JACM

THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE

Volume 00, Number 00, 2019, pp. 1–8
ª Mary Ann Liebert, Inc.
DOI: 10.1089/acm.2019.0140

Effectiveness of Hatha Yoga Versus

Conventional Therapeutic Exercises for Chronic
Nonspecific Low-Back Pain
Osama Neyaz, DNB,1,* Lukram Sumila, MBBS,1 Srishti Nanda, MSc,2 and Sanjay Wadhwa, DNB1
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Abstract
Objective: To determine whether the effectiveness of Hatha yoga therapy is comparable to conventional
therapeutic exercises (CTEs) for reducing back pain intensity and back-related dysfunction in patients with
chronic nonspecific low-back pain (CNLBP).
Design: The study was a prospective randomized comparative trial, divided into two phases: an initial
6-weekly supervised intervention period followed by a 6-week follow-up period.
Settings: This study was conducted at Department of Physical Medicine and Rehabilitation and Centre for
Integrative Medicine and Research of a tertiary care hospital.
Subjects: Patients between 18 and 55 years of age with complaint of CNLBP persisting ‡12 weeks with pain
rating ‡4 on a numerical rating scale (0–10).
Intervention: A total of six standardized 35-min weekly Hatha yoga sessions (yoga group) and similarly 35-
min weekly sessions of CTEs (CTE group), designed for people with CNLBP unaccustomed to structured yoga
or CTE program. Participants were asked to practice on nonclass days at home.
Outcome measures: The primary outcome measures were Defense and Veterans Pain Rating Scale (DVPRS)
(0–10) and 24-point Roland Morris Disability Questionnaire (RDQ). Secondary outcomes were pain medication
usage per week and a postintervention Perceived recovery (Likert seven-point scale) of back-related dys-
function. Outcomes were recorded at the baseline, 6-week follow-up, and 12-week follow-up.
Results: Seventy subjects were randomized to either yoga (n = 35) or CTE group (n = 35). Data were analyzed
using intention-to-treat, with last observation carried forward. Both yoga and the CTE group have shown sig-
nificant improvement in back pain intensity and back-related dysfunction within both the groups at 6- and 12-week
follow-ups compared to baseline. No statistically significant differences in the pain intensity (DVPRS; at 6 weeks:
n = 35, difference of medians 1.0, 95% confidence interval [-5.3 to 3.0], p = 0.5; at 12 weeks: n = 35, 0.0 [-4.2 to
5.0], 0.7) and back-related dysfunction (RDQ; at 6 weeks: n = 35, 1.0 [-9.6 to 10.6], 0.4; at 12 weeks: n = 35, 0.0
[-8.8 to 10.6], 0.3) were noted between two groups. Improvements in pill consumption and perceived recovery
were also comparable between the groups.
Conclusion: Yoga provided similar improvement compared with CTEs, in patients with CNLBP.

Keywords: yoga, exercises, low-back pain, comparative trial

Introduction as chronic when it persists for 12 weeks or more. Non-

specific low-back pain is pain not attributed to a recogniz-

L ow-back pain is pain, muscle tension, or stiffness lo-

calized below the costal margin and above the inferior
gluteal folds, with or without leg pain (sciatica). It is defined
able pathology (such as infection, tumor, osteoporosis,
fracture, or inflammatory disorders).1 Chronic nonspecific
low-back pain (CNLBP) is an extremely common health

Departments of 1Physical Medicine and Rehabilitation and 2Physiology, All India Institute of Medical Sciences, New Delhi,
India.
*Current affiliation: Department of Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, Rishikesh,
India.

