Primary Care Corner with Geoffrey Modest MD: Yoga for chronic low back pain

​​by Dr Geoffrey Modest

A recent community-based study of chronic low back pain found that yoga was non-inferior to physical therapy for function and pain (See doi:10.7326/M16-2579).


— 320 predominantly low income adults with nonspecific chronic low back pain were enrolled in a 12 week, single-blind, 3 group randomized trial, with a 40 week maintenance phase.

— Mean age 45, 60% female, 18% non-Hispanic white/58% non-Hispanic black/14% Hispanic, 32% earned college degree or higher, 45% currently employed, 60% with annual income less than $30,000, BMI 31, mean back pain intensity 7 (on scale of 11), RMDQ score 15 (score range 0 to 23, higher score means worse function), 70% on pain medications (52% NSAIDs/35% acetaminophen/20% opioids), comorbidities of hypertension 35%/neck pain 30%/pulmonary disorders 25%/diabetes 18%/depression 20%. [the Roland Morris Disability Questionnaire (RMDQ) of 15 and pain intensity score of 7 reflect moderate to severe pain]

— the study was done in an academic safety net hospital and 7 affiliated federally-qualified community health centers in ethnically diverse neighborhoods in Boston

— the 3 groups were:

— 12 weekly 75-minute yoga classes, each class beginning with relaxation and meditation exercises, yoga breathing, and yoga philosophy; then yoga poses; and then relaxation. 30 minutes of daily home practice were encouraged, with patients getting a DVD, manual, and take-home yoga supplies

— fifteen 60-minute PT visits, including treatment-based classification, graded exercise, and screening for fear-avoidance beliefs

— an educational book (the Back Pain Helpbook) and newsletters on low back pain self-management, stretching, strengthening, and the role of emotions and fear-avoidance

— the maintenance phase compared yoga drop-in classes vs home practice; or PT booster sessions vs home practice

— primary outcomes: back-related function as measured by the RMDQ, and pain measured by an 11 point scale, both measured at 12 weeks. Prespecified noninferiority margins were 1.5 on the RMDQ scale and 1.0 for the pain scale.

— Secondary outcomes included pain medication use, global improvement, satisfaction with intervention, and health-related quality of life


— median yoga attendance was 7 classes, median PT attendance was 7 appointments.

— home practice was reported by 75% of yoga participants (for median of 27 minutes) and 64% of PT participants (median of 4 exercises, 4 days per week)

— fewer than half of the participants met the predefined adherence goal: at least 9 yoga or 11 PT sessions

— of 59 participants randomly assigned to yoga drop-in classes during the maintenance phase, 53% attended at least one class (median 13); of 54 participants randomly assigned to PT booster sessions, 56% attended at least one (median 2)

— primary outcomes:

— improvement in RMDQ for yoga -3.8, which was noninferior to PT, -3.5. Education was -2.5

— decrease pain for yoga was -1.7, which was noninferior to PT -2.3. Education was -1.4

— yoga and PT were not superior to education at 12 weeks, however both yoga and PT were more likely than education to have a clinically meaningful response in RMDQ (which they define as 3.0 points), but yoga did not reach quite reach their meaningful cutpoint of 2.0.

— secondary outcomes:

— greater than 30% reduction in RMDQ: 48% yoga vs 37% physical therapy vs 23% education

— greater than 30% reduction in back pain 35% yoga vs 43% physical therapy vs 25% education

​– at 12 weeks, use of any pain medication was 55% yoga (33% acetaminophen, 33% NSAIDs, 23% opioids) vs 54% using any pain medication with PT (22% acetaminophen, 43% NSAIDs, 14% opioids) vs 75% using any pain medication in the education group (39% acetaminophen, 48% NSAIDs, 18% opioids)

— self-rated global improvement: 34% improved with yoga vs 42% PT vs 21% education

— satisfaction with intervention: 43% very satisfied with yoga, 50% with physical therapy, 21% with education

–no difference between groups for either SF-36 physical health score or SF-36 mental health score [Short Form-36’s are validated questionnaires]

— in patients who were adherent to the protocol, mean RMDQ changes at 12 weeks were: -4.64 yoga, -5.7 PT, -2.74 education; clinically meaningful improvements in RMDQ in those adherent to the protocol occurred in 57% for yoga, 56% PT, 21% for education. For pain intensity 12 weeks, -2.1 for yoga, -2.6 or PT, -1.34 education, with clinically meaningful pain improvement were present in 50% for yoga, 52% for PT, and 14% with education

— in the maintenance phase, RMDQ or pain changes did not differ significantly between yoga drop-in and yoga home practice, or between PT booster sessions and PT home practice.

— Adverse effects were mild, self-limited joint and back pain.


— as we all know, chronic low back pain is both extraordinarily common (estimates of 10% of the US adults), costly (total costs, including work loss, exceed $200 billion per year), but has low patient satisfaction with treatment.

— Physical therapy is the most common evidence-based, reimbursable, nonpharmacologic therapy prescribed by clinicians. There are several studies suggesting that yoga also helps. So, this study is helpful for showing that yoga is on a par with physical therapy in decreasing pain and improving function.

–although they found that yoga/PT were not superior to education for both function and pain, there were meaningful improvements for RMDQ with yoga and both for PT, the improvements were maintained after one year (which unexpectedly was irrespective of whether the patients had ongoing yoga or PT booster classes or not), and the likely explanation of these results was the low adherence rates to the yoga/PT programs. Looking at the adherent patients, the results were dramatically more impressive for RMDQ and pain, as highlighted above.

— I should also note that several important findings  (eg, use of medications, patient satisfaction, >30% improvements) were also really impressively better with yoga/PT

–this study was particularly useful to many of us because it focused on community-based care in poor and non-white areas, in which there has been documented increased incidence of pain and disability from low back pain, fewer referrals for specialists, and less-intensive rehabilitation for occupational back injuries. Yoga classes, however, are less available and less used in poorer and nonwhite areas

–unfortunately, the use of yoga was not able to decrease the use of opioids much, though other pain meds were decreased



–yoga may well be a useful ​aid for patients with chronic low back pain

–yoga may also be cheaper for patients who have high copays for PT

–and, yoga instruction is readily available to patients with internet connection or DVD players. My overwhelming experience is that patients who do PT for back pain (or other symptoms) rarely continue with significant home-based exercises to maintain their PT benefits, frequently requiring repeat PT programs in the future and/or persistent pain/functional loss. Perhaps one of the difficulties for patients is transitioning from the array of PT therapies (eg using expensive exercise machinery or treatments unavailable at home) to the home-based, low-tech PT exercises.  Yoga might provide a more fluid transition from office-based yoga training and performance, since patients continue to do the same thing at home.