing live streamed yoga classes (the yoga now group) with a wait-list control (the yoga later group, in which participants were offered the virtual intervention after the study but without assessments) among adults with CLBP. Adults 18 to 64 years of age with CLBP were recruited from the Cleveland Clinic Employee Health Plan, a large health system self-insured health plan. Inclusion criteria included a mean LBP intensity score of at least 4 on an 11-point numerical rating scale (scores ranged from 0 to 10, with higher scores indicating worse pain) and daily back pain interference about half or more of the days.

Intervention

Twelve consecutive weekly, 60-minute, virtual, live streamed hatha yoga group classes.

Main Outcomes and Measures

Coprimary outcomes were mean pain intensity in the previous week on the 11-point numerical rating scale and back-related function as assessed using the 23-point modified Roland Morris Disability Questionnaire ([RMDQ], with higher scores reflecting poorer function) at 12 weeks. Secondary and exploratory outcomes included these measures at 24 weeks, pain medication use, and PROMIS sleep quality assessed using the Sleep Disturbance Short Form 8a, item 1 (scores ranged from 0 to 4, with higher scores reflecting better sleep quality). Analyses followed the intention-to-treat principle.

Results

Among 140 participants enrolled (yoga now = 71; yoga later = 69), the mean (SD) age was 47.8 (11.7) years and most were female (113 [80.7%]) and college-educated (103 [73.5%]). Mean (SD) baseline pain intensity (5.7 [1.5]) and RMDQ ([12.1 [4.4]) scores reflected moderate back pain and impairment. At week 12, yoga now compared with yoga later had greater reductions in mean pain intensity (-1.5 [95% CI, -2.2 to -0.7] points; P < .001) and mean RMDQ (-2.8 [95% CI, -4.3 to -1.3] points; P < .001) scores. At 24 weeks, the improvements in pain (mean change, -2.3 [95% CI, -3.1 to -1.6] points; P < .001) and RMDQ (mean change, -4.6 [95% CI, -6.1 to -3.1] points; P < .001) scores were sustained. At 12 weeks, yoga now participants reported 21.4 (95% CI, 5.2-37.6) absolute percentage points less use of any analgesic medication during the past week than yoga later participants and at 24 weeks, 21.2 absolute percentage points (95% CI, 5.2%-37.3%). Improvements in sleep quality were greater for participants in yoga now than among participants in yoga later at 12 weeks (mean change, 0.4 [95% CI, 0.1-0.7] points; P = .008) and 24 weeks (mean change, 0.4 [95% CI, 0.1-0.7] points; P = .005).

Conclusions and Relevance

Results of this randomized clinical trial of 140 adults with CLBP who were members of a large health system self-insured health plan suggest that virtual yoga classes may be a feasible, safe, and effective treatment option.

Trial Registration

ClinicalTrials.gov Identifier: NCT05319691.

Chair-based yoga programme for older adults with multimorbidity: RCT with embedded economic and process evaluations

Background

Older adults with multimorbidity experience impaired health-related quality of life and treatment burden. Yoga has the potential to improve several aspects of health and well-being. The British Wheel of Yoga's Gentle Years Yoga© programme was developed specifically for older adults, including those with chronic conditions. A pilot trial demonstrated feasibility of using Gentle Years Yoga in this population, but there was limited evidence of its effectiveness and cost-effectiveness.

Objective

To determine the effectiveness and cost-effectiveness of the Gentle Years Yoga programme in addition to usual care versus usual care alone in older adults with multimorbidity.

Design

Pragmatic, multisite, individually randomised controlled trial with embedded economic and process evaluations.

Setting

Participants were recruited from 15 general practices in England and Wales from July 2019 with final follow-up in October 2022.

Participants

Community-dwelling adults aged 65 years and over with multimorbidity, defined as two or more chronic health conditions from a predefined list.

Interventions

All participants continued with any usual care provided by primary, secondary, community and social services. The intervention group was offered a 12-week programme of Gentle Years Yoga.

Main outcome measures

The primary outcome and end point were health-related quality of life measured using the EuroQol-5 Dimensions, five-level version utility index score over 12 months. Secondary outcomes were health-related quality of life, depression, anxiety, loneliness, incidence of falls, adverse events and healthcare resource use.

Results

The mean age of the 454 randomised participants was 73.5 years; 60.6% were female, and participants had a median of three chronic conditions. The primary analysis included 422 participants (intervention, n = 227 of 240, 94.6%; usual care, n = 195 of 214, 91.1%). There was no statistically or clinically significant difference in the EuroQol-5 Dimensions, five-level version utility index score over 12 months: the predicted mean score for the intervention group was 0.729 (95% confidence interval 0.712 to 0.747) and for usual care it was 0.710 [95% confidence interval (CI) 0.691 to 0.729], with an adjusted mean difference of 0.020 favouring intervention (95% CI -0.006 to 0.045, p = 0.14). No statistically significant differences were observed in secondary outcomes, except for the pain items of the Patient-Reported Outcomes Measurement Information System-29. No serious, related adverse events were reported. The intervention cost £80.85 more per participant (95% CI £76.73 to £84.97) than usual care, generated an additional 0.0178 quality-adjusted life-years per participant (95% CI 0.0175 to 0.0180) and had a 79% probability of being cost-effective at the National Institute for Health and Care Excellence threshold of £20,000 per quality-adjusted life-year gained. The intervention was acceptable to participants, with seven courses delivered face to face and 12 online.

Limitations

Self-reported outcome data raise the potential for bias in an unblinded trial. The COVID-19 pandemic affected recruitment, follow-up and the mode of intervention delivery.

Conclusions

Although the Gentle Years Yoga programme was not associated with any statistically significant benefits in terms of health-related quality of life, mental health, loneliness or falls, the intervention was safe, acceptable to most participants and highly valued by some. The economic evaluation suggests that the intervention could be cost-effective.

Future work

Longer-term cost-effectiveness modelling and identifying subgroups of people who are most likely to benefit from this type of intervention.

Trial registration

This trial is registered as ISRCTN13567538.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/94/36) and is published in full in Health Technology Assessment; Vol. 28, No. 53. See the NIHR Funding and Awards website for further award information.

Effectiveness and cost-effectiveness of offering a chair-based yoga programme in addition to usual care in older adults with multiple long-term conditions: a pragmatic, parallel group, open label, randomised controlled trial

Background

People with multiple long-term conditions are more likely to have poorer health-related quality of life (HRQOL). Yoga has the potential to improve HRQOL. Gentle Years Yoga© (GYY) is a chair-based yoga programme for older adults. We investigated the effectiveness and cost-effectiveness of the GYY programme in older adults with multiple long-term conditions.

Methods

In this pragmatic, multi-site, open, randomised controlled trial, we recruited adults aged ≥65 years with ≥2 long-term conditions from 15 primary care practices in England and Wales. Participants were randomly assigned to usual care control or a 12-week, group-based, GYY programme delivered face-to-face or online by qualified yoga teachers. The primary outcome was HRQOL (EQ-5D-5L) over 12 months. Secondary outcomes included anxiety, depression, falls, loneliness, healthcare resource use, and adverse events.

Results

Between October 2019 and October 2021, 454 participants were randomised between the intervention (n=240) and control (n=214) groups. Seven GYY courses were delivered face-to-face and 12 courses were delivered online. The mean number of classes attended among all intervention participants was nine (SD 4, median 10). In our intention-to-treat analysis (n=422), there was no statistically significant difference between trial groups in the primary outcome of HRQOL (adjusted difference in mean EQ-5D-5L = 0.020 [favouring intervention]; 95% CI -0.006 to 0.045, p=0.14). There were also no statistically significant differences in key secondary outcomes. No serious, related adverse events were reported. The incremental cost-effectiveness ratio was £4,546 per quality-adjusted life-year (QALY) and the intervention had a 79% probability of being cost-effective at a willingness-to-pay threshold of £20,000 per QALY. The intervention was acceptable to most participants and perceived as useful by some.

Conclusions

The offer of a 12-week chair-based yoga programme in addition to usual care did not improve HRQOL in older adults with multiple long-term conditions. However, the intervention was safe, acceptable, and probably cost-effective.

Adverse events in India's Ayush interventions for cervical and lumbar spondylosis: a systematic review

INTRODUCTION

Low back and neck pain are common musculoskeletal disorders with multiple treatment options. India's traditional medical systems, known as Ayush (Ayurveda, Yoga and Naturopathy, Unani, Siddha, Sowa-Rigpa and Homoeopathy) offer range of interventions and are widely used. In view of limited documentation of adverse events following Ayush interventions for lumbar and cervical spondylosis, we synthesized evidence and estimated proportion of studies reporting adverse events.

METHODS

We systematically searched all published documents from biomedical and multidisciplinary abstract and citation databases and Ayush-specific repositories from their inception to April 2021. We selected studies as per inclusion criteria and extracted information, adhering to PRISMA guidelines. We systematically reviewed the qualitative evidence form the selected studies.

RESULTS

Majority (94%) of the selected 113 studies were interventional studies and included 77 (68.1%) journal articles and 35 (31%) academic dissertations. Among the Ayush systems, considerable proportion was from Ayurveda (32.7%), followed by Siddha (24.8%), Yoga (22.1%), Unani (15.9%) and Homoeopathy (4.4%). Almost three-fourths of the studies were on lumbar spondylosis (65%; n = 74), followed by cervical spondylosis (31%; n = 35), and the remaining four included both. Thirteen percent of the 113 studies described adverse events [Yoga = 9.7%; Unani = 1.8% and Homoeopathy = 1.8%]. More adverse events were reported among the studies on lumbar (9.7%) than cervical spondylosis (2.7%). The nature of interventions were non-pharmacological (10.6%; n = 12), pharmacological (n = 2; 1.8%) or combined (n = 1; 0.9%).

CONCLUSIONS

Only one in eight studies reported any adverse event following Ayush interventions for cervical and lumbar spondylosis. There could be certain degree of underreporting of adverse events and requires further exploration. PROSPERO Registration ID CRD42020167433.

Effectiveness of integrated approach of yoga therapy versus usual care in management on chronic low back pain patients: A randomized controlled pilot study

BACKGROUND

Chronic low back pain is associated with both psychological and functional limitation. Yoga therapy has been shown to improve both the aspects. The present study was planned to evaluate integrated approach of yoga therapy with usaul care.