1
 2 NEYAZ ET AL.
and socioeconomic problem in present society. Prevalence
of low-back pain ranges from 40.7% to 42.4% in Indian
population.2,3
Conventional therapeutic exercises (CTEs) are the most
widely used evidence-based nonpharmacologic treatment
and already proven to be an effective component in treat-
ment of CNLBP.4,5 Yoga-based treatment has also shown
promising results in reducing pain intensity and pain-related
disability in chronic low-back patients and may be an effi-
cacious treatment for CNLBP.6,7
A recent meta-analysis pointed out that the comparison of
yoga with therapeutic exercises for back-related dysfunction
and pain is still limited by the number of studies.8 In ad-
dition, even though Yoga is an ancient practice originating
out of the Indian subcontinent, it was surprising to note that
only a few published studies have evaluated Yoga for pa-
tients with CNLBP in Indian population. Therefore, a clin-
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ical trial was designed to compare the efficacy of Yoga with
therapeutic exercises for CNLBP population. This com-
prised a structured, 35-min weekly series of Yoga therapy,
with CTEs, for 6 weeks, supplemented with home practice,
in decreasing pain intensity and improving back-related
dysfunction for patients with CNLBP. It was hypothesized
that Yoga therapy is as effective as CTEs in decreasing pain
intensity and improving back-related dysfunction in patients
with CNLBP. Alternatively, if Yoga is less effective, this
information will help guide better treatment decisions and
reduce unnecessary expenditure of time and other resources
on less effective treatment.
Methods
Study design
The study was designed as a prospective randomized
comparative trial comparing the effect of 35-min supervised
weekly Yoga sessions and 35-min supervised weekly CTE
sessions, both designed for CNLBP. The trial was divided
into two phases: an initial 6-week intervention period of 35-
min weekly supervised session at institute and practice on
nonclass days at home followed by a 6-week follow-up
period. During the 6-week follow-up period, all participants
were encouraged to practice at home. The study protocol
was approved by institute ethics committee, and all study
participants provided oral informed consent before the eli-
gibility screening and written consent before the baseline
assessment and randomization.
Settings and participants
This study was conducted from February 2017 to April
2018, at Department of Physical Medicine and Rehabilitation
(PMR) and Centre for Integrative Medicine and Research
(CIMR) at tertiary care hospital. Patients aged between 18
and 55 years who were attending outpatient at PMR depart-
ment with complaint of CNLBP persisting ‡12 weeks and
pain rating ‡4 on a 0–10 numerical rating scale (0 = no pain to
10 = worst possible pain) were screened for eligibility. A de-
tailed history was taken, and clinical examination findings
were recorded. Complete blood picture (hemoglobin, total
leukocyte count, differential leukocyte count, erythrocyte
sedimentation rate) and radiograph of lumbar spine (ante-
roposterior and lateral view) were obtained in every patient.
Other investigations were conducted if indicated.
The authors excluded individuals whose back pain was
due to severe scoliosis, sciatica, previous back surgery, or
diagnosed spinal stenosis, potentially attributable to specific
underlying diseases or conditions (e.g., pregnancy, meta-
static cancer, spondylolisthesis, fractured bones or dislocated
joints, large herniated disk, sciatica pain equal to or greater
than back pain) or minimal pain (rating of £4 on a 0–10
numerical rating scale). The authors also excluded conditions
overlapping with symptoms of back pain or confound
treatment effects (rheumatoid arthritis, spondyloarthropathy,
and severe fibromyalgia). The authors excluded individuals
who were currently receiving other back pain treatments or
had participated in Yoga or CTE training for back pain and
those with unstable medical or severe psychiatric conditions
or dementia. Patients who had contraindications (e.g., pro-
gressive neurologic deficits) or schedules that precluded
class participation, those with history of active substance or
alcohol abuse, those who were unwilling to practice at home,
or those who have plans to move out of the area in the next 1
month were also excluded.
Interventions
A total of six standardized 35-min weekly Yoga sessions
were given on individual basis at CIMR and similarly 35-
min weekly CTE sessions at PMR Department. The CTE
intervention was kept identical to the Yoga sessions, in
terms of length of sessions (35 min) and number of sessions
(six sessions). Education regarding postural care for CNLBP
was given in both groups. Participants from both the groups
were asked to practice 30 min on nonclass days at home, and
handouts were given to illustrate technique at home.
Yoga group
An integrated Yoga therapy module for CNLBP was de-
veloped from traditional Hatha yoga practices, in collabora-
tion with CIMR. Due to the convenience and lower cost, a
once weekly 35-min Yoga session was chosen for the current
study. Each session included introduction to Hatha yoga,
flexibility practices, four different Yogasanas, quick relaxa-
tion technique, pranayamas, and deep relaxation technique
(Table 1). Yoga sessions were administered by a trained yoga
therapist. Yoga participants were encouraged to practice at
home for 30 min on days when they did not have session.
CTE group
Weekly sessions were held by trained physiotherapists,
which began with short educational talk that provided in-
formation on proper body mechanics, benefits of exercise,
followed by simple warm-up and three different stretching
and five different strengthening exercises that emphasize
hip, abdominal, and back muscles (Table 2). Frequency of
repetitions of each stretching and strength exercises was 10
with holding time of 10 sec. Each set of strengthening ex-
ercises was followed by a different set of stretching exer-
cise. Sessions ended with a short unguided period of deep
slow breathing.
Outcome measures
The primary outcome measures were back pain intensity
and back-related dysfunction. Secondary outcomes were
 YOGA VERSUS EXERCISE FOR CHRONIC LOW-BACK PAIN 3

