Yoga for Treating Low Back Pain

A Systematic Review and Meta-analysis

Dennis Anheyer; Heidemarie Haller; Romy Lauche; Gustav Dobos; Holger Cramer

Pain. 2022;163(4):e504-e517.

Abstract and Introduction

Abstract

Yoga is frequently used for back pain relief. However, the evidence was judged to be of only low to moderate certainty. To assess the efficacy and safety of yoga in patients with low back pain, a meta-analysis was performed. Therefore, MEDLINE/PubMed, Scopus, and the Cochrane Library were searched to May 26, 2020. Only randomized controlled trials comparing Yoga with passive control (usual care or wait list), or an active comparator, for patients with low back pain and that assessed pain intensity or pain-related disability as a primary outcome were considered to be eligible. Two reviewers independently extracted data on study characteristics, outcome measures, and results at short-term and long-term follow-up. Risk of bias was assessed using the Cochrane risk of bias tool. Thirty articles on 27 individual studies (2702 participants in total) proved eligible for review. Compared with passive control, yoga was associated with short-term improvements in pain intensity (15 RCTs; mean difference [MD] = −0.74 points on a numeric rating scale; 95% confidence interval [CI] = −1.04 to −0.44; standardized mean difference [SMD] = −0.37 95% CI = −0.52 to −0.22), pain-related disability (15 RCTs; MD = −2.28; 95% CI = −3.30 to −1.26; SMD = −0.38 95% CI = −0.55 to −0.21), mental health (7 RCTs; MD = 1.70; 95% CI = 0.20–3.20; SMD = 0.17 95% CI = 0.02–0.32), and physical functioning (9 RCTs; MD = 2.80; 95% CI = 1.00–4.70; SMD = 0.28 95% CI = 0.10–0.47). Except for mental health, all effects were sustained long-term. Compared with an active comparator, yoga was not associated with any significant differences in short-term or long-term outcomes.