AIMS

This controlled randomized trial was done to evaluate the clinical and molecular changes resulting from integrated approach of yoga therapy (IAYT) as an adjunct regimen and compared it with usual care for the management of chronic low back pain patients.

MATERIAL AND METHODS

We enrolled 29 adult patients with non-specific chronic low back pain (CLBP). Patients were randomly divided into two groups. The control group received the usual care of treatment as per institutional protocol. The yoga group received IAYT as an adjunct to usual care. Primary outcomes were pain intensity assessed by verbal numerical rating scale (VNRS) and functional ability assessed by Modified Oswestry Disability Index (MODI). Secondary outcomes were pain catastrophizing, quality of life, fear of movement related to CLBP, type of pain, levels of β-endorphin and TNF-α, and salivary CGRP. All parameters were measured at baseline, 1 and 3 months.

RESULTS

A Significant decrease in VNRS score at 1 and 3 months was observed in both the groups with the yoga group showing a more significant reduction in pain over time than the control group (p = 0.036). MODI improved significantly only in the yoga group at 1 and 3 months. Intergroup comparison revealed significantly better MODI over time in the yoga group (p < 0.001). DN4, PDQ, PCS, HADS (anxiety), and Euro QOL had a statistically significant improvement at 1 and 3 months in the yoga group compared with the control group. The HADS (depression) had a statistically significant reduction scores in the yoga group at 3 months compared with the control group (p = 0.012). There was a significant reduction in TNF-α values in the yoga group compared with baseline (p = 0.004).

CONCLUSION

IAYT therapy helped in addressing the psychological components of pain and improved quality of life patients with chronic low back pain compared with usual care.

Confirmation of the viability of a metaverse yoga class and investigation into the impact on pain, anxiety, and depression associated with low back pain after engaging in virtual yoga sessions

This study aimed to explore the influence of metaverse technology (MT) factors like presence, usability, and enjoyment on patients' satisfaction, with a focus on examining potential mediating effects. In addition, it sought to assess whether the yoga practice as an intervention therapy in MT induces changes in the pain, anxiety, and depression levels of patients experiencing back pain. From the pool of 202 participants, this study chose participants who had reported enduring low back pain over 12 weeks, with a visual analogue scale (VAS) rating of 4 or higher. After completing the questionnaire, patients were randomly assigned to either the control group (COG, n=100) or the yoga exercise group (YEG, n=99). Results showed that the construct validity for questionnaires and a reasonable model fit were confirmed, and that presence showed a statistically significant effect on psychological satisfaction via the mediating path of enjoyment (β=0.592, P=0.001). Following 8 weeks of the yoga practice, the VAS increased for the COG, while it decreased significantly by ~29% for the YEG (P=0.001). YEG also exhibited a decrease in the Oswestry Disability Index by ~17%, anxiety by ~7%, and depression by ~10% (P=0.001). In conclusion, psychological satisfaction in a yoga practice using a metaverse cannot be achieved solely through the sense of presence; enjoyment is necessary for patients' satisfaction. Moreover, it was verified that virtual yoga practice is effective in ameliorating psychological factors resulting from back pain.

Āsana for Back, Hips and Legs to Prevent Musculoskeletal Disorders among Dental Professionals: In-Office Yóga Protocol

Dental professionals are exposed to significant unavoidable physical stress, and theoretical ergonomic recommendations for a sitting workplace are inapplicable in many dental activities. Work-related musculoskeletal disorders (WMSDs) represent a serious health problem among dental professionals (prevalence: 64-93%), showing involvement of 34-60% for the low back and 15-25% for the hips. Muscle stress; prolonged sitting; forward bending and twisting of the torso and head; unbalanced working postures with asymmetrical weight on the hips and uneven shoulders; and others are inevitable for dental professionals. Therefore, the approach for the prevention and treatment of WMSDs must be therapeutic and compensatory. This project was conceived to provide a Yoga protocol for dental professionals to prevent or treat WMSDs from a preventive medicine perspective, and it would represent a Yoga-based guideline for the self-cure and prevention of musculoskeletal problems.

METHODS

Specific Yoga positions (āsana, such as Virāsana, Virabhadrāsana, Garudāsana, Utkatāsana, Trikonāsana, Anuvittāsana, Chakrāsana, Uttanāsana, Pashimottanāsana) have been selected, elaborated on and adapted to be practiced in a dental office using a dental stool or the dental office walls or a dental unit chair. The protocol is specifically devised for dental professionals (dentists, dental hygienists and dental assistants) and targeted for the low back, hips and legs (including knees and ankles). The protocol includes Visranta Karaka Sthiti (supported positions) in sitting (Upavistha Sthiti) and standing (Utthistha Sthiti) positions, twisting/torsions (Parivrtta), flexions/forward bend positions (Pashima) and extensions/arching (Purva) for musculo-articular system decompression and mobilization.

RESULTS

Over 60 Yogāsana-specifically ideated for back detensioning and mobilization, lumbar lordosis restoration, trunk side elongation, hip release and leg stretches and decontraction-are shown and described. The paper provides a meticulous description for each position, including the detailed movement, recommendations and mistakes to avoid, and the breathing pattern (breath control) in all the breath-driven movements (āsana in vinyāsa). An exhaustive analysis of posture-related disorders affecting the lower body among dental professionals is reported, including low-back pain, hip pain and disorders, piriformis syndrome and quadratus femoris dysfunction (gluteal pain), iliopsoas syndrome, multifidus disorders, femoroacetabular and ischiofemoral impingement, spinopelvic mobility, lumbopelvic rhythm, impairment syndromes, lower crossed syndrome, leg pain, knee pain and ankle disorders.

CONCLUSIONS

A detailed guideline of āsana for low-back decompression, hip joint destress, piriformis and gluteal muscle release, lumbar lordosis recovery and a spinopelvic mobility increase has been elaborated on. The designed Yogāsana protocol represents a powerful tool for dental professionals to provide relief to retracted stiff muscles and unbalanced musculoskeletal structures in the lower body.

Systematic Review to Inform a World Health Organization (WHO) Clinical Practice Guideline: Benefits and Harms of Structured Exercise Programs for Chronic Primary Low Back Pain in Adults

PURPOSE

Evaluate benefits and harms of structured exercise programs for chronic primary low back pain (CPLBP) in adults to inform a World Health Organization (WHO) standard clinical guideline.

METHODS

We searched for randomized controlled trials (RCTs) in electronic databases (inception to 17 May 2022). Eligible RCTs targeted structured exercise programs compared to placebo/sham, usual care, or no intervention (including comparison interventions where the attributable effect of exercise could be isolated). We extracted outcomes, appraised risk of bias, conducted meta-analyses where appropriate, and assessed certainty of evidence using GRADE.

RESULTS

We screened 2503 records (after initial screening through Cochrane RCT Classifier and Cochrane Crowd) and 398 full text RCTs. Thirteen RCTs rated with overall low or unclear risk of bias were synthesized. Assessing individual exercise types (predominantly very low certainty evidence), pain reduction was associated with aerobic exercise and Pilates vs. no intervention, and motor control exercise vs. sham. Improved function was associated with mixed exercise vs. usual care, and Pilates vs. no intervention. Temporary increased minor pain was associated with mixed exercise vs. no intervention, and yoga vs. usual care. Little to no difference was found for other comparisons and outcomes. When pooling exercise types, exercise vs. no intervention probably reduces pain in adults (8 RCTs, SMD = - 0.33, 95% CI - 0.58 to - 0.08) and functional limitations in adults and older adults (8 RCTs, SMD = - 0.31, 95% CI - 0.57 to - 0.05) (moderate certainty evidence).

CONCLUSIONS

With moderate certainty, structured exercise programs probably reduce pain and functional limitations in adults and older people with CPLBP.

Meditation: A Promising Approach for Alleviating Chronic Pain

Chronic pain is a complex and pervasive health issue that significantly impacts the lives of millions. Various cultures have been practicing meditation for thousands of years, and it has been shown that it has many positive effects on mental and physical health. The impact of meditation on chronic pain is encouraging as it will form the base for future advancements. Meditation can improve the body's natural pain-relieving processes, lower stress levels, and boost body awareness. Patients can select from a variety of meditation techniques and include them in their treatment plans in a way that suits them best. Although it may not be a permanent solution, meditation can give patients a useful tool for managing their pain. In both clinical and experimental contexts, mindfulness meditation has been shown to lessen pain dramatically. Meditation may be used to manage chronic pain, which has several benefits, including pain alleviation, stress reduction, improved sleep, and general health. The research study provides insights into various kinds of meditation practices as well as the scientific basis of the mechanisms that are mentioned in the literature for the management of pain. Meditation practices have been scientifically shown in numerous randomized controlled studies to reduce pain intensity, enhance pain tolerance, and improve quality of life in those with chronic pain. Although more research is necessary to fully understand the mechanisms underlying the practice, the encouraging evidence is currently available.

Association between Modic changes and intervertebral vacuum phenomenon severity in patients undergoing percutaneous cement discoplasty

BACKGROUND

Modic changes and intervertebral vacuum phenomenon (IVP) are considered spinal degenerative changes. The correlation between Modic and IVP has not been analyzed in the literature.

PURPOSE

To analyze the correlation between IVP severity, Modic changes, and subchondral sclerosis across the lumbar spine in patients with lumbar degeneration.

MATERIAL AND METHODS

This is a retrospective study analyzing patients who underwent percutaneous cement discoplasty at a single institution between 2015 and 2020. Preoperative magnetic resonance imaging and computed tomography scans were analyzed to make the measurements. Modic type and grade as well as severity of IVP were preoperatively measured. The association between Modic type, grade, subchondral sclerosis, and the presence of IVP was analyzed.

RESULTS

In total, 110 patients (mean age = 77.03 ± 7.1 years) were finally included in the study. Per level correlation analysis showed a significant positive association between IVP and Modic type, IVP and Modic grade, and IVP and subchondral sclerosis. Moreover, subchondral sclerosis was significantly associated with Modic type and grade.

CONCLUSION

Our study showed a significant positive correlation among Modic changes, IVP, and subchondral sclerosis throughout the lumbar spine. Our findings support the theory that endplate degeneration parameters are associated with the presence and severity of IVP.