Table 1. Components of Hatha Yoga Session and sensitive to changes.10,11 These primary outcomes were
recorded at baseline, 6-week postintervention, and 12-week
Time follow-up. Those who were more comfortable with local
S. No. Components of each yoga session (min) (Hindi) language were provided with a translated version of
A Introduction of Yoga philosophy 5 the RDQ.
Questions were asked to determine the weekly con-
B Sithilikaran Vyayama (Flexibility practice)
01 Supta Udarakarshanasana (folded 3 sumption of pain medication12 for CNLBP management
leg lumbar stretch) before the intervention. Changes in weekly drug consump-
02 Shavaudarakarshanasana (Crossed 3 tion were recorded in both the groups at 6-week post-
leg lumbar stretch) intervention and 12-week follow-up compared to baseline.
03 Supta Pawanmuktasana (leg lock pose) 2 Perceived recovery of back-related pain and dysfunction
C Yogasanas was rated by patient on a seven-point Likert scale indicating
01 Ustrasana (Camel Pose) 2 ‘‘very large improvement’’ (including complete recovery),
02 Bhujangasana (Cobra Pose) 2 ‘‘much improved’’, ‘‘little improved’’, ‘‘unchanged’’, ‘‘little
03 Salabhasana (Grasshopper Pose) 2 worse’’, ‘‘much worse’’, and ‘‘very much worse’’.13 Scores
04 Setubandasana (Bridge Pose) 2 were evaluated as change from last time point.
D Quick relaxation technique
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01 Savasana (Corpse Pose) with pranayama 5 Sample size calculation

