The Somatic Connection  |   April 2013
Yoga vs Usual Care for Chronic Low Back Pain
Author Affiliations
  • Michael A. Seffinger, DO
    Western University of Health Sciences College of Osteopathic Medicine of the Pacific, Pomona, California
  • Vanessa Mervyn-Cohen, OMS III
    Western University of Health Sciences College of Osteopathic Medicine of the Pacific, Pomona, California
Article Information
The Somatic Connection   |   April 2013
Yoga vs Usual Care for Chronic Low Back Pain
The Journal of the American Osteopathic Association, April 2013, Vol. 113, 350-351. doi:10.7556/jaoa.2013.113.4.350
The Journal of the American Osteopathic Association, April 2013, Vol. 113, 350-351. doi:10.7556/jaoa.2013.113.4.350
Tilbrook HE, Cox H, Hewitt CE, et al. Yoga for chronic low back pain: a randomized trial. Ann Intern Med. 2011;155(9):569-578.  
During the past 20 years, there has been a documented increase in the use of complementary and alternative medicine. Yoga, along with osteopathic manipulative medicine, has been depicted as a form of complementary and alternative medicine in integrative medicine awareness surveys. Many small studies have documented the positive effects of yoga on chronic or recurrent back pain; however, such studies have had various limitations. After completing a review of the literature on yoga research, investigators in the United Kingdom conducted a parallel-group, randomized controlled trial in which a 12-week yoga class was offered to adults. The objective of this trial was to compare the efficacy of yoga vs the efficacy of “usual care” for the management of chronic and recurrent low back pain. 
Participants were chosen from a group of 1093 individuals who were recruited through database searches of 39 general medical practices and through advertisements placed in local media. Participants who were identified through database searches had visited a general medical practice office for low back pain during the 18 months prior to recruitment. All participants were aged between 18 and 65 years, with most being women aged between 45 and 65 years. The average duration of participant back pain was 10 years, and 77% of participants had back pain at the time of recruitment. The 313 participants were randomly allocated to 1 of 2 groups: a usual care group (n=157) or a yoga group (n=156). The median age of participants was 46.4 years in the usual care group and 47.2 years in the yoga group. This number of participants met the requirements of a power analysis to detect an effect size of 0.39. 
Participants assigned to the yoga group were required to attend one 75-minute yoga class per week for 12 weeks. Researchers selected a total of 12 experienced yoga instructors to teach the classes. Two yoga instructors were assigned to teach each yoga class series, with 1 instructor serving as the teacher and the other providing backup. Twice during treatment, the yoga instructors who were providing backup reported on those who were teaching to ensure treatment fidelity. In an attempt to achieve uniformity in teaching, all instructors were required to teach the same form of yoga, in accordance with class plans outlined in the teacher's manual. The pose descriptions and sequences were included in a separate students' manual that was given to the study participants at the first class. 
The Roland-Morris Disability Questionnaire (RMDQ), a questionnaire that measures activities of daily life affected by back pain, was completed by participants at baseline, 3 months (ie, at the end of the yoga intervention), 6 months, and 12 months. 
Analysis of the usual care group and the yoga group was planned in advance by an independent steering committee. Analyses were conducted according to randomized treatment assignment and were completed without regard for adherence to protocol. Analyses were conducted by comparing the changes in RDMQ scores from baseline between groups during the course of the trial. The statistician was blinded to group assignment. 
The RMDQ scores showed that the yoga group had better back function than the usual care group at 3 months (after completion of the 12-week yoga course), 6 months, and 12 months. At the assessment performed at 3 months, the adjusted mean RMDQ score was 2.17 points lower for participants in the yoga group. A Forrest plot was used to compare the RMDQ changes noted in the yoga group at 3 months with the changes noted at 3 months in previously published studies assessing various other treatments for low back pain. The Forrest plot indicated that yoga was superior to exercise, manipulation, manipulation and exercise, cognitive behavioral therapy, and 6 sessions (but not 24 sessions) of treatment with use of the Alexander technique. 
In the UK BEAM (United Kingdom Back Pain Exercise and Manipulation) trial,1 the type of manipulation used was a combination of techniques used by the British physiotherapy, chiropractic, and osteopathic professions. Participants in the UK BEAM trial1 received manipulation for 6 weeks followed by exercise for 6 weeks or they received manipulation alone for 6 weeks. 
With the proposed unified accreditation of graduate medical education programs under the Accreditation Council for Graduate Medical Education, it is important to think about how osteopathic manipulative medicine is categorized and how it compares with the other therapies in its perceived class. A recent article in The DO, titled “‘Self-OMT’: Yoga Boosts Patients' Structure and Function, DOs Say,”2 discusses a possible synergy between yoga and osteopathic manipulative treatment in treatment schemes. Further studies assessing osteopathic manipulative treatment and yoga may enhance our understanding of the capacities of current therapies. 
UK BEAM Trial Team. United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: effectiveness of physical treatments for back pain in primary care. BMJ. 2004;329:1377. [CrossRef] [PubMed]
Raymond R. ‘Self-OMT’: yoga boosts patients' structure and function, DOs say. The DO. January 23 , 2013. Accessed March 9, 2013.