Yoga for Back Pain Yoga Alliance Webinar July 20, 2020 Sat Bir S. - - PowerPoint PPT Presentation

Brigham & Women’s Hospital

Harvard Medical School

Scientific Research on Yoga for Back Pain

Sat Bir S. Khalsa, Ph.D.

Assistant Professor of Medicine, Harvard Medical School Director of Yoga Research, Yoga Alliance Director of Research, Kundalini Research Institute Editor in Chief, International Journal of Yoga Therapy Research Associate, Benson Henry Institute for Mind Body Medicine Research Affiliate, Osher Center for Integrative Medicine

Yoga Alliance Webinar July 20, 2020

https://www.cdc.gov/mmwr/volumes/68/wr/pdfs/mm685152a5-H.pdf

https://www.who.int/bulletin/volumes/97/6/18-226050.pdf?ua=1

https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Low-Back-Pain-Fact-Sheet

Age Fitness level Weight gain Genetics Congenital Skeletal irregularities Spina bifida Injuries Sprains Traumatic Injury Degenerative problems Intervertebral disc degeneration Spondylosis Arthritis or inflammatory disease

https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Low-Back-Pain-Fact-Sheet

Nerve and spinal cord problems Nerve compression, inflammation, injury Sciatica Spinal stenosis Spondylolisthesis Herniated or ruptured discs Infections Cauda equina syndrome Osteoporosis Job-related factors Mental health Smoking Psychological factors Non-spine sources Kidney stones Endometriosis Fibromyalgia Tumors Pregnancy

Risk Factors Causes

Medications Analgesics and NSAIDs Opiods Anticonvulsants Self-management Hot or cold packs Resuming normal activities Exercises Complementary therapies Acupuncture Behavioral approaches Biofeedback Relaxation techniques Cognitive therapy TENS Physical therapy Chiropractic Massage

https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Low-Back-Pain-Fact-Sheet

Treatments

Spinal injections Trigger point injections Epidural steroid injections Radiofrequency ablation Traction Surgery Vertebroplasty and kyphoplasty Spinal laminectomy Discectomy and microdiscectomy Foraminotomy Nucleoplasty Radiofrequency denervation Spinal fusion Artificial disc replacement Interspinous spacers Implanted nerve stimulators Spinal cord stimulation Dorsal root ganglion stimulation Peripheral nerve stimulation Rehabilitation programs

“[progressive aerobic training] and [progressive resistance training] decreased pain intensity in individuals with CNSLBP although neither mode was superior.” “A more prudent approach however, would be to prescribe a combination

• f aerobic and resistance exercise training for CNSLBP, which might

prove more beneficial through a broader range of physical and psychological adaptations than possible with either modality in isolation.”

From: The impact of modified exercise and relaxation therapy on chronic lower back pain in office workers: a randomized clinical trial. Shariat A, Alizadeh R, Moradi V, Afsharnia E, Hakakzadeh A, Ansari NN, Ingle L, Shaw BS, Shaw I. Journal of Exercise and Rehabilitation, 28;15:703-708, 2019. https://www.ncbi.nlm.nih.gov/pmc/arti cles/PMC6834712/pdf/jer-15-5- 703.pdf

Exercise and Relaxation for cLBP

From: Reduced thoracolumbar fascia shear strain in human chronic low back pain. Langevin HM, Fox JR, Koptiuch C, Badger GJ, Greenan-Naumann AC, Bouffard NA, Konofagou EE, Lee WN, Triano JJ, Henry SM, BMC Musculoskeletal Disorders, 19;12:203, 2011.

Low Back Pain and Fascia

https://bmcmusculoskeletdisord.biomedcentral.com/track/pdf/10.1186/1471-2474-12-203

“In vivo tissue stretch mitigated the inflammation-induced changes leading to restored stride length and intrastep distance, decreased mechanical sensitivity

• f the back and reduced macrophage

expression in the nonspecialized connective tissues of the low back.” “This tissue stretch research is relevant to body-based treatments such as yoga…”

From: Stretching of the back improves gait, mechanical sensitivity and connective tissue inflammation in a rodent model, Corey SM, Vizzard MA, Bouffard NA, Badger GJ, Langevin HM, PLoS One, 7(1):e29831, 2012.

Stretching, Inflammation and Fascia

https://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0029831&type=printable

From: Effect of a muscle stretching program using the global postural reeducation method for patients with chronic low back pain: A randomized controlled trial. Lawand P, Lombardi Júnior I, Jones A, Sardim C, Ribeiro LH, Natour J. Joint Bone Spine 82:272-7, 2015.