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Table 1. Characteristics of the included studies.
Author, y	Origin	Sample characteristics	Mean age (±SD)	Sample size randomized		Intervention		Assessment points	Outcome measures	Safety	Received funding
Author, y	Origin	Sample characteristics	Mean age (±SD)	Treatment	Control	Treatment	Control	Assessment points	Outcome measures	Safety	Received funding
Aboagye et al.,¹ 2015 + Brämberg et al.,⁵ 2017	Sweden	Civilians with a diagnosis of nonspecific LBP, no changes in TAU, gender: both	45.7 ± 10.2	N = 52	N_A = 52 N_B = 55	Yoga + TAU Kundalini style with asanas, pranayama, and relaxation, 6 weeks, 60 minutes, twice weekly + home practice	A: Exercise + TAU Strengthening exercise, 6 weeks, 60 minutes, once every 2nd week + home practice B: TAU (written advice)	PI 6mFU 12mFU	Pain intensity (CPGS) Disability (CPGS) Physical quality of life (EQ-5D) Attendance	N.r	Government
Cox et al.,⁸ 2010	United Kingdom	Civilians with LBP ≥ 3 months, without previous spinal surgery, gender: both	45	N = 10	N = 10	Yoga + TAU Iyengar style with asanas, pranayama, and relaxation, 12 weeks, 75 minutes, once weekly + home practice	TAU (written advise)	PI	Pain intensity (ABPS) Disability (RMDQ) Physical quality of life (SF12) Mental quality of life (SF12) Attendance	N.r.	University
Demirel et al.¹⁷ 2019	Turkey	Civilians with nonspecific LBP ≥ 3 months, gender: both	44.9 ± 10.4	N = 40	N = 40	Yoga No specific style, asanas, and pranayama, 6 weeks, 60 minutes, 3 times weekly	Exercise Stabilization exercise, 6 weeks, 60 minutes, 3 times weekly	PI	Pain intensity (NHP-P) Disability (ODI) Physical quality of life (NHP-PA) Mental quality of life (NHP-ER)	N.r.	No funding
Galantino et al.,²¹ 2004	United States	Civilians with LBP > 6 months, at least 2 conservative treatments without relief, no changes in TAU, gender: both	N.r.	N = 11	N = 11	Yoga + TAU Hatha style with asanas, pranayama, relaxation, and meditation, 6 weeks, 60 minutes, twice weekly	Wait list + TAU	PI	Disability (ODI)	N.r	N.r.
Groessl et al.,²⁴ 2017+ Groessl et al.,²⁵ 2019	United States	Veterans with LBP ≥ 6 months, without radicular symptoms, no changes in TAU, gender: both	53.4 ± 13.3	N = 76	N = 76	Yoga + TAU Hatha style with asanas, pranayama and short meditation, 12 weeks, 60 minutes twice weekly + home practice	Wait list + TAU	PI 6mFU	Pain intensity (BPI) Disability (RMDQ) Physical quality of life (SF12) Mental quality of life (SF12) Attendance	Yoga: 2/75 nonserious AEs	Military
Highland et al.,²⁹ 2018	United States	Veterans with a diagnosis of LBP > 3 months, without severe pathology, gender: both	44.3 ± 12.7	N = 34	N = 34	Yoga + TAU Therapeutic approach with asanas, pranayama, and meditation, 8 weeks, 60 minutes, twice weekly until week 4 then once weekly	TAU	PI 6mFU	Pain intensity (DVPRS (NRS)) Disability (RMDQ) Physical quality of life (PROMIS-PFS) Mental quality of life (PROMIS-SD,PI,A,D,F) Attendance	N.r.	Military
Jacobs et al.,³² 2004	United States	Civilians with nonspecific LBP ≥ 6 months, without radicular or severe neurological signs, gender: both	43.4	N = 28	N = 24	Yoga + TAU Iyengar style with asanas, pranayama, and relaxation, 12 weeks, 90 minutes, twice weekly + home practice	Wait list + TAU (written advise)	PI 6mFU	Pain intensity (VAS) Disability (RMDQ) Physical quality of life (SF36-PF) Mental quality of life (SF36-EW) Attendance	N.r.	N.r.
Kim et al.,³³ 2014	South Korea	Civilians with a diagnosis of LBP > 2 months, gender: females	47.4	N = 15	N = 15	Yoga Virtual course with asanas and pranayama, 4 weeks, 30 minutes, 3 times weekly	Exercise Trunk stabilization exercise, 4 weeks, 30 minutes, 3 times weekly	PI	Pain intensity (VAS) Disability (RMDQ)	N.r.	N.r.
Kuvacic et al.,³⁶ 2018	N.r.	Civilians with LBP ≥ 3 months, without specific causes, gender: both	34.2	N = 15	N = 15	Yoga No specific style, asanas, pranayama, relaxation, and meditation, 8 weeks, 60 minutes, twice weekly	TAU (written advise)	PI	Pain intensity (NRS) Disability (ODI)	N.r.	N.r.
Michalsen et al.,³⁸ 2021	Germany	Civilians with nonspecific LBP ≥ 3 months, gender: both	54.6 ± 11.3	N = 100	N_A = 82 N_A = 92	Yoga Hatha style with asanas and relaxation, 8 weeks, 75 minutes, once weekly	A: Exercise Physical therapy (strengthening and stretching exercise),8 weeks, 75 minutes, once weekly B: Eurhythmy contraction/expansion and stretching exercise, 8 weeks, 75 minutes, once weekly	PI	Pain intensity (VAS) Disability (RMDQ) Physical quality of life (SF12) Mental quality of life (SF12) Attendance	Yoga: 13/100 nonserious AEs Exercise: 47/82 nonserious AEs	Foundation
Monro et al.,⁴⁰ 2015	India	Civilians with LBP with disk prolapse or protrusion, without previous surgery, gender: both	36.0 ± 6.8	N = 30	N = 31	Yoga Therapeutic approach with asanas, pranayama, and relaxation, 12 weeks, at least twice weekly for 2 weeks, then once weekly + home practice	TAU	PI	Pain intensity (ABPS) Disability (RMDQ) Attendance	N.r.	N.r.
Nambi et al.,⁴¹ 2014	India	Civilians with nonspecific LBP ≥ 3 months, without neurological signs or prolapse, gender: both	43.9 ± 8.9	N = 30	N = 30	Yoga Iyengar style with asanas and relaxation, 4 weeks, 60 minutes, once weekly + home practice	Exercise Strengthening and stretching exercise, 4 weeks, 1 session + home practice	PI 6mFU	Pain intensity (VAS) Physical quality of life (CDC HRQOL4) Mental quality of life (CDC HRQOL4) Attendance	Yoga: 1/30 nonserious AE	No funding
Neyaz et al.,⁴² 2019	India	Civilians with nonspecific LBP ≥ 3 months, gender: both	N.r.	N = 35	N = 35	Yoga Hatha style with asanas, pranayama, relaxation, and meditation, 12 weeks, 35 minutes, once weekly for 6 weeks + home practice, then home practice for 6 weeks	Exercise Stretching and strengthening exercises, 12 weeks, 35 minutes, once weekly for 6 weeks + home practice, then home practice for 6 weeks		Pain intensity (DVPRS) Disability (RMDQ) Attendance	Yoga: 0/35 serious AEs Exercise: 0/35 serious AEs 3/70 nonserious AEs	N.r.
Patil et al.,⁴³ 2018	India	Civilians with nonspecific LBP ≥ 3 months or lumbar spondylitis or intervertebral disc prolapse, gender: female	32.1	N = 44	N = 44	Yoga Integrated approach with asanas, pranayama, relaxation, and mediation 6 weeks, 60 minutes, 5 times weekly	Exercise Strengthening and stretching exercise, 6 weeks, 60 minutes, 5 times weekly	PI	Physical quality of life (WHOQOL-BREF-PH) Mental quality of life (WHOQOL-BREF-MH)	N.r.	No funding
