Yoga and Low Back Pain Part III - What does the Evidence Say?
Hey Readers! Welcome! I am so glad you are here. Today’s post is Part III of my “Yoga for Low Back Pain” series. If you have not read part I (click here) or part II (click here) yet, I highly recommend that you go back and read those first two installments first. In today’s post, I will go over some of the research that looked at the efficacy of yoga for mitigating the symptoms of chronic low back pain (CLBP). But first, let’s do a little review of how CLBP is typically treated.
There are multiple pharmacological treatment modalities for mechanical LBP, including nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids. NSAIDs are usually only effective for short-term relief of CLBP. While opioids may provide long-term relief for CLBP, they carry a high risk of misuse, abuse, and dependence. There appears to be little-to-no benefit for acetaminophen (Tylenol), skeletal muscle relaxants, lidocaine patches, and transcutaneous electrical nerve stimulation. There is no strong evidence for or against the use of injection therapy – e.g., corticosteroids and other drugs administered at epidural sites, facet joints, or local sites. And, relatively few patients with mechanical LBP seem to benefit from surgery, as the evidence to support surgery is also very limited. In fact, surgery (typically spinal fusion and lumbar disk replacement) is usually only recommended if the pain persists for more than a year after trying other conservative treatments.
There is a growing emphasis on mind-body techniques for controlling pain, with many patients with chronic pain turning to cognitive behavioral therapy (CBT), yoga, meditation, hypnosis, and relaxation procedures to reduce their pain. These techniques include a cognitive component, such as attention or awareness, and an emotional component. Growing evidence shows that these techniques are effective at reducing both chronic and acute pain. Yoga, practiced mindfully, significantly reduces pain and can also relieve fatigue and emotional distress. In some cases, mindful yoga works more effectively than medication, without any of the negative side effects of various medicines. Many people who experience chronic pain reduce, or even eliminate, their need for opioid medications after taking up a regular yoga practice.
Yoga is now considered a recommended treatment from the American College of Physicians for CLBP, as well as exercise, acupuncture, tai chi, and CBT. Yoga is a holistic approach and incorporates body awareness, breathing activities, meditation, and physical postures that build strength, flexibility, and balance. The intensity of yoga can range from gentle to strenuous, with some types of yoga providing a cardiovascular workout, and others focused more on relaxation and calmness. Yoga helps to strengthen and stretch back muscles that might be tight and/or weak, and this can improve mobility therein. Yoga also involves increasing awareness and acceptance of moment-to-moment experiences, including physical discomfort and difficult emotions, and this can help with how an individual perceives pain. Part IV of this series will go over the recommended guidelines when beginning a yoga practice for CLBP, so stay tuned for more on this next week!
Summary of Research Evidence Supporting Yoga for CLBP
When digging through the research on pain and yoga, I found quite a lot of research that confirmed the benefits of yoga on all types of chronic pain, including arthritis, migraines, carpel tunnel syndrome, and of course, CLBP. Obviously, I cannot comb through every single research study that exists about yoga and LBP, but I will summarize several studies in this section. In general, most of the research examining yoga for CLBP compared yoga to either physical therapy (PT), cognitive behavioral therapy (CBT), strength-training, and/or education via “The Back Book.” While I did not specifically read research that looked at massage, acupuncture, or dry needling in the management of CLBP, several of the papers I did read stated that these approaches seem to offer a small benefit in pain outcomes for those with CLBP. Let’s go over some of the research on yoga for CLBP.
Bramberg et al (2017) compared the effects of strength training (5, 60-minute training sessions in 6 weeks), yoga (2, 60-minute classes per week), and education (via “The Back Book”) in subjects with CLBP. The outcome measures included back pain, disability, and number of days missed at work due to LBP. The results of this study showed no differences in outcome measures between the strength training and yoga groups, BUT…, both the strength training and yoga groups differed significantly from the education-only group. Thus, it appears that strength training AND yoga are effective at reducing back pain, disability, and absenteeism from work, but education only does not have that same effect. Interestingly, in this study, more participants adhered to, and participated in, yoga compared to strength training, AND there were less dropouts in the yoga group.
Cherkin et al (2016) randomly assigned participants with CLBP to either a cognitive behavioral therapy (CBT) group, yoga group, or to an education-only group. Participants in the CBT and yoga groups participated in the intervention for 2 hours per week for 8 weeks. Instructions were provided for participants to also carry out the intervention at home (e.g. workbooks, CDs, etc.). Similar to the Bramberg et al (2017) study, there were no significant differences in disability or pain between the yoga and CBT groups; however, both the yoga and CBT groups showed significantly more improvement in back pain and disability measures compared to the education-only group. Also, the participants in the yoga and CBT groups showed significant improvement in depression, anxiety, and general wellness when compared to the education-only group but not when compared to each other.