Stretching and cLBP

From: Indian Journal of Palliative Care, 16:1-7, 2010. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2936076/?report=printable

From: Insular cortex mediates increased pain tolerance in yoga practitioners, Villemure C, Ceko M, Cotton VA, Bushnell MC, Cerebral Cortex, 24:2732-40, 2014. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4153807/pdf/bht124.pdf

Yoga and Pain Tolerance

Yoga and Pain Tolerance

From: Insular cortex mediates increased pain tolerance in yoga practitioners, Villemure C, Ceko M, Cotton VA, Bushnell MC, Cerebral Cortex, 24:2732-40, 2014. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4153807/pdf/bht124.pdf

MBSR for Back Pain

From: Effect of Mindfulness-Based Stress Reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain: A randomized clinical trial, Cherkin DC, Sherman KJ, Balderson BH, Cook AJ, Anderson ML, Hawkes RJ, Hansen KE, Turner JA, Journal of the American Medical Association, 315:1240-9, 2016.

…treatment with MBSR or CBT, compared with usual care, resulted in greater improvement in back pain and functional limitations at 26 weeks, with no significant differences in outcomes between MBSR and CBT.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4914381/pdf/nihms781082.pdf

MBSR for cLBP

From: Mindfulness-Based Stress Reduction for Treating Low Back Pain: A Systematic Review and Meta-analysis. Anheyer D, Haller H, Barth J, Lauche R, Dobos G, Cramer H. Annals of Internal Medicine 6;166:799-807, 2017.

Yoga Practices

Postures, Breathing, Relaxation, Meditation

Fitness

↑Flexibility ↑Strength ↑Coordination/Balance ↑Respiratory Function ↑Self-Efficacy

Global Human Functionality

↑Physical & Mental Health, ↑Physical Performance ↑Stress & Emotion Regulation, ↑Awareness/Mindfulness, ↑Meta-cognition ↑Positive Behavior, ↑Wellbeing, ↑Values, ↑Life Purpose & Meaning, ↑Spirituality

Self-Regulation

↑Stress Regulation ↑Emotion Regulation ↑Resilience ↑Equanimity ↑Self-Efficacy

Awareness

↑Attention ↑Mindfulness ↑Concentration ↑Cognition ↑Meta-cognition

Spirituality

↑Unitive State ↑Transcendence ↑Flow ↑Transformation ↑Life Meaning/Purpose

A Model of Yoga for cLBP

From: Comparison of yoga versus stretching for chronic low back pain: protocol for the Yoga Exercise Self-care (YES) trial, Sherman KJ, Cherkin DC, Cook AJ, Hawkes RJ, Deyo RA, Wellman R, Khalsa PS, Trials 11:36, 2010. https://trialsjournal.biomedcentral.com/track/pdf/10.1186/1745-6215-11-36

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5294833/pdf/CD010671.pdf

From: Comparing yoga, exercise, and a self-care book for chronic low back pain, A randomized, controlled trial, Sherman KJ, Cherkin DC, Erro J, Miglioretti DL, Deyo RA, Annals of Internal Medicine, 143:849-56, 2005.

Yoga for cLBP

Yoga for cLBP

From: Evaluation of the Effectiveness and Efficacy of Iyengar Yoga Therapy on Chronic Low Back Pain, Williams K, Abildso C, Steinberg L, Doyle E, Epstein B, Smith D, Hobbs G, Gross R, Kelley G, Cooper L, Spine 34:2066–2076, 2009.

Visual Analogue Scale (VAS) Pain Intensity Oswestry Disability Index (ODI) Functional Disability

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4393557/pdf/nihms139323.pdf

Back Pain Characteristics

Baseline End Program

Average Score

2 4 6 8 RMDQ Bothersomeness Pain Intensity From: Evaluation of a Yoga Program for Back Pain, Schultz LH, Uyterhoeven S, Khalsa SBS, Journal of Yoga and Physical Therapy, 1:2, 2011.