Pushpika Attanayake et al.,⁴⁴ 2010	India	Civilians with LBP ≥ 3 weeks, without specific causes or neurological symptoms, gender: both	N.r.	N = 6	N = 6	Yoga + TAU Hatha style with asanas, pranayama, and chanting, 3 weeks, 60 minutes, once weekly	TAU (written advice)	PI	Pain intensity (NRS)	N.r.	N.r
Saper et al.,⁴⁹ 2009	United States	Civilians with muscular LBP ≥ 3 months, without back surgery within last 3 years, gender: both	44 ± 12	N = 15	N = 15	Yoga + TAU Hatha style with asanas, pranayama, and relaxation, 12 weeks, 75 minutes, once weekly + home practice	Wait list + TAU (written advise)	PI 6mFU	Pain intensity (NRS) Disability (RMDQ) Physical quality of life (SF36-PHS) Mental quality of life (SF36-MHS)	Yoga: 1/15 nonserious AEs TAU: 0/15	Government
Saper et al.,⁴⁸ 2017	United States	Civilians with nonspecific LBP ≥ 3 months, without specific causes, gender: both	45.7 ± 10.7	N = 127	N_A = 129 N_B = 64	Yoga + TAU Hatha style with asanas, pranayama, relaxation and mediation, 12 weeks, 75 minutes, once weekly + home practice	A: Exercise + TAU Aerobic exercise, 12 weeks, 60 minutes, 15 sessions + home practice B: TAU (written advise)	PI 6mFU 12mFU	Pain intensity (NRS) Disability (RMDQ) Physical quality of life (SF36-PHS) Mental quality of life (SF36-MHS) Attendance	Yoga: 9/127 nonserious AEs Exercise: 14/129 nonserious AEs TAU: 1/64 nonserious AEs	Government
Sherman et al.,⁵⁴ 2005	United States	Civilians with muscular LBP ≥ 3 months, without pathological complications gender: both	44 ± 13	N = 36	N_A = 35 N_B = 30	Yoga + TAU Vini style with asanas, pranayama, and relaxation, 12 weeks, 75 minutes, once weekly + home practice	A: Exercise + TAU Aerobic and strengthening exercise, 12 weeks, 75 minutes, once weekly + home practice B: TAU (written advise)	PI 6mFU	Pain intensity (NRS) Disability (RMDQ) Physical quality of life (SF36-PHS) Mental quality of life (SF36-MHS)	Yoga: 1/36 nonserious AEs Exercise: 1/35 nonserious AEs TAU: 0/30	Government
Sherman et al.,⁵⁵ 2011	United States	Civilians with nonspecific LBP ≥ 3 months, without radiating pain or organic pathology gender: both	48.1 ± 9.8	N = 92	NA = 91 NB = 45	Yoga + TAU Vini style with asanas, pranayama, and relaxation, 12 weeks, 75 minutes, once weekly + home practice	A: Exercise + TAU Aerobic + strengthening exercise, 12 weeks, 75 minutes, once weekly + home practice B: TAU (written advise)	PI 6mFU	Pain intensity (NRS) Disability (RMDQ)	Yoga: 13/92 nonserious A Es + 1 serious AE Exercise: 13/91 nonserious AEs TAU: 1/45 AE nonserious AE	Government
Tekur et al.,⁵⁸ 2008 + Tekur et al.,⁵⁶ 2010	India	Civilians with LBP ≥ 3 months, with or without radiating pain, without organic spinal pathology, gender: both	48.5 ± 3.8	N = 40	N = 40	Yoga Therapeutic approach with asanas, pranayama, relaxation, meditation, lifestyle advise, 1 week, at least 120 minutes, daily	Exercise Physical therapy, breathing, and lifestyle advise, 1 week, at least 120 minutes, daily	PI	Pain intensity (ODI) Disability (ODI) Physical quality of life (WHOQOL-BREF-PH) Mental quality of life (WHOQOL-BREF-MH)	Yoga: 0/40 Exercise: 0/40	University
Telles et al.,⁵⁹ 2016	India	Civilians with LBP due to at least 1 MRI-proven disk degeneration, without previous surgery, gender: both	36.2 ± 6.4	N = 31	N = 31	Yoga + TAU Therapeutic approach with asanas, pranayama, relaxation, and meditation12 weeks, 60 minutes, 3 times weekly for 2 weeks, then once weekly + home practice	TAU	PI	Pain intensity (VAS)	Yoga: 3/20 nonserious AEs TAU: 2/20 nonserious AEs	Foundation
Teut et al.⁶¹ 2016	Germany	Older civilians with LBP ≥ 6 months, without acute prolapse/protrusion or neurological signs, no opioid use, gender: both	73 ± 5.6	N = 61	N_A = 58 N_B = 57	Yoga + TAU Vini style with asanas, pranayama, and meditation, 12 weeks, 45 minutes, twice weekly	A: Qigong Exercise 12 weeks, 90 minutes, once weekly B: Wait list + TAU	PI 6mFU	Pain intensity (VAS) Disability (FFbHR) Physical quality of life (SF36-PHS) Mental quality of life (SF36-MHS) Attendance	Yoga: 1/61 unclear AE	Foundation
Tilbrook et al.,⁶² 2011	United Kingdom	Civilians with LBP ≥ 18 months, without serious spinal neurologic signs or previous spinal surgery, gender: both	46.3 ± 11.4	N = 156	N = 157	Yoga + TAU Iyengar style with Asanas, pranayama, relaxation, and lifestyle advise, 12 weeks, 75 minutes, once weekly + home practice	Wait list + TAU (written advise)	PI 6mFU 12mFU	Pain intensity (ABPS) Disability (RMDQ) Physical quality of life (SF12) Mental quality of life (SF12)	Yoga: 11/156 nonserious AEs + 1 serious AE TAU: 2/157 serious AEs	Charity organization and university
Vyshlova et al.,⁶⁵ 2015	Russia	Civilians with LBP without severe somatic pathology, same pain medication as TAU, gender: both	40.5 ± 7.5	N = 20	N = 20	Yoga + TAU Therapeutic approach with asanas, 4 weeks, 30 minutes, 3 times weekly	TAU	1mFU 2mFU	Pain intensity (VAS)	N.r.	N.r.
Wattamwar et al.,⁶⁶ 2013	India	Civilians with nonspecific LBP ≥ 3 months, without neurological signs or spinal pathology, gender: both	34	N = 12	N = 12	Yoga + exercise Iyengar style with asanas and pranayama, 10 weeks, 45–60 minutes, exercise 2 times weekly + yoga once weekly + home practice	Exercise Back school: strengthening and stretching exercise, 10 weeks, 45–60 minutes, 3 times weekly + home practice	PI	Pain intensity (ODI) Disability (ODI)	N.r.	N.r.
Williams et al.,⁶⁹ 2005	United States	Civilians with LBP ≥ 3 months, without organic origin, gender: both	48.3 ± 7.1	N = 30	N = 30	Yoga + TAU Iyengar style with asanas, 16 weeks, 90 minutes, once weekly + home practice	TAU (written advise)	PI 6mFU	Pain intensity (VAS) Disability (PDI)	Yoga: 1/30 nonserious AE TAU: 1/30 serious AE	University
Williams et al.⁶⁸ 2009	United States	Civilians with LBP ≥ 3 months, without organic origin, gender: both	48.0 ± 1.2	N = 43	N = 47	Yoga Iyengar style with asanas, 24 weeks, 90 minutes, twice weekly + home practice	TAU	PI 6mFU 12mFU	Pain intensity (VAS) Disability (ODI)	Yoga: 1/43 nonserious AE TAU: 0/47	Government