Efficacy and safety of yoga for the management of chronic low back pain: an overview of systematic reviews

Background

Yoga is a non-pharmacological conservative therapeutic modality that can be employed for the management of chronic low back pain (CLBP). In this overview, we have summarized and evaluated data from current systematic reviews (SRs) on the use of yoga for CLBP.

Methods

We comprehensively searched SRs on the use of yoga for CLBP in nine electronic databases from inception to September 2023. The methodological quality was evaluated using the Assessment of Multiple Systematic Review Scale-2 (AMSTAR-2). The reporting quality of the included SRs was evaluated using the Preferred Reporting Item for Systematic Review and Meta-Analysis-2020 (PRISMA-2020), and the quality of data was graded using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Two independent researchers performed the screening, data extraction, and quality assessment process of SRs.

Results

A total of 13 SRs were included. The results of the AMSTAR-2 indicated that the methodological quality of the included studies was relatively low. The PRISMA-2020 checklist evaluation results indicated that methodological limitations in reporting, especially regarding data processing and presentation, were the main weaknesses. The GRADE assessment indicated that 30 outcomes were rated moderate, 42 were rated low level, and 20 were rated very low level. Downgrading factors were mainly due to the limitations of the included studies.

Conclusion

Yoga appears to be an effective and safe non-pharmacological therapeutic modality for the Management of CLBP. Currently, it may exhibit better efficacy in improving pain and functional disability associated with CLBP. However, the methodological quality and quality of evidence for SRs/MAs in the included studies were generally low, and these results should be interpreted cautiously.

Lessons From India: A Narrative Review of Integrating Yoga Within the US Healthcare System

The ancient practice of yoga has gained worldwide popularity as a way for people to improve their overall health and well-being. This manuscript reviews and examines the history of yoga, its physical and mental health benefits, its incorporation into the Indian healthcare system, and the public perception of yoga in India. Many initiatives for yoga exist, including promoting research on yoga, providing education and information on its benefits, and developing evidence-based standardized yoga therapy guidelines. With this in mind, this narrative review article explores the potential benefits of incorporating yoga into the United States (US) healthcare system and the possible challenges of doing so. It also provides valuable insights for policymakers and healthcare professionals.

Characteristics of patients who use yoga for pain management in Indian yoga and naturopathy settings: a retrospective review of electronic medical records

Objectives

The aim of this study is to identify the characteristics of patients who underwent yoga therapy for pain in yoga and naturopathy clinical settings in India.

Methods

Electronic medical records of patients who received yoga therapy for pain in three inpatient yoga and naturopathy hospitals were reviewed retrospectively from January 2021 to September 2022. Demographic characteristics and details on pain condition, socioeconomic status, comorbidities, ancillary therapies received, and insurance status were collected. In addition, we prospectively collected data on adherence to yoga practice through a telephonic interview.

Results

A total of 984 patients were identified from a pool of 3,164 patients who received yoga therapy for pain for an average of 9.48 (1.13) days. Patients aged between 8 and 80 underwent therapy for varying pain conditions and diseases that include pain in the extremities, pain due to infection, trauma, degenerative diseases, autoimmune diseases, and spine and neurological diseases. The majority of the patients were females (66.3%), from middle class families (74.8%), and who did not have any insurance coverage (93.8%). Most of the patients were under naturopathy treatment (99.8%), followed by ayurveda (56%), and physiotherapy (49.3%), along with yoga therapy. All patients reported a significant reduction in pain post-integrated yoga therapy (p < 0.001). Adherence to yoga was significantly associated with underlying pain conditions, the presence of comorbidities, the types of therapies used, and socioeconomic status (p < 0.001).

Conclusion

This study highlights the real-time application of yoga in pain management in Indian yoga and naturopathy settings, as well as implications for future research.

Exercise Increases Pain Self-efficacy in Adults With Nonspecific Chronic Low Back Pain: A Systematic Review and Meta-analysis

OBJECTIVE: To determine the effect of exercise on pain self-efficacy in adults with nonspecific chronic low back pain (NSCLBP). DESIGN: Intervention systematic review with meta-analysis LITERATURE SEARCH: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, PsycINFO, and CINAHL databases from October 20, 2018, to March 23, 2022. SELECTION CRITERIA: We included randomized controlled trials that compared the effect of exercise on pain self-efficacy to control, in adults with NSCLBP. DATA SYNTHESIS: We conducted a meta-analysis using a random-effects model. We evaluated the risk of bias using the Cochrane risk-of-bias tool (RoB 2) and judged the certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework. RESULTS: Seventeen trials were included, of which eight (n = 1121 participants; 60.6% female; mean age: 49.6 years) were included in the meta-analysis. Exercise increased pain self-efficacy by 3.02 points (95% confidence interval: 1.72, 4.32) on the 60-point Pain Self-Efficacy Questionnaire. The certainty of evidence was moderate; all trials were at high risk of bias. CONCLUSION: There was moderate-certainty evidence that exercise increased pain self-efficacy in adults with NSCLBP. Future research should investigate if this effect is meaningful, whether it increases with more targeted treatments to enhance pain self-efficacy, and the effects on outcomes for adults with NSCLBP. J Orthop Sports Phys Ther 2023;53(6):1-8. Epub: 10 May 2023. doi:10.2519/jospt.2023.11622.

Assessment of complementary and alternative medicine methods in the management of ankylosing spondylitis, rheumatoid arthritis, and fibromyalgia syndrome

A wide variety of musculoskeletal, arthritic, connective tissue, and vasculitic diseases fall under the umbrella of "rheumatic diseases". Ankylosing spondylitis, rheumatoid arthritis, and fibromyalgia syndrome are the three members of this disease group with relatively high prevalence. Pharmacological options are at the center of therapeutic algorithms in treating rheumatic diseases, particularly in reducing inflammation. Despite significant advances in pharmacological treatment in recent years, achieving complete treatment success in a group of patients is impossible. Therefore, patients with rheumatic diseases frequently utilize alternative treatment options, such as complementary and alternative medicine. Complementary and alternative medicine is a broad category of health practices not part of the leading health system. Patients with rheumatic diseases turn to complementary and alternative medicine for various reasons, including restricted access to some treatments due to high prices and rigorous regulations, worries about drug side effects, and symptoms that continue despite pharmacological treatment. In addition, because complementary and alternative medicine options are considered natural, they are frequently accepted as well tolerated and have few harmful effects. Ankylosing spondylitis, rheumatoid arthritis, and fibromyalgia syndrome are the primary foci of this comprehensive review. First, we attempted to summarize the non-traditional physical medicine and complementary and alternative medicine options that can be utilized to manage these diseases. Second, we addressed the link between exercise and inflammation in rheumatic diseases. We briefly discussed the possible benefits of exercise-based approaches. In addition, we highlighted the benefits of cooperation between rheumatology and physical medicine-rehabilitation clinics.

Home Exercise Programs Are Infrequently Prescribed in Trials of Supervised Exercise for Individuals With Low Back Pain: A Scoping Review of 292 Randomized Controlled Trials

OBJECTIVES: To (1) determine how often home exercise programs (HEPs) are prescribed in supervised exercise trials for low back pain (LBP) and (2) describe characteristics of the HEP programs (design, purpose, dose, and adherence). DESIGN: Scoping review. LITERATURE SEARCH: PubMed, CINAHL, and Ovid MEDLINE were searched from January 1, 2010, to August 17, 2021. STUDY SELECTION CRITERIA: Randomized controlled trials that included adults with LBP who received exercise interventions. DATA SYNTHESIS: The presence or absence of a prescribed HEP and any details of the HEP including design, dose, and adherence were extracted and summarized. RESULTS: Of 2689 potentially relevant trials, 292 were eligible for inclusion. Ninety-four trials (32%) included a HEP. The most commonly prescribed home exercises were core stability, trunk strengthening, and motor control exercises. There was great variation in the frequency and duration with which HEPs were prescribed. Adherence to HEPs was measured in fewer than half of the trials, and the methods for measuring adherence were inconsistent. Adherence to HEPs ranged from 29% to 82% in the 21 trials that reported adherence. CONCLUSION: Home exercise programs are not regularly prescribed in supervised exercise trials for LBP. There was considerable variation in prescribing HEPs and monitoring exercise adherence in trials of exercise-based treatments for adults with LBP. There is no consistent method used to measure participants' adherence to HEPs, and adherence percentages vary widely. J Orthop Sports Phys Ther 2023;53(3):120-142. Epub: 16 January 2023. doi:10.2519/jospt.2023.11448.

Matching the Outcomes to Treatment Targets of Exercise for Low Back Pain: Does it Make a Difference? Results of Secondary Analyses From Individual Patient Data of Randomised Controlled Trials and Pooling of Results Across Trials in Comparative Meta-analysis

OBJECTIVE

To explore whether using a single matched or composite outcome might affect the results of previous randomized controlled trials (RCTs) testing exercise for non-specific low back pain (NSLBP). The first objective was to explore whether a single matched outcome generated greater standardized mean differences (SMDs) when compared with the original unmatched primary outcome SMD. The second objective was to explore whether a composite measure, composed of matched outcomes, generated a greater SMD when compared with the original primary outcome SMD.

DESIGN

We conducted exploratory secondary analyses of data.

SETTING

Seven RCTs were included, of which 2 were based in the USA (University research clinic, Veterans Affairs medical center) and the UK (primary care clinics, nonmedical centers). One each were based in Norway (clinics), Brazil (primary care), and Japan (outpatient clinics).

PARTICIPANTS

The first analysis comprised 1) 5 RCTs (n=1033) that used an unmatched primary outcome but included (some) matched outcomes as secondary outcomes, and the second analysis comprised 2) 4 RCTs (n=864) that included multiple matched outcomes by developing composite outcomes (N=1897).

INTERVENTION

Exercise compared with no exercise.

MAIN OUTCOME MEASURES

The composite consisted of standardized averaged matched outcomes. All analyses replicated the RCTs' primary outcome analyses.

