Brigham & Women’s Hospital Harvard Medical School

Scientific Research on Yoga for Back

Yoga Alliance Webinar July 20, 2020

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 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 Risk Factors Age Job-related factors Fitness level Mental health Weight gain Smoking Genetics Psychological factors Causes Congenital Nerve and spinal cord problems Non-spine sources Skeletal irregularities Nerve compression, inflammation, injury Kidney stones Spina bifida Sciatica Endometriosis Injuries Spinal stenosis Fibromyalgia Sprains Spondylolisthesis Tumors Traumatic Injury Herniated or ruptured discs Pregnancy Degenerative problems Infections Intervertebral disc degeneration Cauda equina syndrome Spondylosis Osteoporosis Arthritis or inflammatory disease

https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Low-Back-Pain-Fact-Sheet Spinal injections Treatments Trigger point injections Epidural steroid injections Medications Radiofrequency ablation and NSAIDs Traction Opiods Surgery Anticonvulsants Vertebroplasty and kyphoplasty Self-management Spinal laminectomy Hot or cold packs Discectomy and microdiscectomy Resuming normal activities Foraminotomy Exercises Nucleoplasty Complementary therapies Radiofrequency denervation Spinal fusion Behavioral approaches Artificial disc replacement Biofeedback Interspinous spacers Relaxation techniques Implanted nerve stimulators Cognitive therapy Spinal cord stimulation TENS Dorsal root ganglion stimulation Physical therapy Peripheral nerve stimulation Chiropractic Rehabilitation programs Massage https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Low-Back-Pain-Fact-Sheet “[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 of 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.” Exercise and Relaxation for cLBP

From: The impact of modified exercise and relaxation therapy on chronic lower 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 and Fascia

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. https://bmcmusculoskeletdisord.biomedcentral.com/track/pdf/10.1186/1471-2474-12-203 Stretching, Inflammation and Fascia

“In vivo tissue stretch mitigated the inflammation-induced changes leading to restored stride length and intrastep distance, decreased mechanical sensitivity of 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. https://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0029831&type=printable Stretching and cLBP

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

…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. 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. 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 Self-Regulation Awareness Spirituality ↑Flexibility ↑Stress Regulation ↑Attention ↑Unitive State ↑Strength ↑Emotion Regulation ↑Mindfulness ↑Transcendence ↑Coordination/Balance ↑Resilience ↑Concentration ↑Flow ↑Respiratory Function ↑Equanimity ↑Cognition ↑Transformation ↑Self-Efficacy ↑Self-Efficacy ↑Meta-cognition ↑Life Meaning/Purpose

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

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

Oswestry Disability Index (ODI) (VAS) Functional Disability Pain Intensity

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

Back Pain Characteristics 8 RMDQ Bothersomeness 6 Pain Intensity

4

2

Average Score

0 Baseline End Program

From: Evaluation of a Yoga Program for Back Pain, Schultz LH, Uyterhoeven S, Khalsa SBS, Journal of Yoga and Physical Therapy, 1:2, 2011. 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 of 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 Yoga for cLBP

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

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 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% “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), avoidance beliefs around physical activity.”

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.

“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