low back pain: virtual yoga helps

A recent study found profound benefits of virtual yoga for patients with chronic low back pain (see low back pain virtual yoga helps JAMA2024 in dropbox, or doi:10.1001/jamanetworkopen.2024.42339)

 

Details:

-- 140 adult participants aged 18-64 were selected in this single-blind, 24-week, randomized clinical trail, from 2022-2023

-- all patients had a mean low back pain (LBP) pain intensity score of al least 4 on an 11-point numerical rating score (0-10, the higher the worse pain) as well as daily back pain that interfered with activity for at least half of the days

    -- intervention group ("yoga now group"): twelve weekly consecutive 60-minute hatha yoga group classes

    -- control group ("yoga later group"): people interested in the study, were offered the virtual intervention after the study was over, and were on a wait-list

-- mean age 48, 81% female, 82% white/12% Black, 6% Hispanic, high school 5%/some college 21%/college 46%/graduate school 27%, 96% working

-- pain intensity score 5.7, Roland Morris Disability Questionnaire (RMDQ )12.1 [ie, moderate pain and impairment]

-- pain history duration: >5years in 52%/1-5y in 42%; epidural injection none in 59%/1-3 in 25%/>3 in 16%; back surgery none in 86%/1 in 10%; sciatica none in 41%/not sure in 7%/yes in 52%

-- pain meds used: any pain med in 74%/NSAIDs in 64%/acetaminophen in 33%/muscle relaxant in 16%/opioids in 5%/topical cream in 7%

-- sleep quality 1.8 [ie, sleep quality average to poor]

-- BMI 29, smoking never in 71%/former in 42%/current in1%

-- primary outcomes: 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 values reflecting poorer function, at 24 weeks

    -- the minimal clinically significant change is considered to be 2.0 points on the pain intensity scale and 3.0 points on RMDQ

-- secondary and exploratory outcomes: the primary outcome measures as well as assessment of sleep quality using the Sleep Disturbance Short Form 8a, item 1 (score form 0-4, higher scores reflecting better sleep quality); the prescription and over-the-counter pain medications used; the in-class attendance rate, and at-home yoga practice (per an electronic weekly yoga diary); and adverse effects of the intervention

 

Results:

-- yoga classes: 0-9 participants per class; participants assigned to the yoga now group had an adherence rate (defined as at least 50% class attendance) of 36.6% and they attended a median of 4 classes

-- for the 65 participants who returned home practice logs, participants practiced an estimated median of 4 days per week, and a mean of 28.1 minutes per day.

-- follow-up assessment completion rates were lower in the yoga now group than in the yoga later group at 6 weeks (71.8% vs 76.8%), 12 weeks (67.6% vs 87.0%), and 24 weeks (60.6% vs 89.9%).

 

-- mean change from baseline for pain intensity and RMDQ:

    -- week 6:

        -- yoga now group vs yoga later group:

            -- pain intensity:  -1.4 (-1.99 to -0.8) vs -0.1 (-0.6 to 0.4); RMDQ -2.7 (-3.8 go -1.6) vs -0.3 (-1.4 to 0.7)

            -- between group difference: pain intensity -1.3 (-2.1 to -0.6), p<0.001; RMDQ -2.4 (-3.9 to -0.9), p=0.002

    -- week 12:

        -- yoga now group vs yoga later group:

            -- pain intensity:  -1.8 (-2.3 to -1.2) vs -0.3 (-0.8 to 0.4); RMDQ -4.3 (-5.5 to -3.2) vs -1.6 (-2.6 to -0.6)

            -- between group difference: pain intensity -1.5 (-2.2 to -0.7), p<0.001; RMDQ -2.8 (-4.3 to --1.3), p<0.001

            -- percentages of participants experiencing clinically important changes in pain intensity (38.0% vs 20.3%) and RMDQ (42.3% vs 24.6%) scores at 12 weeks were approximately 1.7- to 1.9-fold greater for yoga now compared with yoga later

    -- week 24 (primary outcome, 12 weeks after the end of the virtual yoga classes):

        -- yoga now group vs yoga later group:

            -- pain intensity:  -2.4 (-3.0 to -1.9) vs -0.1 (-0.6 to 0.5); RMDQ -6.0 (-7.1 to -4.9) vs -1.4 (-2.4 to -0.4)

            -- between group difference: pain intensity -2.3 (-3.1 to -1.6), p<0.001; RMDQ -4.6 (-6.1 to -3.1), p<0.001

            -- the mean changes in pain intensity and RMDQ exceeded their predetermined minimal clinically significant change

 

-- mean change from baseline for sleep quality:

    -- week 6:

        -- yoga now group vs yoga later group:

            -- sleep quality: 0.3 (0.1 to 0.5) vs 0.1 (-0.1 to 0.3)

            -- between group difference: 0.2 (-0.1 to 0.5), p=0.17, not significant

    -- week 12:

        -- yoga now group vs yoga later group:

            -- sleep quality: 0.4 (0.2 to 0.7) vs 0.04 (-0.2 to 0.3)

            -- between group difference: 0.4 (0.1 to 0.7), P=0.008

    -- week 24:

        -- yoga now group vs yoga later group:

            -- sleep quality: 0.5 (0.3 to 0.7) vs 0.1 (-0.2 to 0.3)

            -- between group difference: 0.4 (0.1to 0.7), P=0.005

 

-- use of analgesic meds:

 

-- ie, at 12 weeks, yoga now participants reported 21.4 (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 (5.2%-37.3%) absolute percentage points less

    -- the main analgesic reduction was in the use of NSAIDs (the most commonly prescribed by far)

 

-- adverse events:

    -- overall, uncommon in both groups:  yoga now, 3 participants reported transient exacerbation of back pain possibly related to the intervention; one participant in yoga later reported a flare-up of pre-existing neck pain.

