The use of yoga is consistent with recommendations for activity, as tolerated, for patients with low back pain. Literature evaluating the effectiveness of yoga for low back pain is scant, so it is unclear if yoga is equivalent to, or superior to, standard therapies (strength of recommendation: C, based on 1 randomized pilot study and limited case series)

Graves, Nathan

Krepcho, Martin

Mayo, Helen G.

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Does yoga speed healing for patients with low back pain?

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C L I N I C A L  I N Q U I R I E SC O N T I N U E Dment scores for improved balance and flexibility,as well as decreased disability and depression inthe yoga group, but the sample size was too smallto detect significant changes.Patients who practice hatha yoga say it is valu-able for preventing and managing stress-relatedchronic health problems, including low back pain.In a survey of 3000 people receiving yoga forhealth ailments (1142 [38%] with back pain),98% claimed that yoga benefited them.5In a case series of 16 patients using variousasanas for rehabilitation, 11 (69%) reported sig-nificant improvement, with near normal mobilityand absence of pain.6 Those who reported recur-ring back pain also reported irregular practice ofyoga. In another case series, 21 women aged ≥ 60 years (mean age, 75) with hyperkyphosis,participated in twice-weekly 1-hour sessions ofhatha yoga for 12 weeks. Measured heightincreased by a mean of 0.52 cm, forward curva-ture diminished, patients were able to get out ofchairs faster, and they had longer functionalreach. Eleven patients (48%) reported increasedpostural awareness/improvement and improvedwell-being; 58% perceived improvement in theirphysical functioning.7Clearly, more studies are required to determinethe effects of yoga on lower back pain. Larger ran-domized sample sizes, group and individualizedformats, and longer follow-up are needed. Controlgroups should involve both group and nongroupsettings, to detect any benefit that may be derivedfrom group support. No reports of harm from yogain low-back pain therapy were reported in the fewstudies found.■ RECOMMENDATIONS FROM OTHERSThe Philadelphia Panel formulated evidence-based guidelines for selected rehabilitationinterventions in the management of low backpain for outpatient adults.8 Continuation of nor-mal activity improves rate of return to workcompared with enforced bed rest. Randomizedcontrolled trials demonstrate no clinicallyimportant effect (15% improvement compared7. Greenhill LL. Safety and Efficacy of OROS MPH inAdolescents with ADHD. Program and Abstracts of theAmerican Psychiatric Association, 156th AnnualMeeting; Scientific and Clinical Reports. May 17-22,2003; San Francisco, Calif. Abstract S&CR12-37. 8. Greenhill LL, Pliszka S, Dulcan MK, et al. Practiceparameter for the use of stimulant medications in thetreatment of children, adolescents, and adults. J Am AcadChild Adolesc Psychiatry 2002; 41(2 Suppl):26S–49S.Does yoga speed healing forpatients with low back pain?■ EVIDENCE-BASED ANSWERThe use of yoga is consistent with recommenda-tions for activity, as tolerated, for patients withlow back pain. Literature evaluating the effec-tiveness of yoga for low back pain is scant, so itis unclear if yoga is equivalent to, or superior to,standard therapies (strength of recommendation:C, based on 1 randomized pilot study and limitedcase series).■ EVIDENCE SUMMARYYoga, through static physical postures (or asanas),uses stretching to improve muscular strength andflexibility, which could be beneficial for low-back-related pain management.1 Hatha yoga, whichincorporates breathing and movement, has pro-vided limited benefit in musculoskeletal-relatedpain.2 Hatha yoga is distinguished from other yogapractices in that it is based on the knowledge,development, and balance of psychophysical ener-gies. A large systematic review of yoga used forvarious medical conditions found over 120 stud-ies.3 Anecdotal reports were excluded. Theauthors reported no studies directly evaluatingeffect of yoga on back pain.A randomized controlled trial studied a 6-weekmodified hatha yoga protocol with 22 patients.4The yoga group spent an hour with a certifiedinstructor twice weekly, while