E Pranayama (breath control)
01 Nadi suddhi (Alternate nostril breathing) 2 An a priori sample size calculation was done using the
02 Bhramari (Humming breathing) 2 study of Nambi et al.14 in which they have reported mean
F Meditation (Deep relaxation technique) pain related functional disability as 2.5 and standard devi-
01 Savasana (Chanting AUM or OM) 5 ation as 3.0. Assuming 95% power of the study at 5% level
Total 35 of significance, the required sample size for measuring ef-
fect was 30 subjects in each group. Considering 10%
dropout, final sample size was 35 in each group. Total
sample size was 70.
pain medication usage and postintervention perceived re-
covery of back-related pain and dysfunction. Assessments
were done at baseline, after 6 weeks of intervention period, Randomization and blinding
and follow-up at 12-week time points. Participants were randomized using a pregenerated ran-
Pain intensity was quantified by the Defense and Veterans domized sequence (block randomization; 70 subjects were
Pain Rating Scale (DVPRS) (0–10), which is a validated allocated to either of the two blocks consisting of 35 sam-
patient-reported pain assessment tool. It is a brief and easy ples each). Opaque sealed envelopes were used to conceal
to apply scale, which makes it a practical tool in primary the allocation. Investigators associated with study design,
care settings. It enables user to monitor chronic pain over recruitment, eligibility, outcome assessment, and statistical
time more effectively than measuring pain severity alone.9 analysis were unaware of the intervention allocation; only
Back-related dysfunction was assessed using the 24-point the intervention administrators and caregivers were aware of
Roland Morris Disability Questionnaire (RDQ). Each the allocated intervention, but did not have any influence on
question is worth one point so scores can range from 0 (no the recruitment, eligibility, or conclusions of the study.
disability) to 24 (severe disability). RDQ is valid, reliable,
Statistical analysis
Data were checked for normal distribution using Shapiro–
Table 2. Components of Conventional Therapeutic Wilk normality tests. Dependent variables were back pain
Exercise Session
intensity, back pain-related dysfunction, weekly pill con-
Timing sumption, and perceived improvement. Outcome measures
S. No. Target muscle (min) were compared using intention-to-treat (in which missing
data were imputed using last observation carried forward),
A Short introduction regarding benefits 5 as well as per-protocol, analysis. Since normal distribution
of exercises could not be assumed, the numerical variables were ex-
B Warm-up exercises 4 pressed as median (first quartile, third quartile). Two-group
C Hip extensors strengthening both sides 3 comparisons were used to describe the effect of Yoga in
Hamstring stretching both sides 3 comparison to CTEs using Wilcoxon’s signed-rank test for
Rectus abdominis strengthening 2 intention-to-treat protocol and Mann–Whitney U-test for
Erector spinae stretching 2 per-protocol analysis. Multiple group comparisons were
Erector spinae strengthening 2 used to describe the effect of each therapy on back pain
Pyriformis stretching both sides 3 (within group comparisons) using Friedman test for
Oblique abdominal muscle strengthening 3
both sides intention-to-treat protocol and Kruskal–Wallis H-test for
Hip abductor strengthening both sides 3 per-protocol analysis. Categorical data were analyzed using
Chi-square test. Level of significance was set at 0.01, and
D Relaxation 5
Total time 35 analysis was done using GraphPad Prism software (version
8; GraphPad Software, CA).
 4 NEYAZ ET AL.
Additional analysis
Data were further analyzed for adherence with the pre-
scribed interventional sessions and compliance with the
protocol. Participants who attended ‡4 supervised Yoga or
CTE sessions were defined as ‘‘good adherers’’ and those
attending £3 supervised sessions were considered as ‘‘poor
adherers’’. In the same way, participants who reported to the
clinic for scheduled evaluations of outcome measures were
defined as ‘‘completers’’ and those who could not report
back were defined as ‘‘non-completers’’.
Results
Out of 70 patients that were randomized, 43 (61%) re-
ceived 6-week intervention and 35 (50%) completed 12-week
follow-up. Three (4%) patients did not receive intervention
after allocation without any specific reasons. Twenty-four
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FIG. 1. Study flow dia-
gram.
(34%) participants discontinued intervention (13 from the
Yoga group and 11 from the CTE group) without any spec-
ified reasons. Eight (11%) patients were lost to follow-up
(three from the Yoga group and five from the CTE group).
The flow diagram for the study participants is depicted in
Figure 1.
The recruited participants had mean pain intensity of
5.8 – 1.6 and average duration of CNLBP of 23.1 – 18.7
months (range 3–72 months). The mean age of the partici-
pants was 35.8 – 10.6 years with a range of 18–60 years. At
randomization, the baseline variables of both the groups
such as age, gender, marital status, employment status, du-
ration of symptoms, baseline back pain, and back-related
dysfunction were comparable (Tables 3–7).
A univariate analysis of back pain showed significant
improvement in DVPRS within the Yoga group and the
CTE group at 6- and 12-week follow-up compared to the
 Table 3. Baseline Characteristics of Participants
p-Value (between
Yoga (n = 35) CTEs (n = 35) the groups)
Age (years)a 38 (26.5, 43) 33 (27.5, 44) 0.45
Sex (male:female) 18:17 17:18 0.05
Marital status (married:unmarried) 28:7 24:11 0.02
Occupational status (employed:unemployed) 20:15 15:20 1.0
Duration of symptomsa (months) 12 (9.5, 36) 18 (6.3, 30) 0.86
The demographic characteristics such as age, sex, marital status, occupational status, and duration of pain symptoms were comparable at
randomization.
a
Age and duration of symptoms has been depicted as median (first quartile, third quartile).
CTE, conventional therapeutic exercise.