Colgrove et al (2019) compared participants with CLBP to themselves before and after a 12-week yoga intervention. Following the yoga intervention, participants demonstrated improvements in pain, disability, spinal flexibility, and core strength. Regarding pain, participants reported that they experienced a longer duration of pain relief following yoga sessions. Many types of yoga were examined in this paper (e.g. hatha, Iyengar, Viniyoga, etc.). The fact that so many different styles of yoga were included in this study suggests that the principles emphasized in yoga are more important than any specific sequence of postures.
Groessl et al (2017) randomized participants with CLBP from the Veterans Administration (VA) to either a yoga intervention or delayed yoga treatment (DT) comparison group. Participants in the yoga group were scheduled to attend a 12-week yoga program immediately after randomization, whereas the comparison participants were invited to attend the yoga intervention after 6 months. When pain intensity and back pain-related disability were assessed 6-months after the yoga intervention, those that participated in the yoga intervention showed significant decreases in pain intensity and disability compared to the DT group. The study also showed that the proportion of participants using opioid pain medications in the yoga group dropped significantly at 12 weeks and after 6 months. Also, of note, is that no serious adverse events were reported during the 6-month follow up period for study participants. Thus, yoga appears to be safe and can reduce pain and disability among adults with CLBP.
Nambi et al (2014) randomized subjects with CLBP to either an Iyengar yoga group (1 hr group class per week plus 30-min home practice 5 days/week) or a traditional exercise group (including stretching and strengthening for the back and abdominal muscles performed 3 days per week). They examined the outcome measures of pain intensity and quality of life after beginning the two different interventions. Both the yoga and traditional exercise groups demonstrated decreased pain four weeks after beginning the intervention. Both groups also saw improvements in quality of life and participation in activities of daily living (ADLs). Also, these effects were maintained when subjects were assessed again 6-months after beginning the intervention, and interestingly, at this time point, the effects on pain intensity and QOL were significantly greater for the individuals who participated in the yoga intervention as opposed to the traditional exercise treatment, suggesting that it may take time for yoga to take effect on back pain.
Saper et al (2017) compared yoga, physical therapy (PT), and education-only for individuals with CLBP. Both yoga and PT significantly improved physical function of the low back AND reduced pain, and both yoga and PT were more effective for managing pain than the education-only group. Additionally, both yoga and PT participants were more likely to discontinue pain medication than education-only group. Even more exciting – the improvements seen in the yoga and PT groups were maintained when participants were assessed again at the 1-year mark.
Sherman et al (2011) randomly assigned participants with CLBP to one of three groups – yoga, stretching/strengthening, or education-only (they were given a book on LBP). Both the yoga and stretching classes involved stretching and strengthening leg and back muscles. Pain intensity/bothersomeness and quality of life were measured at various time points up to 6 months. There were no statistically significant differences in QOL and pain intensity between the yoga group and stretching/strengthening group; however, both the yoga and stretching/strengthening groups showed significantly less pain and improved QOL compared to the education-only group.
Sherman et al (2013) randomized participants with CLBP to either 12 weeks of weekly yoga classes, 12 weeks of weekly intensive stretching classes, or education-only (via a self-care book). Participants were also asked to practice their intervention at home. Both the yoga and stretching interventions were significantly superior to the education-only group for the outcome measures of: fear-avoidance (specifically for fear regarding movement and exercise), self-efficacy (i.e. confidence about one’s ability to exert control over one’s actions), body awareness (of natural bodily rhythms and cycles), amount of sleep, psychological distress, and back pain dysfunction. Basically, the subjects in the yoga and stretching groups reported less fear regarding exercise, improved self-efficacy and body awareness, enhanced sleep, reduced psychological distress, and improved back functioning. These improvements were not seen in the education-only group.
Telles et al (2016b) randomly assigned individuals with CLBP to a yoga intervention or an education-only group. The results of this study showed that after 12 weeks of yoga, participants with CLBP reported significantly less pain than before participating in yoga AND significantly less state anxiety than before the yoga intervention began. Individuals in the education-only group did not see these changes before or after their intervention.
In summary, most of the research summarized in this blog post suggest that movement and/or mindfulness of any kind (e.g. yoga, strength training, PT, CBT, etc.) helps to reduce the intensity of low back pain AND improve QOL and participation in ADLs. Education-only and pain management via medication are actually not supported by the evidence, as described above. Thus, it seems that the most important thing you can do to reduce CLBP and improve functioning is to simply MOVE YOUR BODY. As the saying goes, "movement is medicine," and it really, truly is. Just sitting around reading about back pain while taking one pain pill after another does not seem to be effective at all in reducing CLBP.
How Does Yoga Help Reduce CLBP?