ABPS, Aberdeen Back Pain Scale; AE, adverse events; BPI, Brief Pain Inventory; CDC HRQOL4, Center for Disease Control and Prevention Healthy Days Core Module; CPGS, Chronic Pain Grade Scale; DVPRS, Defense and Veterans Pain Rating Scale; EQ-5D, EuroQol-5D questionnaire; FFbHR, Hannover Functional questionnaire; LBP, low back pain; NHP-P/PA/ER, Nottingham Health Profile (P, pain subscale; PA, physical abilities subscale; ER, emotional reaction subscale); NRS, numeric rating scale; ODI, Oswestry Disability Index; PDI, Pain Disability Index; PI, postintervention; PROMIS-FF, Patient-Reported Outcomes Measurement Information System (PF, physical functional subscale; SD, sleep disturbance; PI, pain interference; A, anxiety; D, depression; F, fatigue); RMDQ, Roland Morris Disability Questionnaire; SF12/36, Short-Form Health Survey (EW, emotional well-being; PF, physical functioning; PHS, physical health score; MHS, mental health score); STAI-S, State-Anxiety Inventory; TAU, treatment as usual; VAS, visual analogue scale; WHOQOL-BREF, WHO Quality of Life Questionnaire-Abbreviated Version (PH, physical health; MH, mental health).