A comprehensive yoga programs improves pain, anxiety and depression in chronic low back pain patients more than exercise: An RCT
Introduction
Back pain is a common problem affecting around 1 in 5 adults during their lifetime with it's prevalence rising to 40% when asked if they have experienced symptoms during the previous month.1 Its prevalence is well studied: worldwide, 37% of CLBP is attributable to occupational ergonomic stressors, both physical and psychosocial. In South East Asia, including India and China, the figure is 39%.2
A comparative study3 surveyed back pain in 3 groups of manual workers (MW) and 3 groups of office workers (OW) in India and the UK totalling 814 subjects. They found MWs in India to have least prevalence at 15%. In the UK, they found 33% for MWs of Indian origin, and 37% for white MWs. Similarly, in three groups of OWs, the figures were 25% in India, and in the UK, 24% for NRI's, and 28% for whites. In India itself, Sharma et al.4 reported a 23% prevalence of CLBP in a north India outpatient orthopaedic unit.
Psychological disturbances may cause CLBP, or result from it: they have predictive value5, 6, 7 and greater impact than biomechanical factors 8. Most frequently reported disturbances are depression,9 anxiety,8 fear10 and anger.11 Functional disability of any kind has a high psychological impact. CLBP is strongly correlated with state anxiety.12 In patients with lumbar disc herniation, pain and functional disability correlate with scores on both anxiety and depression.13
Non pharmacological CAM studies are being tried of which yoga with its holistic approach has emerged as an important modality in the management of chronic medical conditions recently. Many studies of various kinds of Yoga therapy have shown significant benefits to CLBP and related chronic conditions like osteoarthritis,14 rheumatoid arthritis,15 hypertension16 and asthma.17 Also, mindfulness based stress reduction (MBSR) has produced increased well-being, and decreased stress and pain-related symptoms in patients with both anxiety and chronic pain.18
There are several schools of yoga that use different components of the 8 limbs of yoga as propounded by Sage Patanjali.19 Amongst different studies conducted on yoga therapy specifically designed for CLBP, two RCTs on outpatients have demonstrated its efficacy in reducing pain, analgesic usage, and functional disability: Sherman et al.20 applied 3 months Vini yoga, and Williams et al.21 4 months Iyengar Yoga. Vini yoga has used asanas, pranayama, meditation, and lectures on yoga philosophy. Iyengar yoga has used all the above components with greater emphasis on the physical postures. Short term, 9–10 day, outpatient programs have also been studied: Bijlani et al.22 found improvement in health status, while Gupta et al.23 additionally found benefits to state/trait anxiety. The fast pace of contemporary life means that such intensive, short-term programs are preferred: patients need to return to normalcy quickly.
In response, SVYASA used its 25 years experience of ‘Integrated Approach of Yoga Therapy’ (IAYT) treating similar chronic conditions to design a special back pain module for CLBP, including: asanas for back pain; pranayama; relaxation techniques; meditation; Yogic counselling for stress management; chanting; and lectures on yogic lifestyle and philosophy, for application in week-long, intensive treatments (Table 1a, Table 1b). It was developed from traditional yoga literature (Patanjali Yogasutras, Upanishads, and Yoga Vasishtha). The module was evaluated in unpublished pilot studies, for severity of pain, functional disability, and spinal flexibility. The first full study demonstrated improvements on all 3 variables.24 This led to the present study, which includes associated changes in anxiety and depression, as the most important causative factors. We hypothesized that the yoga group would show greater reductions on all measures than controls.
Section snippets
Methods
Sample size: a required n = 35 was obtained by applying Cohen's formula for an expected Effect Size (ES) of 0.89 and an alpha of 0.05, powered at 0.95, using the G*Power program.25 The ES was calculated from the mean and SD of the pilot study on 120 subjects.26 A study size of 80 subjects was decided on, considerably more than the 35 required.
Subjects: comprised the first 80 of 160 CLBP patients admitted between April 2005 and June 2006, who satisfied the selection criteria.
Inclusion criteria:
Results
Fig. 1 shows the study profile. There were no drop outs. The two groups were similar with respect to socio-demographic and medical characteristics (Table 3). Baseline data for all variables matched between groups (p > 0.05). Baseline values of SAR, BDI and NRS only had minor deviations from normality. Because the two groups had equal sample sizes35 and the repeated measures ANOVA test is robust for small deviations from normality, it was used to analyse results on all variables: group × time
Discussion
This study has shown better improvement in STAI, BDI, NRS and SAR with significant group × time interactions in the Yoga group than the control group. Within groups improvements were significant on all variables in both groups, except STAI in controls.
Conflict of interest statement
None declared.
Source of funding
SVYASA (Institutional).
Acknowledgements
We acknowledge assistance from Ravi Kulkarni PhD – Bio Statistician and Balram Pradhan PhD in statistical analysis. We thank: Mrs. Ritu Mishra (clinical psychologist) and Dr Usha Rani for administering and scoring psychological questionnaires; SVYASA for co-operation in conducting the program; and consultant orthopaedic surgeon Dr John Ebnezer, for opinions on X-ray images. We acknowledge the director of Jubilee Camdarc radiological institute for assistance with x-rays.
References (60)
- et al.
The pain anxiety symptoms scale: development and validation of a scale to measure fear of pain
Pain
(1992) - et al.
The scope and significance of anger in the experience of chronic pain
Pain
(1995) - et al.
Effect of Iyengar yoga therapy for chronic low back pain
Pain
(2005) - et al.
Reluctance to generalize corrective experiences in chronic low back pain patients: a questionnaire study of dysfunctional cognitions
Behav Res Ther
(2005 Aug) - et al.
Increased dopamine tone during meditation-induced change of consciousness
Brain Res Cogn Brain Res
(2002) Epidemiology and natural history of low back pain
Eura Medicophys
(2004 Mar)- et al.
Estimating the global burden of low back pain attributable to combined occupational exposures
Am J Ind Med
(2005) - et al.
Cultural differences in muskuloskeletal symptoms and differences
Int J Epidemiol
(2008) - et al.
Incidence of low back pain in workage adults in rural north India
Indian J Med Sci
(2003) - et al.
Wellness through a comprehensive yogic breathing program – a controlled pilot trial
BMC Complement Altern Med
(2007)