RESULTS

Of 5 RCTs, 3 had greater SMDs with matched outcomes (pooled effect SMD 0.30 [95% confidence interval {CI} 0.04, 0.56], P=.02) compared with an unmatched primary outcome (pooled effect SMD 0.19 [95% CI -0.03, 0.40] P=.09). Of 4 composite outcome analyses, 3 RCTs had greater SMDs in the composite outcome (pooled effect SMD 0.28 [95% CI 0.05, 0.51] P=.02) compared with the primary outcome (pooled effect SMD 0.24 [95% CI -0.04, 0.53] P=.10).

CONCLUSIONS

These exploratory analyses suggest that using an outcome matched to exercise treatment targets in NSLBP RCTs may produce greater SMDs than an unmatched primary outcome. Composite outcomes could offer a meaningful way of investigating superiority of exercise than single domain outcomes.

Yoga Plus Mantram Repetition to Reduce Chronic Pain in Veterans With Post-Traumatic Stress Disorder: A Feasibility Trial

Background

Veterans with post-traumatic stress disorder (PTSD) are more likely to report chronic pain than veterans without PTSD. Yoga has been shown to reduce both chronic pain and PTSD symptoms in clinical trials. The goal of our study was to assess the feasibility and acceptability of conducting a randomized controlled trial (RCT) that combined yoga and mantram repetition (Yoga + MR) into one program for military veterans with both chronic pain and PTSD.

Methods

In this feasibility RCT, 27 veterans were randomized to either Yoga + MR or a relaxation intervention. Due to the COVID-19 pandemic, in-person recruitment, assessments, and intervention attendance were re-evaluated. Although remote delivery of aspects of the study were utilized, interventions were delivered in-person. Feasibility benchmarks met included full recruitment in 12 months or less, 75%+ retention at initial follow-up assessment, 50%+ attendance rate, and 75%+ of participants satisfied with the interventions.

Results

The sample was racially and ethnically diverse, and 15% of participants were women. Participant recruitment lasted approximately 11 months. Out of 32 participants initially randomized, two participants asked to be dropped from the study and three did not meet PTSD symptom criteria. For the remaining 27 participants, retention rates were 85% at 12 weeks and 81% at 18 weeks. Participants attended 66% of in-person yoga and 55% of in-person relaxation sessions. Satisfaction was high, with 100% of yoga participants and 75%/88% of relaxation participants agreeing or strongly agreeing they were satisfied with the intervention/instructors. After 12 weeks (end of intervention), Yoga + MR participants reported reduced back-pain related disability (primary outcome), reduced alcohol use, reduced fatigue, and increased quality of life, while relaxation group participants reported reductions in pain severity, PTSD symptoms, and fatigue.

Conclusions

Amidst many research challenges during the pandemic, recruitment, retention, and efficacy results from this feasibility trial support advancement to a larger RCT to study Yoga + MR for chronic pain and PTSD.

Objective evidence for chronic back pain relief by Medical Yoga therapy

Chronic low back pain (CLBP) is a musculoskeletal ailment that affects millions globally. The pain is disturbing associated with impaired motor activity, reduced flexibility, decreased productivity and strained interpersonal relationships leading to poor quality of life. Inflammatory mediators in vicinity of nociceptors and amplification of neural signals cause peripheral and central sensitization presented as hyperalgesia and/or allodynia. It could be attributed to either diminished descending pain inhibition or exaggerated ascending pain facilitation. Objective measurement of pain is crucial for diagnosis and management. Nociceptive flexion reflex is a reliable and objective tool for measurement of a subject's pain experience. Medical Yoga Therapy (MYT) has proven to relieve chronic pain, but objective evidence-based assessment of its effects is still lacking. We objectively assessed effect of MYT on pain and quality of life in CLBP patients. We recorded VAS (Visual analogue scale), McGill Pain questionnaire and WHOQOL BREF questionnaire scores, NFR response and Diffuse noxious inhibitory control tests. Medical yoga therapy consisted of an 8-week program (4 weeks supervised and 4 weeks at home practice). CLBP patients (42.5 ± 12.6 years) were randomly allocated to MYT (n = 58) and SCT groups (n = 50), and comparisons between the groups and within the groups were done at baseline and at end of 4 and 8 weeks of both interventions. (VAS) scores for patients in both the groups were comparable at baseline, subjective pain rating decreased significantly more after MYT compared to SCT (p = < 0.0001*, p = 0.005*). McGill Pain questionnaire scores revealed significant reduction in pain experience in MYT group compared to SCT. Nociceptive Flexion Reflex threshold increased significantly in MYT group at end of 4 weeks and 8 weeks, p < 0.0001#, p = < 0.0001∞ respectively) whereas for SCT we did not find any significant change in NFR thresholds. DNIC assessed by CPT also showed significant improvement in descending pain modulation after MYT compared to SCT both at end of 4 and 8 weeks. Quality of life also improved significantly more after MYT. Thus, we conclude with objective evidence that Medical Yoga Therapy relieves chronic low back pain, stress and improves quality of life better than standard care.

Yoga for chronic non-specific low back pain

BACKGROUND

Non-specific low back pain is a common, potentially disabling condition usually treated with self-care and non-prescription medication. For chronic low back pain, current guidelines recommend exercise therapy. Yoga is a mind-body exercise sometimes used for non-specific low back pain.

OBJECTIVES

To evaluate the benefits and harms of yoga for treating chronic non-specific low back pain in adults compared to sham yoga, no specific treatment, a minimal intervention (e.g. education), or another active treatment, focusing on pain, function, quality of life, and adverse events.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 31 August 2021 without language or publication status restrictions.

SELECTION CRITERIA

We included randomized controlled trials of yoga compared to sham yoga, no intervention, any other intervention and yoga added to other therapies.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods. Our major outcomes were 1. back-specific function, 2. pain, 3. clinical improvement, 4. mental and physical quality of life, 5. depression, and 6.

ADVERSE EVENTS

Our minor outcome was 1. work disability. We used GRADE to assess certainty of evidence for the major outcomes.

MAIN RESULTS

We included 21 trials (2223 participants) from the USA, India, the UK, Croatia, Germany, Sweden, and Turkey. Participants were recruited from both clinical and community settings. Most were women in their 40s or 50s. Most trials used iyengar, hatha, or viniyoga yoga. Trials compared yoga to a non-exercise control including waiting list, usual care, or education (10 trials); back-focused exercise such as physical therapy (five trials); both exercise and non-exercise controls (four trials); both non-exercise and another mind-body exercise (qigong) (one trial); and yoga plus exercise to exercise alone (one trial). One trial comparing yoga to exercise was an intensive residential one-week program, and we analyzed this trial separately. All trials were at high risk of performance and detection bias because participants and providers were not blinded to treatment, and outcomes were self-assessed. We found no trials comparing yoga to sham yoga. Low-certainty evidence from 11 trials showed that there may be a small clinically unimportant improvement in back-specific function with yoga (mean difference [MD] -1.69, 95% confidence interval [CI] -2.73 to -0.65 on the 0- to 24-point Roland-Morris Disability Questionnaire [RMDQ], lower = better, minimal clinically important difference [MCID] 5 points; 1155 participants) and moderate-certainty evidence from nine trials showed a clinically unimportant improvement in pain (MD -4.53, 95% CI -6.61 to -2.46 on a 0 to 100 scale, 0 no pain, MCID 15 points; 946 participants) compared to no exercise at three months. Low-certainty evidence from four trials showed that there may be a clinical improvement with yoga (risk ratio [RR] 2.33, 95% CI 1.46 to 3.71; assessed as participant rating that back pain was improved or resolved; 353 participants). Moderate-certainty evidence from six trials showed that there is probably a small improvement in physical and mental quality of life (physical: MD 1.80, 95% CI 0.27 to 3.33 on the 36-item Short Form [SF-36] physical health scale, higher = better; mental: MD 2.38, 95% CI 0.60 to 4.17 on the SF-36 mental health scale, higher = better; both 686 participants). Low-certainty evidence from three trials showed little to no improvement in depression (MD -1.25, 95% CI -2.90 to 0.46 on the Beck Depression Inventory, lower = better; 241 participants). There was low-certainty evidence from eight trials that yoga increased the risk of adverse events, primarily increased back pain, at six to 12 months (RR 4.76, 95% CI 2.08 to 10.89; 43/1000 with yoga and 9/1000 with no exercise; 1037 participants). For yoga compared to back-focused exercise controls (8 trials, 912 participants) at three months, we found moderate-certainty evidence from four trials for little or no difference in back-specific function (MD -0.38, 95% CI -1.33 to 0.62 on the RMDQ, lower = better; 575 participants) and very low-certainty evidence from two trials for little or no difference in pain (MD 2.68, 95% CI -2.01 to 7.36 on a 0 to 100 scale, lower = better; 326 participants). We found very low-certainty evidence from three trials for no difference in clinical improvement assessed as participant rating that back pain was improved or resolved (RR 0.97, 95% CI 0.72 to 1.31; 433 participants) and very low-certainty evidence from one trial for little or no difference in physical and mental quality of life (physical: MD 1.30, 95% CI -0.95 to 3.55 on the SF-36 physical health scale, higher = better; mental: MD 1.90, 95% CI -1.17 to 4.97 on the SF-36 mental health scale, higher = better; both 237 participants). No studies reported depression. Low-certainty evidence from five trials showed that there was little or no difference between yoga and exercise in the risk of adverse events at six to 12 months (RR 0.93, 95% CI 0.56 to 1.53; 84/1000 with yoga and 91/1000 with non-yoga exercise; 640 participants).

AUTHORS' CONCLUSIONS

There is low- to moderate-certainty evidence that yoga compared to no exercise results in small and clinically unimportant improvements in back-related function and pain. There is probably little or no difference between yoga and other back-related exercise for back-related function at three months, although it remains uncertain whether there is any difference between yoga and other exercise for pain and quality of life. Yoga is associated with more adverse events than no exercise, but may have the same risk of adverse events as other exercise. In light of these results, decisions to use yoga instead of no exercise or another exercise may depend on availability, cost, and participant or provider preference. Since all studies were unblinded and at high risk of performance and detection bias, it is unlikely that blinded comparisons would find a clinically important benefit.