the control groupreceived the same intervention delayed until thestudy phase was completed. This underpoweredpilot study found trends in functional measure-AUGUST 2004 / VOL 53, NO 8 · The Journal of Family Practice 661JFP_08.04_CI_final  7/21/04  9:25 AM  Page 661C L I N I C A L  I N Q U I R I E STYPE II CLINICAL INQUIRIES662 AUGUST 2004 / VOL 53, NO 8 · The Journal of Family Practicewith control) with stretching or strengtheningexercises, mechanical traction, or TENS. Thepanel found insufficient evidence to support theuse of mechanical traction for patient globalimprovement and return to work. Therapeuticexercise—including stretching, strengthening,and mobility exercises—significantly reducespain and improves function for chronic low backpain (longer than 12 weeks); but there was noclinical benefit in facilitating return to work. Nospecific comments on yoga appeared in theirrecommendations.The US Preventive Services Task Force reportsthat evidence is insufficient to recommend for oragainst counseling patients to exercise to preventlow back pain; it makes no mention about yoga.9Nathan Graves, MD, Martin Krepcho, PhD, HelenG. Mayo, MLS, University of Texas Southwestern MedicalCenter at Dallas■ CLINICAL COMMENTARY:Information suggests yoga—and all exercise—effective for low back painGood evidence supports the concept that activ-ity is more effective than bed rest for acute lowback pain. Recent studies in the rehabilitationand physical therapy literature have empha-sized core stability exercises for acute andchronic back pain. As balance, strength, andflexibility improve, the episodes and intensityof acute low back pain diminish.  It stands to reason that activities such ashatha yoga that improve muscular strength,flexibility, and balance would similarly improvefunction and decrease low back pain. Theavailable information would lead me to recom-mend yoga for my patients with low back pain.Yoga may well be effective, and no reports inthe literature show harm.John Hill, MD, Rose Family Medicine Residency,Denver, ColoREFERENCES1. Luskin FM, Newell KA, Griffith M, et al. A review ofmind/body therapies in the treatment of musculoskeletaldisorders with implications for the elderly. Altern TherHealth Med 2000; 6:46–56. 2. Hudson S. Yoga aids in back pain. Aust Nurs J 1998;5(9):27.3. Raub JA. Psychophysiologic effects of Hatha Yoga onmusculoskeletal and cardiopulmonary function: a litera-ture review. J Altern Complement Med 2002; 8:797–812.4. Galantino ML, Bzdewka TM, Eissler-Russo J, et al. Theimpact of modified Hatha yoga on chronic low back pain:a pilot study. Altern Ther Health Med 2004; 10:56–58.5. Burton Goldberg Group. Alternative Medicine: TheDefinitive Guide. Puyallup, Wash: Future MedicinePublications; 1993.6. Ananthanarayanan TV, Srinivasan TM. Asana-based exer-cises for the management of low-back pain. J Int AssocYoga Therapists 1994; 4:6–15. 7. Greendale GA, McDivit A, Carpenter A, Seeger L, HuangMH. Yoga for women with hyperkyphosis: results of apilot study. Am J Public Health, 2002; 92:1611–1614.8. Philadelphia Panel. Philadelphia Panel evidence-basedclinical practice guidelines on selected rehabilitationinterventions for low back pain. Phys Ther 2001;81:1641–1674.9. US Preventive Services Task Force. Primary care inter-ventions to prevent low back pain. Rockville, Md: USPreventive Services Tack Force; 2004. Available at:www.ahrq.gov/clinic/uspstf/uspsback.htm. Accessed onJuly 8, 2004.Do inhaled beta-agonistscontrol cough in URIs or acute bronchitis?■ EVIDENCE-BASED ANSWERPatients who receive inhaled beta-agonists forcough due to acute upper respiratory infections(URI) are just as likely to report a productivecough at 7 days compared with patients treatedwith placebo (strength of recommendation[SOR]: A, based on a systematic review).One trial, however, showed a reduction inoverall cough at 7 days (number needed to treat[NNT]=3, SOR: B, a small randomized con-trolled trial), and another trial found a reduc-tion in overall symptom score in smokers andthose with wheezing on initial exam (SOR: B,based on a small randomized controlled trial).JFP_08.04_CI_final  7/21/04  9:25 AM  Page 662

Does yoga speed healing for patients with low back pain?

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