Table 4. Comparison of Low-Back Pain Intensity Score (Defense and Veterans Pain Rating Scale)
p-Value (between
n Yoga n CTEs the groups)
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Intention-to-treat Baseline 35 5 (4, 7) 35 6 (5, 7.5) 0.07

6 Weeks 35 4 (2.5, 5) 35 5 (3, 5.5) 0.49
12 Weeks 35 4 (2.5, 5) 35 4 (2, 5) 0.70
p-Value (within the groups) <0.01* <0.01*
Per-protocol Baseline 35 5 (4, 7) 35 6 (5, 7.5) 0.07
6 Weeks 20 3 (2, 4.5) 23 3 (2, 5) 0.33
12 Weeks 17 3 (1, 4) 18 2 (0.3, 4) 0.28
p-Value (within the groups) <0.01* <0.01*
Table showing the effect of yoga and CTE intervention on back pain intensity at baseline, 6-week intervention period, and 12-week
follow-up. Data have been depicted as median (first quartile, third quartile).
*Depicts significance at level of 0.01.

Table 5. Comparison of Back-Related Dysfunction (Roland Morris Disability Questionnaire Score)

p-Value (between
n Yoga n CTEs the groups)
Intention-to-treat Baseline 35 12 (7, 15) 35 10 (7, 14) 0.47
6 Weeks 35 7 (5.5, 12) 35 6 (3, 12) 0.38
12 Weeks 35 6 (3.5, 12) 35 6 (1, 11) 0.26
p-Value (within the groups) <0.01* <0.01*
Per-protocol Baseline 35 12 (7, 15) 35 10 (7, 14) 0.47
6 Weeks 20 6 (3, 8.5) 23 4 (2, 6.5) 0.35
12 Weeks 17 4 (2, 6) 18 1 (0, 3.5) 0.04
p-Value (within the groups) <0.01* <0.01*
Table showing the effect of yoga and CTE intervention on back-related dysfunction at baseline, 6-week intervention period, and 12-week
follow-up. Data have been depicted as median (first quartile, third quartile).
*Depicts significance at level of 0.01.

Table 6. Comparison of Pain Medication Usage (Pills Consumed Per Week)

p-Value (between
n Yoga n CTEs the groups)
Intention-to-treat Baseline 35 12 (0, 15) 35 7 (0, 15) 0.98
6 Weeks 35 6 (0, 14) 35 6 (0, 14) 0.98
12 Weeks 35 0 (0, 12) 35 0 (0, 10) 0.87
p-Value (within the groups) 0.23 0.08
Per-protocol Baseline 35 12 (0, 15) 35 7 (0, 15) 0.98
6 Weeks 20 5 (0, 10) 23 4 (0, 15) 0.86
12 Weeks 17 0 (0,0) 18 0 (0,0) 0.35
p-Value (within the groups) <0.01* <0.01*
Table showing the effect of yoga and CTE intervention on pain medication usage (pills consumed per week) at baseline, 6-week
intervention period, and 12-week follow-up. Data have been depicted as median (first quartile, third quartile).
*Depicts significance at level of 0.01.

5
 6 NEYAZ ET AL.

Table 7. Comparison of Perceived Recovery of Back-Related Dysfunction (Likert Seven-Point Scale)

p-Value (between
n Yoga N CTEs the groups)
Intention-to-treat 6 Weeks 20 2 (2, 3) 23 2 (2, 3) 0.89
12 Weeks 17 2 (1.7, 2.3) 18 2 (1, 2) 0.33
p-Value (within the groups) 0.21 0.01
Per-protocol 6 Weeks 20 2 (2, 3) 23 2 (2, 3) 0.89
12 Weeks 17 2 (1, 2) 18 1.5 (1, 2) 0.22
p-Value (within the groups) 0.12 <0.01*
Table showing the effect of yoga and CTE intervention on perceived recovery of back-related pain and dysfunction from baseline (Likert
seven-point scale) at 6-week intervention period and 12-week follow-up. Data have been depicted as median (first quartile, third quartile).
*Depicts significance at level of 0.01.