Mechanisms Underlying Anti-Inflammatory and Anti-Cancer Properties of Stretching-A Review

Stretching is one of the popular elements in physiotherapy and rehabilitation. When correctly guided, it can help minimize or slow down the disabling effects of chronic health conditions. Most likely, the benefits are associated with reducing inflammation; recent studies demonstrate that this effect from stretching is not just systemic but also local. In this review, we present the current body of knowledge on the anti-inflammatory properties of stretching at a molecular level. A total of 22 papers, focusing on anti-inflammatory and anti-cancer properties of stretching, have been selected and reviewed. We show the regulation of oxidative stress, the expression of pro- and anti-inflammatory genes and mediators, and remodeling of the extracellular matrix, expressed by changes in collagen and matrix metalloproteinases levels, in tissues subjected to stretching. We point out that a better understanding of the anti-inflammatory properties of stretching may result in increasing its importance in treatment and recovery from diseases such as osteoarthritis, systemic sclerosis, and cancer.

Harnessing the benefits of yoga for myositis, muscle dystrophies, and other musculoskeletal disorders

The recent global increase in popularity of home-based yoga, an ancient Indian technique practiced for thousands of years, has translated into its use as a complementary therapy for a multitude of ailments. This review aims to examine the published literature regarding the effects of yoga therapy on systemic chronic diseases; in particular on the inflammatory myopathies (IMs) and other muscle disorders.

Despite the fact that the evidence base for yoga in inflammatory myositis is in its infancy, collateral results in other disorders such as muscular dystrophies are promising. A beneficial effect of yoga in chronic pain has been shown alongside an improvement in motor function and muscle strength. Patients with Duchenne muscular dystrophy with respiratory involvement may find improvement in lung function. Elderly patients may experience reduction in falls secondary to an improvement in balance while practicing long-term yoga therapy.

Further benefits are improving disorders of mental health such as depression and anxiety. A reported improvement in overall quality of life further suggests its efficacy in reducing morbidity in patients with chronic diseases, who often suffer co-existent psychological comorbidities.

A feasibility study on yoga's mechanism of action for chronic low back pain: psychological and neurophysiological changes, including global gene expression and DNA methylation, following a yoga intervention for chronic low back pain

INTRODUCTION

Yoga has been shown to reduce pain and improve function in populations with chronic low back pain (cLBP), yet the underlying molecular mechanisms remain elusive. This study examined the feasibility and acceptability of a yoga research protocol, including recruitment, retention, and data collection, and investigated the preliminary effects of yoga on psychological and neurophysiological functions, including gene expression and DNA methylation profiles, in participants with cLBP.

METHODS

A one-arm trial was conducted with 11 participants with cLBP who enrolled in a 12-week yoga intervention. Data on subjective pain characteristics, quantitative sensory testing, and blood for analysis of differentially expressed genes and CpG methylation was collected prior to the start of the intervention and at study completion.

RESULTS

Based on pre-determined feasibility and acceptability criteria, the yoga intervention was found to be feasible and highly acceptable to participants. There was a reduction in pain severity, interference, and mechanical pain sensitivity post-yoga and an increase in emotion regulation and self-efficacy. No adverse reactions were reported. Differential expression analysis demonstrated that the yoga intervention induced increased expression of antisense genes, some of which serve as antisense to known pain genes. In addition, there were 33 differentially hypomethylated positions after yoga (log2 fold change ≥ 1), with enrichment of genes involved in NIK/NF-kB signaling, a major pathway that modulates immune function and inflammation.

DISCUSSION/CONCLUSIONS

The study supports the feasibility and acceptability of the proposed protocol to test a specific mechanism of action for yoga in individuals with cLBP. These results also support the notion that yoga may operate through our identified psychological and neurophysiologic pathways to influence reduced pain severity and interference.

Comparing Types of Yoga for Chronic Low Back and Neck Pain in Military Personnel: A Feasibility Randomized Controlled Trial

Background

Chronic low back pain (cLBP) and chronic neck pain (cNP) are highly prevalent conditions and common reasons for disability among military personnel. Yoga and other mind-body interventions have been shown to safely decrease pain and disability in persons with cLBP and/or cNP but have not been adequately studied in active duty military personnel. The objective of this study was to examine the feasibility and acceptability of delivering 2 types of yoga (hatha and restorative) to a sample of active-duty military personnel with cLBP/cNP.

Methods

Military personnel with cLBP and/or cNP (n = 49; 59% men) were randomized to either hatha or restorative yoga interventions. Interventions consisted of in-person yoga 1-2x weekly for 12 weeks. Feasibility and acceptability were measured by rates of recruitment, intervention attendance, attrition, adverse events, and satisfaction ratings. Health outcomes including pain and disability were measured at baseline, 12 weeks, and 6 months. Means and effect sizes are presented.

Results

Recruitment was completed ahead of projections. Over 90% of participants agreed or strongly agreed that they enjoyed participation, liked the instructor, and would like to continue yoga. Retention rates were 86% and 80% at 12 week and 6 month assessments, respectively. Intervention attendance was adequate but lower than expected. There were small to moderate reductions in back-pain related disability, pain severity and pain interference, and improvements in quality of life, grip strength, and balance. In general, effects were larger for those who attended at least 50% of intervention classes. Participants with cNP tended to have smaller outcome improvements, but conclusions remain tentative given small sample sizes.

Conclusions

Results demonstrate feasibility for conducting a randomized controlled comparative effectiveness trial of yoga for cLBP and cNP among active duty military personnel. Acceptability was also established. Ongoing work will enhance the intervention for cNP and establish feasibility at another military facility in preparation for a fully-powered comparative effectiveness trial.ClinicalTrials #NCT03504085; registered April 20, 2018.

Do recommended interventions widen or narrow inequalities in musculoskeletal health? An equity-focussed systematic review of differential effectiveness

Background

It is unclear whether seven interventions recommended by Public Health England for preventing and managing common musculoskeletal conditions reduce or widen health inequalities in adults with musculoskeletal conditions.

Methods

We used citation searches of Web of Science (date of ‘parent publication’ for each intervention to April 2021) to identify original research articles reporting subgroup or moderator analyses of intervention effects by social stratifiers defined using the PROGRESS-Plus frameworks. Randomized controlled trials, controlled before-after studies, interrupted time series, systematic reviews presenting subgroup/stratified analyses or meta-regressions, individual participant data meta-analyses and modelling studies were eligible. Two reviewers independently assessed the credibility of effect moderation claims using Instrument to assess the Credibility of Effect Moderation Analyses. A narrative approach to synthesis was used (PROSPERO registration number: CRD42019140018).

Results

Of 1480 potentially relevant studies, seven eligible analyses of single trials and five meta-analyses were included. Among these, we found eight claims of potential differential effectiveness according to social characteristics, but none that were judged to have high credibility.

Conclusions

In the absence of highly credible evidence of differential effectiveness in different social groups, and given ongoing national implementation, equity concerns may be best served by investing in monitoring and action aimed at ensuring fair access to these interventions.

Changes in Pain Self-Efficacy, Coping Skills, and Fear-Avoidance Beliefs in a Randomized Controlled Trial of Yoga, Physical Therapy, and Education for Chronic Low Back Pain

OBJECTIVE

We evaluated exercise interventions for cognitive appraisal of chronic low back pain (cLBP) in an underserved population.

METHODS

We conducted a secondary analysis of the Back to Health Trial, showing yoga to be noninferior to physical therapy (PT) for pain and function outcomes among adults with cLBP (n = 320) recruited from primary care clinics with predominantly low-income patients. Participants were randomized to 12 weeks of yoga, PT, or education. Cognitive appraisal was assessed with the Pain Self-Efficacy Questionnaire (PSEQ), Coping Strategies Questionnaire (CSQ), and Fear-Avoidance Beliefs Questionnaire (FABQ). Using multiple imputation and linear regression, we estimated within- and between-group changes in cognitive appraisal at 12 and 52 weeks, with baseline and the education group as references.

RESULTS

Participants (mean age = 46 years) were majority female (64%) and majority Black (57%), and 54% had an annual household income <$30,000. All three groups showed improvements in PSEQ (range 0-60) at 12 weeks (yoga, mean difference [MD] = 7.0, 95% confidence interval [CI]: 4.9, 9.0; PT, MD = 6.9, 95% CI: 4.7 to 9.1; and education, MD = 3.4, 95% CI: 0.54 to 6.3), with yoga and PT improvements being clinically meaningful. At 12 weeks, improvements in catastrophizing (CSQ, range 0-36) were largest in the yoga and PT groups (MD = -3.0, 95% CI: -4.4 to -1.6; MD = -2.7, 95% CI: -4.2 to -1.2, respectively). Changes in FABQ were small. No statistically significant between-group differences were observed on PSEQ, CSQ, or FABQ at either time point. Many of the changes observed at 12 weeks were sustained at 52 weeks.

CONCLUSION

All three interventions were associated with improvements in self-efficacy and catastrophizing among low-income, racially diverse adults with cLBP.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT01343927.

Exercise therapy for chronic low back pain

BACKGROUND

Low back pain has been the leading cause of disability globally for at least the past three decades and results in enormous direct healthcare and lost productivity costs.

OBJECTIVES

The primary objective of this systematic review is to assess the impact of exercise treatment on pain and functional limitations in adults with chronic non-specific low back pain compared to no treatment, usual care, placebo and other conservative treatments.

SEARCH METHODS

We searched CENTRAL (which includes the Cochrane Back and Neck trials register), MEDLINE, Embase, CINAHL, PsycINFO, PEDro, SPORTDiscus, and trials registries (ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform), and conducted citation searching of relevant systematic reviews to identify additional studies. The review includes data for trials identified in searches up to 27 April 2018. All eligible trials have been identified through searches to 7 December 2020, but have not yet been extracted; these trials will be integrated in the next update.

SELECTION CRITERIA

We included randomised controlled trials that assessed exercise treatment compared to no treatment, usual care, placebo or other conservative treatment on the outcomes of pain or functional limitations for a population of adult participants with chronic non-specific low back pain of more than 12 weeks' duration.

DATA COLLECTION AND ANALYSIS

Two authors screened and assessed studies independently, with consensus. We extracted outcome data using electronic databases; pain and functional limitations outcomes were re-scaled to 0 to 100 points for meta-analyses where 0 is no pain or functional limitations. We assessed risk of bias using the Cochrane risk of bias (RoB) tool and used GRADE to evaluate the overall certainty of the evidence. When required, we contacted study authors to obtain missing data. To interpret meta-analysis results, we considered a 15-point difference in pain and a 10-point difference in functional limitations outcomes to be clinically important for the primary comparison of exercise versus no treatment, usual care or placebo.