Yoga for cLBP

https://www.longdom.org/open-access/evaluation-of-a-yoga-program-for-back-pain-2157-7595.1000e103.pdf

Yoga for cLBP

From: A randomized trial comparing yoga, stretching, and a self-care book for chronic low back pain. Sherman KJ, Cherkin DC, Wellman RD, Cook AJ, Hawkes RJ, Delaney K, Deyo

• RA. Archives of Internal

Medicine, 12;171:2019-26, 2011. https://www.ncbi.nlm.nih.gov /pmc/articles/PMC3279296/ pdf/nihms354570.pdf

Mediators

• f Yoga

for cLBP

“Both yoga and stretching were superior to self-care, and our mediator analyses suggest that increased participation in back exercise and self- efficacy was responsible for most of these benefits. However, these are both complex interventions and qualitative data suggesting that relaxation and increased awareness may have contributed to the benefits of yoga…”

http://downloads.hindawi.com/journals/ecam/2013/130818.pdf

From: Comparing Once- versus Twice-Weekly Yoga Classes for Chronic Low Back Pain in Predominantly Low Income Minorities: A Randomized Dosing Trial, Saper RB, Boah AR, Keosaian J, Cerrada C, Weinberg J, Sherman KJ, Evidence Based Complementary and Alternative Medicine, 2013:658030.

Yoga for cLBP

http://downloads.hindawi.com/journals/ecam/2013/658030.pdf

From: Yoga for chronic low back pain: a randomized trial. Tilbrook HE, Cox H, Hewitt CE, Kang'ombe AR, Chuang LH, Jayakody S, Aplin JD, Semlyen A, Trewhela A, Watt I, Torgerson DJ, Annals of Internal Medicine 155:569-78, 2011.

Yoga for cLBP

Yoga for cLBP in Veterans

From: Yoga for Military Veterans with Chronic Low Back Pain: A Randomized Clinical Trial. Groessl EJ, Liu L, Chang DG, Wetherell JL, Bormann JE, Atkinson JH, Baxi S, Schmalzl

• L. American Journal of Preventive Medicine 53(5):599-608, 2017.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6399016/pdf/nihms-1005956.pdf

Yoga for cLBP

From: Yoga, Physical Therapy, or Education for Chronic Low Back Pain: A Randomized Noninferiority Trial. Saper RB, Lemaster C, Delitto A, Sherman KJ, Herman PM, Sadikova E, Stevans J, Keosaian JE, Cerrada CJ, Femia AL, Roseen EJ, Gardiner P, Gergen Barnett K, Faulkner C, Weinberg J., Annals of Internal Medicine, 167:85-94, 2017. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC6399016/pdf/nihms-1005956.pdf

Perceived Stress and Yoga for cLBP

From: Changes in Perceived Stress After Yoga, Physical Therapy, and Education Interventions for Chronic Low Back Pain: A Secondary Analysis of a Randomized Controlled Trial. Berlowitz J, Hall DL, Joyce C, Fredman L, Sherman KJ, Saper RB, Roseen EJ, Pain Medicine Jun 4:pnaa150, 2020.

Sleep and Yoga for cLBP

From: Yoga, Physical Therapy, and Back Pain Education for Sleep Quality in Low-Income Racially Diverse Adults with Chronic Low Back Pain: a Secondary Analysis of a Randomized Controlled Trial. Roseen EJ, Gerlovin H, Femia A, Cho J, Bertisch S, Redline S, Sherman KJ, Saper R, Journal of General Internal Medicine 35:167-176, 2020 .

Responder Analyses Yoga for cLBP

Percent of responders with at least 30% improvement in the Roland Morris Disability Questionnaire. Yoga: 48% Physical Therapy: 37% Self-Care Book: 23%

From: Which Chronic Low Back Pain Patients Respond Favorably to Yoga, Physical Therapy, and a Self-care Book? Responder Analyses from a Randomized Controlled

• Trial. Roseen EJ, Gerlovin H, Felson DT, Delitto A, Sherman KJ, Saper RB. Pain

Medicine Jul 14:pnaa153, 2020.

“When comparing yoga or PT with self-care, a greater proportion were responders among those using pain meds (OR=5.3), which differed from those not taking pain meds (OR=0.94) at baseline. We also found greater treatment response among those with lower (OR=7.0), but not high (OR=1.3), fear avoidance beliefs around physical activity.”

“The health gains from medical yoga are also cost- efficient from the societal perspective, albeit marginally compared with exercise therapy and self- care advice. Based on these results, if all 3 interventions are constrained by resources, medical yoga treatment is the optimal choice.”

“From a healthcare perspective, yoga yielded an incremental cost-effectiveness ratio of £2103 per QALY…the probability of yoga being cost- effective was 95%. From a societal perspective, yoga was the dominant treatment compared with usual care. At 6 months, electronic staff records showed that yoga participants missed a total of 2 working days due to musculoskeletal conditions compared with 43 days for usual care participants.”

https://www.acpjournals.org/doi/full/10.7326/M16-2367

https://www.healthquality.va.gov/guidelines/Pain/lbp/VADoDLBPCPG092917.pdf