baseline. However, no statistically significant difference in The subjects attended an average of 4.3 – 2.2 classes, with
the improvement was observed when a comparison was 47 subjects (23 in yoga group and 24 in CTE group) having
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made between the Yoga group and the CTE group at 6- and
12-week follow-up (Table 4).
A univariate analysis of back-related dysfunction showed
significant improvement in RDQ scores within the Yoga
group and the CTE group at 6- and 12-week follow-up
compared to baseline. There was no statistically significant
difference observed between the Yoga group and the CTE
group at 6- and 12-week follow-up (Table 5).
At baseline, about 46 (65%) participants were using pain
medication (21 [60%] Yoga group, 25 [71%] CTE group).
The weekly consumption of pain relieving medication was
comparable between the groups at randomization, 6-, and
12-week time point. Both Yoga and CTEs significantly re-
duced the number of pills consumed as per the per-protocol
analysis, but not according to intention-to-treat analysis
(Table 6).
All the participants reported some degree of improvement
from the baseline after the 6-week intervention period, as
well as at 12-week follow-up period, barring one subject in
yoga group who reported no change after the 6-week in-
tervention. At the end of 12-week Yoga protocol, 5 (26%)
participants reported ‘‘very much improvement,’’ and 8
(42%) participants reported ‘‘much improved’’. The num-
bers were 9 (50%) and 7 (38%) for the CTE group in their
respective categories. No statistical differences were found
between the Yoga and CTE group at 6- and 12-week follow-
up (Table 7).
attended ‡4 classes, making them ‘‘good adherers’’. Despite
good adherence, eight subjects dropped out (three from
Yoga group, five from CTE group) and four subjects were
lost to follow-up (three from Yoga group, one from CTE
group). Three out of 70 recruited subjects (two from Yoga
and one from CTE group) did not attend any class, that is,
they did not receive the allocated intervention. Twenty
subjects attended £3 classes, that is, they discontinued the
allocated intervention. Interestingly, those who discontinued
the intervention did not report at 6-week time point. The
authors attempted to assess if any baseline characteristics
could have played a role in the adherence or compliance of
the participants. Comparison of the baseline variables for
adherence (good adherers vs. poor adherers) and compliance
(completers vs. noncompleters) showed no statistical dif-
ferences (Tables 8 and 9).
Adverse events
No serious adverse event was observed in any group.
Nonserious side effects were observed in three patients and
these related to slight increased pain.
Discussion
This study investigated the effect of Yoga compared to
CTEs in terms of change in pain intensity, back-related
dysfunction, pain medication usage, and perceived recovery.

Table 8. Analysis of Baseline Characteristics Between Good and Poor Adherence

Good adherers Poor adherers p-Value (between
(n = 47) (n = 23) the groups)
Agea (years) 35 (29, 41) 36 (26, 47) 0.98
Sex (male:female) 25:22 10:13 0.39
Marital status (married:unmarried) 36:11 16:7 0.53
Occupational status (employed:unemployed) 26:21 9:14 0.20
Duration of symptomsa (months) 21 (8.25, 36) 12 (6, 36) 0.42
Back pain intensitya 5 (5,7) 5 (4, 7) 0.64
Back-related dysfunctiona 10 (7, 14) 12 (8.5, 15.5) 0.31
Weekly pill counta 10 (0, 15) 7 (0, 17.5) 0.85
The table compares the demographic features and baseline characteristics of participants who have shown good adherence versus the ones
who showed poor adherence to the prescribed therapy.
a
Age, duration, back pain intensity, back-related dysfunction, and weekly pill count have been depicted as median (first quartile, third
quartile).
 YOGA VERSUS EXERCISE FOR CHRONIC LOW-BACK PAIN 7