MAIN RESULTS

We included 249 trials of exercise treatment, including studies conducted in Europe (122 studies), Asia (38 studies), North America (33 studies), and the Middle East (24 studies). Sixty-one per cent of studies (151 trials) examined the effectiveness of two or more different types of exercise treatment, and 57% (142 trials) compared exercise treatment to a non-exercise comparison treatment. Study participants had a mean age of 43.7 years and, on average, 59% of study populations were female. Most of the trials were judged to be at risk of bias, including 79% at risk of performance bias due to difficulty blinding exercise treatments. We found moderate-certainty evidence that exercise treatment is more effective for treatment of chronic low back pain compared to no treatment, usual care or placebo comparisons for pain outcomes at earliest follow-up (MD -15.2, 95% CI -18.3 to -12.2), a clinically important difference. Certainty of evidence was downgraded mainly due to heterogeneity. For the same comparison, there was moderate-certainty evidence for functional limitations outcomes (MD -6.8 (95% CI -8.3 to -5.3); this finding did not meet our prespecified threshold for minimal clinically important difference. Certainty of evidence was downgraded mainly due to some evidence of publication bias.  Compared to all other investigated conservative treatments, exercise treatment was found to have improved pain (MD -9.1, 95% CI -12.6 to -5.6) and functional limitations outcomes (MD -4.1, 95% CI -6.0 to -2.2). These effects did not meet our prespecified threshold for clinically important difference. Subgroup analysis of pain outcomes suggested that exercise treatment is probably more effective than education alone (MD -12.2, 95% CI -19.4 to -5.0) or non-exercise physical therapy (MD -10.4, 95% CI -15.2 to -5.6), but with no differences observed for manual therapy (MD 1.0, 95% CI -3.1 to 5.1). In studies that reported adverse effects (86 studies), one or more adverse effects were reported in 37 of 112 exercise groups (33%) and 12 of 42 comparison groups (29%). Twelve included studies reported measuring adverse effects in a systematic way, with a median of 0.14 (IQR 0.01 to 0.57) per participant in the exercise groups (mostly minor harms, e.g. muscle soreness), and 0.12 (IQR 0.02 to 0.32) in comparison groups.

AUTHORS' CONCLUSIONS

We found moderate-certainty evidence that exercise is probably effective for treatment of chronic low back pain compared to no treatment, usual care or placebo for pain. The observed treatment effect for the exercise compared to no treatment, usual care or placebo comparisons is small for functional limitations, not meeting our threshold for minimal clinically important difference. We also found exercise to have improved pain (low-certainty evidence) and functional limitations outcomes (moderate-certainty evidence) compared to other conservative treatments; however, these effects were small and not clinically important when considering all comparisons together. Subgroup analysis suggested that exercise treatment is probably more effective than advice or education alone, or electrotherapy, but with no differences observed for manual therapy treatments.

Dynamic evaluation of the contractile function of lumbodorsal muscles during locust pose in yoga by real-time ultrasound

Background and Purpose

Chronic low back pain (CLBP), which has a close relationship with lumbar muscle degeneration, can be effectively treated by exercise therapy, and yoga has been widely accepted by clinicians and patients with CLBP. The purpose of this study was to observe the changes in the thickness of lumbodorsal muscles that occur during locust pose in yoga and how these changes occur. From the changes in muscle thickness that occur in the locust pose, the contractile function of lumbodorsal muscles can be evaluated.

Methods

Fifty-two healthy volunteers (from May 2019 to August 2019, age from 28 to 68 years, 23 males and 29 females (age: 40 ± 8 years; weight: 68.3 ± 5.2 kg; height: 170.2 ± 13.1 cm) were recruited, and lumbodorsal muscle, including the multifidus, longissimus, iliocostalis, and quadratus lumborum, ultrasonic examinations were carried out in the relaxed and contracted states. The changes in the thickness of the lumbodorsal muscles in the relaxed and contracted states were dynamically observed by real-time ultrasound when subjects were performing the locust yoga pose. Then, the thicknesses of the muscles during the two states were measured to calculate the ratio of contraction of each muscle and determine the statistical significance of the change in thickness of each muscle.

Results

The mean thickness of the left multifidus in the relaxed state was 1.32 ± 0.27 cm (95 % CI: 1.24 ~ 1.39), that in the contracted state was 1.60 ± 0.30 cm (95 % CI: 1.52 ~ 1.69) (obviously different between the relaxed and contracted states, P < 0.001), and those in the corresponding right side were 1.37 ± 0.31 cm (95 % CI: 1.29 ~ 2.46) and 1.68 ± 0.38 cm (95 % CI: 1.58 ~ 1.79) (P < 0.001), respectively. The mean thickness of the left quadratus lumborum in the relaxed state was 1.38 ± 0.32 cm (95 % CI: 1.29 ~ 1.47), that in the contracted state was 1.62 ± 0.40 cm (95 % CI: 1.50 ~ 1.73) (P = 0.001), and those in the corresponding right side were 1.30 ± 0.32 cm (95 % CI: 1.21 ~ 1.39) and 1.55 ± 0.41 cm (95 % CI: 1.44 ~ 1.67) (P = 0.001), respectively. The mean thickness of the left longissimus in the relaxed was 2.33 ± 0.51 cm (95 % CI: 2.19 ~ 2.47), that in the contracted state was 3.20 ± 0.61 cm (95 % CI: 3.03 ~ 3.37) (P < 0.001), and those in the corresponding right side were 2.34 ± 0.49 cm (95 % CI 2.20 ~ 2.48) and 3.26 ± 0.68 cm (95 % CI 3.07 ~ 3.45) (P < 0.001), respectively. The mean thickness of the left iliocostalis in the relaxed state was 1.88 ± 0.41 cm (95 % CI: 1.76 ~ 1.99), that in the contracted state was 2.34 ± 0.49 cm (95 % CI: 2.00 ~ 2.47) (P < 0.001), and those in the corresponding right side were 1.98 ± 0.40 cm (95 % CI: 1.87 ~ 2.09) and 2.44 ± 0.56 cm (95 % CI: 2.29 ~ 2.60) (P < 0.001), respectively. The mean contracted state/resting state (C/R) of the longissimus was 1.39 ± 0.14 on the left and 1.40 ± 0.16 on the right. The multifidus and iliocostalis had the second highest C/R. The mean C/R of the multifidus was 1.23 ± 0.12 on the left and 1.24 ± 0.15 on the right, and the mean C/R of the iliocostalis was 1.25 ± 0.12 on the left and 1.24 ± 0.14 on the right. The quadratus lumborum had the lowest C/R, and the mean C/R of the quadratus lumborum was 1.17 ± 0.10 on the left and 1.19 ± 0.11 on the right.

Conclusions

Ultrasound can be used to dynamically assess the contractile function of the lumbar muscle in the locust pose of yoga, the C/R ratio can be used to indicate the ability of a muscle to contract, and dynamic ultrasound can guide lumbar exercise and feedback the exercise results. The establishment of this model allowed data regarding the contraction state of the lumbar muscle to be obtained in a normal population, and based on this, future studies can further explore and evaluate the contraction state of the lumbar muscle after yoga exercise in CLBP patients, the effect exercise on lumbar instability and on a patient population after lumbar operation.

Yoga for treating low back pain: a systematic review and meta-analysis

ABSTRACT

Yoga is frequently used for back pain relief. However, evidence was judged to be of only low- or moderate. To assess the efficacy and safety of yoga in patients with low back pain a meta-analysis was performed. Therefore Medline/PubMed, Scopus, and the Cochrane Library was searched to May 26 2020. Only randomized controlled trials (RCTs) comparing Yoga with passive control (usual care or waitlist), or an active comparator, for patients with low back pain, that assessed pain intensity or pain-related disability as a primary outcome were considered to be eligible. Two reviewers independently extracted data on study characteristics, outcome measures, and results at short-term and long-term follow-up. Risk of bias was assessed using the Cochrane Risk of Bias Tool. 30 articles on 27 individual studies (2702 participants in total) proved eligible for review. Compared to passive control, yoga was associated with short-term improvements in pain intensity (15 RCTs; Mean Difference (MD)=-0.74 points on a numeric rating scale; 95%CI=-1.04,-0.44; Standardized Mean Difference (SMD)=-0.37 95%CI=-0.52,-0.22), pain-related disability (15 RCTs; MD=-2.28; 95%CI=-3.30,-1.26; SMD=-0.38 95%CI=-0.55,-0.21), mental health (7 RCTs; MD=1.70; 95%CI=0.20,3.20; SMD=0.17 95%CI=0.02,0.32) and physical functioning (9 RCTs; MD=2.80; 95%CI=1.00,4.70; SMD=0.28 95%CI=0.10,0.47). Except for mental health all effects sustained long-term. Compared to an active comparator, yoga was not associated with any significant differences in short- or long-term outcomes.In conclusion, yoga revealed robust short- and long-term effects for pain, disability, physical function and mental health, when compared to non-exercise controls. However these effects were mainly not clinically significant.

A systematic review of the effectiveness of yoga on pain, physical function, and quality of life in older adults with chronic musculoskeletal conditions

OBJECTIVES

Exercise interventions suitable for older adults can help to slow and manage age-related conditions. This systematic review looks at age-related musculoskeletal conditions in a population with a mean age over 50 years, evaluating the effectiveness of yoga for pain, physical function, and quality of life.

METHODS

CENTRAL,CINAHL, Pubmed, PsycInfo, SCOPUS, Sports Discus, Web of Science Core Collection, and Google Scholar were searched. Study selection and quality screening using the Cochrane risk of bias tool were conducted by two reviewers to mitigate bias. PRISMA guidelines were followed in conducting and reporting the review.

RESULTS

11 studies met inclusion criteria with a total sample of 2221 (≥70% female). Eight studies measured pain, six showing significant effectiveness (p=≤0.05), for lower limb osteoarthritis (OA), hand OA, and neck pain. Nine studies measured physical function, four showing significant effects, for lower limb OA and sarcopenia. Significant quality of life effects were found for restless leg syndrome compared to baseline.