 

Commentary:

-- LBP is the leading cause of disability and health care costs in the US, including in healthcare employees (the intervention group targeted in the above study, who have a lifetime LBP prevalence of 55%)

    -- the primary factors leading to LBP in healthcare workers is likely from workplace mechanics, posture, psychosocial stressors, and lack of physical activity

-- over time, outcomes from LBP in the population have gotten worse, with more than one in three having pain and disability 1 year later

-- the results of this chronic pain is profound, with financial, emotional, self-esteem, and physical effects from the chronic pain; these effects are not just in the individual involved but also within their families and communities, as well as the increase in overall societal costs in health care and needed social benefits (health insurance, food/housing subsidies, etc)

-- clinical guidelines do recommend non-pharmacological interventions as the first step, including yoga and physical therapy, then non-opioid pain meds, with opioids being last resort

    -- a pretty recent study found that early PT initiated within 3 days after the acute onset of sciatica led to dramatic decreases in patient self-reported pain and disability one year later: https://gmodestmedblogs.blogspot.com/2020/10/sciatica-early-pt-helps-longterm.html

    -- opioids have not been found to be beneficial for chronic LBP, the target of the above study: https://gmodestmedblogs.blogspot.com/2018/03/opioids-not-better-for-chronic.html 

        -- and, by the way, neither are gabapentinoids very effective, and there are studies finding that yoga, taichi, mindfulness, and home-based cognitive behavioral therapy all have potential benefits (as noted in the above-mentioned blog)

-- other studies have found that yoga is not inferior to physical therapy for those with chronic LBP, per a Cochrane review https://pmc.ncbi.nlm.nih.gov/articles/PMC9673466/#CD010671-sec-0117; their assessment was that there was "moderate‐certainty evidence of little or no difference between yoga and other exercise in back‐related function at short and short–intermediate term, and low‐certainty evidence of little or no difference at intermediate term" and the exercise assessed included physical therapy. for a specific blog on the benefit of yoga, done by the same principal investigator Rob Saper, see https://gmodestmedblogs.blogspot.com/2017/06/yoga-for-chronic-low-back-pain.html 

 

-- this current study adds to the chronic LBP literature finding that  36.6% of patients did attend at least 50% of the virtual yoga classes (though they might have practiced or watched these classes later if necessary, since the classes were recorded and accessible), and the benefits of virtual yoga in the overall group assigned to it continued to increase for the 3 months after the study ended

 

Limitations:

-- the study was limited to the age range 18-64yo, which could limit generalizability to those older than 64yo

-- in addition, this was a nondiverse population (82% white, 81% women), was highly educated, and undoubtedly wealthier than the average population, so the results may not apply so well to others. And, it would also be inapplicable to those either without a computer or technological expertise to have on-line, virtual sessions.

-- the baseline use of opiates was 4-fold less than the participants in prior yoga trials for LBP, per the researchers in this study, and the addictive potential of the opiates in a more varied population might distort the results

-- of course, there are huge benefits of virtual yoga, including the cost (lots available on-line for free, even ones focused on LBP), the freedom to do it at a time best for the patient, no need to deal with travel (which can be challenging for some with chronic low back pain), and not needing to miss work for the sessions

-- assessments were self-reported and might therefore include a self-reporting bias. And the percent of those in the program who returned their home practice logs was small. all of this might distort the actual results.

    -- on average, participants reported an average of 28 minutes of yoga a day, 4 days/week, regardless of whether they attended live classes. But this was largely self-reported

-- the staff were not blinded to the study allocation (of course....), so there could be some bias associated with patients feeling more involved in the process and feeling that their low back pain was being attended to

-- the control group in this study ("yoga later") was not a truly independent control group, though they did mimic the same background and demographics as the "yoga now" group, given that they were from the same background participant pool and were interested in the same program. but were there also other differences from a standard control group? did they perhaps exaggerate their LBP disability since they wanted to continue to be in the next group of people getting virtual yoga? (ie, did they feel there was an incentive to exaggerate their LBP symptoms?). it was noted that assessment of study completion rates were lower in the yoga now group than in the yoga later group, perhaps reflecting that the yoga later group was more engaged in the study than the yoga now group??

-- it is not known what the effective number of classes is needed, the frequency of the yoga, the relative benefit of classes vs just streaming yoga online, the best type of yoga, etc.  It might well be that fewer classes are necessary, or even that just streaming yoga is sufficient. it would be great to have specific studies addressing these issues.

-- as with many studies, it would be great to have longer term results. for one thing, those with LBP are at higher risk of another acute LBP event. Would that be less in those who did the yoga and continued it? Would yoga work as well a second time? Would patients need formal virtual sessions later or would the initial instruction be sufficient?  it was notable that the above-mentioned early PT study for those with acute sciatica did find profound benefits one year after the patients' initial acute sciatica event. would virtual yoga help longterm for patients with acute LBP as the PT did with those with acute sciatica?

 

so,

-- pretty impressive results that virtual yoga sessions for patients with chronic LBP led to decreases in pain, disability, need for analgesics, and improved sleep typically within 6 weeks and increasing over a 24-week period (12 weeks after the end of the formal study). And, not surprisingly, with no real significant adverse effects (especially as compared to meds or surgery...)

-- unfortunately, in-person yoga is not often covered by many health insurers (vs physical therapy, meds, surgery). However, for many patients there are free streaming sites for home-based yoga specifically for low back pain (both acute and chronic), and we clinicians should strongly consider reinforcing this to our patients with LBP

 

geoff

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