The Somatic Connection  |   April 2013
Yoga vs Stretching and Use of a Self-Care Book 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 Stretching and Use of a Self-Care Book for Chronic Low Back Pain
The Journal of the American Osteopathic Association, April 2013, Vol. 113, 351-353. doi:
The Journal of the American Osteopathic Association, April 2013, Vol. 113, 351-353. doi:
Sherman KJ, Cherkin DC, Wellman RD, et al. A randomized trial comparing yoga, stretching, and a self-care book for chronic low back pain. Arch Intern Med. 2011;171(22):2019-2026. doi:10.1001/archinternmed.2011.524  
Chronic low back pain is a common reason for visits to a physician's office. Despite the socioeconomic repercussions of such pain, consistent, highly effective treatment options are lacking. Several studies suggest that yoga may help decrease chronic low back pain. However, many people equate the pain relief derived from yoga as equivalent to that derived from basic stretching. In this study, the National Institutes of Health supported a randomized controlled trial of yoga, conventional stretching, and use of a self-care book for the management of chronic low back pain, to determine whether yoga is more effective than the other 2 treatment modalities. The researchers hypothesized that the mental component of yoga could enhance its physical benefits, making it more effective than both conventional stretching and use of a self-care book. 
A total of 228 adults were recruited to participate in this 3-arm, parallel-group, stratified controlled trial. Patients were randomly assigned (in a 2:2:1 ratio) to 12 weekly classes of either yoga (n=92) or conventional stretching (n=91), or to use of a self-care book (n=45). Primary outcomes were measured using the Roland-Morris Disability Questionnaire (RMDQ) and a self-rating of pain bothersomeness. Participants were assessed at baseline and at 6, 12, and 26 weeks after randomization. The primary criterion for study participation was the presence of nonspecific chronic low back pain. Individuals excluded from the trial were those whose back pain was attributed to a specific cause (eg, spondylolisthesis), was potentially secondary to an underlying medical condition (eg, pregnancy), was complex (eg, required previous back surgery), was rated as less than 3 on the 11-point bothersomeness scale at screening, and was not chronic (defined as pain lasting >3 months). Also excluded were persons with severe disease, those for whom yoga was contraindicated, and those with any form of mental illness. 
A research assistant randomly assigned participants to each recruitment cohort after baseline interviews were completed. Treatment assignments were generated by a statistician and were then embedded in the computer-assisted telephone interviewing program so they could not be accessed by study staff prior to randomization. 
Yoga was taught by using a protocol that the team of researchers had used in a previous trial.1 The style of yoga taught was viniyoga, an approach “that adapts the various means and methods of practice to the unique condition, needs and interests of each individual.”2 A series of 12 standardized, weekly 75-minute yoga and stretching classes were held in group health facilities. The classes used 17 simple postures (with variations and adaptations); 5 to 11 of these postures were practiced in each class. The classes also involved breath work and guided meditation. Experienced registered yoga instructors led the classes. The stretching classes, which were also adapted from those used in a previous trial,1 included aerobic exercise, 10 strength exercises, and 12 stretches led by a licensed physical therapist. The self-care book provided to participants was The Back Pain Helpbook.3 
Primary outcomes were analyzed using regression analysis with general estimating equations. After adjustment for baseline values, the 12-week outcomes for the yoga group were better than those for the self-care group, with a mean difference in function of −2.5 (95% confidence interval [CI], −3.7 to −1.3; P>.001) and a mean difference in symptoms of −1.1 (95% CI, −1.7 to −0.4; P>.001). At 26 weeks, function in the yoga group remained superior to that in the self-care group, with a mean difference of −1.8 (95% CI, −3.1 to −0.5; P>.001). At no point in time was yoga superior to conventional stretching exercises. 
The study investigated 2 additional measures of clinical improvement: a 30% improvement from baseline,4 which indicated minimal improvement, and a 50% improvement from baseline, which indicated substantial improvement. Both 52% of the yoga group and 56% of the stretching group demonstrated clinical improvement of at least 50% on the RMDQ, whereas only 23% of the self-care group had substantial clinical improvement. At 26 weeks, both yoga and stretching had produced substantial benefits compared with that of self-care. However, according to this study, stretching resulted in substantial improvements in the self-rating of pain bothersomeness. 
The authors of this article concluded that although yoga was not more effective than conventional stretching, it was more effective than a self-care book. In both the yoga group and the stretching group, use of pain medications decreased from the levels noted at baseline. The results of this study conflict with those of other studies that highlight yoga as being substantially more effective than an exercise regimen and other treatment modalities for the management of low back pain.5 To assess this difference, the yoga protocol used in this study would need to be compared with other standardized yoga protocols. To gain a greater depth of understanding of the conclusions from the present study, one would need to create a randomized controlled study that compared the stretching protocol and the viniyoga protocol with other standardized yoga protocols that have produced a substantial reduction in low back pain. In the future, specific standardized yoga protocols may be shown to have different effects. The aspects of sequencing yoga postures involve many theories of order and action. It may be the case that not all yoga sequences are equivalent when it comes to treating patients with low back pain. This may also hold true for osteopathic manipulative procedures. 
Sherman KJ, Cherkin DC, Erro J, Miglioretti DL, Deyo RA. Comparing yoga, exercise, and a self-care book for chronic low back pain: a randomized, controlled trial. Ann Intern Med. 2005;115:107-117.
Gary Kraftsow. What is viniyoga? American Viniyoga Institute website. Accessed March 9, 2013.
Moore J, Lorig K, Von Korff M, Gonzalez VM, Laurent DD. The Back Pain Helpbook. Reading, MA: Perseus Books; 1999.
Ostelo RW, Deyo RA, Stratford Pet al. Interpreting change scores for pain and functional status in low back pain: towards international consensus regarding minimal important change. Spine. 2008;33(1):90-94. [CrossRef] [PubMed]
Tilbrook HE, Cox H, Hewitt CEet al. Yoga for chronic low back pain: a randomized trial. Ann Intern Med. 2011;155(9):569-578. [CrossRef] [PubMed]