CONCLUSION

Moderate evidence was found for pain effects, generalisable for OA based on sub-group analysis. Effective trials were mostly short-term using at minimum one 60-min group class, and an average of four 30-min home practice sessions weekly. Findings support the use of props and modifications to address age-related physical limitations. Yoga was well-received with good adherence, but effects on a par with other exercise. There was an absence of quality of life effects in short term. Mixed methods studies could lead to further insight into the qualitative aspects of yoga practice for older adults.

Assessment of a taping method combined with manual therapy as a treatment of non-specific chronic low back pain - a randomized controlled trial

Background

Chronic low back pain is the most frequent medical problem and the condition with the most years lived with disability in Western countries. The objective of this study was to assess a new treatment, Medi-Taping, which aims at reducing complaints by treating pelvic obliquity with a combination of manual treatment of trigger points and kinesio taping in a pragmatic RCT with pilot character.

Methods

One hundred ten patients were randomized at two study centers either to Medi-Taping or to a standard treatment consisting of patient education and physiotherapy as control. Treatment duration was 3 weeks. Measures were taken at baseline, end of treatment and at follow-up after 2 months. Main outcome criteria were low back pain measured with VAS, the Chronic Pain Grade Scale (CPGS) and the Oswestry Low Back Pain Disability Questionnaire (ODQ).

Results

Patients of both groups benefited from the treatment by medium to large effect sizes. All effects were pointing towards the intended direction. While Medi-Taping showed slightly better improvement rates, there were no significant differences for the primary endpoints between groups at the end of treatment (VAS: mean difference in change 0.38, 95-CI [− 0.45; 1.21] p = 0.10; ODQ 2.35 [− 0.77; 5.48] p = 0.14; CPGS − 0.19 [− 0.46; 0.08] p = 0.64) and at follow-up. Health-related quality of life was significantly higher (p = .004) in patients receiving Medi-Taping compared to controls.

Conclusions

Medi-Taping, a purported way of correcting pelvic obliquity and chronic tension resulting from it, is a treatment modality similar in effectiveness to complex physiotherapy and patient education.

Trial registration

This trial was registered retrospectively on July 24th, 2019 as Number DRKS00017051 in the German Register of Clinical Trials (Deutsches Register Klinischer Studien).

URL of trial registry record: https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00017051.

Strength and awareness in action: Feasibility of a yoga-based intervention for post-acute mild TBI headaches among veterans

Background

Mild traumatic brain injury (mTBI) is a signature injury sustained by Veterans during recent conflicts. For some, mTBI/concussion is associated with disabling symptoms, including post-concussive headaches (PCH). However, there are limited evidence-based treatments for persistent PCH.

Objective

Investigators assessed the feasibility of design elements of a yoga-based interventional trial for PCH among Veterans, as well as the acceptability of the intervention.

Methods

This randomized controlled acceptability and feasibility trial was implemented using a waitlist-control design. Design elements of interest included: an exercise run-in class; recruitment and retention strategies; and, ecological momentary assessment (EMA) modalities to track headaches and yoga practice. Veteran satisfaction regarding the intervention was also evaluated. A descriptive analysis was conducted on candidate outcomes including PCH, post-concussive symptoms, pain, and daily functioning.

Results

Twenty-seven participants (out of 70 consented and eligible after Study Visit 1) completed each evaluation timepoint and regularly attended yoga sessions, with 89% of these Veterans reporting moderate to high levels of satisfaction with the intervention at study completion. Qualitatively, participants endorsed improvements in headaches, chronic pain, and mood. Feasibility results were mixed. Initial feasibility criterion regarding yoga attendance was not met; however, modifications, such as expansion to an additional clinic site and reduction of in-person yoga sessions with increased encouragement to use study-created online yoga videos improved feasibility of the study design. Participants most frequently used mobile and web-based EMA modalities to track yoga practice.

Conclusions

Although challenges with feasibility of the study design elements were noted, results suggested acceptability of the yoga-based intervention for Veterans with persistent PCH. Additional exploration regarding the frequency and modality of yoga delivery (e.g., in-person, telehealth) is warranted.

Impact

Veterans found the yoga-based intervention acceptable, however exploration of novel modalities of intervention delivery will likely be necessary to enhance the feasibility of intervention implementation during future trials.

Potential Role of Yoga in the Management of Ankylosing Spondylitis: A Retrospective Study

BACKGROUND

Ankylosing spondylitis (AS) is a chronic autoimmune inflammatory spondyloarthropathy with unclear pathogenesis. The inflammatory pain in AS leads to restricted spinal mobility and significant disability. Yoga is a nonpharmacological intervention that has positive effects on various musculoskeletal-related problems. However, its role in AS is unknown.

OBJECTIVE

The present retrospective study assessed the efficacy of a two-week residential yoga intervention on spinal flexibility among AS patients.

METHODS

The records for 24 male AS patients within the age range 30 to 50 years (average age 38.3 ± 10.5 years) who underwent a two-week residential yoga retreat between 2015 and 2020 were obtained from a yoga center located in South India. Yoga intervention consisted of yoga postures, breathing practices, meditation, a healthy diet, and devotional sessions. Pre and Post data of the sit-and-reach test, blood pressure, heart rate, and symptom score were analyzed using Statistical Package for Social Sciences (SPSS).

RESULTS

Compared to the baseline, the post scores of the sit-and-reach test, systolic blood pressure and heart rate were found to be significantly (P < .05) lower. The symptom score and analgesic medication score also showed significant improvement after two-weeks compared to the baseline.

CONCLUSION

This retrospective study indicates the positive impact of on and analgesic use among AS patients. However, additional studies using robust research designs are warranted.

The Role of Yoga in Treating Stress-Related Symptoms in Dental Hygiene Students

Context:

Research has provided evidence for yoga's effectiveness in the prevention and treatment of pain and stress, both of which have been implicated as significant negative moderators of student performance and experience.

Aims:

This study investigated the feasibility and preliminary impact of a 10-week yoga intervention with dental hygiene students to reduce perceptions of stress and stress-related symptoms.

Settings and Design:

Students self-selected into a yoga treatment versus control condition. They completed stress and pain measures at four time points during and after the intervention or control period of 10-weeks.

Methods:

Participants were students enrolled in a dental hygiene program. All 77 participants completed a 10-week study, self-selecting into an intervention or control group. They completed three self-report questionnaires assessing pain and stress, administered at baseline, mid-point, postintervention, and two follow-ups. The 10-week yoga intervention consisted of 10 90-min yoga sessions that provided check-ins, breathing exercises, sequences of postures, relaxation exercises, and closing meditations.

Statistical Analysis Used:

Independent samples t-tests were used to compare perceived stress levels of participants in the control versus treatment groups. Paired t-test was used to assess differences in stress-related symptom levels across time.

Results:

Results suggested that a yoga intervention is feasible for this group and that active yoga practice can lower perceived stress across multiple domains and across time.

Conclusions:

A specially adapted and designed 10-week yoga protocol appears to be an accessible option for dental hygiene programs that seek to support their students in improving overall wellbeing.

Yoga vs Stretching in Veterans With Chronic Lower Back Pain and the Role of Mindfulness: A Pilot Randomized Controlled Trial

Objective

The purpose of this study was to investigate the feasibility of recruiting, randomizing, enrolling, and collecting outcome data on veteran patients with chronic low back pain (CLBP) who undergo an 8-week, active exercise class with mindfulness (yoga class) and without (stretching class).

Methods

United States veterans with CLBP based on inclusion/exclusion criteria were randomized to 1 of 2 groups. The study design was a pilot randomized controlled trial. Twenty CLBP patients attended a yoga class or stretching class once per week for 8 weeks at the Veterans Affairs Rochester Outpatient Center, Rochester, New York. The following measurements were obtained: recruitment or enrollment data, compliance data to include class attendance and home exercise, and compliance data regarding ability to collect outcome measures at baseline and at completion. Outcome measures included pain (PEG), quality of life (PROMIS Global Health Survey), self-efficacy (2-item questionnaire), fear avoidance belief, catastrophizing, and social engagement in addition to qualitative clinician open-ended questions postintervention.

Results

Forty-five veterans were queried regarding interest in participation. Of these, 34 (76%) met the study's criteria. Twenty (44%) agreed to participate and were consented, randomized, and enrolled in the study. Initial and final outcome measures were obtained for each participant (100%). Forty percent attended more than 80% of the sessions for both yoga and stretching groups.

Conclusion

This pilot study demonstrated feasibility of recruiting, enrolling, and collecting outcome data on CLBP veteran patients participating in yoga and stretching class. The data from this pilot will inform the development of a randomized, comparative effectiveness study of yoga with and without mindfulness in the management of CLBP.

Cost-effectiveness of Yoga for Chronic Low Back Pain in Veterans

BACKGROUND

Yoga interventions can improve function and reduce pain in persons with chronic low back pain (cLBP).

OBJECTIVE

Using data from a recent trial of yoga for military veterans with cLBP, we analyzed the incremental cost-effectiveness of yoga compared with usual care.

METHODS

Participants (n=150) were randomized to either 2× weekly, 60-minute yoga sessions for 12 weeks, or to delayed treatment (DT). Outcomes were measured at 12 weeks, and 6 months. Quality-adjusted life years (QALYs) were measured using the EQ-5D scale. A 30% improvement on the Roland-Morris Disability Questionnaire (primary outcome) served as an additional effectiveness measure. Intervention costs including personnel, materials, and transportation were tracked during the study. Health care costs were obtained from patient medical records. Health care organization and societal perspectives were examined with a 12-month horizon.

RESULTS

Incremental QALYs gained by the yoga group over 12 months were 0.043. Intervention costs to deliver yoga were $307/participant. Negligible differences in health care costs were found between groups. From the health care organization perspective, the incremental cost-effectiveness ratio to provide yoga was $4488/QALY. From the societal perspective, yoga was "dominant" providing both health benefit and cost savings. Probabilistic sensitivity analysis indicates an 89% chance of yoga being cost-effective at a willingness-to-pay of $50,000. A scenario comparing the costs of yoga and physical therapy suggest that yoga may produce similar results at a much lower cost.

DISCUSSION/CONCLUSIONS

Yoga is a cost-effective treatment for reducing pain and disability among military veterans with cLBP.

Update of Markov Model on the Cost-effectiveness of Nonpharmacologic Interventions for Chronic Low Back Pain Compared to Usual Care

STUDY DESIGN

Markov model.