Table 9. Baseline Characteristic Analysis of the Dropouts

Completed Noncompleters p-Value (between
(n = 35) (n = 35) the groups)
Age (years) 36 (29, 42) 35 (26, 44.5) 0.76
Sex (male:female) 21:14 14:21 0.09
Marital status (married:unmarried) 25:10 27:8 0.58
Occupational status (employed:unemployed) 20:15 15:20 0.23
Duration (months) 21 (8.25, 45) 12 (6, 33) 0.22
Back pain intensity 5 (5, 7) 5 (4.5, 7) 0.22
Back-related dysfunction 10 (7, 13.5) 12 (8.5, 15) 0.17
Weekly pill count 6 (0, 12) 15 (7, 18.5) 0.09
The table compares the demographic features and baseline characteristics of participants who completed versus the ones who could not
complete the prescribed therapy. Age, duration, back pain intensity, back-related dysfunction, and weekly pill count have been depicted as
median (first quartile, third quartile).
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There was significant and comparable improvement in back
pain and back-related dysfunction in the Yoga group and the
CTE group by the end of the 6-week intervention, and im-
provements were maintained at the 12-week follow-up. The
results support the hypothesis that the yoga therapy provides
similar improvement in back pain and back-related dys-
function to CNLBP patients compared to CTEs. These
findings are in agreement with previous studies and indicate
that both interventions are effective.15–17
Another outcome of the study was the number of pills
consumed per week. No statistical significance was seen for
Yoga and CTE groups as per intention-to-treat analysis.
While the results are contrary to their expectations, some
caution is advised in this case. On reanalyzing the data as
per protocol, both Yoga and CTE groups were found to be
significant. It may be reasonable to assume that the null
results could be attributed to the dropouts. Indeed, the re-
duction of pill consumption can be ascertained by looking at
the proportions, out of the initial 46 participants who were
consuming pills; in the end only 3 participants continued
with pill consumption, while rest of the participants did not
feel the need to consume pills. Bearing these points in mind,
the authors deemed the effect of Yoga and CTEs on pill
consumption to be clinically significant. Williams et al.6
have reported a similar reduction in pain medications by
Yoga participants at 12 weeks’ time point in their study, but
this evidence needs to be tested as the comparator group was
a nonactive standard care.
Another outcome was the perceived improvement in
back-related pain and dysfunction. No statistical difference
was found between the Yoga and CTE group. The propor-
tion of subjects reporting improvement since the start of the
therapy makes the results clinically important even though it
did not achieve statistical significance.
Both Yoga and the CTE therapy were found to be safe
during the present study with few nonserious side effects
mostly related to increase in low-back pain. Few previous
studies have reported that side effects were mostly related to
mild self-limited joint and back pain and did not differ sig-
nificantly in frequency or severity between the groups.17,18
Among strengths of their study it can be stated that it was
methodologically sound owing to the use of appropriate
outcome variables, computerized randomization ensuring no
selection bias, and blinding of the principal investigator,
outcome assessor, and statistician. Participant blinding could
not have been possible in such a study. Future studies may
investigate the reasons and motivations behind the compli-
ance of the subjects that could inform the development
of patient retention strategies, at least in clinical settings.
On that note, the present protocol neither attempted to im-
prove compliance nor did it use any strategy to motivate the
adherence to the protocol. Such attributes were designed
bearing in mind the general applicability of the results. 19
Nevertheless, investigations in either direction would be in-
teresting to note given that yoga is a deeply rooted practice in
the Indian culture, thus posing its unique set of challenges
and strengths in conducting such studies.20
Conclusion
Yoga provided comparable improvement in terms of pain