So, based on the research discussed above, it’s obvious that yoga is hugely beneficial for mitigating the symptoms of CLBP, such as pain, reduced QOL, and functional limitations in ADLs. Several research studies have examined what the mitigating factors might be for yoga’s effect on back pain. The following areas are hypothesized to be responsible for yoga’s positive influence on back health:
Relaxation response: When your body is in a relaxation response, your body’s tissues can heal and regenerate. Yoga is well documented for improving activity in the parasympathetic nervous system (PNS – click here to read more about the PNS), which causes your breath to slow and deepen, heart rate to lower, blood pressure to drop, and muscle tension to decrease. Chronic pain often causes heightened activity in the sympathetic nervous system (i.e. “fight or flight” system), so getting out of sympathetic overdrive and into a more relaxing state is incredibly therapeutic for the body and the mind.
Daily energy: Yoga can improve sleep, which leads to more energy during the day AND improved cognitive and emotional processing. Recall, from part II of this series that your perception of pain is largely influenced by your cognitive and emotional states. Thus, if you are feeling strong and steady emotionally/cognitively, you might perceive less pain in your low back. Yoga also can have an invigorating effect on physical energy since many styles of yoga involve movement, which can be energizing. Feeling more energetic during the day can make it much easier and less tiring to do everyday tasks.
Acceptance and awareness: Mindfulness, or awareness of the present moment without judgment, is integral to the practice of yoga. Yoga teaches the student how to experience the present moment fully and completely without resisting it or trying to escape it. Often suffering from chronic pain is the result of trying to resist the pain in the body. Through the practice of yoga, the student can learn how to observe the sensations in the body and mind without reacting to it or labeling it as “bad” or “good.” Self-study (i.e. svadhyaya) is also a key concept in yoga. Self-study involves learning about your habits of body and mind. This can help with pain management, as you might start to notice that certain foods, activities, emotions, etc. either amplify or dampen your CLBP. Part of self-study also involves being truthful (i.e. satya) with yourself about what you are feeling in a given moment. For example, you might be so used to being in pain that you just assume your low back will hurt, even if it doesn’t actually hurt in that moment. Through the practice of yoga, the student learns to be honest with him/herself, accept the truth, and study him/herself deep enough to understand what is happening in the body/mind and why.
Asana practice/postures: The practice of doing yoga poses (asanas/postures) can build strength, enhance flexibility, release tension, and improve balance and physical function (e.g. digestion), all of which can contribute to pain relief. Asana practice is also really great at improving proprioception, which is your body’s sense of where it is in space. Improved proprioception can help the student adopt correct posture to relax muscle tension and relieve discomfort. Also, there is evidence that as proprioception improves, nociception (i.e. detection of pain) decreases. It is super important in yoga that postures are steady AND easeful – i.e. in yoga, you learn to move in ways that challenge your body without straining it. Mindfulness helps you to learn to pay attention to skillful bodily movements and to the shifting sensations as you move in/out of a pose or hold a pose. This teaches you how to adjust your body so that you find that “just right” spot where you feel steady AND at ease, with little, or no, discomfort. This can help you to work more skillfully with how you think about pain, how you handle emotional reactions to your discomfort, how you breathe (which affects EVERYTHING in your body), and how you engage in various activities.
Wow! As this post describes, there is quite a lot of evidence that shows that movement in general, including yoga, is super effective for reducing the symptoms of CLBP, including pain intensity, QOL, and participation in ADLs. Several research studies were reviewed that showed that yoga, physical therapy (PT), and strength training (especially for the core and hips) are essentially equally effective for improving back pain. Also, these studies also showed that yoga, PT, and strength training are far superior to the standard of care, which consists of education via a back pain book and pain-reducing medications. Yoga also appears to be a safe treatment option for individuals with CLBP, as very few participants in the studies noted increased pain after engaging in the physical activity. Many subjects with CLBP in the research studies also reported having to use fewer pain medicines after beginning a regular physical movement routine. Thus, while yoga is fabulous for reducing CLBP, it seems that movement in general is the most important factor for reducing back pain symptoms. Part IV of this series will go over various yoga poses and exercises that are generally helpful for reducing back pain.
As always, the information presented in this blog post is derived from my own study of neuroscience, human movement, anatomy, and yoga. If you have specific questions about your low back, please consult with your physician, physical therapist, personal trainer, or private yoga teacher. If you are interested in private yoga and/or personal training sessions with me, Jackie, email me at firstname.lastname@example.org for more information about my services. Also, please subscribe to my website so you can receive my weekly newsletters (scroll to the bottom of the page where you can submit your email address). This will help keep you "in-the-know" about my latest blog releases and other helpful yoga and wellness information. Thanks for reading!
~Namaste, Jackie Allen, M.S., M.Ed., CCC-SLP, RYT-200, RCYT, NASM-CPT
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