OBJECTIVE

Further validity test of a previously published model.

SUMMARY OF BACKGROUND DATA

The previous model was built using data from ten randomized trials and examined the 1-year effectiveness and cost-effectiveness of 17 nonpharmacologic interventions for chronic low back pain (CLBP), each compared to usual care alone. This update incorporated data from five additional trials.

METHODS

Based on transition probabilities that were estimated using patient-level trial data, a hypothetical cohort of CLBP patients transitioned over time among four defined health states: high-impact chronic pain with substantial activity limitations; higher (moderate-impact) and lower (low-impact) pain without activity limitations; and no pain. As patients transitioned among health states, they accumulated quality-adjusted life-years, as well as healthcare and productivity costs. Costs and effects were calculated incremental to each study's version of usual care.

RESULTS

From the societal perspective and assuming a typical patient mix (25% low-impact, 35% moderate-impact, and 40% high-impact chronic pain), most interventions-including those newly added-were cost-effective (<$50,000/QALY) and demonstrated cost savings. From the payer perspective, fewer were cost-saving, but the same number were cost-effective. Results for the new studies generally mirrored others using the same interventions-for example, cognitive behavioral therapy (CBT) and physical therapy. A new acupuncture study had similar effectiveness to other acupuncture studies, but higher usual care costs, resulting in higher cost savings. Two new yoga studies' results were similar, but both differed from those of the original yoga study. Mindfulness-based stress reduction was similar to CBT for a typical patient mix but was twice as effective for those with high-impact chronic pain.

CONCLUSION

Markov modeling facilitates comparisons across interventions not directly compared in trials, using consistent outcome measures after balancing the baseline mix of patients. Outcomes also differed by pain impact level, emphasizing the need to measure CLBP subgroups.

LEVEL OF EVIDENCE

N/A.

Yoga compared to non-exercise or physical therapy exercise on pain, disability, and quality of life for patients with chronic low back pain: A systematic review and meta-analysis of randomized controlled trials

Background

Chronic low back pain (CLBP) is a common and often disabling musculoskeletal condition. Yoga has been proven to be an effective therapy for chronic low back pain. However, there are still controversies about the effects of yoga at different follow-up periods and compared with other physical therapy exercises.

Objective

To critically compare the effects of yoga for patients with chronic low back pain on pain, disability, quality of life with non-exercise (e.g. usual care, education), physical therapy exercise.

Methods

This study was registered in PROSPERO, and the registration number was CRD42020159865. Randomized controlled trials (RCTs) of online databases included PubMed, Web of Science, Cochrane Central Register of Controlled Trials, Embase which evaluated effects of yoga for patients with chronic low back pain on pain, disability, and quality of life were searched from inception time to November 1, 2019. Studies were eligible if they assessed at least one important outcome, namely pain, back-specific disability, quality of life. The Cochrane risk of bias tool was used to assess the methodological quality of included randomized controlled trials. The continuous outcomes were analyzed by calculating the mean difference (MD) or standardized mean difference (SMD) with 95% confidence intervals (CI) according to whether combining outcomes measured on different scales or not.

Results

A total of 18 randomized controlled trials were included in this meta-analysis. Yoga could significantly reduce pain at 4 to 8 weeks (MD = -0.83, 95% CI = -1.19 to -0.48, p<0.00001, I² = 0%), 3 months (MD = -0.43, 95% CI = -0.64 to -0.23, p<0.0001, I² = 0%), 6 to 7 months (MD = -0.56, 95% CI = -1.02 to -0.11, p = 0.02, I² = 50%), and was not significant in 12 months (MD = -0.52, 95% CI = -1.64 to 0.59, p = 0.36, I² = 87%) compared with non-exercise. Yoga was better than non-exercise on disability at 4 to 8 weeks (SMD = -0.30, 95% CI = -0.51 to -0.10, p = 0.003, I² = 0%), 3 months (SMD = -0.31, 95% CI = -0.45 to -0.18, p<0.00001, I² = 30%), 6 months (SMD = -0.38, 95% CI = -0.53 to -0.23, p<0.00001, I² = 0%), 12 months (SMD = -0.33, 95% CI = -0.54 to -0.12, p = 0.002, I² = 9%). There was no significant difference on pain, disability compared with physical therapy exercise group. Furthermore, it suggested that there was a non-significant difference on physical and mental quality of life between yoga and any other interventions.

Conclusion

This meta-analysis provided evidence from very low to moderate investigating the effectiveness of yoga for chronic low back pain patients at different time points. Yoga might decrease pain from short term to intermediate term and improve functional disability status from short term to long term compared with non-exercise (e.g. usual care, education). Yoga had the same effect on pain and disability as any other exercise or physical therapy. Yoga might not improve the physical and mental quality of life based on the result of a merging.

Analogy between classical Yoga/Zen breathing and modern clinical respiratory therapy

Anesthesiologists and intensivists are modern-day professionals who provide appropriate respiratory care, vital for patient survival. Recently, anesthesiologists have increasingly focused their attention on the type of spontaneous breathing made by non-intubated patients with pulmonary disease cared for in an intensive care unit, and also patients with chronic pain receiving cognitive behavioral therapy. Prior to our modern understanding of respiratory physiology, Zen meditators recognized that breathing has a significant impact on a person’s mental state and general physical well-being. Examples of this knowledge regarding respiration include the beneficial effects of deep inhalation and slow exhalation on anxiety and general wellness. The classical literature has noted many suggestions for breathing and its psycho-physical effects. In the present review, we examine the effect of classical breathing methods and find an analogy between typical Yoga/Zen breathing and modern clinical respiratory therapy. Evidence is increasing about historical breathing and related meditation techniques that may be effective in modern clinical practice, especially in the field of anesthesiology, such as in improving respiratory function and reducing chronic pain. Clarification of the detailed mechanisms involved is anticipated.

Which Interventions Enhance Pain Self-efficacy in People With Chronic Musculoskeletal Pain? A Systematic Review With Meta-analysis of Randomized Controlled Trials, Including Over 12 000 Participants

OBJECTIVE

To find out which interventions enhance pain self-efficacy in people with chronic musculoskeletal pain and to evaluate the reporting of interventions designed to enhance pain self-efficacy.

DESIGN

Intervention systematic review with meta-analysis.

LITERATURE SEARCH

PubMed, Embase, Scopus, PsycINFO, CINAHL, PEDro, and the Cochrane Central Register of Controlled Trials were searched from inception up to September 2019.

STUDY SELECTION CRITERIA

Randomized controlled trials evaluating pain self-efficacy as a primary or secondary outcome in chronic musculoskeletal pain.

DATA SYNTHESIS

We used the Cochrane risk of bias tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to evaluate the risk of bias and the certainty of the evidence, respectively.

RESULTS

Sixty randomized controlled trials were included (12 415 participants). There was a small effect of multicomponent, psychological, and exercise interventions improving pain self-efficacy at follow-ups of 0 to 3 months, a small effect of exercise and multicomponent interventions enhancing pain self-efficacy at follow-ups of 4 to 6 months, and a small effect of multicomponent interventions improving pain self-efficacy at follow-ups of 7 to 12 months. No interventions improved pain self-efficacy after 12 months. Self-management interventions did not improve pain self-efficacy at any follow-up time. Risk of bias, the nature of the control group, and the instrument to assess pain self-efficacy moderated the effects of psychological therapies at follow-ups of 7 to 12 months. The certainty of the evidence for all included interventions was low, due to serious risk of bias and indirectness. No trial reported the intervention in sufficient detail to allow full replication.

CONCLUSION

There was low-quality evidence of a small effect of multicomponent exercise and psychological interventions improving pain self-efficacy in people with chronic musculoskeletal pain. J Orthop Sports Phys Ther 2020;50(8):418-430. doi:10.2519/jospt.2020.9319.

Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of low back pain

BACKGROUND CONTEXT

The North American Spine Society's (NASS) Evidence Based Clinical Guideline for the Diagnosis and Treatment of Low Back Pain features evidence-based recommendations for diagnosing and treating adult patients with nonspecific low back pain. The guideline is intended to reflect contemporary treatment concepts for nonspecific low back pain as reflected in the highest quality clinical literature available on this subject as of February 2016.

PURPOSE

The purpose of the guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for adult patients with nonspecific low back pain. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition.

STUDY DESIGN

This is a guideline summary review.

METHODS

This guideline is the product of the Low Back Pain Work Group of NASS' Evidence-Based Clinical Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members utilized NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guideline was submitted to an internal and external peer review process and ultimately approved by the NASS Board of Directors.

RESULTS

Eighty-two clinical questions were addressed, and the answers are summarized in this article. The respective recommendations were graded according to the levels of evidence of the supporting literature.

CONCLUSIONS

The evidence-based clinical guideline has been created using techniques of evidence-based medicine and best available evidence to aid practitioners in the diagnosis and treatment of adult patients with nonspecific low back pain. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flowchart, suggestions for future research, and all of the references, is available electronically on the NASS website at https://www.spine.org/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx.

Establishment of a Novel Porcine Model to Study the Impact of Active Stretching on a Local Carrageenan-Induced Inflammation

OBJECTIVE

Active stretching of the body is integral to complementary mind-body therapies such as yoga, as well as physical therapy, yet the biologic mechanisms underlying its therapeutic effects remain largely unknown. A previous study showed the impact of active stretching on inflammatory processes in rats. The present study tested the feasibility of using a porcine model, with a closer resemblance to human anatomy, to study the effects of active stretching in the resolution of localized inflammation.

DESIGN

A total of 12 pigs were trained to stretch before subcutaneous bilateral Carrageenan injection in the back at the L3 vertebrae, 2 cm from the midline. Animals were randomized to no-stretch or stretch, twice a day for 5 mins over 48 hrs. Animals were euthanized for tissue collection 48 hrs postinjection.

RESULTS

The procedure was well tolerated by the pigs. On average, lesion area was significantly smaller by 36% in the stretch group compared with the no-stretch group (P = 0.03).

CONCLUSION

This porcine model shows promise for studying the impact of active stretching on inflammation-resolution mechanisms. These results are relevant to understanding the stretching-related therapeutic mechanisms of mind-body therapies. Future studies with larger samples are warranted.