intensity and back-related dysfunction in patients with
CNLBP compared to CTEs.
Acknowledgments
The authors thank the study yoga instructor Mr. Niranjan
Parajuli and Nursing research office, Mr. Mansingh Jat at
Centre for Integrative Medicine and Research, and senior
physiotherapist at Department of PMR (Mrs. Ng Dhan-
manjari Devi).
Author Disclosure Statement
No competing financial interests exist.
References
1. Chou R. Low back pain (chronic). BMJ Clin Evid 2010;10:
1116.
2. Ganesan S, Acharya AS, Chauhan, R, Acharya S. Pre-
valence and risk factors for low back pain in 1,355 young
adults: A cross-sectional study. Asian Spine J 2017;11:610–
617.
3. Mathew AC, Safar RS, Anithadevi TS, et al. The preva-
lence and correlates of low back pain in adults: A cross
sectional study from Southern India. Int J Med Public
Health 2013;3:342–346.
4. van Middelkoop M, Rubinstein SM, Verhagen AP, et al.
Exercise therapy for chronic nonspecific low-back pain.
Best Pract Res Clin Rheumatol 2010;24:193–204.
 8 NEYAZ ET AL.
5. Searle A, Spink M, Ho A, Chuter V. Exercise interventions
for the treatment of chronic low back pain: A systematic
review and meta-analysis of randomised controlled trials.
Clin Rehabil 2015;29:1155–1167.
6. Williams K, Abildso C, Steinberg L, et al. Evaluation of the
effectiveness and efficacy of Iyengar yoga therapy on
chronic low back pain. Spine 2009;34:2066–2076.
7. Tekur P, Singphow C, Nagendra HR, Raghuram N. Effect
of short-term intensive yoga program on pain, functional
disability and spinal flexibility in chronic low back pain: A
randomized control study. J Altern Complement Med 2008;
14:637–644.
8. Wieland LS, Skoetz N, Manheimer E, et al. Yoga treatment
for chronic non-specific low-back pain. Cochrane Database
Syst Rev 2017;1:CD10671.
9. Nassif TH, Hull A, Holliday SB, et al. Concurrent validity
of the Defense and Veterans Pain Rating Scale in VA
outpatients. Pain Med 2015;16:2152–2161.
Downloaded by Imperial College School Of Med from www.liebertpub.com at 08/06/19. For personal use only.
10. Roland M, Morris R. A study of the natural history of back
pain: Part I: Development of a reliable and sensitive mea-
sure of disability in low-back pain. Spine 1983;8:141–144.
11. Roland M, Fairbank J. The Roland-Morris disability
questionnaire and the Oswestry disability questionnaire.
Spine 2000;25:3115–3124.
12. Williams KA, Petronis J, Smith D, et al. Effect of Iyengar
yoga therapy for chronic low back pain. Pain 2005;115:
107–117.
13. Jellema P, Van der Roer N, van der Windt DA, et al. Low
back pain in general practice: Cost-effectiveness of a
minimal psychosocial intervention versus usual care. Eur
Spine J 2007;16:1812–1821.
14. Nambi GS, Inbasekaran D, Khuman R, Devi S. Changes in
pain intensity and health related quality of life with Iyengar
yoga in nonspecific chronic low back pain: A randomized
controlled study. Int J Yoga 2014;7:48–53.
15. Sherman KJ, Cherkin DC, Wellman RD, et al. A random-
ized trial comparing yoga, stretching, and a self-care book
for chronic low back pain. Arch Intern Med 2011;171:
2019–2026.
16. Highland KB, Schoomaker A, Rojas W, et al. Benefits of
the restorative exercise and strength training for operational
resilience and excellence yoga program for chronic low
back pain in service members: A pilot randomized con-
trolled trial. Arch Phys Med Rehabil 2018;99:91–98.
17. Saper RB, Lemaster C, Delitto A, et al. Yoga, physical ther-
apy, or education for chronic low back pain: A randomized
noninferiority trial. Ann Intern Med 2017;167:85–94.
18. Tilbrook HE, Cox H, Hewitt CE, et al. Yoga for chronic
low back pain: A randomized trial. Ann Intern Med 2011;
155:569–578.
19. Sedgwick P. Explanatory trials versus pragmatic trials.
BMJ 2014;349:g6694.
20. Cramer H, Lauche R, Langhorst J, Dobos G. Are Indian
yoga trials more likely to be positive than those from other
countries? A systematic review of randomized controlled
trials. Contemp Clin Trials 2015;41:269–272.
Address correspondence to:
Lukram Sumila, MBBS
Department of Physical Medicine and Rehabilitation
All India Institute of Medical Sciences
Ansari Nagar
New Delhi 110029
India
E-mail: sumilalukram124@rediffmail.com